Download Part 1 - Ahmedabad Dental College

ISSN 0976-2256
E-ISSN:2249-6653
Ahmedabad Dental College
& Hospital
Vol. 4, ISSUE 2. SEPTEMBER 2013 - FEBRUARY-2014
OFFICIAL PUBLICATION OF
AHMEDABAD DENTAL COLLEGE AND HOSPITAL
Oral Pathology has been a challenging fiels. What
clinicians cannot perceive with naked eyes, pathologist
can conclude under microscope. Oral pathology is the
subject that concentrates on the morphologic changes at
microscopic level in oral and para oral tissues which
causes disease and the mechanism of the disease
process. Oral pathology represents the confluence of the
basic sciences and the clinical dentistry. Knowledge in
this field is acquired through the adaption of methods
and disciplines of those subjects basic to dental practice
such as gross and microscopic anatomy, histochemistry,
microbiology and physiology. Through the science of
oral pathology, an attempt is made to correlate human
biology with the signs and symptoms of human disease.
Oral health is an integral part of total health and oral
health care professional must adapt to demographic
changes and medical advances and shoulder the
responsibilities of being part of the patients over all
health care team. The oral pathologist understands the
clinical and molecular pathology of oral disease so that it
can be properly and accurately diagnosed and
adequately treated. Oral pathology personnel are well
suited for leading oral health promotion. They can make
people ware about the risk factors such as tobacco,
identify early pre cancerous condition and thus can
significantly contribute in improving oral health.
EDITORIAL
FROM THE EDITOR'S DESK …………………………………………………………………………………………….................... 01
DARSHANA SHAH
REVIEW ARTICLES
1.) STRESS........................................................................................................................................................................ 02
RUSTAM N. RAO*
2.)
OSTEOMYELITIS IN & OUT OF JAWS ...................................................................................................................... 06
NITU SHAH*, SHRINAL MANKIWALA**, KSHITI TRIVEDI***, NEHA VYAS****
3.)
FROZEN SECTION.......................................................................................................................................................10
BRIJESH PATEL*, MANISHA SINGH**, NILESHWAR JADEJA***, ALPESH PATEL****, MINAL BAKSHI*****
ORIGINAL ARTICLES
4.) THE PRE-STERILIZATION CLEANING PROTOCOL FOR ROTARY NI-TI ENDODONTIC FILES ........................... 15
RAJESH MAHANT*, SHRADDHA CHOKSHI**, RUPAL VAIDYA***, PALLAV CHOKSHI****,
GHANSHYAM PATEL*****, PRUTHVI PATEL******
5.)
THE EFFECTS OF NUTRITION ON OCCLUSION OF CHILDREN............................................................................ 22
VIJAY BHASKAR*, RAJAL PATHAK**, MIRA VIRDA***
6.)
DENTAL FLUOROSIS AMONG 12 AND 15 YEAR OLD SCHOOLGOING CHILDREN OF SOLAPUR CITY,
MAHARASHTRA, INDIA............................................................................................................................................... 28
HARSH SHAH*, SUYOG SAVANT** , VASUDHA SODANI***, DEEKSHA SHETTY****,BRIJESH PATEL*****
CASE REPORTS
7.)
C-SHAPED ROOT CANAL CONFIGURATION IN MAXILLARY FIRST MOLAR ........................................................ 34
MAMTA KAUSHIK*, SONAL SINGH**, KUNJAL MISTRY***, ZARNA SANGHVI****
8.)
RADICULAR ATTACHMENT RETAINED OVERDENTURE-CASE REPORT ..............................................................38
DARSHANA N.SHAH*, CHIRAG J. CHAUHAN**, KRUTIKA A. BHATTI***
9.)
CANCER THERAPY INDUCED ORAL MUCOSITIS: PREVENTION AND MANAGEMENT PROTOCOL ..............
41
PARUL BHATIA*, A.R. CHAUDHARY**,YESHA JANI***, SURESH LUDHWANI****
10.)
RADICULAR CYST ENCHROCHING UPON THE MAXILLARY SINUS –A DIAGNOSTIC DILEMMA...................... 41
PURNIMA JETHWA*, MITESH PATEL**,NITU SHAH***, NEHA VYAS****
11.)
ORTHOKERATINIZED ODONTOGENIC KERATOCYST............................................................................................ 41
MINAL BAKSHI*, MANISHA SINGH**, RICHA VASANT***, RIYA ACHU RAJAN****
B
Dear friends,
My heartiest greetings to all the readers for the coming new year 2014.
In today's time, profusion of information regarding the techniques, materials and
treatment modalities rendered to the patient is a challenge not only to the dental
practitioners and the students but also to the patients. We wish to take an initiative to
minimize the impact of diseases of oral and maxillofacial origin on health as well as the
psychological development of the patients.
We appreciate and would like to encourage faculties and students of all institutions to help
us in our endeavour of promoting oral health and reducing oral diseases amongst the
population. We look forward for articles on current perspectives in dentistry for the benefit
of the community at large.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
47
Review Article
STRESS
* Rustom M. Rao
ABSTRACT
In today's world, the stress has become a common problem among all; whether that is a young, old or a child. During
day-to-day life, stress causes occurrence of multiple disorders in an individual.
Stress causes particular disease by temporarily inhibiting certain components of immune system.
Hans Selye, the father of study of stress, established relationship between chronic stress and its effects on the body.
STRESS
Stress, a”SILENT KILLER”, has become a burning
problem in present era.
a.
Stress is defined as a mismatch between
perceived demands and perceived capacities
to meet those demands.
Physiologically, stress is non-specific response to
stimuli
OR
b.
Whenever there is a change in our
environment, which we apraise as a
damaging or harmful, some demand is placed
on us for adjustment.
This sequence of creation of demand, body-mind
responses and the outcome is known as Stress.
Stress is both, physical as well as mental condition.
Stress is essential for growth and development.
Original theory of stress reaction of Cannon [1932]
i.e. Fight and Flight reaction in threatening situation
is thining in 21st century.
Three stages of stress were described by Hans
Selye, which arei.
Alarm Reaction
ii.
Resistance and
iii.
Exhaustion
This is called “General Adaptation syndrome”.
The occurance of stress is associated with
“Stressors”.
STRESSORS:
The responses of our body and mind to the demands
are explained as “Stressors”.
Different individuals have different situations as
their stressors.
The longer a stressor operates, the more severe its
effects. There are different categories of stressors1.
Frustration- All sorts of obstacles produce it.
2.
Conflict- when two or more uncompatible
needs occur.
3.
Pressures- it occurs when we want to achieve
specific goals.
Some of the common stressors area.
Family stressors. e.g. sharing of work load
b.
Physical stressors. e.g. excess of cold , heat,
noise etc.
c.
Career and Job related stressors. e.g.
Interviews, public speaking, deadline for
completion of task, competition and power
struggle.
d.
Interpersonal stressors. e.g. spoiled
relationship with family members, friends,
neighbours or misunderstanding, jealousy
etc.
e.
Socio-economic, environmental and political
stressors. e.g. unemployment, less income,
high cost of living, poor services etc.
Stress is maintained by constant reactions of
thoughts, feelings and behavior.
Women live longer than men. As compared to
women, more men are killed by stress related
disorders including tobacco chewing & smoking,
alcohol & coronary artery diseases.
This suggests that there is some strategy to deal with
stress amongst women.
There are ways to overcome stress to a very good
extent. They includei.
Do something different than what you do
normally.
* Professor of physiology
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+91 9687616779)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
48
ii.
Make time for yourself each day by
relaxation, fun, enjoyment, activities that give
you a sense of closeness to others.
iii. Listening to the music
iv. Relaxation technique
v.
Meditation or Prayer because classification of
all diseases is usually “Stress Related”
(Adhija) and “Not Stress Related”
(Anadhija). e.g. Injuries
vi. Be with others
vii. Talk to someone
viii. Limit your responsibilities- its O.K to say
“NO”
ix. Positive self-talk
x.
Do something creative
xi. Yoga etc.
Yoga is considered especially useful in
management of “stress Related” disorders. Yoga
also helps to prevent certain diseases, especially
important in elderly persons. It is also important in
vulnerable people whose life style is unhealthy (i.e.
in terms of diet, exercise and relaxation).
H O W T O K N O W,
OVERSTRESSED………
W E
A R E
A signal is put on whenever a person is stressed,
irrespective of a stressors to which he/she is
exposed.
Common stress signals area.
Physical – e.g. headache, dryness of mouth,
cold hands & feet, palpitation ( i.e. person
becoming aware of his heartbeat).
b.
Mental/Emotional – e.g. lack of
concentration, frequent mistakes,
forgetfulness, tendency to over react, thought
block etc.
c.
Behavioral- e.g. insomnia (lack of sleep) or
somnolence (excessive sleep), clumsiness,
increased smoking &/or drinking.
POST TRAUMATIC STRESS DISORDER:
Some people after exposure to trauma often develop
high level of fear and anxiety and eventually a
collection of symptoms called- “POST
TRAUMATIC STRESS DISORDERS” [PTSD]
(Girelli et al, 1986).
Sometimes as a result of strenuous repeated
exercise or activities can cause “Stress Fracture”. It
can also occur as a result of osteoporosis.
Some stress called “Eustress” prepares us to meet
certain challenges & therefore it is useful.
Other stress called “Distress” is harmful.
Certain stimuli produce stress responses which
have already been described before as “Stressors”.
Stress is responsible for producing certain diseases
due to inhibition of certain components of immune
system. These stress related disorders areGastritis, Ulcerative Colitis, hypertension (very
common), Asthma, Anxiety, Rheumatoid Arthritis,
Migrain, Anxiety, and a very commonly seen nowa-days is “Stress Diabetes”.
ROLE OF HORMONES IN STRESS:
Response to stress involves multiple hormones like
ACTH, Cortisol, Adrenaline, Nor-Adrenaline,
Thyroxine, Aldosterone etc.
Multiple hormones bring about appropriate
biochemical and physiological responses.
During the severe stress, Cortisol may rise as much
as ten folds more. This is an adaptive response for
survival.
Stress activates hypothalamus –Pituitary-Adrenal
axis.
The CRH-ACTH-Cortisol axis is central to
integrated response to stress.
Cortisol works to provide resistance to stress.
MANAGEMENT OF STRESS:
In managing the stress, the first step is to find out our
own stressors.
A better way to deal with the stress is to convert
“HAVE TO” into “WANT TO”.
Its so hard when “I HAVE TO” and so easy when “I
WANT TO”.
The success of a person (e.g. student, teacher,
doctor, businessman etc.) depends upon more or
less the same attitude of – “I WANT TO” and not “I
HAVE TO”.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
49
DEGREE OF STRESS NOTICEABLE IN STRESSFUL TIMES
SYMPTOM
VERY
FREQUENTLY
4
FREQUENTLY
3
SOMETIMES
2
RARELY
1
NEVER
0
Sleep problems
Pains, e.g. headache,
backache
Extreme variations in
appetite
Reduced selfconfidence
Difficulty in making
decisions
Problems in
concentrating
Worrying more than
usual
Increased irritability
Feeling miserable
Withdrawing from
contact
SCORING -Scores of 30-40 indicate high levels
Scores of 20-29 indicate moderate levels
Scores below 20 indicate within individual's
coping capabilities
CONCLUSION:
The incidences of stress are increasing in day-today life at all ages.
Stress, which is an abnormal type of stimulus,
produces certain abnormal responses, including
physical, mental & behavioral disorders. Several
negative effects appear on an individual gradually
rather than immediately.
Sometimes stress comes in unnoticeable. The
person is not aware of it but in his/her unconscious
mind, there is a definite presence of some sort of
stress.
Truly speaking, noticeable stress is less harmful
than unnoticeable stress.
When there is cumulative stress than it results into
many disorders like- illness, inappropriate
behavior, low energy & performance level etc.
In our present world, the stress has become “A
SILENT KILLER”.
You can always negotiate with “STRESS” as well
as “TERRORIST”.
My life is but a weaving, between my God and
me,
I do not choose the colours, He worketh steadily.
Offtimes He weaves sorrow, and I in foolish
pride,
Forget he sees the upper, and I the underside.
Not till the loom is silent and shuttles cease to fly,
Will God unroll the canvas and explain the reason
why.
The dark threads are needful in the skillful
weaver's hand,
As the threads of gold and silver in the pattern He
has planned.
REFERENCES:
1.
2.
3.
The Bhagwad Geeta, Chapter II/14,32,48 and Chapter X
Bushman B.J (2002). Personality and Social Psychology
Bulletin,28,724-731
Lazarus, R.S, & Folkman, S. (1984), stress appraisal and coping.
New York; Springer
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
50
OSTEOMYELITIS- IN AND OUT OF JAWS
Review Article
* Nitu Shah, ** Shrinal Mankiwala, ***Kshiti Trivedi, ****Neha Vyas
ABSTRACT
All bones of the facial skeleton are susceptible to osteomyelitis due to various predisposing conditions. Current
radiological tools are sufficient to provide adequate diagnosis. Treatment can be conservative resection of the diseased
bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where
resection has to be more radical. Our purpose was to analyse the behaviour of various predisposing factors that lead to
osteomyelitis in the head and neck region. A total of 6 cases of osteomyelitis in head and neck with
trauma,odontogenicinfection, tuberculosisand diabetes were reviewed in a 2 year period. Pus for culture, antibiotic
sensitivity, radiological and histopathological analysis were the main investigations. A medical line of treatment along
with control of predisposing factors plays an important role in success of surgical outcome.
Keywords: osteomyelitis, predisposing factors, antibiotics, sequestrectomy
Introduction
Osteomyelitis is commonly encountered in areas of
poor socioeconomic conditions and is a major
medical problem in the developing countries. The
general lack of awareness of the prevalence of the
disease and its features often leads to a misdiagnosis
and delay in treatment. Early detection of this
condition and prompt attention will pre-empt the
need for a surgical intervention in an otherwise
protracted course of illness.Osteomyelitis can be
defined as an inflammatory condition of the bone,
which begins as an infection of the medullary
cavity, rapidly involves the haversian systems, and
extends to involve the periosteum of the affected
1
area . Infection occurs as a result of a bacteremia, an
inoculation during aseptic or bone surgery or a
contiguous infectious focus. Conditions altering the
vascularity of the bone such as radiation,
malignancy, osteoporosis, and Paget's disease
predispose to osteomyelitis. Systemic diseases like
diabetes, anaemia, tuberculosis and malnutrition
that cause concomitant alteration in host defenses
1
profoundly influence the course of osteomyelitis .
The consequences of this infection range from the
minor nuisance of a draining tract, to a pathologic
fracture at the infected site, to the possible
2
malignant transformation to carcinoma . The bones
reported to be involved by osteomyelitis in the head
and neck are the mandible, frontal bone, cervical
spine, maxilla, nasal bone, temporal bone and skull
base bones. The diagnosis is mainly made by
clinical presentations like discharging sinus,
periosteal thickening and tenderness, confirmed by
the presence of sequestrum or bony destruction with
or without pathological fractures on radiography.
Imaging with radionuclide scans, computed
tomography (CT), and magnetic resonance imaging
(MRI) are used for early detection, when the
diagnosis of osteomyelitis is equivocal or to help
gauge the extent of bone and soft tissue infection.
Surgical treatment involves debridement of
necrotic bone and tissue, obtaining appropriate
cultures, managing dead space, and when
necessary, obtaining bone stability9. Acute cases
respond very well to a medical line of treatment.
Others require surgical intervention with long-term
broad-spectrum antibiotic therapy for 4-6 weeks.
Here we present our experience in managing 6
patients with osteomyelitis of maxilla and mandible
in the head and neck having various predisposing
factors.
Discussion
The term 'osteomyelitis', which was introduced by
Nelaton3 in 1844, implies an infection of the bone
and marrow. Osteomyelitis most commonly results
from bacterial infections, although fungi, parasites,
and viruses can affect the bone and marrow.
Although osteomyelitis in the long bones of the
body can be broadly comparable to the flat and
irregular bones of the head and neck as regards
* Proffesor, ** PG Student, *** Reader, **** Proffesor & HOD ,
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
51
etiopathology, their management varies in the head
and neck due to anatomical and cosmetic
considerations. Osteomyelitisis routinely classified
as anacute, subacute, and chronic osteomyelitis.
Abrupt onset of symptoms and signs during the
initial stage of infection indicates an acute
4
osteomyelitis . If this phase passes without
complete elimination of infection, subacute or
chronic osteomyelitis can become apparent.
Most patients with acute osteomyelitis in the head
5
and neck present with mandibular disease .
Inflammatory lesions are by far the most common
pathologic condition of the jaws. The jaws are
unique from other bones of the body in that the
presence of teeth creates a direct pathway for
infectious and inflammatory agents to invade bone
7
by means of caries and periodontal disease . The
predisposing factors for osteomyelitis include
dental infection, trauma, especially compound
fractures, surgery, infections of the oral cavity
leading to periosteitis, infections from furuncles or
lacerations and systemic conditions like diabetes,
6
9
tuberculosis, malnaurishment . A study by Taher ,
of 88 cases of osteomyelitis of the mandible, found
trauma to be the most common predisposing cause
for osteomyelitis.
The retrospective study of 6 cases of osteomyelitis
of the mandible and maxilla carried out in oral and
maxillofacial surgery department over a period of 2
years. The age, gender, medical history, and
examination findings of these patients were
obtained from case records. Typical clinical
findings included localized bone pain, erythema,
draining sinus tracts, fluctuating abscesses,
deformity, instability, local signs of impaired
vascularity, impaired range of motion, presence of a
previous open wound, and discharge. In addition to
local signs of inflammation and infection, signs of
systemic illness, including fever, irritability, and
11
lethargy were used to diagnose osteomyelitis .
Once a clinical diagnosis of osteomyelitis had been
reached, the following investigations were carried
out at the relevant site. (1) Radiological
investigations such as orthopantomogram, plain Xray of skull bones, X-ray of the neck (anteroposterior and lateral view). (2) CT scan. (3) Pus
from the discharging sinus was investigated for
culture and sensitivity. (4) Wide bore needle
aspiration cytology in cases of ambiguous
diagnosis. (5) Biopsies from the granulation tissues
for histopathological examination. (6) Routine
blood examination, blood sugar analysis, and
ELISA for HIV infection.
Once the diagnosis and the extent of disease were
confirmed, patients were treated either medically,
surgically or both depending on the site, chronicity,
and severity of the lesion. Patients with acute
osteomyelitis were diagnosed by abrupt onset of
symptoms with early radiological changes or
absence of radiological findings. Chronic
osteomyelitis was diagnosed when the symptoms
were long-standing and radiology showed
sequestra, periosteal thickening or abscess, loss of
joint mobility, bony irregularity, loss of bone or
pathological fractures. We found in our series,the
clinical features are the same for both the acute and
chronic variants except that in chronic
osteomyelitis these symptoms are milder. Clinical
features documented are deep intense pain, high
intermittent fever, paraesthesia or anaesthesia of the
lip due to involvement of the mental nerve, pus and
sequestra exudates through fistulae, trismus,
regional lymphadenopathy, induration of soft
tissue, and wooden character of bone with pain and
11
tenderness on palpation . The associated teeth may
be mobile and sensitive to percussion.
The surgical procedure undertaken depended on the
site of the lesion. In allcases, the pus was sent for
microbiological study and intraoperative
g r a n u l a t i o n s , i f a n y, w e r e s e n t f o r
histopathologicalstudy.Control of underlying
systemic condition was done in a cases of dibetes,
tuberculosis. . Where odontogenic cause was
predisposing factor, the related teeth were removed.
All patients were supplemented with a high protein,
multivitamin diet and general nursing care.
In this analysis of six patients, the male female ratio
was 2:1, age ranged from 25 years to 70 year, the
mandible maxilla involvement ratio was 2:1. In
mandible posterior region was more commonly
involved as compared to anterior region while in
maxilla anterior region was more commonly seen.
Osteomyelitis of nasal bone is a very rare entity. It is
usually associated with osteomyelitis of
neighbouring bones such as the maxilla10. We had
one case of osteomyelitis of maxilla and nasal bone
due to a long-standing ulcer and two cases
following trauma.In the following analysis, all
patients had a predisposing factor, out of them two
had trauma, two had odontogenic infection, one had
diabetes and one had tuberculosis . The ratio of
acute to chronic condition was 1:2.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
52
Out of 6 patients diagnosed with osteomyelitis 2
patients were diagnosed as having acute
osteomyelitis, while remaining were chronic cases.
In 4 patients with osteomylitis of mandible, pain
and tenderness were present in all cases, swelling in
2 discharging sinus with sequestra in 4 cases,
periosteal thickening 1 case lymphadenopathy in
all, loosening of tooth in 2 cases.
In maxillary osteomyelitis both the patients had
pain and tenderness over maxilla. Draining sinus
was present in one case. Loosening of teeth was
present in one case.
Radiological findings showed periosteal
thickening, minimal abscess or new bone formation
in acute osteomylitis and
bony destruction,
sequestra, and altered contours of the bone chronic
osteomylitis13.
12
opportunity for reperfusion in the areas of insult .
All patients were managed medically with
intravenous antibiotics and analgesics followed by
oral antibiotics for 4-6 weeks and surgically by
sequestrectomy with saucerisation depending upon
the extension of diseases13. There was no recurrence
of osteomyelitis in any of the cases.
Figure 3 Intraoperative photo of patient with
maxillary osteomyelitis
Figure 1. Osteomyelitis of the maxilla of a patient
who was suffering from diabetes
Pus from the diseased area was sent for culture and
sensitivity for all cases. The organisms cultured
were Staphylococcus aureus in 4 cases,
Streptococcuspyogenes in 1 and Mycobacterium
tuberculosis in 1 case.
Fig 4. Operative specimen of sequestrum of the
maxilla from the same patient
Anti-tubercular therapy was started for one patient
and antidiabetic regime for one diabetic patient .
Fig 5 Microphotograph (10x and H&E ) suggestive
of osteomyelitis of the same patient
Figure 2 CT scan of osteomyelitis of maxilla
The treatment protocol consisted of a combination
of surgery and antimicrobial treatment. The aim of
surgery was elimination of all infected, necrotic
tissue, to facilitate drainage and provide an
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
53
Fig 6 postoperative photograph of the same patient
after two week
Before application of any cross-sectional imaging
modality, the orthopanoramic view is indispensable
in recognizing direct radiographic signs of
osteomyelitis. The orthopanoramic view is the
procedure of choice in follow-up examinations in
patients who have osteomyelitis.
Conclusion
Osteomyelitis in the head and neck is a difficult
disease to treat. The series in the present study
shows that elimination of various predisposing
factors that lead to osteomyelitis results in prompt
resolution .thus the treatment of osteomyelitis
needs prompt clinical examination and supportive
radiological and histo-pathological examination.
The predisposing factors should be treated first for
better surgical outcome.
References
8.
1.
2.
3.
4.
5.
6.
7.
Topazian RG. Osteomyelitis of jaws. In: Topazian RG, Goldberg MH,
editors. Oral and maxillofacial infections, 3rd edn. Philadelphia, PA:
Saunders; 1994. p. 251!86.
Wickenhauser C, Tsironis K, Zirbes TK, Larena-Avellanda A, Dienes HP.
[Highly differentiated squamous epithelial carcinoma as a late
complication of post-traumatic osteomyelitis.] Pathologe 1999;20:236
!41 (in German).
Nelaton A. Elements de pathologiechirurgicale. Paris: Germer-Bailliere;
1844!1859.
Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of
clinical features, therapeutic considerations and unusual aspects (first of
three parts). N Engl J Med 1970 ;/282:198/ !206.
Cierny G, Mader JT, Pennick JJ. A clinical staging system for adult
osteomyelitis. ContempOrthop 1985;10:/ 17/ !37.
Eckardt JJ, Wirganowicz PZ, Mar T. An aggressive surgical approach to
the management of chronic osteomyelitis. ClinOrthopRelat Res
1994;(298):/ 229/ !39.
Lee L. Inflammatory lesions of the jaws. In: White SC, Pharoah MJ,
editors. Oral radiology: principles and interpretation, vol 3, 4th edn.
Missouri: Mosby; 2000. p. 338!54. [8] Shafer WG. Diseases of the pulp
and periapical tissues. In: Shafer WG, Hine MK, Levy BM, eds. A
textbook of oral pathology, 4th edn. Philadelphia, PA: Saunders,
1993:479! 525.
9.
10.
11.
12.
13.
Taher AAY. Osteomyelitis of mandible in Tehran, Iran. Oral Surg Oral
Med Oral Pathol 1993;76:/ 28/ !31.
Schuknecht B, Valavanis A. Osteomyelitis of the mandible.
Neuroimaging Clin North Am 2003;13:/ 605/ !18.
Hao S, Chen HC, Wei F, Chen C, Yeh AR, Su J. Systematic management
of osteoradionecrosis in the head and neck. Laryngoscope 1999;109:/
1324/ !8.
Alan A, Lim T, Karakla DW, Watkins DV. Osteoradionecrosis of the
cervical vertebra and occipital bone: a case report and brief review of the
literature. Am J Otolaryngol 1999;20:/ 408/ !11.
Ang E, Black C, Irish J, Brown DH, Gullane P, O'Sullivan B, et al.
Reconstructive options in the treatment of osteoradionecrosis of the
craniomaxillofacial skeleton. Br J PlastSurg 2003;56:/ 92/ !9.
Shaha AR, Cordeiro PG, Hidalgo DA, Spiro RH, Strong EW, Zlotolow I,
et al. Resection and immediate microvascular reconstruction in the
management of osteoradionecrosis of the mandible. Head Neck
1997;19:/ 406/ !11.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
54
FROZEN SECTION
Review Article
* Brijesh Patel, **Manisha Singh, ***Nileshwari Jadeja, ****Alpesh Patel, *****Minal Bakshi
ABSTRACT
Frozen section is a vital technique for the management of surgical patients. The frozen-section procedure is a widely
used diagnostic test because of the insufficiency of pre-operative diagnostic tools such as imaging and tumor markers.
This technique determines the types and the extent of the surgery that will be performed, primarily for malignancy and
therefore directly impacts the morbidity of the patient. This review article emphasis on the technique, applications,
advantages and limitations of frozen section.
KEYWORDS: Frozen section, diagnostic test, malignancy
INTRODUCTION
The methods used in diagnosis are continually
changing in histopathology. Over the past 60
years, frozen section diagnosis of surgically
resected tumors and tissues has become a wellestablished practice1-4. Despite the use of other
methods (both cytological and histological) of
establishing a preoperative tissue diagnosis, frozen
sections continue to play a part in surgical
decisions. Discrimination of benign and malignant
tumors during surgery is important for the
management of the patient 5,6.
Intraoperative frozen-section analysis gives
information about the characteristics of masses7.
The results of the frozen examination determine the
course of surgery. When performing ablative
procedures for head and neck cancer, the surgeon's
goal is to obtain optimal clearance of the tumor
while sparing as much normal tissue as possible,
thus preserving function and limiting morbidity.
Hence, it is important to know regarding the
positive and negative margins of the surgical field to
avoid unnecessary resections. The prevalence of
frozen section procedure is not very popular
amongst the oral surgeons in India. But the increase
in awareness amongst the surgeons to follow
conservative treatment to avoid patient discomfort
has motivated the oral pathologists to be familiar
with this procedure.
Frozen section may be one of the most vital
procedures performed by the pathologist
throughout his practice. It is a complex procedure.
The pathologist has to arrive at a correct decision in
a shorter duration under pressure based on his
experience, judgment and the knowledge of his
specialty and clinical medicine. He should also have
a keen awareness of the limitations of the method as
the patient's life is often dramatically influenced by
his report.
HISTORY
Three major advances in medical science made
during the mid to late 19th century, have made the
frozen section technique a standard diagnostic tool.
First, the introduction of anesthesia allowed
surgeons to perform longer, more complicated
procedures that required improved diagnostic
skills. Second, there were significant improvements
in both the resolving power and the magnification
capability of the microscope, and lastly there were
many advances in techniques for the preparation of
pathological specimens for microscopic evaluation.
Many physicians around the world were
experimenting simultaneously methods for
freezing tissue for pathologic diagnosis, so it is not
known who truly invented the technique. However,
the first use of the frozen section technique for
pathologic diagnosis was recorded in 1818 by a
8
Dutch anatomist Pieter de Riemer .
Prior to 1870, frozen sections were usually cut
freehand with a razor, but by the late 19th century,
microtomes were developed, resulting in improved
speed and quality of sectioning. In 1890, the use of
frozen sections first appeared in textbooks. With the
introduction of cryostat it became the accepted
9
method of cutting frozen tissue .
* Reader, ** Senior lecturer, *** P.G.Student, ****Proffesor, ***** Reader
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+919898212228)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
55
The frozen section procedure as practiced today in
medical laboratories is based on the description by
Dr Louis B Wilson in 1905. Wilson developed the
technique from earlier reports at the request of Dr
William Mayo and Wilson is generally credited
with truly pioneering the procedure10.
APPLICATIONS
The primary indications for intraoperative frozen
section includes:
• To determine whether a lesion is benign or
malignant
• Surgical margin assessment and in cases where
no immediate diagnosis can be made from the
biopsied specimen, to ensure that the removed
tissue is representative and viable, by which a
definitive diagnosis can be achieved later on the
paraffin sections or through special staining9.
• In the performance of Mohs surgery - a simple
method for 100% margin control of a surgical
specimen.
• If a tumor appears to have metastasized, a sample
of the suspected metastasis is sent for cryosection to
confirm its identity. This helps the surgeon in
deciding whether there is any point in continuing
the operation. Usually, aggressive surgery is
performed only if there is a chance to cure the
patient. If the tumor has metastasized, surgery is
usually not curative, and the surgeon will choose a
more conservative surgery or no resection at all.
• In a sentinel node procedure, a sentinel node
containing tumor tissue prompts a further lymph
node dissection, while a benign node will avoid
such a procedure.
• If surgery is explorative, rapid examination of a
lesion might help identify the possible cause of a
patient's symptoms.
• Rarely, cryosections are used to detect the
presence of substances lost in the traditional
histology technique, for example lipids. They can
also be used to detect some antigens masked by
formalin.
TECHNIQUE 11, 12
Good frozen section technique is learned gradually
and only through experience. The following steps
should be routinely carried out:
1. Gross tissue examination: (Figure 1)
This step is probably the most important step and
unfortunately is one that many pathologists have
not yet learned. The pathologist obtains gross dues
not from just looking at the tissue, but also from
feeling it and cutting it, i.e., soft or gritty. The
pathologist records all gross expressions, i.e., size,
adhesions, weight, similar to the recording of
microscopic features11.
Figure 1
2. Proper communication with the surgeons:
The intercom is located in the frozen section suite;
the room where the surgeon is operating will be
obtained from the pathology department secretary
transmitting the request for frozen section. A list of
operating room procedures appear the day before
the planned surgery, and it is the responsibility of
the resident and staff to be familiar with each case in
advance. This means knowing what tissues have
been removed previously, reviewing any previous
diagnoses that the pathology department has on file,
and reviewing all previous slides of the patient. This
is important because the present procedure may be
related to previous ones. This "research" by the
pathologist is equivalent of the medical history.
Figure 2
3. Embedding the tissue: (Figure 2)
The selected piece of tissue is then placed on a
metallic holder and must be oriented a certain way.
The tissue is embedded in OCT mounting medium
and is then placed either in cooled
2-methyl butane or the cryostat machine where it is
properly frozen.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
56
Figure 3
4. Cryostat: (Figure 3)
The machine, which cuts the tissue, is the cryostat.
Certain things should be routinely checked in the
operation of this machine:
a) Temperature:
The temperature should be at -20°F for most tissues.
For tissues with a large fat component,
-40°F is optimal. This temperature is critical for
optimal sectioning.
Too high (-10°F) and the tissue will not stay frozen
and firm and will not cut crisp.
Too cold (-50°F) and the tissue will crumble and
become powder.
The Ideal tissue should cut like butter, smooth and
in one piece.
b) Blade sharpness and angle:
The blade should be sharp and should be changed
approximately once every 2 weeks. A dull blade
cuts dull. Equally important is the blade angle.
There is an optimal angle between blade and tissue:
Too steep an angle and the tissue will crumble like it
was too cold.
Too shallow, then two things will happen. The
section will alternately skip and not cut and then it
will cut, but too thick.
5. Staining:
Once the tissue is on the slide it can be either airdried or fixed with methanol which depends on the
staining procedure to be used. The choice of stain
depends on what the pathologist is trying to
demonstrate.
6. Interpreting the frozen section: (Figure 4)
The final work is to discuss the slide and render a
diagnosis. Since rapid diagnosis takes precedence
over everything else in the operating room, often
times additional discussion and questions occur
after the diagnosis has been rendered.
Figure 4
7. Controls:
In all science, controls are necessary. Since
pathology is not an exact science, controls cannot be
exact, but an attempt is made to check out frozen
section accuracy. The tissue, which is frozen, is
submitted for permanents and labeled "frozen
section control." This is to be kept separate from the
other additional tissues submitted for permanents.
In this way, the pathologist has a limited check on
his frozen. If anything shows up on the permanents
that is substantially different than the frozen, the
surgeon or doctor taking care of the patient should
be notified immediately.
ADVANTAGES
• If more tissue is needed to make an accurate
diagnosis, the surgeon is able to obtain an additional
sample, avoiding a second operation.
• If the tissue is determined to be cancerous and is
amenable to surgery, the mass can be removed at
that time.
• If the tissue is determined to be benign (not
cancerous), then the mass may not always need to
be removed and the surgery can end.
• The frozen section biopsy can help ensure that
the mass being removed is the intended tissue for
removal.
• It can help ensure that the entire mass and its
surrounding borders are removed.
• It allows for the collection of proper tissue
samples for further scientific research.
• The surgeon and pathologist are able to
collaborate to care for the patient. 11
• The cryostat is available in a small portable
device weighing less than 80 lb (36 kg), to a large
stationary device 500 lb (230 kg) or more. The
entire histologic laboratory can be carried in one
portable box, making frozen section histology a
possible tool in primitive medicine9.
LIMITATIONS 13
Limitations of frozen section need to be taken into
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
57
consideration when requesting for this procedure, in
order to avoid grave mistakes that will be
detrimental to the patient's management. These
limitations can be divided into three main
categories, namely sampling error, technical
problem and interpretative error.
Sampling limitations
(i) Poor sampling of tissue / limitation of the
surgeons:
This is a very obvious limitation for the pathologist
since he has to interpret whatever the tissue is sent
by the surgeon.
(ii) Poor selection of appropriate tissue after
grossing:
The most representative tissue areas of the sample
should be selected. This greatly influences the
interpretation. Sometimes the orientation of the
tissue sent is not clear and communication with the
surgeon intraoperatively is important.
(iii) Extensive tumor degeneration or necrosis:
Sometimes difficultly in sampling a large tumor is
encountered. The surgeon must choose a viable area
and avoid necrotic one. Recognizing areas of tissue
reaction to tumor such as edema and fibrosis are
also important.
(iv) Poor assessment of capsular or vascular
invasion:
Assessment of capsular or vascular invasion is very
difficult in frozen section and subjected to sampling
errors.
Technical limitations
(i) Freezing artifacts / Xylene artifacts:
Freezing artifacts causes much damage to the tissue
structure of the frozen section. Inadequate xylene
treatment and improper coverslipping of slides
cause drying artifacts, whereas any water present in
xylene solution used contributes to cloudy sections.
(ii) Poor quality section:
Frozen tissue section is not easy to cut compared to
paraffin embedded section. The section is usually
thick and occasionally folded. Air bubbles may
easily get into the tissue sections. A thick section
may render it difficult to visualize clearly the
nuclear details.
(iii) Bloated cell morphology:
Depending on how good and how fast the tissue
freezing process is, and its water content, this step
will determine whether the cell morphology is
preserved or not. However, in most cases of frozen
section the cell morphology is inferior to that of the
paraffin embedded section. Frozen section tends to
cause the cells to be larger and appear bloated and
the pathologist must take this into consideration
when examining the tissue sample.
(iv) Poorly stained section:
Freezing may affect the staining quality of the
sections and this factor may affect the pathologist's
judgement. To obtain a better morphology and
staining quality of the slide sections, some
laboratories heat the tissue sample in formalin for a
brief period before subjecting it/them to freezing.
However, this will increase the turn-around time of
the procedure.
Interpretative limitations
Frozen section diagnosis sometimes can be very
tricky. It is the policy of the pathologist to give the
closest diagnosis as possible to the surgeon and
avoid giving the definitive diagnosis if there is any
doubt. It is preferable to delay the definitive
diagnosis of the case especially if the finding is not
going to influence the intra-operative management.
The followings are some difficulties that may be
encountered in frozen section service.
(i) Tumours that are difficult to diagnose:
Certain tumors may mimic the normal tissue or
cells. Malignant blood vessels in angiosarcoma may
appear like ordinary blood vessels and assessment
of normal tissue margin for sarcoma can be very
tricky.
(ii) Heterogeneity of the tumor:
Heterogeneity in tumors especially soft tissue
sarcoma makes it fairly difficult to diagnose the
lesion not only in frozen section but also in tissue
biopsy specimen.
(iii) Mixed tumor and biphasic tumor:
These may again be difficult to interpret.
CONCLUSION
The intra-operative consultation using frozen
section is very useful but one needs to be aware of its
indications and limitations13. Frozen-section
examination is a method with adequate sensitivity
and specificity. It has low false-positive and false 14
negative rates . Nowadays, this technique has come
to be accepted as an integral part in the proper
15
management of the surgical patient .
List of illustrations:
Figure 1
Figure 2
Figure 3
Figure 4
Figure showing grossing of tissues for frozen
section
Figure showing the freezing of tissue sample
enclosed in cryo mold by immersing in
isopentane
Figure showing cryosectioning using brush
technique
Figure showing histopathological picture of a
frozen section
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
58
REFERENCES
1. McCarthy WC. The diagnostic reliability of frozen sections. Am J Pathol
1929;5:377-80.
2. Peters PM. Frozen section diagnosis. Br Med J 1959;i: 1321-3.
3. Bauermeister DE. The role and limitations of frozen sections and needle
aspiration biopsy in breast cancer. Cancer 1980; 46:947-9.
4. Ackerman LV, Ramirez GA. The indications and limitations of frozen
section diagnosis: a review of 1269 consecutive frozen section diagnosis.
Br J Surg 1959;46:336-50.
5. Spann CO, Kennedy JE, Musoke E. Intraoperative consultation of
ovarian neoplasms. J Natl Med Assoc 1994; 86: 141-4.
6. Twaalfhoven FC, Peters AA, Trimbos JB, Hermans J, Fleuren GJ. The
accuracy of frozen section diagnosis of ovarian tumors. Gynecol Oncol
1991; 41:189-92.
7. Michael CW, Lawrence DW, Bedrossian CWM, F.I.A.C. lntraoperative
consultation in ovarian lesions:a comparison between cytology and
frozen section. Diagnostic Cytopathology 1996; 15: 387-94.
8. Goss GR. Frozen section: the stat test of clinical pathology? Adv Med
Lab. 2001;13:8–12, 82.
9. http//www.wikipedia.com
10. Wilson LB. (1905). "A method for the rapid preparation of fresh tissues
for the microscope". J Am Med Assoc 45: 1737.
11. Hamed Ganjali. Frozen section: An overview. Annals of Biological
Research, 2012, 3 (11):5363- 5366
12. Stephen R Peters. A Practical Guide to Frozen Section Technique.
Springer New York Dordrecht Heidelberg London
Hasnan Jaafar
13. . Intra-Operative Frozen Section Consultation: Concepts, Applications
and Limitations. Malays J Med Sci. 2006 January; 13(1): 4–12.
14. Arikan Ilker, Barut Aykut, et al. Accuracy of intra-operative frozen
section in the diagnosis of ovarian tumours. J Pak Med Assoc 61:856;
2011
15. Goss, G. R. Frozen section: the stat test of clinical pathology? Adv Med
Lab 2001. 13:8–12. 82
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
59
THE PRE-STERILIZATION CLEANING
PROTOCOL FOR ROTARY NI-TI ENDODONTIC FILES
Original Article
* Rajesh Mahant, ** Shraddha Chokshi, *** Rupal Vaidya, **** Pallav Chokshi, ***** Ghanshyam Patel, ******Pruthvi Patel
ABSTRACT
Rotary nickel-titanium files have become the most widely used engine driven endodontic instruments for proper
shaping of root canals. Whenever these instruments are re-used proper cross-infection control measures should be
undertaken. The complex miniature architecture of rotary Ni-Ti endodontic files makes pre-sterilization and sterilization
procedures difficult. So, the aim of this study was to determine the effectiveness of various pre-sterilization cleaning
protocols for the rotary endodontic files currently used in dentistry.
Material and Method
60 rotary Ni-Ti endodontic files were collected from P.G. students of department of conservative dentistry and
endodontics of ahmedabad dental college & hospital, ahmedabad. The files were divided into 4 groups. Presterilization cleaning was carried out in Group A with liquid detergent and final rinse with water, in Group B with liquid
detergent, rinsing with water followed by ultrasonic bath, in Group C with 1.52% glutaraldehyde (10% korsolex) and
final rinse with water and group D pre- sterilization cleaning was carried out with 1.52% glutaraldehyde solution, water
rinsing followed by ultrasonic bath. All groups were followed by sterilization process using steam autoclave at 1210 C
temperatures at 15 psi pressure for 15 minutes. Instruments of all the groups were transferred separately by sterile
technique into Todd-Hewitt broth, incubated at 37°C temperature for 72 hours and observed for bacterial growth.
Results were confirmed microscopically using a gram stain.
Results
The files of the groups which were cleaned with 1.52% glutaraldehyde solution and / or ultrasonic bath before
autoclaving procedure showed no bacterial growth in the media. The autoclaved files which were cleaned with liquid
detergent before sterilization showed bacterial growth.
Conclusions
The method used routinely for pre-strerilization cleaning for endodontic instruments is appeared to be ineffective. The
best method is the one that include pre-sterilization cleaning with 1.52% glutaraldehyde or ultrasonic bath or 1.52%
glutaraldehyde followed by ultrasonic bath.
Key Words
Rotary Nickel-Titanium endodontic files, sterilization, ultrasonic cleaners, 1.52% glutaraldehyde
Introduction
Rotary NiTi endodontic instruments are gaining
popularity based on their superior preparation of
canals compared to hand instruments. Several
studies have shown that these NiTi instruments can
be used several times without intra canal failure.
Endodontic files are considered as reusable
instruments. Cross–infection control is a major
issue in dental care setting because of concerns
about transmission of diseases via oral cavity.
Endodontic treatment involves direct contact with
saliva, blood and infected pulp tissue, carrying
bacteria, viruses or prions1. Instruments that are in
direct contact with the vascular system of pulp or
penetrate the oral mucosa are classified as 'Critical
2
Items' and must be sterile before use . so endodontic
files are considered to be critical items and must be
3
cleaned and sterilized before their use.
The basic theorems of asepsis apply to NiTi files
with little variance whenever these instruments are
re-used. Endodontic files and reamers do not have
internal surfaces that are inaccessible, but their
construction and designs, which involve fluted and
twisted sections, don't allow easy access to all the
surfaces and make both mechanical and chemical
cleaning considerably more diffcult.4
Consequently, residual biological debris may
remain on the surface of the instrument even after
sterilization. In this way, potentially infective
material could be transmitted from one infected
5
tooth to other tooth.
Infection control guidelines indicate that Effective
sterilization of used instruments involves cleaning
of instruments to remove organic residue in order to
* PG Student ** Proffesor, *** Proffessor & H.O.D, **** Reader, ***** Lead Biostatistician, ******Reader
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (9033060056)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
60
6
GROUPS PRE-STERILIZATION CLEANING
STERILIZATION
achieve sterility of instruments. It is proven that the
A
Cleaned with brush & detergent
Autoclaved at121 C, 15Lbs for
presence of biological debris may prevent the
liquid & rinsed with water.
15 min
effective penetration of steam to the surface of the
B
Cleaned with brush and
Autoclaved at121 C, 15Lbs for
instrument. Another possibility is that biological
detergent liquid & rinsed with
15 min
debris with low moisture content may increase the
water followed by ultrasonic
heat-resistance of vegetative bacteria and spores. 7 It
cleaning for 5 minutes
has been accepted that the presence of organic
C
Immersed in 1.52%
Autoclaved at121 C, 15Lbs for
debris prevents the antibacterial action of chemical
glutaraldehyde (10 %korsolex)
15 min
disinfectants. Organic materials may inactivate
solution for 15 minutes and
germicidal molecules or, if the organic material
rinsed with water.
becomes dry, the proteinaceous layer resists
D
Immersed in 1.52%
Autoclaved at121 C, 15Lbs for
penetration of the chemical solution.8 Cleaning of
glutaraldehyde solution for 15
15 min
instruments to remove micro-organisms and
minutes and rinsed with water
organic debris (bioburden) effectively eliminates
followed by ultrasonic cleaning
9-11
the majority of micro-organisms. .
for 5 minutes
However, currently there is not a single method
TABLE NO.1
recognized to be absolutely reliable to test the
The following pre-sterilization cleaning protocol
cleanliness (i.e., lack of soil and bioburden) of an
was followed in this study: group A files were
item12. The Australian/New Zealand Standard
cleaned mechanically with a brush & chemically
AS/NZS 4187:2003. stipulates that instruments
with detergent liquid & then rinsed with water for
should be 'clean to the naked eye (macroscopic) and
10 minutes. Group B includes Cleaning with brush
6
free from any protein residues . It does not stipulate
and detergent liquid & then rinsing with water
how protein residues are to be assessed.
followed by ultrasonic cleaning for 5 minutes. In
Recommendations concerning cleaning and
group C files were Immersed in 1.52%
sterilization processes should be based on
glutaraldehyde solution for 15 minutes and then
scientifically obtained and clinically relevant data
rinsed with water. In group D the files were
and be justifiable, achievable, and consistent with
immersed in 1.52% glutaraldehyde solution for 15
13
known risks . Unfortunately, there is little research
minutes and rinsed with water followed by
information available on infection control
ultrasonic cleaning for 5 minutes. All the files were
13
procedures . Cleaning and sterilization
then transferred separately, using sterile techniques,
recommendations made by various groups may in
into individual sterile test tubes containing 3 mL of
fact be too stringent and not possible to follow in
Todd–Hewitt broth. The samples were incubated at
clinical practice.9
37°C temperatures. The test tubes were examined
There is little consistent information available on
after every 24 hours for a total of 72 hours, and any
the optimal procedure for the removal of biological
signs of bacterial growth were documented. A color
debris from contaminated endodontic instruments.
change, cloudy broth and visible precipitate in the
The cleaning procedures that are used include
test tube were all considered as indicative of
mechanical cleaning (use of different kinds of
bacterial growth. If the solution remained clear
brushes and sponges) and chemical cleaning
throughout the incubation period, the sample was
(immersion in 1.52% glutaraldehyde, enzymatic
considered sterile (Fig.1, 2).
cleaners, detergents or sodium hypochlorite),
ultrasonic bath and a final rinse with water before
sterilization14. Our aim is to compare various presterilization cleaning procedures for used rotary NITi endodontic files.
METHODOLOGY
60 used rotary Ni-Ti endodontic files were collected
from P.G. students of department of conservative
dentistry and endodontics of ahmedabad dental
college & hospital, ahmedabad. They had been
divided into 4 groups with 15 files in each group.
Figure 1
figure 2
The groups were made according to the presterilization cleaning procedures
used.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
61
0
0
0
0
Data were collected and tested for significant
differences using Fisher's exact test. The result was
confirmed with light microscope using gram stain.
Result
Sterilization procedures were 100% effective for
group B, C and D; not a single sample in either of
these groups showed contamination following the
72-hour incubation period. Pre-sterilization
cleaning procedure with brush and detergent
solution (group A) was less than 100% effective. In
the group A out of 15 files 5 files (33%) were
contaminated (p = 0.002). Several samples of
bacterial growth from used files were subjected to
gram staining; the resultant staining and bacterial
structure appeared consistent with Staphylococcus
(fig.3).
Figure 3
Discussion
The goal of instrument sterilization in dentistry is to
protect the patients as well as the dentist & the
dental auxillary staff from cross-contamination via
instruments. Careful consideration is required when
devising a sterilization protocol for endodontic
files. Some have suggested that these instruments
should be considered as single-use devices15. A
single-use device is an instrument designed to be
used in one patient only, and the packages for such
devices carry a clear label stating that they are not to
be resterilized16.
In the United Kingdom, concern has been raised
over the potential transmission of prions by
endodontic files because these devices come into
contact with the peripheral branches of the
trigeminal nerve. Of particular concern is the
iatrogenic transmission of variant CreutzfeldtJakob disease, one of the transmissible spongiform
15,17
encephalopathies . The risk of transfer of this
disease via used dental instruments in dentistry is
currently unknown; however, animal studies have
shown that these prions can be transmitted via the
17
oral cavity . Even if the risk of disease transmission
is minimal during endodontic procedures, the high
numbers of root canal treatments could increase the
15
possibility of an adverse event .
Many of the studies claimed that rotary Ni-Ti files
are meant for single use only, irrespective of various
pre-sterilization cleaning and sterilization
15,18
methods . Bagg et al. (2001), in a survey
conducted among dentists in the United Kingdom,
observed that 88% of the practitioners reused
endodontic files17. So it is important to make
emphasis on the effective sterilization procedures
of used endodontic files.
Smith et al found that a large number (76%) of used
files collected from the U.K. dental community
remained visibly contaminated after completion of
the sterilization process15. The results obtained in
the current study reinforce the conclusion that
routine
method of pre-sterilization cleaning
employed in the dental offices are unsatisfactory.
There is no consensus regarding a standard
sterilization protocol for these Ni-Ti rotary files.
This study is an attempt to develop a sterilization
protocol which is simple, quicker and more
predictable using less expensive and easily
available materials. In this experiment, 4 techniques
of pre-sterilization cleaning procedures were tested
and out of 4, 3 techniques were found to be
effective.
The sterilization techniques were 100% effective
for 3 groups which have used 1.52% glutaraldehyde
and/ or ultrasonic bath. Group B, C and D can be
directly compared with group A, because the
sterilization technique used was the same, the only
difference was about pre -sterilization cleaning
protocol.
The files in the group A were cleaned manually with
a brush & liquid detergent before autoclaving and
showed visible debris present on the files. 5 out of
15 files were contaminated following sterilization.
So according to Susan et al the pre-sterilization
cleaning method used in group A was found to be
19
not an effective method of sterilization .
Parashos et al recommends a protocol for cleaning
13
of used endodontic files .
1. 10 vigorous strokes in a scouring sponge soaked
in 0.2% of chlorhexidine solution.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
62
2. 30 minute pre-soaking in an enzymatic
cleaning solution.
3. 15 minute ultrasonication in an enzymatic
cleaning solution.
4. +20 second rinse in running tap water.
In the present study also ultrasonic cleaning prior to
autoclaving is found to be an effective method of
sterilization. One significant finding of this study is
that pre-soaking in 1.52% glutaraldehyde followed
by autoclaving is as effective as ultrasonic cleaning
plus autoclaving. Hence this method can be
recommended in absence of ultrasonic cleaner.
From the results, it is quite apparent that, the presterilization cleaning of used endodontic files to
remove gross debris is a far effective method than
sterilization alone. This relates back to the small
size and complex surface architecture of these
items. If the organic debris can be physically
removed from these items, it is possible to sterilize
them. Groups B, C and D had no organic
contaminating debris and were rendered 100%
sterile by the procedures outlined in Tables 1.
Conclusion
Within the limitations of this study following
conclusions can be drawn:
(a) Pre cleaning with liquid and detergent using
nylon brush is not an effective method of
sterilization.
(b)The following 3 methods are found to be
effective in sterilizing Ni-Ti rotary instruments.
1. Cleaning with brush and detergent liquid &
rinsed with water followed by ultrasonic cleaning
for 5 minutes,
2. Immersing in 1.52% glutaraldehyde solution
for 15 minutes and rinsing with water, followed by
autoclaving are effective methods of sterilization.
3. Immersing in 1.52% glutaraldehyde solution
for 15 minutes and rinsing with water, followed by
ultrasonic cleaning and autoclaving are effective
methods of sterilization.
REFERENCES
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1.
2.
3.
4.
5.
6.
7.
8.
9.
Centers for disease control (1987). Recommendations for the
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National Health and Medical Research Council of Australia. Infection
Control in the Health Care Setting. Canberra: Australian Government
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Martins R, Bahia M, Buono V. Surface analysis of ProFile instruments
by scanning electron microscopy and X-ray energy dispersive
spectroscopy: a preliminary study. AORN J 2002;75:1143-1158.
Heeg P, Roth K, Reichl R, Cogdill P, Bond WW. Decontaminated singleuse devices: an oxymoron that may be placing patients at risk for crosscontamination. Infect Control Hosp Epidemiol 2001;22:542-549.)
Gill DS, Tredwin CJ, Gill SK, Ironside JW (2001) The transmissible
spongiform encephalopathies (prion diseases): a review for dental
surgeons. International Dental Journal 51, 439–46.
Australian/New Zealand Standard 4187. Cleaning, disinfecting and
sterilizing reusable medical and surgical instruments and equipment,
and maintenance of associated environments in health care facilities:
Standards Australia International Ltd/Standards New Zealand, 2003.
Gardner J, Peel M. Sterilization, Disinfection and Infection Control. 3rd
edn. Melbourne: Churchill Livingstone, 1998.
Block S. Disinfection, Sterilization and Preservation. 5th edn.
Philadelphia: Lea & Febiger, 2001.
Rutala W, Gergen M, Jones J, Weber D. Levels of microbial
contamination on surgical instruments. Am J Infect Control
1998;26:143-145.
11.
12.
13.
14.
15.
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19.
Chu N, Chan-Myers H, Ghazanfari N, Antonoplos P. Levels of naturally
occurring microorganisms on surgical instruments after clinical use and
after washing. Am J Infect Control 1999;27:315- 319.
Alvarado C. Sterilization vs disinfection vs clean. Nurs Clin North Am
1999;34:483-491.
Dunn D. Reprocessing single-use devices – the equipment connection.
AORN J 2002a;75:1140-1164.
Miller CH. Applied research still needed on infection control
procedures. Am J Dent 2000;13:285-286
Parashos P, Linsuwanont P, Messer HH (2004) A cleaning protocol for
rotary nickel–titanium endodontic instruments. Australian Dental
Journal 2004; 49, 20–7.
Smith A, Dickson M, Aitken J, Bagg J. Contaminated dental
instruments. J Hosp Infect 2002; 51(3):233–5
Hogg NJ, Morrison AD. Resterilization of instruments used in a hospital
based oral and maxillofacial surgery clinic. J Can Dent Assoc 2005;
71(3):179–82.
Bagg J, Sweeney CP, Roy KM, Sharp T, Smith A. Cross infection control
measures and the treatment of patients at risk of Creutzfeldt Jakob
disease in UK general dental practice. Br Dent J 2001; 191(2):87–90.
Nicholas J.V.Hogg,Archibald Morrison. Resterilization of Instruments
Used in a Hospital- based Oral & Maxillofacial surgery clinic. JCDA
2005;71(3):179-82.
Archie Morrison , Susan Conrod. Dental Burs and Endodontic files: Are
Routine Sterilization Procedures Effective. JCDA 2009;75(1):39-39d.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
63
The Effects Of Nutrition On Occlusion Of Children
Original Research
* VIJAY BHASKAR, ** RAJAL PATHAK, *** MIRA VIRDA
ABSTRACT
Aims & objectives - To investigate the relationship between low BMI and malocclusion in a population of children (9-13
years) Ahmedabad, Gujarat, India.
Materials & method - This cross-sectional study consisted of 350 children including 175 underweight and 175 healthy
children, aged 9-13 years randomly selected from schools in and around Gandhinagar district. The evaluation of dental
occlusion was carried out by means of visual inspection performed under natural lighting, using mouth mirror & probe.
For BMI assessment, children's height was checked using a millimetered measuring tape, and weight was measured by
2
2
using a weighing machine. Body mass index was also measured by calculating weight (kg) per height (m ). BMI
measurement was then plotted on CDC approved growth chart.
Results - The results showed that there was no significant correlation found between type of BMI and occlusion as well
as crowding of teeth in children. There was also no significant correlation found between age & gender of the children
with low BMI. There was positive correlation found between socioeconomical status with BMI.
Conclusion - There was no significant correlation between underweight children and malocclusion but further studies
with increased sample size are needed to investigate possible relation between malnutrition and malocclusion.
Keywords – BMI, Malocclusion
INTRODUCTION
Evidence suggests that energy-protein malnutrition
acts by either exacerbating an existing morbidity or
contributing to the emergence of associated co
morbidities. In the field of oral health, the
association between malnutrition and impaired
growth and the development of facial bones has
been reported by a number of researchers [Caceda
J, Songvasin C] and has been linked to a reduction
in the length of the skull base and jaw height
[Weissman S].
There have also been reports of variations in
maxillo-mandibular width, lower facial height
and dental and skeletal ages [Gulati A et al,
Morales-Sampedro et al] as a result of malnutrition.
It is believed therefore that malnutrition may
also
be
associated
with
malocclusion,
particularly dental crowding, which is defined as
misalignment of the teeth due to insufficient
space for them to erupt in the correct place
[WHO,1997] . Altered bone growth in the
craniofacial complex caused by poor nutrition
could be reflected in reduced space for dental
eruption.
MATERIALS AND METHODS
This cross-sectional study consisted of 350 children
including 175 underweight and 175 healthy
children, aged 9-13 years randomly selected from
schools in and around Gandhinagar district.
The evaluation of dental occlusion was carried out
by means of visual inspection performed under
natural lighting, using mouth mirror & probe. WHO
recommends the body mass index (BMI) as
suitable indicators for evaluating the nutritional
status of children, and these has been used in this
study.
For BMI assessment, children's height was checked
using a millimetered measuring tape, which was
fixed to the wall in a straight line towards the floor
and use an weighing machine with a capacity of up
to 100kg division placed on a flat surface. Body
mass index was also measured by calculating
2
2
weight(kg) per height (m ). BMI measurement was
then plotted on CDC approved growth chart.
*HOD & Proffesor, ** Snr. Lecturer, *** PG Student-III
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (9409153755)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
64
THE QUESTIONNAIRE
There was also no significant correlation found
between age, gender & habits of the children with
low BMI. There was positive correlation found
between socioeconomical status with BMI.
RESULTS
The results showed that there was no significant
correlation found between type of BMI and
occlusion as well as crowding of teeth in children.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
65
DISCUSSION
The relative contribution of genes and the
environment to the aetiology of malocclusion has
been a matter of controversy throughout the
twentieth century. Genetic mechanisms are clearly
predominant during embryonic craniofacial
morphogenesis, but environment is also thought to
influence dentofacial morphology postnatally,
particularly during facial growth [Mossey et al].
The relative influence of genetics and
environmental factors in the aetiology of
malocclusion has been a matter for discussion,
debate and controversy in the orthodontic literature
Erika Thomaz & co work as done study to check
correlation between malnutrition with crowding in
permanent dentition and conclude that no
association was observed between malnutrition and
crowding. Malnutrition is related to crowding in
permanent dentition among mouth breathing
adolescents.
Genetic determination and regulation are
responsible for the morphogenesis of an individual
during embryonic development. There is ample
evidence to indicate that hereditary dentofacial
characteristics can be influenced during post-natal
development by general environmental factors
ranging from climate, nutrition, and lifestyle to oral
dental pressure habits, muscle malformation and
orthodontic treatment.The influence of
environmental factors on the retardation of general
somatic growth is apparent in chronic illness,
prolonged starvation, and situations of excessive
stress (Tanner, 1965).
The variation in shape and size of the cranio-dentofacial structures depends on both genetic and
environmental influences.There have also been
reports of variations in maxillo-mandibular
width, lower facial height and dental and skeletal
ages [Gulati et al, Morales-Sampedro et al] as a
result of malnutrition.
The effects of malnutrition on crowding in
permanent dentition by Thomaz co work as.
concluded that there was no association seen
between malnutrition and crowding. Malnutrition is
related to crowding in permanent dentition among
mouth breathing adolescents.
CONCLUSION
So it can be concluded from this study that there is
no significant correlation between underweight
children and malocclusion but further studies with
increased sample size are needed to investigate
possible relation between malnutrition and
malocclusion.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
66
REFERENCES
1. Erika Thomaz et al. Is malnutrition associated with crowding in
permanent dentition?; international journal of environmental research
& public health; 2010;7:3531-3544.
2. Ana Valenca & E.Thomaz. Relationship between childhood underweight
& dental crowding in deciduous teething, journal of pediatrics; 2009;
85(2):110-116.
3. N. kumar et al, Kuppuswamy’s Socioeconomical status scale updating
for 2007. Indian journal of pediatrics; 2007; 74 : 1131-1132.
4. Weissman S, Sadowsky PL, Jacobson A, Alvarez JO, Caceda J.
Craniofacial growth and development in nutritionally compromised
Peruvian children. J Dent Res 1993; 72:366.
5. Caceda, J. Effect of nutritional status on dental age. In Proceedings of the
72th General Session of the International Association for Dental
Research, Seattle, WA, USA, 1994.
6. Caceda J. Nutritional status and dental and skeletal development in
Peruvian children. J Dent Res 1996; 75:189.
7. Songvasin C. Early malnutrition and craniofacial growth. J Dent Res
1994; 73:123.
8. Miller JP, German RZ. Protein malnutrition affects the growth trajectories
of the craniofacial skeleton in rats. J Nutr. 1999; 129:2061-9.
9. World Health Organization. Health Interview Surveys: Toward
International Harmonization of Methods and Instruments; WHO:
Geneva, Switzerland, 1996.
10. Gulati A, Taneja J, Chopra S, Madan S. Inter-relationship between
dental, skeletal and chronological ages in well-nourished and malnourished children. J. Indian Soc. Pedod. Prev. Dent. 1991; 8:19–23.
11. Morales-Sampedro G, Martínez M, Martín F, Ayala J. Bone age and
dental occlusion. Rev. Cuba. Estomatol. 1993; 30:48–56.
12. Marques L, Barbosa C, Ramos-Jorge, M Pordeus, I Paiva.
Malocclusion prevalence and orthodontic treatment need in 10–14year-old schoolchildren in Belo Horizonte, Minas Gerais State,
Brazil: A psychosocial focus. Cad. Saude Publica 2005; 21: 1099–1106.
13. Batista L.R.V, Moreira E.A.M, Corso A.C.T. Food, nutritional status and
oral condition of the child. Rev. Nutr. 2007; 20: 191–196.
14. Center for disease control & prevention, National center for health
statistics, division of health examination. http:/www.cdc.gov/nhcs
/products /pubs/pubd/hus/tables/2000/updated/00hus069.pdp.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
67
Dental Fluorosis among 12 and 15 year old school
Original Article
going children of Solapur city, Maharashtra, India.
* Harsh Shah, ** Suyog Savant , ***Vasudha Sodani,****Deeksha Shetty,*****Brijesh Patel
ABSTRACT
Aim: To determine the prevalence and degree of dental fluorosis in 12 and 15 years old school going children of Solapur
city, Maharashtra. Methods: A total of 1042 children participated in the study. Convenience sampling was done in which
the sample was divided into 2 groups. Group A, used bore water for drinking at home and at school as there was no
municipal water supply. Group B, where the children, used municipal water supply for drinking both at home and at
school. The data regarding the fluoride content of Borewell water of Solapur city was collected from the office of Public
Works Department (PWD), Solapur. Samples of Borewell water and Muncipal water were collected from the area
nearby school and analysis was done at Superintendant Chemist Laboratory, Solapur, and fluoride levels were
determined. A survey Proforma was prepared with the help of the WHO Oral Health Assessment Form (1997). KarlPearson coefficient for correlation (or simple correlation) and simple regression analysis was used to measure the
correlation between fluoride concentration in drinking water and community fluorosis index (CFI). Chi –square test was
used for estimation of statistical significance. Results: High prevalence of dental fluorosis was found in Group A
(43.99%) as compared to Group B (17.01%). The overall prevalence of dental fluorosis in 12 and 15 year old school
going children of Solapur city was 29.07%. Conclusion: Dental fluorosis is a major dental public health problem in
Solapur city.
(Key Words: Dental fluorosis; Borewell water; Municipal water, Fluoride)
INTRODUCTION
Dental fluoride is a double –edged sword. Fluoride
at optimal level, decreases the incidence of dental
caries and is also necessary for maintaining the
integrity of oral tissues but at the same time when
taken in excess during developmental stages, can
cause adverse effects like dental fluorosis and
1
skeletal fluorosis . Endemic dental fluorosis is a
disturbance in tooth formation caused by excessive
intake of fluoride during the formative period of the
dentition. India is one among the 23 Nations around
the globe where health problems have been reported
due to excessive fluoride in drinking water. Fluoride
concentration in Solapur's groundwater was found
to be much higher than the permissible limit of 0.62
1.5 ppm (parts per million) of fluoride
recommended for potable purposes. Therefore in
these communities, fluorosis is very common. The
study was planned to know the prevalence and
degree of dental fluorosis in 12 and 15 years old
school children of Solapur city.
METHODOLOGY
The present study was conducted to know the
prevalence and severity of dental fluorosis among
12 and 15 years old school going children of
Solapur city. The study was conducted in Solapur
city, Maharashtra State, India. After a pilot study
was conducted, the convenience sampling was done
and 1042 children participated in the study. The
Solapur city was divided into 4 zones and the
schools and subjects were selected using random
sampling method. Sample was divided into 2
groups. Group A, who used bore water for drinking
at home and at school as there was no municipal
water supply. Group B where the children, using
municipal water supply for drinking both at home
and at school. School based approach was used.
Children who were permanent residents since birth
and between 12 to 15 years were selected from the
schools randomly who satisfied the following
inclusion criteria. Children with permanent teeth
and no fillings on facial surface were included in the
study while the rest were excluded. The data
regarding the fluoride content of Borewell water of
Solapur city was collected from Public Welfare
Department (PWD). To confirm these levels of
fluoride, further samples of Borewell water were
collected from the area nearby school and analysis
was done at the office of Superintendant Chemist
* Senior lecturer, ** Senior lecturer, *** Senior lecturer, ****Assistant Professor, *****Reader
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (9429428940)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
68
Laboratory, Solapur. Before scheduling the survey
an ethical clearance was obtained from the Ethical
committee of Dr. D.Y. Patil University, Pune. An
official permission was obtained from Deputy
Director of Public Walfare Department, Pune. A
survey Proforma was prepared with the help of the
WHO Oral Health Assessment Form (1997). It
consisted of two parts, 1st part consisted of
information on demographic data, permanent
residential address, information on source of
drinking water, aids used for oral hygiene
maintenance (fluoridated or nonfluoridated) and
2nd part consisted of table for recording fluorosis
using Dean's index. Karl-Pearson coefficient for
correlation (or simple correlation) and simple
regression analysis was used to measure the
correlation between fluoride concentration in
drinking water and community fluorosis index
(CFI). Chi –square test was used for estimation of
statistical significance.
RESULTS
The data collected was analyzed and calculated
using the necessary statistical tests. Table I, showed
the distribution of the study subjects according to
age, gender, source of drinking water and study
area. The percentage of children in 12 years was
541(51.92%) and 15 years were 501(48.08%).
Table I. Distribution of study subjects according to age, gender and study areas
S.No.
Area
Source
*
**
B
1
A
T
B
2
B
T
B
3
C
Age
12
Total
15
Male
24
6
Female
36
42
78
Male
15
18
33
Table II. Distribution of study subjects according to source of dreinking water
Number
Borewell
Percentage (%)
Municipal
466
576
44.72
55.28
Table III, showed the mean fluoride concentration
in Borewater, zonewise, which ranged from 0.6420.927.
Table III. Showing the fluoride concentration in bore water, zonewise.
ZONES
Mean fluoride concentration (ppm)
A
0.721
B
0.908
C
0.927
D
0.642
Range: 0.642-0.927
MEAN: 0.79
S.D.: 0.122
Table IV, represented the distribution of dental
fluorosis among the study subjects using Borewell
water, of Solapur city (Zone-A, Zone-B, Zone-C,
Zone-D)
Table IV. Prevalence of dental fluorosis of borewell drinking water
Fluoride subjects Subjects
(ppm)
examined with
fluorosis
0.642
78
33(42.3)
0.721
108
47(43.51)
0.908
120
54(45)
0.927
160
71(44.38)
questionable Very
mild
Mild
Moderate severe
CFI
8(10.26)
12(11.11)
4(3.33)
7(4.38)
7(8.97)
11(10.1)
21(17.5)
29(18.13)
2(2.56)
3(2.8)
6(5)
7(4.37)
0.512
0.537
0.708
0.71
16(20.51)
21(19.44)
23(19.16)
27(16.88)
0(0)
0(0)
0(0)
1(.625)
30
Female
34
59
93
Male
32
27
59
Female
41
20
61
Male
38
30
68
Female
46
16
62
Male
69
28
97
Female
18
45
63
Male
21
29
50
Female
29
27
56
39
Table V, shows the distribution of dental fluorosis
among the study subjects using municipal water, of
Solapur city.
Table V. Prevalence of dental fluorosis of municipal drinking water
mild
moderate severe CFI
Fluoride Subjects Subjects questionable Very
mild
(ppm)
examined with
fluorosis
0.3
236
22(9.42) 15(6.36)
15(6.36) 2(0.85) 0(0)
0(0)
0.1
0.4
340
6 6(19.61) 32(9.41)
28(8.24) 6(1.76) 0(0)
0(0)
0.15
Male
14
25
Female
24
15
39
Male
35
76
111
Female
65
38
103
Total Male
248
239
487
Table VI, showed the relationship between Fluoride
concentration and Community Fluorosis Index. The
degree of correlation between the Community
Fluorosis Index (CFI) and fluoride concentration in
drinking water was measured by using linear
regression (Karl Pearson's Coefficient of
Correlation).
Total Female
293
262
555
Table VI. Relationship between fluoride concentration and Community Fluorosis Index
(CFI):
T
B
4
Sex
Table II, indicated the distribution of study subjects
according to source of drinking water.
D
T
Grand Total (M+F)
*4 Zones=A,B,C,D
** B= Borewell
T= Tap (Municipal)
541
501
(51.92%)
(48.08%)
1042
Correlation
between
Mean±SD
Correlation
Coefficient ‘r’
Fluoride
concentration
0.64±0.23
0.98
CFI
0.45±0.24
Regression
Coefficient
‘b’
Prediction equation
1.022
CFI=1.022 (FL.Conc)0.21
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
69
Graph I shows the comparison of Dental Fluorosis
prevalence in Group A (Borewell) and Group B
(Municipal). The percentage of children affected
with fluorosis in Group A was 43.99% whereas in
Group B it was 17.01%.
Graph I. Comparison of dental fluorosis prevalence in Group A (borewell) and group B
(municipal).
BOREWELL (GROUP A)
Graph II shows the prevalence of dental fluorosis
among 12 and 15 years old children based on
fluoride concentration (in ppm). The percentage of
children affected at 12 and 15 years were 26.98%
and 31.33% respectively.
Graph II- Prevalence of dental fluorosis among 12 and 15 years old children based on
fluoride conc. (in ppm).
Graph III shows the positive correlation between
fluoride concentration in drinking water and
Community Fluorosis Index. Karl Pearson
Correlation Coefficient (r) was 0.98. For the
different levels of fluoride concentration the
estimated community fluorosis index values are
depicted (Graph I). For each unit change in fluoride
concentration, there was a change of 1.022 in
Community Fluorosis Index value.
GRAPH-III CORRELATION AND REGRESSION BETWEEN
FLUORIDE CONCENTRATION IN DRINKING WATER AND
COMMUNITY FLUOROSIS INDEX.
0.8
Community Fluorosis Index
0.7
0.6
0.5
CFI=1.0135(Fl.
CONC.)-0.2075
0.4
0.3
OBSERVED VALUES
0.2
PREDICTED VALUES
0.1
0
0.3
0.4
0.642
0.721
0.91
Fluoride concentration (ppm)
r=0.99
0.93
DISCUSSION
Endemic dental fluorosis is most prevalent in areas
where the drinking water contains elevated levels of
fluoride. The report published by the Rajiv Gandhi
National Drinking Water Mission, 1994, reported
14 states and the Union Territory Delhi as endemic
3
for fluorosis. Part of Maharashtra State lies in
endemic fluoride belt and extensive use of
groundwater accounts for widespread prevalence of
fluorosis.2 This study was designed to know the
fluoride concentration of Municipal and Borewell
drinking water in Solapur city and to assess the
prevalence of dental fluorosis in children who were
born and raised in Solapur city. Bardsen et al (1996),
from the county of Hordaland, Norway, reported
fluoride concentration in groundwater in the range
of 0.02-9.48 mg/l 4. Fourteen percent of the wells
contained water with fluoride level = 0.50 mg/l.
Similarly, a study from Northern Maharashtra,
India, reported fluoride concentration in
groundwater in the range of 4.78-1.01 mg/l.5 The
present study too reported high concentration of
fluoride in groundwater as compared to Municipal
water. The fluoride concentration in groundwater of
4 Zones of Solapur city ranged from: 0.64 ppm 0.93 ppm. Edmunds and Smedley (2005) have
identified that there are three main factors that
control the natural fluoride concentration of water;
lithology, geochemical evolution and residence
times of the water which determined water-rock
interactions and mineral dissolution 6. It was noticed
in the present study that at 0.3 and 0.4ppm fluoride
level, 12.26% and 15.87% of children were affected
with fluorosis. These findings were consistent with
earlier study conducted by Chandrashekar et al
(2001), where at 0.22ppm and 0.43ppm fluoride
level, 13.1% and 13.3% of children were affected
7
with fluorosis in Davangere district, Karnataka . At
0.64 ppm and 0.72 ppm fluoride level, 42.3% and
43.51% of children were affected with fluorosis,
whereas at 0.90 ppm and 0.97 ppm fluoride level,
45% and 44.38% of children were affected with
fluorosis respectively. The prevalence of dental
fluorosis in our study group corresponds well with
the findings of study conducted by Heller et al
(1997), where at <0.3, 0.3 to <0.7, 0.7-1.2 and
>1.2ppm fluoride level, 13.5%, 21.7%, 29.9% and
41.4% of children showed dental fluorosis
8
respectively . The prevalence of dental fluorosis is
higher even at low concentration of fluoride in
present study. As compared to Solapur conditions,
the relatively higher daily temperature when
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
70
compared to temperate regions of the world (for
example USA), necessitates comparatively
increased consumption of water per day which
leads to an increased ingestion of fluoride (Galgan
and Lamson 1953, Galgan and Vermillion 1957).
This in turn resulted in higher prevalence of dental
fluorosis. The relationship between the fluoride
concentration of water and dental fluorosis was
complex. But it was observed that as the fluoride
level increased from 0.3 ppm to 0.4 ppm, 0.64 ppm,
0.72 ppm, 0.91 ppm and 0.93 ppm, there was
substantial increase in prevalence of dental
fluorosis from 12.26% to 15.9%, 42.3%, 43.51%,
45% and 44.4% respectively. An increase in
percentage of children affected with dental
fluorosis with every unit increase in fluoride level in
drinking water is in close agreement with other
studies conducted by Dean HT (1942), Moller
(1970),Driscoll (1983), Segreto (1984), Reddy and
Tewari (1985), Akihito (2000), Grobler (2001),
Banu Ermis (2003) and Wondwossen (2004)9-17.
Results of the present study showed a linear
relationship between CFI values of 12 and 15 years
old children and fluoride concentration in water
(r=0.98). These findings were in close agreement
with that of he studies conducted by Dean H.T.
(1942), Driscoll (1983) and Angelillo (1998)9, 11,
18. Dean (1942) stated that CFI values less than 0.4
is not of public health concern. In present study it
was observed, that, for all the study groups
consuming Borewell water the CFI values were
more than 0.4. The overall prevalence of dental
fluorosis in 12 and 15 year old school going children
of Solapur city was found to be 29.07%. This
finding of our study is highly supported by the
observations reported by National Oral Health
Survey Fluoride Mapping 2002-2003
(Maharashtra).19 The Survey reported 32% and
29.6% of 12 and 15 year old having fluorosed teeth
in urban area. Further, our study reported high
prevalence of dental fluorosis in Group A (43.99%)
as compared to Group B (17.01%) Graph I. Also
the study done by Akpata et al (1997) reported that
over 90% of the 12-15 year aged rural children in
Saudi Arabia drinking well water (0.5-2.8 ppm of
fluoride) had fluorosed teeth20. The findings of our
study showed high Fluorosis prevalence amongst
15(31.34%) years as compared to 12 (26.99%)
years. This was in close agreement with the studies
conducted earlier by Abdullah et al (1997) and
Almas et al (1999)21-22. Applying Galgan and
Vermillion formula for Solapur condition whose
maximum average daily temperature is 38.3oC
(100.9oF) for past 5 years, it showed that 0.58 ppm
would be safe level. It is therefore imperative that
each country calculated its own optimal level of
fluoride in drinking water in accordance to the doseresponse relationship of fluoride in drinking water
with the level of caries and fluorosis, climatic
conditions, dietary habits of the population and
other possible fluoride exposures also needed to be
considered in formulating these recommendations.
Conclusion:
High prevalence of dental fluorosis was found in
Group A (43.99%) as compared to Group B
(17.01%). The overall prevalence of dental
fluorosis in 12 and 15 year old school going children
of Solapur city was 29.07%. so we can conclude by
telling that dental fluorosis is a major dental public
health problem in Solapur city.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
71
REFERENCES
1.
Tewari A. “Fluorides and Dental caries” 1986. Indian Edition, 1st
Edition. The Journal of the Indian Dental Association, Publication.
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3. Chakraborti D, Chanda CR, Samanta G, Chowdhury UK, Mukherjee SC.
Fluorosis in Assam, India: Current Science 2000;78(12):1421-1423.
4. Bardsen A, Kjell B, Knut A. Variability in fluoride content of subsurface
water reservoirs. Acta Odontologica Scandinavica.1996;54(6):343-347.
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contamination in drinking water in rural habitations of Northern
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6. Edmunds WM and Smedley P. Fluoride in Natural Waters.
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Essentials of medical geology: Impacts of the Natural Environment on
Public Health. 2005. Selinus, (ed.) Elsevier, Boston.
7. Chandrashekar J, Anuradha KP. Prevalence of dental fluorosis in rural
areas of Davangere, India. Intl Dent J. 2004:54:235-239.
8. Heller KE, Eklund SA, Burt BA. Dental Caries and Dental Fluorosis at
varying fluoride concentrations. J Public Health Dent.1997;57(3):13643.
9. Newbrun E. “cariology”1989. 3rd Edition. The use of fluorides in
preventive dentistry. Pg.331.Quintessence Publishing Co.
10. Moller IJ, Pindborg JJ, Gedalia I, Roed-Petersen B. The prevalence of
dental fluorosis in the people of Uganda. Arch Oral Biol. 1970
Mar;15(3):213-25.
11. Driscoll WA, Horowitz HS, Meyers RJ, Heifetz SB, Zimmerman ER.
Prevalence of dental caries and dental fluorosis in areas with optimal and
above-optimal water fluoride concentrations. J Am Dent Assoc.
1983;107:42-47.
12. Segreto VA , Collins EM, Camann D, Smith CT. A Current study of
mottled enamel in Texas. J Am Dent Assoc. 1984;108:56-58.
13. Subbareddy VV, Tewari A. Enamel Mottling at different levels of fluoride
in drinking water: In an endemic area. J Indian Dent Assoc.1985;57:205212.
14. Akihito Tsutsui, Minoru Yagi, Alice M. Horowitz. The Prevalence of
Dental Caries and Fluorosis in Japanese Communities with up to 1.4ppm
of Naturally Occurring Fluoride. J Public Health Dent. 2000;60(3):14753.
15. Grobler SR, louw AJ, Van W. Kotze TJ. Dental Fluorosis and caries
experience in relation to three different drinking water fluoride levels in
South Africa. Intl J Paed Dent. 2001;11:372-379.
16. Banu Ermis R, Fatma Koray, Guniz Akdeniz. Dental Caries and Fluorosis
in low and high- fluoride areas in Turkey. Quintessence International
2003;34(5):354-360.
17. Wondwossen F, Astrom AN, Bjorvatn K, Bardsen A. The relationship
between dental caries and dental fluorosis in areas with moderate and
high fluoride drinking water in Ethiopia. Community Dent Oral
Epidemiol. 2004;32:337-44.
18. Angelillo IF, Torre I, Nobile CGA, Villari P. Caries and Fluorosis
prevalence in communities with different concentrations of fluoride in the
water. Caries Res. 1999;33:114-122.
19. National Oral Health Survey and Fluoride Mapping 2002-2003,
Maharashtra.
20. Akpata ES , Fakiha Z, Khan N. Dental fluorosis in12-15 year old rural
children exposed to fluorides from well drinking water in the Hail region
of Saudi Arabia. Community Dent Oral Epidemiol. 1997;25:324-327.
21. Abdullah R. Al-Shammery, Ernest Guile E, Mahmoud El Backly. The
prevalence of Dental Fluorosis in Saudi Arabia. Saudi Dental Journal
1997;9(2):58-61.
22. Almas Kh, Shakir ZF, Afzal M. Prevalence and severity of Dental
Fluorosis in Al-Qaseem province- kingdom of Saudi Arabia. Odonto
–Stomatologie Tropicale 1999.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
72
C-shaped root canal configuration in maxillary
first molar
A Case Report
* Mamta Kaushik, ** Sonal Singh, ***Kunjal Mistry,****Zarna Sanghvi
ABSTRACT
Aim: This clinical report presents an unusual C-shaped root canal system in the buccal root of maxillary first molar.
Summary: According to literature, the C-shaped root canal is found more in the mandibular second molar, and its
occurrence in maxillary first molars is rare. This case presents a C-shaped canal in the buccal root of a maxillary first
molar. This report emphasizes the variation in canal morphology of maxillary first molar and suggests the use of latest
adjuncts in successfully diagnosing and negotiating it.
Keywords: C-shaped canal, maxillary first molar, buccal root.
IntroductionA thorough knowledge of the root canal anatomy, its
variations, the presence of additional roots and
unusual root canal morphology is essential, as it
determines the successful outcome of endodontic
treatment1.
The maxillary molars may present a variety of
morphological configurations. Majority of the
reports discuss the prevalence of two or three canals
in the mesiobuccal root 2-5.. Maxillary molars with
two canals in the palatal root, two separate palatal
roots; five and six root canals have also been
reported 5,6,7.
Unlike mandibular molars, where a C shape root
canal system may classically occur8, such a
8-12
configuration is rare in maxillary molars . In the
present case, mesiobuccal and distobuccal canals
are fused. Only one similar case has been reported,
there the C-shaped buccal canal led to three separate
13.
foramina
The purpose of this article is to report an occurrence
of C shape configuration in buccal root of maxillary
first molar that required endodontic therapy.
Case HistoryA 34-year old female patient reported to the
Department of Conservative Dentistry and
Endodontics, with complaint of pain in the upper
left posterior region since three days. Pain was
moderate, intermittent and increased while chewing
food. The patient was taking medication
(analgesics) for the same. The patient's medical and
dental history were non-contributory.
On clinical examination, caries was present on the
distal aspect of the left maxillary first molar. There
was no evidence of swelling or sinus tract in relation
to it. The involved tooth was tender on percussion
and no periodontal pockets were present.
Radiographic evaluation of the concerned tooth
(Fig.1) revealed carious destruction on the distal
aspect in close proximity to the pulp, two
overlapping roots and widening of the lamina dura
for the buccal root at the cervical and middle third.
Based on clinical and radiographic findings a
diagnosis of irreversible pulpitis with apical
periodontitis was made.
Figure 1 Pre-Operative Radiograph
Endodontic treatment was planned for the same.
After administering local anaesthesia, and rubber
dam isolation, all carious tissue was removed and an
access cavity was prepared. Two orifices and canals
(one buccal and one palatal) were located in the first
appointment (Fig 2). It was recognized that the
single canal orifice in the buccal root extended into
mesial and distal to form a C-shape. This was
* Proffesor, ** Senior Lecturer, *** Reader **** Reader
Army College & Dental Sciences, Secunderabad, Andhra Pradesh. (+919391010325)
New Horizon Dental College and Research Institute, Sakri, Bilaspur, Chattisgarh.
Faculty of Dental Science, Dharamsinh Desai University Nadiad, Gujarat.
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
73
further evaluated under the dental operating
microscope (Seiler). Working length was
determined with an electronic apex locator (Propex
II, Dentsply) and confirmed with a radiograph (Fig.
3). Cleaning and shaping for both canals was done
with Mtwo instruments (VDW) under copious
ultrasonic irrigation with 5.25% sodium
hypochlorite. Intra canal medicament of calcium
hydroxide ( Metapex) was placed and the access
cavity was sealed with a temporary restoration
(Cavit).
E
Figure 5 3 months follow up Radiograph
Discussion –
Although C shaped canal morphology is classically
seen with mandibular second molars, involvement
of other teeth have been reported. A literature
review of 8,399 maxillary first molars showed the
14.
incidence of C shapes to be 0.12%
In an examination of 309 Chinese maxillary second
molars, C-shaped root canals were encountered at a
frequency of 4.9% . A fusion of the distobuccal and
palatal root 1 of 83 extracted maxillary first molars
in an Irish population is mentioned9. Another
incidence of a connection between the distobuccal
and the lingual root component has been described
in a study of single-rooted maxillary second molars
16
as 7.69% . Mostly C shape canal is seen by fusion
of distobuccal and palatal roots11,16. In this case,
mesiobuccal and distobuccal canals are fused which
is rare. Only one similar case has been reported
where the C shaped buccal canal led to three
13
separate foramina .
The anatomy of 2175 root-filled maxillary first
molars evaluated radiographically; reported the
12
incidence of C-shapes to be 0.091% .
Radiographic identification of this phenomenon is
difficult, and occasionally it may be found only
14
during access cavity preparation . In the present
case also, the clinical appearance of the pulp
chamber floor, rather than the radiographic
appearance, facilitated the recognition of the
anomaly.
Clinically, an operating microscope may facilitate
the observation of C-shaped canal orifice; but one
cannot assume that the shape continues throughout
the length . Newer diagnostic methods such as cone
beam computerized tomography (CBCT) scanning
greatly facilitate access to the internal root
morphology 17,18. The operating microscope and
CBCT are important for locating and identifying
root canals, and CBCT can be used as a good
method for initial identification of maxillary first
19
molars internal morphology .
15
Figure 2 Access opening showing
C-Shaped orifice in the buccal canal
Figure 3 Working length Determination
On the next appointment, the canals were obturated
(Fig.4) using cold lateral compaction of guttapercha and a resin sealer (AH Plus, Dentsply,
Germany) under 8x magnification of the dental
operating microscope. The patient experienced no
post-treatment discomfort and the tooth was
restored with a posterior composite filling ( tetricN-ceram). The patient was called for follow up
after three months. (Fig. 5)
8
Figure 4 Post obturation Radiograph
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
74
Although the incidence of root variations is rare,
root canal morphology should be examined during
treatment through the evaluation of radiographs
taken from different horizontal angles. The present
case confirms the necessity for meticulous
examination of the pulpal floor at high
magnification under sufficient illumination of the
operating microscope and emphasizes the
importance of newer imaging techniques like
computed tomography in preoperative assessment.
References –
11. Dankner E, Friedman S, Stabholz A. Bilateral C shaped configuration in
maxillary first molars. J Endod 1990;16, 601–3.
12. R. J. G. De Moor. C-shaped root canal configuration in maxillary first
molars, Int Endod J, 2002; 35, 200–8
13. Yilmaz Z, Tuncel B, Serper A, Calt S. C-shaped root canal in a maxillary
first molar: a case report., Int Endod J,2006; 39, 162–166
14. Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of
the human permanent maxillary first molar: A literature review. J Endod
2006; 32:813-821.
15. Yang ZP, Yang SF, Lee G , The root and root canal anatomy of maxillary
molars in a Chinese population. Endodontics and Dental Traumatology,
1988; 4 , 215–8.
16. Carlsen O, Alexandersen V, Heitmann T, Jakobsen P , Root canals in onerooted maxillary second molars. Scandinavian Journal of Dental
Research, 1992; 100 , 249–56.
17. Patel S, Dawood A, Whaites E, et al. New dimensions in endodontic
imaging: part 1.
Conventional and alternative radiographic systems. Int Endod J
2009;42:447–62.
18. Nair MK, Nair UP. Digital and advanced imaging in endodontics: a
review. J Endod 2007;33:1–6.
19. Filho FH, Zaitter S, Haragushiku GA, Campos EA, Abuabara A, and
Correr GM. Anlysis of the Internal Anatomy of Maxillary First Molars by
Using Different Methods. J Endod 2009;35:337–342
1. Malagnino V. Gallotini L. Some unusual clinical cases on root anatomy of
permanent maxillary molar. J Endod 1997;23:127-8
2. Pe´cora JD, WoelfeL JB, Sousa Neto MD, Issa EP. Morphology study of
the maxillary molars, part II: internal anatomy. Braz Dent J 1992;3:53–7.
3. Ayranci LB, Arslan H, Topcuoglu HS. Maxillary first Molar with three
canal orifices in MesioBuccal root. J Conserv Dent 2011;14:436-7
4. Verma P, Love RM. A Micro CT study of the mesiobuccal root canal
morphology of the maxillary first molar tooth. Int Endod J 2011;
44:210–217
5. Acosta Vigouroux SA, Trugeda Bossans SA. Anatomy of the pulp
chamber floor of the permanent maxillary first molars. J Endod
1978;4:214- 9.
6. MarLines Berne A, Ruiz Badanelli P. Maxillary first molars with six
canals. J Endod 1983;9:375-81.
7. Bond JL, Hartwell OH, Porte, FR. Maxillary first molar with six canals. J
Endod 1988;14:258-60.
8. Jafarzadeh H, Wu Y. The C-shaped root canal configuration: A review. J
Endod 2007; 33:517-523.
9. Al Shalabi RM, Omer OE, Glennon J, Jennings M, Claffey NM. Root
canal anatomy of maxillary first and second permanent molars. Int Endod
J ,2000; 33, 405–14.
10. Newton CW, McDonald S. A C-shaped canal configuration in a maxillary
first molar. J Endod 1984;10, 397–9.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
75
RADICULAR ATTACHMENT RETAINED
OVERDENTURE-CASE REPORT
Case Report
* Darshana N.Shah, ** Chirag J. Chauhan, *** Krutika A. Bhatti,
ABSTRACT
Overdentures are those prosthesis, which are supported by the natural teeth or implants. The main advantage of tooth
supported complete dentures are conservation of alveolar bone, improved vertical support and retention, improved
horizontal stability, maintenance of proprioceptive guidance by retained roots, and psychologic benefit to the patient.
When few firm teeth still remain in a compromised dentition, preservation of these teeth for overdentures can improve
the retention and stability.
The authors present a clinical report of a patient treated with a mandibular tooth-borne overdenture with stud
attachment and it describes step by step procedure for preparation of preci-clix radicular attachment retained
overdenture.
Key words: Natural teeth, Attachment supported overdenture, Mandibular complete denture
INTRODUCTION
Retaining teeth for an overdenture is an old concept
1-4
and a viable treatment modality. Overdentures
provide better function than conventional complete
dentures through a variety of factors, such as
improved biting force chewing efficiency, and
increased speed of controlled mandibular
5
movement. In addition, they minimize the
downward and forward setting of a denture, which
6
otherwise occurs with alveolar bone resorption.
The key to success of an overdenture is the selection
of strategic roots or teeth for retention. Elective
endodontics and periodontal therapy make them
excellent abutments for an overdenture. Abutment
teeth are prepared, to create adequate space for the
overlying denture. The shortened crown improves
the crown-to-root ratio, thereby decreasing the
mobility of the abutment teeth under an
7
8
overdenture. In a 4-year-study, Renner et al
showed that 50% of roots, used as overdenture
abutments remained immobile. In addition, 25% of
roots that were initially mobile became less mobile.
Hence, they suggested, that teeth that are generally
compromised can be used for overdentures after
root canal therapy and decoronation.
The use of attachments can redirect occlusal forces
away from weak supporting abutments and onto
soft tissue, or redirect occlusal forces toward
stronger abutments and away from soft tissues.
They act as shock absorbers and stress redirectors,
as well as providing superior retention.
Attachments are often used in overdenture
construction by, either connecting the attachments
to cast abutment copings or connecting into the
prepared post space of the abutment teeth.
Overdenture attachments are classified either as
studs, which connect the prosthesis to the individual
tooth, or as bars which connect the prosthesis to the
splinted abutment teeth. They are further classified
as rigid or resilient. However, since edentulous
ridges and the remaining roots are often
compromised, the prosthesis that relies on resilient
attachments is better able to divert occlusal forces
away from weak abutment teeth. The metal O-ring
attachment system, is considered to be a good
resilient attachment for overdentures.9,10
Radicular attachments are commonly used for
overdentures. They provide the stability and
retention to the prosthesis. This clinical report
describes mandibular overdenture retained with the
help of O-ring stud attachments.
* H.O.D & Proffesor ** Proffesor *** PG Student-III,
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (9909389238)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
76
CASE REPORT
A 45years old male patient was reffered to the
Department of Prosthodontics Ahmedabad Dental
College and Hospital, Ahmedabad with a chief
complaint of difficulty in chewing because of
absence of many lower teeth. A detailed medical,
dental and social history was obtained. The patient
did not have any prosthesis. Primary
impressions(ALGINATE, MARIEFLEXand
diagnostic casts(DENTAL STONE,ASIAN) were
made.
On Intraoral Examination:
Teeth present in maxillary arch 11, 12, 13, 14, 21,
22, 23
Teeth present in mandibular arch 33,34,43 Grade I
mobility in 11,12,21
A treatment plan was developed with the following
aims: to reduce effect of loss of teeth and function,
to improve the esthetics and to restore masticatory
function.
A treatment plan was carried out with 3 phases:
1)Pre prosthetic phase:
The periodontal therapy- The periodontal health of
each tooth was checked, and the tooth was treated
by curettage. Splinting was done for maxillary
teeth. In maxillary arch cast partial denture was
planned.
The endodontic therapy-Endodontic therapy was
routinely done to create a more favorable crownroot ratio. The decreased crown size reduced the
torquing forces and aided in maintaining the
periodontal health of the abutments.11 In this case
periodontal health of the teeth were improved with
the scaling and endodontic therapy was done i.r.t
33,34 and 43( figure 1).
4 mm projecting just above the gingiva. The
exposed dentin of the abutment was polished. Metal
coping was done with routine casting procedure on
a primary cast on 34. Cementation( GIC, 3M ESPE)
was done on 34 with metal coping ( figure 2). After
cementation of metal coping a rubber base
(Photosil, Dental Impression Material) impression
(Figure 3) was made and a cast poured in die
stone(DIE STONE IV , PEARL STONE ).
Figure:2 Dome shaped teeth preparation on 33, 34, 43 and
metal coping 34.
Figure :3 Final impression
The preci-clix radicular attachment kit comprises of
3 drills, insertion tool, metal analogue, 3 flexible
cap red, yellow and white according to resilience,
tin foil( figure 4), metal housing with yellow
medium resilient flexible cap and male attachment
with black ring(figure 5).
Figure :1 Mandibular retained teeth in 33, 34 and 43.
2)Prosthetic phase:
Abutment teeth were prepared in a dome-shaped
contour and hemispherically rounded in all
dimensions. The height of the abutment teeth was 3-
Figure :4 Preci-clix radicular attachment kit.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
77
Figure :5 Metal housing, yellow medium resilient flexible cap
and male attachment with black ring.
Figure :8 Complete denture ready for pick up the female
attachment.
Canal preparation was done for the attachment in
teeth 33 and 43.Sequencial drilling was carried out
with access drill, counter shink drill and final drill.
The adequate length of male attachment
determination was done and its confirmed by
radiographs after that cementation(GIC,3M ESPE)
of attachment was carried out. (figure 6).
Female attachment pick up with cold cure resin
(RAPID REPAIR, Pyrax)in complete denture. After
that excess resin was trimmed and final finishing
and polishing of prosthesis was carried out(figure
9).Reinsert the denture and is checked for its easy
insertion.
Figure:9 Final prosthesis with female attachment.
Figure :6 Male attachment in 33 and 43.
Flexible cap press in the metal housing with the help
of insertion tool and place on the male attachment
with tin foil spacer(figure 7).Tin foil spacer create
space between denture and male attachment for
resilience effect during function.
Figure :7 Metal housing with flexible cap and tin foil spacer
on the male attachment
Create space for the pickup of metal housing with
flexible cap(female attachment) in the final
complete removable denture(figure 8).
3)Maintenance phase :
The instruction was given regarding oral hygiene
maintenance and prosthesis maintenance to the
patient. Patient is recalled every 6 months and is
checked for the resiliency of the flexible cap and
prosthesis.
DISCUSSION
The use of teeth as overdenture abutments is
beneficial to the patients. The psychological aspect
of Patients losing teeth should not be
underestimated and this has been well
documented.12 Careful selection of strategic
abutment is important. The decision must, first be
made to retain the teeth as overdenture abutments
and then the attachment should be planned. The
attitude of the patient to the treatment should be
assessed. Only those who understand the
limitations and benefits of attachments should be
treated with attachment retained overdentures.
Hence, patient selection is critical to the success of
the treatment.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
78
In the present report, flexible cap with metal
housing attachment retained mandibular denture
was fabricated. The attachment used was basically
the implant prosthetic component. It is functionally
classified as a resilient attachment. It does not
transfer forces to the root and only acts as a retentive
devices. Hence, the system is considered to be the
best attachment that acts passively on the remaining
abutment teeth. It also provides the adequate
retention, so that it is easy to insert/remove, and is
comfortable to the patient. There are however, some
disadvantages such as the gradual loss of retention,
due to the wear of flexible cap, and the need for
periodic replacement but the presence of metal
housing give ease for replacing the flexible cap,
With the help of insertion tool we can place the
another flexible cap directly in metal housing,
which is already present in complete denture.
CONCLUSION
Lack of retention of complete mandibular dentures
is a common complaint among the complete
denture patients. With the inception of
ossteointegrated implants, the concept of
overdentures has become more popular, but not all
patients are able to afford the treatment costs. A
tooth-borne overdenture may be advised whenever
several good teeth remain in the arch. The different
attachment designs are suggested in the literature
for implant overdentures, also hold true for toothborne overdentures. The incorporation of
attachments in overdentures into everyday dental
practice will open up another dimension in dental
treatment planning and patient satisfaction. Teeth
that might be considered for extraction, may be
considered as long or short term alternatives to
implant or total edentulousness.
REFERENCES
7.
1.
2.
3.
4.
5.
6.
Tallgren A. Changes in adult face height due to aging, wear, loss of
teeth and prosthetic treatment. Acta Odontol Scand 1957;15:24.
Brill N. Adaptation and the hybrid prosthesis. J Prosthet Dent
1955;5:811-823.
Miller PA. Complete dentures supported by natural teeth. J Prosthet
Dent 1958;8:924-928.
Prince JB. Conservation of the supportive mechanism. J Prosthet
Dent 1965;19:327-338.
Rissin L, House JE, Manly RS, Kapur KK. Clinical comparison of
the masticatory performance and electromyographic activity of
patients with complete dentures, overdentures and natural teeth. J
Prosthet Dent 1978;39:508.
Crum RJ, Rooney GE. Alveolar bone loss in overdentures; a 5-year
study. J Prosthet Dent 1978;40:610-613.
8.
9.
10.
11.
Lovdal A, Schei O, Waerhaug J. Tooth mobility and alveolar bone
resorption as a function of occlusal stress and oral hygiene. Acta
Odontol Scand 1959;17:61-75.
Renner RP, Gomes BC, Shakeen ML. Four year longitudinal study of
the periodontal health status of overdenture patients. J Prosthet Dent
1984;51:593-598.
Tokuhisa M, Matsushita Y, Koyan K. In vitro study of a mandibular
implant overdenture retained with ball, magnet, or bar attachment:
comparison of load transfer and denture stability. Int J Prosthodont
2003;16:128-134.
Ben-Ur Z, Gorfil C, Shifman A. Anterior implant support
overdentures. Quintessence Int 1996;27:603-606.
Wayne R Frantz: The use of natural teeth in overdentures. J Prosthet
Dent 1975;34:135-140.Fiske J, Davis DM, Frances C, Gelbier S.
The emotional effects of tooth loss in edentulous people. BDJ
1998;184:90-93.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
79
CANCER THERAPY INDUCED ORAL MUCOSITIS:
Review Article
PREVENTION AND MANAGEMENT PROTOCOL
* Parul Bhatia, **A.R. Chaudhary,***Yesha Jani, ****Suresh Ludhwani
ABSTRACT
Oral mucositis also called stomatitis, is one of the most common and troublesome occurrence in individuals undergoing
chemotherapy and radiotherapy. Oncology treatment cannot distinguish between healthy and malignant cells. Thus,
the mucosa becomes atrophic and more susceptible to trauma, allowing the development of inflammation followed by
secondary infection, which increases patient discomfort and hampers quality of life. The clinical management of
mucositis includes preventive and palliative strategies. Role of an oral physician in prevention and management of
chemotherapy and radiotherapy induced mucositis is critical.
Introduction
Oral mucositis may be defined as inflammation of
oral mucosa with extensive ulceration and painful
irritation caused by the necrosis of the basal layer of
1
the oral mucosa . Mucositis has received significant
attention from the physician community in the last
two decades of life. It is estimated that oral
mucositis affects 40% of the patients undergoing
chemotherapy, 75% of the patients undergoing
chemotherapy and bone marrow transplantation
and more than 90% patients undergoing
radiotherapy for head and neck cancer2. Oral
mucositis is a complex biological process divided
3
into four phases , which are interdependent and can
occur due to action of cytokines on epithelium.
These phases are
1. Inflammatory or vascular phase: days 0-4
2. Epithelial phase: days 4-6
3. Ulcerative or bacteriologic phase: days 6-12
4. Healing phase: days 12-16
The more important clinical features are erythema
and/or ulceration4, which may extend from the
mouth to the rectum5. It can induce several lifethreatening complications, such as intestinal
obstruction and perforation6, compromising the
patient's quality of life and leading to severe
infections 7.
Pathophysiology
Firstly, the chemotherapy drugs induce the death of
the basal epithelial cells, which may occur by the
generation of free radicals. These free radicals
activate second messengers that transmit signals
from receptors on the cellular surface to the inner
cell environment, leading to up-regulation of proinflammatory cytokines, tissue injury, and cell
death. The anti cancer drugs most commonly
associated with oral mucositis include bleomycin,
doxorubicin, fluorouracil, methotrexate, vincristine
and daunorubicin. Either the use of these drugs or
the cancer itself leads to neutropenia, which
predisposes the mucosa to inflammation and also
enables bacterial invasion of the submucosa and
vascular walls, leading to bacteraemia.
In radiotherapy, an inflammatory response is
influenced by the depth and volume of radiation,
total grays of radiation delivered and the number
and frequency of treatments. The onset, duration
and intensity vary with the individual but most often
the onset starts with second week of therapy or after
a dose of about 2000cGy11.
Later, the mucous membrane tends to become
atrophic, thin and relatively avascular. This long
term atrophy results from progressive obliteration
of the fine vasculature and fibrosis of underlying
connective tissue. These atrophic changes
complicate denture wearing because they may
11
cause oral ulceration of compromised tissue .
CLINICAL MANIFESTATION
The first symptoms reported by patients with oral
mucositis are burning mouth and color changes in
the mucosa, which becomes white because of
insufficient keratin desquamation. Later, this
epithelium is replaced by atrophic, edematous,
erythematous, and friable mucosa, allowing the
* Professor, ** Professor,*** Senior Lecturer, ****P.G.Student
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+91 9898864413)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
80
development of ulcerated areas with the formation
of a pseudomembrane, characterized by the
presence of a fibrinopurulent yellow colored layer
7,12
. The ulcerated lesions are painful and
compromise patient nutrition and oral hygiene.
They are also favorable sites for the development of
local and systemic infections. In the oral mucosa,
this condition involves the ventral surface of
13
tongue, floor of the mouth and soft palate .
Various grading systems for oral mucositis have
been suggested.
Table 1- W.H.O has proposed the following grading system for assessment of oral mucositis
with regard to severity of symptoms (14):
Grade 0
Asymptomatic
Grade 1
Soreness, erythema, no ulceration
Grade 2
Erythema, ulceration, but ability to swallow solid food
Grade 3
Extensive erythema, ulceration, and solid food cannot be swallowed.
Grade 4
Mucositis to the extent of impossible alimentation
The WHO scale [1979] was employed, which
ranges from 0 to 4 and does not measure different
aspects in the different sites analyzed.
Table 2-Modified oral mucositis assessment index (source-from Beck SL, Yasjo, JM: guidelines for
oral care).
CATEGORY
Oral mucosa
1
Smooth,
2
3
pink, Pale and slightly Dry
and
including lip moist and intact
dry; one or two swollen,
& tongue
isolated
dry
and
generalized edematous;
thick
lesions, redness; more than two and
blisters
reddened
4
somewhat Very
or isolated
engorged;
lesions, multiple blisters or
areas. blisters or reddened ulcers.
Entire
Papillae
areas.
generalized tongue
very
prominent,
redness on tongue but inflamed; tip very
particularly at base tip and papillae are red
of tongue.
more
red
in demarcated
appearance
Teeth
Clean; No debris
Minimal
mostly
Thin,
with
coating.
debris; Moderate
debris Teeth
covered
between clinging to one-half of with debris
teeth
Saliva
and
visible enamel
watery, Increase in amount
plentiful
Saliva
maybe
scanty
and Saliva thick and
somewhat ropy,
thicker than normal
viscid
mucus.
or
Mouth
mirror test positive
Oral
dysfunction
No dysfunction
Mild dysfunction
Moderate dysfunction
Severe
dysfunction
(An assessment guide such as the table 2 provides a
tool to quantify the intensity of mucositis. It is
clinically useful to translate the scores into rating
mild (score of 4-5), moderate (score of 5--8) and
severe (score 8-12) 16.
MANAGEMENT OF ORAL MUCOSITIS
· Preventive protocol (Assessment and prevention
for oral cavity before cancer therapy)
· Treatment protocol (Management of mucositis)
· Post treatment protocol (Prevention of
suprainfection)
PREVENTIVE PROTOCOL
Prior to cancer therapy, the patients should be
submitted for an assessment of the oral cavity.
Dental caries or periodontal disease associated with
inadequate oral hygiene may lead to a greater risk
for oral complications during the course of
cytotoxic therapy. These risk factors underscore the
importance of an inspection of the oral environment
before and during treatment as prior assessment
allow differentiating oral mucositis from other preexisting lesions as well as the elimination of
potential sources of infection and sites of chronic
16
irritation . This protocol should be followed by an
oral physician for the patients.
Preventive protocol 16.
Grade 1
Ö Brush with soft bristled nylon brush and floss
daily
Ö Rinse with salt and soda or 15% hydrogen
peroxide
Ö Apply a moisturizer.
Ö Promote oral hydration and nutritional intake
Ö Remove and clean dentures regularly (in denture
wearer patients)
Grade 2 & 3
Ö Increase frequency of oral hygiene to every 2-3
hours
Ö Use foam oral wash if brushing is too painful
Ö Use agents to protect mucosa (mucosal barrier)
Ö Apply topical agents for pain control
Ö Supplement oral intake with proper analgesics
and/or antibiotics if indicated
Grade 4
Ö Continue frequent oral hygiene
Ö I.V antibiotics
Ö Laser therapy
Ö Cryotherapy
Treatment modalities for Oral mucositisMany different treatment protocols are available to
reduce the severity of oral mucositis, although there
is little evidence to recommend one or any approach
as a gold standard procedure. The following have
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
81
been used in the treatment of radiation-induced and
chemotherapy-induced mucositis,
Pharmacological modalities
Non-Pharmacological modalities
-Analgesics - Anti inflammatory - Low intensity laser
drugs
-Antioxidants - Growth factors
- Cryotherapy
-Steroids
- Others
-Immunomodulators
Pharmacological modalities – They can be
administrated in local application, mouthwash and
systemic form.
Analgesics
Treatment should be arranged according to WHO
ladder and pain killers should be given in liquid or
transdermal form as swallowing is usually severely
altered in patient undergoing cancer therapy. Initial
paracetamol soluble tablets (500-1000mg QDS),
usually followed by soluble codeine (300 or 500 mg
1-2 tablets QDS) are given. In severe cases, usually
liquid modified release morphine 12 hourly
preparations or fentanyl patches in increasing doses
are used with the choice based on the patient's
tolerance. Oral solution of oramorph is used for
breakthrough pain 17.
Capsaicin- It is found in chilli peppers and acts
upon nerve endings to provide temporary pain
18
relief. The exact mechanism of action is unknown .
Recipe for capsaicin candies are available & they
are prepared according to ICCR's Research
Kitchen. The dosage schedule of 1 candy every 4-6
hours was determined based on Berger's
observation that most patients required 4-6 candies
per day to maintain pain relief
Morphine- It is a central nervous system analgesic
which depresses pain impulse transmission. It is
effective for managing mucositis pain in cancer
patients, but dry mouth is one of its adverse
reactions 18.
Fentanyl (transdermal patch) - A very potent
short acting opioid, it is used primarily as an
anaesthetic especially useful in patients unable to
take oral medicine. It is available in a sustainedrelease transdermal delivery system (duragesic)
with a half-life of 22 hours 18.
Antioxidants
Antioxidants may be particularly important since
cancer treatment is an oxidative process.
Radiotherapy and chemotherapy generate free
radicals, which require antioxidants to be
neutralized
VitaminsVitamins such as A,E,C & beta-carotene are
involved in detoxification of the reactive oxygen
species (ROS). Vitamin E and betacarotene are
lipophilic antioxidants whereas vitamin C is
hydrophilic antioxidant. Vitamin E functions as a
free radical chain breaker particularly interferes
with the propagation step of lipid peroxidation. The
vitamin A and beta-carotene act by quenching both
singlet oxygen and other free radicals generated by
19
photochemical reactions .
Beta-carotene- The pro-vitamin A (beta-carotene)
when used as an adjunct to radiotherapy in the
treatment of transplantable adenocarcinoma in
mice significantly improved tumour reduction,
survival and wound healing. This has also been
proven to be useful in chemotherapy-induced
mucositis. In one trial, chemotherapy patients were
given 400,000 IU per day for 3 weeks followed by
125,000 IU for an additional 4 weeks. Significant
18
result was seen .
Glutamine- A precursor of glutathione, this is the
most abundant amino acid in the human body, and it
is now considered a conditionally essential amino
acid during periods of catabolism. Early studies
show that glutamine has a positive effect through
three mechanisms: (1) as a cellular fuel; (2) as a
precursor for nucleotides needed for cell
regeneration; and (3) as a source of glutathione,
which is a potent antioxidant. The use of 4 grams of
powdered glutamine in the form of a swish and
swallow suspension, twice daily, decreases the
intensity and duration of the mucositis 21.
Allopurinol- Allopurinol, a xanthine oxidase
inhibitor, has been studied for both prophylaxis and
treatment of fluorouracil-induced mucositis. Two
primary mechanisms have been proposed for such
activity: nonspecific free-radical scavenging and
specific inhibition of fluorouracil activation.
Lysofylline - A protectant that reduces lipid
peroxidation and also decreases oxidative injury. It
is presently being tested in chemoradiation trials of
head and neck cancer 22.
Leucovorin - Leucovorin, or folinic acid, in
combination with hydration is well established as a
rescue agent to reduce mucositis and myelotoxicity
of high-dose methotrexate 14.
Pentoxifylline - Pentoxifylline (PTX) is a
hemorrheologic agent indicated for treatment of
intermittent claudication. PTX has been shown to
reduce the production of tumor necrosis factor- alfa
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
82
(TNF-a) possibly by inhibiting TNF-messengerRNA transcription 14.
Steroids
Clobetasol (0.05% ointment 1:1 with Orabase) As a topical corticosteroid, it plays a role in
inflammation and immunosuppression. It is
contraindicated in presence of infection.
Corticosteroid mouthwashes - These may be
beneficial but are contraindicated if the patient has a
bacterial or viral infection. Triamcinolone
acetonide 0.2% aqueous suspension can be used as a
rinse for 1 minute twice a day and expectorated.
Immunomodulators
Thalidomide- An immunomodulatory and
antiangiogenic agent, it inhibits tumor necrosis
factor-alpha (TNF-a), which is associated with
23,24
oropharyngeal ulcers
. In multiple studies, the
efficacy of this medication against oral and
esophageal ulcers bas been demonstrated. In one
trial, 92% of patients had complete healing after 4
24
weeks by taking 200 mg by mouth at bedtime .
Anti Inflammatory drugs
Benzydamine hydrochloride- It is used as a
mouthwash and topical application agent. Topical
application of benzidamine, a non-steroidal antiinflammatory drug with cytoprotective,
antimicrobial, and analgesic action, relieves the
pain and reduces the use of opioid analgesics ; it also
inhibits pro-inflammatory cytokines, including
TNF-a and is considered a safe product, although its
effectiveness for prevention of mucositis induced
by chemotherapy agents is still unknown. As an oral
rinse, this has been shown to be effective, safe and
well tolerated in ameliorating the symptoms of
cancer treatment induced mucositis. Rinsing and
expectorating 15 ml of 0.15% solution every 2
hours will help in reducing painful inflammation of
the mouth and throat 25.
Growth factors
Amniotic membrane- The amniotic membrane
was shown to be a biocompatible product with the
capacity to adhere to ulcerated mucosal surfaces,
accelerating the healing process by its antiinflammatory activity. In a pre-clinical study by
Goulart et al. it also was found that the amniotic
membrane promotes rapid cell proliferation,
especially of fibroblasts and epithelium cells, and
stimulates vascular neoformation that positively
influences the repair process. This proliferative
capacity is probably due to the presence of stem
cells and growth factors 26.
Recombinant keratinocyte growth factor- It is
known to influence the growth, development, and
repair of epidermal tissues. It also accelerates
wound healing, increases the number of stem cells
that survive a dose of radiation therapy and reduces
the incidence and duration of oral mucositis due to
cancer treatment. This therapy, however, requires
27
further studies .
Epidermal growth factor (EGF)-This is present in
biologic fluids including saliva. Its level decreases
in patients receiving radiation therapy. EGF plays a
role in healing damaged mucosa. In recent studies it
was demonstrated that less tissue damage is
associated with a higher EGF level in saliva 27.
Others
Sucralfate - Sucralfate is a nonabsorbable, basic
aluminum salt of sulfated sucrose indicated for the
treatment of peptic ulcer disease. Sucralfate forms
an ionic bond with proteins in ulcerations, which
produces a protective barrier that promotes healing.
In addition, local production of the cytoprotectant
25
27
prostaglandin E2 is stimulated . Pfeiffer et al
performed a randomized, double-blind cross-over
study of patients receiving a cisplatin/ fluorouracil
regimen for various solid tumors. Patients were
instructed to swish and expectorate or swallow
sucralfate suspension (1 g) or placebo four times per
day for 14 days starting on the first day of
chemotherapy. The objective evaluation revealed
less mucositis with the sucralfate treatment.
Chamomile mouthwashes- These have been used
to improve mucosal healing with controversial
results. However, rinsing with 15 drops of
chamomile in 10 ml of warm water, thrice a day, has
reduced the incidence and severity of mucositis in
cancer patients 28.
Local anesthetic mouthwashes- These may help
to relieve pain on a temporary basis.
Other- Rinsing with bland solutions such as normal
saline with sodium bicarbonate (1 L water with 1/2
teaspoon baking soda and 1/2 teaspoon salt) has
shown to reduce the severity of mucositis16.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
83
Non pharmacologic approach
Cryotherapy- This produces vasoconstriction,
which reduces blood flow and diminishes the
distribution of the chemotherapeutic agent to the
oral mucosa. Ice swishing for 30 minutes following
cancer therapy has been shown to be beneficial for
29
these patients .
Low-intensity Laser therapy- This may improve
wound healing and accelerate replication of the
cells. Low-energy helium-neon (He-Ne) laser
seems to be a safe, simple, atraumatic, and efficient
method for the prevention and treatment of
30
chemotherapy/radiotherapy- induced mucositis .
Post treatment protocol Patients with complications should be treated with
empiric antimicrobial therapy usually with
fluconazole 50 mg OD in case of fungal infection or
penicillin derivates in case of bacterial infection.
Culture and sensitivity evaluation is recommended
when feasible to provide patient with targeted
evidence-based antibiotic therapy 16.
Conclusion
Mucositis is a common side effect of radio and/or
chemotherapy anticancer treatments, but it has a
complex pathophysiology and requires
standardized management strategies. There are
many agents used for the treatment of mucositis
with different mechanisms of action. However,
there are no conclusive evidences on their
effectiveness to establish protocols for patients
undergoing radio and/or chemotherapy. Further
studies are required in future to establish a widely
accepted protocol for treatment of these patients.
References-
16. HYCCN Guidelines for the management of chemotherapy and/or
radiotherapy induced acute mucositis Version 1.1 September 2011
17. Gage TW, Pickett FA, Dental Drug Reference, ed 5, St Louis: Mosby,
2002
18. Mills EED. The modifying effect of beta carotene on radiation and
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21. KJimberg VS, How glutamine protects the gut during irradiation. ICCN
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22. Chao KSC, Perez CA, Brady LW, Radiation Oncology. Management
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23. Jacobson JM, Greenspan JS, Spritzler J, et a!, Thalidomide for the
treatment of oral ulcers in patients with human immunodeficiency virus
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24. Alexander LN. Wilcox CM. A prospective trial of thalidomide for the
treatment of HIV associated idiopathic esophageal ulcers. AIDS Res
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25. Epstein JB, Silverman S Jr, Paggiarino DA, et al. Benzidamine HCl for
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MF. Homogenous amniotic membrane as a biological dressing for oral
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The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
84
RADICULAR CYST ENCHROCHING UPON THE
MAXILLARY SINUS –A DIAGNOSTIC DILEMMA
CASE REPORT
* Purnima Jethwa, **Mitesh Patel,***Nitu Shah, ****Neha Vyas
ABSTRACT
Maxillary sinus, being one of the paraoral structures, is commonly encroached upon by Odontogenic & Nonodontogenic cysts and tumours. Here we are presenting a case of an unusually large cystic lesion in relation with left
maxillary first molar, which has encroached upon the maxillary sinus displacing it up to superior border which clinically
favoured radicular cyst but radiographically it was more likely to be mucocele of maxillary antrum creating a diagnostic
dilemma. Provisional diagnosis of radicular cyst was made by history and examination, correlating it with various
radiographic investigations and aspirational cytology. Enucleation was done under general anesthesia and final
diagnosis was made by histopathologic examination of enucleated specimen.
Keywords:Radicular Cyst, Carious Tooth, Maxillary Sinus
INTRODUCTION
The radicular cyst is the most frequent cyst found in
the jaw (between 38% and 68 % of all the jaw cysts).
The prevalence of periapical cysts varies between
8.7% and 37.7% of chronic inflammatory periapical
1
lesions . It is not uncommon, to find periapical
lesions to extend to the surrounding tissues and not
limit themselves to the apex of the involved tooth.
In the literature most cases of unusually large
periapical lesions of odontogenic origin are found
in the maxilla where the bone is spongy1. Because of
the bone consistency, it is easier for the lesion to
occupy bony space and expand. Lesions have been
found to occupy the entire sinus and even the floor
of the nasal cavity2.
CASE REPORT
A 35 year old male patient came to the department
of oral & maxillofacial surgery with chief complain
of swelling in upper left back jaw region since 6-7
months. Swelling was asymptomatic & gradually
increase in size since 6-7 months. Clinically, there
was a well-defined 3x3 cm ovoid shape swelling
present over left side of mid face region extending
superioinferioraly infra orbital rim to line joining
corner of mouth to tragus & anterioposterioraly
from left side ala to the line joining outer canthus to
inferior border of mandible with a smooth surface
and no any sign of sinus opening. The swelling was
soft, fluctuant, non-tender on palpation. On
intraoral examination, the upper left first molar was
decayed and nonvital. Intraoral examination shows
roughly oval, 2x2 cm size swelling with pink shiny
overlying surface in upper left buccal vestibule in
relation to 26, 27. On palpation swelling is soft,
fluctuant, non-tender, non-redusible (Figure 1).
Figure 1 :Photograph of Patient's oral cavity showing
swelling in relation to molar & premolar region. buccally.
Also, external examination revealed that eye
movements and visual acuities were normal. On
bases on clinical examination patient was
provisionally diagnose as radicular cyst in relation
to 26. For final diagnosis we advised patient for
radiographic examination, in which IOPA of 26 &
radiographs panoramic view (Figure 2) showing
* Reader, ** PG Student,*** Professor, ****Professor & HOD
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+91 9537970751)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
85
well define radiolucency in relation to 26 more
favour to cyst in relation to but when taken
Paranasal Sinus view(Figure 3) is more likely to
mucocele of maxillary sinus.
Figure 2:Panoramic Radiograph of patient revealed an
unusual large lesion invading large maxillary sinus with loss
of lamina dura& no displacement of surrpundin teeth.
CT Scan (Figure 4)revealed an osteolytic
radiolucency well delineated around the roots of the
upper left first molar, the large lesion measured
35mm antero-posteriorly, 24mm medio-lateraly
and 28mm supero-inferiorly which has elevated
mucosal lining of floor of left maxillary sinus &
pushed it to posteriosuperiorly. Coronal CT image
shows expansive process displacing part of nasal
cavity, with intact and sclerotic border, occupying
most of right maxillary sinus. Transverse CT image
shows loss of anteriolateral wall of maxillary bone
with posteriorly displacing maxillary sinus. Sagittal
CT image shows osteolytic radiolucency around the
root of 26 to extending whole maxillary sinus.
Figure 3 :Panoramic Radiograph of patient
revealed an unusual large lesion invading large
maxillary sinus.
Figure 3 :Paranasal sinus view of patient's radiograph revealed
an unusual large lesion invading large maxillary sinus.
From history, clinical and radiographic
examinations, a provisional diagnosis of radicular
cyst was made. It was decided to surgically
enucleate the lesion under general anesthesia.
Incision was given teeth in relation to
22,23,24,25,26,27,28 with releasing incision at 22
& Reflection of a mucoperiosteal flap, followed by
removal of bone and exposure of the lesion
membrane was carried out (Figure 5).
Figure 5: Enucleation of cyst
Figure 4: Respectively transverse, Coronal &Sagital
CT image shows osteolytic radiolucency attach to teeth
26 to extend into left sinus
A spiration of the contents of the cystic lesion was a
valuable diagnostic aid (Figure 6); it revealed a
yellow semi-viscous fluid. The lesional wall was
hypertrophic and adhered partly to the mucosa of
the base of the maxillary sinus; therefore, the
lesional mass was totally curetted to a maximum
extent. Enucleation of the cystic lesion and
extraction of the 26 with care of the wound and
suturing were done with 3-0 vicryl.
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
86
Figure 6: Enucleated of cyst, Extracted tooth,
Aspirated Fluid
Enucleating biopsy of the periapical lesion (Figure
7) was diagnosed histologically as radicular cyst
with a layer of nonkeratinised stratified squamous
epithelium and at some place Pseudostratified
ciliated columnar epithelium is also seen.
Connective tissue capsule shows large numbers of
chronic inflammatory cells, Dilated capillaries &
RBCs .The healing was uneventful without
swelling or other complications. Sutures were
removed 1 week pos1toperatively, at the 8 months
follow-up, no complications or recurrence were
noticed with complete bone healing and
repneumatization of the antrum.
Figure 7: Histological Section
DISCUSSION
The etiopathogenesis of cysts is particularly
controversial; the formation has been explained by
diverse theories, such as epithelial colonization,
epithelial cavitationsor the formation of
microabscesses. The theory of microabscess
formation is based on the degeneration of the
connective tissue leading to the development of the
cyst; the formation of a microabscess in the nucleus
of the granuloma, with the presence of stimulated
epithelial cells, would lead to their growth in an
3
attempt to line the created cavity.
The pathogenesis of cysts has been described in
three phases. During the firstphase, the epithelial
cell rests of Malassez begin to proliferate as a direct
result of the inflammation and influenced by
bacterial antigens, the epidermal growth factors,
metabolic and cellular mediators. In the second, a
cavity is formed, lined by epithelium (according to
the above described theories), and in the third phase
the cyst grows, probably by osmosis.1
Radiographically, the radicular cyst is a unilocular
radiolucent lesion with wellcircumscribed sclerotic
borders that are often radiopaque. The lesion is
associated with the apex of the tooth and a diameter
of at least 1 cm is postulated to be necessary to
differentiate it from that of a normal follicular
4
space .Natkin and el.related radiographic lesion
size to histological findings and concluded that with
a radiographic lesion size of 200 mm2 or larger, the
5
incidence of cysts was almost 100% . Other
odontogenic cysts like dentigerous cysts,
odontogenic keratocysts, and odontogenic tumors
such as ameloblastoma, Pindborg tumor,
odontogenic fibroma, and cementomas may share
the same radiologic features as radicular cysts.
Microscopic evaluation is necessary most of the
time to define the type of lesion6. Our specimen was
diagnosed histologically as radicular cyst with a
layer of nonkeratinised stratified squamous
epithelium, in fact all radicular cysts are lined
partially or completely by nonkeratinized stratified
squamous epithelium. Keratinization is seen in
approximately 2% of cases, and when present
orthokeratinization is more common than
parakeratinization7.
When cysts are especially large, with maxillary
sinus involvement as in our patient, the panoramic
radiograph is often not of great aid. CT scans
provide superior bony detail, allowing for the
visualization of the size and extent of the lesion with
determination of orbital or nasal invasion or
involvement. Again, with larger lesions, it also aids
in planning of a surgical approach. Mucoceles,
retention cysts, and pseudocysts are also included in
the differential diagnosis when a maxillary sinus
cyst is visualized involving maxillary expansion;
this is in addition to the array of radiolucent lesions
mentioned above that can also be visualized on
8
CT .The treatment of pariapical cysts are still under
discussion and many professionals opt for a
conservative treatment by means of endodontic.
However, in large lesions the endodontic treatment
alone is not sufficient and it should be associated to
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
87
a decompression or a marsupialisation (indicated
when cyst is in close proximity to vital structures
and where there is significant risk of injury with
enucleation) or even to enucleation and extraction
of the associated tooth.A large maxillary cyst may
involve the whole sinus and can transmit pressure
to the wallsof the sinus; consequently,
ophthalmologic and nasal symptoms may develop.
With extensive lesions, it is important to carefully
plan the surgical approach. The choice of treatment
may be determined by some factors such as the
extension of the lesion, relation with noble
structures, evolution, origin, clinical characteristic
of the lesion, cooperation and systemic condition of
the patient9. Some authors suggested a nasal
approach; however, in keeping with the law of
gravity, it is reasonable to surmise that the content
from maxillary cysts can be drained much more
easily into the oral cavity. An oral vestibular
approach is therefore more preferable than a nasal
approach. (10-11)
CONCLUSION
It must be kept in mind that chronic periapical
lesions (granuloma, cyst, and scar tissue) are
usually asymptomatic and do not create soft tissue
alterations. However, they can deteriorate,
producing pain and fistulization. Clinician should
be very careful on clinical examination and should
not omit any details. Before beginning any
treatment a careful and complete clinical and
radiographic examination is needed to supply all
the required information. In extensive cases, near to
vital structure routine radiography alone may not be
sufficient to show the full extent of the lesions, and
advanced imaging may be needed.
REFERENCES
6-
1234-
5-
Açikgöz A, Uzun-Bulut E, Ozden B, Gündüz K. Prevalence and
distribution of odontogenic and nonodontogenic cysts in a Turkish
Population. Med Oral Patol Oral Cir Bucal 2012; 17(1):e108-115.
Gibson GM, Pandolfi PJ, Luzader JO. Case report: a large radicular cyst
involving the entire maxillary sinus. Gen Dent 2002; 50(1):80-1.
García CC, Sempere FV, Diago MP, BowenEM. The post-endodontic
periapical lesion: histologic and etiopathogenic aspects Med Oral
Patol Oral Cir Bucal 2007; 1; 12(8):E585-590.
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correlating the presence of a radiopaque lamina with histological
findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;
101(3):389-394.
Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to
diagnosis, incidence, and treatment of periapical cystsand granulomas.
Oral Surg Oral Med Oral Pathol 1984;57:82-93.
FN Pekiner, O Borahan, F Ugurlu, S Horasan, B.M Sener, V Olgaç.
Clinical and radiological reatures of a rarge radicularcyst involving
the entire maxillary sinus. Journal of Marmara University Institute of
H e a l t h S c i e n c e s Vo l u m e : 2 , N u m b e r : 1 , 2 0 1 2 http://musbed.marmara.edu.tr
7- Joshi.N, Sujan.S, Rachappa.M. An unusualcase report of bilateral
mandibular radicular cysts. Contemporary Clinical
Dentistry.2011;2(1):59-62.
8- AS Tournas, MA Tewfik, PJ Chauvin, JJManoukian Multiple unilateral
maxillary dentigerous cysts in a non-syndromic patient: A case report
and review of the literature. Int J Pediatric Otorhinol Extra1,(2) 2006;
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9- Ribeiro, Paulo Domingos Jr. et al. Salusvita, Bauru. Surgical
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The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
88
ORTHOKERATINIZED ODONTOGENIC KERATOCYST
Case Report
* Minal Bakshi, ** Manisha singh, ***Richa Vasant, ****Riya Achu Rajan
ABSTRACT
Orthokeratinized Odontogenic Cyst (OOC) is a developmental cyst that can occur in the maxilla or mandible and was
initially defined by the World Health Organization as the uncommon orthokeratinized type of Odontogenic Keratocyst
(OKC). However, studies have shown that OOC has atypical clinicopathologic aspects when compared with other
developmental odontogenic cysts, especially OKCs. The purpose of the article is to present a case report of OOC
arising in the posterior mandible and highlight the importance of distinguishing it from the more commonly occurring
Keratocystic Odontogenic Tumor (KCOT).
Key words: Orthokeratinized odontogenic cyst (OOC) and Odontogenic Keratocyst(OKC)
INTRODUCTION
The term Odontogenic Keratocyst (OKC) was first
introduced by Philipsen in 1956 to describe a
particular pathological entity characterized by a
fibrous cystic wall lined by keratinized epithelium.
Thus, all cystic lesions of the jaws that had aspects
of odontogenic keratocysts were considered,
regardless of the clinical and other histological
1-4
features . Currently, significant differences
between keratinized cystic lesions are recognized
and orthokeratinized odontogenic cyst (OOC) is no
longer part of the spectrum of odontogenic
3,5-7
keratocyst . Li et al suggested a descriptive term
''orthokeratinized odontogenic cyst,'' which also
reflected its most plausible histogenic origin. The
World Health Organization new classification
(2005) for head and neck tumors has designated
OKC as Keratocystic Odontogenic Tumor (KCOT)
and reclassified it as a neoplasm in view of its
intrinsic growth potential and propensity to recur.
According to this new classification, OOC should
not be part of the spectrum of KCOT and should be
8,9,10
distinguished from the latter .
CASE REPORT
A 27 years old male patient reported to the OPD of
ACDH, Ahmedabad. He presented with swelling of
the lower left side of face since 2 months. On
examination, the region corresponding to the lesion
was located in the premolar region, extending into
the molar region, and was covered by normal
mucosa. On palpation it was found that swelling
was non-fluctuant and non-tender in nature and
radiograph revealed a unilocular radiolucency with
a well defined scalloped rim. Thus, a clinical
diagnosis of ameloblastoma or odontogenic
keratocyst was established. A biopsy was conducted
and the tissue was sent to the department of Oral
Pathology to arrive at final diagnosis.
On histopathological examination, we found
orthokeratinized stratified squamous epithelium of
varying thickness lining a thin fibrous wall. A
hypocellular spinous cell layer was made up of
polyhedral to flattened cells with eosinophilic
cytoplasm. The basal layer cells were low cuboidal
and exhibited little tendency of nuclear
hyperchromatism and palisading.
DISCUSSION
The orthokeratinized odontogenic cyst was clearly
identified as an orthokeratinized variant of the
odontogenic keratocyst for the first time by Wright
in 1981 owing to it's different histopathology and
reduced likelihood to recur8. Although the first two
editions of the World Health Organization's
histological classification of odontogenic tumors
recognized cases with orthokeratosis, the WHO's
2005 edition excluded it from its definition of a
9
KCOT . The 2005 edition reclassified the
parakeratotic type as a Keratocystic Odontogenic
Tumour and stated ''Cystic jaw lesions that are lined
by orthokeratinizing epithelium do not form part of
* Reader, **Senior Lecturer, ***PG Student, ****PG Student
AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.
ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+91 9687616779)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
89
the spectrum of a KCOT. Three histologic variants
were recognized initially: a parakeratinized variant,
an orthokeratinized variant, and combination of the
two. The less aggressive clinical behavior and
recurrence pattern of the orthokeratinized variant
ultimately warranted the designation of the
orthokeratinized variant as a separate entity,
9,11
"Orthokeratinized Odontogenic Cyst” .
The association with unerupted teeth suggests that
many OOCs may have first developed during
adolescence, when the third molars were
developing, and were only noticed later either
owing to the development of symptoms or as an
incidental discovery during investigation of another
dental problem12. Clinically the two entities (OOC
& KCOT) exhibit an overlap in clinical and
radiographic presentation. KCOTs also exhibit
similar findings regarding age, sex and site of
occurrence but they are associated with NBCCS
patients and thus tend to exhibit multiple lesions.
Radiographically OOCs tend to be unilocular
lesions and are more often associated with impacted
teeth as compared to KCOTs12.
Histologically, there are several striking differences
between the epithelial lining of orthokeratinized
and parakeratinized cysts. The typical KCOT
exhibits a highly cellular parakeratinized epithelial
lining with surface corrugations and a palisaded
layer of basal cells. In contrast the OOC lacks these
features and instead the thin, uniform,
orthokeratinized lining epithelium is characterized
by onion-skin–like luminal surface keratinization,
prominent stratum granulosum and low cuboidal or
flattened basal cell layer with minimal tendency for
8
nuclear palisading .
Figure 1
Clinical picture of patient
Figure 2
Gross specimen
Figure 3
Histopathologic picture (10 x)
Figure 4
Histopathologic picture (40 x)
The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
90
CONCLUSION
The significant clinicopathologic differences
between orthokeratinized and parakeratinized
odontogenic cysts make it essential that the
orthokeratinized cyst should be recognized as a
distinct entity. Historically, these cysts have been
7.
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4.
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diagnosed as odontogenic keratocyst. Therefore, in
order to avoid confusion, it is suggested that the
term “orthokeratinized odontogenic keratocyst”
should be used for the cases diagnosed
histopathologically exhibiting the above stated
features.
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Thosaporn W, Iamaroon A, Pongsiriwet S, Ng KH. A comparative study
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Tumours. Lyon, France: IARC Press; 2005. P 306-7.
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The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014
91
Dr. Medha Jain
Dr. Kiran Desai
Professor & Head,
Dept. of Oral Surgery, K.M. Shah Dental College & Hospital,
Vadodara, Gujarat.
Dr. Babu Parmar
Professor & Head,
Dept. of Oral Surgery, Government
Dental College & Hospital,Ahmedabad, Gujarat.
Dr. Bela Dave
Professor & Head,
Dept. of Periodontology, Swarnim Jayanti
Dental College & Hospital, Ahmedabad, Gujarat.
Dr. Rajesh Seturaman
Professor, Dept. of Prosthodontics, K.M. Shah
Dental College & Hospital, Vadodara, Gujarat.
Dr. Saumil Mathur
Professor & Head, Dept. of Prosthodontics,
K.M. Shah Dental College & Hospital,
Vadodara, Gujarat.
Dr. Janki Shah
Asst. Professor, Dept. of Public Health Dentistry,
Government Dental College & Hospital,
Ahmedabad, Gujarat.
92