Volume 2 - Issue 3 (May-Jul)


Volume 2 - Issue 3 (May-Jul)

487 Interferon IRF6 Gene Variants and the Risk of Isolated Cleft lip or Palate in South

Indian Dravidian Population

491 Role of ‘Live Microorganisms’ (Probiotics) in Prevention of Caries: Going on the

Natural Way Towards Oral Health

497 Oral Health and Wellness on Wheels!!!

500 Programmed Self-cell Suicide (Apoptosis) – Current Review, Concepts and Future


507 Oral Health Aspects of Cannabis Use

512 Ayur Health for Dentist’s Wealth

514 Pregnancy Epulis

518 Ludwig’s Angina: A Rare Case Report

522 Management of an Unusual Crown Root Fracture of Mandibular First Primary Molar

526 Follicular Adenomatoid Odontogenic Tumor

529 Sodium Hypochlorite Solution Enhances Healing of Periapical Lesion by Nonsurgical


532 Vital Bleaching with Diode Laser

535 Replantation of Avulsed Tooth after Trauma: A One Year Follow-up Study

Indian Journal of

Multidisciplinary Dentistry

Executive Editor

S Bhuminathan

IJMD’s Editorial Panel


KMK Masthan

IJMD Advisory Board

Volume 2, Issue 3

May-July 2012

Associate Editor

N Aravindha Babu


Mahesh Verma

Srinisha J

Raghavendra Jayesh S

Suresh V Nayar (UK)

Sanjna Nayar

Conservative Dentistry/


Sukumaran VG

Subbiya A

Swaminathan S (Singapore)


John W Thurmond (USA)


Aravind Ramanathan


Abraham Kuriakose M

Oral and Maxillofacial


Ramakrishna Shenoi

Vijay Ebenezer

Raj Kutta (USA)

Oral Pathology and


Vinay K Hazarey

Ipe Vargese V

Puneet Ahuja

Sangeeta P Wanjari

Gouse Mohiddin


Krishna Nayak US

Dhandapani G

Murali RV

Deepak C


Muthiah NS

IJCP’s Editorial Panel

Elumalai M

General Medicine

Rajendran SM


Chandrasekaran SC

Ash Vasanthan (USA)

Oral Medicine and


Nalini Aswath

Panjab V Wanjari

Praveen BN



Krishan Gauba

Ashima Gauba


Julius A


Mahalakshmi K

Dr Sanjiv Chopra

Prof. of Medicine & Faculty Dean

Harvard Medical School

Group Consultant Editor

Dr Deepak Chopra

Chief Editorial Advisor

Dr KK Aggarwal

CMD, Publisher and Group


Dr Veena Aggarwal

Joint MD & Group Executive Editor

Anand Gopal Bhatnagar

Editorial Anchor

IJMD is included in the databases of Genamics Journal Seek, Ulrich International periodical directory,

Index Copernicus International Ltd., HINARI, CINAHL, EBSCO Publishing, Proquest, Chemical Abstracts

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Advisory Bodies

Heart Care Foundation of India, Non-Resident Indians Chamber of Commerce & Industry,

World Fellowship of Religions

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

From the Editor’s desk

From the Editor-in-chief


Dr KMK Masthan

Professor and Head,

Department of Oral Pathology and Microbiology

Sree Balaji Dental College and Hospital


My editorial in the previous issue on academics and research elicited a mixed response ranging from

strong criticisms to “You are stepping on my toes” to surprising applause. My only response to all of

them is what Somerset Maugham once said “It is very hard to be a gentleman and a writer”. In this

issue I write about palliative care since, I was a witness to one patient’s final moments last month. I felt his last

days would have been better if he had received some form of palliative care instead of the well meaning deceit of

his relatives who kept telling him that he was going to get better. Hence, I share what feel about such care with

the readers.

Palliative care is the care given to the dying, encompassing physical, psychological, social and spiritual

dimensions. It is not the efforts of the medical profession alone, but includes the family members and the

society. This is not some thing new and was practised by King Asoka twenty-four centuries back. He had

installed several hospices to attend to the needs of the dying with special care and attention. All countries

face the rapidly increasing burden of patients nearing their end due to cardiovascular disorders, cancers,

diabetes, respiratory diseases, neurological disabilities and psychiatric ailments. In our country especially, certain

factors like extreme changes in lifestyle during the past four decades have brought about higher incidence of

hypertension, diabetes mellitus, cancers due to tobacco chewing and smoking and coronary artery disease due to

junk/fatty food and hence more number of patients facing premature death.

Whereas, we, as Indians, pride ourselves to be more spiritual and religious, the reality is our dying

elders do not get the dignity due to them and the rightful care they deserve. Busy life, mind set, financial

obligations, poverty, trend towards abolition of joint families all contribute to this insensitivity on the part of the

family members and so the due palliative care is not provided to the dying. Another factor that must be mentioned

is the present medical care system including paid hospitals is more geared to cures and alleviation rather than

support and care. The governmental medical care is totally oblivious and frankly resistant to this palliation concept

at all, the common instruction to the patient’s relative being “Take the patient home’’.

In palliative care, most care givers are faced with situations that have obvious solutions, but unsuitable for the

recipient. For example, whether to advise cardio-pulmonary resuscitation for a patient under palliative care. For

a normal person whose heart has failed due to heart attack or electric shock, it is a life saving procedure. But for

a person who is expected to succumb to his/her disease in a few days, is it justified to subject them to this? My

opinion is a definite ‘No’.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


From the Editor-in-chief

The solution is to train community volunteers and to empower them to avail the help of nurses, doctors and

hospices. They can be trained by medical personnel and they can be given access to any other information through

toll free numbers, free on-line training, open access websites and periodic free training at the cost of the NGOs

and government. Even small things like daily visits, emotional support, spiritual counseling, basic patient care

techniques like how to avoid bedsores, advising a suitable diet within the means of the patient, awareness of the

difference between communicable and noncommunicable diseases can help the patient greatly during the last few

days of their life.

One question the care-giver has to face all the time from the patient is “How long will I live?’’. Let us leave all the

mercy and mental agony issues aside and handle this question in a more pragmatic manner. No medical or nonmedical

person can exactly specify when and at what time the patient is likely to die. But patients may have some

goals like settling their properties in the way they choose or seeing their daughters or sons married before they die

etc. Such expectations are not unreasonable and hence the palliative care-giver can clearly inform the patients to

expedite matters on their wishes. Another issue that always hampers the palliative care giver is the pressure of the

close relatives not to tell the patient that the end is nearing. A fair analogy is if I were to be given some money

and am allowed to spend it, without being told only the last few rupees are remaining, will I consider that as fair?

It is always better if we know when we are nearing the end of our resources. So it is more merciful if the patients

were told that their end is nearing. Probably such information will cause a few upset moments.But everyone

knows that when there is birth, there is death. So they will come to terms with it and handle it better.By not

revealing that, we may actually do injustice to the patient. Because he/she might want to speak to certain friends

and relatives, express his/her opinions, concerns and fears better before the end. Another aspect of this revelation

is that the patients may choose not to waste their meagre resources any further on treatments and medicines. If

a person has worked for 20 years earning money for the marriage of his/her daughter, then it is not logical to

let them spend it when the care giver surely knows the outcome. The trouble with concealment is that one can

quite easily drift into deception. I feel minimal levels of wisdom and massive doses of idealism probably lead the

medical professional to adapt this well meaning deceit and frank injustice to the patient. That logic is as circular

as a Mobius strip where an ant can traverse the entire strip without touching edge anywhere. I would welcome

guidance on this multi-faceted issue from the well informed. It is the province of the knowledge to speak and it

is the privilege of wisdom to listen. Now it is time for the readers to speak their mind.

Best wishes.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

From the Desk of IJCP Group Editor-in-Chief


American College of Radiology Five Things

Physicians and Patients should Question

Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee

Sr. Physician and Cardiologist, Moolchand Medcity

President, Heart Care Foundation of India

Group Editor-in-Chief, IJCP Group

Editor-in-Chief, eMedinewS

Chairman Ethical Committee, Delhi Medical Council

Director, IMA AKN Sinha Institute (08-09)

Hony. Finance Secretary, IMA (07-08)

Chairman, IMA AMS (06-07)

President, Delhi Medical Association (05-06)



Krishan Kumar Aggarwal (Facebook)

• Don’t do imaging for uncomplicated headache. Imaging headache patients without specific risk factors for

structural disease is not likely to change management or improve outcome. Those patients with a significant

likelihood of structural disease requiring immediate attention are detected by clinical screens that have been

validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead

to additional medical procedures and expense that do not improve patient well-being.

• Don’t image for suspected pulmonary embolism (PE) without moderate or high pre-test probability. While

deep vein thrombosis (DVT) and PE are relatively common clinically, they are rare in the absence of elevated

blood d-Dimer levels and certain specific risk factors. Imaging, particularly computed tomography (CT)

pulmonary angiography, is a rapid, accurate and widely available test, but has limited value in patients who

are very unlikely, based on serum and clinical criteria, to have significant value. Imaging is helpful to confirm

or exclude PE only for such patients, not for patients with low pre-test probability of PE.

• Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical

exam. Performing routine admission or preoperative chest X-rays is not recommended for ambulatory patients

without specific reasons suggested by the history and/or physical examination findings. Only 2% of such

images lead to a change in management. Obtaining a chest radiograph is reasonable if acute cardiopulmonary

disease is suspected or there is a history of chronic stable cardiopulmonary disease in a patient older than age

70 who has not had chest radiography within six months.

• Don’t do computed tomography (CT) for the evaluation of suspected appendicitis in children until

ultrasound has been considered as an option. Although CT is accurate in the evaluation of suspected

appendicitis in the pediatric population, ultrasound is nearly as good in experienced hands. Since ultrasound

will reduce radiation exposure, ultrasound is the preferred initial consideration for imaging examination in

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


From the Desk of IJCP Group Editor-in-Chief

children. If the results of the ultrasound exam are equivocal, it may be followed by CT. This approach is costeffective,

reduces potential radiation risks and has excellent accuracy, with reported sensitivity and specificity

of 94%.

• Don’t recommend follow-up imaging for clinically inconsequential adnexal cysts. Simple cysts and

hemorrhagic cysts in women of reproductive age are almost always physiologic. Small simple cysts in

postmenopausal women are common, and clinically inconsequential. Ovarian cancer, while typically cystic,

does not arise from these benign-appearing cysts. After a good quality ultrasound in women of reproductive

age, don’t recommend follow-up for a classic corpus luteum or simple cyst


Interferon IRF6 Gene Variants and the Risk of Isolated Cleft lip or

Palate in South Indian Dravidian Population

S Kishore Kumar*, MR Sukumar*, B Saravanan**, Arvind Ramanathan † , M Boominathan ‡


Nonsyndromic clefts of the lip and palate (CL, CP, CL/P) are among the most common congenital defects caused by multifactorial

etiological factors that include both environmental and genetic factors. There is sufficient evidence to hypothesize

that disease locus for this condition can be identified by candidate genes. The purpose of this study is to investigate the

prevalence of mutation in exon 7 of IRF6 gene to determine whether this mutation is implicated in the South Indian Dravidian

population. Material and methods: Blood samples were collected with informed consent from 10 subjects with nonsyndromic

cleft lip/palate and genomic DNA was extracted from the blood samples, polymerase chain reaction was performed and the

products were subjected to direct sequencing. Results: There was a significant positive association between the occurrence of

homozygous valine polymorphic variant and isolated CL, CP and CL or CP (90%, n = 9) relative to heterozygous valine and

isoleucine variant (10%, n = 1) in the present study. Conclusion: The study is clinically significant because it has for the first

time identified the genetic status of exon 7 of IRF6 in Tamil speaking Dravidian population.

Key words: Nonsyndromic cleft lip and palate, IRF6 gene variant, polymerase chain reaction

Development of the head and face comprises

of one of the most complex events during

embryonic development, coordinated by a

network of gene expressions that include transcription

factors and signaling molecules, which confer polarity

of cells. Disturbance of this tightly regulated network

of signaling events may interfere with otherwise normal

cellular function and consequently may result in the

failure of meeting and fusion of the developing facial

primordia, thereby causing orofacial cleft. The extent

of orofacial cleft phenotype varies among the affected

children with some having cleft lip (CL) or cleft palate

(CP) (isolated CL or CP), while the others have cleft lip

with cleft palate (CL/P). Clefts may involve either onehalf

of the oral cavity or both and accordingly they are

classified as unilateral or bilateral clefts. Such orofacial

cleft may either occur as an isolated event (designated as

nonsyndromic) or as a part of complex malformations

(designated as syndromic). Nonsyndromic cleft makes

about 70% of all orofacial clefts, while the remaining




Reader, Dept. of Orthodontics

Principal, Investigator, Human Genetics Laboratory

Postgraduate Student, Dept. of Orthodontics

Sree Balaji Dental College and Hospital, Chennai

Address for correspondence

Dr S Kishore kumar

E-mail: spkishorekumar@yahoo.co.in

30% are accounted for syndrome associated clefts. 1,26,29

The etiology seems complex 2,,3,9,11,12,16 but genetics

plays a major role. 1,4,6,8,15 Various candidate genes have

been associated with nonsyndromal cleft lip/palate

in different populations, but Interferon regulatory

factor-6 (IRF6) is strongly related in various populations

on a consistent basis. 19,20,23,25,27,28 Identification of

etiologic explanation for clefting has included extensive

evaluation of genes. 22

IRF6 belongs to a family of nine transcription

factors that share a highly-conserved helix-turn-helix

DNA-binding domain. The DNA-binding domain

is essential for IRF6 to bind the promoter region of

the genes it regulates (activates). Mutations in IRF6

were first reported in van der Woude syndrome

(VWS). 13 Investigation of the genetic status of IRF6

in nonsyndromic CL/P patients identified common

polymorphic variant G>A at position 820 in the

coding DNA of IRF6 gene. This causes the conversion

of GTC to ATC and creates a valine→isoleucine

substitution at amino acid 274 in the protein-binding

domain of IRF6 gene. 29 GTC encoding valine amino

acid has been found to be significantly associated with

cleft in several populations.

Material and Methods

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


original research

The sample consisted of 10 subjects reporting to the

Dept. of Orthodontics and Dentofacial Orthopedics,

Sree Balaji Dental College and Hospitals, Chennai,

India. The study was carried out after approval from

Institutional Ethical Committee and guidelines from

Helinsiki declaration were followed. Written consents

were obtained from all subjects. Patients with CL or

CP (isolated CL or CP) associated with any history

of developmental disabilities, including learning

disabilities and attention deficits, hearing impairment

and speech deficits or abnormalities were excluded

from the study. Blood samples (1.5 ml) were obtained

from subjects and genomic DNA was purified by

conventional phenol: Chloroform extraction and

ethanol precipitation procedure. A 100 ng DNA was

used as a template to amplify the mutant region in

exon 7 by polymerase chain reaction (PCR) with

the primer sequences mentioned in Table 1. Twenty

microliter l aliquots of amplified PCR products were

subjected to agarose gel electrophoresis in a 1.5%

agarose gel containing ethidium bromide at 100 V

for 30 minutes with 1X TAE (Tris Acetate EDTA)

buffer. The DNA bands were visualized in a long

wavelength UV (364 nm) transilluminator and the

exon 7 specific bands were cut with a clean surgical

blade. Gel blocks containing the exon 7 specific bands

were transferred to a fresh 1.5 ml microcentrifuge tube

and three volumes of solubilization buffer was added.

The tubes were incubated at 55°C for 10 minutes with

intermittent agitation to solubilize the gel blocks. After

the incubation period, 1 gel volume of isopropanol

was added to each tube and mixed by vortex mixer,

following which the contents were transferred to a spin

column. The spin column tubes were centrifuged at

10,000 rpm for one minute at room temperature to

enable binding of the DNA (PCR product of exon

7 of IRF6 gene) to the silica membrane in the spin

columns. The bound DNA was eluted with 40 µl of

elution buffer and 10 ng of the eluted product was

Table 1. IRF6 Exon 7 Mutant Region Primers

Set 1

Sequence Length (T.M*)

Left primer 19 57.35


Right Primer 18 57.47


sequenced with sequencing grade primers (A*STAR

facility, Singapore).


DNA size marker

Lane # 1 2

500 bp

400 bp

300 bp

200 bp

100 bp

Figure 1. Initial PCR product of IRF6 gene (353 bp).

A 100 ng aliquot of the total genomic DNA was used

as template to amplify the exon 7 of IRF6 gene, which

is known to carry the genetic mutation in CP patients

in other races. The mutation converts ‘GTC’, which

is the genetic code for ‘valine’ amino acid to ‘ATC’

the genetic code for ‘isoleucine’ amino acid. In order

to analyze for the presence of the above mutation, we

downloaded the sequence of IRF6 coding region from

the public domain database and designed the primers

to specifically amplify exon 7 (Table 1). Amplifications

in all the samples were of the expected size

(353 bp) and a representative of two samples is shown in

Figure 1 (lanes 1 and 2).

Identification of Genetic Polymorphism in

Exon 7 of IRF6 Gene

A 2 µl aliquot of the eluted DNA was sequenced in

a 20 µl reaction volume and the sequenced data was

analyzed with BioEdit software. The genetic code GTC

that encodes for valine amino acid was found in all the

patients, while ATC that encodes for isoleucine was

not found as an isolated event in any of the patients.

However, ATC occurred in heterozygous state along

with GTC in one of 10 samples (10% of samples)

that were analyzed. There was a significant positive

association between the occurrence of homozygous

valine polymorphic variant and isolated CL, CP and

CL/CP (90%, n = 9) relative to heterozygous valine and

isoleucine variant (10%, n = 1). The data was further

analyzed for the distribution pattern of homozygous


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

original research

valine or valine and isoleucine in heterzygous state in

each of the conditions - isolated CL or isolated CP

or CL with CP. Valine/Valine homozygous vairant was

found in 20% (n = 2) of isolated CL, 0% (n = 0) of

isolated CP and 70% of CL with CP (n = 7), while

valine/isoleucine heterozygous variant were found to

be 10% (n = 1) in isolated CL, 0% (n = 0) in isolated

CP and 0% (n = 0) in CL with CP.

Taken together valine/valine homozygosity was

significantly associated with clefting relative to valine/

isoleucine heterozygosity. This pattern is consistent with

a recessive effect of the valine allele, which requires to

be in homozygous condition to cause orofacial cleft.

While in the heterozygous state, the valine allele being

recessive may not be able to cause orofacial cleft in the

presence of a normal isoleucine allele.


A total of 10 patients of tamil speaking dravidian race,

with isolated nonsyndromic CL, CP or CL/CP were

screened for genetic polymorphism (silent mutation)

in exon 7 of IRF6 gene. The polymorphism converts

GTC that encodes for valine amino acid to ATC,

which encodes for isoleucine amino acid. The screen

identified valine (GTC) in 90% (n = 9) of patients

with CL, CP or CL/CP and both valine (GTC) and

isoleucine (ATC) in heterzygous state in 10% (n = 1) of

them. None of them were found to carry homozygous

isoleucine (ATC) variant.

The IRF6 gene has been shown to be mutated in

patients with VWS and/or Popliteal pterygium

syndrome (PPS) in several populations. 13,17 VWS is

a dominantly inherited disorder characterized by the

presence of pits and/or sinuses on the lower lip in 85%

of cases, CL/P in 50% of the patients and hypodontia

in 20% of them. 7,14,18,21,24 PPS is a less frequent allelic

orofacial clefting disorder. In addition to the signs of

VWS, PPS includes webbing of the knee, syndactyly

(or absence) of the toes and digits, ankyloblepharon,

syngnathia and genital abnormalities. 5 More than 59

different mutations in IRF6 gene have been reported,

which includes silent mutations in protein-binding

domain, frame-shift and nonsense mutations and

deletions all of which either alter or render the protein

functionless. 2,10

IRF6 is expressed at key stages of facial development

in mouse embryos. Specifically, a high level

of IRF6 expression is detected in the ectoderm covering

the facial processes during their fusion to form the

lip and primary palate. Zucchero et al investigated

the prevalence of mutations in IRF6 gene in patients

with nonsyndromic CL, CP or CL/CP, by sequencing

the entire coding region of the IRF6 gene. The study

found strong evidence of overtransmission (67%) of

the valine (GTC) variant at position 274 relative to

isoleucine (ATC) variant in IRF6 protein in Japanese,

Chinese, Vietnamese and Filipino populaiton but not

in Europeans and Indians. 29 In the present study, we

have analyzed a cohort of 10 patients of tamil speaking

dravidian race with CL, CP or CL with CP and found

valine variant to be transmitted in 90% of them

(p ≤ 0.05). When the data was analyzed for stratified

distribution of valine/valine alleles in isolated CL or CP

or CL with CP, the association was found to be significant

relative to valine/isoleucine heterozygous alleles.

Summary and Conclusion

The present study, however, has to be interpreted

carefully since it did not involve analysis of IRF6 gene

from normal individuals. The distribution of valine/

valine and valine/isoleucine alleles in normal individuals

is required to arrive at a more affirmative conclusion.

Nevertheless, the present study has helped us to

understand the genetic status of exon 7 of IRF6 in the

tamil speaking dravidian race. Besides we also made an

interesting observation that 10% of the patients that

we examined carried both valine/isoleucine alleles in

heterozygous state, which is in contrary to Zucchero

et al study 29 who reported this to be rare event in the

Indian population. This may be explained by the fact

that the patients that we investigated were from tamil

speaking dravidian race, while those that were analyzed

by Zucchero et al were from West Bengal.





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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Role of ‘Live Microorganisms’ (Probiotics) in Prevention of

Caries: Going on the Natural Way Towards Oral Health

Vineet Agrawal*, Sonali Kapoor**, Nimisha Shah †

*Senior Lecturer


Dept. of Conservative and Endodontics, MP Dental College and Oral

Research Institute, Vadodara

Professor, Dept. of Conservative and Endodontics, KM Shah Dental

College, Vadodara

Address for correspondence

Dr Vineet Agrawal

E-mail: vineetdent@yahoo.co.in


Science is providing us the tools to diagnose and treat an infection before it causes damage. For some decades now, bacteria

known as probiotics have been added to various foods because of their beneficial effects for human health. Very encouraging

studies have come up in recent past exploring probiotics in fields of caries, periodontal diseases and few other areas and the

results tend to suggest beneficial effects of probiotics on oral health and on whole body in general. The application of probiotic

strategies may, in near future, provide an end to many infections occurring in oral cavity. This article reviews the probiotic

approaches, such as genetically modified Streptococcus mutans and targeted antimicrobials in the prevention of caries and

discuss its future directions.

Key words: Probiotics, dental caries, prevention, Bifidobacterium, Lactobacillus


D Miller first described dental caries as a

bacterially-mediated process more than

100 years ago. 1 Today, we know that dental

caries is a multifaceted disease process. Several models

have been put forward describing mechanism of caries

formation. One of the earlier models that is familiar

to most dentists was put forth by Fitzgerald and

Keyes. 2 They used three overlapping circles describing

the host, bacteria and nutrients required to foment

the production of organic acids and the subsequent

demineralization activity. The beauty of this model is

that all three elements must be present for the disease

to progress. Since all three are required for disease

initiation and progression, removal of any one element

ostensibly leads to the interception of the disease


The surgical approach has been the predominate

mode of caries management for the past 150 years.

Dentistry has, however, in recent years moved

toward an antibiotic/antimicrobial model of disease

management. This approach, however, raises serious

questions: 1) Do the antibiotic/antimicrobial agents

Review article

(chlorhexidine, povidone-iodine, fluoride, etc.) kill

all offending organisms?; 2) if so, do the agents

preclude the re-entry of the same organisms from

external sources? and 3) if the agents do kill all the

offending organisms, do any remaining pathogenic

organisms have selective advantage in repopulating the

tooth surfaces? To overcome the problems inherent

in an antibiotic/antimicrobial approach, probiotic

methods are currently under study as means of caries


What are Probiotics, Prebiotics and


The term ‘probiotic’ is derived from the Latin preposition

pro (‘for’) and the Greek adjective (biotic), the latter

deriving from the noun (bios, ‘life’). 3 It was first used

by Lilly and Stillwell in 1965 to describe “substances

secreted by one microorganism, which stimulates the

growth of another” and thus was contrasted with the

term antibiotic. 4 Today, two main definitions are used.

According to a WHO/FAO report (2002), probiotics

are “live microorganisms which, when administered in

adequate amounts, confer a health benefit on the host”.

International Life Science Institute (ILSI) Europe

suggests a definition according to which a probiotic is

“a live microbial food ingredient that, when ingested

in sufficient quantities, exerts health benefits on the

consumer”. Probiotics are microorganisms, basically

bacteria, that when ingested would confer health

benefit beyond the basic nutrition. 5

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

The term prebiotic was introduced by Gibson and

Roberfroid who exchanged ‘pro’ for ‘pre’ which

means ‘before’ or ‘for’. They defined prebiotics as a

“nondigestible food ingredient that beneficially affects

the host by selectively stimulating the growth and/or

activity of one or a limited number of bacteria in the

colon.” 6 More specifically, prebiotics are short-length

carbohydrates, such as fructooligosaccharides, that

resist digestion in upper gastrointestinal tract or are

fermented in the colon to produce short-chain fatty

acids, such as acetate, butyrate and propionate, which

have positive effects on colonic cell growth and stability,

generate many of the same bacteria as provided in

probiotics. 7

The term synbiotic is used when a product contains

both probiotics and prebiotics. According to this

approach, a food or food supplement will include both

the live cells of the beneficial bacteria and the selective

substrate. The idea being that the beneficial bacterial

cells can grow quickly and competitively because of

the presence of selective substrate and establish their

predominance. 6

Table 1. Possible Mechanism of Probiotics in Oral


Production of antimicrobial substances

Organic acids

Hydrogen peroxide


Binding in oral cavity

Compete with pathogens for adhesion sites

Involvement in metabolism of substrates (competing with

oral microorganisms for substrates



Stimulate nonspecific immunity

Modulate humoral and cellular immune


Modify oral conditions

Modulating pH

Modification of oxidation reduction potential

Mechanism of Probiotics

Probiotics can help prevent and treat disease through

several mechanisms. 8

• Direct interaction: Probiotics interact directly

with the disease-causing microbes, making it

harder for them to cause the disease.

• Competitive exclusion: Beneficial microbes

directly compete with the disease, developing

microbes for nutrition or enterocyte adhesion


• Modulation of host immune response: Probiotics

interact with and strengthen the immune system

and help prevent disease.

In oral cavity, probiotics tend to create a biofilm,

acting as a protective lining for oral tissues against oral

diseases. Such a biofilm keeps bacterial pathogens off

oral tissues by filling a space, which could have served

as a niche for pathogens in future; and competing with

cariogenic bacteria. Table 1 describes the mechanism

of action of probiotics in oral health. 9

Potential Benefits of Probiotics

Probiotics have traditionally been used for prevention

of colon cancer, 10 lowering cholesterol, 10 lowering blood

pressure, 10 managing lactose intolerance, 11 Helicobacter

pylori, 12 improving immune function and preventing

infections, 13 antibiotic-associated diarrhea, 14 reducing

inflammation, 15 improving mineral absorption, 15

preventing harmful bacterial growth under stress, 16

irritable bowel syndrome and colitis, 16 and managing

urogenital health. 16

Common Strains Used in Oral Probiotics

The most commonly-used probiotic strains belong

to the genera, Lactobacillus, Bifidobacterium, 17 and

Streptococcus. 18 Streptococcus salivarius, Streptococcus

mitis and Streptococcus sanguinis showed a significantly

more pronounced reduction in total anerobic bacteria,

black-pigmented bacteria and Campylobacter rectus.

Probiotic strains of Lactobacillus species include

L. salivarius, L. reuteri, L. acidophilus, L. fermentum,

L. lactis, L. helveticus and L. rhamnosus. Lactobacilli

produce different antimicrobial components, such as

organic acids, hydrogen peroxide, low molecular weight

antimicrobial substances, bacteriocins and adhesion

inhibitors. Similarly, Bifidobacterium strains include

B. bifidum, B. longum and B. infantis. 19


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

Administration of Probiotic

Different means of probiotic administration for oral

health purpose are: 20

• A culture concentrate added to a beverage or food

(such as a fruit juice)

• Inoculated into prebiotic fibers

• Inoculants into a milk-based food (dairy products

such as milk, milk drink, yoghurt)

• Yogurt drink, cheese, kefir, biodrink

• As concentrated and dried cells packaged as dietary

supplements (nondairy products)

• Such as powder, capsule, gelatin tablets.

Role of Probiotics in Dental Caries

A number of researchers are developing ‘probiotic’

methods to treat the caries causing pathogens. ‘Probiotic’,

as used here, means that mechanisms are employed to

selectively remove only the (odonto) pathogen while

leaving the remainder of the oral ecosystem intact. 21

One of the replacement therapy options entails the

application of a genetically engineered ‘effector strain’

of S. mutans that will replace the cariogenic or ‘wild

strain’ to prevent or arrest caries and to promote optimal

remineralization of tooth surfaces that have been

demineralized but that have not become cavitated.

In caries, there is an increase in acidogenic and acid

tolerating species such as mutans streptococci and

lactobacilli, although other bacteria with similar

properties can also be found like Bifidobacteria,

nonmutans streptococci, Actinomyces spp.,

Propionibacterium spp., Veillonella spp. and Atopobium

spp. Use of probiotics and molecular genetics to replace

and displace cariogenic bacteria with noncariogenic

bacteria has shown promising results. These studies

have employed different approaches: 22

• Early studies concentrated on utilizing bacteria that

expressed bacteriocins or bacteriocin-like inhibitory

substances (BLIS) that specifically prevented the

growth of cariogenic bacteria.

• One approach has been to identify food grade and

probiotic bacteria, which have ability to colonize

teeth and influence the supragingival plaque.

• Also, strains have been screened for suitable

antagonistic activity against relevant oral bacteria.

• Another approach utilized recombinant strain of

S. mutans expressing urease, which was shown to

reduce the cariogenicity of plaque in an animal


• Similarly, genetically modified probiotics with

enhanced properties can be developed (‘designer

probiotics’). For example, a recombinant strain

of Lactobacillus that expressed antibodies

targeting one of the major adhesions of S. mutans

(antigen I/II) was able to reduce both the viable

counts of S. mutans and the caries score in a rat


• A different way of accomplishing the removal of the

pathogens is to develop ‘targeted antimicrobials’.

The basic idea is to develop an inexpensive

targeting molecule that will reliably attach to only

the organism of interest, in this case S. mutans,

S. sobrinus or other chosen pathogen. Once the

targeting molecule is perfected, then a ‘killer’

molecule is optimized and chained to the targeting

molecule. The combined unit then selectively

eliminates the infection of interest. In the case

of the oral cavity and dental caries, this system is

attractive from the perspective of eliminating all

the pathogens thereby precluding the regrowth

of the original infection. There is also compelling

evidence from clinical trials and laboratory efforts

demonstrating that once the bacterial ecosystem

is free of S. mutans, it is difficult to reintroduce

the organisms (another competitive inhibition

situation). 21,22

Various Studies Involving Probiotics for

Decreasing Dental Caries

Considering the growing body of evidence about

the role of probiotics on caries pathogens, however,

it has been suggested that the operative approach in

caries treatment might be challenged by probiotic

implementation with subsequent less invasive

intervention in clinical dentistry and thus, recently,

many studies are been carried on probiotics.

The first randomized, double-blind, placebo-controlled

intervention study, 23 examining the effect of milk

containing L. rhamnosus GG on caries and the risk

of caries in children when compared with normal

milk was completed in 2001; the study included

594 children, 1-6 years old, who consumed milk

for seven months. Probiotic milk was able to reduce

S. mutans counts at the end of the trial and a

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

significant reduction of caries risk was also observed.

L. rhamnosus is one of the most extensively studied

probiotic and of particular interest in oral biology

since it does not readily ferment sucrose and is safer for

teeth than lactic acid-producing bacteria. Controlled

studies have shown the effectiveness of L. rhamnosus

in reducing caries. L. rhamnosus was found to inhibit

cariogenic S. mutans but colonization of oral cavity by

L. rhamnosus seems improbable. 24 A study aimed at

benefit of cheese containing L. rhamnosus showed that

probiotic intervention helped in reducing the highest

level of Streptococcus mutans. 25

In order to assess whether naturally occurring oral

lactobacilli have probiotic properties, lactobacilli were

isolated from saliva and plaque from children and

adolescents, with or without caries lesions. Twenty-three

Lactobacillus spp. completely inhibited the growth of

all mutans streptococci tested. Species with maximum

interference capacity against mutans streptococci

included Lactobacillus paracasei, Lactobacillus plantarum

and L. rhamnosus. 26

Calgar et al (2006) investigated the effect of probiotic

bacterium L. reuteri on levels of mutans streptococci

and lactobacilli, which was introduced by two different

straw containing L. reuteri and lozenges containing

L. reuteri and concluded that short-term daily ingestion

of lactobacilli-derived probiotics delivered by prepared

straws or lozenges reduced the levels of salivary mutans

streptococci in young adults. 27

Comelli et al (2002) studied 23 dairy bacterial strains

for the prevention of dental caries and reported that

only two strains namely Streptococcus thermophilus and

L. lactis were able to adhere to saliva-coated

hydroxyapatite and were further successfully

incorporated into a biofilm similar to the dental

plaque. Furthermore, they could grow together with

five strains of oral bacterial species commonly found in

supragingival plaque. In this system, L. lactis was able

to modulate the growth of the oral bacteria, and in

particular to diminish the colonization of Streptococcus

oralis, Veillonella dispar, Actinomyces naeslundii and of

the cariogenic S. sobrinus. 28

Few studies have reported reduction in mutans

streptococci levels in saliva following use of probiotic

containing yoghurts but it is not clear whether this

decrease is due to the bactericidal activity of yoghurt

or other mechanisms. Petti et al (2008) investigated

the differences in susceptibility of strains of viridians

streptococci. In vitro, yoghurt with live bacteria showed

selective antimutans activity, suggesting that the overall

decrease in mutans streptococci in vivo could be due to

a bactericidal effect on S. mutans. 29

Calgar et al (2007) evaluated the effect of xylitol and

probiotic chewing gums on salivary mutans streptococci

and lactobacilli and concluded that daily chewing on

gums containing probiotic bacteria or xylitol reduced

the levels of salivary mutans streptococci in a significant

way. However, a combination of probiotic and xylitol

gums did not seem to enhance this effect. 30

Kang et al (2006) did a study in which they found

out that the water-soluble polymers produced from

sucrose by the Weissella cibaria isolates inhibited the

formation of S. mutans biofilm. In the clinical study,

the subjects mouthrinsed with a solution containing

W. cibaria CMS1 and exhibited plaque index reduction

of approximately 20.7%. 31

To study the effect of bifidobacteria a doubleblind,

randomized crossover study was performed.

A statistically significant reduction of salivary mutans

streptococci was recorded after the probiotic yoghurt

consumption containing Bifidobacterium, which

was in contrast to the controls. A similar trend was

seen for lactobacilli, but this decrease failed to reach

statistical significance. Investigators concluded that

probiotic bifidobacteria in yoghurt may reduce the

levels of selected caries-associated microorganisms in

saliva. 18 In a similar study using Bifidobacterium lactis a

statistically significant reduction (p < 0.05) of salivary

mutans streptococci was recorded after consumption

of the probiotic ice-cream in adults. 32


Concept of probiotics is emerging as a fascinating

field and it prompts a new horizon on the relationship

between diet and oral health. Probiotic strategies are

part of the continuing evolution of the treatment of

oral infection that produces the clinical manifestations

of dental caries. As a profession, we are slowly moving

away from the purely surgical approach to treating this

disease. Science is providing us the tools to diagnose

and treat the infection before it causes damage.

The application of probiotic strategies may, in the


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

not-distant future, provide the end of new cavities in

treated populations.

Future Directions

Probiotics can be used as passive local immunization

against dental caries. High titers of antibodies can

also be directed against human cariogenic bacteria

produced in bovine colostrum over the vehicle of

fermented milk.

Studies have been largely conducted in animals, and

human studies have not been of sufficient duration to

assess the impact on caries. Most studies on the effects of

probiotics on caries prevention are aimed at decreasing

the number of mutans streptococci. Primarily probiotic

Lactobacillus and Bifidobacterium strains have been

used along with few more strains. Unfortunately, in

most cases, the study groups were relatively small, and

the studies were fairly short. Preliminary data obtained

has been encouraging, but numerous randomized

clinical studies will be required to clearly establish the

potential of probiotics in prevention of dental caries.

Also complete understanding of the broad ecological

changes induced in the mouth by probiotics or

prebiotics will be essential to assess their long-term

consequences for oral health and disease.










Miller W. Micro-organisms of the Human Mouth. SS

White; Philadelphia, 1890.

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Hamilton-Miller JM, Gibson GR, Bruck W. Some

insights into the derivation and early uses of the word

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de Vrese M, Schrezenmeir J. Probiotics, prebiotics, and

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Meurman JH. Probiotics: do they have a role in oral

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Szajewska H, Ruszczyński M, Radzikowski A. Probiotics

in the prevention of antibiotic-associated diarrhea in

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Minisola G. Probiotic lactobacilli: an innovative tool to

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Reid G. Probiotic agents to protect the urogenital

tract against infection. Am J Clin Nutr 2001;73(2


Comelli EM, Guggenheim B, Stingele F, Neeser JR.

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health. Eur J Oral Sci 2002;110(3):218-24.

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Yli-Knuuttila H, Snäll J, Kari K, Meurman JH.

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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Oral Health and Wellness on Wheels!!!

Review article

R Sushma*, D Nagabhushana**


Fully equipped mobile dental clinics provide on-the-spot diagnostic, preventive, interceptive and curative services to the

doorsteps of the underprivileged, rural population. It’s an innovative, on-site, dental outreach provider to bring state of

the art, preventive dental care to those in need in the most comfortable and effective way possible.

Key words: Mobile dental service, outreach program, mobile dental unit, portable dentistry

The greatest equity of access is said to exist

when need, rather than structural or individual

factors determine who gains entry to the

healthcare system.

Healthcare is a right, not a privilege but is healthcare


Basic oral care facilities should be accessible to every

individual since oral health is an important and crucial

part of one’s overall health and wellness. Over the ages,

oral healthcare has been delivered to the community,

in different ways. The horse back dentistry of olden

days has evolved into the most modern painless dental


All over the world, different countries have different

healthcare delivery systems. In our country, different

state governments have established the dental clinics

at different levels from the state capitals to rural areas,

where salaried dentists give dental treatment. In India

70% of the dentists practice in urban areas and we

seldom find dental clinics in rural areas except for a few

government establishments, which lack the required


Providing universal health insurance coverage and

developing integrated delivery systems may fail to

*Lecturer, Dept. of Public Health Dentistry

**Reader, Dept of Oral Medicine and Radiology

JSS Dental College and Hospital, JSS University, Mysore, Karnataka

Address for correspondence

Dr R Sushma

E-mail: hisushhere@yahoo.co.in

provide universal access. Fully equipped mobile dental

clinics to provide effective dental care to the doorsteps

of the underprivileged, rural population is the need

of the hour. A mobile dental clinic offers dentists

the freedom to offer patients access to care whenever,

wherever. 1

The most persistent problems in healthcare, especially

rural healthcare are:

• Provider shortages

• Fragmented delivery systems

• Cultural and language barriers

• Uninsured populations

• Geographic isolation.

These are just some of the challenges to be

encountered. 2

With the help of dedicated professionals, volunteers

and community support ‘creative solutions’ can provide

vital services to the communities through outreach


Need for Mobile Dental Service

Areas where services do not exist and people are in real

need of it:

• Rural and frontier residents

• The disabled

• The frail elderly

• At-risk pregnant women and their infants and


• The homeless, poor.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

How Mobile Services Started with


In the early 1970s when dentistry was in its infancy,

introduction of public health dentistry initiated the

need for making dental students aware that there

are people who are beyond the reach of available

services. The objective was to expose students to work

in rural setup of country, so that they will be able to

work in rural areas after graduation. This was the act

of reaching out. With this exposure, students enjoyed

working for the needy people, saw more patients, felt

like real dentists and came in contact with other health


Mobile Dental Units are Used in many

Ways and Many Places

• School programs (children)

• Retirement homes (elderly)

• Small communities (rural)

• Corporate (employees)

• Community agencies

• Organizations

• Families in need of oral health services.

The general concept is to drive the ‘clinic on wheels’

to residents of outlying communities where limited

resources and travel are obstacles for receiving timely

dental care. 3

Mobile Dental Clinic is Involved in the

Following Activities 4

Community Programs

• Training of dental students in community dental


• Community awareness and oral health promotion

Dental Services

• Dental check-up and treatment


• Oral health surveys

• Screening of oral diseases

Mobile Dental Clinic 5,6


• Moderate start up costs

• It addresses the problem of transportation to the


• It decreases missed appointments when run in

conjunction with schools

• Services can be made available at multiple sites

• Services are made available to the needy


• Excellent patient attendance

• Treat child without parent

• Transportation issues eliminated


• High maintenance costs

• Difficult to access and store patient records

• Provides limited services and follow-up may be


• Requires permission for site use

• High administrative needs

• High productivity difficult

• Location of appropriate parking

• Patient record access/storage

• Computer and phone access difficult

• Multiple weather related problems

Factors to be Considered to Pursue a

Mobile Unit

Purchasing a mobile unit to deliver healthcare services

can be an expensive undertaking for anyone interested

in pursuing this option. Yet, little information is found

in the literature on planning or designing such vehicles.

A set of guidelines could help administrators to make

better decisions regarding this approach for delivering

healthcare. 7

The process of deciding to pursue a van purchase is

complicated, and administrators may best be served by

obtaining experienced consultants to help them fully

comprehend the issues involved. After the decision to

purchase a mobile unit is made, it is necessary to focus

on van requirements and design. 8

The mobile dental clinic should be equipped with two

dental chairs with all attachments and seating space for

15-20 people. 9

• Equipments to be fitted inside the clinic. 10,11

• Dental chair-Hydraulically operated dental chair

with water connection, spittoon and tumbler.

• Air ventury suction with flow control valve, auto

drain and auto flush system.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

• Aerotor, micromotor and scaler with three scaling


• 3-way-syringe.

• Light cure unit with gun, eye protection shield.

• Multifunctional foot control

• Transparent water booster

• Basin

• Stainless steel instrument tray

• X-ray viewer.

• Dental operator’s stool

• Operating light with two intensity, fixed with

hinge on the top of the Van

• Dental X-ray unit 70 KV, 8 mA with digital arm

timer and day light manual developer.

• Autoclave

• High speed automatic instrument autoclave with

digital timer for wet and cycles, which can achieve

135°C, minimum capacity of 20 lt. Screw type

handle for the door locking to prevent sudden

opening of the door.

• Glass bead sterilizer; Portable, easy to handle with

a very low current consumption. Instruments may

be kept only for 10-30 seconds and will be ready

for use.

• Metal cabinets with wash basin

• Portable dental unit

• Compact compressor: Built in 0.25 HP oil-free,

medical grade Monobloc compressor fitted with

auto head air release valve, safety release valve and

over heat thermo cut off.

• Stabilizer: Highly accurate stabilizer of 4 KV.

It should have high correction speed with the

input range of 170-270 V and output range of

220/230 V.

• Generator: It should be a portable generator with

4 KVA capacity with petrol start and run

• Water Tank: 400 lt capacity

• Oxygen cylinder

• Public address system

• TV and DVD player

• Health education models

The mobile clinic requires a garage with proper security.

The driver has to be full time and an integral part of

the care delivery team.


The focus should be on reducing the major disparities

in oral health status and inequities in access to oral

healthcare, while providing the highest caliber of

dentistry for patients in a highly efficient manner. Most

developing countries cannot afford to build adequate

modern healthcare infrastructures to be accessed by

every citizen. The key to a successful dental practice is a

cohesive dental team, which will create an atmosphere

of cooperation resulting in the achievement of the goal

of oral health.

In order to provide dental health curative and

restorative services along with primary prevention of

dental diseases, it is proposed that there should be well

equipped mobile dental clinics so that the services can

be rendered to the rural masses at their doorsteps, more

so in various remote and inaccessible areas. 12














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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review article

Programmed Self-cell Suicide (Apoptosis) – Current Review,

Concepts and Future Prospects

JP Rajguru*, KMK Masthan**, TS Thirugnanasambandan † , N Aravindha Babu ‡


Homeostasis of tissues depends upon cell division and proliferation. Well-organized or programmed cell death (apoptosis) is

an intrinsic mechanism of our human body playing in various physiological and pathological processes during evolution. This

type of programmed cell death (PCD) is essential for development of highly cellular organisms. Apoptosis plays a major role

in embryogenesis and many diseases like neoplasia, necrosis, acquired-immunodeficiency syndrome (AIDS) and neurogenic

disorders. It releases new essential activated death receptors and mitochondria, which are the beginning of the pathway proposed

for initiating apoptosis. This process is regulated by intra-and extrasomatic signals. Damage of cell results in activation of

a family of caspases (CASP). Caspases are released by inactivated proenzymes activating various organelles in cytosol and

nucleus. This leads to cellular monopoly change and cell death. Uncontrolled mechanisms of signals lead to pathology in the

body. Hence, clinically much pathology is the ultimate result of either increased or decreased apoptosis.

Key words: Apoptosis, necrosis, clinical considerations

Apoptosis (programmed cell death) is a Greek

terminology, meaning “falling of leaves from

tree”. Earlier, it was known as physiological cell

death. Kerr and co-worker (1972), 1 coined the term

Apoptosis. It is a well-organized regulated mechanism

in eukaryotes during the process of embryogenesis.

It is also known as cellular self-destruction; cell self

suicide or programmed cell death (PCD). 2 Apoptosis

is mandatory for normal physiological development

and removal of transformed cells. 3,4 Genetically, it is

a controlled process regulated by complex molecular

signaling systems. In this system, cells undergo change

an organized fashion, an energy-dependant enzymatic

breakdown resulting in cellular fragments. DNA

fragmentation, chromatin condensation, blebbing of

cellular membrane, cell shrinkage and apoptotic bodies

known as Councilman bodies are seen. These fragments


Senior Lecturer, Dept. of Oral Pathology

Saraswati Dental College and Hospital, Lucknow


Professor and Head, Dept. of Oral Pathology and Microbiology

Sree Balaji Dental College and Hospital, Chennai

Professor, Dept. of Oral Pathology

Rajah Muthiah Dental College and Hospital

Annamalai University, Chidambaram

Professor, Dept. of Oral Pathology and Microbiology

Sree Balaji Dental College and Hospital, Chennai

Address for correspondence

Dr JP Rajguru

E-mail: drgurumdsop@gmail.com

are degraded and phagocytosed. 5 Programmed

cell death plays a central role in etiopathogenesis

of human diseases. When apoptotic process is

suppressed, overexpressed or mutated, the imbalanced

or uncontrolled apoptosis leads to pathology of human

diseases. Ischemic cell death can cause nuclear as well as

cytoplasmic swelling and karyolysis. Normal stimulus

are absent in apoptosis but can be seen in necrosis

as shown in Table 1. This mechanism will also cause

disordered apoptosis as shown in Table 2.

Difference between Apoptosis and


Self-suicide is an organized program, through which

unstipulated or destroyed cells undergo destruction with

activated genes. 7 It results in shrinkage of cell, cellular

detachment and fragmentation of bodies preserving

the membrane. Glueksmann distinguished between

apoptosis (physiologically natural cell death) and necrosis

(accidental cell death due to injury or toxins) as shown

in Table 2. 8 Ischemic cell death leads to cytoplasmic

and nuclear swelling. Apoptosis process results in

phagocytosis. 9-12 To overcome noxious stimulus (toxins/

ischemia) cells undergo cell aging and necrosis. 13 On

the other hand, apoptosis refers to cell death occurring

during normal embryogenesis of immature organs and

the maturation of tissues or organs. 14


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

Table 1. Apoptosis vs Necrosis


Late loss of membrane


Asynchronous process in

single cells

Genetically controlled

Physiological and


No inflammatory reaction

Cell shrinkage

Condensation of nuclear


Table 2. Apoptotic Genes

Pro-apoptotic genes

P 53

Bcl-xl, Bax, Bak, Bad




Early loss of membrane integrity

Occurs synchronously in multiple


Caused by overwhelming

noxious stimuli

Always pathological

Inflammatory reaction

Generalized cell and nucleus


Nuclear chromatin disintegration

Anti-apoptotic genes



Caspases family ---


Apoptotic Incentive 17,18

Four group of stimuli are found, which includes group

stimuli: I, II, III, IV.

Group I stimuli includes ionizing and alkylating

agents. They will further induce DNA damage.

Group II stimuli cause apoptosis by stimulation of

death receptors. Group III stimuli include biochemical

agents, which will increase the downstream components

of apoptotic pathway. (e.g.), (phosphatase and kinase

inhibitors including calphotin C). Group IV stimuli

may cause cell boundary damage either by heat, light

and oxidizing agents. If the dose increases, then it may

cause necrosis.

PCD (apoptosis) is a multidirectional process. The

genes activity and mediators influence the cell’s likelihood

of activating it`s self-death programmers. If the

decision phase is properly executed then cell death may


Mechanism 19-21

Apoptosis is an unexplored highly complicated process.

Decision of cell death is not a light mechanism.

Apoptosis process involves two pathways.

Pathway of Apoptosis

It consists of two mechanisms: (Fig. 1)

Apoptosis includes three phases.

• In first phase, cells get detached from its

substratum and adjacent cells. There will

be absence of microvilli and desmosomes. 15

Fragmentation of DNA by specific endonucleases

gets packed into vesicles. We can observe strand

breakage and nuclear chromatin condensation.

The rough endoplasmic reduction (RER) and

smooth endoplasmic reduction (SER) swells and

cell becomes dense and shrinkage of cytoplasm

is seen.

• In second phase, cell produce cell buds by

breaking into multiple membranes and result in

apoptolic bodies.

• In third phase, the permeability of cell membrane

is increased to stain. Later, the apoptotic bodies are


The duration of this mechanism is around 15-25

minutes. 16

Figure 1. Pathway or mechanism of apoptosis.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

• Activation of cell surface death receptors - extrinsic


• Release of cytochrome C from mitochondria -

intrinsic phase.

Activated Cell Surface Death Receptorinduced

Apoptosis: (Extrinsic Phase)

Apoptosis-induced cell surface death receptors are

Fas and tumor necrosis factor (TNF). Fas receptor

is CD95 or APO-1. It is a cytoplasmic protein. It is

activated by binding of Fas legend to cell membrane.

This mechanism is very important in regulating

immune response cytototoxic T lymphocytes and

induces apoptosis. TNF receptor systems show some

differentiation in biochemical pathway. TRIAL (TNFrelated

apoptosis inducing legend) binds to TNF

receptor system and form TRADD (TNF receptor

associated death domain) by following two phases.

Judgment Phase

Important genes, which control apoptosis, are Bcl-2

andp53. Bcl-2 is oncogene 22 and blocks apoptosis. 23

It is also known as cell death suppressor gene.

It directly regulates apoptosis. If the concentration

of Bcl-2 is increased, it prevents apoptosis. Apoptosis

induced death receptors are:

• TNF receptors - TNF receptors system

• FAS receptor

Fas receptor is also known as CD95/APO-1. It is a

transmembrane glycoprotein death receptor. It is

activated by binding Fas legend (Fas-L) to cell molecule.

FADD (Fas-associated death domain) is produced.

These are necessary for controlling immune response

of cytotoxic T lymphocytes and apoptosis.

TNF receptors systems mediate another biochemical

pathway. TNF-related apoptosis inducing legend

(TRAIL) fix to TNF receptor system and create TRADD

(TNF-receptor associated death domain) through two

phases. Two genes are going to regulate the apoptosis

(1) Bcl-2 (2) p53. Bcl-2 is an oncogene or cell death

suppressor gene, because it may suppress apoptosis.

Families of Bcl-2 are - Bcl XL

, Bax, Bak and Bad. They

promote Apoptotic - Proapoptotic proteins. 24 Bcl-2 and

Bcl-XL, present apoptotic - proapoptotic proteins. All

cells depend upon proapoptotic or else antiapoptosis

prevails. P53 gene is a 53 Kda nuclear phosphoprotein,

Table 3. Apoptosis-induced in Various Condition

Decrease apoptosis


Follicular lymphoma

Carcinoma With P 53 Mutations

Autoimmune disorders

Viral disorders

Herpes viruses

Pox viruses


which is seen in chromosome mutation of P 53 . These

genes are predominant in 50% of human cancers and

are associated with resistance to treatment. 25 It is a

proapoptotic mediator. If there is any DNA damage,

then p53 restrict the replication and gives sufficient

time for repairing of the cell. If cell repair can’t be done,

apoptosis will be induced preventing multiplication

of the damaged cell. Cell arrest is quite impossible in

neoplastic cells in which p53 activity is mutated. 26 p53

gene is an important cell growth regulator. Decrease

in p53 in a cell also makes it resistant for radiation

and chemotherapy and inhibiting cancer treatment

(Table 3 Apoptotic supporting genes). 28,29

Implementation Phase

In this phase, proteolysis and mitochondrial inactivation

occurs. Cellular distruption results from activation of

a cystine proteases family known as caspases (CASP). 30

Up to now, CASP 1-10 have been discovered. They are

subclassified in to three subgroups.

• Group - 1: CASP-1, 4 and 5.

They are going to support proinflammatory cytokines.

• Group - 2. CASP-2, 3 and 7.

They are involved in cleavage of apoptotic substrates.

• Group -3. CASP - 6, 8 and 9.

They activate Group-2 caspases. 31

increased Apoptosis


Neurogenerative disorders

Alzheimer’s disease

Parkinson’s disease

Amyotrophic lateral


Retinitis pigmentosa

Few intermediate factors like oncogene C-myc

transcription for E 2

F-1 32 and Ras oncoprotein are

involved in the internal regulation of apoptosis. E 2


is a positive regulator of C-myc protein.

Release of Cytochrome C from Mitochondria

(Intrinsic Phase) 33-38


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

Various stimulations induce binding of proapoptotic

Bcl-2 family members to chief cell organelles

Bcl-2 family members. This will cause release of

cytochrome C and binds cytoplasmic protein Apaf-1.

Apaf-1 activates procaspase-9 allosterically, which again

activates procapase-3 and 7. Activation and activity

is tightly regulated. Mitochondrial pathway signal is

controlled as anti-apoptotic Bcl-2 family members

who inhibit release of cytochrome C.

Apoptosis Promoting Factors

This is a flavoprotein, initiating the caspase independent

pathway by causing fragmentation of DNA and

chromatin condensation. This factor also participates

in the regulation of apoptotic mitochondrial membrane

peremeability and exhibits an NADH oxidase activity.

Under normal physiological process, AIF is programmed

behind the outer mitochondrial membrane. In case

of apoptosis, AIF translocates to the cytoplasm and

nucleus. Decrease in this factor results in resistance of

embryonic stem cell to death following the withdrawal

of GF. Caspase-independent effects can be contributed

to AIF. 39 The mammalian AIF precursors contain

an N-terminal mitochondrial localization sequence.

In humans, one AIF sequence has been recently

discovered, which promotes proapoptotic function.

The redox reaction catalyze by AIF in mitochondrial

in the living cell is in questioned. It has been proposed

that AIF might interact with cytochrome Bcl complex

and catalyze the electron transfer to the mitochondrial

repertory chain. AIF can do a caspase-independent

death receptor. When caspase activation occurs early

during apoptosis activated caspases induced the caspaseactivated

protein t-Bid, which can trigger the regulation

of AIF from mitochondrial. So AIF is released from

mitochondria before cell death occurs. It indicates that,

AIF is required for cytochrome C40 dependent caspaseactivation

cascade. MMP can operate apoptosis. AIF is

an important factor in regulation of apoptosis. Bcl-2

family regulates the release of AIF.

Significance of Apoptosis

Unregulated cell death can be a significant component

of diseases such as cancer, Alzheimer’s disease and

Hutingoton’s disease. Few of them are showing under

expression as well as over expression. All diseases of

human are associated with disordered apoptosis.

In normal human physiology, apoptosis places a key

role to maintain homeostasis. It has been estimated that

around 10 billion cells/day are being made of which few

are lost and few survive. 41 They balanced those dying

by apoptosis. It is an essential mechanism, removing

pathogens invaded cells and plays an important role in

wound healing. 42

apoptosis is also important to estimate aggressive

immune cells. It is also mentioned that adaptive stress

plays an important role in pathophysiology. 43,44

Apoptosis in Various Disease and

Conditions (Table 4 and 5)

Immune System

Autoimmunity is an important factor in apoptosis. 45

Dysregulation of apoptosis cause critical autoimmune

disease, immunodeficiency and lymphoid malignancy.

Apoptosis dysregulation can also cause rheumatoid

arthritis, systemic lupus erythematosus (SLE), bowel

diseases and insulin-dependent diabetes mellitus

(IDDM). 46,47 Increased apoptosis cause Aplastic-A,

β thalassemia. 48

Viral Disorders

Virology also shows a major mode of cell death as

in cytotoxic lymphocyte (CTF)-induced cell killing.

Certain viruses show anti-apoptotic proteins that

lead to development of cancer (e.g. HPV and

adenovirus). 49 HIV can be regarded as a pathological

imbalance between CD 4

cell death rate and cell

replacement. HIV shows depletion of CD 4


lymphocytes, which is to immunodeficiency 50 and

lymphoma. In HIV infection, CD 4

T cells are gradually

lost due to increase apoptosis and leads to AIDS. 50

Central Nervous System

In embryogenesis, the nervous system produces

a surplus of cells. apoptosis are programmed cell

death that removes those neuron cells, which

fail to reach the target. Cytokines (TNF-α)

and reactive oxygen special (ROS) may induced

PCD. 51 Increased apoptosis plays an important

role in neurodegenerative diseases 52 and aging. It

is commonly seen like Alzheimer’s and parkinson’s

disease and malignancies of neuron. 53,54

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

Table 4. Human Diseases associated with

Disordered Apoptosis 6

Decreased apoptosis

• Epithelial tissue • Carcinogenesis

• Blood vessels • Intimal hyperplasia

• Lymphocytes • Autoimmune disorders

• Hemopoeitic • Leukemia, lymphoma


Increased apoptosis

• Macrophages Bacillary dysentery, peri-infarct

Border zone lymphocytes Depletion

In HIV injections and sepsis

• Myocardium neurodegenerative diseases like

Alzheimer’s and Parkinson’s

• Lymphocytes



Table 5. Apoptosis associated with Various Diseases




• Viral disorders

• Herpesviruses

• Poxviruses

• Adenoviruses

Follicular lymphomas

Carcinomas with

P53 mutations

Cardiovascular System

Myocytic degeneration occurs in apoptosis as well as

necrosis. In case of necrosis it occurs due to hypoxia and

ischemia. apoptosis is seen in myocardial infarction,

reperfusion, increases free radical production and

intercellular calcium, which are main inducer of

apoptosis. In cardiac development, apoptosis plays a

major role. Increased apoptosis leads to bradycradia

and sudden death.


Increased apoptosis


• Neurodegenerative disorders

• Alzheimer’s disease

• Parkinson’s disease

• Amyotrophic lateral sclerosis

• Retinitis pigmentosa

• Cerebellar degeneration

Myelodysplastic syndromes/ Aplastic


Ischemic injury/Myocardial infarction/

Stroke/ Reperfusion injury

It is associated with accumulation of neoplastic cells

due to enhanced cell proliferation, decrease cell turn

over or both. Decrease apoptosis plays an important

role in carcinogenic process. 55-57

Gastrointestinal Disorders

We can appreciate decreased or increased apoptosis in

gastrointestinal diseases. Colorectal cancer is associated

with inhibition of apoptosis; Mutated gene may be

seen in case of colonic and gastric cancer. Hepatitis

shows decreased apoptosis. 58

Renal Disorders

In case of renal malignancy, the apoptotic level is

increased. 59

Reproductive System

Due to presence of trophic hormone, apoptosis is

properly regulated. 60

Future Prospects

Since last few years,’ many of advances have been made

to exploit mutated expression of “inhibitors of apoptotic

proteins (IAPs)” for detection and treatment of human

diseases. Many preclinical studies have provided end

line of evidence, that IAPs can be cross-checked by

antisense oligonucleotides, RNA interference or small

molecule compounds. This leads to a new line of

treatment of cancer. But still the question of using

these strategies as diagnostic or therapeutic tools in

clinical management of cancer, autoimmune disorders

or neurodegenerative diseases is to be answered.








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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Oral Health Aspects of Cannabis Use

Review Article

Ramandeep Singh Gambhir*, Prabhleen Brar**, Sameer Anand † , Amaninder Ranhawa ‡ , Heena Kakar #


The use of cannabis, both medicinal and recreational, is growing. There are three main forms of cannabis: Marijuana, hash

and hash oil, all of which contain the main psychoactive constituent THC. Many people are getting addicted to Marijuana,

ignorant of its harmful effects on health. Today, cannabis abuse is a major concern because of its negative effects on general

and oral health. Cannabis users are more prone to develop dental caries, xerostomia, alveolar bone loss, pre-cancerous oral

lesions and other oral infections. The debate over the personal use of marijuana in around the world is extremely contentious

with supporters for decriminalization and legalization, and others who assert the importance of strict prohibition. Public

should have the best information at their disposal about the harms and risks associated with using cannabis in any form.

The present review will throw a spot light on the global prevalence of cannabis use and some of the important oral health

effects of cannabis abuse, which are an important concern to a dental professional.

Key words: Cannabis, oral health, oral cancer, legislation

Cannabis is the generic term used for the

psychoactive substance derived from the three

species of the cannabis plant. The cannabis

plant, cannabis sativa, originated in central Asia and

was introduced into India in the 8th century BC,

where it was used for religious ceremonies and medical

purposes. Subsequently, cannabis was widely used

to treat gastric complaints, headaches, coughing,

hepatitis, gout, ‘hard tumors’, tetanus and rabies. 1

Cannabis contains a unique group of chemicals,

namely cannabinoids, some of which are psychoactive.

Cannabis contains 66 cannabinoids. The most potent

psychoactive substance is delta-9-tetrahydrocannabinol

(THC). However, despite the potential benefits, the

nonmedical use of cannabis can have adverse effects on

the general, mental and oral health of users particularly

when used regularly for an extended period of time. 2

There are three main forms of cannabis: Marijuana,

hash and hash oil. Cannabis has become more closely

*Senior Lecturer, Dept. of Public Health Dentistry

Gian Sagar Dental College and Hospital, Rajpura, Punjab

**Assistant Professor, Dept. of Conservative Dentistry and Endodontics

Punjab University Dental College, Chandigarh

Senior Lecturer, Dept. of Periodontics

Rayat and Bahra Dental College, Punjab

Senior Lecturer, Dept. of Public Health Dentistry

Sri Guru Ram Dass Dental College, Amritsar


Consultant, Apollo Dental Centre, Chandigarh

Address for correspondence

Dr Ramandeep Singh Gambhir

E-mail: raman1g@yahoo.co.in

linked to youth culture and the age of initiation is

usually lower than for other drugs. Cannabis, in the

form of hash and marijuana is thought to be the most

frequently used drug in the United States. 3,4 There

has been a documented link shown between cannabis

smoking and many intraoral disturbances. 5 The present

paper focuses on some of the major implications on

oral health regarding the use of cannabis by people


Global Prevalence of Cannabis Use

Cannabis is the most widely used illicit drug in Europe,

Australia and throughout the western world. About

147 million people, 2.5% of the world population,

consume cannabis (annual prevalence) compared

with 0.2% consuming cocaine and 0.2% consuming

opiates. Nearly, 40% of Australian population aged 14

and above (over 5 million people) have tried cannabis,

and 18% have used it in the last 12 months. As many

as 45% of 14-19 years old and 64% of 20-29 years old

have used cannabis at least once in their life. Estimates

suggest that by the age of 21, 80% of young people

in New Zealand will have used cannabis on at least

one occasion with 10% developing a pattern of heavy

dependent use. 6 In Europe, one out of 5 adults has used

cannabis at least once in his or her lifetime. Estimates

of the actual use of cannabis (use during the past 12

months) in 15-34 years old in Europe vary from 5%

to 20%. On a global basis, regular use of cannabis is

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

highest in Canada and Spain (>15%) and Switzerland

(18.3%) (European Monitoring Centre for Drugs and

Drug Addiction [EMCDDA]. 1 During the past decade,

regular cannabis use by young people (15-24 years old)

has increased in Switzerland. Cannabis consumption

has also increased in the developing world during the

past few years. 7 An estimated 38,200,000 African adults

(or 7.7% of the adult population) consume the drug

each year - far higher than the 3.8% of cannabis users

among the world population aged 15-64. 8 According

to a study reports, smoking, drinking and cannabis

use are common and clustered among adolescents in

Seychelles, a rapidly developing country in the Indian

Ocean. 9 Results of a survey conducted among students

in northern Thailand showed that, at some time in

their lives, 30-40% of the male respondents and 3-6%

of the female respondents had used cannabis. 10

Routes of Cannabis Intake

Smoking marijuana is the most common and efficient

way of using cannabis as it is easy to prepare and

its effects are rapid. Marijuana is smoked in a handrolled

cigarette, which may contain varying amounts

of tobacco to assist burning and, on average, 0.5-l g

of leaves, stalks, flowers or seeds. 2,6 A typical joint

contains 0.5-1 g of leaves. A variety of pipes are also

used to smoke marijuana, the most common being a

water pipe (‘a bong’); smoke is sucked through a layer

of water, which cools it and removes some of the tar

and irritants. Smokers inhale deeply and hold their

breath to maximize absorption.

Hashish can be baked and eaten in foods such as cookies

and cakes because it is soluble in fats and alcohol. It

may also be mixed with tobacco and smoked, or heated

and the vapours inhaled. More commonly, hash oil is

spread on the tip or paper wrapping of a cigarette and

smoked. 6

Pharmacology of Cannabis

About 50% of the THC in a joint of herbal cannabis

is inhaled in the mainstream smoke; nearly all of this

absorbed through the lungs, rapidly enters the bloodstream

and reaches the brain within minutes. Effects

are perceptible within seconds and fully apparent in

a few minutes. 2 Peak levels of THC occur within

10 minutes of smoking and decline to 5-10% of initial

levels within an hour. THC is metabolized in the liver

and forms the major metabolite 11-hydroxy-THC,

which is also a psychoactive agent. 2,11 Because THC is

extremely lipid soluble, it accumulates in fatty tissues,

reaching peak concentrations in 4-5 days. It is then

slowly released back into other body compartments,

including the brain. 2 The tissue elimination half-life of

THC is approximately seven days, and total elimination

may take upto 30 days. When ingested, the amount of

cannabis absorbed is 25-30% less than that of smoking

the same amount due to the first-pass metabolism by

the liver. Therefore, the onset of the effects is delayed

by about 30 minutes to two hours, but the duration of

effects is prolonged. 6

Cannabis exerts its effects on the body by interaction

with specific endogenous receptors, CB 1

and CB 2

. 12

These receptors normally modulate neuronal activity by

affecting second messenger and ion transport systems.

CB 1

receptors are located in the central nervous

system (cerebellum, cerebrum and hippocampus). CB 2

receptors are found in cells in the immune system,

predominantly the macrophages. As there are very few

CB 1

receptors in the brainstem, vital functions are not

affected by the use of cannabis. 2

Cannabis Abuse and Oral Health

Cannabis users are prone to oral infections. Generally,

Cannabis abusers have poorer oral health than nonusers,

with higher decayed, missing and filled (DMF)

teeth scores, 1 higher plaque scores and less healthy

teeth gums. 13 An important side effect of cannabis

abuse is xerostomia (dryness of the mouth caused by

malfunctioning salivary glands). According to a study

report, cannabis smoking and chewing causes changes

in the oral epithelium, termed ‘cannabis stomatitis’. Its

symptoms include irritation and superficial anesthesia

of the oral membranous tissue covering internal organs.

With chronic use, this may progress to neoplasia (growth

of a tumor). 14 Dental treatment on intoxicated patients

can result in the patient experiencing acute anxiety,

dysphoria and psychotic-like paranoiac thoughts. The

use of local anesthetic solutions containing epinephrine

may seriously prolong tachycardia already induced by

an acute dose of cannabis.

Cannabis Abuse Causes Oral Cancer

Chronic smokers of cannabis have an increased risk

of developing oral leukoplakia (thick white patches on


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

mucous membranes of the oral cavity, including the

tongue. It often occurs as a pre-cancerous growth), oral

cancer and other oral infections. Oral cancer related

to cannabis usually occurs on the anterior floor of

the mouth and the tongue. 14,15 Marijuana smoke is

associated with dysplastic changes within the epithelium

of the buccal mucosa (anucleated squamous cells,

immature cell forms, increased nuclear pleomorphism

and increased mitotic activity and abnormalities).

Although smoking marijuana is associated with oral

premalignant lesions, including leukoplakia and

erythroplakia but results of a large population based

study found no association between marijuana use

and development of oral squamous cell carcinoma. 16

The increased incidence of intraoral candidiais in

persons who smoke cannabis may be because of the

hydrocarbons present in marijuana, which act as an

energy source for certain types of Candida species.

Additional factors such as compromised immune

response due to chronic use of marijuana, poor

denture hygiene and nutritional factors should also be

considered. 17

Cannabis Use and Dental Caries

The hypothesis that cannabis increases the risk of

caries was not confirmed according to a study report. 1

However, the difference between groups in the

incidence of decayed surfaces was highly significant.

Cannabis users had considerably more open carious

lesions than those who did not use cannabis. Shortterm

xerostomia and consumption of cariogenic food

and beverages after using cannabis may be responsible

for the high incidence of caries on smooth surfaces.

The cariogenic diet, reduced frequency of oral hygiene

and rare dental control visits indicate that the lifestyle

of cannabis users makes an important contribution to

the incidence of caries. Therefore, the combination of

cannabis use and an unhealthy lifestyle increases the

risk of caries on smooth surfaces. 1,13

Cannabis and Periodontal Disease

Smoking cannabis can affect the nerve endings in the

mouth, masking any sensitivity that may be occurring.

Various effects like fiery-red gingivitis, alveolar

bone loss, gingival inflammation and hyperplastic

gingiva are reported in cannabis smokers. 13,18 Current

knowledge on the effects of cannabis on periodontal

health is inadequate. Controlled epidemiologic studies

are difficult to undertake as the frequency, amount,

duration and mode of administration of cannabis

differ amongst individuals. Personal risk factors

including age, oral hygiene, general health, concurrent

tobacco smoking and poly drug use make it difficult

to identify the specific influence of cannabis abuse on

susceptibility to periodontitis.

The Legal Regulation of Cannabis Use

Cannabis is a controversial drug; debate continues

over its illegal nature and whether or not it should be

legalized. This has become more problematic in recent

years with the emergence of cannabis as a potential

therapeutic agent for some medical problems (such as

multiple sclerosis). Significantly, the issue of the longterm

health effects of cannabis use remains unresolved.

Much of the scientific debate has become entangled

with the wider social question of whether its use should

remain illegal or not. 19 The difficulties with cannabis

prohibition have been noted in a number of reviews,

which have pointed to the difficulties and injustices of

attempting to criminalize the use of a substance, which

is widely used. 20,21

An important legislative issue that requires attention

is the issue of the supply of cannabis to young people

under the age of 18. There is increasing evidence to

suggest that this age group is the most vulnerable to

the effects of cannabis 22,23 and accordingly there are

grounds for suggesting that sentencing in cases of the

supply of cannabis should take into account the ages

of the individuals to whom cannabis is being supplied

with supply to adolescent populations attracting more

severe penalties.

Drug Education in Schools

One approach that has been widely advocated has been

the use of drug education in schools. In particular it

has been argued that by educating young people about

the harms of drugs including cannabis, risks of future

drug use and abuse may be reduced. 24,25 However, the

evidence in support of school-based drug education

is not strong. In general, studies of drug education

programs have found these programs to be most

effective in increasing knowledge about the risks of

drug abuse. 26 Evaluations have found that the program

is effective in increasing student knowledge but that

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

the effects decrease with time and do not appear to

alter later risks of drug abuse.

Treatment of Cannabis Abuse and


There is a need to develop effective clinical services

for the treatment and management of cannabis abuse

and dependence. There are now an increasing number

of studies that have examined the use of a number of

therapeutic approaches to the treatment of cannabis

abuse and dependence. 27,28 These approaches include

cognitive behavioral therapy, motivational enhancement

and contingency management training. While these

treatments have been found in randomized controlled

trials to have some efficacy, 29 their major benefits appear

to be a reduction in levels of cannabis use rather than

ensuring complete abstinence from cannabis. These

results raise issues about the extent to which such

therapy should focus on moderation of cannabis use

rather than complete abstinence.

Conclusion and Recommendations

Cannabis abuse causes a wide array of physical,

psychological, economic and legal issues for the user.

It can lead to serious general as well as oral health

problems. Despite the controversy that surrounds

marijuana use, clinicians will encounter patients who

use it either medicinally or recreationally, and the

oral side effects that accompany its use. The dentist

must use certain precautions while dealing with a

patient who is known to use cannabis in any form in

order to avoid any possible contraindications during

dental treatment and be able to refer such patients, if

so desired by the patient, to the proper professionals

for counseling. Beverages and mouthrinses containing

alcohol should not be prescribed to the patients because

of their drying effects on the oral cavity. Adhering to

a low cariogenic diet and following an effective oral

healthcare regimen that includes fluoride exposure are

also key to inhibiting caries in patients experiencing

xerostomia because of cannabis use. The increasing

prevalence of cannabis use demands awareness of the

diverse adverse effects of cannabis abuse. People should

know about these effects and take timely action in

order to stay away from its negative implications. Laws

should be enforced to regulate cannabis use in different

parts of the world to protect young people from using



















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Review Article








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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Review Article

Ayur Health for Dentist’s Wealth

Pramod S Prasad*, R Jonathan**, Arvind Kumar †


This review reminds us about nature’s hand in healing and relieving some of the cumulative trauma disorders commonly

associated with dentists in general and endodontists in particular. This depicts the problems we face in our day-to-day practice

like backache, carpal tunnel syndrome, cervical spondylitis, chronic bronchitis, hand arm vibration syndrome and the different

natural therapies available to gain relief from the associated symptoms.

Key words: Ergonomics, cumulative trauma disorders, hand arm vibration syndrome, carpal tunnel syndrome

There is always a quest for fame and money

among humans as a race. Dentists as

professionals are not an exception to this, as a

result most dentists practice beyond their physiologic

and psycological limits. Whereby, there is always a

tendency among most of the dentists to violate the

principles of ergonomics, which is the study of man in

relation to his working environment, the adaptation of

machines and general conditions to fit the individual, so

that he may work with maximum efficiency. Where will

this culminate in? They fall as victims to one of the

many occupational related diseases, to be more precise

cumulative trauma disorders (CTD). The common

cumulative trauma disorders encountered by dental

surgeons are cervical spondylitis, chronic bronchitis,

carpal tunnel syndrome, hand arm vibration syndrome

and backache. In this present world of complementary

medicine where both allopathic and ayurvedic forms

combined are gaining in popularity, herbal treatment

modalities are gaining acceptance as safe and effective


Considering the availability, safeness 1 and affordability

of herbal medicines, these can be used to heal or gain

relief from many of the cumulative trauma disorders.

*Postgraduate Student

**Professor and Head


Dept. of Conservative Dentistry and Endodontics

Rajas Dental College and Hospital, Tirunelveli, Tamil Nadu

Address for correspondence

Dr Pramod S Prasad

Postgraduate Student

E-mail: drpspkollam@gmail.com

Some of the commonly encountered cumulative

trauma disorders among dental surgeons and their

herbal remedies are reviewed in brief.

Cervical Spondylitis

This is an inflammatory condition affecting the vertebral

and paravertebral structures in the neck and shoulder

region. Two herbs which are very effective for this

condition are ginger and pineapple. Ginger (Zingiber

officinale) 2,3 contains a proteolytic enzyme called

zingibain, which is a powerful anti-inflammatory agent.

Moreover, ginger contains >12 antioxidants. Increase

of ginger content in our side dishes can be of immense

help. Another most important herb is the pineapple.

Pineapple (Ananas comosus) 2 contains a proteolytic

enzyme called bromelain which is a powerful antiinflammatory

agent. A very famous ayurvedic topical

medicine called ‘Kedaki mooladhi’ 4 is prepared from

pineapple. Pineapple is also very effective when taken

as a diet supplement.

Chronic Bronchitis

It is the chronic inflammation of bronchi in the

lungs caused mainly by cross-contamination from

patients and inhalation of aerosols. Most common

herbal remedy for this are eucalyptus and peppermint.

Eucalyptus (Eucalyptus globulus) 2 and peppermint

(Mentha piperita) 2 oil can be used as steam inhalation.

It helps in loosening the phlegm. Tea can be made

with the leaves of these herbs. Roots of Indian

ginseng (Withania somnifera) commonly called as the

‘ashwagandha’ 5 can be used to improve the immunity

by activating the white blood cells.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Review Article

Hand Arm Vibration Syndrome

Previously, this was known as ‘white finger’- a part of

Raynaud’s phenomenon. This occurs due to decreased

blood flow and is commonly seen in persons who

continuously use high frequency vibrating machines.

Studies reveal that the dentists are more prone for this

disorder than rock drillers. Garlic (Allium sativum) 5

and ginkgo are effective in increasing the circulation.

Systemic garlic consumption can be increased through

our diet. Ginkgo (Ginkgo biloba) 2 leaf extract contains

flavonoids, glycosides, terpenic lactones (ginkgolides),

which increases the elasticity of vessel walls and

rheologic properties of blood.


This is a very common disorder seen among dentists,

which usually originates from the muscles, nerves,

bones or joints. Red pepper and devils claw are

very effective in alleviating back ache. Red pepper

(Capsicum annuum) 6 contains capsaicin, which is a

powerful anti-inflammatory and analgesic agent. It

can be mashed and applied directly over the affected

region. The secondary storage root of devils claw

(Harpagophytum procumbens) commonly called as ‘puli

nakham’ 3 contains glycosides, phenols and flavinoids

and is found to be an effective anti-inflammatory and

analgesic. The harpagosides inhibits the lipooxygenase

and cyclooxygenase pathways of inflammation.

Carpal Tunnel Syndrome

It is considered as a repetitive stress injury more prone to

endodontists caused by frequent flexion and extension

as in a filing motion. Numbness, tinkling or burning

sensation in the thumb and fingers, particularly the

index and middle fingers are the common symptoms

associated with this syndrome. The tunnel formed

by the carpal bones of the wrist houses the median

nerve which gets compressed by inflammation of the

tendons, which pass through it. Resin from bark of

boswellia (Boswellia serrata) 2 is an anti-inflammatory

(lipooxygenase inhibitor) and analgesic agent. Tea

made from the bark of willow (Salix babylonica) 5

provides anti-inflammatory action by inhibiting the

cyclooxygenase pathway. It is called as ‘natural asprin’

as it contains salicin, which has the chemical structure

similar to aspirin. Another most important herb is

turmeric (Curcuma longa) 6 which contains curcumin.

It is a powerful anti-inflammatory agent. Turmeric

inhibits both cyclooxygenase and lipooxygenase

pathway of inflammation.


Hope this review can go a long way in encountering and

preventing most of the cumulative trauma disorders in

a more acceptable way and in accordance with nature.

Thereby, helping the dental surgeon to maintain a

healthy professional life - the ayur way.








Ashtanga Hridayam (Vagbhata Published by Chaukhamba

Sanskrit pratishthana).

Bhaishajya Ratnavali (Govinda Dasa; Published by

Motilal Banarasi Das).

Charaka Samhita (Charaka; Published by Chaukhamba

Sanskrit Pratishthana).



www.who.int (WHO Geneva 2004; Guidelines on

Herbal Pharmacovigilance).

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


case report

Pregnancy Epulis

T Saravanan*, KR Shakila*, K Shanthini*


Pregnancy epulis is a pyogenic granuloma of the gingiva, which develops rarely during pregnancy in women. Here, we report

an unusual case of pregnancy epulis in a 20-year-old pregnant woman, which was surgically excised and give a review of the


Key words: Pregnancy epulis, pregnancy tumor, pyogenic granuloma

Pyogenic granuloma (PG) is one of the

inflammatory hyperplasia seen in the oral cavity

as a tissue response to irritation. The first case

was reported in 1844 by Hullihen 1 and term pyogenic

granuloma or granuloma pyogenicum was coined in

1904 by Hartzell. 2 It is common in skin and oral

cavity especially gingivae, which is keratinized. 3

Currently preferred histologic term is lobular capillary

hemangioma as it represents a benign neoplasm, a

form of capillary hemangioma, rather than a reactive

infectious or traumatic process. Pyogenic granuloma

has a diagnostic, lobular arrangement of capillaries at

its base. 3

Females are slightly more affected than males and

the age at presentation ranges from 18 months to

93 years. The pathogenesis of this benign lesion is

not well-understood. Trauma is felt to be the most

common initiating event but is not always present in

the history. The occasional presence of microorganisms

has led to speculation of an infectious cause. This

has not been proven. There is a higher incidence of

pyogenic granuloma in women during pregnancy. 4

Pyogenic granuloma of the gingiva develops in upto

5% of pregnancies and hence terms like ‘granuloma

gravidaram’ and ‘pregnancy tumor’ are commonly

used. 5

Case Report

A 20-year-old female patient reported to the OPD of

Karpaga Vinayaga Institute of Dental Sciences, with a

chief complaint of painful mass on the gingiva over a

period of four months (Fig. 1). The history revealed

that the growth had gradually increasing in size to

the present size with ulceration and bleeding from

the growth. Clinical examination of the oral cavity

revealed two lobulated hemorrhagic masses one in

palate, of size measuring about 3 × 2 cm and other in

gingiva, 2 × 2 cm in the region of left molars (27, 28)

(Fig. 2 and 3). On examination, the molar teeth (27,

28) were mobile. Radiographic evidence could not be

provided as the patient was in her third trimester of

pregnancy and not cooperative. Routine hemogram

was done. A provisional diagnosis of pregnancy epulis

was given.

The patient was then subjected to excisional biopsy

under local anesthesia and the excised mass was

*Senior Lecturer

Dept. of Oral Medicine and Radiology

Karpaga Vinayaga Institute of Dental Sciences

Chinna Kolampakkam, Kanchipuram, Tamil Nadu

Address for correspondence

Dr T Saravanan

E-mail: sharvy79@gmail.com

Figure 1 and 2. Photograph showing intraoral view of two

lobulated masses.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

Figure 3. Photograph of intraoperative excisional biopsy.

Figure 4. Photograph of excisional biopsy with extracted


Figure 5. Photomicrograph (40x) showing parakeratinized

stratified squamous epithelium associated with fibrovascular

connective tissue.

Figure 6. Postoperative photograph shows good healing

after one day.

sent for histopathological examination (Fig. 4).

Histopathological examination revealed parakeratinized

stratified squamous epithelium associated with

fibrovascular connective tissue. In most of the areas

epithelium was ulcerated. The underlying connective

tissue exhibited numerous dilated blood vessels,

proliferating endothelial cells and extravasated red blood

cells (RBCs). There was diffuse chronic inflammatory

cell infiltration throughout the tissue (Fig.5). Thus, the

final diagnosis of ‘pyogenic granuloma’ was confirmed.

There was a uneventful healing on next day (Fig. 6).


Gingiva is often the site of localized growths that are

considered to be reactive rather than neoplastic in

nature. Most of the lesions in the gingiva are reactive

chronic inflammatory hyperplasia’s with minor trauma

and chronic irritation being the main etiologic factors.

They found an almost equal distribution of lesions

between the maxilla and mandible, with the anterior

maxilla the most prevalent site. 6 It predominantly

occurs in young females in their 2nd and 3rd decades

due to hormonal influences on vasculature.

There is a higher incidence of pyogenic granuloma

in women during pregnancy termed as pregnancy

epulis. Clinically, the pregnancy epulis appears as a

smooth or lobulated and ulcerated mass that is usually

pedunculated or sometimes sessile. Younger tumors are

soft in consistency, progressing to a rubbery texture

on maturation. The color may range from pink to

bright red to purple or brown. 4 Such lesions begin to

develop in first trimester and their incidence increases

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

upto 7th month of pregnancy. The cause for the

pyogenic granuloma in pregnancy is the raised levels

of progesterone and estrogen and it is seen that the

tumor usually regresses postparturition. 4

The hormonal imbalance coincident with pregnancy

heightens the organism’s response to irritation 7

however, bacterial plaque and gingival inflammation

are necessary for subclinical hormone alterations

leading to gingivitis. 8 The development of this

particular kind of gingivitis, typical in pregnancy, not

different from that appearing in nonpregnant women,

suggests the existence of a relationship between the

gingival lesion and the hormonal condition observed in

pregnancy. Sometimes pregnancy gingivitis can show a

tendency towards localized hyperplasia, which is called

pregnancy granuloma. Generally, it appears in the

2nd - 3rd month of pregnancy, the persistent influence

of plaque induces catarrhal inflammation of the gingiva

that serves as a base for development of hyperplastic

gingivitis during the last months, modulated by the

cumulating hormonal stimuli. In uncontrolled cases,

pyogenic granuloma may arise. This lesion is rarely

observed in women with poor oral hygiene in areas

with local irritating factors such as improperly fitting

restorations or dental calculus. During pregnancy,

pyogenic grenuloma when treated by surgical excision

may reappear due to incomplete excision or inadequate

oral hygiene. 9

The molecular mechanism behind the development and

regression of pyogenic granuloma during pregnancy

is due to changes associated with the functions and

structure of the blood and lymph microvasculature

of the skin and mucosa due to profound endocrine

upheaval. 10 Recent studies have revealed that sex

hormones manifest a variety of biological and

immunological effects. Estrogen accelerates wound

healing by stimulating nerve growth factor (NGF)

production in macrophages, granulocyte-macrophagecolony

stimulating factor (GM-CSF) production in

keratinocytes and basic fibroblast growth factor (bFGF)

and transforming growth factor beta 1 (TGF-β1)

production in fibroblasts, leading to granulation tissue

formation. Estrogen enhances vascular endothelial

growth factor (VEGF) production in macrophages, an

effect that is antagonized by androgens and which may

be related to the development of pyogenic grenuloma

during pregnancy. The molecular mechanism for the

regression of pyogenic granuloma after the pregnancy

is not clear. It is proposed that in the absence of VEGF,

the Angiopoietin (Ang-2) causes the blood vessels to

regress and VEGF, which was found high in pregnancy

was found undetectable after parturition.

There are two histological types of pyogenic

granuloma. One type is characterized by proliferating

blood vessels that are organized in lobular aggregates

although superficially the lesion frequently undergoes

no specific change like edema, capillary dilation or

inflammatory granulation tissue reaction. This is

known as lobular capillary hemangioma type, whereas

the second type nonlobular capillary hemangioma

type consists of highly vascular proliferation that

resembles granulation tissue. In the case presented, the

histological picture was that of chronic inflammatory

cell infiltration, which showed that it was nonlobular

capillary hemangioma.

Differential diagnosis includes pyogenic granuloma,

peripheral giant cell granuloma, peripheral ossifying

fibroma and metastatic cancer. The clinical features

of growth with ulceration and bleeding present

interdentally during the period of pregnancy made us

give a provisional diagnosis of pregnancy epulis.

Possible treatment modalities are excision, curettage,

cryotherapy, chemical and electric cauterization,

and the use of lasers. The lasers commonly used are

argon lasers, continuous wave (CW) Nd:YAG laser,

pulsed dye laser and CW carbon dioxide laser, which

permits rapid, minimally invasive surgical treatment,

but the nonspecific coagulation may lead to scars. 11

The management of pyogenic granuloma depends

on the severity of symptoms. Excisional biopsy is

indicated for treatment of pyogenic granuloma,

except when the procedure would produce marked

deformity. 12 Recurrence rate after excision ranges from

0% to 16%. Pyogenic granuloma of pregnancy often

regresses postparturition, they need not be excised

unless symptomatic. 4 As the patient presented with

huge painful mass, which was ulcerated and bleeding

we decided to excise completely.

Treatment considerations during pregnancy are very

important as it is considered that there is a biological

plausibility that periodontal diseases in pregnancy are

associated with pregnancy complications like preterm

births, preterm low birth weight (LBW) babies or even


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

pre-eclampsia. 13 Surgical and periodontal treatment

should be completed, when possible.

Precautions to be taken for teeth and gums during

pregnancy are:

• More frequent visits to your dentist are advisable.

• Try to reduce snacking on food high in sugar









Hullihen SP. Case of aneurysm by anastomosis of the

superior maxillae. Am J Dent Sc 1844;4:160-2.

Hartzell MB. Granuloma pyogenicum. J Cutan Dis

Symph 1904;22:520-5.

Willies-Jacobo LJ, Isaacs H Jr, Stein MT. Pyogenic

granuloma presenting as a congenital epulis. Arch Pediatr

Adolesc Med 2000;154(6):603-5.

Sheth SN, Gomez C, Josephson GD. Pathological

case of the month: diagnosis and discussion; pyogenic

granuloma of the tongue. Arch Pediatr Adolesc Med


Sills ES, Zegarelli DJ, Hoschander MM, Strider WE.

Clinical diagnosis and management of hormonally

responsive oral pregnancy tumor (pyogenic granuloma).

J Reprod Med 1996;41(7):467-70.

Buchner A, Shnaiderman-Shapiro A, Vered M. Relative

frequency of localized reactive hyperplastic lesions of the








gingiva: a retrospective study of 1675 cases from Israel.

J Oral Pathol Med 2010;39(8):631-8.

Eversole LR. Clinical outline of oral pathology: diagnosis

and treatment. 3rd edition, Decker BC (Ed.), Hamilton


Sooriyamoorthy M, Gower DB. Hormonal influences

on gingival tissue: relationship to periodontal disease.

J Clin Periodontol 1989;16(4):201-8.

Boyarova TV, Dryankova MM, Bobeva AI, Genadiev GI.

Pregnancy and gingival hyperplasia. Folia Med (Plovdiv)


Henry F, Quatresooz P, Valverde-Lopez JC, Piérard GE.

Blood vessel changes during pregnancy: a review. Am J

Clin Dermatol 2006;7(1):65-9.

Raulin C, Greve B, Hammes S. The combined continuouswave/pulsed

carbon dioxide laser for treatment of

pyogenic granuloma. Arch Dermatol 2002;138(1):33-7.

Jafarzadeh H, Sanatkhani M, Mohtasham N. Oral

pyogenic granuloma: a review. J Oral Sci 2006;48(4):


Bobetsis YA, Barros SP, Offenbacher S. Exploring the

relationship between periodontal disease and pregnancy

complications. J Am Dent Assoc 2006;137 Suppl:


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


case report

Ludwig’s Angina: A Rare Case Report

S Vijay Parthiban*, R Sathish Muthukumar**, M Alagappan † , M Karthi ‡


Ludwig’s angina is a rapidly progressing cellulitis characterized by the bilateral involvement of the submandibular, sublingual

and submental spaces. It typically originates from an infected or recently extracted tooth, commonly the lower second and

third molars. We present a case of Ludwig’s angina in a 50-year-old man.

Key words: Induration, airway obstruction, incision and drainage

Ludwig’s angina is a potentially life-threatening

infection of the neck and floor of the mouth.

It is a rapidly progressing cellulitis of the

floor of the mouth characterized by firm induration

and elevation of the tongue leading to severe airway

obstruction. This was described by William Frederick

Von Ludwig in 1836, 1 when he presented a clinical

observation and necropsy finding of a patient with the

same clinical condition. He described a firm connective

tissue tumefaction that extends uniformly about

the periphery of the neck, under the chin region of the

jaw and beyond to involve the tissues between larynx

and floor of the mouth.

Criteria for accurate diagnosis of Ludwig’s angina

have been described by Ludwig and Grodinsky. They

describe Ludwig’s angina as cellulitic infection of

submandibular space, usually involving more than

one neck space, producing firm induration of floor

of mouth and posterior displacement of tongue. It

spreads by continuity along the fascial planes, then

by lymphatics and rarely involves the glandular

structures. The condition is known for its aggressive

course, airway compromise and high mortality when

not treated promptly. 2-6 We report a case of Ludwig’s

*Senior Lecturer, Dept. of Oral and Maxillofacial Surgery

**Professor, Dept. of Oral and Maxillofacial Pathology

Reader, Dept. of Oral and Maxillofacial Surgery

Reader, Dept. of Oral and Maxillofacial Pathology

Chettinad Dental College and Research Institute, Chennai

Address for correspondence

Dr S Vijay Parthiban

E-mail: drvijayparthiban79@gmail.com

angina in a 50-year-old and review the presentation

and management of this disease.

Case Presentation

A 50-year-old man weighing 60 kg and 165 cm in

height, presented with complaints of swelling of lowerhalf

of face and neck with difficulty in breathing and

swallowing and inability to open the mouth for the

past three days, and had been spitting out saliva.

He had pain in the right back tooth region one week

before swelling appeared. He was nil by mouth for more

than eight hours. On physical examination, he had no

respiratory distress, but was uncomfortable because of

pain and intraoral drainage of pus. Patient was febrile

(38.8 0 C) with the pulse rate of 106 beats/minute, blood

pressure of 140/90 mmHg and a respiratory rate of

25 breaths/minute. The mouth opening was restricted

with inter-incisal gap of 1 cm. There was a diffuse,

tender and indurated neck swelling, warm on palpation

particularly in submandibular and submental space.

Neck extension was painful and limited. On intraoral

examination, floor of the mouth was erythematous and

indurated. Tongue was elevated from the floor of the

mouth and he was not able to protrude the tongue

beyond the corner of mouth, which is characteristics

of Ludwig’s angina.

A diagnosis of Ludwig’s angina was made and he

was scheduled for emergency drainage of abscess. He

was admitted and observed for 10 days in the ward.

Submental and sublingual incision and drainage was

done and the pus was sent for culture and antibiotic

sensitivity. Corrugated rubber drain was placed through


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

Figure 1. Photograph showing submandibular, submental


Figure 2. Restricted mouth opening, tongue protrusion.

Figure 3 and 4. Photograph showing submental incision and drain in place.

Figure 5 and 6. Photograph showing improved tongue protrusion and mouth opening, respectively.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

muscle into to submaxillary space below and

sublingual space above. The infection spreads among

both the spaces via the posterior edge of mylohyoid

muscle. Further progression occurs superiorly from

submaxillary space to the sublingual space producing

firm induration of floor of the mouth, elevation and

posterior displacement of tongue leading to airway

compromise. If untreated, it can spread posteriorly

along the intrinsic tongue muscles to parapharyngeal

and retropharyngeal spaces, which may progress to the


Figure 7. Photograph of the patient on the day of


a submental incision. Periodontally affected 44, 47

and 48 were extracted. Empirical antibiotic regimen

IV cefotaxime 1 g b.i.d., metronidazole 500 mg b.i.d,

IV dexamethasone 8 mg was started immediately.

The culture and antibiotic sensitivity test reported a

predominant growth of Staphylococcus aureus that was

sensitive to amikacin and ofloxacin. Based on the

antibiotic sensitivity test, the drug regimen was altered.

The patient was kept under observation for 10 days

and discharged following complete recovery.


While described as far back as the writings of

Hippocrates and Galen, necrotizing fasciitis Ludwig’s

angina was first detailed by Wilhelm Frederick

Von Ludwig in 1836. 7 Ludwig’s angina is a rapidly

progressing cellulitis involving the submandibular,

sublingual and submental space. 8 Ludwig’s angina is

odontogenic in origin in 90% of cases. Various other

causes are oral lacerations, mandible fracture and

infection of oral malignant tumor. Recent infection

or extraction of lower 2 nd or 3 rd molar are the most

common cause for Ludwig’s angina as their roots

extend below the mylohyoid line of the mandible.

To understand the pathophysiology of Ludwig’s angina

requires the knowledge of anatomy of submandibular

space. This space is bounded superiorly by the mucosa

of floor of the mouth and inferiorly by superficial layer

of deep cervical fascia as it extends from hyoid bone

to mandible. This space is subdivided by mylohyoid

Ludwig’s angina originates from infected or recently

extracted tooth, most commonly mandibular second

and third molars. 8 Various other causes reported

are mandible fracture, submandibular sialadenitis,

peritonsillar abscess, epiglottitis and oral malignancy.

It begins as a moderate infection and can progress

rapidly to brawny bilateral swelling of upper neck with

pain, trismus and tongue elevation accompanied with

dysphagia and fever. The most serious complication of

Ludwig’s angina is asphyxia due to expanding edema

of soft tissues of neck. 9 Another common cause of

death is acute loss of airway during intervention to

control the condition. 10 Stridors, anxiety, cyanosis,

sitting posture are late signs of impending airway

obstruction and indicate the need for immediate airway

management. 3 Spread of infection to mediastinum,

carotid sheath, skull base and meninges are other

complications. Ludwig’s angina was formerly fatal, but

now with adequate medical and surgical treatment, has

a reduced rate of mortality. 11 Even after the advent of

newer antibiotics Ludwig’s still remains a potentially

life-threatening infection because of the impending

airway crisis. 5 So, the early recognition, diagnosis

and treatment of Ludwig’s angina is very important.

The cornerstone of medical management is the use of

antibiotics active against streptococci, staphylococci and

anaerobic species. Steroid therapy has been suggested

as an adjunct to halt the progression of edema and

prevent the need for artificial airway.


Ludwig’s angina is a life-threatening infection of floor

of the mouth and neck. Early diagnosis and immediate

treatment is the key for successful management of

Ludwig’s angina. In advanced cases, securing the airway,

surgical drainage and antibiotics following culture and

sensitivity test are important.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report








Murphy SC. The person behind the eponym: Wilhelm

Frederick von Ludwig (1790-1865). J Oral Pathol Med


Kurien M, Mathew J, Job A, Zachariah N. Ludwig’s angina.

Clin Otolaryngol Allied Sci 1997;22(3):263-5.

Marple BF. Ludwig angina: a review of current airway

management. Arch Otolaryngol Head Neck Surg


Neff SP, Merry AF, Anderson B. Airway management

in Ludwig’s angina. Anaesth Intensive Care 1999;27(6):


Barakate MS, Jensen MJ, Hemli JM, Graham AR. Ludwig’s

angina: report of a case and review of management issues.

Ann Otol Rhinol Laryngol 2001;110(5 Pt 1):453-6.

Nguyen VD, Potter JL, Hersh-Schick MR. Ludwig angina:

an uncommon and potentially lethal neck infection. AJNR






Am J Neuroradiol 1992;13(1):215-9.

Tshiassny K. Ludwig’s angina: an anatomic study of the

lower molar teeth in its pathogenesis. Arch Otolaryngol

Head Neck Surg 1943;38:485-96.

Durand M, Joseph M. Infections of the upper respiratory

tract. In: Harrison’s Principles of Internal Medicine. Volume

1. 16th edition, Braunwald E, Fauci AS, Kasper DL, et al

(Eds.), McGraw-Hill: New York 2001:p.191.

Spitalnic SJ, Sucov A. Ludwig’s angina: case report and

review. J Emerg Med 1995;13(4):499-503.

Ovassapian A, Tuncbilek M, Weitzel EK, Joshi CW. Airway

management in adult patients with deep neck infections:

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Iwu CO. Ludwig’s angina: report of seven cases and review

of current concepts in management. Br J Oral Maxillofac

Surg 1990;28(3):189-93.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


case report

Management of an Unusual Crown Root Fracture of

Mandibular First Primary Molar

A Vasanthakumari*, R Bharathan**


Crown root fractures are seldom observed in the primary molars. The extensive involvement of the pulp dictates the treatment

of such teeth for extraction. Early extraction of primary molars can lead to transient or permanent malocclusion, esthetic,

phonetic and functional problems. The aim of this case report is to describe the diagnosis of an unusual complicated crownroot

fracture involving the primary molars of a 4-year-old girl child as well as to describe its management in order to preserve

them as a functional unit of the dentition.

Key words: Crown-root fracture, primary molar

The frequency of traumatic dental injuries in

children and teenagers varies considerably

because of the influence of factors such as

gender, age and dentition. Their prevalence in early

ages varies from 4.6% to 30.2% and more specifically

it is about 15% in primary dentition. The peak of

incidence of dentoalveolar trauma in primary dentition

occurs between the age of 2-4 and 8-11 years in mixed

dentition. 1,2

Commonly reported causes for dental injuries are

motor vehicle accidents, contact sports and fall. Boys

are more prone to dental trauma than girls. Increased

overjet and incomplete lip closure are predisposing

factors for trauma. 7

The crown and root fracture is defined as fractures

involving enamel, dentin and cementum and also

classified as complicated and uncomplicated according

to the pulpal involvement. 3 About 86.5% of dental

trauma suffered by preschool children cause injury to

primary incisors, whereas only 0.5% of these cause

injury to primary molars. The incidence of crown and

root fracture in primary molars had been reported to

be only 0.8%. The purpose of the present paper is to

describe the management of an unusual crown root

fracture of mandibular first primary molars. 10

Case Report

A 4-year-old girl came accompanied by her parents,

with the chief complaint of pain in the lower left back

tooth for past two days. History as given by mother

revealed patient had a fall one week back while playing

at home. Patient got laceration to the chin region

(Fig. 1) and consulted a nearby private physician and

suture was placed in the chin region. Broken lower

teeth were asymptomatic due to medication and so

no dental treatment was carried out that time. After

two days the patient developed pain while taking food

and water and her sleep was disturbed. On extraoral

* Professor and Head

**Postgraduate Student

Dept. of Pedodontics and Preventive Dentistry

Sri Ramachandra University, Porur, Chennai

Address for correspondence

Dr A Vasanthakumari

Professor and Head, Dept. of Pedodontics and Preventive Dentistry

Faculty Dental Sciences

Sri Ramachandra University, Porur, Chennai - 600 116

E-mail: vkpedo@gmail.com

Figure 1. Skin of chin exposing scar.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

Figure 2. Fracture evident in 74.

Figure 6. Access opening in 74.

Figure 3. OPG

Figure 7. Pulp therapy with entrance filling in 74.

Figure 4. Preoperative IOPA.

Figure 5. Reattaching fragment in 74.

Figure 8. Placement of SSC in 74.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

the length of time that has passed between the accident

and treatment. 12 Treatment may also depend on the

ability of the child to co-operate with the treatment

and number of teeth involved. 6 The increased incidence

of traumatic injuries to anterior teeth is a consequence

of modern leisure activities and the most common

injuries are crown fractures. 11

The following cases were reported in the literature

wherein the fractured teeth were extracted owing

to either a delay in the treatment instituted or the

inability to provide a secure post-endodontic restoration

and only two cases were reported for preserving

the teeth. 8

Figure 9. Postoperative IOPA.

examination wound dressing in the chin region was

observed, no gross asymmetry; no deviation and

no extraoral swelling were observed. On intraoral

examination revealed a vertical fracture of 74, fracture

line extending mesiodistaly and occluso-gingivally

towards the lingual side in 74 (Fig. 2).

Extraoral examination showed a healing laceration on

the chin. Mouth opening was normal and there was

no pain on examination of temporomandibular joints.

Orthopantomogram (OPG) (Fig. 3) and intraoral

periapical (IOPA) (Fig. 4) confirmed the fracture line

extension to pulpal region in 74. Extraction is usually

the treatment of choice. But, the child being be too

young to lose her teeth, an attempt was made to save

the tooth 74 by attaching fragment with glass ionomer

cement (GIC) type 1X (Fig. 5) followed by pulpectomy

using metapex (Figs. 6 and 7), with placement of

stainless steel crown (Figs. 8 and 9).


Crown root fractures of primary molars are extremely

rare and usually occur as a result of trauma to the

chin, as occurred in this case. Although anterior teeth

are more prone to trauma than the posterior teeth, it

is essential that the posterior teeth are also carefully

examined to ensure an accurate diagnosis, especially

when there has been an injury to the chin. 9

Treatment of the fractured tooth or teeth depends on

the severity and position of the fracture line as well as

The literature reports several different treatments

for this kind of problem, ranging from the

maintenance and use of the tooth fragment either as

a temporary or permanent crown, definitive crown

after an orthodontic or surgical extrusion or a crown

lengthening to an extraction of the residual tooth

followed by an immediate or delayed implant surgery,

or fixed partial denture. 13 There have been reports of

fractured primary molars being successfully treated by

pulp therapy and restoration with preformed metal

crowns but in many cases extraction will be the

necessary treatment. 4

The need for a multidisciplinary approach in the

treatment of routine dental problems has been

recognized for some time, especially for dental traumas

that require comprehensive treatment and an accurate

diagnosis and treatment plan, respecting the biological,

functional and esthetic aspects as well as the patient’s

will. 5

In the present case report, we have attempted to save

the teeth by pulpectomy with placement of stainless

steel crown in order to maintain the masticatory

function and thereby prevented the complicated

clinical problems that may arise after extraction of the

primary molars in such a very young patient.


Treatment of the dental trauma is complex and requires

a comprehensive and accurate diagnosis and suitable

treatment plan. It is also important to consider the

biological, functional, esthetic and economic aspects

as well as the patient’s desire.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

In aiming to minimize the developmental disturbances

in the permanent dentition, the most effective methods

are firstly to obtain an exact diagnosis to provide correct

first aid treatments and lastly to perform regular followup

until the permanent successor has erupted.








Andreasen JO. Etiology and pathogenesis of traumatic

dental injuries. A clinical study of 1,298 cases. Scand J

Dent Res 1970;78(4):329-42.

Andreasen JO, Andreasen FM. Textbook and Colour

Atlas of Traumatic Injuries to the Teeth. 3rd edition,

Copenhagen, Munksgaard: Denmark; 1994.

Kenny DJ, Barrett EJ. Recent developments in dental

traumatology. Pediatr Dent 200;23(6):464-8.

Götze Gda R, Barreira AK, Maia LC. Crown-root fracture

of a lower first primary molar: report of an unusual case.

Dent Traumatol 2008;24(3):e377-80.

Abdelnur JP, da Rosa Götze G, Barreira AK, Maia LC.

Parasymphyseal fracture associated with fracture of a

maxillary primary molar in a child: case report. Dent

Traumatol 2009;25(2):e21-4.

Klein H, Bimstein E. Conservative treatment of multiple

accidental fractures of primary molars and bilateral








fractures of the condyles: report of case. ASDC J Dent

Child 1977;44(3):234-6.

Maréchaux SC. Chin trauma as a cause of primary

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Sockalingam SNMP, Mahyuddin A. Complicated crown

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Sci 2009;4(1):25-8.

Needleman HL, Wolfman MS. Traumatic posterior

dental fractures: report of a case. ASDC J Dent Child


Sasaki H, Ogawa T, Kawaguchi M, Sobue S, Ooshima T.

Multiple fractures of primary molars caused by injuries

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Croll TP. Primary molar shattered by a BB: clinical

report. Pediatr Dent 1985;7(2):145-7.

Soviero VM, Guimarães L, Miasato JM, Ramos ME,

Alto LA. Traumatic fractures of primary molars: a case

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Tejani Z, Johnson A, Mason C, Goodman J. Multiple

crown-root fractures in primary molars and a suspected

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Dent Traumatol 2008;24(2):253-6.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


case report

Follicular Adenomatoid Odontogenic Tumor

S Loganathan*, H Srinvasan**, R Veerakumar † , M Arul Pari ‡


Adenomatoid odontogenic tumor is an uncommon odontogenic lesion, composed of odontogenic epithelium, characterized

histologically by duct like structures with amyloid like deposits, noninvasive lesion with slow but progressive growth. Here

we are reporting a case of adenomatoid odontogenic tumor in a 16-year-old female patient in the maxillary region. This

paper provides the controversies regarding its origin and management in light of recent findings, clinical, radiographic,

histopathologic and therapeutic features of the adenomatoid odontogenic tumor.

Key words: Adenomatoid odontogenic tumor, dentigerous cyst, impacted teeth

Adenomatoid odontogenic tumor, is an

uncommon benign epithelial lesion of

odontogenic origin, accounting for 3-7%

of odontogenic tumors, and was first described

by Drieibaldt in 1907. 1 According to the second

edition of the World Health Organization (WHO)

“Histological typing of odontogenic tumors”, 2

adenomatoid odontogenic tumor is defined as “A tumor

of odontogenic epithelium with duct-like structures

and with varying degrees of inductive change in the

connective tissue. The tumor may be partly cystic, and

in some cases the solid lesion may be present only as

masses in the wall of a large cyst.”

The epithelial lining of the odontogenic cyst may

transform into an odontogenic neoplasm like

ameloblastoma. There are three variants of adenomatoid

odontogenic tumor, follicular variant (73%), which has

a central lesion associated with an embedded tooth, the

extrafollicular variant (24%), which has a central lesion

and no connection with the tooth and the peripheral

variety (3%). 3 The report describes a intraosseous

follicular adenomatoid odontogenic tumor in the

maxilla illustrating the clinical, histopathological and

biological features of the tumor and emphasizes the

importance of the relation between the dental follicle

and the tumor tissue.

Case Report

A 16-year-old female patient reported with a chief

complaint of unerupted tooth and pain in the upper

anterior left maxillary region. The medical history

was insignificant. Intraoral examination disclosed

a nontender, expansible lesion of the left maxilla,

surrounded by normal mucosa and retained deciduous

canine and missing left permanent canine (Fig. 1).

Orthopantomogram (OPG) and maxillary occlusal

view revealed the presence of a significant unilocular

radiolucent area with well-defined sclerotic borders,

*Senior Lecturer, Dept. of Oral and Maxillofacial Surgery, Priyadarshini

Dental College, Pandur, Thiruvallur

**Reader, Dept. of Oral Surgery


Senior Lecturer, Dept. of Pedodontia

Address for correspondence

Dr S Loganathan

Priyadarshini Dental College - Pandur, Thiruvallur, Tamil Nadu

E-mail: drloganathans@gmail.com, srini11@hotmail.com

Figure 1. Intraoral picture showing asymmetry on the left

maxillary region and missing left permanent canine, retained

deciduous canine and malpositioned left lateral incisor.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

involving an impacted upper left permanent canine

(Figs. 2 and 3). According to the clinical and radiological

findings, the lesion was diagnosed as an adenomatoid

odontogenic tumor. Under local anesthesia, excisional

biopsy was performed with excavation of upper left

canine (Fig. 4).

The differential diagnosis was dentigerous cyst, calcified

epithelial odontogenic tumor and odontogenic


Histopathological Features

Figure 2. Panoramic radiograph reveals radiolucency

surrounding the impacted left permanent canine, retained

deciduous canine and displaced lateral incisor.

Figure 3. Occlusal radiograph reveals radiolucency

surrounding the impacted left permanent canine, retained

deciduous canine and displaced lateral incisor.

Figure 4. Picture showing the tumor and the impacted


Odontogenic epithelium is arranged in the form of

sheets, rods and few odontogenic cells, arranged in

duct like structures with eosinophilic material in the

center. A well-defined firm thick fibrous tissue capsule

is seen at the periphery, which confirms the diagnosis

of adenomatoid odontogenic tumor.


Adenomatoid odontogenic tumor is a slow growing

lesion, constituting only 3% of all odontogenic tumors

with a predilection for the anterior maxilla (ratio 2:1) 4

Rick et al have reported adenomatoid odontogenic

tumor to occur with many types of cysts and neoplasm’s

including dentigerous cyst, calcifying odontogenic

cyst, odontoma and ameloblastoma, etc. 5 In relation

with a dentigerous cyst the adenomatoid odontogenic

tumor may demonstrate, grossly and microscopically,

one or more associated cystic cavities. Some of these

cysts are lined by nonkeratinized stratified squamous

epithelium, which is similar to the lining of the

dentigerous cyst or lined by less structured membrane

that may demonstrate bud like extensions into the

connective tissue. In our case, a moderate amount

of the inflammatory component was evident in the

sections, which could cause the cystic epithelium to

lose its characteristic features and hence restrict the

typing to an odontogenic cyst alone.

Odontogenesis is a complex process wherein neoplastic

or hamartomatous lesions can occur at any stage of

odontogenesis. The secondary development of an

ameloblastic proliferation, whether hyperplastic or

neoplastic is well-known, but remains controversial.

In the present case, the multifocal cellular proliferation

had the structure of an AOT although larger lesions

reported in the literature are usually in the dimensions

of 2-3 cm. Radiographically they usually appear as

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

unilocular lesion, may contain fine calcifications with

or without root resorption. 6,7 This appearance must be

differentiated from various types of disease, such as

calcifying odontogenic tumor or cysts. The differential

diagnosis can also be made with ameloblastoma,

ameloblastic fibroma and ameloblastic fibro-odontoma.

The tumor is well-encapsulated and shows an identical

benign behavior. Therefore, conservative surgical

enucleation produces excellent outcome without

recurrence. 8,9 Our patient has been under follow-up

for eight months.


Our case report supports the general description of

adenomatoid odontogenic tumor in the previous

studies. We conclude that the rarity of adenomatoid

odontogenic tumor may be associated with its slowly

growing pattern and symptomless behavior. Therefore,

it should be distinguished from more common

lesions of odontogenic origin in routine dental




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Larsson A, Swartz K, Heikinheimo K. A case of multiple

AOT-like jawbone lesions in a young patient - a new

odontogenic entity? J Oral Pathol Med 2003;32(1):


Dayi E, Gürbüz G, Bilge OM, Ciftcioğlu MA. Adenomatoid

odontogenic tumour (adenoameloblastoma). Case report

and review of the literature. Aust Dent J 1997;42(5):


Philipsen HP, Reichart PA, Nikai H. The adenomatoid

odontogenic tumor (AOT): an update. J Oral Pathol

Med 1997;2:55-60.

Motamedi MH, Shafeie HA, Azizi T. Salvage of an

impacted canine associated with an adenomatoid

odontogenic tumour: a case report. Br Dent J 2005;



Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Sodium Hypochlorite Solution Enhances Healing of Periapical

Lesion by Nonsurgical Method

Subrata Sarkar *, Soumyabrata Sarkar**, Badruddin Ahmed Bazmi † , Sarbani Ghosh ‡

case report


Sodium hypochlorite (NaOC1) is a broad-spectrum antimicrobial agent effective against bacteria, spores, yeast and viruses.

It provides 100% bacterial reduction as it contains 50 ppm available chlorine at 6.7-10.7 pH at 20 0 C in one minute. 5.25%

NaOCl solution has a pH 11-12 and it provides immediate antibacterial action during root canal irrigation. 2.5-3% solution

has a pH of 11-12, which also gives good results. Grossman (1978) and others observed healing of large periapical lesions

by nonsurgical methods using NaOC1 solution, though the exact mechanism of healing is not clear but it is proved that

NaOC1 has good action against bacteria.

Key words: Sodium hypochlorite, root canal irrigation, nonsurgical method

Periapical infection of tooth/teeth is one of the

common problems in young children. Various

factors are responsible for this, of which caries and

trauma are the prime causes. Neglected trauma causes

apical swelling, pain and swallowing problem, which

are the common signs. 1-5 Radiologic examination shows

large radiolucent areas in relation to affected tooth,

which may be an apical abscess, granuloma or cyst.

Gram-positive anaerobic bacteria are cultured and gramnegetive

anaerobic bacteria cause pathological change

in the apical region. This lesion has a connection with

root canals of the tooth. Various types of treatments

have been advocated to overcome this problem such as

root canal treatment along with surgical curettage in

the apical region. 6

Recently, various investigators 7-13 suggested a

nonsurgical treatment procedure, which will control

apical infection and promote healing of large periapical

lesions. Present paper reflects the management of

a periapical lesion of a young boy by a nonsurgical


*Professor and Head, Dept. of Pedo-Preventive Dentistry

**Senior Lecturer, Dept. of Oral Diagnosis

Oral Medicine and Oral Radiology

Senior Lecturer, Dept. of Pedo-Preventive Dentistry

Clinical Tutor, Dept. of Community Dentistry

Guru Nanak Institute of Dental Sciences and Research, Panihati, Kolkata

Address for correspondence

Dr Subrata Sarkar

7, PC Ghosh Road Kolkata - 700 048

E-mail: drssarkar44@yahoo.com

Case Report

A 12-year-young boy came with complaints of pain

and swelling in 41, 42 region for last seven days.

He gave history of trauma in 41, 42 region one year

back. Recently, he developed sudden apical swelling

along with pain, fever, lymphadenitis. After proper

antibiotics, anti-inflammatory and mouth rinse history

of pain and fever subsided.

Investigation: Intraoral periapical X-ray in 41, 42

region was advised. Which showed large radiolucent

area in the region (Fig. 1).

Provisional diagnosis: Chronic periapical abscess in

41, 42 region.

Treatment plan: Nonsurgical endodontic treatment


Treatment procedure: Thermal and electrical pulp

testing was done in 41, 42 region, which failed to

respond indicating nonvital teeth. The access cavity

was prepared with the help of Round-end Fissure

Bur. Canal was kept open for 24 hours to drain out

pus from the canal. After 24 hours, 5.25% sodium

hypochlorite (NaOC1) irrigation was done drop by

drop slowly (Fig. 2).

After 48 hours, with the help of protaper, enlargement

and removal of root canal debris was done. Then again

irrigation was done with 5.25% NaOCl. Access cavity

was sealed with Cavit cement (3M). Same procedure

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

Patient was recalled after one month and intraoral

periapical X-ray was taken, which showed absence of

radiolucent zone in apical region of 41, 42. Healing

had taken place. Radio-opaque root canal fillings were

seen in 41, 42 (Fig. 3).

Figure 1. Intraoral periapical X-ray of 41, 42 region showing

large radiolucency in periapical region.

Figure 2. Sodium hypochlorite irrigation with side vented

needle drop by drop slowly.

Figure 3. Healing of the periapical region in relation to

41, 42 with radio-opaque gutta-percha in root canals.

was repeated after 48 hours intervals for five times.

Canals were debrided and dried and obturated with

gutta-percha and zinc oxide eugenol.


Treatment of effected pulp restore normal physiological

function of tooth. Dental caries, trauma, attrition,

abrasion, erosion, etc., all cause change of pulpal status

and ultimately cause loss of vitality and house various

bacterial growth. Long-standing pathological change of

pulpal status leads to pathologic changes in periapical

region of tooth like granuloma, apical abscess and

radicular cyst.

First evidence of endodontic treatment was reported in

Israel in 2 nd and 3 rd century (BC). After that throughout

the world endodontic treatment was performed by

various investigators in deciduous and permanent

teeth. Various endodontists believe proper and adequate

biochemical preparation can control pulpal infection

and restore normal physiological functions of tooth.

In the year 1978, Grossman stated only biochemical

instrumentation and cleaning of root canal would

not lead to healing of apical region of nonvital tooth.

Root canal irrigation during endodontic treatment

was first introduced in the year 1859. 14 Various

irrigating solutions like normal saline, hydrogen

peroxide (20%vol), povidone-iodine, calcium

hydroxide, mixture of tetracycline, acid detergent,

[MTAD], ethylenediaminetetraacetic acid (EDTA),

soluble terramycin tablet, neem leaves and other

herbal solution) were used by endodontists for proper

debridement of canals by dissolving organic matter.

Ingle and Beveridge 1976, 7 Nicholls 1977, 8 Grossman

1978 were of this opinions that NaOCl was the

best irrigating solutions because NaOC1 has good

antimicrobial property, property of dissolving pulpal

remnants and debris material and heals large periapical

lesions. Shih et al 1970, 9 Ayhan et al (1999), 10

Ercan et al (2004), 11 Abdullah et al (2005), 12 Berber

(2006), 13 and others are of same opinion that NaOC1

is a broad-spectrum antimicrobial irrigating solution

effective against bacteria, spores, yeast and virus. Ingle

and Beveridge (1976), 7 Nicholls (1997) 8 and others

suggested that NaOC1 helps in healing of apical lesions

and debridement of root canal.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

Various endodontists observed NaOC1 has good

bacterial killing efficiency. Thus large apical healing

can be obtained by a nonsurgical method. Present

study supports the above views.


Dental pulpal infection can cause periapical lesion.

Initially endodontists advocated proper root canal

treatment with apical surgical curettage. Other group

of investigators suggested that NaOC1 is broadspectrum

antimicrobial irrigating solution, which can

kill various microorganisms. Proper healing of apical

region by NaOC1 is a nonsurgical method, which can

control pulpal pathology.






Lalonde ER. A new rationale for the management of periapical

granulomas and cysts: an evaluation of histopathological

and radiographic findings. J Am Dent Assoc 1970;80


Baskar SN. Periapical lesions - types, incidence and clinical

features. Oral Surg Oral Med Oral Pathol 1966;21:657-71.

Calişkan MK. Prognosis of large cyst-like periapical lesions

following nonsurgical root canal treatment: a clinical review.

Int Endod J 2004;37(6):408-16.

Simon JH. Incidence of periapical cysts in relation to the

root canal. J Endod 1980;6(11):845-8.











Nair PN. New perspectives on radicular cysts: do they heal?

Int Endod J 1998;31(3):155-60.

Grossman LI. Endodontic practice. 9th edition, Lea &

Febiger: Philadelphia 1978:p.191.

Ingle JL, Beveridge EE. Endodontics. 2nd edition, Lea &

Febiger: Philadelphia 1977:p.138.

Nicholls E. Endodontics. 2nd edition, John Wright & Sons

Ltd., Bristol 1977:p.138.

Shih M, Marshall FJ, Rosen S. The bacterial efficacy of

sodium hypochlorite as an endodontic irrigant. Oral Surg

Oral Med Oral Pathol 1970;29:613-9.

Ayhan H, Sultan N, Cirak M, Ruhi MZ, Bodur H.

Antimicrobial effects of various endodontic irrigants on

selected microorganisms. Int Endod J 1999;32(2):99-102.

Ercan E, Ozekinci T, Atakul F, Gül K. Antibacterial

activity of 2% chlorhexidine gluconate and 5.25% sodium

hypochlorite in infected root canal: in vivo study. J Endod


Abdullah M, Ng YL, Gulabivala K, Moles DR, Spratt DA.

Susceptibilties of two Enterococcus faecalis phenotypes to root

canal medications. J Endod 2005;31(1):30-6.

Berber VB, Gomes BP, Sena NT, Vianna ME, Ferraz CC,

Zaia AA, et al. Efficacy of various concentrations of NaOCl

and instrumentation techniques in reducing Enterococcus

faecalis within root canals and dentinal tubules. Int Endod

J 2006;39(1):10-7.

Miller WD. An introduction to the study of the bacteriopathology

of the dental pulp. Dent Cosmos 1894;36:


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


case report

Vital Bleaching with Diode Laser

Sharath Pare*, SC Loganathan**


Every individual with discolored teeth desires to have whiter teeth. Bleaching corrects or improves the color of teeth, and

it is also the least expensive esthetic treatment option. Introduction of Lasers in dentistry has led to a new era of dental


Key words: Discolored teeth, Laser, bleaching

Discolored anterior teeth are often perceived as an

esthetic detraction. Because of the growing need

for beautiful, white teeth and the establishment

of esthetic treatment methods, the bleaching of discolored

teeth has become increasingly important in recent years.

The objective of laser bleaching is to achieve the ultimate

power bleaching process using the most efficient energy

source, while avoiding any adverse effect. 1 Bleaching is

defined as the lightening of the color of a tooth through

the application of a chemical agent to oxidize the organic

pigmentation in the tooth. 2

The release of hydroxyl-radicals from peroxide is

accelerated by a rise in temperature according to the

following equation:

H 2

O 2

+ 211kJ/mol→2HO.

This is in accordance with an increase in speed of

decomposition of a factor of 2.2 for each temperature

rise of 10 0 C. 3

Hydrogen peroxide bleaching proceeds via perhydroxyl

anion and a hydroxyl radical is formed. Use of light source

such as Light Amplification by Stimulated Emission of

Radiation (LASER) increases the formation of hydroxyl

radicals. 4

Classification: 5

• Nonvital bleaching

• In office bleaching

*PG Student


Dept. of Conservative Dentistry and Endodontics

Thai Moogambigai Dental College and Hospital, Chennai

Address for correspondence

Dr Sharath Pare

E-mail: sharathpare@gmail.com

• Walking bleach

• Vital bleaching

• In office (power bleaching)

• Night guard bleaching

Etiology of intrinsic discolorations 6

• Pre-eruptive causes

• Medications (tetracycline)

• Metabolism (fluorosis)

• Genetics (hyperbilirubinemia, amelogenesis

imperfecta, cystic fibrosis of the pancreas)

• Dental trauma

• Post-eruptive causes

• Pulpal necrosis

• Intrapulpal hemorrhage

• Residual pulp tissue after endodontic


• Endodontic materials

• Filling materials

• Root resorption

• Aging process

Redox reaction: 7 The reaction by which bleaching


Tooth + Bleaching agent

Hydroxyl radicals react with unsaturated bonds

Simpler molecules are formed

Reflects less light or becomes colorless

Larger stain molecules are converted into smaller ones


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

Case 1

A 22-year-old female patient reported to the Dept.

of Conservative Dentistry and Endodontics, Thai

Moogambigai Dental College, Chennai with chief

complaint of color change in her left upper front tooth

region. There was relevant medical history and patient

gave no history of trauma. Oral examination showed that

21 was slightly discolored 36, 37, 46 were restored. Soft

tissue around the tooth was normal. RVG and thermal

testing were used as diagnostic aids. RVG revealed no

periapical changes and coronal portion was calcified

in 21. Thermal test revealed tooth was vital.

Oral prophylaxis was done and bleaching was carried

out using 35% hydrogen peroxide gel and diode

laser. Gingival barrier was applied and light cured for

20 seconds. Then hydrogen peroxide gel is applied over

the affected tooth and laser beam is used at 3 watts

Postoperative (Case 1)

for 20 seconds per tooth in pulse mode. Then the gel

was left on the tooth for 20 minutes. The peroxide

gel was wiped with cotton and the gingival barrier was

removed. Immediately after the treatment, the patient

was happy with the degree of color change. The patient

reported after six months and one year. No change in

the color was seen.

Case 2

Preoperative (Case 1)

A 23-year-old female patient reported to the Dept.

of Conservative Dentistry and Endodontics, Thai

Moogambigai Dental College, Chennai, with chief

complaint of color change in her front teeth. Patient

gave no relevant medical history and no history of

trauma. Oral examination revealed all anteriors were

slightly discolored and soft tissue around the teeth

were normal.

Laser activation (Case1)

Preoperative (Case 2)

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

of ‘photo initiator’ in the gel. Mechanisms of tooth

whitening by peroxide occur by the diffusion of

peroxide through enamel to cause oxidation and hence

lightening the colored species, particularly within the

dentinal regions. The efficacy of light activated systems

of bleaching has better effect on whitening procedure.

In addition, it has been speculated that the light

source can energise the tooth stain to aid the overall

acceleration of the bleaching process. 8


Postoperative (Case 2)

Oral prophylaxis was done and bleaching was carried

out using 35% hydrogen peroxide gel and diode laser.

Gingival barrier was applied and light cured for 20

seconds. Then hydrogen peroxide gel was applied over

the affected teeth and laser beam was used at 3 watts

for 20 seconds per tooth in pulse mode. Then the gel

was left on the tooth for 20 minutes. The peroxide

gel was wiped with cotton and the gingival barrier was

removed. Patient was reviewed after six months with

no change in color.


The use of high-intensity light, for raising the

temperature of the hydrogen peroxide and accelerating

the rate of chemical bleaching of teeth was reported in

1918 by Abbot. 4 If heat or light activation is applied, it

is strongly advised to follow manufacturer’s instructions

with limited duration of heat activation to a short period

of time, in order to avoid undesired pulpal responses.

The light source can be laser (argon, CO 2

), halogen,

plasma arc, light emitting diodes (LED). Light activated

tooth whitening systems such as ‘Brite smile’ system

(400-500 nm) ‘Zoom’ system (350-400 nm). These

systems use light, which matches the wavelength

The light source can activate peroxide to accelerate the

chemical redox reactions of the bleaching process. 9 But

if proper regimens are not undertaken pulpal reactions

can occur. Care should be taken during laser bleaching

with a use of pulse mode, which prevents the increase

of intrapulpal temperature. Therefore, application of

activated bleaching procedures should be critically

assessed considering the physical, physiological and

pathophysiological implications.











Dostalova T, Jelinkova H, Housova D, Sulc J, Nemec M,

Miyagi M, et al. Diode laser-activated bleaching. Braz

Dent J 2004;15 Spec No:SI3-8.

Sturdevant’s Art and Science of Operative Dentistry. 5th

edition. Edited by Roberson, Heyman and Swift, 2009.

Buchalla W, Attin T. External bleaching therapy with

activation by heat, light or laser - a systematic review.

Dent Mater 2007;23(5):586-96.

Joiner A. The bleaching of teeth: a review of the literature.

J Dent 2006;34(7):412-9.

Ingle’s Endodontics. 6th edition by Ingle, Bakland and

Baumgartner, 2008.

Plotino G, Buono L, Grande NM, Pameijer CH, Somma

F. Nonvital tooth bleaching: a review of the literature and

clinical procedures. J Endod 2008;34(4):394-407.

Text Book of Endodontics. Edited by Anil Kohli, 2010.

Smigel I. Laser tooth whitening. Dent Today


Sun G. The role of lasers in cosmetic dentistry. Dent Clin

North Am 2000;44(4):831-50.


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Replantation of Avulsed Tooth after Trauma: A

One Year Follow-up Study

Swaty Jhamb*, Lalit Bida**

case report


Clinical practice has shown that it avulsed teeth are replanted after a delayed extra-alveolar time it compromises the prognosis

of replantation. In case of delayed replantation, the use of adequate media for storage and transportation of avulsed teeth may

improve the prognosis considerably. The case reported in the study is of an accidentally avulsed maxillary right central incisor

that was kept in milk from the moment of trauma until its replantation, 30 minutes later. One year follow-up revealed absence

of root resorption, ankylosis or abnormal mobility, which demonstrates the feasibility of keeping avulsed teeth in milk.

Key words: Replantation, root resorption, ankylosis, prognosis, avulsion

Dentoalveolar traumas are most commonly

observed in children and adolescents,

particularly boys but may affect individuals of

any age. 1,2 Studies have demonstrated that replantation

of avulsed teeth occurs most frequently between one

and 4 hours after avulsion. 1,2 Despite the recognized

therapeutic value of immediate tooth replantation,

clinical practice has shown that most avulsed teeth are

replanted after an extrabuccal time that extrapolates the

adequate conditions for maintenance of the integrity of

periodontal ligament cells. 3 In such cases, wet storage is

considered the best way to store avulsed teeth. 3,4 Some

characteristics of storage medium i.e. pH, osmolarity 5,6

and temperature should be compatible with the survival

of periodontal ligament cells. 4,6 Storage media as Milk,

Hanks balanced salt solution and Viaspan have been

proved to maintain cell viability after long periods. 7

Case Report

A 20-year-old male patient was referred to Dept.

of Conservative Dentistry and Endodontics after

falling from a motorbike and sustaining dental


Routine protocol for management of trauma patients

was carried out. On arrival, the patient was examined

for extraoral signs of injury, including swelling and

asymmetry of face and head. Inspection of facial bones

revealed normal mouth opening. No area of ecchymosis,

crepitus or pain on palpation was observed, which

removed the suspicion of underlying fractures.

Intraoral examination revealed avulsion of maxillary

right central incisor (Fig. 1). The patient had difficulty

This article reports, the case of an accidentally avulsed

right permanent maxillary central incisor that was

kept in milk from the moment of trauma until its

replantation, 30 minutes later. The successful clinical

and radiographic findings observed after 1-year followup

are described.

*Senior Lecturer, Dept. of Conservative and Endodontics

**Senior Lecturer, Dept. of Prosthodontics

Dr. HS Institute of Dental Sciences and Hospital, Chandigarh

Address for correspondence

Dr Swaty Jhamb

H.No. 70/1, Sec-38A, Chandigarh

E-mail: drswaty2007@yahoo.co.in

Figure 1. Preoperative photograph.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report

Figure 2. Tooth stored in milk.

Figure 4. Working length radiograph.

Figure 3a. Replanted tooth in socket.

Figure 5. Post-obturation radiograph.

Figure 3b. Preoperative radiograph with splinted tooth.

Figure 6. Postoperative radiograph after 1-year of


in keeping the tooth in the oral cavity so was instructed

to keep the tooth in milk (Fig. 2). The total time elapsed

from the moment of trauma until tooth replantation

was half an hour.

The treatment consisted of replantation of 11 into

socket after meticulous inspection and irrigation of the

avulsed tooth with saline (Fig. 3a). Splinting was carried

from tooth 12 to 11 using resin composite (Fig. 3b).’


Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Case Report

Antibiotics were administered for 7 days and 0.12%

chlorhexidine mouth rinses daily were prescribed for

7 days. One week after replantation, the root canal

of 11 was biomechanically prepared using step back

technique (Fig. 4). A Calcium Hydroxide paste was

used as an intracanal dressing and was changed 14 days

later, when splinting was removed. Radiographs were

taken and intracanal medication was changed at 30 and

60 days after replantation. The root canal of the tooth

was obturated at 90 days with Gutta-percha points

and Sealapex that is a Calcium Hydroxide based sealer

(Fig 5). The patient wanted restoration of aesthetics so,

a fixed bridge of metal –ceramic was given. The patient

was kept on continuous recall.

The clinical and radiographic findings after 1-year

follow-up revealed absence of root radiolucency,

absence of root resorption, ankylosis and abnormal

mobility of the replanted tooth (Fig. 6).


Milk is mostly used as a storage medium for accidentally

avulsed teeth and therefore, the case reported is

important in the clinical routine or management of

tooth replantation.

Lack of knowledge and possibility of immediate

replantation and unawareness of ideal conditions and

storage media for exarticulated teeth have contributed

to a poor prognosis. Both, the length of extra-alveolar

time and type of storage are significant factors that

can affect the long-term survival of replanted teeth.

Immersion of avulsed teeth in milk at room temperature

preserves the viability of periodontal ligament cells

for upto one hour; whereas, storage in refrigerated

milk is reported to maintain cell viability for additional

45 minutes. 4,8

Irrespective of the type of root surface treatment,

there is consensus in the literature that replanted teeth

should be endodontically treated because the necrotic

pulp and its toxins affect the periodontal ligament

cells through the dentinal tubules and play a decisive

role in the resorption process. 3,9,10 In this case, calcium

hydroxide is the most recommended material for root

canal filling of teeth to be replanted because of its

well-known capacity of controlling the progression of

inflammatory resorption. 11,12

Another aspect of dental replantation is the preparation

of socket, which consists of removal of destructions as

blood clots and bone fragments in order to facilitate

the replantation. 12-15

Contention of replanted teeth is another variable

that might affect the prognosis of tooth replantation.

Basically, it should not interfere with oral hygiene,

allow physiological mobility and remain for a short

time in order to reduce the incidence of ankylosis. 2,16

The goal of antibiotic therapy is to avoid bacterial

proliferation in the area of ongoing process and

contribute to the prevention of inflammatory

resorption. Ideally a broad-spectrum antibiotic should

be administered for seven days. 17

Nevertheless, in the case presented in this paper,

the 1-year clinical and radiographic controls showed

maintainence of root integrity, intact Lamina dura

periradicularly and absence of abnormal mobility,

which are indicative of successful replantation.

Certain precautions were taken while planning the

replantation procedure. The tooth was immersed

in saline prior to replantation to eliminate cell lysis

products resulting from traumatic injury on root

surface, as well as debris and bacteria from saliva. 18-20

Systemic antibiotic therapy was administered and tooth

was endodontically treated to prevent inflammatory

resorption. 21

Root resorption and ankylosis are frequently observed

complications post-replantation. Therefore, despite

the positive results observed after 1-year, clinical and

radiographic follow-up of tooth replanted under the

condition hereby described should be carried for a

longer period.






Grossman LI, Ship II. Survival rate of replanted teeth.

Oral Surg Oral Med Oral Pathol 1970;29(6):899-906.

Andreasan JO, Andreason FM. Textbook and Color Atlas

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Andreasen JO, Borum MK, Jacobsen HL, Andreasen

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Lekic P, Kenny D, Moe HK, Barretti E, McCulloch CA.

Relationship of clonogenic capacity to plating efficiency

and vital dye staining of human periodontal ligament

cells: implications for tooth replantation. J Periodontal

Res 1996;31(4):294-300.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012


Case Report









Blomlöf L, Otteskog P, Hammarström L. Effect of storage

in media with different ion strengths and osmolalities on

human periodontal ligament cells. Scand J Dent Res


Sigalas E, Regan JD, Kramer PR, Witherspoon DE,

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cells in media proposed for transport of avulsed teeth.

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Blomlöf L, Lindskog S, Hammarström L. Periodontal

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Andreasen JO. Relationship between cell damage in the

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development of root resorption. A time-related study in

monkeys. Acta Odontol Scand 1981;39(1):15-25.

Ehnevid H, Jansson L, Lindskog S, Weintraub A,

Blomlöf L. Endodontic pathogens: propagation of

infection through patent dentinal tubules in traumatized

monkey teeth. Endod Dent Traumatol 1995;11(5):


Trope M, Moshonov J, Nissan R, Buxt P, Yesilsoy C.

Short vs. long-term calcium hydroxide treatment of

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Gutmann JL, Oikarinen K, et al; International

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Dent Traumatol 2001;17(5):193-8.










Trope M, Hupp JG, Mesaros SV. The role of the socket

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in ViaSpan for extended periods. Endod Dent Traumatol


Trope M. Clinical management of the avulsed tooth:

present strategies and future directions. Dent Traumatol


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pulpal healing of mature permanent incisors in monkeys.

Int J Oral Surg 1980;9(6):458-61.

von Arx T, Filippi A, Buser D. Splinting of traumatized

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Sae-Lim V, Wang CY, Trope M. Effect of systemic

tetracycline and amoxicillin on inflammatory root

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Andreasen JO. Effect of extra-alveolar period and

storage media upon periodontal and pulpal healing after

replantation of mature permanent incisors in monkeys.

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in dogs and monkeys. Arch Oral Biol 1961;3:176-84.

Cvek M, Granath LE, Hollender L. Treatment of nonvital

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Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

Indian Journal of

Multidisciplinary Dentistry

Information for Authors

Manuscripts should be prepared in accordance with the ‘Uniform

requirements for manuscripts submitted to biomedical journals’ compiled

by the International Committee of Medical Journal Editors (Ann. Intern.

Med. 1992;96:766-767). The Journal strongly disapproves of the submission

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The boxed checklist will help authors in preparing their manuscript

according to our requirements. Improperly prepared manuscripts may be

returned to the author without review. The checklists should accompany

each manuscript.

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deviation from the standard IMRAD format (Introduction, Methods,

Results and Discussion) and should outline the importance of the

paper. Principal/Senior author must sign the covering letter indicating

full responsibility for the paper submitted, preferably with signatures of

all the authors. Articles must be accompanied by a declaration by all

authors stating that the article has not been published in any Journal/

Book. Authors should mention complete designation and departments,

etc., on the manuscript.

Manuscript: Three complete sets of the manuscript should be submitted

and preferably with a CD; typed double spaced throughout (including

references, table and legends to figures). The manuscript should be

arranged as follow: Covering letter, Checklist, Title page, Abstract,

Keywords (for indexing, if required), introduction, Methods, Results,

Discussion, References, Tables, Legends to Figures and Figures. All pages

should be numbered consecutively beginning with the title page.

Types of Submission: Original Research articles, Review articles, Case

reports and Clinical study

Title Page: Should contain the title, short title, names of all the authors

(without degrees of diplomas), names and full location of the departments

and institutions where the work was performed, name of the corresponding

authors, acknowledgement of financial support and abbreviations used. The

title should be of no more than 80 characters and should represent the

major theme of the manuscript. A subtitle can be added if necessary.

A short title of not more than 50 characters (including inter-word spaces)

for use as a running head should be included. The name, telephone

and fax numbers, e-mail and postal addresses of the author to whom

communications are to be sent should be typed in the lower right corner

of the title page.

Abstract: The abstract of not more than 200 words. It must convey the

essential features of the paper. It should not contain abbreviations, footnotes

or references.

Introduction: The introduction should state why the study was carried out

and what were its specific aims/objectives were.

Material and Methods: Theses should be described in sufficient details to

permit evaluation and duplication of the work by others. Ethical guidelines

followed by the investigations should be described.

Results: These should be concise and include only the tables and figures

necessary to enhance the understanding of the text.

Discussion: This should consist of a review of the literature and relate

the major findings of the article to other publications on the subject. The

particular relevance of the results to healthcare in India should be stressed,

e.g., practically and cost.

References: These should conform to the Vancouver style. References

should be numbered in the order in which they appear in the texts and

these numbers should be inserted above the lines on each occasion the

author is cited.

Tables: These should be typed double spaces on a separate sheet and

figure number (in Roman Arabic numerals) and title above the table and

explanatory notes below the table.

Legends: These should be typed double spaces on a separate sheet and

figure numbers (in Arabic numerals) corresponding with the order in which

the figures are presented in the text. The legend must include enough

information to permit interpretation of the figure without reference to the


Figures: Two complete sets of glossy prints of high quality should be

submitted. The labeling must be clear and neat. All photomicrographs

should indicate the magnification of the print. Special features should be

indicated by arrows or letters which contrast with the background. The

back of each illustration should bear the first author’s last name, figure

number and an arrow indicating the top. This should be written lightly

in pencil only. Please do not use a hard pencil, ball point or felt pen.

Color illustrations will be accepted if they make a contribution to the

understanding of the article. Do not use clips/staples on photographs and

artwork. Illustrations must be drawn neatly by an artist and photographs

must be sent on glossy paper. No captions should be written directly on

the photographs or illustration. Legends to all photographs and illustrations

should be typed on a separate sheet of paper. All illustrations and figures

must be referred to in text and abbreviated as ‘Fig’.

Please complete the following checklist and attach to the manuscript:

1. Classification (e.g. original article, review, etc.)_________________

2. Total number of pages____________________________________

3. Number of tables________________________________________

4. Number of figures_______________________________________

5. Special requests_________________________________________

6. Suggestions for reviewers (name and postal address)

Indian 1.______________ Foreign 1. _______________

2._____________________ 2._______________

7. All author’s signatures____________________________________

8. Corresponding author’s name, current postal and e-mail address and

telephone and fax numbers


For Editorial Correspondence

Dr KMK Masthan

Professor and Head

Department of Oral Pathology and Microbiology

Sree Balaji Dental College and Hospital

Velachery Main Road, Narayanapuram, Pallikaranai

Chennai - 600 100, E-mail: masthankmk@yahoo.com,

ijmdent@gmail.com, www.ijmdent.com

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012



Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 3, May-July 2012

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