Volume 1 - Issue-5 (Jul-Aug) Download Pdf - IJMD
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Indian Journal of<br />
Multidisciplinary Dentistry<br />
Executive Editor<br />
S Bhuminathan<br />
<strong>IJMD</strong>’s Editorial Panel<br />
Editor-in-Chief<br />
KMK Masthan<br />
<strong>IJMD</strong> Advisory Board<br />
<strong>Volume</strong> 1, <strong>Issue</strong> 5<br />
<strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
Associate Editor<br />
N Aravindha Babu<br />
Prosthodontics<br />
Mahesh Verma<br />
Srinisha J<br />
Raghavendra Jayesh S<br />
Sanjna Nayar<br />
Conservative Dentistry/<br />
Endodontics<br />
Sukumaran VG<br />
Subbiya A<br />
Swaminathan S (Singapore)<br />
Implantology<br />
John W Thurmond (USA)<br />
Genetics<br />
Aravind Ramanathan<br />
Oncology<br />
Abraham Kuriakose M<br />
Oral and Maxillofacial<br />
Surgery<br />
Ramakrishna Shenoi<br />
Vijay Ebenezer<br />
Raj Kutta (USA)<br />
Oral Pathology and<br />
Microbiology<br />
Vinay K Hazarey<br />
Ipe Vargese V<br />
Puneet Ahuja<br />
Sangeeta P Wanjari<br />
Orthodontics<br />
Krishna Nayak US<br />
Dhandapani G<br />
Murali RV<br />
Deepak C<br />
Pharmacology<br />
Muthiah NS<br />
Elumalai M<br />
General Medicine<br />
Rajendran SM<br />
Periodontics<br />
Chandrasekaran SC<br />
Ash Vasanthan (USA)<br />
Oral Medicine and<br />
Radiology<br />
Nalini Aswath<br />
Panjab V Wanjari<br />
Praveen BN<br />
Mubeen<br />
Pedodontics<br />
Krishan Gauba<br />
Ashima Gauba<br />
Biochemistry<br />
<strong>Jul</strong>ius A<br />
Microbiology<br />
Mahalakshmi K<br />
Dr Sanjiv Chopra<br />
Prof. of Medicine & Faculty Dean<br />
Harvard Medical School<br />
Group Consultant Editor<br />
Dr Deepak Chopra<br />
Chief Editorial Advisor<br />
IJCP’s Editorial Panel<br />
Dr KK Aggarwal<br />
CMD, Publisher and Group<br />
Editor-in-Chief<br />
Dr Veena Aggarwal<br />
Joint MD & Group Executive Editor<br />
Anand Gopal Bhatnagar<br />
Editorial Anchor<br />
<strong>IJMD</strong> is included in the databases of Genamics JournalSeek along with Ulrich<br />
International periodical directory and Index Copernicus International, Ltd.<br />
Advisory Bodies<br />
Heart Care Foundation of India, Non-Resident Indians Chamber of Commerce & Industry,<br />
World Fellowship of Religions
Contents<br />
From the Editor-in-chief 244<br />
From the Desk of IJCP Group Editor-in-Chief<br />
Chlorhexidine and Tooth-brushing as Prevention Strategies in Reducing Ventilator-associated<br />
Pneumonia Rates 245<br />
original research<br />
Incidence of Oral Tuberculosis Lesions in Patients with Pulmonary Tuberculosis 246<br />
Comparison of Efficiency of Various Cleansing Techniques on Dentin Wettability Using Contact Angle Test 250<br />
clinical study<br />
Effect of Surface Treatments on Push-out Strength of Three Glass Fiber Posts: An in vitro Study 255<br />
Prevalence of Facial Neuropathy among Diabetic Peripheral Neuropathy 260<br />
review article<br />
Upsurge of Nanotechnology in Dentistry and Dental Implants 264<br />
Pre-eclampsia: An Oral Infectious Etiology? 269<br />
Oral Lichen Planus: A Review on Current Medical Management 274<br />
Role of Gene in Palate Formation 279<br />
clinical practice<br />
A Technique to Locate Implants during Second Stage Surgery 283<br />
Case report<br />
Extensive Nasopalatine Duct Cyst Causing Nasolabial Protrusion 285<br />
Full Mouth Rehabilitation with Unilateral Distal Extension Prosthesis Attached to Splinted 289<br />
Fixed Partial Denture<br />
Ossifying Fibroma of Maxilla: A Case Report with Review of Literature 293<br />
Dentigerous Cyst Associated with Mandibular First Premolar: A Rare Case Report 296<br />
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From the Editor-in-chief<br />
xxxxxxxxx<br />
Our fourth issue carried some innovative and enthusiastic<br />
articles for which I received several positive and productive<br />
comments. Medicine and Dentistry both have advancing<br />
fronts into modern concepts and techniques, but are still hampered by<br />
the hesitation of the executive arm i.e. physicians and surgeons to adapt<br />
to these newer techniques and concepts, their explanation being that<br />
time-tested methods are safer and long term results of newer methods<br />
and medicines are yet to be seen. Their caution is greatly justified.<br />
However, my perception is that they hesitate to implement these newer<br />
technologies mostly because they do not update themselves and have<br />
lost the enthusiasm to learn and do not care to spend their productive<br />
time in learning the latest methods and medicines. We are in the era<br />
of evidence-based medicine and in spite of the lobbying/promotional maneuvers of pharmaceutical and medical<br />
equipment manufacturers, we get to reach/prescribe/utilize the safest medications and surgical procedures. Hence,<br />
we must update our minds and hands to extend the latest medical/surgical care to our patients. One step you can<br />
take in that direction is to subscribe to journals like this so that you get an uninterrupted flow of knowledge.<br />
A month back I had an opportunity to discuss chronic pain management with an aged doctor working in a<br />
cancer hospice. This institution is a terminal care centre offering free care for the abandoned cancer patients. He<br />
told me he achieves more pain relief for his patients through biofeedback than through all painkillers including<br />
morphine. I was skeptical as I do not know how to teach biofeedback and had never bothered to learn any such<br />
psychotherapy modalities. I thought he was making a tall claim as to the results. So I met several of his patients<br />
and spoke/enquired/literally interrogated them. These patients are not your usual type of people who suffer from<br />
minor ailments, who know that they are going to get well in due course and hence carry the ‘’nothing serious’’<br />
attitude. These are the terminally-ill cancer patients abandoned by medical fraternity; some of them by the society<br />
too and are awaiting death so that their suffering ends. I could not believe my eyes and ears when they spoke<br />
highly about the biofeedback and how it helps to tune their mind away from their pain. This is evidence-based<br />
medicine demonstrated to me raw and in spite of my bias and prejudice, I had to accept that the biofeedback<br />
works. So a mental block within me had prevented me from learning a valid treatment option which I could have<br />
provided to several of my patients. They say a wise man learns from other people’s mistakes and hence let us shed<br />
our misconceptions and learn newer treatment modalities.<br />
Another interaction I had with my student who just passed his examination deserves mention. I asked him what<br />
his plans for the future were. He blinked for a moment and said ‘’No plans’’. Then he added ‘’Why plan? Future<br />
will unfold itself’’. I was unable to digest this philosophical reply. I was reminded of a poem I had read as a<br />
schoolboy.<br />
Only as high as I reach can I grow<br />
Only as far as I seek can I see<br />
Only as deep as I look can I see<br />
Only as much as I dream can I be<br />
Hence I feel in our profession, irrespective of being a budding doctor or roaring practitioner, we need to set goals/<br />
targets and work towards them. For example, the reader could set a target of writing one case report or a review<br />
article within the next month and mail it to ijmdent@gmail.com.<br />
Best Wishes.<br />
Dr KMK Masthan<br />
Professor and Head,<br />
Department of Oral Pathology and Microbiology<br />
Sree Balaji Dental College and Hospital<br />
Chennai<br />
244<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
From the Desk of IJCP Group Editor-in-Chief<br />
xxxxxxxxx<br />
Chlorhexidine and Tooth-brushing as Prevention<br />
Strategies in Reducing Ventilator-associated<br />
Pneumonia Rates<br />
Ventilator-associated pneumonia (VAP) is a common<br />
complication of mechanical ventilation after<br />
endotracheal intubation. The role of chlorhexidine<br />
and tooth-brushing is considered as a clinical intervention to<br />
reduce infection rates.<br />
A paper from Department of Health and Social care, University<br />
of the West of England, Bristol, Avon, UK has shown that<br />
the chlorhexidine is of some value in reducing VAP and is<br />
more effective when used with a solution which targets gramnegative<br />
bacteria.<br />
Tooth-brushing is recommended in providing a higher standard<br />
of oral care to mechanically ventilated patients and reducing<br />
VAP when used with chlorhexidine.<br />
The study showed that CHX was successful in reducing the<br />
rate of VAP and using a combination of CHX and colistine<br />
resulted in better oropharyngeal decontamination which<br />
reduced and delayed VAP.<br />
Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the<br />
potential to reduce nosocomial infections.<br />
Reference<br />
1.<br />
Dr KK Aggarwal<br />
Padma Shri and Dr BC Roy National Awardee<br />
Sr. Physician and Cardiologist, Moolchand Medcity<br />
President, Heart Care Foundation of India<br />
Group Editor-in-Chief, IJCP Group<br />
Editor-in-Chief, eMedinewS<br />
Chairman Ethical Committee, Delhi Medical Council<br />
Director, IMA AKN Sinha Institute (08-09)<br />
Hony. Finance Secretary, IMA (07-08)<br />
Chairman, IMA AMS (06-07)<br />
President, Delhi Medical Association (05-06)<br />
emedinews@gmail.com<br />
http://twitter.com/DrKKAggarwal<br />
Krishan Kumar Aggarwal (Facebook)<br />
N Roberts, BSc (HONS), Y Plas, Ymwlch Fawr, Criccieth, N. Wales LL52 0PW, Gwynedd, UK, Department of Health<br />
and Social care, University of the West of England, Bristol, Avon, UK Dr P Moule, Roberts N, Moule P. Nurs Crit Care<br />
2011 Nov;16(6):295-302. doi: 10.1111/j.1478-5153.2011.00465.x. Epub 2011 <strong>Jul</strong> 26.<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
245
original research<br />
Incidence of Oral Tuberculosis Lesions in Patients<br />
with Pulmonary Tuberculosis<br />
M Sathish Kumar*, TS Thirugnanasambandan**, J Jananee † , M Preethi † , Gouse Mohiddin ‡<br />
Abstract<br />
Tuberculosis (TB) is a specific infectious granulomatous disease that most commonly affects lungs but it can also affect<br />
the intestines, meninges, bone, joints, lymph glands, skin and other tissues of the body. Primary TB of the mouth can be<br />
an invaluable aid in clinical diagnosis and patient management and this article emphasizes the significance of this early<br />
diagnosis.<br />
Key words: Tuberculosis, granulomatous, meninges, Mantoux test<br />
Tuberculosis (TB) is a specific infectious<br />
granulomatous disease caused by Mycobacterium<br />
tuberculosis. It commonly affects<br />
lungs but can also affect the intestines, meninges,<br />
bone, joints, lymph glands, skin and other tissues of<br />
the body. The tubercle bacilli spread via:<br />
• Droplet infection<br />
• Inhalation<br />
• Unpasteurized cow’s milk<br />
On March 24, 1882, Robert Koch discovered the<br />
tubercle bacillus. Anti-TB treatment has been available<br />
since the 1940s and 1950s, making TB 100% curable;<br />
yet, in 1993, the World Health Organization (WHO)<br />
had declared TB a global emergency. 10<br />
The case rate varies from one region to another<br />
and is dependent on factors that favor spread of<br />
communicable disease, such as poor living conditions,<br />
low socioeconomic status, low native resistance<br />
and compromised immunity from debilitating or<br />
immunosuppressed conditions. Of particular concern<br />
is the sharp rise of this disease in people with AIDS<br />
and the implications for further control.<br />
*Professor and Head, Dept. of Oral Pathology<br />
Madha Dental College, Chennai<br />
**Professor, Dept. of Oral Pathology<br />
Raja Muthaiah Dental College, Annamalai University, Chennai<br />
†<br />
Senior Lecturer, Dept. of Oral Pathology<br />
Madha Dental College, Chennai<br />
‡Reader, Dept. of Oral Pathology<br />
Kalinga Dental College, Bhuvaneswar<br />
Address for correspondence<br />
Dr M Sathish Kumar<br />
Madha Dental College, Chennai<br />
E-mail: samanander@yahoo.co.in<br />
The HIV pandemic provides further evidence of<br />
the interplay between TB infection and immunity.<br />
Exposure to TB carries a 10% annual risk of disease in<br />
HIV-positive individuals, compared to a 5% lifetime<br />
risk in the absence of HIV. 10<br />
The emergence of multiple drug-resistant forms of TB<br />
has also raised concerns among health officials in many<br />
cities.<br />
The purpose of this article is to emphasize the<br />
importance of early diagnosis of primary TB of the<br />
mouth, which may be misdiagnosed when oral<br />
lesions are not associated with any apparent systemic<br />
infection. This not only helps in understanding the<br />
disease process but also provides an invaluable aid in<br />
the clinical diagnosis and patient management.<br />
Human TB is principally transmitted by inhalation of<br />
bacilli in moist droplets coughed out by individuals<br />
with open pulmonary TB. Dried bacilli in dust appear<br />
to be less of a health hazard. As a general rule, only<br />
sputum smear-positive individuals are infectious;<br />
l ml of sputum from these individuals contains at least<br />
5,000 tubercle bacilli. Most transmission of the disease<br />
occurs within households, or other environments,<br />
where individuals are close together for long periods<br />
of time.<br />
Primary Tuberculosis<br />
Primary TB is usually symptomless and passes<br />
unnoticed and undiagnosed. Diagnosis is usually made<br />
after a routine chest X-ray or Mantoux test, often as part<br />
of the process of tracing contacts of known patients or<br />
246 Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
original research<br />
during pre-employment health screening. Occasionally,<br />
the primary infection may cause a mild febrile illness,<br />
with or without cough that lasts for about one week.<br />
Medical help is usually not sought and the symptoms<br />
resolve spontaneously (Fig. 1).<br />
Post-primary Tuberculosis<br />
The onset of pulmonary post-primary TB is usually<br />
insidious with no specific symptoms. It is often<br />
diagnosed by chance after a routine chest X-ray. Postprimary<br />
TB is a disease with many variants. When<br />
patients become symptomatic, they often complain of<br />
nonspecific symptoms such as malaise, fever, weight<br />
loss and night sweats. The most commonly presenting<br />
feature is cough which may be either dry or purulent<br />
and blood-stained. Hemoptysis is rare and is usually a<br />
sign of more advanced disease.<br />
Figure 1. Patient with pulmonary TB.<br />
Investigations<br />
For control of the disease to be successful, it is<br />
important not only to diagnose TB, but also to identify<br />
those with asymptomatic infection, who may require<br />
treatment so that they do not infect others. The three<br />
main investigation 6 used are:<br />
• Chest X-ray<br />
• Tuberculin testing<br />
• Bacteriological examination<br />
Figure 2. Materials for biopsy.<br />
Incidence of Oral Tuberculosis<br />
Komet (1965), 8 Stephen (1977), 9 Addlestone (1979) 1<br />
have stated that the occurrence of TB in the oral cavity<br />
and jaw bones is rare.<br />
Literature has shown considerable variation in the<br />
incidence of oral TB. The reported incidence of<br />
clinical oral involvement, particularly as a secondary<br />
manifestation of the disease by Rubin (1975), 2 Brodsky<br />
(1942), 7 Komet (1965), 8 Gupta KB (1977), 4 Rauch<br />
(1978), 5 Purohit et al (1985), 3 ranged from 0.05 to<br />
1.44%. However, performed autopsies on 141 patients<br />
who died of TB and found oral lesions in 19.9% of<br />
cases. Although oral TB can affect all age groups, the<br />
majority of patients are middle-aged and older persons.<br />
Males are affected more frequently than females.<br />
Figure 3. Material for Ziehl-Neelsen staining.<br />
Predisposing Factors<br />
The onset of oral TB infection depends on certain<br />
Figure 4. Material for hemoglobin estimation.<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
247
original research<br />
systemic and local factors including lowered host<br />
resistance and increased virulence of the organisms.<br />
• Poor oral hygiene<br />
• Local trauma<br />
• Pre-existing lesions such as leukoplakia<br />
• Periapical granulomas<br />
• Dental cysts<br />
• Dental abscess<br />
• Jaw fractures<br />
• Periodontitis<br />
Figure 5. Material for ESR.<br />
Aims and Objectives<br />
The objective of this study was to inform the<br />
professionals about the oral manifestations of TB.<br />
Material and Methods<br />
We recruited 227 patients with pulmonary TB<br />
belonging to both sexes (136 males and 91 females).<br />
They were examined for lesion of oral TB. Hematological<br />
and radiological investigations were done, including<br />
sputum smears by Ziehl-Neelsen (ZN) and Fite’s<br />
staining techniques to detect tubercle bacilli. Suspected<br />
lesions were biopsied. The material for biopsy, material<br />
for ZN, material for hemoglobin estimation, material<br />
for erythrocyte sedimentation rate (ESR) are shown in<br />
the Figures 2-5.<br />
Figure 6. Histopathology of periapical granuloma.<br />
Observations<br />
The following observations were made.<br />
• Oral manifestations were seen in 0.88% of patients<br />
with pulmonary TB.<br />
• The incidence of oral lesions in males was 0.7%<br />
and that in females was 1.09%.<br />
• The oral manifestations occurred most commonly<br />
in the age group of 31-45 years (0.88%).<br />
• The mean hemoglobin (g/dl) was 10.4 ± 15.01 in<br />
males and 9.71 ± 14.23 in females.<br />
• ESR was raised in all patients. The mean of ESR<br />
was 22.6 ± 80.44 in males and 10 ± 21.5 in<br />
females.<br />
• The mean total leukocyte count (per cumm) was<br />
7,507 ± 15.26 in males and 9,451.53 ± 14.27 in<br />
females.<br />
• The mean value of lymphocyte count (%) observed<br />
Figure 7. Histopathology of osteomyelitis.<br />
was 56.77 ± 30.69 in males and 60.11 ± 18.8 in<br />
females.<br />
• The mean value of eosinophil (%) was 0.69 ±<br />
47.24 in males and 0.91 ± 33.5 in females.<br />
• The mean value of basophil (%) was 0.55 ± S9.1<br />
in males and 0.54 ± 40.9 in females.<br />
• The mean value of monocyte (%) was 1.12 ± 29.08<br />
in males and 1.13 ± 20.2 in females.<br />
248<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
original research<br />
The sputum smear of all the subjects was positive by<br />
both ZN and Fite’s staining methods. Sputum smear by<br />
ZN method revealed a mean bacilli count of 43.17%,<br />
33.48%, 23.34% in field of 1, 10, 30 and respectively.<br />
The overall mean was 4.8 ± 2.4. Histopathology<br />
pictures of periapical granuloma and osteomyelitis are<br />
shown in the Figures 6-7.<br />
Conclusion<br />
It needs to be pointed out that not all patients with<br />
pulmonary TB had oral manifestations. The incidence<br />
of oral lesions was less. However, most patients in<br />
the study were treated patients or under treatment.<br />
Of particular concern is the sharp rise of pulmonary<br />
TB within the AIDS affected population and the<br />
implications for further control. The HTV pandemic<br />
provides further evidence of the interplay between TB<br />
and immunity. Hence, early diagnosis of oral lesions<br />
not only helps to prevent needless delays in treatment,<br />
it also helps to eliminate the expense of unnecessary<br />
laboratory tests and consultations.<br />
References<br />
1.<br />
Addlestone RB, Witt WS, Kaiser AB. Tuberculosis<br />
of the mandible presenting as ‘lumpy jaw’. JAMA<br />
1979;241(23):2544-5.<br />
2.<br />
3.<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
Rubin CH. Tuberculosis of tongue. J Oral Surg<br />
1975;32:311-5.<br />
Purohit SD, Mathur BB, Gupta PR, Agarwal KC, Hathi<br />
HH. Tuberculous fistula of cheek. Report of a case. Oral<br />
Surg Oral Med Oral Pathol 1985;60(1):41-2.<br />
Strull GE, Dym H. Tuberculosis: diagnosis and<br />
treatment of resurgent disease. J Oral Maxillofac Surg<br />
1995;53(11):1334-40.<br />
Rauch DM, Friedman E. Systemic tuberculosis initially<br />
seen as an oral ulceration: report of case. J Oral Surg<br />
1978;36(5):387-9.<br />
Cotran, Kumar, Robbins. Robbins Pathologic Basis of<br />
Disease. 4th edition, WB Saunders Co, 1989:p63-8.<br />
Brodsky RH, Klattel JS. The tuberculous dental<br />
periapical granuloma. Am J Orthod Oral Surg<br />
1943;29(9):B498‐B502.<br />
Komet H, Schaefer RF, Mahoney PL. Bilateral<br />
tuberculous granulomas of the tongue. Arch Otolaryngol<br />
1965;82(6):649-51.<br />
Stephen AS, Eisenbud L. Tuberculous osteomyelitis<br />
of the mandible. Oral Surg Oral Med Oral Pathol<br />
1977;44(3):425-9.<br />
10. Styblo K. Overview and epidemiologic assessment of the<br />
current global tuberculosis situation with an emphasis on<br />
control in developing countries. Rev Infect Dis 1989;11<br />
Suppl 2:S339-46.<br />
• • •<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
249
Original research<br />
Comparison of Efficiency of Various Cleansing Techniques<br />
on Dentin Wettability Using Contact Angle Test<br />
M Dilipkumar*, Shafath Ahmed**, M Dhivya †<br />
Abstract<br />
Aim: To evaluate the effect of different cleansing techniques in removing the residual provisional cement on prepared abutment<br />
teeth and their influence on wetting properties of dentin. Materials and Methods: Forty coronal portions of human third<br />
molar were mounted in acrylic resin blocks and prepared until dentin was exposed. Specimens were divided into two groups:<br />
Group A and Group B. To simulate the Provisional restoration, discs were made with autopolymerizing resin and specimens<br />
in Group A were luted with Zinc oxide eugenol and Group B with Freegenol cement. All specimens were stored in distilled<br />
water at room temperature for 24 hrs and provisional cements were mechanically removed with explorer and rinsed with<br />
water. Subsequently each group was further divided into four subgroups depending upon the various surface treatments<br />
(Control-air-water spray, Pumice prophylaxis, Ultrasonic scaler with 0.2% Chlorhexidine gluconate, 17% EDTA). Contact<br />
angle measurements were performed to assess wettability of various cleansing agents using the Axisymmetric Drop Shape<br />
Analysis - Contact Diameter (ADSA-CD) technique. Results: Specimens treated with EDTA showed the lowest contact angle<br />
for both the groups. SEM showed that EDTA was most effective solution to remove the smear layer, and pumice prophylaxis<br />
leaves large remnant particles.<br />
Key words: Contact angle, axisymmetric drop shape analysis - contact diameter (ADSA-CD) technique<br />
Residual provisional cements and debris on<br />
prepared abutment teeth may negatively<br />
influence the performance of the definitive<br />
luting agent1. Apart from the choice of restorative<br />
materials, clinical outcome may be influenced<br />
by factors such as tooth preparation, preparation<br />
coarseness, type of luting agent, fit of restoration, type<br />
of provisional cement and also cleansing techniques<br />
used to remove the remnants of provisional cements.<br />
Indirect restorations usually require temporization<br />
for protection of the pulp and to restore the patients<br />
esthetic and functional needs. Terata et al 2 showed that<br />
both residual Zinc Oxide Eugenol and Non Eugenol<br />
containing temporary cements reduced the tensile bond<br />
*Senior Lecturer<br />
**Reader<br />
Dept. of Prosthodontics<br />
SRM Kattankulathur Dental College, Chennai<br />
†<br />
Reader<br />
Dept. of Orthodontics<br />
SRM Kattankulathur Dental College, Chennai<br />
Address for correspondence<br />
Dr Dilip Kumar<br />
Senior Lecturer<br />
Dept. of Prosthodontics, SRM Kattankulathur Dental College<br />
Kanchipuram, Chennai<br />
E-mail: dilipcanine@gmail.com<br />
strength of resin luting agents. For this reason, it is<br />
imperative to remove any remnants of the provisional<br />
luting agent.<br />
Several investigators have studied removal of<br />
provisional cements in vitro. Grasso et al3 showed that<br />
pumice cleansing was known to be more effective than<br />
other cleansing techniques such as explorer/air-water<br />
technique or with 0.12% chlorhexidine gluconate.<br />
Others 4,5 showed that removal of provisional cement<br />
with explorer and use of soap was incomplete and<br />
not recommended for clinical use. Adhesion involves<br />
intimately joining two materials and the contact may<br />
be physical or chemical. For this reason, the resin must<br />
wet the dentinal surface to produce sound adhesion. The<br />
manner in which liquid spreads on a surface expresses<br />
the wettability of the surface. High wettability provides<br />
intimate contact and enhanced adhesion. 6<br />
The newer generation resin cements offer numerous<br />
advantages over conventional cements like good<br />
bonding to dentin, thereby reducing microleakage,<br />
reduced film thickness and almost negligible water<br />
solubility.<br />
The inherent drawbacks associated with resin cements<br />
like microleakage (due to inadequate bonding), higher<br />
250 Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
original research<br />
film thickness and colour instability have been largely<br />
superceded in the newer generation resin luting agents,<br />
thus making their use universal and widespread.<br />
Provisional cements contamination on dentin surface<br />
may interfere with the spreading and penetration of<br />
resin through the dentinal tubules. To increase the bond<br />
strength of resin, acids have been used to demineralize<br />
the dentin surface and to remove the subsequent debris<br />
and remnants of provisional cements present in it.<br />
This In-vitro study is aimed to evaluate<br />
• The influence of these cleansing methods on<br />
wetting properties of the dentin by Axisymmetric<br />
drop Shape Analysis – Contact Diameter technique<br />
(ADSA-CD).<br />
• Cleanliness of resulting dentin surfaces under a<br />
field emission scanning electron microscope.<br />
Materials and Methods<br />
Forty freshly extracted unrestored, caries-free third<br />
molars were cleaned and stored in normal saline at room<br />
temperature. The roots were sectioned at the cementoenamel<br />
junction and the coronal portion were separated<br />
mesiodistally with a water cooled diamond coated<br />
disc. Specimens were then mounted with the buccal or<br />
lingual surfaces facing upward with autopolymerizing<br />
resin (Denture base polymer resin, DPI-RR Cold cure,<br />
India). The buccal and lingual surfaces were prepared<br />
with a standard-grit diamond rotary cutting instrument<br />
until the dentin surface was reached and preparation<br />
was finished with a fine-grit diamond instrument.<br />
To simulate the provisional restoration, discs (3 mm ×<br />
1 mm) were made with autopolymerizing resin (DPI,<br />
Self cure tooth moulding powder, India) and luted<br />
with provisional cement.<br />
All specimens were stored in distilled water at room<br />
temperature for 24 hours. After that, provisional<br />
cements were mechanically removed with explorer until<br />
the dentin surface appeared macroscopically clean and<br />
then dentin surface was thoroughly rinsed with water.<br />
The specimens were divided into two groups (n = 20)<br />
as follows:<br />
• Group A: Specimens cemented with Zinc oxide<br />
Eugenol cement (Dental products of India Ltd).<br />
• Group B: Specimens cemented with Freegenol<br />
cement (Rely X Temp NE, 3M ESPE, Germany)<br />
Subsequently each group was further divided into<br />
4 subgroups (n = 5) according to different surface<br />
treatments as follows:<br />
Subgroup I: Control group - Air water spray<br />
Subgroup II: Cleaned with pumice prophylaxis<br />
Subgroup III: Cleaned with ultrasonic scaler using<br />
0.2% chlorhexidinegluconate as irrigant<br />
Subgroup IV: Scrubbed with cotton pellet soaked in<br />
17% EDTA for 15 seconds (Glyde, Dentsply, USA)<br />
Contact angle test<br />
For contact angle measurement, the Axisymmetric<br />
Drop Shape Analysis – Contact Diameter technique<br />
(ADSA – CD) was used. This technique permits<br />
measurement of the contact angle of sessile drops<br />
when they have a flat profile. This measurement was<br />
made on an anti-vibrational table. One 10µL drop<br />
of deionised water was placed on the cleansed dentin<br />
surface of the prepared specimen and the Scontact angle<br />
was measured. The drop image was captured with a<br />
micro video system when the drop was in equilibrium.<br />
The video signal was transmitted to a computer that<br />
provided the contact angle values.<br />
SEM Observation<br />
Composite (Esthet X Micromatrix restorative<br />
Dentsply, USA) was placed into a plastic transparent<br />
mould of 3 mm diameter and 1mm height and cured<br />
for 20 seconds. Dentin surfaces were etched, dentin<br />
adhesive and dentin bonding agent were applied<br />
according to manufacturer’s instructions. Resin luting<br />
agent (Variolink II, Ivoclar Vivadent, Liechtenstein)<br />
was placed in between composite and dentin surface.<br />
Each specimen was polymerized for 40 seconds at a<br />
distance of 1mm using visible light polymerizing unit<br />
and specimens were stored in distilled water at room<br />
temperature for 24 hours. All specimens were allowed<br />
to dry overnight and were then gold – sputtered and<br />
examined under scanning electron microscope (SEM)<br />
at 15 Kv. The SEM photomicrographs were observed<br />
with 1000x magnification.<br />
Results<br />
The readings are tabulated and the mean, standard<br />
deviation and test of significance of mean values<br />
between the groups were studied using<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
251
original research<br />
SEM Observation:<br />
Plate 1A. Group A ,<br />
Subgroup I<br />
Plate 2A. Group A ,<br />
Subgroup II<br />
Plate 1B. Group B,<br />
Subgroup I<br />
Plate 2B. Group B,<br />
Subgroup II<br />
Table 1. Contact angle values for Zinc-oxide Eugenol<br />
(Group A)<br />
Sub Group Mean ± SD p-value Significance<br />
group at 5% level<br />
I 69.041 ± 0.412<br />
II 63.15 ± 0.845<br />
III 67.389 ± 1.05<br />
IV 62.609 ± 0.635<br />
0.001 IV Vs I, III<br />
Table 2. Contact Angle Values for Freegenol group<br />
(Group B)<br />
Sub Group Mean ± SD p-value Significance<br />
group at 5% level<br />
I 68.459 ± 0.599<br />
II 64.271 ± 0.083<br />
III 65.786 ± 0.639<br />
IV 62.686 ± 0.736<br />
0.001<br />
I Vs II, III, IV<br />
II Vs I, III, IV<br />
III Vs I, II, IV<br />
IV Vs I, II, III<br />
Plate 3A. Group A ,<br />
Subgroup III<br />
Plate 3B. Group B,<br />
Subgroup III<br />
Plate 4A. Group A ,<br />
Subgroup IV<br />
Plate 4B. Group B,<br />
Subgroup IV<br />
• One way ANOVA - to calculate the p value<br />
• Multiple range Tukey HSD procedure - to identify<br />
the significant groups at 5% level.<br />
In Group A, the mean contact angle of Sub group IV is<br />
significantly lower than the Sub group I and Sub group<br />
III (Table 1) In Group B, the mean contact angle value<br />
of Sub Group IV is significantly lower than the mean<br />
contact angle of Sub group II followed by Sub group<br />
III and Sub group I (Table 2).<br />
Under SEM Observation, widespread remnants of the<br />
provisional cements were seen on the micrograph of<br />
the untreated dentin surface (Plate 1. A and B). The<br />
use of pumice prophylaxis for both zinc oxide eugenol<br />
and freegenol groups produced a smoother and cleaner<br />
surface than for other groups, despite formation<br />
of large remnant particles (Plate 2. A and B). The<br />
remnants smeared to the surface were more evident<br />
on the dentin cleansed with the ultrasonic scaler with<br />
0.2% chlorhexidine gluconate irrigant (Plate 3. A<br />
and B). According to Plate. 4 A and B, which shows<br />
that 17% EDTA was most effective solution to<br />
remove the smear layer.<br />
Discussion<br />
The adverse effects of residual eugenol from the<br />
provisional cements on the bonding characteristics of<br />
subsequent restorations have been well documented. 7,8,9,10<br />
Several investigators 2,3 have hypothesized that different<br />
cleaning techniques for the removal of the provisional<br />
cement remnants from the dentin, like air-water spray,<br />
pumice prophylaxis, and use of cleansing agents affect<br />
the bond strength of resin luting agent to the dentin<br />
and the water contact angle of the dentin surface. After<br />
tooth preparation, the dentin is covered with a smear<br />
layer that is composed primarily of cut, mineralized<br />
collagen fibrils. There is no structural continuity<br />
between the smear layer particles and the underlying<br />
dentin. 11 However the smear layer forms a barrier<br />
252<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
original research<br />
that covers the dentin surface, blocking the orifices of<br />
dentin tubules and forming smear plugs.<br />
When Eugenol containing provisional cement is applied<br />
on the smear layer, eugenol leaches into and through<br />
the smear layer to the dentin tubules, contaminating<br />
the dentin surface. 12 After the removal of the provisional<br />
cements, the dentin surface is still covered by the smear<br />
layer, which contains the absorbed eugenol and cement<br />
remnants.<br />
Various techniques of removing the smear layer have<br />
been used in literature. 13,14,15 In comparison, EDTA<br />
and pumice prophylaxis have been found to be more<br />
effective in cleaning the remaining dentinal surface of<br />
residual debris and the smear layer. 16,17,18 Cameron 19<br />
claimed that cleanliness is achieved following<br />
ultrasonically agitated irrigation with distilled water.<br />
For this reason the effectiveness of pumice prophylaxis,<br />
ultrasonic scaler with 0.2% chlorhexidine gluconate<br />
irrigant and cleaning the dentin surface with 17%<br />
EDTA were used in this study to remove the remnants<br />
of the provisional cement from the dentin surface and<br />
the performance of the definitive luting agent was<br />
investigated.<br />
Scleza et al 20 showed that irrigation with 17% EDTA<br />
solution has a good cleaning effect on the dentinal<br />
tubules. Hulsmann 21 et al have reported that 17%<br />
EDTA has a good cleansing effect on dentin and<br />
removes the smear layer by dissolving the inorganic<br />
compounds. This ensures better penetration of resin<br />
and subsequently increases the shear bond strength<br />
values.<br />
The presence of any remnants of provisional luting<br />
agent could interfere with dentin wetting. 22 The result<br />
of the present study showed that the different cleansing<br />
techniques altered the dentin wetting characters. The<br />
extent to which a liquid drop will wet the dentin<br />
surface depends on the chemical interactions between<br />
the liquid and the dentin, physical considerations such<br />
as capillary action, the roughness of the dentin and the<br />
surface energy. 12,23<br />
According to Table 1 and 2, the lowest contact angle<br />
were obtained with 17% EDTA for both Zinc-oxide<br />
Eugenol and Freegenol groups, which indicates that<br />
EDTA is more effective at removal of the remnant of<br />
the provisional cement and the smear layer, so EDTA<br />
creates appropriate physical and chemical interactions<br />
between the resin cement and dentin.<br />
In the present study, all specimens were contaminated<br />
with the provisional cements. However the results of<br />
contact angle analysis showed significant differences<br />
(p
original research<br />
Conclusion<br />
Within the limitation of this study, it was concluded<br />
that<br />
• Significant differences were found with the different<br />
cleansing techniques evaluated.<br />
• EDTA showed the lowest contact angle for both<br />
the groups.<br />
• SEM showed that EDTA was most effective<br />
solution to remove the smear layer, and pumice<br />
prophylaxis leaves large remnant particles.<br />
References<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
Ayad MF, Rosensteil. Surface roughness of dentin after<br />
tooth preparation with different rotary instrumentation.<br />
J. Prosthet Dent 1996;75:122-8.<br />
Tereta et al. Characterization of enamel and dentin<br />
surfaces after removal of temporary cement. Dent<br />
Mater. J 1993;12:18-28.<br />
Grasso et al. In vivo evaluation of three cleansing<br />
techniques for prepared abutment teeth. J Prosthet<br />
Dent 2002;88:437-41.<br />
Bachmann et al. Effect of cleansing dentin with soap<br />
and pumice on shear bond strength of dentin - bonding<br />
agents. J Oral Rehab 1997;24:433-8.<br />
Rodrigo et al. Influence of provisional cements on<br />
ultimate bond strength of indirect composite restoration<br />
to dentin. J Adhes Dent 2005;7:225-30.<br />
Rosales et al. Influence of eugenol contamination on<br />
the wetting of ground and etched dentin. Oper. Dent<br />
2003;28:695-9.<br />
Hansen EK et al. Influence of temporary filling<br />
materials of effect of dentin bonding agents. Scand<br />
J Dent Res 1987;95(6):516-20.<br />
Meyerowitz JM et al. The effect of eugenol containing<br />
and non-eugenol temporary cements on the resin enamel<br />
bond. J Dent Assoc S Africa 1994;49(8):389-92.<br />
Ngeh EC et al. Effects of eugenol on resin bond strengths<br />
to root canal dentin. J Endod 2001;27(6):411-4.<br />
10.<br />
11.<br />
12.<br />
13.<br />
14.<br />
15.<br />
16.<br />
17.<br />
18.<br />
19.<br />
20.<br />
21.<br />
22.<br />
23.<br />
Yap et al. Influence of eugenol – containing temporary<br />
restorations on bond strength of composite to Dentin.<br />
Oper. Dent 2001;26:556-61.<br />
Dugu sarac et al. Effect of the dentin cleaning technique<br />
on dentin wetting and on the bond strength of a resin<br />
luting agent. J Prosthet Dent 2005;94:363-9.<br />
Kielbasa et al. Diffusion behaviour of eugenol from zinc<br />
oxide eugenol mixtures through human and bovine<br />
dentin invitro. Oper. Dentistry 1997;22(1):15-20.<br />
Duke E.S. et al. Effect of various agents in cleaning cut<br />
dentin. J Oral Rehab. 1985; 12(4): 295-302.<br />
Takeda FH et al. A comparative study of the removal of<br />
smear layer by three endodontic irrigants and two types<br />
of laser. Int Endod J 1999;32(1):32-9.<br />
Peters D et al. Effect of eugenl-containing sealer on<br />
marginal adaptations of dentin-bonded resin fillings. Int.<br />
Endod. J 2000;33(1):53-9.<br />
Grasso et al. In vivo evaluation of three cleansing<br />
techniques for prepared abutment teeth. J Prosthet Dent<br />
2002;88:437-41.<br />
Abatt et al. An SEM study of the effects of different<br />
irrigation sequences and ultrasonics. Int Endod J 1991;<br />
24(6):308-16.<br />
Brammstrom et al. The effect of EDTA containing<br />
surface-active solvents on the morphology of prepared<br />
dentin : an invivo study. J Dent Res 1992;59:1127-31.<br />
Cameron. Factors affecting the clinical efficiency of<br />
ultrasonics endodontics. A scanning electro microscopy<br />
study. International Endodontic J 1995;28:47-53.<br />
Scleza et al. Efficacy of funal irrigation - A scanning<br />
electron microscopic evaluation. J Endodontics 2000;<br />
26:355-8.<br />
Hulsmann et al. Chelating agents is root canal treatment<br />
mode of action and indications for their use. Int End<br />
J 2003;36:810-30.<br />
Aykent F et al. Effects of provisional restorations on<br />
the final bond strengths of porcelain laminate veneers.<br />
J Oral Rehab 2005;32:46-50.<br />
Kenneth J. Anusavice. In: Philips science of Dental<br />
Materials. 11th Ed: 38-9.<br />
• • •<br />
254<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Effect of Surface Treatments on Push-out Strength<br />
of Three Glass Fiber Posts: An in vitro Study<br />
AVK Narene*, P Shankar**, R Indira**<br />
clinical study<br />
Abstract<br />
This in vitro study evaluated whether surface treatment for glass fiber posts has an effect on the push-out strength bonded to<br />
human root dentin. Fifty freshly extracted maxillary central incisors were endodontically-treated and post space preparation<br />
was done. A total of 50 FRC Postec, randomly divided into five groups (10 teeth each) were subjected to four different surface<br />
treatments: Silane only (II), Cojet and Silane (III), 10% sodium ethoxide and silane (IV) and 10% hydrogen peroxide (V). The<br />
control group (I) did not receive any surface treatment. The root canals were treated with 37% phosphoric acid and Excite<br />
DSC and all the posts were luted with Variolink II dual cure resin. A push-out test was done to measure bond strength at<br />
different levels of the root. Data were analyzed with one-way ANOVA and post-hoc Tukey HSD test. The results showed no<br />
significant differences between control group and silane treatment. Cojet and Silane (III) showed the highest bond strength<br />
of 15.50 ± 4.2 MPa, which was statistically significant than all the other group (p < 0.001). The coronal segment showed the<br />
highest mean bond strength of 13.74 ± 6.1 MPa (p < 0.001).<br />
Key words: Post, push-out bond strength, surface treatment<br />
The challenge of restoring endodontically-treated<br />
teeth has spawned a considerable diversity<br />
in foundation restorations and a plethora of<br />
publications in dental literature. 1 Pulpless teeth pose<br />
several challenges due to the loss of tooth structure as<br />
a result of caries, defective restoration and endodontic<br />
access preparations.<br />
Use of post system for the rehabilitation of<br />
endodontically-treated teeth requires planning in order<br />
to restore function of the tooth as well as structural<br />
and esthetic strategies. Currently, increasing demand<br />
for esthetic posts and cores has led to the development<br />
of zirconia and fiber posts. 2 These post systems have<br />
been developed to improve the optical effect of esthetic<br />
restorations. 3 Newer adhesive systems and resin-based<br />
luting agents create a genuine adhesive continuum<br />
between the tooth and the post core complex. The use<br />
of these bondable materials allows the practitioner to<br />
unify the structure and morphology of root systems. 4<br />
Zirconium oxide posts demonstrate high fracture<br />
resistance due to high flexural strengths, which is<br />
*Senior Lecturer, Dept. of Conservative and Endodontics<br />
Sree Balaji Dental College and Hospital, Chennai<br />
**Professor, Dept. of Conservative and Endodontics<br />
Ragas Dental College and Hospital, Chennai<br />
Address for correspondence<br />
Dr AVK Narene<br />
8/4, East Tank Street, Thiruvottiyur, Chennai - 600 019<br />
comparable to that of cast gold and titanium posts.<br />
But the fracture of zirconium oxide posts often results<br />
in unrestorable damage to the tooth, whereas in vitro<br />
studies on fracture strength of FRC posts show more<br />
favorable mode of failure. The modulus of elasticity of<br />
FRC posts is closer to that of dentin and distributes<br />
stress evenly over a broad surface area. 5,6<br />
Fiber posts are bonded with resin-luting cements,<br />
which allow the formation of a single unit where<br />
tooth, post and core function as a cohesive unit-<br />
Monobloc configuration. 7 The clinical success of post<br />
retention depends on the bonding of post to the luting<br />
cement and luting cement with the dentin. 8 Surface<br />
treatments are methods by which general adhesive<br />
properties of a material are enhanced by facilitating<br />
chemical and micromechanical retention between<br />
different constituents. 9,10 Various methods of surface<br />
treatments for fiber posts are sand blasting, hydrogen<br />
peroxide (H 2<br />
O 2<br />
), Silane, potassium permanganate,<br />
sodium ethoxide, etc.<br />
Aims and Objectives<br />
In view of the fact that the primary cause of failure of<br />
fiber posts is debonding, the objective of this study was<br />
to test the effect of various surface treatments on the<br />
push-out bond strength of glass fiber posts. The null<br />
hypotheses tested in this study were:<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
255
CLINICAL STUDY<br />
• The use of Silane coupling agent alone does not<br />
have effect on the bond strengths of fiber posts.<br />
• There is no measurable difference in bond strength<br />
after different surface treatment.<br />
• There is no measurable difference in bond strength<br />
at different levels of root.<br />
Methodology<br />
Fifty freshly extracted single rooted human maxillary<br />
central incisors, free of caries and fractures without<br />
any significant canal curvatures and with type 1<br />
canal configuration, were selected and stored in 0.9%<br />
physiologic saline until root canal treatment was<br />
performed. Crowns were decoronated to the level<br />
of cementoenamel junction for all samples using a<br />
diamond disc and pulp was extirpated using barbed<br />
broaches.<br />
An initial 10 size K-file was passed in the canal till its tip<br />
could be seen at the apex and the length was measured.<br />
Working length was calculated by subtracting 1 mm<br />
from the measured length of the initial 10 size K-file.<br />
The coronal third of the canal was prepared using GG<br />
drills from sizes 4 to 1, while apical- and middle-third<br />
were prepared manually with Kfiles using step back<br />
technique. The standard irrigants used in the study<br />
were 3% sodium hypochlorite, 17% EDTA (ethylenediaminetetraacetic<br />
acid) and 0.9% physiological<br />
saline. Master apical size of #35 was standardized and<br />
obturation was done by lateral condensation technique<br />
with AH Plus sealer.<br />
Post space preparation was done using the corresponding<br />
drill supplied by the manufacturer leaving 5 mm of<br />
apical gutta-percha for all the samples. The canals<br />
were then irrigated with distilled water and dried with<br />
paper points. The canal walls of all the experimental<br />
samples were then etched with 37% orthophosphoric<br />
acid gel for 15 seconds using an applicator tip. The<br />
canal walls were then irrigated with distilled water to<br />
remove the excess etchant from the canal and dried<br />
with paper points. The bonding agent Excite DSC<br />
(Ivoclar Vivadent) was applied with Microbrush all<br />
over the prepared post space of the root canal and light<br />
cured for 20 seconds from the orifice. All the samples<br />
were randomly assigned into five experimental groups<br />
of 10 teeth each.<br />
Box 1. Surface Treatment of Posts<br />
• Group I (n = 10): No surface treatment<br />
• Group II (n =10): Silane treatment only (The posts were<br />
surface-treated with Silane coupling agent (Monobond-S)<br />
for 60 seconds and then gently air-dried)<br />
• Group III (n = 10): Cojet and Silane treatment (The posts<br />
were sandblasted (Cojet) for 30 seconds and then treated<br />
with Silane coupling agent for 60 seconds and then gently<br />
air-dried)<br />
• Group IV (n = 10): 10% H 2<br />
O 2<br />
and Silane treatment (The<br />
posts were immersed in 10% H 2<br />
O 2<br />
for 5 minutes, washed<br />
with distilled water and treated with Silane solution for 60<br />
seconds and then gently air-dried)<br />
• Group V (n = 10): Sodium ethoxide and silane treatment<br />
The fiber post FRC Postec (Ivoclar Vivadent) - 1.0<br />
mm diameter (Tip) (n = 50) were grouped as shown<br />
in Box‐1.<br />
The posts were immersed in freshly prepared solution of<br />
sodium ethoxide for five minutes, washed with distilled<br />
water and treated with Silane solution (Monobond-S)<br />
for 60 seconds and then gently air-dried. All the posts<br />
were then luted with Variolink II (Ivoclar Vivadent)<br />
dual cure resin cement. After luting, the samples were<br />
stored in 100% humidity at 37°C and were subjected<br />
to a temperature of 45°C for three minutes, 5 times a<br />
day for 15 days.<br />
Push-out Bond Strength Testing<br />
The apical 5 mm of the samples containing guttapercha<br />
was cut-down with a diamond disc. From<br />
the remaining coronal segment of the samples, three<br />
cross-sections of 2 mm thickness from apical area were<br />
obtained and the thickness was checked with a digital<br />
vernier calipers. The specimens were then placed in an<br />
acrylic mold of 2 mm diameter and then subjected<br />
to push-out bond strength testing. Each section<br />
was attached to the acrylic mold with cyanoacrylate<br />
adhesive ensuring that the coronal surface faces<br />
the mold and the post was centered over the hole of<br />
2 mm diameter in the mold.<br />
The push-out mold was then placed in Lloyds Instron<br />
Universal Testing Machine. The cross-head was lowered<br />
at a speed of 1 mm/min until the post was dislodged.<br />
Push-out bond strengths were calculated for each<br />
section. All the values obtained were tabulated and<br />
subjected to statistical analysis.<br />
256<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
CLINICAL STUDY<br />
Results<br />
The highest mean push-out strength values were<br />
recorded in Group III (Cojet and Silane treatment):<br />
15.50 ± 4.2 MPa followed by Group V (Sodium<br />
ethoxide and Silane treatment): 12.04 ± 3.9 MPa<br />
and Group IV (10% H 2<br />
O 2<br />
and Silane treatment):<br />
11.9 ± 3.5 MPa as shown in Table 1. These results were<br />
analyzed using one-way ANOVA and post-hoc Tukey<br />
HSD test. Group III (Cojet and Silane treatment)<br />
was significant with all the other groups at p < 0.001<br />
level. There was no significant difference between<br />
Group I (No surface treatment) 10.43 ± 3.8 MPa and<br />
Group II (Silane treatment) 10.73 ± 3.5 MPa at p<br />
< 0.05 proving that there was no increase in bond<br />
strength of fiber posts that had undergone only Silane<br />
treatment.<br />
In all the experimental groups, the coronal segment<br />
showed the highest mean bond strength of<br />
13.74 ± 6.1 MPa. The lowest bond strength was<br />
observed with the apical segments (10.58 ± 5.1<br />
MPa). Coronal segments show a statistical significance<br />
(p < 0.001) when compared with the apical and middle<br />
segments.<br />
Discussion<br />
The restoration of endodontically-treated teeth is one<br />
of the extensively studied topics in endodontics and<br />
yet remains controversial from many perspectives.<br />
Today, a variety of posts are available that vary in<br />
composition, mechanical properties and structural<br />
geometry (Custom made cast post, prefabricated<br />
post, titanium post, zirconia and fiber posts). 11 Fiberreinforced<br />
technology is already used for a wide range<br />
of applications in dentistry - splints, complete dentures,<br />
fixed dentures, retainers, etc. Fibers have also been used<br />
for endodontic post build-up restorations to reinforce<br />
composite resins.<br />
Surface treatments are methods by which general<br />
adhesive properties of a material are enhanced by<br />
facilitating chemical and micromechanical retention<br />
between different constituents. As it has been<br />
hypothesized that the primary mode of failure of fiber<br />
posts is debonding, various surface treatment methods<br />
have been suggested to improve the bond between<br />
the post and the luting cement like sandblasting,<br />
silanization, hydrogen peroxide, sodium ethoxide<br />
etching, etc. 12,13<br />
Silanes are hybrid organic-inorganic compounds<br />
that can mediate adhesion between matrices through<br />
their intrinsic dual reactivity. Although the use of<br />
Silane coupling agents as adhesion promoters in fiber<br />
reinforced materials is well-established, their use in pretreatment<br />
of fiber posts still remains controversial. 14,15<br />
Bond integrity is challenged by the limited capacity to<br />
dissipate polymerization shrinkage stresses (C factor) in<br />
long narrow post spaces that exhibit highly unfavorable<br />
cavity geometry. 16-18<br />
The efficacy of one step (self-etch) adhesives in forming<br />
a durable bond with root dentin has been questioned. 19<br />
It was shown that the hybrid layers created by self-etch<br />
adhesives are not uniform and contain nanovoids that<br />
are permeable to water. This may adversely affect the<br />
longevity of bonded root canal fillings and posts. The<br />
increased collagenolytic activity in root dentin due to<br />
the less acidic primers of self-etch adhesives has also<br />
been recently demonstrated. 20 Therefore, a total etch<br />
technique was used in this study.<br />
Excite DSC, dual polymerizing single bottle agent was<br />
used as the bonding agent. The uniform formation of<br />
hybrid layer lies in the wetting of the adhesive entirely<br />
over the etched surfaces. The importance of microbrush<br />
in reaching the narrowest and deepest portion of root<br />
canal preparations has been shown by Vichi et al 21 and<br />
Ferrari et al. 8 This results in a deep diffusion of resin<br />
into the tubules and the formation of uniform hybrid<br />
layer and lateral branches. In an attempt to simulate<br />
the oral condition, a thermocycling protocol was done<br />
to all the test samples.<br />
Table 1. Push-out Bond Strength of Coronal, Middle and Apical Specimens<br />
Groups<br />
Subgroups<br />
I<br />
(MPa)<br />
II<br />
(MPa)<br />
III<br />
(MPa)<br />
IV<br />
(MPa)<br />
V<br />
(MPa)<br />
Coronal 11.9 ± 6.3 12.5 ± 7.2 17.1 ± 7.0 13.5 ± 4.9 13.7 ± 5.5<br />
Middle 10.5 ± 5.5 10.7 ± 6.9 15.2 ± 5.8 11.9 ± 5.2 12.0 ± 7.2<br />
Apical 8.9 ± 7.3 9.0 ± 6.8 14.2 ± 4.9 10.3 ± 6.6 10.5 ± 7.3<br />
Mean 10.43 ± 3.8 10.73 ± 3.5 15.5 ± 4.2 11.9 ± 3.5 12.04 ± 3.9<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
257
CLINICAL STUDY<br />
In a recent study of bonding of resin cements to fiber<br />
posts, it was found that the strength of the bond<br />
depended on the post material, the surface treatment<br />
of the post and the resin cement. 22 The role of Silane<br />
in the bonding of ceramics and composites has<br />
been established but its role in fiber post adhesion<br />
yet remains controversial. Silane due to its low<br />
viscosity would assist substrate wetting, and once an<br />
intimate contact between the interfacing materials is<br />
established, the van der Waals forces would become<br />
effective providing physical adhesion, which may lead<br />
to a tertiary monoblock structure from the existing<br />
secondary monoblock.<br />
The results showed no significant differences between<br />
Groups I and II (No surface treatment and Silane<br />
(10.43 ± 3.8 MPa and 10.73 ± 3.5, respectively)<br />
proving no increase in bond strength of fiber posts<br />
that had undergone only Silane treatment. Hence,<br />
the first null hypothesis tested holds good. These<br />
results were in accordance with the study by Perdigão<br />
et al 23 and Newman et al. 24 The highest mean pushout<br />
strength values were recorded in Group III (Cojet<br />
and Silane): 15.50 ± 4.2 MPa followed by Group V<br />
(Sodium ethoxide and Silane): 12.04 ± 3.9 MPa and<br />
Group IV (10% H 2<br />
O 2<br />
and Silane): 11.9 ± 3.5 MPa.<br />
These results show a statistically significant difference<br />
at p < 0.001.<br />
The highly crosslinked polymers of the matrix of the<br />
glass FRC posts used in this study do not have any<br />
free functional group for reaction. 22,23 This could be<br />
the possible reason for insignificant effect of the Silane<br />
when no surface treatment was done. Etching solutions<br />
such as sodium ethoxide, hydrogen peroxide, potassium<br />
permanganate have been commonly employed to<br />
partially remove the resinous superficial layer of the<br />
fiber posts containing epoxy resin matrix. Increased<br />
bond strength has been observed after the combined<br />
etching and silanization coupling from various studies<br />
than Silane treatment alone.<br />
In the present study, mechanical roughening using<br />
Cojet followed by Silane treatment achieved the<br />
highest bond strength of 15.5 MPa compared to<br />
chemical etching (10% H 2<br />
O 2<br />
, sodium ethoxide) and<br />
Silane treatment. These were significant at p < 0.001.<br />
Additionally, etching with chemical solutions yielded<br />
higher bond strength values than Groups I and II<br />
(Silane and non-Silane). Thus second null hypothesis<br />
tested was proven to be false.<br />
The coronal segment showed the highest mean bond<br />
strength of 13.47 ± 6.1 MPa. The lowest bond strength<br />
was observed with the apical segments. Coronal<br />
segments show a statistical significance (p < 0.001)<br />
when compared with the apical and middle groups.<br />
But no statistical difference was observed between the<br />
middle and apical segments (p > 0.001). These results<br />
were in consistent with the studies of Boff et al, 6 Kalkan<br />
et al 16 and Perdigão et al. 23<br />
Adhesion to root dentin is a viable procedure; but,<br />
structural differences exist between coronal and<br />
radicular dentin. Tubule density is greatest in the<br />
coronal- and middle-third than the apical-third of the<br />
root. As adhesion is enhanced by the penetration of<br />
resin into the tubules, if there were a greater number of<br />
tubules per mm 2 , a stronger bond would be expected.<br />
Moreover, the coronal portion of the canal is the most<br />
accessible part for the canal space, making it easier for<br />
thorough application of the adhesive and therefore<br />
formation of resin tags is more uniform than the deeper<br />
areas of the canal. Hence, the third null hypothesis<br />
tested was proven to be false.<br />
Thus, mechanical roughening of the post (Cojet) and<br />
silanization was proven to be more effective than the<br />
use of the etching solutions and Silane.<br />
Conclusion<br />
Within the limitations of the present study it was<br />
found that:<br />
• Silanization without any surface treatment has<br />
negligible effect on the bond strength of fiber<br />
post.<br />
• Cojet with Silane treatment was proven to be<br />
more effective than silanization done along with<br />
etching solutions.<br />
• There is a marginal increase in bond strength<br />
when the posts were silanated after etching with<br />
10% H 2<br />
O 2<br />
and sodium ethoxide.<br />
• Highest push-out strength was achieved at the<br />
coronal-third of the root when compared with<br />
the middle- and apical-third.<br />
Further studies on these fiber post systems are<br />
required to validate the results of the present study.<br />
More parameters like microleakage, flexural strength,<br />
modulus of elasticity, etc. needs to be evaluated.<br />
258<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
CLINICAL STUDY<br />
References<br />
1. Bateman G, Ricketts DN, Saunders WP. Fibre-based<br />
post systems: a review. Br Dent J 2003;195(1):43-8;<br />
discussion 37.<br />
2. Berekally T. Contemporary perspectives on postcore<br />
systems. Aust Endod J 2003;29(3):120-7.<br />
3. Gluskin AH, Ahmed I, Herrero DB. The aesthetic post<br />
and core: unifying radicular form and structure. Pract<br />
Proced Aesthet Dent 2002;14(4):313-21; quiz 322.<br />
4. Qualtrough AJ, Mannocci F. Tooth-colored post<br />
systems: a review. Oper Dent 2003;28(1):86-91.<br />
5. Balbosh A, Kern M. Effect of surface treatment on<br />
retention of glass-fiber endodontic posts. J Prosthet<br />
Dent 2006;95(3):218-23.<br />
6. Boff LL, Grossi ML, Prates LH, Burnett LH Jr, Shinkai<br />
RS. Effect of the activation mode of post adhesive<br />
cementation on push-out bond strength to root canal<br />
dentin. Quintessence Int 2007;38(5):387-94.<br />
7. Tay FR, Pashley DH. Monoblocks in root<br />
canals: a hypothetical or a tangible goal. J Endod<br />
2007;33(4):391‐8.<br />
8. Ferrari M, Grandini S, Simonetti M, Monticelli F,<br />
Goracci C. Influence of a microbrush on bonding<br />
fiber post into root canals under clinical conditions.<br />
Oral Surg Oral Med Oral Pathol Oral Radiol Endod<br />
2002;94(5):627-31.<br />
9. Ferrari M, Vichi A, Grandini S, Goracci C. Efficacy of a<br />
self-curing adhesive-resin cement system on luting glassfiber<br />
posts into root canals: an SEM investigation. Int<br />
J Prosthodont 2001;14(6):543-9.<br />
10. Monticelli F, Toledano M, Tay FR, Cury AH, Goracci<br />
C, Ferrari M. Post-surface conditioning improves<br />
interfacial adhesion in post/core restorations. Dent<br />
Mater 2006;22(7):602-9.<br />
11. Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NH.<br />
A structured analysis of in vitro failure loads and failure<br />
modes of fiber, metal, and ceramic post-and-core systems.<br />
Int J Prosthodont 2004;17(4):476-82.<br />
12. Goracci C, Fabianelli A, Sadek FT, Papacchini F,<br />
Tay FR, Ferrari M. The contribution of friction to the<br />
dislocation resistance of bonded fiber posts. J Endod<br />
2005;31(8):608-12.<br />
13. Goracci C, Raffaelli O, Monticelli F, Balleri B,<br />
Bertelli E, Ferrari M. The adhesion between prefabricated<br />
FRC posts and composite resin cores: microtensile bond<br />
strength with and without post-silanization. Dent Mater<br />
2005;21(5):437-44.<br />
14. Matinlinna JP, Lassila LV, Ozcan M, Yli-Urpo A,<br />
Vallittu PK. An introduction to Silanes and their<br />
clinical applications in dentistry. Int J Prosthodont<br />
2004;17(2):155-64.<br />
15. Goerig AC, Michelich RJ, Schultz HH. Instrumentation<br />
of root canals in molar using the step-down technique.<br />
J Endod 1982;8(12):550-4.<br />
16. Kalkan M, Usumez A, Ozturk AN, Belli S,<br />
Eskitascioglu G. Bond strength between root dentin<br />
and three glass-fiber post systems. J Prosthet Dent<br />
2006;96(1):41-6.<br />
17. Le Bell AM, Tanner J, Lassila LV, Kangasniemi I,<br />
Vallittu P. Bonding of composite resin luting cement<br />
to fiber-reinforced composite root canal posts. J Adhes<br />
Dent 2004;6(4):319-25.<br />
18. Monticelli F, Toledano M, Tay FR, Sadek FT,<br />
Goracci C, Ferrari M. A simple etching technique for<br />
improving the retention of fiber posts to resin composites.<br />
J Endod 2006;32(1):44-7.<br />
19. Monticelli F, Osorio R, Toledano M, Goracci C, Tay<br />
FR, Ferrari M. Improving the quality of the quartz<br />
fiber postcore bond using sodium ethoxide etching<br />
and combined Silane/adhesive coupling. J Endod<br />
2006;32(5):447-51.<br />
20. Tay FR, Pashley DH, Loushine RJ, Weller RN,<br />
Monticelli F, Osorio R. Self-etching adhesives increase<br />
collagenolytic activity in radicular dentin. J Endod<br />
2006;32(9):862-8.<br />
21. Vichi A, Grandini S, Ferrari M. Clinical procedure for<br />
luting glass-fiber posts. J Adhes Dent 2001;3(4):353-9.<br />
22. Qualtrough AJ, Chandler NP, Purton DG. A comparison<br />
of the retention of tooth-colored posts. Quintessence Int<br />
2003;34(3):199-201.<br />
23. Perdigão J, Gomes G, Lee IK. The effect of Silane<br />
on the bond strengths of fiber posts. Dent Mater<br />
2006;22(8):752-8.<br />
24. Newman MP, Yaman P, Dennison J, Rafter M,<br />
Billy E. Fracture resistance of endodontically treated<br />
teeth restored with composite posts. J Prosthet Dent<br />
2003;89(4):360‐7.<br />
• • •<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
259
clinical study<br />
Prevalence of Facial Neuropathy among Diabetic<br />
Peripheral Neuropathy<br />
R Senthil Nathan*, B Vinodkumar**, K Satheesh † , D Sangeetha ‡ , SM Rajendran #<br />
Abstract<br />
Diabetes mellitus (DM) has a severe influence on the nervous system and it is more likely to occur on the nerves of the upper<br />
and lower extremities than on the cranial nerves. According to the statistics, the incidence of cranial nerve involvement ranges<br />
from 3% to 14%. Aim: To perform facial nerve conduction studies in diabetic patients with peripheral neuropathy, confirmed<br />
by electrophysiological methods, to determine the frequency of affection of cranial nerve conduction in a neuropathy which<br />
mainly occurs in a distal, symmetric fashion. Material and methods: The study was conducted in a group of 30 diabetics who<br />
had electrophysiologically-confirmed polyneuropathy. All of the patients had type 2 DM. Facial nerve conduction was done in<br />
these patients. Results: We found 46% of patients had decreased amplitude, which is suggestive of axonopathy of metabolic<br />
cause. Amplitudes of muscle responses to facial nerve stimulation showed a statistically significant difference from controls<br />
(p < 0.000). Conclusions: This study has shown that proximal nerves like cranial nerves are affected in a high proportion of<br />
cases in a neuropathy which mainly occurs in a distal symmetric fashion. The facial nerve is one of the most easily accessible<br />
nerves in the proximal part of the body (head-face) and makes it suitable for routine evaluation. We believe this conduction<br />
abnormality may give us the chance to classify these neuropathies as more severe than the ones that only have limb conduction<br />
abnormalities. Further studies should be performed in order to confirm these findings.<br />
Key words: Diabetes mellitus, facial conduction time, polyneuropathy<br />
It is a well-known fact that diabetes mellitus (DM)<br />
has a severe influence on the nervous system<br />
and it is more likely to occur on the nerves of<br />
the upper and lower extremities than on the cranial<br />
nerves. According to statistics, the incidence of cranial<br />
nerve involvement ranges anywhere between 3-14%.<br />
Irkeç C, Nazliel B, Yetkin I, Koçer B. Facial nerve<br />
conduction in diabetic neuropathy. Acta Neurol Belg<br />
2001;101(3):177-9. (Mazzotta et al., 1988)<br />
The most common disturbance is an isolated third nerve<br />
lesion, the sixth nerve being affected less frequently. It is<br />
a well-recognized fact that the pupillary innervation is<br />
frequently unaffected in diabetic third nerve palsy. The<br />
fourth nerve is rarely involved alone, but sometimes in<br />
*Lecturer<br />
Oromaxillofacial Surgery, Sri Meenakshi Ammal Dental College<br />
**Postgraduate<br />
Dept. of General Medicine, Sree Balaji Medical College and Hospital, Chennai<br />
†<br />
Postgraduate, Dept. of Pharmacology, Sree Balaji Medical College and<br />
Hospital, Chennai<br />
‡<br />
Post Graduate, Dept. of General Medicine, Sree Balaji Medical College<br />
and Hospital, Chennai<br />
#<br />
Professor, Dept. of General Medicine, Sree Balaji Medical College and<br />
Hospital, Chennai<br />
Address for correspondence<br />
Dr R Senthi Nathan<br />
E-mail: shanmugamrajendran@hotmail.com<br />
combination. Other cranial nerves may also be affected<br />
but less frequently than those to the external ocular<br />
muscles. Besides the third, fourth and sixth nerves,<br />
the seventh cranial nerve is most frequently involved.<br />
(Thomas et al., l993)<br />
Electrophysiological testing of cranial nerves in diabetes<br />
has rarely been performed.<br />
Aims and Objectives<br />
To perform facial nerve conduction in elecrophysiologically-confirmed<br />
diabetic peripheral neuropathy<br />
patients to determine the frequency of affection of<br />
cranial nerve conduction in a neuropathy, which<br />
mainly occurs in a distal symmetric fashion.<br />
Material and methods<br />
Selection Criteria<br />
Cases<br />
Diabetic patients were included if they had symptoms<br />
or clinical signs of diabetic neuropathy. Physical<br />
examination included evaluation of muscle atrophy,<br />
tendon reflexes and sensory deficit. Sensory deficit<br />
evaluation included touch, vibration position, pain,<br />
aching, numbness, cramps paresthesia and definable<br />
260 Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
CLINICAL STUDY<br />
complaints such as restless legs, faintness on standing,<br />
frequent episodes of intermittent diarrhea and hesitancy<br />
before micturition.<br />
Control<br />
Patients with earlier cranial nerve lesions, stroke,<br />
alcohol abuse, chronic renal failure, clinical or<br />
electrophysiological evidence of a hereditary or acquired<br />
neuromuscular disease, patients with edematous limbs<br />
which could make recording or stimulation difficult<br />
during nerve conduction studies and patients treated<br />
with drugs recognized as potentially causing neuropathy<br />
were excluded.<br />
Methodology<br />
Nerve conduction studies were performed in a warm<br />
room, with extremity skin temperature of 32°C or<br />
above, at the side where nerve conduction velocity<br />
measurement (NCV) was done. Median motor and<br />
sensory nerve conduction velocities were obtained in<br />
one upper extremity, posterior tibial, peroneal motor<br />
conduction velocities in one lower extremity and sural<br />
nerve sensory conduction in both lower extremities<br />
were performed by the method described by Oh<br />
(1984). Abnormality was defined as slowed velocity or<br />
an absence of response in at least two nerves. Only<br />
patients with abnormal results were included in the<br />
study for the evaluation of distal latency of muscle<br />
responses to facial nerve stimulation (DML VII).<br />
For the facial nerve, an active electrode was placed over<br />
the midpoint of the lower portion of the orbicularis<br />
oculi and a reference electrode was placed above the<br />
eyebrow along the same vertical plane of the active<br />
electrode. The zygomatic branch of the facial nerve was<br />
stimulated anterior and inferior to the tragus of the<br />
earlobe with a standard distance of 8 cm. Both sides<br />
were tested consecutively. The latency was measured<br />
from the stimulus onset to the first deflection of<br />
the compound muscle action potential (CMAP).<br />
Amplitudes were measured from peak to peak.<br />
Only delays above the average latency ± 3 SD (standard<br />
deviation) of the mean of control subjects, or the<br />
absence of CMAP was considered abnormal.<br />
Study Design<br />
Cross-sectional study<br />
Study Area<br />
Sree Balaji Medical College and Hospital, Chennai,<br />
India.<br />
Study Period<br />
October 2009 to March 2010.<br />
Study Participants<br />
Case group: The study was conducted in a group of<br />
30 diabetic patients, (11 females, 19 males) in the age<br />
range of 45-69 (mean: 58.95) years. The mean duration<br />
of DM was 9.6 ± 0.82. All patients had type 2 DM<br />
according to WHO criteria (The Expert Committee,<br />
2000). The mean glycosylated hemoglobin (HbA 1C<br />
)<br />
value was 7.6 ± 2.0% (normal values: 4.4-5.7%).<br />
Control group: The control group consisted of 20<br />
subjects, (11 males, 9 females), age range 45-72 (mean<br />
58.95) years who were attending the EMG laboratory<br />
for nonspecific complaints. Subjects with central or<br />
peripheral nerve diseases, or those treated with drugs<br />
recognized as potentially causing neuropathy were<br />
excluded. All subjects had a normal neurological<br />
examination.<br />
Statistical Evaluation<br />
The statistical evaluation was performed using<br />
nonparametric Mann-Whitney test and Pearson and<br />
Sperman’s correlation coefficient when appropriate.<br />
The software used for all statistical evaluations was<br />
SPSS 8.0 statistical package program.<br />
Results<br />
Table 1 presents DML VII in normal subjects and<br />
in diabetics. In control subjects, the mean amplitude<br />
of muscle responses to facial nerve stimulation was<br />
2.11 ± 0.09 mV with a range of 1.85-2.30 mV;<br />
it was 1.85 ± 0.44 mV in diabetics with a range of<br />
1.00-2.09 mV. The difference between the two groups<br />
was statistically significant (p < 0.000).<br />
Based on these data, criteria were established for<br />
abnormal response using the mean amplitude plus<br />
3 SD of the lower limit of normal: A facial conduction<br />
time with amplitude
CLINICAL STUDY<br />
Table 1. Facial Nerve mean CMAP Amplitude in<br />
Normal Subjects and in Diabetics<br />
Normal<br />
(n = 20)<br />
Diabetics<br />
(n = 30)<br />
Age (mean and range) 58.95 (45-72) 59.06 (45-69)<br />
Mean duration of DM<br />
(years)<br />
Mean CMAP amplitude<br />
of CN VII (mV)<br />
Conduction time of CN<br />
VII (ms/8.0 cm)<br />
– 9.6 ± 0.82<br />
< p<br />
2.11±0.01 1.85±0.04 0.000<br />
3.24 ± 0.17 3.27±0.04 0.578<br />
Percentage (%)<br />
60<br />
50<br />
40<br />
30<br />
20<br />
10<br />
0<br />
46.67<br />
53.33<br />
Amplitude 2.0<br />
Figure 1. Comparison of amplitude between diabetes and<br />
normal subject.<br />
range of 2.90-3.96 ms, and was 3.27 ± 0.04 ms with a<br />
range of 2.24-5.80 ms in the diabetics. The difference<br />
between the two groups was not statistically significant<br />
(p < 0.578) (Fig. 1).<br />
A facial conduction time with latency >3.3 msec is<br />
defined as abnormal. Two (6.6%) of our patients only<br />
had an abnormal response (Fig. 2). Latency of muscle<br />
responses to facial nerve stimulation in both groups<br />
did not vary greatly. Therefore, the latency of muscle<br />
responses to facial nerve stimulation was not used as an<br />
index of abnormality.<br />
In case group, among 30 subjects, 18 were found to<br />
be diabetic of 3.30<br />
93.33<br />
Latency
CLINICAL STUDY<br />
Hausmanowa-Petrusewicz et al. (l987) found no<br />
changes of the distal motor latency of the facial nerve<br />
in 22 diabetics, who were not further characterized,<br />
but showed only very mild signs of neuropathy. But<br />
they stated that the negative results they reported may<br />
be due to mild nature of DM in their patients.<br />
This procedure evaluates polyneuropathy, not<br />
mononeuropathy, which develops with acute onset<br />
possibly due to vascular involvement of the facial<br />
nerve. In view of length-related involvement of<br />
polyneuropathy, facial nerve conduction may be less<br />
impaired than limb nerve conduction.<br />
Rarely, some patients with severe lower limb edema may<br />
require the use of needle electrodes instead of surface<br />
recording techniques, which is hard and sometimes<br />
unbearable for the patient. We believe that under these<br />
circumstances, this noninvasive conduction abnormality<br />
will give us additional diagnostic information.<br />
Our findings indicate that subclinical facial nerve<br />
involvement is not unusual in DM, although it is<br />
significantly less frequent than the involvement of<br />
limb nerves. This study has revealed that the facial<br />
nerve is affected in a high proportion in a neuropathy<br />
which mainly occurs in a distal symmetric fashion.<br />
Of course, this test is not a gold standard for the<br />
evaluation and confirmation of a neuropathy. But<br />
the facial nerve is one of the most easily accessible<br />
nerves in the proximal part of the body (head-face)<br />
suitable for routine evaluation. In demonstrating the<br />
sensory disturbances of diabetic neuropathy Thomas<br />
and Tomlinson (1993) reported that only in most<br />
severe instances of ‘length-related’ progression of<br />
the distal symmetric neuropathic forms the vertex<br />
of the head may be reached.<br />
Conclusion<br />
We believe this conduction abnormality may give<br />
us the chance to classify these neuropathies as more<br />
severe than the ones that only have limb conduction<br />
abnormalities. Further studies on this subject with<br />
more patients should be performed in order to confirm<br />
these findings.<br />
References<br />
1.<br />
2.<br />
3.<br />
4.<br />
5.<br />
6.<br />
7.<br />
Hausmanowa-Petrusewicz I, Ryniewicz B, Rowińska-<br />
Marcińska K, Emeryk B, Kopeć A. The subclinical<br />
facial nerve involvement in generalized neuropathies.<br />
Electromyogr Clin Neurophysiol 1987;27(4):229-34.<br />
Mazzotta G, Del Gatto F, Firenze C, Gallai V. The<br />
blink reflex in diabetic patients. Electromyogr Clin<br />
Neurophysiol 1988;28(6):291-4.<br />
OH S. Anatomical guide for common nerve conduction<br />
studies. In: Clinical Electromyography: Nerve conduction<br />
studies. Park Press, Baltimore, Maryland 1984:p65-85.<br />
and mononeuropathy multiplex in diabetes mellitus. N<br />
Engl J Med 1968:17-22.<br />
The Expert Committee on the Diagnosis and<br />
Classification of Diabetes Mellitus. Report of the Expert<br />
Committee on the diagnosis and classification of diabetes<br />
mellitus. Diabetes Care 2000;23 Suppl 1:S4-19.<br />
Dyck PJ, Thomas PK, (Eds.), Thomas PK, Tomlinson<br />
DR. Diabetic and hypoglycemic neuropathy. In:<br />
Peripheral Neuropathy. WB Saunders: Philadelphia<br />
1993:1219-50.<br />
Urban PP, Forst T, Lenfers M, Koehler J, Connemann<br />
BJ, Beyer J. Incidence of subclinical trigeminal and facial<br />
nerve involvement in diabetes mellitus. Electromyogr<br />
Clin Neurophysiol 1999;39(5):267-72.<br />
Waylonis GW, Johnson EW. Facial nerve conduction<br />
delay. Arch Phys Med Rehabil 1964;45:539-47.<br />
• • •<br />
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263
eview article<br />
Upsurge of Nanotechnology in Dentistry and<br />
Dental Implants<br />
Sanjna Nayar*, S Bhuminathan**, J Muthuvignesh †<br />
Abstract<br />
Nanotechnology has been defined as “the creation of functional materials, devices and systems through control of matter on<br />
the nanometer scale (1-100 nm), and exploitation of novel phenomena and properties (physical, chemical and biological) at<br />
that length scale”. The article discusses from the inception of nanotechnology, its advantages, disadvantages and its application<br />
in the field of dentistry. The role of nanotechnology in the field of implantology and ceramics cannot be underestimated. The<br />
different types and classification systems of nanotechnology have also been exemplified. Nanotechnology has enhanced the<br />
implant bone contact and hence osseointegration. The article also reviews the role of nanoparticles on the implant surface.<br />
Key words: Nanotechnology, nanomaterials in dentistry, nano in dental implants, biomimetics, osseointegration, hazards,<br />
nanorobots<br />
Current developments during the past decade<br />
in physics, and engineering have resulted<br />
in a tremendous upsurge of interest in the<br />
properties of very minute particles and their possible<br />
applications in different fields. In nanotechnology<br />
the reductions in the size of any particles is upto a<br />
nano scale. The term “Nanotechnology” was coined<br />
by Prof. Kerie E. Drexler, a lecturer and researcher of<br />
nanotechnology. ‘Nanotechnology’ influences almost<br />
every facet of everyday life from security to medicine.<br />
Nanotechnology has been defined as “the creation<br />
of functional materials, devices and systems through<br />
control of matter on the nanometer scale (1-100 nm),<br />
and exploitation of novel phenomena and properties<br />
(physical, chemical and biological) at that length scale<br />
(NASA). 1 The potential of nanosized particles was<br />
speculated as early as in 1959 by the physicist Richard<br />
P Feynman.<br />
Nanotechnology is an interdisciplinary field such<br />
as physics, biology, microbiology engineering,<br />
chemistry, computer science and more. The concept of<br />
* Professor and Head,<br />
**Professor,<br />
†<br />
Senior Lecturer<br />
Dept. of Prosthodontics<br />
Sree Balaji Dental College, Chennai<br />
Address for correspondence<br />
Senior Lecturer, Dept of Prosthodontics<br />
Sree Balaji Dental College-Chennai<br />
E-mail: jayamvignesh@gmail.com<br />
nanotechnology is: when one goes down to the bottom<br />
of things one can discover unlimited possibilities and<br />
potential of the basic particle. In Nanotechnology one<br />
analyzes to the level of manipulating atoms, molecules<br />
and the chemical bonds between them.<br />
Technological innovations have enabled the<br />
manipulation of tiny structures called nanopores,<br />
nanotubes, quantum dots, nanoshells, nanospheres,<br />
nanowires, nanocapsules, dendrimers, nanorods,<br />
etc. 2 More recently, tiny machines, known as<br />
nanoassemblers, which can be controlled by computer<br />
to perform specialized jobs have been invented. The<br />
nanoassemblers could be smaller than a cell nucleus so<br />
that they could fit into places that are hard to reach<br />
by hand or with any other technologies. For example,<br />
in dentistry, it can be used to destroy bacteria in the<br />
mouth that cause dental caries or even repair spots on<br />
the teeth where decay has set in, by use of computer to<br />
direct the nanoassemblers in their tasks.<br />
Nanotechnology is also applied to various medical and<br />
biological fields like pharmacological research, clinical<br />
diagnosis, mechanically reversing artherosclerosis,<br />
Improving respiratory capacity, cryogenic storage of<br />
biological tissues, In enabling instantaneous hemostasis,<br />
vasculoids, detection of proteins, probing of DNA<br />
structure, tissue engineering, tumour destruction via<br />
heating (hyperthermia), separation and purification<br />
of biological molecules and cells, magnetic resonance<br />
imaging (MRI) contrast enhancement, phagokinetic<br />
studies, etc. 3<br />
264 Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Review Article<br />
Products which use nanotechnology are: Burn and<br />
wound dressings, bumpers and catalytic converters<br />
on cars, sunscreens and cosmetics, longer-lasting<br />
tennis balls and lightweight stronger tennis racquets,<br />
protective and glare-reducing coatings for eyeglasses<br />
and stain-free clothing.<br />
Nanotechnology can be classified in terms of application<br />
in three broad and extensively overlapping categories: 4<br />
• Nanoelectronics<br />
• Nanomaterials/particles<br />
• Nano-biotechnology<br />
Nanoelectronics: Refers to the use of nanotechnology<br />
on electronic components, especially transistors,<br />
computer processors, etc.<br />
Nanomaterials are essentially polymers reinforced by<br />
nanoparticles resulting in novel materials which can<br />
be used as light weight replacements for metals. When<br />
brought into a bulk material nanoparticle can strongly<br />
influence the mechanical properties of the materials<br />
like stiffness or elasticity. Nanomaterials are of utmost<br />
significance in dentistry and can be used for better<br />
efficiency of dental materials.<br />
Classification of Nanomaterials 5<br />
Nanomaterials could be classified into four major<br />
types: Carbon-based materials, metal-based materials,<br />
dendrimers and composites.<br />
Methods of Synthesis of Implant<br />
Nanomaterials 5<br />
Numerous techniques are used to fabricate different<br />
nanomaterials that are used to coat the implant surfaces.<br />
Mainly they can be processed by two methods: Topdown<br />
and bottom-up.<br />
Top-down: In this method nanoparticles are produced<br />
from larger structures by use of ultrafine grinders, lasers<br />
and vaporization followed by cooling.<br />
Bottom-up In this method nanoparticles are produced<br />
by arranging molecules to form complex structures<br />
with new and useful properties.<br />
Imaging of Nanomaterials 6<br />
Imaging is an important procedure in nanotechnology<br />
because the coating of nanomaterials should be checked<br />
for their sizes and thickness. Various imaging techniques<br />
involved in nanotechnology are: X-ray diffraction<br />
(XRD), atomic force microscopy (AFM), scanning<br />
electron microscope (SEM), transmission electron<br />
microscopy (TEM), magnetization measurements,<br />
nuclear magnetic resonance (NMR), spectroscopy,<br />
2-D electrophoresis and mass spectrometry of proteins<br />
and confocal microscopy.<br />
Nanomaterials can be used in various fields of dentistry<br />
as nano impression materials, nano bonding agents,<br />
nano drug releasing systems, nano composites, 7 nano<br />
ceramics, nano sterilizing agents 8 and as well in dental<br />
implants.<br />
Nanotechnology in Dental Implants<br />
The application of nanotechnology in dental implants<br />
can be made by coating of nanoparticles over the dental<br />
implants. It has been demonstrated that different cell<br />
types respond positively to nanotopography.<br />
The surface of the implant plays a critical role in<br />
determining biocompatibility and biointegration<br />
because it is in direct contact with the tissues. Implant<br />
surface composition, surface energy, surface roughness<br />
and surface topography are the four material related<br />
factors which can influence events at bone-implant<br />
interfaces. Various surface textures have been created<br />
and used to successfully influence cell and tissue<br />
responses. Surface textures are of three types’ macro,<br />
micro and nano. 1 The ‘nanostructured’ materials can<br />
exhibit enhanced mechanical, electrical, magnetic and/<br />
or optical properties compared with their conventional<br />
micron-scale or macro-scale (larger) counterparts.<br />
Nanostructured (NS) materials contain a large volume<br />
fraction (>50%) of defects such as grain boundaries,<br />
inter phase boundaries, and dislocations, and this<br />
strongly influences their chemical and physical<br />
properties.<br />
In many cases, the intended implant site is compromised<br />
because of poor bone quality or insufficient bone<br />
quantity. Lack of sufficient alveolar ridge height is<br />
often related to the proximity of the implant site to<br />
other anatomical structures. In these situations separate<br />
preparatory procedures may be required to augment the<br />
available volume of bone before the implant placement,<br />
which may result in longer treatment time, greater<br />
risk of complications and higher costs. Alternatively,<br />
orthodontic procedures have been used to extrude and<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
265
Review Article<br />
eventually extract ‘hopeless’ teeth. However, as effective<br />
as these procedures may be, the risks of complications<br />
are greater than for single site procedures, treatment<br />
time and costs are also increased. Biomimetic dental<br />
implants may be the next development in the field. 9<br />
A variety of biomimetics coatings may be helpful for<br />
application in individual patients. For example, coating<br />
implants with nanotextured titanium, hydroxy apatite,<br />
and pharmacological agents such as bisphosponates<br />
may induce cell differentiation and proliferation and<br />
may promote greater vascularity in highly cortical bone,<br />
thereby improving conditions for early and long-term<br />
(in response to functional loading) bone remodeling.<br />
Nanoscale modification of an implant surface could<br />
contribute to the mimicry of cellular environments to<br />
favor the process of rapid bone accrual. Cell adhesion<br />
to basement membranes is an often cited example of<br />
nanoscale biomimetics. 9<br />
Successful osseointegration is influenced by both the<br />
chemical composition and the surface geometry or<br />
topography of the implant. 10 Literature indicates that<br />
degradation of an implant surface coating may help<br />
to promote de novo bone formation, as a result of<br />
either enhanced osteoconductivity due to the resulting<br />
changes in surface topography or enhanced osteogenesis<br />
due to local release of calcium or other elements that<br />
may promote bone formation.<br />
Surface nanotopography affects cell interactions at<br />
surfaces and alters cell behavior when compared to<br />
conventional sized topography. 11,12 Different physical<br />
relationships exist between cells at micron scale<br />
level and nanoscale level. Nanotopography-specific<br />
effects on cellular behavior have been demonstrated<br />
using a wide range of different cell types including<br />
epithelial cells, fibroblasts, myocytes and osteoblasts.<br />
Nanostructured surfaces possess unique properties that<br />
alter cell adhesion by direct 10 (cell-surface interactions)<br />
and indirect (affecting protein-surface interactions)<br />
mechanisms.<br />
Nanoscale topography is a powerful way of altering<br />
protein interactions with the surface. Surface profiles<br />
in the nanometer range play an important role in the<br />
adsorption of proteins, adhesion of osteoblastic cells<br />
and thus the rate of osseointegration. There is an<br />
increased vitronectin adsorption on nanostructured<br />
surfaces when compared to conventional surfaces. 13<br />
This leads to increased osteoblasts adhesion when<br />
compared to other cell types such as fibroblasts, on the<br />
nanosurfaces.<br />
Cell–matrix-substrate interactions associated with cell<br />
signaling occur in the nanoscale level. Such signaling<br />
regulates cell attachment, spreading, migration,<br />
differentiation and gene expression. The cells also<br />
respond differently to the scale of nano roughness.<br />
There is an increased cell integrin signaling in<br />
14-29 nm pits than 45 nm pits, Since, the surface<br />
roughness of bone is approximately 32 nm. 14 Increased<br />
cellular responses have been reported in cell cultures<br />
grown on nanophase ceramics. These types of coatings<br />
onto the surface of implants stimulate cells in the<br />
early stage of bone formation and accelerate the bone<br />
formation around the implant site, thereby enhancing<br />
the primary implant stabilization.<br />
In addition to the dimensional similarity to bone/<br />
cartilage tissue, nanomaterials also exhibit unique<br />
surface properties (such as surface topography, surface<br />
chemistry, surface wettability and surface energy) due to<br />
their significantly increased surface area and roughness<br />
compared to conventional or micron structured<br />
materials. As is known, material surface properties<br />
mediate specific protein (such as fibronectin, vitronectin<br />
and laminin) adsorption and bioactivity before cells<br />
adhere on implants, further regulating cell behavior<br />
and dictating tissue regeneration. Furthermore, an<br />
important criterion for designing orthopedic implant<br />
materials is the formation of sufficient osseointegration<br />
between synthetic materials and bone tissue. Studies<br />
have demonstrated that nanostructured materials<br />
with cell favorable surface properties may promote<br />
greater amounts of specific protein interactions to<br />
more efficiently stimulate new bone growth compared<br />
to conventional materials. This may be one of the<br />
underlying mechanisms why nanomaterials are superior<br />
to conventional materials for bone growth.<br />
Modifying the surface characteristics of the implant<br />
in nanoscale can promote migration of mesenchymal<br />
cells to the implant surface, enhance attachment and<br />
proliferation of these cells, and, in some instances,<br />
stimulate osteoblastic differentiation. 15<br />
Some reports have suggested that in designing a<br />
biomimetics implant one should choose a surface<br />
texture of high roughness (presumably with some<br />
266<br />
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Review Article<br />
optimum value) and ensure a high surface area, to<br />
optimize the ability of the implant to act as a ‘carrier’<br />
for the planned biomimetics coatings. 16-18 Such a design<br />
might also enhance osteoconductivity and osteogenesis,<br />
and thereby improve long-term fixation of the implant<br />
through more effective mechanical interlock at the<br />
bone-to-implant interface after osseointegration.<br />
The so-called bioactive implants (devices capable<br />
of implant to bone chemical bonding) will become<br />
popular because such implants combine biomechanical<br />
and chemical bonding of the surfaces. 19 The advantage<br />
of chemical bonding is primarily that it is rapid, in<br />
contrast to biomechanical bonding (typical of implants<br />
of today), which develops gradually as bone forms and<br />
invades implant surface irregularities. In time, doped<br />
surfaces containing nano bone morphogenetic proteins<br />
that are gradually released from the surfaces will be<br />
developed. Doped surfaces will improve the outcome<br />
of implants in grafted bone or where implants might<br />
otherwise be unstable, but they will be of little use in<br />
the ordinary stabilized implant situation.<br />
In basic science, there is currently considerable interest<br />
in nanostructures. With respect to surface roughness,<br />
it is unknown whether nanometer-sized irregularities<br />
will affect the bone response. Changes in implant<br />
roughness at the micrometer level of resolution may<br />
simultaneously result in changes at the nanometer<br />
level. It is therefore difficult to reliably exclude the<br />
possibility that nanometer-sized surface irregularities<br />
may influence the bone response to an implant.<br />
One study showed that macrophage cell lines react<br />
to microgrooves at the nanometer level, whereas<br />
another investigation saw no significant effects in cell<br />
adhesion to different nanotopographies. 20 There is a<br />
need for more in vitro and of course in vivo, data to<br />
decide on the potential importance of nanostructures.<br />
Nevertheless, for clinical purposes, the relevant way to<br />
describe an oral implant surface is by referring to its<br />
micrometer-sized irregularities.<br />
Nanobiotechnology<br />
Nanorobots play an important role in nanobiotechnology.<br />
They can be used for cell repairs in the human body.<br />
Nanorobotics<br />
Nanorobots are theoretical microscopic devices<br />
measured on the scale of nanometers (1 nm equals<br />
one millionth of 1 mm). 21 When fully released from<br />
the hypothetical stage, they would work at the atomic,<br />
molecular and cellular level to perform tasks in both<br />
the medical and industrial fields that have heretofore<br />
been the stuff of science fiction. Feynman has<br />
mentioned how these nanotechnologies can be applied<br />
to nanomedicine. He offered the first known proposal<br />
for nanomedical procedure to heart disease.<br />
Nanorobotics in Dentistry<br />
The growing interest in the future of dental applications<br />
of nanotechnology is leading to the emergence of a<br />
new field called nanodentistry. Nanorobots induce<br />
oral analgesia, desensitize tooth; manipulate the tissue<br />
to realign and straighten irregular set of teeth and to<br />
improve durability of teeth. Further, it is explained that<br />
how nanorobots are used to do preventive, restorative,<br />
curative procedures, major tooth repair, tooth durability<br />
and appearance, anesthesia, surgery and orthodontic<br />
treatment has been documented.<br />
Hazards of Nano<br />
The potential deleterious effect that these materials<br />
can produce on humans or the environment should<br />
be analyzed so that expanded development and use<br />
of nanotechnology can proceed. There has been one<br />
reported rapid withdrawal of a nanotechnology-based<br />
product, Magic Nano, a spray-on ceramic sealant to<br />
repel dirt. 22 Over 110 consumers in Europe reported<br />
respiratory symptoms after using the spray. The product<br />
was withdrawn in March 2006.<br />
Potential Risks of Nanomaterialsto<br />
Human Exposure 8<br />
Skin<br />
Skin consists of several layers of dead keratinized cells<br />
which, when intact, prevent entry of most ionic and<br />
water soluble substances. There is no adequate data<br />
available on penetration of the skin by nano particles.<br />
Micrometer-sized particles of titanium dioxide can<br />
penetrate the surface of the skin and get into hair follicles<br />
but are not thought to react with living tissues. But<br />
some smaller particles were reported to penetrate deeply<br />
enough to be taken up by macrophages. Currently, it<br />
is impossible to predict whether nanoparticles will pass<br />
through the skin to a significant extent.<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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Lungs<br />
Most dust particles get entrapped by the mucus<br />
lining during inhalation. Nanoparticles can penetrate<br />
deep into the lungs, into the alveoli because of their<br />
size. Higher concentrations of these particles can<br />
cause inflammation, as they cannot be engulfed by<br />
macrophages. They can also produce nervous and<br />
cardiovascular adverse effects.<br />
Gastrointestinal Tract/Circulatory System<br />
Nanoparticles can be absorbed from the gastrointestinal<br />
tract and enter the circulatory system. Nanoparticles<br />
are readily taken up by many types of cells in vitro and<br />
are expected to cross the blood-brain barrier (BBB) that<br />
excludes many substances that are harmful to the brain.<br />
Some reports suggest that nanoparticles cause oxidative<br />
stress in the liver, precipitate lung inflammation and<br />
activate blood platelets that may contribute to clot<br />
formation. Certain in vitro studies have proved that<br />
fullerenes can cause morphological changes in vascular<br />
endothelial cells and in high concentrations induce<br />
cytotoxicity. Further in vivo studies are required to<br />
evaluate and overcome these hazards.<br />
Conclusion<br />
This article demonstrates the modern and upcoming<br />
technology. The article features the type, mode of action<br />
and drawbacks of nanotechnology in general and in<br />
the field of dentistry specifically. Nanotechnology has<br />
made numerous strides to improve the bone-implant<br />
contact thus opening the avenues of successful implant<br />
therapy. Clinical trials need to be evaluated over a<br />
longer period of time and to interpret the success and<br />
hazards of nanotechnology. The benefits provided by<br />
the nanotechnology overrun its shortcomings. No<br />
wonder as Richard P Feynman Said “This is a<br />
Development Which Cannot Be Avoided”.<br />
References<br />
1. Gustavo mendonça et al. Advancing dental implant<br />
surface technology – from micron to nanotopography.<br />
Biomaterials 3822-3835.<br />
2. Nanotechnology and nanoparticles in dentistry. Anna V.<br />
Rybachuk, Ivan S. Chekman, Tetyana Yu. Nebesna.<br />
3. Salata OV. Applications of nanoparticles in biology and<br />
medicine. Journal of Nanobiotechnology<br />
4. Majumder DD, et al. IETE technical review. 2007;<br />
24:#1: 9-25.<br />
5. Singh DN. IETE technical review nanotechnology: an<br />
Indian perspective 2007; 24:#1: 43-49.<br />
6. Bhatnagar K, Varma A. IETE technical reviewnanobiogenomics.<br />
education and research. 2007;<br />
24:#1:27-30.<br />
7. Sumita B, Mitra, et al. An application of nanotechnology<br />
in advanced dental materials. JADA 2003;134:1382-90.<br />
8. Nanotechnology: a brief literature review. M. Ellin<br />
Doyle, Ph.D.<br />
9. Ziv Simon,.Biomimetic Dental Implants - New Ways<br />
to Enhance Osseointegration. DMD: J Can dent Assoc<br />
2002:286-8.<br />
10. L Le Gu´ehennec. Surface treatments of titanium<br />
dental implants for rapid osseointegration. Biomaterials<br />
2007:844-54.<br />
11. Meyer U, Buchter A, et al. Basic reactions of osteoblasts<br />
on structured material surfaces. Euro Cells Mater<br />
2005;9:39-49.<br />
12. Possible medical applications of nanotechnology.<br />
Nanotechnology research and perspectives. MIT press<br />
1992:p251<br />
13. Wennerberg A, Alberektsson T. Implant surfaces beyond<br />
micron roughness. Experimental and clinical knowledge<br />
of surface topography and surface chemistry. Inte Dent<br />
SA vol 8, #6 :14-17.<br />
14. Hansen JC, Lim JY, et al. Effect of surface nanoscale<br />
topography on elastic modulus of individual osteoblastic<br />
cells as determined by atomic force microscopy. J<br />
Biomech 2007;40:2865-71.<br />
15. Lyndon F. Cooper, DDS, PhDa. A role for surface<br />
topography in creating and maintaining bone at titanium<br />
endosseous implants. : JPD vol 84 #5.<br />
16. Adriane Yaeko Togashi. The role of implant surface<br />
chemistry in the biological bone response. RPG Rev Pós<br />
Grad 2007;13(4):340-4.<br />
17. Nanodentistry: Freitas RA. American Dental Association.<br />
2000;131:1559-66.<br />
18. JS Kadadevaramath. IETE technical review. vol 24:#1;<br />
2007:5-8<br />
19. Parak WJ, Gerion D, et al. Biological applications of<br />
colloidal nanocrystals. Nanotechnology 2003;14:R15-<br />
R27.<br />
20. Brite Groessener, et al: Fibroblast growth on surfacemodified<br />
dental implants- in vitro study. J biomed<br />
materials research. -64a: 591-593.<br />
21. Nanorobots: Abhilash M: International Journal of<br />
Pharma and Bio Sciences: 2010.<br />
22. Pankhurst QA, et al. Applications of magnetic<br />
nanoparticles in biomedicine. J Phys D: Appl Phys 2003,<br />
36:R167-R181.<br />
268<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Pre-eclampsia: An Oral Infectious Etiology?<br />
review article<br />
Jaideep Mahendra*, Khushbu Desai**, Little Mahendra †<br />
Abstract<br />
Pre-eclampsia is a common hypertensive disorder of pregnancy, affecting 5-10% of pregnancies and contributing significantly<br />
to natural and periodontal morbidity and mortality. It has been recently studied that women were at higher risk for preeclampsia,<br />
if they had severe periodontal disease at delivery. Periodontal disease may provide a chronic burden of endotoxin<br />
and inflammatory cytokines, which serve to initiate and exacerbate atherogenesis and thrombogenesis. It is possible that<br />
the placenta may be similarly burdened in pregnant women who develop pre-eclampsia. Pre-eclampsia and periodontitis are<br />
both mutlifactorial diseases and obtaining a good oral hygiene measures can reduce the risk for periodontal disease thereby<br />
also reducing the further risk for pre-eclampsia in the pregnant women.<br />
Key words: Pre-eclampsia, periodontitis, hypertension, pregnancy<br />
Periodontitis is an inflammatory disease that<br />
affects the supporting tissues of the teeth,<br />
causing progressive destruction of connective<br />
tissue attachment and loss of alveolar bone. This<br />
causes formation of a periodontal pocket defined as<br />
apical migration of junctional epithelium as well as<br />
deepening of gingival sulcus, along with production<br />
of proinflammatory cytokines. Due to its chronic<br />
inflammatory nature, periodontitis can be considered<br />
as a systemic exposure leading to a variety of systemic<br />
illnesses. 1 Periodontitis causes bleeding gingiva<br />
when brushing, spacing of teeth due to pathologic<br />
migration, mobility and areas of localized pain. 2 This<br />
disease, characterized as a chronic low-grade systemic<br />
stressor, is associated with various systemic illness such<br />
as atherosclerosis, diabetes and respiratory disorders. 1<br />
Detection of oral pathogens in atherosclerotic plaque<br />
confirms their role in development and progression of<br />
atherosclerosis leading to coronary heart disease. 1<br />
Pre-eclampsia is a dangerous disease of human<br />
pregnancy, which affects both the mother and<br />
*Professor, Dept. of Periodontics<br />
**Postgraduate Student<br />
Meenakshi Ammal Dental College, Chennai<br />
†<br />
Senior Lecturer<br />
Raja Muthaiah Dental College, Annamalai University, Chennai<br />
Address for correspondence<br />
Dr Jaideep Mahendra<br />
Professor, Dept. of Periodontics<br />
Meenakshi Ammal Dental College, Chennai<br />
E-mail: jaideep_m_23@yahoo.co.in<br />
her fetus. It is defined as blood pressure (BP)<br />
>140/90 mmHg on two separate occasions after<br />
Week 20 of gestation and >1+ proteinuria. 3 It is a<br />
common obstetric syndrome that affects approximately<br />
7-10% of pregnant women and remains one of the<br />
two most common causes of maternal mortality in<br />
the developed world. There are two syndromes in<br />
pre-eclampsia. The first is maternal, characterized<br />
by endothelial cell activation, hypertension and<br />
proteinuria. The second is fetal, manifested primarily by<br />
intrauterine growth restriction (IUGR). The symptoms<br />
of this syndrome appear during the second and third<br />
trimesters of pregnancy. Although this disease is of<br />
major obstetric importance throughout the world, it<br />
remains an enigma. Despite extensive research, neither<br />
its cause nor possible mechanism have been clearly<br />
defined. 4 It is characterized by abnormal vascular<br />
response to placentation, reduced organ perfusion,<br />
vasospasm, activation of the coagulation system,<br />
inflammatory-like responses, oxidative stress and some<br />
perturbations in volume and BP control, affecting<br />
the placenta, kidney, liver and brain. Recent studies<br />
suggest that periodontal inflammation plays a key role<br />
in causing pre-eclampsia or its manifestations. Normal<br />
pregnancy evokes a mild increase in the systemic<br />
inflammatory response that becomes considerably<br />
greater in pre-eclampsia. 5 Periodontal disease may<br />
also serve primarily as a vascular stressor and bring<br />
an additional infectious/inflammatory burden to the<br />
placental-fetal unit, thereby increasing the risk of<br />
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preterm delivery in preeclamptic women. 6 Based on<br />
this concept, some authors have hypothesized that<br />
infection might be involved in the etiology and<br />
pathogenesis of pre-eclampsia, both in terms of its<br />
initiation (by increasing the risk of acute uteroplacental<br />
atherosis) and/or its potentiation (by amplifying the<br />
maternal systemic inflammatory response). 5<br />
Incidence of Pre-eclampsia<br />
The incidence of pre-eclampsia in India is around<br />
10% and around 2-5% in the US. 7 It occurs mostly in<br />
the second or third trimester i.e., around 32nd week<br />
or as early as 20 weeks, though it is rare. It is more<br />
common in women with first pregnancies, pre-existing<br />
hypertension, diabetes, autoimmune diseases like<br />
lupus, inherited thrombophilias like Factor V Leiden<br />
or renal disease, family history of pre-eclampsia, obese<br />
women and in women with multiple gestations. 8 The<br />
single most significant risk factor for developing preeclampsia<br />
is women who have suffered from the same<br />
disease in their earlier pregnancy. 9<br />
Degree of Severity<br />
Pre-eclampsia can be divided based on its degree of<br />
severity into mild and severe. Mild pre-eclampsia<br />
is characterized by diastolic BP >90 mmHg but<br />
160 mmHg or diastolic BP is ≥110 mmHg on<br />
at least two occasions at least four hours apart;<br />
proteinuria ≥5 g in 24 hours; oliguria ≤400 ml in<br />
24 hours, cerebral or visual disturbances and severe<br />
headache or epigastric pain. 10<br />
Predisposing Factors<br />
Some of the general predisposing factors of preeclampsia<br />
are:<br />
• Pre-eclampsia in an earlier pregnancy, family<br />
history of mother or sister suffering from preeclampsia<br />
8<br />
• Immunological: Primigravida, new partner 3<br />
• Vascular disease: Essential hypertension, family<br />
history of hypertension, renal disease, diabetes<br />
mellitus, connective tissue disease like systemic<br />
lupus erythematosus 11<br />
• Hyperplacentosis: Multiple pregnancy, diabetes<br />
mellitus, uterine malformation, molar pregnancy<br />
and hydrops fetalis 10<br />
• Inflammatory diseases: Periodontitis<br />
Major predisposing factors given to explain cause of<br />
pre-eclampsia could be as: 9<br />
• Endothelial cell injury<br />
• Immune reflection of placenta<br />
• Compromised placental perfusion<br />
• Altered vascular reactivity<br />
• Imbalance between prostacyclin and thromboxane<br />
• Decreased glomerular filtration rate (GFR) with<br />
salt and water retention<br />
• Decreased intravascular volume<br />
• Increased central nervous system irritability<br />
• Disseminated intravascular coagulation<br />
• Uterine muscle stretch (ischemia)<br />
• Dietary factors including vitamin deficiency<br />
• Genetic factors<br />
• Elevated serum lipid ratio<br />
• No prenatal care<br />
Pathophysiology of Pre-eclampsia<br />
There are alternate segments of vasodilatation and<br />
vasoconstriction throughout the body causing vasospasm.<br />
The constricted segments contribute to the heightened<br />
peripheral resistance and hence to hypertension. 12 In<br />
the dilated segments, there are endothelial cell breaks<br />
in the capillary wall and exudation of plasma proteins<br />
occurs through these breaks leading to cardiovascular<br />
changes. Due to extravasation, there is increased<br />
hematocrit, low platelet count and decreased fibrinogen.<br />
Hemolytic anemia may also be present. 10<br />
Various organs of the body undergo certain<br />
morphological changes in preeclamptic women. In<br />
kidneys, the GFR decreases, blood urea, nitrogen,<br />
creatinine and uric acid increase, nonselective<br />
proteinuria comprising albumin and globulin occurs.<br />
In severe pre-eclampsia, acute renal failure may develop<br />
due to acute tubular necrosis, which is reversible after<br />
delivery. Liver may undergo periportal hemorrhagic<br />
necrosis giving rise to elevated enzyme levels. 13 These<br />
microhemorrhages may then coalesce to give rise<br />
to a subcapsular hematoma that causes epigastric<br />
pain. Similarly, brain undergoes changes like edema,<br />
hyperemia, infarcts, thrombosis and hemorrhage.<br />
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The CNS manifestations of pre-eclampsia include<br />
seizures, blindness or unconsciousness. In retina<br />
there could be localized vascular spasm, generalized<br />
narrowing, hemorrhage and papilledema. 10<br />
Vasospasm and hypovolemia compromise the<br />
uteroplacental perfusion. In pregnancy, the trophoblasts<br />
erode into the maternal blood vessels and form the<br />
uteroplacental bed. But, this process is incomplete in<br />
pre-eclampsia causing intact maternal blood vessels to<br />
respond to any circulating vasoconstrictor substances<br />
compromising the placental blood flow and in the long<br />
run leading to IUGR. 10<br />
Prostaglandins: The Key Factor in Preeclampsia<br />
In pre-eclampsia, there is an imbalance in the<br />
levels of prostacyclin and thromboxane A 2<br />
. The level<br />
of latter is much more than the former. 14 Prostacyclin is<br />
vasodilatory, uterine relaxant and platelet deaggregating<br />
substance as opposed to thromboxane A 2<br />
, the actions of<br />
which are just the opposite. In pre-eclampsia, the levels<br />
of thromboxane A 2<br />
are raised leading to proteinuria,<br />
decreased glomerular filtration rate and altered liver<br />
function. 14<br />
Oral Infection Contributing Towards Preeclampsia:<br />
Recognizing the New Risk<br />
Factor<br />
Periodontal disease is the most common chronic gramnegative<br />
anaerobic infection. Periodontium affected<br />
with the periodontal disease acts as a toxic reservoir of<br />
pathogenic gram-negative bacteria. The toxins produced<br />
by the bacteria attack the gums, ligaments and bone<br />
surrounding the teeth to produce infected pockets that<br />
are similar to large infected wounds in the mouth. 15<br />
These bacteria gain access to the bloodstream and<br />
travel throughout the body; they even enter the cervix<br />
causing increase in prostaglandin E 2<br />
in the placenta. 16<br />
Fluid that bathes the tooth at the gingival margin,<br />
known as gingival crevicular fluid, often contains<br />
inflammatory mediators and the oral pathogens<br />
associated with periodontitis. The mechanisms<br />
underlying this destructive process involve both direct<br />
tissue damage resulting from plaque bacterial products,<br />
and indirect damage through bacterial induction of<br />
the host inflammatory and immune responses. While<br />
periodontitis is a chronic, local oral infection, there is<br />
evidence that both local and systemic inflammation<br />
may occur. 15<br />
The biological mechanisms involve bacterially-induced<br />
activation of cell-mediated immunity, which lead to<br />
production of cytokines, synthesis of tumor necrosis<br />
factor (TNF)-α and release of prostaglandins. During<br />
normal pregnancy, when the intra-amniotic levels are<br />
reached, cervical dilatation and delivery are induced.<br />
Abnormal production of these mediators during the<br />
pregnancy in the setting of infection triggers preterm<br />
labor and low birth weight. Cytokines like interleukins<br />
(IL)-1, IL-6 and TNF-α can cross human fetal<br />
membranes.<br />
Active periodontal disease during pregnancy may<br />
have transient translocation of oral organisms to the<br />
uteroplacental unit, inciting placental inflammation or<br />
oxidative stress early in pregnancy, which may ultimately<br />
produce placental damage and clinical manifestations<br />
of pre-eclampsia. 17 Subgingival microorganisms like<br />
Porphyromonas gingivalis, Tannerella forsythia and<br />
Treponema denticola occur more frequently or in<br />
higher levels in periodontitis sites. 18 Bacteria known as<br />
Fusobacterium nucleatum have been linked with adverse<br />
pregnancy outcomes. Since F. nucleatum is associated<br />
with periodontal infection rather than genital or<br />
uterine infections, it is hypothesized that the infection<br />
does not enter the womb by an ascendant route<br />
coming through the genital tract; instead it enters the<br />
mother’s bloodstream from the oral cavity making it<br />
way down. 19 The virulence factors of P. gingivalis have<br />
been linked to various complications in pregnancy<br />
outcome and pathogenesis of atherosclerosis. 19<br />
This gram-negative periodontal pathogen found in<br />
periodontal disease may find its way into the patient’s<br />
bloodstream through oral hygiene procedures or even<br />
chewing. 18 The cysteine proteinases produced by<br />
P. gingivalis termed ‘gingipains’ have deleterious effects<br />
in activating coagulation factors and platelet aggregation<br />
and in altering the cytokine response in human<br />
umbilical-vein-endothelial cells. 20 Other virulent factors<br />
like fimbriae and lipopolysaccharides that can activate<br />
spleen cells and peripheral blood monocytes result<br />
in the release of proinflammatory cytokines like IL-1,<br />
IL-6 and TNF-α. 18 T. forsythia possesses virulence<br />
traits, including the production of LPS and a trypsinlike<br />
protease as well as the ability to penetrate and induce<br />
apoptosis in host cells. 21 This may explain the possible<br />
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mechanisms of P. gingivalis and T. forsythia virulence<br />
factors involved in pre-eclampsia development. 18<br />
Endothelial cell dysfunction is the key feature of preeclampsia,<br />
potentially explaining the multi-organ nature<br />
of the disorder. This dysfunction is demonstrated by<br />
the structural changes in the placental bed and uterine<br />
boundary vessels and the high maternal blood levels<br />
of markers of endothelial damage like fibronectin,<br />
von Willebrand factor, endothelin, tissue plasminogen<br />
activator and thrombomodulin. 22 Endothelial cell<br />
dysfunction may be because of increase in oxidative<br />
stress due to reduced placental perfusion. Placental<br />
ischemia is a common feature of pre-eclampsia and<br />
enhances the synthesis of inflammatory cytokines like<br />
TNF-α, which induces oxidative damage. 23 Under<br />
hypoxic conditions, free radicals are formed that can<br />
stimulate lipid peroxidation of free-fatty acids, leading<br />
to the injury of endothelial cells. 24 The consequence of<br />
this oxidative stress includes activation of microvascular<br />
coagulation, increased capillary permeability and the<br />
production of lipid-laden macrophage foam cells,<br />
which are the characteristic features of atherosis.<br />
Acute atherosis, the placental lesion of pre-eclampsia,<br />
shares a similar pathology, pathogenesis (inflammation)<br />
and clinical setting (endothelial cell damage) with<br />
atherosclerosis. It is characterized by infiltration of<br />
the perivascular spaces by mononuclear cells, an<br />
accumulation of lipid-laden macrophage foam cells<br />
and lipoprotein deposition. 19 Increased plasma levels of<br />
free 8-isoprostane, a marker of lipid peroxidation and a<br />
potent vasoconstrictor, have been found in preeclamptic<br />
women. 25 It is also found that periodontal disease is<br />
a vascular stressor as evidenced by increase in serum<br />
levels of soluble intercellular adhesion molecules. 26<br />
Periodontal disease may burden pregnant women<br />
systemically with endotoxin, inflammatory cytokines<br />
and oxidative stressors at the maternal-fetus interface. 18<br />
It is suggested that oral infection could also be an<br />
important trigger of the chronic inflammatory response<br />
that characterizes pre-eclampsia and could also initiate<br />
the preeclamptic process by increasing the risk for<br />
acute uteroplacental atherosis. 27<br />
Conclusion<br />
Association between pre-eclampsia and chronic<br />
periodontal diseases should be interpreted with<br />
prudence, as the etiology of both events is likely<br />
multifactorial. Various longitudinal and cross-sectional<br />
studies in future are necessary to further elicit the role of<br />
periodontal infection in pre-eclampsia. It is important<br />
to emphasize that primary healthcare services must<br />
be able to diagnose and control periodontal disease<br />
during pregnancy. Managing periodontal disease may<br />
represent a novel strategy to reduce the incidence<br />
and/or complications from this pregnancy hypertensive<br />
disorder. Thus periodontal treatment during pregnancy<br />
could be one of the future aspects in giving better<br />
prenatal care. 1<br />
References<br />
1. Cota LO, Guimarães AN, Costa JE, Lorentz TC,<br />
Costa FO. Association between maternal periodontitis<br />
and an increased risk of pre-eclampsia. J Periodontol<br />
2006;77(12):2063-9.<br />
2. Michael G. Newman, Henry H. Takei, Perry R.<br />
Klokkevold, Fermin A. Carranza: Clinical Periodontology.<br />
10th edition, Chapter 31:p494-9.<br />
3. Siqueira FM, Cota LO, Costa JE, Haddad JP,<br />
Lana AM, Costa FO. Maternal periodontitis as a<br />
potential risk variable for pre-eclampsia: a case-control<br />
study. J Periodontol 2008;79(2):207-15.<br />
4. Canakci V, Canakci CF, Canakci H, Canakci E,<br />
Cicek Y, Ingec M, et al. Periodontal disease as a risk<br />
factor for pre-eclampsia: a case control study. Aust N Z J<br />
Obstet Gynaecol 2004;44(6):568-73.<br />
5. Conde-Agudelo A, Villar J, Lindheimer M. Maternal<br />
infection and risk of pre-eclampsia: systematic review and<br />
metaanalysis. Am J Obstet Gynecol 2008;198(1):7‐22.<br />
6. Riché EL, Boggess KA, Lieff S, Murtha AP, Auten RL,<br />
Beck JD, et al. Periodontal disease increases the risk<br />
of preterm delivery among preeclamptic women. Ann<br />
Periodontol 2002;7(1):95-101.<br />
7. National High Blood Pressure Education Program<br />
Working Group Report on High Blood Pressure<br />
in Pregnancy. Am J Obstet Gynecol 1990;163<br />
(5 Pt 1):1691‐712.<br />
8. Cincotta RB, Brennecke SP. Family history of preeclampsia<br />
as a predictor for pre-eclampsia in primigravidas.<br />
Int J Gynaecol Obstet 1998;60(1):23-7.<br />
9. Taylor DJ. The epidemiology of hypertension during<br />
pregnancy. In: Hypertension in Pregnancy. Rubin PC,<br />
(Ed.), Elsevier Science: Amsterdam 1988:233-40.<br />
10. Shirish N. Daftary, Sudip Chakravarti. Manual of<br />
Obstetrics. 2nd edition, Chapter 11:p99-111.<br />
11. Dekker GA. Risk factors for pre-eclampsia. Clin Obstet<br />
Gynecol 1999;42(3):422-35.<br />
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12.<br />
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20.<br />
Pascoal IF, Lindheimer MD, Nalbantian-<br />
Brandt C, Umans JG. Pre-eclampsia selectively impairs<br />
endothelium-dependent relaxation and leads to<br />
oscillatory activity in small omental arteries. J Clin Invest<br />
1998;101(2):464‐70.<br />
Sibai BM. Diagnosis, controversies, and management<br />
of the syndrome of hemolysis, elevated liver enzymes,<br />
and low platelet count. Obstet Gynecol 2004;103<br />
(5 Pt 1):981-91.<br />
Ylikorkala O, Mäkilä UM. Prostacyclin and thromboxane<br />
in gynecology and obstetrics. Am J Obstet Gynecol<br />
1985;152(3):318-29.<br />
Boggess KA. Is there a link between periodontal<br />
disease and preterm birth? Contemporary Ob/Gyn<br />
2003;48:79‐84.<br />
Hill GB. Preterm birth: associations with genital<br />
and possibly oral microflora. Ann Periodontol<br />
1998;3(1):222‐32.<br />
Oettinger-Barak O, Barak S, Ohel G, Oettinger M,<br />
Kreutzer H, Peled M, et al. Severe pregnancy complication<br />
(pre-eclampsia) is associated with greater periodontal<br />
destruction. J Periodontol 2005;76(1):134-7.<br />
Contreras A, Herrera JA, Soto JE, Arce RM, Jaramillo A,<br />
Botero JE. Periodontitis is associated with pre-eclampsia<br />
in pregnant women. J Periodontol 2006;77(2):182-8.<br />
Barak S, Oettinger-Barak O, Machtei EE, Sprecher H,<br />
Ohel G. Evidence of periopathogenic microorganisms<br />
in placentas of women with pre-eclampsia. J Periodontol<br />
2007;78(4):670-6.<br />
Baba A, Kadowaki T, Asao T, Yamamoto K. Roles for<br />
Arg- and Lys-gingipains in the disruption of cytokine<br />
responses and loss of viability of human endothelial<br />
cells by Porphyromonas gingivalis infection. Biol Chem<br />
2002;383(7-8):1223-30.<br />
21. Moncla BJ, Braham P, Rabe LK, Hillier SL. Rapid<br />
presumptive identification of black-pigmented<br />
gram-negative anaerobic bacteria by using<br />
4-methylumbelliferone derivatives. J Clin Microbiol<br />
1991;29(9):1955-8.<br />
22. Aydin S, Benian A, Madazli R, Uludag S, Uzun H,<br />
Kaya S. Plasma malondialdehyde, superoxide dismutase,<br />
sE-selectin, fibronectin, endothelin-1 and nitric oxide<br />
levels in women with pre-eclampsia. Eur J Obstet<br />
Gynecol Reprod Biol 2004;113(1):21-5.<br />
23. Hubel CA. Oxidative stress in the pathogenesis<br />
of pre-eclampsia. Proc Soc Exp Biol Med 1999;<br />
222(3):222‐35.<br />
24. Conrad KP, Benyo DF. Placental cytokines and the<br />
pathogenesis of pre-eclampsia. Am J Reprod Immunol<br />
1997;37(3):240-9.<br />
25. Staff AC, Halvorsen B, Ranheim T, Henriksen T.<br />
Elevated level of free 8-iso-prostaglandin F2alpha in<br />
the decidua basalis of women with pre-eclampsia. Am J<br />
Obstet Gynecol 1999;181(5 Pt 1):1211-5.<br />
26. Beck JD, Offenbacher S. The association between<br />
periodontal diseases and cardiovascular diseases: a stateof-the-science<br />
review. Ann Periodontol 2001;6(1):9-15.<br />
27. von Dadelszen P, Magee LA. Could an infectious trigger<br />
explain the differential maternal response to the shared<br />
placental pathology of pre-eclampsia and normotensive<br />
intrauterine growth restriction? Acta Obstet Gynecol<br />
Scand 2002;81(7):642-8.<br />
• • •<br />
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eview article<br />
Oral Lichen Planus: A Review on Current Medical<br />
Management<br />
D Anusha*, KT Magesh**, T Elangovan † , Yakob Martin ‡<br />
Abstract<br />
Lichen planus is a chronic inflammatory mucocutaneous disease of unknown etiology. The prevalence of lichen planus is<br />
unknown, but it is estimated to occur in
Review Article<br />
Corticosteroids<br />
These agents have profound anti-inflammatory<br />
properties, they induce varied metabolic effects,<br />
modify the body’s immune response to diverse<br />
stimuli and decreases inflammation by reversing the<br />
increased capillary permeability and by suppressing<br />
polymorphonuclear neutrophils (PMN) activity. They<br />
are available in both systemic and topical forms.<br />
Steroids in ointment form reduce pruritus in cutaneous<br />
lichen planus, but they have not been proven to induce<br />
remission. 3<br />
Topical Corticosteroids<br />
Several topical agents have been employed in the<br />
management of OLP by different authors with varying<br />
degree of success.<br />
Betamethasone is one of the most widely used topical<br />
corticosteroid. In a study by Malhotra et al, 4 it was<br />
shown that betamethasone oral therapy improves the<br />
clinical outcome in patients with moderate-to-severe<br />
OLP, and its efficacy was comparable with that of<br />
topical triamcinolone acetonide. It should be used in<br />
pediatrics with extreme caution since children have a<br />
larger skin surface area to body weight ratio and less<br />
developed, thinner skin, which may result in greater<br />
amounts of topical steroid being absorbed compared<br />
with adults. For OLP, the gel has to be applied to the<br />
affected area q 4-6 hour for 2-3 months.<br />
Mometasone is a potent synthetic glucocorticoid and<br />
has demonstrated a greater anti-inflammatory activity<br />
and longer duration of action than betamethasone with<br />
less side effects. To avoid the difficulty of application of<br />
topical corticosteroids in the oral cavity, to increase the<br />
ability to reach posterior areas and to cover extensive<br />
and multiple areas, mometasone furoate 0.1% is used<br />
in new form as microemulsion mouth wash (5 ml for<br />
5 minutes 3 times a day). It is safe and effective in the<br />
treatment of erosive-ulcerative OLP. 2<br />
Carrozzo and Gandolfo in their study 5 have shown<br />
topical clobetasol to be successful in 50-65% of<br />
patients, bringing about total reduction of symptoms,<br />
in comparison with other topical steroids. Thongprasom<br />
et al in their 2-year clinical evaluation follow-up 6 have<br />
shown that topical fluocinolone acetonide in either<br />
orabase or solution form can produce improved results<br />
in the management of OLP.<br />
Topical steroids unlike systemic steroids do not cause<br />
adrenal suppression even if administered for a long<br />
time. Patients are instructed to apply a small amount<br />
of the drug on the lesional area, abstain from speaking<br />
or eating for about an hour and then to rinse the<br />
mouth thereafter to prevent systemic absorption;<br />
the only adverse effect could be the occurence of<br />
pseudomembranous candidiasis which can be prevented<br />
by concomitant use of antifungal gels or chlorhexidine<br />
mouthwash. 7<br />
Systemic Corticosteroids<br />
Indicated at high dose (1.5-2 mg/kg/day) for<br />
patients with recalcitrant severe erosive atrophic OLP<br />
where topical approaches have failed or for diffuse<br />
mucocutaneous involvement. Systemic triamcinolone<br />
available as parental injections has been reported to be<br />
effective. Oral lesions can be treated with intralesional<br />
injection of 5-10 mg/ml. Systemic prednisone<br />
also proved to be very effective for severe OLP. It<br />
should be administered for adult with dosage of<br />
30-60 mg/day PO for 4-6 weeks followed by gradual<br />
taper. 8 For pediatric purpose 4-5 mg/m 2 /dday PO;<br />
alternatively, 0.05-2 mg/kg PO divided b.i.d/q.i.d and<br />
should be tapered over two weeks as the symptoms<br />
resolve. Systemic steroids are contraindicated in<br />
hepatitis C virus (HCV)-related lichen planus as it<br />
increases HCV viremia leading to a worsening of liver<br />
damage. 9<br />
Retinoids<br />
Retinoids are a class of chemical compounds that are<br />
related chemically to vitamin A and are used in medicine<br />
primarily due to the way they regulate epithelial<br />
cell growth. These agents regulate cell proliferation<br />
and differentiation, growth of bone tissues, immune<br />
function and activation of tumor suppressor genes.<br />
Drug isotretinoin, a first-generation retinoid is used as<br />
an oral agent to treat serious dermatologic conditions.<br />
It is a synthetic 13-cis isomer of the naturally occurring<br />
tretinoin (trans-retinoic acid). Both agents are<br />
structurally-related to vitamin A. It decreases sebaceous<br />
gland size and sebum production and inhibit sebaceous<br />
gland differentiation and abnormal keratinization.<br />
Topical tretinoin 0.1% in an adhesive gel used<br />
4 times a day for two months completely or partially<br />
heals atrophic-erosive and reticular plaque lesions.<br />
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Both topically and systemically applied retinoids are<br />
used as adjuvant therapy when steroids fail to be<br />
effective. 10<br />
Toxicities that may occur with vitamin A are pseudotumor<br />
cerebri or papilledema, it may reduce plasma levels<br />
of carbamazepine, increases toxicity of methotrexate<br />
(avoid concomitant use), interferes with effects of<br />
microdose progestin minipill, coadministration with<br />
alcohol may result in formation of etretinate, which has<br />
much longer half-life than acitretin (>120 days) and it<br />
also increases toxicity of phenytoin. Moreover, these<br />
analogs may decrease night vision, cause inflammatory<br />
bowel disease, may be associated with development of<br />
hepatitis and pancreatitis and diabetic patients may<br />
experience problems in controlling blood glucose.<br />
The drug should be discontinued if rectal bleeding,<br />
abdominal pain or severe diarrhea occurs. Drug should<br />
be administered with extreme precaution in patients<br />
with history of depression since the drug can induce<br />
mood swings and depression.<br />
Immunosuppressants<br />
These agents modulate the immune system. It induces<br />
a substantial decrease of T cells and a corresponding<br />
reduction in activated CD25-positive cells and in<br />
antigen presenting cells possibly by inhibition of<br />
interferon-gamma production.<br />
Cyclosporine mouthwash solutions have been effective<br />
for OLP but seem to be no better than corticosteroids. 11<br />
Systemic treatment has been used for severe resistant<br />
cutaneous disease, oral or ulcerative foot involvement<br />
and lichen planopilaris of the scalp. Pediatric<br />
population may require higher or more frequent<br />
dosing because of accelerated clearance but should be<br />
used with extreme caution. For adults 1-2 mg/kg/day<br />
PO is the recommended starting dosage and if no<br />
response in disease pattern, dosage can be increased<br />
to 5 mg/kg/day. Renal and liver functions have to be<br />
assessed before usage, since the drug is hepatotoxic<br />
and nephrotoxic. IV use is reserved only for those<br />
who cannot take PO. Other adverse effects include<br />
hypertension, gingival enlargement, hyperkalemia,<br />
hypomagnesemia, pancreatitis and paresthesia. Due<br />
to the severe adverse effects and the oral lesions being<br />
often chronic in nature, the usage is limited.<br />
Drug tacrolimus has a powerful immunosuppressive<br />
activities by inhibiting T-cell production of<br />
proinflammatory cytokines. Topical application induce<br />
a rapid improvement in OLP. 12 Recent studies have<br />
showed tacrolimus has an impact on cancer signaling<br />
pathways such as MAPK and the P53 pathways. This<br />
suspected causal relation ship and development of<br />
squamous cell carcinoma suggest that carcinogenicity<br />
go beyond immunosuppression. 13<br />
Levamisole is another effective immunomodulating<br />
agent that can restore the normal phagocytic activity<br />
of macrophages and neutrophills. Levamisole<br />
monotherapy is effective for treating OLP patients who<br />
are unable to use steroids and who had no response to<br />
convetional treatment. 14 Topical rapamycin (sirolimus)<br />
impedes the response of interleukin-2 (IL-2), and thus<br />
prevents T and B cell activation. Rapamycin has both<br />
immunomodulatory and tumor inhibitory nature and<br />
hence blocks malignant transformation of OLP to some<br />
extent. In a study by Soria et al, 3-month application<br />
of rapamycin showed complete remission in 57% and<br />
partial remission in 30% of cases. 15<br />
Psoralen and Ultraviolet A (PUVA)<br />
PUVA (psoralen + ultraviolet A) are photosensitising<br />
agents found in plants. They are applied or taken<br />
orally to sensitise the skin, before exposing the latter to<br />
UVA. PUVA has been effectively used to treat several<br />
dermatological conditions like eczema, psoriasis, mycosis<br />
and vitiligo. Ultraviolet irradiation in combination<br />
with psoralens is indicated in the treatment of OLP as<br />
it reduces T suppressor cell function.<br />
In a study by Gonzalez et al 16 80% of the lichen planus<br />
patients treated with PUVA showed positive response.<br />
The major concern in using PUVA therapy is its<br />
carcinogenic potential and its use in the premalignant<br />
lesion like lichen planus, could theoretically increase<br />
the risk of cancer. In India, photochemotherapy with<br />
solar radiation (PUVASOL) has been found to be<br />
effective and a cheaper alternative. Sharma and Mishra<br />
in their study have shown PUVASOL therapy to be<br />
more effective than other regimen, 17 with nausea and<br />
sunburn occurring as side effects in few cases.<br />
Antifungal Agents<br />
Topical antimycotic drugs-like griseofulvin and<br />
amphotericin have shown good results in patients with<br />
and candidiasis and OLP. It is used as an adjunctive<br />
276<br />
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Review Article<br />
therapy along with steroids. Dexamethasone is given<br />
in combination with nystatin, and clobetasol with<br />
miconazole. 18<br />
Other Modalities<br />
Adalimumab, infliximab, etanercept monoclonal antibody<br />
(TNF antagonist), basiliximab (anti IL-2 receptor),<br />
alefacept, efalizumab (LFA fusion proteins) with its anti<br />
inflammatory activity have shown almost fully resolved<br />
response but safety and efficacy is in trial. 19<br />
Aloe vera is a stem-less or very short-stemmed<br />
succulent plant. There is some preliminary evidence<br />
that Aloe vera extracts may be useful in the treatment<br />
of wound, burn healing and minor skin infections. Aloe<br />
vera extracts have also been used to produce symptomatic<br />
relief and improve the quality-of-life in patients<br />
with OLP. 20<br />
Hyaluronic acid is an anionic nonsulfated<br />
glycosaminoglycan distributed widely througout<br />
connective, epithelial and neural tissues and is a major<br />
component of both the skin and cartilage. It appears to<br />
be of some benefit in the management of erosive lichen<br />
planus but its action is not long-lasting. It also needs<br />
frequent applications. 21<br />
Lasers have been used in patients whose condition<br />
is unresponsive to topical corticosteroids. CO 2<br />
laser<br />
evaporation can cause long-term remission of symptoms,<br />
and may be the treatment of choice in patients suffering<br />
from painful OLP. 22 Diode laser treatment is effective<br />
for plaque like-lichen planus lesions. 23<br />
Stress and Lichen Planus<br />
Stress epidemic in modern life has been proved to trigger<br />
inflammatory skin diseases. Skin and nervous system<br />
develop side by side in ectoderm of fetus and remain<br />
intimately interconnected through the cutaneous<br />
sensory hormone. Skin is the largest sense organ of<br />
body and vital to protection and health. Significant<br />
psychosomatic or behavior component may lead to<br />
skin disorders. Relaxation, meditation and hypnosis<br />
have positive impact on many cutaneous diseases and<br />
helps to calm and rebalance the inflammatory response<br />
which can ameliorate inflammatory skin disorders.<br />
Breath relaxation in traditional yoga with slow and<br />
deepen breathing over rapid and shallow one, and<br />
slower diaphragmatic abdominal breathing improve<br />
psycshostomatic aspects of skin disorders. Hypnosis<br />
is the intentional inducing, deepening, maintenance<br />
and termination of trance state for a specific purpose.<br />
It promotes healing, regulates blood flow and other<br />
autonomous function not usually under conscious<br />
control. 24<br />
Summary and Conclusion<br />
The management of OLP should begin by taking<br />
proper history and clinical examination. Elimination<br />
of any form of irritants-like maloccluded teeth, illfitting<br />
dentures, amalgam fillings should be removed.<br />
Biopsy should be done to confirm the diagnosis. After<br />
establishment of diagnosis topical corticosteroid in<br />
an adhesive medium is the first drug of choice. For<br />
recalcitrant lesions systemic corticosteroid could be<br />
used. In steroid unresponsive cases immunosuppresantslike<br />
cyclosporines and tacrolimus should be considered.<br />
Topical Antimyotic drugs should be used in patients<br />
with candidiasis and OLP. Both topically and<br />
systemically applied retinoids can be considered when<br />
steroids and immunosuppresants fail to be effective.<br />
CO 2<br />
laser evaporation can also be considered when<br />
the lesions fail to respond for systemic and topical<br />
therapies. One should not forget the relationship<br />
of stress and inflammatory skin diseases. Regular<br />
relaxation exercises, meditation and hypnosis help to<br />
calm and rebalance inflammatory response which can<br />
ameliorate inflammatory skin disorders.<br />
References<br />
1. Sugerman PB, Savage NW, Walsh LJ, Zhao ZZ, Zhou<br />
XJ, Khan A, et al. The pathogenesis of oral lichen planus.<br />
Crit Rev Oral Biol Med 2002;13(4):350-65.<br />
2. Aguirre JM, Bagán JV, Rodriguez C, Jimenez Y,<br />
Martínez-Conde R, Díaz de Rojas F, et al. Efficay of<br />
mometasone furoate microemulsion in the treatment of<br />
erosive-ulcerative oral lichen planus: pilot study. J Oral<br />
Pathol Med 2004;33(7):381-5.<br />
3. Sugerman PB, Savage NW. Oral lichen planus:<br />
causes, diagnosis and management. Aust Dent J<br />
2002;47(4):290‐7.<br />
4. Malhotra AK, Khaitan BK, Sethuraman G, Sharma VK.<br />
Betamethasone oral mini-pulse therapy compared with<br />
topical triamcinolone acetonide (0.1%) paste in oral<br />
lichen planus: a randomized comparative study. J Am<br />
Acad Dermatol 2008;58(4):596-602.<br />
5. Carrozzo M, Gandolfo S. The management of oral lichen<br />
planus. Oral Dis 1999;5(3):196-205.<br />
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6.<br />
7.<br />
8.<br />
9.<br />
10.<br />
11.<br />
12.<br />
13.<br />
14.<br />
Thongprasom K, Leuengvisut P, Wongwatanakij A,<br />
Boonjatturus C. Clinical evaluation in treatment of oral<br />
lichen planus with topical fluocinolone acetonide: a<br />
2-year follow up. J Oral Pathol Med 2003:32(6):<br />
315‐22.<br />
Lodi G, Tarozzi M, Sardella A, Demarosi F, Canegallo L,<br />
Di Benedetto D, et al. Miconazole as adjuvant therapy<br />
of oral lichen planus: a double-blind randomized control<br />
trial. Br J Dermatol 2007;156(6):1336-41.<br />
Carbone M, Gross E, Carrozzo M, Castellano S,<br />
Conrotto D, Broccoletti R, et al. Systemic and topical<br />
corticosteroid treatment of oral lichen planus: a<br />
comparative study with long-term follow-up. J Oral<br />
Pathol Med 2003;32(6):323-9.<br />
Bechade D, Oui B, Mayet F, Trouette H, Schouler L,<br />
Jouglen J, et al Appearance of hepatitis C virus replication<br />
and increase in serum aminotransferase levels after<br />
corticoid therapy of presumed autoimmune hepatitis. 2<br />
cases. Gastroenterol Clin Biol 1996;20(8-9):696-9.<br />
Camisa C, Allen CM. Treatment of oral erosive lichen<br />
planus with systemic isoretinoin. Oral Surg Oral Med<br />
Oral Pathol 1986;62(4):393-6.<br />
Conrotto D, Carbone M, Caorrozzo M, Arduino P,<br />
Broccoletti R, Pentenero M, et al. Ciclosporin vs.<br />
clobetasol in the topical management of atrophic and<br />
erosive oral lichen planus: a double-blind randomized<br />
controlled trial. Br J Dermatol 2006;154(1):139-45.<br />
Shichinohe R, Shibaki A, Nishie W, Tateishi Y,<br />
Shimizu H. Successful treatment of severe recalcitrant<br />
erosive oral lichen planus with topical tacrolimus. J Eur<br />
Acad Dermatol Venereol 2006;20(1):66-8.<br />
Becker JC, Houben R, Vetter CS, Brocker EB. The<br />
carcinogenic potential of tacrolimus ointment beyond<br />
immune suppression: a hypothesis creating case report.<br />
BMC Cancer 2006;6:7.<br />
Won TH, Park SY, Kim BS, Seo PS, Park SD. Levamisole<br />
monotherapy for oral lichen planus. Ann Dermatol<br />
2009;21(3):250-4.<br />
15. Soria A, Agbo-Godeau S, Taieb A, Francés C. Treatment<br />
of refractory oral erosive lichen planus with topical<br />
rapamycin: 7 cases. Dermatology 2009;218(1):22-5.<br />
16. Gonzalez E, Momtaz-T K, Freedman S. Bilateral<br />
comparison of generalized lichen planus treated with<br />
psoralens and ultraviolet A. J Am Acad Dermatol<br />
1984;10(6):958-61.<br />
17. Sharma L, Mishra MK. A comparative study of<br />
PUVASOL therapy in lichen planus. Indian J Dermatol<br />
Venereol Leprol 2003;69(3):212-3.<br />
18. Thongprasom K, Carrozzo M, Furness S, Lodi G.<br />
Interventions for treating oral lichen planus. Cochrane<br />
Database Syst Rev 2011;(7):CD001168.<br />
19. Chao TJ. Adalimumab in the management of cutaneous<br />
and oral lichen planus. Cutis 2009;84(6):325-8.<br />
20. Choonhakarn C, Busaracome P, Sripanidkulchai B,<br />
Sarakarn P. The efficacy of aloe vera gel in the treatment<br />
of oral lichen planus: a randomized controlled trial. Br J<br />
Dermatol 2008;158(3):573-7.<br />
21. Nolan A, Badminton J, Maguire J, Seymour RA.<br />
The efficacy of topical hyaluronic acid in the<br />
management of oral lichen planus. J Oral Pathol Med<br />
2009;38(3):299‐303.<br />
22. van der Hem PS, Egges M, van der Wal JE, Roodenburg<br />
JL. CO 2<br />
laser evaporation of oral lichen planus. Int J<br />
Oral Maxillofac Surg 2008;37(7):630-3.<br />
23. Sivolella S, Berengo M, Cernuschi S, Valente M. Diode<br />
laser treatment is effective for plaque-like lichen planus<br />
of the tongue: a case report. Lasers Med Sci 2011 <strong>Jul</strong> 31.<br />
[Epub ahead of print].<br />
24. Shenefelt PD. Relaxation, meditation, and hypnosis<br />
for skin disorders and procedures. In: Mind-Body and<br />
Relaxation Research Focus. deLuca BN, (Ed.), Nova<br />
Science Publishers: Hauppauge, NY 2008:p45-63.<br />
• • •<br />
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Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Role of Gene in Palate Formation<br />
Review Article<br />
Subrata Sarkar*, Soumyabrata Sarkar**, Gargee Maitra †<br />
Abstract<br />
Genes are the ultramicroscopic structure of DNA. Genes and their products i.e. enzymes, control various metabolic processes.<br />
There are two types of genes: Structural genes and control or regulatory genes. Without the help of the genes, palate formation<br />
cannot take place.<br />
Key words: Palate formation, genes<br />
Palate, a natural bony separator, is a part of<br />
orofacial structure that separates the oral cavity<br />
and the nasal cavity. Palate is divided into two<br />
parts: Anterior and posterior. The anterior part is made<br />
up of bony structure and the posterior part is made up<br />
of soft tissue structures. 1-4 At one stage of development,<br />
the oral cavity communicates with the nasal cavity.<br />
According to anatomists development of palate occurs<br />
as follows:<br />
• A partition grows backward from the frontonasal<br />
process to meet the buccopharyngeal membrane.<br />
This partition is called the bucconasal membrane<br />
(or the primitive palate), the anterior part of which<br />
only persists to form the premaxilla.<br />
• Horizontal process, one on either side, grows from<br />
the maxillary process of the mandibular arch to<br />
form the definitive palate. These two horizontal<br />
processes cannot meet the premaxilla due to the<br />
position of the tongue.<br />
At this stage, the entire oral cavity is filled up by the<br />
tongue. During 7th week of intrauterine period, two<br />
tubercles develop in the lingual side of mandible i.e.<br />
genial tubercles. From here, the genioglossus and<br />
geniohyoid muscles develop and then attach with the<br />
*Professor and Head<br />
Dept. of Pedodontics and Preventive Dentistry<br />
**Senior Lecturer<br />
Dept. of Oral Diagnosis, Oral Medicine and Oral Radiology<br />
†<br />
Intern, Dept. of Pedodontics and Preventive Dentistry<br />
GNIDSR, Kolkata<br />
Address for correspondence<br />
Dr Subrata Sarkar<br />
Professor and Head<br />
Dept. of Pedodontics and Preventive Dentistry<br />
GNIDSR, 114/F, Nilgung Road, Panihati, Sodepur, Kolkata -700 114<br />
E-mail: drssarkar44@yahoo.com<br />
tongue. After neural connection with hyoglossal and<br />
hypoglossal nerves, the downward pulling of tongue<br />
takes place. At that time palatal shelves transposition<br />
occurs as a result of which fusion of 2 ‘L’ shaped<br />
palatine processes takes place. During this period<br />
premaxilla and the two palatine processes join together<br />
and ultimately palate forms. 5-7,10<br />
• The anterior three-fourth of the mesodermal<br />
partition becomes cartilaginous and helps to form<br />
the hard palate.<br />
• Posterior one-fourth forms the fibrous part of the<br />
soft palate. All muscles of the soft palate migrate<br />
from the sixth arch myotome except the tensor<br />
palate which comes from the first arch myotome<br />
(Figs. A-E).<br />
Anatomists have described the time schedule of the<br />
formation of various structures as shown below:<br />
Structures<br />
Stomodium<br />
Frontal process<br />
Mandibular process<br />
Maxillary process<br />
Lateral nasal process<br />
Globular process<br />
Face formation<br />
Time (intrauterine period)<br />
3rd week<br />
4th week<br />
5th week<br />
5.5th week<br />
6th week<br />
7th week<br />
8th week<br />
Various genetic engineers have suggested that genes<br />
play an important role in palate formation. According<br />
to them genes are of two types:<br />
• Structural genes, which synthesize specific protein<br />
molecule<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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Review Article<br />
Lateral nasal<br />
process<br />
Medial nasal<br />
process<br />
Maxillary process<br />
Area of secondary<br />
palate<br />
A<br />
Figure A. At the completion of primary palate formation.<br />
B<br />
C<br />
Primary palate<br />
Palatal shelves<br />
Primary palate<br />
Palatal shelves<br />
after elevation<br />
Figure B. Before elevation of palatal<br />
shelves.<br />
Figure C. Shelves during elevation.<br />
D<br />
E<br />
Incisive foramen<br />
Point of incisive<br />
foramen<br />
Point of initial<br />
fusion<br />
Odontogenic<br />
epithelium<br />
Line of fusion<br />
Figure D. Initial fusion of the<br />
shelves.<br />
Figure E. Secondary palate after<br />
fusion.<br />
From Contemporary Orthodontics, 2008 edition, Proffit R. William, Elsevier.<br />
280<br />
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• Control or regulatory genes, which regulate<br />
the synthesis and activity of structural gene and<br />
also promote or inhibit steps of transcription of<br />
structural gene and protein. 8,9<br />
The frontonasal process is formed by synthesis of<br />
retinoid acid which is present in ectoderm. Retinoid<br />
acid helps fibroblast growth factor-8 (FGF-8) and<br />
Sonic hedgehog (SHH) gene to stimulate neural crest<br />
cell and helps to form frontonasal process. During<br />
4.5-5th weeks of intrauterine period, the proliferation<br />
of frontonasal process takes place. During this period<br />
maxillary, mandibular, medial and lateral nasal processes<br />
start growing (Figs. F-H).<br />
It is clear that without the help of genes, no growth<br />
and development of various facial processes and sutural<br />
growth of palate can occur. At the time of suture<br />
morphogenesis (before birth), the following genes<br />
become very active:<br />
• MSX-2<br />
• FGF-1<br />
• TGF-2<br />
• TGF-3<br />
These genes help in sutural growth of palate. Thus<br />
formation of palate along with formation of face<br />
occurs.<br />
Various anatomists and dental scientists have observed<br />
improper formation and fusion of palatine processes<br />
as a result of which various types of cleft palate are<br />
formed.<br />
The functions of various genes are given below:<br />
• FGF-8 is the molecular centre of maxillary<br />
processes.<br />
• MSX-1 (Muscle segment homeobox gene 1) gene<br />
helps to grow mesenchyme of all facial processes.<br />
• OTX-2 gene is the precursor of first branchial<br />
arch.<br />
• FGF-2 and FGF-4 are signaling centers of<br />
epithelium, which help in the growth of<br />
mesenchyme.<br />
• DLX-1 and DLX-2 are important genes present in<br />
maxillary process.<br />
Retinoid acid<br />
FGF-8<br />
SHH FGF-8<br />
FGF-8<br />
Figure F. Early development of face.<br />
-8<br />
-1<br />
-8<br />
-1<br />
-2<br />
Frontonasal process<br />
Stomodium<br />
Maxillary process<br />
Mandibular process<br />
2nd branchial arch<br />
3rd branchial arch<br />
Eye<br />
Medial nasal process<br />
Lateral nasal process<br />
Maxillary process<br />
Stomodium<br />
Mandibular process<br />
Figure G. Development of medial and dateral nasal<br />
processes.<br />
SHH<br />
EGF<br />
MAX-1<br />
BMP-4<br />
BMP-2<br />
Figure H. Various genes help in palate growth.<br />
Nasal septum<br />
Nasal cavity<br />
Lateral palatine process<br />
Oral cavity<br />
Tongue<br />
The following genes are required for palate formation:<br />
• Retinoid acid<br />
• FGF-8<br />
• SHH<br />
• MSX-1<br />
• OTX-2<br />
• DLX-1 and DLX-2<br />
Conclusion<br />
Palate is the bony separator between oral cavity<br />
and nasal cavity. Palate formation takes place in the<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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Review Article<br />
intrauterine period, which is formed by premaxilla and<br />
two palatal processes of maxilla (right and left). Dental<br />
anatomists and general anatomists have observed that<br />
transposition of palatine shelves has a major role in<br />
palate formation.<br />
Genetic engineers have stated that different genes<br />
have important role in formation of palate along with<br />
fusion of bones. Improper formation and fusion causes<br />
various types of palatal clefts.<br />
References<br />
1.<br />
2.<br />
3.<br />
Peter WL, Gray’s Anatomy. 38th edition, Churchill<br />
Livingstone, 200;1688-1691.<br />
Mahindra AK, Anand’s Human Anatomy. 1st edition,<br />
The Arora Medical Book Publisher’s Pvt. Ltd, 2002:<br />
279.<br />
Chaurasia BD. Chaurasia’s Human Anatomy. 3rd edition,<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
10.<br />
CBS Publishers and Distributors 2002:178-9, 313.<br />
Singh I. Human Embriology. 7th edition, Macmillan,<br />
2001:147.<br />
Antonio N, Ten Cate’s Oral Histology, Development,<br />
Structure and Function. 4th edition, Mosby, Page No:<br />
22, 24-27,418,424.<br />
Bhaskar SN Orban’s Oral Histology and Embryology.<br />
11th edition, Elsevier, 2004:283-9.<br />
Avery K James. Oral Development and Histology, 3rd<br />
edition, Thieme, 2007;26, 28-31, 252-4, 417.<br />
Pal GP, Niladri M, Genetics In Dentistry. 1st edition,<br />
Jaypee Brothers, New Delhi, 2010:120-5.<br />
Peter T & Ellard Sian, Emery’s Elements of Medical<br />
Genetics, 13th edition, 2007, Churchill Livingstone,<br />
Page No: 139, 238, 246, 393, 410.<br />
Stewart RE, Prescott GH. Orofacial Genetics. C.V<br />
Mosby Company, 1976:475-7, 494.<br />
• • •<br />
282<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
A Technique to Locate Implants during Second Stage<br />
Surgery<br />
CJ Venkatakrishnan*, M Narasimman**<br />
clinical practice<br />
Abstract<br />
This article describes a technique of uncovering implants during the second stage surgery. This technique was done with a<br />
surgical stent which is used during the implant placement.<br />
Key words: Implant placement, surgical stent<br />
Dental implants have been considered as a<br />
standard of treatment for partially edentulous<br />
and completely edentulous patients for<br />
several decades. The accurate placement of implants is<br />
done with the help of a surgical stent. Various surgical<br />
stents have been used in the literature. 1-10 The implant<br />
placement can be a single or two stage procedure. In<br />
single stage procedure the implant is accessible in the<br />
oral cavity by placing the healing cap or prosthesis or<br />
the implant design itself. In two stage procedure the<br />
first stage will be placement of implant and the second<br />
stage will be uncovering the implant by opening the<br />
mucoperiosteal flap.<br />
The implant is uncovered after a healing period of<br />
three months in the conventional method. In this two<br />
stage procedure the second stage generally requires<br />
elevation of mucoperiosteal flap followed by suture<br />
placement. This conventional procedure requires<br />
suture placement and an extended period of healing<br />
time. This article describes a technique to locate the<br />
implants during second stage surgery by the use of<br />
surgical stent which does not need suture placement<br />
and requires less healing time.<br />
• Using the diagnostic waxup a surgical stent was<br />
made.<br />
• Under local anesthesia full thickness flap was<br />
elevated and the endosteal implant is placed using<br />
the surgical stent.<br />
• After three months of healing period the surgical<br />
stent was repositioned (Fig. 1).<br />
Figure 1. Repositioning of the surgical stent.<br />
Technique<br />
• Diagnostic waxup was made using the diagnostic<br />
impression.<br />
*Professor and Head<br />
**Senior Lecturer<br />
Dept. of Prosthodontics and Crown and Bridge<br />
Tagore Dental College and Hospital, Chennai<br />
Address for correspondence<br />
Dr CJ Venkatakrishnan<br />
Dept. of Prosthodontics and Crown and Bridge<br />
Tagore Dental College and Hospital, Chennai<br />
E-mail: drvenkat93@gmail.com<br />
Figure 2. Implant site marked with periodontal probe.<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
283
CLINICAL practice<br />
Figure 3. Mucoperiosteum removed.<br />
Figure 5. Cover screw removed.<br />
Figure 4. Use of rotary punch.<br />
Figure 6. Healing cap placed.<br />
• Periodontal probe was used to mark the implant<br />
site through surgical stent access hole (Fig. 2).<br />
• A rotary punch was used (Fig. 3) to remove the<br />
mucoperiosteam overlying the cover screw of the<br />
implant (Fig. 4).<br />
• Cover screw was removed and the suitable healing<br />
cap was placed (Fig. 5).<br />
Discussion<br />
This technique eliminates the need of full thickness flap<br />
elevation, reducing the healing period, thus increases<br />
the patient comfort during and after the second stage<br />
surgery. The implant or abutment level impression<br />
can be made immediately after this technique. This<br />
technique can be used in single and multiple implants<br />
and it will be more ideal in uncovering implants for<br />
mandibular retained over denture. ‘This technique<br />
cannot be used if, there is any change in the remaining<br />
dentition or prosthesis after the surgical stent has been<br />
fabricated, since the stent cannot be repositioned.’<br />
References<br />
1.<br />
2.<br />
3.<br />
Ganz SD. Techniques for the use of CT imaging for the<br />
fabrication of surgical guides. Atlas Oral Maxillofac Surg<br />
Clin North Am 2006;14(1):75-97.<br />
Marchack CB. An immediately loaded CAD/CAMguided<br />
definitive prosthesis: a clinical report. J Prosthet<br />
Dent 2005;93(1):8-12.<br />
van Steenberghe D, Glauser R, Blomback U,<br />
Andersson M, Schutyser F, Pettersson A. A computed<br />
tomographic scan-derived customized surgical<br />
template and fixed prosthesis for flapless surgery and<br />
immediate loading of implants in fully edentulous<br />
maxillae: a prospective multicenter study. Clin<br />
Implant Dent Relat Res 2005;7 Suppl 1:S111-20.<br />
Continued page 287...<br />
284<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Extensive Nasopalatine Duct Cyst Causing<br />
Nasolabial Protrusion<br />
Case report<br />
AR Tariq Salamm*, Vijay Parthiban*, Gopinath**, R Karpagam †<br />
Abstract<br />
The nasopalatine duct cyst (NPDC), also known as nasopalatine cyst or elevator shaft cyst, is a developmental, non-neoplastic<br />
cyst that is considered to be the most common nonodontogenic cyst. It is one of many pathologic processes that may occur<br />
within the jawbones, but it is unique in that it develops in only a single location, in the midline anterior maxilla. Nasopalatine<br />
cysts are usually asymptomatic, but may sometimes produce an elevation in the anterior portion of the palate, and are<br />
discovered incidentally during routine radiological examination. Radiographically, it appears as a heart-shaped radiolucency.<br />
In this article, we report a case of nasopalatine duct cyst along with a review of its epidemiology, etiology, diagnostic<br />
work-up, differential diagnosis and therapeutic strategies.<br />
Key words: Elevator shaft cyst, non-neoplastic, nonodontogenic cyst<br />
The nasopalatine cyst was first described by<br />
Meyer in 1914. 1 It is believed to arise from<br />
remnants of nasopalatine duct, an embryologic<br />
structure connecting the oral and nasal cavities in the<br />
area of incisive canal. 2 It is one of the most common<br />
nonodontogenic cysts, 3 comprising 10% of jaw cysts<br />
and occurring in one of every 100 persons with slight<br />
male predilection, the mean age being 42.5 years. 4<br />
These cysts are usually asymptomatic, unless they are<br />
secondarily infected. 27 The most commonly reported<br />
clinical symptom, if at all present, is swelling in the<br />
anterior part of the palate. These entities are usually<br />
treated by surgical enucleation. 5,25<br />
Case Report<br />
A 55-year-old female patient reported to the outpatient<br />
department with a complaint of swelling in the upper<br />
lip for the past three months. The patient noted the<br />
swelling along the upper lip, which gradually increased<br />
to the present size. The swelling was associated with<br />
a dull aching intermittent pain. Extraorally, there<br />
was a swelling in the anterior part of the upper lip<br />
*Dept. of Oral Surgery<br />
**Dept. of Periodontia<br />
Chettinad Dental College and Research Institute, Chennai<br />
†<br />
Dental Surgeon<br />
Address for correspondence<br />
Dr R Karpagam<br />
Dental Surgeon<br />
E-mail: mailkarpu@yahoo.com<br />
measuring about 2 × 2 cm, causing the floor of the<br />
nose to bulge. There were no palpable lymph nodes<br />
present. Intraoral examination revealed a well-defined<br />
oval-shaped bluish swelling measuring approximately<br />
2 × 2 cm, located along the labial vestibule. The swelling<br />
was fluctuant and nontender. The teeth in relation, 12<br />
and 21, were mobile with severe periodontal problems.<br />
Intraoral periapical and occlusal radiographs revealed a<br />
well-defined radiolucency located anteriorly, between<br />
the apical third of roots of maxillary central incisors<br />
with an impacted supernumerary tooth (Fig. 1). The<br />
radiolucency extending laterally along the apex of the<br />
roots of the lateral incisors, then extending superiorly<br />
and medially to give ‘heart-shaped’ radiolucency, which<br />
is the characteristic feature of a nasopalatine cyst. The<br />
periphery of the lesion was well-defined. There was an<br />
evidence of resorption and displacement of the tooth<br />
roots. The teeth in relation to 11 and 21 were extracted<br />
one week prior to surgery.<br />
Treatment Done<br />
On the basis of the clinical and radiographic findings,<br />
a provisional diagnosis of nasopalatine cyst was made<br />
(Figs. 2 and 3). Cyst was enucleated along with the<br />
impacted supernumerary teeth and the specimen with<br />
the mesiodens (Fig. 5) was sent for histopathological<br />
examination.<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
285
Case Report<br />
Figure 1. OPG showing a ‘heart-shaped’ radiolucency with<br />
a supernumerary teeth.<br />
Figure 3. After enucleation.<br />
Figure 2. Lesion exposed.<br />
Histopatholog ical Examination<br />
On microscopic examination, the cyst was lined with a<br />
cuboidal epithelium and the cyst wall contained small<br />
muscular arteries lined by endothelial cells, veins;<br />
features of hemorrhage were also seen.<br />
Differential Diagnosis<br />
Periapical cyst, dentigerous cyst, adenomatoid<br />
odontogenic tumor<br />
Discussion<br />
The nasopalatine duct cyst (NPDC) is a developmental,<br />
non-neoplastic cyst. It is the most common of the<br />
nonodontogenic cysts of the oral cavity, occurring in<br />
about 1% of population. 8,9,13 Most studies show a higher<br />
incidence of NPDC among males than females with<br />
Figure 4. Closure.<br />
the ratio being 1.7:15. The age distribution is broad,<br />
with most cases being discovered in the fourth through<br />
sixth decade. In spite of being a developmental cyst, it<br />
is rarely seen in the first decade of life. Nasopalatine<br />
cysts are believed to develop from epithelial remnants<br />
of paired embryonic nasopalatine ducts within the<br />
incisive canal. 8,9,13 The stimulus for cyst formation<br />
from the epithelial remnants of the nasopalatine canal<br />
is uncertain, although trauma and bacterial infection<br />
are thought to have a role. It has also been suggested<br />
that the mucous glands within the lining may cause<br />
cyst formation as a result of mucin secretion. 18,24<br />
Most of these cysts are asymptomatic or cause such<br />
minor symptoms that they are tolerated for very<br />
long periods. Usually patients complain of a small<br />
asymptomatic swelling just posterior to palatine<br />
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Case Report<br />
CT findings of a nasopalatine cyst reveal a midline<br />
location, smooth expansion with sclerotic margins.<br />
Figure 5. Excised lesion with the supernumerary tooth.<br />
Figure 6.<br />
papilla. If the cyst is near the surface, the swelling will<br />
be fluctuant and blue. The deeper cyst is covered with<br />
normal appearing mucosa, which may be ulcerated<br />
due to masticatory trauma. 11,12 In some cases, the<br />
swelling may occur in the midline on the labial aspect<br />
of the alveolar ridge and in some patients through and<br />
through fluctuation can be palpated between the labial<br />
and palatal swellings. The cyst may produce bulging<br />
of the floor of nose. 15 In various cases, the swelling<br />
is associated with a burning sensation, numbness over<br />
the palatal mucosa and pain as a result of pressure<br />
on the nasopalatine nerves. Various combinations of<br />
swelling, discharge and pain may occur. 10,14 Discharge<br />
may be mucoid, in which case the patients describe<br />
a salty taste, or it may be purulent and the patient<br />
may complain of a foul taste. A cyst with a mesiodens<br />
or bilateral mesiodens and displacement of teeth as in<br />
this case is a rare finding. 16<br />
Even though definitive diagnosis of a nasopalatine cyst<br />
is more easily made on plain films, other advanced<br />
imaging modalities such as computed tomography<br />
(CT) and magnetic resonance imaging (MRI) are being<br />
used to differentiate this entity from other lesions. 21<br />
As the incisive canal and foramen may normally vary<br />
greatly in size, the clinician may have some difficulty<br />
in distinguishing between a large incisive foramen and<br />
a small asymptomatic incisive canal cyst on the basis of<br />
radiographic evidence alone. 26 Some clinicians follow<br />
the rule of thumb that radiolucencies of the incisive<br />
canal measuring
Case Report<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
10.<br />
11.<br />
12.<br />
13.<br />
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15.<br />
16.<br />
Elliott KA, Franzese CB, Pitman KT. Diagnosis and<br />
surgical management of nasopalatine duct cysts.<br />
Laryngoscope 2004;114(8):1336-40.<br />
Hegde RJ, Shetty R. Nasopalatine duct cyst. J Indian<br />
Soc Pedod Prev Dent 2006;24 Suppl 1:S31-2.<br />
Ely N, Sheehy EC, McDonald F. Nasopalatine duct cyst:<br />
a case report. Int J Paediatr Dent 2001;11(2):135-7.<br />
Gnanasekhar JD, Walvekar SV, al-Kandari AM,<br />
al-Duwairi Y. Misdiagnosis and mismanagement of a<br />
nasopalatine duct cyst and its corrective therapy. A case<br />
report. Oral Surg Oral Med Oral Pathol Oral Radiol<br />
Endod 1995;80(4):465-70.<br />
Harris IR, Brown JE. Application of cross-sectional<br />
imaging in the differential diagnosis of apical radiolucency.<br />
Int Endod J 1997;30(4):288-90.<br />
Herráez-Vilas JM, Gay-Escoda C, Berini-Aytés L. Quiste<br />
del conductonasopalatino. Revisión de la literatura y<br />
aportación de 14 casos. Rev Eur Odonto-Estomatol<br />
1994;6(4):231-6.<br />
Hisatomi M, Asaumi J, Konouchi H, Shigehara H, Yanagi<br />
Y, Kishi K. MR imaging of epithelial cysts of the oral and<br />
maxillofacial region. Eur J Radiol 2003;48(2):178-82.<br />
Hisatomi M, Asaumi J, Konouchi H, Matsuzaki H,<br />
Kishi K. MR imaging of nasopalatine duct cysts. Eur J<br />
Radiol 2001;39(2):73-6.<br />
Kreidler JF, Raubenheimer EJ, van Heerden WF.<br />
A retrospective analysis of 367 cystic lesions of the<br />
jaw - the Ulm experience. J Craniomaxillofac Surg<br />
1993;21(8):339-41.<br />
Mermer RW, Rider CA, Cleveland DB. Nasopalatine<br />
canal cyst: a rare sequelae of surgical rapid palatal<br />
expansion. Oral Surg Oral Med Oral Pathol Oral Radiol<br />
Endod 1995;80(6):620.<br />
Moss HD, Hellstein JW, Johnson JD. Endodontic<br />
considerations of the nasopalatine duct region. J Endod<br />
2000;26(2):107-10.<br />
Neville BW, Damm DD, Brock T. Odontogenic<br />
keratocysts of the midline maxillary region. J Oral<br />
Maxillofac Surg 1997;55(4):340-4.<br />
Neville BW, Damm DD, Allen CM, Bouquot JE.<br />
Oral and maxillofacial pathology. In: Developmental<br />
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24.<br />
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27.<br />
defects of the oral and maxillofacial region. 2nd edition<br />
Saunders 2005:p27-30.<br />
Pevsner PH, Bast WG, Lumerman H, Pivawer G. CT<br />
analysis of a complicated nasopalatine duct cyst. N Y<br />
State Dent J 2000 Jun-<strong>Jul</strong>;66(6):18-20.<br />
Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology<br />
clinical pathologic correlations. In: Cysts of the jaws and<br />
neck.4th edition, Saunders 2003:p256-7.<br />
Righini CA, Boubagra K, Bettega G, Verougstreate G,<br />
Reyt E. Nasopalatine canal cyst: 4 cases and a review of<br />
the literature. Ann Otolaryngol Chir Cervicofac 2004<br />
Apr;121(2):115-9.<br />
Robertson H, Palacios E. Nasopalatine duct cyst. Ear<br />
Nose Throat J 2004;83(5):313.<br />
Swanson KS, Kaugars GE, Gunsolley JC. Nasopalatine<br />
duct cyst: an analysis of 334 cases. J Oral Maxillofac<br />
Surg 1991;49(3):268-71.<br />
Tanaka S, Iida S, Murakami S, Kishino M,<br />
Yamada C, Okura M. Extensive nasopalatine duct cyst<br />
causing nasolabial protrusion. Oral Surg Oral Med<br />
Oral Pathol Oral Radiol Endod 2008;106(4):e46-50.<br />
Vasconcelos R, de Aguiar MF, Castro W, de Araújo<br />
VC, Mesquita R. Retrospective analysis of 31 cases of<br />
nasopalatine duct cyst. Oral Dis 1999;5(4):325-8.<br />
Velasquez-Smith MT, Mason C, Coonar H, Bennett J.<br />
A nasopalatine cyst in an 8-year-old child. Int J Paediatr<br />
Dent 1999;9(2):123-7.<br />
Wood NK, Goaz PW. Differential diagnosis of oral and<br />
maxillofacial lesions. In: Interradicular radiolucencies.<br />
5th edition Mosby 1997:p303-5.<br />
White SC, Pharoah MJ. Oral radiology principles and<br />
interpretation. In: Cyst of jaws. 5th edition, Mosby<br />
2000:p400-1.<br />
Yih WY, Krump JL. Odontogenic keratocyst in the<br />
nasopalatine duct associated with mural cartilaginous<br />
metaplasia. J Oral Maxillofac Surg 2005 Sep;63(9):<br />
1382-4.<br />
• • •<br />
288<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Full Mouth Rehabilitation with Unilateral Distal Extension<br />
Prosthesis Attached to Splinted Fixed Partial Denture<br />
N Gopi Chander<br />
case report<br />
Abstract<br />
This article describes the design of a unilateral distal extension removable partial denture attached to a splinted fixed partial<br />
denture (FPD) with a semi-precious attachment. The clinical results of the dentures used in selected situations are admirable,<br />
however, it is emphasized that a unilateral denture is only an alternative rather than a routine.<br />
Key words: Splinted fixed partial denture, unilateral denture<br />
The clinical use of a unilateral removable<br />
partial denture (RPD) is limited because of<br />
its poor stability and retention. 1,2 A regular<br />
problem faced by the partially edentulous patients is<br />
the intricacy of adapting to a removable prosthesis.<br />
A unilateral prosthesis is always less stable, because it<br />
lacks the effect of cross arch stabilization. 3,4 There is<br />
also an emotional component for some patients who<br />
do not like that their teeth are removable. The stability<br />
can be improved by re-basing the edentulous area of<br />
the removable prosthesis on needed occasions. This<br />
requires recall of patient for scheduled visits and it<br />
may not create a high level of comfort and function<br />
for many patients. Alternative treatments for partially<br />
edentulous patients include a conventional cast partial<br />
denture to an implant-supported prosthesis. 5-10 These<br />
procedures are not always acceptable treatment options<br />
for the patient. The disadvantages of a implantsupported<br />
prosthesis could be functional, economical<br />
and biomechanical. 11,12<br />
An alternative reconstructive option that does not involve<br />
complex procedures for the patient is combination<br />
prosthesis with fixed and removal partial denture<br />
connected with attachments. This prosthetic option,<br />
in addition to the esthetics and functional advantage<br />
Professor<br />
Dept. of Prosthodontics<br />
SRM Dental College, Ramapuram, Chennai<br />
Address for correspondence<br />
Dr N Gopi Chander<br />
496, 3rd Main Road<br />
TNHB Colony, Velachery, Chennai - 600 042<br />
E-mail: drgopichander@gmail.com<br />
of a fixed denture, gives a decreased compression of<br />
the edentulous ridge and enhanced mastication and<br />
phonetics. This clinical report describes the treatment<br />
of a patient with this prosthetic solution of fixed<br />
removable prosthesis with semi-precision attachment.<br />
Clinical Report<br />
A 75-year-old man was evaluated for treatment. His<br />
chief complaint was missing teeth and he wanted a<br />
stable retained prosthesis. The patient’s medical history<br />
was evaluated and was found to be noncontributory.<br />
The missing teeth were 14, 15, 16, 24, 25, 26, 27, 32, 34,<br />
35, 44, 45, 46 Several treatment options were offered<br />
to the patient: a removable partial denture, an implantsupported<br />
prosthesis, combination of a fixed prosthesis<br />
with RPD and combination denture with fixed and<br />
removal prosthesis with attachments. After reviewing<br />
the options, the patient accepted the latter treatment<br />
option. Diagnostic models made with the primary<br />
impression. The treatment plan was charted for fixed<br />
prosthesis and the maxillary attachment denture.<br />
Procedure<br />
• Abutment teeth 11, 12, 13, 17, 21, 22, 23, 31, 33,<br />
36, 37, 41, 42, 43, 47 were prepared for full veneer<br />
metal ceramic retainers for mandibular fixed partial<br />
denture and maxillary fixed-removal attachment<br />
denture. Regular precautions of preparation were<br />
followed.<br />
• Conventional tissue management procedures were<br />
pursued and single step putty reline impression was<br />
made. Cast was made and the maxillary anterior<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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Case Report<br />
Figure 1. Preoperative.<br />
Figure 5. Buccal view of denture in occlusion.<br />
Figure 2. Attachment for distal extension.<br />
Figure 6. Palatal view of denture in occlusion.<br />
Figure 3. Patrix attached to the cast partial denture.<br />
Figure 7. Postoperative in occlusion.<br />
Figure 4. Buccal view of denture in occlusion.<br />
Figure 8. Postoperative occlusal view.<br />
290<br />
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Case Report<br />
Fixed partial denture (FPD) and mandibular FPD<br />
were fabricated. Dalbo attachment was attached to<br />
maxillary anterior FPD.<br />
• Metal try-in of the coping was done to evaluate<br />
the fit of the casting. Ceramic layering was done<br />
on the metal frame work tried.<br />
• The fabricated metal ceramic FPD was provisionally<br />
cemented with the patrix attached to the casting and<br />
picked up using putty impression for fabricating<br />
the removal partial denture.<br />
• Cast was made from the impression and the regular<br />
fabrication of removal denture was done.<br />
• Once the framework was fabricated, it was tried<br />
on the patient; maxillo-mandibular relationship<br />
was recorded, teeth arrangement was done and the<br />
denture fabricated.<br />
• Mandibular FPD was cemented with glass ionomer<br />
cement. Maxillary FPD was cemented with glass<br />
ionomer with the RPD. After the cement was set,<br />
the RPD was separated and excess cement from all<br />
areas was removed.<br />
Discussion<br />
For the patient described, the maxillary RPD was<br />
connected to an FPD with an attachment system. The<br />
disadvantages reportedly associated with RPD such as<br />
patient discomfort, ill-fitting, loose prosthesis, decreased<br />
phonetics and masticatory efficiency were avoided. 13-15<br />
The recommended procedure has several advantages<br />
over the conventional prosthesis. The advantages of<br />
attachment denture are beneficial and the limitation<br />
of RPD are reduced. Patient comfort and psychology<br />
are drastically improved. Being attachment prosthesis,<br />
the RPD can be removed and maintained as a regular<br />
denture. Added to this the laboratory procedures are<br />
simple, and treatment is economical compared to the<br />
more complex treatment options. 16-19<br />
The extracoronal precision attachments for RPDs are<br />
recommended to this clinical situation because all teeth<br />
were involved as primary and secondary abutments for<br />
RPD tooth preparation. Splinting of maxillary teeth<br />
was possible with single unit casting of all teeth, and<br />
the partially edentulous teeth present close this splinted<br />
FPD aided to attach semi-precision attachment. 20-22<br />
Extracoronal semi-precision attachments are easier to<br />
insert and remove. It is also esthetic and can be used<br />
for patients with limited manual dexterity, or when the<br />
prosthesis has a difficult path of insertion and removal.<br />
Extracoronal precision attachments are normally<br />
resilient and allow free movement of the prosthesis to<br />
distribute potentially destructive forces or loads away<br />
from the abutments to supportive bone and tissue. 23-26<br />
Though limitations exist with the attachment system,<br />
this Kennedy Class 2 partially edentulous situation<br />
attached with fixed or removable prosthesis has greater<br />
advantage clinically as discussed earlier.<br />
Summary<br />
This clinical report illustrates the option of achieving<br />
encouraging results with a removable prosthesis<br />
attached to a fixed prosthesis. The support of the RPD<br />
and its connection with the fixed prosthesis generate<br />
stability throughout masticatory activity and permit<br />
a functional action similar to that involving a fixed<br />
denture. The execution of the stress-director system<br />
is effective and decreases the risk of loss of function.<br />
Further long-term follow-up studies with a larger<br />
patient population are needed to confirm the clinical<br />
and biomechanical validity of the prosthetic solution<br />
described in this clinical report.<br />
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removable partial dentures. J Oral Rehabil<br />
2003;30(5):482-7.<br />
Grasso JE. A new removable partial denture clasp<br />
assembly. J Prosthet Dent 1980;43(6):618-21.<br />
Givan DA, Kolodney H Jr. Removable partial denture<br />
design with a splint bar and precision attachments.<br />
Compendium 1993;14(5):670, 672, 674-6; quiz 678.<br />
Grageda E. Achieving an aesthetic anterior-posterior<br />
rotational path partial denture: case report. Dent Today<br />
2007;26(4):130, 132-5; quiz 135.<br />
Colt SG, Millstein PL. A prefabricated semi-precision<br />
intracoronal attachment for removable partial dentures:<br />
the P.D. attachment. Quintessence Int Dent Dig<br />
1979;10(11):19-24.<br />
De Rossi A, Albuquerque RF Jr, Bezzon OL. Esthetic<br />
options for the fabrication of removable partial dentures:<br />
a clinical report. J Prosthet Dent 2001;86(5):465-7.<br />
• • •<br />
...Continued from page 279<br />
4.<br />
5.<br />
6.<br />
7.<br />
Lal K, White GS, Morea DN, Wright RF. Use<br />
of stereolithographic templates for surgical and<br />
prosthodontic implant planning and placement. Part I.<br />
The concept. J Prosthodont 2006;15(1):51-8.<br />
Lal K, White GS, Morea DN, Wright RF. Use<br />
of stereolithographic templates for surgical and<br />
prosthodontic implant planning and placement. Part II.<br />
A clinical report. J Prosthodont 2006;15(2):117-22.<br />
Simon H. Use of transitional implants to support a<br />
surgical guide: enhancing the accuracy of implant<br />
placement. J Prosthet Dent 2002;87(2):229-32.<br />
Cehreli MC, Aslan Y, Sahin S. Bilaminar dual-purpose<br />
8.<br />
9.<br />
10.<br />
stent for placement of dental implants. J Prosthet Dent<br />
2000;84(1):55-8.<br />
Al-Harbi SA, Verrett RG. Fabrication of a stable surgical<br />
template using staged tooth extraction for immediate<br />
implant placement. J Prosthet Dent 2005;94(7):394-7.<br />
Kuzmanovic DV, Waddell JN. Fabrication of a selfretaining<br />
surgical template for surgical placement of<br />
dental implants for the partially edentulous patient.<br />
J Prosthet Dent 2005;93:95-6.<br />
Meitner SW, Tallents RH. Surgical templates for<br />
prosthetically guided implant placement. J Prosthet<br />
Dent 2004;92:569-74.<br />
292<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Ossifying Fibroma of Maxilla: A Case Report with<br />
Review of Literature<br />
V Sathyabama*, C Saravanan**, SS Sharma † , R Kamal Kanthan*<br />
case report<br />
Abstract<br />
Fibro-osseous lesions of bone have evolved over several decades to integrate two major entities: Fibrous dysplasia and ossifying<br />
fibroma along with the other entities such as periapical dysplasia, osteitis deformans, hyperparathyroidism and Paget’s disease<br />
with hypercementosis in the late stages. A case of a young adult male with maxillary ossifying fibroma measuring about<br />
12 × 6 cm in the upper right quadrant is presented herein. The patient was managed surgically by a conservative intra-oral<br />
approach preserving the median nasal base, orbital floor and the palatal shelf. The patient was later rehabilitated by a toothsupported<br />
removable dental prosthesis. A review of literature regarding the course, prognosis and the management of maxillary<br />
cemento-ossifying fibroma is also discussed.<br />
Key words: Fibro-osseous lesion, ossifying fibroma, odontogenic tumor, maxilla<br />
Ossifying fibroma of the maxilla is an<br />
uncommon tumor. It is a well-circumscribed<br />
tumor, which grows exponentially with<br />
clear and defined margins. It occurs in middle-aged<br />
adults with a marked predilection for females. Though<br />
generally a benign tumor, it can explicitly present an<br />
aggressive behavior.<br />
In the early stages, the lesion is totally radiolucent.<br />
Intermediate stages of the lesion exhibit mixed<br />
radiolucent and radiopaque densities depending on<br />
the amount of the calcified material. It can appear as<br />
ground glass (similar to the pattern seen on fibrous<br />
dysplasia), cotton wool, or present a flocculent<br />
appearance (similar to large snowflakes). Cementumlike<br />
structures called ‘cementicles’ (similar to those<br />
seen on cemental dysplasia) can also be present.<br />
Histopathologically, a large number of fibroblasts and<br />
cementoblasts with flat elongated nuclei are present<br />
within a network of interlacing collagen fibers. At the<br />
later stages, the cementoblasts coalesce to present as<br />
*Senior Lecturer<br />
**Reader<br />
†<br />
Professor<br />
Dept. of Oral and Maxillofacial Surgery<br />
SRM Kattankulathur Dental College and Hospital<br />
Potheri, Kancheepuram, Tamil Nadu<br />
Address for correspondence<br />
Dr V Sathyabama<br />
Senior Lecturer<br />
Dept. of Oral and Maxillofacial Surgery<br />
SRM Kattankulathur Dental College<br />
Potheri, Kanchipuram, Tamil Nadu<br />
the common islands of bony calcification. These appear<br />
woven at the center while they appear lamellar at the<br />
periphery.<br />
Surgery is the treatment of choice including aggressive<br />
curettage, localized surgical resection and segmental<br />
resection. When the tumor is present in association<br />
with the craniofacial complex, treatment is more<br />
aggressive to protect the vital structures.<br />
Case Report<br />
A 29-year-old young male presented with a complaint<br />
of progressively increasing extraoral mass of the right<br />
maxilla obstructing his right nostril and causing<br />
disfigurement of the right upper lip.<br />
According to the patient, the mass had been slowly<br />
expanding over the last six years. Though pain was<br />
not a presenting feature, he underwent extraction of a<br />
single tooth in the region by a local dental practitioner<br />
suspecting it to be the reason for the swelling. He<br />
had repeated nasal obstructions, and an increasing<br />
paresthesia of the right infraorbital region. He also had<br />
intermittent epiphora on the affected side. There was<br />
no regional lymphadenopathy. The patient’s general<br />
health was good with no co-morbid conditions. There<br />
was no associated family history of similar type of<br />
tumors.<br />
Clinical examination revealed a well-circumscribed<br />
slow-growing lesion causing massive bony expansion.<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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Case Report<br />
Figure 1. CT scan pre.<br />
Figure 2. En mass<br />
enucleation.<br />
Figure 5. Specimen.<br />
Figure 3. Intra operative<br />
obturator.<br />
Figure 4. Ossifying fibroma.<br />
The mass was firm to hard in consistency. The mass<br />
caused a facial disfigurement with the swelling extending<br />
from the angle of the mouth to the malar region. Intraorally,<br />
the buccal vestibule was completely obliterated<br />
with the mass extending from the canine fossa region<br />
on to the maxillary tuberosity region. Palatally, the<br />
soft tissue was healthy with minimal expansion of<br />
the palatal alveolus. The vault of the palate was not<br />
involved and the midline was not violated.<br />
The maxillary right first bicuspid was missing, which<br />
was apparently extracted a few months ago. There was<br />
paresthesia on the infraorbital region on the right side.<br />
The nasal passage was partially obstructed on the right<br />
side.<br />
On radiographic evaluation, orthopantomogram<br />
(OPG) revealed a well-circumscribed mixed, radiopaque<br />
lesion obliterating the entire maxillary sinus. CT scan<br />
confirmed the extent of the mass. It also established<br />
that in spite of the massive expansion, there were no<br />
noticeable perforations and soft tissue infiltrations into<br />
the adjacent infratemporal and pterygopalatine fossae<br />
with the nasal turbinates and the palate being intact<br />
(Fig. 1). Incisional biopsy was performed under local<br />
anesthesia via a buccal sulcus approach. The tumor had<br />
cheesy firm consistency. Histopathology confirmed the<br />
lesion to be cemento-ossifying fibroma (Fig. 4).<br />
Management<br />
After routine work-up and obtaining anesthetic<br />
fitness, the patient was taken to the operating theater.<br />
Under general anesthesia, the tumor was surgically<br />
removed through a transoral approach instead of<br />
the regular Weber-Ferguson maxillectomy approach.<br />
Intraoperatively, the tumor was found to be wellencapsulated<br />
with a cleavage plane to allow it to be<br />
shelled out from its surrounding structures. The orbital<br />
and the nasal floors were preserved and maintained.<br />
The palatal mucoperiosteum was preserved and the<br />
tumor was removed en masse in one piece with no<br />
perforations. Surgical cavity was debrided and a<br />
surgical obturator with a bismuth iodoform paraffin<br />
paste (BIPP) pack was secured in place using<br />
circumzygomatic wiring (Figs. 2-5).<br />
Post-op recovery was uneventful. The surgical cavity<br />
was debrided periodically with change of the BIPP<br />
pack. After epithelialization of the defect, a final<br />
obturator with teeth and hollow bulb was fabricated<br />
after six weeks. Patient remains asymptomatic for the<br />
past eight months with minimal facial disfigurement<br />
and no visible facial scar. Clinical and radiographic<br />
evaluation of the upper left quadrant shows no change<br />
of the lesion, which we are planning to follow-up<br />
periodically.<br />
Review of Literature<br />
Ossifying fibroma of the jaws is a benign fibro-osseous<br />
lesion. The origin is supposed to be from periodontal<br />
ligament.<br />
In 1968, Hamner et al 1 analyzed 249 cases of fibroosseous<br />
jaw lesions of periodontal membrane origin<br />
and classified them. 13 In 1973, Waldron and Giansanti 2<br />
reported 65 cases (of which 43 cases had adequate<br />
clinical histories and radiographs) and concluded that<br />
this group of lesions was best considered as a spectrum<br />
of processes arising from cells in the periodontal<br />
ligament. In 1985, Eversole et al 3 described the<br />
294<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Case Report<br />
radiographic characteristics of central ossifying fibroma<br />
and two major patterns were noted, expansile unilocular<br />
radiolucencies and as a multilocular configuration.<br />
Various studies conducted have elicited that females<br />
were twice affected than males. 4,6,7 Age group between<br />
second and fourth decades 5,7,10 are usually affected.<br />
These lesions are more commonly present in the<br />
mandible and commonly diagnosed accidentally on<br />
a radiograph. 7 When left untreated, the resultant<br />
expansion presents with cosmetic facial asymmetry. 2,11<br />
Radiographically, the lesion presents different stages<br />
of development 14 with a centrifugal growth pattern.<br />
Therefore, lesions grow by expansion equally in all<br />
direction and present as round tumor masses. A<br />
thin fibrous capsule demarcates the lesion from the<br />
adjoining normal bone. 11<br />
A variable presentation is the juvenile ossifying fibroma.<br />
Children below the age group of 15 were affected<br />
with this aggressive tumor that requires an aggressive<br />
surgical resection and a long-term follow-up due to its<br />
high recurrence rate of 30-58%. 3,8,12,15<br />
However, the adult variant has shown recurrence in one<br />
of the 20 cases followed up by Liu et al demonstrating<br />
that a surgical intervention might stimulate the growth<br />
of the tumor. 13 This warrants a thorough follow-up of<br />
the cases with the surgical enucleation being mandatory<br />
for the cosmetically disfiguring lesions.<br />
References<br />
1.<br />
2.<br />
3.<br />
Hamner JE 3rd, Scofied HH, Cornyn J. Benign fibroosseous<br />
jaw lesions of periodontal membrane origin. An<br />
analysis of 249 cases. Cancer 1968;22(4):861-78.<br />
Waldron CA, Giansanti JS. Benign fibro-osseous lesions<br />
of the jaws: a clinical-radiologic-histologic review of<br />
sixty-five cases. II. Benign fibro-osseous lesions of<br />
periodontal ligament origin. Oral Surg Oral Med Oral<br />
Pathol 1973;35(3):340-50.<br />
Eversole LR, Merrell PW, Strub D. Radiographic<br />
characteristics of central ossifying fibroma. Oral Surg<br />
Oral Med Oral Pathol 1985;59(5):522-7.<br />
4. Summerlin DJ, Tomich CE. Focal cemento-osseous<br />
dysplasia: a clinicopathologic study of 221 cases. Oral<br />
Surg Oral Med Oral Pathol 1994;78(5):611-20.<br />
5. Langdon JD, Rapidis AD, Patel MF. Ossifying Fibromaone<br />
disease or six? An analysis of 39 fibro-osseous lesions<br />
of the jaws. Br J Oral Surg 1976;14(1):1-11.<br />
6. Hamner JE 3rd, Lightbody PM, Ketcham AS,<br />
Swerdlow H. Cemento-ossifying fibroma of the maxilla.<br />
Oral Surg Oral Med Oral Pathol 1968;26(4):57-87.<br />
7. Jayachandran S, Meenakshi R. Cemento ossifying<br />
fibroma. Indian J Dent Res 2004;15(1):35-9.<br />
8. Breheret R, Jeufroy C, Cassagnau E, Malard O.<br />
Juvenile ossifying fibroma of the maxilla. Eur Ann<br />
Otorhinolaryngol Head Neck Dis 2011 May 17. [Epub<br />
ahead of print]<br />
9. Ayub T, Katpar S, Shafique S, Mirza T. En bloc resection<br />
of huge cemento-ossifying fibroma of mandible:<br />
avoiding lower lip split incision. J Coll Physicians Surg<br />
Pak 2011;21(5):306-8.<br />
10. Alsharif MJ, Sun ZJ, Chen XM, Wang SP, Zhao YF.<br />
Benign fibro-osseous lesions of the jaws: a study of 127<br />
Chinese patients and review of the literature. Int J Surg<br />
Pathol 2009;17(2):122-34.<br />
11. Su L, Weathers DR, Waldron CA. Distinguishing<br />
features of focal cemento-osseous dysplasia and cementoossifying<br />
fibromas. II. A clinical and radiologic spectrum<br />
of 316 cases. Oral Surg Oral Med Oral Pathol Oral<br />
Radiol Endod 1997;84(5):540-9.<br />
12. Patil K, Mahima VG, Balaji P. Juvenile aggressive<br />
cemento-ossifying fibroma. A case report. Indian J Dent<br />
Res 2003;14(2):111-9.<br />
13. Liu Y, Wang H, You M, Yang Z, Miao J, Shimizutani<br />
K, et al. Ossifying fibromas of the jaw bone: 20 cases.<br />
Dentomaxillofac Radiol 2010;39(1):57-63.<br />
14. Sarwar HG, Jindal MK, Ahmad S. A case report of<br />
cemento-ossifying fibroma. J Maxillofac Oral Surg<br />
2010;9(2):178‐81.<br />
15. Shekhar MG, Bokhari K. Juvenile aggressive ossifying<br />
fibroma of the maxilla. J Indian Soc Pedod Prev Dent<br />
2009;27(3):170‐4.<br />
• • •<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
295
Case Report<br />
Dentigerous Cyst Associated with Mandibular First<br />
Premolar: A Rare Case Report<br />
R Sathish Muthukumar*, S Vijay Parthiban**, M Alagappan † , Sandhya Arunkumar ‡<br />
Abstract<br />
Dentigerous cysts are benign odontogenic cysts associated with crowns of unerupted or impacted teeth. They are usually<br />
solitary in occurrence and mostly associated with the mandibular third molars. Dentigerous cysts involving impacted first<br />
premolars are rarely reported in the literatures. We present a rare case of dentigerous cyst in a 62 year old female patient<br />
associated with an impacted mandibular first premolar.<br />
Key words: Dentigerous cyst, odontogenic cyst, impacted teeth<br />
Dentigerous cyst is the second most common<br />
cyst of odontogenic origin. They are mostly<br />
associated with an impacted mandibular third<br />
molar and rare lesions of dentigerous cyst involving<br />
the maxillary and mandibular premolars have been<br />
reported in the literature. 1 The prevalence rate of this<br />
cyst is more in males than females, mostly unilateral in<br />
the second and third decade 2,3 whereas bilateral lesions<br />
occur between first to sixth decade. 4 In this article we<br />
present a rare case of dentigerous cyst associated with<br />
an impacted mandibular right first premolar in a sixtytwo<br />
year old female patient.<br />
Figure 1. Orthopantomogram showing the unilocular<br />
radiolucency with scelerotic border inrelation to the crown<br />
of impacted mandibular right first premolar.<br />
Case Report<br />
A 62-year-old female patient reported with a gradually<br />
increasing swelling with dull pain on the right side of the<br />
lower jaw for the past two to three months. Extra oral<br />
examination revealed mild asymmetry of the lower jaw<br />
and palpable submandibular lymph nodes on the right<br />
side. Intraoral examination presented a well defined<br />
*Professor and Head<br />
Dept. of Oral and Maxillofacial Pathology<br />
Chettinad Dental College and Research Institute, Kelambakkam, Chennai<br />
**Senior Lecturer<br />
†<br />
Reader<br />
Dept. of Oral and Maxillofacial Surgery<br />
Chettinad Dental College and Research Institute<br />
‡<br />
Reader<br />
Dept. of Oral and Maxillofacial Pathology<br />
Chettinad Dental College and Research Institute, Kelambakkam, Chennai<br />
Address for correspondence<br />
Dr Sathish Muthukumar R<br />
Chettinad Dental College and Research Institute, Padur, Kanchipuram,<br />
Tamil Nadu<br />
E-mail: drsmkop@gmail.com<br />
Figure 2. Photomicrograph showing non-keratinized<br />
epithelium lining supported by loose connective tissue<br />
stroma (H&E, x5).<br />
bluish tinged, ovoid swelling causing expansion of the<br />
buccal cortex. On palpation, the lesion was soft and<br />
tender. FNAC revealed a blood tinged fluid and non-<br />
296 Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011
Case Report<br />
tooth. They can occur at any location of the jaw but<br />
frequently seen in relation to impacted mandibular<br />
third molars followed by the maxillary canines and<br />
maxillary third molars. 4,6,8 Occasionally these cysts<br />
become painful when infected causing swelling and<br />
erythema. The cyst is usually small but when large,<br />
results in the expansion and thinning of the cortex<br />
leading to pathological fracture. 4,7 Although the clinical<br />
presentations are classical of a dentigerous cyst, in our<br />
case it is associated with mandibular first premolar<br />
which has not been reported.<br />
Figure 3. Photomicrograph showing focal area of epithelial<br />
hyperplasia (H&E, x10).<br />
specific inflammatory cells on cytological examination.<br />
Orthopantomogram demonstrated a well defined<br />
unilocular radiolucent lesion with sclerotic border, in<br />
relation to the crown of impacted mandibular right<br />
first premolar (Fig. 1). The radiographic appearance<br />
was characteristic of dentigerous cyst associated with<br />
mandibular first premolar. The lesion was enucleated<br />
along with the impacted tooth. Histopathological<br />
examination revealed non-keratinized epithelium<br />
consisting of 3-5 layers of flat to cuboidal cells lining<br />
the cystic lumen with focal area of epithelial thickening<br />
(Fig. 2 and 3). The connective tissue wall was composed<br />
of loosely arranged collagen fibers, young fibroblast and<br />
infiltrated with chronic inflammatory cells. The patient<br />
is under routine follow up and has no complication.<br />
Discussion<br />
Dentigerous cysts are developmental cyst of<br />
odontogenic orgin and the most prevalent, comprising<br />
14-24% of the entire jaw cyst. 2,5 They are caused by<br />
the accumulation of fluid between the crown and<br />
reduced enamel epithelium, attached at the cementoenamel<br />
junction of an impacted or unerupted tooth. 4,6<br />
Whites are more affected than blacks. 4 They are seen<br />
in a wide age range but usually common between the<br />
ages of 10 and 30 years. 7 The sex predilection is 1.6:1<br />
in favor of male. Our case is a rarity as it occurred in<br />
a 60-year-old female patient.<br />
Dentigerous cysts are usually solitary, slow growing,<br />
asymptomatic lesions that are incidentally found<br />
during routine radiographs taken to identify a missing<br />
Radiographic features are specific to the lesion<br />
characterized by a well defined radiolucency<br />
circumscribed by a sclerotic border, associated with the<br />
crown of an impacted or unerupted tooth. The borders<br />
may be ill-defined when infected. Rarely may they be<br />
found with odontoma or a supernumerary tooth. 7,8<br />
Although they mimic a normal tooth follicle, literatures<br />
suggest any follicular space of more than 4 mm to be a<br />
dentigerous cyst. 4 Radiographically the cyst is classified<br />
according to its relation with the involve tooth crown<br />
as central, lateral and circumferential type. The central<br />
type is the most common and presents surrounding<br />
the crown. The lateral dentigerous cyst is that, which<br />
partially surrounds the crown and extends along the<br />
side of the root. The circumferential variant surrounds<br />
both the crown and the root of the involved tooth. 7<br />
Histologically, the lumen is lined by 2 to 4 cell layers<br />
of cuboidal to flattened non-keratinized epithelial cells<br />
but may form keratin by metaplasia. 9 The epithelium<br />
may be hyperplastic with the presence of hyaline bodies<br />
associated with inflammation. The connective tissue is<br />
more collagenous when inflamed and contain varying<br />
degree of chronic inflammatory cell infiltration. 4,7<br />
Occasionally the cyst lining may contain ciliated and<br />
mucous secreting cells. 4<br />
Dentigerous cysts are treated most commonly by<br />
Enucleation 5 , Marsupialization 3 and decompression<br />
of cyst by fenestration. 10 Motamedi et al suggested<br />
the criteria for selecting the treatment modality based<br />
on the age, size, location, stage of root development,<br />
position of the involved tooth and relation of the lesion<br />
to the adjacent tooth and vital structure. 11 The most<br />
preferred treatment is enucleation with the removal of<br />
unerupted or impacted tooth. If the cyst is associated<br />
with the canine or premolar with favorable eruptive<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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Case Report<br />
position, then extraction of the associated tooth<br />
is deferred. Large dentigerous cyst may be treated<br />
with marsupialization followed by enucleation. The<br />
prognosis is excellent when the cyst is enucleated in<br />
toto and recurrence is rare. As the lining epithelium has<br />
the pluripotential capacity, these lesions may progress<br />
to ameloblastoma, mucoepidermoid carcinoma and<br />
squamous cell carcinoma. 4<br />
Conclusion<br />
Dentigerous cyst associated with an impacted first<br />
premolar is extremely rare. As the clinical finding of<br />
unerupted tooth may be the only presenting symptom of<br />
a dentigerous cyst, a thorough radiographic evaluation<br />
is mandatory for all unerupted teeth that have well past<br />
their expected eruption date. These lesions demand an<br />
early detection and surgical elimination in order to<br />
avoid the potential morbidity.<br />
References<br />
1.<br />
2.<br />
3.<br />
Miyakawi S , Hyomoto M, Kirita J, Sugimura M.<br />
Eruption speed and rate of angulation change of a<br />
cyst associated mandibular second premolar after<br />
marsupialization of a dentigerous cyst. AM J Ortho<br />
Dentofacial Orthop 1999;116:578-84.<br />
Regezi AJ , Sciubba JJ. Cysts of the oral region, In Oral<br />
pathology: Clinical Pathologic Correlations, 3rd edition<br />
Philadelphia: WB Saunders 1999:288-321.<br />
Murakami A, Kawabata K, Suzuki A, Murakami S,<br />
4.<br />
5.<br />
6.<br />
7.<br />
8.<br />
9.<br />
10.<br />
11.<br />
Ooshima T. Eruption of an impacted second premolar<br />
after marsupialization of a large dentigerous cyst: A case<br />
report. Pediatr Dent 1995;17:372-4.<br />
Sumita M, Vineet R, Karen B, Thomas G. Nonsyndromic<br />
bilateral dentigerous cysts of mandibular<br />
premolars: a rare case and review of literature. Hong<br />
Kong Dental Journal 2006;3:129-33.<br />
Rubin DM, Vendrenne D, Portnof JE. Orthodontically<br />
guided eruption of mandibular second premolar<br />
following enucleation of an inflammatory cyst: A Case<br />
Report. J Clinical Pediatr Dent 2002;27:19-24.<br />
Shah N, Thuau H, Beale T. Spontaneous regression of<br />
bilateral dentigerous cysts associated with impacted<br />
mandibular third molars. British Dental Journal 2002;<br />
192:75-76.<br />
Aziz SR, Dourmas MA, Roser SM. Inferior alveolar nerve<br />
paresthesia associated with a mandibular dentigerous<br />
cyst. J Oral Maxillofac Surg 2002;60:457-9.<br />
Pradeep KM, Namita J. Conservative management of a<br />
dentigerous cyst associated with an impacted mandibular<br />
second premolar in mixed dentition: A case report. J<br />
Dent Res Dent Clin Dent Prospect 2009;3(3):98-102.<br />
Shear M. Dentigerous cyst. In: Shear M, editor. Cysts of<br />
the oral regions. Mumbai: Varghese Publishing House;<br />
reprinted in 1996; originally published in 1992.<br />
Ziccardi, Eggleston TI, Schneider RE. Using a<br />
fenestration technique to treat a large dentigerous cyst.<br />
J Sm Dent Assoc 1997;128:201-5.<br />
Motamedi M, Talesh KT. Management of extensive<br />
dentigerous cyst. Br Dent J 2005;198:203-6.<br />
• • •<br />
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Indian Journal of<br />
Multidisciplinary Dentistry<br />
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Case Report<br />
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Covering Letter: The covering letter should explain if there is any<br />
deviation from the standard IMRAD format (Introduction, Methods,<br />
Results and Discussion) and should outline the importance of the<br />
paper. Principal/Senior author must sign the covering letter indicating<br />
full responsibility for the paper submitted, preferably with signatures of<br />
all the authors. Articles must be accompanied by a declaration by all<br />
authors stating that the article has not been published in any Journal/<br />
Book. Authors should mention complete designation and departments,<br />
etc., on the manuscript.<br />
Manuscript: Three complete sets of the manuscript should be submitted<br />
and preferably with a CD; typed double spaced throughout (including<br />
references, table and legends to figures). The manuscript should be<br />
arranged as follow: Covering letter, Checklist, Title page, Abstract,<br />
Keywords (for indexing, if required), introduction, Methods, Results,<br />
Discussion, References, Tables, Legends to Figures and Figures. All pages<br />
should be numbered consecutively beginning with the title page.<br />
Types of Submission: Original Research articles, Review articles, Case<br />
reports and Clinical study<br />
Title Page: Should contain the title, short title, names of all the authors<br />
(without degrees of diplomas), names and full location of the departments<br />
and institutions where the work was performed, name of the corresponding<br />
authors, acknowledgement of financial support and abbreviations used. The<br />
title should be of no more than 80 characters and should represent the<br />
major theme of the manuscript. A subtitle can be added if necessary.<br />
A short title of not more than 50 characters (including inter-word spaces)<br />
for use as a running head should be included. The name, telephone<br />
and fax numbers, e-mail and postal addresses of the author to whom<br />
communications are to be sent should be typed in the lower right corner<br />
of the title page.<br />
Abstract: The abstract of not more than 200 words. It must convey the<br />
essential features of the paper. It should not contain abbreviations, footnotes<br />
or references.<br />
Introduction: The introduction should state why the study was carried out<br />
and what were its specific aims/objectives were.<br />
Material and Methods: Theses should be described in sufficient details to<br />
permit evaluation and duplication of the work by others. Ethical guidelines<br />
followed by the investigations should be described.<br />
Results: These should be concise and include only the tables and figures<br />
necessary to enhance the understanding of the text.<br />
Discussion: This should consist of a review of the literature and relate<br />
the major findings of the article to other publications on the subject. The<br />
particular relevance of the results to healthcare in India should be stressed,<br />
e.g., practically and cost.<br />
References: These should conform to the Vancouver style. References<br />
should be numbered in the order in which they appear in the texts and<br />
these numbers should be inserted above the lines on each occasion the<br />
author is cited.<br />
Tables: These should be typed double spaces on a separate sheet and<br />
figure number (in Roman Arabic numerals) and title above the table and<br />
explanatory notes below the table.<br />
Legends: These should be typed double spaces on a separate sheet and<br />
figure numbers (in Arabic numerals) corresponding with the order in which<br />
the figures are presented in the text. The legend must include enough<br />
information to permit interpretation of the figure without reference to the<br />
text.<br />
Figures: Two complete sets of glossy prints of high quality should be<br />
submitted. The labeling must be clear and neat. All photomicrographs<br />
should indicate the magnification of the print. Special features should be<br />
indicated by arrows or letters which contrast with the background. The<br />
back of each illustration should bear the first author’s last name, figure<br />
number and an arrow indicating the top. This should be written lightly<br />
in pencil only. Please do not use a hard pencil, ball point or felt pen.<br />
Color illustrations will be accepted if they make a contribution to the<br />
understanding of the article. Do not use clips/staples on photographs and<br />
artwork. Illustrations must be drawn neatly by an artist and photographs<br />
must be sent on glossy paper. No captions should be written directly on<br />
the photographs or illustration. Legends to all photographs and illustrations<br />
should be typed on a separate sheet of paper. All illustrations and figures<br />
must be referred to in text and abbreviated as ‘Fig’.<br />
Please complete the following checklist and attach to the manuscript:<br />
1. Classification (e.g. original article, review, etc.)_________________<br />
2. Total number of pages____________________________________<br />
3. Number of tables________________________________________<br />
4. Number of figures_______________________________________<br />
5. Special requests_________________________________________<br />
6. Suggestions for reviewers (name and postal address)<br />
Indian 1.______________ Foreign 1. _______________<br />
2._____________________ 2._______________<br />
7. All author’s signatures____________________________________<br />
8. Corresponding author’s name, current postal and e-mail address and<br />
telephone and fax numbers<br />
__________________________________________________________<br />
For Editorial Correspondence<br />
Dr KMK Masthan<br />
Professor and Head<br />
Department of Oral Pathology and Microbiology<br />
Sree Balaji Dental College and Hospital<br />
Velachery Main Road, Narayanapuram, Pallikaranai<br />
Chennai - 600 100, E-mail: masthankmk@yahoo.com,<br />
ijmdent@gmail.com<br />
Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011<br />
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