Dr. Deepesh K.Gupta JournalDr. Deepesh K.Gupta. An official publication of Ayush and Health Sciences...
Transcript of Dr. Deepesh K.Gupta JournalDr. Deepesh K.Gupta. An official publication of Ayush and Health Sciences...
An offical publication of Ayush and Health Sciences University ChhattisgarhCHHATTISGARH JOURNAL OF HEALTH SCIENCES
Patron Dr. G. B. Gupta
Vice Chancellor
Executive Editorial Board
Dr. K. L. Tiwari – Registrar Ayush & Health Sciences UniversityDr. N. Gandhi – Dean Faculty Medical
Dr. Anil G. Ghom – Dean Faculty, Dental Mrs. Abhilekha Biswal –Dean Faculty Nursing
Dr. D. Katariya – Dean Faculty Ayurvedic Dr. A. R. Rudrajwar –Dean Faculty Homoeopathy
Associate Editors
Dr. Raghavendra ShettyDr. Divya Sahu
Dr. A. K. Chandrakar Dr. S. Pawar Dr. A K Vishwakarma Dr. Rajendra Prasad Dr. Tripti Nagaria Dr. O. P. Khandelwal Dr. Rajendra K.Dubey Dr. Sanjay B.Nyamati Mrs. Sreelata Pillai Dr. Anand Sharma Dr. S. R. Inchulkar Dr.Vineeta Gupta Dr. R.P. Gupta Mrs. Uma Shendey Mrs. Preetha Sunil Ms. Bhuneshwari Sahare Dr. Rohit Rajput
Editorial Board
(I)
Jou
rnal
ISSN 2348 - 4195
An official publication of Ayush and Health Sciences University Chhattisgarh
CHHATTISGARH JOURNAL OF HEALTH SCIENCES
Volume 2 issue 1 ISSN 2348-4195
CONTENTS
REVIEW ARTICLE
Lasers in dentistry R.Mithra Rajan, C.A. Mathew,N. Vidya Sankari, Arul Kumar ........01
ORIGINAL ARTICLETo determine the antimicrobial property of MTA when mixed with triple antibiotic paste and
chlorhexidine gluconate: An invitro study
S. Naveen, A. Cicilia Subbulakshmi, Immanuel sathish solomon, Vineeta Gupta ........09
Pulmonary function test in chronic kidney disease patients : A study from tertiary care hospital
P. Gupta, Mukund G. ........14
Oral lichen planus : A diagnostic marker of chronic liver disease
Vaibhav Kumar Garg, Mayuri Garg ........20
A comparative evaluation of inter articulator reproducibility of protrusive condylar guidance
registration in four different semi adjustable articulators using two different recording materials
C.Dhinesh Kumar, Jayashree Mohan, N.Vidyasankari, Deepesh K. Gupta, S.Senthil kumar, Indumati ........29
Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane manipulated
with and without petroleum gel : An invitro study Adarsh Shetty, Jagadish Konchada, Balasubramaniyan R , Shailendra Sahu, Anurag Dani, Manikandan R. ........37
Dermatoglyphics in oral clefts Chinar Fating, Rolly Gupta, Anil Agrawal, Rana K. Varghese, Gopkumar Nair , Preeti Thakur ........42
Carcinoma cervix and renal failure : A study from central India
Sanjay Verma ,Punit Gupta, Prakash Khunte ........47
CASE REPORTImmediate denture as an immediate solution
N.Vidyasankari, S.Senthil kumar, Deepesh K. Gupta, Maheshwaren ........51
Unrecognized swallowing of a partial denture and surgical retrieval by cervical
oesophagotomy: A case report C. Sunil Kumar,B. M. M. Reddy, A. Samantaray, D. S. R. Reddy ........55
(ii)
“Great discoveries and achievement invariably involve co-operation of many minds”
The journal is very important mouth piece and advertisement for any society. It reflects a knowledge and research of our colleagues. What lies before us and what lies behind us is nothing compare to what lies within us. So this journal is giving an opportunity to the people of our faculty for their skills and achievement as it is said ‘when you are curious you find lots of interesting thing to do’.
It gives me immense pleasure to bring out the current issue of this year, “Chhattisgarh Journal Of Health Sciences”. This journal represents the brain of faculties of our university.
Our constant search of excellence in medicine remains the challenge. We are committed continuously to report new discoveries and research, finding and exploring new ideas, methods and advancement technology along with various dimension of learning. Besides the content we pirates around the numerous material, technique and technologies to enable our professionals to put the knowledge into immediate clinical use.
I will try to deliver my best in every issue of the journal. Your suggestions for the improvement of the journal will be accepted. The timely advice of the editorial board, advisors and review board has catalyzed the publication of this journal. The moral boost and the continuing support of all our colleagues help us to take out the journal in time.
I request all the authors to submit research and original articles which will be great help to us for indexing at higher level.
Anil G Ghom(Editor-in-Chief)e-mail: [email protected]@gmail.com
Editorial
E
dit
or
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(iii)
ABSTRACT
The word “laser” invokes many significant qualities like precision, efficiency, and innovation in the mind's eye. The
successful use of laser light has been proved in diverse branches of medicine and dentistry. The scope of laser in
dental procedure and number of dental professionals using them is steadily increasing. Based on recent
advancements and the minimum intervention principles, lasers has revolutionized various surgical, non surgical and
laboratory procedures of dentistry. Low level laser therapy (LLLT) can offer tremendous therapeutic benefits to
patients, such as painless as well as bloodless procedures, with more efficacy and accelerated healing. The purpose
of this article is to explain the basic principles of lasers and to explore the uses of lasers in general dental practice.
Key words: 2 Hard tissue lasers, Soft tissue lasers, Nd YAG laser, CO laser
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) 1
INTRODUCTION
The field of dentistry have come a long way from just
drilling, filling or replacing teeth by simple mechanics to
the boundless era of modern technology. Over the past
several years, tremendous advances in the field of laser
have enormous impact in every disciplines of dentistry.
The word laser started as an acronym for "light
amplification by stimulated emission of radiation”. A
laser is a device that emits light (electromagnetic
radiation) through a process of optical amplification
based on the stimulated emission of photons. 1
Although Maiman first investigated the potential uses
of the ruby laser in dentistry in 1960, laser gained
popularity among the clinicians only after 1990s when
numerous studies were published on laser applications
in dentistry. The purpose of this article is to review the
literature on fundamentals of lasers and their
applications in various fields of dentistry.
2Components of a typical laser:
1. Active medium
This may be consists of a solid, liquid or gas that emits
laser light when stimulated. This is positioned within
the laser cavity, an internally-polished tube, with
mirrors co-axially positioned at each end and
surrounded by the external energising input, or
pumping mechanism. The 'active medium' (CO or 2
Nd:YAG) defines the type of laser and the emission
wavelength of the laser (10,600 nm and 1,064 nm
respectively). Other lasers of significance in dentistry
use rare earth and other metal ions within a 'doped' YAG
crystal lattice, eg. erbium (Er: YAG) and holmium
(Ho:YAG), together with another erbium and
chromium-doped garnet of yttrium, scandium and
gallium (Er,Cr: YSGG).
2. Pumping mechanism
1 2 3 4R.Mithra Rajan , C.A. Mathew ,N. Vidya Sankari , Arul Kumar1. PG Student, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)2. Professor & Head, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)3. Reader, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)4. PG Student, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)
Corresponding author : Dr.N. Vidya SankariReader, Department of Prosthodontics K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)Mobile no- 09443940244, E-Mail ID: [email protected]
REVIEW
Ayush & Health Sciences University of Chhattisgarh
REV
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Lasers in dentistry
ISSN 2348 - 4195
Lasers in Dentistry
2
This is a source of primary energy that excites the active
medium. This is usually a light source, either a flashlight
or arc-light, but can be a diode laser unit or an
electromagnetic coil. Energy from this primary source is
absorbed by the active medium, resulting in the
production of laser light.
3. Optical resonator
Laser light produced by the stimulated active medium is
bounced back and forth through the axis of the laser
cavity, using two mirrors placed at either end, thus
amplifying the power. The distal mirror is totally
reflective and the proximal mirror is partly transmissive,
allowing light of sufficient energy to exit the optical
cavity. The parallelism of the mirrors insures that the
light is collimated.
4. Delivery system
Currently, two delivery systems are used (for surgical
lasers):
a) A flexible hollow waveguide/tube attached to a
handpiece (non-contact mode) or an accesory
tip of saphire or hollow metal (contact mode)
connected to the end of the wave guide.
b) A glass fiberoptic cable attached to a handpiece
(non contact mode) or a sapphire or quartz tip (contact
mode). Most of the times it is used in contact mode.
5. Cooling system
Heat production is a by-product of laser light
propagation. It increases with the power output of the
laser and hence, with heavy-duty tissue cutting lasers,
the cooling system represents the bulkiest component.
Co-axial coolant systems may be air- or water-assisted.
6. Control panel
This allows variation in power output with time, above
that defined by the pumping mechanism frequency.
Other facilities may allow wavelength change (multi-
laser instruments) and print-out of delivered laser
energy during clinical use.
Characteristics of laser:
With respect to the monochromatic nature of laser
light, a number of emission wavelengths have been
developed for the purposes of current clinical dentistry.
The wavelengths of commonly used lasers range from
the visible to the far infrared portions of the
electromagnetic spectrum (approximately 400 - 10,600
nm). Unlike visible light, laser is monochromatic and
coherent (all the waves are in the same phase & have
identical wave shapes). Collimation is another prime
property of laser light in that its acceptance is based
upon transmission through a vacuum.
3Photobiologic Effects of Laser
1. Photothermal effect
2. Photochemical effect
3. Photoacoustic effect.
Photothermal Effect
The principle effect of laser energy is photothermal, i.e.
the conversion of light energy into heat. The rate of
temperature rise plays an important role in this effect
and is dependent on several factors such as
- Cooling of the surgical site
- Ability of the surrounding tissues to dissipate heat
- Various laser parameters such as emission mode,
power density and the time of exposure.
Photochemical Effect
The laser light can stim ulate chemical reactions (e.g.
curing of composite resin) and breaking of chemical
bonds (e.g. using photosensitized drugs exposed to
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Fig 1. The basic components of a typical laser cavity.
3
Commonly used lasers and their wavelength:
Ultraviolet (0.180 μm – 0.400 μm)
Laser Type Wavelength (μm)
Argon 0.275, 0.351, 0.363
Xenon Chloride 0.308
Xenon Fluoride 0.351
Neodymium:YAG (3rd harmonic) 0.355
Visible (0.400 μm – 0.700 μm)
Laser Type Wavelength (μm)
Rhodamine 6G 0.450, 0.650
Argon 0.457, 0.476, 0.488, 0.514
Krypton 0.530
Neodymium:YAG (2nd harmonic) 0.532
Helium Neon 0.543, 0.632
Indium Gallium Aluminum Phosphide 0.670
Ruby 0.694
laser light to destroy tumor cells, a process called
photodynamic therapy).
Photoacoustic effect
The pulse of laser energy on a crystalline structure (e.g.
dental hard tissues) can produce an audible shock wave,
which could explode or pulverize the tissue with
mechanical energy creating an abraded crater. This
phenomenon is called the photoacoustic effect of laser
light.
Fig 2. Fotona laser (Slovenia, EU)
Lasers in Dentistry
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Lasers in Dentistry
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The shorter wavelengths (500–1,000 nm) are readily
absorbed in pigmented tissue and blood elements.
Argon is highly attenuated by hemoglobin. Diode and
Nd:YAG have a high affinity for melanin and less
interaction with hemoglobin.
The longer wavelengths (2,000–10,600 nm) are more
interactive with water and hydroxyapatite. The largest
absorption peak for water is at the Er:YAG wavelength
(just below 3,000 nm. Erbium is also well absorbed by
hydroxyapatite. CO (at 10,600 nm) is well absorbed by 2
water and has the greatest affinity for tooth structure.
Analgesic Effects of Laser :
Low-power lasers inhibit the release of mediators from
injured tissues. In other words, they decrease
concentration of chemical agents such as histamine,
acetylcholine, serotonin, H+ and K+, all of which are
pain mediators. Low-power lasers inhibit concentration
of acetylcholine, a pain mediator, through increased
acety lchol ine esterase act iv i ty. They cause
vasodilatation and increase blood flow to tissues,
accelerating excretion of secreted factors. Lasers
decrease tissue edema by increasing lymph drainage.
They also remove the pressure on nerve endings,
resulting in stimulation decrease. These lasers decrease
sensitivity of pain receptors as well as transmission of
impulses. They decrease cell membrane permeability
for Na + and K + and cause neuronal hyperpolarization,
resulting in increased pain threshold. Injured tissue
metabolism is increased by electromagnetic energy of
laser. This is induced by ATP production and cell
membrane repolarization. Low-power lasers increase
descending analgesic impulses at dorsal spinal horn and
inhibit pain feeling at cortex level. They balance the
Far-infrared (3.000 μm – 1 mm)
Laser Type Wavelength (μm)
Helium Neon 3.390
Carbon Monoxide 5.000 – 5.500
Carbon Dioxide 10.6
Near-infrared (0.700 μm – 1.400 μm)
Laser Type Wavelength (μm)
Ti-Sapphire 0.700 – 1.000
Gallium Aluminum Arsenide 0.780, 0.850
Gallium Arsenide 0.905
Neodymium:YAG 1.064
Helium Neon 1.180, 1.152
Mid-infrared (1.400 μm – 3.000 μm)
Laser Type Wavelength (μm)
Erbium:Glass 1.540
Homium 2.100
Hydrogen Fluoride 2.600 – 3.000
Erbium 2.940
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
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activity of adrenalin and noradrenalin system
(autonomous system) as a response to pain. Low-power
lasers increase the urinary excretion of serotonin and
glucocorticoids, increasing the production of β-4endorphin.
Diagnostic applications of laser:5
Laser fluorescence is commonly used for
a. Detection of dental caries (DIAGNOdent)
b. Detection of subgingival calculus
c. Detection of crown/root fractures
d. Assessment pulpal blood flow (Laser doppler
flowmetry)
e. Scanning of phosphor plate digital radiographs
/ conventional radiographs for teleradiology.
Laser as an in-vitro research tool:6
Nd:YAG (1064nm) is utilized for Raman spectroscopic
analysis of tooth structure and Terahertz imaging of
internal tooth structure. Er:YAG (2940nm) can be used
for breakdown spectroscopic analysis of tooth
structure. Argon (488 and 515nm) is useful in confocal
microscopic imaging of soft and hard tissues, flow
cytometric analysis of cells and cell sorting. Helium-
neon (633nm) and other diode lasers are proved to be
successful in profiling of tooth surfaces and dental
restorations.
LASERS IN ORAL MEDICINE
Laser vaporization offers a precise means of treating
oral lesions that reduces the potential for pain and
scarring. Oral lesions treated with laser surgery include
aphthous ulcers, lymphangiomas, hemangiomas and
verrucous carcinomas. Laser irradiation acts in the final
stage of HSV-1 replication by limiting viral spread from
cell to cell and that laser therapy acts also on the host
immune response unblocking the suppression of
proinflammatory mediators induced by accumulation
of progeny virus in infected epithelial cells.7
A more powerful laser-initiated photochemical reaction
is photodynamic therapy (PDT), which has been
employed in the treatment of malignancies of the oral
mucosa, particularly multi-focal squamous cell
carcinoma. Laser-activation of a sensitizing dye in PDT 8
generates reactive oxygen species. These in-turn
directly damage cells and the associated blood vascular
network, triggering both necrosis and apoptosis. There
is accumulating evidence that PDT activates the host
immune response, and promotes anti-tumour
immunity through the activation of macrophages and T
lymphocytes.
CO laser and diode laser has been found useful for the 2
treatment of vascular anomalies of the oral cavity and
concluded that laser is a suitable tool for the treatment
of these lesions and sometimes the laser cannot
remove the entire tumour in one treatment, so more
t re at m e nt s m ay b e n e e d e d . I n f ra re d l a s e r
photodynamic therapy over the projection of the
sinuses will lower the sensation of pressure and
tenderness. Irradiation into the nostrils will reduce the
mucosal swelling and open the nasal obstruction.9
LASERS IN PERIODONTICS:
The application of laser in periodontics was first
documented in 1985 when CO laser was used for the 2
removal of phenytoin hyperplasia. Early efforts were
l imited to those soft t issue procedures l ike
gingivoplasty, operculectomy, gingival troughing, crown
lengthening, Sulcular debridement (removal of
inflamed soft tissue in the periodontal pocket), flap
surgery and for guided tissue regeneration.10
Erbium lasers show potential for effective root
debridement. The Er:YAG laser has been shown, in vitro,
to remove calculus and to negate endotoxin. Clinical 11
data also exist that suggest the Er:YAG laser can result in
a superior calculated clinical attachment gain compared
with mechanical scaling and root planning.
LASERS IN CONSERVATIVE DENTISTRY AND
ENDODONTICS:
Er:YAG laser is used for caries removal, restoration
removal, hard tissue surface roughening and etching,
enameloplasty, excavation of pits and fissures for
placement of sealants, hypersensitive dentin. Esthetics
and smile has become important issues in modern
society. Bleaching has become the common method for
tooth whitening. Bleaching using diode lasers results in
immediate shade change and less tooth sensitivity and
is preferred among in office bleaching systems. 12
Lasers in Dentistry
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Lasers in Dentistry
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Lasers are also useful for access cavity preparation,
pulpotomy, cleaning and shaping of the root canal. In
periapical surgery, laser is used for incision of soft tissue
to prepare a flap and expose the bone, cutting bone to
prepare a window access to the apex (apices) of the
roots, apicoectomy – amputation of the root end, root
end preparation for retro filling, removal of pathological
tissues (i.e., cysts, neoplasm or abscess) and
hyperplastic tissues (i.e., granulation tissue) around the
apex.13
LASER IN ORAL AND MAXILLOFACIAL SURGERY:
A diode laser can be used for incision instead of a
scalpel. Hard tissue lasers are used for osteoplasty and
osseous recontouring (removal of bone to correct
osseous defects and create physiologic osseous
contours), ostectomy (resection of bone to restore bony
architecture, resection of bone for grafting, etc.),
osseous crown lengthening, vestibuloplasty, sinus lift
procedure. The yttrium-scandium-gallium-garnet
(YSGG) laser is the optimal choice for not cutting the
sinus membrane. The YSGG laser can also be used to
make the osteotomy for a ramal or symphyseal block
graft.
Diode lasers are attracted to pigments. Frena are
typically thicker fibrous tissue and have very little
pigment to them. The lack of pigment and more fibrous
nature of the tissue require higher energies to ablate
this tissue. Other wavelengths such as Er:YAG lasers
may ablate frena faster, and can be used in non contact
mode, but the drawback compared to diode lasers is an
increased risk of bleeding. 14
LASERS IN PROSTHODONTICS:
Fixed Prosthetics: 15
One of the essential elements of success of lasers in
fixed prosthodontics is the care and accuracy of the
component treatment stages and the laser often can
confer minimal collateral tissue damage through proper
consideration of the use of minimal laser energy of the
correct wavelength. Argon laser energy has peak
absorption in haemoglobin, thus lending itself to
providing excellent haemostasis and efficient
coagulation and vaporization of oral tissues. The
removal and recontouring of gingival tissues around
laminates can be easily accomplished with the argon
lasers.
Most commonly used in
i. Crown lengthening
ii. Soft tissue management around abutments
iii. Osseous crown lengthening
iv. Troughing
v. Formation of ovate pontic sites
vi. Altered passive eruption management
vii. Modification of soft tissue around laminates
Fig 3. Nd:YAG (200 μm laser fiber at 1.5 W and 15 Hz )
used for root canal disinfection.
Fig 4. Er:YAG Lasers for Fast and Precise
caries removal and tooth preparation.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
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viii. Bleaching
ix. Veneer removal
x. Laser etching of enamel, dentin, titanium,
zirconia
In pre-prosthetic surgery:16
i. Treatment of undercuts
ii. Tuberosity reduction
iii. Torus reduction
iv. Soft tissue modification
v. Epulis fissurata
vi. Denture stomatitis
vi. Residual ridge modification
In Implant dentistry: 17
i. Implant recovery
ii. Implant uncovering
iii. Implant site preparation
iv. Laser assisted cementation
v. Implant Surface Modification Using Laser
Guided Coatings
vi. Peri-implantitis
Laser applications in the dental laboratory: 18
I. Scanning of models for orthodontics.
II. Holographic interferometry.
III. Scanning of crown preparations for CAD-CAM
IV. Welding of alloys (Co-Cr,Ni-Cr,gold, titanium)
V. Sintering of ceramics
VI. Laser pointer surveyor
VII. CAD-sintering fabrication
VIII. CAD-polymer fabrication of splints or surgical
models Cutting of ceramics
Laser technology in fabrication of maxilla facial
prosthesis:19
i. Laser Digitizing Technology
ii. Selective Laser Sintering(SLS) technology 20
Laser Hazards and Laser Safety:21
The subject of dental laser safety is broad in scope,
including not only an awareness of the potential risks
and hazards related to how lasers are used, but also a
recognition of existing standards of care and a thorough
understanding of safety control measures.
Laser Hazard Class for according to ANSI and OSHA
Standards:
Class I - Low powered lasers that are safe to view
Class IIa - Low powered visible lasers that are
hazardous only when viewed directly for
longer than 1000 sec.
Class IIb - Low powered visible lasers that are
hazardous when viewed for longer than
0.25 sec.
Class IIIa - Medium powered lasers or systems that
are normally not hazardous if viewed for
less than 0.25 sec without magnifying
optics.
Class IIIb - Medium powered lasers (0.5w max) that
can be hazardous if viewed directly.
Class IV - High powered lasers (>0.5W) that
produce ocular, skin and fire hazards.
The types of hazards can be grouped as follows:
1. Ocular injury
2. Tissue damage
3. Respiratory hazards
4. Fire and explosion
5. Electrical shock
Proper training and education should be given for all the
dental personnel to follow standard operating
procedures. Personal protective equipment like
appropriate eye wear, clothing etc.
CONCLUSION :
It is most important for the dental practitioner to
become very familiar with the principles of recent
advances like laser and should have thorough clinical
experience. Although there is some overlap of the type
of tissue interaction, each wavelength has specific
qualities that will accomplish a specific treatment
objective. Laser energy requires some procedures to be
performed much differently than with conventional
instrumentation, but the indications for laser use
continue to expand and further benefit patient care.
Lasers in Dentistry
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Lasers in Dentistry
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1 2 3 4 S. Naveen , A. Cicilia Subbulakshmi , Immanuel sathish solomon , Vineeta Gupta1. Senior Lecturer, Department of Conservative dentistry, VMS Dental college, Seeragapady Salem (TN)2. Senior Lecturer, Dept. of Oral Medicine and Radiology, KSR Institute of Dental Sciences, Trichengodu Namakkal (TN) 3. Professor, Dept. of Conservative Dentistry, R M Dental College & Hospital, Annamalai nagar, Chidambaram (TN)4. Reader, Department of Periodontics , Government Dental College, Raipur (C.G)
Corresponding Author :Dr. A. Cicilia subbulakshmiAddress: 6/3, Chaithanya Appartments, 5th cross, Brindhavan road, Fairlands, Salem-636016.Ph.no: 9488062382, E-mail: [email protected].
ABSTRACT
Context : Mineral trioxide aggregate [MTA] has several superior properties as a root end filling material but its
antibacterial property is not lethal against E.faecalis which is the main organism for endodontic treatment failure.
Hence antibacterial mixing agents was considered.
Aim : The aim of this in vitro study was to compare and determine whether the chlorhexidine gluconate[CHX] and
triple antibiotic agent(ciprofloxacin/metronidazole/minocycline) when used as a mixing agent for mineral trioxide
aggregate[MTA] would enhance the antimicrobial activity against E. faecalis.
Materials and methods : 30 single rooted tooth samples were endodontically treated, sterilized and divided into
three groups. Group A, B and C whose root ends were filled with MTA mixed in saline, CHX and antibiotic paste
respectively. The antimicrobial property was studied by placing MTA blocks in BHI (brain heart infusion broth) agar
plates suspended with bacteria and incubating it, after which the inhibition zones were measured.
Statistical analysis used : Kruskal Wallis test to ascertain the statistical significance.
Results : Group C showed enhanced antimicrobial property when compared to other groups.
Key words : MTA, antimicrobial property, CHX, triple antibiotic paste.
Key message : The properties of MTA will be enhanced when mixed with triple antibiotic paste or CHX.
INTRODUCTION:
When non-surgical endodontic treatment fails
periradicular surgery is advised. But the success of the
periradicular surgery depends on the root end sealing
material used. Ease of handling, dimensional stability,
radio opacity, insolubility and moisture resistance are
the properties of an ideal root end filling material .1
MTA which has several potential clinical applications
has all the above mentioned properties in addition has
the ability to stimulate osteoblastic activity. The original
study of Torabinejad et al found that MTA was effective
against some facultative microorganisms but not
“ To determine the antimicrobial property of MTA when mixed with triple antibiotic paste and chlorhexidine gluconate:
An invitro study”
ORIGINAL ARTICLE
Ayush & Health Sciences University of Chhattisgarh
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against other bacterial strains, including Enterococcus
faecalis .2
E.faecalis is a nonspore-forming, fermentative,
facultatively anaerobic, Gram-positive coccus. It can
penetrate deep into dentinal tubules and resist
bactericidal substances commonly used in endodontic
procedures.
Chlorhexidine (CHX) which is active against Gram
positive and Gram-negative bacteria, especially E.
feacalis facultative anaerobes and aerobes, moulds,
yeasts and viruses acts by adsorbing onto the cell wall of
the microorganism and causing leakage of intracellular
components and eventually leading to cell death . The 3
triple-antibiotic paste was first tested in vitro by Sato et
al. and was found to be effective in treating dentin
infected with E.faecalis .4
Hence this study was done to compare the
antimicrobial property of MTA when mixed with CHX
and triple antibiotic paste.
MATERIALS USED IN THE STUDY:
Extracted human lower premolars ( 30 ) Enterococcus faecalis strain Culture media (Pfizer selective Enterococcus agar) Culture media jar ( 1000 ml jar ) Culture plates ( Diameter 60mm;25 nos ) Distilled water Micropipette, micropipette tips ( 0.5µl ) Incubator, Autoclave Glass test tubes (5ml) Plastic test tubes (5ml),Swab and cotton Bunsen burner, Spirit Gloves and face mask Permanent marker Centrifuge tubes ( 3ML ) Test tube stand Diamond points ( round bur 08 ) Sterilization pouches and pouch sealer High speed air rotor hand piece.
K – files Size 10, Sizes 15 – 40, Sizes 45 – 80 . Sodium HypoChlorite 3% 5 ML irrigating syringe Mini Endo Block, PulpDent 17% EDTA, Saline Straight hand piece, Micro motor unit Carborundum disks with mandrel Lentulo spiral Ball burnisher Contra angle micromotor hand piece Epoxy glue Nail varnish. Digital Camera Pro root tooth colored MTA. Triple antibiotic (ciprofloxacin, metronidazole and minocycline) Chlorhexidine gluconate, Measuring scale
METHODOLOGY
Culturing of the bacterial strain
20 ml BHI broth was taken in a test tube and heated in a Bunsen burner for 60 seconds and allowed to cool to reach room temperature. The freeze dried vacuum sealed E.faecalis sample was opened from one end and the sample was mixed in the BHI broth by shaking followed by moving the test tube in circular motion. The test tube was then incubated for 4 hours before inoculation.
Preparation of the teeth samples
30 extracted human single rooted mandibular premolars[fig-1] were collected and stored in saline.
The diamond points used for access cavity were autoclaved. Access opening was performed with a high speed air rotor handpiece with water coolent. The initial
entry was made with a 0.08 round diamond abrasive point. The access cavity was extended with a non end cutting diamond point and the working length was estimated by visual method by deducting 1mm from the initial file visible beyond the apex. The canals were instrumented to an apical size of ISO file size #60 with step back technique with recapitulation after every instrument used. The canals were copiously irrigated
To Determine the Antimicrobial Property of MTA
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Fig - 1
To Determine the Antimicrobial Property of MTA
11
with 5ml of 3% sodium hypochloride between each instrument.
The smear layer was removed with a 2ml aqueous solution of 17% EDTA. The teeth samples were then flushed finally with saline as a final rinse. Then decoronation was done. The roots were kept on wet gauze to maintain humidity and autoclaved in sealed sterilization pouches sealed for 15 mins at 121º C.
After sterilization, 2 samples were inoculated in BHI broth and incubated anaerobically for 24 hours at 37º C to confirm sterility of the samples. After confirming the sterility of the broth, the study was performed in aseptic conditions and the 30 teeth were randomly divided into 3 groups with 10 samples in each group. Groups are Group A – MTA mixed with sterile water Group B – MTA mixed with chlorhexidine Group C – MTA mixed with triple antibiotic paste.
Preparation of MTA :
Tooth colored ProRoot MTA was used in this study. 100mg of MTA was taken for each Group.
In Group A MTA was mixed with sterile water according to the manufacture instructions. In this Group 100mg of MTA was mixed with 36μl of sterile water.
In Group B MTA was mixed with 36μl chlorhexidine 0.12% solution.
In group C triple antibiotic was mixed with saline and then 36μl test solution was mixed with MTA.
Placement of the root end filling material:
Root-end resections were made by removing 3 mm of the apex at a 90° angle to the long axis of the root with a cylindric carbide bur using a high-speed handpiece with coolent water spray.
The root experimental samples were randomly divided into 3 groups of 10 each (MTA with sterile water, MTA with 0.12% CHX, MTA with triple antibiotic paste). The material was mixed and placed into the root end with an amalgam carrier.
Agar diffusion test :
200 μl of bacterial s u s p e n s i o n (approximately 5 ×10 7
colony-forming units) were spread on BHI agar plates. Freshly mixed specimens of size 5mm diameter from each test material were prepared and placed in the agar p l a t e s . A f t e r incubation at 37°C for 24 hrs and 7 days under anaerobic conditions, the agar plates were examined for bacterial- inhibition zones. The diameter of the halo formed in the bacterial lawn was measured in millimeters. An independent observer who was blind to the study measured the zones of inhibition[fig-2].
RESULTS :
The zones of inhibition of the three groups MTA/sterile water, MTA/CHX, MTA/antibiotic paste were measured in millimetres after 7 days in anaerobic condition. The results obtained are shown in the Table-1.
The mean value of the individual groups was subjected to Kruskal Wallis test to ascertain the statistical significance.
The mean value obtained in Group A is 11.1mm. The mean value obtained in Group B was 13.6mm.The mean value obtained in Group C was 14.1mm. (Table-2).
Comparing the data obtained from the three Groups (Group A Versus Group B and Group C) shows (p<0.005) significance value. Group A was compared with Group B (p<0.011) showed significant difference. Group A was compared with Group C (p<0.002) showed significant difference. No significant difference was found when Group B was compared with Group C (p>0.529).
Coming to the sealing ability no turbidity was formed in the lower compartment of the test apparatus in any of the groups. Hence there was no significant difference in the sealing ability of the three groups.
Samples 1 2 3 4 5 6 7 8 9 10
MTA/sterile water 10 11 12 10 11 13 10 11 12 11
MTA/CHX 13 11 16 18 13 15 12 10 13 15
MTA/antibiotic 14 12 15 16 10 16 15 14 13 16
TABLE I: Zone of inhibition of three groups (in millimeters)
Fig -2
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
12
TABLE II: Mean Zone of inhibition of three groups (in millimeters)
Material used Mean K.W value P value MultipleK.W test
MTA/sterile water 11.1
10.620 0.005 1 Vs 2,3 MTA/CHX 13.6
MTA/antibiotic 14.1
DISCUSSION:
Several different microorganisms play a key role in
endodontic treatment failures of which E.faecalis is the
most frequently recovered microorganism from
periapical periodontitis . Treatment outcome depends 5
on successful e l iminat ion of the associated
microorganisms and infected tissues as well as the
effective seal of the root-end site. The root-end filling
material used should also have certain anti-microbial
property to prevent future recontamination . 6
Cabiscol et al demonstrated that MTA in an aerobic
atmosphere can generate ROS [reactive oxygen
species], which have antimicrobial activity .The apical 6
third of the infected root canal is an anaerobic
atmosphere, hence the use of MTA does not favour the
formation of ROS. E.feacalis has high alkali tolerance
which might result in resistance to certain intracanal
medicaments and ability to survive conventional root
canal therapy .5
The original study of Torabinejad et al found that MTA
was not effective against E.faecalis . Hence this study 2
was done to compare the antimicrobial property of MTA
when mixed with CHX and triple antibiotic paste.
MTA itself has some antimicrobial property due to its
high PH of 11 to 12 which it can maintain for 78 days. E.
feacalis can survive in extra alkaline environment.
Perhaps the inherent, persistent high alkalinity of MTA
is just enough to overwhelm the E. faecalis , which could 7
have contributed to the zone of inhibition observed in
the Group I MTA/sterile water.
It has been proved that CHX has better antimicrobial
property, but Pucher states that CHX was shown to be
highly cytotoxic to human fibroblasts in vitro .8
Gabler et al concluded that serum present during the
initial healing period seems to provide significant
protection against these cytotoxic effects . Stowe et al 9 10
have demonstrated that MTA has better antibacterial
properties when mixed with 0.12% CHX instead of
water.
Luiz et al stated that When combined with calcium
hydroxide, production of ROS is increased .It is proved 11
that MTA on hydration produces calcium hydroxide. we
assume that this hydration of calcium hydroxide
combined with CHX increases the production of ROS
and has better antibacterial property than MTA mixed
with sterile water in this study.
The first reported local use of an antibiotic in
endodontics was in 1951, when Grossman used a
polyantibiotic paste known as PBSC (a mixture of
penicillin, bacitracin and streptomycin and caprylate
sodium) In this study the antibiotics used are 12
ciprofloxacin, metronidazole and minocycline pastes.
Metronidazole is a nitroimidazole compound that
exhibits a broad spectrum of activity against anaerobes
but it had no activity against aerobes. Tetracyclines, are
a group of bacteriostatic antimicrobials having broad
spectrum of activity against both gram-positive and
gram-negative microorganisms. In endodontics,
tetracyclines have been used to remove the smear layer
from instrumented root canal walls for irrigation of
apical root-end cavities during periapical surgical
procedures.
Ciprof loxacin is a synthet ic f loroquinolone.
Ciprofloxacin has very potent activity against gram-
negative pathogens but very limited activity against
gram-positive bacteria. Most anaerobic bacteria are
resistant to ciprofloxacin hence it is often combined
with metronidazole in the treatment of mixed
infections .13
In the present study the zone of inhibition was more for
To Determine the Antimicrobial Property of MTA
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
To Determine the Antimicrobial Property of MTA
13
MTA/antibiotic mixture than MTA/CHX and MTA/water.
Here the interaction between MTA and triple antibiotic
paste was not known. In this study E.faecalis was used,
which was a facultative anaerobe. The action of
metronidazole is more predominant for anaerobic
bacteria. The use of a combination of drugs was also
another reason for more antibacterial activity. Another
advantage of using a combination of drug is that, it will
decrease the likelihood of the development of resistant
bacterial strains. Sato et al evaluated the potential of 14
this mixture to kill bacteria in the deep layers of root
canal dentin in situ.
In present study it is noted that MTA/CHX mixture sets
more rapidly than MTA/water. This was concluded in
the study by Stowe et al, that MTA/CHX mixture seemed
to set more rapidly (1–2 min) than the MTA/water
mixture (5–6 min) and take on a more crumbly texture
at placement .10
REFERENCES:
1. Achristos Maltezos and Gerald N. Glickman.
Comparison of the Sealing of Resilon, Pro Root
MTA, and Super-EBA as Root-End Filling
Materials: A Bacterial Leakage Study.
JOE—2006; 32 ( 4) : 324-327.
2. Khalid Al-Hezaimi.MTA preparations from
different origins may vary in their antimicrobial
activity. OOOE 2009;107:e85-e88.
3. E. P. Hernandez et al. Effect of ProRoot MTA
mixed with chlorhexidine on apoptosis and cell
cycle of fibroblasts and macrophages in vitro.
IEJ 2005; 38 : 137–143.
4. Ozlem Marti Akgun et al. Use of triple antibiotic
paste as a disinfectant for a traumatized
immature tooth with a periapical lesion: A case
report. OOOE, 2009;108:e62-e65.
5. Hui Zhang et al. Dentin Enhances the
Antibacterial Effect of Mineral Trioxide
A g g r e g a t e a n d B i o a g g r e g a t e . J O E
2009;35:221–224.
6. Zio de Janeiro, Caroline S, Raphael H. The
antimicrobial activity of gray-colored mineral
trioxide aggregate (GMTA) and white-colored
MTA (WMTA) under aerobic and anaerobic
conditions. OOOE, 2010;109:e109-e112.
7. Dennis M. Holt, Thomas J. Beeson, Richard E.
The Anti-microbial Effect Against Enterococcus
faecalis and the Compressive Strength of Two
Types of Mineral Trioxide Aggregate Mixed
With Sterile Water or 2% Chlorhexidine
Liquid.JOE 2007; 33 ( 7) : 844-847.
8. P u c h e r J J , D a n i e l J C . T h e e f fe c t s o f
ch lorhex id ine d ig luconate on human
f i b r o b l a s t s i n v i t r o . J P e r i o d o n t o l
1992;63:526–32.
9. Gabler WL, Roberts D, Harold W. The effect of
chlorhexidine on blood cells. J Periodont Res
1987;22:150-153.
10. Ted J. Stowe. The effects of chlorhexidine
gluconate (0.12%) on the antimicrobial
properties of tooth-colored proroot mineral
trioxide aggregate. JOE 2004; 30 ( 6) : 429-431.
11. Luiz Eduardo Barbinet al. Determination of
para-Chloroaniline and Reactive Oxygen
Species in Chlorhexidine and Chlorhexidine
Associated with Calcium Hydroxide. JOE2008;
34: 1508 –1514.
12. Z. Mohammadi, P. V. Abbott. On the local
applications of antibiotics and antibiotic-based
a g e n t s i n e n d o d o n t i c s a n d d e n t a l
traumatology.IEJ 2009; 42:555–567.
13. Windley W, Teixeira F, Levin L, Sigurdsson A,
Trope M .Disinfection of immature teeth with a
triple antibiotic paste. JOE 2005; 31:439–43.
14. Sato I, Ando N, Kota K. Sterilization of infected
root-canal dentine by topical application of a
mixture of ciprofloxacin, metronidazole and
minocycline in situ. IEJ 1996; 29: 118 –24.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Pulmonary function test in chronic kidney disease patients : A study from tertiary care hospital
P. Gupta , Mukund .G1 2
1. Associate Professor, Nephrology Unit, Department of Medicine, Pt. J.N.M. Medical college, Raipur(C.G)2. MD Medicine, Private Practioner, Raipur
Corresponding author : Dr.Punit Gupta
Associate Professor, Nephrology Unit, Department of Medicine, Pt. J.N.M. Medical college, Raipur(C.G)Email : Mobile no- [email protected]
ABSTRACTContext: Malnutrition and inflammation are associated with impaired pulmonary function in pre-dialysis patients. Aims: To study variation in Spirometry due to malnutrition and inflammation. Methods and Material: Fifty Chronic Kidney Disease patients admitted in Pt.J.N.M medical college & GBG kidney care hospital, Raipur were studied. Pulmonary function test was performed as per ''ATS/ERS TASK FORCE Guidelines. Malnutrition and inflammation were assessed by Subjective Global Assessment scores (SGA) and CRP respectively. Statistical analysis used: Chi-square test, Student's t-test and Spearman's rank correlation. Results: Males were 70% and females were 30%. Restrictive pattern on pulmonary function test was present in 84%. Pulmonary restriction was severe in 43% males, and 8.3% females. Subjective global assessment score was B or C in 94% of which 20% were SGA C. Mean predicted Forced Vital Capacity was 37 ± 11% in SGA C and 82 ± 5% in SGA A. Mean predicted Forced Expiratory Volume in 1st second (FEV1) was 41 ± 13% in SGA C and 86 ± 3% in SGA A. Mean Peak Expiratory Flow Rate (PEFR) was 27 ± 9% in SGA C and 65 ± 23% in SGA A. Spearman's rank correlation (Rho) of CRP with percent predicted FVC, FEV1 and PEFR were Rho= -0.84, -0.60 and-0.35 respectively. Conclusions: Restrictive pattern was the most common pulmonary function anomaly. ( < 0.001) .Severe restriction Pwas significantly more common in males than in females ( < 0.01). Percent predicted FVC, FEV1 and PEFR were Psignificantly lower in severely malnourished than in well nourished. ( < 0.05). Severity of restriction on pulmonary Pfunction test increased in co-relation with increase in the level of CRP. Key-words: Malnutrition, Inflammation, Chronic Kidney Disease, pulmonary function, Subjective Global Assessment scores (SGA), CRP
INTRODUCTIONChronic kidney disease (CKD) is a devastating medical, social, and economic problem for patients and their families Prevalence CKD patients will continue to rise, 1.reflecting the growing elderly population and increasing numbers of patients with diabetes and hypertension. 2,3
Inflammation and malnutrition are common findings in patients of chronic kidney disease (CKD). Approximately 30-50% of patients with CKD have elevated serum levels of C-reactive protein (CRP). In CKD patients the acute phase response may be influenced by a number of
factors such as age, race, residual renal function and gender. Since malnutrition also occurs in pre-dialysis 4
patients, it is evident that dialysis-unrelated factors, e.g. infectious and inflammatory complications, as evidenced by increased levels of pro-inflammatory cytokines and CRP, is common in CKD patients and may cause malnutrition and progressive atherosclerotic cardiovascular disease. 5,6,7,8
SGA is a clinically useful measure of protein-energy nutritional status and is helpful in identifying patients with increased risk of morbidity and mortality in the setting of CKD. There is controversy over the degree to 9,10
ORIGINAL ARTICLE
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which albumin and nutrition are interrelated. 11
Physiologically, the lungs and kidneys are intricately related , Impairment of spirometric function in
12
patients with renal insufficiency is continual, with reduction of GFR, and thus small airways dysfunction may be expected not only in patients with end-stage renal failure, but also in those with moderate GFR reduction. This pulmonary dysfunction may be a direct 13
result of the circulation of toxins or, indirectly, from the excess volume due to the increased quantities of circulating body fluids, anemia, immunological suppression, drugs and deficient nutrition. 14
A low lung function has been associated with increased levelsof fibrinogen, C-reactive protein and white blood
cells. Several papers reported that inflammation 15
markers fibrinogen and C-reactive protein (CRP) were
inversely associated with lung function in cross-
sectional analyses. FVC is significantly and inversely 16
associated with plasma levels of inflammation sensitive plasma proteins. Impaired pulmonary function was associated with malnutrition and inflammation. 17
To best of our knowledge there is no Indian study regarding the association of CRP and SGA with impaired pulmonary function in pre-dialysis patients of CKD. Hence we have done this study to establish the relation between SGA , a marker of protein energy wasting and CRP, a marker of inflammation with lung function in CKD patients.
AIMS AND OBJECTIVESStudy of was conducted in the department of medicine, Dr.B.R.A.M hospital, Raipur (C.G) with the aims and objectives of:
1. To study Statistical correlation between various stages of CKD and pulmonary function anomalies (FVC, FEV1, FVC/FEV and PEFR) 1
2. To study Statistical correlation between Subjective global assessment score and pulmonary function anomalies (FVC, FEV1, FVC/FEV and PEFR) 1
3. To study Statistical correlation between Serum CRP with Pulmonary function anomalies (FVC, FEV1, FVC/FEV and PEFR) 1
4. To assess the Statistical correlation between Subjective global assessment score and serum CRP with pulmonary function anomalies (FVC, FEV1, FEV1/FVC and PEFR)
SUBJECTS AND METHODS
The study was conducted in the department of medicine, Pt. J.N.M. medical College and Dr. B.R.A.M. hospital, Raipur. In this study 50 chronic Kidney Disease patients, as per National Kidney Foundation, 2002 Kidney Disease outcome Quality Initiative (K/DOQI) guidelines, admitted in the wards of Medicine Department were selected as cases.Inclusion criteria for study group1. Patients with CKD according to the NFK-DOQI definition.2. Stage 0, I, II, III, IV and V CKD.3. Diabetics and non diabetics with CKD.4. Chest X ray showing absence of any active or old lung pathology.5. If Smoker then with <1 Cigarette pack per year.6. If Tobacco chewer then included in the study. 7. Age >15 years to ≤ 70 years. Patients were assessed by:a. History and physical examinationDetailed clinical history was recorded regarding age, sex, presenting complaints and duration of symptoms and significant past history of each patient. All patients underwent complete clinical examination including pulse, blood pressure, general examination and systemic examination. Height and weight were expressed in centimetres and kilograms respectively. b. Investigations: All routine investigation was done in all the cases.c. Assessment of Malnutrition, inflammation and pulmonary function abnormalities.i) Malnutrition: Malnutrition was assessed by Subjective global assessment, body mass index and serum albumin. Every patient was assessed and different SGA scores were given as per Detsky et al. 22
ii) Inflammation: Inflammation was assessed by measuring CRP (C reactive protein). The plasma concentrations of CRP were measured by CRP Latex
agglutination method.iii) Pulmonary Function Test: Pulmonary function test was performed three times and best of the three efforts were considered as appropriate .PFT was performed as per ''ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING'' 2005. Following activities were strictly avoided before the spirometry-Smoking within at least 1 h of testing-Consuming alcohol within 4 h of testing-Performing vigorous exercise within 30 min of testing-Wearing clothing that substantially restricts full chest
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Pulmonary function test in CKD patients
and abdominal expansion-Eating a large meal within 2 h of testing -Lab records: Ambient temperature, barometric pressure and time of day were recorded. Statistical Analysis Chi-square test has been applied to find any association between two categorical variables. Student's t-test has been used to find any significant difference between the normal and abnormal groups of variables with respect to average values. Spearman's rank correlation was applied to find relation between the Level of CRP and FVC,FEV and FEV /FVC.1 1
RESULTS The number of male patients was 2.33 times higher than the number of female patients of CKD. Mean age for all patients was 42.58 ± 13.85 years. Mean age of male patients was 43.6 ± 13.8 years while that of female patients was 40.2 ± 14.14 years.The leading cause of chronic kidney disease in patients from urban areas (n=25) is diabetes mellitus accounting for 24% along with chronic glomerulonephritis (24%) of cases, followed by Hypertension (16%), Obstructive nephropathy(12%). UTI/Chronic pyelonephritis (8%) and sickle cell disease, renal stone and Polycystic Kidney disease in 4% each.Among patients from rural areas (n=25) chronic glomerulonephritis was the etiology of chronic kidney disease in 20% of cases followed by obstructive nephropathy in 16% of cases. While Renal stone, UTI and hypertension were observed in 12% each. In patients from rural areas diabetes mellitus was etiological factor responsible for CKD in 8% while in urban it accounted for 24% of cases. Diabetes was significantly more common in urban cases as compared to rural.( < 0.01)PRestrictive pattern on pulmonary function test was the most common anomaly accounting for 84% of the total cases followed by mixed pattern (6%) and obstructive pattern (4%). No anomaly was detected in 6% of the cases.Severe restriction was significantly more common in males as compared to females.Majority of patients who had restrictive pattern on PFT testing 38 (90.47%) were in stage III, IV and V (Overt nephropathy) while only 4 (9.53%) were in stage I and II (covert nephropathy).Severe restriction in stage V CKD was significantly more
common than in stage III and IV.There was no statistically significant difference between the mean hemoglobin in males and females in any stage of CKD. That Mean Hb was low in stage IV (6.62 ± 1.90) and stage V (6.68 ± 2.69) CKD as compared to other stages. Malnutrition in the form SGA B or C was present in 94% of the patients included in study. Out of which 20% were severely malnourished. More Co-morbidities in the form of diabetes, hypertension and smoking were present in SGA C as compared to SGA B. Mean Serum albumin was s ignif icant ly lower in severely malnourished (SGA C) as compared to well nourished (SGA A). Markers of inflammation were significantly more common in severely malnourished as compared to well nourished.Mean forced vital capacity was lowest (37 ± 11) in severely malnourished SGA C and highest (82 ± 5) in well nourished (SGA A). Mean forced expiratory volume in 1st
second (FEV ) was lowest (41 ± 13) in severely 1
malnourished (SGA C) and highest (86 ± 3 in well nourished (SGA A). Mean Peak Expiratory Flow Rate (PEFR) was lowest in SGA C (27 ± 9) and highest in SGA A (65 ± 23). Mean FEV /FVC is almost same in SGA A, SGA B 1
and SGA C . Severe restriction is seen in 70% of severely malnourished (SGA C).Mean Age of hs CRP positive patients was significantly more than hs CRP negative patients.The mean hsCRP level was 9.6 ± 10.8 (range 1.2-38.4)mg/l. Mean GFR in CRP positive patients were 29.4 while it was 40 in CRP negative patients. Lower GFR was present in CRP positive patients.Significant negative correlations were found between hs CRP and the percent predicted value of FVC%, FEV1and PEFR.
DISCUSSION Analysis of Subjective Global Assessment status in CKD There was no statistically significant difference as per the comorbid conditions are concerned between
23malnourished and wellnourished as per SGA. Various studies reported protein energy wasting in 19 to 20% 24,25. While other studies demonstrate prevalence of
8,26,15,27malnutrition in the range of 30 to 50%. In our study the total patients with malnutrition were 47 out of 50.that shows that 94%. The reason for this is that in Indian cases malnutrition is widely prevalent. In eastern India, overall prevalence of malnutrition was 65% in
28predialysis patients. The cause of such a high amount
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Pulmonary function test in CKD patients
17
of malnutrition in our study can be because of its small sample size (n=50). Apart from that, most important is that the study is being done on low socioeconomic strata of the society. They are already malnourished in nature. If we consider severe malnutrition then our study demonstrated severe malnutrition in 20% (n=10). SGA is deficient in differentiating between mild to
55moderate malnutrition. Protein intake of Indian 29 patients on a vegeterian diet is normally low. With low
protein intake the wear and tear of the skeletal muscles is on stake, protein calorie malnutrition ensues and is responsible for the high SGA Score.In study done under the name of CANUSA (CANADA-30
USA (CANUSA) peritoneal dialysis study group under principal investigators Churchill DN, et al 1996 on patients of CKD, there were 30 patients (4.2%) with severe malnutrition, 364 (51 .2%) with mild to moderate malnutrition according to SGA. While in our study 20% (n=10) had severe malnutrition and 74% (n=37) had mild to moderate malnutrition. According to SGA, 70% of the patients had a normal nutritional status, 29% were classified as being mild to moderately malnourished and only 1% were classified as being severely malnourished in the study done by. Jansen 23
MAM, et al 2001 on behalf of NECOSAD Study Group.Prevalence of malnutrition in the form of SGA > 1 i.e SGA B or C was 36%. 13
Our results suggest that the prevalence of inflammation among the pre-ESRD population is high and that an
increased CRP in pre-dialysis patients predicts a
constant inflammatory state. And this result is in accordance of Barany P et al 2001 and Prakash J, et al 32 28
2007. On measuring the mean CRP level of 18 patients, the CRP level of which was documented by our laboratory. We found that the mean CRP level was 9.6 ± 10.8 (range 1.2-38.4). As compared to the result of Ortega O, et al 31
2002 the average CRP level in their study was 8.3 ± 14.2 mg/l (range 2-95 mg/l; median 2 mg/l). The mean value of hsCRP was 14.3 ± 11.4 mg/L (range 0.36-44.2 mg/L) in the study done by Abraham G et al 2009.14
Analysis of Pulmonary function on the basis of SGA status and CRP In this study difference in FVC (% predicted), FEV (% 1
predicted) and PEFR (% predicted) in SGA C as compared to SGA A was statistically significant [( < 0.001), ( < P P0.001) and ( < 0.05) respectively]. While in study done Pby Nascimento, et al in 2004 on pre dialysis patients 8
reported significant difference in mean FEV (% 1
predicted) and FVC (% predicted) in well nourished and malnourished but not regarding PEF (% predicted). The different spirometric parameter namely Spo2, FEV1, FVC, FEV1/FVC and PEFR was compared in between CRP positive and CRP negative group. Only statistically significant difference was found in mean FVC of the two groups. Nascimento MM, et al 2004 reported the difference in FEV , FVC, and FEV1/FVC and 1
mean PEFR. The Present study represents the restrictive pattern of intrapulmonary in nature . The reduction can be due to an increase in quantity of interstitial tissue in lung, for example interstitial pneumonitis, fibrosis, infiltration or edema. Altenatively the reduced lung compliance can be due to fibrosis of the visceral pleura and subpleural tissue. Any of these changes can increase the retractive force exerted on the walls of lung airways; the retraction reduces the airway resistance and increases the FEV1%. In this circumstance the peak expiratory flow can be well preserved or even supra maximal early in the disease process but, once lung volume becomes severely reduced the PEF also declines because it is then measured at a relatively small lung volume. 39
Spearman's rank correlation of different parameters of pulmonary function with level of hs CRPWe compared the level of hsCRP in hsCRP positive patients with that of % decrease in FVC, FEV and PEFR. 1
We applied Spearman's rank correlation for this variables and found significant degree of negative correlation of hs CRP with that of FVC%, FEV % but not 1
for PEFR. In the study done by Nascimento MM, et al they got 8
significant association between the CRP level and FVC%, FEV % and PEFR. Thus serum CRP assay must be 1
routinely done on pre-dialysis patients as there level negatively correlates with the degree of restriction in pulmonary function testing. Thus measures to curb high level of inflammation in these pre-dialysis patients such as higher antibiotic support and higher and proper nutrition be given to these patients thus preventing the fatal complication of high CRP level in these patients.
CONCLUSIONThe present study shows that chiefly malnutrition and inflammation are responsible for severe restriction encountered on pulmonary function in pre-dialysis
Pulmonary function test in CKD patients
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
cases of CKD. Improvement in malnutrition by adequate nutrition to patients of CKD leads to a better outcome as far as pulmonary functions are concerned. Numerous studies have shown that there is a relation of FVC and cardiovascular mortality thus by improvising nutrition we can not only improvise the pulmonary function but also improve the cardiovascular profile even before starting dialysis.
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2. Thomas R, Kanso A, Sedor JR. Chronic Kidney Disease and Its Complications. Prim Care. 2008 35(2): 329–332.
3. Bommer J. Prevalence and socio-economic aspects of chronic kidney disease. Nephrol Dial Transplant 2002: 17 [Suppl 11]: 8–12.
4. Nascimento MM, Qureshi AR, Stenvinkel P, Pecoits-Filho R, Heimburger O, Cederholm T et a l .Malnutr it ion and inf lammation are associated with impaired pulmonary function in patients of Chronic Kidney disease.Nephrol Dial Transplant 2004 : 19:1823-28.
5. Adey D, Kumar R, McCarthy JT, Nair KS. Reduced synthesis of muscle proteins in chronic renal failure. Am J Physiol Endocrinol Metab. 2000. 278: E219-E225.
6. Ikizler TA, Greene JH, Wingard RL, Parker RA, and Hakim RM. Spontaneous Dietary Protein Intake During Progression of Chronic Renal Failure. J. Am. Soc. Nephrol. 1995; 6:1380-91.
7. Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergstorm J. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant .2000; 15: 953-60.
8. Abraham G, Sundaram V, Mathew M, Leslie N, Sathiah V. C-Reactive protein, a valuable predictive marker in chronic kidney disease. Saudi J Kidney Dis Transpl 2009;20:811
9. Asgarani F, Mahdavi-Mazdeh M ,Lessan-Pezeshki M, Kh. Makhdoomi A and Nafar M, Correlation Between Modified Subjective Global Assessment With Anthropometric M e a s u r e m e n t s A n d L a b o r a t o r y
Parameters.Acta Medica Irnica, ; 2004, 42(5): 331-7.
10. Lawson JA, Lazarus R, Kelly JJ.Prevalence and Prognostic Significance of Malnutrition in Chronic Renal Insufficiency.Journal of renal nutrition, 2001; 11(1):16-22 .
11. Jones CH, Newstead CG, Will EJ, Smye SW, Davison AM. Assessment of nutritional status in CAPD patients: serum albumin is not a useful measure. Nephrol Dial Transplant .1997; 12: 1406–13.
12. Hassan IS, Ghalib MB. Lung Disease in Relation to Kidney Diseases. Saudi J Kidney Dis Transpl 2005.16:282-7.
13. Tkácová R, Tkác I: Spirometric alterations in patients with reduced renal function. Wien Klin Wochenschr. 1993;105(1):21-4.
14. Engström G,Lind P, Hedblad B, Wollmer P,Stavenow L, Janzon L, Lindgärde F. Lung Function and Cardiovascular Risk :Relationship With Inflammation-Sensitive Plasma Proteins . Circulation. 2002;106:2555-60.
15. Jiang R, Burke GL, Enright PL, Newman AB, Margolis HG, Cushman M, Tracy RP, Wang Y, Kronmal RA and Barr RG. Inflammatory ,
Markers and Longitudinal Lung Function Decline in the Elderly. American Journal of Epidemiology 2008;168:602-10.
16. Yoon SH, Choi NW, Yun SR et al. Pulmonary D ys f u n c t i o n I s Po s s i b l y a M a r ke r o f Malnutrition and Inflammation but Not Mortality in Patients with End-Stage Renal Disease. Nephron Clin Pract 2009;111:c1-c6.
17. Detsky AS,Mclaughlin JR,Baker JP,Johnston N, whittaker S,Mendelson RA,Jeejeebhoy KN.What is Subjective Global Assessment of Nutritional Status?. Journal Of Parenteral And Enteral Nutrition. 1987. 11(1):8-13.
18. Jansen MAM,korevaar JC,Dekker FW,Jager KJ,Boeschoten EW,Krediet RT et al: Renal Function and Nutritional Status at the Start of Chronic Dialysis Treatment:J Am Soc Nephrol, 2001. 12:157-163.
19. Bruchfeld A, Qureshi AR, Lindholm B, Barany P, Yang L, Stenvinkel P, Tracey KJ. High Mobility Group Box Protein-1 Correlates with Renal Function in Chronic Kidney Disease (CKD). Mol Med. 2008 Mar–Apr; 14(3-4): 109–115.
20. Campbell KL, Susan A, Bauer JD and Davies
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PSW. Evaluation of nutrition assessment tools compared with body cell mass for the assessment of malnutrition in chronic kidney d i s e a s e . J o u r n a l o f R e n a l Nutrition.2007;17:189-95.
21. Caravaca F,Arrobas M,pizarro JL ,sanchez-casado E. Uraemic symptoms, nutritional status and renal function in pre-dialysis end-stage renal failure patients . Nephrol Dial Transplant 2001;16 : 776-82.
22. Cupisti A , D'Alessandro C, Morelli E, Rizza GM, Galetta F, Franzoni F, Barsotti G. Nutritional status and dietary manipulation in predialysis chronic renal failure patients. J Ren Nutr. 2004 Jul; 14(3):127-33.
23. Prakash J , Raja R , Mishra RN , Vohra R , Sharma N , Wani IA et al . High Prevalence of Malnutrition and Inflammation in Undialyzed Patients with Chronic Renal Failure in Developing Countries: A Single Center Experience from Eastern India. Renal Failure 2007;29: 811-816.
24. eheray SS.Dietary protein intake in Indian patients with chronic renal failure. Indian Journal of Nephrology. 1996 ; 6: 19-21.
25. Churchi l l DN,Taylor DW,Keshaviah PR. Adequacy of Dialysis and Nutrit ion in Continuous Peritoneal Dialysis: Association with Cl in ical Outcomes. CANADA-USA (CANUSA) Peritoneal Dialysis Study Group. J, Am. Soc. Nephrol. 1996; 7:198-207.
26. Ortega O,Rodriguez I,Gallar P,Carreño A, Ortiz M,Espejo B, et al . Significance of high C-reactive protein levels in pre-dialysis patients. Nephrol Dial Transplant .2002;17: 1105-09.
27. Bárány P.Inflammation, serum C-reactive protein, and erythropoietin resistance. Nephrol Dial Transplant.2001;16: 224-7.
28. Hekmat R, Boskabady MH, Khajavi A, Nazary A.The effect of hoemodialysis on pulmonary function tests and respiratory symptoms in patients with chronic renal failure. Pak J Med Sci .2007; 23:862-6.
29. Navari K, Farshidi H, Pour-Reza-Gholi F , Nafar M, Zand S, Pour HS, Eftekhaari TE. Spirometry P a r a m e t e r s i n P a t i e n t s U n d e r g o i n g Hemodialysis With Bicarbonate and Acetate Dialysates. IJKD 2008;2:149-53.
30. M e m o n M A , S a n d i l a M P, A h m e d S T. Spirometric reference values in healthy, non-smoking, urban Pakistani population. J Pak Med Assoc. 2007 Apr;57:193-5.
31. Utaka S, Avesani CM, Draibe SA, Kamimura MA, Andreoni S, Cuppari L. Inflammation is associated with increased energy expenditure in patients with chronic kidney disease. Am J Clin Nutr 2005; 82:801–5.
32. Gorek DA, Ulubay G, Bayraktar N, Eminsoy I, Öner Eyüboğlu F. The effects of cachexia and related components on pulmonary functions in Patients with COPD. Tüberküloz ve Toraks Dergisi 2009; 57: 298-05.
33. Nainani N, Panesar M. Nephrogenic Systemic Fibrosis. Am J Nephrol 2009;29:1–9.
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1
ABSTRACT
Objectives: To correlate clinical presentation and gender of patients with oral lichen planus with chronic liver
disease by estimating the serum transaminase level.
Material & Methods: The present study included two groups; test group (patients with oral lichen planus) and
control group (normal healthy adults without any clinical evidence of oral mucosal lesions) of 45 patients each. Both
the groups were subjected to serum transaminase level test.
Results : At least one of two assays (either AST or ALT) showed altered results in 3 patients in the control group and
11(13.33%) patients in the test group. Both assays were raised in 2 patients in the control group and 6 patients in the
test group. Out of these, six (4 males and 2 females) patients with elevated transaminase levels had erosive lesions.
Conclusion: We conclude that the presence of oral lichen planus particularly the erosive variant should be seen as a
presentation of alteration in the functioning of the hepatocytes, which on further investigations might bring to light
an asymptomatic liver disease.
Key Words: Oral Lichen Planus, Alanine transaminase (ALT), Aspartate transaminase (AST), Chronic active hepatitis,
Primary biliary cirrhosis
INTRODUCTION
Lichen planus is derived from a Greek word LICHEN
which means ‘Tree moss’ and a Latin word PLANUS
which means ‘flat’. 1
The strange name of the condition was provided by the
British physician Erasmus Wilson, who first described
the lesion in 1869. 2
Lichen planus, one of the most common dermatologic
immunopathological diseases to affect the oral mucous
membrane, is a chronic, inflammatory, mucocutaneous
disorder of undetermined etiology. The care and 3
management of patients with oral lichen planus
continues to challenge even the most experienced
clinician, and strongly suspected associations with
chronic liver disease further complicate matters.
In recent years a number of case reports have drawn
attention to the possible association of mucocutaneous
lichen planus with chronic liver diseases – namely,
primary biliary cirrhosis and chronic active hepatitis
being the prime ones, followed by primary sclerosing
cholangitis, Wilson's disease, hemochromatosis and
alpha-1-antitrypsin deficiency. 4
The histological abnormalities of lymphocytic
infiltration of parenchymal tissue in liver disease and
oral l ichen planus, along with immunological
abnormalities, autoimmune phenomenon and humoral
immunity, are the factors that can be responsible for the
association between the two diseases.
In the initial stage of chronic liver diseases, where the
normal lobular architecture is preserved and the
patients often remain well without progression of their
1 2Vaibhav Kumar Garg , Mayuri Garg1. Reader, Oral Medicine & Radiology, Dr. B.R. Ambedkar Institute of Dental Sciences & Hospital, Patna, Bihar2. Senior Lecturer, Oral Medicine & Radiology, Dr. B.R. Ambedkar Institute of Dental Sciences & Hospital, Patna, Bihar
Corresponding Author : Vaibhav Kumar Garg,Reader, Oral Medicine & Radiology, Dr. B.R. Ambedkar Institute of Dental Sciences & Hospital, Patna, BiharMobile: 093591 04415, E-mail:[email protected]
Oral lichen planus : A diagnostic marker of chronic liver disease
ORIGINAL ARTICLE
Ayush & Health Sciences University of ChhattisgarhO
RIG
INA
L A
RTI
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20 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) ISSN 2348 - 4195
21
disease over long periods, that is, patient is
asymptomatic and completely unaware of the hepatic
status, oral health care professionals, on a careful
examination of the oral cavity with oral lichen planus,
should be aware of possible existence and provide for
timely diagnosis and institution of proper treatment. 5
The present study has been undertaken to find out if
there exists any association with the type of clinical
presentation of oral lichen planus and the level of serum
transaminases.
PATIENTS AND METHODS
The present study comprised of two groups of patients.
A detailed case history performa was recorded for all
the patients.
Study Group : 45 patients of oral lichen planus were
recorded from the out patients attending the
department of Oral medicine. All the patients were
carefully examined for clinical assessment of OLP (their
type and clinical symptoms), subjected to incisonal
biopsy (for histopathological confirmation), and were
subjected to serum SGOT and SGPT levels using BASIC
version of clinical chemistry system manufactured by
SECOMAM, loaded with 2.0 software was used
Control Group: A control group of 45 normal healthy
subjects, without any clinical evidence of oral lichen
planus, were recorded from among the out patients
attending the department of Oral medicine. They were
tested for serum SGOT and SGPT levels.
Following patients were excluded from our study:
1. Patients with habit of alcohol, tobacco
consumption (clinically evident tobacco related
lesions namely leukoplakia, pre-leukoplakia,
erythroplakia, nicotina stomatitis, tobacco
pouch keratosis)
2. Patients with clinically compatible oral
lichenoid lesions who were diagnosed as
having following histopathological features : 6
· The sub epithelial infiltrate is more
diffuse and less bank-like, with deeper
extension in to the connective tissue,
and a more mixed cell population,
including eosinophils and plasma cells.
· Perivascualar infiltrate.
· Parakeratosis.
· Colloid bodies in the epithelial layer.
3. Patients, under medications( NSAIDS,
antibiotics, HMG Co-A-reductase inhibitors,
antiepileptic drugs, antituberculous drugs,
herbal medications, illicit drug use), Celiac
d i s e a s e ; E n d o c r i n e d i s e a s e l i k e
hypothyroidism, Addison's disease; suffering
from Congestive cardiac failure and ischemic
hepatitis, Diseases of striated muscle, Glycogen
storage diseases.
4. Patients with debilitating diseases which
render them unfit for taking biopsy, including
pregnant and lactating women.
5. Any soft tissue oral lesions that had obvious
etiology were excluded, such as cheek biting,
scar tissue, Fordyce's granules, or linea alba &
retro molar hyperkeratosis.
RESULTS AND FINDINGS
In the present study 45 patients with different types of
Oral lichen planus have been recorded. Out of the 45
patients 21 were males and 24 were females. The
mean age of the overall test group, being 38.22 years
with a standard deviation 38.31 9.22.
The test group contained only two types viz, reticular,
(66.67%), which dominated, and the erosive variety
(33.33%). The odds ratio was calculated which were
2.20. Although female patients were more affected with
oral lichen planus, the reticular form of oral lichen
planus was more common among the male patients
(76.20%), than in the female (58.33%) patients. On the
other hand the erosive form of oral lichen planus was
seen to affect female more (41.67%), than the males
(23.80%).
It was found that although reticular type dominated all
the age groups, erosive type was more prevalent than
the reticular type in the 51-60 years of age group.
Oral lichen planus: A diagnostic marker of CLD
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Transaminase levels Control Group (n=45) Test Group (n=45)
Elevated AST levels (>35) 03 11 (M:6; F:5)
Elevated ALT levels(>45) 02 06 (M:4; F:2)
Elevated Transaminase levels (both
AST & ALT)
02 (4.44%) 06 (13.33%)
(M:4; F:2)
Table I
Only aspartate transaminase (AST) levels were elevated
in 11 patients (24.44%), and only alanine transaminase
(ALT) levels were elevated in 6 patients (13.33%) who
also had a raised aspartate transaminase (AST) level.
Therefore out of total of 45 test group 6 patients
(13.33%) had raised transaminase levels (both AST &
ALT). (Table 1). Elevated transaminase levels (both AST
& ALT) was seen more in male than female patients
(Table I, Graph I)
A t-Test was conducted which showed the mean of
aspartate transaminase (AST) level (p=0.035), mean of
the alanine transaminase (ALT) level (p=0.030) and the
mean of transaminase levels (both AST & ALT), for the
two groups viz, control group and the test group as
statistically significant (p=0.30, which was <0.05).
Graph I
The erosive variant was associated with a greater
alteration in transaminase levels (both AST & ALT) than
its reticular counterpart. A t-Test showed this as
statistically significant (p=0.032) (Table II & Graph II)
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)122
Oral lichen planus: A diagnostic marker of CLD
Type of OLP Elevated AST Elevated ALT
Elevated Transaminase levels
(both AST & ALT)
Reticular type 3 (6.67%) 0 0
Erosive type 8 (17.77%) 6 (13.33%) 6 (13.33%)
23
Table II- Elevated AST & ALT levels in the type of oral lichen planus
Graph II
All the cases of raised levels of AST & ALT had lesion of
lichen planus in buccal mucosa, while tongue was also
involved in two cases of raised levels of AST & ALT and
gingiva was also affected in one case each of raised
levels of AST & ALT.
Fig 1A &1B: Reticular Lichen Planus
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Oral lichen planus: A diagnostic marker of CLD
24
Fig 2A & 2B: Erosive Lichen planus
Fig 3A &3B: Erosive Lichen planus
DISCUSSION
The present study has been conducted for clinical
analysis of oral lichen planus with specific reference to
its association with the levels of serum transaminase.
In analyzing 45 cases of oral lichen planus it was found
that incidence of oral lichen planus to be more in
females. This observation is in confirmation with the
previous studies. 7, 8, 9, 10, 11
Oral lichen planus can occur in the age group of 20-60
years, in both male and female sex, but in the present
study it was observed that lichen planus was
predominant in the middle age group, particularly
between 31-40 years age group which was followed by
41-50 years.
Oral lichen planus exists in many clinical forms, but in
the present study only two clinical forms viz; reticular
and erosive could be recorded. The incidence of
reticular lichen planus was the highest in the test group.
This finding matched with the study, where 95% of
patients belong to the reticular variant. 12
The erosive form was more prevalent in females; it was
double the number as compared to males. This finding
matched with a study of seven patients with erosive
lichen planus out of which five were females and two
were males 13
All the cases of lichen planus in the present study were
located on the buccal mucosa. This finding was
observed previously in many studies which stated the
involvement of buccal mucosa ranging from 80% to
94%. There was one case in the hard palate in a female 6
patient.
The present study included two groups viz; test group
(patients with oral lichen planus) and control group
(normal healthy adults) of 45 patients each. Both the
groups were subjected to serum transaminase level
test. At least one of two assays (either AST or ALT)
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Oral lichen planus: A diagnostic marker of CLD
25
showed altered results in 3 patients in the control group
and 11 patients in the test group. Both assays were
raised in 2 patients in the control group and 6 patients in
the test group.
Out of the six patients with elevated transaminase
levels, all had erosive lesions. This is in accordance with
the following previous studies. A study in which five out
of seven patients having chronic liver disease had 14erosive type of lichen planus.
Another study stated that prevalence of liver disease 9 .was higher in erosive than the reticular variety Also
statistical correlation between erosive variant and 18hepatic damage was found . It was observed that
erosive variety occupied a central role in relation to 15
association with chronic hepatopathies. It was
co n c l u d e d t h at t h e e ro s i ve l e s i o n s c l e a r l y
predominated among patients with oral lichen planus 35 who had altered liver test results which also lends
support to the above finding.
In a study on 40 patients with different types of oral
lichen planus, showed that SGOT and SGPT levels, was
elevated in 19 cases (47.5%) and in 4 cases (10%) of
the study group and control group, respectively (P =
0.0002). In relation to the type of oral lichen planus,
out of 15 erosive cases, 80% (12 cases) showed
elevated SGOT/SGPT levels. They concluded that
elevated transaminase levels might be related to the
development of oral lichen planus lesions. There is a
strong association between elevated SGOT/SGPT levels
and detection of erosive type of such lesions 16
Results of a recent study regarding relationship
between transaminase level and type of OLP, about
87.5% patients with erosive forms showed elevated
SGOT/SGPT .These findings are suggestive enough to
indicate that in presence of severe liver pathologies
leading to change in SGOT/SGPT levels (increase) there
is greater tendency to development of aggressive OLP
lesions. From this it can be inferred that the association
of oral lichen planus with liver disorders is not a mere
coincidence17.
The results showed that in the erosive type the average
AST level was found to be 39 IU/L, while the average AST
level in the reticular type was 20.03 IU/L. On the other
hand the average level of ALT in the erosive type was
42.46 IU/L, while than in the reticular type was 23.23
IU/L. This data reinforced the findings of the above 6, 9, 15, 18, 12, 16, 17mentioned studies
Considering the gender involved, among the total of six
patients in which both assays were raised, 4 were males
and 2 females. This finding hits the bull's eye with two
separate studies, in which out of a total number of six
patients who had altered laboratory findings, four were 19, 20males and two were females
The site which was associated with raised levels of both
the assays, was buccal mucosa, which can be attributed
to the fact that the majority of the patients (95%), had
lesions on the buccal mucosa.
Although the aminotransferase levels are an excellent
marker of hepatocellular injury, it is alanine transferase
(ALT), more specific to the liver. Hepatocellular injury
and not necessarily cell death is the trigger for release of 21these enzymes in the circulation.
Since 6 cases (13.33%) of oral lichen planus, among the
test group, had raised levels of both the assays (AST &
ALT), as compared to the control group, in which only
two patients showed an elevated level of both the
assays, it can be safely said, that the proportion of cases
o f o r a l l i c h e n p l a n u s w i t h a l t e r a t i o n o f
aminotransferase were significantly higher than that of
controls (p value being less than 0.05)
In the past few years, several cases of oral lichen planus
with abnormal liver function tests have been observed.
This had prompted many to investigate the occurrence
of abnormal liver function test and / or liver disease in
patients with oral lichen planus and few of the studies 19, 22, 23, 20, 24, 25, have found some association between them.
26, 27, 29
Chronic liver disease comprising primarily of primary
biliary cirrhosis, chronic active hepatitis and hepatic
cirrhosis manifests clinically with signs such as jaundice,
hepatomegaly, splenomegaly, hyperpigmentation,
fatigue, pruritis and elevated serum amino – 27transaminase levels.
The association of chronic liver disease and oral lichen
planus may be derived on an immunological basis. The
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Oral lichen planus: A diagnostic marker of CLD
26
immunopathogenesis is explained by expression of the
MHC class II antigen by the epithelial cells that are 28
attacked and destroyed by activated T cells.
It has been hypothesized that lesions of oral lichen
planus, occur as a part of an immune response to some
antigens presented to T-lymphocytes by epidermal
Langerhans cells that subsequently induce T cell
mediated responses directed against basal layer
24keratinocytes.
It is possible that factors altering keratinocyte
antigenicity may induce reactions that can damage
keratinocytes and to some extent, hepatocytes. It is also
possible that lichen planus is a nonspecific cutaneous
manifestation of certain internal diseases that may or 24may not be limited to liver disorders.
13, 30, 31, 32A simplified hypothesis for the pathogenesis is as follows:
Unknown antigenic change in OMM
Focal accumulation of Langerhans cells within the epithelium
Activated helper/inducer T lymphocyte in the lamina propria.
Expression of ICAM and HLA-DR on the surface of keratinocytes
Influx of cytotoxic/supressor T-cells within the epithelium
Keratinocyte damage
Basal cell degeneration
Pyknotic and shrunken basal cells (civatte bodies)
Pyknotic and shrunken basal cells (civatte bodies)
Apoptosis of Keratinocytes
Failure of Phagocytosis of Apoptotic cells
Colloid bodies (Underlying Dermis)
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Oral lichen planus: A diagnostic marker of CLD
27
In discussing the overall observations of the present
study, it can be said that although, the raised levels of
serum transaminase (AST & ALT), are not specific
marker of chronic liver disease, but in the absence of
other common causes of raised transaminases, it
should raise an eye brow of suspicion, regarding the
hepatic status of that particular patient. The nature of
the clinical presentation of oral lichen planus, should
cast some light on the possible association of the two
diseases, which may turn it into an invaluable clue for
diagnosis, prognosis and monitoring the liver disorder,
as it was observed in the previous studies, where
alterations in at least one or both of the two assays (AST,
ALT), were diagnosed (liver biopsies) to be liver cirrhosis 26,29,16,17 19, 22, 20, 24, 26, 29, chronic active hepatitis primary biliary
cirrhosis 21,27
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c h r o n i c l i v e r d i s e a s e . J A m A c a d
Derm.1986;14(1): 139-40.
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Dermatologia (GISED).Epidemiological
evidence of the association between lichen
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Alopecia areata and ulcerative colitis. Arch
Dermatol.1991, 688-691.
13. Lodi G, Scully C et al. Current controversies in
oral lichen planus: report of an international
consensus meeting. Part 1. Viral infections and
etiopathogenesis. Surg Oral Med Oral Pathol
Oral Radiol Endod. 2005 ;100(1):40-51.
14. Lodi G, Scully C et al. Current controversies in
oral lichen planus: report of an international
c o n s e n s u s m e e t i n g . Pa r t 2 . C l i n i c a l
management and malignant transformation.
Surg Oral Med Oral Pathol Oral Radiol Endod.
2005;100(2):164-78.
15. Olmo del J.A. et al.Oral lichen planus and
hepat ic c i r rhos i s . Anna ls o f Interna l
Medicine.1989;110(8):666.
16. Ali AA and Suresh CS. Oral lichen planus in
relation to transaminase levels and hepatitis C
virus. JOPM 2007; 36(10): 604–608.
17. Chalkoo AH. Oral Lichen Planus. Relation with
transaminases levels and diabetes. JIAOMR
2010;22(1):1-3
18. Matarasso S. et al. Lichen planus Orale ed
epatopatie Croniche.Minerva Stomatol. 1989;
38:795-800.
19. Limdi J K and Hyde G M.Evaluation of abnormal
liver function tests. Postgrad. Med. J. 2003; 79:
307-312.
20. Powell F.C. et al.Lichen planus, primary biliary
cirrhosis and penicillamine. Br J Dermatology.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Oral lichen planus: A diagnostic marker of CLD
28
1982;107:616.
21. Kouroumal is E l ias and Notas George.
Pathogenesis of primary biliary Cirrhosis: A
unifying model. World J Gastroenterol
2006;12(15):2320-2327.
22. Rebora A et al. Chronic Active Hepatitis and
L i c h e n P l a n u s . A c t a D e r m Ve n e r o l
(Stockh),.1981;62:351-352.
23. Korkij Wiwat et al.Liver abnormalities in
patients with lichen planus. J Am Acad
Dermatol.1984: 11:609-615.
24. Alfredo Rebora and Rongioletti Franco.Lichen
planus and chronic active hepatitis – A
retrospective study. Acta Derm Venereol
(Stockh). 1984: 64:52-56.
25. Epstein O. Lichen Planus and Liver disease;
British Journal of Dermatologists.1984, 111:
473- 475.
26. Barry Monk Lichen planus and the liver.
J Am Acad Dermatol.1985:12(1):122-123.
27. Scully Crispian et al.Update on oral lichen
planus: Etiopathogenesis and management.
Crit Rev Oral Biol Med. 1988; 9(1):86-122.
28. Carmen Gheorghe; lelia mihai, loanina
parlatescu, serban tovanu. Medica-a Journal of
Clinical Medicine, 2014; 9(1):98-103.
29. Strauss A. Robert et al. The association of
mucocutaneous lichen planus and chronic liver
disease. Oral Surg Oral Med Oral Pathol.1989;
68:406-10.
30. Sugerman P.B., Savage N.W. et al. The
pathogenesis of oral lichen planus. Crit Rev Oral
Biol Med 13(4):350-365 (2002)
31. Sugerman PB, Savage NW. Oral lichen planus:
Causes, diagnosis and management. Australian
Dental Journal 2002;47:(4):290-297
32. Boorghani Marzieh, Gholizadeh Narges et al.
Oral Lichen Planus: Clinical Features, Etiology,
Treatment and Management; A Review of
Literature. JODDD 2010; 4 (1).
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Oral lichen planus: A diagnostic marker of CLD
1 2 3 4 5C.Dhinesh Kumar , Jayashree Mohan , N.Vidyasankari , Deepesh K Gupta , S.Senthil kumar , 6
Indumathi1. Senior Lecturer, Department of Prosthodontics, JKK Nataraja Dental College, Salem (TN)2. Professor & HOD, Department of Prosthodontics, VMS Dental College, Salem (TN)3. Reader, Department of Prosthodontics, K.S.R Dental College, Salem (TN)4. Reader, Department of Prosthodontics, Govt. Dental College, Raipur (CG)5. Professor, Department of Restorative dentistry, JKK Nataraja Dental College, Salem (TN)6. Reader, Department of Prosthodontics, Bheemavaram (AP)
Corresponding Author:Dr. N.Vidyasankari, 12 S.S.D Road, Thiruchengodu (TN)Contact Number – 919443940244, E-Mail ID: [email protected]
ABSTRACT
The semi-adjustable articulators are being used in the fabrication of complete dentures are commonly programmed
using the interocclusal records. This study was conducted to evaluate the interarticulator reproducibility of
protrusive condylar guidance registration in four semi-adjustable articulators Hanau®Wide Vue ,WhipMix® Model
No.2240, Stratos® 300, Dentatus®ARH semi-adjustable articulators with two interocclusal recording materials in
completely edentulous patient. The Quick setting plaster and Luxabite (bisacrylic composite) was used as
interocclusal recording materials to program the protrusive condylar guidance angles in the articulators..The
reproducibility of protrusive condylar guidance registrations between materials and between articulators was
compared with the radiographically determined angle of inclination of articular eminence and protrusive condylar
path angles. The study was concluded that the Luxabite material demonstrated better reproducibility of protrusive
condylar guidance registration than the Quick setting plaster. The Non-arcon Dentatus® ARH semi-adjustable
articulator showed reliable registration of protrusive condylar guidance angulations when compared to the
radiographically determined angle of inclination of articular eminence to Frankforts horizontal plane. The Arcon
articulators – Hanau® Wide Vue ,Stratos® 300, WhipMix® Model No.2240 , showed better reproducibility of
protrusive condylar guidance angles when compared to the radiographically determined protrusive condylar path
angles obtained from Quick setting plaster record and Luxabite material record.
Keywords : Interoccclusal record, Protrusive condylar guidance, Semi-adjustable articulator.
A comparative evaluation of inter articulator reproducibility of protrusive condylar guidance registration in four
different semi adjustable articulators using two differentrecording materials
ORIGINAL ARTICLE
Ayush & Health Sciences University of Chhattisgarh
OR
IGIN
AL
AR
TIC
LE
29Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) ISSN 2348 - 4195
INTRODUCTION
The International Prosthodontic Workshop on
Complete Denture Occlusion at the University of
Michigan in 1972 classified articulators into four 1
classes Class I, Class II, Class III and Class IV based on
instrument's function.²The so called Semi-adjustable
articulators comes under Class III classification that
stimulates condylar pathways by using averages or
mechanical equivalents for all or part of the motion.
These instruments may be arcon or non arcon and
allow orientation of the casts relative to the TMJs. They
are more popularly used in construction of several
prosthesis for their simplicity in handling and
programming. Interocclusal records either protrusive or
lateral records are used to program the condylar
guidance values of the semi-adjustable articulators. In
this study the horizontal condylar guidance angles
obtained with the two interocclusal recording materials
Quick setting plaster and Luxabite-bisacryl composite in
all four semi-adjustable articulators Hanau® Wide Vue,
WhipMix® Model No.2240, Dentatus® ARH and
Stratos® 300 were compared with radiographically
determined protrusive condylar path and anatomic
angle of inclination of articular eminence to determine
the ideal interocclusal material and articulator for
obtaining the accurate horizontal condylar guidance of
the completely edentulous patient.
OBJECTIVES OF THE STUDY
1) To compare the effect of two interocclusal
recording materials namely Quick setting plaster,
a n d b i s a c r y l i c co m p o s i te ( L u xa b i te ) o n
reproducibility of protrusive condylar guidance
records.
2) To compare the inter articulator reproducibility of
protrusive condylar guidance records in four semi-
adjustable articulators (Hanau® Wide Vue,
WhipMix® Model No.2240, Dentatus® ARH and
Stratos® 300) in completely edentulous patient.
3) To compare the radiographic protrusive condylar
guidance values obtained in all four semi-
adjustable articulators from Quick setting plaster
record and Luxabite record with angle of inclination
of articular eminence in lateral cephalograph.
METHODOLOGY
The completely edentulous patient with ideal Class I
ridge relation, proper vertical dimension and
neuromuscular coordination was selected for the study.
Impressions and master cast for maxillary and
mandibular arches were fabricated and duplicated into
four pairs for articulating in four semi-adjustable
articulators. Four set of maxillary casts were mounted
onto four different semi-adjustable articulators with
facebow transfer (Fig-1) followed by mandibular casts
mounted in tentative centric relation. The Extraoral 16Gothic arch tracer with the pin was attached to the
maxillary occlusal rim and correspondingly the tracing
plate was attached to the mandibular occlusal rim. The
occlusal rims with the tracers were inserted into the
patient mouth and the centric, right lateral, left lateral
and protrusive movements were obtained in the form
of Arrow point tracing. The centre of the arrow
represents the centric position, the right and left arms
representing right and left lateral movements and the
central line represents the protrusive movement. The
interocclusal recording materials used in the study are
Bis-acrylic bite registration resin and Luxabite (DMG,
Germany), Quick setting plaster. The Quick setting 12 plaster was obtained by mixing the 50g of Dental
Plaster Type II with 30 ml of isotonic saline containing
sodium chloride (which accelerates the setting of the
plaster to 2%) and anti-expansion solution containing
4% potassium sulphate. Six interocclusal records were
made using each material and these records were used
to program the four semi-adjustable articulators.(Fig-
2). Two operators performed the articulator settings for
all the protrusive interocclusal records to prevent
operator bias. The horizontal condylar guidance angles
recorded in each articulator for each of the protrusive
interocclusal records was noted and tabulated. Total of
48 interocclusal records with 96 horizontal condylar
guidance readings are obtained. The values are
stastically analysed to compare the repeatability of
recordings within and between the articulators Lateral
Cephalometric radiographs were made with centric
position and protrusive position using Gothic arch
Inter articulator reproducibility of protrusive condylar guidance
30 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
31
tracers with interocclusal recording materials Quick
setting plaster, Luxabite (DMG, Germany) for both right
and left sides of the patient.(Fig-3,4,5,6). The tracings of
the radiographs were done. The tracings of the
protrusive condylar positions were overlapped onto the
tracing of centric positions for both right and left sides 4,5,10.The angle between the protrusive condylar path and
the Frankfort horizontal plane were measured for both
sides.The mean protrusive condylar guidance values of
both right and left sides obtained with two different
interocclusal recording materials in four different semi-
adjustable articulators was then compared with the
protrusive condylar path angles of right and left sides to
the Frankfort horizontal plane, obtained from
radiographic tracings.The angle formed between the
slope of the articular eminence and Frankfort
Horizontal plane may also be value in setting the 10,13condylar guidance in semi-adjustable articulators .
Fig-1-Semi-adjustable Articulators and Facebows used in the study.
Fig -2-Protrusive Interocclusal records made with Quick setting plaster and Luxabite
Fig-3&4- Lateral cephalometric radiograph and cephalometric tracing showing Centric position.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Inter articulator reproducibility of protrusive condylar guidance
The condylar path from centric to protrusive position
follows the slope of the articular eminence.There exists
strong correlation between the protrusive condylar
path and the inclination of articular eminence which
was mathematically expressed and stastically
described. So in Lateral Cephalometric radiographs
made with centric position's the angle of inclination of
articular eminence was marked.i.e. the angle formed at
the intersection of the two lines-the slope of articular
eminence and tangent to Frankforts horizontal plane
was noted down which gives degree of inclination of
articular eminence to horizontal plane (34 ).This value
was used to compare the condylar guidance values
obtained from Cephalometric tracing with two
interocclusal recording materials Quick setting plaster,
Luxab i te (DMG, Germany) . Descr ipt ive and
comparative statistics are presented as Mean, Standard
Deviation and Coefficient of Variance.(Tables-1,2,3,4).
Two-way ANOVA was also carried out to know possible
interaction effect (interocclusal recording materials X
articulators) on protrusive condylar guidance
angles.Average deviations from the reference angles
obtained from radiographic tracings of protrusive
condylar path angle to the Frankfort horizontal plane
was also presented for determining the articulator
ability to simulate patient's protrusive condylar
guidance angle.(Fig-7,8).
Fig-5&6- Lateral cephalometric radiograph and cephalometric tracing showing protrusive position.
Fig-7-Arrticulators records made of Quick setting plaster to angle of slope of articular eminence.
Fig-8-Arrticulators records made of Luxabite to angle of slope of articular eminence.
32 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Inter articulator reproducibility of protrusive condylar guidance
33
Table.1..Comparison of Protrusive condylar guidance angles in four articulators with two interocclusal recording
materials to the reference condylar path angle to the Frankfort horizontal plane,obtained from radiographic tracings
using protrusive records of two materials Quick setting plaster and Luxabite .
Reference angle In
degrees
Hanau® Dentatus® Stratos® WhipMix®
Quick setting
plaster
41.5o
41.8o
▲ = 0.3
%=0.7
38.2o
▲ =-3.3
%=8
40.8o
▲ =-0.7
%=1.7
39.6o
▲ =-1.9
%=4.6
Luxabite
37o
36.6o
▲ =-0.4
%=1.1
35.6o
▲ =-1.4
%=3.8
36.7o
▲ =-0.3
%=1
36.1o
▲ =-0.9
%=2.4
RESULTS
1) The Luxabite recording material gave better
reproducibility than Quick setting plaster with less
variation of protrusive condylar guidance angle
value(1.4 – 0.3 more than radiographic value) in all
four semi-adjustable articulator with relation to
radiographically determined protrusive condylar
path angle with Luxabite record and of about only
3 more than radiographic value of angle of o
inclination of articular eminence(34 ).
2) The Non-arcon Dentatus® ARH semi-adjustable
articulator showed reliable registration of
angulations with minimumpercentage deviation of
4.7% than the Arcon articulators - WhipMix® Model
No.2240 , Hanau® Wide Vue ,Stratos® 300 when
compared to the radiographically determined
angle of inclination of articular eminence to
Frankforts horizontal plane i.e (34 ) which can be
taken as a guide in setting Protrusive condylar
guidance registrat ion in semi-adjustable
articulators.
3) The Arcon articulators - Hanau® Wide Vue ,Stratos®
300 WhipMix® Model No.2240 , showed better
reproducibility of protrusive condylar guidance
angles when compared to the radiographically
determined protrusive condylar path angles.The
Hanau® Wide Vue showed minimum percentage
deviation of 0.7%,Stratos® 300 (1.7%),WhipMix®
Table.2. Comparison of the reference condylar path angle to the Frankfort horizontal plane,obtained from
radiographic tracings using protrusive records of two materials Quick setting plaster and Luxabite to the
radiographically determined angle of slope of articular eminence.
Refernce angle-angle of slope of
slope of articular eminence Quick setting plaster Luxabite
34o
41.5o
▲ = -7.5
%=22
37o
▲ = -3
%=9
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Inter articulator reproducibility of protrusive condylar guidance
model no.2240(4.6%),Dentatus® ARH showed
maximum percentage deviation of 8% when
compared to the radiographic value.
DISCUSSION
Stimulation of jaw movements in an articulator
requires the articulation parameters to be registered at
the patient and transferred to the mechanical device
(articulator). These parameters comprise of the
protrusive condylar guidance angle, the Bennett angle,
the inter-condylar distance, and the spatial relations of
the dental arches with respect to the inter-condylar
axis. If articulator settings do not match the patient's
individual parameters, the developed occlusion in the
prosthesis may be of inaccurate and hampering the
function. According to Weinberhg (1963)². “neither
Arcon and nonArcon articulators has mathematical
advantage over the other and they produce the same
motion of condylar ball on the inclined plane”thus the
arcon as well as non-arcon articulators gave the same
registration of protrusive condylar guidance angle
irrespective of the materials and methods. Among the
articulators the Non-Arcon semi-adjustable articulator
showed significantly less reproducibility of protrusive
condylar guidance angle value than the Arcon semi-
adjustable articulators using both the materials Quick
setting plaster record and Luxabite record when
compared to the the radiographic value of protrusive
condylar path angles .But when compared to the
radiographically determined angle of inclination of
articular eminence to Frankforts horizontal plane i.e (34
) which can be taken as a guide in setting Protrusive
condylar guidance registration in semi-adjustable
articulators, the Nonarcon Dentatus® ARH articulator
showed reliable registration of angulations than the
Table.3.Comparison of Protrusive condylar guidance angles in four articulators obtained with Quick setting plaster
interocclusal records to the radiographically determined angle of slope of articular eminence.
Refernce angle –
Angle of slope of
articular
Hanau®
Dentatus®
Stratos®
WhipMix®
34o
41.8
Δ=-7.8
%=23%
38.2
Δ=-4.2
%=12.4%
40.8
Δ=-6.8
%=20%
39.6
Δ=-5.6
%=16.5%
Table.4. Comparison of Protrusive condylar guidance angles in four articulators obtained with Luxabite interocclusal
records to the radiographically determined angle of slope of articular eminence.
Refernce angle-
angle of slope of
articular eminence.
Hanau®
Dentatus®
Stratos®
WhipMix®
34o
36.6
Δ=-2.6
%=7.6%
35.6
Δ=-1.6
%=4.7%
36.7
Δ=-2.7
%=8%
36.1
Δ=-2.1
%=6%
%= Percentage deviations
▲= Mean deviations from reference angle-ve = negative sign indicated higher value compared to reference angle.
34 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Inter articulator reproducibility of protrusive condylar guidance
35
Arcon articulators - WhipMix® Model no.2240 , Hanau
Wide Vue Stratos® 300 . Brewka,Gilboa et al Norman
E.Corbett used cephalometric radiographic analysis 14
for their studies on protrusive condylar path
registrations in semi-adjustable articulators.Hence the
lateral cephalometric radiograph method of
comparative analysis was followed in this study.
Jankelson (1962), Ren YF, Isberg A, Westesson(1991),
Pammekiate S, Petersson A, Akerman S (1995), Gilboa.
Cardash, Kaffe, Gross(2008), Gilboa et al(2008) have 13
shown that the angle formed between the slope of the
articular eminence and Frankfort Horizontal plane may
also be value in setting the condylar guidance in semi-
adjustable articulators.Hence we determined the
inclination of articular eminence to Frankforts
horizontal plane in lateral cephalogram to predict the
horizontal condylar guidance value for programming
the articulator without using the protrusive
interocclusal records. Among the materials the Luxabite
recording material gives the nearly reliable protrusive
condylar guidance angle value in all four semi-
adjustable articulator with relation to radiographically
determined protrusive condylar path angle and also
with radiographically determined angle of inclination
of articular eminence to Frankforts horizontal plane.
Skurnik emphasized that the bisacrylic resin is easy to 11
handle and has reproductive accuracy and is rigid when
it sets; making it a good bite registration material for
fixed, removable, unilateral and bilateral restorations.
Although the angulations registered in each of the
articulator differ they may produce similar mandibular
movements as the condylar assemblies manufactured
by the different companies may vary and the
graduations will be given according to some relative
values. The articulators need to be more freely adjusted
to the interocclusal records so that they can be
programmed more easily and accurately.
CONCLUSION
From the analysis of this study the setting of protrusive
condylar guidance angle value in semi-adjustable
a r t i c u l a t o r w a s i n f l u e n c e d b y r e c o r d i n g
materials,methods and also the inclination of articular
eminence to Frankfort horizontal plane . So further
research and evaluation can be attempted to correlate
this inclination of articular eminence to protrusive
condylar path settings of the articulators.The
interocclusal recording materials Quick setting plaster
and Luxabite i.e from the oldest to recent materials was
compared in this study and the Luxabite material was
dimensionally stable and made more precise
protrusive interocclusal record in edentulous patients
for programming the horizontal condylar guidance of
the semi adjustable articulators. The ideal combination
of material and technique for making interocclusal
records along with proper articulator selection would
allow the fabrication of complete dentures in
edentulous pat ients with minimum occlusal
interferences and mandibular movements.
REFERENCES
1) Gysi, A. Some reasons for the necessity of using
adaptable articulators.Dent Dig.37 ; 224-1931.
2) Articulator development and condylar paths in
full denture prosthesis.-Balkwill., reviewed by
Gillis.J.Am.Dent.Assoc.1926.13;2.
3) Hanau®.R.L.DentalEngineering.Reprinted
from.J.Nat.Dent,Ass.July,1922
4) Olsson A,Posselt U.Relationship of various skull
reference lines.J Prosthet Dent.1961;11:1045-
9.
5) Posselt U, Skyttting, B.Registration of the
condyle path inclination:variations using the
Gysi technique.J Prosthet Dent.1960;10:243-
47.
6) Needles; J. W. Mandibular movements and
articulator design.J.A.DA.10;927;1923.
7) I l a n G i l b o a . H a r o l d S . C o n d y l a r
guidance.Correlation between articular
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Inter articulator reproducibility of protrusive condylar guidance
morphology and Panoramic images in Dry
Human Skulls.J Prosthet Dent.2008.pg no-477-
82.
8) Weinberg LA.Arcon principle in the condylar
mechanism of adjustable articulators.J
Prosthet Dent.1963; 13:263-68..
9) We i n b e rg L A . A N eva l u at i o n o f b a s i c
articulators and their concept parts.J Prosthet
Dent.1963;13-622-663,873-887.
10) Domagoj-Davor-Denis.Josip-comparative
study of condylar inclination settings in two
types of semi-adjustable articulators-J Prosthet
dent-2009-33(2).431-5.
11) J L Vivas, M Sierraalata ; Interocclusal record
fabricated with bis- acrylic composite resin ans
vinyl polysiloxane registration material; J
Prosthet Dent 2009: 102:199-2008.
12) Anusavice; Philips science of Dental materials.
Eleventh Edition, India 2003; Saunders
Publication.
13) Norman E.Corbett.Robert Huffer.The Relation
of Articular eminence to Condylar Path in
Mandibular Protrusion.Vol.41.no.4.Journal of
orthodontics. Oct 1971.pg.no.286-292.
14) Brewka RE. Pantographic evaluation of
cephalometric hinge axis. Am J Orthod 1981;
79: 1-19. Analysis of the condyle/fossa
relationship in Kennedy class I and IIpartially
edentulous subjects*Nuran Yanikoglu1, M.
Ustun Guldag.OHDMBSC - Vol. V - No. 1 -
March, 2006.
15) Yoshiyuki Watnabe.Observation of Horizontal
mandibular positions in an edentulous patients
using digital gothic arch tracers.A Clinical
report.J Prosthet dent.2004.91;15-9.
16) Preti G, Scotti RS,Bruscagin C.A clinical study of
graphic registration of the condylar path
inclination .J Prosthet Dent 1982;48-461-6..
36 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Inter articulator reproducibility of protrusive condylar guidance
37
INTRODUCTION
A negative replica made with an impression material
must be securely attached to the tray to assure an
accurate impression resulting in dimensionally stable
cast. As the mechanical locking of the impression 1
material with the custom tray is minimal, some means
of bonding is to be provided to secure the same to the
tray. Hence the accuracy and consistency are best
maintained with the help of adhesive between custom
tray and impression. Metal and plastic trays are used 2
routinely for dental impressions with the putty
material, but chances of air entrapment are more and
hence not accurate as custom trays. The use of custom
tray is recommended to reduce the quantity of material
for making impression. Therefore, any dimensional
changes attributed to the materials can be minimized.3
Silicone impression materials used for border molding
require sufficient working time, especially while
1 2 3 4 5Adarsh Shetty , Jagadish Konchada , Balasubramaniyan R , Shailendra Sahu , Anurag Dani , 6Manikandan R
1. Senior Lecturer, Department of Prosthodontics, Yogita Dental College & Hospital, Khad (MH)2. Senior Lecturer, Department of Prosthodontics, C D C R I, Rajnadngoan, (CG)3. Professor, Department of Prosthodontics, Rajah Muthiah Dental Coleege & Hospital, Chidambaram, (TN)4. Reader, Department of Prosthodontics, C D C R I, Rajnadngoan, (CG)5. Reader, Department of Prosthodontics, C D C R I, Rajnadngoan, (CG)6. Senior Lecturer, Department of Prosthodontics, Rajah Muthiah Dental Coleege & Hospital, Chidambaram, (TN)
Corresponding author :Anurag Dani, Prosthodontist, Dani Hospital, Kelabadi, Civil Lines, Durg-491001,Chhattisgarh.Email: [email protected], Phone: 09893464987
ABSTRACT
Statement of problem: Clinicians tend to add petroleum gel with polyvinyl siloxane impression materials to extend
working time especially while doing border molding in mandibular arches.
Purpose: To know the effect of petroleum gel on tensile bond strength between tray adhesive and poly vinyl siloxane
impression materials
Material and Methods: a study was carried out in 120 identical specimens, out of which 60 were used as control
Group –A, impression material was manipulated as per manufacturer instructions. Remaining 60 were used as
Group- B in which petroleum gel (0.3ml) was included while manipulating impression material. The difference in
tensile bond strength between the groups is to be evaluated.
Results: The results revealed that tensile bond strength measured high for control group-A than the test group-B.
Conclusion: Addition of Petroleum gel, however, increased the working time, but decreased the effective tensile
bond strength between the tray adhesive and the resin custom tray.
Keywords: Tensile bond strength, Polyvinyl Siloxane impression material, Tray adhesive, Petroleum gel.
Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane manipulated with
and without petroleum gel : An invitro study
ORIGINAL ARTICLE
Ayush & Health Sciences University of Chhattisgarh
OR
IGIN
AL
AR
TIC
LE
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)ISSN 2348 - 4195
Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane
38
working in mandibular arch. Clinicians tend to add
Petroleum gel with polyvinyl siloxane impression
materials to extend the working time. A pilot study was
conducted to evaluate the Effect of Petroleum gel on
working time and setting time of poly vinyl siloxane
(Aquasil, Dentsply) impression material. The results
obtained from the pilot study proved that the working
and setting time of the impression material is increased.
Further, this fact initiated us to know the effect of
petroleum gel on tensile bond strength between the
tray adhesive and poly vinyl siloxane impression
material. Studies have been done to evaluate the tensile
bond strength between poly vinyl siloxane impression
material and tray adhesive. The present study is aimed
at evaluating the difference in tensile bond strength
between tray adhesive and poly vinyl siloxane
impression material manipulated with and without
petroleum gel.
MATERIALS AND METHODS
The study was conducted on 120 identical specimens,
out of which 60 were used as control Group-A,
impression material was manipulated as per
manufacturer instructions. Remaining 60 were used as
Group-B in which Petroleum gel (0.3ml) was included
w h i l e m a n i p u l a t i n g i m p r e s s i o n m a t e r i a l .
The difference in tensile bond strength between the
groups is to be evaluated. Acrylic resin specimens of
uniform size are made using metal mould (30mm ×
1.5mm) to standardize. Following the manufacturer's
recommendation acrylic resin was mixed and poured
into the metal mould. Hundred and twenty identical
round acrylic resin tray specimens were obtained
(Figure-1). The tray specimen was allowed to
polymerize and the excess material beyond the mold
was trimmed. A small (1 inch) attachment screw was
inserted into the tray specimen when it is in dough
stage, on the opposite side of the test surface. The test
surface was polished with 80 grit sand paper and tray
adhesive (caulk, Dentsply) was applied once uniformly
and allowed to polymerize for 15 minutes (Figure-2). A
standard round die stone mould of 30 mm inner
diameter and 3 mm depth without undercuts and
smooth inner surface was made ready for making
uniform sized impression material specimens (Figure-
3). Each test consists of two acrylic specimens with
impression material in between. The difference in
tensile bond strength between the tray adhesive and
poly vinyl siloxane in group A and group B was
evaluated.
To evaluate the bonding efficiency of the tray adhesive
on acrylic specimens, Universal testing machine is used.
The test side of the first tray specimen which was coated
with tray adhesive is attached to the PVS impression
material (Aquasil, Dentsply) (Figure-4). The optimum
technique for the use of poly vinyl siloxane impression is
to construct a custom tray and make the impression. 4
Thus the material used in this study was poly vinyl
siloxane -putty impression material (Aquasil, Dentsply).
In the mould and the impression material was taken
along with that. Adhesive coated free surface of the
second tray specimen is attached with the free end of
Figure-1: Acrylic Resin Specimens.
Figure-2: Tray Specimen Treated With 80 Grit Sand Paper And Tray Adhesive Applied.
Figure-3: Stone Mould.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
39
the impression material. Excess material beyond the
tray specimens was carefully removed with sharp BP
blade. Care was taken not to compress the impression
material. The whole assembly was allowed to
polymerize for 5 minutes as recommended by the
manufacturer. (Group-A)
According to pilot study, 0.5 ml of petroleum gel added
to the impression material, increased the working time
by two folds. As our area of concern was regarding the
tensile bond strength such an extended working time
was not desired and so decided to add less amount of
Petroleum gel (0.3ml). To ensure homogenous mix of
Petroleum gel with putty impression material, polyvinyl
siloxane base material was mixed with Petroleum gel
(0.3ml) at the first instant, followed by the accelerator
with Petroleum gel mixed base. Thus 30 remaining
samples were prepared which formed the Test Group-B.
Adhesive applied tray specimens was attached to the
impression material in the mould as like control Group-
A. Each of the Group-A and Group-B assembled
specimens was attached to the Universal testing
machine (SERVO, UNITEK -94100, Crosshead speed:
0.5mm-250mm/min Load range: 0-100KN) (Figure-5)
with bigger size hooks. The specimens were tested for
its tensile strength using automated universal testing
machine which offered the facility of recording the
exact bond strength during the time of detachment of
the impression materials from the tray specimens.
RESULTS
Tensile bond strength between the tray adhesive and
poly vinyl siloxane impression materials are measured
in KN (Kilo Newton). In group-A (control group) the
minimum tensile bond strength measured as 0.070 KN
and a maximum as 0.120 KN (Table-1). In group-B (test
group) the minimum tensile bond strength measured as
Specimen No. Bond Strength Specimen No. Bond Strength Specimen No. Bond Strength
1 0.080 11 0.085 21 0.095
2 0.070 12 0.085 22 0.085
3 0.070 13 0.095 23 0.095
4 0.085 14 0.085 24 0.115
5 0.115 15 0.085 25 0.100
6 0.070 16 0.080 26 0.100
7 0.100 17 0.075 27 0.090
8 0.075 18 0.070 28 0.070
9 0.080 19 0.090 29 0.120
10 0.085 20 0.070 30 0.105
Table-1: Representing Control Group- A specimens (where bond strength is measured without addition of Petroleum gel with impression material)
Figure-4: Aquasil (dentsply) Putty And Tray Adhesive.
Figure-5: Universal Testing Machine.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane
40
0.050 KN and a maximum as 0.090 KN (Table-2). The
results thus obtained ( Table- 1and Table- 2 ) were
evaluated statistically for p-value as given in (Table-
3).Mean average values obtained for group A is 0.09 and
group B is 0.07 with a significant p-value 0.001
DISCUSSION
An impression made with an impression material must
be securely attached to the tray to assure an accurate
impression resulting in dimensionally stable cast. It has 1
been suggested that custom trays to be fabricated at
least 24 hours before the impressions are made,
allowing the material to become dimensionally stable.
Autopolymerising custom tray material is most
commonly employed for tray fabrication because of
ease in fabrication and is cost effective as compared to
visible light cured resin. Hence the samples in this study 1
were made with the auto-polymerising custom tray
material. As the mechanical locking of the impression
material with the custom tray is minimal, some means
of bonding is to be provided to secure the same to the
tray. Hence the accuracy and consistency are best
maintained with the help of adhesive between custom
tray and impression. Metal and plastic trays are used 2
routinely for dental impressions with the putty
material, but chances of air entrapment are more and
hence not accurate as custom trays. The use of custom
tray is recommended to reduce the quantity of material
for making impression. Therefore, any dimensional
changes attributed to the materials can be minimized. 3
The custom acrylic resin trays with occlusal stops ensure
a uniform distribution of impression material.5,6,7
Addition of petroleum gel when manipulating PVS putty
material is widely believed technique. It increases the
working and setting time. It provides sufficient time for
the intraoral procedures to be carried out. The tensile
bond strength between tray adhesive and poly vinyl
siloxane impression material showed a significant
difference in the values between Group A and B.
According to results obtained test specimen mixed with
Petroleum gel (Group-B) showed less bond strength
than the specimen without Petroleum gel (Group-A).
PVS material for the test specimens were hand mixed,
whereas it is strongly recommended that the materials 8should be automixed. Mixing time variation between
the samples could also be the reason for difference
within the test groups. Moreover when a auto mixing
dispenser is used, less chances of air entrapment is
been proved. In this study impression material was
Specimen No. Bond Strength Specimen No. Bond Strength Specimen No. Bond Strength
1 0.060 11 0.085 21 0.055
2 0.060 12 0.050 22 0.050
3 0.080 13 0.065 23 0.080
4 0.050 14 0.065 24 0.090
5 0.060 15 0.080 25 0.065
6 0.070 16 0.065 26 0.090
7 0.080 17 0.085 27 0.090
8 0.075 18 0.070 28 0.065
9 0.060 19 0.070 29 0.065
10 0.060 20 0.070 30 0.075
Table-2: Representing Test Group- B specimens (where bond strength is measured with
addition of Petroleum gel with impression material).
Groups N Mean SD t-value p value
Group A 30 0.09 0.01 5.792 0.001
Group B 30 0.07 0.02
Table-3: Mean comparison between Group-A and Group-B.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
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41
hand mixed and attached to the tray resin material, with
hand pressure and every effort was made to maintain
the even thickness between the test specimens. So
chances of air inclusions between the adhesive layer
and the PVS materials are always present. According to
the results obtained from the study it showed less bond 2,9,10strength when compared with previous studies.
Inclusion of Petroleum gel, may also be the reason for
decrease in bond strength.
Retention of an impression adhesive on a tray material
depends on the ability of solvent in the adhesive to
dissolve the tray material. Actually dimethyl
polysiloxane reacts with the tray material to create
micro porosities so that the adhesive bonds physically
and mechanically. Role of Petroleum gel on dimethyl
polysiloxane is not known .So this also could be the
reason for decrease in bond strength when Petroleum
gel is used.
CONCLUSION
The results revealed that tensile bond strength
measured high for control group than the test group.
Addition of Petroleum gel, however, increased the
working time, but decreased the effective tensile bond
strength between the tray adhesive and the resin
custom tray. Reasons for decrease in tensile bond
strength may be attributed to Inclusion of Petroleum
gel.
Impression materials were hand mixed; auto mixing is
preferred to avoid air inclusion and to ensure
homogenic mix.
Elastomeric impression materials should be stored in
23 C, whereas study was carried out in room 0
temperature of (30-32 C). 0
Further studies are required to know the role of
petroleum gel with impression material in altering the
working time and alteration of properties of the
impression material.
BIBILOGRAPHY
1. Abdhullah M A, Talic Y F. The effect of custom tray
material type and fabrication technique on tensile
bond strength of impression material adhesive
systems. Oral Rehabilitation 2003;30:312-17.
2. Anusavice K G. Impression materials: Science of
dental materials. Chapter 9: Craig R G, Powers J M
Editors. Philips science of dental materials.
Saunders publication;1995: p 205-54.
3. Bindra B, Heath JR. Adhesion of elastomeric
impression materials to trays. Oral Rehabilitation
1997; 24 (1):63-9.
4. Bolton LJ, Gage JP, Vincent PF, Basford KJE. A
laboratory study of dimensional changes for three
elastomeric impression materials using custom and
stock trays. Aust Dent J 1996;41(6);398-04.
5. Bomberg TJ, Goldfogel MH, Bomberg SE.
Consideration for adhesion of elastomeric
impression materials to impression trays. J Prosthet
Dent 1988:60(6):681-84.
6. Chai J Y, Jameson L M, Moser J B, Hesby R A.
Adhesive properties of several impression material
systems: Part2. J Prosthet Dent 1991:66(3):287-92.
7. Chai J Y, Jameson L M, Moser J B, Hesby R A.
Adhesive properties of several impression material
systems: Part1. J Prosthet Dent 1991:66(3):201-9.
8. Chee WWL, Donovan TE. Poly Vinyl Siloxane
Impression Materials: A Review Properties And
Techniques. J Prosthet Dent 1992: 68(5):728-32.
9. Chee WWL, Alexander ML. Impression technique
for arches requiring both implant and natural tooth
restorations. J Prosthodont 1998; 7(1):45-8.
10. Cho G C, Donovan T E, Chee W W L, White S N.
Tensile bond strength of polyvinyl siloxane
impressions bonded to a custom tray as a function
of drying time. Part time(1). J Prosthet Dent
1995;73(5):419-23.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane
1 2 3 4 5 6Chinar Fating , Rolly Gupta , Anil Agrawal , Rana K Varghese , Gopkumar Nair , Preeti Thakur1. Senior Lecturer, Department of Oral Medicine and Radiology, CDCRI, Rajnandgaon, Chhattisgarh, India.2. Senior Lecturer, Department of Oral Pathology and Microbiology, CDCRI, Rajnandgaon, Chhattisgarh, India. 3. Senior Lecturer, Community and Preventive Dentistry, New Horizon Dental College , Bilaspur , Chhattisgarh , India4. Prof. and Head, Department of Conservative Dentistry, New Horizon Dental College , Bilaspur , Chhattisgarh , India5. Prof. and Head, Deartment of Oral Medicine, New Horizon Dental College , Bilaspur Chhattisgarh , India 6. MS (Ayurved)
Corresponding Author: Dr. Chinar Fating, Senior Lecturer, Department of Oral Medicine and Radiology, CDCRI, Rajnandgaon, CG, India, Email : [email protected], Contact No: 9754550098
ABSTRACT
Objectives: To evaluate variations seen in the dermatoglyphic pattern between children with oral cleft and normal
children and to determine the significance of dermatoglyphics while studying the genetic etiology of oral clefts.
Study Design: Study was conducted on 60 children, 30 with cleft lip and palate (CL/P) and 30 control groups; and
dermal patterns were obtained using the Ink and Pad technique.
Results: The dermal pattern on the finger bulbs showed an increase in ulnar loops and the “atd” angle showed an
increase and fluctuating asymmetry was also noted.
Conclusion: Changes in the palmar patterns, “atd” angle and the asymmetry led to the conclusion that there is some
degree of genetic instability in Oral Cleft cases and dermatoglyphics can serve as a useful tool in diagnosis of such
cases.
Keywords: dermatoglyphics, oral clefts, ulnar loops, atd angle.
INTRODUCTION
Dermatoglyphics, is the study of dermal ridge
configurations on palmar and plantar surfaces of hands
and feet. It was first introduced by Cummins and Midlo
in 1926. They have been studied for fortune telling by
palmists and as a definitive and unalterable tool for
identification by forensic experts. From cradle to grave
until the body decomposes finger prints remain
unchanged i.e. the dermal patterns once formed
remain constant throughout the life. Dermatoglyphics
can be cons idered a window of congeni ta l
abnormalities and is a sensitive indicator of intrauterine
abnormalities.1,2,3.
Dermatoglyphic studies have gained scientific
acceptance in the recent years and were being used as
an adjunct to other diagnostic methods in identifying
specific syndromes of genetic origin. The current status
of dermatoglyphics is such that the diagnosis of some
illnesses can be done solely on dermatoglyphic analysis.
Several researchers claim high degree of accuracy in
their prognostic ability from the features of the hand.2,3.
Cleft of the lip and palate are inherited defects having a
broad phenotypic gamut and represent failure of the
facial and palatal processes to completely fuse during
embryonic development. Cleft of the lip and palate
account for about 65% of all congenital malformations.
They are observed with a frequency in about 1/500 to
1/2500 live births depending on geographic origin and 4.socioeconomic status. The study of congenital cleft lip
and palate anomalies has been the subject of
controversy regarding the etiology and mode of
transmission. While most of the cases have a polygenic
Dermatoglyphics in oral clefts
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mode of inheritance, a certain proportion results from
rare mutant genes, chromosomal aberrations and
unknown exogenous factors. However, the exact
etiology and mechanism of transmission of these 5,6,7malformations is still obscure.
The development of the dermal ridges takes place along
with the development of the primary palate during 7 th
week of Intrauterine Life (IUL) and is completed by the
12 to 13 week of IUL and both are ectodermal in th th
origin. The genetic code that is deciphered for palate
and dermal ridges (normal/abnormal) is reflected in the
dermatoglyphics. 8
Hence this study was conducted to evaluate the
differences in dermatoglyphic pattern between
children with cleft and normal children and to
determine the significance of dermatoglyphics in
studying the genetic etiology of oral clefts.
MATERIALS AND METHOD
This study was performed in the Department of Oral
Medicine & Radiology, New Horizon Dental College,
Bilaspur after obtaining approval from the institutional
ethical committee. A total of 60 children were included
in this study that were between the ages of 5-9 years
with no difference between the sexes. The control
group consisted of 30 normal and healthy children
without any medical or congenital anomalies. The study
group consisted of 30 non-syndromic children with oral
clefts without any other external manifestations. After
informed verbal consent (as it is a non-invasive
procedure), bilateral palmar and fingerprints were
collected using the ink and pad technique. (Fig. 1)
Fig. 1---The patterns on the terminal phalange of the
digits were classified as either as loops, whorls, arches
or composite patterns ( Galton in 1892). The frequency 1.
of different patterns occurring on the terminal phalange
of the digits of oral cleft children were then compared
with that of the normal children. (Fig.2)
The triradius formed at the base of the fingers have
been designated as 'a,b,c and d' along the base of the
index finger to the base of the little finger respectively
(Fig.3). The triradius formed at the base of the palm, i.e.,
the thenar area is designated as't'. Figure – 1
a) Simple Arch b) Tented Arch
c) Ulnar Loop d) Double whorl
e)Spiral whorl
Figure - 2
Dermatoglyphics in oral clefts
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Figure - 3
Figure – 4
For the present study the angle formed between 'atd'
along with the symmetry of the “atd” angle was taken
into consideration (Fig.4). The frequency of true
patterns of arches, loops and whorls were observed in
both groups.
The “atd” angle was measured on the palms of the oral
cleft and normal children and classified into four groups,
i.e., <40°, 40-45°, 45-50° & >50°. Statistical analysis was
done using the Chi-square test and Pearson's
correlation coefficient.
The fluctuating asymmetry of the “atd” angle between
the hands were seen in each individual and classified
into four groups 0°, between 1-4°, 4-7° and >8°
Results
On comparison of the fingerprint patterns on the distal
phalanges of the sixty children, it was observed that the
children with CL/P had greater frequency of ulnar loops
(24/30) as compared to control group who had ulnar
Diagram 1
The atd angle was greater (45-50˚) in children with cleft
(16/30) which was highly significant.
A higher frequency of normal children had the atd angle
<45° which was also highly significant. (diagram 2).
Asymmetry of the atd angle was higher in children with
cleft (4-7˚). The results showed significant p-value, and
Diagram 2
44 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Dermatoglyphics in oral clefts
45
DISCUSSION
Cleft lip and palate are most common congenital facial
abnormalities. The etiology is complex and both
polygenic and multifactorial inheritance pattern has
been proposed. 3,4,9
It is known that the finger and palm prints are formed
during the first 6-7 weeks of the embryonic period and
are
completed af ter 15-20 weeks of gestat ion.
Abnormalities in these areas are influenced by a
combination of hereditary and environmental factors,
but only when the combined factors exceed a certain
level, can these abnormalities be expected to appear. 3,4,10.
The epidermal ridges of the fingers and palms are
formed from the same embryonic tissues (ectoderm)
during the same embryonic period (6-9 weeks) as is the
development of lip and palate. Since the facial
structures like lip, alveolus and palate also develop at 6-
9 weeks, the genetic and environmental factors that are
responsible for causing cleft lip and palate may also
cause peculiarities in the dermatoglyphic patterns. . 11,12
Fluctuating asymmetry is defined as the random
differences between two sides of quantitative traits in
an individual which increases in parallel to the
Table I. Pearson's correlation of the predominant pattern.
Pattern Cleft Normal
p- value
Loop 24 9
16.68
0.0008
p<0.05
Significant
Whorl 6 15
Arch 0 3
Composite 0 3
Table II. Pearson's correlation of the atd angle.
“atd” angle
(degree)
Cleft Normal
z- value p- value
35-40 4 5
27.57
0.0001
p<0.05
Significant
40-45 5 23
45-50 16 2
50-55 5 0
decreasing buffering ability of an organism and hence
inability to maintain developmental homeostasis. In the
case of dermatoglyphics, it is the degree of asymmetry,
which will already be present during the early fetal
stages, and the magnitude of fluctuating asymmetry
that will express the level of developmental
homeostasis of the individual. 13,14.
Isolated or non-syndromic CL/P is considered to be
multifactorial in origin with both genetic and
environmental factors playing a role.
In this study, we observed that the children with oral
clefts had an increasing frequency of ulnar loops
(24/30) on the distal phalanges of fingers whereas
normal children had an increased frequency of whorls
(15/30). On comparison of the add angles between the
children with oral clefts and the normal children, the
children with clefts were found to have an atd angle in
the higher ranges, i.e., 45-50˚ (16/30) as compared to
that of normal children (2/30). The asymmetry of the
atd angle was greater in children with cleft (4-7˚) than in
normal children.
The findings of the present study reveal statistically
significant difference between dermatoglyphic
patterns of controls and those of children with cleft
lip/palate. As the dermatoglyphics are genetically
determined and develop at the same time as the
development of the palate, any deviation in the
dermatoglyphic features indicates a genetic difference
in the study group and the controls. Thus indicating a
definite correlation between dermal ridge pattern and
cleft lip and palate. Considering the expenses involved
in chromosomal analysis; dermatoglyphics can prove to
be an extremely useful tool for prel iminary
investigations in subjects with suspected genetic
abnormality, by being non-invasive and cost effective
procedure. But further studies have to be done with a
larger sample size in order to evaluate the significance
of these variations in the dermatoglyphic features in
the oral cleft individual.
REFERENCES
1. Soni A, Singh SK, Gupta A. Implications of
Dermatoglyphics in Dentistry. journal of dento
facial sciences, 2013; 2(2): 27-30.
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
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z- value
2 . B l a n k a S c h a u m a n n , M i l t o n , A l t e r.
Dermatoglyphics in medical disorders.
Springer- Verlage. New York, Heidel berg,
Berlin, 1976.
3. Elder D, Elenitsas R et al. Lever's Histopathology
of the skin. Lippincot William's & Wilkins (2001) th8 Edition. Pp 10-15.
4. Rajendran R, Sivapathasundaram B. Shafer's thTextbook of Oral Pathology. Elsevier (2009) 6
Edition Pg 16-17.
5. Balgir RS. Dermatoglyphic features in
congenital cleft lip and cleft palate anomalies.
JIMA 1986; 84:369-72.
6. Gorlin RJ, Pindborg: Syndromes of the Head and
Neck. New York, McGraw Hill (1964) page 97.
7. Lubs HA, Koeing EV, Brandt IK. Lancet
1961;2:1001-2.
8 . Ba lg i r RS . Congen i ta l o ra l c lef t s and
dermatoglyphics. J Med Sci 1984;20:622-4
9. Vaishali V Inamdar, SA Vaidya, Pratima Kulkarni:
Dermatoglyphics in carcinoma cervix. J Anat
Soc.India.
10. Natekar PE, DeSouza, Fatima M.: Fluctuating
asymmetry in dermatoglyphics of carcinoma of
breast. J Human Genetics. 2006; 12:76-81.
11. Noboru K, Yukiko Yoshida, N Kishi et al. Study on
abnormalities in the appearance of finger and
palm prints in children with cleft lip, alveolus
and palate.
12. Philip Stainer, Gudrun E. Moore: Genetics of
cleft lip and palate: Syndromic genes contribute
to non-syndromic clefts. Human molecular
Genetics. 2004; 13:
13 Mathew L, Hegde AM. Rai K: Dermatoglyphic .
peculiarities in children with oral clefts. J
Indian Soc Pedod. Prev Dent. 2005; 23:179-182.
14. Chintamani, Rohan Khandelwal.: Qualitative
and quantitative dermatoglyphic traits in
patients with breast cancer: a prospective
clinical study. BMC cancer. 2007; 7:44.
46 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Dermatoglyphics in oral clefts
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1 2 3Sanjay Verma ,Punit Gupta , Prakash Khunte1. Associate Prof., Pt.J.N.M.Medical College & Dr.B.R.A.M.Hospital Raipur (C.G.)2. Associate Prof., Nephrology Unit, Deptt.of Medicine, Pt.J.N.M.Medical College, Raipur (C.G.)3. PG Student, Dept. of Medicine, Pt.J.N.M.Medical College & Dr.B.R.A.M.Hospital Raipur (C.G.)
Corresponding Author :Sanjay VermaAssociate Professor, Department of Medicine, Pt.J.N.M.Medical College & Dr.B.R.A.M.Hospital Raipur (C.G)Mobile No.- 9826136022, E-Mail ID: [email protected]
ABSTRACT A total of 31 patients of Carcinoma Cervix was studied in Nephrology Unit at Dr.B.R.A.M Hospital Raipur C.G. An underlying malignant disorder was the cause of the obstruction in most of the patients. Carcinoma of the cervix was the most frequent malignant disorders, resulting in more severe renal failure.The mean age of presentation of Carcinoma of the cervix was 45.77 ± 11.25 years. Out of 31 patient 19 patient underwent hemodialysis . The mean urea level were 146.4 ± 47.6 mg/dl, creatinine level were 8.7 ± 4.7 mg/dl. Most patients were severely anaemic,mean hemoglobin level were 7.7 ± 2.1 gm%. Most patient have bilateral hydronephrosis obstructive uropathy in ultrasonographic finding resulting in severe renal failure.5 patients were dead before the hemodialysis. Most patient were hypoalbuminia and electrolyte abnormality. The overall prognosis was poor and most patient require hemodialysis.
INTRODUCTIONCancer of the uterine cervix is one of the leading causes of cancer death among women worldwide. The estimated new cancer cervix cases per year are 500,000 of which 79% occur in the developing countries. (Shanta V et al ).Cervical cancer is the most common female cancer in the developing countries and its incidence in India is about 32 per 100,000 women. (National Cancer Registry Programme 2005 ). Over 70% of the cases present in advanced stages of the disease with associated poor prognosis and high mortality rate Cancer cervix occupies either the top rank among cancers in women in the developing countries. The cervical cancer burden in India alone is estimated as 100,000 in the year 2001. The differential pattern of cervical cancer and the wide variation in incidence are possibly related to environmental differences. About 70% of them present as locally advanced disease, and one-third of them with renal failure. Such patients have dismal prognosis and are usually managed with palliative radiation or sometimes best supportive care. Kidney disease frequently complicates malignancy and its treatment. The spectrum of disease in this setting includes acute kidney
injury, chronic renal failure, and tubular disorders. Fortunately, these complications are often preventable or reversible with prompt diagnosis and treatment. ( Turka LA et al )
MATERIAL & METHOD: This study was conducted at Nephrology Unit , Dept of Medicine,Dr.B.R.A.M. Hospital & Pt.J.N.M.Medical College ,Raipur (C.G).Study was conducted among 31 patients and age between 30 years and 654 years.Complete laboratory investigation was were complete blood count, blood urea, serum creatine, serum lipid profile, thyroid profile, serum albumin level, ds. Chest Xray ,E.C.G ,ultrasonography was done in all patients.
RESULTS
All patient were female with minimum age was 30 years
and maximum age was 65 years .The mean age of
presentation of Carcinoma of the cervix was 45.77 ±
11.25 years.The most common presentation was
decrease urine out put followed by facial puffiness seen
in most patients , the mean blood pressure was
131.1+23.1/76.5+10.9 mmhg ,pulse rate was 96.9+10.3
Carcinoma cervix and renal failure : A study from central India.
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/min. Pallor,oedema seen in 100 % of cases. Mean
hemoglobin level was 7.7 ± 2.11 gms,total leucocyte
were 10900 ± 4972 /mm3. Renal failure seen in all cases
with mean blood urea and creatinine level 146.4 ± 47.6
and 8.7 ± 4.7 mg/dl. Grade + protienuria seen in 60 % of
cases. Hypocalcemia seen in 26 % cases followed by and
hyperkalemia ,hypernatremia in 22% & 8 % cases.
Hyponatremia and hypkalemia in 18 % and 22 % cases.
19 patients were underwent hemodialysis and 5 patient
died due to late presentation of diaseses. 70 % shows
bilateral hydronephrosis obstructive uropathy. Most
patient have hypoalbuminimia.
Graph 2 -shows symptoms presenting with the disease.
Graph -1 showing mean age of presentation of carcinoma cervix.
Carcinoma cervix and renal failure
48 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
49
DISCUSSIONAcute kidney injury (AkI) secondary to bilateral ureteric obstruction (BUO) is a common urological problem and the underlying etiology can be malignant or benign. Malignant obstruction is often from direct tumour compression of the distal ureters, most frequently from genitourinary most common carcinoma cervix cancers.(Nandakumar A et al )
Over 70% of the cases present in advanced stages of the disease and are associated with poor prognosis and high mortality rates. In many of them, it is difficult to offer definitive treatment as they present in uremia due to associated obstructive uropathy.. The results are unpredictable in terms of benefits achieved in these cases. (Vick CW et al )
Cervical cancer can spread to adjacent structures like the lower uterine segment, vagina and para cervical space along the broad and uterosacral ligaments. It can also have lymphatic and hematogenous spread. The parametrium is the connective tissue between the leaves of the broad ligament. Medially, it abuts the uterus, cervix, and proximal vagina. Laterally, it extends to the pelvic side wall. Inferiorly, it is contiguous with the cardinal ligament. The parametrium consists primarily of fat through which uterine vessels, nerves, fibrous tissues and lymphatic vessels run. The distal ureter is in the parametrium as it passes from the pelvic side wall to the bladder approximately two centimeters lateral to the margin of the cervix. When cervical cancer extends into the parametrium, the ureter can be encased by tumor and th i s leads to hydro ureteronephrosis and eventually renal failure. (Lee SK et al ) .
Ureteral obstruction due to malignancy carries a poor prognosis with a resulting median survival of three to seven months. Hence most patients are treated with b e s t s u p p o r t i v e c a r e o r s o m e p a l l i a t i v e diversionprocedure.
It is very important to select patients for curative treatment. Patients with features of uremia, frozen parametrium, non-functioning kidney are unlikely to show response and hence are best treated with supportive care.The non-recovery of renal function after the relief of hydro ureteronephrosis is dependent on age and renal cortical thickness. Age beyond 50 years
and decreased renal cortical thickness (less than 13 mm) indicate poor recovery of renal function. Use of cisplatin as radio sensitizer with radiation is avoided as it is a nephrotoxic drug and worsens the pre existing renal failure. Various other chemotherapeutic drugs like carboplatin and gemcitabine can be tried. (James M et al )
Crude mortality rates in critically ill patients with AKI are systematically higher in those with cancer than in those without. The performance status and associated comorbidities have an additional adverse impact on both short-term and long-term outcome in cancer patients.
Age and cancer characteristics by itself, with of extensive metastatic or uncontrolled recurrent disease in solid tumor patients, have only a minor impact on the 6-month mortality in critically ill cancern patients. (James M et al)
Furthermore, outcomes have been found to be worse in patients who experience further deterioration in renal function despite advanced life support in the ICU. AKI may also play an important role. Sepsis-induced AKI is often associated with protracted multiple organ dysfunction whereas this will be less or only rarely the case in AK I caused by nephrotox ic drugs . (Cohen E P et al )
In both the benign and malignant groups, the degree of renal impairment as measured by presenting serum creatinine was similar and did not serve as a differentiating variable. After relief of obstruction with percutaneous nephrostomy tubes or ureteric stents, renal function improved significantly and was decreasing on discharge in both groups. Multiple studies have shown both stents and nephrostomy tubes are effective methods to restore kidney function after ureteric obstruction
CONCLUSION
The overall prognosis is poor in patients requiring
hemodialysis and high mortality rate in carcinoma
cervix with renal failure patients. Early diagnosis of
disease is required for good prognosis of patients.
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Carcinoma cervix and renal failure
REFERENCES
1. Shanta V, Krishnamurthi S, Gajalakshmi CK, Swaminathan R, Ravichandran K. Epidemiology of cancer of the cervix: global and national perspective. J Indian Med Assoc 2000;98:49- 52. 2. Nandakumar A, Anantha N, Venugopal TC. Incidence, mortality and survival in cancer of the cerv ix in Bangalore, Ind ia . Br J Cancer 1995;71:1348-52 3. Vick CW, Walsh JW, Wheelock JB, Brewer WH. CT of the normal and abnormal parametria in c e r v i c a l c a n c e r. A J R A m J R o e n t g e n o l 1984;143:597-603. 4. Lutaif NA, Yu L, Abdulkader RC. Factors influencing the non-recovery of renal function after the relief of urinary tract obstruction in w o m e n w i t h c a n c e r o f c e r v i x . R e n F a i l 2003;25:215-23.
5. Lee SK, Jones HW., 3rd Prognostic significance o f uretera l obstruct ion in pr imary cer v ica l cancer. Int J Gynaecol Obstet. 1994;44:59–65 6. J a m e s M , Pa n n u N . M e t h o d o l o g i c a l cons iderat ions for observat ional studies of acute kidney injury using existing data sources. J Nephrol. 2009;22:295–305 7. National Cancer Registry Programme, Annual Report, ICMR, New Delhi: 2005 8. inshaw KA, Rao DN, Ganesh B. Tata Memorial H o s p i t a l C a n c e r R e g i s t r y A n n u a l R e p o r t , Mumbai, India: 1999 9. Cohen EP, Sobrero M, Roxe DM, Levin ML. R e v e r s i b i l i t y o f l o n g s t a n d i n g u r i n a r y obstruction requiring long term dialysis. Arch Intern Med 1992;152:177-9. 10. Turka LA, Rose BD. Clinical aspects of urinary tract obstruction. In acute renal failure. 2 nd ed. Lazarus JM, Brenner BM, editors. New York: Churchill Livingstone; 1988. p. 581-96.
50 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
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1 2 3 4N.Vidyasankari , S.Senthil kumar , Deepesh K. Gupta , Maheshwaren1. Reader, Department of Oral and Maxillofacial Prosthodontics, K.S.R Dental College, Salem (TN)2. Professor, Department of Restorative dentistry, JKK Nataraja Dental College, Salem (TN)3. Reader, Department of Prosthodontics, Govt. Dental College, Raipur (CG) India.4. Senior Lecturer, Department of Prosthodontics, K.S.R Dental College, Salem (TN)
corresponding Author :Dr. N. Vidyasankari, MDS, 12 S.S.D Road, Thiruchengodu – 637211, Tamil Nadu, India.Contact Number – 09443940244, E-Mail ID: [email protected]
ABSTRACT
An immediate denture is "a complete denture or removable partial denture inserted immediately after the removal
of natural teeth”. The primary advantage of an immediate denture is the maintenance of patient's appearance
because there is no edentulous period. Circum-oral support, muscle tone, vertical dimension of occlusion, jaw
relationship, and facial height can be maintained. Thus this article speaks about the needs and construction of an
immediate complete denture.
Key words – Denture, Surgical Templates, Extraction, Transitional Denture
INTRODUCTION
One of the most bewildering clinical problems to the
prosthodontist & general dentist is to encounter the
patients who are going for complete edentulism.
Immediate dentures are one of the options for the
patient facing the edentulous state. It provides
restoration of esthetics, phonetics and masticatory
function. Immediate dentures act as a bandage or
splint, promotes healing and protects blood clots,
patient gets used to the immediate dentures as sooner
than conventional dentures, can resume their daily
work early. Patients do not have to endure a long
healing process without teeth . In addition, it 1,2,3,4
facilitates the transition from dentulous to the
edentulous state.
Immediate dentures are more challenging to make than
routine complete dentures for both the dentist and the
patient, because anterior wax try-in is not possible
beforehand and the patient may not be completely
comfortable with the resulting appearance and fit of the
immediate denture when inserted . Hence the dentist 1,2,4
must explain the patient must about the limitations of
the procedure before the treatment begins.
CASE REPORT:A 46 year old female patient with
partially edentulous upper and lower arches was
reported to the Department of Prosthodontics for the
prosthesis. On examination the teeth present were
11,12,13,14,16, 21, 22, 23, 27, 34, 36, 41, 43 & 45. The
periodontal status of all the remaining natural teeth
was poor with grade III mobility and poor oral hygiene.
The treatment plan was total extraction of remaining
natural teeth followed by conventional complete
denture rehabilitation and was suggested to the
patient. However, the patient was so conscious about
her appearance & refused for the treatment because of
the fear of being edentulous for 3 months since
extraction. Hence, it was decided for Transitional
Immediate denture rehabilitation. All the remaining
lower teeth and the upper posterior teeth were
extracted except the upper six anterior teeth [fig 1].
Immediate denture as an immediate solution
CASE REPORT
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Immediate Denture as an Immediate Solution
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Initial phase - pre extraction procedures:
Initial impression was made with irreversible
hydrocolloid in a stock tray, and poured with dental
stone. A custom-made tray was fabricated with Auto-
polymerizing Acrylic resin by covering the remaining
teeth with a double thickness base plate wax. The
custom tray was placed in the patient's mouth and
evaluated for overextensions and borders refined by
using low fusing green stick compound. Perforations &
tray adhesives were placed in the tray to enhance the
retention of impression material. Light-bodied
polysiloxane rubber base impression material was used
for the final impression . 5, 6, 7
Record blocks were fabricated with temporary denture
base made of autopolymerizing acrylic resin. Jaw
relation was recorded [fig 2]. Appropriate shape, size and shade of the teeth were selected. The posteriors
were arranged first to provide multiple posterior
contacts in centric relation. The lower anteriors were
set according to the remaining upper natural teeth with
no contacts in centric relation. Posterior try-in was
scheduled to verify centric relation, vertical dimension
and the posterior palatal seal.
Preparation of surgical template:
The predetermined cross marked teeth to be extracted
were trimmed using a sharp knife and round bur up to
the level of gingival margin for cast modification [fig 3
and 4]. The gingival margins on the facial and lingual
surfaces of the cast were outlined. A pencil line 2mm
above and parallel to this gingival contoured line were
scribed on the cast. The stone cast was beveled from
labial to lingual aspect with the depth of 2mm at the
gingival margin areas. A duplicated cast was made on
which a clear acrylic surgical template was fabricated to
evaluate the surgical site latter . 6
The remaining anterior teeth were arranged in their
position. The contours of the dentures were waxed
properly. The dentures were processed using heat
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
53
activated acrylic resin.
Surgical phase – extraction procedure:
The six anterior teeth were extracted under local
anesthesia following proper surgical protocol [fig 5].
Surgical template [fig 6] was used to check for any tissue
blanching. The hard tissue was trimmed at the blanched
area. Simple interrupted suture was placed without
tension [fig 7].
The maxillary denture was positioned and seated &
checked for pre-mature contacts. Only gross pre-
maturities were eliminated, the final correction was not
done to avoid further trauma to the extraction sites. The
denture adapts well and the labial undercut present
provides a better retention [fig 8,9,10].The patient was
discharged with the instruction of not removing the
denture for 24 hours, have fluid food and report the
dental clinic the next day.
Immediate Denture as an Immediate Solution
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Immediate Denture as an Immediate Solution
54
Post insertion review:
During follow-up review occlusion was verified and any
ulceration from denture pressure or over extension was
relieved. Dentures were cleaned for debris and the
patient was asked to rinse the mouth with mouthwash
gently. Denture reinserted & advised the patient not to
remove the denture for the next 24 hours.
The same procedures done on the first day was
repeated on the second consequent visit. Patient asked
to have soft cold baby feeds and chopped vegetables.
Patient asked to report after 5 days. After a week,
sutures were removed [fig 11]. Tissue surface was
examined with pressure indicator paste and there was
no soreness or irritation found. Hence the need for
tissue conditioner was eliminated.
After a month, the occlusion was refined. The patient
was told to report for checkup once in a month. Later
after 6 months, the interim denture can be replaced
with the conventional new denture.
CONCLUSION
Immediate dentures are a more challenging modality
than complete dentures because the presence of teeth
makes impressions and maxillomandibular positions
more difficult to record. An occlusal adjustment, or
even selective pretreatment extractions, may be
needed to make accurate records at the proper vertical
dimension of occlusion.
The most compelling reasons for the immediate
denture prescription are the patient wish not to live
without teeth for a day and consequently an
uninterrupted normal lifestyle of smiling, talking,
eating, and socializing. The patient is likely to adapt
more easily to dentures at the same time recovery from
surgery is progressing. Speech and mastication are
rarely compromised, and nutrition can be maintained.
Overall, the patient's psychological and social well-
being is preserved.
Thus a careful planning, operator experience,
attention to details of the technique and proper
motivation of the patient best address this inherent
problem of being edentulous.
REFERENCES:
1. Sheldon Winkler: Essentials of complete
prosthodontics – 2 edition P: 361-374.nd
2. Zarb – Bolender: Prosthodortic treatment for
edentulous patients – 12 edition P: 123 – 159.th
3. Farmer JB: Surgical template fabrication for
immediate dentures; J.Prosthet Dent 1983; 49: 579
– 580.
4. Heartwell CM & Salisbury FW: Immediate
Dentures: an evaluation J. Prosthet Dent 1965;
15(4): 616-618.
5. Seals RR, Kucbker WA, Stewart KL: Immediate
Complete dentures, Dent Clin North Am 1996;
40:151.
6. Stanley G.Standard: Preparation of casts for
immediate dentures. J. Prosthet. Dent 1988; 8 (7):
26 – 30.
7. Campagnia, S.J. An impression technique for
immediate dentures. J Prosthet Dent 1968; 20:196-
203.
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1 2 3 4C. Sunil Kumar, B. M. M. Reddy, A. Samantaray, D. S. R. Reddy1.Professor,Department of Conservative Dentistry ,C.K.S Theja Institute of Dental Sciences & Research, Tirupati, A.P 2.Professor, Department of Prosthodontics,C.K.S Theja Institute of Dental Sciences & Research, Tirupati, A.P 3.Additional Professor,Department of Anaesthesiology and Critical Care, SVIMS, Tirupati, A.P 4.Reader, Department of Conservative Dentistry & Endodontics.C.K.S.T. Institute of Dental Sciences & Research, Tirupati, A.P
Corresponding Author :Dr. C. Sunil Kumar, 1.Professor,Department of Conservative Dentistry ,C.K.S Theja Institute of Dental Sciences & Research, Tirupati, A.P Phone No :- 9849481124, E-Mail – [email protected]
ABSTRACT
Dental prosthesis may be swallowed or can be aspirated that may result in acute medical or life threatening
emergencies. A case of accidental swallowing of a four-unit removable partial denture by Dementia patient is
reported, and the important fact is that, the patient was unaware that the denture was ingested and came to the
clinic for a new partial denture. Patients with removable dental prosthesis should be informed of this potential risk of
swallowing and sometimes even unrecognised.
Key words :Removable dentures, Ingestion, Foreign body, Impaction, oesophagotomy
INTRODUCTION
Cases of impaction of foreign bodies in the upper part of the alimentary canal are not infrequently met within hospital practice, but the greater proportion are cases in which the foreign body is lodged in the pharynx, and can generally be dealt with from the mouth. Foreign bodies arrested in the oesophagus command attention because their presence is a source of great danger and their removal becomes immediately a very vital problem. Aspiration and accidental swallowing of foreign bodies is more common in children, because of their curiosity, habitual insertion of objects into their mouths while playing and speaking, and the lack of posterior dentition. Reviews from otolaryngology reports coins, marbles, buttons, batteries, safety pins, bottle tops and screws are the common objects ingested in children. In adults, about 62 % of the cases are due to chicken bones, fish bones, or poorly fitted
1artificial teeth. In regard to the situation at which foreign bodies may become lodged, it has been observed that small pointed bodies which easily penetrate the mucous membrane
may become fixed at any point in the oesophagus. Larger bodies usually cannot pass through the isthmus and remain in the pharynx. The larger variety of foreign body which has passed through the pharynx lodges at those places where, the oesophagus is constricted, just behind the crycoid cartilage, the middle constriction which is about opposite the bifurcation of the trachea at level of 7th cervical vertebra, and the inferior constriction, where the oesophagus passes through the
3diaphragm. Swallowing of dental objects may also occur away from the clinic and seems to be more common than aspiration in the elderly. In the older age group, the most common foreign body swallowed is a denture because of decreased sensation of the oral cavity in denture wearers, and poor motor control of
2laryngopharynx . Other reasons for aspiration can be maxillofacial trauma, dental treatment procedures, dementia or intellectual impairment, autism, Parkinson's disease, Cerebral palsy and mental retardation. Swallowing of dental materials and devices may be a serious complication during routine dental treatment.
Unrecognized swallowing of a partial denture and surgical retrieval by cervical oesophagotomy: A case report
CASE REPORT
Ayush & Health Sciences University of Chhattisgarh
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Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)ISSN 2348 - 4195
Surgical retrieval of a partial denture by cervical oesophagotomy
For example, screw driver or implant itself during implant placement, a cast crown, bands and brackets during orthodontic treatment, a file or a reamer during endodontic therapy has been reported in the literature1. Various measures have been proposed to prevent such occurrences such as using barriers (rubber dam, throat packs) and ligation of object (Eg. Files, Reamers, Rubberdam clamps etc) because they carry some risk of ingestion.The majority of foreign bodies entering the oropharynx will pass through the alimentary canal if they are small or they may cause perforation of the Gut if sharp, which may lead to serious complications and even death.4 If the denture is made of radiolucent material as in acrylic removable partial denture, endoscopic examination and removal is suggested in a symptomatic patient with positive history6. Surgery is rarely performed unless the foreign body is impacted, or failure to remove by routine endoscopic method. This report presents removal of an impacted removable partial denture with cervical oesophagotomy under general anaesthesia. The dangers of Oesophagotomy for foreign bodies are by no means negligible, chief causes being heamorrage,
4shock and infection resulting in death sometimes.
CASE REPORTA 78-year old dementia patient came to the clinic for replacement of maxillary anterior teeth. The patient was using removable acrylic partial denture since 5
years. Patient complains that the denture was missing since 1 month and they could not find the denture anywhere in the house. So she decided to get a new denture fabricated. Maxillary and mandibular impressions were made. During impression making patient complained of pain in the neck region. On proper enquiry about the patient's general health, her son revealed that she was complaining of pain and difficulty during swallowing solid food and was under liquid diet for the past 15 days that too with great difficulty.Correlating the symptoms of the patient, with missing denture a suspicion aroused about the swallowing of removable partial denture where the patient immediately denied the possibility. To confirm the suspicion the case was referred to Sri Venkateswara Institute of Medical Sciences, Tirupati. Preliminary radiological examination did not reveal anything but subsequent endoscopic examination showed a foreign body about 22 cm away from maxillary incisors in the midoesophageal region. Routine retrieval procedure was not successful because the denture was swallowed 1 month back and was deeply impacted in the mid oesophagus. The patient was subsequently posted for cervical oesophagotomy under general anaesthesia (fig.1,fig.2, fig.3). Impacted denture was removed successfully(fig.4) and absence of any fistulous tract into the trachea was confirmed. Intraoperative course was uneventful. The patient was extubated in the operation theatre and shifted to intensive care unit. In
Fig. 1: Initial incision at the mid oesophageal region. Fig. 2: Exposure of deeper structures at mid oesophageal region
Fig.4: Retrieval of partial denture
56 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
57
I.C.U. the patient was kept under observation for 7 days and discharged on 7th postoperative day.The cause of aspiration in this case is because of old age with impaired cough reflexes and some degree of intellectual impairment as evidenced by the lack of a clear positive history of swallowing her own loose fitting denture during sleep one month back.
DISCUSSIONAccording to the National Health and Nutrition Examination Survey (NHANES) 1 of every 5 persons between the ages of 18 and 74 years has full or partial dentures. The inadvertent swallowing of a dental prosthesis is not uncommon in the adult population. In a study by Abdullah et al 2 out of 200 patients were with a known history of an impacted tracheal or oesophageal foreign body, dental prostheses accounted for 11.5% of t h e ca s es .E xa m in at io n o f t h e p at ient w i t h definite/suspected foreign body ingestion/entrapmentThis is often unhelpful, but careful examination should be carried out for acute clinical and medicolegal reasons:· Assess the airway and respiratory function to exclude any compromise.· Check vital signs, open the mouth and observe the oropharynx with a bright light.· Consider indirect laryngoscopy and/or fibre-optic examination of the pharynx.· Gently palpate the neck and assess tracheal position/compression.· Formally examine the chest and listen to the lungs.· Perform a cardiovascular examination.
7· Carefully examine the abdomenClinical history may be vague, and patients may or may not report a definite history of swallowing their dentures. Patients can present with vague symptoms of neck pain, dysphagia, odynophagia, and excessive salivation. Thus further reports may also be anticipated of sore throat, choking sensation, retrosternal pain, sweating and a raised temperature and coughing up blood. If not diagnosed early, progressive edema, infarction, ulceration and necrosis may lead to perforation and fistula formation. Fistulas can involve the trachea, oesophagus, mediastinum, aorta and bronchial tree in various combinations.Early diagnosis and treatment can avoid late complications that may require surgical intervention. The use of a unilateral removable partial denture to replace one or two missing teeth especially in elderly patients should be
avoided because small size makes it easy for a patient to ingest or aspirate this prosthesis, with potentially serious consequences. Difficulty has been reported in the identification and location of prosthesis when it is made of radiolucent acrylic resin (PMMA) with little or no metal framework. The inclusion of radiopaque materials into these types of prostheses is strongly advised3. Computerized tomography (CT) may be used to localize the offending object in 3-dimensions and also in locating the prosthesis because it has greater contrast resolution than conventional radiography and
8may reveal a radiolucent foreign body of dental origin .Differential diagnosiso This clinical scenario is unlikely to be confused with
another illness, with the possible exception of space-occupying oesophageal pathology – eg : oesophageal carcinoma causing obstruction of a normal food bolus.
o Always consider the possibility that a foreign body has been inhaled, particularly if a patient presents acutely with respiratory compromise or with chronic chest symptoms.
o An acute presentation of mediastinitis may be due to perforation by a swallowed foreign body, or the primary form of the disease.
o Retropharyngeal abscess can cause similar symptoms to impacted objects in the upper oesophageal area.
Investigations Blood tests are usually unhelpful, with the
exception of chronic presentations or febrile patients where FBC/ESR may provide useful clues as to the cause of symptoms
o Plain X-rays:Where there is a history of a swallowed radio-opaque object that may be located within the upper gastrointestinal (GI) tract, plain X-ray should be carried out to confirm or refute the possibility of oesophageal entrapment.Where the ingested object is not radio-opaque, X-ray investigations are unlikely to help and will probably only delay more relevant investigations such as upper GI endoscopy.
Very small children can be imaged using a mouth-to-anus radiograph. In adults, a PA and lateral chest radiograph and/or plain abdominal X-ray are more useful.Only about 20-50% of food bones will be
7visible on X-rays.o CT scans: - CT scanning of the thorax/abdomen is
highly useful for locating entrapped objects of various types and considered superior by many to plain X-ray imaging. CT scanning is the investigation
Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)
Surgical retrieval of a partial denture by cervical oesophagotomy
of choice if there is reason to suspect perforation or abscess formation.
o Endoscopy:Urgent endoscopy is mandatory in cases where there is airway obstruction or evidence of other severe complications.When there is a clear history of swallowing objects, such as toothpicks and/or aluminium bott le caps/can r ings, endoscopy is the investigation/procedure of choice, as there is a high risk of complications with such objects. Definite indications for endoscopy are objects that are sharp, non-radio-opaque, elongated, or when there are multiple swallowed
7objects or a high risk of oesophageal injury. Endoscopy is also indicated for gastric or proximal-duodenal foreign bodies that have a diameter of > 2 cm, and length of > 5-7 cm. Endoscopy is a relatively safe procedure in experienced hands, but expensive,and should therefore be avoided as a routine intervention if possible.
o Other tests:- Barium swallows are sometimes used to detect
non-radio-opaque items but CT is usually preferred, as there is a better yield and barium must be avoided when perforation is suspected.
- Hand-held metal detectors can be used to trace the passage of metallic objects through the GI tract and reduce exposure to ionising radiation.
CONCLUSIONSince foreign body ingestion may result in acute medical or life threatening emergency, prevention of such occurrence is therefore the best approach. Knowledge of the dental team of the signs and symptoms of a swallowed object, documentation and proper medical follow-up are all essential for better management of ingested objects.Configurations and overall dimensions of prosthesis are important and patients receiving small dentures should be informed of this potential risk of
swallowing. Fixed bridges with good cementation is preferred to removable prosthesis. However, fixed prosthesis may also be ingested if inadequately retained. So proper design and adequate retention of partial dentures is most important, either removable or fixed. Dentures also require proper fitting and checking on a regular basis to maintain an optimum fit. Elderly patients must be advised not to gulp large pieces of meat. Patients should be informed strongly to avoid wearing dentures during sleep. unilateral single tooth replacement should be avoided as it does not have cross arch stabilization and accidental ingestion will be easier.
REFERENCES:
1. Chua Y K D, See J Y, Ti T. Oesophageal-impacted denture requiring open surgery. Singapore Med J 2006; 47(9):820-821.
2. Carbery A, Provencal M. A case of swallowing a partial denture. J Can Dent Assoc 1993;59: 841-4.
3. Tsao DH, Guilford HJ, Kazanoglu A, Bell DH. Clinical evaluation of a radiopaque denture base resin. J Prosthet Dent 1984;51: 456-8.
4. Cooke LD, Baxter PW. Accidental impaction of p a r t i a l d e nta l p ro st h e s e s i n t h e u p p e r gastrointestinal tract. Br Dent J 1992;172: 451-2.
5. Green JG, Durham TM, King TA. Management of patients with swallowed dental objects. Am J Dent 1988;1: 147-50.
6. Brunello DL, Mandikos MN. A denture swallowed. Case report.Aust Dent J. 1995;40(6):349-51.
7. Munter D; Foreign Bodies, Gastrointestinal Foreign Bodies in Emergency Medicine, Medscape, Mar 2010.
8. Auluck A, Desai R. Accidental swallowing of prosthesis. Dent Update. 2008;35(8):577-9.
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