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 Indian Journal of Contemporary Dentistry
EDITOR-IN-CHIEF
Prof. (Dr) R.K. Sharma
Formerly at All India Institute of Medical Sciences, New Delhi
E-mail: editor.ijocd@gmail.com
NATIONAL EDITORIAL ADVISORY BOARD
1 Dr. Sabyasachi Saha (Prof & Head)
Department of Public Health Dentistry, Sardar Patel Post
Graduate Institute of Dental and Medical Sciences, Lucknow
2 Dr. Bastian T S (Professor & Head)
Oral Pathology and Microbiology Mahe institute of Dental
Sciences. MAHE - Puducherry-673310
3 Dr. Yogesh Kumar (Director Principal)
Surendera Dental College & Research Institute Ganganagar,
Rajasthan
4 Dr K K Gupta (Professor)
Department of Periodontology & Implantology Sardar Patel
Post Graduate Institute of Dental & Medical Sciences
Raibareily Road, Lucknow
5 Dr. Neeta Mishra (Professor)
Dept. Oral Medicine & Radiology BBD College of Dental
Sciences,Lucknow
6 Dr. Pradyumna Misra (Professor)
Dept. of Conservative Dentistry & Endodontics, Babu Banarsi
Das College of Dental Sciences, Lucknow
7 Dr. B.N.V.S. Satish (Professor)
Department of Oral Pathology and microbiology at HKESSN
Institute of Dental Sciences, Gulbarga, Karnataka
8 Dr. Sonal Vahanwala (Professor)
Department of Oral Medicine & Radiology, Dr. D.Y. Patil Dental
College & Hospital, Nerul
9 Dr. Jayashree A Mudda (Principal)
HKESS Nijalingappa Institute of Dental Sciences & Research
Gulbarga Karnatak
10. Dr. V. V. Kulkarni (Professor)
Department of Oral Pathology and Microbiology,
Bharati Vidyapeeth Dental College and Hospital, Pune
11. Dr. A S Aanand (Professor) of Pathology at Navodaya Medical
College,Raichur, Karnataka
SCIENTIFIC COMMITTEE
1. Dr. Ridhi Narang (Senior Lecturer)
Surendera Dental College and Research Institute, Sri Ganganagar
2. Dr. Amit Mahajan (Associate Professor)
Oral & Maxillofacial, Surgery Department KM Shah Dental
College and Hospital Piparia, Gujarat
Print-ISSN:2320-5806 Electronic-ISSN:2320-5962 Frequency : Six Monthly
Indian Journal of Contemporary Dentistry is a double blind peer reviewed
international journal which has commenced its publication from January
2013. The journal is half yearly in frequency. The journal covers all aspects
of odontology including Forensic Odontology. The journal has been assigned
ISSN 2320-5806 (Print Version) and ISSN 2320-5962 (Online Version). The
journal is covered by many international data bases and is eligible under
category 1 as per Dental Council of India norms.
Website www.ijocd.com
All rights reserved. The views expressed by authorsin journal are
notnecessarily views of Indian Journalof Contemporary Dentistry.
The advertisements arepurely commercial in nature and journal does
notguarantee their efficacy.
SCIENTIFIC COMMITTEE
3. Dr. Anshu Sharma (Reader)
Department of Pedodontics and preventive dentistry
Teerthanker Mahaveer Dental College and Research Centre, Dr
4. Dr. Manju Gopakumar (Assoc. Professor)
A.B. Shetty Memorial Institute of Dental Sciences, Deralakatte,
Mangalore / Nitte University Karnataka
5. Dr. Dakshita Joy Sinha (Reader)
Conservative Dentistry and Endodontics Kothiwal dental
College and Research Institute, Moradabad,U.P, India
6. Dr. Heena Zainab Department of Oral Pathology &
Microbiology, Al-Badar Rural Dental College & Hospital
Gulbarga, Karnataka
7. Dr. Pavan G. Kulkarni (Assistant Professo)
Dept.of Oral Pathology & Microbiology, at Bapuji Dental
College & Hospital, Davangere (Karnataka)
8. Dr. Shikha Shrivastava (Assistant Professor)
Dept. of Oral Pathology & Microbiology, Government Dental
College & Hospital, Jaipur.
9. Dr. Vishwas Bhatia (Assistant Professor)
Department of Prosthodontics and Implantology, Eklavya
Dental College, Delhi Jaipur Expressway, Rajasthan
10. Dr. Ashish Amit Sinha (Reader)
Pedodontics and Preventive Dentistry, Kothiwal Dental
College and Research Centre Moradabad, Uttar Pradesh
11. Dr. Ceena Denny (Assoc. Professor)
Dept of Oral Medicine and Radiology. Manipal College of
Dental Sciences Manipal University Mangalore
12. Dr. Garima Bhatia (Senior Lecturer)
Eklavya Dental College and Hospital ,Rajasthan
13. Dr. Prashant (Reader)
Department of Oral Pathology and microbiology, HKESSN
Institute of Dental Sciences, Gulbarga, Karnataka
14. Dr. Sowmya A.R. (Reader)
Public Health Dentistry DJ College of Dental Sciences and
Research, Modinagar
15. Dr. Sachin Sinha (Reader)
Dept. of Oral Pathology & Microbiology Daswani Dental College &
Research Centre, Rajasthan
Editor
Dr. R.K. Sharma
Institute of Medico-legal Publications
4 Floor, Statesman House Building, Barakhamba Road,
th
Connaught Place, New Delhi-110 001
Printed, published and owned by
Dr. R.K. Sharma
Institute of Medico-legal Publications
4th Floor, Statesman House Building, Barakhamba Road,
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Published at
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4th Floor, Statesman House Building, Barakhamba Road,
Connaught Place, New Delhi-110 001
 Indian Journal of Contemporary Dentistry

www.ijocd.com

CONTENTS

Volume 4, Number 1 January-June 2016

1. Regenerative Periodontal Therapy and Its Clinical Implication .................................................................. 01

Brijesh Sharma, Suraj Pandey, Vandana A Pant, Sunil C Verma, Mayank
Das, Akshay Verma, Ajay Kumar Sharma

2. Enamel and Dentin Adhesion Mechanism ....................................................................................................... 07

Prashanth Kumar Ka�a, Sandeep Rajalbandi, Sreedhara S

3. Use of Herbs- A Natural Approach in Dentistry ............................................................................................. 12

Deepika Singh, Ankita Jain, Smita Govila

4. Advances in Esthetic Dentistry .......................................................................................................................... 18

Prashanth Kumar Ka�a, Meghraj D, Sandeep Rajalbandi, Sreedhara S

5. Talons Cusps: The Achilles’ Heel of the Incisors ............................................................................................. 23

Preeti Dhawan, Vivek Gaurav, Aditi Singh, Shilpi Singh

6. Orthokeratinised Odontogenic Cyst in Anterior Maxilla – A Mosaic Enigma ........................................... 26

Anisha Perepa, Ramen Sinha, Prabhat K Tiwari, B V Ramakrishna Reddy,
Anmol Agarwal, Snehal Reddy

7. Effect of Prior Application of 2% Calcium Dobesilate on Direct Pulp Capping with ............................... 29
MTA- A Preliminary Randomized Clinical Trial
Lalit Chandra Boruah, B Rajkumar, Pallavi Bhuyan

8. Evaluation of the Anti-plaque Efficacy of a Jamun Extract Containing Mouthwash ................................ 34

Silvia V Rodrigues, Janhavi S Rane, Dipika K Mitra, Rohit A Shah, Pragalbha N Pathare, Harshad N Vijayakar

9. Tobacco Cessation Need of an Hour in India: A Review ............................................................................... 39

Shivanjali Grover, Rohit Grover

10. Platelet Rich Plasma & Platelet Rich Fibrin: Dental Applications ................................................................. 44
Prashanth Kumar Ka�a

11. Oral Hemangiomatous Granuloma: A Case Report ....................................................................................... 48

Shreeyam Mohapatra, Akshay Verma, Ajay Kumar Sharma, Mayank Das, Pankaj Sharma, Prashant Kumar

12. Cleft Lip and Palate: A Review .......................................................................................................................... 53

Chaudhary I, Tripathi AM, Yadav G, Dhinsa K
13. Assessment of Dental Anxiety Levels of Adult Patients A�ending the Department ................................ 59
of Periodontology: an Analytical Study
Navale Shwetambari R, Devkar Nihal D, Kalra Dheeraj D, Lele Suresh V, Ansari Muniba M, Kaulgud Anupam

14. The Curious Case of the Insólito Primary Molar ............................................................................................ 64

Vivek Gaurav, Preeti Dhawan, Mahima Sehgal, Shilpi Singh, Aditi Singh

15. Prevalence of Oral Lichen Planus and Oral Lichenoid Reaction in Patients Visiting ................................ 67
Dental College in Jaipur, Rajasthan
Rohit Sharma, Vikram Sharma, Vijay Agarwal, Niharika Sharma, Pradeep Kumar, Amit Kumar Sharma

16. Ranula- A Case Report ........................................................................................................................................ 71

Jitesh Sahgal, Abhilasha Sahgal

17. The Art and Science of Ceramic Veneers .......................................................................................................... 75

Prashanth Kumar Ka�a, Sreedhara S, Sandeep Rajalbandi

18. Periodontal Infections in Pregnancy: A Risk Factor for the Newborn- An Epidemiological ................... 79
and Microbiological Study
Jayaprasad Kodoth, Shailesh Kudva, Dhanya Radhan

19. Bell’s Palsy: A Systematic Review of Two Cases ............................................................................................. 84

Puneet Bhargava, OD Toshniwal, Rohit Sharma, Mayank Das, Shreyam Mohapatra, Akshay Verma

20. Prevalence of Recurrent Aphthous Ulcer in University Students of Jaipur, Rajasthan ............................. 88
Rohit Sharma, Niharika Sharma, O D Toshniwal, Vijay Agarwal, Vikram Sharma, Harshdeep Dhailwal

21. Impressions in Microstomia: A Systematic Review ........................................................................................ 92

Savisha Mehta, Renu Gupta, RP Luthra, Naresh Kumar, Reena Sirohi

22. Fibrous Dysplasia- A Hallmark Fibro-Osseous Lesion of Bone : An Overview ......................................... 96

Ankita Khare, Krishna Deo Prasad, Karan Sublok, Jalaj Tak, Vineet Gupta,
Ruchita Bali, Iram Jan, Sachin Mi�al
 DOI Number: 10.5958/2320-5962.2016.00001.2

Regenerative Periodontal Therapy and Its

Clinical Implication

Brijesh Sharma1, Suraj Pandey2, Vandana A Pant3, Sunil C Verma4, Mayank Das5,
Akshay Verma6, Ajay Kumar Sharma6
1
Post Graduate Student Final Year, 2Reader, 3Professor, Babu Banarasi Das College of Dental Sciences, Lucknow,
4
Reader, Babu Banarasi Das College of Dental Sciences, Lucknow, 5Senior Lecturer, Department of Oral Medicine
& Radiology, NIMS Dental College, Jaipur, Rajasthan, India, 6Senior Lecturer, Department of Oral Pathology and
Microbiology, Rajasthan Dental College and Hospital, Jaipur Rajasthan

ABSTRACT

The ultimate goal of periodontal therapy is the regeneration of the tissues destroyed as a result of
periodontal disease. Conventional surgical approaches continue to put forward time-tested and
consistent methods to access and a�ain improved periodontal architecture. However, these techniques
offer only limited potential towards recovering tissues destroyed during earlier disease phases. There
is limited data available for the clinical effectiveness of other biologically active molecules, such as
growth factors and platelet concentrates, and although promising results have been reported, further
clinical trials are required in order to confirm their effectiveness. Current active areas of research are
centered on tissue engineering and gene therapy strategies which may result in more predictable
regenerative outcomes in the future.

Keywords: Periodontal regeneration, guided tissue regeneration, enamel matrix derivative, growth factors,
platelet rich fibrin.

INTRODUCTION functional a�achment apparatus which inserts in the

Regeneration of the damaged tissues is the
ultimate goal of periodontal therapy after the
inflammation has been taken care of. Periodontal
wound healing studies generally imply that
conventional periodontal therapy usually presents
with apical migration of gingival epithelium and
repair by collagenous scar tissue.1 The aims of the
present regenerative techniques are directed towards
‘‘new a�achment’’ less towards “repair”.Periodontal
regeneration occurs due to the migration of the
progenitor periodontal ligament cells to the denuded
root surface and proliferation into an organized and
Corresponding author:
Dr. Akshay Verma
Seniour Lecturer, Department of Oral Pathology and
microbiology, Rajasthan Dental College & Hospital,
Jaipur, Rajasthan, India
E-mail: dr.akashyavermaop@gmail.com
Ph no.-+91-9509222226
new formed cementum. The concept of periodontal
regeneration is therefore based on the principle that
the healing site a�racts cells having the potential to
promote regeneration. This article provides an outline
of different regenerative therapies used today and
also enumerates the patient and surgical variables
affecting the outcome certainty.
OSSEOUS GRAFTS
With the aim of promoting periodontal
regeneration, bone and bone substitutes are been
placed in the debrided periodontal defect. A number
of literature reviews support the fact that using
autogenous and allogenic bone grafting techniques,
considerable levels of new probing a�achment and
bone fill can take place.2-5 The clinical outcome using
bone grafting techniques in the regeneration of
intrabony and furcation defects has been assessed at
length in a systematic review.6 The authors concluded
that clinical a�achment level was increased along
with decrease in probing with bone grafts, compared
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
to OFD procedures, in cases of intrabony defects.
The use of different grafting materials did not result
in any variations in clinical outcome. In cases of
furcation defects, some positive clinical outcome was
noted in the treatment of Class II furcations. On the
contrary, a systematic review did not support the use
of bone replacement graft materials due to lack of
sufficient evidence.7 Few studies provide histological
evidence that use of autogenous and allogeneic
bone grafts results in no new a�achment.8,9 Due to
unavailability of demineralized allogenic bone grafts
in many parts of the world and practicality of using
autogenous bone grafts in periodontal regeneration is
often questionable due to the involvement of a second
surgical site. Hence, the use ‘‘off the shelf’’ xenografts
or alloplastic materials may prove to be more
practical. The available data however indicates that,
periodontal repair is supported by alloplastic grafts
rather than periodontal regeneration.6 On the whole;
the use of bone grafts in combination with surgical
debridement is not well supported by the existing
evidence for the purpose of promoting periodontal
regeneration.
GUIDED TISSUE REGENERATION
GTR is a clinical technique that makes use of a
barrier membrane. The principle entails that only
the periodontal ligament, contains cells capable of
forming new cementum which further establish new
a�achment between cementum and bone.10 This ability
is not possessed by the gingival connective tissue or
bone. The first use of GTR in humans was reported
in 1982, and histological evidence of new a�achment
was seen.11 Initially studies utilized non-resorbable
membrane made of expanded polytetrafluroethelene
(e-PTFE), which were held in place for six weeks
and later removed by re-entering the surgical site.12
Resorbable membranes were introduced to overcome
the limitations of non-resorbable membranes like
exposure and infection, which affected the outcomes
of the regenerative therapy.13,14
In a review, comparing GTR with OFD for treating
intrabony defects, GTR had a statistically significant
effect on clinical outcomes compared with OFD,
with gain in CAL, pocket depth reduction, decreased
gingival recession at re-entry.15 In a systemic review,
for treating class II furcations the effectiveness of GTR
compared to OFD was investigated.16 The application
2
of GTR for Class III furcations is limited and hence
clinically insignificant.17 A meta-analysis indicated
that GTR can result in average probing depth
reductions and a�achment gain in deep intrabony
defects.18 GTR combined with bone grafts, have an
added advantage of providing support to resorbable
membranes, which prevents its collapse into the
defect. The addition of bone grafts yielded similar
results as compared to GTR alone in treatment of
intrabony defects.15
ROOT BIOMODIFICATION
The use of citric acid and tetracycline has been
advocated to promote ‘‘new a�achment’’ formation
by demineralizing the dentin and exposing collagen
fibrils. The underlying principle is that cementum
formation is enhanced by induction of mesenchymal
cells that result in cementoblasts differentiation.
Clinical trials on humans using root conditioning, did
not result in any improvement in clinical parameters.
In a systematic review to analyze the efficacy of
root surface conditioning it was concluded, that no
clinically significant evidence of regeneration was
seen in patients with chronic periodontitis when citric
acid, tetracycline or EDTA were used to modify the
root surface.19 However, few studies using animal
models yielded good results with connective tissue
a�achment being demonstrated histologically.20,21
Since no such disadvantage has been shown in
clinical and histological data, clinicians may include
root conditioning as an additional measure for
periodontal regeneration.
GROWTH FACTORS
Platelet derived growth factor (PDGF)
Different growth factors have been assessed for
their use in periodontal regeneration comprising
of in-vitro and animal studies.22 Due to its potential
to induce periodontal regeneration seen in human
clinical trials, PDGF has been the maximum studied
growth factor.23 In a clinical trial the regenerative
potential in intrabony defects was assessed
combining PDGF and IGF, which was delivered in a
methylcellulose gel.24 The results showed a superior
bone fill compared to the control at 6–9 months
at high concentration. Two different recombinant
human PDGF doses used in combination with an
alloplastic material β-tricalcium phosphate were
3 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
compared with β-TCP in deep intrabony defects. The
extent of clinical a�achment gain after six months did
not show any noteworthy difference, even though
both PDGF formulations were considerably more
effective than the control group.25
Platelet rich plasma
PRP is a platelet concentrate containing a number
of growth factors including PDGF, TGF-β and IGF
have shown to put forth a positive effect on periodontal
wound healing.26 Reports suggest that PRP may lead
to be�er wound healing, reduced postoperative
pain. In comparison to the use of a graft and GTR
individually in intrabony defects, no additional
benefit of PRP was seen with the combination of a
graft and GTR.27,28 Contradictory results have been
observed with the use of PRP combined with various
grafts for the treatment of intrabony defects.
Platelet rich fibrin
PRF described by Choukroun is a second-
generation platelet concentrate prepared from
the patient’s own blood.29 It does not require
any anticoagulant or other synthetic biochemical
modifications. Several studies have shown that the
use of PRF resulted in rapid and accelerated wound
healing.30,31 Healing potential of both hard and soft
tissue is increased with use of PRF, that is enhanced
with platelets, growth factors and cytokines.32,33.
Treatment of furcation, periodontal intrabony defects,
sinus lift procedures have been carried out with the
help of PRF.30,31. In a study osteoblasts showed an
enhanced affinity to the PRF membrane than to that
of the PRP.34
Enamel matrix derivative (EMD)
A commercially available bioactive agent
EMD (Emdogain-Straumann, Basel, Swi�erland)
is a resultant from the unerupted porcine teeth.
It contains amelogenins and enzyme components
which plays a significant role in stimulating
cementogenesis.35,36 Various studies have been carried
out in animal and human models to demonstrate the
evidence of regeneration. In a meta-analysis, which
included 955 intrabony defects, treated with EMD
resulted in a reduction in mean probing depth and
a gain in CAL.37 The effectiveness of EMD compared
to the clinical outcome of using EMD with OFD or
GTR in the management of intrabony defects was
evaluated in a systematic review.38 The use of EMD as
an adjunct with other regenerative procedures found
no advantage in the treatment of intrabony defects by
combining EMD and GTR .39 However, combination
of EMD with various bone grafting materials, has
shown to enhance the efficacy of EMD.39
FUTURE PERSPECTIVE
Stem cells
Advances in regenerative medicine and stem
cell biology have offered opportunities for tissue
engineering in periodontal therapy. The first
human dental stem cells were isolated from dental
pulp tissue of extracted third-molar teeth.40 When
implanted into immunocompromised mice these
stem cells were found to be highly proliferative,
capable of differentiating into odontoblast-like cells.43
Consequently, human mesenchymal stem cells were
isolated from exfoliated deciduous teeth and induced
bone and dentin formation in-vivo.41 Refinement of
current laboratory techniques to facilitate handling of
stem cells and their rendition to a clinical se�ing will
be equally critical in advancing the field.
Tissue engineering
Tissue engineering is a platform whereby the
construction of periodontal tissues is carried out
under controlled conditions in the laboratory and
then surgically implanted into defects.42 Appropriate
progenitor cells, signaling molecules, extracellular
matrix and an adequate blood supply are the main
requisites for the production of an engineered
tissue.43,44 Animal studies demonstrating evidence for
the viability of tissue engineering show that in-vivo
regeneration is supported by autologous cultured
periodontal cells.45 Periodontal cell sheets prepared in
vitro and later transplanted into periodontal defects
resulted in regeneration of periodontal ligament
tissues when transplanted in animal models.46,47
Gene therapy
Relocation of the platelet-derived growth factor
gene into periodontal cell types like cementoblasts
and other cells has been accomplished with the aid
of gene therapy. The utilization of this technique
demonstrated periodontal ligament and alveolar bone
regeneration in rats.47 With experimental studies on
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
gene therapy our understanding of gene regulation of
growth factors has enhanced, but the potential risks
and effectiveness of gene therapy for regeneration are
yet to be completely evaluated.
CONCLUSION
Significant improvement in clinical outcome
using different regenerative materials in periodontal
defects have been demonstrated which were way
be�er than those achieved with debridement only.
The application of regenerative therapy can change
the prognosis of a hopeless tooth into a maintainable
unit. The implementation of a clinical approach
for optimal application of materials and surgical
approach could increase the efficacy of periodontal
regeneration and provide superior clinical outcomes.
Provided that the patient maintains a good oral
hygiene and infection control, clinical outcomes
obtained with periodontal regeneration can be stably
maintained on a long-term basis.
Acknowledgment: None
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance : Not Needed
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Z. The use of enamel matrix derivative in the
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38. Esposito M, Grusovin MG, Coulthard P,
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in intrabony defects. Cochrane Database Syst
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40. Gronthos S, Mankani M, Brahim J, Robey PG,
Shi S. Postnatal human dental pulp stem cells
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 DOI Number: 10.5958/2320-5962.2016.00002.4

Enamel and Dentin Adhesion Mechanism

Prashanth Kumar Ka�a1, Sandeep Rajalbandi2, Sreedhara S3

1
Assistant Professor, College of Dentsitry, King Khalid University, Abha, Kingdom of Saudi Arabia,
2
Reader, Sharavathi Dental College, Shivamogga, 3Professor, Department of Orthodontics,
S J M Dental College, Chitradurga

ABSTRACT

Bonding to dentin and enamel is very critical and important for the success of adhesive restorations.
However, bonding to enamel, dentin and carious tooth structure is totally different. The chemical
structure of all the above mentioned hard tissues is different hence the bonding mechanism. This
article explains the structure and the mechanism of bond formed between the bonding agent and the
hard tissues.

Keywords: Bonding, caries, dentin, enamel.

INTRODUCTION 7. Bond periodontal splints and conservative tooth-

Adhesion of the composite restoration is
paramount to the success of composite restoration.
This adhesion is micromechanical. Over decades,
lot of research has taken place and is continuing to
this day to improve the bond strength between the
composite, dentin and enamel. The mechanism of
bond to enamel is different from the bond to dentin as
the two hard tissues are different in composition1, 2.
Adhesive restorative techniques currently are
used to accomplish the following1:
1. Restore Class I, II, III, IV, V, and VI carious or
traumatic defects
2. Change the shape and the color of anterior teeth
(e.g., with full or partial resin veneers)
3. Improve retention for porcelain-fused-to-metal
(ceramometal) or metallic crowns
4. Bond all-ceramic restorations
5. Seal pits and fissures
6. Bond orthodontic brackets
Corresponding author:
Dr. Prashanth Kumar Ka�a MDS
Assistant Professor, College of Dentsitry, King
Khalid University, Abha, Kingdom of Saudi Arabia,
Mobile: +966538073497
E-mail:drprashanthkumar@yahoo.com
replacement prostheses
8. Repair existing restorations (composite,
amalgam, ceramic, or ceramometal)
9. Provide foundations for crowns
10. Desensitize exposed root surfaces
11. Seal beneath or bond amalgam restorations to
tooth structure
12. Impregnate dentin that has been exposed to the
oral fluids, making it less susceptible to caries
13. Bond fractured fragments of anterior teeth
14. Bond prefabricated fiber or metal posts and cast
posts
15. Reinforce fragile endodontically treated roots
internally
16. Seal root canals during endodontic therapy
17. Seal apical restorations placed during endodontic
surgery
ENAMEL
Selective dissolution of hydroxyapatite crystals
through etching (commonly with a 30-40% phosphoric-
acid gel) is followed by in situ polymerization of
resin that is readily absorbed by capillary a�raction
within the created etch pits, thereby, enveloping
individually exposed hydroxyapatite crystals. Two
types of resin tags interlock within the etch-pits.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
“Macro”-tags fill the space surrounding the enamel
prisms while numerous “micro”-tags result from
resin infiltration/polymerization within the tiny etch-
pits at the cores of the etched enamel prisms. The
la�er are especially thought to contribute the most
with regard to retention to enamel2, 3.
When we bond to enamel, we apply and then
rinse away a 37% phosphoric acid solution. No
worries, your stomach is more acidic than this. The
solution etches the surface of the enamel, which is a
substance made up of crystals. Highly magnified, it
looks like this afterwards:
The surface becomes rough on a very small scale.
We then apply a resin (the first part of these composite
resin fillings of ours) that becomes micromechanically
interlocked into the roughened surface. The strength
of this bond is incredible. We can bond composite
resin onto teeth in very functional areas and it often
stays on for years without breaking or staining. We
measure bond strengths in MegaPascals or MPa, and
30 is a very good number to achieve. (Don’t worry
about exactly what a Mega Pascal is; all we need to
do for the purposes of this discussion is to look at
relative numbers.) We need to hit at least 17 MPa to
keep restorations sealed and on the tooth.
On enamel, acid-etching selectively dissolves
the enamel rods, creating microporosities which are
readily penetrated, even by ordinary hydrophobic
bonding agents, by capillary a�raction. Upon
polymerization, this micromechanical interlocking of
tiny resin tags within the acid-etched enamel surface
still provides the best achievable bond to the dental
substrate. It not only effectively seals the restoration
margins in the long term, but also protects the more
vulnerable bond to dentine against degradation1.
Dentin: phosphoric-acid treatment exposes
a microporous network of collagen that is nearly
totally deprived of hydroxyapatite High-resolution
transmission electron microscopy (TEM) and
chemical surface analysis by energy dispersive X-
ray spectroscopy (EDXS) and X-ray photoelectron
spectroscopy (XPS) have confirmed that nearly all
calcium phosphates were removed or at least became
under detection limit (Van Meerbeek & others, 1996;
Yoshida & Van Meerbeek, 2002). As a result, the
primary bonding mechanism of etch&rinse adhesives
to dentin is primarily diffusion-based and depends
8
on hybridization or infiltration of resin within the
exposed collagen fibril scaffold, which should be as
complete as possible. True chemical bonding is rather
unlikely, because the functional groups of monomers
may have only weak affinity to the “hydroxyapati
tedepleted’’ collagen. Such challenging monomer-
collagen interaction might be the principle reason
for what has been documented as manifesting in the
form of “nanoleakage” phenomena (Sano & others,
1994b, 1995).
Bonding to dentin, though- that was a lot more
difficult. After removing decay with a drill there is
a smear layer (yes, that’s really its scientific name)
of microscopic debris left all over the inside of the
cavity prep. This is removed with the etchant. There
are also tubules which are normal channels that run
through the dentin2, 4:
ACCORDING TO THE BRILLIANT DAVID
PASHLEY
“The success of bonding resins to acid-etched
enamel is because of the fact that enamel contains
li�le protein, and it can be dried without causing any
collapse of the roughened surface. When Buonocore
et al tried those same procedures on dentin, they
were disappointed to find that the resin-dentin bond
strengths to acid-etched dentin were very low (5 to
10 MPa) and were about the same as resin-dentin
bonds made to smear layer-covered dentin. They did
not know that acid-etching dentin transformed the
surface from a hard, mineralized surface to a very
soft, mineral-free, collagen-rich surface that collapses
when air-dried. Although it is now known that acid-
etching removes the smear layer and smear plugs,
thereby making the tubules available for resin tag
formation, drying the surface collapses the spaghe�i-
like collagen fibrils, making resin infiltration
difficult.”
DENTINE HYBRIDISATION1, 5
Diffusion is the only mechanism whereby
a monomer can pass across into demineralised
dentine.
The most important factor for dentine adhesion
under clinical conditions is the permeation of resin
into intertubular dentine
The chemical reactivity of collagen is quite low
9 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
because any reactive functional groups (eg;- COOH,
-NH2) are involved in covalent type bonding between
peptides in the collagen fibres
PROBLEMS IN BONDING TO DENTIN
The main hindrance is the heterogeneous nature
of dentine, with hydroxyapatite deposited on a mesh
of collagen fibres. In addition; dentine is intimately
connected with pulpal tissue by means of numerous
fluid-filled tubules, which traverse through dentine
from the pulp to the dentino-enamel junction. Once
under constant outward pressure, this fluid renders
the exposed dentine surface naturally moist and
thus intrinsically hydrophilic. This hydrophilicity
definitely represents one of the major challenges for
the interaction of modern adhesives with dentine.
It has in essence led to the different bond strategies
currently available. The presence of cu�ing debris on
instrumented dental surfaces in the form of smear
layer and smear plugs that obstruct the dentine
tubules is also a primary co-factor that may not be
underestimated5, 6.
Bonding to enamel is a relatively simple process,
without major technical requirements or difficulties.
Bonding to dentin presents a much greater challenge.
Several factors account for this difference between
enamel and dentin bonding. Enamel is a highly
mineralized tissue composed of more than 90% (by
volume) hydroxyapatite, whereas dentin contains a
substantial proportion of water and organic material,
primarily type I collagen. Dentin also contains a
dense network of tubules that connect the pulp
with the dentinoenamel junction (DEJ). A cuff of
hypermineralized dentin called peritubular dentin lines
the tubules. The less mineralized intertubular dentin
contains collagen fibrils with the characteristic
collagen banding. Intertubular dentin is penetrated
by submicron channels, which allow the passage
of tubular liquid and fibers between neighboring
tubules, forming intertubular anastomoses.
Dentin is an intrinsically hydrated tissue,
penetrated by a maze of fluid-filled tubules.
Movement of fluid from the pulp to the DEJ is a
result of a slight but constant pulpal pressure. Pulpal
pressure has a magnitude of 25-30 mm Hg or 34 to
40 cm H2O.
Dentinal tubules enclose cellular extensions from
the odontoblasts and are in direct communication
with the pulp. Inside the tubule lumen, other fibrous
organic structures such as the lamina limitans are
present, which substantially decreases the functional
radius of the tubule. The relative area occupied by
dentin tubules decreases with increasing distance
from the pulp. The number of tubules decreases
from about 45,000/mm2 close to the pulp to about
20,000/mm2 near the DEJ. The tubules occupy an area
of only 1% of the total surface near the DEJ, whereas
they occupy 22% of the surface close to the pulp. The
average tubule diameter ranges from 0.63 µm at the
periphery to 2.37 µm near the pulp.
Adhesion can be affected by the remaining dentin
thickness after tooth preparation. Bond strengths
are generally less in deep dentin than in superficial
dentin. Nevertheless, some dentin adhesives,
including one-step self-etch adhesives, do not seem to
be affected by dentin depth.
Whenever tooth structure is prepared with a bur
or other instrument, residual organic and inorganic
components form a “smear layer” of debris on the
surface. The smear layer fills the orifices of dentin
tubules, forming “smear plugs”, and decreases dentin
permeability by nearly 90%. The composition of the
smear layer is basically hydroxyapatite and altered
denatured collagen. This altered collagen can acquire
a gelatinized consistency because of the friction and
heat created by the preparation procedure. Submicron
porosity of the smear layer still allows for diffusion of
dentinal fluid53. Removal of the smear layer and smear
plugs with acidic solutions results in an increase of the
fluid flow onto the exposed dentin surface. This fluid
can interfere with adhesion because hydrophobic
resins do not adhere to hydrophilic substrates, even if
resin tags are formed in the dentin tubules3, 6, 7.
Several additional factors affect dentin
permeability. Besides the use of vasoconstrictors in
local anesthetics, which decrease pulpal pressure and
fluid flow in the tubules, factors such as the radius
and length of the tubules, the viscosity of dentin
fluid, the pressure gradient, the molecular size of
the substances dissolved in the tubular fluid, and the
rate of removal of substances by the blood vessels in
the pulp affect permeability. All of these variables
make dentin a dynamic substrate and consequently a
difficult substrate for bonding.
10 Indian Journal of Contemporary Dentistry, July-December, 2015, Vol.3, No.2
TYPES OF ACID ETCHING2, 8
According to Silverstone et al there are 5 types of
acid etching pa�ern:
1. Type 1: preferential dissolution of prism cores,
resulting in honey comb like appearance.
2. Type II: preferential dissolution of prism
peripheries, giving cobblestone like appearance.
3. Type III: a mixture of type I and II pa�ern.
4. Type VI: pi�ed enamel surfaces as well as
structures that look like unfinished puzzle, maps
or networks.
5. Type V: flat, smooth surface
• Acid etching removes approximately 10 µm of
enamel surface and creates a morphologically
porous layer (5 µm to 50 µm deep).
• The low-viscosity fluid resin contacts the
surface and is a�racted to the interior of these
microporosities created by capillary a�raction.
• Resin tags are formed into microporosities
of conditioned enamel that after adequate
polymerization, provide a resistant, long-lasting
bond by micromechanical interlocking with this
tissue9, 10.
Acid-etching transforms the smooth enamel into
an irregular surface and increases its surface free
energy. When a fluid resin-based material is applied
to the irregular etched surface, the resin penetrates
into the surface, aided by capillary action. Monomers
in the material polymerize, and the material becomes
interlocked with the enamel surface The formation
of resin microtags within the enamel surface is the
fundamental mechanism of resin-enamel adhesion.
The acid-etch technique has revolutionized the
practice of restorative dentistry.
Enamel etching results in three different
micromorphologic pa�erns.
ADHESION TO CARIOUS TISSUE4, 5, 11
The presence of carious dentin results in thicker
hybrid layers and lower bond strengths. The bond
strength of adhesives to carious dentin has been
reported to be inversely proportional to the degree
of caries progression, with caries-infected dentin
presenting the lowest bond strength. The thickness of
the hybrid layer is indirectly correlated to the degree
of caries progression, with caries-infected dentin
presenting thicker hybrid layers, followed by caries-
affected and sound dentin.
Caries excavation frequently results in a
complex substrate involving areas of caries-
infected, cariesaffected, sclerotic, eroded and sound
dentine. Carious dentin consists of a superficial
first layer and a deeper second layer[11–13]. The
outer layer was characterized as highly decalcified,
physiologically unrecalcifiable, fuchsin-stainable,
showing degenerated collagen fibers with virtual
disappearance of cross-links indicating irreversible
denaturation of collagen. The inner layer was depicted
as intermediately decalcified, physiologically
recalcifiable, fuchsin-unstainable, with expanded
odontoblastic processes, sound collagen fibers, and
apatite crystals bound to the fibers.
CONCLUSION
The goal of adhesive dentistry is to restore the
tissues to normal using best adhesive material so
that the restoration will serve for a considerably
long time without any problems like staing at the
interface, microleakage and secondary caries. Proper
understanding of the mechanism of adhesion will
allow the dentist to use the current adhesives for
optimum results without adversely affecting the
bond strength and esthetics.
Conflict of Interest: None
Source of Funding: Self
Acknowledgement: None
Ethical Clearance: Not applicable
REFERENCES
1. MV Cardoso, A de Almeida Neves, A Mine,
E Coutinho, K Van Landuyt, J De Munck, B
Van Meerbeek, Current aspects on bonding
effectiveness and stability in adhesive dentistry,
Australian Dental Journal 2011; 56:(1 Suppl):
31–44
2. Aline de Almeida Nevesa/Eduardo Coutinhob/
Marcio Vivan Cardosoc/Paul Lambrechtsd/
Bart Van Meerbeek, Current Concepts and
Techniques for Caries Excavation and Adhesion
 Indian Journal of Contemporary Dentistry, July-December, 2015, Vol.3, No.2
to Residual Dentin, J Adhes Dent 2011; 13; 7-22.
3. Jorge Perdigão, Dentin bonding—Variables
related to the clinical situation and the substrate
treatment, dental materials 26 (2010) e24–e37
4. MJ Tyas, MF Burrow, Adhesive restorative
materials: A review, Australian Dental Journal
2004;49:(3):112-121
5. Perdigão J1, Frankenberger R, Rosa BT, Breschi
L. New trends in dentin/enamel adhesion. Am J
Dent. 2000 Nov;13(Spec No):25D-30D.
6 Hewle� ER1. Resin adhesion to enamel and
dentin: a review. J Calif Dent Assoc. 2003
Jun;31(6):469-76.
7 Manuja N1, Nagpal R, Pandit IK. Dental
adhesion: mechanism, techniques and durability.
11
J Clin Pediatr Dent. 2012 Spring;36(3):223-34.
8. Perdigão J1. New developments in dental
adhesion. Dent Clin North Am. 2007 Apr;51(2):
333-57, viii.
9. Ozer F1, Bla� MB. Self-etch and etch-and-rinse
adhesive systems in clinical dentistry. Compend
Contin Educ Dent. 2013 Jan;34(1):12-4, 16, 18;
quiz 20, 30.
10. J Krithikada�a, Clinical effectiveness of
contemporary dentin bonding agents, J Conserv
Dent. 2010 Oct-Dec; 13(4): 173 -183.
11. Perdigão J1, Duarte S Jr, Lopes MM. Advances
in dentin adhesion. Compend Contin Educ
Dent. 2003 Aug;24(8 Suppl):10-6; quiz 61.
 DOI Number: 10.5958/2320-5962.2016.00003.6

Use of Herbs- A Natural Approach in Dentistry

Deepika Singh1, Ankita Jain2, Smita Govila3

1
Senior Lecturer, Departments of Conservative Dentistry and Endodontics, 2Department of Public Health Dentistry,
Teerthanker, Mahaveer Dental College and Research Centre, Moradabad, U�ar Pradesh, India, 3Reader, Dept. of
Conservative Dentistry & Endodontics, U P Dental College & Research Centre, Lucknow

ABSTRACT

The health industry has always used natural products as an alternative to the conventional allopathic
formulations available for the treatment of various ailments. Herbs are novel drugs with a range of
therapeutic activities gifted to the world by Ayurveda. They have potential to treat a variety of human
ills with minimal or no side effects. Dentistry is still in search of drugs for diseases affecting hard and
soft tissues of oral cavity with good efficacy and minimal side effects. Herbal medicines seem to fulfill
most of these requirements without any adverse effect on oral tissues and at very minimal cost as
compared to commercially available products today.Therefore, there is a need to conduct extensive
researches to find plant based alternatives for the conventional drugs.

Keywords: Oral diseases, phytomedicines, herbs.

INTRODUCTION Now a day, interest in herbal drugs has again

renewed. In dentistry phytomedicine has been
Oral health is an essential part of general health.
used as anti-inflammatory, antibiotic, antifungals,
Oral diseases continue to be a major health problem
antivirals, analgesic, sedative and also as endodontic
worldwide. Dental caries, periodontal diseases, and
irrigant. They also aid in healing and are effective
oral lesions are of most significant concern. Most of
in controlling microbial plaque in gingivitis and
the oral diseases are caused due to bacterial infection.
periodontitis and thereby improving immunity.3
Conventional drugs usually provide effective
With herbal, and holistic or alternative medicine
antibiotic therapy for bacterial infections, but there
gaining increasing popularity among the public, as
is an increasing problem of antibiotic resistance,
dental practioners we have a responsibility to explore
immune suppression, hypersensitivity, allergic
and understand these products and extrapolate their
reactions; also some are mutagenic and cytotoxic. It
implications on our current patient management
aroused the need for an alternative approach which
strategies. The dentist needs to be more informed
is affordable, non-toxic and effective.1 India has an
regarding the use, safety and effectiveness of various
ancient heritage of traditional herbal medicine. Long
traditional medicine. Thus this review aims at
before the advent of modern medicine, herbs were
providing a comprehensive overview of the various
the mainstream remedies for nearly all ailments.
herbal medicines and their efficacy in carrying out
According to WHO herbal medicine is defined as
treatment of oral dieseas.
plant derived material or preparation which contains
raw or processed ingredients from one or more plants THE DIFFERENT HERBS AND THEIR
with therapeutic values.2 APPLICATION IN DENTISTRY

Corresponding author:
Dr Deepika Singh
Senior Lecturer, Departments of Conservative
Dentistry and Endodontics, Teerthanker Mahaveer
Dental College and Research Centre, Moradabad,
Email: deepikasdpr@gmail.com, Ph. No:7409688476
Propolis
Propolis, is a brownish resinous substance that
honey bees collect from trees of poplars and conifers.
It is used to reinforce their hives and keep the
environment aseptic. It is an effective antimicrobial,
anti-inflammatory and antioxidant due to the
13 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

presence of flavonoids, phenolics and aromatics.
It is also used as an intracanal medicament4, root
canal irrigant,5 as a storage media for avulsed teeth
to maintain viability of periodontal ligament6, to
prevent dentinal hypersensitivity7, as a pulp capping
agent8, as a cariostatic agent9, for the treatment of
periodontitis and denture stomatitis10.
intracanal irrigant. MCJ juice also as its applications
in periodontics. It can be used to treat the gingival
inflammation.17 Noni leaf aqeous extract are also
found to promote osteogenic differentiation as well
as matrix mineralization in periodontal ligament cells
and data suggest that noni leaves have therapeutic
benefits in bone and periodontal tissue regeneration.

A study conducted by Grange and Davey11 TRIPHALA

have shown the antimicrobial efficacy of propolis
This is an ayurvedic medicine consisting of
against Enterococcus species, streptococcus aureus
Amulaki (emblica officinalis), Bibhitaki (terminalia
and candida albicans. Al-Qathami and Al-Madi 12
bellirica) and Halituki (terminalia chebula). Its fruit
compared the antimicrobial efficacy of propolis,
is rich in citric acid, which may aid in removal of
sodium hypochlorite and saline as an intracanal
smear layer thereby acting as chelating agent and also
irrigants. The results of this study indicated that
found to be alternative to sodium hypochlorite for
the propolis has antimicrobial activity equal to that
root canal irrigation. It has Anti-collagenase activity,
of sodium hypochlorite. When using Propolis as a
Anti-microbial and anti-oxidant effect . It can be used
storage media for avuled tooth, Martin and Pileggi
as an anti-caries agent, as a root canal irrigant, and as
13
found that propolis may be a be�er alternative
a as a mouth rinse. 18 In a study, Propolis and triphala
to HBSS, milk, or saline in terms of maintaining
were found to be as efficacious as NaOCl against
periodontal ligament cell viability after avulsion
Enterococcus fecalis biofilm.19 0.6% Triphala
and storage. Hayacibara et al.14 evaluated the
mouthwash has shown to have significant anti-caries
anti cariogenic property of propolis on mutans
activity, which is comparable to that of chlorhexidine
streptococci viability, glucosyltransferases activity
without possessing disadvantages as staining of teeth
and caries development in rats. The data suggested
and at much less cost although there was no evidence
that propolis is a potentially novel anti-caries agent.
of re-mineralization of tooth structure. 20 Triphala
MORINDA CITRIFOLIA (NONI) in treating periodontal disease does not produce
side-effects of tetracycline compounds as well as other
Morinda Citrifolia commercially known as Noni,
synthetic drugs.Triphala has strong inhibitory activity
is indigenous to tropical countries. It is also called
against PMN-type collagenase, especially MMP-9 at
as Indian Mulberry, Nono or Nonu, Cheese fruit and
a 1500 g/ml concentration, which is well within the
Nhan. Its juice has a broad range of therapeutic effects
safety profile of toxicological studies.21 The triphala
including antibacterial, anti-inflammatory, antiviral,
extract is also found to be successful in preventing
antitumor, antihelmenthic, analgesic, hypotensive,
plaque formation, as it inhibites the sucrose-induced
anti-inflammatory and immune enhancing effects.
adherence and the glucan-induced aggregation, the
These compounds have been shown to fight against
two processes which foster the colonization of the
infectious bacteria strains such as P. aeruginosa,
organism on the surface of the tooth.22
Proteus morgaii, Staphylococcus aureus, Baciillis
subtilis, E. coli, Salmonella, and Shigela.15 GREEN TEA POLYPHENOLS

In an in vitro study conducted by Murray PE et
al 16, comparing the effectiveness of Morinda citrifolia
juice (MCJ) with sodium hypochlorite (NaOCl)
and chlorhexidine gluconate (CHX) to remove the
smear layer from the canal walls of endodontically
instrumented teeth, it was found that MCJ was more
effective than CHX for removing smear layer and
saline as the negative control. The efficacy of MJC
was similar to NaOCl in conjunction with EDTA as an
It is prepared from the young shoots of tea plant
Camellia Sinensis. It has significant antioxidant,
anticariogenic, anti-inflammatory, thermogenic,
probiotic and antimicrobial properties. It can be
used as an effective antiplaque agent because of its
antioxidant properties and it can effectively inhibit
the biofilm formation.23
An in vitro study conducted to evaluate
the antimicrobial efficacy of Triphala, green tea
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
polyphenols (GTPs), MTAD and 5% NaOCl against
E. faecalis biofilm formed on tooth substrate showed
maximum antibacterial activity with NaOCl and
statistically significant antibacterial activity with
Triphala, GTPs and MTAD. The antimicrobial
activity is due to inhibition of bacterial enzyme
gyrase by binding to ATP B sub unit.24 Madhu Pujar
et al, compared the efficiency of triphala, gren tea
polyphenols and 3% sodium hypochlorite against
E.faecalis and it was observed that triphala and
green tea polyphenols showed significantly be�er
antibacterial activity against 2 week biofilm.25 Three
percent concentration of green tea extract showed an
antibacterial activity equivalent to 2% CHX against E.
faecalis. GTE can also be used as a suitable, alternative
storage medium for avulsed teeth..
AZADIRACHTA INDICA – NEEM TREE
Each part of the Neem tree has some medicinal
property and is thus commercially exploitable. It is
a good antimicrobial. This product has been proved
to be effective against E. faecalis and Candida
albicans.26.
The results of a study suggested that the dental
gel containing Neem extract had significantly reduced
the plaque index and bacterial count than that of the
CHX gluconate group.27
The bark as well as the twigs helps in dental care
ba�ling gingivitis and preventing cavities. Neem
extract is added in many organic toothpastes and
mouthwashes. In the preliminary findings by Vanka
et al.28 neem inhibited Streptococcus mutans and
reversed incipient carious lesions.
A study has also indicated that the ethanolic
neem leaf extract can be used successfully within
the root canal as an irrigant with demonstrable
anti-microbial efficacy. A combination of Sodium
hypochlorite and the ethanolic neem leaf extract is
synergistic antimicrobially.29
ALOE BARBADENSIS MILLER (ALOE
VERA)
Aloe vera possesses good anti bacterial and
anti fungal activity. In a study anti microbial
effect of water, alcohol, chloroform extracts of aloe
vera gel were investigated and it was found that
chloroform extract of aloe vera had significant anti
14
microbial effect against E.faecalis. It also has been
found to be effective against the resistant micro
organisms commonly found in the pulp. It has also
got wound healing properties. Yagi et al.30 reported
that Aloe vera gel contains a glycoprotein with cell
proliferating-promoting activity, while Davis et al.31
noted that Aloe vera gel improved wound healing
by increasing blood supply (angiogenesis), which
increased oxygenation as a result. Beside this aloe
vera gel also has its application in the treatment of
aphthous ulcer,oral lichen planus, angular Chelitis,
burning mouth syndrome and gingivitis.It can also
be applied directly at sites of periodontal surgery;
and as an adjunct to Scaling and root planning in
periodontitis. Extraction sites respond comfortably
and empty purses do not develop when aloe vera
is applied.patients with sore gums and teeth with
dentures maladaptive may also benefit.Aloe vera can
also be used around dental implants to control
inflammation caused by bacterial contamination.32
SALVADORA PERSICA SOLUTION
(Miswak)
Its chewing sticks contain trimethyl amine,
salvadorime chloride and fluoride in large amounts.
It has exhibited Antimicrobial and Anticariogenic
effects. Fifteen percent alcoholic extracts of it has
maximum antimicrobial action. It can be used as a
substitute for sodium hypochlorite and chlorexidine
as root canal irrigant.33 Many reports have revealed
that S. persica miswak effectively reduced gingivitis
and dental plaque.
CURCUMA LONGA (TURMERIC)
Curcumin, a member of a ginger family possesses
anti inflammatory, anti oxidant , anti microbial
and anti cancer activity. It has been shown that
curcumin has significant anti bacterial activity against
E.faecalis and can be used as an alternative to sodium
hypochlorite for root canal irrigation. Thus this herb
can be used especially in endodontics for root canal
failure cases. It can also be used in Pit and fissure
sealant and dental-plaque detection system.34
ACACIA NILOTICA (BABOOL)
Acacia nilotica also known as the gum Arabic
tree, possesses good anti microbial, anti oxidant,
anti fungal, anti viral and antibiotic activity. It has
15 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
been shown by Rosina Khan et al35 that this tree
possesses anti bacterial activity against streptococcus
mutans and E.faecalis. Babool has shown to possess
antibacterial activity against Streptococcus mutans
and E. faecalis. Antimicrobial function is believed to
be due to tannins, phenolic compounds, essential oil,
and flavonoids.
CITRUS LIMONUM RISSO. (NIMBUKA
- LEMON)
Fresh lemon solution is used as root canal
medicament due to its wide antibacterial efficiency
including E. faecalis. Oil of lemon is topically used for
the treatment of oral thrush and stomatitis.
CONCLUSION
It is inspirational to see that traditional herbal
plants have now been used to prepare several
therapeutically and industrially useful preparations
and compounds. It generates encouragement
among the scientists to explore more information
about the herbal medicinal plants. As the global
circumstances are now changing towards the use of
nontoxic plant products having traditional medicinal
use, development of modern drugs synthesized
from herbs should be emphasized for the control of
various diseases. In fact, time has come to make good
use of centuries-old information on herbs through
contemporary approaches of drug development. For
the last few years, there has been an increasing trend
and awareness in herbal research. Quite a significant
amount of research has already been carried out
during the past few decades in exploring the
chemistry of different herbs. An extensive research
and development work should be undertaken on
herbal medicines and their be�er economic and
therapeutic utilization.
Acknowledgement – Nil
Ethical Clearance- Taken from..institutional
ethical commi�ee, Teerthankar Mahaveer dental
college
Source of Funding- Self
Conflict of Interest - Nil
REFERENCES
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Antibacterial potentials of some herbal
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15. Neelakantan P, Jagannathan N, Nazar
N. Ethnopharmacological approach in
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et.al. Evaluation of Antimicrobial Efficacy
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25. Pujar M, Patil C and Kadam A. Comparison
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H. Isolation and characterization of the
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cells in vitro from Aloe vera gel. Planta
Medica, 1997 ; 63, : 18 -21.
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M. E. Anti-inflammatory activity of Aloe vera
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17 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

32 Vird H. K., Jain S., Sharma S. Effect of locally
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oral health. Saudi Dent J. 2012; 24: 63 -69
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Shazi Shakil , Anis Ahmad ,S. Manazir Ali ,
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Molecules,14, 2009, 586-597.
 DOI Number: 10.5958/2320-5962.2016.00004.8

Advances in Esthetic Dentistry

Prashanth Kumar Ka�a1, Meghraj D2, Sandeep Rajalbandi3, Sreedhara S4

1
Assistant Professor, College of Dentsitry, King Khalid University, Abha, Kingdom of Saudi Arabia, 2Department of
Prosthodontics, Faculty of Medical Technology, Libya, 3Reader, Sharavathi Dental College, Shivamogga,
4
Professor, Department of Orthodontics, SJM Dental College, Chitradurga

ABSTRACT

Esthetic dentistry deals with the smile designing, the shape and form of teeth that best improves the
esthetics in harmony with the surrounding hard and soft tissues and must be in sync with oro-facial
elements. Cosmetic dentistry refers to a range of dental treatments formulated to improve the smile
and rectify chipped, cracked, discoloured and malposed unevenly spaced teeth. It ranges from ceramic
veneers to teeth-colored restorations; patients can select from a wide range of cosmetic dentistry
treatment procedures for restoring and or improving the health and vitality of their smile.

Keywords: Esthetics, smile, bleaching.

INTRODUCTION 1. Silicate cements (no more used) 2. Acrylic

resins 3. Composite resins and sealants 4. Glass
Everyone smiles in the same language. The smile
Ionomers
of an individual a�racts every person he meets.
• Identify the available esthetic restorative
More people are growing consciousness about
materials
dental esthetics. Advancements in esthetic treatment
modalities have resulted in more reliable and less Direct:
invasive procedures. This article describes the various 1. Composites
methods available to improve the esthetics1. 2. Giomers
3. Compomers
Balance between the prominent features of a face
adds to creating a beautiful face. The “Facial prominent 4. Resin-modified glass ionomer
Features” are the smile with its components, teeth,
Table 1: Uses of Composites, Compomers, Resin-
gingiva and lips; eyes and facial frame.
Modified Glass Ionomers, and Glass Ionomers4, 2, 3
The word aesthetic speaks about an
TYPE USES
understanding of beauty. Hence, it is necessary to
have a comprehensive knowledge of beauty and the All-purpose Class I, II, III, IV, V, patients
composite with low risk of caries
artistic instruments available to create a beautiful
smile2. Microfilled Class III, V
composite
Esthetic restorative materials3, 1:
Nanofilled Class I, II, III, IV, V
The four main types of direct esthetic restorative composite
materials include:
Packable Class I, II, VI (mesial, occlusal,
Corresponding author: composite distal = MOD)
Dr. Prashanth Kumar Ka�a MDS Flowable Cervical lesions, pediatric
Assistant Professor, College of Dentsitry, King composite restorations, small, low-stress-
bearing restorations
Khalid University, Abha, Kingdom of Saudi Arabia,
Laboratory Class II, three-unit bridge (with
Mob: +966538073497
composite fiber reinforcement)
Email:drprashanthkumar@yahoo.com
19 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

Compomer Cervical lesions, Class III
primary teeth, Class I, II
restorations in children, Class
II (with sandwich technique),
patients with medium risk of
caries
Resin- Cervical lesions, Class III, V,
modified II (with sandwich technique),
glass pediatric restorations primary
ionomer teeth, Class I restorations in
children, sandwich technique
(Class II), patients with a high
risk of caries
1. Always remember that posts merely aid in
restoration retention. Instead of strengthening the
tooth, they may weaken it.
2. Choose systems that are organized, color-
coded, and offer multiple diameters.
3. Err on the side of tooth conservation; post
length is more retentive than diameter.
4. Prepare a post depth as long as the intended
finished crown length.

Glass Cervical lesions, Class V 5. Prepare the tooth margin at least 1 mm to 2

ionomer restorations in adults in whom mm below the build-up.
esthetics are less important than
that of other types, patients
6. Use dual-cure bonding agents and luting
with a high risk of caries
materials to ensure material cure regardless of post
light transmission.
Indirect:
7. Communicate final build-up shades so the
a. Ceramics
ceramist can limit restoration opacity.
b. Indirect composites
• Understand the esthetic and strength Color and integrating color into direct
characteristics of current materials and indirect restorations: Color has two basic
characteristics: Hue and Chroma. Natural tooth color
• Describe the bonding & cementation
also displays these same characteristics. Hue can be
requirements for specific materials
defined as the actual color such, as yellow or gray.
• Identify Material Selection choices for Chroma is the intensity of that color and is sometimes
discolored preps called saturation. Value is the brightness of a tooth2.
• Define the parameters of anterior veneer
Shade taking:
preparation
• Describe full coverage preparations 1. If patient is wearing bright colored clothing,
drape him or her with a neutral colored cover.
• Understand the preparation requirements for
posterior all ceramic onlays 2. Have patient remove lipstick and other make-
Esthetic Post Systems: up, as well as eyewear.
Advantages of Fiber-Resin Post Systems 3. Teeth must have been cleaned.
1. Metal-free, more esthetic result
4. The shade taking should be done at the
2. Ability to transmit curing light
beginning of the appointment, so that teeth are moist
3. May provide flexibility to decrease root (the patient must lick their teeth constantly to keep
stresses them moist) and your eyes fresh.
4. Bondable, not cemented, which may aid in
5. The operatory light should be turned off or
retention
pointed in another direction. It must not focus on the
5. Will never corrode and are relatively easy to patient.
remove for endodontic or restorative failure
6. The room light conditions should have a
6. Biocompatible
temperature of 5500-6500° K. (when pictures are
Keys to Increase Success of Esthetic Post taken, these parameters are no longer relevant,
Placement5, 3 because the light of the flash will prevail).
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 20

7. Obtain value levels by squinting.
8. Women are far less likely to be color blind than
men, so it is a good idea to have your assistant assist
in shade taking decisions (assuming that the assistant
is a woman and not color blind)6, 7, 2
Fundamental adhesive concepts
tissue. Several potential factors could contribute to a
gummy smile. For example, the muscle controlling
the movement of the upper lip could be hyperactive,
resulting in an upper lip that rises higher than
normal. When this occurs, more of the gingival tissue
is exposed when smiling8, 6.

How to select and integrate restorative materials Techniques: Depends on etiological factors,
and adhesive protocols with sound fundamental perception and patient needs.
design principles for direct /indirect composite and 1. Orthododntics
ceramic restorations 2. orthognathic surgery
How to develop an anatomical morphological 3. Periodontal surgery: Apically positioned flap
thinking with osteotomy
Anterior and Posterior Composites 4. Cosmetic surgery
Depigmentation: While the normal gum color is 5. LASER gingivectomy
pale pink, abnormally high amounts of melanin can Gingival enlargements
cause dark spots and patches to appear on the gum a) Gingivoplasty
tissue7.
b) Gingivectomy
Techniques:
c) Flap surgery
1. Radiosurgery
2. Scalpel Surgery Crown lengthening: Exposure of a greater height
of clinical crown in the esthetic zone may by crown
3. Electrosurgery
lengthening include an apically positioned flap or
Treatment of gummy smile: Gummy smile
gingivectomy (with a scalpel or electrosurgery) or
(excessive gingival display) is a condition in which a
flap surgery with osseous recontouring9, 1.
high lip-line exposes an abnormal amount of gingival

Table 2: Classification System for Aesthetic Crown Lengthening Procedures8

Classification Characteristics Advantages Disadvantages

Adequate soft tissue allows May be performed by the restorative

gingival exposure of the dentist. Provisional restorations of
Type I
alveolar crest or violation of the the desired length may be placed
biologic width. immediately.

Will tolerate a temporary violation

Adequate soft tissue allows
gingivectomy without exposure
Type II
of the alveolar crest but in
violation of the biologic width.
of the biologic width. Allows staging
of the gingival excision and bone Requires osseous
contouring technique. contouring. May require a
Temporary restorations of the surgical referral.
desired length may be placed
immediately.

Staging of the procedures and

alternative treatment sequence Requires osseous
Gingivectomy to the desired
may minimize display of exposed contouring. May require a
Type III clinical crown length will
subgingival structures. Provisional surgical referral.
expose the alveolar crest.
restorations of desired length may be Limited flexibility.
placed at second-stage gingivectomy
Limited surgical options.
No flexibility.
Gingival excision will result in
A staged approach is not
Type IV inadequate band of a�ached
advantageous.
gingiva.
May require a surgical
referral.
21 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

Gingival Veneers10: Periodontal disease, trauma, Esthetics can be compromised when

and congenital defects can result in both soft tissue supragingival or equigingival preparations are done.
and hard tissue defects that can present with aesthetic In case of zirconia, metal or alumina, the technique
problems. The gingival veneer is a viable treatment will be more cumbersome because the margin itself
option for restoring anterior esthetics in clinical is more opaque. Anytime you’re using a more opaque
situations where there are esthetic concerns caused restorative material of any thickness, there will be a
by significant gingival recession. difference in opacity of the margin and tooth shade
causing a visible line at the junction where the
Table 3: Indications and contraindications for
restoration meets the tooth. It’s necessary to go below
the use of gingival veneers
the tissue to hide discolored teeth and the junction
with the restorative material. It should also be noted
Indications Contraindications
that whenever you are using more opaque materials,
Poor aesthetics it’s ideal to go subgingivally to hide margins11, 5, 3.
characterized by
interdental “black CONCLUSION
triangles,” Poor oral hygiene
exposed root surfaces, Esthetic dentistry is a vast field. It encompasses
and/or
crown margins esthetic restorative materials, smile designing and
improving the form and function of the teeth by
Food packing in
interdental Limited manual dexterity maintaining the harmony with the surrounding
spaces orofacial structures. Thorough understanding of the
Lack of saliva control High caries activity/risk science of esthetic restorative materials in association
with the indications and need for smile enhancement
Incomplete periodontal
Impaired speech
therapy
will give the best results.

Allergy to fabrication Conflict of Interest: None

Root-dentine sensitivity
materials
Source of Funding: Self
Basic consideration in full coverage restorations,
indications, contraindications, tooth preparation Acknowledgements: None
techniques, gingival tissue management, Ethical Clearance: Not applicable
impression, provisional restoration, lab procedure,
try in, cementation of ceramic jacket crown and REFERENCES
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Under preparation results in poor aesthetics or 3. Touyz LZ, Raviv E, Harel-Raviv M, Cosmetic
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 DOI Number: 10.5958/2320-5962.2016.00005.X

Talons Cusps: The Achilles’ Heel of the Incisors

Preeti Dhawan1, Vivek Gaurav2, Aditi Singh3 , Shilpi Singh4

1
Professor, Department of Paedodontics and Preventive Dentistry, 2Asst Professor, Department of Paedodontics and
Preventive Dentistry, 3Postgraduate Student, Department of Paedodontics & Preventive Dentistry, Seema Dental
College & Hospital, Rishikesh, U�arakhand, India, 4Reader, Department of Public Health & Dentistry
DJ College of Dental Sciences & Research, Modinagar, U�arPradesh

ABSTRACT

Abnormalities in tooth morphology are not uncommon. However talon’s cusp is a recherché dental
anomaly of the permanent dentition. It’s an anomalous structure resembling an eagle’s talon that
projects lingually from the cingulum area of a maxillary or mandibular permanent incisor. Presence of
bilateral talon’s cusp in primary lateral incisors is an extremely recondite clinical finding. Its presence
makes the otherwise caries resistant incisors prone to tooth decay. It is generally asymptomatic
but sometimes it may pose functional or esthetic problems and so it demands a preventive line of
management. This paper reports one such rare case of non-syndromic bilateral talon’s cusp in primary
lateral incisors during mixed dentition period and its preventive management.

Keywords: Bilateral Talon’s cusp, dens evaginatus, Primary lateral incisors.

INTRODUCTION The incidence has been found to range from less

A talon cusp, also known as an “eagle’s talon”,
is an extra cusp on an anterior tooth. The term refers
to the same condition as dens evaginatus, but the
talon cusp is the manifestation of dens evaginatus on
anterior teeth. Shulze defined talon cusp as a very high
accessory cusp, which may connect with the incisal
edge to produce a “T” form or a “Y”-shaped crown
contour.1 Mader in 1981 and Davis in 1986 redefined
this entity as “a morphologically well-delineated cusp
that projects from the lingual surface of the primary
or permanent anterior tooth and extends at least half
the distance from the cementoenamel junction to the
incisal edge.2
Ha�ab et al classified this anomaly into 3 types
on the basis of the degree of cusp formation and
extension. Type I (talon) has an additional cusp that
projects from the palatal surface of an anterior tooth
and extend at least one half the distance from the
cementoenamel junction to the incisal edge. Type II
(semitalon) has an additional cusp 1 mm or more in
length but extending less than one half the distance
from the cementoenamel junction to the incisal
edge. Type III (trace talon) manifest enlarged and
prominent cingula and their variation.3
than 1% to 6% of the population.1 Of all cases, 55%
occur on the permanent maxillary lateral incisor, and
33% occur on the permanent maxillary central incisor.
They are found rarely in primary teeth.1
Henderson in 1977 first reported a case of talon’s
cusp in primary dentition. Since then numerous cases
have been reported, but bilateral talons cusp is rarely
found. The only reported cases of bilateral talon’s
cusp in primary dentition were by Chin Ying et al in
primary central incisors.2
This article for the first time represents a case of
bilateral talon’s cusp in primary lateral incisors and
their preventive management.
CASE REPORT: A 7 year old girl reported to
the Department of Paedodontics of Seema Dental
College and Hospital, Rishikesh for a routine dental
checkup. On examination she had a mixed dentition
with carious tooth no.54, 55 and presence of talon’s
cusp with respect to tooth no.52, 62 (Type III i.e. trace
talon). (Fig.1). History of extraction was reported in
relation to tooth no. 64 one month back. Radiographs
and Orthopantomogram confirmed the presence of
bilateral talon’s cusps (Fig 2, Fig 3). Oral prophylaxis
was performed and carious teeth were restored,
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 24

tooth no. 54, 55 extracted followed by bilateral space which should be done at periodic intervals with an
maintainer and pit andfissure sealant application aim to facilitate reparative dentin formation.2 In the
over tooth no. 52, 62.Patient was asked to come for present case to prevent any carious involvement of
periodic reevaluation. the incisors pit and fissure sealants were applied.
Since there was no occlusal interference its correction
DISCUSSION
was not required and the patient was put on periodic
The prevalence of talon cusp varies with race, recall.
age, and the criteria used to define this abnormality.
A prevalence of 0.17% in the United States, 0.06%
in Mexico, 5.2% in Malaysia, and 7.7% in the North
Indian population has been reported. A review of
the literature suggests that 75% of the cases are in
the permanent dentition and 25% in the primary
dentition. This anomaly has a greater predilection
in the maxilla (with more than 90% of the cases
reported) than in the mandible (only 10 % of the
cases).In the permanent dentition, 55% of the cases
involved maxillary lateral incisors, 33% involved
central incisors, and 4% involved canines.2 Gardner
and Girgis found out that talon’s cusp appears to Fig. 1 : Intraoral view of maxillary arch
be more prevalent in persons with the Rubinstein
Taybi syndrome (developmental retardation, broad
thumbs and great toes, characteristic facial features,
delayed or incomplete descent of testes in males, and
stature, head circumference, and bone age below
the fiftieth percentile). The talon cusp has not been
reported as an integral part of any other syndrome,
although Mader, in his thorough review, suggested
that it may be associated with other somatic and
odontogenic anomalies.2

No definite data has been reported in the primary

dentition especially the primary lateral incisors.
Talon’s cusp is an anomaly with obscured etiology
.The most accepted theory is that it might occur Fig. 2 : Orthopantomogram of the patient
as a result of an outward folding of inner enamel
epithelial cells and a transient focal hyperplasia of
mesenchymal dental papilla.3,4

The presence of talon’s cusp can cause many

problems like occlusal interference or predisposition
to dental caries.Treatment may differ, depending
on each case. Small talon cusps are usually
asymptomatic, necessitating no treatment. However,
large prominent talon cusps necessitate definitive
treatment.5 Preventive treatment towards dental
caries should be done in every case by sealing the Fig. 3 : Intra Oral Periapical Radiograph in relation to 52,
interface of the talon’s cusp. Occlusal disturbance 62
and unpleasant esthetics necessitate cusp reduction
25 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
CONCLUSION
Such anomalies should be correctly identified
and reported so that other clinicians are also able to
identify these anomalies and treat them accordingly.
Ethical Clearance: Was obtained from the our
institution’s ethical commi�ee & informed consent
was obtained from the child’s parent prior to
reporting of the case.
Source of Interest : Nil
Conflict of Interest : None Declared.
Acknowledgement : None
REFERENCES
1. Neville, B.W., D. Damm, C. Allen, J. Bouquot.
Oral and Maxillofacial Pathology. Second
edition. 2002.p.69-71.
2. J. Jeevarathan, A. Deepti, M.S. Muthu,N.
Sivakumar, K. Soujanya; Labial and lingual
talon’s cusp of a primary lateral incisor;
Pediatric Dentistry;2005 ;27(4):303-306.
3. Ha�ab FN. Yassin OM. Al-Nimri KS. Talon cusp
in permanent dentition associated with other
dental anomalies: review of literature and report
of seven cases. J Dent Child 1996; 63:368-76
4. H. Cern Gungor, Nil Altay, F. Figen Kaymaz,
Ankara.Pulpal tissue in bilateral talon cusps of
primary central incisors.Report of a case. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2000;89:
231-5
5. Tulunoglu O, Cankala DU Ozdemir RC. Talon’s
cuspReport of four unusual cases Indian Soc
Pedod Prev Den2007: 25:1:52-55.
 DOI Number: 10.5958/2320-5962.2016.00006.1

Orthokeratinised Odontogenic Cyst in Anterior

Maxilla – A Mosaic Enigma

Anisha Perepa1, Ramen Sinha2, Prabhat K Tiwari3, B V Ramakrishna Reddy3,

Anmol Agarwal4, Snehal Reddy5
1
Post Graduate Student, 2Professor and Head, 3Assistant Professor, 4Associate Professor, Department of Oral and
Maxillofacial Surgery, 5Post Graduate Student, Department of Oral and Maxillofacial Pathology,
Sri Sai College of Dental Surgery, Vikarabad, Telangana, India

ABSTRACT

Orthokeratinized odontogenic keratocyst cyst (OOC) is a developmental cyst of jaw, initially considered
by the World Health Organization (1992) as an uncommon variant of Keratocyst odontogenic tumor
(KCOT). However, OOC presents peculiar clinicopathologic features which is at variance with other
developmental odontogenic cysts, especially OKC. The purpose of the article is to discuss a rare OOC
arising in the anterior maxilla and to review the pertinent literature.

Keywords – Maxilla, Orthokeratinised Odontogenic Cyst, Ki 67 positive cells.

INTRODUCTION unique case of OOC in the anterior maxilla, an unusual

site for the lesion and highlight the importance of
The OOC is a relatively rare developmental distinguishing it from the more common KCOT.
odontogenic cyst arising from remnants of the dental
lamina 1,2. It was first described by Schul� in 1927 3 as CASE REPORT
orthokeratinized variant of odontogenic keratocyst . Li
A 21yr male was referred to our department by an
et al.(1998) suggested “orthokeratinized odontogenic
orthodontist with an unaesthetic and unpleasant smile
cyst,” which is now widely accepted. 2, 4.The World
for the past 10years. His previous medical history was
Health Organization (WHO) for head and neck
not of any relevance and his general physical status
tumors (2005) has designated odontogenic keratocyst
was good. Extra orally,a diffuse swelling was noticed
(OKC) as (KCOT)5 and lists OOC as a separate entity
on the right cheek, starting 3cms posterior to corner of
independent of the spectrum of KCOT. OOC now
mouth and 0.5cms infront of ear lobule, 2cms below the
stands out as a distinct entity in the class of jaw cysts
zygomatic arch to angle of mandible associated with
comprising 5.2% to 16.2% of cases that had been
paresthesia and tenderness in the right infra-orbital
previously designated as an OKC.6 These cysts are
region. Intraorally, a missing canine on right side
often asymptomatic and discovered as an incidental
along with a bony hard swelling extending from 11 to
finding especially in the orthodontic radiographs,2,7 .
15 with obliteration of buccal vestibule was noticed.
OOCs involvement of maxilla is rather rare, as borne
A provisional diagnosis of adenomatoid odontogenic
out by the mandibular predilection of 9.17:1,and a
tumor of impacted canine and a differential diagnosis
propensity for the posterior region.8. We present a
of dentigerous cyst, unicystic ameloblastoma were
made. Radiographs revealed an impacted canine in
Corresponding author :
relation to nasal floor on the right side.(Fig1). Surgical
Anisha Perepa
enucleation followed by application of Carnoy’s
Post Graduate Student, Department of Oral &
solution was carried out & specimen was sent for
Maxillofacial Surgery, Sri Sai College of Dental
histopathological examination, along with the white
Surgery, Vikarabad, Telangana, India.
cheesy material evacuated from the cystic cavity.
Contact No. + 91 9849859690
The associated impacted canine was also removed
Email – kperepa@gmail.com
surgically. H& E section revealed a well defined cystic
27 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
lining with 2-4 layers of orthokeratinising stratified
squamous epithelium with underlying connective
tissue showing inflammatory infiltrate in the form of
lymphocytes, foci of bony trabaculae, nerve bundles,
hemorrhage with hemosiderin, extravasated red
blood cells and lumen filled with keratin flakes were
seen (Fig 2) and Immunocytochemistry demonstrated
significantly fewer Ki-67-positive proliferating cells
in the epithelial lining.(Fig 3)Considering the clinical
,radiological and histopathological findings, a final
diagnosis of OOC was made.
FFig 1 - CBCT Radiograph showing impacted canine in
relation to nasal fl oor on the right side.
Fig 2 - Histopathological slide photograph
Fig 3 - Immunocytochemistry demonstrated significantly
fewer Ki-67-positive proliferating cells in the epithelial
lining.(Fig 3)
DISCUSSION
The prevalence of OOC is very low and the
information regarding this variant is still scant.8 OOC
are difficult to diagnose due to lack of specific clinical
and radiographic characters.9 A predilection for the
posterior mandible (68%)8,1% of all cases of OKC
in the maxilla with sinus involvement have been
reported10.OOC occur in 3rd ,4th decades with a male
to female ratio of 2.59:1 10 .Hence, involvement of an
unusual location, like the maxillary anterior region,
makes the present case unique.H/E demonstrates
several striking differences between the epithelial
lining of orthokeratinized and parakeratinized cysts.
OOC exhibits a thin, uniform, orthokeratinized
lining epithelium characterized by onion skin-like
luminal surface keratinization, prominent stratum
granulosum and low cuboidal or fla�ened basal cell
layer with li�le tendency of nuclear palisading.11
Epithelial lining of OOC shows a higher degree of
squamous differentiation and exhibits low degree of
cellular activity than KCOT . The high, predominantly
suprabasal proliferative activity suggests a difference
in the proliferation and maturation of the two types
of epithelia.9 While the study by Crowley, Kaugars
and Gunsolle suggested recurrence rates of the OKC
and OOC were 42.6% and 2.2%, respectively.11OOC
presents as unilocular (87.0%) or multilocular
radiolucencies often associated with impacted
teeth (60.8%)10 .One way of differentiating OOC is
the lack of root resorption, which is characteristic of
ameloblastomas and KCOT10. In conclusion , it is
important to differentiate OOC from other entities
because its unique features have a direct bearing on
the treatment plan , the prognosis and the required
follow up.
Conflict of Interest: We have no conflict of
interest.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Ethics Statement/confirmation of patient
permission: All patients gave informed consents for
clinical images for publication.
Orthokeratinised odontogenic cyst in anterior
maxilla – A mosaic enigma
Acknowledgement - Nil
Source of Funding - Self
REFERENCES
1. T.-J. Li, M. Kitano, X.-M. Chen et
al.Orthokeratinized odontogenic cyst: a Surg.1988;26:215– 20.
clinicopathological and immunocytochemical
study of 15 cases, Histopathology. 1998; 32:
242–51.
2. Q. Dong, S. Pan, L.-S. Sun, and T.-J. Li.
Orthokeratinized odontogenic cyst A 480.
clinicopathologic study of 61 cases.Archives of
Pathology and Laboratory Medicine.2010; 134,
271–5.
3. L. Schul�. Cysts of the maxillae and
mandible. The Journal of the American Dental
Association.1927;14 :1395–02.
4. D S MacDonald-Jankowski ,T K Li.
Orthokeratinized odontogenic cyst in a Hong
Kong community: the clinical and radiological
features. Dentomaxillofac Radiol. 2010 ; 39:
240–5.
5. Rahul Devidas Pimpalkar, Suresh R Barpande,
Jyoti D Bhavthankar, and Mandakini S Mandale.
Bilateral orthokeratinized odontogenic cyst: A
28
rare case report and review J Oral Maxillofac
Pathol. 2014; 18: 262–6.
6. Vikrant O Kasat, Harish Saluja, Jitendra V
Kalburge, Yogesh Kini, Atul Nikam, Ruchi
Laddha .Multiple bilateral supernumerary
mandibular premolars in a non-syndromic
patient with associated orthokeratised
odontogenic cyst- A case report and review of
literature .Contemp Clin Dent 2012;3, S2482.
7. Siar CH, Ng KH.Orthokeratinised odontogenic
keratocysts in Malaysians. Br J Oral Maxillofac
8. Meena Kulkarni, Supriya Kheur, Tripti Agrawal,
and Yashwant Ingle .Orthokeratinizing
odontogenic cyst of maxilla with complex
odontoma. J Oral Maxillofac Pathol. 2013; 17 :
9. Brannon RB, The odontogenic keratocyst. A
clinicopathologic study of 312 cases. Part I.
Clinical features.Oral Surg Oral Med Oral Pathol.
1976 ; 42 :54-72.
10. Bhasin N, Sreedevi, Pathak S, Pu�alingaiah
VD. Orthokeratinized odontogenic cyst: A rare
presentation . J Indian Acad Oral Med Radiol.
2014; 26: 119-23.
11. Thosaporn W, Iamaroon A, Pongsiriwet S,
Ng KH. A comparative study of epithelial cell
proliferation between the odontogenic keratocyst,
orthokeratinized odontogenic cyst, dentigerous
cyst, and ameloblastoma. Oral Diseases. 2004; 10:
22–6.
 DOI Number: 10.5958/2320-5962.2016.00007.3

Effect of Prior Application of 2% Calcium Dobesilate

on Direct Pulp Capping with MTA- A Preliminary
Randomized Clinical Trial

Lalit Chandra Boruah1, B Rajkumar2, Pallavi Bhuyan3

1
Department of Endodontics, 2Prof., Department of Endodontics, BBD College of Dental Sciences,
Lucknow, India, 3Statistician, Lucknow, India

ABSTRACT

Aim of the Study: To observe the effect of prior application of calcium dobesilate on direct pulp
capping with MTA.

Outline of Methodology: Clinically and radiographically confirmed cases of direct pulp exposed teeth
were randomly stratified into two groups; Group I- Pulp capping done with MTA with prior application
of calcium dobesilate and Group II- Pulp capping done with MTA without prior application of calcium
dobesilate.

The experimented teeth were evaluated clinically and radiographically for 6 months post operatively.

Results: All the teeth that were followed showed favourable outcomes on the basis of radiographic
appearance, subjective symptoms and cold testing. Group I showed faster results as compared to
Group II.

Conclusion: Prior application of calcium dobesiltae has shown to increase the efficacy of MTA as a
direct pulp capping agent.

Keywords: Calcium dobesilate , Direct pulp capping, Mineral Trioxide Aggregate.

INTRODUCTION Cochrane Review found that evidence is lacking as

The consequences of pulp exposure from caries,
trauma or tooth preparation misadventure can
be severe, with pain and infection the result. The
morbidity associated with treating pulp exposures
is consequential, often requiring either extraction
or root canal therapy. An alternative procedure to
extraction or endodontic therapy is pulp capping
in an a�empt to maintain pulp vitality. A number
of materials have been suggested for use in direct
pulp capping. Interestingly, no one material seems
to enjoy a significant preference among practitioners.
In a survey in which private practitioners were asked
what direct pulp capping material they use, the
respondents listed different materials like Calcium
Hydroxide, MineralTrioxide Aggregate (MTA),
Adhesive systems and RMGIC/GIC with none being
preferred by a clear majority of users.1 Although
many products have been suggested, a recent
to the most appropriate pulp capping material.2 MTA
has been described very recently as “the material of
choice” in pulp capping procedures, particularly in
permanent teeth as compared to Calcium hydroxide
in long term studies3. Calcium dobesilate is a
vasoactive drug with presumed effects on endothelial
integrity, capillary permeability and blood viscosity.
It is often recommended for venous disorders,
and also prescribed for diabetic retinopathy and
other microvascular disorders.4-6Till now there is
no reported use of this drug in dentistry for direct
pulp capping. In this study it was used as a local
application in direct pulp capping along with MTA.
AIM OF THE STUDY
To clinically observe the effect of prior application
of calcium dobesilate on direct pulp capping with
MTA.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
SELECTION CRITERIA
A total of 40 patients were randomly selected
from the undergraduate out patient within the age
group 18 to 34 years .Teeth presented with caries in
close proximity to the pulp in relation to mandibular
molars with no signs of extra oral or intraoral swelling
or sinus tract formation were selected. All teeth were
negative to percussion and palpation tests and the
mobility was within normal limits. The research
protocol and informed consent were reviewed and
approved by an institutional research commi�ee
(IRC) prior to study initiation. All patients were
informed about the procedure and informed consent
was obtained.
Group Distribution
For blinding purpose each subject was asked to
select a sealed pouch ( total 40 pouches) labeled with
unique number which was required for investigation
research. Selected cases were then divided into
following groups: Group I- Pulp capping with
Calcium dobesilate + MTA (n=20) Group II- Pulp
capping with MTA only (n=20) as per the unique
number selected.
PREPARATION OF CALCIUM DOBISILATE
SOLUTION
Manual grinding of 500mg Calcium dobesilate
monohydrate tablets (Ranbaxy,India) was done in
morter and pestle until fine grains were obtained. 1
ml of normal saline(9 g/L Sodium Chloride) , USP
(NaCl) with an osmolarity of 308 mOsmol/L was
added to obtain 2% calcium dobesilate solution
(20mg/ml) W/V.
Treatment Protocol
The initial treatment plan was removal of
the carious lesion followed by clinical evaluation
of the pulp exposure. Direct pulp capping with
MTA ANGELUS –WHITE (Angelus Indústria de
Produtos Odontológicos BRASIL) was planned for
the anticipated pulp exposure with and without
application of Calcium dobesilate solution. Patients
were informed about the procedure and consent
was obtained along with the information about
the potential need for root canal therapy in case
of abnormal signs and symptoms. Following
administration of local anaesthesia, teeth were
30
isolated with rubber dam. Caries removal was
performed using a no. 4 sterile round bur on a low
speed handpiece with copious water irrigation.
During or after removal of caries, exposure of pulp
with moderate bleeding was observed .A sterile
co�on pellet moistened with saline was used to apply
moderate pressure to the exposed pulp for 5 min and
haemostasis was achieved. The cavity was lightly
dabbed with a moist pellet to remove the excess
moisture.
Group I (n=20)
In this group 0.5 ml solution 2% calcium dobesilate
was applied on the exposure site with the help of
disposable calibrated syringes( Dispovan,Single use
insulin syringes). Immediately 1-2 mm thick layer of
MTA was placed over the exposure site and adjacent
dentinal surface with a plastic filling instrument. The
mix was then padded with a moist co�on pellet to
ensure optimum contact of MTA with exposed pulp
tissue. IRM (Caulk, DENTSPLY) was placed over the
MTA. A light cured Glass Ionomer Cement (GC Light
cured universal restorative) was used as a permanent
restoration.
Group II (n=20) In this group 1-2 mm thick
layer of MTA was placed over the exposure site and
restored with same procedure as Group I.
Patients were scheduled for 1week, 1 month, 3
months and 6 months follow up in order to monitor
for any signs or symptoms. Patients were asked to
call and inform if any pain or discomfort occurred.
In follow up visits clinical examination was done
to evaluate an intact restoration and absence of any
abnormal signs or symptoms. Teeth were tested for
vitality by various vitality tests (heat test, cold test,
electric pulp test). Periapical radiographs were taken
to evaluate any periapical changes.
Criteria for success was based on subjective and
objective responses. It was on the ability to show
response of a normal pulp at earliest possible time
frame.( 1 week,1 month,3 months and six months) as
compared to persistent abnormal pulpal symptoms.
31 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

RESULTS AND OBSERVATIONS

Table 1: statistical analysis

Number
Normal Reversible Chi-Square
Time Period Group No. of patients Level of Significance
Response Pulpitis values
reported
Group 1 20 18 2 p= 0.05833
After 7 days 3.5842 Significant
Group 2 20 18 7 p< 0.10
Group 1 19 19 0 p = 0.039615
After 1 month 4.2343 Significant
Group 2 20 16 4 P < 0.10
Group 1 18 18 0 p=0.0336342 Not
After 3 months 0.9243
Group 2 20 19 1 significant at p <0.10

Group 1 16 16 0 0
After 6 months
Group 2 17 17 0 Not significant at p <0.10

All the teeth that were followed showed
favourable outcomes on the basis of radiographic
appearance, subjective symptoms and cold testing.
(Total 33 patients at the end of 6 months, 1 patient
undergone RCT in Group II after 3 months follow
up). Inter group comparison was done with chi
–square test. No significant differences were observed
radiographically between both the groups. Group I
showed faster results as compared to Group II in the
early phase of treatment (±1 months).
DISCUSSION
Calcium dobesilate (C6H5O5S) 2,5-
dihydroxybenzene sulfonate, Molecular Weight :
418.41) is an orally administered angioprotective
agent which promotes venous blood flow. Calcium
dobesilate has three main indications: chronic venous
disease, diabetic retinopathy and the symptoms
of hemorrhoids. It acts on the capillary walls by
regulating its impaired physiological functions-
increased permeability and decreased resistance.
It increases erythrocyte flexibility, inhibits platelet
hyper aggregation and reduces plasma and blood
hyper viscosity, thus improving blood rheological
properties and tissue irrigation and contributes
to reduce edema. These effects allow to correct
capillary dysfunctions either of functional origin
or caused by constitutional or acquired disorders.
Rarely in sensitive persons some nausea or gastric
discomfort may occur but this rapidly disappears
.6-7 The prevalence of calcium dobesilate-induced
agranulocytosis estimated as 0.32 cases per million
treated patient.It has extremely low toxicity . In case
over dosage is suspected it is recommended that
vomiting be induced or gastric lavage be performed,
and such symptomatic supportive therapy be
administered as appears indicated.7 In our study 0.5
ml of 2% concentration of Calcium dobesilate used as
a local application and none of the patients reported
any side effects.
In our study a faster healing was observed with
calcium dobesilate and found to be statistically
significant (p < 0.10)in the early phases( ± 1 month)
of treatment which may be a�ributed to effect
of Calcium Dobesilate on the impaired capillary
functions the involved pulp.
MTA has been compared with various capping
materials including calcium hydroxide. The
deficiencies of calcium hydroxide include poor
adherence to dentin, inability to form a long-term
seal against bacterial microleakage and a porous
dentinal bridge formation.8 Pulps capped with
MTA consistently demonstrated complete tubular
bridge formation and lack of pulpal inflammation.
The dentinogenic effects of MTA can be a�ributed
mainly to its sealing ability and biocompatibility with
subjacent tissues, which facilitates restoring normalcy
to the pulpal and periradicular tissues.9 In this study
MTA Angelus- White was used as it has faster se�ing
time (10 -15 minutes) hence restoration is possible on
same visit.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 32

In cases where a permanent seal is placed over Some studies have shown that a tooth is more
the direct pulp capping material and the therapy likely to survive direct pulp capping if the initial
proved successful during the follow-up evaluation, exposure is due to mechanical reasons rather than
there is no further need for barrier verification or caries. Caries penetration to the pulp will result in
immediate endodontic treatment. bacterial invasion of the pulp, resulting in pulpal
inflammation. This leaves the pulp less able to
Being a preliminary clinical trial it needs further
respond and heal, compared to a mechanical
studies with a larger sample size aiming at the
exposure in which preexisting inflammation is not
histological extent and degree of inflammation and
present. A logical explanation of this is that teeth that
related changes in pulp due to calcium dobesilate
are asymptomatic and exhibit no clinical or radiologic
and for a longer follow-up period. The current study
signs of pathology at the time of pulp capping tend to
included factors that are believed to give indications
fare be�er than those teeth with such factors present16
of the health and healing capacity of pulpal tissue
but in reality we encounter more of the carious
prior to treatment i.e. age of the patient, size of
exposure cases which were considered for the present
exposure and radiographic appearance. Each of these
study.
factors has been cited in the literature as having some
relevance in the ability of the pulp to recover from a CLINICAL PHOTOGRAPHS
pulp exposure (carious or otherwise), 10-12 but none has
been shown to be reliably predictive in our study.

The true “gold standard” of pulp status is

histological analysis which is an invasive procedure.
Unfortunately, the true state of pulp health or
pathology cannot be determined by clinical signs,
symptoms or radiologic appearance Clinicians have
relied on assessments, such as the application of hot
or cold temperatures, an electric current, percussion
of the tooth, changes in the appearance of associated
Fig 1 a) Pre operative photograph of tooth no 36
soft tissues and patient reports of symptoms.
Fig 1 b) Pre operative radiograph of 36
However, numerous studies including histological
analysis have demonstrated a chronically inflamed
pulp, but the patients reported no symptoms, the
investigators discerned no signs and no apical or
radicular pathology were noted on radiographs.11-15
It must also be kept in mind that most studies that
include histological analysis are of quite a short
duration, typically two to four months. Maintaining
a consistent methodology within the study in direct
pulp capping cases are extremely difficult. This can Fig 2 a) Intra operative photographs with rubber dam
placement
hamper interpreting the results, since it is difficult to
2b) calcium dobesilate application
determine whether differences in the pulp status are
the result of the pulp cap regimen or the restorative
procedure or other factors. Although no studies were
carried out targeting dental pulp but large number
of studies including clinical trials have established
calcium dobesilate as a vasoactive and angioprotective
drug for micro circulation disturbances in structures
like human retina. Moreover as the present clinical
trial was purely based on subjective responses which Fig 3 a) Post operative photographs after final restoration
is practically possible only in human subjects. 3b) radiographs after 6 months follow-up
33 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
CONCLUSION
Within the limitation of this preliminary clinical
trial it was observed that 2% solution of Calcium
dobesilate significantly improved the healing rate
of injured dental pulp along with the sealing and
dentinogenic effects of MTA.Further clinical studies
are suggested including histological analysis of the
tissue changes during its application.
Acknowledgement: Institutional
Commi�ee, BBD College of Dental Sciences
Conflict of Interest : none
Source of Funding: Self
Ethical Clearance: Taken from IEC.
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Part III: Clinical Applications, Drawbacks, and
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4. Hoeben A, Landuyt B, Highley MS, et al.
Vascular endothelial growth factor and
angiogenesis.Pharmacol Rev. 2004;56:549–80.
5. Tejerina T, Ruiz E.Calcium dobesilate:
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induced endothelial proliferation, arterial
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chronic venous disease, diabetic retinopathy and
haemorrhoids. Drug Safety 2004,27(9):649-660.
8. Cox CF, Subay RK RK, Ostro E, Suzuki SH. Tunnel
defects in dentin bridges: their formation
following direct pulp capping. Oper Dent1996;21:
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9. Cox CF, Tarim B, Kopel H, Gurel G, Hafez
A. Technique sensitivity: biological factors
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AJ. Histomorphometric analysis of dentine bridge
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Int 2002;33:600–608.
11. Kitasako Y
Y, Ikeda M, Tagami J. Pulpal responses
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Traumatol 2008;24:201–206 .
12. Barthel C, Rosenkranz B, Leuenberg A, Roule�e
J. Pulp capping of carious exposures: Treatment
outcome after 5 and 10 years: A restrospective
study. J Endod 2000;26(9):525–528
13. Baume L, Holz J. Long-term clinical assessment
of direct pulp capping. Int Dent J 1981;31(4):
251–260.
14. Accorinte ML, Loguercio AD, Reis A, Carneiro E,
Grande RH, Murata SS, et al. Response of human
dental pulp capped with MTA and calcium
hydroxide powder. Oper Dent. 2008;33:488-95.
15. de Sousa Costa C, Oliveira M, Giro E, Hebling J.
Biocompatibility of resin-based materials used
as pulp-capping agents. Int Endod J. 2003;36:
831–839.
16 .Hilton T. Keys to Clinical Success with Pulp
Capping: A Review of the Literature. Oper Dent
2009;34(5):615-625.
 DOI Number: 10.5958/2320-5962.2016.00008.5

Evaluation of the Anti-plaque Efficacy of a Jamun Extract

Containing Mouthwash

Silvia V Rodrigues1, Janhavi S Rane2, Dipika K Mitra3, Rohit A Shah4,

Pragalbha N Pathare5, Harshad N Vijayakar6
1
Reader, 2Post Graduate Student, 3Professor, 4Reader, 5Senior Lecturer, 6Head, Department of Periodontology,
TPCT’s Terna Dental College & Hospital, Nerul, Navi Mumbai

ABSTRACT

Background: The present study was carried out to evaluate the effect of a jamun extract containing
mouthwash on plaque formation and evaluate its antibacterial properties against selected oral
pathogens in vitro. Materials and methods : Forty five periodontally healthy subjects were randomly
divided into three groups, they refrained from all mechanical oral hygiene measures for 4 days and
used one of the randomly assigned mouthwashes (A, jamun; B, chlorhexidine; or C, distilled
water [placebo]) twice daily. The Plaque Index (PI) was assessed at the baseline and the 5th
day. Jamun extract was tested against Streptococcus mitis, Porphyromonas gingivalis and Tanerella
Forsythia. Results: In all groups, the PI significantly increased from the baseline to day 5 (P <.0
1) There was a statistically significant difference (P < 0.01) between the chlorhexidine and placebo
mouthwash and the jamun and placebo mouthwash, but no statistically significant difference was
found between the chlorhexidine and jamun mouthwash with respect to the PI. Jamun extract showed
effective inhibition of Tanerella forsythia at 15 % concentration. Conclusion: These results indicate that
the jamun mouthwash has an antiplaque effect. Jamun extract is efficacious against Tanerella forsythia
strains in vitro. Thus, Jamun mouthwash should be explored as a long-term antiplaque rinse with
prophylactic benefits.

Keywords: Jamun, mouthwash, plaque,anti inflammatory, gingivitis, anti oxidant.

INTRODUCTION The most effective method for the prevention

Periodontal disease is a chronic inflammatory
disease characterized by loss of connective tissue,
alveolar bone resorption and formation of periodontal
pockets as a result of the complex interaction between
pathogenic bacteria and the host’s immune response.[1]
Periodontitis starts with inflammation of the gingiva,
which, if left untreated, may progress and eventually
involve and compromise the entire periodontal
a�achment apparatus of the affected teeth.[2]
Corresponding author:
Dr. Janhavi Rane
Terna Dental College and Hospital, Sector 22, Plot no
12, Nerul, Navi Mumbai – 400706.
Phone number - +91- 9821523234
E-mail: janhavi2189@gmail.com
and control of periodontal disease is mechanical as
well as chemical plaque control.[3] Several chemical
plaque control agents have been evaluated for their
effectiveness on supragingival plaque which include
bis- biguinaides, essential oils, enzymes, and even
herbal extracts.
Chlorhexidine, considered the gold stand
ard [4] cannot be prescribed for extended periods
because it causes staining of teeth, an unpleasant
taste, and, rarely, painful desquamations of the oral
mucosa.[5] Besides chlorhexidine rinses, only essen
tial oil rinses have been extensively evaluated and
subsequently shown to be of value as an adjunct to
mechanical oral procedures. However, the alcohol
content of essential oil rinses and their unpleasant
taste is unacceptable to some patients. Hence, the
search for new formulations of equal efficacy and
35 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
fewer side effects still continues.
It is a well- recognized fact that consumption of
large amounts of fresh fruits and vegetables can bring
substantial health benefits. In India due to the diversity
in climate, soil, altitudes and other eco- geographical
conditions, rich sources of wild /undersized fruits
are available. These undersized fruits have never
demanded a�ention of researchers but have chiefly
served as a natural source of treatment for curing
various diseases and ailments of local inhabitants.[6]
Hence, these underutilized fruits provide unlimited
opportunities for screening of new drugs as they
are known to possess an array of chemical diversity,
which needs to be investigated.
Syzygium cumini is a traditional medicinal plant
of Indian origin, belonging to family Myrtaceae.[7] It
is commonly known as Jamun in Hindi, Naaval in
Tamil, Java plum, Black plum, Jambul and Indian
Blackberry.[8] This fruit has been a�ributed to possess
several medicinal properties in the Indian Folklore
medicine system.[9]
There have been studies in the past which have
shown that the seeds of S.cumini have significant
anti-inflammatory, anticancerous and central
nervous system activities.[10], [11] The seeds in regard
to its antibacterial, in vitro antioxidant and in vitro
cytotoxic activities were evaluated in the past.[12] The
seed extract of S. cumini contains high amount of
polyphenolic components which may be responsible
for its potential antioxidant activity.[13] Several other
medicinal uses have been a�ributed to this fruit such
as, it enriches blood, strengthens teeth and gums, it is
a useful astringent in diarrhoea and a good gargle for
sore throat.[9]
However, its use for the treatment of gingivitis
and periodontitis is not very clear. Hence the aim of
the present study was to evaluate the anti - plaque
efficacy of jamun (black plum) extract mouthwash
in comparison with 0.2% chlorhexidine and a water
based mouthwash.
MATERIALS & METHOD
In vivo study design-
The current clinical trial was a double blinded,
randomized, parallel longitudinal study. Forty five
periodontally healthy subjects (14 males and 31
females) between the age group of 18 to 21 years
(mean age 20 years) participated in the 4-day study.
The study was performed by a single examiner who
was blinded for the mouthwashes, and the three
mouthwashes were labelled as A, B, and C by
another investigator.
Mouthwash A (test) was a jamun
extract mouthwash; mouthwash B (positive
control) was a commercially available 0.2%
chlorhexidine mouthwash (ICPA Health care
products, Anlkeshwar, Gujarat), and mouthwash
C (placebo control) was a placebo that constitute
d distilled water.
For mouthwash A, jamun extract powder
(Konark Herbals, Parel, Mumbai) was used. The
solubility of the mouthwash was 15 mg per 100 ml
of water. It was dissolved in distilled water for an
effective concentration of 15 g%.
Subjects with good systemic health with at
least 24 scorable teeth (not including third molars
or crowned teeth) were included in the study.
Subjects who consumed a high poly- phenolic diet
(including green tea catechin or soya diet), wor
e fixed or removable orthodontic appliances or
prostheses, were prescribed antibiotics or other
medications in the previous 3 months that might
interfere with plaque formation, or had undergone
periodontal treatment in the previous 6 months were
excluded from the study. Subjects having any disease
that would increase oxidative stress such as diabetics
and subjects not willing to comply with the study
protocol were excluded from the study.
Forty -five students, studying in Terna Dental
College, Nerul, Navi Mumbai, India, who fit thes
e criteria volunteered for the study and provided
informed consent. This study was approved by the
ethical commi�ee of the same institution and was
conducted in accordance with the Declaration of
Helskinsi and principles of good clinical practice.
The subjects were divided into three equal
groups (15 subjects per group) to form par
allel groups and randomly assigned into three
mouthwash groups. At the baseline, thorough oral
prophylaxis was carried out for all the subjects by
the investigator. Plaque was disclosed using Two
Tone Plaque Disclosing Agent ( Dento Plaq, India) to
ensure that all deposits had been removed. Subjects
were instructed not to use toothbrushes, toothpastes,
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
or any other interdental cleaning aid or chewing gum
for the next 4 days. Instead, subjects were asked to
use one of the three randomly assigned mouthwashes
twice daily. At a particular specified time during
the day, all subjects were asked to rinse twice for 1
minute with 10 mL of the randomly allocated r
inse. At each rinsing, 10 mL of the solution
was swished around the mouth for about 60
seconds and then expectorated. On day 5, the
subjects were recalled; Plaque index (Turesky et al
modification of Quigley Hein plaque index) was re
corded, and subjects were allowed to resume their
routine oral hygiene regimens.
DATA COLLECTION
The amount of plaque was assessed at days
0 and 5. Adverse effects such as burning sensat
ions, taste alteration, and desquamation of gingival
epithelium if any were also evaluated on the 5th day.
In vitro study design
The jamun extract was tested against three
organisms: Streptococcus mitis, Porphyromonas
gingivalis and Tanerella forsythia.
Media Used-
The Brain Heart Infusion agar was used, agar
plates were brought to room temperature before use.
Inoculum preparation-
Using a swab, the colonies of the three
microorganisms (Streptococcus mitis, Porphyromonas
gingivalis, Tanerella forsythia) were transferred
to the agar plates. Turbidity was visually adjusted
and the entire suspension was standardized with
a photometric device. Triplicate cultures were
performed (ie, the cultures were performed on three
agar plates for all the three organisms).[14]
Inoculation of Agar plate-
Within 15 min of adjusting the inoculum, a sterile
co�on swab was dipped into the inoculum and
rotated against the wall of the tube above the liquid to
remove excess inoculum.
Entire surface of the agar plate was swabbed three
times, rotating the plates approximately 60º between
streaking to ensure even distribution. The inoculated
plate was allowed to stand for at least 3 minutes but
no longer than 15 min before making wells.
36
Addition of compound into plate -
Various concentrations of the jamun extract 20
µl,15 µl, 10 µl and 5 µl were added into the respective
wells of each plate.
Incubation-
For streptococcus mitis, agar plates were
incubated in the Co2 Jar and the jar was kept in the
incubator at 37 ºC for 24 hours. Agar plates were
incubated in the anaerobic jar for Porphyromonas
gingivalis and Tanerella forsythia.
Reading plates-
The diameter of inhibition zone to nearest whole
millimetre was measured by holding the measuring
device.
STATISTICAL ANALYSIS
After the indices were calculated and the
mouthwash order was decoded, further evaluation w
as carried out with SPSS 17 software. The mean was
calculated for each mouthwash. Analysis of variance
(ANOVA) was performed. Differences between the
mouthwash solutions and placebo were determined
via the Bonferroni multiple comparison test.
RESULTS/FINDINGS
Forty five subjects, 14 males and 31 females,
completed the study. In all groups, PI (Plaque
Index) showed significant (P <0.01) increase from
the baseline to the 5th day. The in vivo results
showed that the mean PI values were the highest
for the placebo mouthwash (1.92) and the least
for Jamun extract mouthwash (0.93). The mean P
I value for chlorhexidine (0.99) was higher than
the jamun group. ANOVA showed a statistically
significant difference between the PI scores from the
baseline to day 5 (P = 0.00).
Differences between the individual mouthw
ash solutions and the placebo solution, determined
via the Bonferroni multiple comparison test,
demonstrated significantly less plaque regrowth with
respect to both chlorhexidine (P = 0.99) and jamun
(P = 0.93) as compared to the placebo. However,
the difference between the chlorhexidine and Jamun
group was not statistically significant (P=1), suggesting
that the two mouthwashes at the 95% confidence
interval have a similar clinical efficacy.
37 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
The results of the ANOVA test are given
in Table 1, while those of the Bonferroni multiple
comparison test are given in Table 2. There was no
burning sensation or taste alteration reported by
any of the subjects at the end of the study period
. Also, there was no evidence of gingival epithelial
desquamation on intraoral examination in any of the
subjects at the end of the study.
The in vitro study showed that only Tanerella
Forsythia was inhibited at the concentration of
15 mg/ml while Porphyromonas gingivalis and
Streptococcus mitis were found to be resistant for all
concentrations of the jamun extract mouthwash.
Table 1.Results of Plaque Index and comparison
between groups using one-way ANOVA
Sample Mean SD P value
Jamun 0.9373 0.229 0.00
Chlorhexidine 0.9933 0.109
Placebo 1.923 0.464
Table 2. Comparison between groups using
Bonferroni multiple comparison test
Sample compared
Chlorhexidine vs jamun
Chlorhexidine vs Placebo
Jamun vs Placebo
DISCUSSION
Jamun is a fruit of Indian origin commonly known
as Black plum, found growing widely in different
agro-climatic conditions. These fruits have been
a�ributed to possess several medicinal properties in
the Indian Folklore medicine system.[9]
S. cumini seeds have been reported to possess
anti-oxidant and free radical scavenging activities,
anti-bacterial, anti-fungal and, anti- inflammatory
properties.[9]
The antibacterial activity of ethanolic extracts of
Syzygium cumini Seeds Powder against various gram
positive as well as gram negative strains has been
evaluated in vitro against various pathogens such
as S. Aureus, K.Pneumoniae, E. Coli, Pseudomonas
aeruginosa and the results of these studies have
confirmed the same.[15]
The present short-term study model dealt with the
antiplaque efficacy of a new jamun mouthwash and
also aimed to evaluate whether the mouthwash had
any adverse effects. A placebo solution (negative
control) and 0.2% chlorhexidine solution
(positive control) served as comparison. The
study design (4-day plaque regrowth study) h
as been used in numerous investigations and can
be described as an established method for testing
the plaque-inhibiting effect of an oral hygiene
product.[16],[17] The advantage of a 4-day plaque
regrowth study design is that it eliminates the effect
of the adjunctive mechanical oral hygiene practices
as they are disallowed during the trial period. This
study was conducted in a parallel design similar to a
previously conducted study.[18]
In all the groups, PI showed significant
(P < .01) increase from baseline to day 5.The
present study showed significant and comparable
reduction in plaque index in the jamun and
chlorhexidine group as compared to the placebo
mouthwash.( P=00) However ,there was no significant
reduction in plaque index between the jamun and
chlorhexidine groups.(P=1) with jamun group
showing greater reduction than the chlorhexidin
P value group.
1 The results of this study are similar to a study
0.00 by Bhadbade et al wherein no statistically significant
0.00
difference was found between the chlorhexidine and
a 5 % pomegranate rinse (anti-bacterial, anti-oxidant)
with respect to the PI. [18] To the best of our knowledge,
this is the first study of its kind where in the anti-
plaque efficacy of the jamun (black plum) extract
mouthwash has been compared with chlorhexidine.
One of the shortcomings of this study is the
smaller sample size. At the end of the study, no
adverse effects of the jamun mouthwash were seen
in any of the subjects. The duration of the study was
short—4 days—as the plaque regrowth model was
used. Therefore, the anti-gingivitis efficacy of the
jamun extract mouthwash was not tested. Thus,
more studies using a longer duration can be
performed and the parallel design used could be
replaced by a crossover model in further research.
CONCLUSION
Thus, within the limitations of the present study,
it can be concluded that 5% Jamun extract -containing
mouthwash was comparable to chlorhexidine in
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
inhibiting plaque growth and should be further
researched as it holds promise to be a herbal
alternative to a chemical chlorhexidine mouthwash.
Acknowledgement- Nil
Conflicts of Interest - None
Source of Funding- None
REFERENCES
1. Kaur H, Jain S, Kaur A. Comparative evaluation of
the antiplaque effectiveness of green tea catechin
mouthwash with chlorhexidine gluconate. J
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2. Page RC, Kornman KS. The pathogenesis
of human periodontitis: An introduction.
Periodontol 2000 1997;14:9-11.
3. Botelho MA, Bezerra Filho JG, Correa LL,
Heukelbach J. Effect of a novel essential oil
mouthrinse without alcohol on gingivitis: A
double-blinded randomized controlled trial. J
Appl Oral Sci 2007;15:175-80.
4. Jones CG. Chlorhexidine: Is it still the gold
standard? Periodontol 2000 1997;15:55-62.
5. Flotra L. Different modes of chlorhexidine
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Periodontal Res Suppl 1973;8:41-44.
6. Rao MR, Palada MC, Becker BN. Medicinal and
aromatic plants in agroforestry system.Agrofor
Syt. 2004;61:107-122.
7. Modi DC, Patel JK, Shah BN ,Nayak BS:
Pharmacognostic Studies of the Seed of
Syzygium cumini Linn. Pharma Science Monitor
2010;1:20-26.
8. Kirtikar KR, Basu BD: Indian Medicinal Plants.
Periodical Experts.1975;2:1052-1053.
9. Patel P, Rao R. Antibacterial activity of
underutilized fruits of jamun (syzygium cumini
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SKEELS) International journal of current
pharmaceutical research .2012;4(1):36-39.
10. Kumar A, Ilavarasan R, JayachandranT,
Decaraman M, Kumar RM, Aravindhan P,
Padmanabhan N and Krishan MRV. Anti-
inflammatory activity of Syzygium cumini seed.
J Biotechnol 2008;7:941-943.
11. Parmar J, Sharma P, Verma P, Sharma P, Goyal PK.
Chemopreventive Action of Syzygium cumini on
DMBA - induced Skin Papillomagenesis in Mice.
Asian Pac J Cancer Prev 2010;11:261-265.
12. Narendhirakannan, Banerjee, International
Journal of pharmaceutical sciences and research.
2011;2(7):1799-1806.
13. Ruan ZP, Zhang LL, Lin YM. Evaluation of the
Antioxidant Activity of Syzygium cumini leaves.
Molecules 2008;13:2545- 2556.
14. Barry AL. Procedure of testing antimicrobial
agents in agar media; theoretical considerations.
J Clin Microbiol 1985;21:409-414.
15. Gangadhar A. Antibacterial Study and Effect
of Ethanolic Extracts of Syzygium cumini Seeds
Powder on Glucoamylase invitro J. Pharm. Sci. &
Res.2011;2:1060-1063.
16. Rosin M, Welk A, Kocher T, MajicTodt A, Kramer
A, Pi�en FA. The effect of polyhexamethylene
biguanide mouthrinse compared to an essential
oil rinse and a chlorhexidine rinse on bacterial
counts and 4 day plaque re-growth. J Clin
Periodontol 2002;98:392-399.
17. Addy M, Willis L, Moran J. Effect of toothpaste
rinses compared with chlorhexidine on plaque
formation during a 4-day period. J Clin
Periodontol 1983;10:89-99.
18. Bhadbhade S, Acharya A, Rodrigues S, Thakur
S. The antiplaque efficacy of pomegranate
mouthrinse. Quintessence lnt 2011;42(1):29-36.
 DOI Number: 10.5958/2320-5962.2016.00009.7

Tobacco Cessation Need of an Hour in India:

A Review

Shivanjali Grover1, Rohit Grover2

1
Reader, Department of Public Health Dentistry, 2Reader, Department of Conservative Dentistry and Endodontics,
Sardar Patel Postgraduate Institute of Dental and Medical Sciences, Lucknow

ABSTRACT

Tobacco use is a leading cause of preventable deaths all over the world. India too is fighting against
the same cause for deaths. Awareness is being created, actions are being taken for tobacco cessation
but still the efforts are failed. Tobacco cessation has become a need of an hour for controlling major
diseases and preventable deaths in the country. Thus tobacco cessation is a practice for every health
care professional to control large number of deaths due to use of tobacco.

Keywords: Tobacco cessation, awareness, public health challenge.

INTRODUCTION in tobacco cessation. Tobacco cessation centers are

emerging in urban areas of India whereas rural areas
India is the second largest consumer of tobacco
with high prevalence of in use of tobacco.2
products in the world in spite of the advances in
public health campaigns complemented with tobacco HISTORY OF TOBACCO
control laws. Nearly 900, 000 people die every
The origin of the word tobacco is derived from
year in India due to diseases a�ributed to tobacco.
the Arabic word tabaq, meaning euphoria producing
According to the Global Adult Tobacco Survey
herb. It is possible that the word tobacco comes from
(GATS), the prevalence of tobacco use among males
the island of Tobago in the Carribean. Some sources
in India is 48% compared with 20% among females
refer to the origin of this word from the Tabasco state
(GATS: India, 2010). In India, khaini or tobacco-lime
in Mexico. The word cigare is derived from the Mayan
mixture (12%) is the most commonly used smokeless
word sikar which means to smoke.2
tobacco product, followed by gutkha (a mixture of
tobacco, lime and areca nut) (8%), betel quid with Cultivation of the tobacco plant probably dates
tobacco (6%) and tobacco dentifrice (5%) Bidi (9%) is back 8000 years when two species of the plant,
most commonly used smoking product, followed by nicotiana rustica and Nicotiana tabacum. Tobacco
cigare�e (6%) and hukkah (1%).1,2 seeds were discovered in archaeological excavations
in Mexico and Peru, and the remains of permanent
It has assumed the dimension of an epidemic
se�lements built around 3500 BC showed that tobacco
resulting in enormous disability, disease and death. It
was an important article to the inhabitants. Tobacco
is estimated that five million preventable deaths occur
belongs to the family of plants called Solanaceae
every year globally, a�ributable to tobacco use. At this
or the night shade family, which contains about 60
rate, the number of such deaths is expected to double
species including potato and the genus Nicotiana. N.
by 2020.1 Health professionals have got a major role
rustica, a mild-flavoured, fast-burning species, was
the tobacco originally raised in Virginia, but it is now
Corresponding author: grown chiefly in Turkey, India and Russia.2,3
Dr. Shivanjali Grover
Tobacco was introduced into India by Portuguese
Reader, Department of Public Health Dentistry,
traders during AD 1600. Its use and production
Sardar Patel Post Graduate Institute of Dental and
proliferated to such a great extent that today India is
Medical Sciences, Lucknow.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
the second largest producer of tobacco in the world.
Soon after its introduction, it became a valuable
commodity of barter trade in India. Trade expanded
and tobacco spread rapidly along the Portuguese
trade routes in the East, via Africa to India, Malaysia,
Japan and China. During this period, the habit of
smoking spread across several South Asian countries.
Virtually every household in the Portuguese colonies
took up the newly introduced habits of smoking and
chewing tobacco. Cochin and Goa, on the West Coast
of India, and Machilipatnam along the East Coast,
were the main ports for Portuguese trade. Tobacco
was first introduced in the kingdom of Adil Shahi, the
capital city of Bijapur, presently in Karnataka in south
India, along the trading route of the Portuguese. Asad
Beg, ambassador of the Mughal Emperor Akbar,
visited Bijapur during 1604. In 1605 , took back large
quantities of tobacco from Bijapur to the Mughal
Kingdom in the north and presented some to Akbar
along with jewel-encrusted European-style pipes.
The presentation of this herb to the emperor was
discussed animatedly in the court of Akbar.3,4
HEALTH CONSEQUENCES OF TOBACCO
USE
Cancer is a public health problem worldwide. It
affects all people from the young to the old; the rich
to the poor; men, women and children. Of the several
causes investigated for cancer, the use of tobacco has
shown strong and consistent associations with cancer
at several sites of the body.4
Presently, more than 10 million people globally
are diagnosed with cancer every year. It is estimated
that by 2020, there will be 15 million new cases every
year. Cancer causes 6 million deaths every year, or
12% of deaths worldwide. The top five or six cancers
in men are all tobacco-related cancers: of the lung,
oral cavity, larynx, oesophagus and pharynx. In
women, the leading cancer sites include those related
to tobacco: cervix, oral cavity, oesophagus and lung,
in addition to other cancers not considered to be
tobacco related (breast and ovary).4
The International Agency for Research on Cancer
(IARC) Monograph states that tobacco smoking is the
major cause of lung cancer (all types) and is associated
with oral cancer, cancers of the oropharynx and
hypopharynx, oesophagus, stomach, liver, pancreas,
larynx, nasopharynx, nasal cavity and nasal sinuses
40
leukaemia. In addition, exposure to second hand
tobacco smoke has also been conclusively shown to
be carcinogenic to the lungs.4
Tobacco an Addiction4,5,6
Cigare�es and other forms of tobacco are
addictive because of the presence of nicotine. Nicotine
blood levels achieved by smokeless tobacco use are
similar to those from cigare�e smoking.
Nicotine – A Stimulant
Nicotine, the chemical that makes addicts out of
tobacco users, is a stimulant with properties similar to
those of cocaine and amphetamines. It increases the
heart rate, blood pressure, and respiratory rate, and
makes the user feel more alert. Chronic use affects
brainstem structures (locus ceruleus); Noradrenergic
cells become more excitable. When a person abstains,
the firing rates become abnormally high, causing
withdrawal symptoms like feeling tense and
irritable, trouble in concentrating, sleep disturbance,
headaches, digestive upset etc.
Acetaldehyde & Carbon Monoxide
Acetaldehyde, a by-product of cigare�e smoke
has some sedative properties. The carbon monoxide
in cigare�es makes people feel dull the way one
would in a stuffy room without enough air. These
chemicals seem to dampen some people’s feelings of
tension, anger, or strong emotion.
Other Psychological Effects
Conditioning occurs over many years after
exposure to things in the environment, which
stimulate the user to want a cigare�e or other forms of
tobacco. People learn to manage their emotions with
tobacco. These “triggers” are the reason why qui�ing
involves more than just kicking the nicotine habit.
Pa�erns of behaviour are very difficult to change.
Counseling and strategies for tobacco
cessation2,4
Counseling by public health professionals and
physicians can help people quit tobacco. A minimum
counseling of 3 minutes can create an urge for qui�ing
tobacco use in a person. National cancer Institute,
USA has formulated brief strategies to help the
patients willing to quit and this includes a “5A” (ask,
41 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
advise, assess, assist and arrange) based intervention
in a primary care set up.
• ASK: the patients about tobacco use and
identified at each visit. Tobacco use status is queried
and documented, and general and vital information
are obtained.
• ADVICE: to the patient should be clear,
strong and personalized according to the patient’s
current health/ illness, motivation level or impact on
children in the household.
• ASSESS: the willingness of the patient to quit.
Provide motivational assistance to those unwilling to
quit and provide additional information in special
situations such as adolescence and pregnancy.
• ASSIST: the patient with a quit plan. Set a
quit date within the next two weeks. Patient is advised
to tell friends, family and co-workers about qui�ing
and request understanding and support. Anticipate
challenges to quit a�empt and educate about nicotine
withdrawal symptoms. Remove all tobacco products
from environment and avoid places associated with
smoking. Total abstinence is essential. Anticipate
triggers or challenges in upcoming a�empts.
Encourage housemates to quit smoking or not smoke
in subject’s presence.
• ARRANG: for follow up contact. Timing of
the first contact should be soon after the quit date
and the second follow up depends on physician
preference preferably within the first month of quit
date. Congratulate those who have succeeded to quit
smoking.
This counseling method also includes 5 “R” as a
procedure of counseling too.
THE 5 “R”S APPROACH4
For tobacco users who are not ready to make a
quit a�empt, provide a brief intervention designed
to promote the motivation to quit and information
about harmful effect of tobacco. The tobacco user
may have fears and concerns about qui�ing, or may
be demoralized because of previous unsuccessful
a�empts and relapse. This group may respond to
a motivational intervention designed to educate,
reassure and motivate and build around the 5 “R”s;
i.e. Relevance, Risk, Rewards, Roadblocks and
Repetition.
• RELEVANCE: Encourage the tobacco user to
consider the personal relevance of cessation. Take into
account the disease status (if any), family or social
situation, health concerns, age and gender.
• RISKS: Discuss short term, long term and
environmental risks of continued tobacco use,
including effects of exposure to second hand smoke
on the family members especially children. Relate
with the symptoms.
• REWARDS: Encourage tobacco user to
identify benefits of cessation. These may include
withdrawal symptoms, fear and concern associated
with qui�ing, depression, lack of social support,
weight gain etc. Discuss strategies to address potential
barriers.
• ROADBLOCKS: Barriers that the tobacco
user may face in his/her quit a�empt should be
identified. Withdrawal symptoms, fear and concern
associated with qui�ing, depression, lack of social
support, enjoyment of tobacco are some of the
barriers that the tobacco user may face in an a�empt.
• REPETITION: This information should be
reviewed regularly with tobacco users who are not
yet ready to quit.
Se�ing up tobacco cessation services7
While all health care providers must provide brief
counseling for tobacco cessation as part of routine
health care, dedicated tobacco cessation services can
be set up in different health care se�ings at primary,
secondary and tertiary care se�ings. Specialist care
may be provided particularly to help people with
more severe tobacco dependence.
Tobacco cessation services can be set up
preferably in different departments of a hospital/
medical college e.g. dental, medicine, surgery, ENT,
psychiatry, community medicine, TB & chest diseases,
pediatrics, obstetrics & gynecology etc. A specialized
se�ing can be run by a team consisting of a trained
physician, counselor or social worker a�endant. A
trained nurse, pharmacist or health worker can also
provide counseling services.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Pharmacotherapy used for tobacco cessation4,6
Pharmacotherapy is indicated when counseling is
not sufficient to help patients quit smoking. Various
drugs used are:
Nicotine Replacement Therapies (NRTs) are
the appropriate first line agents. Numerous studies
indicate that nicotine replacement therapy in any
form (nicotine gum, inhaler, nasal spray, transdermal
patch, sublingual tablet, or lozenge) reliably
increases long-term smoking abstinence rates.
Nicotine replacement therapy is more effective when
combined with counseling and behavior therapy. For
those smoking 1-24 cigare�es per day, 2mg gum and
for those smoking >25 cigare�es per day a 4mg gum is
recommended. One gum to be chewed for 30 minutes
every 1 or 2 hours and not more than 25 gums per day
to be chewed. Duration of treatment is 12 weeks. Side
effects are soreness and dyspepsia.
Nicotine Inhaler doubles smoking cessation rate
as compared to placebo inhaler.20 Duration of therapy
is 6 months with dose tapering in last 3 months. Local
irritation, cough and rhinitis are frequent side effects.
Nicotine Nasal Spray more than doubles smoking
cessation rate as compared to placebo nasal sprays.20
Dose is one spray of 0.5 mg into each nostril starting
at 1-2 doses per hour to about 5 per hour according
to symptom relief. Duration of therapy is 3-6 months.
Side effects are nasal irritation, nasal congestion and
a dependence potential in 15-20% of the patients in
terms of length of use more than the recommended
duration of 3-6 months.
Nicotine Patch doubles smoking cessation rate as
compared to placebo patch. 20 Dose is a 16 or 24 hour
patch to be applied for 8 weeks. Side effects are skin
reactions and insomnia. Rotate the patch sites and
apply 1% hydrocortisone for skin reaction. Use of 16
hour patch is recommended for those who suffer from
insomnia. The patch is generally favoured over the
gum because it requires less training for effective use
and is associated with fewer compliance problems.
Medical contraindications to nicotine replacement
therapy include unstable coronary artery disease,
untreated peptic ulcer disease, and recent myocardial
infarction or stroke.
42
Other Drugs
A. Medications that mimic nicotine effects can
be used as second line pharmacotherapy.
• Bupropion SR : Bupropion SR is a non-
nicotine medication with abstinence rate twice that
of the placebo. The drug is generally well tolerated
in cardiovascular disease patients and can be used in
pregnancy. Insomnia (35-40%) and dry mouth (10%)
are most common adverse events. It is contraindicated
in seizure disorders, eating disorders and if patient
has used MAO inhibitor in past 14 days. It is given
in a dose of 150mg OD for 3 days then 150 mg BD is
continued for next 7-12 weeks following the quit date
which is preferably between the first or second week
of treatment. Consider giving maintenance therapy
for 6-12 months in selected patients.
• Varenicline : Varenicline is a new nicotinic
acetylcholine receptor partial agonist that aids
smoking cessation. The dose is 0.5 mg once a day
for 1-3 days, then 0.5 mg twice a day for 4-7 days,
followed by 1 mg twice a day from day 8 to end of
treatment which is for a duration of 12 weeks.
• Clonidinie : Clonidine is a postsynaptic
2 agonist that dampens sympathetic activity
originating at the locus ceruleus. Clonidine in doses
0.1-0.4 mg/day for 2-6 weeks has been found to be
useful. The most common side effects of Clonidine
are dry mouth, sedation and constipation. Clonidine
appears to increase the quit rates similar to nicotine
replacement therapy.
• Anxiolytics : Anxiety is a prominent
symptom of nicotine withdrawal. Smoking decreases
some measures of anxiety and may reduce stress
induced anxiety. Diazepam and beta blockers have
been widely used with mixed results. Buspirone is
a serotoninergic agonist, which acts as an anxiolytic
but produces mixed results, when used for smoking
cessation. Advantage over the benzodiazepines
being non-sedating and does not have an addictive
potential.
• Antidepressants : Many antidepressants
have been tried with varied results. These are helpful
only when the patients have underlying depression.
43 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
• Stimulants : The aim is to replace the
stimulant effects of nicotine (e.g. improved energy
and concentration) with medication in the first week
of cessation. The drugs that have been used are
amphetamine and methylphenidate.
• Anorectics : Anorectics were used initially
to combat post cessation hunger and weight gain.
Encouraging results were obtained with fenfluramine
and phenylpropanolamine in short term trials.
• Sensory Replacement : Black pepper
extracts, capsaicin, denicotinised tobacco, flavourings
all decrease cigare�e craving and withdrawals.
• Acupuncture : Acupuncture technique is also
used in smoking cessation. One common rationale
for using acupuncture for smoking cessation is that
acupuncture can release endorphins that assist in
cessation. Ultimately it is the willingness/ motivation
of the patient which is of utmost importance in the
success of smoking cessation. Only when the patient
is willing to stop smoking, the physician can help
him.
B. Antagonists - The goal of the antagonists
is to prevent cigare�es from producing positive
reinforcing and subjective effects.
• Mecamylamine : Mecamylamine is a non-
competitive blocker of both central and peripheral
nervous system nicotine receptors that decreases the
positive subjective effects of cigare�es. It does not
precipitate withdrawal in humans, perhaps because it
is indirect blocker.
• Naltrexone : Naltrexone is a long acting
form of opioid antagonist naloxone. The rationale
for using Naltrexone for smoking cessation is that the
performance enhancing and other positive effects of
nicotine may be opioid mediated. Couple of studies
point out the beneficial effects of Naltrexone.
C. Medication that make intake aversive: Silver
Acetate combines with the sulphides in tobacco
smoke to produce a bad taste. Silver Acetate has been
tested as a gum and as a pill. Compliance is very poor
with this drug.
CONCLUSION
Tobacco cessation must be practiced by all health
professionals as a must to help Indian population to
survive. Use of tobacco is addictive. It not only affects
the psychologically but also physically. Its ill effects
are more which lead to loss of health as well as social
status of a man. Awareness regarding side effects and
use of tobacco is being created in people but still it’s
a failure.
Health care professionals should counsel people
coming to them for a minimum time of 5 – 15 minutes
which can create and urge to quit tobacco use. Thus
it will help achieving the goal of tobacco cessation in
India.
Acknowledgment: I would like to acknowledge
my family and co- authors for their cooperation.
Conflict of Interest: not needed as it is review
article.
Funding: Self
Ethical Clearance: ethical clearance not required
as it is a review article
REFERENCES
1. K Srinath Reddy and Prakash C. Gupta. Report of
Tobacco Control in India. Ministry of Health and
Family Welfare. Govt. of India. 2004
2. Manual of training Cancer control. National
Cancer control programme. Ministry of Health
and Family Welfare. Novem ber 2005.
3. Raj Kumar, V K Vijiyan. Smoking Cessation
Programs and Other Preventive Strategies
for Chronic Obstructive Pulmonary Diseases.
Supplement to JAPI; February 2012 ; Vol. 60; 53-
56.
4. R Jayakrishnan, Aleyamma Mathew, An�i Uutela,
Patrik Finne. A Community Based Smoking
Cessation Intervention Trial for Rural Kerala,
India. Asian Pacific Journal of Cancer Prevention,
Vol 12, 2011.3191 – 3195.
5. Robin L Corelli and Karen Suchanek Hudmon.
Medications for smoking cessation. Medicine
cabinet Volume 176 March 2002. 131 – 135
6. Smokeless tobacco and how to quit it. American
Cancer society. 2012.
7. Tobacco Dependence Treatment Guidelines.
National Tobacco Control Programme. Ministry
of Health and Family welfare. Govt. of India
2011.
 DOI Number: 10.5958/2320-5962.2016.00010.3

Platelet Rich Plasma & Platelet Rich Fibrin: Dental

Applications

Prashanth Kumar Ka�a

Assistant Professor, College of Dentsitry, King Khalid University, Abha, Kingdom of Saudi Arabia

ABSTRACT

synthetic materials have long been used for treating perforations, apexification cases and other surgical
procedures. Lately, platelet rich plasma & platelet rich fibrin have been used for these reasons with
success and patient response. This article explains the preparation of these organic agents, their
potential advantages and disadvantages and applications in dentistry.

Keywords: Applications, Platelet rich plasma, preparation.

INTRODUCTION bloodstream due to endothelial injury.

Medical research has shown that own blood Platelets release stored intercellular mediators
cells, can be used to accelerate tissue healing, repair and cytokines from the cytoplasmic pool and let go
and regeneration after surgery. Platelets, plasma, their α-granule content after aggregation.
and white blood cells especially are useful for this
This secretion is intense during the first hour and
approach. The protein that is present within the
platelets continue manufacture more cytokines and
platelets is the main constituent that is used in for
growth factors from their mRNA reserves for at least
wound healing and numerous surgical techniques,
next 7 days.
including oral surgery.
More than 800 different proteins are secreted
The USE of platelet concentrates as bioactive
into the surrounding media, which pocess paracrine
surgical additives that are administered locally
effect on different cell types: myocytes, tendon
to hasten wound healing originates from the use
cells, mesenchymal stem cells from various origins,
of fibrin adhesives. Since 1990, medical field has
chondrocytes, osteoblasts, fibroblasts and endothelial
identified many components in blood, that are a part
cells.
of the natural healing process; when added to injured
tissues or surgical sites, they have the prospective to Cell proliferation, angiogenesis and cell migration
accelerate healing1, 2. are invigorated, resulting in tissue regeneration.

The chief tasks of platelets are3:
Preventing acute blood loss and restore vascular
walls and adjoining tissues post injury. During
wound healing process, platelets get activated when
they come in contact with collagen, exposed to the
Corresponding author:
Dr. Prashanth Kumar Ka�a
Assistant Professor, College of Dentsitry, King
Khalid University, Abha, Kingdom of Saudi Arabia
Mobile: +966538073497
Email:drprashanthkumar@yahoo.com
There are also reports proving that platelets
release antimicrobial peptides, suggesting an
antibiotic effect.
What is Platelet Rich Plasma (PRP) It is
obtained from blood (plasma) that is rich in platelets.
New automation permits the clinician to collect and
produce enough quantity of platelets from just 55cc
of blood collected from the patient3, 4.
Classification4, 6
According to the classification proposed by
Ehrenfest et al. (2009), four main categories of
45 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
preparations can be defined, based on their cell
content and fibrin architecture2.
1. Pure Platelet-Rich Plasma (P-PRP) or
leucocyte-poor PRP products are preparations
without leucocytes and with a low-density fibrin
network after activation.
2. Leucocyte- and PRP (L-PRP) products are
preparations with leucocytes and with a low-density
fibrin network after activation. It is in this family that
the largest number of commercial or experimental
systems exists. Particularly, many automated
protocols have been developed in the last years,
requiring the use of specific kits that allow minimum
handling of the blood samples and maximum
standardization of the preparations.
3. Pure platelet-rich fibrin (P-PRF) or leucocyte-
poor platelet-rich fibrin preparations are without
leucocytes and with a high-density fibrin network.
These products only exist in a strongly activated gel
form, and cannot be injected or used like traditional
fibrin glues.
4. Leucocyte- and platelet-rich fibrin (L-PRF)
or second-generation PRP products are preparations
with leucocytes and with a high-density fibrin
network.
Why all the excitement about PRP? PRP allows
the body to take the benefit of the normal healing
process at a greatly accelerated rate. During the
healing stage, the body pumps many cells and
cell-types to the site of wound in order to start the
healing process. One of those cell types is platelets.
Platelets serve many functions, including formation
of a blood clot and release of growth factors (GF)
into the wound. These GF (platelet derived growth
factors PGDF, transforming growth factor beta TGF,
and insulin-like growth factor ILGF) function to help
the body in recuperating by stimulating stem cells to
produce new tissue7.
Clinical applications:
1. Bone grafting for dental implants. This
includes onlay and inlay grafts, sinus lift procedures,
ridge augmentation procedures, and closure of cleft
lip and palate defects.
2. Repair of bone defects creating by removal of
teeth or small cysts.
3. Repair of fistulas between the sinus cavity
and mouth.
4. PRP can be used in the treatment of
regenerative endodontic therapies. The use of PRP in
immature teeth with periapical lesion has been firstly
reported by Torabinejad and Turman1
Preparation of PRP:
PRP can be prepared by two techniques. The
techniques differ in their technical aspects and are
divided into:
1. General-purpose cell separators
2. Platelet-concentrating cell separators
After the first round, the whole blood (WB)
separates into three layers: top layer that is comprised
chiefly by platelets and WBC, middle layer that
is called buffy coat and that is rich in WBCs, and
lowermost layer that contains mainly of RBCs. Only
the top layer or the upper layer plus buffy coat are
taken in a different empty tube. The second spin step
is then carried out. The upper portion of the volume
that is composed mainly of PPP (platelet-poor plasma)
is removed to prepare the PRP (Platelet-Rich Plasma).
The concentrations of platelets and WBC in each of
the various layers are measured to characterize the
quality of PRP4, 6, 7.
Risks of using PRP
Sanchez et al. have explained the potential risks
associated with the use of PRP. The preparation of
PRP involves the isolation of PRP after which gel
formation is accelerated using calcium chloride and
bovine thrombin. It has been fopund that the bovine
thrombin usage may lead to the development of
antibodies to the factors V, XI and thrombin, resulting
in the risk such as life-threatening coagulopathies.
Bovine thrombin preparations have been shown to
contain factor V, which could result in the stimulation
of the immune system when challenged with a
foreign protein.
Other methods for safer preparation of PRP are
the utilization of recombinant human thrombin,
autologous thrombin or perhaps extrapurified
thrombin. Landesberg et al. have suggested that
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 46

alternative methods of activating PRP musr be three layers:

investigated before it can be recommended for the
1. Top layer consisting of acellular PPP (platelet
dental fraternity3, 8.
poor plasma)
Platelet-rich fibrin (PRF):
2. PRF clot in the centre
PRF was first developed in France by Choukroun
3. RBCs at the lower layer
et al. often it has been called as a second-generation
platelet concentrate. Due to the absence of an anticoagulant, blood
begins to coagulate as soon as it comes in contact with
Fibrin: It is the activated form of a plasmatic
the glass surface. Therefore, for successful preparation
molecule called fibrinogen. This soluble fibrillary
of PRF, speedy blood collection and immediate
molecule is massively present both in plasma and
centrifugation, before the clo�ing cascade is initiated,
in the platelet a-granules and plays a determining
is absolutely essential. PRF can be obtained in the
role in platelet aggregation during hemostasis. It
form of a membrane by squeezing out the fluids in
is transformed into a kind of biologic glue capable
the fibrin clot.
of consolidating the initial platelet cluster, thus
constituting a protective wall along vascular breaches Applications11:
during coagulation. In fact, fibrinogen is the final
substrate of all coagulation reactions. Being a soluble 1) Biodegradable barrier membranes for guided
protein, fibrinogen is transformed into an insoluble tissue regeneration, including alveolar ridge
fibrin by thrombin while the polymerized fibrin gel augmentation
constitutes the first cicatricial matrix of the injured
2) A source (or reservoir) of growth factors as a
site.
gel form of PRP for tissue regeneration, such as bone
Table 1: advantages and disadvantages of induction
platelet rich fibrin over platelet rich plasma9
3) Biodegradable scaffolds for tissue engineering
Advantages Disadvantages CONCLUSION
Biochemical handling of blood
Quantity is PRP has several advantages. Using PRP can avoid
is simplified and economical,
less because of
also bovine thrombin and disease transmission by using foreign substances for
autologous blood
anticoagulants is not needed
regeneration of tissues. It can be easily prepared and
Be�er handling of is fresh when needed. The cost incurred is also less.
Be�er healing due to slow
blood is essential,
polymerization
soon after collection.
The rate of healing and the body’s response to the
treatment procedures is also good. It helps the repair
Greater cell migration and
proliferation and regeneration of both hard and soft tissues.

It has a cumulative effect on Conflict of Interest: None

immune system
Aids in hemostasis Source of Funding: Self

Preparation of PRF10: Acknowledgement: None

The advantages of PRF over PRP are its simplified Ethical Clearance: Not applicable
preparation and lack of biochemical handling of the REFERENCES
blood. The required quantity of blood is drawn
into 10-ml test tubes without an anticoagulant and 1. Torabinejad M, Turman M. Revitalization of
centrifuged immediately. Blood is centrifuged using tooth with necrotic pulp and open apex by
a tabletop centrifuge for 12 min at 2,700 rpm. using platelet-rich plasma: a case report. J
Endod 2011; 37:265-268.
The resultant product consists of the following
2. Dohan Ehrenfest DM, Rasmusson L,
47 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Albrektsson T. Classification of platelet
concentrates: From pure platelet-rich plasma
(P-PRP) to leucocyte- and platelet-rich fibrin
(L-PRF) Trends Biotechnol. 2009; 27:158–67.
3. Amable et al.: Platelet-rich plasma preparation
for regenerative medicine: optimization and
quantification of cytokines and growth factors.
Stem Cell Research & Therapy 2013 4:67.
4. Dohan DM, Choukroun J, Diss A, Dohan SL,
Dohan AJ, Mouhyi J, Gogly B. Platelet-rich
fibrin (PRF): A second-generation platelet
concentrate. Part I: Technological concepts and
evolution, Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2006; 101:E37-44
5. Sunitha Raja V, Munirathnam Naidu E.
Platelet-rich fibrin: evolution of a second-
generation platelet concentrate, Indian J Dent
Res. 2008 Jan-Mar; 19(1):42-6.
6. Simonpieri A, Del Corso M, Vervelle A, Jimbo
R, , Sammartino G, Dohan Ehrenfest DM.
Current knowledge and perspectives for the use
of platelet-rich plasma (PRP) and platelet-rich
fibrin (PRF) in oral and maxillofacial surgery
part 2: Bone graft, implant and reconstructive
surgery. Curr Pharm Biotechnol. 2012 Jun;
13(7):1231-56.
7. Bielecki T1, Dohan Ehrenfest DM. Platelet-rich
plasma (PRP) and Platelet-Rich Fibrin (PRF):
surgical adjuvants, preparations for in situ
regenerative medicine and tools for tissue
engineering. Curr Pharm Biotechnol. 2012
Jun;13(7):1121-30.
8. Del Corso M1, Vervelle A, Simonpieri A,
Jimbo R, Inchingolo F, Sammartino G, Dohan
Ehrenfest DM. Current knowledge and
perspectives for the use of platelet-rich plasma
(PRP) and platelet-rich fibrin (PRF) in oral and
maxillofacial surgery part 1: Periodontal and
dentoalveolar surgery. Curr Pharm Biotechnol.
2012 Jun; 13(7):1207-30.
9. Saluja H, Dehane V, Mahindra U. Platelet-
Rich fibrin: A second generation platelet
concentrate and a new friend of oral and
maxillofacial surgeons.Annals of Maxillofacial
Surgery. 2011; 1(1):53-57.
10. Naik B, Karunakar P, Jayadev M, Marshal VR.
Role of Platelet rich fi brin in wound healing:
A critical review. J Conserv Dent 2013; 16:284-
93.
11. Kobayashi M1, Kawase T, Horimizu M, Okuda
K, , Yoshie H. A proposed protocol for the
standardized preparation of PRF membranes for
clinical use, Biologicals 40 (2012) 323-329.
 DOI Number: 10.5958/2320-5962.2016.00011.5

Oral Hemangiomatous Granuloma: A Case Report

Shreeyam Mohapatra1, Akshay Verma2, Ajay Kumar Sharma2, Mayank Das3,

Pankaj Sharma4, Prashant Kumar5

Post Graduate Student. Department of Oral Medicine & Radiology, 2Post Graduate Student. Department of
1

Oral Pathology & Microbiology, Rajasthan Dental College & Hospital, Jaipur, Rajasthan, India, 3Senior Lecturer,
Department of Oral Medicine & Radiology. NIMS Dental College, Jaipur, Rajasthan, India, 4Post Graduate Student,
Department of Prosthodontics, 5Post Graduate Student, Department of Oral Medicine & Radiology, Rajasthan Dental
College & Hospital, Jaipur, Rajasthan ,India.

ABSTRACT

Pyogenic granuloma is one of the inflammatory hyperplasia seen in the oral cavity. It usually arises
in response to various stimuli such as low-grade local irritation, traumatic injury, hormonal factors,
or certain kinds of drugs. Clinically oral pyogenic granuloma is seen as a smooth exophytic lesion
with usually hemorrhagic base. The surface presents from pink to red to purple. This case report
describes a pyogenic granuloma in a 32-year-old female patient, discussing the clinical features and
histopathologic features that distinguish this lesion from other similar oral mucosa lesions and also the
successful management of the lesion.

Keywords: Hyperplasia, Oral cavity, Pyogenic granuloma.

INTRODUCTION numerous blood vessels and the inflammatory nature

Pyogenic granuloma (PG) is a common reactive
neoformation of the oral cavity, which is composed of
granulation tissue and develops in response to local
irritation or trauma.
Hullihen 1 in 1844 described the first case of
pyogenic granuloma in English literature. In 1897,
pyogenic granuloma in man was described as
“botryomycosis hominis.” 2 by Poncet and Dor.
Har�ell in 1904 is credited with giving the
current term of “pyogenic granuloma” or “granuloma
pyogenicum.” It was also called a Crocker and
Har�ell’s disease. 3
Angelopoulos 4 histologically described it as
“hemangiomatous granuloma” due to the presence of
Corresponding author:
Dr. Shreeyam Mohapatra
Post Graduate Student, Department of Oral
Medicine & Radiology, Rajasthan Dental College &
Hospital, Jaipur, Rajasthan, India.
E-mail: shreeyam080@gmail.com,
Ph no.-+91-9166907904
of the lesion.
Cawson et al., 5 in dermatologic literature have
described it as “granuloma telangiectacticum” due
to the presence of numerous blood vessels seen in
histological sections. They described two forms
of pyogenic granulomas, the lobular capillary
hemangioma (LCH) and the non-lobular capillary
hemangioma (non-LCH). Pyogenic granulomas
commonly occur on the skin or the oral cavity but
seldom in the gastrointestinal tract.
In this article, we have presented a case report of a
large pyogenic granuloma of the gingiva in a 32-year-
old female patient who presented with a localized
tumor like enlargement in the lower front quadrant
of the jaw. We have also reviewed the literature
and discussed the present case with reference to the
same.
CASE REPORT
A 32-year-old female reported to the Department
of Oral Medicine & Radiology, with a chief complaint
of overgrowth of gums in the lower front teeth
region since 4 months, which caused discomfort
49 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
while eating. The patient reported that he noticed
the swelling 4 months ago, which was painless and
gradually increased in size, during this period she
had visited a medical doctor who had given him gum
paint for application. She had stopped brushing the
area due to bleeding from the area since 1 month.
She also complained of increase of gap inbetween the
tooth as the size of the growth increased.
Clinical Examination
On extraoral examination, there was no visible
swelling on the lower front 1/3rd of the face. Intraoral
examination revealed a large sessile lobulated oval
gingival overgrowth seen on the interdental gingiva
irt 31 and 32 on the labial side(FIG 1) which as
running back into the lingual surface. It involves
marginal and a�ached gingival, measuring 9X9X3mm
in size labialy.
Lingualy(FIG 2), the overgrowth is round and
with the gingival overgrowth reaching middle 1/3rd of
31, measuring around 12X8X6mm . The surrounding
areas are normal with gingival recession present on
41. The color of the gingival growth is reddish pink
and seems to be highly vascular with no ulcerations
.Roatated 31 is seen. Oral hygiene was fair and
the mouth showed fair amounts of calculus. The
overgrowth was smooth, mobile, firm and granular
in consistency & mild tender. Spontaneous bleeding
on probing was seen from the lesion. Grade I mobility
was seen wrt 31 ,41. A provisional diagnosis of
pyogenic granuloma was made on the basis of history
& clinical examination.
Intra oral periapical radiograph (FIG 3)revealed
interdental bone loss seen in the region of 31,32
reaching upto the apical 1/3rd. Routine hemogram
was found to be normal.. The differential diagnosis
included peripheral ossifying fibroma, peripheral
giant cell granuloma, hemangioma and fibroma.
The patient did not have any systemic problems
and so the case was prepared for surgery on the
basis of the clinical and radiographic evidence.
Oral prophylaxis was completed and the lesion was
excised under aseptic conditions.(fig 4)
Histopathological Examination
HP examination (FIG 5) revealed a ulcerative
epithelium overlying a fibrovascular connective tissue,
with moderate amount of chronic inflammatory cells
predominately made up of lymphocytes & plasma
cells. Prominent endothelial lined blood vessels
are seen with extravasated RBC’s. The clinical and
histopathological findings confirmed it to be a case of
pyogenic granuloma.
The patient was recalled every 3rd month for
maintenance and to check for possible recurrence.
This case was followed up for a period of 1 year and
there has been no recurrence so far
DISCUSSION
Oral pyogenic granuloma (PyG) is a kind of
inflammatory cellular and vascular proliferation
resulting from different stimuli such as chronic local
denture irritation, drug reaction, hormonal variations
and responses to grafts.6
The name pyogenic granuloma is a misnomer
since the condition is not associated with pus and
does not represent a granuloma histologically.
It is a reactive inflammatory process filled with
proliferating vascular channels, immature
fibroblastic connective tissue, and sca�ered
inflammatory cells. The surface usually is ulcerated,
and the lesion exhibits a lobular architecture.
Regezi et al 7 suggested that pyogenic granuloma
is caused by a known stimulant or injury such as
calculus or foreign material within the gingival
crevice resulting in exuberant proliferation of
connective tissue. Ainamo 8 suggested that routine
tooth brushing habits cause repeated trauma to
the gingiva resulting in irritation and formation
of these lesions .The other factors in literature
are Trauma to deciduous teeth, 9 aberrant tooth
development, occlusal interferences, immunosuppre
ssive drugs such as cyclosporine and wrong selection
of healing cap for implants are some of the other
precipitating factors for pyogenic granulomas.
From the numerous etiologies enumerated
above , the probable etiologic factors applicable in
this case included the presence of large amounts of
calculus due to poor oral hygiene habits,7 repeated
trauma and occlusal interference while eating due to
the size and position of the lesion and as described
by Ainamo, 8 recurrent trauma occurring during
tooth brushing or function with the release of various
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
endogenous and angiogenic factors contributing to
the increased vascularity of the lesion. These factors
probably contributed to the development of this
lesion.
Davies et al., 10 noted that the fibroblasts in
pyogenic granulomas showed increased synthetic
activity and presence of intranuclear inclusion bodies
suggesting that pyogenic granulomas of the skin arise
from disordered growth of the papillary dermis.
Bhaskar and Jacoway 2 demonstrated the
presence of gram positive and gram negative bacilli
in the superficial areas of the ulcerated form of
pyogenic granuloma, rather than the non-ulcerated
form suggesting that these organisms could be
contaminants from the oral cavity. This probably
justifies the inclusion of the term “pyogenic” in
pyogenic granuloma. Oral pyogenic granuloma show
prominent capillary growth within a granulomatous
mass rather than the real pyogenic organisms and
pus, so the term pyogenic granuloma is a misnomer
and it is not a granuloma in the real sense.7 The lesion
in the patient was not ulcerated.
Oral pyogenic granuloma occurs over a wide
age range of 4.5 to 93 years with highest incidence
in second and fifth decades and females are slightly
more affected than males because of the hormonal
changes that occur in women during puberty,
pregnancy and menopause. The pyogenic granuloma
has been called a “pregnancy tumor” and does occur
in 1% of pregnant women. When possible, wait
until after delivery to remove the lesion in pregnant
women because of a greater tendency for recurrence
during pregnancy. In a number of cases, mastication
on the lesion causes bleeding and pain and requires
surgical intervention before parturition. Some
pyogenic granulomas regress after childbirth without
surgical intervention Gingiva was the predominant
site followed by lips, tongue, buccal mucosa, and
hard plate. Other sites were the cheek, lips, tongue,
palate, mucobuccal fold, and frenum.
Pyogenic granuloma of the oral cavity appears
as an elevated, smooth or exophytic, sessile or
pedunculated growth covered with red hemorrhagic
and compressible erythematous papules, which
appear lobulated and warty showing ulcerations and
covered by yellow fibrinous membrane. 6 The color
50
varies from red, reddish purple to pink depending on
the vascularity of the growth. The gingiva, especially
the marginal gingiva is affected more than the
alveolar part. 11
Differential diagnosis of pyogenic granuloma
includes peripheral giant cell granuloma, peripheral
ossifying fibroma, fibroma, peripheral odontogenic
fibroma, hemangioma, conventional granulation
tissue, hyperplastic gingival inflammation, Kaposi’s
sarcoma, bacillary angiomatosis, angiosarcoma, and
Non-Hodgkin’s lymphoma.12
Radiographic findings are usually absent.
Angelopoulos 4 concluded that in some long standing
gingival pyogenic granulomas caused localized
alveolar bone resorption.
Microscopically pyogenic granuloma is partly
or completely covered by parakeratotic or non-
keratinized stratified squamous epithelium. Major
bulk of the lesion is formed by a lobulated or a non
lobulated mass of angiomatous tissue. Usually,
lobulated lesions are composed of solid endothelial
proliferation or proliferation of capillary sized blood
vessels. The amount of collagen in the connective
tissue of pyogenic granuloma is usually sparse.
Surface can be ulcerated and in such ulcerated
lesions, edema was a prominent feature and the
lesion is infiltrated by plasma cells, lymphocytes and
neutrophils. 2
Surgical excision is the treatment of choice. After
surgical excision of gingival lesions, cure�age of
underlying tissue is recommended.13 Excision with 2
mm margins at its clinical periphery and to a depth
to the periosteum or to the causative agent.Foreign
body, calculus, or defective restoration should be
removed .
Taira et al., 14 have shown a recurrence rate of 16% in
excised lesions and also described a case of multiple
deep satellite lesions surrounding the original excised
lesion in a case of Warner Wilson James syndrome.
Incomplete excision, failure to remove etiologic
factors or repeated trauma contributes to recurrence
of these lesions. 7
51 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

Fig 1. Labial view of gingival growth Fig 5 Histopath picture(20x)

Acknowledgment: None

Conflict of Interest: None

Source of Funding: Self

Ethical Clearance : Not Needed

CONCLUSION

Pyogenic granuloma is a common oral lesion.

It can be adequately treated with the correct
diagnosis and proper treatment planning. This
Fig 2. Occlusal view of the lingual side
case report presents a case of a gingival pyogenic
granuloma in a female patient giving an insight into
its different etiologies, clinical features, histological
presentations.

REFERENCES

1. Hullihen SP. Case of aneurism by anastomosis

of the superior maxillae. Am J Dent Sci 1844;4:
160- 2.
2. Bhaskar SN, Jacoway JR. Pyogenic granuloma -
Clinical features, incidence, histology, and result
of treatment: Report of 242 cases. J Oral Surg
1966;24:391-8.
Fig 3. Intra oral periapical radiograph.
3. Har�ell MB. Granuloma pyogenicum. J Cutan
Dis Syph 1904;22:520-5.
4. Angelopoulos AP. Pyogenic granuloma of the
oral cavity: Statistical analysis of its clinical
features. J Oral Surg 1971;29:840-7.
5. Cawson RA, Binnie WH, Speight PM, Barre�
AW, Wright JM. Lucas Pathology of Tumors of
OralTissues.5 th ed.Missouri:Mosby;1998.p.252-4.
6. Neville BW, Damm DD, Allen CM, Bouquot JE
(2009)Oral & maxillofacial pathology.3rd ed,WB
Fig 4.Excised Lesion Saunders,Philadelphia, 517-518
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
7. Regezi JA, Sciubba JJ, Jordan RC. Oral Pathology:
Clinical Pathological Considerations.4 th ed.Phila
delphia:WBSaunders;2003.p.115-6 .
8. Ainamo J. The effect of habitual toothcleansing
on the occurrence of periodontal disease and
dentalcaries.SuomHammaslaakToim.1971;67:
63-70.
9. Aguilo L. Pyogenic granuloma subsequent to
injury of a primary tooth. A case report. Int J
PaediatrDent2002;12:438-41.
10. Davies MG, Barton SP, Atai F, Marks R. The
abnormal dermis in pyogenic granuloma.
Histochemical and ultrastructural observations.
J Am Acad Dermatol 1980;2:122-42 .
11. Mubeen K, Vijaylakshmi KR, Abhishek RP. Oral
pyogenic granuloma with mandible involvement:
An unusual presentation. J Dent Oral Hyg 2011;3:
6-9.
52
12. Sato H, Takeda Y, Satoh M. Expression of
the endothelial receptor tyrosine kinase Tie2
in lobular capillary hemangioma of the oral
mucosa: An immunohistochemical study. J Oral
Pathol Med 2002;31:432-8.
13. Wood NK, Goaz PW. Differential diagnosis of
oral and maxillofacial lesions. 5 th ed. Missouri:
Mosby; 1998. p. 129.
14. Patil K, Mahima VG, Lahari K. Extragingival
pyogenic granuloma. Indian J Dent Res 2006;17:
199-202.
15. Taira JW, Hill TL, Evere� MA. Lobular capillary
hemangioma (pyogenic granuloma) with
satellitosis. J Am Acad Dermatol 1992;27:297-
300.
 DOI Number: 10.5958/2320-5962.2016.00012.7

Cleft Lip and Palate: A Review

Chaudhary I1, Tripathi AM2, Yadav G3, Dhinsa K4

1
Post Graduate Student, 2Professor & Head of Department, 3Reader, 4Senior Lecturer, Department of Pedodontics and
Preventive Dentistry, Sardar Patel Post Graduate Institute of Dental and Medical Sciences, Lucknow.

ABSTRACT

Orofacial clefts comprise a range of congenital deformities and are the most common head and neck
congenital malformation. Cleft has significant psychological and socio-economic effect on patient
quality of life and requires a multidisciplinary team approach for management. The complex interplay
between genetic and environmental factors plays a significant role in the incidence and cause of
cleft. In the following review article, the embryology, classification, etiology, clinical features and
management of cleft lip and palate are discussed along with primary goals of surgical repair to restore
normal function, speech development, and facial esthetics. Different techniques are employed based on
surgeon expertise and the unique patient presentations.

Keywords: Cleft Lip, Cleft Palate, Orofacial region and Congenital anomaly.

INTRODUCTION along with the fusion of medial nasal prominences.

Human birth defects arise from many etiologies
including single-gene disorders, choromosome
aberrations, exposure to teratogens, and sporadic
conditions of unknown cause. Of all these, cleft lip
and palate are one of the most common congenital
deformities seen at birth. A newborn child with a cleft
lip and palate has a devastating impact on the mother.
It can be defined as a congenital abnormal gap in the
palate that may occur alone or in conjunction with lip
and alveolus cleft.1
PREVALENCE
It has an incidence of 0.28 to 3.74 per 1000 live
births globally.
It comprises of labial, upper jaw and palatal
component.
b) Secondary Palate: Palatine shelves appear
in the sixth week of development and are directed
downward obliquely on each side of the tongue.
In the seventh week, the palatine shelves ascend to
a�ain a horizontal position above the tongue and
fuse resulting in the formation of secondary palate.
Anteriorly shelves fuse with the triangular primary
palate and the incisive foramen is the midline mark
between the primary and secondary palate. At the
same time as the palatine shelves fuse, the nasal
septum grows down and joins with the cephalic
aspect of the newly formed palate).2

EMBRYOLOGY OF DEVELOPMENT OF THE Pathogenesis: Defects with the complete lack of

PALATE
a) Intermaxillary segment: It is formed by
the medial growth of the maxillary prominences
Corresponding author:
Dr. Iqra Chaudhary
Post Graduate Student, Department of Pedodontics
and Preventive dentistry, Sardar Patel Post Graduate
Institute of Dental and Medical Sciences, Lucknow,
E-mail: iqrachaudhary18@gmail.com, 08052516316
fusion of the maxillary prominence with the medial
nasal prominence on one or both sides may lead to
lateral cleft lip, cleft upper jaw and cleft between
the primary and secondary palates. Those that lie
posterior to the incisive foramen include cleft palate
and cleft uvula. Cleft palate results from lack of
fusion of the palatal shelves, which may be either due
to shortening of the shelves, failure of the shelves to
elevate, inhibition of the fusion process itself or failure
of the tongue to drop between the shelves because of
micrognathia.3
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 54

ETIOLOGY OF CLEFT • Class I: Unilateral notching of vermilion

border and not extending into the lip.
Hereditary: Previously it was thought that the
• Class II: Unilateral notching of vermilion
condition was inherited by autosomal recessive mode
border with cleft extending into lip but not including
of inheritance, possible with a variable degree of
floor of the nose.
expressivity.
• Class III: Unilateral cleft of vermilion border
Risk Factors: extending into floor of nose.
Study done by Tolarva (1996), can be useful in • Class IV: Any bilateral cleft of lip (complete
explaining the parents, the chance of them having a or incomplete).
baby with a cleft lip and palate. According to him, if Cleft palate:
both the parents are normal, the chance is 4%, but if
• Class I: Involving only soft palate
both the parents are affected, the chance increases to
• Class II: Involving soft and hard palate but
12%.
not alveolus.
Genetic Factors: • Class III: Involving soft and hard palate and
Transforming growth factor alpha (TGFA), alveolus of one side.
Transforming Growth Factor Beta 2 (TGFB2) and • Class IV: Involving both soft and hard palate
Msh homeobox 1 (MSX1) genes have been identified and alveolus on both sides of the pre- maxilla.5
as having a major role in the development of Cleft CLINICAL FEATURES
Lip or Cleft Palate through linkage and association
Cleft lip:
studies. Adipocyte protein 2, Interferon regulatory
factor 6 are the other genes that have been identified • Nasal distortion
in the development of Cleft Lip or Cleft Palate.4 • Hare lip
• Unilateral cleft lip
Environmental Factors:
• Bilateral cleft lip
• Womb environment
Cleft palate:
• External environment
• Eating and drinking difficulties
• Nutrition
• Speech problems
• Drugs: Antiepileptic drugs (phenytoin,
valproic acid), thalidomide, pesticide, retinoic • Defect in smelling4
acid, maternal alcohol use and maternal cigare�e DENTAL PROBLEMS COMMONLY
smoking. ASSOCIATED WITH CLEFT LIP AND
Other Factors: PALATE
• Infections • Natal or Neonatal teeth
• Lack of inherent developmental force • Congenitally missing teeth
• Nutritional disturbances during • T-shaped cingulum
development • Peg-shaped teeth
• Physiologic, emotional or traumatic stresses • Thick curved hypoplastic incisor
during development
• Gemination or Fused supernumerary teeth
• Defective vascular supply to the area present
involved2
• Delayed eruption of permanent teeth
CLASSIFICATION OF CLEFT LIP AND
PALATE • High incidence of hypoplasia in incisors
• Feeding difficulty
Veaus’s classification (1938)
ASSOCIATED CONDITIONS
Cleft lip:
• Hearing loss and middle ear infection (Nober
55 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
1968)
• Nasal deformities
• Speech difficulties: Hypernasal speech (Nasal
twang in voice). Consonant sounds are affected (P b t
d k g).
• Psychological effect2
MANAGEMENT OF CLEFT CHILD
Optimal care is best achieved by multiple types of
clinical expertise as follows:-
a) ROLE OF PEDODONTIST
The paediatric dentist is responsible for the
overall dental care of the patient. They are involved
in the fabrication of obturators, assessment of growth
and presurgical and postsurgical treatment phase
of maxillary orthopedics. Both active and passive
appliances are used to bring the cleft segments into
a more ideal alignment and thereby promote a more
favourable initial surgical outcome.
b) ROLE OF ORTHODONTIST
The orthodontist plays a key role in the diagnosis
and treatment of a cleft condition by obtaining records
necessary for diagnosis and treatment planning. These
include cephalometric and panoramic radiographs,
study models, and diagnostic photographs. The
orthodontist also provides comprehensive orthodontic
care for patients. If surgical treatment is indicated, the
orthodontist works closely with the surgeon.
c) ROLE OF ORAL AND MAXILLOFACIAL
SURGEON
Their role on the cleft team evaluates all patients
for facial form and functions and jaw position. The
surgical placement of primary and secondary alveolar
cleft bone grafts is another important role of the oral
and maxillofacial surgeon. These grafts aid in dental
rehabilitation. The grafted bone supports the teeth
adjacent to the cleft site and provides bone through
which teeth may erupt.
d) ROLE OF MAXILLOFACIAL
PROSTHODONTIST
This specialist fabricates prosthetic appliances to
rehabilitate mastication, deglutition, speech and oral
esthetics. Many patients with clefts have congenitally
missing teeth or malformed teeth that may need to
be removed. Patients demonstrate aberrant speech
pa�erns caused by failure of the soft palate to elevate
properly. In such cases, a palatal lift appliance is
fabricated to aid the speech mechanism. In other cases
the maxillofacial prosthodontist may fabricate speech
bulb prosthesis to aid or augment the velopharyngeal
mechanism.
e) ROLE OF PAEDIATRICIAN
He is responsible for maintenance of the patient’s
overall health.
f) ROLE OF MEDICAL GENETICIST
He examines the patient to find characteristics of
syndromes associated with cleft lip and palate.
g) ROLE OF THE PLASTIC AND
RECONSTRUCTIVE SURGEON
They usually begin with a determination of the
timing and method of lip closure. With complete
clefts, the plastic surgeon may next be responsible
for obtaining bone grafts to be used in closing defects
of the maxillary dental alveolus. They perform a
pharyngoplasty to improve velopharyngeal function.
h) SOCIAL WORKER
They provide supportive counseling and facilitate
communication between the family and medical or
hospital personnel.
i) PSYCHIATRIST AND PSYCHOLOGIST
They evaluate the patient for strengths and
weaknesses in cognitive, interpersonal, emotional,
behavioural and social development.
j) SPEECH PATHOLOGIST
They function essentially as a monitor of speech
output.
k) AUDIOLOGIST
They perform tests to identify any hearing
difficulties.5
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
MANAGEMENT IS DIVIDED INTO FOUR
STAGES:
STAGE I (MAXILLARY ORTHOPEDIC STAGE:
BIRTH TO 18 MONTHS)
This stage includes the followings things:
Standard nipple
These nipple provide improved ejection of the
milk into the infant’s mouth with a minimum of
effort which can be done by Mead Johnson Bo�le,
Haberman Feeder Bo�le, and etc.2
Figure 2: Heberman feeder
Maxillary obturators
These are constructed to facilitate feeding
with unilateral or bilateral cleft lip and palate.5
Feeding problems are often associated with cleft
anomalies, which make it difficult for the infant
to maintain adequate nutrition. These problems
include insufficient suction to pull milk from the
nipple, excessive air intake during feeding (requiring
several burpings), choking, nasal discharge and
excessive time required to take nourishment. An
intraoral maxillary obturator, has proved beneficial
by providing an artificial palate.2
Clinical Management of Initial Obturator
Therapy (Birth to 3 Months)
The appliance is positioned in the infant’s mouth.
Areas of excessive pressure on any intraoral tissues by
the acrylic resin are identified by observation and then
reduced. Care is taken to keep the acrylic resin from
impinging on muscle a�achments or extending to the
depth of the buccal vestibule. Parents are instructed
in placement and removal of the appliance and its
daily cleaning. In most cases, this appliance will serve
until the time of initial lip closure at approximately 3
months of age.6
Premaxillary Orthopedics (Birth to 4 or 5
Months)
In some cases of bilateral cleft lip and palate, the
infant has a premaxillary segment positioned severely
anterior to the maxillary arch segments or deviated
laterally to one side of the cleft defect. If lip surgery is
undertaken with the premaxilla in such an abnormal
56
position, the chances of lip dehiscence (lip separation
caused by increased pressure at the suture lines) is
increased. The use of a head cap and premaxillary
strap to reposition the premaxilla is indicated. This
type of apparatus is useful for anteroposterior and
vertical repositioning. After delivery of the obturator,
the infant is allowed to become accustomed to the
appliance for 1 week. At the second appointment
the infant is fi�ed with a premaxillary retraction
appliance.
Airway Obstruction
Infants with airway obstruction secondary to
Pierre Robin sydrome (micrognathia, glossoptosis,
and cleft palate) may require intervention to aid
breathing. An obturator with a posterior palatal
extension should be used in an a�empt to reposition
the tongue downward and forward out of the cleft
site.
Cheiloplasty
The appearance of an unrepaired wide cleft
lip can be distressing. Some parents feel anxiety,
depression, guilt or rejection. Lip surgery will
significantly improve the infant’s appearance.
Surgical closure is usually accomplished at 10 weeks
of age. At the time of lip closure, when the infant is
under general anesthesia, an impression is made of
the maxillary arch for construction of a new obturator.
This is necessary to accommodate craniofacial growth
during the first few months of life.5
Timing of surgery
It was Mallard (1957) who proposed the
commonly used “rule of 10” for the timing of repair
stated as weight over 10lbs hemoglobin over 10g, age
over 10 weeks.7
Maxillary Orthopedics (3 to 9 Months)
After definitive lip closure at about 3 months of
age, maxillary arch collapse in unilateral or bilateral
completed cleft is common. It is a�ributed to the
increased tension placed on the segments by the
repaired lip. To prevent this collapse, the obturator is
used to provide cross-arch stability and support. As
pressure is exerted on the anterior segments of the
maxilla by the repaired lip, orthopedic molding of the
segments can be achieved. This molding is facilitated
57 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
by the obturator, which provides a fulcrum around
which the anterior portion of the greater segment
rotates. At the same time the appliance resists any
tendency for the greater and lesser segments to
collapse toward the midline. In bilateral cleft cases,
the repaired lip provides further retraction at the
premaxilla, positioning it between the two lateral
maxillary segments.
Bone Grafting of Alveolar Cleft Defects
Bone grafting of alveolar cleft defects has been a
confusing issue to many patients and practitioners.
Primary bone grafting refers to bone-grafting
procedures involving alveolar cleft defects in children
younger than 2 years of age; this term implies nothing
about technique.
Early secondary bone grafting refers to bone-
grafting procedures performed between 2 and 4 years
of age.
Secondary bone grafting is done between 4 and
15 years of age
Late secondary bone grafting refers to
reconstruction of residual alveolar cleft defects in the
adult.
Palatoplasty
Closure of the palate is accomplished between
12 months and 2 years of age. The primary purpose
of completing palate closure by 2 years of age is to
facilitate the acquisition of normal speech, because
this correlates with the age at which most children
begin to talk. The procedure may also improve
hearing and swallowing by aligning the cleft palatal
musculature.
STAGE II (PRIMARY DENTITION STAGE:
18 MONTHS TO 5 YEARS OF AGE)
Meticulous daily oral hygiene for the child is
established to reduce the possibility of development
of dental caries. Ectopic eruption of the primary
maxillary anterior dentition is common around the
cleft defect. Special care should be taken to keep
these teeth free from caries because food often is
lodged in and around the cleft defect. Periodic recall
examinations, possibly 3- to 4-month intervals, enable
the dentist to intercept areas of decalcification.
STAGE III (LATE PRIMARY OR MIXED
DENTITION STAGE: 6 TO 10 OR 11 YEARS
OF AGE)
Many problems encountered during the late
primary and mixed dentition stage of dental
development arise from ectopically erupting
permanent central and lateral incisors or crossbites
of the posterior dental segments. Hence, interceptive
correction of a traumatic occlusion is essential
to prevent destruction of enamel in the involved
dentition. Maxillary expansion is accomplished by
palatal expansion, especially in patients who have
not undergone primary alveolar cleft bone grafting.
Once the condition is corrected, retention can be
maintained by passive holding appliances.
STAGE IV (PERMANENT DENTITION
STAGE: 12 TO 18 YEARS OF AGE)
Most surgical procedures involving the maxilla
and mandible are deferred until the teenage years,
when maximum growth of the jaws has been a�ained
and all permanent teeth except the third molars have
erupted. In boys, surgeons usually delay osteotomies
until approximately 17 to 18 years of age; in girls,
surgery sometime after 15 years of age is possible. In
some instances, children with a cleft with a severely
retrusive maxilla cannot undergo orthodontic
correction with conventional therapy. In these cases
the surgical procedure often used is the LeFort I
maxillary advancement.
Cosmetic Surgery: Major nasal bone surgery
may be deferred until the patient is in the early teens.
However, cartilaginous nasal tip asymmetries may
be corrected at any time. Additional tip-cartilage
revisions may be performed as needed.5
Acknowledgement: Nil
Conflict of Intrest: None
Source of Funding: None
Ethical Clearance: Taken from institutional
ethical commi�ee
REFRENCES
1. Damle SG. Management of children with cleft
lip and palate. In: Damle SG, editor. Text book of
pediatric dentistry 4th ed, 2012; New Delhi: Arya
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Medi Publishing House Pvt Ltd. p. 793-825.
2. Marwah N, Maganur PC. Cleft lip and palate. In:
Marwah N, editor. Textbook book of Pediatric
Dentistry 3rd ed, 2014; New Delhi: Jaypee
Brothers Medical Publishers Ltd. p. 859-879.
3. Sadler TW. Head and neck. In: Taylor C, editor.
Langman’s medical embryology 12th ed, 2012;
Hongkong: Lippinco� Williiams and Wilkins. p.
260-286.
4. King NM, Wei SHY. Management of children
with cleft lip and palate. In: Wei SHY, editor.
Pediatric dentistry: Total pateint care illustrated
ed, 1988; philadelphia: Lea & Febiger. p. 374-
383.
58
5. Jones JE, Sadove MA, Dean JA, Huebener DV.
Multidisciplinary team approach to cleft lip
and palate management. In: Rudolf P, editor.
Dentistry for the child and adolescent 8th ed,
2004; United States of America: Mosby. p. 684-
711.
6. Costello BJ, Ruiz RL. Cleft lip and palate:
Comprehensive treatment planning and primary
repair. In: Miloro M, editor. Peterson’s of oral
and maxillofacial surgery 2nd ed, 2004; New
Delhi: Elsevier health sciences division. p. 839-
858.
7. Habel A, Sell D, Mars M. Management of cleft
lip and palate. Archives of disease in Childhood
1996; 74: 360-366.
 DOI Number: 10.5958/2320-5962.2016.00013.9

Assessment of Dental Anxiety Levels of Adult Patients

A�ending the Department of Periodontology: an
Analytical Study

Navale Shwetambari R1, Devkar Nihal D2, Kalra Dheeraj D3, Lele Suresh V4,
Ansari Muniba M5, Kaulgud Anupam5
1
PG Student, 2Professor, Department of Periodontology,Sinhgad Dental College and Hospital, Pune, Maharashtra,
India, 3Sr Lecturer and Incharge, Department of Public Health Dentistry, YMT Dental College and Hospital, Kharghar,
Navi Mumbai, 4Professor and Head of Department, 5PG Student, Department of Periodontology,
Sinhgad Dental College and Hospital, Pune, Maharashtra, India

ABSTRACT

Purpose/Objectives: Dental anxiety afflicts a significant portion of people of all ages and from different
social classes and often results in poor oral health. The objectives of present study were to measure the
dental anxiety level of adult patients a�ending department of Periodontology, Sinhgad Dental College
and Hospital, Pune, Maharashtra, India as response to various periodontal procedures and to correlate
the dental anxiety levels associated with periodontal procedures with demographic factors like age,
gender, Socio Economic Status (SES), frequency of dental visit and past dental experience.

Method: All patients visiting the Out Patient Department section in February 2014 consented to
complete a questionnaire consisting of Modified Dental Anxiety Scale with some questions designed
and framed according to the specific procedures performed in department of Periodontology. A total
of 300 patients were surveyed (all 300 responded, response rate 100%).

Results: An independent t test and ANOVA were used to compare dental anxiety score with age,
gender, SES, frequency of dental visit and past dental experience. Among 300 (198 males & 102 females)
patients surveyed, a higher Mean Dental Anxiety Score was found in females as compared to males, in
younger patients as compared to older, in lower socio economic status and in patients visiting a dentist
infrequently.

Conclusion: A higher MDAS was observed in females as compared to males, in younger patients as
compared to older, in lower socio economic status and in patients visiting a dentist infrequently.

Keywords: Dental anxiety, age, gender

INTRODUCTION anxiety afflicts a significant portion of people of

Dental fear or anxiety may be described as a
subjective state of feeling or reaction to a known
source of danger that lies in the subconscious.1 Dental
Corresponding author:
Dr. Dheeraj D Kalra,
Snr. Lecturer and Incharge, Department of Public
Health Dentistry, YMT Dental College and Hospital,
Kharghar, Navi Mumbai, Phone: +91 8806252969
Email: drdhrj@gmail.com
all ages and from different social classes and often
result in poor oral health by complete avoidance of
dental treatment, irregular dental a�endance or poor
cooperation.2 Dental anxiety is generally manifested
through negative past experiences with the dentist
or vicariously through negative perceptions of
the dentist.3 This could affect the patient-dentist
relationship and the dental treatment plan, avoidance
of dental treatment due to anxiety is very common
and appears to be strongly associated with extreme
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
deterioration of oral and dental health.4 Therefore
before dental treatment, patients anxiety and fear
levels should be assessed. However, there were no
studies done to evaluate the dental anxiety related to
various non-surgical and surgical procedures in the
department of Periodontology.
The assessment of dental anxiety has encouraged
the development of a variety of measures. 5,6
Various scales used are Corah’s DAS (Corah and
Pantera 1968), Kleinknecht’s Dental Fear Scale
(Kleinknecht’s et al 1973), Stouthard’s Dental Anxiety
Inventory (Stouthards 1989). The majority of these are
self report questionnaires. The direct a p p r o a c h
of inviting individuals to state their own rating has
merit.7 The reliability of the Modified Dental Anxiety
Scale given by Humphris et al 19958 appears to be
independent of anxiety level. The significant
associations with self reported a�endance and a single
item assessing respondent’s ‘nervousness’ about
dental treatment supports the scale’s construct.8
In the present study, we aimed to evaluate the
dental anxiety level of adult patients a�ending
department of Periodontology in a dental college. The
objectives of present study were to measure the dental
anxiety level of adult patients as response to various
periodontal procedures and to correlate the dental
anxiety levels associated with periodontal procedures
with factors like age, gender, SES, frequency of dental
visit, past dental history and past dental experience.
MATERIALS & METHODS
The present study is an analytical study carried out
among the patients visiting Out Patient Department
(OPD) section of Department of Periodontology,
Sinhgad Dental College and Hospital, Pune,
Maharashtra, India from 10th of February 2014 to 25th
of February 2014.
Prior to the start of the study all necessary
permissions were taken from the Head of the
Department, the Principal of the Institution and the
study proposal was sent to the Institutional Research
Board (IRB) and after the review process by two
blinded reviewers, the approval to start the study was
given. (IRB Le�er no. SDCH/IRB/2013-14/68)
The participation in the survey was kept
anonymous and voluntary. Those patients who
60
were willing to sign the wri�en informed consent
were included. Those who did not give consent were
excluded from the study. Sample size prior to the start
of the study was obtained by a pilot study done on 30
people. By consulting a statistician, who suggested
including a minimum of 250 patients for the present
study by using a single proportion sampling formula
and applying a correction for a finite population,
however a simple random sampling was done and a
total of 300 (198 males & 102 females) patients were
surveyed.
The instrument to record data was a questionnaire
in the medium of English and local language.
Translation and reverse translation of the
questionnaire in local language was done by an
expert in the subject and reliability and validity of the
questions including translation was checked in the
pilot study. The questionnaire had 2 sections.
Section 1 collected Demographic data like age,
gender and socio economic status (SES) according
to Kuppuswamy’s scale 1976 and its modification
for 20139,10,11 and dental anxiety was measured using
Modified Dental Anxiety Scale [(MDAS) Humphris
et al 1995]8, frequency of dental visit and past dental
experience.
Section 2 had 9 questions each having 5 possible
answers with assigned scores ranging from 1 to 5
(Annexure 1). The final anxiety score was a sum total
of answers of all 9 questions with minimum score of 9
and maximum score of 45.
Statistical methods:
All the forms were numbered serially and coded.
Data was compiled on Microsoft excel sheet (MS Office
2010). Mean and standard deviation of ages of the
respondents and total anxiety score were calculated.
Results are presented as tables and graphs. Statistical
tests like t test and ANOVA were used for comparing
dental anxiety score with age, gender, SES, frequency
of dental visit and past dental experience were carried
out using SPSS software. (v 17.0 Chicago, ILL) p
value less than 0.05 was considered to be statistically
significant.
RESULTS
Table 1 shows demographic characteristics of
61 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
the study participants i.e. age, gender and socio
economic status, frequency of dental visit and past
dental experience expressed as percentage and
frequency. Table 2 shows comparison of mean MDAS
score with independent variables like age, gender and
socio economic status, frequency of dental visit and
past dental experience using t test and ANOVA. It is
seen that there is a statistically significant difference
between the mean MDAS scores when age groups
are considered, highest MDAS [21.71 (SD 6.11)] was
seen in patients age grouped 18 to 28 years and the
least [11.50 (SD 2.12)] was found in age group 68 and
above with statistically significant difference (p<0.05)
(Table 2). Also mean MDAS in females was found to
be higher than in males [19.14(SD 6.35)] for males and
[21.95(SD 6.33)] with statistically significant difference
(p<0.05) Also it is seen that patients from upper class
had mean score of [18.89 (SD 7.81)] showed lowest
anxiety scores and patients from lower class showed
the maximum anxiety score of [26.33(SD 3.78)] with
a statistically significant difference (p<0.05) From
the results it is evident that patients who visited
the dentist or utilized any kind of dental services
sometimes had a higher MDAS score (22.88) than
those who visited regularly once a year (15.91) with
statistically significant difference (p<0.05). Also there
was a statistically significant difference (p<0.05) found
in the mean MDAS scores in patients who had past
dental experience [19.95(SD 6.32)] when compared to
patients without any past dental experience [21.27(SD
6.42)].
DISCUSSION
Despite the technological advances in
dentistry, anxiety about dental treatment
and the fear of pain associated with dentistry
remains globally widespread and is considered
a major barrier to dental treatment. Nearly two
thirds of dentists believe that treating an anxious
patient presents a challenge to them in everyday
practice.13 Dental anxiety is a multidimensional
complex phenomenon and no one single variable can
exclusively account for its development.
Within the literature, a number of factors that
have consistently been linked with a greater
incidence of dental anxiety include personality
characteristics, fear of pain, past traumatic dental
experiences particularly in childhood (conditioning
experiences) etc.13 Identifying these patients and
pu�ing appropriate measures in place is therefore
essential. The DAS is designed to evaluate a patients
overall dental anxiety level both real and imagined.1
In the present study the MDAS was higher in
patients aged 18 to 28 years. The possible reason for
the high levels of anxiety can be a�ributed
to the high percentage of young patients who are
usually apprehensive. There was a significant inverse
relationship of age and anxiety, anxiety decreased
with advancing age. This is in agreement with
previous studies by Klienchect et al 1973, Corah et al
1978, Morgan et al 1980, Corkey and Freeman 1988.
18
Explanations proposed as to why dental anxiety
might decrease with age include the ability to cope
with experiences or the phenomenon may be due to
the ageing process itself characterized by a general
decline in anxiety.
The anxiety levels among females tend to be
higher than males. This finding is consistent with
previous studies1,14 This finding may be explained on
the basis that women have higher levels of neuroticism
(tendency to experience negative emotional states)
than men and that anxiety is positively associated
with neuroticism.15,16 Similar results are obtained
in the present study which reports a significant
difference in the anxiety of males and females.
In the present study the lowest SES group was
found to rate the highest on the perceived dental
anxiety scale. The possible reason may be more
health awareness in upper class people. Adults with
low socio economic status and education are more
likely to have higher dental anxiety score (Moore et al
1993)6. Klingberg et al (1994) and Folayan et al (2003)
reported that there was no relationship between SES
and dental anxiety18. However, Folayan et al
noted a relationship between the type of the child’s
school and dental anxiety.
From the reports of a previous study it was found
that generally patients having previous experience of
painful dental treatment had higher DAS than those
who never had visited a dentist.1 Highly anxious
patients have a higher probability of irregular dental
a�endance and/or total avoidance of dental care.17
Within the limitation of present study, it can
be concluded that there is a higher level of anxiety
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 62

among patients and measures to reduce such anxiety Table 2: Shows comparison of MDAS score with
is highly recommended. The use of dental fear scale independent variables like age, gender,
should be included in routine practice which will give
the dentist a more clear idea about patient’s responses Mean
Independent
and avoidance of fear of specific stimuli during dental MDAS P value
variables
score
procedure.
18-28 years 21.71
Table 1: Shows Demographic details of 29-38 years 20.01
respondents. 39-48 years 18.76

Age 49-58 years 18.06 0.004*

Age Frequency (n) Percent (%)
59-68 years 17.9
18-28 173 57.7 68 years & above 11.5
29-38 68 22.7 Male 19.94
39-48 29 9.7 Gender
Female 21.95 0.010*
49-58 18 6.0
59-68 10 3.3 Upper class 18.89
69 & above 2 .7 Upper Middle 20.99
Gender Socio Lower middle 19.02
Male 198 66.0 economic Upper lower 21.96 0.011*
status
Female 102 34.0 Lower class 26.33
Socio Economic
Status 6 month 18.6
Upper 9 3.0 Once a year 15.91
Upper middle 110 36.7 Sometimes 22.88
Lower middle 95 31.7 Frequency of Having a
20.05 0.017*
dental visit problem
Upper lower 83 27.7
Lower 3 1.0 First visit 21.47
Frequency of Dental Past dental Yes 19.95
visit experience 0.000*
No 21.27
6 Months 5 1.7
Once a Year 11 3.7 * indicates p<0.05 i.e. statistically significant.
Sometimes 17 5.7
When having CONCLUSION
a problem or 142 47.3
emergency Amongst patients visiting Dept of Periodontology,
First visit 125 41.7 a higher MDAS was observed in females as compared
Past Dental to males, in younger patients as compared to older, in
Experience lower socio economic status and in patients visiting
Yes 146 48.7 a dentist infrequently. These findings should alert
No 154 51.3 both researchers and dental practitioners to this very
real issue with the objective of seeking ways to
address and improve the dental anxiety associated
with periodontal procedures.

Acknowledgement: the authors would like to

acknowledge all subjects who participated in the
study.

Conflicts of Interest: Nil

Source of Funding: Self funded

63 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Ethical Clearance: The present study was
approved by the Institutional Research Board (IRB)
of Sinhgad Dental College and Hospital, Pune with
reference no. SDCH/IRB/2013-14/68.
REFERENCES
1. Hula E, Zuhre ZA, Emre B. Dental fear and
anxiety levels of patients a�ending a dental
clinic.Quintessence Int 2006;37:304-10.
2. Shashidhar A, Da�atreya KS. Dental anxiety
and its relationship with self perceived health
locus of control among Indian dental students.
Oral Health Prev Dent 2010;8:9-14.
3. De Donno MA. Dental anxiety, dental visits and
oral hygiene practices. Oral Health Prev Dent
2012;10:129-33.
4. Benjamin P, Jonathan M. Dental anxiety among
Israeli dental students: a 4 year longitudinal
study. Eur J Dent Educ 2000;4:133-7.
5. Aartman I, Van-Everdingen T, Hoogstraten J,
et al. Appraisal of behavioural measurement
techniques for assessing dental anxiety and fear
in children: A review. J Psychopathol Behav
Assess 1996;18:153-71.
6. Kleinknect R, McGlynn F D, Thorndike R M, et
al. Factor analysis of the dental fear survey with
cross validation. Jour Am Dent Assoc 1984;108:
59-61.
7. Corah N L. Methodological needs and
behavioural research with adult dental patients.
Anaestheia Pmg1986;33:46-9.
8. G.M. Humphris, R.Freeman, J.Cambell et
al. Further evidence for the reliability and
validity of the modified dental anxiety scale.
International Dental Journal 2000;50: 367-70.
9. Kuppuswamy B. Manual of socio economic
status scale (urban) Delhi, Manasyan, 1981.
10. Ravikumar BP, Shankar RD, Rao AR.
Kuppuswamy’s socio economic status
scale- A revision of economic parameter for
2012. International Journal of Research and
Development of Health 2013;1(1):2-4.
11. Vijaya K, Ravikiran E. Kuppuswamy’s socio
economic status scale- updating income ranges
for the year 2013. National journal of research in
community medicine 2013;2(2);079-148.
12. Ayise BC, Heikki M. A comparison of
physcosocial factors related to dental anxiety
among Turkish and Finnish pre adolescents.
Oral Health Prev Dent 2007;5:173-9.
13. Hmud R, Walsh LJ. Dental anxiety: causes,
complications and management approaches. J
Minim Interv Dent 2009;2(1):
14. Tani MQ. Dental anxiety and regulatory of
dental a�endance in younger adults. J Oral
Rehabil 2002;29:604-8.
15. Freeman R. A psychodynamic theory for dental
phobia. Br Dent J 1998;184:170-2.
16. Freeman R. Communicating effectively: some
practical suggestions. Br Dent J 1999;187:240-4.
17. Zac M. Dental anxiety is very high in the
Republic of Kiribati. South Pacific Studies
2007;28:23-30.
18. Dogan MC, Seydaoglu G, Uguz S, Inanc BY. The
effect of age, gender and socio economic factors
on perceived dental anxiety determined by a
modified scale in children. Oral Health Prev
Dent 2006;4:235-41.
 DOI Number: 10.5958/2320-5962.2016.00014.0

The Curious Case of the Insólito Primary Molar

Vivek Gaurav1, Preeti Dhawan2, Mahima Sehgal3, Shilpi Singh4, Aditi Singh5
Asst Professor, 2Professor, 3Postgraduate Student, Department of Paedodontics & Preventive Dentistry, Seema Dental
1

College & Hospital, Rishikesh, U�arakhand, India, 4Senior Lecturer, Department of Public Health & Dentistry DJ
College of Dental Sciences & Research, Modinagar, U�arPradesh, 5Postgraduate Student, Department of Paedodontics
& Preventive Dentistry, Seema Dental College & Hospital, Rishikesh, U�arakhand, India

ABSTRACT

Presence of an accessory root in anterior and posterior teeth in primary dentition is rarely found.
Radiographic and clinical evaluation is necessary for further treatment of such anomalies. This report
describes the management of such anomalous tooth.

Keywords : Primary maxillary second molar, accessory root, radix entomolaris.

INTRODUCTION side (mesiobuccal, distobuccal, mesiopalatal and

Various anatomic and morphologic variations
are seen in root canal system of primary teeth.
These variations are seen less in primary teeth than
permanent teeth1. Usually three roots are seen in
primary maxillary molar (mesiobuccal, distobuccal
and palatal) and two roots in primary mandibular
molar( mesial and distal).
“Radix entomolaris” (RE) an additional third
root in mandibular molars was first mentioned in
the literature by Carabelli2 in 1844 and is described
by various terms, such as “extra third root” or
“distolingual root” or “extra distolingual root.”3 Radix
paramolaris (RP) is known as the extra “mesiobuccal
root in mandibular molars4 which was first described
by Bolk5 in 1915.
Cases of accessory root have been reported in
the past & they are more common in mandibular
molars than in maxillary molars. However accessory
root formation is most uncommon finding in primary
dentition. Treatment planning of such cases depends
upon their clinical and radiographic situation. In
the present case an extra root was seen on palatal
Corresponding author:
Dr. Vivek Gaurav
Asst Professor, Department of Paedodontics and
Preventive Dentistry, Seema Dental College and
Hospital, Rishikesh, U�arakhand, India, 249203.
Ph. – +91-9897581019, Email-vgdrivivek@gmail.com
distopalatal) in primary maxillary second molar
which makes it very rare. Here the treatment plan
involved surgical extraction of the tooth followed by
space maintainer.
CASE REPORT
An 8 year old male patient reported to the
Department of Pedodontics and Preventive Dentistry
of Seema Dental College, Rishikesh with the complaint
of pain in the upper posterior region of the mouth
on both sides since one month. On examination,
maxillary primary second molar was found to be
deeply carious on both sides whereas primary first
molar was deeply carious on left side. Both molars
on left side were treated with pulpectomy after
radiographic evaluation followed by stainless steel
crowns. (Fig.1) IOPA of involved tooth on right side
revealed radiolucency involving mesial side of tooth
approaching furcation and two third of the root was
resorbed & instead of three roots, an accessory root
was seen on palatal side.(Fig.2). Based on clinical &
radiographic evaluation a treatment plan was chalked
out which involved extraction of the involved tooth
on right side as it was beyond restoration by pulpal
therapy, followed by space maintainer to prevent
mesial drifting of the adjacent permanent molar till
eruption of the permanent teeth. So extraction of the
involved tooth was done under local anaesthesia
followed by transpalatal arch space maintainer one
hour after extraction (Fig.3 & 4).The patient was put
65 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

on a periodic recall after every six months.

DISCUSSION

The exact etiology of accessory roots in teeth

is unknown however dysmorphic extra roots in
teeth is caused due to external aberrations during
odontogenesis process , or penetrance of an atavistic
gene whereas in eumorphic roots, racial genetics
play a crucial role. Christie, et al has proposed a
Fig 2 : Intraoral Periapical radiograph of Maxillary
classification system for four rooted maxillary second primary second molar of right side
molar abnormalities viz.:

Type I: with long tortuous divergent separate

palatal roots.

Type II: with short blunt and parallel roots.

Type III: those with three convergent roots and Fig 3 : Extraced maxillary primary second molar of right
side
distinctly divergent fourth distobuccal root.6

In the present case the right primary maxillary

molar showed Type I root pa�ern as per this
classification system. There was carious involvement
of the tooth which was associated with pain. There
was more than two third root resorption which
was beyond restoration by pulp therapy so it was
extracted followed by a space maintainer.

A similar case was reported by Chabra N et al in

2013 where endodontic management of retained four
Fig.4 : Postoperative intraoral view with transpalatal arch
rooted primary maxillary molar was carried out in 18 space maintainer
year old patient similar to that of permanent teeth due
to absence of permanent successor to prevent arch loss CONCLUSION
and further orthodontic intervention1. Libfeld and
Some teeth have morphologic discrepancy in
Rostein also examined 1200 teeth radiographically,
their roots which is at times gruelling for dentists
and reported that four rooted primary maxillary
especially in children. Heedful diagnosis through
second molars occurred in 0.416% of cases7.In the
periapical radiographs (taken at different angles to
Indian population there was only one case reported
visualize anomalous root) is imperative for buoyant
so far which makes this a very recherché anomaly.
treatment of such teeth.
FIGURES
Ethical clearance was obtained from the our
institution’s ethical commi�ee & informed consent
was obtained from the child’s parent prior to
reporting of the case

Source of Interenst : Nil

Conflict of Interest: None declared.

Acknowledgement : None

Fig 1 : Intraoral photo of the patient

 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 66

REFERENCES 4. Carlsen O, Alexandersen V. Radix paramolaris in

permanent mandibular molars: Identification and
1. Chhabra N. Endodontic management of a four morphology. Scand J Dent Res 1991;99:189-95.
rooted retained primary maxillary second molar.
5. Bolk L. Bemerkungenuber Wurzelvariationenam
J Conserv Dent 2013;16:576-8.
menschlichenunteren Molaren. Zeiting fur
2. Carabelli G. Systematisches Handbuch der Morphologie Anthropologie 1915;17;605-10.
Zahnheikunde. 2nd ed. 114. Vienna: Braumuller
6. Joshi PD. A case report: Unusual anatomy of
and Seidel; 1844.
maxillary second molar. Dent Trib 2010;7-8.
3. De Moor RJ, Deroose CA, Calberson FL. The
7. Libfeld H, Rotstein I. Incidence of four-rooted
radix entomolaris in mandibular first molars: An
maxillary second molars: literature review and
endodontic challenge. Int Endod J 2004;37:789-99.
radiographic survey of 1, 200 teeth. J Endodontics
1989; 15: 129-131.
 DOI Number: 10.5958/2320-5962.2016.00015.2

Prevalence of Oral Lichen Planus and Oral Lichenoid

Reaction in Patients Visiting Dental College in Jaipur,
Rajasthan

Rohit Sharma1, Vikram Sharma2, Vijay Agarwal3, Niharika Sharma4,

Pradeep Kumar5, Amit Kumar Sharma6
Reader, Department of Oral Medicine & Radiology, 2Senior Lecturer, Department of Oral & Maxillofacial Surgery,
1

3
Reader, Department of Orthodontics, 4P G Student, Department of Oral & Maxillofacial Pathology, NIMS Dental
College &Hospital, Jaipur, Rajasthan, 5Reader, Department of Periodontics, Rajasthan Dental College &Hospital,
Jaipur, Rajasthan, 6Reader, Department of Oral Surgery,
Jaipur Dental College & Hospital, Jaipur, Rajasthan

ABSTRACT

Objectives: The study was conducted to assess the prevalence of Oral Lichen Planus and Oral Lichenoid
Reaction, to study the gender prevalence and age distribution among patients visiting Dental College
in Jaipur, Rajasthan aged 15 years and above.

Material & Methods: An observational study was conducted to access the prevalence of Oral Lichen
Planus and Oral Lichenoid Reaction among 6800 out patients at NIMS Dental College, Jaipur,
Rajasthan. Subjects were interviewed using a structured proforma. The clinical diagnosis of Oral
Lichen Planus and Oral Lichenoid Reaction was made when patient showed characteristic features of
Oral Lichen Planus and Oral Lichenoid Reaction. The statistical analysis was done with SPSS software
version 11.5.

Results: The prevalence of Oral Lichen Planus in the study population was 58 (0.85%) and in Oral
Lichenoid Reaction were 142 (2.08%). Majority of subjects were females 32 (0.47%) in patients with Oral
Lichen Planus but male patients predominates in Oral Lichenoid Reaction i.e. 84 (1.23%). Oral Lichen
Planus is seen bilaterally but Oral Lichenoid Reaction is noted unilaterally where the subjects use to
keep tobacco and betel nut substances like Gutka, Khaini etc.

Conclusion: The observations and findings of the study clearly indicate that prevalence of Oral Lichen
Planus and Oral Lichenoid Reaction was 0.85% and 2.08% respectively in the study population.
Prevalence of both Oral Lichen Planus and Oral Lichenoid Reaction was more in middle age group (35-
44 years) however OPL was seen more in females but OLR was more in males.

Keywords: White lesions, Oral reactionary lesions, Etiology, Clinical Presentation

INTRODUCTION This is a disease of unknown aetiology first described

Lichen Planus (LP) is a mucocutaneous disease
reportedly affecting 0.5% to 2.0% of the population.
Corresponding author:
Dr. Rohit Sharma
13, Govardhan Colony, New Sanghaner Road,
Behind Central Bank, Sodala, Jaipur, Rajasthan, India
Contact No. - 0141-2290295, 09799568676,
E-mail: rohitsharmasam@yahoo.co.in
in 1869 by Wilson. The possibility of autoimmunity
has been raised in many studies, especially in cases
where LP is associated with one or more autoimmune
diseases. Many authors have also suggested emotional
stress and enzymatic alterations as etiologic factors.1,2
The reviews of literature shows about 50% of the
patients with skin lesions have oral lesions, whereas
about 25% of all LP patients have only oral lesions1.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Clinically, these can appear in at least six forms:
reticular, papular, plaque-like, atrophic, erosive,
and bullous lesions that can occur separately or
simultaneously.3, 4
The term oral lichenoid reaction (OLR) or oral
lichenoid lesion has been applied to a group of mucosal
disorders mimicking oral lichen planus (OLP), albeit
with a different natural history in interventional
studies. These lesions invariably present a direct
cause and effect relationship with different etiological
factors, such as restorative materials, drugs, graft
versus host disease, and occasionally, with the use
of quid. A quid may be defined as a substance or
mixture of substances, placed in the mouth or chewed
and remaining in contact with the mucosa, usually
containing one or both of the two basic ingredients,
tobacco or areca nut, in raw or any manufactured or
processed form. The term betel-quid lichenoid lesion
has been proposed for an entity found exclusively in
betel tobacco chewers.5, 6, 7
The data on prevalence of OLP and OLR has not
been recorded in many part of Rajasthan. Hence,
objective of this study was to determine the prevalence
of Oral Lichen Planus and Oral Lichenoid Reaction, to
study the gender prevalence and prevalence among
different age groups in patients visiting Dental
College in Jaipur, Rajasthan.
MATERIALS & METHODS
An observational study was conducted in Out
Patient Department, NIMS Dental College and
Hospital, Jaipur, Rajasthan. Total of 6800 patients
were interviewed and examined for Oral Lichen
Planus and Oral Lichenoid Reaction for time period
of 6 months from July 2010 to December 2010.
Subjects willing to participate and aged 15 years
& above were included in the study. Subjects with
any systemic diseases and malignancy were excluded
from the study. An Ethical clearance was obtained
from ethical commi�ee of NIMS Dental College and
Hospital, Jaipur. Oral consent was obtained from
each participant prior to the study. A pilot study was
conducted to check the validity of the questionnaire
and based upon the results; modifications were done
in the design of the questionnaire.
Patients were classified into four age groups: 15-
68
24 years, 25-34 years, 35-44 years and 45-54 years. The
examination was done by principal examiner and
trained recording clerk was present to record the
data in the predesigned proforma. Armamentariums
used were sterile mouth mirror, explorer, tweezers,
kidney tray instrument pouch, savlon, disposable
surgical latex gloves, disposable mouth mask and
questionnaires. The clinical diagnosis of lesions was
made when subject showed characteristic features
of Oral Lichen Planus (OLP) and Oral Lichenoid
Reaction (OLR) mentioned in text books.8
The statistical analysis was done with SPSS
software version 11.5.
RESULTS
Oral Lichen Planus is seen bilaterally but Oral
Lichenoid Reaction is noted unilaterally where the
subjects use to keep tobacco and betel nut substances
like Gutka, Khaini etc.
Table 1 Out of 6800 subjects, 58 (0.85%) subjects
presented with Oral Lichen Planus and 142 (2.08%)
of patients with Oral Lichenoid Reaction. In patients
with Oral Lichen Planus majority of subjects 32
(0.47%) were female compared with males 26 (0.38%).
In patients with Oral Lichenoid Reaction majority of
subjects 84 (1.23%) were male compared with females
58 (0.85%).
Graph 1 Shows 26 (44.82%) patients with the Oral
Lichen Planus were female compared to 32 (55.17%)
males & in patients with Oral Lichenoid Reaction
84 (59.15%) subjects males compared to 58 (40.84%)
females.
Table 2 Out of 6800 subjects, 58 (0.85%) subjects
presented with OLP. Majority of subjects i.e. 27
belonged to 35-44 years of age group, followed by 13
subjects in 45-54 years, 10 subjects in 25-34 years and
08 subjects in 15-24 years.
Out of 6800 subjects, 142 (2.08%) subjects
presented with OLR. Majority of subjects i.e. 71
belonged to 35-44 years of age group, followed by 34
subjects in 25-34 years, 25 subjects in 45-54 years, and
12 subjects belong to 15-24 years.
Table 3 Shows the most of the lesion of Oral
Lichenoid Reaction were seen in patients with Gutka
and Khaini chewers.
69 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

DISCUSSION Graph 1 Shows distribution of study Population &

subjects with Oral Lichen Planus and Oral Lichenoid
Lichen Planus derives its name “lichen” as it Reaction according to male & female
looked like lichens growing on the rock and Planus
is for flat. LP may involve various mucosal surfaces
either independently or concurrently (oral, skin,
and oral and skin lesions). Oral form may precede
or accompany the skin lesions or it may be the only
manifestation of the disease.4 Prevalence of oral LP is
reported between 0.1% and 2.2% 1 and another study
done by Vincent, S.D. et al showed 0.5 % to 2%2. In
Oral Lichen Planus Oral Lichenoid Reaction
the present study, prevalence of oral lichen planus
was calculated to be 0.85% and lesions occurred more Table- 1: Incidence of Oral Lichen Planus and
in female and in 35-44 yrs of age group.1, 4, 9 Oral Lichenoid Reaction in the population of 6800
in both sexes.
The clinical manifestations of oral lichenoid
lesions are indistinguishable from those of oral lichen Lesion with Percentage
planus with mainly erythematous erosive lesions
Oral Lichen Oral Lichenoid
and an important ulcerative component. All these Gender
Planus Reaction
lesions are characterized by the presence of whitish
Male 26 (0.38%) 84 (1.23%)
streaks known as Wickham striae, similar to those
Female 32 (0.47%) 58 (0.85%)
seen in lichen planus. However, a very significant
Total 58 (0.85%) 142 (2.08%)
distinguishing factor with respect to OLP is their
atypical location, and particularly the absence of bi- Table- 2: Age distribution of patients with oral
laterality of the manifestations.11, 12 lesions
So far the data on prevalence of oral lichenoid
15-24 25-34 35-44 45-54
reactions is not very concluding as mentioned by Lesion
yrs yrs yrs yrs
Total
Greenberg MS, Glick M Burket’s.13 In the present
Oral Lichen
study, the prevalence of oral lichenoid reactions 08 10 27 13 58
Planus
2.08%. Oral Lichenoid Reaction was seen more in
males and in middle age group (35-44 years).13 Oral
Lichenoid 12 34 71 25 142
Reaction
A quid may be defined as a substance or mixture
of substances, placed in the mouth or chewed and
Table- 3: Shows etiologic cause of Oral
remaining in contact with the mucosa, usually
Lichenoid Reactions
containing one or both of the two basic ingredients,
tobacco or areca nut, in raw or any manufactured or
Lesion Gutka Khaini Drugs Others Total
processed form. The term betel-quid lichenoid lesion
has been proposed for an entity found exclusively in Oral
betel tobacco chewers.5 Lichenoid 62 54 23 25 142
Reaction

In the current study most of the subjects presenting

with oral lichenoid reaction had an associated habit of
chewing tobacco and betel nut substances like Gutka,
Khaini etc.
CONCLUSION
The observations and findings of the study
clearly indicate that prevalence of Oral Lichen Planus
and Oral Lichenoid Reaction was 0.85% and 2.08%
respectively in the study population. Prevalence of
both Oral Lichen Planus and Oral Lichenoid Reaction
was more in middle age group (35-44 years) however
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 70

OPL was seen more in females but OLR was more in I. The possible premalignant character of oral
males. lichen planus and oral lichenoid lesions: A
prospective study. Oral surg Oral Med Oral
Financial Support: No
Pathol Oral Radiol Endod 2003 Aug;96(2):164-
Conflict of Interest: No 71.
7. Cortes-Ramirez DA, Gainza-Cirauqui ML,
Acknowledgement: I am very thankful to Dr. Y.
Echebarria-Goikouria MA, Aguirre-Urizar
G. Reddy, Principal, Professor & Head, NIMS Dental
JM. Oral lichenoid disease as a premalignant
College for his kind help and support to conduct this
condition: The controversies unknown. Med
study.
Oral Patol Oral Cir Buccal 2009 Mar 1;14(3):E118-
REFERENCES 22.
8. William G. Shafer, Maynard K. Hine, Barnet M.
1. Isaac Van der Waal I. Oral lichen planus and
Levy. A text book of Oral Pathology. 4th edition.
oral lichenoid lesions; a critical appraisal with
W. B. Saunders Company; 1983.
emphasis on the diagnostic aspects. Med Oral
Patol Oral Cir Bucal. 2009 Jul 1;14 (7):E310-4. 9. Bhonsle RB, Pindborg JJ, Gupta PC,
Murti PR, Mehta FS. Incidence rate
2. Vincent, S.D, Fotos PG, Baker KA, Williams TP.
of oral lichen planus among Indian
Oral lichen planus: the clinical, historical, and
villagers. Acta Derm Venereol. 1979;59(3):
therapeutic features of 100 cases. Oral Surg Oral
255-7.
Med Oral Pathol. 1990 Aug;70(2):165-71.
10. Do Prado RF, Marocchio LS, Felipini RC. Oral
3. Schlosser BJ. Lichen planus and lichenoid
lichen planus versus oral lichenoid reaction:
reactions of the oral mucosa. Dermatol Ther.
Difficulties in the diagnosis. Indian J Dent Res.
2010 May-Jun;23(3):251-67
2009 Jul-Sep;20(3):361-4.
4. Omal P, Jacob V, Prathap A, Thomas NG.
11. Serrano-Sánchez P, Bagán JV, Jiménez-Soriano,
Prevalence of oral, skin, and oral and skin lesions
Sarrión G. Drug induced oral lichenoid reactions.
of lichen planus in patients visiting a dental
A literature review. J Clin Exp Dent. 2010;2(2):92-
school in Southern India. Indian J Dermatol. 2012
96.
Mar;57(2):107-9.
12. Sugerman PB, Savage NW. Oral lichen planus:
5. Vishal Dang, Madhav Nagpal. Quid-Induced
Causes, diagnosis and management Aust Dent J.
Lichenoid Reactions: A Prevalence Study
2002 Dec;47:(4):290-7.
Journal of Indian Academy of Oral Medicine and
Radiology, January-March 2011;23(1):39-41 13. Martin S. Greenberg, Michael Glick. Burkit’s
Oral Medicine diagnosis and treatment. 10th
6. Van der Meij EH, Schepman KP, Van der Waal
edition. India: Elsevier; 2003.
 DOI Number: 10.5958/2320-5962.2016.00016.4

Ranula- A Case Report

Jitesh Sahgal1, Abhilasha Sahgal2

1
Reader, Dept of Oral and Maxillofacial Surgery, 2Senior Lecturer, Dept. of Periodontics,
Inderprastha Dental College, Sahibabad, Ghaziabad, UP

ABSTRACT

Ranulas occur due to extravasation of saliva from one of the 20 ducts that arise from the sublingual
gland and empty in to the floor of the mouth or into the anterior portion of wharton’s duct. They form
a characteristically blue tense vesicle in the floor of the mouth. This paper highlights a case report of
ranula in the posterior floor of the mouth that has been successfully treated by enucleation and primary
closure.

Keywords: Mucocele, Cyst, Salivary gland, Mucus, Extravasation, Retention phenomenon, Enuclation,
Marsupialization

INTRODUCTION surgical excision of the ipsilateral sublingual gland,

Ranulas are mucoceles that occur in the floor of
the mouth. Ranula formation is excretory duct rupture
followed by extravasation and accumulation of saliva
into the surrounding tissue.1 The accumulation
of mucous into the surrounding connective tissue
forms a pseudocyst that lacks an epithelial lining.2
Ranulas usually involve the major salivary glands.
Specifically, the ranula originates in the body of the
sublingual gland, in the ducts of the sublingual gland,
in the Wharton’s duct of the submandibular gland or
infrequently from the minor salivary glands at this
location. The gender predilection of oral ranulas
slightly favors females, with a male-to-female ratio
of 1:1.4, while cervical ranulas have a predilection for
males.3 Ranulas usually occur in children and young
adults, with the peak frequency in the second decade.
The cervical variant tends to occur a li�le later in the
third decade.3 These lesions have not known to have
malignant potential, but one report of a squamous
cell carcinoma exists.4
The analysis of the saliva reveals a high protein
and amylase concentration consistent with secretions
from the mucinous acini in the sublingual gland. The
high protein content may produce a very intense
inflammatory reaction and mediate pseudocyst
formation.5 Many methods of treatment for ranulas
have been described in literature, including excision
of ranula only, excision of ranula and the ipsilateral
sublingual gland, marsupialisation and cryosurgery.6
The definitive treatment is now considered to be
which is supported by recent studies.7
CASE REPORT
A 12 year old young female patient reported
to our practice with a chief complaint of painless
swelling below the tongue on the right side of the
oral cavity for the past 2 months. The swelling had
gradually increased in its size to a�ain the present
status (Fig.1) On examination, a 3cm x 5cm bluish,
fluctuant swelling was found in the posterior floor of
the mouth on the right side (Fig. 2). The swelling was
painless on palpation. Based on the clinical picture
the case was provisionally diagnosed to be ranula.
Aspiration biopsy yielded thick, viscous fluid and
histopathological examination (HPE) revealed it to
be mucous. After routine preoperative investigations,
eneucleation of ranula (Fig.3) is carried out under
general anesthesia taking care of the lingual nerve
(Fig.5) and other important structures such as the
submandibular duct, keeping its patency intact (Fig.
4&5) The cavity resulting from enucleation was
irrigated with Povidone Iodine solution and then was
closed primarily using resorbable sutures (Fig.6) A
small portion of the tissue that was removed during
the procedure was submi�ed to HPE for confirmation.
HPE report confimed the specimen to be ranula. The
microscopic appearance of ranula is similar to that
of a mucocele in other locations. The spilled mucin
elicits a granulation tissue response that typically
contains foamy histiocytes. The case was followed for
6 months at bimonthly intervals with no postoperative
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 72

complications and recurrence (Fig.7) preparation13 or botulinum toxin.14 Alternatively,

DISCUSSION
The term “ranula” is derived from the Latin word
“rana” (meaningfrog) and is a descriptive of the bluish
colour. It causes gradual enlargement of the floor of
the mouth to form a painless, fluctuant, translucent,
dome-shaped swelling, which is said to resemble the
underbelly of a frog.8 Ranula can be classified into
two groups, simple (Intra oral) and the plunging
(Cervical) type. Simple ranula is much more common
than plunging type. A simple ranula represents a
localised collection of mucous within the floor of the
mouth. In plunging ranula, the mucous collection is in
the sub mandibular and sub mental space of the neck
with or without an associated intraoral collection.3 If a
patient presents with a painless cervical swelling that
gradually increases in size, a possibility of a plunging
ranula should be considered particularly if there is a
history of oral trauma, including dental or other oral
surgical procedures. There are two different concepts
in the pathogenesis of ranula. One is a true cyst
formation due to ductal obstruction with an epithelial
lining, and the other is a pseudocyst formation due to
ductal injury and extravasation of mucus without an
epithelial lining.9
the ranula can be treated with the placement of a silk
suture or seton into the dome of the cyst.15 Optimal
management of pediatric oral cavity ranulas may
include observation for five months for spontaneous
resolution.16 Definitive treatment yielding the lowest
recurrence and complication rates for all ranulas is
transoral excision of the ipsilateral sublingual gland
with ranula evacuation.15 If symptoms are minimal
in young age group, aspiration of the lesions and
periodic follow-up for 6 months have been suggested
as an alternative to surgery.5 Laser ablation and
cryosurgery, either alone or after marsupialization,
have been used for some patients with oral ranula .15
The recurrence rates of an oral ranula with various
surgical treatment methods are as follows: Incision
and drainage (71–100%); Ranula excision only (0–25%);
Marsupialization only (61–89%); Marsupialization
with packing (0–12%) (Limited studies), Complete
excision of the ranula and sublingual gland (0–2%).7

Ranula may also uncommonly present as a

rapidly enlarging swelling following infection.8
Oral and plunging ranulas, if large, may affect Figure 1 Preoperative View of the lesion
swallowing, speech, or mastication and may result
in airway obstruction. The very rare thoracic ranula
may compromise respiratory function and may be
life threatening.10 The diagnosis of ranula is based
principally on the clinical examination and sometimes
on computerised tomographic or magnetic resonance
imaging findings for the plunging lesion.3 If there is a
doubt about the diagnosis, aspiration of the mucous
from the lesion and a laboratory determination
of amylase content should make the diagnosis of Figure 2 Preoperative view of the lesion
ranula obvious.3 Aside from ranula, a number of
other lesions may be encountered in the floor of the
mouth or submandibular space region. These include
congenital abnormalities (cystic hygromas, branchial
cysts, and thyroglossal duct cysts), benign lesions
(epidermoid cysts, dermoid tumors, and lipomas),
malignant neoplasia, and other lesions (abscess,
mucocele, and acidosis).8 Treatment of an intraoral
ranula consists of surgical excision,11 marsupialization
with and without packing12 or currently intracystic Figure 3 Dissection of the Sublingual Gland
injection therapy with OK-432, streptococcal
73 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Figure 4 Identification of the Sublingual Gland
Figure 5 Preservation of Lingual Nerve
Figure 6 Closure of the incision after excision of the
gland
Figure 7 Two weeks Postoperative
CONCLUSION
Effective and optimal management of salivary
gland disorders requires accurate diagnosis of the
specific disease followed by a regular post operative
follow up. In case of pediatric oral cavity ranulas, an
observation for 5 months for spontaneous resolution
may be included. If the lesion does not resolve or recurs
repeatedly, surgical treatment is recommended. The
pseudocyst and affected sublingual gland should be
removed in totality. Identification and preservation
of the lingual nerve is necessary since injury to this
nerve and sublingual duct are potential complications
associated with surgical procedures.
Acknowledgement – Nil
Ethical Clearance- Not needed as this is a case
report of our personal patient
Source of Funding- Self
Conflict of Interest - Nil
REFERENCES
1. Morton RP, Bartley JR. Simple sublingual
ranulas: pathogenesis and management. J
Otolaryngol. 1995;24(4):253-4.
2. Bronstein SL, Clark MS. Sublingual gland
salivary fistula and sialocele. Oral Surg Oral
Med Oral Pathol. 1984;57(4):357-61.
3. Zhao YF, Jia Y, Chen XM, Zhang WF. Clinical
review of 580 ranulas. Oral Surgery, Oral
Medicine, Oral Pathology, Oral Radiology and
Endodontics 2004 Sep;98(3):281-7
4. Ali MK, Chiancone G, Knox GW. Squamous
cell carcinoma arising in a plunging ranula.
Journal of Oral and Maxillofacial Surgery 1990
Mar;48(3): 305–8
5. Zhi K, Wen Y, Ren W, Zhang Y. Management
of infant ranula. Int J Pediatr Otorhinolaryngol.
2008;72(6):823-6
6. Yoshimura Y, Obara S, Kondoh T, Naitoh S. A
comparison of three methods used for treatment
of ranula. J Oral Maxillofac Surg. 1995; 53(3):280-
2
7. Zhao YF, Jia J, Jia Y. Complications associated
with surgical management of ranulas. J Oral
Maxillofac Surg. 2005; 63(1):51-4.
8. Urso-Baiarda F, Saravanappa N, Courteney-
Harris R. Radiology quiz case 1. Intra-oral
ranula. Archives of Otolaryngology – Head and
Neck Surgery 2003;129:490-2
9. Suman Jaishankar, Manimaran, Kannan &
Christeffi Mabel Ranula: A Case Report JIADS
2010 July- Sept;1 (3) :52-3
10. Pang CE, Lee TS, Pang KP, Pang YT. Thoracic
ranula: an extremely rare case. Journal of
Laryngology and Otology 2005 Mar;119(3):
233–4.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
11. Haberal I, Gocmen H, Samim E. Surgical
management of pediatric ranula. International
Journal of Pediatric Otorhinolaryngology
2004;68:161–3.
12. Baurmash HD. Marsupialization for treatment
of oral ranula a second look at the procedure.
Journal of Oral and Maxillofacial Surgery
1992;50:1274–9.
13. Watanabe K, Tomiyama S, Jinnouchi K,
Nakajima H, Yagi T. Local injection of OK-432 in
the treatment of ranula: a case report. Ear, Nose,
and Throat Journal 2002;81:97-8
74
14. Chow TL, Chan SW, Lam SH. Ranula successfully
treated by botulinum toxin type A: report of
3 cases. Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontics
2008 Jan;105(1):41–2.
15. Mihir RP, Allison MD, William WS. Oral and
plunging ranulas: what is the most effective
treatment? Laryngoscope 2009;119(8):1501–9.
16. Pandit RT, Park AH. Management of pediatric
ranula. Otolaryngology - Head and Neck
Surgery 2002;127:115–8.
 DOI Number: 10.5958/2320-5962.2016.00017.6

The Art and Science of Ceramic Veneers

Prashanth Kumar Ka�a1, Sreedhara S2, Sandeep Rajalbandi3

1
Assistant Professor, College of Dentsitry, King Khalid University, Abha, Kingdom of Saudi Arabia,
2
Professor, Department of Orthodontics, S J M Dental College, Chitradurga,
3
Reader, Sharavathi Dental College, Shivamogga

ABSTRACT

Deep intrinsic tooth discoloration can be managed in conservative way by placing veneers. It can be
either no prep or minimal preparation veneers. As long as the patient is cooperative and follows the
instructions veneers is a viable option.

Keywords: Types, preparation, cementation, replacement, repair.

INTRODUCTION placed outside for esthetics and protection. Despite

Discolouration of tooth is a commonly
encountered problem in day to day practice. The
cause of discolouration can be multiple. There are
multiple options to treat these problems which
include vital and non-vital bleaching, veneers and all
porcelain crowns. Veneers are more conservative than
crowns but more invasive than bleaching. The astute
clinician must judge the best possible treatment for a
particular case. The following is a review about the
types, advantages and indications of veneers1.
What is a veneer?
A veneer is a thin covering over another surface. In
dentistry a veneer is a thin layer of dental restorative
material, usually porcelain that replaces enamel.
having similarities, there is marked aberration
between the two words.
Taking the differences into consideration, one
may refer to the porcelain laminate as a thin layer
of translucent porcelain fashioned to improve the
form and color of natural teeth. In contradiction, the
porcelain veneer is a layer of porcelain fashioned not
just to improve the form, but also to modify the color
of natural teeth.
TYPES OF VENEERS4, 1
Veneers can be placed either directly or indirectly.
Directly placed veneers routinely are of composites,
and other materials can also be used for indirectly
placed veneers.

The word porcelain veneer is used synonymously These include:

with porcelain laminate and ceramic or porcelain
1. Conventional powder-slurry ceramic
facing. Differentiating between the terms laminate and
(feldspathic porcelain). This type of porcelain is
veneer should be clear cut when esthetic requirements
layered on the refractory die in the lab.
are explained to patients or ceramists2,3.
2. Heat-pressed ceramic. These products are
The word laminate means a thin clear layer or
melted at high temperature ranges and pressed into
sheet, while the veneer is a lining of different color
a mold prepared by lost-wax technique (e.g., IPS
Empress 1 and 2, OPC).
Corresponding author
3. Machineable (CAD/CAM) ceramics (e.g.,
Dr. Prashanth Kumar Ka�a MDS
CEREC, E4D).
Assistant Professor, College of Dentsitry, King
Khalid University, Abha, Kingdom of Saudi Arabia,
Mob: +966538073497
E-mail:drprashanthkumar@yahoo.com
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 76

Table 1: Indications and contraindications of veneers5

Indications Contraindications

• Stained or darkened teeth

• Insufficient tooth substrate (enamel for bonding)
• Hypocalcification
• Labial version
• Multiple diastemas
• Excessive interdental spacing
• Peg laterals
• Poor oral hygiene or caries
• Chipped teeth
• Parafunctional habits (clenching, bruxism)
• Lingual positioned teeth
• Moderate to severe malposition or crowding
• Malposed teeth not requiring orthodontics

Table 2: Advantages and disadvantages of veneers5, 6

Advantages Disadvantages
1. Natural looking results: Porcelain veneers give a natural display to 1. Can’t be used in patients with bruxism
tooth. They simulate the light reflecting properties of natural teeth and clenching habits.
and a�ributes of tooth enamel very well. They can be fabricated 2. Costly
very thin and translucent. 3. If not taken care can chip or fracture
Very enduring material and long lasting solution in appropriate and entire veneer should be replaced.
cases that are prepared well by the dentist and well looked after by
patient; porcelain veneers can be expected to serve more than 10 4. Strictly intra-enamel preparation.
years. 5. Indicating only in case of mouth with
Match existing teeth. The colour of the porcelain veneer matches less dental fillings and good hygiene.
natural teeth very closely when properly done. 6. Some times post operative sensitivity
marked and swift results is a problem which lasts for short
2. Multiple veneers can give significant and rapid improvements in duration.
smile. 7. Veneers are not as strong as crowns.
3. Correct numerous flaws: Porcelain veneers can enhance shape,
colour and position (if minor) all at the same time. An array of
esthetic defects like spaces, discolouration, staining, chipped
or fractured teeth, can be corrected in conjunction with other
treatment modalities.
Minimal preparation: This type of veneer requires the removal of
less tooth structure compare to a full crown and less destructive to
pulp.
4. Resistant to extrinsic stains: Ceramics don’t get discolored due
to beverages like tea and coffee and even the soft tissues like gums
respond well.
Fractured teeth can be conservatively treated with veneers and
strengthen them.
No extra care is needed other than proper oral hygiene.
Tailor made: The shape, colour and size of the veneers can be
custom made according to patients needs.

Clinical Technique7, 3: As the enamel has different thickness at the

Tooth preparation confined to enamel is very
important for the success:
• Adequate space for porcelain build up and to
avoid over contouring.
• Avoid sharp line angles and areas of stress
concentration.
gingival (0.3–0.5 mm), middle (0.6–1 mm) and incisal
(1.0–2.1 mm) 1/3rds labially, a special diamond
instrument to facilitate the labial preparation is
needed.
A mini-chamfer 0.3 mm is used to prepare finish
line for all the gingival margins, essentially done with
the round end fissure diamond bur.

• A definite finish line is must.

77 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
PROXIMAL
1. Don’t break the contact as it is difficult to
build the contact.
2. In case of diastema correction, the preparation
should end slightly lingually to get be�er esthetics.
Incisal:
1. Window
2. Feather
3. Bevel
4. Incisal overlap
Fig 1: burs used for dental veneer preparation
PREPARATION DESIGN8
Conservative reduction: if the colour and value
of underlying tooth structure is normal and there is
li�le change in esthetics requirement, a conservative
tooth preparation can be done.
Conventional reduction: this is done if there
is moderate change needed in the final colour and
value.
Significant reduction: In case of high colour
and value changes, or multiple crowns and veneers
are needed, more reduction is done to permit the
restorative material to be similar in all prostheses.
To ensure be�er colour and translucency of veneer
in the outcome, minimum 0.5mm enamel reduction
is done.
Few basic principles must be considered8, 9:
1) Bonding to enamel substrate must be ensured
wherever feasible
2) In case of tooth wear/ heavy occlusal loading
patients
3) Don’t over-promise the ability of a veneer to
mask deep discolourations
4) Veneers should be avoided to provide ‘instant
orthodontics’
5) Old restorations must be replaced before
veneer placement
6) Keen a�ention must be given to clinical
technique
LUMINEERS10, 7
Advancement in bonding systems and in
porcelain technology that permit exceptionally thin
veneers because of improved strength, no preparation
veneers came into the market. The thickness of veneers
span between 0.3 mm - 0.5 mm. as the thickness is
very minimal there is no need to cut tooth structure
and can be merely bonded to the tooth surface.
ADVANTAGES
Anesthetizing and temporization is not needed.
Finishing and contouring of the gingival region
is easily achieved when the bonding system is
integrated to the porcelain.
Be�er patient acceptance as the tooth is not cut.
No damage is inflicted on pulp.
A extra a�ribute of the no prep technique is
the ability to bond porcelain veneers over existing
prosthesis that are esthetically unacceptable.
Shade selection11, 4
1. Shade selection done before starting.
2. A digital photograph of shade tab needed
placed next to teeth is taken.
3. Bleaching procedure should be accomplished
before preparation of veneers
4. One shade higher chroma may be selected
for the canines and the cervical areas of incisors for
a more natural appearance in spite of the fact that,
when going light many patients like the teeth uniform
light.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 78

5. Opacity level selected after tooth REFERENCES

preparation.
The underlying tooth structure may be
discoloured due to previous endodontics, old
restorations, age, trauma and tetracycline cases. The
colour of the existing teeth should be communicated
to the ceramist (stump shade), so that the ceramist can
determine the final opacity and translucency of the
restoration required. The influence of the substrate
determines the final shade.
FEW FACTS ABOUT PORCELAIN VENEERS
• Veneers need around 0.5 mm of tooth reduction,
and it’s an irreversible treatment procedure.
• A local anesthetic is recommended in extremely
sensitive patients12.
1. Do’s and Don’ts of Porcelain Laminate
Veneers, Chad J. Anderson, MS, DMD et al,
dentalcare.com Continuing Education Course,
Revised July 23, 2013
2. Crowns and other extra-coronal restorations:
Porcelain laminate veneers A. W. G. Walls, J.
G. Steele, R. W. Wassell, British Dental Journal,
Volume 193 no. 2 July 27 2002
3. Porcelain veneers – preparation design: A
retrospective review Kosovka B. Obradović-
Đuričić, Hem. Ind. 68 (2) 179–192, 2014
4. Selection of Luting Resins for Bonding Porcelain
Veneers and Laminates, Nasser Barghi, DDS,
Ma, Dental Research & Applications: Series 1,
Number 1

• The cementation of laminate veneers can be 5.
accomplished with or without local anesthetic. This
visit is longer. Light cure resin cements are used to
cement veneers.
6.
CONCLUSION
Everyone wants there smile to be good and 7.
the teeth to be white and shiny. Veneers are very
useful and viable treatment option for intrinsically
discoloured teeth. Advancements in ceramics have 8.
made it possible to do minimal or no preparation
veneers. As this treatment is irreversible and costly,
this should be the last option when other treatment
9.
modalities like bleaching and micro/macro abrasion
have not been useful. Also, the limitations of the
treatment also should be considered.
10. Porcelain veneers: a review of the literature, M.
Conflict of Interest: None
Source of Funding: Self
11. Porcelain veneers: Treatment guidelines for
Acknowledgements: None
Ethical Clearance: Not applicable
12. The
Hidden effects of stump shades-Using the
right tools you and your clients can correctly
identify stump shade color and achieve optimal
restorative esthetics,
By Luke S. Kahng, dental lab products, February
2010
Cementing porcelain laminate veneers, Dr.
Wes Urich, h�p://www.dentaleconomics.com,
volume-95, issue-3.
Ceramic veneers in general dental practice, Part
five: After care and dealing with failure, Siobhan
Owen, Volume 2 Number 4, July 2008
Porcelain veneers: techniques and precautions,
basil Mizrahi, international dentistry SA vol. 9,
no. 6
Peumans, , B. Van Meerbeek, P. Lambrechts,
Journal of Dentistry 28,163–177, 2000
optimal aesthetics, Christopher CK Ho, BDS
(Hons), Australasian Dental Practice, March/
April 2011
Zirconia-Based Porcelain Veneer,
Elliot Mechanic, BSc, DDS, h�p://
www.dentistrytoday.com, 16 July 2012
 DOI Number: 10.5958/2320-5962.2016.00018.8

Periodontal Infections in Pregnancy: A Risk Factor for the

Newborn- An Epidemiological and Microbiological Study

Jayaprasad Kodoth1, Shailesh Kudva2, Dhanya Radhan3

1
Principal and Professor & Head, Department of Periodontics, Century Dental College, Poinachi, Kasaragod, Kerala
State, 2Professor and Head, Department of Oral & Maxillofacial Pathology, Srinivas Dental College, Mangalore,
Karnataka, 3Post Graduate, Dept of Endodontics, College of Dental Sciences, Mangalore, Karnataka

ABSTRACT

Preterm infants with below average bodyweight represent a major social and economic public health
problem in developed countries and possess a threat of greater magnitude in developing countries.
Preterm birth cases are defined as newly borns weighing less than 2500 gms and/or gestational period
less than 37 weeks. The periodontal infection in pregnancy is considered as a significant risk factor
for preterm and/or premature babies. In the present study, a clinical oral examination was done on
pregnant and postpartum mothers. A full mouth periodontal examination was performed on all
the patients selected. Subjects of the study were divided broadly into two groups depending upon
the gestation period during delivery and body-weight of their new born. The control group had
mothers with normal body-weight babies and the case study group had mothers with preterm below
average body-weight babies. The final results were statistically analysed and significance evaluated.
Majority of mothers with preterm below avereage body weight babies were found to have established
periodontitis.

Keywords: Periodontal infection , pregnancy, preterm, low birth weight

INTRODUCTION Irrespective of adequate care taken to avoid these

Preterm below average body-weight ( BAW
)infants born represent a major social and economic
public health problem in developed countries and
possess a threat of greater magnitude in developing
countries like India. Preterm below average body-
weight babies are defined as mothers with a
newly born weighing less than 2500 gms and/or
20, 27
gestational period less than 37 weeks. Some of
the previously recognized risk factors associated
with preterm low birth weight are low maternal
age, low socio-economic status, inadequate prenatal
care, drug abuse, alcohol and tobacco consumption,
hypertension, genito-urinary tract infections, diabetes
8
and multiple pregnancies.
Corresponding author:
Shailesh Kudva
Professor and Head, Department of Oral &
Maxillofacial Pathology, Srinivas Dental College,
Mangalore, Karnataka 575003
Mobile no : 9448470228
known obstetric risk factors, there still has been only a
relatively small decrease in the proportion of preterm
BAW infants. The main reasons cited for this being
poor awareness of the risk factors. Several studies
in the past have demonstrated a definite association
between infections and BAW. The genitor-urinary
tract infection in pregnancy has been established to
8,27
be one of them.
The periodontal infection in pregnancy is
considered as a significant risk factor for preterm
and/or BAW. Only few studies have correlated
this relation, such as those being conducted at the
20,27
University of North California and by Slavkin CH.
The scientists have consistently found that mothers
with more healthy sextants had a statistically lower
8,20,27
risk of giving birth to low birth weight babies.
These studies provide a potentially significant
association between BAW and poor periodontal
health of the mother as an independent risk factor.
This study tries to evaluate whether the prevalence
of periodontal infection could be associated with
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
preterm BAW controlling all the known obstetric risk
factors.
MATERIALS & METHODS
In the present study, a clinical oral examination
was done on postpartum mothers admi�ed in
civil hospital, Thavarageri maternity nursing home,
Shaikh Homeopathic medical college and pregnant
women who visited S.D.M. Dental college, Dharwad
for dental treatment. A sample size of 200 patients in
age group of 18-36 years were taken for the study.
Information on current and historical pregnancy
outcomes were obtained from the respective
Gynecologist of the patient and detailed history
taken verbally from the patient about the previous
pregnancy outcomes and outcome of current
pregnancy. Hospital record of the patients were
verified for the dates of admission, any obstetric risk
factors and birth weight of the new born. Consent
from the Dept. of Medicine and Gynecology were
taken on the nutritional status and built of the
individuals.
CRITERIA FOR CASE SELECTION
1. Postpartum mothers were selected for the
study.
2. No history of any antibiotic therapy or any
medication during pregnancy was selected.
3. Patients with systemic diseases were not
taken into considerations.
4. Only moderately to well built patients were
taken for the study.
5. All obstetric risk factors were excluded while
selecting the patients.
6. Only patients who conceived naturally and
delivered normally were taken into consideration.
A complete clinical oral examination including
periodontal examination was performed on all the
patients selected. The oral examination was done
with the help of artificial light source, mouth mirror
and Williams graduated periodontal probe. Russell’s
periodontal index was used for this purpose.
Pregnancy outcomes were categorized into two
groups each group numbering 100, the control group
80
comprising mothers with normal body weight babies
(NBW) and full term labor and case group comprising
mothers with BAW or preterm labor.
Microbiological samples of the subgingival
plaques were collected from both control and case
groups to find out the predominant microbial
flora using standardized techniques. Specimen
was inoculated onto a freshly prepared fastidious
anaerobic blood agar (Dyna micro) which was
supplemented with vitamin K and Hemin. Incubated
anaerobically (Dyna micro anaerobic jar)
o
at 37 C
for 48 hours, 72 hours upto 7 days. Whenever found
necessary, the plates were recharged anaerobically
after 48-72 hours and incubated further and the
colonies counted thereafter.
RESULTS
The control and case group and their average
birth weight are shown in table No.1. When the
periodontal status of the case group patients having
BAW were studied, 68 out of 100 of them had poor
periodontal status . Comparison of average birth
weight and periodontal status by using Russell’s
periodontal index in both groups are shown in table
no.2. The results were statistically analysed using X2
test.
It was found that most of the isolates from the case
group plaque sample cultures were predominantly
gram negative black pigmented bactericides and
Fusobacterium species whereas in the control group
the anaerobic microbiota was less and facultative
anaerobes like staphylococcus pyogens, hemolytic
streptococcus, streptococcus viridians were more.
When comparison of microbiological population
in cases group and control group was made and
subjected to stastical analysis by student ‘t’ test,
the difference between mean in microbiological
population (Anaerobic Aerobic and facultative
anaerobic) in case group and control group were
statistically found to be highly significant at 1% level
of (p<0.01). The mean values were 15-45% of anaerobic
and 55-85% aerobic and facultative anaerobic micro-
organisms in the control group whereas the mean
values were 55-75% and 25-50% respectively in the
case group. This was statistically significant (p<0.01).
81 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

Table No 1: Average Birth weight among and control group being mothers with normal body-
groups weight babies (>2500gm).

Groups No. of patients Average birth
weight of new born
(kg)
Control 100 2.951
Case 100 1.973
Table No. 2: Comparison of Average birth
weight and periodontal status in groups
Groups Average birth Russel’s Index - 0 to 6
weight of new 6 to 8
born (kg)
Control 2.951 76% 24%
Case 1.973 32% 68%
DISCUSSION
The vast literature available indicates that
periodontal disease are universally prevalent and
has a potentially remarkable association in pregnant
1-25
women. These changes such as hyperemia, edema
and marked tendency towards bleeding are consistent
with the clinical description of gingivitis and have
been termed pregnancy gingivitis. The prevalence
of this phenomenon is reported to range from 10 to
35 percent in most studies conducted in the past. Its
severity was found to increase gradually until the
36th week of gestation.
It is in interesting paradox that a mother can
expose an infant to infectious microbes through
intimate contact, yet she can also transfer a number
of diverse antibodies through her breast milk that
confer immunity against some of the very microbes
20,27
that infected her during pregnancy. Furthermore,
the mother’s oral health can be a major determinant
risk factor in the health of developing foetus or new
born infant. Till date there are not many studies
comparing the prevalence of periodontal infection
in pregnant woman and the birth weight of the
newborn of the respective woman. Hence an a�empt
was made to evaluate the periodontal health status of
Indian women admi�ed in Gynecology ward in some
of the hospitals and weight analysis of their new born,
excluding all the known obstetric risk factors.
The first aspect of the study involved the selection
of subjects for the study. The intent was to conduct
a case-control study with case group being mothers
who experienced preterm labor and BAW babies
The second aspect of the study involved the
measurement of periodontal status. In all the case-
control group mothers, the periodontal conditions
were determined using clinical oral examination
within 3 days of birth of their new born. The
periodontal examination conducted within 3 days
of their child’s birth is a measurement of prior
disease activity during the pregnancy. Although the
periodontal disease measured in the study occurred
prior to birth of child, we cannot however, determine
whether the disease actually was in an active cycle
during pregnancy. This type of error would tend to
bias the results. Thus to rectify this, the data from this
case-control design the subjects were drawn from the
same race and population.
There are few biochemical, immunologic and
histologic evidence in the literature which support
the hypothesis that periodontal disease is one among
the few factors contributing to BAW babies.19,20,27
Periodontal diseases usually comprises chronic
20
gram-negative anaerobic infections. Periodontal
disease once established, provides a biological burden
of endotoxin and inflammatory cytokines. Endtoxins
are lipopolysaccharides which could target the
26
placental membranes via the blood streams. Studies
by Dongan-Bag�oglon found that these lipo-
polysacchrides induce gingival fibroblasts to produce
PGE2, 1L-1B,1L-6,1L-8 and TNF levels and have
recently found to be associated with the extent of
disease progression in periodontitis affected patients
who are undergoing active periodontal ligament
20
a�achment loss. These findings suggest that the
infected periodontium can represent an endocrine like
source of potentially deleterious cytokines and lipid
mediators. These lipopolysaccharides and cytokine-
dependant mechanisms have been suggested as an
explanation for the observed association between
oral infections and other systemic inflammatory
conditions. It is also possible that there are unknown
genetic or environmental factors playing a role in
both periodontal disease and preterm BAW. In
1931, Galloway suggested that periodontal disease
induced by gram negative anaerobic infection may
provide sufficient infectious microbial challenge to
have potentially harmful effects on the pregnant
20
mother and developing foetus. Thus the association
between highly prevalent chronic oral infections and
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
preterm BAW is not unprecedented.
The study conducted by G.B. Hill of Duke
University gave an additional role for hematogenously
spread oral microbes in premature delivery and BAW.
Fusobacterium nucleatum is the most frequent isolate
cultured from amniotic fluid among women with
preterm labour in the presence of intact membranes
and yet this organism is not prevalant in the vaginal
microflora. Fusobacterium nucleatum is commonly
found in the mouth and possibly could spread to
amniotic fluid via a transient bacteremia, particularly
in the presence of oral disease.
SUMMARY AND CONCLUSIONS
Established periodontitis were found to be less in
percentage in mothers of normal birth weight babies.
Majority of mothers with preterm BAW babies were
found to have established periodontitis. As evident
from this study, it can be stated that a significant
difference exists between poor periodontal status
of subjects and the incidence of BAW babies. Hence
the periodontal infections in pregnant women can
be viewed as a potential obsteric risk factor.The fact
that the periodontal infections are both preventable
and readily treated, provide new opportunities for
intervention strategies to reduced the incidence of
preterm BAW.
Conflict of Interest – Nil
Source of Funding – Self
Ethical Clearance: taken from the Ethical
commi�ee
Acknowledgment - Nil
REFERENCES
1. Aragat H.A. 1974 “periodontal status during
pregnancy”: J. Periodontal 45:641-643
2. Bag�oglu.D. 1996, “production of inflammatory
mediators and cytokines by human gingival
fibroblasts following bacterial Challenge; J.
Periodontol Res, 31:90-98
3. Beck J., Raul G. 1996 “Periodontal disease and
cardiovascular disease. J. Periodontal, 67: 1123-
1137
4. Carranza F.A. Glickman’s Clinical
Periodontology, 8th edition, India: W.B.
Saunder’s company, 1996, 194 pp.
82
5. Collins J.G., 1994,’Effects of Escherichia coli and
Porphyromonas gingivalis lipopolysaccharide
on pregnancy coutcome in the golden hamster”.
Infect immum, 62:4652-4655.
6. Durlacher R. 1994, “Experimental gingivitis
during pregnancy and postpartum: clinical,
endocrinological and microbiological aspects”.
J.clin periodontol, 21:549:558
7. Fiese R. 1988, “Issues in dental and surgical
management of the pregnant patient”. Oral surg
Oral med, Oral pathol, 65: 292. 297
8. Gibbs R.S. 1992, “A review of premature birth
and subclinical infection”. Am J. Obstect
Gynecol, 166: 1515-1528
9. Gortmaker L.S. 1979, “The effects of prenatal
care upon the health of the newborn” ; Am J.
Pulic Health, 69:653:660
10. Gran D.A, Periodontics in the tradition of
Go�lieb and Orban, 6th edition, India: CV
Mosby Co., 1988, 334-35pp
11. Heasman A.P. 1993, “Modulation of host PGE2
secretion as a determinant of periodontal disease
expression J. Periodontal, 64: 432-444
12. Jenkins W., Guide to Periodontics, 2nd ed,
London: Heineman Dental books, 1988, 22pp
13. Jensen J. Lilje Mark 1981, “The effect of female sex
hormones on subgingival plaque”; J. Periodontol
52: 599-602.
14. Koran S. 1980, “:The subgingival microbial flfora
during pregnancy. J. Periodontol Res, 15:111-122
15. Lindhe.J., Text book of clinical Periodontology
2nd edition, Denmark: Munksgaard copenhagen
co., 1995, 280-228pp.
16. Li Y. Caufield P.W. 1995,”The fidelity of intial
qcquisition of mutans streptococci by infants
from their mothers”. J. Dent. Res. 74: 681-685.
17. Moller M., 1984, “Rupture fetal membranes
and premature delivery associated with group
B streptococci in urine of pregnant women”,
Lancet 11:69-70
18. Neil O. TCA. 1976, “Maternal T-Lymphocyte
response and gingivitis in pregnancy”; J.
Periodontal, 47:178:184
19. Newman, GM,E Sigmund 1976, “Studies of
microbiology of periodontistis”, J. Periodontol
47:373:379.
20. Offenbacher S.V. Ka�, 1996, “Periodontal
83 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
infections as a possible risk factor for preterm
low birth weight. J. Periodontol, 67: 1103 - 1113.
21. Ratnam SS, Obstetrics and Gynecology for post
graduates, vol 1, India: Orient Longman Ltd.,
1992, 88-93 pp.
22. Ringsodor WM, A.B., Powell, 1962, “Periodontal
status in pregnancy; Am J. ObstectGynecol 83:
258
23. Rmero R., John .C., 1988, “Endotoxin Stimulates
Prostglandin E2 production by Human Amnion”.
J. Obstect Gynecol: 71:227-228.
24. Ronald L., M. Peter 1982, “Identifying the sources
of the recent decline in perinatal mortality rates
in California”. N Engl. J. Med.d, 306: 207-21
25. Samant A., Amlik, 1976, “Gingivitis and
periodontal disease in Pregnancy”; .Periodontol,
47:415-418.
26. Schlugers S., Ralph Yuodelis, Periodontal
diseases, basic phenomena, clinical management
and occlusal and restorative interrrelationsips
2nd edition, London: Lea and Febiger Co.,1990,
144 pp.
27. Slavkin c.H. 1997, “First encounters. Transmission
of infectious oral disease from mother to child”.
JADA 128:773-778.
 DOI Number: 10.5958/2320-5962.2016.00019.X

Bell’s Palsy: A Systematic Review of Two Cases

Puneet Bhargava1, OD Toshniwal2, Rohit Sharma3, Mayank Das4, Shreyam Mohapatra5, Akshay Verma6
1
Associate Professor, 2Professor & HOD, Dept of Oral Medicine & Radiology NIMS Dental College, Jaipur, Rajasthan,
3
Associate Professor, Dept of Oral Medicine & Radiology NIMS Dental College, Udaipur, Rajasthan, 4Assistant
Professor, Dept of Oral Medicine & Radiology, NIMS Dental College, Jaipur, Rajasthan,
5
PG Student, Dept of Oral Medicine & Radiology, 6Senior Lecturer, Dept of Oral Pathology and Microbiology,
Rajasthan Dental College, Jaipur, Rajasthan

ABSTRACT

Bell’s palsy is the most common facial nerve disease and has a sudden onset. It is an acute unilateral
paralysis of the seventh cranial nerve of unknown etiology. Patients with Bell’s palsy present with facial
weakness, inability to keep an eye closed, inability to keep food in the buccal vestibule, impairment
of taste and lacrimation. Untreated Bell’s palsy leaves some patients with major facial dysfunction
and a reduced quality of life. In most of the cases there is partial to complete recovery which occurs
spontaneously in 4 to 6 months. We present here a systematic review of two cases with manifestation
of Bell’s palsy which includes clinical features, differential diagnosis, treatment and referrals to
neurosurgeon if required.

Keywords: Facial nerve, Bell’s palsy, Lower motor neuron lesion, Orbicularis oculi, Orbicularis oris,
Coticosteroids, Antiviral.

INTRODUCTION Although the cause is unknown, several

Bell’s palsy is an acute unilateral paralysis of
the seventh cranial nerve, resulting from traumatic,
infective, inflammatory, compressive or metabolic
abnormalities, though in many cases the etiology
is difficult to be identified. In most of the cases
there is partial to complete recovery which occurs
spontaneously in 4 to 6 months.
The name was given by Sir Charles Bell in 1821.
He described complete facial paralysis after injury
of the stylomastoid foramen.1 Bell’s palsy is the
most common facial nerve disease and has a sudden
onset. Male and female are equally affected with
a slight predominance in males over 40 years. The
incidence is about 20/year/100,000 population.2 Social
activities and self reputation is also affected.3
Corresponding author:
Dr. Akshay Verma
Address- 68 Jai Bhawani Colony Khatipura Jaipur
Rajasthan, Senior Lecturer , Dept Of Oral Pathology
And Microbiology, Rajasthan Dental College, Jaipur,
Rajasthan, India, Mobile no: 9509222226
Email : dr.akashyavermaop@gmail.com
etiologies has been put forward viz. Viral infections
– (Herpes zoster, Mumps, E.B. virus), Otitis media,
Cerebellopontile tumors, Melkersson – Rosenthal
syndrome, Sudden exposure to cold or surgical
procedure (removal of parotid gland or injection of
local anaesthesia). The widely accepted mechanism is
inflammation of the seventh cranial nerve during its
course through the bony labyrinth part of the facial
canal, which leads to compression and demyelination
of the axons and cessation of blood supply to the
nerve itself.4
FACIAL NERVE ANATOMY
The facial nerve is the seventh cranial nerve. It is
nerve of the second branchial arch and has motor and
sensory root. Lower part of pons contains four nuclei
namely Motor nucleus, Gustatory Nucleus of Tractus
Solitarius and Parasympathetic Superior Salivatory
and Lacrimatory nucleus.
Axons of motor part of facial nerve incline
dorsomedially towards 4th ventricle below Abducent
nucleus ascends medial to medial longitudinal
fasciculus curve anterolaterally round abducent
85 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
nucleus, descends through reticular formation and
emerges as two roots at caudal border of pons. Two
roots runs with VIII cranial nerve to reach internal
acoustic meatus. In facial canal it gives three branches
as Greater petrosal nerve supplying lacrimal gland
and gustatory fibers to palate, nerve to stapedius
muscle and gustatory fibers to anterior 2/3rd of tongue
through chorda tympani nerve. VII nerve leaves skull
through stylomastoid foramen and branches off as
digastric branch to posterior belly of digastrics and
stylohyoid branch to stylohyoid muscle. It then enters
parotid gland and emerges oout from same as five
terminal branches as temporal, zygomatic, buccal,
mandibular and cervical nerves to all muscles of
facial expression.
Central versus Peripheral Lesions of the Facial
Nerve
The facial nerve predominantly innervates
the muscles of facial expression. Central type and
peripheral type of paralysis is classified according to
site of lesion. Part of nucleus that supply muscles of
upper part of face receives fibers from motor cortex of
both right and left sides and lower part of face from
opposite cerebral hemispheres. (fig. 1).
The central type lesions are usually situated
between cerebral cortex and the cells of the motor
nucleus of facial nerve involving and interrupting
the corticobulbar fibers, thus results in paralysis
only of the lower facial muscles on the opposite side
of the lesion. Reason being that the corticobulbar
fibers to the forehead and the upper half of the face
are distributed bilaterally; however, the fibers to the
lower half of the face are predominantly crossed.
Central type lesion is less severe type but may
produce serious complications in the brain
The peripheral type lesions are situated between
pons and terminal end of facial nerve thus producing
total facial paralysis on the same side as the lesion.
This can be differentiated from central type by
presence of wrinkling only of half of the forehead.
CASE REPORT 1
A male patient aged 25 years reported to Oral
Medicine department with a complaint of sudden
onset of weakness on right side of the face since 2
days. Patient also noticed that whenever he smiles,
the mouth deviate towards left side. Since last night,
patient is also experiencing difficulty in chewing the
food and drooling of saliva from right side. Patient
was also unable to close the right eye. Symptoms
aggravates in the night with exposure to cold wind.
There was no history of loss of consciousness, trauma,
seizures and headache. There was no significant
medical history and this is patient’s first dental visit.
Family history was non contributory.
On physical examination patient was moderately
built and nourished with all the vital signs were in
normal limit. Extra Oral Examination revealed facial
asymmetry with normal soft tissue movement only
on left side of face. There was absence of wrinkling
over the right frontal region of head when asked to
raise the eye brows (fig. 2). Patient was unable to close
the right eye when asked to do so and eye ball rolls
up (fig. 3). Close observation reveals fla�ening of
the nasolabial fold of right side. Patient was unable
to show the teeth of right side when asked to do so
(fig. 4).
Intraorally there was presence of food debris in
the right lower vestibule of which patient was not
aware. No puffing of right cheek and whistling from
the mouth was noticed when asked to blow air from
mouth. Right commissure of mouth looks moistened.
Hard tissue examination showed full complement of
teeth with periodontium in good health.
Correlating all the clinical findings, the diagnosis
of Right side Bell’s palsy secondary to lower motor
neuron lesion was made.
MRI of brain showed no signs of space occupying
lesions and all other blood and serum investigations
were also normal.
Patient was advised to take steroids
(Prednisolone) 60 mg per day for 5 days then reduced
by 10 mg per day (for a total treatment time of 10
days) and antiviral (Acyclovir) 2400 mg per day for
five days. In daytime artificial tears and in night eye
patch was advised to prevent corneal abrasions and
exposure keratitis. Patient was recalled for follow up
after 1 week. Symptoms of Bell’s palsy were hardly
noticeable. At a recall visit 2 months later, the patient
had complete resolution of Bell’s palsy fig. 5).
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 86

CASE REPORT 2 turns leads to dribbling of saliva from affected side.

A male patient aged 45 years reported to Oral
Medicine department with a complaint of inability to
close right eye since 3 days.. Patient was also unable to
close the right eye (fig. 6). He also noticed that mouth
deviates towards left side when he tries to brush his
front teeth (fig. 7). As seen in case 1, this patient also
showed presence of food debris in the right lower
vestibule of which he was not aware. More so ever,
similar complaints were found in this patient as in
case 1, but this patient also experienced loss of taste
sensation over right half of anterior 2/3rd of tongue.
MRI of brain and blood investigations was
normal. Diagnosis of Right side Bell’s palsy secondary
to lower motor neuron lesion was made.
Steroids and Antiviral were prescribed and
patient showed complete resolution in 3 months (fig.
8).
DISCUSSION
There are many theories behind the cause of
Bell’s palsy, etiology being unknown. Many authors
have proposed the viral etiology predominantly
being Herpes simplex or zoster.5, 6, 7 Some authors
stated that venous congestion and ischemia leads to
compression of facial nerve in the canal leads to Bell’s
palsy.6, 8 Aberrant facial canal has also been reported
in few cases.8, 9, 10
Inactivity of Buccinator muscle leads to inability
to puff out cheek with respiration, inability to keep
food in the correct position when chewing food and
thus food accumulates in the vestibule as seen in these
two patients. Lesions between Geniculate ganglion
and chorda tympani nerve causes hoarseness of
voice, tinnitus and loss of taste. In present study Case
no. 2 suffered loss of taste.
Bell’s palsy should be a diagnosis of exclusion.
Sometime syndromic condition like Melkersson-
Rosenthal syndrome, Mobius syndrome and
DiGeorge syndrome and autoimmune condition like
von Recklinghausen neurofibromatosis, Dominant
and recessive craniometaphyseal dysplasia should
also be ruled out in cases of Facial paralysis. As was
the case with both of these patients, the dentist may
be the first to diagnose such patients because of the
orofacial involvement with paralysis of the facial
nerve. Correct anatomy and knowledge of the facial
nerve, its innervations to various muscles of facial
expression is essential to reach to accurate diagnosis.
Appropriate medication and referral to neurologist to
rule out any intracranial pathology may improve the
patient’s prognosis.
FIGURES

Whatever the etiology, there is complete or partial

paralysis of muscles of facial expression. Involvement
of Temporal and Zygomatic branch of facial nerve
leads to paralysis of orbital part of Orbicularis oculi
causes difficulty in closure of eye and if a�empted,
eye ball turns upward and outwards (Bell’s
phenomenon) and involvement of palpebral portion
leads to abolishment of involuntary blinking.
Fig 1: Muscle paralysis difference between a central
Paralysis of frontal head of Occipitofrontalis lesion and a peripheral lesion of the facial nerve
causes loss of wrinkling of forehead. Paralysis of
Corrugator Supercilli and Procerus give rise inability
to wrinkle the brows and frowning of forehead.
Involvement of Buccal branch of facial nerve causes
inability to whistle and mouth deviates towards
opposite side due to paralysis of Orbicularis oris
and Zygomaticus major which leads to fla�ening
of nasolabial fold and inability to hold the saliva, in
Fig 2: Paralysis of Right side Frontal Head of Occipitalis
87 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Fig 3: Incomplete right eye closure due to paralysis of
Right Orbicularis oculi (Bell’s sign)
Fig 4: Paralysis of Right Orbicularis oris leading to
inability to show teeth on right teeth
Fig 5: Complete recovery of Case 1 after two months
Fig 6: Case 2 showing paralysis of Right Orbicularis oculi
Fig 7: Paralysis of Right Orbicularis oris leading to
inability to show teeth on right teeth
Fig 8: Complete resolution of symptoms in Case 2 after
three months
Acknowledgment: None
Conflict of Interest: None
Source of Funding: Self
Ethical Clearance : Not Needed
REFERENCES
1. Bell C. On the nerves: giving an account of some
experiments on their structure and functions,
which lead to a new arrangement of the system.
Phil Trans R Soc Lond 1821; 111: 398–428
2. Hauser WA, Karnes WE, Annis J, Kurland LT.
Incidence and prognosis of Bell’s palsy in the
population of Rochester, Minnesota. Mayo Clin
Proc. 1971; 46: 258–64
3. Weir AM, Pentland B, Crosswaite A, Murray J,
Mountain R: Bell’s palsy: the effect on self-image,
mood state and social activity. Clin Rehabil 1995;
9: 121-5
4. Jackson CG, von Doersten PG: The facial nerve.
Current trends in diagnosis, treatment, and
rehabilitation. Med Clin North Am 1999; 83:
179-95.
5. Adour KK: Current concepts in neurology--
diagnosis and management of facial paralysis.
N Engl J Med 1982; 307: 348-51
6. Olsen KD: Facial nerve paralysis 1. General
evaluation, Bell’s palsy. Postgrad Med 1984; 75:
219-25.
7. McGovern FH, Estevez J: Current concepts in
the etiology and pathology of Bell’s palsy. Va
Med 1983; 110: 544-46.
8. Shafer WG, Hine MK, Levy BM: A Textbook
of Oral Pathology, 4th ed. Philadelphia; WB
Saunders Co, 1983 pp 859-60.
9. Burzynski NJ, Weisskopf B: Familial occurrence
of Bell’s palsy. Oral Surg 1973; 36: 504-6
10. Samuel J: Familial Bell’s palsy. J Laryngol Otol
1984; 98: 977-79.
 DOI Number: 10.5958/2320-5962.2016.00020.6

Prevalence of Recurrent Aphthous Ulcer in University

Students of Jaipur, Rajasthan

Rohit Sharma1, Niharika Sharma2, O D Toshniwal3, Vijay Agarwal4,

Vikram Sharma5, Harshdeep Dhailwal6
Reader, Department of Oral Medicine & Radiology, 2P G Student, Department of Oral & Maxillofacial Pathology,
1

3
Professor & Head , Department of Oral Medicine & Radiology, 4Reader, Department of Orthodontics, 5Senior Lecturer,
Department of Oral & Maxillofacial Surgery, NIMS Dental College &Hospital, Jaipur, Rajasthan, 6P G Student,
Department of Oral Medicine & Radiology, Mahatama Gandhi Dental College & Hospital, Jaipur, Rajasthan

ABSTRACT

Aims & Objectives: The study was conducted to assess the prevalence of recurrent aphthous ulcer in
University students of Jaipur, Rajasthan aged 17-28 years.

Se�ing & Design- An observational study was conducted to assess the prevalence of aphthous ulcers
among 500 College students at NIMS University of Jaipur, Rajasthan.

Material & Methods: Subjects were interviewed using a structured Performa. The clinical diagnosis of
aphthous ulcer was made when patient showed characteristic features of aphthous ulcer. The statistical
analysis was done with SPSS software version 11.5.

Statistical analysis used: SPSS software version 11.5.

Results: The result of present study shows that 69 (13.8%) subjects having RAU among 500 College
students at NIMS University of Jaipur

Conclusion: The observations and findings of the study clearly indicate that prevalence of recurrent
aphthous ulcer & it has multifactoral causes are in younger age group.

Keywords: Prevalence, recurrent aphthous ulcer, stress, other factors.

INTRODUCTION that mainly affect non-keratinized oral mucosa.1, 2 A

Recurrent aphthous ulcers (RAU) are the most
common oral ulcerative disease, affecting 10% to 20%
of the population. There are 3 clinical subtypes-minor,
major, and herpetiform. Minor aphthous ulcers
are the most common subtype, representing 80%
to 90% of all recurrent aphthous ulcers. The classic
presentation of RAS is recurrent, self-limiting ulcers
prodromal burning sensation lasting 24 to 48 hours
can often precede the onset of ulcers. Minor RAS,
which makes up more than 80% of all RAS cases, is a
small (up to 1 cm in diameter), shallow, painful, well-
circumscribed, and round-shaped ulceration that is
covered by a yellow-grayish pseudo-membrane and
surrounded by an erythematous halo. The ulceration
generally heals without scarring after 10 to 14 days.4

Corresponding author: Major RAS is characterized by ulcers that

Dr. Rohit Sharma
13, Govardhan Colony, New Sanghaner Road,
Behind Central Bank, Sodala, Jaipur,
Rajasthan, India, Contact No. - 0141-2290295
Mobile No. - 09799568676,
Email-rohitsharmasam@yahoo.co.in
are typically larger and deeper than minor RAS.
Furthermore, they heal more slowly and often cause
scarring. Herpetiform ulcers manifest as multiple
recurrent clusters of small ulcers (less than 4 mm
in diameter) that are sca�ered throughout the oral
mucosa. These ulcers may further coalesce into larger
89 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
ulcerations.5
Previous studies have suggested that
psychological disturbances such as stress and anxiety
could play a role in the onset and recurrence of RAS
lesions.6, 7 However, other studies showed varied
results.8 Therefore, the aim of this study was to
conduct a case-control investigation of the influence
of psychological stress on RAS onset.
MATERIALS & METHODS
An observational study was conducted in students
of different College i.e. Engineering, MBA, Pharmacy,
Medical and Dental of NIMS University Jaipur,
Rajasthan. Total of 500 students were interviewed
and examined for prevalence of recurrent aphthous
ulcers and its etiologic factors for time period of 2
months from November 2014 to December 2014.
Subjects willing to participate and aged 17 to
28 years were included in the study. An Ethical
clearance was obtained from ethical commi�ee of
Dental College and Hospital, Jaipur. Oral consent
was obtained from each participant prior to the study.
Patients were classified into three age groups: 17-20
years, 21-24 years and 25-28 years.
The examination was done by principal examiner
and trained recording clerk was present to record the
data in the predesigned proforma, patients having
other lesion with aphthous ulcers were excluded.
The clinical diagnosis of recurrent aphthous ulcer
was made when subject showed clinical features
such as shallow, painful, well-circumscribed, and
round-shaped ulceration that is covered by a yellow-
grayish pseudo-membrane and surrounded by an
erythematous halo.1,2,3 Subjects were also interviewed
for size, number, shape and occurrence of similar
ulcers in the past six months.
Armamentariums used were sterile mouth mirror,
explorer, tweezers, kidney tray instrument pouch,
savlon, disposable surgical latex gloves, disposable
mouth mask, measuring scale and divider.
The statistical analysis was done with SPSS
software version 11.5.
RESULTS
Table-1: A total of 500 subjects were considered
in the study out of which 69 (13.8%) presented with
RAU. Out of 394 male and 206 female subjects in the
study, 31 (6.2%) and 38 (7.6%) males and females
presented with RAU respectively.
Table 2- Considering patients according to age
group, 211 (42.2%) subjects were in age group of 17-
20 years, 184 (36.8%) in age group 21-24 years and 105
(21%) in 25-28 years of age. In total 69 (13.8%) subjects
with RAU, majority of subjects i.e. 28 (40.5%) belong
to 17-20 years of age group, followed by 26 (37.8%)
subjects in 21-24 years and 15 (21.7%) subjects in 25-
28 years.
Table 3- Shows that out of total subjects 69
(13.8%) subjects having RAU, 27 (39.1%) subjects
were having psychological & emotional stress at the
time of ulcers and 42 (60.9%) of subjects had no stress
related history.
Table 4- Shows that 10 (14.5%) subjects had
recurrence of RAU once in the six months, 31 (45.1%)
subjects had twice, 22 (31.9%) subjects had thrice and
06 (8.6%) subjects had ulcers more than three times in
six months.
DISCUSSION
The worldwide distribution, high frequency and
decreased quality of life generated by RAU have
resulted in a great deal of research into the etiology
and efficient therapy of this disease.9 However, the
etiology of RAU still remains unclear and the currently
available therapy remains inadequate. Many factors
have already been implicated in the promotion
and/or exacerbation of RAU; these include positive
family history, local trauma, nutritional deficiency,
food hypersensitivity, immune disturbance, smoking
cessation, and psychological stress, among others.10,
11, 12
In the present of 500 subjects, 69 (13.8%) subjects
presented with RAU. Similar results were also
obtained in the studies by Shashy RG et al2 and
Krisdapong S et al13. In the present study out of
500 subjects there were 394 male and 206 female,
out of which 31 (6.2%) males and 38 (7.6%) females
presented with RAU respectively, which showed
slightly high prevalence in female subjects which is
agreed by Crispian Scully14, and Krisdapong S, et al13.
However, Ship JA15 et al showed no sex predilection
for RAU.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 90

In the present study, out of total 69 (13.8%)
subjects with RAU, majority of subjects i.e. 28 (40.5%)
belong to 17-20 years of age group followed by older
age group, which is agreed by Krisdapong S, et al13
and Pere� B16.
The present study also shows that out of 69
(13.8%) subjects having RAU, 27 (39.1%) subjects gave
history of psychological & emotional stress. Studies
by Larato DC17, Camila de Barros Gallo et al18 and
Chiappelli F, et al19 have also concluded the same.
Psychological stress as a triggering factor for
RAU has already been mentioned in the literature
and is typically observed during stressful situations20
such as school exam periods, dental treatments, 21 and
periods of significant changes in life.22 Thirty nine
percent of patients reported that the occurrence of
RAU was associated with some of the aforementioned
situations, particularly changes in life such as family
problems, exam stress, emotional disturbance, new
location of residence etc.
Psychological stress induces immunoregulatory
activity by increasing the number of leukocytes at
sites of inflammation, this is a characteristic often
observed during the pathogenesis of RAU.21, 23 The
pathophysiologic consequences of stress on patients
are not uniform, especially given the dynamic
and complex mechanisms that affect individuals
in different ways. Similarly, the same patient may
exhibit different degrees of manifestation associated
with the same kind of emotional stress.19, 20
In the study, recurrence of aphthous ulcers as
per the history obtained for last 6 months was seen
with 10 (14.5%) subjects having RAU once, 31 (45.1%)
subjects having twice, 22 (31.9%) subjects having
thrice and 06 (8.6%) subjects having ulcers more than
three times.

Table -1 Shows gender distribution of subjects with RAU

Sex Distribution Subjects Aphthous ulcer subjects Percentage

male 394 31 6.2

Female 206 38 7.6
Total 500 69 13.8

Table - 2 Shows age distribution of subjects and aphthous ulcers

Total subjects Subjects showing Aphthous ulcer
Variables Age in Years
No. % No. %
17-20 211 42.2 28 40.5
Age 21-24 184 36.8 26 37.8
25-28 105 21 15 21.7
Total 500 100 69 100

Table -3 Shows subjects having stress induced RAU

Associated factor Subjects Percentage
Stress related 27 39.1
Non stress related 42 60.9
Total 69 100

Table -4 Recurrence of aphthous ulcer in subjects in last one year

Frequency in 1 year No. of Subjects Percentage
Once 10 14.5
Twice 31 45.1
Thrice 22 31.9
More than thrice 06 8.6
Total 69 100
91 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
CONCLUSION
Recurrent aphthous ulceration is quite common
condition affecting the oral cavity and is often
distressing. In addition, it interferes with normal
life activities by affecting eating and swallowing
of sufferers. Studying the prevalence of recurrent
aphthous ulceration and its association with stress is
important since it gives insight into the proportion of
people who suffer from the condition as well as other
possible causal factors.
Acknowledgement: I am very thankful to Dr. Y.
G. Reddy, Principal, Professor & Head, NIMS Dental
College for his kind help and support to conduct this
study.
Financial Support: No
Conflict of Interest: No
REFERENCES
1. Witman PM, Rogers RS: Pediatric oral medicine.
Dermatol Clin 2003, 21:157-170.
2. Shashy RG, Ridley MB. Aphthous ulcers: a
difficult clinical entity. Am J Otolaryngol. 2000
Nov-Dec; 21(6):389-93.
3. Scully C, Porter S: Oral mucosal disease:
recurrent aphthous stomatitis. Br J Oral
Maxillofac Surg 2008, 46:198-206.
4. Greenberg MS, Glick M Burket’s Oral medicine,
diagnosis and treatment. 10th edition, Elsevier,
India. 2003; 117-118.
5. Neville BW, Damm DD, Allen CM –Oral
and maxillofacial pathology, 2nd edition
Philadelphia, WB Saunders Co. 2002; 349-350.
6. Kaufman AY. Aphthous stomatitis as a featuring
syndrome of emotional stress in dental
treatment. Quintessence Int Dent Dig. 1976 Sep;
7(9):75-8.
7. Tang L, Ma L, Liu N. Effects of psychosocial
factors on recurrent aphthous ulcer. Hua Xi Kou
Qiang Yi Xue Za Zhi. 2001 Apr; 19(2):102-3.
8. Pedersen A. Psychologic stress and recurrent
aphthous ulceration. J Oral Pathol Med. 1989
Feb; 18(2):119-22.
9. Shafer, Hine and Levy. Shafer’s textbook of oral
pathology, 5th edition, Philadelphia, Elsevier
publication, 2006; 136-139.
10. David R Mcbride, Management of aphthous
ulcers. Am Fam Physician. 2000 Jul 1; 62(1):149-
154.
11. Natah SS, Kon�inen YT, Ena�ah NS,
Ashammakhi N, Sharkey KA, Häyrinen-
Immonen R. Recurrent aphthous ulcers today:
a review of the growing knowledge. Int J Oral
Maxillofac Surg. 2004 Apr; 33(3):221-34.
12. Weusten BL, van de Wiel A. Aphthous ulcers
and vitamin B12 deficiency. Neth J Med. 1998
Oct; 53(4):172-5.
13. Krisdapong S, Sheiham A, Tsakos G. Impacts of
recurrent aphthous stomatitis on quality of life
of 12- and 15-year-old Thai children. Qual Life
Res. 2012 Feb; 21(1):71-6.
14. Crispian Scully. Aphthous Ulceration. N Engl J
Med 2006; 355:165-172.
15. Ship JA, Chavez EM, Doerr PA, Henson BS,
Sarmadi M. Recurrent aphthous stomatitis.
Quintessence Int. 2000 Feb; 31(2):95-112.
16. Pere� B. Major recurrent aphthous stomatitis
in an 11-year-old girl: case report. J Clin Pediatr
Dent. 1994 Summer; 18(4):309-12.
17. Larato DC. Stress and aphthous ulcers. J Acad
Gen Dent. 1972 Sep; 20(5):25-6.
18. Camila de Barros Gallo, I Maria Angela Martins
Mimura, and Norberto Nobuo SugayaI.
Psychological Stress and Recurrent Aphthous
Stomatitis. Clinics (Sao Paulo). 2009 July; 64(7):
645–648.
19. Chiappelli F, Cajulis OS. Psychobiologic views
on stress-related oral ulcers. Quintessence Int.
2004 Mar; 35(3):223-7.
20. Soto Araya M, Rojas Alcayaga G, Esguep A.
Association between psychological disorders
and the presence of Oral lichen planus, Burning
mouth syndrome and recurrent aphthous
stomatitis. Med Oral. 2004 Jan-Feb; 9(1):1-7.
21. Redwine L, Snow S, Mills P, Irwin M. Acute
psychological stress: effects on chemotaxis
and cellular adhesion molecule expression.
Psychosom Med. 2003; 65:598–603.
22. Scully C, Gorsky M, Lozada-Nur F. The
diagnosis and management of recurrent
aphthous stomatitis: a consensus approach. J
Am Dent Assoc. 2003; 134:200–7.
23. Sircus W, Church R, Kelleher J. Recurrent
aphthous ulceration of the mouth; a study of
the natural history, aetiology and treatment. Q J
Med. 1957; 26:235–49.
 DOI Number: 10.5958/2320-5962.2016.00021.8

Impressions in Microstomia: A Systematic Review

Savisha Mehta1, Renu Gupta2, RP Luthra3, Naresh Kumar1, Reena Sirohi1

1
Junior Resident, 2Professor and Head, 3Professor and Principal, Department of Prosthodontics, H.P.G.D.C. Shimla

ABSTRACT

Statement of problem – Microstomiapose problem in tray selection and impression making due
to reduced mouth opening. Compromised impression leads to compromised prosthesis. Therefore
modification of standard impression procedure is obligatory in microstomia patients.

Purpose- The purposes of this review was to review and compile various modifications of impression
making for preliminary and definitive dental impressions described in the literature.

Material and Method- An electronic search was performed in June 2015 of PUBMED, EBSCOhost,
Scopus and Web of Sciencedatabases with various combinations of keywords supplemented by a
manual search of selected journals. After executing the search strategies, predetermined inclusion and
exclusion criteria articles were selected to be included in the review process.

Results- A total of 15 articles were included in the review. The included studies evaluated regarding
impression making.

Summary and Conclusion-Limited mouth opening often complicates and compromises the
prosthodontic treatment of patients. However with careful treatment planning, prudent designing and
the use of sectional impression techniques, it is possible to overcome many of the clinical difficulties.

Keywords – Microstomia, impression, impressions, sectional trays, sectional impressions

INTRODUCTION impression making as loaded impression tray is

The term microstomia refers to an abnormally
reduced size of oral aperture associated with
associated surgical treatment of orofacial trauma,
burns, cleft, radiotherapy or genetic disorders, severe
enough to compromise aesthetics, functions and
quality of life.1 Various treatment modalities include
surgery, use of dynamic opening devices called as
microstomia orthoses, tongue blades, stretching
exercises and modifications of denture design if not
manageable by la�er two approaches.2,3
the largest item requiring intra-oral placement.
Compromised impression leads to compromised
prosthesis, consequently modification of standard
impression procedure is obligatory in microstomia
patients.
The purpose of this study was to systematically
review and summarize the literature pertaining
to various modifications in impression procedure
and to provide an update to previously prepared
publications with the same objective

Microstomia, in its congenital or acquired MATERIAL & METHOD

forms, poses difficulty in prosthetic rehabilitation
Electronic search was performed using
and requires an ingenious approach right from
PubMed (MEDLINE), EBSCOhost, Scopus and
Web of Sciencein June 2015, seeking evidence of
Correspondence address-
various modifications in impression procedures in
Dr. Savisha Mehta
microstomia. No limits were placed regarding year of
Room No. 409, Department of Prosthodontics,
publication. The following keywords were combined:
H.P.G.D.C. Shimla. Shimla, Himachal Pradesh.
“microstomia”, “impression”, “impressions”,
Pin – 171001, E-mail: savishamehta@gmail.com
“sectional trays”, “and sectional impressions”. Search
93 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

was supplemented with hand search of Journal of
Prosthetic Dentistry and journal of prosthodontics
to enrich the results. The search was aimed to obtain
all the English peer-reviewed articles published up
to June 2015, focussed exclusively on impression
making in microstomia except clinical reports and
review articles. Bibliographies of the identified
articles were also reviewed. First- stage screening of
titles and abstracts was performed based upon the
study purpose, followed by second- stage screening
of selected full-text articles. The studies selected were
then submi�ed for data extraction.
RESULT
General results of the literature search
in 52 titles in the search of PubMed (MEDLINE), 22 in
EBSCOhost, 10 in Scopus and 55 in Web of science. 11
of them were found to be of possible interest according
to the inclusion criteria. (Table 1). Hand search of the
selected journals identified 4 more citations. Hence
a total of 15 articles were (selected following all the
inclusion and exclusion criteria’s for conducting the
systematic review) considered acceptable for this
systemic review.
Data analysis and summarization
The analysis was primarily related to the
significant variations in impression making. The
selected studies were evaluated and the data collected
was summarized (Table 2)

The various combinations of keywords resulted

Table 1: Search Methodology

Electronic Combination of Citations Case Reviews Not related to Total No.
databse Keywords used reports the topic of articles
(English peer- selected
reviewed)
Pubmed “Microstomia and 52 35 2 4
(MEDLINE) impression”

“Microstomia and
EBSCOhost impressions” 22 14 2 2

“Microstomia and
Scopus sectional trays” 10 3 7 11

Web of Science “Microstomia 55 35 2 7

and sectional
impressions”

Table 2: Impression Technique Summarized

Author (year) Impression Technique

Primary impression was made using sectional stock tray and impression plastic. First half of the
impression tray was made and repositioned in mouth after lubricating with petroleum jelly. Then
Conroy et impression of other half wasmade and both the sectional impressions are reassembled outside the
al.(1971) mouth.
Acrylic resin bases incorporating stainless steel hinge in midline and anterolingually for maxillary
and mandibular arches repectively. Final impressions are made inside the prepared hinge bases.
Naylor et Irreversible hydrocolloid impression of edentulous arch made with sectional impression tray
al(1983) technique
Arcuri et al
Impressions were made using sectional trays, reassembled extraorally with the help of keyways.
(1986)
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1 94

Cont... Table 2: Impression Technique Summarized

Sectional modelling plastic impressions were made for construction of primary cast. For secondary
Winkler et
impression, sectional impression trays with locking segments were used. Sectional impressions are
al(1984)
made and reassembled outside mouth.

A caliper was used to measure arch width which helped in selecting size of plastic tray. Plaster/stone
was poured into platic tray to make stone matrix. Thereafter, plastic tray was cut into sections. Three
Luebke (1984)
LEGO plastic buildings blocks were used to reapproximate the sectional tray as one unit when
sectional impressions were placed on stone matrix.

Optosil pu�y with sufficient accelerator was placed to patient’s mouth, adapted to hard and soft
Whitsi� et tissues. It was quickly removed from the mouth and filled with injectable silicone to obtain a more
al(1984) detailed impression. Impression was stabilized by placing to nondisplacing mix of dental stone
before it was boxed and poured. Cast so obtained was used for making sectional custom tray.

One stock tray was sectioned anteroposteriorly following a line passing to the left side of midline
Moghadam
and other tray was sectioned to the right side of the midline. Cast poured into one impression was
(1992)
positioned into second impression, to make diagnostic casts.

Wahle et Irreversible hydrocolloid impression of mandibular arch was made using modified stock tray for
al(1992) making primary cast. A sectional custom tray was fabricated as advocated by Leubke

Sectional custom trays with orthodontic expansion screw (2 guide pins and a screw) as a guide
Mirfazaelian
placed in the overlay piece in case of mandibular tray and in the other half for the maxillary tray was
(2000)
used for making final impressions.

Preliminary impression was made using irreversible hydrocolloid and a modified stock tray with
flanges trimmed, if not possible sectioned.
Baker et al
Secondary impression was made using a light cured sectional custom tray with horizontal locking
(2000)
component and a knob on inside of the handle on one half of tray that fits into the nail head and
opening on inside of the handle respectively ,on other half of tray .

5 sizes each of commercially available complete arch trays for edentulous and dentulous situations
Ohkubo et were selected and divided into 2 halves, along the midline. 4 holes were made in the handle and
al(2003) provided with a locking nut and screw. Sectional impressions were reassembled using these 4 dowel
plug holes and a screw joint.

Vinay et al Secondary impressions were made using sectional custom tray with dual pins and sleeves in the
(2012) handle for reassembling.

Bulent et al Primary impressions were made using plastic mini stock trays and irreversible hydrocolloid.
(2013) Secondary impressions were made using sectional custom trays.

Primary impression was made using a modified stock tray.

Gregory et al Sectional custom trays with their flat surfaces intimately in contact with each other and provided
(2014) with gold cylinders and guide pins for reassembling outside mouth were used for making final
impression.

Preliminary impressions were made with a method described by Moghadam.

Ehsan et al
Secondary impressions were made using sectional custom trays provided with 2 pins in one half and
(2014)
sleeves in other half of tray for reconnecting outside mouth.

Primary impression was made using modelling plastic compound and polyvinylsiloxane in three
sections, reassembled extra-orally.
Sinavarat et al
Sectional custom trays with a steeped joint along the midline were fabricated over maxillary and
(2015)
mandibular casts. Secondary impressions were made using green stick compound and low- viscosity
polysulphide.
95 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
SUMMARY AND CONCLUSION
Limited mouth opening often complicates and
compromises the prosthodontic treatment of patients.
It is often difficult to use conventional methodsfor
fabricating dentures for patients with restricted stromal
opening, compromised by lack of clearance. However
with careful treatment planning, prudent designing
and the use of sectional impression techniques,
many of the clinical difficulties encountered can be
overcome. Various techniques have been explained
in the past toobtain animpression for a patient with
microstomia. Sectional impression technique is less
tedious as the 2 halves can be inserted independently,
removed separately, and reassembled extraorally.
Each of the impression tray designs mentioned in
this article differ only in the complexity of the design
and the successful orientation of the sectional trays
together. Hence, the skill of the prosthodontist plays
a pivotal role in the successful rehabilitation of these
patients.Accuracy of the orientation of sectional
impressions further need to be investigated.
Acknowledgement-Nil
Conflict of Interest – Nil
Source of Funding- Self
Ethical Clearance- Not Required
REFERENCES
1. Klostermyer U, Flinton R. Implant
rehabilitation of a denture-wearingpatient with
microstomia.Quintessence Int 2011;42:193–199
2. Dikbas I,Koksal T, Kazazoglu E. Fabricating
sectional-collapsible completedentures for an
edentulous patient with microstomia induced
by scleroderma.QuintessenceInt 2007;38:15–22
3. Colvenkar S.S. Sectional Impression Tray
and Sectional Denturefor a Microstomia
Patient.Journal of Prosthodontics 2010;19:161–
165
4. Conroy B, Rei�ik M. Prosthetic restoration in
microstomia. J Prosthet Dent 1971;26:324-7.
5. Naylor WP, Manor RC. Fabrication of a flexible
prosthesis for the edentulous scleroderma
patient with microstomia. J Prosthet Dent
1983;50:536-8.
6. Arcuri MR, Eikel L, Deets K. Maxillary sectional
impression technique for microstomic patients.
Quintessence Dental Technol 1986;10:627-9.
7. Winkler S, Wongthai P, Wazney JT. An improved
split denture technique. J Prosthet Dent 1984;51:
276-9.
8. Luebke RJ. Sectional impression tray for patients
with constricted oral opening. J Prosthet Dent
1984;52:135–7.
9. Whitsi� JA, Ba�le LW. Technique for making
flexible impression trays for the microstomic
patient. J Prosthet Dent 1984;52:608–9.
10. Moghadam BK. Preliminary impression in
patients with microstomia. J Prosthet Dent
1992;67:23-5.
11. Wahle JJ, Gardner LK, Fiebiger M. The
mandibular swing-lock complete denture for
patients with microstomia. J Prosthet Dent
1992;68:523-7.
12. Mirfazaelian A. Use of orthodontic expansion
screw in fabricating section custom trays. J
Prosthet Dent 2000;83:474–5.
13. Baker PS, Brandt RL, Boyajian G. Impression
procedure for patients with severely limited
mouth opening. J Prosthet Dent 2000;84:241–4.
14. Ohkubo C, Ohkubo C, Hosoi T, Kur� KS.
A sectional stock tray system for making
impressions. J Prosthet Dent 2003;90:201–4.
15. Bachhav V.C, Aras M.A. A simple method for
fabricating custom sectional impression trays for
making definitive impressions in patients with
microstomia. Eur J Dent 2012;6:244-247
16. Uludag B, Polat S, Sahin V, Tokar E, Ertug O.
A simplified technique for solving the transfer
problem of implant –supported fixed partial
dentures for patients with microstomia.JOI ;
39(2):169-71.
17. Paprocki.G.J, Karunagaran S, Jain V. A screw-
connected sectional impressiontray for patient
with limited opening. J Prosthet Dent 2014;111:
529-531.
18. Sinavarat P, Anunmana C. Sectional collapsible
complete removable dental prosthesis fora
patient with microstomia. J Prosthet Dent 2015.
 DOI Number: 10.5958/2320-5962.2016.00022.X

Fibrous Dysplasia- A Hallmark Fibro-Osseous

Lesion of Bone : An Overview

Ankita Khare1, Krishna Deo Prasad2, Karan Sublok3, Jalaj Tak4, Vineet Gupta4,
Ruchita Bali5, Iram Jan1, Sachin Mi�al6
Post Graduate Student, 2Prof. & Head, Dept. of Oral Pathology & Microbiology, 3Post Graduate Student, Dept. of Oral
1

& maxillofacial Surgery, 4Reader, 5Senior Lecturer, Dept. of Oral Pathology & Microbiology, 6Reader, Dept. of Oral
Medicine & Radiology, Shree Bankey Bihari Dental College & Research Centre, Ghaziabad, U�ar Pradesh

ABSTRACT

Fibrous dysplasia is a common benign skeletal lesion that may involve one bone (monostotic) or
multiple bones (polyostotic) and occurs throughout the skeleton with a predilection for the long bones,
ribs, and craniofacial bones. The etiology of Fibrous dysplasia has been linked to the pos�ygotic
mutation in the GNAS 1 (guanine nucleotide-binding protein, alpha stimulating activity polypeptide
1) gene (20ql3.2-13.3) resulting in up-regulation of cAMP. It may be isolated to a single skeletal site
or multiple sites and sometimes is associated with extraskeletal manifestations in the skin and/or
endocrine organs (McCune-Albright syndrome).

Keywords: Fibrous Dysplasia, Monostotic, Polyostotic, GNAS1, cAMP

INTRODUCTION surgeon. Its compression of the optic nerve with

resulting visual impairment is especially alarming.2
Lichtenstein (1938) introduced the term Fibrous
dysplasia. Fibrous dysplasia (FD) is a developmental ETIOLOGY
tumour like condition that is characterised by
The exact cause of Fibrous dysplasia is not known.
replacement of normal bone by an excessive
Fibrous dysplasia is a sporadic condition that results
proliferation of cellular fibrous connective tissue
from a pos�ygotic mutation in the GNAS 1 (guanine
intermixed with irregular bony trabeculae. It is a
nucleotide-binding protein, alpha stimulating activity
bone tumor that, although benign, has the potential to
polypeptide 1) gene (20ql3.2-13.3). This encodes the
cause significant cosmetic and functional disturbance,
alpha subunit of the stimulatory G protein-coupled
particularly in the craniofacial skeleton. It is a
receptor, Gs-alpha. The activating mutations occur
nonhereditary disorder of unknown cause.1 Fibrous
post-zygotically, replacing the arginine residue
Dysplasia is a developmental dysplastic disorder
amino acid with either a cysteine or a histidine
of bone. The lesion contains irregular trabeculae
amino acid. The mutation selectively inhibits GTPase
of partially calcified osteoid. Some believe that
activity, resulting in constitutive stimulation of AMP-
the immature woven bone is formed directly from
protein kinase, an intracellular signal transduction
abnormal fibrous connective tissue that is unable to
pathway. The systemic manifestations of the mutated
form mature lamellar bone, hence the term dysplasia.
Gs-alpha protein-coupled receptor complex include
Its management poses significant challenges to the
autonomous function in bone through parathyroid
hormone receptor; in skin through melanocyte-
Corresponding author: stimulating hormone receptor.3
Dr. Ankita Khare
The mutations of the Gs alpha gene lead to
Post Graduate Student, Dept. of Oral and
increased activation of the adenyl cyclase and
Maxillofacial Pathology, Shree Bankey Bihari Dental
consecutively elevated intra cellular cyclic adenosine
College and Research Centre, Ghaziabad, U�ar
monophosphate. The high concentrations of cAMP
Pradesh. Email: ankita.khare14@gmail.com
97 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
lead to increased proliferation and inappropriate
differentiation of the mutated cells, causing the
formation of a disorganized immature fibrotic matrix.
Somatic mutation in early embryonic development
is likely to result in McCune – Albright syndrome,
while at a later stage it may result in the polyostotic
fibrous dysplasia. A mutation in postnatal life, during
infancy of adult life may result in the monostotic
fibrous dysplasia.4 The increased signalling through
the cAMP pathway is believed to be responsible for
the clinical characteristics of the McCune Albright
syndrome.5
CLINICAL FEATURES
The following disease pa�erns are recognized:6
1. Monostotic form
2. Polyostotic form
a. Jaffe’s type.
b. Albright syndrome
3. Craniofacial form
4. Cherubism
MONOSTOTIC FORM
Approximately 70-80% of FDs are monostotic
with the jaws being among the most commonly
affected sites. This type affects mainly single bone.
This form most frequently occurs in the rib (28%),
femur (23%), tibia, craniofacial bones (10-25 %), and
humerus, in decreasing order of frequency. The
monostotic form generally occurs during second
decade of life and becomes dormant by the third
decade. Hormonal changes, such as those seen in
pregnancy, can reactivate a dormant lesion. In general
males and females are thought to be affected evenly,
although recent research has shown a slight female
preponderance. When the anatomic spaces and
foramina are constricted because of encroachment
of the lesions, the patient may experience a variety
of symptoms, including headaches, loss of vision,
proptosis, diplopia, loss of hearing, anosmia, nasal
obstruction and symptoms mimicking sinusitis.7
POLYOSTOTIC FORM
The condition is a disorder of childhood which
becomes arrested in adult life. This type affects
multiple bones. The sexes are equally affected. The
expectation of life is not diminished, but deformities
and pathological fractures are common.8 Polyostotic
fibrous dysplasia has been found to localize in
most cases to long bones, ribs and skull, occurring
unilaterally in most cases with involvement of skull
bones such as ethmoid, sphenoid, frontal, maxillary,
temporal and occipital bones in decreasing order
of frequency. Approximately 20-30 % of Fibrous
Dysplasias are polyostotic. Usually there is unilateral
involvement, but in severe cases bilateral disease
can occur. The craniofacial bones (40 to 50%) are
more often involved. It is 40 times less common then
monostotic fibrous dysplasia. Extensive maxillary
involvement results in facial distortion, referred
to as leontiasis ossea (“lion face”).9 The primary
orthopaedic problems associated are pain, fracture
and pathognomic deformity which is shepherd’s
crook deformity of the proximal femur which can be
extremely debilitating.10
Two apparently separate types of polyostotic FD
are described:
1. FD involving a variable number of bones, the
number of involved bones varies from a few to 75% of
the entire skeleton accompanied by pigmented lesions
of the skin or ‘Café-au-lait’ spots (coffee with milk),
the process is termed jaffe – Lichtenstein syndrome.6 It
consists of well-defined generally unilateral macules
on the trunk and thighs. The margins of the café- au-
lait spots are typically very irregular, resembling a
map of the coastline of maine. This is in contrast to
café- au- lait spots of neurofibromatosis which have
smooth borders (like the coast of California).11
2. Polyostotic combined with café au lait
pigmentation and multiple endocrinopathies
such as sexual precocity, pituitary adenoma or
hyperthyroidism. This pa�ern is known as McCune
Albright Syndrome.6
Fig.1. “Coast-of-Maine” café-au-lait spots on patient
with McCune-Albright syndrome.
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
MCCUNE-ALBRIGHT SYNDROME
McCune-Albright syndrome is classically defined
by the triad of polyostotic fibrous dysplasia, café-au-
lait skin hyperpigmentation and hyperfunctioning
endocrinopathies and is often associated with
phosphaturia. The accompanying endocrinopathies
and phosphaturia may have a direct effect on the
fibrous dysplastic skeleton. In both diseases the
cutaneous change evidently reflects an increase in
melanin content of the basal cell layer of epidermis.
These spots show no tendency to follow the
distribution of the bony lesions. Breast development
and pubic hair may be apparent within the first
few years of life in affected girls.10 The molecular
defect arises from missense mutations in exon of
the GNAS gene that lead to replacement of arginine
and conversion to the gsp oncogene that encodes the
stimulatory guanine nucleotide binding regulatory
protein alpha lacking intrinsic GTPase activity.12
Sexual precocity is seen in females with Albright
syndrome. The menarche has been reported as early
as 2nd day of life. This precocity is true one because
numerous females so afflicted have eventually
had normal pregnancies. Skeletal precocity is less
impressive but even more frequent than early
menarche and development of secondary sexual
characteristics. Thyroid dysfunction is frequently
encountered. There is high incidence of mental
retardation seen.13
MAZABRAUD’S SYNDROME
It is a rare disease caused due to association of
FD and intramuscular myxoma that occur in the
same anatomical region. Patients with soft tissue
myxomas should be thoroughly examined for FD as
greater risk of sarcomatous transformation in FD with
Mazabraud’s syndrome has been reported. Malignant
transformation of fibrous dysplasia may include:6
• OsteosarcoMcCune Albright Syndrome
(most common),
• ChondrosarcoMcCune Albright Syndrome,
• FibrosarcoMcCune Albright Syndrome,
• LiposarcoMcCune Albright Syndrome.
These malignancies occur most commonly in the
98
se�ing of therapeutic irradiation exposure. Females
may have a greater risk for breast cancer, probably
due to their prolonged exposure to elevated estrogen
levels. The underlying GS alpha gene mutation may
also play a role in this.6
CRANIO FACIAL FORM
This pa�ern of the disease occurs in 10-25 % of
patients with the monostotic form and in 50 % with
the polyostotic form. Sites of involvement most
commonly include the frontal, sphenoid, maxillary,
and ethmoidal bones. The occipital and temporal bones
are less commonly affected. Hypertelorism, cranial
asymmetry, facial deformity, visual impairment,
exophthalmos, diplopia, proptosis or visual changes
and blindness may occur because of involvement
of orbital and periorbital bones. Involvement of the
sphenoid wing and temporal bones may result in
vestibular dysfunction, tinnitus, and hearing loss.
Frontal, sphenoid, nasoethmoid and maxillary bone
involvement may result in nasal obstruction, sinus
obliteration and subsequent sinusitis.13
The dental anomalies included rotation,
oligodontia, displacement, enamel hypoplasia
and hypomineralisation, taurodontism, retained
deciduous teeth and a�rition. The eruption,
development and shedding of primary teeth followed
by the development and eruption of permanent
teeth that may be altered by metabolic dysfunction
or presence of bony pathosis within the jaws.14
Malignant deformation of fibrous dysplasia is a
rare phenomenon but well recognized complication.
Malignant degeneration usually develops in the
3rd or 4th decade of life. The average age onset is 32
years. It seems that irradiation provokes the fibrous
dysplasia to undergo sarcomatous change. Therefore,
radiotherapy should not be used for the treatment of
fibrous dysplasia.14
LABORATORY FINDINGS
Biochemical abnormalities are rare in monostotic
FD. Serum alkaline phosphatase is elevated in
polyostotic form, depending upon the severity of
involvement. Occasionally a slightly elevated serum
calcium and rarely an increased urinary calcium
excretion. Premature secretion of pituitary follicle
stimulating hormone has been reported, as well as
moderately elevated serum PTH.15
99 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1

RADIOGRAPHIC FINDINGS

The radiographic features of fibrous dysplasia

vary widely. The normal bone is replaced by tissue
that is more radiolucent, with a grayish “ground-
glass” pa�ern that is similar to the density of
cancellous bone but is homogeneous, with no visible
trabecular pa�ern.16

Fig. 3: photomicrograph of fibrous dysplasia showing

irregular shaped bony trabeculae embedded within a
moderately cellular fibrous stroma (Haematoxylin &
eosin, x100).

Fig. 2: Radiograph reveals ground glass appearance of

the lesion

SCINTIGRAPHY

Radionuclide bone scintigraphy is useful

to demonstrate the extent of the disease. Some
characteristic findings within lesions of fibrous
dysplasia are a bar-shaped pa�ern, whole bone
involvement, and a close match between the size of
the lesion on radiographs and the size of the area of
uptake.16
HISTOLOGICAL FEATURES
The tissue contains some areas in which cellular
fibrous connective tissue predominates and other
areas dominated by immature metaplastic bone with
a woven pa�ern. Irregular trabeculae of woven bone
are distributed in the stroma. Bony trabeculae lack
osteoblastic rimming. The configuration of these bony
trabeculae are often referred to as resembling Chinese
characters. The mesenchymal stroma surrounding
the dysplastic trabeculae is relatively hypocellular.17
Blending of lesional tissue with surrounding normal
bone and the cortical plates is a feature that separates
it from ossifying fibroma.18 (Fig. 3 & 4)
Fig.4: Higher magnification emphasizes the lack
of osteoblast rimming and wide osteoid seams
(Hematoxylin and Eosin, x400)
TREATMENT
Surgery is indicated for confirmatory biopsy,
correction of deformity, prevention of pathologic
fracture, and/or eradication of symptomatic lesions.
The use of cortical grafts is preferred over cancellous
grafts or bone-graft substitutes because of the superior
physical qualities of remodeled cortical bone.16
CONCLUSION
Fibrous dysplasia is a benign skeletal lesion that
can involve one or more bones. Its etiology has been
linked to an activating mutation of Gsα gene and the
downstream effects of the resultant increase in cAMP.
Polyostotic lesions tend to be larger than monostotic
lesions and result in more skeletal complications,
including pain, deformity, and fractures. Some
patients with polyostotic bone involvement also
have skin lesions and endocrinopathies (McCune-
 Indian Journal of Contemporary Dentistry, January-June 2016, Vol.4, No.1
Albright disease) or multiple myxomas (Mazabraud
syndrome). Most importantly, each patient may
present with variable symptoms and clinical findings,
thus the care of these patients must be customized to
their needs and sites of involvement.
Acknowledgement: None
Conflict of Interest: None
Source of Funding: None
Ethical Clearance: Taken from ethical clearance
commi�ee of Shree Bankey Bihari Dental College,
Ghaziabad, U.P
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