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Dental doctrine Team

Editor in chief: Dr. Richa Shrivastava ( CEO, Dental Udaan)

Co- Editor: Dr. Hitesh Chopra ( Senior Lecturer, Dept of Endodontics, SBA University, Saudi Arabia)

Advisors: Dr. V.S. Shrivastava (Senior Dental Surgeon) Dr. Mamta Shrivastava (Ex CMO, Govt of MP) Dr. Suman Lata Saxena (Mother and Child health Specialist) Dr. Nishant R. Chourasiya( Maxillofacial surgeon and implantologist, Rishiraj Dental College, Bhopal) Dr. Puneet Shrivastava (Practicing Orthopedic Surgeon) Dr. Ankita Vastani (Maxillofacial surgeon, Rishiraj Dental College, Bhopal) Dr. Neera Ohri (Oral radiologist and physician, Govt. Of HP)

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Index:
SECTION 1: SCIENTIFIC SECTION:
1) Brown tumor of maxilla- brief review and a case report 2) Halitosis: A Brief Review 3) Minimally Invasive Treatment of Gummy Smile Using Botulinum Toxin

SECTION 2: CDE SECTION

SECTION 3: PRODUCT PROFILES & REVIEWS PRODUCT PROFILES:
1) Zirconomer 2) Algin Plus 3) Oraverse 4) Smart Implants 5) Revo-S files

PRODUCT REVIEWS
I-Root Apex locator by S-Denti

SECTION 4: LIFESTYLE SECTION
1) Travelog: Barot- A hidden treasure

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TYPE OF MANUSCRIPT: Case report TITLE: Brown Tumor of Maxilla- Brief Review And a Case Report RUNNING TITLE: A case report on brown tumor of maxilla AUTHORS: 1. Dr. Vipul Garg MDS* Senior lecturer 2. Dr. Swati Roy MDS# Senior lecturer 3. Dr. Neera Ohri MDS^ Medical Officer

BROWN TUMOR OF MAXILLA – BRIEF REVIEW AND A CASE REPORT ABSTRACT: BACKGROUND: Primary hyperparathyroidism is usually identified as hypercalcemia and hypophosphatemia; however in a scenario especially in developing countries, the disease is often recognised in its overt phase. DESIGN: Report of a 36 year old male patient who presented with a mid face and palatal swelling and was later diagnosed as a case of hyperparathyroidism after complete serological and histopathological examination. RESULT: Hyperparathyroidism should be considered in the list of differential diagnosis for mid face swelling. Routine blood examination coupled with histopathological report is considered to be the gold standard for arriving to a diagnosis of brown tumor. Keywords: Primary Hyperparathyroidism; Biochemical Serum Examination; Histopathology BROWN TUMOR OF MAXILLA – BRIEF REVIEW AND A CASE REPORT INTRODUCTION Primary hyperparathyroidism (HPT) is characterized by hypersecretion of parathormone (PTH), which is caused by adenomas in 85% of all cases. Most cases of primary HPT are identified by hypercalcemia and hypophosphatemia on routine multipanel serum testing. Less than 5% of cases are recognized by the presence of brown tumors.1 Routine biochemical screening has resulted in earlier diagnosis of primary hyperparathyroidism (PHPT) at an asymptomatic or minimally symptomatic stage. This has led to a changing pattern of clinical presentation of PHPT from an overt disease with predominantly skeletal manifestations of the 1970s to a more subtle disease of the 1990s. However, although this is true for the Western population, in the Indian subcontinent, with a vitamin Ddeficient population, PHPT still has a predominant skeletal presentation.1 Vitamin D

*Department of Oral and Maxillofacial Surgery # Department of Oral and Maxillofacial Pathology ^ Govt. of Himachal Pradesh CORRESPONDING AUTHOR: Dr. Vipul Garg Department of Oral and Maxillofacial Surgery Himachal institute of dental sciences, Paonta Sahib E-mail: vips.saggy@gmail.com Mobile No: +91-9882042753 Number of Photographs: 4 Word Count: Abstract- 95, Full text- 1868.

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deficiency may become more common because of widespread use of protective sunscreens that block UV light and, with it; PHPT may again become a more symptomatic disease. Therefore, the oral and maxillofacial surgeon must remain aware of these lesions and their association with PHPT. 2, 3 Brown tumors develop in bones, most commonly in jaws, presenting as welldemarcated, circumscribed, osteolytic lesions. Their histological picture is characterized by masses of soft tissue composed of giant cells in a fibrovascular stroma with cyst like spaces lined by connective tissue, foci of haemorrhage, all simulating changes that may be related to microfractures undergoing organization with the release of hemosiderin. These areas appear as a friable redbrownmass, hence the term brown tumors.1,4 While most authors agree that the initial treatment of PHPT is surgical excision of the diseased parathyroid gland thereby causing the bony lesions secondary to the disease to regress, others have combined parathyroidectomy with curettage and enucleation of the jaw lesions.5, 6, 7 The following report describes a case of PHPT with a brown tumor of the right maxilla. The case and the review highlights the importance of a thorough diagnostic work-up for all lesions in the maxillofacial region and also serves to add another facet to the myriad of presentations associated with primary hyperparathyroidism. Case Report A 36-year-old male patient of Asian Indian descent was referred to the department of oral and maxillofacial surgery, for evaluation of a painless swelling in right maxilla, occupying nearly the entire palate of right side. The initial clinical and radiological evaluation indicated an aggressive odontogenic neoplasm or a metastasis from an unknown primary; the suspicion of a systemic metabolic or endocrine disorder lay low on the list of differential diagnosis.

The patient gave history of gradually progressive swelling of the right palatal aspect of maxilla since last 2 years. The size had increased rapidly in the last 5–6 months. He denied any history of renal stone, neuropsychiatric symptoms or gastrointestinal symptoms. The patient also complained of gradual generalized weakness and weight loss along with difficulty in walking and performing routine domestic work. Extra-oral examination revealed a 5 x 5cm hard, non-tender, non-pulsatile, maxillary swelling with non adherent normal overlying skin (Fig 1). The rest of the physical examination was unremarkable. Grossly the swelling involved the entire right maxilla extending from right infraorbital margin to lateral nasal wall and resulted in gross right sided facial asymmetry which exhibited crepitus in some places. On palpation, the right submandibular region revealed enlarged, tender and mobile lymph nodes with a firm consistency. On intra oral examination a swelling of size 2 x 2 cm was noted on the right half of the hard palate (Fig 2). Few teeth were clinically seen in the mouth and nearly all of them were mobile (Miller‟s grade II/III). Radiographic examination showed radioopacity of the left maxillary sinus. Computerized tomography (CT) of the maxilla revealed an ill-defined radiolucency extending from the right infraorbital rim till alveolar process including the lateral wall of nose perforating the cortical plate buccally and palatally. Routine blood investigations showed anaemia with Hb of 9.9 gm/dL. Clotting studies were normal. Serum chemistry results were within normal range. Based on the age, gender, clinical, radiological and haematological findings, differential diagnosis of the lesion included osteogenic osteosarcoma, desmoplastic fibroma of bone, ameloblastoma, metastasis from unknown primary, or brown tumour of hyperparathyroidism.

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Incisional biopsy was performed under local anaesthesia. The histopathology report revealed a giant cell granuloma. Microscopically, the lesion was composed of multinucleated giant cells scattered in a loose fibrillar matrix with many ovoid or spindleshaped mononuclear cells (Fig 3A, 3B). These giant cells varied in both size and shape, contained multiple nuclei, and were unevenly distributed throughout the lesion (Fig 3C). Areas of haemorrhage, newly formed osteoid, and bone tissue were also observed. Subsequent blood analysis revealed an elevated parathyroid hormone level (314 pg/ml: normal, 12–72 pg/ml), while serum calcium levels were normal. This led to a possibility of brown tumor secondary to PHPT. The neck ultrasound revealed a well-defined 2 x 2 cm hypoechoic mass posterior to the right lobe of the thyroid, which showed internal flow on Doppler suggestive of a parathyroid neoplasm. Finally, ultrasound guided FNAC of the parathyroid was conducted. The parathryroid smears were moderately cellular, and the cells had round nuclei and scanty cytoplasm arranged singly in clusters, suggestive of a parathyroid adenoma. Based on the above clinical, radiological, biochemical and cytopathological findings, a final diagnosis of normocalcaemic primary hyperparathyroidism presenting as a massive maxillary brown tumour was made. Discussion HPT is a disease of excess PTH secretion and can be sub classified into four types. Primary HPT is the unregulated overproduction of PTH caused by either a single adenoma in a parathyroid gland or diffuse hyperplasia of one or more glands. The overproduction of PTH can also be secondary to a chronic, abnormal stimulus for its production, such as low serum calcium associated with renal failure or vitamin D deficiency. Most patients who

receive dialysis for renal failure have some level of HPT. The tertiary form is characterized by autonomous hypersecretion of PTH and develops after renal transplantation in patients with chronic, secondary HPT. The fourth type occurs due to ectopic parathyroid hormone produced by hormone secreting malignant tumors .8,9 Primary hyperparathyroidism is most commonly caused by adenoma (81%) followed by hyperplasia (15%), with carcinoma accounting for only 0.5%-4%.5,10 It may also be inherited as an autosomal dominant condition in patients with hyperparathyroidism jaw tumor syndrome (HPT-JT syndrome) and multiple endocrine neoplasia syndrome (MEN syndrome).5,11 Most of the patients with primary hyperparathyroidism are above 60 years and women are affected two to four times more commonly. Patients with a classic triad of signs and symptoms of hyperparathyroidism are described as having “stones, bones and abdominal groans”. Stones refer to the fact that the patients have a marked tendency to develop renal stones (nephrolithiasis) because of elevated serum calcium levels. Metastatic calcifications are also seen. Bones refer to the variety of osseous changes that may occur in conjunction with hyperparathyroidism. Abdominal groans refers to the tendency for the development of duodenal ulcers.12 Brown tumors represent the terminal stage of HPT. This lesion is a well documented feature of this endocrinopathy. In the past, bone lesions were recognized in 80% to 90% of patients with primary or secondary HPT. In the last few years, these rates have declined to 10% to 15%. This is because of early diagnosis (new and more objective PTH radioimmunoassay techniques) and successful treatment of the disease. 1,13 the bones most commonly involved by brown tumor of HPT are the ribs, clavicles, pelvic girdle, and mandible. Maxillary involvement is quiet rare.14-16 This makes this case unique.

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Intraorally, brown tumors present as painful, hard, clearly visible, and palpable swelling.1,14 Radiographically, they appear as welldemarcated monolocular or multilocular osteolytic lesions. In the mandible, the cortical bone is expanded and thinned. Brown tumors of the jaws occasionally result in root resorption and loss of the lamina dura and may present as a space-occupying mass in the sinus.1 Rosenburg and Guralnick reported that loss of the lamina dura was common radiographic feature in 40% of the patients in their study. Silverman et al found that in 55 patients, none showed complete loss of lamina dura and only 6% exhibited partial loss. Bras et al have suggested that radiographic changes of the jaws may be a late finding in HPT and their interpretations may be complicated by periodontal disease.1 Other skeletal radiographic findings include subperiosteal resorption of bone, typically of the medial aspect of the middle phalanges and erosion of distal digital tufts and margins of some joints .The skull radiograph characteristically shows a salt and pepper effect.1,2 Jaw lesions of HPT exhibit a picture that is similar to that of central giant cell tumors. A proliferation of spindle cells with extravasated blood and haphazardly arranged, variably sized, multinucleated giant cells is seen. These are osteoclasts, and the action of which is influenced by PTH. Osteoid formation may also occur. All types of PTH present similar histological findings. Histological features alone cannot establish a certain diagnosis, because of many giant cell lesions of the bone (giant cell granuloma, aneurysmal bone cyst, cherubism) show similar histological picture. A certain diagnosis is suggested by clinical history and confirmed by the endocrinologic status of the patient.17-20 At present, the most common method of diagnosis is the incidental detection of hypercalcemia in an asymptomatic patient.5 This may be attributed to the inclusion of serum calcium levels to the routine blood investigations, which has resulted in early

diagnosis and treatment.21 Increased levels of serum calcium and parathyroid hormones and reduced levels of serum phosphate as well as increased urinary levels of phosphates and calcium are sufficient to diagnose PHPT. Ultrasound, CT scan, or technetium scan techniques can be used to detect the diseased parathyroid gland.5 There is general consensus that the most logical approach to the treatment of primary hyperparathyroidism is parathyroidectomy. Opinions are divided on the course of management of the bony lesions once parathyroidectomy has been done. Most authors believe that the bone lesions regress with time after parathyroidectomy with rapid conversion of the bony lesions to normal bone.1, 2, 5 But according to few authors, surgical intervention should be performed after parathyroidectomy for adenoma because spontaneous regression may take longer than 5 years. Knevezic et al in their study suggested that the patient‟s age was a relevant factor in the duration of the healing. This is supported by Silverman et al who reported a case of primary hyperparathyroidism in a 15-year-old patient which resolved in 6 months after parathyroidectomy. However, some lesions do not regress but extend beyond the normal anatomy and calcify, and interfere with function and/or esthetics.5, 22 Therefore considering the varying school of thought, the final treatment decision lies in the hand of the surgeon. In the present case the patient underwent parathyroidectomy (figure 4) and is under regular follow up and reports a decrease in the size of maxillary mass.

CONCLUSION: Brown tumors of the jaw may commonly involve the mandible and rarely involve the maxilla in association with primary hyperparathyroidism. The presence of underlying primary hyperparathyroidism should be sought in all unexplained mandibular and maxillary lesions. A majority of these lesions may disappear with the

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removal of the parathyroid pathology. This case report emphasizes the importance of recognizing the clinical presentation of this disease entity, a condition that is remediable by surgical and medical treatment. REFERENCES 1. Triantafillidou K, Zouloumis L, Karakinaris G, Kalimeras E, Iordanidis F. Brown tumors of the jaws associated with primary or secondary hyperparathyroidism. A clinical study and review of the literature. American Journal of Otolaryngology 2006;27:281– 286. 2. Kar DK, Gupta SK, Agarwal A, Mishra S. Brown tumor of the palate and mandible in association with primary hyperparathyroidism. J Oral Maxillofac Surg 2001;59:1352-1354. 3. Harinarayan DV, Gupta N, Kochupillai N. Vitamin D status in primary hyperparathyroidism in India. Clin Endocrinol 1995;43:351-356. 4. Parisien M, Silverberg SJ, Shane E, Dempster DW, Bilezikian JP. Bone diseases in primary hyperparathyroidism. Endocrinol Metab Clin North Am 1990;19:18- 34. 5. Spencer J, Daniels M. Primary hyperparathyroidism presenting as a palatal brown tumor. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98:409-13. 6. Smith AC, Bradley JC. Non-surgical management of hyperparathyroidism of the jaws. J Oral Maxillofac Surg 1987;45:176-81. 7. Yamazaki H, Ota Y, Aoki T, Karakida K. Brown tumor of the maxilla and mandible: Progressive mandibular brown tumor after removal of parathyroid adenoma. J Oral Maxillofac Surg 2003;61:719-22. 8. Allerheiligen DA, Schoeber J, Houston RE, et al: Hyperparathyroidism. Am Fam Physician 1998; 57:1795. 9. Choi C, Terzian E, Schneider R, Trochesset DA. Peripheral giant cell granuloma associated with hyperparathyroidism secondary to end-stage renal disease: A Case Report. J Oral Maxillofac Surg 2008;66:10631066. 10. Masson EA, Macfarlane IA, Bodmer CW, Vaughan ED. Parathyroid carcinoma presenting with a brown tumour of mandible

in a young man. Br J Oral Maxillofac Surg 1993;31:117-19. 11. Hobbs MR, Pole AR, Pidwirny GN, Rosen IB, Zarbo RJ, Coon H, Heath H, Leppert M, Jackson CE. Hyperparathyroidism jaw tumor syndrome: the HRPT2 locus is within 0.7-cM region on chromosome 1q. Am J Human Genet 1999;64:518-25. 12. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology. Second edition; 451,724. 13. Auclair PL, Arendt DM, Hellstein JW, et al. Giant cell lesions of the jaws In Oral and Maxillofacial Surgery. Clinics of North America 1997;9:655-80. 14. Guney E, Yigibasi OG, Bayram F, Ozer V, Canoz O. Brown tumor of the maxilla associated with primary hyperparathyroidism. Auris Nasus Larynx 2001;28:369- 72. 15. Merz MN, Massich DP, Marsh W, et al. Hyperparathyroidism presenting as brown tumor of the maxilla. Am J Otolaryngol 2002;23:173 -76. 16. Martinez-Gavidia EM, Began JV, MilianMasanet MA, et al. Highly aggressive brown tumor of the maxilla as first manifestation of primary hyperparathyroidism. Int J Oral Maxillofac Surg 2000;29:447- 49. 17.Cicconeti A, Matteini C, Piro FR. Differential diagnosis in a case of brown tumor caused by primary hyperparathyroidism. Minerva Stomatol 1999;11:553 - 58. 18. Lehnerdt G, Metz KA, Kruger C, et al. A bone-destroying tumor of the maxilla. Reparative giant cell granuloma or brown tumor? Head and neck oncology 2003;51:239 - 44. 19. Thorwarth M, Rupprecht S, Schlegel A, et al. Central giant cell granuloma and osteitis fibrosa cystica of hyperparathyroidism. A challenge in differential diagnosis of patients with osteolytic jaw bone lesions and a history of cancer. Mund Kiefer Gesichtschir 2004;8:316-21. 20. Manus MR, Abbas BY, Lampe H, et al. Maxillary giant cell granuloma, pheochromocytoma, and hyperparathyroidism without medullary thyroid carcinoma. Ear Nose Throat J 2000;79:590-3.

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21. Smith BR, Fowler CB, Svane TJ. Primary hyperparathyroidism presenting as a „„peripheral‟‟ giant cell granuloma. J Oral Maxillofac Surg 1988;46:65-9. 22. Silverman JS, Ware WH, Gillooly JC. Dental aspects of hyperparathyroidism. Oral Surg Oral Med Oral Pathol 1968;26:184 - 9. Figure Legends: FIGURE 1A,1B, 1C: Exraoral : Lesional mass causing swelling on the right cheek and proptosis FIGURE 1D: Intraoral: lesional mass causing swelling of one half of the palate FIGURE 2: Computed tomographic image showing the extent of the lesion FIGURE 3A: Hematoxylin and eosin image40X magnification- cluster of giant cells and extravasated red blood cells FIGURE 3B: Hematoxylin and eosin image100X magnification- multinucleated giant cells interspersed in delicate fibrillar stroma

FIGURE 3C: Hematoxylin and eosin image200X magnification-multinucleated giant cell with variable number of nuclei FIGURE 4: parathyroidectomy incision

FIGURES:

FIGURE 1A

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FIGURE 1B

FIGURE 1C

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FIGURE 1D

FIGURE 2

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FIGURE 2A

FIGURE 3B

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FIGURE 3C

FIGURE 4

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HALITOSIS: A BRIEF REVIEW
Dr. Himanjai Saxena (BDS) Private Practice 32 Stars Dental Clinic ABSTRACT: Halitosisis probably most common oral problem and is usually self reported. Self reported Halitosis can be due to many causes and can be of many types. It is a challenge for dentist to convince his patient about his self reported problem and ways to cure it as sometimes cure may be extraoral or sometimes psychological. Many times the cure is very simple and no dental procedure is needed. The correct diagnosis of cause is utmost important for a correct approach towards problem.

Yashoda parisar Complex Kolar Road Bhopal Mob. No. 9754854009

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INTRODUCTION: Halitosis, or fetor ex oreor simply bad breath is one of the commonest oral disease. It is usually self-reported by patient or by his/her close associate. Halitosis usually comes with a psychological dent to patient and sometimes associated with social stigma. Contrary to popular belief oral malodour usually occurs due to organic decomposition of organic matter in oral cavity. Around 85-90% of cases have origin in oral cavity. Bacteria decompose organic substance into Volatile Sulphur compounds mainly Hydrogen Sulphide and methyl mercaptan. Dimethyl sulphide is main contributor of blood borne halitosis. Other causes include Gingivitis, Periodontitis, Xerostomia, Liver Disease, Diabetes, Upper respiratory tract problem, GI Disturbances. Sometimes patient is on medications which contribute towards malodour. It can be due to consuming pungent food items like Garlic, onions etc. Smokers usually are common patients or halitosis. Many a times patient feels that he has malodour but nor we not anyone is able to diagnose the problem, or even feel the malodour. These are psychogenic cases but somehow it becomes our duty to try to solve their problem.

make things simple Miyazaki and othersclassified Halitosis.Halitosis can be classified as following depending upon the types and cause: 1) Genuine halitosis A. Physiologic halitosis B. Pathologic halitosis: (ii) Extra-oral 2) Pseudohalitosis 3) Halitophobia (i) Oral

Tangerman and Winkel classification This one is the latest classification, given in Europe in 2002, it only deals with genuine Halitosis 1) Intra-oral halitosis 2) Extra-oral halitosis A. Blood borne halitosis: (i) Systemic diseases (ii) Metabolic diseases (iii) Food (iv) Medication B. Non-blood borne halitosis: (i) Upper respiratory tract (ii) Lower respiratory tract

CLASSIFICATION Miyazaki et al. classification To properly treat a case of halitosis we must diagnose the cause and type of halitosis. To

DIAGNOSIS Self diagnosed Halitosis: In most of the cases when patient reports to a clinician, he usually has himself diagnosed the condition. If he hadn‟t

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diagnosed himself then someone very close to him may have diagnosed the condition. Professional diagnosis: There are many ways such as Halimeter, BANA Test, beta- galatoside test but usually these equipments are not found in an average set up. DIFFERENTIAL DIAGNOSIS A dentist must recognise the cause of Halitosis. There must be a thorough check up of oral cavity and if there is any oral cause of halitosis, it must be dealt with in first visit itself. If there is no cause in oral cavity, the clinician must explore the medical history, eating habits, bowel habits and must refer to a physician to know the exact systemic cause. Now lies the most difficult patients to satisfy. We call them “Psychogenic” patients. We doctors have a very good at one thing, if we are not able to find a cause of the symptom, we generally term that disease as “Psychogenic”. We tend to forget that its our duty to treat the patient and help him to overcome his problem. Most of the time such patients give a common history, they feel bad breath when they wake up and it diminishes as the day progresses. The cause of this can be dryness of mouth overnight due to less intake of water at night and stagnation of saliva during night time.

MANAGEMENT The golden rule in management of halitosis lies in treatment of underlying cause as well as providing with some medication of immediate relief. If the case is due to oral condition, we should correct that in first visit. The most common source of oral malodour is mouth, the most common cause inside the oral cavity is calculus and debris. Thorough Scaling is a must of these patients. If the malodour is due to other reasons such as abscess then we should treat the disease. As supportive treatment we can give mouthwashes containing mint and menthol. If the cause is systemic we must assure the patient that the malodour will disappear if the disease is controlled and refer the patient to a physician. If there is no diagnosed cause of the condition, and we are not able to detect a malodour then patient needs to be counselled and reassured that there is no problem and symptoms will subside. He/she should be told to drink a lot of water and should be given menthol mouthwashes as supportive treatment. Severe cases may need help of a Psychologist or Psychiatrist.

CONCLUSION Managing a halitosis patient is not as simple as it seems. It require a sharp clinical judgement about the cause and type of halitosis and a calm head to assure the patient that

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his suffering is going to end. Halitosis is the condition which gives a social and emotional set back to patient and we need to heal his soul also.

7. Scully C, Rosenberg M. Halitosis. Dent Update. 2003 May; 8. Zalewska, A; Zatoński, M; Jabłonka-Strom, A; Paradowska, A; Kawala, B; Litwin, A (2012 Sep). "Halitosis--a common medical and social problem. A review on pathology, diagnosis and treatment."

REFERENCES: 1. Carranza‟s Clinical Peridontology, 9th Edition by Newman et al

2. Tonzetich J. Direct gas chromatographic analysis of sulphur compounds in mouth air in man. Arch Oral Biol 1971; 16:58797.

3. Kaizu T. [Analysis of volatile sulphur compounds in mouth air by gas chromatography]. Nippon Shishubyo Gakkai Kaishi 1976; 18:1-12. Japanese.

4. Kaizu T. [Halitosis, its etiology and prevention]. Nippon Shika Ishikai Zasshi 1976; 29:228-35. Japanese.

5. Yaegaki K. In: Rosenberg M, editor. Bad Breath Research Perspectives. Tel-Aviv: Ramot Publishing-Tel Aviv University; 1995.

6. ^ Jump up to: a b c d Rosenberg, M (1996). "Clinical assessment of bad breath: Current concepts". Journal of the American Dental Association (1939) 127 (4): 475– 82. PMID 8655868.

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MINIMALLY INVASIVE TREATMENT OF GUMMY SMILE USING BOTULINUM TOXIN

Dr. Saurav Chaturvedi
BDS, MDS* (Orthodontics) Peoples College of Dental Sciences & Research Centre, Bhopal (MP) Dr Saurav is the Founder of the Dental Networking website fourthmolar.com and has recently started a Blog Dedicated to Orthodontics – ORTHO CAFE (ortho.fourthmolar.com) Saurav121@gmail.com

ABSTRACT An upper gingival display of more than 2mm during smile is referred to as a gummy smile .A good percentage of patients report with this form of malocclusion. Even though gummy smiles have a strong genetic trend, it could also be caused by other factors like nasopharyngeal obstruction, short upper lip, vertical maxillary excess, altered passive eruption, hyperactive upper lip and hyper plastic gingiva. According to the etiology it could be corrected by various modalities like headgears, implants, surgical correction and even periodontal surgery. A new concept in correction of gummy smile is by the use of injection botulinum toxin type A. It prevents the conduction of acetylcholine at the neuromuscular junction resulting in relaxation of elevator muscle of upper lip. This causes the lip to lengthen, thus camouflaging the gummy smile. More than it being a simple technique, it is the most advantageous in being able to be used even when all the other treatment modalities have failed or have only partly corrected the situation.

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GUMMY SMILE The smile is the most recognisable signal in the world. Smiles are such an important part of communication that we can see them far more clearly than any other expression. We can pick up a smile at even 100 metres – the length of a football field. Just as a nice smile can act as an excellent communication tool, an unpleasing or anaesthetic smile can have an equally powerful negative impact and this is often one of the reasons why people seek orthodontic treatment. The smile itself and the aesthetics of the smile are influenced by 3 components: teeth, gums, and lips. An attractive smile depends on the proper proportion and arrangement of these 3 elements. The upper lip should symmetrically expose up to 3 mm of the gum and the gum line must follow the contour of the upper lip. The exposure of more than 3 mm of the gum during the smile is known as gingival or gummy smile.

alaquae nasii, levator anguli oris and zygomaticus muscles), vertical maxillary excess, gingival inflammation resulting from medication or aggravated by orthodontic appliances and altered passive eruption when the gingivae does not recede to a normal level after the teeth have erupted. There are a number of surgical and non surgical options but some patients do not want to go through the pre surgical orthodontic treatments and some want to avoid the possible complications surrounding surgery such as post operative pain, swelling, infection, nerve damage etc.

(Levator Labii Superioris Muscle) BOTULINUM TOXIN - BOTOX “All things are poisons, and there is nothing that is harmless; the dose alone decides that something is a poison.” Paracelsus (1493-1541) Though botulinum toxin is considered to be one of the most toxic substances in nature, commercial preparations have been established through clinical research for wide application in the treatment of several conditions. Botulinum toxin „BOTOX‟ therefore is a desirable minimally invasive alternative to treat excessive gingival

It may be present due to many factors like hyperfunction of the upper lip elevator muscles ( levator labii superioris, levator labii superioris

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display for a number of patients. It has been used in medicine since the 1970s for treating excessive muscular contraction and aesthetic indications to treat wrinkles of face.

60-120 kilos would be the LD50 for the human population. While the raw toxin has potential as a biological weapon, hundreds of thousands of vials of the pharmaceutical product would have to be obtained to create a real threat. MODE OF ACTION The action of Botulinum toxin at the neuromuscular junction is to interrupt transmission and in effect to denervate muscle. This chemodenervation effect persists for weeks to months. The duration of effect may depend on serotype. The mechanism for this extended duration has been hypothesized to arise from either continued protease activity within the cell or from persistent interference by cleaved substrate with normal membrane fusion. Currently, there is no known way to reverse the paralytic effects of Botulinum toxin after it has been internalized. Both active and passive immunization can inactivate toxin in the circulation, but antibody cannot enter nerves to neutralize internalized toxin. Recovery from Botulinum toxin occurs spontaneously and may take months to be complete. At the cellular level, 3 to 4 weeks after a single injection of Botulinum toxin/A in mice, there is sprouting of new processes along the nerve axon, with formation of multiple synapses with the muscle and up regulation of the muscle nicotinic receptors. Subsequently, the neuronal sprouts undergo regression and the original synaptic connection is restored, with restoration of the original neuromuscular junction.

Botulinum toxins are exotoxins produced by Clostridium botulinum, an anaerobic gram positive sporulating organism. Different serotypes produce different toxins. Botulinum toxin is the most potent toxic substance in nature. Biological activity of the toxin is measured in mouse units, mouse LD50 or simply a „unit‟, which is defined as the amount of toxin required to kill 50% of a group of Swiss-Webster mice, after intraperitoneal injection. While LD50 calculations for humans are projections from primate data, 2700-3000 mouse units is the dose usually cited as the LD50 for a 70 kilogram human. For BOTOX® (Allergan, Inc.) 5 nanograms is 100 units, and 135-150 nanograms would be a lethal dose (27-30 vials injected intravenously). Assuming that 10-20 micrograms is the lethal dose orally,

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ADMINISTRATION • Manufacturers recommend that reconstitution be done few hours prior to use with 2.5 ml 0.9% sterile saline solution for 100 units. Ask client to smile deeply while palpating the nasolabial groove on the maxilla. Assess for asymmetry. Leave your finger in position and inject just above and on the medial edge of your finger. Use 25 units of BOTOX® on each side; dose asymmetrically if necessary. At 2-week follow-up, re-evaluate and re-inject 12 units, if needed.

Adverse effects are minor and reversible, administration errors may take a few weeks to get back to previous condition. CONTRAINDICATIONS Patients should not be treated or treated with extreme caution who are: • Psychologically unstable or who have questionable motives and unrealistic expectations. • Afflicted with a neuromuscular disorder (e.g. myasthenia gravis, Eaton-Lambert syndrome). • Allergic to any of the components of BTX-A or BTX-B (i.e. BTX, human albumin, saline, lactose and sodium succinate). • Taking certain medications that can interfere with neuromuscular impulse transmission and potentiate the effects of BTX (e.g. aminoglycosides, penicillamine, quinine, and calcium blockers). • Pregnant or lactating (BTXs are classified as pregnancy category C drugs). LIMITATIONS

• •

• •

ADVERSE EFFECTS • Mild stinging, burning or pain with injection • Edema around injection site • Erythema around injection site • Lack of intended cosmetic effect • Asymmetric smile • Lip Ptosis

Although this mode of treatment is minimally invasive, it can‟t replace permanent treatment modalities. Botox can be used in patients who need temporary correction or can‟t go for surgical treatment for given time.

WORD OF CAUTION • Effect stays for 4-6 months depending on patients.

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Always take proper consent and photographs before administration. Advice patients to avoid exercise, spa, air travels etc because botox may migrate to other muscles. Always administer small doses and later re inject after 2 weeks if needed.

CONCLUSION When compared to other surgical procedures botulinum toxin has been proved to be a minimally invasive, effective alternate for the correction of gummy smile caused by upper lip elevator muscles. To conclude injecting botulinum toxin is a useful adjunctive procedure to enhance aesthetics and to improve patient satisfaction where orthognathic surgery alone is inadequate.

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REFERENCES 1. Blumenfeld A. Botulinum toxin type A in the treatment of Dental conditions. Inside Dent 2007;2:1-5. 2. 2. Katz H, Blumenfeld A. Can Botulinum toxin A (BOTOX) save your teeth and enhance your smile? Available from: http://sci.techarchive.net/ Archive/sci.med. dentistry/2004-06/0484.html. [last cited on 2009]. 3. Ezquerra F, Berrazueta MJ, RuizCapillas A, Arregui JS. New approach to the gummy smile. Plast Reconstr Surg. 1999; 104:1143–1150. 4. Landsberg CJ, Sarne O. Management of excessive gingival display following adult orthodontic treatment: a case report. Pract Proced Aesthet Dent. 2006;18:89–94; quiz 96, 122. 5. 5. Botulinum toxins: Pharmacology and its current therapeutic evidence for use. Neurology India OctoberDecember 2003 Vol 51 Issue 4

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Cde Section
Pre PG coaching:
1) Regular Classroom Series by DENTAL UDAAN: Classes Monday to Friday evening, which will consist of Discussion and doubt clearing sessions. Test every Saturday morning followed by discussion. Sunday Holiday.Begins 18th January 2014. For Details mail to dentaludaan@gmail.com, visit www.dentaludaan.weebly.com or call 9754854009

Clinical courses section:
1) IMPLANTSURG: The most comprehensive Implant program which is integrated with minor oral surgical procedures. Participant will learn implants with 3 different systems. ARDS, Biohorizon and Equinox and will also learn procedures like IMF, Surgical extractions, on patients. Plus special lectures on Practice management and LASERS will be incorporated in the program. The program is or 12 contact sessions/ 6 modules spread over 3 months. The program is held every 3 months. Speakers include: Dr.Nishant R. Chourasia, Dr.NitinBhola, Dr.AnkitaVastani and many more (team of 7 speakers) For Details contact 9754854009 or mail to dentaludaan@gmail.com Venue: BHOPAL 2) IMPLAT-O-NOMICS: Six Modules spread over Six months Small batches for better learning Team of 5-Professionals carrying an impeccable academic and clinical record in Implant Dentistry. LIVE Recording of surgeries done by all participants. Venue: New Delhi Visit www.targeteducare.com for details 3) “Smile: The Best Make-Up”: Hands on Module on bleaching and tooth jewellery. Candidate will be doing patient with their own hands under able Guidance of Dr.Himanjai Saxena Date: 9th Feb 2014

2) Comprehensive test series and online test series by DENTAL UDAAN: Test every Saturday. Students will get study material in a soft copy. Study material includes National Boards, University of Birmingham, Dental Deks, Cawson and Skully, Atlas of human Anatomy.etc. Begins 18th January 2014 For Details mail to dentaludaan@gmail.com, visit www.dentaludaan.weebly.com or call 9754854009

3) Postal Test Series by DENTAL UDAAN: Students will get tests and study material through Speed post/Courier and student will be sending the papers back by the stipulated date. Begins January 2014 onwards For Details mail to dentaludaan@gmail.com, visit www.dentaludaan.weebly.com or call 9754854009

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Venue: Bhopal Call:9754854009 or mail to dentaludaan@gmail.com for more details 4) IDC 2014: Indian Dental Congress will be held in Hyderabad 21st, 22nd and 23rdfeb. It will be a grand gala with lots of preconference courses, trade fares and banquet. Venue: Hyderabad Dates: 21-23 Feb 2014 Visit: www.idc2014.in for details and registration 5) Fellowship in Rotary Endodontics: Healthmantra in association with International Association of rotary endodontics bring FIARE Visit: http://www.healthmantra.com/rotary/types.sht ml for details.

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Product profiles

1) ZIRCONOMER: Zirconomer defines a
new class of restorative that promises the strength and durability of amalgam with the protective benefits of glass ionomer while completely eliminating the hazard of mercury. The inclusion of specially micronized zirconia fillers in the glass component of Zirconomer reinforces the structural integrity of the restoration and imparts superior mechanical properties for the restoration of load bearing permanent teeth. Zirconomer raises the bar for restorative glass ionomer by outperforming conventional glass ionomers in stress bearing posterior restorations with notably high compressive strength (more than 340 MPa in 24 hours), very low creep and dimensional stability for long-lasting performance. Combination of outstanding strength, durability and sustained fluoride protection deems it ideal for multiple applications. It is suitable for the restoration of Class I and II cavities, repair of fractured amalgam, as a strong base under amalgam and composite restorations, all classes of cavities where radiopacity is a prime requirement, build-up of structural core, on the root surfaces where overdentures are placed, as long term temporary replacement for cusps as well as for minimal intervention treatment and ART techniques.

2) ALGINPLUS: Extra-high precision
alginate for impressions with chromatic phase indicator. New enriched formula for enhanced details reproduction. The excellent dimensional stability allows casting of the impressions after 5 days (if correctly stored in sealed container). Alginplus Fast exceeds ISO 1563 requirements. Marketed in India by Retail Denmart Pvt Ltd.

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3) ORAVERSE:OraVerse (phentolamine
mesylate) is marketed by Septodont and is the first and only local anesthesia reversal agent that allows you to bring patients back to normal sensation twice as fast. In clinical trials, the median time to recovery of normal sensation in the upper lip was 50 minutes for OraVerse patients vs. 133 minutes for the control group, and in the lower lip was 70 minutes for OraVerse patients vs. 155 minutes for the control.

as each thread penetrates deeper than the one before. The Smart is suitable for all bone types including especially low quality bones. All smart implants are packed together with a single use leading pin ARDS Drilling technique is recommended for use with the Smart implants but standard drilling is optional as well.

4) REVO-S FILES: This new sequence 4) SMART IMPLANT BY ARDS IMPLANT SYSTEM: The Smart implant
is a dual thread internal hex implant, slightly tapered at its lower part with a 3.75mmØ universal platform. The Smart's unique dual thread design and exceptionally large surface area enables optimal grip of the implant both in the cortical and the spongiosal bone, thus creating excellent primary stability and equal distribution of forces along the implant. The Smart is self tapping and compresses the bone with only 3 nickel-titanium instruments simplifies the initial endodontic treatment and optimizes the cleaning. The asymmetrical cross section of the Revo-STM facilitates penetration by a "snake-like" movement, and offers a root canal shaping which is adapted to the biological and ergonomic imperatives. This sequence has a cutting, debris elimination and cleaning cycle which optimizes the root canal cleaning by improving the upward removal of the generated dentine debris. It also offers the choice of an apical finishing (AS30, AS35 and AS40) which is most closely adapted to the anatomical and ecological criteria of the canal. Advantages: -Enables a

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better root canal penetration due to a "snakelike" movement = better progression of the instrument toward the apical region of the root canal. -Facilitates the elimination of debris upward the coronal thanks to the increased available volume for debris. -Avoids the grooves to be obstructed and thus avoids the extrusion of debris beyond the instrument tip and apical foramen. -Reduces the stress on the instrument thanks to the rippling movement of the file along the canal walls: no screwing effect, more flexibility, better ability to negotiate curves.

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Product reviews
I Root Apex Locator: By Dr. Himanjai Saxena

It‟s been 6 months now that I have been using I-Root apex locator. I was using an Apex locator earlier and I was really not satisfied with the results. I wanted to change my apex locator so that I did not waste a lot of time in finding working length. After a much research, talks with dealers I chose I root. In these Six months I am more than satisfied with the product. It has an amazing accuracy. Really , haven‟t conducted a research or don‟t have a data but according to me this device has 99.5% accuracy. It works on Dual frequency method which Root ZX also uses but costs almost 40% less than it. The researches and studies I checked before buying it also quoted it as one of three most accurate apex locators along with Root ZX and Propex. Overall I am satisfied with the product. Don‟t know about other International apex locators but the battery back-up of I root is amazing. I can say that I Made a correct choice in purchasing it.

Dr. Himanjai Saxena can be contacted through himanjaisaxena@gmail.com

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Barot – A Hidden Treasure
I, often, and quite vividly, never miss a chance in distinguishing a tourist from a traveler. I consider myself both, though more latter than the former. I believe if you‟re the same one as me, you‟d know the difference yourself. The coming fifteen minutes of read is everything about a beautiful, quaint love of mine, love with the town of Barot. Somewhat „remote‟ for a tourist, largely unknown and unheard of, this small village lies in Uhl Valley in district Mandi of Himachal Pradesh. I first visited this place three years back on a biking trip. It took us around 5 hours from Dharamshala and to be honest, it was somewhat tricky ride especially the last 25 kms which took us the longest time to cover. The road was narrow, meandering, not at all in good shape then. It was late in the evening at around 6 and it was beginning to get dark. Luckily, we reached Barot while there was still sufficient sunlight, sunlight not to support driving but to offer us the first glimpse of this magical place. I have been in love with the place since that very moment, and since then I‟ve started to believe in Love at First Sight! We were welcomed to the valley by small, tiny potato fields which formed a very presentable view in connexion with the huge blocks of mountains. We passed by the small hamlets en-route, often asking directions and how much time it‟ll take, we finally reached the town, well almost reached the town. The small dam of English times and its very small reservoir said to me that it‟s going to be one quiet and wonderful holiday, just the way I wanted. We drove through the town, searching for a perfect place to stay, actually a place to stay! We drove past a lovely Rest House, one of the prettiest buildings in the area. After trying our luck at a few local guest houses and

home-stays, we finally landed at River-View Guest House, at the very end of the road. It probably was a great luck to find this amazing little place. Very basic but great considering the place; who‟s looking for luxury here anyway. Our window and gallery opened right next to the river. The town went pitch dark at night; stars were clearer and bigger than ever before. Sound of the gushing river could be heard out loud. I felt as if you don‟t need meditation and yoga for peace anymore (of course, if you find a place like this!) Next morning was a little adventurous, we went to see the dam (sadly, boating has been banned after an unfortunate incident) and then we headed towards the abandoned pulley-rail developed by the Englishmen for timber and men. We were amazed to see the incline of the rail track which at places approached 60 degrees vertical! We started climbing the rail and it was actually tough trek up. It was as if there was a long ladder to climb. Not to ignore the fact that I‟m a regular trekker in Himalayas and have been part of many trekking expeditions even the harder ones. Nevertheless, it was fun. Something new, something I‟ll not find elsewhere easily. After the trek, rather climb on the „ladder‟ rail track, it was time to sit back, relax and try out our hand in Angling. Luckily, and to surprise of others sitting next to me, I was quick to catch a Trout fish, medium sized and which was very, very, delicious if not anything else. I just had a bite or two to try it out and went back on my vegetarian meal. My cousin accompanying me told that it was one of the best fish he had ever feasted upon. Soon, as it was a short visit, we had to pack our bags and ride back home. We were byebye-d by group of local kids selling locally picked vegetables roadside for some small bucks for perhaps toffees or their big savings.

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But that wasn‟t the end of my rendezvous with Barot. We‟ve met twice since then. We‟ve enjoyed bonfire barbeque parties, body surfing in ice-cold river water, and yes games on the winter snow. Every time, she has treated me nicer than before. Every time, my love for her has grown stronger. I do not try to alter with my place of stays or eat-outs each time I visit, I know maybe there are better ones, but those are simply perfect for me. At almost zero price! (Rs. 600 for a great stay in today‟s world). I‟ll come to you again, very soon, probably trekking this time from Billing (which in itself is another great place and also heart of paragliding in India). Barot is a lovely, little, lonely place, that takes you back in time. With world changing so fast, this place has resisted the change so far. It is one of the hidden treasures and places to explore. Though, at some level, I do wish, it remains hidden from the outside world. Visharad Saxena, Traveler and Travel Expert at CrazyPeaks.com

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Barot, Himachal Pradesh

Hydroelectric Project at Barot on River Uhl

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Railway Track with one of the steepest inclines in the background

Date of construction (It‟s 1904!)

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The unbelievable steep slope of the track after the climb

Local children having a laugh with us!

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