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IMAGE 2010-11 ISSN: 2229-5658 Vol No: 11 ISSUE No: 4 1 

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The International Journal of Indian Dental Association, Kunnamkulam Branch. Indexed in Journals Master List of IC TM





EDITORIAL BOARD 2011 

1. Dr.Mercy Joji ñ Editor-In-Chief. 

2. Dr.Joji George ñ Associate Editor. 

3. Dr.Geo Joy.K ñ Ex Officio. 

4. Dr.Mohammed Faris ñ Ex Officio. 

5. Dr.Gregory.T.M ñ Editorial Board Member (Oral Surgery). 

6. Dr.Vinod.M.A ñ Editorial Board Member (Endodontics). 

7. Dr.Sunil Mohammed ñ Editorial Board Member (Pedodontics). 

8. Dr.Biju.P.Babu ñ Editorial Board Member (Conservative Dentistry) 

9. Dr.Hari Prasad.A ñ Editorial Board Member (Orthodontics). 

10. Dr.Poulosekutty ñ Representative to state (General Practitioner). 




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Dear IDA Members, 

PRESIDENTíS MESSAGE 

It is the high time to write a few words of gratitude to all 

members for the Co-operation and involvement shown towards IDA Kunnamkulam 

Branch activities. From the depth of my heart, I thank all office bearers, members, 

family, IDA state office & IDA National Office for making the year 2010-11 a 

marvellous one. 

I take the opportunity to thank our branch Editor & Editorial board members 

for bringing out our journal IMAGE 2010-1; issue No:4 on time. The Scientific 

quality of our journal has improved a lot because of itís work of editing, profound 

articles and benefactors. 

Let all of us work hard for the coming year 2011-12 with unity & enthusiasm 

Dear Brothers and Sisters, 


The International Journal of Indian Dental Association, Kunnamkulam Branch. Indexed in Journals Master List of IC TM 

Thank you 

Dr.Geo Joy, President, IDA Kunnamkulam Branch. 

ASSOCIATE EDITORíS MESSAGE 

The Issue No.4 of IMAGE our journal has a variety of articles this time. I would like to request 

all of you to go through them. It will definitely add numerous tips to your 

academic and clinical knowledge. 

Reforming or improving the quality of skills would be the dream of doctors 

especially dental surgeons. For this, you require knowledge. Knowledge could 

be attained through reading and seeing. This mission & vision is now at you 

finger tips. Make use of it. 

Our journal is flying to newer heights; from ISSN to many bibliographic 

distribution. This makes it a member of universal journals; where international 

interactions are brought in. 

JAI HO, IDA Kunnamkulam & IMAGE. 

Dr. Joji George.

Dr. George 

Thomas 


EDITORIAL 

IMAGE; issue No.4 has many inclusions like research works case reports and reviews. Articles 

are from a number of sources. But remember that there was a time we had scarcity of articles. We did a lot 

of hard work to bring up it into the present stage. The effort consisted years together. 

The great help of our branch, our state branch, and national head office was with us when needed. 

At the same time, also from contributors and benefactors. 

Dr. Ashok 

Dhoble 

Dr.Santhosh 

Sreedhar 

Dr. Shibu 

Rajagopal 

Dr.Geo Joy Dr.Mohammed 

Faris 

Dr.Marilyn 

Alias 

I salute the national president Dr.George Thomas, a great person of principle and simple 

behaviour. I also salute Dr.Ashok Dhoble, our national Secretary for his co-ordination and determination. 

Dr.Santhosh Sreedhar, Our IDA Kerala State president needs a special appreciation for his 

truthfulness and honesty. He could bring our state branch to a new horizon. Especially I congratulate his 

efforts to bring the women members to the front line through IDA Womenís wing. Dr.Shibu Rajagopal, 

our state secretary also needs a remark for his energy and friendship to make all IDA events memorable. 

I congratulate IDA Womenís wing office bearers, the chair person Dr.Merilyn Alias and Dr.Sudha 

Santhosh for their boldness and hard work. 

Our branch president, Dr. Geo Joy and secretary, Dr. Mohammed Faris stood as embodiments of 

Freedom and Sincerity to bring new concepts and ideas. I wish our journal IMAGE the best in future. 

Thanking you 

Yours sincerely, Dr. Mercy Joji 



Dr.Sudha 

Santhosh 

Editor.


SINGLE VISIT DENTURE: A PSYCHOLOGICAL AID FOR EDENTULOUS PATIENT - 

CLINICAL REPORT - Kumar Lakshya(Lecturer),Singh Kamleshwar (Astt Prof.), Mishra Neeraj(Astt 

Prof.)- Department of Prosthodontics Faculty of Dental Sciences C .S.M Medical University Lucknow. 

Yadav Akanksha(PG Student), Department of Oral Medicine & Radiology, B.B.D College Of Dental 

Sciences, Lucknow. Page :11- 14 

OBSTRUCTIVE SLEEP APNEA - A REVIEW 

Dr Shruthi C S, Reader, Dept of Prosthodontics and Implantology M R Ambedkar Dental College and 

Hospital Bangalore, Dr Vinod Kumar R, Professor, Dept of Conservative Dentistry and Endodontics 

Dayanand Sagar College of Dental Sciences Bangalore.,Dr .Upendranath Reddy,Senior Lecturer, Dept of 

Conservative Dentistry and Endodontics Pulla Reddy Dental College Kurnool.,Dr Paras, Reader, Dept of 

Conservative Dentistry and Endodontics JSS Dental College and Hospital Mysore. 

Page : 15- 20 

PHYTOCHEMISTRY IN CANCER TREATMENT 

Mity Thambi, Doctorate Student, Calicut University, Calicut. MSc, BEd, MPhil. 

Page : 25 ñ 28 

STRATEGIES OF SCHOOL DENTAL HEALTH EDUCATION 

Dr.Sunil Mohammed, Professor and HOD, Department of Pedodontics, Royal 

Dental College, Chalissery, Kerala. 

Page : 21 ñ 24 

MANAGEMENT OF GAG IN DENTAL PRACTICE - A REVIEW 

Dr. Sandeep garg, MDS, professor, Dr. Sushant garg, MDS, Professor & head, Dr. Kusum yadav, Post graduate 

student - M.M. College of Dental Sciences & Research, Mullana, Ambala (Haryana), India 

PAGE : 29- 33 




HALITOSIS AND DRY MOUTH SYNDROME 

PRETTY PRINCE. P, BDS student Mar Baselious dental college, Kothamangalam. 

Page : 34- 37 

COMPARISON BETWEEN CONVENTIONAL RADIOGRAPHY AND RADIOVISIOGRAPHY WITH 

RAYPEX5 APEX LOCATOR FOR IMAGING ROOT CANAL LENGTH. 

Dr. Gurudutt Nayak MDS (Reader), Dr. Shashit ShettyMDS (Professor and Head) - Department 

of Conservative Dentistry and Endodontics, K.D. Dental College and Hospital, Mathura, 

Uttar Pradesh-281006. Dr. Surya Dahiya MDS (Assistant Professor) - Department of 

Conservative Dentistry and Endodontics, Himachal Dental College, Sundar Nagar, 

Himachal Pradesh. 

INVISIBLE BRACKETS 

Page :38- 43 

Dr.Bastian Varkey N, Moderen Dental Clinic, Thaikkad, Guruvayoor. 

Page : 44 ñ 46 

SYNERGISTIC COMBINATION OF ACECLOFENAC AND 

THIOCOLCHICOSIDE - An advanced and modern treatment modality. 

Dr.Shilpa Burundy 

Page :47- 49 

ERGONOMICS: A SOLUTION TO MUSCULOSKELETAL DISORDERS 

Dr. Subodh Shankar Natu B.D.S, M.D.S. Sr. Lecturer, Department of Oral & Maxillofacial Surgery, 

Career Postgraduate Institute of Dental Sciences & Hospital 

Dr. Vrishali Ajit Kulkarni B.D.S Lecturer Career Postgraduate Institute of Dental Sciences & 

Hospital 

Page : 50- 56 

ORAL MEDICINE, DIAGNOSIS & ORAL RADIOLOGY - 

DR.B.K.VENKATARAMAN, THE FATHER OF ORAL 

MEDICINE IN INDIA. 

Dr.Joji George 

Page : 57-59 




ëSATISFACTORY SMILEí WITH A RESTORATIVE APPROACH- A CASE 

REPORT 

Dr. Rekha Rao, Dr. Sanjith Simon (Reader), Reader, Dept. Of Conservative Dentistry & 

Endodontics, Century International Institute Of Dental Research Centre, Poinachi, Kasaragod. 

Dr. Shashi Rashmi Acharya, Professor, Dept. Of Conservative Dentistry & Endodontics, MCODS, 

Manipal. Page : 60 - 63 

ORAL SUB MUCOUS FIBROSIS 

Dr:STIFFY KUKREJA, KUKREJA DENTAL CARE, PANCHKULA, HARYANA 

STATE 

Page : 64-71 

EARLY ORTHODONTIC INTERVENTION 

A SURGICAL CASE TO A NON SURGICAL CASE ñ IS IT POSSIBLE??? 

Dr.P.U.Bijoy, MDS, Reader, Annoor Dental College, Muvattupuzha, Eranamkulam 

Page : 72-74 

Secretaryís Report (In Photos) 

Dr.Mohammed Faris. 

Pages : 79-82 

IMPLANT SUPPORTED OVERDENTURE IN THE 

REHABILITATION OF THE ATROPHIC MANDIBLE 

Page : 75-78 

Author : DR. BYJU PAUL KURIAN MDS,Professor, Dept. of Prosthodontics, Annoor 

Dental College, Muvattupuzha. Co-Author : DR RANJITH KUMAR. P MDS,Reader, 

Dept. Of Prosthodontics,Royal Dental College, Palakkad. 




SINGLE VISIT DENTURE 

A PSYCHOLOGICAL AID FOR EDENTULOUS PATIENT - CLINICAL REPORT 

Kumar Lakshya(Lecturer),Singh Kamleshwar (Astt Prof.), Mishra Neeraj(Astt Prof.)- Department of 

Prosthodontics Faculty of Dental Sciences C .S.M Medical University Lucknow. Yadav Akanksha(PG 

Student), Department of Oral Medicine & Radiology, B.B.D College Of Dental Sciences, Lucknow. 

INTRODUCTION 

An immediate denture is a dental prosthesis 

constructed to replace the lost dentition and 

associated structures of the maxillae and 

mandible and inserted immediately 

following removal of the remaining teeth. 1 

This can be partial or complete interim, 

conventional and immediate overdenture 

prosthesis. The main advantage of 

immediate denture is that help in 

maintaining psychological status of the 

patient. There are some contraindications to 

immediate dentures, such as cardiac, 

endocrine, and blood disturbances, slow 

healing potential, acute periapical or 

periodontal diseases, extensive bone loss, or 

mental incapacity, indifferent and 

uncooperative patients. 

CASE REPORT 

The female patient 56 years of age has 

reported to the department. Patient chief 

complaint was that she wants replacement of 

missing teeth. On clinical examination it 

was diagnosed that patient is partially 

edentulous having 11,13,14,21,22, 

23,24,25,28,32,42,43 No tooth. The 

condition of all the teeth was compromised 

(Fig.1) presenting with advanced 

PROSTHODONTICS 

ABSTRACT: 

Psychological impact of the edntulousness is well known, the impact of losing teeth can be traumatic for 

the young, the old, and everyone in between it affect the social and personal life of the patient. There are 

many advantages to immediate as opposed to conventional complete denture. From the patientís point of 

view, the preservation of the natural appearance of a person is of major importance. The aim of this 

clinical report is to present clinical procedure helps in maintaining psychological status of the patient. 

KEYWORDS: immediate denture, dental prosthesis, Single visit denture. 

periodontal disease. Medical history was not 

significant. Depending of the oral condition 

patient was advised to go for total extraction 

and later on replacement by complete 

denture prosthesis. The patient was teacher 

by occupation & she was quite adamant for 

not being edentulous for any length of time 

because it might be quite embarrassing for 

her. Patient was very cooperative and of 

philosophical type. 

The patient was referred to the dept of 

periodontics for oral prophylaxis. After 

complete scaling the primary impression of 

the maxillary and mandibular arch was made 

in irreversible hydrocolloid (Zelgan 2002, 

Dentsply, India) impression material. The 

mandibular teeth were grade III mobile. So 

impression was made after blocking the 

teeth with the wax 2 .The sectional maxillary 

secondary impression was made by the nonaqueous 

electrometric impression material 

(Reprosil TM , Dentsply-Caulk, Milford, DE, 

USA). (Fig 2,3) mandibular impression was 

made in irreversible hydrocolloid (Zelgan 

2002, Dentsply, India). 

Maxillomandibular jaw relation records 

were made to articulate the casts. The proper 

shade and size of teeth were selected. The 

posterior artificial teeth arrangement was 




completed and evaluated in the patientís 

mouth to confirm maxillo-mandibular 

relation records. (Fig.4, 5). While arranging 

the anterior teeth the every other tooth was 

trimmed from the cast and artificial teeth 

were placed respectively. Artificial anterior 

teeth were arranged in such a fashion that it 

reflect the position of the patientís natural 

teeth. While arranging anterior teeth we 

estimate the amount of ridge to be removed 

from the stone model 3 . The maxillary and 

mandibular wax up was completed, at the 

stage of dewaxing the casts was duplicated 

and on the duplicated casts surgical template 

were fabricated (Fig 6). These templates 

were also invested and cured in clear heat 

cure acrylic (DPI, New Delhi, India). The 

remaining three teeth were extracted on the 

very next appointment and with the help of 

surgical template necessary modification of 

alveolar ridges were performed. After 

satisfactory fit of the templates on the 

alveolar tissue (Fig. 7). Tissue Flaps were 

sutured and patient was referred back to the 

Dept of Prosthodontics for complete denture 

insertion. The maxillary and mandibular 

dentures were inserted and checked for areas 

of excessive pressure and adjusted (Fig.8). If 

the fit of dentures is not satisfactory then it 

can be relined lined with a tissue 

conditioning material. 

The patient was given postoperative home 

care instructions, which include: not 

removing the denture for 24h, the use of 

analgesics and ice packs, if necessary, and 

appointed the next day for postoperative 

examination and any needed adjustments. 

After one week, at the recall, we proceeded 

to reline the immediate complete denture 

with a permanent soft resilient silicone 

(Permasoft, Dentsply, India). The patient 

was satisfied with both the retention and the 

esthetics of the complete denture (Fig. 9). 

DISCUSSION 

Patients vary greatly in what they want, 

expect and demand. To attain the maximum 

degree of success, the following 

requirements should be satisfied: 

1) Compatibility with the surrounding oral 

environment; 

2) Restoration of masticator efficiency; 

3) Harmony with the functions of speech, 

respiration and deglutition; 

4) Esthetic acceptability 

5) Preservation of the remaining tissues. 4 

For the dentist it is a challenge to 

accomplish the requirements in immediate 

denture service. To accomplish these 

requirements, it is mandatory that each 

patient be analyzed and evaluated on an 

individual basis. The best patient for 

immediate dentures is the philosophical 

type. Their motivation for denture is the 

maintenance of health and appearance, and 

they accept replacement of natural teeth that 

cannot be saved as a normal procedure. 

These patients overcome conflicts and 

organize their time and habits in an orderly 

manner. They eliminate frustrations and 

learn to adjust rapidly. The philosophic 

patient will listen to and carry out 

instructions in an intelligent manner. Their 

mental attitude contributes to a favorable 

prognosis for the immediate 

denture. 5 Advantages : 

1. Patient does not have to suffer 

through edentulous period 

2. Reduced pain and swelling 

3. Current esthetics retained in 

dentures 

4. Patient adapts rapidly 

5. Good speech and appearance are 

retained 

6. Patient does not develop undesirable 

habits and is more cooperative 

emotionally 

7. Acts as a bandage to control 

hemorrhage, Promotes rapid healing 

8. Provides for minimum social 

interruptions and maximum 

psychological advantages. 




Disadvantages: 

1. The procedures are time consuming and 

require more appointments, particularly 

during the adjustment phase. 

2. The resorbtion is faster than the healed 

tissue. So frequent relining is required to 

keep the denture in functional state. 

3. There is no anterior teeth try-in 

appointment. Another limitation of the 

immediate denture is that the laboratory 

technician may not have sufficient space to 

position the teeth correctly and esthetically. 

The soft tissue and overall ridge are very full 

at the time of extraction, but after several 

weeks the resorbtion is accentuated. 6 It will 

Figure Legends: 

improve the fit and comfort of the complete 

immediate denture. 

SUMMARY & CONCLUSION 

The fabrication of single visit denture is 

quite challenging because it only depends 

upon the clinical expertise and skills of the 

prosthodontist. It is important for both the 

patient and the dentist to understand the 

limitations of the procedure. Relining of the 

single visit denture with soft resilient 

materials may be sometime required to 

improve fitting. Single visit dentures leads 

to undisturbed social and business activities 

without being in edentulous state. 

Figure 1 ñ Pre -op intraoral view Figure 2- Maxillary secondary impression 

Figure 3-Mandibular secondary impression Figure 4- Try ñIn (Left lateral view) 




Figure 5- Try ñIn (Right lateral view) Figure 6- Maxillary and Mandibular Surgical 

templates 

Figure 7- Surgical templates in place Figure 8- Immediate denture inserted 

REFERENCES 

Figure 9- Patient one week post operative 

1. Rahn AO, Hearthwell CH. Textbook of complete dentures. 5th ed. Philadelphia: Lea 

&Febiger 1993, p.486-8. 

2. Ashok Soni. Use of loose fitting copper bands over extremely mobile teeth while making 

impressions for immediate dentures J Prosthet Dent 1999; 81:638-9. 

3. Rodney D. Phoenix JeffreyD. Fleigel, Cast modification for immediate complete dentures: 

Traditional and contemporary considerations with an introduction of spatial modeling. J 

Prosthet Dent 2008; 100:399-405. 

4. Jonkman RE, Van Maas MA, Kalk W. Satisfaction with complete dentures and complete 

immediate overdentures. A 1-year survey. J Oral Rehab 1995; 22:791-6. 

5. Gotlieb A, Askinas S. An atypical immediate denture: A clinical report. J Prosthet Dent 

2001; 3:241-3. 

6. Gardner LK, Parr GR, Rahn AO. Modification of immediate denture sectional 

impression technique using vinyl polysiloxane. J Prosthet Dent 1990; 64:182-4 

****************** 




OBSTRUCTIVE SLEEP APNEA - A REVIEW 

Dr Shruthi C S, Reader, Dept of Prosthodontics and Implantology M R Ambedkar Dental College and Hospital 

Bangalore, Dr Vinod Kumar R, Professor, Dept of Conservative Dentistry and Endodontics Dayanand Sagar College 

of Dental Sciences Bangalore.,Dr .Upendranath Reddy,Senior Lecturer, Dept of Conservative Dentistry and 

Endodontics Pulla Reddy Dental College Kurnool.,Dr Paras, Reader, Dept of Conservative Dentistry and Endodontics 

JSS Dental College and Hospital Mysore. 

Abstract 

Obstructive sleep apnea is characterized by repetitive episodes of pharyngeal collapse with 

increased airflow resistance during sleep. It appears to have multiple contributing causes and 

patients who have this disease are at risk for many deleterious conditions, including chronic 

snoring, hypertension, excessive daytime sleepiness, decreased libido, fatigue, and an increased 

tendency for accidents. Children may also exhibit poor school performance and hyperactivity. 

The proper recognition and treatment of these patients is critical. 

Key Words: Sleep Apnea, Snoring, Mandibular Advancement Appliance. 

INTRODUCTION 

Sleep apneas are classified into three types; 

obstructive, central, and mixed. Central 

apneas are characterized by the 

simultaneous cessation of both airflow and 

respiratory effort. Obstructive sleep apnea 

(OSA) is characterized by repetitive 

episodes of pharyngeal collapse with 

increased airflow resistance during sleep. 

During mixed apnea, a central respiratory 

pause is followed by obstructed ventilatory 

efforts. 

An arousal is a change in sleep to a lighter 

stage and/or an actual awakening. Apnea is 

defined as a cessation of airflow (breathing) 

lasting for at least 10 seconds. Hypopnea is 

a 50% reduction in airflow for 10 seconds or 

more, usually associated with a fall in blood 

oxygen saturation. The Apnea Index (AI) is 

the number of apneic episodes per hour of 

sleep. The total number of apneic and 

hypopneic episodes per hour of sleep is 

referred to as the Apnea-Hypopnea Index 

(AHI) or the Respiratory-Disturbance Index 

(RDI). 1 

Up to 25% of adults have OSA (i.e., an 

apneañhypopnea index (AHI) _5/h) and 

roughly 10% of all adults have moderate to 

severe disease (i.e., an AHI _15/h). 2 OSA is 

associated with higher rates of 

cardiovascular and cerebrovascular 

morbidity and mortality as well as excessive 

daytime sleepiness, fatigue and 

PROSTHODONTICS & ORAL MEDICINE 

neurocognitive deficits. When left untreated, 

the mortality rate for severe OSA 

approaches 30% at 15 years. 

Upper Airway Sleep Disorders 

Upper airway sleep disorders (UASDs) are 

conditions that occur in the upper airway 

that diminish sleep time and/or sleep quality. 

USAD syndromes described in the literature 

include sleep apnea syndrome, and upper 

airway resistance syndrome (UARS). 3 

Snoring is a common symptom of these 

syndromes. Sleep apnea syndrome is a sleep 

interference disorder characterized by apneic 

and possibly hypopneic events, resulting in 

low oxygen levels to the lungs (hypoxia), 

blood oxygen desaturation, and a sleep 

arousal or awakening. UARS is a condition 

that can cause the clinical manifestations of 

sleep apnea syndromes and yet, the patient 

exhibits no apnea or hypopnea events. These 

patients exhibit a narrowing of the upper 

airway that requires a greater effort on their 

part to breathe. 

Physiology of Upper Airway Sleep 

Disorder 

The term upper airway includes the 

structures of the hypopharynx, oropharynx, 

and nasopharynx (Fig. 1). As illustrated in 

Figure 1, the upper airway is a nonrigid soft 

tissue structure with minimal bony support. 

The negative pressure during inspiration 

tends to cause a change in shape of the 

airway, which is resisted to a large extent by 




the activity of the tensor veli palatini and the genioglossus muscles in a individual normal 

. 

Fig. 1. Upper airway space of Fig. 2. Upper airway anatomy of OSA patient 

patient with normal anatomy. reveals complete closure of airway 

Most snoring and obstructive sleep apnea 

(OSA) patients have an initially 

compromised airway space that is often 

caused by obesity but may be caused by any 

condition that impinges on the space. The 

genioglossus and tensor veli muscles may 

have increased activity in the awake OSA 

patients and thus help maintain the shape of 

the upper airway. 4 However, when the 

patient assumes a supine position and goes 

to sleep, there is a decrease in the activity of 

the genioglossus and tensor veli palatini 

muscles that results in a decreased airway 

space. 5 This decrease in airway size may 

result in an increase in the velocity of the air 

passing through the airway, increasing the 

degree of subatmospheric pressure. 

The combination of increased negative 

pressure and decrease in muscle activity 

allows the tongue and soft palate to move 

toward and often contact the posterior wall 

of the oropharynx, resulting in a decreased 

airway space. If the blockage is not 

complete, the increase in airflow velocity 

during inspiration and expiration may cause 

the soft tissues, particularly the uvula, to 

vibrate (Fig. 2). For other patients, this 

combination of negative pressure, decreased 

muscle activity and movement of tongue and 

soft palate toward the posterior wall of the 

pharynx, results in a complete blockage of 

the airway (Fig. 3). The resulting conditions 

may be snoring and/or OSA. 6 Any anatomic 

abnormality of the nose, nasopharynx, 

oropharynx, larynx, and oral cavity may also 

cause the initial reduction of airway space. 

These conditions may include obesity, 

polyps, tumors, edema of the epiglottis, 

adenotonsillar hypertrophy, and other 

structural changes in the upper airway. 

Obstructive Sleep Apnea 

OSA is still a poorly recognized medical 

condition the cause of which is multifaceted. 

Any obstructive condition coupled with 

assuming the supine position may cause a 

blockage of the upper airway. Anatomic 

alterations may reduce airway space in 

moderate-to-severe OSA patients, 7 and 

include posteriorly positioned maxillae and 

mandibles, steep occlusal planes, 

overerupted anterior teeth, large gonial 

angles, anterior open bites in association 

with long tongues, posteriorly placed 

pharyngeal walls, retrognathic mandibles, 

large tongue and soft palate, large airway 

volumes, and anteroposterior discrepancies 

between the maxilla and mandible. 

Micrognathia, acromegaly, and Downís 

syndrome may also be predisposing 

conditions. 

Blockage of the airway causes an apnea 

and/or hypopnea event(s) and results in 




reduced airflow to the lungs, producing 

hypoxemia that eventually causes the patient 

to arouse enough to resume breathing. This 

arousal is an interruption in the patientís 

sleep, though often not severe enough to 

completely awaken the patient. Severe apnea 

patients experience up to 1- minute apnea, 

producing a significant hypoxemia before 

arousal occurs. They may exhibit repeated 

sleep/arousal cycles throughout the night. 

Hypoxia resulting from apnea may lead to 

severe medical conditions that include 

bradycardia, tachycardia, systemic 

hypertension, pulmonary hypertension, 

acute pulmonary edema, reversible highgrade 

proteinuria, and possibly sudden 

infant death syndrome. This lack of sleep 

and the poor quality of sleep cause common 

symptoms such as hypertension, excessive 

daytime sleepiness, cognitive dysfunction, 

memory and judgment impairment, 

irritability, decreased libido, nocturia, 

sweating, fatigue, headaches, depression, 

and an increased tendency for accidents. 

Children with sleep apnea may exhibit poor 

school performance and hyperactivity. 

Diagnosis 

Although the dentist is a part of the 

treatment team, the dentist does not 

diagnose or determine treatment for sleep 

apnea patients. However, dentists must be 

able to identify potential apnea patients, 

refer them to a physician for definitive 

diagnoses and treatment planning, and serve 

as a part of the treatment team. After a 

preliminary examination the physician may 

refer the patient for an overnight 

polysomnography study in a sleep clinic. 

The polysomnogram (PSG) is used to 

evaluate the sleep and breathing patterns. 

The PSG can determine the existence, type 

(central, obstructive or mixed), and severity 

of any apnea disorders. The PSG is also 

used to later determine the effectiveness of 

any completed treatment. If the PSG reveals 

the existence of a sleep apnea, further 

diagnostic tests, such as a complete blood 

count and thyroid function, may be helpful 

in evaluating these patients. If an upper 

airway obstruction is diagnosed, other 

studies such as ENT examinations and 

radiographs may be required to determine 

the cause of the obstruction. 

The patientís respiratory muscles making no 

effort to breathe characterizes central apnea. 

Obstructive apnea is characterized by the 

respiratory muscles making an attempt to 

breath but the airflow is either blocked or 

severely limited because of some 

obstruction in the upper airway. Mixed 

apnea is a combination of central and 

obstructive apneas. 

The common sleep apnea patient is a 

middle-aged to older, obese, male, smoker, 

who uses alcohol and/or sedatives and who 

snores loudly. However, any patient 

complaining of snoring or excessive daytime 

somnolence should be considered a potential 

sleep apnea patient. 

Treating OSA Patients 

The ideal results of treating OSA patients 

would be increased life expectancy, 

decreased health hazards, and improved 

quality of life. Because of the potentially 

ìlife-threateningî severity of apnea, 

diagnosis and selection of the proper course 

of treatment, which may include behavioral 

modification, surgical intervention, nasal 

continuous positive air pressure (NCPAP), 

medication, and/or removable dental 

prostheses, are vital. 

Behavioral Changes 

Behavioral changes, which may include 

weight loss, changing sleep positions, head 

posture, quitting smoking, and avoidance of 

central nervous system depressors, may be 

beneficial for some patients. 



8, 9 

Surgical Intervention 

The following surgical procedures have 

been suggested for the treatment of OSA: 

tracheostomy, mandibular surgery, nasal 

septal surgery, hyoid bone suspension, 

partial tongue resection, maxillomandibular 

advancement osteotomy, inferior mandibular 

osteotomy, lingualplasty, genioglossal 

advancement with hyoid myotomy and 

suspension, and 

uvulopalatopharyngoplasty. 10 Tonsillectomy 

and adenoidectomy may be indicated for 

children with OSA caused by adenotonsillar


hypertrophy. Tracheostomy is successful 

because it provides an airway below the 

obstruction; however, because of negative 

psychological and esthetic effects, its 

indication is limited. 

The use of palatoplasties has produced 

contrasting results. Maxillary and 

mandibular osteotomies are recommended 

for patients with severe OSA, morbid 

obesity, and severe mandibular deficiency. A 

two-phase surgical procedure, genioglossal 

advancement with hyoid myotomy and 

suspension and uvulopalatopharyngoplasty 

has been shown to be effective in 60% or 

more of patients with OSA, which compares 

very favorably with NCPAP. 

Nasal Continuous Positive Airway 

Pressure (NCPAP) 

NCPAP is a method of providing room air 

under pressure to patients by using a small 

air pump connected to either a sealed face or 

nose mask. The technique appears to work 

by splinting the pharyngeal airway open and 

preventing the soft tissues from collapsing 

and blocking the airway. 11 Although NCPAP 

has been shown to be successful in 62% of 

OSA patients, patient compliance is poor 

because of mask discomfort, pump noise, 

dryness, and portability problems. 

Medications and Dental Devices 

There are many published studies that 

describe the use of medications for treating 

sleep apnea. However, few studies have 

reported positive benefits and none have 

been shown to be significantly effective. 

Dental devices used most often include the 

tongue retaining device (TRD) and 

mandibular advancement appliances 

(MAAs) (Figs. 3 through 5). With the TRD 

the tongue is prevented from dropping 

posteriorly by suction created when the 

patient forces the tongue into a hollow bulb 

built into the device. Patients can maintain 

the tongue in the bulb for several hours per 

night, often all night long, once they are 

accustomed to wearing the device. 

An advantage of this device over the MAAs 

is that it can be used for edentulous patients. 

12 In counteracting fluctuating genioglossus 

muscle activity, they also block the oral 

airway and therefore any compromise of the 

nasal passage must be surgically corrected. 

Rationale for the Use of Mandibular 

Advancement Appliances 

It is postulated that the principal mechanism 

of action of these appliances is: 

Anatomical: which include increased upper 

airway calibre and decreased upper airway 

compliance. 13 Thus, forward and inferior 

displacement of the mandible not only acts 

to increase the size of the pharyngeal airway 

by drawing the tongue forward through its 

muscular attachments, but preserves the 

velopharyngeal airway by stretching the 

palatoglossal and palatopharyngeal arch, 

thereby reducing airway collapsibility of the 

airway. 

Physiological: There is some evidence 

relating to the effect of MAA on upper 

airway dilatory muscle activity, which may 

serve to compensate for the reduction in 

tone, observed during sleep disordered 

breathing. 14 

Design Features 

There is considerable variation in the design 

of MAA, but all posture the mandible 

forwards, to a varying extent, with a degree 

of vertical opening. They may be 

prefabricated or custom-made using a soft or 

hard plastic and as a one- or two-piece 

design. This is not appropriate in subjects 

with epilepsy, as it could potentially obstruct 

the airway if it were to become dislodged 

during a nocturnal seizure. 

The currently available appliances could be 

broadly classified in to three types, based on 

a succession of design modifications, which 

importantly permit incremental 

advancement of the mandible. 

First Generation 

These were primarily one-piece in design, 

with no ability to advance the mandible 

incrementally without a new appliance being 

fabricated (Figure 3). 




Fig: 3. First generation vacuum-formed 

mandibular advancement appliance. 

Second Generation. 

This type of appliance was principally twopiece 

in design and offered the potential for 

incremental advancement (Figure 4). 

However, this would often necessitate 

laboratory support and was potentially more 

time-consuming at the chairside. 

Fig: 4. Second generation Herbst removable 

mandibular advancement appliance. 

Based on the available literature, The 

American Academy of Sleep Medicine 

(AASM) issued the most recent 

recommendations on the use of MAA, 

supporting their use primarily in patients 

with non-apnoeic snoring and mild to 

moderate OSA. There still, however, 

remains a need for larger studies as well as 

data on the long-term efficacy of MAA 

therapy. 

Short-term side-effects are common and 

include discomfort in the muscles of 

mastication, excessive salivation, dry mouth 

and abnormalities of the bite on awakening. 

These effects appear to be transient and tend 

to resolve with regular wear. Later 

complications, which may preclude the use 

Third Generation 

These appliances may be regarded as the 

ëgold standardí in design. They not only 

permit incremental advancement, which is 

self-adjustable, but also lateral movement of 

the mandible and ensure that the mandible is 

retained in its postured state during sleep 

(Figure 5). 

Fig: 5. Third generation Medical 

Dental Sleep Appliance. 

of a MAA, include temporomandibular joint 

discomfort and the risk of skeletal and 

dentoalveolar changes. The literature is 

conclusive in reporting that MAA wear does 

not produce changes in the craniofacial 

skeleton or TMJ. 

Conclusion 

Many snoring and OSA patients can 

successfully be treated using surgical 

procedures, NCPAP, behavioral 

modification, and/or dental devices. 

However, because obstruction may occur at 

differing levels of the upper airway, any 

specific treatment modality will not address 

the problems of all patients. Dental 

treatment has been shown to be a successful 

and conservative method to treat mild-to- 




moderate OSA. It should be considered by 

the medical profession over more invasive 

treatment modalities or in patients who do 

not respond to behavioral modifications. 

REFERENCES 

1. American Sleep Disorder Association. 

Obstructive sleep apnea syndrome : The 

International Classification of Sleep 

Disorders. Diagnostics and Coding Manual. 

Rochester (MN): Davies Printing; 1997. p. 

337-51. 

2. Duran J, Esnaola S, Rubio R, Iztueta A. 

Obstructive sleep apnea-hypopnea and 

related clinical features in a populationbased 

sample of subjects aged 30 to 70 yr. 

Am J Respir Crit Care Med 2001;163:685ñ 

9. 

3. Man GC. Obstructive sleep apnea. 

Diagnosis and treatment. Med Clin North 

Am 1996;80:803-20. 

4. Mezzanotte WS, Tangel DJ, White DP. 

Influence of sleep onset on upper airway 

muscle activity in apnea patients versus 

normal controls. Am J Respir Crit Care Med 

1996;153(6 Pt 1):1880-7. 

5. Adachi S, Lowe AA, Tsuchiya M, Ryan 

CF, Fleetham JA. Genioglossus muscle 

activity and inspiratory timing in obstructive 

sleep apnea. Am J Orthod Dentofacial 

Orthop 1993;104:138-45. 

6. Suratt PM, Dee P, Atkinson RL, 

Armstrong P, Wilhoit SC. Fluoroscopic and 

computed tomographic features of the 

pharyngeal airway in obstructive sleep 

apnea. Am Rev Respir Dis 1983;127:487- 

92. 

7. Lowe AA, Santamaria JD, Fleetham JA, 

Price C. Facial morphology and obstructive 

*********** 

sleep apnea. Am J Orthod Dentofac Orthop 

1986;90:484-91. 

8. Harman EM, Wynne JW, Block AJ. The 

effect of weight loss on sleep-disoriented 

breathing and oxygen desaturation in 

morbidly obese men. Chest 1982;82:291-4. 

9. Makofsky HW. Snoring and obstructive 

sleep apnea: does head posture play a role? 

Cranio 1997;15:68-73. 

10. Practice parameters for the treatment of 

obstructive sleep apnea in adults: the 

efficacy of surgical modifications of the 

upper airway. Report of the American Sleep 

Disorders Association. Sleep 1996;19:152-5. 

11. Sullivan CE, Berthon-Jones M, Issa FG. 

Remission of severe obesity hypoventilation 

syndrome after short-term treatment during 

sleep with nasal continuous positive air 

pressure. Am Rev Respir Dis 1983;128:177- 

81. 

12. Ferguson KA, Ono T, Lowe AA, 

Keenan SP, Fleetham JA. A randomized 

crossover study of an oral appliance vs 

nasal-continuous positive airway pressure in 

the treatment of mild-moderate obstructive 

sleep apnea. Chest 1996;109:1269-75. 

13. Johal A, Battagel JM. An investigation 

into the changes in airway dimension and 

the efficacy of mandibular advancement 

appliances in subjects with obstructive sleep 

apnoea. Br J Orthod 1999; 26: 205−210. 

14. Ono T, Lowe AA, Ferguson KA, Pae 

EK, Fleetham JA. The effect of the tongue 

retaining device on awake genioglossus 

muscle activity in patients with obstructive 

sleep apnea. Am J Orthodont Dentofac 

Orthopaed 1996; 110: 28−35. 




ABSTRACT 

STRATEGIES OF SCHOOL DENTAL HEALTH EDUCATION 

Dr.Sunil Mohammed, Professor and HOD, Department of Pedodontics, Royal Dental College, 

Chalissery, Kerala. 

The Oral health of children is important to their overall well-being. Just as the mouth cannot be 

separated from the rest of the body, oral health cannot be considered separate from the rest of childrenís 

health. Oral health actually includes all the sensory, digestive, respiratory, structural and emotional 

functions of the teeth, the mouth, and associated facial structures. 

INTRODUCTION 

PEDODONTICS & COMMUNITY DENTISTRY 

Oral health must be considered in the 

context of social, cultural, and environmental 

factors. Dental and oral disorders can have a 

profound impact on children, and the burden of 

untreated dental health problems is substantial. 

Untreated dental decay (cavities) can result in 

pain, infection, tooth loss, difficulty in eating or 

speaking, and poor appearance, all of which 

present challenges for maintaining self-esteem 

and attentiveness to learning. Chronic pain can 

alter a childís ability to sleep and play, and it 

hinders efforts to show them that their personal 

actions can make a difference in their own 

health. 

Tooth decay is one of the most common 

chronic childhood diseases. It is five times more 

common than asthma. By the first grade, more 

than 50 percent of children in the United States 

have dental caries (decay) in their primary teeth, 

and more than 80 percent of U.S. adolescents 

have dental decay by age seventeen. Despite the 

availability of cost-effective preventive 

measures and improvements in childrenís oral 

health, many children still lack needed care. 

There are significant and important disparities in 

oral health and access to dental care for poor and 

minority children, and for those with unusual 

health care needs. In addition, children from 

low-income families are much less likely to have 

access to dental care than their peers, and their 

disease is almost twice as likely to remain 

untreated. Sadly, the children at greatest risk for 

problems resulting from tooth decay are also 

those least likely to receive dental care. In fact, 

dental care has become the most frequently 

reported unmet need of children. 

PREVENTION OF DENTAL DISEASES 

Fortunately, most dental diseases can be 

prevented. The most common oral health 

problem for children is dental decay, which is 

preventable by a combination of community, 

professional, and individual measures, including 

water fluoridation, professionally applied topical 

fluorides and dental sealants (protective plastic 

coatings), regular use of fluoride toothpastes, 

and healthful dietary practices. Childhood is also 

a time to form healthful habits to reduce injury 

to the mouth or face, especially during sporting 

and recreational activities. Use of protective 

devices in schools may help young athletes 

recognize the hazards posed by their athletic 

interests and as they attain adulthood they may 

be more comfortable using the devices than if 

they had not used them at a younger age. A 

significant proportion of other oral problems, 

such as destructive gum disease and mouth and 

throat cancer, do not commonly arise until 

adulthood, and much of this burden can be 

attributed to the use of tobacco. Most daily 

smokers started smoking before age eighteen. 

School programs to prevent tobacco use could 

become one of the most effective strategies to 

reduce tobacco use. 

Community water fluoridation is the 

most effective way to prevent dental caries in all 

children, regardless of socioeconomic status, 

race, or ethnicity; and it can reduce cavities in 

children by up to 40 percent. Yet, more than 100 




million people do not have fluoridated water. 

Where children do not have fluoridated water 

and dental screenings have identified them to be 

at high risk for dental caries, fluoride can be 

provided through school programs that offer 

supplemental tablets or rinses, and the 

importance of brushing with fluoride toothpaste 

at home every day can be reinforced. 

Unfortunately, fluoride has somewhat 

limited effectiveness on the chewing surfaces of 

teeth. Not surprisingly,. More than 80 percent of 

tooth decay in schoolchildren is on the chewing 

surfaces of molar (back) teeth. The use of dental 

sealants applied to the chewing surfaces can 

prevent 60 percent of decay on these surfaces, 

but only about one in four children have at least 

one sealed tooth. Among poor minority children, 

less than 5 percent have received dental sealants, 

except those who attend schools that have 

programs to assure access to this service. 

SCHOOL ñ BASED HEALTH CARE 

SERVICES. 

The School is a good setting for 

programs to assure that children have an 

opportunity to receive protective dental sealants 

in a timely manner to prevent tooth decay. 

Although such programs can be a component of 

more comprehensive dental programs, it is more 

common for school programs to be more 

narrowly focused on these effective preventive 

services. Dental sealants can be provided at 

school or through active referred to participating 

dentists in the community. Although these 

programs have been found to be effective among 

children of varying socioeconomic status and 

risk of decay, most such programs in the United 

States target those vulnerable populations less 

likely to receive private dental care, such as 

children eligible for free or reduced-cost lunch 

programs. Accordingly, these programs can not 

only increase the prevalence of dental sealants, 

but also reduce disparities in sealant use by race 

or income. 

Health education programs in schools 

can stress the importance of oral health, increase 

understanding of the disease process, promote 

healthful behaviors, and reinforce the value of 

regular professional care for prevention. Such a 

role for professional care may not be consistent 

with the experiences of children who have not 

received dental care or who only associate it 

with treatment of toothaches. Instruction of the 

children and their parents ñ through educational 

materials that are taken home ñ can help 

alleviate the consequences of some parentís own 

experiences and dental fears, which may impede 

their seeking care for their children. 

When preventive measures fail to 

completely stop disease, schools can assure that 

tooth decay is treated early so that it does not 

negatively affect learning and quality of life. 

Some schools have programs of screening and 

referral, which are not only helpful to the 

individual children referred for care, but also 

provide information that enables the public 

health system to target, organize, and evaluate 

programs. In addition, some have health centers 

on the grounds, which have been critical 

providers of health services for young people, 

particularly those who are uninsured. Central to 

the effectiveness of these centers are 

partnerships with community-based providers 

and collaboration with parents and school 

administrators. 

Through the initiatives described here, 

schools can make important contributions to the 

quality of life of low-income, minority, migrant 

and immigrant children, who frequently have 

difficulty accessing information and services for 

both the prevention of disease and dental care. 

When these children do not get the dental care 

they need, their already difficult lives can 

become even more stressful, and they may be 

less likely to overcome obstacles, achieve their 

dreams, and contribute to society. 

DENTAL HEALTH EDUCATION 

CURRICULUM FOR SCHOOL CHILDREN 

The ideal dental-health education 

curriculum would encourage students to think 

about the relationships between knowledge, 

choice, behaviour, and enhanced human health. 

Knowledge and choice equals power, and having 

power and engaging in appropriate behavior can 

lead to enhanced human health. In addition to 




acquiring knowledge, students need to develop 

the skills to incorporate healthful behaviors into 

their lives. Behaviors that promote oral health 

and prevent disease include brushing teeth with 

fluoride toothpaste, reducing the number of 

times sugar-rich foods are eaten, and resisting 

tobacco use. Curricula should be age-appropriate 

for both childrenís cognitive abilities and the 

main health risks they face at each stage of 

development. 

During the preschool years, 

development, of the habit of using fluoride 

toothpaste twice per day and acquisition of a 

positive attitude about visiting the dentist are the 

most important outcomes of education about 

oral health. Parental participation may be 

particularly important for children from 

disadvantaged homes, where parents may not 

otherwise appreciate the importance of these 

behaviors. 

During the primary school years, the 

dental-health education curriculum can support 

the type of learning that frames experiences for 

children in a way that builds on their prior 

knowledge and encourages them to explore and 

seek answers to new concepts by themselves. 

Ideally, such a curriculum, should link lessons 

with the National Science Education Standard. 

Children at this age can learn to brush plaque 

from their teeth, and to protect their teeth with a 

toothpaste containing fluoride. In addition, these 

children should receive dental care within a year 

after the eruption of their first permanent molars 

(age six or seven), so that protective sealants can 

be placed on the chewing surfaces. These 

children are old enough to understand that eating 

several times during the day can create as many 

problems as eating too many sugary or starchy 

foods, especially if they eat those foods as 

between-meal snacks. Curricula should help 

students see that choices they make can affect 

their overall oral health. 

During adolescence, when children 

increasingly make their own decisions regarding 

both self-care and diet, the health education 

curriculum should reinforce oral hygiene, 

prevention of tobacco use, and healthful dietary 

practices. Interest in the social advantages of a 

healthy mouth can make students more receptive 

to information about oral hygiene techniques, as 

they can be shown that appropriate use of the 

toothbrush and dental floss can make their teeth 

more attractive, prevent bleeding gums, and 

reduce halitosis (bad breath). These are the years 

to reinforce healthful lifestyle behaviors that will 

have important consequences for maintain oral 

health with minimal need for expensive dental 

repair ñ behaviors that will provide for a 

lifetime. 

Indian Scenario 

To serve community, school health is an 

economical and powerful means of raising 

community health in the future generation. 

Children have a direct effect, what so ever they 

get taught in their schools. In 1946, Bhore 

Committee reported that school health service 

are practically non-existent in India, and if exist 

then under developing stage. In1953, the 

Secondary Education Committee emphasizes the 

need of School Nutrition Programme. In1960, 

the Government of India constituted a School 

Health Committee, which submitted report in 

1961.Ministry of Health & Family Welfare, 

Govt of India, accepted in principle,National 

Oral Health Policy in the year of 1985 to be 

included in National Health Policy. In pursuance 

to National Oral Health Policy, NOHP, National 

Oral Health Care Programme, NOHCP, has been 

launched as ëPilot Projectí in five states. 

1. Oral health for all by 2010 AD. 

2. To bring down the incidence oral and dental 

diseases to less than 40% from the existence 

prevalence of 90%. 

3. To bring down the DMFT rate in school 

children between 6-12 yrs of the age to less to 2, 

which is approximately 4 at present. 

4. To reduce high prevalence of periodontal 

diseases to lower prevalence. 

5. At the age of 18 yrs 85% should retain all 

teeth. 

6. To achieve 50% reduction in edentulous ness 

between the age of 35-44 yrs. 




7. To achieve 25% reduction in edentulous ness 

at the age of 65 yrs. 

8. To achieve 50% reduction in present level of 

malocclusion and dentofacial deformities. 

9. To reduce the number of cases of Oral cancer 

and precancerous lesions from existing level. 

NOHCP stressed on implementation of three 

prolonged strategies; 

1. Oral health education. 

2. Preventive programme. 

3. Curative services programme. 

CONCLUSION 

The oral health of children is essential to 

their overall well-being. Education in schools 

prepares girls and boys to accept responsibility 

for their own health and to engage in personal 

care that will maintain and improve health. The 

use of precious classroom time to teach personal 

self-care skills, using the classroom to deliver 

fluoride products, and using the school setting to 

screen and refer children for needed dental 

services can be justified by the impact on 

childrenís health and welfare. Dental health 

problems can profoundly affect children, 

impairing their performance as students, 

lowering self-esteem, and slowing personal 

development. In addition, failure to prevent 

dental diseases has a large effect on school 

attendance. It is estimated that more than 50 

million school hours are lost nationally each 

year due to dental-related illness or care, a loss 

that could be sharply reduced with more timely 

receipt of preventive services. 

REFERENCES 

********************* 

Biological Sciences Curriculum Study 

and Video discovery, Inc. 2002. Open Wide and 

Trek Inside. NIH Publication No. 00-4869. 

Bethesda, MD: National Institutes of Health. 

Centers for Disease Control and 

Prevention. 1994. ìGuidelines for School Health 

Programs to Prevent Tobacco Use and 

Addiction.î Morbidity and Mortally Weekly 

Report 43 (RR-2):1-18. 


Prevention. 2001. ìImpact of Targeted, School- 

Based Dental Sealant Programs in Reducing 

Racial and Economic Disparities in Sealant 

Prevalence among School Children ñ Ohio, 

1998-1999.î Morbidity and Mortality Weekly 

Report 45 (34):736-738. 


Prevention. 2001. ìPromoting Oral Health: 

Interventions for Preventing Dental Caries, Oral 

and Pharyngeal Cancers, and Sports-Related 

Craniofacial Injuries; A Report on the 

Recommendations of the Task Force on 

community Preventive Services.î Morbidity and 

Mortality Weekly Report 50 (RR-21): 1 ñ 13. 

http://www.answers.com/topic/dentalhealth-and-children. 

http://hp.gov.in/ddhs/file.axd?file=2011 

%2F2%2FSchool+Dental+Health+Programmw- 

+Kinnaur%2CHP..pdf 




Abstract 

CHEMISTRY AND ONCOLOGY 

\\ 

PHYTOCHEMISTRY IN CANCER TREATMENT 

Mity Thambi, Doctorate Student, Calicut University. 

Phytochemistry have been found to have interesting applications over and above their wellknown 

medical uses. Most important among them is it is used as anticancer agent. Secondary 

metabolites not only play a major role in the adaptation of plants to their environment but also 

acting as anticancer, antibiotics, antifungal, antimicrobial agents. The separation, identification 

and structure determination of biologically active compounds has been facilitated by continual 

development of chromatographic and spectroscopic methods of analysis. 

Introduction 

It is belived that the birth of 

ëëphytochemistryíí was the isolation of tartaric 

acid from grapes in 1769 by the Swedish 

chemist Carl Wilhelm Scheele, although 

Marggraf had isolated sucrose from sugar beets 

22 years earlier. The seeds (ëëarcanumíí) of 

biological activity in medicinal plants to which 

Theophrastus Bombastus von Hohenheim 

(ëëParacelsusíí) referred in the 15th century, we 

now call molecules. It was the therapeutic 

properties of these plants, disclosed by diverse 

cultures over the millennia, which formed the 

basis of health care the world over. In early part 

of the 19th century, one of the challenges was to 

study these active principles.[1] Plants are 

stunning chemical factories, and 

chemotaxonomy has provided some broad, 

albeit substantially incomplete, assessments 

regarding the distribution of various structural 

classes of secondary metabolites, such as 

alkaloids, quassinoids, flavonoids, betalains, etc. 

Secondary metabolites also referred to as natural 

products, are the products of metabolism not 

essential for normal growth, development or 

reproduction of an organism. These compounds 

serve to meet secondary requirements of 

producing organisms. Within a decade, there 

were a number of dramatic advances in 

analytical techniques including TLC and GC, 

IR, 1 H NMR and MS that were powerful tools 

for separation and structure determination. The 

pharmaceutical industry was synthesizing and 

marketing highly potent clinically effective 

drugs, e.g. amphetamines, barbiturates, 

sulphonamides and tranquillisers. The antibiotics 

and reserpine were among the few novel clinical 

drugs derived from natural sources and it was 

confidently anticipated that all drugs, including 

natural ones, would be produced synthetically. 

Alkaloids in cancer treatment 

Alkaloids comprise one of the major 

groups of medicinally used plant constituents 

and Indole and Biogenetically Related Alkaloids 

was selected as the subject of a PSE meeting 

held in 1979 (2). Several of these alkaloids were 

in clinical use, including reserpine (the first 

tranquilliser) and the dimeric indole alkaloids 

vinblastine and vincristine (anticancer agents). 

Other indole alkaloids, not in clinical use, 

possessed potent pharmacological properties, 

e.g. strychnine (a muscle contractor) and the 

toxiferines (muscle relaxants). By 1986, the NCI 

natural products programme had resulted in the 

discovery of a number of highly active 

anticancer compounds including taxol and 

camptothecin discovered by Monroe Wall and 

colleagues. During the past 50 years, plants have 

provided several more clinically used drugs. The 

Catharanthus alkaloids vinblastine and 

vincristine, currently used for the treatment of 

leukaemias, lymphomas and some solid tumors, 

were introduced through the Eli Lilly Company 

in the 1960s. The NCI collaborative research 

programme into natural products with anticancer 




activity was initiated by Jonathan Hartwell in 

1957. Between 1960 and 1986 more than 35,000 

species and 108,330 extracts were screened 

against murine tumours and from 11 compounds 

approved for extensive tumour panel testing, 2 

came into clinical use. An extract of the bark of 

the Pacific yew, Taxus baccata, was shown to be 

highly active in the KB anti-tumour test in 1964 

by Monroe Wall and colleagues (Kingston, 

2000). It was not until 1971 that the chemical 

structure of the active compound taxol 

(paclitaxel) was determined. Interest in taxol 

was renewed in 1979 when it was shown that it 

promoted the assembly of tubulin into stable 

microtuband, eventually, in late 1980, it was 

introduced into clinical practice. Currently, taxol 

is used for the treatment of ovarian cancer and in 

the secondary treatment of breast cancer. New 

synthetic and semisynthetic analogues of natural 

products have continued to be developed during 

the past 50 years. Although Podophyllum 

species have reputations for treating cancers, 

podophyllotoxin 1, and related lignans, were 

shown in the 1950s to be too toxic for clinical 

use. Some 40 years later, attempts were made to 

modify their toxicity and poor water solubility 

resulting in the introduction of new clinical 

agents. Etoposide 2 is used for the treatment of 

small cell lung cancer, lymphomas and testicular 

cancer, whereas teniposide 3 is used to treat 

brain tumours. Both of these semisynthetic drugs 

are epimeric at position 1 to podophyllotoxin 

and differ markedly in their mode of action. 

Podophyllotoxin binds to tubulin and the 

modified drugs are topoisomerase II inhibitors, 

preventing DNA synthesis. Semisynthetic 

analogues of vinblastine 4 and vincristine 5 in 

clinical use include vindesine 6 (treatment of 

leukaemia and lung cancer) and vinorelbine 7 

(breast cancer) (Kinghorn and Balandrin, 1993). 

Taxol 8 is obtained as a minor component from 

the bark of mature trees of Taxus brevifolia and 

if sourced as such for anticancer chemotherapy, 

would result in massive loss of the species. 

Partial synthesis is used for commercial 

production utilising 10-deacetylbaccatin III 9 

which occurs in high yields in the needles (a 

renewable source) of Taxus species. A 

semisynthetic analogue, taxotere 10, is used in 

adjuvant treatment of breast cancer and nonsmall 

cell lung cancer (Kingston, 2000). 

Camptothecin 11 co-occurs with other alkaloids 

including 10-hydroxycamptothecin 12 which 

proved to be more active in anticancer test 

systems. 

Further modifications to the molecule were 

made to improve water solubility and lower 

toxicity resulting in two new clinical drugs, 

topotecan 13 and irinotecan 14. Topotecan (9dimethylaminomethyl-10-hydroxy-20(S)camptothecin) 

is used in the treatment of 

metastatic ovarian cancer and irinotecan (7ethyl-10-[4-(1-piperidino)-1-piperidino] 

carbonyloxycamptothecin) is used to treat 

colorectal cancer (Kinghorn and Balandrin, 

1993). [2] 







Conclusion 

The past 50 years has seen the 

introduction of novel natural product drugs into 

clinical use, e.g. vinblastine, vincristine, taxol, 

artemisinin, galantamine, and also semisynthetic 

analogues of natural products, e.g. vindesine, 

vinorelbine, taxotere, etoposide, teniposide, 

irinotecan, The introduction of vinblastine and 

vincristine into cancer chemotherapy coupled 

with the NCI natural product anticancer 

***************** 

screening programme, awakened the possibility 

that plants could be useful in drug discovery . 

References 

[1] Geoffery A.Cordell 

(2011)Phytochemistry letters. 

[2] J.David Phillipson (2007)Phytochemistry 

.68,2960-2972. 




Abstract 

MANAGEMENT OF GAG IN DENTAL PRACTICE - A REVIEW 

Dr. Sandeep garg, MDS, professor, Dr. Sushant garg, MDS, Professor & head, Dr. Kusum yadav, Post graduate 

student - M.M. College of Dental Sciences & Research, Mullana, Ambala (Haryana), India 

The gag reflex is a normal defense mechanism to prevent foreign objects from entering the trachea. In 

some individuals this reflex is active to the point that can be overridden by the desire to eject any object in 

the mouth. Gagging has been generally classified either somatogenic (induced by touching a trigger area) 

or psychogenic (stimulation appears to be psychic in origin). A number of techniques for reduction of 

gagging have been suggested, including distraction of patient's attention from the dental procedure, 

relaxation, hypnosis, acupressure and drugs .This article reviews the management of patients with an 

exaggerated gag reflex and includes strategies to assist clinicians. 

Key Words : Gag Reflex, Retching, Acupressure. 

Introduction 

Most difficult and common problem, which is 

descried and analyzed by many dentists, is 

gagging or retching, which has been found 

extremely difficult to treat. The gag reflex is a 

normal defense mechanism that prevents foreign 

bodies from entering the trachea, pharynx, or 

larynx. The patient who gags may present with a 

range of disruptive reactions; from simple 

contraction of palatal or circumoral musculature 

to spasm of the pharyngeal structures, 

accompanied by vomiting. 1 Gagging may be 

accompanied by excessive salivation, 

lacrimation, sweating, fainting, or, in a minority 

of patients, a panic attack. 2 Pronounced gag 

reflexes can be a severe limitation to the 

patientís ability to accept dental care and it can 

compromise all aspects of dentistry, from the 

diagnostic procedures of examination to any 

form of active treatment. Gagging has been 

generally classified either somatogenic (induced 

by touching a trigger area) or psychogenic 

(stimulation appears to be psychic in origin). 

Five intraoral areas are known to be ëëtrigger 

zonesíí: palatoglossal and palatopharyngeal 

folds, base of tongue, palate, uvula, and 

posterior pharyngeal wall. 3 Interestingly, the 

passage of food across these areas does not 

usually incite retching. factors that are believed 

to be responsible for gagging are usually divided 

into anatomic factors ( eg. A long soft palate, a 

sudden drop at the junction of hard and soft 

ORAL MEDICINE AND SURGERY 

palate), psychological factors ( eg. Fear, stress), 

physiologic factors ( non tactile sensations such 

as visual, auditory, or olfactory stimuli 4,5 ) , 

iatrogenic factors ( eg. inadequate posterior 

palatal seal, unstable and poorly retained 

prosthesis, overloaded impression trays) and 

local and systemic disorders ( eg. nasal 

obstruction, postnasal drip, chronic GI diseases). 

Management 

Effective management of gagging depends on 

treating the cause and not merely the symptoms. 

Through examination, adequate medical history, 

and conversation with patient are important for 

correct diagnosis of the cause of the gagging. 

The different approaches for management of 

gagging fall into following categories : 

Psychological management. 

Prosthodontic management. 

Pharmacological measures. 

Alternative measures. 

Psychologic management: 

These techniques are mainly based on diverting 

the attention of the patient from gagging 

stimuli e.g. Talking to the patient on some topic 

of interest, have the patient count from 1 to 20 , 

by asking the patient to raise his leg and to hold 




it in air. Faigenblum 6 suggested that patient can 

be instructed to prolong the expiratory effort at 

the expense of inspiration . This will produce a 

state of mild apnea, and gagging will be 

discouraged, as vomiting is impossible during 

apnea. He also suggested that well rested , 

relaxed and empty stomach patient is less likely 

to gag. 

Prosthodontic management: 

Impression technique-Daniel W. Borkin 7 

described an impression technique in which he 

used a material that will give the dentist full 

control of the setting time and which can be 

easily corrected. A preliminary impression of the 

edentulous area is made using an appropriate 

stock tray and red modeling compound, this 

impression can be removed from the mouth at 

will, warmed, and reseated between paroxysms 

of gagging until a fairly accurate impression is 

obtained. A cast of stone or plaster is poured and 

a tray is made of acrylic resin or shellac base 

plate, but it must be made with rolled borders 

which are slightly short of the reflections. The 

tray is tried in the mouth and a low-fusing wax 

is added to this accurately fitted tray. Particular 

attention is paid to adding wax to the borders of 

the tray. When the tray is completely covered 

with warm wax, it is carried quickly to the 

mouth and inserted, using as much force as is 

necessary to properly seat the tray. Muscle 

trimming is done to the patient tolerance. This 

procedure is repeated as many times as is 

necessary to make an acceptable impression. 

Since low-fusing wax will not set hard at mouth 

temperature. When the impression is acceptable, 

the low-fusing wax must be hardened in the 

mouth by squirting ice water from a bulb syringe 

along the borders of the completed impression 

and over as much of the impression surface as 

possible. The ice water will retard the 

paroxysms of gagging by its cooling effect so 

this chilling can be done with a minimum of 

difficulty. Once set, remove it and pour. Faiez N. 

Hattab 8 suggested management of gag while 

making an irreversible hydrocolloid impression. 

He dispensed 1 capsule of local anesthetic 

solution (1.8 mL of 2% lidocaine with 1 part in 

100,000 epinephrine) to the plastic measuring 

cylinder and then added water to the correct 

volume. Then he mixed the water/anesthetic 

mixture to the alginate powder and impression 

were made. Results proved to be satisfactory. 

Callision 9 proposed a maxillary custom tray in 

which a saliva ejector tip is embedded in order 

to suck excess impression material into vacuum 

chamber at the posterior extent of the tray. 

Ansari 10 recommended the use of a highviscosity 

elastomer for making a primary 

impression of a maxillary partial edentulous 

patient, in an attempt to minimize the distal flow 

of the material to sensitive areas. 

Marble technique- Singers 11 marble technique is 

a method by which the gag reflex can be 

exhausted. At the first office visit five rounded, 

glass marbles approximately inch in diameter 

were placed on a tray in front of the patient and 

was asked to put the marbles in his mouth, one 

at a time, until all marbles were in his mouth. 

The patient was assured that if he swallows the 

marble, it could not harm him. He was urged to 

keep five marbles in his mouth continuously for 

one week, except when eating and sleeping. On 

2 nd visit, the patient was given assurance, which 

further bolstered his own motivation. On 3 rd 

visit, before impression making; the hard palate, 

soft palate, cheeks, lips and tongue were 

swabbed with 2% pentocaine solution in order to 

produce topical anesthesia. Preliminary 

impression is made and Base plate of matte 

finish is prepared. On 4 th visit the lower base 

plate is inserted, and the patient was told to 

continue to keep three marbles in his mouth, in 

addition to base plate. A training bead (a small 

bead of colored acrylic resin) was placed on the 

lingual aspect of the lower base plate at the 

normal position of the lower central incisors. On 

5 th visit the upper base plate was inserted, he 

was asked to keep both of them in his mouth 

continuously, except when eating. The use of 

marbles was discontinued. On 6 th visit jaw 

relations were established and patient was 

instructed to continue with the upper and lower 

base plate. On 7 th visit the completed lower 

denture was inserted first and used in 

conjunction with the upper base plate. The 

training bead was placed in the lower denture as 

a guide to tongue position. The patient should be 

instructed to keep the tip of the tongue always 

touching the bead, which would prevent the 




lower denture from lifting. Next the upper 

denture was inserted. ìMARBLE TECHNIQUE 

IS USEFUL IN ASSURING SO CALLED 

HOPELESS GAGGERS.î 

Roofless dentures 12 - Patient with this type of 

denture reported that reduction of the palatal 

coverage influences their sense of taste 

positively and reduces the gagging tendency. A 

cast metal denture base is recommended. The 

primary advantage is the achievement of 

intimate contact between the denture base and 

the underlying tissue, thus increases the 

retention of the prosthesis 13,14 . Also the metal 

base provides rigidity to resist breakage 

warpage, a beaded metal finish line on the 

palatal surface, and a stable substructure for 

recording jaw relation. However it would only 

be satisfactory, if maxillary ridge is well formed. 

Training bases 15 ñ In this technique a patient is 

progressively supplied with a series of small to 

full ñsize denture bases. A thin acrylic denture 

base, without teeth is fabricated and the patient 

is asked to wear it at home, gradually increasing 

the length of time the training base is worn. A 

suitable regime may be 5 minutes once each day, 

then twice each day. After 1 week the patient is 

asked to increase this to 10 minutes 3 times each 

day, then 15 minutes, 30 minutes, and 1 hour. 

Eventually the patient is able to tolerate the 

training base for most of the day. The timing and 

rate of progress will vary between patients 

depending upon individual needs and 

expectations. 

Matte finish denture- Jordan 16 in 1954 

suggested that a smooth highly polished surface 

which is coated with saliva may produce a slimy 

sensation which is sufficient to cause gagging in 

some patients; a matte finish has been advocated 

as more acceptable in this situation. 

Modification while making radiographs- 

Posterior radiographs can be difficult and 

uncomfortable for patient with extreme gag 

reflex. Friedman and Weintraub 17 described a 

simple method where the patient is instructed to 

extend his or her tongue, and the tip of the 

tongue is briefly salted (for approx. 5 sec) with 

ordinary table salt. The impression or radiograph 

can usually be taken with no difficulty. The gag 

reflex is extinguished by a superimposed 

simultaneous stimulation of the chorda tympani 

branches to the taste buds in the anterior twothirds 

of the tongue. The gag reflex elicited 

while taking intraoral radiographs can also be 

minimized by the use of fast-speed film, 

presetting the timer, moistening the film pack, 

and asking the patient to rinse the mouth with 

cold water. When all such efforts fail, it is 

recommended to take extraoral radiographs. 

Pharmacologic Measures 15 : 

When clinical procedures fail, pharmacological 

assistance is taken to control the gagging. Drugs 

controlling gagging can be divided into- 

Peripherally acting drugs: These are topical and 

local anaesthetics, applied in as sprays gels, or 

lozenges or by injection. These are of use only 

in patients with minor gagging only. Topical 

application over palate, dorsum of tongue is 

reported to be useful. More severely affected 

patients are given injection of L.A into region 

posterior to hard palate. 

Centrally acting drugs 18 : These are only a short 

term solution for severe gagging problem and 

should not be used routinely. These can be 

categorized as tranquilizers, antihistamines, 

parasympatholytics and general anesthesia in a 

few patients who do not respond to any form of 

sedation or behavioral therapy as a last resort. 

Conscious sedation- Removal of anxiety may 

prevent gagging. Nitrous Oxide alters the 

perception of external stimuli and it is suggested 

that this altered perception depresses the gag 

reflex. The patient tolerance to the placement of 

intraoral object is increased and the anxiolytic 

properties of Nitrous Oxide can reduce or 

abolish negative cognition associated with 

gagging. Intravenous sedation is often much 

more predictable than oral sedation, and can be 

of use in patient were inhalation sedation is 

ineffective. 

Alternative Measures: 

Acupuncture 19 - Acupuncture is a system of 

medicine in which a fine needle is inserted 

through the skin to a depth of a few millimetres, 




left in place for a time, sometimes manipulated 

and then withdrawn. The effectiveness of 

acupuncture in preventing gagging was assessed 

and results were quite positive. Ear acupuncture 

was selected since there is a specific, recognized 

anti-gagging point on the ear. The technique 

involves the insertion of one, fine, single-use 

disposable needle of 7mm length into the antigagging 

point of each ear to a depth of 3 mm. 

The needles are manipulated for 30 seconds 

prior to carrying out dental treatment. The 

needles remain in Situ throughout treatment and 

are removed before the patient is discharged. 

The patient does not require an escort and is not 

inconvenienced in anyway following treatment. 

Acupressure 20 - follows the same principle as 

acupuncture, but the former stimulate the points 

with gentle finger pressure rather than fine 

needles and therefore is a less invasive 

technique. Chengjiang (REN-24) is an effective 

acupressure point for controlling the gag reflex 

during impression making. To make use of it 

locate the REN-24 point. It is situated in the 

horizontal mentolabial groove, approximately 

midway between the chin and the lower lip. 

Apply light finger pressure with the index 

finger. Progressively increase the finger pressure 

until the patient feels discomfort and distension. 

The acupressure should start at least 5 min. 

before impression making, continue through the 

impression procedure, and be terminated only 

after the impression has been removed from the 

patients mouth. Pressure can be applied by the 

patient, dental assistant, or dentist. 

Hypnosis 21 - Hypnosis has been used as a tool to 

deal with psychologic etiology of gagging . 

Results are also quite successful , but the time 

involved with the multiple sessions is an 

limiting factor for its routine use in dental 

practice. 

Discussion 

Overt gagging can be distressing for both the 

patient and clinician. The most serious problem 

associated with an overactive gag reflex is the 

strong potential for compromised treatment and 

it presents as a challenge to the capability of a 

dentist. Most patients who gag can be 

successfully treated if the cause can be 

determined. A complete oral examination, 

medical history, and conversation with the 

patient are important sources of information that 

assist with the management of gagging 

problems. Many techniques are available for 

controlling the exaggerated gag reflex and no 

single technique will solve each patientsí 

problem. 2 The conscious mind of the patient 

must be regarded by the dentist as the primary 

factors for the inhibition of gagging. Building a 

relation based on confidence is more valuable 

than applying most medicaments. 22 

Conclusion 

There appears to be no universal remedy for the 

successful management of the gagging patient. 

A variety of management strategies have been 

suggested and these should be tailored to suit the 

needs of individual patients. It appears that the 

attitude of the clinician toward the patient and 

his or her problem is an important part of the 

treatment. 

References 

1. Logemann JA. Swallowing physiology and 

pathophysiology. Otolaryngol Clin North 

Am 1988;21:613-23. 

2. Conny DJ, Tedesco LA. The gagging 

problem in prosthodontic treatment Part I: 

Description and causes. J Prosthet Dent 

1983;49:601-6. 

3. Meeker HG, Magalee R. The conservative 

management of the gag reflex in full denture 

patients. N Y State Dent J 1986;52:11-4. 

4. Murphy WM. A clinical survey of gagging 

patients. J Prosthet Dent 1979;42:145-8. 

5. Wilks CG, Marks IM. Reducing 

hypersensitive gagging. Br Dent J 

1983;155:263-5. 

6. Faigenblum MJ. Retching, its causes and 

management in prosthetic practise. Br Dent 

J 1968;125:485-90. 

7. Borkin DW. Impression technique for 

patients that gag. J Prosthet Dent 

1959;9:386-7. 

8. Hattab FN, Al-Omari MA, Al-Dwairi ZN. 

Management of a patientís gag reflex in 

making an irreversible hydrocolloid 

impression. J Prosthet Dent 1999;81:369. 

9. Callison GM. A modified edentulous 

maxillary custom tray to help prevent 

gagging. J Prosthet Dent 1989;62:48-50. 




10. Ansari IH. Management for maxillary 

removable partial denture patients who gag. 

J Prosthet Dent 1994;72:448. 

11. Singer IL. The marble technique. J Prosthet 

Dent 1973;29:146-50. 

12. Farmer JB, Connelly ME. Palateless 

dentures- Help for the gagging patient. J 

Prosthet Dent 1984;52:691-4. 

13. Akeel R, Assery M, Al-Dalgan S. The 

effectiveness of palate-less versus complete 

palatal coverage dentures (a pilot study). Eur 

J Prosthodont Restor Dent 2000;8:63-6. 

14. Fl¯ystrand F, Karlsen K, Saxegaard E, 

Orstavik JS. Effects on retention of reducing 

the palatal coverage of complete maxillary 

dentures. Acta Odontol Scand 1986;44:77- 

83. 

15. Bassi GS, Humphris GM, Longman LP. The 

etiology and management of gagging: a 

review of the literature. J Prosthet Dent 

2004;91:459-67. 

16. Jordan LG. Are prominent rugae and glossy 

tongue surfaces on artificial dentures to be 

desired? J Prosthet Dent 1954;4:52-3. 

****************** 

17. Friedman MH, Weintraub MI. Temporary 

elimination of gag reflex for dental 

procedures. J Prosthet Dent 1995;73:319. 

18. Kalra A, Kinra M, Agarwal S. Gaggers and 

their Management. Int J Med Dent Sciences 

2009;1:54-65. 

19. Fiske J, Dickinson C.. The role of 

acupuncture in controlling the gagging 

reflex using a review of ten cases. Br Dent J 

2001;190:611-3. 

20. Vachiramon A, Wang WC. Acupressure 

technique to control gag reflex during 

maxillary impression procedures. J Prosthet 

Dent 2002;88:236. 

21. Dickinson CM, Fiske J. A review of gagging 

problems in dentistry: 2.Clinical assessment 

and management. Dent Update 2005;32:74- 

6, 78-80. 

22. Kabra SK, Shastry YM, Singh S. Gagging- 

Causes and management in prosthodontic 

treatment: A review of literature. J Ind 

Prosthodont Soc 2004;4:28-31. 




Introduction 

HALITOSIS AND DRY MOUTH SYNDROME 

PRETTY PRINCE. P, BDS student Mar Baselious dental college, Kothamangalam. 

Apart from pain, halitosis and a dry mouth are probably the two most common conditions our patients 

seek advice for on a daily basis. Halitosis or malodor is a frequently occurring oral condition that is 

due to many things but the most common is the presence of reasonably advanced periodontal disease 

or some carious teeth causing traps leading to retention of food in the spaces. Halitosis is not a serious 

medical condition; however, it can make a person feel awkward in social situations, cause emotional 

distress, and lower a personís self-esteem. Because of halitosis ,many people spend enormous 

amounts of money each year on chewing gum, sprays, and mouthwash. Halitosis affects a majority of 

people in society and the causes vary as much as the individuals who suffer from this condition. 

Virtually the entire adult population suffers from chronic adult periodontitis so the number of patients 

with bad breath can be quite alarming. 

Halitosis Causes 

� Oral sepsis 

� Dry mouth 

� Starvation 

� Some foods 

� Habits: smoking, alcohol and some drugs 

� Systemic diseases 

� Diabetic ketoacidosis 

� Gastrointestinal diseases 

� Hepatic failure 

� Renal failure 

� Respiratory diseases 

� Trimethylaminuria 

� Psychogenic factors 

Halitosis is most commonly caused by 

consuming certain types of foods. Most often, 

the foods that come to mind when a person 

mentions halitosis include onions, garlic, fish, or 

any foods that are high in fats. As our bodies 

begin the digestion process, chemicals from 

these foods are absorbed into the bloodstream 

where they travel into the lungs and are released 

into the atmosphere as we breathe. As you 

breathe out, others breathe in and may smell the 

unmistakable odor of halitosis. This being said, 

not all cases of halitosis are caused by food. If a 

PERIODONTICS 

person is on a low calorie diet, decided to skip a 

meal, or fasts for an extended period of time, 

halitosis can occur as well. As we sleep, the 

amount of saliva that is produced in our mouths 

is decreased, resulting in decay and excess food 

particles remaining in the oral cavity. This can 

lead to halitosis, or morning breath, when we 

awake. 

Other Causes of Halitosis 

Other causes of halitosis include smoking, 

alcohol consumption, or not brushing or flossing 

teeth properly or on a regular basis. Certain 

medical conditions can also lead to the 

formation of halitosis. Chronic lung or sinus 

infections can cause a build-up of bacteria or 

viruses that contribute to halitosis as can oral 

infections such as thrush or Candida. Other 

medical conditions such as diabetes, liver 

disease, or kidney disorders can also cause 

halitosis to flare up. Gum diseases and other oral 

problems can cause bacteria to accumulate in 

hard to reach crevasses and corners of the teeth 

and gums will lead to halitosis if proper oral 

hygiene is not followed. 

Halitosis Medication 

In some cases, certain medications that are 

prescribed by a physician can also lead to 




halitosis. There are many medications that are 

prescribed for health conditions that cause dry 

mouth. The same thing occurs while we are 

sleeping; the salivary glands do not produce 

ample saliva and therefore, bacteria will grow in 

the mouth, causing halitosis. Such medications 

include antidepressants, antihistamines, 

decongestants, and high blood pressure 

medications. When you purchase a prescription, 

most pharmacies will provide patients with an 

information sheet that lists possible side effects. 

If dry mouth is one of the side effects listed, then 

you could counteract the possible development 

of halitosis by consuming more water when you 

are taking the medication. 

Many people are not even aware that they suffer 

from halitosis. The simple reason for this is 

because our bodies become used to our own 

odor. In other words, we become desensitized to 

any negative smells that our own bodies may 

emit. Most people with halitosis or strong body 

odor will walk around unaware that they are 

offending those around them. Halitosis is usually 

a temporary condition but it can also be 

classified as chronic or persistent halitosis. If 

this is the case, then consulting a physician can 

provide you with many treatment options. 

Halitosis Diagnosis 

It is relatively simple and painless to diagnose 

halitosis. The first clue is visual; you may notice 

subtle clues such as others keeping their distance 

from you or they may come straight out and 

inform you that you have halitosis. You can also 

self-diagnose halitosis. The most common 

method of self-diagnosis is by licking your wrist 

and then smelling the area after a few seconds. 

Allow the saliva to dry before smelling your 

wrist. You could also cup your hand or hands 

over your mouth and breathe. Asking your 

friends or family if you have halitosis can also 

suffice, providing that they are honest enough to 

tell you the truth without fear of offending you. 

When you visit your dentist, you can also 

inquire as to whether or not they believe you 

suffer from halitosis. Your dentist will probably 

provide you with the most accurate and unbiased 

diagnosis. 

If you do come to the realization that you have 

halitosis, there is no need to despair. There are 

many treatment options available that are simple 

and cost efficient. One of the most common 

methods of treating halitosis is through regular 

use of a mouthwash. A mouthwash is certainly 

effective in giving a personís mouth a clean, 

minty smell, but the downside is that this effect 

only lasts for a short time. In fact, many 

mouthwashes contain alcohols and sugars that 

can actually contribute to oral issues such as 

tooth decay. This can even initiate halitosis once 

the minty taste fades out. The same is true with 

certain gums or breath mints. They serve only to 

mask halitosis temporarily. Once the flavor is 

gone, chances are that the halitosis will return. 

Because some cases of halitosis are caused by 

medical conditions, the best way to help 

eliminate it would be to treat the disease or 

illness first. Once this medical condition is under 

control, then the halitosis can be addressed. If 

the halitosis doesnít disappear once the medical 

condition has been treated, then the focus can be 

directed to applying different methods to combat 

the bad breath. Even if you follow all of the 

above precautions and you find that you still 

have halitosis, the cause may be one that is out 

of your control. If you regularly take drugs or 

medications that are prescribed by your doctor, 

ask them to explain the side effects. You may be 

experiencing dry mouth as a result, which causes 

halitosis in some cases. Ask your doctor if there 

are any alternate medications that you can use to 

treat your medical condition that will not cause 

dry mouth. There may also be natural or herbal 

remedies that you can take to alleviate your 

symptoms. This way, you can eliminate the 

contributing factors to halitosis and treat your 

medical conditions in a safe way. 

Halitosis Treatment 

Perhaps the most effective way to fight halitosis 

is by performing regular and proper oral 

hygiene. Dentists recommend that you visit at 

least once every 6 months for a checkup. During 

this examination, the dentist will do x-rays, 

check the condition of your teeth and gums, and 

perform a total cleaning. If any major problems 




are present at this time, they will be addressed 

and corrected. These actions alone can be a 

major help to stopping halitosis. By being 

diligent and fastidious when performing oral 

hygiene rituals, you will find that instances of 

halitosis will gradual become reduced. 

Your dentist will also provide you with several 

tips to keep halitosis at bay. It is important to 

brush your teeth at least 3 times a day and floss 

at least once a day, preferably at bedtime. This 

will remove any stray food particles that may be 

stuck between teeth or in the gum area. If these 

food particles remain as you sleep, they can 

harbor bacteria, which can lead to halitosis. 

When you brush your teeth you should pay 

attention to the tongue as well. Brush it gently 

with your toothbrush to remove any bacteria or 

food particles that may be residing there. If you 

neglect the tongue, halitosis can occur. 

While it is true that eating certain foods is the 

major contributor to halitosis, donít allow this to 

make you shy away from eating regularly. 

Fasting or skipping a meal will also cause 

halitosis. When you do eat, fibrous or hard to 

chew foods will help stimulate your salivary 

glands into producing more saliva. The same 

concept applies to foods that contain a lot of 

citric acid. Oranges or lemons also encourage 

the production of saliva, which will help wash 

away bacteria and small food particles that lead 

to halitosis. If you drink a lot of alcohol or 

coffee, try replacing these beverages with water 

instead. Like saliva, water keeps your mouth 

evenly and regularly moist and can help to keep 

your mouth free of bacteria causing food 

particles. This will help reduce the chance of 

developing halitosis. 

Causes of dry mouth 

Iatrogenic 

� Drugs 

� Irradiation 

� Graft versus host diseases 

� Diseases 

� Dehydration 

� Psychogenic 

� Salivary gland diseases 

� Sjogrenís syndrome 

� sarcoidosis 

Sometimes, people get a condition called dry 

mouth, caused by the lack of saliva. It is an 

annoying condition that can affect not only 

swallowing of your food but also the overall 

health of your mouth. If you have this condition, 

do not let it go unnoticed. 

Dry mouth can lead to other symptoms such as 

bad breath, mouth infections, grinding of teeth 

or bruxism, and constant chewing. It can also 

cause unwarranted teeth decay. 

There are a number of factors that causes dry 

mouth. Some medications, alcohol intake, 

abnormalities in the salivary glands (the glands 

that produce saliva), dehydration, and even 

anxiety can all lead to cotton mouth. 

Management of dry mouth 

o One way of treating cotton mouth is by 

going to your dentist. He or she can 

recommend sugar free candies or gum 

that can help you produce more saliva. 

Moisture in the mouth could also be 

restored by artificial saliva or medicated 

oral rinses. A proven effective product is 

GC dry mouth gel 

o If you are suffering from asthma, oral 

inhalers can also be a reason for dry 

mouth. Most doctors prescribe rinsing 

the mouth after using this type of 

medication. 

o Keeping your mouth hydrated will also 

aid in keeping dry mouth away. Drink 

plenty of water, moisten your food, take 

small bites, and chew very well. When 

you are going on trips, or even just short 

errands, keep a water bottle with you to 

enable you to sip water all day. 

o Lastly, keep your mouth clean at all 

times. Use a toothbrush with soft bristles 

and gargle before and after meals. Stay 

away from mouthwash products that 




contain alcohol as it is likely to worsen 

cotton mouth. 

o Eat soft creamy fooods or cool foods 

with high liquid content .moisten fooods 

with gravies ,sauses ,extra oil or yogurt 

.pineapple has an enzyme that helps 

clean the mouth. 

o Protect the lips from lip balm or 

petroleum jelly 

Reference 

www.bad breath.net 

www.oralhealth.com 

*********************** 

Oral and Maxillofaceial (volume 2) 

Crispian sully(page no:70 to 90) 




COMPARISON BETWEEN CONVENTIONAL RADIOGRAPHY AND 

RADIOVISIOGRAPHY WITH RAYPEX5 APEX LOCATOR FOR 

IMAGING ROOT CANAL LENGTH. 

Dr. Gurudutt Nayak MDS (Reader), Dr. Shashit ShettyMDS (Professor and Head) - Department of Conservative 

Dentistry and Endodontics, K.D. Dental College and Hospital, Mathura, Uttar Pradesh-281006. 

Dr. Surya Dahiya MDS (Assistant Professor) - Department of Conservative Dentistry and Endodontics, Himachal 

Dental College, Sundar Nagar, Himachal Pradesh-175002 

Corresponding author: Dr. Gurudutt Nayak MDS (Associate Professor), Department of Conservative Dentistry and 

Endodontics, K.D. Dental College and Hospital, Mathura, Uttar Pradesh-281006. 

Abstract 

Introduction 

The determination of the working length 

(WL) and its maintenance during cleaning and 

shaping procedures is a key factor for successful 

endodontic treatment. This determines, how far 

into the canal the instruments are advanced and 

worked while limiting the depth to which the 

canal filling may be placed 1 . The literature 

suggests two valid positions for terminating the 

apical extent of endodontic instrumentation and 

obturation at the cementodentinal junction (CDJ) 

1, 2 or at the apical foramen 4 . However, in most 

cases (50ñ98% of all roots) it is well known that 

the anatomical apex may or may not coincide 

with the apical foramen. A mean distance of 0.5ñ 

ENDODONTICS AND ORAL RADIOLOGY 

The purpose of this in vitro study was to evaluate the utility of Raypex5 electronic apex locator 

(EAL) in determining the root canal length (RCL) in comparison to conventional radiography and 

radiovisiography (RVG). 

Forty single rooted anterior teeth were selected for the study. Diagnostic images were obtained 

with conventional radiograph and RVG and RCL was calculated for both the images. Following access 

opening, actual root canal length (ARCL) was determined. Electronic RCL was determined by using 

Raypex5 EAL. Position of file on conventional radiography and RVG with respect to the RCL obtained 

through Raypex5 EAL was done. 

The results indicated that the Raypex5 was 90% accuracy in locating the apical foramen in 

comparison to conventional radiography and RVG which were 72.5% and 85% respectively. 

It was concluded from this study that electronic method proved to be more accurate 

than conventional radiography and RVG in determining RCL. 

Key words: Electronic apex locator, radiovisiography, Raypex5, root canal length. 

1.0 mm exists between the anatomical apex and 

the apical foramen 5 . 

Traditionally, conventional radiography 

has been a popular tool employed in WL 

determination. However, computed 

radiovisiography (RVG) has been developed that 

generates images by means of an X-ray sensor 

instead of conventional film. But both 

techniques are only able to provide reliable 

information on the location of the radiographic 

apex 2 . The use of electronic apex locators 

(EALs) in WL determination is in its 

revolutionary phase. Everyday claims of so 

called newer generations of apex locators are 

being published in the literature. But here the 




question is how reliable and accurate these 

methods are in calibrating the exact WL. 

In view of the possible variation 

between the radiographic apex, anatomical apex 

and apical foramen, this in vitro study was done 

to evaluate the accuracy of Raypex5 (VDW, 

Munich, Germany) electronic apex locator 

(EAL) in determining the RCL in comparison 

to conventional radiography and RVG. 

Materials and Methods 

Forty single rooted anterior teeth 

exhibiting normal and mature root condition 

were used in this study. For RCL measurement 

by conventional radiography the specimens were 

directly positioned on a geometrically 

standardized support equipped with a horizontal 

goniometer (Fig. 1). As a result, it was not 

necessary to rotate the X-ray tube since the tooth 

could be turned to directly select the horizontal 

position of the X-ray beam with respect to the 

specimen. X-ray cone position was standardized 

with the use of XCP Rinn fixed to the X-ray tube 

so that the X-ray film was perpendicular to the 

beam at all times (Fig. 1). In order to ensure 

centered and reproducible positioning of the 

teeth, a coronal reference point was marked by 

making ditch cut on labial surface (2x5x2 mm) 

and filled it with amalgam. All the specimens 

were kept at a constant distance of 10 mm from 

the X-ray film and 50mm from the X-ray cone 

(Fig. 1). Tooth localization was always 

referenced to calibrated graph paper, to allow Xray 

cone positioning parallel to the paper lines. 

After all these standardization, preoperative Xray 

images with size zero intraoral periapical 

film (Kodak, Rochester, NY, USA) were 

obtained and developed with an automatic 

Periomat device (D¸rr Dental GmbH & Co. KG, 

Bietigheim-Bissingen, Germany). 

Preoperative digitized X-ray images 

were also taken in the same approach but by 

replacing a size zero IOPA film with a same size 

sensor (eva with proimage Æ , DENT.X, Elmsford, 

NY, USA). On the sensor, 10mm premeasured 

metal wire was fixed with the help of cello tape 

for giving precaliberation measurements of 

digitized images. Digital vernier caliper (Sankin, 

Mitutoyo Co., Kanagawa, Japan) with accuracy 

to the nearest 0.01mm was in turn used to obtain 

measurements of each specimen from all the 

preoperative X-ray images by viewing them on 

viewerís box. RVG provided calibrated 

measurements between different points in a 

given image and the maximum radiovisiographic 

length of each sample was recorded by 

calibrating the device for each projection. 

Maximum preoperative root length of both 

conventional and digitized images was recorded 

by measuring the distance between the incisal 

edge and the radiographic apex. 

Standard access preparation was carried 

out and the root canals were located. 

Measurement of actual root canal length 

(ARCL) was calculated by inserting a size 15 Kfile 

into the canal until the tip of the file was just 

visible at the level of apical foramen under 

2.5x-420 magnifying loupes (Galilean loupes Æ , 

Lifecare Medical Equipments Co., Ltd., 

Zhejiang, China). A rubber stopper was then 

carefully adjusted to the reference level, file was 

removed and the distance between the rubber 

stopper and the file tip was measured and 

recorded with a digital vernier caliper to the 

nearest 0.01mm. 

Electronic measurement of RCL was 

calculated for each specimen using Raypex5 

apex locator by four blinded observers. In order 

to reproduce clinical conditions involved in the 

electronic measurement of root canal length, 

each specimen was mounted in alginate 6 . The 

relative stiffness of the alginate mould prevented 

fluid movement inside the canal that is 

responsible for premature electronic reading 

registered with previous models 7,8 . All 

measurements were made within 2 hours of the 

model being prepared in order to ensure the 

alginate was kept sufficiently humid 9 . The labial 

clip of the Apit device was in contact with the 

alginate at all times (Fig. 2). Each canal was 

irrigated with 3% sodium hypochlorite and size 

15 K-file attached to the instrumental clip was 

inserted into the root canal till the red mark was 

visible on the screen of apex locator. The red 

mark indicated the position of the apical 

foramen. Point at which red mark was seen the 

rubber stopper was adjusted to the reference 

level, file was taken out and its length was 




measured with the help of digital vernier caliper. 

The tooth was demounted and file was reinserted 

with rubber stopper adjusted at the measured 

electronic length. The tooth was again mounted 

on the adjustable jig and radiographic images 

with file were taken by conventional radiograph 

and RVG. Now the position of the file at its tip 

was noted and recorded similarly as done before. 

If it was at the apex it was recorded as ì*î, if file 

tip is 0.5 mm beyond the apex it was designated 

as ì+îand if it was 0.5mm short of apex it was 

designated as ì-î.Measurements within ± 0.5 

mm of the apical foramen were considered 

acceptable 7,19 . 

Statistical analysis 

Data were analysed using the one-way 

analysis of variance (ANOVA) and Cronbachís 

alpha-reliability analysis to compare between 

different blinded observers. Student pair t-test 

was used for comparison between different 

groups. Statistical significance was considered 

to be P ≤ 0.05. The statistical analysis was 

carried out with SPSS version 11.5 software 

(SPSS Inc., Chicago, USA). 

Results 

In this study, RCL obtained by 

conventional radiography and RVG when 

compared to ARCL using Student pair t-test, 

significant difference (P=0.00) was observed 

(Table 1). Mean of the RCL obtained from four 

different blinded observers with Raypex5 apex 

locator, when compared with ARCL no 

significant difference was found (P= 0.719) 

(Table 1). Also no significant difference was 

seen when comparison was done within four 

different observers (P=1.00). The reliability 

coefficient among them was found to be 0.9929, 

which indicates very good agreement among 

them (Table 2). 

Evaluation of the position of file with 

respect to the apical foramen was based on the 

distance from file tip to apical foramen. 

Measurement was regarded as correct or 

incorrect when this distance was under or over 

0.5 mm in absolute terms (Table 3). From the 

data obtained, conventional radiograph showed 

accuracy in 72.5% of cases (i.e. within ± 0.5 mm 

of the apical foramen), 25% fell short of ñ0.5 

mm, and 2.5% exceeded +0.5 mm. With respect 

to RVG, 85% of cases showed to be within the 

acceptable range (i.e. within ± 0.5 mm of the 

apical foramen), 10% fell short of ñ0.5 mm, and 

5% exceeded +0.5 mm. In turn, Raypex5 EAL 

provided good measurements in 90% of cases 

(i.e. within ± 0.5 mm of the apical foramen), 

2.5% fell short of ñ0.5 mm, and 7.5% exceeded 

+0.5 mm. 

Discussion 

Based on the two possible points for 

terminating instrumentation, i.e. the CDJ and the 

apical foramen, it should be taken into account 

that systematic working to the apical 

constriction entails the risk of leaving tissue 

remains within the apical region; as this tissue 

may be diseased, treatment may fail. In contrast, 

over-obturation can result using the radiographic 

apex as reference. Most experts agree that the 

WL should terminate at the CDJ which is 

usually found about 0.5-1mm short of the 

radiographic apex 2,10 . However CDJ is a 

histological term and microscope is needed to 

find it. Clinically this is not practical. In this 

sense, we considered the apical foramen to be an 

appropriate reference and moreover no welldefined 

apical constriction has been clearly 

confirmed in all root canals. 

Different studies that have compared 

digital and conventional radiography and has 

considered the reliability of the former technique 

in measuring working length to be equal or even 

superior to that of conventional 

radiography 1,11,12,13 . Similarly, experience 

accumulated over the years clearly confirms the 

reliability of EALs. Various studies 14,15,16,17,18,19 

have reported the accuracy of EALs to be 

between 80 to 95% , whereas some have even 

found radiographic better than EAL 20 . This large 

variation is due different type of EALs. 

According to the manufacturer, Raypex5 

apex locator is based on the principle that 

impedance measurement not only differs 

between two electrodes depending on the 

frequencies used, but also differs greatly 




between at an apical constriction region. This 

device uses two frequencies, 400 Hz and 8 KHz, 

produced by a variable frequency generator but 

uses only one frequency at a time. 

From the various methods available in 

locating the apical foramen (with a margin of 

error of ±0.5 mm) and determining the WL, 

accuracy of Raypex5 EAL in this study was 

90% accurate in comparison to conventional 

radiography and RVG which were 72.5% and 

85% accurate. The results of present study were 

almost in accordance with the study carried out 

by Sadeghi & Abolghasemi 21 , who reported 70% 

and 50% accuracy for determining WL within ± 

0.5 mm of actual working length in anterior 

teeth with Raypex5 apex locator and 

conventional radiograph respectively. Chopra et 

al. 22 reported 75.93% accuracy for determining 

WL in anterior teeth with Raypex5 apex locator. 

In this study only anterior teeth were 

involved, most of which had straight canals and 

curvature if seen was only in apical third region. 

Moreover, due to standardization of position of 

teeth on jig and radiographic cone, the 

probability of elongation and foreshortening of 

images was minimized. This could be the 

probable cause of the increased accuracy 

percentage of conventional radiography and 

RVG. But such shortcomings can neither be 

overcome nor ignored clinically. 

It should be emphasized that the results 

obtained in this in vitro study cannot be directly 

extrapolated to the clinical situation. Clinically, a 

higher variation of measurements is expected in 

contrast to in vitro studies as favourable 

environment for precise measurements are not 

available. 

Conclusion 

Under the conditions of this in vitro 

study it was concluded that Raypex5 is more 

accurate than conventional radiography and 

RVG in WL determination and location of 

apical foramen. 

References 

1. Martinez-Lozano MA, Forner Navarro L, 

Sanchez Cortes JL, Liena Puy C. 

Methodological considerations in the 

determination of working length. Int Endo J 

2001; 34: 371-76. 

2. Kuttler Y. Microscopic investigation of root 

apexes. J Am Dent Assoc 1955; 50, 544-52. 

3. Burch JG, Hulen S. The relationship of the 

apical foramen to the anatomic apex of the 

tooth root. Oral Surg Oral Med Oral Pathol 

1972; 34, 262ñ68. 

4. Altman M, Gultuso J, Seidberg BH. Apical 

root canal anatomy of human maxillary 

central incisors. Oral Surg Oral Med Oral 

Pathol 1970; 30, 694ñ69. 

5. Palmer MJ, Weine FS, Healy HJ. Position of 

the apical foramen in relation to endodontic 

therapy. J Canad Dent Assoc1971; 37, 305ñ 

08. 

6. Tinaz AC, Alacam T, Topuz. A simple model 

to demonstrate the electronic apex locator. 

Int Endo J 2002; 35: 940-45 

7. Fouad AF, Krell KV, McKendry DJ, 

Koorbusch GF, Olson RA. A clinical 

evaluation of five electronic root canal length 

measuring instruments. J Endodon 1990; 16: 

446-49. 

8. Czerw RJ, Fulkerson MS, Donnelly JC. An in 

vitro test of a simplified model to 

demonstrate the operation of electronic rootcanal 

measuring devices. J Endodon 1994; 

20: 605-6. 

9. Plotino G, Grande NM, Brigante L, Lesti B, 

Somma F. Ex vivo accuracy of three 

electronic apex locators: Root ZX, Elements 

Diagnostic Unit and Apex locator and 

ProPex. Int Endo J 2006; 39: 408-14. 

10. Weine FS. Calculation of working Length. 

In: Weine FS, eds. Endodontic Therapy. 6th 

ed. St. Louis: CV Mosby Co; 2004: 240- 

265. 

11. Shearer AC, Horner K, Wilson NHF. 

Radiovisiography for imaging root canals. 

An in vitro comparison with conventional 

radiography. Quintessence Int 1990; 21, 

789ñ94. 

12. Hedrick RT, Dove SB, Peters DD, McDavid 

WD. Radiographic determination of canal 

length: direct digital radiography versus 

conventional radiography. J Endodon 1994; 

20, 320ñ26. 

13. Ellingsen MA, Hollender LG, Odont D, 

Harrington GW. Radiovisiography versus 




conventional radiography for detection of 

small instruments in endodontic length 

determination: In vivo evaluation. J 

Endodon 1995; 29: 516-20. 

14. Blank LW, Joseph I, George B. Reliability 

of electronic measuring devices in 

endodontic therapy. J Endodon 1975; 1: 

141-44. 

15. Busch LR, Leonard R, Lance C, Goldsteln 

G. Determination of the accuracy of the 

Sono-Explorer for establishing endodontic 

measurement control. J Endodon 1976; 2: 

295-97. 

16. Plant JJ, Newman RF. Clinical evaluation 

of the Sono-Explorer. J Endodon 1976; 2: 

215-17. 

17. Farber PJ, Bernstein M. The effect of 

instrumentation on root canal length as 

measured with an electronic device. J 

Endodon 1983; 3: 114-15. 

Pair 1 

Pair 2 

Pair 3 

18. Pallares A, Faus V. An in vivo comparative 

study of two apex locators. J Endodon 

1994; 20: 576-79. 

19. Shabahang S, Goon WWY, Gluskin AH. 

An in vivo evaluation of Root ZX electronic 

apex locator. J Endodon 1996; 22: 616-18. 

20. Becker GJ, Lankelma P, Wesselink PR. 

Electronic determination of root canal 

length. J Endodon 1980; 6: 876-80. 

21. Sadeghi SH, Alghasemi AM. A 

comparison between the Raypex 5 apex 

locator and conventional radiography for 

determining working length of straight and 

curved canals. Iranian Endo J 2007; 2: 101- 

04. 

22. Chopra V, Grover S, Prasad SD. In vitro 

evaluation of the accuracy of two 

electronic apex locators. J Conservative 

Dent 2008; 11: 82-85. 

Pair N Mean S.D t -test P-Value 

Actual root canal length 40 23.06 2.74 

Conventional radiography 40 22.54 2.91 


Radiovisiography 40 22.78 2.80 


Raypex5(mean) 40 23.01 2.73 

6.323 

5.151 

0.363 

Table 1 Comparison of the root canal lengths obtained by three different methods 

with actual root canal length. 

Blinded Observer N Mean S.D F P-Value 

Observer 1 40 23.02 2.77 

Observer 2 40 23.03 2.74 

Observer 3 40 22.97 2.72 

Observer 4 40 23.02 2.82 

0.004 1.000 

0.000 

0.000 

0.719 




Cronbach's Alpha 

Reliability coefficient 0.9929 Very good agreement 

Table 2 Comparison between four blinded observers and their reliability. 

Various methods N Short Over Acceptable Accuracy (%) 

Conventional radiography 40 10 1 29 72.5 

Radiovisiography 40 4 2 34 85 

Raypex5 apex locator 40 1 3 36 90 

Table 3 Evaluation of the position of file with respect to the apical foramen. 

Legends 

1. Table 1 Comparison of the root canal 

lengths obtained by three different 

methods with actual root canal length. 

2. Table 2 Comparison between four 

blinded observers and their reliability. 

3. Table 3 Evaluation of the position of file 

with respect to the apical foramen. 

4. Figure 1 Mounted tooth on prepared jig. 

5. Figure 2 Measurement with apex 

locator. 

Figure 1 Mounted tooth on prepared Figure 2 Measurement with apex locator 

********************** 




Mode of action of a bracket 

The application of braces moves the teeth as a 

result of force and pressure on the teeth. There 

are four basic elements that are needed in order 

to help move the teeth. In the case of traditional 

metal or wire braces, one uses brackets, bonding 

material, arch wire, and ligature elastic, also 

called an ìO-ringî to help align the teeth. The 

teeth move when the arch wire puts pressure on 

the brackets and teeth. Sometimes springs or 

rubber bands are used to put more force in a 

specific direction. Braces have constant 

pressure, which over time, move teeth into their 

proper positions. Occasionally adults may need 

to wear headgear to keep certain teeth from 

moving. When braces put pressure on ones teeth, 

the periodontal membrane stretches on one side 

and is compressed on the other. This movement 

needs to be done slowly otherwise the patient 

risks losing his or her teeth. This is why braces 

are commonly worn for approximately two and a 

half years and adjustments are only made every 

three or four weeks. This process loosens the 

tooth and then new bone grows in to support the 

tooth in its new position which is technically 

called bone remodeling. Bone remodeling is a 

biomechanical process responsible for making 

bones stronger in response to sustained loadbearing 

activity and weaker in the absence of 

carrying a load. Bones are made of cells called 

osteoclasts and osteoblasts. Two different kinds 

of bone resorption are possible which are called 

direct resorption, starting from the lining cells of 

the alveolar bone, and indirect or retrograde 

resorption, which takes place when the 

periodontal ligament has become subjected to an 

excessive amount and duration of compressive 

stress. Another important factor associated with 

tooth movement is bone deposition. Bone 

deposition occurs in the distracted periodontal 

ligament and without bone deposition, the tooth 

will loosen and voids will occur distal to the 

direction of tooth movement. A tooth will 

ORTHODONTICS 

INVISIBLE BRACKETS 

Dr.Bastian Varkey N, Modern Dental Clinic, Thaikkad, Guruvayoor. 

usually move about a millimeter per month 

during orthodontic movement, but there is high 

individual variability. Orthodontic mechanics 

can vary in efficiency, which partly explains the 

wide range of response to orthodontic treatment. 

Straight teeth and a revitalized smile may no 

longer need to come from a mouth full of 

unattractive wire and bracket braces. Enhancing 

self-esteem and physical confidence, invisible 

braces offer an esthetic and barely visible 

alternative to conventional wire/bracket braces. 

The clear aligners (also called clear braces) are 

manufactured using advanced computer 

technology that predicts tooth movement, 

making it possible for the removable orthodontic 

appliance to gradually straighten teeth. 

Conditions Treated with Invisible Braces 

While invisible braces may not be suitable for 

certain misalignment cases or the complex bite 

problems that are better addressed by 

traditional orthodontics, invisible braces can be 

used to treat the following orthodontic 

conditions: 

� Overbite or overjet 

� Crowded or widely spaced teeth 

� Crooked teeth 

Invisible braces are designed for adults and older 

teenagers; invisible braces are not recommended 

when baby teeth remain. Children and younger 

teenagers faced with orthodontic problems will 

require traditional metal braces with 

brackets/wires on the front of the teeth. 

However, only your dentist or orthodontist can 

determine if you are a candidate for invisible 

braces. The clear aligner treatment was designed 

primarily for adults due to the need for absolute 

and rigid cooperation; the trays are worn 22 

hours per day and should not be forgotten or 

lost. 




Types of Invisible Braces 

Popular types of cosmetic braces include 

ceramic brackets, inside braces and clear 

aligners. Ceramic braces are just like metal 

braces, except that they use tooth-colored 

brackets (and sometimes tooth-colored wires) 

rather than metal to straighten teeth. Generally 

non-staining, the tooth-colored ceramic "blends" 

with your teeth, making them less noticeable 

than metal, but not as "invisible" as inside braces 

or clear aligners. Inside braces ó also called 

inside invisible braces, lingual braces or 

"iBraces" ó and clear aligners go one step 

further, making treatment virtually invisible. 

Each alternative has its advantages and 

disadvantages. 

"Ceramic, or "clear," braces are made of 

composite materials that are weaker and more 

brittle than metal braces. Ceramic brackets are 

larger than metal brackets and require small 

rubber bands, or ligatures, (or built in spring 

clips on "self ligating" brackets) to hold them to 

the arch wire. Because the ligatures are white or 

clear, they can stain. However, staining is not a 

big problem because ligatures are changed every 

time you get an adjustment (generally monthly). 

The "self ligatiing" clips do not require retying 

with wires or elastics. 

A 

lso like metal braces, ceramic brackets are not 

removable until treatment is completed, can 

produce irritation and discomfort, and may 

complicate regular tooth care, eating and 

speaking. 

Because they are not as strong as metal braces, 

clear braces require a longer treatment time, 

since your orthodontist may need to apply a 

slower, more gradual force to ensure the strength 

capabilities of the clear brackets are not 

overtaxed. Ceramic brackets also are usually 

more expensive than traditional metal brackets 

(about $500 more). As a cost-saving measure, 

some patients may opt to have ceramic braces 

placed only on the most visible teeth ó 

typically the upper teeth or just the upper center 

teeth ó while using traditional metal brackets 

on the remaining teeth that need straightening. 

Also, there is some possibility of tooth abrasion 

if the incisal edges of the upper front teeth touch 

the lower ceramic brackets. 

Inside braces (including such brands as 3M's 

Incognito Orthodontic Braces) are attached to 

the back of the teeth so they are hidden from 

view. Current iBraces use scanned images of the 

insides of the teeth to create special, computerdesigned 

custom brackets that are attached to the 

insides of the upper and sometimes lower teeth. 

This makes them appealing to people who are 

often in public and might feel self-conscious 

about wearing clear aligners or braces with 

metal or ceramic brackets/wires on the front of 

their teeth. Whereas clear, removable aligners 

can be misplaced or lost, thereby delaying 

treatment, iBraces are fixed and not removable. 

Elastics can be used with iBraces to help hasten 

treatment. Such elastics are available for use 

with clear aligners but are more difficult to use. 

Disadvantages of iBraces include a higher cost 

than traditional braces used on the front of the 

teeth due to the computer customization required 

to make the brackets. Since computer 

manufactured iBraces represent a newer 

technique, many orthodontists are not 

comfortable or experienced in performing 

invisible braces treatment and, therefore, shy 

away from offering them as a treatment plan. 

Speech, comfort, maintaining dental hygiene and 




removing dental plaque may pose challenges 

with iBraces. 

Clear aligners (including such brands as Align 

Technologies' Invisalign and ClearCorrect 

Inc.'sClearCorrect) are a series of clear, 

removable aligners custom-fit to your teeth to 

provide virtually irritation-free treatment with 

minimal adjustment discomfort. Clear aligners 

are nearly invisible, minimally invasive and 

resistant to clouding from wear. With clear 

aligners, there are no brackets to come off or 

wires to break and poke. Clear aligners can be 

removed for eating, drinking and special events, 

making it easier to brush and floss. 

However, since clear aligners are removable, 

they may require more motivation and selfdiscipline 

to wear consistently, and they are 

easier to misplace or lose. Lost clear aligners 

may result in treatment delay and additional 

replacement costs. While fairly comfortable, 

clear aligners can cause discomfort or mild pain, 

particularly at the beginning when new aligners 

are placed and exert pressure on the teeth to 

move them. Additionally, clear aligners are 

available only from dentists or orthodontists 

manufacturer-certified and trained to offer them; 

they also may require special and costly 

maintenance. For example, Invisalign's custom 

brand cleansers are available only from its 

manufacturer and are relatively expensive 

(nearly $100) compared to traditional cleansers 

used for orthodontic retainers. 

***************** 

Clear aligners are made after your 

dentist/orthodontist takes three-dimensional 

impressions of your teeth and sends them to a 

manufacturer-specific laboratory that fabricates 

your custom-fit clear aligners using 

computerized technology. These aligners are 

then sent to your dentist/orthodontist to be tried 

on and evaluated for suitability. Clear aligners 

are provided in sets. The number of aligners will 

depend on your specific orthodontic problem. 

You will wear each new aligner set for a 

specified amount of time, removing them only to 

eat, drink, brush and floss. With each new 

aligner set, your teeth slowly adjust and 

gradually realign to your desired smile. At 

periodic visits, your dentist/orthodontist will 

provide the next aligner set and evaluate your 

progress throughout treatment. Revision aligners 

are often requested at the end of the first series 

of aligners to correct any unfinished detailing. 

The length of treatment depends on your 

situation and the type of invisible braces you are 

wearing. Typically, braces are worn from 18 to 

24 months, though they are sometimes worn 

longer. 

Metal braces work the best because they are 

made from the strongest materials. Ceramic 

braces, while strong and better looking, often 

take more time because they are not as strong as 

metal braces. Inside braces also can take more 

time to work effectively. 

The treatment times with clear aligners vary. For 

example, Invisalign treatment, typically 

requiring 20 to 30 aligners for the upper and 

lower teeth, usually averages nine to 15 months 

to complete. ClearCorrect treatment times vary 

from 12 to 24 months and depends on the 

specific alignment problem; treatment for 

moderate cases requires 32 steps of treatment, 

delivered in eight phases, while minor cases 

require 12 steps of treatment, delivered in three 

phases. 




SYNERGISTIC COMBINATION OF ACECLOFENAC AND 

THIOCOLCHICOSIDE 

An advanced and modern treatment modality. 

Dr.Shilpa Burundy 

ABSTRACT 

Dental surgeons encounter many muscular disorders in their clinical practice. Trismus, Dry socket, TMJ 

disorders, Neuro Muscular conditions, etc need fixed dose combination of NSAID and muscle relaxants. 

This article presents a synergistic combination of Aceclofenac and Thiocolchicoside- an advanced and 

modern treatment for the above said conditions. 

CLINICAL PHARMACOLOGY 

Pharmacodynamics 

Aceclofenac 

Aceclofenac is a non-steroidal agent with 

marked anti-inflammatory and analgesic 

properties. 

The mode of action of aceclofenac is largely 

based on the inhibition of prostagiandin 

synthesis. Aceclofenac is a potent inhibitor of 

the enzyme cyclo-oxygenase, which is involved 

in the production of prostaglandins. 

Thiocolchicoside 

In-vitro thicolchicoside only binds to GASA-A 

and strychnino sensitive glycine 

receptors. Thicolchicoside act as a GABA-A 

receptor antagonist, its myorelaxant effects 

could be exerted at the supraspinal level, via 

complex regulatory mechanisms, although a 

glycinergic mechanism of action cannot be 

excluded. The characteristics of the interaction 

of thiocolchicoside with GABA-A receptors are 

quaitatively and quantitatively shared by its 

main circulating metabolite, glucuronidated 

derivative. 

In vivo, the myorelaxant properties of 

thiocolchicoside and its main metabolite have 

been demonstrated in various predictive models. 

The lack of myorelaxant effect of 

thiocokhicoside in spinalized rats suggests a 

predominant supraspinal action for this 

compound. Thiocolchicoside was also found to 

possess anti-inflammatory and analgesic 

activities in a variety of experimental models 

after oral, subcutaneous, intraperitoneal and 

intramuscular administration. 

Pharmacokinetics 

Aceclofenac 

CLINICAL PHARMACOLOGY 

After oral administration, aceclofenac is rapidly 

absorbed and the bioavailability is almost 100%. 

Peak concentrations are reached approximately 

1.25 to 3 hours following ingestion. Time is 

delayed with concomitant food intake whereas 

the degree of absorption is not influenced. 

Aceclofenac is highly protein-bound (99.7%). 

Aceclofenac penetrates into the synovial fluid 

where the concentrations reach 

approximately 60% of those in plasma. the 

volume of distribution is approximately 30L. 

Aceclofenac is probably metabolized via 

CYP2C9 to the main metabolite 

4-hydroxyaceclofenac. The mean plasma 

elimination half-life is 4-4,3 hours. 

Approximately two-thirds of the administered 

dose is excreted via the urine mainly as 

conjugated hydroxymetabolites. Only 1% of an 

oral single dose is excreted unchanged. A slower 

rate of elimination of aceclofencac has been 

detected in patients with 

decreased liver function after a single dose of 

aceclofenac. In a multiple dose study using 

100mg once daily, there was no difference in the 

pharmacokinetic parameters between subjects 

with mild to moderate liver cirrhosis and normal 

subjects. In 

patients with mild to moderate renal impairment, 

no clinically significant differences inn the 

pharmacokinetics were observed after a single 

dose. 

Thiocolchicoside 

Thiocoichicoside is rapidly absorbed after oral 

administration, and metabolized into 3 main 

metabolites. The two main circulating forms 

were the thiocolchicoside 

aglycon and the glucuronidated derivative of 




thiocolchicoside, which is active. in humans, the 

binding of thiocolchicoside to human serum 

proteins is low (13%) and not dependent on the 

therapeutic concentration of thiocolchicoside 

and serum 

albumin is mainly involved in serum protein 

binding. After oral administration in healthy 

volunteers, no traces of thiocolchicoside are 

detected. the active glucuronidated metaboite 

appears rapidly in plasma with a median Tmax 

(Time to reach maxium plasma concentration of 

a drug) at 1 hour, and is eliminated with a mean 

apparent terminal half-life of about 7 hours. 

After a single 8mg oral administration of 

thiocolchicoside. The man area under the curve 

(AUC) of the active glucuronidated metabolite 

which reflects exposure to the active entities is 

aboutn 126ng.h/ml. After oral administration of 

14C-radiolabelled thiocolchicoside (14C- 

Radioactive Carbon), 79% of the dose is 

recovered in faces and 20% in urine. The 

apparent volume of distribution and systemic 

clearance of thiocolchicoside are about 43L and 

19Lh respectively. 

INDICATIONS 

Dental conditions like Trismus, Dry Socket, and 

painful muscle spasm associated with trauma, 

inflammation, neurological disorders, 

degenerative vertebral disorders, low back 

pain, vertebral static problem, torticollis, and 

other painful conditions associated with skeletal 

muscle spasm. 

COMPOSITION 

Each firm coated tablet contains: 

Aceclofenac IP 100mg 

Thiocolchicoside 4mg 

And 

Aceclofenac IP 100mg 

Thiocolchicoside IP 8mg 

DOSAGE, ADMINISTRATION AND 

PRESENTATION. 

One tablet to be given 2 times day. (For eg: Intas 

Pharma) 

CONTRAINDICATIONS 

Contradicted in: 

* Individuals having hypersensitivity to 

thiocolchicoside, aceclofenac or any 

Of itís recipients. 

* Pregnancy and lactation. 

* In patients in whom substances with a 

similar action (c.g. aspirin, or other 

NSAIDs) precipitate attacks of asthma 

bronchospasm, acute rhinitis or 

urticaria or patients are hypersensitive to 

these drugs. 

* Severe heart failure or severely impaired 

hepatic or renal function and during 

the last three months of pregnancy. 

WARNING AND PRECAUTIONS 

Thiocolchicoside is not recommended for use in 

children. in adults, reduce the dosage, if 

necessary. in case of diarrhoea. 

* Close medical surveillance is imperative 

in patients with symptoms indicative of 

gastrointestinal disorders, with a history 

suggestive of gastrointestinal 

ulceration, with ulcerative colitis or with 

Crohnís disease, bleeding diathesis or 

hematological abnormalities. 

* Gastrointestinal bleeding or ulcertative 

perforation, haematemesis and melaena have in 

eneral more serious consequences in the elderly. 

They can occur at any time during treatment, 

with or without warning symptoms or previous 

history. In the rare instances, where 

gastrointestinal bleeding or ulceration occurs in 

patients receiving aceclofenac, the drug should 

be withdrawn. Close medical surveillance is also 

imperative in patients suffering from severe 

impairment of hepatic function. 

* Aceclofenac should be given with 

caution to elderly patients with renal, hepatic or 

cardiovascular impairment and to those 

receiving other medication. the lowest effective 

dose should be used and renal function 

mentioned regularly. 

As with other NSAIDs, allergic reactions 

including anaphylactic/anaphylactoid reactions 

can also occur without earlier exposure to the 

drug. 




* The importance of prostaglandins in 

maintaining renal blood flow should be 

taken into account in patients with 

impaired cardiac or renal function, those 

being treated with diuretics or 

recovering from major surgery. Effects on 

renal function are usually reversible on 

withdrawal of aceclofenac. 

Renal impairment: Patients with mild renal 

impairment should be kept under surveillance 

since the use of NSAIDs may result in 

deterioration of renal function. the lowest 

effective dose should be used and renal function 

monitored regularly. 

Hepatic Impairment: dose should be 

appropriately reduced. 

Pediatric use: In Children, It is not 

recommended. 

Geriatric use: Generally no dose reduction is 

necessary, however, consider the 

precautions. 

Pregnancy & Lactation: The combinations are 

not recommended in pregnant & breast-feeding 

women. 

Effect on ability to drive and use machines: 

There are not data available of the effect on 

driving vehicles and using machines. Although 

only rare cases of drowsiness have been 

reported, this has to be taken into account when 

driving vehicles and operating machines. 

****************** 

DRUG INTERACTIONS: 

Drug interactions with other drugs are not 

known/reported with thiocolchicoside. 

Similar to other NSAIDs aceclofenac may 

increase plasma concentrations of lithium, 

digoxin and methotrexate, increase the activity 

of anticoagulants, inhibit the activity of 

diuretics, enhance cyclosporin nephrotoxicity 

and precipitate convulsions when 

co-administered with quinolone antibiotics. 

When concomitant administration with 

potassium sparing diuretics is employed, 

serum potassium should be monitored. 

Further more, hypo or hyperglycaemia may 

result from the concomitant administration of 

aceclofenac and antidiabetic drugs althoug this 

is rare. the co-administration of aceclofenac with 

other NSAIDs or carticosteroids may result in 

increased frequency of side effects. 

Caution should be exercised in NSAIDs and 

methotrexate are administered within 2-4 hours 

of each other, since NSAIDs may increase 

methotrexate plasma levels, resulting in 

increased toxicity. 

ADVERSE EFFECTS: 

Commonly reported adverse events: 

Gastrointestinal disorders such as diarrhoea. 

gastralgia, nausea, vomiting, drowsiness & 

Cutaneous allergic reactions including 

angioedema, elevated liver enzymes. 

OVERDOSAGE: 

There are no published reports of overdose. In 

cases of overdose. The stomach should be 

emptied promptly by lavage or by induction of 

Standard supportive measures. 




Abstract: 

ERGONOMICS: A SOLUTION TO MUSCULOSKELETAL 

DISORDERS 

Dr. Subodh Shankar Natu B.D.S, M.D.S. Sr. Lecturer, Department of Oral & Maxillofacial Surgery, 

Career Postgraduate Institute of Dental Sciences & Hospital 

Dr. Vrishali Ajit Kulkarni B.D.S Lecturer Career Postgraduate Institute of Dental Sciences & Hospital 

Work related musculoskeletal disorders are a part of each and every profession and dentistry is no 

exception to it. Posture, positioning, and instrumentation principles have formed an integral aspect of 

dental education for years. Dentists are at a higher risk as compared to the general population. The most 

frequent injuries occur in the neck, shoulders, elbows, hands and lower back. Certain procedures place the 

clinician at high risk for finger and hand injuries. Sitting in an appropriate chair, using magnification for 

visualization, and the selection of ergonomically friendly equipment are essential for the health of dental 

clinicians. Working ergonomically helps prevent work related injuries. Attention must be given to 

improper postural habits and selecting equipment conducive to good posture. The first critical step 

towards ergonomic habits is recognition of these factors and layout work environment conducive for 

musculoskeletal system otherwise shortens clinicianís career unnecessarily. 

Keywords: Ergonomics, Musculoskeletal Disorders, Dentistry 

Introduction: 

Dentistry is a profession that generally 

produces muscular pain and soreness, they are 

usually slow to appear, consequently, the 

symptoms are usually ignored until they become 

chronic and permanent lesions. No dentist is 

immune to musculoskeletal disorder (MSD). 

The changes start at the time they join their 

professional studies and it stays with them 

during their professional practice affecting the 

spine, neck, shoulders and hands. Prior to 1985, 

low back pain was the most commonly reported 

musculoskeletal disorder or repetitive injury for 

dentists and dental hygienists. The human body 

is not built to handle these kinds of stresses, and 

the positions in which dentists repeatedly put 

themselves which results in MSDs. 

The discomfort described most often 

occurred in the lower back followed by the neck, 

upper back, shoulders and legs. The percentage 

of dentists experiencing lower back pain was 

reported to range from one-third to one-half of 

the dental population. 1,2 Fixed prosthodontic 

procedures were cited as the dental activity most 

ERGONOMICS 

likely to produce musculoskeletal pain. 3 The 

musculoskeletal pain can be prevented by 

adopting a proper sitting posture, reduce large 

scale movements and engage in periodic 

stretching. 

Epidemiology: 

A study done by the British Dental 

Association in 1963, revealed that in a sample of 

2,288 dentists, 49% suffered from low back 

pain. 4 In a similar study by Bassett, who 

surveyed 18 dentists in Toronto area to 

determine the lifetime incidence of back 

problem and found that 62.2% had suffered back 

and neck pain at sometime during their lives. 5 

Lindfors et al. in 2006 reported that the female 

group of dentists showed a higher incidence of 

muscular skeletal disorders. 6 Hope-Ross and 

Corcornan investigated the incidence of pain 

and discomfort in 650 dentists of the Irish 

Dental Association. 7 

Ergonomics: 

Ergonomic is defined as a systematic 

approach to study the relationship between the 

individuals, their tools and the environment at 

work. 8 




Pathophysiology of Musculoskeletal disorder: 

For a success of dental treatments high 

degree of dexterity, visual and manipulative 

elements are required. Hence dentistry is 

predominantly associated with difficult working 

postures like rotation and flexion of the cervical 

spine, flexion of the elbow, and repetitive 

forceful hand grip. 9 Poor working postures 

generate high static loads leading to increased 

muscle tension, which create musculoskeletal 

discomfort or fatigue in the neck, shoulders, and 

upper back, and also work-related injury among 

professionals. 10,11,12,13,14 

Instruments that generate vibration, 

require force to hold or manipulate, have smalldiameter 

handles, or are difficult to grip can 

potentially contribute to MSDs. 15 Carpal tunnel 

Some Signs of MSDs 

ïDecreased range of motion 

ïLoss of normal sensation 

ïDecreased grip strength 

ïLoss of coordination 

Some Symptoms of MSDs 

ïExcessive fatigue in the shoulders and neck 

ïTingling, burning, or other pain in arms 

ïWeak grip, cramping of hands 

ïNumbness in fingers and hands 

ïHypersensitivity in hands and fingers 

Off-the-Job Activities That Can Contribute to MSDs 

ïHome computer use 

ïRepetitive activities using the fingers 

ïProlonged/awkward postures at home 

Musculoskeletal Disorders Resulting from 

Prolonged Static Posture: 

Kyphosis ñ Defined as an abnormal 

increase in the curvature of the thoracic spine. 

This can be induced from prolonged poor 

posture. The round back musculoskeletal 

deformity can lead to symptoms that include 

pain, stiffness, and loss of range of motion. 17 

Increased Lordosis ñ Defined as an 

increased curvature in the lumbar spine. The 

buttocks appear prominent as a result to 

excessive arching. This can lead to increased 

syndrome is one of the most common MSD, 

which results when there is compression of the 

median nerve as it passes through a small 

opening bordered by bones and ligament. When 

subjected to repeated forceful motion of the 

wrist, the tendons that pass through the carpal 

tunnel with the nerve swell and compress the 

median nerve and limit its blood supply. The 

compression and/or obstruction of the vascular 

supply causes the symptoms associated with this 

painful syndrome. 

The use of ultrasonic instrumentation 

was associated with an increased incidence of 

MSDs in the legs. This may be related to the 

positioning of the foot pedal or the use of larger 

foot pedals, both of which can result in 

imbalanced hip and leg postures. 16 

strain of the lower back that may cause low back 

pain, sciatica/leg pain, and lack of mobility. 17 

Scoliosis ñ Defined as an abnormal 

lateral curvature of the spine. It can be 

congenital or acquired from prolonged lateral or 

rotated positioning toward the patient. This can 

cause shortened muscles on one side or the spine 

which could trigger muscle spasms and induce 

chronic pain. Self-induced scoliosis is the bodyís 

attempt to adapt to an abnormal body position. 17 

Prevention: 

The Proprioceptive Derivation (Pd 

concept), earlier known as performance logic, 




was developed by Dr. Daryl R. Beach. 18, 19, 20 It 

aimed to provide the dentists with a good 

posture and optimal control to perform dental 

tasks while minimizing musculoskeletal 

discomfort. Ideal Posture described in the Pd 

concept, is the dentist sitting upright, both hands 

at the level of the heart, being able to easily 

reach necessary equipment and materials; the 

patient lying horizontally. The Pd concept guides 

dentists in determining their most comfortable 

working posture and position to maintain 

maximum balance and comfort. 

Certain factors are strongly associated 

with decreased risk of MSDs in dentistry and 

include the following: 16 

ï Use of an articulating headrest 

ï Operating seats that adjust readily in 

height 

ï Operatories designed with freedom for 

clinicians to position themselves in the 

oíclocks around clients 

ï Supine client positioning for maxillary 

treatment 

ï Dominant elbows resting at the 

clinicians sides 

ï Operatory light positioned close to 

clinicians sightline 

ï Use of surgical magnification 

ï Equipment that is designed and used so 

clinicians legs can be positioned directly 

under the client chair during treatment 

1) Maintain the low back curve: 

Research shows that maintaining the 

low back curve ie the lumbar lordosis when 

.21, 22 

sitting can reduce or prevent low back pain. 

The chair should be adjusted in such a way that 

the operatorís hips are slightly higher than the 

knees and feet placed firmly on the floor to 

distribute the body weight evenly. The forward 

edge of the chair should not compress the backs 

of the thighs. Tilt the seat angle slightly forward 

5 to 15 degrees to increase the low back curve. 23 

The lumbar support of the chair should be 

adjusted so that it is in contact with the operators 

back. One should sit tall with a slight curve in 

the low back, exhale, and pull the navel toward 

the spine without letting the curve flatten to 

stabilize the low back curve. 

2) Use Magnification: 

Use of magnification systems has helped 

the dentist to decrease neck and low back pain, 

as they allowed operators to maintain healthier 

postures. 24 Working in postures with greater than 

20 degrees of neck flexion is associated with 

increased neck pain. 25 Magnification of x2 with 

declination angle of the scopes provides working 

field detail that is approximately identical to the 

one seen by hunching over the patient without 

scopes. This reduces the degree of neck flexion 

to less than 20. Magnification helps in 

maintaining a working distance that allows 

optimal posture, with shoulders relaxed and 

elbows close to the operatorís sides. 

3) Light Adjustment: 

Light positioning is one of the most 

critical factors affecting the posture of clinicians. 

For optimal illumination, the light-line must be 

as close as possible to clinicianís sightline. 

Greater the deviation of light-line from the 

cliniciansí sightline, the greater the shadowing 

occurs. As long as the light-line and sightline are 

within 15 degrees of each other, the view will be 

essentially unshadowed and highly visible using 

standard mouth mirrors. 26 

4) Avoid static postures: 

According to Lehto and colleagues, the 

concept of a single correct work posture may be 

physiologically invalid, as the human body may 

be made for movement and ever-changing 

postures. 27 Increasingly, the literature supports 

the idea that workers should vary their work 

positions as often as possible to shift the 

workload from one group of muscles to 

another. 1,22,23,28,29 

5) Alternate between standing and sitting: 

Alternating between standing and sitting 

also can be an effective tool in preventing 

injuries. 29 Different muscle groups are used in 

standing and sitting positions; therefore, 

alternating between the two positions lets one 

group of muscles rest, while the workload is 




shifted to another group of muscles. One study 

revealed that dentists who worked solely in a 

seated position had more severe low back pain 

than did those who alternated between standing 

and sitting. 30 

6) Reposition the feet: 

Subtle changes in foot position can shift 

the workload from one group of low back 

muscles to another, allowing the overworked 

tissues to be replenished with nutrients. 

7) Use of Reinforced Instrumentation: 

The definition of reinforce is to 

strengthen with some added piece or support. 31 

If a clinician experiences pain due to a 

cumulative trauma injury, the utilization of 

reinforced instrumentation techniques help to 

decrease hand, wrist and arm pain. 17 The 

increase in strength while utilizing reinforced 

fulcrums and rests occurs from the utilization of 

both hands. The use of both hands allows the 

clinician to use the larger, stronger muscle 

groups in the arms versus the smaller muscle 

groups in the hands. An effective, well 

established finger rest is essential for stability, 

unit control, prevention of injury, comfort to the 

patient and control of length of stroke. 32 

Factors that reduce the risk of repetitive 

strain injuries are: 

� Use of instruments with larger 

diameter handles - requires less 

gripping force 

� Instruments that are textured - 

allow easier gripping 

� Avoidance awkward wrist 

positions 

� Small rest breaks when 

performing repetitive tasks 

� Use of mechanical scaling 

devices - decrease the duration 

of the stressful activity. 

8) Patient positioning sequence: Upper arch 

Patient positioned to a fully supine 

position. Patient must scoot to the end of the 

headrest as reaching or leaning over the ìdeadî 

headrest space can lead to a myriad of 

musculoskeletal dysfunctions. 33 The occlusal 

plane of the upper jaw should be tilted backward 

up to 25 in relation to the vertical plane 34 and 

the occlusal surface should be at elbow level or 

slightly higher while operating. 23 Dentistís 

forearms should be parallel to the floor or 

sloping 10 upward. 23 

9) Patient-positioning sequence: Lower arch 

Patient positioned to a semi-supine 

position (20 elevated from the horizontal supine 

position). The occlusal plane of the lower jaw 

should be parallel to the horizontal plane. 34 The 

height of the patient chair should be adjust so 

that forearms are parallel to the floor or sloping 

10 upward. The height of the patient chair when 

treating the mandibular arch will need to be 

lower than when treating the maxillary arch. 

Wear comfortable, fitted gloves that do 

not restrict or impinge movement. The proper fit 

will help avoid muscle strain while scaling. 

Surgical glove-induced injury is a type of 

musculoskeletal disorder that is caused by 

improperly fitting gloves. Symptoms include 

tingling or pain in the wrist and or fingers and 

numbness. The disorder occurs as a result of 

wearing ambidextrous gloves that are not fitted 

or from wearing gloves that are too tight. It is 

best to wear right-and left-fitted gloves that are 

loose fitting across the palm of the hand and 

wrist. 35 

Management 

There are various approaches to treat 

musculoskeletal problems. The following are 

general guidelines observed successful in 

treating the above- mentioned problems. 36 

1) Health Care Consultation 

If dentists have developed low back pain 

for the first time they should consult: 

ï A health care professional 

(family doctor) 

ï A specialist physiotherapist 




One should also seek advice if there are 

complications to back pain: e.g., 

ï Constant pain, which is 

referred into leg all the way to 

the feet. 

ï Numbness or weak muscle. 

All these circumstances indicate the 

need to consult a health professional. 

2) Relief Exercises 

The purpose of the exercises is to 

abolish pain and to restore normal function, that 

is to regain full mobility in the low back or as 

much movement as possible under the given 

circumstances. 

The exercises programmed consist of 

seven exercises of which four are extension 

(bending backward) exercises and three are 

flexion exercises (bending forward). 

Exercise No. (1) Lying face down; (2) 

Remain face down; (3) Extension in lying; (4) 

Extension in standing; (5) Flexion in lying; (6) 

Flexion in sitting; (7) Flexion in standing. 

In order to determine whether the 

exercise programmed is working effectively or 

not, it is very important to observe closely any 

changes in the intensity or location of pain. 

Centralization of pain that occurs with exercise 

is a good sign. 

3) Medicine and Drugs 

The most common medications used are 

Non Steroidal Anti-Inflammatory Drugs which 

have only a supportive role in treatment of 

MSDís. Most of the common back pains are 

mechanical in origin, drugs and medications are 

not capable or removing the causes of back 

pains. 

4) Bed rest 

When back pain is so severe that bed 

rest of two or three days is advised. 

5) Acupuncture 

Acupuncture is capable to relieve pain 

but it does not correct the underlying mechanical 

problem. 

6) Electro therapy: 

Conclusion 

The primary objective of Ergonomics is 

the prevention of work related musculoskeletal 

disorders, or the symptoms that aggravate these 

disorders. Good working ergonomics is essential 

to achieve maximum work capability, efficiency 

and clinical level of treatment throughout the 

working life of a dental professional. The 

importance of following proper ergonomic 

principles should be realized so that these 

problems can be avoided by creating an 

awareness of the postures, designing of the 

workstation, examining the impact of instrument 

use on upper extremity pain, and following 

healthy work practices to reduce the stress on 

the practitionerís body. 

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Prevent Pain and Extend Your Career. 

Portland, Ore: Posturedontics Press; 

2008. 

34. Hokwerda O, de Ruijter R, Shaw S. 

Adopting a healthy sitting working 

posture during patient treatment. 

optergo.com/uk/images/Adopting.pdf. 

Accessed on March 13, 2010. 

35. Nield-Gehrig, J. S. (2008). 

Fundamentals of periodontal 

instrumentation & advanced root 

instrumentation (6th ed.). Baltimore, 

MD: Lippincott Williams, & Wilkins. 

36. McKenzie R. Acute back and exercises. 

NZ Med J 1994; 107: 318-22. 




ORAL MEDICINE, DIAGNOSIS & ORAL RADIOLOGY 

ORAL MEDICINE, DIAGNOSIS & ORAL RADIOLOGY 

Dr. B.K.VenkataRaman - The father of Oral medicine in India. 

Dr.Joji George 

A BRIEF HISTORY 

Sir Jonathan Hutchinson (1828 ñ 1900) 

a Surgeon at the London hospital is regarded as 

the father of oral medicine. Dental (Oral) 

manifestations of systemic diseases were 

documented by the dermatologist Dr. Erasmus 

Wilson. Sir William Osler recognized the 

importance of Oral cavity with respect to overall 

health. In 1926, Dr. Gile reported to suggest that 

Oral medicine must be included in the dental 

school Curriculum. Dr.Lester Burkett published 

a definitive text book of Oral medicine in 1946 

and stressed the incorporation of Oral medicine 

in the Curriculum. AAOM; The American 

academy of oral medicine was organized in 1945 

by Samuel Charles Miller. European Academy 

of Oral medicine (EAOM) was founded in 

1998.Oral & maxillofacial radiology is the 

newest dental specialty recognized by American 

dental association, ADA. 

Sir Jonathan Hutchinson Sir William Osler Dr.Lester Burket Dr. Gile 

Oral Medicine, Diagnosis & Oral 

Radiology ñin India 

Government dental college (GDC), Bangalore is 

the first institute to start Oral medicine, 

diagnosis and Oral radiology as a new speciality 

and included in the curriculum of BDS in 1966 

and GDC, Bangalore was the first institute to 

start MDS course in Oral medicine, diagnosis & 

radiology in 1970. 

The first OPG, x ñ Ray Unit of India was 

commissioned and installed in GDC, Bangalore 

in 1970. It was a gift from WHO. 

Dr. B.K.VenkataRaman was the founder of Oral 

medicine, diagnosis and Oral radiology specialty 

in India (1966). He was the first professor of 

Oral medicine diagnosis and oral radiology in 

India (1966) GDC, Bangalore) 

In 1982, 20 th June, Indian academy of Oral 

medicine (which was renamed to Indian 

academy of Oral medicine and radiology) was 

founded. The founder members were Dr. B.K 

Venkataraman and Dr. Ramachandra Reddy in 

Bangalore (Karnataka Societyís registration Act 

1960) 

Indian academy of Oral medicine & Radiology 

launched its official publication, Journal of 

Indian Academy of Oral medicine & Radiology 

in the year 1986. 

Dr. B.K.VenkataRaman - The 

father of Oral medicine in India. 

Dr.B.K.VenkataRaman, the father of 

Oral medicine in India was born in Hiriyur ; a 

village of Chitradurga which belonged to old 

Mysore State. 




Born to Dr. Krishnaswamy, the famous 

doctor in Mysore and Mrs. Mangaryakarazi 

(means: Queen among women) in the year 1925, 

Dr. B.K.Venkataraman graduated in 1949. After 

his MBBS graduation, he was appointed as a 

human anatomy lecturer in Mysore medical 

college in 1950 and later on an Ophthalmology 

lecturer. He worked there for 4 1/2years and 

after that he was appointed as the assistant 

surgeon in various hospitals in Karnataka state. 

Government of Karnataka deputed him to 

Bombay, from where he took BDS in 1961. 

Having graduation in the field of medicine and 

dentistry, he had the spirit of combining the oral 

medicine and systemic medicine. Govt. of 

Karnataka posted him as the professor of oral & 

maxillofacial surgery in government dental 

college, Bangalore .Services in the field of 

dental surgery in the department of oral surgery 

paved the way to USA, for mastering in oral 

medicine oral pathology and endocrinology. 

World health organization (WHO) was the soul 

agency behind this. Again he was deputed to 

Germany to have the training in cleft palate 

surgery. There he worked as the professor of 

facial surgery, Oral pathology and oral diagnosis 

department. 

Dr.B.K.Venkataraman. Dr.B.K.Venkataraman and Dr.Joji George 

After having rendered the fabulous Scientific 

Studies & researches he returned to his mother 

land, India. A Herculean task of introducing the 

new specialty of oral medicine, diagnosis and 

oral radiology in the curriculum of BDS course 

for first time in India was on the shoulders of 

Dr.B.K.Venkataraman. Year 1966 witnessed this 

great event of marking a legend in the historical 

timeline of India. 

In 1970, The master degree 

Course; MDS- a 3 year programme for oral 

medicine,diagnosis and oral radiology was 

started in Government dental college Bangalore 

for the first time in Indian history, under the 

guidance of this great professor. After that in 

1979, he moved on to Libya, an African Country 

where he was appointed as the professor and 

chairman of periodontia, oral medicine, oral 

diagnosis & oral radiology. In 1972 he also 

worked in St. Marthaís hospital, Bangalore- a 

famous Catholic hospital in Bangalore. 




He had become the president of Dental 

Council of India and president of Karnataka 

state dental council for 5 years 

Award By Dental Council Of India to Dr.B.K.Venkataraman 

Other meritorious credentials of Dr. 

B.K.Venkitaraman were principal of Govt. 

dental, College, Bangalore, Prof. Oral Medicine 

and Vice Principal, Govt. Dental College, 

Bangalore, Prof. Oral and Maxillofacial Surgery, 

Prof. Oral Pathology, Dean, Faculty of 

Medicine, Bangalore University, Chairman of 

International College of Dentists (USA), Indian 

Section, Chairman of Pierre Fauchard Academy 

(USA), Indian Section, Chairman and professor 

conservation Depts., Faculty of Dentistry, 

Benghazi, Libya, Principal MRA Dental 

College, Bangalore, Principal Dr. Ambedkar 

Medical College, Bangalore, Dean Sri 

Siddhartha Dental College, Tumkur and 

Academic Director of Sri Rajarajeshwari Dental 

College, Bangalore. 

At present, he bears the glorious rank of patron 

of IAOMR, Indian association of oral medicine 

& Radiology (log on to IAOMR website.) 

He is married to Mrs. Bhuvaneswari and 

blessed with one Son, Dr. Murali Mohan and 

one daughter Mrs. Sujaya Lakshmi. Dr. Prathima 

and Dr. Col.V.Bhaskaran are his daughter ñinlaw 

and son ñ in - law respectively. 

The Brilliance of his knowledge and the 

genius in him thrilled many in the field of 

medicine & dentistry. The author of this article 

had a golden opportunity to feel the evergreen 

******************** 

outflow of his proficient orations & profound 

lectures delivered during his post as a Dean of 

Sree Siddhartha dental College, Tumkur. 

According to, Dr. B.K. Venkataraman, 

Honesty is the best policy and service to the 

millions of poor and illiterate masses of our own 

country without any expectation must be the aim 

and motto of the noble profession of being a 

dental surgeon; a doctor. 

May the almighty shower his abundant 

blessings on our great Indian Guru and founder 

of Oral medicine, diagnosis and oral radiology 

in India forever & ever 

Long live Dr. B.K.Venkataraman and his 

school of thought. 

References 

1. www.iaomr2011conference.com 

2. https://www.karnatakastatedentalcouncil 

.com/Abtpresident.aspx 

3. iaomr.org/pastpresident.htm 

4. www.kaomfr.org/board/bd_download.ht 

ml?boardid=bd 

5. books.google.co.in/books?isbn=813121 

5679... 




ëSATISFACTORY SMILEí WITH A RESTORATIVE APPROACH- 

A CASE REPORT 

Abstract 

Dr. Rekha Rao, Dr. Sanjith Simon (Reader), Reader, Dept. Of Conservative Dentistry & Endodontics, Century 

International Institute Of Dental Research Centre, Poinachi, Kasaragod. 

Dr. Shashi Rashmi Acharya, Professor, Dept. Of Conservative Dentistry & Endodontics, MCODS, Manipal. 

In attempting to provide a solution for cases that have been compromised by malpositioned anterior teeth, 

clinicians traditionally decide orthodontic approach. Nevertheless in some cases changes in tooth 

morphology, tooth size and shape is compulsory for optimal esthetics. The advent in contemporary 

esthetic materials and preparation techniques empowered the clinicians to deliver a promising result with 

minimal biologic cost. This article presents the clinical consideration that must be addressed when 

providing a prosthetic restoration of crowded anterior teeth. A 23yr old female patient who had 

malaligned anterior teeth was rehabilitated with endodontic therapy and all-ceramic crowns due to her 

rejection of orthodontic treatment. 

Key words 

Malpositioned teeth, endodontic therapy, all ceramic crowns, resin cement 

Introduction 

CONSERVATIVE DENTISTRY AND ENDODONTICS 

Maxillary anterior teeth provide an existing 

challenge to our artistic and technical abilities 

and call upon our knowledge of smile design, 

principles of proportion, symmetry, harmony 

and tooth morphology. Smile rejuvenation can 

positively impact a patientís self esteem and 

emotional health through improved appearance. 

[1] Many patients have slightly crowded or 

overlapping anterior teeth that are not an esthetic 

problem. However, when an individual who 

finds this situation unesthetic seeks treatment, it 

may present a challenge for the dentist. 

Choosing the correct approach is the most 

important aspect of the treatment. The most 

conservative alternative of crowded anterior 

teeth is orthodontic approach. Nevertheless 

orthodontic therapy may be rejected by the 

patient, due to occupational limitations of time 

and appearance during treatment. The potential 

for orthodontic relapse has inspired the use of 

tooth preparation and restorative dentistry to 

recreate tooth dimensions and proportions 

commensurate with post orthodontic results 

from both esthetic and functional clinical 

outcome, thereby eliminating the potential for 

relapse. [2] 

Case presentation 

A 22yr old female patient came to my practice 

with a chief complaint of malaligned teeth and 

desired a more esthetic smile. She also desired 

results in a short period of time. On clinical 

examination, the distal line angle of two central 

incisors were overlapping the mesial aspect of 

respective lateral incisors. (Fig-1) Oral hygiene 

was satisfactory and soft tissue health of the 

patient was good. She exhibited an Angleís class 

I malocclusion with anterior crowding. Left 

central incisor showed a discoloured class III 

composite restoration and a slight discoloration 

of the tooth. Vitality test showed a negative 

response in relation to left central incisor tooth. 




Intra oral periapical radiograph of the region 

(Fig-2) showed periapical changes indicating 

apical periodontitis with irreversible pulpitis. So 

endodontic therapy of 21 was indicated. 

As the patient wanted immediate esthetic 

treatment, orthodontic therapy for the derotation 

of the teeth was not choosen, instead 

conventional endodontic therapy for left central 

incisor and intentional endodontic therapy for 

Fig-1 ñPre-operative view 

Fig - 2 Pre-operative IOPA 

Fig-3-IOPA showing obdurated incisors 

Access cavity of the incisors were restored with 

composite which was continued with a free hand 

palatal build up to allign the rotated incisors 

into the labial arch.(Fig-4) Shade selection was 

the right central incisor were planned and allceramic 

crowns were considered. 

Treatment Done 

Endodontic treatment of 21 was completed. With 

the consent of the patient, elective endodontic 

therapy was executed on 11 to avoid 

compromising the pulp during crown 

preparation.(Fig-3) 

done with a value based system. Tooth 

preparation were done for All ceramic crowns 

with an equigingival shoulder margin.(Fig-5) 




Fig-4-Free hand palatal build up of composite 

Fig-5-Tooth preparation 

Gingival retraction was done and impressions 

were made with rubber base impression material 

after which temporary crowns were cemented. In 

Discussion 

Esthetics has become the major component of 

modern dentistry. Ortodontics can be used to 

facilitate esthetic dentistry in many ways and it 

is also part of conservative treatment for 

remodelling the dental appearance and smile. 

However when the patient rejects the 

orthodontic treatment due to occupational time 

limitation, appearance during treatment or 

esthetics and psychological concerns, other 

alternative has been available for the patient. [3] 

In this case orthodontic treatment was offered to 

the patient but the suggestion was rejected. The 

commonest methods for rehabilitating the 

problem of malalignment without orthodontic 

therapy is by the fabrication of veneers and 

crowns. The goals of therapy for orthodontic and 

Fig-6-Post-operative view 

the next appointment all-ceramic crowns were 

cemented with resin cement. (Fig-6) 

restorative dentistry are similar, how they 

achieve the results is the only difference. [2] 

Development of an appropriate treatment plan 

for the correction of crowded teeth should 

follow a stategy. First it is necessary to identify 

what type of correction and how much 

correction of tooth contour are required to 

achieve the desired esthetic results. Then it 

becomes necessary to evaluate the dentition, 

identify clinical limitation to treatment, and 

select appropriate restorative options that will 

accomplish the esthetic outcome. [4] 

I n our case as one tooth was nonvital with 

periapical periodontitis, endodontic treatment 

was done. The ability to reposition the crown 

into ideal esthetic location can more easily be 

accomplished when the tooth has been treated 




with rootcanal. So an elective endodontic 

treatment for the adjacent tooth was done. [5] 

The decision whether to laminate or crown 

should be made primarily on the position of the 

overlapping teeth. To restore the arch or near the 

labial most position of the teeth porcelain 

laminates can be used. However if the choice is 

to use maximum position (including vital pulp 

extripation) then crowns will probably be the 

best choice. [4] 

The selection of the best restoration for an 

endodontically treated tooth in the esthetic zone 

depends on strength and the ability to recreate 

the form, function and esthetics of the natural 

tooth. The increased use of all ceramic system is 

a result of improved ceramic materials and 

adhesive systems. All ceramic systems offer a 

promising alternative for the restoration of 

anterior teeth and short term clinical evaluation 

have demonstrated high success rate. [6] 

Resin based cements were developed to 

overcome the drawbacks of nonresinous 

materials including low strength, high stability 

and opacity. Resin materials are indicated for 

luting all-ceramic restorations. Correct choice of 

luting material with optimal physical properties 

is centre to success in indirect restorations. [7] 

Conclusion 

The new smile was satisfactory for the patient 

and the esthetics was considered as excellent. 

References 

************************ 

1. Rosenthal l. Aesthetic smile 

enhancement using porcelain laminate 

veneers. Practical Periodontics and 

Aesthetic Dentistry Winter 1995 

Supplement 2-8. 

2. Kim J, Chu S, Gurel G, Cisneros G. 

Restorative space management: 

treatment planning and clinical 

considerations for insufficient space. 

Pract Proced Aesthet Dent. 2005;17:19- 

25. 

3. Javaheri D. Considerations for planning 

esthetic treatment with veneers 

involving no or minimal preparation. J 

Am Dent Assoc.2007;138:331-337. 

4. Geoffrey W.Sheen, Ronald E. Goldstein, 

Steven T.Hackman, Restorative 

Treatment of Crowded Teeth, Chapter 

24. 

5. Fradeani M, Aquilino a, Barducci G. 

Aesthetic restoration of endodontically 

treated teeth. Pract Periodont Aesthet 

Dent 1999;11:761-8. 

6. Trushkowsky RD, Esthetic and 

functional consideration in restoring 

endodontically treated teeth. Dent Clin 

North Am, 2011 Apr;55(2):403-10. 

7. Burke FJ. Trends in indirect dentistry: 3. 

Luting materials, Dent Update. 2005, 

Jun;32(5):251-4,257-8,260. 




Background 

Oral submucous fibrosis (OSF) is a chronic 

debilitating disease and a potentially 

malignant condition of the oral cavity 

associated with betel nut chewing. 

OSF is characterized by a generalized 

submucosal fibrosis of the oral soft tissue, 

resulting in marked rigidity and progressive 

inability to open the mouth (Cox, 1996; 

Aziz, 1997). 

In patients with OSF, the buccal mucosa is 

the most commonly involved site, but any 

part of the oral cavity and, occasionally, the 

pharynx can be involved (Paissat, 1981). 

Introduction 

Oral sub mucous fibrosis is a chronic, 

progressive, scarring disease that 

predominantly affects the people of South- 

East Asian origin. 

This condition was described first by 

Schwartz (1952), to which he ascribed the 

descriptive term ìatrophia idiopathica 

(tropica) mucosae orisî. 

Later in 1953, Joshi from Bombay 

redesignated the condition as oral sub 

mucous fibrosis, implying predominantly its 

histological nature. 

The onset of the disease is insidious over a 

2-5 year period. 

The prodromal symptoms (early OSF) 

include a burning sensation in the mouth 

when consuming spicy food, appearance of 

blisters, ulcerations of recurrent generalized 

inflammation of the oral mucosa, petechiae, 

excessive salivation, defective gustatory 

sensation and dryness of the mouth. 

ORAL MEDICINE 

ORAL SUB MUCOUS FIBROSIS 

Dr:STIFFY KUKREJA, KUKREJA DENTAL CARE, PANCHKULA, HARYANA STATE 

As the disease progresses (advanced OSF), 

the oral mucosa becomes blanched and 

slightly opaque and white fibrous bands 

appear. The Buccal mucosa and the lips are 

affected at an early stage. 

The oral mucosa is involved symmetrically 

(with possible exception) and the fibrous 

bands in the buccal mucosa run in a vertical 

direction. 

Aetiology 

There is a compelling evidence to implicate 

the habitual chewing of areca nut with the 

development of OSF. 

Other forms of pan masala 

Prevalence 

The prevalence of oral sub mucous fibrosis 

is increasing in India, from an estimated 

2,50,000 cases in 1980 to an estimated 2 

million cases in 1993 

The rapidly increasing prevalence of this 

habit is judged from the reports that the 

Indian market for pan masala is worth 2000 

million (US $ 116 million). 

Oral sub mucous fibrosis associated with 

chewing of betel nut products has an 

estimated prevalence of 0.2-1.2% in India. 

In oral sub mucous fibrosis there is an 

increased incidence of oral cancer of 7.6% 

for a median 10 year follow up period. 

The reported prevalence of SMF in 

Bhavnagar Dist in 1967 was 0.16%. In the 

resurvey of the same area by the same group 

in 1998, the prevalence increased to 3.36% 




The prevalence of SMF in teenage school 

children is 1.98% in Bhopal city . 

Hazare and Goel have worked out the 

relative risk for developing SMF by pan 

masala consumption, which showed 

proportionate increase with the increase in 

pan masala use. 

RELATIVE RISK OF ORAL 

SUBMUCOUS FIBROSIS BY THE 

DAILY FREQUENCY OF ARECA NUT 

USE 

PREVALENCE OF TOBACCO USE 

AMONG SUBJECTS WITH ORAL 

SUBMUCOUS FIBROSIS (OSF) 

Pathophysiology 

The pathogenesis of the disease is not well 

established, but OSF is believed to have 

multifactorial causes. 

A number of factors trigger the disease 

process by causing a juxtaepithelial 

inflammatory reaction in the oral mucosa. 

Factors include areca nut chewing, 

ingestion of chilies, genetic and 

immunologic processes, nutritional 

deficiencies, and other factors. 

Areca nut (betel nut) chewing 

The areca nut component of betel quid plays 

a major role in the pathogenesis of OSF 

(Liao, 2001). 

Arecoline, an active alkaloid found in betel 

nuts, stimulates fibroblasts to increase 

production of collagen by 150% (Canniff, 

1981). Flavanoid, catechin, and tannin in 

betel nuts cause collagen fibers to cross-link, 

making them less susceptible to collagenase 

degradation (Harvey, 1986). 

This results in increased fibrosis by causing 

both increased collagen production and 

decreased collagen breakdown (Aziz, 1997). 

OSF remains active even after cessation of 

the chewing habit, suggesting that 

components of the areca nut initiate OSF 

and then affect gene expression in the 

fibroblasts, which then produce greater 

amounts of normal collagen (van Wyk, 

1993; Meghji, 1987). 

Arecoline is an inhibitor of 

metalloproteinases (particularly 

metalloproteinase-2) and a stimulator of 

tissue inhibitor of metalloproteinases, thus 

decreasing the overall breakdown of tissue 

collagen (Chang, 2001). 

In 3 separate but similar studies, 

keratinocyte growth factor-1, insulinlike 

growth factor-1, and interleukin 6 

expression, which have all been implicated 

in tissue fibrogenesis, were also significantly 

up-regulated in OSF (Tsai, Feb 2005; Tsai, 

Oct 2005; Tsai, Nov 2005). 

Areca nuts have also been shown to have a 

high copper content, and chewing areca nuts 

for 5-30 minutes significantly increases 

soluble copper levels in oral fluids. 

This increased level of soluble copper 

supports the hypothesis that copper acts as 

an initiating factor in OSF by stimulating 

fibrogenesis through up-regulation of copper 

dependent lysyl oxidase activity (Trivedy, 

2000). 

Ingestion of chilies 

The role of chili ingestion in the 

pathogenesis of OSF is controversial. 

The incidence of OSF is lower in Mexico 

and South America than in India despite the 

higher dietary intake of chilies (Pillai, 1962). 

A hypersensitivity reaction to chilies is 

believed to contribute to OSF (Aziz, 1997). 

One study demonstrated that the capsaicin 

in chilies stimulates widespread palatal 

fibrosis in rats (Sirsat, 1960), while another 

study failed to duplicate the results 

(Hamner, 1974). 




Genetic and immunologic processes 

A genetic component is assumed to be 

involved in OSF because of reported cases 

of OSF in nonñbetel nut chewers (Liao, 

2001). 

There is an increased frequency of human 

leukocyte antigen A10 (HLA-A10), human 

leukocyte antigen B7 (HLA-B7), and human 

leukocyte antigen DR3 (HLA-DR3) (Aziz, 

1997). 

Recently some authors demonstrated 

increased levels of proinflammatory 

cytokines and reduced antifibrotic interferon 

gamma (IFN-gamma) in patients with OSF, 

which may be central to the pathogenesis of 

OSF (Haque, 2000). 

An immunologic process is believed to play 

a role in the pathogenesis of OSF (Canniff, 

1985). The increase in CD4 complement and 

cells with HLA-DR in OSF tissues suggests 

that most lymphocytes are activated and that 

the number of Langerhans cells is increased. 

The presence of these immunocompetent 

cells and the high ratio of complement CD4 

to CD8 in OSF tissues suggest an ongoing 

cellular immune response that results in an 

imbalance of immunoregulation and 

alteration in local tissue architecture (Haque, 

1997). 

Nutritional deficiencies 

Iron deficiency anemia, vitamin B complex 

deficiency, and malnutrition are promoting 

factors that derange the repair of the 

inflamed oral mucosa, leading to defective 

healing and scarring (Aziz, 1997). 

The resulting atrophic oral mucosa is more 

susceptible to the effects of chilies or betel 

nuts. 

Other significant factors 

Some authors have found a high frequency 

of mutations in the APC gene and low 

expression of wild-type TP53 tumor 

suppressor gene product in patients with 

OSF, providing some explanation for the 

increased risk of oral squamous cell 

carcinoma development in patients with 

OSF (Liao, 2001). 

Other studies have suggested that altered 

expression of retinoic acid receptor-beta 

may have a relation to disease pathogenesis 

(Kaur, 2004). 

Frequency: 

Internationally: Worldwide, estimates of 

OSF indicate that 2.5 million people are 

affected, with most cases concentrated on 

the Indian subcontinent, especially southern 

India (Cox, 1996). 

The rate varies from 0.2-2.3% in males and 

1.2-4.57% in females in Indian communities 

(Aziz, 1997). OSF is widely prevalent in all 

age groups and across all socioeconomic 

strata in India. 

A sharp increase in the incidence of OSF 

was noted after pan parag came onto the 

market, and the incidence is increasing. OSF 

also occurs in other parts of Asia and the 

Pacific Islands (Cox, 1996). 

Mortality/Morbidity: 

OSF has a high rate of morbidity because of 

the progressive inability to open the mouth, 

resulting in difficulty eating and nutritional 

deficiencies. OSF also has a significant 

mortality rate because of transformation to 

oral cancer, particularly SCC, with a rate 

being in the order of 7.6% (Aziz, 1997). 

Race: 

OSF occurs on the Indian subcontinent and 

in Indian immigrants to other countries as 

well as among Asians and Pacific Islanders 

(Cox, 1997). 

Sex: 




The male-to-female ratio of OSF was found 

to be 1:7 in a study from Durban, South 

Africa. Studies in Pakistan found a male-tofemale 

ratio of 1:2.3 (Aziz, 1997). The 

male-to-female ratio in betel nut chewers 

was found to be 1:9. 

Age: 

The age range in patients with OSF is wide 

and regional; it is even prevalent among 

teenagers in India. In a study performed in 

Saipan, 8.8% of teenagers with a mean age 

16.3 years (±1.5 y) were found to have OSF 

(Oakley, 2005). Generally, patient ages 

range from 14-60 years; most patients are 

aged 45-54 years and chew betel nuts 5 

times per day (Aziz, 1997). 

Clinical features: 

Symptoms of OSF include the following 

(Murti, 1992; Cox, 1996): 

Progressive inability to open the mouth 

(trismus) due to oral fibrosis and scarring 

Oral pain and burning sensation upon 

consumption of spicy foodstuffs 

Other symptoms 

Increased salivation 

Change of gustatory sensation 

Hearing loss due to stenosis of the 

eustachian tubes 

Dryness of the mouth 

Nasal tonality to the voice 

Dysphagia to solids (if the esophagus is 

involved) 

Impaired mouth movements (eg, eating, 

whistling, blowing, sucking) 

Staging of OSF 

OSF is clinically divided into 3 stages 

(Pindborg, 1989), and the physical findings 

vary accordingly, as follows (Murti, 1992; 

Cox, 1996; Aziz, 1997; Pindborg, 1989): 

Stage 1: Stomatitis includes erythematous 

mucosa, vesicles, mucosal ulcers, melanotic 

mucosal pigmentation, and mucosal 

petechia. 

Stage 2: Fibrosis occurs in ruptured vesicles 

and ulcers when they heal, which is the 

hallmark of this stage. 

Early lesions demonstrate blanching of the 

oral mucosa. 

Older lesions include vertical and circular 

palpable fibrous bands in the buccal mucosa 

and around the mouth opening or lips, 

resulting in a mottled marblelike appearance 

of the mucosa because of the vertical, thick, 

fibrous bands running in a blanching 

mucosa. Specific findings include the 

following: 

Reduction of the mouth opening (trismus) 

Stiff and small tongue 

Blanched and leathery floor of the mouth 

Fibrotic and depigmented gingiva 

Rubbery soft palate with decreased mobility 

Blanched and atrophic tonsils 

Shrunken budlike uvula 

Sinking of the cheeks, not commensurate 

with age or nutritional status 

Stage 3: Sequelae of OSF are as follows: 

Leukoplakia is precancerous and is found in 

more than 25% of individuals with OSF. 

Speech and hearing deficits may occur 

because of involvement of the tongue and 

the eustachian tubes. 




Classification system for the surgical 

management of trismus has been developed 

by Khanna and Andrade, 1995. 

Group I: This is the earliest stage and is not 

associated with mouth opening limitations. 

It refers to patients with an interincisal 

distance greater than 35 mm. 

Group II: This refers to patients with an 

interincisal distance of 26-35 mm. 

Group III: These are moderately advanced 

cases. This stage refers to patients with an 

interincisal distance of 15-26 mm. Fibrotic 

bands are visible at the soft palate, and 

pterygomandibular raphe and anterior pillars 

of fauces are present. 

Group IV A: Trismus is severe, with an 

interincisal distance of less than 15 mm and 

extensive fibrosis of all the oral mucosa. 

Group IV B: Disease is most advanced, with 

premalignant and malignant changes 

throughout the mucosa. 

ORAL CHANGES IN PAN MASALA 

USERS 

1.Melanin pigment changes 

2.Sub mucous fibrosis 

3.Leukoplakia 

4.Erythroplakia 

5.Squamous cell carcinoma 

Pigmentary changes 

Leukoplakia 

Erythroplakia 

Oral cancer 

Systemic changes in pan masala users 

1.Anxiety 

2.Desperation 

3.Depression. 

4.Loss of temper 

5.Mental derangement. 

6.Suicidal tendencies. 

7.Homo sexuality 

8.Impotency 

Lab Studies: 

No specific laboratory tests are available for 

OSF. Some OSF studies report the following 

laboratory findings: 

Decreased hemoglobin levels 

Decreased iron levels 

Decreased protein levels 

Increased erythrocyte sedimentation rate 

Decreased vitamin B complex levels 

Other Tests: 

Cytologic smears may be performed. 

A neural networkñbased oral precancer 

stage detection method has been proposed 

(Paul, 2005). This new technique uses 

wavelet coefficients from transmission 

electron micrography images of 

subepithelial fibrillar collagen in normal oral 

submucosa and in OSF tissues. 

These wavelet coefficients are used to 

choose the feature vector, which, in turn, can 

be used to train an artificial neural network. 

This trained network is able to classify 

normal and oral precancer stages (less 

advanced and advanced) after obtaining the 

image as an input. It may be used as an 

adjunct to hematoxylin and eosin histologic 

evaluations in the near future. 

Procedures: 




Currently, oral biopsy provides the most 

definitive diagnosis and is crucial because of 

the association of OSF with oral cancer 

(Aziz, 1997). 

Histological Findings: Histologic findings 

vary according to the stage of the disease. 

Very early stage 

Fine fibrillar collagen, marked edema, large 

fibroblasts, dilated and congested blood 

vessels, and inflammatory infiltrates 

(primarily polymorphonuclear leukocytes 

and eosinophils) are found. 

Early stage 

Early hyalinization is characterized by 

thickened collagen bundles, moderate 

numbers of fibroblasts, and inflammatory 

cells (primarily lymphocytes, eosinophils, 

and plasma cells). 

Moderately advanced and advanced 

stages 

Dense bundles and sheets of collagen, thick 

bands of subepithelial hyalinization 

extending into the submucosal tissues 

(replacing fat or fibrovascular tissue), 

decreased vascularity, no edema, and 

inflammatory cells (lymphocytes and plasma 

cells) are found. 

OSF is generally characterized by diffuse 

hyalinization of the subepithelial stroma 

with pigment incontinence from the 

overlying epithelial melanin (Pindborg, 

1985). Other histologic findings include an 

atrophic epithelium and intercellular edema, 

with or without hyperkeratosis, 

parakeratosis, or orthokeratosis; epithelial 

dysplasia (25% of patients who underwent 

biopsy); squamous cell carcinoma 

histologically identical to garden-variety 

squamous cell carcinomas; chronic 

inflammation and fibrosis in the minor 

salivary glands in the area of quid 

placement; and atrophy of the underlying 

muscle (Pingborg, 1966; Canniff, 1986). 

Ultrastructural changes in OSF include an 

increase in collagen type I; however, fibrils 

retain the normal structure (van Wyk, 1990). 

Histopatholgy 

Atrophy of epithelium with mild to 

moderate hyalinization of collagenic fibers( 

low power) 

Treatment modalities 

Medical Care: 

The treatment of patients with OSF depends 

on the degree of clinical involvement. If the 

disease is detected at a very early stage, 

cessation of the habit is sufficient. 

Most patients with OSF present with 

moderate-to-severe disease. Moderate-tosevere 

OSF is irreversible. Medical 

treatment is symptomatic and aimed at 

improving mouth movements. 

Treatment includes the following (Aziz, 

1997): 

Steroids: In patients with moderate OSF, 

weekly submucosal intralesional injections 

or topical application of steroids may help 

prevent further damage. 

Placental extracts: The rationale for using 

placental extract (PE) in patients with OSF 

derives from its proposed anti-inflammatory 

effect (Sur, 2003), hence, preventing or 

inhibiting mucosal damage. Cessation of 

areca nut chewing and submucosal 

administration of aqueous extract of healthy 

human PE (Placentrex) showed marked 

improvement of the condition (Anil, 1993). 

Hyaluronidase: The use of topical 

hyaluronidase has been shown to have 

quicker improvement in symptoms 

compared with steroids alone. The 

combination of steroids and topical 

hyaluronidase shows better long-term results 

than either agent used alone (Kakar, 1985). 




IFN-gamma: This plays a role in the 

treatment of patients with OSF because of 

its immunoregulatory effect. IFN-gamma is 

a known antifibrotic cytokine. Patients 

treated with an intralesional injection of 

IFN-gamma experienced improvement of 

symptoms. IFN-gamma, through its effect of 

altering collagen synthesis, appears to be a 

key factor to the treatment of patients with 

OSF, and intralesional injections of the 

cytokine may have a significant therapeutic 

effect on OSF (Haque, 2001). 

The role of PEs, hyaluronidase, and 

interferon is still evolving. The US Food and 

Drug Administration has not yet approved 

these drugs for the treatment of OSF. 

Surgical Care: Surgical treatment is 

indicated in patients with severe trismus 

and/or biopsy results revealing dysplastic or 

neoplastic changes. Surgical modalities that 

have been used include the following: 

Simple excision of the fibrous bands: 

Excision can result in contracture of the 

tissue exacerbating the condition. 

Split-thickness skin grafting following 

bilateral temporalis myotomy or 

coronoidectomy: Trismus associated with 

OSF may be due to changes in the 

temporalis tendon secondary to OSF; 

therefore, skin grafts may relieve symptoms 

(Canniff, 1986). 

Nasolabial flaps and lingual pedicle flaps: 

Surgery to create flaps is performed only in 

patients with OSF in whom the tongue is not 

involved (Kavarana, 1987; Hosein, 1994). 

Consultations: 

Consult an ear, nose, and throat specialist 

for evaluation of dysplasia and close followup 

monitoring for the development of oral 

cancer. 

Consult a plastic surgeon for patients with 

severe trismus, in whom reconstructive 

surgery may be possible. 

Diet: Dietary focus should be on reducing 

exposure to the risk factors, especially the 

use of betel quid, and correcting any 

nutritional deficiencies, such as iron and 

vitamin B complex deficiencies (Cox, 

1996). 

Activity: Muscle stretching exercises for the 

mouth may be helpful to prevent further 

limitation of the mouth. 

Further Outpatient Care: 

Regular physical examinations, biopsy 

specimen analysis, and cytologic smear 

testing should be scheduled to detect oral 

dysplasia or carcinoma, especially in 

patients with severe OSF. 

Patients with surface leukoplakias require 

close follow-up monitoring and repeat 

biopsies. 

Patients with dysplasias and carcinomas 

should receive routine treatment for these 

entities (Borle, 1991). 

Prognosis: 

No treatment is effective in patients with 

OSF, and the condition is irreversible 

(Murti, 1985; Jayanthi, 1992). Recent 

reports claim improvement of the condition 

if the habit is discontinued following 

diagnosis at an early stage (Anil, 1993). 

Patients with OSF have an increased risk of 

developing oral cancer. The malignant 

potential and the origin of cancer were 

attributed to the generalized epithelial 

atrophy in OSF (Murti, 1985). 

Patient Education: 

Instruct patients regarding the importance of 

discontinuing the habit of chewing betel 

quid. 




Inform patients that eliminating tobacco 

from the quid product may reduce the risk of 

oral cancer. 

Instruct patients to avoid spicy foodstuffs. 

Instruct patients to eat a complete and 

healthy diet to avoid malnutrition. 

Instruct patients regarding maintaining 

proper oral hygiene and scheduling regular 

oral examinations. 

Intervention studies and public health 

campaigns against oral habits linked to OSF 

may be the best way of controlling the 

disease at the community level. Educate the 

community regarding the local adverse 

effects of chewable agents, which although 

not inhaled, are still not harmless. 

Special Concerns: 

Watch for signs that indicate malignant 

change, which include the following: 

An unhealing ulcer in the lesion 

Lesion undergoing red changes 

(erythroplakia) 

A burning sensation in the mouth 

An exophytic mass 

A lump in the neck 

Difficulty in chewing, swallowing, or 

speaking 

CONCLUSION 

There is a ban in some of the states like 

Tamilnadu & A.P on pan masala containing 

gutka and legal ban by a few high courts of 

India. 

******************** 

Despite the ban there is a feeling that the 

consumption of pan masala is on the 

increase. 

Therefore a central legislation is urgently 

needed to control production, storage and 

sale of pan masala especially with gutka. 

REFERENCES 

Babu Mathew:The cultural aspects of betel 

quid chewing.abstract book XI world 

conference on tobacco and 

health,Chicago,vol 2 page 288, 2000 

Samar Halrarnkar:a new way to die? India 

today aug 11,pages 72-73 1997 

Manjit Singh:localized submucous fibrosis 

in pan masala chewing college students 

coming for orthodontic treatment-personal 

communication, 1995 

P.C Gupta ,P.N Sinor,R.B.Bhonsle et al: 

Oral submucous fibrosis in India:A new 

epidemic? Vol 11, no,3,1998 page 113 ñ116 

5. P.C Gupta, Pindborg J.J: Comparison of 

carcinogenicity of betel quid with and 

without tobacco:an epidemiological review; 

Entrez-PubMed(1982) Vol 1:213-219 

Sanyal. Prevalence of oral submucous 

fibrosis in school children of Bhopal city 

(personal communication 2004) 

Hazare and Gupta. Osmf, arecanut & pan 

masala use- A case control study; National 

Medical Journal of India (1998) 11: page 

299 

Babu Mathew: pan masala : A prelude to 

oral cancer epidemic in south east Asia- 

International journal of cancer. 

Supplement13,pages80-81,2002 




ABSTRACT 

Early Orthodontic intervention 

A Surgical case to a Non surgical case ñ is it possible??? 

Dr.P.U.Bijoy, MDS, Reader, Annoor Dental College, Muvattupuzha, Eranamkulam. 

Skeletal Class II malocclusion is not a single entity but rather it can result from numerous 

combinations of components like 

1. Retrognathic mandible. 

2. Prognathic Maxilla. 

3. Increased vertical growth. 

4. Combinations of above. 

Among that Retrognathic mandible is the most common one. The treatment of 

choice is Myofunctional appliances, but it is not beneficial in patients with increased lower facial 

height and vertical growth pattern. Myofunctional appliance increases the lower facial height and 

negates the treatment benefits in those patients. 

Tueshre modified activators with headgear to control vertical growth along with 

mandibular advancement. Clark also suggested using extra oral traction along with twin block to 

give intrusive effect in the maxillary posterior segment. 

Maxillary Intrusion Splint is another appliance which is found effective in correction of 

class to with vertical maxillary excess. 

A combination of Maxillary Intrusion splint with twin block is the treatment of choice in 

cases with severe skeletal class II with increase lower facial height. 

CASE REPORT 

ORTHODONTICS 

An 11 year old girl came to the clinic with severe skeletal class II. Family history revealed mother had 

similar malocclusion and underwent Orthognathic surgery. The mother wanted correction of the 

Daughterís malocclusion without surgery. 

On clinical examination she had convex profile,Retrognathic mandible, increased lower 

anterior facial height, vertical growth pattern,gummy smile, severe protrusion of upper anteriors. She had 

an overjet of 13mm. 

Since she was in prepubertal growth period, the treatment plan was to use maxillary intrusion 

splint with twin block appliance for growth modification and later fixed appliance therapy for Dentoalveolar 

correction. 




1 st phase of treatment with MIS with twin block took almost three and a half years. Then as 

planned, extraction of all the first bicuspids done which was followed by pre adjusted appliance for 

another two years. 

The post treatment result shows balanced facial profile, reduced overjet, improved mandibular 

and chin position and good smile. 

Even though the treatment took more than 5 years to complete, the post treatment result proved it 

was worth while. 

PRE TREATMENT 

APPLIANCE 




AFTER FUNCTIONAL APPLIANCE 

Post treatment after fixed Appliance 

Acknowledgements 

I express my Sincere thanks to Dr.C.J.Paul, Chavakkad for giving me enough support while 

treating this case. 

******************* 




IMPLANT SUPPORTED OVERDENTURE IN THE REHABILITATION OF 

THE ATROPHIC MANDIBLE 

Dr. BYJU PAUL KURIAN MDS,Professor, Dept. of Prosthodontics, Annoor Dental College, Muvattupuzha 

Dr RANJITH KUMAR. P MDS,Reader, Dept. Of Prosthodontics,Royal Dental College, Palakkad. 

ABSTRACT 

Patients with a severely resorbed edentulous mandible often suffer from problems with the lower denture. 

These problems include: insufficient retention of the lower denture, intolerance to loading by the mucosa, 

pain, difficulties with eating and speech, loss of soft-tissue support, and altered facial appearance. Dental 

implants have been shown to provide a reliable basis for fixed and removable prostheses. This has 

resulted in a drastic change in the treatment concepts for management of the severely resorbed edentulous 

mandible 

INTRODUCTION 

The prosthetic management of the edentulous 

patient has long been a major challenge for 

dentistry. Tooth extraction is followed by a loss 

of bone width and bone height during the first 

year. The loss of bone width occurs on the labial 

aspect of the alveolar ridge, resulting in the 

residual ridge being shifted to the lingual. In 

long-term denture wearers, the bone loss may be 

extensive. After many years, the alveolar ridge is 

completely resorbed, leaving only the basal 

bone. The absence of the alveolar ridge 

compromises the retention and stability of the 

dentures. With advanced bone loss, the 

mandibular dentures become non functional. 

The loss of alveolar bone would result in 

prominent internal oblique ridges and the genial 

tubercles; therefore, increased sore spots and 

exaggerated movements in the mandibular 

dentures would be observed. The atrophic 

mandible would also result in muscle 

attachments, such as the buccinator and 

mylohyoid being close to the crest of the ridge, 

thereby elevating the prostheses during function. 

Paresthesia may occur due to dehiscence of the 

neurovascular bundle. There is loss of facial 

height, resulting in poor esthetics. There is also a 

risk of mandibular fracture. The ability to restore 

PROSTHODONTICS 

the atrophic mandible with endosteal implants 

has revolutionized dentistry. With removable 

denture wearers, bone loss continues over the 

years. If, however, endosteal implants are placed 

and the bone is stimulated by forces transmitted 

to the bone from implants, the bone loss is 

minimal. 

CASE REPORT 

A 64 year old woman reported the clinic with 

complaints of loose lower denture. Patient was 

edentulous for the 5 years and was using 

conventional complete denture. Intraoral 

examination showed edentulous maxilla and 

mandible with severe resorption of mandibular 

arch. Panoramic radiograph revealed an 

edentulous mandible with distinct atrophy (Fig. 

1). Since the patient was satisfied with the 

existing denture aesthetically and was 

complaining looseness of the mandibular 

denture only an implant supported over denture 

supported by 4 implants was planned in the 

mandibular arch. Thorough medical history was 

taken and routine investigations were done. A 

preliminary impression was taken with putty 

consistency addition silicone impression 

material and a surgical stent was fabricated with 

holes indicating the sites for implant placement. 




Surgical procedure was done under local 

anesthesia following strict aseptic measures and 

under antibiotic coverage. Initial punch holes 

were placed using pilot bur through the surgical 

stent and four small diameter one piece ball head 

implants made of titanium (KOS-K 3.2 x 12 

implant) were placed in the mandibular anterior 

region (between the mental foramina) with 

flapless surgical procedure (Fig. 2). Patients 

existing lower denture was modified into over 

denture. Holes were drilled in the denture at the 

sites of implants and nylon caps were placed 

over the implants (Fig. 3). Self cure acrylic resin 

was mixed into dough consistency and lower 

denture placed over the nylon caps so that the 

nylon caps got attached to the lower denture and 

allowed to polymerise. The denture was 

removed from the mouth and placed in warm 

water for 15 min allowing complete 

polymerization. Excess acrylic resin was 

removed, edges of the denture was smoothened 

and polished (Fig. 4). Denture was inserted in 

patientís mouth and checked for retention and 

occlusion (Fig. 5). Patient was given 

postsurgical instructions and analgesics and 

antibiotic gel for local application were 

prescribed. Patientís postoperative radiograph 

was evaluated (Fig. 6) and was recalled 

periodically for regular check up. 

DISCUSSION 

The implant-supported over denture has many 

advantages. Although as few as two to four 

implants may be used for support, it is beneficial 

to use more than two implants in the unlikely 

event that one of the implants fails to function 

during the patientís life span. Implant placement 

surgery is relatively simple to perform and, in 

experienced hands, may take less than an hour. 

Many options are available for retention of the 

prosthesis, including magnets, clips, bars and 

balls. The resultant implant-supported denture 

has good stability and retention, and patients 

who have received them have reported improved 

function and satisfaction. Another benefit of 

implant supported prostheses is that after 

receiving implants, patients may eat a diet with 

more fiber. Therefore, the implant-supported 

denture would make an important contribution 

to general health and well-being. The rate of 

resorption is decreased significantly from the 

rates seen with conventional dentures, and recent 

research has shown that the height of the 

posterior ridge increases with continued use of 

implant-supported prostheses. 

DISADVANTAGES OF THE COMPLETE 

REMOVABLE DENTURE 

� Extensive detail required for proper 

fabrication 

� Lack of stability and retention 

� Continued loss of alveolar bone leading 

to further instability and lack of 

retention 

� Lack of chewing function when illfitting 

� Social concerns (slippage, unnatural 

appearance) 

ADVANTAGES OF THE IMPLANT- 

SUPPORTED OVERDENTURE 

� As few as two to four implants may be 

used for support 

� Good stability and retention 

� Improved function and esthetics 

� Reduced residual ridge resorption 

� Simplest implant-supported prosthesis 

� Possible incorporation of existing 

denture into the new prosthesis 

RISK FACTORS FOR FAILURE OF 

DENTAL IMPLANTS 

� Smoking 

� Factors that affect healing of bone (such 

as diabetes, use of steroids) 

� Untreated periodontal disease 




� Anatomy (if bone in recipient site is 

inadequate, grafting may be necessary) 

� Poor bone quality 

CONCLUSION 

The literature and clinical experience indicate 

that the implant-supported prosthesis provides 

predictable results with improved stability and 

function and a high degree of satisfaction as 

compared with conventional removable 

dentures. Clinical studies in the literature in 

which implants were used in the mandible 

anterior to the foramen indicate that the success 

rate for implants in the lower mandible is 95 

percent or greater. These data indicate that 

implant-supported prostheses should be 

considered in planning treatment for the fully 

edentulous patient 

REFERENCES 

1) Carlsson GE, Kronstrˆm M, de Baat C, 

Cune M, Davis D, Garefis P, Heo SJ, 

Jokstad A, Matsuura M, N‰rhi T, Ow R, 

Pissiotis A, Sato H, Zarb GA (2004) A 

survey of the use of mandibular implant 

overdentures in 10 countries. Int J 

Prosthodont 17(2):211ñ 217 

2) Deporter D, Watson P, Pharoah M, 

Todescan R, Tomlinson G (2002) Tenyear 

results of a prospective study using 

poroussurfaced dental implants and a 

mandibular overdenture. Clin Implant 

Dent Relat Res 4(4):183ñ189 

3) Lopes N, Oliveira DM, Vajgel A, Pita I, 

Bezerra T, Vasconcellos RJ (2009) A 

new approach for reconstruction of a 

severely atrophic mandible. J Oral 

Maxillofac Surg 67:2455ñ2459 

4) Stellingsma C, Vissink A, Meijer HJ, 

Kuiper C, Raghoebar GM (2004) 

Implantology and the severely resorbed 

edentulous mandible. Crit Rev Oral Biol 

Med 15:240ñ248 

5) Stellingsma C, Meijer HJ, Raghoebar 

GM (2000) Use of short endosseous 

implants and an overdenture in the 

extremely resorbed mandible: a fiveyear 

retrospective study. J Oral 

Maxillofac Surg 58:382ñ387 

6) Triplett RG, Mason ME, Alfonso WF, 

McAnear JT (1991) Endosseous 

cylinder implants in severely atrophic 

mandibles. Int J Oral Maxillofac 

Implants 6(3):264ñ269 

LIST OF FIGURES 

1) Fig. 1 Pre operative X-ray 

2) Fig. 2 Implants fixed to mandible 

3) Fig. 3 Nylon Caps attached to Implant 

4) Fig. 4 Nylon caps attached to Denture 

5) Fig. 5 Complete Denture in Occlusion 

6) Fig. 6 Post operative X-ray 

7) Fig. 7 Pre operative View 

8) Fig. 8 Post operative View 

Fig. 1 Pre operative X-ray Fig. 2 Implants fixed to mandible 




Fig. 3 Nylon Caps attached to Implant Fig. 4 Nylon caps attached to 

Denture 

Fig. 5 Complete Denture in Occlusion Fig. 6 Post operative X-ray 

Fig. 7 Pre operative View Fig. 8 Post operative View 

************** 




RELEASE OF IMAGE ISSUE No: 3 

PRIZE FOR TUG OF WAR 




Dr.SUSHANTH BEING HONOURED BY IDA NATIONAL PRESIDENT 

PROMISING DENTIST AWARD 2011 TO Dr.PRADEEP M JOB 




ONAM & EID CELEBRATIONS 






IDA KERALA STATE FAMILY SPORTS MEET 

IDA KERALA STATE WOMENíS WING OFFICE BEARERS

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