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Singapore Dental Journal
The Journal of the
Singapore Dental Association
MCI (P) 164/05/2014
SDJ
Singapore Dental Journal
ISSN 0377-5291
CONTENTS
December 2014 • Vol 35
Giving Hope and Seeing Hope
With permission from Lim Songping Nicholas
An ageing population poses dental challenges
Oral health status and complete denture status of
independent-living Singaporean elderly residing
in a community home
Factors contributing to tooth loss among the elderly:
A cross sectional study
Challenges in anaesthesia for elderly
Clinical issues in occlusion – Part I
Diagnosis of oral pigmentations and malignant
transformations
Endodontic irrigant as a root conditioning agent:
An in vitro scanning electron microscopic study
evaluating the ability of MTAD to remove smear layer
from periodontally affected root surfaces
Complications associated with the occurrence and
treatment of impacted maxillary canines
Gingival crevicular fluid levels of MMP-1 and TIMP-1
in periodontal health and disease
Complete denture copy technique – A practical
application
Delayed replantation of avulsed tooth with 15-hours
extra-oral time: 3-year follow-up
Patient induced unusual metallic obturation of the root
canal of permanent maxillary central incisor with an
immature apex – A rare case report
Rapid fabrication of silicone orbital prosthesis using
conventional methods
ELSEVIER
December 2014 • Vol 35
Singapore Dental Journal
Editorial Staff
Editor
SUM Chee Peng
Reviewers
CHUNG Kong Mun
GAN Tsering Sapphire
GEORGE Saji
GOH Kwee Chien Benny
HO Kok Sen
HONG Hsu Ling Catherine
HU Xiaoli
KALRA Mehek
KEY William
KUAH Hong Guan
LEE Chee Wee
LIM Chong Yang Arthur
LIM Sze Kheng
LOH Fun Chee
LOW Huey Moon
LOW Hwee Hiang
MAUNG Than Zaw Oo
NG Chai Hoon Clarisse
NG Dih Hann Simon
NGIM Chun-Han
ONG Meng Ann Marianne
ROBINSON Narendran Andrew
ROSSI-FEDELE Giampiero
SEE TOH Yoong Liang
SOH Mui Siang
TAN Kai Soo
TAN Kwong Shen Winston
TAY Chong Meng
TEO Juin Wei
TONG Huei Jinn
WANG Chia-Wei Wendy
WEE Tze Haur
WONG Mun Loke
YANG Shi Lin Sherine
YAP U Jin Adrian
YEO Boon Keng Alvin
ZHOU Haiwen
ISSN 0377-5291
© 2014 Elsevier
Published by Elsevier (Singapore) Pte. Ltd.
General Information
The Singapore Dental Journal (SDJ) is the official, peer-reviewed
publication of the Singapore Dental Association. It is published
annually by Elsevier (Singapore) Pte Ltd. The SDJ is listed in
MEDLINE.
The SDJ aims to advance the practice of dentistry and care of
patients among members of the Association and dentists in the
region through the dissemination of information and research
findings in the field of dental science and technology. The scope of
the journal covers all fields related to the present-day practice of
dentistry, and includes Restorative Dentistry (Operative Dentistry,
Dental Materials, Prosthodontics and Endodontics), Preventive
Dentistry (Periodontics, Orthodontics, Paediatric Dentistry, Public
Health and Health Services), Oral Medicine, Oral Surgery and Oral
Pathology. Articles pertaining to dental education and the social,
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welcomed.
Articles are divided into four types: Reviews, Scientific/Clinical
articles, Case Reports/Techniques, and Posters.
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Singapore Dental Journal
December 2014 Vol 35
C o n t e n t s
Letter from the Editor
Sum Chee Peng
1
Review Article
An ageing population poses dental challenges
William Murray Thomson and Sunyoung Ma
3
Scientific Articles
Oral health status and complete denture status of independent-living Singaporean elderly
residing in a community home
Tan Mei Na, Rahul Nair, Joanna Ngo Di Ying and Robert Yee
Factors contributing to tooth loss among the elderly: A cross sectional study
Zuhair S. Natto, Majdi Aladmawy, Mohammed Alasqah and Athena Papas
9
17
Review Articles
Challenges in anaesthesia for elderly
C. Strøm and L.S. Rasmussen
23
Clinical issues in occlusion – Part 1
Aws Alani and Mahul Patel
31
Diagnosis of oral pigmentations and malignant transformations
Bassel Tarakji, Ayeisha Umair, Durga Prasad and Mohammed Alsakran Altamimi
39
Scientific Articles
Endodontic irrigant as a root conditioning agent: An in vitro scanning electron microscopic
study evaluating the ability of MTAD to remove smear layer from periodontally affected root
surfaces
Afaf Zia, Syed Mukhtar-Un-Nisar Andrabi, Afshan Bey, Ashok Kumar and Zareen Fatima
47
Complications associated with the occurrence and treatment of impacted maxillary canines
Anand K. Sajnani and Nigel M. King
53
Gingival crevicular fluid levels of Matrix Metalloproteinase-1 (MMP-1) and Tissue Inhibitor of
Metalloproteinase-1 (TIMP-1) in periodontal health and disease
Ravi P. Popat, Neeta V. Bhavsar and Parita R. Popat
59
Case Reports
Complete denture copy technique—A practical application
Steven Soo and Ansgar C. Cheng
65
Delayed replantation of avulsed tooth with 15-hours extra-oral time: 3-year follow-up
D. Sardana, A. Goyal and K. Gauba
71
Patient induced unusual metallic obturation of the root canal of permanent maxillary central
incisor with an immature apex – A rare case report
Manoj Mahadeo Ramugade, Kishor Dattatray Sapkale and Sachin Shashikant Metkari
77
Rapid fabrication of silicone orbital prosthesis using conventional methods
Binit Shrestha, Reiyal Goveas and Sita Thaworanunta
83
Singapore Dental Journal 35 (2014) 1
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Letter from the Editor
What does ageing mean?
Of course to each of us, ageing mean many different
things, we come from different homes, spring from different
circumstances and arrive at different platforms after many
years at work. When we see a patient who is ageing – do we
stop for a moment to think about what it means to him?
What is in his psyche? Perhaps the hardest to deal with in
ageing is not just the frailty of the body, but rather it is the
decay of the mind and the spirit.
I have excerpted two verses from a poem below:
Ageing
“Now that I'm really old
there seems little left to say.
Pointless to bewail
the decline, bodily and mental;
undignified; boring
not to me only but everyone,”
…
“When I saw that young girl on her blades,
wind in her hair, sun on her face,
like a magazine illustration
from childhood days, racing
her boyfriend along the pavement:
– then I understood ageing.”
(From Ageing By Ruth Fainlight; accessed at http://www.
theguardian.com/books/2010/mar/13/carol-ann-duffy-poem
s-ageing on 4 Nov 2014).
These two verses show two states of the mind. The former
seems to be of a disgruntled defeated grumpy old chap; and
the latter a more reflective man with some measure of
wisdom, more enlightened, but who would love to still have
a spot of active living.
How should we treat these two patients? Will they respond
differently to our treatment plans? Should we offer them the
same treatment plan? Should we do more work to understand
the former state of mind? I am sure we would all want to
understand the patient's state of mind better during treatment
planning.
Almost as insidiously as we have aged, the Singapore
population has aged. As the proportion of the elderly increases
among us, the nature of practice will also change. As spending
habits of patients who now become elderly change, will the
types of treatment adopted change? How it will be for dental
practice in Singapore as a whole, nobody can foretell. But change
will surely come. How should dentists prepare for these
changes? Are there additional skill-sets which are required to
make practicing with elderly patients more meaningful, for them
as well as for us – the professionals? Are there new medico-legal
issues that would crop up with a more elderly patient? What
attitudes should we adopt when dealing with a difficult elderly
patient? Indeed issues that should be considered, during a
professional disciplinary inquiry, might well have to change if
the patient involved was an elderly patient.
Continuing medical education programmes have thus far, as
far as I have been made aware, done scanty little to address the
issues of dealing with an elderly patient. Although much
needed, such as special devices to clean teeth with wider
inter-radicular spaces; few companies have dental supplies or
materials dealing strictly with elderly patients. It is not “glamorous” to talk about the elderly. However, to this end, we are
pleased to inform you that the World Congress 2015 – Dental
care and oral health for healthy longevity in an aging society –
is scheduled to be held over the three days of March 13 (Friday)
to March 15 (Sunday), 2015. This congress will be held at the
Tokyo International Forum co-hosted by the World Health
Organization (WHO) and supported by the FDI World Dental
Federation. The Japanese Dental Association has made the
theme for the FDI 2015 (Tokyo ) – Ageing!
Whilst much of the buildings around Singapore are gearing
up for the so called “silver tsunami”, I wonder how prepared our
profession is with our population ageing at such an alarming
rate. To help the profession come to terms with the impending
arrival of the “silver tide”, several articles have been invited
from renowned authors in their fields. These deal with patient
management and treatment planning issues, medico-legal
issues among others. We hope these will be useful for you to
“train” yourselves to be ready. Whilst it was possible to beg, on
your behalf, for a few authors to write about ageing and the
physiological changes as they apply to dentistry, it was not
possible to find one to write about the mind of the elderly, how
an older person may appreciate dental treatment needs, something that we think should be very instructive.
The editorial board is always on the look-out for ways of
keeping our members informed and up-to date. If you have
any suggestions please do not hesitate to write to us at
[email protected].
Many Happy returns in the New Year.
Editor
Sum Chee Peng
& 2014 Published by Elsevier B.V.
http://dx.doi.org/10.1016/j.sdj.2014.11.001
Singapore Dental Journal 35 (2014) 3–8
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Review
An ageing population poses dental challenges
William Murray Thomsonn, Sunyoung Ma
Sir John Walsh Research Institute, School of Dentistry, The University of Otago, New Zealand
art i cle i nfo
ab st rac t
In this narrative review paper, we summarise what is known about the oral health of older
Keywords:
people, with a specific focus on the most common oral conditions in that age group. After
Older people
that, the implications for older people's oral care are considered, along with ways of
Ageing
developing and maintaining a gerodontologically capable and responsive workforce and
Dental care
oral care delivery system.
& 2014 Published by Elsevier B.V.
Contents
The oral health of older people . . . . . . . . . . . . . . . . . . . . . . . . . .
What do these data mean for the oral care of older people? . . .
Shaping a gerodontologically capable and responsive workforce
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The oral health of older people
A feature of industrialised societies over the last century or so
has been their steady ageing. Falling birth rates have combined with increases in longevity, with the result that older
people make up an increasing proportion of the population
[1]. The most striking example of this phenomenon is Japan,
where people aged 65þ currently make up 23% of the
population and are expected to reach 38% by 2050 [2]. Similar
trends are evident (but not be as marked) in other developed
countries. In North America, the equivalent estimates are
13% and 22%; in Europe, they are 16% and 27%; and in China,
they are 8% and 23%. In New Zealand, where those estimates
are 14% and 25%, people aged 80 or more currently comprise
n
Corresponding author.
E-mail address: [email protected] (W.M. Thomson).
http://dx.doi.org/10.1016/j.sdj.2014.10.001
0377-5291/& 2014 Published by Elsevier B.V.
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3
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6
about 25% of those aged 65þ, but that will rise to 40% by 2050.
Singapore is no exception to this phenomenon, with the
median age having virtually doubled since 1970; in the same
period, the total fertility rate more than halved, and life
expectancy at birth increased by just over 16 years [3]. The
11% of the population who were aged 65 or over remains
relatively low by international standards (for example, it is
currently 14% in New Zealand and expected to rise to 25% by
2050), but it is important to consider that it has been
increasing steadily: the key trend is the same.
Alongside the inexorable increase in the proportion of older
people, a “dental transition” has been occurring, whereby
the proportion of that group who are edentulous has also
been steadily falling. This is likely to have been more marked
4
Singapore Dental Journal 35 (2014) 3–8
in countries where edentulism has been a widespread
sociocultural phenomenon, such as New Zealand, Australia
and Scotland [4], but there is a lack of comparative data from
other countries. Nevertheless, it can safely be assumed that
retention into old age of at least part of the natural dentition is
increasing in developed countries.
The most common oral conditions among older people
are tooth loss, dental caries, periodontitis, dry mouth
and oral precancer/cancer [5]. These all can compromise
older people's quality of life. Each of these issues is briefly
discussed below.
Edentulism is the state of having lost all of the natural
teeth; it should be distinguished conceptually and practically
from the more common loss of teeth which tends to occur
incremental throughout adult life. Becoming edentulous
requires the patient and dentist to collude in the decision
to remove the remaining dentition, usually in a single operation. Edentulism comes about because of both disease-related
and societal influences [6]. It is now far less common than
incremental tooth loss, irrespective of age. Indeed, it can be
argued that the unplanned, crisis-driven and incremental
loss of teeth as we age presents more of a problem for the
profession and the public, because the piecemeal loss of teeth
can result in the drifting of adjacent teeth and the overeruption of opposing units, thus complicating prosthodontic
rehabilitation at a later date. Reports from cohort studies of
older adults confirm the phenomenon of incremental tooth
loss in people aged 65 or older [7–13].
Dental caries is perhaps the major oral problem among older
people. Reports from prospective cohort studies of populationbased samples of community-dwelling older people [10,14–16]
have shown that dental caries is remarkably active among
older people, with a mean increment of about 1 surface per year
[17,18]. That rate is no different from the increment observed
among adolescents and younger adults [19]. Somewhat surprisingly for most dentists, the greater contribution to that increment among older people is made by coronal caries rather than
root surface caries (respectively comprising 60% and 40% of the
increment). South Australian research by the late Dr Jane
Chalmers demonstrated that the annual dental caries increment among older people residing in nursing homes is more
than double that observed among their community-dwelling
counterparts; among those with dementia, it is more than twice
as high again [20]. These longitudinal study data lend credibility
to anecdotal reports of dentitions being ravaged relatively
quickly after admission to a nursing home.
Periodontitis is not a highly prevalent condition among
older people. A review in Periodontology 2000 summarised
knowledge of the occurrence of periodontitis in older populations at that time [21], and concluded that periodontitis is a
disease of ageing; that is, ageing is a risk factor for loss of
periodontal attachment (other factors being equal). Essentially, most older people have had some periodontitis, with
moderate levels of attachment loss. Advanced attachment
loss (affecting relatively few sites) is apparent in a small
proportion, and a substantial minority experience ongoing
attachment loss, mainly in the form of increases in gingival
recession rather than in probing depth. Research published in
the years since that authoritative review by Locker and
colleagues has not materially changed those conclusions [22].
Chronic dry mouth occurs in a substantial proportion of
older people, affecting their speaking, enjoyment and ingestion of food, and denture wearing [23,24]. About one in five
older people suffers from dry mouth [25,26], and they are
likely to be at higher risk of dental caries, whether because of
their compromised salivary buffering or the efforts they
go to to relieve their symptoms (such as by sucking sweets).
Higher rates of dry mouth are seen in those taking medications such as antidepressants, respiratory agents, opiatecontaining analgesics, or some cardiac or antihypertensive
drugs [27–29]. Whether older people taking particular medications are at greater risk of caries is not supported by the
available epidemiological evidence [16], but dry mouth is an
important oral condition among older populations because of
its effects on sufferers' quality of life.
Oral mucosal lesions are more common among older
people. The term “oral precancer” generally refers to leukoplakia, lichen planus and erythroplakia, conditions with
recognised potential (especially the latter) for malignant
transformation. By contrast, the term “oral cancer” usually
refers to oral squamous cell carcinoma [30]. Although epidemiological data on the occurrence of oral precancer and
cancer in representative samples are hard to find, most cases
of oral cancer occur among older people, and they occur less
commonly in developed countries than less developed ones
[5]. Clinicians should always be aware of the possibility of
such lesions being present.
All of the above conditions can affect older people's oralhealth-related quality of life (OHRQoL). Given the cumulative
nature of those conditions, it might be expected that the
OHRQoL of older people is far poorer than that of younger
adults, but that is not the case. In an interesting analysis
of Australian national oral health survey data, Slade and
Sanders [31] recently pointed out the paradox of apparently
better OHRQoL among older adults, with scale scores being
lowest among the oldest Australians. They stressed that it
should not be assumed that older people are necessarily
disabled by their accumulated burden of clinical oral disorders (such as tooth loss, dental caries, periodontal attachment loss and dry mouth); instead, it appears that their ageassociated stoicism, adaptability, capacity for coping and
ongoing reappraisal of what is actually important mean that
most manage reasonably well from day to day. Notwithstanding that phenomenon, however, the epidemiological
literature shows that OHRQoL tends to be poorer among
seniors who wear dentures, have higher numbers of missing
teeth or decayed teeth, have dry mouth, or have difficulty in
eating because of—or alongside—those states. In other
words, adaptation and stoicism enable most older people to
cope despite difficulties in chewing.
What do these data mean for the oral care of older
people?
An increasing number of dentate older adults will place great
demands on the resources and skills of the dental workforce,
because of not only their having more teeth, active dental
caries and ongoing incremental tooth loss, but also because
they are more sophisticated in their demands on the oral
Singapore Dental Journal 35 (2014) 3–8
health care system. Functional dependency among older people has been reported to be a major barrier to service utilisation
[32]. The relationship between frailty and oral health is not
fully understood, but it is likely to be a two-way phenomenon.
Poor oral health can contribute to frailty (a) by leading to
chronic undernutrition (and eventually sarcopenia, or muscle
wasting), and (b) through periodontitis-associated increases in
inflammatory markers creating systemic perturbations which
themselves increase the risk of frailty [33]. The seminal longitudinal work of Chalmers and colleagues [20] has highlighted
the contribution of frailty and dependency to higher dental
caries rates among older people.
In New Zealand, at least half of the older population will
end up in a residential aged-care facility at some stage, and
only a small proportion of those will return to their own homes
[34]; most will end their days in a care facility. Aged residential
care for the approximately 32,000 individuals in such care
currently costs the New Zealand taxpayer about $800 million
per year [35]. There are challenges in maintaining oral health
among (and providing care for) older people who are in care
[36]. Many agencies and professional groups are involved.
There are workforce issues (not only with the various dental
personnel but also with care facility staff), along with problems
in monitoring oral health and determining need, and with the
funding of any preventive or palliative care which may be
involved. Important complicating factors include the everincreasing proportion of dentate residents, and (in New Zealand, at least) the trend seen in recent decades for dependency
levels upon admission to have increased over time [37]. Those
entering care facilities have more teeth but are less able to take
care of themselves; their needs are more diverse. Recent
attention has been focused on developing a more systematic,
evidence-based approach to assessing and delivering care to
older dental patients, using dental care pathways which are
specific to particular levels of dependency [38]. Their use
should improve the likelihood of consistent and predictable
care because evidence-based and standardised levels of care
are provided, but it is too early to be able to evaluate their
effectiveness.
US work by Kiyak et al. [39] found that dental practitioners
held many negative stereotypes about older adults and that
they had only limited knowledge of geriatric dentistry. A
subsequent exploration of New Zealand dentists' knowledge
of older people's oral health found that it was generally
sound, but that most were not involved in providing ongoing
care to residents of nursing homes [40]. Most were unwilling
to get involved in such care because of the inconvenience of
leaving their practices to do so.
Shaping a gerodontologically capable
and responsive workforce
Meeting the oral health needs of the burgeoning older
population will require a diverse and capable dental workforce. A two-pronged approach is required, focusing on both
(a) new entrants to the profession via Dental Schools, and (b)
existing dentists. The latter will be through continuing
professional development for the majority of dentists, but
there will also be a greater need for postgraduate-level
5
education and training. Previous commentators have highlighted the need for geriatric dentistry to be incorporated into
both the undergraduate and postgraduate dental curricula
[5,41]. The need for a recognised dental specialty in gerodontology has also been raised recently [42], and there is merit in
such a consideration. However, considering that dentistry is
already a specialised health sciences field with several existing sub-specialties, it could be argued that specialists in the
fields where the older population already constitutes a large
proportion of the patient pool could be trained further in
order to meet those gerodontological requirements. Prosthodontics and special needs dentistry are two such dental
specialties where older patients and people who are medically compromised are already routinely seen. The International College of Prosthodontists recently asserted that dental
geriatrics should be included as one of the major courses in
the postgraduate prosthodontic programme curriculum [43].
Conversely, it could be argued that prosthodontists might not
want to spend a lot of their clinical time dealing with
relatively low-level problems, and that there is indeed scope
(and room) for the specialist gerodontologist. The scarcity of
special needs dentistry specialists complicates the issue: they
would be ideally placed to provide care to the geriatric
population, but there are too few of them at present. There
is, of course, scope for the further deployment of dental
hygienists (or the relatively recent dual-qualified threrapisthygienists) in the sector alongside the dentists and dental
specialists.
Turning to the dental curriculum, the topics taught in
gerodontology need to be broad, ranging from ageing theories, older persons' nutrition, and the neuromuscular function of aged individuals to more dentally oriented subjects
such as the management of root surface caries and changes
to tissues in the denture space. Prior to treating older
patients, it is necessary for students to have sound knowledge about variations in biological ageing and for them to be
able to differentiate between normal ageing-associated
changes and the pathological effects of diseases [44]. Effective
clinical education programmes need to go beyond merely
minimum exposure to various older people to intensive and
stimulating clinical experiences in an environment that
provides the oversight and guidance which allow students
to develop a greater degree of comfort in treating older people
and provides the foundations for caring for those populations
in dental practice rather than always in an institutional
setting [45].
Currently, there is considerable room for improvement in
the education and training of dentists. For example, a substantial proportion of graduating dental students across the US
felt insufficiently trained in treating older people and were
therefore less willing to manage those patients [46]. This
perception is also reflected in dentists' general reluctance to
treat (and low interest in treating) older people residing in
long-term care facilities [40,47]. Dental professionals regard
providing such a service as a minimal financial gain and
this lack of competence, confidence and interest must be
addressed by adequate training in the area of gerodontology
so that the older population in need can be served [48].
Undergraduate education is the seedbed for conscientious
professionals [49], and it is therefore important to place
6
Singapore Dental Journal 35 (2014) 3–8
appropriate emphasis on oral health care for older patients in
the undergraduate curriculum [50–53]. There is some evidence
that undergraduate clinical exposure to gerodontology results
in a higher likelihood of dentists subsequently providing
comprehensive care in nursing homes, because they are
exposed to a different group of older people during those
crucial undergraduate years [54,55]. Similarly, extramural activities involving older people contribute to the formation of
positive attitudes and a willingness to work with older patients
upon qualification [49].
The skills necessary for treating older patients can differ
according to the dependency level of the individual concerned. A proportion of the older population would have
received extensive dental treatment requiring comprehensive
and sophisticated designs. However, as the patients become
more debilitated or faced with restricted financial circumstances, the ongoing maintenance issues need to be dealt
with in a timely and simple manner. The clinician needs to
adjust from a “treat everything” philosophy to treating and
restoring what is necessary for patients to function comfortably [56]. There is also the need to “plan for failure”, so that
the proportion of the dentition affected by the failure of a
component or unit is minimised and the patient is not
disadvantaged any more than absolutely necessary. That
failure can result from biological complications—such as
dental caries and periodontitis—or patient-related failure,
where the individual is no longer able to sustain the meticulous self-care which is required to maintain complex restorations such as implant-supported bridges or overdentures. It is
crucial that the initial treatment provided can be modified in
the future to allow easier maintenance. For example, an
implant fixed bridge should be designed in such a way that
it can be converted to either a removable implant prosthesis
(to improve oral hygiene access for patients who struggle
with their manual dexterity) or even more traditional conventional dentures for those who may develop severe
dementia or difficulty in maintaining adequate self-care.
While oral implants have shown to improve quality of life
for older edentulous patients [57], they can also rapidly
become a burden to those who are unable to receive satisfactory maintenance [58].
It is important that clinicians are clinically competent and
experienced in a wide range of dental procedures, so that the
treatment can be delivered in the most effective and efficient
manner. The cost of dental treatment can be high; it can be
invasive and require multiple visits, and many older patients
may opt for “easier” (or indeed cheaper) options at the cost of
their longer-term oral health.
The fall in the prevalence of edentulism has led to a
gradual withdrawal from complete denture prosthodontics in
dental education. It has been pointed out that many recent
graduates in the UK are not confident or competent in
treating edentulous patients. The removable prosthodontics
curriculum has been reduced to a bare minimum [59].
As pointed out in respect of New Zealand, an ongoing
absolute fall in the number of edentulous people has led to
a de facto abandoning of complete denture prosthodontics
and its relegation to clinical dental technicians [60]. The overrepresentation of low-income adults among the edentulous
population has further hastened the dental profession's
general abandoning of that area of practice. Earlier commentators have already suggested the possibility of teaching
complete dentures through the approach of duplicating
patients' existing dentures or modifying these duplicate
dentures according to patients’ needs [59,61]. This could
enable simplification of the removable prosthodontic curriculum, but dentists are the ones who must diagnose, treat
and plan for any future oral health needs of our older
patients. Without an ongoing, comprehensive understanding
of removable prosthodontics, the profession's ability to meet
the ongoing needs of edentulous (or even partially dentate)
older patients would be compromised.
Conclusions
Steady increases in both the absolute and relative numbers of
older people—together with increases in tooth retention into
old age—pose particular challenges for the oral care system.
Although the other oral conditions are important, dental
caries remains by far the greatest clinical challenge faced
by those treating older people. The dental profession will
have to be equipped to meet the dual challenges of treating
and preventing the disease in a group which is usually
hard to reach and which has not enjoyed much attention
from policy-makers to date, at least where oral health is
concerned. There is a need to identify, develop and test
innovative approaches to catering for older people's oral
health needs.
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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Scientific article
Oral health status and complete denture status
of independent-living Singaporean elderly residing
in a community home
Tan Mei Naa, Rahul Nairb,n, Joanna Ngo Di Yingc, Robert Yeeb
a
University Dental Cluster, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074
Discipline of Oral Sciences, Faculty of Dentistry, National University of Singapore, 11 Lower Kent Ridge Road, Singapore
119083, Singapore
c
Faculty of Dentistry, University of Otago, New Zealand
b
art i cle i nfo
ab st rac t
Aim: Past studies have examined the oral health status of elderly Singaporean adults
Keywords:
residing in long term care facilities and living in residential housing but no oral health
Geriatric dentistry oral health
research has been conducted on elderly Singaporeans residing in community homes. The
Dental caries
aim of this paper is to report on the oral health status and complete denture status of a
Prosthodontics
group of free living (community dwelling) elderly in Singapore from the AWWA Commu-
Periodontal index
nity Home for Senior Citizens, and investigate the relation between the clinical findings
and demographic data.
Materials and methods: This research used a cross-sectional design and was conducted in
the month of December 2011. Consenting residents of the AWWA home who were over the
age of 60 participated in this study. Sampling strategy was census. Two calibrated
interviewers collected demographic information from the participants and four calibrated
dentists conducted extra-oral and intra-oral soft tissue examinations along with assessment of dentition, periodontal and denture status.
Statistical analysis: All data were input into Microsoft Excel 2010™ and analysed in SPSS
21.0™. Descriptive analysis and bivariate analysis were performed on the demographic
factors and other variables of interest. The Spearman's test, Mann–Whitney U and ChiSquare test were used to examine the correlation between the clinical findings and age,
gender and education level respectively.
Results: Among the 70 participants, two subjects (2.9%) had complete dentition, 34 (48.6%)
were partially dentate, and 34 (48.6%) had no teeth. The mean number of teeth among the
partially dentate participants was 11.28 while the mean number of anterior, posterior and
total occlusal contacts were 1.61, 2.17 and 3.78 respectively. The mean number of decayed
teeth (DT) and filled teeth (FT) were 2.81 and 0.25, giving a mean DFT score of 3.06. The
mean Root Caries Index was 0.13. Periodontal examination revealed that only 5 (13.9%)
individuals had healthy periodontal tissues, while 2 (5.6%) had the highest score of 1, 9
(25.0%) had the highest score of 2, 11 (30.6%) had the highest score of 3 and 7 (19.4%) had
n
Corresponding author. Tel.: þ65 67724989; fax: þ65 67785742.
E-mail addresses: [email protected] (T. Mei Na), [email protected] (R. Nair), [email protected] (J.N. Di Ying),
[email protected] (R. Yee).
http://dx.doi.org/10.1016/j.sdj.2014.07.002
0377-5291/& 2014 Published by Elsevier B.V.
10
Singapore Dental Journal 35 (2014) 9–15
the highest score of 4. Amongst the partially dentate, 14 had dentures and 20 had none.
There were 34 edentulous participants and 23 had at least one denture while 11 did not
have any complete dentures. The most frequent unsatisfactory finding for complete
dentures was inadequate retention of the mandibular dentures. When the dentures were
grouped into those that were satisfactory and those that had at least one unsatisfactory
factor, 11 of the 26 maxillary dentures and 17 of the 23 mandibular dentures fell to the
latter category. Analysis revealed that there was a correlation between age and the number
of teeth with a correlation coefficient of 0.43 (p ¼ 0.01) and age with the mean DFT, 0.33
(p¼0.05).
Conclusion: The findings of this study revealed a high treatment need for this group of
elderly.
& 2014 Published by Elsevier B.V.
Introduction
Singapore has one of the world's fastest ageing populations,
with the proportion of elderly adults rising from 10.5% of the
total population in 2013 to almost 20% of the total population
by 2030 [1]. By 2030, it is estimated that the number of seniors
above 65 in Singapore will increase to almost one million.
One of the challenges with an ageing population is ensuring
that the needs of the elderly, including their oral health needs
are well provided for. Studies have shown that oral health
can have a significant impact on the general health and
quality of life of individuals; therefore, public health policies
need to take into consideration the oral health status and
needs of the elderly population [2,3]. This will encourage
active and healthy ageing amongst the elderly population.
Peer-reviewed reports on the oral health of the elderly in
Singapore date back to the 1990s. Soh et al. examined the
status of the dentition, soft tissue and periodontium of 479
institutionalized elderly living in long-term care facilities and
found that the mean DMFT for the cohort was 27.0 [4]. Fiftysix percent of the elderly were edentulous and 78.8% were
without dentures. They also found that 52.2% of the subjects
presented with a dental condition that required immediate
care. Loh et al. studied the oral health of 891 elderly
residential residing adults and found that the percentage of
edentulous individuals was 27.3% and there was a significant
difference in the percentage of edentulous individuals in the
different age groups [5]. The mean DMFT of the elderly in
their study group was 19.4 and showed an upward trend with
each increasing age cohort. Thean et al. found the treatment
needs of 184 nursing home residents to be high [6]. More than
half the complete dentures examined were unsatisfactory
and untreated decay and retained roots were prevalent.
Currently, there is not any information on the oral health
status of elderly Singaporeans residing in community homes.
In 2011, about 97 per cent of the elderly population resided in
residential housing, while the remaining were living in
institutions such as community and nursing homes [7].
Community homes, also known as sheltered homes, provide
residential care for ambulant destitute or low-income elderly
who are without family support and can live independently
while nursing homes provide care for the elderly with medical conditions who need nursing care. This paper reports on
the oral health status and complete denture status of a group
of elderly Singaporeans residing in the AWWA Community
Home for Senior Citizens, and investigates the relation
between the clinical findings and demographic data.
Materials and methods
This research used a cross-sectional design and was conducted in the month of December 2011. The participants of
this study were free-living residents of the Asian Women's
Welfare Association (AWWA) Community Home for Senior
Citizens. Sampling strategy was census, as all the residents
over the age of 60 years were invited to participate. The study
was explained to the residents and written consent was
obtained from all volunteer participants. Those unable to
answer the questionnaire were excluded from the study. The
participants were given an oral care kit as a token of gratitude
for their participation. Ethical approval to conduct this
research was received from the National University of Singapore Institutional Review Board, Reference Code 10-155.
Two calibrated interviewers collected demographic information and four calibrated dentists performed the clinical
examinations on the participants. Demographic data collected included information regarding age, gender, level of
education, number of years in Singapore, and monthly
income. Clinical examinations were carried out on location
using portable headlamps, mouth mirrors, CPI probe with
0.5 mm ball end, magnifying loops (Heine HR 2.5 S frame),
with the participants reclining on portable dental chairs.
Clinical examination included extra-oral and intra-oral soft
tissue examination along with assessment of dentition,
periodontal and denture status.
Dentition status included the presence of natural teeth,
the number of posterior and anterior occlusal contacts and
presence of caries. The number of occlusal contacts was
observed by asking the participant to bite in maximum
intercuspation. The number of posterior contacts counted
the presence of contacts on mandibular premolars and
molars while the number of anterior tooth contacts was
counted by observing the number of contacts achieved on
the mandibular anterior teeth. Dental caries was assessed
using criteria described in ICDAS-2 with mouth mirrors, CPI
11
Singapore Dental Journal 35 (2014) 9–15
probes with a 0.5 mm ball tip, and headlamps [8]. ICDAS
Caries codes 0 and 1 were not differentiated, as compressed
air was not used for the examinations, but the rest of the
codes and criteria were applied. Both coronal and exposed
root surfaces were scored for the presence of caries and
restorations. For this report, the scores were converted to
decayed and filled surfaces, while missing surfaces are not
reported due to recall error by the participants. For root
surfaces, the findings are reported using the Root Caries
Index [9].
Periodontal status was assessed using the Community
Periodontal Index (CPI) according to the WHO methodology
using a CPI probe with a 0.5 mm ball tip [10]. The scoring
system is shown in Table 1. The mouth was divided into six
sextants defined by teeth numbers 18–14, 13–23 24–28, 38–34,
33–43, and 44–48 and a sextant was examined only if there
were two or more teeth present and not indicated for
extraction. The two molars in each posterior sextant are
paired for recording, and if one is missing, there is no
replacement. If no index tooth was present in a sextant
qualifying for examination, all the remaining teeth in that
sextant were examined.
Complete dentures were assessed for retention, stability,
defects and occlusion. Retention of maxillary dentures was
assessed with the examiner placing his index finger and
thumb in the premolar areas and exerting a gentle vertical
downward pressure while for the mandibular dentures the
index finger and thumb of one hand were used to grip either
side of the central incisors and a gentle upward force was
exerted [4]. Stability was assessed with the examiner placing
their index fingers and thumbs on either side of the premolars and applying rotatory and lateral forces on the
complete denture. Occlusal relationship was recorded by
asking the patient to bite down from his resting position,
with the examiner gently supporting the lower denture with
his index fingers. The relationship was recorded as inadequate if there was a slide of greater than one quarter cusp
length into intercuspal position from first contact, if first
contact was uneven, leading to displacement of the dentures
on further closure or if first contact was clearly uneven
between right and left or where all contact was on the
anterior teeth, even in the absence of significant displacement. Defects in the form of broken teeth, missing teeth,
fractured base and deficient base were noted for both maxillary and mandibular complete dentures. A score of 0 was
given for each of the items if the item assessed was
Table 1 – CPI scoring system.
Score
Description
0
1
Healthy
Bleeding observed, directly or by
using mouth mirror, after sensing
Calculus felt during probing but all the
black area of the of probe is visible
Pocket 4 or 5 mm (gingival margin situated
on black area of probe)
Pocket46 mm (black area of probe not visible)
Excluded sextant
Not recorded
2
3
4
X
9
satisfactory and a score of 1 was given if the examination
showed unsatisfactory findings. The scores were then tabulated to reflect the denture status and higher scores were
associated with more problems with the complete dentures.
Partial dentures were examined for the Kennedy classification, type of support, and retention. However, due to the
variability of partial dentures, the status of partial dentures is
not reported in this paper.
Data analyses
All data were input into Microsoft Excel 2010™ and analysed
in SPSS 21.0™. Descriptive analysis and bivariate analysis
were carried out for the demographic factors and other
variables of interest. The Spearman's test, Mann–Whitney U
and Chi-Square test were used to examine the correlation
between the clinical findings and age, gender and education
level respectively.
Results
Demographic distribution
Seventy participants were recruited in this study (47 (67%)
males; 23 (33%) females). The demographic distribution of the
study population is shown in Table 2. The mean age of the
participants was 74.4, with the oldest being 91 years of age.
Sixty-four (91%) were Chinese, 5 (7%) were Malays and there
was 1 (1%) Indian participant. Whilst 19 (27%) of the participants had no formal education, 32 (46%) had up to primary
Table 2 – Distribution of some socio-demographical
characteristics of elderly subjects (n ¼70).
Demographic variables
Gender
Male
Female
Age
60–69
70–79
80 and above
Ethnicity
Chinese
Malay
Indian
n (%)
47 (67.1)
23 (32.9)
15 (21.4)
34 (48.6)
21 (30.0)
64 (91.4)
5 (7.1)
1 (1.4)
Education level
No formal qualification
Primary school education
Secondary school education
Professional qualification
19
32
18
1
Marital
Single
Married
Divorced
54 (77.1)
12 (17.1)
4 (5.7)
Monthly income
No income
Up to $999
(27.1)
(45.7)
(25.8)
(1.4)
9(12.9)
61 (87.1)
12
Singapore Dental Journal 35 (2014) 9–15
school education, 18 (26%) had up to secondary school education, and only 1 had a professional qualification. Fifty-four
(77%) of the participants were single, 12 (17%) were married,
and 4 (6%) were divorced. The majority of the participants, 61
(87%) were engaged in the work force and only 9 (13%)
were not.
The mean number of teeth was 11.28. The mean number of
anterior, posterior and total occlusal contacts were 1.61, 2.17
and 3.78 respectively. The mean number of decayed teeth
(DT) was 2.81 while that of filled teeth (FT) was 0.25, giving a
mean decayed and filled teeth (DFT) score of 3.06. The mean
RCI index was 0.13. Table 4 shows the dentition status of the
36 dentate participants. There was a correlation between age
and the number of teeth with a correlation coefficient of
0.43 (p ¼0.01) and age with the mean DFT, 0.33 (p ¼0.05).
There was no correlation noted between age, gender and
education level with the other factors considered in dentition
status. The intra-class correlation for inter-examiner reliability was 0.94 for DT.
Prevalence of edentulism and denture usage
Amongst the participants, 4 (5.7%) had all maxillary teeth
present (with the exception of the third molars) and 2 (2.9%)
had intact mandibular dentition. Twenty-five (36%) were
partially edentulous on the maxillary arch and 12 of them
had partial dentures. For the mandibular arch, 32 (46%) were
partially edentulous and 7 had partial dentures. Forty-one
(56%) of the participants were edentulous on the maxillary
arch and 26 had complete denture prosthesis. On the mandibular arch, 36 (51%) were edentulous and 23 had complete
denture prosthesis. Two subjects (2.9%) had complete dentition, 34 (48.6%) were partially dentate, and 34 (48.6%) were
edentulous. Amongst the partially dentate, 14 had dentures
and 20 had none. Amongst the edentulous participants, 23
had at least one denture and 11 did not have any complete
dentures. Table 3 summarises the data on prevalence of
edentulism and denture usage.
Periodontal status
Table 5 shows the periodontal status of the participants
according to CPI. Only 5 (13.9%) individuals had healthy
periodontal tissues, while 2 (5.6%) had the highest score of
1, 9 (25.0%) had the highest score of 2, 11 (30.6%) had the
highest score of 3, and 7 (19.4%) had the highest score of 4.
There were no significant correlations noted between the
highest CPI score and age, gender and education level.
Status of complete dentures and its relationship
with demographic factors
Dentition status
The results for complete denture status are shown in Table 6.
For maxillary complete dentures, 18 (69%) had satisfactory
retention and the remaining 8 were deemed unsatisfactory.
Of the 70 participants, 34 were edentulous; thus, only 36 were
included in the examination and analysis of dentition status.
Table 3 – Prevalence of edentulism and denture usage according to arch.
Maxillary arch n (%)
Mandibular arch n (%)
All teeth present (except 8s)
Partially dentate with denture
Partially dentate without denture
Complete edentulism with denture
Complete edentulism without denture
4
12
13
26
15
2
7
25
23
13
Total
70 (100)
(5.7)
(17.0)
(18.6)
(37.1)
(21.4)
(2.9)
(10.0)
(35.7)
(32.6)
(18.6)
70 (100)
Table 4 – Dentition status among the 36 dentate participants.
Male (n ¼25)
Mean (95% C.I.)
Number of natural teeth
Number of anterior occlusal contacts
Number of posterior contacts
Total occlusal contacts
10.6
1.6
2
3.6
DT
FT
DFT
3.32 (1.87–4.77)
0.12 (–0.13–0.37)
3.44 (2.02–4.86)
No. of root surfaces with decay
No. of root surfaces with permanent fillings
No. of sound root surfaces
Root Caries Index
0.68
3.12
23.08
0.13
(6.98–14.30)
(0.69–2.51)
(0.46–3.54)
(1.25–5.95)
( 0.35–1.71)
(0.37–6.20)
(16.04–30.11)
(0.06–0.21)
Female (n ¼ 11)
Mean (95% C.I.)
12.7
1.63
2.55
4.18
(7.46–18.00)
(0.39–2.89)
( 0.45–5.54)
(1.00–7.36)
1.64 (0.13–3.15)
0.55 ( 0.15–1.24)
2.18 (0.69–3.68)
1.36
2.55
31.27
0.12
( 0.66–3.39)
(0.14–4.96)
(17.69–44.86)
(0.03–0.20)
Total (n ¼36)
Mean (95% C.I.)
11.28
1.61
2.17
3.78
(8.40–14.16)
(0.91–2.31)
(0.84–3.49)
(1.97–5.59)
2.81 (1.71–3.90)
0.25 ( 0.01–0.51)
3.06 (1.99–4.12)
0.89
2.94
25.58
0.13
(0.00–1.78)
(0.75–5.14)
(19.44–31.73)
(0.07–0.19)
13
Singapore Dental Journal 35 (2014) 9–15
Table 5 – Periodontal status according to CPI, in relation to gender (n ¼36).
Number of subjects with highest score of
Male
Female
Total
Mean number of sextants scores
0
1
2
3
4
0
1–4
2–4
3–4
4
X
4
1
5
1
1
2
3
6
9
11
2
13
6
1
7
0.36
0.45
0.39
2.44
2.55
2.48
2.08
2.18
2.11
0.88
0.36
0.72
0.28
0.09
0.22
1.55
1.43
1.51
Table 6 – Status of 26 maxillary and 23 mandibular
complete dentures.
Discussion
clinical findings and income level, since the participants had
no or limited income. It is important to note that the findings
of this study describe the oral health status of this unique
group of elderly and should not be generalised to the general
elderly population in Singapore. It does, however, reveal the
need for oral health care amongst this group of elderly.
A high percentage of the participants (48.6%) in this study
were edentulous and among those partially dentate, the
mean number of natural teeth was 11.28 and the mean
number of occluding contacts was 3.78 (Table 4). While it
has been noted that globally the elderly are living longer and
retaining more teeth, this trend might not be the case for
elderly who are of low economic status [13]. Amongst the
partially dentate, 20 (58.9%) of the partially dentate participants did not have any partial dentures and 23 (32.4%) of the
edentulous participants had no complete dentures. This
proportion was lower than the 94% of the partially dentate
participants and 78.8% of the edentate participants who could
have benefitted from prosthetic treatment in the study by
Soh et al. [4]. The necessity of dentures may be questioned for
partially dentate individuals, since the presence of dentures
may increase the incidence of caries, periodontal problems
and denture stomatitis in the absence of proper oral care. It
has also been suggested that there was sufficient adaptive
capacity in subjects with at least four occlusal units and that
it was not necessary to restore an individual to complete
dentition of 28 teeth [14]. On the other hand, dentures may
aid in masticatory function, especially in subjects who have
fewer than 3 occluding pairs of teeth, and help to improve
aesthetics and thus self-esteem [15]. In this study population,
given that the mean number of natural teeth and occluding
contacts were low, participants may be able to benefit from
the provision of partial dentures. The presence of complete
dentures may also be beneficial for edentate individuals since
the absence of complete dentures has been linked to the risk
of malnutrition in edentate subjects [16].
This is the first study in Singapore reporting on the oral
health of independent residents of a community home.
Unlike residents of nursing homes, these elderly were ambulant and active and studies have shown that active elderly
tend to have better oral health than dependent elderly [11].
However, residents of community homes have limited financial income and as shown in Table 2, 72.8% of the participants
in this study attained only primary school education and 61
(87.1%) reported monthly income up to $999 while 9 (12.9%)
reported no income. Low income and education level have
been associated with poor oral health in the elderly, who tend
to be underserved with regards to oral care [12]. In this study,
no attempt was made to determine the correlation between
A global survey by the World Health Organisation revealed
a huge unmet need for denture treatment and restorative
dental care amongst older people [12]. However, the provision
of dental care based on normative treatment need alone
might not be sufficient to determine if prosthetic treatment
should be provided since the impact of missing teeth might
not affect the functioning, social and psychological wellbeing of these individuals. Using the sociodental approach
might provide a more relevant estimation of treatment need
in the provision of dentures in the elderly population [17].
This approach involves identifying both normative needs and
socio-dental factors, such as perceived impacts and oral
health-related behaviours, and should be utilised in subsequent studies.
Maxillary n (%)
Mandibular n (%)
Denture retention
Satisfactory
Unsatisfactory
18 (69.0)
8 (31.0)
6 (26.0)
17 (74.0)
Denture stability
Satisfactory
Unsatisfactory
22 (85.0)
4 (15.0)
14 (61.0)
9 (39.0)
Defects
Present
Not present
7 (27.0)
19 (73.0)
4 (17.0)
19 (83.0)
Occlusal relationship
Satisfactory
Unsatisfactory
17 (65.0)
9 (35.0)
In terms of stability, 22 (85%) of the maxillary complete
dentures were satisfactory while 4 (15%) were unsatisfactory.
For mandibular complete dentures, only 6 (26%) had satisfactory retention, 14 (61%) had satisfactory stability, in contrast
to the 17 (74.0%) and 9 (39.0%) which had inadequate retention and inadequate stability, respectively. Eleven out of the
49 complete dentures examined had defects. Seventeen (65%)
of the 26 dentures had satisfactory occlusion with the
opposing arch. When the dentures were grouped into those
which were satisfactory and those which had at least one
unsatisfactory factor, 11 of the 26 maxillary dentures and 17
of the 23 mandibular dentures fell to the latter category. The
status of complete dentures was not related to age, gender or
educational level.
14
Singapore Dental Journal 35 (2014) 9–15
Complete denture examination showed that 17 out of the
23 mandibular prostheses had unsatisfactory retention. This
is similar to the findings of the study by Thean et al. which
showed that almost 50% of the complete dentures had
inadequate retention [6]. The study by Soh et al. revealed
that 20% of the complete dentures needed replacement due
to inadequate retention or stability [4]. Elderly adults may be
satisfied with the function of their poor fitting dentures since
there may be a lack of association between clinicians'
evaluation of dentures and patients' satisfaction [18]. In cases
where it is difficult to achieve retention for mandibular
complete dentures, it has been suggested that implant
retained mandibular overdentures be considered and studies
have shown that such an intervention can help to improve
the quality of life of the elderly [19]. However, the increased
cost and greater need of maintenance for implant-retained
overdentures may deter the elderly from seeking this modality of treatment.
This study omitted the reporting of the mean number of
missing teeth due to caries (MT) since it was difficult for the
elderly to recall accurately the reasons for the extraction of
their teeth; hence only mean DFT was reported. The study by
Loh et al. on community-dwelling elderly found that the
mean DT and the FT was 1.2 and 2.0 respectively [5]. The DT
of 2.21 was higher in this study but the FT of 0.25 was much
lower than the study by Loh et al. [5]. However, our values for
DT and DFT correspond closely with those found in India and
China [20,21]. The DT for a study amongst the elderly in India
(n ¼300) was 2.5 and another study in China (n ¼23452) found
the DFT to be 2.5. The mean DT of 2.81 and mean decayed
root surface of 0.89 reflect a high treatment need for this
group of independent living elderly. The low FT of 0.25 and
high DT could be due to a preference for tooth extraction in
older people or may reflect an underutilisation of restorative
care due to various reasons. The use of professional dental
services has been shown to be low amongst elderly adults,
particularly among the socio-economically disadvantaged [22].
Dental caries is a major public health problem in older people
and it is closely linked to social and behavioural factors such
as irregular dental attendance and lack of proper oral hygiene
habits [13]. This study also showed that the number of teeth
and mean DFT were significantly correlated with age (p¼0.01
and 0.05 respectively), similar to findings in other studies
[23,24].
The high prevalence of subjects with the highest CPI score
2 and 3 has been noted in other countries as was the case for
this study, where 61% of the participants had the highest CPI
score 2 and 3, reflecting poor oral hygiene, while 19.4% had
CPI-4, an indication of severe periodontal disease [12].
A study in Hong Kong among low-income middle-aged to
elderly participants had results similar to this study, where
64.1% of the participants had the highest CPI score 2 and 3
while 35.9% had CPI-4 [25]. While age was not associated with
the incidence of periodontal disease, earlier studies have
shown that females and those with a higher level of education had better periodontal health [26,27]. However, this was
not the case in our sample population and could possibly be
due to the small sample size, resulting in a Type II error. The
promotion of good oral self care and regular visits to dentists
throughout the adult lifespan might be beneficial in
improving the oral health status of the elderly population.
Oral hygiene education programmes targeting the elderly
have been shown to improve self-care skills and may ultimately impact positively on the oral health status of the
elderly [28]. This may result in the retention of more natural
teeth, which has been associated with better oral-health
quality of life of individuals [3].
6.
Conclusion
The results from this study showed there is a great normative
need for dental care in this group of elderly. There is also
a significant correlation between age and the number of
natural teeth and DFT (p¼ 0.01 and 0.05 respectively).
Acknowledgement
This research was funded by the Ministry of Education AcRF
Tier 1 Grant (WBS R-221-000-035-112).
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Singapore Dental Journal 35 (2014) 17–22
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Scientific Article
Factors contributing to tooth loss among the elderly:
A cross sectional study
Zuhair S. Nattoa,b,n, Majdi Aladmawya, Mohammed Alasqaha, Athena Papasc
a
Department of Periodontology, Tufts University School of Dental Medicine, One Kneeland Street, Boston, MA 02111, USA
Department of Dental Public Health, King Abdualziz University, School of Dentistry, Jeddah, Saudi Arabia
c
Division of Dental Public Health Research and Oral Medicine, Tufts University School of Dental Medicine, Boston,
MA 02111, USA
b
art i cle i nfo
ab st rac t
Background: The present study evaluates the influence of several demographic, health,
Keywords:
personal, and clinical factors on the number of missing teeth in old age sample.
Aged
Methods: The number of patients included was 259; they received a full mouth examination
Periodontal disease
and answered a questionnaire provided by one examiner. All the variables related to teeth
Teeth loss
loss based on the literature were included. These variables focused on age, gender, race,
Factors
marital status, clinical attachment level, pocket depth, year of smoking, number of cigarettes
smoked per day, number of medications, root decay, coronal decay, health status, and year
of education. Statistical analysis involved stepwise multivariate linear regression.
Results: Teeth loss was statistically associated with clinical attachment level (CAL)(p value
0.0001), pocket depth (PD) (0.0007) and education level (0.0048). When smoking was included
in the model, age was significantly associated with teeth loss (0.0037). At least one of these
four factors was also related to teeth loss in several specific groups such as diabetes mellitus,
male, and White. The multiple linear regressions for all the proposed variables showed that
they contributed to teeth loss by about 23%.
Conclusions: It can be concluded that less education or increased clinical attachment level
loss may increase number of missing teeth. Additionally, age may cause teeth loss in the
presence of smoking.
& 2014 Published by Elsevier B.V.
Introduction
Tooth loss in elderly population, was reported by several
studies in the past, showing a strong association with
mortality [1-3]. Periodontitis is considered as one of the
etiologic factors contributing to tooth loss, it is hypothesized
that the environment in the subgingiva plays a role on what
n
Corresponding author. Tel.: þ1 909 702 4119; fax: þ1 617 636 0911.
E-mail address: [email protected] (Z.S. Natto).
http://dx.doi.org/10.1016/j.sdj.2014.11.002
0377-5291/& 2014 Published by Elsevier B.V.
type of microbial flora will flourish in that area, this elicits
and inflammatory response from the host, which drives the
condition from health to disease [4]. Several factors such as
bleeding, deep probing, clinical attachment level increase and
bone loss, eventually lead to tooth loss [5]. Periodontal
breakdown of a crowned tooth structure is the most common
reason contributing to tooth loss (59%) [6], other factors that
18
Singapore Dental Journal 35 (2014) 17–22
contribute to tooth loss or extractions include un-restorable
teeth (either from fractures or caries) (27%), or periapical
lesions (12%), however 35.6% of the teeth extracted had an
endodontic treatment [6]. Anand et al. reported on extraction
trends in India, caries was observed as the main etiologic
factor for extraction at 44%, periodontal breakdown at 33%,
Orthodontic reasons at 11%, impactions and prosthodontics
purposes were at 2% [7]. Reports from previous studies stated
that periodontitis is associated with coronary heart disease
[8] and diabetes mellitus [9,10].
Genco et al. [11] found an association between various
markers of periodontitis and cardiovascular disease (CVD). A
good oral hygiene is needed to reduce the mortality risk
among elderly population. It was reported that people who
maintain good oral hygiene, and visit the dentist at least once
a year, had a lower mortality risk when compared with
people who did not have good oral hygiene maintenance
[12,13]. However, elderly patients with periodontal disease
need to have a more aggressive therapy than what is
commonly practiced [14].
Rosén et al. found that, patients who did not visit their
dentists at least once annually were more susceptible to
periodontal progression [15]. Other studies found that, the
use of dentures had a relationship with reduction of mortality
rates for older patients, who are missing teeth; this can be
explained by the reduction of teeth that can harbor specific
ecology group of micro-organisms that might have an association with systemic conditions [16–18].
Bachwald et al. examined the relationship between individual
income status, and chronic systemic inflammation, to assess the
progression of periodontal disease and tooth loss in Pomerania,
Germany, 2566 participants had a 5 year follow up. They
concluded that there was an association between individual
income status and periodontitis, as the income decreased the
progression of periodontitis was more evident [19].
Linden et al. reported that age was found to be associated
with tooth loss, due to the progressive loss of attachment
level [20]. Renvert et al. in 2013 found that, prevalence of
probing depth more than, or equal to 5 mm with radiographic
bone loss more than 5 mm increased with age, regardless of
frequent dental visits [21].
Chen et al. 2012 found that coronal root caries, and
removable dentures had a synergistic effect on tooth loss in
the old population; patients who wore dentures had multiple
carious areas, when the areas were treated they had the
highest risk of tooth loss [22].
Tooth loss is associated with a lower quality of life due to
more bacterial accumulation around the sulcus of the teeth,
and/or the dentures [23]. Chronic inflammation contributes to
the formation of diseases like coronary disease, stroke,
hypertension, diabetes mellitus, and chronic obstructive
pulmonary disease [24].
There are limited studies that report on tooth loss with
different variables such as education level, race, age, smoking, coronal caries, and number of medications. In the Linden
et al. study [20], the final outcome reported was mortality; in
contrast to what is being researched in the current study,
which is tooth loss. Previously mentioned studies [19–24]
reported on one or two of the following variables: education
level, race, age, smoking, coronal caries, and number of
medications; however, there was no study that combined
all of those variables as a multi-variable interaction.
Teeth maintenance in elderly population deserves some
attention as it increases the quality of life, which requires a
stable dentition to aid in food digestion [25], having tooth loss
might decrease the quality of life for the patient.
The aim of our current study is to evaluate if there is an
association between, tooth loss and several other variables
like coronal root caries, smoking, patient education level,
race, diabetes, medication use, and age.
Materials and methods
The volunteers recruited for this study came from either
Tufts Geriatric Outreach program (57% of participants) or
Tufts dental clinics (43%). The Tufts Geriatric Outreach
program performs dental screening, nutritional screening,
and educational sessions for elderly people and is conducted
at 30 different locations in the greater Boston area.
Selection criteria for enrollment in the study included
being a community dwelling resident, having six or more
teeth, being free from wasting illness (endocrine disease that
would affect nutrition; recent unexplained weight loss; and
active alcoholism), and being willing and able to complete a
3-d food diary in a predetermined manner. Each participant
signed a consent form agreeing to participate in the study.
The study was approved by the Human Investigation Review
Committee of Tufts University.
Clinical oral examinations were conducted at Tufts University School of Dental Medicine by one examiner using
artificial light, explorer, mirror, and air syringe. The teeth
were dried before examination to assess the dental decay.
The coronal and root caries and periodontal measurements
were made on all subjects according to the diagnostic criteria
used in the US adult survey [26]. Third molars were excluded
from examination. Training and calibration sessions to standardize caries and periodontal measurements based on the
diagnostic criteria used in the US adult survey [26] were held
semi-annually. Intraclass correlation coefficients for clinical
attachment level and probing depth were 0.92 and 0.88,
respectively. Self-administered questionnaires on general
and health knowledge, attitudes and behavior, and medication history were also administered.
Sample size
We expected to have 95% power based on squared multiple
correlation ρ2 of 0.1, effect size of 0.11 and 10 predictors, a
sample size of 195, and α¼0.05. We expect about 20% drop
out due to age of the participants. So, the total sample size
was at least 245. The sample size was calculated using
Gnpower software, version 3.1 (University Kiel, Germany).
Statistical analysis
Descriptive statistics were expressed as mean7SD or N (%).
Univariate analysis and the stepwise model selection technique determined the significant variables that are more
commonly associated with actual number of teeth loss.
19
Singapore Dental Journal 35 (2014) 17–22
Table 1 – Descriptive statistics of the study sample.
Variable
N ¼259
Age (mean7SD)
Gender, n (%)
Male
Female
Race, n (%)
White
African American
Marital status, n (%)
Single
Married
Others
Clinical attachment level (CAL)
(mean7SD)
Clinical attachment level (CAL) n (%)
Z 3 mm
o3 mm
Pocket depth (mean7SD)
Pocket depth, n (%)
Z 3 mm
o3 mm
Years of smoking (mean7SD)
Number of cigarette per day
72.41715.43
Number of medications
Missing teeth
Root decay
Coronal decay
Total decay (rootþcoronal)
Disease, n (%)
CVD
Diabetes
Medical stable
Years of education (mean7SD)
Table 2 – Simple linear regression (univariate) analysis for
all groups when teeth loss was associated with several
demographic, health, personal and clinical factors.
estimate
SE
R2
All: excluding smoking
Mean CAL
0.0001n
Mean PD
0.0007n
Education
0.0048n
1.73290
3.84605
0.54821
0.44054
1.11906
0.19254
0.066
0.115
0.147
All: including smoking
Age
0.0037n
0.17869
0.06035
0.071
CVD
None
–
–
–
–
DM
Mean CAL
o0.0001n
5.54010
1.13992
0.396
Medically stable
None
–
–
–
–
252(97.30)
7(2.70)
4.92712.53
85420.907
137382.52
0.7271.57
8.7377.00
0.3971.12
0.6472.35
1.0272.81
Male
Mean CAL
Mean PD
Age
o0.0001n
0.0006n
0.0075n
2.57647
5.33759
0.11748
0.58867
1.49555
0.04303
0.164
0.261
0.314
Female
None
–
–
–
–
White
Mean CAL
Mean PD
0.0002n
0.0010n
1.71620
4.39621
0.45805
1.31887
0.067
0.117
63(24.32)
47(18.15)
149(57.53)
13.3672.46
African American
None
–
–
–
–
108(44.08)
137(55.92)
218(89.71)
25(10.29)
55(22.63)
126(51.85)
62(25.51)
3.3371.02
107(41.31)
152(58.69)
2.0170.43
Multiple linear regressions were used to assess potential
associations of actual number of teeth loss and several
variables. The multicollinearity was checked. The adjustment
and adequation of the final model was checked by the C(p),
and R2 adjusted. Analyses were performed using SAS 9.3 (SAS
Institute, Cary NC).
Results
Table 1 shows the demographic features of the study, the
prevalent population was female, white, married, completed
13 years of education, and is about 72 years old. The population had deeper clinical attachment level ( Z3 mm) and
shallower pocket depth (o3 mm).
Variables associated with actual number of teeth loss
Actual number of teeth loss was statistically associated with
clinical attachment level (p value 0.0001), pocket depth
(0.0007) and education (0.0048) (Table 2). Number of teeth
loss increased with more recession, less pocket depth, and
less education. When smoking was included in the model,
age was significant and positively associated with teeth loss
(0.0037). At least one of these four factors was also related to
Group and
variable
n
P value
P valueo0.05.
number of teeth loss in several specific groups such as
diabetes mellitus, male, and White.
Full model associated with actual number of teeth loss
In further analyses, multiple linear regression with smoking
excluded due to number of missing, the variables clinical
attachment level, pocket depth and education were significant (Table 3). Other variables indicated that tooth loss was
higher with increased number of medications and root caries.
Single, African American, females that had diabetes or
cardiovascular disease, were more likely to demonstrate
increased tooth loss. Adding smoking to the model which
reduced the total subject to 146 due to case wise deletion
characteristic of multiple linear regression, showed the same
result, except more teeth loss was observed with increased
coronal caries and among married population (Table 4). Both
models found that these variables together explained bout
23% of factors associated with teeth loss.
Discussion
This study had a population of (44%) males compared to
females (56%), most of the population was white (90%), and
almost half of the population was married (52%).
20
Singapore Dental Journal 35 (2014) 17–22
Table 3 – Multiple linear regression analysis when teeth loss was associated with all demographic, health, personal and
clinical factors excluding smoking.
Variable
P value
estimate
SE
Intercept
Number of medication
African American vs. White
Female vs. male
Mean CAL
Mean PD
Age
Education
Root caries
Coronal caries
CVD vs. medically stable
DM vs. medically stable
Married vs. single
Other vs. single
0.2521
0.0419
0.1318
0.1393
o0.0001n
0.0008n
0.0469
0.0187n
0.7468
0.8628
0.0946
0.3544
0.8409
0.2876
5.57695
0.67996
2.31266
1.35147
2.25749
4.00146
0.06359
0.46014
0.1333
0.03147
1.86617
1.13126
0.90663
0.27006
4.85635
0.33216
1.52853
0.91052
0.51155
1.17242
0.03181
0.19405
0.41238
0.18181
1.11116
1.21877
1.10113
1.34364
R2
0.2284
Other includes: divorced and widow.
P valueo0.05.
n
Table 4 – Multiple linear regression analysis when teeth loss was associated with all demographic, health, personal and
clinical factors including smoking.
Variable
P value
Estimate
SE
Intercept
Number of medication
African American vs. White
Female vs. male
Mean CAL
Mean PD
Age
Education
Root caries
Coronal caries
CVD vs. medically stable
DM vs. medically stable
Married vs. single
Other vs. single
Total smoking
0.5944
0.1002
0.0854
0.6541
0.0655
0.057
0.1177
0.0517
0.7346
0.8062
0.2359
0.896
0.6291
0.2598
0.4006
4.27353
0.61305
4.22634
0.58244
1.22509
2.89193
0.10955
0.53849
0.14641
0.04675
1.84542
0.23005
0.83191
2.26903
0.0000041
8.00098
0.36954
2.4332
1.29606
0.658
1.5018
0.06943
0.27347
0.43072
0.19007
1.54752
1.75596
1.71727
2.00233
0.000005
R2
0.2383
P valueo0.05.
Other includes: divorced and widow.
It was found that tooth loss was associated with (a) increased
clinical attachment level (CAL), (b) decreased probing depth (PD),
and (c) less education level. When a tooth has increased CAL, it is
less associated with the bone structure, PDL, and connective
tissue, this increases its mobility and susceptibility to infection
from bacteria due to the exposed dental tubules and apical
migration, as the CAL progresses it causes the probing depth to
decrease, hence we get shallower pocket depth.
Patient education was statically significant with tooth loss,
when the population was more educated they had more teeth
present, in contrast to the population with lower education
that tended to have more teeth loss, our findings in patient
education agreed with the findings from Buchwald et al. that
reported Low education levels and low individual income
were associated with higher chances of tooth loss [19].
Smoking and age were found to have a significant effect
on tooth loss; hence if an individual was smoking and aging,
he will have a higher chance of losing teeth compared to nonsmokers. Ando et al. found that smoking, low education level,
and poor nutritional status, had an association with tooth
loss among middle-aged and elderly Japanese population [27],
this agrees with our findings in the current study.
De Marchi et al. reported on a combination of factors that
might influence tooth loss such as being old, male, married,
living in the countryside, with less education, and was not
satisfied with methods to obtain health services. All of the
previous factors were associated with tooth loss [28].
Another study that has a different result, regarding smoking and age affecting tooth loss, is a study by Jiang et al., who
studied the adult population in Rhode Island, and found
Singapore Dental Journal 35 (2014) 17–22
individuals that smoked had a high chance of losing teeth,
and age was not related to tooth loss [29].
Being a white, male, and smoking increased the risk of
tooth loss with increased CAL, decreased PD, and increased
age. Diabetes mellitus (DM) was positively correlated to tooth
loss with smoking, Meisel et al. in Germany found C-reactive
protein (CRP), and other inflammatory mediators were elevated due to chronic inflammation, which affects the bone
hemostasis and results in bone resorption around areas that
involve the tooth structure [30].
Increasing the number of medications taken daily was
also significant (without the smoking variable) to tooth loss
incidence. Taking too many medications has a negative effect
on the salivary glands, it reduces its function, and it favors
more bacterial accumulation. Locker et al. reported that
xerostomia has an important influence on the quality of life
of the population [31].
When caries activity is associated with the root dentine, it
produced a positive relation to tooth loss, as restoring these
teeth becomes more challenging than restoring caries in the
enamel surface, the main reason for tooth loss was the
persistence of periodontal disease, followed by smoking,
however when root caries was involved, it had an additional
cause to tooth loss [32].
Caries in the crown area has less association with tooth
loss. Both variables were not significant (p ¼0.746 root,
p¼ 0.862 crown caries) but it showed positive and negative
correlations respectively to tooth loss. Imazato et al. reported
on root caries among elderly population and concluded that
root caries was more prevalent with patients that are taking
increased number of medications, which induces xerostomia
[33].
When we combine multiple variables like Married (M) vs.
Single (S) there was a negative correlation to tooth loss, being
single has a positive relation to tooth loss. African American
(AM) vs. white had a positive relation to tooth loss. DM or
CVD had positive relation to tooth loss.
When smoking variable was excluded in Table 3, it was
found that CAL, PD, and EL variables were still statistically
significant to tooth loss, however the PD had a negative
relation because, as the tooth losses more bone support the
distance from the gingival margin to the apex of the root
decreases, hence the decrease in PD, this gives the negative
relation right before the tooth is lost. The remaining variables
in the table were not significant alone; however, when all are
combined it can give a significant positive correlation to tooth
loss. When we add smoking to the variables S, AM, and DM/
CVD, it will enhance the positive correlation to tooth loss (up
to 23%).
There are some limitations to the current study, (a) small
sample size, (b) sample not representative as we got a
convenient sample, and (c) lack of other studies that have
the same study design with similar variables to compare the
results.
We found that it might be beneficial to increase awareness
and education, as this would help in encouraging the dwelling community to take a better care of their oral cavity. A
regular dental visit helps to further maintain the teeth. Senior
citizens that smoke are at an increased risk from losing their
dentition. There should be a consideration when taking many
21
medications as it can lead to a decrease in the salivary flow,
which might induce more caries formation on the tooth and
root. It is important to try and maintain teeth at a healthy
state to have a good quality of life, especially in elderly
population. A good masticatory performance or dietary intake
is associated with good oral health status [34]. This study
enables us to understand how different individual variables
can interact with each other to result in an outcome of
tooth loss.
Conclusion
It can be concluded that less education or more clinical
attachment level loss may increase number of missing teeth.
Additionally, age may cause teeth loss in the presence of
smoking. Other variables indicated tooth loss was higher with
increased number of medications, root decreased coronal
caries. Also it was found that Single African American
females, that had diabetes or cardiovascular disease were
more likely to demonstrate increased tooth loss. It is important to maintain teeth in a healthy status, to increase the
quality of life among elderly population. However, we need a
bigger sample size to further investigate this relationship.
Conflict of interest
None declared.
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Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Review
Challenges in anaesthesia for elderly
C. Strømn, L.S. Rasmussen
Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital,
Copenhagen, Denmark
art i cle i nfo
ab st rac t
The segment of elderly individuals comprises a growing proportion of the global popula-
Keywords:
tion. Health care systems and health care providers worldwide need to understand the
Anaesthesia
specific challenges related to treatment of this heterogeneous patient population. The
Postoperative delirium
process of ageing is complex and under constant influence by numerous factors, for which
Postoperative cognitive dysfunction
reason the way human age is extremely individual.
Elderly
It is important to understand and acknowledge how elderly differ from younger adults,
and how management needs to be modified and tailored to the individual patient in order to
improve outcomes. The goal of treatment of an elderly patient is not necessarily to increase
human longevity regardless of the consequences, but to increase active longevity free from
disability and functional dependence. For older people, deterioration in function can be
devastating and is often precipitated by a stressful event such as an acute episode of illness
or injury. Therefore a mainstay of treatment of the aged is prevention of functional decline.
In this review, we will outline the extreme variability in the aging process, and its
implications for tailoring the perioperative care for the elderly. We will provide an overview
of the challenges, when dealing with the aged surgical population with emphasis on
postoperative cognitive changes.
& 2014 Published by Elsevier B.V.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ageing and the aged patient population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Important aspects of perioperative care of the aged . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Syndromes of postoperative cognitive deterioration in the elderly. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Postoperative delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Postoperative cognitive dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Diagnosing postoperative cognitive impairment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Anaesthetic management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
n
Corresponding author. Tel.: þ45 35 456389; fax: þ45 35 452950.
E-mail address: [email protected] (C. Strøm).
http://dx.doi.org/10.1016/j.sdj.2014.11.003
0377-5291/& 2014 Published by Elsevier B.V.
24
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25
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27
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Singapore Dental Journal 35 (2014) 23–29
Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Introduction
Important aspects of perioperative care of the aged
In recent years a growing interest has revolved around the
impact of surgery and anaesthesia on the elderly. As life
expectancy increases with more elderly patients undergoing
surgery [1], it is imperative that knowledge on this important
topic is disseminated for health care systems and providers
to understand why elderly are different and how management needs to be modified to improve outcome.
Especially postoperative cognitive decline is much more
common in the elderly and this has been associated with
higher morbidity and mortality among elderly, which challenges the benefits of surgery in this population.
In this review, we will provide an overview of the problems
when dealing with the aged, with emphasis on postoperative
cognitive changes.
A preoperative consultation is essential to evaluate the
perioperative risks and plan preventive perioperative actions.
It is important to address all the aspects of the elderly
patient, which include changes induced by the process of
aging, the cumulative impact of co-existing diseases, presence of polypharmacy, difficulties in communication and
comprehension (reduced hearing or vision), compromised
cognitive function, and a consideration whether the patient
can provide informed consent [7]. It should always be considered, where a certain procedure for the individual patient
could be best carried out. Certain patients should only be
treated in places where supportive care and increased monitoring are available, for example elderly patients with bleeding disorders, or significant heart disease going through more
invasive procedures. Relevant specialists e.g. a geriatrician
should be consulted whenever in doubt how to provide best
practice of care.
Generally, adjustment of drug selection and dosage is
required for the elderly. Elderly patients are generally more
sensitive to analgesics and sedatives. As polypharmacy is
frequent, one should be aware of potential interactions. The
variability in pharmacodynamics and kinetics is high;
usually, smaller doses are needed for clinical effect compared
to the adult population, and the duration of action is
prolonged. Therefore dosing should be carefully titrated by
the principle: “start low – go slow” [8]. Using local anaesthetics for elderly is usually safe. Not different from other
adults, clinicians should be aware of allergies, decreased liver
and kidney function, and pay attention to correct dosing of
local anaesthetics to prevent toxic reactions [9].
It is essential to avoid inadequate pain relief; particular
awareness should be given to the patients lacking communication abilities, as they may not be able to express if they
experience pain (for an example a patient with severe
dementia, or a patient suffering from a severe stroke). The
use of multimodal analgesia is usually beneficial. This
includes a combination of different analgesics and adjuvants.
Anti-inflammatory drugs should be used cautiously, especially because of the risk of gastric bleeding, and renal
impairment [10].
Sedation should be carried out with extreme caution since
elderly are more susceptible to drugs acting on the central
nervous system. Premedication with anxiolytics with weak
sedative effects may be feasible with no further monitoring
[11]; however deeper sedation should be carried out under
continuous monitoring of vital functions (oxygen saturation,
respiratory rate, heart rate, blood pressure, and electrocardiogram). General anaesthesia can be performed with either
intravenous or inhaled anaesthetics. Selection of anaesthesia
has to be individualized and influenced not only by the
condition, but also by the anaesthesiologist's skill and expertise.
Elderly are at higher risks for complications postoperatively. The immune system is not as effective as in the
younger population, why elderly are more prone to hospital
Ageing and the aged patient population
Ageing is a physiological process, where the structure and
functional capacity of organs and tissue progressively degenerates over time. The ageing process is extra-ordinarily
complex, and is constantly influenced by numerous factors;
such as life style choices, environment, genetics, social network and chronic diseases [2]. The geriatric population has a
higher prevalence of numerous medical conditions and comorbidity; including atherosclerosis, heart failure, diabetes,
chronic obstructive lung disease, kidney impairment, and
dementia. Often patients receive several drugs for their
chronic diseases, which may have negative connotations.
Polypharmacy can be associated with increased risk of
adverse drug reactions, problematic drug interactions, and
medication errors [3].
Humans age differently, for which reason the elderly
patient population is health-wise extremely diverse. A large
proportion of elderly is functionally independent; they are
healthy or have well treated milder chronic diseases. However, a significant proportion of elderly are particularly frail;
they have severe chronic diseases, high level of co-morbidity,
and may have low functional capacity.
The human body has the capability to compensate for the
age related changes to some extent, but elderly, healthy or
sick, have a limited physiological reserve that can become
evident upon application of stressors [4,5]. The increased
frailty renders the elderly patient at risk of transient disabilities. This can potentially push the elderly into a vicious
cycle that ultimately may lead to permanent loss of daily
functions, loss of self-care capacity, dependence on supportive care or institutionalization [6]. Clinicians should be
particularly aware of tailoring care and support to the
individual patient's needs, and for the elderly this may
include careful considerations on how to prevent functional
decline and disabilities
Singapore Dental Journal 35 (2014) 23–29
acquired and surgical infections. Other common complications include thromboembolic events, dehydration, insufficient nutrition intake, and insufficient pain treatment [12].
In past years, a growing interest has revolved around a
significant part of elderly patients that experience cognitive
decline after an operation. It has been proposed, that anaesthetics could induce cognitive alterations.
Syndromes of postoperative cognitive
deterioration in the elderly
Postoperative cognitive impairment can potentially affect
patients of all ages, but is predominantly seen in the elderly.
Postoperative delirium (POD) and postoperative cognitive
dysfunction (POCD) are the most common syndromes of
neurobehavioral disturbances presenting after surgery; it is
an on-going discussion whether these syndromes are part of
a continuum or separate entities [1,13,14].
Postoperative delirium
Two types of delirium can be present in the postoperative
phase; emergence delirium (ED) and postoperative delirium
(POD). ED is benign temporal cognitive disorientation, that
can occur during the transition from anaesthesia to wakefulness and resolves within minutes or hours [15,16], whilst
(POD) is an acute organic brain syndrome that usually develops within the first few postoperative days [13,16].
POD is a common condition; approximately 15% of elderly
patients experience POD after elective procedures, with a
pronounced higher incidence rate (30–70%) for elderly undergoing emergency or major surgery [17,18]. A key feature of
POD is the sudden onset of symptoms that tend to fluctuate
during the course of the day. Following a lucid interval after
surgery, patients characteristically debut with a disturbance
in consciousness (reduced clarity of awareness, reduced
ability to focus or sustain attention, reduced awareness of
the surrounding environment). This is accompanied by cognitive changes (memory deficit, disorientation, language disturbances) or/and perceptual disturbances such as vivid
hallucinations [18,19]. The severity of symptoms varies tremendously, which has been acknowledged by implementation of sub-diagnoses of POD based upon the patient's
psychomotor behaviour. The psychomotor types of delirium
can range from hypoactive states e.g. the patient is sluggish
or lethargic to hyperactive states, where the patient may be
restless, agitated or even aggressive or violent [16]. Hypoactive forms of POD may be under-diagnosed due to a relatively
non-disturbing behaviour, or misdiagnosed as symptomatic
manifestations of dementia or depression [20]. However,
clinicians should be particularly aware of signs of psychomotoric inhibition in elderly patients (to the point of stupor),
as patients that develop a hypoactive form of POD seem to
have a relatively increased mortality [20].
The pathophysiology of POD is still poorly understood.
It may be related to disturbances in the production, release,
or inactivation of neurotransmitters [21]. Another suspected
culprit of POD is modulation of the inflammatory signalling
system. This hypothesis suggests recruitment and activation
25
of inflammatory substances in response to the surgical stress
and anaesthesia may trigger neuroinflammation, thus attributing to POD [22–26].
Despite the underlying mechanism is still poorly understood, several predisposing and eliciting factors have been
recognized. Predisposing factors include advanced age, preoperative cognitive impairment such as dementia, preexisting medical disease burden, and genetic factors, for an
example patients with a high-risk gene identified in Alzheimer's disease (apolipoprotein E4 phenotype) have higher
incidence and longer duration of POD [27].
Eliciting factors have been identified to include infection/
inflammation, metabolite disturbances, substance withdrawal, medications, discomfort, environmental disturbances
including sleep disruption, and severe pain with inadequate
analgesia [28]. The risk factor for developing POD is additive,
therefore recognizing the presence of one or more of the
factors should render clinicians particularly aware of cognitive changes in the postoperative phase. Treatment of POD
requires a multicomponent strategy aimed at both optimizing
preventative measures in addition to eliminating eliciting
triggers, if this does not reverse the symptoms, pharmacologic intervention with haloperidol may be required after
excluding modifiable causes [29].
POD is an acute disorder, but has been associated with a
wide range of negative long-term outcomes for the elderly,
despite that patients may initially recover completely [28,30].
POD is associated with reduced function and independence,
increased short- and long-term mortality, and prolonged
cognitive impairment in survivors [28]. It has been suggested,
that POD could induce dementia, but the association is not
confirmed. There seems to be a significantly higher proportion of patients who experience POD that eventually will be
given a diagnosis of dementia [31], but this may reflect that
patients with pre-existing cognitive impairment may be more
frail thus developing cognitive problems more easily.
Postoperative cognitive dysfunction
Opposed to POD, postoperative cognitive dysfunction (POCD)
is more subtle. POCD can affect a wide spectrum of neuropsychological domains such as memory, psychomotor speed,
information processing, and executive functions. The patient
experiences, or their relatives observe, a subtle deterioration
of daily cognitive performance that typically last for weeks or
months postoperatively [31,32]. The majority of patients
experiencing POCD debut with minor decrement of cognitive
function such as discrete memory problems, mild personality
changes, or the experience that formerly uncomplicated daily
tasks suddenly are somewhat difficult to execute; for an
example patients report that they cannot concentrate sufficiently to read the newspaper, or have forgotten how to brew
coffee. Profound changes with significant loss of memory,
intellectual abilities, or executive functions can be seen. Most
patients return to their preoperative function after a shorter
period of time, but whether POCD can precede a permanent
deterioration of a patient's cognitive trajectory is still debated
and not entirely clear [13,30].
Approximately 10% of elderly undergoing surgery will
develop POCD [33]. The true incidence is probably
26
Singapore Dental Journal 35 (2014) 23–29
underestimated, since many studies have excluded patients
with pre-existing cognitive impairment or dementia at baseline [32,33].
The pathogenic mechanism leading to POCD is not well
understood. Loss of cognitive reserve, cumulative effect of
chronic disease, altered response to anaesthetics, and toxic
effects of anaesthetics have been suggested, but not been
proven to be responsible for postoperative cognitive decline
in the elderly [34–36]. Similar to POD, the incidence rate of
POCD varies with higher incidence in the subpopulation of
elderly undergoing major surgery suggesting that a profound
systemic inflammatory response may induce alteration of
neurotransmitter function, neuroendocrine or immunomodulatory pathways [37–40], which eventually can lead to
cognitive dysfunction.
Predisposing factors for POCD have been identified, which
are quite similar to POD. These include advanced age, prior
cognitive impairment, post- and perioperative complications
(infection, second operation), and lower levels of education
[1,41,42]. However, the evidence is slightly divergent, as some
studies support while others cannot confirm correlations
between these factors and POCD [36].
The development of POCD may adversely influence long
health term outcome; it is associated with impairments of
daily functioning, premature departure from the labour
market and dependency on financial and personal support
from government or family after hospital discharge, and most
disturbingly is POCD associated with increased mortality
[1,42,43].
Diagnosing postoperative cognitive impairment
To detect a postoperative cognitive decline, the clinician
must foremost be aware of the patient's habitual cognitive
status to make a reasonable evaluation of changes from their
individual baseline status. Various studies of both POCD and
POD indicate that new onset of cerebral dysfunction in
elderly is readily overlooked due to an incorrect assumption
of pre-existing cognitive dysfunction.
The diagnosis of POD is based on detection of symptoms,
where POCD encompass more subtle cognitive changes of
one or more cognitive domains, which is why detection
requires repeatedly neuropsychological testing.
Delirium is well defined in international disease classification systems, which relies on various compositions of
diagnostic criteria [44,45]. Nevertheless, rapid bed-side
assessment tools are more clinically appropriate for discovering delirium for the individual patient. Numerous suggestions
of user-friendly diagnostic tools such as The Confusion
Assessment Method (CAM), Nursing Delirium Symptom
Checklist (NuDESC) have been developed. The Confusion
Assessment Method for the Intensive Care Unit (CAM-ICU)
have been validated in non-postoperative settings [46,47].
However, there are shortcomings of these tools; they have
failed to stratify severity of delirium [48], and studies have
questioned their specificity when used in postoperative settings [46]. Invention of an easy and exact clinically applicable
delirium tool validated in postoperative settings is still
demanded. Full-scale hyperactive delirium is usually easy
to detect; however when suspicion of milder and fluctuating
neuropsychological changes arises, repeatedly testing to
capture the presence of POD should be initiated.
POCD has been vigorously studied since it first was
described in scientific literature half a century ago; however
the understanding of POCD is still evolving, thus no international classification system has formulated diagnostic criteria
for POCD. A general consensus in scientific literature has
formed, that POCD reflects affection of numerous neuropsychological domains, implying that detection relies on preand postoperative repeated testing of cognitive function by a
battery of comprehensive neuropsychological tests [49]. Still
core issues remain to be clarified; what determinate a clinical
relevant decline in cognitive function, what are the optimal
tests for measuring POCD, what are the timeframe in which a
cognitive decline could merely be attributed to the perioperative trajectory instead of normal changes related to the
ageing process of the human brain, what is the optimal
timing for testing cognitive function before and after surgery?
Adjustment for anxiety through inclusion of mood and
anxiety scores may also be incorporated, because performance may be negatively affected by surgery-associated
anxiety [50,51].
The difficulties of understanding and establishing diagnostic criteria for POCD may be ascribed to large diversity and
methodological limitations among previous studies; lack of
appropriate control groups, lack of baseline data on cognitive
function, variation in definition on the magnitude of cognitive change attributed to cognitive dysfunction, missing
validation of observations, inconsistent timing of testing,
variation in test selection, or use of insensitive test batteries
e.g. tests that do not address the patient's affected cognitive
domains, or tests that are insufficient to detect changes in
cognitive function over time [49–51].
Anaesthetic management
At this point, no evidence supports the choice of one anaesthetic over another. The same applies for anaesthetic technique. In the early days of studying patients' postoperative
cognitive trajectories, an association between the anaesthetic
technique and POCD was proposed, contemplating that
general anaesthesia led to higher incidences of POCD and
POD. However, a growing amount of evidence shows that
the choice of general versus regional anaesthesia does not
appear to influence on the occurrence or magnitude of POD
or POCD [42,52,53].
As the pathogenesis of postoperative changes has been
associated with inflammatory mediators, intra-operatively
use of intravenous lidocaine was believed to provide neuroprotection by modulation of the inflammatory response,
however no current evidence supports this theory [54].
Sedation may be employed in elderly in conjunction with
regional anaesthesia, but careful age-related dose reduction
is needed, and the feasibility of sedation is not quite elucidated [53,55]. In one trial, patient-controlled sedation was
administered in elective ophthalmologic day-surgery with a
Singapore Dental Journal 35 (2014) 23–29
high level of patient satisfaction and no adverse effects on
cognitive function [56], but the technique has not yet been
validated in other studies. Perioperative sedation by dexmedetomidine infusion may be superior to other sedatives in
reducing the incidence of POD [57,58], the effect on POCD is
yet not elucidated.
Intraoperative close monitoring is believed to be essential
to sustain physiologic homoeostasis (e.g. continuous measuring by arterial gasses including status of electrolytes, temperature, urinary output, saturation, cardiac output, depth
of sedation, brain oxygenation). However, the impact of
extended monitoring and goal directed therapy on postoperative cognitive changes is not entirely clear. Carefully
titrating anaesthesia using perioperative brain monitoring
has been a research area of great interest [59]; cerebral
oxygen oximetery can be measured by intra-operative nearinfrared spectroscopy (NIRS), and depth of anaesthesia can be
guided by continuous recordings of electroencephalograms
processed by a bispectral index (BIS) monitor or auditory
evoked potentials [32,55,59–64].
The evidence on effectiveness of minimizing cerebral
oxygen desaturation and depth of sleep has been divergent
[32,55,59–66], but there is mounting evidence from several
randomised, controlled trials that anaesthetic administration guided by BIS-protocols can decrease POD [62].
However, future research with larger trials is needed to draw
conclusions.
Currently there is no good evidence for the efficacy of any
specific intervention to decrease POCD and POD. Distinct
patient-related risk factors may be of greater aetiological
importance than perioperative surgical or anaesthetic management [49,51,67]. From the patient's hospital admission to
discharge, emphases to maintain homoeostasis and restore
daily physical function may be most important.
Conclusion
Postoperative cognitive complications are often transitory,
but can be associated with devastating outcomes in elderly
patients. Understanding the causality concerning both POD
and POCD is pending, but seems to be multifactorial.
To further substantiate the optimal management of these
patients, future trials should be carefully designed, and
employ administration of valid pre- and postoperative tests,
that are easily applicable in clinical practice.
To this point, careful patient-centred management is
essential to provide elderly patients their best chance of
returning to their previous level of function.
Competing interest
No external funding and no competing interests declared.
Dr. Camilla Strøm is supported from Regions Sjaelland and
Copenhagen University. Professor Lars S. Rasmussen, MD.
DMSci is supported by Tryg Foundation.
27
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Singapore Dental Journal 35 (2014) 31–38
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Review
Clinical issues in occlusion – Part I$
Aws Alanin, Mahul Patel
Department of Restorative Dentistry and Traumatology, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
art i cle i nfo
ab st rac t
Good occlusal practise provides an important cornerstone to optimal patient care. Occlusal
Keywords:
problems can manifest in different areas of dentistry but these are more apparent when
Occlusion
there are restorative aspects to the patient's problem. This review highlights areas of
Occlusal trauma
restorative dentistry where the appreciation of occlusal aspects can optimise diagnosis and
Parafunction
follow up care.
& 2014 Published by Elsevier B.V.
Fremitus
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusion and tooth surface loss (TSL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusion and restoring/increasing the occlusal vertical dimension (OVD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusion and mechanical failure of teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
The need to protect non-vital teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusion and the periodontium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusion and temporomandibular joint dysfunction (TMJD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Occlusion and the ageing patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
The Glossary of Prosthodontic Terms defines Occlusion as ‘the
act or process of closure or of being closed or shut off’ or ‘the
static relationship between the incising or masticating surfaces
of the maxillary or mandibular teeth or tooth analogues’ [1].
However, it is both static and dynamic relationships between
different components of the masticatory system that are usually
$
considered simultaneously when occlusion is examined or
recorded. In essence, this describes the relationship between
the opposing masticating surfaces of teeth and the movements
of the mandible dictated by way of the temporomandibular
joint and associated orofacial musculature. Therefore, occlusion
represents a spectrum of anatomical and physiological principles
varying in their complexity and intricacies. These principles can
lack robust evidence to advocate their usage and as such,
Part II of this article will be published in the next issue of the journal.
Corresponding author.
E-mail address: [email protected] (A. Alani).
n
http://dx.doi.org/10.1016/j.sdj.2014.09.001
0377-5291/& 2014 Published by Elsevier B.V.
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Singapore Dental Journal 35 (2014) 31–38
confusion and uncertainty can result. Recreating the occlusal
relationships inaccurately outside of the mouth can result in
frustration for the dentist, technician and most importantly the
patient. In contrast there maybe situations (with appropriate
planning) where restorations maybe cemented at an increased
vertical dimension which may otherwise be considered
unconventional.
The awareness of occlusal aspects when examining a patient
as well as associating these with signs and symptoms provides
information for optimal management. This ethos should be
considered on a backdrop of changes in patient demographics,
social pressures and increased patient expectations. The first
part in this series will look at specific occlusal problems and their
aetiology and diagnosis. The second part will illustrate occlusal
registration techniques and subsequent management.
Occlusion and tooth surface loss (TSL)
Attrition results from tooth-to-tooth contact resulting in welldefined wear facets on the occluding surfaces of teeth which
correspond between the maxilla and the mandible (Fig. 1).
Physiological tooth wear is expected to a certain level when
taking into account the age of the patient. Pathological
toothwear (where the rate is greater than that expected
physiologically) as a result of parafunctional activity results
in the accelerated loss of tooth tissue, threatens pulp health
and can result in axial tooth movement that will make future
restorative management difficult due to changes in interocclusal relationships, potential differential tooth movement
and loss of interocclusal space. In its mildest form faceting
within enamel may provide early signs of attrition. In the
latter stages tooth tissue may become significantly damaged
resulting in difficulties in restoration and pulpal involvement
(Table 1). The key in these situations is to identify patients
with parafunctional activity, recognising this at the planning
stages of any procedure and protecting tooth structure and
restorations by way of individual design characteristics or
considerations for long term appliance therapy. If such
parafunctional activity is allowed to progress the prognosis
for survival of teeth and their associated restorations is likely
to diminish (Table 2).
Fig. 1 – A 28 year old patient presenting with attrition,
amelogenesis and hypodontia.
One notable risk factor for parafunctional activity is
psychological stress [2]. Current research shows that psychological stress is increasing in the general population and this
is more often than not associated with vocation related
pressures [3]. In such cases a thorough social history is likely
to inform the treatment planning process and aide delivery
of care. Other much cited risk factors include occlusal
relationships such as the retruded contact-, intercuspal position slide and lateral guidance pathways such as canine
or group function [4,5]. There is no evidence to suggest
that any occlusal relationship will result in a greater
likelihood of parafunction or indeed temporomandibular
dysfunction [4,5].
General conservative management of attrition type TSL
would be the provision of a stabilisation splint in the first
instance in order to prevent further hard tissue surface loss.
Parafunction against the splint would lead to favourable attrition of the acrylic splint material [6]. A upper soft bite guard
could be made in acute cases as a quick urgent way of relief.
Occlusion and restoring/increasing the occlusal
vertical dimension (OVD)
In cases of severe TSL due to a combination of attritive or
erosive processes there may be extensive loss of the dental hard
tissues, and commonly the teeth appear to look grossly shorter
in clinical crown height from gingival aspect to the incisal edge
or occlusal surface. It could appear that there is a loss of OVD
here, however in most cases in dentate patients this is not the
case due to physiological dentoalveolar compensation that
occurs [7]. The compensatory mechanism is noticeable due to
the varied position of the gingival zeniths of the anterior
segment (Fig. 1). If the rate of tooth destruction occurs at a
faster rate than compensation, an open bite can occur.
In cases where compensation has occurred there is a loss
of interocclusal space, increasing the existing OVD is a
treatment strategy that may be considered. Other more
drastic treatment methods have been proposed such as
elective extraction, surgical crown lengthening and orthodontic intrusion. These techniques vary in their invasiveness
and as such irreversible damage. Although considered invasive and damaging to sound tooth tissue and supporting
structures these techniques can still be considered with
appropriate care and planning. A technique routinely utilised
in the UK is increasing the OVD using a method modelled on
a concept first illustrated by Dahl [8]. Dahl and colleagues
were the first to discover this phenomenon in the 1970s by
utilising a removable cobalt chromium intrusion appliance
with a bite platform anteriorly. This concept was developed
further in the 1990s in the UK by utilising composite resin to
restore worn teeth (Fig. 2). This involves the placement of
composite restorations at an increased OVD on anterior teeth
leaving posterior teeth with no occlusal contacts. A period of
occlusal adaptation results with a combination of intrusion of
the anterior teeth and vertical migration of posterior teeth
resulting in the relinquishing of contacts over time.
This treatment modality shows good short to medium
term results although the requirement for maintenance
maybe high [9]. Despite this, the advent of placement of
Singapore Dental Journal 35 (2014) 31–38
33
Table 1-Smith & Knight TSL Index
Score
Surface
Criterion
0
BLOI
C
No loss of enamel surface characteristics
No change of contour
1
BLOI
C
Loss of enamel surface characteristics
Minimal loss of contour
2
BLO
I
C
Enamel loss just exposing dentine o1/3 of the surface
Enamel loss just exposing dentine
Defect less than 1 mm deep
3
BLO
I
C
Enamel loss just exposing dentine 41/3 of the surface
Enamel loss and substantial dentine loss but no pulp exposure
Defect 1-2 mm deep
4
BLO
I
C
Complete enamel loss or pulp exposure or secondary dentine exposure
Pulp exposure or secondary dentine exposure
Defect more than 2 mm deep, or pulp exposure or secondary dentine exposure
Each surface of each tooth is given a score between 0 and 4 according to its appearance.
B ¼buccal or labial, L¼ lingual or palatal, O ¼occlusal, I ¼incisal, C ¼ cervical.
Table 2
Occlusal Problem
Clinical presentation
Tooth surface loss
Shortened teeth
Wear faceting
Dentine sensitivity
Restoration of teeth with
limited interocclusal space
and tooth surface loss
The need to create space for restorations that will be
functional and aesthetic
Crack/fracturing of teeth
Teeth with large restorations which restore
marginal ridges or those with decay resulting in
poor support of remaining tooth tissue
The reduction in tooth tissue as above coupled with
the presence of an access cavity for endodontics
results in significant weakening of the remaining
crown
Periodontal disease may be exacerbated by the
presence of occlusal trauma. The evidence for
occlusal factors causing periodontal inflammation is
very weak
Protecting non-vital teeth
Occlusal trauma and
periodontal disease
Occlusion and TMJD
Occlusion and the ageing
population
Pain associated with the muscles of mastication and
the TMJ
Signs of wear or faceting
Clicking of TMJ
Locking of TMJ
These cohort of patients are likely to have increased
needs for complete denture prosthodontics and
maintenance of these prostheses
Management
Preventive
Splint therapy
Patient education
Invasive
Provision of composite restorations at an
increased occlusal vertical dimension
Dahl technique
Surgical crown lengthening
Orthodontic intrusion
Elective extraction
Provision of cuspal coverage restoration such as
an overlaid plastic restoration or an extra-coronal
restoration such as a crown or onlay
Provision of a copper band or an orthodontic band
during endodontic therapy
Provision of an extra-coronal restoration on
completion of root canal treatment
Management of periodontal disease as per required
without the instigation of occlusal adjustment/
modification
Conservative management involving patient
education on risk factors for TMJD and how to
minimise these
The reduction of stress, avoidance of habitual
chewing such as nail biting, avoidance of a poor
posture, and the prescription of TMJ joint exercises
should always be the first line of treatment
When deciding the occlusal scheme it maybe more
advisable to maintain certain aspects such as the
OVD from previous prostheses for purposes of
adaptability. There is weak evidence advocating one
occlusal scheme such as bilateral balanced over
others when considering functionality of the
prostheses
34
Singapore Dental Journal 35 (2014) 31–38
Fig. 2 – Direct composite restorations placed on the upper
and lower anteriors at an increased occlusal vertical
dimension.
composite restorations at an increased OVD is biologically
the kindest treatment modality when directly comparing to
crowns, surgical crown lengthening or orthodontic intrusion.
Fig. 3 – Lower right 6 with a fractured lingual cusp. The tooth
was still responsive to sensibility testing. The fracture was
investigated and found to be subgingival but within normal
limits of restorability. This tooth was restored with an onlay
restoration.
Occlusion and mechanical failure of teeth
The cracking or fracture of teeth is a problem that is increasing and is notoriously difficult to diagnose in the early
stages especially when the clinical picture does not always
consistently correlate with the symptoms of the patient [10].
More often than not patients may present with parafunctional tendencies that are likely to stress and strain teeth
prior to inception of a crack or fracture (Fig. 3). Other patients
may give a history of trauma related to biting into something
very hard at the inception of symptoms or fairly specific
symptoms associated with pain on release, biting certain
foods or biting in a certain way [9]. Cracks and fractures of
teeth are significantly associated with large restorations and
also mandibular molars [11,12]. The prevalence increases
in patients forty years or older with women being more
affected than men [13]. The incidence of complete fractures
is approximately 5% in the adult population with the overwhelming majority being posterior teeth [13]. Of the 5% of
complete fractures 15% result in pulpal involvement or
extraction [13]. Aetiological factors associated with fractured teeth are numerous. These can be split into local and
general factors. General factors are likely to be associated
with parafunctional activity or attrition placing teeth under
significant loads for long periods. Local factors include morphology and the tooth's restorative status. Teeth with steep
cuspal inclines maybe naturally more prone to cracking when
put under stress or strain [14]. This is in part associated with
the wedging effect of the cusp fossa relationship putting
teeth under tensile and internal shearing stresses [14].
Further to this teeth with large restorations and cusps that
are poorly supported with an absence of underlying tooth
tissue [15]. As tooth bulk decreases so does the remaining
tissues ability to resist force and prevent fracture [15]. This is
best illustrated by mesial occlusal distal (MOD) restorations
on premolar teeth. Vale and colleagues discovered that with
increased width of restoration isthmus a decreased resistance resulted. Where unsupported cusps are involved in
Fig. 4 – This patient complained of pain on release and on
eating certain types of granary bread. Utilisation of
disclosing solution on the upper left 5 revealed a crack that
ran from mesial to the distal portion of the tooth.
non-working side interferences this is likely to compound the
risk of fracture [16]. Despite the effect of reduction of tooth
tissue a recent study found that the split between restored
and unrestored teeth that suffered with cracks was approximately 50% [17] (Figs. 4 and 5).
Cuspal coverage of teeth with reduced tooth tissue provides a
means to reduce the likelihood of fracturing or cracking. Cuspal
coverage has been shown to provide greater resistance to
fracture than non-cuspal coverage restorations and unrestored
teeth [16]. These results were echoed by Salis and colleagues
who found that MOD restorations weakened teeth when lacking
an overlaying [18] (Fig. 6). Further aspects that may make teeth
prone to fracture include the position within the arch. Frequently
first molars have been cited due to their close proximity to the
muscles of mastication and the temporomandibular joint making the forces exerted upon them greater than teeth further
away [17]. Indeed the decision to provide cuspal coverage can be
difficult to make. Where an extra-coronal restoration maybe
indicated the removal of more tooth tissue, hence making the
tooth even weaker, will be required prior to the provision of a
Singapore Dental Journal 35 (2014) 31–38
35
significantly if marginal integrity is broken [23]. Reeh and coworkers found that an MOD cavity preparation reduced tooth
stiffness by 63%. The defining factor in resisting occlusal
loads of both vital and non-vital teeth seems to be the
amount of remaining tooth tissue and as such minimising
tissue removal during access cavity preparation is advised.
Further to this chemo-mechanical endodontic procedures
weaken teeth. The utilisation of hypochlorite and EDTA
significantly weakened teeth and increased tooth surface
strain [24,25]. These biomechanical factors need to be considered in tandem with the need for optimal coronal seal as
lack of tooth tissue will not only make teeth susceptible to
fracture but also compromise post root canal treatment
failure due to re-infection [20].
Fig. 5 – Upon removal of the restoration the crack ran along
the floor of the cavity. This tooth was restored with a
minimally invasive onlay restoration.
Fig. 6 – An amalgam overlay restoration provided for the
lower left six.
crown. As yet there seems to be no objective consensus as to
when to provide cuspal coverage to protect the remaining tooth
tissue in vital teeth. This of course needs to be weighed against
the greater probability of irreversible pulpal damage by the
preparation [19]. In comparison the literature for cuspal coverage
of non-vital teeth is more robust [20].
Occlusion and the periodontium
Occlusal trauma is defined as ‘trauma to the periodontium
from functional or parafunctional forces causing damage to
the attachment apparatus of the periodontium by exceeding
its adaptive and reparative capacities. It may be self-limiting or
progressive’ [2] (Figs. 7 and 8). What seems clear within the
literature and in practice is the need to distinguish between
association and causation [26]. Periodontitis may be associated
with a multitude of local, general or patient based factors
ranging from overhanging restorations to inflammatory systematic diseases manifesting in the periodontium [26].
Few clinical studies have identified a link between trauma
from occlusion and inflammatory periodontitis in man [27].
Although both processes cause destruction of the apparatus in
different ways the exact mechanisms and whether there is true
synergy between the two pathological processes is yet
to be realised. It may be fair to say that occlusal trauma
may exacerbate already present periodontal inflammation
whereas orthodontic force is unlikely to exacerbate periodontal
tissue loss. Where frank plaque induced periodontitis and
occlusal trauma is present gradual widening of the periodontal
ligament space with mobility and angular bone loss can be
The need to protect non-vital teeth
Non-vital teeth have a significantly decreased ability to
withstand occlusal loads when compared to vital teeth [21].
The pulp is likely to provide proprioceptive feedback that
allows the masticatory system to avoid overloading and thus
catastrophic fracture. This was illustrated in a classical study
by Randow and Glantz where cantilevered loads were applied
to vital and non-vital teeth. Pain perception by the patient
manifested with occlusal loads that were twice as high for
non-vital than vital teeth [22]. These differences were not
present when the teeth were anaesthetised. This study
illustrated the likelihood of mechanoreceptor function of
the pulp and detection of occlusal loads. Once loss of vitality
is established and root canal treatment is required the
presence of an endodontic access cavity weakens teeth and
so affects structural integrity [23]. The relative stiffness of a
tooth reduces with an occlusal access cavity which increases
Fig. 7 – Primary occlusal trauma affecting the upper left 5.
Note the marked gingival inflammation localised to this
tooth. There was pocketing of greater than 4 mm
circumferentially.
36
Singapore Dental Journal 35 (2014) 31–38
Fig. 8 – In intercuspal position the tooth exhibited significant
fremitus.
expected. In the absence of periodontitis occlusal trauma does
not result in attachment loss but does result in tooth mobility
which is reversed once the trauma is removed.
The utilisation of occlusal adjustment to reduce non-axial
loading of teeth in an attempt to prevent occlusal trauma and so
periodontal disease is controversial with poor or limited evidence
to support it. The removal of sound tooth tissue to aide what is
an inflammatory process fuelled by the presence of bacteria is
difficult to recommend. In a randomised controlled trial two
groups of patients underwent periodontal therapy with and
without occlusal adjustment. There was no effect of occlusal
adjustment on changes in pocket depth [28]. These findings were
later confirmed by way of a Cochrane systematic review [29].
Due to the above findings it seems unsurprising that the
authors recommend a conservative approach to TMJD treatment that are reversible and do not remove sound tooth
tissue. The provision of an occlusal stabilisation splint,
although reversible, does not provide significant benefit over
ultra-conservative treatment [35]. In a randomised controlled
trial comparing splint therapy to patient education and
muscle exercise there was no detectable benefit of splint
provision [35]. The emerging evidence shows that patient
education coupled with jaw exercises provide patients with
measurable improvements especially in patient centred outcome studies [36,37].
The current evidence is too weak to advocate occlusal
adjustment and relatively ambiguous to advocate routine
stabilisation splint therapy prescription. Conservative modalities such as patient education and muscle exercises seem
to be the assured way of treatment at the current time [38].
Occlusion and the ageing patient
Our patients are living longer. As we age our adaptive
capacity to changes decreases and this maybe the case with
Occlusion and temporomandibular joint
dysfunction (TMJD)
The role of occlusion in the development of TMJD is controversial
as the majority of reasoning behind causation is based upon
anecdotal rather than scientific evidence. Weak evidence
between occlusal scheme and TMJD development has been
identified [30,31]. In a series of studies by Seligman and Pullinger
an overjet of greater than 5 mm, unilateral posterior crossbite
and retruded contact position intercuspal position slides of
greater than 1.75 mm were associated with TMJD although this
was statistically weak. The fact that this was an association and
not implication also requires some thought. Further to these
findings Clark and colleagues in a systematic review found that
the introduction of occlusal interferences did not result in
significant evidence for development of TMJD [32]. Aetiology
based on occlusal scheme does not stand up to scrutiny when
considering fibromyalgic patients – 75% of which may present
with TMJD regardless of occlusal scheme [33]. Indeed there is
limited evidence for either occlusal splint therapy or occlusal
adjustment in the treatment of TMJD [34]. In a systematic review
examining both modalities the benefit of occlusal splint therapy
was unclear, and none of the twenty studies included in the
analysis could provide beneficial evidence for occlusal adjustment [35].
Fig. 9 – This 92 year old patient presented complaining of old
and worn dentures which he had been wearing for 40 years. A
new set of dentures were provided with an increased occlusal
vertical dimension and improved extensions. Unfortunately
despite these ‘improvements’ the patient was unable to tolerate
these changes and requested his old set of dentures be copied.
Fig. 10 – Due to the loss of maxillary teeth vertical migration
of the mandibular molars has resulted in loss of interocclusal
space for a removable prosthesis.
Singapore Dental Journal 35 (2014) 31–38
occlusal modifications. Where complete dentures require
replacement the adaptive capacity of the patient may need
consideration when deciding on provision of a conventional
prosthesis or simply copying the current dentures and modifying where required (Fig. 9). Other aspects include the loss
of interocclusal space in isolated areas due to the overeruption of opposing teeth making prosthetic rehabilitation difficult to achieve. In such situations localised intrusion devices
maybe utilised to recreate space for future restorations
(Fig. 10).
When considering the prescription of occlusal scheme for
complete dentures the evidence seems unequivocal. When
examining the true advantage of bilateral balanced tooth set
up there was no detectable advantage functionally in the
majority of studies examined in a systematic review [39].
[10]
[11]
[12]
[13]
[14]
[15]
Summary
[16]
Some may argue that occlusion plays an integral part in
many situations. The presence of occlusal problems may not
be readily apparent when examining clinically and as such
further analysis maybe required (Table 2). The mounting of
models to aide in diagnosis and treatment planning is
invaluable especially where multiple restorations are
planned. Virtual planning on models by way of adjustments
or wax-ups provides the clinician with foresight as to the
achievability and predictability of a chosen plan. These
techniques will be described in further detail in Part II of this
series.
r e f e r e n c e s
[1] The glossary of prosthodontic terms, J. Prosthet. Dent. 94 (1)
(2005) 10–92.
[2] D. Manfredini, N. Landi, A. Bandettini Di Poggio, L. Dell’Osso,
M. Bosco, A critical review on the importance of
psychological factors in temporomandibular disorders,
Minerva Stomatol. 52 (6) (2003) 321–326 (327–330).
[3] M.A. Rantala, J. Ahlberg, T.I. Suvinen, M. Nissinen, H.
Lindholm, A. Savolainen, M. Könönen, Temporomandibular
joint related painless symptoms, orofacial pain, neck pain,
headache, and psychosocial factors among non-patients,
Acta Odontol. Scand. 61 (4) (2003) 217–222.
[4] D.A. Seligman, A.G. Pullinger, The role of functional occlusal
relationships in temporomandibular disorders: a review, J.
Craniomandib. Disord. 5 (4) (1991) 265–279.
[5] A.A. Marzooq, M. Yatabe, M. Ai, What types of occlusal
factors play a role in temporomandibular disorders…? A
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Singapore Dental Journal 35 (2014) 39–46
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Review
Diagnosis of oral pigmentations and
malignant transformations
Bassel Tarakjia,n, Ayeisha Umaira, Durga Prasada, Mohammed Alsakran
Altamimib
a
Department of Oral Maxillofacial sciences, Al-Farabi College of Dentistry and Nursing, Riyadh, Saudi Arabia
Department of Restorative Dental Sciences, Al-Farabi College of Dentistry and Nursing, Riyadh, Saudi Arabia
b
art i cle i nfo
ab st rac t
Background: Oral pigmentation is a common finding in the mouth. Pigmentation can be
Keywords:
either normal or abnormal discoloration of oral mucous membrane. The purpose of this
Pigmentation
review mainly focuses on the main oral pigmented lesions, in order to help the clinicians
Melanin
establish a better approach towards the patients with pigmented oral lesions and to
Oral
provide thorough knowledge regarding such lesions for patient reassurance, early defini-
Diagnosis
tive diagnosis and prompt treatment.
Methods: Relevant data concerning oral pigmented lesions, clinical features and the
possibility of malignant transformation of such lesions were reviewed thoroughly from
pubmed literature published in English. Pigmented lesions affecting the skin were not
included in our review.
Results: Few pigmented lesions have been identified and their tendency to become
malignant has been reported in the literature. The oral lesions showing malignant
transformation reported were mostly case series. Unfortunately, due to lack of long-term
studies, follow ups and randomized controlled studies in this respect it was difficult to
draw a statistical analysis. This information is quite crucial for general dental practitioners
to improve their understanding regarding oral lesions and to differentiate between normal
and diseased conditions, so that they can master the skill of differential diagnosis,
definitive diagnosis and prompt treatment.
Conclusion: Oral pigmentation may present as focal, multifocal or diffused macular or
tumefactive lesions. They may greatly vary in color as blue, purple, brown, gray or black
depending on the quantity and site of melanin in the tissues [1]. Etiology of pigmentation can be
multi factorial. Mostly pigmentation is physiologic but at times it can be a precursor of severe
diseases.
Lesions may be caused by localized harmless accumulations of melanin, hemosiderin or
exogenous metals or they may be a sign of underlying systemic or genetic disease. A few lesions
may be associated with life-threatening medical conditions that require immediate intervention. The differential diagnosis for any pigmented lesion is extensive, as it includes examples of
endogenous and exogenous pigmentations. Although biopsy is a helpful and necessary aid in
n
Corresponding author.
E-mail address: [email protected] (B. Tarakji).
http://dx.doi.org/10.1016/j.sdj.2014.03.001
0377-5291/& 2014 Published by Elsevier B.V.
40
Singapore Dental Journal 35 (2014) 39–46
the diagnosis of focally pigmented lesions, with diffuse pigmentation lesions require a thorough
dental and medical history and laboratory investigations.
& 2014 Published by Elsevier B.V.
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pigmented lesions of the oral mucosa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Classification of oral pigmentations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Ephelides. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Melanotic macules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Heavy metal pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kaposi's sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Post-inflammatory pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Chemically induced melanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Smoker's melanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Amalgam tattoo and other foreign-body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Pigmentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Drug-induced pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Disease-associated melanosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Peutz–Jeghers syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Addison's disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Melanocytic nevi. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral melanoacanthoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Oral melanoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Focal pigmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hemangioma and vascular malformation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Varix and thrombus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hematoma and other hemorrhagic lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Introduction
Pigmented lesions of the oral mucosa
Oral mucosa is not uniformly colored. The color varies in
different physiological and pathological conditions [1–6]. Physiological pigmentation is frequent in Asians, Africans and Mediterranean people [3]. The color change of the oral mucosa could
be due to accumulation of one or more pigments in tissues.
Pigments associated with mucosal discoloration could be classified as endogenous (e.g. melanin and blood-related pigments)
and exogenous (e.g. metals and drug-related pigments). Melaninassociated lesions are most common pigmentations. They may
present as benign melanocytic nevi or extremely aggressive
neoplasm as mucosal melanoma [1–7]. Benign melaninassociated pigmentations of the oral mucosa includes racial
pigmentations, melanotic macules, oral melanocytic, naevi
(OMNs), melanoacanthoma, post-inflammatory pigmentations
and so-called smoker's melanosis [1–6]. Several systemic diseases such as Peutz–Jeghers, Laugier–Hunziker syndromes as
well as the Addison's disease are also characterized by the
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presence of benign melanin-associated lesions of the oral and
perioral tissues. Non-melanin associated pigmentations may be
caused by blood-related entities (bilirubin and biliverdin, ironcontaining ferritin and hemosiderin) and metal pigments (e.g.
silver, gold, lead and mercury) [1–6]. Among these, the most
frequent is amalgam pigmentation (amalgam tattoo). Several
drugs have been reported to induce mucosal discoloration
through direct deposition on oral surfaces, local accumulation
after systemic absorption, stimulation of melanin-related pathways and bacterial metabolism [1–6].
It is important to have a thorough checkup of all the systems
of the body and to study the previous medical and surgical
history to determine the presence of any atypical, unstable or
malignant skin lesions. Similarly a positive family history of oral
pigmentation or hereditary systemic diseases is crucial in the
overall evaluation of the patient. For clinical assessment good
lighting and a mouth mirror or magnifying glass should be used.
Examination of the mouth should begin with the evaluation of
pigmentation of facial skin, especially the perioral region, followed by labial vermilion border and mucosal surfaces, the
mucogingival junction as well as the attached gingiva.
Singapore Dental Journal 35 (2014) 39–46
Classification of oral pigmentations
Kauzman et al. [8] proposed a Classification based on the
distribution of the pigmentation.
Diffuse and bilateral
Early onset: physiological pigmentation, Peutzjegher's
syndrome.
Predominantly adult onset.
With systemic signs and symptoms.
Addison's disease, heavy metal pigmentation, Kaposi's
sarcoma.
No systemic signs and symptoms.
Drug induced pigmentation, post-inflammatory.
Smoker's melanosis.
Focal
Red, blue, and purple.
Blanching: hemangioma, varix.
Nonblanching: thrombosis, hematoma.
Blue-gray: amalgam tattoo, other foreign body tattoo,
blue nevus.
Brown: melanotic macule, pigmented nevus, melanoacanthoma, melanomas.
The clinical features and presentation of most commonly
found pigmented lesions in the oral cavity are as follows:
Physiologic Melanotic Lesions.
Physiologic Pigmentation (Racial).
Racial pigmentation of oral mucosa is the most common
cause of oral pigmentation; however it is not directly related
to the color of the skin [9–11]. The pigmentation is symmetrically distributed, especially on the gingival [Fig. 1] and
buccal mucosa, on the hard palate, lips and tongue may also
be seen as brown patches with well-defined borders. Gaeta
et al. [3] stated that it is more common in African, Asian and
Mediterranean populations. This increase in pigmentation is
due to increase in melanocyte activity and not due to greater
number of melanocytes. The degree of gingival pigmentation
is directly related to skin pigmentation. In light skinned
individuals gingiva is mostly non-pigmented but in dark
skinned people the chance of having pigmented gingiva is
extremely high [4]. It is seen during the first two decades of
life but may not come to the patient's attention until later.
The color ranges from light to dark brown. The attached
gingiva is the most common site, where it appears as
a bilateral, well-demarcated, ribbon-like, dark brown band
Fig. 1 – Shows physiologic (racial) pigmentation on the
gingiva for black man.
41
that usually spares the marginal gingiva [1]. The pigmentation is asymptomatic therefore no treatment is required.
Since these lesions are considered physiological so there are
no chances of malignant transformation, having said this, it
is critical to differentiate between normal and premalignant
lesions.
Ephelides
Ephelides are common small, brown macules (5 mm) [8,9].
They appear on sun-exposed areas of the perioral skin and
lips. These lesions darken after sun light exposure. It is a
self limiting condition depending on the amount of exposure
to the sun. There have been no reports on malignant
transformation.
Melanotic macules
Weathers et al. [12] stated that the labial melanotic macule is
a benign pigmented lesion that is common on the lower lip,
and the oral melanotic macule is the same lesion seen inside
the oral cavity, most commonly on the gingiva, buccal
mucosa and palate. It is caused by increased melanin production without increase in the number of melanocytes.
Melanotic macules are usually smaller than 1 cm in diameter
and show a well-demarcated smooth border. They usually
occur as single lesions, but multiple lesions are sometimes
seen. The color is homogenous light or dark brown. Melanotic
macules are more common in women and young adults [13].
Melanotic macules are benign and hardly ever transform into
melanoma. For any melanotic macules seen on the palate
that has been reported by the patient to increase in size, a
biopsy should be performed. This was because is usually
required to establish the diagnosis and to rule out melanoma,
especially for lesions involving the palate, where malignant
melanoma is most prevalent and malignant transformation
of melanotic macules is rare [14]. No further treatment is
required once the diagnosis has been established.
Heavy metal pigmentation
Increase in heavy metal (e.g. lead, bismuth, mercury, silver,
arsenic and gold) levels in the blood leads to oral mucosal
discoloration. It is mostly seen in individuals exposed to
heavy metal vapors (occupational) or patients taking drugs
containing heavy metals such as arsenic, previously used for
the treatment of syphilis. Use of water or paints containing
lead and drugs containing mercury or silver can also cause
mucosal discoloration [8]. The pigmentation appears as a
blue-black line along the gingival margin and seems to be
proportional to the amount of gingival inflammation as
stated by Esen et al. [15,16]. Other oral mucosal sites may
also be involved [Fig. 2]. A variety of systemic signs and
symptoms may be seen depending on the type of heavy
metal exposure [15]. Malignant transformation of oral pigmentation due to heavy metal pigmentation has not been
reported. Yet care should be taken regarding severe systemic
toxicity.
42
Singapore Dental Journal 35 (2014) 39–46
Chemically induced melanosis
Smoker's melanosis
Fig. 2 – Shows heavy metal pigmentation on oral mucosa.
Kaposi's sarcoma
Kaposi's sarcoma (KS) is a multifocal vascular malignancy seen
predominantly in HIV-infected individuals. The development
of this tumor is considered diagnostic of AIDS progression.
A human herpes virus (HHV-8, also called Kaposi's sarcomaassociated herpes virus) has been implicated as the cause. KS in
the oral mucosa most commonly affects the hard palate,
gingiva and tongue. It appears as a bilateral flat or slightly
elevated brown to purple colored lesion in early stages.
Advanced lesions may appear as dark red to purple plaques
or nodules that may exhibit ulceration, bleeding and necrosis.
A definitive diagnosis requires biopsy, which shows the proliferation of spindle-shaped cells, surrounded by poorly formed
vascular spaces or slits with numerous extravasated red blood
cells [15,16]. With new treatments for AIDS, KS has become less
common in the United States, and it now occurs at a rate of
about 6 cases per million people each year. In the United States,
KS is much more common in men than in women, and it is
rarely seen in children. It is also more common in African
Americans than in whites in the United States.
Transplant recipients are another group that gets KS. About
1 in 200 transplant patients in the United States gets KS. Most
people who develop Kaposi's sarcoma have been infected with
the virus prior to organ transplantation. The drugs taken to
suppress the immune system of the patient after transplantation is done, allows KS to develop. In areas of the world (such
as Africa) where KSHV and HIV infection rates are high, both
endemic and HIV-associated KS are seen, and KS occurs in
men, women, and children. Early detection of HIV thorough
investigations and management of the immune modulation
will turn down further complications associated with HIV.
Hedin et al. stated that smoking may cause oral pigmentation in
light-skinned individuals and accentuate the pigmentation of
dark skinned patients [18]. There is increased production of
melanin, which may provide a biologic defense against the
noxious agents present in tobacco smoke [19]. Smoker's melanosis occurs in up to 21.5% of smokers [20]. It is proved that the
intensity of the pigmentation is related to the duration and
amount of smoking [20,21]. Women are more commonly affected
than men, which suggest a possible synergistic effect between
the female sex hormones and smoking [20]. According to them,
the brown-black lesions most often involve the anterior labial
gingiva, followed by the buccal mucosa [20]. Smoker's melanosis
usually disappears within 3 years of smoking cessation. Zaraa
et al. [15] mentioned that biopsy should be performed if there is
surface elevation or increased pigment intensity or if the
pigmentation is in an unexpected site. There is no evidence
supporting the malignant transformation of smoker's melanosis,
but caution should be taken about other systemic complications
associated with smoking. Smoker's melanosis can be used as a
clinical finding to identify the smoking history [21].
Amalgam tattoo and other foreign-body
Pigmentation
Amalgam tattoo is one of the most common causes of
intraoral pigmentation [22]. It presents clinically as a localized flat, blue-gray lesion of variable dimensions [Fig. 3]. The
gingiva and alveolar mucosa are the most common sites, but
these lesions may also involve the floor of the mouth and the
buccal mucosa. No signs of inflammation are present at the
periphery of the lesion. Diascopy is a test whether lesion is
vascular or nonvascular or hemorrhagic by applying pressure
with a finger glass slide and observing color changes [23].
A negative response was seen with diascopy. In some cases,
especially when the amalgam particles are large enough, they
can be seen in intraoral radiographs as fine radiopaque
granules. In these circumstances, the diagnosis of amalgam
Post-inflammatory pigmentation
Long-standing inflammatory mucosal diseases, particularly
lichen planus, can cause mucosal pigmentation [1]. This is
seen more frequently in dark-skinned individuals. Clinically,
multiple brown-black pigmented areas are noted adjacent to
reticular or erosive lesions of lichen planus. Halder et al.
mentioned that the pathogenesis of post-inflammatory pigmentation remains unclear [17]. Histologically, there is
increased production of melanin by the melanocytes and
accumulation of melanin laden macrophages in the superficial connective tissue. There is no literature on hand about
its transformation into malignancy.
Fig. 3 – Shows amalgam tattoo as blue-gray lesion on
alveolar mucosa. (For interpretation of the references to
color in this figure legend, the reader is referred to the
web version of this article.)
Singapore Dental Journal 35 (2014) 39–46
tattoo can be made on the basis of the clinical and radiographic findings. In case of doubt, a biopsy should be
performed to demonstrate the presence of amalgam particles
in the connective tissue [8]. Graphite may be introduced into
the oral mucosa through accidental injury with a graphite
pencil. The lesion occurs most frequently in the anterior
palate of young children, appearing as an irregular gray to
black macule. A history of injury confirms the diagnosis;
otherwise, a biopsy should be performed to exclude the
possibility of melanoma. As amalgam fillings still are ubiquitous and amalgam tattoos remain one of the most common
causes of intraoral pigmentation, we consider amalgam
tattoos to be an important differential diagnosis consideration, when assessing patients suspected for mucosal melanoma of the oral cavity. Information regarding previous
prosthetic dental work should be included in the patient's
medical history, and an X-ray showing metal deposits in the
mucosa can safely rule out mucosal melanoma. But when in
doubt, we recommend a diagnostic biopsy for histopathological examination [8]. This lesion is just a localized reaction to
metal deposition in the mucosa.
Drug-induced pigmentation
A number of medications may cause oral mucosal pigmentation
such as Antimalarials (quinacrine, chloroquine, hydroxychloroquine, Quinidine, Zidovudine (AZT), Tetracycline, Minocycline,
and Chlorpromazine), Oral contraceptives, Clofazimine, and
Ketoconazole. The pathogenesis of drug-induced pigmentation
varies, depending on the causative drug. It may involve accumulation of melanin, deposits of the drug or its metabolites,
synthesis of pigments under the influence of the drug or
deposition of iron after damage to the dermal vessels [9].
Chloroquine and other quinine derivatives are used in the
treatment of malaria, cardiac arrhythmia and a variety of
immunologic diseases including systemic and discoid lupus
erythematosus and rheumatoid arthritis. Mucosal discoloration
associated with these drugs mostly involves the hard palate only
and appear as blue-gray or blue-black in color [9,10,24]. Laboratory studies have shown that these drugs may produce a direct
stimulatory effect on the melanocytes [25]. However, the reason
why this effect is limited to the palatal mucosa is not understood. Minocycline is a synthetic tetracycline used in the long
term treatment of refractory acne vulgaris. It can cause pigmentation of the alveolar bone, which can be seen through the thin
overlying oral mucosa (especially the maxillary anterior alveolar
mucosa) as a gray discolouration [26]. Minocycline has also been
reported to cause pigmentation of the tongue mucosa. [27]. Drug
induced lesions are local reactions which are seen in oral cavity
and no reports of malignant transformation have been reported
in this regard.
Disease-associated melanosis
Peutz–Jeghers syndrome
Peutz–Jeghers syndrome is a rare genetic disorder and is
characterized by pigmented mucocutaneous macules, intestinal hamartomatous polyposis and increased risk of cancer in
many organs, including the small intestine, colon, stomach,
43
pancreas, breast and genital tract [4–6]. The melanotic spots
of Peutz–Jeghers syndrome are characteristically small and
multiple, and are very obvious around the lips. Pigmented
spots also occur inside the mouth, in the mucosa of the nose,
conjunctiva and rectum, and on the skin of the extremities
[7]. The melanotic spots do not require treatment and are not
associated with increased risk of melanoma. However, the
patient should be monitored for the development of internal
malignancies. Such oral lesions help in early diagnosis and
should alert the clinician to prompt the patient to screen for
cancers in organs implicated in this syndrome.
Addison's disease
Oral mucosal pigmentation associated with Addison's disease develops and progresses during adult life and is usually
accompanied by systemic manifestations including weakness, nausea and vomiting, abdominal pain, constipation or
diarrhea, weight loss and hypotension. Addison's disease, or
primary hypoadrenalism, is due to progressive bilateral
destruction of the adrenal cortex by autoimmune disease,
infection or malignancy [11]. The lack of adrenocortical
hormones in the blood stimulates production of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland. The
increased production of ACTH induces melanocytestimulating hormone, which results in diffuse pigmentation
of the skin and oral mucosa. Oral involvement presents as
diffuse brown patches on the gingiva, buccal mucosa, palate
and tongue, which may resemble physiologic pigmentation
[15]. However patients presenting with these features should
be sent for medical evaluation and laboratory tests to assess
levels of ACTH, plasma cortisol and serum electrolytes.
Addison's disease can be fatal if left untreated. Management
involves treatment of the underlying cause and corticosteroid
replacement therapy. No cases of malignant transformation
have been reported.
Melanocytic nevi
Pigmented nevi are a rare cause of focal oral pigmentation.
They present as either brown or blue lesions. Histologically,
nevi are composed of an accumulation of nevus cells in the
basal epithelial layers, the connective tissue or both. As such,
they are classified as junctional, intradermal or intramucosal,
and compound nevi. Junctional nevi are flat and dark brown
in color because the nevus cells proliferate at the tips of the
rete pegs close to the surface. Intramucosal and compound
nevi are typically light brown, dome-shaped lesions. Blue
nevi are characterized by proliferation of dermal melanocytes
within the deep connective tissue at some distance from the
surface epithelium, which accounts for the blue color. Buchner et al. [28] stated that intramucosal nevus is the most
common type and is seen most frequently on the buccal
mucosa. The blue nevus is the second most common type,
occurring most commonly in the palate [28]. It may be
difficult to differentiate clinically between a nevus and an
early lesion of mucosal melanoma, especially in the palate,
the most common site for both lesions. Although transformation of oral pigmented nevi to melanoma has not been well
documented, it is believed that nevi may represent precursor
44
Singapore Dental Journal 35 (2014) 39–46
lesions to oral mucosal melanoma [29]. It is therefore recommended to completely excise these lesions and submit it for
histopathologic examination.
Oral melanoacanthoma
Oral melanoacanthoma is uncommon benign pigmented
lesion of the oral mucosa, characterized by proliferation of
dendritic melanocytes dispersed throughout the thickness of
an acanthotic and hyperkeratotic surface epithelium [15,30].
Clinically, the lesion appears hyper pigmented black or brown,
flat or slightly raised. This lesion, in contrast to most of the
benign pigmented lesions discussed above, has a tendency to
enlarge rapidly, which raises the possibility of a malignant
process in the clinical differential diagnosis [31]. However its
tendency to occur in young black females distinguishes it from
melanoma, which is uncommon in this age and racial group.
Goode et al. stated that the buccal mucosa is the most
common site of occurrence, which may be related to greater
frequency of trauma in this area [30]. Oral melanoacanthoma
appears to be a reactive lesion with no malignant potential. In
some cases, the lesion disappears after incisional biopsy or
removal of the offending stimulus [31].
than the 0.2–8% reported in the United States and Europe.
Although occurrence of cutaneous melanomas is less common in dark skinned races, these races have a greater relative
incidence of oral mucosal melanomas. Oral mucosal melanoma tends to be more aggressive than its cutaneous counterparts and is mostly presented at a later stage of the
disease. Treatment involves radical surgical excision with
clear margins. This may be difficult to accomplish because of
anatomic constraints and proximity to vital structures. Radiation and chemotherapy are ineffective, which further makes
the management of this malignancy complicated. The prognosis for patients with oral melanoma is poorer than those
with cutaneous lesions, and the overall 5-year survival rate is
15%. The best way to improve prognosis is early diagnosis
[29,33]. Primary oral mucosal melanomas are biologically
aggressive malignancies though they are rare. Oral melanoma clinically mimics many other pigmented lesions of the
oral cavity. It is essential to include oral examination as a
part of full body examination along with skin examinations,
dentures should be removed for examination. Suspicious
pigmented and non-pigmented lesions should be biopsied
appropriately. Early diagnosis and intervention result in
a better prognosis [8].
Oral melanoma
Focal pigmentation
Oral mucosal melanoma is rare. It accounts for less than 1%
of all oral malignancies. It is characterized by proliferation of
malignant melanocytes along the junction between the
epithelium and connective tissue or may occur deep inside
the connective tissue. The palate is the most common site,
which account for about 40% of cases, and gingival account
for one third of case [29]. Other oral mucosal sites may also be
affected [Fig. 4]. Oral melanoma is generally encountered
between the fourth and seventh decades of life, with a greater
incidence in men than women [32]. Clinically; oral melanoma
may present as an asymptomatic, slowly-growing brown or
black patch with asymmetric and irregular borders or as a
rapidly enlarging mass associated with ulceration, bleeding,
pain and bone destruction. A few oral melanomas are nonpigmented (amelanotic). Although oral mucosal melanomas
are rare, they represent a serious and often fatal disease.
Internationally, oral melanoma is more common in the
Japanese than in other groups. In Japan, oral melanomas
account for 11–12.4% of all melanomas, and males may be
affected slightly more than females. This percentage is higher
Fig. 4 – Shows oral melanoma on lips.
Hemangioma and vascular malformation
Hemangioma is a benign proliferation of the endothelial cells
that line vascular channels [8]. Vascular malformation is a
structural anomaly of blood vessels without endothelial
proliferation. Both lesions are developmental abnormalities,
characterized by onset during infancy. Hemangiomas regress
as the patient ages, but vascular malformation persists
throughout life. The multi nodularity is racemose and diffuse.
Tongue angiomas frequently extend deeply between the
intrinsic muscles of the tongue. The lip mucosa is another
common site for hemangiomas in children; they appear
mostly as localized, raised blue tumors.
Varix and thrombus
Pathologic dilatations of veins or venules are varices or
varicosities, and the chief site of such involvement in the
oral tissues is the ventral tongue [3–5]. Varicosities become
progressively prominent with age, thus lingual varicosities
are mostly seen in elderly individuals. Lingual varicosities
appear as tortuous serpentine blue, red or purple elevations
that course over the ventrolateral surface of the tongue, with
extending anteriorly. Even though they may be quite striking
in some patients, they represent a degenerative change in the
adventitia of the venous wall and are of no clinical consequence. They are painless and are not subjected to rupture
and hemorrhage. If the varix contains a thrombus, it presents
as a firm bluish purple nodule that does not blanch on
diascopy. Thrombi are more common on the lower lip and
buccal mucosa [15].
Singapore Dental Journal 35 (2014) 39–46
Hematoma and other hemorrhagic lesions
As stated by Barker et al. [32]. Hematomas, petechiae, purpurae and ecchymoses are caused by extravasation of blood
into the soft tissues. They may appear as nonblanching flat or
elevated pigmented lesions. They may occur spontaneously
in certain systemic conditions such as idiopathic thrombocytopenic purpura, or they may result from trauma [21]. The
color produced due to degradation of hemoglobin to bilirubin
and biliverdin, varies among red, purple, blue and bluish
black depending on the length of time the blood has been
present in the extravascular spaces. It may take up to 2 weeks
for the color to become normal again. If hemorrhagic lesions
occur in the absence of recent trauma, the patient should be
investigated for platelet disorders and coagulopathies.
Discussion
Intraoral pigmentations could be focal, diffuse or multifocal.
They may be black, gray, blue, purple or brown in color. They
may be flat or swollen. They can be localized accumulations of
melanin, hemosiderin, exogenous metal or some are even
indications of an internal disease. The differential diagnosis
can be lengthy in certain conditions with multiple and complex
lesions with pigmentations. Although biopsy is a helpful aid to
diagnosis for localized lesions, the more diffuse lesions will
require a thorough history and laboratory studies in order to
arrive at a definitive diagnosis [8]. Thorough examination of the
oral pigmentation together with complete history and clinical
findings are necessary for early diagnosis and prompt treatment. Even though only a few lesions are reported to undergo
malignant transformation, yet this limited data regarding
malignancy transformation in oral lesions cannot be simply
ruled out. All general practitioners should have thorough
knowledge in order to establish a probable differential diagnosis
as well as definitive diagnosis for prompt treatment. In case of a
doubt referral to specialist is recommended.
Conclusion
The diagnostic procedure of pigmented lesions of the oral
cavity and perioral tissues is quite challenging. Clinicians
may benefit to a certain extent from the available epidemiological data or they can make the diagnoses on clinical
grounds alone; however such diagnosis will remain “provisional”. Histopathological evaluation of oral pigmentation is
required for a definitive diagnosis. Unfortunately the available data based on randomized controlled trials is quite
limited to draw a statistical analysis. We have tried to highlight the oral pigmented lesions that clinicians can most
possibly come across during a routine checkup of the
patients. The management of pigmented oral lesions varies
greatly based on the diagnosis, understanding of the underlying causes of mucosal pigmentation and appropriate evaluation of the patient is therefore essential.
General dental practitioners can benefit from this review
as it delineates the factors that will help them to differentially diagnose pigmented lesions of the oral cavity and also
45
improve their understanding differentiate between normal
and diseased conditions, so that they can master the skill of
early definitive diagnosis and prompt treatment.
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Singapore Dental Journal 35 (2014) 47–52
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Scientific article
Endodontic irrigant as a root conditioning agent: An
in vitro scanning electron microscopic study
evaluating the ability of MTAD to remove smear layer
from periodontally affected root surfaces
Afaf Zia, Syed Mukhtar-Un-Nisar Andrabi, Afshan Bey, Ashok Kumar,
Zareen Fatima
Dr. Z.A Dental College, Aligarh Muslim University, Aligarh, India
art i cle i nfo
ab st rac t
Background: Instrumentation of the root surface, results in formation of a smear layer of
Keywords:
organic and mineralized debris which serves as a physical barrier, inhibiting new
Periodontal root surface
connective tissue attachment to the root surface. The present study advocates the use of
Root Conditioning
an endodontic irrigant MTAD (mixture of tetracycline, citric acid and detergent) as a root
MTAD
conditioning agent.
EDTA
The main aim of the study was to compare the root conditioning ability of an
endodontic irrigant MTAD (mixture of tetracycline, acid and detergent) with 17% EDTA
(ethylenediaminetetraacetic acid).
Materials and methods: Sixty freshly extracted human single rooted teeth with confirmed
periodontal involvement were selected for this study and decoronated. The apical third of
each root was removed and the remaining root was sectioned longitudinally to produce a
6 mm to 8 mm long tooth section. The root surface was then instrumented by hand using a
sharp Gracey 1–2 periodontal curette with 6–8 strokes per area to achieve a smooth glasslike surface. A total of 60 specimens were prepared which were randomly divided into
three groups (n¼ 20). Each group received the root conditioning treatments as follows:
Group A: Control Group: only saline rinsing.
Group B: root conditioning treatment with 17% EDTA for 5 min.
Group C: root conditioning treatment with BioPure MTAD for 5 min.
All specimens were prepared for SEM and scored according to the presence of
smear layer.
Results and conclusions: MTAD removed the smear layer successfully from the root surfaces.
The mean smear score for samples treated with Biopure MTAD was lower than those
treated with EDTA, (p ¼ 0.04). MTAD can be used as a root conditioning agent with efficient
smear layer removal ability and known antimicrobial and anticollagenase activity.
& 2014 Published by Elsevier B.V.
http://dx.doi.org/10.1016/j.sdj.2014.04.002
0377-5291/& 2014 Published by Elsevier B.V.
48
Singapore Dental Journal 35 (2014) 47–52
Introduction
The main aim of periodontal therapy is to achieve predictable regeneration of the periodontal tissues in areas previously affected by disease. Teeth affected by periodontal
disease are exposed to bacterial products from the plaque
and calculus and such teeth become hypermineralized and
contaminated with the endotoxins as well as other toxic
bacterial products [1]. Such a surface does not encourage cell
attachment or migrations which are necessary events for
optimal spontaneous periodontal healing [2]. Decontamination of these diseased root surfaces is not possible exclusively with mechanical instrumentation (i.e. by scaling and
root planning alone), because it often leads to creation of a
smear layer [3,4]. The smear layer may range in thickness
from 2 to 15 μm and serve as a physical barrier between the
periodontal tissues and the root surface inhibiting new
connective tissue attachment to the root surface [5,6].
Therefore the root surfaces must be devoid of any smear
layer in order to facilitate periodontal healing through
regeneration or new attachment [6]. Conditioning of the
root surface after scaling and root planning with various
acids and chelating agents has been advocated as an
effective procedure for smear layer removal and detoxification. Root conditioning with various chemical agents is seen
as an adjunct to mechanical root therapy and has been
performed as early as the latter half of the 19th century. Till
now a variety of chemicals like EDTA, phosphoric acid, citric
acid, and tetracycline have been tested in this direction but
none has come out as a gold standard. Among these chemicals
citric acid and tetracycline HCl have shown to have additional
effect of demineralizing the root surface, removing the smear
layer and exposing collagen matrix of the mineralized radicular dentin [7,8]. Tetracyclines comprise a broad-spectrum
antimicrobial agent, which is effective against many species
of periodontal pathogens. Besides its antimicrobial effectiveness, this group of drugs has other special properties which
include its anti-inflammatory action, collagenase inhibition,
bone resorption inhibition and its ability to improve fibroblast
attachment. Tetracyclines are still used in association with
bone grafting and as conditioner agents for the root surface,
and they enhance periodontal tissue regeneration [9,10]. The
substantivity of tetracyclines is another important property for
periodontal therapy. This property allows the substance to
affix to a substrate and realize slow release, which is important in maintaining the antimicrobial and nonantimicrobial
properties acting on the periodontal tissues for an extended
time, when the drug is locally applied after periodontal
instrumentation [7,10]. Even though some studies have
demonstrated that the use of citric acid as root conditioner
agent is similar to tetracycline [8,11] this substance has no
antimicrobial or anti-inflammatory properties [12]. A combination of citric acid and tetracycline along with a detergent is
found in a present day endodontic irrigant MTAD (mixture of
tetracycline, acid and detergent). The introduction of MTAD by
Torabinejad et al. in 2003 [12] represents an advance in
endodontic irrigation research. The tetracycline present in
MTAD is doxycycline hyclate, acid is citric acid and the
detergent is Tween-80 (polysorbate-80). MTAD has been
reported to remove smear layer effectively, eliminate microbes
that are resistant to conventional endodontic irrigants and
dressings, and provide sustained antimicrobial activity [13–15].
Thus MTAD can be seen as a potential root conditioning and
smear layer removal agent.
The aim of this study was to compare the effectiveness of
root conditioning ability of MTAD to EDTA.
Materials and methods
Sixty freshly extracted human single rooted teeth were
selected for this study. The teeth selected were periodontally
involved and showed clinical gingival recession, and loss of
attachment. After extraction the teeth were stored saline
solution to avoid dehydration of the specimens. The present
study involved mainly the use of anterior teeth with majority
of teeth being mandibular incisors and no premolars were
used. All teeth were decoronated with the help of a diamond
disc at high speed under water cooling. The apical third of
each root was removed and the remaining root was sectioned
longitudinally through the root canal to produce a 6 mm to
8 mm long tooth section. All pulpal tissue was thoroughly
removed and an identification notch placed on the pulpal
root surface. The root surface was then instrumented by
hand using a sharp Gracey 1–2 periodontal curette with 6–8
strokes per area to achieve a smooth glass-like surface. A
total of 60 specimens were prepared from extracted teeth.
After this the specimens were randomly divided into three
groups, two experimental groups and one control group. Each
group comprised 20 specimens.
The groups were formed on the basis of the root conditioning agent to be used. The root surfaces of the specimens in each group received the root conditioning
treatments as follows:
Group A: Control Group (n ¼20): received only saline
rinsing of the root surface and no other root conditioning
treatment.
Group B: EDTA Group (n¼ 20): received root conditioning
treatment with 17% EDTA (Canalarge; Ammdent, Chandigarh, India) for 5 min.
Group C: MTAD Group (n¼ 20): received root conditioning
treatment with BioPure MTAD (Dentsply Tulsa Dental,
Tulsa, OK, USA) for 5 min.
The root conditioning treatment of the specimen was
done according to a fixed protocol in all groups so that there
was no difference in the method of conditioning and the time
period for which the conditioning agent was in contact with
the root surface of the specimen. The conditioning agents
were applied with cotton pellets which were replaced every
30 s to ensure the uniform contact of the root surface area of
each specimen with the conditioning agent. After this the
samples were thoroughly rinsed with 5 ml of distilled water
to rid the specimens off any remaining/pooled conditioning
agent on the root surface. Washed samples were then dried
and scheduled for scanning electron microscopic evaluation.
Singapore Dental Journal 35 (2014) 47–52
The dried samples were coded before sending for scanning
electron microscopic evaluation to ensure blinding with
respect to the type of irrigant used.
SEM evaluation
Specimens were dehydrated with ascending concentrations
of ethyl alcohol (30–100%), and placed in a desiccator for at
least 24 h, mounted on metallic stubs, gold sputtered and
viewed under scanning electron microscope (Inca-x 50,
Oxford Instruments, England 2.0 nm@ 30 kV 5 –500000 ,).
After a general survey scan of each specimen at a magnification of 250 an image of the most representative area of that
specimen was taken with 500 , 1000 and 2000 . The
images of 1000 were then analyzed for the amount of
smear layer present by three independent observers without
knowing which group they were analyzing. Evaluation was
repeated twice for the first 10 specimens to ensure intraexaminer consistency.
The amount of smear layer remained on the root surface
and dentinal tubules were scored according to the following
criteria used [16]:
49
0¼ No smear layer (Fig. 1a)
1¼ Smear layer involving random areas of surface that
totals between 1–32% of total surface area. (Fig. 1b)
2¼ Smear layer involving random areas of surface that
totals between 33–65% of total surface area. (Fig. 1c)
3¼ Smear layer involving466% of total surface area.
(Fig. 1d)
The data was analyzed through Mann–Whitney U-test and
comparisons were made as follows:
1) Comparison of all groups with the control.
2) Comparison of the experimental groups with each other.
Results
The examination of the root surfaces in group A (control
group) showed the presence of a heavy smear layer throughout the entire prepared surface of the root (Fig. 2a and b). The
examination of the root surfaces in both experimental groups
Fig. 1 – (a) Score 0¼0 ¼ No smear layer, (b) Score 1 ¼Smear layer involving random areas of surface that totals between 1% and
32% of total surface area. (c) Score 2 ¼ Smear layer involving random areas of surface that totals between 33% and 65% of total
surface area. (d) Score 3 ¼Smear layer involving 466% of total surface area.
50
Singapore Dental Journal 35 (2014) 47–52
Fig. 2 – Scanning electron microscopic images of group A (control group): (a) 1000 image and (b) 2000 image.
Fig. 3 – Scanning electron microscopic images of group B (EDTA group): (a) 1000 image and (b) 2000 image.
showed the smear layer removed and dentinal tubules
opened (Fig. 3a and b, Fig. 4a and b). The mean smear scores
of the samples for both experimental groups (groups B and C)
were less than those of the control group (Table 1). The
comparison of both the experimental groups with the control
group showed that the root surfaces were significantly
cleaner in both group B and group C than in group A
(po0.001). Intergroup comparison of groups B and C showed
that the root surfaces were comparatively cleaner in group C
(where MTAD was used as root conditioning agent) than in
group B (where EDTA was used) with mean score of group C
(1.05) less than that of group B (1.65), (Table 1). However the
difference between the two results was just marginally
significant (p ¼0.04).
Discussion
Regeneration of supporting tissue to tooth surfaces affected
by periodontitis has long been an ideal of periodontal therapy. Periodontitis affected root surfaces are hypermineralized
and contaminated with cytotoxic and other biologically active
substances [17]. Such surfaces are not biocompatible with
adjacent periodontal cells the proliferation of which is pivotal
for periodontal wound healing [18]. Traditional treatment of
pathologically altered root surfaces has relied on mechanical
removal of plaque, calculus, root bound toxins and contaminated cementum and appears to be essential for periodontal
regeneration [19]. Instrumentation of the root surface, however, results in formation of a smear layer of organic and
mineralized debris. This smear layer usually ranges from 2 to
15 μm in thickness and may serve as a physical barrier
between the periodontal tissues and the root surface inhibiting the formation of new connective tissue attachment to the
root surface [4,20]. Furthermore, it is not possible to completely decontaminate the root surface by mechanical therapy
alone therefore biological modification or conditioning of the
root surfaces is often needed to make these surfaces more
conducive to the periodontal regeneration [21].
Demineralization of root surfaces during periodontal therapy has been performed to enhance regeneration of the
lost periodontal attachment. Demineralizing agents have
been shown to expose dentinal collagen, widening the orifices of dentinal tubules and cementum bound proteins [22].
Singapore Dental Journal 35 (2014) 47–52
51
Fig. 4 – Scanning electron microscopic images of group C (MTAD group): (a) 1000 image and (b) 2000 image.
Table 1 – Mean smear scores (7SD) for all groups.
Group
Saline (control group)
EDTA
MTAD
Score
Mean7SD
0
1
2
3
0
3
5
0
4
8
0
10
6
20
3
1
3
1.65
1.05
Furthermore, demineralizing agents have been found to elute
retained toxins from the altered root surface. A number of
agents have been proposed for the demineralization procedures including phosphoric acid, EDTA, citric acid, PDGF-BB,
IGF-1 and tetracycline. The present study tested an endodontic irrigant MTAD (mixture of tetracycline, citric acid and
detergent) for its root conditioning ability.
MTAD (commercially available as BioPure ™ MTAD, Dentsply Tulsa Dental, Tulsa, OK, USA) was developed by Torabinejad et al. [13] as a final endodontic irrigant to disinfect the
canal and remove the smear layer. Shabahang et al. [14,23]
showed that BioPure MTAD was an effective disinfectant of
the root canal system and a combination of 1.3% NaOCl and
BioPure MTAD as a final treatment eliminated E. faecalis from
human tooth cementum and dentin. They attributed the
effectiveness of BioPure MTAD to its anticollagenase activity,
low pH, and ability to be released gradually over time. BioPure
MTAD has been found to adsorb to hydroxyapatite with
prolonged and gradual release at therapeutic levels [24]. In
addition, presence of a detergent (Tween 80) in BioPure MTAD
reduces its surface tension and thus improves its penetration
into deep layers of dentin. In a study [24] evaluating the
antimicrobial substantivity of MTAD, chlorohexidine (CHX)
and sodium hypochlorite, BioPure MTAD showed significantly higher antimicrobial substantivity than CHX and was
retained in root canal dentin for at least 28 days. These
properties of Biopure MTAD can be useful in periodontal root
conditioning. Biopure MTAD will remove the smear layer,
show improved penetration into the root surface dentin and/
or cementum, expose the dentinal tubules, and provide
antimicrobial activity.
Present study compared the root conditioning ability of
EDTA and Biopure MTAD (a final endodontic irrigant) with
normal saline as control. Both the experimental solutions
removed the smear layer successfully from the root surfaces
and the experimental samples were significantly cleaner than
the control group (po0.001). The results demonstrated that
the mean smear score (Table 1) for samples treated with
Biopure MTAD was lower than those treated with EDTA,
however the results were marginally statistically significant
(p¼ 0.04). The cleaner root surfaces in the samples treated
with Biopure MTAD can be attributed to its low pH and
presence of detergent (tween-80) enhancing its penetration
and thus better removal of the smear layer and more
effective opening of dentinal tubules. Therefore Biopure
MTAD can be seen as a potential root conditioning agent
with effective smear layer removal from the root surfaces.
However, MTAD has antimicrobial activity, anti-collagenolytic activity and the presence of polysorbate-80 (TWEEN80)
likely improves its penetration into the cementum and root
dentine and hence make it more effective than EDTA.
Conclusion
Within the experimental protocol of the present study it can
be concluded that Biopure MTAD is an effective root conditioning agent showing similar smear layer removing ability
when compared to EDTA. Further studies should be conducted before considering the use of MTAD as a periodontal
root conditioner.
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Singapore Dental Journal 35 (2014) 53–57
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Scientific article
Complications associated with the occurrence
and treatment of impacted maxillary canines
Anand K. Sajnania,n, Nigel M. Kingb
a
Department of Paediatric and Preventive Dentistry, Kerala Institute of Medical Sciences, Qatar Medical Centre,
Abdulrahman Bin Jassim Al Thani Street, P.O. Box 82125, Wakra, Qatar
b
Paediatric Dentistry, School of Dentistry, University of Western Australia, Perth, Australia
art i cle i nfo
ab st rac t
Background: The aim of this study was to evaluate the complications associated with the
Keywords:
occurrence and treatment of impacted maxillary canines.
Impacted maxillary canine
Methods: This retrospective study was conducted on 533 Southern Chinese children and
Complications of impacted canine
adolescents who attended the Paediatric Dentistry and Orthodontics Clinics and had at
Treatment of impacted canine
least one impacted maxillary canine. The study material included all the documentation
Root resorption
files and radiographs of these patients. Complications that had been recorded in the
clinical and surgical notes and that could be diagnosed from the available radiographs
were noted. The data obtained were descriptively analyzed.
Results: The most frequently reported phenomenon associated with the occurrence of
impacted maxillary canine (prior to surgical treatment) was root resorption of an adjacent
permanent tooth in 22 (4.1%) patients. The most frequently reported sequelae observed
after any surgical procedure was swelling of the soft tissues around the operation site
which often persisted for 48 h as seen in 76 (18.8%) patients. Complications reported most
commonly after any form of surgery included post-operative bleeding: 7(1.7%), hematoma:
7(1.7%), post-operative pain: 6(1.5%) and purulent discharge: 6(1.5%), post-operative
complications in relation to surgical exposure and bonding of an attachment which
included breakage of ligature wire: 5.7%; de-bonding of the attachment: 4.3% and inability
to bond the attachment during surgery: 1.4% occurred rarely.
Conclusions: The frequency of root resorption of teeth adjacent to an impacted maxillary
canine was low. Swelling of the soft tissue 48 h post-operatively was the most commonly
occurring complication after surgical intervention.
& 2014 Published by Elsevier B.V.
Introduction
The prevalence of impacted maxillary canines is reportedly
between 1% and 3% and the preferred management of an ectopic
n
Corresponding author. Tel.: þ974 30181952.
E-mail address: [email protected] (A.K. Sajnani).
http://dx.doi.org/10.1016/j.sdj.2014.07.001
0377-5291/& 2014 Published by Elsevier B.V.
permanent canine is early diagnosis and interceptive treatment
which involves extraction of the associated primary canine [1–3].
The success of this form of treatment is related to the timing of
the treatment and availability of space in the dental arch [1,3–5].
54
Singapore Dental Journal 35 (2014) 53–57
However, frequently, the diagnosis of an impacted canine is
delayed and the patient often requires surgical intervention as a
part of the comprehensive treatment. While most surgical
procedures proceed without untoward events, some produce
secondary effects and complications depending on the degree of
tissue damage [6]. These complications include ecchymosis of
the soft tissues, infection, paresthesia and damage to adjacent
structures [7,8]. Further, the presence of an impacted canine may
cause resorption of the adjacent tooth; most likely a lateral
incisor or the canine itself may undergo cystic changes [2,9]. The
capability to recognize and manage these unexpected situations
is essential for the practitioners providing the treatment. The
ability to understand potential complications and to avoid them
facilitates efficient therapy. Although there have been numerous
reports on the complications associated with surgery on
impacted third molars, very few studies have been carried out
to determine the post-operative complications associated with
the treatment of impacted maxillary canines [5,10–12]. Therefore,
the aim of this retrospective study was to evaluate the complications associated with the occurrence and treatment of impacted
maxillary permanent canines.
Subjects and methods
This retrospective investigation was conducted on 533 (206
males and 327 females) Southern Chinese children and adolescents who attended the Paediatric Dentistry and Orthodontics
Clinics at the Prince Philip Dental Hospital, Hong Kong SAR
between February 1982 and February 2009 and had at least one
impacted maxillary permanent canine. Efforts were taken to
trace every patient from the clinical and patient records and
patients with any form of oro-facial cleft; medical complications
including metabolic and endocrine disorders were excluded.
The study material included all the documentation files and
radiographs of these patients. The diagnosis of an impacted
maxillary canine was confirmed and the location of the tooth
determined on the basis of radiographs according to established
standardized techniques [13]. Complications that were recorded
in the clinical and surgical notes and their diagnosis based on
the available radiographs were noted. Clinical photographs,
where available, were also used to determine the complications
associated with the occurrence and treatment of the impacted
maxillary canines. The data thus obtained were descriptively
analyzed.
most of these patients required surgical removal of the
impacted canine as a part of their comprehensive treatment
plan, 70 (13.1%) of them required surgical exposure and
bonding of an attachment as a part of their treatment.
Amongst the 404 patients who needed surgical intervention,
142 (35.1%) were males, 262 (64.9%) were females while 69 (17.1%)
had bilateral impactions. The chronologic age of these patients at
the time of surgery ranged from 10.2 to 25.8 years with a mean of
16.7 years. The most frequently reported phenomenon associated with the occurrence of impacted maxillary canines, prior
to surgery, was root resorption of an adjacent permanent tooth.
A total of 22 patients (male¼ 7, female¼15) with a total of 28
teeth were diagnosed with resorption of adjacent teeth. Half of
these patients (n¼ 11, 50%) had buccally impacted canines whilst
7 (31.8%) had palatally impacted canines; the remaining 4 (18.2%)
patients had the impacted canine within the line of the arch. The
maxillary lateral incisors were the most commonly affected
teeth (n¼ 16), followed by the maxillary central incisors (n¼ 11)
and in one case a first premolar.
Likewise, the most frequently reported complication associated with the occurrence of impacted maxillary canines, prior
to surgery, was pain (n¼8, 1.5%) in the impacted tooth (Table 1).
Six (1.1%) patients reported with cystic changes whilst two
(0.4%) complained of swelling in relation to the tooth.
The most frequently reported post-operative sequelae
observed was swelling of the soft tissues around the surgery
site in 76 (18.8%) patients which was persistent even after 48 h.
The most frequently reported complication observed after any
form of surgery was post-operative bleeding from the surgical
site: 7 (1.7%) and hematoma: 7 (1.7%) of the adjacent tissues
(Table 2). Also, other complications reported were postoperative pain: 6 (1.5%), purulent discharge: 6 (1.5%), transient
paresthesia: 5 (1.2%), unsatisfactory healing: 5 (1.2%), iatrogenic
damage to adjacent soft tissue: 4 (1.0%), maxillary sinus
perforation: 2 (0.5%), sub-conjuctival hemorrhage: 2 (0.5%) and
discoloration of adjacent teeth: 1 (0.3%) (Table 2).
Post-operative complications were reported by 10 (14.3%) of
the 70 patients who underwent surgery to expose and bond an
attachment to facilitate orthodontic traction. The complications
specifically in relation to this procedure are listed in Table 3 and
included breakage of the ligature wire: 4 (5.7%); de-bonding of the
attachment: 3 (4.3%), no movement of the tooth after traction: 2
(2.9%) and failure to bond the attachment during surgery: 1
(1.4%).
Results
Discussion
Of the 533 patients who had an impacted canine, surgical
intervention was required in 404 (75.8%) patients. Whilst
Incisor root resorption is a well recognized phenomenon
caused by impacted canine. This most commonly affects
Table 1 – The pre-operative complication experienced by 16 of the 533 patients with impacted maxillary canines.
Pre-operative complications
Number of patients
Percentage
Pain in the impacted tooth
Cystic changes
Swelling in relation to the impacted tooth
8 (1M, 7F)
6 (2M, 4F)
2 (2F)
1.5
1.1
0.4
*M ¼ male and F ¼female.
55
Singapore Dental Journal 35 (2014) 53–57
Table 2 – Post-operative complications experienced by 404 of the 533 patients who underwent any form of surgery for
treatment of an impacted maxillary canine.
Post-operative complication
Number of patients
Percentage
Bleeding from the site of the surgery
Hematoma
Post-operative pain
Purulent discharge
Transient paresthesia
Unsatisfactory healing
Iatrogenic damage to adjacent soft tissue
Maxillary sinus perforation
Sub-conjunctival hemorrhage
Discoloration of adjacent teeth (non-vital)
7
7
6
6
5
5
4
2
2
1
1.7
1.7
1.5
1.5
1.2
1.2
1.0
0.5
0.5
0.3
(2M,
(3M,
(3M,
(4M,
(1M,
(3M,
(1M,
(2F)
(1M,
(1M)
5F)
4F)
3F)
2F)
4F)
2F)
3F)
1F)
*M ¼male and F ¼ female.
Table 3 – The complications experienced by the 10 patients out of the group of 70 who underwent surgery to bond
attachment for orthodontic traction of an impacted maxillary canine.
Complication
Number of patients
Percentage
Breakage of the ligature wire
De-bonding of the attachment
No movement of the tooth after traction
Attachment could not be bonded during surgery
4
3
2
1
5.7
4.3
2.9
1.4
(2M, 2F)
(3F)
(1M, 1F)
(1F)
*M ¼male and F ¼ female.
maxillary lateral incisors and while central incisors may also
be involved, rarely first premolars are affected. In the current
study too, maxillary lateral incisors were the most commonly
affected teeth followed by the maxillary central incisor there
by confirming previous studies [14,15]. Most studies had
focused on the resorption caused by palatally impacted
canines, although buccally impacted canines can also cause
resorption of incisors [15,16]. Knight in his study found that
33% of the canines associated with root resorption were
buccally placed [16]. While the present study supports his
finding; the occurrence was much higher with 50% of the
patients with buccally impacted canines exhibiting root
resorption. Also, a further 31.8% of the patients with root
resorption had their canines palatally impacted. Many studies have found resorption of an incisor to be more common
in females. These studies have quoted the female:male ratio
variously as 2:1, 4:1 and 10:1 [14,15,17]. Our study is in
agreement with the lower ratio of 2:1.
The reported frequency of resorption varies widely from
1% to 12% and may in part depend upon the imaging
technique used [7,15,18]. Superimposition of the incisor roots
and the crown of an impacted canine on intra-oral radiographs are said to obscure the root morphology in 45% of
cases [19]. Computed tomography (CT) overcomes this problem as it provides detailed images of the location of an
impacted canine and root resorption [20]. The use of CT
by Ericson and Kurol indicated that 48% of patients with
impacted canines exhibited root resorption of adjacent
teeth [21]. While in the present study, the frequency of
root resorption was found to be much lower (4.1%); it was
in agreement with the findings of Olow-Nordenram and
Anneroth [22]. All available radiographs were used to determine the status of the roots of adjacent teeth to achieve as
accurate a figure as possible. As the study was in part
dependent upon the availability of suitable radiographs,
which had been taken solely for clinical purposes and so CT
images were available for only a few cases. Thus, the reported
frequency of root resorption in this study should be considered to be an under estimation.
The most frequently reported complication associated
with the occurrence of impacted maxillary canines, prior to
surgery, was pain associated with the impacted tooth. Due to
the retrospective nature of the study, it was difficult to
determine the exact cause of the pain. However, it was noted
that six of the patients who complained of pain had cystic
changes associated with the impacted tooth. Further, the
remaining two patients had a retained carious primary
canine and it can only be hypothesized that the carious
primary canine may be the cause of pain. Cystic changes
with impacted maxillary canines have been reported previously [9]. In a four-year-period retrospective study of 12,129
Turkish patients aged 14–80 years, 970 had impacted maxillary canines. Fifty-five (5.7%) of the patients with impacted
maxillary canines demonstrated cystic changes associated
with the impacted tooth [9]. In the preset study, six patients
reported with cystic changes associated with their impacted
canines. Radiographically, the cysts in all the cases showed a
well-defined radiolucency surrounding the crown of the
unerupted canine making this finding consistent with the
diagnosis of a dentigerous cyst [9,23]. Two patients reportedly
complained of swelling in relation to the unerupted canine.
However, from the clinical records it was derived that both
56
Singapore Dental Journal 35 (2014) 53–57
the patients had mistaken the bony canine eminence for the
swelling in relation to the tooth. The location of the canine
requires extra-anchorage which is furnished by the length
and shape of their roots and by the bony projection or canine
eminence.
The most commonly occurring post-operative sequela was
found to be swelling of the soft tissue which was persistent
even after 48 h (18.8%). In post-surgical wound healing,
swelling is one of the key factors alerting patients to seek
professional care out of concern for diminished healing
[24,25]. Post-operative swelling results from accumulation of
protein rich exudates within the surrounding tissue. This
reaction may be a consequence of the formation of prostaglandins and other mediators of inflammation derived from
membrane phospholipids which are released during surgery
[25,26]. Whilst post-operative swelling associated with surgical removal of an impacted tooth is dependent on a number
of factors including age, operation time and type of impaction; most swellings subside considerably within 48 h [27,28].
One prospective study, reported that approximately 3% of the
patients who were treated using the closed eruption technique
reported severe pain on the third day after surgery and none in
the subsequent days, whilst severe pain was reported in patients
who had been treated using the open-eruption technique up to
the seventh day after surgery [29]. The closed eruption technique
is most often employed when the tooth is in a position that does
not permit the repositioning of the flap after crown exposure.
This technique is frequently used for palatal impactions that are
not close to the ridge of the alveolar process. In addition, when a
canine is impacted high on the buccal aspect of the maxilla, this
technique provides exposure without compromising the periodontal status [30]. However, if the permanent canine has the
correct inclination, the open surgical exposure is the treatment
of choice. In this technique the tooth is identified, uncovered and
left exposed to the oral cavity to allow the canine to erupt
naturally [31]. Excision of the gingival over the canine with bone
removal is sufficient to allow eruption of the canine. The
orthodontic attachment may or may not be placed at the time
of the surgery.
All surgical procedures produce secondary effects and complications; the intensity of which depends upon a number of
factors including the degree of tissue damage [6]. As with any
surgical procedure, patients often experience some degree of
pain; moreover it has been suggested that there is slightly more
post-operative pain from surgery on impacted maxillary canines
than for the surgery related to other impacted teeth [8]. However,
a significantly lower incidence of pain (1.5%) was reported by
the patients in this study 48 h after the surgery. The overall
lower recovery time could have been influenced by the surgical
techniques employed and the almost routine use of antibiotics and suitable analgesics. Future investigations to evaluate
the efficacy of pre-operative medication, surgical techniques
employed, post-operative analgesics and antibiotics and other
variables need to be conducted to determine the exact role of
surgical trauma in causing post-operative complications.
Uneventful healing of a post-extraction alveolus occurs in
most cases following the surgical removal of an impacted tooth
[25]. However, occasionally healing is unsatisfactory and not
only limited to localized symptoms of pain and swelling but
also complications of healing such as alveolar osteitis, acutely
inflamed alveolus and acutely infected alveolus [25]. The clinical
evaluation of the post-extraction alveolus healing was based on
the following criteria: severe pain accompanied by a partially or
totally disintegrated blood clot, painful alveolus with profoundly
inflamed tissue or a painful alveolus with suppuration, erythema
and edema with or without systemic fever [25]. Further, unsatisfactory healing is often the result of interruption of the blood
supply to the soft tissue flap during surgery or post-operative
infection [8]. When a flap is thin it is easy to compromise the
blood supply and hence careful designing and handling of the
flap is important to avoid post-operative unsatisfactory healing.
In the present study, only 1.2% of the patients presented with
unsatisfactory healing after the surgical procedure. This figure is
very low when compared to results from other studies involving
impacted teeth [24,25]. A possible explanation for this discrepancy could be the absence of absolute and objective clinical
criteria to assess unsatisfactory healing and the varying methodology used in the different studies.
The position of an impacted canine in the arch influences the
potential sequelae and complications that may arise with the
occurrence and surgical management of the impacted tooth.
The location of the impacted canine in close proximity to the
roots of the neighboring teeth may cause damage to them [7].
Displacement of a root into the maxillary sinus, or nasal cavity
can occur during surgical removal [8]. Also, an oro-antral or
naso-antral fistula can follow surgical removal of an ectopic
maxillary canine [7]. However, these post-operative complications are uncommon. Likewise, when an impacted maxillary
canine is located near to the neurovascular bundle, paresthesia
may be sequelae of surgery [8]. If the maxillary canine is
impacted palatally, the nasopalatine nerve may be affected,
although it rarely presents a problem for the patient. Our study
is concomitant with these findings as the complications
associated with the occurrence and surgical management of
impacted maxillary canines were observed in very low numbers.
Brackets and lingual buttons were commonly used in patients
who required surgical exposure and bonding of an attachment
as a part of the comprehensive treatment plan. After the tooth
was surgically exposed the enamel was etched for 30 s and
then irrigated. Success is often directly related to the degree
of hemostasis. Once hemostasis was achieved, the primer was
placed on the tooth. The bonding agent was then placed on the
bracket and pressed firmly against the enamel surface of the
tooth followed by curing for 20–40 s. The ligature wire was then
attached to the arch wire if present or a tooth if not present.
The vector of force used to move the canine could be changed to
move the canine away from the incisor roots and then move it
vertically. It is advisable for the surgeon to provide photographic
or pictorial documentation to familiarize the orthodontist with
the relative position of the canine.
Undesirable complications during the course of orthodontic
traction to manage impacted canines include failure to erupt,
bond failure and ankylosis [2]. Also, it has been suggested that
the disadvantage of applying an attachment at the time of
surgical exposure is that it is technique sensitive and that the
use of a ligature wire to facilitate traction is unreliable [32].
However, in our study the bracket could not be bonded, at the
time of surgery, in only one (1.4%) case suggesting that the
complications associated with orthodontic traction to manage
impacted canines are minimal. Also, breakage of the ligature
Singapore Dental Journal 35 (2014) 53–57
wire subsequently occurred in only 4 (5.7%) of the 70 cases
treated by surgery. There was no movement of the impacted
canine in just two cases (2.9%) after traction was applied postoperatively. Subsequently, in one of the cases, repeat surgery led
to successful traction of the impacted canine. While, it could
not be definitely concluded that the failed traction occurred due
to ankylosis of the tooth, it is unlikely as the tooth was not
apparently ankylosed when investigated during the pre-surgical
procedures.
The results of this study suggest that exposure of impacted
canines followed by bonding of an attachment in the closed flap
technique, followed by orthodontic eruption produces a predictable successful outcome with minimal complications.
[11]
[12]
[13]
[14]
[15]
Conclusions
The frequency of root resorption of teeth adjacent to an
impacted maxillary canine was found to be low. Females were
found to exhibit root resorption of adjacent teeth twice more
often than males. Complications after surgical intervention
which occurred rarely were post-operative bleeding from the
surgical site, hematoma, post-operative pain, purulent discharge,
transient paresthesia, unsatisfactory healing, iatrogenic damage
to adjacent soft tissue, maxillary sinus perforation, sub-conjuctival hemorrhage and discoloration of adjacent teeth. Nevertheless, surgical exposure of an impacted maxillary canine and
bonding of an attachment to allow orthodontic traction is a
reliable treatment option with minimal complications.
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Singapore Dental Journal 35 (2014) 59–64
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Scientific article
Gingival crevicular fluid levels of Matrix
Metalloproteinase-1 (MMP-1) and Tissue Inhibitor of
Metalloproteinase-1 (TIMP-1) in periodontal health
and disease
Ravi P. Popatn, Neeta V. Bhavsar, Parita R. Popat
Govt. Dental College & Hospital, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
art i cle i nfo
ab st rac t
Background: Matrix Metalloproteinases (MMPs) are directly responsible for pathogenesis of
Keywords:
periodontal diseases and their activity is regulated by Tissue Inhibitor of Metalloprotei-
MMP-1
nases (TIMPs). This study was aimed to evaluate changes in gingival crevicular fluid (GCF)
TIMP-1
levels of MMP-1 and TIMP-1 in periodontal health and disease.
Periodontitis
Materials and method: Clinical parameters were recorded and GCF samples were collected
Periodontal disease
from 30 subjects with chronic generalised periodontitis and 20 periodontally healthy
subjects. Subjects with periodontitis underwent scaling and root planing (SRP). GCF
samples were collected and clinical parameters were recorded again after 1 month of
SRP. GCF levels of MMP-1 and TIMP-1 were detected by ELISA.
Results: GCF levels of MMP-1 were significantly increased in subjects with periodontitis at
baseline (P0) as compared to periodontally healthy subjects (C). GCF levels of MMP-1
reduced significantly in subjects with periodontitis after treatment (P1) as compared to P0.
GCF levels of TIMP-1 were significantly reduced in P0 as compared to C. GCF levels of TIMP1 increased significantly in P1 as compared to P0.
Conclusion: Substantial elevation in GCF levels of MMP-1 and reduction in TIMP-1 were
found in periodontitis as compared to healthy subjects. GCF levels of MMP-1 and TIMP-1
improved significantly after treatment.
& 2014 Published by Elsevier B.V.
Introduction
Periodontitis is a multifactorial infectious disease characterised by destruction of the bone and connective tissue
caused primarily by specific periodontopathic bacteria and
modified by interaction with host and environmental factor
n
[1]. The initial host response comprises an innate recognition
of microbial components – lipopolysaccharides (LPS) complex
by host cells and the subsequent production of inflammatory
mediators, such as; eicosanoids, reactive oxygen species,
Matrix Metalloproteinases (MMPs), chemokines and cytokines
which are directly responsible for periodontal destruction [2].
Correspondence to: “Vrundavan”, 30-Basera Park, Near Rani Tower, Kalawad Road, Rajkot 360005, Gujarat, India. Tel.: þ91 9824232272.
E-mail address: [email protected] (R. P. Popat).
http://dx.doi.org/10.1016/j.sdj.2014.07.003
0377-5291/& 2014 Published by Elsevier B.V.
60
Singapore Dental Journal 35 (2014) 59–64
MMPs are a zinc/calcium-dependent family of neutral proteases that are released from different cell types including
macrophages, leucocytes, fibroblasts and other resident cells
[3]. They are believed to participate in embryonic development,
arthritis, angiogenesis, morphogenesis, reproduction, tissue
resorption, tissue remodelling and tumour growth, invasion
and its metastasis through breakdown of extracellular matrix
(ECM) [4]. MMP-1, prototype interstitial collagenase is the first
vertebrate collagenase [5]. It is distributed widely in tissues and
expressed by fibroblasts, keratinocytes, endothelial cells, osteoblasts, chondrocytes, and monocytes/macrophages [6,7].
Activity of various MMPs is regulated at multiple levels
(transcriptional, post-transcriptional, and post-translational)
and also by endogenous inducible inhibitors, the Tissue
Inhibitors of Metalloproteinases (TIMPs) [3]. TIMPs, family of
proteins, appear to regulate matrix degradation both by
proteinase inhibition and by blockage of autocatalytic MMP
activation [8]. Among all the TIMPs, TIMP-1 inhibit collagenase more effectively. TIMP-1 is a 30-kDa glycoprotein that is
synthesised and secreted by most connective tissue cells as
well as by macrophages; it can be identified in most body
fluids [9].
Previously, increased expression of MMP-1 mRNA was
found in inflamed gingival tissue of subjects with chronic
periodontitis as compared to healthy controls in various
studies [7,10–13]. But, very few studies available demonstrating changes in gingival crevicular fluid (GCF) levels of MMP-1
and TIMP-1 in periodontal health and in periodontal disease.
Also, only few reports available showing association between
clinical parameters and GCF levels of MMP-1 and TIMP-1.
Therefore, the present study was aimed to evaluate changes
in gingival crevicular fluid (GCF) levels of MMP-1 and TIMP-1
in periodontal health and disease before and after periodontal treatment. Furthermore, we also correlated biochemical
parameters with clinical parameters.
Materials and method
Study population
30 subjects with chronic generalised periodontitis (13 male
and 17 female, mean age 37 yr) and 20 periodontally healthy
subjects (10 male and 10 female, mean age 34 yr) were
enrolled in this study from Department of Periodontology,
during August 2012 to November 2012. All selected subjects
were in good general health. Selected subjects had age range
of 21–55 yr.
The periodontal status of all included subjects were
assessed according to the classification of periodontal disease
by the American Academy of Periodontology [14]. Diagnosis of
subjects with chronic generalised periodontitis was based on
clinical and radiographic findings. Subjects with probing depth
(PD) Z4 mm and clinical attachment loss (CAL) Z2 mm in at
least 30% of sites and radiographic evidence of bone loss were
selected. While subjects who had clinically healthy gingiva, no
clinical attachment loss (CAL) and probing depth (PD) o3 mm
were categorised as periodontally healthy subjects.
The following exclusion criteria were used; (1) presence of
o20 permanent teeth, (2) individual with history of systemic
conditions such as heart disease, diabetes, Tuberculosis, etc., (3)
postmenopausal women and smokers, (4) any medication use
that could affect the manifestations of periodontal disease,
such as chronic antibiotic use, phenytoin, cyclosporine,
anti-inflammatory drugs, or calcium channel blockers, (5)
individual with periodontal abscess, necrotising ulcerative diseases, aggressive periodontitis, (6) those who have received any
type of periodontal treatment in past 6 months or subjects on
periodontal maintenance therapy.
Clinical examination
All selected subjects were fully informed about purpose of the
study and consent was obtained. Clinical evaluation was
based on the following indices: gingival index (GI) [15], plaque
index (PI) [16], probing depths (PD) and Clinical attachment
loss (CAL). Clinical parameters for each subject were recorded
by a single examiner with full mouth clinical examination,
excluding third molars. All clinical parameters were recorded
on 4 sites per tooth (mesiobuccal, buccal, distobuccal, palatal)
using calibrated UNC-15 Probe. Probing depth and CAL were
measured with a calibrated UNC-15 Probe, using free gingival
margin and cement-enamel junction as reference point.
Collection and storage of gingival crevicular fluid sample
Subjects were made to sit comfortably in an upright position
on the dental chair with proper illumination. The most
severely affected upper anterior sextant (maxillary incisors
and the canine teeth) was chosen for the study due to good
accessibility in that area. The test site was air dried, isolated
with cotton rolls and supragingival plaque was removed
without touching the marginal gingiva. Colour coded 1–5 μl
calibrated volumetric microcapillary pipettes were used for
collecting GCF samples. Samples were collected by placing
the tip of the pipette in to gingival crevice. The test sites
which did not express any volume of GCF and micropipette
contaminated with blood and saliva were excluded from the
study. Samples were immediately transferred to plastic vials
and stored at 70 1C till the time of the assay.
Periodontal treatment
After clinical examination and GCF collection, subject with
periodontitis underwent periodontal treatment at the same
appointment. Periodontal treatment included oral hygiene
instructions as well as scaling and root planning (SRP).
Scaling and root planing were performed using extremely
sharp sickles, Gracey curettes and ultrasonic instruments.
After 1 month of SRP, clinical parameters were recorded and
GCF samples were collected from same site of each subject
with periodontitis. During whole study period of a month
each subject with periodontitis were recalled at intervals of 1
week and plaque control measures were performed.
Enzyme Linked Immunoabsorbent Assay (ELISA)
GCF levels of MMP-1 and TIMP-1 were analysed using ELISA,
performed by using a commercial ELISA kit (RayBiosHuman
MMP-1 ELISA Kit and RayBiosHuman TIMP-1 ELISA Kit)
61
Singapore Dental Journal 35 (2014) 59–64
specific for human MMP-1 and human TIMP-1. GCF samples
were expelled from micropipettes with jet of air using blower
provided with pipette and by further washing with fixed
amount of diluent. The samples were diluted with the diluent
provided with ELISA kit in the ratio of 1:40 for MMP-1 and 1:100
for TIMP-1. All assay procedures were carried out according to
the manufacturer's instructions. After preparation, samples
and standards were incubated 2.5 h at room temperature in
precoated wells. Then the solution was discarded and each
well was washed 4 times. 100 μl prepared biotin antibody was
added and incubated 1 h at room temperature. Followed by
washing, 100 μl prepared HRP Streptavidin solution was added
and incubated 45 min at room temperature. After washing,
100 μl tetramethylbenzedine one-step substrate reagent was
added and incubated 30 min at room temperature and then
the reaction was stopped by adding 50 μl Stop Solution to each
well. Optical densities of standards and samples were obtained
by reading immediately at 450 nm wavelength. Standard curve
was plotted with standard concentration on the x-axis and
absorbance on the y-axis to determine levels of MMP-1 and
TIMP-1.
Statistical analysis
Data analysis was performed using the statistical package
SPSS 19 software. The clinical and biochemical parameters of
subjects with chronic periodontitis before periodontal treatment (P0) and after periodontal treatment (P1) were analysed
using Wilcoxon signed-rank test. Mann–Whitney U test was
used to determine significant difference among healthy controls (C) and subjects with periodontitis before treatment (P0)
and among healthy controls (C) and subjects with periodontitis after treatment (P1). Correlation (r) between clinical
and biochemical parameters among subjects with periodontitis were analysed with Pearson's correlation test. The P
value o0.05 was considered as statistically significant.
0.026). GCF levels of MMP-1 were significantly reduced in P1
(9.26715.9 ng/ml) as compared to P0 (P value 0.004). There
was no significant difference found in GCF levels of MMP-1
among C and P1 (P value 0.63) (Table 1, Fig. 1).
GCF levels of TIMP-1 were significantly lower among P0
(113.657137.11 ng/ml) as compared to C (351.46799.5 ng/ml)
(Po0.001). GCF levels of TIMP-1 were significantly raised in P1
(280.397162.15) as compared to P0 (Po0.001). There was no
significant difference found in GCF levels of TIMP-1 among C
and P1 (P value 0.087) (Table 1, Fig. 2).
The ratio of MMP-1 to TIMP-1 in GCF was significantly
higher in P0 (0.8871.47) than C (0.0870.26) (P value 0.021), but
it reduced significantly in P1 (0.1370.46) as compared to P0 (P
value 0.002) and there was no significant difference found in
ratio of MMP-1 to TIMP-1 among P1 and C (P value 0.671)
(Table 1, Fig. 3).
Clinical parameters
Gingival Index (GI) scores (Mean7SD) were significantly higher
among P0 (1.9470.08) as compared to C (0.6570.27) (Po0.001).
GI scores were significantly reduced in P1 (0.9570.24) as
compared to P0 (Po0.001). Statistically significant difference
was found between P1 and C (Po0.001) (Table 1).
Results
Biochemical parameters
GCF levels of MMP-1 were significantly higher among P0
(20.36723.55 ng/ml) as compared to C (7.29711.83) (P value
Fig. 1 – Comparison of GCF levels of MMP-1 among subjects
with chronic periodontitis at baseline (P0), at the 1 month
after treatment (P1) and healthy controls (C).
Table 1 – Comparison GCF levels of MMP-1, TIMP-1, MMP-1/TIMP-1 and clinical parameters in subjects with periodontitis
before treatment (P0), after treatment (P1) and healthy control (C). (Mean7Standard Deviation).
Periodontitis
baseline (P0)
MMP-1 (ng/ml)
TIMP-1 (ng/ml)
MMP-1/TIMP-1
Gingival Index (GI)
Plaque Index (PI)
Probing Depth (PD)
Clinical Attachment
Loss (CAL)
20.36723.55
113.657137.11
0.8871.47
1.9470.08
2.1270.2
4.2470.54
2.0370.69
Periodontitis 1 month after
treatment (P1)
9.26715.9
280.397162.15
0.1370.46
0.9570.24
1.0570.23
3.6670.47
1.6670.71
Control (C)
7.29711.83
351.46799.5
0.0870.26
0.6570.27
0.6970.3
1.5270.35
0
P value
P0–P1
P0–C
P1–C
0.004
o0.001
0.002
o0.001
o0.001
o0.001
o0.001
0.026
o0.001
0.021
o0.001
o0.001
o0.001
o0.001
0.63
0.087
0.671
o0.001
o0.001
o0.001
o0.001
62
Singapore Dental Journal 35 (2014) 59–64
Plaque Index (PI) scores (Mean7SD) were significantly higher
among P0 (2.1270.2) as compared to C (0.6970.3) (Po0.001). PI
scores were significantly reduced in P1 (1.0570.23) as compared
to P0 (Po0.001). Statistically significant difference was found
between P1 and C (Po0.001) (Table 1).
Probing Depth (PD) scores (Mean7SD) were significantly
higher among P0 (4.2470.54) as compared to C (1.5270.35)
(Po0.001). PD scores were significantly reduced in P1 (3.667
0.47) as compared to P0 (Po0.001). Statistically significant
difference was found between P1 and C (Po0.001) (Table 1).
Clinical Attachment Loss (CAL) scores (Mean7SD) were
significantly higher among P0 (2.0370.69) as compared to C
(070) (Po0.001). CAL scores were significantly reduced in P1
(1.6670.71) as compared to P0 (Po0.001). Statistically significant difference was found between P1 and C (Po0.001)
(Table 1).
Correlation among clinical and biochemical parameters
Statistically significant negative correlation was found
between GCF levels of MMP-1 and TIMP-1 (r 0.22, P 0.088).
GCF levels of MMP-1 had shown significant positive correlation with GI (r 0.28, P 0.028) and PI (r 0.28, P 0.031). GCF levels
of TIMP-1 had shown significantly negative correlation with
GI (r 0.62, Po0.001), PI (r 0.65, Po0.001), PD (r 0.47,
Po0.001) and CAL (r 0.36, P 0.005) (Table 2).
Discussion
Fig. 2 – Comparison of GCF levels of TIMP-1 among subjects
with chronic periodontitis at baseline (P0), at the 1 month
after treatment (P1) and healthy controls (C).
Fig. 3 – Comparison of ratio of GCF levels of MMP-1/TIMP-1
among subjects with chronic periodontitis at baseline (P0), at
the 1 month after treatment (P1) and healthy controls (C).
Periodontitis is an inflammatory disease of supporting structures of teeth resulting in destruction of alveolar bone and
connective tissue. Possible mechanism for the degradation of
collagen fibres and extracellular matrix in periodontitis is
independent and/or cooperative action of both human and
bacterial proteinases [17,18]. Periodontal destruction is most
likely caused by host cell derived MMPs [19]. It has been
suggested that MMP-1 may play an important role in the
initiation of collagen degradation in periodontal disease [7].
Previously, increased expression of MMP-1 mRNA was found
in inflamed gingival tissue of subjects with chronic periodontitis as compared to healthy controls in various studies
[7,10–13]. Tissue inhibitors of metalloproteinases bind to
Matrix Metalloproteinases and irreversibly inhibit their
enzyme activity. Altered TIMP expression is also known to
occur in many disease processes and affects the processing of
extracellular matrix [20]. Moreover, it was speculated that
TIMP-1 appears to be more effectively inhibit MMP-1 [9].
Hence, we investigated changes in GCF levels of MMP-1 and
TIMP-1 in subjects with periodontal health and disease.
Wide varieties of immunological method are used to
detect GCF levels of MMPs and TIMPs. In comparison to other
assay systems, ELISA tests have several advantages including
improved sensitivity (at least compared to zymography), ease
of use, moderately rapid throughput, the ability to quantify
enzyme levels and the flexibility to test for multiple MMPs
in single samples. Moreover, ELISAs may be more adaptable to use in office settings because of their simpler and
more robust instrumentation [21]. Therefore ELISA has been
Table 2 – Correlation among GCF levels of MMP-1, TIMP-1 and clinical parameters.
MMP-1
MMP-1
Correlation r
Significance P
TIMP-1
Correlation r
Significance P
1
0.22
0.088
TIMP-1
0.22
0.088
1
GI
PI
PD
CAL
0.28
0.028
0.28
0.031
0.1
0.427
0.08
0.534
0.62
o0.001
0.65
o0.001
0.47
o0.001
0.36
0.005
Singapore Dental Journal 35 (2014) 59–64
selected for detection of GCF levels of MMP-1 and TIMP-1 in
gingival crevicular fluid in present study.
In this study, we found that GCF levels of MMP-1 were
significantly elevated in subjects with periodontitis before
treatment (P0) as compared to healthy subjects (C), which is
in agreement with previous studies [22,23]. It is in contrast
with Birdt et al. [24], stated that there was no significant
difference in GCF levels of MMP-1 in diseased and healthy
sites. This variation in finding can be due to difference in
sample size as well as other difference in methodology of
both studies. We also found that GCF levels of MMP-1 were
significantly reduced in subjects with chronic periodontitis 1
month after scaling and root planning (P1) as compared to P0
and remained close to GCF levels MMP-1 of healthy subjects
(C). These findings are in accordance with Tuter et al. [23].
In present study, we found that GCF levels of TIMP-1 were
significantly reduced in P0 as compared to C which is in
accordance with previous findings by Bildt et al. [24]. GCF
levels of TIMP-1 were increased significantly in P1 as compared to P0. These findings are in accordance with Pozo et al.
[25] and Tuter et al. [26]. Furthermore, our findings are
consistent with Haerian et al. [27] who reported that the
GCF levels of TIMP increases at follow up examination at 6
weeks hygiene phase therapy.
In present study, we found the ratio of MMP-1/TIMP-1
significantly higher in subjects with periodontitis before
treatment and it decreased significantly after treatment.
Thus, it can be suggested that balance in GCF levels of
MMP-1 and TIMP-1 also play significant role in maintaining
healthy periodontal condition.
We also found that all the clinical parameters improved
significantly in periodontitis after SRP. Considerable evidences
support role of SRP as an essential and effective therapy for
reductions in inflammation and progression of periodontal
diseases. This reduction in inflammation inhibits up-regulated
MMPs expression in periodontitis, resulting in decreased
MMP-1 after SRP [28,29]. Several possible explanations for the
increased TIMP-1 levels after periodontal therapy: (1) a reduction in MMP-1, which would bind to free TIMP; however, the
regulation of TIMP-1 may not solely be dependent on the
MMP-1 [9], (2) the decreased levels of TIMP-1 in periodontally
diseased subjects may be due to the selective degradation of
TIMP-1 by neutrophil elastase or the inactivation of TIMP-1 by
neutrophils themselves following oxidant release [30,31], (3)
the increased levels of its TIMP-1 may reflect its involvement
in the healing process, (4) unidentified mechanisms for clearance of MMP-TIMP-1 complexes [27].
On comparison of biochemical and clinical parameters in
present study showed significantly negative correlation
among GCF levels of MMP-1 and TIMP-1 which is accordance
with Tuter et al. [23]. We also found significantly negative
correlation of GCF levels of TIMP-1 with all the clinical
parameters (GI, PI, PD, CAL) which are in accordance with;
Pozo et al. [25], found negative correlation among GCF levels
of TIMP-1 and probing depth and CAL and Tuter et al. [26],
found negative correlation between GCF levels of TIMP-1 and
gingival index, plaque index and probing depth.
While, significantly positive correlation of GCF levels of
MMP-1 was found with GI and PI, which is in contrast with
Tuter et al. [26] who did not find any significant correlation.
63
Furthermore, Villela et al. [32] reported a positive but rather
weak correlation between PD and GI and collagenase activity
while Gangbar et al. [33] failed to find any correlations between
collagenase activity and clinical parameters. Different methods
of GCF sampling and laboratory techniques as well as variations
in reporting the results may influence the variation found in
correlation between clinical and biochemical parameters in
various studies.
In present study, we used ELISA to determine GCF levels of
MMP-1 and TIMP-1, which measure total enzyme level (both
active and latent) in GCF rather than active enzyme level. It
can be possible that proportional amount of active enzyme
would be low after treatment. Thus, it is advisable in future to
perform study that can discriminate between active and
latent (inactive) form of enzymes. In the present study we
evaluated GCF levels of MMP-1 and TIMP-1 in periodontitis
before and after SRP but, longitudinal studies which determine prognostic values of GCF levels of MMP-1 and TIMP-1
will be required to carry out in future to further clarify the
role of MMP-1 and TIMP-1 in periodontal destruction. Understanding of expression patterns and levels of MMPs in
periodontal tissues and various oral fluids help for the future
development of functional and/or immunological MMP diagnostic tools to monitor the course of periodontitis as well as
the effects of various treatment modalities of periodontitis.
Conclusion
Within the limits of present study we concluded that a
substantial elevation in GCF levels of MMP-1 and reduction
in GCF levels of TIMP-1 were found in subjects with periodontitis as compared with healthy controls. GCF levels of
MMP-1 decreased and TIMP-1 increased after scaling and root
planing as compared with their level before treatment. This
indicate important role of MMP-1 and TIMP-1 in periodontal
destruction.
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Singapore Dental Journal 35 (2014) 65–70
Available online at www.sciencedirect.com
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Case report
Complete denture copy technique—A
practical application
Steven Sooa,n, Ansgar C. Chenga,b,c
a
Specialist Dental Group, Mount Elizabeth Hospital, Republic of Singapore
National University of Singapore, Republic of Singapore
c
University of Hong Kong, Hong Kong
b
art i cle i nfo
ab st rac t
Article history:
The copy denture technique is a misnomer for the clinical and laboratory procedures
Received 24 September 2013
involved in making complete dentures that replicate most of the features of the original
Received in revised form
prosthesis. The aim is to replicate the good features of an otherwise successful prosthesis
2 December 2013
that now requires replacement and to alter the poor features and so it is strictly speaking
Accepted 3 December 2013
not a copy. There are many purported advantages to this technique which include reduced
treatment time, increased patient acceptance especially for the elderly who may not adapt
Keywords:
so well to a new prosthesis, maintenance of tooth position and vertical dimension.
Copy denture
A typical case is presented illustrating the clinical stages involved with a discussion of
Replica technique
the merits of this technique.
& 2013 Published by Elsevier B.V.
Complete dentures
Introduction
The copy denture technique is not a single technique, but a
variety of techniques designed to replicate complete dentures
[1–3]. A range of techniques both clinical and laboratory exist
which vary in their ability to “copy” a prosthesis. If one thinks
of a denture as having three surfaces—occlusal, polished and
fit surface—then it becomes easier to decide which of these
one should copy or alter as the clinical situation requires.
Of course prior to constructing a new prosthesis, the clinician
should have a good indication for using this treatment modality
based on an accurate diagnosis of the problem and reason for
replacement. An exact copy of a denture may be indicated if the
patient is entirely satisfied with the prosthesis and there are no
errors of a technical variety that impact clinically.
For example, if the denture material has simply degraded
or has fractured and cannot be repaired satisfactorily then a
direct copy may be indicated. A patient may request a spare
set of dentures.
However, it is more common to see dentures in which one
or more surfaces can be improved by relining or replacing
worn teeth. The polished surface is probably the least often
cited requiring alteration and the one the patient will notice
the most if changed. An exception to this might be if speech
is not satisfactory changes are need to the palatal contour to
aid pronunciation of certain sounds. Therefore, by definition,
if the dentures are modified in any way it is not a “copy” and
hence the term “replica” might be more suitable.
Case study
Mr N was a 49 year old male who presented with a fractured
upper complete denture. His present dentures were made 3
n
Correspondence to: Specialist Dental Group, Mount Elizabeth Medical Centre, 3 Mount Elizabeth, #08-08, Singapore 228510,
Republic of Singapore. Tel.: þ65 6734 9393; fax: þ65 6733 6032.
E-mail address: [email protected] (S. Soo).
0377-5291/$ - see front matter & 2013 Published by Elsevier B.V.
http://dx.doi.org/10.1016/j.sdj.2013.12.001
66
Singapore Dental Journal 35 (2014) 65–70
years ago following the loss of all his teeth i.e. an immediate
denture. He was otherwise very happy with the appearance,
comfort and function and wanted a replacement set without
too many changes that others might notice.
Clinical findings
The upper and lower arches were U-shaped with well-formed
minimally resorbed ridges showing signs of scalloping where
the natural teeth were present. The ridges were firm and the
mucosa healthy (Figs. 1–3).
Fig. 3 – Lower arch.
Current dentures
The upper and lower dentures were stable, retentive and
well-supported. With both dentures in situ the appearance,
centre line and occlusal vertical dimension (OVD) were
acceptable (Fig. 4). The occlusal plane and incisal level were
satisfactory. There was a partial fracture in the midline of the
upper denture palatally (Fig. 8).
Examination of the static occlusion showed bilateral
simultaneous contacts in maximum intercuspation (MI)
which was coincident with retruded contact position (RCP).
Examination of the dynamic occlusion showed that in
protrusion there were only posterior contacts with no
Fig. 4 – Current dentures in ICP.
Fig. 1 – Edentulous ridges at approximate final vertical
opening.
Fig. 5 – Current dentures in protrusion.
anterior contact (Fig. 5). Lateral excursions were canine
guided and there were no non-working side (NWS) contacts
(Figs. 6 and 7).
Diagnosis
The following diagnoses were made:
Fig. 2 – Upper arch showing uneven resorption.
1. Fractured upper denture and stained lower denture (Figs. 8
and 9).
2. Poor occlusal scheme not ideal for removable complete
prostheses.
Singapore Dental Journal 35 (2014) 65–70
Fig. 6 – Current dentures in right lateral excursion.
67
Fig. 9 – Current lower denture showing staining from
smoking.
the occlusal surface. The appearance could be improved with
minor changes in the tooth arrangement and a better mould
using higher quality teeth. Interestingly the patient had no
complaints pertaining to the fit or occlusal surface, but from a
clinical and technical perspective improvements could be
made.
Treatment plan
The treatment plan is outlined below:
Fig. 7 – Current dentures in left lateral excursion.
1. Repair existing upper denture to be kept as a spare.
2. Construct new upper and lower dentures using copy
technique to replicate tooth position and polished surfaces, but allow for minor improvements to mould, shade
and arrangement.
3. Take wash impressions to improve accuracy of fit surface.
4. Ensure balanced occlusion and articulation at the same
OVD.
Treatment
Fig. 8 – Current upper denture showing fracture palatal
to upper centrals.
The treatment objective was to replicate the bucco-lingual
tooth position and maintain the OVD. After 3 years postextraction a degree of bone resorption was expected and
hence a new fitting surface was indicated. The occlusal
scheme was unsatisfactory and a balanced occlusion and
articulation was to be developed necessitating a change in
1. Make clear acrylic copies of existing dentures in laboratory
silicone (Figs. 10–12).
Heavy bodied silicone is rigid enough to be used without
additional support. However, if extra rigidity is required
then two large stock trays for each denture can be used to
contain and support the impression material.
2. Take wash impression, after reduction of any undercuts,
with ZnOE using open mouth technique (Figs. 13 and 14).
The acrylic copies are effectively used as close-fitting
special trays. They must have the undercuts removed
prior to the wash so that once poured in die-stone, the
denture can be removed without damage to the model.
A fluid wash impression material is used to ensure a thin
impression which will not significantly increase the OVD
and also capture the denture bearing area accurately.
Pressure relief holes in the palatal vault will aid escape
68
Singapore Dental Journal 35 (2014) 65–70
Fig. 13 – ZnOE wash in upper copy.
Fig. 10 – Acrylic copy of upper denture.
Fig. 14 – ZnOE wash in lower denture.
Fig. 11 – Acrylic copy of lower denture.
Fig. 12 – Acrylic copies in situ.
of material, reduce pressure build up and ensure a thin
impression.
An open mouth technique is clinically easier to perform
than a closed mouth technique the advantage of which it
is thought will minimise changes in the OVD. In practice it
is very difficult for the patient to occlude with precisely
the correct force to avoid changes in the vertical dimension. Border moulding is also easier with the open mouth
technique. If the OVD is recorded and checked at each
stage then as the occlusal surface is being changed, it is
easy to keep control of this dimension.
3. Take jaw registration at same visit as step 2. Maintain the
same OVD. Silicone jaw registration material to be used
(Fig. 15).
The acrylic copies serve a double purpose i.e. that of a
registration block as well as special tray. If the OVD has
increased then it will have to be reduced with an acrylic
bur and balanced occlusal contact developed. The choice
of jaw registration material is up to the clinician.
4. Facebow record and mounting on Kavo semi-adjustable
articulator.
The need to take a facebow record will necessitate that the
jaw registration material will allow separation of the
dentures. Silicone will allow this to be done cleanly and
easily.
5. Tooth-try in wax to verify tooth position and OVD (Figs. 16
and 17).
Tooth mould and shade information can be taken from
the existing dentures. However, the patient may wish to
take this opportunity to change the aesthetics. The buccolingual tooth position was replicated by removing and
replacing one tooth at a time. If bucco-lingual tooth
position is critical then a buccal putty index can aid
Singapore Dental Journal 35 (2014) 65–70
69
Fig. 18 – Finished dentures in situ.
Fig. 15 – Jaw registration with silicone material.
Fig. 19 – New dentures in protrusion.
Fig. 16 – Tooth try-in on articulator.
Fig. 17 – Tooth try-in in situ.
accurate tooth placement. In this case the contours of the
polished surfaces were not critical and were replicated by
hand carving the wax.
6. Finish in pink veined high impact acrylic and delivery of
dentures (Figs. 18–24).
Discussion
The technique presented above was appropriate and successful in this case. Its use depended upon a correct assessment of the problem that needed addressing. If not applied
correctly then it would be all too easy to perpetuate a
Fig. 20 – New dentures in right lateral excursion.
deteriorating denture situation. The technique has often been
used incorrectly when the clinician is unable to correctly
diagnose the denture fault with which the patient presents.
In these types of cases, copies can be made of the dentures
for trial modifications, such as extending borders, adding
post-dams, balancing occlusion and increasing or reducing
OVD. The patient's original dentures have not been altered in
any way and so nothing is lost. Once the patient is happy
with the modifications, then this is copied to make a
definitive denture.
There are several ways to make copies of dentures. Metal
denture flasks are probably the best option. Alginate is mixed
and loaded into one half and the denture is pressed into it so
that the alginate is level with the flange. Once set a second
70
Singapore Dental Journal 35 (2014) 65–70
Fig. 21 – Balancing contacts on the left in right lateral
excursion.
Fig. 22 – New dentures in left lateral excursion.
Fig. 24 – A satisfied patient.
If the patient is able to leave the dentures at the laboratory
for a period then reversible laboratory hydrocolloid can be
used. In the clinic, a heavy-bodied silicone putty is simplest
with or without support using metal stock trays.
Replicating immediate dentures preserves valuable information on tooth position and vertical dimension without
having to resort to biometric guidelines applied to the “blank
canvas” of edentulous ridges. There is some saving in clinical
time at the wash and jaw registration phase which are done
at the same time rather than as two separate stages. There
can also be time saved at the try-in stage if tooth position is
not significantly altered.
The term replicating technique is more accurate than copy
technique as there are few situations where an exact copy is
what is required. Applied appropriately, it is a useful addition
to the prosthodontists treatment choices.
Conclusion
A denture replication technique was used to make a new set
of complete dentures. Tooth position and vertical dimension
were copied and alterations to the fit surface, to account for
resorption and the occlusal surface, to provide balanced
occlusion and articulation, were made.
Correct application of this technique can reduce both
clinical and laboratory time, but depends on an accurate
diagnosis of the problem and an understanding of the
advantages and limitations of this method.
Fig. 23 – Balancing contacts on the right in left lateral
excursion.
mix of alginate is mixed and loaded into the other half of the
flask and the two halves closed. In order to avoid trapping air
into the mould, alginate is preloaded into deep depressions or
undercuts using a finger. Once set the flask is opened and the
denture retrieved. Holes are cut into the heels of the mould
for pouring cold cure acrylic resin.
r e f e r e n c e s
[1] R.M. Basker, J.C. Davenport, H.R. Tomlin, Prosthetic Treatment
of the Edentulous Patient, First edition, The Macmillan Press
Ltd., London and Basingstoke, 1981.
[2] J.A. Hobkirk, A Colour Atlas of Complete Dentures, Wolfe
Medical Publications Ltd., 1985.
[3] JA. Hobkirk, Complete Dentures, IOP Publishing Ltd., Bristol,
1986.
Singapore Dental Journal 35 (2014) 71–76
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Case report
Delayed replantation of avulsed tooth with 15-hours
extra-oral time: 3-year follow-up
D. Sardanan, A. Goyal, K. Gauba
Unit of Pedodontics and Preventive Dentistry Oral Health Sciences Center Post-graduate Institute of Medical Education
and Research, Chandigarh, India
art i cle i nfo
ab st rac t
Background: Avulsion is one of the most serious injuries of the tooth which is most
Keywords:
commonly seen in young children and occurs in the upper front teeth. Immediate
Avulsion
transplantation of the avulsed tooth is recommended treatment and results in good
Delayed replantation
prognosis although this may not be always possible.
Trauma
Case report: The present case highlights the 3-year follow-up of delayed replantation (after
Splint
15 h) of maxillary central incisor which was avulsed due to trauma. The complications
seen in the present case were ankylosis and inflammatory resorption, but clinically the
tooth was asymptomatic and maintains the esthetics of the individual signifying the
importance of delayed replantation even after prolonged extra-oral time.
Clinical implications and conclusion: Although complications like ankylosis or root resorption
may be unavoidable, delayed replantation of avulsed tooth may be a good alternative to
prosthesis (implant or fixed partial denture) till the growth is completed due to preservation of
the alveolar bone and psychological benefit to the patient. Also efforts should be made to
educate and update children, teachers and parents regarding management of avulsed tooth at
accident site and also the dentists regarding its management in dental office.
& 2014 Published by Elsevier B.V.
Introduction
Injury to the teeth and associated oro-facial structures is
quite disturbing to the child and his parents due to contribution of these structures in esthetics and its subsequent
psychological impact. Although all forms of injuries require
some immediate attention and management, tooth avulsion
(ex-articulation) is a special form of injury in which the
prognosis is associated with the duration between the time
the tooth is avulsed and when it is replanted [1,2]. Also this
n
Corresponding author.
E-mail address: [email protected] (D. Sardana).
http://dx.doi.org/10.1016/j.sdj.2014.04.001
0377-5291/& 2014 Published by Elsevier B.V.
form of injury is important because it most commonly
involves maxillary central incisors [3] which makes a major
esthetic contribution to the smile.
Although recommended, immediate transplantation of
the avulsed tooth is not always possible due to the patient‘s
concomitant injuries at the time of accident and lack of
knowledge in the management of such injuries at the site
of the accident [4]. The purpose of this case report is to report
the 3-year follow-up of avulsed 11 which was replanted in the
dental office after a period of 15 h.
72
Singapore Dental Journal 35 (2014) 71–76
Case report
A 12-year female child reported to the unit of Pediatric
Dentistry, Oral Health Sciences Center, PGIMER, Chandigarh
with a chief complaint of broken upper front tooth due to
trauma 15 hs back (Figs. 1 and 2). The trauma occurred while
the child was playing in the park and there was no history of
loss of consciousness or vomiting. The tooth was taken home
wherein the tooth was placed in cold milk after half an hour
of extra-oral dry time and taken to local dentist. The local
dentist referred the patient to our department for subsequent
treatment which was far away from the place and hence total
extra-oral time for the avulsed tooth was 15 h. On examination, there were no other signs of injury intra-orally and
extra-orally. Examination of the tooth socket did not reveal
any fracture of the bony wall or tooth segment. An intra-oral
periapical radiograph was taken to rule out any broken tooth
or bony segment in the socket (Fig. 3). In the dental office, the
root surface and the socket were washed with stream of
saline and all the debris was removed gently. The root surface
was also cleaned with soft pumice prophylaxis and subsequently kept in 2% sodium fluoride solution till the patient
was prepared for the procedure of replantation. The tooth
was placed in the socket under local anesthesia and splinting
was done from canine to canine using multiflex wire for one
month (Fig. 4). The occlusion of the patient was checked to
verify that there were no pre-mature contacts while biting to
avoid further injury to the adjacent periodontal tissues.
Esthetics was restored by maintaining the incisal edge of
the replanted tooth at same level as the adjacent tooth. A
radiograph was also taken to verify the position of reimplanted tooth in the socket (Fig. 5). Access opening was
Fig. 3 – Pre-treatment radiograph.
Fig. 4 – Acid-etch composite splint from canine-to-canine.
Fig. 1 – Pre-treatment photograph showing avulsed 11.
Fig. 5 – Radiograph post-splinting to verify position of reimplanted tooth.
Fig. 2 – Pre-treatment photograph showing avulsed 11.
prepared on the same day and pulp extirpated from the
canal. The canal was subsequently filled with calcium hydroxide and the chamber sealed with Glass ionomer cement
(GIC). The patient was kept on antibiotics (Doxycycline
100 mg twice daily and Ibuprufen 400 mg thrice daily for 7
Singapore Dental Journal 35 (2014) 71–76
73
Fig. 6 – 1-year follow-up radiograph.
Fig. 8 – 3-year follow-up radiograph.
Fig. 9 – Post-treatment photograph.
Fig. 7 – 2-year follow-up radiograph.
Fig. 10 – Post-treatment photograph.
days). The splint was removed after 4 weeks and intra-canal
medicament was changed. The patient was recalled after 1
month and root canal treatment was completed. The patient
was kept on routine follow-ups every 6 months. No resorption was evident radiographically at 1 year follow-up (Fig. 6);
however initial root resorption was evident at 2-year follow
up (Fig. 7) and resorption of the apical third was evident at 3
year-follow-up (Fig. 8). Clinically, the patient has been
asymptomatic with no mobility since the splint was removed
(Figs. 9 and 10). After 6 months of follow-up, the tooth showed
metallic sound on percussion suggestive of ankylosis. The
patient will be monitored till her growth is complete and
appropriate treatment will be carried out if needed.
74
Singapore Dental Journal 35 (2014) 71–76
Discussion
Tooth avulsion is a serious injury resulting in complete
displacement of the tooth outside the socket and consequently damaging its supporting apparatus (i.e. periodontal
ligament and bone). Tooth avulsion is more prevalent in
males (male: female ¼ 3: 1) and age group of 7–14 years is
most commonly affected [3]. In the present case milk was
used as interim transport media for 15 h. Milk is a reasonably good storage media because of its osmolarity and pH
and therefore has been shown to preserve PDL cells for up to
8 h [5,6]. However, in the present case the tooth was stored
in milk for long time i.e. 15 h; hence it was supposed that
the periodontal ligament cells were dead and the condition
was categorized into category 4 [7]. Removal of dead periodontal ligament cells is one of the most important actions
which need to be taken to slow down the osseous replacement of the root surface [8,9]. To achieve this, the root
surface was cleaned with soft pumice prophylaxis to
remove remaining non-viable periodontal ligament cells
which may act as source of infection and subsequently
accelerates infection related resorption [7]. Some authors
have even suggested periodontal curettes and scalers for
removal of these necrotic periodontal ligament cells; however, excessive scraping of cementum may further accelerate the resorptive process instead of decreasing it. Thus,
to maintain a balance of avoiding excessive scraping of
cemental layer and at the same time completely remove
necrotic periodontal ligament cells, we used soft pumice
prophylaxis. The tooth was then immersed in 2% sodium
fluoride solution for 20 min till the armamentarium and the
patient was prepared for the procedure to minimize loss of
precious time. The rationale for this fluoride soak is based
on evidence that this procedure will delay but not prevent
ankylosis [10]. The pre-treatment of root surface with
sodium fluoride has been hypothesized since 1968 due to
its beneficial effect by decreasing the rate of osseous
replacement in replanted teeth of monkeys [11]. A similar
study in humans also demonstrated 50% reduction in
progression of root surface resorption after replantation
[12]. Stannous fluoride is an alternative that has also been
used for treatment of root surfaces before replantation;
however, its use was associated with long-standing inflammatory reaction in periodontal ligament [13]. Due to this
sodium fluoride solution has remained as the only useful
and tested method for root-pre-treatment before replantation [12].
Tooth was placed in the socket and semi-rigid splinting
was done for 4 weeks using acid-etch composite resin and
multi-flex wire from canine-to-canine. A flexible type of
splint (or semi-rigid splint) is the preferred type of splint in
avulsion injuries because rigid splints have been shown to
accelerate root resorption in both mature and immature teeth
[14–16]. Although various types of semi-rigid splints have
been suggested, this particular splint was used based on the
immediate availability in the department. Also acid etch
bonded splint allows maintenance of oral hygiene and is
easily tolerated by the patient [17]. Systemic antibiotics in the
form of Doxycycline (in a standard dose of 100 mg twice daily)
was prescribed as this has been shown to lessen the resorptive attack on the root surface; although pulpal healing
remains unaffected [18]. Also, the patient in present case
was of 12 years of age and hence, chance of tetracycline
discolouration was minimal. If the patient would have been
younger than 12 years, penicillin would have been the drug of
choice because its antibacterial effect is similar to tetracycline;
however; penicillin has the disadvantage that it lacks the
anti-resorptive present in tetracycline [18,19].
Endodontic access was prepared in the same visit and
pulp debrided. Thereafter, the root canal was filled with
calcium hydroxide because it is anti-bacterial [20,21] and
microbes are considered an etiology behind root resorption
and hence may cause rapid loss of tooth [22]. Calcium
hydroxide changes the environment to a more alkaline pH,
which may slow the action of the resorptive cells and
promote hard tissue formation [23,24]. However, the changing of the calcium hydroxide should be kept to a minimum
(not more than every 3 months) because it has a necrotizing
effect on the cells that are attempting to repopulate the
damaged root surface [25]. The calcium hydroxide was
placed in the canal for a total of 2 months in the present
case and endodontic treatment completed just after
removal of calcium hydroxide. GIC was used as an intermediate restorative material in the present case because of
its longer durability and excellent seal [26]. Jensen et al.
(2007) [27] have recommended Glass ionomer with a different color as a preferable material to be used as interim
restorative material except when there are esthetic considerations (as in the present case) where-in tooth colored
GIC should be used. The patient was recalled at 3 months, 6
months, 1 year, 2 year, 3 year after trauma and is still on
yearly follow up.
The complications associated in the present case were
inflammatory root resorption and ankylosis (replacement
resorption) and it is expected that the tooth will be lost
eventually by gradual resorption of the root surface followed
by replacement with the bone. Radiographically, ankylosis is
characterized by absent periodontal ligament space and
continuous replacement of root substance with the bone
until little or no tooth substance remains. In contrast,
inflammatory resorption is characterized by radiolucent bowl
shaped cavitations along the root surface with corresponding
excavations in the adjacent bone, often beginning in the
cervical third of the root. However, both ankylosis and
inflammatory root resorption are similar that they both are
usually evident within the first two years after replantation.
Clinically, the ankylosed tooth is immobile and infraoccluded
whereas the tooth with inflammatory root resorption appears
loose and extruded. The percussion tone is often diagnostic
in cases of ankylosis which is high compared to a dull tone in
teeth with inflammatory root resorption. It should be noted
however that in teeth with inflammatory resorption; replacement resorption takes over the resorbed area by filling the
defect with bone once the inflammatory resorption process
decelerates [28]. Although occurrence of ankylosis can be
delayed to some extent by treatment of the root surface;
inflammatory root resorption is a factor not under the control
of a dentist and seen in 26% of replanted teeth [29]. An
ankylosed tooth is often a desirable outcome as a transitional
Singapore Dental Journal 35 (2014) 71–76
condition for a growing child or adolescent [30]. An avulsed
tooth that is maintained until growth is completed should be
considered a successful outcome because tooth loss before
this time often includes loss of the alveolar bone as well as
further resorption of the bone in the site. This later circumstance greatly compromises options for the missing tooth or
teeth and may involve extensive and costly procedures, such
as bone augmentation and grafting [7]. Preserving the root
preserves the alveolar bone and is advantageous for implant
replacement when the child has completed growth. Hence;
after the growth is completed other treatment options will be
considered for the present case like dental implants or fixed
partial dentures.
Another factor which should be highlighted in the present
case is to understand the basic reason for delay in seeking
treatment in the present case. If the tooth could have been
re-implanted immediately by the patient/parents and
immediate treatment provided by the private practitioner,
the prognosis could have been much better in terms that the
resorptive process and its signs could have been delayed or in
best circumstances (as in case of immediate replantation) completely prevented. If signs of root resorption are not present
within the first two years of injury, the risk of root resorption
is significantly reduced, but can still occur [28]. In the present
case, resorptive signs appeared radiographically after 2 years
of replantation considering that the extra-oral time was 15 h.
According to us, the present case can be considered a clinical
success because the patient was already 15 years of age at 3year follow-up and the tooth may be preserved for few more
years till the patient completes her growth and further
treatment of implants is carried out without doing any bone
grafting.
To conclude, it is important that all dentists, teachers of
primary schools, physical education teachers and primary
healthcare personnel, including nurses, be educated about
the importance of preserving an avulsed tooth, its method of
preservation and the rationale for replantation and update
them the recent guidelines on management of such teeth.
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[6] L. Blomlof, S. Lindskog, L. Andersson, K.G. Hedstrom,
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[10] K.A. Selvig, H.A. Zander, Chemical analysis and
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[11] L.B. Shulman, P. Kalis, P. Goldhaber, Fluoride inhibition of
tooth-replant root resorption in cebus monkeys, J. Oral Ther.
Pharmacol. 4 (1998) 331–337.
[12] C.T. Coccia, A clinical inverstigation of root resorption rate in
replanted young permanent incisors: a five year study, J.
Endod. 6 (1980) 413–420.
[13] K. Bjorvatn, K.A. Selvig, B. Klinge, Effect of tetracycline and
SnF2 on root resorption in replanted incisors in dogs, Scand.
J. Dent. Res. 97 (1989) 477–482.
[14] L. Kristerson, J.O. Andreasen, The effect of splinting upon
periodontal and pulpal healing after autotransplantation of
mature and immature permanent incisors in monkeys, Int. J.
Oral Surg. 12 (1983) 239–249.
[15] J.O. Andreasen, The effect of splinting upon periodontal
healing after replantation of permanent incisors in monkeys,
Acta Odontol. Scand. 33 (1975) 313–323.
[16] R.S. Morley, R. Malloy, R.V.V. Hurst, R. James, Analysis of
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Dent. Res. 57 (1978) (IADR Abstract no.53).
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[19] V. Sae-Lim, C.Y. Wang, M. Trope, Effect of systemic
tetracycline and amoxicillin on inflammatory root resorption
of replanted dogs‘ teeth, Endod. Dent. Traumatol. 14 (1998)
216–220.
[20] A. Bystrom, R. Claesson, G. Sundqvist, The antibacterial
effect of camphorated paramonochlorphenol, camphorated
phenol and calcium hydroxide in the treatment of infected
root canals, Endod. Dent. Traumatol. 1 (1985) 170–177.
[21] U. Sjogren, D. Figdor, L. Spangberg, G. Sundqvist, The
antimicrobial effect of calcium hydroxide as a short term
intracanal dressing, Int. Endod. J. 24 (1991) 119–125.
[22] L. Tronstad, Root resorption etiology, terminology and
clinical manifestations, Endod. Dent. Traumatol (1988)
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[23] L. Tronstad, J.O. Andreasen, G. Hasselgren, L. Kristerson, I.
Riis, pH changes in dental tissues following root canal filling
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[24] F.B. Teixeira, L.G. Levin, M. Trope, Investigation of pH at
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Oral Radiol. Endod. 4 (2005) 511–516.
[25] A. Lengheden, L. Blomlof, S. Lindskog, Effect of delayed
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Singapore Dental Journal 35 (2014) 77–82
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Case report
Patient induced unusual metallic obturation of the
root canal of permanent maxillary central incisor
with an immature apex – A rare case report
Manoj Mahadeo Ramugaden, Kishor Dattatray Sapkale1,
Sachin Shashikant Metkari2
Department of Conservative Dentistry and Endodontics, Nair Hospital Dental College, Mumbai Central, Mumbai-08, India
art i cle i nfo
ab st rac t
Discovery of multiple foreign objects in the root canal is unusual and their removal is often
Keywords:
difficult and challenging procedure. Entrapment of the foreign object in the pulp chamber
Foreign objects
or in root canal usually occur accidentally in children with the habit of chewing or placing
Sewing needles
various objects in the oral cavity. Clinically it was often encountered in tooth with wide
Immature apex
carious lesion, exposed pulp chamber due to trauma or tooth left open for the drainage
Non-surgical endodontic treatment
during root canal treatment. This impacted foreign body may act as a potential source of
pain or infection. The attempt to retrieve such foreign object from the root canal with
immature apex increases the risk of its displacement into periapical area. The present case
report describes an unusual case of a patient with two metallic sewing needles inadvertently broken down in the root canal of the permanent maxillary left central incisor and it's
successful retrieval by non-surgical endodontic treatment.
& 2014 Published by Elsevier B.V.
Introduction
Discovery of a foreign object in the root canal is an uncommon
finding and often revealed accidentally during routine radiographic examination. Entrapment of such foreign object in the
pulp chamber or in root canal is usually encountered in children
with the tendency of chewing or placing different objects in the
oral cavity. Ingestion or aspiration of the foreign object could be
frightening and stressful situation [1]. In most cases parents are
unaware of the bizarre situation as children are scared to inform
n
them. The impacted foreign object may act as potential source of
infection resulting in pain or swelling.
Various foreign objects lodged in the pulp chamber and
root canal of the tooth have been reported in the literature
such as, stapler pin [2,3], pencil leads [4], darning needles [5],
metal screws [6], beads [7], nail [8], plastic chop stick [9], hat
pins [10], dressing pins [11], ornament piece [12] and a conical
metallic object [13].
The present case report describes a patient with two sewing
needles entrapped in the root canal of permanent maxillary left
Corresponding author. Tel.: þ91 9869159131, þ91 9664541227.
E-mail addresses:
[email protected], [email protected] (M.M. Ramugade), [email protected] (K.D. Sapkale),
[email protected] (S.S. Metkari).
1
Tel.: þ91 8149797060.
2
Tel.: þ91 9167699805.
http://dx.doi.org/10.1016/j.sdj.2014.08.001
0377-5291/& 2014 Published by Elsevier B.V.
78
Singapore Dental Journal 35 (2014) 77–82
central incisor with an immature apex and its successful conservative management.
Case report
A healthy 13-year-old male patient reported with his father to
the Department of Conservative Dentistry and Endodontics,
with a complaint of pain and pus discharge from upper front
tooth region since last four days.
Patient's history and intra-oral examination exhibited
following findings:
History of trauma to maxillary anterior teeth; 5 years ago.
Fractured tooth 21 (Federation Dentaire Internationale) up
to the middle third with discoloured crown (Fig. 1).
Tooth 21 showed a small incisal opening into the pulp
chamber (Fig. 2).
Presence of draining sinus on the gingiva near the apex of
tooth 21.
Pain on percussion associated with tooth 21.
Electric pulp test (EPT) showed no response in tooth no. 21
and a normal response exhibited in teeth nos. 11, 12 and 22.
Intra-oral periapical radiograph of tooth 11 and 21 revealed,
the presence of two slender, pointed radiopaque images with
radiolucent eyes; appearing one above the other, in the
middle and apical thirds of the root canal of tooth 21. Tooth
21 also showed an immature apex and periapical radiolu-
cency (Fig. 3). Widening of periodontal ligament was evident
in tooth 11.
After taking the patient and his parent into confidence a
careful enquiry of patient regarding the presence of the
foreign objects in the tooth 21 was done. It was revealed
that, the patient frequently used sewing needle as a toothpick
to clean the lodged food from pulp chamber of tooth 21.
Three months back during one of such attempts, one sewing
needle was inadvertently broken down in the root canal of
tooth 21. Subsequently patient tried to remove that needle
from the root canal with the help of another sewing needle.
Unfortunately, the second needle also broke over the first
embedded needle. After this incidence the patient did not
inform his parents about the broken needles inside the tooth,
due to fear of getting reprimanded. On further questioning,
patient revealed that he used to get sewing needles from his
uncle who was a professional tailor. After evaluating the
clinical and radiographic evidences; the following treatment
plan was advised and informed consent of patient's parent
was obtained.
(1) To retrieve both foreign objects by a simple non-surgical
technique.
(2) Endodontic treatment of tooth 21 followed by aesthetic
restoration.
Treatment sequence
(1) Removal of coronal sewing needle:
The tooth 21 was isolated under rubber dam and access
cavity was prepared under 3.5 magnifying loupes. The
debris from pulp chamber was cleaned by copious irrigation
with physiologic saline. To prevent the rusting of the
Fig. 1 – Pre-operative photograph – labial view – tooth 21.
Fig. 2 – Pre-operative photograph – palatal view – tooth 21.
Fig. 3 – Pre-operative intra-oral periapical radiograph
showing two foreign objects in root canal of tooth 21
resembling the heads of sewing needles.
Singapore Dental Journal 35 (2014) 77–82
metallic objects in root canal and its accidental escape into
periapical tissues through an open apex; irrigation with
5.2% sodium hypochlorite was initially avoided. Exploration
of the root canal was done with No.10 Kerr-file (K-file, Mani
Inc., Japan) to feel any resistance in the root canal. Though
the root canal was wide; the foreign object offered a
resistance for its easy retrieval. Firstly instrumentation with
No. 10 K-file was done to bypass the coronal object from the
mesial and then from the distal aspect of root canal
wall. Later, the root canal was sequentially bypassed with
No. 15, No. 20 and No. 25 K-files. Subsequently two, No. 25
Headstrom-files (H-file), one from mesial and other from
distal aspect of the root canal were inserted. Files were
twisted together to engage the coronal object and pulled
incisally using braiding technique. After such multiple
attempts, the coronal object moved incisally in pulp chamber. It was retrieved successfully with the tweezer and
79
examined carefully (Fig. 4). The object was identified as a
sewing needle measured about 7 mm in length and 1.5 mm
width. Radiograph of tooth 21 was taken to visualise and
ensure the position of the impacted apical object (Fig. 5).
(2) Removal of apical sewing needle:
Similarly, exploration of apical portion of root canal of tooth
21 was done using No.10 K-file but the apical object offered
more resistance for its retrieval than coronal object. Similar
steps were followed for retrieval of the apical object. The
apical object was bypassed with No. 25 K file from the mesial
aspect. Subsequently No. 25 H-file was inserted from the
mesial aspect and engaged apically to prevent the slippage of
the object into the periapical area. An activated ultrasonic
scaler tip was put in contact with the metallic blank of No. 25
H-file to facilitate the loosening of an object. Within few
minutes the apical object felt slightly loosened and was
retrieved successfully in similar manner as for coronal
needle. An apical object was also found to be a sewing
needle (Fig. 6). Confirmatory radiograph was taken to ensure
Fig. 4 – Intra-oral photograph of retrieved coronal needle in
the access cavity – tooth 21.
Fig. 6 – Photograph showing two retrieved sewing needles
each measured 7 mm in length.
Fig. 5 – Intra-oral periapical radiograph after retrieval of
coronal sewing needle from root canal – tooth 21.
Fig. 7 – Intra-oral periapical radiograph after retrieval of both
sewing needles from the root canal – tooth 21.
80
Singapore Dental Journal 35 (2014) 77–82
the retrieval of both the sewing needles from the root canal
of tooth 21 (Fig. 7). Following the retrieval of both the needles,
working length was established (Fig. 8). Cleaning and shaping
of the root canal was accomplished by conventional
technique. Final irrigation of the root canal with 5.25% of
sodium hypochlorite using Endo-activator (Dentsply, Tulsa
Dental) was performed. Calcium hydroxide was placed as
intracanal medicament in tooth 21 and the radiograph was
taken (Fig. 9). Intracanal calcium hydroxide was replaced in
tooth 21 after 1month recall. At this time EPT in teeth 11, 12
and 22 showed normal response compared to control teeth.
Patient was recalled for regular follow-up of 3 months.
Periapical radiograph of tooth 21, revealed the presence of
unresorbed calcium hydroxide in the periapex of tooth 21
(Fig. 10). After 6 months follow-up, the periapical radiograph
of tooth 21 exhibited the complete resorption of periapical
calcium hydroxide with calcific apical barrier formation.
At this time root canal obturation using rolled cone method
was planned. To prepare a customised master cone, three No.
80 standardized gutta percha (GP) cones were brought
together and passed over an alcohol flame. Immediately
cones were rolled together on a glass slab with the help of
another cooled glass slab. The customised GP cone was
softened over a flame and then tried as a master cone in
the root canal of tooth 21. The procedure was repeated for
several times till apical tug back was achieved. The root canal
was obturated using the prepared customised GP cone [14]
(Fig. 11). After 1 year follow up, EPT of teeth 11, 12 and 22
showed normal response as the control teeth and resolving
periapical lesion was observed in the radiograph of tooth 21
(Fig. 12). Patient was scheduled for the post endodontic
restoration and an aesthetic crown with tooth 21 but unfortunately, the patient failed to report for the further follow ups
as he had been shifted to reside to his native place.
Discussion
Fig. 8 – Working length radiograph – tooth 21.
Fig. 9 – Immediate intra-oral periapical radiograph after
intracanal calcium hydroxide cement placement in tooth 21.
Patient reporting with the presence of foreign object in the
tooth is a rare scenario in dental office. Everytime the dental
office may not be prepared to tackle such situation which
demands combination of skills, immediate investigations, various radiographs and necessary instruments. Retrieval of the
foreign object may be done by conservative means or need
surgical intervention depending on position of the foreign
object in the root canal and associated complexity in its
retrieval. There is a need for proper classification of foreign
Fig. 10 – Intra-oral periapical radiograph after 3 months
follow up – tooth 21.
Singapore Dental Journal 35 (2014) 77–82
Fig. 11 – Post obturation intra-oral periapical radiograph
after 6 months follow up – tooth 21.
81
in determining its type, location and size [15]. For retrieval of
the foreign object from root canal; use of ultrasonic instruments [16], Masserann kit [17], modified Castroveijo needle
holder [18] and the dental microscope [19] are reported in
literature.
Removal of one foreign object from the root canal is often
tedious. However, in the present case it becomes difficult and
more risky procedure; when two foreign objects present one
above the other and snugly fit in the root canal of tooth with
an immature apex. These foreign objects block the root canal
and prevent its complete negotiation. Thus, their removal
becomes necessary to eradicate the infection and for successful endodontic treatment of affected tooth. To remove such
objects, they should be made free from hindrance and at the
same time reasonable care should be taken to prevent its
displacement into periapical area. In present case, two
impacted sewing needles were retrieved with H-files and
indirect ultrasonics causing minimal damage to subjacent
root dentin [19] avoiding the need of periapical surgery or
intentional reimplantation [20].
After retrieval of the foreign object from the tooth with an
open apex, closure of the apex is of paramount consideration.
Traditionally apexification was performed using intracanal
calcium hydroxide due to its long term antimicrobial
effect [21], predictable induction of apical closure and its
low cost. Caution should be taken for long term use of
intracanal calcium hydroxide; as it would significantly
increase the risk of root fracture after long term application
[22,23]. However, with the advent of Mineral Trioxide Aggregate (MTA), apical barrier is achieved in one visit. The
advantages of MTA are reported as, less crucial patient
compliance, no alteration in physical properties of dentin
and earlier restoration of the tooth [24]. Though MTA is
biocompatible material and the procedure is time saving; its
cost is the major factor of consideration for its routine clinical
use in tertiary dental care centres in developing countries.
Summary
Fig. 12 – Intra-oral periapical radiograph after 1 year followup showing healing of periapical pathology – tooth 21.
objects found in teeth and oral cavity with an appropriate
treatment protocol to be followed in such special situations.
A tooth with wide carious lesion, traumatic pulp exposure
or tooth left open for the drainage; endangers the patient to a
risk of foreign body entrapment in the root canal. Thus in
case where access cavity is left open for the drainage, the
patient and their parents should be instructed about the
potential risk of foreign object impaction in the pulp chamber
or the root canal of involved tooth. The practitioner should
close the access cavity as soon as the purpose of drainage is
accomplished.
Various radiographic techniques such as parallax views,
triangulation techniques, stereo radiography and tomography [2] play a pivotal role in localisation of the foreign object,
The case report describes conservative management of the
patient having a complicated crown fracture; along with
accidentally impacted sewing needles in the root canal of
tooth 21, with an immature apex and periapical pathology.
r e f e r e nc e s
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[2] N. Macauliffc, N.A. Drage, B. Hunter, Staple diet: a foreign
body in a tooth, Int. J. Paediatr. Dent. 15 (2005) 468–471.
[3] K. Chand, S. Joseph, J.M. Varughese, M.G. Nair, S. Prasanth,
Endodontic management of an unusual foreign body in a
maxillary central incisor, J. Conserv. Dent. 16 (2013) 474–476.
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Child. 36 (1969) 213–216.
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An unusual foreign body in an unerupted supernumerary
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Singapore Dental Journal 35 (2014) 83–86
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/sdj
Case report
Rapid fabrication of silicone orbital prosthesis using
conventional methods
Binit Shrestha, Reiyal Goveas, Sita Thaworanuntan
Maxillofacial Prosthetic Service, Department of Prosthodontics, Mahidol University, 6th Yothi Street, Rachathewi,
Phyathai, Bangkok 10400, Thailand
art i cle i nfo
ab st rac t
Restoration of orbital defects with silicone prosthesis has been a well-documented and
Keywords:
accepted treatment option. Adhesive retained prosthesis offer the patients with adequate
Orbital prosthesis
retention and treatment satisfaction. However, marginal breakdown and discoloration are
Orbital exenteration
common problems associated with these prostheses, necessitating their refabrication.
Silicone prosthesis
Fabrication of a silicone orbital prosthesis is time consuming and requires multiple clinical
Facial defect
and laboratory procedures. This technical article describes simple and cost effective steps
for rapid fabrication of a silicone prosthesis using conventional methods.
& 2014 Published by Elsevier B.V.
Introduction
Exenteration of the eye can lead to a debilitating defect that
can negatively affect patient's quality of life. To minimize
these effects, exenterated orbital defects are rehabilitated
using facial prosthesis, which mimic the patients' normal
anatomy. Silicone elastomers are the most widely used
material for prosthesis fabrication due to their acceptable
color integration and texture [1]. However, they have to be
refabricated every 1.5–2 years due to the damaging effects of
weathering and regular wear and tear [2].
The conventional method of silicone prosthesis fabrication requires several clinical settings and laboratory hours to
be completed. Computer-aided design and computer-aided
manufacturing technologies (CAD–CAM) have helped to
reduce this time significantly [3] but they are not readily
accessible to most clinicians primarily due to high equipment
cost and lack of technical expertise. The objective of this
article is to describe clinical and laboratory steps to duplicate
n
Corresponding author.
E-mail address: [email protected] (S. Thaworanunta).
http://dx.doi.org/10.1016/j.sdj.2014.10.002
0377-5291/& 2014 Published by Elsevier B.V.
patient's existing prosthesis in order to fabricate a new one in
a relatively short period of time, reducing the patient's
burden of multiple visits to the clinic.
Technique
(1) Take chair-side impression of the defect side using
polyvinyl siloxane impression material (Multisil Epithetik soft and hard form; bredent GmbH & Co. KG, Senden,
Germany) (Fig. 1). Use wooden sticks as a matrix for the
impression material.
(2) Fabricate a working cast of the defect side by pouring
the impression with Type IV dental stone (Nok Stone;
Lafarge, Thonburi, Thailand) (Fig. 2).
(3) Mix irreversible hydrocolloid impression material
(Kromopan; Lascod SpA, Firenza, Italy) and place it on
the lower half of a metal flask (Varsity Flask; Hanau, NY).
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Singapore Dental Journal 35 (2014) 83–86
Fig. 1 – Impression of the defect side with polyvinyl siloxane
impression material with wooden sticks matrix.
Fig. 3 – Duplication of the patient's existing prosthesis with
irreversible hydrocolloid impression material.
Fig. 2 – Type IV dental stone cast of the orbital defect.
Fig. 4 – Molten baseplate wax poured through the channel
into the mold space.
(4)
(5)
(6)
(7)
(8)
(9)
Remove the ocular prosthesis from the existing silicone
orbital prosthesis. Place the orbital prosthesis in the impression material such that the cameo surface of the prosthesis
faces downwards and the margins of the silicone prosthesis
are submerged in the impression material.
After the impression material sets, place the upper half
of the flask. Mix irreversible hydrocolloid impression
material and pour it into the flask to adequately cover
the intaglio surface of the prosthesis.
Separate the upper and lower halves of the flask, after
the impression material sets. Carefully remove the silicone orbital prosthesis from the flask.
Using a circular hollow tube of 10 mm diameter remove
the irreversible hydrocolloid impression material from
the upper part of the flask to create a channel which can
access the mold space formed after removal of the
orbital prosthesis (Fig. 3).
Place the upper and lower halves of the metal flask together.
Heat baseplate wax (Cavex TT 100 Soft; Cavex, Haarlem,
Netherlands) at 60 1C in a water-bath (Hanau Low Temperature Water Bath; Teledyne Hanau, NY) and pour the molten
wax through the channel into the mold space (Fig. 4).
Separate the upper and lower halves of the metal flask
after the wax solidifies to obtain a wax replica of the
existing orbital prosthesis (Fig. 5).
Remove wax from the intaglio surface of the wax replica
until the space for the ocular prosthesis is reached.
Fig. 5 – Wax replica obtained after solidification of the
baseplate wax.
(10) Place the patient's existing ocular prosthesis in the wax
replica using an intaglio approach and seal with baseplate wax (Fig. 6).
(11) Clinically evaluate the wax replica in the patient and
verify the position of the ocular prosthesis (Fig. 7).
(12) Adapt the margins of the wax replica on the new
working cast and perform necessary adjustments on
the wax-up to replicate the patient's non-defect side.
Singapore Dental Journal 35 (2014) 83–86
85
Fig. 6 – Patient's existing ocular prosthesis attached to the
wax replica.
Fig. 8 – Two-piece stone mold with the ocular prosthesis
attached to the upper half of the mold.
Fig. 7 – Clinical evaluation of the wax replica for verification
of form and marginal adaptation.
Fig. 9 – Two-piece mold with the new silicone prosthesis
after complete vulcanization.
(13) Try-in the final wax replica to confirm its form and
adaptation. Place the wax replica on the stone mold
and seal with margins with baseplate wax. Attach a 1 cm
long acrylic resin rod to the center of the ocular prosthesis using a cyanoacrylate adhesive. Apply separating
medium (F-901 Separating Film Tinfoil Substitute; Factor
II Inc., Ariz) on the working cast. Adapt boxing wax
(Boxing Strips; Kerr Corp., Calif) along the periphery of
the new working cast and pour type IV dental stone in it
to fabricate a two-piece mold.
(14) After complete setting of the mold, perform de-waxing.
The ocular prosthesis will be attached to the intaglio
surface of the upper half of the two-piece mold (Fig. 8).
Apply separating medium (F-901 Separating Film Tinfoil
Substitute; Factor II Inc., Ariz) to the surfaces of the
upper and lower halves of the two-piece mold.
(15) Dispense room temperature vulcanizing silicone (Multisil-Epithetik; bredent GmbH & Co. KG) in a mixing pad
and add intrinsic color pigments (Intrinsic coloring kit,
Factor II Inc.) to obtain a base shade matching to that of
the patient.
(16) Pack the silicone into the upper and lower halves of the
stone mold.
(17) After complete polymerization, separate the two halves
of the mold (Fig. 9). Remove the ocular prosthesis from
the upper half of the two-piece mold and place it in the
new silicone prosthesis. Trim the excess flash and perform chair-side extrinsic staining.
(18) Fix the extrinsic staining with a silicone medical adhesive (A-564; Medical Adhesive, Factor II Inc.) and deliver
the new orbital prosthesis to the patient (Fig. 10).
Discussion
The fabrication of silicone prosthesis has a significant positive impact on the patient's quality of life [4,5]. Although
implant retained prosthesis offers greater retention and overall treatment satisfaction [4], an adhesive retained prosthesis
is a cost effective and noninvasive treatment option. However, frequent aftercare is one of the major drawbacks
associated with silicone prosthesis. Discolouration and
breakdown of the margins following use is commonly
observed with adhesive retained prosthesis [5]. This can
affect the overall retention and esthetics of the prosthesis,
necessitating their refabrication.
Unlike auricular and nasal prostheses, the previous stone
mold cannot be reused during refabrication of orbital prosthesis because it comprises of two parts – the acrylic ocular
prosthesis and the silicone prosthesis. It is difficult to reattach the ocular prosthesis back into the correct orientation in
86
Singapore Dental Journal 35 (2014) 83–86
the details for duplication but delayed pouring may affect its
dimensional stability [6]. Baseplate wax was used because of
its easy availability, reusability and low cost. To prevent
distortion of the baseplate wax, adequate time should be
given for the material to cool down. It is recommended that
the wax replica be clinically tried to reconfirm the form and
marginal adaptation before silicone is packed. However, if the
prosthesis is lost, this technique cannot be applied as it
involves the duplication of the existing prosthesis to fabricate
a new one.
Conclusion
This straightforward technique for duplication of existing
silicone orbital prosthesis is both cost effective and time
saving for the clinician and the patient. It is suitable for rapid
prosthesis fabrication when digital duplication and milling
techniques are not available.
r e f e r e n c e s
Fig. 10 – Delivery of the new adhesive retained orbital
prosthesis.
the mold, once it is removed. The described duplication
technique is simple and cost effective, and a new prosthesis
can be fabricated within two appointments. By following
these steps, a wax replica of the prosthesis can be easily
obtained which saves a significant amount of time as compared to carving an entirely new wax-up. During the wax
trial, the margins can be reconfirmed to the new working cast
for better adaptation. The form and counters of the wax
replica can be clinically adjusted and verified to improve
upon the esthetics of the original prosthesis.
Adequate knowledge of the materials and laboratory skills
are required to obtain the ideal results. Irreversible hydrocolloid impression material provides good reproduction of
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silicone rubber maxillofacial prosthetic materials, J. Dent. 31
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[2] N. Ariani, A. Visser, R.P. van Oort, L. Kusdhany, T.B. Rahardjo,
B.P. Krom, H.C. van der Mei, A. Vissink, Current state of
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[3] P. Liacouras, J. Garnes, N. Roman, A. Petrich, G.T. Grant,
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[4] T.L. Chang, N. Garrett, E. Roumanas, J. Beumer 3rd, Treatment
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[5] J.C. Markt, J.C. Lemon, Extraoral maxillofacial prosthetic
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126–133.
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