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Journal ISSN 2348 - 4195 CHHATTISGARH JOURNAL OF HEALTH SCIENCES An official publication of Ayush and Health Sciences University, Chhattisgarh Patron Dr. G. B. Gupta Vice Chancellor Executive Editorial Board Dr. K. L. Tiwari– Registrar Ayush & Health Sciences University Dr. N. Gandhi – Dean Faculty Medical Dr. Anil G. Ghom – Dean Faculty, Dental Mrs. Abhilekha Biswal –Dean Faculty Nursing Dr. D. Katariya – Dean Faculty Ayurvedic Dr. A. R. Rudrajwar –Dean Faculty Homoeopathy Associate Editors Dr. Raghavendra Shetty Dr. Divya Sahu Editorial Board Dr. A. K. Chandrakar Dr. S. Pawar Dr. A K Vishwakarma Dr. Rajendra Prasad Dr. Tripti Nagaria Dr. O. P. Khandelwal Dr. Rajendra K. Dubey Dr. Sanjay N Mrs. Sreelata Pillai Dr. Anand Sharma Dr. Deepesh K. Gupta Dr. S. R. Inchulkar Dr. Vineeta Gupta Dr. R.P. Gupta Mrs. Uma Shendey Mrs. Preetha Sunil Ms. Bhuneshwari Sahare Dr. Rohit Rajput (I) CHHATTISGARH JOURNAL OF HEALTH SCIENCES An official publication of Ayush and Health Sciences University, Chhattisgarh Volume 2 issue 2 ISSN 2348-4195 CONTENTS REVIEW ARTICLE Intensity modulated radiotherapy in head and neck cancer : A review Jaideep Sur, Rachita Jain, Latha.S, Fatima Khan, Fiza Khan, Divya Chaurasia .......01 Diagnosis & management of the pathological temporomandibular joint M.S. Senthil kumar, Senthil kumar S., Deepesh Gupta, N.Vidyasankari .......06 ORIGINAL ARTICLE Sex determination using dental pulp in permanent & deciduous dentition N.Mohan, Sukriti Kumar, Jayashree Mohan .......10 Evaluation of pentraxin-3 inflammatory Marker level in generalized chronic periodontitis before and after mechanical therapy (scaling and root lanning) Kokila G, Renuka Devi R, Vineeta Gupta .......15 Study of serum phosphate levels and risk of infection in hemodialysis patients P. Gupta, S. Verma, P. Dubey .......22 Edentulousness , prosthetic status and prosthetic need ofinstitutionalized elderly people in old age homes of Chhattisgarh R. K. Dubey, P. Shetty, D. K. Gupta, S. Pandey .......25 Trends in epidemiology of oral cancer in central part of India in Madhya Pradesh : An institutional study Vanita Rathod, Chandan Rathod .......32 Assessment of dental aesthetic index among school children of Bilaspur, Chhattisgarh : A pilot study R S Makkad, Madhu Pandey, S Hamdani, V. Agrawal, M Motlani , Gunjan Agrawal .......37 CASE REPORT Neurofibroma of spindle cell origin, a diagnostic dilemma to general dentist Swapnil Moghe, Ajay Kumar Pillai, Vineeta Gupta, Geeta Mishra .......42 TMJ ankylosis associated with odontogenic keratocyst of mandibular ramus : A rare case report Biju Pappachan, R K Dubey, Manish Raghani, Raghav Agrawal .......45 Wilckodontics demystified : A case report Sumit Gandhi, Lokesh Advani, Javed Sodawala, G. Anita, Srinias T.S., Parul Agrawal (ii) .......48 Editorial Editorial It is my proud privilege to present you the “Chhattisgarh Journal Of Health Sciences” that reflects voice of medicine professionals in Chhattisgarh. As, an Editor, I humbly accept the responsibilities entrusted to me and assure you that I will do my best to prove worthy of it. I vow that I will do everything to uphold the standard of our quarterly bulletin. All the advances in medicine field are meaningless if the masses do not have the access to healthcare facilities and get the benefit of these advances. To move forward with this vision, it is wise to look backward with a perception not to blame ourselves or our predecessors but to learn from history and plan for the future. You have precious skill & abilities to make a lot many lives in the community happier. I invite your valuable articles, suggestions, write-ups, views, book reviews, achievement & classified advertisement to make the journal adequately interactive and interesting one. Our quarterly bulletin is a complete scientific publication for the benefit of our members. Once again thanks to all for motivation and co-operation. Anil G Ghom (Editor-in-Chief) e-mail: [email protected] [email protected] (iii) Ayush & Health Sciences University of Chhattisgarh REVIEW Intensity modulated radiotherapy in head and neck cancer : A review 1. 2. 3. 4. 5. 6. Jaideep Sur, Associate Professor, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Rachita Jain, Post Graduate Student, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Latha.S, Professor & HOD, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Fatima Khan, Senior Lecturer, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Fiza Khan, Post Graduate Student, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Divya Chaurasia, Post Graduate Student, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Corresponding Author : Dr. Jaideep Sur Dept of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.) Email: [email protected], Mobile No: 93029 97444 ABSTRACT: Radiation therapy is a principal modality in the treatment of head and neck cancer. Its capabilities have steadily progressed with the increase in clinical knowledge and technological development. Intensity-modulated radiotherapy (IMRT) concept had been described back in 1978, but it was not until the 90's that it was applied in practice, following improvement and development of computer equipment. A big step forward was made in the past decade by constructing a device with Multi Leaf Collimators. IMRT appears to be clinically justifiable for cancers in the nasopharynx, sinonasal region, parotid gland, tonsil, buccal mucosa, gingiva, and thyroid. IMRT may also be useful in the re-treatment of previously irradiated head and neck cancers, due to its ability to spare adjacent normal tissues with acceptable target dose uniformity. IMRT represents a significant advance in conformal radiotherapy. In particular, it allows the delivery of dose distributions with concave isodose profiles such that radiosensitive normal tissue close to, or even within a concavity of, a tumour may be spared from radiation injury. Key words: IMRT, head and neck cancer, Multi Leaf Collimators. INTRODUCTION Overall 57.5% of global head and neck cancers occur in 1 Asia, especially in India. The greatest challenge for radiation therapy or any cancer therapy is to attain the highest probability of cure with the least morbidity. The simplest way in theory to increase this therapeutic ratio with radiation is to encompass all cancer cells with sufficient doses of radiation during each fraction, while simultaneously sparing surrounding normal tissues. In practice, however, we have been hampered by our abilities to both identify the cancer cells and target them with radiation. Over the past decade, enormous progress has been made on both fronts. Technical improvements in the application of X-rays, computed tomography scans, magnetic resonance imaging with and without spectroscopy, ultrasound, PET scans, and electronic portal imaging—and our understanding of ISSN 2348 - 4195 their limitations— have greatly improved our ability to identify tumors.2 In 1960, Professor Shinji Takahashi developed a method of conformation radiotherapy that used multileaf collimators. In 1967, a 6-MV linear accelerator at the Aichi Cancer Center became the first in Japan to be equipped with a multileaf collimator. This unit was used in conformational radiotherapy for various types of cancers. In the 1980s, rotation radiography devices used for conformational radiotherapy were replaced by CT devices. Moreover, conformational radiotherapy evolved into intensity-modulated radiation therapy 3 (IMRT), which gained widespread use in the 1990s. Three-dimensional (3D), or CT-based, planning was a major advance because it took into account axial Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 1 REVIEW Jaideep Sur1, Rachita Jain2, Latha.S3, Fatima Khan4, Fiza Khan5, Divya Chaurasia6 IMRT in head and neck cancer anatomy and complex tissue contours such as the hourglass shape of the neck and shoulders. While 3D planning allowed for accurate dose calculations to such irregular shapes, we were still limited in the corrections we could make. As its name implies, intensitymodulated radiation allows us to modulate the intensity of each radiation beam, so each field may have one or many areas of high intensity radiation and any number of lower intensity areas within the same field, thus allowing for greater control of the dose 2 distribution with the target. Two opposing beams of single intensities, represented by the yellow arrows, create a single-dose distribution through a nasopharynx tumor (GTV in red, CTV in purple) and normal tissue alike in two-dimensional radiotherapy, whereas IMRT creates a highly sculpted dose distribution with relative sparing of the brain, brainstem, and parotid glands by delivering beams of 2 different intensities as shown in figure 1. FIGURE 1: Beam Delivery in radiotherapy A: Two dimensional Radiotherapy B: IMRT Advanced treatment planning software has furthered our ability to modulate radiation dose. Instead of the clinician choosing every beam angle and weighting, computer optimization techniques can now help determine the distribution of beam intensities across a treatment volume, which often include a non-intuitive distribution of “beamlets,” or 1 cm2 areas of 2,4 isointensity. IMRT for head and neck tumors refers to a new approach that aims at increasing the radiation dose gradient between the target tissues and the surrounding normal tissues at risk, thus offering the prospect of increasing the locoregional control 5 probability while decreasing the complication rate. PRODUCTION OF INTENSITY MODULATED BEAMS Techniques for generation of intensity modulated beams: Metal compensators: A specifically manufactured metallic compensator is milled or moulded so that a variable thickness of the absorber is presented before the radiation beam.6 Multiple segments per field: Each treatment field is divided into several smaller segments or subfields, 2 which are delivered sequentially (the “step and shoot'' method). Each segment shape is defined by a MLC or by shaped blocks. Addition of several segments produces 5 an IMB. Dynamic MLC (dMLC): Modulation of beam intensity by pairs of moving MLC leaves characterizes this technique 6 (also known as the ``sliding window'' technique). Tomotherapy: To mo t h era py d es crib es I M RT techniques that irradiate the target slice by slice. The NOMOS Corporation developed the first commercially available tomotherapy machine, the multivane intensity modulating collimator (MIMiC), which is in use in several centre.5 This device attaches to the head of the linear accelerator (LINAC), which arcs about the craniocaudal axis of the patient.6,7 ADVANTAGES OF IMRT: IMRT has attracted wide spread interest because of its dosimetric and potential clinical advantages.8 Numerous dosimetry studies on linear accelerator based IMRT treatments of different anatomical sites Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) IMRT in head and neck cancer have been reported, and all of them show that IMRT can have definite dosimetry advantages over 2D and 9,10 conventional 3DCRT treatments. Whether the dosimetric advantages of IMRT can be realized clinically would depend on a number of factors, including (a) the accuracy in localisation and delineation of the tumour and the adjacent critical tissue structures, (b) understanding of the optimum relationship between dose and response for the individual tumour, and (c) delivery of the prescription doses according to the treatment plans. IMRT's high conformity with dose facilitates escalation of dose and better protection of normal tissue structures.11,12 These features make it particularly suitable for the treatment of diseases that involve high rates of local recurrence and toxicity and complications 13,14 related to treatment. Radiotherapy plays an important role in head and neck tumor treatment because of the cosmetic and functional preservation that becomes possible.15 IMRT significantly improves broad aspects of health related quality of life in head and neck cancer survivors.16 It highly reduces parotid irradiation and thus reduces 17 post radiotherapy xerostomia. With the advent of IMRT and its capability to treat multiple targets simultaneously to different doses, a new accelerated fractionation scheme is introduced. It is known as simultaneous modulated accelerated radiation therapy 18 (SMART) boost. SMART boost can be applied to various sites including head and neck, brain and prostate. The principle is to treat two different targets with different fraction sizes to different total doses.19 and supports a best practices model of multidisciplinary team involvement. Intensity-modulated radiotherapy (IMRT) has been widely adopted as a standard technology for head and neck cancer. IMRT therefore offers a significant advance in conformal therapy, by improving conformality and reducing radiation dose to radiosensitive normal tissues close to the tumour even if they lie within a concavity in the planning target 6 volume (PTV). In radiotherapy there are many clinical situations where radiosensitive normal tissues lie within a concavity surrounded by the PTV. Treatment of patients with tumours of the larynx, pharynx or thyroid offers a good example. The CTV often includes a midline target and bilateral cervical lymph nodes producing a horse- shoe shaped PTV with the spinal cord within the concavity. Homogenous irradiation of these PTVs to radical doses (50-66 Gy) with the conventional external beam radiotherapy is difficult. Typically, parallel-opposed photon portals are matched to electron beams. This technique leads to dose inhomogenity at the photonelectron match line, and also underdoses posterior cervical lymph nodes close to the spinal cord. Figure 2 shows, an intensity modulated radiotherapy dose distribution produced by inverse planning to treat the thyroid bed and adjacent lymph nodes (minimum dose 60 Gy, red isodose line) and spinal cord dose less than 30 Gy (light blue circular isodose line).6 Significant normal tissue sparing using IMRT has also According to a study done by Beadle et al on 3172 patients with head and neck cancers IMRT treated patients experienced significant improvements in cause specific survival (CSS) compared with patients treated with non-IMRT techniques. IMRT improves the overall 20 survival rate in patients. CLINICAL APPLICATIONS OF IMRT IN HEAD AND NECK CANCER: The management of head and neck cancer in recent years has involved increasingly complex, combinedmodality programs, as well as the integration of new diagnostic and therapeutic technologies. That head and neck cancer is the most complex “organ site” for treatment decision making is not an overstatement, FIGURE 2: Inverse planning IMRT to treat carcinoma of thyroid bed and adjacent lymph nodes been demonstrated in planning studies for tumours of the maxillary antrum and nasopharynx.6 The treatment of nasopharyngeal carcinoma with minimal dose Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 3 IMRT in head and neck cancer delivery to parotid gland bilaterally (26 Gy) and sparing of optic structure with a minimum dose of 30 Gy in a patient with sinonasal carcinoma can be achieved using IMRT6 as shown in figure3. A B FIGURE 3: IMRT in A: Nasopharynx cancer, B: Sinonasal cancer. Complex dose distributions can be delivered that avoid a number of radiosensitive normal tissues close to a t u m o u r. F o r e x a m p l e , i n t h e t r e a t m e n t o f nasopharyngeal cancer, large parallel-opposed lateral portals are used to encompass macroscopic disease and sites of occult metastases. With this technique parotid glands, spinal cord and brainstem are inevitably included in the irradiated volume although these structures do not need to be included in the target 11 volume. . By defining concavities in the PTV, IMRT can produce a dose distribution that reduces the radiation dose to these organs and this promises a significant reduction in treatment morbidity. IMRT could be used for the whole duration of a radiotherapy treatment, or FIGURE 4: Inverse planning in carcinoma of nasopharynx. 4 simply as a boost after more conventional treatment. The appropriateness of these two approaches is likely to depend on the tolerance doses of surrounding 6,12,14 radiosensitive normal tissues. IMRT also reduces parotid dose to less than 15Gy in treatment of nasopharyngeal carcinoma6,11 as shown in figure 4. Issues in clinical application of IMRT includes, increased risk of a marginal miss because of intrafraction target movements, accurate determination of the target volume and the geometry of the organs at risk (OAR) is difficult.21,22 Another issue is the high cost, which limits 23 the large scale implementation of IMRT. CONCLUSION: Head and neck sites have always been among the most challenging, complex and time consuming to plan because of their complex anatomy. IMRT is designed to deliver more dose to the cancer and less to surrounding healthy tissues. This allows for less normal tissue toxicity, which maintains the patient's quality of life and also improves survival rate. Excellent disease control can be achieved by IMRT with minimum complications like xerostomia, mucositis, dysphagia. The future of head and neck radiotherapy lies in optimally using targeted therapy (IMRT) in order to maximize the therapeutic ratio with minimal morbidity. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) IMRT in head and neck cancer REFERENCES: 1. Kulkarni RM. Head and Neck Cancer Burden in India. International Journal of Head and Neck Surgery 2013;4:29-35. 2. Bucci MK, Bewan A, Roach M. Advances in radiation therapy: Conventional to 3D, to IMRT, to 4D, and beyond. CA Cancer J Clin 2005;55:117-34. 3. Doi K, Morita K, Sakuma S, Takahashi M. Shinji Takahashi, M.D. (1912–1985): pioneer in early development toward CT and IMRT. Radiol Phys Technol 2012;5:1–4. 4. Bourhis J AC, Pignon JP. Update of MACH-NC (Metaanalysis of chemotherapy in head and neck cancer) database focussed on concomitant chemotherapy. J Clin Oncol 2004;22:5505. 5. Vincent G, Awilfried N. Intensity modulated radiotherapy for head and neck carcinoma. The Oncologist 2007;12:555-64. 6. Nutting C. Intensity modulated radiation therapy: a clinical review. The British Journal of Radiology 2000;73: 459-69. 7. Woo SY, Sanders M, Grant W, Butler EB. Does the ``Peacock'' have anything to do with radiotherapy? Int J Radiat Oncol Biol Phys 1994;29:213-14. 8. Lanceford M, Hunt CA. IMRT For Head And Neck Cancer, A Practical Guide to Intensity-Modulated Radiation Therapy. Madison,Wis: Medical Physics Pub,c2003. 191-216. 9. Kam MK, Chau RM, Suen J. Intensity-modulated ra d i o t h e ra py i n n a s o p h a r y n ge a l ca rc i n o m a : Dosimetric advantage over conventional plans and feasibility of dose escalation. Int J Radiat Oncol Biol Phys 2003;56:145-57. 10. Hunt MA, Zelefsky MJ, Wolden S. Treatment planning and delivery of intensity-modulated radiation therapy for primary nasopharynx cancer. Int J Radiat Oncol Biol Phys 2001;49:623-32. 11. Wu Q, Manning M, Schmidt RU. The potential for sparing of parotids and escalation of biologically effective dose with intensity-modulated radiation treatments of head and neck cancers: a treatment d e s i g n s t u d y. I n t J R a d i a t O n c o l B i o l P hy s 2000;46:195-205. 12. Nutting CM, Rowbottom CG, Cosgrove VP. Optimisation of radiotherapy for carcinoma of the parotid gland: A comparison of conventional, threedimensional conformal, and intensitymodulated techniques. Radiother Oncol 2001;60:163-72. 13. Pirzkall A, Carol M, Lohr F, Höss A, Wannenmacher M, Debus J. Comparison of intensity modulated ra d i o t h e ra p y w i t h c o n v e n t i o n a l c o n fo r m a l radiotherapy for complex-shaped tumors. Int J Radiat Oncol Biol Phys 2000;48:1371-80. 14. KY Cheung. Intensity modulated radiotherapy: advantages, limitations and future developments Biomed Imaging Interv J 2006;2:1-19. 15. Obinata K, Nakamura M, Carrozzo M, Macleod L, C a r r A , S h i ra i S . C h a n g e s i n p a ro t i d g l a n d morphology and function in patients treated with intensity-modulated radiotherapy for nasopharyngeal and oropharyngeal tumors. Oral Radiol 2014;30:135–41. 16. Leung S, Lee T, Chien C. Health-related Quality of life in 640 head and neck cancer survivors after radiotherapy using EORTC, QLQ-C30 and QLQ-H & N35 questionnaires. BMC Cancer 2011;11:128-38. 17. Anand AK, Jain J, Negi PS, Chaudhoory AR, Sinha SN, Choudhury PS. Can dose reduction to one parotid gland prevent xerostomia? A feasibility study for locally advanced head and neck cancer patients treated with intensity-modulated radiotherapy. C l i n Oncol 2006;18:497-504. 18. Butler EB, Teh BS, Grant WH et al. SMART (Simultaneous Modulated Radiation Therapy) boost-a new accelerated fractionation schedule for the treatment of head and neck cancer with intensity modulated radiotherapy. Int J Radiat Oncol Biol Phys 1999;45:21-32. 19. Teh BS, Woo SY, Butler EB. Intensity Modulated Radiation Therapy (IMRT): A New Promising Technology in Radiation Oncology. The Oncologist 1999;4:433-42. 20. Beadle BM, Liao KP, Elting LS, , Ang KK, Garden AS, Guadagnolo BA. Improved survival using in head and neck cancer: a SEER-Medicare analysis. Cancer 2014;20:702-10. 21. Mendenhall WM, Amdur RJ, Palta JR. Intensitymodulated radiotherapy in the standard management of head and neck cancer: promises a n d pitfalls. J Clin Oncol 2006;24:2618-23. 22. Sankaralingam M, Glegg M, Smith S, James A, Rizwanullah M. Quantitative comparison of volumetric modulated arc therapy and intensity modulated radiotherapy plan quality in sino nasal cancer. J Med Phys 2012;37:8-13. 23. Verbakel WF, Cuijpers JP, Hoffmans D, Bieker M, Slotman BJ, Senan S. Volumetric intensity-modulated arc therapy vs. conventional IMRT in head and neck cancer: A comparative planning and dosimetric study. Int J Radiat Oncol Biol Phys 2009;74:252-9. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 5 Ayush & Health Sciences University of Chhattisgarh REVIEW Diagnosis and management of the pathological temporomandibular joint REVIEW M.S. Senthil kumar1, Senthil kumar S.2, Deepesh K Gupta3, N.Vidyasankari4 1. 2. 3. 4. Associate Professor, Department of Oral and Maxillofacial Surgery, SRK Dental College, Coimbatore (TN) Professor, Department of Restorative dentistry, JKK Nataraja Dental College, Salem (TN) Reader, Department of Oral and Maxillofacial Prosthodontics, Govt. Dental College, Raipur (CG) Reader, Department of Oral and Maxillofacial Prosthodontics, K.S.R Dental College, Salem, (TN) Correspondence Author : Dr. M.S.Senthil kumar, Sri Ramakrishna Dental Colloge, Coimbatore (TN) Contact Number – 09443505060 ABSTRACT Temporomandibular joint (TMJ) is a unique joint for the practitioner not by its anatomy and function but by the complexity in the diagnosis and treatment. It is widely accepted that palliative and conservative therapy is the best treatment choice. This discussion is about the importance of documenting all the clinical signs, symptoms and findings that are not so common to the internal derangement of the temporomandibular joint. Pathological temporomandibular joint requires simple biochemical and radiological investigations in addition to an altered medical and occlusal therapy as discussed here. INTRODUCTION Temporomandibular joint (TMJ) pain involves the joint and the muscles of mastication. The pain involves the lateral face region that radiates to the neck and the ear region. Patients usually visit or treated by other specialities before being referred to a dental practitioner. Most patients can identify the predisposing factor that leads to the pain in their questionnaire or during examination. The predisposing factors usually are trauma, sports injury, dietary habits, chewing pattern, prolonged dental treatment etc. Dental practitioners first priority is to identify the occlusal harmony of the mouth. Any missing tooth or dental filling or prosthesis leads to the habit of chewing on one side which is identified by the timing of the clicking noise in the TMJ or irregular movement of the joint as whole. Severe pain will be experienced by the individuals who try to change their chewing pattern. These are patients who broadly fall under the category of internal derangement of the TMJ1, 2 . These patients are usually treated conservatively with soft diet, stabilization splints, occlusal rehabilitation and modification in the chewing pattern. Patients who 6 understand that medical and surgical management is of no use usually accept life style changes and respond well to treatment. Patient without occlusal disharmony fall under the broad category of myofacial group with or without etiological factors3. These patients are usually treated with occlusal splints to relieve the pressure on the disc and analgesics for a short period of time. Both categories of patients need long term follow up. A modification in the regular protocol is indicated if it involves psycho social factors, with opinion from other specialities. The third category of patients includes inflammatory TMJ who exhibits the same clinical signs and symptoms but do not respond for the regular treatment protocol. Failure to identify the etiological and clinical factors will worsen the disease. DISEASE DIAGNOSING AND IMAGING Much has been written and documented about the management of diagnosis and treatment of the joint. A basic understanding of the anatomy, diagnosis, classification and the routine protocol in the management of the Temporomandibular disorders is Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195 Diagnosis & management of the pathological TMJ needed to treat a case successfully. Various protocols have been suggested from the diagnosis and treatment point of TMJ. Pain on palpating in relation to the temporal and massetric region, intra oral palpation of the coronoid region which is usually very tender is a single indication of the non harmonious muscle movements. Routine radiological investigations include an Fig - 2 Fig - 1 orthopantomogram and open/closed mouth view of 4 the bilateral Temporomandibular joint . An asymmetry or change in the long axis of the condyle when compared with the other side in an open mouth view indicates a internal derangement.(Fig1) A radiological discontinuity in the head of the condyle indicates pathological changes usually osteoarthritis. However not all pathological joints are arthritic as age, development and systemic changes play a role in the pathological classification. The other pathologies include rheumatoid arthritis, arthrosis, Stills disease (Juvenile osteoarthritis) and Metabolic disorders5. Inflammatory or degenerative joints exhibit a disocclusion or an open bite apart from the pain, difficulty in mouth opening, clicking or hyper mobility of the joint. (Fig2) Arthritic changes in the joint are elicited by the presence of osteophytes and erosion with a good radiologic imaging.(Fig 3) The structural damages to the disk and perforations if any are better diagnosed by an Fig - 3 6 MRI . Biochemical investigation for rheumatoid arthritis is elicited by the presence of Rheumatoid factor. A broader understanding is achieved by complete systemic evaluation and an opinion from the orthopaedic surgeon if needed. If the patient is already on medical management, only a conservative approach is advised. MANAGEMENT The inspection, palpation and auscultation of the TMJ is followed by the recording of the clinical findings like Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 7 Diagnosis & management of the pathological TMJ maximum mouth opening, relationship of the dental midline (upper maxillary incisor midline) to the facial midline on opening and closing. Deviation, dislocation and deflection of the mandible (with reference to the dental midline) on opening and closing, timing of the clicking on opening and closing are to be documented. As these finding play an important role in evaluating the prognosis. The authors follow the below mentioned protocol in their line of management. Initial/Pain management: 1. Ice pack on the affected side 2. Soft diet 3. Analgesics and anti depressants After pain reduces : 4. Mouth opening exercises- regular opening and closing 5. Conscious bilateral chewing on both sides (practiced with mirror in front) 6. Conventional Occlusal splint- to relieve stress at the TMJ- to be worn at nights, travel, watching TV Patients with reduced mouth opening : 7. Warm fomentation bilaterally on the lateral side of the face, temporal region and neck regions. 8. Physiotherapy- ultra shortwave diathermy or TENS 9. Low level laser therapy Further management: 10. Occlusal rehabilitation to aid in bilateral chewingreplacement of missing teeth, extraction of supra erupted maxillary wisdom teeth, to check functional occlusion if all teeth are present. Pathological management: 11. Tricyclic antidepressants 12. Glucosamine and chondroitin sulphate 13. Steroids 14. Patients who do not respond to this protocol are further evaluated with MRI and minimally invasive surgical therapy. Evaluation of the occlusal splint and the treatment as a whole can be assessed by the timing of the clicking in the opening and closing movements. The deviation of the mandible from the dental midline reduces. Anterior repositioning appliance has also been documented of 7 good use if properly made . Medical management is not a long term option, it should be reduced or discontinued as needed. As mentioned earlier the 8 treatment protocol will not be effective if appropriate care is not given to the occlusal rehabilitation. Often patients do not report to the dentist after their acute phase subsides. Hence the need for occlusal harmony should be stressed during every visit. DISCUSSION Pain and pathology of TMJ is multi factorial which makes the diagnosis and treatment more complex. It 8 requires a multi disciplinary approach . Occlusal rehabilitation should be the prime target for the dental practitioner as various studies has pointed out. One should also understand occlusal splint therapy is a supportive splint therapy. During occlusal rehabilitation the endodontic procedures should not be for long duration and the prosthodontic aim should be focused on achieving good functional occlusion. The supportive occlusal splints can be hard, soft or functional as needed. The role of surgery is always indicated for those patients with limited or no mouth opening at all. S i m p l e i nva s i ve s u rg i ca l t h e ra p i e s l i ke T M J 9 arthrocentesis should be considered before an open 10 surgery . Conservative and palliative management seems to provide better and long term results with less or no morbidity. CONCLUSION Fo l l o w i n g t h e b a s i c p ro t o c o l w i t h m i n i m a l investigations and occlusal therapies which are aimed at patient education and long term follow should be the goals in the treatment of pathological Temporomandibular joints. REFERENCES 1. Dworkin SF, LeResche L. Research diagmostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandib Disord. 1992;6:301–355 2. Wilkes CH. Internal derangements of the temporomandibular joint: pathological variations. Arch Otolaryngol Head Neck Surg. 1989; 115: 469–477 3. In: de Leeuw R editors. Orofacial pain: guidelines for asssessment, diagnosis, and management. 4th Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Diagnosis & management of the pathological TMJ ed.. Chicago: Quintessence Publishing; 2008 4. Inclination of the temporomandibular joint eminence and anterior disc displacement. Int J of Oral Maxillofac Surg.1989;18:229-232 5. Gynther GW, Holmlund AB, Reinholt FP, Lindblad S. Temporomandibular joint involvement in generalized osteoarthritis and rheumatoid arthritis: a c l i n i c a l , a r t h ro s c o p i c , h i s t o l o g i c , a n d immunohistochemical study. Int J Oral Maxillofac Surg. 1997;26:10–16 6. L.M.J. Helenius, P. Tervahartiala, I. Helenius, J. AlSukhun, et al. Clinical, radiographic and MRI findings of the temporomandibular joint in patients with different rheumatic diseases International J o u r n a l o f O ra l & M ax i l l o fa c i a l S u rge r y. 2006;35:11:983-989 7. Roger A. Solow. Customized anterior guidance for occlusal devices: Classification and rationale.The Journal of Prosthetic Dentistry, 2013;110:4:259263 8. Epidemiology, Diagnosis, and Treatment of Temporomandibular DisordersReview Article. Dental Clinics of North America 2013;57: 465-479 9. F.A. Al-Belasy, M.F. Dolwick. Arthrocentesis for the treatment of temporomandibular joint closed lock: a review article. International Journal of Oral & Maxillofacial Surgery 2007;36:773-782 10. Dolwick MF, Dimitroulis G. Is there a role for temporomandibular joint surgery. Br J Oral Maxillofac Surg. 1994;32:307–313 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 9 Ayush & Health Sciences University of Chhattisgarh ORIGINAL ARTICLE ORIGINAL ARTICLE Sex determination using dental pulp in permanent and deciduous dentition 1 2 3 N.Mohan , Sukriti Kumar , Jayashree Mohan 1. 2. 3. Professor & HOD, Department of Oral Medicine & Radiology, VMS Dental college, Salem (TN) Post Graduate Student, Dept. of Oral medicine & Radiology, VMS Dental college, Salem (TN) Professor & HOD, Department of Prosthodontics, VMS Dental college, Salem (TN) Corresponding Author: Dr. N. Mohan, Professor, Department of Oral Medicine & Radiology, VMS Dental college, Salem (TN) Email : [email protected], Mobile: 09843082608 ABSTRACT Objective : This study was carried out to determine the reliability of sex determination from tooth pulp tissue. Methods : This study was carried on 30 teeth samples. Out of which 15 were permanent and 15 were deciduous teeth. (8 male teeth and 7 female teeth in each group) which were indicated for extraction advised for orthodontic treatment, Retained deciduous& Periodontally compromised tooth. Teeth was extracted and pulp taken out after access opening was transferred in to fixative solution for 24 hours. the pulp cells were stained with harris's hemotoxylin and eosin stains which was examined under oil immersion lens of light microscope to study the barr body. Results : Study of sex determination with tooth pulp proved to be reliable for deciduous teeth when association of barr body and sex of permanent and deciduous teeth were tested. And also the overall statistical analysis of sex wise estimation of barr bodies involving both deciduous and permanent teeth showed significant results for female group. Conclusion : The Barr body test is shown to be a reliable, simple, and cost-effective technique for sex identification. Keywords : Barr bodies, sex determination, tooth pulp tissue,odontology INTRODUCTION: 1 Forensic odontology can be defined in many ways . The Federation Dentaire Internationale (FDI) defines forensic odontology as that branch of dentistry which, in the interest of justice, deals with the proper handling and examination of dental evidence and with the proper evaluation and presentation of dental findings. According to the American Society of Forensic Odontology, forensic odontology is by definition, the application of dental science to the law, i.e. the use of dental evidence in the interest of justice.Human identification is one of the major fields of study and research in forensic science because it deals with the 2 human body and aims at establishing human identity Tooth enamel is the hardest tissue in the body, and the teeth remain intact after death, thus making them useful for forensic identification of sex with respect to morphological characteristics (Haga, 1959; Gonda, 1959;Garm, 1964) and soft tissues (Das et al., 2004)2 Determining the sex from either dental pulp or dentin of Figure 1. showing diagrammatic representation of barr body in the cell nucleus. 10 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195 Sex Determination Using Dental Pulp tooth can also provide criminal investigators with useful intelligence and can aid the identification of missing persons and disaster victims. Forensic odontology is 3 useful in identification of age and sex of patients Sex of the individual can be determined by using X and Y chromosomes in the cells which are inactive. X chromatin in its inactivated form is present as a mass against the nuclear membrane in females is known as Barr body as it was first named by Barr and Bertem (1949)(Fig 1). These Barr bodies are present in 40% of females who are considered as chromatin positive and absent in males who are considered as chromatin negative. MATERIAL AND METHODS: A total of 30 teeth were collected and were grouped in to permanent and deciduous. Each group comprised of 15 teeth . Out of 15 teeth (7 males and 8 females) were selected out of patients who came for treatment in vinayaka missions sankarachariyar dental college salem .Eligibility criteria included was extractions advised for orthodontic treatment. Retained deciduous.,Periodontally compromised tooth, age criteria:-up to 45 years .and those Teeth with dental caries,Grossly destructed teeth, Non vital tooth were excluded from the study. An ethical committee clearance was taken and informed consent was obtained .Either the patients or their guardians, if they are minors, were informed about the objectives of the investigation. The teeth were removed by conventional technique, washed with sterile water to remove residual blood, The pulp was conventionally obtained through the normal access cavity on the occlusal surface of the teeth; dental pulp tissues were obtained using standardized K-files(Fig 5). The pulp tissue was then transferred to the dry and clean conical centrifuge tubes containing 5 ml. of fixative (3 Methanol: 1 Glacial acetic acid) and left as such for about half an hour to 24 hours for the fixation of the pulp cells. It was then crushed / teased with the glass rod sufficiently to isolate the pulp cells. A suspension thus obtained was centrifuged for 10 Figure 5. Pictures showing material and method involved in the study Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 11 Sex Determination Using Dental Pulp permanent teeth(Table1). Hence,suggesting study to be more reliable for the deciduous teeth. minutes at 1000 rpm. The supernatant was discarded, leaving behind the pellet in the centrifuge tube. 5ml of fresh fixative was then added to re-suspend the pellet and the process was repeated thrice till a clear suspension of the pulp cells was obtained. Overall statistical analysis of sex wise estimation of barr bodies involving both deciduous and permanent teeth (Table3) showed p-value 0.001 which was highly significant at 1% therefore more percentage of barr bodies was observed in female group. Thin smears were prepared on chilled microscope slides of 1 mm thickness by the air drying method i.e. by dropping 2 –3 drops of the above suspension on the slide from a distance of inches to get a homogenous population of cells. Two smears were made from each suspension of the specimen; one slide was stained with Harris's Hemotoxylin and Eosin stain to study the Barr 3 bodies And finally, the association between the type of teeth and presence of barr bodies were tested with chi square test , Table 4 showed that the p-value is less than 0.5 hence the result is significant at 5%,Therefore it is concluded that there is significant association found between the type of teeth and barr bodies.It was observed from the study that deciduous teeth is showing more percentage towards barr bodies than permanent teeth. Estimation of barr bodies in deciduous teeth were more significant when compared to permanent teeth RESULTS: When association of barr body and sex of permanent and deciduous teeth were tested with chi square test and compared it was observed that p-value was highly significant in deciduous (Table 2) and significant in Table 1 . Association between sex and Barr Bodies - Permanent Teeth Barr bodies Sex Positive N Negative % Male Total N % 8 100.00 8 Female 3 42.86 4 57.14 7 Total 3 20.00 12 80.00 15 Chi square p 4.28 0.038* * Significant at 5 % Table 2 . Association between sex and Barr Bodies - Deciduous Teeth Barr bodies Sex Positive Negative Total N % N % Male 1 14.29 6 85.71 7 Female 8 100.00 - - 8 Total 9 60.00 6 40.00 15 ** Significant at 1 % (Highly Significant) 12 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Chi square p 11.43 0.001** Sex Determination Using Dental Pulp Table 3 . Association between sex and Barr Bodies - Deciduous Teet3 Barr bodies Type of Teeth Positive Negative Total N % N % Permanent Teeth 3 20 12 80 15 Deciduous Teeth 9 60 6 40 15 Total 12 40 18 60 30 Chi square p 5.00 0.025* Chi square p Table 4 . Association between sex and Barr Bodies - Deciduous Teeth Barr bodies Sex Positive Negative Total N % N % Male 1 6.67 14 93.33 15 Female 11 73.33 4 26.67 15 Total 12 40.00 18 60.00 30 13.89 Figure 2. Picture showing positive barr body along the nuclear membrane observed in 100x magnification of light microscope under oil immersion. <0.001** Figure 4. Picture showing cell without a barr body. observed in 100x magnification of light microscope under oil immersion DISCUSSION: In the study we were able to differentiate the sex of an individual by observation of barr bodies in both deciduous and permanent teeth.(Fig 2,Fig 3) The association between sex and barr bodies in permanent teeth showed 42.86% positive result for females and 100% negative result in males. Figure 3. Picture showing positive barr body along the nuclear membrane observed in 100x magnification of light microscope under oil immersion. And the association between sex and barr bodies in deciduous teeth showed 85.71% negative result for males whereas in females it showed 100% positive results. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 13 Sex Determination Using Dental Pulp The overall association between sex and barr bodies revealed 73.33% positive results in females and 6.67 % in males with 93.33% and 26.67% negative results respectively in males and females . The most significant association was observed between the type of teeth and barr bodies. Here deciduous teeth showed 60% positive result and 20% negative results was seen in permanent teeth. Das et al., reported that 24.92% of women pulp cells 2 were positive for Barr body observation Yunis & Chandler (1979) indicated that in women with a normal karyotype, Barr bodies were observed in approximately 30% of cellular nuclei, with a range 4 between 15% and 40% Gajendra veeraraghavan et al stated that freshly extracted teeth which were examined one month later showed positive 100% results in sensitivity, 3 specificity,positive predictive value and efficiency Our study involved permanent as well as deciduous teeth and the results were more reliable in female deciduous tooth pulp than the female permanent tooth pulp. Though the determination of sex does not give 100 % of results in its predictive value and efficiency every time we perform the study, still it has got some advantages like it is Rapid and is easily implemented because it requires little equipment in contrast to techniques, such as PCR (Murakami et al.) and LAMP method (Nogami et al., 2008).And IT can be observed with most of the nuclear stains, such as hematoxylineosin, Papanicolaou, Feulgen, cresyl violet, acetoorcein, carbol-fuchsin, and fluorescence 5 Alterations at the chromosomal level in patients with a bnormalities can yield false negatives or false positives . CONCLUSION Along with forensic investigations, antemortum records also have equal importance for identification of the individual. Forensic odontology has a prime role in identification of the individual even in a critical situation where the obtained sample is severely damaged and decomposed. REFERENCES: 1. Ivan Suazo Galdames et al. Sex Determination by Observation of Barr Body in Teeth Subjected to High Temperatures. Int. J. Morphol 2011; 29(1):199-203. 2. Dr. Nirmal Das et al. Sex determination from pulpal tissue. Jiafm 2004; 26(2): 50-54. 3. Gajendra Veeraraghavan1, Ashok Lingappa et al. Determination of sex from tooth pulp tissue. Libyan J Med 2010, 5: 5084 4. Bar MC, Bertam LF and Lendsay HA. The morphology of the nerve cell nucleus according to sex. Anat Rec 1950: 107 -283 5. Dufy JB, Waterfield JD and Skinner MF. Isolationof Tooth pulp cells for sex chromatin studies inexperimental dehydrated and cremated remains.Forensic Science International. 191; 49: 127-141. 6. Shamim T, Ipe Varughese V, Shameena PM, S u d h a S . Fo re n s i o d o n t o l o g y : a n e w perspective. Medicolegal Update 2006; 6:1-4. 14 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Ayush & Health Sciences University of Chhattisgarh Evaluation of pentraxin-3 inflammatory Marker level in generalized chronic periodontitis before and after mechanical therapy (scaling and root planing) 1 2 3 Kokila G , Renuka Devi R , Vineeta Gupta 1. 2. 3. Lecturer, Department of Periodontics, KSR Institute of Dental Science and Research, Tiruchengode, (TN) India Reader, Department of Periodontics, KSR Institute of Dental Science and Research, Tiruchengode, (TN) India Reader, Department of Periodontics , Government Dental College Raipur (C.G) Corresponding Author : Dr. G. Kokila Lecturer, Department of Periodontics, KSR Institute of Dental Science and Research Tiruchengode – 637215, email: [email protected] ABSTRACT : Background : Pentraxins are acute phase proteins which belong to a family of evolutionarily conserved proteins, considered as markers of inflammation. Pentraxin 3 (PTX3) is a prototype of the long pentraxin group. It is suggested to play an important role in innate immunity, regulation of inflammation and clearance of apoptotic cells. Hence this study was planned and designed to estimate the level of pentraxin-3 in chronic periodontitis before and after non surgical periodontal therapy and correlate its level with disease severity (healthy, gingivitis and periodontitis). Materials and methods : A total of 45 individuals both males and females of age group (23-50yrs) were included in the study and they were divided into three groups of 15 in each. Control group A (group I, = 15) healthy, Control group B (group II = 15) gingivitis, Test group (group III =15) generalized chronic periodontitis.3weeks after intervention (scaling and root lanning), the 15 subjects from Group III were categorized as fourth group (Group IV). GCF and plasma samples obtained from each subjects were quantified for pentraxin-3 using sandwich enzyme linked immunosorbent assay (ELISA) technique. Statistical analysis : Chi-square test, ANOVA, ANCOVA, Spearman correlation coefficient and Paired t test were used for statistical analysis of this study. P value of less than 0.05 was considered to be statistically significant. Results : The mean GCFPTX3 concentration increased from healthy to gingivitis groups and then from gingivitis to periodontitis groups (1.402 ng/ml <2.299 ng/ml <3.184 ng/ml). Similarly the mean plasma PTX3 concentration was highest in periodontitis group (2.885ng/ml) followed by the gingivitis group (2.118 ng/ml) and lowest in the healthy group (0.983 ng/ml). The mean differences between the groups were also statistically significant (p<0.001). The GCF and plasma PTX3 concentrations in chronic periodontitis decreased (2.14 ± 0.57, 1.95 ± 0.58) after treatment. Conclusion : Pentraxin3 level increases in GCF and plasma, from periodontal health to the diseased condition, as well as there is distinct decrease in the level after periodontal therapy. This data indicates that pentraxin-3 plays a key role in periodontal disease and could be considered as a biomarker in periodontal disease progression. Key Words : Chronic periodontitis, Enzyme linked immunoabsorbent assay, Gingival crevicular fluid, Pentraxin-3. ISSN 2348 - 4195 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 15 ORIGINAL ARTICLE ORIGINAL ARTICLE Pentraxin-3 in periodontal diseases INTRODUCTION Chronic periodontitis is an infectious disease of bacteria characterized by the inflammatory breakdown of tooth supporting structures including hard and soft tissues. The initiation and progression of periodontal disease is caused by interaction between periodontal pathogens and host immune system. The periodontal pathogens contains a number of potential virulence factors like antigens, lipopolysaccharide and heat shock proteins, which trigger the local and systemic immune and inflammatory response. The local inflammatory response stimulates hepatocytes and the other cells including neutrophils, monocytes, macrophages, vascular endothelial cells, fibroblast and smooth muscle cells to release various acute phase proteins (APR).1,2,3 Pentraxins, a super family of acute phase proteins are identified as biomarkers in inflammatory conditions. It has an important role in the innate immune system. Pentraxins are divided into two groups based on primary structure of the subunit: short pentraxin (Creactive protein and serum amyloid protein), long pentraxins (pentraxin-3 [PTX3] and PTX4), and several 4, 5 neuronal pentraxins. Pentraxin-3 is identified as first member of the long pentraxin super family. It is produced by macrophages and other cell types in response to IL-1β, tumour necrosis factor-alpha [TNF- α ] and microbial 6, 7 components including lipopolysaccharides. Measurement of pentraxin-3 in GCF or plasma may help in the identification of a subset of patients who are at a higher risk for destructive disease or those who are 8 undergoing the process of periodontal breakdown. To date, this is the second study to examine the effect of nonsurgical periodontal therapy on GCF and serum level of pentraxin-3. The aim of study was to estimate the level of pentraxin-3 in GCF and blood before and after non surgical periodontal therapy in chronic periodontitis and correlate its levels with disease severity. MATERIALS AND METHODS The study protocol was analyzed and approved by the Institutional Ethical Review Board. Written and verbal informed consent was obtained from the subjects participating in the study. A total of 45 subjects (20 males and 25 females) were participated in the study. Inclusion criteria: 1. Age group 23 to 55yrs 2. At least 20 natural teeth 3. Good general health without any history of systemic disease Exclusion criteria: 1. Any autoimmune disease or other systemic diseases that could change the course of periodontal disease. 2. Subjects having history of smoking or any form of tobacco use previously 3. Use of a medication like antibiotic drugs or anti inflammatory drugs in the past 3 weeks 4. History of periodontal therapy in the past 6 months 5. Pregnant/ lactating women 6. Unwillingness to join in the study. Each subject underwent full mouth periodontal probing and charting, along with digital OPG. The subjects were divided into 3 groups of 15 each based on scores of plaque index (Sillness and Loe 1964), gingival index (Loe and Sillness 1963), sulcus bleeding index (Muhlemann 1971), probing depth (PD), clinical attachment level (CAL) and radiographic evidence of bone loss. Control group (Group 1 = clinically healthy [n=15 (no bleeding on probing, gingival index = 0 probing depth ≤ 3mm, CAL=0, radiographically no bone loss). Control group (Group 2 = gingivitis [n=15 (clinically, signs of gingival inflammation and bleeding on probing present, gingival index >1, probing depth ≤ 3mm and no CAL or radiographic bone loss). Test group (Group 3= generalized chronic periodontitis [n=15 (clinically, signs of gingival inflammation and bleeding on probing present, gingival index >1, probing depth ≥ 5mm, CAL ≥ 3mm and radiographic evidence of bone loss). Group 4 = Group 3 patients [n=15 (generalized chronic periodontitis) receiving non surgical therapy (scaling and root planning) are converted into Group4. 16 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Pentraxin-3 in periodontal diseases EXAMINATION METHOD Non surgical periodontal therapy The clinical and radiographic examinations, group allocations were performed by single examiner for all patients. Samples were collected from predetermined sites in each patient on the following day by same examiner. This was carried out to avoid the contamination of GCF with blood associated with the probing of inflamed sites. Only one site per subject was selected as sampling site in group 2 (gingivitis) and group 3 (generalized chronic periodontitis) whereas, in group 1 (healthy), many sites were sampled. Probing depth and clinical attachment levels were measured by using a William graduated periodontal probe. The patient in group 3 received non surgical periodontal therapy (scaling and root planning) within 1 or 2 visits according to patient needs. Oral hygiene instructions were given which included, tooth brushing techniques and the use of dental floss. If patient reported any sensitivity, instruction was given to use desensitizing tooth paste (Thermoseal). The patients were recalled after 21 days for recording of plaque index, gingival index, sulcus bleeding index, probing depth and CAL. GCF and blood samples were collected and sent to laboratory and stored at -70◦C GCF Collection After drying the selected area, supragingival plaque was removed by using the Gracey curettes. Care was taken not to touch the gingival margins after which the area was isolated with cotton rolls to prevent saliva contamination. GCF was collected by gently placing the microcapillary tube at the entrance of the gingival sulcus. A standardized volume of 1μl was collected in each group by using the cal ibration on black colour–coded 1- to 5-μL calibrated volumetric microcapillary tubes. Maximum of 10-15 minutes were allotted for each sample. If GCF is not expressed within the allotted time, that sites were excluded. This was done to ensure atraumatism. The micropipettes that were suspected to be contaminated with blood or saliva were also excluded. Collected GCF samples were immediately transferred to airtight plastic vials and were diluted with phosphate buffer saline up to 100μl and immediately transferred and stored at -700C until assayed. Blood Collection 2ml of blood was collected from anticubital fossa by venipuncture using a graduated syringe with 20 gauge needle. The collected blood was transferred to a test tube containing EDTA. Immediately the collected samples were sent to laboratory for processing. Plasma was separated within 30 minutes from collected blood by centrifuging at 1000 x g for 15 minutes and immediately transferred to a plastic vial and stored at ◦ 70 C until assayed. Assay Procedure The pentraxin-3 levels in collected GCF and blood sample were assayed using an enzyme-linked immunosorbent assay (ELISA KIT). The assay employed the quantitative sandwich enzyme immunoassay technique. Antibody specific for PTX3 was pre-coated onto a microplate and antigen samples to be tested was added into the wells and any PTX3 present was bound by the immobilized antibody. After removing any unbound substances, a biotin-conjugated antibody specific for PTX3 was added to the wells. After washing, avidin conjugated Horseradish Peroxidase (HRP) was added to the wells. Following a wash to remove any unbound avidin-enzyme reagent, a substrate solution was added to the wells and color developed in proportion to the amount of PTX3 bound in the initial step. Once pentraxin-3 binds with antibody completely, the color development stops and the intensity of the color was measured. The absorbance of each well is read on an ELISA reader using 450 nm as the primary wavelength. The concentration of PTX3 in the tested samples was estimated using the standard curve.4 Statistical Analysis Statistical analysis was done using software program. One way ANOVA was carried out to compare the mean clinical parameters between the groups. In addition, Chi-square test was done to assess sex distribution of subjects in groups. Pearson's correlation coefficient has been applied to find out the relationship between the pentraxin-3 level and the selected variables. Paired t test was used to analyze mean and standard deviation Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 17 Pentraxin-3 in periodontal diseases of clinical parameters and pentraxin-3 levels before and after SRP for group III patients. P <0.05 was considered to be statistically significant. RESULTS Descriptive statistics of baseline parameters of the study population are shown in Table1. The results of the present study indicated that the mean PTX3 concentration in GCF was highest in group III (3.184ng/ml).The mean GCFPTX3 concentration increased from healthy to gingivitis groups and then from gingivitis to periodontitis groups (1.402 ng/ml <2.299 ng/ml <3.184 ng/ml) (Table 2). Similarly the mean plasma PTX3 concentration was highest in periodontitis group (2.885ng/ml) followed by the gingivitis group (2.118 ng/ml) and lowest in the healthy group (0.983 ng/ml). The mean differences between the groups were also statistically significant (p<0.001) (Table 3). Paired t test showed a statistically very highly significant reduction of clinical parameters and GCF and plasma PTX3 levels of group III after SRP. The clinical parameters has been reduced from (1.65 ± 38, 2.16 ± 0.36, 3.06± 0.57, 5.91± 1.01 and 5.49 ± 0.81) at baseline to (0.85 ±0.10, 1.34 ±0.64, 1.84 ± 0.89, 5.37 ±1.19 and 4.82 ± 0.91) at the end of 3 weeks (Table 4). Result of group III revealed that there was a very highly statistically significant (p < 0.001) reduction of GCF pentraxin-3 from (3.18 ± 0.64) at baseline to (2.14 ± Table 1: Descriptive statistics of baseline parameters in the study population PI (Mean±SD) GI (Mean±SD) SBI (Mean±SD) CAL Mean±SD) PPD Mean±SD) Group I 0.338 ± 0.11 0.216 0.226 1.402 ± 0.29 0.938± 0.29 Group II 0.675 ±0.21 0.964 1.224 2.299± 0.36 2.118± 0.41 Group III 1.654 ±0.38 2.162 3.064 3.184± 0.64 2.885± 0.49 Table 2: Descriptive statistics of pentraxin-3 inflammatory marker level in GCF Pentraxin-3 in GCF Mean Standard deviation Minimum Group I Maximum 1.402 0.29 0.87 1.87 Group II 2.299 0.36 1.54 2.83 Group III 3.184 0.64 1.98 4.25 ANOVA- P-value Scheffe’s multiple comparison test result <0.001 GI<GII<GIII Scheffe’s multiple comparison test result GI <GII <GIII X² - value 56.76 Table 3: Descriptive statistics of pentraxin-3 inflammatory marker level in plasma Pentraxin-3 in plasma Mean Standard deviation Minimum Maximum ANOVAX²- value Pvalue Group I 0.938 0.29 0.32 1.56 84.90 <0.001 Group II 2.118 0.41 1.35 3.00 Group III 2.885 0.49 1.63 3.56 18 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Pentraxin-3 in periodontal diseases Table 4: mean and standard deviation of the dental parameters before and after SRP for chronic periodontitis patients. Variable Before SRP After SRP Paired ttest P-value Mean Standard Deviation Mean Standard Deviation Plaque Index 1.654 0.38 0.856 0.10 8.154 <0.001 Gingival Index 2.163 0.36 1.340 0.65 5.938 <0.001 SBI 3.064 0.57 1.849 0.89 6.392 <0.001 CAL 5.912 1.01 5.375 1.19 6.255 <0.001 PPD 5.493 0.81 4.821 0.91 4.846 <0.001 Pentraxin-3 in GCF 3.184 0.64 2.141 0.57 5.334 <0.001 Pentraxin-3 in plasma 2.885 0.49 1.956 0.58 5.552 <0.001 0.57) at the end of 3 weeks and serum pentraxin-3 from (2.88 ± 0.49) at baseline to (1.95± 0.58) at the end of 3 weeks (Table 4). DISCUSSION Periodontal disease is a multifactorial infectious disease characterized by inflammatory breakdown of tooth supporting structures; although the most important cause of periodontal disease is the presence of periodontal microorganisms. Consequent progression and disease severity are considered to be determined by the host immune response. Mediators formed as a part of host response that contribute to tissue destruction comprise of acute-phase proteins, cytokines, and prostaglandins. Pentraxin 3 is the first long pentraxin to be identified and is produced by a variety of cells like the dendritic cells, endothelial cells, fibroblasts and neutrophils. It has an important role in innate immunity, regulation of inflammatory reaction and the clearance of apoptotic cells.9, 6, 7 Plasma levels of PTX3 are raised in inflammatory conditions resulting from a wide range of diseased states from infection to autoimmune and/or degenerative disorders.10 In the past, few studies showed that there was an increase in the levels of PTX3 in GCF and serum in periodontal disease conditions. These studies suggested that level of PTX3 were directly related to amount of inflammatory condition and therefore it can be considered as a marker of inflammation in 4, 9, 11 periodontal diseases. The main objective of this study was to estimate the level of pentraxin-3, in chronic periodontitis patients before and after non surgical periodontal therapy and to correlate the levels of pentraxin-3 with disease severity (healthy, gingivitis and periodontitis). This study was initiated to determine, whether PTX3 levels were altered after non surgical therapy. In our study, GCF and serum PTX3 levels were found to be significantly higher in periodontitis group compared with healthy and gingivitis groups. This indicates that the severity of the inflammation is more in patients with generalized chronic periodontitis than in healthy and gingivitis. As the disease progresses from healthy to gingivitis and then periodontitis, there is more accumulation of neutrophils and monocytes at disease sites and augmentation of cytokines such as IL-1 and 4,12 TNF-β for PTX3 synthesis. In the present study, the GCF was collected by using micro-capillary tube to avoid non-specific attachment of PTX3 to filter papers, which can lead to a false decline in measurable PTX3 levels and thus can miscalculate the correlation of PTX3 levels of disease severity and progression. The sandwich ELISA, known for sensitivity and specificity, is used in this study for accurate quantification of PTX3. As per various studies immunohistochemistry can also be used for PTX3 analysis.13 Pradeep et al (2011) recently reported the levels of PTX3 in GCF and serum in chronic periodontitis patients as 3.378 ± 1.45003 ng/ml and 3.074 ± 0.71829 ng/ml Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 19 Pentraxin-3 in periodontal diseases respectively using the ELISA technique. The deepest probing sites were used for sample collection.4 In our study, the samples were obtained from sites with deepest probing depth and PTX3 values in the GCF and serum from patients with chronic periodontitis were estimated at 3.184 ± 0.64 ng/ml and 2.885 ± 0.49 ng/ml respectively. In our study, PTX3 concentrations positively correlate with clinical parameters in the periodontitis group. The positive correlation between clinical parameters and PTX3 levels can be attributed to the production of cytokines at tissue injury sites. Neutrophils appear early at sites of infection and injury. They represent a reservoir of pre-stored PTX3 that are ready for rapid release. These specific granules of PTX3 are released from neutrophils in response to inflammatory signals.4 A study by Yuzo Fugita et al in 2012 reported GCF PTX3 levels to be significantly higher in patients with periodontal disease site (0.64 ± 0.39 ng/ml) than periodontal healthy sites (0.06 ± 0.10ng/ml) in patients with chronic periodontitis. A strong positive correlation was also observed between mean gingival index, pocket depth, bleeding on probing, GCF levels and PTX3 [11] levels. The GCF PTX3 level in the above study is almost 6 times lower than the level obtained in our study (3.184±0.64ng/ml). The result of the present study revealed statistically significant (p < 0.001) increase in the mean concentration of PTX3 in GCF as the diseases progressed from healthy (1.402 ± 0.29) to gingivitis (2.299 ± 0.36) to periodontitis (3.184 ± 0.64). The results were in accordance with the result of a study done by Yuzo Fugita et al (2012) which showed that the mean concentration of PTX3 was significantly higher (p < 0.01) in diseased sites (0.64 ± 0.39) as compared to healthy sites (0.06 ± 0.10). Enas Ahmed Elgand et al (2013) study was conducted to evaluate the effectiveness of SRP (Group I) and SRP with adjunct treatment of tea tree oil (Group II) on clinical parameters and level of pentraxin-3 in chronic periodontitis. Serum samples were collected to measure the serum PTX3 levels by using ELISA. This study showed statistically significant reduction in clinical parameters PTX3 levels in group II compared with group I.14 The patients after non surgical periodontal therapy (scaling and root planning) showed reduced GCF and serum PTX3 levels and clinical parameters. Serum PTX3 was reduced from 2.885 ± 0.49 to 1.956 ± 0.5 at the end of 3 weeks and GCF PTX3 also reduced from 3.184 ± 0.64 to 2.141 ± 0.57. Mean pentraxin 3 values in comparison were analysed before and after non surgical therapy in GCF and plasma by using paired t test. Mean values shows statistically (p < 0.001) significant differences. The result of our study revealed that there was a highly statistically significant (p < 0.001) reduction of clinical parameters and GCF PTX3 levels in patient with chronic periodontitis after nonsurgical therapy. Clinical improvement after periodontal therapy was associated with significant reduction in PTX3 in GCF and plasma. Non surgical therapy (Scaling and root planning) controls the local bacterial infection and leads to minimum influx of PMN into GCF and reduces PTX3 expression in GCF. At the same time it decreases the entry of bacteria into systemic circulation, thus 15, 16 reducing PTX3 expression in serum. To date, only one study by Enas Ahmed Elgend et al (2013) showed effect of non-surgical therapy on pentraxin-3 level in GCF samples of patients with 14 periodontal diseases. Limitations of our study were, Gingivitis patients did not receive any SRP, because the aim of our study was to check the impact of SRP on inflammatory marker PTX3 in GCF and plasma samples and for that the most destructive periodontal disease was selected to obtain better results. Other systemic inflammatory markers were not analysed. CONCLUSION Quantitative sandwich enzyme immunoassay techniques revealed the GCF and plasma PTX3 levels are higher in patients with generalized chronic periodontitis than healthy patients and those with gingivitis. After non surgical therapy the PTX3 levels reduced in both GCF and plasma. PTX3 concentration was elevated with increasing severity of periodontal diseases and decreases with lower level of inflammatory conditions. 20 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Pentraxin-3 in periodontal diseases REFERENCES: 1. Newman MG, Takei H, Klokkevold PR, Carranza FA. Microbial interactions with the host in periodontal diseases. Clinical Periodontology 2006; 10th edition: 228-246. 2. Sema Becerik, Veli Ozgen Ozturk, Harika Atmaca, Gul Atilla, Gulnur Emingil. Gingival crevicular fluid and plasma Acute-phase cytokine levels in different periodontal diseases. J Periodontol 2012; 83: 1304-1313. 3. Fa ra h Az iz Kh a n , M o h d Fa reed Kh a n . Inflammation and acute phase response. International Journal of Applied Biology and Pharmaceutical Technology 2010; I (2): 312321. 4. Pradeep A.R, Rahul Kathariya, Raghavendra N.M, Anuj Sharma. Level of pentraxin-3 in gingival crevicular fluid and plasma in periodontal health and disease. J Periodontol 2011; 82:734-740. 5. Alok Agrawal, Prem Prakash Singh, Barbara Bottazzi, Cecilia Garlanda, Alberto Mantovani. Pattern Recognition by pentraxins. Adv Exp Med Biol 2009; 653: 98-116 6. Alberto Mantovani, Cecilia Garlanda, Andrea Doni, Barbara Bottazzi. Pentraxins in innate immunity; From C-reactive protein to the long pentraxin PTX3. J Clin Immunol 2008; 28: 1-13 7. Cecilia Garlanda, Barbara Bottazzi, Antonio Bastone, Alberto Mantovani. Pentraxins at the crossroads between innate immunity, inflammation, matrix deposition and female fertility. Annu Rev Immunol 2005; 23: 337-66. 8. Newman MG, Takei H, Klokkevold PR, Carranza FA. Defence mechanism of gingiva. Clinical th Periodontology 2006; 10 edition: 344-354. p e n t ra x i n - 3 a n d f i b r i n o g e n l e v e l s i n experimental periodontitis model. Mediators of Inflammation 2012; 1-7. 10. Pawel Cieslik and Antoni Hrycek. Long pentraxin 3 in the light of its structure, mechanism of action and clinical implications. Autoimmunity 2012; 45(2):119-128. 11. Yuzo Fujita, Hiroshi Ito, Satoshi Sekino, Yukihiro Numabe. Correlations between pentraxin 3 or cytokine levels in gingival crevicular fluid and clinical parameters of chronic periodontits. Odontology 2012; 100: 215-221. 12. Pradeep A.R, Rahul Kathariya, Arjun Raju P, Sushma Rani R, Anuj Sharma, Raghavendra N.M. Risk factors for chronic kidney diseases may include periodontal diseases, as estimated by the correlations of plasma pentraxin-3 levels: a case-control study. Int Urol Nephrol 2012; 44: 829-839. 13. Luchetti M.M et al. Expression and production of the long pentraxin PTX3 in rheumatoid arthritis. Clin Exp Immunol 2000; 119:196-202. 14. Enas Ahamed Elendy, Shereen Abdel Moula, Doaa Hussien Zineldeen. Effect of local application of tea tree oil gel on long pentraxin level used as an adjunctive treatment of chronic periodontitis: A randomized controlled clinical study. Indian society of periodontology 2013; 17: 444-448. 15. Barbara Noack, Genco J, Maurizio Trevisan, Sara Grossi, Zambon J, Ernesto De Nardin. Periodontal infections contribute to elevated systemic C- reactive protein level. J Periodontol 2001; 72: 1221-1227. 16. Chung RM, Grbic JT, Lamster IB. Interleukin-8 and β-glucuronidase in gingival crevicular fluid. J Clin Periodontol 1997; 24: 146-152. 9. Gonca Cayir Keles et al. Biochemical analysis of Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 21 Ayush & Health Sciences University of Chhattisgarh ORIGINAL ARTICLE ORIGINAL ARTICLE Study of serum phosphate levels and risk of infection in hemodialysis patients 1 2 3 P. Gupta , S. Verma , P. Dubey 1 Associate Professor, Nephrology Unit, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur 2 Associate Professor, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur 3. PG Student, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur Corresponding Author: Dr. P. Gupta Associate Professor, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur, Email : [email protected], Mob: 9009200001 ABSTRACT Objectives: Hyperphosphatemia is highly prevalent in dialysis patients and may be associated with immune dysfunction. The association of serum phosphate level with infection remains largely unexamined. Material and method: A study group contain total of 100 patients, out of which 15 patients blood culture and central venous catheter tip culture was positive. All Patients were underwent investigation in form of renal function test, c reactive protein level, serum phosphorus, blood culture,urine culture, central line tip culture. Results: Out of 15 patients of renal failure on hemodialysis with sepsis none had serum phosphate level less than 3.5 mg /dl, 4 (26.67%) had serum phosphorus level between 3.5 – 5.5 mg/dl and 11 (73.33%) patients had serum phosphorus level > 5.5 mg/dl. Infections of any type were more frequent among patients with high phosphate levels at baseline, relative to normal. Male sex, advanced age, diabetes, anemia, hypoalbuminemia were found to be risk factors for infections.Gram positive cocci (Staphylococcus aureus) was the most common organism found in blood of 80% patients of renal failure on haemodialysis with sepsis. Incidence of sepsis was high with femoral vein (66.67%) usage and prolonged hemodialysis (more than 21 days). Serum Phosphorus level was high in 73.33% patients and CRP was raised in all 15 patients with sepsis. Most of the patients were euthyroid and their lipid profile was normal. Conclusions: High phosphate levels may be associated with increased risk for infection, contributing further to the rationale for aggressive management of hyperphosphatemia in dialysis patients. INTRODUCTION Hyperphosphatemia is highly prevalent in dialysis patients and may be associated with immune 1 dysfunction . The association of serum phosphate level with infection remains largely unexamined. Disorders of bone mineral metabolism, including hypo- and hyperphosphatemia, have been shown to be associated with increased risk for all-cause and cardiovascular 2-5 mortality and morbidity in dialysis patients . The risk for infectious morbidity and mortality has also been shown to be increased in patients with increased 6 phosphate levels . Hyperphosphatemia could be associated with the risk for infection in dialysis patients through other mechanisms. Phosphate may act purely as a surrogate for the uremic state, which has also been associated 8 with immune dysfunction . 7 Yoon et al. showed that hyperphosphatemia was directly associated with diminished populations of naive and central memory T lymphocytes. This observation may in part contribute to the acquired impaired immune response of this population, leading to an increased risk for infection. MATERIAL METHOD This study was conducted in Department of Medicine, Dr. B. R. A. M. Hospital Raipur (C.G.) from 2013 to 2014. 100 Indoor patients of both sexes who were diagnosed 22 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195 Serum phosphate levels and infection risk in hemodialysis patients as a case of renal failure that include both Acute Kidney Injury and Chronic Kidney Disease on basis of clinical history, examination, biochemical markers and who were advised for hemodialysis were included in the study. The criteria used for AKI in the study was RIFLE criteria and CKD is diagnosed by KDOQI guidelines. A i m o f o u r st u d y to f i n d o f a s s o c i at i o n o f hyperphosphatemia in hemodialysis patients and its relation with sepsis. All patients will undergo complete clinical examination including pulse, blood pressure, general examination, systemic examination including Local examination at catheter site. Following investigations were done in all the patients whom included: Haematological test (Hb%, TLC, DLC, Platelet count) , RFT (S.creatinine, Blood urea, S.electrolyte), CRP, Serum Phosphorus, LFT (SGOT, SGPT, S.Bilurubin ,S. Total Protein, S. Albumin, Alkaline phospatase), TFT (T3, T4, and TSH) , Viral markers (HBsAg, HCV, HIV), Blood Culture,Central Line Tip Culture , Urine Routine/Microscopy, CXR P/A view, USG Abdomen and KUB. RESULTS Total 100 patients were taken for our study, 15 patients have signs and symptoms of sepsis and their blood culture was positive. Out of these 15 patients, 11 (73.33%) patients have raised serum phosphorus level. In this study group were 63.33 % males and 36.67% were females patients suffering from catheter related infection in the form of fever with chills and rigors, redness and induration over the site of catheter insertion and their blood culture was positive. Mean age in our study was 41.78 ± 13.61 year. 30% patients were diabetic. Among these 11 patients 27.28% patients has mild anemia (Hb 9 – 11 gm%), 36.36% has moderate anemia( Hb 7 - 9 gm%) and 36.36% (Hb < 7gm%) has severe anemia. Mean Hb was 8.18 ± 1.91 m %. Hypoalbuminemia found in 55.55%. Hypothyroidism found in 18.19% patients. 63.37% patients have femoral catheter and 36.63% patients have internal jugular catheter. None has subclavian catheter. Mean duration of dialysis was 15.86 ± 7.19 days. Most common organism found was S. aureus. CRP was high in all these patients. All patients have creatinine level more than 6 mg/dl. On statistical analysis of above observation, data found significant. (P value < 0.005) suggest strong association of serum phosphorus level and infection. Fig showing serum Phosphorus level in Renal Failure patients on hemodialysis DISCUSSION Phosphorus is essential for life. As phosphate, it is a component of DNA , RNA , ATP, and also the phospholipids that form all cell membranes. In addition to being essential for the structural stability of bones and teeth, cell membranes (phospholipids), and nucleic acid molecules, phosphorus plays an important role in metabolic activity such as carbohydrate and energy metabolism that inherently depends on the capacity to phosphorylate intermediate metabolites and to store energy released during oxidation in high-energy phosphate bonds such as ATP or phosphocreatine. Phosphorus is an integral component of 2,3-DPG, a compound that regulates oxygen release from hemoglobin and therefore is critical for oxygen delivery to tissues. Inorganic phosphorus (phosphate, PO4, or Pi) is also an important buffer in the body. Quantification of phosphate levels is useful for diagnosis and management of bone, parathyroid, and renal disease, as well as various other disorders. Refferance range is Age 18 years or older - Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 23 Serum phosphate levels and infection risk in hemodialysis patients 2.5-4.5 mg/dL(Walter Gruenberg 2014) 11 Laura C Plantinga et al (10) conducted a prospective cohort study found that high levels of phosphate i.e > 5.5 mg/dl in 37.3% early in the course of dialysis were associated with increased risk for subsequent infection. This association was not explained by evidence of secondary hyperparathyroidism or uremia as a result of poor dialysis, suggesting that phosphate may be an independent risk factor for infection. They Found sepsis is associated with high level of phosphate level. CONCLUSISON High levels of phosphate early in the course of dialysis were associated with increased risk for subsequent infection. Thus phosphorus can be use as a significant marker of infection in dialysis patients, And More aggressive management of hyperphosphatemia in dialysis patients could result in decreased infectious morbidity among dialysis patients. REFERENCES 1. National Kidney Foundation: Kidney Disease Outcomes Quality Initiative (K/DOQI).Accessed December 15, 2007 2. Block GA, Hulbert-Shearon TE, Levin NW, Port FK: Association of serum phosphorus and calcium x phosphate 3. product with mortality risk in chronic hemodialysis patients: a national study. Am J Kidney Dis 31: 607–617, 1998. 4. 3. Block GA, Klassen PS, Lazarus JM, Ofsthun N, 5. 6. 7. 8. 9. 10. 11. Lowrie EG, Chertow GM: Mineral metabolism, mortality, and morbidity in maintenance hemodialysis. J Am Soc Nephrol 15: 2208–2218, 2004. Melamed ML, Eustace JA, Plantinga L, Jaar BG, Fink NE, Coresh J, Klag MJ, Powe NR: Changes in serum calcium, phosphate, and PTH and the risk of death in incident dialysis patients: A l o n g i t u d i n a l s t u d y. K i d n e y I n t 7 0 : 351–357,2006. Ganesh SK, Stack AG, Levin NW, HulbertShearon T, Port FK: Association of elevated serum PO(4), Ca x PO(4) product, and parathyroid hormone with cardiac mortality risk in chronic hemodialysis patients. J Am Soc Nephrol 12:2131–2138, 2001. Lange LG, Hartman M, Sobel BE: Oxygen at physiological concentrations: A potential, paradoxical mediator of reperfusion injury to mitochondria induced by phosphate. J Clin Invest 73: 1046–1052, 1984. Yoon JW, Gollapudi S, Pahl MV, Vaziri ND: Naive and central memory T-cell lymphopenia in endstage renal disease. Kidney Int 70: 371–376, 2006. Laura C. Plantinga, Nancy E. Fink, Michal L. Melamed, William A. Briggs, Neil R. Powe, and Bernard G. Jaar CJASN Clin J Am Soc Nephrol. Sep 2008; 3(5): 1398–1406. Walter Gruenberg, DrMedVet, MS, PhD, DECAR, DECBHM April 2014 24 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Ayush & Health Sciences University of Chhattisgarh Edentulousness , prosthetic status and prosthetic need of institutionalized elderly people in old age homes of Chhattisgarh R. K. Dubey1, P. Shetty2, D. K. Gupta3, S. Pandey4 1. Professor, Department of Prosthodontics, Government Dental College, Raipur (C.G.) 2. Professor, Department of Prosthodontics, TIDS, Bilaspur 3. Associate Professor, Department of Prosthodontics, GDC, Raipur 4. Lecturer, Department of Prosthodontics, TIDS, Bilaspur Corresponding Author : Dr. R. K. Dubey Professor, Department of Prosthodontics, Government Dental College, Raipur (C.G.) Mob. No.- 9229927756, E-mail ID – [email protected] ABSTRACT: Objectives: A descriptive cross-sectional study was conducted among institutionalized geriatric individuals in cities of Chhattisgarh to assess their oral health status primarily concerned with prosthetic status and needs that would aid in formulating plan for oral health service programs. Materials and methods: The oral examination of the study subjects was carried out using Basic Oral Health Surveys WHO 1997 guidelines. Results: A total of 125 individuals were included in the study out of which 68 were males and 57 were females. 11(8.8%) study participants had some prosthesis at the time of examination, whereas 119 (95.2%) were in need of prosthesis. 51(40.8%) people, with all or more than 20 teeth missing/root stumps, had intense prosthetic need to restore oral function and consequently the general health. 48(39.2%) residents had need of U/L RPD followed by need of U/L CD among 37(29.6%) persons. 15.2%(19) people requires combination of RPD and CD in upper and lower dental arch while 11.2%(14)of residents had need of either FPD or combination of RPD and FPD. Conclusions: The prosthetic status of the institutionalized geriatric individuals in cities of Chhattisgarh is poor with higher unfulfilled prosthetic needs. A planed strategy is needed to address this problem of elderly people. INTRODUCTION: Though aging is an inevitable natural phenomenon, the advancement in medical discoveries and improving socio economic condition has created possible environment of enhanced lifespan throughout the world1. The consequences strengthen the expectation and reflected in literature that there will be 1.2 billion elderly peoples worldwide by 2025 and will reach to the mark of 2 billion by 2050 out of which 80% will belong to 1, 2 developing nation . Mission of the health professional is not merely to increase the life span but also perhaps more importantly to make the later life more productive and enjoyable3. The joint family system and traditional Indian society have been instrumental in safe guarding the social and economic securities of older peoples in country. ISSN 2348 - 4195 However, the rapid change in social scenario and emerging trend of nuclear family set up in India, the elderly people are likely to be exposed physical, emotional and financial insecurities in years to come4. Government of India has adopted 'National policy on senior citizens 2011' to help such elderly peoples and number of programs are being efficiently implemented by various state governments to provide shelter and support to the elderly peoples. The loss of teeth is an end product of oral disease and reflects the attitudes of the patients, the dentists in a society, the availability and accessibility of dental care as well as the prevailing philosophies of care5. The lower socioeconomic condition, cultural misbelieves, unfavorable environmental and demographic situation may further aggravate the causative factors of tooth Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 25 ORIGINAL ARTICLE ORIGINAL ARTICLE Prosthetic status and prosthetic need of institutionalized elderly of CG loss. The barriers to oral health care like, impaired mobility that impedes access to oral health care, financial hardship following retirement, the cost or perceived cost of dental treatment, together with poor attitudes to oral health, may further exaggerated the edentulousness in institutionalized elderly people6. Improved oral health maintains nutritional status of geriatric person and consequently improves their self confidence, ability to contribute their possible services to society and active happy social contacts. Numerous Old age Homes are delivering their sincere help to such elderly with credible support of state government across the whole Chhattisgarh. Oral health care needs of these elderly living in such care facilities has been least addressed till date. In order to promote oral health and formulating a plan for an oral health care program for such institutionalized elderly, we need to acquire the baseline information regarding their oral health status, prosthetic status and prosthetic needs. As of today no data available for state of Chhattisgarh. Hence, an effort was performed to collect this baseline information. were the recording of the number of teeth lost by dental caries/periodontal diseases, number of existing prostheses (if any) and a detailed prosthodontic treatment requirement (Complete removable dental prosthesis, Partial removable dental prosthesis, Fixed dental prosthesis) based on the clinical assessment of the operator and patient's acceptability of the type of treatment. Primary aim was to record all information advocated in 'WHO oral health status assessment form' approved for such investigation in 1997. But, due to practical problems like diminished co-operation for detail examination in older age and inadequate seating arrangement for comfortable periodontal examination with probe, all information as per WHO Performa 1997 had not been recorded. Only status of dentition (decayed, missing, and level of abrasion and attrition) and superficial periodontal health observation (gingival recession, periodontal condition) had been performed. Prosthodontic status and needs were recorded as per WHO oral health status assessment form 1997.The extract of observation was tabulated. Simple statistical analysis was done to draw prosthodontic treatment requirements and prosthetic status in residents of old age homes. MATERIAL AND METHOD: The present study was conducted among elderly peoples residing in old age home of Chhattisgarh with prior written permission of concerned authority and informed verbal &written consent of all individual examined. The examiners were trained and intraexaminer calibration showed a good agreement statically. All the available residents of 5 old age homes of Chhattisgarh had interviewed for their sociodemographic factors like age, sex, education, habits. Clinical examination of dentition status and treatment needs has been performed using a mouth mirror and a Community Periodontal Index Probe in proper light. The assessment of dentition status and treatment needs RESULTS: Total 125 residents were examined from 5 old age home of Chhattisgarh (two from Raipur, one from Durg, Rajnandgoan and Bilaspur). Few residents from each center were not examined due to unavailability on date of examination, not interested for examination or their much compromised general health. Among the examined people, 68(54.4%) and 57 (45.6%) were male and female respectively (Table -1). 52residents (41.6%) were of age group 70-80 yrs followed by 48(38.4%) of 60-70 yrs and 20% (25 residents) were above the age of 80 yrs (Table- 2). Table-1. Total number of residents examined = 125 Table-2. Distribution of subjects by age Male subjects Female subjects 26 = 68 (54.4%) = 57 (45.6%) Age (years) 60-69 70-79 > 80 Total Number of subjects 48 52 25 125 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Percentage 38.4 41.6 20.0 100.0 Prosthetic status and prosthetic need of institutionalized elderly of CG Only 09(7.2%) of the examined residents had fully intact dentition. Among 116(92.8%) of the subjects having 01 or more than 01 teeth loss, 40(32%) person had lost 20 or more than 20 teeth in both arches (Table-3). 17(13.6%) people were fully edentulous. When root stumps were also added with missing teeth it was found that only 7(5.6%) had no tooth mortality. Large number of people (40.8%) had 20 or more than 20 missing teeth and root stump (Table-4). Table-3. Subjects by Number of missing teeth and sex No. of missing teeth 0 01-09 10 -19 ?20 Fully Edentulous Total Male 04(5.88%) 25(36.76%) 16(23.53%) 14(20.58%) 09(13.23%) 68(100%) Female 05(8.77%) 24(42.1%) 11(19.2%) 09 (15.7%) O8 (14.03%) 57(100%) Total 09(7.2%) 49(39.2%) 27(21.6%) 23 (18.4%) 17(13.6%) 125(100%) Table-4. Subjects by Sex and Tooth mortality in form of missing and root stump No. of missing teeth + root stump 0 01-09 10-19 ?20 Total Male 04(5.88%) 18(26.47%) 19(27.94%) 27(39.7%) 68(100%) Prosthetic need were evaluated on the basis of missing teeth, root stumps, tooth/teeth to be extracted due to mobility or gross mutilation of coronal part due to caries, abrasion or attrition . It was observed that 119(95.2%) residents had need of some kinds of dental prosthesis. The overall prosthetic needs in females (96.4%) were little higher than males (94.1%) but statically Female 03(5.2%) 22(38.59%) 08(14.03%) 24(42.1%) 57(100%) Total 07(5.6%) 40(32.0%) 27(21.6%) 51(40.8%) 125(100%) insignificant (table-5). Need for dental prosthesis was slightly higher in lower arch (92.0%) compared to upper arch (87.2%) both among male as well as female subjects but statistically insignificant. Need of multiunit prosthesis in upper [50(40.0%)] or lower arches [52(41.6%)] of the subjects surveyed was highest followed by full prosthesis in upper [45(36.0%)] or lower arches [48(38.4%)] (table-6). Table -5.Correlation between overall prosthetic need and sex Male Prosthetic needs Total n % n 64 94.1 55 68 100.0 57 P-value > 0.1 2 X = 0.539 The surveyed male subjects had highest need of multiunit prosthesis [44.11% in Upper & lower arches respectively] followed by full dental prosthesis in both upper (32.35%) and lower arches (33.82%). Whereas the female subjects Female % 96.4 100.0 Total n 119 125 % 95.2 100.0 experienced highest need of full dental prosthesis [U (40.35%) & L (43.85%)] followed by multiunit prosthesis in upper (35.01%) or lower arches (38.59%) [table-6]. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 27 Prosthetic status and prosthetic need of institutionalized elderly of CG Table -6. Prosthetic needs in Subjects by jaw type and sex (oral health assessment criteria 1997) Prosthetic needs No prosthesis needed Need for one unit prosthesis Need for multi unit prosthesis Need for combination of oneand/or multi unit prosthesis Need for full prosthesis Total Male 10 (14.71%) 04 (5.88%) 30 (44.11%) 02 (2.94%) 22 (32.35%) 68 (100%) Upper Arch Female 06 (10.52%) 04 (7.01%) 20 (35.01%) 04 (7.01%) 23 (40.35%) 57 (100%) Total 16 (12.8%) 08 (6.4%) 50 (40.0%) 6 (4.8%) 45 (36.0%) 125 (100%) In terms of need for RPD, FPD, CD and Combination of RPD& FPD the surveyed subjects experienced highest need of RPD followed by CD. The male subjects had same pattern of need as the overall subjects. But the females entailed more need of CD compared to RPD in both upper and lower arches (table-7). It has been observed that only 11(8.8%) residents have Lower Arch Male 06 (8.82%) 04 (5.88%) 30 (44.11%) 05 (7.35%) 23 (33.82%) 68 (100%) Female 04 (7.01%) 03 (5.26%) 22 (38.59%) 03 (5.26%) 25 (43.85%) 57 (100%) Total 10 (8.0%) 07 (5.6%) 52 (41.6%) 08 (6.4%) 48 (38.4%) 125 (100%) availed opportunity to get dental prosthesis fabricated, however only 06(4.8%) subjects were wearing the prosthesis successfully. Prosthetic status in females (7.02%) was poor compared to males (12.3%) [table-08] . The prosthetic status in surveyed subjects was nearly same in both and upper arches. Table -7.Prosthetic need in Subjects by sex and jaw type (In terms of RPD, CD and FPD) Prosthetic needs No need RPD FPD Combination of RPD& FPD CD Total MALE UPPER LOWER ARCH ARCH 10(14.71%) 06(8.82%) 28(41.17%) 33(48.52%) 06(8.82%) 01(1.47%) 02(2.94%) 05(7.35%) FEMALE UPPER LOWER ARCH ARCH 06(10.52%) 04(7.01%) 20(35.08%) 22(38.59%) 04(7.01%) 03(5.26%) 04(7.01%) 03(5.26%) TOTAL UPPER LOWER ARCH ARCH 16(12.8%) 10(8.0%) 48(38.4%) 55(44.0%) 10 (8.0%) 04(3.2%) 06(4.8%) 08(6.4%) 22(32.35%) 68(100%) 23(40.35%) 57(100%) 45(36.0%) 125(100%) 23(33.82%) 68(100%) 25(43.86%) 57(100%) 48(38.4%) 125(100%) Table -08 Overall Prosthetic Status by sex Prosthetic Status No prosthesis Prosthesis ( RPD, FPD or CD) wearer in U/L or U and L both arch Total Male Number of subjects 61 % 89.7 Female Number of % subjects 53 92.98 7 12.3 4 7.02 68 100.0 57 100.0 *Unsatisfied with dental prosthesis and not wearing the prosthesis 28 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Total Number of % subjects 114 91.2 11 (5 US*) 125 8.8 (4.0) 100 Prosthetic status and prosthetic need of institutionalized elderly of CG Table -09 Prosthetic Status by sex and jaw type Prosthetic status No prosthesis Bridge/ Crown >one Bridge Partial denture Both Bridges & Partial Denture Full mouth Removable denture Total MALE UPPER ARCH 61(89.7%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) LOWER ARCH 61(89.7%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) FEMALE UPPER ARCH 54(94.3%) 00(0.0%) 00(0.0%) 01(.17%) 00(0.0%) 7(32.35%) 7(33.82%) 2(40.35%) 2(43.86%) 09( 05US*) (7.2%) 09( 05US*) (7.2%) 68(100%) 68(100%) 57(100%) 57(100%) 125(100%) 125(100%) LOWER ARCH 53(92.9%) 00(0.0%) 00(0.0%) 02(.34%) 00(0.0%) TOTAL UPPER ARCH 115(92.0%) 00(0.0%) 00(0.0%) 01(0.8%) 00(0.0%) LOWER ARCH 114(91.2%) 00(0.0%) 00(0.0%) 02(1.6%) 00(0.0%) *Unsatisfied with dental prosthesis and not wearing the prosthesis DISCUSSION119(95.2%) people residing in old age homes of Raipur, Bilaspur, Durg and Rajnandgoan (Chhattisgarh) had one or more than one teeth missing / root stumps and they had need of dental prosthesis. This result is a little higher but nearly accordance with similar studies conducted by S. Chaware et.al.7 and Suryakant C. 8 Deogade et.al. among subjects of old age homes of Nasik (MH) and Jabalpur(MP) respectively. But it is much higher than some like studies 9-11 carried out in Indian places reporting prosthetic needs within range of 70-80%. Almost all the current studies 12-16 from places of world other than India reported edentulousness more than 70% in elderly peoples. Reason for higher prosthetic needs among institutionalized elderly may ascribe to old age and factors associated with old age such as reduced salivary flow rate, quality and quantity, lowered immunity and the reduced ability of the body 17 to repair itself . Several other factors such as multiple chronic diseases, intake of several medications and their side effects, psychological factors such as depression and isolation (because of gradual loss of spouse and friends and feeling of being unwanted by family members), feeling of low self worth owing to loss of earning power and social recognition which leads to 18, 19 poor oral hygiene health , may result into higher edentulousness and prosthetic needs. 51(40.8%) of the surveyed people had all or more than 20 teeth missing/root stumps out of which 17(13.7%) subjects were fully edentulous. The prevalence of edentulism apparently looks lower than the report of World Oral Health 2003o i.e.19% in Indian population but it appeared much higher in terms of need of full dental prosthesis in our study. The reason might be the involvement of the socio economically disadvantaged elderly subjects who were deficient to avail the already scant dental facilities for extraction of the mobile / grossly decayed teeth. The loss of more than 20 teeth badly affects oral function and consequently the general health of these people. Thus, they have intense call for restoration with dental prosthesis as early as possible. The examined men had little lower overall dental prosthetic need compared to women. The women experienced more need of full dental prosthesis compared to men whereas the men were in more need of multiunit prosthesis compared to women. These findings are supported in an analogous study 8 performed. However results are contrast to the similar studies7,10,11conducted at other places in India. The social & economical dependency since the beginning and much higher illiteracy in the women surveyed in this study may be one reason for such results. The post menopausal osteoporotic changes in the women may also be a contributory factor. The prosthetic status observed among residents of old age homes of Chhattisgarh is very poor. Only 11(8.8%) persons had availed the facility of dental prosthetic treatment out of which 5(4.0%) were unsatisfied with their prosthesis and not using the prosthesis. Thus, merely 4.8% (6) of the examined old age home dwellers had successful dental prosthesis. The prosthetic status in females was more worrying compared to males. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 29 Prosthetic status and prosthetic need of institutionalized elderly of CG Comparable outcome were observed by R P Shenoy et.al. (12%)10, A Srivastava et.al.11 (~11.5%) and V Bansal 9 et.al.(13.8%) in institutionalized elderly. A little better prosthetic status(≥30%) was noticed in like studies by S Chaware et.al.7,S C Deogade et.al8. and V Thakare et.al.20 All the like mentioned studies were reported poor prosthetic status in females compared to males as recognized in our study. The poor prosthetic status among subjects of present study may be due to the fact that institutionalized elderly underuse the available dental facilities due to lack of awareness, financial constraint, lack of interest, reduced mobility and components of dental care like poor access to services and higher costs of dental care. The dependency on their counterpart (males), higher level of illiteracy and lack of self earning in our society may further worsen the prosthetic status in females. CONCLUSION: The findings of this survey demonstrate a high unmet need for prosthetic care among the population of old age homes of Raipur, Bilaspur, Durg and Rajnandgoan. Most of the institutionalized elderly also requires extraction. The Study demonistrates that most of the residents have lack of knowledge as well as priority for oral health. Thus it is suggested to initiate immediate preventive measure programs to reduce edentulousness and provide oral health care & rehabilitation facilities to these residents with help of state government, non-government organization, nearby dental institution and private institutions. Acknowledgment; Sincere thanks to Department of Social and Family welfare, Chhattisgarh for the permission to perform the study, especially Rajesh Tiwari, Deputy Director and Mr. M. L.Pandey, Joint Director for their kind support throughout the survey. We would also like to thanks all participants who have contributed to the completion of this study. REFERENCES; 1. United Nations Population Division. World population prospects: 332 the 2002 revision, New York, 2003. http://www.un.org/esa/ 333 population/publications/wpp2002/WPP2002HIGHLIGHTSrev1. 334 PDF. 2. World Health Organization (2002) Active ageing: a policy 344framework. WHO, Geneva 30 3. Goel P, Singh K, Kaur A, Verma M . Oral health care for 339 elderly: identifying the needs and feasible strategies for service 340 provision. Indian J Dent Res2006; 17:11–21 4. N a t i o n a l p o l i c y o n o l d e r persons.www.socialjustice.nic.in/hindi 342/pdf/npopcomplete.pdf. Accessed on 24.05.2014 5. Burt BA and Eklund SA. Tooth loss. Dentistry, D e n ta l P ra c t i c e a n d t h e C o m m u n i t y. W.B.Saunder Company. Philadelphia. 5th edition: 203-211 6. Zarb GA, Bolender CL. Prosthodontic th treatment for edentulous patients. 12 ed. St. Louis: Mosby, 2004:6–23. 7. Chaware S, Ghodpage SL, Sinha M, Chauhan V, Thakare V. Prosthetic Status and Prosthetic Needs among Institutionalized Geriatric Individuals in Nashik City,Maharashtra: A Descriptive Study. J Contemp Dent Pract 2011;12 (3):192-195. 8. Suryakant C. Deogade, S. Vinay, S. Naidu Dental Prosthetic Status and Prosthetic Needs of Institutionalised Elderly Population in Oldage Homes of Jabalpur City, Madhya Pradesh, India. J Indian Prosthodont Soc.2013 . 9. Bansal, GM Sogi, KL Veeresha Assessment of oral health status and treatment needs of elders associated with elders' homes of Ambala division, Haryana, India Indian J Dent Res 2010;21:244-7 10. R. P. Shenoy and V. Hegde Dental Prosthetic Status and Prosthetic Need of the Institutionalized Elderly Living in Geriatric Homes in Mangalore: A Pilot Study ISRN Dent. 2011; 11. A. Shrivastav, A. Bhambal, V. Reddy,M. Jain Dental prosthetic status and needs of the residents of geriatric homes in Madhya Pradesh, India J. Int Oral Health 2011;3(4):9- 14 12. Bonakdarchian M, Ghorbanipour R, Majdzadeh F, Hojati T. Prevalence of edentulism among adults aged 35 years and over and associated factors in Yasooj (Iran). Journal of Isfahan Dental School 2011; 7(1):101-4 13. Mamai-Homata E, Margaritis V, Koletsi-Kounari H, Oulis C, Polychronopoulou A, Topitsoglou V. Tooth loss and oral rehabilitation in Greek Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Prosthetic status and prosthetic need of institutionalized elderly of CG middle-aged adults and senior citizens. Int J Prosthodont. 2012;25(2):173-9. 14. Nadia Khalifa, Patrick F. Allen, Neamat H. Abubakr, and Manar E. Abdel-Rahman4. Factors associated with tooth loss and prosthodontic status among Sudanese adults Journal of Oral Science2012; 54(4):303-312. 15. Adrienne Nickles, Dr. Sheila Vandenbush et. al. Results from a 2010 Oral Health Screening and Needs Assessment of Michigan Residents and Managers of Alternative Long-Term Care F a c i l i t i e s . http//www.michigon.gov./senior_smile_repor t_final_050311_355 assesed on Accessed on 24.05.2014 16. Kethy Phipps, Nicole Laws et. al. The Commonwealth's High-Risk Senior Population; Results and Recommendations from 2009 Statewide Oral Health Assessment in 17. 18. 19. 20. M a s s a c h u s e t t s . www.mossgov/eohhs/doc/../senior-oralhealth-assessment-report pdf Navazesh M. Dry mouth: aging and oral health. Compend Contin Educ Dent2002;23(10):41–48 Ganguli M, Dube S, Johnston JM, Pandav R,Chandra V, Dodge HH. Depressive symptoms,cognitive impairment and functional impairment in a rural elderly population in India: a Hindi version of the geriatric depression scale (GDS-H). Int J Geriatr Psychiatry 1999; 14: 807–820. Shah N. Geriatric oral health issues in India. Int Dent J 2001; 51: 212–218. Thakare V, Ajith Krishnan CG. Periodontal status, prosthetic status and prosthetic needs among institutionalized geriatric individuals in Vadodara City, Gujarat—A descriptive study. J Ind Asso Public Health Dentistry 2010(15):15357. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 31 Ayush & Health Sciences University of Chhattisgarh ORIGINAL ARTICLE ORIGINAL ARTICLE Trends in epidemiology of oral cancer in central part of India in Madhya Pradesh : An institutional study 1 2 Vanita Rathod , Chandan Rathod 1. Professor, Department of Oral Pathology, Rungta College of Dental Sciences & Research Centre, Bhilai (CG) 2. Lecturer, Department of Prosthodontics, Rungta College of Dental Sciences & Research Centre, Bhilai (CG) Corresponding Author : Dr. Vanita Rathod Professor, Department of Oral Pathology, Rungta College of Dental Sciences & Research Centre, Bhilai (CG) E: mail: [email protected] ABSTRACT Objective: The purpose of the study was to identify trends in incidence rates of oral squamous cell carcinoma (OSCC) at specific anatomic sites or within specific age or sex groups in the central Madhya Pradesh population. Materials and Methods: The study covers the period of January 2007 through July 2011. OSCC cases were retrospectively analyzed for site, age, gender, habits and histopathological grading. And the findings were formulated to chart the trends in Madhya Pradesh. Results: The study revealed a male to female ratio of 2:1 with the largest number of OSCCs developing in the peak age of 46-55 years. Overall, the most common site was the alveolar mucosa and buccal mucosa followed by tongue, palatal mucosa, floor of mouth, retro molar area. Smokeless tobacco habit was more prevalent than smoking tobacco in both men as well as women. Smokeless tobacco in the form of gutkha is more prevalent in this region. Conclusion: OSCC is significant cause of mortality and morbidity worldwide with an incidence rate that varies widely by geographic location. Even within one geographic location, the incidence varies among group categorized by age, sex, site or habits. Key words : epidemiology, oral squamous cell carcinoma, trends. INTRODUCTION Squamous cell carcinoma is the most common malignant neoplasm of the oral cavity and represents about 90% of all oral malignancies. 1 Oral squamous cell carcinoma (OSCC) is significant cause of morbidity and mortality worldwide with an incidence rate that varies 2 widely by geographic location. In India, oral cancer represent a major health problem constituting up to 40% of all cancer in males and the third most prevalent in females. Even within one geographic location, the incidence varies among groups categorized by age, sex, 1,2 or race. Recent publications have highlighted variations in oral cancer trends by geographic area are vital for many reasons including understanding the extent of the problem , determining which groups within the population are at highest and lowest risk, and relating the burden of oral cancer, consequently it helps in evaluating the allocation of resources for research, prevention, treatment and support services3,4 Despite several diagnostic and therapeutic advances, the overall incidence and mortality associated with OSCC are rising. The current estimates of age-standardized incidence and mortality is and 3.1/100,000 and 2.9/100,000 in men and women respectively. 5 32 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195 Trends in epidemiology of oral cancer in central part of India not included in this study. Charts were made listing the age, sex, site, habits and histopathology grading of eighty OSCC patients. A comprehensive analysis was done on the data collected and the results were formulated. Studies reported on the incidence and pattern of OSCCs from various parts of the world is 4.7./100000. However, very few studies have reported on the incidence and trends of OSCCs in Madhya Pradesh (M.P.) population. The purpose of this retrospective study was to identify trends in the number of cases or incidence rates of OSCCs at specific anatomic sites or within specific age or sex groups in the Madhya Pradesh population. RESULTS: Of the 82 OSCC patients, males represented a higher proportion (66%) of squamous cell carcinomas than females (33%) {Diagram 1}. Larger numbers of cases were seen to develop in 46-56 years followed by 36-45 and 25-35 years. Over all alveolar mucosa and buccal mucosa were the most common sites involved 42.5%, and 37.5% respectively. While the floor of the mouth, retromolar areas showed least incidence in this region of India (3.7%) {Diagram 2}. The study also revealed that larger number of patients had the smokeless tobacco in the form of gutkha and quid chewing than the bidi and cigarette smoking habit. {Diagram 3} MATERIALS AND METHODS 82 Histologically proven in cases of OSCCs verified in the oral pathology and microbiology from January 2007 to July 2011 were extracted from the archives of Hitkarini dental college Jabalpur. The anatomic sites included in the study were alveolar mucosa, buccal mucosa, floor of mouth, retro molar area, tongue and hard palate. As the pathophysiologic and epidemiologic behavior of the lip cancer is believed to be substantially different from the oral cavity sites, cancers originating in the lip were Table 1: OSCC trends in central part India in M.P. population according to age, sex, site and habits. SEX male female SITE PM LM BM AM 25-35 5 7 4 4 7 4 1 36-45 5 11 5 7 11 3 2 46-55 20 10 13 11 2 1 2 1 20 6 4 56-65 10 4 4 2 - 2 1 1 9 3 2 66-75 4 3 3 3 1 1 1 5 2 76-85 - 2 1 1 1 1 86-95 1 Total 45 FM RA SL 2 37 30 30 HABITS ST NH 1 2 4 4 3 53 20 9 Sites S: BM-Buccal mucosa, AM-Alveolar mucosa, PM-Palatal mucosa, LM- Labial mucosa, FM- Floor of mouth, RARetro molar area. Habits : SL- Smokeless Tobacco (gutakha & quid chewing), ST- Smoking tobacco and NH- No habits . Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 33 Trends in epidemiology of oral cancer in central part of India DISCUSSION: Diag. 1: OSCC in 82 patients (Gender with respect to age) The incidence of OSCC seems to be increasing and is global health problem with increasing incidence and mortality rates. Around 3,00,000 patients are annually 4,7,8 estimated to have oral cancer worldwide. OSCC is known to show geographic variation with respect to the age, site, sex and habits of the population.1,2,4,8,9 The present study revealed a male to female ratio of 2:1 with the largest number of OSCCs developing in peak age of 46-55 years. This is consistent with an earlier 8 report by Mehrotra and coworkers confirming that oral cancer in Northern India was a disease of the middle aged men. An epidemiologic study on palatal changes in reverse smokers conducted in Andhra 10 Pradesh (Southern India) by Mehta et al. showed a predominance of females in the middle age group (3554years). Regarding the site of preference for intra-oral SCC, our study showed some degree of variation from most of the studies conducted at Spain, Canada, Scandianavia 11-13 and some part of India. A retrospective study 14 conducted by S. manuel and co-workers, in 2003, at the regional Cancer (RCC), Thiruvananthapuram Kerala analyzed one of the largest series of young patients under the age of 45 years having SCC of the oral tongue. Diag. 2: OSCC in 82 patients (Sites with respect to age) In the present study, the alveolar mucosa and buccal mucosa were the most frequent involved sites (41 and 37.5% respectively) while the floor of mouth was the least commonly involved site (3.75%). These regional difference may be attributed to the exclusive use of chewing tobacco in the India subcontinent compared 12-14 to smoking in the west. SCC of buccal mucosa is one of the most common cancers along the geographical belt extending from central to south east asia because of practice of chewing pan a combination of tobacco, 15 nut and lime. In contrast, the lateral tongue and floor of mouth are the more commonly involved site in the 11-13 rd West. The anterior 2/3 of the tongue is commonly involved in India, while the posterior lateral border and ventral surfaces are frequently involved in the United State.(8 In 1969,the result of first epidemiologic survey of Diag. 3: OSCC in 82 patients (Habits with respect to age) 34 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Trends in epidemiology of oral cancer in central part of India palatal changes in reverse smokers in the Srikakulam district of Andra Pradesh in India was reported by 10 Mehta FS et al, who later emphasized that the palatal changes seen in reverse smokers exhibited greater clinical variation than the leukokeratosis nicotina palate known from the Western countries. Earlier, OSCC was thought to be a disease primarily of the elderly. 1,2 Some recent studies conducted in united states, South East of England, Spain and Scandinavia have , however, shown that the incidences of oral cancer are increasingly being reported in the young (<40 years of age) also particularly younger male patients.13,14,16,17 Our study finds increasing number of OSCC cases being recorded th th in the 4 and 5 decades of life. This may be related to the habits like tobacco and alcohol. Men represented a higher proportion of OSCCs than women simulating the trends in many recent publications.3,6,11,18 Some studies show the opposite trend with the increased incidence among women, which may be due to the changing social habit in the high socioeconomics groups or cultural habits of some 10,16 rural area of India. Interestingly, 3.75% of the patient were not associated with any habits like tobacco smoking or chewing in our study, Probably attributed to other etiological factors of OSCCs like certain viruses (such as human papilloma virus), low consumption of 16 fruits and vegetables, genetic predisposition ,etc. Gutkha chewing or Pan chewing were the most prevalent habits recorded in the study. The incidence was highest at mucosal sites with prolonged contact with carcinogens. There has been strong evidence that smokless tobacco can cause oral cancer and 8 precancerous oral lesions like leukoplakia. smokeless tobacco is thought to induce cancer in regions where it is held in direct contact, such as the cheek or gum.8 The clinicopathological profile of Indian oral cancers shows significant differences from oral cancer in several developed countries of world, including the USA, UK, France and Japan, where it is associated with tobacco smoking with or without alcohol consumption 19 CONCLUSSION: As useful clinical information on the trends of OSCCs among mid of the central part of India in Madhya Pradesh population is limited, this retrospective study was undertaken to present a compressive data on the trends of OSCC in M.P. population. Different levels of tobacco and alcohol exposure, diet, socio economic circumstances factors in the diff age, gender and sites are the causative factors in the difference seen in the incidence rates of OSCC in various populations globally. Because of the magnitude of the oral cancer problem and trends reported serious thought should be given to plans for prevention and early detection of premalignant and malignant oral diseases in central part of India in M.P. race, ethnicity and age cannot be altered; however, lifestyle behavior such as use of tobacco and alcohol are amenable to change and increased intake of fruits and vegetables must be addressed. The dental profession has a well deserved reputation for preventing other oral diseases. Now is time to focus on the prevention and early detection of oral cancer. REFERENCES: 1. Lawoyin JO, Lawoyin DO,Aderinokun G. IntraOral squamous cell carcinoma in Ibadan: a review of 90 cases. Afr J Med Sci 1997; 26:1878. 2. Howell RE, Wright BA, Dewar R. Trends in oral cancer in Nova scotia from 1983 to 1997. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95:205-12. 3. Schantz SP, Yu Gp, Head and Neck cancer incidence trends in young American, 19731997, with aa special analysis for tongue cancer. Arch Otolaryangol Head Neck SURG 2002 ; 128:268-74. 4. Rautava J, Luukkaa M, Heikinheimo K, Happone RP. Squamous cell carcinomas arising from different types of oral epithelia differ in their tumour and patient characteristics and survival. Oral Oncol 2007; 43:911-9. 5. Carvalho AL, Singh B, Spiro RH, Kowalski LP, Shah JP. Cancer of the oral cavity: a comparison between institutions in a developing and a developed nation, Head Neck 2004; 26:31-8. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 35 Trends in epidemiology of oral cancer in central part of India 6. Llewelly3n CD, Linklater K,Bell J, Johnson NW, Warnakulasuriya KA. Squamous cell carcinoma of the oral cavity in the patients aged 45 years and under: a discriptiveanalysis of 116 cases diagnosed in the south east of England from 1990 to 1997. Oral Oncol 2003; 39:106-14. Med Oral Pathol Oral Radiol Endod 2004; 98:546-52. 13. Annertz K, Anderson H, Biorklund A, Moller T, Kantola S, Mork J, et al. incidence and survival oral squamous cell carcinoma of the tongue in Scandinavia, with spcial reference to young adults. Int J Cancer 2004; 101:95-9. 7. Funk GF, Karnell LH, Robinos RA, Zhen WK, Trask DK, Hoffiman HT. Presentation, treatment, and outcome of oral cavity: a national cancer data base report. Head Neck 2002; 24:165-80. 14. Manuel S, Raghavan SK, Pandey M, Sebastian P. Survival in patients under 45 tears with squmaous cell carcinoma of the tongue. Int J Oral Maxillofac Surg 2003; 32:167-73. 8. Mehrotra R, Singh MK, Pandya S, Singh M. The use of an oral brush biopsy without computerassisted analysis in the oral lesions. A study of 94 patients. Oral Surg Oral Pathol Oral Radiol Endod 2008; 106:204-53. 15. Diaz EM Jr, Holsinger FC, Zuniga ER, Robert DB, Sorensen DM. Squamous cell carcinoma of the buccal mucosa: one institution's experience with 119 previously untreated patients. Head Neck 2003; 25:267-73. 9. Shiboski CH, Shiboski SC, Silverman S Jr.Ttrends in oral cancer rates in the united states, 19731996. Community Dent Oral Epidemiol 2000; 28:249-56. 16. Silverman S Jr. demographic and occurrence of oral and pharyngeal cancers. The outcomes, the trends, the challenge. J AM Dent Assoc 2001; 132:57-11. 10. Mehta FS, Jalnawalla PN, Daftary DK,Gupta PC,Pindborg JJ. Reverse smoking in Andhra Pradesh, India: variability of clinical and histologic appearance of palate changes. Int J Oral Surg 1997; 6:75-83. 17. Rodriguez T Altieri A, Chatenoud L, GallusS,et al. risk factors for oral and pharyngeal cancer in young adults. Oral Oncol 2004; 40:207-13. 11. Martin-Granizo R, Rodriguez-Campo F, Naval l, Diaz Gonzalez FJ. Squamous cell carcinoma of the oral cavity in patients younger than 40 years. Otolaryngyol Head Neck Surg 1997; 117:268-75. 12. Gorsky M, Epstein JB, Oakley C, Le ND, Hay J, Stevenson- Moore P. Carcinoma o f tongue : a series analysis of clinical presentation, risk factors, staging, and outcome. Oral Surg Oral 18. Shiboski CH, Schmidt BL, Jordan RC. Tongue and tonsil carcinoma increasing trends in the U.S. population ages 20-44years. Cancer 2005; 103:1843-9. 19. Jane C, Nerurkar AV, Shirsat NV, Deshpande RB, Amrapurkar AD, Karjodkar FR. Incresed surviving expression in high grade oral squamous cell carcinoma: a study in Indian tobacco chewers. J Oral Pathol Med 2006; 35:595-601. 36 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Ayush & Health Sciences University of Chhattisgarh Assessment of dental aesthetic index among school children of Bilaspur, Chhattisgarh : A pilot study 1 2 3 4 5 6 R S Makkad , Madhu Pandey , S Hamdani , V. Agrawal , M Motlani , Gunjan Agrawal 1. 2. 3. 4. 5. 6. Lecturer, Department of Oral Medicine & Radiology, New Horizon Dental College and Research Institute, Bilaspur, (CG) Lecturer, Department of Orthodontics, Rungta Dental College and Hospital, Bhilai, (CG) Post Graduate, Department of Orthodontics, Rungta Dental College and Hospital, Bhilai, (CG) Lecturer, Department of Oral and Maxillofacial Surgery, Maitri Dental College, Anjora, Durg (CG) Lecturer, Department of Endodontics, Chhattisgarh Dental College and Research Institute, Rajnandgaon (CG) Lecturer, Department Oral and Maxillofacial Surgery, Pt. Jawaharlal Nehru Medical College, Raipur (CG) Corresponding Author: Dr. Ramanpal Singh Makkad Lecturer, Department Oral Medicine & Radiology, New Horizon Dental College and Research Institute, Bilaspur, (CG) Mobile no- 090986 99300 email: [email protected] ABSTRACT Objectives-This study is to know the prevalence of malocclusion and orthodontic treatment needs among 12-15yr old school children of Bilaspur. Materials and Methods-A total of 351 study subjects were selected based on convenience sampling and examination was carried out under natural light and data was recorded using WHO Proforma 1997. The collected data was subjected to statistical analysis using SPSS16. Results-Out of the 351 children examined, 46.2% were boys & 53.8% were girls and their mean age was 13.89yrs. One and two segment crowding was seen in 24.5% & 11.4% respectively. Normal molar relation was seen in 80.3% of children. Definite, severe and very severe or handicapping malocclusion was seen in 9.7%, 4.3% & 3.4% of children respectively. There is no statistically significant difference in malocclusion status between boys and girls. Conclusion-Only 4.3% and 3.4% of children required highly desirable and mandatory orthodontic treatment needs. KEYWORDS- Malocclusion, Dental Aesthetic Index, OrthodonticTreatment needs. INTRODUCTION Dento-facial appearance has a lot to do with the way the people are perceived in the society.1 People equate good dental appearance with success in many aspects.2 Social interactions that have a negative effect on self-image, career advancement and a peer group acceptance have been associated with an unacceptable dental 3 appearance. The prevalence of malocclusion varies from country to country and among different 1 races. The reasons to develop malocclusion could be genetic or environmental and/or combination of both the factors along with various local factors such as adverse oral habits, tooth anomalies, form ISSN 2348 - 4195 and developmental posit ion of teeth can cause malocclusion. Orthodontics has traditionally focussed on children and adolescents.4 There is an increases concern for dental appearance during adolescents to early childhood has been observed.2 Malocclusions are 3rd in the ranking of priorities among the problems of dental public health worldwide, surpassed only by dental cavity and 5 periodontal diseases. The benefits of taking orthodontic treatment are to prevention of tissue damage and correction of aesthetic component, 2 improve the physical function . A variety of indices have been developed to assist professionals in categorizing malocclusion according to the Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 37 ORIGINAL ARTICLE ORIGINAL ARTICLE Assessment of dental aesthetic index 6 treatment needs . Dental Aesthetic Index (DAI) introduced by Cons et al(1986), which links clinical and aesthetic components. It was developed originally based on North American Caucasian 7 sample. The World Health Organization concerning to acknowledge the real malocclusions conditions in different countries, adopted it as a cross cultural index and advocated it in the 4th Edition of the Manual of Basic Oral Health Survey, so there would be a suitable instrument to gather epidemiological data collection and assessment of 5,7-9 orthodontic treatment needs . DAI is proven to be reliable, valid, versatile, simple and easily 7,9 applied index . Most of the malocclusion can be corrected if detected early by correctional methods.1 This study was intended to evaluate the prevalence of malocclusion, its severity and the orthodontic treatment needs using DAI, among 1215yr old school children of Bilaspur, Chattishgarh. MATERIALS AND METHODS: The present study was conducted among 12-15yr old school children of Bilaspur, Chattishgarh. The schools were selected based on convenience sampling. A total of 351 school children of both sexes were selected for the study based on convenience sampling. Approval was obtained from the concerned authorities before the start of the study. All examinations were performed at schools while children were seated on chair under normal illumination. The examiners were trained and intra-examiner calibration was done. Kappa statistics showed a good agreement. Sufficient number of autoclaved instruments was taken to the examination site. The WHO Proforma (1997) was used to assess the malocclusion. Data collected was coded, processed and subjected to statistical analysis using SPSS version16. RESULTS The study population consisted of about 351 school children aged 12-15years in Bilaspur city, out of which 46.2% were males and 53.8% were females (Table 1). Table 2 shows the distribution of DAI components. Out of 351 school children, 24.5% had one segment crowding and 11.4% had two segments crowding. One and two segment spacing was seen in 8.5% and 1.7% school children respectively. Diastema of 1-3mm was seen among 5.7% of the study subjects. Largest maxillary irregularity of 0, 1-3 and >3mm was seen among 80.9%, 17.1% and 2% of school children respectively. Largest mandibular irregularity of 0, 1-3 and >3mm was seen among 72.1%, 27.6% and 0.3% of school children respectively. Maxillary over-jet of 0-3mm is considered normal and was seen among 76.4% of school children and >3mm was seen among 23.6%of school children. Mandibular overjet of 0-3mm was among 99.4% of school children and 0.6% of them had >3mm of overjet. Open bite of >3mm was seen among 0.9% of study subjects. Molar relation was normal among 80.3% of school children whereas half cusp and full cusp molar relation was seen among 14.8% TABLE 1. AGE WISE DISTRIBUTION OF STUDY POPULATION AGE 12 13 14 15 TOTAL FREQUENCY 13 95 133 110 351 PERCENTAGE 3.7 27.1 37.9 31.3 100 38 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Assessment of dental aesthetic index ASSESSMENT OF DENTAL AESTHETIC INDEX TABLE 2: DISTRIBUTION OF DAI COMPONENT DAI COMPONENTS CROWDING 0 0NE SEGMENT TWO SEGMENT SPACING 0 0NE SEGMENT TWO SEGMENT DIASTEMA 0 1-3 LARGEST MAXILLARY 0 IRREGULARITY(mm) 0-3 >3 LARGEST MANDIBULAR 0 IRREGULARITY(mm) 0-3 >3 MAXILLARY OVERJET (mm) 0-3 >3 MANDIBULAR OVERJET(mm) 0 >3 OPEN BITE(mm) 0 >3 MOLAR RELATION NORMAL HALF CUSP FULL CUSP PERCENTAGE (%) 64.1 24.5 11.4 89.7 8.5 1.7 94.3 5.7 80.9 17.1 2 72.1 27.6 0.3 76.4 23.6 99.4 0.6 99.1 0.9 80.3 14.8 4.8 TABLE 3: DISTRIBUTION OF THE SUBJECTS ACCORDING TO DAI SCORES, SEVERITY OF MALOCCLUSION, TREATMENT NEEDS AND GENDER (P=3.946). DAI SCORE <25 26-30 31-35 >35 TOTAL Severity Of Malocclusion No/ minor Malocclusion Definite Malocclusion Severe Malocclusion Very severe or handicapping malocclusion Treatment Indicated No/slight Treatment Elective Highly Desirable Mandatory MALE (%) FEMALE (%) TOTAL (%) 84 81.5 82.6 8 11.1 9.7 3.1 5.3 4.3 4.9 2.1 3.4 100 100 100 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 39 Assessment of dental aesthetic index and 4.8% of school children. There was no statistically significant difference between the DAI scores and the gender. Table 3 shows the distribution of according to DAI score, severity of malocclusion, treatment indicated and gender. 4.3% and 3.4% of the study subjects had severe and very severe malocclusion respectively and required highly desirable and mandatory orthodontic treatment needs. DISCUSSION Many epidemiological studies have been conducted worldwide utilizing various indices for quantifying the extent of malocclusion.1 Crowding of incisal segment affects half of all children in mixed dentitions and it worsens in adolescent years as the permanent teeth erupt and continues 2 to increases as the age progresses. In the current study, 35.9% of the study population had incisal crowding. The results of the current study are in correlation with the study conducted by Shivakumar et al2 and in contrast with a study conducted by Bhardwaj et al1. Both the upper and lower incisal segments were examined for spacing. In the present study, 10.2% had incisal segment spacing either in one or both the arches which was in correlation with the study conducted by Artenio 5 Jose Isper Garbin et al . Diastema>1mm was seen among 5.7% of school children and this result was in correlation to the study conducted by Artenio 5 Jose IsperGarbin et al . Irregularity may occur with or without crowding. In the current study, 19.1% of the children had maxillary anterior irregularity of >1mm, and the results are in correlation with the study conducted by Shivakumar et al2 and Artenio Jose IsperGarbin et al5. 27.9% had mandibular anterior irregularity >1mm and the result were in contrast with the study conducted by Bhardwaj et al1, DS Rwakatema et al8, B. Eduardo and F.M Carlos9. In the present study, maxillary overjet of >3mm was seen in 23.6% and it was similar to the study conducted by B. Eduardo and F.M Carlos9 and 1 Bhardwaj et al and in contrast to a study 10 conducted by Matilda Mtaya et al . Mandibular overjet of >3mm was seen in 0.6% of school children and it was in correlation with 2 studies conducted by Shivakumar et al , DS Rwakatema et al8 , Bhardwaj et al1 and Artenio Jose IsperGarbin et al5. An anterior openbite of >3mm was seen in 0.9% of school children which was similar to studies conducted by Bhardwaj et al1 and B. Eduardo and F.M Carlos9. Normal molar relation was seen in 80.3% of the school children and which was similar 1 to the study conducted by Bhardwaj et al and was in contrast with the study conducted by Artenio 5 Jose IsperGarbin et al . Definite malocclusion was seen in 9.7% of the school children, severe malocclusion was seen in 4.3% of school children and very severe or handicapping malocclusion was seen in 3.4% of children. Similar results were found in the study conducted by Vijaya Hedge and RekhaShenoy11, Bhardwaj et al1 and Shivakumar et 2 al , whereas it was in contrast with the study 9 conducted by B. Eduardo and F.M Carlos and D.S 8 Rwakatema et al . CONCLUSION Thus the present study concluded that out of 351 study subjects, 4.3% and 3.4% of school children required highly desirable and mandatory type of orthodontic treatment needs respectively. The information from this study forms a part of the basis not only for further research, but also for planning orthodontic care. 40 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Assessment of dental aesthetic index REFERENCES 1. VK Bhardwaj, KL Veeresha and KR Sharma. Prevalence of malocclusion and orthodontic needs among 16 and 17year old school going children in Shimla city, Himachal Pradesh. Indian Journal of Dental Research 2011;22(4): 556-560. 2. Shivakumar KM, Chandu GN, Subba Reddy VV, etal. Prevalence of malocclusion and orthodontic treatment needs among middle a n d high school children of Davangere city, India by Dental Aesthetic Index. J India SocPedodPrev Dent 2009; 27:211-218. 3. H. Nihal, B. Guvenc and U. Ersin.Dental Aesthetic Index scores and perception of personal dental appearance among Turkish university students. European Journal of Orthodontics 2009; 31: 168-173. 4. B.A Carlos, M.C Jose-Maria, M.P David, et al. Orthodontic treatment need in Spanish young adult population. Med Oral Patol Oral Cir Bucal 2012; 17(4):638-643. 5. I.G Artenio Jose , P.P Paulo Cesar, S.G CleaAdas, et al. Malocclusion prevalence and comparison between the Angle classification and the Dental Aesthetic Index in scholars in the interior of Sao Paulo state- Brazil. Dental Press J Orthod 2010; 15(4):94-102. 6. Poonacha KS, Deshpande SD, Shigli AL. Dental A e s t h e t i c I n d ex , a p p l i c a b i l i t y i n I n d i a n population: a retrospective study. J Indian PedodPrev Debt 2010; 28: 13-17. 7. B. Venkatesh, Gopu H. Assessment of Orthodontic treatment needs according to Dental Aesthetic Index. Journal of Dental Sciences and Research 2011; 2(2):9-13. 8. D.S Rwakatema, P.M. Ng'ang'a and A.M. Kemoli. Orthodontic treatment needs among 12-15 year olds in Moshi, Tanzania. East African Medical Journal 2007; 84(5): 226-232. 9. B. Eduardo and F.M Carlos. Orthdontic treatment need in Peruvian young adults evaluated through Dental Aesthetic Index. Angle Orthodontist 2006; 76(3): 417- 421. 10. M Matilda, B. Pongsri and A. Anne Nordrehaug. Prevalence of malocclusion and its relationship with socio-demographic factors, dental caries and oral hygiene in 12 to 14 year old Tanzanian school children. European Journal of Orthodontics 2009; 31: 467-476. 11. H. Vijaya and S. Rekha.Dentition status, treatment needs and malocclusion status among 15 year old school children of Mangalore- a pilot study. JIDA 2010; 4 (12): 568569. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 41 Ayush & Health Sciences University of Chhattisgarh CASE REPORT Neurofibroma of spindle cell origin, a diagnostic dilemma to general dentist 1. 2. 3. 4. CASE REPORT Swapnil Moghe1, Ajay Kumar Pillai2, Vineeta Gupta3, Geeta Mishra4 Reader, Department of MaxilloFacial Surgery, Peoples Dental Academy, Bhopal (MP) Reader, Department of MaxilloFacial Surgery, Peoples Dental Academy, Bhopal (MP) Reader, Department of Periodontics, Govt. Dental College, Raipur (CG) Assistant Professor, Department of Dentistry, Govt.Medical College. Rewa (MP) Corresponding author : Dr. Ajay Kumar Pillai Reader, Department of Maxillofacial Surgery, Peoples Dental Academy, Bhopal (MP) Contact No: 98932 60776, Email : [email protected] ABSTRACT Neurofibroma is a benign tumor of neural origin derived from peripheral nerve sheath. Nerve sheath tumors are extremely rate. There is no sex predilection and average age of occurrence is 28 years. In the present case it was 22 yr. old patient . The surgical removal of tumor mass was done under GA and histological confirmation was done. Key Words: Neurofibroma, Spindle cell, Tumor INTRODUCTION: localized excision. Neurofibromas arise from a mixture of cell types including Schwann cells and perineural fibroblasts. They may occur as solitary lesions or in association with neurofibromatosis. Although most commonly reported in soft tissues, neurofibromas do occur in bone. And very few cases have been reported in association with the inferior alveolar nerve. We report a case of neurofibroma of spindle cell origin associated with the inferior alveolar nerve in a 22 year old man. Pain or paresthesia may result from lesions of the inferior alveolar nerve. Patients presents with cortical expansion. Intra-osseous lesions may produce a well demarcated or poorly defined unilocular or multilocular radiolucency. Adjacent soft tissue neurofibromas may produce cortical erosion. Solitary neurofibromas and those found in association with neurofibromatosis share the same microscopic features1. The tumor is composed of spindle-shaped cells with fusiform or wavy nuclei in a delicate connective tissue matrix. It is not encapsulated and may blend with the adjacent connective tissues. The normally recommended treatment of solitary lesions following biopsy is CASE PRESENTATION The patient reported a slow growing lesion in lower left nd mandibular region extending from canine to 2 molar region. A 22-year-old man presented to the department of the Oral and Maxillofacial Surgery with a 1 month history symptom of paraesthesia of lower left side of mandible extending from corner of mouth to angle of mandible. His medical history was unremarkable and there was no history of gum-related disease or trauma to the maxillofacial complex. Mobility of teeth was absent, also, a history of numbness of the lower lip since 2 months with no history of extraoral swelling was significant. An intraoral examination revealed a obliteration of muco-buccal fold of about 3 × 1 cm in the left lower canine- molar region with no signs of ulceration (Figure 1). On palpation, the swelling was firm in consistency with underlying bone from left canine to molar region. No neck nodes were palpable and the cranial examination was normal. Funelling & widening of inferior alveolar canal was evident on OPG. (Figure 2) 42 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195 Neurofibroma of spindle cell origin Figure 1: Obliteration of muco-buccal fold with 33-36 region. Figure 3: Exposed tumor mass Figure 2: Funelling & widening of inferior alveolar canal. Figure 4: Excised Tumor mass. Figure 5: Histopathology shows a tumor of Proliferative spindle cells with a stroma of Irregular collagen fibers (HE, × 100). Figure 6: Post -operative OPG after 6 months. Not many cases have been reported in the literature for the same. Under all aseptic conditions, the patient was intubated under G.A. & local anesthetic was infiltrated around lower anterior & posterior mandibular region on the left side. A crevicular incision was placed from the lower left side central incisor till second molar with bilateral releasing incisions. A full thickness muco- periosteal flap was raised, the tumor mass was exposed (Figure 3) & through the opened window, the tumor mass was removed (Figure 4). Nerve avulsion was done to remove the remnants of IAN. The surgical site was irrigated with betadine & saline. Hemostasis was achieved & closure was done with 3-0. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 43 Neurofibroma of spindle cell origin 4 Investigations canal, as was seen in our case . Orthopantamogram revealed an osteolytic scalloped lesion extending from the lower left canine region to the second molar. The lesion also shows erosion of buccal cortical plate. Histologically the tumor is composed of spindle cells arranged in bundles within collagen and mucopolysaccharides matrix that makes the tumor soft & even gelatinous. The nerve fibres are within the lesion. The tri-chrome stains like Mallory's or Masson's may be useful in identifying collagen. Alcian blue stain is helpful in staining perineural mucin which is not present in scar tissue. Microscopically the tumor is composed of an irregular pattern of proliferative spindle cells (Figure 5). The stroma is composed of collagen fibers and mucoid masses. Small axons all over the tumoral tissue are demonstrated with silver staining. Treatment & follow up: The patient was followed up for 6 months (Figure 6).The postoperative OPG showed good healing with no signs of recurrence at the surgical site. DISCUSSION: Neurofibroma (NF) is a benign tumor of neural origin derived from the peripheral nerve sheath that may have variable histology. Nerve sheath tumors located in the jaw are extremely rare, having published only a few cases of central neurofibroma of the mandible. There is no sex predilection and average age of occurrence is 28 years. In our case it was 22 years old man. Ninety percent of the neurofibromas are associated with neurofibromatosis 2 type 1, so the physical examination and family history should be elicited to exclude the disease. In this case, there were no clinical signs or family history suggestive of neurofibromatosis. The lesion was a solitary one. 3 Hubner and Lewis developed an animal model to investigate the causative factors in the development of the lesion. They reported that the peripheral nerve section resulted in the formation of an expanded connective tissue cap at the end of the proximal segment. Nerve fibers attempting to re-establish continuity with the distal segment penetrated into and beyond the cap, becoming tangled and entrapped in the soft tissue. But in our case, there was no history of trauma. In the mandible, the lesions most commonly arise from the mandibular nerve with accompanying pain and par aesthesia. In such cases the radiograph shows flaring of mandibular foramen, the so called “blunderbuss' foramen or fusiform enlargement of the mandibular The lesion should be differentiated with schwanomma (Antoni A and Antoni B areas) and perineuroma (pattern 5 similar to onion bulbs), as proposed by Ide . The solitary intraosseous neurofibroma may be the first manifestation of neurofibromatosis. It is important to put patient on regular follow-up & correlating clinically & radiographically, since recurrence and malignant changes have been reported6. REFERENCES: 1. Zachariades N, Mezitis M, Vairaktaris E, Triantafyllou D, Skoura- Kafoussia C, KonsolakiAgouridaki E, Hadjiolou E, Papavassiliou D: Benign neurogenic tumors of the oral cavity. Int J Oral Maxillofac Surg 1987, 16:70-76. 2. Sharma P, Narwal A, Rana AS, Kumar S. Intraosseous neurofibroma of maxilla in a child. J Indian Soc Pedod Prev Dent. 2009; 27: 62-4. 3. H U B E . A m p u ta t i o n n e u ro m a s : T h e i r development and prevention. Archives of Surgery 1920; 1(1):85. 4. Rajendran R, Sivapada Sundaram B. Benign and malignant tumors of the oral cavity. Shafer, Hine, Lavy, editors Shafer's Text book of Oral Pathology India: Elsevier2009:120-7. 5. Ide F, Shimoyama T, Horie N, Kusama K. Comparative ultrastructural and immunohistochemical study of perineurioma and neurofibroma of the oral mucosa. Oral Oncol. 2004; 40: 948-53. 6. Mori H, Kakuta S, Yamaguchi A, Nagumo M. Solitary intraosseous neurofibroma of the maxilla: report of a case. J Oral Maxillofac Surg. 1993; 51:688-90. 44 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Ayush & Health Sciences University of Chhattisgarh CASE REPORT TMJ ankylosis associated with odontogenic keratocyst of mandibular ramus : A rare case report 2 3 4 1. Professor, Dept of Oral And Maxillofacial Surgery Govt Dental College, Raipur, Chhattisgarh,India. 2. Professor, Dept Of Prosthodontics, Govt Dental College Raipur 3. Lecturer, Govt Dental College, Raipur, Chhattisgarh, India. 4. Private Practioner, Raipur, Chhattisgarh, India. Corresponding Author : Biju Pappachan 572/10-47, Lane No-6, New Shanti Nagar, Raipur Chhattisgarh E MAIL- [email protected], Tel- 00918109006001 ABSTRACT A range of disorder affects temporomandibular joint(TMJ) and structures associated to limit its motion. If the restriction is because of fusion in TMJ, it may be complete or incomplete. We present here a case of incomplete fusion of TMJ where complete restriction in mobility was noted following appearance of odontogenic keratocyst in the ramus. The treatment here was a gap arthroplasty which included the pathology in the block of bone which was resected. Key-words: Temporomandibular Joint Ankylosis, Odontogenic Keratocyst INTRODUCTION Temporomandibular joint (TMJ) ankylosis is a disorder that leads to a restriction of the mouth opening from partial reduction to complete immobility of the jaw. Ankylosis is most commonly associated with trauma (31% to 98%), local or systemic infection (10% to 49%), 1-4 or systemic disease(10%). Infection is most commonly secondary to spread from otitis media or mastoiditis, but may also result from hematogenous spread, including tuberculosis, gonorrhea, and scarlet fever. Systemic causes of TMJ ankylosis include ankylosing 5,6 spondylitis, rheumatoid arthritis, and psoriasis. TMJ ankylosis may be classified by a combination of location (intra- or extra- articular), type of tissue involved (boney, fibrous, or fibro-osseous), and extent of fusion (complete or incomplete). Literature classifies ankylosis as true and false.Any condition that gives rise to osseous or fibrous adhesion between the surfaces of the TMJ is true ankylosis. False ankylosis results from pathological condition not directly related to the joint.7 This case report presents a unique case of fibrous Temporomandibular joint ankylosis associated with odontogenic keratocyst. ISSN 2348 - 4195 CASE REPORT A 48 years old male patient reported to the department of Oral and Maxillofacial Surgery with chief complaint of Inability to open the mouth since –2 years, Pain and swelling over left mandibular posterior region since – 2 years. Patient was apparently all right 2 years back when he noticed swelling over left mandibular posterior region (Angle and Ramus) accompanied with pain. Pain was dull in nature and intermittent. The swelling was initially small but gradually increased in size. Mouth opening was around one and half finger width, which gradually reduced to nil. Extra- orally – small swelling was present over left mandibular angle and ramus region. Deep antegonial notch present over left angle of mandible. Chin was retruded with slight deviation towards left. TMJ movements were not palpable in left side with slight movement of right side. Intra-orally – Mouth opening was NIL. OPG shows unilocular radiolucency over left ramus region involving the coronoid process ( Fig-1). Lower left third molar was displaced upwards and inverted Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 45 CASE REPORT 1 Biju Pappachan , R K Dubey , Manish Raghani , Raghav Agrawal TMJ ankylosis associated with odontogenic keratocyst inside the radiolucent cavity. Second molar displaced and involved in the radiolucent cavity. Left TMJ region, joint space was partially obliterated with incomplete fusion; condylar demarcation was not clear in left side. fig-1 OPG showing ankylosed mass with odontogenic keratocyst of ramus mandibularis fig-2 showing the osteo-arthrectomy with cystic lesion within the resected mass The length of ramus and body were comparable both sides. Aspiration with wide bore needle was negative.A provisional diagnosis of left sided TMJ ankylosis associated with Odontogenic Keratocyst / Ameloblastoma was made. Histopathology confirmed Odontogenic keratocyst. Patient was planned for excision of the lesion which consequently would create gap arthroplasty. Under G.A. the left Temporomandibular Joint was approached through Risdon incision. The lesion and the ankylotic mass was resected in a block (Fig-2). DISCUSSION: TMJ ankylosis commonly presents as facial asymmetry, chin deviation to the affected side, elongation and flatness on the non affected side with roundness and fullness on the affected side when observed from a frontal view. A bony thickening is often felt in the preauricular area of the affected TMJ. Mandibular morphology is severely influenced in terms of size, and shape with marked antegonial notch, enlarged coronoid process, reduced vertical ramus height on the affected side, and flattened mandibular body and ramus on the non affected side. The ankylosed mandibular condyle can be hyperplastic with irregular 8 contours and absent joint spaces. This case of our clinically had features similar to TMJ ankylosis, but further investigation suggested that the features were secondary to an underlying pathology which is dreaded for it notorious presentation and high rate of recurrence. This case is unique because there was only a minimum restriction before the pathology appeared. With expansion of the pathology in the bone the boney interfaces moved towards each other increasing the degree of ankylosis. This later progressed to full hypomobility with the appearance of odontogenic keratocyst. The pathology here itself may have not primarily caused ankylosis but was the reason for complete hypomobility of the joint. This case is again unique because there was only a minimum restriction before the pathology appeared. This later progressed to full hypomobility with the appearance of odontogenic keratocyst. The pathology here itself may have not primarily caused ankylosis but was the reason for complete hypomobility of the joint. All cysts in the angle of the mandible with extension into the ascending ramus, or completely located in the ramus, should be treated as potentially aggressive cysts9. Many operative techniques have been described in the literature. The most frequently reported operations include gap arthroplasty,interpositional arthroplasty, and excision and joint reconstruction. 1 0 Gap arthroplasty has fallen out of favour because of potential chance of reankylosis and other 5,10,11 disadvantages and complications. However in specific cases like this it is useful as a larger block of 46 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) TMJ ankylosis associated with odontogenic keratocyst bone is removed and chances of reankylosis is none.This particular case was unique in the sense that, the bone required to be removed for creating the gap in itself contained an aggressive cyst. Recently distraction osteogenesis has been used successfully to reconstruct ramus and condylar portions of mandible. 12-15. In this case patient refused for any reconstructive procedure. CONCLUSION In such cases where multiple pathologic findings are observed, a well planned treatment is to be performed following all basic principles of treatment. A group of findings in same patient does not rule out possibility of syndrome or the reason of one or more incidental findings can be because of the effect of the present pathology. Proper case study, advanced investigations and basic principle of surgery with periodic follow up are key to manage such pathologies. REFERENCES: 1. MM Chidzonga. Temporomandibular joint ankylosis: review of thirty-two cases. British Journal of Oral and Maxillofacial Surgery 1999;37: 123–126 2. Guralnick WC, Kaban LB: Surgical treatment of mandibular hypomobility. J Oral Surg 1976; 34:34345 3. Topazian RG. Etiology of ankylosis of the TMJ: Analysis of 44 cases. J Oral Surg Anesth Hosp Dent Serv1964; 22:227-31 4.. Sawhney CP. Bony ankylosis of the TMJ: Follow up of 70 patients treated with arthroplasty and acrylic spacer interposition. Plast Reconstr Surg1986; 77:29-33 5. Moorthy AP, Finch LD: Interpositional arthroplasty for ankylosis of the temporomandibular joint. Oral Surg 1983;55:45-47 6. K Su-Gwan: Treatment oftemporomandibular joint ankylosiswith temporalis muscle and fascia f l a p . International journal of oral and maxillofacial surgery2001; 30: 189–193 7. M Jagannathan: Temporomandibular joint ankylosis. Indian journal of plastic surgery2009; 42(2): 187–188. 8. Belmiro Cavalcanti Do Egito V, Ricardo V, BessaN o g u e i ra , R afa e l VC, Tre at m e nt o f Te m p o ro m a n d i b u l a r J o i nt A n k y l o s i s b y ga p Arthroplasty. Med Oral Patol Oral Cir Bucal 2006;11:E 66-69 9. Paul J.W. Stoelinga :The management of aggressive cysts of the jaws. J Maxillofac.oral surg2012 11(1):2-12-16. 10. Topazian RG: Comparison of gap and interposition arthroplasty in the treatment of TMJ ankylosis. J O r a l Surg 1966; 24:405-08. 11. Hili G, Kaneda T, Oka T: Indication and appreciation of operative procedures for mandibular ankylosis. Int J Oral Surg 1978;7:333-36 12. A Roychoudhury, H Parkash, A Trikha -. Functional restoration by gap arthroplasty in tem poromandibular joint ankylosis: a report of 50 cases. Oral Surgery, Oral Medicine, Oral pathology 1999; 87: 166–169 13. Stucki-McCormick SU: Reconstruction of the mandibular condyle using transport distraction osteogenesis. J Craniofac Surg1997;8:48-51 14. Dean A, Alamillos F: Mandibular distraction in temporomandibular joint ankylosis. Plast Reconstr Surg1999; 104:2021-26 15. Piero C, Alessandro A, Giorgio S, et al: Combined surgical therapy of temporomandibular joint ankylosis and secondary deformity using intraoral distraction. J Craniofac Surg2002 13:401-5 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 47 Ayush & Health Sciences University of Chhattisgarh CASE REPORT Wilckodontics demystified : A case report 1 2 3 4 5 6 CASE REPORT Sumit Gandhi , Lokesh Advani , Javed Sodawala , G. Anita , Srinias T.S. , Parul Agrawal 1 2. 3. 4. 5. 6. Reader, Department of Orthodontics, Rungta College of Dental Sciences and Research. Post Graduate student, Department of Orthodontics, Rungta College of Dental Sciences and Research. Reader, Department of Orthodontics, Rungta College of Dental Sciences and Research. Proffessor and H.O.D, Department of Orthodontics, Rungta College of Dental Sciences and Research. Reader, Department of Periodontics, Rungta College of Dental Sciences and Research. Post Graduate student, Department of Periodontics, Rungta College of Dental Sciences and Research. Corresponding author : Dr. Sumit Gandhi Dept. of Orthodontics & Dentofacial Orthopedics, Rungta College of Dental Sciences and Research Kohka kurud Road, Bhilai- 490023 Contact no.- 9826992112, Email id.- [email protected] ABSTRACT: This paper illustrates the combined nonextraction orthodontic treatment with the corticotomy technique in an adult patient with severely spaced arches to accelerate tooth movement and shorten the treatment time. Initial fixed orthodontic appliances were bonded and three months later corticotomy procedure in the maxilla and mandible was performed. The space closure was performed in 10 weeks with elastics (sliding mechanics). Key words: Corticotomy, Adult orthodontics, PAOO INTRODUCTION The number of adult patients seeking orthodontic treatment has been increasing in the recent years. There are several psychological, biological and clinical differences between the orthodontic treatment of adults and adolescents. Adults have more specific objectives and concerns related to facial and dental aesthetics, the type of orthodontic appliance and the duration of treatment. Growth is an almost insignificant factor in adults compared to children, and there is increasing chance that hyalinization will occur during treatment. In addition, cell mobilization and conversion of collagen fibers is much slower in adults than in children. Finally, adult patients are more prone to periodontal complications since their teeth are 1 confined in non-flexible alveolar bone .All these factors make adult orthodontic treatment a challenging therapeutic modality in dentistry, which necessitates the need for an improvised concepts and procedures for the purpose of creating a functional dentition in a healthy periodontal environment. Corticotomy - assisted orthodontic treatment and Periodontally Assisted Osteogenic Orthodontics (PAOO) opened doors and offered solutions to many limitations in the orthodontic treatment of adults, that included increased anchorage control,reduced treatment duration and lesser chances of relapse.2 This paper highlights a case report of an adult patient who was treated with Corticotomy Assisted Orthodontic Treatment. CASE REPORT A 19 year old adult male patient reported to the OPD of Department of Orthodontics, Rungta College Of Dental Sciences & Research with a chief complaint of forwardly placed upper and lower front teeth and spacing between the teeth. Pretreatment Evaluation. Extra oral examination revealed that patient had a convex profile with protrusive and potentially competent lips & reduced Nasolabial angle (Fig.1). Intra oral examination revealed a Angle's Class II molar 48 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195 Wilckodontics demystified Fig 1: Pre Treatment Extraoral Photographs. Fig. 2: Pre Treatment Intraoral Photographs. Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 49 Wilckodontics demystified and Class II canine relationship with 8 mm overjet and 1 mm overbite. Maxillary arch had spacing of 10 mm and mandibular arch had spacing of 6.5 mm with severely proclined upper anterior teeth & lower anterior teeth (Fig.2). Upper midline was deviated to the left side of facial midline by 2mm. Orthopantogram of the patient revealed normal hard tissue structures and absence of pathology (Fig.3). SNA 870 SNB 820 ANB 50 Wits 5mm FMPA 130 UI-NA 330, 11 mm LI-NB 420, 11 mm IMPA 1250 Nasolabial angle 900 S LINE UL 6 mm ahead LL 7 mm ahead Table 1: Cephalometric values (Pre treatment) Fig 3 Pre Treatment Panoramic Radiograph. Treatment Plan. As the patient only desired the space closure within a shorter duration of time, a nonextraction orthodontic treatment plan with fixed appliances (Pre adjusted edgewise MBT .018 slot) along with the corticotomy procedure in both the arches was decided. Treatment Progress. 018 MBT fixed appliance (Ormco) was bonded and .014 inch NiTi arch wire was inserted for initial leveling and alignment, which was followed by .018NiTi, .016 X .022 NiTi & .017 X .025 SS. Fig. 4: Pre Treatment Lateral Cephalogram. Pre Treatment Lateral Cephalogram (Fig.4) and Cephalometric measurements showed a skeletal class II pattern, hypodivergent mandibular plane with proclined upper and lower incisors.(Table 1) Surgical Procedure. Corticotomy technique as described by Wilcko 1 was performed by the periodontist (fig.5). After administering the proper local anesthetic dose, a full thickness flap was reflected sharply facially, from canine to canine in the maxilla and between the central incisors in the mandibular arch. The flap was released with a sulcular incision and with papillary preservation technique. No vertical releasing 3 incisions were used. Cuts in the alveolus that penetrate the entire thickness of the cortical plate and penetrate just barely into the medullary bone were performed 4,5,6 buccally & lingualy around the teeth in both arches. Vertical decortication cuts were made between the roots of the teeth and they were stopped 2-3mm shy of the alveolar crest. Horizontal cuts were used to connect the vertical cuts along with perforations in the cortical 50 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Wilckodontics demystified (a) (b) (c) (f) (d) (e) (g) (h) (j) (i) (k) Fig.5: Corticotomy in maxillary and mandibular arch. plate. Flaps were repositioned to their presurgical positions and sutured with interrupted loop sutures. The sutures were removed after 7 days from the procedure. The patient was kept under antibiotic regimen for 5 days following the surgery. After removal of sutures, 0.017 × 0.025-inch SS Fig. 6: Comparison of Pre Treatment and Post space closure Profile photographs Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 51 Wilckodontics demystified archwires with power arms were inserted in both the arches. Short clear E chain (Rabbit Force, Libral) was used for the enmass retraction of the anteriors & 150 g force was applied. Post space closure profile photographs showed reduced convexity and competent lips (fig.6). After the active treatment of 10 Fig.7: Extraoral photographs (Post space closure) weeks, space closure was achieved. (fig 7) DISCUSSION The corticotomy was planned as an adjunct to the treatment in this case to achieve a better anchorage control.5 Another reason why corticotomy was planned was the desire of the patient to get the treatment finished in a shorter duration.6The chances of relapse in patients with spacing is reduced with corticotomy as the procedure require incisional cuts that are extended to the bone level that sever the periodontal fibres in particular the transeptal fibres.7 The space closure in this patient was achieved in 10 weeks, which is significantly less than the normal duration which is (6 months) required by conventional orthodontic treatment.8 Intraoral photographs showed that arches were well aligned and spacing have been closed (fig.8). 52 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) Wilckodontics demystified Fig.8: Intraoral photographs (Post space closure) Pretreatment and post space closure values when compared showed that there was a reduction in the proclination of anteriors in the maxillary and mandibular arches (Table 2). PARAMETERS PRE-TREATMENT POST SPACE CLOSURE SNA 870 860 SNB 820 840 ANB 50 40 WITS 5 mm 4 mm FMPA 130 120 U1-NA 330,11 mm 240,6.5 mm L1-NB 420,11 mm 380,7 mm IMPA 1250 1180 Nasolabial Angle 900 990 S Line UL 6 mm ahead 4 mm ahead 7 mm ahead 3 mm ahead LL Table 2: Comparison of Pre treatment and Post space closure cephalometric values. CONCLUSION REFERENCES Corticotomy Assisted Orthodontic Treatment is a promising technique that has many applications in the orthodontic treatment of adults because it helps to overcome many of the current limitations of this treatment including lengthy duration, potential for periodontal complications, lack of growth and the limited envelope of tooth movement. 1. Murphy KG, Wilcko MT, Wilcko WM, Fergusson WJ. Periodontal Accelerated Osteogenic Orthodontics: A Description Of The Surgical Technique. J Oral Maxillo Surg 2009; 67:2160-2166. 2. Aljhani AS, Zawai KH Nonextraction Treatment of Severe Crowding with the Aid of Corticotomy- Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) 53 Wilckodontics demystified 3. Thakur A. Halwai H,Corticotomy Assisted Orthodontic Treatment Journal of Universal College of Medical Sciences 2013;1(1):1-6 6 . Ka ra nt h S , R a m e s h A ,T h o m a s B, J o h n A M . Periodontally accelerated osteogenic orthodontics: Review on a surgical technique and a case report. Journal of Inter disciplinary Dentistry 2012;2(3):179-185. 4. Goyal A et al. Periodontally accelerated osteogenic orthodontics (PAOO) - A review. J Clin Exp Dent 2012;4(5):292-6. 7. Ali H, Ahmed A. Corticotomy-Assisted Orthodontic Treatment: Review. The Open Dentistry Journal 2010;4: 159-164. 5. Bhat SG, Singh V. PAOO technique for the bimaxillary protrusion: Perio - ortho interrelationship. Journal of Indian Society of Periodontology 2012;16 (4):584-87 8. Fischer TJ. Orthodontic Treatment Acceleration with Corticotomy-assisted Exposure of Palatally Impacted Canines. Angle Orthodontist 2007; 77(3 ): 417-420. Assisted Orthodontics. Case Reports In Dentistry 2012;2012:694527(1-8). 54 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014)