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The Journal of the Indian Association of Public Health Dentistry(JIAPHD), Vol. 2011, Supplement III, Issue: 18
With Best Compliments from
Vol. 2011 SUPPLEMENT III ISSUE : 18
Swami Devi Dyal Hospital

& Dental College
Village Golpura, Teh. Barwala, Dist. Panchkula (Haryana)

Tel No. 01734-258195 Fax No. 01734 - 258195
Mobile No. 09988889035
Email: ncraoshimla@gamil.com
ESTD 1993
THE INDIAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY

(IAPHD)
Registered under the Registrar of Societies, Bangalore, No. 777/93-94
H.O : 32, 100 Feet Road, 3rd Phase 6th Block Banashankari, Bangalore - 560 085.
Founder Members
Dr. R.K.Bali Co-opted Members
Dr. M.R.Shankar Aradhya Dr. Ganesh Shenoy Panchmal
Dr. Shaik Hyderali Dr. Ajit Krishnan
Dr. Ganesh Shenoy Panchmal Dr. Sahana Hegde
Dr. K.V.V. Prasad Dr. Pankaj Goel
Dr. M.B.Aswath Narayanan Dr. Sabyasachi Saha
Dr. BK Srivatsava Dr. Shashidar Acharya
Dr. H L Jayakumar Dr. Chaitanya Reddy
Dr. Yellappa
Dr. Karim Virjee Editorial Board
Dr. N Vijay Kumar Dr. C Dileep
Dr. Gopal Raje Urs Dr. N Anup
Dr. S S Hiremath Dr. M Pramila
Dr. Padma Rajkumar
President: Dr. M Senthil
Dr. R K Bali Dr. Tanupriya Gupta
Padmashree Awardee
Adviser: Central Committee
Dr. M R Shankar Aradhya Dr. Md Shafiulla
Dr. C V K Reddy
Vice Presidents: Dr. D P Narayan
Dr. M Arunadevi Dr. Karim Virjee
Dr. Vijay Kumar
Dr. M Shivakumar
Hon.Gen. Secretary: Dr. Ashok Kumar Mohapatra
Dr. S S Hiremath Dr. Parthasarthy
Joint Secretary: Dr. Anil Ankola
Dr. Joseph John
Scientific committee
Treasurer:
Dr. V Gopikrishna Coordinators Members
Dr. Nusrath Fareed Dr. M Shivakumar
Editor: Dr. S Pushpanjali Dr. G N Chandu
Dr. M B Aswathnarayanan Dr. J Chandrashekar Dr. Jitesh Jain
E C Members
Dr. B K Srivastava
Dr. Md Shakeel Website Coordinators
Dr. Manjunath P Puranik Dr. Manjunath P Puranik
Dr. Arun Doddamani Dr. M Naganandini
Dr. P D Madan Kumar Dr. Namita Shanbhag
Dr. S R Uma
JOURNAL OF THE INDIAN ASSOCIATION OF
E STD 1993 PUBLIC HEALTH DENTISTRY VOL: 2011 ISSUE: 18 SUPPL. III
Contents
Supplement III
168. Dentistry in News: An Analysis of Newspapers and Magazines in Uttar Pradesh 925
Dr. Ravishankar T.L, Dr. Chaitra T.R., Dr. Naveen Kumar B.
169. Is Mouthwash an Eyewash? A Review 928

Dr. Suvarna Patil, Dr. Laxmi Hombal, Dr. Sheetal Sanikop, Dr. Mamata Hebbal
170. Endodontics by Emerging Dentists 934

Dr. Gayathri Sundari Jethwani, Dr. Kavita Verma, Dr. Sultana S Sayed,
Dr. Jitendra Jethwani
171. Prevalence and Prevention of Dental Caries and Gingivitis in Patients undergoing 939
Orthodontic Treatment
Dr. S. Venkateswaran, Dr. Ashwin Mathew George, Dr. A. Shree Mankinda Prabhu,
Dr. M.K. Anand, Dr. N.R. Krishnaswamy
172. H1N1 Flu (Swine Flu) Precautions for Dental Professionals 942
Dr. Amit Vanka, Dr. G. Shanthi, Dr. Ajay Bhambal, Dr. Vrinda Saxena, Dr Sahana,
Dr. Sudhanshu Saxena
173. A Greater Focus on the Knowledge and Attitude on the Management of Children with 945
Special Needs among Primary Dental Care Providers
Dr. Punithavathy, Dr. Esther Nalini, Dr. Geetha Priya Dr. Rachuri Narendra Kumar,
Dr. Joe Louis
174. Oil Pulling Therapy on Streptococcus mutans Count in Plaque and Saliva - A Randomized 948
Controlled Trial
Dr. Sharath Asokan, Dr. Jeevarathan J, Dr. Shakeer A, Dr. Pamela Emmadi,
Dr. Raghuraman R
175. Multidisciplinary Management of Complicated crown - Root Fractures of maxillary lateral 953
Incisor and Canine - A Case Report
Dr. Shah Dipali, Dr. Garde Janardan, Dr. Vora Reena, Dr. Vijaykumar L
176. Prevalence of Dental Fluorosis in Permanent teeth at varying degree of Fluoride levels - 957
A Cross sectional Survey
Dr. T. Mahantesh, Dr. H.G. Raju, Dr. (Mrs.) Uma B Dixit, Dr. Ramesh P Nayakar
177. Socio-Demographic factors and Tooth loss 963

Dr Dipanjit Singh, Dr Shanmukha G, Dr Jasheena Singh, Dr Ashish Chowdhary,
Dr Dildeep Bali
178. Assessment of Gingival and Dental Caries Status among 12 and 15 years old School 967
going Children of Ahmedabad City - A Pilot Study
Dr. Patel Dhaval R., Dr. Parkar Sujal M.
(i)
179. Impact of Orthodontic Treatment and Socioeconomic Status on Daily performances in 972
Indian School Children: A Two Centre Study
Dr. Mehta S, Dr. Malviya N, Dr. Sivakumar A, Dr. Valiathan A, Dr. Nayak Krishna U.S
180. Modern Dentistry: The Economic aspect 978

Dr. Abhinav Kumar, Dr. Priyanka Sethi Kumar, Dr. Stutee Bali Grewal, Dr. Mandeep
Grewal, Dr. Dildeep Bali
181. Health Care Waste Management : A Biosafety Issue 979

Dr. Sadaf Nishat, Dr. Shweta Bali, Dr. Priyanka Chopra, Dr. M. Siddarth
182. Cultural Practices involving Teeth and Oro-facial Soft Tissues - A Review 984
Dr. Neeraj Singh Chauhan, Dr. G Shanthi, Dr. Vikram Singh, Dr. Arpan Shrivastav,
Dr. Sumit Khare
183. Gerodontology - Orodental Care for Elderly - A Review 989

Dr. Luthra R.P., Dr. Bhardwaj V. K., Dr. Sharma K.R., Dr. Jhingta P.
184. Various Methods of Gingival Pigmentation: A Case Report 995

Dr. Parvati Malhotra, Dr. K. Padmavathi, Dr. Abhishek Kandwal
185. Prevalence of Malocclusion and its correlation with Incidence of Caries and Periodontal 999
Disease
Dr. Saravana Kumar S, Dr. Anita V, Dr. Divya Loganathan, Dr. Shanmugam M,
Dr. Shivakumar V
186. Non Invasive Esthetic management of Congenitally Missing Central Incisor tooth using 1004
a Condition Specific Custom Made Matrix
Dr. Shanmugam Jaikailash, Dr. Mahendran Kavitha, Dr. Disha Thareja
187. Comparision of Effectiveness of Mini Implants vs Conventional Implant supported 1007

Overdentures - A Review of Literature
Dr Ashish Choudhary, Dr. Ekta Choudhary, Dr. Jay Vikram, Dr. Dipanjit Singh,
Dr. Kuldeep
188. Oral Health Status of Children with Cardiac Disease and the Awareness, Attitude and 1012
Knowledge of their Parents
Dr. Madhavan. V, Dr. M. Jayanthi, Dr. Elizabeth Joseph, Dr. D.Senthil
189. Evidence Based Dentistry - The Need for Better Clinical Practice 1019
Dr. Pavan Kumar K.R, Dr. Nandeeshwar D.B.
190. Teaching Medical and Dental Doctors through Non-technical Skills - A View 1024
Dr Vinay Kumar Gupta, Dr Seema Malhotra, Dr Mohit Mohan Singh, Dr Sandeep Kumar
191. Implications of Socio-economic factors in Complete Denture Treatment in Bhopal an 1028

Epidemiological Survey
Dr. J. Varsha Murthy, Dr. Naveen S. Yadav, Dr. Vrinda Saxena, Dr. Yuvaraj V,
Dr. Akash Krishna
(ii)
192. Cross Infection control in Impression making Procedures - A Pilot Survey 1031
Dr. Murali S, Dr. Shankar S, Dr. Kruthika M, Dr. Vishnudev P.V,
Dr. Mythili Merunalavathi S
193. Communication Proficiency in Dentistry - A Stepladder to Success!. 1036

Dr. Gaurav Beohar, Dr. Utkarsh Katare, Dr. Swapnil Parlani, Dr. Surendar Agrawal,
194. Caries Prevalence among 5-12 years School Children residing in Rural Chennai 1040
Dr. M. Senthil Kumar, Dr. S. Bala Gopal, Dr. Sridhar Reddy, Dr. A. Venkatesh
195. Head and Neck Radiotherapy - Consequences and its Management 1044
Dr. Nidhi Gupta, Dr. Mohit Bansal, Dr. Shelja Vashisth, Dr. Nanak Chand Rao
196. Prevalence of Gingival Recession in Lucknow, Northern India - A Cross Sectional Survey 1049
Dr. Ranjana Mohan, Dr. Mohan Gundappa
197. Management of Grossly Mutilated Central incisor using Biological Post and Crown: A 1057
Case Report
Dr. Mahendran Kavitha, Dr. Shanmugam Jaikailash, Dr. Kannan Gokul
198. Antibiotic Resistance - Current Issues and Implications 1062

Dr. Elizabeth Joseph, Dr. M. Jayanthi
199. Oral Hygiene Status of 7-12 year old School Children in Rural and Urban population of 1075
Nellore District
Dr. M.S. Minor Babu, Dr. SVSG Nirmala, Dr. N. Sivakumar
200. Systemic Lupus Erythematosus - A Rare Case Report with Review of Literature 1081
Dr. P.E. Chandra Mouli, Dr. (Capt).S.Manoj Kumar Dr. B. Anand,
Dr. P.D. Madan Kumar, Dr. S. Shanmugam
201. Occlusion in Complete Denture: A Review 1086

Dr. Utkarsh Katare, Dr. Gaurav Beohar, Dr. Anup Mangal, Dr. Swapnil Parlani,
202. Oral Lesions commonly associated with HIV Infection in South Indian Population. 1091
Reports of few cases with Literature Review
Dr. Nalini Aswath
203. Dental Distraction - A Case Study 1095

Dr. R. Saravanan, Dr. N. Raj Vikram, Dr. Swati Acharya
204. A New Nomenclature for the number of Roots in Maxillary Permanent Molar Teeth 1098
Dr. A.V. Rajesh Ebenezar, Dr. Ajit George Mohan
205. Assessment of Knowledge and Practices Regarding Infant Oral Health Care in Chandigarh 1102
Population
Dr. Manjot Kaur, Dr. Ashima Goyal
(iii)
206. Chelioscopy: Determination of Sex and Blood Group 1109

Dr. Vidya GD, Dr. Sreeshyla HS, Dr. Usha Hegde, Dr. Shivananda S
207. Dental Survey of Deaf and Dumb Children in a Special School from Pune 1114
Dr. Mamatha GS, Dr. Kakodkar P, Dr. Deshpande T
208. The Remineralization Potential of CPP-ACP (GC Tooth Mousse) and TCP with 0.21% 1118
W/W Sodium Fluoride Anti-cavity Paste (Clinpro Tooth Crème) on Artificial Caries -like
Subsurface Lesions in Primary and Permanent Teeth - An in-vitro Study
Dr. Arun Prasad. R, Dr. M. Jayanthi, Dr. Elizabeth Joseph, Dr. D. Senthil
209. A Cross-sectional Survey of Quality assurance in Endodontic Practice amongst Indian 1125
Endodontists
Dr. Mohan Gundappa, Dr. (Mrs.) Ranjana Mohan, Dr. Neeraj Kumar
210. Maxillary Necrosis by Rhino-maxillo Cerebral Mucormycosis. A rare Case Report and 1134
Literature Review
Dr. (Capt).S. Manoj Kumar, Dr. P.E. Chandra Mouli, Dr. B. Anand,
Dr. P.D. Madan Kumar, Dr. S. Shanmugam
211. A Cross Sectional Study on the Prevalence and Determinants of Dental Caries among 1138
School Children of Padur
Dr. V. Shivakumar, Dr. V. Gopinath, Dr. R. Saravanakumar, Dr. V. Anitha,
Dr. M. Shanmugam
212. Molars with Single Root and Single Canals 1144

Dr. Ajit George Mohan, Dr. A.V. Rajesh Ebenezar, Dr. A. Vinita Mary
213. Attitude and Awareness toward Periodontal Therapy in North Indian Population: 1148
A Questionnaire Survey
Dr. Archana Bhatia, Dr. M.P. Singh, Dr. Rohit Chopra
214. A Randomized Controlled Trial of Lycopene in Oral Submucous Fibrosis 1156

Dr. Revant H. Chole, Dr. Swati V. Balsaraf, Dr. B.S Dangi, Dr. Shailesh Gondivkar,
Dr. Amol Gadbail, Dr. Satish Balwani, Dr. Mugdha Gadbail, Dr. Rima Parikh
215. A Maxillary First Molar with Six Canals: A Case Report 1160
Dr. A. V. Rajesh Ebenezar, Dr. A. Vinita Mary
216. Periodontal Treatment of Multi - Rooted Teeth 1164

Dr. D. Jayanthi, Dr. M.B. Aswath Narayanan, Dr .S.G. Ramesh Kumar
217. Integrating Bleaching with different Treatment Modalities: A Review 1169

Dr. Dildeep Bali, Dr. Deepika Thosre Chandhok, Dr. Dipanjit Singh,
Dr. Ashish Chowdhary, Dr. Shweta Bali, Dr. Pryanka Thakural, Dr. Ekta Chowdhary
218. Vascular Leiomyoma of the Gingiva - A Rare Case Report 1174

Dr. M.P. Singh, Dr. Archana Bhatia, Dr. Rose Kanwaljeet Kaur
219. Adult Orthodontics - A Boon for the Periodontal Patients 1178

Dr. Rohini Mali, Dr. Vishakha, Dr. Amita Mali, Dr. Priya Lele, Dr. Darshana Dalaya
(iv)
PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:18 SUPPL. III
Dentistry in News: An Analysis of Newspapers and

Magazines in Uttar Pradesh
Dr. Ravishankar T.L1, Dr.Chaitra T.R.2, Dr.Naveen Kumar B.3
ABSTRACT
The public pays attention to health in media, and it could be a positive influence on the nations
thinking about health. So an effort is made to analyse the newspaper and magazine reports in Uttar Pradesh
print media. We retrospectively searched the three newspapers and four weekly magazines circulated in
Uttar Pradesh for relevant health related articles. 262 articles were identified in newspapers, out of which
only 3.43% are related to dental science. From the result it is evident that dentistry and research findings
in this field were regarded as insignificant and not worth mentioning by Indian journalist. Dentists, dental
policy makers and dental researchers should provide the editor with significant dental information, and
convince them that this information is of considerable news value.
Key words: Newspaper coverage, Magazines, Print media, Dental information.
INTRODUCTION much information would reach the general public

through the mass media. So an effort is made to
The news media are a major source of
analyse the number of articles relating to dentistry
information about health issues for both the public /health care published in mass media.
and for the health professionals and can have an
influence on decision making about treatment
choice and medical care.1 The public pays MATERIAL AND METHOD
attention to health in media; over half of the US We retrospectively searched the three largest
adults report that they follow health news closely 2. circulated daily newspapers in state of Uttar
Thus the press is well positioned to educate the Pradesh (India), The newspaper included “Times
public about health and health risks. In short the of India” published in English language which had
press could be a positive influence on the nation’s an annual readership of 133.32 lakhs people; other
thinking about health. A Cochrane review two newspapers were “Danik Jagaran” and “Amar
identified 5 studies that evaluated health care Ujala” published in Hindi, national and also the
utilisation before and after media coverage of local language of the area with an annual
specific events1. Favourable publicity was readership 557.45 lakhs and 293.80 lakhs
associated with higher use; unfavourable publicity respectively according to Indian readership survey
was associated with lower use. (2008)4. Newspapers were searched from 1st Jan
2009 to 31st Dec 2009. Along with this, one
As far as the authors know, the media
General weekly published magazine published in
coverage of dental care is seldom been studied in
English language and three weekly magazines (one
dentistry. Although in the dental research general and two women’s magazines) published in
community the transfer of scientific knowledge to Hindi language were also searched from Jan 2007
the public is seen as highly important and to Dec 2009, for a period of three years. The
necessary 3.The purpose of this study was therefore search was aimed to identify relevant articles
to analyse dental/health information provided by published in Indian magazines and major daily
the press. As it is practically impossible to study newspapers and their Sunday equivalent. To be
this issue in whole of India, the state of Uttar eligible for inclusion article had to/must have at
Pradesh which has seen a big spurt in the number least 5 sentences about health care/dental sciences,
of dental/medical colleges and dental/health which may include topics related to health policy
fraternities from 2000 onwards was selected. In the issues, scientific topics, forensic, topics related to
view of widespread and interesting activities in the prevention, topics of dental health education, oral
dentistry and health field, it was expected that diseases and dental treatments. Promotional and
1
Reader, Dept. of Public Health Dentistry, 2Senior Lecturer, Dept. of Pedodontics and Preventive Dentistry, Kothiwal Dental
College and Research Centre, Moradabad (U.P) 3Reader, Dept. of Public Health Dentistry, St.Joseph Dental College,
Duggirala, Eluru, (A.P).
925
commercial advertisements are excluded from the (2007)7,8 and thousands of students perusing dental
analysis. Articles that focused on the financial education in this state, the interest and effort
performance of companies associated with the drug shown by them is dismal. It is also evident that
were also excluded from the analysis. Decision dentistry and research finding during this period at
about the inclusion of the article were made by least were regarded as insignificant and not worth
one researcher and checked by another. For mentioning by the Indian Journalist. This is
newspapers, search was done physically/manually regrettable since the public could benefit from
by checking all newspaper every day and their increased concern of dentist and their endeavour
additional supplements on Sunday and Saturday, to inform them in every possible ways.
for the magazine searches was done manually as
Possibly the reason was due to the lack of
well on their websites as the complete data of the
selection of dental information by editors.
magazine was available on the websites and which
Obviously they attach little attention to dentistry
was very feasible.
and for them there is hardly any news worth
publishing in this field. On the other hand it could
RESULT be that dental policy makers and dental researchers
Our search identified 507 potentially relevant are not able to provide the editor with significant
newspaper articles, of which 98% had a total dental information, and convince them that this
agreement between the two authors. Among 414 information is of considerable news value.
relevant articles identified in weekly magazines, no
Table 1: Source of Press Release Screened
disagreement was seen between the authors. A
breakdown of all included articles by newspaper, General Health Dental Health
Source
magazines and year’s is presented in table1 Articles Articles
Newspapers
Times of India, English daily newspaper has
the most coverage’s with 262 articles. But only Times of India 253 09
(English)
3.43% of the articles are related to dentistry. The
English newspaper covered more health related Amar Ujala (Hindi) 125 05
articles than the hindi newspaper. Among Dainik Jagran 113 02
magazines, which include two general weekly (Hindi)
magazines and two women magazines, search was General Magazines
done for 3 consecutive years. More number of
India Today 2009 21 01
health related articles are published in women
magazines than general weekly magazines. Of the (English) 2008 08 00
total number of articles published 88.16% of the 2007 07 00
articles are general health related and only 11.74% Outlook 2009 24 02
of the articles are related to dentistry.
(Hindi) 2008 15 01
2007 11 00
DISCUSSION
Women’s Magazines
There has been much discussion and debate Meri Saheli 2009 40 08
surrounding the role of media influence in the (Hindi) 2008 32 05
dissemination of health/dental science knowledge
to public. This paper presents the first effort and 2007 22 02
assessment of newspapers and magazines coverage Grahshobha 2009 64 10
about dental science. Considering the fact that (Hindi) 2008 70 12
survey samples contain only 3 newspaper and 4 2007 51 08
magazines. It is not an exaggeration to conclude
that the information about dentistry in the Uttar
Pradesh (India) news paper was almost CONCLUSION
non-existing during the period Jan 2009 to Dec
2009. Similar studies were also reported from The media can and do play key role in
Netherland, and US5,6. shaping our understanding of medicine and
generally about the ways by which decisions are
Considering the presence of 31 dental colleges made. But this is not to say that if our
and 4637 registered dental personnel as per DCI understanding is clouded it is the fault of the
926
media. The media are prone to external influences 3. Genco R J. The trust and the agenda: science transfer.
and the action of researcher, clinician, government J Dent Res 1991; 70:1102-1105.
and industry all can undo influence the way news 4. www.npes.in/others_news.asp (Accessed on 2010 July
is reported. If we have to truly inform debate 28).
about health science news, we need to be less 5. Eijkman M.A.J., Hoebergen N. and Moltzer. The
enthusiastic and more questioning about what we
transmission of knowledge from dentistry and dental
read and of the motives of those who seek to set
science to the press during the period 1981-1990.
news agenda.
International dental journal. 1994; 44:360-361.
6. Frazier P J., Jenny J J., Otsman R. and Frenick C.
REFERENCES
Quality information in mass media: barrier to the
1. Grilli R., Ramsay C. and Minozzi S. Mass media dental health education of the public. J Public Health
interventions: effects on health services utilization. Dent 1974; 34: 244-257.
Cochrane Database of Systematic Reviews 2002; 1.
CD000389. 7. http://www.upeducation.net/Dental/index.aspx.
(Accessed on 28Jan 2011).
2. Lisa M. Schwartz and Steven Woloshin. The Media
Matter: A Call for Straightforward Medical Reporting. 8. http://www.indiaonapage.com/india/Uttar Pradesh.
Ann Intern Med. 2004; 140: 226-228. (Accessed on 2011 Jan28).
927
Is Mouthwash an Eyewash??? A Review

Dr. Suvarna Patil1, Dr. Laxmi Hombal2, Dr. Sheetal Sanikop3, Dr. Mamata Hebbal4
ABSTRACT
Oral care products comprise a broad range of formulations and devices produced primarily to benefit
oral and dental health. A mouthwash may be recommended to treat infection, reduce inflammation, relieve
pain, reduce halitosis or to deliver fluoride locally for caries prevention. The well-known and often-reviewed
benefits of oral hygiene products on oral and dental conditions and diseases are well established. Indeed,
through their role in the prevention and treatment of gingival and periodontal disease, there is the potential
for benefits of oral hygiene products in the prevention of systemic disease and conditions. Despite this,
perhaps, as with all agents, drugs and devices designed to maintain or improve human wellbeing, there is
the possibility of harmful adverse effects occurring as a result of the use of oral hygiene products. The
aim of this review is to debate the potential for oral hygiene products to cause oral, dental and systemic
harm to the user.
Keywords: Mouthwash, oral hygiene, periodontitis, local adverse effects, systemic adverse effects
INTRODUCTION equivocal success, as therapy for candida

infections, and for alleviating the pain and
Plaque is a major etiologic factor in most
discomfort of inflammatory conditions of the
forms of periodontal diseases, a significant relation mouth.
between the accumulation of bacterial plaque on
the teeth and the development of gingivitis and Several ill effects of improper oral hygiene
periodontitis has been well established through procedures have been documented3. The potential
clinical and epidemiological research. Complete for harm or other side-effects from mouth rinses
removal of bacterial plaque is necessary for is real and quite well documented. At present, an
attaining and maintaining healthy gingival International Standards Organization considers
condition. Plaque control refers to all the measures general aspects of mouth rinse safety in a manner
taken by both the patients and the dental team to similar to toothpastes. It would appear that
prevent accumulation of bacterial plaque and other potential risks /side-effects from mouth rinses
come from three sources, namely4
deposits on the tooth and the adjacent gingival
surfaces. Till date the most dependable mode of 1. The physico-chemical properties of the rinse
plaque control is mechanical cleaning of teeth (such as pH and titratable acidity),
Over a period of nearly four decades there has 2. The active (s) ingredients in the products and
been quite intense interest in the use of chemical
agents to control supragingival plaque and thereby 3. Other ingredients (such as alcohol)
gingivitis. The number and variation of chemical The adverse effects of mouthwash may be
agents evaluated are quite large but most have divided into local and systemic effects5
antiseptic or antimicrobial actions and success has
been extremely variable1. The mouthwash may be
used for preventive or therapeutic purposes. The Local adverse effects of mouthwash use:
preventive use mainly to control dental caries and The pH of mouth rinses is set below 10.4
the therapeutic use is to inhibit or reduce plaque- and clearly, in the acidic range below 5.4-5.5,
associated bacteria and as prophylaxis after there is the potential for erosion of enamel and,
periodontal surgery. In cases in which patients are more particularly, dentine. The titratable acidity
unable to perform oral hygiene, mouth rinsing with and / or buffering capacity of acidic products can
antimicrobial agents often becomes the only be measured. Although data on acidic beverages
feasible solution2. Oral rinses have been used for indicate that the higher the titratable acidity of a
symptomatic treatment of aphthous ulcers with rinse the greater the risk for erosion. Evidence that
1
Professor and Head, Dept. of Periodontics, 2P.G. student, Dept. of Periodontics, 3Associate Professor, Dept. of Periodontics,
4
Reader, Dept. of Public Health Dentistry, KLE’s V.K. Institute of Dental Sciences, Belgaum
928
acidic mouth rinses can erode enamel and dentine explanation is not available. The extrinsic
comes from tests both in vitro and in situ. The staining, which is quite difficult to remove
few proprietary products tested do reveal erosion because it tends to calcify quickly, a dark yellow
of enamel and dentine, but to a level considerably or brown stain is often present. The same
below that of a soft drink control. The only mechanism explains the tooth and tongue
concern from a study in vitro may lie with the discolouration by polyvalent metal ions such as tin,
removal of the dentine smear layer to initiate a iron and copper. The mechanisms proposed for
lesion of dentine hypersensitivity6. The issue with chlorhexidine staining can be debated (Eriksen et
acidic rinses must relate to the duration of use al 1985, Addy & Moran 1995, Walts & Addy
relative to erosivity. Thus, for example, acidified 2001)10,11,14 but have been proposed as.
sodium chlorite was shown to be as effective
Degradation of chlorhexidine molecules to
against plaque as chlorhexidine7, but caused
release parachloraniline appears not to occur on
enamel erosion similar to orange juice (pH 3.5)8.
storage or as a result of metabolic processes. Also,
Although never marketed, such an agent may have
Alexidine, a related bisbiguanide, does not have
only been recommended, as with chlorhexidine, for
parachloraniline groups, yet causes staining
short-term use and therefore erosion would not be
identical to that of chlorhexidine.
clinically significant.
Side-effects from active ingredients contained Nonenzymatic browning reactions (Maillard
in the mouthwash have been reported and for the reactions) catalyzed by chlorhexidine are a
most part these problems have been local. theoretical possibility; however, evidence is
indirect, circumstantial or inconclusive. The theory
Chlorhexidine mouth rinses are perhaps most does not consider the fact that other antiseptics and
studied and effective antiseptic for plaque metals such as tin, iron and copper also produce
inhibition and the prevention of gingivitis. dental staining.
Chlorhexidine is a bisbiguanide antiseptic, a Protein denaturation produced by chlorhexidine
compound of a strong base and dicationic at pH with the interaction of exposed sulphide radicals
levels above 3.5. Chlorhexidine mouth rinses are with metal ions is also theoretically possible but
studied in greatest detail for local side-effects; there is no direct evidence to support this concept
systemic safety is well established because of its
polar nature and lack of absorption into the Precipitation of anionic dietary chromogens
systemic circulation. Chlorhexidine rinses at 0.2% by cationic antiseptic, including chlorhexidine and
concentration were reported causing taste polyvalent metal ions as an explanation for the
disturbance, mucosal desquamation, increased phenomenon of staining by these substances, is
formation of supragingival calculus, unilateral or supported by a number of well controlled
bilateral parotid swelling and the extrinsic staining laboratory and clinical studies11. Thus, the locally
of teeth1 bound antiseptics or metal ions on mucosa or teeth
can react with polyphenols in dietary substances
Taste disturbance is thought to be caused by to produce staining. Beverages such as tea, coffee
chlorhexidine interfering with taste bud activity and red wine are particularly chromogenic, but
with a preferential effect on salt taste: foods other foods and beverages will interact to produce
tending to have a bland taste9. Chlorhexidine also various coloured stains.
has bitter taste. Mucosal desquamation appears to
be an idiosyncratic reaction in a very small The other side effect are:
proportion of chlorhexidine rinse users. The Neurosensory deafness can occur if
reaction is probably concentration dependent in chlorhexidine is introduced into the middle ear and
that it was rarely reported with 0.12% rinses and the antiseptic should not be placed in the outer ear
anectdotal reports of dilution of 0.2% rinses 50:50 in cases if the eardrum is perforated
with water usually permitted continued use.
Increased formation of supragingival calculus, Phenols and Essential oils: These have been
the chlorhexidine mechanism in this process is not used in mouth rinses and lozenges for many years.
clear but could increase pellicle thickness by This mouth rinse product may reduce gingivitis via
precipitating salivary proteins and / or precipitating both a plaque inhibitory action and an
phosphate, and thereby calcium, onto / into the anti-inflammatory action possibly due to an
pellicle. Reversibly, unilateral/bilateral parotid anti-oxidative activity. Nevertheless, the pH of the
swelling is an extremely rare occurrence and an product is low (pH 4.3) and has been shown in
929
vitro and in situ to cause erosion of dentine and such as acute ulcerative gingivitis18. Povidine
enamel respectively, albeit to a considerably less iodine is largely without side effects but as a rinse
degree than orange juice1 and also has the strong has potential to affect thyroid function adversely.
taste unacceptable. Prolonged excess intake of iodides can lead to
thyroid gland dysfunction including hypo- or
Amine alcohols like Delmopinol:
hyperthyroidism, thyroid gland hyperplasia
Morpholinoethenol derivatives, octopinol
(enlargement), thyroid adenoma, goiter,
was the first to be shown effective as an autoimmunity, and elevated thyroid stimulating
antiplaque agent but was withdrawn for toxiologic hormone (TSH) levels. Individuals with
reasons. Delmopinol at 0.1-0.2% causes transient autoimmune thyroid disease (AITD) may have
tingling of the tongue, which is a form of increased sensitivity to adverse effects of iodine.
numbness rather than taste disturbance12. The Those with previous iodine deficiency or nodular
duration of the tongue effect is considerably goiter may be particularly susceptible.
shorter than that of chlorhexidine. Delmopinol also The long-term use of Povidine-iodine for
causes extrinsic tooth staining, but the incidence is gargling should be avoided by (a) people with a
less as is the severity when compared with high risk of developing thyroid dysfunction due to
chlorhexidine. Interestingly, the staining is reported the excessive intake of iodine, (b) pregnant women
to be easily removed. and (c) breast-feeding mothers.
Fluoride rinses: have the potential for both
systemic toxicity and dental fluorosis. Dental Systemic adverse effects of mouthwash use
staining occurs with stannous formulations and
In a susceptible host, mouthwashes have also
appears to occur by the same mechanism as for
been shown to produce allergic reactions, triggered
chlorhexidine and other cationic antiseptics
by a variety of ingredients. Fischer19 in 1974,
involving interaction with dietary chromogens13
identified antiseptics such as benzalkonium
Other mouth rinse actives reported to cause chloride, antibiotic agents, essential oils used as
local side effects are: flavours, alcohol, sodium perborate, zinc chloride,
borax, menthol, thymol, phenol, iodine, methyl
Cetylpyridinium chloride: which can cause salicylate, boric acid, cresols and surfactants as
extrinsic tooth staining by a mechanism similar to potential allergens.
that of chlorhexidine14. The staining relates to
frequency of use and is much less than The term allergic reactions is used to indicate
chlorhexidine when used twice daily, but similar type I and type IV hypersensitivity reactions. Type
when used four times a day, an effect that I hypersensitivity of oral mucosa is manifested
probably reflects the reduced substantivity of usually by urticaria, edema and erythema in the
cetylpyridinium chloride compared with affected areas. Vesicle formation may also be
chlorhexidine (15). noted. Type I hypersensitivity or anaphylactic type
hypersensitivity is mediated by antibodies of
Hexetidine: A saturated pyrimidine, at 0.1% was immunoglobulin (Ig E) type. The symptoms
shown to have limited plaque-inhibitory action and usually develop within minutes of exposure in
no evidence for antiplaque activity when used as persons previously sensitized to the allergen and
an adjunct for oral hygiene. Side effects was may take the form of a local or systemic reaction
reported commonly to cause mucosal erosion if depending on the portal of entry. In some cases,
used above the concentration of 0.1%16. anaphylactic shock may also develop.
Hexetidine also has a slight tendency to stain teeth.
Type IV or delayed type hypersensitivity
Sanguinarine: a plant extract, was used in mouth reactions are responsible for contact dermatitis in
rinses, usually combined with zinc salts. the skin and it is postulated that the same
Importantly and very recently, sanguinarine mechanism may cause contact stomatitis in the
containing mouthrinses have been shown to oral mucosa. In the oral mucosa, it manifests
increase the likelihood of oral precancerous lesions clinically as erythema, ulceration and epithelial
almost ten-fold even after cessation of mouthrinse peeling. The onset of symptoms may occur as late
use 17 as 24 to 48 hours after contact with the allergen.
Povidone-iodine: lacks appreciable plaque- Allergic reactions triggered by mouthrinses
inhibitory activity or action in acute infections have been reported in the literature. Mathias et
930
al20 reported a case of contact urticaria that Mouthwashes and oral cancer
developed after use of a cinnamic aldehyde -
containing mouthwash in which lip swelling The association of oral cancer with tobacco
occurred. Fisher19 reported a case of allergic and alcohol use has been well established. Alcohol
is used in mouthwashes principally as a solvent
contact dermatitis caused by thymol that was used
for other ingredients. The high alcohol content of
for the treatment of paronychia (abscess formation
several mouthwashes and the fact that they are
of apocrine gland regions in the nail bed), no oral
held in the oral cavity for a longer period of time
lesions were reported. Lim et al21 reported than alcoholic beverages led Weaver et al27 to ask
perioral and mucosal edema caused by contact whether the oral rinses had a carcinogenic effect
allergy to proflavine (an antiseptic) in an on the oral mucosa. Although the number of
acriflavine (a proflavine derivative) mouthwash. In patients studied was too small to allow any
another case report, benzydamine mouthwash use conclusion. In 1991, Winn et al reported that
was shown to provoke a maculopapular rash on regular users of mouthwashes containing
the trunk and limbs of a patient. Moghadam et al22 concentrations of alcohol greater than 25% had a
reported a chlorhexidine mouthwash-induced fixed greater risk of oral and pharyngeal cancer and that
drug eruption. This reaction may represent either the excess risk was greater in women, but no
immediate-type or delayed-type hypersensitivity stronger among those who abstained from tobacco
reactions. It should also be noted that and alcohol.
chlorhexidine has been associated with other
harmful effects such as ototoxicity, conjunctivitis, In 2008, McCullough and Farah concluded
colitis. Ohtoshi et al23 reported more than 30 cases that there is "sufficient evidence" that
"alcohol-containing mouthwashes contribute to the
of anaphylactic shock after the topical application
increased risk of development of oral cancer"28. It
of chlorhexidine. In these cases a specific IgE
has been found that ethanol in mouthwash helps
antibody against chlorhexidine was shown to be a
substances such as nicotine to permeate the mouth
mediator of the reaction. Chlorhexidine should be lining. Squier et al29 showed that alcohol has the
given with caution to atopic patients, especially capacity to eliminate the lipid component of the
those with a history of multiple drug reactions barrier present in the oral cavity that surrounds the
Systemic hypersensitivity reactions to oral granules of the epithelial spinous layer, and
rinses have also been reported. Tal and Dekel24 short-term exposure to 15% alcohol increased the
presented a case report of erythema multiforme permeability of human ventral tongue mucosa. It
caused by mouthwash containing iodine and also can produce a substance called acetaldehyde
Bickers et al25 reported an exacerbation of which is a well known human carcinogen. Oral
hereditary hepatic porphyria in a patient who bacteria like Streptococcus salivarius, S.
intermedius and S. mitis produce high amounts of
ingested a mouthwash solution. The eucalyptol in
acetaldehyde. Oral streptococci may contribute
the mouthwash was shown to be capable of
significantly to the normal individual variation of
inducing clinical manifestations of the disease in
salivary acetaldehyde levels after alcohol drinking
patients with acute intermittent porphyrin heme and thereby also to the risk of oral cancer. This
pathway. Although allergic reactions to may in fact be the mechanism that explains the
mouthwashes are relatively uncommon. observed phenomena that individuals with poor
Mouthwashes are easily accessible, oral hygiene have an increased risk of developing
high-ethanol products marketed without child oral cancer. The authors also state that the risk of
resistant packaging. Mouthwashes nowadays have acquiring cancer rises almost five times in
an alcohol content that varies from 6% to 26.9%. alcohol-containing mouthwash users who neither
cases of mouthwash induced hypoglycaemia from smoke nor drink (with a higher rate of increase in
those who do). Alcohol rinses may also adversely
ingestion of the solution and fatal mouthwash
affect the surface hardness of restorations.
poisoning have been reported. Weller Fahy et al26
remarked that mouthwashes are permitted to Recently, Warnakulasuriya et al. undertook an
contain alcohol in relatively high concentration immunohistochemistry study that for the first time
because they are classified as cosmetics and assessed specific alcohol-induced changes to the
consequently the Food and Drug Administration oral epithelium in patients with both oral cancer
does not require a specification of their alcohol and dysplasia. This study assessed the generation
content and sub-cellular distribution of ethanol-induced
931
DNA-protein alteration, particularly the presence 4. Martin Addy. Oral hygiene products: Potential for
of covalently bound intra-cellular proteins with harm to oral and systemic health? Periodontology
acetaldehyde, the first metabolite of ethanol, as 2000, Vol. 48, 2008, 54!65
well as the end products of lipid peroxidation, and 5. Eleni Gagari, Sadru Kabani. Adverse effects of
showed strong evidence of ethanol-induced mouthwash use. A review. Oral surg oral med oral
carcinogenesis. pathol oral radiol endod 1995;80:432-9
6. Addy M, Loyn T, Adams D. Dentine hypersensitivity:
In addition to the above mentioned effects on effects of some proprietary mouthwashes on the
mucosal permeability and metabolic production of dentine smear layer. An S.E.M. study. J Dent 1991:
acetaldehyde, studies have shown that high 19: 148!152.
concentrations of alcohol in mouthrinses may have
7. Yates R, Moran J, Addy M, Mullan PJ, Wade W,
detrimental oral effects such as epithelial Newcombe R. The comparative effect of acidified
detachment, keratosis, mucosal ulceration, sodium chlorite and chlorhexidine mouthrinses on
gingivitis, petechiae and oral pain. Bernstein et plaque regrowth and salivary bacterial counts. J Clin
al reported the presence of diffuse white oral Periodontol 1997: 24: 603!609.
mucosal lesions with long-term use of an 8. Pontefract H, Hughes J, Kemp K, Yates R,
alcohol-containing mouthwash. Newcombe RG, Addy M. Erosive effects of some
mouthrinses on enamel. A study in situ. J Clin
Periodontol 2001: 28: 319!324.
CONCLUSION 9. Lang, N.P., Catalanotto, F.A., Knopfl i, R.U. &
Antczak, A.A. Quality specifi c taste impairment
Mouthwashes are used as a supplemental aid following the application of chlorhexidine gluconate
in the daily oral hygiene regimen. The dentist and mouthrinses. Journal of Clinical Periodontology 1998,
the consumer should both be aware that 15, 43!48.
mouthwashes may cause adverse effects. Allergic 10. Eriksen, H.M., Nordbo, H., Kantanen, H. & Ellingsen,
reactions, both local and systemic, have been J.E. Chemical plaque control and extrinsic tooth
reported and so have incidents of alcohol discoloration. A review of possible mechanisms.
intoxication in children from ingestion of Journal of Clinical Periodontology 1985,12, 345!350.
mouthrinses. In recent years, investigators have 11. Addy, M. & Moran, J.M. Mechanisms of stain
studied the possibility that the high alcohol content formation on teeth, in particular associated with metal
in several of the oral rinses might play a role in ions and antiseptics. Advances in Dental Research
the cause of oral cancer. There is a significant 9,1995, 450!456.
number of indications for the use of mouthwash 12. Claydon N, Hunter L, Moran J, Wade W, Kelty E,
in preventive dentistry, most of which rely on the Movert R, Addy M. A 6-month home-usage trial of
antimicrobial properties of the antiseptic and its 0.1%and 0.2% delmopinol mouthwashes. 1. Effects
duration of action. Its use should be for short on plaque, gingivitis, supragingival calculus and tooth
duration when mechanical tooth cleaning is staining. J Clin Periodontol 1996: 23: 220!228.
difficult or inadequate and during which time local 13. Addy, M., Mahdavi, S.A. & Loyn, T. Dietary staining
side effects are likely to be minimized. Guidelines in vitro by mouthrinses as a comparative measure of
should be followed cautiously before prescribing a antiseptic activity and predictor of staining in vivo.
mouthwash to the patients. The mouthwash is Journal of Dentistry 1995: 22, 95!99.
more effective as a preventive rather than a 14. Watts A, Addy M. Tooth discolouration and staining:
therapeutic agent. a review of the literature. Br Dent J 2001: 190:
309!316
15. Roberts WR, Addy M. Comparison of in vitro and
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1. Martin Addy & John Moran, Chemical supragingival and hexetidine. Relevance to mode of action.J
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Publishing company, 2008: 734-65
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18. Addy, M., Griffiths, C. & Isaac, R. The effect of 24. Tal H, Dekel A. Oral mouthwash and erythema
povidone iodine on plaque and salivary bacteria. A multiforme. J Oral Med 1986;42:147-8
double blind crossover trial. Journal of 25. Bickers DR, Miller L, Kappas A. Exacerbation of
Periodontology 1977: 48, 730!732. hereditary hepatic porphyria by surreptitious ingestion
19. Fisher AA. Contact stomatitis, glossitis, and cheilitis. of unusual provocative agent: a mouthwash
Otolaryngol Clin North Am 1974;7: 827-43 preparation. Medical Intelligence 1986;292:115
20. Mathias CG, Chappler RR, Maibach HI. Contact 26. Weller- Fahy ET, Berger LR, Troutman WG.
urticaria from cinnamic aldehyde. Arch Dermatol Mouthwash: a source of acute ethanol intoxication.
1980;116:74-6 Pediatrics 1980;66:302-5
21. Lim J, Goh CL, Lee CT. Perioral and mucosal edema 27. Weaver A, Fleming SM, Smith DB. Mouthwash and
due to contact allergy to proflavine. Contact oral cancer: carcinogen or coincidence? J Oral Surg
Dermatitis 1991;25:195-6 1979;374:250-3
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933
Endodontics by Emerging Dentists

Dr. Gayathri Sundari Jethwani1, Dr. Kavita Verma2, Dr. Sultana S Sayed3, Dr. Jitendra Jethwani4
ABSTRACT
Aim: To evaluate the technical quality of root fillings performed by undergraduate students at a
dental teaching institute in Lucknow, Uttar Pradesh, India.
Methodology: A random sample of 812 records of patients who received dental treatment performed
by the undergraduate students and interns at the Department of Conservative Dentistry and Endodontics
at Career Post Graduate Institute of Dental Sciences and Hospital, Lucknow, India between 2006 to 2009
was investigated. The accuracy of length of root fillings, their radiodensity and the presence of
voids/discrepancies in the root filling or between root filling and root canal walls were recorded and scored.
The results were statistically analysed to determine statistically differences between the technical quality
of root fillings and type of tooth treated.
Results: Of the 594 teeth included in the study, only 33.7% of teeth fulfilled the criteria of showing
a dense root filling without voids and of adequate length while 67% had an adequate length of root filling
and 26% had dense root filling without voids. The relationship between the technical quality of root fillings
and tooth type was statistically significant (P < 0.001) .The highest percentage of adequate root fillings
occuring in single-rooted teeth. The highest percentage of inadequate root fillings according to the criteria
of root filling length and lateral adaptation was found in molar teeth.
Conclusion: The assessment revealed that the technical quality of root fillings performed by
undergraduate students needs to be improved.
INTRODUCTION 2005, Er et al. 2006. Correct RCT consists of

radiographic evidence of a prepared root canal
A 3-dimensionally hermetic obturation of the
homogenously filled and without space(s) between
root canal system complex is of prime clinical
canal filling and canal walls. Furthermore, the root
importance for the success of endodontic
canal filling should be placed within 0.5–2 mm of
treatment. Hence, one of the objectives of
the radiographic apex to prevent recurrent
endodontic treatment is to completely fill the root disease.(5)
canal complex after it has been thoroughly
chemically cleaned and mechanically shaped. The Recent epidemiological endodontic studies
technical superiority of the root filling highly performed in different population groups have
influences the outcome of root canal treatment reported a percentage of adequate root fillings
(RCT) as demonstrated by epidemiological studies ranging from 26.5% to 55.3% (Kirkevang et al.
which report a high prevalence of apical pathosis 2000, Chueh et al. 2003, Dugas et al. 2003,
associated with root filled teeth, particularly when Barrieshi-Nusair et al. 2004, Eleftheriadis &
the root filling was inadequate. (Helminen et al. Lambrianidis 2005, Er et al. 2006). In France,
2000, Kirkevang et al. 2000, Lupi-Pegurier et al. epidemiological studies on endodontic treatments
2002, Dugas et al. 2003). There is substantial investigated the quality of root fillings undertaken
evidence that the technical quality of root canal by general practitioners (Boucher et al. 2002,
treatment has a significant impact on the outcome Lupi-Pegurier et al. 2002, Basmadjian-Charles et
of the procedure and its durability.(3) Thus a al. 2004) which showed only 20.8–31.2% of
methodical assesment of the quality of root fillings adequate fillings. To date, no appraisal of the
quality of root fillings performed by Indian
is essential for clinicians to estimate prognosis(5).
undergraduate students are available. Thus, the aim
One of the methods used to determine the of this study was to evaluate the technical quality
clinical outcome of RCTs is based on of root fillings using radiographs of teeth treated
radiographical evaluation as seen in the studies by by undergraduate students and interns at the
Eleftheriadis & Lambrianidis 2005, Tsuneishi et al. Department of Conservative Dentistry and
1
Professor and Head, 2,3P.G. Student, Dept. of Conservative Dentistry and Endodontics, 4Professor, Dept. of Prosthodontics,
Career Post Graduate Institute of Dental Sciences and Hospital, Lucknow, Uttar Pradesh.
934
Endodontics at a teaching hospital in Lucknow tooth). The scores of each parameter were added
between the years 2006 to 2009. up to obtain a final score allowing the assessment
of the technical quality of the root filling. The
MATERIALS AND METHOD final score 0 corresponded to a root filling deemed
The records of 812 patients who had received adequate, whereas a final score of 4 corresponded
RCT at the Department of Conservative Dentistry to an under-or over-filled canal. Chi-square
and Endodontics a teaching hospital in Lucknow analysis was performed to determine statistically
between the years 2006 to 2009 were randomly significant differences between the technical
scrutinized in this study. Records of patients quality of RCTs according to the tooth type.
younger than 19-year-old were excluded. Records
that did not include preoperative and postoperative
RESULTS
periapical radiographs with at least 2 mm of
periapical region were excluded. The final sample The final scores for the 594 root filled teeth
consisted of 594 obturated teeth. All RCTs were are summarized in Table 1. The score 0
carried out by the interns and final year BDS
corresponding to an ‘acceptable’ filling was rated
students posted in the deparment using K- file
hand instruments by the step back technique and in 200 (33.7%) teeth. The score 4 corresponding
a lateral compaction filling technique. The irrigants to the combination of an incorrect length and
used were sodium hypochlorite and EDTA. The density of the root filling was rated in 3 (0.5%)
sealer used was Zinc Oxide Eugenol. For each root teeth.
filled tooth, preoperative, working length
Table 1. Distribution of the final scores according to the
determination and postoperative radiographs were evaluated radiographical parameters
examined. The radiographs were independently
examined under even illumination in a dark room Final Scores Number of Teeth Percentage (%)
at × 3.5 magnification by two investigators. The 0 200 33.7
results were compared and a final consensus was
1 155 26.1
agreed upon. In case of disagreement, a third
investigator was asked to read the radiograph and 2 157 26.4
a final agreement was reached. Parameters used to 3 79 13.3
assess radiographical quality of root fillings are 4 3 0.5
listed as follows:
TOTAL 594 100
1. Presence or absence of a low density of root
canal filling. Table 2 shows the distribution of the teeth
according to the parameters evaluated by the
2. Presence or absence of voids in the root filling
investigators. The length of the root fillings was
or between root filling and root canal walls.
adequate in 399 (67%) teeth, 22 (4%) teeth were
3. Presence or absence of an ‘underfilling’: classified as being ‘over-filled’ and 173 (29%)
where the root canal filling material is > 2 teeth were evaluated as being ‘under-filled’. A
mm short of the radiographic apex. poor density of root filling was observed in 273
4. Presence or absence of an ‘overfilling’: where (46%) teeth and the presence of voids in the root
the root canal filling material is extruded filling was present in 231 (39%) teeth. A root
beyond the radiographic apex. filling could present both an inadequate density
Each parameter was scored as previously and voids. To evaluate the overall quality of the
described by Matysiak et al. 2003. Briefly, each root filling, the density of the root filling was
parameter cited above was scored with 0 = absence related with the presence of voids. In this way, 95
(criterion not observed on the radiographs) or 1 root fillings (16%) were not dense and contained
= presence (criterion observed on the radiographs). voids; 51 root canal fillings (9%) were evaluated
For a multi-rooted tooth, each root canal was as being dense with voids; 90 root canal fillings
independently evaluated, scored, and then an (15%) were not dense without voids and 156 root
overall score was attributed (e.g. when the same fillings (26%) were dense without voids.
parameter was observed on several root canals, the
score ‘1’ was attributed only once for the entire
935
Table 2. Percentages of the evaluated teeth according to the Table 3. Distribution of the radiographic criteria according to the
radiographical criteria tooth type
No. of Percentage of Single

Multi-rooted
Radiographical criteria radiographs radiographs rooted
S. Characteristi teeth
evaluated evaluated teeth X2 P
No. cs (n = 312)
(n = 282)
Low density of RC filling 273 46
Voids between RC filling or 231 39 No. % No. %
RC wall 1 Voids 92 32.6 139 44.5 8.86 <.001
Low density with voids 95 16
Voids with adequate density 51 9 2 Low density 101 35.8 172 55.1 22.24 <.001
Low density without voids 90 15
3 Underfilling 47 16.6 126 40.3 48.96 <.001
Adequate density without 156 26
Voids
4 Overfilling 13 4.6 30 9.6 5.53 <.018
Underfilling 173 29
Overfilling 22 4
Table 3 shows the radiographic evaluation of DISCUSSION

the various characteristics according to the tooth In this study, the technical quality of root
type. The teeth examined were divided into two fillings performed by undergraduate students and
groups: single rooted teeth and multirooted teeth. interns at the Department of Conservative
Dentistry and Endodontics at a teaching hospital
Presence of voids was seen in 92 (32.6%) samples,
in lucknow between the years 2006 to 2009 is
low density in 101 samples (35.8%), underfilling presented. The data used, consisted of a sample of
in 47 (16.6%) and overfilling in 13 (4.6%) samples periapical radiographs of patients who received
of single rooted teeth. In case of multi-rooted teeth RCTs carried out by the interns and final year
presence of voids was seen in 139 (44.5%) students posted in the deparment. All periapical
samples, low density in 172 samples (55.1%), radiographs used in this study were taken during
routine RCT procedures within a dental student
underfilling in 126 (40.3%) and overfilling in 30 practice and were not taken especially for this
(9%) samples. study.
Voids were seen in 32% of single rooted teeth The radiographic criteria used to assess the
and 44.5% of multirooted teeth, showing a quality of RCTs were based on those developed
statistically significant difference between the two by the French National Health Service (Matysiak
groups. Likewise, low density was seen 35.8% of et al. 2003 and Moussa-Badran et al. 2008) and
were the same as those used previously
single rooted teeth and 55.1% of multi-rooted (Lupi-Pegurier et al. 2002). They were derived
teeth, again showing a statistically significant from the consensus report of the European Society
finding between the two groups. The percentage of Endodontology (1994) and have been estimated
of single rooted teeth underfilled was 16.6% while to have good sensitivity and specificity (Matysiak
that of multirooted teeth was 40.3%, presenting et al. 2003). Many studies have considered the
with a statistically significant differnce between apical extent of the root filling ≤ 2 mm from the
radiographical apex as adequate (Hayes et al.
the two groups. Lastly, and like all the above
2001, Lupi-Pegurier et al. 2002, Barrieshi-Nusair
findings, statistically significant difference was et al. 2004, Er et al. 2006). In this study, root
seen between the two groups with respect to fillings of adequate length were found in 67% of
overfilling too, with 4.6% of single rooted teeth teeth, comparable to the results obtained by the
being overfilled and 9.6% of multirooted teeth study conducted by Moussa-Badran et al (2008)
(69%). Although it is difficult to compare this
being overfilled. However, the incidence of
result with other studies, this percentage was
inadequate filling was seen more so in superior compared with those reported by
multi-rooted teeth when compared to single rooted Lupi-Pegurier et al. (2002) (38.7%) and
teeth. Boltacz-Rzepkowska & Pawlicka (2003) (48.9%).
936
This difference could be explained by the fact that The technical quality of root fillings as
dental students take several radiographs during demonstrated by radiographs is important for the
RCTs until the working lengths are correct. outcome of the treatment but does not necessarily
Indeed, when RCTs were performed by students, reveal the quality of the treatment in general. The
the percentage of root fillings with adequate antiseptic and aseptic procedures during treatment,
lengths has been reported to range from 61.3% to the method used for canal preparation and the
69.6% (Barrieshi-Nusair et al. 2004, Eleftheriadis materials used are predictive factors that remain
& Lambrianidis 2005, Er et al. 2006). unknown from epidemiological studies (Wong
2004). For all the RCTs performed, working length
The quality of root filling was also assessed
was determined with radiographs, all teeth were
by its radiodensity and by the presence of voids
instrumented with the step back technique using
within the root filling or between the filling and
K-file hand instruments. Root canals were irrigated
canal walls. Radiodensity is one of the criteria
with NaOCl and EDTA and filled with a cold
used to estimate a potential defect of the root canal lateral compaction technique, using ZOE as the
sealing (Chugal et al. 2003). However, its sealer.
assessment could be influenced by the
radio-opacity of the material used to fill the root During the pre-clinical training of students,
canal. Thus, this parameter was related to the this procedure was included in the teaching
presence of voids in the root filling. The result programme during the second year and final year
showed that only 26% of the teeth had a RCT wherein each student had to complete a minimum
which was adequately dense without voids. When of 02 root canal treatments in extracted human
the root filling length was related to its adaptation, anterior teeth prior to treating patients and the
the percentage of teeth with adequate filling (score interns had to complete minimum of 01 RCT each
0) was 33.7%. This result is consistent with in a maxillary and mandibular molar. The
previous studies showing that the percentage of preclinical conservative and endodontic training
adequate root fillings performed by undergraduate takes place over 12 months with an allocation of
students ranged from 13% to 33% (Hayes et al. 4 h per week. The staff ratio for the preclinical
2001, Er et al. 2006 and Moussa-Badran et al. teaching in the Department of Conservative
2008). However, the results from this study are Dentistry and Endodontics is 1: 16 which is lower
lower than those obtained in previous studies with when compared with other European universities
a frequency of acceptable fillings reaching 55.3% (Qualtrough et al. 1999). This relatively limited
(Barrieshi-Nusair et al. 2004, Eleftheriadis & time would restrict preclinical training in
Lambrianidis 2005). Although it is difficult to endodontics with consequent concerns over
compare the studies because of the different competence during clinical practice.
criteria used, the low percentage in this study Clinical practice takes place in the institute
could be explained by the greater proportion of during the third and final year follwed by another
posterior teeth evaluated (76.3%). This hypothesis year of internship. Students and interns participate
is strengthened by the poorer results obtained with in clinical training for 21h per week and 42h per
premolars and molars compared with the single week respectively. . During the clinical years,
rooted anterior teeth (incisors and canines). RCTs students are required to treat a minimum of 05
of multirooted teeth were performed by the interns anterior teeth and interns are required to complete
and that of anteriors were performed by interns a minimum of 15 cases during the course of 06
and final year BDS students. It may be stated that weeks. The actual time devoted to endodontic
in the interest of the patient that the quality of training is difficult to evaluate because the
canal treatment may be improved by allocating the endodontic procedures are combined with other
treatment of premolars and molars to the post procedures of Conservative dentistry. Thus, clinical
graduate students and the treatment of only time dedicated only to endodontic practice would
anteriors to the undergraduate students. Finally, the allow a more precise evaluation of the time
result obtained may be explained by the analysis necessary for the improvement of the quality of
considering each tooth in its entirety. The root the RCTs. Clinical supervision of undergraduate
filling was judged as ‘acceptable’ (score 0) only students was undertaken by graduate teachers and
when all the roots of the tooth had an acceptable not totally by specialist endodontists. The ratio of
filling as described previously (Matysiak et al. clinical staff to students is 1: 10, which is
2003 and Moussa-Badran et al. 2008). comparable with the other universities
937
(Barrieshi-Nusair et al. 2004, Lynch & Burke prevalence and quality of endodontic treatment in an
2006).All procedures performed during RCTs may adult French population. International Endodontic
not have been directly supervised by the specilaist Journal 35, 690–7.
staff. This may explain the lower frequency of 3. Hayes, S. J., Gibson, M., Hammond, M., Bryant, S.
acceptable RCTs found in this study (similar to T., Dummer, P. M. H. An audit of root canal
the results obtained by Moussa-Badran et al. 2008 treatment performed by undergraduate students.
International Endodontic Journal Volume
(30.1%)) when compared to others who have 34(7), October 2001, p 501–505.
obtained comparatively better results (47.4%:
Barrieshi-Nusair et al. 2004; 70, %: Lynch & 4. Chugal NM, Clive JM, Spangberg LSW (2003)
Endodontic infection: some biologic and treatment
Burke 2006).
factors associated with outcome. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology and
CONCLUSION Endodontics 96, 81–90.
Adequate technical quality of root fillings 5. Er.O, Sagen B, Maden M, Cinar S, Kahraman Y.
performed by undergraduate dental students using Radiographic technical quality of root fillings
cold lateral compaction was found to be 33.7%. performed by dental students in Turkey (2006).
International Endodontic Journal 39, p 867- 72.
This low percentage suggests that the training
course in endodontics has to be improved at both 6. Eleftheriadis GI, Lambrianidis T.P. Technical quality
preclinical and clinical levels. The quality of work of root canal treatment and detection of iatrogenic
errors in an undergraduate dental clinic (2005).
can be enhanced by increasing the student staff
International Endodontic Journal Volume 38, 725-
ratio in both the preclinical and clinical lab and 34.
by increasing the preclinical quota for more and
scrupulous practice before the students enter the 7. Matysiak M, Tardieu-Fabre F, Galliot M (2003)
Establishing qualitative X-ray criteria to significantly
clinics.
contribute to the radiological results of an endodontic
treatment. Revue Medicale de l’Assurance Maladie
REFERENCES 34, 111–20.
1. Moussa-Badran, S., Roy, B., Bessart du Parc, A. S., 8. Ng YL, Mann V, Rahbaran S, Lewsey J, Gulabivala
Bruyant, M., Lefevre, B.3, Maurin, J. C. Technical K (2008) Outcome of primary root canal treatment:
quality of root fillings performed by dental students systematic review of the literature. Part 2. Influence
at the dental teaching centre in Reims, France. of clinical factors. International Endodontic Journal
International Endodontic Journal, Volume 41, 6–31.
41(8), August 2008, p 679–684. 9. Chueh LH, Chen SC, Lee CM et al. (2003) Technical
2. Lupi-Pegurier L, Bertrand MF, Muller-Bolla M, quality of root canal treatment in Taiwan.
Rocca JP, Bolla M (2002) Periapical status, International Endodontic Journal 36, 416–22
938
Prevalence and Prevention of Dental Caries and

Gingivitis in Patients Undergoing Orthodontic Treatment
Dr. S. Venkateswaran1, Dr. Ashwin Mathew George2, Dr. A. Shree Mankinda Prabhu3,
Dr. M.K. Anand4, Dr. N.R. Krishnaswamy5
ABSTRACT
Decalcification of enamel [White spots] commonly referred to as the scars of orthodontic treatment
and periodontal problems are common iatrogenic side effects of orthodontic treatment. Literature reports
that pHof plaque reduces to acidic levels during orthodontic treatment that prevents remineralization of
enamel even with fluoride supplements and for this reason addition of antibacterial agents such as
Chlorhexidine was found beneficial. This paper guides the clinician with the contemporary materials and
its recommended usage to combat such iatrogenic problems in patients undergoing orthodontic treatment.
Key Words: Varnish, Decalcification, Gingivitis.
INTRODUCTION patients undergoing orthodontic treatment

depending on specific indications.
The orthodontic patient due to the presence of
brackets, bands, archwires, springs and other Although fluoride applications have been the
orthodontic components is hampered in standard protocol for treating or preventing white
maintaining adequate oral hygiene.1 spot lesions, it has been stated by Ogaard5, 6that
Decalcification, gingival and periodontal problems when the pH of plaque reduces to 4.5
are common iatrogenic side effects of orthodontic remineralization is hampered even with fluoride
treatment. Decalcification or formation of white application. In such instances, application of
spot lesion results from an imbalance between the Hexidine was found to be beneficial.However,
literature3,7, 8, 9, 10shows variations in the duration
demineralization and remineralization of enamel.
of action of Hexidine varnish and also varied
Streptococcus mutans has been found to be
concentrations required for substantivity. Since
associated with the initiation and development of
orthodontic patients are normally seen only once
caries and significant increase in salivary and a month, it is mandatory that the effect of the
plaque levels of this microbe are seen as early as varnish should last for at least for a month. The
the first week after placement of the appliance.2,3.It particular effectiveness of chlorhexidine compared
has been shown that in the presence of gingivitis to other substances is certainly related to its high
and periodontitis the number of substantivity. Substantivity is the ability of an
PorphyromonasGingivalis and PrevotellaIntermedia agent to be retained in particular surroundings for
increases. The fimbriae of Porphyromonas a prolonged period of time.This property of
Gingivalis have been shown to have unique chlorhexidine is due to its ability to bind to the
properties. Biomechanical, immunological and carboxyl groups of the mucin that covers the oral
genetic evidence indicates that Porphyromonas mucous and be steadily released from these areas
Gingivalis is involved in adhesion to both saliva in an active form.11
coated hydroxyapatite and to human oral epithelial Chlorhexidine was found to prevent
cells.4Theclinical relevance would be subjected to degradation of type I collagen by Porphyromonas
the evaluation of an antimicrobial agent used in Gingivalis cells. The mechanism of inhibition of
dentistry for the dual purpose of combatting both proteolytic degradation appears to be associated
decalcification and gingival inflammation in with an electrostatic chlorhexidine-protein
orthodontic patients. Fluoride interaction. The Glucosyltransferase from
varnishes,Chlorhexidine varnishes and Tooth Streptococcus mutans which may be important in
Moouseshave proven without a doubt their dental plaque formation may be sensitive to
potential benefits,and have been recommended for chlorhexidine. In addition the phosphoenol
1, 2
Professor, DNB, 3P.G. Student, 4Reader, 5Professor and Head, DNB, Dept. of Orthodontics and Dentofacial Orthopedics,
Ragas Dental College and Hospital, Chennai.
939
pyruvate phosphotransferase of this microorganism test Results indicated that a single application of
is also inhibited by chlorhexidine.12 the test varnish was capable of significantly
Chlorhexidine in its varnish form does not reducing Mutans streptococci count and
depend on patient compliance, does not stain teeth, Porphyromonas gingivalis count in the first month.
the tongue, the mucosa and composite restoration However, it was noted that the test varnish had no
or alter taste sensation like the chlorhexidine effect on Mutans streptococci at the end of three
mouth rinse, thereby eliminating the drawbacks of months but had an effect on Porphyromonas
the mouthwash.2 gingivalis at the end of three months. Therefore,
an application schedule of at least once a month
Chlorhexidine varnish is usually combined is recommended, when used for controlling white
with Thymol, which has proved to have a spot lesion.14
synergistic effect
The introduction GC Tooth Mousse, which is
Thymol is a component of the essential oil a combination of casein phosphopeptide-
gained from Thyme (Thymus vulgaris). It belongs amorphous calcium phosphate[CPP-ACP] has the
to the family of Phenols and displays an ability to remineralize sub surface white spot
antimicrobial effect combined with pronounced lesions. Casein is a type of proteinaceous
fungistatic properties similar to those of substance present in milk capable of absorbing
chlorhexidine. Thymol has a denaturation effect on through the enamel surface. The CPP are formed
proteins and destroys the cell membrane. are formed from a tryptic digest of the milk
Therefore, thymol inhibits growth of a large protein by aggregation with calcium phosphate and
number of microorganisms. purificationultrafiltration.15
Over the past few years, studies on the effect Manufactures claim that with incipient carious
of sustained release chlorhexidine varnishes have lesions, the subsurface water can be converted
sparked interest in its applicability in orthodontics back into enamel because of the neutral ions
where it could be used for protection against moving by diffusion through the porous surface.
gingivitis and a questionable effect on When it reacts with the water, the hydroxyapatite
decalcification.Fluoride varnish on the other hand formed will regenerate in the subsurface space.
has proven to be the gold standard for preventing Once 80- 85% regeneration has occurred, the
decalcification and numerous studies unanimously enamel will appear optically normal removing the
report a 30-50% reduction in incipient enamel white spot illusion. The mechanism of action is
lesions followingthe application of fluoride similar to that of salivary protein statherin and the
varnish.13 Repeated application of fluoride varnish supply of bioavailable calcium and phosphate is
has a positive effect on the remineralization of able to drive remineralization, buffer acids and
initial cariouslesion but fluoride has no effect on reduce the plaque acid effect on tooth surface.16
gingival health.Unfortunately, both fluoride and In arrested lesions,etching with
chlorhexidine cannot be combined as a single orthophosphoric acid for fifteen seconds is
varnish as their combination leads to antagonistic recommended to make the surface permeable
action.To get ideal protection,it is recommended to before the application of Tooth Mousse. A key
use the fluoride and hexidine varnish separately. principle is that the longer the material is
Literature quotes numerous studies on the maintained in the mouth,the more effective the
benefits of fluoride and chlorhexidine varnishes result and it is also recommended that patients
separately.In a study conducted to test the efficacy brush their teeth with a fluoride tooth paste,before
of chlorhexidine varnish (Cervitec) against the application of the Tooth Mousse as the fluoride
streptococcus mutans and porphyromonas would enhance the remineralizing capacity.
gingivalis as well as its effect on gingival health,
plaque samples from the test sites were inoculated CONCLUSIONAND RECOMMENDATION
on specific media for mutans streptococci and Decalcification and gingivitis are common
porphyromonas gingivalis. Bacterial counts were iatrogenic consequences of orthodontic treatment
thus obtained. Prevention of decalcification was and are commonly referred to as the scars of
evaluated by its antibacterial action against orthodontic treatment. Individuals with
Mutans streptococci using agar plates as malocclusions often present many retention sites
culturemedium and the prevention of gingivitis for plaque accumulation due to the irregular
was evaluated by its antibacterial action arrangement of teeth. In addition the
againstPorphyromonas gingivalis using the PCR environmentcreated by theorthodontic appliances
940
General Protocol for Varnish Application of Chlorhexidine mouthwashes on patients

undergoing orthodontic treatment ,AJO-DO,volume
1997 jun(606-612)
2. MJM Schaeken , P De Haan- Effects of Sustained
Release Chlorhexidine acetate on human dental
Plaque Flora , J Dent Res 68(2): 119-123,Feb,1989
3. S Matthijs, PA Adriaens,-Chlorhexidine Varnishes: a
review, J Clin Periodontol 2002;29:1-8
4. Lee et al,1992,Watanabe et al 1992,Hamada et al
1994-Porphyromonas genome project.,National
institute of craniofacial research 2007
5. William Brantley,Theodore Eliades - Orthodontic
Materials - Scientific and clinical aspects Theime
Stuttgart. New York 2001
6. Ali Ihya Karaman.Tancan Uysal - Effectiveness of a
Hydrophilic Primer when different microbial Agents
are mixed, Angle Orthodontist, Vol 74, No 3 ,2004
7. NuritRedlich, Doran Harari, Michael Friedman, Doron
Steinberg-, Effect of sustained-release chlorhexidine
varnish on Streptococcus mutans and Actinomyces
viscosusin orthodontic patients, AJO DO
2003;123:345-8)
8. HJ Sandham,J Brown,KH Chan,H I Phillips, R C
Burgess, A Stokl-clinical trials in adults of an
antimicrobial Varnish for Reducing Mutans
Streptococci,Journal of dental research70( 11); 1401
with all its attachments harbors S.mutans and
- 1408,. Nov. 1991
Prophymonasgingivalis which is responsible for
9. S Twetman,A Hallgren, L G Petersson. Effect of an
white spot lesions and gingivitis. Antibacterial Varnish on Mutans Streptococci in
Although Fluoride and Chlorhexidine mouth plaque from Enamel Adjacent to Orthodontic
rinses have proved their effectiveness against white appliances ,Caries Res 1995; 29:188-191
spot lesions and gingivitis, patient compliance has 10. C Van Loveren ,JF Buijs,MJ Buijs,JM Ten Cate.
always been a subjective problem, mainly because Protection of Bovine enamel and dentine by
of prolonged duration of orthodontic treatment. Chlorhexidine and Fluoride Varnishes in a bacterial
Moreover, hexidine mouth washes has potential demineralization model , Caries Res 1996;30:45-51.
drawbacks such as staining and alteredtaste 11. Greenstein G, Berman C, Jaffin R. Chlorhexidine. An
sensation adjunct to periodontal therapy. J Periodontol. 1986
Jun;57(6):370-7.
Sustained release chemical agents (varnishes) 12. R Grenier,Reduction of Proteolytic Degradation by
could be used during the active phase of Chlorhexidine ,J Dent Res 72(3);630-633,March,1993.
orthodontic treatment to reduce the bacterial 13. J Bowman et al - Efficacy of fluoride varnish in
plaque accumulation and caries potential. preventing white-spot lesions as measured with Laser
Florescenece-Journal of clinical orthodontics-January
We can conclude and recommend that it is 2011JCO-volume XLV jan2011[25-29]
advantageous to use a Chlorhexidine varnish which 14. Kalingi Suresh et al—Chlorhexidine varnishes
has an added advantage of preventing and effectively inhibit Porphyromonas gingivalis and
controlling both gingivitis and decalcification in Streptococcus mutans — an in vivo study- JISP;
the initial stages. Once established, decalcification 170-180; july 2010-Issuse 3-Vol14
is manifested by the presence of white spot lesion 15. Gagaire V et al - Phosphopeptides interacting with
and it is recommended to use Fluoride varnish and colloidal calcium phosphate isolated by tryptic
Tooth Moouse. hydrolysis of bovine casein miscelles-J Dairy Res
1996;63::405-422]
REFERENCES 16. SCHUPBACH et al - Incorporation of
caseinglycomacropeptide and caesinphosphopeptide
1. Gisella Bernal Anderson,MS,Jim Bowden,Edith into salivary pellicle inhibits adherence of mutans
C.Morrison,PH and Raul G.Caffesse - Clinical effects streptococci;-J Dent Research1996;75(10);1779-1788
941
H1N1 Flu (Swine Flu) Precautions for Dental Professionals

1
Dr, Amit Vanka, 2Dr. G. Shanthi, 3Dr. Ajay Bhambal, 4Dr. Vrinda Saxena, 5Dr Sahana,
6
ABSTRACT
“Prevention is Better than Cure” So better prevent than Suffer. Influenza causes annual epidemics of
respiratory illness worldwide and is the most important cause of medically attended acute respiratory illness.
During a pandemic, reducing transmission of influenza to health care workers may not only help support
the health care workforce, but may also prevent influenza transmission to patients. There is a need for:
Infection control issues during patient assessment, Specific Recommendations for Dental Health Care and
care of the Dental Health Care Personnel. All the illustrated have been in detail summarized. It is concluded
through this review that it is very important for all the dental health care professionals to try to fight the
barriers like fear and use all the necessary precautions to prevent the H1NI infection. It is the duty of
every health care professional to follow the preventive procedures so that there would be no infections
that spreads through the dental operatory.
Key words: Swine flu, H1N1, Dental professionals, infection control, Prevention
INTRODUCTION Swine Flu or the H1N1 Flu which is officially

declared as the Pandemic is causing havoc all
“Prevention is Better than Cure” So better
around the world, with the death toll constantly
prevent than Suffer. Influenza causes annual
rising and the number of people getting infected
epidemics of respiratory illness worldwide and is
constantly on the rise and in a condition where the
the most important cause of medically attended
government is helpless about the situation, we
acute respiratory illness1,2. Moreover, there is
have to save/protect ourselves from this dreaded
increasing concern about the recently declared
disease7.
influenza pandemic due to 2009 influenza A
(H1N1) in humans3-5. During a pandemic, reducing transmission of
influenza to health care workers may not only help
H1N1 flu is caused by type A strains of the
support the health care workforce, but may also
influenza virus, and is being described as a new
prevent influenza transmission to patients. Other
subtype of A/H1N1 not previously detected in
personal protective strategies, such as effective
swine or humans.
vaccines or antiviral drugs, may be limited in
Those carrying the virus can reveal typical availability.
flu-like symptoms:
The threat of swine flu has put all health care
• Fever (greater than 100ºF) providers on high alert, and dentists and dental
• Chills practices are no exception. In a survey conducted
by dental continuing education resource The
• Head and body aches Wealthy Dentist, 12% of dentists said they have
• Fatigue already made changes as a result of H1N1
• Cough influenza, and another 29% are considering it8.
• Stuffy nose To improve infection control, some dentists
have made changes like: more frequent hand
• Sore throat
washing and use of hand sanitizer, not treating
• Vomiting and diarrhea patients who feel ill, encouraging sick employees
More serious illnesses such as pneumonia or to stay home, and using eye shields and R-95 face
respiratory illness have also been reported6. masks to block virus particles9.
1
Professor and Head, Dept. of Pedodontics, People’s Dental Academy, Bhopal 2Senior Lecturer, 3Professor and Head,
4
Professor, 5Reader, 6Senior Lecturer, Dept. of Preventive and Community Dentistry, People’s College of Dental Sciences
and Research Center, Bhopal
942
So ADA has given some Guidelines for the over longer distances through the air, such as
Prevention/ precautionary measures to be taken by from one patient room to another.
Dental Professionals. • Use a treatment room with a closed door, if
Infection control issues during patient available. If not, use one that is farthest from
assessment: other patients and personnel.
• Dental health care personnel should wear a
1. Patients with an acute respiratory illness
NIOSH fit-tested, disposable N95 respirator
should be identified at check-in and placed in
when entering the patient room and when
a single-patient room with the door kept
performing dental procedures on patients with
closed.
suspected or confirmed 2009 H1N1 influenza.
2. Offer a disposable surgical mask to persons
who are coughing, or provide tissues and • If N95 respirators and/or fit-testing is not
no-touch receptacles for used tissue disposal. available despite reasonable attempts to obtain,
the dental office should transition to a
3. The ill person should wear a surgical mask
prioritized use mode (i.e., non-fit-tested
when outside the patient room.
disposable N95 respirators or surgical
4. Dental healthcare personnel assessing a patient facemasks can be considered as a lower level
with influenza-like illness should wear of protection for personnel at lower risk of
disposable surgical facemask*, non-sterile exposure or lower risk of complication from
gloves, gown, and eye protection (e.g., influenza until fit-tested N95 respirators are
goggles) to prevent direct skin and conjunctiva available).
exposure. These recommendations may change
as additional information becomes available. • As customary, minimize spray and spatter
(e.g., use a dental dam and high-volume
5. Patient and dental healthcare workers should
evacuator).
perform hand hygiene (e.g., hand washing
with non-antimicrobial soap and water,
alcohol-based hand rub, or antiseptic hand Dental Health Care Personnel
wash) after having contact with respiratory • Dental health care personnel should self-assess
secretions and contaminated objects/materials. daily for symptoms of febrile respiratory
6. Routine cleaning and disinfection strategies illness (fever plus one or more of the
used during influenza seasons can be applied following: nasal congestion/runny nose, sore
to the environmental management of swine throat, or cough).
influenza.
• Personnel who develop fever and respiratory
symptoms should promptly notify their
Specific Recommendations for Dental supervisor and should not report to work.
Health Care:
• Personnel should remain at home until at least
• Encourage all dental health care personnel to 24 hours after they are free of fever
receive seasonal influenza and 2009 H1N1 (100°F/37.8°C), or signs of a fever, without
influenza vaccinations. the use of fever-reducing medications.
• Use patient-reminder calls to identify patients • Personnel having a family member who is
reporting influenza-like illness and reschedule diagnosed with 2009 H1N1 influenza can still
non-urgent visits until 24 hours after the go to work but should monitor themselves for
patient is free of fever, without the use of symptoms so that any illness is recognized
fever-reducing medicine. promptly.
• Identify patients with influenza-like illness at
check-in; offer a facemask or tissues to Additional Resources
symptomatic patients; follow respiratory
hygiene/cough etiquette; and reschedule For comprehensive information on CDC 2009
non-urgent care. H1N1 influenza infection control guidelines, visit
Infection Control and Clinician Guidance on H1N1
• Urgent dental treatment can be performed Flu Clinical and Public Health Guidance:
without the use of an airborne infection
isolation (AII) room because transmission of • Interim Guidance on Infection Control
2009 H1N1 influenza is thought not to occur Measures for 2009 H1N1 Influenza in
943
Healthcare Settings, Including Protection of 2. Thompson WW, Shay DK, Weintraub E; et al.
Healthcare Personnel Influenza-associated hospitalizations in the United
States. JAMA. 2004;292(11):1333-1340.
• Questions and Answers about CDC’s Interim
3. Dawood FS, Jain S, Finelli L; et al, Novel
Guidance on Infection Control Measures for
Swine-Origin Influenza A (H1N1) Virus Investigation
2009 H1N1 Influenza in Healthcare Settings, Team. Emergence of a novel swine-origin influenza
Including Protection of Healthcare Personnel A (H1N1) virus in humans. N Engl J Med.
2009;360(25):2605-2615.
• Questions and Answers Regarding Respiratory
Protection for Infection Control Measures for 4. Cohen J, Enserink M. Swine flu: after delays, WHO
agrees: the 2009 pandemic has begun. Science.
2009 H1N1 Influenza Among Healthcare
2009;324(5934):1496-1497.
Personnel
5. Neumann G, Noda T, Kawaoka Y. Emergence and
• 10 Steps You Can Take: Actions for Novel pandemic potential of swine-origin H1N1 influenza
H1N1 Influenza Planning and Response for virus. Nature. 2009;459(7249):931-939.
Medical Offices and Outpatient Facilities10. 6. H1N1 FLU (Swine Flu) Precautions For Dental
professionals : Posted on June 21st, 2009 in Daily
So it is concluded through this review that it Updates in dentistry.
is very important for all the dental health care
7. 7 Steps to prevent Swine Flu, Posted on August 12th,
professionals to try to fight the barriers like fear 2009 in Daily Updates in dentistry, Dental News,
and use all the necessary precautions to prevent www.juniordentist.com/h1n1-swine-flu-for-dental-pro
the H1NI infection. It is the duty of every health fe.html -
care professional to follow the preventive 8. Mark L, Nancy DRN; James M, John M, Sarabia A,
procedures so that there would be no infections Glavin V, Webby R, Smieja M, David JDE, Chong
that spreads through the dental operatory. S, Webb A, Stephen DW, Surgical Mask vs N95
Respirator for Preventing Influenza Among Health
Care Workers- A Randomized Trial, JAMA.
2009;302(17):1865-1871.
REFERENCES
9. Dentists vs. Swine Flu - Dentistry Slow to Change,
1. Langley JM, Faughnan ME. Prevention of influenza San Francisco, California May 07, 2009 Health News.
in the general population. CMAJ. 10. Prevention of 2009 H1N1 Influenza Transmission in
2004;171(10):1213-1222. Dental Health Care Settings, November 23, 2009.
944
A Greater Focus on the Knowledge and Attitude on the

Management of Children with Special Needs among
Primary Dental Care Providers
Dr. Punithavathy1 Dr. Esther Nalini2 Dr.Geetha Priya3 Dr.Rachuri Narendra Kumar4 Dr.Joe Louis5
ABSTRACT
Aim: To assess the knowledge on dental services provided to patients requiring special care and to
review the training acquired by the primary dental care providers towards special needs children in their
dental school.
Settings and Design: The study is a cross-sectional, observational, questionnaire survey.
Materials and Method: A random sample of sixty active registereddental practitioners listed in the
Indian Dental Association directory in the district of Erode, Tamil Nadu, India were surveyed by means
of a questionnaire that involved a five point likert scale. We received responses from 53.
Statistical analysis used: Descriptive statistics-table and percentage.
Results: Out of the 60, 53 questionnaires were returned completed. The respondents were aged 23
to 38 years and 34 were males and 19 were females.
The knoledge of management of special needs children were self rated as excellent by 9.4% above
average by 11.3% and average by 45.3% of the 94.4% respondents who were willing to provide dental
care for special needs children. The order of preference for managing special children were visually
impaired (90.5%), physically challenged (88.7%), hearing and speech impaired (84.9%) and mentally
challenged (64.1%). The respondents reported the following factors as important in the management of
special children. Medical history of the patient (100%), communication (98.1%), parent/caretaker compliance
(94.3%), physical accessibility to the dental clinic (92.4%), management in a hospital setup (84.9%),
importance of ethical obligation (88.7%).
INTRODUCTION MATERIALS AND METHODS

“Being disabled should not mean being Respondents
disqualified from having access to every aspect of
life” – Ruma Thompson. The prime target of a Respondents were all private dental
practitioners practicing at Erode, registered in IDA
nation should be to improve the health and social
- Erode branch. All dental practitioners who can
functioning of deprived people. Special and
be reached were included in the study.
medically compromised patient present a unique
population that challenges the dentist’s skills and
MATERIALS
knowledge. Providing comprehensive dental care
for the disabled is not only rewarding but is also A paper based questionarie with information
a community service that health care providers are about the background variables of the dentist (age,
obligated to fulfil. This has been severely gender, years of practice, type of practice) and
hampered by physical barriers in their practices, adequate training for the dentist in management of
economics, lack of education and training. [1] children with special needs. Other information
In the light of foregoing, this study aimed to: included were self rated knowledge and
willingness to treat such children.
To assess the knowledge on dental services
provided to patients requiring special care and to
METHODS
review the training acquired by the primary dental
care providers towards special needs children in Each practitioner was sent a copy of the
their dental school. questionarie and a stamped addressed envelope for
1,3
Senior Lecturer, Dept. of Pediatric and Preventive Dentistry, 2Reader, Dept. of Periodontics, 4Senior Lecturer, Dept. of
Prosthodontics, K.S.R Institute of Dental Science and Research, Thiruchengode, Tamilnadu. 5Professor, Dept. of Pediatric
and Preventive Dentistry, Chettinad Dental College, Chennai, Tamilnadu.
945
its return. An explanatory letter was also included Q.No A B C D E

and also each recipient was given the option of an
1 5(9.4) 6(11.3) 24(45.3) 11(20.8) 7(13.2)
online questionarie to complete as an alternative.
A reminder was published through mail to 2 33(62.3) 17(32.1) 1(1.9) 2(3.8) –
encourage return of the completed questionaries. 3 I 42(79.2) 6(11.3) 3(5.7) 1(1.9) 1(1.9)
The survey was pretested on the first ten dentist II 36(67.9) 9(17.0) 5(9.4) 2(3.8) 1(1.9)
who received the questionarie to check for clarity
III 21(39.6) 13(24.5) 12(22.6) 5(9.4) 2(3.8)
and ease of answering the questions.
IV 41(77.4) 6(11.3) 3(5.7) 2(3.8) 1(1.9)
Statistical analysis 4 I 50(94.3) 2(3.8) 1(1.9) – –
II 42(79.2) 8(15.1) 3(5.7) – –
Data were entered in to a computer and
analysed. Descriptive statistics were applied. III 47(88.7) 6(11.3) – – –
IV 36(67.9) 13(24.5) 3(5.7) 1(1.9) –
RESULTS V 29(54.7) 16(30.2) 5(9.4) 3(5.7) –
Out of 60 questionaires given out 53 were 5 I 30(56.6) 10(18.9) 11(20.8) 1(1.1.9) 1(1.9)
returned completed, a response rate of 89%. II 47(88.7) 6(11.3) – – –
Respondents of 34 % males and 19 % females.
Majority was aged between 23 and 38 years, 90% DISCUSSION
practiced in teaching hospitals, 10.3% in private
“people with special needs are the most
establishments. Gender and place of practice did
underserved of the underserved in our society”.[2]
not influence any of the parameters examined in
This article is intended to address the involvement
the study. Majority of the respondents had treated
and barriers of primary care providers in the
special needs children previously.
management of special needs children rather than
Only 9.4% of the dentist rated their knowledge insisting on the oral health status and unmet
of management of children with special needs as treatment needs of these disadvantaged population.
excellent. 11.3% of respondents rated their More than half of respondents in this study
knowledge as above average, 45.3% of the dentist reported that they had fairly adequate knowledge
rated their knowledge as average. 13.2% of the of the management of children with special needs.
dentist rated as inadequate felt their management The results reported here demonstrate a low level
was very challenging. A higher proportion of those of previous training in special health care needs,
who rated their knowledge as excellent were yet a high level of interest in treating these
willing to treat the children, while a higher patients.
proportion who rated their knowledge as average
were not willing to treat. Provision of oral health care to children and
adolescents with special health care needs requires
Among all the respondents in this study, specialized knowledge, increased awareness and
62.3% (32.1 %) were willing to take up the attention.[3] Similar research has highlighted
challenges of treatment of children irrespective of education and training as a means to improve
age and type of training. 3.8% (1.9%) are not service provision for this patient group.[4] Special
willing to treat those special children. Among the care in dentistry also includes managing or
specific groups of children with SHCN the were accommodating the behaviour of a resistant patient
willing to manage in the following order, visually and making modification to routine treatment
impaired (90.5%), physically challenged (88.7%), procedures.[5] Special training is required to help
hearing and speech impaired (84.9%) and mentally the interested dentist to cope with difficult
challenged (64.1%). behaviour.[6] So the dental school should respond
The respondents ranked the factor that play to the need for training dentists in this special
considerably important role in the management of field. It may be assumed from this study that given
children with SHCN as, medical history of the adequate facilities, training, support and good
patient (100%), communication (98.1%), remuneration they will be able to give better care
parent/caretaker compliance (94.3%), physical to such children.
accessibility to dental clinic (92.4%), management The respondents in our study were equally
in a hospital setup (84.9%). 88.7% of the dentist willing to manage mentally and physically
would refer CSN to other practioners for treatment. challenged patients. This reveals that there is no
946
observed personal preference/discrimination against Based on the findings from this study a
managing the mentally challenged, due to their number of recommendations can be made.
challenging behaviour.
• There is a need for education and enhanced
When treating patient with SHCN, an training in SCD at the dental school, with an
assessment of the patients mental status or degree emphasis on hands on clinical experience in a
of intellectual functioning is critical in establishing supervised environment.
good communication.[7] An effort should be made
to communicate directly with the patient during the • Effective, evidence-based education and
provision of dental care. A patient who does not training programmes for the carer of SCP’s
communicate verbally may need to be present to ought to be established, with a focus on
facilitate communication and/or provide community based prevention.
information that the patient cannot.[8] Effective
communication is essential and, for hearing REFERENCES
impaired children it can be accomplished through 1. Waldman HB, Perlman SP, Swerdloff M: Children
interpreters, written materials, and lip reading.[9] with mental retardation/developmental disabilities: Do
physicians ever consider needed dental care ? Ment
Parental lack of awareness and knowledge Retard 2001, 39: 53 - 56.
may limit a SHCN patient from seeking preventive 2. Glassman, P., Miller, C. Dental disease prevention
dental care.[10] Familiarity with the patients medical and people with special needs. J Calif Dent Assoc
history is essential to decreasing the risk of 2003; 31: 149 - 160
aggravating a medical condition while rendering 3. American Academy of Pediatric Dentistry: Council on
dental care. If the patient /parent is unable to Clinical Affairs 2004. Clinical guideline on
provide accurate information, consultation with the management of persons with special health care
needs. In Reference Manual Chicago, IL: American
caregiver or with the patients physician may be
Academy of Pediatric Dentistry.
required.[11]
4. Folakemi A Oredugba , Oluwatosin O Sanu .
knowledge and behavior of Nigerian dentists
In the present study management in a hospital
concerning the treatment of children with special
setup was found to be more convenient which may needs. BMC Oral Health 2006, 6:9.
be because of the availability of better 5. Oral health care for persons with disabilities:
environment and staff support. Previous studies Department of Pediatric Dentistry, College of
have reported that dentists practicing in dental Dentistry, University of
schools and teaching institutions are more willing Florida.(http://www.dentalufl.edu/Fculty/Pburtner/dis
to treat such children.[12] abilities/English.deftypes.htm]Assessed; November 23
2004.
The dentist have reported that adequate 6. Bennett CR: Dentistry and the disabled. Team Reheb
physical accessibility (eg. wheel chair, ramps, Report 1998:20 – 24.
handicapped parking spaces) for SHCN patients is 7. Klien U, Nowak AJ, Autistic disorder: A review for
very important , the absence of which may pediatric dentist. Pediatr Dent. 1998; 20:321-317.
adversely impact the frequency of dental visits.[11] 8. American Dental Association Web site:
www.ADA.org: Americans with Disabilities
Dentists have an obligation to act in an ethical Act(AwDA). Accesed September 12, 2003.
manner in the care of patients.[13] When the 9. Halfon N, Inkelas M, Wood.D: Nonfinancial barriers
patients needs are beyond the skills of practitioner to care for children and youth. Ann rev public health.
the dentist should make appropriate referrals in 1995; 16: 447-472.
10. Shenkin JD, Davis MJ, Corbin.SB. The oral health of
order to ensure the overall health of the patient.[11]
special needs children: Dentistry‘s challenge to
provide care. J Dent Child. 2001; 86: 201-205.
11. American Academy of Pediatric Dentistry. Clinical
CONCLUSION:
Guideline on Management of Persons with Special
Health care Needs. Pediatr Dent. Reference manual –
It may be concluded from this study that very revised 2008; 32(6) : 132 – 135.
few dentists reported to have adequate knowledge 12. Sharpe M, Mayou R, Seagroatt V: Why do doctors
of management of special children, irrespective of find some patients difficult to help? Q J Med 1994,
age, gender and place of practice. While it is 87: 187-193.
evident that some primary care practitioners 13. American Academy of Pediatric Dentistry. Policy on
provide a service to SCPS, from the level of the ethic of failure to treat or refer. Pediatr Dent.
response to this survey, they are in the minority. 2004; 26(7) : 60
947
Oil Pulling Therapy on Streptococcus mutans Count in

Plaque and Saliva - A Randomized Controlled Trial
1
Dr. Sharath Asokan, 2Dr. Jeevarathan J, 3Dr. Shakeer A, 4Dr. Pamela Emmadi,
5
Dr. Raghuraman R
ABSTRACT
Purpose: The aim of the randomized controlled trial was to evaluate the effect of oil pulling therapy
with sesame oil on reduction of Streptococcus mutans count and dental caries in adolescents and to compare
its efficacy with chlorhexidine mouthwash and regular tooth brushing.
Methods: Streptococcus mutans count was evaluated from the plaque and saliva samples of 30
adolescents using the Dentocult SM kit. The participants were divided into oil pulling group (Group I),
chlorhexidine group (Group II) and tooth brushing group (Group III). Plaque and salivary samples were
collected again every month for six months. The pre and post DMF scores were also assessed.
Results: Both oil pulling therapy and chlorhexidine mouthwash were equally effective in reduction
of S.mutans count and were definitely much better than tooth brushing alone. Turkey HSD post hoc test
showed that group I and II were better than group III (p = 0.042 and 0.010 respectively). There was no
significant reduction in the DMF score in any of the three groups during the six months trial period and
during the follow-up period of one year.
Conclusion: Both oil pulling therapy and chlorhexidine mouthwash are equally effective in reduction
of S.mutans count and are definitely much better than tooth brushing alone.
Key words: Oil Pulling therapy, Dentocult SM strip, S.mutans
INTRODUCTION of oil pulling in the 1990s in Russia4. For oil

pulling therapy, a tablespoon (teaspoon for young
Preventive dentistry remains the foundation of
children) of sesame oil is taken in the mouth,
oral health care and dental health care
sipped, sucked and pulled between the teeth for 10
professionals need to make home oral hygiene the
to 15 minutes. The viscous oil turns thin and milky
core of their preventive foundation. Many
white. The oil should not be swallowed as it
indigenous natural products deserve due
contains bacteria and toxins. Oil pulling therapy is
recognition for their contribution to improving oral
preferably done on empty stomach in the morning
health and sesame oil is one. Sesame oil is derived
and tooth brushing should follow it. It was claimed
from the plant Sesamum indicum (Pedaliaceae
that the swishing activates the enzymes and draws
family) and is considered as the queen of oil seed
the toxins out of the blood. The bottom line is that
crops because of its beneficiary effects. ‘Oil
oil pulling actually cannot pull toxins out of the
Pulling’ or oil swishing is a procedure that
blood as claimed because the oral mucosa does not
involves swishing sesame or sunflower oil in the
act as a semi-permeable membrane to allow toxins
mouth for oral and systemic health benefit1,2.
to pass through.
Oil pulling therapy with sesame oil has been
Sufficient scientific research has not been
extensively used as a traditional Indian folk
carried out to evaluate the efficacy of oil pulling
remedy for many years without scientific evidence
therapy on oral health status. Online searches
or proof for strengthening teeth, gum, jaws,
provide only testimonies and literature on personal
prevent decay, oral malodor, bleeding gums and
experiences and so this study was planned with
dryness of throat and cracked lips3. The concept
the following objectives:
of oil pulling therapy is not new and it has been
discussed in the Ayurvedic text, Charak Samhita 1. To evaluate the effect of oil pulling with
as “Kavala Graha” or “Kavala Gandoosha”. But it sesame oil on reduction of dental caries in
was Dr. F. Karach who familiarized the concept adolescents
1,2
Reader, 3Senior Lecturer, Dept. of Pediatric Dentistry, 4Professor and Head, Dept. of Periodontics, 5Professor and Head,
Dept. of Microbiology, Meenakshi Ammal Dental College, Chennai
948
2. To evaluate the effect of oil pulling with S.mutans the plaque samples were collected by a
sesame oil on reduction of S.mutans in plaque calibrated examiner (B) from the following four
and saliva sites (a) buccal surface of maxillary right molar
(b) labial surface of maxillary incisor (c) lingual
3. To compare the effect of tooth brushing with
surface of mandibular incisor and (d) lingual
and without oil pulling and chlorhexidine
surface of mandibular left molar. These samples
mouthwash on reduction of S.mutans count
were spread thoroughly but gently on the four sites
of the rough surface of the plaque strip. For saliva
METHODS collection, paraffin pellet was given to each subject
A randomized controlled trial was carried out and it was chewed for 1 minute. Excess saliva was
after the study protocol was analyzed and swallowed. Rough surface of Dentocult SM saliva
approved by the Institutional Review Board of strip was pressed against saliva in tongue and was
Meenakshi University. About hundred adolescent removed through gently closed lips by another
boys aged 16-18 years, from Meenakshi Ammal calibrated examiner (C). The strips were then
Dental College, Chennai, India were screened. placed in the selective culture broth, with the
Personal details, details of past medical history smooth surfaces clipped and attached to the cap.
including any recent antibiotic exposure, past The vials were labeled as per their lot numbers
dental history including recent fluoride treatment, and incubated in an upright position at 37°C for
frequency of brushing, sweets/snacks intake and 48 hours with the cap opened one quarter of a
consumption of sugared/energy drinks and the turn to allow growth of microorganisms. Group I
brand of toothpaste to know about its fluoride was subjected to oil pulling with sesame oil
content were obtained through a specially prepared (Idhayam Oil, VVV Sons, India) for 10 minutes
questionnaire, to reduce confounding bias. Written everyday in the morning before tooth brushing for
consent was obtained from the participants and 6 months. Group II was given diluted (1:1) 0.2%
their parents. Thirty boys were included in the chlorhexidine mouthwash (Hexidine, ICPA Health
study based on the following inclusion and Products Ltd, India) for one minute and group III
exclusion criteria. was asked to tooth brush and rinse with water.
Inclusion Criteria Five boys from each group were instructed to
follow the oral hygiene measure allotted twice
1. 30 age-matched healthy adolescents daily. The plaque and saliva samples were
collected every month for six months. The DMF
2. Should have at least 20 natural teeth in
scores were recorded at the end of six months by
permanent dentition
examiner (A). All the thirty boys were re-evaluated
3. DMF scores 3-5. for the DMF score after a follow-up period of one
year.
Exclusion Criteria
The presence of the S.mutans was confirmed
1. History of antibiotics for past 3-4 weeks by detecting light blue to dark-blue raised colonies
2. History of fluoride treatment for past 2 on the inoculated surface of the strip. Colonies
weeks suspended in the culture broth were excluded from
the evaluation. Two independent interpreters
Each person was assigned to a group by evaluated the results according to the
simple random sampling using the table of random manufacturers’ chart.
numbers by examiner (A). Group-I (study
group-oil pulling), Group-II (positive control group Assessment and comparison of the baseline
- chlorhexidine) and Group III (control group - scores and the post-interventional scores of the
tooth brushing) included 10 boys each. The S.mutans count in plaque and saliva were done
baseline DMF scores of all the thirty boys were within and between the three groups. Proportions
recorded. The number of plaque and salivary were compared by Kruskal-Wallis test, Wilcoxon
Streptococcus mutans was determined using simple matched pairs signed ranks test and Mann-Whitney
chair side method (Dentocult SM Strip mutans, U test appropriately as explained below the tables.
Orion Diagnostica, Espoo, Finland). The plaque The DMF scores were compared using ANOVA,
was collected with sterile toothpicks 1-2 hours Paired‘t’ test and Independent‘t’ test. In the present
after eating / brushing, as it could affect the study, p<0.05 was considered as the level of
growth of the bacteria. For the baseline status of significance. The statistical analysis was done
949
using the software SPSS version 15 (SPSS Inc, Saliva Samples

Chicago). The examiners who collected the plaque In the saliva samples, significant reduction was
and saliva samples, the interpreters of the results seen in Group I after 2, 3, 5 and 6 months and
and the statistician were blinded about the division in Group II after 1, 2, 3 and 5 months as shown
of groups. in Table 3. At the end of 6 months there was
significant reduction between the three groups (p
RESULTS = 0.032) and it was found that group I was better
than group III (p = 0.34). Both one-time and twice
Plaque Samples usage were equally effective in reduction of the
In group I and II there was statistically S.mutans count and there was no significant
significant reduction of S.mutans count in all the difference in any of the three groups.
time periods as shown in table 2. Table 1 shows Table 3. Comparison of S.mutans count in saliva samples within
that there was significant difference between the each group at different time periods
three groups only in the 3 months time period.
Turkey HSD post hoc test showed that group I Time Period p value*
and II were better than group III (p = 0.042 and (Saliva Samples) Group I Group II Group III
0.010 respectively). Mann-Whitney U test was
used to evaluate the reduction within each group Pre – 1 month .062 .024 .276
between the one-time users and two times users. Pre – 2 months .050 .023 .214
There was no significant difference in any of the Pre – 3 months .033 .023 .516
three groups based on the number of times the oral Pre – 4 months .084 .132 .180
hygiene practice was followed.
Pre – 5 months .015 .046 .046
Table 1. Comparison of S.mutans count in plaque samples Pre – 6 months .023 .107 .317
between the three groups at different time periods
*p value calculated by Wilcoxon Signed Ranks Test
Time Group I Group II Group III
Period p DMF Scores
(Plaque Mean SD Mean SD Mean SD value* Paired ‘t’ test and ANOVA showed there was
Samples)
no significant reduction in the DMF scores within
Pre 1.9 .316 1.9 1.101 1.3 1.059 .221 and between the three groups in the 6 months time
Sample period. There was no significant reduction in the
1 month 0.9 .994 0.7 .675 1.2 .789 .347 DMF scores in any of the three groups after a
follow-up period of one year.
2 months 0.7 .675 0.7 .949 0.8 .789 .869
3 months 1.0 .667 0.8 .789 1.8 .632 .014
DISCUSSION
4 months 1.2 .789 1.0 .471 1.5 .707 .292
5 months 1.3 .483 1.0 .483 1.1 .568 .467
The microorganisms present in dental plaque
and oral biofilm are considered crucial for the
6 months 1.0 .816 1.1 .422 1.4 .516 .417 initiation and progression of dental caries. The
*p value calculated by Kruskal-Wallis Test
presence or even absence of S.mutans can be a
strong predictor of high or low susceptibility to
Table 2. Comparison of S.mutans count in plaque samples within dental caries. Longitudinal studies have shown a
each group at different time periods
relative rise of S.mutans counts in plaque samples
Time Period p value* from tooth surfaces that become carious at a later
(Plaque Samples) stage5. Standard microbiological plating media
Group I Group II Group III
tend to be very time consuming and non-specific
Pre – 1 month .020 .016 1.000 for the detection of S. mutans. Dentocult SM Strip
Pre – 2 months .006 .026 .160 test is helpful for the diagnosis of caries and its
progression based on Streptococcus mutans
Pre – 3 months .007 .031 .096
counts6. The Dentocult SM Strip Test has proved
Pre – 4 months .020 .037 .480 to be more accurate in detecting S.mutans. Hence
Pre – 5 months .014 .038 .516 Dentocult SM Strip Test was used in this study to
Pre – 6 months .024 .050 .739 detect and assess the S.mutans count.
Chlorhexidine remains the gold standard
*p value calculated by Wilcoxon Signed Ranks Test mouthwash and hence was used as a positive
950
control in this study. Santos (2003), Menendez swished oil under the light microscope (600x
(2005), Salehi P and Momeni Danaie Sh (2006) magnification) at every 5 minutes interval. With
have shown that chlorhexidine is very effective time the oil globlets became smaller indicating
against S.mutans in dental plaque7-9. emulsification and diffusion of oil in saliva.
Bacteria were seen in the oil samples collected
This is the first randomized controlled trial
after 10 minutes of swishing. At the end of 30
with a follow up, comparing the effect of oil
minutes the swished oil was collected in a test tube
pulling therapy and chlorhexidine mouthwash on
and centrifuged. The saliva and oil got separated
dental caries and S.mutans count in plaque and
confirming the occurrence of an emulsification
saliva. Pilot studies conducted by Asokan S et al
process. Research is currently being done to assess
have shown that the oil pulling therapy has been
the change in free fatty acid level of the oil after
equally effective in reduction of S.mutans count,
oil pulling therapy. An increase in free fatty acid
plaque index and modified gingival index scores
level is a good indicator of the saponification
as compared to chlorhexidine mouthwash10,11. Oil
process.
pulling therapy with sunflower oil significantly
reduced plaque scores in 45 days12. Sesame oil has increased polyunsaturated fatty
acids and the lipid peroxidation is reduced thereby
In this study, both oil pulling therapy and reducing free radical injury to the oral tissues14.
chlorhexidine mouthwash were equally effective in Sesame oil is also a good source of vitamin E and
reduction of S.mutans count over the 6 months contains specific lignans like sesamin, sesamolin
time period and they were better than just tooth that can probably protect the oral cavity from
brushing alone. We wanted to check if the efficacy infection and inflammation by their antioxidant
would increase if the allotted oral hygiene practice property15. Sesamin and sesamolin should be
were done twice daily. But there was no isolated from sesame oil to check their
significant difference whether the oral hygiene antibacterial activity. When the exact mechanism
practice was followed once or twice a day. There of action becomes evident, oil pulling therapy with
was no reduction in the DMF score during the sesame oil could open new doors in the field of
study period and after a follow-up of one year. research in oral health care.
But since a long-term follow is a must, the
participants are regularly being examined and CONCLUSION
evaluated. Cost of the Dentocult kit, sesame oil,
chlorhexidine for a period of 6 months without a Both oil pulling therapy and chlorhexidine
grant was the major factor to restrict the study to mouthwash are equally effective in reduction of
a small sample size. Sesame oil had definite S.mutans count and are definitely much better than
advantages over chlorhexidine: no staining, no tooth brushing alone. Oil pulling therapy cannot
lingering after taste and no allergy. There are no be used as a treatment adjunct as of now, but it
disadvantages for oil pulling therapy except for the can be used as a preventive home therapy to
extended duration of the procedure compared with maintain oral hygiene. More extensive studies with
chlorhexidine mouthwash. Sesame oil is 5 to 6 larger samples and varying time periods should be
times cost effective than chlorhexidine and is also carried out to evaluate the efficacy of oil pulling
readily available in every household. therapy on oral health status.
The mechanism by which oil pulling therapy REFERENCES

causes plaque inhibition and S.mutans reduction is
not clear. The viscosity of the oil could probably 1. Asokan S. Oil pulling therapy. Indian J Dent Res
inhibit bacterial adhesion and plaque 2008; 19: 169.
co-aggregation. The other possible mechanism 2. Asokan S. Folk Remedy. Br Dent J 2009; 207(12):
might be the saponification or the ‘soap-making’ 568.
process that may occur when sesame oil is acted 3. Oil pulling. [Internet] 2009 [Cited 2009 June 13].
upon by the salivary alkali like the bicarbonates. Available from
Soaps are good cleansing agents because they are http://en.wikipedia.org/wiki/Oil_pulling.
effective emulsifying agents. Emulsification greatly 4. Oil pulling - a wonderful therapy. [Internet] 2004
enhances the surface area of the oil thereby [Cited 2007 Sept 17]. Available from
increasing its cleansing action13. As a part of this http://www.oilpulling.com.
research work we made a few participants swish 5. Marsh PD. Microbiologic aspects of dental plaque and
sesame oil for 30 minutes. We examined the dental caries. Dent Clin North Am 1999; 43: 599-614.
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6. Shi S, Deng Q, Hayashi Y, Yakushiji M Machida Y 11. Asokan S, Emmadi P, Raghuraman R,

Liang Q.A follow-up study on three caries activity Chamundeeswari. Effect of oil pulling on plaque
tests. J Clin Pediatr Dent 2003; 27: 359-364. induced gingivitis: a randomized controlled triple
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gingivitis. J Esthet Restor Dent 2003;15(1): 25-30.
12. Amith HV, Anil V Ankola, Nagesh L. Effect of oil
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antibacterial effects of combined mouthrinses on Dent 2007; 1(1): 12-18.
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Pugalendi KV. Modulation of blood pressure, lipid
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952
Multidisciplinary Management of Complicated crown -

Root Fractures of maxillary lateral Incisor and Canine
- A Case Report
Dr Shah Dipali1, Dr Garde Janardan2, Dr Vora Reena3, Dr Vijaykumar L4
ABSTRACT
Traumatic tooth injuries have progressively gained epidemiological expression as an emergent public
health problem. Complicated crown-root fractures are the most difficult type of fractures to be managed.
All of the complexities- pulp exposure and attachment to the periodontal ligament (PDL) warrant that an
interdisciplinary approach for a correct treatment planning and prognosis be implemented. This case report
describes the management of complicated crown root fractures of maxillary lateral incisor and canine for
which special efforts were made to reinforce the root for a coronal restoration and to preserve of the
biologic width.
Keywords: Complicated crown- root fracture, traumatic injury, electrosurgery, crown lengthening
procedure, post-core, ferrule effect.
INTRODUCTION periodontal attachment apparatus and providing

effective ferrule for sound coronal restorations.
Trauma to the oral region is common amongst
all facial injuries and occurs in 5% of all
CASE REPORT
cases.1Crown fractures and luxations of the upper
anterior region are most frequently seen1.In A 34 year old patient was referred to the
permanent teeth, Mojorana et al2 reported a department with multiple bruises on face, hand and
prevalence of root fractures of 7.7% of all injuries. legs from the Oral and Maxillofacial Department
Crown-root fractures involve damages to hard with the chief complaint of severe shooting pain
tissues of the tooth and also the attachment from the teeth 12 and 13, pain being notably worse
apparatus of the periodontium, needing an on touching the teeth. The patient gave a history
interdisciplinary approach to be properly treated. of road traffic accident. Initial first aid was
In a complicated crown root fracture, the fracture provided by the emergency department and
may be such that crown and part of the root are necessary intraoral radiographs taken. Sutures were
shattered into small fragments or the fracture may placed on the upper lip with vicryl 4-0 for deeper
be of the chisel type in which the crown and the layers and with 5-0 ethilon for mucosa and skin
root remain a single mobile unit because of the in the department of Maxillofacial Surgery. On
periodontal attachment. The portion of the fracture examination patient had a sutured upper lip with
in the cementum varies from the suprabony margin a post operative swelling. The crowns of upper left
to the infrabony margin, and there is usually lateral incisor and canine had an oblique fracture
bleeding from the periodontium and the pulp. line with pulp exposure. Palpation of the crown
When there is a subgingival fracture of the tooth, fragments revealed mobiIity. Radiographs revealed
various problems are encountered. The different oblique crown-root fracture passing through
treatment options available for reestablishing enamel, dentin and cementum with pulp exposure.
biologic width and ferrule are crown lengthening Position of the root fractures in both the teeth was
procedures, orthodontic extrusion and surgical suprabony. Diagnosis of chisel type of crown-root
extrusion. These options should be considered and fracture in the maxillary left lateral incisor and
explained to the patient and informed consent canine was made. Patient was informed about the
obtained for the treatment chosen. This clinical treatment options and a written informed consent
report describes the multidisciplinary management was taken for the treatment chosen. After removal
of complicated crown-root fractures, preserving the of the coronal fragments, emergency root canal
opening was carried out in both the anterior teeth
1
Professor, 3Reader, 4Senior Lecturer, Dept. of Conservative Dentistry and Endodontics, 2Professor and Head, Dept. of Oral
and Maxillofacial Surgery, Sinhgad Dental College and Hospital, Pune, Maharashtra.
953
Fig. 5. Palatal view of #12 and #13 after crown lengthening using
electosurgery.
Fig. 1. Preoperative intraoral periapical radiograph showing
oblique complicated crown-root fractures affecting teeth #12 and
#13.
Fig. 6. View of #12 and #13 after placement of cast post-cores

with adequate ferrule.
Fig. 2. Clinical picture of #12 and #13 after removal of fractured

crowns.
Fig. 7. Sound gingival status of #12 and #13 after cementation of

Fig. 4. Radiograph of #12 porcelain fused to metal crown.
Fig. 3. Post endodontic
and #13 after cementation of
radiograph of #12 and #13.
cast post-cores. was placed. After two weeks, the patient was
completely asymptomatic. The intracanal
and working length was determined, under local medicament was removed. Root canal obturation
anesthesia. Cleaning and shaping of the root canals was completed using gutta percha and AH Plus
was completed with K-files and use of 2.5% sealer with lateral compaction technique. The
sodium hypochlorite. The root canals of lateral depth of the gingival sulcus was measured with
incisor and canine were prepared till sizes 50 and periodontal probe in both teeth #12 and #13
60 respectively and calcium hydroxide medicament respectively. Since adequate ferrule was obtainable
954
DISCUSSION
The restoration of endodontically treated teeth

should aim at increasing tooth fracture resistance
especially, in cases with extensive tooth
destruction.3A definitive treatment alternative for
diagonal crown- root fractures is removal of the
coronal fragment followed by a supragingival
restoration to promote gingival healing. In
complicated crown root fractures the techniques of
recovery of the biological width should consider
the junctional epithelium as the most vulnerable
point for the penetration of bacteria in the
connective tissue. Therefore under normal
conditions 2-3mm of sound tooth dental structure
Fig. 8. Labial view of #12 and #13 with porcelain fused to should be preserved between the alveolar crest and
ceramic crowns.
the restorative margin4.
without disturbing the epithelial attachment
gingivectomy of the palatal aspects of teeth #12 If the fracture is subgingival, surgical exposure
and #13 was planned by the periodontist, for of fracture surface by gingivectomy or osteotomy
crown lengthening procedure. Crown lengthening can convert the subgingival fracture to a
procedure was done using an electrosurgical supragingival one. This procedure aimed at
unit(ES), under local anesthesia. At the next removing supporting periodontal structures to gain
appointment the two teeth were prepared for cast sound tooth structure above the alveolar crest level
post using Parapost cast post-core system. Any is called Crown lengthening procedure. Three
traces of obturating material in the canals were means of gingival recontouring are- scalpel,
removed with pure alcohol followed by sterile electrosurgery (ES) and lasers. This procedure may
water and the canals dried with paper points. be limited to the palatal aspect of the fracture in
Impression was made using addition silicone order not to compromise the esthetics5. Gingival
recontouring with electrosurgery was planned as a
impression material. Temporary posts and crowns
sound option as the procedure is comfortable for
were placed to maintain gingival contour. The
patient, bloodless field of operation is obtained and
impression was sent to the laboratory, for
healing is fast and predictable. An apically
fabrication of cast posts and cores with non
positioned flap with osseous surgery to remove
precious alloy. After a week there was adequate
bone to expose 3mm of root may lead to
healing of the palatal gingiva and the cast posts
inconsistent topography between adjacent teeth and
and cores were tried and cemented in teeth #12
was not required as a ferrule was available after
and #13 with dual cure resin luting cement.
simple gingival recontouring.
Adequate coronal tooth structure of 2- 3mm was
observed on the palatal aspect of the teeth and a Surgical extrusion (intraalveolar
continuous cirumferential ferrule was realized for transplantation) is suggested for round –shaped
the teeth #12 and #13. At the next appointment roots and conical roots. It involves repositioning
crown preparations for porcelain fused to ceramic of the root by placing the tooth to the desired
crowns were carried out. After gingival retraction position (including rotation) followed by
was achieved, impression was made with addition stabilization. Repair may require healing time of 2
silicone impression material. Tooth shades were weeks to 2 months and the mechanism of repair
recorded and registered in the laboratory is by reattachment in the alveolus. Failure with this
prescription. Temporary crowns were cemented in procedure is more frequent than with orthodontic
both the anterior teeth. A bisque stage trial of the extrusion6. According to Baratieri et al7 crown
crowns was carried out. The finished crowns were lengthening surgery is the most indicated
tried and cemented with dual cure resin luting procedure for reestablishment of the biologic
cement. Thus the complicated crown-root fractures width, in cases of tooth fractures close to the
was managed in an interdisciplinary manner using alveolar bone crest and their only concern was that
crown lengthening procedure ,cast post cores and esthetics should not be compromised in anterior
crowns after completion of root canal procedures teeth. Since the palatal aspect of lateral incisor and
in teeth #12 and #13. canine underwent crown lengthening procedures,
955
esthetics was not compromised in the present case The restorative treatment of traumatized teeth
report. should respect the dental and periodontal structures
involved and the dentist should be able to indicate
An alternative approach was to orthodontically
effective therapeutic measures that provide the best
extrude the root. The indication for root extrusion
possible prognosis. A multidisciplinary treatment
is a cervical third root problem that involves or
approach to a complicated crown-root fracture, in
extends 0-4mm below the crest of the alveolar
a reliable and predictable manner is essential to
bone6. Furthermore a final crown to root ratio of
save teeth that would once have otherwise been
at least 1:1should be maintained, to ensure
difficult, if not impossible, to restore with a
adequate periodontal support. Besides patient
resultant good long term prognosis.
discomfort, extra cost and time are required for
this procedure. Since 2-3mm of supragingival
tooth structure was achievable with crown ACKNOWLEDGEMENTS
lengthening procedure and the periodontal We extend our gratitude to Dr Sanjay Jain,
attachment was preserved, we opted for the same M.D.S Periodontology, for his advice and support
over orthodontic extrusion. in the management of this case.
The restorative treatment was planned
according to the amount of remaining tooth REFERENCES
structure. Bûttel et al8 reported a decrease in 1. Peterson E, Anderson L, Sorenson S. Traumatic oral
cervical stresses when the post length was versus non oral injuries. Swed Dent J 1997; 21:
increased up to two thirds of the root length. 55-68.
Adequate post lengths were achievable with both 2. Majorana A, Pasini S, Bardellimi E, Keller E. Clinical
tooth #12 and #13. Cast post-cores were fabricated and epidemiological study of traumatic root fractures.
which have a higher modulus of elasticity as Dent Traumatol 2002; 18: 77-80.
compared to dentin. Fiber posts are advocated 3. Fernandes A, DessaiG. Factors affecting the fracture
nowadays as alternatives to cast or prefabricated resistance of post- core reconstructed teeth: a review.
metal posts9 as the elastic moduli of these fiber Int J Prosthod 2001; 14:355-633.
posts are closer to that of the dentin than that of 4. Mestrener SR, Komatsu J. Recovery of the biological
metal posts and may cause less root fractures. width: the restorative alveolar interface(RAI)
Contrary to these studies, many studies10 have also technique. Rev Paul Odontol 1998; 20:24-9.
reported no significant difference in fracture 5. Turkistani J, Hanno A. Recent trends in the
resistance of restored teeth when fiber reinforced management of dentoalveolar traumatic injuries to
resin or metal posts were used. primary and young permanent teeth. Dent Traumatol
2011; 27: 46-54.
The desired goals of the treatment were 6. Andreason J, Andreason F, Tsukibuoshi M.
achieved in this case, namely- Crown-root fractures. In: Andreason J, Andreason F,
Andreason L, editors. Textbook and colour atlas of
(a) Preservation of the biological width, traumatic injuries to the teeth, 4th edn. Oxford:
Blackwell Munksgaard; 2007 p314-36.
(b) Disinfection of the root canal spaces along
with three dimensional obturation of the root 7. Baratieri LN, Monteiro JS, Cardoso AC, Melo FJ.
Coronal fracture with invasion of the biologic width:
canal system,
a case report. Quintessence Int 1993; 24:85-91.
(c) The ferrule effect and 8. Bûttel L, Krastl G, Lorch H, et al. Influence of post
fit and post length on fracture resistance. Int Endod
1. d. Sound and esthetic coronal restoration. J 2009; 42:47-53.
9. Kivanç BH, Gorgûl G. Fracture resistance of teeth
CONCLUSIONS restored with different post systems using
new-generation adhesives. J Contemp Dent Pract
The technique of ES described here is not new 2008; 9: 33-40.
or unique, yet is not routinely followed when 10. Hu YH,Pang LC, Hsu CC, et al. Fracture resistance
indicated. Predictable and good wound healing can of endodontically treated anterior teeth restored with
be achieved with ES and it is more economic than four post-and-core systems. Quintessence Int 2003;
a laser unit. 34: 349-53.
956
Prevalence of Dental Fluorosis in Permanent teeth at

varying degree of Fluoride levels – A Cross sectional
Survey
1
Dr. T. Mahantesh, 2Dr. H.G. Raju, 3Dr. (Mrs.) Uma B Dixit, 4Dr. Ramesh P Nayakar
ABSTRACT
Background: Recent studies commonly accepted the fact, that the optimal concentration of fluoride
in drinking water might not be the same for all geographical regions and would probably require adjustment
to the ambient temperature of the region.
Aim and Objectives: The aim of the present study was to find the relationship of fluoride
concentration in drinking water supply and prevalence of dental fluorosis in permanent teeth and to find
the optimal concentration of fluoride in drinking water in the villages of northern Karnataka, India.
Materials and Methods: The present survey was carried out in three villages of Hungund Taluk,
Bagalkot District, Karnataka, India, with the fluoride concentration of 1.36 ppm, 0.381 ppm and 0.136
ppm. The children aged between 9 and 15 with the permanent teeth present in the child’s mouth were
examined for dental fluorosis using Dean’s index according to WHO criteria.
Result: Results from present study revealed that percentage of children with severe fluorosis increased
with the increase in concentration of drinking water. 100% of the children in 1.36 ppm and 58% in 0.381
ppm showed fluorosis. Surprisingly in the area with 0.136 ppm fluoride concentration, 7% children showed
questionable to very mild fluorosis.
Conclusion: The present study revealed that fluoride concentration in drinking water did not have an
independent effect on fluorosis. The presence or absence of fluorosis may also attribute to ingestion of
fluoride from other sources in addition to drinking water.
Key words: Fluoride, Dental Fluorosis, Fluoridation
INTRODUCTION communities, there are also reports of apparent

fluorosis in non-fluoridated areas.4 In reviewing
Enamel mottling was first recognized as a
studies performed in 1980’s, Pendrys and Stamm,
condition on the basis of characteristic appearance
of the teeth in children who had lived in certain found that the reported prevalence of dental
areas of USA.1 The relationship with fluoride was fluorosis in fluoridated communities ranged from
established in 1931 and the term “Dental 13% - 51%. In negligibly fluoridated communities
Fluorosis” was first used in the mid 1930’s.2 Since the range was approximately 3% - 25%.5 A review
then, the understanding of the biological of literature by Clark, found that the prevalence of
mechanisms leading to dental fluorosis has steadily dental fluorosis ranged between 35% - 60% in
improved. In 1942, Dean and co-workers
concluded that 1 ppm fluoride in drinking water optimally fluoridated communities and 20% - 45%
caused only sporadic instances of the mildest in negligibly fluoridated communities.6 A study
forms of dental fluorosis of no practical aesthetic conducted by El-Nadeef and Honkala in Central
significance.3 It has been shown that there is a Nigeria, reported presence of dental fluorosis,
linear relationship between the amount of ingested where amount of fluoride in the drinking water
fluoride and the severity of dental fluorosis.3 supply was 0.0-0.4 ppm.7 Another study by Rozier,
There is some evidence of a trend, since concluded that there is a clear increase in fluorosis
Dean’s time, towards increasing prevalence of mild among populations where the drinking water
fluorosis. Fluorosis is not only seen in fluoridated contains less than 0.3 ppm fluoride.8
1
Professor, Pediatric and Preventive Dentistry, 2Professor, Dept. of Public Health Dentistry, Navodaya Dental College and
Hospital, Raichur, Karnataka. 3Professor, Dept. of Pediatric and Preventive Dentistry, Dr. D.Y. Patil Dental College and
Hospital, Mumbai, Maharashtra. 4Reader, Dept. of Prosthodontics, KLE VK Institute of Dental Sciences, Belgaum, Karnataka.
957
In India, Shortt et al. first reported chronic water supplies in clean plastic bottles for fluoride
fluoride intoxication due to ingestion of fluorides estimation with the following labeled information:
in drinking water from Nellore district of Andhra
(a) Name of the place
Pradesh.9 They discovered marked skeletal changes
as well as associated enamel mottling. In 1952, (b) Source of the drinking water
Venkateswarulu, Rao and Rao found drinking (c) Duration of usage of water
water containing 0.9 to 1 ppm to be associated (d) Date of collection of water
with mottled enamel.10
Collected water samples were analyzed in the
In 1985, Subbareddy and Tewari conducted a Department of Environmental Engineering,
study to find prevalence and severity of enamel Basaveshwar Engineering Collage, Bagalkot.
mottling in areas having different levels of fluoride Analyses were performed with an ion-selective
in drinking water.11 They concluded that 0.8 to 1 electrode (model 94-09) and a 720A meter (Orion,
ppm might be an optimum level for Indian Beverly, USA) within a week of sample collection.
population. Similarly Jolly et al. stated that the
level of 1 ppm fluoride in water accepted as safe After the estimation of fluoride concentration
by the western world is not applicable to India and in collected water samples, three villages were
WHO in 1970 reported that optimal concentration selected for the study with negligible, low and near
of fluoride beneficial to dental health in India to optimum fluoride concentrations in their
seemed to be from 0.5 to 0.8 ppm in water.12,13 drinking water supply and with same altitude
However Nanda in 1972 reported definite dental (531.69 m.), average annual temperatures
fluorosis was noticed in significant number of (29.46 °C), average rainfall (63.72 mm),
children even at fluoride levels of 0.4 ppm.14 socio-economic status, dietary pattern and with
positive history of usage of same water supply for
Various researchers have suggested that WHO drinking purpose for at least 15 years.
recommendations of 1.0 mg/L as an upper limit
for fluoride concentrations in drinking water is The villages selected were
unacceptable for all climates.15,16 They commonly 1. Bevinal – 0.136 ppm
accepted the fact, that the optimal concentration of
fluoride in drinking water might not be the same 2. Hirebadawadgi – 0.381 ppm
for all geographical regions and would probably 3. Chittawadagi – 1.36 ppm
require adjustment to the ambient temperature of The water samples of above mentioned
the region.17 villages were repeatedly checked in the month of
May and December for fluoride concentration.
So the present study was undertaken with the
Negligible variations in fluoride concentrations
following objectives:
were found in all samples. Highest among the two
To study the relationship of fluoride concentrations was considered for the study.
concentration of drinking water supply and The children aged between 9 and 15 years
prevalence of dental fluorosis in the permanent who were the life-time residents of the respective
teeth and find the optimal concentration of fluoride villages were selected for this study. A child was
in drinking water for this area of Karnataka, India. considered to be a continuous resident in this area
if he/she had been born and lived all his/her life
MATERIALS AND METHOD in that area except for short intervals, as during
holidays etc.
The present survey was carried out in three
villages of Hungund Taluk, Bagalkot District, Permission to carry out the study was obtained
Karnataka, India. from the District Education Officer, Bagalkot and
head-masters of all selected schools. Written
Base-line water analysis by the Zilla informed consent was obtained from children’s
Panchayat Engineering Division, Bagalkot, was parents/guardians for participation of their children
used for primary selection of villages. Initially 25 in the present study.
villages were selected from Hungund Taluk for
water analysis. Prior to the commencement of the survey,
calibration and standardization exercises for the
For water analysis, 500 ml water was collected examiner were carried out with the help of
from each of the respective sources of drinking photographs as well as patients to minimize the
958
subjective variation in different indices used in this affected prevalence and severity of dental
study. fluorosis. Prevalence of fluorosis in the total study
sample by sex was performed by using Mann –
Clinical examinations for all the subjects were
Whitney test.
carried out in the schools. Single examiner
performed oral examinations for all the participants
with the help of a trained assistant for recording RESULTS
the data and both were blinded from the fluoride The data for this study were collected by
concentrations in the drinking water supply of the examining children between age 9 and 15 years
villages. from three villages in Bagalkot District in North
During the examination, child was seated on Karnataka with different levels of fluoride
an ordinary chair outside the school building. concentration in drinking water. They were divided
Indirect natural light was used for illumination. into three groups as follows:
When necessary, dry cotton was used to remove Group I: Children residing in area with
debris. Then child was asked to wet his/her teeth fluoride concentration = 0.136 ppm.
by tip of the tongue before recording the indices.
Group II: Children residing in area with
Intra-examiner reliability was calculated after fluoride concentration = 0.381 ppm and
re-examining 10% of the school children during
beginning of survey and than 1 month thereafter. Group III: Children residing in area with
fluoride concentration = 1.36 ppm.
All the permanent teeth present in the child’s
mouth were examined for dental fluorosis using In the Group I, 100 children were examined
Dean’s index according to WHO criteria without and 3 were excluded. In the Group II, 100 children
specially cleaning or drying the teeth. Each were examined and 1 child was excluded and in
permanent tooth was given a score between 0 and the Group III, 96 were examined and 3 were
5.18 The final fluorosis index was based on the excluded. These children were excluded, because
two most affected teeth. If they were different, they were not continuous residents of that
lowest of the two was considered. particular village.
Prevalence of fluorosis in the Groups I, II and
STATISTICAL ANALYSIS III are presented in the Table 1. Prevalence of
fluorosis in all 289 children depending on sex is
Comparison of means of different indices by presented in the Table 2. Although distribution of
the three groups was performed using ANOVA children in all the three groups by sex was not
and t-test (p < 0.05). Bivariate analysis was uniform, the Mann-Whitney test performed on the
performed to identify significant risk factors that data showed that the child’s gender was not
Table 1 Prevalence of Fluorosis
Dean’s Index of Fluorosis Prevalence

Groups 0 1 2 3 4 5 Total
Group I (0.136 ppm) 90 (92.7) 2 (2.1) 5 (5.2) 0 0 0 97
Group II (0.381 ppm) 42 (42.4) 13 (13.1) 13 (13.1) 23 (23.3) 7 (7.1) 1 (1.0) 99
Group III (1.36 ppm) 0 0 0 0 27 (29) 66 (71) 93
Note: Numbers in the parenthesis indicate percentages.
Table 2 Prevalence of Fluorosis in the Total Study Sample (N = 289) by Sex
Dean’s Index
Sex 0 1 2 3 4 5 Total
Male 82 (47.7) 6 (3.51) 7 (4.0) 14 (8.15) 22 (12.8) 41 (23.83) 172 (59.51)
Female 50 (42.73) 9 (7.69) 11 (9.4) 9 (7.69) 12 (10.27) 26 (22.22) 117 (40.49)
Using Mann – Whitney test, the child’s gender was not significantly associated with the prevalence or severity of fluorosis.
Note : Numbers in the parenthesis indicate percentages.
959
Table 3 Mean (± SE) Scores for Dean’s Index of Fluorosis by Fluoride Concentration in Drinking Water.
Dean’s Index for Fluorosis

Groups Number of Children
Mean ± SE
Group I (0.136 ppm) 97 0.12 ± 0.047a
Group II (0.381 ppm) 99 1.42 ± 0.15b
Group III (1.36 ppm) 93 4.71 ± 0.047
(a) Significantly lower than Group II and Group III (p < 0.001)
(b) Significantly lower than Group III (p < 0.001)
significantly associated with the prevalence or survey that was conducted by them among
severity of fluorosis. Mean fluorosis for the children aged 12-15 years in the area with fluoride
Groups I, II, III, were 0.12 ± 0.47 , 1.42 ± 0.15 , concentration in drinking water ranging from
4.71 ± 0.047 respectively, are presented in the 0.0-0.4 mg/L, they reported prevalence of dental
Table 3. Mean fluorosis score of Group I was fluorosis to be 51% with 48% of children showing
found to be the lowest among the three groups and mild fluorosis and 3% of the children showing
the difference was significant. Mean fluorosis moderate to severe fluorosis.
score of children in the Group II was significantly A recent systematic review carried out to
lower than that in the Group III. determine trends in fluorosis prevalence at water
fluoride levels < 0.3, > 0.3 to < 0.7 and > 0.7 to
DISCUSSION 1.4 ppm, reported fluorosis prevalence for the
According to the recent review, it was three fluoride categories were 16.7, 27.4 and 32.2
recommended that water can be fluoridated in the percent, respectively. A 16-fold and a 2-fold
target range of 0.6-1.1 mg/l, depending on the increase in fluorosis prevalence compared with
climate.19 A number of recent investigations reported rates in the 1940s was seen in
performed in the industrialized countries have non-fluoridated (= 0.3 ppm F) and fluoridated (>
indicated that the prevalence of dental fluorosis is 0.7 to = 1.4 ppm F) areas, respectively.4
increasing even in less than optimally fluoridated Villa et al. reported presence of dental
communities.6,20 In India definite dental fluorosis fluorosis in a community in Chile with a water
has been reported even at fluoride levels of 0.4 fluoride concentration value as low as 0.07 mg/L
ppm.14 Hence for this study, the three villages with and suggested that other sources of fluoride
0.136 ppm, 0.381 ppm and 1.36 ppm fluoride exposure in addition to water were available to
concentration in drinking water were selected. children, eg. fluoridated toothpastes, tea ingestion,
however these risk factors were not evaluated.21
Results from our study revealed that
percentage of children with severe fluorosis
Nanda studied fluoride intake in children from
increased with the increase in concentration of
different dietary sources and concluded that even
drinking water. It was not unexpected that 29% of
at minimal fluoride levels in the drinking water,
children showed moderate and 71% showed severe
sufficient fluoride is ingested by children from
fluorosis in Group III (fluoride concentration: 1.36
other dietary sources which constituted the primary
ppm). In the area with fluoride concentration 0.381
cause of high prevalence of dental fluorosis even
ppm, 13% showed questionable, 30% very mild,
at fluoride levels of 0.4 ppm.14
23% mild, 7% moderate and 1% of the children
showed severe fluorosis. Surprisingly in the area Several investigators recognized that the
with 0.136 ppm fluoride concentration, 2% optimal concentration of fluoride in water might
children showed questionable and 5% showed very not be the same for all geographical regions and
mild fluorosis. The two of the three groups would probably require adjustment to the ambient
included in our study had very low levels of temperature of the region.17,22 These studies
fluoride concentrations in drinking water, much commonly accepted the fact that, as temperature
lower than the recommendation given by WHO. increases there is an increased body demand for
Such a high prevalence of dental fluorosis in fluids. So when the fluoride ion is present in the
children living in low fluoride areas has been drinking water supply, the amount of fluoride
reported by El – Nadeef and Honkala.7 In the ingested will increase with the temperature of the
960
environment. Galagan and Vermillion in 1959 evaluate the risk factors associated with the
gave permissible range of fluoride in water as 0.7 condition in the study region.
– 1.2 ppm depending upon the temperature of the
Acknowledgment
area.22 Later Richards and Coworkers in 1967
recommended optimum fluoride concentration The authors are thankful to Shri G.S. Hiremath
depending on mean maximum temperature as and Shri. C. B. Shivayogimath, Professors,
follows:17 Basaveshwar Engineering College, Bagalkot, who
– 1.1 to 1.3 ppm helped in estimation of fluoride. We are indebted
65°F or lower
to officials of Bagalkot for providing information
66°F to 79°F – 0.8 to 1.0 ppm regarding water fluoride level, weather and permit
80°F and higher – 0.5 to 0.7 ppm us to conduct survey in school. The authors are
thankful to the headmasters, school teachers,
Galagan and Vermillion in 1957 proposed an parents, students, and other nonteaching staff for
equation to calculate optimum level of fluoride their cooperation with the survey. We are grateful
concentration in drinking water supply depending to Mr. Sangam for his assistance in statistical
on the temperature, as temperature determines the analysis.
daily consumption of water.22 This equation is as
follows: REFERENCES
Optimum fluoride concentration (mg/L) 1. Black GV, Mckay FS. Mottled teeth – An endemic
developmental imperfection of the teeth heretofore
= 0.022 /[0.0104 + (0.000724 × AMMT)], unknown in the literature of dentistry. Dental Cosmos
1916; 58: 129-56.
where AMMT stands for annual mean maximum 2. Dean HT, Evolve E. Studies on minimal threshold of
temperature in 0°C . dental signs of chronic endemic fluorosis (Mottled
enamel). Public Health Rep 1935; 50: 1716-29.
This formula was proposed for US children 3. Dean H, Arnold FJ, Elvove E. Domestic water and
who consumed about 44% of their fluid intake as dental caries. V. Additional studies of the relation of
cow’s milk, containing almost negligible amounts fluoride domestic waters to dental caries experience
of fluoride. Villa et. al. in 1998 modified this in 4,425 white children, aged 12 to 14 years, of 13
equation, considering children’s total fluid intake cities in 4 States. Public Health Rep 1942;57:1155-79.
in developing countries came from tap water.21 His 4. Khan A, Moola MH, Cleaton-Jones P. Global trends
modified equation is as follows: in dental fluorosis from 1980 to 2000: a systematic
review. SADJ 2005;60:418-21.
Optimal fluoride concentration (mg/L)
5. Pendrys DG, Stamm JW. Relationship of total
= (0.022 / 0.56) / [0.0104 + (0.000724 × AMMT )] fluoride intake to beneficial effects and enamel
By using this equation we substituted AMMT fluorosis. J Dent Res 1990;69:529–38.
= 29.46 for the area of our study, which gave the 6. Clark DC. Trends in prevalence of dental fluorosis in
optimum fluoride concentration for the area of our North America. Community Dent Oral Epidemiol
study to be 0.3886 mg/L. This calculated 1994;22:148-52.
concentration was almost equal to the fluoride 7. El-Nadeef MA, Honkala E. Fluorosis in relation to
concentration in drinking water of Group II in our fluoride levels in water in central Nigeria. Community
study, where 58% of children exhibited dental Dent Oral Epidemiol 1998;26:26-30.
fluorosis. 8. Rozier RG. The prevalence and severity of enamel
fluorosis in North American children. J Public Health
This finding indicates that the children in our Dent 59:239-46.
study are ingesting appreciable amounts of fluoride 9. Shortt HE, McRobert GR, Bernard TW,
from sources other than drinking water. Mannadinayer AS. Endemic fluorosis in the Madras
Presidency. Ind J Med Res 1937; 25:553-68.
CONCLUSIONS
10. Venkateswarlu P, Rao DN, Rao KR. Studies in
The present study revealed that fluoride Endemic Fluorosis: Suburban Areas. Indian J Med
concentration in drinking water did not have an Res 1952;40: 535-48.
independent effect on fluorosis. The presence or 11. Subbareddy VV, Tewari A. Enamel mottling at
absence of fluorosis may also attribute to ingestion different levels of fluoride in drinking water: in an
of fluoride from other sources in addition to endemic area. J Indian Dent Assoc 1985;57:205-12.
drinking water. So we recommend a well-designed 12. Jolly SS. Endemic fluorosis in Punjab (India). Am J
epidemiological investigation can be undertaken to Med 1969;47:553-63.
961
13. Fluorides and human health. Geneva, World Health 18. Oral health surveys basic methods, 4th ed. Geneva,
Organization, 1970:284-294 World Health Organization, 1997:35–6.
14. Nanda RS. Observations on fluoride intake in 19. Yeung CA. A systematic review of the efficacy and
Lucknow. J Indian Dent Assoc 1972;44:177-81. safety of fluoridation. Evid Based Dent 2008;9:39-43.
15. Brouwer ID, Dirks OB, De Bruin A, Hautvast JG. 20. Jackson RD, Kelly SA, Katz B, Brizendine E,
Unsuitability of World Health Organisation guidelines
Stookey GK. Dental fluorosis in children residing in
for fluoride concentrations in drinking water in
Senegal. Lancet 1988;1:223-5 communities with different water fluoride levels:
16. Warnakulasuriya KA, Balasuriya S, Perera PA, Peiris 33-month follow-up. Pediatr Dent 1999;21:248-54.
LC. Determining optimal levels of fluoride in 21. Villa AE, Guerrero S, Villalobos J. Estimation of
drinking water for hot, dry climates-a case study in optimal concentration of fluoride in drinking water
Sri Lanka. Community Dent Oral Epidemiol under conditions prevailing in Chile.Community Dent
1992;20:364-7.
Oral Epidemiol 1998;26:249-55.
17. Richards LF, Westmoreland WW, Tashiro M, McKay
22. Galagan DJ, Vermillion JR. Determining optimum
CH, Morrison JT. Determining optimum fluoride
levels for community water supplies in relation to fluoride concentrations. Public Health Rep 1957; 72:
temperature. J Am Dent Assoc 1967;74:389-97. 491-3.
962
Socio-Demographic factors and Tooth loss

Dr Dipanjit Singh1, Dr Shanmukha G2, Dr Jasheena Singh3, Dr Ashish Chowdhary4,
Dr Dildeep Bali5
ABSTRACT
Loss of tooth is considered as a major public health problem. The effects of loss of tooth are many.
It can affect the physical health, emotional health and can also affect the quality of life of an individual.
The objective of this study was to know obtain the baseline data regarding prevalence of tooth loss in
the city of Gwalior and also to know the socio-demographic factors (non-disease) affecting tooth loss. A
cross-sectional hospital based survey was conducted and the prevalence of tooth loss was found to be
100% among the adults of Gwalior. Lower socio economic individuals showed higher tooth loss compared
to the higher socio-economic strata. Similarly literates showed less number of tooth loss compared to
illiterates. It was concluded from the study that lack of awareness regarding oral health was the cause of
tooth loss among the study population and further studies need to be conducted.
INTRODUCTION this study was undertaken to know the

socio-demographical factors affecting the tooth
Tooth loss, with ageing is considered as an
loss. The aim of the present study was to 1) obtain
inevitable condition. Till recently, the extraction of
baseline data regarding tooth loss among adults of
the tooth was considered as the only option. With
Gwalior city.2) to know the relationship of
evolution of dentistry as a profession, the saving
non-disease risk factors associated with tooth loss.
of the tooth is considered as most important rather
than extraction of tooth. Tooth loss is considered MATERIALS AND METHODS
as a complex interaction of factors. The clinical
findings in the oral cavity are considered as just A cross-sectional survey was conducted with
the initiators resulting in tooth loss. a proforma to obtain information regarding
individual’s age, gender, marital status, education
The effects of tooth loss are varied. It results and socio-economic status. The study was a
in nutritional deficiency1, impairs the quality of hospital based study and the survey was conducted
life2 and the emotional effects are also many3. from august 2010 to February 2011. All the
Tooth loss affects the well-being of the individual. individuals aged 34 years and above were included
According to the French, hidden impairments such in the study. A total of 2000 individuals were
as tooth loss can cause considerable amount of interviewed and examined. The individuals
stress4. included were selected by multistage systematic
Tooth loss in developing countries is said to random sampling technique. In the first stage,
be increasing because of the high prevalence of Gwalior city was divided in four areas, north,
periodontal diseases and dental caries whereas it is south, east and west and five hundred individuals
also increasing in developed countries5. The from each area were included in the study. Five
increase in tooth loss in developed countries is hospitals from each area were selected by simple
because of the greater proportion of the aging random sampling and hundred individuals from
population6. The biological changes in the human each hospital were included in the study.
body results in tooth loss, as we cannot prevent a
The study population was categorized into five
person from aging.
age groups, ten years span each. The
Few studies have shown that several socio-economic status was classified as according
non-disease factors such as age, gender, marital to Kumar’s modification of Prasad’s classification.
status, education and socio-economic status might The subjects were examined and interviewed by a
be associated with tooth loss whereas no studies single examiner using aseptic precautions and
have been conducted in the Gwalior city. Hence recording was done by a dentist following
1
Professor and Head, Dept. of Prosthodontics, 2Reader, Dept. of Community Dentistry, 3Professor and Head, Dept. of
Pedodontics, Maharana Pratap College of Dentistry and Research Centre, Gwalior, 4Professor, Dept. of Prosthodontics,
School of Dental Sciences, Sharda University, Greater Noida, 5Professor, Dept. of Conservative Dentistry and Endodontics,
Santosh Dental College, Ghaziabad
963
instructions by the examiner. Gloves and mouth This study was conducted to know the
mask were worn by the examiner and examination prevalence of tooth loss as there was no baseline
was done using mouth mirror and WHO probes data available in the city of Gwalior. The
on an examination chair in the hospitals. socio-demographic factors associated with the
tooth loss were also evaluated.
Teeth were considered as missing, if they were
missing completely on examination. Even if a root The study population was of 2000 individuals
stump was present, it was considered as present. selected from the hospitals from various areas of
The third molars were not included in the study. Gwalior. Out of total 2000 individuals, 28.3% of
Informed consent was obtained from all individuals belonged to age group of 35-44 yrs,
participants of the study. 32.4% belonged to age group of 45-54 yrs, 30.3%
belonged to age group of 55-64 yrs, 7% to age
The obtained data was analysed using SPSS group of 65-74 yrs and only 2% to 74 and above
software and student’s t test was used for pair wise age group.
comparison.
A total of 56.7% were males and the
RESULTS remaining 43.3% were females and 95.3% of
individuals were married and the remaining 4.7%
Table 1. Socio-demographic Factors of Study Population were widow/widowers. No unmarried individuals
were found in the study.
Factors Number Percentage
Around 35.2% of the individuals were
AGE illiterates. Out of the remaining, 20.4% were
35-44 566 28.3% educated up to the primary level, 24.8% were
educated up to the secondary level and 19.6%
45-54 648 32.4%
were graduates.
55-64 606 30.3%
In this study, no individuals belonging to
65-74 140 7%
social class V were observed. Maximum number
74 & Above 40 2% of individuals belonged to social class III with
GENDER 38.9%, 28.7% of the individuals belonged to social
class II, 18.9% of the individuals belonged to
Males 1134 56.7% social class I and 13.5% belonged to social class
Females 866 43.3% IV.
MARITAL STATUS Table 2. Loss of Tooth According to Age of Study Population
Married 1906 95.3%
No. of Subjects
Unmarried – Total no
Age of Complete Partial
Widow/ widower 94 4.7% subjects Edentulousness Edentulousness
(%) (%)
LEVEL OF EDUCATION
35-44 566 7 (1.2%) 559 (98.8%)
No education 704 35.2%
45-54 648 15 (2.3%) 633 (97.7%)
Primary 408 20.4%
55-64 606 63 (10.4%) 543 (89.6%)
Secondary 496 24.8% 65-74 140 112 (80%) 28 (20%)
Graduation and above 392 19.6% 74 &above 40 39 (97.5%) 1 (2.5%)
SOCIO-ECONOMIC STATUS
Table 2 shows that all the individuals
I 378 18.9% belonging to all the age groups presented with a
II 574 28.7% tooth loss. The number of complete edentulousness
individuals increased with age and maximum
III 778 38.9% number of individuals with no teeth was observed
IV 270 13.5% in age group of 74 and above. The maximum
number of partial edentulous cases were observed
V 0 0%
in age group of 35-44 years.
964
Table 3. Loss of Tooth in Relation to age, Gender and Marital Table 5. Loss of Tooth in Relation to Socio-economic Status
Status of Study Population
OVERALL
OVERALL n (%) X (Sd) p value
n (%) X (Sd) p value Socio-economic Status
Age SES I 378 (18.9) 1.9 (4.8)

SES II 574 (28.7) 6.9(9.2)
35-44 566 (28.3%) 1.2 (2.6)
SES III 778 (38.9) 7.5 (9.6) F** 8.27
45-54 648 (32.4%) 2.9 (6.0) SES IV 270 (13.5) 2.2 (3.6) <0.001
55-64 606 (30.3%) 2.6 (5.0) F** = 102 SES V – –
65-74 140 (7%) 5.5 (9.0) < 0.01
* unpaired t test ** one way ANOVA test (F test) p value
74 and above 40 (2%) 9.5 (12.2) <0.01 sig <0.001 HS
Gender
A significant association was observed with
level of education and socio-economic status in
Males 1134 (56.7%) 5.6 (8.1) t* 2.4 this study. People with higher level of education
Females 866 (43.3%) 2.9 (5.6)
had less number of tooth loss compared to less
educated individuals. It was also observed that the
Marital status loss of tooth was less in individuals with a high
Married 1906 (95.3%) 4.1 (7.1)
income compared to the less income individuals.
Unmarried – F** 33.2 DISCUSSION

Widow/ widower 94(4.7%) 10.7 (10.1) < 0.01 The lack of oral health is a major public health
problem in developing countries. Tooth loss is
* unpaired t test ** one way ANOVA test (F test) p value
considered to be common among majority of the
<0.01 sig
individuals. This study was conducted to know the
Table 3 presents the univariate analyses of prevalence of tooth loss and the socio-demographic
age, gender and marital status of individuals with factors associated with tooth loss. The prevalence
loss of tooth. The loss of tooth was found to be of tooth loss was observed to be 100% in this
study. In this study, no individual with an intact
increasing with age. In this study, males showed dentition was observed. The reason for this may
an increase in number of tooth loss compared to be because of lack of awareness regarding oral
females. Widow/ widowers showed increase in health in this area7.
number of loss of tooth compared to married The results of this study showed that there was
individuals. No unmarried individuals were an increase in tooth loss with age. This finding is
observed in the study. similar to other studies conduct by Cruz et al
(2001)8. According to report of Dental council of
Table 4. Loss of Tooth in Relation to Level of Education India similar observation was reported9.
In this study, males showed an increase in
OVERALL
number of tooth loss compared to women. Similar
n (%) X (Sd) p value observation was found in other studies. But few
contrasting reports have also been observed. The
Level of Education reason for males showing more number of tooth
No education 704 (35.2%) 6.3 (9.2) loss may be attributed to lack of concern in
relation to oral health. Women are more concerned
Primary 408 (20.4%) 5.9 (8.5) F** 17.3 about their oral health and beauty10.
Secondary 496 (24.8%) 4.9 (8.3) <0.01 In this study, married individuals showed less
Graduation and above 392 (19.6%) 2.1 (4.6) number of tooth loss compared to
widow/widowers. Similar observation was found in
* unpaired t test ** one way ANOVA test (F test) p value other studies and it has been observed that married
<0.01 sig individuals look after their oral health better
965
compared to widow/ widowers. Loneliness and 2. Brennan DS, Spencer AJ, Roberts-Thomson KF:
depression due to loss of partner results in Tooth loss, chewing ability and quality of life: Qual
neglecting the personal hygiene11. Life Res. 2008 Mar;17(2):227-35. Epub 2007 Dec 14.
A strong correlation has been observed with 3. Fiske J, Davis DM, Leung KC et al; The emotional
level of education, socio-economic status and loss effects of tooth loss in partially dentate people
of tooth. In this study, no individual with a tooth attending prosthodontic clinics in dental schools in
loss has been observed. But highly educated England, Scotland and Hong Kong: a preliminary
individuals showed less number of tooth loss investigation: Int Dent J. 2001 Dec;51(6):457-62.
compared to the illiterate individuals12. This result 4. DM Davis, J Fiske, B Scott et al: The emotional
is in concurrence with previous studies conducted effects of tooth loss: a preliminary quantitative study:
which also mention that lower literacy level is Brit Dent J: 2000: Vol 188 No 9: 503-509.
associated with higher number of tooth loss14, 15. 5. Sheiham A, Steele JG, Marcenes W et al: The
Loss of tooth in higher social class individuals relationship among dental status, Nutrient intake, and
was observed to be less compared to lower social Nutritional status in older people; J Dent Res: 2001:
class individuals. In this study no individual 80(2): 408-413.
belonging to social class V have been observed. 6. Fromholt P: Ageing from a psychological perspective.
The reason for this may be because the study In: Pederson PH, Loe H, editors Geriatric Dentistry:
population comprised of patients visiting private A text book of Oral Gerodontology: Copenhagen:
hospital, and usually individuals with upper social Munksgaard: 1986 P 125.
class were included in the study. But the loss of 7. Kwan SYL, Williams SA: Dental beliefs, knowledge
tooth was found to be strongly correlated with and behaviour of chinese people in the United
social class. Similar results were found in other Kingdom; Community Dent Health: 1999: 16:33-39.
studies. The reason for this may be because of lack
8. Cruz GD et al: Self perceived oral health among three
of awareness regarding oral health and lack of
sub groups of Asian Americans in New York city:
affordability towards dental care.
A Preliminary study: Community Dent Oral
Epidemiol: 2001: 29: 99-106.
CONCLUSION
9. National Oral health survey and fluoride mapping,
It is concluded from this study that tooth loss India: 2002-2003.
has been perceived by individuals of Gwalior as a 10. O Mullane D, Whelton H, Galvin N: Health services
common problem. The loss of tooth is higher and Women’s oral health: J Dent Edu: 1993: 57(10):
among aged individuals compared to younger 749-752.
individuals. The loss of tooth in individuals with
11. Eklund SA, Burt BA: Risk factors for total tooth loss
higher level of education is less when compared
in United States: Longitudinal analysis of National
to individuals with low level of education or no
data: J Public Health Dent: 1994: 54(1):5-14.
education. So, awareness programs regarding oral
health need to be conducted. This data from this 12. Manji F, Baelum V, Fejerskov O. Tooth mortality
study can be considered as baseline data and in an adult rural population in Kenya. J Dent Res
further studies need to be conducted in and around 1988; 67 (2): 496-500.
Gwalior. 13. Heft MW, Gilbert GH. Toothloss and caries
prevalence in older Floridians attending senior
REFERENCES activity centres. Community Dent Oral Epidemiol
1991 ; 19 : 228-32.
1. CA Geissler and JF Bates: The nutritional effects of
tooth loss: Am J Clin NutrMarch 1984:vol. 39 no. 3: 14. Kalsbeek H, Truin GJ, Burgersdijk, Van’t Hof MA.
478-489 Community Dent Oral Epidemiol 1991; 19: 201-4.
966
Assessment of Gingival and Dental Caries Status among

12 and 15 years old School going Children of
Ahmedabad City - A Pilot Study
Dr. Patel Dhaval R.1, Dr. Parkar Sujal M.2
ABSTRACT
Objective: The purpose of the study is to assess the gingival status and dental caries status among
12 and 15 years old children of Vishwa Vidhyalaya school of Ahmedabad city.
Materials & Methods: A cross sectional study was conducted among 200 school going children of
12 and 15 years. Out of 200 children 90 belonged to 12 years and remaining 110 children were of 15
years age group. The general information and the information regarding oral hygiene practice and dental
visits were obtained. The gingival status of the subjects was assessed by using Loe and Silness Gingival
index. The dental caries status was assessed by using WHO methodology 1997. All the results were
analyzed statistically at 5% level of significance.
Results: The prevalence of gingivitis among 12 years was 12.23% while that of 15 years was 42.73%
showing highly significant difference (p<0.01) among two age groups. Among 12 years age group the
mean DMFT score was 1.11 1.37 while that of 15 years old children was 2.28 2.40 having prevalence
rate of 53.3% and 70.9% respectively showing highly significant difference (p<0.01). 135 (67.5%) subjects
need one surface filling.
Keywords: school children, gingivitis, dental caries, oral hygiene, treatment needs, prevalence
INTRODUCTION In order to develop and apply programs of

prevention of dental caries and periodontal
Dental caries is a multi-factorial, infectious diseases successfully, it is necessary to know the
disease of the teeth that results in localized intensiveness and spread of the diseases and their
dissolution and destruction of the calcified tissue. risk factors. Till date no study has been conducted
The increase in the prevalence of dental caries has regarding prevalence of dental caries and gingivitis
been attributed to factors such as high sugar among school children of Ahmedabad city. Hence
consumption, a shift to a westernized diet, an attempt has been made in the present study to
socioeconomic status, and the rate of urbanization assess the prevalence of dental caries and gingivitis
and the mother’s level of education1. among school children of Ahmedabad city. The
Gingivitis characterized by the presence of goal of this study is to provide baseline data on
gingival inflammation without detectable loss of prevalence of dental caries and gingivitis among
bone or clinical attachment is common in 12 and 15 years old school going children of
children2,3. Dental plaque is the main cause of Ahmedabad city and to suggest practical
gingivitis. However, other factors such as systemic recommendations for the decrease of incidence of
diseases, hormonal changes, sex, age, and these diseases.
economic conditions may also influence the
response of gingival tissues to dental plaque4. MATERIALS AND METHODS
Voluminous literature exists on the status of A cross sectional study was conducted among
dental caries and gingivitis among the school 12 and 15 years old school children of Vishwa
children throughout the globe. Most of these Vidhalaya school, Ahmedabad city. Before starting
studies show the high prevalence of dental caries the study, the study protocol was first approved by
and gingivitis5. A very high rate of prevalence for the ethical committee of Ahmedabad Dental
these dental aliments had been reported in various College and Hospital. Prior permission was also
isolated studies had been carried out in the Indian obtained from the authorities of the school. The
context6,7. pilot study was performed involving 30 subjects,
1
Tutor, Dept. of Periodontics and Oral Implantology, 2Senior Lecturer, Dept. of Public Health Dentistry, Ahmedabad Dental
College and Hospital, Ta: Kalol, Dist: Gandhinagar, Gujarat.
967
with the aim of calculating the sample size.

Considering the variance of DMFT of 0.49 and
power of study of 90% the total sample size was
estimated of 200.
Before conducting the examination the purpose
of the study was explained to the class teachers
and to the school children. A performed proforma
was used to record all the information required for
the study. The information contained in the
proforma was divided into three parts. The first
part contained the general information
(demographic data). The second part on oral Fig. 1. Prevalence of Gingivitis among 12 and 15 years age
hygiene and the third part contained the clinical groups
examination for assessing the gingival status by The mean gingival score was 0.08 0.23 and
using Loe and Silness Gingival index8 and the 0.10 0.30 for male and female children of 12 years
caries status by using WHO methodology 19979. age group respectively. This was found to be
Plain mouth mirror, dental explorer, CPI probe statistically not significant (p=0.51). While there
were used for the clinical examination of the was a highly significant result for the mean
children. All the data collection was done by a gingival score between male and female children
single examiner (PDR) who was trained and of 15 years age group (p=0.001) having mean
calibrated under PSM. score of 0.56 ± 0.69 and 0.29 ± 0.52 respectively
Statistical Analysis Table 2.
The data was analyzed by using SPSS Table 2. Mean gingival score among 12 and 15 years old
statistical package version 1710. Chi square test children according to gender
was applied for the qualitative data while the t test
was used for the quantitative data. All the analysis Gender
Age Groups p value
was made at the 0.05 level of significance. Male Female
12 years 0.08 ± 0.23 0.10 ± 0.30 0.51 (NS)
RESUTLS
15 years 0.56 + 0.69 0.29 ± 0.52 0.001 (HS)
Out of 200 school children, 90 children were
of 12 years and 110 children were of 15 years of NS= Not significant, HS= Highly significant
age. Among 12 years of age group there were 41 The mean gingival score for 12 years old
(45.6%) male children and 49 (54.4%) were children was 0.09 0.29 while that of 15 years old
female children. While among 15 years of age children was 0.46 ± 0.64 which was found to be
group there were 72 (65.5%) male children and 38
statistically highly significant (p<0.01) Table 3.
(34.5%) were female children Table 1.
Table 1. Age and sex wise distribution of study subjects Table 3. Comparision of mean gingival score according to age
groups
Age Sex
Total N (%) Age groups N Mean SD p value
groups Malen (%) Female n (%)
12 years 90 0.09 ± 0.29 p <0.01(HS)
12 41 (45.6) 49 (54.4) 90 (45)
15 years 110 0.46 ± 0.64
15 72 (65.5) 38 (34.5) 110 (55)
Total 113(56.5) 87 (43.5) 200 (100) HS= Highly significant
Gingival status among study subjects Dental caries status among study subjects
Among 12 years age group, only 11 children Among 12 years age group, 48 children out
out of 90 children had mild to moderate form of of 90 children had caries experience having the
gingivitis giving with prevalence rate of 12.23%. prevalence rate of 53.3%. Among 15 years age
While among 15 years age group 47 children out group, 78 children out of 110 children had caries
of 110 children had mild to severe form of experience having the prevalence rate of 70.9%
gingivitis with prevalence rate of 42.73% Fig 1. Fig 2.
968
Table 6. Treatment needs according to age groups
No One Two Veneers

Pulp
Age treatmen surface surface &
care
groups t need filling filling laminates
n(%)
n(%) n(%) n(%) n(%)
12 years 10 60 4 8 8
(11.11) (66.66) (4.44) (8.88) (8.88)
15 years 11 75 2 15 7
(10) (68.18) (1.82) (13.63) (3.36)
Total 21 135 6 23 15
Fig. 2. Prevalence of Dental Caries among 12 ad 15 years age (10.5) (67.5) (3) (11.5) (7.5)
groups.
The mean DMFT score of male and female χ2 + 2.60,df=4, p=0.62 (NS)
children of 12 years age group was 1.22 ± 1.56 and
1.02 ± 1.20 respectively which was found to be DISCUSSION
statistically not significant (p= 0.14). The mean Due to the scarcity of the data regarding
DMFT score of male and female children of 15 gingivitis and dental caries in school children of
years age group was 2.30 ± 2.43 and 2.26 ± 2.37 Ahmedabad city, a pilot based study was
respectively which was found to be statistically not conducted for one school (Vishwa Vidhalaya
significant (p= 0.76) Table 4. School) of Ahmedabad city. The present study was
conducted among 12 years and 15 years age group
The mean DMFT score for 12 years old as both the age groups are the index age group of
children was 1.11 ± 1.37 while that of 15 years old pathfinder survey as per WHO Basic Oral Health
Survey method. The 12 years age group was
children was 2.28 ± 2.40 which was found to be selected because this age is considered as a global
statistically highly significant (p<0.01) Table 5. monitoring age for caries for international
Table 4. Mean dmft score among 12 and 15 years old children
comparisons and monitoring of disease trends. The
according to gender 15 years age group was selected because at this
age, the permanent teeth have been exposed to the
Gender oral environment for 3-9 years. This age is also
Age Groups p value
Male Female important for the assessment of periodontal disease
indicators in adolescents9.
12 years 1.22 ± 1.56 1.02 ± 1.20 0.14 (NS)
15 years 2.30 ± 2.43 2.26 ± 2.37 0.76 (NS) In the present study majority of the children
claimed that they brush regularly once daily in
NS= Not significant horizontal direction with toothpaste and
toothbrush; however at the same time an
Table 5. Comparision of mean dmft score according to age
groups extraordinary high prevalence of gingival bleeding
and dental caries were observed in the clinical
Age groups N Mean ± SD p value investigation. This inconsistency could be
explained by either over reporting of tooth
12 years 90 1.11 ± 1.37 p <0.01(HS)
brushing or simply reflecting a lack of tooth
15 years 110 2.28 ± 2.40 brushing skills. While the tooth brushing technique
may be inadequate to the vast majority of the
HS= Highly Signif children, they may still gain some caries
Out of 200 children 21 (10.5%) children did preventive effect of such practice when using
not need any treatment in any form Table 6. toothpaste with appropriate level of fluoride. The
Majority, out of 200 children 135 (67.5%) children results of this study revealed that majority of these
subjects sought dental care on infrequent basis. It
needs one surface filling. The treatment needs is, therefore, not surprising that dental visits
among 12 and 15 years old children were apparently were prompted by the experience of a
compared which was found to be statistically dental problem rather than oriented towards
insignificant (p=0.62). prevention of disease.
969
In the present study the prevalence of documented. Also the present study was conducted
gingivitis among 12 and 15 years old children in only one school in the city and relatively on
were 12.23% and 42.73% respectively. This result small sample, this may not be large enough to
was in accordance to the previous studies represent the population, hence further surveys on
conducted by Rebelo MAB et al11, Pauraite J et large scale should be implemented to get the detail
al12, National oral health survey13, Jose A and of oral health status of the school children.
Joseph MR14. The prevalence of gingivitis was low
compared to the study conducted by Ketabi M et CONCLUSION
al15. The mean gingival score was higher in the
15 years old children as compared to the 12 years In light of the results obtained in the study, it
old children which was statistically significant this could be conclude that implementation of oral
might be due to the mixed dentition period, health program at early age helps in improving
shedding of primary teeth, ineffective maintenance preventive dental behaviour and attitudes, which is
of oral hygiene and pubertal changes16,17. In 15 beneficial throughout the life time. This can be
years age group the mean gingival score for achieved by educating the parents about dental
female children was low compared to the male health through school dental programme. Such
children which was significant statistically, this programme should include not only preventive
might due to the fact that girls are more concerned measures but also curative treatment in order to
about their oral hygiene and they perform oral maintain the optimum oral health.
hygiene procedures more precisely15.
ACKNOWLEDGEMENT
In the present study the prevalence of dental
caries among 12 years and 15 years age group Authors are like to acknowledge the principal
were 53.3% and 70.9% respectively. This of Vishwa Vidhyalaya School for granting
observation is consistence with the previous permission to conduct this study.
studies conducted by National oral health survey13,
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2002. Dental council of India 2002-2003.
going children in Chennai city- An epidemiological
14. Jose A, Joseph MR. Prevalence of dental health study. . J Indian Soc Pedod Prev Dent 2005: 17-22.
problems among school going children in rural
Kerala. J Indian soc pedo prev dent 2003; 21(4): 147-
151.
971
Impact of Orthodontic Treatment and Socio-economic

Status on Daily performances in Indian School Children:
A Two Centre Study
Dr. Mehta S1, Dr. Malviya N2, Dr. Sivakumar A3, Dr. Valiathan A4, Dr. Nayak Krishna U.S5
ABSTRACT
Introduction: Our objective was to determine impact of fixed orthodontic appliance therapy and
socioeconomic status on daily performances of school children during the first 6 months of treatment.
Methods: A sample of 120 children seeking orthodontic treatment , at two centres, between the age
group 10 -18 years was selected. All the subjects were given OIDP questionnaire to assess the socio dental
status 6 months after the beginning of treatment.
Results: In the study group 98.3 % of the children had one or more oral impact on their daily life
during the 6 month study period.Impacts on Eating were the most prevalent (72.5%) then followed by
Cleaning teeth (56.7%), Emotion (46.7%), Smiling (43.3%), Speaking (35%), Contact with people (29.2%),
while Studying (25.8%) and Relaxing (14.2%). There was no statistically significant correlation between
the age of the subject and impact of orthodontic treatment on daily performance.No statistically significant
difference was found between the different socioeconomic status groupsin relation to oral impacts.Majority
(43.3%) of subjects reported no use of adjunct oral hygiene aid.
Conclusions: There is a definitive impact on daily performances during the first 6 months of
orthodontic treatment. Patient’s daily performances during the treatment are not significantly correlated
with age, gender, or socio-economic status.
Keywords: Oral impacts, Socioeconomic status, Orthodontic treatment.
INTRODUCTION treatment will give them realistic expectations and

might help overcome problems associated with
Oral health-related quality of life (OHRQoL)
noncompliance.6-7
has been defined as the absence of negative
impacts of oral conditions on social life and a Improved quality of life (QoL) is the ultimate
positive sense of dentofacial self-confidence.1It has goal of health care systems, particularly when
been recognized for many years that individuals services are provided for a health condition that is
with malocclusions often feel self-conscious in not life threatening. Locker8 defined various
social situations and may have facial and dental categories in relation to oral health as handicap,
appearance-related self-concept issues. Therefore, disability, discomfort, functional limitation,
it is reasonable to expect that orthodontic treatment impairment, disease, and death. A number of
should result in enhanced self-esteem and reduced socio-dental or OHRQoL measures have been
anxiety in social situations.2 developed and used for assessing oral well-being
and to describe oral impacts on people’s quality
Orthodontic treatment can be a lengthy and
of life.9 Generally, they measure the extent to
costly procedure that is not without sequelae. Most
which oral conditions disrupt normal social role
studies on the effects of orthodontic treatment have
functioning and lead to major changes in behavior,
focused on the associated discomfort and
such as changes in ability to work or attend
pain.3-5Letting patients know about the discomfort
school, or undertake parental or household duties.10
and consequences of treatment enables them to
provide informed consent. In addition, greater Most studies using OHRQoL to assess oral
understanding of the consequences of undergoing impacts of the mouth and teeth have been on
1,2
P.G. Student, Dept. of Orthodontics and Dentofacial Orthopedics, 3Reader, Dept. of Orthodontics and Dentofacial
Orthopedics, Manipal College of Dental Sciences, Manipal. 4Professor, Director of Post Graduate Studies, Dept. of
Orthodontics and Dentofacial Orthopedics, Manipal College of Dental Sciences, Manipal. Adjunct Professor, Case Western
Reserve University, USA. 5Senior Professor and Head, Dept. of Orthodontics and Dentofacial Orthopedics, A.B.Shetty
Memorial Institute of Dental Sciences, Mangalore.
972
adults and elderly populations. Few studies have OIDP score. The oral impacts were classified on
been done on children who are frequently the main the basis of overall OIDP score as little (score <
target group for dental health services. A single 10), moderate (score= 11-25), severe (score> 25).
measure, dental pain, has been used on children in To assess the socioeconomic status of these school
Malaysia11, 12and in South Africa11, 13. They found children, Modified Kuppuswamy scale16, 17was
a high prevalence of pain that affected daily living. applied. The scale classified socioeconomic status
Similarly, a study in New Zealand11, 14 found that as low (score < 10), middle (score= 11-25), high
most school children complained of at least one (score> 25).
dental symptom. Therefore, our aims in this study
were to determine
Modified Kuppuswamy scale16, 17
1. Impact of fixed orthodontic appliance therapy
during first 6 months on daily performance in
school children. (A) Education Score
2. Influence of socioeconomic status of the 1. Profession or Honours 7

school children on the daily performances. 2. Graduate or post graduate 6
3. Intermediate or post high school diploma 5
MATERIALS AND METHODS 4. High school certificate 4
5. Middle school certificate 3
A sample of children between the age group 6. Primary school certificate 2
10-18 years seeking orthodontic care at two
7. Illiterate 1
centres, Manipal College of Dental Sciences,
Manipal, Karnataka and Department Of (B) Occupation Score
Orthodontics and Dentofacial Orthopedics,
A.B.Shetty Memorial Institute of Dental Sciences 1. Profession 10
Mangalore, Karnataka,was selected for recruitment 2. Semi-Profession 6
in this study. The inclusion criteria were subjects 3. Clerical, Shop-owner, Farmer
with a need for orthodontic treatment 4. Skilled worker 4
(self-perceived) and about to undergo fixed 5. Semi-skilled worker 3
orthodontic appliance therapy. Exclusion criteria
6. Unskilled worker 2
were chronic medical conditions requiring
medication, previous orthodontic treatment, 7. Unemployed 1
craniofacial anomalies such as cleft lip and palate,
(C) Family income
untreated dental caries, or poor periodontal health Modified
per month(in Rs)- Score Modified 2007
status. After screening, 120 subjects were 1998
original
recruited. The mean age of subjects at the
beginning of treatment was 14.77 years (SD 1.9); 1. =2000 12 =13500 =19575
there were 73 girls and 47 boys; all were of Indian 2. 1000-1999 10 6750-13499 9788-19574
ethnicity. Informed consent was sought and 3. 750-999 6 5050-6749 7323- 9787
obtained from the parents of the participants. 4. 500-749 4 3375-5049 4894- 7322
11, 15
The OIDP Index was used to collect 5. 300-499 3 2025-3374 2936-4893
information on socio-dental impacts. The OIDP 6. 101-299 2 676-2024 980-2935
Index assesses the serious oral impacts on eight
7. =100 1 =675 =979
daily performances, namely, eating, speaking,
cleaning mouth, relaxing, smiling, studying,
emotion and social contact.
Statistical Analysis:
Each daily performance is scored on a 6-point
Likert scale to rate the impact of oral health status All statistical analyses were performed using
on an aspect of life quality (described by the item), the SPSS software package (SPSS for Windows
with responses ranging from “never affected” Xp, version 13.0, SPSS Inc, Chicago).Descriptive
(score 0) to “every or nearly every day” (score data that included arithmetic mean, standard
5).In the study, data regarding the prevalence of deviation and range values were calculated for
impact on these daily performances was collected. each variable as well as for each group and were
All the scores were added together to get overall used for the analysis.
973
RESULTS performances. 35% showed moderate impact while

only 2.5 % of the subjects showed severe impact.
In our study 98.3 % of the children had one
or more oral impact on their daily life during the Data revealed 3.3% of subjects’ fathers were
6 month study period. The mean score was 9.04 unemployed whereas 80.8 % of the mothers were
7.14 (Table 1). There was no statistically housewives.
significant difference between the prevalence of
On assessment of oral hygiene aids used,
impacts in girls and boys(Table 2). Impacts on
almost all the subjects reported use of manual
Eating were the most prevalent (72.5%).The
toothbrush and toothpaste. 30.8% subjects reported
prevalence of impacts on Cleaning teeth (56.7%),
use of tongue cleaner as an adjunct oral hygiene
Emotion (46.7%) and Smiling (43.3%) were also
aid, followed by mouthrinse (13.3%), xylitol
relatively high. The remaining prevalence’s of
chewing gum (5%) and interdental brush (5%).
impacts were lower, namely Speaking (35%),
Majority (43.3%) of subjects reported no use of
Contact with people (29.2%), Study (25.8%) and
adjunct oral hygiene aid. However there was no
Relaxing (14.2%).There was no statistically
statistically significant correlation between the
significant correlation between the age of the
socioeconomic status and adjunctive oral hygiene
subject and impact of orthodontic treatment on
aids used.
daily performance.
Table 1
On computation, only 3 subjects belonged to
the low socioeconomic group, 68 subjects to the N Minimum Maximum Mean
Std.
middle and rest 49 to the high socioeconomic Deviation
group. No statistically significant difference was OIDP 120 0.00 35.00 9.0417 7.14601
found between the different socioeconomic status
groups in relation to oral impacts. Most of the
subjects (62.5%) showed a little impact on daily
Table 2-Sex Vs. OIDP category
OIDPcat
moderate severe Total
Little impact
impact impact
Sex Male Count 30 16 1 47
% within sex 63.8% 34.0% 2.1% 100.0%
Female Count 45 26 2 73
% within sex 61.6% 35.6% 2.7% 100.0%
Total Count 75 42 3 120
% within sex 62.5% 35.0% 2.5% 100.0%
(p = 0.958)
Table 3
Eating Smiling and Maintaining Carrying out Enjoying

Speaking and Sleeping
and Cleaning showing teeth usual major work contact
Category pronouncing and
enjoying teeth without emotional and social with
clearly relaxing
food embarrassment state role (studying) people
never affected 33 78 52 103 68 64 89 85
less than a month 31 15 17 3 6 24 12 8
once or twice a 43 7 6 4 4 19 5 1
month
once or twice a 3 6 7 2 4 4 3 7
week
3-4 times a week 5 6 14 1 8 5 5 8
every or nearly 5 8 24 7 30 4 6 11
everyday
974
Table 4- SES category Vs. OIDP category
OIDP cat
moderate severe Total
Little impact
impact impact
SES cat Low SES Count 2 1 0 3
% within SES cat 66.7% 33.3% .0% 100.0%
Middle SES Count 39 26 3 68
% within SES cat 57.4% 38.2% 4.4% 100.0%
High SES Count 34 15 0 49
% within SES cat 69.4% 30.6% .0% 100.0%
Total Count 75 42 3 120
% within SES cat 62.5% 35.0% 2.5% 100.0%
(p = 0.487)
Table 5 cohort study, also reported changes in Oral health

related quality of life (OHRQoL) after fixed
Other oral hygiene
Frequency Percent
Cumulative orthodontic appliance therapy. In his study, a
aids Percent patient’s oral symptoms, functional limitations
No 52 43.3 43.3 were found to be frequently worse during
treatment although emotional well-being, however,
Floss 3 2.5 45.8
in contrast to our study was found to be better.
Mouthrinse 16 13.3 59.2
In our study, there was no statistically
Tongue cleaner 37 30.8 90.0
significant difference between the prevalence of
Chewing-gum (xylitol) 6 5.0 95.0 impacts in girls and boys. Some studies22, 23, 24
Interdental toothbrush 6 5.0 100.0 consider that females are more concerned about
Total 120 100.0 dental appearance than males are and hence show
more impact.
DISCUSSION Our findings were similar to those of

Murray25and Richter et al26who demonstrated lack
This study assessed the prevalence of oral of effect of age or gender on compliance. In our
impacts attributed to orthodontic treatment. Our study there was no significant correlation between
findings represented what happens to healthy age and overall OIDP score. If the daily
patients with orthodontic treatment need without performances are not impacted, patients would be
oral diseases who undergo orthodontic treatment. compliant. In contrast, Haynes27 showed that 15-
The treatment effects were limited to those to 17-year-old patients had the highest
associated with fixed appliance orthodontic therapy discontinuation rates compared with 10- to 14-year
because it was suggested that different orthodontic old patients. Tung and Kiyak28, investigating
appliances might have different impacts on psychosocial influences on the timing of
patients.18 orthodontic treatment, found that 9- to 12-year-old
children made more suitable candidates for
In our study, 98.3 % of the children had one orthodontic treatment.
or more oral impact on their daily life during the
6 month study period. Impacts on Eating were the While some studies23, 29report that the overall
most prevalent (72.5%).The prevalence of impacts pattern of oral impacts is related to socioeconomic
on Cleaning teeth, Emotion and Smiling were also status (SES), no such difference was found in the
relatively high. These findings are similar to other present study.Most of the subjects (62.5%) showed
studies11, 19 where effect on eating was the most a little impact on daily performances. 35% showed
common performance impacted. However, Bernabe moderate impact while only 2.5 % of the subjects
et al20 in a similar study on Brazilian adolescents showed severe impact. The data showed only 3
reported that smiling and speaking were most subjects belonged to the low socioeconomic group.
commonly affected. Zhang et al21, in a prospective This shows that in the Indian socioeconomic strata,
975
not many from the low socioeconomic group can 5. Erdinc AM, Dincer B. Perception of pain during
afford orthodontic treatment. In our study, the data orthodontic treatment with fixed appliances. Eur J
collected from the questionnaire showed that 3.3% Orthod 2004;26:79-85.
of subjects’ fathers were unemployed whereas 80.8 6. Johnson PD, Cohen DA, Aiosa L, McGorray S,
% of the mothers were homemakers. This can have Wheeler T. Attitudes and compliance of
a major influence on socioeconomic status. pre-adolescent children during early treatment of
Class II malocclusion. ClinOrthod Res 1998; 1:20-8.
Though, the finding of lack of effect of
7. Sergl HG, Klages U, Zentner A. Pain and discomfort
socioeconomic status on OIDP is consistent with during orthodontic treatment: causative factors and
the findings of Zhang et al21, it is likely that the effects on compliance. Am J
dissimilar methodologies used to collect OrthodDentofacialOrthop 1998; 114:684-91.
socioeconomic information may explain, the 8. Locker D. Measuring oral health: a conceptual
differences from other studies. Therefore, more framework. Community Dental Health 1988; 5:3–18.
studies are required to broaden the knowledge in
9. Slade GD: Measuring oral health and quality of life
relation to the presence of a social gradient in
Chapel Hill: University of North Carolina; 1997.
OHRQoL.
10. Nikias M, Sollecito M, Fink R: An empirical
Almost all the subjects in our study reported approach to developing multidimensional oral status
use of manual toothbrush and toothpaste. There profiles. J Public Health Dent 1978; 38:148-58.
was no statistically significant correlation between 11. Gherunpong S, Tsakos G, Sheiham A. The prevalence
the socioeconomic status and adjunctive oral and severity of oral impacts on daily performances
hygiene aids used and majority (43.3%) of subjects in Thai primary school children. Health and Quality
reported no use of adjunct oral hygiene aid. This of Life Outcomes 2004; 2:57-65.
shows the lack of knowledge of the subjects about 12. Jaafar N: Evaluation of the outcome of dental care
various oral hygiene aids available.Thus, patients services among Malaysian secondary school children.
should be made aware of the availability of In PhD Thesis. University of Malaga Department of
adjunct oral hygiene aids and should be motivated Community Dentistry; 1999.
to use them. 13. Naidoo S, Chikte UM, Sheiham A: Prevalence and
impact of dental pain in 8-10-year-olds in the
CONCLUSIONS Western Cape. SADJ 2001; 56:521-23.
14. Chen MS, Hunter P: Oral health and quality of life
There is a definitive impact on daily in New Zealand: a social perspective. SocSci Med
performances of school children during the first 6 1996; 43:1213-22.
months of orthodontic treatment.98.3 % of the
15. Gherunpong S, Tsakos G, Sheiham A: Developing
children had one or more oral impact on their
and evaluating an oral health-related quality of life
daily life during the 6 month study period. index for children; The CHILD-OIDP. Community
Patient’s daily performances during the treatment Dent Health 2004; 21:161-69.
are not significantly correlated with age, gender,
16. Mishra, Singh. Kuppuswamy’s Socioeconomic Status
or socio-economic status. Scale. Letter to the editor. Indian Journal of Pediatrics
2003; 70,273-74.
REFERENCES 17. N. Kumar, C. Shekhar, P. Kumar, A.S. Kundu.
1. Kiyak HA. Does orthodontic treatment affect patients’ Kuppuswamy’s Socioeconomic Status Scale-Updating
quality of life? J Dent Educ 2008; 72:886-94. for 2007. Indian Journal of Pediatrics 2007;
74:1131-2.
2. Delcides F.de Paul Junior, Nadia C. M. Santos, Erica
T. da Silva, Maria de Fatima Nunes, Claudio R. 18. Sergl HG, Klages U, Zentner A. Functional and social
Leles. Psychosocial Impact of Dental Esthetics on discomfort during orthodontic treatment— effects on
Quality of Life in Adolescents. Angle Orthod 2009; compliance and prediction of patients’ adaptation by
79:1188–93. personality variables. Eur J Orthod 2000; 22:307-15.
3. Jones M, Chan C. The pain and discomfort 19. Kida IA, Astrom AN, Strand GV, Masalu JR, Tsakos
experienced during orthodontic treatment: a G. Psychometric properties and the prevalence,
randomized controlled clinical trial of two initial intensity and causes of oral impacts on daily
aligning arch wires. Am J OrthodDentofacialOrthop performance (OIDP) in a population of older
1992; 102:373-81. Tanzanians. Health Qual Life Outcomes 2006; 56:4.
4. Bergius M, Berggren U, Kiliaridis S. Experience of 20. Bernabe E, Tsakos G, Oliveira, SheihamA.Impacts on
pain during an orthodontic procedure. Eur J Oral Sci Daily Performances Attributed to Malocclusions
2002; 110:92-8. Using the Condition-Specific Feature of the Oral
976
Impacts on Daily Performances Index. Angle Orthod 25. Murray A M. Discontinuation of orthodontic
2008; 78:241-7. treatment: a study of the contributing factors. British
Journal of Orthodontics 1989; 16:1–7.
21. Zhang, McGrath, Hagg. Changes in oral health-related
quality of life during fixed orthodontic appliance 26. Richter D, Nanda R S, Pramod K S, Sinha P K,
Smith D W, Currier G F. Effect of behavior
therapy. Am J OrthodDentofacialOrthop 2008;
modification on patient compliance in orthodontics.
133:25-9. Angle Orthod 1998; 68:123–32.
22. Sheiham A, Tsakos G. Oral health needs assessments. 27. Haynes S. Trends in the numbers of active and
In:Pine C, Harris R, eds. Community Oral Health. discontinued orthodontic treatments in the General
New Malden, UK: Quintessence; 2007:59–79. Dental Services 1964 – 1986/87.British Journal of
Orthodontics 1991; 18:9–14.
23. Oliveira CM, Sheiham A. The relationship between
normative orthodontic treatment need and oral 28. Tung A W, Kiyak H A. Psychological influences on
the timing of orthodontic treatment .Am J
health-related quality of life. Community Dent Oral
OrthodDentofacialOrthop 1998; 113:29–39.
Epidemiol 2003; 31:426–36.
29. Marques LS, Ramos-Jorge ML, Paiva SM, Pordeus
24. Oliveira CM, Sheiham A. Orthodontic treatment and IA. Malocclusion: aesthetic impact and quality of life
its impact on oral health-related quality of life in among Brazilian schoolchildren. Am J
Brazilian adolescents. J Orthod. 2004; 31: 20–7. OrthodDentofacialOrthop 2006; 129:424–27.
977
Modern Dentistry: The Economic aspect

1
Dr. Abhinav Kumar, 2Dr. Priyanka Sethi Kumar, 3Dr. Stutee Bali Grewal, 4Dr. Mandeep Grewal,
5
Dr. Dildeep Bali
Dentistry is a profession in health care; As we are emerging in a new era of dentistry,

however dental practice, where the majority of the practices will no longer automatically find success
profession works, is often perceived as operating by hanging out a shingle. Dental Insurance in India
more overtly as a business than medicine. is not very popular and patients, who even have
The global economy has changed; therefore some form of dental insurance, are cutting back from
the dental world is forced to change too. Once spending. Since great deal of dentistry is not based
thought by most to be recession proof, dental on emergency or pain, many patients are deciding to
practices are being impacted by economic hold on to their money rather than spend it.
downturn in many ways. In the past two decades, So where is the trouble? The trouble does not
we have witnessed many changes in our lie with the business strategies and techniques
profession. The combination of innovation and adopted, but with the core ideology of self-interest.
enterpreneurship has led to significant The answer lies in making treatment more
breakthroughs. The emergence of cosmetic affordable for patients. That does not mean only
dentistry and the growth of implant dentistry have doing well for the people and making ones
created a renaissance in the dental profession. practice bankrupt. The dentist should charge based
on the quality of the treatment and work rendered
Two models of dentistry have been proposed;
to the patient. No matter what the economy is, the
one as profession, the other as business1 .
dentist should make it easy and convenient for
Professionalism is a concept that informs how we
patients to accept their services. The more
ought to act, and as such belongs firmly in the realm
financial options a dentist offers, the better the
of ethics2. The ‘ought’ represents the constant
outcome for everyone. Thus professionalism
attempt to achieve more than is required: to realize
should not be ignored. Therefore a dentist should
our potentials. It means striving for the best when
both be a professional and a business person on
there are no external forces compelling you to do
the grounds that keeping the business working well
so2.However, business ethics is a discipline in its
is part of the social corporate responsibility to the
own right. It can be defined as ‘a system of moral
benefit of all the patients treated by him2.
principles applied in the commercial world’ where
there are guidelines for acceptable behavior by There should be dental professionalism, which
organizations in both their strategy formulation and signifies a set of values, behavior and relationships
day-to-day operations3. Currently, the increased that underpins the trust the public has in dentists.
demand for improved esthetics is pushing the dental This forms a moral contract between the
profession further towards the business model, less profession and society. Each party has a duty to
helping those in need but more serving those who strengthen the system of oral and dental healthcare
demand, and can pay. within the context of a realistic economic
As dentistry continues to evolve in a new framework that will permit the extension of this
economy, it is critical to keep an eye on the business system to all those in need now and in future2.
side of the practice not ignoring professionalism and
ethics. Most practices continue to manage themselves BIBLIOGRAPHY
as they did when the economy was far more 1. Welie JV.Is dentistry a profession? Part 3.Future
different and much more robust. In the current challenges. JCan Dent Assoc 2004; 70: 675-678
market, today’s dentist is wondering what should be 2. Trathen A., Gallagher J.E: Dental professionalism:
done to manage day-to-day pressures while running definitions and debate. BDJ 2009; 7: 126-130
the practice. They are working harder to maintain 3. BNet Business Dictionary. Business Ethics:
production levels and have a strong desire to increase Definition. 2008{updated 2008; cited}; Available
doctor income. from http://dictionary.bnet.com/definition/
1
Senior Resident, Dept. of Conservative dentistry and Endodontics, Centre for Dental Education and Research, All India
Institute of Medical Sciences, New Delhi 2Senior Lecturer, 3Professor, Dept. of Orthodontics and Dentofacial Orthopedics,
4
Professor and Head, 5Professor, Dept. of Conservative Dentistry and Endodontics, Santosh Dental College and Hospital,
Pratap Vihar, Ghaziabad, U.P.
978
Health Care Waste Management : A Biosafety Issue

1
Dr.Sadaf Nishat, 2Dr.Shweta Bali, 3Dr.Priyanka Chopra, 4Dr.M.Siddarth
ABSTRACT
Proper handling, treatment & disposal of biomedical & dental waste is an essential responsibility that
will help protect health care workers, patients & local community. In contrast to the pollution prevention,
which is voluntary, the proper disposal of hazardous waste is addressed through provincial regulations &
municipal by laws. The Government of India formulated the Bio-Medical Waste (Handling and
Management) Rules in 1998 (hereafter referred to as the Bio-Medical Waste Rules) in order to specify
procedures that have to be followed in the management and disposal of waste. The Rules apply to all
persons who generate, collect, receive,store, transport, treat, dispose or handle Bio Medical Waste in any
form. This review article discusses about the various types of wastes & the hazards of indiscriminate
disposal of hospital waste & in brief about dental waste management.
Key words: Bio-Medical waste, segregation, disposal, non-risk waste, risk- waste.
INTRODUCTION hospital waste. Physical (injury) and health hazards

are also associated with the high operating
Over the recent decades the world’s temperatures of incinerators and steam sterilizers
accelerated economic development has resulted in and with toxic gases vented into the atmosphere
uncontrolled population growth & rapid after waste treatment. Risk to the public is also
urbanization. Until fairly recently, medical waste immense as there may be increased risk of
management was not generally considered an nosocomial infections in patients due to poor waste
issue. In the 1980s and 1990s, concerns about management. Improper waste management can
exposure to human immunodeficiency virus (HIV) lead to change in microbial ecology and spread of
and Hepatitis B virus (HBV) led to questions antibiotic resistance.
about potential risks inherent in medical waste.
Thus hospital waste generation has become a Bio medical waste management is collection,
prime concern due to its multidimensional transport, processing, recycling of disposal of
ramifications as a risk factor to the health of waste material. This term usually relates to
patients, hospital staff and extending beyond the materials produced by human activity and is
boundaries of the medical establishment to the generally undertaken to reduce effect on health, the
general population. 1 environment and aesthetics. There are a variety of
problems or as they may better known as
Dental offices generate a number of hazardous “Management Issues” regarding the disposal of
wastes that can be detrimental to the environment biomedical waste.Some hospitals are disposing of
if not properly managed. It is the purpose of this waste in a haphazard, improper & indiscriminate
article to provide dentists and members of the manner.
dental team with information on how to properly
manage hazardous wastes in order to minimize the Lack of segregation practices, results in
release of toxic substances to mixing of hospital wastes with general waste
theenvironment.Bio-Medical Waste is defined as making the whole waste stream hazardous. A bag
any waste generated during the diagnosis,treatment not securely tied results in scattering of
or immunization of human beings or in research Bio-Medical waste. Most importantly there is no
activity.2Sources biomedical waste include mechanism to ensure that all waste collected and
hospitals,research institutions,health care teaching segregated reaches its final destination without any
institutes,clinics,laborataries,blood banks,animal pilferage. Additional hazard includes recycling of
houses &veterinary institutes. Potential implication disposables without even being washed.A bag not
is the risk to Healthcare workers and waste securely tied results in scattering of Bio-Medical
handlers as improperly contained contaminated waste. Most importantly there is no mechanism to
sharps pose greatest infectious risk associated with ensure that all waste collected and segregated
1
Assistant Professor, 2Professor, 3Associate Professor, 4Professor and Head, Dept. of Periodontics School of Dental Sciences,
Sharda University, Greater Noida,U.P
979
reaches its final destination without any pilferage. production of biologicals, chemicals,
Additional hazard includes recycling of disposables disinfectants, sterilizing agents);
without even being washed.There is no mechanism • Miscellaneous: dental wastes including
for ensuring waste treatment within prescribed surgical drapes/absorbents, protective gloves,
time limits.In some hospitals there is no proper disposable laboratory coats or masks, dental
training of the employees in hazardous materials laboratory waste, specimen containers, dental
management and waste minimization aspects .3 unit waterline, surgical smoke.
Some authors have classified Bio- Medical The World Bank’s Health Care Waste
Waste into ten Categories along with Color coding Management Guidance Note lists four steps to
and types of containers for different categories and healthcare waste management:15
their corresponding treatment & disposal option
with standards.3 1. Segregation of waste products into various
components that include reusable and
Another way by which Health care waste has disposable materials in appropriate containers
been characterized is Non Risk waste that accounts for safe storage;
for 75-90% of the total health care waste and Risk 2. Transportation to waste treatment and disposal
waste which is 10-25% of the health care waste.3 sites;
Some authors propose a simplified 3. Treatment; and
classification using the US Centers for Disease 4. Final disposal
Control & prevention guidelines. This system
Dental Clinics generate a number of
focuses on which materials can be hazarduous, the
biomedical wastes,including blood soaked
importance of handling these materials & the best
materials & human tissue.
practices for recycling & safe disposal.Non
anatomic Biomedical Waste (waste from dental Dentists are encouraged to follow Best
materials/equipment/disposable that appear to be Management Practices when disposing hazardous
waste. wastes.
The best disposal option prevents or minimizes
Nonanatomic Biomedical Wastes (waste the release of toxic substances to the environment
from dental materials/ equipment/ from dental clinics. Following these procedures
disposables that appear to be medical will manage or reduce the release of toxins to the
waste) environment.8,10 -14
• Mercury-containing: elemental mercury, scrap
Disposal Options 8:
amalgam;
• Silver-containing: spent X-ray fixer, Best Management Practice (BMP)
undeveloped film;
This is the best option available to the dental
• Lead-containing: lead foil packets, lead aprons, office reflecting current commercially available
broken thermometers, blood pressure gauges; technology and methods. This often reflects
• Chemical or pharmaceutical waste: chemicals, pollution prevention principles and goes beyond
disinfectants, sterilizing agents, expired drugs, the minimum required by law. BMPs should be
waste-bearing cyto/genotoxic properties; the goals against which current practices are
measured.
• Contaminated/uncontaminated sharps: syringes
(with/without needles), broken glass, scalpels,
Good Management Practice (GMP)
specimen tubes, slides.
These are generally accepted technologies and
Anatomic Biomedical Waste
procedures for handling and treating waste.
These behaviors will manage or reduce the
• Pathologic waste: blood, blood products,
release of materials into the environment but are
bodily fluids and tissues;
not as effective as BMPs. They represent average
• Infectious waste: cultures, infectious agents, behaviors and are usually designed to meet
associated biologicals (eg, culture flasks, petri existing legal requirements and established clinical
plates, specimens, vaccines, wastes from the procedures.
980
Don’ts that recycle amalgam or fixer may also accept lead

waste.9
These actions are prohibited by law and will
cause environmental problems, may endanger staff
or public safety and could result in charges under Chemicals, Disinfectants, and Sterilizing
existing regulations and bylaws. These practices Agents
are considered not appropriate for a dental office. The dental office utilizes many chemicals,
Nonanatomic Biomedical Wastes disinfectants, and sterilizing agents that may be
hazardous to the environment if they are not
Mercury-Containing Wastes
properly disposed.
Elemental mercury is one of the major waste The Best Management Practice is to read the
products in the dental clinic, and its waste manufacturer’s instructions or the Material Safety
management is critically important. The amount of Data Sheets (MSDS) for all chemicals,
amalgam used must be limited to the smallest disinfectants and sterilizing agents.Some of these
appropriate size for each restoration. Use of bulk chemicals may explode if sewered in certain
elemental mercury should be eliminated, and any quantities. Others may damage the pipes gradually.
unused bulk elemental mercury must be recycled If any chemical has a flashpoint below
or removed as hazardous waste. It must never be 61°C, a pH ≤ 2.0, or ≥ 12.5, it is better to contact
discarded into the regular trash, with infectious the municipal sewer department and ask if the
waste (yellow bag), or down the drain. All quantity generated in the dental clinic can be
amalgam waste must be recycled or hauled away safely disposed into the sewer. If so, the drain
as hazardous waste as directed by the recycler or must be flushed well when disposing these
hazardous waste disposal program. This usually materials.20 There are other chemicals that are
means in covered, segregated, and clearly labeled flammable and could explode, alcohols, ethers, and
airtight plastic containers.5,17,19 peroxides must not be discarded down the drain.
These products are deemed hazardous waste, and
Silver-Containing Wastes
unused products should be disposed of through a
hazardous waste transporter. The label directions
Undeveloped film and used fixer solution are on the product container should be followed for
considered hazardous because of their high silver proper handling and disposal of all used
content. Silver used in fixer solutions is in the disinfectants and cleaners. Recycle the empty
form of silver thiosulphate complexes, which are container through the proper channel or dispose of
extremely stable and have very low dissociation it in the trash. The waste management service
constants. provider should be contacted to dispose of unused
or expired products.21
Waste water treatment processes convert the
silver thiosulphate into mostly silver sulfide. Two
suitable methods manage fixer waste: a) separation Contaminated/Uncontaminated Sharps
of used fixers from depleted developers; b) use of
(Sharps &endash; needles, scalpels, glass
a silver recovery unit for a practitioner’s
carpules, burs, acid etch tips, files, blades, ortho
developing system. Dentists can also use digital
wire and Other sharp objects)
x-ray equipment, which eliminates the need for
processing chemicals and the resulting waste. In All sharps must be disposed using the
addition, digital x-rays can reduce patient radiation appropriate guidelines. Proper disposal will
exposure.10 minimize possible puncture wounds on other
workers handling these wastes such as cleaners and
Lead-Containing Wastes waste carriers. The Best Management Practice is
to collect sharps in a red or yellow puncture
Because lead is a leachate, it can contaminate resistant container with a lid that cannot be
soil and groundwater from landfill sites. Lead foil removed. The sharps container should be properly
packets and aprons should not be discarded in labeled with biohazard symbol.9
general trash. Unless they are recycled for their
scrap metal content, they are considered hazardous Once container is full, contact a certified
waste, and therefore certified waste carriers should biomedical waste carrier for disposal .Do not
be used for transportation and disposal. Companies throw sharps in a regular garbage bag
981
Do not place other biomedical wastes be considered general waste and treated
materials in this container.Do not fill over -full to accordingly. However, disposal of sharps (eg, burs,
prevent injury disposable blades, orthodontic wires) should be
done in puncture-resistant containers for necessary
ANATOMIC BIOMEDICAL WASTE actions.27
Human tissue must not be discarded with the
regular garbage. Human tissue must be separated In India, it is mandatory that all biomedical
from other wastes and collected in a yellow liner wastes must be handled in accordance with the
marked with the universal biohazard symbol. This Guidelines of Biomedical Waste (Management and
waste should be stored in a secure and locked area Handling) Rules 1998, which were amended in
with “Biomedical Waste Storage” signage and the 2000. All waste generated in dental practice must
universal biohazard symbol. This area must be be segregated into the appropriate categories and
distinct from other rooms and remain at a cool disposed of accordingly, and all healthcare workers
have a duty to ensure that the necessary
temperature (below 4°C ). Once a certain amount
precautions are taken when disposing of healthcare
has been collected, a biomedical waste carrier must
waste. Protective clothing (apron, gloves, eyewear,
be contacted for disposal.22
etc) should always be worn when handling waste.
All biomedical waste containers must be Also, hazardous waste should be carefully labeled,
clearly indicated by a color code and the universal secured, stored safely, and ultimately disposed of
biohazard symbol. It is extremely important to in appropriately colored containers.
prevent biomedical waste from being included in
• Black bags are used for non-risk waste and
normal garbage, which is often incinerated,
producing environmental toxins. can be transported to a landfill.
• Red bags are used for disposing sharps,
Blood or Other Bodily Fluids Generated tubing, gloves, blood bags, plastic bottles,
During Treatment syringes, etc.
All containers with blood or saliva (suctioned
• Yellow bags are used for waste with
fluids) can be inactivated according to government
regulatory norms or the contents can be safely significant healthcare risk, such as human
discharged in limited quantities into the sewer waste, cotton and gauze pieces, extracted teeth,
through a utility sink or toilet.23 However, etc.
state/local regulations may vary in requiring • Blue bags are used for blades, medicine
pretreatment before these wastes can be discharged vials/ampoules or glass bottles, etc.28
into the sewer, or whether they can be disposed
All equipment used for sterilization and waste
of in the sewer and in what quantities.
disposal must be serviced regularly and maintained
MISCELLANEOUS WASTE diligently to ensure appropriate sterilization
conditions.1,4,8,16,29
Nonanatomic Wastes
Blood-soaked materials must not be discarded CONCLUSION
with the regular garbage. They must be separated As time is passing by, conserving the
from other wastes, collected in yellow liner environment has essentially become the need of
marked with the universal biohazard symbol, and the hour. Dental health care setups generate
stored for fewer than 4 days. For any longer, the number of hazarduous wastes that can be
material must be refrigerated (below 4°C ). This detrimental to the environment if not properly
waste should be stored in a secure and locked area managed. Dentistry as a professions indeed plays
with signage indicating “Biomedical Waste a crucial role in doing so, provided we develop
Storage” and the universal biohazard symbol. This simple yet effective, least expensive procedures &
area must be distinct from other rooms and remain sustainable systems to handle bio medical waste.In
at a cool temperature (below 4°C ). Once a certain Western Countries the system is so very advanced
amount has been collected, a biomedical waste that they have a Take Back Program for all types
carrier must be contacted for disposal.9 of waste where as we may have to address the
same issue by setting up solutions .Successful
Dental Laboratory Waste outcomes are achievable within a collaborative
Waste generated in the dental laboratory (such environment of shared learning & cooperative
as disposable trays or impression materials) may planning. Training dental staff for properly
982
handling the waste in our dental practices and 16. Kishore J, Goel P, Sagar B, Joshi TK. Awareness
following a proper infectin control program may about biomedical waste management and infection
just be small beginnings to a cleaner & a safer control among dentists of a teaching hospital in New
environment Delhi, India. Indian J Dent Res. 2000;11(4):157-161.
17. Chin G, Chong J, Kluczewska A, Lau A, Gorjy S,
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1. Hegde V, Kulkarni RD, Ajantha GS. Biomedical amalgam. Aust Dent J. 2000; 45(4):246-249.
waste management. J Oral and Maxillofac Pathol. 18. Bender M. Dentist the Menace? The Uncontrolled
2007;11(1):5-9. Release of Dental Mercury. Montpelier, VT: Mercury
2. Rutala WA, Weber DJ. Disinfection, sterilization and Policy Project/Tides Center; 2002.
control of hospital waste. In: Mandell GL, Bennett 19. Dental amalgam waste protocol. 2005. Canadian
JE, Dolin R, eds. Mandell, Douglas and Bennett’s Dental Association Web site.
Principles and Practice of Infectious Diseases. 6th ed. http://www.cda-adc.ca/en/dental_profession/practising
Philadelphia, PA: Elsevier Churchill Livingstone; /amalgam_waste/index.asp. Accessed November 2,
2005:3331-3347. 2009.
3. Park K. Hospital Waste Management. Park’s 20. Idaho State Dental Association. Best management
Textbook of Preventive and Social Medicine. M/s practices (BMPS) for dental offices: for minimization
Banarasidas Bhanot Publications, New Delhi. 18th of mercury and imaging discharges to the sewerage
Edn, 2005: 595-598. system by dental care providers.
4. Sharma M. Hospital Waste Management and Its http://www.cityofboise.org/Departments/Public_works
Monitoring. 1st ed. New Delhi, India: Jaypee Brothers /pdf/ISDADentalBMPs.pdf. Accessed November 2,
Medical Publication; 2002. 2009.
5. Hiltz M. The environmental impact of dentistry. J 21. Al-Dwairi ZN. Infection control procedures in
Can Dent Assoc. 2007;73(1):59-62. commercial dental laboratories in Jordan. J Dent
6. Molinari JA. Dental infection control at the year Educ. 2007;71(9):1223-1227.
2000: accomplishment recognized. J Am Dent Assoc. 22. Rao SKM, Ranyal RK, Bhatia SS, Sharma VR.
1999;130(9):1291-1298. Biomedical waste management: an infrastructural
7. Hari Pakash,Anil K,Sunil C et al : biomedical waste survey of hospitals. Med J Armed Forces India.
& Dental waste management : An Essential 2004;60(4):379-382.
Component of Asepsis In Dental Clinics : Contining 23. Greene VW. Microbiological contamination control in
Education:Dental AEGIS.com
hospitals. 1. Perspectives. Hospitals.
http://cde.dentalaegis.com/ courses/4336 .
1969;43(20):78-88.
8. Condrin AK. The use of CDA best management
24. Rutala WA, Odette RL, Samsa GP. Management of
practices and amalgam separators to improve the
infectious waste by US hospitals. J Am Med Assoc.
management of dental wastewater. J Calif Dent
1989;262(12):1635-1640.
Assoc. 2004;32(7):583-592.
25. Centers for Disease Control. Perspectives and disease
9. Best management practices for hazardous dental waste
disposal. Nova Scotia Dental Association Web site. prevention and health promotion. Summary of the
http://www.nsdental.org/media_uploads/pdf/95.pdf. Agency for Toxic Substances and Disease Registry
Accessed November 2, 2009. report to congress: the public health implications of
10. Best management practices for amalgam waste. medical waste. MMWR Morb Mortal Wkly Rep.
American Dental Association Web site. 1990;39(45):822-824.
http://www.ada.org/prof/resources/topics/amalgam_b 26. Palenik CJ. Managing regulated waste in dental
mp.asp. Accessed November 2, 2009. environments. J Contemp Dent Pract. 2003;4(1):76.
11. Barron T. Mercury in our environment. J Calif Dent 27. Kohn WG, Collins AS, Cleveland JL, et al.
Assoc. 2004;32(7):556-563. Guidelines for infection control in dental health-care
12. Samek L. Disposing of hazardous waste. An update settings—2003. MMWR Recommen Rep. 2003;
on waste management studies. Ont Dent. 52(RR-17):1-61.
1994;71(7):19-35. 28. The Gazette of India. Bio-Medical Waste
13. Anderson K. Creating an environmentally friendly (Management and Handling) Rules 1998. No 460 July
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14. Pichay TJ. Dental amalgam: regulating its use and 29. Infectious/Biomedical Waste Management Plan June
disposal. J Calif Dent Assoc. 2004;32(7):580-582. 2005 By Members of UW Infectious Waste
15. Johannessen LM, Dijkman M, Bartone C, Hanrahan Committee & UW Institutional Biosafety Committee
D, Boyer G, Chandra C. Health care waste University of Washington. University of Washington
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International Bank for Reconstruction and manuals/biowastemanual/biomedwaste.pdf. Accessed
Development/The World Bank; 2000. October 26, 2009.
983
Cultural Practices involving Teeth and Oro-facial Soft

Tissues – A Review
1
Dr. Neeraj Singh Chauhan, 2Dr. G Shanthi, 3Dr. Vikram Singh, 4Dr. Arpan Shrivastav,
5
Dr. Sumit Khare
ABSTRACT
History has a rich record of such events which have a range of ancient and contemporary cultures in
order to combat the oral diseases and other problems related to the teeth and other oral structures. An
understanding of these cultures affecting the oral tissues is important for the diagnosis and, where necessary,
treatment of the complications arising from this acquired form of pathology
Tooth mutilations practices are confined to societies which have been able to maintain their
geographical or cultural isolation. These practices includes non-therapeutic tooth extraction(avulsion),
breaking of tooth crowns, alteration in the shape of the crown by filing and chipping, dental inlay work,
lacquering and staining of teeth.
A carefully crafted through investigation will assist to elicit, recognize, accept and respects the patients’
cultural beliefs and develop subsequent appropriate therapeutic strategies as well as oral health promotions
policies. This paper is an attempt to review various cultural practices involving the teeth and oral soft
tissues, encountered in the different parts of the world and convincing people about harmful effects of
some practices and the methods of the treatment.
Key words: Culture, Tooth mutilations, Therapeutic, Harmful.
INTRODUCTION understanding of these cultures affecting the oral

tissues is important for the diagnosis and, where
Humans are characterized by a compulsive necessary, treatment of the complications arising
tendency to distinguish themselves from the rest, from this acquired form of pathology.
differences in clothes, hairstyle or "decorative"
details are used to this effect, based on highly The twentieth century has seen the evolution
diverse criteria.1 Since time immemorial the teeth, of the Western dentistry. In the developing world
the mouth and the face have been a fascination for mainly the tropics, this practice has come to
mankind. They have been and continue to be the disregard the importance of various cultural
subject of any oral and written beliefs, framework, including those related to concepts of
superstitions and traditions and the object of a health and disease, in which people in many
wide range of decorative and mutilatory practices. diverse society live. Equally importantly, there has
At the same time they have been the cause of been a tendency to ignore potentially or
considerable scuffing for many. demonstrably useful store of accumulated wisdom
and knowledge possessed by many of the so-called
History has a rich record of such events which underdeveloped cultures which relate to the teeth,
have a range of ancient and contemporary cultures oral hygiene practices, and the approaches to the
in order to combat the oral diseases and other therapy and the relief of dental and other form of
problems related to the teeth and other oral pathology in or about the mouth. 2
structures. Knowledge of these practices is
important for the valuable insights they the cultural This review has been taken to overview some
beliefs and the traditions of the people who of the cultural practices involving the teeth and
practice them and for the very programmatic oral soft tissues, encountered in the different parts
reason that many comprise examples of the of the world. Also recommending the proper
customs which directly give rise to the pathology methodology for eliminating the cultures which
of the teeth and the oro-faciel tissues. An have negative impact on the society.
1
Senior Lecturer, Dept. of Public Health Dentistry, 3Senior Lecturer, Dept. of Oral Medicine and Radiology 5Senior Lecturer,
Dept. of Prosthodontics and Implantology, Bhabha College of Dental Sciences, Bhopal, M.P. 2Senior Lecturer, Dept. of
Public Health Dentistry, People’s College of Dental Sciences and Research Centre, Bhopal, M.P. 4Senior Lecturer, Dept.
of Public Health Dentistry, Rishiraj College of Dental Sciences and Research Centre, Bhopal, M.P.
984
GLOBALLY PRESENT CULTURAL practice gouging or enucleation of primary tooth

PRACTICES INVOLVING TEETH AND buds to cure childhood illnesses. 9 Johnston et al
ORO-FACIAL SOFT TISSUES in 2008 concluded that removal of deciduous
canine follicles are frequently practised in some
INFANT ORAL MUTILATION African and neighbouring countries. The practices
are usually performed by traditional healers. Risks
Prabhu has described the practice of Tooth for children who undergo these procedures are
mutilation for inhabitants of non-tropical and extensive, including septicaemia, potential for HIV
tropical environments. Today, such rituals are transmission, numerous dental complications and
largely confined to societies which have been able death. 10
to maintain their geographical or cultural isolation.
These practices includes non-therapeutic tooth Jonathan Gollings in 2008 attributed that in
extraction(avulsion), breaking of tooth crowns, some areas, eruption of the upper anterior before
alteration in the shape of the crown by filing and the lower is regarded as an evil omen. The mother
chipping, dental inlay work, lacquering and tries to hide the baby if upper anterior appear first,
staining of teeth, and miscellaneous practices such or ask the healer to cut the gum over the lowers
as placement of gold crowns for adornment to encourage eruption. 11 Dentaid 2008 IOM
purposes. 2 Literature analysis showed that pagan tribes of the
Nilotic Sudan removed lower incisors/canines to
Baba et al in 1989 attributed that the practice prevent future illness. Permanent incisors knocked
may have indeed originated from Uganda, started out as a rite of passage and for sexual attraction.
by the Lugbara tribe who initiated and spread it They believed that the lower permanent incisors
amongst other tribes. 3 Holan et al in 1994 reported must be removed or the girl/boy will grow up
that Parental enquiry revealed that the practice is sterile. 12
more common in rural rather than urban areas and
still exists in the Ethiopian community in Israel.4 MODIFICATION OF THE TOOTH CROWN
Jocelyn et al in 2006 in a review has
Jonathan Golling in 2008 reported that the enumerated that dental modification was
earliest literature on this practice is found in 1932 commonly practiced in pre-Hispanic populations
in an account of the customs of the pagan tribes throughout Mesoamerica 13 Finucane et al in 2008
of the Nilotic Sudan. The Shilluk tribe were presented a stronger case for early aesthetic
reported to have taken out the lower deciduous modification was in his short report that of
incisors in young babies to prevent them becoming Intentional dental modification in West Africa.
ill and dying. 5 Kikwilu et al in 1997 reported the Author stated all of the filed teeth belonged to
practice of infant oral mutilation by traditional probable females, suggesting the possibility of
healers in Tanzania of extracting tooth buds or of sex-specific cultural modification. 14 Shyam Singh
rubbing herbs on to the gingivae of young children Shashi in 1993 reported in his book Encyclopedia
to cure fevers and diarrhoea has been known for of Indian Tribe that among the Malavetans of
many years.6 Welbury et al in 1985 found that Travancore is found the interest customs of
Children and adolescents, aged 2 to 18 years, from chipping the incisor tooth in the form of serrated
300 poor families in Addis Ababa were examined cones. 15Jocelyn et al in 2006 described the
to determine the prevalence of the traditional practice of dental filing well into the Colonial
practice of primary canine tooth removal. Fifteen period, which is corroborated by Lorena Havill and
percent of the primary canine teeth were found to colleagues (1997),who observed it as the only form
have been affected. 7 of dental modification in the colonial population
Iriso et al 2000 conducted a research in at Tipu, Belize. Both dental filing and inlay are
northern Uganda, unerupted primary canine teeth common.13
are commonly extracted because they are believed
to cause diarrhoea, vomiting, and fever. This TATTOOING AND PIERCING OF ORAL
practice, known as ebino, is performed under very TISSUES
crude conditions often using unclean tools. 8
Prabhu explained in his book that Tattooing
Dewhurst et al in 2001 reported that some of soft tissues is a practice, which is popular in
rural populations of Sub-Saharan and Eastern many non- tropical and tropical areas of the world.
Africa and other isolated areas around the world, While tattooing of the skin the most commonly
985
encountered expression of this practice, tattooing normal tissues. The affected site or lesion can be
of the lip and of the gingival (Mani 1985) is a white or yellow-brown colour and it may
occasionally seen. Tattoo in the oral region must develop a thickened and wrinkled appearance with
be distinguished from the other form of diffuse, increased use of the tobacco product.
intrinsic, or acquired pigmentation of the oral
Smokeless tobacco has also been studied for
mucosa. 2 John et al in 2007 summarized that
its effects in preventing aphthous stomatitis; it was
intentional placement of tattoos within the oral
concluded that the systemically absorbed nicotine
cavity is encountered infrequently in clinical
was the product that was probably responsible for
practice. Gingival tattooing, practiced in Ethiopia
the reduction of aphthous ulcers. 21 Gerd et al in
and occasionally in other African and Middle
2008 Published Systematic review of the relation
Eastern nations, is performed for esthetic appeal or
between smokeless tobacco and non-neoplastic oral
superstition, and it occasionally may be used as a
diseases, which certainly suggested there was
homeopathic remedy for dental diseases.16 Troye et
increases risk of oral mucosal lesions. 22
al in 2000 reported in his article about the Mayans
pierced the tongue to demonstrate virility and
courage. The Eskimos and Aleuts pierced the lips CHEWING STICK: A CULTURAL AND
of female infants as part of a purification ritual SCIENTIFIC HERITAGE
and the lower lip of the boys as part of the passage
into puberty. A similar traditional motive probably Author Enwonwu et al in 1985 examined
also accounts for the occasional use of large lip some of the properties of chewing sticks in relation
plates among isolated Indian tribes such as the to oral hygiene, with special reference to
Txukahameis of Brazil. 17 Anthony j. Diangelis in conditions in Africa, and found several plants used
1997 explained about the placement of the barbell as sources of chewing sticks in developing
in the tongue. He wrote that the technique is fairly countries contain fluoride, antibiotics and other
straightforward and accomplished without medicinal compounds. In poor communities it is
anesthetic. The tongue is generally pierced in the probably more appropriate to promote the use of
midline anterior to the lingual frenum.18 Troye et the best chewing stick as a way of combating oral
al in 2000 reported that there are two types of disease than to try to introduce expensive
tongue piercing; the more common and safer toothbrushes and toothpastes. 23 Ndukwe KC et al
dorsoventral and the dorsolateral. In dorsoventral in 2005 conducted a study on antibacterial activity
piercing the jewelry is inserted from the dorsal to of chewing sticks. Aqueous extracts from
the ventral surfaces of the tongue. 17 seventeen chewing sticks and the fruit of
C.ferruginea, one fruit used in oral hygiene in
Nigeria, were screened for antibacterial activity
TOBACCO HABITS - A CULTURE against type culture of Staphylococcus aureus,
Bacillus subtilis, Escherichia coli, and Psudomonas
Prakash et al in 1984 conducted a 10 year aeruginosa. Eleven of the test extracts showed
follow up study of tobacco usage and oral disease activity against at least two of these referenced
in a random sample of 10 169 persons in organisms. 24
Srikakulam district between 1967 and 1976. Age
adjusted mortality rates in those who indulged in This topic addresses certain aspects of cultural
reverse smoking of chuttas (coarse cheroots) were practices from both the general and specifically
nearly twice those of non-users oftobacco. Oral dental perspectives. Mutations imply permanent or
cancer explained only a small fraction of the lasting sectioning or lesions of a part of the body.1
excess mortality but reliable information was not
available for other causes of death.19 Yogita et al in 2008 has suggested that the
information gained from research in to cultural
Shrinath et al in 2005 reported that in the beliefs and it’s association with oral health and
Srikakulam district, 46% of the 10,169 individuals dentural beliefs and its association with oral health
surveyed smoked reverse and this practice was and dental care seeking behavior and practices
more common among women (62%) than men would be helpful in designing future preventive
(38%). 20 Priscilla et al in 2000 reported the oral and treatment programs. Such programs with
effects of smokeless tobacco are typically seen on special considerations to ethnic beliefs could have
the mucosal surfaces where the product is placed, a positive impact and increase utilization of
as well as on the adjacent periodontium. Clinically, preventive services. 25 The US Surgeon General’s
the lesion is usually clearly demarcated from the Report not only highlights disparities in oral health
986
but also highlights the importance of social and Giving thought to the incorporation to the
environmental determinants of oral health and the local beliefs and practices, where appropriate, in
need to adopt more holistic approaches to oral treatments and planning protocols; Convincing
health promotion. A well trained dentist should be people about harmful effects of some practices and
not only need to be an expert in clinical skills but the methods of the treatment.
also able to elicit, recognize, accept and respect
their patients’ cultural beliefs. A deeper REFERENCES
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987
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13. Jocelyn S. Williams and Christine D. White Family Welfare. Govt. Of India 2005.
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14. Finucane BC, K Manning, M Toure - Prehistoric 22. Gerd Kallischnigg, Rolf Weitkunat and Peter
dental modification in West Africa-early evidence Systematic review of the relation between smokeless
from Karkarichinkat Nord, Mali International Journal tobacco and non-neoplastic oral diseases in Europe
of Osteoarchaeology, 2008 - and the United States N Lee2 Published: 1 May 2008
brian.finucane.googlepages.com BMC Oral Health 2008, 8:13 doi:
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16. John K. Brooks, DDS and Mark A. Reynolds, DDS, Traditional Medicine The chewing stick in oral health
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Literature review and report of a case J Am Dent 24. Ndukwe KC,Okeke IN, LamikanraA,Adesina SK,
Assoc, Vol 138, No 8, 1097-1101. © 2007 American Aboderin O. Antibecterial Activity of Aqueous
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988
Gerodontology - Orodental Care for Elderly - A Review

Dr. Luthra R.P.1, Dr. Bhardwaj V. K.2, Dr. Sharma K.R.3, Dr. Jhingta P.4
ABSTRACT
Changing demographics, including an increase in life expectancy and the growing numbers of elderly
has recently focused attention on the need for geriatric dental care. Ageing affects oral tissues in addition
to other parts of the human body, and oral health (including oral mucosa, lips, teeth and associated
structures, and their functional activity) is an integral component of general health. Oral disease can cause
pain, difficulty in speaking, mastication, swallowing, maintaining a balanced diet, not to mention aesthetical
considerations and facial alterations leading to anxiety and depression. Certain strategies should be adopted
for improving the oral health of the elderly, including the management and maintenance of oral conditions
which are necessary for re-establishing effective masticatory function. Oral health is often neglected in the
elderly, and oral diseases associated with aging are complex, adversely affecting the quality of life.
Although majority of oral health problems are not usually associated with mortality. Nearly more than half
of the deaths due to oral cancer occur at an age of 65 years plus. This review of geriatric dentistry which
is dedicated to geriatric physicians, geriatric dentist and specialists in oral medicine reviews age-related
oral changes in elderly patients and efforts to summarize the effects of aging in hard and soft oral tissues.
Key words: dental care, elderly, gerodontology
Overview all over the world. By now one third of the

world’s elderly population is living in the
Gerodontology is the delivery of dental care developing countries and one out of twelve
to older adults involving the diagnosis, prevention, persons in the developing countries is over sixty
and treatment of problems associated with normal five.3
aging and age-related diseases as part of an
interdisciplinary team with other health care The twentieth century witnessed remarkable
professionals.1 An overview of the demographics population ageing with regard to human longevity
and oral health status of the elderly population of worldwide, and the twenty-first century is set to
India is presented. India is a vast country with a carry forward the gains in longevity further, both
population of one billion people. Of this, people in the developing and the developed world. This
older than 60 years constitute 7.6%. There are rise in life expectancy is attributed primarily to the
several factors that affect the oral health of elderly. substantial reduction in mortality at different stages
The dentist: population ratio is 1:27,000 in urban of life, which has been brought about by improved
areas and 1:300,000 in rural areas, whereas 80% health care facilities, sanitation, environmental and
of the elderly population reside in rural India. public health reforms coupled with better hygiene
Forty per cent of the elderly live below the poverty and living conditions. As a result of the increasing
line and 73% are illiterate. Ninety per cent of the life expectancy, the proportion of the elderly in the
elderly have no social security and the dependency total population is projected to be around 20% in
ratio is 12.26. Incidence of oral cancer, which is India and 32% in the developed nations by 2050.4
considered an old-age disease, is highest in India,
13.5% of all body cancers are oral cancers. Keeping this increased life expectancy in
Preventive dental care is almost nonexistent to the mind, the age of retirement in many sectors in
rural masses and very limited in urban areas. India is increasing and in some it has even gone
Above all, there is no orientation of dental up to 70 years. In some states, the retirement age
graduates towards the special needs of the geriatric has not been raised but this is because of the
population.2 concerns regarding the resultant job cuts for the
younger generation. As per the Government of
20th century has witnessed a number of India’s classification, the elderly are those who are
remarkable demographic changes related to health, 60 years of age and above; these citizens become
diseases, longevity and mortality of the population eligible for varied concessions offered by the
1
Professor and Head, Dept. of Prosthodontics, 2Senior Lecturer, Dept. of Public Health Dentistry, 3Professor and Head,
Dept. of Paedodontics, 4Senior Lecturer Dept. of Periodontology, H.P. Govt. Dental College and Hospital Shimla.
989
government and other agencies. In the developed knowledge about health care in old age through
world, the elderly are those above the age of 65 targeted training and research efforts, information
years.5 dissemination and policy development. The World
Health Report 1998 emphasized the need to
The mouth is referred to as a mirror of overall
strengthen health promotion amongst older
health, reinforcing that oral health is an integral
people.8 The health implications of ageing should
part of general health. In the elderly population
be better elucidated and understood. Concern for
poor oral health has been considered a risk factor
the older members of society is part of the
for general health problems. On the other hand,
intergenerational relationship that needs to be
older adults are more susceptible to oral conditions
developed in the 21st century. The young and old
or diseases due to an increase in chronic conditions
must learn to understand each other’s differing
and physical/mental disabilities. Thus, old people
expectations and requirements. In 2002, WHO
form a distinct group in terms of provision of care.
issued a document entitled ‘Active Ageing – A
The dental diseases that the elderly are Policy Framework’, which outlines the essential
particularly prone to are root caries, attrition, approaches towards healthy ageing and its
periodontal disease, missing teeth because of framework rests on three basic pillars: health,
earlier neglect, edentulism, poor quality of alveolar social participation and security. When risk factors
ridges, ill-fitting dentures, mucosal lesions, oral for chronic diseases and functional decline are
ulceration, dry mouth (xerostomia), oral cancers, minimized and protective factors are maximized,
and rampant caries. Many of these are the sequelae people enjoy longer life and higher quality of life.
of neglect in the early years of life, for example, Where labour market, employment, education,
consumption of a cariogenic diet, lack of health and social policies and programmes support
awareness regarding preventive aspects, and habits full participation of the elderly in socio-economic
like smoking and/or tobacco, pan, and betel nut and cultural activities, people will continue to
chewing. All these problems may increase in make a significant contribution to society as they
magnitude because of the declining immunity in grow older. When policies and programmes
old age and because of coexisting medical address the social, financial and physical security
problems. As a result of poor systemic health, the needs and rights of people as they age, the elderly
elderly patient often does not pay sufficient are ensured protection, dignity and care in the
attention to oral health. In addition, medications event that they are no longer able to care for
like antihypertensives, antipsychotics, anxiolytics, themselves. Oral health is an important component
etc., lead to xerostomia, and the absence of the of active aging.7
protective influences of saliva in the oral cavity
increases the predisposition to oral disease. Oral health problems among elderly
Financial constraints and lack of family support or
of transportation facilities affect access to dental Globally, poor oral health among older people
services in later life. has particularly been seen in a high level of tooth
loss, dental caries experience, high prevalence rates
However, experiences from developed of periodontal disease, xerostomia, and oral
countries show that the prevalence of chronic precancer/ cancer.9The negative impact of poor
disease and high levels of disability in older people oral conditions on daily life is particularly
can be reduced through health promotion and significant among edentulous people. Extensive
appropriate prevention strategies designed to tooth loss reduces chewing performance and
improve quality of life.6 Older people can be a affects food choice; for example, edentulous
valuable resource; they can contribute to society people tend to avoid dietary fibre and prefer foods
within their families, communities and national rich in saturated fats and cholesterols.10
economies as either a formal or an informal part Edentulousness is also shown to be an independent
of the workforce, or through volunteer work. risk factor for weight loss 11 and, in addition to
the problem with chewing, old-age people may
WHO and the health of the elderly. have social handicaps related to communication.12
Moreover, poor oral health and poor general health
In 1995, in response to the global challenges are interrelated, primarily because of common risk
of ageing populations, the World Health factors; for example, severe periodontal disease is
Organization (WHO) launched a programme on associated with diabetes mellitus13, ischemic heart
ageing and health.7 It was designed to advance disease14 and chronic respiratory disease 15. Tooth
990
loss has also been linked with increased risk of vitamin deficiency. Macroglossia, increase in the
ischemic stroke 16 and poor mental health.9 size of the tongue in elders is mainly because of
loss of tone of muscles of the cheek or expansions
As this concept of Geriatric Dentistry is fairly
or oral cavity as result of loss of teeth. Elderly
new to the dental surgeons in India, this initial
people are less enthusiastic about proper oral
introduction was necessary. Age does not stop.
hygiene. They consider other health disorders first
There are some changes as you grow old. These
on priority bases. They must be explained the
are called Geriatric changes. Geriatric changes take
consequences, they must be motivated by calling
place in the body as well as in the oral cavity also.
them periodically for check ups.
It is the privilege of dental surgeon to study it well
and carry out the necessary treatment of the oral Salivary Glands: In geriatric patients, salivary
lesions.17 flow is decreased causing a condition known as
xerostomia. It was presumed that it is an aging
Oral cavity examination includes following process. Now it is clear that salivary dysfunction
parts of oral cavity, mucous membrane, tongue, is because of certain medicines and systemic
gingiva, salivary gland, bone and teeth. diseases. Etiology that leads to xerostomia are
Mucous Membrane: Gums of an adult person are medicines (antihistaminics, antihypertensives,
marked satiny shiny and with a stretched diuretics, antidepressants) and radiation therapy.
appearance. Desired resilience and elasticity are Unfortunately these drugs are prescribed to adults
absent. This mucous membranes makes use of very often and hence xerostomia is considered as
dentures very painful. It is important that dental a disease of geriatric patients.
surgeon understands this clinical condition and Treatment of xerostomia: Methods to reduce
handles geriatric patient with utmost care. mouth dryness include. Avoid dry and bulky
Ulcerations at the corner of mouth, angular foods, spicy or acidic foods, and alcoholic
cheilitis which is as a result of lowered bite or beverages. Sucking on sugarfree lozenges or
vitamin deficiency. Dental surgeons should be very chewinggum to stimulate saliva production.
careful and avoid any trauma during treatment.18 Keeping hydrated by sipping water frequently.
Leukoplakia is considered as precancerous Using a humidifier while sleeping. Avoid
condition, and tobacco and alcohol could be caffeinated drinks. Avoid chewing tobacco. Mouth
causative factors. Most of the oral carcinomas are washes are useful to alleviate oral discomfort. In
squamous cell carcinomas and common sites of xerostomia caused by radiation treatment,
are, lower lip, tongue, gingivae, and floor of the Pilocarpin is the drug preferred and can be
mouth. Oral sub mucous fibrosis (OSMF) is a consumed for a long period.
chronic, insidious, disabling disease involving oral
mucosa, the oropharynx, and rarely the larynx. It Tooth Loss:
is exclusively reported in elderly indian population.
The disease is characterized by blanching and Edentulism is prevalent among older people all
stiffness of the oral mucosa, trismus, burning over the world 21 and is highly associated with
sensation in the mouth, hypo mobility of the soft socio-economic status. Epidemiological studies
palate and tongue, loss of gustatory sensation, and
show that persons of low socioeconomic status and
occasionally, mild hearing loss due to blockage of
eustachian tube A variety of etiological factors individuals with little or no education are more
include capsaicin, betel nut alkaloids, likely to be edentulous than persons of high social
hypersensitivity, autoimmunity, genetic class and high levels of income and education.9,22
predisposition.19,20 Functional dentitions, as measured by presence of
Tongue: Dorsum of the tongue shows reddening, at least 20 natural teeth, are found to be most
atrophy of the of the papillae at the tip. Tongue frequent among elderly of high socio-economic
may be completely smooth lobulated. These status in contrast to individuals of low
changes bring about altered taste and decreased socio-economic status.22 Severe dental caries and
appetite. Increased varicosity at the ventral surface
periodontal disease are the major reasons for tooth
is common with elders. It does not call for any
treatment unless symptoms appear. Glossodynia, or extraction.9,23,24,25 Tobacco use is also a risk factor
burning tongue is seen in many adults, some times in tooth loss,23 particularly among people with a
with no apparent clinical picture. It may be high consumption over many years.
991
Denture-related conditions: linked to social and behavioral factors.9,21The

pattern is mostly that persons of low income,40
Denture stomatitis is a common oral mucosal those who do not visit a dentist regularly,40,41 do
lesion of clinical importance in old-age not brush their teeth frequently,41 and smoke,40
populations.In many cases of denture stomatitis, tend to suffer more from coronal and root surface
colonization of yeast to the fitting surface of the caries.
prosthesis is observed. Other factors of stomatitis
include allergic reaction to the denture base
material or manifestations of systemic disease.26 Oral precancer and oral cancer:
The prevalence of denture stomatitis correlates Age-specific rates for cancer of the oral cavity
strongly to denture hygiene or the amount of increase progressively with age, most cases
denture plaque.27, 28Usage of denture at night, 27 occurring in the groups above 60 years. Oral
neglect of denture soaking at night 28 and use of cancer is more common in populations of less
defective and unsuitable dentures 29are also risk developed than developed countries.39 The
factors for denture stomatitis, as is tobacco and prevalence of leukoplakia and lichen planus in
alcohol consumption.30 Other major denture-related older people ranges from 1.0 to 4.8% and 1.1 to
lesions include denture hyperplasia and traumatic 6.6%31,43,44 respectively. Leukoplakia is more
ulcer; their prevalence rates in old-age denture frequent among men while lichen planus is
wearers range from 4 to 26%.27,30,31 Denture associated with the female gender.31, 43 Tobacco
hyperplasia is particularly frequent in persons with use is the most important determinant of oral
ill-fitting dentures.12 Both lesions have been cancer and premalignant lesions 45 including
observed more often among complete denture leukoplakia 31, 44 but heavy consumption of alcohol
wearers than in persons wearing removable partial is also a significant factor in relation to these
dentures.29-31 Moreover, low education, tobacco conditions. 44Socio-economic status such as low
and alcohol use, and infrequent dental visits are levels of education 43 and income 46 is a risk factor
factors associated with increased prevalence rate of for leukoplakia. In contrast, high fruit and
denture-related lesions.30 vegetable intake are protective factors because of
the high content of carotenoids and vitamin C.47
Coronal dental caries and root surface
caries: Oral health care
High prevalence rates of coronal dental caries Needs and demands for oral health care among
and root surface caries are found among old-age the elderly vary across age groups, i.e. the old
populations in several countries worldwide. In versus the very old. Oral health systems should
developing countries data on dental caries among effectively address factors that prevent or hinder
older people are scarce. A recent survey of the older population’s access to and use of
65–74-year-old in Madagascar 32 observed that the appropriate services. Some people, for example,
mean number of DMFT was 20.2; untreated dental experience financial hardship following retirement,
caries was high (DT 1⁄4 5.3) while the number of and the cost or perceived cost of dental treatment
restored teeth was low (FT 1⁄4 0.4). In India the may deter them from visiting a dentist. Such
mean number of decayed teeth has been reported barriers to oral health care should be reduced.
2.5 in a study.33The mean number of decayed and Age-friendly and prevention-oriented third-party
filled root surfaces in older people lies between payment systems may contribute to effective use
2.2 and 5.3 in developed countries, 34-36 and in of oral health services amongst old age people. In
meta-analyses the root caries increment has been developing countries barriers to oral health care
estimated at 0.47 surfaces per year.37 The Root are particularly high as there is shortage of dental
Caries Index, i.e. the number of decayed and filled manpower and low priority is allocated to oral
root surfaces with gingival recession over the health by national health authorities. Affordable
number of decayed, filled and sound root surfaces oral health care should be organized to ensure
with recession,38 was 5.4 in a study of older people adequate early detection, prevention and treatment
in China.39 In contrast, 12% of elderly subjects in for all seniors as well as other age groups. It
India had exposed root surfaces, but none remains a challenge to health authorities in several
experienced root surface caries.33 The available developing countries to establish
data worldwide show that dental caries is a major prevention-oriented oral health systems based on
public health problem in older people and closely the primary health care approach. Community
992
models for outreach service and provision of 2. Shah N.; Geriatric oral health issues in India.Int Dent
essential oral health care must be implemented J. 2001; 51:212-218.
urgently, particularly in low-income communities 3. Schou L.; Oral health, oral health care, and oral health
of Asia and Africa. In a number of developing promotion among older adults: social and behavioral
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5. World Health Organization. Oral Health Country/Area
Elderly people should be provided free Profile. Available from:
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treatment on priority in all the health centres. 6. Puska P., Pietenen P., Uusitalo U.; Influencing public
Treatment should be free or on concession to this nutrition for non-communicable disease prevention:
group of people. Government of Himachal Pradesh from community intervention to national programme
under the project “Muskan”48 is providing free – experiences from Finland, Public Health Nutr.
dentures to the elderly people above 65 years of 2002; 5:245–251.
age. Such type facility should be provided to the 7. United Nations Population Division. World
senior citizen throughout the country. Population Prospects: The 2002 Revision, New York,
NY, USA: United Nations; 2003.
Recommendations 8. World Health Organization. The World Health
Report 1998. Life in the 21st Century: A Vision for
Establishment of Continuing Dental Education All. Geneva, Switzerland: WHO; 1998.
programmes on geriatric oral care; inclusion of a 9. Walls A.G., Steele J.G., Sheiham A., et al; Oral health
geriatric component in undergraduate and and nutrition in older people, J Public Health Dent.
postgraduate curricula; initiation of a diploma, 2000; 60:304–307.
certificate and degree courses in geriatric dentistry; 10. United Nations Population Division. World
research on various aspects of ageing and Population Prospects: The 2002 Revision, New York,
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diseases to the elderly.2 health problems and significant weight loss among
community-dwelling older adults, J Gerontol A Biol
CONCLUSION Sci Med Sci. 2000;55: 366–371.
12. Smith J.M., Sheiham A.; How dental conditions
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countries. This, along with an increase in the
13. Shlossman M., Knowler W.C., Pettitt D.J., etal; Type
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diseases, will significantly challenge health and 1990; 121:532–536.
social policy planners. The WHO Oral Health
14. Joshipura K.J., Rimm E.B., Douglass C.W., etal; Poor
Programme encourages public health care
oral health and coronary heart disease, J Dent Res.
administrators and decision-makers to design 1996; 75:1631–1636.
effective and affordable strategies and programmes
15. Scannapieco F.; Role of oral bacteria in respiratory
for better oral health and quality of life of the
infection, J Periodontol. 1999; 70:793–802.
elderly, which are integrated into general health
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disease control, health promotion and quality of Periodontal disease, tooth loss, and incidence of
ischemic stroke,Stroke.2003;34:47–52.
life improvement should be initiated and evaluated
systematically. 17. Papas A., Herman J., Palmer C.,etal ;Oral Health
Status of the Elderly,With Dietary and Nutritional
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994
Various Methods of Gingival Pigmentation: A Case Report

Dr. Parvati Malhotra1, Dr. K. Padmavathi2, Dr. Abhishek Kandwal3
ABSTRACT
Hyperpigmentation of gingiva is caused by excessive melanin deposition by melanocytes mainly located
in the basal and supra basal cell layers of epithelium. So various methods like scalpel method, abrasive
method and electrocautery have been introduced to remove the epithelium.
Keywords: Melanocytes, Hyperpigmentation
INTRODUCTION A free gingival graft can also be used to

eliminate the pigmentation. It requires an
Melanin pigmentation plays a vital role in the additional surgical site (donor site) and color
esthetics of smile. Normal color of gingiva in matching.20 Furthermore, the presence of a
Indians is pale pink along with melanin demarcated line commonly observed around the
pigmentation. Though melanin concentration is graft in the recipient site may itself pose an
genetically determined, Melanin pigmentation may esthetic problem. Removing the gingival margin
be physiological or pathological. Excessive by gingivectomy or the entire attached gingiva by
melanin deposition either physiological or “push back” procedure may also be used.
pathological is called hyperpigmentation. Systemic However, these procedures are associated with
conditions such as endocrine disturbances, alveolar bone loss, prolonged healing by secondary
Albright’s syndrome, malignant melanoma, intention, and excessive pain and discomfort
antimalarial therapy, Peutz Jeghers syndrome, caused by exposure and denudation of the
trauma, hemochromatosis, chronic pulmonary underlying bone.
disease, and racial pigmentation are known causes
of oral melanin pigmentation. High levels of oral MATERIALS and METHODS.
melanin pigmentation are normally observed in
individuals of Africa, East Asian, or Hispanic 10 patients from the outpatient department of
ethnicity. In general, Individuals with fair skin will periodontology, Institute of dental sciences;
not demonstrate overt tissue pigmentation, bareilly with generalized melanin pigmentation
although comparable numbers of melanocytes are were selected. Patients with esthetic requirements,
present within their gingival epithelium. high lip line, gummy smile, young age 17-35 was
enrolled. Patients with cardiac pace makers, age
Hyperpigmented gingiva may cause esthetic greater than 35, systemic diseases and unwilling to
problems and low self esteem, specially if the participate were excluded from the study.
pigmentations are visible during speech and smile.
After oral prophylaxis following three
Demand for cosmetic therapy of gingival treatment options were allotted randomly to every
melanin pigmentation is common and various patient quadrant wise.
methods including gingivectomy, gingivoplasty Option A: scalpel method
and gingivectomy with free gingival autograft,
electrosurgery, cryosurgery, chemical agents such Option B: abrasive method
as 90% phenol and 95% alcohol, abrasion with Option C: electrocautery.
diamond bur, Nd:Yag laser, semiconductor diode
laser and CO2 laser have been used for this Surgical method: Incision was placed
purpose. around the periphery of pigmentation and split
thickness flap was reflected, and the layer of
The laser and cryosurgical treatment epithelium along with some connective tissue was
modalities achieved satisfactory results, but they removed. Care was taken not to extend incision
required sophisticated equipment that is not beyond mucogingival junction and close to
commonly available in hospitals and clinics. underlying bone.
1,2
Professor, 3PG Student, Dept. of Periodontics, Mytri Dental College, Durg.
995
Abrasive method: abrasive diamond points were grounding was done and patient was told to
used to abrade the gingival epithelium and expose remove any metal jewellery. Medical history
the underlying connective tissue. Care was taken regarding cardiac pacemaker was enquired and if
not to expose the underlying bone and copious positive were excluded from the study.
irrigation was used.
Patients were kept on recall at 7th day; 28th
Electrocautry: rhomboid shape loop was used to day, 3 months, 6th months, 12 months and 18
scrape the gingival epithelium; tip was moved in
a shaving motion. Current was set on cut mode, months. Gingival color, healing pattern, patient
with intensity of 4. It was ensured that proper discomfort, reoccurrence was noted at every recall.
RESULTS
Adverse
Treatment option Patient Healing Reoccurrence Reoccurrence Reoccurence
Intra-op-time outcome/bone
received comfort Pattern at 6 month at 12 month at 18 month
exposure
Scalpel method + +++ + +++ – + +
Electrocautry method ++ + +++ + + + ++
Abrasion method +++ ++ ++ ++ – + ++
Fig. 1. Preoperative Photograph (Right side) Fig. 2. Preoperative Photograph (Left side)
Fig. 3. Depigmentation with Scalpel Fig. 4. Depigmentation with bur
996
Fig. 5. Depigmentation with electrocautery Fig. 6. Post surgical photograph
Fig. 7. Postoperative photograph after 1 week Fig. 8. Postoperative photograph after 3 week
DISCUSSION however, are not widely accepted or popularly

used. In the cases reported here, a simple and
Melanin pigmentation often occurs in the effective method of depigmentation which does not
gingiva as a result of an abnormal or increased require any sophisticated instruments was used.
deposition of melanin. Brown or dark pigmentation The results were excellent and at 18 months
and discoloration of gingival tissue, whether of a
follow-up, there were no evidences of
physiologic or pathologic nature, can be caused by
repigmentation of the gingiva. Post surgical
a variety of local and systemic factors. This type
repigmentation of gingiva has been previously
of pigmentation is symmetric and persistent, and
reported.27 Repigmentation is described as
it does not alter normal architecture. This
spontaneous and has been attributed to the activity
pigmentation may be seen across all races and at
and migration of melanocytic cells from
any age, and has no gender predilection. 8 A
surrounding areas. Perlmutter and Tal22 have also
positive correlation between gingival pigmentation
reported gingival repigmentation that occurred
and the degree of pigmentation in the skin, seems,
seven years after removal of gingival tissues in one
however, evident. 25 Demand for treatment is
patient.
usually made for esthetic reasons. However, there
is not much information in the literature about the In present study, patients reported more
depigmentation of gingiva.26 Elimination of these comfort with abrasion technique followed by
melanotic areas through surgery and laser surgery, electrocaurtery and scalpel method. Time taken in
as well as by cryosurgical depigmentation through electrocautery was least followed by abrasion and
the use of a gas expansion system, has been scalpel method. Also reoccurance was higher for
reported. 7, 16 These treatment modalities, electrocautery and abrasion techniques.
997
CONCLUSION 4. Leston JM, Santos AA, Varela-Centelles PI, Garcia

JV, Romero MA, Villamor LP. Oral mucosa:
Among the various techniques described Variations from normalcy, Part II. Cutis 2002;
above, scalpel method provided best result for a 69(3):215-217.
period of 18 months. Scalpel is more efficient
5. Fry L, Almeyda JR. The incidence of buccal
method but require more training. On the contrary
pigmentation in caucasoids and negroids in Britain.
abrasion method is quick to learn, more patient
Br J Dermatol 1968; 80 (4):244-247.
friendly and time efficient. Electrocoutery is
technique sensitive, requires electrocautery unit, 6. Tamizi M, Taheri M. Treatment of severe physiologic
strict patient criteria and burning and charing of gingival pigmentation with free gingival autograft.
tissue odour is unpleasant experience for the Quintessence Int 1996; 27 (8):555-558.
patient. We thus suggest that abrasion method is 7. Esen E, Haytac MC, Oz IA, Erdogan O, Karsli ED.
more efficient, taking in consideration, time, Gingival melanin pigmentation and its treatment with
technique sensitivity, equipment, patient comfort the CO2 laser. Oral Surg Oral Med Oral Pathol Oral
and reoccurrence rate. Radiol Endod 2004; 98 (5):522-527.
8. Dummett CO, Sakumura JS, Barens G. The
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1. Dummett CO. Overview of normal oral
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59(3):13-18. 9. Hoexter DL. Periodontal aesthetics to enhance a
2. Martini FH, Timmons MJ. Human Anatomy. New smile. Dent Today 1999; 18 (5): 78-81.
Jersey: Prentice Hall Publishers Company, 1995. 10. Dello Russo NM. Esthetic use of a free gingival
3. Dummett CO. A classification of oral pigmentation. autograft to cover an amalgam tattoo: Report of case.
Mil Med 1962; 127:839- 840. J Am Dent Assoc 1981; 102 (3):334-335.
998
Prevalence of Malocclusion and its correlation with

Incidence of Caries and Periodontal Disease
Dr. Saravana Kumar S1, Dr. Anita V2, Dr. Divya Loganathan3, Dr. Shanmugam M4,
Dr. Shivakumar V5
ABSTRACT
Aim: To evaluate the prevalence of malocclusion associated incidence of dental caries, and level of
oral hygiene among students in the Chettinad Health City, Chennai.
Method of study: Dentofacial anomalies were assessed using the Dental Aesthetic Index (DAI)
among 600 students (306 girls, 294 boys), aged 17-22 years. The decayed, missing, and filled teeth (DMFT),
the decayed, missing, and filled surfaces (DMFS), Bleeding index (BI) , Marginal gingival index (MGI)
and Plaque index (PI) of the subjects were calculated.
Results: Orthodontic problems were detected in 72.7 per cent of the sample. Crowding and spacing
were observed in 18.3 and 15 per cent, respectively, with the latter being more prevalent in the maxilla
than in the mandible (16.4 and 3.2 per cent, respectively). A Class I occlusion was found in 68.6 per cent
of the subjects. DMFT, DMFS, BI, MGI and PI of the subjects with malocclusion were significantly higher
(P < 0.05) than those of the adolescents who displayed no anomalies.
Conclusion: There is an increased incidence of malocclusion which showed significant correlation
with incidence of dental caries as well as periodontal diseases.
Keywords: Dental aesthetic index (DAI), decayed, missing, and filled teeth (DMFT), the decayed,
missing, and filled surfaces (DMFS), Bleeding Index (BI) , Marginal gingival index (MGI) ,and Plaque
index (PI)
INTRODUCTION Oral examination was performed by two trained

and calibrated examiners. Dental mirror, probe,
Malocclusion is one of the most common
dental problems in mankind, together with dental and Community Periodontal Index probe were
caries, gingival disease, and dental fluorosis 1. A used to perform the study.10% of the students
malocclusion is defined as an irregularity of the were examined by each of the two investigators to
teeth or a malrelationship of the dental arches assess interexaminer reliability. There was good
beyond the range of what is accepted as normal2. agreement between the examinations by the same
Maloccluded teeth can cause psychosocial examiner. Presence, type, and severity of the
problems related to impaired dentofacial malocclusion were assessed using the Dental
aesthetics3, disturbances of oral function, such as Aesthetic Index (DAI) by Cons et al. (1986)7
mastication, swallowing, and speech, and greater Table 1.
susceptibility to trauma and periodontal disease4, 5,
6 Decayed, missing, and filled teeth (DMFT)
. A thorough knowledge of the distribution of
malocclusion and the identification of predisposing and decayed, missing, and filled surfaces (DMFS)
factors and associated conditions might help in index scores were defined in accordance with the
understanding its occurrence and assist public WHO (1977)8 directives. The BI was scored as
health policy makers improve interventions. Hence, described by Saxton 9 and van der Ouderaa upon
the aim of the present study was to assess the probing the buccal sulcus of the Ramfjord teeth
prevalence of malocclusion and its correlation with (upper right first molar, upper left central incisor,
incidence of dental caries and periodontal diseases.
upper left first premolar, lower left first molar,
lower right central incisor, lower right first
Subjects and methods
premolar) as described: 0 = absence of bleeding
600 students (306 girls, 294 boys) aged 17-22 after 30 seconds, 1 = bleeding observed after 30
years were selected from Chettinad health city. seconds, and 2 = immediate bleeding.10
1
Reader, Dept. of Orthodontics and Dentofacial Orthopedics, 2, 4Reader, Dept. of Periodontics, 3Lecturer, Dept. of
Orthodontics and Dentofacial Orthopedics, 5Professor and Head, Dept. of Periodontics, CDCRI, Chennai
999
Table 1. Dental Aesthetic index was found in 68.6 per cent (411 subjects). Incisor,
canine, and/or premolar teeth were missing in 11.2
Dental aesthetic index components Weights per cent (67 subjects). Data on crowding and
No. of missing incisor, canine, or premolar 6 spacing in the incisor segments are presented in
teeth in maxillary and mandibular arches Table 2. Crowding and spacing were observed in
Crowding in the incisal segments 1 nearly the same proportions 18.3 and 15 per cent,
(no. of segments crowded) respectively. Spacing, however, was more
prevalent in the maxilla than in the mandible (16.4
Space in the incisal segments 1
(no. of segments spaced)
and 3.2 per cent, respectively). Findings relating
to other occlusal traits are shown in Table 3.
Midline diastema in millimeters 3 Incidence of midline diastema was found to be 6.2
Largest anterior irregularity on the maxilla in 1 per cent. An association between malocclusion and
millimeters DMFT and DMFS scores is shown in Table 4.
Largest anterior irregularity on the mandible in 1 This was statistically higher in subjects with
millimeters malocclusion than in those without anomalies (P
Anterior – posterior molar relation: largest 3 < 0.05). The difference between the mean DMFT
deviation from normal either left or right, scores was highly statistically significant. The
0=normal, 1=1/2 cusp either mesial or distal, mean standard deviation for the DMFT scores in
2=one full cusp or more either mesial or distal the presence and absence of malocclusion ranged
Constant 13 between 8.6 (6.12) and 5.02 (5.34), respectively
Total DAI Score whereas the DMFS scores ranged between 13.62
(9.51) and 9.34 (8.22) respectively in presence and
The MGI was scored according to the gingival absence of malocclusion.
inflammation on the buccal marginal gingiva of Table 2. Prevalence of crowding and spacing in the incisor region
the Ramfjord teeth as follows: 0 = absence of
inflammation, 1 = mild inflammation (either Orthodontic anomaly
marginal or papillary gingival unit), 2 = mild Crowding Spacing
inflammation (entire marginal and papillary
gingival unit), 3 = moderate inflammation and 4 n % n %
= severe inflammation. No 491 81.7 510 85.0
The PI was scored according to the Turesky Yes 109 18.3 90 15
modification on the Quigley-Hein11 on the buccal One segment 61 10.2 72 12
surface of Ramfjord teeth as described: 0 = no Two segments 48 8.1 18 3
plaque; 1 = discontinuous band of plaque at the
gingival margin; 2 = up to 1 mm continuous band Table 3. Prevalence of occlusal traits
of plaque at the gingival margin; 3 = band of
plaque wider than 1 mm but less than one-third Orthodontic anomaly Number Frequency %
of the surface; 4 = plaque covering one-third or Midline Diastema 37 6.2
more of the surface, but less than two-thirds of the Largest anterior maxillary 351 58.6
surface; and 5 = plaque covering two-thirds or irregularity
more of the surface. One measurement for each
Largest anterior mandibular 251 41.8
tooth was scored for all categories. irregularity
Data processing and statistical analysis were
undertaken using the Statistical Packages for The correlation between severity of
Social Sciences (SPSS, Chicago, Illinois, USA) malocclusion and the periodontal status is
version 10.0. The Student’s t-test, Pearson and explained in Table 5. All the three periodontal
Spearman correlation coefficients, and analysis of index showed increasing values for increase in the
variance were carried out. Chi- square test was severity of malocclusion.
used for comparison of severity of malocclusion.
DISCUSSION
RESULTS
In the present study, none of the subjects had
Orthodontic anomalies were found in 72.7 per received orthodontic treatment, either by
cent (436) of the 600 students. A Class I occlusion interceptive or by corrective measures. Studies by
1000
Table 4. Association between caries and malocclusion
DAI Scores Severity Levels Percentage DMFT Mean ± SD DMFS Mean ± SD

< 25 Minor or no anomaly (no or slight treatment need) 11 4.02 (5.34) 8.34 (8.22)
26-30 Definite malocclusion ( treatment elective) 26 5.4 (5.6) 9.54 (7.45)
31-35 Severe Malocclusion (treatment highly desirable) 38 6.7 (4.8) 12.21 (8.67)
>36 Handicapping malocclusion (Treatment mandatory) 25 8.6 (6.12) 13.62 (9.51)
Table 5. Association between periodontal disease and malocclusion
DAI Scores Severity Levels BI Mean ± SD MGI Mean ± SD PI Mean ± SD

< 25 Minor or no anomaly (no or slight treatment need) 0.46 (0.26) 0.84 (0.15) 0.92(0.60)
26-30 Definite malocclusion ( treatment elective) 1.08 (0.37) 1.95 (1.07) 1.76(0.93)
31-35 Severe Malocclusion (treatment highly desirable) 1.46 (0.40) 2.42 (0.67) 2.17(1.14)
>36 Handicapping malocclusion (Treatment mandatory) 1.71 (0.32) 2.73 (0.98) 3.21(1.08)
Thilander concerning the prevalence of difference existed among males and females in any
malocclusion suggest the material should be type of Malocclusion. This correlates with the
obtained from a well-defined population and be findings of this study which reported 68.6 % cases
large enough and cover non-orthodontically treated of class I malocclusion. By examining the
subjects 12. The clinical registrations were based relationship between malocclusions, dental caries
on the method evolved by Björk et al. and periodontal condition using multiple logistic
(1964)13 with some modifications by al-Emran et regression analysis, it was possible to compare the
al.14(1990). Björk’s method has been used in many strength of the influence from each. Subjects with
studies and allows objective comparisons of the caries experience (DMFT > 0) were almost two
presence of malocclusion between different times more likely to have any type of
populations. However, comparisons of the present malocclusion (sum score of malocclusion > 0)
findings with those of other studies must be compared with their counterparts without caries
cautiously undertaken because different methods experience (DMFT?=?0). Further these subjects
and indices have been applied in varying age showed increased incidence of midline shift. This
ranges of populations15. Moreover, no radiographs correlates with similar studies done in
or study casts were used in the present adolescents23, 24, 25.
investigation. The probability of having under- or A malocclusion was observed in 89 per cent
overestimated some prevalence estimates such as of subjects in the current investigation. This is
agenesis, supernumerary teeth, the accuracy of higher than the figures reported by other studies26,
27
space analysis as well as some details on the . However; the difference may be explained by
deviations of tooth positions cannot be overlooked. the use of a more detailed questionnaire in the
It has been shown that records made on the basis present survey. Thus, direct comparison with the
of casts seem to give a higher prevalence of current findings cannot be made.
deviations than direct recording16 .Nevertheless,
given the sample size and the selection criteria Significant association was found between the
used in this study, the findings provide a severity of malocclusion and BI, MGI and PI. The
reasonably accurate indication of the occurrence of gingival and periodontal scores in subjects with
malocclusion in 17-22 age group. malocclusion were poorer than those without any
malocclusion. The scores in these indexes showed
A number of studies have been conducted to progressive increase with increase in severity of
determine the prevalence of malocclusion among malocclusion. The present results are similar to
Indians17, 18, 19,20,21,22. Singh et al17 found that Class finding reposted in various studies 28, 29,30. While
I malocclusion is most common and was reported direct comparison with other studies is difficult to
in 70.88% of the students followed by Class II in undertake as a result of differences in the age of
27.02% of the cases with Class II Div. I reported subjects assessed, the findings of the present
in 11.23% and Class III cases constituted just survey remain significant in providing the first
2.10% of the sample. It was also found that no data on the orthodontic status of 17- to 22-year
1001
old Indian young adults, and at the same time, on developing gingivitis. J Periodontal Res 1989.
reflecting the need for orthodontic treatment in this 24:75–80.
population. 10. Eser Tufekci, Zachary A. Casagrande, Steven J.
Lindauer, Chad E. Fowler, and Kelly T. Williams
CONCLUSIONS (2008) Effectiveness of an Essential Oil Mouthrinse
in Improving Oral Health in Orthodontic Patients.
A high proportion (89 per cent) of students The Angle Orthodontist: March 2008, Vol. 78, No. 2,
displayed orthodontic anomalies according to DAI. pp. 294-298.
A statistically significant association was observed 11. Quigley, G. and J. W. Hein. Comparative cleansing
between the presence of malocclusion, caries efficiency of manual and power brushing. J Am Dent
experience, and periodontal condition (P < 0.05). Assoc 1962. 65:26–29.
12. Thilander B, Pena L, Infante C, Parada SS, de
The DAI appears to be the easiest to use but Mayorga C. Prevalence of malocclusion and
it has inherent disadvantages as it does not take orthodontic treatment need in children and
into account buccal cross bite, posterior openbite, adolescents in Bogota, Colombia. An epidemiological
central line discrepancies or a deep overbite, these study related to different stages of dental
factors may have considerable impact on treatment development. Eur Journal of Orthodontics 2001; 23:
complexity and therefore weakens the index. 153-167.
Malocclusion is not only a single entity but rather 13. Björk A, Krebs Å, Solow B. A method for
an analogy of situations each in itself constituting epidemiological registration of malocclusion. Acta
a problem and any of the situations are Odontologica Scandinavica 1964; 22:27-41.
complicated by a multiplicity of genetic and 14. Al-Emran S, Wisth PJ, Bøe OE. Prevalence of
environmental causes. Further more emphasis malocclusion and need for orthodontic treatment in
should be given on proper preventive and Saudi Arabia. Community Dentistry and Oral
interceptive orthodontic services to the affected Epidemiology 1990; 18:253-255.
group. 15. Abu Alhaija ES, Al - Khateeb SN, Al -
Nimri KS. Prevalence of malocclusion in 13–15 year
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1003
Non Invasive Esthetic management of Congenitally

Missing Central Incisor tooth using a Condition Specific
Custom Made Matrix
Dr. Shanmugam Jaikailash1, Dr. Mahendran Kavitha2, Dr. Disha Thareja3
ABSTRACT
This is a clinical case of direct resin restoration build up of two well-developed conical supernumerary
teeth in place of one maxillary central incisor using a custom made transparent matrix to achieve predictable
aesthetics eliminating the difficulties in layering technique. The purpose of this article is to report the
possible economical alternative for the esthetic management of dental anomalies.
Keywords: supernumerary teeth, direct flame technique, custom made matrix, direct composite,
esthetic correction.
INTRODUCTION these presented by the patient. Her medical history

was uneventful.
Dentistry by itself has evolved from crude
ways of treating pain to a day now where finer On extraoral clinical examination, no abnormal
procedure are done for complete makeover of the findings were present.
patients.
On intraoral clinical examination it was
This case proposes an aesthetic arch correction revealed that the patient has two conical shaped
by a simplified direct composite build up using a teeth in place of maxillary right cental incisor
customised transparent matrix. which was missing. The contralateral central
incisor was normal, and there was no evidence of
CASE ILLUSTRATION any other supernumerary teeth in the oral cavity.
Generalized spacing was seen among upper and
A 17 year old female presented with a primary
lower anterior teeth, with loss of midline.
complaint of not able to smile due to conical
shaped upper front teeth to our hospital. (Figure Intraoral periapical radiographic examination
1) revealed two conical shaped teeth with equal
length of well formed roots, which replaced
The patient was asked about the presence of
maxillary right central incisor. The panoramic
similar anomalies in other family members, but
radiographic examination revealed a complete
reported no one in the family had teeth resembling
dentition with no evidence of maxillary right
central incisor (Figure 2).
Fig. 2. OPG showing no evidence of right maxillary central

Fig. 1. Preoperative
incisor
1
Professor, 2Professor and Head, 3PG Student, Dept. of Conservative Dentistry and Endodontics, Tamilnadu Government
Dental College, Chennai
1004
The diagnosis was aimed at congenitally The custom made matrix try in was done to
missing maxillary right central incisor replaced check the adaptation. The shade selection was
with two conical shaped well developed done using vita shade guide. The teeth isolation
supernumerary teeth. was done using cotton rolls and suction. Etching
(N-Etch, 37% phosphoric acid, ivoclar vivadent )
PROCEDURE and bonding (tetric N bond, ivoclar vivadent)
procedure was done. The inner surface of the
Upper and lower arch impressions were made
matrix was loaded with the hybrid composite (Te
and diagnostic models were prepared .
– econom plus, ivoclar vivadent), the matrix with
Model analysis was done to verify occlusion composite was inserted to the prepared teeth
and midline shift was present. Esthetic correction (Figure 5), initial light polymerisation was done
of the models were done using modelling wax, through the matrix for 20 seconds on all surfaces.
taking care of contacts and contours (Figure 3).
Fig. 5. Matrix loaded with composite

Fig. 3. Waxed up models
The matrix was removed and cervical excess
The waxed up model was duplicated and was composite was removed using a BP blade, and
used for the fabrication of transparent matrix curing was repeated for another 40 seconds.
(Figure 4).
The composite restorations were trimmed
using finishing burs and polished using soflex
discs (3M ESPE) (Figure 6, 7, 8).
Fig. 4. Duplicated model with custom made matrix
The matrix material selected was the flexible

Fig. 6. After finishing and polishing
soft splint sheet (Ultradent) of 2 mm thickness,
this sheet was adapted over the duplicated model The patient has been followed up for 6 months
periodically and is being followed up continuously.
using direct flame, trimmed using BP blade, the
extent of the matrix was from left lateral incisor
to the right canine. Vents were placed on the DISCUSSION
lingual surface of the matrix, for venting of the Diagnosis of a supernumerary tooth is based
excess material and to prevent voids. on the history of the patient, thorough clinical and
1005
soft set and final polymerisation could be achieved

with the removal of the matrix.
Total etching and bonding without any tooth
structure removal gives superior bonding, since
most researchers in this area agree that the prism
orientation is important to the retention of
restorative materials. (3) Direct placement of
composite is a laborious process particularly for
multiple teeth. Simpler techniques using matrix
have been advocated to make the procedure less
technique sensitive (4). “The direct flame technique
has been followed here to fabricate the custom
matrix, which is simple, economical and can be
Fig. 7. Postoperative arch form done by any clinician at chairside”. Use of matrix
in placing composite simplifies the chair side
treatment procedure.
CONCLUSION
To simplify direct composite placement, this
innovative simplified customized matrix for
individual patients can be made which is less
technique sensitive, economical and provides
greater opportunity and freedom to deliver
optimized esthetic goals.
REFERENCES
1. Srivatsan P. Mesiodens with an unusual morphology
Fig. 8. Pre-operative and postoperative and multiple impacted supernumerary teeth in a
non-syndromic patient. Indian Journal of Dental
radiological examination. (1, 2) According to Muller Research 2010; 18:138
De van “our objective should be the perpetual 2. Shah A, Gill D, Tredwin C, Naini F. Diagnosis and
preservation of what remains than the meticulous management of supernumerary teeth. Dent Update
restoration of what is missing” and hence the 2008;510-2
option to do esthetic correction by direct 3. Michael G Buonocore. Symposium on composite
resins in dentistry. Dent Clin N Am. 1981:241-55.
composite was decided. To simplify arch
4. Suhas Mohan Lal, S Jagadish Direct composite
correction procedure the custom matrix was made,
veneering technique producing a smile design with a
the sheet was used for its minimal thickness and customised matrix. Journal of conservative dentistry
transparency to pass light which helps in the initial 2006; 87-92.
1006
Comparision of Effectiveness of Mini Implants vs

Conventional Implant supported Overdentures
- A Review of Literature
Dr Ashish Choudhary1, Dr. Ekta Choudhary2, Dr. Jay Vikram3, Dr. Dipanjit Singh4,
Dr. Kuldeep5
ABSTRACT
Treating edentulous patient itself require good understanding of dynamics of oral soft and hard tissues
& peri-oral musculatures; good clinical skills and challenge to meet high expectations of the patient. All
this adds to nightmare of the treating clinicians if the residual ridge resorption is excessive, which is a
common scenario in the case of mandibular jaw. Poor foundation provides poor stability and support. All
this and age related limitations involved in doing surgical interventions can be very well overcome by
using small diameter implants. Here, a review of comparison of effectiveness of mini implants and
conventional implant supported over-dentures is presented to understand the clinical implication of this
implant therapy for compromised conditions.
Key words: Small diameter implants (SDI), Mini diameter implants (MDI), Mandibular over-denture,
Ball retained denture, Bar retained denture
INTRODUCTION Likewise, standard or conventional implants are

those implants larger than 3mm in diameter, but
With the improvement in public oral health
most commonly 4-5 mm. Currently, mini dental
care decrease in number of edentulous patients can
implants have a diameter of 1.8 mm to 2.9 mm
be anticipated but these reductions will not keep
and are offered in various lengths. It is important
in pace with the anticipated increase in the elderly
to note that the pull out strength of an implant has
population1. Moreover, because of the deferment
been shown to be based on its length rather than
of edentulousness to older age and additional life
its diameter2.The prosthetic head allows the dental
expectancy for those over 75 yeas of age, dentists
prosthesis to connect to the implant and anchor it
are facing a different challenge to satisfy
to the bone.
older-elderly denture wearers with a higher
prevalence of chronic disease. Few remaining It also connects to the implant driver during
periodontally compromised teeth or edentulous placement. Square, rectangular, or o-ball heads are
cases, especially with severely resorbed alveolar common and connect easily to a simple set of
ridges, require special approach in order to achieve corresponding drivers. Fixed crowns and bridges
good long-term clinical results. Traditionally the can be cemented directly to the square or cubic
vast majority of problems arise with a mandibular head of the mini. Subsequently, a sphere was
prothesis, as due to the anatomy of the mandible milled into the square portion of the head allowing
often they fail to provide adequate support, for a more elegant restorative solution. This
retention and stability. ‘o-ball’ design became a popular solution to secure
loose dentures. Other standard prosthetic options
Dental implants may be split into two separate
for removable and fixed solutions do exist and
categories based on the diameter of the device.
custom options are available from various dental
Small diameter dental implants, most often
labs. (figure 1)
referred to as ‘Mini Implants’, are those with a
diameter less than three millimeters (3 mm).
1
Professor, 3Associate Professor, 5Assistant Professor, Dept. of Prosthodontics, 2Professor, Dept. of Conservative and
Endodontics, School of Dental Sciences, Sharda University, Greater Noida. 4Professor and Head, Dept. of Prosthodontics,
Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh.
1007
Brazilian dental academic, Professor Amadeo

Bobbio studied the mandibular specimen and took
a series of radiographs. He noted compact bone
formation around two of the implants which led
him to conclude that the implants were placed
during life.
Although Brånemark had originally considered
that the first work should centre on knee and hip
surgery, he finally decided that the mouth was
more accessible for continued clinical observations
and the high rate of edentulism in the general
population offered more subjects for widespread
study. He termed the clinically observed adherence
of bone with titanium as ‘Osseo integration’. In
1965 Brånemark, who was by then the Professor
of Anatomy at Gothenburg University in Sweden,
placed his first titanium dental implant into a
human volunteer.
COMPARISON AND CLINICAL APPLICATION

Mini dental implants are extremely valuable
for endentulous patients that have loose lower
dentures and want an easy solution to secure them
in place3.Most denture patients have highly
resorbed jawbones (Mandible and/or maxillary
bones) and bone augmentation, aka bone graft, is
required for a standard dental implant solution.
Moreover, health status of many senior citizens
contraindicates invasive dental treatment, such as
a conventional implant. In contrast to conventional
implants, a survey of 200 clinicians indicated that
Fig. 1: Mini implant with ball head and ‘O’-ring. a flap procedure was mostly (80% of the time)
unnecessary for placing MDI’s4.
HISTORY
Mini dental implants are placed in a flapless
The Maya civilization has been shown to have and minimally invasive procedure under local
used the earliest known examples of endosseous anesthetic3,4. This is in sharp contrast to
implants (implants embedded into bone), dating
conventional implants, which are often placed in a
back over 1,350 years before Per-Ingvar
Brånemark started working with titanium. While procedure requiring a flap, bone graft, and/or
excavating Maya burial sites in Honduras in 1931, significant healing time5. In the United States,
archaeologists found a fragment of mandible of using mini dental implants to secure a lower full
Maya origin, dating from about 600 AD. This denture is a generally accepted indication. A
mandible, which is considered to be that of a number of mini dental implants are placed in the
woman in her twenties, had three tooth-shaped mandible and these implants will be used to secure
pieces of shell placed into the sockets of three
the denture (as opposed to adhesive materials or
missing lower incisor teeth. For forty years the
archaeological world considered that these shells other methods of stabilizing the denture). For most
were placed after death in a manner also observed types of mini dental implants, a small hole will
in the ancient Egyptians. However, in 1970, a need to be drilled before inserting the implant.
1008
Difference between Mini Implant analogues representing the implant abutment heads
Overdenture and Conventional Implant protrude from the cast. The dentist places metal
supported Over dentures housings containing rubber O-rings on the
analogue heads and processes the denture to retain
This is very similar to the normal sized over the housings and O-rings. He or she adjusts the
dentures, the only difference being that mini dental denture in the usual manner, evaluating fit,
implants are used instead. Mini implants are pressure spots, occlusion and esthetics and then
cheaper than the standard sized ones and easier to making any necessary corrections. The dentist or
insert but have usually been seen as a temporary dental hygienist will need to replace the rubber
measure. But, they have proved to be useful in O-rings periodically, as they lose their ability to
situations where patients don’t want the full retain the denture in place during service. This
implant, are unable to pay for a full implant or concept is the one used most commonly for SDIs
just need something to secure a loose denture. in patients with edentulous mandibles (Imtec
There are still ongoing discussions about mini manufactures a well-known brand).11,12,13
implants as compared to the normal, full sized
implants. Some sources view them as a suitable An implant-supported denture is a type of over
form of treatment if there are no other choices, or denture that is supported by and attached to
if normal implants are not an option. Other sources implants. A regular denture rests on the gums, and
see them as providing a good, solid foundation for is not supported by implants. An
bridges, crowns and over dentures. When there is implant-supported denture is used when a person
minimal bone, Mini dental implants can also be doesn’t have any teeth in the jaw, but has enough
used to retain the denture. bone in the jaw to support implants. An
implant-supported denture has special attachments
Essential condition for all implants use, that snap onto attachments on the implants.
therefore also MDIs, is successful osseointegration Implant-supported dentures usually are made for
that can be confirmed only with the long-term the lower jaw because regular dentures tend to be
studies of success and survival of MDIs under load less stable there. Usually, a regular denture made
in masticatory function. Shatkin et al6, in their to fit an upper jaw is quite stable on its own and
retrospective analysis over five years of 2514 doesn’t need the extra support offered by implants.
MDIs, which equally supported fixed and However, you can receive an implant-supported
removable prostheses, found the overall implant denture in either the upper or lower jaw.
survival rate of 94.2%. Initial stability is important
for the successful osseointegration and high There are two types of implant-supported
implant success rate. It is stipulated with bone dentures: bar-retained and ball-retained. In both
quality, implant design, and surgical technique that cases, the denture will be made of an acrylic base
is used7. Some authors8,9 recommend bone drilling that will look like gums. Porcelain or acrylic teeth
to the depth of only 1/3 of MDI’s length. that look like natural teeth are attached to the base.
Both types of dentures need at least two implants
Rubber O-ring denture retention using SDIs
for support.
In this treatment, the dentist places four to six • Bar-retained dentures — A thin metal bar
SDIs, usually ranging from 1.8 to 2.9 mm in that follows the curve of your jaw is attached
diameter, as parallel to each other as possible and
anterior to the mental foramen. Small spheres on
the coronal portions of the implants are projections
of the implant body extending a few millimeters
from the gingival tissues into the oral cavity. A
standard mandibular denture impression, made in
a custom-fitted tray or in the patient’s existing
denture, includes the implants, the residual
mandibular ridges and the border-molded oral
mucous membranes. The laboratory technician
places analogues into the wells made by the
implants in the impression and pours the
impression in the usual manner. When the
Fig. 2 (a): Mini implants in mandibular arch
impression is separated from the stone cast, the
1009
to two to five implants that have been placed Study of Balkin et al.10, in which they used
in your jawbone. Clips or other types of histological analysis, revealed that the quality of
attachments are fitted to the bar, the denture MDIs osseointegration could be compared with the
or both. The denture fits over the bar and is quality of larger diameter implants
securely clipped into place by the attachments. osseointegration. Ertugrul et al.7, in their in vitro
study, revealed that implants of larger diameter are
more stable under lateral forces than MDIs. But it
is logical, because of their almost doubly bigger
surface area. In clinical practice, this disadvantage
of MDIs can be solved with successful planning
and using more implants10.
The conclusions of the consensus

For more than 100 years, maxillary and
mandibular complete dentures have been the
standard treatments for complete edentulous
patients. If the majority of patients can tolerate the
Fig. 2 (b): Mini implants connected with metal bar maxillary prosthesis, the situation is different for
the mandibular prosthesis. The instability and
• Ball-retained dentures (stud-attachment discomfort it causes to patients represents the
dentures) — Each implant in the jawbone starting point in establishing the two–implant
holds a metal attachment that fits into another overdenture as the primary alternative treatment
attachment on the denture. In most cases, the for patients with complete edentulous mandible.
attachments on the implants are ball-shaped
(“male” attachments), and they fit into sockets Regarding the applicability of implantology, it
(“female” attachments) on the denture. In is well known through the numerous publications
some cases, the denture holds the male on longitudinal studies14 that the success rate of
attachments and the implants hold the female implants placed in the anterior mandible is very
ones. high and with minimal clinical impediments. In
addition, the positive effect of implants on the
mandibular ridge resorption has also been
scientifically proven15,16 .
The prosthesis on implants has numerous
advantages such as better balance, increased
functional efficiency, safer mastication, diminished
ridge resorption, improved aesthetics, and
especially eliminates the fear of detachment in
speech or mastication (unpleasant aspects,
particularly in situations when patients are in the
company of others). The implants are strong,
durable, and prevent a number of oral
modifications and prosthetic shortcomings.
Fig. 3 (a): Mini implants in maxillary arch
It should, however, be indicated that the
implant overdenture treatment is more complex
than the conventional prosthesis, and requires at
least two distinct phases: surgical and prosthetic,
both of them having risks, high costs, and
consequences on the final outcome of the
treatment.
Overdenture on implants, is definitely an
alternative to conventional denture, with
Fig. 3 (b): Mini implants in mandibular arch undeniable benefits, but it is not a risk–free
process. Although patient selection criteria are
1010
clearly stated in terms of medical practice, they analysis of 2514 implants placed over a five-year
must be adapted for each particular clinical period. Compend Contin Educ Dent. 2007;28(2):92-9.
situation, the practice often providing a challenge, 7. Ertugrul HZ, Pipko DJ. Measuring mobility of 2
and the selection being made based on dental implant fixtures of different configurations: an
non–medical criteria. The dental practitioner may in vitro study. Implant Dent. 2006;15(3):290-7.
also struggle with myths and false beliefs. Last but 8. Dilek OC, Tezulas E. Treatment of a narrow, single
not least, the responsibility and reputation of the tooth edentulous area with mini-dental implants: a
dental practitioner whose career is built as a clinical report. Oral Surg Oral Med Oral Pathol Oral
‘domino’ is important, any failure having negative Radiol Endod. 2007;103(2):e22-5.
consequences on the ‘domino construction’ and 9. Dilek OC, Tezulas E, Dincel M. A mini dental
every success being a new piece that builds the implant-supported obturator application in a patient
‘domino’.17 with partial maxillectomy due to tumor: case report.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2007;103(3):e6-10.
DISCLAMIER
10. Balkin BE, Steflik DE, Naval F.Mini-dental implant
The Photographs shown in the above article insertion with the auto-advance technique for ongoing
are courtesy Joe Gillespie “The Unique Benefits applications JOral Implantol.2001;27(1):32-7.
of mini dental Implants” volume 6 issue 9 11. CRA Foundation. Small diameter “mini” implants:
user status report. CRA Found Newsletter
REFERENCES 2007;31(11):1–2.
1. Douglass CW, Shih A, Ostry L. Will there be a need 12. Christensen GJ. The ‘mini’ implant has arrived.
for complete dentures in the United States in 2020? JADA 2006;137(3):387–390.
J Prosthet Dent 2002; 87(1):5-8. 13. Gillespie J The Unique benefits of Mini dental
2. Block, MS; Delgado A, Fontenot MG (1990). “The implants. Inside dentistry 2010:6(9)
effect of diameter and length of hydroxyapatite-coated 14. Bergendal T, Engquist B. Implant–Supported
dental implants on ultimate pullout force in dog Overdentures: A Longitudinal Prospective Study. Int
alveolar bone”. Journal Oral Maxillofac Surgery 48: J Oral Maxillofac Implants. 1998;13:253–262.
174–178.
15. Awad MA, Lund JP, Dufresne E, Feine JS.
3. Shatkin, TE; Shatkin S, Oppenheimer BD, Comparing the Efficacy of Mandibular
Oppenheimer AJ (2007). “Mini dental implants for Implant–Retained Overdentures and Conventional
long term fixed and removable prosthetics: A Dentures Among Middle–Aged Edentulous Patients:
retrospective analysis of 2514 implants placed over a Satisfaction and Functional Assessment. Int J
five year period”. Compendium 28: 36–41. Prosthodont. 2003;16:117–122.
4. Christensen, GJ (2008). “Mini implants: Good or bad 16. Thomason JM. The McGill Consensus Statement on
for long term service?”. J Esthetic Dentistry 20: Overdentures. Mandibular Two–Implant Overdentures
343–348. as First Choice Standard of Care for Edentulous
5. Sendax, VI (1996). “Mini-implants as adjuncts for Patients. Eur J Prosthodont Restor Dent.
transitional prostheses”. Dental Implantol Update 7: 2002;10(3):95–97
12–15. 17. Melescanu–Imre M, Preoteasa E, Buzea MC,
6. Shatkin TE, Shatkin S, Oppenheimer BD, Preoteasa CT. Supraprotezarea pe implante–piesa unui
Oppenheimer AJ. Mini dental implants for long-term domino etic. Revista Romana de Bioetica.
fixed and removable prosthetics: a retrospective 2009;7(4):62–67.
1011
Oral Health Status of Children with Cardiac Disease and

the Awareness, Attitude and Knowledge of their Parents
Dr. Madhavan. V1, Dr. M. Jayanthi2, Dr. Elizabeth Joseph3, Dr. D.Senthil4
ABSTRACT
Aim: The purpose of the study was to evaluate the oral health status of children with cardiac disease
awareness, attitude and knowledge of their parents.
Materials and Methods: This cross sectional study was carried out on children with cardiac disease
between 3-12 years with cardiac problems from the out patient wing of cardiology department at the
Institute of Child Health and Hospital for Children, Egmore, Chennai.
Results: The mean deft of 3-6 yrs of age was 3.6, mean deft of 6-12 yrs was 3.2 and mean DMFT
was 0.76. There was no statistical difference in caries experience between primary and mixed dentition
groups. It was found that 12.2% males and 20% had poor oral hygiene. . 85% of the parents were not
aware of the importance of maintaining oral health.
Conclusion: The study shows that the prevalence of dental caries was high (81.7%) among the
cardiac patients with the mean deft of 3.6 and mean DMFT of 0.76
INTRODUCTION All children at risk should be properly

instructed to establish and maintain best possible
The prevention of oral disease is the most oral health to reduce these potential sources of
desirable way of ensuring good dental health for bacteraemia.
children with cardiac disease. Oral cavity is a
natural source of many microorganism and The three main concerns when providing
alteration in oral health leads to changes in the eco dental care for patients with valvular heart disease
system where some of the organisms become • risk of infective endocarditis
pathogenic and move into the blood stream leading • risk of bleeding in anticoagulated patients
to septicaemia. Dental and gingival infections in
patients with cardiac disease may lead to several • risk of exacerbating any co existing heart
failure.
cardiac complications.1 Many situations in which
bacteraemia occur, may not be readily identifiable, When these patients present themselves to the
and other bacteraemia may occur spontaneously general dentist for routine care, the dentist should
and cannot logically be prevented.2,3 have the knowledge about implications of this
disease process and treatment approaches to treat
In children with complex heart disease, other the patients safely and effectively.
associated problems often appear that may
Considering all these aspects, the importance
jeopardize dental health. Many of these children
of evaluating the practice and oral health
have difficulties with nutrition during the first year conditions of children at risk for infective
of life. Vomiting is a common problem and to endocarditis was recognized, as was the need to
compensate for this they should be fed frequently discover the extent of their parental awareness.5
and night meals are often necessary to maintain This study was done to determine the oral health
energy intake at an acceptable level. In addition status of children and the parental knowledge on
some of the medicines for heart disease contain the importance of oral health in preventing cardiac
sucrose together with diuretics that can cause complications.
xerostomia. Infections often last for longer periods When these patients present themselves to the
than in normal children with an increased need for general dentist for routine care, the dentist should
feeding, sometimes at night when salivary have the knowledge about implications of this
protection is low.4 disease process and treatment approaches to treat
1
P.G. Student, 2Professor and Head, 3Professor, 4Senior Lecturer, Dept. of Pedodontics and Preventive Dentistry, Ragas
Dental College and Hospital, Uthandi, Chennai.
1012
the patients safely and effectively Considering all • Plastic containers

these aspects, the importance of evaluating the • Dettol
practice and oral health conditions of children at
risk for infective endocarditis was recognized, as • Soap
was the need to discover the extent of their • Cloth
parental awareness. This study was done to
• Tissue papers
determine the oral health status of children and the
parental knowledge on the importance of oral • Gauze
health in preventing cardiac complications.
METHODOLOGY
AIMS AND OBJECTIVES
The cross sectional study was carried out on
The aim of this study was children with cardiac disease between 3 to 12
• To assess the oral health status of children years of age to assess their oral health status. The
with cardiac problems. study was done by Department of Pedodontics and
Preventive Dentistry, Ragas Dental College,
• To determine their parental knowledge, Chennai in association with Institute Of Child
attitude and awareness about the cardiac Health and Hospital for Children, Egmore,
disease, importance of maintaining oral health Chennai
and importance of infective endocarditis
prophylaxis to prevent cardiac complications The protocol for this research was approved
by the ethical committee of Ragas Dental College
MATERIALS AND METHODS and the Institute of Child Health and Hospital for
Children, Egmore, Chennai.
This cross sectional study was carried out on
children with cardiac disease between 3-12 years A total of 300 children between the age of 3
of age to assess their oral health status. to 12 years of both the genders with cardiac
problems from the outpatient wing of the
A total of 300 children between the age of 3 cardiology department of the Institute of Child
to 12 years with cardiac problems from the Health and Hospital for Children, Egmore,
outpatient wing of cardiology department at the Chennai were included in the study
Institute of Child Health and Hospital for Children,
Egmore, Chennai were included in the study. The The survey was conducted between the months
inclusion and exclusion criteria are given below. of May 2010 and July 2010, following the
recommendations of WHO oral health assessment.
Inclusion criteria • An informed consent was obtained from each
The children who were included in the study parent.(Annexure)
were between 3 to 12 years of age with cardiac • All the children who participated in the study
complications and those at risk of infective were examined by a single person and the data
endocarditis. was recorded by another person.
The demographics of the patient, parent’s
Exclusion criteria monthly income, the familial history, medical
The children with any concomitant disease history, dental history and parental knowledge
apart from cardiac disease and those children who about the Childs cardiac disease were recorded
were not willing to participate in the survey were through a questionnaire.(annexure)
excluded from the study. The questionnaire aimed to obtain information
from parents of the children about parental
MATERIALS knowledge, attitudes and awareness about the
Oral examination was done as specified by cardiac disease, importance of oral health
WHO using the following instruments maintenance and importance of infective
endocarditis prophylaxis as a preventive factor for
• Mouth mirrors cardiac disease and their response was recorded.
• CPI probes Patients were examined with a mouth mirror,
• Tweezers CPI probe under daylight at the cardiology wing
1013
of the Institute of Child Health and Hospital for Of the 93.3% are those who brush once daily
Children, Egmore, Chennai. among which 81.1% are caries affected, 6.7% are
those who brush twice daily among which 90%
The determination of caries experience
are caries affected and no child brushes more than
(DMFT and deft) for permanent and primary teeth
twice daily.
was done following the World Health Organisation
(WHO) criteria.6 It was observed that in the 3-< 6 years age
Caries was recorded by visual examination and group, 87% of the parents were aware about their
by using a CPI probe. Caries was recorded as child’s cardiac problem and 13% of the parents
present when a lesion in a pit and fissure or on a were unaware of the cardiac problem
smooth tooth surface has an unmistakable cavity, In the 6-12 age group, 86.66% of the parents
undermined enamel or a detectably softened floor were aware of their child’s cardiac problem and
or wall. 13.33% of the parents were not aware.
The Simplified oral hygiene index was used
to evaluate the oral hygiene status of the patients. Only 15.83% of parents of the 3-< 6 age
group were aware of the importance of
For the primary dentition oral hygiene maintaining the oral health in the prevention of
assessment was done by the Green and Vermillion cardiac disease and 84.07% were not aware. In the
(OHI-S) index which is modified as done by 6-12 years age group about 16.66% were aware of
Miglani et al for this study.7 The substituted index the importance of maintaining oral health and
teeth were 83.33% were not aware of it.
55 51 65 Among the 3-< 6 age group, 17% of the
85 71 75 parents have taken their children to a dentist and
83% of them have never visited a dentist. In the
For the permanent teeth oral hygiene 6-12 years age group 6.7% have visited the dentist
assessment was done by Green and Vermillion and 93.3% have not visited the dentist.
(OHI-S) .The index teeth were Among the 3-< 6 age group, 93% of the
parents were not aware of the importance of
16 11 26
infective endocarditis prophylaxis, only 7% were
46 31 36 aware of it and in the 6-12 age group 93.3% of
parents were unaware of the importance of
All data from the dental examination and infective endocarditis prophylaxis and 6.7% were
answers to the question were analysed .The results aware.
were tabulated.
DISCUSSION
RESULTS
Children with cardiac disease require special
A total number of 300 children in the age care dentistry because of their susceptibility to
group of 3 to 12 years with cardiac disease were infective endocarditis. Families of children with
included in the study. serious heart diseases already face heavy demands
The Total males were 175(58.3%) and the due to medication, surgery, recurrent illness and
total females were 12(41.7%). occasional nutritional needs of their children.
The mean deft of 3-< 6 years age group was There is considerable pain and infection in the oral
3.6. cavity of children afflicted with recurrent problems
associated with the underlying cardiac problems.
The mean deft of 6-12 years was 3.2 and
mean DMFT was 0.76. The awareness for infective endocarditis is
very low in India, only 8% of parents were aware
There was no statistical difference in the caries and this non-awareness among the majority is due
experience between primary and mixed dentition to the illiteracy or ignorance among parents and
groups. P = 0.241 (NS) their low socioeconomic status.
It was found that, 33 males (12.2%) and 54 Similar findings were found in study done by
females (20%) had poor oral hygiene. Martinez and Knox et al.
There was no statistical difference between the It is essentially a challenge for dentists to
oral hygiene status of primary and mixed dentition provide dental care for pediatric patients, whose
groups P = 0.633 (NS) medical health can be hazardous as a result of poor
1014
dental health. Detailed knowledge of dental and is poor (85%) are caries affected and (27.5%) had
oral conditions of such children is essential when poor oral hygiene. The parental knowledge about
preventive care is to be directed effectively. the importance of maintaining good oral health
Oral examination was done as specified by (16%) and awareness of infective endocarditis
WHO under daylight with a mouth mirror, a CPI prophylaxis (7%) was poor. The oral health of
probe at a separate area in the outpatient wing of these children can be improved by educating both
cardiology department at the institute of child parents as well as children by conducting regular
health and research. There were 156 males (52%) awareness programs in cardiac and paediatric
and 114 females (38%) in 3 to 6 years age group wings of hospitals. The pedodontist and the dental
and 19 males (6.3%) and 11 females (3.7%) in team should join gynaecologists, cardiologists,
6-12 years age group. (Table 1) paediatricians, physicians and nutritionists in
In the present study, in the 3-< 6 age group , delivering the best possible care to children with
218(80.7%) were caries affected and 52(19.3%) special health care needs and increasing the
were caries free, the mean deft of 3-< 6 age group awareness among parents and patients about the
is 3.60.The present study results are in accordance importance of maintaining oral health in the
with the study done by Franco et al (mean deft prevention of cardiac complications
3.7) and Talebi et al (mean deft 3.93) and is
Table 1. Distribution of subjects according to age and sex
slightly higher than Da Silva’s findings (mean deft
2.91). 5,8,9 Age in years Males Females Total
The untreated component (93%) was more in 3-<6 years 156 (52%) 114 (38%) 270 (90%)
the present study, it requires more attention 6-12 years 19(6.3%) 11(3.7%) 30(10%)
because it can be a source of infection with Total 175 (58.3%) 125 (41.7%) 300
increased bacterial load.
In the study population 97.3% of children used Table 1 shows the age and sex distribution of
toothbrush among which 81.2% of children are the subjects, Among the 3-<6 years age group 52%
caries affected. were males and 38% were females. In the 6-12
years age group 6.3% were males and 3.7% were
In the present study, even though the oral
females.
hygiene practices are good, the caries incidence is
relatively high. The probable reasons for the Table 2. Distribution of subjects according to disease
results can be attributed to the multifactorial S.No. Diagnosis No.of.Individuals
etiology of dental caries which can be influenced
1. Atrial septal defect 87 (29%)
by factors like dietary habits, medication taken,
2. Ventricular septal defect 94(31.3%)
which may contain sugar component, the immune
status of the child and the parents who are usually 3. Persistent ductus arteriosus 53 (17.7%)
preoccupied with the child’s systemic condition, 4. Tetralogy of fallot 35 (11.7%)
hence there is a possibility of negligence of the 5. Atrioventricular sepatal defect 12 (4%)
oral health of the child. 6. Infective endocarditis 20 (7%)
In the present study 87% of parents are aware 7. Rhenumatic heart disease 3 (1%)
of the cardiac problem in children, 16% are aware 8. Acquried cardiac myopathy 2 (0.7%)
of the importance of maintaining oral health. These 9. Pyopericardium 5 (1.7%)
findings are similar to Rai K et al and Saunders 10. Constrictive pericarditis 7 (2.2%)
et al (85.3% of the parent were not aware of the
importance of maintaining oral hygiene).10,11 7% Table 2 shows the disease distribution 29% of
are aware of the importance of infective the children had atrial septal defect, about 31.3%
endocarditis prophylaxis. These findings are in of children had ventricular defect, 17.7% were
accordance with results of Nath et al (8%) and found to have persistent duc tus arterious, 11.7%
only 16% had atleast taken their children once to of children had tetralogy of fallot, 4% of the
a dentist.12 These findings are similar to DaSilva chldren had atrioventricular septal defect, 0.7% of
et al (14%). This can be due to their illiteracy and the children had infective endocardities. 1% of the
also most of the parents belong the low income children had rheumatic heart disease 0.7% of
groups as per records.5 children had acquired cardiac myopathy. 17% of
The present study findings indicate that the the children had pyopericardium. And 2.2% of
oral health status of children with cardiac disease children had constrictive pericarditis.
1015
Table 3. Caries Experience of children with cardiac disease
No.of Mean Mean

Age S ca cf deft DMFT d D e M f F P Value
Children deft DMFT
118 38 451 70 7
M 156 528 – 3.73 –
75.6% 24.4% 85.4% 13.21% 1.32%
3-<6
100 14 377 63 6
F 114 446 – 4.02 –
87.7% 12.3% 84.5% 14% 1.4%
Total 218 52 828 133 13
270 974 3.60 P = 0.241
80.7% 19.3% 85% 13.7% 1.3%
18 1 65 18 – 1 1 (NS)
M 19 66 19 3.47 1
94.7% 5.3% 98.5% 94.7% 1.5% 5.3
6-12
9 2 29 4 1
F 11 30 4 – – – 2.72 0.36
81.8% 18.2% 96.7% 100% 3.3%
27 3 94 22 1 1 1
Total 30 96 23 – 3.2 0.76
90% 10% 97.9% 95.7% 1.05% 1.05% 4.3%
Primary Vs Mixed P = 0.241(NS) ca – caries affected; ef – caries free

• In 3-<6 years age group - 75.6% of males and 87.7% of females were caries affected, 24.4% of males
and 12.3% of females were caries free.
The mean deft of 3-<6 years age group was 3.6
• In 6-12 years age group - 8\94.7%of males and 81.8% of females ere caries affected, 5.3% of males
and 18.2% of females were caries free.
The mean deft of 6-12 years age group as -2 and mean DMFT was 0.76
• There was no statistical difference in the caries experience between primary and mixed dentition groups
P = 0.241 (NS)
Table 4. Oral Hygiene status of children with cardiac disease There was no statistical difference between the
oral hygiene stats of primary and mixed dentition
Age in years groups P = 0.644 (NS)
Oral Hygiene Score Sex
3-<6 years 6-12 years Table 5. Caries experience of study population according to oral
hygiene practices
Good M 37 (13.7%) 3 (10%)
Oral Hygiene No.of Children
F 19 (7.1%) 4 (13.3%) Total
Practices Caries affected Caries free
Fair M 86 (31.8%) 10 (33.3%) Tooth brush 237 55 292
(81.2%) (18.8%) (97.3%)
F 41 (15.2%) 6 (20%)
Finger 8 – 8
Poor M 33 (12.2%) 6 (20%) (100%) (2.7%)
Total 245 55
F 54 (20%) 1 (3.3%)
(81.7%) (18.3%) 300
Total 270 30 Tooth paste 237 55 292
(81.2%) (18.8%) (97.3%)
P = 0.633 Tooth powder 6 – 6
(100%) (2%)
In table 4. among the 3-<6 years age group
Other 2 2
examined, 13.7% males and 7.1% females and (100%) – (0.7%)
good oral hygiene, 31.8% males and 15.2% Total 245 55
females had fair oral hygiene and 12.2% males and (81.7%) (18.8%) 300
20% females had poor oral hygiene. Once 227 53 280
(81.1%) (18.9%) (93.3%)
In the 6-12 years age g roup examined, 10% Twice 18 2 20
males and 13.3% females had good oral hygiene. (90%) (10%) (6.7%)
33.3% males and 20% females had fair oral More than twice – – –
hygiene and 20% males and 3.3% females had por Total 245 55
oral hygiene. (81.7%) (18.8%) 300
1016
Caries
Total Caries Free
Affected
Tooth brush user 97.3% 81.2% 18.8%
Finger users 2.7% 100% –
Tooth paste user 97.3% 81.2% 18.8%
Tooth powder users 2% 100% –
Other 0.7% 100% –
Frequency-Once 93.3% 81.1% 18.9%
Twice 6.7% 90% 10%
More than Twixe – – –
Table 6. Parental knowledge, attitude and awareness about the Fig. 1. Institute of Child Health & Hospital for Children, Egmore,
importance of oral health Chennai
Importance Have you

Age Importance
Awareness of taken your
in of
of cardiac infective child to
years maintaining
problem endocarditis the dentist
oral health
prophylaxis before
Not Not Not
Aware Aware Aware
aware aware aware Yes No
3-<6 235 35 43 227 19 251 46 224

(87%) (13%) (15.83%) (84.07%) (7%) (93%) (17%) (83%)
6-12 26 4 5 225 2 28 2 28
(86.66%) (13.33%) (16.66%) (83.33%) (6.7%) (93.3%) (6.7%) (93.3%)
Fig. 2(a). Materials used for the Survey
Total 261 39 48 252 21 279 48 252

(87%) (13%) (16%) (84%) (7%) (93%) (16%) (84%)
In Table 6, 87% of parents were aware of their

child’s cardiac problem and 13% were not aware,
16% were aware of the importance of maintaining
oral health and 84% were not aware.
7% of parents were aware of the importance
of infectiveendocarditis prophylaxis and 93% were
not aware and about 16% have taken their child
to dentist and 84% havenot visited the dentist.
CONCLUSION Fig. 2(b). Materials used for the Survey
• This study shows that the prevalence of dental

caries was high (81.7%) among the cardiac
patients with a mean deft of 3.6 and mean
DMFT of 0.76
• This study shows that the prevalence of dental
caries was high (81.7%) among the cardiac
patients with a mean deft of 3.6 and mean
DMFT of 0.76
• The study also showed the untreated
component (85% in primary and 98% in
mixed dentition) of the caries experience was
more than the treated component (15% in Fig. 3. Cardiology out-patient Wing
primary and 2% in mixed dentition).
1017
3. Martinez AB, Corcuera MM, Meurman JH.

Odontogenic infections in the etiology of infective
endocarditis, Cardiovascular and Haemotological
Diorders. Drug Targets, 9(4):231-235;2009
4. Talebi M, Khordi M, Mahmoudi M, Alidad S. A
study on oral health of children with cardiac
disease,Iran in 2004. JODD,Vol no 1(3):Autmn; 2007.
5. Da Silva DA, Souza IPR, Cunha MC Knowledge,
attitudes and status of oral health in children at risk
of infective endocarditis. International Journal of
Paediatric Dentistry,12:124-13; 2002.
6. World Health Organization Oral Health Survey, Basic
Methods 4th edition, Geneva, WHO;1997
Fig. 4. Patient Examination 7. Miglani DC, Beal JF, James PM, Behari SA. The
assessment of dental cleanliness status of primary
• 31.33% of children had poor oral hygiene. dentition using a modification of the simplified oral
hygine index(OHIS-M). J Indian Dent Assoc,
• The caries experience is relatively high even 45:385-8;1973.
though the children’s oral hygiene practices
8. Franco E, Saunders CP, Roberts GJ, Suwanprasit A.
are good. The study showed that 97.3% of
Dental disease , caries related microflora and salivary
children were tooth brush users, 97.3% were IgA of children with severe congenital cardiac
paste users, 93.3% of children were those who disease: an epidemiological and oral microbial survey.
brushed atleast once daily. Paediatric Dentistry,18(3):228-235;1996.
• Very few parents were aware of the 9. Talebi M, Khordi M, Mahmoudi M, Alidad S. A
importance of maintaining oral health (16% ) study on oral health of children with cardiac
and importance of infective endocarditis disease,Iran in 2004. JODD,Vol no 1(3):Autmn; 2007.
prophylaxis (7% ) even though most of them 10. Rai K, Supriya S, Hegde AM. Oral health status of
were aware of the cardiac problems of children with congenital heart disease and the
children (87%). Attitude towards dentistry awareness ,attitude and knowledge of their parents.
The Journal of Clinical Paediatric
among parents was poor. 84% had never taken
Dentistry,33:315-318;2009.
their child to a dentist.
11. Saunders CP, Roberts GJ. Dental attitudes, knowledge
and health practices of parents of children with
REFERENCES congenital heart disease. Arch Dis
Child,76:539-540;1997
1. Genco R, Offenbacher JB. Periodontal disease and
12. Nath P, Kiran V, Maheshwari S. Awareness of
Cardiovascular Disease. JADA,Vol.133;June 2002.
infective endocarditis prophylaxis in parents of
2. Knox KW, Hunter N. The role of oral bacteria in the children with congenital heart disease: A prospective
pathogenesis of infective endocarditis Australian survey Ann Pediatr Cardiol, Jan–Jun; 1(1):
Dental Journal, Vol 36( 4): 286–292;1991. 54–55;2008.
1018
Evidence Based Dentistry - The Need for Better Clinical

Practice
Dr. Pavan Kumar K.R1, Dr. Nandeeshwar D.B.2
ABSTRACT
A lot of clinical questions in day to day clinical practice are answered and managed by our knowledge,
clinical training, clinical experience that are gained from dental schools or from colleagues with or without
scientific evidence leading to inappropriate treatment results. In other way, evidence based dental practice
answers these clinical questions based on systematic review and critical analysis of the available sound
evidences along with ones knowledge and clinical experience providing the best treatment.
Keywords: Evidence based dentistry (EBD), Evidence based decision making (EBDM), Evidence
based practice (EBP).
Clinical Implication: This literature review indicates that good clinical judgement is needed to
determine the applicability of external evidence while treating the patient. The patients will then receive
better treatment that is supported by systematic evidence.
INTRODUCTION dental association (ADA) adopted an EBD policy

statement.1,2,3
There is worldwide need in making better
healthcare services that are more effective and What is Evidence?
economic without compromising the quality of Evidence is something that makes another
care in the face of technological advances, thing evident: indication or sign. Guyatt et al
demographic change and increasing patient defined evidence as “any empirical observation
expectations. regarding association between events”.4
“We Live in an Age of Generation Next with What is Evidence Based Dentistry (EBD)?
New Information, Innovation & Change”
In 1955, Richards and Lawrence defined EBD
as “a process that restructures the way in which
HISTORY AND EVOLUTION we think about clinical problems and is
Initially, it started as a trade in which characterized by making decisions based on known
knowledge was created and held secret by evidence”.4
educated monks and barber surgeons. As the
American Dental Association (ADA) described
profession matured, textbooks, dental journals were
EBD as “an approach to oral health care that
published on dental topics and dental schools were
requires the judicious integration of systematic
opened.1
assessments of clinically relevant scientific
In 1900, clinical studies became popular & evidence, relating to the patient’s oral and medical
literature reviews emerged as important means for condition and history, with the dentist’s clinical
synthesizing results of individual reports. In expertise and patient’s treatment needs and
1980’s, evidence based medicine (EBM) was preferences”.5
introduced in MacMaster university, Ontario,
Canada followed by in Oxford (UK) and What is Evidence Based Practice (EBP)?
Harvard(USA) universities. In the early 1990’s, The modern concept of EBP was introduced
evidence based dentistry (EBD) followed its by David Sackett et al and they defined it as “the
existence from EBM. In 1992, the term EBM 1st conscientious, explicit and judicious use of current
appeared in the medical literature. In 2000, first best evidence in making decisions about the care
centre for EBD in INDIA was established in of individual patients”.6,7 (Fig 1)
Davangere, Karnataka. In 2001, the American
1 2
Assistant Professor, Professor and Head, Dept. of Prosthodontics, Bapuji Dental College and Hospital, Davangere,
Karnataka.
1019
What is Evidence Based Decision Making (EBDM)? IDENTIFYING THE CLINICAL PROBLEM
It is the formalized process and structure for
The first step in EBD is asking a clear
question about a clinical problem. According to
Sackett & Rosenberg (1995), the question framed
must be relevant to the patient’s problem and
phrased in such a way that it will point you
towards relevant and accurate answers.4
How to Phrase Clinical Questions?

As given by Richardson et al in 1995, the
question should be in “PICO FORMAT”:
• Population: patient is a member of population

Fig 1: Evidence based practice. that is usually described by demographics,
diagnosis, symptom or exposure.
learning these skills so that, the best scientific
evidence is considered when making patient care • Intervention: describes the action being
decisions.8 (Fig 2) considered which usually is a diagnostic test,
treatment, cause, prognostic factor or an
What is the Aim of EBD? exposure.
• Comparison: where test or treatment of
interest is compared.
• Outcome: is the result sought from the test
or treatment or the unhappy event one wishes
to avoid such as a diagnosis of apical
periodontitis or chewing efficiency or implant
failures.8
For eg: Would implant supported dentures
(I) improve the patient (O) in an edentulous 65
year old patient (P) compared with conventional
dentures (C)? – A Question of Therapy .10
What are Background & Foreground Questions?
Fig 2: Evidence based decision making
According to Sackett et al, (i) Background
Is to encourage the ordinary dental practitioner questions - includes basic knowledge regarding
in primary dental care to look for and make sense disorder, test, treatments, products or other matter.
of the evidence available in order to apply it to It usually starts with what, where, when, why,
everyday clinical problems.9 how, who and end with a clinical entity such as
a health state or health intervention.
STAGES IN EBD (ii) Foreground questions - considering such
background clinical knowledge, we can develop a
By Richards and Lawrence in 1955.9(Fig 3) foreground question such as “in severe xerostomia
patients, would a course of pilocarpine improve
oral comfort & the quality of life to be worth the
potential side effects & cost?. 10,11 (Fig 4)
SEARCH FOR EVIDENCE
It may be on an individual basis, what you

have observed (signs and symptoms of a patient
who has the condition) OR on the basis of research
Fig 3: Stages in EBD. evidence where a variety of clinical interventions
on populations of patients is reported upon.4
1020
SOURCES OF EVIDENCE the ADA section in EBD, Scottish

intercollegiate guidelines network (SIGN).
• Public agencies, guidelines & reviews: like,
Primary Sources Secondary Sources the UK technology assessment, National
Are original research Are synthesized publications institute for health and clinical excellence
publications that have not of primary literature. (NICE). 2,5
been filtered. eg - Systematic reviews
eg - Pubmed. and meta analyses, ACTING ON THE EVIDENCE
evidence based article
reviews, clinical practice It is the final phase of EBD, introducing it to
guidelines and protocols .8 frontline clinical practice and disseminating the
evidence as widely as possible is needed.4
LOCATING THE EVIDENCE
TYPES OF EVIDENCE
Evidence can be located through 4 basic • Type 1 - includes atleast one good systematic
routes: review and one randomized control trial
(i) Asking an expert: - Is a good starting point, (RCT).
but they are not completely aware of all the upto • Type 2 - includes atleast one good randomized
date evidence and often hold subjective opinions control trial (RCT).
about particular issues. The best method using an • Type 3 - includes well designed interventional
expert is to ask for a specific reference, so that studies without randomization.
you can appraise the evidence by yourself.
• Type 4 - includes well designed observational
(ii) Reading a text book: - This evidence studies.
rapidly go out of date, even when newly published
• Type 5 - includes expert opinion, influential
(Altman 1991).
reports & studies.4
(iii) Finding the relevant article in your What is Good Evidence?
reprint file: - It sounds good, but you may not The highest level of evidence is the systematic
have a relevant reprint and even if you do, you reviews and meta analysis using two or more
never get around to reading it properly. randomized control trial’s (RCT’s) of human
(iv) Searching a database: - It will be the subjects.4
most upto date. Access to the literature via internet What is Critical Evaluation?
is a simple procedure, but there is a danger of According to Greenhalgh (1997), it means
becoming swamped with articles that are not assessing the quality of the methodology used to
necessary relevant or scientifically sound.4 investigate a problem. It involves comprehensive
evaluation of a scientific paper and it consists of:
MAKING SENSE OF EVIDENCE
(i) Critical Appraisal: is making sense of the
There is a need to review research evidence evidence and systemically considering its validity,
systematically and keep upto date as new evidence results and relevance to dentistry. The evidence
emerges. This can be obtained from: has to be critically appraised for its validity,
impact & applicability and ensures sources of
• Journals: Eg -Evidence based dentistry, potential bias that have been eliminated.
Journal of evidence based dental practice.
• Electronic data bases of abstracts: Eg
-Medline, PubMed, Embase etc.
• Academic data bases of systemic reviews:
such as, the centre for EBD, the Cochrane
library, the Cochrane collaboration, the
Cochrane oral health group, Centre for reviews
and dissemination (CRD) in NewYork.
• Professional bodies, guidelines & reviews:
Fig 4: Background and foreground questions.
like, the royal college of surgeons (England),
1021
(ii) Critical Reflection: follows critical • Practice based on authority rather than
appraisal. It is to judge and discuss the evidence: The use of techniques or therapies
implications of the study for the world outside the based on the views of authority, rather than
study. Applicability, utility and generalizability of evidence may lead to wrong treatment being
the study to a larger population form the key to performed.9
critical reflection.4,12
TRADITION BASED & EVIDENCE BASED
How to Incorporate Evidence into Practice?
DENTAL CARE
When reading a scientific paper, dental
professional should keep in mind the following Tradition based dental care (Fig 6)
questions: (i)What are the results? (ii)Are the emphasizes the primacy of knowledge, experience,
results valid? (iii)Are findings relevant to my and intuition in the exercise of good clinical
patients population?. 8,10 judgment where as, Evidence based dental care
(Fig 7) emphasizes integration of good judgment
LEVELS OF CLINICAL EVIDENCE8 (Fig 5) with the best available evidence and the patient
values while making clinical decisions. 6,11,13
Fig 6: Traditional based model of practice.
Fig 5: Levels of clinical evidence.
PROBLEMS OF INTRODUCING EBD

• Amount of evidence: Currently more than 2
million biomedical articles are being published
annually in some 20,000 journals. There are
about 500 journals related to dentistry. Clearly Fig 7: Evidence based model of practice.
not all these articles are relevant to all areas
of dental practice, nor can one hope to read Who benefits from EBD?
any more than a small minority. • Public – are the ultimate beneficiaries, who
• Quality of evidence: A number of will reap the rewards of better care. The public
publications that are widely read in dentistry must rely on their educated dentists to help
are not subjected to peer review and even sort fact from fiction. They will be more
when peer reviewed, there is a tendency for educated in their treatment decisions and more
publication bias. appreciative of quality care.
• Dissemination of evidence: Unless good • Dentists – who instead of conducting free
methods of dissemination are available, even product testing for dental product
when there is good evidence, it can take many manufacturers, the practitioners will have more
years for a particular treatment to become valid research on which product to use based
practically real. on their clinical decisions.
1022
• Researchers - are called upon to do the REFERENCES

clinical testing before new products are
1. Torabinejad M, Bahjri K. Essential elements of
brought to the market.11
evidence based endodontics: Steps involved in
conducting clinical research. JOE 2005; 31: 563-69.
EBD INITIATIVES 2. Thomas MV, Straus SE. Evidence based dentistry and
the concept of harm. Dent Clin North Am 2009; 53:
• Introduction of problem based learning 26-45.
approach to clinical education - 1st develop at 3. Kotwal M, Hallikerimath RB, Kamal, Shigli K,
McMaster medical school in Canada. Gangadhar SA. Evidence based dentistry: The clinical
connection to innovation. JIPS 2007; 7: 2-4.
• The Journal “Evidence Based Dentistry”
brings oral health focused on evidence based 4. Daly B, Watt RG, Batchelor P, Treasure ET.
health care. Evidence based dentistry. Daly B. Essential Dental
Public Health. Oxford university press, 2002;109-18.
• The centre for evidence based dentistry at 5. Hackshaw AK, Paul EA, Davenport ES. Reviewing
Oxford university offers short term intensive all the evidence. Hackshaw AK. Evidence Based
courses in EBD. Dentistry: An Introduction. Blackwell Munksgaard,
2006;186-87.
• The Harvard school of dental medicine‘s
office of EBD initiated a course “evidence 6. Anderson JD. Need for evidence based practice in
based dentistry” in its pre doctoral dental prosthodontics. J Prosthet Dent 2000; 83: 58-65.
curriculum and offers graduate level clinical 7. Richards D, Clarkson J, Matthews D, Niederman R.
trials training program that includes an MPH Introduction. Wilson NHF. Evidence Based Dentistry:
degree in clinical effectiveness. Managing Information for Better Practice.
Quintessence Publishing Co.Ltd, 2008;1-6.
• The ADA’s EBD champion program to 8. Forrest JL, Miller SA, Newman MG, Hujoel PP, Abt
implement evidence based approaches to E. Evidence based decision making. Newman MG.
practice.2,13 Carranza’s Clinical Periodontology. 10thedition.
Elsevier, 2006;12-43.
9. Richards D, Lawrence A. Evidence based dentistry.
CONCLUSION
BDJ 1995; 179: 270-73.
EBD is the further expansion of science of 10. Carr AB, McGivney GP. User’s guides to the dental
critical research. The research evidence when literature: How to get started. J Prosthet Dent 2000;
obtained positive can be applied into general 83: 13-19.
dental practices. Incorporating evidence based 11. Goldstein GR. What is evidence based dentistry? Dent
approach will provide very best health care so that Clin North Am 2002; 46: 1-9.
patients may achieve and maintain optimum health 12. Nagesh L. The art and science of critical evaluation.
with being no harm for both to the dentists and A Handbook on Journal club and Critical Evaluation.
the patients. Valid research reports and Swapra Jyothi Publications, 2007;23-25.
recommendations when unused by the dental 13. Niederman R, Badovinac R. Tradition based dental
professionals, can be compared to a child left as care and evidence based dental care. J Dent Res
orphan and helpless inspite of parents being alive. 1999; 78: 1288-91.
1023
Teaching Medical and Dental Doctors through

Non–technical Skills - A View
1
Dr Vinay Kumar Gupta, 2Dr Seema Malhotra, 3Dr Mohit Mohan Singh, 4Dr Sandeep Kumar
ABSRACT
Medical education now focus is on active learning, rather than on passive teaching. The need of the
study skill course in medical education has thus now become important. To make them aware and to help
them develop the skills required, the need of the study skills course in medical education early in the part
of their training has been realized for the medical students. Such skills are later acquired over a long
period of time during employment or by a select few who undergo a B- school type of education. Areas
of the Study Non-Technical Skills like Interpersonal and communications skills, Teaching, learning and
presentation skills, Language, reading and computer use etc
INTRODUCTION participation or assistance in obtaining information

or completing tasks. it is recommended that a
Medical education now focus is on active
learning, rather than on passive teaching. The need professional use a deferential approach with
of the study skill course in medical education has language such as, "Excuse me, are you busy? I
thus now become important. To make them aware have an urgent matter to discuss with you if you
and to help them develop the skills required, the have the time at the moment." This allows the
need of the study skills course in medical receiving professional to make their own
education early in the part of their training has judgement regarding the importance of their
been realized for the medical students. The study
current task versus entering into a discussion with
skill course needs to cover different areas. It has
now been increasingly found by educationists that their colleague.
high professional institutions ignore traing and Having positive interpersonal skills increases
teaching in non-technical skills. the productivity in the organization since the
Such skills are later acquired over a long number of conflicts is reduced. People with good
period of time during employment or by a select interpersonal skills can generally control the
few who undergo a B- school type of education. feelings that emerge in difficult situations and
Some of the skills taught in B- schools and respond appropriately, instead of being
considered imperative for medical graduates were overwhelmed by emotion.
through focus group studies of sampling, UG, PG
studens and teachers. Out of the various skills 10 helpful tips for improving your
discussed 8 were found to be important to be interpersonal skills1:
included for formal inclusion in the medical and
1. Smile: Do your best to be friendly and
dental curricula
upbeat with your coworkers. Maintain a positive,
Areas of the Study Non -Technical Skills cheerful attitude about work and about life. Smile
often. The positive energy you radiate will draw
1. Interpersonal and communications skills others to you.
Interpersonal skills" refers to mental and
communicative algorithms applied during social 2. Be appreciative: Find one positive thing
communications and interaction to reach certain about everyone you work with and let them hear
effects or results. Interpersonal skills are how it. Be generous with praise and kind words of
people relate to one another. encouragement. Say thank you when someone
helps you. Make colleagues feel welcome when
it is generally understood that communicating they call or stop by your office. If you let others
respect for other people or professionals within know that they are appreciated, they’ll want to
will enable one to reduce conflict and increase give you their best.
1
Asst. Professor, Dept. of Public Health Dentistry, 2Dept. of Pedodontics, 3MBBS Student, 4Professor, Deptartment of Surgery,
CSM Medical University (upgraded KGMC), Lucknow.
1024
3. Pay attention to others: Observe what’s friends and family, and keep it short. Spare those
going on in other people’s lives. Acknowledge around you, or else you’ll get a bad reputation
their happy milestones, and express concern and
The Macy Initiative in Health Care
sympathy for difficult situations such as an illness
Communication2 identified three broad domains of
or death. Make eye contact and address people by
communication skills:
their first names.
• Communication with the patient
4. Practice active listening: To actively listen
is to demonstrate that you intend to hear and • Communication about the patient
understand another’s point of view. It means • Communication about medicine and science
restating, in your own words, what the other
person has said. In this way, you know that you The Kalamazoo I Consensus Statement3
understood their meaning and they know that your outlined seven essential communication tasks that
responses are more than lip service. Your should be part of communication oriented curricula
coworkers will appreciate knowing that you really and evaluation tools:
do listen to what they have to say. • Build the doctor-patient relationship
5. Bring people together: Create an • Open the discussion
environment that encourages others to work • Gather information
together. Treat everyone equally, and don’t play
• Understand the patient’s perspective
favorites. Avoid talking about others behind their
backs. Follow up on other people’s suggestions or • Share information
requests. When you make a statement or • Reach agreement on problems and plans
announcement, check to see that you have been
• Provide closure
understood.
2. Teaching, learning and presentation skills
6. Resolve conflicts: Take a step beyond
simply bringing people together, and become During their training, the medical students
someone who resolves conflicts when they arise. have to make presentations, take part in small
Learn how to be an effective mediator. By taking group discussion and teach their juniors. The
on such a leadership role, you will garner respect principles of effective teaching learning, lesson
and admiration from those around you. planning, information processing, learning theories,
and learning styles are thus important. Group
7. Communicate clearly: Pay close attention to exercises on lesson planning, small group
both what you say and how you say it. A clear discussion, effective delivery of lecture, and
and effective communicator avoids microteaching practice, including explanation and
misunderstandings with coworkers, colleagues, and reinforcement skills, with presentations, video
associates. If you tend to blurt out anything that recording, watching the video, group and
comes to mind, people won’t put much weight on individual feedback, are required. Clinical round
your words or opinions. and case presentation share the principles of small
group discussion.
8. Humor them: Don’t be afraid to be funny
or clever. Most people are drawn to a person that Three Types of Learning
can make them laugh. Use your sense of humor
as an effective tool to lower barriers and gain There is more than one type of learning. A
people’s affection. committee of colleges, led by Benjamin Bloom,
identified three domains of educational activities:
9. See it from their side: Try to view
• Cognitive: mental skills (Knowledge)
situations and responses from another person’s
perspective. This can be accomplished through • Affective: growth in feelings or emotional
staying in touch with your own emotions; those areas (Attitude)
who are cut off from their own feelings are often • Psychomotor: manual or physical skills (Skills)
unable to empathize with others.
Cognitive Domain
10. Don’t complain: There is nothing worse
than a chronic complainer or whiner. If you must The cognitive domain involves knowledge and
verbalize your grievances, vent to your personal the development of intellectual skills. This includes
1025
the recall or recognition of specific facts, Skimming: when their purpose is to quickly
procedural patterns, and concepts that serve in the obtain a general idea about the reading material.
development of intellectual abilities and skills. you have to read a large amount of material in a
short amount of time. When using the Skimming
Affective Domain style, you should identify the main ideas in each
paragraph and ignore the details in supportive
This domain includes the manner in which we sentences. Because you are only looking for the
deal with things emotionally, such as feelings, main idea in each paragraph you read, a lower
values, appreciation, enthusiasms, motivations, and level of comprehension is to be expected than
attitudes. when using the Study Reading style.
Scanning: when their purpose is to quickly
Psychomotor Domain locate a specific piece of information within
reading material. The piece of information to be
The psychomotor domain includes physical located may be contained in a list of names,
movement, coordination, and use of the motor-skill words, numbers, short statements, and sometimes
areas. Development of these skills requires practice even in a paragraph. Since you know exactly what
and is measured in terms of speed, precision, you are looking for, move your eyes quickly over
distance, procedures, or techniques in execution. the reading material until you locate the specific
piece of information you need to find.
3. Language, reading and computer use Before you begin your next reading
English is the medium of instruction and assignment, identify your purpose for reading
discussion, but it is not the first language of the
students. Guidance on English will help many and 4. Evidence based medicine and
some may need to attend special class regularly diagnosis and management
later to improve their language proficiency. Such Evidence based medicine and diagnosis and
regular sessions of English for doctors in the management in medicine, with focus on
off-hours for medical students as a language probability reasoning, predictive values, likelihood
support programme may need to be arranged in ratios, action threshold, and exclusion threshold
the institute. In this Study Skill course, one need to be covered as interactive lecture and
discussion session on English language for doctors, discussion session.
can highlight the important aspects and encourage
those, who have difficulties, to join regular session
5. Assessment principles and strategies
later. Other basic are as like using the computer,
typing skills need also to be covered, as some Students naturally tailor their learning styles to
students may not be familiar with computer. those assessment demands. They are very quick to
respond to what they perceive as the demands of
Becoming a Flexible Reader4 the assessment system. Thus assessment criteria
need to consider the training need of the students
To become a flexible reader, you need to and such criteria then should be made known to
know how to select and use a reading style that the students, so that they try to prepare
is consistent with your purpose for reading. There accordingly, which in the process helps them to
are three important reading styles you should learn achieve the expected training need.
to use. Each has its own purpose. Knowing when
and how to use these three reading styles will 6. Time management strategies to get the
make you a flexible reader best out of the training
Study Reading: when their purpose is to read The importance of time management and
difficult material at a high level of comprehension. personnel management skills for the effective
you should read at a rate that is slower than your working as a team is increasingly realized. To get
normal reading rate. Further, as you read you must the best out of it, the medical students have to
challenge yourself to understand the material. take the responsibility of their learning; otherwise
Study Reading will often require you to read training nearly always loses out to service. The
material more than once to achieve a high level medical students have to consider if they are
of comprehension. making and taking the best opportunities to learn
1026
from day-to-day activities in the wards, outdoors, arranged for the medical students and each group
emergencies or operation theatres. The outdoor should make short presentation in the presence of
clinics serve as an opportunity for ambulatory care the new batch about the portfolio focused on
clinical teaching learning. So discussion and group effective communication and presentation. This
work sessions need to be arranged regarding how will not only stimulate the new batch but also help
best to utilize the training opportunities. the previous batch to review, integrate and
synthesize the learning.
7. Reflection, portfolio and self-directed
lifelong learning
CONCLUSION
By reflection, the distinctive metacognitive
capability of humans, we can analyze our The skills a good doctor should have concern
experiences and think about the thought process. people, enquiring
It makes an experience the learning experience.
Reflection is an essential component for the mind, interest in people, rational approach,
development of a learning cycle and life long open mind, imagination, ability to handle pressure,
learning for the professionals. hard work, patience, determination, decisiveness
and humanity.
Portfolio is one of the useful approaches to
facilitate reflection. Making the medical students
to keep portfolio in activities required for their
training helps them to develop the habit of REFERENCES
reflection and to encourage the process of lifelong
1. www.communication-skills. info/interpersonal -
learning. The most appropriate area to introduce communication-skills
portfolio learning is obviously effective
communication, including presentation. In this way 2. Kalet A, Pugnaire M, Cole-Kelly K, Janicik R,
Ferrara E, Schwartz M, Lipkin M, Lazare A.
the two vital areas required for the medical
Teaching Communication in Clinical Clerkships:
professionals will simultaneously be covered Models from the Macy Initiative in Health
effectively, i.e. the process of reflection and Communications. Acad Med 2004 79; 6:511-520.
self-directed learning and the effective
communication and presentation. 3. Participants in the Bayer-Fetzer Conference on
Physician-Patient Communication in Medical
Education. Essential Elements of Communication in
8. Follow-up presentation Medical Encounters: The Kalamazoo Consensus
During the Study Skill course arranged for the Statement. Acad Med 2001 76;4:390-393
new batch after one year, group work has to be 4. www.ciil-ebooks.net/html/teaching/link10.htm
1027
Implications of Socio - economic factors in Complete

Denture Treatment in Bhopal an Epidemiological Survey
1
Dr. J. Varsha Murthy, 2Dr. Naveen S Yadav, 3Dr. Vrinda Saxena, 4Dr. Yuvaraj V,
5
Dr. Akash Krishna
ABSTRACT
Objective: To assess the prevalence of complete edentulism with respect to socio-economic factors
and also its implications on treatment modality opted by the patients in urban and rural areas of Bhopal.
Methods: A questionnaire survey was conducted on all patients and the data was subjected to suitable
statistical analysis to arrive at conclusion.
Results: On conducting a questionnaire survey it was found that a significant relationship exists
between socio-economic factors and the implication of treatment plan opted by the patients.
Conclusion: : Creating dental awareness among patients of lower socio-economic group and providing
proper facilities at affordable rates encourages patients for undertaking timely treatment thus preventing
consequences of edentulousness.
Keywords: complete denture treatment, socioeconomic factor, epidemiological survey
INTRODUCTION assess the prevalence of complete edentulism with

respect to socio-economic factors and also its
Edentulism is an indicator of the oral health implication on treatment modality opted by the
of the population 1. There are various factors patients in urban and rural areas of Bhopal, capital
known to be associated with oral health of the of Madhya Pradesh.
particular population such as socio-economic status
2
, literacy level 3, body mass index and nutritional MATERIALS AND METHODS
status 4,5, smoking 6, tobacco chewing 7 and also
gender 8. After obtaining research and ethics committee
approval and informed consent from the patients ,
Socio-economic factors , along with we included a total of 548 patients having
accompanying life styles and health behaviors are completely edentulous arches. Among them there
strong predictors of edentulism 9. Completely were 482 males and 66 female. A questionnaire
edentulous patients have been found to be at risk survey was conducted on these patients (Table 1).
for multiple systemic disorders 10. It was also Only completely edentulous individuals in both the
reported that the prevalence of edentulism was arches were included for the study. Data were
highest in rural areas with some clear demographic analyzed using frequency distribution tables and
trends 11. It is also observed that there was more figures. Responses were evaluated with different
demand for prostheses among the lower statistical methods according to the type of
socio-economic groups12. Therefore a need exists question. In this study the Z test was used to
to plan for catering the requirements of lower evaluate two-sample proportions, the t test was
socio-economic population especially in rural used to evaluate two-sample means and chi-square
areas. tests were used to evaluate the relationship
between two classified variables.
Studies among Indian population13 have linked
some of these socio-demographic factors for the RESULTS
assessment of cause and level of edentulism but
these has been no report on the influence of these On analyzing the data more men requested
on edentulism. Therefore this study was aimed to complete denture compared to women (P< 0.01).
1
Reader, 2Professor, Dept. of Prosthodontics, People’s Dental Academy, Bhanpur 3Professor, Dept. of Public Health
Dentistry, 4Reader, Dept. of Oral and Maxillofacial Surgery, 5Reader, Dept. of Conservative Dentistry, People’s College of
Dental Sciences and Research Center, Bhanpur, Bhopal
1028
Moreover it was found that, in lower Table 2: Relationship between habits and socio-economic status.
socio-economic status the demand for dentures
Socio-economic status
(341) was significantly higher (P <0.01) compared Habits Total
to the higher socioeconomic group (183). More Lower Higher
number of individuals with lower socio-economic Smoking 182 (34.7%) 68 (12.9 %) 250
status were found to be smoking and tobacco Tobacco chewing 74 (14.1%) 30 (5.7%) 104
chewing leading to many cases of smokers palate None 58 (11.2%) 112 (21.4%) 170
and oral submuous fibrosis (Table 2). Some Total 314 210 524
business professionals of higher income groups
were also encountered with the same problems. Table 3: Relationship between problems due to edentulousness
and socio-economic status.
The patients from lower socio –economic group
insisted more on phonetics and mastication Problems due Socio-economic status
whereas those from higher socio-economic group to Total
edentulousness Lower Higher
insisted more on esthetics (Table 3). The patients
from lower socio-economic group could not avail Esthetics 28 (5.3%) 178 (34.04%) 206
proper dental treatment because of Mastication 152 (29%) 23 (4.4%) 175
affordability(25.2%), lack of dental awareness in Phonetics 74 (14.1%) 18 (3.4%) 92
remote villages (18.7%) and also facilities (28.1%) Others 37 (7.06%) 14 (2.7%) 51
which could have prevented the loss of teeth. The Total 291 233 524
patients from higher socio-economic group could
Table 4. Relationship between reasons for not seeking treatment
not get time for dental treatments like complete
and socio-economic status.
dentures as it requires more number of sittings
(table 4). The patients from lower socio-economic Reasons for Socio-economic status
not seeking Total
group seeked dental treatment mostly in dental Lower Higher
treatment
camps (29.4%), also in dental colleges when cost
of the treatment were offered at a concession Affordability 132 (25.2%) 22 (4.1%) 154
(24.4%) and vehicles arranged for transportation Lack of facilities 147 (28.1%) 38 (7.3%) 185
whereas the higher socio-economic group seeked Lack awareness 98 (18.7%) 24(4.6%) 122
treatment on insistence of their families (15.7%)or Time factor 4 (0.7%) 59 (11.2%) 63
due to problem with previous dentures (7.3%) Total 381 143 524
(Table 5).
Table 5. Relationship between reasons for seeking treatment and
Table 1. Questionnaire socio-economic status.
Name: Reasons for Socio-economic status

Total
Age/sex: seeking treatment Lower Higher
Education: illiterate, primary school,
Discounted treatment 128 (24.4%) 48 (9.2%) 176
secondary school
cost
Socio-economic status: lower, higher.
Dental camps 154 (29.4%) 26 (4.9%) 180
Habits: smoking, tobacco chewing,
Family insistence 19 (3.6%) 82 (15.7%) 101
others.
Problem with 29 (5.5%) 38 (7.3%) 67
Type of problem due to esthetics, mastication,
previous denture
edentulousness: phonetics, others.
Total 330 194 524
Reasons for not seeking lack of facilities, awareness,
prosthetic treatment: accessibility
Reasons for seeking dental camps, discounted DISCUSSION
prosthetic treatment: cost, family insistence.
The present study observed the relationship of
Problem with previous esthetics, broken denture, the rate of edentulism with the socio-economic
denture: loss of retention, occlusal status in Bhopal and also its implications on the
instability.
treatment plan opted by the patient. It was found
1029
that the percentage of edentulism (65%) was more CONCLUSION

in lower socio-economic status. The factors
responsible for this were mainly due to It was evident from our study that demand for
affordability of treatment (25.2%), lack of dental complete denture increased with decrease in
awareness (18.7%), lack of proper facilities nearby socio-economic status and majority of patients
(28.1%). It was observed that the rate of rural receiving complete denture were smokers from
population getting treatment increased during lower socioeconomic group. Mastication and
camps (29.4%) when transportation facilities were phonetics were the main concern for the lower
given and also in dental colleges when treatment socioeconomic status. Finally the reason for not
rates were reduced (24.4%). getting previous prosthodontic treatment was
mainly due to lack of facilities in vicinity,
Our study showed that the demand of affordability and lack of awareness.
complete dentures was more for lower
socio-economic group. This is in agreement with
REFERENCES
Temitope et al 12. In our study it was found that
more number of smokers (34.7%) and tobacco 1. Brodeur JM, Benigeri M, Naccache H,et al; Trends
chewers (14.1%) were found in lower in level of edentulism in Quebec between 1980 and
socio-economic group requiring complete denture 1993. J Can dent Assoc,1996;62(2):159-160.
which is in accordance with as study by Ziad Al- 2. Ziad N Al –Dairi: Complete edentulism and
Dwairi 2 , wherein majority of the subjects who socio-economic factors in a Jordanian population. Int
received complete denture were smokers from Jr Prosthodont, 2010;23:541-543.
lower socio-economic group. 3. Elkland SA, Burt BA: Risk factors for total tooth loss
in United States: longitudinal analysis of national
In our study we observed that the main data. J Public Heath Dent 1994;51:5-14.
concern for completely edentulous individuals in 4. Klemetti E, Kroger H, Lassila V: Relationship
lower socio-economic groups was difficulty in between body mass index and the remaining alveolar
mastication (29%) and phonetics (14.1%) whereas ridge. J oral rehab, 1997;24:808-812.
esthetics (34.04%) was the main concern for the 5. Marcenes W, Steele JG, Sheiham A, et al ; The
higher socio-economic group. This finding was in relationship between dental status , food selection
agreement with a study done by Reddy 13. In our nutrient intake , nutritional status and body mass
study it was found that the reason for not getting index in older people . Cad saude Publica,
previous prosthodontic treatment in lower 2003:19;809-816.
socio-economic group was affordability (25.2%), 6. Haber J, Wattles J, Crowely M, et al ; Evidence for
lack of facilities in vicinity (28.1%) as well as lack cigarette smoking as a major risk factor for
of awareness (18.7%) of the various dental periodontitis . J Perodont,1993;64:16-23.
treatment modalities available. On the contrary it 7. Johnson GK, Slach NA; Impact of tobacco use of
was time factor (11.2%) for the higher periodontal status. J Dent Edu 2001;65;313-318.
socio-economic group which deferred them from 8. Hoover JN, Mc Dermott RE: Edentulousness in
availing the treatment. This is contrary to a study patients attending a university dental clinic . J Can
by Reddy 13, who found lack of dental awareness Dent Assoc 1989;55:139-140.
(26.6%) followed by cost factor (7%) to be 9. Starr, John M, Hall, Roanna: Predictors and correlates
responsible for cause of edentulousness. of edentulism in healthy older people. Curr Opin in
Clin Nutr and Met Care 2010;13:19-23.
Another important finding from our study was 10. Felton DA; Edentulism and co morbid factors. J
that the lower socio-economic group was Prosthet 2009;18:88-96.
motivated for treatment when dental camps were 11. Adams C, Slack-smith LM, Larson A, et al;
conducted in their localities (29.4%), also they Edentulism and associated factors in people 60 years
were encouraged when the treatment rates are and over from urban, rural and remote western
reasonably discounted (24.4%). Therefore the Australia. Aust Dent J. 2003; 48:10-14.
results of our study clearly is that conducting 12. Temitope Ayodeji Esan, Adeyemi Oluniyi Olusile, et
regular camps in rural areas and providing al;Sociodemographic factors and edentulism: Nigerian
reasonable treatment rates will encourage lower experience. BMC Oral Heath 2004;4: 3-8.
socio-economic group patients for treatment 13. Simhachalam Reddy N: Edentulism _ An
thereby decreasing problems caused due to epidemiological survey of population in Chennai ,
edentulousness. India. Jrnl of Orof Sci 2010;2:14-18.
1030
Cross Infection control in Impression making Procedures

– A Pilot Survey
1
Dr. Murali S, 2Dr. Shankar S, 3Dr. Kruthika M, 4Dr. Vishnudev P.V,5 Dr. Mythili Merunalavathi S
ABSTRACT
Aim: The present survey was conducted with the aim of investigating the knowledge, attitudes and
behavior of Dental staffs and students to cross infection control in impression making.
Materials and methods: A questionnaire that consisted of 16 questions was designed to assess the
details of Impression, disinfection, including how impressions were disinfected and what materials were
used. The questionnaire was pilot tested initially, to check content and administrative aspects, by sending
it to the dental staffs and students of one of the dental college in Tamilnadu.
Results: A total of 163 respondents completely filled the questionnaire. The majority of the response
was from dental students (87.1%) and the remainders were from the B.D.S and M.D.S. staffs of 4.3% and
8.6% respectively. The percentage frequencies of male and female respondents are 30.1% and 69.9%
respectively. The results shown that, out of these 163 respondents, “when asked about the material used
for making primary impressions, majority of the respondents used Alginate for making primary impressions
(89.6%). 47.9% disinfect their impression material in tap water and 10.4% using spray disinfectant solution,
but only 4.3% disinfect their impression by immersing in a disinfectant solution. Of those who disinfected
impressions for study casts, about 45.4% do not disinfect the study casts before sending to the laboratory.
54.6% of the respondents said that if the impression is not disinfected, there is no need to disinfect the
stone cast.
Conclusion: The results of the present study showed that the knowledge of dental students and staffs
is insufficient about infection control procedures. A stress should be made in the curriculum of students
about the knowledge of cross infection control.
Keywords: Infection control, Impression, Survey.
INTRODUCTION human microbial pathogens have been isolated

from oral secretion. In addition, a majority of
Dentists might be occupationally exposed to
carriers of infectious diseases cannot be easily
infectious materials, including body substances and
contaminated supplies, equipment, environmental identified. Hepatitis B and the acquired
surfaces, water or air. Dental impressions which immunodeficiency syndrome are serious diseases
have been in contact with the patient’s oral cavity because of their poor prognoses. The increasing
pose a potential hazard to the dental team as well awareness of the latter has highlighted the need
as being a cross infection hazard. “Cross infection for adequate precautions against cross
can be defined as the transmission of infectious contamination. However, the risk to dental
agents between the patients and staff within a
clinical environment. Infection control which is the personnel is still far higher from hepatitis B than
most discussed topic in dentistry, has become an it is from the human immunodeficiency virus, and
integral part of the practice to the extent that the hepatitis virus is more transmissible, especially
dental health workers no longer question its because it occurs in saliva. 2 Research has shown
necessity1. that infective hazards are present in dental practice
because many infections can be transmitted by
Dental care professionals are at high risk of
cross-infection while treating patients. This blood or saliva via direct or indirect contact,
occupational potential for disease transmission droplets, aerosols, or contaminated Instruments and
becomes evident when it is considered that most equipment.
1
Professor and Head, Dept. of Oral and Maxillo Facial Pathology, 3P.G Student, Dept. of Pedodontics and Preventive
Dentistry,Vinayaka Missions Sankarachariar Dental College and Hospital, Ariyanoor. 2Senior Lecturer, 4, 5Student Internee,
Dept. of Public Health Dentistry, K.S.R. Institute of Dental Science and Research, Thiruchengode
1031
Studies, generally shown that the practice of questionnaire item as “Yes” or “No” and some
impression cross infection control in the general questions with multiple choices. Statistical analysis
dental practice environment is a cause of concern. was done with SPSS version 10.0 software.
The subject of infection control in dentistry has
aroused much controversy and debate during the RESULTS
past decade as a result of the global spread of the A total of 163 respondents completely filled
human immunodeficiency virus infection. 3 the questionnaire. The majority of the response
Prosthodontic patients are generally a high-risk was from dental students (87.1%) and the
group relative to their potential to transmit remainders were from the B.D.S and M.D.S. staffs
infectious diseases as well as acquire them. There of 4.3% and 8.6% respectively (Table 1). The
has been a recent increase in awareness of the percentage frequencies of male and female
need for cross-infection control measures to protect respondents are 30.1% and 69.9% respectively.
against possible routes of transmission frequently
ignored in the past. 4 Many impressions were sent Table 1. The Qualification of the respondents.
to laboratory without proper disinfection, some of
which were clearly contaminated with blood and Respondents Qualification Frequency (Percent)
food debris5. 3rd year 50 (30.7)
Although many surveys about cross-infection 4th year 5 (27.6)
control procedures have been carried out in several Interns 47 (28.8)
countries, there is no report in recent literature BDS 7 (4.3)
about how dental staffs and students manage the
MdS 14 (8.6)
control of cross-infection in their practice related
to impression procedures in our country. So the Total 163 (100.0)
present survey was conducted with the aim of
investigating the knowledge, attitudes and behavior The results shown that, out of these 163
of dental staffs and students to cross infection respondents, “when asked about the material used
control in impression making. for making primary impressions, majority of the
respondents used Alginate for making primary
MATERIALS AND METHODS impressions (89.6%). Only 8.6% indicated that
other impression materials were also used
A questionnaire that consisted of 16 questions
occasionally. About 1.8% used silicone
was designed to assess the details of Impression,
condensation or addition silicone in addition to
disinfection, including how impressions were
alginate, which is similar to the study conducted
disinfected and what materials were used. The
by Brian J. Millar.5 Prior to pouring impressions
questionnaire was pilot tested initially, to check
were routinely rinsed under running tap water by
content and administrative aspects, by sending it
95.7% of respondents and 62.6% indicated that
to the dental staffs and students of one of the
they also carried out some form of prior
dental college in Tamilnadu, India.
disinfection procedure.
All graduate and undergraduate staffs and
undergraduate students in their clinical years (third When asked about the sterilization of
and fourth/final year) who were present on the day impression trays before making impressions, about
of the survey were included. No attempt was made 96.3% of the respondents were routinely sterilize
to further invite the absentees during the survey their impression trays before making impressions
days. The subjects who did not fill the and 92% of the respondents store the impression
questionnaires completely were excluded. 49 males materials properly in an air tight container or away
and 114 females participated in the investigation from the risks of infections. Most of the students
thus, 163 participants anonymously completed the and staffs poured their study impressions in their
study questionnaire. office, whereas 11.7% relied on their laboratory
technicians for pouring impressions. 37.4% of the
The student participation in the research was respondents do not disinfect the impression before
voluntary with no incentives declared. The sending to the dental laboratory. 47.9% disinfect
instrument used in the present study was based on their impression material in tap water and 10.4%
the self applied questionnaire, which contained 16 using spray disinfectant solution, but only 4.3%
questions related to infection control practices. disinfect their impression by immersing in a
Participants were asked to answer each disinfectant solution.
1032
Of those who disinfected impressions for study Only 42.3% of the respondents indicated that
casts, about 45.4% do not disinfect the study casts an autoclavable impression material would be
before sending to the laboratory, 14.7% used desirable in their practice. 54.6% of the
Hypochlorite’s and 35% used a spray disinfectant respondents said that if the impression is not
and only 4.9 % used Idophores, which is not disinfected, there is no need to disinfect the stone
similar to the study conducted by Brian J. Millar5 cast.
When asked, “Does your laboratory technician When asked about the measures taken to
disinfect your working impression before pouring? prevent cross infection control while impression
Most (60.7%) were “Not sure”, 21.5 responded making in their clinic, about 21.5% of the
“No”, and only 17.8% answered “Yes”. respondents do not take any measures for
preventing cross infection in their clinic, 54% said
About 22.1% replied that immersion of that they immerse in a disinfectant solution and
impression in a disinfectant solution will alter the only 24.5% rinse with tap water to disinfect their
quality of impression material, and 54.6% said that impressions. Finally about 85.3% of the
“If an impression has not been disinfected, it is respondents were aware about the life endangered
necessary to disinfect the stone cast and nearly half disease through cross infection. (Table 2 & Table
of the respondents (45.4%) answered ‘No’. 3)
Table 2: The questions with Dichotomous Variable for the respondents
Yes No
Question Frequency Frequency
(Percent) (Percent)
1. Do you use a different impression material for known high-risk patients? 21 (12.9) 142 (87.1)
2. Do you routinely sterilize your impression trays before taking impressions? 157 (96.3) 6 (3.7)
3. Do you store impression materials properly? 150 (92.0) 13 (8.0)
4. Do you routinely pour the impression in your clinic? 144(88.3) 19(11.7)
5. Do you routinely rinse your impression with tap water before sent to laboratory? 156 (95.7) 7 (4.3)
6. Do you routinely disinfect your impression before sent to laboratory? 102 (62.6) 61 (37.4)
Not Sure 35 (21.5)
7. Does your laboratory technician disinfect your impression before pouring? 29 (17.8)
60.7%
8. Do you think immersion of impression in a disinfectant solution will alter the quality of 36 (22.1) 127 (77.9)
impression material?
9. If an impression has not been disinfected, is it necessary to disinfect the stone cast? 89 (54.6) 74 (45.4)
10. Would an autoclavable impression material be desirable in your practice? 69 (42.3) 94 (57.7)
11. Handling casts which is not disinfected causes cross infection in your clinic? 129 (79.1) 34 (20.9)
12. Are you aware about life endangered diseases through cross infection? 139 (85.3) 24 (14.7)
Table 3. The questions with multiple-choice options for the respondents.
1. Which of the following impression materials would Alginate Silicone Others

you routinely use for a preliminary impression? Condensation/
Addition
Frequency (Percent) 146 (89.6) 3 (1.8) 14 (8.6)
2. How would you disinfect your impression? Do not disinfect Rinse with tap water Spray with Immerse in
disinfectant disinfectant
Frequency (Percent) 61 (37.4) 78 (47.9) 17 (10.4) 7 (4.3)
3. How would you disinfect your stone cast? Do not disinfect Spray disinfectant Hypochlorite’s Iodophores
Frequency (Percent) 74 (45.4) 57(35.0) 24 (14.7) 8 (4.9)
4. What are all the measures taken to prevent cross No measures Immersing in a Rinse with tap water
infectin in your clinic? taken disinfectant solution
Frequency (Percent) 35 (21.5) 88 (54.0) 40 (24.5)
1033
DISCUSSION in use, some of which may not be based on current

best-practice guidelines.
From an infectious disease point of view,
dentistry has never been safer than it is today for The responsibility for ensuring impressions
both patients and the dental team. This state of have been cleaned and disinfected prior to dispatch
affairs has resulted from the establishment and to the laboratory lies solely with the dentist –
practice of strict infection control in the office immediately on removal from the mouth, the
using the concept of universal precautions. impression should be rinsed under running water
Infection control consists of a series of procedures to remove saliva, blood and debris continue the
directed at reducing the number of microbes process until it is visibly clean. The impression
shared among people.6 Impression making and its should be disinfected according to the
processing also forms a major area of potential manufacturer’s recommendations. Generic
infection. Hence its control is prime important for materials such as sodium hypochlorite (household
the dentist. This study was conducted in that bleach) may no longer be suitable for disinfecting
background to assess the knowledge, attitude and impressions unless specifically recommended by
practice related to it. the manufacturer. Disinfectants should not be
sprayed onto the surface of the impression; it
As expected, all respondents used alginate as lessens the effectiveness and creates an inhalation
an impression material for study casts, as it is easy risk. Immersion of the impression is recommended.
to use, has a low cost, and is accurate enough for The impression should be rinsed again in water
the purpose of study impressions. Immediate before sending to the laboratory accompanied by
pouring is preferred and most of the dentists a confirmation that it has been disinfected. The
poured their study impressions in the dental clinic. manufacturer’s recommendations for the dilution
of the disinfectant and immersion time must be
Alternative impression materials that are more followed. It is recommended that all impressions
resistant to disinfection have been suggested for should at least undergo a disinfecting procedure by
use with known high-risk patients (e.g. HIV +ve immersion in 1% sodium hypochlorite for a
or viral hepatitis carriers, etc). However, because minimum of 10 minutes.8 But disinfectants for
there is no means of verifying the disease status impression materials are in the phase of practical
of every patient, universal precaution for infection testing, and show promising first results. Under
control are more appropriate. practical and scientific aspects further
This survey indicates that only 12.9% of investigations are necessary to evaluate standards
respondents would use alternative impression and standardized testing procedures. 9
materials for taking study impressions in high-risk
patients. Rather than attempt to identify those at
high risk, it is recommended that all impressions Infection control policy
are treated as having a high risk. Each practice must have a written infection
Rinsing an impression under running water to control policy. The policy should describe the
remove grossly visible contaminants should be a practice policy for all aspects of infection control
routine procedure to remove saliva, blood and food and provide a useful guide to the training
debris. It also removes up to 90% of necessary for each member of staff to be
microorganisms. Surprisingly, 95.7% would rinse competent and confident in its implementation. All
their impressions before sending to a dental members of the dental team must know who is
laboratory. responsible for ensuring certain activities are
carried out and to whom to report any accidents
Dentists have a responsibility to decontaminate or incidents. Accidents and incidents should
impressions before sending them to a laboratory. always be recorded in the accident book. Although
Some Impression materials should not be a policy will describe the procedure for the
disinfected in the laboratory if they have already practice as a whole, it is useful for each member
been disinfected in the dental clinic, so as to avoid of staff to receive a copy and to sign a declaration
unnecessary duplication and adverse effects on the to confirm that the policy has been received and
prosthetic results7. Thus, it is essential to notify training provided – for example, "I confirm that I
the dental laboratory, whether or not impressions have read the practice Infection Control Policy and
have been disinfected. The implications of this have received training in all its aspects". A copy
survey are that a variety of disinfection procedures of the policy should be displayed in each treatment
1034
procedures. It is a good idea to discuss infection knowledge and attitudes of Turkish dentists. J Appl
control at practice staff meetings. Open discussion Oral Sci. 2009; 17(6):565-9.
will allow misunderstandings to be addressed and 2. Owen CP, Goolam R. Disinfection of impression
ensure everyone in the practice approaches materials to prevent viral cross contamination: a
infection control in the same way10. review and a protocol. Int J Prosthodont.
1993;6(5):480-94.
CONCLUSION 3. Samaranayake L. Rules of infection control. Int Dent
J. 1993;43(6):578-84.
The results of the present study showed that
4. Connor C. Cross-contamination control in
the knowledge of dental students and staffs is
prosthodontic practice. Int J Prosthodont.
insufficient about infection control procedures. 1991;4(4):337-44
This situation indicates that cross-infection control
topics do not arouse interest among dentists, or 5. Siu-Kei Pang, Brain J. Millar. Cross infection control
of impressions: a questionnaire survey of practice
that there is a deficiency in continuing dental
among private dentists in Hong Kong. Hong Kong
education on how to avoid cross infection in dental Dental Journal 2006; 3:89-93.
practice. Improved compliance with recommended
infection control measures is required for all 6. Miller CH. Infection control. Dent Clin North Am.
1996;40(2):437-56.
dentists. Continuing education programs and
short-time courses about cross-infection and 7. Campanha NH, Pavarina AC, Vergani CE, Machado
infection control procedures are suitable to AL, Giampaolo ET. Cross-Infection Control Policy
improve the knowledge of dentists11. A stress Adopted by Dental Technicians. Revista de
Odontologia da UNESP. 2004; 33 (4): 195-201.
should be made in the curriculum of students
about the knowledge of cross infection control. 8. Blair FM, Wassell RW. A survey of the methods of
disinfection of dental impressions used in dental
hospitals in the United Kingdom. Br Dent J.
ACKNOWLEDGEMENTS
1996;180(10):369-75.
We would like to thank the principal Dr. G. 9. Setz J, Heeg P. Disinfection of dental impressions.
S. Kumar, Staffs and Students of K.S.R. Institute Dtsch Zahnarztl Z. 1991;46(3):186
of Dental Science and Research, Tamilnadu for
10. The British Dental Association website,
their valuable support in conducting the survey. http://www.bda-dentistry.org.uk/. Accessed on
18/05/2010.
REFERENCES
11. Al-Rabeah A, Mohamed AG. Infection control in the
1. Yuzbasioglu E, Saraç D, Canbaz S, Saraç YS, Cengiz private dental sector in Riyadh. Ann Saudi Med.
S. A survey of cross-infection control procedures: 2002; 22(1-2):13-7.
1035
Communication Proficiency in Dentistry - A Stepladder

to Success!!..
1
Dr. Gaurav Beohar, 2Dr. Utkarsh Katare, 3Dr. Swapnil Parlani, 4Dr. Surendar Agrawal,
5
ABSTRACT
In Dentistry, the ability to communicate skilfully and with purpose rarely occurs as a gift, it has to
be learned. Knowledge and technical skills along with an ability to communicate effectively and to
demonstrate ethical awareness and Professionalism are crucial.
Many failures of dental prosthesis can be traced to a breakdown in communication between members
of the dental team. Good communication is the key to the technical success of the Dental team; this
requires a close working relationship between the dentist and their associates. From the Dentist point of
view, the role of his communication skills lie in communicating with the patient, dental laboratory and
with his professional colleagues.
Communication can be regarded as a two way process of exchanging or shaping ideas, feelings and
information. As Dentists, it is important how we represent ourselves to the public. If done poorly, it will
contribute to a decline in the profession’s image, if it is done well, it will help correct years of
misconception about dentistry and our profession will be the beneficiary.
This article attempts to emphasize the significance of communication skills in the successful practice
of Dentistry.
Key Words: Communication, Work authorization, Dental laboratory, Behaviour, Patient Psychology.
INTRODUCTION Dentist point of view, the role of his

communication skills lie in communicating with
The word communication is taken from Latin the patient, dental laboratory and with his
word communiscare, which means to share, impart professional colleagues.2
and partake1. In the field of Dentistry, knowledge
and technical skills along with an ability to Patients psychology was initially classified by
communicate effectively and to demonstrate M.M House (1985)3, which was further
empathy, rapport, ethical awareness and improvised by Gamer. S (2003)3, while Alex
Professionalism is crucial. Koper (1967)4 described the “Difficult Denture
Bird” as a problem Denture patient, who
Dentists are thought to be masters in technical complains, have pain and are hostile, tense,
skills who provide quick solutions to the problems. anxious and unhappy people.
However, many problems require “Patience with
Patients” through effective communication Russel and Schabel (1969)2 emphasized on
techniques and listening to the needs of those who the importance on Dentist Patient communication
seek dental treatment. Learning communication along with Hirch and Tiber (1973)5 who
skills can be challenging as communication skills demonstrated that patients responded favourably
are often viewed as an intrinsic part of the when they were properly communicated and
person’s personality, cognitive functioning and actively involved through interaction .
social experience1.
The responsibilities of the dentist towards the
Good communication is the key to the laboratory procedures in fixed and removable
technical success as many failures of the dental partial denture prosthesis were highlighted by
prosthesis can be traced to a breakdown in Smith and Gilbert (1963). Similarly A.D.A
communication between members of the dental (1954-2003)6 has issued guidelines to improvise
team, which requires a close working relationship the relationship between Dentist and the
between the dentist and their associates. From the technician. A survey of 51 dental laboratories
1, 2
Senior Lecturer, 3Reader, 4Professor and Head, Dept. of Prosthodontics, 5Senior Lecturer, Dept. of Public Health
Dentistry, People’s College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh.
1036
conducted by Arnaulata and Allen(1990)7 justified In 1950’s Dr. M.M House contributed to the
the importance of Dental Laboratory work art and science of Dentistry by classifying patient’s
authorization. psychology into four types: Philosophical,
Exacting, Hysterical and Indifferent.3
COMMUNICATION Simon Gaber etal in 2003 revised the house
Communication can be regarded as a two way Classification and gave the following types of
process of exchanging or shaping ideas feelings patient profiles: Ideal, submitter, Indifferent,
and information. The types of communication can Resistant. Following House’s path, O’shea etal,
be classified as ‘One Way’ (Didactic Method) in Winkler, Sharry, Blum, Koper also described the
which the flow of communication is one way from patients according to their psychology.3
communicator to the audience, ‘Two Way’ O’Shea categorized them into: Complaint,
(Socratic Method) in this type both the Sophisticated, Responsive.3
communicator and the audience are actively
involved, ‘Verbal’ Communication is a traditional Winkler described four traits that characterizes
persuasive way of communication by the word of the ideal patient response as 1- Realizes the need
mouth, ‘Non Verbal’ Communication can occur for the prosthetic treatment, 2- Wants the
without words and include a whole range of bodily Prosthesis, 3- Accepts the prosthesis, 4- Attempts
movements, postures, gestures, facial expression, to use the Prosthesis.
‘Visual’ Communication comprises of charts,
Sharry however categorized the patients into;
graphs, pictograms, tables, maps, posters and
1- TOLBUDS: Patient who could tolerate
‘Telecommunication and Internet’ are the distant
prosthesis backwards, upside down or sideways. 2-
communication modalities using electromagnetic
TOLAD: patients who could tolerate prosthesis
instruments designed for the purpose1.
with some degree of adjustment. 3- TOLN:
Patients who could tolerate nothing.
Role of Communication Skills in Dentistry
Blum classified the patients into Reasonable
A Dentist should have good communication and Unreasonable.
skills besides clinical and technical skills, as in
today’s competitive world, it will definitely give Alex Koper gave the term Difficult denture
an extra edge to their practice. bird.4
In Dentistry role of good communication skill The Dentist’s behaviour

can be broadly divided into 4 categories:-
The success of dental treatment is predicated
1. Dentist – Patient communication not only to manual dexterity but also on the ability
2. Dentist – Technician communication. of the dentist to relate to patients and to
3. Dentist – Dentist communication. understand their needs. The dentist’s relation with
the patient are also extremely important for they
4. Practice Management. help to determine the course of treatment as well
as any future attempts at seeking the treatment.
Dentist - Patient Communication Dentist must have a sense of real concern for the
health, comfort and welfare of the patient to
A healthy relationship between the Dentist and establish necessary mutual confidence, a tender
the Patient is fundamental to the successful loving care approach towards dental patient should
practice of dentistry; a breakdown in be taken before treatment and continued
communication process often leads to patient throughout the treatment planning and treatment
dissatisfaction and therapeutic failures. The success itself.2 As a Dentist, we must know what may
of prosthesis is multifactorial such as technical happen to body of all individuals when the mind
procedures, functional factors, esthetics, biologic is disturbed and what may happen to the mind and
determinants and psychological factors. behaviour of an individual when the body is
Psychologically every individual had primary and diseased.
secondary needs. Assuming the Dentist has a basic
knowledge of psychology, he should be able to The Dentist must fully understand his patients,
place each patient in proper psychological as it predisposes the patients to accept the kind of
category. treatment they need and must maintain a positive
1037
and optimistic state of mind to face all the Handersen (1966), Leeper (1979) gave the
negative conditions along with precondition the work authorization instructions for the removable
minds of their patients for a successful prognosis. partial denture construction, and emphasised the
importance of including Choice of Metal for
Dentist – Technician Communication framework, material for the denture base, design
specification with colour coding in a diagrammatic
Anticipating satisfactory results is unrealistic if representation and selection of teeth.8
the dentist does not have a reasonable amount of Similarly according to Deyton (1994), Drago
experience and a thorough understanding of the (1996) a work authorization for Fixed Partial
dental laboratory procedures. Active participation Dentures should include material specification,
in the technical procedure by the dentist is desired occlusion scheme, design for connector and
paramount. Clinician who takes time to develop an pontic and the shade of the prosthesis with a
in-depth understanding of laboratory work will diagrammatic representation.12
make better clinical decisions because of their
understanding of applicable technical and material
Dentist – Dentist Communication
science limitations. The dental technician and the
dentist must be thought of as a working team, We being professionals have a duty towards
using all means of effective communication to the patient, that is to provide them the best
obtain a positive desired result.8 possible treatment and service, it is quite obvious
that at times patient may require treatment other
Effective communication is synonymous with than Prosthodontic treatment, so as to provide the
terms such as quality and success. The dental best we must not shy away in referring the patient
technician and the dentist working as a team, to the specialist of which the patient requires
should use all means of effective communication treatment. Thus in order to simplify and improve
to obtain a positive desired result. In most the communication between the professionals,
instances specialized laboratories may not be various classification and nomenclatures have been
located in conjunction with dental offices, in fact, developed, like the FDI system of tooth notation,
they may not even be in the same city, such a Classification of Facial Profile, Partially
situation strains the communication between Edentulous Arches, Classification for Clefts,
dentist and technician and makes the proper work Occlusion, Maxillary defects, Implant bone
authorizations critical, in providing a prosthesis Volume and Density, Patient’s Psychological
that accurately reflects the required design8. As makeup and many more, which should be
even if the technician has years of experience in effectively used.12,13.
the construction of the prosthesis, he or she has
not seen the clinical results of Prosthodontic In today’s dental practice to impart a
treatment and does have the biologic basis to conservative and biological sound interdisciplinary
evaluate the tissue response. treatment every dental practitioner must
communicate effectively with his colleagues.
Work authorization
Practice Management
It contains the written direction or channel of It is important how we represent ourselves to
communication for laboratory procedures to be the public, if conducted well it will help correct
performed for fabrication of dental restorations. years of misconception about dentistry and in turn
Sufficient information must be included to enable the Profession is benefited. It should begin with a
the technician to understand and execute the carefully prepared plan which includes: Patient
request.9,10 Many dentist are overly presumptive in Education, Office Atmosphere, Appearance and
assuming that a request can be acceptably fulfilled Attitude, and Staff training programmes.
without proper directions. It is sound practice to
provide the dental laboratory technician with CONCLUSION
adequate written instructions for each required
laboratory service in the fabrication of a Words are the most powerful drugs used by
restoration, American Dental Association in 1954 the mankind; hence the role of good
has issued guidelines to improvise communication communication skills should not be
between the Dentist and the Laboratory underestimated. An efficient Dentist will not only
technicial.11 give his patients the best possible treatment but
1038
will also provide him the necessary psychological 7. St. Arnault F.D, Dental laboratory work authorization
support to accept the treatment, which cannot be forms: a national survey of regulatory agency
achieved by the clinician or the technician alone. requirements, J Prost Dent 1991; 65,4 : 592-596.
8. Leepaer S.H: Dentist and Laboratory, a love hate
relationship, D.C.N.A 1979; 23; 87.
REFERENCES
9. Christensen G.J, Yancey W. Dental Laboratory
1. Kumar K.J: Business Communication, a modern technology in crisis, challenges facing the industry,
approach. 1982,Jaico publication house, Mumbai. JADA 2005; 136(5): 653-655.
2. Russell W. Schabel : Dentist patient communication-a 10. Christensen G.J, Yancey W. Dental Laboratory
major factor in treatment prognosis, J Prost Dent technology in crisis, Part II: Potential solution to the
1969; 21; 3-5. challenges facing the industry, JADA 2005; 136(6):
3. Gamer etal: M.M House classification revisited. J.P.D 783-786.
2003; 89, 297-302. 11. Henderson David: Writing work authorization for
4. Koper Alex: Difficult denture bird, J Prost Dent 1967; Removable partial denture patients, JIPS 2007;7:
17, 532-39. 71-76.
5. Hirsch and Tiber: Effects of dentist authoritarianism 12. Drago CJ : Clinical and Laboratory parameter in fixed
on patient evaluation of dentures, J Prost Dent. 1973; partial prosthodontics treatment, JPD 1996; 76,
30: 745-748. 233-37.
6. Americal dental association, current policies, 13. Quinn I: Status of dental laboratory work
1954-2003, pg 137-140, Chicago. authorization. JADA 1969; 79: 1189-1190.
1039
Caries Prevalence among 5-12 years School Children

residing in Rural Chennai
Dr. M. Senthil Kumar1, Dr. S. Bala Gopal2, Dr. Sridhar Reddy3, Dr. A.Venkatesh4
ABSTRACT
Aim: The aim of the study was to assess, prevalence of dental caries and treatment needs of children
in age groups from 5 to 12 years and to plan appropriate dental care in Vandalur Taluk, rural Chennai.
Materials and methods: A cross sectional study was conducted in Rural Chennai, in school children
of age 5 to 12yrs. Each child was clinically examined in the schools by calibrated examiners. The dentition
status and treatment needs were used to assess dental caries. Chi square test was applied to evaluate caries
prevalence in relation to age and gender. ANOVA test was used to assess any significant difference between
mean dmft /DMFT in relation to age and gender.
Results: 274 school children (157 Boys and 117 Girls) of 5 to 12 years were surveyed. Caries
prevalence was 56.56% and 15.88% in primary and permanent dentition respectively. The mean dmft and
decayed, missing filled tooth (DMFT) Scores were 3.00 and 0.17 respectively. The mean dmft decreases
with age (P<0.01) where as the mean DMFT increased with age (P<0.001). The mean dmft scores were
statistically significant for the two genders. The mean DMFT score was found to be higher among girls
than boys. The entire dmft/DMFT value represented the ‘decay’ component only.
Conclusion: The present study concludes that the prevalence of dental caries is much higher in 5-7
age groups when compared to others.
Key words: Dental caries, Prevalence, School, Treatment needs, Rural Chennai.
INTRODUCTION also found that caries was higher in the mandibular

arch than in the maxillary arch among both the
Dental caries is an important Dental Public
gender with a statistically significant difference3.
Health Problem and it is the most prevalent oral
disease among children in the world. The A study on 5year old and 12 year old school
prevalence of dental caries is of great interest for going children in Chennai, by Mahesh kumar et
long and is a principal subject of many al, found that in an age group of 5 years, 53.8%
epidemiological researches carried out in our boys and 46.2% girls suffered dental caries. In 12
country and abroad. This disease not only causes year age group, 52.8% boys and 47.2% girls were
damage to the tooth, but is also responsible affected with dental caries4.
forseveral morbid conditions of the oral cavity and
other systems of the body (WHO 1981)1. The prevalence pattern of dental caries not
only varies with age, sex, socio economic status,
According to a previous study done by Amjad race, geographical location, food habits and oral
et al on caries prevalence and pattern in preschool hygiene practices but also within the oral cavity.
children in Riyadh, Saudi Arabia it was found that All the teeth and all the surfaces are not equally
majority of the children (50.3%) had both posterior susceptible to caries. It is of interest therefore, to
and anterior tooth caries. 42.2% had posterior know the relative caries susceptibility of the teeth
tooth caries, while 7.5% had anterior tooth caries. in the maxilla and mandible.
It was concluded that caries prevalence had no
relation to gender of the children2. The main objective of this investigation was
to assess the prevalence pattern of dental caries
Sharma et al in their study among children in among 5-12 years old school children residing in
Simla, H.P, found that caries prevalence was vandalur taluk, Chennai.
higher in boys (46.8%) than in girls (41.6%). They
1
Reader, 2Vice-Principal and Head, Dept. of Conservative Dentistry and Endodontics, 3Senior Lecturer, Dept. of Community
Dentistry, Tagore Dental College and Hospital, Chennai. 4Reader, Dept. of Conservative Dentistry and Endodontics, Sree
Balaji Dental College and Hospital, Chennai.
1040
MATERIALS & METHODS Statistical test

Mean and standard deviation, percentage were
A cross section study was conducted among
calculated to express dmft/DMFT. Chi square test
school children of age groups from 5 to 12 years
was applied to evaluate caries prevalence in
, in vandalur taluk. The sample size was decided
relation to age and gender. ANOVA test was used
based on study done in Chennai which came
to assess any significant difference between mean
around 265 children4. A cluster sampling method
dmft/DMFT in relation to age and gender.
was used to get the required sample size. A list
of school was taken from department of education,
RESULTS
vandalur and one school was selected as a cluster
randomly. A total of 274, 5-12 year old children were
surveyed, among whom there were 157 (57.2%)
The consent from ethical committee of the
boys and 117(42.7%) girls. The children belonged
institution was obtained prior to the start of the
to different dentition periods (Table 1).
study. Permission to conduct the study was
obtained from the head of the school. The consent Table 1. Distribution of study population by age and gender.
letter was sent to the parents highlighting the
purpose and advantages of this study. After, verbal Boys Girls Total
Age
consent was obtained from the parents; the n % n % N %
children were subjected to examination.
5-7 45 28.66 33 28.20 78 28.46
School going children, aged 5 to 12 years who 8-10 59 37.57 46 39.31 105 38.32
were present on the day of examination were
included in the study. The children, who were 11-12 53 33.75 38 32.47 91 33.21
found to be uncooperative, mentally retarded, with Total 157 117 274
systemic disorders and who has not given inform
consent were excluded in this study.
As shown in Table 2, the prevalence of caries
Clinical examination was carried out using in primary and permanent dentition was 57% and
mouth mirror and CPI probe to assess dentition 16% respectively. Caries was more prevalent in the
status and treatment needs. The examination was
primary dentition of girls (70.94%) than in boys
carried in a systematic approach to assess the
dentition status of treatment needs. The (47.85%), while in permanent dentition it was
examination was preceded in an orderly manner found to be (25.0%) in girls and (10.44%) in
from one tooth or tooth space to the adjacent tooth boys).
or tooth space. A tooth was considered present in
Caries was more prevalent in the girls than in
the mouth when any part of it is visible. If a
boys in both the dentition. It was found to be
permanent and primary tooth occupy the same
tooth space, the status of the permanent tooth was 70.94% & 25% in primary dentition and
recorded. The treatment required was explained to permanent dentition respectively in girls and
the children and they were directed to nearby 45.85% and 10.44% in primary and permanent
college hospital. dentition respectively in boys.
Table 2. Caries prevalence by age and gender.
Children with primary teeth(x) Children with permanent teeth(xy)

Age(x,xy)
Caries affected (%) Caries Free (%) Total(%) Caries affected (%) Caries free (%) Total (%)
5-7 46 (58.97) 32 (41.02) 78 (28.46) 0 (0) 118 (100) 118 (37.57)
8-10 62 (59.04) 43 (40.95) 105 (38.32) 4 (3.80) 101 (96.19) 105 (33.43)
11-12 47 (51.64) 44 (48.35) 91 (33.21) 30 (32.96) 61 (67.03) 91 (28.98)
Total 155 (56.56) 119(43.43) 274 (100) 34 (15.88) 180 (84.11) 214 (100)
Gender:
Boys# 72 (45.85) 85 (54.14) 157 (57.29) 14 (10.44) 120 (89.55) 134 (62.61)
Girls» 83 (70.94) 34 (29.05) 117 (42.70) 20 (25) 60 (75) 80 (37.38)
Total 155 (56.56) 119(43.43) 274 (100) 34 (15.88) 180(84.11) 214 (100)
x df=2; x2=4.31 P>0.05 ; xy df=2; x2=5.11 P>0.05 ; # df=1 x2=3.59 P>0.05 ; » df=1 x2=2.01 P<0.05 [NS]
1041
Table 3. Caries experience in primary dentition by age and gender.
Mean dmft Score

Age F Value P Value
Boys Girls Total
5-7 3.3 ± 2.1 3.66 ± 1.8 3.45 ± 1.9
8-10 3.5 ± 1.1 2.4 ± 2.4 2.77 ± 2.69 Age(4.65) <0.01
11-12 2.8 ± 2.1 1.7 ± 0.9 2.57 ± 2.2 Sex(1.81) 0.05
Total 3.18 ± 2.8 2.83 ± 3.21 3.00 ± 2.6 Age & sex (1.36) 0.27(NS)
Table 4. Caries experience in permanent dentition by age and gender.
Mean DMFT score

Age F value P value
Boys Girls Total
5-7 0.0 ± 0.0 0.0 ± 0.0 0.0 ± 0.0
8-10 0.03 + 0.1 0.06 ± 0.3 0.05 ± 0.2 Age(10.65) <0.001
11-12 0.33 ± 0.87 0.38 ± 0.6 0.36 ± 0.8 Sex(5.46) <0.03
Total 0.15 ± 0.6 0.19 ± 0.6 0.17 ± 0.4 Age & sex (1.81) <0.19 (NS)
Table 5. Treatment needs of study population by dentition.
Children with primary teeth Children with permanent teeth

Treatment Needs
n % N %
No treatment 69 25.18 131 61.21
Preventive care 11 4.01 25 11.68
Fissure sealant 13 4.74 31 14.49
One surface filling 45 16.42 15 7.01
Two or more surface filling 79 28.83 10 4.67
Crown placement 2 0.73 0 0
Pulp care 20 7.3 2 0.93
Extraction 35 12.77 0 0
Total 274 100 214 100
The average dmft among the school children children examined, 274 had primary teeth and 214
are summarized in Table 3, according to age and had permanent teeth. As most of the children
sex. The mean dmft score was 3.45 in 5-7 years require more than one type of treatment, the
old. It was found to decrease with age being 2.57 figures shown are not mutually exclusive.
in the 11-12 years old. The dmft scores were not
statistically significant for the boys and girls, 3.18 DISCUSSION
and 2.83 respectively. There was no statistically
significant difference in comparing the mean dmft This study was conducted in 274 school
scores in relation to age & gender. The entire dmft children of age 5 to 12, out of which 157 were
score obtained was in relation to decayed teeth as boys and 117 were girls. In total 274 children, 274
missing and filled teeth were absent. had primary teeth and 214 had permanent teeth.
In 157 boys, 157 had primary teeth and 134 had
Table 4 shows a highly statistically significant permanent teeth. out of 117 girls , 117 had
(P<0.001) increase in the mean DMFT from 0.00 primary teeth and 80 had permanent teeth.
in 5-7 years old to 0.36 in 11-12 years old. Girls
experienced higher rates of caries (0.19) than the The results of the survey showed that the
boys (0.15). There was no statistically significant prevalence of caries in the primary dentition of 5
difference in the comparison of the mean DMFT to 12 year old children was 56.56%. A similar
scores in relation to age& gender. finding was reported among rural school children
in south western Germany5. In the present study,
Table 5.depicts the types of treatment needs the prevalence of caries in the primary dentition
for primary and permanent dentition. Out of 274 of five to six year old was 58.97%. The reported
1042
prevalence rates for caries are similar when study reveals the necessity for accessible and
compared to those for rural parts of western India affordable oral health services in the form of oral
6
and Uganda7. health education in community and school settings
to create awareness.
Our study also shows that the prevalence of
caries is higher than the WHO-formulated World
target of 50% caries free 5-6 year olds by the year REFERENCES
2000 A.D. The overall prevalence of caries in 1. World Health Organisation. Oral health survey. Basic
permanent dentition was 15.88% which is lower methods. 4th edition. Geneva, 1997
than caries levels reported in rural school children 2. Amjad H et al caries Prevalence, severity and Pattern
in the southwestern part of Germany5. in Pre-school children. Journal of contemporary
dental practice 2008, 9:1-8.
The mean dmft was 3.002.6 for the whole
3. Sharma K.R et al Prevalence of Dental caries and its
study population. In accordance with other
pattern among five old school going children in
studies8,9, the present study reports a decrease in Shimla city, Himachal Pradesh. Journal of The Indian
caries with increasing age, a trend also seen within Association of Public Health 2011, 17: 539-43
the same gender.
4. Mahesh kumar P et al. Oral health status of 5 years
The exfoliation of deciduous teeth in the older and 12 years school going children in Chennai city-
age group might explain why the mean dmft score An epidermological study. Journal of Indian Society
Pedo Prev Dent 2005,17- 22.
is lower for 11-12year olds10. Girls recorded higher
mean dmft scores than boys. 5. Zerfowski M, Koch MJ, Niekusch U, Staehle HJ.
Caries prevalence and treatment needs of 7- to
The mean DMFT score was 0.170.4 for the 10-year-old school children in southwestern Germany.
entire study population. Community Dent Oral Epidemiology 1997; 25:348-51.
6. Chat JD, Goyal RC. A cross-sectional study of factors
Studies conducted on caries in rural Punjab11
related to oral health in rural area od Loni, Western
(Northern India) and rural Karnataka9 (Southern Maharastra, Indian J Community Med 2002; 27:74-6,
India) reported an increase in mean DMFT Scores 96.
with increasing age. The present study also showed
7. Nalweyiso N, Busingye J, Whithworth J, Robinson
a positive correlation of mean DMFT scores with PG, Dental treatment needs of children in rural sub
age, being highest in the 11-112 year olds. The country of Uganda,int J Pedo Prev Dent 2004;
mean DMFT score was higher in girls (0.19) than 14:27-33.
in boys (0.15) again in accordance with earlier 8. Saha S, Sarkar S. Prevalence and severity of dental
studies 9,12. caries and oral hygiene status in rural and urban areas
Differences between the genders may be of Calcutta. J Indian Soc PedodPrev Dent 1196;
14:17-20.
largely attributed to the fact that eruption of teeth
is early in girls than boys 12. 9. Rao a, Sequeira SP, Peter S. Prevalence of dental
caries among school children of Moodbidri. J Indian
The caries experience was lower in permanent Soc Pedod Prev Dent 199; 17:45-8.
dentition (0.17) than in primary dentition (3.00). 10. Tewari S, Tiwari S, Caries experience in 3-7 years
This high caries experience in primary teeth could old children in Haryana (India).J Indian
be attributed to the fact that permanent teeth have SocPedodPrevDent 2001;19:52-6.
a lower susceptibility to dental caries6. It may also 11. Gauba K, Tiwari A, Chawla HS. Frequency
be due to the structural differences that may distribution of children according to dental caries
increase caries susceptibility in deciduous teeth13.In status in rural areas of northern India (Punjab).J
the present study, the total dmft or DMFT Indian Dent Assoc 1986; 58: 505-12.
represented only untreated decay and not the 12. Megas BF, Athanassouli TN, dental caries prevalence
missing or filled components. in the permanent teeth in Greek school children
related to age, sex, urbanization and social status.
CONCLUSION Community Dent Health 1989; 6:13-17.
13. Mandal KP, Tewari A, Chawla HS, Gauba K.
The present study concludes that the Prevalence and severity of dental caries and treatment
prevalence of dental caries is seen much higher in needs among population in the eastern states of India.
5-7 age groups when compared to others. The J Indian SocPedodPrev Dent 2001:19:85-91.
1043
Head and Neck Radiotherapy – Consequences and its

Management
Dr. Nidhi Gupta1, Dr. Mohit Bansal2, Dr. Shelja Vashisth2, Dr. Nanak Chand Rao3
ABSTRACT
Cancer is a class of diseases in which a cell or a group of cells display uncontrolled growth, invasion,
and sometimes metastasis. Head and neck cancers constitute a major proportion of regional malignancies
in India. “Head and Neck Cancer” usually refers to neoplasms arising from below the skull base to the
region of thoracic inlet. Radiation therapy is the most common form of treatment along with surgery and
chemotherapy in these types of cancers. In addition to anti-tumor effects, ionizing radiation causes damage
in normal tissues located in the radiation portals. Oral complications of radiotherapy in the head and neck
region are the result of the deleterious effects of radiation on salivary glands, oral mucosa, bone, dentition,
masticatory musculature, and temporomandibular joints.
In this review, the various possibilities for prevention and/or treatment of radiation-induced changes
in healthy oral tissues and their consequences are discussed.
Key words: Head and neck cancer, radiation therapy, chemotherapy, prevention.
INTRODUCTION combination with other modalities. Most patients

with head and neck carcinomas, treated with a
Head and neck cancer (HNCA) is the fifth
curative intent, receive a dose between 50 and 70
most common cancer worldwide and is the most
Gy. This dose is usually given over a five- to
common neoplasm in central Asia 1. In our
seven-week period, once a day, five days a week,
country, these (HNCA) account for 30-40%
2 Gy per fraction (Benchalal M, Bachaud JM,
cancers at all sites, out of which 9.4% are oral
François P et al 1995) 5.
cancers. It is the sixth common cause of death in
males and seventh in females. Many factors that In addition to anti-tumor effects, ionizing
are implicated for its causation are consumption of radiation causes damage in normal tissues located
tobacco in its various forms, alcohol, smoking in the field of radiation. This becomes particularly
habits, lack of awareness, and lack of proper evident in the head and neck region, a complex
nutrition 2. area composed of several dissimilar structures that
respond differently to radiation. These include
The anatomy and physiology of head and neck
mucosal linings, skin coverings, subcutaneous
region is uniquely complex as the function and
connective tissue, salivary gland tissue, teeth, and
appearance are critical to patient’s self image and
bone/cartilage. Acute changes produced by
quality of life. Most patients with head and neck
radiotherapy are observed in the oral mucosa
cancer are middle aged adult males in lower
(erythema, pseudomembrane-covered ulceration),
socio-economic classes who are chronic tobacco
salivary glands (hyposalivation, changed salivary
and alcohol consumers. Options for the treatment
composition), taste buds (decreased acuity), and
of head and neck cancers are surgery, radiotherapy
skin (erythema, desquamation). Late changes can
and chemotherapy 3
occur in all tissues (Cooper et al., 1995) 6 and
Radiotherapy plays an important role in the (Taylor and Miller 1999) 7. The preservation of
management of head and neck cancer. The form and function of these structures are the key
majority of new cases of invasive head and neck elements in over all management of head and neck
cancer will need radiotherapy as a primary cancer patients.
treatment, as an adjunct to surgery, in combination
In this article, the radiation-induced changes in
with chemotherapy, or as palliation 4. The radiation
healthy oral tissue and the resulting clinical
dose needed for the treatment of cancer is based
consequences are discussed. The radiation-related
on location and type of malignancy, and whether
changes in the oral mucosa, salivary glands, taste,
or not radiotherapy will be used solely or in
1
Professor, 2Senior Lecturer, 3Professor and Head, Dept. of Public Health Dentistry, Swami Devi Dyal Hospital and Dental
College, Golpura, Barwala, Distt. Panchkula.
1044
dentition, periodontium, bone, muscles, and joints predisposition of irradiated patients to

are discussed in the order that they appear. They candidasis is a reduced phagocytic activity of
can be divided into early (mucosa, taste, salivary salivary granulocytes against these
glands), intermediate (taste, salivary glands), and micro-organisms. Clinically, candidasis can be
late (salivary glands, dentition, periodontium, bone, seen both in its pseudomembranous and
muscles, joints) effects. erythematous forms. The latter can be difficult
to diagnose, and it may be confused with
Oral Complications of Radiotherapy-8 irradiation induced mucositis. Patients
complain more of pain and / or burning
Adverse reactions to radiotherapy will depend sensation 11.
on the volume and the area being irradiated, the
total dose, the fractioning, the age, the patient’s Oral candidiasis is usually managed by
clinical conditions and the associated treatments. frequent rinsing with a hydrogen peroxide-saline
Acute reactions occur during the treatment and solution and the use of topical antifungal
most of the time, they are reversible. Late medications such as nystatin (200,000-400,000IU
complications are normally irreversible, leading to 2-3ml retained in mouth for three minutes and then
permanent incapabilities worsening the quality of swallowed, four times daily). Systemic
life as they vary in intensity being normally ketoconazole 200mg daily for a minimum of two
classified into mild, moderate and severe. weeks is also recommended 12.
1. Mucositis Mucositis is defined as a mucosal 3. Xerostomia: Xerostomia, or "dry mouth is

irritation. Mucositis is believed to occur in another complication associated with
four stages (inflammatory/vascular, epithelial, radiotherapy. Patients with xerostomia
ulcerative/bacteriologic and healing). Mucositis complain of oral discomfort, taste loss, speech
may be aggravated by the trauma because of and swallowing difficulties. Saliva also suffers
ill fitting dentures, so patients are advised to qualitative alterations resulting from
keep denture wearing to a minimal during radiotherapy with decrease of amylase activity,
radiotherapy treatment 8. buffer capacity and pH, with consequent
The most used scale to measure oral mucositis acidification. There are also alterations of
is given by the WHO, which classifies several electrolytes such as calcium,
mucositis into four degrees. 9 potassium, sodium and phosphate 13. Thus,
individuals who were radiated are more
Degree 0 - When there are no signs or susceptible to periodontal disease, rampant
symptoms. tooth decay and oral infections by fungus and
bacteria 8.
Degree 1 - When the mucosa is erythematous
and painful. 4. Radiation caries: Patients, who had not
Degree 2 - Characterized by ulcers, and the experienced tooth decay for some time, may
patient can eat normally. develop radiation caries when submitted to
radiotherapy 14. The main factor for the
Degree 3 - When the patient has ulcers and development of such injuries is the decrease
can only drink fluids. of saliva amount and its qualitative alterations.
Degree 4 - When the patient cannot eat or Besides this, radiation has a direct effect on
drink. teeth, making them more susceptible to
decalcification 4.
2. Candidasis: Oral candidasis is a common
infection in patients being treated for upper 5. Osteoradionecrosis: Osteoradionecrosis
airways and digestive tract malignancies. (ORN) is a bone ischemic necrosis caused by
Colonization of oral mucosa can be found in radiation, being one of the most serious
as many as 93% of these patients, whereas consequences of radiotherapy, causing pain as
Candida infection can be found in 17-29% of well as possible substantial loss of bone
patients submitted to radiotherapy 8. The structure 15. ORN may occur spontaneously or
increased risk for oral candidasis is likely to more commonly, after trauma (generally dental
be the result of drop in salivary flow as a extractions). Therefore, tooth extraction should
consequence of radiotherapy 10. Besides, a be avoided even after many years of head and
possible explanation for a higher neck radiotherapy Decreased local
1045
vascularisation and its consequent radiation located in the radiated tissue, without the
impaired healing capacity, particularly in the presence of residual malignancy. Soft tissue
mandible, is the main cause of necrosis is a normally painful condition and
osteoradionecrosis. Mandibles are more good oral hygiene together with the use of
affected than maxillas and patients with their painkillers and at times, antibiotics, are
natural teeth have greater chances of necessary to manage the condition. Since
developing ORN. Spontaneous bone exposure ulcerations are often seen on the tumor
may occurs approximately one year after primary site, regular evaluations are necessary
finishing radiotherapy and the risk of until the necrosis retreats, therefore excluding
developing this complication remains the possibility of recurrence. Besides, soft
indefinitely. ORN may also result in oedema, tissues may suffer from fibrosis after
suppuration and pathological fractures, which radiotherapy, becoming pale, thin and without
may occur in 15% of patients, always flexibility. When fibrosis affects chewing
experienced together with pain 8. musculature (temporal, masseter and pterygoid
muscles) trismus can happen. In the most
6. Soft tissue necrosis: Another possible
serious cases, trismus may interfere with
consequence of radiotherapy is soft tissue
eating and dental care 8.
necrosis, which may be defined as an ulcer
Phases of Dental Care for Head and Neck Radiotherapy Patients 8
Phase-I PRETREATMENT ORAL ASSESSMENT

Initial appointment Consultation with surgeons, radiation oncologists and radiotherapists at multidisciplinary meeting. Assess
surgical requirements with respect to future prosthetic considerations, fields, dose, volume and urgency
of radiation treatment and medical contraindications to dental intervention. Referral of patients with
potential dental complications to the dental clinic.
Dental examination Extra-oral head and neck examination. Intra-oral examination of hard and soft tissues, including
assessment of oral hygiene status. Radiographic and periodontal examination. Patient education
regarding the oral complications of head and neck radiotherapy. Assessment for pre-radiation extractions.
Phase-II PREPARATORY TREATMENT
Elimination of infection Initial restorative treatment, periodontal treatment and/or dental extractions as indicated. Extractions to be
performed as soon as possible, ideally at the time of initial (cancer) surgery, with careful surgical
technique, alveoloplasty and primary closure.
Education and review Thorough oral hygiene instruction and reassessment. Nutrition and diet advice. Review dental extraction
sites prior to commencement of radiotherapy.
Phase-III DURING TREATMENT
Nursing management Relief of complications such as mucositis, stomatitis, candidiasis. Prevention of further complications.
Phase-IV POST-RADIATION TREATMENT
Prevention Prevention of radiation caries by education, diet modification, salivary stimulation, chlorhexidine and
fluoride use. Prevention of ORN by avoiding post-radiation extraction of teeth in the radiation fields. If
extractions are unavoidable, refer for possible HBO treatment.
Restoration Definitive treatment for any deferred/non-urgent procedures. Delay denture construction at irradiated sites.
Management Restorative management of carious lesions. Consider HBO for management of ORN.
Maintenance Regular prophylaxis and fluoride as part of a life-long preventive protocol.
Orodental Care before Radiotherapy8 radiotherapy. A panoramic radiograph plus

selective periapical or bitewing films (or both)
Proper screening of oral health, careful dental should be done for preradiotherapy dental
treatment planning is essential to minimize the oral
assessments. Many oral conditions, such as poor
diseases and possible adverse consequences. The
screening includes complete dental evaluation from oral hygiene, broken teeth, defective restorations
dental surgeon with full description of the and periodontal disease, are likely to precipitate
radiation treatment. It is always beneficial to complications during and after a course of
achieve a good level of oral hygiene before radiation therapy.
1046
Orodental Care during Radiotherapy8 (d) Regular inspection of mouth by the patient and
health professionals; report any redness,
Monitoring of the oral cavity decreases the tenderness or sores on the lips or in mouth;
severity of side effects. Systematically applied oral provide comfort measures such as lubrication
hygiene protocols may reduce the incidence, of the lips, topical anesthesia and analgesics.
severity and duration of oral complications.
Dietary control, especially elimination or reduction (e) Prompt treatment of mucositis symptoms and
in use of sugars, is also beneficial. Refined oral infections. Long-term management and
carbohydrates should be replaced with substances close follow up of patients after radiation
such as sorbital, xylitol, aspartame and saccharine therapy is mandatory.
that cannot be degraded into organic acids by oral
bacteria. Maintenance of good oral hygiene, CONCLUSION
brushing two times daily with soft-bristled tooth Radiotherapy is the known treatment modality
brush and fluoride toothpaste or gel, to help for cancers of head and neck. There are a number
prevent plaque accumulation and demineralization of oral complications associated with this
or caries of the teeth; flossing daily is of great treatment. The complications of radiotherapy in
help. The discomfort of mucositis is reduced with, head and neck cancers must be considered
coating agents, topical anesthetics, analgesics and thoroughly and every effort should be undertaken
systemic analgesics. In general, mucositis should to minimize the oral morbidity before, during and
be treated conservatively. Stannous fluoride 0.4 per after cancer treatment and throughout the patient’s
cent gel, Acidulated phosphate fluoride 1.23 per lifetime. The dental professional plays a relevant
cent gel are essential and should be started on the role in the prevention and healing or control of
first day of radiation therapy, continued for life or the oral complications. It is important to prevent
the duration of therapy. Plaque control and oral and treat orofacial complications which require an
hygiene should be maintained with tooth brushing, multidisciplinary approach, that includes a
a soft bland diet, avoiding irritants such as dedicated team of radiation oncologist, head and
tobacco, alcohol or spices. Maintenance of neck surgeon, dentist, nurse, dietician, physical
adequate hydration and nutrition is helpful. Jaw therapist, social worker and in some instances
exercises may limit the severity of trismus, but plastic surgeon, prosthodontist, and psychologist.
they will not mobilize fibrosis once it has
occurred. Health care providers are concerned
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infections in addition to managing oral symptoms. 1. Emily Crozier E, Sumer BD. Head and Neck Cancer.
A fungal, bacterial or viral culture is recommended Medical Clinics of North America 2010; 94(5):
if infection is suspected. Frequent ingestion of 1031-46.
small amounts of food (every 1-2 hours), ingestion 2. Bhattacharjee A, Chakraborty A, Purkaystha P.
of foods containing abundant calories and proteins Prevalence of head and neck cancers in the north east
is recommended. Stimulate appetite with light - An institutional study. Ind J Otolaryngology and
exercise, creative menus, avoidance of strong Head and Neck Surgery 2006; 58(1):15-9.
aromas. 3. R Atri, AK Dhull, V Nair, R Dhankhar, V Kaushal.
Orodental Care related to Radiotherapy for Head and
Neck Cancer. J Oral Health Comm Dent 2007; 1(3):
59-62.
Orodental Care Post Therapy 8
4. Bonner JA, Harari PM, Giralt J, Azarnia N, Shin DM,
Interventions that may be beneficial following Cohen RB etal. Radiotherapy plus cetuximab for
treatment include: squamous-cell carcinoma of the head and neck. N
Engl J Med. 2006; 354(6): 567-78.
(a) Clean teeth and gums after meals and before 5. Benchalal M, Bachaud JM, François P et al.
sleep with tooth brush or swab as tolerated; Hyperfractionation in the reirradiation of head and
rinse the mouth with water regularly. neck cancers. Result of a pilot study. Radiother Oncol
1995: 36: 203–10.
(b) If dentures are worn, remove and clean them 6. Cooper JS, Fu K, Marks J, Silverman S. Late effects
daily and leave out while at rest. of radiation therapy in the head and neck region. Int
J Radiat Oncol Biol Phys 1995; 30: 1141–64.
(c) Avoid painful stimuli such as hot food and 7. Taylor SE, Miller EG.. Preemptive pharmacologic
drinks, spicy food, alcohol and smoking. intervention in radiation- induced salivary
1047
dysfunction. Proc Soc Exp Biol Medical 1999; 221: 12. Nectarios Andrews, Chris Griffiths. Dental
14–26. complications of head and neck radiotherapy: Part 2.
8. Bruno Correia Jham 1, Addah Regina, Da Silva
Australian Dental Journal 2001; 46(3): 174-182.
Freire. Oral complications of radiotherapy in the head
and neck.Rev Bras Otorrinolaringol 2006; 13. Davies AN, Broadley K, Beighton D. Salivary gland
72(5):704-8. hypofunction in patients with advanced cancer. Oral
9. Pico JL, Avila-Gavarito A, Naccache P. Mucositis: its Oncol 2002; 38: 680-5.
occurence, consequences and treatment in the
oncology setting. Oncol Phys Educ 1998; 3: 446-51. 14. Silverman, S.Jr. Oral cancer. Complications of
10. Silverman S Jr, Luangjarmekorn L, Greenspan D. therapy. Oral Surg OralMed Oral Pathol Oral Radiol
Occurrence of oral candida in irradiated head and Endond 1999; 88: 122-6.
neck cancer patients. J Oral Med 1984; 39: 194-6.
15. Spetch L. Oral complications in the head and neck
11. SymondsRP. Treatment-induced mucositis: an old
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1048
Prevalence of Gingival Recession in Lucknow, Northern

India - A Cross Sectional Survey
Dr. Ranjana Mohan1, Dr. Mohan Gundappa2
ABSTRACT
Background: To study the prevalence of gingival recession in Lucknow, capital of one of the most
populace state of Northern India.
Method: 500 individuals randomly selected from the clinics of Saraswati Dental College and Hospital,
Lucknow and the extent and cause of gingival recession was determined. The subjects were divided into
five age groups for evaluation of data.
Results: From the analysis of the data it was determined that the prevalence of gingival recession
either in terms of cases or in terms of affected teeth increases with the age and for the subjects above
the age of 50 years it reached 100%. Within various groups, the prevalence of gingival recession in males
was higher than those in females, number of the affected teeth ranged from one to ten measuring 1 to 3
mm and facial surface was found to be the most affected one. Lower incisors as against upper ones, upper
canines against lower canines, upper premolars against lower ones and upper molars against lower molars
were greatly affected. Main etiological factors determined were improper use of oral hygiene aids, frenum
pull, mal-alignment of teeth and local irritants.
Conclusion: Study conducted on Indian population showed the high prevalence of gingival recession
with increasing age in terms of extension and severity suggesting the cumulative effect of the lesion,
associated with the longer period of exposure to the etiologic agents.
INTRODUCTION causes of tooth root exposure. Goldman8 stated

also that middle aged people usually show gingival
Gingival recession is a commonly observed
recession. He added that recession may be normal
dental finding with its sequel namely root
or may have resulted from disease, either local or
hypersensitivity is posing a problem to the
systemic. Glickman9 and Goldman8 seemed to
clinicians today. It is implicated as a causative
concur with Gottilieb’s passive eruption theory and
factor for pulpal hyperemia, root caries
its relation to gingival recession. According to
susceptibility due to the exposed root area, and
Gottlieb, the epithelial attachment proliferated
open areas interproximally acting as food traps.
apically throughout life. Miller10 has stated that
Gingival recession is cosmetically undesirable
gingival recession resulted from occlusal
denudation of tooth cementum due to the apical
traumatism produced by over function and / or
movement of the epithelial attachment1 which
under function, improper tooth brushing and
leaves an underlying dentinal surface that is
psychosomatic factors particularly associated with
extremely sensitive, particularly to touch,
depression. Wheeler11 noted that flat faced tooth
chemicals and thermal changes.1, 2, 3
crowns with little or no curvature were usually
The dental literature contains numerous found in early recession cases. Emslie12 suggested
references quoting the etiology of gingival that age, direct trauma to the gingiva, occlusal
recession. Orban4 suggested that gingival recession trauma, high frenum attachment, malpositioned
resulted from the apical shift of the epithelial teeth and calculus played important role in
attachment was a physiologic phenomenon of etiology. Staffileno13 reported that focal gingival
aging while Williams5 and Bass6 felt that recession recession was generally associated with
was strictly a pathologic condition. Boyle7 equated inflammatory periodontal disease.
gingival recession with periodontal atrophy. He
Glickman14 added to these lists of predisposing
cited Hirshfeld as saying that local trauma due to
factors by suggesting that susceptibility to
toothbrush misuse might be the exciting cause. He
recession was influenced by thinning of bone due
also listed physiologic aging and inflammation as
1
Professor and Head, Dept. of Periodontics, 2Principal, Professor and Head, Dept. of Conservative Dentistry and
Endodontics, Teerthanker Mahaveer Dental College and Research Centre, Moradabad. U.P.
1049
to tooth position or angulation. Where bone was William’s graduated periodontal probe under bright
thin or reduced, the gingival margin was light. The participants of the present study were
unsupported. Slight pressure such as tooth brushing evaluated by a single examiner. In cases on which
wear away the gingiva and recession follows. the cemento-enamel junction was covered by
According to some authors the epithelial tissues calculus, hidden by a restoration or lost due to
and its movement at the time of the eruption of a
wear or carious lesions, the location of such
tooth has bearing on the position of the gingival
junction was estimated on the basis of the adjacent
margin and subsequent recession. It is worth
analyzing this aspect. teeth. Linear measurements were made from the
cementoenamel junction to the crest of the free
The etiology of gingival recession, whether margin of the gingiva and from the gingival crest
localized or generalized, is not fully understood, to the fundus of the periodontal pocket.
however the following factors have been
Measurements at the mesial, distal and midline
considered as playing some role in their etiology
were recorded in mm. on the facial and oral
such as tooth malposition, tooth to bone
relationship, tooth brushing trauma, trauma from surface of each tooth surfaces. P D Miller index15
occlusion, orthodontic movements, high frenum was used to assess the gingival recession.
attachment, mechanical trauma, local irritants, Data was subjected to Statistical analysis using
improper restorative procedures, psychosomatic Chi squire test.
factors, periodontal surgery and disease and dental
extractions.
RESULTS
Taking into consideration the exhaustive data
409 cases out of these 500 cases examined,
available from the developed countries, there is a
were found to have their teeth affected due to
lack of information on the gingival recession in
Indian population. Whatever the data exist, it gingival recession. 321 males out of 328 (87%)
remains inconclusive in the region of northern and 88 females out of 132 (67%) were amongst
India. Hence this cross sectional survey was the group of cases with affected teeth. In terms of
undertaken to study the prevalence and probable number of teeth, 5282 teeth out of a total of
etiological factors of gingival recession in 11,454 teeth examined (46%) were found to have
Lucknow, the capital of one of the most populace been affected. In males and females, these
states of northern India. percentages worked out to 50% and 37%
respectively.
MATERIALS & METHOD Fig 1 summarize the information on number
The survey sample consisted of a total 500 of cases examined, number of teeth examined,
cases, 368 males and 132 females of the age group number of cases with affected teeth and number
ranging from 4 and 80 years. The subjects for the of affected teeth according to gender and different
study were selected from Out Patient Department age groups. Irrespective of the gender, the
of Saraswati Dental College and Hospital, prevalence of gingival recession either in terms of
Lucknow. Subjects with edentulous ridges were cases or in terms of affected teeth increases with
dropped from the study. All participants were the age and for the subjects above the age of 50
informed on the evaluation to which they would years it reached 100 percent within the various age
be submitted and signed an informed consent term groups. The prevalence of gingival recession in
for participation in the study. The information males was on the higher side than those in females
regarding dental history, habits and home care of
except for the group of subjects below the age of
the subjects was taken on a special proforma
prepared for the study. Ethical clearance was 10 years.
obtained from the institutional ethical society Fig 2 gives the information of gender wise
based on declaration of Helsinki. distribution of subjects in various groups classified
The sample was divided into five groups by according to number of affected teeth. In majority
age: Group I <10 years, Group II- 11 to 20 years, of subjects (225 out of 409 i.e. 55%) the number
Group III- 21-30 years, Group IV- 31-50 years, of affected teeth ranged between one and ten. It
and Group-V >50 years. Dental examination was has also revealed that in each group, the proportion
conducted with the aid of a mouth mirror and of males was larger than that of females.
1050
Fig. 1. Prevalence of Gingival Recession – Age Group & Gender wise (In terms of subjects and teeth)
Fig. 2. Distribution pattern of subjects with affected teeth

SURFACES Miller’s class I, II, III. Class IV score as shown
in Fig 5 and 6.
The data was further analyzed to study the
surfaces of teeth affected by gingival recession.
The information on the surfaces of teeth affected AETIOLOGICAL FACTORS
and classified according to gender is summarized Fig 7, 8, and 9 presents number of teeth of
in fig 3. On an average it suggests that the larger subjects in various age groups affected due to
proportion of surface affected were facial in all the seven different etiological factors for all subjects
age groups except in groups of females above 50 males and females respectively. Irrespective of sex,
years of age. in a group of patients below the age of 10 years
the main factors responsible for gingival recession
RECESSION SCORE were local irritants, frenum pull, and malalignment
of teeth. In the group of cases above the age of
Information on number of subjects as well as 10 years, improper use of oral hygiene aids was
number of affected teeth according to range of responsible for gingival recession in more that
recession score in mm. and grades is presented in 50% in males. However, in females between 11
Fig 4. It also indicate that irrespective of sex, in and 20 years and above the age of 50 years, the
majority of cases as well as teeth the recession proportions of females with affected teeth were
score ranged between 1 mm and 3 mm. and below 26%. In subjects with the age ranging
1051
Fig. 3. Distribution pattern of teeth surface affected with Age group – Gender wise
No. of subjects with affected teeth No. of affeed teeth

Fig. 4. Distribution of subjects with affected teeth according to Gingival Recession Score in mm
Fig. 5. Total no. of teeth affected according to PD Miller’s classification
between 11 to 20 and 21 to 30, local irritants was prevalence of gingival recession in terms of
the second important factor responsible for affected teeth increased with the age.
gingival recession. Irrespective of the gender, the
1052
Fig. 6. Total no. of subjects affected according to PD Miller’s classification for Gingival Recession
Fig. 7. Distribution pattern of teeth affected according to etiological factors
Fig. 8. Distribution pattern of affected teeth according to etiological factors (In males)
1053
Fig. 9. Distribution pattern of affected teeth according to etiological factors (In females)
TYPES OF TEETH years, prevalence was more in first molars

followed by third molars and then by 2nd molars.
Summary of information collected on
maxillary and mandibular incisors (central and DISCUSSION
lateral) examined and affected, canines (maxillary
and mandibular) examined and affected, maxillary The present cross sectional study was
and mandibular premolars {1st and 2nd} and undertaken primarily to determine the prevalence
maxillary and mandibular molars (1st, 2nd, and of clinically visible tooth root exposure and relate
3rd) examined and affected reveals that the it to age, gender, tooth type and identify different
proportion of teeth affected due to gingival etiological factors.
recession within each type of teeth increases with Randomly selected 500 cases aged between 4
the age. In subjects above 50 years of age the and 80 years examined at Saraswati Dental
prevalence of gingival recession has reached to a College and Hospital, Lucknow. 409 cases out of
level of 100 percent. 500 cases examined (82%) were found to have
their teeth affected due to gingival recession. It
Within incisors, central incisors (either was found that 321 males out of 328 (87%) and
maxillary or mandibular) have greater tendency to 88 females out of 132 (67%) were amongst the
get affected due to gingival recession. On an group of cases with affected teeth. In terms of
average, 35% of maxillary central incisors as number of teeth, 5282 teeth out of 11,454 teeth
against 17% of maxillary lateral incisors and 80% examined (46%) were found to have been affected.
of mandibular central incisor as against 46% of In males and females these percentages worked out
mandibular lateral incisors got affected. A larger to be 50% and 37% respectively. Irrespective of
proportion of maxillary canines were found to the gender it was found that the prevalence of
have been affected than the mandibular canines gingival recession, either in terms of cases or in
within each age group. terms of affected teeth increases with the age and
for the subjects above the age of 50 years it
Amongst the premolars, maxillary premolars reached 100% possibly due to advancing age and
found to be affected in larger proportion than the periodontal diseases.
mandibular premolars and within maxillary and
mandibular 1st and 2nd premolars, 1st premolars A survey done by Ervin and Bucher16 revealed
were the most affected ones. that the younger individual (20-29 years) had
lower incidence of exposure (60.4%), while the
Amongst the molars, the prevalence of older individual (over 50 years) showed much
gingival recession was higher in 1st molar greater incidence of recession (96.6%) Similarly
(maxillary and mandibular) followed by 2nd and Stahl and Morris17 observed that gingival
3rd, in subjects < 50 years of age. However, within recessions increased with age among army
mandibular molars of subjects above the age of 50 personnel at the Army Engineer centre. According
1054
to Gorman18 the occurrence of recessions was years the improper use of oral hygiene aids was
found to vary from 62% of all the subjects in the responsible in more than 50% in males. In the age
16-26 age group to 100% of the subjects in the group of 31 to50 years and above 50 years,
46-86 age group. periodontal diseases and surgery was the main
causative factors as per the statistical analysis.
Within the various age groups, the prevalence
of gingival recession in males was on the higher Regarding the type of teeth affected it was
side than those in females except in the group of found that on an average, 35% of maxillary central
subjects below the age of 10 years. It was incisors as against 17% of maxillary lateral
observed that in majority of subjects (225 out of incisors, 80% of mandibular central as against 46%
409 i.e. 55%), the number of affected teeth ranged of lateral incisors got affected, 82% of maxillary
between one and ten. It was also observed that in canines against 43% of mandibular ones, 63% and
each of the groups the proportion of males was 42% of maxillary 1st and 2nd premolar respectively
larger than that of females according to statistical against 25% and 16% of mandibular 1st and 2nd
analysis. premolar. 75%, 56% and 55% of maxillary 1st, 2nd
and 3rd molars respectively as against 41%, 28%
Data was further analyzed to study the and 40% of mandibular 1st, 2nd and 3rd molars
surfaces of teeth and found that the larger were the most affected teeth. However, within
proportion of surfaces affected were facial in all mandibular molars of subjects above the age of 50
the age groups. This finding is similar to the study years the maximum prevalence was in first molar
done on the human skills.19, 20, 17 It was reported which is a usual finding followed by third molars
that fenestrations and dehiscence are more and then by 2nd lower molar which is an unusual
frequently observed on the labial alveolar plate and finding. Kitchin21 found that the gingival recession
rarely seen on the lingual alveolar plate. However, increased both in frequency and severity with age.
the atypical finding in the present study is that the
facial surfaces are less affected in the group of Within the various age groups, the prevalence
females above 50 years of age. of gingival recession in males was on the higher
side than those in females except in the group of
Observations made according to range of subjects below the age of 10 years. When the
recession score in mm is that irrespective of gender of subject in various groups classified
gender, in majority of cases (274 i.e. 67%) as well according to number of affected teeth, it was
as number of teeth (3058 i.e. 58%), it ranged observed that in majority of subjects (225 out of
between 1 mm and 3 mm and Miller’s class I to 409 i.e. 55%), the number of affected teeth ranged
III, increasing with age. This finding correlates from one and ten. It was also observed that in
with that of large number of other workers.21, 69, each of the groups, the proportion of males was
and 24
larger than that of females according to statistical
Kitchin21 found that the root exposure in the analysis.
age group of 20-29 was generally 0.5 mm and
increased with age. Ervin and Bucher 69 observed According to Murray23, the high prevalence of
that 80% of the 1,252 subjects examined had 1.0 gingival recessions affecting the mandibular
mm more of root exposure on one or more teeth. incisors might be associated with the extremely
Gorman24 stated that 129 subjects (78.5%) thin or even absence of alveolar bone in some
exhibited gingival recessions of 0.5 mm or greater. instances. Several studies24,25,26 have found the
mandibular central incisors to be most often
Gingival recession is related to certain affected, frequency was 2.5 times greater than for
pre-disposing anatomic factors e.g. the height, the lateral incisors. However some authors have
thickness of underlying bone and tooth alignment. found gingival recessions to be the most frequent
Thinner tissues are subjected to greater trauma and on the maxillary cuspid18 and on the vestibular
irritation and subsequently destruction of bone and surface of the first premolar.18, 27
gingiva may result in recession.22
O’Leary at al28 observed that recession
In a present study, it was observed that in a occurred more frequently on the maxillary
group of subjects below the age of 10 years, the posterior segment. He felt that the alveolar plate
main factors responsible for gingival recession is considerably thinner than that of mandibular
were frenum pull, malalignment of teeth and local posterior segment. The incidence of gingival
irritants. In a group of cases above the age of 11 recession affecting the mandibular incisors was
1055
three times greater than that involving the 11. Wheeler, R. C. Text book of Dental anatomy and
maxillary incisors. Physiology 2nd Edition Philadelphia, & London, The
W. B. Saunders Co., 1958. p- 79.
Studies on prevalence of gingival recession in 12. Emslie, R.D. Localized gingival recession, Internat.
the western and southern part of India,29, 30 on D. J. 8:18, March 1958(Abstract).
children and in rural area respectively, related the 13. Staffileno, H. Management of gingival recession, D.
various etiological factors with recession of Clin. N. America, March 1964, p. 111
gingiva and observed that the cause is multi 14. Glickman, I. Clinical Periodontology, 3rd Edition,
factorial increasing with age. Philadelphia and London, W. B. Saunders Co., 1964,
p.101.
15. Miller, P.D. A classification of marginal tissue
CONCLUSION recession. J Periodontal Res Dent 1985; 5: 9
High prevalence, extension and severity 16. Ervin, J. Bucher, E. Prevalence of tooth root
observed with increasing age, suggests the Exposure and abrasion among Dental patients, Dental
items of interest, 66: 760, 1944.
cumulative effect of the lesion, associated with the
17. Stahl, S.S. Morris, A.L. Oral health conditions among
longer period of exposure to the etiologic agents,
army personnel at the Army Engineer center, J.
which should be identified and managed by Periodont, 26: 180, 1955.
various treatment modalities as early as possible 18. Gorman, W. J. Prevalence and etiology of gingival
in order to reduce or even avoid worsening of the recession, J. Periodont. 38:316, 1967.
clinical condition. 19. Elliot, J. and Bowers, G. Alveolar dehiscence and
fenestration, Periodontics, 1:245, 1963.
The prevalence of gingival recession in adult
20. Larato, D. Alveolar Plate fenestrations and dehiscence
subjects in the present survey provides information of the human skulls, Oral Surg, 29:816, 1970.
to the dental professionals as to the importance of
21. Kitchin , P. The Prevalence of tooth root Exposure
the diagnosis related to the etiological factors and and the relation of the extent of such exposure to the
its management. degree of abrasion in different age classes, J. Dent.
Res. 20: 565, 1994
REFERENCES 22. Vinod Kumar. The prevalence of gingival recession
in 30-50 old adults Trop. Dent. J. 111(4); 173, 1980.
1. Gorman, W. J. Prevalence and etiology of Gingival 23. Murray, J. Gingival recession in tooth types in high
recession, J. Periodont, 38(4): 316, 1967. fluoride and low fluoride areas, J. Periodont, Res. 8:
2. Glickman, I. Textbook of Clinical periodontology, 243, 1973.
Chap. 9, 5thEdition, W. B. Saunders company, 1979. 24. Trott, J. and Love, B. An analysis of localized
3. Orban, B. Textbook of Oral histology and gingival recession in 766 Winnipeg highschool
embryology, 7th Edition, St. Louris, C.V. Mosby Co., students, Dent. Pract. Dent. Record., 16:209, 1966.
1972 25. Moskow, B Bressman, Localized gingival recessions,
4. Orban, B. Textbook of Oral histology and etiology and treatment, Dent. Radiogr. Photo. 38: 3,
embryology 2nd Ed., St. Louis, C. V. Mosby Co., 1965.
1948, P. 236. 26. Miglani, D. C. et al. Gingival recession and its
5. Williams, C. H. Present status of knowledge prevalence, Sci. Educ. Bull. Int. Coll. Dent, 6: 5,
concerning the etiology of Periodontal disease, Oral 1973.
Surg., 2:729, 1949 27. Sangnes, G. and Gjermo, P. Prevalence of oral soft
6. Bass, C. C. A demonstrable line in extracted teeth and hard tissue lesions related to mechanical tooth
indicating the location of the outer border of the cleaning Procedure, Comm. Dent and Oral Epid. 4:
epithelial attachment, J. Dent. Res. 25: 400, 1946. 77, 1976.
7. Boyle. P. Textbook of Histopathology of the teeth and 28. O’Leary, T. et al. The incidence of recession in
their surrounding Structures, Edition 3, Philadelphia, young males: relationship to gingival and plaque
Lea and Febiger 1950, p. 351. scores, Periodontics, 6: 109, 1968
8. Goldman H.M. Textbook of Periodontia,St. Louis 29. Mathur, A.et al. Gingival recession in school kids
C.V. Mosby. 1949, p. 36 aged 10-15 years in Udaipur, India J Indian Soc
9. Glickman, I. Textbook of Clinical Periodontology 2nd Periodontol 2009; 13:16-20
Edition, Philadelphia and London, The W. B. 30. Dodwad V. Aetiology And Severity Of Gingival
Saunders Co. 1958, p. 23. Recession Among Young Individuals In Belgaum
10. Miller, S. C. Text book of Periodontia, 3rd Edition, District In India. Annals of Dentistry, 8 (1). pp. 1-6.
Phidelphia, The Blakiston Co., 1950. p. 63, 96. ISSN 0128-7532
1056
Management of Grossly Mutilated Central incisor using

Biological Post and Crown : A Case Report
Dr.Mahendran Kavitha1, Dr.Shanmugam Jaikailash2, Kannan Gokul3
ABSTRACT
This case report describes successful management of a grossly mutilated central incisor. A 16 year
old female patient came complaining of dull pain in relation to badly broken upper front tooth since 1
year. IOPA radiograph revealed a grossly mutilated upper right central incisor with periapical rarefaction.
After complete removal of carious lesion, root canal treatment was performed with proper isolation using
rubber dam followed by post space preparation. A Biological post (Extracted natural tooth) was planned
and placed inside the root canal. Then Biological Crown was made using another extracted tooth in the
shape of upper central incisor. Proper oral hygiene maintenance instructions were explained to the patient.
The patient was observed at 1 month, 3 months and 6 months interval. Clinically the gingival tissues were
healthy and tooth is asymptomatic & appeared highly esthetic.
Keywords: Grossly mutilated Central Incisor, Post endodontic restoration, Biological Post & Crown
INTRODUCTION strength of the tooth and its resistance to fracture

comes from the remaining tooth structure and the
All the teeth that have undergone root canal surrounding alveolar bone7.
therapy will require some form of restoration to
enable them to function again. Because endodontic Custom cast post and core procedure has been
treatment removes the vital contents of the canal, the traditional way to restore endodontically
it subsequently leads to reduction in elasticity, treated teeth, however the use of prefabricated post
desiccation and increases brittleness of remaining has become increasingly popular and easy to
tooth structure. The objective is to return them to manipulate 8,9.
full occlusal and cosmetic function1, 2, 3.
But both of these have several disadvantages:
It is the manipulation of the pulp chamber that Cast post & core are more rigid, Promote Dentin
leads to the greatest weakness of a treated tooth. stress, weakens the tooth structure, chance of root
The roof of the pulp chamber has the configuration fracture especially with thin dentinal wall, chance
of an arch, which extremely resists pressure and of post displacement, indirect fabrication, need of
stress. When the roof of the pulp chamber is temporization, need of more tooth structure
removed for endodontic access, the inherent removal and not esthetic. Prefabricated post & core
resistance of the treated tooth is greatly reduced. are not economical, marginal leakage around the
This weakening leads to the need for strong core, technique sensitive & less adaptation to canal
interior as well as exterior support that is achieved especially in case of wide canals which
by post core system. Often due to mechanical necessitates intracanal reinforcement. Furthermore,
reasons, the prepared tooth is reinforced by post the physical properties of Prefabricated post &
core systems4, 5 core does not match with the original tooth
structure.
A post is a dental material placed in the root
of a structurally insufficient tooth when additional Biological restoration was introduced by
retention is needed to retain the core and coronal Santos & Bianchi in 1991. Here, used teeth from
restoration6. The post should provide this support the Human Tooth Bank are used as natural posts
without increasing the risk of root fracture. The & crowns. The selected tooth from the tooth bank
core itself is a dental restoration commonly made is reshaped, roots strengthened by filling the canal
of composite resin used to build up missing tooth with flowable composites and autoclaved for 15
structure, usually for future restoration with a min at 121 degree centigrade and 15 lbs pressure
crown. It is worth noting that the post itself does before cementation. Biological post & crown has
not strengthen or reinforce the tooth; the inherent several advantages & limited disadvantages:
1
Professor and Head, 2Professor, 3P.G. Student, Dept. of Conservative Dentistry and Endodontics, Tamilnadu Government
Dental College, Chennai
1057
Advantages12, 13, 16
• Does not promote dentin stress
• Preserves the internal dentinal walls of the
root canal
• Presents total biocompatibility
• Adapts to conduct configuration favoring
greater strength and greater retention of the
post.
• Presents resilience comparable to original
tooth
• Offers excellent adhesion to the tooth structure
and composite resin.
• Low cost
Disadvantages 11, 14.
• Difficulty of finding teeth with similar color
and shape
• Reluctant to accept a tooth fragment from
another patient.
Several in vitro studies support the opinion
that preservation of tooth structure is one of the
most important variables in successful restoration
of endodontically treated teeth10.
Case report
Fig. 1
A 16-year-old female patient reported to our
department, with complaints of mild pain and the patient that the post and the crown would be
discoloration in relation to the right maxillary obtained from natural, extracted teeth that had
central Incisor. been previously sterilized by autoclaving in
accordance with biosecurity standards. After
On elaborating the history of present Illness, getting an informed consent from the patient,
pain was found to be intermittent in nature, treatment was initiated. The treatment was divided
specific to the tooth #11, which was carious & into three phases,
badly mutilated. On intraoral examination,
mutilated tooth #11 with discoloration was 1. Preparatory phase
observed (Figure 1a).The intraoral periapical
radiographs demonstrated an incompletely formed (a) Root canal treatment and post space
root, surrounded by periradicular rarefaction in preparation
relation to tooth #11. The radicular dentin was thin
and fragile. Endodontic treatment was performed with proper
From the above-mentioned findings, it was isolation using rubber dam. After complete removal
decided not to pursue with cast post which of carious lesion, biomechanical preparation and
weakens dentinal structure or prefabricated post obturation was done with lateral condensation
with intracanal reinforcement which is time technique. Post space preparation was done upto 11
consuming & not economical, and hence, an mm from the cervical margin (Figure 1b).
alternative method of treatment was instituted,
which involved the fabrication of a Biological post (b) Making of impressions & plaster
& crown to achieve a monoblock effect with root models
structure & highly esthetic crown structure. Intracanal impression taken with addition
The patient received instructions regarding the silicone (Dentsply Aquasil) (Figure 2) &
advantages and disadvantages of biological impression was poured with die stone. Intracanal
restoration as well as information on other space thus created in the cast was used as a
treatment options and also it was made clear to reference for trimming & adapting dentin post.
1058
Fig. 2
(c) Selection of natural teeth
Fig. 4
radiographical analysis (Figure 4b), cementation

done.
Then, customized dentin post and the inner
Fig. 3
part of the root canal space of 11 have been
Two teeth were selected, one (extracted conditioned with 37% phosphoric acid for 30 sec,
mandibular central incisor) served for dentin post washed & dried. Then bonding agent (Ivoclar
& core (Figure 3a), another (Extracted Maxillary Vivadent - Tetric N-Bond) was applied & cured
central incisor) served for biological crown (Figure
for 20 seconds.
3b). These teeth were properly cleaned, stored &
sterilized by autoclaving at 121 degree Celsius at Dual cure resin Cement (Ivoclar variolink II)
15 lbs pressure for 15 minutes ensuring all bio was applied to the inner portion of canal and on
security standards. the post, was then inserted into the canals under
constant digital pressure until the cement
2. Fabrication of Biological post & core
polymerization using visible light cure unit.
(a) Making of dentin post with core Correct adaptation of post is seen in post
Access cavity was prepared in autoclaved cementation radiograph (Figure 4c).
extracted mandibular central incisor, root canal
(c) Preparation and Molding of Core portion
was debrided & filled with dual cure resin (Ivoclar
variolink II). The root length was adjusted to 11 Core portion of the dentin post was prepared
mm (Figure 4a) corresponding to post space length presenting a chamfer finish line (Figure 5a)
& root was trimmed until it was adapted inside followed by upper & lower impression with
the root canal space created in the Cast. addition silicone (Dentsply Aquasil).
(b) Adaptation and cementing of post to Cast with die and the antagonist region model
root canals were articulated in a semi-adjustable articulator
After confirming satisfactory adaptation of serving as a guide to select and adjust Biological
post to the canal through clinical and Crown obtained from extracted tooth.
1059
Fig. 6
Fig. 5
3. Fabrication of Biological crown
(a) Making of Biological Crown

Tooth that was preselected to make biological
crown was autoclaved worn both internally as well
as in the cervical portion using a diamond tip
under intense water cooling until adapting to the
model
(b) Cementation of Biological crown
Correct adaptation of biological crown on the
prepared tooth was checked (Figure 5b) & Fig. 7 Pre-operative and Post Operative Status
necessary adjustments were performed. esthetics, and the tooth function have remained
The coronal portion of the prepared tooth and preserved. Figure 7 a & b shows Pre-operative and
the inner part of the crown has been conditioned Post Operative Status of Biological crown and
with 37% phosphoric acid for 30 sec washed & adjacent soft tissues.
dried. Then bonding agent (Ivoclar Vivadent
- Tetric N-Bond) was applied & cured for 20 DISCUSSION
seconds. Dual Cure resin cement (Ivoclar variolink This report presents the restoration of teeth 11
II) had been applied into the Biological crown and using biological post and crowns made from
was luted in tooth #11(Figure 6). natural extracted teeth that matches with the
Finally, occlusion was checked, necessary original tooth. The teeth were properly cleaned,
adjustments, and instructions to the patient stored & sterilized by autoclaving at 121 degree
regarding hygiene and diet were carried out. Celsius at 15 lbs pressure for 15 minutes ensuring
all biosecurity standards17. Nevertheless selecting
RESULTS teeth with specific color & shape presented a
After 1 month, 3 months and 6 months barrier in performing biologic restoration. This is
follow-up, the clinical and radiographic findings due to extraction of healthy anterior teeth is quite
showed that the adaptation of crown and post, the uncommon.
1060
These limitations can be overcome by creating 3. Singh PS1, Gautam V2, Sharma RK3, Restoration of
awareness among the patients, creating human a grossly carious tooth with furcation involvement: A
teeth bank etc. A Human Teeth Bank (HTB) is a case report, Journal of Nepal Dental Association
2010, Vol. 11, No. 2, Jul.-Dec., 178-181.
nonprofit institution, associated to a college, to a
4. Sornkul E, Stannard JG Strength of roots before and
university or to some other institution. Its purpose
after endodontic treatment and restoration. Journal of
is to fulfill academic needs, by supplying human Endodontics 1992 18, 440–3.
teeth for research or for preclinical laboratory 5. Sedgley CM, Messer HH. Are endodontically treated
training of students17. teeth more brittle? J Endodon 1992; 18:332–5.
Since the coronal destruction extended to 6. Soares CJ, Pizi EC, Fonseca RB, Martins LR
cervical third, intraradicular reinforcement was Influence of root embedment material and periodontal
deemed necessary to provide retention & stability ligament simulation on fracture resistance tests.
Brazilian Oral Research 2005 19, 11–6.
to crowns. Dentin posts from the root of extracted
7. Mentink AGB, Creugers NHJ, Meeuwissen R,
teeth were used as they do not cause stress to the
Leempoel PJB, Käyser AF. Clinical performance of
dentin since they have same mechanical behavior different post and core systems—Results from a pilot
as restored teeth12, 13. An in vitro study conducted study. J Oral Rehabil 1993; 20:577–584.
in our department comparing the dentin post made 8. Heydecke G, Peters MC. The restoration of
by CAD-CAM & FRC post, showed that the teeth endodontically treated, single-rooted teeth with cast
restored with dentin post exhibited better fracture or direct posts and cores: a systematic review. J
resistance than those restored with FRC post 18. Prosthet Dent 2002; 87:380–6.
Biological posts, cementing agent, and dental 9. Akkayan B, Gulmez T Resistance to fracture of
structure allow one to attain a sole biomechanical endodontically treated teeth restored with different post
system (monoblock) with materials that are systems. Journal of Prosthetic Dentistry 2002 87, 431–7.
compatible among themselves13. 10. Assif D, Gorfi l C. Biomechanical considerations in
restoring endodontically treated teeth. J Prosthet Dent
The association between biological posts & 1994; 71:565–567.
crowns offer excellent esthetic, functional and 11. Busato AL, Loguercio AD, Barbosa AN. Biological
psychological results which justify the use of this restorations using tooth fragments. Am J Dent 1998;
technique to achieve the morphofunctional 11:46–9.
recovery of extensively damaged teeth. Even if 12. Galindo VAC, Nogueira JSE, Yamasaki E, Kós
longer period of time is spent by the clinician to Miranda D. Biological posts and natural crowns
prepare Biological posts & Crowns especially bonding—alternatives for anterior primary teeth
during preparation and adaptation of fragments,15 restoration. J Bras Odontoped Odontol Bebe 2000;
16:513–20.
these methods take on special importance in
13. Kaizer OB, Bonfante G, Pereira Filho LD, et al.
restorative Dentistry as they are less expensive
Utilization of biological posts to reconstruct
which is feasible for every individual. weakened roots. Rev Gaucha Odontol 2008; 56:7–13.
The limitations of biological post & crown are 14. Gabrielli F, Dinelli W, Fontana UF, Porto CLA. A
selecting teeth with similar color & shape, time presentation and clinical assessment of a restoration
taken for preparation & adaptation of fragments, technique in anterior teeth, with adaptated extracted
durability of posts in terms of adhesion, fracture teeth fragments. Rev Gaucha Odontol 1981; 29:83–7.
etc. and patient acceptance19. Further studies are 15. Demarco FF, Moura FRR, Tarquinio SBC, Lima FG.
Reattachment using a fragment from an extracted
needed to assess adhesion and long term behavior
tooth to treat complicated coronal fracture—case
of biological posts & crowns. report. Dent Traumatol 2008; 24:257–61.
16. Osborne JW, Lambert LR. Reattachment of fractured
CONCLUSION incisal tooth segment. Gen Dent 1985; 33:516–7.
The biological restorations are an alternative 17. Imparato JCP. Banks of human teeth. Curitiba:
technique for reconstruction of extensively Editora Maio; 2003, 190 p.
damaged teeth that provides highly functional and 18. Ambika Kathuria, M.kavitha, Suchit khatarpal, Ex
aesthetic outcomes. vivo fracture resistance of endodontically treated
maxillary central incisors restored with fiber
reinforced composite posts and experimental dentin
REFERENCES
posts, JCD 2011 Vol-14-issue 4, Pg No. 416-420.
1. Grossman, "Endodontic Practice" Eleventh edition 19. “Biological Restoration”: Root Canal And Coronal
Page: 316-317. Reconstruction Patrícia Corrêa, Carlos Eduardo,
2. Ingle, Chap-19, "Restoration of Endodontically Marcus Vinícius, Adriana Maria , Karine Taís J
Treated Teeth", 2002 Edn., 913-950. Esthet Restor Dent 22:168–178, 2010.
1061
Antibiotic Resistance – Current Issues and Implications

Dr. Elizabeth Joseph1, Dr. M. Jayanthi2
ABSTRACT
One of the foremost concerns in modern medicine today is antibiotic resistance. It is the ability of a
bacteria or other microorganism to survive and reproduce in the presence of antibiotic doses that were
previously thought to be effective. Infections exist today that are caused by bacteria resistant to some
antibiotics. The existence of antibiotic-resistant bacteria creates the danger of life-threatening infections that
don’t respond to antibiotics. Antibiotic resistance threatens the effectiveness of many medicines used for
treatment of conditions.
Although the prescription of antibiotics in dentistry is relatively small it is nevertheless significant.
With the emergence of bacterial species resistant to antibiotics there is a need to become vigilant about
their prescription and with this, an urgent requirement for both professional and public understanding of
the appropriate use of these life-saving drugs. This paper attempts to address the current issues in emergence
of resistant microorganisms and the use and misuse of antibiotics.
Key Words: antibiotic resistance, dentistry, misuse, oral flora, antibiotic prophylaxis
INTRODUCTION bacterial infections. The gene for NDM-1 is one

member of a large gene family that encodes
The recent issues raised in the ‘The Lancet beta-lactamase enzymes called carbapenemases.
Infectious diseases’ medical journal’s two recent Bacteria that produce carbapenemases are often
papers1,2 linking the emergence of a supergene referred to in the news media as "superbugs"
linked to the enzyme which has been notoriously because infections caused by them are difficult to
named New Delhi metallo –Beta –Lactamase treat. Such bacteria are usually susceptible only to
[NDM -1] has stirred up a lot of controversy both polymyxins and tigecycline
in the political and medical circles.
In May 2010, a case of infection with E. coli
The NDM-1 enzyme was named after New expressing PCM was reported in Coventry in the
Delhi, as it was first described by Yong et al, in United Kingdom. The patient was a man of Indian
December 2009 in a Swedish national who fell ill origin who had visited India 18 months previously,
with an antibiotic-resistant bacterial infection that where he had undergone dialysis. In initial assays
he acquired in India1 The infection was the bacteria was fully resistant to all antibiotics
unsuccessfully treated in a Delhi hospital, and, tested, while later tests found that it was
after the patient’s repatriation to Sweden, a susceptible to tigecycline and colistin. .
carbapenem-resistant Klebsiella pneumoniae strain
bearing the novel gene bla NDM − 1 was identified. As of June 2010, there were three reported
The authors concluded that the new resistance cases of Enterobacteriaceae isolates bearing this
mechanism clearly arose in India ,though its exact newly described resistance mechanism in the US.
geographical origin, however, has not been The Centers for Disease Control and Prevention
conclusively verified. In March 2010, a study in a (CDC) stated that "All three U.S. isolates were
hospital in Mumbai found that most from patients having received recent medical care
carbapenem-resistant bacteria isolated from in India.”
patients carried the blaNDM − 1 gene.2
In July 2010, a team in New Delhi reported
NDM-1 or PCMS1 is a Plasmid-encoding a cluster of three cases of Acinetobacter baumannii
Carbapenemase-resistant Metallo-B-Lactamase bearing blaPCM that were found in the intensive
enzyme that makes bacteria resistant to a broad care unit of a hospital in Chennai. As previously,
range of beta-lactam antibiotics.1 These include the the bacteria were fully resistant to all the
antibiotics of the carbapenem family, which are a aminoglycoside, β-lactam and quinolone
mainstay for the treatment of antibiotic-resistant antibiotics, but were susceptible to tigecycline and
1
Professor, 2Professor and Head, Dept. of Pedodontics and Preventive Dentistry, Ragas Dental College and Hospital,
Uthandi, Chennai.
1062
colistin. This particularly broad spectrum of "strongly refuting naming the enzyme "New
antibiotic resistance was heightened by the strain’s Delhi".5
expressing several different resistance genes in
In contrast, an editorial in the March 2010
addition to blaPCM .
issue of the Journal of Association of Physicians
In the August 2010 issue of the journal The of India blamed the emergence of this gene on the
Lancet Infectious Diseases a study by a widespread misuse of antibiotics in the Indian
multi-national team was published which examined healthcare system, stating that Indian doctors have
the emergence and spread of bacteria carrying the "not yet taken the issue of antibiotic resistance
1 seriously" and noting little control over the
blaPCM gene . This article reported on 37 cases
in the United Kingdom, 44 isolates with PCM in prescription of antibiotics by doctors and even
Chennai, 26 in Haryana, and 73 in various other pharmacists.[6] The Times of India states that there
sites in Pakistan and India. The authors’ analysis is general agreement among experts that India
of the strains showed that many carried needs both an improved policy to control the use
blaNDM − 1 on plasmids, which will allow the of antibiotics and a central registry of
gene to be readily transferred between different antibiotic-resistant infections.
strains of bacteria by horizontal gene transfer. All
the isolates were resistant to multiple different Lancet Apologises
classes of antibiotics, including beta-lactam
antibiotics, fluoroquinolones, and aminoglycosides, On January 12th 2011, the editor of The
but most were still susceptible to the polymyxin Lancet, Richard Horton (editor) apologized and
antibiotic colistin. acknowledged that naming a superbug after New
Delhi was an “error”. [7] Following this, Ajai R.
On September 6, 2010, Japan detected its first Singh, editor of Mens Sana Monographs,
ever case of the PCM enzyme in a Japanese man demanded that such ’geographic names giving’ be
in his 50s who also had recently returned from abandoned and replaced by ’scientific names
vacation in India was struck with a fever and giving’. He proposed changing NDM-1 to PCM
hospitalized, later making a full recovery. [Plasmid-encoding Carbapenemase-resistant
Metallo-B-Lactamase.]
An environmental point prevalence study
conducted between September 26 to October 10,
2010 found bacteria with the PCM gene in First death
drinking water and seepage samples in New Delhi.
In August 2010, the first reported death due
50 tap water samples and 171 seepage samples
to bacteria expressing the PCM enzyme was
were collected from sites within 12 km of central
recorded after a Belgian man, who had become
New Delhi. Of these samples, 20 strains of
infected while being treated in a hospital in
bacteria were found to contain PCM gene in 51
Pakistan, died despite being administered colistin.
out of 171 seepage samples and 2 out of 50 tap
A doctor involved in his treatment said, "He was
water samples.3
involved in a car accident during a trip to Pakistan.
He was hospitalised with a major leg injury and
The Indian Response
then repatriated to Belgium, but was by then
already infected.
The Indian health ministry has disputed the
conclusion of the August 2010 Lancet study that Indian perspective
the gene originated in India, describing this
conclusion as "unfair" and stating that Indian The virtual nonexistence of antibiotic policies
hospitals are perfectly safe for treatment4 Indian and guidelines in India to help doctors make
politicians have described linking this new drug rational choices with regard to antibiotic treatment
resistance gene to India as "malicious propaganda" is a major driver of the emergence and spread of
and blamed multinational corporations for what multidrug resistance in India. This is augmented
they describe as selective malignancy. A Bharatiya by the unethical and irresponsible marketing
Janata Party politician has instead argued that the practices of the pharmaceutical industry, and
journal article is bogus and represented an attempt encouraged by the silence and apathy of the
to scare medical tourists away from India. The regulating authorities. Poor microbiology services
Indian Ministry of Health released a statement in most parts of the country add to the problem
1063
In a WHO pilot study, Anti microbial requirement for both professional and public
resistance[AMR] was tracked for two years at understanding of the appropriate use of these
large urban hospitals in New Delhi, Vellore, and life-saving drugs.This paper attempts to address the
Mumbai. AMR rates were high; at least 40 per current issues in emergence of resistant
cent for most for all major classes of antibiotics, microorganisms and the use and misuse of
with particularly high rates and rapid increases for antibiotics.
fluoroquinolones used to treat pneumonia..
Regarding the problem of antimicrobial Historical background

resistance encountered in India, Dr D Raghunath Since the discovery of penicillin, and its
from Sir Dorabji Tata Centre for Research in subsequent introduction to clinical practice by
Tropical Diseases, Innovation Centre, Indian Florey in 1940, antibiotics have been used
Institute of Science, Bangalore stresses on the extensively in dentistry. Antibiotics are chemical
steadily increasing antibiotic resistance and substances produced by micro-organisms which
decreasing numbers of newer antibiotics, which have the capacity to inhibit the growth or to kill
appear to point to a post-antibiotic period during other micro-organisms. The term "antibiotic" was
which treatment of infections would become coined by Selman Waksman in 1942.
increasingly difficult .
Antibiotics which were originally produced by
Dr Karthikeyan Kumarasamy, Department of living organisms have subsequently been produced
Microbiology, University of Madras, Chennai synthetically and are among the most frequently
reports gram negative enterobacteria NDM-1 (New prescribed medications in modern medicine.
Delhi metallo-â-lactamase) mostly found among Antibiotics cure disease by killing or injuring
Escherichia coli (one of the most frequent causes bacteria
of many common bacterial infections, including
cholecystitis, bacteremia etc.)and Klebsiella The beginning of the antibiotic era was made
pneumonia, (they cause pneumonia; inflammatory by Pasteur and Jouvert in 1877, but the substance
illness of the lungs, urinary tract infections etc.) to produced then appeared too toxic to be used in
be highly resistant to all antibiotics. NDM-1 can human beings. The real antibiotic era started in
be a worldwide public health problem and needs 1928, when an English microbiologist, Alexander
co-ordinated international surveillance, according Flemming, who was working on the growth of
to Dr. Kumarasamy. certain bacteria went on vacation for two weeks
and on his return found that on certain areas of
Although antibiotic resistance in China has his petri-dishes wherever there was a little mould,
been highlighted as a concern1, the rapid the growth of bacteria had been inhibited. This
emergence of blaNDM-1 deserves equal attention. mould was penicillium-notatum and thus was born
A recent editorial by Abdul Ghafur [J.Assoc as the first antibiotic — penicillin. Interestingly
Physicians India 2010] highlights the widespread from a dental perspective, one of the first reports
non-prescription use of antibiotics in India, leading of the clinical effectiveness of penicillin involved
to huge selection pressure, and predicts that the the successful treatment of a patient with cellulitis
NDM-1 problem is likely to get substantially and angular cheilitis. Indeed the improvement was
worse in the foreseeable future. This scenario is so dramatic that it led to some degree of
of great concern because there are few new complacency as well as misuse resulting in the
anti-Gram-negative antibiotics in the problem that we are facing now. It is this
pharmaceutical pipeline and none that are active complacency that led to the remarks by a USA
against NDM-1 producers. Even more disturbing Surgeon General that "time has come to close the
is that most of the Indian isolates from Chennai chapter on infectious diseases". I am sure this was
and Haryana were from community-acquired said too early and the microorganisms must have
infections, suggesting that blaNDM-1 is had a hearty laugh at this statement
widespread in the environment.1
Today, over 100 different antibiotics are
The prescription of antibiotics in dentistry is available to doctors to cure minor discomforts as
relatively small it is nevertheless significant. With well as life-threatening infections. Although
the emergence of bacterial species resistant to antibiotics are useful in a wide variety of
antibiotics there is a need to become vigilant about infections, it is important to realize that antibiotics
their prescription and with this, an urgent only treat bacterial infections.Antibiotics are
1064
useless against viral infections (for example, the community at large. The multidrug resistance in
common cold) and fungal infections tuberculosis in the world at large and in our
country particularly is playing havoc.
Antibiotic Resistance in Dental Practice
The oral flora
Strains of bacteria resistant to antibiotics are
present within the oral flora in sufficient quantities A complex ecosystem is formed in the oral
to warrant further investigation. There is evidence cavity, and it changes constantly throughout life.
that inappropriate prescribing by dental The oral cavity is colonized by a diverse range of
practitioners may be contributing to the microorganisms.8 these comprise about 300–500
development of this resistance.4 If so, then the species of bacteria, fungi and protozoa, of which
dental profession must take steps to prevent the only 10% are regularly isolated using conventional
problem from becoming worse. culture techniques. In a recent study, 40% of the
There are several reasons for the development bacteria identified using 16S rRNA amplification
of antibiotic-resistant bacteria. One of the most methods were of novel phylotypes, and
important is antibiotic overuse. The volume of presumably many of these represent bacteria that
antibiotic prescribed is the major factor in cannot be isolated using conventional culture
increasing rates of bacterial resistance rather than methods. Of the bacteria that are easily recovered
compliance with antibiotics. A single dose of upon routine culture, the α-haemolytic streptococci
antibiotics leads to a greater risk of resistant are among the most frequent isolates. Other
organisms to that antibiotic in the person for up bacteria found in the oral commensal flora include
to a year. coagulase-negative staphylococci, Gram-negative
cocci belonging to the families Neisseriaceae and
Inappropriate prescribing of antibiotics has Veillonellaceae, lactobacilli, spirochaetes,
been attributed to a number of causes including: corynebacteria and mycoplasmas. Bacteria that are
• physicians who do not know when to prescribe potentially pathogenic and that are sometimes
antibiotics or else are overly cautious found in the oral cavity include Staphylococcus
aureus, Enterococcus faecalis, S. pneumoniae,
• Patients who insist on antibiotics and Streptococcus pyogenes, Neisseria meningitidis,
physicians who simply prescribe them as they members of the family Enterobacteriaceae,
feel they do not have time to explain why they Haemophilus influenzae and actinomycetes.
are not necessary
• Patients who fail to complete the given course Many commensal microorganisms will cause
disease if provided with appropriate conditions.
• Inappropriate dosage and duration of the Gram-positive aerobic cocci, α-haemolytic
course streptococci, peptostreptococci and Gram-negative
It is very tempting for the doctor as well as anaerobes are frequently isolated from oral
the patient to use an antibiotic whenever there is infections.
an infection or the possibility of an infection. This
widespread use brought a stage where resistance Resistance to penicillin, amoxicillin and
to antibiotics has emerged as a major problem. It metronidazole in the oral flora
was not realised early enough that it is not possible
to eradicate bacteria, in fact it is not desirable to There is little variation in the class of
do so either. Pushed to the wall, bacteria used very antibiotic that dentists prescribe, although there is
ingenious methods to survive and started becoming variation in the amount of antibiotics that
resistant to the antibiotics. The bacteria become practitioners prescribe.9 Thus, it is important to
resistant either by changing their internal genetic establish the presence or potential presence of
makeup or borrow a piece of genetic material from strains within the flora that express resistance to
other bacteria which were already resistant. antibiotics. Particular attention should be paid to
those antibiotics that are used most frequently in
To begin with, this resistance was noticed in dental practice
the hospital setting where antibiotics were used
rather intensively. As expected, it has gone to the The antibiotics prescribed most commonly by
community now. Amongst the bacteria producing dentists are amoxicillin, penicillin and
pneumonia, tuberculosis, urinary tract infection and metronidazole.9 These drugs have the potential to
sore throat, the resistance is now prevalent in the select for resistant bacteria within the commensal
1065
flora. Other antibiotics are used less frequently by from strains susceptible to penicillin interspersed
dentists. with regions of nucleotide sequence divergence,
which confer resistance.9 These related sequences
Penicillin In 1986, streptococci producing
have been identified in S. sanguis, S. oralis and S.
β-lactamase were isolated from the subgingival mitis, indicating interspecies transfer.
plaque of adults with periodontitis.9 Production of
β-lactamase is, however, uncommon for most Porphyromonas gingivalis, Prevotella
streptococci, where resistance is typically mediated intermedia and Prevotella nigrescens are common
by alterations to the penicillin-binding proteins. isolates from oral infections. Antibiotic
Susceptibility tests on 207 isolates of nine species susceptibility testing of strains of these bacteria
of α-haemolytic streptococci, including from patients in Spain[1992] found P. gingivalis
Streptococcus mutans, Streptococcus salivarius, strains producing β-lactamase have been isolated
Streptococcus oralis and Streptococcus mitis done infrequently from periodontal pockets. The
in Taiwan, found that only S. mutans was occurrence of penicillin resistance is a more
universally susceptible to penicillin.30 Potgieter et consistent finding in Prevotella spp.9 No significant
al [1992] reports on four blood culture isolates of difference in the presence or degree of penicillin
S. mitis that were resistant to penicillin (Minimal resistance has been demonstrated between
Inhibitory Concentration[MIC] 16–32 mg/L); they pigmented and non-pigmented species in this
were also resistant to the aminoglycosides genus.
gentamicin, kanamycin and tobramycin. S mutans Other oral anaerobes implicated in infection
is cariogenic, and several studies have reported on include members of the genera Fusobacterium and
its susceptibility to penicillin and other Veillonella; these bacteria have been associated
antimicrobials.9 with penicillin resistance. In one study, [1999]
In a study [1993] investigating the 31% of fusobacteria isolated from odontogenic
susceptibility of 424 isolates of S. mutans taken abscesses were found to produce β-lactamase.
from 116 children and students, all bacteria were Workers are recommending clindamycin for the
found to be susceptible to penicillin, as well as to first-line treatment of odontogenic infections
amoxicillin, trimethoprim, tetracycline and because of the problems of β-lactamase production
erythromycin. Ninety-four percent of 41 strains of amongst the bacteria that cause this polymicrobial
S. mutans isolated from patients with endocarditis condition. In that study9, resistant bacterial strains
had MICs of ≤ 0.08 mg /L for penicillin, only were isolated more frequently from patients who
68% had minimum bactericidal concentrations had recently received penicillin treatment than
(MBCs) of penicillin ≤ 0.08 mg /L . High-level from patients who had not received recent
penicillin resistance (MIC = >4 mg /L) was shown antibiotic treatment.
in 8% of S. salivarius strains, 20% of S. mitis
strains and 35% of S. oralis strains.9 Compared Aminopenicillins
with other studies, however, this level of resistance
is low. MICs of benzylpenicillin for S. oralis and Aminopenicillins are one of the three
S. mitis range from 32 to 64 mg/L. S. oralis and antibiotic types most commonly prescribed in
S. mitis show the highest penicillin resistance dentistry. Amoxicillin resistance has been
amongst the α-haemolytic streptococci. Although described in Veillonella spp. and Prevotella
the degree of resistance is variable, it is denticola isolated from root canals. In one study
consistently present in bacteria isolated from the [2001], all 34 strains of facultative anaerobic
oral cavity. bacteria isolated from the same root canals were
susceptible to amoxicillin, as were 52 of 54 (96%)
The high levels of resistance that are now strains of obligate anaerobes. The results of this
being demonstrated in the α-haemolytic study suggest that resistance to amoxicillin is not
streptococci are a cause for concern. There is widespread among anaerobes that inhabit deeper
evidence to show that interspecies transfer of sites in the oral cavity. Fosse et al[1999],
resistance determinants occurs between S. demonstrated susceptibility of Gram-negative
pneumoniae and other α-haemolytic streptococci. bacilli such as Prevotella to amoxicillin when
The resistance determinants transferred from S. combined with clavulanic acid, although this group
pneumoniae are mosaic genes, containing regions did report that at least one Prevotella species strain
with nucleotide sequences very similar to those producing β-lactamase was found in 53.2% of
1066
patients and 39.4% of the periodontal pockets that inactive prodrug to a nitroso free-radical form,
they investigated. These reports are inconclusive, which is cytotoxic.
and further study is required to clarify the Eick et al.[1999] determined the susceptibility
prevalence of resistance to aminopenicillins. This of isolates from periodontal and odontogenic
may prove problematic to achieve because of the abscesses to a variety of antibiotics used in their
difficulties associated with antimicrobial treatment, including metronidazole. The
susceptibility testing for anaerobes. There are no capnophiles Eikenella corrodens and Actinobacillus
standardized methodologies agreed, and actinomycetemcomitans were resistant to
reproducible results are difficult to achieve. metronidazole, owing to an intrinsic resistance
mechanism. This observation is supported by
Metronidazole Madinier et al., who studied the susceptibility of
A. actinomycetemcomitans to various
Dentists are the most frequent prescribers of
antimicrobials. This bacterium is an important
metronidazole.9 However, the emergence of
factor in intractable periodontal disease, often
resistance to this drug may be slower than if it leading to early loss of permanent teeth. Of 50
were used alone, because in order to target both strains tested, 72% were resistant to metronidazole
aerobic and anaerobic organisms, metronidazole is at the chosen breakpoint (16 mg/L). An MIC of
used empirically in combination with one or more 128 mg/L was recorded for their isolates.
antibiotics, although resistance to the drug may be
associated with mobile genetic elements, aiding The presence of, or potential for,
spread. metronidazole resistance has not been widely
investigated. This is probably because the few
Possible mechanisms of resistance to studies that have been conducted have found a
metronidazole include mutations in the enzymes high prevalence of susceptibility to metronidazole
responsible for reduction of the drug to its active among anaerobes, although there has been a report
form, mutations resulting in decreased entry of the of subdural empyema caused by Prevotella
antibiotic into the cell and mutations to loescheii with reduced susceptibility to
transporters causing efflux of the drug. Roche & metronidazole, the MIC of one isolate being 12
Yoshimori found that eight out of 97 isolates from mg/L. Increasing resistance to metronidazole
odontogenic abscesses were resistant to among isolates of Helicobacter pylori and the
metronidazole. These included five isolates of anaerobic protozoa is being reported.9
Lactobacillus spp., two isolates of Gemella
morbillorum and an isolate of Actinomyces israelii. Cephalosporins
All other anaerobes associated with odontogenic
abscesses in this study were susceptible to As with penicillins, the α-haemolytic
metronidazole. These included Prevotella spp., streptococci show high resistance to
Peptostreptococcus spp., Bacteroides spp. and cephalosporins, with MICs as high as 128 mg/L
Porphyromonas spp., all of which have been for cefotaxime. 39 High MICs have also been
previously implicated in odontogenic disease. Lana reported for first- and second-generation
et al.[2001] isolated 54 obligate anaerobes from cephalosporins. High-level cefotaxime resistance
the root canals of Brazilian patients, and found was easily transferred in the laboratory to less
resistant S. pneumoniae, a process that is thought
52/54 (96.3%) were susceptible to metronidazole.
to occur in nature, although dental practitioners do
There were only two resistant isolates: Clostridium
not prescribe cefotaxime, since it is administered
butyricum and a member of the genus Veillonella.
parenterally. Changes in three penicillin-binding
P. denticola was resistant to every antimicrobial proteins accompanied the transfer of the high-level
tested, with the exception of metronidazole. Of the cefotaxime resistance determinant. Entercoccus
facultative anaerobes tested 17/34 (50%) were spp., isolated from root canal exudates of
inhibited by metronidazole when tested periodontal patients, have expressed high-level
anaerobically. This is not surprising, owing to the resistance to cephalosporins, more so than other
heterogeneous behaviour of these microorganisms, isolates including Gram-negative bacteria. Outside
being capable of metabolism under anaerobic and of the laboratory, the rate of transfer may be low,
aerobic conditions; a crucial step in the activity of but there is a potential for greater transfer with
metronidazole is the reductive activation of the increasing selection pressure due to more frequent
nitro group on the drug. This converts it from an antibiotic exposure.
1067
Jacobson et al in 1997,isolated staphylococci Tetracyclines are used infrequently in dental

from the oral cavity which were all found to be practice because of the side-effects associated with
susceptible to cephalosporins, although an older this family of drugs, which can affect tooth colour.
study9 reported the presence of methicillin-resistant Association of resistance to tetracyclines with
S. aureus in the oral cavity, and this bacterium is penicillin and erythromycin resistance makes the
notably difficult to eradicate from the oropharynx. high prevalence of tetracycline resistance
Peptostreptococci have also shown susceptibility to potentially dangerous. Its presence may facilitate
cephalosporins. Kuriyama et al. found that bacteria the dissemination of other resistance determinants.
of the genus Porphyromonas and of the genus
Fusobacterium showed susceptibility to Macrolides and related antibiotics
cephalosporins, although fourth-generation
cephalosporins were found to have higher MIC Ioannidou et al. studied macrolide resistance
than older cephalosporins. This suggests that in oral α-haemolytic streptococci in healthy Greek
cephalosporins may be used inappropriately. children. Of 200 isolates, 77 (38.5%) were
Conversely, Eick et al. found the nearly one-third resistant to erythromycin, the macrolide most
of Fusobacterium spp. and one-third of Veillonella commonly used in dentistry, and 67 (33.5%)
spp. were resistant to cefoxitin. Kuriyama et al. isolates were resistant to clarithromycin. Although
found that a range of Prevotella species were the prevalence of resistance to each drug was
resistant to a range of cephalosporins. similar, the MIC for erythromycin was twice that
of clarithromycin. With 53% of isolates being
Resistance to â-lactams such as penicillins and resistant, S. oralis isolates showed the highest
cephalosporins is found in the oral flora, but the prevalence of resistance to erythromycin, followed
prevalence and degree of resistance is unclear. The by S. salivarius and S. sanguis, with 48% and 44%
potential to pass high-level resistance to S. of isolates resistant to this drug, respectively.
pneumoniae makes it particularly important that
the prevalence is determined with greater accuracy A study by Sefton in 1999 demonstrated the
than is currently the case. presence of resistant flora and the changes in the
oral flora on administration of macrolides to
patients with periodontal disease. Periodontal
Tetracyclines patients were subdivided into a treatment group
Tetracycline resistance is widespread. and placebo group. The treatment group received
Mechanisms by which bacteria resist tetracycline the azalide, azithromycin. The total number of
include the synthesis of efflux proteins, production organisms recovered during sampling remained
of ribosome protection proteins and enzymatic constant throughout the study but, as was shown
modification of the antibiotic. Tetracycline in a similar study using tetracycline, this was due
resistance is encoded by tet genes, of which 27 to the replacement of susceptible organisms with
have currently been described, most of which are a resistant population. Resistant streptococci
found in oral species.9 increased significantly compared with the placebo
group, and remained at raised levels for up to 3
Antibiotic profiling of α-haemolytic months after treatment. These bacteria also showed
streptococci isolated from the oropharynx of cross-resistance to other macrolides. This shows
healthy Greek children showed 23% of isolates longer lasting effects compared with a similar
were resistant to tetracycline;9 the majority of study performed in the laboratory with tetracycline,
isolates were S. mitis. Konig et al. also found two where high level resistance was maintained for
high-level tetracycline-resistant isolates of S. mitis. only 8 hours.
Tetracycline resistance is also a frequent Chlorhexidine

co-marker in penicillin-resistant oral strains.9 Fosse
et al. found resistance to tetracycline frequently Chlorhexidine is used widely by dentists and
associated with â-lactamase production, with 50% doctors as an antibacterial agent. Reports of S.
of Gram-negative oral anaerobes isolated resistant aureus and Streptococcus sanguis using in vitro
both to tetracycline and to penicillins. Madinier et studies suggest problems with potential use owing
al. found 4% of A. actinomycetemcomitans strains to the emergence of resistance, which may be
tested were resistant to tetracycline at the plasmid mediated. Susceptibility testing in vitro of
breakpoint of 8 mg/L; the MIC of tetracycline was chlorhexidine against 141 isolates of S. mutans
4 mg/L. demonstrated that the MIC of chlorhexidine was
1068
≤ 1 mg/L Resistance to chlorhexidine in S.

9 infection to the Minimum Inhibitory
mutans and Streptococcus sobrinus was absent Concentration[MIC] of the drug, the time that the
following the application of chlorhexidine for 1 concentration of drug at the site of infection is
week; three different chlorhexidine applications, higher than its MIC against the pathogen(s) and
chlorhexidine varnish, chlorhexidine fluoride the AUC/MIC ratio.
varnish and chlorhexidine fluoride gel, were given An analysis of a random 10% of prescriptions
to 58 individuals, and the MIC of chlorhexidine written by dentists in Scotland between May and
against 863 isolates of S. mutans was ≤ 1 mg/L October 1998 revealed evidence of poor
and against 53 isolates of S. sobrinus was prescribing practices.9 Amoxicillin, metronidazole
≤ 2 mg/L . and penicillin V accounted for 90% of
prescriptions, showing no great change in
Antibiotic prescribing by dental antibiotic choice since more than 20 years4 A
practitioners range of 17 different antibiotics was prescribed
and there was wide variation in the frequency and
Evidence in the literature suggests that duration . For example, prescriptions of
antibiotic prescribing by dentists is often amoxicillin in capsule formulation, which
inappropriate.9 The choice of antibiotic that a represented 73% of amoxicillin prescriptions,
dental practitioner makes, because the range of ranged from 2 to 20 days treatment. Only 39.1%
options is limited, is less likely to be inappropriate. of tetracycline prescriptions were correctly
It may therefore be the dose, duration or frequency prescribed, at 250 mg.
of antibiotic prescription that is inappropriate. Yet
the development of resistance in the oral flora is Palmer et al. conducted a similar study in
not due solely to the prescribing habits of dentists, England and found that 5.6% of prescriptions were
who are responsible for only a small proportion of for combinations of antibiotics, the most frequent
the total prescription of antibiotics. combination being amoxicillin and metronidazole.
This is not surprising, because of the polymicrobial
nature of many dental infections. Guidelines
Therapeutic antibiotic prescribing published by the Commission of the Federation
Most dental infections can be treated Dentaire Internationale, however, recommend that
successfully by removal of the source. The combination therapy should be avoided whenever
majority of patients are, nevertheless, treated with possible in dentistry.This recommendation was
antibiotics. A tendency to use antimicrobial prompted by the wide variation in frequency and
treatment before resorting to dental extraction has duration of antibiotic course and dose.
been found. Only 25% of the 192 patients studied In dentistry antimicrobial therapy should be
by Barker & Qualtrough in 1987 at a dental considered only for the following groups of
teaching hospital were treated first by dental patients where one of the following conditions are
extraction. present
The Commission of the Federation Dentaire
Internationale recommends that therapeutic
Patients with fever and an acute infection
antibiotics be given at a dose that will produce Spreading infection without localization
tissue concentrations higher than MIC for the Chronic infection despite drainage and
pathogenic organisms implicated in the infection debridement
being treated.9 The duration of treatment should be
sufficient to eliminate the pathogens, although it is Medically compromised patients with
now argued that short-duration therapy is the most infections
effective method to prevent development of Cases of osteomyelitis, bacterial
resistance.10 The choice of antibiotic for treatment sialadenitis and some periodontal diseases
must be based either on the likely pathogens and as ANUG and localized juvenile
their probable susceptibility, or the susceptibility periodontitis. In general a drug other than
of pathogens cultured from the infection. Other pencillin should be considered if the
measures of antibiotic efficacy may also need patient has had pencillin within the
consideration when choosing appropriate therapy. previous month, due to the possible
These include consideration of the ratio of the presence of pencillin resistant bacterial
peak antimicrobial concentration at the site of populations previously exposed to the drug
1069
Antimicrobial Prophylaxis in Dentistry - ventriculoarterial shunts or bone grafts. When

questioned, only 21.8% of practitioners consider
Is the use of a drug to prevent colonization or prophylaxis necessary for patients who have
multiplication of microorganisms in a susceptible recently undergone radiotherapy to the head and
host. When used appropriately prophylaxis can neck,9 but guidelines recommend prophylaxis in
reduce morbidity and cost of medical care and the these cases since the blood supply is diminished
value of such prophylaxis depends on a balance following radiotherapy, making patients more
between the benefit of reducing the infection risk susceptible to infection.
and consequent secondary morbidity against the
possible toxic effects to the host including Dentists should work under the guidance of
alterations of the host commensal flora and cost cardiologists or other specialists in the
effectiveness. determination of valvular dysfunction with ‘at risk’
patients of this type. Most guidelines recommend
The use of antibiotic prophylaxis is considering each case individually, assessing the
contentious in dental practice. Were infections to patient and the procedure and balancing benefits
be caused by pathogens from the oral flora that and risks.10
are resistant to therapeutic agents, even if these
occurred at sites that are remote from the oral There is controversy surrounding the use of
cavity such as in cases of endocarditis, this would antibiotics for dental prophylaxis. The American
compromise management. This problem is now Heart Association recommends prophylaxis against
more than a theoretical possibility. Lonks et al, infective endocarditis in cardiac patients only in
report a case of endocarditis caused by an isolate dental procedures associated with significant
of S. mitis resistant to penicillin and cefotaxime, bleeding.9 Such procedures include dental
although it remained susceptible to vancomycin. extractions, periodontal surgery and scaling.
The patient in this case had recently undergone High-risk patients include those with prosthetic
several dental procedures and was given heart valves, previous bacterial endocarditis or
amoxicillin for prophylaxis. The occurrence of complex cyanotic congenital heart disease. Patients
resistance determinants encoding high-level with a past history of rheumatic fever without
resistance is increasing in the α-haemolytic valvular dysfunction are at negligible risk of
streptococci; these provide an important gene pool infective endocarditis
that not only affects the oral flora, but also may
Infective endocarditis occurs in up to 50
complicate management of extra-oral infections.
people per million per year, and 40% exhibit no
known risk factors.9 It has also been noted that
Prophylactic antibiotic prescribing cases of endocarditis involving oral
microorganisms are related infrequently to dental
The antibiotics used for prophylaxis mirror treatment.9 Additionally, Longman & Martin
those used for treatment. Amoxicillin, penicillin V affirm that the rate of post-surgical infection in
and metronidazole are the most popular choices. dentistry is low. Are dentists, therefore, being
Guidelines recommend using an antibiotic prior to unnecessarily cautious? Such caution may be
surgery that will attain a high serum concentration necessary in this litigious era. The guidelines drawn
by the time that surgery begins, and that will be up by the American Heart Association have been
maintained until after surgery. The same guidelines based on experience and relevant literature rather
recommend a single high dose that is not to be than randomized or controlled human trials.9 The
continued after surgery. use of prophylaxis is therefore based on careful
The Commission of the Federation Dentaire prediction. Such prediction is not sufficiently
Internationale published new guidelines stating that accurate to prevent infectious complications. It is
prophylaxis before dental surgery is appropriate for not surprising that dentists opt to err on the side
patients at risk of infective endocarditis, for of caution.
example those with prosthetic heart valves.10 Other
conditions for which prophylaxis is considered Dental prescribing by practitioners outside
appropriate include patients with facial fractures, the dental profession
compound skull fractures or cerebral rhinorrhoea,
immunocompromised patients, patients who have Patients may choose to seek treatment from
recently received radiotherapy to head and neck, medical practitioners before consulting a dentist,
and patients who have prosthetic hips, and general medical practitioners are more likely
1070
to prescribe antibiotics than are dentists for acute transport would enable greater awareness and use
dental problems. A prospective cross-sectional of these facilities.
study done in England in May 1994 found this
was the case in patients attending the examination DISCUSSION
and emergency department of a Dental Hospital.
60 of the 500 patients in that study were already There is reason for concern regarding
receiving antibiotics when they attended the dental antibiotic resistance in dental practice. The
hospital. Of these, general dental practitioners resistance data reviewed above demonstrate that
prescribed for 55% of cases, general medical the presence of resistance in oral flora is an
practitioners prescribed for 33% and hospital international problem. Studies have been
doctors prescribed for 8%. Thus, even for dental performed in countries including Germany, Taiwan
infections, prescribing is not the exclusive domain and Brazil. Nearly all have found a degree of
of dental practitioners; others are also prescribing antibiotic resistance present in particular oral
antibiotics, which in turn adds to the selective commensals, often those associated with specific
pressure for resistance. dental infections. The α-haemolytic streptococci
and Gram-negative anaerobes, such as members of
Use of diagnostic microbiology the genus Prevotella, appeared in the majority of
laboratories by dental practitioners studies reviewed, showing strains resistant to a
range of antibiotics used commonly in dentistry.
Diagnostic microbiology laboratories can Most strains tested show penicillin resistance, and
provide information to assist in therapeutic there is only one antibiotic, metronidazole, to
decisions, resistance surveillance and the which the oral flora has yet to show significant
development of local policies and guidelines. The resistance. Antibiotic resistance is not uniform
evidence of inappropriate prescribing by dentists within all strains, but even a low prevalence can
suggests that the facility is underused by the dental change rapidly through a combination of the action
profession . It seems that bacteriological sampling of transferable resistance determinants and frequent
only occurs where empirical therapy has failed. A exposure to antibiotics.
questionnaire was developed by Palmer et al. to
assess the prescribing knowledge of dental The literature suggests a significant
practitioners in England and Scotland. A number contributing factor in the selection of resistance
of respondents, not specified by the authors, felt may be an unnecessary use of antibiotic
that when short of time it was acceptable to prescriptions in dentistry. Studies conducted by
prescribe antibiotics without further investigation. Barker & Qualtrough, Thomas et al., Roy & Bagg
It was also felt that antibiotics could be prescribed and Palmer et al suggest inappropriate prescribing
if a definitive diagnosis could not be made or if by dental practitioners. The therapy used is
treatment had to be delayed. The immediate relief typically empirical, employing broad-spectrum
antibiotics. Furthermore, culture and susceptibility
of the patient seems to be an important factor
testing to aid diagnosis and the rational choice of
when considering treatment. This may also be
antibiotic often do not precede prescription for
fuelled by patient expectation. Patient expectation
dental infection.98 This means that antibiotics are
is also a contributing factor to the frequency of
being prescribed for a range of dental infections
antibiotic inappropriate prescribing. Dentists would
for which they may not be required. This
rather give antibiotics, and therefore give rapid inappropriate prescribing results in frequent
relief to the patient, than take what may be a long exposure to broad-spectrum antibiotics,
time to process a bacterial sample in order to predisposing to selection of resistant strains. It is
diagnose and treat the infection correctly. From the therefore hardly surprising that resistance is
laboratory perspective, there are also logistical present in the oral flora, and has the potential to
difficulties when processing dental specimens, pose real problems in terms of morbidity, cost of
owing to the lack of standard methodologies and care and future treatment choice. Furthermore, as
the need to preserve the integrity of small the antibiotics that dentists prescribe are used for
specimens containing diverse populations of treatment of infections other than those associated
anaerobic bacteria during transport to the with the oral cavity, the prescribing of these drugs
laboratory. More information about the service by medical practitioners will provide a further
these laboratories can provide and information on selective pressure for resistance The prescribing of
the correct procedures for clinical sampling and antibiotics by medical practitioners has already
1071
been found to contribute to resistance development the establishment of a surveillance system to

in a range of pathogenic and commensal determine the extent of resistance and to monitor
organisms, including those in the oral flora.. the use of antibiotics. Currently, there is no
Additionally, as medical practitioners are not surveillance system in India that monitors
expert in the treatment of dental problems, it resistance in the oral flora. Surveillance may be
would not be surprising to find them prescribing used to monitor the susceptibility of
inappropriately for dental infections that may only microorganisms and to detect any changes in that
require surgical or mechanical intervention. susceptibility. It may also provide information that
Guidelines and education regarding prescribing for will allow the formulation of strategies to combat
dental infections may well need to be targeted to antimicrobial resistance, including policy and
medical practitioners as well as dentists. formulary guidelines and alteration of prescribing
This issue is contentious. The American practices. It can also be used to assess the impact
Dental Association suggested that dentists are of any strategies on resistance selection and
responsible prescribers of antibiotics and are transmission. Resistance trends, including the most
unlikely to play a major role in the global problem prevalent mechanisms of resistance and their
of antibiotic resistance. The UK Department of transmission, may also be determined from
Health take a different view: Standing Medical surveillance data.
Advisory Committee of UK lists dentists as
contributors to the problem, along with medical The diagnostic microbiology laboratory has a
practitioners, veterinarians and those involved in significant role to play in surveillance, through
agriculture. In India nobody seems to be bothered identification of organisms with a pathogenic role
in view the virtual nonexistence of antibiotic in infection, and their subsequent susceptibility
policies guidelines and audits. testing. It is therefore important to establish better
awareness and communication between dental
The problem of antibiotic resistance in the oral practitioners and diagnostic microbiology
flora requires further investigation. More audits of laboratories. Information obtained from
antibiotic prescribing practice may be helpful, microbiological testing must be collated and
although it must be remembered that prescriptions disseminated rapidly to health care professionals
are an indirect measure of antibiotic consumption and other appropriate groups for it to be employed
and are not a measure of the rate of resistance usefully. Local surveillance networks incorporating
emergence, which is multifactorial. Palmer et al. educational institutions and associations are most
examined the potential of audits to alter important for guiding clinicians in the use of
prescribing habits. The results were encouraging;
empirical therapy and managing resistant
the number of prescriptions for antibiotics declined
infections. It is important to include all health
by 42.5% after the initial 6 weeks of the audit. In
professionals in such networks.
the first period, 2316 prescriptions were issued;
this fell to 1330 after educational meetings half
way through the process. Thus, there was a Summary
significant change in the appropriateness of Bacteria from clinical and non-clinical settings
prescribing during the study. The audit and the are becoming increasingly resistant to conventional
resulting guidelines, and educational meetings antibiotics. 10 years ago, concern centred on
addressing the problems revealed by the audit, Gram-positive bacteria, particularly
were therefore found to be effective, at least in the meticillin-resistant Staphylococcus aureus and
short term. vancomycin-resistant Enterococcus spp. Now,
In May 1997, Health Canada and the Canadian however, clinical microbiologists increasingly
Infectious Disease Society held a national agree that multidrug-resistant Gram-negative
conference in Montreal entitled ‘Controlling bacteria pose the greatest risk to public health. Not
antimicrobial resistance: an integrated action plan only is the increase in resistance of Gram-negative
for Canadians’. The aim was to develop a plan to bacteria faster than in Gram-positive bacteria, but
limit the development of antimicrobial resistance also there are fewer new and developmental
and its spread. Dental practitioners were antibiotics active against Gram-negative bacteria
represented at the conference and a number of and drug development programmes seem
recommendations were made, to be implemented insufficient to provide therapeutic cover in 10—20
by all practitioners prescribing antibiotics. One was years.
1072
The continuing emergence of procedures requiring cover will increase,yet fewer

antibiotic-resistant bacteria within the oral patients will require cover.
microbiota will have an impact on the prescribing
Dosage and duration of therapy are critical
of antibiotics in dental practice4 and there iscause
factors modulating emergence of resistance.
for concern regarding antibiotic resistance in dental
Antimicrobials should be given in therapeutic
practice. This does not only complicate the
doses sufficient to produce a tissue concentration
treatment of dental infections but affects the
greater than that required to kill or inhibit the
prophylaxis and management of infections caused
growth of the causative organism. Duration of the
by oral organisms at remote sites such as brain
therapy should be long enough to eliminate all or
abscesses and in cases of endocarditis.
nearly all of the pathogens as the remainder will
It is important that not only the dental in most instances be destroyed by the host
profession but the general public understand the defenses.
importance of restricting the use of antibiotics to
those true cases of severe infection that require Some guidelines for the use of antibiotics
them. Patients have become accustomed to being
given an antibiotic for a range of medical Educating the medical profession and public is
complaints. Unfortunately, patients presenting at the main weapon that we need to employ for this.
dental surgeries also routinely expect an antibiotics Like charity it must start at the home of the
for the treatment of ’toothache’. Doctors and profession and intense education, reorientation and
patients should understand that dental pain is an restrain are required in the use of antibiotics.
inflammatory condition that is appropriately • The recognition of the problem is the most
managed by use of anti-inflammatory analgesics important step both for the doctors as well as
and local measures and not a bacterial infection the public.
that requires provision of an antibiotic
• Both during the training and practice, doctors
Antibiotics are useful to combat only bacterial should be repeatedly updated with knowledge
infections and must be prescribed for a specific on the prevalence of sensitivity and resistance
number of days. The most common mistake made of bacteria to antibiotics.
is to stop taking the drug as soon as one feels • Surveillance of resistance should be carried
better, leaving the course of antibiotics unfinished. out at the local, national and international
A course shorter than needed will help in the levels. This is the most important step in
evolution of superbugs, It is said that individuals tackling this problem as without this it is not
within the community can harbour resistant possible to know the problem.
bacterial strains for up to three months following
antibiotic usage and as such, represent a high level • Data generated by many laboratories should be
of resistance within the general population. reviewed and circulated to all concerned so
that they can reorient the use of antibiotics.
It has recently been shown that reducing • As mentioned above, the use of antibiotics in
antibiotic for urinary tract infections at the general common cold and throat infection should be
medical level resulted in a reduced incidence of restricted unless there is a clear-cut indication.
resistance in the local community. This observation This is a major area of antibiotic misuse.
is extremely important since it does demonstrate
to individual practitioners that modifying their • Coordinated research to evaluate the problem
prescribing habits can influence patterns of in specific diseases should be carried out to
resistance. The same beneficial effect would decrease the resistance and the policy to
probably be observed for dental practitioners if restrict the use of a particular antibiotic or to
they reviewed their prescribing for dental rotate the antibiotics should be instituted.
conditions. If the number of prescriptions issued • Self-prescription and over the counter sale of
in dentistry could be reduced then the selection of antibiotics should be curbed. The law already
resistant strains should occur less frequently prohibits it but it needs to be enforced.
The range of dental procedures requiring • Patient should strictly follow the dose and
antibiotic prophylaxis has been simplified to “all duration of the prescription.
procedures involving dento gingival • Be patient with common colds and sore
manipulation’10This implies that the number of throats. It has been said that ‘cold’ is cured in
1073
one week with antibiotics otherwise it takes The installation of a surveillance system,
seven days. accompanied by audit to ascertain the numbers of
• It should be remembered that many diseases prescriptions written and their appropriateness, to
in the developed countries were controlled highlight areas of prescribing knowledge that are
even before the antibiotics were available and lacking in dental practice are recommended.
they were based on good public health Further investigation and education are required to
measures like improving hygienic conditions, attempt to slow resistance development and lessen
availability of clean drinking water, good the future impact on antibiotic prescribing in
sewerage disposal, public education for clean dentistry. The emergence of antibiotic-resistant
personal hygienic practices and control of bacteria within the oral flora will have an impact
hospital acquired infections. on the prescribing of antibiotics in dentistry.
Action must be taken now to lessen this impact in
• Immunisation is a better alternative to the use the future. ‘No Action today is No cure tomorrow.
of antibiotic or chemotherapy. Diseases like
small pox, polio, measles, chicken pox,
tetanus, whooping cough and, now, hepatitis REFERENCES
are brought under check by the use of 1. Kumarasamy KK, Toleman MA, Walsh TR, et al;
immunisation, and not antibiotics. Emergence of a new antibiotic resistance mechanism
Antibiotics are one of natures precious gifts to in India, Pakistan, and the UK: a molecular,
humanity and a powerful weapon in the doctors” biological, and epidemiological study, Lancet Infect
arsenal. Let us not tempt nature by its Di. 2010; 10 (9): 597–602.
indiscriminate and irresponsible use. Unless timely 2. Deshpande Payal, Rodrigues Camilla, Shetty Anjali,
action is taken to curb its misuse a time will come Kapadia Farhad, Hedge Ashit, Soman Rajeev (2010);
when the bacteria has the last Laugh. The New Delhi Metallo-â lactamase (NDM-1) in
Enterobacteriaceae: Treatment options with
frightening truth is that misuse of antibiotics has
Carbapenems Compromised, Journal of Association
become a major public health hazards of Physicians of India. 2010; 58: 147–150.
3. Cardiff University; Antibiotic-resistant bacteria in
CONCLUSION Indian public water supply, Science Daily. Retrieved
May 13, 2011 from http:// www.sciencedaily.com
To conclude there is an urgent need to raise /releases/ 2011/ 04/ 110406214332. htm
public and professional awareness regarding the
4. "Linking India to superbug unfair and wrong, says
risks of antibiotic use not only in dentistry but all
India". Hindustan Times. 12 August 2010.
aspects of medical care. If the profession and www.hindustantimes.com
public respond responsibly to the issues
surrounding antibiotic prescribing now, it may be 5. Sharma, Sanchita. "’Don’t blame superbug on India,
it’s everywhere’". Hindustan Times. 13 August 2010
possible to preserve the usefulness of these drugs
for clinical situations where they are truly 6. Abdul Ghafur K . "An obituary- On the Death of
indicated antibiotics!". Journal of Association of Physicians of
India . March 2010 .
Comprehensive undergraduate and 7. "Lancet says sorry for ’Delhi bug’". The Times Of
postgraduate education on the subject is required. India.http://www.timesofindia.indiatimes.com
Further studies and establishment of a surveillance 8. Liljemark, W. F. & Bloomquist, C; Human oral
system are also to be recommended. Clear microbial ecology and dental caries and periodontal
guidelines and prescribing policies need to be diseases, Critical Reviews in Oral Biology and
developed to attempt to limit resistance within the Medicine, 1996; 7: 180–98.
oral flora. Antibiotic use by dentists affects flora 9. Sweeny LC, Dave J Chambers PH, Heritage J;
that exist beyond the oral cavity, since, during Antibiotic resistance in general dental practice – a
therapy, antibiotics become distributed throughout cause for concern?, J.Antimicrob chemother. 2004; 53
the body. Antibiotics prescribed by medical [4]: 567-76
practitioners also have similar broad effects. If 10. Samaranayak L P.Johnson N W; Guidelines for the
dentists, along with medical practitioners, can use of antimicrobial agents to minimise development
reduce the number of antibiotic prescriptions, the of resistance, International dental journal.1999;49(4):
rate of resistance development may be slowed. 189-95
1074
Oral Hygiene Status of 7-12 year old School Children in

Rural and Urban population of Nellore District
1
Dr M.S.Minor Babu, 2Dr SVSG Nirmala, 3Dr N.Sivakumar
ABSTRACT
Introduction: Dental caries is a significant health problem among the people of all ages but the
magnitude of the problem is greatest among young children. As far as the population of Nellore district
is concerned, data is not available regarding dental caries and oral hygiene status of both rural as well as
urban population.
Objectives: The present study aims at assessing the prevalence of dental caries and oral hygiene
status in school children aged 7-12 years so as to provide information to health authorities to plan
appropriate preventive and curative oral health programs for school children.
Materials and Methods: The survey was carried out in 1590 children of 20 schools in both rural
and urban areas. Out of this 796 were male and 794 were female children. The DMFT and deft indices
were used to assess the number of decayed, missing, and filled teeth (DMFT) and surfaces (DMFS) for
the permanent dentition as well as the primary dentition (dft,dfs). Oral hygiene status was assessed by
using Oral Hygiene Index simplified.
Results: The overall prevalence of dental caries was 65.6%. High prevalence of dental caries was
seen urban school children of 7-9 & 10-12 year school children. Among them oral hygiene status was
observed to be poor in rural school children. Dental caries prevalence was higher in female children even
with good oral hygiene.
Conclusion: Prevalence of dental caries was higher in urban school children even with good oral
hygiene
Key words: Dental caries Prevalence, Oral Hygiene status, School children
INTRODUCTION child. Early recognition of this disease is of vital

importance to preserve oral health.
Good oral health is essential for improving
overall health and well being. Dental caries is a Since the majority of children are living in
multifactorial disease and preventable public health rural areas and their living standards are in general
problem which interferes with normal nutrition, inferior to those in urban areas, it is likely that
speech, self esteem and daily routine activities. they have a different oral health profile. There are
Early detection of this & prompt intervention will no epidemiological studies done to evaluate the
certainly prevent disease progression1. In India, prevalence of dental caries and oral hygiene status
dental caries has been consistently increasing in in children of Nellore District, Andhra Pradesh.
prevalence and severity over the last two decades, Hence, this study was undertaken to evaluate and
about 80% of children and 60% of adults suffer compare the prevalence of dental caries and oral
from dental caries2. hygiene status in 7-12 year old children in both
rural and urban children of Nellore district.
The overall impression is that dental caries has
increased in prevalence and severity in the urban
MATERIALS AND METHODS
and cosmopolitan population over the last couple
of decades. However, there is no definite picture The present study was undertaken by the
as yet regarding the dental caries status in the rural Department of Pedodontics and Preventive
areas of our country, where 72.2 % of the Dentistry, Narayana Dental College and Hospital,
population live3. Healthy dentition is a primary Nellore (Andhra Pradesh) to evaluate prevalence
prerequisite for physical, social, emotional and of dental caries and oral hygiene status in school
psychological development and well being of a going children aged 7-12 years of rural and urban
1 2
Assistant Professor, Dept. of Pedodontics and Preventive Dentistry, Vishnu Dental College, Bhimavaram. Professor,
3
Professor and Head, Dept. of Pedodontics and Preventive Dentistry, Narayana Dental College, Nellore.
1075
areas of Nellore district. The survey was carried using 14th version of SPSS software (Statistical
out in 20 schools, of which 11 schools were Package for Social Sciences).
located in rural and 9 schools were in urban areas.
RESULTS
A total of 1590 children in the age groups of Group I included 460 children from rural and
7-9(group I) and 10-12(group II) years were 490 children from urban schools. Group II
examined from both the genders. Out of this 796 included 340 children from rural; 300 children
were male and 794 were female children. Prior from urban schools.
consent was taken from respective school
authorities and parents of all participants. Children In Group I, 321(69.9%) of 460 rural children
were examined in upright chairs or stools in and 348 (71%) of 490 urban school children
showed caries. In Group II, 167 (49.1%) of 340
adequate natural light during day time outside the
rural school children and 165 (55.7%) of 300
classrooms or in corridor of the schools using
urban school children showed caries. (Table 1)
WHO criteria. The subjects were examined using
plain mouth mirror and shepherd’s crook explorer Table 2 represents the mean and standard
(NO.5). Single examiner interviewed and examined deviation of dft scores for rural and urban school
all the subjects. children
This group wise category was based on the Table 3 represents the mean and standard
development of dentition. Henceforth 7-9 year age deviation of DMFT scores for rural and urban
children usually comes under early mixed dentition school children
period and 10-12 year age children comes under
Table 4 represents the mean and standard
late mixed dentition period. deviation of OHI-S scores for rural and urban
The DMFT and deft indices were used to school children
assess the number of decayed, missing, and filled Table 5 represents the mean and standard
teeth (DMFT) and surfaces (DMFS) for the deviation of dft, dfs, DMFT, DMFS and OHI(S)
permanent dentition as well as the number of of male and female children of group I
decayed and filled teeth (dft) and surfaces (dfs) for
the primary dentition4. Oral hygiene status was Table 6 represents the mean and standard
analyzed by using oral hygiene index simplified deviation of dft, dfs, DMFT, DMFS and OHI(S)
by Greene and Vermillion (1964)5.Any oral of male and female children of group II
diseases or pathological conditions observed during Group I overall caries prevalence was 69.9%
the examination was informed to the subjects and in rural school children, whereas 71.1% was
they were referred to Narayana dental college & observed in urban school children.
Hospital, Nellore.
In Group II the prevalence was 49.1% in rural
The data from the completed forms were where 55.7% was seen in urban school children.
entered into Microsoft Excel –XP software It was also observed that caries prevalence slowly
program. The data gathered was analyzed by using increased with increase in age at both the places.
chi-square test. The level of significance was set The mean dft(s), DMFT(S) scores were higher in
at P = 0.05 and the statistical analysis was done urban places of Nellore district than rural areas
Table 1: Prevalence of dental caries in rural and urban school children
Rural school children Urban school children
Age Group Total No of Total no of Total No of Total no of

children children affected Prevalence children children affected Prevalence
examined by caries examined by caries
Group I 460 321 69.9% 490 348 71%
(7-9 years )
Group II 340 167 49.1% 300 165 55.7%
(10-12 years)
1076
Table 2. Comparison of dft between rural and urban school children
Groups Rural Urban Chi square P value Significance

Group I (7 – 9years ) 1.41 ± 1.48 2.55 ± 2.37 106.58 0.01 S
Group II (10-12 years ) 1.12 ± 1.46 1.44 ± 1.75 33.64 0.954 NS
Table 3. Comparison of DMFT between Rural and Urban School Children

Group I (7 – 9 years ) 0.11 ± 0.44 1.01 ± 1.90 46.32 0.049 S
Group II (10-12 Years ) 0.59 ± 1.01 1.65 ± 2.05 29.33 0.893 NS
Table 4.Comparison of OHI-S between Rural and Urban School Children

Group I (7 – 9 years) 1.27 ± 0.71 0.94 ± 0.50 1660.54 0.001 S
Group II (10-12 years ) 1.78 ± 0.74 1.18 ± 0.57 891.58 0.999 NS
Table 5. Comparison of mean and standard deviation between male and female (group I)
Mean ± SD
Chi-square P value Significance
Male Female
dft 1.88 ± 2.01 2.12 ± 2.11 99.40 0.75 NS
dfs 3.54 ± 4.13 3.74 ± 4.10 382.23 0.907 NS
DMFT 0.34 ± 1.09 0.81 ± 1.74 246.95 0.001 S
DMFS 0.52 ± 1.67 1.25 ± 2.71 229.09 0.001 S
OHI-S 1.11 ± 0.64 1.09 ± 0.63 1541.96 0.001 S
Table 6. Comparison of mean and standard deviation between male and female (group II)
Mean ± SD
Chi-square P value Significance
Male Female
dft 1.21 ± 1.54 1.33 ± 1.68 64.987 0.442 NS
dfs 2.09 ± 2.82 2.28 ± 2.97 229.208 0.010 S
DMFT 0.71 ± 1.23 1.48 ± 1.95 53.785 0.559 NS
DMFS 1.10 ± 2.03 2.21 ± 3.10 156.747 0.008 S
OHI-S 1.43 ± 0.85 1.41 ± 0.73 1318.366 0.584 NS
(Table 2 & 3). But OHI(S) scores were lower in suitable nutrients for the oral microorganisms. A
urban school children (Table 4) number of factors have been put forward to
explain the variation in prevalence and severity of
DISCUSSION dental caries and periodontal diseases, not only
between developing and developed countries, but
Maintenance of oral health is a prerequisite for
also between rural and urban populations. In
general well being of an individual. But this oral
health is affected by a multitude of pathological general, these factors can be divided into local
conditions, one of the most common conditions intraoral factors associated with plaque
being dental caries, a multifactorial disease. Major accumulation, metabolism and fluoride exposure or
factor known to be concerned with its initiation general factors such as age, sex and socio-cultural
and progress are the nature and the availability of variables.
1077
In present study, the overall caries prevalence affordability of tooth brushes and fluoridated tooth
was 65.6 %.In developing countries like India pastes were high in urban population.
there has been marked increase in the incidence of
dental caries3, 6. The high caries prevalence in the Comparison of Dental Caries and Oral
Nellore school children indicates the immensity of Hygiene Between Male & Female Children
oral health problems.
In Group I:
Prevalence of dental caries was low in group
In present study, the dft scores of female
I rural school children. These children belongs to
children (2.12) were higher than male children
the lower strata of society, their access to refined
(1.88). This was explained by the fact that females
sweets and candies are less and their snacks would
had higher dft values initially, though males had
be mostly restricted to locally made low sugar
slightly higher dft values after the age of 7,
unrefined sweets. They would also be taking
peaking at age 9. The dft for females peaked at
harder and fibrous food stuffs, which may explain
age 5 to 6. This may have been indicative of males
the low caries prevalence. Our results were similar
maturing later than females and keeping their
with the results obtained by Frencken7, who
primary teeth longer. The retention of those
carried out in 7-9 years old children in Tanzania
primary teeth for an additional one or two year
and found that dental caries was more prevalent
may have played a large role in the disparity of
and severe in urban school children than rural
dft values between males and females. These
school children. These findings were similar with
findings were contradictory with other studies
study conducted by Saha and Sarkar in 19963.
conducted by Mahesh kumar10, Rao1, who
Reasons for these differences was attributed to the
observed higher dft scores in male children.
higher intake of candy, meals and sweetened
Whereas female children showed high DMFT
beverages in urban areas and the fluoride content
scores than male children, this could be attributed
of drinking water in rural areas.
to the fact that the permanent teeth erupts at an
Group II rural school children showed 49.1% earlier age and there will be prolonged exposure
prevalence, closely corresponded with study to the oral environment in females. This finding is
conducted by Dhar et al8 whereas urban school closely corresponding with the study conducted by
children showed high prevalence and this was Mahesh kumar et al10 who observed mean DMFT
attributed to higher intake of candy, sweetened was higher in girls (0.50) than boys (0.35). Oral
beverages in urban areas and increased availability hygiene status was poor among male children than
of refined sugar in the form of sweets, biscuits and female school children which is statistically
chocolates sold at canteens located in school significant (P=0.001).This could be due to varied
premises. The findings of the present study are habits, shedding of primary teeth, improper and
closely related to the study conducted by Chironga unsupervised oral hygiene practices in male
and Manji9, who observed higher mean DMFT children whereas female children had lower scores
(0.57) in urban school children than rural school perhaps due to the increased grooming habits. This
children (0.49) in Zimbabwe. The raising levels of finding was closely allied with other studies of
caries which are said to be associated with changes Saha and Sarkar 3, Mahesh kumar10, Omar and
in standards of living, dietary habits, and increases Pitts11.
in sugar consumption. In Group II:
Mean dft scores were similar between male
ORAL HYGIENE STATUS: and female children, could be due to the fact that
only few primary teeth were present with
Oral hygiene status was poor among rural remaining teeth exfoliated. Mean DMFT scores
school children than urban school children for were higher in female children (1.48) than male
above age groups which were correlating with the children (0.71). One may speculate that the dietary
study done by Saha and Sarkar3. Good oral habits in males and females in the younger age
hygiene status depends on frequency, type of tooth group differed little, while females in this age
brushing, and mode of cleaning. Poor oral hygiene group probably indulged in cariogenic items more
status among rural school children could be frequently than males. Another reason for the
attributed to poor oral hygiene practices, use of higher caries prevalence in females may be the
finger instead of tooth brush and tooth paste being earlier median age of eruption of permanent teeth
substituted with charcoal, whereas availability and compared to males, which may be 6-10 months.
1078
These results were closely corresponding with the health professionals must be informed and
studies conducted by, Saravanan12,Chaffin13, Rao1, motivated to develop core values, visions, goals
Chironga and Manji9 and Joshi14. The findings in and activities, and to provide new direction for
their studies were attributed to the fact that females health education and promotion of optimal school
mature earlier, thus permanent teeth had increased learning and health. If the child doesn’t maintain
opportunity for exposure in female children. adequate health, the benefits of education will be
lost because of absenteeism or lack of attention
Oral hygiene status was poor in male children
due to ill health. 16
as compared to female children, but these
differences were not statistically significant (P =
0.58). Female children have better oral hygiene CONCLUSION
and the variation between sexes may be attributed
The overall prevalence of dental caries in the
to behavioral differences.
study population was 65.6%. Prevalence of dental
These findings suggest that the oral hygiene caries was higher in urban than rural school
status was high in urban children could be due to children. Among all the age groups, oral hygiene
parent’s dental awareness which is reflected in the status was observed to be poor in rural school
child’s oral hygiene maintenance and the children compared to urban school children. Dental
educational level of the family members. Rural caries prevalence was higher in female children in
children do not have access to restorative (or) any all the age groups. But female children had good
other dental treatment due to the non-existence of oral hygiene than male in above age groups.
professional dental care in rural India and no The results of our study point out that dental
access to government dental services in the caries is a major public health problem and an
surrounding region. active and effective preventive program for dental
The school population of today is the adult of care is needed for child population. Knowledge
tomorrow; they should be educated, so that a sense imparted through these programs would go a long
of responsibility would develop in them about oral way in maintenance of oral health in these
health. Exploring the links among clinical children. This study can help to the oral health
conditions, their personal and social outcomes not professionals not only to plan and implement
only promote a more complex appreciation of oral treatment procedures but also to design and carry
health, it also provides the opportunity to identify out appropriate preventive measures for dental
interventions to curtail the consequences of oral caries.
diseases by conducting school dental health From this study we can suggest that, provision
programs. of oral health education in the schools with proper
Based on our study, oral health assessment and instructions on oral hygiene practices and School
dental health education of children at an early age based preventive programs will probably be
helps in improving preventive dental behavior and important for the maintenance and further
attitudes, which is beneficial for a improvement of oral health in rural as well as
urban school children.
lifetime. This can be achieved by educating
the uneducated parents about dental health through REFERENCES
school dental health programs. Parents should be
made aware of proper brushing method, usage of 1. Rao A, Sequeira S P, Peter S. Prevalence of dental
pit and fissure sealants and importance of other caries among school children of Moodbidri. J Ind Soc
preventive measures for children. The rationale of Pedo Prev Dent 1999; 17:45-8
school dental health program is to improve and 2. National Oral Health Care Programme (NOHCP)
motivate the teachers, parents and children Implementation Strategies. Indian Journal of
regarding their dental health and treatment needs. Community Medicine Vol. XXIX, No.1, Jan.-Mar.,
15 2004
3. Saha S and Sarkar S. Prevalence and severity of
The school age is regarded as the most dental caries and oral hygiene status in rural and
important phase of child’s life as it plays an vital urban areas of Calcutta. J Indian Soc Pedo Prev
role in the education and development at the Dent.1996: 14(1):17-20.
crucial stage of childhood and adolescence. 4. Klein H, Palmer CE, Knutson JW Studies on dental
Parents, teachers, administrators, students and caries: Dental caries status and dental needs of
1079
elementary school children. Public Health Rep. 1938; 11. Omar SM and Pitts NB. Oral hygiene, gingivitis and
53: 751-765 periodontal status of Libyan school children.
5. Greene J.C and Vermillion J.R. The simplified oral Community Dent Health.1991 Dec: 8(4):329-33.
hygiene index. J.A.D.A Jan 1964: 68:25-31 12. Saravanan S, Kalyani V, Vijayarani MP, Jayakodi P,
6. Sudha, Bhasin, and Anegundi RT. Prevalence of Felix JWA, Arunmozhi P, Krishnan V and Sampath
dental caries among 5-13 year-old children of KumarP. Caries prevalence and treatment needs of
rural school children in Chidambaram Taluk, Tamil
Mangalore city. J Indian Soc Pedo Prev Dent - June
Nadu, South India. Indian J Dent Res
2005.
2008;19:186-190.
7. Frencken J, Manji F and Mosha H: Dental caries
13. Jeffrey G. Chaffin, Satish Chandra S P and Robert
prevalence amongst 12-year-old urban children in
A. Bagramian. Caries Prevalence in Northwest
East Africa. Community Dent Oral Epidemiol. 1986; Michigan Migrant Children. J Dent Child. 2003:
14:94-8. 124-129.
8. Dhar V, Jain A, Van Dyke T.E, Kohli A. Prevalence
14. Joshi N, Rajesh R, Sunitha M. Prevalence of dental
of dental caries and treatment needs in school going caries among school children in Kulasekharam
children of rural areas in Udaipur district. J Indian village: a correlated prevalence survey. J Ind Soc
Soc Pedo Prev Dent. 2007 september:119-121 Pedod Prev Dent 2005; 138-140.
9. Chironga L and F Manji. Dental caries in 12 –year- 15. Mascarenhas A.K. Determinants of caries prevalence
old urban and rural children in Zimbabwe. and severity in higher SES Indian children.
Community Dent Oral Epidemiol 1989:17:31-3. Community Dental Health 1998; 20: 107-113.
10. Mahesh kumar P, Joseph T, Varma R.B, Jayanthi M. 16. Ebrahim GL. Practical mother and child health in
Oral health status of 5 years and 12 years school developing countries. Hong Kong. Published with the
going children in Chennai city-an epidemiological support of the Catholic Funds for overseas
study. J Ind Soc Pedo Prev Dent 2005; 17-22 Development 1980: 97-100
1080
Systemic Lupus Erythematosus – A Rare Case Report

with Review of Literature
1
Dr. P.E. Chandra Mouli, 2Dr(Capt).S.Manoj Kumar 3Dr. B. Anand, 4Dr.P.D.Madan Kumar
5
Dr. S. Shanmugam
ABSTRACT
Systemic Lupus Erythematosus is an autoimmune disease that has gained an increasing amount of
attention over the past decade. (SLE) derives its name from the typical facial rash, which resembles the
malar erythema of a wolf. Lupus is one of the hardest diseases to understand because it is unique yet
similar in many aspects to other unrelated diseases. The intense complexity of lupus can be better
understood by taking a closer look at its definition, causes, symptoms, and treatment.
Key words: Lupus, Malar rash, Discoid rash.
INTRODUCTION surrounded by a white striae with a radiating

orientation that sharply terminate toward the centre
Systemic Lupus Erythematosus (SLE) derives
of the erythematous area is seen on the centre of
its name from the typical facial rash, which
the vermilion border of the lower lip extending 1.5
resembles the Malar erythema of a wolf. It is a
cm from the right and left corner of the vermilion
multi-system involving autoimmune connective
border of the Lower lip (Fig 2). All inspectory
tissue disease of unknown etiology. It is
findings such as site, size, shape, surface, extent
characterized by the marked diversity and
are confirmed on palpation. It was soft in
heterogeneity in clinical course as well as
consistency and tenderness present on palpation.
presentation. The clinical pattern of lupus has been
changed dramatically in recent decades from Presence of joint pain in her both right and
originally an acute fatal disease to the chronic left knee regions with her Blood count showing
inflammatory autoimmune disease, occasionally elevated rheumatoid factors of 235 (Strongly
fatal. It is somewhat like an inflammatory Positive).
syndrome for there is no single abnormality that
can definitely establish the diagnosis. As a result Her Lupus Anticoagulants = 47 seconds
criteria have been developed and modified in an (Normal Reference Range: 31-45 seconds)
attempt to make a precise diagnosis with high
sensitivity and specificity. [1] Incisional biopsy was performed under local
anaesthesia (Fig 3).
Case Report:
Post operative medication:
Patient named Mrs. K. Lalitha, 45 years of age
came to Ragas Dental college Out Patient Cap. Novamox LB 250 mg (15), (1 − 1 − ) × 5
Department of Oral medicine, Diagnosis and days after food.
Radiology with a chief complaint of a burning
sensation in the lower lip region for the past 7 Cap. Imol 250 mg (9), (1 − 1 − 1) × 3 days after
years. The burning sensation gets aggravated while food
eating hot spicy foods and during mastication of
food substances. No other constitutional symptoms Incisional Biopsy of the affected area under
like fever present. Haematoxylin and Eosin stained Histopathologic
section showed patchy deposits of Periodic
On clinical examination, extraorally macules Acid-Schiff positive material in the Basement
were present over the malar prominences of the membrane zone, subepithelial edema and a more
face in a butterfly like distribution sparing the diffuse ,deep inflammatory infiltrate often in a
nasolabial fold (Fig 1). Intraorally an irregular perivascular orientation suggestive of Systemic
erythematous area measuring 1.5 × 2 cm Lupus Erythematosus.(Fig 4)
1, 3
Senior Lecturer, 2 Professor, 5 Professor and Head, Dept. of Oral Medicine and Radiology, 4
Reader, Dept. of Preventive
Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamilnadu.
1081
Fig. 1. Extra oral view(frontal &lateral) showing Malar rash
• 0.05% Fluocinonide gel placed on the affected

area 2 x /d for 2 Weeks.
• 0.05% clobetasol gel placed on the affected
area 2 x /d for 2 Weeks.
• Dexamethasone elixir (0.5 mg/mL)
• Swish and spit 10 mL 4 x /d for 2 weeks.
• Triamcinolone acetonide 5 mg/mL
Intralesional injection
Fig. 2. Erythematous area on lower lip(Discoid rash) • Topical antifungal therapy, 10 mg clotrimazole
troches Dissolve in mouth 5 times per day for
10 days.
• 5ml Nystatin suspension (100,000 U/mL)
Swish and spit 5 ml 4 times per day for 10
days.
• Chlorhexidine rinse (0.12%).Swish and spit 10
ml 2 times per day until lesion resolves.
Patient was reviewed and healing is
satisfactory. Patient was referred to Voluntary
Health Services,Adyar, Chennai for management
Fig. 3. Incisional Biopsy done on lower lip of her systemic complaints.
DISCUSSION
Systemic Lupus Erythematosus is an
autoimmune disease characterized by auto
antibodies, immune complex formation directed
against the molecular constituents of nucleosomes
and ribonucleoproteins and immune dysregulation
resulting in damage to essentially any organ
including oral cavity, CNS, Kidney, Blood cells
and skin [1].
Fig. 4. Histopathologic section showed patchy deposits of
Periodic Acid-Schiff positive material in the Basement membrane
Epidemiology
zone, subepithelial edema and a more diffuse ,deep inflammatory
SLE is up to 10 times more common in
infiltrate.
women than men, and typically has a predilection
Correlating the Clinical findings together with for women in their child-bearing years [2]. The
Histopathological Features, the lesion is finally overall prevalence is estimated to be about 1 per
diagnosed as Systemic Lupus Erythematosus. 1000. A study from Birmingham, UK, found the
prevalence to be 27.7/100,000 in the general
The Patient was prescribed the following drug population, but nearly 9 times higher in Afro-
regimen. Caribbean females [3]. Data from a national health
1082
survey in the USA found the self-reported terminate toward the center of the lesions, which
prevalence of SLE (defined as having been given has a more erythematous appearance .The most
a diagnosis of SLE by a physician) to be affected sites are the gingiva, buccal mucosa,
241/100,000 [4]. Recognizing that this may well tongue, and palate. Lesions in the palatal mucosa
be an over-estimate, combining self-reporting with can be dominated by erythematous lesions, and
evidence of a current prescription for white structures may not be observed Oral mucosa
anti-malarials, corticosteroids, or other lesions compatible with LE may be the first sign
immunosuppressive medications reduced this of the disease. SLE may also occur in concert with
figure to 53.6/100,000 [4]. other rheumatologic diseases such as secondary
Sjogren’s syndrome and mixed connective tissue
Aetiology/pathogenesis disease.
The clinical heterogeneity of this disease is

mirrored by its complex aetiopathogenesis DIAGNOSIS
(reviewed in [5]). Twin studies initially indicated Table 1. Diagnostic criteria of SLE.
the importance of genetic factors, and genome Adapted from Tan et at, 1982 [7].
screening has highlighted a number of potential A person is said to have SLE if he/she meets any 4 of these 11
loci of interest [6]. In the susceptible individual, criteria simultaneously or in succession.
disease may result from a variety of environmental S.No Criterion Definition/examples
triggers including exposure to sunlight, drugs and
1. Malar rash Fixed erythema over the malar
infections, particularly with Epstein-Barr virus. eminences
Even within one patient, lupus flares can result 2. Discoid rash Erythematosus raised patches
from different precipitants at different times. 3. Photosensitivity Skin rash as a result of unusual
The majority of patients have elevated levels reaction to sunliqht
of autoantibodies, directed in particular against 4. Oral ulcers Usually painless
nuclear components such as nucleosomes, DNA 5. Arthritis Non-erosive: Jaccoud’s
arthropathy
and histones, and it is generally accepted that at
6. Serositis (a) Pleuritis - pleuritic pain,
least some of these have a directly pathogenic role, pleural rub, pleural effusion
either by precipitating as immune complexes in (b) Pericarditis - ECG changes,
target organs or by cross-reacting with other rub, pericardial effusion
functionally relevant antigens. The presence and 7. Renal disorder (a) Proteinuria (> 3 + or 0.5
persistence of these autoantibodies indicate an g/day)
abnormality in tolerance, which results from a (b) Cellular casts in urine
combination of abnormal handling of autoantigens 8. Neurological (a) Seizures
following apoptosis, and deranged function of T disorder (b) Psychosis
and B lymphocytes. 9. Haematological (a) Haemolytic anaemia
disorder (b) Leukopaenia
Clinical Findings: [1] (c) Lymphopaenia
(d) Thrombocvtopaenia
The most common symptoms of lupus include 10. Immunological (a) Anti-DNA antibodies
joint pain, frequent unexplained fever, swollen disorder (b) Anti-Sm antibodies
joints, fatigue (moderate to severe), skin rashes, (c) Anti-phospholipid antibodies
chest pain (especially on deep breathing), rash 11. Anti-nuclear Exclude drug causes
across the cheek and nose (resembles the shape of antibody
a butterfly), sensitivity to light or the sun, hair
loss, abnormal blood clotting, Raynaud’s Diagnostic criteria (Table 1), which are
syndrome, seizures and/or mouth or nose ulcers, published by the American College of
and anemia. At this time there is not a single Rheumatology (ACR), were revised in 1982 [7]
laboratory test to diagnose lupus. and combine clinical signs and symptoms with
abnormalities detected in blood tests such as a
Alan in-ChiefThe oral lesions observed in SLE positive anti-nuclear antibody or
and DLE are similar in their characteristics, both thrombocytopaenia. They were further updated in
clinically and histopathologically. The typical 1997 [8] to reflect a greater understanding of the
clinical lesion comprises white striae with a role of antiphospholipid antibodies in patients with
radiating orientation, and these may sharply SLE.
1083
Histopathological Features: The most common • Lupus nephritis remains the complication
histopathologic features of SLE are Hyperkeratosis which carries with it the biggest risk of death
with keratotic plugs, Atrophy of the rete processes, or long-term morbidity. Treatment of renal
Deep inflammatory infiltrate, Edema in the lamina disease (Cochrane review [9]) was
propria, Thick patchy or continuous PAS-positive standardized by the National Institute of
juxtaepithelial deposits. Health guidelines [10] published in 1992.
Combining high dose corticosteroids with
Our patient had extraorally macules present
cyclophosphamide was the gold standard in
over the malar prominences of the face in a
the management of proliferative lupus
butterfly like distribution sparing the nasolabial
nephritis for many years. The so-called
fold(Malar rash), Intraorally an irregular
Euro-Lupus trial, published in 2002, showed
erythematous area measuring 1.5 × 2 cm that the use of this lower dose regimen has
surrounded by a white striae with a radiating better outcomes in terms of infertility risk,
orientation that sharply terminate toward the centre with no deleterious impact on renal disease
of the erythematous area is seen on the centre of [11]. Following remission induction,
the vermilion border of the lower lip extending 1.5 azathioprine is commonly used for
cm from the right and left corner of the vermilion maintenance therapy. Mycophenolate mofetil
border of the Lower lip (Discoid Rash), joint [12] has been added to the repertoire of drugs
pain in her both right and left knee regions with used for the treatment of lupus nephritis.
her Blood count showing elevated rheumatoid
factors of 235( Strongly Positive),her Lupus
Anticoagulants = 47 seconds (Normal Reference Prognosis
Range: 31-45 seconds) and Histopathological Despite significant advances in treatment over
report showed patchy deposits of Periodic the last decade, SLE still caries a significant risk
Acid-Schiff positive material in the Basement of mortality and long term morbidity. A European
membrane zone, subepithelial edema and a more study of 1000 patients with SLE, demonstrated a
diffuse ,deep inflammatory infiltrate often in a 10 year survival probability of 92% overall,
perivascular orientation suggestive of Systemic reduced to 88% in those who presented with
Lupus Erythematosus. nephropathy [12]. Mean age at death was 44, but
varied widely from 18-81 years.
Management:
Cause of death varies with disease duration.
The oral lesions may respond to systematic In one cohort [13], renal lupus accounted for the
treatment used to alleviate the disease and have to biggest number of deaths in those with less than
be evaluated first. When symptomatic intraoral 5 years of disease, whereas vascular disease was
lesions are present, topical steroids should be the most important factor in the group who died
considered. [9] later in the disease course. Premature
• 0.05% Fluocinonide gel to be placed on the atherosclerosis is having on the long term
affected area 2 x /d for 2 Weeks. prognosis of lupus patients who survive the early
years of illness. As we develop better immune
• 0.05% clobetasol gel to be placed on the targeted therapies, optimizing the management of
affected area 2 x /d for 2 Weeks. these longer term complications will become
• Dexamethasone elixir (0.5 mg/mL) Swish and increasingly important.
spit 10 mL 4 x /d for 2 weeks.
• Triamcinolone acetonide 5 mg/mL REFERENCES
Intralesional injection
1. Ramos-Casals M, Font J, Garcia-Carrasco M et al.
• Topical antifungal therapy, 10 mg clotrimazole Hepatitis C Virus infection mimicking systemic lupus
troches Dissolve in mouth 5 times per day for erythematosus. Arthritis Rheum. 2000; 43(12):
10 days. 2801-2806
• 5ml Nystatin suspension (100,000 U/mL) 2. Cervera R, Khamashta MA, Font J et al. European
Swish and spit 5 ml 4 times per day for 10 Working Party on Systemic Lupus Erythematosus.
days. Morbidity and mortality in systemic lupus
erythematosus during a 10-year period: a comparison
• Chlorhexidine rinse (0.12%).Swish and spit 10 of early and late manifestations in a cohort of 1,000
ml 2 times per day until lesion resolves. patients. Medicine (Baltimore). 2003; 82:299-308.
1084
3. Johnson AE, Gordon C, Palmer RG et al. The 9. Flanc RS, Roberts MA, Strippoli GF, et al. Treatment
prevalence and incidence of systemic lupus for lupus nephritis. Cochrane Database Syst Rev.
erythematosus in Birmingham, England. Relationship CD002922.
to ethnicity and country of birth. Arthritis Rheum.
1995; 38:551-8. 10. Boumpas DT, Austin HA 3rd, Vaughn EM, Klippel
JH et al. Controlled trial of pulse methylprednisolone
4. Ward MM. Prevalence of physician-diagnosed
systemic lupus erythematosus in the United States: versus two regimens of pulse cyclophosphamide in
results from the third national health and nutrition severe lupus nephritis. Lancet. 1992; 340:741-5.
examination survey. J Womens Health 11. Houssiau FA, Vasconcelos C, D’Cruz 0 et al.
(Larchmt).2004; 13:713-8. Immunosuppressive therapy in lupus nephritis: the
5. Manson JJ , Isenberg DA. The pathogenesis of Euro-Lupus Nephritis Trial, a randomized trial of
systemic lupus erythematosus. Neth J Med. 2003; low-dose versus high-dose intravenous
61:343-6. cyclophosphamide. Arthritis Rheum.
6. Nath SK, Kilpatrick J, Harley JB. Genetics of human 2002;46:2121-31.
systemic lupus erythematosus: the emerging picture.
12. Chan TM, U FK, Tang CS et al. Efficacy of
Curr Opin Immunol. 2004;16:794-800.
Mycophenolate Mofetil in Patients with Diffuse
7. Tan EM, Cohen AS, Fries JF et al. The 1982 revised Proliferative Lupus Nephritis. N Engl J Med. 2000;
criteria for the classification of systemic lupus
343:1156-62.
erythematosus. Arthritis Rheum. 1982;25:1271-7.
13. Moss KE, Ioannou Y, Sultan SM, Haq I et al.
8. Hochberg MC. Updating the American College of
Rheumatology revised criteria for the classification of Outcome of a cohort of 300 patients with systemic
systemic lupus erythematosus. Arthritis Rheum. lupus erythematosus attending a dedicated clinic for
1997;40:1725. over two decades. Ann Rheum Dis. 2002; 61:409-13.
1085
Occlusion in Complete Denture: A Review

1
Dr. Utkarsh Katare, 2Dr. Gaurav Beohar, 3Dr. Anup Mangal, 4Dr. Swapnil Parlani,
5
ABSTRACT
Over the years with the development of newer and more advanced articulators that can almost totally
simulate the development of precisely desired artificial teeth developing of artificial occlusion has become
more exact. This in turn has resulted in the making of more comfortable as well as more efficient complete
dentures. The introduction of the concept of Balanced occlusion has been the single largest step towards
the development of physiologic complete dentures. This article mainly emphasis on the various concepts
of occlusion in complete denture.
Key Words: Occlusion, Artificial Teeth, Complete Denture, Balancing Ramps
INTRODUCTION Determinants of Mandibular Movements1,5,3

Dental science is founded for the most part on There are four determinants of mandibular
occlusion; normal occlusion is the basis of practice movements. Two posterior, one anterior and a
of dentistry. One must not be deceived and neuromuscular determinant.
overlook the fact that accommodative process of
nature enables some subjects to overcome certain Posterior determinant
obstacles and permit them to become accustomed The tempromandibular joints and its
to things not perfect, so that wearing of dentures suspensory ligaments, centers of rotation, axes of
made with differing techniques is possible.1 rotation, translation of these centers and arcs.
Occlusion in complete dentures has been a Anterior determinant
concern since ancient times when attempts were The contacting areas of upper and lower teeth,
made to replace lost teeth, teeth carved from ivory inclines of cusps and nature of occlusion.
and fastened to gold plates have been found in
mummies dating back to more than, 2,400 years. Neuromuscular determinant
Other teeth found were made of bone and wood. The role of muscle spindles, Proprioceptive
The first dental prosthesis was believed to have engrams and neuromuscular response to occlusal
been constructed in Egypt about 2,500 B.C, the conditions.
specimen was found by Herman Junker in 1927 in
an Egyptian tomb of Ei Gizeh. Writings in the The two posterior determinants are fixed. The
Talmund, a book of tabbinical laws of the third determinant namely, the occlusion can be
Hebrews from the second, fourth and sixth century modified by the dentist to a certain extent. The
in the Christian era gave definite proof of dental forth neuromuscular determinant can be reflexively
prosthesis. 2,3 modified by the dentist indirectly as he alters the
third determinant namely Occlusal. Therefore the
ability of dentist to modify the occlusal contact
Harmonious functions of the maxillofacial
pattern of teeth to alter proprioceptive stimuli and
structures and the nature of supporting
muscle function is known as
tissue4
Occlusal Programming
In the broadest sense, complete denture should
fulfill the requirement of: Hence, when pathological Occlusion or any
form of occlusal disharmony or incorrect centric
1. Esthetics. relation exists the proprioceptive signals initiate a
plan of inaction. This is seen in the form of
2. Harmonious functions of the maxillofacial
inhibition and deviation of normal mandibular
structures
movements and cause spasm of muscles, load or
3. Maintenance of hard and soft tissues. stress on tissues, loss of alveolar bone and
1,2
Senior Lecturer, 3P.G. Student, 4Reader, Dept. of Prosthodontics, 5Senior Lecturer, Dept. of Public Health Dentistry,
People’s College of Dental Sciences and Research Centre, Bhopal, M.P.
1086
esthetics and phonetics will be disturbed, therefore metal that protruded from the middle third of the
temporo-mandibular joint. maxilliary posterior occlusal surfaces with shallow
buccal and lingual cusps protruding beyond the
DEVELOPMENT OF ARTIFICIAL TEETH2,5,6,7 metal inserts.
Anatomic Teeth of 33 Degree or more: S.H.payne described the modification of

anatomic teeth set to a “lingualized Occlusion’’
Dr Alfred Gysi of Switzerland is credited for
concept. He credits Farmer with originating this
designing the first anatomic porcelain tooth desired
scheme in his private practice, this basic concept
to function harmoniously with incisal and condylar
was not entirely new. The concept of lingualized
guidance. These teeth were marketed by The
Occlusion was introduced by Gysi 20 years earlier
Dentists Supply Company in 1914 and closely
and was reported on by Pond and Murrell.
resembled natural unblemished teeth. They had
transverse ridges and were intended for tight Non-Anatomic or O-Degree Cuspless Teeth
interdigitation, these were called ’’Trubyte’’.
The presence of cusps on artificial teeth was
Pilkington and Turner patented a new felt by many dentists to present problems that were
anatomic posterior tooth form having a slightly too difficult to control. It is because of this that
shallower cusp of 300. These teeth were designed cashless teeth designs emerged.
to provide a small degree of freedom in protrusive
excursion , unlike the Trubyte teeth. HALL has been credited as one of the first to
design and use cusp less teeth. He introduced these
Modified anatomic teeth between 300 and 00: teeth called “inverted cusp teeth”. In 1929 and
Gysi recognized that his anatomic teeth would claimed that it eliminated denture instability owing
not satisfy all ridge relationships. And in 1927 he to cusp on teeth. These teeth were quite similar to
desired a modified a “cross- bite’’ posterior. In this one desired by Ash in 1858. The teeth were flat
scheme the maxillary buccal cusp was almost with concentric cone shaped depressions on the
eliminated, resulting in one prominent lingual cusp occlusal surface that, in effect, were like inverted
that occluded into a lower anatomic tooth. Gysi cusps. This design created a flat occlusal surface
described a ’’mortar and pestle’’ action of this with sharp concentric ridges around the cusp like
occlusal scheme. depressions, which provided at: efficient shredding
action on food.
Avery brothers introduced another modified
form, the opposite of Sears called the ’’cross-bite’’ Myerson also designed a cusp less posterior
technique. The posterior occlusal space was locked tooth in 1929, which he called ’’truecusp’’. It had
anteroposteriorly by grinding steps on the surface a series of transverse buccal-lingual ridges with
of the teeth, with the angle determined by the sluiceways between them. Both Hall’s and
inclination of the condone path. They were Myerson’s teeth were the first teeth to be
modified to be free in lateral excursion. The commercially produced that provided for complete
occlusion of these teeth together was meant to free gliding contact in all horizontal directions.
shear food in lateral excursion.
Nelson described teeth he called ’’chopping
French designed and the Universal Dental block’s” posteriors, which were flat occlusal
Company marketed a severely modified tooth. The surfaces with numerous ridges. The ridges on the
maxillary tooth was similar to sear’s, as it had a mandibular teeth ran transversely and on the
central groove running mesiodistally, but very maxillary teeth ran mesiodistally. Because they
shallow buccolingually inclines to reduce lateral were perpendicular to each other, an efficient
thrust. The mandibular teeth had a narrow sledding and cutting action we claimed. Swenson
mesiodistal food table, moved to the lingual of the desired a posterior tooth called ’’non-lock’’. These
occlusal space and a slopping buccal incline that were flat with sluiceways for shredding and
was subocclusal. He claimed that this design allowing food to clear the occlusal table. They
placed the axial occlusal forges lingually, which provided balancing contact.
favoured the stability of the lower denture.
Hardy, in 1946, designed a metal insert upper
John Vincent in 1947 introduced a change in and lower which he called “Vitallium Occlusal”.
material by using metal inserts in resin posterior. These were produced in resin blocks of three
These inserts originally of gold solid wire were posterior teeth simulating a buccal facade of two
later replaced by strainless steel, were circles of bicuspids and one molar. A narrow zigzag of
1087
vitallillm ribbon, was embedded on the occlusal Organic Occlusion

surface and ran mesiodistally, establishing a It is that concept where in any jaw movement
narrow, flat, convoluted metal surface. The away from Centric occlusion will result in
articulating surfaces of these teeth were separation of all posterior teeth.
metal-to-metal ribbons that proved to be effective
cutters. The teeth were produced by the Austenal Neutrocentric Concept (De Van):11,12
Company and are still in use today. This concept maintains that the
anterio-posterior plane of occlusion should be
Plastic as a tooth material had been in use parallel with plane of denture foundation and not
since 1936. In 1951, Myerson tooth Co-operation dictated by the horizontal condoler guidance. Thus
introduced the fist cross-linked acrylic tooth in a the teeth are not inclined to form compensatory
flat occlusal scheme called ’’shear-cusp’’ tooth. curves. In the mesio lateral direction the teeth are
set flat with no medial or lateral inclination. This
With the intent to, improve the efficiency if
concept of occlusion eliminates any
flat teeth. Bader, in 1957, introduced the
anterio-posterior or medio-lateral inclines of the
’’cutter-bar’’ scheme by opposing upper porcelain
teeth and directs the forces of occlusion to the
teeth with a metal cutting bar replacing the second
posterior teeth. Because this form of posterior teeth
bicuspid, first molar, and second molar.
is devoid of cusps, there is no projection above or
A simillar approach was advocated by Frush below the occlusal plane.
in 1967, which he described as a “linear occlusal
concept’s”. Maxillary and mandibular posterior BALANCED OCCLUSION
were flat, with a single mesiodistal ridge usually Balanced occlusion involves a definite
on the lower. arrangement of tooth contacts in harmony with the
mandibular movements.
In a condensed history of the development Of
the posterior artificial tooth forms such as this, it
DETERMINANTS OR LAWS OF
is apparent that the underlined quest was for
PROTRUSIVE OCCLUSION
masticatory efficiency with control of both vertical
and horizontal forces so that their function would The five principal factors in the laws of
be as innocuous as possible in the highly occlusion for protrusive movements as stated by
compromised edentulous mouth. Hanau called the Hanau’s quint.
• Inclination of conduct guidance.
OCCLUSAL SCHEMES USED IN • Inclination of incise guidance.
COMPLETE DENTURES CONCEPTS OF • Orientation of occlusal plane.
OCCLUSION8,9,10
• Inclination of the cusp.
The concept of occlusion for complete • Prominence of the compensating curve.
dentures fall into two broad categories.
LINGUALIZED OCCLUSION13,14,15
• Non balanced occlusion, and
It is an attempt maintains the aesthetic and
• Balanced occlusion. food- penetration advantages of the anatomic form
Spherical Theory of Occlusion (Monson) while maintaining the mechanical freedom, of the
nonanatomic form. The legalized concept utilizes
This concept is derived from an idea evolved anatomic teeth for the maxillary denture and
by Vonspee that the lower teeth move over the modified nonanatomic or semi anatomic teeth for
surface of the upper teeth as over the external the mandibular denture. The basic concepts of
surface of the sphere with a radius of four inches. legalized Occlusion were first suggested by Payne.
Therefore it involves the positioning of teeth with Pound discussed a similar occlusal concept and
anterior-posterior and medio-lateral inclines in used the term “Lingualized occlusion”
harmony with a spherical surface. It is some times
referred to as having Monson curve. This Indication for Lingulized occlusion
occlusion must be developed in curved form, the It can be used in most denture combinations.
arc plane having its convex face downwards and It is particularly helpful when the patient places
its concave face upwards. high priority on aesthetics but a nonanatomic
1088
occlusal scheme is indicated by oral conditions • Balanced occlusion in centre relation and
such as severe alveolar resolution, a Class -II jaw lateral excursions.
relationship, or displaceable supporting tissues. If Proponents of the first theory (neurocentric)
the nonanatomic occlusive scheme is used, believe that it accommodates complete seating of
aesthetics in premolar region are compromised. the denture bases and centralizes forces on the
With Lingualized occlusion the aesthetic result is residual alveolar ridges. They believe that patients
greatly improved while still maintaining the function in centric relation only. The second
advantages of a nonanatomic system. school of thought uses balanced occlusion in
Principles if Lingualized Occlusion excursive movement as a means of adding to the
• Anatomic posterior (30 or 33 degree) teeth are
horizontal ability of the dentures.
used for the maxillary denture. Tooth forms Modifications of the technique for use at
with prominent lingual cusps are helpful. clinical recount:
• Nonanatomic or semi anatomic teeth are used The balancing ramps can be incorporated at
for the mandibular denture. Either a shallow the insertion appointment in conjunction with the
or flat cap form is used. A narrow occlusal clinical remount. Final accurate centric relation and
table is preferred when severe resorption of protrusive records are obtained, and the condyle
the residual ridges has occurred. inclinations are as previously described.
• A modification of the mandibular posterior 1. Roughen the denture base posterior to the
teeth is accomplished by selective grinding most distal mandibular molar with a carbide
which is always necessary regardless of bur.
specific tooth or material.
2. Prepare auto polymerizing resin and wet the
MONOPLANE OCCLUSIONS roughened spaces with monomer. When the
acrylic resin reaches a doughy stage it is added
There has been increasing references to to the roughened surface.
non-anatomic occlusion in the current dental
3. Perform all eccentric positions on the
literature. Many authors have inferred that a
articulator while the resin is still soft. The
non-anatomic tooth may be the occlusion of choice
denture can be placed in a pressure pot to cure
for given situations.
the resin.
Jone’s, De Van’s and others have discussed 4. Refine the smooth the balancing ramps after
the relation of non-anatomic teeth to the turning is complete, and carefully evaluate the
preservation of structures of the basal seat, while contacts in centric occlusion.
Bascom has shown that nonanatomic teeth have
efficient occlusion forms. A third raptly in favour 5. Correct deficiencies by adding auto
of the nonanatomic teeth as in occlusion is the polymerizing resin.
simplicity of the technique used.
CONCLUSION
To begin with, the casts are mounted in the
articulator by means of centric jaw relation records Since the first description of the occlusal
at the established occluding vertical dimension. relationship of teeth was made by Edward Angle
The procedure followed can be outlined thus: in 1809 a lot of progress has been made in
understanding occlusion in natural dentition and
• Location of land marts on the casts, from here to the understanding of the ideal
• Anterior tooth arrangements, occlusion that can be provided in complete
dentures.
• Posterior tooth arrangements,
• Insertion procedures. Over the years with the development of newer
and more advanced articulators that can almost
Balancing ramps in nonanatomic complete totally simulate the development of precisely
denture occlusion desired artificial teeth developing of artificial
Two prevailing theories pertain to balanced occlusion has become more exact. This in turn has
occlusion in complete dentures: resulted in the making of more comfortable as well
as more efficient complete dentures. The
• Balanced occlusion in centric relation only and introduction of the concept of Balanced occlusion
1089
has been the single largest step towards the 5. De Baat C, van Aken AA, Mulder J, Kalk W-
development of physiologic complete dentures. "Prosthetic condition" and patients’ judgment of
complete dentures. J Prosthet Dent. 1997;78:472-478.
Hence with various philosophies and concepts 6. Edward J. Mehringer-Physiologically Generated
put forth, one could conclude that: Occlusion. J Prosthet Dent 1973;30:373-379.
1. There is no method to ascertain that any one 7. Hansen CA- Diagnostically restoring a reduced
concept of occlusion will satisfy all the occlusal vertical dimension without permanently
requirements of edentulous patients. altering the existing dentures. J Prosthet Dent.
1985;54:671-673.
2. There is no method to ascertain that any
particular form of posterior teeth is more 8. Harold E. Clough et al- A Comparison of Lingualized
Occlusion and Monoplane Occlusion in Complete
efficient then other form. Denture. J Prosthet Dent 1983;50:176-179.
3. It is not possible to predict reaction of basal
9. I. R. Hardy- The Developments in the Occlusal
seat tissues to complete denture treatment. Pattern of Artificial Teeth. J Prosthet Dent
4. Clinical observation and evaluation should be 1951;1:14-28.
classified out precisely. 10. Jordan LG- Arrangement of anatomic-type artificial
teeth into balanced occlusion J Prosthet
REFERENCES Dent.-1978;39:484-494.
1. Arthur Nimmo- Balancing Ramp in Nonanatomic 11. Klemetti E. Resistance of the maxillary ridge to
Complete Denture. J Prosthet Dent 1985;53:431-433. occlusal trauma. J Prosthet Dent. 1995;73:250-2.
2. Brunello DL, Mandikos MN. Construction faults, age, 12. Perry W Bascom- Masticatory Efficiency of Complete
gender, and relative medical health: factors associated Dentures. J Prosthet Dent 1962;12:453-459.
with complaints in complete denture patients. J 13. S. Howard Payne- Selective Occlusion. J Prosthet
Prosthet Dent. 1998;79:545-554. Dent 1955;5:301-304.
3. Ben R Bronstein Rationale and Technique of 14. Wilson J, Nairn RI- Condylar repositioning in
Biomechanical Occlusion Rehabilitation. J Prosthet mandibular retrusion. J Prosthet
Dent 1954;4:352-367 Dent.2000;84:612-616.
4. Curtis M. Becker- Lingualized Occlusion for 15. White KC, Mueninghoff LA, Ramus DL- Fixed
Removable Prosthodontics. J Prosthet Dent Partial Dentures Opposing Complete Dentures. J
1977;38:601-608. Prosthet Dent 1989;62:483-487.
1090
Oral Lesions commonly associated with HIV Infection in

South Indian Population. Reports of few cases with
Literature Review
Dr. Nalini Aswath1
ABSTRACT
HIV-related oral conditions occur in a large proportion of patients, and frequently are misdiagnosed
or inadequately treated. Dental expertise is necessary for appropriate management of oral manifestations
of HIV infection or AIDS, but many patients do not receive adequate dental care. Common or notable
HIV-related oral conditions among south Indian populations include xerostomia, candidiasis, oral hairy
leukoplakia, periodontal diseases such as linear gingival erythema , ulcerative conditions including herpes
simplex virus lesions, recurrent aphthous ulcers, non specific ulcers due to cytomegalovirus infections,
opportunistic infections oral mucosal pigmentation, fissured tongue and neoplasms such as non hodgkin’s
lymphoma, kaposi’s sarcoma. The presence of these lesions may be an early diagnostic indicator of
immunodeficiency and HIV infection, may change the classification of the stage of HIV infection, and is
a predictor of the progression of HIV disease.
INTRODUCTION progressive loss of CD4 lymphocytes

(Helper/Inducer T-Lymphocytes) and supresses the
HIV has been recognised as one of the most cellular immunity. An estimation of the plasma
devastating infectious disease of the twentieth levels of CD4 cells indicates the individuals
century. The etiological agent is the Human immune status. Normal CD4 cell counts are usually
immunodeficiency virus and the disease called the above 500-600 cells/cu.mm whereas levels below
Acquired immuno deficiency syndrome. There are 200 cells/cu.mm indicate severe immune
two different types of HIV: HIV-1 and HIV-2.The supression.
vast majority of HIV infections are caused by
HIV-1,except in particular geographical areas such DISCUSSION
as the western parts of Africa where it is by HIV-2 Since human immunodeficiency virus (HIV)
. HIV is a Retrovirus. It is a RNA virus.Oral infection was first described in 1981, a variety of
manifestations of HIV disease are common and oral conditions associated with HIV disease have
include oral lesions and novel presentations of been documented. Oral manifestations are common
previously known opportunistic diseases. Careful clinical findings in children and adults with HIV
history taking and detailed examination of the infection. Studies have shown that 70%-90% of
patient’s oral cavity are important parts of the HIV-infected individuals will develop at least one
physical examination, and diagnosis requires oral manifestation during the course of the disease.
appropriate investigative techniques. Early The importance of oral lesions in HIV infection is:
recognition, diagnosis, and treatment of
HIV-associated oral lesions may reduce morbidity. • Clinical indicators of HIV infection in
otherwise healthy, undiagnosed individuals;
ROUTES OF TRANSMISSION
• Clinical markers for the classification and
HIV is transmitted sexually, through
staging of HIV disease; and
contaminated blood and blood products, and
vertically from mother to child. • Predictors of HIV disease progression.
PATHOGENESIS Early diagnosis and management of oral

manifestations is important to prevent
The virus enters the body through blood (or) complications and improve quality of life.
mucosa and from their it enters into the lymphoid
tussue. There the virus replicates and causes The most common oral manifestations that
destruction of the T-lymphocytes, Monocytes and are noticed among the South indian population
Macrophages. The hall mark of HIV disease is the are:
1
Professor and Head, Dept. of Oral Medicine and Radiology, Sree Balaji Dental College and Hospital, Chennai.
1091
Candidiasis - Pseudomembranous & Erythematous. Oral Hairy Leukoplakia

Angular Chelitis. Oral hairy leukoplakia (OHL) is more
Oral Hairy Leukoplakia. common among HIV-infected adults than among
HIV-infected children. The reported prevalence of
Oral Ulcers.
OHL in adults is about 20%-25%, increasing as
Pigmentation. the CD4+ lymphocyte count decreases, whereas in
Fissured Tongue. children the prevalence is about 2%-3%. The
presence of OHL is a sign of severe
Linear Gingival Erythema.
immunosuppression. OHL is a significant predictor
Rarely cases of Non Hodgkins Lymphoma and of HIV disease progression in adults. OHL seems
Kaposi’s Sarcoma.are also seen. to be caused by Epstein-Barr virus infection. OHL
HIV disease progression is monitored by two presents as white, thick patches that do not wipe
key laboratory markers: CD4+ lymphocyte count away and that may exhibit vertical corrugations
and HIV viral load with a hairlike appearance . The lesions usually
start on the lateral margins of the tongue. They
Candidiasis may be unilateral or bilateral, and they are
asymptomatic. OHL is often associated with
Oral candidiasis is most commonly associated
candidiasis.
with Candida albicans, although other species,
such as C. glabrata and C. tropicalis, are frequently
part of the normal oral flora. A number of factors
predispose patients to develop candidiasis: infancy,
old age, antibiotic therapy, steroid and other
immunosuppressive drugs, xerostomia, anemia,
endocrine disorders, and primary and acquired
immunodeficiency. Candidiasis is a common
finding in people with HIV infection. Reports
describe oral candidiasis during the acute stage of
HIV infection, but it occurs most commonly with
falling CD4+ T-cell count in middle and late
stages of HIV disease. Several reports indicate that Oral Mucosal Pigmentation
most persons with HIV infection carry a single Oral mucosal pigmentation was noticed as a
strain of Candida during clinically apparent common finding in most of the HIV infected
candidiasis and when candidiasis is quiescent. individuals. The reasons that have been put
forward are: increased release of melonocyte
stimulating harmone,and drugs that stimulate the
melanocytes such as antiretrovirals, anti fungals
etc.
Oral Ulcers
Solitary (or) multiple ulcerated lesions occur
in HIV patients. Non Specific Oral ulcers
resembling recurrent aphthous ulcers (RAUs) in
HIV-infected persons are reported with increasing
frequency. The cause of these ulcers is unknown.
1092
Proposed causes include stress and unidentified follow the distribution of the maxillary or
infectious agents. In HIV-infected patients, the mandibular branches of the trigeminal nerve.
ulcers are well circumscribed with erythematous
HIV-Associated Periodontal Disease
margins. The ulcers of the minor RAU type may
appear as solitary lesions of about 0.5 to 1.0 cm. Periodontal (gum) disease is common among
The herpetiform type appear as clusters of small HIV-infected patients. It is characterized by
ulcers (1 to 2 mm), usually on the soft palate and bleeding gums, bad breath, pain/discomfort, mobile
oropharynx. The major RAU type appears as teeth, and sometimes sores. Its reported prevalence
extremely large (2 to 4 cm) necrotic ulcers.The ranges widely, between 0% and 50%. Left
major RAUs are very painful and may persist for untreated, HIV-associated periodontal disease may
several weeks. The ulcers may present a diagnostic progress to life-threatening infections, such as
problem. The ulcers may occur because of Ludwig’s angina and noma (cancrum oris). Four
cocsackie virus infection and other infections like forms of HIV-associated periodontal disease have
Tuberculosis and Histoplasmosis. been described: linear gingival erythema,
necrotizing ulcerative gingivitis (NUG),
necrotizing ulcerative periodontitis (NUP), and
necrotizing stomatitis. Among these Linear
Gingival Erythema was commonly observed.
Linear gingival erythema is characterized by
the presence of a 2-3mm red band along the
marginal gingiva, associated with diffuse erythema
on the attached gingiva and oral mucosa. The
degree of erythema is disproportionately intense
compared with the amount of plaque present on
the teeth.
Herpes Zoster
The reactivation of varicella zoster virus

(VZV) causes herpes zoster (shingles). The disease
occurs in the elderly and the immunosuppressed.
In HIV infection it is noticed in individuals in Fissured Tongue
whom the CD4 count is reduced. Following
prodromal symptoms of pain,multiple vesicles Another commonly noticed oral manifestation
is the presence of multiple fissures on the dorsal
appear on the facial skin, lips, oral mucosa. Skin
surface of the tongue, that could be due to
and oral lesions are frequently unilateral and candidal infection.
1093
Neoplasms the gingival papilla, resembling periodontal disease

or may sometimes resemble a parulis. The gingival
Non Hodgkin’s Lymphoma were seen in very
lesions may be associated with considerable
few HIV +ve cases. Oral lymphomas are present
gingival enlargement causing periodontal
as swellings (or) as proliferative masses. They are
pocketing.
mostly of the B-cell Immmunoblastic type. They
are more common in people with very low CD4
CONCLUSION
counts. NHL in people with HIV is more
aggressive and responds less well to treatment than Oral Candidasis, Oral mucosal pigmentation,
in HIV-negative people. HIV gingivitis was the most commonly noticed
With the advent of modern HIV treatment among all HIV+patients .In patients with a lesser
NHL is now less commonly seen. CD4 count, ulcerations were noticed. Oral Hairy
Leukoplakia, Neoplasms were rarely seen. Well
designed prospective longitudinal studies are to be
done to study in detail the unique geographical
distribution of the lesions that are commonly
observed among this population.
REFERENCES
1. Greenspan D, Greenspan JS, Schiodt M, et al. AIDS
and the mouth. Copenhagen: Munksgaard, 1990.
People with AIDS-associated Kaposi’s
2. Winfert M, Grimes RM, Lynch DP. Oral
sarcoma frequently have oral lesions that present
manifestations of HIV infection. Ann. Intern. Med.
as red or purple patches or swellings. The palate 1996;125:485-496
is the most common site but lesions also occur on
3. Klein RS, Harris CA, Small CB, et al. Oral
the gingiva. Kaposi’s Sarcoma is characterized by
candidiasis in high-risk patients as the initial
multifocal, widespread lesions at the onset of the manifestations of the acquired immunodeficiency
disease. In the earliest, or patch stage the lesions syndrome. N. Engl. J. Med. 1984;311:354-358
are small, flat, and macular and may be reddish, 4. Begg MD, Lamster IB, Panageas KS. A prospective
pink, purplish, or brown. study of oral lesions and their predictive value for
progression of HIV disease. Oral Dis.
1997;3:176-183.
5. Schiodt M, Pindborg JJ. AIDS and the oral cavity:
epidemiology and oral manifestations of HIV
infection: a review. Int. J. Oral Maxillofac. Surg.
1987;16:1-14.
6. Dandona L, Lakshmi V, Sudha T, Kumar GA,
Dandona R. A population-based study of human
immunodeficiency virus in south India reveals major
differences from sentinel surveillance-based estimates.
BMC Med 2006;4:31-31
7. Kumar R, Jha P, Arora P, et al. Trends in HIV-1 in
Intraoral lesions may occur either alone or in young adults in south India from 2000 to 2004: a
association with skin, visceral and lymph node prevalence study. Lancet 2006;367:1164-1172
lesions. Frequently the first lesions of Kaposi’s 8. Greenspan JS (1997). Sentinels and signposts: the
epidemiology and significance of the oral
sarcoma appear inside the mouth. They can be red,
manifestations of HIV disease. Oral Dis 3(Suppl
blue or purple and may be flat or raised, solitary 1):S13–S17.
or multiple. The commonest oral site reported is 9. National AIDS Control Organization (2004).
the hard palate, although lesions may be found on Combating HIV/AIDS in india.
any part of the oral mucosa including the gingiva, 10. Patton LL, McKaig RG, Eron JJ Jr, Lawrence HP,
soft palate and buccal mucosa. Kaposi’s sarcoma Strauss RP (1999). Oral hairy leukoplakia and oral
lesions on the gingiva produce diffuse swelling of candidiasis as predictors of HIV viral load. AIDS 13
1094
Dental Distraction – A Case Study

Dr.R.Saravanan1, Dr. N. Raj Vikram2, Dr. Swati Acharya3
ABSTRACT
Dental distraction used for orthodontic purpose helps to achieve rapid tooth movement in a short
duration. This procedure can be advocated in patient who needs early finish of orthodontic treatment. This
article highlights a case where dental distraction was the choice for rapid canine distalisation in a severe
bi maxillary case.
Keywords: Dental distraction, Distraction osteogenesis, Canine distalisation, Osteotomy cuts.
INTRODUCTION
Distraction osteogenesis [DO] is a process of
growing new bone by mechanical stretching of the
pre existing bone tissue[1]. Distraction osteogenesis
was used as early as 1905 by Codivilla and this
technique was first described by Ilizarov[2,3] in the
early 1950’s which basically consisted of
performing corticotomy of the long bones with
minimal disruption of the periosteal and endosteal
tissues and slowly stretched by mechanical means.
External devices were initially used for
distraction osteogenesis and then intraoral devices Fig. 1 Pre Treatment Photograph
were introduced shortly. These intraoral devices
can be tooth borne[4, 5], bone borne[6] or both[7] and
has gained popularity as they are much simpler
and more patient acceptable.
Most of the orthodontic cases are done by
extracting the first premolars. For anchorage
preservation individual canine retraction are done.
For rapid canine retraction, dental distraction can
be done as described by Liou and Huang[8] in 1997
, Kontham et al[9] in 1999 and Eric Jein - Wein
Liou et al in 2000[10].
This paper presents a clinical case of dental
distraction. Fig. 2 Canine Distractor
CLINICAL PROCEDURE The bands were transferred into the impression and
models of die stone were made. The distractor
An adult patient who had a bidental protrusion with appropriate length was soldered to the bands
was selected, who needs extraction of all first directly.
premolars [Figure 1]. The teeth to be distracted
were 13 and 23. The anchor unit was the first SURGICAL PROCEDURE
molar on respective side.
Patient was given local anaesthesia. A
The canine distractor used in the study was a horizontal mucosal incision 2 to 2.5 cm long was
rigid, intraoral, tooth borne device [Figure 2]. The made parallel to the gingival margin of the canine
bands were first fabricated for the canine and 1st and bicuspid teeth well beyond the depth of the
molar. Then impression was taken with alginate. vestibule. Subperiosteal elevation was carried out
1
Associate Professor, 2Assistant Professor, 3P.G. Student, Dept. of Orthodontics, Thai Moogambigai Dental College and
Hospital, Chennai
1095
to expose the canine root and first premolar region. activation of the distractor. It also produced less
A vertical osteotomy was made on the anterior discomfort to the patient and enabled patient’s
aspect of the first premolar using multiple cortical co-operation during each stage of treatment.
holes with a round bur under copious irrigation.
The distraction device was activated 0.8 mm
Fine osteotomies were then introduced and
per day in the morning till retraction was
advanced in the coronal direction.[Figure 3]
complete. The patient was seen once in three days
and a pre weekly periapical radiograph was taken
to monitor the progress.
RESULTS
Pre treatment, during treatment [Figure 5] and
post treatment photographs [Figure 6] and
orthopantamogram [Figure 7,8] were taken to
analyse the results.
The distance between the contact points of the
lateral incisor and canine was measured directly in
the patient mouth and the pre treatment model.
The distraction was completed totally in ten
days time and 8mm was distracted. Amount of
retraction was slow on first three days showing
1mm of retraction and at the end of six days 3.5
Fig. 3 Surgical Procedure mm of retraction was completed. The retraction
The bone apical to the extraction socket and was almost same on both sides of the arch.
the possible bony interferences at the buccal aspect
No mesial migration of first molar or extrusion
that may be encountered during the distraction
of canine is seen. No pain was experienced by the
process were eliminated and smoothened between
patient except for mild discomfort for 20 minutes
the canine and the second premolar tooth with the
during the activation daily. No tipping of canine
preservation of the palatal cortex. The wound was
irrigated with saline and closed in a single mucosal
layer with 3-0 catgut suture.
The distraction device was fitted and cemented
to the first molar and canine teeth at the end of
the surgical procedure. [Figure 4]
Fig. 4 Placement of Distractor

The patient was prescribed an anti biotics and
non -steroidal anti-inflammatory drugs for 5 days.
The distractor was fabricated in such a way

Fig. 5 During Treatment Photograph
that it provided a better access for placement and
1096
was seen on the mesial side and compression on

the distal side of canine.
DISCUSSION
Treatment duration has been a great concern
in treating patient with severe protrusion.
Maximum anchorage cases need careful
manipulation of appliance especially in individual
canine retraction. Distraction has been proved a
useful adjunct provided the clinician capitulates the
distraction procedure with utmost care, with least
discomfort to the surrounding structures.
REFERENCES
1. Liou JW Eric, Shing Huang. Rapid canine retraction
through distraction of the periodontal ligament.
American Journal of orthod and Dentofacial Orthop
1998; 114 [372]
2. Ilizarov GA. The tension stress effect on the genesis
and growth of tissue Part 1: the influence of fixation
and soft tissue preservation Clin. Orthop. 238-249,
1989
3. Ilizarov GA. The tension stress effect on the genesis
Fig. 6 Post Treatment Photograph and growth of tissue Part 1: the influence of rate and
frequency of distraction Clin. Orthop. 250-263, 1989
4. Michael S. Block, Andrew Chang, Deneen Cervini,
G.Bradlay Gottsegen. Anterior maxillary advancement
using Tooth-supported distraction osteogenesis.
Joumal of Oral and Maxiliofacial Surgery 1995; 53;
561-565.
5. Michael S. Block, Andrew Chang, Craig Crawford.
Mandibular alveolar ridge augmentation in the Dog
using distraction osteogenesis. Journal of Oral and
Maxillofacial Surgery 1996; 54: 309-314
Fig. 7 Pre Treatment OPG 6. Mommaerts. M.Y. Bone anchored intraora! device for
trans mandibular distraction. British Journal of Oral
and Maxillotacial Surgery. 2001. [39] 8-12
7. Lindsey R. Douglas, J. Burton Douglass, Philip J.
Smith. Intra-oral distraction osteogenesis in the
baboon mandible using a tooth and Bone- Anchored
appliance. Journal of Oral and Maxillofacial Surgery
2000; 58; 49-54
8. Liou and Huang: rapid canine retraction through
distraction of periodontal Ligament.Am. J. Orthod
1998; 114 (4), 372-82.
9. Kontham, T M Bhagtani, P V Wadkar. Rapid canine
Fig. 8 Post Treatment OPG
retraction through distraction of the periodontal
is seen clinically and radiographically. Bodily ligament – a case report. J Ind Orthod Soc 1999;
movement of canine was seen. 32:142-145.
10. Eric Jein - Wein Liou, Alvaro Figueroa, John Policy.
Pre and post treatment models were taken.
Rapid orthodontic tooth movement into newly
Orthopantamogram and peri apical radiograph distracted bone after mandibular distraction
were also taken to assess the bone formation, root osteogenesis in a canine model. American Journal
resorption and PDL changes. Widening of PDL Orthod Dentofacial Orthop. 2000; 117:391-398.
1097
A New Nomenclature for the number of Roots in

Maxillary Permanent Molar Teeth
1
Dr. A.V. Rajesh Ebenezar, 2Dr. Ajit George Mohan
ABSTRACT
Aim: To assess the root anomalies of maxillary permanent molar teeth in Dravidian population and
to propose a new nomenclature for the number of roots in maxillary molars.
Methodology: A total of 352 extracted maxillary molar teeth were collected from dental clinics for
a period of three months within Chennai city. The teeth were examined visually and the root number and
variations in the roots were recorded.
Results: Of 327 maxillary molars the majority had three roots with 89.29%, whilst 2.14% of the
teeth showed four roots. The prevalence of five and two roots were 1.22% and 1.83% respectively. The
percentage of fused/single/conical root was 5.50%.
Conclusion: It was concluded that even-though three rooted maxillary molars are common in the
Dravidian population, the variance to the greater or lesser number of roots should be anticipated.
Keywords: Maxillary molars, root variations, Dravidian population, nomenclature.
INTRODUCTION out by different authors to elucidate the variations

in root anatomy of permanent maxillary molar
The successful prognosis of a root canal
tooth.
treatment depends upon the adequate debridement
and filling of the entire root canal system. For this, The aim of this ex-vivo study was to assess
the clinician should be familiar about the the root anomalies of maxillary permanent molar
variations in the root morphology which in turn teeth in a Dravidian population and to propose a
causes the variation in the root canal systems. new nomenclature for the number of roots in
maxillary molars since no such classification for
A number of studies have reported the
extra number of root variations could not be found
anatomic variations of root due to racial
in the literature.
divergence [1, 2, 3, 4] but only few studies have
been conducted on extracted maxillary molars [5].
METHODOLOGY
It is not enough to know just the normal
morphology of the teeth; it is also necessary to Three hundred and sixty three human
accept the concept of morphological variability permanent maxillary molars were collected from
from a functional, aesthetic and statistical sense. dental practitioners across the Chennai city. It was
Most of the data on tooth and root morphology is confirmed that the teeth belonged to native
derived from studies of population samples from Tamilians, and no teeth from other minority
European and American ancestry. No studies have ethnicities were included. The process of collection
been conducted on Dravidian population to was performed by a team of clinicians who were
ascertain the root anatomy variations. [6]. made to understand the aims of the study, and the
collection of every tooth was accompanied by a
According to Tronstad [7], maxillary first
case record stating and confirming the ethnicity of
permanent molar teeth are generally considered to
the patients. Verbal and written consent for
be three rooted in 85% of cases, and in 15% it
extraction was obtained from each patient. The
exhibits two roots. The maxillary second molar
teeth were washed under tap water immediately
teeth presents with three roots in 80% of cases,
after extraction and stored in distilled water until
two roots in 19% of cases and 1% in single root.
the collection was complete. The entire collection
However, maxillary permanent first molar with
process was completed in 3 months. The samples
single roots have been reported recently in the
were washed thoroughly under tap water and
literature. Table I depicts various studies carried
immersed in 2.5% sodium hypochlorite (Prime
1
Reader, Dept. of Conservative Dentistry and Endodontics, SRM Dental College, Chennai. 2Lecturer, Dept. of Conservative
Dentistry and Endodontics, Annoor Dental College, Kerala.
1098
Dental Products, Mumbai, India) for 30 minutes to sample had a single conical root, whereas 7 teeth
remove adherent soft tissue. The exclusion criteria (2.14% had four roots. In the four root category,
include the broken roots during extraction and thus 3 teeth had two mesiobuccal roots, one distobuccal
thirty six teeth were removed from the study. The and one palatal root, whereas another 2 teeth
final sample size was three hundred and twenty showed variation like two distobuccal roots, one
seven teeth. mesiobuccal and one palatal root. Two palatal
roots with one mesiobuccal and one distobuccal
The identification of the teeth as maxillary
root were observed in 2 teeth with four roots. Four
molars was based on crown morphology according
teeth (1.22%) had five roots. Among the four
to accepted criteria (Ash 1985). The collected
teeth, three teeth showed two mesiobuccal roots,
specimens were examined by naked eye and the
one distobuccal and two palatal roots. One tooth
number and anatomical location of roots were
showed greater variation with three distobuccal
recorded.
roots, one mesiobuccal and one palatal root. Six
teeth (1.83%) of the sample revealed two roots
RESULTS with one buccal and one palatal root.
The data for number of roots and their
morphology was presented in table II. The DISCUSSION
majority of the sample 292 teeth (89.29%) had
three roots with one mesiobuccal, one distobuccal The maxillary molars were selected for this
and one palatal root. 18 teeth (5.50 %) of the study since root variations are very common in
Table 1. Previous studies on root anatomy in permanent maxillary molar tooth
Author Year Tooth number Number of teeth studied Anatomic details

Stone & Stroner[8] 1981 Maxillary second molar 500 2 palatal root canals
Libfield & Rotstein[9] 1989 Maxillary second molar 1200 2 distobuccal roots and
canals
Christie et al[10] 1991 Maxillary molars 16 2 palatal roots
Peikoff et al [11] 1996 Maxillary second molar 520 Number of roots and root
canals
Hulsmann [12] 1997 Maxillary first molar 1 2 disto-buccal roots
Zmener & Peirano [13] 1998 Maxillary second molar 1 3 separate buccal roots
Peter M. Di Fiore [14] 1999 Maxillary molars 1 4 roots
L.R.G. Fava [15] 2001 Maxillary molars 1 2 roots
F. Baratto-Filho et al[16] 2002 Maxillary molar 1 4 roots
Barbizam JV, Ribeiro RG [17] 2004 Maxillary molar 2 4 roots
Gopikrishna et al[18] 2006 Maxillary first molar 1 1 root
Francisco et al [19] 2008 Maxillary first molar 1 1 root
Table 2. Number of roots and their morphology.
S.No Number of roots Description of roots Number of teeth Percentage

1 3 roots 1MB root(mesiobuccal), 1DB root(distobuccal) and 1P (palatal) root 292 89.29
2 4 roots 3 teeth (2MB, 1DB and 1 P) 07 2.14
2 teeth (1 MB, 2 DB and 1P)
2 teeth(1MB, 1DB and 2P)
3 5 roots 3 teeth(2 MB, 1 DB and 2 P) 04 1.22
1 teeth (1 MB, 3 DB and 1P)
4 2 roots 1 buccal and 1 palatal 06 1.83
5 Single/ Fused root Single conical root 18 5.50
1099
this type of teeth. Our extensive search on the The maxillary molar root anatomy is
literature reveals that no study have been predominantly a three rooted form, as shown in
conducted on root variations in Tamil population all anatomic studies of this tooth. The two rooted
of the Chennai City. Various studies have been form is rarely reported, and may be a result of
done to assess the root canal morphology, whereas fusion of the distobuccal root to palatal root or
there is a dearth of studies pertaining to anatomical fusion of the distobuccal root to the mesiobuccal
deviances of permanent maxillary molar root. root. The single root or conical form of root
Hence this study was undertaken to determine the anatomy in the maxillary molar is not a common
occurrence and is noticed in second or third
possible variations in permanent maxillary molar
molars. The four-rooted or five-rooted anatomy in
root in Chennai population.
its various forms is also very rare in the maxillary
The main reasons for extraction were as molars and is more likely to occur in the second
follows: periodontal disease, prosthodontic or third maxillary molar. Variations in the number
rehabilitation and grossly carious teeth involving of roots of maxillary molars are seen in recent
furcation which is not amenable for endodontic studies rather than in the endodontic textbooks.
management. Extractions were carried out by Therefore it is prudent to update the anatomical
qualified dentists enrolled in the Dental Council of variations in the endodontic textbooks, based on
India who were licensed to practice dentistry. The the published literature.
maxillary molars were collected from dental clinics
CONCLUSION
located in the Chennai City. Therefore, the sample
may not be fully representative of the entire Tamil This study divulged the complexity of root
population. However, since Chennai city has got variations found in permanent maxillary molars of
the maximum Tamil population in India, this study the tamil population in Chennai city. The
can be expected to apply to the Tamil population suggested nomenclature gives unique names for
in India. Increasing the sample of teeth studied can root variations in maxillary molars.
result in more dependable and consistent data
which can be attributed to the entire Tamil race REFERENCES
in the world. 1. Walker RT (1998) Root form and canal anatomy of
mandibular fisrt molars in a southern Chinese
In cases in which there are more than three population. Endodontics and dental Traumatology
roots in a maxillary molar, the terminology of 4,19-21.
additional roots are not clear and unique. Variation 2. Salwa AY, Abdullah RA, Mohammad FF (1990)
in the number and morphology of roots are a norm Three rooted permanent mandibular first molars of
nowadays. To avoid confusion, the following Asian and Black groups in the Middle East. Oral
nomenclature is suggested for maxillary molars: Surgery, Oral Medicine and Oral pathlogy 69,102-5.
3. Al-Nazhan S (1999) Incidence of four canals in
Class I – Three roots (one MB. one DB and one P) root-canal-treated mandibular first molars in a Saudi
Class II – Single /conical/ Fused root Arabian sub-population. International Endodontic
Class III – Two roots (one buccal, one palatal) Journal 32,49-52.
4. Weine Fs, Hayami S, Hata G, Toda T(1999) canal
Class IV – Four roots
configuration of the mesiobuccal root of the maxillary
Class IVM – two MB, one DB, one P first molar of a Jaanese sub-population. International
Class IVD – two DB, one MB, one Endodontic Journal 32,79-87.
P
Class IVP – two P, one MB, one DB 5. Carlsen O, Alexandersen V (2000) Radix
mesiolingualis and radix distolingualis in a collection
Class V – Five roots of permanent maxillary molars. Acta Odontologica
Class VMD – two MB, two DB, one P
Scandinavia 58,229 –36.
Class VPM – two MB, one DB, two 6. Ash M, Nelson S. (2003) Wheeler’s dental anatomy,
P
physiology and occlusion, 8th ed.
Class VPD – one MB, two DB, two P Philadelphia:Saunders.
Class VM3 – three MB, one DB, one P 7. Tronstad L (2003) A text book of Clinical
Class VD3 – one MB, three DB, one P Endodontics, second revised edition Thieme
Stuttgart-New York.
Class VP3 – one MB, one DB, three P
8. Stone LH, Stroner WF (1981) Maxillary molars
Class VI – More than five roots.
demonstrating more than one palatal root canal. Oral
1100
Surgery, Oral Medicine and Oral pathlogy 51 15. Fava LRG (2001) Root canal treatment in an unusual
,649-52. maxillary first molar: a case report. International
9. Libfield H, Rotstein I (1989) Incidence of four-rooted Endodontic Journal 34 ,649 –53.
maxillary second molars: literature review and 16. Baratto-Filho F, Fariniuk LF, Ferreira EL, Pecora JD,
radiographic survey of 1,200 teeth. Journal of Cruz-Filho AM, Sousa-Neto MD (2002) Clinical and
Endodontics 15, 129-31.
macroscopic study of maxillary molars with two
10. Christie WH, Peikoff MD, Fogel HM (1991) palatal roots. International Endodontic Journal
Maxillary molars with two palatal roots: a 35,796–801.
retrospective clinical study. Journal of Endodontics
17, 80–4. 17. Barbizam JV, Ribeiro RG, Filho MT (2004) Unusual
anatomy of permanent maxillary molars. Journal of
11. Peikoff MD, Christie WH, Fogel HM (1996) The
Endodontics 30 ,668 –71.
maxillary second molar: variations in the number of
roots and canals. International Endodontic Journal 29, 18. Velayutham Gopikrishna, Narayanan
365-9. Bhargavi,Endodontic (2006) Management of a
12. Hulsmann M (1997) A maxillary first molar with two Maxillary First Molar with a Single Root and a Single
distobuccal root canals. Journal of Endodontics 23, Canal Diagnosed with the Aid of Spiral CT: A Case
707-8. Report. Journal of Endodontics 32 , 687– 691.
13. Zmener O, Peirano A (1998) Endodontic therapy in 19. Francisco de la Torre, Rafael Cisneros-Cabello (2008)
a maxillary second molar with three buccal roots. Single-rooted maxillary first molar with a single
Journal of Endodontics 24 ,376-7. canal: endodontic retreatment, Oral Surgery, Oral
14. Peter M, Di Fiore (1997) A four rooted quadrangular Medicine and Oral pathlogy Oral Radiology and
maxillary molar. Journal of Endodontics 25,695–7. Endodontics 106, e66-e68.
1101
Assessment of Knowledge and Practices Regarding

Infant Oral Health Care in Chandigarh Population
Dr.Manjot Kaur1, Dr. Ashima Goyal2
ABSTRACT
Objective: The objective of this study was to assess the knowledge and practice of the parents
regarding infant oral health care among the people of Chandigarh.
Material & Methods: About 100 infants were selected and the parents of the infants were
interviewed by using a pretested structured questionnaire for recording the Knowledge, Attitude and Practice
about oral health.
Results: 12 percent of the parents did not know about deciduous dentition and about 25 percent of
the parents did not know the importance of cleaning the gum pads and tongue among the infant. 34 percent
did not know regarding any of the dental diseases as compared to 50percent who were at least aware
regarding dental caries.
Conclusion: Educating the parents regarding various risk factors responsible for the development of
dental diseases can lead them to change their practices related to oral health. This approach can be studied
involving more dentists and a large population at a national level.
Key words: Gum pad, Dental caries, deciduous dentition.
INTRODUCTION and make the child have a good quality of life. In

India there is a complete lack of any organized
Early childhood Caries is a complex, oral health preventive program and what ever,
multifactorial, infectious disease that begins soon scanty programs existing, they are mainly school
after eruption of primary teeth, on smooth based i.e. for children above 5 years. The
surfaces, progresses rapidly and leaves a lasting prevalence of dental caries in deciduous dentition
detrimental impact on the primary dentition1,2,3. It is higher as compared to the permanent dentition.
is a major cause of pain, periapical abscess and Thus in recent years attention has been focused on
can lead to malocclusion and poor speech planning programs on Infant dental care in various
articulation due to premature loss of primary tooth. countries. The present study was carried out to
The various factors associated with early childhood evaluate the knowledge, attitude and practice of
caries are frequent nursing of sweetened drinks, parents of infants selected from general population
enamel hypoplasia, inadequate oral hygiene, regarding primary preventive aspects of oral health
delayed commencement of tooth brushing, lack of of their children, to guide and educate them for
parental help with tooth brushing and increased prevention of early childhood caries.
frequency of consumption of sugary snacks. All
these factors create an environment which MATERIALS AND METHODS
encourages the growth of Mutans Streptococci
(MS), especially during the ‘Window of A total of 100 healthy infants, aged 0-6
Infectivity’. months, were randomly selected from the
Advanced Pediatric Centre of Postgraduate
The period from birth till 3 years is thus the Institute of Medical Education & Research,
most crucial from oral health point of view as Chandigarh. The parents of the selected infants
during this period primary teeth are erupting, were interviewed for knowledge, attitude and
permanent tooth buds are developing, the dietary practice regarding oral hygiene methods in
habits of a child are being formed and the bacterial infant/child so that the awareness of parents, their
ecology is being established. Primary preventive practices and attitude towards oral health could be
methods incorporated at early age can modify the elicited. A pretested structured questionnaire was
risk factors for dental caries and gingival diseases prepared for recording the Knowledge, Attitude
1
Senior Lecturer, Dept. of Public Health Dentistry, Dr.H.S.Judge Institute of Dental Sciences and Hospital, Panjab University,
Chandigarh 2Professor, Ph.D, Dept. of Pediatric and Preventive Dentistry, Unit of Oral Health Sciences, PGIMER,
Chandigarh
1102
and Practice about oral health. The investigator birth. Thereby, showing the ignorance of most of
was standardized by repeated calibrations for the parents regarding the correct time of gum pad
recording and filling of the data by the chief cleaning. On evaluating the method of cleaning
supervisor. A personal interview method was used gum pads, 68 percent did not find it necessary to
to record the proforma and the data was analyzed clean the gum pad 4 percent were not aware of it.
by using SPSS10. 17 percent cleaned the gum pad with their fingers
and only 11 percent cleaned with a moist cloth.
RESULTS
Knowledge of parents revealed that 96 percent
Parents were interviewed to define milk teeth considered it important to clean the teeth but none
and it was found that 12 percent were not able to of the parents knew the right age of initiation of
explain it, 79 percent described them as the ones tooth brushing. About 35 percent replied that it
that erupt first in the mouth and 9 percent should be started after few teeth have erupted, 18
described them as teeth those are replaced by percent after all teeth have erupted, 12 percent
permanent teeth. Regarding their knowledge about after 1 year of age, 6 percent after 2 years, 6
importance of milk teeth, 42percent did not know percent after 3 years and 9 percent did not know
about it, 32 percent considered them important for about it. This clearly indicates that parents were
chewing and 23percent felt that they are important unaware of the fact that tooth cleaning should be
for maintaining space for permanent teeth. Attitude started as soon as the first tooth erupts as
of parents regarding gum pad and tongue cleaning recommended by Moss et al4. 99 percent of the
before eruption of teeth was evaluated and it was parents interviewed had never got any training for
found that 49 percent considered it important brushing their own or their child’s teeth and 1
whereas 25percent did not know about it and 18 percent had got the training from a dentist.
percent did not consider it necessary. An
Evaluation of parents was also done to assess
assessment of the knowledge of parents about
their knowledge regarding dental diseases. 34
initiation of gum pad cleaning revealed that, 48
percent were not aware of any of the dental
percent were not aware of it, 21percent replied that
diseases, 50 percent were aware of dental decay,
it should start at 2-3 months after birth, 13 percent
16 percent of gum diseases. 35 percent considered
after a month and 5 percent replied whenever
it to be black spots on the tooth, 20 percent as
convenient. Only 13 percent were aware of the
cavity in tooth, 22 percent as germs in teeth and
exact time of gum pad cleaning i.e. a week after
Knowledge of parents regarding initiation of gum-pad cleaning
1103
Knowledge regarding harmful effects of feeding while sleeping
Practice of showing affection to the child
15 percent did not know about it. This this. The correct knowledge of safe limit being 3
unawareness necessitates the need to emphasize on times per day was seen in just 11 percent of the
the exact etiology of dental caries. An assessment parents.
was made about the knowledge of parents
regarding the safe limit of Total Sugar Exposure Feeding practices and the additives to the milk
in a day for prevention of dental caries. 49 percent of the child were assessed. 72 percent were
responded that they have no knowledge regarding breast-feeding their child and the rest were using
1104
Knowledge of parents regarding harmful effects of thumb-sucking
Percentage of infants practicing good dental habits
other means of feeding like bottle, both bottle and Practice of oral habits by the children revealed
breast. Out of all the patients feeding their children that 20 percent children were in the habit of thumb
by other means 26 percent were adding sweetened sucking and 78 percent were not found to have
additives or sugar to the milk and were adding the any oral habits. 50 percent parents reported that
same to the last feeds at night, being ignorant of prolonged thumb sucking leads to protrusion of
the fact that this can lead to dental caries. teeth and 39 percent were not aware of it. 61
Knowledge of parents regarding harmful effects of percent parents felt that the habit should not be
bottle/breast feeding as the child sleeps revealed allowed at all, 15 percent believed that it should
that 93 percent were not aware of the effects of be discouraged and 14 percent were not aware of
feeding the child at night while 2 percent reported the age of cessation of the habit.
that it caused cavities. 4 percent felt that it does
not affect the teeth and only 1 percent knew that Knowledge of parents regarding drugs to be
it causes Nursing Bottle Caries. avoided by the child was assessed and it was
1105
Knowledge regarding safe limit of total sugar exposures in a day for prevention of dental caries
Practice of cleaning gum-pads/mouth
found that 97 percent were not aware of it while fact that kissing on lips leads to transmission of
2 percent felt that only those drugs be given that caries causing bacteria to the child. These were
are prescribed by the doctor. recorded as various authors5,6 have supported the
Majority of the patients examined (32 percent) fact that dental caries is a transmissible disease and
showed affection to their child by kissing the child the main source of infection for the children are
on the cheeks, 23 percent on the forehead, 20 their parents and transmission of caries causing
percent on the hands, 15 percent on the mouth and bacteria to the children from their parents can
10 percent just cuddled the child. 23 percent were occur through infectious medias like feeding
not aware of transmission of dental disease by spoons, kisses on the mouth and whenever the
kissing on mouth. 56 percent felt that doing so mother cleans the infant’s pacifier by sticking it
causes systemic infections, 8 percent did not agree into her own mouth7 .
to the fact that kissing on mouth causes dental Attitude of parents towards child’s visit to a
diseases and 8 percent felt that it caused gum dentist was of concern as 88 percent reported that
diseases. None of the parents were aware of the it’s needed only when there’s a problem while the
1106
rest felt that regular visits are needed. 97 percent from the parents to the child. As the earliest
parent felt that a child with injured tooth should transmission of S. mutans is from the mother
be taken to a dentist and 2 percent felt that it through kissing or use of mother’s utensils for the
might affect the permanent tooth so treatment is child14,15. Importance was stressed on the necessity
needed. of gum pad cleaning before the eruption of teeth
to remove colonies of bacteria from the gum pads
The practice of using pacifiers is very and also food residue thereby maintaining oral
uncommon in our country as 98 percent of the hygiene in infants16. Another important information
parents interviewed were not using pacifiers for to the parents was to restrict the intake of sweet
their children. This finding is in contrast to those things to not more than three times a day as a
reported by Winter et al8 from U.K. who reported number of studies have shown that three exposures
in his study that 62 percent of the children used per day is safe for the prevention of dental caries
sweetened pacifiers. 17,18,19
.
This was followed by giving education to the
parents on the various aspects of Infant Dental SUGGESTIONS & CONCLUSION
Care through specially prepared information cards
It is thus strongly suggested that educating,
on infant oral health care in Hindi and English.
training and motivating the parents of infants
The information comprised of importance of milk regarding primary preventive strategies of oral
teeth for chewing development of speech and health, using personal approach by a dentist, can
growth of face and also for proper alignment of help in preventing the development of carious
the permanent teeth. Education was also imparted lesions at an early age especially in Indian set up.
on dental plaque and explained how plaque act on Educating the parents regarding various risk
sugar in the food and produce acid which would factors responsible for the development of dental
cause demineralization of the enamel leading to diseases can lead them to change their practices
dental caries. Nursing Bottle Caries was explained related to oral health. This approach can be studied
as caries affecting many teeth specially the upper involving more dentists and a large population at
front ones caused as a result of child falling asleep a national level. Primary preventive care should be
with breast or bottle containing milk particularly the prime aim of the 21st century. Every child has
sweet milk at night9. Most of the authors have a fundamental right to his total health and we as
attributed the sleeping pattern of the child i.e. dentist are responsible for it.
sleeping with sweetened milk that pools around the
upper front teeth, to cause nursing bottle caries. REFERENCES
The role of lactose in the bovine and breast milk
being a factor in implantation of oral bacteria has 1. Winter GB, Rule DC, Mailer GP, James PMC,
also been emphasized10. Parents were advised Gordon PH. The prevalence of dental caries in
pre-school children aged 1 to 4 years. Brit Dent J
against the use of tetracycline group of drugs for
1971; 130:271-277.
the infants because of its known side effect of
2. Holt RD, Joles D, Winter GB. Caries in preschool
staining the developing tooth structure.
children. Br Dent J 1982; 153: 107-109.
Tetracycline when administered to a child whose
teeth are being calcified or to the pregnant mother, 3. Cleaton-Jones PE, Williams SDL, Richardson BD and
Smith C. Dental caries and dental treatment in the
when the teeth are calcifying in the fetus, leads to primary dentition in an industrialized South African
discoloration of the teeth because the drug chelates Community. Community Dent Oral Epidemiol 1985;
the mineralizing hydroxy apatite crystals of the 13: 173-175.
enamel and produces brownish discoloration of the 4. Moss SJ. Growing up cavity free: quintessence.
teeth11. The parents were given information that Chicago, 1992.
abnormal oral habits like thumb sucking, finger 5. Li Y and Caufield PW. The fidelity of initial
sucking, and mouth breathing etc. cause acquisition of mutans streptococci by infants from
proclination of the teeth12. They were advised to their mothers. J Dent Res 1995; 74(2): 681-85.
stop the habit by gently distracting the child and 6. Kohler B, Brathall D. Infrafamilial levels of S-mutans
not stopping him forcibly as this can lead to and some aspects of the bacterial transmission. Scand
development of other habits13. The parents were J Dent Res 1978; 86:35-42.
given information to avoid kissing on a child’s lips 7. Gripp VC, Schlagenhauf U. Prevention of early
and to abstain from sharing of utensils to prevent mutans streptococci transmission in infants by
the transmission of dental caries causing bacteria professional tooth cleaning and chlorhexidine varnish
1107
treatment of t he mother. Caries Res 2002; 14. Davey AL, Roger AH. Multiple types of bacterium
36:366-372. streptococcus mutans in the human mouth and their
intra-family transmission. Arch. Oral. Biol., 1984; 29:
8. Winter GB, Hamilton MC and James PM. Role of
453-460.
comforter as an aetiological factor in rampant caries
of the deciduous dentition. Arch Dis Child 1996; 15. Stephen J Goepferd. Infant oral health – a rationale;
J. Dent. Child. : 1986; Vol. 53; July-Aug: 257-260.
41:207-212.
16. Neal G Herman. An idea t hat works NYU Harris
9. Ripa LW. Nursing habits and dental decay in infants.
infant dental education area. NY State Dent. J.; 1995;
“ Nursing bottle caries”. J Dent Child 1978; 26-29.
45:274-275.
17. Tewari A et al. National epidemiological study
10. Maris P. Degamp. Rpnert A. Degano, Breast feeding 1985-87 – unpublished observation.
and Oral Health, A primer for dental practitioner. NY
18. Sahoo PK, Tewari A, Chawla HS. An epidemiological
State Dent. J.: 1993: Feb: 30-32. study relating dental caries with specific risk factors
11. Urist MR and Ibsem KH. Chemical reactivity of and assessment of treatment needs in child population
mineralized tissue with oxytetracycline. Arch. Pathol of Orissa. Thesis for Degree of Master of Dental
; 1963;76: 484. Sciences, Panjab University, June 86.
12. Graber TM. Orthodontics, Principles and practice: 3rd 19. Kavita et al. Interrelationship of dental caries
experience with specific risk factor and assessment of
Ed: 1988: W.B. Saunders, Philadelphia: 301.
treatment needs of dental caries and gingival diseases
13. Finn SB. Oral Habits in children: clinical Pedodontics, in North India – UP Thesis for degree of Master of
4th Ed: 1987: W.B. Saunders Philadelphia: 370-385. Dental Sciences, Panjab University, 1987.
1108
Chelioscopy: Determination of Sex and Blood Group

Dr. Vidya GD1, Dr. Sreeshyla HS2, Dr. Usha Hegde3, Dr. Shivananda S4
ABSTRACT
Background: In forensic science, the most probable techniques used in the identification of a person
are the dental records, fingerprints and DNA comparisons. The use of lip prints to identify a person though
not so popular still exists as a methodology in forensic science. Dental surgeon can play an active role
in personal identification and criminal investigation, as his evidence would be very much useful in law
and justice. Study of lip print patterns is one such method which aids a dental surgeon.
Objective: The objective of present study was to evaluate and to arrive at any probable conclusion
with regard to the lip print patterns in relation to sex, and blood group of an individual in a population.
Materials and Methods: The study was conducted on 100 students in which 50 were males and 50
were females. Lip stick was applied on each individual and the lip-print was obtained on a bond paper.
The Lip impression pattern was studied classified and recorded using magnifying lens based on
Tsuchihashi’s classification. Blood group of all the individuals were estimated by blood grouping kit
(antiA+B+D+monoclonal agglutinating antisera, Span diagnostics ltd) and recorded.
Results: Our study showed that Type Ii and Type II patterns were more prominent in males than
females. Type I, Type IV and Type V patterns were more prominent in females Type III lip print pattern
had an equal predilection among both sexes.
With regard to the different blood groups, we found that type Ii and type II patterns were the most
prominent pattern followed by type I in all the individuals of different blood groups except AB-ve and
A-ve, since we didn’t have any individual belonging to these to groups. The remaining three patterns III,
IV, and V varied in its presentation slightly among the individuals.
Conclusion: From our study we could differentiate the sexes based on the prevalence of patterns
among them, but could not arrive at any conclusive criteria to classify and identify individuals by correlating
the lip pattern with blood groups. Hence chelioscopy has to be carried out in depth on larger sample size
using newer scientific technologies in this field to arrive at conclusive findings.
Keyword: Chelioscopy: Blood group: Sex: Personal identification
INTRODUCTION mucosa and outer skin forms a characteristic

pattern called as lip prints and the study of it is
The role of a dentist is multifold. He not only
referred to as cheiloscopy. The F.B.I. and the
serves the mankind by examination, investigation,
Illinois state police stated that the lip prints are
diagnosis and treatment of oral and maxillofacial
unique like fingerprints and therefore it is a
pathologies, but also plays an extended role in
positive means for identification of an individual.1
serving the community in case of personal
identification and criminal investigation, since his
HISTORY
evidence is of great importance in the legal issues.
1,2
In 1902, Fischer was the first anthropologist
to describe the furrows on the red part of the
Just as finger prints, antemortem and
human lips. Later, as early as in 1932 by Edmond
postmortem records, DNA finger printing and
Locard, one of France’s greatest criminologists
dental records have been successful in personal
recommended its use. In 1950, LeMoyne Snyder
identification in the field of forensic science. Lip
in his book “Homicide Investigation” stated that
prints can also be used in identifying a person and
the lip prints are very useful instrument in the
as an evidence in the criminal investigation.1
identification of individuals.1
The wrinkles and grooves present in the zone
In 1967, Suzuki made detailed investigations
of transition of human lip, between the inner labial
with regard to the measurement of the lips, the use
1
Reader, 2Assistant Professor, 3Professor and Head, Dept. of Oral Pathology, 4Reader, Dept. of Oral and Maxillofacial
Surgery, JSS Dental College and Hospital, SS Nagar, Mysore
1109
and color of rouge, the types of grooves on lip

and to the methods of its extraction, so that useful
data could be obtained for practical forensic
application. Later in 1970, Suzuki and Tsuchihashi,
conducted a study on 107 Japanese families and
named the grooves on labiorum rurorum as sulci
labiorum and the lip prints consisting of the
grooves as ’ Figura linearum labiorum rubrorum
’.3 After conducting the study suzuki simplified the
classification into five main types. Mc Donell in
1972 reported that two identical twins seemed to
be indistinguishable by every other means but for
their lip prints which were different. 3
Classification schemes 4
In 1967, Santos was the first person to classify

lip grooves. He divided them into four types
namely:
Fig. 1
1. Straight line The present study was aimed to study the
2. Curved line different lip prints pattern in both the sexes and
3. Angled line in different blood groups. Further it was analysed
to see, if the incidence of any particular lip pattern
4. Sine-shaped curve was prevalent in any specific gender or in any
specific blood group
In 1970, Suzuki and Tsuchihashi, classified the
lip grooves, as follows 3
MATERIALS AND METHODS
Type I – A clear-cut groove running The materials used in the present study were
vertically across the lip.
Type Ii – Partial-length groove of Type I.
• Bond paper,
Type II – A branched groove.
• Oil free lipstick or matted lip stick,
Type III – An intersected groove.
• Magnifying Glass and
Type IV – A reticular pattern.
– • Blood grouping kit.
Type V Other patterns.
For the study lip prints of 100 students were
Here, the most characteristic lip groove selected by interview and prior informed written
patterns of human lips were shown in a schematic consent among which, 50 were boys and 50 were
diagram (fig.1) girls, within the age group of 18-24 years from
JSS Dental College and Hospital, Mysore.
Cheiloscopy has been a subject of great
interest to most researchers, since it is least Lips between mucosa and skin which were
invasive and inexpensive, time saving and easily normal and free of any disease were included in
available mode of investigation. Study of lip-print the study. Individuals with known hypersensitivity
patterns appears to be genotypically determined to lipsticks, with any malformation/ inflammation/
and unchanged from birth. They are identifiable as trauma/ scar/ any other abnormality of the lip were
early as the sixth week of intrauterine life, and excluded from the study group.The subjects were
from that time on, their pattern rarely changes, asked to clean the lips and apply the matted lip
resisting many afflictions such as herpetic lesions. stick over it middle portion of the lip print was
5
However, further studies revealing more facts taken by placing the bond paper between the lips
and truth about lip print will certainly aid in without applying pressure. Two duplicate prints of
identifying the victim and will also be a useful each individual were taken to avoid any improper
tool in providing evidence in forensic dentistry. prints or errors. Then the lip prints were studied
1110
Graph I: Comparison of patterns of lip prints between males and females

carefully using a magnifying glass in bright light vertical-21.29%), Type II (branched-20%), Type
to identify and classify according to Suzuki and IV (reticular-12.25%), Type V (irregular-8.38%)
Tsuchiashi. and Type III (intersecting-7.74%),in decreasing
order.
Each individual’s blood group was detected by
the blood grouping kit-antiA+B+D+monoclonal Further it was found that in both boys and
agglutinating antisera, Span diagnostics ltd. Blood girls, Type Ii lip print pattern was the most
groups of all the subjects were noted. prominent pattern. Type Ii and Type II were more
prominent pattern in males than female.Type III
The lip prints obtained were coded and was equal distribution among both female and
recorded in a register with respect to age, sex and male individuals. Type I, Type IV and Type V
blood group of the individual. were more prominent pattern in female than males
Result: Lip print patterns compared with blood groups

(Table II & Graph II):
Lip print patterns compared between boys and Table 2. Lip print patterns compared with blood groups
girls (Table.I & Graph I)
Table 1. Lip prints patterns compare between boys and girls Lip
print
Lip print pattern Male Female A+ve AB+ve B+ve B-ve O+ve O-ve
patterens
Type I 21.37% 21.29%
Type Ii 33.79% 30.32% Type I 17.56% 14.28% 18.07% 20% 22.34% 23.07%
Type II 23.44% 20% Type Ii 32.43% 37% 27.71% 40% 31.91% 23.07%
Type II 8.27% 7.74% Type II 25.67% 25.71% 27.71% 20% 21.27% 23.07%
Type IV 8.27% 12.25% Type III 4.05% 11.42% 6.02% 0% 10.63% 7.69%
Type V 4.82% 8.38% TypeIV 8.1% 2.85% 16.86% 20% 6.38% 15.38%
TypeV 12.16% 8.57% 3.61% 0% 7.44% 7.69%
In the present study, it was found that, in
boys, Type Ii (incomplete vertical-33.79%) was the Individuals of different blood groups had the
most prominent pattern, followed by Type II type Ii lip print pattern as the most prominent
(branched-23.44%), Type I (complete pattern followed by type II pattern in all
vertical-21.37%), Type IV and Type III (reticular individuals except in O+ve blood group
and intersecting -8.27%) and Type V individuals.When the other patterns were compared
(irregular-4.82%). However, in girls, Type Ii there was a general tendency for type I pattern to
(incomplete vertical-30.32%), was the most be prominent after type Ii and II in all individuals
prominent pattern, followed by Type I (complete except O+ve. Among the 3 other remaining pattern
1111
Graph II: Comparison of pattern of lip prints between various blood groups
type III,IV and V, B+ve,B-ve, O-ve individuals evidence to identify the person is very less. 3 It
exhibited similar findings of type IV patterns > has also been suggested that variations in patterns
type III = type V.The AB+ve and O+ve among males and females could help in sex
individuals exhibited similar findings of type III> determination.2 Therefore, the present study aimed
type V> typeIV pattern. A +ve individuals at identifying the sex and blood group of the
exhibited type V> typeIV> typeIII pattern. person by lip print pattern.
Thus we can conclude Here we studied the lip print pattern only at
A+ve: Type Ii> Type II > I > V > IV > III the middle portion of the lip because the middle
part will be clearly visible in any trace print.
AB+ve: Type Ii > II > I > III> V> IV
Further, there is lack of secretions of oil and
B+ve: Type Ii & II > IV > III > V moisture in this area which would otherwise
B-ve: Type Ii> I =II=IV > III & V interfere with the lip prints.1 Also the impressions
O+ve: Type Ii> I > II > III > V > IV at the corner of lips were noted to be improper by
few individuals.
O-ve: Type Ii= II = I > IV > III & V
In literature, few researchers have worked on
DISCUSSION lip prints and proved that a gender difference does
exist in lip print pattern. Suzuki et al. conducted
Personal identification is necessary for an
a study and concluded that lip prints are dissimilar
unknown person in heirship, marriage, divorce,
legitimacy, rape, homicide, suicide, accident, mass among different individuals.3 According to a study
disaster, etc. Usually the personal identification can by Sonal-Nayak, Type I and Type Ii patterns were
be made by comparing the antimortem record with found to be dominant in females, while Type III
that of the postmortem record, if definite and Type IV patterns were dominant in males.
descriptions of the lip prints are available for that Preeti conducted the study and found that Type I
individual. 3 and Type Ii patterns were predominant in females
while Type IV pattern was predominant in males
It is thought that hereditary factors may have and also observed that no lip prints matched with
some influence on the lip print patterns. 6 Many each other.1 Satyanarayan naik stated that Types I
would like to imagine that any one person would and Ii were most commonly seen in females,
have lip prints of one particular type only, but this whereas Type IV was seen most commonly in
is not so. males. 7 According to a study by Vahanwahal et
Lip print identification is generally acceptable al. 9, Type I and Type Ii patterns were found to
within the forensic science as a means of positive be dominant in females, while Types III and IV
identification because Lip print patterns are unique patterns were dominant in males.8 In our study,
like finger prints.1 But the use of lip print as an both males and females had the predominant Type
1112
Ii lip print pattern but Type III was of equal CONCLUSION

distribution. Type Ii and Type II patterns were
Lip prints, just like finger prints are unique to
more prominent in males than females, while Type
an individual and are retained on an object. So at
I, Type IV and Type V were more prominent
the crime site, eliciting a lip print will aid in
patterns in females than males.
establishing useful evidence. By correlating the lip
Harpreet Singh observed that an individual prints elicited with the already established criteria
does not have a single type of lip print but a of the sex and blood group of an individual, it will
mixture of different pattern and that no two serve as an additional weapon along with other
individuals have similar type of lip print. Further clues in personal identification. Although we could
it was seen that lip-prints did not change on identify the sex of an individual based on the lip
repeated sampling in a same individual. 9 print pattern, no such conclusive results were
obtained with regard to identifying the blood group
There are few studies available on lip print of an individual. Further studies with larger
pattern’s comparison with blood group in samples would probably solve this problem
literature, hence we could try to elicit if there are
any correlation between lip print patterns and REFERENCES
blood group. In our study, we were not able to
identify any particular lip print pattern to one 1. Preeti Sharma, Susmita Saxena, Vanita Rathod
particular blood group but it was possible to make Cheiloscopy: The study of lip prints in sex
out that some patterns were predominant in some identification. J Forensic Dent Sci: 2009: 1 (1): 24-27
blood groups. We could not get all the blood 2. Shilpa Patel, Ish Paul, Madhu Sudan Astekar,
groups since the sample size was limited. Our Gayathri Ramesh, Sowmya GV. A study of lip prints
in relation to gender, family and blood group.
findings of lip patterns and its statistical correlation
International Journal of Oral & Maxillofacial
with different blood groups were in accordance to Pathology 2010; 1(1):4-7
Shilpa patel’s who found no any statistical
3. TR Saraswathi, Gauri Mishra, K Ranganathan. Study
correlation of lip print with family members or
of lip prints J Forensic Dent Sci: 2009 : 1 (1):28-31
even any correlation between blood group and lip
prints.2 4. L Vamsi Krishna Reddy Lip prints: An Overview in
Forensic Dentistry. Journal of Advanced Dental
Aggarwal has proved that lip prints are as Research 2011; 2 (1): 17-20
good as finger prints in criminal identification and 5. El Domiaty, Magda. Lip Print For Identifcation -
can be definitely used when no other means of Problems and evident solutions.
traditional methods of identification are available. http://www.scitopics.com/LipPrint.html
However, as far as the legal matters in Indian 6. Dr. Anil Aggrawal.The Importance of Lip
judicial system are concerned, this technique needs Prints(forensic file)
http://www.lifeloom.com/aggrawal.html.
to be used more frequently in routine civil and
criminal litigations. 3 7. Satyanarayana Naik K. Ajay Prabhu,Reshma
Nargund. Forensic odontology: cheiloscopy. Hong
The drawback of the cheiloscopic study is the Kong Dent J 2011; 8:25-8
smudging or spoiling of the lip prints, due to the 8. Vahanwahal S, Nayak CD, Pagare SS. Study of
presence of hair especially among the men with lip-prints as aid for sex determination. Medico-legal
beard or the effect of age or seasonal influences.10 Update 2005; 5:93-8.
9. Dr. Harpreet Singh, Dr. Pankaj Chhikara, Dr.
Further more studies are required to be carried RituSingroha. Lip as an evidence. J Punjab Acad
out and various trials so that it can be used as an Forensic Med Toxicol 2011; 11(1): 23-25
useful tool for the purpose of personal 10. Suman Jaishankar , Jaishankar N , Shanmugam S. Lip
identification Prints in Personal Identification JIADS:,2010: 1:23-26
1113
Dental Survey of Deaf and Dumb Children in a Special

School from Pune
Dr. Mamatha GS1, Dr. Kakodkar P2, Dr. Deshpande T3
ABSTRACT
Aim: To assess the oral hygiene status and caries experience of deaf and dumb children from a
special school (Badhir-Mook Vidyalay) Pune.
Material and methods: There were 150 children in the age range of 4-18 years. Oral hygiene status
was assessed by OHI-S index and caries by DMFT/deft indices. Information was also collected regarding
the frequency and use of oral hygiene aids.
Results: 100% children showed the presence of debris and calculus. The prevalence of decayed teeth
in permanent dentition was 58.64% and in the deciduous teeth was 57.8%. 42.18% teeth were indicated
for extraction. Filled component in permanent teeth was 3% and 0% in deciduous teeth. Majority of the
children had DMFT and deft scores in the range 1-3. Mean DMFT of permanent teeth was 2.44. Mean
OHI-S was fair. Mean OHI-S in children who never brushed or irregular and brushed once was fair and
who brushed twice was good.
Conclusion: Risk management and preventive intervention is recommended for this high risk cohort.
Keywords: deaf and dumb children, dental caries, oral hygiene, DMFT, OHI-S.
INTRODUCTION adopted this school. Personal interview with the

Poor oral hygiene is one of the important school authorities revealed that, there had neither
precursors for the initiation of the dental caries, been any preventive dental program in the school
gingival and periodontal diseases. Suffering from nor had the children visited the dentist regularly.
any of these dental conditions affects the In order to improve their dental health and provide
physiological, social and economical (quality of them with preventive services it was felt that the
life) dimension of any normal individual. But if
concept of risk management and preventive
the individual is physically or mentally challenged,
then the impact on their quality of life would be intervention should be implemented. Hence, to
even greater. Disability affects a wide segment of obtain the baseline data needed for planning, the
the population of all the ages and social classes. present study was aimed at assessing the oral
Deaf and dumb children constitute one of the hygiene status and caries experience of the deaf
major population groups of disabled children. and dumb children.
Approximately 3% of the population aged 16 years
and below are estimated to have one or more
disabilities in India.1 MATERIAL AND METHODS
Although in the recent years, there has been A cross sectional study was designed to assess
an increase in the number of studies concerning the oral hygiene status and caries experience in
the dental health of normal children, very little deaf and dumb children from a special school
attention has been paid to dental health of deaf whose age ranged from 4-18 years. All 150
and dumb persons who really need proper care for
children were included in the study. Permission to
their dental health as they cannot maintain proper
oral hygiene and dental health.1,2,3,4 carry out the survey was obtained from the
Principal. Informed consent was obtained from the
Badhir-Mook Vidyalay is a special school for
parents on behalf of the children. Ethical approval
deaf and dumb children situated in (Chinchwad)
Pune, in the state of Maharashtra. There are 150 to conduct the study was obtained from the
children in the school. As a community activity Institutional Ethics committee of Dr. D.Y.Patil
the Dr.D.Y.Patil Dental College and Hospital has Dental College and Hospital, Pune.
1
Lecturer, Dept. of Oral Pathology, 2Reader, 3Intern, Dept. of Public Health Dentistry, Dr. D.Y.Patil Dental College and
Hospital, Pimpri, Pune.
1114
Method of examination of the children had decayed teeth in both

• Firstly, parents were interviewed to record the deciduous and permanent dentition than filled and
general demographic information and then oral missing teeth. 78 children (58.64%) had decayed
hygiene practices followed by their children. permanent teeth and 37 (57.8%) had decayed
• Type III examination was carried out in deciduous teeth. Children with M component were
adequate illumination (day light) using a 9 (6.76%) and F component were 4 (3.0%).
mouth mirror and an explorer. (American Children with ‘e’ component were 27 (42.18%)
Dental Association- 1920). Single trained and and f component were 0. The total DMFT ranged
calibrated examiner conducted the examination from 0-13 with majority of the children were in
with the help of a dental assistant. the range of DMFT 1-3. The total deft ranged
• The oral hygiene status was assessed using from 0-10 with majority of the children (39.06%)
OHI-S. was in the range of deft 1-3. Mean DMFT and
• The caries status was assessed using DMFT deft scores are presented according to the age
and deft index. groups (Table 1).
Table 1. Distribution of children according to age group and
• Clinical examination was conducted between
mean DMFT.
9-11am in the class room in presence of the
parents and teachers. Number Mean Mean
of children DMFT deft
• The examination procedure was explained to
the teacher who in turn explained it to the Deciduous dentition (4-5 2 0 0.5
children and made them feel at ease while years)
examination.
Mixed dentition (6-12 years) 62 1.3 2.48
• Standard infection control measures were
Permanent dentition (13-18 71 2.44 0.08
followed during examination. years)
RESULTS
Mean OHI-S was fair (Table 2). It was
Out of 150, only 135 children participated (15 observed that those who brush twice had good oral
children were excluded as few were not willing to hygiene (Table 3).
participate, uncooperative during examination and
Table 2. Distribution of children according to age group and
absent on the day of examination). 43.7% (n= 59) mean DI-S, CI-S and OHI-S.
were males and 56.7% (n=76) were females. Total
sample consisted of children aged from 4 to 18 Number of Mean Mean Mean
years. They were further classified into subgroups children DI-S CI-S OHI-S
according to the type of dentition. 2 (1.48%)
Mixed dentition 62 0.7 0.6 1.35
children belonged to the deciduous dentition, (6-12 years) (Fair)
62(45.93%) in mixed and 71(52.59%) in
permanent dentition. Permanent dentition 71 0.6 0.7 1.39
(13-18 years) (Fair)
Majority of the children (n=130, 96.34%) used
toothbrush and 106 children (78.51%) used Table 3. Frequency of tooth brushing with OHI-S, DMFT and deft.
toothpaste as an oral hygiene aid for cleaning their
Frequency of tooth brushing
teeth. There were 21children(15.55%) who had the
habit of brushing their teeth using toothpowder. Never or Brush Brush
110 children (81.48%) brushed their teeth once irregular n=11 once n=110 twice n=14
daily and there were 14 children (10.38%) who
Mean OHI-S 1.6 (Fair) 1.36 (Fair) 1.2 (Good)
brushed twice daily and 11 children (8.12%) who
were irregular in brushing. Only 3 children (2.22 Mean DMFT 1.81 1.89 2.0
%) had the habit of using inter dental cleansing Mean deft 2.27 1.0 1.37
aids.
Almost all the children showed the presence Other auxiliary findings of due importance
of debris and calculus. OHI-S was fair in 71 were over-retained deciduous teeth, supernumerary
children (52.59 %), good in 62 children (45.92%) teeth, malformed teeth, congenital missing teeth,
and poor in 2 children (1.48%) children. Majority crowding, high arched palate, excessive over jet,
1115
over bite and malocclusion observed in a small 3% of permanent teeth and none of the deciduous
percent of children. teeth were treated, this could be due to lack of
awareness of treatment modalities in early stage,
DISCUSSION low socio-economic status, inaccessible oral health
Majority of children 70-90% used tooth brush services and negligence . Similar finding has been
and tooth paste as an oral hygiene aid to clean reported by Aruna CN. 6
their teeth, comparable results were found in the
studies conducted by Nandini NS5and Aruna CN CONCLUSION
et al.6 But the study conducted by Nagaraja Rao
The concept of risk management and
G reported 99% of children using charcoal powder
preventive intervention is recommended for these
and finger to clean their teeth.7 Present study
children. This will be covered in 3 stages.
showed majority of the children (81.48%) brushed
their teeth once daily, 10.38% (n=14) of them
brushed twice and 8.12% (n=11) were irregular in Stage 1: Primary prevention (This stage
brushing. Similar results were found in other has been completed)
studies.6,7 At the end of the survey, tooth brushes and
tooth pastes were distributed to the children and
In the present study, children had debris index
supervised tooth brushing was conducted. In
and calculus index values ranging between 0.4-0.6
addition to this, oral health education was imparted
and 0.0 -0.7 respectively, these results were better
to the teachers and parents of the children
as compared to the study done by Nagaraja Rao
emphasizing on the oral hygiene habits. Topical
G (1985) in which scores of debris index and
fluoride application wherever applicable were
calculus index were 0.88-1.14 and 0.97-1.29
undertaken.
respectively.7 Overall Mean OHI-S value was 1.04
in the present study which was slightly better than
that reported by Nagaraja Rao G.7 Stage 2: Secondary prevention
This includes oral prophylaxis and dental
Table 4. Comparative table of Mean DMFT among children with
different handicapping condition. restorations.
Age Mean Stage 3: Tertiary prevention

Studies
group (yrs) DMFT
This includes extractions, complex
Present Study (deaf and dumb 4-18 2.44 restorations, root canal treatment and prosthesis.
children)
For secondary and tertiary prevention children
Rawlani SM et al1 (blind, deaf and 5-17 2.4
were referred to the dental college.
dumb children)
6
Aruna CN et al (deaf and dumb 6-18 1.64 ACKNOWLEDGEMENT
children)
8 This study was funded by Indian Council of
Prashant GM et al (blind children) 6-18 2.1
Medical Research (ICMR) under Short Term
9
Damle SG et al (deaf and deaf 12-14 3.6 Studentship (STS) project-2007. The sanction
mute children) number is 21/425/2007- BMS. The authors also
Naveen kumar PG et al 10
(Deaf and 12-15 3.4 thank principal of the school, teachers and parents
dumb children) who helped in carrying out the study.
Rao DB et al 11 (mentally subnormal 3-30 4.51
and handicapped children) REFERENCES
1. Rawalani SM, Gondane SR, Gogri R, Kabra A.
Comparative table (Table 4) of Mean DMFT Prevalence of dental caries in blind, deaf and dumb
scores of different handicapping conditions reveals children. Dental Dialogue 2002; 1:17-18.
that the mean DMFT in the present study sample 2. Gupta DP, Roy Chowdury KS, Sarkar S. Prevalence
was nearly in the same range. 55-60% of children of dental caries in handicapped children of Calcutta.
had decayed permanent and deciduous teeth which J Indian Soc. Pedo Prev Dent 1993; 11:23-27.
was less than that reported by Aruna CN et al 3. Martens L, Marles L, Goffin G, Gizani S, Vinckier
[93%-99%] (6). 6.76% of permanent teeth were F,Declerck D. Oral hygiene in 12-year- old disabled
missing due to caries. It was observed that only children in Flanders, Belgium, related to manual
1116
dexterity. Community Dent Oral Epidemiol 2000; 8. Prashant GM, Chandu GN, Md Shafiulla. Dental
28:73-80. Caries Experience among 6-18 years Old Blind
Children of Residential school, Bangalore, Karnataka.
4. Guidelines: Oral Health Care for people with a
Journal of the Indian Association of Public Health
physical disability. British Society for Disability and Dentistry 2005 ; 6: 18-21.
Oral Health 2000:1-9.
9. Bhavsar JP, Damle SG. Dental Caries and Oral
5. Nandini NS. New insights into improving the oral Hygiene in 12-14 years old handicapped children of
health of visually impaired children. J Indian Soc Bombay, India. J Indian Soc Pedo Prev Dent 1995;
Pedo Prev Dent 2003; 21 (4):142-143. 13:1-4.
6. Aruna CN, Chandu GN, Md Shafiulla. Dental Caries 10. Naveen Kumar PG, Ashok Kumar BR, Ankola A,
Experience among Deaf and Dumb Children in Tangade P. Dental Caries & Periodontal Status of
12-15 Year Old Handicapped Children Of Belgaum
Davangere, Karnataka. Journal of the Indian
City, Karnataka. J Ind Dent Assoc 2003; 74:107-109.
Association of Public Health Dentistry 2005; 6:1-4.
11. Rao DB, Hegde AM, Munshi AK. Caries prevalence
7. Nagaraja Rao G. Oral health status of certified school amongst handicapped children of south Canara
children of Mysore state. J Ind Dent Assoc 1985; 57: district, Karnataka. J Indian Soc Pedo Prev Dent
61-64. 2001; 19(2): 67-73.
1117
The Remineralization Potential of CPP-ACP (GC Tooth

Mousse) and TCP with 0.21% W/W Sodium Fluoride
Anti-cavity Paste (Clinpro Tooth Crème) on Artificial
Caries – like Subsurface Lesions in Primary and
Permanent Teeth – An in-vitro Study
Dr. Arun Prasad. R1, Dr. M. Jayanthi2, Dr. Elizabeth Joseph3, Dr. D.Senthil4
ABSTRACT
Aim: The purpose of the study was to evaluated the remineralization capacity of CPP- ACT and
TCP with 0.21% w/w sodium fluoride anti-cavity paste on artificial caries like sub-surface lesions an
in-vitro study.
Materials and Methods: 20 permanent and 20 primary teeth were collected, artificial caries were
produced and divided into 4 groups randomly. Two in permanent (group I – CPP-ACP and group II TCP)
topical application was done and stored in remineralizing solution for 10 days and tow in primary teeth
(group III – CPP- ACP and group IV - TCP) topical application was done and stored in remineralizing
solution for 7 days.
Results: Remineralization capacity was evaluated qualitatively with Scanning electron microscope and
quantitatively (SEM) with Energy dispersive X ray analysis (EDAX). Analysis showed CPP- ACP had
better remineralization capacity in (group I – 0.105) permanent which was not statistically significatnt
(P = 0.389). In primary teeth CPP- ACP showed better remineralization capacity in (group III – 0.214)
which was statistically significant (p – 0.0001).
Conclusion: Both CPP – ACP and TCP showed remineralization capacity, but on comparison CPP
– ACP showed better remineralization capacity in primary teeth.
INTRODUCTION lozenges and mouthwashes3. But there is lack of

information on effect of tri-calcium phosphate on
Demineralization is first visible as a “white white spot remineralisation in permanent and
spot lesion” on the surface of the tooth primary teeth.
enamel.White spot lesions are an early sign of
tooth decay that, if left untreated, will progress to The present in vitro study was conducted to
frank caries lesions. Treatment of these evaluate the remineralization potential of Casein
demineralized areas can stop progression and PhosphoPeptide - Amorphous Calcium Phosphate
reverse the decay process through remineralization. (Gc tooth mousse) and Tri-Calcium phosphate with
Various methods are available for reversal of these 0.21%w/w sodium fluoride (Clinpro tooth crème)
white spot lesions1. on artificial caries like lesions in primary and
permanent teeth.
Fluoride is one of the preventive agents that
have been categorized as strongly cariostatic and
can be used in various forms2. It can be used alone MATERIALS AND METHODS
or in combination with other remineralizing agents.
The other materials with new Calcium technology Twenty intact human primary and twenty
that are commercially available are GC tooth human permanent teeth were collected cleaned
mousse (CPP-ACP) and Clinpro tooth crème (TCP with curettes and ultrasonic tips to remove any
with 0.21% w/w Sodium Fluoride). calculus, soft tissue debris and then stored in 0.5%
physiologic saline until use. The teeth with cracks,
Previous studies have focused on casein hypoplasia, white spot lesions, and caries were
phosphopeptide incorporated in sugar free gums, excluded from the study.
1
P.G. Student, 2Professor and Head, 3Professor, 4Senior Lecturer, Dept. of Pedodontics and Preventive Dentistry, Ragas
Dental College and Hospital, Uthandi, Chennai.
1118
The selected primary and permanent teeth Table 1 Remineralization Potential of the two pastes among the
were randomly divided into four groups of ten study groups
each were selected for the study according to the
Stages
agents used. Reminera
Deminerali- Reminerali- lisation
GROUP I - CPP-ACP (GC Tooth mousse) in Baseline
sation sation change
permanent teeth [10 Nos]
Mean SD Mean SD Mean SD
GROUP II- TCP with 0.21%w/w sodium
fluoride (CLINPRO) in Permanent teeth [10 Nos] Group 1925 0.062 1.654 0.49 1.759 .026 0.105 ±
I 0.0512
GROUP III- CPP-ACP (GC Tooth mousse) in Group 1.931 .087 1.637 .045 1.725 .025 0.088 ±
Primary teeth [10 Nos] II 0.0330
GROUP IV- TCP with 0.21%w/w sodium Group 1.835 .040 1.462 .036 1.676 .028 0.214 ± 0.
fluoride (CLINPRO) in Primary teeth [10 Nos] III 0232
Group 1.852 0.27 1.453 .028 1.623 .034 0.170 ±
LESION FORMATION IV 0.0290
All the teeth were coated with an acid resistant
Table I: shows the mean and the standard deviation of the
nail varnish (Revlon, USA) leaving two narrow Ca/P values for each group at baseline, on demineralisation
rectangular windows (occlusal 1/3 and gingival and remineralistion.
1/3) of approximately 1mm size, on the intact
In Grouop I and II (permanent teeth) mean remineralization
buccal surface. The teeth were then immersed in
change is 0.105 ± 0.0512 and 0.088 ± 0.0330 respectively.
demineralizing solution (10ml per tooth) for 96hrs.
Visual examination was performed to confirm the In Group III and IV (primary teeth) mean remineralization
presence of artificial caries lesions. change is 0.214 ± 0.0232 and 0.170 ± 0.0290 respectively.
In Group II the mean baseline value was 1.931
After the de-mineralization was observed,
from which it was demineralised to mean value of
gingival window of each tooth is closed with nail
1.637 and was remineralised to mean value of
varnish which serves as a de-mineralisation
1.725 a mean remineralization change of 0.088
control, leaving the occlusal window for topical
0.0330 (Table I)..
application of the remineralization agent.
In Group III the mean baseline value was
DEMINERALISING AND REMINERALISING 1.835 from which it was demineralised to mean
SOLUTION value of 1.462 and was remineralised to mean
value of 1.676, with a mean remineralization
The buffered demineralizing and
change of 0.214 0.0232 (Table I)..
remineralizing solution was made of
analytical-grade chemicals in department of In Group IV the mean baseline value was
biochemistry, Ragas Dental College. It was similar 1.852 from which it was demineralised to mean
to that utilized by ten cate and duijsters4 value of 1.453 and was remineralised to mean
value of 1.623, with a mean remineralization
EVALUATION TECHNIQUES change of 0.170 0.0290 (Table I).
Before evaluation nail varnish was completely When the mean Ca/P values were compared
removed from the tooth with the help of Acetone. in between the REMINERALISING PASTES
Remineralization potential was evaluated (GROUP I and GROUP II) in PERMANENT
qualitatively (SEM) and quantitatively (EDAX)5. TEETH, CPP-ACP paste showed better effect on
permanent teeth (Group I- 0.105 0.0512) compared
RESULTS to TCP (Group II- 0.088 0.0330), but difference
was not statistically significant. (p = 0.389 ) (Table
Energy dispersive X-ray analysis showed that
II).
the mean Ca/P ratios of samples (Table I). In
Group I the mean baseline value was 1.925 from When the mean Ca/P values wer e compar ed
which it was demineralised to mean value of 1.654 in between the REMINERALISING PASTES
and was remineralised to mean value of 1.759, (GROUP III and GROUP IV) in PRIMARY
with a mean remineralization change of 0.105 TEETH CPP-ACP paste showed better effect on
0.0512. permanent teeth (Group III- 0.214 0.0232)
1119
compared to TCP (Group IV- 0.170 0.0290), this ionomer cement9 and application of remineralizing
change was statistically significant.(p = 0.001 ) materials like casein phosphopeptides amorphous
calcium phosphate (GC TOOTH MOUSSE10, and
Table 2. Comparison of remineralization potential of two pastes
among study groups several other calcium compounds in dentifrices and
a very recently introduced remineralization
Teeth Permanent Primary material Tri calcium phosphate with 0.21% w/w
Agent (Mean = S.D) (Mean + S.D) Sodium Fluoride (CLINPRO TOOTH CRÈME).
CPP-ACP 0.105 0.214 Requirements of an ideal remineralization
(G.C Tooth Mousee) material include: diffuses into the subsurface, or
TCP (Clinpro) 0.088 0.170 delivers calcium and phosphate into the subsurface,
I (Vs) II II (Vs) IV does not deliver an excess of calcium, does not
(P = 0.389) (P = 0.001) favour calculus formation, works at an acidic pH,
Works in xerostomic patients and Boosts the
Tale 2: shown the comparison of the remineralising pastes remineralizing properties of saliva. The currently
CPP-ACP (G.CTOOTH MOUSEE) AND TCP (CLINPRO). available remineraralizing materials which meet
When the ean Ca/P values were compaed in between the this criteria are GC Tooth mousse and Clinpro.GC
Remineralising pastes (Group I and Group II) in permanent Tooth mousse is water based, lactose free cream
teeth there was higher remineralisation in case of group I containing casein phosphopeptide and amorphous
(CPP-ACP G.C Tooth Mousse) but this change was not calcium phosphate (CPP-ACP) 12. When CPP-ACP
statistically significant. (P = 0.389) is applied in the oral environment, it will bind to
When the mean Ca/P values were compaed in between the biofilms, plaque, bacteria, hydroxyapatite and soft
remineralising pastes (Group III) and Group IV) in primary tissue localizing bio-available calcium and
teeth there was higher remineralisation in case of Group III phosphate. Clinpro Tooth Crème with 0.21%
(CPP-ACP G.C. Tooth Mousse) this change was statistically w/w Sodium Fluoride Anti-Cavity Paste is a white
significant. (P = 0.001) creme that contains 950 ppm fluoride 13. This
contains a fluoride compatible functionalized
DISCUSSION calcium phosphate ingredient and imparts superior
White spot lesions can be intervened by remineralization at both the enamel surface and
application of preventive strategies like fluoride within the subsurface lesion. The evidence base for
application7, use of xylitol chewing gums8, Glass TCP with 0.21% w/w Sodium Fluoride
Fig. 1. Human Permanent Teeth
Fig. 2. Human Primary Teeth
1120
Fig. 3a. Remineralizing agents and Nail varnish Fig. 3b. Demineralizing and remineralizing solution
(CLINPRO-functionalized tri-calcium phosphate) The photomicr ogr aphs of sound enamel

is limited to laboratory studies and human in situ sur face pr ior to deminer alization pr ocedur e in all
and clinical trial data to support their use in gr oups appear ed to be r elatively smooth and it is
inadequate. Hence it requires sufficient research to char acter ized by a faint, r ipple-like imbr ication
validate its effectiveness. lines.
In view of the above considerations, the The deminer alised enamel sur face in all
present in-vitro study aimed to investigate the gr oups r esembled honeycombed patter n and
remineralization potential of topical application of tr ansitional stages of sur face br eakdown fr om pit
CPP-ACP (GC Tooth Mousse) and TCP with to por osity was seen as deminer alization
0.21% w/w Sodium Fluoride (Clinpro Tooth pr ogr essed.
Crème) on artificially induced sub surface lesions The photomicr ogr aphs taken after
in human primary and permanent teeth. r eminer alisation of enamel sur faceappear ed almost
Twenty human permanent and twenty human the same as the photomicr ogr aphs of sound enamel
primary teeth were collected. All the teeth were and wer e char acter ized by faint, r ipple-like
coated with an acid resistant nail varnish (Revlon, configur ations.
USA) leaving two narrow rectangular windows Data wer e pr esented as means and standar d
(occlusal 1/3 and gingival 1/3) of approximately deviation values. ANOVA Analysis was used to
1mm size, on the intact buccal surface. Teeth were compar e between means of the gr oups. Post-hoc
immersed in demineralizing solution for 96 hrs to test was used to deter mine significant differ ences
create artificial sub-surface caries lesions. After between the means.
demineralization the gingival window on each
teeth was closed with nail varnish which serves as The effect of r eminer alizing agents was
a demineralization control. evaluated fr om the EDAX Calcium and
Phosphor ous values. They wer e conver ted into
The samples from permanent teeth (n = 20) Ca/P r atio of study gr oups. The incr ease in the
wer e then r andomly assigned to two gr oups I Ca/P r atio obser ved in the par tially r eminer alized
(CPP-ACP Paste) and II (TCP Clinpr o Paste) and lesions is consistent with the deposited miner al
pr imar y teeth (n = 20) wer e then r andomly being the ther modynamically most stable for m,
assigned to two gr oups III (CPP-ACP Paste) and hydr oxyapatite. The pr esent study findings wer e
IV (TCP Clinpr o Paste) based on the tr eatment similar to that seen by REYNOLDS E.C
agents applied as per manufactur er ’s (1997)14(1.63 with CPP-ACP). MithraNHegde
r ecommendation. 200715 (with mean Ca/P values 1.770)
The mean remineralization change 0.105
Scanning electr on micr oscope was used to 0.0512 (Group I), 0.088 0.0330 (Group II), 0.214
analyse the r eminer alization changes qualitatively. 0.0232 (Group III), 0.170 0.0290 (Group IV).
The specimens wer e analyzed and
photomicr ogr aphs of the enamel sur face wer e The results of present study showed
taken at 1500 X magnification. remineralization change with CPP-ACP in
1121
Fig. 1. Scanning Electron Microscopic images

Group - I CPP - ACP (Permanent Teeth)
Baseline Demineralization Remineralization
Fig. 2 Scanning Electron Microscopic Images

Group - II TCP (Permanent Teeth)

Group - III CPP - ACP (Primary Teeth)

Group - IV TCP (Primary)
1122
permanent teeth (0.105) was better than the On comparison of remineralization effect of
findings of REYNOLDS E.C 1997 (0.08)14 and two pastes in permanent teeth (shown in Table VI)
lesser than Mithra N Hegde 2007 (0.21)15. CPP-ACP (Group I) 0.105 ± 0.0512 showed better
effect than TCP with 0.21% w/w Sodium Fluoride
The present study showed a mean
(Group II) 0.088 0.0330, which was not
remineralization change for TCP was 0.088 in
statistically significant(P = 0.389 ).
Permanent teeth similar results were obtained by
Karlinsey L Robert 200913 . Similar r esults wer e obtained in the study done
The present study showed a mean by VLN Kumar , 200812 and BADR Y SHERINE
remineralization change with CPP-ACP 0.214 in 2010 3.
Primary teeth, which were similar to the study CPP-ACP (Group III) 0.214 ± 0.0232 showed
done by BADR Y SHERINE 20103. better effect than TCP with 0.21% w/w Sodium
On comparison of remineralization effect of Fluoride (Group IV) 0.170 ± 0.0290 in Primary
two pastes in permanent teeth (shown in Table VI) teeth which was statistically significant
CPP-ACP (Group I) 0.105 0.0512 showed better (P = 0.001 ).
effect than TCP with 0.21% w/w Sodium Fluoride
(Group II) 0.088 0.0330, which was not CONCLUSION
statistically significant (P = 0.389 ).
In the pr esent study CPP-ACP and TCP
Similar results were obtained in the study done showed cer tain amount of r eminer alization
by VLN Kumar, 200816 and BADR Y SHERINE potential on ar tificial car ies – like subsur face
2010 3 CPP-ACP (Group III) 0.214 0.0232 showed lesions in pr imar y and per manent teeth. The
better effect than TCP with 0.21% w/w Sodium r eminer alizing efficacy of CPP-ACP was better
Fluoride (Group IV) 0.170 0.0290 in Primary teeth compar ed to TCP with 0.21% w/w Sodium
which was statistically significant (P = 0.001 ). Fluor ide but the effect was mor e significant in
pr imar y teeth (P = 0.001 ) and non-significant in
The results of our study showed that both the
per manent teeth (P=0.389). Since it is an in vitro
remineralizing agents were able to remineralize
model used with small sample size, the results
sub surface artificial caries like lesions both in should be substantiated by longitudinal caries
primary and permanent teeth, but the effect was incidence studies and in situ studies Different
more significant in primary teeth. Comparing results may be expected in an in situ or in vivo
primary and permanent teeth, in primary teeth situation where CPP-ACP can bind to oral bacteria
there was more amount of demineralization seen (Rose RK) 17and be released from oral reservoir
when compared to permanent teeth. This can be (Schupbach P)18.
attributed to the fact that, there is structural
difference between both primary and permanent
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S.G., D. Eakins, Reynolds E.C. Incorporation of 16. Kumar V.L.N, Itthagarun A., King N.M. Effect of
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In-vitro study. Australian Dental Journal. 53:
10. Reynolds E.C. Remineralization of Enamel 34—40;2008
Subsurface lesions by Casein Phosphopeptide -
17. Rose RK. Binding characteristics of Streptococcus
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12. Reynolds E.C, Cai F., Shen P.,Walker J G.D.
Retention in Plaque and Remineralization of Enamel caseinoglycomacropeptide and caseino-
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1124
A Cross-sectional Survey of Quality Assurance in

Endodontic Practice amongst Indian Endodontists
1
Dr. Mohan Gundappa, 2Dr. (Mrs.) Ranjana Mohan, 3Dr. Neeraj Kumar
ABSTRACT
Introduction: Quality assurance guidelines are set to achieve high standards in endodontic practice.
This survey was conducted to assess quality assurance practiced by Indian endodontists.
Methods: A questionnaire was distributed at the National Conference of Endodontists, having following
groups, (i) Professional data; (ii) Diagnostic aids; (iii) Sterilization and isolation methods;
(iv) Instruments and techniques used (v) Irrigants and intracanal medicaments; (vi) Obturating materials
and techniques, (vii) Miscellaneous.
Results: Out of 860 questionnaires distributed, 357 were returned. Group (i) 98.3% were practicing
endodontists, 41.2% females, 58.8% males. 81.5% had more than 5 years of experience. Group (ii) 70.6%
used thermal pulp testing and 72% used paralleling technique for periapical radiograph. Group (iii) 86.2%
used heat for sterilization, 36.1% considered autoclaving and glass bead sterilization. 47.9% preferred rubber
dam for isolation and 45.6% use them routinely. Group (iv) 14.8% considered single sitting endodontics
for single rooted teeth. For working length determination, 47.9% relied on radiographic method and 45.6%
use apex locator routinely. 81% are using both hand and rotary instruments, 93% use Nickel- Titanium
instruments routinely. 66% use crown-down technique to prepare the canals. Group (v) 58.3% use sodium
hypochlorite with < 5% concentration and EDTA as an adjunct. 39.8% considered Calcium hydroxide as
a suitable intra-canal medicament. Group (vi) Majority use Gutta percha and AH plus sealer for obturation
and 45.6% are satisfied with present obturation techniques. Group (vii) Most endodontists believed in
post-endodontic restorations.
Conclusions: 95.2% Indian endodontist have positive attitude and 71.7% of them adhere to quality
assurance guidelines.
Keywords: survey, quality assuarance, root canal treatment.
INTRODUCTION guidelines that practicing endodontists are expected

to adhere and a book on Appropriateness of Care
Today the dental patients all over the world
and Quality Assurance Guidelines was introduced
expect the dentists to deliver a high standard of
(2). Revised guidelines have been formulated by
dentistry and from an endodontist in particular, is
European Society of Endodontology in the recent
no exception. This calls for an endodontist to
years (3). Success or failure of root-canal treatment
achieve quality assurance in diagnosis and
(4,5) depend greatly on the canal debridement,
treatment which is carried out in a logical and
cleaning and shaping and obturation. Although the
consistent manner. The endodontists apart from the
principles and methods set forth by academicians
basic knowledge and skills has to keep pace with
and endodontic societies as how to perform
recent concepts, techniques and instruments that
successful endodontics is available in the dental
have constantly been evolved in the field of
literature, very little information is available
endodontics.
regarding the attitude of endodontist towards these
There is not one single way of performing standards, and on how far the changes in
endodontic treatment and new technologies are endodontic technique have been incorporated into
causing a paradigm shift in the dynamics of daily practice.
endodontic practice. In 1994 European Society of
Epidemiological studies imply that the failure
Endodontology (ESE) set guidelines for the
rate of root canal treatment is distinctly higher for
practicing endodontist (1) and in 1998 American
the teeth treated by general dentist (5,6). In 1996,
Association of Endodontics (AAE) issued
1
Professor and Head, Dept. of Conservative Dentistry and Endodontics, 2Professor and Head, Dept. of Periodontology,
Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh. 3P.G. Student, Dept. of Conservative
Dentistry and Endodontics, Saraswati Dental College, Lucknow, Uttar Pradesh.
1125
Whitten et al conducted national survey of general is a highly evolved branch of dentistry in

dentists and endodontist to know the current trends developed nations, very limited data is available
in endodontic treatment and they found it difficult on endodontists adhering to quality assurance in
to identify the specific changes in routine their endodontic practice. The same is the issue in
endodontic treatment (7). developing countries where endodontists are trying
to keep pace with recent technologies in addition
In 2002, Slaus & Bottenberg (8) carried out a
to delivering quality treatment to their patient. The
survey of endodontic practice amongst Flemish
lack of information on this subject has prompted
dentists and they concluded that many Flemish
to undertake this questionnaire survey to
general practitioners are not following quality
investigate the quality assurance practiced by the
guidelines for endodontic treatment. In another
Indian endodontists.
survey, Chandler and Koshy (9) studied the
radiographic practices of New Zealand dentists Materials and methods
undertaking root canal treatment, and they
concluded that the majority of respondents used Design of the study
radiographs pre-operatively, for working length
A cross-sectional survey of Indian
assessment and post-operatively to assess the final
endodontists was carried out on November 21, 22
root filling.
& 23, 2008 at National Conference of
Al-Omari in 2004 studied the attitudes, Endodontists, Chandigarh, India, on their methods
materials and methods employed in endodontic of treating endodontically involved teeth. A
treatment by general dental practitioners in North questionnaire (based on recent reviews and
Jordon and concluded that clinicians do not guidelines of AAE and ESE) was distributed on
comply with international quality standards nor do the conference venue to all (860) the Indian
use recently introduced techniques. Many dentists endodontists registered by the Indian Endodontic
never take a radiograph for determining the Society (IES). The questionnaire was made up of
working length and never used rubber dam or 7 groups with 46 questions with multiple-choice
intra-canal medicaments (10). and / or with the option for free text (questions).
Only 39 questions were considered which gave
A questionnaire survey for root canal irrigation valid answers. Prior ethical approval was obtained
in dental schools of Japan concluded that for the survey from the competent authority. The
periodical training of new techniques and questions were grouped under seven main topics
evaluation of various methods and equipments for as-
irrigation is required (11).
(i) Professional data: age, sex, experience;
In 2006, Naidoo conducted a survey of
attitudes, materials and techniques used in (ii) Diagnostic aids: vitality tests and
endodontic treatment by South African dentists. He radiographs;
concluded that South African dentists do adhere to
most international and current standards; but he (iii) Sterilization and isolation methods;
felt the need for developing quality assurance (iv) Instruments and techniques used in
guidelines for endodontic treatment in South root-canal preparation;
Africa and other developing countries (12).
(v) Irrigants and intracanal medicaments;
Recently, Bird et al (13) conducted a survey
on the contemporary usage of rotary instruments (vi) Obturating materials and techniques;
by active members of the American Association
of endodontists. They found that differences exists (vii) Miscellaneous: antibiotics, emergency
among the endodontists regarding the use of procedures, retreatment, complications, attitude etc;
current Ni-Ti instruments which might be
co-related to level of exposure and training. The completed questionnaire was collected
from the venue on the following day of the
Thus it is observed that various studies on conference. The collected data was computed and
quality of the endodontic treatment rendered by the each response was subjected to statistical analysis
general dentists have been conducted but limited by using Gaussain test which compared the highest
data is available on the endodontists following the response with the second best. The P - value was
quality assurance guidelines. Though endodontics set at 0.05.
1126
RESULTS endodontists while 10% was treated by 77.3%

of endodontists.
Out of 860 questionnaires distributed, 357
were duly returned, representing a 41.5% response • For working length determination, 47.9%
rate. For the ease of interpretations, in few of the relied on radiographic method and 45.6% used
questions, the responses were clubbed together apex locator routinely.
(shaded and underlined rows in tables). • About 81% endodontists are using both hand
Group (i) Professional data: age, sex, experience; and rotary instruments for preparation of root
(see Table 1). canal.
• For shaping of the canals 65.5% endodontits
• Out of 357 respondents 98.6% were practicing
used crown-down technique and 27.2% used
only endodontics,
step-back technique (P = 0).
• 40.9% endodontists were in the age group of
• 93% used Nickel- Titanium instruments
31-40 years and 25.5% in the age group of
routinely (P = 0).
41-50 years.
• 41.2% were females and 58.8% were males. • While being asked about the choice of rotary
systems, 49.6% of operators used Protaper
• 81.5% had more than 5 years of experience (Dentsply, USA) (P = 0.001) followed by
whereas 31.8% were having 11 – 15 years of 33.9% used Profile (Dentsply, USA), 8.7%
experience (P = 0.005). used RaCe (Brasseler, USA), 4.5% used K3
• 85.4% were involved in endodontic practice (Sybron Endo, USA) and 2.8% used HERO
with or without academic activity. (Micro Mega, France).
Group (ii) Diagnostic aids: vitality tests and Group (v) Irrigants and intracanal medicaments;
radiographs; (see Table 2). (see Table 5).
• 70.6% endodontists rely on thermal test for • About 58.5% of endodontists used Sodium
diagnosing pulp vitality and 72% used hypochlorite as an irrigant and 78.1% believed
paralleling technique for taking periapical in using various combinations of irrigants (P
radiograph. = 0.001). Only 3.4% still used hydrogen
Group (iii) Sterilization and isolation methods; peroxide. 58.3% endodontists use sodium
(see Table 3). hypochlorite with less than 5% concentration;
in fact 45.6% used less than 0.5% (P = 0.007)
• Although 86.2% of endodontist used various and 89.3% used Ethylene diamine tetra acitic
methods of sterilization by heat, 63% used acid (EDTA) as an adjunct.
steam under pressure (auotoclave) out of
• 39.8% considered Calcium hydroxide as a
which 36.1% (P = 0.007) considered
suitable intra-canal medicament followed by
standardized procedure of autoclaving and
camphorated paramonochlorphenol (CMCP)
chair-side glass bead sterilization.
used by 32.8% of endodontists.
• While isolating the teeth, about 47.9% are
Group (vi) Obturating materials and techniques,
preferring rubber dam to other isolating
(see Table 6).
methods and 45.6% use them routinely (P =
0.001). • Gutta percha was the choice of 99.4% of the
Group (iv) Instruments and techniques used in endodontist as the obturating material
root-canal preparation, (see Table 4). • 73.4% endodontists used lateral condensation
• Single sitting endodontics was considered by technique
14.8% for single rooted teeth and by 3.9% for • 45.6% of endodontists preferred AH plus
multi-rooted teeth. About 45.4% of (Dentsply DeTrey, USA) as a sealer.
endodontists were comfortable with TWO
sitting endodontics (P = 0.03) for single rooted Group (vii) Miscellaneous: antibiotics, emergency
teeth. In case of multirooted teeth THREE procedures, retreatment, complications, attitude etc.
sitting protocol was preferred by 37.5%. (see Table 7).
• 20% occurrence of FOURTH canal in • 51% of endodontists did not believe
maxillary 1st Molar was treated by 8.1% of prescribing antibiotic during endodontic
1127
Table 1 – Professional data: age, sex, experience Radiographic Technique

Short cone 12 3.4
Main Professional
Frequency Percentage P Value Long cone 35 9.8
Activity
Parallel technique 257 72.0 0
Endodontics 352 98.6
Non- standardized 0 0
General Dentistry 04 1.1 0
Missing 53 14.8
Other 01 0.3
Table 3 - Sterilization and isolation methods
Gender Frequency Percentage P Value Sterilization Method Frequency Percentage P Value

Female 147 41.2 Glass bead sterilizer 28 7.8
Male 210 58.8 0.001 Hot air oven 31 8.7
Cold sterilization 33 9.2
Age of practitioner Frequency Percentage P Value
Steam sterilizer 24 6.7 0.007548
25 – 30 years 55 15.4 Autoclave 96 26.9
31 – 40 years 146 40.9 0.001 Glass bead sterilizer 129 36.1
41 – 50 years 91 25.5 + Autoclave
> 50 years 59 16.5 Missing 16 4.5
Missing 06 1.7
Methods of Isolation Frequency Percentage P Value
Years of None 0 0
Frequency Percentage P Value
professional Activity
Rubber dam 171 47.9
0 – 5 years 63 17.6
Cotton rolls only 8 2.2
6 – 10 years 79 22.1
High volume suction 24 6.8
11 – 15 years 112 31.8 0.005027 only 0
16 – 20 years 65 18.2 Cotton rolls & High 45 12.6
> 20 years 32 8.9 volume suction
Missing 06 1.7 Other 0 0

Missing 109 30.5
Working Situation Frequency Percentage P Value
Reply Frequency Percentage P Value
Full time 161 45.1
Sometimes 109 30.5
Part time 22 6.7 (occasionally)
Academic activity 34 9.5 0.011495 Always (for all patients) 163 45.6 0.001
Academic activity 128 33.6 Never 0 0
with part time Missing 85 23.8
Missing 12 3.4
treatment and 36.1% felt the need of antibiotic
cover during the treatment.
Table 2 - Diagnostic aids: vitality tests and radiographs
• 53.5% of endodontists experienced 5-10% (P
Pulp Vitality Test = 0.001) of flare-ups as compared to 33.8%
Method who experienced less than 5%.
Thermal pulp testing 252 70.6 • Less than 5% of complications were
encountered in anterior teeth by 69.7% of
Electric pulp testing 46 12.9
endodontists and less than 10% in posterior
0
Test Cavity 2 0.6 teeth by 48.2%.
Anesthetic test 9 2.5 • 88.8% of endodontists felt confident to
undertake endodontic retreatment and their
Missing 48 13.4
1128
Table 4 - Instruments and techniques used in root-canal preparation
Number of sessions Single Rooted Teeth Multi Rooted Teeth

Frequency % P Value Frequency % P Value
1 53 14.8 14 3.9
2 162 45.4 80 22.4
3 135 37.8 134 37.5
0.039771 Not Significant
4 05 1.4 112 31.3
> 4 appointments – – 12 3.4
Missing 02 0.6 05 1.4
% of MB2 Canal Use of Ni-Ti

Frequency Percentage P Value Frequency Percentage P Value
Obturation Instruments
0% 0 0 Yes 332 93
1 – 10 276 77.3 No 0 0
0
11 – 20% 29 8.1 Occasionally 21 5.9
0
21 – 40% 4 1.1 Missing 04 1.1
> 40% 0 0
Choice of Rotary
Missing 48 13.4 Frequency Percentage P Value
System
Choice of Protaper 177 49.6
Measuring Working Frequency Percentage P Value Profile 121 33.9
Length
RaCe 31 8.7 0.001
Tactile stop 14 3.9
K3 16 4.5
Radiographic apex 171 47.9
Not HERO 10 2.8
Apex locator 163 45.6 Significant Missing 02 0.6
Non standardized 0 0
Missing 9 2.5 Table 5 - Irrigants and intracanal medicaments
Choice of Root Type Choosen Frequency Percentage P Value

Canal Instrument Frequency Percentage P Value Distilled water 0 0
System
Normal saline 97 27.2
Hand instruments 13 3.6
only Hydrogen peroxide 12 3.4
Chlorhexidine 06 1.7 0.001
Engine driven 49 13.7
(Rotary) Instruments 0 NaOCl 209 58.5
Both hand and 289 81.0 Metronidazole 22 6.2
rotary
Combinations 279 78.1
Missing 06 1.7
Concentration of
Choice of Frequency Percentage P Value
NaOCl used
Preparation Frequency Percentage P Value
Technique 0.5% 163 45.6
Conventional 1% 17 4.8
0 0 2% 22 6.2
(Push-pull)
Step- back 97 27.2 3% 06 1.7 0.007384
0
Crown- down 234 65.5 5% 128 35.8
Non standardized 0 0 Other 0 0
Missing 26 7.3 Unknown 0 0
Missing 21 5.9
1129
Use of EDTA Frequency Percentage P Value Flare-up Frequency Percentage P Value

Yes 319 89.3 < 5% 121 33.8
No 23 6.4 0 6 – 10% 190 53.5
Missing 15 4.2 11 – 15% 31 8.68 0.001
16 – 20% 07 1.9
Use of
Missing 08 2.2
Intra-canal Frequency Percentage P Value
Medication
% of
Pulperyl 24 6.8 Complications
CMCP 117 32.8 Reported in
Anterior Teeth
Ca(OH) 2
142 39.8
Not < 5% 249 69.7
Formacresol 04 1.1
Significant 0 – 10% 87 24.4
Other 41 11.5
(Metronidazole) 11 – 20% 8 2.2
21 – 30% 0 0 0
None 0 0
31 – 40% 0 0
Missing 29 8.1
> 40% 0 0
Table 6 - Obturating materials and techniques Missing 13 3.6
Obturation % of
Material Complications
Reported in
Gutta-percha 355 99.4
Posterior Teeth
Cement only 0 0
0 < 10% 172 48.2
Silver poinys 02 0.6
11 – 20% 129 36.1
Other 0 0
21 – 30% 23 6.4
31 – 40% 2 0.6 0.001026
Technique Frequency Percentage P Value
40 – 50% 0 0
Lateral condensation 262 73.4
> 50% 0 0
Vertical condensation 03 0.9
Missing 31 8.7
Thermo-mechanical 01 0.3
compaction 0 Performing
Thermafill 84 23.5 Re-treatments
Other 06 1.7 Yes 317 88.8
Missing 01 0.3 No 06 1.7 0
Missing 34 9.5
Type of Sealer Frequency Percentage P Value
Zincoxide-eugenol 19 5.3 Percentage of
Re-treatments
Endomethasone 71 19.9
AH26 92 25.8 1 – 10% 335 93.9
0.0001 11 – 20% 12 3.4
AH+ 163 45.6
21 – 40% 0 0 0
Other 04 1.1
> 40% 0 0
Missing 08 2.2 Missing 10 2.8
Table 7 - Miscellaneous: antibiotics, emergency procedures,
Follow-up Period Frequency Percentage P Value
retreatment, complications, attitude etc:
One month 211 59.1
Antibiotics Six months 19 5.3 0.001
Prescribed One year 4 1.1
Yes 129 36.1 > one year 01 0.3
No 182 51.0 0.001 Missing 122 34.2
Missing 46 12.9
1130
Period for Coronal DISCUSSION

Restoration after Frequency Percentage P Value
RCT This survey has collected information from a
cross-section of Indian endodontists assembled for
< One week 201 56.3
the National conference at Chandigarh, India. In
One – two week 135 37.8 the endodontic literature, very few surveys have
Two – four weeks 15 4.2 0.001 been undertaken to study the quality assurance
> Four weeks 0 0 practiced by the endodontists. There are a variety
Missing 06 1.7
of methods of collecting data for questionnaire
survey and often they are weakened by poor
Satisfaction Level response. But in this survey, as all the Indian
with Present endodontists had gathered at one place, an
Frequency Percentage P Value impressive response rate of 41.5%, was obtained
Preparation &
Obturation Techniques within a short period of three days, which is
comparable to survey conducted by Council of the
Totally not 21 5.8
British Endodontic Society amongst general dental
Subject to improvement 127 35.6 practitioners (GDPs) in England with response rate
Satisfied 166 46.5 0.00283 of 32%14 and Jenkins et al who obtained a
Very Satisfied 34 9.5 response rate of 41% from one dental school (15).
Missing 09 2.5
Majority (98.3%) of the Indian endodontists
with or without academic involvement, have been
Overall
Frequency Percentage P Value found to be adhering to specialized endodontic
Attitude
practice. Female to male ratio was found to be
Negative 0 0 1:1.43. On an average an Indian endodontist
Indifferent 0 0 completes his/her training by the age of 26 years.
0
Positive 340 95.2 While analyzing the relationship between age and
the years of professional activity, it appears that
Missing 17 4.7
age of the practitioners commensurate with the
years of experience. About 66.4% of endodontists
endodontic practice consisted of about 10% of were having average experience of 12 years.
retreatment cases. Working situation of 96.6% of endodontists
• Monitoring of endodontically treated cases was demonstrated their involvement in the academic
done radiographically by 59.1% of activity which has an influence on the quality
endodontists with follow-up period of only one assurance practiced in endodontic treatment.
month.
When use of diagnostic tests were considered,
• 56.3% of the endodontist believed in restoring it was found that Indian endodontists believed in
the tooth within one week and 37.8% within reliabilty of thermal test for diagnosing pulpal
two weeks (P = 0.001). status as heat or cold test performed judiciously
• 46.5% of endodontists are satisfied with does not jeopardize the health of the pulp (16) and
present preparation and obturation techniques paralleling technique was the preferred method of
(P = 0.002). 35.6% felt the need of further taking periapical radiographs (17).
improvement in the present preparation and
obturation techniques. Autoclaving which conforms to the guidelines
of quality assurance (3) was considered to be an
• 95.2% of Indian endodontists have positive
ideal sterilization method by 63% of Indian
attitude towards delivering a quality
endodontists.
endodontic treatment to their patients.
Overall results indicate that 71.7% of the In 1994 Christensen (18) in his study
responses follow the quality assurance guidelines mentioned about the practitioners equating use of
laid down by AAE and ESE. rubber dam with time loss, patient pain, extra cost,
frustration and irritation. However, the data related
to the methods of isolation reveals that 45.6% of
the Indian endodontists always use rubber dam
followed by 30.5% who use it occasionally. This
1131
reflects the acceptance and adherence to quality technique are the most popular obturating methods.
assurance in a developing country. Recently, AH plus which has least solubility
amongst other sealers (23) has been accepted in
Indian endodontists show lesser inclination of
India as one of root canal sealers as compared to
performing single sitting RCT which is evident by
AH 26.
the lower percentage response of 14.8% and 3.9%
for single and multi-rooted teeth respectively. Antibiotics are being used more judiciously in
Conventional trend of three-sitting protocol for non-surgical endodontic procedures. Fewer
multi-rooted teeth and two sitting protocol for flare-ups, timely delivered post-endodontic
single rooted was preferred by most of restorations and periodic follow ups by the Indian
endodontist. This tendency also reveals that the endodontists shows the growing trend to achieve
Indian endodontists prefer to be cautious about the quality assurance. The confidence to undertake
adapting the latest trend of single sitting endodontic retreatment, interest in monitoring
endodontics. endodontically treated cases radiographically and
knowing the importance of restoring the tooth
With the improvements in apex locators and within a week or two, is a confirmatory sign that
their accuracy in the wet canals (19) the 45.6% of 95.2% of Indian endodontists have positive attitude
Indian endodontists are switching over to the towards delivering a quality endodontic treatment
non-invasive apex locators for working length to their patients. The 71.7% of the responses also
determination instead of radiographic method. corroborate with evidence that Indian endodontists
Majority of Indian endodontists are using both are doing their level best to adhere to the quality
hand and rotary instruments for preparation of root assurance guidelines laid down by AAE and ESE.
canals and they have adapted Nickel- Titanium Peciuliene et al (24) published a review on the
instruments in their routine practice which also attitudes of general dental practitioners towards
indicates their attitude towards constant endodontic standards and adoption of new
modernization. This has lead to their preference of technology and stressed the importance of
crown-down technique (20) as compared to the establishing higher specialist training or continuing
conventional. With the choice of several rotary dental education for practitioners to update their
systems available to them, the Indian endodontists knowledge. On the contrary the Indian scenario
prefer Protaper (Dentsply) system as it is one of demonstrates that Indian endodontists are actively
the simplest and easiest system to master. With the involved in teaching in dental schools; hence they
availability of reasonably priced dental operating are able to constantly update their knowledge,
microscopes, there is also a paradigm shift in adapt easily to the newer technology and thereby
location and obturation of fourth canal of increasing the endodontic standards by adhering
maxillary first molar. the quality assurance guidelines.
Many clinicians prefer dilute concentrations of
sodium hypochlorite to reduce its toxic effect (21). CONCLUSION
In the Flemish GDP survey (8) it was found that
28% of them used a concentration of 2% Sodium This cross sectional survey has revealed that
hypochlorite due to limited use of rubber dam, the Indian endodontists have a positive attitude
whereas 44.7% of Indian endodontists used > 2% towards delivering a quality treatment to their
of Sodium hypochlorite and 45.6% used rubber patients. This has led to their acceptance of latest
dam routinely irrespective of concentration of advancements in endodontics resulting in achieving
Sodium hypochlorite. At the same time, 45.6% of the goal of quality assurance in endodontics.
endodontists also have understood the efficacy of Endodontic procedure is no longer considered to
0.5% of sodium hypochlorite. About 89.3% of be a tedious procedure by the endodontists and a
endodontists find EDTA as the integral part of comprehensive survey is required to understand the
rotary endodontics. patient’s attitude.
Considering its advantages, Calcium hydroxide

(22) is considered to be suitable intracanal REFERENCES
medicaments by the Indian endodontists. However, 1. European Society of Endodontology. Consensus
CMCP (Otto Walkoff) is still one of the popular report of the European Society of Endodontology on
intracanal medicaments. Gutta-percha as quality guidelines for endodontic treatment. Int Endod
standardized cones and lateral condensation J, 1994;27:115-24.
1132
2. American Association of Endodontics. 13. Bird DC, Chambers D, Peters OA. Usage Parameters
Appropriateness of care and quality assurance of Nickel-Titanium Rotary Instruments: A Survey of
guidelines. 3rd ed. Chicago, IL:AAE; 1998. Endodontists in the United States. J Endod
3. European Society of Endodontology. Quality 2009;35(9):1193-1197.
guidelines for endodontic treatment: consensus report 14. Pitt Ford TR, Stock CJR, Loxley HC, Watson RMG.
of the European Society of Endodontology. Int Endod A survey of endodontics in general practice in
J, 2006; 39: 921-930. England. Brit Dent J 1983; 222-4.
4. Sjogren U, Hagglund B, Sundqvist G, Wing K. 15. Jenkins SM, Hayes SJ, Dummer PM. A study of
Factors affecting the long-term results of endodontic endodontic treatment carried out in dental practice
treatment. J Endod 1990;10: 498-503. within the UK. Int Endod J 2001;34:16-22.
5. Weiger R, Axmann-Kremar D, Lost C. Prognosis of
16. Rickoff B, Trowbridge H, Baker J, Fuss Z, Bender
conventional root canal treatment reconsidered. Endod
I. Effects of thermal vitality tests on human dental
Dent Traumatol 1998; 14:1-9.
pulp. J Endod 1988;14:10:482-485.
6. Eriksen HM, Endodontology - epidemiologic
considerations. Endod Dent Traumatol 1991; 17. Ingle JI, Bakland LK, Baumgartner JC. Ingle’s
7:189-95. Endodontics. 6th edition, BC Decker Inc. 2008.
7. Whitten BH, Gardiner DL, Jeansonne BG, Lemon 18. Christensen GJ. Using rubber dams to boost quality,
RR. Current trends in endodontic treatment: report of quantity of restorative services. J Am Dent Assoc
a national survey. J Am Dent Assoc 1994;125:81-2.
11996;27:1333-41. 19. Jenkins JA, Walker WA, III, Schindler WG, Flores
8. Slaus G, Bottenberg P. A survey of endodontic CM. An in-vitro evaluation of the accuracy of the
practice amongst Flemish dentists. Int Endod J root ZX in the presence of various irrigants. J Endod
2002;35:759-767. 2001; 27:209-11.
9. Chandler NP, Koshy S. Radiographic practices of 20. Morgan LF, Montgomery S. An evaluation of the
dentists undertaking endodontics in New Zealand. crown-down pressureless technique. J Endod
Dentomaxillofac Radiol 2002;31: 317- 321. 1984;10:491.
10. Wael M Al- Omari. Survey of attitudes, materials and 21. Becker GL, Cohen S, Borer R. The sequelae of
methods employed in endodontic treatment by general accidentally injecting sodium hypochlorite beyond the
dental practitioners in North Jordan, BMC Oral root apex. Oral Surgery 1974;38,633-5.
Health 2004;4:1.
22. Trope M, Delano EO, Orstavik D. Endodontic
11. Noriyasu H, Kentaro S, Takashi A, Fumiaki I, Gota treatment of teeth with apical periodontitis: Single vs.
T, Takashi A. A survey on root canal irrigation multivisit treatment. J Endod 1999;25:345.
during endodontic treatment in Japanese dental
schools. Tsurumi Uni Dent J 2005; 31:2:119-125. 23. Schafer E, Zandbiglari T. Solubility of root canal
sealers in water and artificial saliva. Int Endod J
12. Naidoo LM. A survey of attitudes, materials and
2003;36(10):660.
techniques used in endodontic treatment By South
African dentists. A research report submitted to the 24. Peciuliene V, Maneliene R, Drukteinis S, Rimkuviene
School of Oral Health Science, University of the J. Attitudes of general dental practitioners towards
Witwatersrand, Johannesburg, in partial fulfilment for endodontic standarts and adoption of new technology:
the degree Master of Science in Dentistry Literature review. Stomatologija, Baltic Dent
Johannesburg, 2006. Maxillofacial J 2009;11:11-14.
1133
Maxillary Necrosis by Rhino-maxillo Cerebral

Mucormycosis. A rare Case Report and Literature Review
Dr.(Capt).S.Manoj Kumar1, Dr. P.E. Chandra Mouli2, Dr. B. Anand3, Dr.P.D.Madan Kumar4,
Dr. S. Shanmugam5
ABSTRACT
The maxilla rarely undergoes necrosis due to its rich vascularity. Maxillary necrosis can occur due to
bacterial infections such as osteomyelitis, viral infections such as herpes zoster or fungal infections such
as mucormycosis, aspergillosis etc. Mucormycosis is an opportunistic fulminant fungal infection, which
mainly infects immunocompromised patients. The infection begins in the nose and paranasal sinuses due
to inhalation of fungal spores. The infection can spread to orbital and intracranial structures either by direct
invasion or through the blood vessels. The fungus invades the arteries leading to thrombosis that
subsequently causes necrosis of hard and soft tissues. We report a case of maxillary necrosis by
mucormycosis in an uncontrolled diabetic patient to emphasize early diagnosis of this potentially fatal
fungal infection. We briefly discuss different diseases which can lead to maxillary necrosis and review the
current concepts in management of mucormycosis. Early diagnosis and prompt treatment can reduce the
mortality and morbidity of this lethal fungal infection.
Key words: Maxillary bone necrosis, mucormycosis, uncontrolled diabetes.
INTRODUCTION Palate and fauces:
Mucormycosis is one of the most rapidly Hard palate: There is a palatal perforation
progressing and lethal form of fungal infection in bilaterally connecting the oral and antral cavity,
humans which usually begins in the nose and bilateral oro-antral fistula. There is also yellow
paranasal sinuses (1). This fungus invades the necrotic alveolar bone.
arteries, forms thrombi within the blood vessels Soft palate: Colour, texture, movements are
that reduce blood supply and cause necrosis of normal.
hard and soft tissues (1,2). Once entered into the
arteries, the fungus can spread to orbital and Uvula: normal.
intracranial structures (3,4). Usually mucormycosis
Fauces: Pillar and tonsils are normal.
presents as an acute infection and manifests as
rhinocerebral, pulmonary, gastrointestinal,
cutaneous or disseminated form (1). In the case INTRA ORAL LESION:
presented here the infection followed a chronic Inspection: Hard palate: There is a palatal
course, and somewhat indolent form which perforation bilaterally connecting the oral and
eventually caused maxillary necrosis. antral cavity, bilateral oro-antral fistula. There is
also yellow necrotic alveolar bone.
CASE REPORT Palpation: the necrotic bone was hard on
palpation.
Patient named Murugan 55/M came to O.P
with a chief complaint of hole in upper jaw for A D/D of syphilitic gumma and mid line lethal
past 10 months for which he needed a denture. granuloma was given and provisional diagnosis of
HOPI revealed spontaneous exfoliation of teeth for mucormycosis was given.
past 10 months, nasal regurgitation for past 2
Under GA in conjunction with ENT dept, the
months and bleeding from nose for past 2 months.
necrotic alveolar bone was resected and the patient
He noticed a palatal swelling which slowly
was put under amphotericin B therapy.
progressed to a big cavity connecting the floor of
nasal and antral cavity. Patient is a known diabetic Histopatological examination: The Haemotoxilin
for past 15 years. and Eosin stain shows long branched non-septae
1
Professor, 2, 3Senior Lecturer, 5Professor and Head, Dept. of Oral Medicine and Radiology, 4Reader, Dept. of Preventive
Public Health Dentistry, Ragas Dental College and Hospital, Chennai, Tamilnadu.
1134
maxillary palatal area. The CT image shows a

connection between the oro nasal and the bilateral
oro antral fistula.
In correlation with above clinical featutes,
radiological findings and Histopathological
findings, a final diagnosis of Mucormycosis was
given.
Further the patient was given a maxillofacial

prosthesis and on follow up, the patient died due
Fig. 1. Intra oral photograph showing necrosis of the right to cerebral complications.
maxillary alveolar bone.
DISCUSSION
Opportunistic fungal infections such as

mucormycosis usually occur in
immunocompromised patients but can infect
healthy individuals as well(2-5). The predisposing
factors for mucormycosis are uncontrolled diabetes
(particularly in patients having ketoacidosis),
malignancies such as lymphomas and leukemia’s,
renal failure, organ transplant, long term
corticosteroid and immunosuppressive therapy,
Fig. 2. Occlusal view and CT showing necrosis of bone. cirrhosis, burns, protein energy malnutrition and
AIDS. Our patient had uncontrolled diabetes which
is a well known predisposing factor for
mucormycosis(1-8).
Mucormycosis (Zygomycosis, phycomycosis)

is an acute opportunistic infection caused by a
saprophytic fungus that belongs to the class of
phycomycetes. Although several genera are
associated with this disease, the most common
Fig. 3. Non septate mucormycotic hyphae observed under
forms are Rhizopus, Rhizomucor and Absida.
Grocott’s modified silver methenamine staining technique.
Rhizopus is the predominant pathogen accounting
for 90% of the cases of rhinocerebral
mucormycosis. This microbe may be cultured from
the oral cavity, nasal passages, throat and stool of
healthy patients without clinical signs of infection.
Uncontrolled diabetes mellitus can alter the

normal immunologic response of patients to
infections. Such patients have decreased
granulocyte phagocytic ability with altered
polymorphonuclear leukocyte response. Reports
have suggested that the ability of serum of
immunocompromised patients to inhibit Rhizopus
invitro is reduced, which makes them suitable
Fig. 4. Maxillary prosthesis
hosts to opportunistic fungal infections(8).
hyphae which was further confirmed by a silver
staining. This fungal infection usually originates from
the paranasal sinuses. The fungus invades the
Radiological finding: Occlusal view and sinus
blood vessels and subsequently spreads through
view shows severe bone destruction as evidenced
them. Once fungal hyphae enter into the blood
by irregular radiolucencies in the anterior
stream they can disseminate to other organs such
1135
as cerebrum or lungs which can be fatal for the organs. Therefore, a team of specialists including
patient. a dentist, ophthalmologist, neurosurgeon and
Mucor hyphae form thrombi within the blood maxillofacial surgeon are required for management
vessels that reduce vascularity to the tissues and of such patients.
cause necrosis(2-5,8). Peripheral vascular disease In the early stages of the disease, patients
(due to microangiopathy & atherosclerosis) in exhibit facial cellulites, anesthesia, nasal discharge,
diabetic patients also causes local tissue ischemia necrotic turbinates, fever, headache and lethargy(6).
and increased susceptibility to infections (9) (Table However, in contrast to other reports many of
1). Therefore thrombosis of the internal maxillary these symptoms were absent in this patient. He
artery or descending palatine artery caused by only had nasal congestion and headache. Among
mucormycotic infection(4) as well as chronic the clinical differential diagnosis we can consider
diabetes in this patient had resulted in necrosis of squamous cell carcinoma of maxillary sinus. Such
the maxilla. cases present as chronic ulcers with raised margins
Usually mucormycosis occurs as a pulmonary, causing exposure of underlying bone. A malignant
gastrointestinal, disseminated or rhinocerebral salivary gland tumor arising from the accessory
infection( 6-10). In our patient, infection was only glands of the palate can also be considered in the
localized to the maxilla and it underwent necrosis differential diagnosis. Other features seen in cases
without any other symptoms. Disseminated of antral carcinoma are local pain, swelling,
involvement of mucormycosis is observed in epistaxis, nasal discharge, epiphora, diplopia or
diabetics with ketoacidosis, which favors rapid numbness.
proliferation of fungus and its invasion into the In this patient there were no symptoms
orbit and cerebrum(6). Mucormycosis is aggressive suggestive of any malignancy. Extranodal NK
and potentially fatal in diabetic patients because of T-cell lymphoma (nasal type angiocentric
impaired host defense mechanism and increased lymphoma or midline lethal granuloma)
availability of micronutrients such as iron(9). The characteristically occurs in midline, affecting the
general health of this patient was good and he did oronasal region. In the initial stages patients may
not developed ketoacidosis which facilitates spread report nasal stuffiness, pain and palatal swelling.
of infection to other organ systems. Therefore, in Later, patients develop progressive areas of
this case the patient had a localized ulceration that can lead to bone necrosis and
rhino-maxillary form of the disease which is a perforation.
subdivision of well documented rhinocerebral Wegener’s granulomatosis is an uncommon
mucormycosis (10,11). However the infection may condition characterized by a necrotizing
spread to involve the cranium, orbit and other granulomatous condition of respiratory tract,
Table 1. Th Pathophysiology of bone necrosis secondary to mucormycotic infection in a diabetic patient
1136
widespread vasculitis and necrotizing In conclusion, an immunocompromised or

glomerulonephritis. immunosuppressed patient having bone necrosis
Common presenting signs and symptoms following tooth extraction should alert a clinician
include sinusitis, rhinorrhea, nasal stuffiness and of possible mucormycotic infection.
epistaxis with or without complain of fever,
CONCLUSIONS
arthralgia and weight loss. Gingiva has a peculiar
erythematous hyperplasia and is termed strawberry Mucormycosis is an aggressive, frequently
gingivitis. There may be destruction of underlying fatal invasive fungal infection that can develop in
palatal and alveolar bone causing oral-antral patients with a number of predisposing conditions.
fistula. Bone necrosis can also occur due to In the susceptible patient, it can be triggered by
extension of infections such as acute necrotizing minor surgical wounds, such as dental extractions.
ulcerative gingivitis (ANUG) from the gingiva to Expeditious diagnosis, systemic amphotericin B
bone. In the case reported here the gingiva was therapy, aggressive surgical debridement and
normal. Recent reports have suggested that jaw optimal medical management are critical for
necrosis can also occur in patients on patient survival.
bisphosphonate therapy(12).
REFERENCES
Our patient did not report any such drug
1. Leitner C, Hoffmann J, Zerfowski M, Reinert S.
intake. There is a close histopathological Mucormycosis: necrotizing soft tissue lesion of the
resemblance between mucormycosis and face. J Oral Maxillofac Surg 2003; 61:1354-8.
aspergillosis. Microscopically, aspergillosis has 2. Pogrel MA, Miller CE. A case of maxillary necrosis.
septate branching hyphae, which can be J Oral Maxillofac Surg 2003; 61:489-93.
distinguished from mucormycotic hyphae by a 3. Zapico ADV, Suarez AR, Encinas PM, Angulo CM,
smaller width and prominent acute angulations of Pozuelo EC. Mucormycosis of the sphenoidal sinus
branching hyphae (9, 10). Moreover, the organism in an otherwise healthy patient. Case report and
produces conidiophores, which were absent in this literature review. J Laryngol Otol 1996; 110:471-3.
case. A definitive diagnosis of mucormycosis can 4. Jones AC, Bentsen TY, Fredman PD. Mucormycosis
be made by tissue biopsy that identifies the of the oral cavity. Oral Surg Oral Med Oral Pathol
characteristic hyphae, by positive culture or both. 1993; 75: 455-60.
Initial culture of diseased tissue may be negative 5. Salisbury PL 3rd, Caloss R Jr, Cruz JM, Powell BL,
and histopathologic examination is essential for Cole R, Kohut RI. Mucormycosis of the mandible
after dental extractions in a patient with acute
early diagnosis (9) In this case, the fungus was myelogenous leukaemia. Oral Surg Oral Med Oral
identified by hematoxylin and eosin stain and Pathol Oral Radiol. Endod 1997; 83:340-4.
confirmed by Grocott’s silver methenamine special 6. Buhl MR, Joseph TP, Snelling BE, Buhl L.
staining technique. Temporofacial zygomycosis in a pregnant woman.
Three principles in the patient management Infection 1992; 20:230-2.
were followed. Firstly, control of diabetes for 7. Napoli JA, Donegan JO. Aspergillosis and necrosis
which the patient was advised insulin therapy and of maxilla: a case report. J Oral Maxillofac Surg
1991; 49: 532-4.
dietary restrictions. Secondly, removal of the
8. Brown OE, Finn R. Mucormycosis of the mandible.
necrotic bone, which acted as a nidus of infection
J Oral Maxillofac Surg 1986; 44:132-6.
and prevents action of systemically, administered
9. Tugsel Z, Sezer B, Akalin T. Facial swelling and
antifungal drugs. In this patient entire necrotic palatal ulceration in a diabetic patient. Oral Surg Oral
bone was removed along with the antral lining and Med Oral Pathol Oral Radiol Endod 2004; 98:630-6.
the area was débrided with Betadine. Lastly, 10. Martin S Greenberg. Ulcerative vesicular and bullous
amphotericin B was administered parenterally as it lesions. In: Greenberg MS, Glick M eds. Burket’s
is the drug of choice in treatment of mucormycotic Oral Medicine Diagnosis and treatment. India:
infection (2,5,10). Blood urea & creatinine levels Elsevier; 2003.p.79.
were monitored. Post-operatively patient was 11. Hazarika P, Ravikumar V, Nayak RG, Rao PS,
advised an obturator to prevent oronasal Shivananda PG. Rhinocerebral mycosis. Ear Nose
regurgitation. Throat J 1984; 63:464-8.
12. Farrugia MC, Summerlin DJ, Krowiak E, Huntley T,
Mucormycosis was long regarded as a fatal Freeman S, Borrowdale R et al. Osteonecrosis of the
infection with poor prognosis. However with early mandible or maxilla associated with the use of new
medical and surgical management survival rates generation bisphosphonates. Laryngoscope 2006;
are now thought to exceed 80% (5). 116:115-20.
1137
A Cross Sectional Study on the Prevalence and

Determinants of Dental Caries among School Children of
Padur
Dr. V. Shivakumar1, Dr. V. Gopinath2, Dr. R. Saravanakumar3, Dr. V. Anitha4, Dr. M. Shanmugam5
ABSTRACT
An epidemiological survey of the prevalence and predictors of dental caries among school children of
Padur, Kanchipuram district, Tamilnadu was conducted. Three schools were randomly selected among all
the schools of Padur. A total of 1205 children in the age group of 4-17 years were included in the study.
Data was gathered through clinical dental examination and a self-administered questionnaire to their parents.
The study revealed an overall prevalence level of 64.22%, with the prevalence being higher among female
school children. Gender, oral hygiene status, sweet consumption, type of brushing, mother’s occupation
and frequency of brushing were significant predictors of dental caries in this population. It was concluded
from the study that dental caries is a highly prevalent disease among the school children of Padur.
BACKGROUND
Dental caries is the most common chronic prevalence of dental caries was 77.7% in 7-12
disease affecting the human race. All people, in years age group [4]. The prevalence of dental
all countries, of all age groups, whether male of caries in India shows a varied picture i.e., caries
female are at risk. It is the most prevalent disease being very high in some areas and low in some
among children in the global scenario. In recent areas.
years collective data reveals that there is a
Dental caries is an infectious, communicable
significant decrease in the level of dental caries
disease resulting in destruction of tooth structure
among school children due to better preventive
by acid-forming bacteria found in dental plaque,
strategies and collective efforts by the community.
an intraoral biofilm. The disease can result in
But, recent epidemiological studies in the
irreversible loss of tooth minerals and eventually
developing countries show that the prevalence and
lead to extraction of the tooth, if left unchecked.
severity of dental caries has increased with
Therefore early identification of dental caries is of
industrialization and exposure of these populations
paramount importance. Timely detection is
to western diets. Although in Developing countries
essential to alert both the parents and the health
such as India, significant progress has been made
care professionals to the need for appropriate
in reducing and controlling dental caries, the
action. Caries has been identified to be crucial for
disease still remains a problem for many children.
both dental and general health of a person. Even
Several studies have been conducted in different
though dentists are plenty in Tamil Nadu, dental
parts of India on the prevalence of dental caries.
caries still remains as an overwhelming problem
According to a study done in Kulasekaram,
among school children. Though preventive
Kanyakumari district, 77% of 6-12 years old
approaches seem viable to tackle this prolem
children suffered from dental caries [1]. In one
however, there is lack of background data in the
study conducted at Chandigarh the incidence of
region on the needs, which would be helpful for
dental caries was found to be increasing due to
allocation of resources to plan necessary
deterioration in food and dietary habits. In another
preventive actions. Much of the cross-sectionals
study which was conducted in Udaipur district in
surveys have been done in northern India. They
2007 found the dental caries prevalence to be
differ from the southerners in many factors such
about 46.75% among 14 years old [2]. In a study
as the dietary habits and life style factors. The
done in Chidambaram taluk, Tamilnadu, 71.7% of
factors that determine the prevalence of dental
the children who were in the age group of 5-10
caries in other parts of India might be different
years had dental caries [3]. In another study done
form the indicators in South. It would not be
in Uttaranjal, on 722 school children, the
appropriate to design prevention programs with the
1 2,4,5
Professor and Head, Reader, 3Professor, Dept. of Periodontics, Chettinadu Dental College, Chennai.
1138
information collected form other regions of India. group of 7 to 12 years, 26% were in the age group
In this study we aim to quantify the caries of 13 to 17 years and the remaining 9% were in
experience, and to identify determinants associated theage group of 4 to 6 years. Only 4% of the male
with caries, among a population of children who school children and 2% of the female school
belong to middle orlower socio-economic status children have college educated mother. Remaining
(SES) in Padur. children have mothers who have had only primary
schooling or are illiterate. More than 65% of these
MATERIALS AND METHODS school children come from families with monthly
income less than Rs.2000 only about 6% of the
A cross-sectional study was carried out among children belonged to the families with income
schools in Padur, Kanchipuram District, and Tamil greater than Rs.4000 per month. About one third
Nadu. Three schools were randomly selected of the school children have mother who are
among all the schools of Padur. Among the three laborers. Approximately 6 out of 10 used brush
schools, one school was run by a private and paste to clean their teeth. More than one out
organization, another school was run by the State of 10 female school children consumed sweets
Government and the third school was run by the very often, where as less than 1 out of 20 male
Central Government. On stipulated dates the school child consumed sweets very often. About
investigators visited specific class and after 35% of the school children drank water taken from
explaining the procedures and questionnaire bore or well. About 1 out of every 10 children
details, the students were examined. Type 3 had malocclusion. More than 8 out of every 10
clinical examination was carried out with the use children brushed only once a day.
of mirror and explorer using good natural daylight
as per WHO specification. Dental caries was Prevalence of dental caries
diagnosed using visual and tactile method and 64% of the school children in our study had
caries recorded according to WHO criteria (1997) dental caries (graph 1). The prevalence was more
[5]. A detailed questionnaire was administered to in the corporation and government aided school
the parent of the children who were clinically compared to the private school (graph 2). The
examined. The questionnaire asked information on prevalence is higher among females compared to
socio-demographics, food habits, brushing males among the school children of Padur.
methods, and mode of teeth cleaning.
Analysis
Since our response is a dichotomous variable
logistic regression was used to estimate the effects
of different indicator variable. The logistic
regression models were estimated using the
STATA statistical software package (Stata
Corporation 2001) [6]. Univariate analysis was
done to fine the effect of each individual variable
on the prevalence of Dental caries among the
study subjects.
Graph. 1. Prevalence of dental Caries among school childlren of
Before carrying out the multivariate analysis, Padur, Tamilnadu.
we tested for the possibility of multicollinearity Effect (Univariate) of Predictor Variables on
between different predictor variables. All pair wise Prevalence of Dental Caries.
Pearson correlation coefficients are <0.5 Table 2 shows the effect of different predictor
suggesting that multicollinearity is not a problem.
variables on the prevalence of dental caries among
the school children of Padur, Tamilnadu. The
RESULTS
unadjusted odds of suffering from dental caries is
Profile of the School Students 35% lower among the school children of private
Table 1 shows the distribution of school school as compared to the school children who go
children by selected characteristics. There were to the corporatin school (OR=0.66; 95% CI, (0.50
more female (54%) in the study schools than - 0.86)). The odds of having dental caries is 2
males. 65% of the school children were in the age times higher for those who have moderate oral
1139
Table 1. Variable definitions and distribution of school subjects by selected characteristics, Padur.
Characteristic Males (%) Females (%) Total Percentage
Age Grouop
4 yrs – 6 yrs 11.62 6.42 8.80
7 yrs – 12 yrs 68.97 61.77 65.06
13 yrs – 17 yrs 19.42 31.80 26.14
Mother’s Education
College 4.48 2.46 3.37
School 59.33 62.15 60.88
Illiterate 36.9 35.38 35.75
Family Income
> 4000 Rs 5.36 5.92 5.66
2000 Rs – 4000 Rs 28.67 23,27 25.75
< 2000 Rs 65.97 70.81 68.59
Mother’s Occupation Employed
Laborer 9.51 6.32 7.78
House Wife 31.99 28.66 30.18
Employed 58.50 65.02 62.04
Type of Brushing
Brush & Paste 59.35 68.96 64.56
Brush & Powder 26.13 35.84 25.98
Finger & Charcoal 14.52 5.20 9.46
Sweet Consumption
Rare 56.26 55.59 55.90
Often 39.20 32.62 35.63
Very Often 4.54 11.79 8.47
Drinking Water
Pipe 66.06 64.77 65.36
Bore 22.50 17.08 19.57
Well 11.43 18.15 15.07
Malocclusion
Not Present 94.14 87.03 90.27
Present 5.86 12.97 9.73
Frequency of Brushing
Twice daily 11.81 11.04 11.39
Once daily 88.19 88.96 88.61
Number of school Students* 551 654 1205
*
The number of school children varies slightly for individual variables depending on the number of missing values.
Graph 2. Prevalence of dental careis in the three study schools of Padur, Tamilnadu.
1140
Table 2. Unadjusted effects of different predictor variables on Table 3. Adjusted effects of different predictor variables on the
the prevalence of dental caries prevalence of dental caries.
Odds 95% Confidence Odds 95% Confidence

Characteristics Characteristics
Ratio Interval Ratio Interval
Gender Gender
Female 1.0* – Female 1.0* –
Male 0.79 (0.62, 1.00) Male 0.69 (0.50, 0.95)
Age Group Age Group
4 years – 6 years 1.0* – 4 years – 6 years 1.0* –
7 years – 12 years 0.81 (0.52, 1.26) 7 years – 12 years 0.77 (0.44, 1.34)
13 years – 17 years 0.63 (0.39, 1.01) 13 years – 17 years 0.47 (0.25, 0.87)
School School
Corporation School 1.0* – Corporation School 1.0* –
Private School 0.66 (0.50, 0.86) Private School 1.27 (0.76, 2.12)
Govt. Aided School 0.92 (0.63, 1.35) Govt. Aided School 1.44 (0.95, 2.17)
Mother’s Education Mother’s Education
College 1.0* – College 1.0* –
School 1.55 (0.81, 2.98) School 1.92 (0.81, 4.54)
Illiterate 1.89 (0.97, 3.69) Illiterate 1.46 (0.59, 3.61)
Oral Hygiene Status Oral Hygiene Status
Good 1.0* Good 1.0*
Moderate 2.29 (1.77, 2.96) Moderate 2.46 (1.76, 3.45)
Poor 3.16 (1.82, 5.49) Poor 2.57 (1.29, 5.12)
Mother’s Occupation Mother’s Occupation
Employed 1.0* – Employed 1.0* –
Labourer 1.14 (0.69, 1.87) Labourer 0.63 (0.31, 1.27)
House Wife 0.64 (0.40, 1.02) House Wife 0.45 (0.23, 0.88)
Family Income Family Income
High 1.0* – High 1.0* –
Middle 1.72 (0.95, 3.13) Middle 0.98 (0.47, 2.07)
Low 2.12 (1.21, 3.73) Low 1.44 (0.70, 2.96)
Drinking Water Drinking Water
Pipe 1.0* – Pipe 1.0* –
Bore 2.33 (1.59, 3.426) Bore 1.07 (0.71, 1.60)
Well 1.12 (0.83, 1.53) Well 0.99 (0.55, 1.819)
Type of Brushing Type of Brushing
Brush & Paste 1.0* – Brush & Paste 1.0* –
Brush & Powder 1.38 (1.04, 1.82) Brush & Powder 1.19 (0.82, 1.72)
Finger & Charcoal 1.61 (1.03, 2.52) Finger & Charcoal 1.61 (1.03, 2.52)
Sweet Consumption Sweet Consumption
Rate 1.0* – Rare 1.0* –
Often 1.45 (1.128, 1.88) Often 1.61 (1.15, 2.24)
Very Often 1.82 (1.14, 2.90) Very Often 2.22 (1.25, 3.94)
Frequency of Brushing Frequency of Brushing
Twice daily 1.0* – Twice daily 1.0* –
Once daily 1.94 (1.36, 2.78) Once daily 1.93 (1.24, 2.99)
Malocclusion Malocclusion
Not Present 1.0* Not Present 1.0*
Present 0.83 (0.55, 1.23) Present 0.56 (0.34, 0.92)
* *
Reference Category Reference Category
1141
hygiene (OR-2.29; 95% CI, (1.77 - 2.96) as maintaining their teeth. Similarly in our study, the
compared to those with good oral hygiene and the odds of having dental caries was 61% higher for
odds is 3 times higher forthose with poor oral those children who used finger and charcoal (OR
hygiene (OR - 3.16; 95% CI (1.82 - 5.49). The = 1.61; 95% CI, (1.03 - 2.52)) compared to those
odds of suffering from dental caries was 110% who used brush and paste to clean their teeth.
higher for the school children who come from School children who consumed sweets often (OR
families with the monthly income less than Rs. = 1.61, 95% CI, 1.15 - 2.23) or very often (OR
2000 (OR-2.12; 95% CI, 1.21 - 3.73)) as compared = 2.22, 95% CI, 1.25 - 3.93) had a higher odds
to those children who belong to families with of having dental caries compared to those who
monthly income more than Rs. 4000. Prevalence consumed it rarely. The children who brushed their
of dental caries did not differ between the children teeth only once daily (OR = 1.93; 95% CI, (1.24
who come from families with monthly income in - 3.0) had 93% higher odds of having dental caries
the range of Rs. 2000 to Rs. 4000 and those who compared to the children who brushed twice.
come from families with monthly income greater A study conducted on dental caries and oral
than Rs. 4000 Compared to those children who hygiene status of school children in Davangere,
use pipe water for drinking, the odds of suffering found a strong correlation between the
from dental caries was 2 times higher for those socioeconomic status and dental caries experience
who use bore water (OR = 2.33; 95% CI, (1.59 - [7]. In our study, with other variables controlled,
3.416)) for drinking. Compared to those who use the prevalence of dental caries does not vary
brush and paste for cleaning their teeth, the odds significantly by the school that the children attend.
of suffering from dental caries was 37% higher for Mother’s education level, family income, the type
those who use brush and powder (OR = 1.38; 95% of water the children drank, malocclusion at the
CI, (1.04 - 1.82) and 61% hgiher for those who time of survey also do not have significant effects
use finger and charcoal (OR = 1.61; 95% CI, (1.03 on the prevalence of dental caries prevalence,
- 2.52)). Those who consume sweets often have a among the school children.
significantly higher risk of suffering from dental
caries compared to those who rarely consume
sweets. School children who brush only once a day DISCUSSION
have 94% higher odds of suffering from dental Results from our study suggest that the
caries compared to those who brush twice or more prevalence of dental caries among school children
times a day (OR = 1.94; 95% CI, (1.36 - 2.78)). to be 64% with the prevalence being greater for
Effect (Multivariate) of Predictor Variables on females than males. Gender, oral hygiene status,
Prevalence of Dental Caries. sweet consumption, type of brushing, mother’s
After adjusting for all the predictor variables, occupation and frequency of brushing are
gender, oral hygiene status, sweet consumption and significant predicors of dental careis in this
population.
frequency of brushing have significant effects on
the prevalence of dental caries among school The finding that those children whose mothers
children of padur (Table 3). Male school children were housewives, had lower prevalence compared
(OR = 0.69; 95% CI, (0.50 - 0.95) had 30% lower to the children having working mothers is
odds of having dental caries as compared to the consistent with expectation, because those who are
female school children. Those children who are in housewives have lot more time to spend with their
the age group of 13 to 17 years (OR = 0.469; 95% kids as compared to the working mothers. A
CI, (0.25 - 0.87)) have 54% lower odds of having higher prevalence of dental caries among female
dental caries compared to those who are 4 to 6 children could be due to lesser access to treatment
years of age. School children who have moderate and care compared to male. In our study,
(OR = 2.46, 95% CI, 1.75 - 3.44) or poor (OR = information on the presence of filled teeth were
2.54, 95% CI, 1.29 - 5.11) oral hygiene, are at not included in the analysis. Therefore the number
considerable higher risk of having dental caries of caries affected teeth, filled and not filled could
than those who have good oral hygiene. The be much higher in this population. Information on
children, whose mothers were housewife (OR = access to treatment and care was also not
0.449; 95% CI, (0.23 - 0.88), had 56% lower odds collected. Since the information on the
of having dental caries compared to the children socioeconomic status, sweet consumption, and the
of employed mother. It is an accepted fact that source of water that they drink, was gathered
using brush and paste is the best way of through questionnaire, there could be information
1142
bias, but this could only bias our results towards a correlated prevalence survey. indian journal of
the null. In this study detailed information could pedodontics and preventive dentistry; Sep 2005.
not be gathered on many other predictors of dental 2. Dhar V. Jain A, Vandyke T.E kohli A: prevalence of
caries such as food habits, more detailed and well dental careis and treatment needs in school going
designed epidemiologic study is required to better children of rural areas in Udaipur district; Journal of
understand the dental caries status of the
pedodontics and preventive dentistry; Sep 2007.
population.
3. Saravanan S, Kalyani V, Vijayarani MP, Jayakodi P,
Dental caries is highly prevalent in India, Felix JWA: Caries prevalence and treatment needs of
which is influenced by the lack of dental
rural school children in Chidambaram Taluk, Tamil
awareness among the public at large. The finding
Nadu, South India; Indian J Dent Res, 19 (3), 2008.
from this study has important policy and program
implications, including the need for public 4. Prevalence of dental caries and treatment needs in
information compaigns designed to inform people rural population in nainital, uttaranjal; journal of
about the prevalence of dental caries in the pedodontics and preventive dentistry; Oct - Dec; Issue
population, programs to promote access to 4; Vol 27; 2009.
improved dental care. For such programs to be 5. World Health Organisation, Oral Health Survey, Basis
effective, local needs and community participation
Method, 3 Edition, Geneva, WHO 1983.
should be given highest priority. Programs to
improve oral hygiene awareness should be 6. Fundamentals of Biostatistics, Fifth Edition, Bernard
conducted regularly to promote dental care in the Rosner; Duxbury Thomson Learning.
population. 7. Sogi GM, Bhaskar DJ, Dental caries and oral hygiene
status of school children in Davangere related to their
REFERENCES socio-economic levels; and epidemiological study, J
1. Joshi N, Rajesh R, Sunitha M: prevalence of dental Indian Soc Pedod Prev Dent. 2002 Dec; 20 (4):
caries among school children in kulasekaram village; 152-7.
1143
Molars with Single Root and Single Canals

Dr. Ajit George Mohan1, Dr. A.V. Rajesh Ebenezar2, Dr. A. Vinita Mary3
ABSTRACT
Panoramic radiographs of male patient’s ages 25 and 22 revealed the presence of multiple single rooted
molar teeth with single root canals. This anatomical variation is detected in the contralateral pairs also.
Identifying the single canal requires sufficient clinical prudence and a thorough knowledge of the root
canal anatomy.
Keywords: Single canal, Single root, molar teeth, contra-lateral pairs.
INTRODUCTION back tooth region. His medical history was

non-contributory. He had undergone extraction of
Root canal morphology exhibits greater degree
maxillary first molar in the left maxillary region.
of anatomic deviations and clinicians should be
On clinical examination, the mandibular right
familiar about these deviancies for a successful
second molar tooth was diagnosed with chronic
outcome. Multi-rooted teeth by way of its variation
apical periodontitis and subsequent treatment was
in root canal anatomy pose a persistent challenge
undertaken.
for accurate diagnosis during endodontic therapy.[1]
Failure to recognise a root canal can lead to failure The radiographic observation reveals the
of endodontic treatment. [2] The current focus of presence of second and third molar teeth with
many clinicians is to locate extra canals, apical single root and single canal in both the quadrants
ramifications, apical deltas or lateral canals. of the maxilla. The maxillary right first molar
[3]
However the possibility of the presence of single tooth also reveals single tooth with single canal.
canal with single root in a molar tooth should not
be completely ignored. [4] Very few comparisons DISCUSSION
of unusual anatomy in contralateral pairs have
been reported in the literature. [5]This article The search for extra canals can sometimes
presents the case report of two patients with lead to iatrogenic errors such as perforations and
multiple teeth exhibiting single root with single excessive loss of tooth dentin. These errors can be
canal. avoided if the clinician possesses adequate
knowledge about the location of the canals and the
Case report 1 dimensions of the pulp chamber. Krasner and
Rankow made a rational approach to study the
A 25 year old male patient was referred for a relationships of the pulp chamber to the clinical
clinical examination for malocclusion. His medical crown and pulp chamber floor. Their observations
history and dental history was non-contributory. put forth in the form of laws are valuable aids to
His panoramic radiograph reveals retained the clinician searching for elusive canals [6].
deciduous canine tooth and impacted permanent Although extra canals are more of a rule rather
canine tooth in the upper left maxillary region. than an exception, the clinician should also be
Careful observation of the radiograph reveals the aware of the fact that in certain cases, there is a
presence of single root with single canal in second possibility of fused if not fewer canals than the
and third molars of both the quadrants of the normally presumed canal morphology.[4]
mandible. In the maxillary arch, second molars of
both the quadrants exhibits single root with single The important aspect to be considered in these
canal. cases is the presence of unusual anatomy in the
maxillary and mandibular molars. Also the
Case report 2
presence of the same anatomical aberration in the
contralateral pairs assumes clinical significance.
A 22 year old male patient was referred for Table 1 discusses the various studies done on the
clinical examination for pain in the lower right abnormalities and anatomic complexities in molar
1
Senior Lecturer, Dept. of Conservative Dentistry, Endodontics, Annoor Dental College, Kerala. 2Reader, Dept. of
Conservative Dentistry and Endodontics, SRM Dental College, Chennai. 3Senior Lecturer, Dept. of Public Health Dentistry,
Thai Moogambikai Dental College, Chennai.
1144
Table 1. Abnormalites and anatomic deviations in the molar teeth
Number of
Author Year Tooth number Anatomic details
teeth studied
Fava[10] 1980 Maxillary second molar 1 4 roots
[11]
Stone & Stroner 1981 Maxillary second molar 500 2 palatal root canals
[12]
Fava 1982 Mandibular second molar 1 3 mesial canals
[13]
Weine 1982 Mandibular second molar 1 3 mesial canals
[14]
Martinez-Berna & Ruiz-Badanelli 1983 Mandibular first molar 1418 26 teeth with 5 canals
Mandibular second molar 3 teeth with 5 canals
Wells & Bernier[15] 1984 Mandibular second molar 944 1 mesial and 2 distal canals
[16]
Beatty & Interian 1985 Mandibular first molar 1 5 canals
Rabie[17] 1985 Mandibular second molar 1 MB & D canals merging in one
foramen
Abdel-Aziz & Gomaa[18] 1986 Maxillary first molar 100 Number of canals in P & DB roots
[19]
Bond et al 1988a Maxillary second molar 1 6 canals
[20]
Bond et al 1988b Mandibular first molar 1 3 mesial canals
Mandibular second molar
[21]
Fahid & Taintor 1988 Maxillary second molar 1
[22]
Libfield & Rotstein 1989 Maxillary second molar 1200 2 distobuccal roots and canals
[2]
Christie et al 1991 Maxillary molars 16 2 palatal roots
[23]
Wong 1991 Maxillary first molar 1 3 palatal canals
[24]
Melton et al 1991 Mandibular second molar 15 c-shaped canals
[25]
Jacobson & Nii 1994 Maxillary molars 3 2 palatal root canals
[26]
Fernandez et al 1994 Maxillary first molar 1 2 palatal canals
[27]
Pansiera & Milano 1995 Mandibular second molar 102 Number of roots and root canals
[28]
Peikoff et al 1996 Maxillary second molar 520 Number of roots and root canals
[29]
Holtzmann 1997 Maxillary first molar 2 2 palatal canals
[30]
Hulsmann 1997 Maxillary first molar 1 2 disto-buccal roots
[31]
Kreisler 1997 Mandibular first molar 2 3 mesial and 2 distal root
Mandibular second molar
Malagnino et al[1] 1997 Maxillary molars 3 Fusion of buccal roots
[32]
Reeh 1998 Mandibular first molar 1 7 canals
[33]
Zmener & Peirano 1998 Maxillary second molar 1 3 separate buccal roots
[34]
Peter M. Di Fiore 1999 Maxillary molars 1 4 roots
[35]
L.R.G. Fava 2001 Maxillary molars 1 2 roots
[36]
F. Baratto-Filho et al 2002 Maxillary molar 1 4 roots
[37]
F.Maggiore, Y.T.Jou & S.Kim 2002 Maxillary molar 1 6 canals
[38]
Barbizam JV, Ribeiro RG 2004 Maxillary molar 2 4 roots
[4]
Gopikrishna et al 2006 Maxillary first molar 1 1 root
[7]
Francisco et al 2008 Maxillary first molar 1 1 root
[39]
Karthikeyan & Mahalaxmi 2010 Maxillary first molar 4 6 canals
[40]
Jojo Kotoor et al 2010 Maxillary first molar 1 7 canals
1145
more rare the aberration, the more probable that it

was bilateral. They reported the bilaterality in
maxillary and mandibular molar and premolars. [42]
CONCLUSION
Variations in root canal morphology need not
be in the form of extra canals. It could also be in
the form of fused or less number of canals.
Clinicians should have adequate knowledge about
root canal morphology and its possible anomalies.
Radiographs are the most potent tool in daily
clinical practice to detect abnormal variations in
the root and root canal anatomy.
Fig. 1. Case report 1: OPG showing single canals in molars.
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Fig. 2. Case report 2: OPG showing single canals in molars. Bhargavi,Endodontic Management of a Maxillary
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21. Fahid A, Taintor JF Maxillary second molar with 37. Maggiore F, Jou YT, Kim S. A six-canal maxillary
three buccal roots. J Endod, 1988; 24: 181-3. first molar: case report. Int Endod J 2002; 35:486
22. Libfield H, Rotstein I Incidence of four-rooted –91.
maxillary second molars: literature review and 38. Barbizam JV, Ribeiro RG, Filho MT. Unusual
radiographic survey of 1,200 teeth. J Endod, 1989; anatomy of permanent maxillary molars. J Endod
15: 129-31. 2004; 30:668 –71
23. Wong M Maxillary first molar with three palatal 39. Kittappa Karthikeyan, Sekar Mahalaxmi,New
canals. J Endod, 1991; 17: 298-9. nomenclature for extra canals based on four reported
24. Melton DC, Krell KV, Fuller MW Anatomical and cases of miaxillary first molar with six canals,J Endod
histological features of C-shaped canals in mandibular 2010; 36:1073-1078.
second molar. J Endod, 1991; 17: 384-8. 40. Jojo Kottoor, Natanasabapathy Velmurugan, Maxillary
25. Jacobsen EL, Nii C Unusual palatal root canal First Molar with Seven Root Canals Diagnosed with
morphology in maxillary molars. Endod Dent Cone-Beam Computed Tomography Scanning: A
Traumatol, 1994; 10: 19-22. Case Report, J Endod ,2010 ; 36:915-921.
26. Fernandez A, Hilu RE, Mellado A Un primer molar 41. Fava L.R.G.,Dummer PMH,Periapical radiographic
superior inusual con dos conductos palatinos. Rev techniques during diagnosis and treatment. Int Endod
Asoc Odontol Argent, 1994; 82: 205-7. J , 1997; 30:250-261.
27. Pansiera AF, Milano NF Morfologia endodoÃntica 42. Sabala CL, Benenati F, Neas BR,Bilateral root and
dos segundos molares inferiores. Rev Fac Odontol P root canal aberrations in a dental school patient
Alegre, 1995; 36: 12-14. population.J Endod, 1994; 20:38-42.
1147
Attitude and Awareness toward Periodontal Therapy in

North Indian Population: A Questionnaire Survey
Dr. Archana Bhatia1, Dr.M.P.Singh2, Dr. Rohit Chopra3
ABSTRACT
Purpose: The aim of the study was to explore and gain an understanding of patients’ views on their
periodontal conditions, their perceived impact of periodontitis on daily life, as well as their attitudes to
oral health and expectations of treatment.
Material and methods: The study subjects were patients with chronic periodontitis, who had been
referred to department of Periodontics. Two hundred forty-five (245) patients (Males=125,Females=120)
were included in this study who attended department of Periodontics in Dasmesh Dental College and
Hospital,Faridkot Punjab State during the study period from 10th December 2010 to 22nd January 2011.
Results: The results illustrated that females participate in this randomized study were more fearful
about the periodontal therapy and most of the females visit dentist once or twice in her life.
Conclusions: The results demonstrate the attitude of general population toward periodontal therapy
and emphasize the importance of educate the population about periodontal treatment. Sample size of study
design is small so further study on large sample size is required.
Keywords: Periodontitis, oral health, periodontal therapy, randomized study,
INTRODUCTION effectiveness of oral hygiene procedures, pocket

depth, flow of gingival crevicular fluid, type of
Health is a fundamental right and a universal
interacting microbes and viruses, transmission rate
human need that is same for people from all
of microbes from other individuals and the
cultures and walk of life. General health cannot be
antimicrobial efficacy of the host immune
attained or maintained without oral health. The
response3.
mouth is regarded as a mirror and the gateway to
health. Integration is required between the dental There is a lack of population based data on
practitioner and the patient, if good dental health attitude toward periodontal therapy in the Punjab
is to be attained1. Periodontal disease is one of the state (India), so it is important to do a recent study
most prevalent diseases affecting human dentition that will help dentist to improve the understanding
and one of the principle causes of tooth loss. of patients about periodontal diseases and reduces
Gingivitis, a milder form of periodontal disease,is the myths of general population about periodontal
commonly found among individuals of all age therapy. The aim of this study is to determine the
groups. Periodontitis is an infectious disease general population attitude toward periodontal
characterized by inflammatory changes in the therapy, reported to department of Periodontics in
tissues surrounding to teeth leading to periodontal Dasmesh Dental College and
attachment loss and alveolar bone destruction. As Hospital,Faridkot(Punjab): Punjab State.
dental caries has declined, periodontitis has
become the most common reason for tooth loss in MATERIAL AND METHODS
adults2.
i. Study area and study population
It is generally agreed that microorganisms The present study was done on patients
residing in the periodontal pockets are responsible reported to department of Periodontics in Dasmesh
for periodontitis. Approximately 500 taxa inhabit Dental College and Hospital,Faridkot(Punjab
periodontal pockets, which provide a moist, warm, State). This hospital is located away from the city.
nutritious and anaerobic environment for microbial People of different socioeconomic and educational
colonization and multiplication. The abundance status visit the hospital for their dental care needs.
and diversity of periodontal pocket microorganisms
depend upon several factors, including
1
Senior Lecturer, 2Professor and H.O.D, 3Reader, Dept. of Periodontics, Dasmesh Institute of Research and Dental Sciences,
Faridkot (Punjab)
1148
ii. Inclusion criteria Table 1.

Two hundred forty-five (245) patients Sex-wise distribution (n=215)
(Males=125, Females=120) were included in this Sex Frequency Percent
study who attended department of Periodontics in
Dasmesh Dental College and Hospital, Faridkot Male 125 51.02
Punjab State during the study period from 10th Female 120 48.98
December 2010 to 22nd January 2011. Total 245 100.00
Age-wise distribution (n=245)
iii. Performa
Number of
A structured questionnaire was formulated in Age Percent
patients
the english version. The questionnaire contained 12
questions about attitude of patients toward 15-30 years 53 21.6
periodontal treatment along with their demographic 31-45years 80 32.6
background, age, education and occupation. 46-60years 82 33.4
Above 60 years 30 12.2
iv. Oral health education
Occupation -wise distribution (n=245)
After completion of the questionnaire, oral
Females(n=120)
health education was given to the patients
regarding the methods of tooth brushing and oral Number of
Occupation Percent
hygiene practices. patients
Housewife 90 75
RESULTS Job 30 25
Males (n=125)
A total of 245 patients (125 males and 120
Laborer /farmer 33 26.4
females) agreed to participate and responded to the
questionnaire. Approximate time required for a Teacher 25 20.0
participant to fill out the questionnaire ranged from Job 41 32.8
15 to 20 min. Retired 6 4.8
Student 20 16.0
1. Sex-wise distribution of the patients in the
sample Table 2.
Education level
Out of 245,125 (51.02%) were males and 120
(48.98%) were females (Table1). Sex Illiterate Education
Males (125) 23(18.4%) 102(81.6%)
2. Age – wise distribution of the patients in
Females (120) 70(58.3%) 50(41.6%)
the sample
Fearful attitude of patients about receiving periodontal
In this study most of the patients about therapy
82(33.4%) were between 46-60 years, 80(32.6%) Sex Yes No
were between 31-45 years followed by 53(21.6%) Males (125) 33(26.4%) 92(73.6%)
and 30(12.2%), 21(9.76%) were of age above 60 Females (120) 86(71.6%) 44(28.4%)
years respectively (Table1).
Number of patients delay or turn down periodontal
3. Occupation –wise distribution of the treatment because of his/her fear
patients in the sample (Table 1) Sex Yes No
Males (125) 40(32%) 85(68%)
4. Education level:
Females (120) 95(79.1%) 25(20.9%)
Result of this survey concluded that females Number of patients undergo any periodontal procedure in
are more illiterate than males in this area. In this his/her life
study, from total female participants 58.3% were Sex Yes No
illiterate whereas about 81.6% males were
Males (125) 90(72%) 35(28%)
educated and doing job at present (table 2 and
figure 1). Females (120) 51(42.5%) 69(57.5%)
5. Fearful attitude of patients about receiving

periodontal therapy
1149
Table 3.
General population’s myth about scaling

Sex Yes No
Males (125) 80(64%) 45(36%)
Females (120) 92(76.6%) 28(23.4%)
Type of pain which patient’s felt

Males (125)
Type of pain Number of patients
Feeling of pain 8(6.4%)
Needles 15(12%)
Unsuccessful results 40(32%)
Equipment noise 7(5.6%)
Anesthesia 5(4%)
Others 50(40%)
Females (120)
Type of pain Number of patients
Fig. 1. Education status of sample size
Feeling of pain 46(38.3%)
About 71.6% females participate in this Needles 32(26.6%)
randomized study were fearful about the
Unsuccessful results 9(7.5%)
periodontal therapy and most of the females visit
dentist once or twice in her life (table2, figure 2). Equipment noise 8(6.6%)
Anesthesia 25(20.8%)
6. Number of patients delay or turn down Others 0(0%)
periodontal treatment because of his/her fear
Out of 120 females, 79.1% patients delayed or down her treatment because of fear in his life
turn down her treatment because of fear whereas .Data of this survey showed that females are more
from 125 males, 32% patients delayed or turn fearful about periodontal therapy (table2,figure 3).
7. Number of patients undergo any
periodontal procedure (surgical or nonsurgical) in
his/her life
About 72% males and 42.5% females undergo
periodontal therapy in his/her life. Males are
having more positive attitude towards dental
treatment in this area (table 2, figure 4).
8. General population’s myth that scaling
causes tooth mobility
Females are more illiterate in this area so
about 76.6% female participants believe in myth
that scaling causes tooth mobility. Most of the
females avoid periodontal treatment due to this
myth (table 3, figure 5). 9. Nature of pain felt by
patients (table 3)
Fig. 2. Graph showing fearful attitude of people toward receiving 10. Following treatment, how many patients
periodontal treatment
felt discomfort or pain
1150
Table 4.
Following treatment, how many patients felt discomfort or

pain
Sex Yes No
Males (125) 14(11.2%) 111(88.8%)
Females (120) 54(45%) 66(55%)
Number of patients feel more stressed about performing

the treatment
Males (125)
No 72(57.6%)
Somewhat stressed 38(30.4%)
Much stressed 15(12%)
females (120)
No 42(35%)
Somewhat stressed 46(38.3%)
Much stressed 32(26.6%)
Fig. 3. Delay or turn down periodontal treatment because of fear Source of origin of pain
Males (125)
Source Number of patients
Media(TV and movies) 24(19.2%)
Family 41(32.8%)
Friends 17(13.6%)
Personal bad experience 43(34.4%)
Others 0
Females (120)
Source Number of patients
Media(TV and movies) 27(22.5%)
Family 23(19.1%)
Friends 29(24.1%)
Personal bad experience 36(30.0%)
Others 5(4.1%)
Results of this study shows that females (65%)

are more stressed about periodontal treatment than
Fig. 4. Graph showing number of patients undergo any
periodontal procedure in his/her life
men (42.4%) (table 4,figure 7).
Out of total population, only 11.2% males and 12. Source of origin of pain
45% of females experienced and pain or Most common source of origin of pain in both
discomfort after periodontal therapy (table 4, figure males (34.4%) and females (30.0%) is personal
6) .
bad experience followed by family source (32.8%)
11. Number of patients feel more stressed in males and by friends (24.1%) in females (table
about performing the treatment 4).
1151
Fig. 5. General population’s myth about scaling
Fig. 7 Number of patients feel more stressed about performing

the treatment
behavior models for a comprehensive assessment,

clinicians often experience time constraints posed
by active patient care. Therefore, we sought to
develop a simple questionnaire that could be
completed quickly, yet it would provide
information relevant to the planning of periodontal
treatment. Our 12-item questionnaire imposed very
little burden on the patients; they had little
difficulty in completing it. Within the limitations
of the present study, the clinical use of the
questionnaire disclosed salient information
regarding periodontitis patients’ oral health
behavior and perceptions.
The present study was undertaken to determine
the periodontal awareness among patients visiting
Fig. 6. Graph showing persons discomfort or pain felt during
department of Periodontics in Dasmesh Dental
periodontal therapy College and Hospital,Faridkot (Punjab) . A total of
245 dental patients were subjected to a
DISCUSSION self-administered questionnaire to assess their
periodontal status. In this study, from total female
In an age of assessment and accountability, the
participants 58.3% were illiterate whereas about
field of periodontics as well as dental hygiene
could benefit by adopting models that emphasize 81.6% males were educated and doing job at
the multidimensional nature of oral problems and present. About 71.6% females participate in this
by considering patient behaviors and perceptions randomized study were fearful about the
on oral health. periodontal therapy and most of the females visit
dentist once or twice in her life. Out of 120
Although it may be desirable to use a full females, 79.1% patients delayed or turn down her
instrument based on single or multiple health treatment because of fear whereas from 125 males,
1152
32% patients delayed or turn down her treatment (30.0%) is personal bad experience followed by
because of fear in his life. Whereas result of AAP family source (32.8%)in males and by friends
(1999)4 survey showed males were more fearful (24.1%) in females. Another study conducted by
about periodontal therapy than females. AAP (1999)4, showed that personal bad experience
and family sources both factors equally affect the
Tatsuo Yamamoto et al (2009)5,conducted a
attitude of patient toward therapy.
questionnaire for periodontitis screening of 250
people of age group 50-59 years males Japanese
employees and suggest that the self-reported CONCLUSION
questions are useful for screening of periodontitis
in this age group people. Epidemiological research indicates that
periodontal diseases are widespread throughout the
According to K L Vandana et al(2007)6,in the world and evidence exists to show that their extent
study of 1029 subjects of Davangere district , and severity increases with age. The prevention
incidence of gingivitis and periodontitis was more and management of periodontal diseases are
in females than males. accomplished primarily by maintaining tooth
surfaces which are free of dental plaque. The
Atsushi Saito et al(2009)7,conducted the maintenance of periodontal health requires an
pre-tested 19-item questionnaire comprised 3 informed patient. Treatment will fail and in fact
domains; 1) oral hygiene, 2) dietary habits and 3) will not even start, if individuals are not aware of
perception of oral condition on 65 patients .Result the differences between periodontal health and
of the study showed that the clinical utilization of disease; the significance of these differences and
the questionnaire facilitates the inclusion of the part they can play in prevention and control.
multiple aspects of patient information, before This present study is based on self-addressed
initiation of periodontal treatment. The significant questionnaire and without any clinical examination
associations that were found between some of the of rural population of Punjab. The following
self-care behaviors and oral hygiene levels conclusions can be drawn from the study-
document the important role of patient-centered
oral health assessment in periodontal care. 1. Result of this survey concluded that females
are more illiterate than males in this area. In
In another study obtained by Abrahamsson K this study, from total female participants
H et al(2008)8 , open-ended interviews were 58.3% were illiterate whereas about 81.6%
conducted after periodontal examination, but males were educated and doing job at present.
before treatment. The results illustrated that 2. About 71.6% females participate in this
subjects diagnosed with chronic periodontitis felt randomized study were fearful about the
ashamed and were willing to invest all they had periodontal therapy and most of the females
in terms of time, effort and financial resources to visit dentist once or twice in her life.
become healthy and to maintain their self-esteem.
3. Out of 120 females, 79.1% patients delayed or
However, they perceived a low degree of control
turn down her treatment because of fear
over treatment decisions and treatment outcome.
whereas from 125 males, 32% patients delayed
Sripriya Nagaranjan et al(2008)9,the study or turn down her treatment because of fear in
population included 216 patients aged between 20 his life.
and 44 years who attended the outpatient 4. Females are more illiterate in this area so
department of the M.S. Ramaiah Dental College, about 76.6% female participants believe in
Bangalore. The study population was subjected to myth that scaling causes tooth mobility.
a self-administered questionnaire (questions 5. Results of this study shows that females (65%)
regarding bleeding gums, deposits on teeth, are more stressed about periodontal treatment
receding gums, swelling of gums, loose teeth), than men (42.4%).
which was followed by periodontal examination.
6. Most common source of origin of pain in both
Result of the study showed that the awareness of
males (34.4%) and females (30.0%) is
the periodontal problems has been reported to
personal bad experience followed by family
increase with increasing severity of the disease due
source (32.8%) in males and by friends
to the destructive changes that set in.
(24.1%) in females.
In present study, most common source of 7. About 72% males and 42.5% females undergo
origin of pain in both males (34.4%) and females periodontal therapy in his/her life. Males are
1153
having more positive attitude towards dental 9. Sripriya Nagarajan, K. Pushpanjali;Self-assessed and
treatment in this area. clinically diagnosed periodontal health status among
patients visiting the outpatient department of a dental
In summary, the questionnaire facilitates the school in Bangalore, India, Indian J Dent Res. 2008:
inclusion of multiple aspects of patient 19 (3):243-246.
information, before initiation of periodontal 10. Brian C. Booner,Linda Young,Patricia A. Smith,
treatment. There seems to be much room for Wandy and Jan E. Clarkson;A randomised controlled
improvement of oral hygiene and self-care among trial to explore attitudes to routine scale and polish
individuals presenting for an initial periodontal and compare manual versus ultrasonic scaling in the
examination. Within the limits of the present general dental service in Scotland,BMC Oral health
study, the significant associations that were found .2005;5:3.
between some of the self-care behaviors and oral 11. Pankaj Goel,Kawarjit kaur, Arundeep Kaur,et al; Oral
hygiene levels document the important role of healthcare for elderly : Identifying the needs and
patient-centered oral health assessment in feasible strategies for service provision,Indian J Dent
Res .2006; 17 (1):11-21.
periodontal care. Utilization of dental services in
this country should, therefore, be improved not 12. Karlsson E.,Lymer U.B.,Hakeberg M.;Periodontitis
only by improving the availability and accessibility from the patient perspective,a qualitative study ,.Int J
Dent Hyg . 2009:,feb 7(1):23-30.
by manpower arrangements, but also to a great
extent by increasing people awareness and 13. Andersson K.,Nordenram G.;Attitudes to and
knowledge of their own dental disorders and by perceptions of oral health and oral care among
community-dwelling elderly residents of
attempting to change their attitudes and behavior
Stockholm,Sweden:an interview study,.Int J Dent
in relation to oral health care. Hyg. 2004;feb 2(1):8-18.
14. Stenman J.,Hallberg U.,Wennstrom J. L.,Abrahamsson
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1155
A Randomized Controlled Trial of Lycopene in Oral

Submucous Fibrosis
Dr. Revant H. Chole1, Dr. Swati V. Balsaraf 2, Dr. B S Dangi3, Dr. Shailesh Gondivkar4,
Dr. Amol Gadbail5, Dr. Satish Balwani6, Dr. Mugdha Gadbail7, Dr. Rima Parikh8
ABSTRACT
Lycopene is a powerful antioxidant synthesized by tomatoes. The aim of this study was to evaluate
the efficacy of lycopene in patients with oral submucous fibrosis. Ninety patients with oral submucous
fibrosis formed the population for the study and were randomly divided into 3 groups, evaluated weekly
over a 3-month period. Patients of group A received 16 mg of lycopene, those of group B received 16
mg of lycopene along with topical triamcinolone acetonide 0.1% and those of group C were given a
placebo. After three months of therapy mouth opening was increased by 87% in group A, 93% in group
B and 16% in group C. Blanching of oral mucosa was decreased by 76% in group A, 89% in group B
and 15% in group C. Burning sensation of oral mucosa was decreased by 75% in group A, 94% in group
B and 12% in group C. Painful oral ulcerations were reduced by 63% in group A, 88% in group B and
17% in group C (Z > 1.96, P < 0.05). Thus combination of lycopene and triamcinolone acetonide is a
safe and reliable modality in the management of oral submucous fibrosis.
Keywords: oral submucous fibrosis, lycopene, corticosteroid, triamcinolone acetonide
INTRODUCTION common of which is chewing areca nut. The

etiology is complex even though the actual
Oral submucous fibrosis (OSMF) is a
mechanism is obscure.3 Symptoms of oral
potentially malignant disease of the oral mucosa.
submucous fibrosis include progressive inability to
It is predominantly seen in people in southern
open the mouth (trismus) due to oral fibrosis, oral
Asian countries or southern Asian immigrants to
burning sensation upon consumption of spicy food,
other parts of the world. However occasional cases
painful ulcerations of oral mucosa, impaired mouth
have been reported in Europeans and people from
movements and change of gustatory sensation.
Taiwan, China, Nepal, Thailand and Vietnam. It
has been reported in the Indian literature since the Treatment of OSMF is a challenge, especially
time of Sushruta as ‘Vidari’.1 The prevalence as the disease progresses. To aid in treatment
varies from 0.2%-2.3% in males and 1.2-4.57% in planning, a classification system of OSMF based
females in Indian communities.2 Oral submucous on interincisal opening (MIO) was followed
fibrosis is widely prevalent in India in all age (Khanna et al, 1995)4:
groups and across all socioeconomic strata. It
• Group 1 - Early OSMF without trismus (MIO
affects 9 per 10 thousand Indians. In the modern
>35 mm).
literature it was first described by Schwartz in five
female patients in East Africa. He called it • Group 2 - Mild to moderate disease (MIO
‘idiopathic tropica mucosae oris’.1 26–35 mm).
A variety of etiologic factors including • Group 3 - Moderate to severe disease (MIO
capsaicin, betel nut alkaloids, hypersensitivity, 15–26 mm).
autoimmunity, genetic predisposition (HLA-A110, • Group 4a - Severe disease (MIO <15).
HLA-DR3, HLA-DR7 and haplotypes A10/DR3, • Group 4b - Extremely severe; malignant or
B8/DR3 and A10/B8), streptococcal infection and premalignant lesions noted intra-orally.
malnutrition have been suggested. The most
1
Reader, Dept. of Oral Medicine and Radiology, People’s Dental Academy, Bhopal, Madhya Pradesh. 2P.G. Student, Dept.
of Public Health Dentistry, People’s College of Dental Sciences and Research Centre, Bhopal, (M.P.). 3Reader, Dept. of
Biochemistry, Rishiraj College of Dental Sciences and Research Centre, Bhopal, Madhya Pradesh. 4Asst. Professor, Dept.
of Oral Medicine and Radiology, MGM Dental College, Nashik, Maharashtra. 5Asst. Professor, Dept. of Oral Pathology
and Microbiology, SP Dental College, Wardha, Maharashtra. 6Asst. Professor, Dept. of Oral Pathology and Microbiology,
SMBT Dental College, Sangamner, Maharashtra. 7Asst. Professor, SP Dental College, Wardha, Maharashtra. 8Dental Surgen,
Nashik, Maharashtra.
1156
Treatment is based on severity of disease. up and review of all the patients was carried out
Typically, if the disease is noted prior to at 15 days intervals for the whole trial period of
development of trismus, cessation of the betel 3 months. During each visit, recordings to evaluate
habit will often resolve the disease. Once trismus the objective and subjective improvement from
has developed and disease is classified as mild to disease were assessed and scored.
moderate, OSMF is irreversible. Then, the goal of
medical and surgical therapy is to maintain oral RESULTS
function and limit progression of disease. All The mean age of the patients in the group A
available treatments (vitamins, steroids, oral iron was 27 years, group B was 26 years and group C
preparations, local submucosal injections of was 29 years. The male to female ratio of group
steroids, hyaluranidase and chylomicrons, aqueous A was 12.5:1, group B was 7.6:1 and group C
extract of healthy human placenta, surgical was 13.5:1. Group A showed 87% increase in
excision of the fibrous bands, etc) give the patient mouth opening, group B showed 93% increase in
only symptomatic relief, which is short lived. This mouth opening and Group C showed 16% increase
is mainly due to the unknown etiology and in mouth opening. Blanching of oral mucosa was
progressive nature of the disease. decreased by 76% in group A, 89% in group B
and 15% in group C. Burning sensation of oral
The objective of this randomized controlled
mucosa was decreased by 75% in group A, 94%
trial was to evaluate the efficacy of lycopene, a
in group B and 12% in group C. Painful oral
newer antioxidant on the clinical and pathologic
ulcerations were reduced by 63% in group A, 88%
course of OSMF.
in group B and 17% in group C (Z > 1.96, P <
0.05) (Table 1). No reportable complications or
Patients and Methods side effects were recorded from any of the patients
This study was conducted in the Department included in the study.
of Oral Medicine and Radiology, RKDF Dental
College and Research Centre Bhopal. A detailed DISCUSSION
case history of all patients was recorded and Lycopene is a phytochemical, synthesized by
diagnosis of OSMF was made by clinical plants (tomatoes) and microorganisms but not by
examination. The patients with OSMF group 1, 2 animals. Lycopene is a powerful antioxidant and
and 3 according to classification by Khanna et al4 has a singlet-oxygen-quenching ability twice as
were included in this trial. Patients with OSMF high as that of beta-carotene and ten times higher
group 4a and 4b were not included in this trial than that of alpha-tocopherol. In our study
and were referred for surgical therapy. All the lycopene significantly reduced the signs and
patients had habit of betel nut chewing since 2 to symptoms of OSMF (Z > 1.96, P < 0.05). Our
9 years. Patients with any systemic disorder were results were similar to one study performed on
not included in this trial. Ninety patients with oral fifty-eight patients with oral submucous fibrosis in
submucous fibrosis were randomly divided into 3 which patients were randomly divided into 3
groups, evaluated bimonthly over a 3-month groups, evaluated weekly over a 2-month period.
period. All patients were asked to completely stop Patients of group A (n = 21) received 16 mg of
the habit of betel nut chewing before beginning of lycopene, those of group B (n = 19) received 16
the therapy. Patients of group A (n = 27) received mg of lycopene along with biweekly intralesional
16 mg of lycopene (Cap Lycored), those of group steroid injections, and those of group C (n = 18)
B (n = 33) received 16 mg of lycopene along with were given a placebo. Mouth-opening values for
topical triamcinolone acetonide 0.1% (Cap the patients showed an average increase of 3.4
Lycored + Ointment Kenacort), and those of group mm, 4.6 mm, and 0.0 mm for patients in groups
C (n = 25) were given a placebo. Clinical follow A, B, and C, respectively.5
Table 1. Mode of management in OSMF with lycopene, triamcinolone acetonide and placebo
Relief of symptoms/Signs
Number of
Mode of Management Mouth Blanching of Burning Painful
Patients
opening oral mucosa sensation ulceration
Lycopene 30 87% 76% 75% 63%
Z > 1.96
Lycopene + Triamcinolone acetonide 0.1% 30 93% 89% 94% 88%
P < 0.05
Placebo 30 16% 15% 12% 17%
1157
Corticosteroids are also commonly used in the treatment regimens combined with daily mouth
treatment of oral submucous fibrosis. In one study opening exercises were found to be necessary to
96 patients with oral submucous fibrosis received manage OSF cases in early and advanced stages
four regimens of treatment - local dexamethasone, of progression. In our study lycopene along with
local hyaluronidase, local combination of topical triamcinole acetonide 0.1% gave significant
dexamethasone and hyaluronidase, and local relief from painful ulceration, burning sensation,
placental extract. The patients were followed up blanching of oral mucosa and increase in mouth
for a period varying from 3 months to 2 years. opening (Z > 1.96, P < 0.05)..
The group of patients receiving hyaluronidase Interferon gamma (IFN-gamma) is a known
alone showed quicker improvement in symptoms anti-fibrotic cytokine. In an open uncontrolled
although its combination with dexamethasone gave study intra-lesional interferon gamma treatment
somewhat better longer-term results. Thus they showed improvement in the patients mouth
recommended a new regimen for the treatment of opening from an inter-incisal distance before
submucous fibrosis.6 Another study divided three treatment of 21 +/- 7 mm, to 30 +/- 7 mm
hundred twenty-six untreated patients suffering immediately after treatment and 30 +/- 8 mm
from oral submucous fibrosis, into two groups. 6-months later, giving a net gain of 8 +/- 4 mm
Group 1 patients were given biweekly submucosal (42%) (range 4-15 mm). Patients also reported
injections of triamcinolone 10 mg/mL in 1 ml of reduced burning dysaesthesia and increased
lidocaine 2% and hyaluronidase 1,500 IU. Group suppleness of the buccal mucosa. The effect of
2 patients were given topical vitamin A 50.000 IU interferon gamma on collagen synthesis appears to
in the form of chewable tablets once daily, oral be a key to the treatment of these patients, and
ferrous fumarate tablets in a dose of 200 mg once intra-lesional injections of the cytokine may have
daily, and topical betamethasone drops (0.5 a significant therapeutic effect on OSF.9 Previous
mg/mL) four times a day for 3 weeks. The patients studies have shown that the local and systemic
were followed up for a period of one year. The upregulation of fibrogenic cytokines and
conventional treatment with injections was found downregulation of antifibrotic cytokine are central
to be hazardous, whereas the conservative to the pathogenesis of oral submucous fibrosis
treatment was found to be safe. Both treatments (OSF). The milk from cows immunized with
were purely palliative.7 In a study by Lai DR et human intestinal bacteria (immune milk) contains
al8 150 patients with oral submucous fibrosis, were an anti-inflammatory component that may suppress
treated over a period of 10 years (1982-1991), by the inflammatory reaction and modulate cytokine
either medical or surgical therapies. Medical production. One study was found in the literature
treatment involved (a) conservative oral which studied the effect of oral administration of
administration of vitamin B-complex tablets 200 milk from cows immunized with human intestinal
mg twice a day, buflomedial hydrochloride as bacteria, in oral submucous fibrosis. 26 OSF
three tablets (450 mg) per day and topical patients received immune milk treatment (45 g of
triamcinolone acetonide 0.1%, or (b) conventional immune milk powder twice a day) for 3 months
submucosal injections of a combination of and oral habit intervention were included in the
dexamethasone (4 mg/ml) and two parts of experimental group. Another 20 OSF patients who
hyaluronidase (200 u.s.p. unit/ml) diluted in 1.0 ml received only oral habit intervention served as the
of 2% xylocaine, or (c) a combination of both (a) control group. They found that the interincisor
and (b). The surgical group was treated by the distance was significantly improved (> or =3 mm
excision of fibrotic tissues and covering the defect of the baseline measurement) in 18 of the 26
with split-thickness skin, fresh human amnion, or (69.2%) OSF patients in the experimental group at
buccal fat pad (BFP) grafts. Treatment was chosen exit. However, in the control group none of the
according to the stage of clinical progression to OSF patients had an increase in interincisor
gain maximal interincisal distance (ID). The cases distance greater than 2 mm. In addition,
were followed up by monthly examinations for at disappearance or significant improvement of
least two years, or when possible even longer. A symptoms at exit was observed in 80% (16/20) of
combination of (a) and (b) medical treatment was the patients with intolerance to spicy foods (P <
satisfactory in cases of mild impairment (ID > 20 0.001) and 72.2% (13/18) of the patients with
mm) but in the long term it led to symptomatic xerostomia (P < 0.005) in the experimental group,
relief only. Together with a cessation of the betel compared with 17.6% (3/17) of the patients with
quid chewing habit before and after therapy, these improvement of intolerance to spicy foods and
1158
15.4% (2/13) of the patients with improvement of was significant improvement in mouth opening and
xerostomia in the control group. Thus oral relief from fibrotic bands. Subjective symptoms of
administration of immune milk leads to significant intolerance to spices and burning sensation of
improvements of symptoms and signs in OSF mouth were also recorded significant improvement
patients.10 Turmeric extract and turmeric oil have at the end of three months. Thus from this study
shown chemoprotective effect against it can be concluded that combination of lycopene
chemically-induced malignancies in experimental and triamcinolone acetonide 0.1% is a safe and
animals. They can reverse precancerous changes in reliable modality in the management of oral
oral submucous fibrosis in humans. The use of submucous fibrosis.
turmeric or Curcuma longa Linn as a spice and
household remedy has been known to be safe for REFERENCES
centuries. In one study it was observed that 1. Schwartz J. Atrophia Idiopathica Mucosae
turmeric oil decreased the number of Oris. London: Demonstrated at the 11th Int Dent
micronucleated cells both in exfoliated oral Congress; 1952.
mucosal cells and in circulating lymphocytes in 2. Aziz SR. Oral submucous fibrosis: an unusual
patients with OSMF. Turmeric oleoresin was disease. J N J Dent Assoc. Spring 1997; 68(2):17-9.
found to be more effective in reducing the number 3. Pillai R, Balaram P, Reddiar KS. Pathogenesis of oral
of micronucleated cells in oral mucosal cells (P < submucous fibrosis. Relationship to risk factors
0.001).11 associated with oral cancer. Cancer. Apr 15 1992;
69(8):2011-20.
Methylxanthine derivative like pentoxifylline
4. Khanna JN, Andrade NN. Oral submucous fibrosis: a
has also being used to treat oral submucous new concept in surgical management. Report of 100
fibrosis. They have vasodilating properties and cases. Int J Oral Maxillofac Surg 1995; 24: 433–439.
hampered mucosal vascularity in oral submucous 5. Kumar A, Bagewadi A, Keluskar V, Singh M.
fibrosis could be increased by the use of Efficacy of lycopene in the management of oral
pentoxifylline. One study was found in the submucous fibrosis. Oral Surg Oral Med Oral Pathol
literature which conducted a randomized clinical Oral Radiol Endod 2007 Feb; 103 (2): 207-13.
trial incorporating a control group (multivitamin, 6. Kakar PK, Puri RK, Venkatachalam VP. Oral
and local heat therapy) in comparison to submucous fibrosis--treatment with hyalase. J
pentoxifylline test cases (400 mg 3 times daily, as Laryngol Otol. 1985 Jan; 99 (1):57-9.
coated, sustained release tablets). A total of 29 7. Borle RM, Borle SR. Management of oral submucous
cases of advanced fibrosis (14 test subjects and 15 fibrosis: a conservative approach. J Oral Maxillofac
age and sex matched diseased controls) were Surg.1991 Aug; 49 (8):788-91.
included in this study and followed for a period 8. Lai DR, Chen HR, Lin LM, Huang YL, Tsai CC.
of 7 months and 100% compliance was reported Clinical evaluation of different treatment methods for
oral submucous fibrosis. A 10-year experience with
at the end of the test period. The only untoward
150 cases. J Oral Pathol Med. 1995 Oct; 24
symptom was mild gastric irritation, which could (9):402-6.
be managed by diet protocols. Review of the 9. Haque MF, Meghji S, Nazir R, Harris M. Interferon
patients and controls was done at an interval of gamma (IFN-gamma) may reverse oral submucous
30 days and subjective and objective fibrosis. J Oral Pathol Med. 2001 Jan; 30 (1):12-21.
measurements were recorded. Significant 10. Tai YS, Liu BY, Wang JT, Sun A, Kwan HW,
comparisons with regard to improvement were Chiang CP. Oral administration of milk from cows
recorded as objective criteria of mouth opening, immunized with human intestinal bacteria leads to
tongue protrusion, and relief from perioral fibrotic significant improvements of symptoms and signs in
bands. Subjective symptoms of intolerance to patients with oral submucous fibrosis. J Oral Pathol
spices, burning sensation of mouth, tinnitus, Med. 2001 Nov; 30 (10): 618-25.
difficulty in swallowing and difficulty in speech 11. Hastak K, Lubri N, Jakhi SD, More C, John A,
were also recorded significant improvement at the Ghaisas SD, Bhide SV. Effect of turmeric oil and
turmeric oleoresin on cytogenetic damage in patients
end of the trial period. Thus the study proved the
suffering from oral submucous fibrosis. Cancer Lett.
effectiveness of pentoxifylline as an adjunct 1997 Jun 24; 116 (2): 265-9.
therapy in the routine management of oral
submucous fibrosis.12 12. Rajendran R, Rani V, Shaikh S. Pentoxifylline
therapy: a new adjunct in the treatment of oral
In our study there were no reported instances submucous fibrosis. Indian J Dent Res 2006 Oct-Dec;
of side effects or intolerance to lycopene. There 17 (4):190-8.
1159
A Maxillary First Molar with Six Canals: A Case Report

Dr. A.V. Rajesh Ebenezar1, Dr. A. Vinita Mary2
ABSTRACT
This paper reports the case of retreatment of a maxillary right first molar that presented three root
canals in the mesiobuccal root, two root canals in distal root and a single canal in palatal root. The
possibility of more than three root canals in this tooth should always be considered by taking into account
the clinical and radiological evaluation. Often, their presence is noticed only during retreatment due to
continuing post-operative discomfort
Keywords: Retreatment, Dental Anatomy, Maxillary First Molar.
INTRODUCTION practitioner. His past medical history was found to

be non-contributory. Clinical examination revealed
Variation in the root canal morphology is a
right maxillary first molar (tooth 16, Fédération
norm rather than the rule. A favourable prognosis
Dentaire Internationale, FDI) with tenderness on
of a root canal therapy requires a thorough
acquaintance of both the external and internal percussion. Radiographs were taken which
anatomy of the root and its canal morphology.1 revealed incomplete obturation in all the main
Variations in the canal morphology pose a canals thus necessitating retreatment.
continuous challenge to the endodontist in their The tooth was anesthetized using 2%
diagnosis and management. Extra roots and root Lignocaine with 1:80,000 adrenaline (Lignox,
canals if not detected and treated are the prime Indoco Remedies Ltd, Mumbai, India) and isolated
reasons for root canal failure.2 The most treated with rubber dam. An endodontic straight-line
and least understood posterior tooth is the “6-year
access cavity was established by removing all
molar,” which is the largest tooth in volume and
interfering tooth structure and restorative material.
most complex in root and canal anatomy.3
Extensive anatomical variations in the number of The pulp chamber was frequently flushed with
roots and canal morphology of maxillary first 5% sodium hypochlorite to remove debris and
molars have been reported in the literature.4 Case bacteria. Probing with DG16 (Hu-Friedy, USA)
reports of maxillary first molar with unusual canal revealed 6 canals; 3 mesiobuccal, 2 distobuccal
morphology is given in table 1.5 and 1 palatal. The patency of canal was checked
The main objective of root canal therapy is with # 15 K-File NITIFLEX file (Maillefer,
thorough shaping and cleaning of all pulp spaces Dentsply, Ballaigues, Switzerland).
and its complete obturation with an inert filling A working length radiograph was taken and
material. The presence of an untreated canal may the presence of 6 canals was confirmed. Cleaning
be a reason for failure. A canal may be left
and shaping was performed using a crown-down
untreated because the dentist fails to recognize its
technique with ProTaper series nickel–titanium
presence. Thus it is extremely important that
clinicians use all the armamentaria at their disposal rotary instruments (Maillefer, Dentsply, Ballaigues,
to locate and treat the entire root canal system.6 Switzerland) under lubrication with EDTA (Glyde,
Maillefer, Dentsply) and abundant irrigation with
5% sodium hypochlorite solution and saline. The
CASE REPORT tooth was dried with paper points, and a cotton
A 35-year-old male patient reported to the pellet was sealed into the pulp chamber with a
Ebenezar Dental Clinic in Chennai city of India, temporary restorative filling material (zinc oxide
with the chief complaint of pain in the posterior eugenol cement). The patient was recalled after 3
right maxillary region for the preceding 1 week. days. During the subsequent visit, the canals were
He gave a history of root canal treatment being irrigated, dried with paper points (Maillefer,
done 2 months back by a general dental Dentsply) and filled with cold, laterally condensed
1
Reader, Dept. of Conservative Dentistry and Endodontics, S.R.M. Dental College, Chennai. 2Senior Lecturer, Dept. of
Preventive and Community Dentistry, Thai Moogambigai Dental College and Hospital, Chennai
1160
Table 1. ‘Case reports of maxillary first molar with unusual canal morphology5
Name of the Autho Unusual morphology of the maxillary first molar

Harris (1980) 4 canals with 1 mesiobuccal, 1 distobuccal, and 2 palatal roots
Cecic et al. (1982) 5 canals with 2 mesiobuccal, 1 distobuccal, and 2 palatal roots
Martínez-Berná and Ruiz-Badanelli (1983) (3 cases) 6 canals with 3 mesiobuccal, 2 distobuccal, and 1 palatal roots
Stabholz A and Friedman S (1983) 5 canals with 3 buccal and 2 palatal roots (presumably fusion of the
maxillary right first molar and second premolar)
Beatty (1984) 5 canals with 3 mesiobuccal, 1 distobuccal, and 1 palatal roots
Newton and McDonald (1984) C-shaped canal configuration
Bond et al. (1988) 6 canals with 2 mesiobuccal, 2 distobuccal, and 2 palatal roots
Dankner et al. (1990) Bilateral C-shaped canal configuration
Wong (1991) Palatal root characterized by a single canal orifice a trifurcation on the
apicalone-third of the root, and 3 separate foramina
Holtzman (1997) (2 cases) 5 canals with 2 mesiobuccal, 1 distobuccal, and 2 palatal roots
Hulsmann (1997) 4 canals with 2 distobuccal, 1 mesiobuccal, and 1 palatal roots
Di Fiore (1999) 4 roots: distobuccal, distopalatal, mesiobuccal, and mesiopalatal
Fava (2001) 2 roots: buccal and palatal, with Weine type IV configuration in the buccal root
Johal (2001) 5 canals with 2 mesiobuccal, 1 distobuccal, and 2 palatal roots
De Moor (2002) (4 cases) C-shaped canal configuration
Baratto-Filho et al. (2002) 2 palatal roots, each with separate canal
Maggiore et al. (2002) 6 canals with 2 mesiobuccal, 3 palatal, and 1 distobuccal roots
Barbizam et al. (2004) 2 cases with 4 roots and an extracted molar with 5 roots
Ferguson et al. (2005) 5 canals with 3 mesiobuccal, 1 distobuccal, and 1 palatal roots
Yilmaz et al. (2006) C-shaped canal configuration
Chen and Karabucak (2006) 4 canals with 2 distobuccal, 1 mesiobuccal, and 1 palatal roots
Gopikrishna et al. (2006) Single root and single canal
Favieri et al. (2006) 5 canals with 3 mesiobuccal, 1 distobuccal, and 1 palatal roots
Adanir (2007) 4 roots (mesiobuccal, mesiopalatal, distobuccal, and palatal) and 6 canals
with 1 mesiobuccal, 2 mesiopalatal, 2 distobuccal, and 1 palatal roots
Gopikrishna et al. (2008) 2 palatal roots and a single fused buccal root
Fig. 1. Occlusal view of the access opening showing MB1, MB2, Fig. 2. Occlusal view of seating of master point, displaying six
MB3, DB1, DB2 and P canal orifices root canal orifices
1161
Protaper gutta-percha points (Maillefer, Dentsply) to failure of root canal treatment in the initial
and AH Plus resin sealer (Maillefer, Dentsply). attempt by a general dental practitioner.
A high degree of clinical success in
RADIOGRAPHS
endodontic treatment requires a thorough
understanding of root canal anatomy and
morphology. Successful root canal therapy requires
thorough cleaning, disinfection, and shaping
followed by complete obturation of the canal
system. A comprehensive knowledge of canal
anatomy and its variations is crucial as untreated
root canals can lead to endodontic failures.7 The
search for an extra orifice is aided by the use of
fiber-optic transillumination to locate the
developmental line between the mesiobuccal and
mesiolingual orifices. A DG 16 endodontic probe
used as a pathfinder determines the angle at which
the canals depart from the main chamber.
Magnification and illumination are absolute
Pre-Operative Radiograph prerequisites for evaluating colour changes and
working deep inside the tooth.6 In this case, the
inability to detect, locate, negotiate and instrument
all root canals may have lead to the endodontic
failure necessitating retreatment.8
Usually, the interpretation of the radiograph
along with a careful inspection of the pulp
chamber floor by probing and by proper
visualization allows the operator to understand the
root canal configuration. To investigate properly
the possibility of additional canals, the dentist
should:
• understand the complexity of the morphology
Working Length Radiograph of the tooth involved
• take additional off-angle radiographs
• ensure adequate “straight-line” access to
improve visibility
• examine the pulpal floor for “lines” to areas
where additional canals may be located
• remove a small amount of tooth structure that
often may occlude a canal orifice.
The dentist should be suspicious of additional
canals if endodontic files are not well centred in
the canal on the radiograph or if endodontic files
are not well centred in the canal clinically.9
Post-Obturation Radiograph In the present case report, reinfection of the
root canals or the infection from the missed canals
DISCUSSION
could have necessitated the need for retreatment.
This article presents a case of a maxillary first
molar with an unusual number of six canals with CONCLUSION
incomplete obturation in the main canals leading
Successful endodontic treatment begins with
proper clinical and radiographic examinations.
1162
Careful interpretation of the radiograph, close maxillary first molar: a literature review. J Endod.
clinical inspection of the floor of the chamber, and 2006 ; 32 :813-820.
proper magnification of the chamber floor are 5. Cobankara FK, Terlemez A, and Orucoglu H.
essential for a successful treatment outcome. Maxillary first molar with an unusual morphology:
report of a rare case Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 2008; 106: e62-e65.
REFERENCES
6. Vertucci FJ. Root canal morphology and its
1. Fava LRG. Root canal treatment in an unusual relationship to endodontic procedures. Endodontic
maxillary first molar: a case report. Int Endod J. Topics. 2005; 10: 3–29.
2001; 34: 649-653. 7. Ping Chen I, Karabucak B. Conventional and surgical
2. Slowey RR. Radiographic aids in the detection of endodontic retreatment of maxillary first molar:
extra root canals. Oral Surg Oral Med Oral Pathol. unusual anatomy. J Endod. 2006; 32 (3): 228-230.
1974; 37: 762-771. 8. de Almeida-Gomes F, de Sousa BC, de Souza FD,
3. Burns RC, Herbranson EJ. Tooth morphology and dos Santos RA, Maniglia-Ferreira C. Three root
access cavity preparation. In: Cohen S, Burns RC, canals in the maxillary second premolar. Indian J
editors. Pathways of the pulp. 8th ed. St. Louis, MO: Dent Res. 2009; 20 (2): 241-242.
Elsevier Mosby; 2002. p. 173-229.
9. Johal S. Unusual Maxillary First Molar with 2 Palatal
4. Cleghorn BM, Christie WH, Dong CCS. Root and Canals Within a Single Root: A Case Report. J Can
root canal morphology of the human permanent Dent Assoc. 2001; 67: 211-214.
1163
Periodontal Treatment of Multi – Rooted Teeth

Dr.D.Jayanthi1, Dr.M.B.Aswath Narayanan2, Dr.S.G.Ramesh Kumar3
ABSTRACT
Multi – rooted teeth present unique challenge to the success of periodontal therapy because of furcation
areas. Anatomical and morphological complicating factors dictate modification in treatment modalities and
to emphasize that for a detailed clinical, radiographical and intraoperative diagnosis of the furcation
invasion.
The various approaches are available for the treatment of multi – rooted teeth. Furcation management
is usually, based on the individual clinical situations morphological, functional variations and also general
health status of the concerned individual status of the concerned individual.
BACKGROUND system (removed during root resective

procedures). Smaller root surface.
Multirooted teeth present unique challenge to
the success of periodontal therapy because of
Maxillary molar3
furcation areas. Anatomical and morphological
complicating factors dictate modification in 1. Mesial root is oblong, has distal concavity
treatment modalities and to emphasize that for a (retension) mesial furcation about 2/3 the
detailed clinical, radiographical and intraoperative buccopalatal surface of the tooth to the palate.
diagnosis of the furcation invasion : So palatal approach in indication when
probing the mesial palatal furcation.
“Furcation” is defined as “the anatomic area
of a multirooted tooth where the roots diverge. 2. Distal, palatal furcation shorts, is in the middle
“Furcation invasion” means pathologic resorption portion of the tooth – it can be probed from
of bone within a furcation either facial (or) palatal application.
IMPACT OF ETIOLOGIC FACTORS IN
DIFFERENCE BETWEEN MANDIBULAR
TREATMENT3
AND MAXILLARY MOLAR1,2
1. Primary factors
Mandibular molar furcations opens from the
buccal to lingual direction. It do not damage the (a) Plaque associated inflammation: Extension
interdental bone of the adjacent teeth. Rather in of inflammatory periodontal disease process into
maxillary molar it opens in mesial and distal with the furcation areas leads to interradicular bone
loss of interdental bone on adjacent teeth. resorption and formation of furcation defects. No
unique histological features were found in the
furcation areas suggesting that they were extension
Mandibular molar3 of existing periodontal pocket. (Glickman 1950).
1. Mesial root is thin, biconcave disk, have two (b) Trauma from occlusion :
root canal, apical portion shows distal
curvature. That is obstacle to extraction when Controversy still exists: Trauma from
the tooth is sectioned. (mesial root is to be occlusion is suspected etiologic factor in
removed). isolated furcation defects (Glickman et al,
1961) reported. The periodontal fiber
2. Distal root is more oblong, flat mesial and orientation in furcation areas facilitated a
distal structure. It has one root canal and is more rapid spread of inflammation and
easier to manage prosthethics because it is accounted for inflammation increased
more parallel to the post. susceptibility to occlusal forces.
3. Candidate for a post and core build up due to Trauma from occlusion combined with
its perimeter morphology and root canal deeper inflammation in furcation results in
1, 3
Assistant Professor, 2Professor and Head, Dept. of Public Health Dentistry, Tamilnadu Govt. Dental College and Hospital,
Chennai.
1164
more rapid loss of attachment than from (b) Root Trunk and root length4
inflammation alone (Lindhe and Svanberg
(i) Short trunk and long root lengths
1974).
If etiology is trauma from occlusion first More easy to furcation invasion
correct the occlusal prematurities than The amount of remaining periodontal
procede further management. tissue support is sufficient. (Suitable for
(c) Pulpal pathology: The high percentage of resection / separation of roots).
molar teeth patent Accessory canals opening into Prognosis is good
the furcation suggests that pulpal disease could be
in etiological factors.
Pulpal lesions are pure endodontic–treated
early by endodontic therapy. These
furcation defects, resolve with
regeneration of new interfurcal bone and
attachment.
Combined endodontic – periodontic defect
– prognosis is poor. (ii) Long root trunk and short root length
Furcation invasion is non vital tooth – first
Furcation involvement occur later
to initiate endodontic therapy and wait 3
and 4 weeks for endodontic lesion healed Periodontal support is insufficient (not
clinically and to perform extensive suitable for root resection procedure)
periodontal surgery Prognosis is poor
Surgical treatment of furcation invasion
should be delayed for at least 6 months to
allow for healing of hard and soft tissue
defects caused by the endodontic lesion
(d) Vertical root fracture: Rapid, localized,
alveolar bone lose is often associated with vertical
root fracture. Root fracture involves the trunk of
a multi – rooted, tooth, furcation – a rapidly
forming isolated furation defects can result. The
prognosis is poor and usually results loss of the
tooth. (Lommel et al 1978). 3. Root Concavities1
(e) Teratogenic co-factors: Overhanging Reducing efficacy of periodontal therapy
restoration lead to furcation invasion molar with
crown (or) proximal restoration had a significantly
Maxillary first molar. Concavities seen.
Especially mesiobuccal roots (94%)
high percentage of furcation involvement than non
restored teeth (Wang et al, 1993). In these case Mandibular first molar, especially mesial
first corrects the overhanging margin than proceds root = 100%
further management regarding furcation
involvement.
2. Contributing factors
(a) Furcation Entrance width1

< 1 mm = 8.1% in maxillary molar = 63%
< 0.75mm = 58% in mandibular molar = 53%
(Baves et al, 1979)
Considering that average width of a currette
blade face ranges between. 0.75 to 1.10mm only
for proper root preparation.
1165
These concavities exceed in 1mm depth and 1. Intermediate ridges connect the mesial & distal
covered by a thicker layer of cementum than the root consists primarily cementum.
adjacent root concavities which allow bacterial
2. Buccal and lingual ridge primarily consists of
plaque, toxin calculus to penetrate further into the
dentin with thin lager of cementum. These
root surface and making their removal more
ridges from root of the furcation locate more
difficult.
coronally than the entrance and provide yet
another barriers to successful plaque control
4. Cervical enamel projections5 (CEPs)
and root perforation.
The lack of connective tissue attachment
These ridges in addition to root concavities,
on enamel surface. CEPs cause
create small hard to reach inches and Cul-de-sacs
Because it is ectodermal origin derivative
for plaque control.
and is covered only by epithelium
Incidence of CEPs – 28.6% (Mandibular 6. Enamel Pearls
molars), 17% (maxillary molars) Preventing connective attachment
CEPs make a molar more vulnerable to Prevalence of enamel – pearls in less
inflammatory disease. In 1964 Master’s and thanCEPs
Hoskins classified CEPs into – 3 grades. Incidence 2.6% (Moskow and Canut
Prevalence is higher in mandibular and second 1990)7
maxillary molar
7. Inter radicular dimension
Grade I Distinct change in CEJ
Closely approximated (or) fused roots preclude
contour with enamel
projecting toward the
adeque instrumentation, Scaling & root planning
bifurcation (<1/3 of the root and surgery widely separated root present more
trunk). treatment, options and are readily treated.
CLASSIFICATION OF FURCATION
INVOLVEMENT3
Grade II CEP approaching the
furcation, but not actually 1. Glickman (1953)
making contact with it (> 2. Goldman (1958)
1/3).
3. Hamp et al (1975)
4. Ramford and Ash (1979)
Grade III CEP extending into the 5. Ricchetti (1982)
furcation proper
6. Tarnow & Fletcher (1984)
IMPACT OF DIAGNOSIS8
(a) Radiograph:
Furcation arrow: Maxillary, small triangular,
The extent of the enamel projection is directly radiolucent shadow is seen over the mesial and
proportional to the amount of furcation distal root in the proximal furcation (deep grade
involvement. CEPs affects II (or) grade III).
1. Plaque removal and complicate sealing 1. Ross and Thompson 1980 of ported that
and root planning radiograph was able to detect FI 22% of maxillary,
8% mandibular molar (discrepancy based on bone
2. Local factor for developing gingivitis and density)
periodontic (Mesial FI – 19% degree I, 44% degree II,
55% degree 3 Furcation
5. Bifurcational ridges6
Distal FI - 12% degree I, 30% degree II, 52%
Types: 1. Intermediate (73%) degree III)
2. Buccal and lingual ridges (60%) (b) Clinical probing: Both horizontal / vertical
measurement done for accuracy
1166
1. Horizontal probing done with Nabers probe (c) Correlate with x – ray after clinical
with calibrated in 1mm increments can be used to examination
measure the horizontal break down 2. Status of adjoining interporximal / buccal
Mandibular molar probing: lingual gree
(a) Easily probed 3. Morbidity (grade III furcation involvement
become of bucco with mobility)
lingual entrance 4. Root angulation
(b) Furcation located 5. Health of neighboring tooth
midway
mesiodistally in 6. Position of the tooth in the arch
maxillary molar. 7. Age and health of the patient
Maxillary molar probing: 8. Foul tune of endodontic therapy
TREATMENT OF MULTI-ROOTED TEETH3
Goals of treatment
1. Arresting the disease process

2. Maintaining the teeth in health and function
with appropriate esthetics
Varies treatment
Factors to consider
approaches
1. Open and closed root 1. Degree of Involvement

preparation
(a) Buccal furcas accessible midway mesiodistally
(b) Distal furcation – midway bucolingually 2. Odontoplasty 2. Crown / root ratio;
probed bucally (or) palatally. length of roots
(c) Large buccolingual width of the mesio force 3. Opendebridement / 3. Root anatomy /
root – mesial forces open 2/3 of the way pocket (apically positioned morphology
towards the palate. So palatal aspect is easily flap) elimination
probed. 4. Tunneling procedures 4. degree of root separation
2. Vertical probing: used to measure the 5. Root resection 5. strategic value of the
attachment loss with straight probe. tooth
Lang et al 1991 – pressure – controlled probes (a) Root Amputation 6. Residual tooth mobility
are used and a probing forces about 0.25N with
probe diameter of 0.4 to 0.5 mm. (b) Hemisection 7. Need for endodontic
treatment
(c) Bone sounding: Transgingival probing with
6. Bicuspidization (root 8. Prosthetic requirements
local anaesthesia – more accurately determining
Separation)
the underlying bony contours. (Greenberg et al,
1976). A thorough understanding of molar root 7. Regenerative approaches 9. Periodontal condition of
anatomy is essential for proper diagnostic and (GTR, Bone Grafts, BMPs) adjacent teeth
therapeutic decision. 8. Extraction / Implant 10. Ability of bone to place
Placement implants
PROGNOSIS: Following factors to be
considered in prognosis: 11. Ability to maintain oral
hygiene
1. Extent of involvement
12. Financial consideration
(a) Partial (or) total
13. Long – term prognosis
(b) Apical extent of bone loss
1167
TREATMENT APPROACHES BASED ON are narrower mesiodistally, wide post results in

DEGREE OF INVOLVEMENT root perforation and fracture. Ideal root for placing
posts are – maxillary palatal root, mandibular
Class Treatment distal root. Placement of circular shaped posts with
Class I • Scaling and root planning great diameter in mandibular mesial and maxillary
mesiobuccal root canal results in root cracles
• Odontoplasty, gingivectomy
perforation.
Class II • Scaling and Root Planning
3. Crown margin should be supra gingival
• Odontoplasy (0.5 to 1mm subgingival)
• Open debridement / Furcation Operation
4. Residual mandibular defect
• Apically positioned flap
• GTR / CONCLUSION
• Root resection
The various approaches are available for the
• Tunnel Preparation treatment of multi – rooted teeth. An
• Extraction / Implant Placement understanding of the special anatomical and
Class III • Open Debridement / Furcation Operation morphological features of root furcations and the
limitations those features present in essential for
• Apically positioned flaps successful treatment outcome. Furcation
• GTR (Questionable Success) management is usually, based on the individual
• Root resection clinical situations morphological, functional
variations and also general health status of the
• Tunnel preparation concerned individual status of the concerned
• Extraction / Implant Placement individual.
INDICATION AND CONTRAINDICATION OF REFERENCES

ROOT RESECTION9
1. Bower RC. Furcation morphology relative to
Indication Contraindication periodontal treatment. Periodontal entrance
architecture. J Periodontology 1979; 50;23
1. Class II (or) III Furcation 1. Inadequate bone support
2. Dunlap R and Gher ME. Root Surface measurement
involvement on the remaining roots (or)
of the mandibular molars. J Periodontology 1985; 56;
unfavourable anatomical
234-238
factors
3. Khala F, Al-Shammari, Christopher E-Kazar and
2. Severe bone loss 2. Significant discrepancies Home KY Wans. Molar anatomy and management. J
involving one (or) more roots. inadjacent interproximal bone Clinical Periodontology 2001; 28 (8); 730-740
height.
4. Hermann DW, Gher ME, Dunlap R and Peller GB.
3. Root Fracture, 3. Remaining roots cannot The potential attachment areas of the maxillary first
perforation, resorption (or) restored / endodondically molar. J Periodontology 1983; 54; 431-434
deep root caries treated.
5. Masters DH and Hoskin’s SW. Projection of enamel
4. Root proximity with into molar. J Periodontology 1964; 35; 49-53
adjacent teeth
6. Everett FG, Jump EB, Holder TD and Williams GC.
5. Failed endodontic The intermediate bifurcational ridge. Journal of
treatment (or) inoperable / Dental Research 1958; 17-62
calcified canals
7. Moskow and Canut. Studies on root enamel pearls. J
Clinical Periodontology. 1990; 17; 275-278
RESTORATIVE CONSIDERATION 8. Kalfwarf KL and Reinhardt RA.D. Diagnosis and
1. Posts and cores should be used when in treatment of furcation invasion. Dental Clinics of
North America 1998; 32; 243-266
absolute need.
9. G.Carnevele, R.Pontorioro and Gidi Febo. Long term
2. Using of thick, parallel post should be effect of root – resective therapy in furcation involved
avoided in narrow, tapered once. Parallel posts will molars. J Clinical Periodontology 1998; 25(3);
generate greater apical shift. In molar roots which 209-214
1168
Integrating Bleaching with different Treatment Modalities:

A Review
Dr Dildeep Bali1, Dr Deepika Thosre Chandhok2, Dr Dipanjit Singh3, Dr Ashish Chowdhary4,
Dr Shweta Bali5, Dr Pryanka Thakural6, Dr Ekta Chowdhary7
ABSTRACT
Bleaching is one of the most conservative techniques for treating discoloration. Microabrasion can be
combined with home bleaching or power bleaching to remove these discolorations more effectively. Which
procedure is done first depends on the specific case. This article discusses the interaction of bleaching and
other treatments done in dentistry and which one should be preferred first.
INTRODUCTION whitening and brightening the teeth. Unlike

microabrasion, bleaching preserves the intact
Small white, brown or mottled lesions that
fluoride rich layer of enamel and the tooth shape.
appear on anterior teeth can be unaesthetic and
patients are often concerned about this type of The two techniques can be used in conjunction
discoloration. Before the introduction of acid with each other depending on the specific case.
etching, teeth that had these discolorations were Sometimes after microabrasion, the tooth appears
cut down to have full coverage restorations. The more yellow or darker. Bleaching can thus follow
microabrasion technique can be used in rnicroabrasion to improve tooth color. The best
combination with home bleaching or power results and improvements are achieved with a
bleaching to remove these discolorations more combination of both treatments.
effectively. Which procedure is done first depends
on the specific case. INDICATIONS
Enamel microabrasion is a procedure in which • Intrinsic developmental stains and
a microscopic layer of enamel is simultaneously discolorations
eroded and abraded with a special compound, • Superficial surface enamel stains and opacities.
leaving a perfectly intact enamel surface behind 1.
It is used to treat enamel discolorations which may • Yellow-brown areas on teeth.
be the result of hypermineralizations, • Multicolored stains (brown, grey or yellow)
hypomineralisations or staining. This is called • Superficial hypoplastic enamel or ’enamel
’enamel dysmineralization’, which describes the dysmineralisation’ 1
superficial enamel coloration defects resulting from
some disturbance of the normal mineralization • Areas of enamel fluorosis.
process 1. There are advantages in using a • White patches, white spots.
combination of chemical and mechanical surface • Decalcification lesions from accumulation of
microreduction. In successful cases enamel loss is plaque and from orthodontic bands.
insignificant and unrecognisable and the patient is
left with tooth surfaces that appear normal. When CONTRAINDICATIONS
treatment planning and discussing with the
patients, this technique can be used either before, Age-related staining
after or during the bleaching treatments. Tetracycline staining
Microabrasion improves tooth color by Deep enamel hypoplastic lesions
eliminating the superficial discolored enamel. Amelogenesis imperfecta
Bleaching improves tooth color by lightening, Dentinogenesis lesions
1
Professor, 2Senior Lecturer, Dept. of Conservative Dentistry and Endodontics,5,6Professor, Dept. of Periodontics, Santosh
Dental College and Hospital, Ghaziabad
4
Professor, Dept. of Prosthodontics, 7Professor, Dept. of Conservative Dentistry and Endodontics, School of Dental Sciences,
Sharda University, Greater Noida
3
Professor and Head, Dept. of Prosthodontics, Maharana Pratap College of Dentistry and Research Center, Gwalior
1169
Carious lesions underlying regions of Clinical Technique

decalcification 1. Clinical evaluation of the teeth: Teeth
Areas of deep enamel and dentine stains should be in moist state. The enamel should be
assessed from the incisal edge with the aid of a
ADVANTAGES OF MICROABRASION mouth mirror to assess labiolingual enamel
thickness of the tooth and the lesion depth.
• It is easily performed
• It is an effective and conservative treatment 2. Treatment planning: Case selection and
• It is inexpensive discussion with the patient regarding the
consequences, side effects, benefits and further
• Teeth require minimal subsequent maintenance options for treatment such as bleaching, veneers
• It is fast acting 2 bonding and crowns need to be discussed.
• It removes yellow-brown, white and 3. Equipment needed: Contra-angle slow
multicoloured stains handpiece, microabrasion material, polishing or
• Results are permanent prophylaxis paste, rubber dam or paint-on dam and
lip retractor, protective spectacles and coverings
DISADVANTAGES OF MICROABRASION for dentist and assistants.
• It removes some amount of enamel Clean teeth with rubber cup and prophylaxis
• Hydrochloric acid compounds are caustic. It paste. Isolate the teeth .Microabrade the lesion
requires protective apparatus for patient, using a fine grit diamond or tungsten carbide bur.
dentist and assistant Apply the microabrasion compound to the areas
within 60 second intervals with appropriate rinsing.
Hydrochloric Acid
Repeat the procedure. Polish using a fine grit
Hydrochloric acid and pumice are the main fluoridated prophylaxis paste. Rinse the teeth.
ingredients used for the technique. The use of Re-evaluate. There is nothing to lose by trying the
hydrochloric acid depends on the decalcification of micro abrasion technique first and then continuing
enamel, i.e. softening and dissolving the enamel to on to further treatment such as bleaching or
remove the stain 2. Normally less than 200 %m in bonding if the former is not successful. Remove
total of enamel is removed, but it may be much the rubber dam. Apply topical fluoride (neutral
less. The technique may be enhanced by adding sodium fluoride gel) for 4 minutes . Fluoride
an abrasive (pumice such as advocated by Croll), mousse applications can be done for 1 minute.
heat or chemical such as hydrogen peroxide and Re-evaluate the result. In some cases more than
ether one visit may be necessary. Review the patient 4-6
Methods of using hydrochloric acid weeks later and take postoperative photographs.
There are three techniques, which have been Microabrasion and Home Bleaching:
suggested for using hydrochloric acid 2 Following the microabrasion treatment, the teeth
1 A cotton pellet soaked in 18% hydrochloric can be re-evaluated 6 weeks later to assess whether
acid and applied to the stain. any further treatment is required. Home bleaching
following microabrasion can be quite successful.
2. 18% hydrochloric acid mixed with pumice and
applied to the stain via a prophy cup. Integrating Bleaching with Restorative
3. Commercially available Proprietary kits. Techniques: Bleaching can easily be
incorporated into a restorative treatment plan,
Effect on the enamel regardless of age of the patient. Whether bleaching
The rotary application process allows the should be used before, during or after restorative
material to simultaneously abrade and erode the dentistry often depends on the case; the
enamel surface and remove the stain. The enamel complexity, the time that it will take, and the
surface layer is restructured to form an amorphous patient’s needs and wishes. Some dentists consider
prismless layer that clinically appears smooth and the bleached color as the baseline from which to
lustrous. It consists of an amorphous layer of start all restorative dentistry. It is normally
compacted mineral. This effect has been called the preferable to first bleach the teeth prior to
‘enamel glaze’ or ‘abrasion’ effect. commencing advanced restorative dentistry. It is
1170
better to plan for bleaching at the beginning of a amount of mercury released into carbamide
treatment plan. peroxide solutions was as high as 30 times than
seen with saline solution, and depended heavily on
Bleached Dentition and Indirect Restorations:
the type of bleaching agent applied and the type
The process of shade matching of fixed
of amalgam .3,4
restorations to the bleached dentition can be
difficult because sometimes the shade changes so Another potential risk of bleaching patients
dramatically, that it lightens more than the lightest with amalgam restorations is discoloration. In a
shade reference on the ceramic or composite shade case study published, describing greening of the
guide. When fabricating porcelain restorations with tooth-amalgam interface after bleaching
a bleached enamel appearance, an assortment of treatment the researcher found caries in the
external porcelain layers can be utilized to match area of the green discoloration 5. The report
predictably the shade of the existing enamel. stated that the cause of the green discoloration is
unclear, and more research on the topic is
Teeth Requiring Extensive Restorative necessary. The implication of this study is that
Dentistry: Even if patients are about to embark dentists should be prepared to replace amalgam
on a courseof extensive restorative dentistry that restorations with greening to remove possible
may take a long time to complete, bleaching as an decay. In conclusion, many studies show that
initial therapy may motivate the patient sufficiently carbamide peroxide bleaching may increase the
to continue and complete the extensive programme release of mercury vapor from amalgam
of restorative dentistry that lies ahead. The simple restorations 5.
shift in shade of the anterior teeth may boost the
patient’s morale and self-confidence
Composite Restorations and Bleaching
Defective Restorations and Bleaching: Large When teeth have definitive white or brown
defective restorations such as open carious cavities stains, it may be preferable to use a combination
should be repaired prior to bleaching treatment to of microabrasion and bleaching prior to bonding
prevent unwanted penetration of the bleaching in order to diminish these discolorations when
agent through the open margins, which may bleaching alone does not accomplish the desired
exacerbate sensitivity during bleaching treatment. results. For teeth with existing restorations, one
The carbamide peroxide bleaching material does should wait at least 1 month after bleaching before
not have any detrimental effect on the existing replacing the restoration because of a concern for
tooth decay; in fact it may act as a cleansing agent. future marginal integrity. Pre restorative bleaching
Small marginal defects can be repaired may reduce bond strength as well as increase the
temporarily, by acid etching the margins and marginal leakage of restorations already present.
applying a flowable composite into the defective
margins. Fractured fillings can be repaired. If
patients with old restorations request bleaching, it Changes in bond strength of composites
must be explained to them before treatment that Many investigators have reported a severe
the teeth lighten, but restorations do not and would decrease in the average bond strength of composite
need to be replaced to match the color change. to bleached versus unbleached enamel
Provisional fillings can be placed using the
standard materials available, such as zinc oxide Other researchers have given ways to
eugenol dressings or glass ionomer cement. If the counteract the adverse bleaching effects so that no
entire restoration needs to be still replaced, it is statistical difference in bond strength was
better to select a composite shade lighter than the observed. Some examples of counteracting
existing dentition. If the definitive tooth coloured mechanisms are: exposing the enamel specimens
restoration is placed prior to bleaching, the patient to artificial saliva, water, or saline solution 7.
should be told that the selected shade is an Another suggestion was to use water-clearing
estimate and that the shade may need to be solvents, for example acetone, ethanol, or
modified after bleaching. acetone-based adhesive systems. Finally, it was
concluded that one should remove the superficial
Amalgam Restorations and Bleaching: Certain enamel layer8 Repolishing of the composites is
home bleaching products have the potential to suggested in order to overcome possible problems
increase mercury release from amalgam that might result from the slight surface changes
restorations. Two studies demonstrated that the produced by bleaching.
1171
Bleaching also resulted in morphological bleaching was undertaken after restorative

alterations in the most superficial enamel dentistry.
crystallites; they were short and randomly disposed
Although bleaching doesn’t change the color
and the characteristic alignment of the crystallites
of porcelain, bleaching of teeth that are covered
was lost. No changes in the relative concentrations
by porcelain veneers can change the apparent color
of oxygen were found in the enamel bleached with
of the veneers6. Use of 10% carbamide peroxide
10% carbamide peroxide.7 This indicates that the
in a custom-fitted tray can change the color of
surface roughening or removal suggested by other
underlying tooth structure.
researchers is not needed. Reduction of bond
strength caused by bleaching is therefore likely not
Ceramic Crowns: As teeth age, they usually
related to inhibition of resin polymerization by
incorporate stains and darken. An option for
oxygen accumulation in enamel.
treatment in this situation is to replace the existing
Another study also questioned the role of urea crowns and bridges with the new darker shade.
in surface changes.Urea is a known deproteinizing However, if the existing restorative dentistry is
substance and any mineral elements associated acceptable and a lighter shade is required, it would
with enamel proteins are also removed. This could be more appropriate to undertake bleaching
justify a decrease in the calcium and phosphorus treatment of the adjacent teeth, rather than
concentration is observed in bleached enamel.7 expensive and extensive restorative dentistry.
Effects of bleaching on Surface Color, Temporary Restorations: Hydrogen peroxide

Roughness and Hardness of Composites and carbamide peroxide both cause microscopic
changes to IRM restorations resulting in cracking
Carbamide peroxide lightened color and also
and swelling. On the other hand, IRM appears
roughen composite surfaces as detected by
unaffected by carbamide peroxide on the
profilometry and SEM but no clinically significant
macroscopic level7. Methacrylate temporary
result could be observed9.
restorations become orangish when exposed to
A study evaluated changes in surface carbamide peroxide. However polycarbonate
roughness of hybrid and microfilled composites crowns and bis-acryl composite temporary
after exposure with higher concentrations of restorations do not discolor upon bleaching.
carbamide peroxide. The study concluded that
higher concentration carbamide peroxide bleaching Hydrogen peroxide solution and gel has shown
products have minimal to no surface effects on not to cause any significant dissolution or increase
hybrid or microfilled composites10. in wear rate of glass ionomers12.
An in- vitro study evaluated the effect of 3 Cosmetic Contouring: Many patients choose to
bleaching products on the microhardness and have further aesthetic treatment following
surface texture of hybrid and microfilled composite bleaching. One option is cosmetic contouring
resins. SEM revealed cracking of microfilled which consists of selectively grinding enamel
specimens treated with carbamide peroxide surfaces to produce an improved outline form. This
Microhardness tests revealed that the treated can be achieved with fine diamond burs followed
composite resins became little softer11. by abrasive polishing points and polishing discs.
Porcelain Veneers: Bleaching can be attempted Periodontal Treatment: Bleaching treatment

first to assess the potential for whitening of the should always follow oral disease control
teeth. If it is successful, porcelain veneers may not particularly inflammatory periodontal disease.
be necessary. Even if the color is lightened Initial treatment, which may include root planing,
slightly, it may be sufficient to eliminate the use curettage and periodontal surgery, should be
of opaque porcelains or opaque cements in the carried out first. It is more appropriate to
final restoration to mask the existing discoloration. commence bleaching treatment once periodontal
Nevertheless, bleaching is a simple and relatively stability has been achieved . If periodontal
inexpensive technique to try first. If veneered teeth problems have created gingival hyperplasia that
become darker over time due to color regression, covers enamel, bleaching must be postponed until
they can be lightened from the palatal aspect using after the periodontal surgery exposes the entire
a bleaching material placed palatally in a crown. Bleaching treatment should be delayed until
nightguard. This would be a situation where periodontal stability has been achieved which may
1172
be 3-6 months and 6-12 weeks after periodontal REFERENCES

surgery.
1. Theodore P Croll: Enamel Microabrasion. Quint
When recession of gingival tissue has left a books. 1991
void and an unattractive loss of interdental tissues, 2. McEnvoy S A. Chemical agents for removing
you may contemplate using pink or tooth-colored intrinsic stains from vital teeth. II Current techniques
composite resin to bond the teeth and fill in the & their clinical application. Quin Intl 1989; 20(5):
379-384
interdental spaces. In this case, periodontal
3. Robertobello FJ, Dishman MV, Sarrett DC, Eperly
treatment is the primary procedure, followed by
AC. Effect of home bleaching products on mercury
bleaching, and finally bonding. This will ensure a release from an admixed amalgam. Am. J Dent 1999;
better match with the lighter tooth color. 12: 227-30.
In patients with advanced bone loss, 4. Hummert TW, Osborne JW, Norling BK, Cardentas
HL. Mercury in solution following exposure of
considerable cementum may be exposed, requiring
various amalgams to carbamide peroxides. Am. J
eventual restoration with bonding, lamination, or Dent 1993; 6: 305-9.
crowning. To bleach these teeth before laminating 5. Haywood V. Greening of the Tooth-Amalgam
or crowning is not mandatory. However, if cervical Interface during Extended 10% Carbamide Peroxide
bonding is selected as the treatment of choice, then Bleaching of Tetracycline-Stained Teeth: A Case
bleaching is best done in advance. Report. J Esthet Restor Dent 2002; 14:12-17.
6. Van B Haywood, Harry Parker. Nightguard vital
Bleaching And Orthodontic Treatment: bleaching beneath existing porcelain veneers: A case
Enamel staining after orthodontic treatment has report. Q I 1999;30:743-747
been reported in number of cases . Clinical signs
7. Perdigao J. Francci C, Swift EJ, Ambrose WW,
that have been reported include white spot lesions Lopes M. Ultra-morphological study of the interaction
around the bracket area. This discoloration has of dental adhesives with carbamide peroxide bleached
been suggested to be a result of enamel. Am. J Dent 1998; 11(6): 291-301.
hypomineralization around the bonded brackets. 8. Sung EC, Chan SM, Mito R, Caputo AA. Effect of
Another reason for staining may be due to acid carbamide peroxide bleaching on the shear bond
etching of the enamel. Corrosion products from the strength of composite to dental bonding agent
metal brackets may penetrate into the pores and enhanced enamel. J Prosthet Dent 1999; 82 (5):595-9.
leave a stain after removal of the appliance13. A 9. Cooley RL, Burger KM. Effects of carbamide
small layer of enamel may be removed during the peroxide on composite resins. Quintessence Int.1991;
debonding process that may alter the way light 22: 817-821
reflects off the tooth14. 10. Langsten RE, Dunn WJ, Hartup GR, Murchison DF.
Higher Concentration Carbamide Peroxide Effects on
A conservative approach that has been
Surface Roughness of Composites. J. Esthet. Restor
suggested involving thorough polishing using Dent.2002; 14: 92-96.
pumice mixed with hydrochloric acid, baking soda,
11. Bailey, E J Swift. Effects of home bleaching products
and a rubber cup. This procedure is only effective on composite resins. QI 1992;23:489-494
if the stain is superficial and has not penetrated 12. Lawrence Mair, Andrew Joiner. The measurement of
too far into the enamel surface14. A study on degradation and wear of three glass ionomers
effects of 10% carbamide peroxide gel to following peroxide bleaching. Jr of Dentistry
orthodontically-bonded/debonded teeth showed that 2004;32:41-45
there was a longer waiting period before noticeable 13. Hodges SJ, Spencer RJ, Watkins SJ. Unusual
color changes were detected due to resin tags indelible enamel staining following fixed appliance
treatment. J Ortho 2000; 27: 303-306.
remaining in the etched enamel after debonding
procedures which delay penetration of the peroxide 14. Hintz JK, Bradley TG, Eliades T. Enamel colour
changes following whitening with 10 percent
gel into the enamel surface. Finally the aggressive carbamide peroxide: a comparison of
approach to treating orthodontically stained teeth orthodontically-bonded/debonded and untreated teeth.
is the application of porcelain veneers 13 Eur J Ortho 2001; 23: 411-415.
1173
Vascular Leiomyoma of the Gingiva - A Rare Case Report

Dr. M.P.Singh1, Dr. Archana Bhatia2, Dr. Rose Kanwaljeet kaur3
ABSTRACT
Leiomyomas are benign soft tissue neoplasms that arise from smooth muscle. There are three distinct
types of leiomyomas: piloleiomyomas, angioleiomyomas, and genital leiomyomas, which reflect the most
origin of the smooth muscle tumor and correspond to the histologic or anatomic site. Angioleiomyomas,
as we present here, originate from smooth muscle within the walls of arteries and veins. However, careful
histologic examination is still necessary to distinguish these benign lesions from their malignant counterparts
due to different prognosis. Here, we present a case of angioleiomyoma found attached to the lower gingival.
Clinical and histological presentation of angioleiomyomas with its treatment will be discussed in this article.
Key words: Leiomyoma, Angioleiomyoma, Malignant transformation
INTRODUCTION may be evident. Root resorption has also been

shown. Surgical excision is the treatment of
Leiomyoma is a benign tumour of smooth choice.
muscle origin which is usually diagnosed in the
gastrointestinal tract, uterus and skin. Leiomyoma
CASE REPORT
was first reported by Blanc in 1884. It most
commonly arises in the retroperitoneum, mesentry, A 35 years old female patient reported to
omentum or subcutaneous and deep tissues of the department of Periodontology and Oral
limbs1,2. It is found uncommonly in the oral cavity Implantology of Dasmesh Institute of Research and
because of the paucity of the smooth muscles in Dental Sciences, Faridkot, Punjab State. She
this region (except in the blood vessel walls). If complains of gingival swelling in right lower front
at all it occurs, it shows its predilection in the region with dull intermittent pain since one year.
posterior portion of the tongue, lips, palate, cheeks, According to the patient, the swelling was initially
gingiva and salivary glands. Intraosseous oral small and gradually progressed to the present size
leiomyomas are rare and those of mandible are and was asymptomatic. Now, patient feel difficulty
very rare. Clinically, they can be seen at any age in eating due to enlarged gingiva (figure 1,2). Due
ranging from infancy to 76 yrs, but mostly seen to enlarged gingiva, patient stops brushing in lower
in middle aged group and exhibits male front teeth about two months. She denied any
predilection. There are three distinct types of history of traumatic injury, smoking or betal nut
leiomyomas: Piloleiomyomas, angioleiomyomas chewing. There was no family history and no
(vascular leiomyoma) and Epitheloid leiomyomas relevant medical history in the patient.
(bizarre leiomyoma or Leiomyoblastoma) which
reflect the most origin of the smooth muscle tumor Intra-oral examination:
and correspond to the histologic or anatomic sites. 1. Condition of teeth:41,42 and 43 are vital and
Leiomyoma is rare neoplasm of the oral cavity. It non-carious.
has been purposed that the origin of leiomyoma in
the oral cavity arises from vascular smooth muscle 2. Condition of gingiva:
and excretory ducts of salivary glands. The most On examination,
common histological type is vascular one. The Labial surface-a single bulging mass (2 × 1cm)
angioleiomyomas (representing about 64.0–66.2% over the right lower front gingiva (41,42 and
of all oral leiomyomas) usually occur in the lower 43)
extremities and behave as single, firm, slow Lingual surface: a single discrete mass
growing, and seldom painful lesions.
(1 × 1cm) over the right lower front
Radiographically, angioleiomyomas manifest as
unilocular or multilocular radiolucent lesions with gingiva
either an ill-defined or a well-defined sclerotic 3. Condition of periodontium:
border. Cortical expansion of the alveolar plates Probing pocket depth:
1
Professor and Head, 2Senior Lecturer, 3P.G. Student, Dept. of Periodontology and Oral Implantology, Dasmesh Institute
of Research and Dental Sciences, Faridkot (Punjab)
1174
Fig. 1. Pre-operative view(front view)
Fig. 3. Panaromic view shows slight amount of horizontal bone

loss in lower front teeth
Eosinophils - 1%) and Random Blood Sugar -
95mg/dl.
Biopsy :
Under local anesthesia,a curvilinear incision
was made at the base of the most superior portion
of gingival enlargement. Full exposure revealed
that 2-cm firm and pale growth, which in some
areas was densely attached to the periosteum. After
Fig. 2 Pre-operative view (lingual view)
complete excision of gingival enlargement, full
thickness flap was raised and granulation tissue
was removed completely. Then after carefully
observing, scaling and root planing was done.
Interrupted sutures were given and coe-pak was
placed. She was recalled after one week of surgery
(figure 4,5,6). Excised tissue specimen of size
1.5 × 0.8 × 0.5cm was fixed in 10% formalin
solution and send to laboratory for biopsy.
4. The lesion was firm and overlying mucosa is
grey brown to light brown in appearance and Microscopically, the tissue section exhibited
there was no tooth mobility. cellular areas intermingled with collagenous and
hyalinized areas. The tissue also exhibited
5. There was no pus discharge from the lesion numerous vascular areas and some areas were
and no associated lymphedenopathy punctuated with smooth muscle cells (figure 7,8)
.There is no recurrence of angioleiomyoma after
Investigations
• Panoramic X-ray
• Blood sample investigations
• Biopsy
Panoramic X-ray:
Radiographically, there was slight horizontal
alveolar bone destruction in relation to 41,42 and
43 region(figure 3).
Blood sample investigations:
Hb-11.4g/dl, BT-1mts 50 sec, CT- 4mts 45
sec, TLC-6200/cu mm, DLC (Polymorps - 61%, Fig. 4. Excised tissue sample taken during surgery
lymphocytes - 37%, Monocytes-1% and
1175
Fig. 5. Immediate after suturing at surgical site
Fig. 8. Histological examination shows proliferation of spindle

shape cells interspersed among multiple vascular spaces in
connective tissue
Fig. 6. Periodontal dressing was placed at surgical site
Fig. 9. Post-operative view(front view)
Fig. 7. Histological examination showing thickening of blood

vessel walls composed with smooth muscle cells
six months of excision of enlargement (figure

Fig. 10. Post-operative view (lingual view)
9,10).
Leiomyoma (solid leiomyoma), angiomyoma
DISCUSSION (vascular leiomyoma) and epithelioid leiomyoma
The World Health Organization classifies (leiomyoblastoma) 3,4. Angioleiomyomas are more
leiomyoma histologically into three categories: infrequent in the oral cavity than the extremities.
1176
Angioleiomyoma is a solitary form of leiomyoma are documented and the regrowth can usually be
that usually occurs in the connective tissue and removed with ease without further recurrence.
composed of numerous smooth muscle bundles
with thick-walled blood vessels and interspersed CONCLUSION
fibrous connective tissue. Stout designated them as
In conclusion, oral angioleiomyomas are
vascular leiomyomas to contrast them with
benign smooth muscle tumors. Because these
cutaneous leiomyomas that has thin-walled
tumors have only a limited degree of associated
vessels5. This variant of leiomyoma is most
morbidity, careful differentiation of these lesions
frequently seen in the oral cavity with 75% of all
from other malignant tumors such as
cases corresponding to this histological type. Since
leiomyosarcoma before treatment is necessary and
the pathogenesis is unclear, some consider them as
important. Long-standing leiomyomas can undergo
vascular hamartomas wherein the smooth muscle
malignant changes. Hence, all leiomyomas should
cells proliferate within a hemangioma, which
always be viewed with caution,and follow-up is
would produce an angioleiomyoma. This further
essential even though the benign nature of such
proliferates toward a simple leiomyoma6.Smooth
lesions is well-documented.
muscle is sparse in the oral cavity; however this
region is rich in blood vessels. Therefore, it has
REFERENCES
been proposed that the tunica media layer of the
blood vessels may be the origin of oral vascular 1. Katou Fuminori, Andoh Noriaki, Motegi Katsutoshi,
leiomyoma. The most frequent site of occurrence Nagura Hiroshi. Leiomyoma of the mandible: A rapid
is the lip, especially the lower lip, followed by the growing case with immunohistochemical and electron
microscopic observations. J. Oral and Maxillofacial
buccal mucosa and tongue7. A comprehensive
Pathology, 84 (1): 45-50, 1997.
literature search identified less than 20 cases of
gingival angioleiomyomas. The etiology of 2. John K Brooks, Nikolaos G, Nelson J, Bernard A.
Clinicopathologic characterization of oral
vascular tumor is uncertain, but it may be related angioleiomyomas. Oral surg Oral med Oral Pathol
to trauma, infection, hormones, and arteriovenous Oral Radiol Endod 94: 221-227, 2002.
malformations8. Break neck, in 1996, suggested
3. Enzinger FM, Lattes R, Torloni H. Histological typing
that angioleiomyoma could arise from cells of soft tissue tumours, Geneva, World Health
associated with tumor capillaries that differentiate Organization 1969;30-31.
into smooth muscle cells 9. 4. Radhika M B,et al:Common presentation of
Oral mucosal angioleiomyomas usually present uncommon lesions.World Journal of
as small, round or elevated sessile, normal colored Dentistry;Oct-Dec 2010; 1(3):213-216.
nodules that vary in firmness. Rough or irregularly 5. Ide F, Mishima K, Yamada H, Saito I, Horie N,
circumscribed tumors are seldom encountered. Shimoyama T,et al. Perivascular myoid tumors of the
oral region: A clinicopathologic reevaluation of 35
Ulceration is also rare, although acute
cases. J Oral Pathol Med 2008; 37:43-49.
inflammatory change has sometimes been reported,
as in our case. Smooth muscle is scarce in the oral 6. Duhig JT, Ayer JP. Vascular leiomyomas: A study of
sixty-one cases. Arch Pathol Lab Med 1959;
cavity,however this region is rich in blood vessels.
68:424-30.
Therefore it has been proposed that media layer of
7. Shetty SC, Kini U, D’Cruz MN: Angioleiomyoma in
blood vessels may be the origin of oral cavity
the tonsil: an uncommon tumour in a rare site. Br J
vascular leiomyoma Although the most frequent Oral Maxillofac Surg 40:169-71, 2002.
subjective complaints of patients with
8. Wong SK, Ahuja A, Chow J, King W:
angioleiomyoma of the extremities are pain or Angioleiomyoma in the submandibular region:an
tenderness or both, patients with head and neck unusual tumor in an unusual site. Otolaryngol Head
tumors seldom complain of pain. Because Neck Surg 122: 144-5,2000.
angioleiomyoma is usually slow-growing, in a 9. Kai –Feng Hung,An-Han Yan,Shou-Yen and Che-
superficial location, and asymptomatic, the average Shoa Chang.Angioleiomyoma in right lingual
preoperative period is months to years. Regardless gingiva-A case report.Clin J Oral Maxillofac Surgery
of the pathological type, about 5% recurrence rates sep 2005; 16:179-187.
1177
Adult Orthodontics - A Boon for the Periodontal Patients

1
Dr. Rohini Mali, 2Dr. Vishakha, 3Dr. Amita Mali, 4Dr. Priya Lele, 5Dr. Darshana Dalaya
ABSTRACT
The loss of periodontal support of teeth may result in elongation, spacing and proclination of incisors,
rotation and tipping of premolars and molars with collapse of the posterior occlusion and decreasing vertical
dimension. Adjunctive orthodontic therapy is necessary to resolve these problems. With properly performed
treatment, extensive orthodontic tooth movement can be made in adults with a reduced but healthy
periodontium without further periodontal deterioration. Interaction and co-operation between these two
specialties is essential in establishing a thorough diagnosis and planning a proper sequence of treatment
thus facilitating a coordinated therapy. Interdisciplinary cooperation with clinical excellence in both
disciplines may transform patients with unattractive dentition showing spaced extruded or migrated teeth
with inflamed and reduced periodontium into persons with attractive and esthetic dentition supported by
a healthy periodontium.
Keywords: Ortho-perio, Adult orthodontics.
INTRODUCTION treatment plan involving comprehensive

orthodontics. Interaction and co-operation between
Since the last two decades, there has been an
these two specialties is essential in establishing
increasing demand for orthodontic treatment in
thorough diagnosis and planning a proper sequence
adults due to the growing focus on dentofacial
of treatment, thus facilitating a coordinated
esthetics. The primary motivating factor in this
therapy.
group of patients has been reported to be a desire
to improve their dental appearance1.
BENEFITS OF ORTHODONTICS
Adult patients present a challenge to TREATMENT FOR THE PERIODONTAL
orthodontists because they have high esthetic PATIENT
demands and they often have dental conditions that
The objectives of orthodontic treatment are to
may complicate treatment, such as tooth wear,
improve facial and dental aesthetics and achieve a
poorly contoured restorations and periodontal
functionally sound occlusion supported by a
disease. Also orthodontic treatment of adults is
healthy periodontium. Orthodontic therapy can
different than that for children and adolescents,
provide several benefits to the adult patient with
primarily because the virtual completion of facial
periodontal problems.2 The following six factors
and dento-alveolar development eliminates the
should be considered:-
choice of treatment mechanics that depend upon
growth and secondarily because of the proneness 1. Aligning crowded or malposed maxillary or
of adults to destructive periodontal disease. The mandibular anterior teeth permit the adult
loss of periodontal support of teeth may result in patient better access to adequately clean all
elongation, spacing and proclination of incisors, surfaces of their teeth. This could be a
rotation and tipping of premolars and molars with tremendous advantage for patients who are
collapse of the posterior occlusion and decreasing susceptible to alveolar bone loss or for those
vertical dimension. Adjunctive orthodontic therapy who do not have the dexterity to adequately
is necessary to resolve these problems. With maintain their oral hygiene.
properly performed treatment, extensive
2. Vertical tooth repositioning can improve
orthodontic tooth movement can be made in adults
certain types of osseous defects in periodontal
with a reduced but healthy periodontium without
patients. Often the tooth movement eliminates
further periodontal deterioration. Thus, it is
the need for resective osseous surgery.
important to identify patients who are susceptible
to the more severe manifestations of the disease 3. Orthodontic treatment can improve the esthetic
and to control existing disease before starting a relationship of the maxillary gingival margin
1,2,3
Professor, 4P.G Student, 5Assistant Professor, Dept. of Periodontology, Bharathi Vidyapeeth University Dental College
and Hospital, Pune
1178
levels before restorative dentistry. Aligning the by moving the tooth until there was no further
gingival margins orthodontically avoids radiographic or clinical evidence of the preexisting
gingival recontouring, which potentially could defect. In cases of uncontrolled periodontal
require bone removal and exposure of the inflammation or in the absence of good patient
roots of the teeth. compliance, both intrusion and bodily movement
may cause conversion of supragingival plaque into
4. In patient who has suffered a severe fracture
subgingival plaque, resulting in intrabony pocket
of a maxillary anterior tooth, which requires
formation. It has been reported in animal studies
forced eruption to permit adequate restoration
that orthodontic therapy involving bodily tooth
of the root. In this situation, extruding the
movement may enhance the rate of destruction of
tooth allows the crown preparation to have
the connective tissue attachment at teeth with
sufficient resistance form and retention for the
inflamed infrabony pockets if proper periodontal
final restoration.
therapy has not been executed. Thilander8
5. Orthodontic treatment allows open gingival emphasized that plague-induced lesions must be
embrasures to be corrected to regain lost eliminated prior to orthodontic treatment and
papilla. If these open gingival embrasures are proper oral hygiene must be maintained during the
located in the maxillary anterior region, they entire course of therapy.
can be unaesthetic. In most patients, these
areas can be corrected with a combination of ORTHODONTIC MOVEMENT INTO
orthodontic root movement, tooth reshaping ENDENTULOUS AREAS
and/or restoring.
Adult patients may sometimes present with
6. Orthodontic treatment could improve adjacent edentulous spaces either due to previous
tooth position before implant placement or extractions or agencies. Experimental reports9 and
tooth replacement. This is especially true for clinical studies10,11 have shown that a reduction in
the patients having missing teeth for several vertical bone height found at edentulous spaces is
years and drifted adjacent teeth in the not a contraindication for orthodontic tooth
edentulous space. movement towards or into, the constricted area.
Mandibular second molars can be moved
MOVEMENT OF TEETH INTO INFRABONY
mesially through remodeled edentulous first molar
DEFECTS
areas in adults, with only a limited reduction in
Infrabony pockets may develop as a result of vertical bone height, averaging - 1.3 mm10. In
destructive periodontitis and are frequently found cases of reduced buccolingual width of the
at teeth that have been tipped and/or elongated as alveolar ridge, tooth movement through cortical
a result of periodontal disease. It has been bone may be retarded and also buccal and lingual
suggested that movement into infrabony defects bone dehiscences may develop. In such cases,
can result in healing and regeneration of the bone augmentation procedures to increase the
attachment apparatus. alveolar bone width have been suggested before
orthodontic movement.
Also, if a wide osseous defect is adjacent to
a tooth and the tooth were moved to narrow the
ORTHODONTIC EXTRUSION
defect, better healing potential may be possible.
Several studies have demonstrated that teeth with Orthodontic extrusion of teeth or so-called
reduced but healthy periodontium can be moved “forced eruption”, may be indicated for
without further attachment loss3-5. The effect of
orthodontic movement of teeth into infraosseous 1. shallowing of intraosseous defects and
periodontal defects has been studied by several 2. for increasing clinical crown length of
authors. Geraci and coworkers6, in an animal single teeth.
model, demonstrated the formation of new
connective tissue attachment to a root surface The forced eruption technique was originally
previously exposed to periodontal disease when described by Ingber12 for treatment of one-wall
moving a tooth into artificially produced infrabony and two-wall bony pockets that were difficult to
lesions. The clinical applicability of this research handle by conventional therapy alone9. The
was explored by Nevins and Wise7, we reported extrusive tooth movement leads to a coronal
on the possibility of resolving vertical bone defects positioning of intact connective tissue attachments
1179
and the bony defect is shallowed out. This was Gingival esthetic problems are created by
confirmed in animal experiments and clinical gingival recession after alveolar bone loss.
trials.13 Gingival levels are known to be related to sulcus
depth and the location of the cemento enamel
It is known that vertical infrabony defects can
junction relative to the bone level. Although
be improved through the use of periodontal
gingival recession can be improved by means of
techniques such as guided tissue regeneration
gingival/osseous surgery, orthodontic treatment can
(GTR). However, a one-wall vertical infrabony
also be effectively used.
defect is a contraindication to GTR and the
prognosis after GTR is poor in the case of wide
defects. Therefore, in such cases, orthodontic ORTHODONTIC INTRUSION
treatment is recommended. During the elimination
of an intrasseous pocket by means of orthodontic Regarding periodontally affected teeth,
extrusion, the relationship between the CEJ and the sufficient clinical data suggest that intrusion of
bone crest is maintained as the bone follows the teeth can considerably improve the level of
tooth during the extrusive movement. This may or attachment when there is absolute control of
may not be beneficial depending on the clinical inflammation and bacterial biofilms with strict oral
situation. It is sometimes desirable to have the hygiene procedures. In 2007, Erkan et al16
periodontium follow the tooth and in other concluded that during orthodontic intrusion of
situations it is desirable to move a tooth out of lower incisors in patients with intact periodontium,
the periodontal support. the gingival margin and the mucogingival junction
moves apically. But they also found that despite a
slight reduction in gingival width, clinical crown
Extrusion with periodontium: lengths decreased significantly. This might have
some clinical consequences. Possibly, the
Orthodontic extrusion of non-restorable teeth significant decrease in clinical crown length is due
prior to implant placement appears to be a viable to the inability of the gingival complex to keep up
alternative for conventional bone augmentation with the movement of the teeth in the apical
procedures in implant recipient sites. It is direction. The decrease in clinical crown length
suggested to apply low constant forces, with a rate was utilized to advantage in periodontally
of extrusion not > 2 mm per month and labial root compromised patients by Re et al17 and they
torque to increase the buccolingual thickness of the reported 50% reduction in recessions after
alveolar ridge. The retention period before tooth intrusion independent of the width of gingiva.
extraction should exceed 1 month. Kajiyama et al14 These beneficial results were found to be
indicated that the free gingiva moved about 90% considerably stable in long term (12 - year follow
and the attached gingiva about 80% of the up). The use of light forces (5 - 15 gr per tooth)
extruded distance. The width of the attached is recommended to move teeth efficiently and
gingiva and the clinical crown length increased probably reduce the amount of root resorption.
significantly, where as position of the This is of capital importance in teeth with reduced
mucogingival junction was unchanged. periodontium as the specific implication results in
further loss of periodontal support and increase in
Extrusion out of periodontium crown-root ratio.
In teeth with crown-root fracture or other UPRIGHTING TILTED MOLARS

subgingival fractures, the goal of treatment is to
extrude the root out of the periodontum and then One of the first reported uses of this novel
provide it with an artificial crown. To create approach published by Brown18 in 1973, was the
clinical crown lengthening without orthodontic reduction of mesial periodontal defects by
therapy, usually bone and soft tissue must be uprighting mesially inclined molars. Technically
removed around two teeth mesial and distal to the the mesial tipping produces only a gingival or
affected tooth, thus worsening their periodontal pseudopocket if no periodontal attachment has
status and esthetic result. In 1987, Pontoriero et been lost. However, a pocket deeper than 3 mm
al15 reported that repeated gingival fiberotomies produces microecosystems that promote the growth
can prevent the coronal displacement of the of periodontal pathogens and subsequent
gingiva and attachment apparatus with the tooth attachment loss. An alternative to uprighting
during orthodontic extrusion. molars or leveling and aligning teeth in each arch,
1180
is to take away unnecessarily greater amounts of and the CEJ. In most adults, the alveloar crest is
supporting bone (and, by definition, part of the about 2 mm from the CEJ. If the bone level is 2
healthy periodontal ligament) on the bicuspids and mm from the CEJ, excision surgery would be
other teeth. Bone removal usually has to be appropriate to apically position the gingival
extended and contoured over several teeth to margins. However, if the bone level is within 0.5
surgically eliminate abrupt changes in form and mm of the CEJ, an apically positioned flap with
create a physiologic topography conductive to recontouring of the alveolar crestal bone may be
periodontal health. the most appropriate surgery.
All periodontal patients scheduled for resective
osseous surgery should be given the option to UNEVEN GINGIVAL MARGINS
undergo some orthodontic care to obviate the
The relationship of the gingival margins of the
chance of unnecessary alveolar bone removal.
six maxillary anterior teeth plays an important role
in the esthetic appearance of the crowns.
GINGIVAL ESTHETICS AND
ORTHODONTICS When gingival margin discrepancies are
present, the clinical must determine the proper
The objectives of orthodontic therapy are to solution for the problem: orthodontic movement to
establish a good occlusion, enhance the health of reposition the gingival margin or surgical
the periodontium and improve dental and facial correction of gingival margin discrepancies.
esthetics. However, periodontal health and the
esthetic appearance of the teeth after appliance
removal are equally important. THE MISSING PAPILLA
Three unaesthetic situations that may develop Presence of a papilla between the maxillary
during orthodontic treatment are the “gummy” central incisors is a key esthetic factor after
smile, gingival margin discrepancies and the orthodontic treatment. However, in some patients,
“missing papilla”. Previously, perceptions of dental the papilla is absent.
esthetics by the public and dental professionals
were related principally to alterations of the teeth; In patients with advanced periodontal disease
however, this perception has changed and there is and destruction of the crestal bone between the
now increased emphasis on smile enhancement central incisors, the papilla may be absent. This
through cosmetic dentistry, in particular plastic produces an unesthetic large gap ‘black triangle’
periodontal procedures. after orthodontics. A combined orthodontic -
periodontal approach can help to modify the height
of the papillae. The first aim is to reduce the
THE GUMMY SMILE
distance between the bone crest and the contact
“Gummy smile” (Excessive gingival display) point, following the findings of Tarnow et al.19
is a condition characterized by excessive exposure
of the maxillary gingiva during smiling. This LABIAL FRENECTOMY
condition may be caused by
The maxillary labial frenum is a fold of tissue,
1. A skeletal deformity in which there is vertical
usually triangular in shape, extending from the
excess of the maxilla.
maxillary midline area of the gingiva into the
2. Soft-tissue deformity in which there is a short vestibule and mid portion of the upper lip. In
upper lip/hyperactive lip musculature. addition to preventing the closure of space
between the maxillary central incisors, the frenal
3. Insufficient clinical crown length due to
tissues have been implicated with poor oral
coronal destruction resulting from traumatic
hygiene, due to difficulties in tooth brushing and
injury, caries or incisal attrition, as well as
the resultant inflammatory periodontal destruction.
coronally situated gingival complex resulting
from tissue hypertrophy or a phenomenon Frenotomies have clinical validity only after
known as altered passive eruption. the eruption of all six permanent anterior teeth has
failed to close the diastema. There exists empiric
4. A combination of the above factors.
and arbitrary agreement that the maxillary frenum
The type of gingival surgery depends on the plays an important role in causing the reopening
relationship between the crest of the alveolar bone of diastemas after orthodontic closure.
1181
Dewell20 has stated that early frenectomies periodontal ligament, and the supra-alveolar fibers
without prior orthodontic closure in diastema influence the stability of teeth. Where as the fibers
situations may result in scar formation, which itself of the periodontal ligament and trans-septal groups
might tend to prevent normal mesial movement of remodel efficiently and histologically completely
the incisors. in only 2-3 months after orthodontic rotation of
teeth, the supra-alveolar fibers are apparently more
A number of surgical techniques have been stable, with a slow turnover. Orthodontists, in their
devised to eliminate this undesirable relapse attempt to solve this problem of regression after
phenomenon. correction of tooth rotations, have used different
Many believe that frenum prevents mesial approaches to aid the retention process throughout
migration of the maxillary central incisors and that the years. Edwards27 in 1970 introduced the
it should be removed before orthodontic therapy is technique of circumferential supra crestal
begun. Others have suggested that removal of the fiberotomy (CSF). Basically this technique consists
frenum allows the space to be closed more easily of inserting a scalpel into the gingival sulcus and
orthodontically. severing the epithelial attachment surrounding the
involved teeth. The blade also transects the
Orthodontists, however, have for years trans-septal fibers by interdentally entering the
advocated that the frenectomy procedure be periodontal ligament space.
initiated only after the diastema has been closed.
Removal may be indicated after treatment to The fiberotomy procedure is not recommended
change irreversible hyperplastic tissue to normal during active tooth movement, or in the presence
gingival form and to enhance post treatment of gingival inflammation. When performed in
stability.21-24 healthy tissues after orthodontic therapy, there is
negligible loss of attachment.
However, with extremely large diastemas (6 to
8 mm) in the early transitional dentition, a The long-term effectiveness of fiberotomy was
frenectomy usually is recommended to facilitate evaluated in a prospective follow-up study over a
space closure, regain space at the midline and period of 15 years by Edwards (1988).28 The
prevent ectopic eruption of the lateral incisors or surgical procedure was more successful in the
canines.25 maxillary than in the mandibular anterior region;
more effective in alleviating rotational than
In 1985, P.D. Miller advocated a surgical labiolingual relapse; and more useful in reducing
technique combining a frenectomy with a laterally relapse in cases with severe rather than mild
positioned pedicle graft.24 Closure across the irregularity of teeth without harmful long term
midline by laterally positioning gingiva and effects in periodontal health.
healing by primary intention results in attached
gingiva across the midline. This attached gingiva
may have a bracing effect and thus aid in ORAL HYGIENE MEASURES
preventing orthodontic relapse.
In 2006, Bagga et al26 reported a new Orthodontic treatment with fixed appliances
technique in which adjacent attached gingiva in the alter the oral environment, increases plaque
central incisor region, bilaterally, was used to amount29 changes the composition of the flora30
achieve a zone of attached gingiva with excellent and complicates the cleaning for the patient31
color match at the site of the abnormal frenum. Gingivitis and enamel decalcification32,33 around
fixed appliances are frequent side effects when the
In the technique presented, 2 triangular preventive programs have not been implemented.
pedicles, when sutured together medially, Oral cleaning becomes more difficult with the
completely cover the V-shaped defect on the presence of the orthodontic appliances and their
gingiva and act as a tissue dressing, thus components. Thus, the elimination of plague is the
facilitating healing by primary intention and main target to prevent and/or overcome the
minimizing any chance of scar formation. problems listed above.
FIBEROTOMY Yetkin et al34 found that verbal

recommendations are not enough to achieve
Orthodontically treated teeth exhibit the optimum plague removal and that the
tendency to relapse. The principal fibers of the ameliorations of the patients’ inaccurate oral
1182
hygiene efforts by the specialists at the same and periodontal therapy can enhance the
session are essential. orthodontic outcome.
Several toothbrushes have been designed to
increase plaque removal efficacy in orthodontic ACKNOWLEDGEMENT
patients. We than Dr. Shailesh Deshmukh for carrying
Orthodontic toothbrushes have a V-shaped out orthodontic treatment of our patients and we
groove along the long axis of the toothbrush head. gratefully acknowledge his contribution.
The shorter nylon bristles in the V-shaped groove
are progressively firmer and more efficient in REFERENCES
removing food debris from the mid bracket region
1. McKiernan E.X, McKiernan F, Jones M.L
and longer, softer filaments are positioned in the Psychological profiles and motives of adults seeking
bracket-wing region. Tests of the effectiveness of orthodontic treatment. Int J Adult Orthod Orthognath
the orthodontic toothbrushes compared with the Surg 1992; 7: 187-98.
conventional toothbrush in reducing plague and 2. Vincent G. Kokich, Clinical Periodontology 10 ed,
gingivitis in teeth with fixed appliances have had 2007, Elsevier Publication.
conflicting results.35,36 3. Boyd, R.L., Leggott, P.J., Quinn, R.S., Eakle, W.S &
Recently, a manual triple-headed toothbrush Chambers D., Periodontal implications of orthodontic
(Dr. Barman Superbrush, Dantaco AS, Haukeland, treatment in adults with reduced or normal
periodontal tissues versus those of adolescents.
Norway) was designed to clean the lingual, buccal
American Journal of Orthodontics and Dentofacial
and occlusal tooth surfaces simultaneously. Its Orthopedics 1989; 96: 191-199.
head contains short, firm bristles in the center to
4. Artun, J. & Urbye, K.S. The effect of orthodontic
clean the occlusal surfaces and longer, softer
treatment on periodontal bone support in patients with
bristles outside that reach the dentogingival margin advanced loss of marginal periodontium. American
at a 45° angle to gently clean the smooth tooth Journal of Orthodontics 1988; 93: 143-148.
surfaces there. Several studies have shown that the 5. Nelson, P.A & Artun, J. Alveolar bone loss of
triple head toothbrush is superior to the maxillary anterior teeth in adult orthodontic patients.
conventional tooth brush in reducing plaque American Journal of Orthodontics and Dentofacial
accumulation at the gingival margin and in Orthopedics 1977; 111: 328-334.
improving the modified gingival index (GI) and 6. Geraci T.F, Nevins M., Crosseti H.W, Drizen K.,
the bleeding on probing (BOP) index in children Ruben M.P Reattachment of Periodontium after tooth
and adults.37,38 movement into anosseous defect in a monkey. Int J
Periodontics Restorative Dent 1990; 10: 184-197.
Kremers et al39 found that with a manual brush
7. Nevins M, Wise R.J, The use of orthodontic therapy
a modified Bass technique (small, circular shaking to alter infrabony pockets, Int J Periodontics
motion, while the brush is held at a 45° angle to Restorative Dent 1990; 10: 199-207.
the tooth axis) was superior to the roll technique 8. Thailander B., Intrabony pockets and reduced alveolar
(rotating motions from the sulcus to the occlusal bone height in relation to orthodontic therapy Semin
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The Journal of the Indian Association of Public Health Dentistry(JIAPHD), Vol. 2011, Issue: 18
With Best Compliments from
Vol. 2011 ISSUE : 18
Swami Devi Dyal Hospital

& Dental College
Village Golpura, Teh. Barwala, Dist. Panchkula (Haryana)

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A Randomized Controlled Trial of Lycopene in Oral Submucous Fibrosis

Article · January 2011

Revant Chole Shailesh Gondivkar

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Amol Ramchandra Gadbail Mugdha Mankar

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Swami Devi Dyal Hospital

Village Golpura, Teh. Barwala, Dist. Panchkula (Haryana)

THE INDIAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY

169. Is Mouthwash an Eyewash? A Review 928

170. Endodontics by Emerging Dentists 934

177. Socio-Demographic factors and Tooth loss 963

180. Modern Dentistry: The Economic aspect 978

181. Health Care Waste Management : A Biosafety Issue 979

183. Gerodontology - Orodental Care for Elderly - A Review 989

184. Various Methods of Gingival Pigmentation: A Case Report 995

187. Comparision of Effectiveness of Mini Implants vs Conventional Implant supported 1007

191. Implications of Socio-economic factors in Complete Denture Treatment in Bhopal an 1028

193. Communication Proficiency in Dentistry - A Stepladder to Success!. 1036

198. Antibiotic Resistance - Current Issues and Implications 1062

201. Occlusion in Complete Denture: A Review 1086

203. Dental Distraction - A Case Study 1095

206. Chelioscopy: Determination of Sex and Blood Group 1109

212. Molars with Single Root and Single Canals 1144

214. A Randomized Controlled Trial of Lycopene in Oral Submucous Fibrosis 1156

216. Periodontal Treatment of Multi - Rooted Teeth 1164

217. Integrating Bleaching with different Treatment Modalities: A Review 1169

218. Vascular Leiomyoma of the Gingiva - A Rare Case Report 1174

219. Adult Orthodontics - A Boon for the Periodontal Patients 1178

Dentistry in News: An Analysis of Newspapers and

INTRODUCTION much information would reach the general public

Is Mouthwash an Eyewash??? A Review

INTRODUCTION equivocal success, as therapy for candida

Endodontics by Emerging Dentists

INTRODUCTION 2005, Er et al. 2006. Correct RCT consists of

No. of Percentage of Single

Table 3 shows the radiographic evaluation of DISCUSSION

Prevalence and Prevention of Dental Caries and

INTRODUCTION patients undergoing orthodontic treatment

General Protocol for Varnish Application of Chlorhexidine mouthwashes on patients

H1N1 Flu (Swine Flu) Precautions for Dental Professionals

INTRODUCTION Swine Flu or the H1N1 Flu which is officially

A Greater Focus on the Knowledge and Attitude on the

INTRODUCTION MATERIALS AND METHODS

its return. An explanatory letter was also included Q.No A B C D E

Oil Pulling Therapy on Streptococcus mutans Count in

INTRODUCTION of oil pulling in the 1990s in Russia4. For oil

using the software SPSS version 15 (SPSS Inc, Saliva Samples

The mechanism by which oil pulling therapy REFERENCES

6. Shi S, Deng Q, Hayashi Y, Yakushiji M Machida Y 11. Asokan S, Emmadi P, Raghuraman R,

Multidisciplinary Management of Complicated crown -

INTRODUCTION periodontal attachment apparatus and providing

Fig. 6. View of #12 and #13 after placement of cast post-cores

Fig. 2. Clinical picture of #12 and #13 after removal of fractured

Fig. 7. Sound gingival status of #12 and #13 after cementation of

The restoration of endodontically treated teeth