Professional Documents
Culture Documents
Volume 1, Issue 3
March-April 2011
Indian Journal of
Volume 1, Issue 3, March-April 2011, Indian Journal of Multidisciplinary Dentistry, Page (121-180)
Multidisciplinary
DENTISTRY
http://ebook.ijcpgroup.com/ijmd/index.htm
Indian Journal of
Multidisciplinary Dentistry Volume 1, Issue 3
March-April 2011
Orthodontics Pedodontics
Implantology
Krishna Nayak US Krishan Gauba
John W Thurmond (USA)
Dhandapani G Ashima Gauba
Murali RV
Genetics Deepak C Biochemistry
Aravind Ramanathan Julius A
Pharmacology
Oncology Muthiah NS Microbiology
Abraham Kuriakose M Elumalai M Mahalakshmi K
review article
Comparative Study of Manual Cephalometric Tracing and Computerized Cephalometric
Tracing in Digital Lateral Cephalogram for Accuracy and Reliability of Landmarks 126
Case report
Minimally Invasive Atraumatic Extraction of Fractured Tooth Using Implant Drills and Immediate
Implant Placement 147
Rhinocerebral Mucormycosis with Palatal Involvement Associated with Diabetes Mellitus Type II:
A Case Report 152
clinical study
Comparison of Enzyme Alkaline Phosphatase Levels Around Healthy and Diseased Implants:
A Clinical Study 169
Dr KMK Masthan
Professor and Head, Department of Oral Pathology and Microbiology
Sree Balaji Dental College and Hospital, Chennai
O
ur second issue had some additions like the Another sensitive subject that deserves our time and
orderly arrangement of articles and advisory attention is myopic jurisdictional attitude of some
board members and some deletions like of our fellow professionals. I have come across such
leaving out some extraneous names. I received some situations, where a periodontist is criticized for doing
suggestions like grouping of articles according to RCTs and an oral pathologist is denied access to
the sub-specialties and maintaining the same e-link clinical cases. Now, how will the periodontist treat an
endo-perio lesion if he should not do RCTs and how
for the subsequent issues. The second suggestion, I
will an oral pathologist learn clinical features of an oral
have requested our IJCP editorial team to consider disease if he does not get a chance to see the patient?
whereas the first suggestion, in my opinion defeats the Are we there for patients and their problems or are
whole purpose of a multi disciplinary journal and the the patients there for providing us a prestigious degree
intention towards an interdisciplinary discussion. Let us and a lucrative income? Patient’s welfare must come
consider, for example, a learned discussion on implants. first and the right to educate a student adequately and
It consists of a surgical phase for placing an implant, a comprehensively utilizing all available resources must
periodontic part for abutment attachment and the most come second.
difficult prosthodontic part of providing an esthetically Another incident that merits mention is an article that
pleasing tooth attachment. In addition, the role of a was submitted. We had received a wonderful article,
radiologist is paramount in deciding a safe location for painstakingly written on Oral Radiology from a junior
the implant so that sinus space is not breached and staff member from a dental college that I am familiar
an inadvertent nerve damage is not encountered. Now, with. Then I received an urgent request from the author
which speciality can hold a proprietary interest in that? withdrawing the article. When I enquired why, I was
If the history of implantology is reviewed, the implants told a shocking and a staggering reply. The HOD does
were introduced and promoted by general dentists not like the juniors to publish even though the author
had the grace to put the HOD as the first author.
with support from engineering, metallurgy and pure
When the Dental Council is making the publications
research like animal studies. a mandatory requirement and the institutions are
I have seen heated discussions when this subject literally begging the staff members to publish and the
is broached and I feel that we are looking at the whole profession stands to benefit by publications,
whole concept with tunnel vision. Dentistry was the HOD does not like the juniors to get the credit
divided into several branches and will continue to that the junior truly deserves. The institution will
be divided further in the future into several more also suffer due to lesser number of publications at the
because the sheer amount of literature, armamentarium, time of inspections. Monumental egos, unreasonable
techniques and the skill were and are becoming too wide insecurities and personal prejudices have no place in a
for one singe dental professional to master in his or profession that is growth-bound and let us remember
her limited undergraduate and postgraduate academic nature has a way of weeding out such impediments.
time window. But any dental/medical education is Now, that our journal has gained some popularity
a continuous lifelong process and an intellectual and is privileged to be included in databases of several
pursuit and the speciality sticker should in no way indexing bureaus, I make an appeal to the readers and
act as a barrier for someone who thirsts at knowledge authors to recommend some sponsors and advertisers
and wants to master newer technologies and since more funds will help us to elevate the journal to
procedures. My view is supported by CDE/CME a higher standard.
program which are enthusiastically attended by several
undergraduates since they do not recognize any such My wholehearted thanks to IJCP for accommodating
mental blocks, whereas the postgraduates of one sub- my nagging demands and bringing out wonderful
specialty consider it beneath their pride even to enroll issues.
in such workshops. Now who is the loser? Best wishes...
Dr KK Aggarwal
Padma Shri and Dr BC Roy National Awardee
Sr Physician and Cardiologist, Moolchand Medcity
President, Heart Care Foundation of India
Group Editor-in-Chief, IJCP Group
Editor-in-chief, eMedinewS
Chairman Ethical Committee, Delhi Medical Council
Director, IMA AKN Sinha Institute (08-09)
Hony. Finance Secretary, IMA (07-08)
Chairman, IMA AMS (06-07)
President, Delhi Medical Association (05-06)
emedinews@gmail.com
http://twitter.com/DrKKAggarwal
Krishan Kumar Aggarwal (Facebook)
P
oorly controlled diabetes is a risk factor for increased severity of periodontitis and poor response to
periodontal treatment. Patients may present with xerostomia, candidiasis, and caries as well as periodontal
disease. Patients with poor control of diabetes and severe periodontitis show improvement in their A1C
levels, as well as decrease in periodontal inflammation, with treatment of the periodontitis1,2 not all studies confirm
improvement in glycemic control, however.3-5
There is no strong scientific evidence on the effects of periodontal treatment on glycemic control and systemic
inflammation.6 Efforts should be made to counsel all diabetics to take care of their dental hygiene and if an
infection is present to control it simultaneously.
And much more in this issue...
References
1. Stewart JE, Wager KA, Friedlander AH, Zadeh HH. The effect of periodontal treatment on glycemic control in patients
with type 2 diabetes mellitus. J Clin Periodontol 2001;28(4):306-10.
2. Kiran M, Arpak N, Unsal E, Erdoğan MF. The effect of improved periodontal health on metabolic control in type 2
diabetes mellitus. J Clin Periodontol 2005;32(3):266-72.
3. Aldridge JP, Lester V, Watts TL, Collins A, Viberti G, Wilson RF. Single-blind studies of the effects of improved periodontal
health on metabolic control in type 1 diabetes mellitus. J Clin Periodontol 1995;22(4):271-5.
4. Christgau M, Palitzsch KD, Schmalz G, Kreiner U, Frenzel S. Healing response to non-surgical periodontal therapy in
patients with diabetes mellitus: clinical, microbiological, and immunologic results. J Clin Periodontol 1998;25(2):112-24.
5. Promsudthi A, Pimapansri S, Deerochanawong C, Kanchanavasita W. The effect of periodontal therapy on uncontrolled
type 2 diabetes mellitus in older subjects. Oral Dis 2005;11(5):293-28.
6. Salvi GE, Carollo-Bittel B, Lang NP. Effects of diabetes mellitus on periodontal and peri-implant conditions. Update on
associations and risks. J Clin Periodontol 2008;35(Suppl 8):349.
n n n
Abstract
Introduction: The purpose of the study was to evaluate the skeletal, dental and soft tissue variables accuracy and reliability
in digital cephalogram by two methods of tracing - i.e., manual tracing and computerized (Vistadent) cephalometric tracing.
Material and methods: A sample of 80 pre-treatment standardized lateral cephalogram were analyzed by a single observer,
who performed the manual and computerized tracings of all 80 radiographs. Thirty-three anatomical landmarks were defined
on each radiograph by a single investigator and 37 variables were calculated. Data were subjected to statistical analysis.
Statistical analysis was undertaken using SPSS 16.0 version statistical software program. No differentiations were made
for age or gender. For statistical evaluation of the principal data, differences in measurements between manual tracing and
Vistadent tracing were evaluated using t-test. A level of p < 0.05 was considered to be significant. To evaluate the method error,
30 randomly selected radiographs were retraced 1-week after the initial measurements and paired t-test was done. The retracing
values of manual and Vistadent tracing was evaluated using t-test. A level of p < 0.05 was considered to be significant. Results
and conclusions: Most of the variables showed consistency between the two methods except for Pog-Nperp, Jarabak ratio,
ANS-Me, IMPA, L1-NB, SnPerp-Pog’ and nasolabial angle. The study indicates that most of the variables show consistency
between manual tracing and computerized tracing while most of the cephalometric variables were reliable.
Key words: Skeletal variables, dental variables, soft tissue variables, computerized tracing, manual tracing
I
maging is one of the most ubiquitous tools has several drawbacks, including a high-risk of error in
orthodontists use to measure and record the tracing, landmark identification and measurement.9,14
size and form of craniofacial structures. Despite Cephalometric errors can be divided into those
the diverse image acquisition technologies currently related to acquisition, identification, and technical
available, standards have been adopted in effort to measurement. Reproducibility of measurements by the
balance the anticipated benefits with associated costs operator is also a significant factor in determining
and risks. Because of these considerations, orthodontists the accuracy of any method of analysis. The use of
routinely use an array of two-dimensional static imaging computers in treatment planning is expected to reduce
techniques to record the three-dimensional anatomy of the incidence of personal errors due to operator fatigue
craniofacial region.4 and provide standardized, fast and effective evaluation
with a high rate of reproducibility. The literature
In orthodontics cephalometric radiography is an contains only a few studies comparing the accuracy
essential tool for studying growth and development of digital cephalometric measurements with the hand-
of the facial skeleton, diagnosis and treatment tracing method.3,6,11 There is still a need to evaluate any
planning, and evaluating pre- and post-treatment possible differences in errors between newly emerging
changes.8,13,14 However, despite its widespread use in cephalometric software and earlier programs.
orthodontics, the technique is time consuming and
Hence, the present study was undertaken to evaluate
*Professor and Head the skeletal, dental, soft tissue variables accuracy and
**Professor
†
Associate Professor
reliability in digital cephalogram by two methods
‡
Postgraduate Student of tracing: i.e., manual tracing and computerized
Dept. of Orthodontics and Dentofacial Orthopedics cephalometric tracing (Vistadent).
Sree Balaji Dental College and Hospital, Chennai
Address for correspondence
Dr RV Murali Material and Methods
Professor and Head
Dept. of Orthodontics and Dentofacial Orthopedics Pre-treatment lateral cephalometric radiographs of 80
Sree Balaji Dental College and Hospitals
Pallikaranai, Chennai - 600 100 patients were randomly selected from the archives of
E-mail: muralikothai@gmail.com dental OPG X-ray Center with the following criteria:
Good quality radiographs without any artifacts statistical evaluation of the principal data, differences
that might interfere with the location of the in measurements between hand tracing and Vistadent
anatomical points. tracing was evaluated using t-test. A level of p < 0.05
No craniofacial deformity or asymmetry. was considered to be significant. To evaluate the
Patient biting in occlusion (maximum inter- method error, 30 randomly selected radiographs were
cuspation). retraced 1-week after the initial measurements and
paired t-test was done. The retracing values of hand
Permanent dentition with no missing teeth.
No excess soft tissue (as determined from the
radiographs) that could interfere with locating
anatomical points. Gi
N
Ba Aplu A Cotg
PNS Sn
Digital Tracing Lslu
Ls
Is 11 Stm-s
ppOcP Stm-i
The digital images were stored in a laptop (Hp pavilion Li 11 Li
Sto
Is1u
Statistical Analysis
Figure 2. Skeletal variables used.
Statistical analysis was undertaken using SPSS 1-SNA (°), 2-SNB (°), 3-ANB (°), 4-Nperp-A (mm), 5-Nperp-Pog (mm),
6-Cond-A (mm), 7-Cond-Gn (mm), 8-Max-Mand (mm), 9-Wits (mm),
16.0 version statistical software program. No 10-Ba N-NA (°), 11-SpP-GoMe (°), 12-SN-GoMe (°), 13-Jarabak ratio
differentiations were made for age or gender. For (S-Go:N-Me), 14-ArGo-Me (°), 15-ANS-Me (mm), 16-Go-Me (mm).
Figure 3. Dental variables used. SN-GoMe (°) Angle of anterior cranial base to
mandibular plane
1-IMPA (°), 2-Max1-NA (°), 3-Mand1-NB (°), 4-1u-NA (mm), 5-1l-NB
(mm), 6-Overjet (mm), 7-Overbite (mm), 8-Interincisal (°), 9-SpP-OcP (°), (S-Go:N-Me) Ratio of posterior and anterior facial
10-MeGo-OcP (°). height
ArGo-Me (°) Gonial angle
ANS-Me (mm) Lower facial height
Go-Me (mm) Mandibular length
Dental variables
IMPA (°) Angle of axis of 1l to mandibular. Base
1 Max1-NA (°) Angle of axis of 1u to N-A
Mand1-NB (°) Angle of axis of 1l to N-B
1u-NA (mm) Distance of labial outline of 1u to N-A
6
10 3
1l-NB (mm) Distance of labial outline of 1l to N-B
2 Overjet (mm) Overjet
11
7
Overbite (mm) Overbite
Interincisal (°) Interincisal angle
4
8
SpP-OcP (°) Angle of palatal to occlusal plane
MeGo-OcP (°) Angle of mandible to occlusal plane
Figure 4. Soft tissue variables used. Soft tissue variables
1-Gl’-Sn (mm), 2-Sn-Me’ (mm), 3-Sn-stm-s (mm), 4-Stm-i-Me’ (mm),
5-Stm-s - Stm-i (mm), 6-SnPerp-Ls (mm), 7-SnPerp-Li (mm), Gl’-Sn (mm) Upper facial height
8-SnPerp-Pog’ (mm), 9-CotgSnLs (°), 10-Ls-NsPog’ (mm), Sn-Me’ (mm) Lower facial height
11-Li-NsPog’ (mm).
Sn-stm-s (mm) Upper lip length
and Vistadent tracing was evaluated using t-test. Stm-i-Me’ (mm) Lower lip length
A level of p < 0.05 was considered to be significant. Stm-s - Stm-i (mm) Interlabial gap
SnPerp-Ls (mm) Distance of upper lip to SnPerp
Results SnPerp-Li (mm) Distance of lower lip to SnPerp
SnPerp-Pog’ (mm) Distance of chin to SnPerp
Statistical evaluation of skeletal, dental, soft tissue
CotgSnLs (°) Nasolabial angle
variables between Group I (manual tracing), Group II
Ls-NsPog’ (mm) Upper lip to esthetic line
(Vistadent) (Table 2) shows the following variables
Li-NsPog’ (mm) Lower lip to esthetic line
were significant (p < 0.05) Nperp-Pog (p = 0.032),
Table 3. Statistical Evaluation of Skeletal, Dental, Soft Tissue Variables: Manual Tracing and Retracing after
1-week - 30 Samples
Variables Tracing-initial Retracing 1-week after Paired t-test
Sig p < 0.05
Skeletal variables
SNA (°) 83.7000 ± 0.75071 83.7667 ± 0.74999 0.161
SNB (°) 78.5667 ± 0.82446 78.6333 ± 0.81011 0.161
ANB (°) 5.1333 ± 0.37056 5.1667 ± 0.37473 0.573
Nperp-A (mm) 1.5000 ± 0.73773 1.5333 ± 0.74546 0.573
Nperp-Pog (mm) –6.0333 ± 0.91033 –6.0333 ± 0.89633 1.000
Cond-A (mm) 95.6000 ± 0.99146 95.6667 ± 0.99808 0.161
Cond-Gn (mm) 119.5000 ± 1.40258 119.5667 ± 1.41639 0.161
Max-Mand (mm) 23.7667 ± 0.80041 23.8000 ± 0.81987 0.573
Wits (mm) 3.5333 ± 0.46420 3.4667 ± 0.46420 0.161
Ba N-NA (°) 64.1333 ± 0.59255 64.2000 ± 0.62034 0.326
SpP-GoMe (°) 22.0667 ± 0.88530 22.1333 ± 0.88634 0.161
SN-GoMe (°) 29.7667 ± 1.02574 29.8333 ± 1.03954 0.161
(S-Go:N-Me) 68.6000 ± 0.85715 68.7333 ± 0.86561 0.043
ArGo-Me (°) 123.1000 ± 1.15206 123.1333 ± 1.16435 0.573
ANS-Me (mm) 68.4667 ± 1.20510 68.5333 ± 1.19840 0.021
Go-Me (mm) 75.4667 ± 1.01113 75.5333 ± 0.99969 0.161
Dental variables
IMPA (°) 106.6667 ± 1.35132 106.8000 ± 1.34027 0.073
Max1-NA (°) 30.4667 ± 1.25004 30.4333 ± 1.25275 0.573
Mand1-NB (°) 32.7667 ± 1.54376 32.7333 ± 1.54692 0.573
1u-NA (mm) 6.2000 ± 0.33010 6.2667 ± 0.32495 0.161
1l-NB (mm) 7.7333 ± 0.45469 7.8000 ± 0.45080 0.161
Overjet (mm) 5.8667 ± 0.39750 5.9000 ± 0.40215 0.573
Overbite (mm) 2.7433 ± 0.25260 2.8100 ± 0.25910 0.161
Interincisal (°) 111.8333 ± 2.27130 111.9000 ± 2.26637 0.161
SpP-OcP (°) 6.7333 ± 0.63415 0.161
6.8000 ± 0.63499
MeGo-OcP (°) 15.2069 ± 0.71813 0.184
15.1034 ± 0.72829
Soft tissue variables
Gl’-Sn (mm) 65.5667 ± 0.82306 65.6333 ± 0.82557 0.161
Sn-Me’ (mm) 66.0333 ± 1.19046 66.1000 ± 1.18453 0.161
Sn-stm-s (mm) 19.5900 ± 0.50543 19.6167 ± 0.5068 0.118
Stm-s - Stm-i (mm) 5.0300 ± 0.55602 5.0467 ± 0.55588 0.283
Stm-i-Me’ (mm) 43.8333 ± 0.86287 43.8733 ± 0.86766 0.090
SnPerp-Ls (mm) -4.4000 ± 0.27332 0.326
–4.4667 ± 0.41725
SnPerp-Li (mm) -0.2667 ± 0.76854 0.573
–0.3000 ± 0.77630
SnPerp-Pog’ (mm) 9.9000 ± 0.82539 0.042
10.8333 ± 0.82974
CotgSnLs (°) 97.1667 ± 1.89202 0.032
99.6333 ± 1.89772
Ls-NsPog’ (mm) 0.161
–1.0000 ± 0.43150
Li-NsPog’ (mm) –0.9333 ± 0.44704
1.9667 ± 0.62969 0.083
2.0333 ± 0.65026
Table 4. Statistical Evaluation of Skeletal, Dental, Soft Tissue Variables: Vistadent Tracing and Retracing after
1-week - 30 Samples
Variables Tracing-initial Retracing 1-week after Paired t-test
Sig p < 0.05
Skeletal variables
SNA (°) 83.7000 ± 0.7507 83.8000 ± 0.7512 0.083
SNB (°) 78.5667 ± 0.8245 78.6000 ± 0.8285 0.573
ANB (°) 5.1333 ± 0.3706 5.2000 ± 0.3601 0.161
Nperp-A (mm) 0.9333 ± 0.5929 0.9000 ± 0.5899 0.573
Nperp-Pog (mm) –6.4667 ± 1.0654 –6.4000 ± 1.0866 0.161
Cond-A (mm) 95.6000 ± 0.9915 95.6667 ± 0.9981 0.161
Cond-Gn (mm) 119.5000 ± 1.4026 119.5333 ± 1.4026 0.573
Max-Mand (mm) 23.7667 ± 0.8004 23.8333 ± 0.8010 0.161
Wits (mm) 3.3667 ± 0.4806 3.4000 ± 0.4997 0.573
Ba N-NA (°) 64.1333 ± 0.5925 64.1667 ± 0.5952 0.573
SpP-GoMe (°) 22.0667 ± 0.8853 22.1000 ± 0.8701 0.573
SN-GoMe (°) 29.7667 ± 1.0257 29.8000 ± 1.0265 0.573
(S-Go:N-Me) 68.2667 ± 0.8853 70.1667 ± 0.9149 0.280
ArGo-Me (°) 121.0667 ± 1.1254 123.3333 ± 1.1520 0.161
ANS-Me (mm) 66.0000 ± 1.2327 68.3333 ± 1.2095 0.573
Go-Me (mm) 75.4667 ± 1.0111 75.5333 ± 1.0134 0.161
Dental variables
IMPA (°) 104.3333 ± 1.3496 104.6000 ± 1.3136 0.088
Max1-NA (°) 30.4800 ± 1.2627 30.4700 ± 1.2610 0.794
Mand1-NB (°) 32.6700 ± 1.4877 32.6700 ± 1.4877 0.161
1u-NA (mm) 6.2000 ± 0.3301 6.2667 ± 0.3285 0.161
1l-NB (mm) 6.4333 ± 0.4929 6.5333 ± 0.4953 0.083
Overjet (mm) 5.8567 ± 0.4058 5.8833 ± 0.4038 0.608
Overbite (mm) 2.6633 ± 0.2602 2.6867 ± 0.2590 0.090
Interincisal (°) 111.8333 ± 2.2713 111.9333 ± 2.2848 0.083
SpP-OcP (°) 6.7333 ± 0.6341 6.8333 ± 0.6362 0.083
MeGo-OcP (°) 15.2069 ± 0.7181 15.2759 ± 0.7343 0.424
Soft tissue variables
Gl’-Sn (mm) 65.5667 ± 0.8231 65.6667 ± 0.8295 0.083
Sn-Me’ (mm) 66.0333 ± 1.1905 66.0667 ± 1.1870 0.326
Sn-stm-s (mm) 19.5900 ± 0.5054 19.6167 ± 0.5068 0.103
Stm-s - Stmi (mm) 5.0300 ± 0.5560 5.0800 ± 0.5689 0.154
Stm-i-Me’ (mm) 43.8333 ± 0.8629 43.8733 ± 0.8564 0.103
SnPerp-Ls (mm) –3.9667 ± 0.2733 –4.0667 ± 0.2874 0.083
SnPerp-Li (mm) 0.161
–0.4000 ± 0.5805 –0.3333 ± 0.5918
SnPerp-Pog’ (mm) 0.047
8.4000 ± 0.8525 9.3333 ± 0.8608
CotgSnLs (°) 0.032
98.1667 ± 1.8920 100.6333 ± 1.8977
Ls-NsPog’ (mm) 1.000
–1.0000 ± 0.4315 –1.0000 ± 0.4315
Li-NsPog’ (mm) 0.161
1.9667 ± 0.6297 2.0333 ± 0.6370
Skeletal Variables
SNA (°) 83.7667 ± 0.74999 83.8000 ± 0.7511 0.975
SNB (°) 78.6333 ± 0.81011 78.6000 ± 0.8285 0.977
ANB (°) 5.1667 ± 0.37473 5.2000 ± 0.3601 0.949
Nperp-A (mm) 1.5333 ± 0.74546 0.9000 ± 0.5899 0.508
Nperp-Pog (mm) –6.0333 ± 0.89633 –5.4000 ± 1.0866 0.043
Cond-A (mm) 95.6667 ± 0.99808 95.6667 ± 0.9981 1.000
Cond-Gn (mm) 119.5667 ± 1.41639 119.5333 ± 1.4026 0.987
Max-Mand (mm) 23.8000 ± 0.81987 23.8333 ± 0.8010 0.977
Wits (mm) 3.4667 ± 0.46420 3.4000 ± 0.4997 0.922
Ba N-NA (°) 64.2000 ± 0.62034 64.1667 ± 0.5952 0.969
SpP-GoMe (°) 22.1333 ± 0.88634 22.1000 ± 0.8701 0.979
SN-GoMe (°) 29.8333 ± 1.03954 29.8000 ± 1.0265 0.982
(S-Go:N-Me) 68.7333 ± 0.86561 70.1667 ± 0.9149 0.023
ArGo-Me (°) 123.1333 ± 1.16435 123.3333 ± 1.1520 0.903
ANS-Me (mm) 66.5333 ± 1.19840 68.3333 ± 1.2095 0.034
Go-Me (mm) 75.5633 ± 0.99969 75.5333 ± 1.0134 0.989
Dental variables
IMPA (°) 106.8000 ± 1.34027 104.6000 ± 1.3136 0.246
Max1-NA (°) 30.4333 ± 1.25275 30.4700 ± 1.2610 0.984
Mand1-NB (°) 32.7333 ± 1.54692 32.6700 ± 1.4877 0.977
1u-NA (mm) 6.2667 ± 0.32495 6.2667 ± 0.3285 1.000
1l-NB (mm) 7.1000 ± 0.45080 6.8333 ± 0.4953 0.646
Overjet (mm) 5.9000 ± 0.40215 5.8833 ± 0.4038 0.977
Overbite (mm) 2.8100 ± 0.25910 2.6867 ± 0.259 0.738
Interincisal (°) 111.9000 ± 2.26637 111.9333 ± 2.2848 0.992
SpP-OcP (°) 6.8000 ± 0.63499 6.8333 ± 0.6362 0.971
MeGo-OcP (°) 15.1034 ± 0.72829 15.2759 ± 0.7343 0.895
Soft tissue variables
Gl’-Sn (mm) 65.6333 ± 0.82557 65.6667 ± 0.8295 0.977
Sn-Me’ (mm) 66.1000 ± 0.16637 66.0667 ± 1.1870 0.984
Sn-stm-s (mm) 19.6167 ± 0.5068 19.6167 ± 0.5068 1.000
Stm-s - Stm-i (mm) 5.0800 ± 0.5689 5.0800 ± 0.5689 0.967
Stm-i-Me’ (mm) 43.8733 ± 0.8564 43.8733 ± 0.8564 1.000
SnPerp-Ls (mm) –4.0667 ± 0.2874 –4.0667 ± 0.2874 0.433
SnPerp-Li (mm) –0.3333 ± 0.5918 –0.3333 ± 0.5918 0.973
SnPerp-Pog’ (mm) 9.7333 ± 0.8608 8.3333 ± 0.8608 0.034
CotgSnLs (°) 102.6333 ± 1.8977 100.6333 ± 1.8977 0.047
Ls-NsPog’ (mm) –1.0000 ± 0.4315 –1.0000 ± 0.4315 0.915
Li-NsPog’ (mm) 2.0333 ± 0.6370 2.0333 ± 0.6370 0.971
Jarbak ratio (p = 0.021), ANS-Me (p = 0.043), IMPA all measurements in this study were carried out by
(p = 0.032), Mand1-NB (p = 0.043), SnPerp-Pog’ one examiner. In this study, the overall differences of
(p = 0.041) and CotgSnLs (p = 0.023). When comparing landmark location between the two modalities were
hand tracing initial and Retracing 1-week later statistically significant. The extent of difference for
(Table 3), Jarabak ratio (p = 0.043), ANS-Me each landmark depends on the radiographic
(p = 0.021), Snperp-Pog’ (p = 0.042) and nasolabial complexities, which are also associated with the
angle (p = 0.032) showed significant difference. reliability of landmarks. The representation of
head films and observers should be considered as
Between Vistadent tracing initial and retracing 1-week
possible sources of error when comparing computer-
later (Table 4), Snperp-Pog’ (p = 0.047) and CotgSnLs
aided cephalometric analysis based on conventional
(p = 0.032) showed significant difference. When radiographs and digitized images.
comparing hand and vistadent retracing 1-week later
(Table 5), Nperp-pog (p = 0.043), Jarabak ratio Between hand tracing and Vistadent tracing, out of
(p = 0.023), ANS-Me (p = 0.034), Snperp-Pog’ 16 skeletal variables compared, three variables showed
(p = 0.034) and CotgSnLs (p = 0.047) showed significant difference i.e., Pog-N-perp (p = 0.032),
significant difference. Jarabak ratio (p = 0.021) and ANS-Me (p = 0.043).
The uncertainty in locating the Me and Gn points
Discussion may be caused by the difficulty of delineating a
landmark on a curved anatomical boundary. Lim and
Landmark identification from digital images can Foong,5 in his article ‘Phosphor-stimulated computed
be affected by several factors such as spatial and cephalometry, reliability of landmark identification’
contrast resolution of the display device, background stated anatomical landmarks with low radiodensity,
luminance level and luminance range of the display e.g., orbitale; a point and those ending in thin taper,
system, brightness uniformity, extraneous light e.g., anterior and posterior nasal spine tend to be less
in the reading room, displayed field size, viewing reliable. Chen et al17 assessed landmark identification on
distance magnification functions and user interface as digital images in comparison with those obtained from
stated by Yu et al.10 Linear measurements may be original radiographs and reported low reproducibility
affected by the inclination of the reference line, and for Go, Me, and Po25. Santoro et al11 evaluated the
angular measurements cannot indicate correctly accuracy of cephalometric measurements obtained
the jaw relationship in the case of extreme facial with digital tracing software compared with equivalent
divergence as stated by Williams et al.16 Therefore, it is hand-traced measurement and reported differences
reasonable to evaluate a set of structural relationships between the two methods for SNA, ANB, S-Go:
by multiple cephalometric parameters rather than by N-Me, U1/L1, L1-GoGn and N-ANS:ANS-Me were
a single parameter. This is the reason why as many as statistically significant.
37 variables were included in our customized
Among the 10 dental variables compared, two showed
cephalometric analysis.
significant difference i.e., IMPA (p = 0.032) and
The cephalometric radiographs used in this study L1-NB (p = 0.043). The significant measurement
were randomly selected and represented the quality of difference for L1-NB angle could be due to differences
daily routine work. The skeletal, dental and soft tissue in the horizontal component of the location of
variables used in this study were commonly used Gonçalves et al2 in comparison of cephalometric
cephalometric variables for orthodontic diagnosis, measurements from three radiological clinics stated
treatment planning and evaluation of treatment IMPA cephalometric measurements presented
results. with statistically significant difference. In order to
determine the error of both conventional and digitized
Landmark identification is greatly affected by operator cephalometric methods, a study by Martins et al7
experience, which might be as important as the demonstrated that regardless of the method used, the
tracing method itself. Because interoperator error has incorporation of errors may occur, particularly for
in general been found to be greater than intraoperator those measurements involving incisors, which present
error as stated by Sayinsu et al,12 to minimize the error a greater number of errors.
Among the soft tissue variables SnPerp-Pog’ 4. Quintero JC, Trosien A, Hatcher D, Kapila S. Cranio-
(p = 0.041) and nasolabial angle (p = 0.023) showed facial imaging in orthodontics: historical perspective,
significant difference. The results of nasolabial current status, and future developments. Angle Orthod
1999;69(6):491-506.
angle coincides with the results of Celik et al1
nasolabial angle, depends on landmarks that are placed 5. Lim KF, Foong KW. Phosphor-stimulated computed
on a curve with wide radii which show proportionally cephalometry: reliability of landmark identification.
Br J Orthod 1997;24(4):301-8.
greater errors of measurements as reported by
Baumrind and Frantz.13,14 This type of error can 6. Gregston MD, Kula T, Hardman P, Glaros A, Kula K.
A comparison of conventional and digital radiographic
be made regardless of the method (digital-manual)
methods and cephalometric analysis software: I-Hard
used for measurement as reported by Sayinsu et al.12
tissue. Semin Orthod 2004;10(3):204-11.
When comparing hand tracing, initial and retracing
7. Martins LP, Pinto AS, Martins JCR, Mendes AJD. Error
1-week later, out of 16 skeletal variables two variables
reproducibility of cephalometric analysis of Steiner and
Jarabak ratio (p = 0.043) and ANS-Me (p = 0.021) Ricketts, the conventional method and the computerized
showed significant difference. Among the soft tissue method. Orthodontics 1995;28(1):4-17.
variables SnPerp-Pog’ (p = 0.042) and nasolabial angle
8. Ricketts MM. Perspectives in the clinical application
(p = 0.032) showed significant difference. Between of cephalometries. The first fifty years. Angle Orthod
Vistadent tracing, initial and retracing 1-week later, 1981;51(2):115-50.
among the soft tissue variables SnPerp-Pog’ (p = 0.047) 9. Sandler PJ. Reproducibility of cephalometric measure-
and nasolabial angle (p = 0.032) showed significant ments. Br Orthod 1988;15(2):105-10.
difference.
10. Yu SH, Nahm DS, Baek SH. Reliability of
When comparing hand and Vistadent retracing 1-week landmark identification on monitor-displayed lateral
later, out of 16 skeletal variables three variables - Nperp- cephalometric images. Am J Orthod Dentofacial Orthop
2008;133(6):790.e1-6;discussion e1.
Pog (p = 0.043), Jarabak ratio (p = 0.023), ANS-Me
(p = 0.034) showed significant difference. Among 11. Santoro M, Jarjoura K, Cangialosi TJ. Accuracy of
digital and analogue cephalometric measurements
the soft tissue variables SnPerp-Pog’ (p = 0.034)
assessed with the sandwich technique. Am J Orthod
and nasolabial angle (p = 0.047) showed significant Dentofacial Orthop 2006;129(3):345-51.
difference.
12. Sayinsu K, Isik F, Trakyali G, Arun T. An evaluation of
Conclusion the errors in cephalometric measurements on scanned
cephalometric images and conventional tracings. Eur J
The study indicates that most of the variables show Orthod 2007;29(1):105-8.
consistency between manual tracing and computerized 13. Baumrind S, Frantz RC. The reliability of head film
tracing while most of the cephalometric variables were measurements. Landmark identification. Am J Orthod
reliable. 1971;60(2):111-27.
14. Baumrind S, Frantz RC. The reliability of head film
Suggested Reading measurements. 2. Conventional angular and linear
1. Celik E, Polat-Ozsoy O, Toygar Memikoglu TU. measures. Am J Orthod 1971;60(5):505-17.
Comparison of cephalometric measurements with digital
15. Trindade Junior AS, Adams GA, Capelozza Son L.
versus conventional cephalometric analysis. Eur J Orthod
Rapid maxillary expansion: a prospective cephalometric
2009;31(3):241-6.
analysis. Orthodo 1999;32(1):45-56.
2. Gonçalves FA, Schiavon L, Pereira Neto JS, Nouer DF.
Comparison of cephalometric measurements from three 16. Williams S, Leighton BC, Nielsen JH. Linear evaluation
radiological clinics. Braz Oral Res 2006;20(2):162-6. of the development of sagittal jaw relationship. Am
J Orthod 1985;88:(3)235-41.
3. Geelen W, Wenzel A, Gotfredsen E, Kruger M,
Hansson LG. Reproducibility of cephalometric 17. Chen YJ, Chen SK, Chang HF, Chen KC. Comparison
landmarks on conventional film, hardcopy, and monitor- of landmark identification in traditional versus
displayed images obtained by the storage phosphor computer-aided digital cephalometry. Angle Orthod
technique. Eur J Orthod 1998;20(3):331-40. 2000;70(5):387-92.
n n n
Abstract
Peripheral ameloblastoma (PA) is a rare soft tissue neoplasm of odontogenic origin that arises in the tooth-bearing gingiva of
the maxilla and mandible. This article describes a case of PA located in the lingual gingiva of the mandible in a 48-year-old
male with a review of the English literature.
Key words: Peripheral ameloblastoma, lingual gingiva, soft tissue ameloblastoma, extraosseous ameloblastoma, ameloblastoma
of the gingiva
P
eripheral ameloblastoma (PA) is a relatively extending from the lingual gingiva spanning from the
uncommon odontogenic tumor that is mandibular left central incisor to the left canine. The
histologically identical to the classic intraosseous growth was ovoid, reddish grey in color, firm and fixed
ameloblastoma.1 It originates in the soft tissues of to the underlying structures and measured 1 × 1 cm2
the oral cavity namely alveolar mucosa or gingiva.2 approximately. All the involved teeth tested vital.
It accounts for 1-5% of all ameloblastomas.3,4 Kuru,
first reported PA in 1911.5,6 However, Philipsen et al The patient had a very poor oral hygiene and also
stated that what Kuru described was not a peripheral, suffered from generalized periodontitis. The patient’s
but rather an intraosseous ameloblastoma having social history was significant for use of chewing betel
penetrated through the alveolar bone, fused with the nut quid and consumption of alcohol for the past
oral epithelium and eventually presented itself clinically five and 15 years, respectively. The radiographic
as a ‘peripheral lesion’. examination did not reveal any signs of bone
involvement (Fig. 1).
They also supported the fact that the first completely
documented case of a PA must be attributed to The differential diagnosis included: Pyogenic
Stanley and Krogh, who defined the clinical and granuloma, peripheral ossifying fibroma and benign
histopathologic characteristics of the lesion in 1959.5-8 fibrous lesion. The growth was surgically excised
This article describes a case of gingival PA of the under local anesthesia. The mass could be easily
mandible and reviews the English literature. separated from the underlying bone but there was
profuse bleeding associated with it. The surgical wound
Case Report healed uneventfully.
A 48-year-old male patient reported to our OPD with On microscopic examination, the tissue depicted dense
a complaint of growth on the lingual aspect of the left connective tissue stroma containing islands and cords
side of the mandible. The growth had been present for of odontogenic epithelium. Some portion of the lesion
the previous 1-year and was slowly increasing in size. was covered by stratified squamous epithelium with
The intraoral examination disclosed a nontender mass mild acanthotic changes (Fig. 2).
Many islands and cords showed microcyst formation
*Assistant Professor and central polygonal cells surrounded by ameloblast-
**Associate Professor, Dept. of Oral Pathology
†
Associate Professor, Dept. of Oral Surgery like cells (Fig. 3). Some islands exhibited squamous
Dr HSJ Institute of Dental Sciences and Hospital, Chandigarh metaplasia of the central stellate reticulum-like cells
Address for correspondence
Dr Renu Yadav (Fig. 4). The histologic findings were consistent with a
House No.: 924, Ashirwad Enclave
Sector-49-A, Chandigarh -160 047
diagnosis of peripheral ameloblastoma, follicular type
E-mail: renyadava@gmail.com with acanthomatous changes.
Figure 1. No bone involvement is seen in the IOPA. Figure 2. Surface epithelium showing acanthosis (H&E
stain, X10).
Figure 3. Islands and cords of odontogenic epithelium Figure 4. Island exhibiting squamous metaplasia of the central
showing microcysts and central polygonal cells surrounded stellate reticulum-like cells (H&E stain, X40).
by ameloblast-like cells (H&E stain, X10).
small lesions have an inferior margin that is usually tuberosity region was the most common followed by
superficial to the cortical bone. The large lesions have premolar region.12 In the present case the lesion was
an advancing margin that produces a cup-shaped found in the mandibular anterior region and the age
resorption of the cortical plate. Occasionally, there will of the patient was 48 years which is well within the
be a superficial saucerization of the cortical plate seen age range mentioned in the literature.
radiologically or at surgery.14 Cupping or saucerization
In Philipsen et al’s study, the extragingival lesions were
is thought to be due to pressure resorption6,16 in
not accepted under the diagnosis of PA.7 They further
contrast to resorption caused by neoplastic invasion.7
quoted that the extragingival lesions most likely
PA is rarely the initial presenting diagnosis to be made.7 represent basal cell adenomas with a histopathological
The differential diagnosis must be made with fibrous resemblance to an ameloblastoma or the rare
nodule, gingival tumors, peripheral odontogenic ameloblastoid variant of the squamous cell carcinoma.
fibroma, peripheral ossifying fibroma, pyogenic It is characteristic that all cases reported as extragingival
granuloma, peripheral giant-cell granuloma, papilloma, PA developed around the orifices of either the Stensen’s
peripheral squamous odontogenic tumor and other duct or the Wharton’s duct and could thus represent
hyperplastic swellings superficial to the alveolar tumors of salivary origin. In addition seven cases of
ridge.3,7,14,17 When the PA arises on the edentulous extragingival PA have been reported out of which six
alveolar mucosa in denture wearing patients, the PA were found in the buccal mucosa and one in the floor
may be diagnosed as denture irritation hyperplasia. of the mouth.22,23
However, the final diagnosis requires histologic Two histogenetic origins for the PA have been proposed.
evaluation.7 Tumors that show complete separation from overlying
PA accounts for 1-10% for all ameloblastomas.18 surface epithelium probably arise from odontogenic
According to Philipsen et al PA comprises 2-10% epithelial remnants. Tumors showing direct extension
of all ameloblastomas. They also mentioned that PA from the surface epithelium may arise from the basal
is in fact more prevalent than hitherto anticipated7 cell layer of the overlying epithelium,9,10,24,25 although
whereas according to WHO, PA comprises 1.3-10% a collision phenomenon cannot be entirely ruled
of all ameloblastomas.8,13 The age range of the patients out.1,17,26 The gross specimen consists of a firm to
with PA as reported by Philipsen et al is between slightly spongy mass of pink to pinkish grey color.
9 and 92 years at the time of diagnosis with an overall The cut surface may contain minute cystic spaces filled
average of 52.1 years.6-8 Pekiner et al and Shiba et al with clear, pale yellow fluid.7 Histologically, the tissue
have documented patients’ age range to be between is composed of islands and strands of odontogenic
23-82 years.14,19 According to Gurol et al the average epithelium, usually resembling the follicular pattern
age was 62 years.20 The PA is more commonly seen of intraosseous ameloblastoma. Most of the islands
in men with a male-to-female ratio of 1.9:1.7,8,13 In a exhibit palisading of columnar basal cells and a stellate
study by El-Mofty and Gurol, no gender predilection reticulum is seldom conspicuous.7,14 The epithelial
was found.1,20 A male-to female ratio of 1.7:1 has been islands commonly exhibit the acanthomatous variant
observed by Mintz and Buchner in their studies.15,16 of this pattern, with central areas of keratin formation,
or the cystic pattern. In some lesions, the epithelial
Mandible has been clearly the most common site of strands are in continuity with the surface epithelium
occurrence for PA.7,12,15,20,21 The maxilla-to-mandible and appear to arise from this origin. The epithelial
ratio is 1:2.46,13 with the mandibular premolar region to islands and strands are usually surrounded by fibrous
be the most common site of involvement15,19 followed tissue.14 Literature reveals a documented case of a
by anterior mandibular region and maxillary tuberosity. PA with clear cells differentiation. The lesion in this
In the mandible, the lingual aspect of the gingiva is case depicted a follicular pattern with few islands
the most common site of involvement.7 According to exhibiting acanthomatous changes. The clear cells have
Zhu et al’s study of 16 cases, the sites of involvement vesicular, centrally placed nuclei and faintly granular
in the mandible were the canine-premolar region, or vacuolated cytoplasm.27 Redman et al reported 0.4
molar region, incisor region while in the maxilla, the mitotic figures per field (207 in 477 fields) and those
The recommended treatment for peripheral 7. Philipsen HP, Reichart PA, Nikai H, Takata T,
Kudo Y. Peripheral ameloblastoma: biological profile
ameloblastoma differs from the treatment of other
based on 160 cases from the literature. Oral Oncol
forms of ameloblastoma because the tumor is usually 2001;37(1):17-27.
small and remains localized to the superficial soft
8. Gomes CC, Garcia BG, Gomez RS, de Freitas JB,
tissue.14 Most lesions are successfully managed with Mesquita RA. A clinical case of peripheral ameloblastoma.
local excision that includes a small margin of normal Braz J Oral Sci 2007;6(21):1364-6.
tissue.14,31,32 The inferior margin should include the 9. Vanoven BJ, Parker NP, Petruzzelli GJ. Peripheral
periosteum to ensure that bone penetration has not ameloblastoma of the maxilla: a case report and literature
occurred. review. Am J Otolaryngol 2008;29(5):357-60.
According to Ide et al en bloc resection seems curative 10. Ide F, Mishima K, Miyazaki Y, Saito I, Kusama K.
Peripheral ameloblastoma in-situ: an evidential fact of
when PA presents as a large papillary tumor (larger
surface epithelium origin. Oral Surg Oral Med Oral Pathol
than 1.5-2.0 cm) with an erosion of the underlying Oral Radiol Endod 2009;108(5):763-7.
bone.32,33 Ide et al34 suggested that large size (over 2
11. Woo SB, Smith-Williams JE, Sciubba JJ, Lipper S.
cm in diameter) is a powerful predictor of aggressive
Peripheral ameloblastoma of the buccal mucosa: case
behavior of PA, no matter how bland.34 PA does not report and review of the English literature. Oral Surg
show invasive behavior and conservative excision is Oral Med Oral Pathol 1987;63(1):78-84.
the treatment of choice. The recurrence rate is low 12. Zhu EX, Okada N, Takagi M. Peripheral ameloblastoma:
(16-19%).8,13 Long-term follow-up is recommended24,31 case report and review of literature. J Oral Maxillofac
especially for lesions with aggressive behavior.13,22,33 Surg 1995;53(5):590-4.
The present case was treated by surgical excision with 13. WHO classification of tumors. Pathology and
wide margins and has not shown any recurrence in the Genetics of Head and Neck Tumors Chapter 6.
2-year follow-up. Odontogenic tumors; IARC: Lyon 2006:297-8.
14. Pekiner FN, Özbayrak S, Şener BC, Olgaç V, and review of the literature. Int J Oral Surg
Sinanoğlu A. Peripheral ameloblastoma: a case report. 1983;12(1):51‑5.
Dentomaxillofac Radiol 2007;36(3):183-6. 25. Califano L, Maremonti P, Boscaino A, De Rosa G,
15. Mintz S, Anavi Y, Sabes WR. Peripheral ameloblastoma Giardino C. Peripheral ameloblastoma: report of a
of the gingiva. A case report. J Periodontol case with malignant aspect. Br J Oral Maxillofac Surg
1990;61(10):649‑52. 1996;34(3):240-2.
16. Redman RS, Keegan BP, Spector CJ, Patterson RH. 26. Gardner DG. Peripheral ameloblastoma: a study of 21
Peripheral ameloblastoma with unusual mitotic activity cases, including 5 reported as basal cell carcinoma of the
and conflicting evidence regarding histogenesis. J Oral gingiva. Cancer 1977;39(4):1625-33.
Maxillofac Surg 1994;52(2):192-7. 27. Ng KH, Siar CH. Peripheral ameloblastoma with clear
17. Orsini G, Fioroni M, Rubini C, Piattelli A. Peripheral cell differentiation. Oral Surg Oral Med Oral Pathol
ameloblastoma: a report of 2 cases. J Periodontol 2000; 1990;70(2):210-3.
71(7):1174-6. 28. Curtis NJ, Zoellner H. Surgical management of an
ameloblastoma in soft tissues of the cheek. Br J Oral
18. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral
Maxillofac Surg 2006;44(6):495-6.
and maxillofacial pathology. In: Odontogenic Cysts and
Tumors. 3rd edition, Neville BW, Damm DD, Allen 29. Kishino M, Murakami S, Yuki M, Iida S, Ogawa I,
CM, Bouquot JE, (Eds.), Elsevier: Noida 2009:710. Kogo M, et al. An immunohistochemical study of the
peripheral ameloblastoma. Oral Dis 2007;13(6):575‑80.
19. Shiba R, Sakoda S, Yamada N. Peripheral ameloblastoma.
J Oral Maxillofac Surg 1983;41(7):460-3. 30. Lentini M, Simone A, Carrozza G. Peripheral
ameloblastoma: use of cytokeratin 19 and Ber-EP4
20. Gurol M, Burkes EJ Jr. Peripheral ameloblastoma. to distinguish it from basal cell carcinoma. Oral
J Periodontol 1995;66(12):1065-8. Oncol Extra 2004;40(6-7):79-80.
21. Smullin SE, Faquin W, Susarla SM, Kaban LB. Peripheral 31. Anneroth G, Johansson B. Peripheral ameloblastoma.
desmoplastic ameloblastoma: report of a case and Int J Oral Surg 1985;14(3):295-9.
literature review. Oral Surg Oral Med Oral Pathol Oral
32. Ide F, Kusama K, Tanaka A, Sakashita H. Peripheral
Radiol Endod 2008;105(1):37-40.
ameloblastoma is not a hamartoma but rather more of a
22. Isomura ET, Okura M, Ishimoto S, Yamada C, neoplasm. Oral Oncol 2002;38(3):318-20.
Ono Y, Kishino M, et al. Case report of
33. Tajima Y, Kuroda-Kawasaki M, Ohno J, Yi J,
extragingival peripheral ameloblastoma in buccal Kusama K, Tanaka H, et al. Peripheral ameloblastoma
mucosa. Oral Surg Oral Med Oral Pathol Oral Radiol with potentially malignant features: report of
Endod 2009;108(4):577-9. a case with special regard to its keratin profile.
23. Ramnarayan K, Nayak RG, Kavalam AG. Peripheral J Oral Pathol Med 2001;30(8):494-8.
ameloblastoma. Int J Oral Surg 1985;14(3):300-1. 34. Ide F, Kusama K. Difficulty in predicting biological
24. Patrikiou A, Papanicolaou S, Stylogianni E, behavior of peripheral ameloblastoma. Oral Oncol
Sotiriadou S. Peripheral ameloblastoma. Case report 2004;40(6):651-2.
n n n
Abstract
Periodontal disease is considered an inflammatory disorder that damages tissue through the complex interactions between
periodontopathic bacteria and host defense systems. It is likely that the role of reactive oxygen species (ROS) is common
to both bacterial- and host-mediated pathways of tissue damage. In recent years, there has been a tremendous expansion in
the medical and dental research concerned with free radicals (FR), ROS and antioxidant defense mechanisms. This review is
intended to provide a critical up-to-date summary of the field with particular emphasis on the evidence for oxidative damage
and compromised antioxidant status in periodontal diseases.
Key words: Reactive oxygen species/free radicals, antioxidants, polymorphonuclear neutrophils, periodontal disease
P
eriodontitis, an inflammatory disease, is phagocytic or soluble stimulus, both neutrophils and
considered to be initiated and perpetuated by macrophages experience a ‘respiratory burst’, which is
a small group of predominantly gram-negative, characterized by an increase in oxygen consumption,
anaerobic or microaerophilic bacteria that colonize the activation of the hexose-monophosphate (HMP)
subgingival area. Bacteria cause the observed tissue shunt and generation of free radicals (FR), reactive
destruction directly by toxic products and indirectly by species and their metabolic products.5 At sites of chronic
activating host defense systems (i.e. inflammation).1 inflammation, there is considerable over production of
FR and reactive species.
Polymorphonuclear Leukocytes: A Key
Role in Periodontitis Free Radicals Definition and Formation
Polymorphonuclear leukocytes (PMNs) are the A FR may be defined as an atomic or molecular
predominant leukocytes in blood and constitute the species capable of independent existence with one or
primary cellular host resistance factor against infection.2 more unpaired electrons in its structure.6 FR can be
In the oral cavity, following plaque accumulation positively (NAD°+) or negatively charged (O2°¯) or
and the development of clinical inflammation, 90% electrically neutral (OH°).
of leukocytes that enter the gingival crevicular fluid
(GCF) and 50% of those that infiltrate junctional A feature of the reactions of FR is that they tend to
epithelium are PMNs.3 proceed as chain reactions, one radical begets another
one and so on.6 The reactive species including reactive
PMNs possess at least two main pathways for oxygen species (ROS), reactive chlorine species (e.g.,
controlling micro-organisms (i.e., oxidative and HOCl hypochlorous acid) and reactive nitrogen species
nonoxidative) which either kill bacteria, influence (RNS) are produced in large quantities by activated
bacterial growth or modify bacterial colonization in neutrophils.7
relation to the periodontium.4 Upon recognition of a
ROS Definition and Formation
In recent years the term ROS has been adopted to
*Reader
**Professor and Head, Division of Periodontia, RMDCH include molecules such as hydrogen peroxide (H2O2),
Annamalai University, Chidambaram, Tamil Nadu hypochlorous acid (HOCl) and singlet oxygen (1O2),
Address for correspondence
Dr S Lakshmi Sree which whilst not radicals in nature, are capable of
Aishwaryam, 7(110), 8th Cross, Kanagasabai Nagar radical formation in the extra- and intracellular
Chidambaram, Tamil Nadu - 608 001
E-mail: periolakshmi@gmail.com environments.3
The most important species implicated in inflammatory Protein damage, including gingival hyaluronic acid
injuries to tissues are the hydroxyl (OH°) radical, and proteoglycans.8
the superoxide anion (O2°¯), the nitric oxide (NO°) Oxidation of important enzymes e.g. antiproteases
radical (where ‘°’ signifies an unpaired electron) and such as α-1antitrypsin.
hypochlorous acid, hydrogen peroxide and 1O2, which
Stimulation of pro-inflammatory cytokine release
are ROS.3
by monocytes and macrophages by depleting
Potential Mechanisms for Periodontal intracellular thiol compounds and activating
Tissue Destruction by ROS (Fig. 1) nuclear factor kB (NFkB).
Whilst most ROS have extremely short half-lives as Recent reports1 have also suggested that ROS are
10–9 to 10–6 s (Pryor 1986), they can cause substantial produced by osteoclasts at the ruffled border/bone
tissue damage by initiating free radical chain reactions. interface and may play a role in resorption. However,
Different mechanisms, which mediate tissue damage, certain ROS, such as superoxide and hydrogen peroxide
include the following:3 have been found to play a role in the activation of
DNA damage osteoclasts, rather than in the direct degradation
Lipid peroxidation (through activation of cyclo- of the bone matrix, whilst NO has been found to
oxygenases and lipo-oxygenases). inhibit bone resorption.
Periodontal Pathogens
Crevicular/Junctional Inflammatory
TIMPs ↓
cytokines,
epithelium + other PDL cells IL-8
MMPs ↑ chemokines,
Receptor mediated adhesion GM-CSF
TNF-α E-selectin
Osteoclast molecules, etc.
Activation of NF-κB & AP-1 LPS LPS
Activation/ e.g. TNF-α, IL-1, IL-8
GM-CSF, TNF-α
Differentiation Nonreceptor mediated
E-selectin
Release of traditional
inflammatory mediators
Generation of
Tissue
oxidation products -
Damage Lipid peroxides,
oxidized proteins
Inactivation of TIMPs
Figure 1. Simplified diagram illustrating a central role of ROS in generating chronic inflammation and tissue damage in
response to periodontal pathogens.
MMP = Matrix metalloproteinase; TIMP = Tissue inhibitor of matrix metalloproteinase; NF-κB = Nuclear factor kappa B; AP-1 = Activating protein-1;
PDL = Periodontal ligament; TNF = Tumor necrosis factor; IL = Interleukin; GM-CSF = Granulocyte-macrophage colony-stimulating factor;
LPS = Lipopolysaccharide; ROS = Reactive oxygen species.
Garrett et al9 demonstrated both in vivo and in vitro Table 1. A Functional Classification of Antioxidant
that when free oxygen radicals were generated in Systems
the bone environment, osteoclasts were formed and Types of Mode of action Examples
bone resorption occurred. Few studies have addressed defense
the degradation of the periodontal extracellular matrix system
by ROS. Earlier studies by Bartold et al8 demonstrated Preventive Suppress the formation Catalase, GPX and
antioxidants of FR: Nonradical serum-transferase
the in vitro ability of ROS particularly the OH° species,
decomposition of
to degrade hyaluronan and proteoglycans extracted LOOH and H2O2
from porcine gingivae and within cryostat sections
Sequestration of metal Transferrin,
of tissue. by chelation ceruloplasmin,
albumin, haptoglobin
Proteoglycans and glycosaminoglycans (GAGs) when
Quenching of active O2 SOD, carotenoids
exposed to a broad-spectrum of ROS species of
differing reactivity and over differing periods of time Radical- Scavenge radicals to Lipophilic: Ubiquinol,
scavenging inhibit chain initiation vitamin A, vitamin E,
were found to undergo chain depolymerization and antioxidants and break chain carotenoids
residue modification to varying degrees, particularly propagation Hydrophilic: Uric
in the presence of the highly reactive OH° species. acid, ascorbic acid,
Moreover, the nonsulfated GAG, hyaluronan was albumin, bilirubin
identified as being more susceptible to degradation by Repair and Repair the damage DNA repair
ROS than sulfated GAG.1 de novo and reconstitute enzymes, protease,
enzymes membranes transferase, lipase
The highly reactive OH° species was also shown to
exert the most detrimental degradative effects on the
small chondroitin sulfate, proteoglycans from alveolar Superoxide Dismutase
bone, compared to other ROS.1
Superoxide dismutase (SOD) is an antioxidant enzyme
Antioxidants: What are they and how do that catalyses the dismutation of the highly reactive
they Act? superoxide anion to O2 and to the less reactive species
“An antioxidant is any substance that, when present at H2O2, accelerating it upto 10,000 times.2
low concentrations compared to those of an oxidisable 2O2°¯ + 2H+ SOD
H2O2 + O2
substrate, significantly delays or prevents oxidation of
that substrate”.2 In humans, there are three forms of SOD: Cytosolic
Cu/Zn-SOD, mitochondrial Mn-SOD and extra-
Several biologically important compounds have been cellular SOD (EC-SOD). Though, Cu/Zn-SOD
reported to have antioxidant functions. These include is believed to play a major role in the first-line of
vitamin C (ascorbic acid), vitamin E (α-tocopherol), antioxidant defense, recent reports have revealed
vitamin A, b-carotene, metallothionein, polyamines, that Mn-SOD is essential for life whereas Cu/Zn-SOD
melatonin, nicotinamide adenine dinucleotide is not.10 SOD has been localized within human
phosphate (NADPH), adenosine, co-enzyme Q-10, periodontal ligament and may represent an important
urate, ubiquinol, polyphenols, flavonoids, phytoe- defense mechanism with in gingival fibroblasts against
strogens, cysteine, homocysteine, taurine, methionine, excess superoxide release.11
S-adenosyl-L-methionine, resveratrol, nitroxides,
reduced glutathione (GSH), glutathione peroxidase Catalase
(GPX), superoxide dismutase (SOD), catalase (CAT),
Catalase (CAT) is an antioxidant enzyme, which
nitric oxide synthase (NOS), heme oxygenase-1
contains heme bound iron and is mainly located in
(HO-1) and eosinophil peroxidase (EPO).10
peroxisomes.2 It reacts very efficiently with H2O2 to
A functional classification of antioxidant systems based form water and molecular oxygen and with hydrogen
on the way they act (Niki 1996) appears to be the donors (methanol, ethanol, formic acid or phenols)
most useful (Table 1).2 with peroxidase activity.10
antioxidant status lack relevance or significance, given between cases and controls. However, no difference was
their low concentrations and rates of activity, relative reported in the SOD activity in GCF of periodontitis
to the antioxidant scavengers. subjects.29
Salivary Antioxidant Status in Periodontal Reduced GSH was the most important antioxidant in
Diseases GCF with levels 1,000-fold higher than paired plasma
samples27 and was significantly lower in periodontitis
Moore et al,19 who were the first to explore salivary relative to matched control subjects.22
total antioxidant activity found no difference in TAOC
levels in periodontitis and nonperiodontitis subjects. The antioxidant enzyme GPX correlated negatively with
The predominant antioxidant component of saliva was pocket depth and attachment loss and increased post-
uric acid (>70% of antioxidant activity). therapy (Hung et al 2000).12 However, significantly
greater levels of GPX, lactoferrin, myeloperoxidase and
However, Chapple et al20 found lower total antioxidant IL-1b in the GCF were in periodontally diseased sites
concentration in the saliva of periodontitis patients when compared to healthy sites.30,31
when compared to periodontally healthy controls.
Studies investigating oxidative stress and antioxidant
Similar results were observed in a larger cohort study21 status both locally and peripherally (in serum, saliva
and in small case-control studies (Diab Ladki et al12 and GCF) in periodontitis patients reported higher
and Brock et al15). Lower TAOC was reported in levels of malondialdehyde and total oxidant status,
women than men. A higher level of protein carbonyls which decreased following Phase I therapy.32-34
(oxidative stress) was found in periodontitis patients
than in controls.21 Tsai et al22 reported a positive correlation between
GCF lipid peroxidation and periodontopathogens
Salivary antioxidant levels (SOD, GPX, reduced GHS, and a negative correlation between GCF GPX and
ascorbic acid, a-tocopherol) were observed to be lower periodontopathogens. They concluded that the
in periodontitis patients22,23 as well as in patients under increased levels of lipid peroxidation with decreased
antiepileptic therapy with gingival hyperplasia.24 level of antioxidants provided the evidence that
Markers of oxidative damage such as malondial- oxidative stress, after the stimulation of periodonto-
dehyde23,25 8-hydroxy-deoxy-guanosine23,26 were found pathogens might play a role in the pathogenesis of
to be higher in saliva of patients with periodontitis periodontitis.
which decreased following initial treatment appro- A negative correlation between serum and GCF
aching the mean control values.26 TAOC and gingival inflammation was reported in
miniature poodle dogs (Pavlica et al 2004).12 Similarly,
Overall, the relevance of saliva as a medium for
TAOC in the GCF of periodontitis subjects was
assessing surrogate markers of reactive oxygen and
significantly lower.15 Based on GCF studies, it can be
antioxidant species in periodontitis patients must be
concluded that local antioxidant scavenging defenses
open to question. Moreover, saliva contains GCF and
are compromised in periodontitis, but whether this
the contribution of GCF antioxidants to saliva will
represents a predisposition to disease or results from
vary according to the degree of salivary stimulation.27
the inflammatory lesion is not clear.
GCF Antioxidant Status in Periodontal
Diseases Periodontal Tissue Antioxidant Status in
Periodontal Diseases
GCF is the most appropriate fluid to sample
Gingivitis subjects exhibited higher levels of GSH in
when investigating biomarkers of tissue events in
gingival tissue samples when compared to controls
periodontium.
(Giorgi et al, 1992).12 Tissue levels of CAT and
Guarnieri et al28 observed spontaneous generation SOD decreased with increasing pocket depth in
of superoxide in the GCF of periodontitis subjects, periodontitis patients scheduled for extractions.35
with no differences in antioxidant scavenging capacity On the contrary, higher levels of SOD activity was
observed in the GCF and gingival tissue samples of 2. Battino M, Bullon P, Wilson M, Newman H.
periodontitis patients.29 Oxidative injury and inflammatory periodontal
diseases: the challenge of antioxidants to free radicals
Smokers with periodontitis exhibited increased and reactive oxygen species. Crit Rev Oral Biol Med
levels of metallothionein (a radical scavenging 1999;10(4):458‑76.
and preventive antioxidant) in the gingival tissue 3. Chapple IL. Reactive oxygen species and antioxidants
indicating a protective response to the increased in inflammatory diseases. J Clin Periodontol 1997;24(5):
inflammation in these patients.36 Another study in 287-96.
smokers37 observed higher levels of HO-1 antioxidant 4. Miyasaki KT. The neutrophil: mechanisms of
enzyme levels in smokers with periodontitis than in controlling periodontal bacteria. J Periodontol
nonsmoker periodontitis patients. Higher levels of 1991;62(12):761‑74.
thiobarbituric acid reactive substances (TBARS), 5. Firatli E, Unal T, Onan U, Sandalli P. Antioxidative
a marker of oxidative stress was found in the activities of some chemotherapeutics. A possible
gingival tissue obtained from unresolved pockets mechanism in reducing gingival inflammation. J Clin
following Phase I therapy in patients with chronic Periodontol 1994;21(10):680-3.
periodontitis.38 In a similar study, Panjamurthy 6. Halliwell B. Tell me about free radicals, doctor: a review.
et al14 also observed higher levels of TBARS and J Royal Soc Med 1989;82(12):747-52.
enzyme antioxidants with lower levels of scavenging 7. Halliwell B. Oral inflammation and reactive species: a
antioxidants in the gingival tissue of periodontitis missed opportunity? Oral Dis 2000;6(3):136-7.
subjects when compared to controls. 8. Bartold PM, Weibkin OW, Thonard JC. The effect of
oxygen-derived free radicals on gingival proteoglycans
Recently, Borges et al39 reported increased activities and hyaluronic acid. J Periodont Res 1984;19(4):
of myeloperoxidase, GPX, glutathione-S-transferase, 390‑400.
oxidized GSH and higher levels of TBARS in gingival
9. Garrett IR, Boyce BF, Oreffo RO, Bonewald L, Poser
tissue of chronic periodontitis patients when compared J, Mundy GR. Oxygen-derived free radicals stimulate
to controls, suggesting a correlation between oxidative osteoclastic bone resorption in rodent bone in vitro and
stress biomarkers and periodontal diseases. Biopsy in vivo. J Clin Invest 1990;85(3):632‑9.
studies are difficult to implement for ethical and 10. Matés JM. Effects of antioxidant enzymes in the
technical reasons, but the limited data so far confirm molecular control of reactive oxygen species toxicology.
the presence of more significant oxidative stress in the Toxicology 2000;153(1-3):83-104.
periodontal tissues of diseased periodontium relative 11. Jacoby BH, Davis WL. The electron microscopic
to control tissue and the apparent upregulation of immunolocalization of a copper-zinc superoxide
antioxidant enzyme systems. dismutase in association with collagen fibers of perio-
dontal soft tissues. J Periodontol 1991;62(7):413‑20.
Conclusion
12. Chapple IL, Matthews JB. The role of reactive oxygen
Whilst a myriad of possible mechanisms leading to the and antioxidant species in periodontal tissue destruction.
destruction of periodontal tissues exist, ROS would Periodontol 2000 2007;43:160-232.
appear to play a significant role in the pathology of 13. Battino M, Ferreiro MS, Bompadre S, Leone L,
periodontal diseases. Oxidative stress observed in a Mosca F, Bullon P. Elevated hydroperoxide levels and
diseased periodontium could result directly from excess antioxidant patterns in Papillon-Lefèvve syndrome.
ROS activity or antioxidant deficiency or indirectly by J Periodontol 2001;72(12):1760-6.
creating a pro-inflammatory state. Novel adjunctive 14. Panjamurthy K, Manoharan S, Ramachandran CR. Lipid
antioxidant and anti-inflammatory strategies to the peroxidation and antioxidant status in patients with
traditional periodontal therapy can help us in achieving periodontitis. Cell Mol Biol Lett 2005;10(2):255‑64.
good clinical results. 15. Brock GR, Butterworth CJ, Matthews JB, Chapple IL.
Local and systemic antioxidant capacity in periodontal
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Yamanaka R, Takeuchi N, et al. Relationship Free Radic Res Commun 1991;15(1):11-6.
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18. Linden GJ, McClean KM, Woodside JV, Patterson
30. Tsai CC, Wei PF, Ho KY. Proinflammatory cytokines
CC, Evans A, Young IS, et al. Antioxidants and
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19. Moore S, Calder KA, Miller NJ, Rice-Evans CA.
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Free Radic Res 1994;21(6):417-25. The investigation of glutathione peroxidase, lactoferrin,
myeloperoxidase and interleukin-1beta in gingival
20. Chapple IL, Mason GI, Garner I, Matthews JB, Thorpe
crevicular fluid: implications for oxidative stress in human
GH, Maxwell SR, et al. Enhanced chemiluminescent
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21. Sculley DV, Langley-Evans SC. Periodontal disease is et al. Lipid peroxidation: a possible role in the induction
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Increased levels of 8-hydroxydeoxyguanosine and superoxide dismutase in serum, saliva and gingival
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37. Chang YC, Lai CC, Lin LF, Ni WF, Tsai CH. The
26. Takane M, Sugano N, Iwasaki H, Iwano Y, Shimizu N,
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Ito K. New biomarker evidence of oxidative DNA
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27. Chapple IL, Brock G, Eftimiadi C, Matthews JB. thiobarbituric acid reactive substance (TBARS) levels
Glutathione in gingival crevicular fluid and it relation after phase I periodontal therapy in patients with chronic
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Valentini AF, Calandriello M. Enhanced superoxide stress markers in patients with periodontal disease.
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Abstract
Implant placement has been a constant challenge in the field of dentistry. This case report demonstrates a novel extraction of
fractured tooth at the cervical region. The tooth was endodontically treated two years back and radiograph revealed periapical
radiolucency. The technique involves atraumatic extraction of root using implant drills followed by placing bone graft and
immediate implant placement.
E
sthetic and functional components play an room for error. Several authors have reported success
integral part in periodontal practice. Implants rates of more than 95%2,4 for implants placed into
today have cascading effect from yesteryears. fresh extraction sites. This case report demonstrates
Extraction was done after thinning the root walls with minimally invasive extraction without flap reflection
the help of the implant drills.1 Extraction of the root and immediate implant placement with single-stage
with periapical lesion was done in totality.2 Implant surgical procedure in the esthetic zone. Peri-implant
sites were prepared and filled with bone graft* and bone defect was minimal, as the implant chosen
then implants were inserted. was wider than the dimensions of the extraction
Immediate implants are placed into a prepared socket. Nevertheless, the periapical void was filled with
bone graft*.
extraction socket following tooth removal. Short-term
animal and human studies have shown these implants Case History
to be comparable with implants placed into healed
bone. The advantages of this procedure include fewer A 27-year-old female patient presented to the Dept.
of Periodontology and Oral Implantology, Sree Balaji
surgical sessions, elimination of the waiting period
Dental College and Hospital complaining of mobile
for socket healing, shortened edentulous time period,
anterior tooth. On clinical examination, tooth number
reduced overall cost, as well as preservation of bone
21 was found to be fractured with the fracture line
height and width.3 Although immediate implants is
running subgingivally (Fig. 1). Radiograph confirmed
more demanding both surgically and prosthetically, that root canal treatment was performed on the tooth
compared to the conventional placement technique, previously with a periapical lesion in relation to tooth
the advantages make it very appealing to patients #21 (Fig. 2). The patient was given the option of
in need of both extraction and implant placement extraction followed by immediate implant placement.
in one sitting. Implant placement in the esthetic Pros and cons of the procedure were explained to
zone is a technique-sensitive procedure with little the patient and informed consent was obtained.
Preoperative evaluation included study of diagnostic
*Postgraduate Student casts, photographs, periapical radiograph and
**Professor and Head
†
Professor
computerized tomography for assessment of implant
‡
Senior Lecturer size, position of implant and anatomical landmarks.
Dept. of Periodontology and Oral Implantology
Sree Balaji Dental College and Hospital, Chennai Surgery was performed according to standard
Address for correspondence
Dr Jebin Paul Nesaline J protocols. After administration of local anesthesia
Dept. of Periodontology and Oral Implantology
Sree Balaji Dental College and Hospital, Chennai - 600 100
(2% lignocaine 1:80,000 adrenaline), the fractured
E-mail: dr.jebin@yahoo.co.in crown was removed (Fig. 3). Root extraction was
Figure 3. Fractured crown removed. Figure 4. Tapered fissure airotor bur used to widen the
root canal.
Figure 5. Pilot implant drill used to thin the root canal wall. Figure 6. Periapical granuloma removed in totality.
initiated with airotor using tapering fissure bur (Fig. 6). The root was extracted atraumatically without
(Fig. 4) to widen the root canal so as to accommodate flap reflection (Fig. 7). A periodontal probe was used
the initial 2 mm implant drill (Fig. 5). Progressive to explore and estimate the integrity of the bony walls
implant drills upto 3.3 mm were used to thin the of the alveolus and periapical radiographs were taken
root wall. Mosquito artery forceps was used to remove to confirm the total removal of the tooth remnants
the root and the periapical granuloma in totality (Fig. 8). It was planned to fill the periapical void
Figure 11. Wrench break at 40 Ncm. Figure 12. Cyanoacrylate tissue adhesive between flap
and implant.
with bone graft (Fig. 9) prior to implant placement*. stability was confirmed by the wrench breaking at
The socket was prepared with sequential drills to place 40 Ncm (Fig. 11). Since primary closure was not
a 4.8 mm diameter implant. After osteotomy, the possible it was decided to close the minor space between
periapical void was filled with bone graft* followed by implant and gingiva with one layer of cyanoacrylate
4.8 × 14 mm implant #placement (Fig. 10). Primary tissue adhesive$ (Fig. 12). Temporary restoration was
Figure 13. Temporary restoration. Figure 14. Three-month postoperative clinical photograph.
Figure 15. Three-month postoperative radiograph. Figure 16. One-year postoperative clinical photograph.
Discussion
Minimally invasive extraction without flap reflection
and immediate implant placement with single-stage
surgical procedure is a sensitive technique. Many
clinicians postpone treatment of sites exhibiting
infection. Novaes et al5 and Villa and Rangert6
Figure 17. One-year postoperative radiograph. recently reported on a case series of patients where
implants were installed immediately after extraction,
provided using an adhesive resin bridge (Fig. 13). and where the extracted teeth exhibited signs of
After surgery postoperative instructions along with periodontal or endodontic infections. At two years
antibiotics and analgesics were prescribed for five days. post-treatment, the cumulative survival rate was 100%.
Patient was placed on regular maintenance protocol. In immediate implant placement, it is very important
n n n
Abstract
Zygomycosis or mucormycosis is an increasingly frequent life-threatening infection caused by opportunistic fungal organisms
of the class zygomycetes. The pathognomonic feature is the presence of invasive aseptate mycelia that are larger than other
filamentous fungi with the hyphae exhibiting right angle and haphazard branching. Usually classified as rhinocerebral,
disseminated and cutaneous types, this classification serves as important predictor of pathogenesis and prognosis. These occur
mostly in immunosuppressed patients including individuals with diabetes (43% exhibit the rhinocerebral form) and patients
with organ transplants and hematologic malignancies. Without early aggressive treatment, the disease follows a dismal and fatal
course. Early recognition and aggressive treatment have reduced the mortality and morbidity. We present a case of rhinocerebral
mucormycosis with palatal perforation who presented with a slowly progressive swelling of the left cheek.
Mucorales - order
Mucoraceae - family
Absidia - genus
Mucor
Rhizomucor
Rhizopus - species
Figure 1a and B. Extraoral and intraoral patient picture.
Cunninghamellacaeae
Case Report
A 60-year-old male patient reported to Dept. of Oral
and Maxillofacial Pathology of Sree Balaji Dental
College and Hospital with a chief complaint of pain
and swelling in the left upper back region since four
days. History revealed that left upper first molar
was extracted 15 days back due to compromised
periodontal status in a private clinic.
Past medical history revealed that the patient is a non-
insulin-dependent diabetes mellitus (NIDDM) and
under medication. Patient had been hospitalized few
Figure 2. CT scan reveal soft tissue mass in left maxillary
years back for high increase in glucose and hematuria. sinus.
Extraoral manifestation showed diffuse swelling over
the left upper cheek region, with signs of inflammation
(Fig. 1a).
Intraorally a linear ragged ulcer with 0.5 × 2 cm
dimension appreciated in the mid palatine region
(hard palate). The border of the ulcer was raised,
erythematous with lateral area of exposed bone
(Fig. 1b).
Provisional diagnosis was given as squamous cell
carcinoma of palate, necrotizing sialometaplasia, Figure 3. H&E aseptate hyphae branching at acute angle
mucormycosis and midline lethal granuloma. CT scan (10x and 40X).
suggested soft tissue mass in the left maxillary sinus
eroding and destroying medial and lateral wall of formation (Fig. 3). Periodic acid-Schiff (PAS)
maxillary sinus (Fig. 2). stain suggested a final diagnosis of mucormycosis
(Fig. 4a and b).
Hemogram showed mild polymorphonuclear
leukocytosis. Biochemical investigation showed HbA1C The patient was started on IV amphotericin B
of 8.7%. Random blood sugar was 193 mg/dl and 60 mg in four divided doses, cefotaxime lg b.i.d. and
associated with ketonuria. An incisional biopsy was metronidazole 500 mg t.d.s. Amphotericin-induced
done under glycemic control. Histopathological nephrotoxicity was monitored carefully. Surgical
examination was characterized by nonseptate hyphae debridement of the necrotic tissues was done under
with acute right angle branchings suggestive of mucor general anesthesia and a temporary palatal obturator
species with focal areas of necrosis and thrombi was given.
9. Husain S, Alexander BD, Munoz P, Avery RK, Infections in patients with diabetes mellitus. N Engl J
Houston S, Pruett T, et al. Opportunistic mycelial fungal Med 1999;341(25):1906-12.
infections in organ transplant recipients: emerging 18. Lee FYW, Mossad SB, Adal KA. Pulmonary
importance of non-Aspergillus mycelial fungi. Clin mucormycosis: the last 30 years. Arch Intern Med
Infect Dis 2003;37(2):221-9. 1999;159:1301-9.
10. Gleissner B, Schilling A, Anagnostopolous I, Siehl I, 19. Tuqsel Z, Sezer B, Akalon T. Facial swelling and palatal
Thiel E. Improved outcome of zygomycosis in patients ulceration in a diabetic patient. Oral Surg Oral Pathol
with hematological diseases? Leuk Lymphoma Oral Radiol Endod 2004;98:630-6.
2004;45(7):1351-60.
20. Jayachandran S, Kritika C. Mucor mycosis presented
11. Tryfon S, Stanopoulos I, Kakavelas E, Nikolaidou A, as palatal perforation. Indian J Dent Res 2006;17(3):
Kioumis I. Rhinocerebral mucormycosis in a patient 139-42.
with latent diabetes mellitus: a case report. J Oral
Maxillofac Surg 2002;60(Supll 2):328-30. 21. Klemptner A. Pulmonary mucormycosis in a patient
with COPD. Am Fam Physician 1999;59(9):
12. Prabhu RM, Patel R. Mucormycosis and entomo- 2428,2430.
phthoramycosis: a review of the clinical manifestations,
diagnosis and treatment. Clin Microbiol Infect 22. Marr KA, Carter RA, Crippa F, Wald A, Corey L.
2004;10(Suppl 1):31-47. Epidemiology and outcome of mould infections in
hematopoietic stem cell transplant recipients. Clin
13. Khor BS, Lee MH, Leu HS, Liu JW. Rhinocerebral Infect Dis 2002;34(7):909-17.
mucormycosis in Taiwan. J Microbiol Immunol Infect
2003;36(4):266-9. 23. Bhansali A, Bhadada S, Sharma A, Suresh V,
Gupta A, Singh P, et al. Presentation and outcome of
14. Blonde L. State of diabetes care in the US. Am J Manag rhino-orbital-cerebral mucormycosis in patients with
Care 2007;13(Suppl 2):S36-40. diabetes. Postgrad Med J 2004;80:670-4.
15. Paultauf A. Mycosis mucorina. Virchows Arch Path Anat 24. Spellberg B, Edwards Jr, Ibrahim A. Novel perspectives
1885;102:543-64. on mucormycosis: pathophysiology, presentation, and
16. Petrikkos G, Skiada A, Sambatakou H, Toskas A, management. Clin Microbiol Rev 2005;18(3)556-9.
Vaiopoulos G, Giannopoulou M, et al. Mucormycosis: 25. Roden MM, Zaoutis TE, Buchanan WL, Knudsen TA,
ten-year experience at a tertiary-care center in Greece. Sarkisova TA, Schaufele RL, et al. Epidemiology and
Eur J Clin Microbiol Infect Dis 2003;22(12):753-6. outcome of zygomycosis: a review of 929 reported cases.
17. Joshi N, Caputo GM, Weitekamp MR, Karchmer AW. Clin Infect Dis 2005;41(5):634-53.
n n n
Abstract
The treatment involving the facial esthetics is not only demanding for the patient but also tasking for the clinician. It
involves the astute skill of the prosthodontist, maintaining the health of all the oral structures. This clinical report describes
the prosthodontic management of a 37-year-old male patient with severe attrition of natural dentition. The treatment plan
was executed keeping in mind not only the worn down dentition but also treating the whole stomatognathic system. Utmost
care was taken to achieve harmonious occlusion with no possible occlusal interferences which will further initiate the habit
of bruxism and thereby cause more wear of teeth. The treatment was spread over a period of time so as to achieve perfect
harmony within the masticatory system. The step-wise treatment procedure followed while treating this case has been
presented in a simple and systematic manner.
Key words: Attrition, esthetics, anterior deprogramming, anterior guidance, group function occlusion
F
ull mouth rehabilitation is a challenging comprehensive examination, diagnostic mounting and
treatment modality that enhances the diagnostic wax-up, careful planning and sequencing
appearance of the patient and corrects of various steps, discussion with the patient of the
imperfections in the occlusion. It is a combination different treatment alternatives and careful execution
of the science of neuromuscular dentistry with the of the treatment plan.3
flourish of artistic dentistry. Vertical dimension,
centric relation, speech and muscle tone are it’s Case Report
essential elements. The practitioner needs to analyze
A 37-year-old male patient reported with severely
each aspect carefully with regard to existing natural
attrited maxillary and mandibular teeth. The patient’s
dentition and its relationship with the stomatognathic
main concern was to improve his appearance. Complete
system. Full mouth rehabilitation tends to create
medical and dental history was obtained. The patient
smile that is not only esthetic but also functionally
gave a history of previously done root canal treatment
comfortable.1
in mandibular anteriors. He also gave a history of
The complexity in treating full mouth rehabilitation wearing nightguard for the past five years to prevent
cases is not only because of its long treatment time further attrition due to night grinding. The patient did
but also at times the lack of clarity in the treatment not have any symptoms of temporomandibular joint
objective. A case has to be treated not only by correcting (TMJ) disorder.
worn out, broken or discolored teeth but also requires
treating the oral cavity holistically. Every patient with Extraoral examination revealed no facial asymmetry or
extreme tooth wear has unique treatment needs.2 muscle tenderness. The mandibular movements were
The steps in treatment of these patients include a normal. Intraoral examination revealed overclosure,
generalized severely worn dentition.
The mandibular anteriors were severely worn
*Professor down till the gingival level (Fig. 1). The posterior
**Senior Lecturer
†
Associate Professor, Dept. of Prosthodontics teeth showed marked areas of attrition but with
‡
Professor, Dept. of Prosthodontics no complaints of dentinal sensitivity. The patient
Sree Balaji Dental College and Hospital, Chennai
Address for correspondence was explained about the treatment plan. The
Prof. Dr Sanjna Nayar aim of the treatment was to improve esthetics and
Professor, Dept. of Prosthodontics
Sree Balaji Dental College and Hospital, Pallikaranai, Chennai - 600 100 restore occlusion so as to achieve optimum oral health
E-mail: Sanjna101@yahoo.com for the patient.
Figure 1. Preoperative intraoral view of the patient. Figure 2. Face bow transfer. Figure 3. Diagnostic wax-up.
disclusion, establishing the plane of occlusion and A properly made provisional restoration psychologically
deciding the type of occlusal scheme. Disclusion comforts the patient. The patient should be fully satisfied
refers to separation of opposing teeth during eccentric with the results of the provisional restoration before
movements of mandible, as reported by Christensen, proceeding to the final restorations. The putty index
D’Amico.8 Posterior occlusion should have equal made on the diagnostic wax-up helps in fabricating a
simultaneous contacts so that it does not interfere with good provisional restoration in a time saving manner.
either the TMJs in the back or the anterior guidance The final modifications of the provisionals can be
in the front. Occlusal interference can be detrimental made in the patient’s mouth. The final restorations
to the health of the patient. Deflective occlusal were cemented with temporary luting agent initially
interference can cause painful symptoms in the muscle, to observe for acceptance from the patient and for
teeth or other orofacial structures. A proper plane of correction of occlusal interferences and then followed
occlusion must permit disclusion of all the teeth on the by cementation with permanent luting agent.
balancing side when the mandible is moved laterally.
The reconstruction of vertical dimension of occlusion Conclusion
should be done at the centric relation and it should be
acceptable for the patient at the neuromuscular level.9 Full mouth rehabilitation is a treatment modality
which not only focuses on the esthetics and functional
The patient had severely worn down mandibular aspect of the dentition but also improves upon
anteriors and wear facets on the canine. Hence group the health of the whole stomatognathic system.10
function occlusion was followed to avoid functional A detailed diagnosis and treatment planning is
overload on canines, which can be detrimental to the necessary to achieve predictable success.
overall oral health of the patient. Group function refers
to the distribution of lateral forces to a group of teeth References
rather than assigning all forces to one particular tooth. 1. Dawson PE. Functional occlusion from TMJ to smile
Lateral pressure is distributed to all working side teeth design. Mosby St. Louis, Elsevier. 2007:18-26, 27-32,
in order to prevent overloading of the canine. Little or 75-83, 429-52.
no modification was done on the occlusal surface for 2. Binkley TK, Binkley CJ. A practical approach to full
this patient to preserve the tooth structure for better mouth rehabilitation. J Prosthet Dent 1987;57(3):
structural durability. 261-6.
3. Rivera-Moreles WC, Mohl ND. Restoration of vertical
A permissive splint with a medium thermoplastic sheet
dimension of occlusion in the severely worn dentition.
was fabricated and given to the patient also to prevent Dent Clin North Am 1992;36(3):651-64.
further tooth damage due to bruxism. A permissive
4. Lucia VO. Modern Gnathological concept: updated.
splint has a smooth surface on one side that allows
Quintessence, Chicago, 1983.
the muscle to move the condyles into centric relation
without interference from deflective tooth inclines.1 5. Lynch CD, McConnell RJ. Prosthodontic management
of the curve of Spee: use of the Broadrick flag. J Prosthet
This eliminates the muscle activity and causes most
Dent 2002;87(6):593-7.
of the elevator muscles to release contraction. This is
achieved by separation of all posteriors, allowing only 6. Christensen GJ. Treating bruxism and clenching. J Am
Dent Assoc 2000;131(2):233-5.
anterior tooth contact against a smooth surface or by
allowing all the occlusal surfaces to freely guide against 7. Schuyler CH. The function and importance of incisal
guidance in oral rehabilitation, 1963. J Prosthet Dent
a smooth surface.
2001;86(3):219-32.
The provisional restorations play a critical role in the 8. Pokorny PH, Wiens JP, Litvak H. Occlusion for fixed
successful treatment of the full mouth rehabilitation prosthodontics: a historical perspective of gnathological
patient. Good quality provisional restorations are influence. J Prosthet Dent 2008;99(9):299-313.
essential to achieve predictability with comprehensive 9. Bloom DR, Padayachy JN. Increasing occlusal
cases involving severe parafunctional habits. The vertical dimension- Why, When and How. Br Dent J
provisional restorations should be esthetic and also 2006;200(4):199-203.
fulfil the functions so that the effect can be followed 10. Goldman I. The goal of full mouth rehabilitation.
in the temporary before making the final restoration. J Prosthet Dent 1952;2(2):246-51.
Abstract
The presence of abraded or worn dentition, decreased bony support, temporomandibular joint (TMJ) dysfunction are
challenges in the orthodontic treatment of adults. Deep overbite is one of the most common components of a malocclusion
as well as a major challenge even for a competent orthodontist. Intrusion should be the treatment of choice for adult patients,
who have had significant bone loss around the incisors. In this case report, we document an interdisciplinary approach for the
treatment of deep bite in an adult patient. The treatment of a young adult patient is reported to illustrate the importance of
sequencing treatments from one discipline to another, communication among the team players and the benefits of working
together in an interdisciplinary approach. Orthodontics, endodontics, prosthodontics was combined to achieve the treatment
goals: A bilateral Class I relationship, correction of the anterior deep bite, an esthetic smile displaying four incisors and a
harmonious profile.
T
he presence of abraded or attrited dentition, teeth, flaring of anterior teeth in the case of lingually
decreased bony support, temporo- tipped incisors, intrusion of incisors and the surgical
mandibular joint (TMJ) dysfunction are method. Among the other types of tooth movement,
challenges in the orthodontic treatment of adults. Dermaut and De Pauw3 stressed the importance of
Orthodontists often have to resort to less than intrusion of incisors in adults for whom bite opening
ideal treatment to provide an acceptable result. is a goal. Increasing the lower anterior facial height
A comprehensive treatment plan utilizing the combined by extrusion of molars may not always result in a
expertise of a team of specialists is essential for the stable situation in adult patients4 and also difficult
successful outcome. to accomplish as it is opposed by strong muscles of
mastication. In addition, it is less stable in nongrowing
Deep overbite is one of the most common components
individuals as the extruded posterior teeth would
of a malocclusion as well as a major challenge even
impinge on the freeway space, leaving the prognosis
for a competent orthodontist. Moyers and Riolo1
for the levelling technique in doubt.5,6
reported that deep bite, as a clinical problem, is not
defined in terms of millimeters present today, but in Intrusion should be the treatment of choice for adult
the light of future changes in esthetics and function. patients, who have had significant bone loss around
If left untreated, deep bite can cause attrition of lower the incisors.7 A clinical study by Burzin and Nanda8
incisors, ulceration of the gingival tissues. The attrition showed that the relapse of intruded teeth (intruded an
of lower anterior can be so severe as to have pulpal average of 2.3 mm) is almost insignificant (an average
involvement, gingival hyperplasia and bone loss. of 0.15 mm) upto two years after treatment.
Nanda2 classified the correction of deep overbite by four In this case report, we document an interdisciplinary
types of tooth movement, i.e., extrusion of posterior approach for the treatment of deep bite in an adult
patient. The treatment of a young adult patient is
*Professor and Head, Dept. of Orthodontics, Sree Balaji Dental College reported to illustrate the importance of sequencing
and Hospital, Chennai
**Professor, Dept. of Prosthodontics, Asan Dental College and treatments from one discipline to another,
Hospital, Chennai communication among the team players and the benefits
†
Lecturer, Dept. of Orthodontics, SRM Dental College, Chennai
Address for correspondence of working together in an interdisciplinary approach.
Dr RV Murali The objectives of treatment were to get a good arch
Professor and Head, Dept. of Orthodontics and Dentofacial Orthopedics
Sree Balaji Dental College and Hospital, Pallikaranai, Chennai - 600 100
form with an ideal over bite, an esthetic smile
E-mail: muralikothai@gmail.com displaying the incisors and a harmonious profile.
Orthodontic Phase
3. Dermaut LR, De Pauw G. Biomechanical aspects of 8. Burzin J, Nanda R. The stability of deep overbite
Class II mechanics with special emphasis in deep bite correction. In: Retention and Stability in Orthodontics.
correction as part of the treatment goal. In: Biomechanics Nanda R, Burstone CJ, (Eds.), W.B. Saunders Co:
in Clinical Orthodontics. Nanda R, (Ed.), W.B. Saunders Philadelphia, Pa 1993:61-79.
Co: Philadelphia, Pa 1997:86-98. 9. Arunpraditkul S, Saengsanon S, Pakviwat W. Fracture
4. Seong-Hun Kim, Young-Guk Park, Kyurhim Chung. resistance of endodontically treated teeth: three walls
Severe Class II anterior deep bite malocclusion versus four walls of remaining coronal tooth structure. J
treated with a C-lingual retractor. Angle Orthodont Prosthodont 2009;18(1):49-53.
2004;74(2):280-5. 10. Harradine NW. Self-ligating brackets and treatment
5. Dake ML, Sinclair PM. A comparison of the Ricketts efficiency. Clin Orthod Res 2001;4(4):220-7.
and Tweed-type arch leveling techniques. Am J Orthod 11. Eberting JJ, Straja SR, Tuncay OC. Treatment time,
Dentofacial Orthop 1989;95(1):72-8. outcome, and patient satisfaction comparisons of
6. Wylie WL. Overbite and vertical facial dimensions in Damon and conventional brackets. Clin Orthod Res
terms of muscle balance. Angle Orthod 1994;14:13-7. 2001;4(4): 228-34.
7. Melsen B, Agerbaek N, Markenstam G. Intrusion of 12. Damon DH. The Damon low-friction bracket: a
incisors in adult patients with marginal bone loss. Am J biologically compatible straight-wire system. J Clin
Orthod Dentofacial Orthop 1989;96(3):232-41. Orthod 1998;32(11):670-80.
n n n
Abstract
Panfacial trauma is those fractures, which involve frontal bones, zygomaticomaxillary complex, naso orbito ethmoid region,
nasal region, mandible with concomitant occlusal disturbances. These kind of fractures are often associated with CSF rhinorrhea
and base of the skull fracture. Nasal and oral endo tracheal intubation presents a clinical challenge to the anesthesiologists
and also interferes with surgical procedures. The options in these situations are either tracheostomy or submental intubation.
As the tracheostomy needs transtracheal dissection and carries significant morbidity, submental intubation is simple, safe
technique with low morbidity for operative airway management in maxillofacial trauma.
O
pen reduction and internal fixation of adjacent vital structures especially the vocal chords,
maxillofacial fractures requires general emphysema, pneumothorax or pneumomediastinum,
anesthesia which necessitates endotracheal blockage or displacement of cannula, tracheitis,
intubation for ventilation. Since almost all maxillo- cellulitis, tracheal stenosis and tracheoesophageal
mandibular fractures are reduced with the occlusion fistula, pulmonary atelectasis, tracheoinnominate
as key, oral intubation is often cumbersome and fistula, tracheocutaneous fistula, tracheomalacia,
hence nasoendotracheal intubation is preferred. granulation, tracheal stenosis and failure to decannulate.
But in panfacial fractures where the nasal bones are Though, these complications can be avoided with
fractured, or the anterior skull base is involved, nasal care, tracheotomy is generally avoided unless the
intubation is difficult and sometimes not indicated.1 patient needs to be kept intubated, for maintaining
Nasal intubation in cases of concomitant anterior skull airway, even after the surgery.5
base fractures is mostly avoided since there is a risk
of creating a communication between nasal cavity and A new technique called submental intubation was
anterior cranial fossa, which may cause inadvertent published in 1986, that promises to circumvent the
damage to the brain.2 In such circumstances, when morbidity of tracheostomy and aid ventilation when
both oral and nasal routes for intubation cannot be the oronasal routes cannot be used.6 This technique
chosen, tracheostomy is the next, standard route to achieved tracheal intubation by passing the tube
the trachea.3 However, there are reports of 14-45% through a submental skin incision in the mouth. This
morbidity and 1.6-16% mortality associated with establishes an airway with unhampered intraoperative
tracheostomy procedures.4 It has often been reported access to the dental occlusion and to the nasal pyramid.
to lead to complications such as bleeding, injury to The technique has been tried and tested and has now
gained acceptance. This case report details a case of
panfacial trauma in which the patient was treated
*Reader under general anesthesia after submental intubation.
**Senior Lecturer
†
Professor
‡
Professor and Head Case Report
Dept. of Oral and Maxillofacial Surgery
Sree Balaji Dental College and Hospital, Chennai A 24-year-old Indian male was brought to the hospital
Address for correspondence
Dr Abudakir
with a severe injury to the face after a road traffic
Dept. of Oral and Maxillofacial Surgery accident sustained while traveling on a motor cycle.
Sree Balaji Dental College and Hospital
Pallikaranai, Chennai - 600 100
The patient was conscious, oriented, afebrile. He
E-mail: drabu_dakir@yahoo.co.in reported a loss of consciousness for a period of half
A B
mandible in the submental area beside the midline. The the endotracheal tube were grasped by artery forceps
right side was preferred over the left because it allows and pulled outside in sequence. During this maneuver,
better visualization of the position of the tube with the tube was fixed in the mouth to prevent slipping
direct laryngoscopy. A curved artery forceps was used from the trachea either manually or with McGill’s
to perform blunt dissection through the subcutaneous forceps. Then, the surgical glove finger was removed;
fat, platysma, deep cervical fascia and mylohyoid the connection tube was restored and ventilation
muscle. The mucosal layer in the floor of the mouth circuit was re-established. The tube is then secured to
was incised over the distal end of the forceps, which the skin of the submental area (Figs. 7 a and b) by
was then opened, creating a tunnel at the junction strong silk suture after verifying unchanged tracheal
of lingual-attached gingiva and free mucosa. At this insertion of the tube by auscultation of the chest and
point, the endotracheal tube was briefly disconnected checking the proper intraoral positioning of the tube
from the breathing circuit and the tube connector in the paralingual groove.
was removed. The distal end of the tube was covered Ventilation was continued via orotracheal intubation
with a size eight surgical glove finger to facilitate the until extubation. At the end of the procedure, the
passage through the tunnel and prevent entering of deflated pilot tube cuff and the tube were pulled back
blood and soft tissue, and the tube end, and cuff were in the reverse order. The skin wound was sutured and
externalized. The deflated pilot tube cuff followed by the intraoral wound was left to heal secondarily.
Abstract
The levels of the enzyme alkaline phosphatase have proved to be a good indicator gingival health and disease. In this study,
their levels were compared around healthy and diseased implants. The enzyme was taken from peri-implant sulcular fluid
of healthy and diseased implants and was estimated. The results indicate an increase in the enzyme levels around diseased
implants when compared to the healthy implants.
T
itanium implants are frequently used in The association among host response and clinical
the rehabilitation of totally and partially and radiographic measurements may be useful to
edentulous patients. There are two general determine the success of the dental implant system
types of surgical procedures for the placement and used, to ascertain factors affecting the success of the
restoration of missing teeth using endosseous dental therapy, and to identify method-specific problems.
implants. In the first type, the top of the implant is at Analysis of the peri-implant sulcular fluid provides a
the alveolar crest and the mucosa is sutured over the means by which different aspects of the multifaceted
implant, which result in a submerged surgical approach host response in inflammatory diseases of implants
(Two-step surgical procedure). The second approach can be studied. This provides a noninvasive means
places the coronal aspect of the implant coronal to the of evaluating the role of host response in periodontal
alveolar crest, and the mucosa is sutured around the
disease. This fluid contains locally and systemically
transmucosal aspect of the implant. This results in a
derived markers of periodontal disease and hence may
nonsubmerged surgical approach.1
offer the basis for a patient-specific diagnostic test for
Despite the favorable treatment results in both the diseases affecting the supporting apparatus.2
type of surgical procedures, complications may arise
during the maintenance and retention of implants. It has been well-established that alkaline phosphatase
The tissues supporting the osseointegrated dental enzyme play a crucial role in the pathogenesis
implants are susceptible to inflammatory disease that of periodontal disease. Alkaline phosphatase is a
may lead to implant loss.1 membrane bound glycoprotein produced by many
cells within the area of the periodontium and
The sulcus formed around the prosthesis of the implant gingival crevice. The main sources of the enzyme are
is termed as ‘peri-implant sulcus’ and the fluid found polymorphonuclear leukocytes, bacteria within dental
in this sulcus is called ‘peri-implant sulcular fluid’. It plaque and osteoblast and fibroblast cells. Alkaline
has been found through different studies that the peri-
phosphatase is an important biochemical component
implant sulcus simulates the gingival sulcus and the
of the gingival crevicular fluid and has demonstrated
peri-implant sulcular fluid contents are nearly similar
a strongly positive relationship between the levels of
to that of the gingival sulcular fluid.
the enzyme in the gingival crevicular fluid (GCF) and
*Associate Professor, Dept. of Periodontics previous disease activity.3
Tagore Dental College and Hospital, Chennai
**Professor, Dept. of Periodontics It has been proved in a number of clinical studies
Meenakshi Ammal Dental College and Hospital, Chennai
Address for correspondence
that changes occur in the alkaline phosphatase levels
Dr MN Prabhu found in the gingival sulcular fluid, with changes
Associate Professor, Dept. of Periodontics
Tagore Dental College and Hospital, Chennai
in the health status of the periodontium surrounding
E-mail: prabhumds@rediffmail.com the normal tooth. A similar finding is likely to occur
Before the collection of the peri-implant sulcular The alkaline phosphatase levels in the experimental
fluid, all supragingival plaque was removed from each group consisting of nine failing implants were
sampled site. The sites chosen for sample collection found to be 3302 ± 418.426 (measured in micro-
were isolated with cotton roles. The fluid was collected international units per site). The results are represented
using standardized filter paper strips held within the
crevice. The strip was inserted into the sulcus or pocket 4000
until slight resistance was felt and was left in place for
Mean alkaline phosphatase - mean
3302
20 seconds. Then it was transferred immediately into
plastic vials containing 300 µl of saline with 0.1% 3000
n n n
Abstract
Pathogenic microbes may be transmitted directly from the dentist to the patient or from the patient to the doctor, and
indirectly from patient-to-patient. The latter may occur via contaminated instruments or surfaces, and is referred to as cross-
contamination. This presents an enormous challenge in the current scenario as it has been proved that blood and saliva are
high-risk sources of contracting hepatitis B, human immunodeficiency virus and herpes. In addition to that mouth is the
reservoir of several pathogens which can be easily transmitted from patient-to-patient or to the doctor. It is a well-known
fact that oral surgeons deal with blood and are supposed to work in a high-risk zone, but very often we tend to give a blind
eye to the fact that the so called ‘blue collared’ specialists, orthodontists and endodontists, too have a high-risk of pricks and
cut injuries with sharp instruments and are only second to oral surgeons in risk for contracting hepatitis B virus. Effective
sterilization and disinfection techniques must be rigidly followed as per the accepted protocols to prevent the incidence of
cross infections in the dental office. This article offers practical guidelines and recommendations for effective sterilization in
the orthodontic and endodontic office. These guidelines are suited for easy implementation with the instrument longevity
in mind. Various sterilization protocols for orthodontic and endodontic instruments are reviewed concomitantly with
relevant scientific data. Additionally, contributory factors of instrument damage are enumerated to emphasize the
importance of adhering to precise protocols and manufacturer recommendations as well as in alleviating some misconceptions
about sterilization-induced instrument damage.
S
terilization plays a very important role in the for nonparenteral spread of hepatitis B.5 HIV and
prevention of cross infection in dental practice. herpes virus complex are other high-risk cross infection
Sterilization of orthodontic and endodontic spreading through saliva and blood. Instruments
instruments must be done keeping in mind the need used for root canal therapy are high-risk sources of
for faster turnaround times and instrument longevity. infection. Considering the enormity of the challenge
Matlack’s1 review of orthodontic offices confirmed this that infectious agents pose as well as their nature to
insufficiency despite the fact that orthodontic and continuously multiply in real time, the implementation
endodontic offices were at a high-risk of contracting of effective infection control protocol among all health-
infections like hepatitis.2,3 Although unlike surgeons, care communities including our dental office is vital.
orthodontists generally do not work in a blood Against this backdrop, an appraisal of the current
contaminated area, orthodontic arch wires and ligatures sterilization protocols from an orthodontic and
can traumatize patients’ mucosa, causing bleeding. The endodontic perspective is outlined so that it would
risk of infection is greater for the orthodontist and his facilitate the orthodontist and endodontist in us to make
staff than for the patients.4 Saliva is one of the modes an informed decision towards effectively implementing
the protocol for our own safety as well as the patients’
welfare. Various methods of sterilization are reviewed
*Professor and Head, Dept. of Orthodontics
**Assistant Professor concomitantly with relevant scientific data. Although
Dept. of Orthodontics and Dentofacial Orthopedics the focus of this article is on sterilization protocols
†
Assistant Professor
Dept. of Conservative Dentistry and Endodontics pertaining to orthodontic and endodontic instruments
Priyadarshini Dental College and Hospital, Thiruvallur, Tamil Nadu and materials, it is hoped that these insights will
Address for correspondence
Priyadarshini Dental College and Hospital guide the clinician towards the understanding and
VGR Nagar, Thiruvallur
Pandur - 631 203, Tamil Nadu
implementation of additional infection control
E-mail: nazeerortho@yahoo.co.in measures with the overall office in mind.
Ultrasonic baths and instrument washer and according to the manufacturer’s recommendation. It is
disinfectors have taken their place, which is much recommended only for heat sensitive nonsurgical
safer than debriding by hand. Special solutions instruments and alginate impressions. The main
containing enzymes and having antirust properties drawback is that this type of sterilization requires
have been recommended for effective breakdown of prolonged immersion and instrument turnover
the contaminating particles. time is increased. This type of sterilization is not
Precleaning cycles usually last between 10-15 minutes, recommended for dental office instruments as there
depending on the instrument load. The instruments is no method available to verify their effectiveness in
can be placed in specially designed cassettes to reduce providing complete sterilization as well as the fact
the chances of instrument damage. It is very important that present day protocols are combined with heat
that any residual moisture present must be completely sterilization for maximum sterilization effectiveness.
eliminated to prevent instrument corrosion. The other disadvantage is the lingering unpleasant
strong odor in the room where the solution is kept
Sterilization and requires adequate ventilation.
Various methods are currently being used for sterili- Pitting type of corrosion have been observed in
zation of orthodontic and endodontic instruments. orthodontic cutters and pliers8,9 and there is a
compromise in the integrity of the instrument
Autoclave
when subjected to chemical disinfectants. Chrome
Steam autoclave: At 250°F (30 psi), total time about plated pliers appeared more resistant to damage and
one hour. There is good penetration and it maintains maintained their appearance better than stainless steel
integrity of liquids, like hand piece lubricants, due to pliers.10
the 100% humidity within the chamber.
In dental office chemical sterilization is used to disinfect
Disadvantages alginate impressions before pouring the model.
Recent research11 is directed in finding a alginate
Nonstainless steel metal items corrode, use of hard
disinfecting solution capable of releasing nitric oxide
water may leave deposits, and it may damage plastic
(a broad- spectrum antimicrobial agent) with additional
and rubber items. Sharp instruments get dulled.
anti-viral activity (herpes simplex virus) which
Rapid steam autoclave: At 275°F (35 psi), total
would be a good alternative to the present chemical
time is 15-20 minutes. It is very convenient and
disinfectants.
easy to operate.
Sporicidin solution can be used to disinfect rubber
Disadvantages
clamps and X-ray holders. For disinfection it requires
Requires use of distilled water and small chamber size 10 minutes at room temperature where as for
necessitates frequent cycles. sterilization 6.75 hours is needed. Tincture of metaphen
1:200 (untinted) can be scrubbed against surface to be
Endodontic reamers and files can be inserted into
sterilized for sheath of contra-angle and hand piece, tip
synthetic sponges and subjected to autoclaving.
of electric pulp tester, tooth clamp and surrounding
According to Boyd6 and Vélez7 the sponges do not
area of rubber dam.
obstruct the autoclaving process.
Gutta-percha cones are soaked in 5.2% sodium
Chemiclave or Chemical Vapor Sterilization
hypochlorite for 1-minute and then rinsed with
It is effective against all fungi, viruses and bacteria hydrogen peroxide and dried between two layers of
including spores. Two percent glutaraldehyde solution sterile gauze. Dappen dishes can be swabbed with
and chlorine dioxide are commonly used and has merthiolate followed by 70% alcohol. Long handle
been approved by the ADA. Sterilization time with instruments, tips of cotton pliers, blades of scissors
2% glutaraldehyde is 10 hours without dilution can be dipped in isopropyl alcohol (90%) and then
and with chlorine dioxide is six hours when mixed subjected to flaming before use.
Glass bead sterilization uses small glass beads Very long cycle time. If the cycle is interrupted before
1.2-1.5 mm in diameter. The recommended completion, there can be possibility of ethylene oxide
temperature is between 217-232°C (424-450°F) and exposure. It requires the use of several single use items
should not exceed 250°C. The duration of the cycle is that can be purchased only from the manufacturer.
between 3-5 seconds.
Dry Heat Sterilization
In orthodontics, although the possibility of being able
to sterilize 1-2 orthodontic pliers within 30 seconds has Their main advantage is they do not cause instrument
been highlighted with a stress on correct positioning corrosion and hence recommended for sterilization of
for maximum effectiveness,12 these recommendations orthodontic pliers and metal hand instruments.
are deleterious as the instruments are exposed to
higher temperature ranges against most manufacturer Orthodontic Pliers Sterilization
warnings (193°C/380°F). Nisalak13 showed that it was The current recommendations for effective sterilization
possible to kill all the vegetative cells and bacterial without compromising the longevity of the instruments
spores by scrubbing the contaminated pliers with have been enumerated below.
alcohol and placing in a glass bead sterilizer for three
minutes and hence can be a useful adjunct when rapid Placement in ultrasonic cleaner for 5-12 minutes
chair side sterilization is required. Smith14 found that depending on the capacity of the unit.
it was possible to relive a single band of bacteria in 15 Thorough rinsing with distilled water as tap water
seconds at 223°C and could be relieved of spores when may contain impurities and pH imbalances which
placed for 45 seconds at a temperature of 226°C but may cause corrosion.
may not practically feasible as sterilization of multiple Complete moisture removal by drying with oil-
tried in bands would require more duration which can free compressed air.
alter the physical properties of the molar bands.
Dry heat sterilization at 190°C for 6-12 minutes.
Root canal instruments such as reamers, spreaders, Never expose the instruments to more than
broaches and files can be effectively sterilized in glass 193°C.
bead sterilizer at 218-246°C in 10 seconds. Position the instruments in the ‘open’ position to
ensure thorough sterilization of joints.
Hot Salt Sterilization
Using silicone bases lubricants for the instrument
The following endodontic instruments can be sterilized joints. Oil based lubricants are not recommended
in hot salt sterilizer. The temperature ranges between as they tend to clog the pliers.
425-475°F.
Storage in a dry area free from moisture and
Ten seconds paper points, cotton pellets humidity.
Five seconds - reamers, files, broaches, burs,
spreaders, pluggers, any metallic instrument Autoclaving should be a second option and is
introduced in the canal, silver cones recommended only if a dry heat sterilizer is not
available. A shorter cycle at 134°C for three minutes
It must be made sure that the instruments are immersed is recommended due to the deleterious effect it has
at least a quarter-inch below the salt surface in the
on the instruments and the instruments must be freed
peripheral area as the ideal temperature is present in
of any residual moisture and wrapped before being
the periphery of the sterilizer.
subjected to autoclaving.
Ethylene Oxide Gas Contaminated orthodontic instruments and bands
Kills microorganisms. The total time from start of placed in OMS-ASAP system instrument and band
cycle to the end of degas is 14 hours. It can be used for cassettes15 and then subjected to heat sterilization were
heat sensitive items. The instruments are cool and dry also efficiently decontaminated of spores and instrument
at the completion of cycle. cassettes can be useful adjuncts for sterilization.
Aging of instruments: Sterilization accelerated 10. Jones ML. An initial assessment of the effect on
corrosion in instruments which have been orthodontic pliers of various sterilization and
subjected to wear and tear over a long period disinfection regimes. Br J Orthod 1989;16(4):251-8.
of time due to surface roughening and 11. Patel MP. Development of a self-disinfecting alginate
irregularities. impression material. Biological and Medicinal Research,
University of London, 2009.
Conclusion 12. Miller JA, Harrower KM, Costello MJ. A novel method
of sterilizing orthodontic instruments. Aust Orthod J
It is incumbent upon each orthodontist and
1992;12(3):151-2.
endodontist to conduct their practice in a manner
13. Nisalak P, Prachyabrued W, Leelaprute V. Glass bead
that restricts the spread of infection and cross
sterilization of orthodontic pliers. J Dent Assoc Thai
contamination. By following the procedures 1990;40(4):177-84.
described here, they can minimize and even prevent
14. Smith GE. Glass bead sterilization of orthodontic
the possibility of crossinfection. This is the best bands. Am J Orthod Dentofacial Orthop
protection against the transmission of hepatitis 1986;90(3):243‑9.
and other diseases. Asepsis in the dental office is of 15. Hohlt WF, Miller CH, Need JM, Sheldrake MA.
utmost importance. Sterilization and disinfection Sterilization of orthodontic instruments and bands in
significantly decreases the risk of infectious disease for cassettes. Am J Orthod 1990;98(5):411-6.
the doctor, the staff and the patient. The oral cavity 16. George O, Benoit F, Rapin C, Aranda L, Berthod P,
is the main portal of entry for pathogenic microbes Steinmetz P, et al. Effect of surgical sterilization
into the body and asepsis of the instruments and hand procedures on orthodontic pliers: a preliminary report.
prevents contamination by way of the respiratory Eur Cells Materials 2005;10(Suppl 4):13.
system, blood or saliva. 17. Wichelhaus A, Bader F, Sarder FG, Krieger D,
Merters T. Effective disinfection of orthodontic pliers.
References J Orofac Orthop 2006;67(5):316-36.
1. Matlack RE. Instrument sterilization in orthodontic 18. Dowsing P, Benson PE. Molar band re-use and
offices. Angle Orthod 1979;49(3):205-21. decontamination: a survey of specialists. J Orthod
2. Buckthal JE. Survey of sterilization and disinfection 2006;33(1):30‑7; discussion 28.
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