new concept of dental arch in children

Knowledge . Service . Love

Journal of the Indian Dental AssociationTamil Nadu State Branch

ALA ST SN OE CD IAN TA II OD NN I

Journal Office : Vel Dental Home, No.10, Bharathi Street,Pondicherry - 605 001.

Volume 5 Issue 16Jan. - Mar. 2013

AdvisorsDr. S. ThillainayagamDr. C.R. RamachandranDr. Gunaseelan RajanDr. George PaulDr. SivapathasundaramDr. S.M .BalajiDr. N.R. Krishnaswamy

Editor in chief

Associate Editors

Assistant Editors

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Reviewers

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Dr. A. Thangavelu

Dr. Jayantha PadmanabanDr. G. Ulaganathan

Dr. J. SelvakumarDr. V. Arun Prasad RaoDr. Thamarai SelviDr. R. Madhan

Dr. A. TamizhchelvanDr. G. MohanDr. Vijay VaikunthDr. S. RajasekarDr. R. SasirekhaDr. A.P. MaheswarDr. S. MurugesanDr. Subramanium

Dr. S. RamaswamyDr. VijayalakshimiDr. Madhavan NirmalDr. Vidya Dr. S. KarthikeyaniDr. A.L. MeenakshisundaramDr. T.R. SudharsonDr. J. Johnson RajaDr. C. Hari PrasathDr. V. BalakumarDr. Y.A. BindhuDr. A. Arvind KumarDr. Senthil KumarDr. J. KannaperumanDr. M. RamaswamyDr. N. Dhineksh KumarDr. Jagdeep Raju

Dr. Srivatsa KengasubbiahDr. Yoganand

Dr. K. Vasanthakumar

PublisherIDA TN State Branch

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DR. D. SENTHIL KUMAR

DR. C. SIVAKUMAR

DR. T.S. RANJITH

DR. S. THILLAINAYAGAM

DR. K. RAJASIGAMANI

DR. A.P. MAHESWAR

DR. RADHA KRISHNAN

DR. V. BASKAR

DR. M. SETHU ANANDAN

DR. A.L. MEENAKSHISUNDARAM

DR. J. SELVAKUMAR

DR. S. THIRUNEELAKANDAN

DR. ANNAMALAI THANGAVELU

Convenor - Care & Concern DR. BALA. SIVA GOVINDAN

Edited byProf . Dr. A. Thangavelu MDS,DNB.

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Dr. Murali Baskaran .KDr. RajasigamaniDr. Rajmohan .ADr. Senthilkumar D.Dr. Surendaran .G.PDr. Sivakumar .CDr. Sudharson .T.RDr. Sethumadhavan .UDr. Umashanka .K.KDr. Vijayakumar .P

Guidelines for Authors

Submit all manuscripts to :

Prof. Dr. A. Thangavelu, MDS, DNB.,Vel Dental Home,

No.10, Bharathi Street,

Pondicherry - 605 001.

1. A Covering letter with the following words signed by all the authors should be submitted "The submitted

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copyright of the paper if published will stand transferred to the Journal of Indian Dental Association. We will

indemnify and keep indemnified The IDA Tamilnadu State Branch and the Editorial Committee and the Editor

of the Journal of the Indian Dental Association Tamilnadu against all claims and expenses including legal costs

in case of breach of copyright or other laws arising as a result of publication of our articles"

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At the outset I take this opportunity to thank all my IDA members and well wishers for honouring me on taking

over as the President of IDA-Tamilnadu for the year 2013. I wish everyone of you to have a very productive and fruitful

New year 2013.

A month has passed and I am happy to inform you that I have already touched the ground and visited a few

branches. It was a pleasure to meet and interact with several office bearers and members of Marthandam and Madurai.

I am happy to see the enthusiasm among several of our members and I hope this spirit continues to prevail all

across the state so that all of us together can make IDA truly a larger and stronger body.

I strongly believe that as dentists we have a strong commitment to the community in which we live.

The basic aim of IDA is to promote oral health and hygiene in the country and all the efforts of IDA are directed

at attaining this cherished goal.

At the same time enhancing the image of our members in the public and promoting their professional

advancements and their family security are matters very close to IDA.

Organising lectures and scientific symposia are means of keeping abreast with the changing world of dental

science and we are working on it.

We need your cooperation and support in taking dentistry to higher levels of excellence and without that IDA

would not be able to achieve the goals it has set for itself. Vazhga IDA.

Dr. D. Senthil Kumar BDS

President, IDA-Tamil nadu

C.Doraiswami Nalayini Dental Clinic,

8,Azad Street,Udumalpet.642126.

9842225506, [email protected].

From the President's desk

From the Secretary's desk

Dear Friends,

Wish You All Very Happy Prosperous New Year.

Dentist are specialty oriented professional, each and every specialty in dentistry are interrelated and the specialist have

great relationship with each other The present day development in the Dental field especially the technological advances

in each specialty create a great challenge to update and to put it in our day to day practice for the benefits of our patients

.There is a wide range of technological changes in Dental Science- today. In these situations the journal published by

State Branch of IDA plays a major role in getting the update information to the clinic desk .

I am sure the Tamilnadu Journal (JIDAT) is severing the purpose for more than a year and continues to do so. Each and

every member reading the journal should promote the journal and motivate the other members to subscribe for the

journal. Similarly another field were we should improve is “Service and creation of Awareness among the rural patient.

We can improve this by improving our local branch CDH programs. CDE Credit Point is must to renew our council

registration. I sincerely request all the members to attend all IDA activities, and get the maximum benefit from our

association .

Do more CDH Activities.

Best Wishes.

Dr.C. Sivakumar

Hon. Sec IDA TN

Dear Pals

Wishes for a happy and prosperous new year. Hope this New Year brings all the strength and prosperity to our profession. After a long contemplation about 21st Dec 2012 – “The End Of The World “ , in spite of all prophesies , Mayans calendar, earth changing the axis, comets hitting the earth ,we now see the survival of the human continue to exist towards 2013 and further .

Life is like that!...we pass through the difficulties we face , we cross all the hurdles we come across . Its sure that nothing can stops us from living. The thing is how we live is the questions? We should think and take that path which lead us to live with morality, ethic and humanity. Each and every individual should try to live for good. All of us should take a task to improve our standards There are lots of things to ponder, to enjoy, to correct , to modify and to change Let the new year give all that strength to all our members to take a resolution , take a chance ,join hands and fight for our rights and to stabilize our profession “ Dentistry” .

Each one of us have a great role in it , let us not blame each others for the flaws Everyone has a responsibility, if each one of us walk towards that good changes I am sure our profession will leap ahead and be an envy to our colleagues, job opportunities, irregularities in dental education, Unethical practices, service to the needy and developing a clear identity among the health professional are the areas of concern. So Let us arise, join hands to solve our problems,

Let us change for the CHANGE and create a history.

From the Editor's desk

Knowledge, Service, Love

Nothing as Empowering as Knowledge,

Nothing as Compassionate as Service, &

Nothing as Gratifying as Love!!!

Prof. Dr. A. Thangavelu, MDS, DNB.,

Editor-in-Chief, JIDAT

Journal of the Indian Dental Association - Tamil Nadu

Vol. 5 Issue. 16 Jan. 2013

Contents

Force Systems in Orthodontics – An Overview of Traditional and Recent Concepts 01

Dr. Santhana Krishanan, Dr. K.Rajasigamani, Dr. N. Kurunji kumaran, Dr. V. Venkataramana

Cranial Bone Graft for Orbital Floor Reconstruction 04

Dr.C. Hari Prasath MDS, MOMS RCPS, Prof. Vinod Narayanan, MDS; FRDRCS; MOMS RCPS

Comparison of Radicular and Intra Radicular Stud Attachments: Case Reports 10

Dr. Bharanija Kalidasan Selvi, Dr. Eazhil Raj, Dr. Jaya KrishnaKumar S, Dr. Azhagarasan N.S

An Insight to Single Visit Endodontics 14

Dr. A. Shafie Ahamed, Dr. Deepa Vinoth Kumar

Common and Uncommon form of Oral Mucocele 18

Dr. Sudhaa Mani MDS , Dr. Eswaramurthy BDS

Interim and Esthetic Management of an Avulsed Tooth 22

Dr. S. Leena Sankari M.D.S

Periodontal Disease and Respiratory Infection - A Link 25

Dr. P.l. Ravishankar, Dr. S. Rajsekhar

Milestones in Periodontics 27

Dr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)

Patient-Friendly Approach to the Management of Periodontal Disease 33

Dr. M. Vijayalakshmi, Dr. Gayathri. S, Dr. M. G. Krishna Baba, Dr. Sumathi. H. Rao, Dr. T. Geetha

Pathophysiology of Acute Necrotizing Ulcerative Gingivitis

(Anug) / Vincent's Infection - A Review 36

Dr. K. Sasireka M.D.S, Dr. M. Devi M.D.S

A New Concept of Dental Arch of Children in Normal Occlusion 39

Abu-Hussein Muhamad DDS, MScD, MSc, DPD, FICD, Sarafianou Aspasia DDS, PhD

Mobile Dental Clinic – An Outreach Government Programme - An Overview 45

Dr. Ramasubramanian .S, BDS

Non Pharmacological Management of Dental Anxiety in Adults 48

Dr. A.M.Devapriya MDS, Dr.D.Mythireyi MDS

Vol. 5 Issue. 16 Jan. 2013

JIDAT, Vol.5, Iss.16, Jan.-Mar.-201301

stages of tooth movement

INTRODUCTION:

Mechanotransduction is the field which discusses the mechanism of biotransformation of force into biological reaction. In orthodontics force is used to correct a given malocclusion, the tooth responds to the applied force and move towards the proposed final ideal position. A better understanding of force systems on the basis of physics, mechanics and biology is a mandatory for proper understanding of orthodontic mechanotherapy.

In this context, the present overview emphasizes on the traditional and recent concepts of force systems utilized in orthodontics and their corresponding biological response produced by teeth.

1. OPTIMUM ORTHODONTIC FORCE

The magnitude of the optimum force will vary depending on the way it is distributed in the periodontal ligament i.e. it is different for different types of tooth movement.

1Smith and Storey in their study on tooth movement in 8 patients concluded that optimal lower canine movement occurs with 150 to 250 grams of force. At higher force levels of 400 to 600 grams, the anchor unit of the second premolar and first molar moved more than the canine.

2Fortin recommends 147 gm as the optimum force for 3premolar translation in dogs. Reitan advocates 250 gms

for retraction of human lower canines. Lee recommends 150 gms to 260 gms as optimum canine retraction force. Rickctts and associates prescribe 75 gms as optimum force for canine retraction.

2. PHYSIOLOGY OF TOOTH MOVEMENT

4Ruel W. Bench et al in 1978 put forth the physiology of tooth movement. The orthodontic movement of teeth occurs as a result of the biological response and the

1 2 3 4Dr. Santhana Krishanan , Dr. K.Rajasigamani , Dr. N. Kurunji kumaran , Dr. V. Venkataramana

1. Assistant professor, 2. Vice principal, 3. Reader, 4. Reader,Department of Orthodontics, Raja Muthiah Dental College and Hospital, Annamalai University, Chidambaram

FORCE SYSTEMS IN ORTHODONTICS –

AN OVERVIEW OF TRADITIONAL AND RECENT CONCEPTS

ABSTRACT:

There is little doubt that the prevalence of patients with underlying medical conditions seeking orthodontic care has increased over the past two decades. In this literature we are discussing some major medical problems and precautions to be taken during orthodontic treatment.

physiological reaction to the forces applied by mechanical procedures. The physiological process of resorption by the osteoclastic cells is the basic activity that allows the bone to change and tooth to move. Since these osteoclastic cells are carried by the blood to the site of their activity and resultant bone resorption, the key factor in the efficiency movement of teeth seems to be the blood supply carries cell and sustains their activity. When a generous blood supply can be maintained by applying a light force, tooth movement is more efficient. When blood supply to the area, the osteoclastic activity of bone resorption is limited and the teeth do not move or they move slowly. Heavy forces that squeeze out the blood cells can limit the physiologic response and markedly affect the rate of tooth movement.

3. STAGES IN TOOTH MOVEMENT

Figure 1, explains the stages of tooth movement after an application of a moderate orthodontic load of 20 to 50g.

Tooth movement can be differentiated into three phases.

3.1 Initial Phase

This is characterized by rapid tooth movement. It lasts for a few days normally. The rapid onset of displacement immediately after force application suggests that tooth movement in the initial phase largely represents displacement of the tooth in the periodontal space.

Types of forces

3.2 Lag Phase

Tooth does not move or show a relatively low rate of displacement compared to the initial phase. This lag in tooth displacement is due to the hyalinization (non vitalization) of the periodontal ligament in maximal stress areas. No tooth movement can occur until the area of non vitalization has been removed by cellular process.

3.3 Post Lag Phase

Here, there is sudden increase in rate of tooth movement. As the hyalinized zones disappear, force producing frontal resorption on the alveolar bone increases the rate of tooth movement.

4. DESIGN FACTORS IN ORTHODONTIC APPLIANCES

In order to achieve the desired tooth movements, the proper force system is a critical requirement. Few terms must be borne in mind before determining the design factors.

A force is a load applied to an object that will tend to move it to a different position in space.

The moment of a force is equal to the magnitude of the force multiplied by the perpendicular distance from its line of action to the centre of resistance.

The only force system that can produce pure rotation(i.e. a moment with no net force) is a couple which is two equal and opposite, non-collinear but parallel forces.

The point around which rotation actually occurs when an object is being moved is center of rotation.

Center of resistance is that point at which a free object or body can be perfectly balanced. At this point, resistance to movement is concentrated for mathematical analysis.

5. FACTORS DETERMINING CENTRE OF RESISTANCE

Root lengths, Marginal bone level, characteristic of 5periodontal ligament are some factors that has to be

considered while determining center of resistance. In order to produce movement other than uncontrolled tipping by applying a force system only at the bracket, a single force alone is insufficient [movements such as bodily translation as required in space closure using edgewise and preadjusted edgewise appliances]. In these cases, a rotational tendency (moment) must also be applied to the bracket.

The proportion of the rotational tendency (moment) to the force applied at the bracket will determine the type of

tooth movement produced. This center of rotation (which characterizes the type of tooth movement) is determined by the M/F parameter for a given tooth.

6. WAYS OF INCREASING M/F RATIO

6Poul Gjessing observed that M/F ratio could be raised by I) Increasing the vertical dimension gingival to the bracket 2) Increasing the horizontal dimension in the apical part of the loop 3) Decreasing the interbracket distance 4) Positioning of the loop close to the tooth to be retracted 5) Angulating the mesial and distal legs of the spring 6) Adding more wire gingival to the bracket.

7. FORCE DECAY

The force magnitude of springs or loops gradually declines as the tooth moves. This decline is force decay. Only in theory, it is possible to make a perfect spring, one that would deliver the same force day after day, no matter how much of how little the tooth moved in response to that force. With many orthodontic device the force may even fall to zero.

Based on force decay, force duration is classified as (figure 2)

ContinuousInterrupted Intermittent

In order to attain a desirable tooth movement, an optimum and a constant force is required. This is possible only with a proper load deflection rate.

JIDAT, Vol.5, Iss.16, Jan.-Mar.-2013 02

8. LOAD DEFLECTION RATE

Refers to the amount of force produced for every unit of activation of an orthodontic wire or spring. If the rate is lower, the force is more constant as the tooth moves.

8.1. Wire Cross Section

The load deflection rate in a round wire is directly dependent on the fourth, power of wire diameter. For example, if the cross-sectional diameter of a spring is reduced from 0.016 inch to 0.014 inch (Only 0.002 inch), the load deflection rate is nearly halved. The load deflection rate of a rectangular wire is directly dependent on the third power of the diameter. The rate is dependent on the orientation of the rectangular dimensions.

8.2. Wire Length

The wire length changes the load deflection rate inversely as the third power. For example, if the length of the spring is tripled, the load-deflection rate is dramatically reduced by one twenty seventh its initial rate. Therefore, small increase in the length of the wire dramatically reduces the load deflection rate.

8.3. Wire Material

Altering the material affects the spring rate in direct proportion to its modulus of elasticity. Stainless steel alloys have replaced the lower strength gold alloys many years ago. In order to improve the characteristics of stainless steel arch wire, multistrand wires with greater flexibility (i.e.) reduced load deflection rates have been introduced.

ROOT RESORPTION

Reitan has shown that external root resorption is weakly related to force magnitude and closely related to the type of tooth movement, specifically intrusion and tipping. External root resorption (ERR) is initiated 14 to 20 days after force onset and the process of ERR continues even during retention periods of up to 1 year. It is a product of average force and the time during which it acts.

Dougherty made a clinical observation that in the cases, in which maximum anchorage preparation was necessary and extreme tip back bends placed, there was a greater resorption of mandibular 1st molars especially the distal roots.

Root resorption is the same, irrespective of the treatment modality. Be it Begg or edgewise, it is accepted that extensive tooth displacement, torque movements and

7jiggling forces are responsible for resorption .

Light, intermittent forces during closing spaces allows the resorbed cementum to heal and prevent further

8 9resorption . Mc Fadden et al found no difference in the extent of root resorption in patients treated with or without extractions.

CONCLUSION

Till date force is the only medicine available in the hand by orthodontists to cure malocclusion. Various methods of force generations have been attempted using elastics, coil springs, alloy materials, magnets, and screws. Irrespective of the utilized methods the applied force should be optional in Biological nature to overcome the iatrogenic root resorption and non vitality of tooth during or after orthodontic treatment.

A sound knowledge for biological response for an applied force is the key to success in orthodontic treatment.

REFERENCES

1. Story E and Smith R. Force in orthodontics and its relation to tooth movement. Aust dent j. 1952:56;11-18

2. Fortin JM: Translation of premolars in dogs by controlling the moment to force ratio on the crown. American Journal of Orthodontics and Dentofacial Orthopedics; 1971; 59; 541- 551.

3. Reitan K: Some factors determining the evaluation of forces in orthodontics. American Journal of Orthodontics and Dentofacial Orthopedics; 1957;43:1;32-45.

4. Ruel W. Bench, Carl F. Gugino, James J. Hilgers -Bioprogressive therapy part - 6. Journal of Clinical Orthodontics 1978:12;2;123-139

5. Kazuo Tanne, Koenig, Charles J. Burstone - Moment to force ratios and center of rotation. American Journal of Orthodontics and Dentofacial Orthopedics 1988; 94: 426 -431.

6. Poul Gjessing - Biomechanical design and clinical evaluation of new canine retraction spring. American Journal of orthodontics and dentofacial orthopedics 1985;87:5;353-362.

7. Reitan. K. Biomechanical principles and reaction: In: Graber TM. Swain BT. Orthodontics-current principles and techniques: St. Louis CV Mosby.

8. Steadman Sr. Resume of the literature on root resorption. Angle Orthodontist 1942:12;1;28-38

9. Mcfadden et al. a study of the relationship between incisor intrusion and root shortening. American Journal of orthodontics and dentofacial Orthopedics 1989; 96:5;390-396


8resorption

INTRODUCTION:

Fractures in and around the orbit are common. The important aspect of orbital injuries is their intimate relationship with the globe, periorbital soft tissue, eyelids, sinuses, brain and the lacrimal apparatus. Blowout fractures of the orbit most commonly involve the floor and/or medial wall. The displacement of the walls can have serious sequelae regarding function and

1appearance of the eye . It can cause a number of problems, including diplopia, ocular muscle entrapment, and enophthalmos. From the functional standpoint, displacement of a bony wall disturbs the position of the soft tissues, causing problems of eye movement and diplopia. Additionally, direct damage to the soft tissue can lead to scar contracture, globe dystopia, and dysmotility. If the globe is injured, there can be a loss of

2vision .

Several theories have been proposed to explain the effect 2of trauma to the orbit. In the hydraulic theory , a hard

object strikes the soft tissues of the orbit and transfers pressures from these tissues to one of the orbital walls. The inner wall then opens like a trap door in to the adjacent sinus, and the soft tissues are pushed through the

3defect. In another theory, called buckling theory , a force to the orbital rim causes the orbital walls to buckle, deforming them and the soft tissues. The deformity of the soft tissues of the orbit recovers much more slowly than

1 2Dr.C. Hari Prasath MDS, MOMS RCPS , Prof. VinodNarayanan, MDS; FRDRCS; MOMS RCPS

1. Senior Lecturer, Division of Oral and Maxillofacial Surgery, Rajah Muthiah Dental College and Hospital, Annamalai University, Chidambaram, Tamilnadu. 2. Division of Oral and Maxillofacial Surgery, Saveetha Dental College and Hospital, Saveetha University, Chennai.

CRANIAL BONE GRAFT FOR ORBITAL FLOOR RECONSTRUCTION

Purpose : The study was to evaluate use of cranial bone grafts in orbital floor reconstruction.

Patients and Methods : 12 patients with unilateral orbital floor fracture underwent cranial bone graft for correction of enophthalmos, hypopthalmos and diplopia. The inclusion criteria were pure blowout fracture of the orbit or impure blowout fracture of the orbit. Preoperative and postoperative CT scans, Radiographs and measurements were recorded.

Results : Reconstruction of the orbital floor was done in twelve patients. The period of follow-up and evaluation for the cranial bone graft was 1 week, 3 months and 6 months. These patients underwent CT scans at six months period for evaluation of graft position, uptake. The pre operative enophthalmos in twelve orbital floor fractures varied from 3-6 mm. In this series of twelve orbital floor fracture the post operative enophthalmos score was =2 mm. Five out of twelve patients in the series had preoperative diplopia and none had postoperative diplopia at the time of follow-up and improvement of the eye position and gaze was also found during the checkups.

Conclusion : Cranial bone is an accessible autogenous tissue which should be considered when an autogenous graft is needed for orbital floor fracture reconstructions.

the deformity of the bony structures, and this predisposes to entrapment of the soft tissues by the bony fragments.

Surgical correction mandates replacement of the bony and soft tissues into anatomic position and if necessary,

4,5,6 correction of the deficit in volume

Despite the general good results of orbital reconstruction, there are cases in which the cosmetic outcomes may be different than those noted immediately after surgery. It is suspected that the implant/graft and soft tissue undergoes resorption, which also affects the position and possibly function of the globe. However it is agreed that the reconstruction of the orbital walls is essential to maintain

7,8,9shape and function of the orbit . Autogenous cranial bone grafts have been the preferred material for

10,11 reconstruction of the orbital walls for many years . The purpose of the study was to evaluate use of cranial bone grafts in orbital floor reconstruction.

MATERIALS AND METHODS:

The study consists of twelve patients who had orbital floor fracture during the period April 2006 to March 2007. The inclusion criteria were patient with pure blowout fracture of the orbit, impure blowout fracture of the orbit. The exclusion criteria were orbital fracture with neurological complications, associated skull base fracture, direct trauma to the orbit.


These patients had a previous history of blunt trauma or

road traffic accident to the facial skeleton or orbit.

Opthalmological and neurological evaluation 12 was

obtained for all the patients. Routine radiographs 13 and

computer tomography scans taken to identify the site and

size of the fracture. Patients underwent orbital floor

reconstruction with cranial bone graft for enophthalmos

and impairment in the range of ocular movements.

Pre operative and post operative enophthalmos were measured by corneal projection using a Hertel Exopthalometer. More than 2mm difference was needed to show clinically evident enophthalmos. The eye position on one side could also be used as a control for the other in the absence of orbital rim displacement. Ocular motility was tested in the field of gaze for any muscle entrapment. The purpose of the surgery was to reduce the enophthalmos to as close to zero as possible when comparing the pre operative values. Reconstruction with cranial bone graft was done in twelve patients. In this series the cause of injury were blunt trauma in 4 patients and road traffic accident in 8 patients. The age ranged from 24 yrs to 39 yrs with a mean of 30.25 years.

The post operative follow up was scheduled for One week, Three months and Six months after surgery and post operative CT scans and radiographs were taken to evaluate the graft position, uptake. These post operative follow ups were used for determining resolution of enophthalmos and diplopia.

OPERATIVE TECHNIQUE:

Lower mid lid- crease incision is placed on the skin or the dissection is carried through the existing wound. Unfortunately, there are limitation to dissect within the

5orbit and are described as “Safe distances” . The subcutaneous dissection is carried out in inferior direction to the orbicularis muscle fibers and stopping when the orbital septum is encountered. Once the septum is encountered, the preseptal approach is then carried out inferiorly to the orbital rim. The periosteum is incised just below it and subperiosteal dissection is carried out from orbital rim to the fracture site.

Cranial bone graft is harvested by placing approximately 6cm skin incision on the mid portion of the parietal bone and dissection is carried till the periosteum. Once the periosteum is incised, bony marks are placed on the cranial bone. Cuts are deepened and limited to the outer dipole. The ends are beveled in 45° angulations and the chisel and mallet is used for harvesting of the graft. The bony graft harvested is usually exceeding the size of the

fracture site. Donor defect is packed with surgical (oxidized cellulose). The harvested cranial graft is prepared and ends are smoothened. Osteotomy cuts are placed if needed to gain the shape of the floor. The cranial graft is inserted in the defect site and globe position and level is compared clinically with the opposite normal side.

RESULTS

Reconstruction of the orbital floor was done in twelve patients. The time from initial injury to surgery varied from one week to twelve weeks with a median of six weeks. The period of follow-up and evaluation for the cranial bone graft was 1 week, 3 months and 6 months.

The most common preoperative clinical findings in this series were limited ocular motility, paresthesia, diplopia and enophthalmos. The indication for surgery in the patients was orbital floor defect with herniation of orbital tissue or orbital floor defects associated with other midface fractures with significant enophthalmos.

Out of twelve patients, one had developed post operative infection in the surgical site after one month and ectropion of the lower eyelid was present. Plate removal was done for that patient after six months since the fixation was found to be loose on re-exploration. Scar revision was done for the ectropion of the lower eye lid. In these twelve patients graft was left in situ with out plating or other kind of fixation. In this series one patient had a breach of inner cortex of the calvarium with a dural tear and venous bleed. The adjacent temporalis muscle was taken, crushed, and used as a plug to close the defect and to stop bleeding. The patient was evaluated for signs of neurologic changes which were found to be completely absent.

These patients underwent computer tomography scans at six months period for evaluation of graft position, uptake. They were also evaluated as to whether the enophthalmos became clinically insignificant or reduced. The pre operative enophthalmos in twelve orbital floor fractures varied from 3-6 mm. The post operative enophthalmos was analyzed at three and six months, a time when swelling was believed to have subsided. The patients out come were recorded as either successful (a post score of =2 mm) or unsuccessful (a post score of >2 mm). In this series of twelve orbital floor fracture the post operative enophthalmos score was =2 mm. Five out of twelve patients had preoperative diplopia and none had postoperative diplopia at the time of follow-up and improvement of the eye position and gaze was also found during the check ups.


DISCUSSION

The use of bone grafts has played an important role in oral and maxillofacial surgery with relative disagreement among surgeons on the different grafting methods existing. The important criteria’s to be considered when evaluating grafting materials include biocompatibility, availability, osteogenesis, ability to act as a matrix, and

14,15mechanical stability

The standard regenerative bone grafting material used is autogenous bone for its capability to support osteogenesis, osteoinductive and osteoconductive properties. Three forms of free bone grafts include

16cortical, cancellous, and corticocancellous . Cortical grafts are able to withstand early mechanical forces; however, they require more time to revascularize. Common donor sites for bone grafting are cranial vault, iliac crest, ribs, mandibular symphysis, and external

7,16oblique ridge . Particularly the calvarial bone is more 14permanent than bone from other donor sites . Variable

rates of resorption are seen, if iliac bone is used. But an appropriate graft selection should be based upon the goals of reconstruction.

Different materials are used for orbital floor fractures 2,7 reconstructions are autogenous and allogenous grafts

(cranial bone, iliac, rib, symphysis, septal and auricular cartilage) or synthetic material (alloplastic materials- titanium mesh). When alloplastic materials are used complications such as extrusion, foreign body reaction,

7infection, displacements are possible sequelae . The ideal management of orbital floor fractures continues to be debated.

Cranial bone grafts are widely used for numerous maxillofacial reconstructive surgical procedures. We sought to illustrate the usefulness of cranial bone grafts in orbital floor fracture reconstruction mainly because of the histomorphological similarities of the bone, curvature of the bone to the recipient site and it is particular integration with the facial bone structure. An ideal

16material should closely replicate the tissue it replaces .

Advantages with calvarial bone grafting are minimal postoperative pain, scar is hidden in the hair line, propensity to maintain original graft volume, local availability, low infection rate and less donor site

10,11morbidity . Disadvantages with calvarial bone grafting can be difficulty to run two surgical teams simultaneously, may not yield sufficient cancellous bone (<30cc), neurologic sequelae may arise with other

10potential complications . Possible Complication rate were 5.6-7.6%. Reported complications are, hematoma/seroma, infection, dural tear with possible CSF leakage, leptomeningeal cyst, laceration of superior

< 2mm –Successful, > 2mm - unsuccessful

1

2

3

4

5

6

7

8

9

10

11

12

4

5

3

4

4

5

6

3

4

3

5

6

_

+_

_

_

+

+_

_

_

+

+

0

2

0

1

0

2

2

0

2

1

2

2

_

_

_

_

_

_

_

_

_

_

_

_

GRAFT NO

PRE OP ENAOPTAHM

POST OP ENAOPTAHM

POST OP DIPLOPIA

PRE OP DIPLOPIA

Preoperative CT

Intra operative graft Harvest

Postoperative CT


sagittal sinus. Voska P et al used cranial bone grafts for treating posttraumatic defects, defects originated after tumor removal and cranial anomalies in 95 patients. No serious postoperative complications appeared in any of the 95 patients. In 10% of the cases, when bone grafts were used like onlays, he reported resorption was up to 20% of the volume. Author in conclusion added that rigid method of fixation of the graft will reduce the resorption

11rate . Smolka et al states that calvarial split bone grafts shows low rate of bone resorption after extensive alveolar

17ridge reconstruction .

Stanislaw B.Bartkowski et al evaluates 90 patients with blow-out fracture of the orbit and states that in cases with a defect of the orbital floor fracture reconstruction, the

18best material is autogenous bone graft . V. Ilankovan et al in 1992 states that orbital reconstruction can be performed using with cranial bone graft in 222 patients with 279 calvarial grafts. There were 13 (4.6%) complications, most occurring during harvesting full-thickness calvarial grafts.

The main aim of surgical treatment is the anatomical correction of the bony defect by restoring the anatomy and volume of the orbit to avoid any complications. Orbital floor morphology differs with age and gender. The inclination of the orbital floor is steeper in children than in adults and in males than in females. Also the lowest point shifts lower and more posteriorly as patient

19ages

In case of orbital blowout fractures the most commonly fractured area is the orbital floor; where intrusion and entrapment of the orbital content, and more specifically, of the inferior rectus and the inferior oblique muscles or their facial attachments into the fracture lines and toward the maxillary sinus . They account to approximately 11%

20of fractures involving the orbit . The indications and 5,6timing for fracture repair are still controversial . Lester M

Cramer1 study shows that the earlier the surgery is performed the easier it is to accomplish successful anatomic reductions and to ensure uniform excellent results. The “ideal” time to intervene after fracture occurrence cannot be precisely defined. Ultimately, the decision to proceed with surgery should be based on the patient’s symptoms, clinical findings, and thorough informed consent about the risks and benefits of surgical

8intervention .

Symptoms of orbital floor fractures include orbital pain, enophthalmos, hypesthesia in the V2 distribution (infraorbital: cheek and teeth), and diplopia. Eyelid ecchymosis, subcutaneous emphysema, ptosis, epistaxis, lacrimal system injuries, and pupillary dilation may be

6,21associated with orbital floor fractures . Thorough

ocular examination is necessary; in particular, special attention is required to check vision and pupillary response for optic neuropathy and to assess extraocular motility and forced ductions/generations for extraocular muscle entrapment, ischemia, hemorrhage, or orbital

22compartment syndrome . Following the findings, a carefully planned surgical treatment of blow-out fractures is proposed in correlation with the clinical symptoms and radiological evidence and proper history.

CT scans are the method for evaluation of orbital floor 4fractures . Axial and coronal CT scans is the standard

diagnostic imaging technique for assessing orbital trauma, and careful analysis of CT slices can contribute

23,24,25,26toward improved planning of treatment . Calculations of blow-out fractures of the orbital floor by 3D-CT and 2D-CT method are accurate for assessing the

23area of fracture and the volume of herniated tissue .

In our clinical study, twelve patients with orbital floor fracture were analyzed from 2006 to 2007 at the department of Oral and Maxillo-Facial Surgery. Age ranged from 24 to 39 yrs. The reconstruction was made by calvarial bone grafts taken only from the outer table of the calvarium. The size of the graft was approximately from 2cm to 2.5cm. In this study we analyze the pro and vs of calvarial bone grafting. Today alloplastic materials merit certain circumstances only when bone autogenous graft is contraindicated or when the surgeon don't want to use it and is also cost effective. At the end of six months we found that the graft position, uptake was excellent with less resorption rate and no donor site morbidity.

Orbital surgery is not risk free. The decision to proceed with surgery must consider potential surgical complications, which can include blindness, subsequent infection of implanted material, orbital implant migration, postoperative mydriasis, epiphora, and

27,28worsening diplopia .

We are in the conclusion that on the basis of our investigations early surgical treatment leads to satisfactory long-term results. As a result of favorable biological response in our study with no surgical complications, cranial bone graft was considered to be a promising autogenous material for orbital floor fracture reconstructions with advantages of minimal postoperative pain, scar hidden in the hair line, propensity to maintain original graft volume and less donor site morbidity. This, together with our favorable experience, encourages us to continue to use cranial bone graft in the future. Thus we conclude by saying that cranial bone graft is an ideal autogenous material for orbital floor fracture reconstruction.


REFERENCES:

1. Lester M. Cramer, Frank M. Tooze and Sidney Lerman. Blowout fractures of the orbit, Br J of Plast Surg, 1965, 18; 171-179.

2. Dongmei He, Preston H. Blomquist and Edward Ellis III. Association between Ocular Injuries and Internal Orbital Fractures, J Oral Maxillofac Surg, 2007, 65(4); 713-720.

3. Shoab A. Siddique and Robert H. Mathog. Comparison of parietal and iliac crest bone grafts for orbital reconstruction, J Oral Maxillofac Surg, 2002, 60(1); 44-50.

4. Oliver Ploder, Clemens Klug, Werner Backfrieder, Martin Voracek, Christian Czerny and Manfred Tschabitscher. 2D- and 3D-based measurements of orbital floor fractures from CT scans, J Cranio-Maxillofac Surg, 2002, 30(2); 153-159

5. B.T. Evans and A.A.C. Webb. Post-traumatic orbital reconstruction: Anatomical landmarks and the concept of the deep orbit, Brit J Oral Maxillofac Surg, 2007, 45(3); 183-189.

6. Hartstein ME, Roper-Hall G. Update on orbital floor fractures: indications and timing for repair, Facial Plast Surg. 2000, 16(2); 95-106.

7. Mordechai Kraus, Albert Gatot and Dan M. Fliss. Repair of traumatic inferior orbital wall defects with nasoseptal cartilage, J Oral Maxillofac Surg, 2001, 59(12); 1397-1400.

8. Lena Folkestad and Gösta Granström. A prospective study of orbital fracture sequelae after change of surgical routines, J Oral Maxillofac Surg, 2003, 61(9); 1038-1044.

9. M. Marasco and F.S. De Ponte. Reconstruction of orbital floor fractures. A current surgical management, J Cranio-Maxillofac Surg, 2006, 34(1);11.

10. V. Ilankovan and I.T. Jackson. Experince in the use of calvarial bone grafts in orbital reconstruction, Brit J Oral Maxillofac Surg, 1992, 30(2); 92-96.

11. Koz~k J., Voska P. Long-term experiences with calvarial bone grafts in cranio- maxillo-facial surgery, J Cranio-Maxillofac Surg, 1996, 24(1); 65.

12. Thomas H. O'Hare. Blow-out fractures: A review, J Emerg Med, 1991, 9(4); 253-263.

13. Stephen H. Miller and William J. MorrisCurrent. Current concepts in the diagnosis and management of fractures of the orbital floor, The Am J Surg, 1972, 123(5); 560-563.

14. Edward Ellis III, Elias Messo. Use of nonresorbable alloplastic implants for internal orbital reconstruction, J Oral Maxillofac Surg, 2004, 62(3); 873-81.

15. Mario F. Muoz Guerra, Jesus sastre Terez et al. Reconstruction of orbital fractures with dehydrated human duramater, J oral maxillofac surg, 2000, 58(12): 1361-1366.

16. Risto Kontio. Treatment of orbital fractures: The case for reconstruction with autogenous bone, J Oral Maxillofac Surg, 2004, 62(1); 863-68.

17. Smolka W, Eggensperger N , Carollo V, Ozdoba C, Lizuka T. Changes in the volume and dentistry of calvarial split bone grafts after alveolar ridge augmentation. Clin Oral Impl Res. 2006, 17; 149-55.

18. Bartkowski SB, Krzystkowa KM: Blow-out fracture of the o rb i t . D iagnos t i c and the rapeu t ic considerations, and results in 90 patients treated, J Oral Maxillofac Surg, 1982, 10; 155-164.

19. Tomohisa Nagasao, Makoto Hikosaka, Tadaaki Morotomi, Maki Nagasao, Kaoru Ogawa and Tatsuo Nakajima. Analysis of the orbital floor morphology, J Cranio-Maxillofac Surg, 2007, 35(2); 112-119.

20. Chen JM, Zingg M, Laedrach K, Raveh J. Early surgical intervention for orbital floor fractures, J Oral Maxillofac Surg, 1992, 52; 935-41.

21. Michael A. Burnstine, Clinical Recommendations for Repair of Isolated Orbital Floor Fractures An Evidence-based Analysis, Ophthalmol 2002, 109; 1207–1213.

22. K. de Man, R. Wijngaarde, J. Hes and P.T. de Jong. Influence of age on the management of blow-out fractures of the orbital floor, Int J Oral Maxillofac Surg, 1991, 20(6); 330-336.

23. Harris GJ, Garcia GH, Logani SC, MurphyML, Sheth BP, Seth AK: Orbital blow-out fractures: correlation of preoperative computed tomography and postoperative ocular motility. Trans Am Ophthalmol Soc 1998 96: 329–347.

24. Edward Ellis and Yinghui Tan. Assessment of internal orbital reconstructions for pure blowout fractures: Cranial bone grafts versus titanium mesh, J Oral Maxillofac Surg, 2003, 61(4); 442-453.


Corresponding author :Dr C. Hariprasath, Senior Lecturer,Division of Oral and Maxillofacial Surgery,Rajah Muthiah Dental College and Hospital,Annamalai University, Chidambaram,Tamil Nadu – 608002, INDIA [email protected]+ 91 9487474246

25. Stewart MG, Patrinely JR, Appling WD: Late proptosis following orbital floor fracture repair. Arch Otolaryngol Head Neck Surg, 1995, 121:649.

26. Sachs ME: Orbital floor fractures: The maxillary approach. Adv Ophthalmic Plast Reconstr Surg 6:387, 1987

27. Lena Fol kestad and Thomas Westin: Long-term sequelae after surgery for orbital floor fractures, Otolaryngol Head Neck Surg 1999;120:914-21.

28. H. Popat and Liu D. Blindness after blow-out fracture r e p a i r . O p h t h a l P l a s t R e c o n s t r S u r g 2007;10:206–10.


Short running title: Clinical report on usage of stud attachments.

ARTICLE PROPER

INTRODUCTION:

Edentulousness was once considered to be a normal part of aging and the conventional way of treating edentulous patients was by means of complete dentures. However, limitations such as residual ridge resorption, loss of occlusal stability, undermined esthetic appearance & decrease in neuromuscular skills in manipulating the dentures as age progresses has detracted the quality of life

1of such patients . Considerable clinical experience and documented research have underscored the merits of retained natural teeth or substitution by dental implants to serve as abutments under complete dentures and partial

2-6denture . In this regards overdentures have found increased application in prosthodontics.

Periodontally compromised teeth are often too weak to support a partial denture for long term. The larger crown root ratio created by periodontal disease results in forces that can gradually extract the remaining teeth. Reduction of the clinical crown creates a more favorable crown to root ratio to compensate for progressive bone loss, to increase the longevity of remaining natural teeth and provides adequate place for the overlying artificial

4,7,8denture tooth and denture base . They also provide psychological benefit to the patient, tactile discrimination, better load transmission of the prosthesis to the underlying structures and improve stability &

1 2 3 4Dr. Bharaniraja Kalidasan Selvi , Dr. Eazhil Raj , Dr. Jaya KrishnaKumar S , Dr. Azhagarasan N.S

1. Senior lecturer, Department of Prosthodontics, SRM Dental College, Bharathi salai, Ramapuram, Chennai-89.2. Reader, Department of Prosthodontics, Chettinad Dental college and Research Institute, OMR, Padur, Chennai- 603103.3. Professor, Department of Prosthodontics, Ragas Dental College & Hospital, 2/102, East Coast Road, Uthandi, Chennai-119. .4. Professor & H.O.D, Department of Prosthodontics, Ragas Dental College & Hospital, 2/102, East Coast Road, Uthandi, Chennai-119.

COMPARISON OF RADICULAR AND INTRA RADICULAR

STUD ATTACHMENTS: CASE REPORTS

ABSTRACT:

Complete dentures present many problems that may be avoided by the retention of roots of selected key teeth. Retention of these roots makes possible to fabricate a denture that provides support, retention, stability and comfort, superior to that of a conventional complete denture. Alveolar bone is preserved, and the occlusal vertical dimension and centric relation are maintained. Facial and lip changes are minimized, while the ability to masticate is maximized. The patient experiences a sense of security and feels that he has his teeth and he looks his best. Despite recent developments in dental implantology, the conservative approach to root preservation is still valid. Placement of attachments in the abutments further increases retention of overdentures. Though many attachments such as stud and bar attachments are available, proper selection to meet patient’s needs is essential.

Key words: Tooth supported overdenture, stud attachments, radicular attachments, intra radicular attachments.

retention of the denture, thereby helps in better 9,10,11mastication . The overdentures render maximum

support and improve compromised esthetic appearance in patients with congenital anomalies such as cleft palate, ectodermal dysplasia, hypodontia, those with sequelae of

1maxillofacial trauma and tumor . Other patients who may benefit from tooth-supported dentures are those with malrelated ridges, those facing the loss of teeth in one dental arch while the other arch is dentulous, those with unfavourable tongue positions, muscle attachments, or residual ridges and those who encounter difficulty with

2stability or retention of conventional complete denture .

The tooth supported overdentures are of two types, 1,12conventional and with attachments . The notion of

underscoring the use of attachments shifts the conventional overdenture design which provides stability and retardation of RRR, to major emphasis on prosthesis retention. Overdenture attachments are available for chair side procedure or requiring a laboratory casting. The attachments are of bar and stud

1,12types . Stud type attachments may be positioned over the root/ implant (radicular) or in the root/ implant abutment (intra radicular). In intra radicular stud type attachments, a prefabricated component is placed within the center of the teeth root and the male component is incorporated in the impression surface of overdenture. The radicular attachment is incorporated on or into a post and coping type casting. The crown root ratio is also enhanced with the low profile of the stud type

12attachments .


CASE REPORTS:

Case 1: A 74 year old female patient presented with the complaint of inability to retain partial denture in the lower arch. Her dental history revealed that the patient had been completely edentulous in upper arch and partially edentulous in lower arch for past five years and had been wearing dentures. Clinical examination revealed ill fitting lower denture with the presence of 33,35,41 and 43. Patient had been a known diabetic for past 10 years and has neuromuscular inco-ordination and under medication the same. Radiographic investigations revealed generalized bone loss.

Taking into consideration patient’s age, medical and psychological status, overdentures with stud attachments were planned with 33 and 43 as abutments. The height and width of the abutments were evaluated radiographically and clinically and intra radicular stud type attachment was selected (zest standard, zest anchors attachment system, CA).

Abutment teeth adequately prepared after elective endodontic procedure.

Metal female element luted in prepared root recess.

Resilient male element placed in position.

Intaglio surface of the denture with resilient female element.

Sprue former attached to wax patterns with castable male component.

Metal female element oriented over cemented male components.

Orientation of male component analog in reline impression.

Intaglio surface of denture with female components.


Endodontic procedures for the abutment teeth were completed and adequately prepared for overdenture procedures (fig 1). The complete denture was fabricated. The abutment was clinically reduced to the height of about 1mm above the gingival tissue level and a pilot hole made in canal orifice with No 700 carbide bur of a depth of 7mm. The drill was aligned parallel to path of insertion of the denture. The pilot hole was enlarged using No 6 round carbide bur to a depth of 4mm. The diamond sizing bur was used to create a full 360 degree recessed seat in the occlusal surface. The metal female element was tried in the prepared root recesses for proper fit and then cemented using glass ionomer cement (fig 2). The resilient male element was attached to female element (fig 3). The lower denture was tried in to check for clearance to accept resilient males. A small vent hole was made on the lingual surface of the denture. Self cure acrylic resin of thin consistency was placed in the denture recess and also painted around the male elements. Denture was seated in the patient’s mouth and was asked to occlude. Excess material was expressed through the vent hole and sufficient time was allowed for the resin material to set. The overdenture was removed, finished and polished. (fig 4).

Case 2: A 63yr old patient presented with complaint of inability to eat and speak properly due to missing teeth. He gave history of partial edentulousm for past two years. Clinical and radiographic examination revealed presence of 33 and 44 with adequate bone support. Various treatment options were explained to patient and removable prosthesis was considered. The inter ridge distance was found to be adequate for placement of radicular attachments. The adequate tooth preparation was performed and denture construction was done till the trial denture stage. Root preparation was done and the castable male component was attached to the post pattern and parallelism checked. After investing (fig 5), casting, finishing and polishing, the post was cemented. The metallic female was oriented over the male component (fig 6) and a reline impression was made using trial denture. The analog of male component was oriented to the female component in the impression (fig 7) and denture was processed. The retention rings were placed in the female component incorporated in the final denture (fig 8). Denture was seated intraorally and evaluated.

DISCUSSION:

Extraction of entire dentitions with complete denture replacements was used to be promoted as an inexpensive and permanent solution for oral health care in the past. The structure of maxillae and mandible was designed to hold the natural teeth roots, but not to act as a supporting factor for artificial dentures. So it is certain that resorption

4,13occurs if this structure is disturbed . The rate of resorption depends on three factors; the character of the

bone, the health of the individual, and the amount of 4trauma to which the structures are subjected .

The concept of overdentures developed as a simple and economic alternative to prolong the retention and function of the last few remaining teeth in a compromised dentition. The biological maintenance of a neuromuscular mechanism, the temporomandibular articulation and a better medium for support and stability for a denture can be accomplished better by retained

4natural teeth than by the mucoperiosteum . The area that is most critical for maintaining teeth to retain alveolar bone is the anterior region of the mandible. Preservation of atleast two roots in the anterior mandible to avoid the advanced resorption of the anterior edentulous mandible

7has been the primary application of the overdenture .

Natural roots may prevent or retard residual alveolar bone loss. The threshold of minimal perceived pressure was significantly lower with overdentures supported by tooth roots than by implants due to presence of receptors

10,14,15in periodontal ligament .

Stud attachments are simple and versatile in connecting complete denture to remaining natural teeth / implants. A solid attachment as that used in case 2, allows no movement between the male and female elements. This feature transfers stress towards the roots / implants and away from the ridge. The intra radicular resilient stud type attachments allow movement in any plane and transfers stress away from the root/ implants and towards the tissues. For this reason, resilient attachments are selected much more frequently than solid attachments. Retention achieved is satisfactory and they promote better oral hygiene. The intra radicular attachment requires less space than other attachments and doesn’t require additional precious metal casting. Any significant divergence between the roots or between roots and path of insertion of the denture results in rapid wear of male

12components and requires frequent replacement .

Disadvantages of overdenture include fracture of denture base resin, fracture of teeth, need for changes of prosthetic design followed by fabrication of new prosthesis. Prosthesis related adjustments include sore spots, relining of overdenture, occlusal adjustments, changes of tooth arrangement for esthetic reasons,

10excessive wear of teeth .

SUMMARY:

Now a days numerous attachments are available suitable for various clinical scenario. With proper case selection, treatment plan considering biological and prosthodontic aspects and post insertion maintainence, overdentures with attachments can be used with great success to improve retention and esthetics.


REFERENCES

1. Zarb GA, Bolender CL, Carlsson G,editors.

Boucher’s prosthodontic treatment for edentulous

patients. 11th ed. St Louis: Mosby-Year Book; 1997.

2. Morrow RM, Feldmann EE, Rudd KD, Trovillin

HM.Tooth-supported complete dentures:An

approach to preventive prosthodontics J Prosthet

Dent. 1969;21(5):513-22.

3. Lord JL, Teel S. The overdenture. Dent Clin North Am

1969;13:871-81.

4. Miller PA,Complete dentures supported by natural

teeth J Prosthet Dent. 1958: 8(6):924-928.

5. Fenton AH, Hahn N. Tissue response to overdenture

therapy. J Prosthet Dent 1978; 40: 492-8.

6. Toolson LB, Taylor TD. A 10- year report of a

longitudinal recall of overdenture patients. J Prosthet

Dent 1989; 62:179-81.

7. Fenton AH. The decade of overdenture: 1970-1980. J

Prosthet Dent 1998;79(1):31-6.

8. Crum RJ, Rooney GE. Alveolar bone loss in

overdentures; a 5year study. J Prosthet Dent 1978;

40:610-3.

9. Bassi F. Comparing overdenture therapies with teeth

and implant abutments. Int J Prosthodont 2009;

22(5): 527-28.

10. Hug S, Mantokondis D, Mericske-Stern R. Clinical

evaluation of 3 overdenture concepts with tooth

roots and implants: 2-year results. Int J Prosthodont

2006; 19(3): 236-243.

11. 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; 39:508-11.

12. Prieskel H. Overdentures may easy. Berlin:

Quintessence; 1996.

13. Atwood DA, Coy WA. Clinical, cephalometric, and

densitometric study of reduction of residual ridges. J

Prosthet Dent 1971; 26: 280-5.

14. Mericske-Stern R, Hofmann J, Wedig A, Geering AH.

In vivo measurements of maximal occlusal force and

minimal pressure threshold on overdentures

supported by implants or natural roots: A

comparative study, Part I. Int J Oral Maxillofac

Implants 1994; 9: 63-70.

15. Crum J, Loiselle RJ. Oral perfection and

proprioceptions. A review of the literature and its

significance to Prosthodontics. J Prosthet Dent 1972;

28: 215-30.

Corresponding author :

Dr.K.S.Bharaniraja, M.D.S. Senior lecturer, Department of Prosthodontics, SRM Dental College,Bharathi salai, Ramapuram, Chennai-89. Tamil Nadu, India.Email id: [email protected] Mobile number: 919841228066,Fax number: 044- 22492429.


INTRODUCTION:

Single visit endodontics (SVE) is gaining popularity these days as compared to multiple visits. SVE implies ‘Conservat ive non-surgical t reatment of an endodontically involved tooth consisting of complete biomechanical preparation and obturation of the root canal system in one visit’.The concept of single visit endodontics started at least 100 years old. In the recent years single visit endodontics has gained increased acceptance as the best treatment for many cases. Recent studies have also shown that there is no difference in quality of treatment and incidence of post treatment complication or success rates between single visit and multiple visit root canal treatment (Albashaireh and Alnegrish, 1998;Weiger et al.,2000;Sathorn et al.,2005;Field et al.,2004). Many dentists nowadays prefer single visit endodontic treatment because of many advantages. Perhaps, the most important advantage is the prevention of root canal contamination and bacterial re-growth that can occur when the treatment is prolonged over an extended period due to leakage of temporary seal (Trope et al., 1999; Soltanoff and Montclair, 1978; Pekruhn, 1981; Rudner and Oliet, 1981; Lin et al.,2007 ).

REASONS FOR NOT DOING SVE

1) Fear of post-op pain.

2) Fear of failure.

3) Lack of time.

4) Lack of clinical experience.

5) Lack of equipment.

6) Fear of being “unconventional”.

7) Fear of patient not accepting SVE

8) Discomfort to the patient.

GUIDELINES FOR SVE

1. Accurate diagnosis

2. Proper case selection

3. Skilled operator

4. Working time not more than 60 minutes

1 2Dr. A. Shafie Ahamed , Dr. Deepa Vinoth Kumar

1. Professor, Dept of Conservative Dentistry and Endodontics,Rajah Muthiah Dental College, Annamalai University, Chidambaram. Tamil nadu.

AN INSIGHT TO SINGLE VISIT ENDODONTICS

Key words: Periapical lesions, calcium hydroxide, nonsurgical endodontic therapy

INDICATIONS FOR SVE :

• Uncomplicated vital teeth.

• Physically compromised patients who have to make an effort to come to the dental clinic.

• Medically compromised patients who require antibiotic prophylaxis and sometimes alteration in the medication they take.

• Fractured anterior where esthetics is a concern.

• Apprehensive but cooperative patient

• Patients who require sedation or operation room.

• Uncomplicated non vital teeth with sinus tract.

CONTRA INDICATIONS FOR SVE :

• Acute alveolar abscess cases with pus discharge.

• Patients who have acute apical periodontitis with severe pain on percussion

• Painful non vital tooth with no sinus tract.

• Asymptomatic teeth with apical lesion and no sinus tract.

• Cases with procedural difficulties like calcified canals, curvatures, extra canals, etc....

• Patients with TMJ disorders and inability to open the mouth.

• Teeth with limited access.

• Non surgical retreatment cases.

OLIET’S CRITERIA FOR CASE SELECTION

• Positive patient’s acceptance.

• Sufficient available time to complete the procedure properly.

• Absence of any acute symptoms requiring drainage via the canal and of persistent continuous flow of exudates or blood.

• Absence of anatomical obstacles like calcification in the canals and procedural difficulties (ledge formation, blockage, perforation).


ADVANTAGES

• Intimate awareness of the canal anatomy immediately following instrumentation.

• No risk of losing important landmarks.

• Canal is never cleaner than immediately after proper instrumentation.

• No risk of flare-up induced by leakage of temporary seal.

• Teeth are ready for final restoration, diminishing the risk of a fracture necessitating extraction.

• Patient’s pre appointment anxiety and post-operative discomfort are limited to one episode.

• Time is saved for the patient and for practitioner since the treatment is completed in one visit.

DISADVANTAGES

• Inability to dry the canals completely.

• Insufficient time to complete the procedure.

• Possible stress of TMJ musculature or increased psychological stress on patients or clinicians because of longer appointment time or both.

• Flare-ups cannot be easily treated by opening the tooth for drainage.

IS THE PROGNOSIS?

Compromised by performing RCT in One appointment----NO

In Humans, over whelming evidence shows the healing is same for both single or multiple visits regardless of pulp vitality (Trope et al., 1999; Weiger et al., 2000; Peters and Wesselink, 2002).

Studies evaluating healing of single visit and multiple visit

root canal treatment

Trope et al (1999) 64 Vs 74 %

Weiger et al (2000) 83 Vs 71 %

Peters and Wesselink (2002) 81 Vs 71 %

The success of endodontic treatment is directly

associated with infection control. The literature indicates

that rotary, hand or hybrid instrumentation, even when

performed correctly, is inadequate to clear all organic

and inorganic debris from the root canal system. For this

and other reasons, irrigating solutions play an important

role making up for the shortcomings of instrumentation

and complementing endodontic disinfection procedures

(Almeida et al., 2012; Bashetty and Hegde, 2010). Post

instrumentation sampling showed reductions of

cultivable microbiota. However bacteria still found in

62% of teeth in one visit group and 64% in two visit group

(Kvist et al., 2004). Mechanical debridement with

antibacterial irrigation (0.5% NaOCl) can render 40-60%

of treated teeth bacteria negative (Bystrom and Sundqvist,

1983, Sjogren et al.,1997). Intraradicular microbes

surviving root canal treatment- entomed by obturation

and die as a result of inadequate nutrients. Kronfeld’s

theory, bacterial count decreases –suitable environment

for healing.

POST-OPERATIVE PAIN AND FLARE-UP IN SVE

There are numerous studies focusing on post operative

pain and flare up in SVE and MVE. Most of the studies

result showed that there is not much significant difference

in the post operative pain between SVE and MVE.

• Pekruhn-1981,1986

• Almeida et al-2012

• Bashetty and Hegde -2010

• El Mubarak et al-2010

• Siqueira and Barnett-2004

• Di Renzo et al-2002

• Albashaireh and Alnegrish -1998

• Fava-1995

• Oliet-1983

• Roane et al-1983

• Soltanoff and Montclair-1978

• Fox et al-1970

• Al-Jabreen and Tarik -2002

• Eleazer and Eleazer-1998

• Oginni and Udoye-2004

• Trope-1991

• Imura and Zuolo-1995

• Walton and Fouad-1992

Post operative pain Flare up


Morse defines “Flare-up” as either patient’s report of pain not controlled with over the counter medication or as increased swelling.

Walton defines “Flare-up” within a few hours to a few days after a root canal treatment procedure, a patient has either pain or swelling or combination of both.

The factors that can reduce the incidence of flare-up, pain and swelling are prophylactic antibiotics (Penicillin V or erythromycin). Intentional over instrumentation of root into the approximate center of the bony lesion reduces the prevalence of flare-ups from about 20% to 1.5% (non-vital) (Fox et al., 1970).

Pain in endodontic procedures is related to the presence or absence of inflammation. It is reasonable to assume that if severe inflammation exists before treatment, there would be a tendency to expect a distinct increase in the postoperative pain after a single-visit procedure rather than if two or more visits were used. If single-visit procedure is performed on teeth that have a potential for a "flare-up," antibiotics are suggested beginning 48 hours preoperatively. This routine has greatly reduced the number of flare-ups (Soltanoff and Montclair.,1978).

SUCCESS RATE AND FAILURE OF SVE:

Prognostic studies have shown that there is no substantial difference in the success rate of single and multiple appointment cases ( Sathorn et al.,2005;Figini et al.,2008;Field et al.,2004). Necrotic teeth with apical periodontitis showed favorable periapical healing at 12 months, with no statistically significant differences between groups (Penesis et al., 2008). Failure of 5.2% in single visit cases. The incidence of failure was higher in teeth with periapical extension of pulpal disease which had no prior access opening (Pekruhn, 1986).

Healing following endodontic therapy will usually occur following an accurate diagnosis, proper case selection, and the use of skilled techniques of treatment. These procedures are based upon known biological principles incorporated into the technique triad, specifically: biomechanical preparation of the canal system, debridement and disinfection, and complete obturation of the prepared canals. Each of these objectives must be achieved in order to ensure a successful result.

CONCLUSION

As far as the endodontic treatment aspect is concerned, whether it is SVE/MVE three basic phases has to be met to obtain success.

1. Diagnostic phase – disease determination and design of treatment plan

2. Preparatory phase – contents of root canal removed and canal prepared for filling material

3. Restorative phase – filling of the canal to obtain a hermetic seal at the cementodentinal junction and post endodontic restoration

SVE is now within the reach of most practitioners, as new technology provides better designs of instruments for canal shaping and efficient cleaning protocols for meticulous canal cleaning and disinfection followed by three dimensional filling of the canal.SVE is successful when there is careful case selection and strict adherence to standard endodontic principles.

REFRERENCE

Albashaireh ZS, Alnegrish AS (1998). Postobturation pain after single and multiple-visit endodontic therapy. Aprospective study.J Dent 26(3):227-32.

Al-Jabreen, Tarik M (2002) Single visit endodontics: Incidence of post-operative pain after instrumentation with three different techniques:An objective evaluation study. Saudi Dental Journal: 14(3);136-139

Almeida G, Marques E, De Martin AS, da Silveira Bueno CE, Nowakowski A, Cunha RS (2012). Influence of Irrigating Solution on Postoperative Pain Following Single-Visit Endodontic Treatment: Randomized Clinical Trial. J Can Dent Assoc78:c84

Bashetty K, Hegde J (2010). Comparison of 2% chlorhexidine and 5.25% sodium hypochlorite irrigating solutions on postoperative pain: a randomized clinical trial. Indian J Dent Res 21:523-7

Byström A, Sundqvist G (1983). Bacteriologic evaluation of the effect of 0.5 per cent sodium hypochlorite in endodontic therapy. Oral Surgery, Oral Medicine and Oral Pathology 55, 307–12.

DiRenzo A, Gresla T, Johnson BR, Rogers M, Tucker D, BeGole EA( 2002). Postoperative pain after 1 and 2 visit root canal therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 93(5):605-10

El Mubarak AH, Abu-bakr NH, Ibrahim YE(2010 ). Postoperative pain in multiple-visit and single-visit root canal treatment. J Endod 36:36-9.

Eleazer PD, Eleazer KR (1998). Flare-up rate in pulpally necrotic molars in one-visit versus two-visit endodontic treatment. J Endod 24:614-6.

Fava LR (1995).Single visit root canal treatment: incidence of postoperative pain using three different instrumentation techniques. Int Endod J 28:103-7.


Field JW, Gutmann JL, Solomon ES, Rakusin H( 2004). A clinical radiographic retrospective assessment of the success rate of single-visit root canal treatment .Int Endod J 37:70-82.

Figini L, Lodi G, Gorni F, Gagliani M(2008). Single versus multiple visits for endodontic treatment of permanent teeth: a Cochrane systematic review. J Endod. 34(9):1041-7.

Fox J, Atkinson JS, Dinin AP, Greenfield E, Hechtman E, Reeman CA, Salkind M, Todaro CJ(1970). Incidence of pain following one-visit endodontic treatment. Oral Surg Oral Med Oral Pathol. (1):123-30.

Gagliani M, Figini L, Lodi G, Gorni F (2008). Single Versus Multiple Visits for Endodontic Treatment of Permanent Teeth: A Cochrane Systematic Review. Journal of Endodontics 34, 9: 1041-104.

Imura N, Zuolo ML(1995) Factors associated with endodontic flareups: a prospective study. Int Endod J, 28:261-5.

Jacob S (2006), Single Visit endodontic Famdent practical dentistry handbook 6:1-6

Kvist T, Molander A, Dahlen G, Reit C ( 2004) Microbiological evaluation of one and two-visit endodontic treatment of teeth with apical periodontitis: a randomized clinical trial. J Endod 30:572-6.

Lin LM, Lin J, Rosenberg PA(2007). One-appointment endodontic therapy:Biologic considerations J Am Dent Assoc 138(11):1456-62

Oginni AO, Udoye CI(2004) Endodontic flare-ups: Comparison of incidence between single and multiple visit procedures in patients attending a Nigerian teaching hospital BMC Oral Health, 4:1-6

Oliet S (1983) Single-visit Endodontics: A Clinical Study.JOE 4:147-152

Pekruhn RB (1986). The incidence of failure following single-visit endodontic therapy.J Endod 12(2):68-72.

Pekruhn RB (1981). Single-visit endodontic therapy: a preliminary clinical study. J Am Dent Assoc.103 :875-7.

Penesis VA,Fitzgerald PI, Fayad MI, Wenckus CS, BeGole EA, Johnson BR(2008) Outcome of One-visit and Two-visit Endodontic Treatment of Necrotic Teeth with Apical Periodontitis: A Randomized Controlled Trial with One-year Evaluation JOE 34 :251-257

Peters LB, Wesselink PR(2002) Periapical healing of endodontically treated teeth in one and two visits obturated in the presence or absence of detectable microorganisms.Int Endod J 35:660-7.

Roane JB, Dryden JA, Grimes EW (1983). Incidence of postoperative pain after single and multiple-visit endodontic procedures. Oral Surg Oral Med Oral Pathol. 55(1):68-72.

Rudner WL, Oliet S (1981).Single-visit endodontics: a concept and a clinical study. Compend Contin Educ Dent. 2(2):63-8.

Sathorn C, Parashos P & Messer HH (2005) .Effectiveness of single versus multiple-visit endodontic treatment of teeth with apical periodontitis: a symptomatic review and meta-analysis. IEJ 38: 347–355

Sathorn C, Parashos P, Messer HH (2006). Single-visit more effective than multiple-visit root canal treatment? Evidence-Based Dentistry 7, 13–14.

Siqueira JJ, Barnett F (2004). Interappointment pain: mechanisms, diagnosis, and treatment. Endod Topics 7:93-109.

Sjögren U, Figdor D , Persson S, Sundqvist G(1997). Influence of infection at the time of root filling on the outcome of endodontic treatment of teeth with apical periodontitis. International Endodontic Journal 30, 297–306

Soltanoff W, Montclair NJ (1978) A Comparative Study of the Single-Visit and the Multiple-Visit Endodontic Procedure. JOE 4:278-281

Trope M (1991). Flare-up rate of single-visit endodontics. Int Endod J 24(1):24-6.

Trope M, Delano EO, Orstavik D (1999). Endodontic treatment of teeth with apical periodontitis: single vs. multivisit treatment.J Endod 25:345-50.

Walton R, Fouad A (1992) Endodontic interappointment flare-ups: a prospective study of incidence and related factors. J Endod\, 18:172-7.

Weiger R, Rosendahl R, Lost C(2000) Influence of calcium hydroxide intracanal dressings on the prognosis of teeth with endodontically induced periapical lesions. Int Endod J 33:219-26.


Dr. Deepa Vinoth kumar, Senior lecturer, Dept of Conservative Dentistry and Endodontics,Rajah Muthiah Dental College, Annamalai University,Chidambaram. Tamil [email protected]


INTRODUCTION

Mucocele is a clinical term that applies to mucous extravasation phenomenon(MEP) and mucus retention cyst(MRC).Each has a distinctive pathogenesis and microscopy, they are considered separately.

MUCUS EXTRAVASATION PHENOMENON

Etiology of MEP is traumatic severance of a salivary gland excretory duct, resulting in mucus escape, or extravasation , into surrounding connective tissue.

Clinical feature shows that lower lip is the most common site, but buccal mucosa, anterior ventral surface of the tongue, floor of the mouth and retromolar region are often affected. Lesions are uncommonly found in other intraoral regions where salivary glands are located, probably because of a lower susceptibility to trauma. It presents as relatively painless smooth surfaced mass ranging in size from few millimeters to 2 cm in diameter. It has a bluish color when mucin is superficially located. Adolescents and children are more commonly affected

1_4than adults.

Superficial mucocele is a variant of extravasation type. It is believed to arise as a result of increased pressure in the outer most part of the excretory duct. These lesions are asymptomatic and numerous, occurring most commonly in the retromolar area, soft palate and posterior buccal mucosa. Their clinical appearance suggests a

ABSTRACT:

Mucocele is a common lesion of the oral mucosa that results from an alteration of minor salivary glands due to a mucous accumulation. Mucocele involves mucin accumulation causing limited swelling. Two histological types exist – extravasation and retention. Mucoceles can appear at any site of the oral mucosa where minor salivary glands are present. Diagnosis is principally clinical; therefore, the anamnesis should be carried out correctly, looking for previous trauma. The most common location of the extravasation mucocele is the lower lip, while retention mucoceles can be found at any other site. Mucoceles can affect the general population,but most commonly young patients (20-30years old). Clinically they consist of a soft, bluish and transparent cystic swelling which normally resolves spontaneously. Treatment frequently involves surgical removal. Nevertheless micromarsupialization, cryosurgery, steroid injections and CO2 laser are also described.

We felt it would be interesting to present two different clinical characteristics of mucoceles,as it is common lesion. It would be clinically significant for their treatment and evolution in order to aid decision-making in daily clinical practice.

vesiculobullous disease, but the lesions persist for 5extended time.

Histopathology reveals that extravasation mucoceles

undergo three evolutionary phases. In the first phase,

mucous spills diffusely from the excretory duct into

connective tissues where some leucocytes and

histiocytes are found. Granulomas appear during the

resorption phase due to histocytes, macrophages and

giant multinucleated cells associated with a foreign body

reaction. In the final phase connective tissue cells form a 6,7pseudocapsule without epithelium around the mucosa.

MUCUS RETENTION CYST (MRC)

Etiology of MRC is due to obstruction of salivary flow

because of a sialolith, periductal scar, or impinging

tumour.

Clinical feature shows that MRC is less common than

MEP.It usually appears in an older age group and is most

commonly seen in the upper lip, palate, cheek, and floor

of the mouth. Lesions present as asymptomatic swellings,

usually without antecedent trauma. They vary in size

from 3 to 10 mm and on palpation swelling is mobile and

non tender. The overlying mucosa is intact and of normal

color. Mucin in floor of mouth lesions may penetrate

musculature and escape into the soft tissues of the neck, 8causing a ‘plunging ranula’.

COMMON AND UNCOMMON FORM OF ORAL MUCOCELE 1 2Dr. Sudhaa Mani MDS , Dr.Eswaramurthy BDS

Keywords: Mucocele, mucocele treatment, Minor salivary Glands

1. Department of Oral Medicine & Radiology, Reader, Vivekanandha Dental college for women, Tiruchengodu.2. Kannan Dental Clinic, 658,Sathy Main Road, Masjid Building, Kavindapadi, Bhavani tk, Erode dt


Histopathology reveals that cyst like cavity is formed lined by normal but compressed ductal epithelial cells. cyst lumen contains inspissated mucin or a calcified sialolith. The connective tissue around the lesion is minimally inflamed, although the associated gland shows obstructive change.

DIAGNOSIS

Diagnosis is principally clinical; therefore, the anamnesis should be carried out correctly, looking for previous trauma. The appearance of mucoceles is pathognomonic and the following data are crucial: lesion location, history of trauma, rapid appearance, variations in size, bluish colour and the consistency .

DIFFERENTIAL DIAGNOSIS

Palpation can be helpful for a correct differential diagnosis. Lipomas and tumors of minor salivary glands present no fluctuation while cysts, mucoceles, abscess and hemangiomas do. Mucoceles are mobile lesions with soft and elastic consistency depending on how much tissue is present over the lesion .Despite this fluctuation, a drained mucocele would not fluctuate and a chronic mucocele with a developed fibrosis would have less fluctuation. A simple technique known as fine needle aspiration biopsy (FNAB) is very helpful, especially when differential diagnosis of angiomatous lesions is involved. Abundant mucosa without epithelial components is found within mucoceles as well as many inflammatory cells, especially histiocytes. A histopathologic study is crucial to confirm the diagnosis and to ensure that glandular tissue is completely removed. Two types of mucoceles exist: retention mucoceles and extravasation mucoceles. In the case of retention mucoceles a cyst cavity can be found, this is generally well defined with an epithelial wall covered with a row of cuboidal or flat cells produced from the excretory duct of the salivary glands. Compared to extravasation mucoceles, retention mucoceles show no inflammatory reaction and are true cysts with an epithelial covering Extravasation mucoceles are pseudocysts without defined walls. The extravasated mucous is surrounded by a layer of inflammatory cells and then by a reactive granulation tissue made up of fibroblasts caused by an immune reaction. Eventhough there is no epithelial covering around the mucosa, this is

9,10well encapsulated by the granulation tissue.

TREATMENT

Some mucoceles spontaneously resolve on their own after a short time. Others are chronic and require surgical removal. Recurrence may occur, and thus the adjacent salivary gland is excised as a preventive measure. Small mucoceles can be removed completely with the marginal glandular tissue before suture. In the case of larger

mucoceles, marsupialization would avoid damage to vital structures. 10 Clinically there is no difference between both types of mucocele, and are therefore treated in the same manner. Nevertheless when an obstruction of retention mucoceles is detected treatment involves the removing the top of the cyst and introducing a lacrimal catheter into the duct to dilate it .A non-surgical option that may be effective for a small or newly identified mucocele is to rinse the mouth thoroughly with salt water (one tablespoon of salt per cup) four to six times a day for a few days. This may draw out the fluid trapped underneath the skin without further damaging the surrounding tissue.

CASE REPORT 1:

A 60 year old female reported to the dental clinic with the chief complaint of swelling in the upper lip for the past 5 years.(FIG 1) History reveals swelling initially smaller in size and gradually increases in its size. It was painless and completely asymptomatic. she reveals that application of salt over swelling and by compressing it, there was expulsion of fluid which results in decrease in size of swelling. After few days there was again increase in size of swelling.

On examination , swelling situated over inner aspect of midline of upper lip. It measures about 2cm in size. Surface appears smooth and normal in colour. On palpation it is nontender. Consistency varies from fluctuant to firmness in few areas . It is freely mobile.

Hard tissue examination reveals there was fractured 11&21.

Provisionally diagnosed as mucocele based on history of painless swelling, repeated collapse and refilling of fluid. Furthermore on fine needle aspiration cystic fluid was aspirated (FIG 2). Treatment includes aspiration which results in shrinkage of swelling. Later vertical incision was done and the fibrosed tissue completely excised along with glandular structures.

Histopathological examination of excised tissue shows extravasation of free mucin with an inflammatory response that is followed by connective tissue repair. Neutrophils and macrophages are seen and granulation tissue forms around the mucin pool. Based on these investigations final diagnosis of mucus extravasation phenomenon was made. Patient was recalled after a week in which complete healing of the lesion observed (FIG 3)

CASE REPORT 2 :

A 40 year old female complains of swelling over left inner side of cheek mucosa for past 6 months. History reveals it was painless swelling with gradual increase in size. On


examination ,swelling located over left buccal mucosa. It measures about 1x1 cm. Surface appears as smooth, translucent, pale coloured mocosa with mild pigmentation (FIG 5). Palpation reveals nontender and consistency as soft and fluctuant. Provisionally diagnosed as mucocele .

Under local anaesthesia complete surgical excision and suturing was done (FIG6). The removed mucous plug (FIG7) was subjected to histopathological examination. Microscopic examination reveals the extravasated mucous is surrounded by a layer of inflammatory cells and then by a reactive granulation tissue made up of fibroblasts. Final diagnosis of mucous extravasation cyst was given.

DISCUSSION

Clinical significance of discussing this common lesion is to emphasize the unique clinical presentation of first case report. Commonly the presentation of MEP's site of occurrence is lower lip lateral to midline with age predilection of younger group.

While in this case report 1 location is midline of upper lip and the occurrence of lesion also in older age which is quite uncommon. Further consistency also varies from fluctuant to firm. It signifies that in longer duration mucocele, there would be fibrosis which results in firmness. Hence we Dental surgeons should consider all the above features in ruling out the differential diagnosis of swelling in upper lip. Case report 2 shows common presentation of mucocele.

Fig 1 Swelling in Upper Lip

Fig 2 Shrinkage of Swelling on Aspiration

Fig 3 Follow Up After a Week

Fig 4 Swelling Over Left Buccal Mucosa

Fig 5 Excised Mucous Plug

Fig 6 – Post Operative

Fig 7 Showing Extravasation of free mucin with an inflammatory response that is followed by connective tissue repair.


REFERENCES

1. Baurmash HD. Mucoceles and ranulas. J Oral Maxillofac Surg. 2003;61:369-78.

2. Huang IY, Chen CM, Kao YH, Worthington P. Treatment of mucocele of the lower lip with carbon dioxide laser. J Oral Maxillofac Surg. 2007;65:855-8.

3. Anastassov GE, Haiavy J, Solodnik P, et al. Submandibular gland mucocele: diagnosis and management. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89(2):159-63.

4. Azuma M, Tamatani T, Fukui K, et al. Proteolytic enzymes in salivary extravasation mucoceles. J Oral Pathol Med 1995;24(7): 299-302.

5. Baurmash H:The etiology of superficial oral mucoceles. J Oral Maxillofac Surg 2002;60:237-38.

6. Samer, Terezhatmy & Moore: Mucocele: Quintesscence International: 2004;35(9)766-67.

7. Jinbu Y, Kusama M, Itoh H, et al. Mucocele of the g l ands o f B l and in -Nuhn : c l in i ca l and histopathologic analysis of 26 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003;95(4):467-70.

8. Sugerman PB, Savage NW, Young WG. Mucocele of the anterior salivary glands: Report of 8 cases. Oral Surg Oral Med Oral Patho Oral Radiol Endod 2000;90: 478-82.

9. Vander Goten A, Hermans R, Smet Mh, Baert AL. Submandibular gland Mucocele of the extravasation type. Pediatr Radiol 1995;25:366-68.

10. Luiz AC, Hiraki KR, Lemos CA Jr, Hirota SK, Migliari DA. Treatment of painful and recurrent oral mucoceles with a high-potency topical a corticosteroid: a case report. J Oral Maxillofac Surg. 2008;66:1737-9

Corresponding author :Dr. Sudhaa Mani MDS,658, Sathy Main Road, Masjid Building, Kavindapadi, Bhavani tk, Erode dt-638455Mobile No:99427 41216E-Mail:[email protected]


INTRODUCTION:

Trauma, advanced periodontal disease, repeated failure of endodontic treatment, root resorption may inevitably

[1,2]result in loss of a tooth . 1- 16% of trauma results in complete loss of a tooth or tooth avulsion. Maxillary central incisors are the most vulnerable teeth to be avulsed during trauma. Tooth avulsion may occur at any age group but the most common age for permanent

[3]dentition is 8-12 years . A wide range of treatment modalities are available for the management of an avulsed tooth each having its own merits and demerits. The best option has to be chosen according to the age of the patient, socio-economic status, condition of the

[1] adjacent teeth and systemic illness .

First and foremost option to be considered when an anterior tooth is avulsed is replantation of the same, provided the tooth was preserved accordingly, since long storage time would result in inflammatory root resorption

[4]or ankylosis . Conventional removable prosthesis on prime esthetic zone is not preferred for a young patient as the selection of right colour, size and shape of an acrylic tooth and provision of retention clasp is aesthetically less

[1,4]convincing . Fixed partial denture needs adjacent tooth preparation which is not advisable for young age patients

[5] due to higher chances of pulpal exposure . Implant supported prosthesis is not economically feasible for all the patients and systemic disorder may contradict the

[5]procedure .

Composite resin bonded bridge reinforced with wire, using a natural tooth as a pontic is an immediate, cost effective simple technique to be considered. Using the natural tooth itself as a pontic is esthetically well accepted by the patient as it has its own advantages of providing the right size, shape, colour and psychological benefit to the

[6]patient .

ABSTRACT:

A spectrum of treatment modalities are available for the replacement of missing tooth, the options expands from replacement with conventional removable prosthesis to titanium based implant prosthesis. When the loss of anterior tooth occurs in younger age group then choosing the right treatment modality, with minimal or no adjacent tooth preparation, immediate restoration of esthetics and cost effective management to a patient is quite challenging to any dental practitioner. Aim of this paper is to describe the treatment performed in a 12 year old boy for whom the clinical crown of his avulsed right maxillary central incisor was used as a pontic and this procedure was advocated over other replacement procedures.

CASE REPORT:

A 12 year old boy reported to our dental office with a

chief complaint of avulsed maxillary right central incisor.

Patient had been traumatized by a fall from bicycle before

a month and had fractured his leg apart from this avulsion

injury. He went to a general physician for emergency

management of the fractures wherein they had

immobilized the patient for a month. He also had deep

lacerations in his lower lip during the accident for which

the general physician had placed sutures and had done

the emergency management.

Patient had brought his avulsed tooth when he reported

to our dental office but the tooth was contaminated and

was under dry storage for a month since the time of

avulsion [Figure 1] On clinical examination, the adjacent

anterior teeth 21 and 12 showed positive response to

vitality testing and the soft tissue around the socket was

almost closed and healed [Figure 2]. The occlusion was

normal and no signs of parafunctional habits were

observed. Since patient was so concerned and

apprehensive due to anterior tooth loss, he needed

immediate replacement of the anterior tooth.

A decision was taken against replantation in this case

since the extra oral dry storage time was almost a month

and the soft tissue around the socket had nearly healed.

Fixed partial denture was not indicated considering the

age of the patient as adjacent tooth preparation would be

required which might probably damage the pulp tissue.

Implant was also not indicated considering the age and

poor socio economic status of the patient. In view of all

the above factors it was decided to use the clinical crown

of the avulsed tooth as a natural tooth pontic and splint it

to the adjacent teeth using composite.

INTERIM AND ESTHETIC MANAGEMENT OF AN AVULSED TOOTHDr. S. Leena Sankari M.D.SAssociate professor, Shree Balaji dental college and hospital, Oral pathology.


CLINICAL PROCEDURE:

1. A pre-operative irreversible hydrocolloid impression

(Vignette, Dentsply India) was made for the upper arch

and cast was poured using dental stone [Figure 3].

2. The crown was separated from the root of the avulsed

tooth using diamond disc.

3. After sectioning, the newly created apical opening of

the pulp canal was cleaned and sealed using flowable

composite resin. (Tetric N flow, Ivoclar, Vivadent,

Leichtenstein).

4. A modified ridge lap shape was given to the cervical

area to facilitate cleaning and provide an emergence

profile.

5. Position of the natural tooth pontic was tried and

verified on the cast [Figure 4].

6. For added mechanical retention, grooves were placed

on the lingual aspect of the pontic.

7. A 30 gauge ligature wire was twisted and bonded to the

natural tooth pontic using flowable composite resin

(Tetric N flow, Ivoclar, Vivadent, Leichtenstein) and

appropriate length of the wire necessary to be bonded to

the adjacent abutment teeth was cut [Figure 5and 6].

8. The natural tooth pontic was then tried in the patient’s

mouth and necessary occlusal adjustments were made.

9. The enamel surfaces of the abutment teeth (21 and 12)

were scaled and polished with pumice and thoroughly

rinsed and dried. No mechanical retention was prepared

on the abutment teeth.

10. The lingual enamel surface of the abutment teeth was

etched with 37% ortho phosphoric acid gel for 20

seconds, rinsed and dried.

11. After application of the bonding agent (3M Adper

single bond) and curing, a thin layer of light cured

composite was applied to all etched surfaces and the

ligature wire was slightly embedded in that layer and

cured. Finally a second layer of composite was added to

the lingual side of the ligature wire and light cured.

12. Excess composite resin was removed and occlusal

interferences were again checked during protrusive and

lateral excursions.

13. Finishing and polishing procedures were carried out

using composite finishing discs (Soflex discs, 3M).

[Figure 7].

14. Oral hygiene instructions were given to the patient.

15. First recall appointment was made a week later.

The patient was highly motivated by the esthetic result

[Figure 8].

Avulsed tooth 11 Pre treatment view

Pre treatment model Trial fit of the pontic in the model after root resection

Natural tooth pontic with twisted wire bonded to it

– labial view

Natural tooth pontic with twisted wire bonded to

it-palatal view

Post treatment view


DISCUSSION:

Loss of permanent anterior tooth compromises speech and esthetics, impairs personality, affects mastication and

[4]encourages tongue thrusting. Boys show a higher prevalence of avulsion injuries as compared to girls in the ratio of 3:1, probably because of more outdoor sports

[7]related trauma. The immediate treatment for avulsion is replantation and stabilization in its anatomically correct location to optimize healing of the periodontal ligament and neuro-vascular supply while maintaining esthetic and functional integrity. At times replantation is contraindicated due to the child's dental development stage (risk of ankylosis where considerable alveolar growth has to take place), compromised medical condition and compromised integrity of the avulsed tooth

[8]or supporting tissues.

Replantation upto 60 minutes of extra oral dry times, of avulsed immature teeth has been reported where only

[7] 15% showed evidence of periodontal healing. But with extra oral dry times of more than 1 hour it is unwise to replant the tooth because of an increased incidence of replacement resorption. The immediate treatment that can be provided to the patient or trauma related tooth avulsion is in the form of a space maintainer. Failure to do so can lead to drifting of the adjacent teeth, midline deviation and space loss apart from over eruption of antagonistic teeth. Mastication, speech and esthetics

[7]also get compromised.

The space loss following dental avulsion can be bridged by a removable partial denture, but it may be bulky and

[9] uncomfortable for the patient, and may impede healing.They also have the disadvantage of being more dependent on patient compliance and can get lost or

[7] broken. More permanent solutions in the form of fixed partial dentures or cast partial dentures are available which are not cost effective and also are not ideal as the abutment teeth available are not best suited to receive

[6]these prosthesis. A composite resin bonded bridge reinforced with wire, using a natural tooth pontic is a cost effective, simple and easy technique providing the best esthetically acceptable immediate result. Using the natural tooth itself as a pontic has varied advantages of being in the right size, shape and most importantly of the same colour. The psychological benefit on the patient of using own tooth as a pontic is of great value and

[6]advantage.

CONCLUSION:

In our case considering all the above factors it was decided to use the patient’s natural tooth as pontic and retention was obtained by bonding it to the adjacent tooth using a ligature wire which will serve as an interim

prosthesis. A fixed bridge or an implant could be designed later on. This paper thus highlights an esthetic, fixed and interim solution to an avulsed tooth in children where replantation and other mode of treatment are considered undesirable.

REFERENCE:

1. Parolia A, Shenoy KM, Thomas MS, Mohan M. Use of a natural tooth crown as a pontic following cervical root fracture: a case report. Aust endod J 2010; 36:35-38.

2. Reddy R, Reddy S. Natural tooth as a pontic, a long term provisional fixed partial denture using a fibre reinforced composites over an integrated implants: case report. Andhra Pradesh State dental journal 2010;3(3):98-100.

3. Lee JY, Vann WF, Sigurdsson A. Management of avulsed permanent incisors: A decision analysis based on changing concepts. American academy of pediatric dentistry 2001; 23(3): 357-360.

4. Ulusoy AT, Cehreli ZC. Provisional use of a natural tooth crown following failure of replantation: a case report. Dental traumatology 2008; 24:96-99.

5. Kermanshah H, Motevasselian F. Immediate tooth replacement using fibre-reinforced composite and natural tooth pontic. Operative dentistry 2010; 35(2); 238-245.

6. Reddy MN, Mehta DS. Natural tooth pontic for periodontally compromised anterior teeth. Andhra Pradesh State dental journal 2010; 3(3):125-127.

7. Sharma U,Garg AK ,Gauba K.An interim fixed prosthesis using natural tooth crown as pon t i c .Con tempora ry C l in ica l Den t i s t ry 2010;1(2):130-132.

8. Guidelines for the management of traumatic dental injuries II:Avulsion of permanent teeth. Dental traumatology .2007; 23(2):66-71.

9. Kretzschmar JL. The natural tooth pontic: a temporary solution for a difficult esthetic situation. J am Dent Assoc 2001; 132: 1552-1553.


Dr.S.Leena Sankari M.D.SAssociate professorShree Balaji dental college and hospitalOral pathologyTamilnadu, India.Email: [email protected],


INTRODUCTION:

Periodontitis is considered to be the most frequent oral disease. Microorganisms and products of their metabolism are responsible for its development, and for the destruction of the supportive apparatus of the tooth. From the large number of the bacteria dwelling in the biofilm on the tooth surface, Porphyromonas and Prevotella (previously black pigmented Bacteroides species), Bacteroides forsythus and Actinobacillus actinomycetemcomitans have been emphasized because

(1)of their pathogenic influence on the periodontal tissue . The microorganisms of the dental plaque, and their metabolic product may - especially in advanced cases of the disease - enter the blood stream during mastication or therapeutical procedures. The consequences may occur in the most distant organs, which is the case in the development of sub acute endocarditis, some respiratory diseases (pneumonia, emphysema, and chronic obstructive pulmonary disease), coronary heart disease, atherosclerosis and ischemic stroke, and diabetic glycemic control changes.

EFFECT ON RESPIRATORY DISEASE:

Bacteria that reproduce in the mouth can also be carried into the airways in the throat and lungs, increasing the risks for respiratory diseases and worsening chronic lung conditions, such as emphysema.

As early as 1968 Potter et al. described the presence of dental diseases in subjects with pulmonary diseases. Oral bacteria can enter the lower respiratory tract by aspiration and cause pneumonia. Severe infections of the lungs can develop after aspiration of salivary secretion, especially

ABSTRACT:

When putatative periodontal bacteria from the mouth and throat are inhaled into the lower respiratory tract, they can cause infection or make existing conditions - such as chronic obstructive pulmonary disease, emphysema etc. Literature suggests PD sufferers have elevated levels of bacteria, including gram-negative enteric species and Psuedomonas aeruginosa. In fact, scientists estimate the prevalence of certain microorganisms - staphylococci, Enterobacteriaceae, and yeasts - in dental plaque at upwards of 77 percent. Some are particularly difficult to eradicate, remaining in patients with PD following antibiotic treatment. Any bacterial presence, in turn, places individuals at higher risk for developing disorders like pneumonia. This life-threatening infection affects patients of all ages, but particularly the elderly and immunocompromised individuals.

This article provides the biologic basis for the connection between periodontal disease and respiratory disease.

1 2Dr. P.l. Ravishankar , Dr. S. Rajsekhar

1. Professor & HOD, Dept of Periodontics, Sri Sai Dental College & Research Institute, Srikakulam (AP)2. Professor, Dept of Periodontics, Rajah Muthaih Dental College & Hospital, Chidambaram.

PERIODONTAL DISEASE AND RESPIRATORY INFECTION- A LINK

Keywords: Periodontal disease,COPD,oral systemic relation.

in patients with periodontitis. 30 to 40 % of aspiration pneumonia, predominantly necrotizing pneumonia or lung abscesses, has anaerobes in etiology, the most frequent organisms being Proteus gingivalis (PG), Bacteroides oralis, Eikenella corrodens, Fusobacterium nucleatum, Actinobacillus actinomycetemcomitans, Peptostreptococcus and Clostridium. It is possible that even Streptococcus viridans plays a role in the development and/or progression of pneumonia.

Bacterial respiratory infections are thought to be acquired through aspiration (inhaling) of fine droplets from the mouth and throat into the lungs. These droplets contain germs that can breed and multiply within the lungs to cause damage. Recent research suggests that bacteria found in the throat, as well as bacteria found in the mouth, can be drawn into the lower respiratory tract. This can cause infections or worsen existing lung conditions. People with respiratory diseases, such as chronic obstructive pulmonary disease, typically suffer from reduced protective systems, making it difficult to eliminate bacteria from the lungs.

Scientists have found that bacteria that grow in the oral cavity can be aspirated into the lung to cause respiratory diseases such as pneumonia, especially in people with periodontal disease. This discovery leads researchers to believe that these respiratory bacteria can travel from the oral cavity into the lungs to cause infection.

Chronic obstructive pulmonary diseases (COPD) cause persistent obstruction of the airways. The main cause of this disease is thought to be long-term smoking. Chemicals from smoke or air pollution irritate the airways to cause obstruction. Further damage to the tissue and


working function of the lungs can be prevented, but already damaged tissue cannot be restored - untreated or undetected COPD can result in irreversible damage. Scientists believe that through the aspiration process, bacteria can cause frequent bouts of infection in patients with COPD. Studies are now in progress to learn to what extent oral hygiene and periodontal disease may be associated with more frequents bouts of respiratory disease in COPD patients.

Biologically credible Mechanisms:

Several biologically plausible mechanisms have been put forth to explain how periodontitis can lead to respiratory disease. Salivary enzyme activity is increased in periodontitis and can promote the adhesion of pathogenic bacteria to the oral surfaces, thereby altering

8,26oropharyngeal colonization patterns . In addition, oral bacteria involved in periodontitis can stimulate oral tissues and periodontium to release cytokines, which are proteins involved in cellular interactions and immune responses. These cytokines can promote adhesion of respiratory pathogens to mucosal surfaces, thereby leading to oropharyngeal colonization.

Periodontitis may also affect pathogen adhesion to respiratory epithelium. In vitro studies indicate that the presence of Streptococcus gordonii, a key bacteria in dental plaque formation, enhances the ability of pathogens such as H. influenza to adhere to respiratory epithelial cells. In response to bacterial adhesion, respiratory epithelial cells may release cytokines and attract neutrophils, which in turn release proteolytic enzymes that damage the epithelium and increase its susceptibility to infection. In addition, cytokines released from inflamed periodontal tissues may enter the respiratory tract in aspirated saliva, triggering the same sequence of events, including neutrophil recruitment,

(2)epithelial damage, and infection .

There are a number of other possible mechanisms in the influence of bacteria on the pathogenesis of respiratory diseases:

• Aspiration of oral pathogens (PG or AA, for example).

• Alteration of the mucous surface by salivary enzymes in periodontitis, leading to an increase in adhesion and colonization of respiratory pathogens.

• Periodontal disease-associated enzymes may destroy salivary pellicles on pathogenic bacteria.

• Alteration of respiratory epithelium by cytokines from periodontal disease facilitating the infection of the

(3,4)epithelium with respiratory pathogens .

CONCLUSION:

Poor oral hygiene leads to an increase in the mass and complexity of dental bacterial plaque. Periodontitis can result and may complicate subsequent efforts to improve oral hygiene. In susceptible patients such as those who are debilitated, hospitalized, or residing in long-term care facilities, this increased bacterial burden may increase the risk of pneumonia and may also play a role in exacerbation or progression of COPD. Improving oral hygiene and treating the periodontal disease could decrease oropharyngeal colonization by pathogenic bacteria and thereby reduce the significant costs, morbidity, and mortality associated with serious respiratory infections in vulnerable patients. Dentists are more often able to contribute to the improvement and maintenance of general health of their patients. New, evidence-based, advances in periodontology, and in general medical specialties, clearly show a relationship between oral and systemic diseases.

REFRENCES:

1. Mojon P. Oral health and respiratory infection. J Can Dent Assoc. 2002;68:340-345.

2.. Russell SL, Boylan RJ, Kaslick RS, et al. Respiratory pathogen colonization of the dental plaque of institutionalized elders. Spec Care Dentist. 1999;19:128-134

3. Scannapieco FA. Role of oral bacteria in respiratory infection. J Periodontol. 1999;70:793-802.

4. www.perio.org


Dr. S. RajsekharProfessor, Dept Of Periodontics,

Rajah Muthaih Dental College&hospital,

Chidambaram.


INTRODUCTION

Periodontal diseases are considered to be as old as the history of mankind1. The earliest evidence of periodontal disease is dated back to the ancient Egyptian and Middle Eastern world, where there are skeletal and written

2records . However, methodical or therapeutic approaches did not exist until the middle ages and modern treatment with a scientific base and sophisticated

1instrumentation did not develop until the 18th century . Before the 1950s diseases pertaining to the teeth were treated by root debridement and extraction of the affected teeth. Prior to the 1970s the symptoms of periodontal diseases were treated with the goal of radical elimination of the periodontal pocket. The procedures done were gingivectomy, flap procedures and osseous surgery. The control of subgingival infection by means of scaling and root planning with or without antibiotics was followed in the 1980s. At present it is expected that the clinicians will be met with new possibilities as a paradigm shift is inevitable for periodontal practice in the new millennium. This strongly suggests that by the end of the first quarter of the twenty-first century, local delivery of antimicrobials, growth and differentiation factors, and root biomodification agents will have a major impact on

13the practice of periodontics . The history of implant dentistry spans not only decades, but millennia. The ancient cultures of the world in Egypt, Honduras, China, and Turkey, among others substituted missing dentition with shells, stones, ivory, and other human or animal

15teeth . The establishment of metal replacements for teeth is a relatively recent development. Researchers also suggest that lasers could be applied for dental treatments including periodontal, restorative and surgical

16treatments . Another fascinating technique of periodontal microsurgery is an evolution of surgical

17procedures to permit reduced trauma . The application of plastic surgical principles to periodontal tissues comprises the field of periodontal plastic surgery. It has progressed to become an inevitable part of periodontal practice.

HISTORY OF PERIODONTOLOGY

2The time periods of the evolution of periodontics are

1. The prehistoric era and early Civilizations

2. Classical and medieval ages

3. The Middle Ages

1Dr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)

1. Tutor, Department of Periodontics, Sathyabama University, Dental College & Hospital, Chennai - 600119.

MILESTONES IN PERIODONTICS

4. The Modern Era

5. The Nineteenth century

6. The Twentieth century

The Prehistoric Era and the Early Middle Eastern & Egyptian Civilizations

Evidence of chronic periodontal disease and chronic abscess has been found in the extensive paleolithic material available. Babylonian and Assyrian medicine comes from the clay tablets of the great library of Ashurbanipal (king of Assyria) which includes a number of remedies for periodontal disease. One such remedy was that if a man’s teeth were loose and itchy, a mixture of myrrh, asafoetida and opopanax as well as pine-turpentine shall be rubbed on his teeth until blood comes

2forth and he would recover .

Ancient Egyptians are known for the first artistic drawings that emphasize the importance of beauty and hygiene. In addition to the practice of bathing in oils, the Egyptians used many products to freshen their breath. They chewed sodium carbonate or rinsed their mouth with honey and water to which goose fat, frankincense, cumin, and ocher

4had been added .

The medical treatises of ancient Egypt were recorded on papyrus and they were mostly based on magic and

2religion . The papyrus on the primary surgical treatise was the Edwin Smith Papyrus. A prescription to strengthen the periodontally diseased teeth was one part each of powdered flint stones, green lead and honey rubbed on the teeth. Hesy-Re, an Egyptian scribe, was often called the first dentist. In ancient India during the Brahman period of Indian medicine Susruta Samhita and Charaka Samhita described gum disease and its treatment. Susruta described how the gums of the teeth swell, become

5putrefied, slimy and emit a fetid smell . He has also devoted a section to proper tooth brushing and the use of mouthwashes to cleanse the tongue. Charaka’s work was devoted to oral hygiene and the management of oral diseases but it was considered less interesting as it was a mixture of magic and religion.

In China medicine became more sophisticated. They also used various mixtures of herbs and minerals such as

2powder of dried up mouse bone and urine of a child .


They also used chopsticks as toothpicks. A system of dental decoration with jadeite inlays evolved in Mayan civilization which was purely cosmetic and not

20restorative. [Image 1]. Although these led to prevention of caries sometimes many harmful side effects like periapical abscesses developed. During the middle eastern and Mediterranean civilizations they followed the rabbinical laws founded on tradition which was called as the Talmud. According to the Talmud, when a man looses his teeth his nutrition is diminished, and that until 40 years solid food is necessary but after 40 years liquid food is sufficient due to early loss of teeth and inefficient mastication.

The Phoenicians excelled in working with gold. They 2bound loose periodontally involved teeth with gold.

[Image 2]

CLASSICAL AND MEDIEVAL AGES

Aristotle investigated oral disease and talked about the causes of periodontal disease and discussed the nature of occlusion and the shape of teeth. In Rome Celsus offered treatment for a number of periodontal conditions. Oribasius has a number of sections on toothache and gingival inflammation. Haly Abbas recommends methods for cleaning the mouth in Arabian medicine. Avicennas used extensive materia medica for periodontal diseases. Albucasis understood that calculus deposits on the teeth were the major etiologic factors of

2periodontitis . He described in detail the technique of scaling the calculus deposits from the teeth with a set of instruments he developed. [Image 3]

THE MIDDLE AGES

During the Early Middle Ages in Europe medicine, surgery, and dentistry were generally practiced by monks, the most educated people of the period. The Arabic treatises derived their information from Greek medical treatises but added many refinements, particularly in surgical specialities. The Guy de Chauliac offers extensive medicaments for the treatment of various

2diseases of the teeth, gingiva and oral mucosa . Pomegranate juice was considered an excellent astringent mouthwash. Tartar was removed by scalers, since rinses and tooth powders would not have any effect

2upon it.

THE MODERN ERA

2The first dental book was published in German in 1530. Paracelsus developed an engrossing hypothesis of disease and claimed pathologic calcification occurs in a variety of organs due to a metabolic disturbance. Eustachius offered modern treatment for periodontal disease which includes scaling and curettage of granulation tissue to allow reattachment of the gingival

2and periodontal tissues.

THE RENAISSANCE

Dentistry made little progress in the 17th century. Surgeons and barbers who practiced dentistry were

2considered inferior and self taught. A series of Papal edicts prohibited monks from performing any type of surgery, bloodletting or tooth extraction. Barbers often assisted monks in their surgical ministry because they visited monasteries to shave the heads of monks and the tools of the barber trade were sharp knives and razors that were useful for surgery. After the edicts, barbers assumed the monks’ surgical duties such as bloodletting, lancing abscesses, extracting teeth, etc.

Paracelsus developed an interesting and unusual theory of disease, the doctrine of calculus. Antony van Leeuwenhoek, a tradesman in Holland who learned to grind glasses around 1668 made simple microscopes and observed with them. In 1683 he wrote to the royal society about his observations on the plaque he found between his own teeth, describing that it is a little white matter,

2thick as a batter. He coined the term dental plaque . He also described Oral microbial flora and conducted antiplaque experiments using strong vinegar in his own mouth and in vitro on bacteria in a dish. Antony van Leeuwenhoek and Marcello Malphigi are considered important in the development of sciences that later

2became fundamental to Periodontology .

THE EIGHTEENTH CENTURY

Dentistry in general and periodontics in particular, especially because of Pierre Fauchard went through a period of great progress in this century. According to Pierre Fauchard [Image 4] the severe mouth diseases that sailors suffered, particularly scurvy, has induced him to

6specialize in the treatment of the diseases of the mouth . Fauchard was one who had belief in the local etiology of periodontitis as opposed to the contemporary theory of a systemic causation. He introduced five instruments calling them the rabbit chisel, parrot’s bill, graver with

2three facets, hook like a Z, and a knife . John Hunter portrays the displacement of teeth as a consequence of the loss of adjacent or opposing teeth. He described pocket formation and bone loss. He also differentiated scurvy from other gum diseases.

THE NINETEENTH CENTURY

In the second half of the 19th century the discovery of anesthesia, germ theory of disease and the discovery of x-

5rays had a particular impact on periodontics . Hence periodontal surgical techniques became more complex and sophisticated, not only for solving disease problems but also for esthetics and function.


PERIODONTAL MICROBIOLOGY

In the 1880s the germ theory of disease, proven by Pasteur and Koch, suggested that periodontal disease was also caused by germs. Over time, specific bacterial types, such as Porphyromonas gingivalis, were discovered and shown to be important in the cause of periodontal disease. At the same time, inflammatory mediators, such as prostaglandins and interleukins, and enzymes, such as matrix metalloproteinases, were discovered and found to be important participants in the destruction of

7periodontal tissues .

Adolf Witzel in 1881 presented clinical manifestations of periodontal disease (infectious alveolitis), describing gingival recession, pocket formation, calculus deposits and suppuration. He differentiated bone loss caused by senile atrophy of the alveoli and described treatment for alveolar pyorrhea. Between 1871 - 1907 Miller published his classic book “The microorganisms of the human mouth” and described the features of periodontal disease, considering the role of predisposing factors, irritational factors and bacteria in the etiology of pyorrhea alveolaris.

CLINICAL PERIODONTOLOGY

Leonard Koecker in1821 described inflammatory changes in gingiva following the presence of calculus, which lead to mobility and exfoliation of teeth. The local factors include inordinate use of mercury, irregularities in tooth position and neglect of cleanliness. Levi Spear Parmly (1790-1859) was the father of oral hygiene and

2the inventor of the dental floss . Dental floss is defined as a waxen silken thread which is to be passed through the interstices of the teeth between their necks and the arches of the gum, to dislodge the irritating matter which no brush could remove. John M Riggs is considered as the first Periodontist in history[Image 5]. He described periodontal disease occurring in 4 stages which was

2called Riggs disease .

1st : margin of gingiva

2nd : alveolar border, pockets filled with pus.

3rd : thicker portions of alveolar bone

4th : involved all portions of the alveolar bone and the gingiva

William J Younger in 1897 designed scaling instruments which have been the basis for modern instruments.

THE TWENTIETH CENTURY

Throughout the 20th century, an understanding of the role of causative bacteria and the susceptible host in the initiation and progression of periodontal disease has emerged from the efforts of scientists and clinicians

8worldwide . In 1900, the English physician William

Hunter reported in the British Medical Journal on the topic "Oral Sepsis as a Cause of Disease" blaming poor dental health and conservative dentistry as the cause of the plethora of systemic diseases. The report was based

3on the focal infection theory . A focal infection is a localized or generalized infection caused by dissemination of microorganisms or toxic products from a

3focus of infection . The present evidence for the relationship of oral microorganisms and systemic disease, particularly that of the coronary arteries, is very limited due not only to a dearth of prospective studies and a complete lack of interventional studies but also to very significant methodological difficulties associated with the

3clinical studies that have been performed. Also, the occurrence of metastatic infections from the mouth to distant bodily sites is rare. Hunter and other advocates of the theory were unable to elucidate possible interactive mechanism between oral and systemic health.

Calculus was considered as the consequence and not a cause for pocket formation.

Spirochetes, Fusiform Bacilli & Streptococcus viridians were considered in the search for an etiologic agent for periodontal disease. Morris Karolyi 1901 and Paul R Stillman described traumatic occlusion. Many paradigms concerning the epidemiology, pathogenesis, and systemic impact of periodontal diseases have been modified. For example, bacterial biofilms are essential to induce periodontitis but their mere presence is not

9sufficient to initiate disease . It is also now recognized that the host response to these biofilms causes most of the destruction of the periodontal tissues.

Due to the improvement of facilities in the dental offices during the 20th century gingival changes were detected much easily and the significance was analysed. The periodontal probe, and its use was described by F.V.Simonton in 1925. Simonton insists that the only way to determine the existence and extent of pyorrhea is the measurement of the pockets either instrumentally, roentgenographically or both. Periodontal probe (Periodontometer) was developed by Hanford & Patten. The first use of radiograph for Periodontal diagnosis was by William Herberst robins in December 1896. Atlas documented patterns of bone loss & correlated them to

2clinical findings .

The phase of nonsurgical therapy was developed during 1900 – 1950. The champion of non-surgical therapy is Isador Hirschfeld. Some of the instruments used were Riggs’ set of scalers, William J Younger’s delicate blades and David Smith’s files.

Plaque control techniques were brought forth in the twentieth century. The brushing techniques were explained by Alfred Fones in 1934, Paul R Stillman in 1932, William J Charters in 1935 and Charles C Bass in

21940 .


Periodontal surgery (1900 to 1950): Robert Neumann proposed a surgical flap in 1912. He took radiographs, performed frenotomies, presurgical scaling, provisional splinting, and demonstrated toothbrushing with horizontal strokes. In 1917, Leonard Widman performed surgery to gain access to the root. Olin Kirkland in 1932, performed modified flap operation with Kirkland gingivectomy knives. Henry Goldman in 1942, published a book on periodontology. He performed gingivoplasty by reshaping the gingiva for purpose of attaining a most desirable form and not for pocket eradication. A. W Harlan 1906, performed root coverage of isolated recessions. Fermin Carranza proposed indications for osseous removal.

Hans R Muhlemann described methods to measure tooth mobility, Sulcus bleeding index and introduced the dentifrice. Per-Ingvar Branemark conducted vital microscopy studies of bone marrow in rabbit fistula and demonstrated integration of the titanium chamber and presence of osseointegration after placement of implants. Dahl in 1940 created the subperiosteal implant, a structure that rested on and not in, the jaw. These implants developed complications including infection and bone resorption. Leonard Linkow developed the blade fixture for areas of deficient bone. With time, the blade design fell out of favor as its complication rate precluded its use. In its place came the root form implant,

15 which is the current standard shape.

Image 1– A system of dental decoration with jadeite inlays in Mayan civilization

Courtesy: Concepts of Esthetic Dentistry –

Pathways of the Dentist

Courtesy: www.periocraze.com

Image 3 – Instruments developed by Abulcasis for scaling the calculus deposits from the teeth

Courtesy: Fermin A. Carranza. Carranza’s clinical periodontology 9th edition, 2002

Image 4 – Pierre Fauchard


Image 5 – John riggs


Image 6 – Periodontal microsurgery equipment

Courtesy: Dennis A. Shanelac, Periodontal Microsurgery J Esthet Restor Dent 15: 2003.


RECENT ADVANCES IN PERIODONTICS:

The future of Periodontology can be renamed as the speciality of Periodontal medicine and surgery. Plastic surgery is a clinical discipline in which surgical techniques are employed to reconstruct or repair bodily structures. These may be missing, defective, or damaged through injury or disease. Microsurgery offers new possibilities to improve periodontal care in a variety of ways. Periodontal plastic microsurgery [Image 6] involves correcting gingival recession, restoring the edentulous ridge, establishing an esthetic smile line, and an excellent wound healing after surgical procedures. Its benefits include improved cosmetics, rapid healing,

17minimal discomfort, and enhanced patient acceptance.

The use of lasers for treatment has become a common phenomenon in the medical field. The first laser device was made by Maiman in 1960, based on theories derived

16by Einstein in the early 1900s . Lasers have the advantage of reduced bleeding intraoperatively and less pain postoperatively. Several hard tissue lasers with similar wavelengths are used for cavity preparation and caries

18removal eg Er : YAG, Er : YSGG. The hard tissue procedures done with lasers in periodontics are scaling of root surfaces, calculus removal, osteoplasty and ostectomy [Image 7]. The soft tissue procedures performed in periodontics are soft tissue ablation, sub gingival curettage, photoactivated dye disinfection of periodontal pocket and deepithelialization to assist regeneration and the lasers used are Erbium: Yttrium- aluminium-garnet, Holmium: Yttrium-aluminium-

19garnet .

DISCUSSION AND CONCLUSION

Milestones in Periodontics have evolved from the prehistoric era till date. Evidence of Periodontal disease was found in the prehistoric era and the remedies for the

2same were put forth. The ingredients for freshening the 4breath were formulated many years back. We have been

able to appreciate the binding of loose periodontal teeth 5during the same era.

Another milestone of development occurred in the middle ages, modern era and the renaissance where medicaments were developed for the treatment of teeth, gingival, and oral mucosa. Books were also published. The discovery of microorganisms is discussed and periodontics progressed to a great extent in the

5eighteenth century.

Instruments were developed for scaling and curettage which have been discussed. The dawn of the nineteenth century witnessed the discovery of x-rays, anaesthesia and the development of the germ theory of disease by Pasteur and Koch.

The twentieth century saw the major milestones in periodontics such as the focal infection theory discussed in detail, the development of many instruments surgical techniques by Robert Neumann and the principle of implants, thereby giving an upliftment to the field of

2periodontics.

Further, advanced and recently introduced techniques 16that have been discussed include lasers and periodontal

17microsurgery which focus on esthetics and function that is more acceptable to the patient. As we look back at the milestones of development in periodontics we feel we have come a long way and the urge to discover many such treatment modalities.

A view of the evolution of periodontics has shown a gradual progress from a small beginning to a very advanced stage. But there are many more goals to be achieved which is possible only by having a complete knowledge about the history and evolution of periodontology. The usefulness of the implant trends discussed above is yet to be determined. With time, some of these innovations may become conventions; others will end up as historical sidenotes. Lasers and periodontal

17microsurgery are considered the current trends in periodontal therapy which is widely accepted by the patient. Nevertheless there is a great need to develop an evidence based approach to the use of lasers for the treatment of periodontal diseases, as there is insufficient evidence to suggest that any specific wavelength of laser

19is superior to the traditional modalities of therapy . Advances in the fields of molecular biology, human genetics and stem cell biology have set the stage for

Image 7 - Subgingival scaling done with laser Er : YAG

Courtesy: Dae Hyun Lee, Application of laser in periodontics: A new approach in periodontal treatment, October 2007,

volume 12, No.10.


Corresponding author :1Dr. D. Ida Sibylla BDS, M.Sc., (Neuroscience)

Tutor, Department of Periodontics, Sathyabama University,

Dental College & Hospital, Chennai - 600119.

e-mail : [email protected]

Cell : 9940266853

significant discoveries that will pave the way for the development of procedures needed for the predictable

10regeneration of periodontal tissues .

BIBLIOGRAPHY

1. Yilmaz et al, the evolution of clinical periodontal therapy, J Marmara university, 1994 sept 2(1): 414 – 23

2. The history of periodontology downloaded from www.periocraze.com.

3. Thomas j. pallasch, DDS, MS and Michael J wahl DDS, the focal infection theory: appraisal and reappraisal, 2000 journal of the California dental association.

4. The evolution of mouthwash

5. Saxen l proc Historical background of periodontology finn dent soc, 1986:82(3): 152-62.

6. Muroff F the rationale of periodontal therapy Mcgill Dent Rev 1969 Jan – feb:31(2):28-30.

7. Williams RC, understanding and managing periodontal diseases: a notable past, a promising future, J periodontology 2008 Aug: 79(8 suppl): 1552-9.

8. Williams RC: a century of progress in understanding periodontal disease, compend contin educ Dec 2002 (5 suppl): 3 – 10.

9. Greenstein G and Lamster, Changing periodontal paradigms therapeutic implications. Int J periodontics and restorative dentistry 2000 Aug 20(4): 336 – 57

10. Armitage GC and Robertson PB, the biology, prevention, diagnosis and treatment of periodontal diseases: scientific advances in the united states. Journal of American dental association 2009 sept 140, suppl1: 36s-43s.

11. Tonetti MS, advances in periodontology. Prim dental care 2000 oct: 7(4):149-52.

12. Anjus chiedozic, ehow contributor, the history of periodontics.

13. Vandersall DC, Periodontics in the new millennium. Dent clin North America 1998 July: 42(3) : 543-60

14. Fermin A. Carranza. Carranza’s clinical periodontology 9th edition, 2002

15. Michael Sonick, Implant Dentistry: Evolution and Current Trends, Inside dentistry, October 2006, volume 2, issue 6

16. Dae-hyun Lee Application of laser in periodontics: A new approach in periodontal treatment, October 2007, volume 12, No.10.

17. Dennis A. Shanelac, Periodontal Microsurgery J Esthet Restor Dent 15:XXX–XXX, 2003.

18. L J Walsh, The current status of laser applications in dentistry, Australian dental Journal 2003; 48: (3): 146-155.

19. Charles M. Cobb Lasers in periodontics: A review of the literature. Journal of periodontology; vol.77, No.4

20. Courtesy : Pathways of the Dentist – Concepts of esthetic dentistry


INTRODUCTION:

The basic complaints by patients in day to day dental practice are bleeding gums bad breath, gaps between teeth, loose tooth, and tooth or root sensitivity. Most patients are apprehensive about visiting a dentist either due to some previous bad experience or transferred fear from others. The most common misconceptions associated with periodontal treatment and which are naively believed and cited by patients as the reason for not availing treatment and spread to others are :-

A. Teeth become weak and irregular after dental scaling or cleaning

B. The teeth become mobile and sensitive with regular cleaning

C. Teeth develop gaps due to cleaning

D. Dental treatment or intervention causes tooth loss

These results from lack of knowledge about the disease, importance of oral hygiene, treatment and complications if any. Thorough examination, which marks the main forte of proper diagnosis along with treatment planning, patient education and regular patient follow up forms the four pillars of successful management of the periodontal disease.

Patient education and motivation and thereby the patient compliance are critical for successful periodontal management. The Practitioner’s role in achieving the above is crucial.

DIAGNOSIS:

Patients should be thoroughly examined after taking a detailed history. Routine dental education as to nature and progression of the diagnosed periodontal disease along with treatment planning must be given to the

ABSTRACT:

Pemphigus vulgaris (PV) is a chronic autoimmune intraepithelial blistering disease. PV almost always affects the mouth and it can be the initial site of presentation in about 40% to 50% of cases, before skin and other mucosal sites (esophagus, pharynx, larynx, nasal and genital) become involved. The blister break to form large denuded areas of skin which can prove fatal if extensive areas are involved. Early recognition of this lesion may prevent delayed diagnosis and inappropriate treatment of a potentially fatal chronic dermatological condition.

1. Senior lecturer 2. Professor & Head of Department 3. Reader 4. LecturerDepartment Of Periodontology, Sathyabama University Dental College And Hospital, Chennai

PATIENT-FRIENDLY APPROACH TO THE MANAGEMENT OF PERIODONTAL DISEASE

1 2 3 4Dr. M. Vijayalakshmi, Dr. Gayathri. S , Dr. M. G. Krishna Baba , Dr. Sumathi. H. Rao , Dr. T. Geetha

Keywords: Desmoglein, auto-antibodies, corticosteroid.

patient. The patient should know what he is suffering from and why; what treatment he has to undergo, what he can expect during and after treatment, the prognosis, number of sittings and cost. This is essential so that patient understands the nature and cause of the disease and also clears any misgivings, will relax and be co-operative during the treatment.

A correlation between the patient’s systemic health and dental health and further its significance is much harped in literature. Physiological conditions such as pregnancy

1which alter the gingival health ,the importance of periodontal care in patients with systemic conditions

2such as diabetes , heart problems pose a challenge to the overall dental treatment. An insight to periodontal medicine and its importance has to be highlighted in relevant cases.

After diagnosis the patient must be told what he /she is suffering from and what is the cause for the disease, how the problem usually started and how it had progressed. What is Biofilm/Plaque needs to be explained with examples so that he/she can understand what he must look for and eliminate while brushing. An explanation about the formation of biofilm, its prevention and its removal after formed will also aid in education.

INFORMATION TO PATIENT

Post-operative sequelae such as possibility of bleeding, developing of gaps between teeth and sensitivity and loosening of teeth and whether the changes are temporary or permanent must be informed and explained. Information about the post-operative care and maintenance must be given and insisted upon.

EDUCATION OF MASSES: The following topics have to explained:-


WHAT IS PERIODONTAL DISEASE?

This question must be answered and explained in simple terms. The role of oral hygiene, local and systemic factors explained in simple terms.

BIOFILM:

Biofilms have been defined as matrix embedded microbial populations, adherent to each other and or to surfaces or interfaces. Biofilms colonize a diverse set of moist surfaces including the oral cavity, bottom of boats and the inside of pipes and drainage as well as rocks in streams. The role of constant moistness and stagnation can be explained with simple examples like the slime layer found on the walls of a glass of water that has been

3left idle for a few days .

Periodontal disease is a biofilm mediated disease and for example Porphyromonasgingivalis is an anaerobic bacterium that resides within the biofilm community in the gingival crevice and is regarded as a major causative agent in the initiation and progression of severe forms of

4this disease .

DENTAL PLAQUE:

Dental plaque which is the biofilm attached to tooth surface as a result of persistent moistness. It is composed mainly of bacteria embedded in a matrix of extracellular bacterial polymers and salivary or gingival exudate products. It is well documented that accumulation of bacterial plaque at the gingival margin results in the development of gingivitis and the gingivitis can be reversed with the implementation of oral hygiene

5, 6measures . Some patients with severe loss of attachment may have minimal levels of bacterial plaque on the affected teeth, indicating that the quantity of plaque is not of major importance in the disease process. Thus the importance of the composition or quality of the

WHAT ARE THE COMMON SIGNS AND SYMPTOMS OF PERIODOTNAL DISEASE?

The patient has to be told that he/she may have periodontal disease if they have -

! Bleeding gums when brushing

! Red, swollen puffy looking or tender gums

! Abscess on the gums

! Pus secreting between the teeth and gums

! Shaky teeth

! Teeth appearing to drift apart from its original position

! Receding gum line

! Persistent bad breath

! Vague discomfort or dull ache of gums and teeth

TREATMENT PLANNING:

A thorough case sheet listing the dental status of the patient on day one and the possible treatment suggestions have to be clearly recorded. The patient is made to understand the various treatment modalities and further accept the current trends of treatment.

Proper case reviews are done from time to time to check and reassess the prognosis. The recall of the patient is done periodically and photographs and radiographs are assessed. Patient education pre-operative, and reinforcing the same during, and post the procedure aids in increasing the belief of the patient towards periodontal disease prognosis.

Some patients do not turn up due to relief from their main complaint. Hence constant patient motivation and encouragement of the patient for complete treatment should be stressed for better final outcome of the case. A regular maintenance program of 6-month recalls helps the patient understand the importance of the dental treatment and improves the survival rate of the teeth.

Patient education includes audiovisual aids, pamphlets, instruction sheets, model demonstrations of the brushing, flossing and interdental brushing techniques reiterate the fact the communication in all forms makes dental education simplified for the patient. Post treatment complaints should be handled with care answering every question of the patient and if handled properly these patients come for regular recall and turn out to be brand ambassadors of the treatment.

I N F O R M A T I O N A B O U T P R O G N O S I S T O PATIENT:

WHAT ARE THE BENEFITS OF TREATMENT?

Immediately after scaling and root planing there is a dramatic reduction in microorganisms. Reevaluation of the periodontal case should be carried out at about 4 weeks after completion of the scaling and root planing procedures. This permits time for both epithelial and connective tissue healing and allows the patient time to practice and perfect oral hygiene skills to achieve maximum improvement. Gingival inflammation is usually substantially reduced or eliminated within 3 to 4 weeks after removal of calculus and local irritants. Healing consists of the formation of a long junctional epithelium rather than new connective tissue attachment to the tooth surfaces. The attachment epithelium reappears in 1 to 2 weeks. Gradual reduction in inflammatory cell population, crevicular fluid flow, and repair of connective tissue result in decreased clinical

7signs of inflammation with less redness and swelling .


WHAT WILL HAPPEN IF PAITENT DOES NOT CONTINUE THE TREATMENT?

If gingivitis is not treated it can progress to periodontitis. The gums start to pull away from the teeth and are filled with plaque and become infected. As the plaque spreads and grows beneath the gum line the body immune system fights the bacteria. Bacterial toxins and body enzymes fighting the infection actually starts to break down the bone and connective tissue that hold teeth in place. If left untreated the underlying bone and connective tissue attachment is destroyed. The teeth may eventually become loose and may need removal. Periodontitis can range from mild to moderate to even severe forms.

The prognosis for patients with gingival and periodontal disease is critically dependent on the patient’s attitude; these mainly are, the desire to retain the natural teeth and willingness and ability to maintain good oral hygiene. Without these, treatment cannot succeed. Patients should be clearly informed of the important role they must play for treatment to succeed. If patients are unwilling or unable to perform adequate plaque control and to report for the timely periodic maintenance checkups and treatments that the dentists deems necessary, they can refuse to accept the patient for treatment or extract teeth that have a hopeless or poor prognosis and perform scaling and root planning on the remaining teeth.

The dentist should make it clear to the patient that if the periodontal condition is treatable; the best results are obtained by prompt treatment and patient cooperation. If the condition is not treatable or the patient is not willing for any aspect of the plan, the teeth should be just as promptly extracted.

SUPPORTIVE PERIODONTAL TREATMENT:

This term expresses the essential need for therapeutic measure to support the patient’s own efforts to control the periodontal infections and to avoid re-infection. Like cardiovascular disease and diabetes, periodontal disease is a chronic ailment that has to be closely monitored on an on-going basis. After completion of the active phase of periodontal treatment, a personalized program of supportive periodontal treatment will help the patient maintain periodontal health.

Daily brushing and flossing will keep the formation of calculus to a minimum but would not prevent it completely. Thorough or meticulous plaque control, periodontal maintenance procedures are designed to minimize the recurrence and progression of periodontal disease in patients who have been previously treated for periodontal problems.

Periodontal maintenance is an evaluation geared towards identifying factors that may interfere with oral health. These visits may be scheduled every few weeks or every

8, 9, 10six months . The dentist determines the frequency of the visits, which depends on the severity of the disease, the overall oral health, and the risk factors involved. Most people with a history of periodontal disease start with a three-month supportive periodontal treatment schedule.

After reviewing changes in the medical and dental history, an oral examination will be performed to check for hidden problems which include an oral cancer screening and a thorough periodontal examination. Radiographs may be taken to check for cavities and changes in bone levels. Oral hygiene is evaluated, reviewed and reinforced. Scientific research has proven Supportive Periodontal Treatment will avoid the

11recurrence and progression of periodontal disease .

In short, to conclude, the patient needs to be heard, talked to, be told, made to understand and willingly submit for treatment and maintenance program.

REFERENCES:

1. LoeH:Periodontal changes in pregnancy,J Periodontol 36:209,1965.

2. HirschfeldI :Periodontal symptoms associated with diabetes,J Periodontal 5:37, 1934.

3. Jill S. Nield Gehrig: Foundations of periodontics for the dental hygienist.

4. Haffajee A.D. & SocranskyS.S (1994) Microbial etiological agents of destructive periodontal diseases, Periodontol 2000 5:78, 1994.

5. MariottiA: Dental plaque-induced gingival disease, Ann Periodontol 4:7, 1999.

6. LoeH,TheladeE, Jensen SB: Experimental gingivitis in man JPeriodontol 36:177, 1965.

7. Cobb CM: Non-Surgical pocket therapy – mechanical, Ann Periodontol 1:443, 1996

8. Lindhe J, Nyman S. Long-term maintenance of patients treated for advanced periodontal disease, J ClinPeriodontol1984;11:504-514.

9. Haffajee AD, Socransky SS, Smith C, Dibart S. Relation of baseline microbial parameters to future p e r i o d o n t a l a t t a c h m e n t l o s s . J ClinPeriodontol1991;18: 744-750.

10. Lindhe J, Nyman S. The effect of plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced disease J ClinPeriodontol1975;2:67-79.

11. Cohen RE, Position paper: Periodontal maintenance. J Periodontol 2003;74:1395-1401.


ABSTRACT:

Necrotizing ulcerative gingivitis is one of the relatively common acute lesions involving the oral mucous membrane. It is generally involved in the younger age group. It is destructive and ulcerative lesions of the oral mucous membrane that may be in severe cases extend into the alveolar mucosa and perforate the skin of the cheek.

PATHOPHYSIOLOGY OF ACUTE NECROTIZING ULCERATIVE GINGIVITIS (ANUG) / VINCENT'S INFECTION - A REVIEW

1 2Dr. K. Sasireka M.D.S , Dr. M. Devi M.D.S

1. Professor-Dept of Periodontics, 2. Reader-Dept of Oral Pathology, Adhiparasakthi Dental College and Hospital.

Keywords: Necrotizing ulcerative gingivitis, acute lesions, and oral mucous membrane.

INTRODUCTION

Acute necrotizing ulcerative gingivitis (ANUG) is an inflammatory destructive disease of gingiva that presents characteristic signs and symptoms. It was recognized by Xenophon who mentioned that Greek soldiers were affected with sore mouth and foul smelling breath, hi 1778 John Hunter described the clinical findings of ANUG. hi 1886 Hersch a German pathologist discussed some of the features associated with the disease such as enlarged lymph nodes, fever, malaise and increased salivation. In 1890 Plaut and Vincent described the disease and attributed its origin to fusiform bacilli and spirochetes. It was commonly known as Vincent's

thinfection during the first half of the 20 century, but its current designation is acute necrotisizing ulcerative gingivitis.

CLINICAL FEATURES:

ANUG is characterized by sudden onset, sometimes following an episode of debilitating disease or acute respiratory tract infections. A change in living habits, protracted work without rest and physiological stress are frequent features of patient's history

CLASSIFICATION

• Necrotizing ulcerative gingivitis most often occurs as an acute disease.

• Its relatively mild and more persistent form 'is referred to as sub acute disease

• Recurrent disease is marked by periods of remission and exacerbation

ORAL SIGNS

• Characteristic lesions of ANUG are punched out, crater like depressions at the crest interdental papillae, subsequently extending to the marginal gingival.

• The surface of the gingival craters is covered by a gray, pseudomembranous slough demarcated from the remainder of the gingival mucosa by a pronounced linear erythema.

• In some cases the lesions are denuded of the surface pseudomembrane, exposing the gingival margins which is red,shiny and hemorrhagic.

• The characteristic lesion progressively destroys the gingival and underlying periodontal disease.

• Spontaneous gingival bleeding or pronounced bleeding on the slightest stimulation are the additional characteristics clinical signs.

• Other signs include foteid odour and increased salivation.

• ANUG can occur in otherwise disease free mouths or can be super imposed on chronic gingivitis or periodontal pocket.

ORAL SYMPTOMS

• The lesions are extremely sensitive to touch and patients complain of a constant radiating gnawing type of pain that is intensified by spicy or hot foods and chewing.

• There is metallic foul taste and patient is conscious of an excessive amount of pasty saliva.

EXTRA ORAL AND SYSTEMIC SIGNS AND SYMPTOMS

• Patients are usually ambulatory.

• Local lymphadenopathy and a slight elevation in temperature are common features of the mild and moderate stage of the disease.

• In severe cases there are marked systemic complications such as high fever, increased pulse rate, leucocytosis and loss of appetite and general lassitude.


• Systemic reactions are more severe in children insomnia, constipation, gatrointestinal disorders, headache and mental depression accompany the condition.

CLINICAL COURSE

The clinical course is indefinite if untreated ANUG may result in progressive destruction of the periodontium and denudation of the roots.

HISTOPATHOLOGY

Microscopically the lesion appears as a non specific acute necrotizing inflammation at the gingival margin involving both the stratified squamous epithelium and underlying connective tissue. The surface epithelium is destroyed and replaced by a pseudomembraneous mesh wo rk o f f i b r i n , nec ro t i c ep i t he l i a l c e l l s polymorphonuclear neutrophils (PMNs) and microorganisms.

Bacteria associated with ANUG: Listgarten et al studied the lesions of ANUG under electron microscope and described four zones.

ZONE 1: Bacterial zone - The most superficial zone consists of different bacteria including a few spirochetes of small, medium and large types.

ZONE2: Neutrophil rich zone - This zone contains numerous leucocytes, mainly neutrophils and bacteria including many spirochetes between the leucocytes.

ZONES3: Necrotic zone - The zone consists of disintegrated cells, fibrillar material, remnants of collagen fibers and numerous intermediate as well as the large spirochetes

ZONE4: Spirochetal infiltration - This zone consists of well preserved tissue infiltrated with intermediate and large spirochetes

PREDISPOSING FACTORS OF ANUG

• Preexisting periodontal disease

• Smoking

• Nutritional deficiency

• Psychosomatic factors

PREVALENCE OF ANUG

Epidemiological studies have shown rather low prevalence of ANUG prior to 1914 in USA and EUROPE but during World War I and II, there were many episodes of ANUG among the allied troops.

DIAGNOSIS OF ANUG

Diagnosis is based on clinical findings - A bacterial smear may be used to corroborate the clinical diagnosis. Microscopic examination of the biopsy specimen is not sufficiently specific to be diagnostic.

DIFFERENTIAL DIAGNOSIS OF ANUG

• Acute herpetic gingivostomatitis

• Desquamative gingivitis

• Periodontal pocket

• Streptococcal gingivostomatitis

• Apthous stomatitis

• Gonococcal gingivostomatitis

• Syphilitic lesion

MANAGEMENT OF ANUG

Treatment of ANUG consists of management of the acute inflammation of the gingiva, alleviation of generalized toxic symptoms like fever, malaise and management of systemic predisposing factors.

First visit - The clinician should record the detailed history of the patient such as socioeconomic status, type of employment, mental stress, dietary habits, recent illness and information regarding the onset and duration of the acute gingival condition. Oral cavity is examined thoroughly. Clinical appearance of the ulcer, oral hygiene status and the periodontal status are evaluated. Sub mandibular and sub mental lymph node areas should be palpated. Body temperature of the patient should also be checked. Patient is advised to confine tooth brushing to remove surface debris with dentifrice to maintain good oral hygiene.

Second visit -1-2 days later supra gingival scaling must be done. Patient's condition is improved. Patient is asked to follow the same instructions.

Third visit - 1-2 days later sub gingival scaling and root planning is completed. Plaque control instructions were reinforced. Hydrogen peroxide rinses were discontinued but chlorhexidine rinses were maintained for 2 weeks.

Subsequent visit - The affected area were checked. Oral hygiene instructions were reinforced. Patient is treated for generalized chronic gingivitis and marginal gingivitis. Patient is placed on maintenance program and recalled on monthly basis for further check up. The patient was explained the need for intensive approximal cleaning to avoid recurrence of ANUG.


CONCLUSION

Necrotizing ulcerative gingivitis usually runs an acute course, is rapidly destructive and debilitating and could have various stages of the same disease (horning and cohen 1995). The treatment of the necrotizing periodontal diseases is divided into 2 phases such as acute and maintenance phase. The aim of the acute phase treatment is to eliminate disease activity. The maintenance phase treatment aims the eliminating all gingival defects and creating optimal conditions for future plaque control. The elimination of predisposing factors is most important to prevent recurrence.

REFERENCES

1. GLICKMANS CARANZA -Textbook of clinical periodontology 10* edition

2. COHEN - Textbook of Periodontology

3. LINDHE - Textbook of clinical Periodontology

4. B.R.R VARMA, R.P NAYAK - Textbook of clinical Peridontology 2nd edition

5. Folayan MO. The epidemiology, etiology, and pathophysiology of ANUG. The journal of contemporary dental practice (2004) Volume: 5, Issue: 3, Pages: 28-41


Dr. K. Sasireka M.D.S

Professor-Dept of Periodontics

Adhiparasakthi Dental College and Hospital


ABSTRACT:

The development of human dentition from adolescence to adulthood has been the subject of extensive study by numerous dentists, orthodontists and other experts in the past. While prevention and cure of dental diseases, surgical reconstitution to address teeth anomalies and research studies on teeth and development of the dental arch during the growing up years has been the main concerns across the past decades, in recent years, substantial effort has been evident in the field of mathematical analysis of the dental arch curve, particularly of children from varied age groups and diverse ethnic and national origins. The proper care and development of the primary dentition into permanent dentition is of major importance and the dental arch curvature, whose study has been related intimately by a growing number of dentists and orthodontists to the prospective achievement of ideal occlusion and normal permanent dentition, has eluded a proper definition of form and shape. Many eminent authors have put forth mathematical models to describe the teeth arch curve in humans. Some have imagined it as a parabola, ellipse or conic while others have viewed the same as a cubic spline. Still others have viewed the beta function as best describing the actual shape of the dental arch curve. Both finite mathematical functions as also polynomials ranging from 2nd order to 6th order have been cited as appropriate definitions of the arch in various studies by eminent authors. Each such model had advantages and disadvantages, but none could exactly define the shape of the human dental arch curvature and factor in its features like shape, spacing and symmetry/asymmetry. Recent advances in imaging techniques and computer-aided simulation have added to the attempts to determine dental arch form in children in normal occlusion. This paper presents key mathematical models & compares them through some secondary research study.

A NEW CONCEPT OF DENTAL ARCH OF CHILDRENIN NORMAL OCCLUSION

1 2 Abu-Hussein Muhamad DDS,MScD,MSc,DPD,FICD, Sarafianou Aspasia DDS,PhD

1, 2. University Of Athens, GreeceKeywords: dental arch,occlusion

INTRODUCTION

Primary dentition in children needs to be as close as possible to the ideal in order that during future adulthood, the children may exhibit normal dental features like normal mastication and appearance, space and occlusion for proper and healthy functioning of permanent dentition. Physical appearance does directly impact on the self-esteem and inter-personal behaviour of the human individual, while dental health challenges like malocclusions, dental caries, gum disease and tooth loss do require preventive and curative interventions right from childhood so that permanent dentition may be normal in later years. Prabhakaran, S., et al, (2006) maintain that the various parts of the dental arch during childhood, viz., canine, incisor and molar play a vital role in shaping space and occlusion characteristics during permanent dentition and also stress the importance of the arch dimensions in properly aligning teeth, stabilizing the form, alleviating arch crowding, and providing for a normal overbite and over jet, stable occlusion and a balanced facial profile. Both research aims and clinical diagnosis and treatment have long required the study of dental arch forms, shape, size and other parameters like over jet and overbite, as also the spacing in deciduous dentition. In fact, arch size has been seen to be more important than even teeth size (Facal-Garcia et al., 2001). While various efforts have been made to formulate a

mathematical model for the dental arch in humans, the earliest description of the arch was via terms like elliptic, parabolic, etc and, also, in terms of measurement, the arch circumference, width and depth were some of the previous methods for measuring the dental arch curve. Various experts have defined the dental arch curvature through use of biometry by measurement of angles, linear distances & ratios (Brader, 1972; Ferrario et al., 1997, 1999, 2001; Harris, 1997; Braun et al., 1998; Burris and Harris, 2000; Noroozi et al., 2001). Such analysis, however, has some limitations in describing a three-dimensional (3D) structure like the dental arch (Poggio et al., 2000). Whereas, there are numerous mathematical models and geometrical forms that have been put forth by various experts, no two models appear to be clearly defined by means of a single parameter (Noroozi, H., et al, 2001).

DEFINING THE DENTAL ARCH

Models for describing the dental arch curvature include conic sections (Biggerstaff, 1972; Sampson, 1981), parabolas (Jones & Richmond, 1989), cubic spline curves (BeGole, E.A., 1980), catenary curves (Battagel, J.M., 1996), and polynomials of second to eight degree (Pepe, S.H., 1975), mixed models and the beta function (Braun, et al, 1998). The definitions differ as because of differences in objectives, dissimilarity of samples studied


and diverse methodologies adopted and uniform results in defining and arriving at a generalized model factoring in all symmetries and asymmetries of curvature elude experts even today. Some model may be suitable in one case while others may be more so in another situation. In this respect, conic sections which are 2nd order curves, can only be applied to specific shapes like hyperbolas, eclipse, etc and their efficiency as ideal fit to any shape of the dental arch is thus limited (AlHarbi, S, et al, 2006). The beta function, although superior, considers only the parameters of molar width and arch depth and does not factor in other dental landmarks. Nor does it consider asymmetrical forms. In contrast, the 4th order polynomial functions are better effective in defining the dental arch than either cubic spline or the beta function (AlHarbi, et al, 2006). AlHadi and others (2006) also maintain that important considerations in defining the human dental arch through mathematical modelling like symmetry or asymmetry, objective, landmarks used and required level of accuracy do influence the actual choice of model made.

OCCLUSION AND ITS TYPES

Occlusion is the manner in which the lower and upper teeth intercuspate between each other in all mandibular positions or movements. Ash & Ramfjord (1982) state that it is a result of neuromuscular control of the components of the mastication systems viz., teeth, maxilla & mandibular, periodontal structures, temporomandibular joints and their related muscles and ligaments. Ross (1970) also differentiated between physiological and pathological occlusion, in which the various components function smoothly and without any pain, and also remain in good health. Furthermore, occlusion is a phenomenon that has been generally classified by experts into three types, namely, normal occlusion, ideal occlusion and malocclusion.

IDEAL OCCLUSION

Ideal occlusion is a hypothetical state, an ideal situation. McDonald & Ireland (1998) defined ideal occlusions as a condition when maxilla and mandible have their skeletal bases of correct size relative to one another, and the teeth are in correct relationship in the three spatial planes at rest. Houston et al (1992) has also given various other concepts relating to ideal occlusion in permanent dentition and these concern ideal mesiodistal & buccolingual inclinations, correct approximal relationships of teeth, exact overlapping of upper and lower arch both laterally and anteriorly, existence of mandible in position of centric relation, and also presence of correct functional relationship during mandibular excursions.

NORMAL OCCLUSION AND ITS CHARACTERISTICS

Normal occlusion was first clearly defined by Angle (1899) which was the occlusion when upper and lower molars were in relationship such that the mesiobuccal cusp of upper molar occluded in buccal cavity of lower molar and teeth were all arranged in a smoothly curving line. Houston et al, (1992) defined normal occlusion as an occlusion within accepted definition of the ideal and which caused no functional or aesthetic problems. Andrews (1972) had previously also mentioned of six distinct characteristics observed consistently in orthodontic patients having normal occlusion, viz., molar relationship, correct crown angulation & inclination, absence of undesirable teeth rotations, tightness of proximal points, and flat occlusal plane (the curve of Spee having no more than a slight arch and deepest curve being 1.5 mm). To this, Roth (1981) added some more characteristics as being features of normal occlusion, viz., coincidence of centric occlusion and relationship, exclusion of posterior teeth during protrusion, inclusion of canine teeth solely during lateral excursions of the mandible and prevalence of even bilateral contacts in buccal segments during centric excursion of teeth. Oltramari, PVP et al (2007) maintain that success of orthodontic treatments can be achieved when all static & functional objectives of occlusion exist and achieving stable centric relation with all teeth in Maxim intercuspal position is the main criteria for a functional occlusion

MATHEMATICAL MODELS FOR MEASURING THE DENTAL ARCH CURVE

Whether for detecting future orthodontic problems, or for ensuring normal occlusion, a study of the dental arch characteristics becomes essential. Additionally, intra-arch spacing also needs to be studied so as to help the dentist forecast and prevent ectopic or premature teeth eruption. While studies in the past on dentition in children and young adults have shown significant variations among diverse populations (Prabhakaran et al, 2006), dentists are continuously seized of the need to generalize their research findings and arrive at a uniform mathematical model for defining the human dental arch and assessing the generalizations, if any, in the dental shape, size, spacing and other characteristics. Prabhakaran et al (2006) also maintain that such mathematical modelling and analysis during primary dentition is very important in assessing the arch dimensions and spacing as also for helping ensure a proper alignment in permanent dentition during the crucial period which follows the complete eruption of primary dentition in children. They are also of the view that proper prediction of arch variations and state of occlusion during this period can be crucial for establishing ideal desired esthetic and functional occlusion in later years.


While all dentists and orthodontists seem to be more or less unanimous in perceiving as important the mathematical analysis of the dental arch in children in normal occlusion, no two experts seem agreeable in defining the dental arch by means of a single generalized model. A single model eludes the foremost dental practitioners owing to the differences in samples studied with regard to their origins, size, features, ages, etc. Thus while one author may have studied and derived his results from studying some Brazilian children under some previously defined test conditions, another author may have studied Afro-American children of another age group, sample size or geographical origins. Also, within the same set of samples studied, there are also marked variations in dental arch shapes, sizes and spacing as found out by leading experts in the field. Shapes are also unpredictable as to the symmetry or asymmetry and this is another obstacle to the theoretical generalization that could evolve a single uniform mathematical model. However, some notable studies in the past decades do stand out and may be singled out as the most relevant and significant developments in the field till date.

The earliest models were necessarily qualitative, rather than quantitative. Dentists talked of ellipse, parabola, conic section, etc when describing the human dental arch. Earlier authors like Hayashi (1962) and Lu (1966) did attempt to explain mathematically the human dental arch in terms of polynomial equations of different orders. However, their theory could not explain asymmetrical features or predict fully all forms of the arch. Later on, authors like Pepe (1975), Biggerstaff (1972), Jones & Richmond (1989), Hayashi (1976), BeGole (1980) made their valuable contributions to the literature in the dental field through their pioneering studies on teeth of various sample populations of children in general, and a mathematical analysis of the dental arch in particular. While authors like Pepe and Biggerstaff relied on symmetrical features of dental curvature, BeGole was a pioneer in the field in that he utilized the asymmetrical cubic splines to describe the dental arch. His model assumed that the arch could not be symmetrical and he tried to evolve a mathematical best fit for defining and assessing the arch curve by using the cubic splines. BeGole developed a FORTRAN program on the computer that he used for interpolating different cubic splines for each subject studied and essentially tried to substantiate a radical view of many experts that the arch curve defied geometrical definition and such perfect geometrical shapes like the parabola or ellipse could not satisfactorily define the same. He was of the view that the cubic spline appropriately represented the general maxillary arch form of persons in normal occlusion. His work directly contrasted efforts by Biggerstaff (1972) who defined the dental arch form through a set of quadratic equations and Pepe who used polynomial equations of degree less than eight to fit on the dental arch curve

(1975). In Pepe’s view, there could be supposed to exist, at least in theory, a unique polynomial equation having degree (n + 1) or less (n was number of data points) that would ensure exact data fit of points on the dental arch curve. An example would be the polynomial equation based on Le-Grange's interpolation formula viz.,

nY = ΣV ∏[i≠i](x-x )/x -x ), where xi, yi were data points. i=1 i i i i

In 1989, Jones & Richmond used the parabolic curve to explain the form of the dental arch quite effectively. Their effort did contribute to both pre and post treatment benefits based on research on the dental arch. However, Battagel (1996) used the catenary curves as a fit for the arch curvature and published the findings in the popular British Journal of Orthodontics, proving that the British researchers were not far behind their American counterparts. Then, Harris (1997) made a longitudinal study on the arch form while the next year (1998), Braun and others put forth their famous beta function model for defining the dental arch. Braun expressed the beta function by means of a mathematical equation thus :

In the Braun equation, W was molar width in mm and denoted the measured distance between right and left 2nd molar distobuccal cusp points and D the depth of the arch. A notable thing was that the beta function was a symmetrical function and did not explain observed variations in form and shape in actual human samples studied by others. Although it was observed by Pepe (1975) that 4th order polynomials were actually a better fit than the splines, in later analyses in the 1990s, it appeared that these were even better than the beta (AlHarbi et al, 2006). In the latter part of the 1990s, Ferrario et al (1999) expressed the dental curve as a 3-D structure. These experts conducted some diverse studies on the dental arch in getting to know the 3-D inclinations of the dental axes, assessing arch curves of both adolescents and adults and statistically analysing the Monson’s sphere in healthy human permanent dentition. Other key authors like Burris et al (2000), who studied the maxillary arch sizes and shapes in American whites and blacks, Poggio et al (2000) who pointed out the deficiencies in using biometrical methods in describing the dental arch curvature, and Noroozi et al (2001) who showed that the beta function was solely insufficient to describe an expanded square dental arch form, perhaps, constitute some of the most relevant mathematical analyses of recent years.

Most recently, one of the most relevant analyses seems to have been carried out by AlHarbi ad others (2006) who essentially studied the dental arch curvature of individuals in normal occlusion. They studied 40 sets of


plaster dental casts - both upper and lower - of male and female subjects from ages 18 to 25 years. Although their samples were from adults, they considered four most relevant functions, namely, the beta function, the polynomial functions, the natural cubic splines, and the Hermite cubic splines. They found that, whereas the polynomials of 4th order best fit the dental arch exhibiting symmetrical form, the Hermite cubic splines best described those dental arch curves which were irregular in shape, and particularly useful in tracking treatment variations. They formed the opinion at the end of their study of subjects – all sourced, incidentally, from nationals of Saudi Arabia – that the 4th order polynomials could be effectively used to define a smooth dental arch curve which could further be applied into fabricating custom arch wires or a fixed orthodontic apparatus, which could substantially aid in dental arch reconstruction or even in enhancement of esthetic beauty in patients.

COMPARISON OF DIFFERENT MODELS FOR ANALYSING THE DENTAL ARCH

The dental arch has emerged as an important part of modern dentistry for a variety reasons. The need for an early detection and prevention of malocclusion is one important reason whereby dentists hope to ensure a normal and ideal permanent dentition. Dentists also increasingly wish to facilitate normal facial appearance in case of teeth and space abnormalities in children and adults. What constitutes the ideal occlusion, ideal intra-arch and adjacent space and correct arch curvature is a matter of comparison among leading dentists and orthodontists.

Previous studies done in analyzing dental arch shape have used conventional anatomical points on incisal edges and on molar cusp tips so as to classify forms of the dental arch through various mathematical forms like ellipse, parabola, cubical spline, etc, as has been mentioned in the foregoing paragraphs. Other geometric shapes used to describe and measure the dental arch include the catenary curves. Hayashi (1962) used

n α(x-β)mathematical equations of the form: y = ax + e and applied them to anatomic landmarks on buccal cusps and incisal edges of numerous dental casts. However, the method was complex and required estimation of the

parameters like α, β, etc. Also, Hayashi did not consider the asymmetrical curvature of the arch. In contrast, Lu (1966) introduced the concept of fourth degree polynomial for defining the dental arch curve. Later, Biggerstaff (1973) introduced a generalized quadratic equation for studying the close fit of shapes like the parabola, hyperbola and ellipse for describing the form of the dental arch. However, sixth degree polynomials ensured a better curve fit as mentioned in studies by Pepe, SH (1975). Many authors like Biggerstaff (1972) have

used a parabola of the form x2 = -2py for describing the shape of the dental arch while others like Pepe (1975) have stressed on the catenary curve form defined by the equation y = (ex + e-x)/2. Biggerstaff (1973) has also mentioned of the equation (x2/b2) + (y2/a2) = 1 that defines an ellipse. BeGole (1980) then developed a computer program in FORTRAN which was used to interpolate a cubic spline for individual subjects who were studied to effectively find out the perfect mathematical model to define the dental arch. The method due to BeGole essentially utilized the cubic equations and the splines used in analysis were either symmetrical or asymmetrical. Another method, finite element analysis used in comparing dental-arch forms was affected by homology function and the drawbacks of element design. Another, multivariate principal component analyses, as performed by Buschang et al (1994) so as to determine size and shape factors from numerous linear measurements could not satisfactorily explain major variations in dental arch forms and the method failed to provide for a larger generalization in explaining the arch forms.

ANALYSING DENTAL ARCH CURVE IN CHILDREN IN NORMAL OCCLUSION

Various studies have been conducted by different experts for defining human dental arch curves by a mathematical model and whose curvature has assumed importance, particularly in prediction, correction and alignment of dental arch in children in normal occlusion. The study of children in primary dentition have led to some notable advances in dental care and treatment of various dental diseases and conditions, although, an exact mathematical model for the dental arch curve is yet to be arrived at. Some characteristic features that have emerged during the course of various studies over time indicate that no single arch form could be found to relate to all types of samples studied since the basic objectives, origin and heredity of the children under study, the drawbacks of the various mathematical tools, etc, do inhibit a satisfactory and perfect fit of any one model in describing the dental arch form to any degree of correction. However, it has been evident through the years of continuous study by dentists and clinical orthodontists that children exhibit certain common features during their childhood, when their dentition is yet to develop into permanent dental form. For example, a common feature is the eruption of primary dentition in children that generally follows a fixed pattern. The time of eruption of various teeth like incisors, molars, canines, etc follow this definite pattern over the growing up years of the child. The differences of teeth forms, shape, size, arch spacing and curvature, etc, that characterize a given sample under study for mathematical analysis, also essentially vary with the nationality and ethnic origin of a child. In one longitudinal study by Henrikson et al (2001) that studied


30 children of Scandinavian origin with normal occlusion, it was found that when children pass from adolescence into adulthood, a significant lack of stability in arch form was discernible. In another study, experts have also indicated that dental arches in some children were symmetrical, while in others this was not so, indicating that symmetrical form of a dental arch was not a prerequisite for normal occlusion. All these studies based on mathematical analysis of one kind or another have thrown up more data rather than been correlated to deliver a generalized theory that can satisfactorily associate a single mathematical model for all dental arch forms in children with normal occlusion.

CONCLUSION

Factors that determine satisfactory diagnosis in orthodontic treatment include teeth spacing and size, the dental arch form and size. Commonly used plaster model analysis is cumbersome, whereas many scanning tools, like laser, destructive and computer tomography scans, structured light, magnetic resonance imaging, and ultrasound techniques, do exist now for accurate 3-D reconstruction of the human anatomy. The plaster orthodontic methods can verily be replaced successfully by 3-D models using computer images for arriving at better accurate results of study. The teeth measurement using computer imaging are accurate, efficient and easy to do and would prove to be very useful in measuring tooth and dental arch sizes and also the phenomenon of dental crowding. Mathematical analysis, though now quite old, can be applied satisfactorily in various issues relating to dentistry and the advances in computer imaging, digitalization and computer analysis through state-of-the-art software programs, do herald a new age in mathematical modelling of the human dental arch which could yet bring in substantial advancement in the field of Orthodontics and Pedodontics. This could in turn usher in an ideal dental care and treatment environment so necessary for countering lack of dental awareness and prevalence of dental diseases and inconsistencies in children across the world.

BIBLIOGRAPHY

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Andrews LF, 1972, "The six keys to normal occlusion", American Journal of Orthodontics & Dento-facial Orthopaedics, 62(3): 296-309

Angle E.H., 1899, “Classification of malocclusion”, Dental Cosmos, 4: 248-264

Ash M.M., and Ramfjord S.P.1982, Occlusion, 3rd edn, Philadelphia: W.B. Saunders Co

Battagel J.M., 1996, “Individualized catenary curves: their relationship to arch form and perimeter”, British Journal of Orthodontics, 23:21–28.

BeGole E. A., 1980, “Application of the cubic spline function in the description of dental arch form”, J Dent Res., 59:1549–1556.

Biggerstaff, R.H., 1972, “Three variations in dental arch form estimated by a quadratic equation”, Journal of Dental Research, 51: 1509

Brader A C, 1972, “Dental arch form related to intra-oral force: PR = C”, American Journal of Orthodontics, 61: 541–561

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Burris B G, and Harris F H, 2000, “Maxillary arch size and shape in American blacks and whites”, Angle Orthodontist, 70: 297–302

Buschang PH, Stroud J, and Alexander RG, 1994, “Differences in dental arch morphology among adult females with untreated Class I and Class II malocclusion”, European Journal of Orthodontics, 16: 47-52

Facal-Garcia M, de Nova-Garcia J, and Suarez-Quintanilla D., 2001, “The diastemas in deciduous dentition: the relationship to the tooth size and the dental arches dimensions”. J Clinical Paediatric Dentistry, 2001, 26:65-9.

Ferrario V F, Sforza C, and Miani Jr A, 1997, “Statistical evaluation of Monson’s sphere in healthy permanent dentitions in man”, Archives of Oral Biology, 42: 365–369

Ferrario V F, Sforza C, Colombo A, Ciusa V, and Serrao G, 2001, “3- dimensional inclination of the dental axes in healthy permanent dentitions – a cross-sectional study in normal population”, Angle Orthodontist, 71: 257–264

Ferrario V F, Sforza C, Poggio C E, Serrao G, and Colombo A, 1999, Three dimensional dental arch curvature in human adolescents and adults”, American Journal of Orthodontics and Dento-facial Orthopaedics, 115: 401–405

Harris E F, 1997, “A longitudinal study of arch size and form in untreated Adults”, American Journal of Orthodontics and Dento-facial Orthopaedics, 111: 419–427

Hayashi, T., 1962, “A Mathematical Analysis of the Curve of the Dental Arch”, Bull, Tokyo Medical Dental University, 3: 175-218


Hendrikson, J., Persson, M., and Thilander, B., 2001, “Long term stability of dental arch in normal occlusion from 13 to 31 years of age”, European Journal of Orthodontics, Pub 23: 51-61

Houston WJB, Stephens CD and Tulley WJ, 1992, A Textbook of Orthodontics, Great Britain: Wright, pp.1-13.

Jones, M.L. and Richmond, S., 1989, “An assessment of the fit of a parabolic curve to pre- and post-treatment dental arches”, British Journal of Orthodontics, 16: 85-93

Lu, K.H., 1966, “An Orthogonal Analysis of the Form, Symmetry and Asymmetry of the Dental Arch”, Oral Biology, 11: 1057-1069

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Abu-Hussein Muhamad, DDS,MScD.MSc,DPD,FICD

123 Argus Street

10441 Athens

Greece

[email protected]


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ABSTRACT:

The Mobile Dental Unit programme of Government of Puducherry Health Services is entirely funded by Government of Puducherry and has eight staff; so as to reach rural Primary Health Centres and Schools for Dental awareness Programmes and treatment camps inside the dental chair fitted van. The complete functioning is this community programme discussed.

MOBILE DENTAL CLINIC – AN OUTREACH GOVERNMENTPROGRAMME - AN OVERVIEW 1 Dr. Ramasubramanian .S, BDS

Madras Dental College and Formerly Assistant Dental Surgeon, CMC Hospital, Vellore,Now Chief Dental Surgeon, Mobile Dental Unit, Health Services, Government of Puducherry.

HISTORY:

This unit was started about 35 years ago along with student health programme with a fully equipped van under Directorate of Health & Family Welfare Services, Government of Puducherry, since then with enormous changes the programme is still functioning.

HUMAN RESOURCES:

Dental Surgeon - 1Public Health Nurse - 1Staff Nurse - 1Dental Hygienist - 1Lower Division Clerk - 1Driver - 1Sanitary Assistant - 1(Part Time)Peon - 1

VEHICLE:

The Mobile Dental unit Van is a six wheeler Swaraj mazda Van, which has a long clinic cabin fitted with ISO 9001-2000 CERTIFIED DENTAL chair and accessories with diesel as fuel. The present van was purchased in 1996. Electricity is drawn by a lengthy wire into van from the power source of school or Primary Health Centre. Vehicle is fuelled and maintained by Government Automobile Workshop, the clinic cabin is fumigated with formalin once a week.

EQUIPMENTS

An ISO 9001:2000 certified dental chair with compressor, airotor, micromotor, LED Light Cure, filling materials like IXGP glass ionomer, IRM, ZnOE usual GP, silver amalgam/ Electrically operated Programmable

autoclave, ultrasonic scaler and cleaner RC instruments, reduction hand piece amalgamator. In addition the staff nurse maintains an oxygen cylinder, emergency drug tray, ambu bag with mask, oral airway, foot operated suction apparatus and BP apparatus.

ACTIVITIES:

The Mobile Dental Team visits both Rural Primary Health Centres and Government Schools.

1. PRIMARY HEALTH CENTRES:

The Rural Primary Health Centres are informed well in advance by post called Advance Tour Programme so as to reach at least 2-4 weeks in advance then this date is prominently displayed, sometimes certain Sub-Centres are also visited for Dental Screening Purposes.

The van with all staff along with autoclaved instruments goes to the Primary Health Centre almost daily. In Primary Health Centres, usually simple extractions, scaling, fillings with glass Ionomer, miracle mix are done, inside the van. Sometimes ,if x-rays are available anterior root canal treatment is also done. Local Anesthesia used in the van is injection 2% Lignocaine with Adrenaline 1:200000, Plain LA & Injection 0.5% Bupivacaine, which helps the patients to have a painless period of about 5 to 6 hours. Chlorhexidine and desensitising dentifrice are given for the needy patients. Mechanical tooth brush is given for a small number of differently abled students and patients.

Third molars and medically compromised are usually referred to nearest teaching dental Hospital, JIPMER etc., After PHC’s visit the van returns to base-office for autoclaving instruments refilling, gloves, LA, drugs etc., and get ready for the next day visit.


2. RURAL GOVERNMENT SCHOOL DENTAL HEALTH PROGRAMME:The School authorities are approached during April – May and appropriate permission sought usually for Rural Government High/ Higher Secondary Schools. Then the programme starts by second week of June or so. The Advance tour Programme reaches the school well in advance.The Public health Nurse, staff nurse and dental hygienist as a team help the dental surgeon to do the following,

a) IEC

On the day of the visit to school the banners are displayed for students on various topics like Dental & Oral Health, Dental Caries progression, Oral Cancer and ill effects of tobacco. The Hygienist demonstrates the ideal brushing technique with the help of dental models.

b) Restoration

Meanwhile the van is parked in a shady place wire plugged in school mains. Then some students preferably girls from (BPL) below poverty line families, are selected from IX th to XIIth , who have initial caries (class I) . Then inside the dental van, cavity is prepared with airotor and restored with glass ionomer / miracle mix or even silver amalgam, sometimes anterior LC fillings are also done.

c) APF GEL Topical Fluoride

Students from VI th To VIII th of rural high and higher secondary schools are called for topical fluoride application with gel. The APF gel(acidulated phosphate fluoride) is applied directly over the teeth by students themselves for 3 to 4 minutes. The applicator trays are expensive hence used for differently abled students. APF Gel i.e., 1.23 % w/w fluoride ion from 2.72% Sodium fluoride manufactured by Pascal international Inc.,WA 98004 USA 48 L is used. The work of Public health nurse is appreciated.

The students who require extractions are selected and asked to come to the nearest Primary Health Centre with parent for treatment on a later date.

FINANCIAL OUTLAY:

This year the fund was about one lakh rupees for fuel and vehicle repair and rupee 2 lakhs for consumables, under Non-plan head of account.

MANAGEMENT:

The office is situated on the First Floor of an Urban Primary Health Centre. The consumables are purchased by placing orders after usual 3-4 quotation. The clerk helps in purchase of materials and settling the bills on time.

The mobile dental van parked inside the rural primary health centre.

View of ISO 9001:2000 certified dental chair and accessories fitted inside the van

The dental team at work as the school headmaster has a glimpse.

The dental hygienist demonstrates the ideal brushing technique with a large dental model,

also seen are banners on dental caries, brushing and oral cancer.


CONCLUSION:

The Mobile Dental Programme has been a success as both a preventive and treatment programme, since treatment like extraction; Scaling and filling are done at their door step.

In future the fuel of the vehicle can be CNG, fitted with GPRS, and computer, to have on line real time consultation etc., plan to rope in house surgeons and community PG’s from nearby dental colleges.

Suggestions welcome Director, DHFW Services, Saram, Puducherry – 605 013. Phone 0413—2249350. FAX 0413-2249351

A differently abled woman using a mechanical tooth brush provided by this unit.

A Student receiving treatment inside the van.

Corresponding author :Dr. S. RamasubramanianChife Dental Surgeon, Mobile Dental Unit,Office of the Programme Officer, National Programme for Control of Blindness,1st Floor, Primary Health Centre,Murungapakkam, Puducherry – 605 004.Ph : 0413-2356803 Mobile : 09443293001

ACKNOWLEDGEMENT:

The programme bestows its gratitude to the former Director Dr. DilipKumar Baliga M.B.B.S.,M S., for his visionary zeal, encouragement and supporting in general and specially for topical fluoride application for school students as rural preventive oral health programme.

Thanks to Mr. J.Jayapragash Stenographer in preparation of this manuscript


NON PHARMACOLOGICAL MANAGEMENT OF DENTAL ANXIETY IN ADULTS

1 2Dr.A.M.Devapriya MDS , Dr.D.Mythireyi MDS

1,2. SRM Dental College , Department of Public Health Dentistry, Ramapuram, Chennai-600 089.

INTRODUCTION:

Dental anxiety is a very common problem encountered

almost everyday by the dental practitioner. In spite of the

advances in the field of dentistry, and increased oral

health awareness, dental treatment is frequently

associated with pain and creates fear, anxiety, and

apprehension in the minds of people. Successful

management of these patients need clear understanding

of their reason for fear and anxiety and can prove to be a

challenging experience for the dental team.

EPIDEMIOLOGY:

Dental anxiety has been ranked 5th among commonly 1feared objects or situations . It has been estimated that 6 -

15% of worlds adult population suffers from high dental 2 3,4anxiety and phobia . Dental anxiety varies with age

3,4,,gender culture5 and from person to person. Women

have been reported to have higher level of dental anxiety 3,4than men . Older people tend to have less dental anxiety

3 6than younger individuals while studies have shown that

it remains unchanged with age.

TERMINOLOGY:

! Anxiety: is a general non specific feeling, an

unpleasant emotional state, signaling the body to

prepare for something unpleasant to happen. Dental

anxiety is a state of apprehension that something

dreadful is going to happen in relation to dental

treatment or certain aspects of dental treatment .

! Fear: is a response to immediate threat. It is a short

lived phenomenon, disappearing when the external

threat passes.

! Phobia: form of fear which is Irrational and out of

proportion to the demands of the situation, is beyond

voluntary control, cannot be explained or reasoned,

persists for an extended period of time and is not age

specific. Dental phobia is abnormal fear or dread of

visiting the dentist for preventive care or therapy and

unwarranted anxiety over dental procedures.

AETIOLOGY OF DENTAL ANXIETY:

a. Direct conditioning : originates due to traumatic encounters in the dental office

b. Vicarious learning, through role models, such as family, peers and society

c. Psychodynamic and personality aspects i.e., specific traits that when present, increase the patient’s proneness for apprehension in the dental setting.

d. Fear of pain: pain is a source of anxiety, anxiety is a factor which increases pain and increased pain incites further anxiety.

e. Blood injury fears

f. Defined dental treatment factors: Specific dental treatment factors can arouse anxiety like injection and drill.

g. Other factors like fear of criticism by the dentist, dentist attitude, dental environment etc

7Weiner and Sheehan (1990) suggested that dental anxiety could be classified into two groups, with respect to the source of their anxiety as

1. Exogenous - conditioning via traumatic dental experiences or vicarious learning

2. Endogenous - vulnerability to anxiety disorders, as evidenced by general anxiety states, multiple severe fears, and disorders of mood Consequences of dental anxiety for patient and dentist:

1) Patients avoid dental treatment or postpone treatment until painful symptoms surfaces.

2) Patients are uncooperative, frequently interrupt 8during dental treatment, take longer time to treat ,

9miss appointment , generally do not follow recommendations, have frequent gagging , experience problems in achieving adequate local anaesthesia,

10 3) Stressful effect on the dentist and the dental team in the form of frustration and a sense of inadequacy.

4) Failure to recognize dental fear and anxiety can affect pain threshold of patient. This may lead to increased stress and stress related emergencies including hyperventilation and vasodepressor syncope.


11IDENTIFYING DENTALLY ANXIOUS PATIENTS :

Moderately anxious patients:

Patients hide their anxiety. Prior dental experience indicates history of emergency care only and multiple cancelled appointments. Patient appears to sit at the edge of chair , eyes roaming around room, taking in everything, unnaturally stiff posture, arms and legs tensed. “White knuckle syndrome” patient clutches the arm rest of dental chair so tightly that their knuckles become ischemic, Sweating of palm and forehead noticed with expressions like it’s hot in here, and when questioned these patients answer quickly.

SEVERELY ANXIOUS PATIENTS:

These patients do not attempt to hide their fear and anxiety from the dentist. They usually avoid dental care and present with severe pain, they would have tried all home remedy and over the counter prescriptions and when none of these worked they visit the dentist. Although these patients want to get treated, their extreme fear of dentistry makes them unable to tolerate dental procedure. These patients have raised blood pressure, heart rate, have excessive sweating and dilated pupils

MEASUREMENT OF DENTAL ANXIETY:

Use of dental anxiety questionnaires like

12! Corahs dental anxiety scale ,

13! Modified Corah dental anxiety scale ,

14! Dental fear survey (Ronald kleinknecht) ,

15! Speilberger state trait anxiety inventory ,

! Visual analogue scale,

! Short dental anxiety scale16

PATIENT MANAGEMENT:

Management can be:

1) Non pharmacological management

• Behaviour management

• Acupuncture analgesia

• TENS

2) Pharmacological management-

• Anxiolytics

• Sedatives

• Hypnotics

• Anti histamines,

• Conscious sedation and

• General anaesthesia

NON PHARMACOLOGICAL MANAGEMENT:

A. BEHAVIOUR MANAGEMENT:

American Academy of Pediatric Dentistry (AAPD) has recently changed the terminology from “behaviour management” to “behavioral guidance” to better describe a continuum of individualized interaction involving the dentist and patient, directed toward communication and education, “which ultimately builds

17trust and allays fear and anxiety.”

BEHAVIOUR MANAGEMENT TECHNIQUES ARE AS FOLLOWS

1) Minimizing provoking stimulus: Behaviour management starts from the time the patient enters the dental clinic, any provoking stimulus should be avoided ,this should be taken care of by well mannered staff, friendly and caring attitude of the dentist.

2) Positive distractions : distracting by television, walkman phones ( fig 1), audiovisual aids

3) Tell, show, do technique: There is an element of fear in all unknown situations, so informing verbally and demonstrating practically before performing the procedure is called as tell, show, do technique, but this technique is not effective in phobic or neurotic patients.

4) Simple relaxation techniques: Active relaxation techniques by asking the patient to count backward from 1000 in steps of seven while concentrating on regular breathing, passive relaxation by playing soft music.

5) Modeling technique: The person observes someone else receiving dental treatment through a visual presentation like films, slides, pictures or in person. When the anxiety producing situation is portrayed, the model shows no anxiety. Modeling leads a person to

18imitate the same response as the model .

6) Latrosedation : Relief of anxiety through the doctors behaviour. It involves use of euphemistic language ,concern towards the patient, greeting the patient, spending few moment before starting the treatment, caring for the patient. Effective iatrosedation,minimizes the depth of pharmacosedation (use of drugs to control anxiety) required to reach a desired level of relaxation ,also maximizes the effectiveness of pharmacosedative technique used.

7) Contingent escape : Contingent escape offers momentary cessation in treatment conditional upon periods of acceptable target behavior. Escape, in this technique, is used as positive reinforcement and is usually nothing more than a rest period from the


procedure. The rest period is earned (contingent) upon completion of a desired behavior (acceptable tolerance or participation in the procedure for a specific period of

18time) .

8) Voice control: Voice control describes alterations of vocal volume, pace, and intonation to gain patient’s attention and influence.

9) Biofeedback techniques : Biofeedback is a type of distraction technique that trains people to consciously control certain bodily processes that normally happen involuntarily, such as heart rate, blood pressure, muscle tension, and skin temperature.. The most commonly used forms of biofeedback therapy for controlling dental anxiety are Electromyography (EMG), which measures muscle tension, Thermal biofeedback, which measures skin temperature , electrodermograph (EDG) measures skin electrical activity and Neurofeedback or electroencephalography (EEG) measures brain wave activity. Respiratory rate biofeedback19 and voluntary

20heart biofeedback techniques have also been helpful in the amelioration of dental anxiety

10) Conditioning techniques: systematic desensitization – gradually acclimatizing the patient to very minor stimuli and teaching them to relax whilst they are being applied. Once relaxation is achieved the stimulus can be gradually increased usually over a considerable period of time until the even most feared situation is manageable. In clinical situation it is applied by first introducing mirror, then probe , hand scalers, maxillary infiltration etc

11) Cognitive behavioural therapy (CBT): Cognitive techniques can be used to help people gain conscious control over their mental stress-inducing processes, it is a form of psychotherapy that emphasizes the important role of thinking in how we feel and what we do. Cognitive Behaviour Therapy was developed from

21cognitive theory . It works to modify biased and dysfunctional cognitive processing. Patients are encouraged to test out and experience new ways of thinking and behaviour. CBT has been shown to reduce

22dental anxiety .

12) Hypnosis : It is defined as “altered condition or state of consciousness characterized by a markedly increased receptivity to suggestions, the capacity for modification of perceptions and memory, and the potential for systematic control of variety of usually involuntary physiological functions ”BARBER 1996 .

It can be incorporated in practice for treatment of dental anxiety ( fig 2) and phobias, pain management in TMJ disorders, facial neuralgias, comfort during prolonged treatment. modification of noxious dental habits, reduce the need for anaesthesia or analgesia, postoperative

analgesia, substitution for premedication in general anaesthesia, control of reflex and autonomic processes like gagging, nausea, salivary flow, bleeding ,valuable in eliminating fear of injections, claustrophobic feeling during nitrous oxide inhalation .

13) Guided imagery: Guided-imagery therapy is a psychotherapeutic method employing a patients own internal imagery to uncover and resolve emotional conflicts . Guided imagery requires the therapist to take an active role in guiding the patient through an exploration of fantasies, dreams, meditations, and other creations of the imagination. It offers a number of benefits over traditional psychotherapeutic approaches,and is now finding widespread scientific and public acceptance, and it is being used to teach psychophysiological relaxation, alleviate anxiety25 and depression. This invaluable mind-body intervention can be applied with patients at all levels of ability/disability.

B. ACUPUNCTURE ANALGESIA: Acupuncture needle has been shown to affect 3 areas of the central nervous system:

i. spinal cord centre where enkephalins and endorphins block incoming pain impulses

ii. the midbrain where endorphins activate the raphe descending system to inhibit spinal cord pain transmission by monoamide neurotransmitters

iii. the hypothalamus pituitary axis which releases beta endorphins into the CSF to cause analgesia

Endorphins released by acupuncture needle ( fig -3 ) will produce opoid like sedation, more of anxiolysis ,takes 20-30 min to produce, and lasts for approximately 8-12 hrs, eliminates only pain sensation, can be used in combination with local anesthesia to reduce dose requirement .

C. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION: TENS (fig -4) activates large diameter non-noxious afferents which close the pain gate at spinal segments related to the pain. TENS effects may be due to

23release of endogenous opioids which generate their analgesic action at peripheral, spinal and supraspinal sites. However, other neurochemicals have been implicated in TENS analgesia including GABA acetylcholine, 5-HT , noradrenaline and adenosine. Another less often used technique, is acupuncture-like TENS (AL-TENS). This activates small diameter afferents which has been shown to close the pain gate using extra-

24segmental mechanisms . TENS can also be used as a counter-irritant, termed intense TENS, using high-intensity and high-frequency currents.


CONCLUSION:

Dental anxiety is a multidimensional complex phenomenon, which is influenced by personality characteristics, fear of pain, past traumatic dental experiences in childhood, and by dentally anxious family members or peers. Handling anxious patients in dental clinics becomes bothersome. This may be due to the fact that practitioners are not adequately trained to handle such situations. Emphasizing behavioural management technique in dental curriculum and undergoing adequate

training programs can help to fill this lacunae. Since a large proportion of patients can be treated by Behaviour modification alone, dental practitioners should recognize and apply these psychological methods for managing anxious patients in everyday practice.

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Fig 1 : Positive distraction using Walkman phones

Fig 2 : behavior modification therapy through hypnosis

Fig 3: Acupuncture analgesia

Fig 4: TENS Device


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NOTES


new concept of dental arch in children

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