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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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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 />

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Review Article<br />

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 />

13.<br />

14.<br />

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16.<br />

17.<br />

18.<br />

19.<br />

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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Review Article<br />

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 />

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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 />

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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 />

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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 />

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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 />

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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 />

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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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20.<br />

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24.<br />

25.<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 />

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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 />

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Wood NK, Goaz PW. Differential diagnosis of oral and<br />

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interpretation. In: Cyst of jaws. 5th edition, Mosby<br />

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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 />

289


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 />

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Indian Journal of Multidisciplinary Dentistry, Vol. 1, <strong>Issue</strong> 5, <strong>Jul</strong>y-<strong>Aug</strong>ust 2011


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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Saito M, Miura Y, Notani K, Kawasaki T. Stress<br />

distribution of abutments and base displacement<br />

with precision attachment- and telescopic crownretained<br />

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 />

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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 />

298<br />

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Case Report<br />

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The boxed checklist will help authors in preparing their manuscript<br />

according to our requirements. Improperly prepared manuscripts may be<br />

returned to the author without review. The checklists should accompany<br />

each manuscript.<br />

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 />

299

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