Second Artical 2014-2

Vol. 4, ISSUE 2. SEPTEMBER 2013 - FEBRUARY-2014

ISSN 0976-2256E-ISSN:2249-6653

Ahmedabad Dental CollegeAhmedabad Dental College

& Hospital& Hospital

OFFICIAL PUBLICATION OFOFFICIAL PUBLICATION OF

AHMEDABAD DENTAL COLLEGE AND HOSPITALAHMEDABAD DENTAL COLLEGE AND HOSPITAL

Oral Pathology has been a challenging fiels. What clinicians cannot perceive with naked eyes, pathologist can conclude under microscope. Oral pathology is the subject that concentrates on the morphologic changes at microscopic level in oral and para oral tissues which causes disease and the mechanism of the disease process. Oral pathology represents the confluence of the basic sciences and the clinical dentistry. Knowledge in this field is acquired through the adaption of methods and disciplines of those subjects basic to dental practice such as gross and microscopic anatomy, histochemistry, microbiology and physiology. Through the science of oral pathology, an attempt is made to correlate human biology with the signs and symptoms of human disease. Oral health is an integral part of total health and oral health care professional must adapt to demographic changes and medical advances and shoulder the responsibilities of being part of the patients over all health care team. The oral pathologist understands the clinical and molecular pathology of oral disease so that it can be properly and accurately diagnosed and adequately treated. Oral pathology personnel are well suited for leading oral health promotion. They can make people ware about the risk factors such as tobacco, identify early pre cancerous condition and thus can significantly contribute in improving oral health.

EDITORIAL

FROM THE EDITOR'S DESK ……………………………………………………………………………………………....................01DARSHANA SHAH

REVIEW ARTICLES

1.) STRESS........................................................................................................................................................................ 02

RUSTAM N. RAO*

2.) OSTEOMYELITIS IN & OUT OF JAWS ...................................................................................................................... 06

NITU SHAH*, SHRINAL MANKIWALA**, KSHITI TRIVEDI***, NEHA VYAS****

3.) FROZEN SECTION.......................................................................................................................................................10

ORIGINAL ARTICLES

4.) ........................... 15

5.) ............................................................................ 22

6.)

.............................................................................................................................................. 28

CASE REPORTS

7.) ........................................................ 34

8.) ..............................................................38

9.) .............. 41

10.) ...................... 41

11.) ...................... 41

BRIJESH PATEL*, MANISHA SINGH**, NILESHWAR JADEJA***, ALPESH PATEL****, MINAL BAKSHI*****

THE PRE-STERILIZATION CLEANING PROTOCOL FOR ROTARY NI-TI ENDODONTIC FILES RAJESH MAHANT*, SHRADDHA CHOKSHI**, RUPAL VAIDYA***, PALLAV CHOKSHI****,

GHANSHYAM PATEL*****, PRUTHVI PATEL******

THE EFFECTS OF NUTRITION ON OCCLUSION OF CHILDRENVIJAY BHASKAR*, RAJAL PATHAK**, MIRA VIRDA***

DENTAL FLUOROSIS AMONG 12 AND 15 YEAR OLD SCHOOLGOING CHILDREN OF SOLAPUR CITY,

MAHARASHTRA, INDIA.HARSH SHAH*, SUYOG SAVANT** , VASUDHA SODANI***, DEEKSHA SHETTY****,BRIJESH PATEL*****

C-SHAPED ROOT CANAL CONFIGURATION IN MAXILLARY FIRST MOLAR

MAMTA KAUSHIK*, SONAL SINGH**, KUNJAL MISTRY***, ZARNA SANGHVI****

RADICULAR ATTACHMENT RETAINED OVERDENTURE-CASE REPORT

DARSHANA N.SHAH*, CHIRAG J. CHAUHAN**, KRUTIKA A. BHATTI***

CANCER THERAPY INDUCED ORAL MUCOSITIS: PREVENTION AND MANAGEMENT PROTOCOL

PARUL BHATIA*, A.R. CHAUDHARY**,YESHA JANI***, SURESH LUDHWANI****

RADICULAR CYST ENCHROCHING UPON THE MAXILLARY SINUS –A DIAGNOSTIC DILEMMA

PURNIMA JETHWA*, MITESH PATEL**,NITU SHAH***, NEHA VYAS****

ORTHOKERATINIZED ODONTOGENIC KERATOCYST......................................................................

MINAL BAKSHI*, MANISHA SINGH**, RICHA VASANT***, RIYA ACHU RAJAN****

B

Dear friends,My heartiest greetings to all the readers for the coming new year 2014.

In today's time, profusion of information regarding the techniques, materials and treatment modalities rendered to the patient is a challenge not only to the dental practitioners and the students but also to the patients. We wish to take an initiative to minimize the impact of diseases of oral and maxillofacial origin on health as well as the psychological development of the patients.

We appreciate and would like to encourage faculties and students of all institutions to help us in our endeavour of promoting oral health and reducing oral diseases amongst the population. We look forward for articles on current perspectives in dentistry for the benefit of the community at large.

The Journal of Ahmedabad Dental College and Hospital; 4(2), September 2013- February 2014 47

STRESS

STRESSORS:

Stress, a”SILENT KILLER”, has become a burning problem in present era.a. Stress is defined as a mismatch between

perceived demands and perceived capacities to meet those demands.

Physiologically, stress is non-specific response to stimuli

ORb. Whenever there is a change in our

environment, which we apraise as a damaging or harmful, some demand is placed on us for adjustment.

This sequence of creation of demand, body-mind responses and the outcome is known as Stress.Stress is both, physical as well as mental condition. Stress is essential for growth and development.Original theory of stress reaction of Cannon [1932] i.e. Fight and Flight reaction in threatening situation is thining in 21st century.Three stages of stress were described by Hans Selye, which are-

i. Alarm Reactionii. Resistance andiii. Exhaustion

This is called “General Adaptation syndrome”.The occurance of stress is associated with “Stressors”.

The responses of our body and mind to the demands are explained as “Stressors”.Different individuals have different situations as their stressors.

The longer a stressor operates, the more severe its effects. There are different categories of stressors-1. Frustration- All sorts of obstacles produce it.2. Conflict- when two or more uncompatible

needs occur.3. Pressures- it occurs when we want to achieve

specific goals.Some of the common stressors are-

a. Family stressors. e.g. sharing of work loadb. Physical stressors. e.g. excess of cold , heat,

noise etc.c. Career and Job related stressors. e.g.

Interviews, public speaking, deadline for completion of task, competition and power struggle.

d. Interpersonal stressors. e.g. spoiled relationship with family members, friends, neighbours or misunderstanding, jealousy etc.

e. Socio-economic, environmental and political stressors. e.g. unemployment, less income, high cost of living, poor services etc.

Stress is maintained by constant reactions of thoughts, feelings and behavior.Women live longer than men. As compared to women, more men are killed by stress related disorders including tobacco chewing & smoking, alcohol & coronary artery diseases.This suggests that there is some strategy to deal with stress amongst women.There are ways to overcome stress to a very good extent. They include-i. Do something different than what you do

normally.

STRESS

* Rustom M. Rao

ABSTRACT

In today's world, the stress has become a common problem among all; whether that is a young, old or a child. During day-to-day life, stress causes occurrence of multiple disorders in an individual.

Stress causes particular disease by temporarily inhibiting certain components of immune system.

Hans Selye, the father of study of stress, established relationship between chronic stress and its effects on the body.

AHMEDABAD DENTAL COLLEGE & HOSPITAL, BHADAJ-RANCHHODPURA ROAD, TA:- KALOL DIST:-GANDHINAGAR.

ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+91 9687616779)

* Professor of physiology

Review Article


ii. Make time for yourself each day by relaxation, fun, enjoyment, activities that give you a sense of closeness to others.

iii. Listening to the musiciv. Relaxation techniquev. Meditation or Prayer because classification of

all diseases is usually “Stress Related” (Adhija) and “Not Stress Related” (Anadhija). e.g. Injuries

vi. Be with othersvii. Talk to someoneviii. Limit your responsibilities- its O.K to say

“NO”ix. Positive self-talkx. Do something creativexi. Yoga etc.Yoga is considered especially useful in management of “stress Related” disorders. Yoga also helps to prevent certain diseases, especially important in elderly persons. It is also important in vulnerable people whose life style is unhealthy (i.e. in terms of diet, exercise and relaxation).

A signal is put on whenever a person is stressed, irrespective of a stressors to which he/she is exposed.Common stress signals are-a. Physical – e.g. headache, dryness of mouth,

cold hands & feet, palpitation ( i.e. person becoming aware of his heartbeat).

b. Men ta l /Emot iona l – e .g . l a ck o f concen t ra t ion , f r equen t mis t akes , forgetfulness, tendency to over react, thought block etc.

c. Behavioral- e.g. insomnia (lack of sleep) or somnolence (excessive sleep), clumsiness, increased smoking &/or drinking.

Some people after exposure to trauma often develop high level of fear and anxiety and eventually a collection of symptoms called- “POST TRAUMATIC STRESS DISORDERS” [PTSD] (Girelli et al, 1986).Sometimes as a result of strenuous repeated exercise or activities can cause “Stress Fracture”. It can also occur as a result of osteoporosis.Some stress called “Eustress” prepares us to meet certain challenges & therefore it is useful.

H O W T O K N O W , W E A R E OVERSTRESSED………

POST TRAUMATIC STRESS DISORDER:

Other stress called “Distress” is harmful.Certain stimuli produce stress responses which have already been described before as “Stressors”.Stress is responsible for producing certain diseases due to inhibition of certain components of immune system. These stress related disorders are-Gastritis, Ulcerative Colitis, hypertension (very common), Asthma, Anxiety, Rheumatoid Arthritis, Migrain, Anxiety, and a very commonly seen now-a-days is “Stress Diabetes”.

Response to stress involves multiple hormones like ACTH, Cortisol, Adrenaline, Nor-Adrenaline, Thyroxine, Aldosterone etc.Multiple hormones bring about appropriate biochemical and physiological responses.During the severe stress, Cortisol may rise as much as ten folds more. This is an adaptive response for survival.Stress activates hypothalamus –Pituitary-Adrenal axis.The CRH-ACTH-Cortisol axis is central to integrated response to stress.Cortisol works to provide resistance to stress.

In managing the stress, the first step is to find out our own stressors.A better way to deal with the stress is to convert “HAVE TO” into “WANT TO”.Its so hard when “I HAVE TO” and so easy when “I WANT TO”.

The success of a person (e.g. student, teacher, doctor, businessman etc.) depends upon more or less the same attitude of – “I WANT TO” and not “I HAVE TO”.

ROLE OF HORMONES IN STRESS:

MANAGEMENT OF STRESS:


SCORING --Scores of 30-40 indicate high levels Scores of 20-29 indicate moderate levelsScores below 20 indicate within individual's

coping capabilities

The incidences of stress are increasing in day-to-day life at all ages.Stress, which is an abnormal type of stimulus, produces certain abnormal responses, including physical, mental & behavioral disorders. Several negative effects appear on an individual gradually rather than immediately.

CONCLUSION:

Sometimes stress comes in unnoticeable. The person is not aware of it but in his/her unconscious mind, there is a definite presence of some sort of stress.Truly speaking, noticeable stress is less harmful than unnoticeable stress.When there is cumulative stress than it results into many disorders like- illness, inappropriate behavior, low energy & performance level etc.In our present world, the stress has become “A SILENT KILLER”.You can always negotiate with “STRESS” as well as “TERRORIST”.

My life is but a weaving, between my God and me,

I do not choose the colours, He worketh steadily.Offtimes He weaves sorrow, and I in foolish

pride,Forget he sees the upper, and I the underside.

Not till the loom is silent and shuttles cease to fly,Will God unroll the canvas and explain the reason

why.The dark threads are needful in the skillful

weaver's hand,As the threads of gold and silver in the pattern He

has planned.

DEGREE OF STRESS NOTICEABLE IN STRESSFUL TIMES

SYMPTOMVERY

FREQUENTLY4

FREQUENTLY3

SOMETIMES2

RARELY1

NEVER0

Sleep problems

Pains, e.g. headache,backache

Extreme variations inappetite

Reduced self-confidence

Difficulty in makingdecisions

Problems inconcentrating

Worrying more thanusual

Increased irritability

Feeling miserable

Withdrawing fromcontact

REFERENCES:

1. The Bhagwad Geeta, Chapter II/14,32,48 and Chapter X2. Bushman B.J (2002). Personality and Social Psychology

Bulletin,28,724-7313. Lazarus, R.S, & Folkman, S. (1984), stress appraisal and coping.

New York; Springer


Introduction Osteomyelitis is commonly encountered in areas of poor socioeconomic conditions and is a major medical problem in the developing countries. The general lack of awareness of the prevalence of the disease and its features often leads to a misdiagnosis and delay in treatment. Early detection of this condition and prompt attention will pre-empt the need for a surgical intervention in an otherwise protracted course of illness.Osteomyelitis can be defined as an inflammatory condition of the bone, which begins as an infection of the medullary cavity, rapidly involves the haversian systems, and extends to involve the periosteum of the affected

1area . Infection occurs as a result of a bacteremia, an inoculation during aseptic or bone surgery or a contiguous infectious focus. Conditions altering the vascularity of the bone such as radiation, malignancy, osteoporosis, and Paget's disease predispose to osteomyelitis. Systemic diseases like diabetes, anaemia, tuberculosis and malnutrition that cause concomitant alteration in host defenses

1profoundly influence the course of osteomyelitis . The consequences of this infection range from the minor nuisance of a draining tract, to a pathologic fracture at the infected site, to the possible

2malignant transformation to carcinoma . The bones reported to be involved by osteomyelitis in the head and neck are the mandible, frontal bone, cervical spine, maxilla, nasal bone, temporal bone and skull

base bones. The diagnosis is mainly made by clinical presentations like discharging sinus, periosteal thickening and tenderness, confirmed by the presence of sequestrum or bony destruction with or without pathological fractures on radiography. Imaging with radionuclide scans, computed tomography (CT), and magnetic resonance imaging (MRI) are used for early detection, when the diagnosis of osteomyelitis is equivocal or to help gauge the extent of bone and soft tissue infection. Surgical treatment involves debridement of necrotic bone and tissue, obtaining appropriate cultures, managing dead space, and when

9necessary, obtaining bone stability . Acute cases respond very well to a medical line of treatment. Others require surgical intervention with long-term broad-spectrum antibiotic therapy for 4-6 weeks. Here we present our experience in managing 6 patients with osteomyelitis of maxilla and mandible in the head and neck having various predisposing factors.

The term 'osteomyelitis', which was introduced by 3Nelaton in 1844, implies an infection of the bone

and marrow. Osteomyelitis most commonly results from bacterial infections, although fungi, parasites, and viruses can affect the bone and marrow. Although osteomyelitis in the long bones of the body can be broadly comparable to the flat and irregular bones of the head and neck as regards

Discussion

OSTEOMYELITIS- IN AND OUT OF JAWS Review Article

* Nitu Shah, ** Shrinal Mankiwala, ***Kshiti Trivedi, ****Neha Vyas

ABSTRACTAll bones of the facial skeleton are susceptible to osteomyelitis due to various predisposing conditions. Current radiological tools are sufficient to provide adequate diagnosis. Treatment can be conservative resection of the diseased bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more radical. Our purpose was to analyse the behaviour of various predisposing factors that lead to osteomyelitis in the head and neck region. A total of 6 cases of osteomyelitis in head and neck with trauma,odontogenicinfection, tuberculosisand diabetes were reviewed in a 2 year period. Pus for culture, antibiotic sensitivity, radiological and histopathological analysis were the main investigations. A medical line of treatment along with control of predisposing factors plays an important role in success of surgical outcome.Keywords: osteomyelitis, predisposing factors, antibiotics, sequestrectomy


ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE

* Proffesor, ** PG Student, *** Reader, **** Proffesor & HOD ,


etiopathology, their management varies in the head and neck due to anatomical and cosmetic considerations. Osteomyelitisis routinely classified as anacute, subacute, and chronic osteomyelitis. Abrupt onset of symptoms and signs during the initial stage of infection indicates an acute

4osteomyelitis . If this phase passes without complete elimination of infection, subacute or chronic osteomyelitis can become apparent. Most patients with acute osteomyelitis in the head

5and neck present with mandibular disease . Inflammatory lesions are by far the most common pathologic condition of the jaws. The jaws are unique from other bones of the body in that the presence of teeth creates a direct pathway for infectious and inflammatory agents to invade bone

7by means of caries and periodontal disease . The predisposing factors for osteomyelitis include dental infection, trauma, especially compound fractures, surgery, infections of the oral cavity leading to periosteitis, infections from furuncles or lacerations and systemic conditions like diabetes,

6 9tuberculosis, malnaurishment . A study by Taher , of 88 cases of osteomyelitis of the mandible, found trauma to be the most common predisposing cause for osteomyelitis.The retrospective study of 6 cases of osteomyelitis of the mandible and maxilla carried out in oral and maxillofacial surgery department over a period of 2 years. The age, gender, medical history, and examination findings of these patients were obtained from case records. Typical clinical findings included localized bone pain, erythema, draining sinus tracts, fluctuating abscesses, deformity, instability, local signs of impaired vascularity, impaired range of motion, presence of a previous open wound, and discharge. In addition to local signs of inflammation and infection, signs of systemic illness, including fever, irritability, and

11lethargy were used to diagnose osteomyelitis . Once a clinical diagnosis of osteomyelitis had been reached, the following investigations were carried out at the relevant site. (1) Radiological investigations such as orthopantomogram, plain X-ray of skull bones, X-ray of the neck (antero-posterior and lateral view). (2) CT scan. (3) Pus from the discharging sinus was investigated for culture and sensitivity. (4) Wide bore needle aspiration cytology in cases of ambiguous diagnosis. (5) Biopsies from the granulation tissues for histopathological examination. (6) Routine

blood examination, blood sugar analysis, and ELISA for HIV infection.Once the diagnosis and the extent of disease were confirmed, patients were treated either medically, surgically or both depending on the site, chronicity, and severity of the lesion. Patients with acute osteomyelitis were diagnosed by abrupt onset of symptoms with early radiological changes or absence of radiological findings. Chronic osteomyelitis was diagnosed when the symptoms were long-standing and radiology showed sequestra, periosteal thickening or abscess, loss of joint mobility, bony irregularity, loss of bone or pathological fractures. We found in our series,the clinical features are the same for both the acute and chronic variants except that in chronic osteomyelitis these symptoms are milder. Clinical features documented are deep intense pain, high intermittent fever, paraesthesia or anaesthesia of the lip due to involvement of the mental nerve, pus and sequestra exudates through fistulae, trismus, regional lymphadenopathy, induration of soft tissue, and wooden character of bone with pain and

11tenderness on palpation . The associated teeth may be mobile and sensitive to percussion. The surgical procedure undertaken depended on the site of the lesion. In allcases, the pus was sent for microbiological study and intraoperative g r a n u l a t i o n s , i f a n y, w e r e s e n t f o r histopathologicalstudy.Control of underlying systemic condition was done in a cases of dibetes, tuberculosis. . Where odontogenic cause was predisposing factor, the related teeth were removed. All patients were supplemented with a high protein, multivitamin diet and general nursing care. In this analysis of six patients, the male female ratio was 2:1, age ranged from 25 years to 70 year, the mandible maxilla involvement ratio was 2:1. In mandible posterior region was more commonly involved as compared to anterior region while in maxilla anterior region was more commonly seen. Osteomyelitis of nasal bone is a very rare entity. It is usually associated with osteomyelitis of

10neighbouring bones such as the maxilla . We had one case of osteomyelitis of maxilla and nasal bone due to a long-standing ulcer and two cases following trauma.In the following analysis, all patients had a predisposing factor, out of them two had trauma, two had odontogenic infection, one had diabetes and one had tuberculosis . The ratio of acute to chronic condition was 1:2.


Out of 6 patients diagnosed with osteomyelitis 2 patients were diagnosed as having acute osteomyelitis, while remaining were chronic cases. In 4 patients with osteomylitis of mandible, pain and tenderness were present in all cases, swelling in 2 discharging sinus with sequestra in 4 cases, periosteal thickening 1 case lymphadenopathy in all, loosening of tooth in 2 cases.In maxillary osteomyelitis both the patients had pain and tenderness over maxilla. Draining sinus was present in one case. Loosening of teeth was present in one case.Radiological findings showed periosteal thickening, minimal abscess or new bone formation in acute osteomylitis and bony destruction, sequestra, and altered contours of the bone chronic

13osteomylitis .

Figure 1. Osteomyelitis of the maxilla of a patient who was suffering from diabetesPus from the diseased area was sent for culture and sensitivity for all cases. The organisms cultured were Staphylococcus aureus in 4 cases, Streptococcuspyogenes in 1 and Mycobacterium tuberculosis in 1 case.

Figure 2 CT scan of osteomyelitis of maxilla The treatment protocol consisted of a combination of surgery and antimicrobial treatment. The aim of surgery was elimination of all infected, necrotic tissue, to facilitate drainage and provide an

opportunity for reperfusion in the areas of insult . All patients were managed medically with intravenous antibiotics and analgesics followed by oral antibiotics for 4-6 weeks and surgically by sequestrectomy with saucerisation depending upon

13the extension of diseases . There was no recurrence of osteomyelitis in any of the cases.

Figure 3 Intraoperative photo of patient with maxillary osteomyelitis

Fig 4. Operative specimen of sequestrum of the maxilla from the same patient Anti-tubercular therapy was started for one patient and antidiabetic regime for one diabetic patient .

Fig 5 Microphotograph (10x and H&E ) suggestive of osteomyelitis of the same patient

12


Fig 6 postoperative photograph of the same patient after two week Before application of any cross-sectional imaging modality, the orthopanoramic view is indispensable in recognizing direct radiographic signs of osteomyelitis. The orthopanoramic view is the procedure of choice in follow-up examinations in patients who have osteomyelitis.

ConclusionOsteomyelitis in the head and neck is a difficult disease to treat. The series in the present study shows that elimination of various predisposing factors that lead to osteomyelitis results in prompt resolution .thus the treatment of osteomyelitis needs prompt clinical examination and supportive radiological and histo-pathological examination. The predisposing factors should be treated first for better surgical outcome.

References1. Topazian RG. Osteomyelitis of jaws. In: Topazian RG, Goldberg MH,

editors. Oral and maxillofacial infections, 3rd edn. Philadelphia, PA: Saunders; 1994. p. 251!86.

2. Wickenhauser C, Tsironis K, Zirbes TK, Larena-Avellanda A, Dienes HP. [Highly differentiated squamous epithelial carcinoma as a late complication of post-traumatic osteomyelitis.] Pathologe 1999;20:236 !41 (in German).

3. Nelaton A. Elements de pathologiechirurgicale. Paris: Germer-Bailliere; 1844!1859.

4. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects (first of three parts). N Engl J Med 1970 ;/282:198/ !206.

5. Cierny G, Mader JT, Pennick JJ. A clinical staging system for adult osteomyelitis. ContempOrthop 1985;10:/ 17/ !37.

6. Eckardt JJ, Wirganowicz PZ, Mar T. An aggressive surgical approach to the management of chronic osteomyelitis. ClinOrthopRelat Res 1994;(298):/ 229/ !39.

7. Lee L. Inflammatory lesions of the jaws. In: White SC, Pharoah MJ, editors. Oral radiology: principles and interpretation, vol 3, 4th edn. Missouri: Mosby; 2000. p. 338!54. [8] Shafer WG. Diseases of the pulp and periapical tissues. In: Shafer WG, Hine MK, Levy BM, eds. A textbook of oral pathology, 4th edn. Philadelphia, PA: Saunders, 1993:479! 525.

8. Taher AAY. Osteomyelitis of mandible in Tehran, Iran. Oral Surg Oral Med Oral Pathol 1993;76:/ 28/ !31.

9. Schuknecht B, Valavanis A. Osteomyelitis of the mandible. Neuroimaging Clin North Am 2003;13:/ 605/ !18.

10. Hao S, Chen HC, Wei F, Chen C, Yeh AR, Su J. Systematic management of osteoradionecrosis in the head and neck. Laryngoscope 1999;109:/ 1324/ !8.

11. Alan A, Lim T, Karakla DW, Watkins DV. Osteoradionecrosis of the cervical vertebra and occipital bone: a case report and brief review of the literature. Am J Otolaryngol 1999;20:/ 408/ !11.

12. Ang E, Black C, Irish J, Brown DH, Gullane P, O'Sullivan B, et al. Reconstructive options in the treatment of osteoradionecrosis of the craniomaxillofacial skeleton. Br J PlastSurg 2003;56:/ 92/ !9.

13. Shaha AR, Cordeiro PG, Hidalgo DA, Spiro RH, Strong EW, Zlotolow I, et al. Resection and immediate microvascular reconstruction in the management of osteoradionecrosis of the mandible. Head Neck 1997;19:/ 406/ !11.


INTRODUCTIONThe methods used in diagnosis are continually changing in histopathology. Over the past 60 years, frozen section diagnosis of surgically resected tumors and tissues has become a well-

1-4established practice . Despite the use of other methods (both cytological and histological) of establishing a preoperative tissue diagnosis, frozen sections continue to play a part in surgical decisions. Discrimination of benign and malignant tumors during surgery is important for the

5,6management of the patient .Intraoperative frozen-section analysis gives

7information about the characteristics of masses . The results of the frozen examination determine the course of surgery. When performing ablative procedures for head and neck cancer, the surgeon's goal is to obtain optimal clearance of the tumor while sparing as much normal tissue as possible, thus preserving function and limiting morbidity. Hence, it is important to know regarding the positive and negative margins of the surgical field to avoid unnecessary resections. The prevalence of frozen section procedure is not very popular amongst the oral surgeons in India. But the increase in awareness amongst the surgeons to follow conservative treatment to avoid patient discomfort has motivated the oral pathologists to be familiar with this procedure. Frozen section may be one of the most vital procedures performed by the pathologist throughout his practice. It is a complex procedure.

The pathologist has to arrive at a correct decision in a shorter duration under pressure based on his experience, judgment and the knowledge of his specialty and clinical medicine. He should also have a keen awareness of the limitations of the method as the patient's life is often dramatically influenced by his report.

Three major advances in medical science made during the mid to late 19th century, have made the frozen section technique a standard diagnostic tool. First, the introduction of anesthesia allowed surgeons to perform longer, more complicated procedures that required improved diagnostic skills. Second, there were significant improvements in both the resolving power and the magnification capability of the microscope, and lastly there were many advances in techniques for the preparation of pathological specimens for microscopic evaluation. Many physicians around the world were experimenting simultaneously methods for freezing tissue for pathologic diagnosis, so it is not known who truly invented the technique. However, the first use of the frozen section technique for pathologic diagnosis was recorded in 1818 by a

8Dutch anatomist Pieter de Riemer .Prior to 1870, frozen sections were usually cut freehand with a razor, but by the late 19th century, microtomes were developed, resulting in improved speed and quality of sectioning. In 1890, the use of frozen sections first appeared in textbooks. With the introduction of cryostat it became the accepted

9method of cutting frozen tissue .

HISTORY

FROZEN SECTION Review Article

* Brijesh Patel, **Manisha Singh, ***Nileshwari Jadeja, ****Alpesh Patel, *****Minal Bakshi


ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (+919898212228)

* Reader, ** *** Senior lecturer, P.G.Student, ****Proffesor, ***** Reader

ABSTRACTFrozen section is a vital technique for the management of surgical patients. The frozen-section procedure is a widely used diagnostic test because of the insufficiency of pre-operative diagnostic tools such as imaging and tumor markers. This technique determines the types and the extent of the surgery that will be performed, primarily for malignancy and therefore directly impacts the morbidity of the patient. This review article emphasis on the technique, applications, advantages and limitations of frozen section. KEYWORDS: Frozen section, diagnostic test, malignancy


The frozen section procedure as practiced today in medical laboratories is based on the description by Dr Louis B Wilson in 1905. Wilson developed the technique from earlier reports at the request of Dr William Mayo and Wilson is generally credited

10with truly pioneering the procedure .

The primary indications for intraoperative frozen section includes:• To determine whether a lesion is benign or malignant• Surgical margin assessment and in cases where no immediate diagnosis can be made from the biopsied specimen, to ensure that the removed tissue is representative and viable, by which a definitive diagnosis can be achieved later on the

9paraffin sections or through special staining . • In the performance of Mohs surgery - a simple method for 100% margin control of a surgical specimen.• If a tumor appears to have metastasized, a sample of the suspected metastasis is sent for cryosection to confirm its identity. This helps the surgeon in deciding whether there is any point in continuing the operation. Usually, aggressive surgery is performed only if there is a chance to cure the patient. If the tumor has metastasized, surgery is usually not curative, and the surgeon will choose a more conservative surgery or no resection at all.• In a sentinel node procedure, a sentinel node containing tumor tissue prompts a further lymph node dissection, while a benign node will avoid such a procedure.• If surgery is explorative, rapid examination of a lesion might help identify the possible cause of a patient's symptoms.• Rarely, cryosections are used to detect the presence of substances lost in the traditional histology technique, for example lipids. They can also be used to detect some antigens masked by formalin.

Good frozen section technique is learned gradually and only through experience. The following steps should be routinely carried out: 1. Gross tissue examination: (Figure 1)This step is probably the most important step and unfortunately is one that many pathologists have not yet learned. The pathologist obtains gross dues not from just looking at the tissue, but also from feeling it and cutting it, i.e., soft or gritty. The pathologist records all gross expressions, i.e., size,

APPLICATIONS

TECHNIQUE 11, 12

adhesions, weight, similar to the recording of 11microscopic features .

2. Proper communication with the surgeons:The intercom is located in the frozen section suite; the room where the surgeon is operating will be obtained from the pathology department secretary transmitting the request for frozen section. A list of operating room procedures appear the day before the planned surgery, and it is the responsibility of the resident and staff to be familiar with each case in advance. This means knowing what tissues have been removed previously, reviewing any previous diagnoses that the pathology department has on file, and reviewing all previous slides of the patient. This is important because the present procedure may be related to previous ones. This "research" by the pathologist is equivalent of the medical history.

3. Embedding the tissue: (Figure 2)The selected piece of tissue is then placed on a metallic holder and must be oriented a certain way. The tissue is embedded in OCT mounting medium and is then placed either in cooled 2-methyl butane or the cryostat machine where it is properly frozen.

Figure 1

Figure 2


4. Cryostat: (Figure 3)The machine, which cuts the tissue, is the cryostat. Certain things should be routinely checked in the operation of this machine:a) Temperature:The temperature should be at -20°F for most tissues. For tissues with a large fat component, -40°F is optimal. This temperature is critical for optimal sectioning. Too high (-10°F) and the tissue will not stay frozen and firm and will not cut crisp.Too cold (-50°F) and the tissue will crumble and become powder.The Ideal tissue should cut like butter, smooth and in one piece.b) Blade sharpness and angle:The blade should be sharp and should be changed approximately once every 2 weeks. A dull blade cuts dull. Equally important is the blade angle. There is an optimal angle between blade and tissue:Too steep an angle and the tissue will crumble like it was too cold.Too shallow, then two things will happen. The section will alternately skip and not cut and then it will cut, but too thick.5. Staining:Once the tissue is on the slide it can be either air-dried or fixed with methanol which depends on the staining procedure to be used. The choice of stain depends on what the pathologist is trying to demonstrate. 6. Interpreting the frozen section: (Figure 4)The final work is to discuss the slide and render a diagnosis. Since rapid diagnosis takes precedence over everything else in the operating room, often times additional discussion and questions occur after the diagnosis has been rendered.

7. Controls:In all science, controls are necessary. Since pathology is not an exact science, controls cannot be exact, but an attempt is made to check out frozen section accuracy. The tissue, which is frozen, is submitted for permanents and labeled "frozen section control." This is to be kept separate from the other additional tissues submitted for permanents. In this way, the pathologist has a limited check on his frozen. If anything shows up on the permanents that is substantially different than the frozen, the surgeon or doctor taking care of the patient should be notified immediately.

• If more tissue is needed to make an accurate diagnosis, the surgeon is able to obtain an additional sample, avoiding a second operation.• If the tissue is determined to be cancerous and is amenable to surgery, the mass can be removed at that time.• If the tissue is determined to be benign (not cancerous), then the mass may not always need to be removed and the surgery can end.• The frozen section biopsy can help ensure that the mass being removed is the intended tissue for removal.• It can help ensure that the entire mass and its surrounding borders are removed.• It allows for the collection of proper tissue samples for further scientific research.• The surgeon and pathologist are able to

11collaborate to care for the patient. • The cryostat is available in a small portable device weighing less than 80 lb (36 kg), to a large stationary device 500 lb (230 kg) or more. The entire histologic laboratory can be carried in one portable box, making frozen section histology a

9possible tool in primitive medicine .LIMITATIONS 13Limitations of frozen section need to be taken into

ADVANTAGES

Figure 3

Figure 4


List of illustrations:

Figure 1 Figure showing grossing of tissues for frozen section

Figure 2 Figure showing the freezing of tissue sampleenclosed in cryo mold by immersing inisopentane

Figure 3 Figure showing cryosectioning using brush technique

Figure 4 Figure showing histopathological picture of a frozen section

consideration when requesting for this procedure, in order to avoid grave mistakes that will be detrimental to the patient's management. These limitations can be divided into three main categories, namely sampling error, technical problem and interpretative error.Sampling limitations(i) Poor sampling of tissue / limitation of the surgeons:This is a very obvious limitation for the pathologist since he has to interpret whatever the tissue is sent by the surgeon. (ii) Poor selection of appropriate tissue after grossing:The most representative tissue areas of the sample should be selected. This greatly influences the interpretation. Sometimes the orientation of the tissue sent is not clear and communication with the surgeon intraoperatively is important.(iii) Extensive tumor degeneration or necrosis:Sometimes difficultly in sampling a large tumor is encountered. The surgeon must choose a viable area and avoid necrotic one. Recognizing areas of tissue reaction to tumor such as edema and fibrosis are also important.(iv) Poor assessment of capsular or vascular invasion:Assessment of capsular or vascular invasion is very difficult in frozen section and subjected to sampling errors. Technical limitations(i) Freezing artifacts / Xylene artifacts:Freezing artifacts causes much damage to the tissue structure of the frozen section. Inadequate xylene treatment and improper coverslipping of slides cause drying artifacts, whereas any water present in xylene solution used contributes to cloudy sections. (ii) Poor quality section:Frozen tissue section is not easy to cut compared to paraffin embedded section. The section is usually thick and occasionally folded. Air bubbles may easily get into the tissue sections. A thick section may render it difficult to visualize clearly the nuclear details.(iii) Bloated cell morphology:Depending on how good and how fast the tissue freezing process is, and its water content, this step will determine whether the cell morphology is preserved or not. However, in most cases of frozen section the cell morphology is inferior to that of the paraffin embedded section. Frozen section tends to cause the cells to be larger and appear bloated and the pathologist must take this into consideration when examining the tissue sample.

(iv) Poorly stained section:Freezing may affect the staining quality of the sections and this factor may affect the pathologist's judgement. To obtain a better morphology and staining quality of the slide sections, some laboratories heat the tissue sample in formalin for a brief period before subjecting it/them to freezing. However, this will increase the turn-around time of the procedure.Interpretative limitationsFrozen section diagnosis sometimes can be very tricky. It is the policy of the pathologist to give the closest diagnosis as possible to the surgeon and avoid giving the definitive diagnosis if there is any doubt. It is preferable to delay the definitive diagnosis of the case especially if the finding is not going to influence the intra-operative management. The followings are some difficulties that may be encountered in frozen section service.(i) Tumours that are difficult to diagnose:Certain tumors may mimic the normal tissue or cells. Malignant blood vessels in angiosarcoma may appear like ordinary blood vessels and assessment of normal tissue margin for sarcoma can be very tricky. (ii) Heterogeneity of the tumor:Heterogeneity in tumors especially soft tissue sarcoma makes it fairly difficult to diagnose the lesion not only in frozen section but also in tissue biopsy specimen. (iii) Mixed tumor and biphasic tumor:These may again be difficult to interpret.CONCLUSIONThe intra-operative consultation using frozen section is very useful but one needs to be aware of its

13indications and limitations . Frozen-section examination is a method with adequate sensitivity and specificity. It has low false-positive and false -

14negative rates . Nowadays, this technique has come to be accepted as an integral part in the proper

15management of the surgical patient .


REFERENCES1. McCarthy WC. The diagnostic reliability of frozen sections. Am J Pathol

1929;5:377-80.2. Peters PM. Frozen section diagnosis. Br Med J 1959;i: 1321-3.3. Bauermeister DE. The role and limitations of frozen sections and needle

aspiration biopsy in breast cancer. Cancer 1980; 46:947-9.4. Ackerman LV, Ramirez GA. The indications and limitations of frozen

section diagnosis: a review of 1269 consecutive frozen section diagnosis. Br J Surg 1959;46:336-50.

5. Spann CO, Kennedy JE, Musoke E. Intraoperative consultation of ovarian neoplasms. J Natl Med Assoc 1994; 86: 141-4.

6. Twaalfhoven FC, Peters AA, Trimbos JB, Hermans J, Fleuren GJ. The accuracy of frozen section diagnosis of ovarian tumors. Gynecol Oncol 1991; 41:189-92.

7. Michael CW, Lawrence DW, Bedrossian CWM, F.I.A.C. lntraoperative consultation in ovarian lesions:a comparison between cytology and frozen section. Diagnostic Cytopathology 1996; 15: 387-94.

8. Goss GR. Frozen section: the stat test of clinical pathology? Adv Med Lab. 2001;13:8–12, 82.

9. http//www.wikipedia.com10. Wilson LB. (1905). "A method for the rapid preparation of fresh tissues

for the microscope". J Am Med Assoc 45: 1737.11. Hamed Ganjali. Frozen section: An overview. Annals of Biological

Research, 2012, 3 (11):5363- 536612. Stephen R Peters. A Practical Guide to Frozen Section Technique.

Springer New York Dordrecht Heidelberg LondonHasnan Jaafar13. . Intra-Operative Frozen Section Consultation: Concepts, Applications

and Limitations. Malays J Med Sci. 2006 January; 13(1): 4–12.14. Arikan Ilker, Barut Aykut, et al. Accuracy of intra-operative frozen

section in the diagnosis of ovarian tumours. J Pak Med Assoc 61:856; 2011

15. Goss, G. R. Frozen section: the stat test of clinical pathology? Adv Med Lab 2001. 13:8–12. 82


THE PRE-STERILIZATION CLEANING

PROTOCOL FOR ROTARY NI-TI ENDODONTIC FILES

* Rajesh Mahant, ** Shraddha Chokshi, *** Rupal Vaidya, **** Pallav Chokshi, ***** Ghanshyam Patel, ******Pruthvi Patel

IntroductionRotary NiTi endodontic instruments are gaining popularity based on their superior preparation of canals compared to hand instruments. Several studies have shown that these NiTi instruments can be used several times without intra canal failure. Endodontic files are considered as reusable instruments. Cross–infection control is a major issue in dental care setting because of concerns about transmission of diseases via oral cavity. Endodontic treatment involves direct contact with saliva, blood and infected pulp tissue, carrying

1bacteria, viruses or prions . Instruments that are in direct contact with the vascular system of pulp or penetrate the oral mucosa are classified as 'Critical

2Items' and must be sterile before use . so endodontic files are considered to be critical items and must be

cleaned and sterilized before their use. The basic theorems of asepsis apply to NiTi files with little variance whenever these instruments are re-used. Endodontic files and reamers do not have internal surfaces that are inaccessible, but their construction and designs, which involve fluted and twisted sections, don't allow easy access to all the surfaces and make both mechanical and chemical

4c l ean ing cons ide rab ly more d i f f cu l t . Consequently, residual biological debris may remain on the surface of the instrument even after sterilization. In this way, potentially infective material could be transmitted from one infected

5tooth to other tooth.Infection control guidelines indicate that Effective sterilization of used instruments involves cleaning of instruments to remove organic residue in order to

3

ABSTRACTRotary nickel-titanium files have become the most widely used engine driven endodontic instruments for proper shaping of root canals. Whenever these instruments are re-used proper cross-infection control measures should be undertaken. The complex miniature architecture of rotary Ni-Ti endodontic files makes pre-sterilization and sterilization procedures difficult. So, the aim of this study was to determine the effectiveness of various pre-sterilization cleaning protocols for the rotary endodontic files currently used in dentistry.Material and Method60 rotary Ni-Ti endodontic files were collected from P.G. students of department of conservative dentistry and endodontics of ahmedabad dental college & hospital, ahmedabad. The files were divided into 4 groups. Pre-sterilization cleaning was carried out in Group A with liquid detergent and final rinse with water, in Group B with liquid detergent, rinsing with water followed by ultrasonic bath, in Group C with 1.52% glutaraldehyde (10% korsolex) and final rinse with water and group D pre- sterilization cleaning was carried out with 1.52% glutaraldehyde solution, water rinsing followed by ultrasonic bath. All groups were followed by sterilization process using steam autoclave at 1210 C temperatures at 15 psi pressure for 15 minutes. Instruments of all the groups were transferred separately by sterile technique into Todd-Hewitt broth, incubated at 37°C temperature for 72 hours and observed for bacterial growth. Results were confirmed microscopically using a gram stain.ResultsThe files of the groups which were cleaned with 1.52% glutaraldehyde solution and / or ultrasonic bath before autoclaving procedure showed no bacterial growth in the media. The autoclaved files which were cleaned with liquid detergent before sterilization showed bacterial growth.ConclusionsThe method used routinely for pre-strerilization cleaning for endodontic instruments is appeared to be ineffective. The best method is the one that include pre-sterilization cleaning with 1.52% glutaraldehyde or ultrasonic bath or 1.52% glutaraldehyde followed by ultrasonic bath.Key WordsRotary Nickel-Titanium endodontic files, sterilization, ultrasonic cleaners, 1.52% glutaraldehyde


ADDRESS FOR CORRESPONDENCE, AHMEDABAD DENTAL COLLEGE PHONE:- (9033060056)

* PG Student ** Proffesor, *** Proffessor & H.O.D, **** Reader, ***** Lead Biostatistician, ******Reader

Original Article


achieve sterility of instruments. It is proven that the presence of biological debris may prevent the effective penetration of steam to the surface of the instrument. Another possibility is that biological debris with low moisture content may increase the

7heat-resistance of vegetative bacteria and spores. It has been accepted that the presence of organic debris prevents the antibacterial action of chemical disinfectants. Organic materials may inactivate germicidal molecules or, if the organic material becomes dry, the proteinaceous layer resists

8penetration of the chemical solution. Cleaning of instruments to remove micro-organisms and organic debris (bioburden) effectively eliminates

9-11the majority of micro-organisms. .However, currently there is not a single method recognized to be absolutely reliable to test the cleanliness (i.e., lack of soil and bioburden) of an

12item . The Australian/New Zealand Standard AS/NZS 4187:2003. stipulates that instruments should be 'clean to the naked eye (macroscopic) and

6free from any protein residues . It does not stipulate how protein residues are to be assessed. Recommendations concerning cleaning and sterilization processes should be based on scientifically obtained and clinically relevant data and be justifiable, achievable, and consistent with

13known risks . Unfortunately, there is little research information available on infection control

1 3procedures . Cleaning and sterilization recommendations made by various groups may in fact be too stringent and not possible to follow in

9clinical practice.There is little consistent information available on the optimal procedure for the removal of biological debris from contaminated endodontic instruments. The cleaning procedures that are used include mechanical cleaning (use of different kinds of brushes and sponges) and chemical cleaning (immersion in 1.52% glutaraldehyde, enzymatic cleaners, detergents or sodium hypochlorite), ultrasonic bath and a final rinse with water before

14sterilization . Our aim is to compare various pre-sterilization cleaning procedures for used rotary NI-Ti endodontic files.

60 used rotary Ni-Ti endodontic files were collected from P.G. students of department of conservative dentistry and endodontics of ahmedabad dental college & hospital, ahmedabad. They had been divided into 4 groups with 15 files in each group. The groups were made according to the pre-sterilization cleaning procedures used.

6

METHODOLOGY

The following pre-sterilization cleaning protocol was followed in this study: group A files were cleaned mechanically with a brush & chemically with detergent liquid & then rinsed with water for 10 minutes. Group B includes Cleaning with brush and detergent liquid & then rinsing with water followed by ultrasonic cleaning for 5 minutes. In group C files were Immersed in 1.52% glutaraldehyde solution for 15 minutes and then rinsed with water. In group D the files were immersed in 1.52% glutaraldehyde solution for 15 minutes and rinsed with water followed by ultrasonic cleaning for 5 minutes. All the files were then transferred separately, using sterile techniques, into individual sterile test tubes containing 3 mL of Todd–Hewitt broth. The samples were incubated at 37°C temperatures. The test tubes were examined after every 24 hours for a total of 72 hours, and any signs of bacterial growth were documented. A color change, cloudy broth and visible precipitate in the test tube were all considered as indicative of bacterial growth. If the solution remained clear throughout the incubation period, the sample was considered sterile (Fig.1, 2).

GROUPS PRE-STERILIZATION CLEANING STERILIZATION

A Cleaned with brush & detergent

liquid & rinsed with water.

Autoclaved at1210 C, 15Lbs for

15 min

B Cleaned with brush and

detergent liquid & rinsed with

water followed by ultrasonic

cleaning for 5 minutes


15 min

C Immersed in 1.52%

glutaraldehyde (10 %korsolex)

solution for 15 minutes and

rinsed with water.


15 min

D Immersed in 1.52%

glutaraldehyde solution for 15

minutes and rinsed with water

followed by ultrasonic cleaning

for 5 minutes


15 min

TABLE NO.1

Figure 1 figure 2


Data were collected and tested for significant differences using Fisher's exact test. The result was confirmed with light microscope using gram stain. ResultSterilization procedures were 100% effective for group B, C and D; not a single sample in either of these groups showed contamination following the 72-hour incubation period. Pre-sterilization cleaning procedure with brush and detergent solution (group A) was less than 100% effective. In the group A out of 15 files 5 files (33%) were contaminated (p = 0.002). Several samples of bacterial growth from used files were subjected to gram staining; the resultant staining and bacterial structure appeared consistent with Staphylococcus (fig.3).

The goal of instrument sterilization in dentistry is to protect the patients as well as the dentist & the dental auxillary staff from cross-contamination via instruments. Careful consideration is required when devising a sterilization protocol for endodontic files. Some have suggested that these instruments

15should be considered as single-use devices . A single-use device is an instrument designed to be used in one patient only, and the packages for such devices carry a clear label stating that they are not to

16be resterilized .In the United Kingdom, concern has been raised over the potential transmission of prions by endodontic files because these devices come into contact with the peripheral branches of the trigeminal nerve. Of particular concern is the iatrogenic transmission of variant Creutzfeldt-Jakob disease, one of the transmissible spongiform

Discussion

encephalopathies . The risk of transfer of this disease via used dental instruments in dentistry is currently unknown; however, animal studies have shown that these prions can be transmitted via the

17oral cavity . Even if the risk of disease transmission is minimal during endodontic procedures, the high numbers of root canal treatments could increase the

15possibility of an adverse event . Many of the studies claimed that rotary Ni-Ti files are meant for single use only, irrespective of various pre-sterilization cleaning and sterilization

15,18methods . Bagg et al. (2001), in a survey conducted among dentists in the United Kingdom, observed that 88% of the practitioners reused

17endodontic files . So it is important to make emphasis on the effective sterilization procedures of used endodontic files.Smith et al found that a large number (76%) of used files collected from the U.K. dental community remained visibly contaminated after completion of

15the sterilization process . The results obtained in the current study reinforce the conclusion that routine method of pre-sterilization cleaning employed in the dental offices are unsatisfactory. There is no consensus regarding a standard sterilization protocol for these Ni-Ti rotary files.This study is an attempt to develop a sterilization protocol which is simple, quicker and more predictable using less expensive and easily available materials. In this experiment, 4 techniques of pre-sterilization cleaning procedures were tested and out of 4, 3 techniques were found to be effective.The sterilization techniques were 100% effective for 3 groups which have used 1.52% glutaraldehyde and/ or ultrasonic bath. Group B, C and D can be directly compared with group A, because the sterilization technique used was the same, the only difference was about pre -sterilization cleaning protocol. The files in the group A were cleaned manually with a brush & liquid detergent before autoclaving and showed visible debris present on the files. 5 out of 15 files were contaminated following sterilization. So according to Susan et al the pre-sterilization cleaning method used in group A was found to be

19not an effective method of sterilization . Parashos et al recommends a protocol for cleaning

13of used endodontic files .1. 10 vigorous strokes in a scouring sponge soaked in 0.2% of chlorhexidine solution.

15,17

Figure 3


2. 30 minute pre-soaking in an enzymatic cleaning solution.3. 15 minute ultrasonication in an enzymatic cleaning solution.4. +20 second rinse in running tap water.In the present study also ultrasonic cleaning prior to autoclaving is found to be an effective method of sterilization. One significant finding of this study is that pre-soaking in 1.52% glutaraldehyde followed by autoclaving is as effective as ultrasonic cleaning plus autoclaving. Hence this method can be recommended in absence of ultrasonic cleaner. From the results, it is quite apparent that, the pre- sterilization cleaning of used endodontic files to remove gross debris is a far effective method than sterilization alone. This relates back to the small size and complex surface architecture of these items. If the organic debris can be physically removed from these items, it is possible to sterilize them. Groups B, C and D had no organic contaminating debris and were rendered 100% sterile by the procedures outlined in Tables 1.

ConclusionWithin the limitations of this study following conclusions can be drawn:(a) Pre cleaning with liquid and detergent using nylon brush is not an effective method of sterilization.(b)The following 3 methods are found to be effective in sterilizing Ni-Ti rotary instruments.1. Cleaning with brush and detergent liquid & rinsed with water followed by ultrasonic cleaning for 5 minutes, 2. Immersing in 1.52% glutaraldehyde solution for 15 minutes and rinsing with water, followed by autoclaving are effective methods of sterilization. 3. Immersing in 1.52% glutaraldehyde solution for 15 minutes and rinsing with water, followed by ultrasonic cleaning and autoclaving are effective methods of sterilization.

REFERENCES1. Centers for disease control (1987). Recommendations for the

prevention of HIV transmission in health care settings, Morbidity and mortality weekly report: 36, 3s-18s.

2. National Health and Medical Research Council of Australia. Infection Control in the Health Care Setting. Canberra: Australian Government Publishing Service, 2002.

3. Martins R, Bahia M, Buono V. Surface analysis of ProFile instruments by scanning electron microscopy and X-ray energy dispersive spectroscopy: a preliminary study. AORN J 2002;75:1143-1158.

4. Heeg P, Roth K, Reichl R, Cogdill P, Bond WW. Decontaminated single-use devices: an oxymoron that may be placing patients at risk for cross-contamination. Infect Control Hosp Epidemiol 2001;22:542-549.)

5. Gill DS, Tredwin CJ, Gill SK, Ironside JW (2001) The transmissible spongiform encephalopathies (prion diseases): a review for dental surgeons. International Dental Journal 51, 439–46.

6. Australian/New Zealand Standard 4187. Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities: Standards Australia International Ltd/Standards New Zealand, 2003.

7. Gardner J, Peel M. Sterilization, Disinfection and Infection Control. 3rd edn. Melbourne: Churchill Livingstone, 1998.

8. Block S. Disinfection, Sterilization and Preservation. 5th edn. Philadelphia: Lea & Febiger, 2001.

9. Rutala W, Gergen M, Jones J, Weber D. Levels of microbial contamination on surgical instruments. Am J Infect Control 1998;26:143-145.

10. Chu N, Chan-Myers H, Ghazanfari N, Antonoplos P. Levels of naturally occurring microorganisms on surgical instruments after clinical use and after washing. Am J Infect Control 1999;27:315- 319.

11. Alvarado C. Sterilization vs disinfection vs clean. Nurs Clin North Am 1999;34:483-491.

12. Dunn D. Reprocessing single-use devices – the equipment connection. AORN J 2002a;75:1140-1164.

13. Miller CH. Applied research still needed on infection control procedures. Am J Dent 2000;13:285-286

14. Parashos P, Linsuwanont P, Messer HH (2004) A cleaning protocol for rotary nickel–titanium endodontic instruments. Australian Dental Journal 2004; 49, 20–7.

15. Smith A, Dickson M, Aitken J, Bagg J. Contaminated dental instruments. J Hosp Infect 2002; 51(3):233–5

16. Hogg NJ, Morrison AD. Resterilization of instruments used in a hospital based oral and maxillofacial surgery clinic. J Can Dent Assoc 2005; 71(3):179–82.

17. Bagg J, Sweeney CP, Roy KM, Sharp T, Smith A. Cross infection control measures and the treatment of patients at risk of Creutzfeldt Jakob disease in UK general dental practice. Br Dent J 2001; 191(2):87–90.

18. Nicholas J.V.Hogg,Archibald Morrison. Resterilization of Instruments Used in a Hospital- based Oral & Maxillofacial surgery clinic. JCDA 2005;71(3):179-82.

19. Archie Morrison , Susan Conrod. Dental Burs and Endodontic files: Are Routine Sterilization Procedures Effective. JCDA 2009;75(1):39-39d.




*HOD & Proffesor, ** Snr. Lecturer, *** PG Student-III

The Effects Of Nutrition On Occlusion Of Children

* VIJAY BHASKAR, ** RAJAL PATHAK, *** MIRA VIRDA

ABSTRACTAims & objectives - To investigate the relationship between low BMI and malocclusion in a population of children (9-13 years) Ahmedabad, Gujarat, India.Materials & method - This cross-sectional study consisted of 350 children including 175 underweight and 175 healthy children, aged 9-13 years randomly selected from schools in and around Gandhinagar district. The evaluation of dental occlusion was carried out by means of visual inspection performed under natural lighting, using mouth mirror & probe. For BMI assessment, children's height was checked using a millimetered measuring tape, and weight was measured by

2 2using a weighing machine. Body mass index was also measured by calculating weight (kg) per height (m ). BMI measurement was then plotted on CDC approved growth chart.Results - The results showed that there was no significant correlation found between type of BMI and occlusion as well as crowding of teeth in children. There was also no significant correlation found between age & gender of the children with low BMI. There was positive correlation found between socioeconomical status with BMI.Conclusion - There was no significant correlation between underweight children and malocclusion but further studies with increased sample size are needed to investigate possible relation between malnutrition and malocclusion.Keywords – BMI, Malocclusion

INTRODUCTION Evidence suggests that energy-protein malnutrition acts by either exacerbating an existing morbidity or contributing to the emergence of associated co morbidities. In the field of oral health, the association between malnutrition and impaired growth and the development of facial bones has been reported by a number of researchers [Caceda J, Songvasin C] and has been linked to a reduction in the length of the skull base and jaw height [Weissman S]. There have also been reports of variations in maxillo-mandibular width, lower facial height and dental and skeletal ages [Gulati A et al, Morales-Sampedro et al] as a result of malnutrition. It is believed therefore that malnutrition may also be associated with malocclusion, particularly dental crowding, which is defined as misalignment of the teeth due to insufficient space for them to erupt in the correct place [WHO,1997] . Altered bone growth in the craniofacial complex caused by poor nutrition could be reflected in reduced space for dental eruption.

MATERIALS AND METHODSThis cross-sectional study consisted of 350 children including 175 underweight and 175 healthy children, aged 9-13 years randomly selected from schools in and around Gandhinagar district.

The evaluation of dental occlusion was carried out

by means of visual inspection performed under

natural lighting, using mouth mirror & probe. WHO

recommends the body mass index (BMI) as

suitable indicators for evaluating the nutritional

status of children, and these has been used in this

study.

For BMI assessment, children's height was checked

using a millimetered measuring tape, which was

fixed to the wall in a straight line towards the floor

and use an weighing machine with a capacity of up

to 100kg division placed on a flat surface. Body

mass index was also measured by calculating 2 2

weight(kg) per height (m ). BMI measurement was

then plotted on CDC approved growth chart.

Original Research


THE QUESTIONNAIRE

There was also no significant correlation found between age, gender & habits of the children with low BMI. There was positive correlation found between socioeconomical status with BMI.

RESULTS The results showed that there was no significant correlation found between type of BMI and occlusion as well as crowding of teeth in children.


DISCUSSION The relative contribution of genes and the environment to the aetiology of malocclusion has been a matter of controversy throughout the twentieth century. Genetic mechanisms are clearly predominant during embryonic craniofacial morphogenesis, but environment is also thought to influence dentofacial morphology postnatally, particularly during facial growth [Mossey et al]. The relative influence of genetics and environmental factors in the aetiology of malocclusion has been a matter for discussion, debate and controversy in the orthodontic literatureErika Thomaz & co work as done study to check correlation between malnutrition with crowding in permanent dentition and conclude that no association was observed between malnutrition and crowding. Malnutrition is related to crowding in permanent dentition among mouth breathing adolescents.

Genetic determination and regulation are responsible for the morphogenesis of an individual during embryonic development. There is ample evidence to indicate that hereditary dentofacial characteristics can be influenced during post-natal development by general environmental factors ranging from climate, nutrition, and lifestyle to oral dental pressure habits, muscle malformation and orthodontic t reatment.The influence of environmental factors on the retardation of general somatic growth is apparent in chronic illness, prolonged starvation, and situations of excessive stress (Tanner, 1965). The variation in shape and size of the cranio-dento-facial structures depends on both genetic and environmental influences.There have also been reports of variations in maxillo-mandibular width, lower facial height and dental and skeletal ages [Gulati et al, Morales-Sampedro et al] as a result of malnutrition. The effects of malnutrition on crowding in permanent dentition by Thomaz co work as. concluded that there was no association seen between malnutrition and crowding. Malnutrition is related to crowding in permanent dentition among mouth breathing adolescents.

So it can be concluded from this study that there is no significant correlation between underweight children and malocclusion but further studies with increased sample size are needed to investigate possible relation between malnutrition and malocclusion.

CONCLUSION


REFERENCES 1. Erika Thomaz et al. Is malnutrition associated with crowding in

permanent dentition?; international journal of environmental research & public health; 2010;7:3531-3544.

2. Ana Valenca & E.Thomaz. Relationship between childhood underweight & dental crowding in deciduous teething, journal of pediatrics; 2009; 85(2):110-116.

3. N. kumar et al, Kuppuswamy’s Socioeconomical status scale updating for 2007. Indian journal of pediatrics; 2007; 74 : 1131-1132.

4. Weissman S, Sadowsky PL, Jacobson A, Alvarez JO, Caceda J. Craniofacial growth and development in nutritionally compromised Peruvian children. J Dent Res 1993; 72:366.

5. Caceda, J. Effect of nutritional status on dental age. In Proceedings of the 72th General Session of the International Association for Dental Research, Seattle, WA, USA, 1994.

6. Caceda J. Nutritional status and dental and skeletal development in Peruvian children. J Dent Res 1996; 75:189.

7. Songvasin C. Early malnutrition and craniofacial growth. J Dent Res 1994; 73:123.

8. Miller JP, German RZ. Protein malnutrition affects the growth trajectories of the craniofacial skeleton in rats. J Nutr. 1999; 129:2061-9.

9. World Health Organization. Health Interview Surveys: Toward International Harmonization of Methods and Instruments; WHO: Geneva, Switzerland, 1996.

10. Gulati A, Taneja J, Chopra S, Madan S. Inter-relationship between dental, skeletal and chronological ages in well-nourished and mal-nourished children. J. Indian Soc. Pedod. Prev. Dent. 1991; 8:19–23.

11. Morales-Sampedro G, Martínez M, Martín F, Ayala J. Bone age and dental occlusion. Rev. Cuba. Estomatol. 1993; 30:48–56.

12. Marques L, Barbosa C, Ramos-Jorge, M Pordeus, I Paiva. Malocclusion prevalence and orthodontic treatment need in 10–14-year-old schoolchildren in Belo Horizonte, Minas Gerais State, Brazil: A psychosocial focus. Cad. Saude Publica 2005; 21: 1099–1106.

13. Batista L.R.V, Moreira E.A.M, Corso A.C.T. Food, nutritional status and oral condition of the child. Rev. Nutr. 2007; 20: 191–196.

14. Center for disease control & prevention, National center for health statistics, division of health examination. http:/www.cdc.gov/nhcs /products /pubs/pubd/hus/tables/2000/updated/00hus069.pdp.


Dental Fluorosis among 12 and 15 year old school

going children of Solapur city, Maharashtra, India.

* Harsh Shah, ** , *** ****Suyog Savant Vasudha Sodani, Deeksha Shetty,*****Brijesh Patel

ABSTRACTAim: To determine the prevalence and degree of dental fluorosis in 12 and 15 years old school going children of Solapur city, Maharashtra. Methods: A total of 1042 children participated in the study. Convenience sampling was done in which the sample was divided into 2 groups. Group A, used bore water for drinking at home and at school as there was no municipal water supply. Group B, where the children, used municipal water supply for drinking both at home and at school. The data regarding the fluoride content of Borewell water of Solapur city was collected from the office of Public Works Department (PWD), Solapur. Samples of Borewell water and Muncipal water were collected from the area nearby school and analysis was done at Superintendant Chemist Laboratory, Solapur, and fluoride levels were determined. A survey Proforma was prepared with the help of the WHO Oral Health Assessment Form (1997). Karl-Pearson coefficient for correlation (or simple correlation) and simple regression analysis was used to measure the correlation between fluoride concentration in drinking water and community fluorosis index (CFI). Chi –square test was used for estimation of statistical significance. Results: High prevalence of dental fluorosis was found in Group A (43.99%) as compared to Group B (17.01%). The overall prevalence of dental fluorosis in 12 and 15 year old school going children of Solapur city was 29.07%. Conclusion: Dental fluorosis is a major dental public health problem in Solapur city.(Key Words: Dental fluorosis; Borewell water; Municipal water, Fluoride)



* Senior lecturer, ** *** Senior lecturer, Senior lecturer, ****Assistant Professor, *****Reader

INTRODUCTION

METHODOLOGY

Dental fluoride is a double –edged sword. Fluoride at optimal level, decreases the incidence of dental caries and is also necessary for maintaining the integrity of oral tissues but at the same time when taken in excess during developmental stages, can cause adverse effects like dental fluorosis and

1skeletal fluorosis . Endemic dental fluorosis is a disturbance in tooth formation caused by excessive intake of fluoride during the formative period of the dentition. India is one among the 23 Nations around the globe where health problems have been reported due to excessive fluoride in drinking water. Fluoride concentration in Solapur's groundwater was found to be much higher than the permissible limit of 0.6-

21.5 ppm (parts per million) of fluoride recommended for potable purposes. Therefore in these communities, fluorosis is very common. The study was planned to know the prevalence and degree of dental fluorosis in 12 and 15 years old school children of Solapur city.

The present study was conducted to know the prevalence and severity of dental fluorosis among

12 and 15 years old school going children of Solapur city. The study was conducted in Solapur city, Maharashtra State, India. After a pilot study was conducted, the convenience sampling was done and 1042 children participated in the study. The Solapur city was divided into 4 zones and the schools and subjects were selected using random sampling method. Sample was divided into 2 groups. Group A, who used bore water for drinking at home and at school as there was no municipal water supply. Group B where the children, using municipal water supply for drinking both at home and at school. School based approach was used. Children who were permanent residents since birth and between 12 to 15 years were selected from the schools randomly who satisfied the following inclusion criteria. Children with permanent teeth and no fillings on facial surface were included in the study while the rest were excluded. The data regarding the fluoride content of Borewell water of Solapur city was collected from Public Welfare Department (PWD). To confirm these levels of fluoride, further samples of Borewell water were collected from the area nearby school and analysis was done at the office of Superintendant Chemist

Original Article


Laboratory, Solapur. Before scheduling the survey an ethical clearance was obtained from the Ethical committee of Dr. D.Y. Patil University, Pune. An official permission was obtained from Deputy Director of Public Walfare Department, Pune. A survey Proforma was prepared with the help of the WHO Oral Health Assessment Form (1997). It consisted of two parts, 1st part consisted of information on demographic data, permanent residential address, information on source of drinking water, aids used for oral hygiene maintenance (fluoridated or nonfluoridated) and 2nd part consisted of table for recording fluorosis using Dean's index. Karl-Pearson coefficient for correlation (or simple correlation) and simple regression analysis was used to measure the correlation between fluoride concentration in drinking water and community fluorosis index (CFI). Chi –square test was used for estimation of statistical significance.

The data collected was analyzed and calculated using the necessary statistical tests. Table I, showed the distribution of the study subjects according to age, gender, source of drinking water and study area. The percentage of children in 12 years was 541(51.92%) and 15 years were 501(48.08%).

RESULTS

Table II, indicated the distribution of study subjects according to source of drinking water.

Table III, showed the mean fluoride concentration in Borewater, zonewise, which ranged from 0.642-0.927.

Table IV, represented the distribution of dental fluorosis among the study subjects using Borewell water, of Solapur city (Zone-A, Zone-B, Zone-C, Zone-D)

Table V, shows the distribution of dental fluorosis among the study subjects using municipal water, of Solapur city.

Table VI, showed the relationship between Fluoride concentration and Community Fluorosis Index. The degree of correlation between the Community Fluorosis Index (CFI) and fluoride concentration in drinking water was measured by using linear regression (Karl Pearson's Coefficient of Correlation).

Table I. Distribution of study subjects according to age, gender and study areas

S.No. Area Source Sex Age Total

* ** 12 15

1 A

B Male 24 6 30

Female 36 42 78

T Male 15 18 33

Female 34 59 93

2 B

B Male 32 27 59

Female 41 20 61

T Male 38 30 68

Female 46 16 62

3 C

B Male 69 28 97

Female 18 45 63

T Male 21 29 50

Female 29 27 56

4 D

B Male 14 25 39

Female 24 15 39

T

Male 35 76 111

Female 65 38 103

Total Male 248 239 487

Total Female 293 262 555

Grand Total (M+F) 541

(51.92%)

501

(48.08%) 1042

*4 Zones=A,B,C,D ** B= Borewell T= Tap (Municipal)

Table II. Distribution of study subjects according to source of dreinking water

Number Borewell Municipal

466 576

Percentage (%) 44.72 55.28

Table III. Showing the fluoride concentration in bore water, zonewise.

ZONES Mean fluoride concentration (ppm)

A 0.721

B 0.908

C 0.927

D 0.642

Range: 0.642-0.927 MEAN: 0.79 S.D.: 0.122

Table IV. Prevalence of dental fluorosis of borewell drinking water

Fluoride (ppm)

subjects examined

Subjects with fluorosis

questionable Very mild

Mild Moderate severe CFI

0.642 78 33(42.3) 8(10.26) 16(20.51) 7(8.97) 2(2.56) 0(0) 0.5120.721 108 47(43.51) 12(11.11) 21(19.44) 11(10.1) 3(2.8) 0(0) 0.5370.908 120 54(45) 4(3.33) 23(19.16) 21(17.5) 6(5) 0(0) 0.7080.927 160 71(44.38) 7(4.38) 27(16.88) 29(18.13) 7(4.37) 1(.625) 0.71

Table V. Prevalence of dental fluorosis of municipal drinking water

Fluoride (ppm)

Subjects examined

Subjects with fluorosis

questionable Very mild

mild moderate severe CFI

0.3 236 22(9.42) 15(6.36) 15(6.36) 2(0.85) 0(0) 0(0) 0.1 0.4 340 6 6(19.61) 32(9.41) 2 8(8.24) 6(1.76) 0(0) 0(0) 0 . 1 5

Table VI. Relationship between fluoride concentration and Community Fluorosis Index (CFI):

Correlation between

Mean±SD Correlation Coefficient ‘r’

Regression Coefficient ‘b’

Prediction equation

Fluoride concentration

0.64±0.23 0.98

1.022

CFI=1.022 (FL.Conc)-0.21

CFI 0.45±0.24


Graph I shows the comparison of Dental Fluorosis prevalence in Group A (Borewell) and Group B (Municipal). The percentage of children affected with fluorosis in Group A was 43.99% whereas in Group B it was 17.01%.

Graph II shows the prevalence of dental fluorosis among 12 and 15 years old children based on fluoride concentration (in ppm). The percentage of children affected at 12 and 15 years were 26.98% and 31.33% respectively.

Graph III shows the positive correlation between fluoride concentration in drinking water and Community Fluorosis Index. Karl Pearson Correlation Coefficient (r) was 0.98. For the different levels of fluoride concentration the estimated community fluorosis index values are depicted (Graph I). For each unit change in fluoride concentration, there was a change of 1.022 in Community Fluorosis Index value.

DISCUSSIONEndemic dental fluorosis is most prevalent in areas where the drinking water contains elevated levels of fluoride. The report published by the Rajiv Gandhi National Drinking Water Mission, 1994, reported 14 states and the Union Territory Delhi as endemic

3for fluorosis. Part of Maharashtra State lies in endemic fluoride belt and extensive use of groundwater accounts for widespread prevalence of

2fluorosis. This study was designed to know the fluoride concentration of Municipal and Borewell drinking water in Solapur city and to assess the prevalence of dental fluorosis in children who were born and raised in Solapur city. Bardsen et al (1996), from the county of Hordaland, Norway, reported fluoride concentration in groundwater in the range of 0.02-9.48 mg/l 4. Fourteen percent of the wells contained water with fluoride level = 0.50 mg/l. Similarly, a study from Northern Maharashtra, India, reported fluoride concentration in groundwater in the range of 4.78-1.01 mg/l.5 The present study too reported high concentration of fluoride in groundwater as compared to Municipal water. The fluoride concentration in groundwater of 4 Zones of Solapur city ranged from: 0.64 ppm -0.93 ppm. Edmunds and Smedley (2005) have identified that there are three main factors that control the natural fluoride concentration of water; lithology, geochemical evolution and residence times of the water which determined water-rock

6interactions and mineral dissolution . It was noticed in the present study that at 0.3 and 0.4ppm fluoride level, 12.26% and 15.87% of children were affected with fluorosis. These findings were consistent with earlier study conducted by Chandrashekar et al (2001), where at 0.22ppm and 0.43ppm fluoride level, 13.1% and 13.3% of children were affected

7with fluorosis in Davangere district, Karnataka . At 0.64 ppm and 0.72 ppm fluoride level, 42.3% and 43.51% of children were affected with fluorosis, whereas at 0.90 ppm and 0.97 ppm fluoride level, 45% and 44.38% of children were affected with fluorosis respectively. The prevalence of dental fluorosis in our study group corresponds well with the findings of study conducted by Heller et al (1997), where at <0.3, 0.3 to <0.7, 0.7-1.2 and >1.2ppm fluoride level, 13.5%, 21.7%, 29.9% and 41.4% of children showed dental fluorosis

8respectively . The prevalence of dental fluorosis is higher even at low concentration of fluoride in present study. As compared to Solapur conditions, the relatively higher daily temperature when

Graph I. Comparison of dental fluorosis prevalence in Group A (borewell) and group B (municipal).

BOREWELL (GROUP A)

Graph II- Prevalence of dental fluorosis among 12 and 15 years old children based on fluoride conc. (in ppm).

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.3 0.4 0.642 0.721 0.91 0.93

Com

mun

ity

Fluo

rosi

sIn

dex

Fluoride concentration (ppm)r=0.99

GRAPH-III CORRELATION AND REGRESSION BETWEEN FLUORIDE CONCENTRATION IN DRINKING WATER AND

COMMUNITY FLUOROSIS INDEX.

OBSERVED VALUES

PREDICTED VALUES

CFI=1.0135(Fl.CONC.)-0.2075


compared to temperate regions of the world (for example USA), necessitates comparatively increased consumption of water per day which leads to an increased ingestion of fluoride (Galgan and Lamson 1953, Galgan and Vermillion 1957). This in turn resulted in higher prevalence of dental fluorosis. The relationship between the fluoride concentration of water and dental fluorosis was complex. But it was observed that as the fluoride level increased from 0.3 ppm to 0.4 ppm, 0.64 ppm, 0.72 ppm, 0.91 ppm and 0.93 ppm, there was substantial increase in prevalence of dental fluorosis from 12.26% to 15.9%, 42.3%, 43.51%, 45% and 44.4% respectively. An increase in percentage of children affected with dental fluorosis with every unit increase in fluoride level in drinking water is in close agreement with other studies conducted by Dean HT (1942), Moller (1970),Driscoll (1983), Segreto (1984), Reddy and Tewari (1985), Akihito (2000), Grobler (2001), Banu Ermis (2003) and Wondwossen (2004)9-17. Results of the present study showed a linear relationship between CFI values of 12 and 15 years old children and fluoride concentration in water (r=0.98). These findings were in close agreement with that of he studies conducted by Dean H.T. (1942), Driscoll (1983) and Angelillo (1998)9, 11, 18. Dean (1942) stated that CFI values less than 0.4 is not of public health concern. In present study it was observed, that, for all the study groups consuming Borewell water the CFI values were more than 0.4. The overall prevalence of dental fluorosis in 12 and 15 year old school going children of Solapur city was found to be 29.07%. This finding of our study is highly supported by the observations reported by National Oral Health S u r v e y F l u o r i d e M a p p i n g 2 0 0 2 - 2 0 0 3

19(Maharashtra). The Survey reported 32% and 29.6% of 12 and 15 year old having fluorosed teeth in urban area. Further, our study reported high prevalence of dental fluorosis in Group A (43.99%) as compared to Group B (17.01%) Graph I. Also the study done by Akpata et al (1997) reported that over 90% of the 12-15 year aged rural children in Saudi Arabia drinking well water (0.5-2.8 ppm of

20fluoride) had fluorosed teeth . The findings of our study showed high Fluorosis prevalence amongst 15(31.34%) years as compared to 12 (26.99%) years. This was in close agreement with the studies conducted earlier by Abdullah et al (1997) and Almas et al (1999)21-22. Applying Galgan and Vermillion formula for Solapur condition whose

maximum average daily temperature is 38.3oC (100.9oF) for past 5 years, it showed that 0.58 ppm would be safe level. It is therefore imperative that each country calculated its own optimal level of fluoride in drinking water in accordance to the dose-response relationship of fluoride in drinking water with the level of caries and fluorosis, climatic conditions, dietary habits of the population and other possible fluoride exposures also needed to be considered in formulating these recommendations. Conclusion: High prevalence of dental fluorosis was found in Group A (43.99%) as compared to Group B (17.01%). The overall prevalence of dental fluorosis in 12 and 15 year old school going children of Solapur city was 29.07%. so we can conclude by telling that dental fluorosis is a major dental public health problem in Solapur city.


REFERENCES

1. Tewari A. “Fluorides and Dental caries” 1986. Indian Edition, 1st Edition. The Journal of the Indian Dental Association, Publication.

2. National Oral Health Survey and Fluoride Mapping 2002-2003, India. 3. Chakraborti D, Chanda CR, Samanta G, Chowdhury UK, Mukherjee SC.

Fluorosis in Assam, India: Current Science 2000;78(12):1421-1423. 4. Bardsen A, Kjell B, Knut A. Variability in fluoride content of subsurface

water reservoirs. Acta Odontologica Scandinavica.1996;54(6):343-347.5. Suthar S, Vinod K, Sushant J, Simarjeet k, Nidhi G, Sushma S. Fluoride

contamination in drinking water in rural habitations of Northern Maharashtra, India. Environmental Monitoring and Assessment 2007.

6. Edmunds WM and Smedley P. Fluoride in Natural Waters. In: Essentials of medical geology: Impacts of the Natural Environment on Public Health. 2005. Selinus, (ed.) Elsevier, Boston.

7. Chandrashekar J, Anuradha KP. Prevalence of dental fluorosis in rural areas of Davangere, India. Intl Dent J. 2004:54:235-239.

8. Heller KE, Eklund SA, Burt BA. Dental Caries and Dental Fluorosis at varying fluoride concentrations. J Public Health Dent.1997;57(3):136-43.

9. Newbrun E. “cariology”1989. 3rd Edition. The use of fluorides in preventive dentistry. Pg.331.Quintessence Publishing Co.

10. Moller IJ, Pindborg JJ, Gedalia I, Roed-Petersen B. The prevalence of dental fluorosis in the people of Uganda. Arch Oral Biol. 1970 Mar;15(3):213-25.

11. Driscoll WA, Horowitz HS, Meyers RJ, Heifetz SB, Zimmerman ER. Prevalence of dental caries and dental fluorosis in areas with optimal and above-optimal water fluoride concentrations. J Am Dent Assoc. 1983;107:42-47.

12. Segreto VA , Collins EM, Camann D, Smith CT. A Current study of mottled enamel in Texas. J Am Dent Assoc. 1984;108:56-58.

13. Subbareddy VV, Tewari A. Enamel Mottling at different levels of fluoride in drinking water: In an endemic area. J Indian Dent Assoc.1985;57:205-212.

14. Akihito Tsutsui, Minoru Yagi, Alice M. Horowitz. The Prevalence of Dental Caries and Fluorosis in Japanese Communities with up to 1.4ppm of Naturally Occurring Fluoride. J Public Health Dent. 2000;60(3):147-53.

15. Grobler SR, louw AJ, Van W. Kotze TJ. Dental Fluorosis and caries experience in relation to three different drinking water fluoride levels in South Africa. Intl J Paed Dent. 2001;11:372-379.

16. Banu Ermis R, Fatma Koray, Guniz Akdeniz. Dental Caries and Fluorosis in low and high- fluoride areas in Turkey. Quintessence International 2003;34(5):354-360.

17. Wondwossen F, Astrom AN, Bjorvatn K, Bardsen A. The relationship between dental caries and dental fluorosis in areas with moderate and high fluoride drinking water in Ethiopia. Community Dent Oral Epidemiol. 2004;32:337-44.

18. Angelillo IF, Torre I, Nobile CGA, Villari P. Caries and Fluorosis prevalence in communities with different concentrations of fluoride in the water. Caries Res. 1999;33:114-122.

19. National Oral Health Survey and Fluoride Mapping 2002-2003, Maharashtra.

20. Akpata ES , Fakiha Z, Khan N. Dental fluorosis in12-15 year old rural children exposed to fluorides from well drinking water in the Hail region of Saudi Arabia. Community Dent Oral Epidemiol. 1997;25:324-327.

21. Abdullah R. Al-Shammery, Ernest Guile E, Mahmoud El Backly. The prevalence of Dental Fluorosis in Saudi Arabia. Saudi Dental Journal 1997;9(2):58-61.

22. Almas Kh, Shakir ZF, Afzal M. Prevalence and severity of Dental Fluorosis in Al-Qaseem province- kingdom of Saudi Arabia. Odonto –Stomatologie Tropicale 1999.


Introduction-

Case History-

A thorough knowledge of the root canal anatomy, its variations, the presence of additional roots and unusual root canal morphology is essential, as it determines the successful outcome of endodontic

1treatment . The maxillary molars may present a variety of morphological configurations. Majority of the reports discuss the prevalence of two or three canals

2-5.in the mesiobuccal root . Maxillary molars with two canals in the palatal root, two separate palatal roots; five and six root canals have also been

5,6,7.reported Unlike mandibular molars, where a C shape root

8canal system may classically occur , such a 8-12

configuration is rare in maxillary molars . In the present case, mesiobuccal and distobuccal canals are fused. Only one similar case has been reported, there the C-shaped buccal canal led to three separate

13. foramina The purpose of this article is to report an occurrence of C shape configuration in buccal root of maxillary first molar that required endodontic therapy.

A 34-year old female patient reported to the Department of Conservative Dentistry and Endodontics, with complaint of pain in the upper left posterior region since three days. Pain was moderate, intermittent and increased while chewing food. The patient was taking medication (analgesics) for the same. The patient's medical and dental history were non-contributory.

On clinical examination, caries was present on the distal aspect of the left maxillary first molar. There was no evidence of swelling or sinus tract in relation to it. The involved tooth was tender on percussion and no periodontal pockets were present. Radiographic evaluation of the concerned tooth (Fig.1) revealed carious destruction on the distal aspect in close proximity to the pulp, two overlapping roots and widening of the lamina dura for the buccal root at the cervical and middle third. Based on clinical and radiographic findings a diagnosis of irreversible pulpitis with apical periodontitis was made.

Endodontic treatment was planned for the same. After administering local anaesthesia, and rubber dam isolation, all carious tissue was removed and an access cavity was prepared. Two orifices and canals (one buccal and one palatal) were located in the first appointment (Fig 2). It was recognized that the single canal orifice in the buccal root extended into mesial and distal to form a C-shape. This was

C-shaped root canal configuration in maxillary first molar

A Case Report

* Mamta Kaushik, ** Sonal Singh, ***Kunjal Mistry,****Zarna Sanghvi

* Proffesor, ** Senior Lecturer, *** **** Reader Reader

ABSTRACTAim: This clinical report presents an unusual C-shaped root canal system in the buccal root of maxillary first molar. Summary: According to literature, the C-shaped root canal is found more in the mandibular second molar, and its occurrence in maxillary first molars is rare. This case presents a C-shaped canal in the buccal root of a maxillary first molar. This report emphasizes the variation in canal morphology of maxillary first molar and suggests the use of latest adjuncts in successfully diagnosing and negotiating it.Keywords: C-shaped canal, maxillary first molar, buccal root.

Figure 1 Pre-Operative Radiograph

Army College & Dental Sciences, Secunderabad, Andhra Pradesh. (+919391010325)New Horizon Dental College and Research Institute, Sakri, Bilaspur, Chattisgarh.Faculty of Dental Science, Dharamsinh Desai University Nadiad, Gujarat.



further evaluated under the dental operating microscope (Seiler). Working length was determined with an electronic apex locator (Propex II, Dentsply) and confirmed with a radiograph (Fig. 3). Cleaning and shaping for both canals was done with Mtwo instruments (VDW) under copious ultrasonic irrigation with 5.25% sodium hypochlorite. Intra canal medicament of calcium hydroxide ( Metapex) was placed and the access cavity was sealed with a temporary restoration (Cavit).

On the next appointment, the canals were obturated (Fig.4) using cold lateral compaction of gutta-percha and a resin sealer (AH Plus, Dentsply, Germany) under 8x magnification of the dental operating microscope. The patient experienced no post-treatment discomfort and the tooth was restored with a posterior composite filling ( tetric-N-ceram). The patient was called for follow up after three months. (Fig. 5)

Discussion – Although C shaped canal morphology is classically seen with mandibular second molars, involvement of other teeth have been reported. A literature review of 8,399 maxillary first molars showed the

14. incidence of C shapes to be 0.12% In an examination of 309 Chinese maxillary second molars, C-shaped root canals were encountered at a

15frequency of 4.9% . A fusion of the distobuccal and palatal root 1 of 83 extracted maxillary first molars

9in an Irish population is mentioned . Another incidence of a connection between the distobuccal and the lingual root component has been described in a study of single-rooted maxillary second molars

16as 7.69% . Mostly C shape canal is seen by fusion

11,16. of distobuccal and palatal roots In this case, mesiobuccal and distobuccal canals are fused which is rare. Only one similar case has been reported where the C shaped buccal canal led to three

13separate foramina . The anatomy of 2175 root-filled maxillary first molars evaluated radiographically; reported the

12incidence of C-shapes to be 0.091% . Radiographic identification of this phenomenon is difficult, and occasionally it may be found only

14during access cavity preparation . In the present case also, the clinical appearance of the pulp chamber floor, rather than the radiographic appearance, facilitated the recognition of the anomaly. Clinically, an operating microscope may facilitate the observation of C-shaped canal orifice; but one cannot assume that the shape continues throughout

8the length . Newer diagnostic methods such as cone beam computerized tomography (CBCT) scanning greatly facilitate access to the internal root

17,18morphology . The operating microscope and CBCT are important for locating and identifying root canals, and CBCT can be used as a good method for initial identification of maxillary first

19molars internal morphology .

Figure 2 Access opening showing C-Shaped orifice in the buccal canal

Figure 3 Working length Determination

Figure 4 Post obturation Radiograph

E

Figure 5 3 months follow up Radiograph


Although the incidence of root variations is rare, root canal morphology should be examined during treatment through the evaluation of radiographs taken from different horizontal angles. The present case confirms the necessity for meticulous examination of the pulpal floor at high

magnification under sufficient illumination of the operating microscope and emphasizes the importance of newer imaging techniques like computed tomography in preoperative assessment.

References –1. Malagnino V. Gallotini L. Some unusual clinical cases on root anatomy of

permanent maxillary molar. J Endod 1997;23:127-82. Pe´cora JD, WoelfeL JB, Sousa Neto MD, Issa EP. Morphology study of

the maxillary molars, part II: internal anatomy. Braz Dent J 1992;3:53–7.3. Ayranci LB, Arslan H, Topcuoglu HS. Maxillary first Molar with three

canal orifices in MesioBuccal root. J Conserv Dent 2011;14:436-74. Verma P, Love RM. A Micro CT study of the mesiobuccal root canal

morphology of the maxillary first molar tooth. Int Endod J 2011; 44:210–217

5. Acosta Vigouroux SA, Trugeda Bossans SA. Anatomy of the pulp chamber floor of the permanent maxillary first molars. J Endod 1978;4:214- 9.

6. MarLines Berne A, Ruiz Badanelli P. Maxillary first molars with six canals. J Endod 1983;9:375-81.

7. Bond JL, Hartwell OH, Porte, FR. Maxillary first molar with six canals. J Endod 1988;14:258-60.

8. Jafarzadeh H, Wu Y. The C-shaped root canal configuration: A review. J Endod 2007; 33:517-523.

9. Al Shalabi RM, Omer OE, Glennon J, Jennings M, Claffey NM. Root canal anatomy of maxillary first and second permanent molars. Int Endod J ,2000; 33, 405–14.

10. Newton CW, McDonald S. A C-shaped canal configuration in a maxillary first molar. J Endod 1984;10, 397–9.

11. Dankner E, Friedman S, Stabholz A. Bilateral C shaped configuration in maxillary first molars. J Endod 1990;16, 601–3.

12. R. J. G. De Moor. C-shaped root canal configuration in maxillary first molars, Int Endod J, 2002; 35, 200–8

13. Yilmaz Z, Tuncel B, Serper A, Calt S. C-shaped root canal in a maxillary first molar: a case report., Int Endod J,2006; 39, 162–166

14. Cleghorn BM, Christie WH, Dong CC. Root and root canal morphology of the human permanent maxillary first molar: A literature review. J Endod 2006; 32:813-821.

15. Yang ZP, Yang SF, Lee G , The root and root canal anatomy of maxillary molars in a Chinese population. Endodontics and Dental Traumatology, 1988; 4 , 215–8.

16. Carlsen O, Alexandersen V, Heitmann T, Jakobsen P , Root canals in one-rooted maxillary second molars. Scandinavian Journal of Dental Research, 1992; 100 , 249–56.

17. Patel S, Dawood A, Whaites E, et al. New dimensions in endodontic imaging: part 1.Conventional and alternative radiographic systems. Int Endod J 2009;42:447–62.

18. Nair MK, Nair UP. Digital and advanced imaging in endodontics: a review. J Endod 2007;33:1–6.

19. Filho FH, Zaitter S, Haragushiku GA, Campos EA, Abuabara A, and Correr GM. Anlysis of the Internal Anatomy of Maxillary First Molars by Using Different Methods. J Endod 2009;35:337–342


Case Report

* Darshana N.Shah, ** Chirag J. Chauhan, *** Krutika A. Bhatti,

ABSTRACT

Overdentures are those prosthesis, which are supported by the natural teeth or implants. The main advantage of tooth supported complete dentures are conservation of alveolar bone, improved vertical support and retention, improved horizontal stability, maintenance of proprioceptive guidance by retained roots, and psychologic benefit to the patient. When few firm teeth still remain in a compromised dentition, preservation of these teeth for overdentures can improve the retention and stability.The authors present a clinical report of a patient treated with a mandibular tooth-borne overdenture with stud attachment and it describes step by step procedure for preparation of preci-clix radicular attachment retained overdenture.Key words: Natural teeth, Attachment supported overdenture, Mandibular complete denture



* H.O.D & Proffesor ** Proffesor *** PG Student-III,

INTRODUCTIONRetaining teeth for an overdenture is an old concept

1-4and a viable treatment modality. Overdentures provide better function than conventional complete dentures through a variety of factors, such as improved biting force chewing efficiency, and increased speed of controlled mandibular

5movement. In addition, they minimize the downward and forward setting of a denture, which

6otherwise occurs with alveolar bone resorption. The key to success of an overdenture is the selection of strategic roots or teeth for retention. Elective endodontics and periodontal therapy make them excellent abutments for an overdenture. Abutment teeth are prepared, to create adequate space for the overlying denture. The shortened crown improves the crown-to-root ratio, thereby decreasing the mobility of the abutment teeth under an

7 8overdenture. In a 4-year-study, Renner et al showed that 50% of roots, used as overdenture abutments remained immobile. In addition, 25% of roots that were initially mobile became less mobile. Hence, they suggested, that teeth that are generally compromised can be used for overdentures after root canal therapy and decoronation.The use of attachments can redirect occlusal forces

away from weak supporting abutments and onto soft tissue, or redirect occlusal forces toward stronger abutments and away from soft tissues. They act as shock absorbers and stress redirectors, as well as providing superior retention. Attachments are often used in overdenture construction by, either connecting the attachments to cast abutment copings or connecting into the prepared post space of the abutment teeth. Overdenture attachments are classified either as studs, which connect the prosthesis to the individual tooth, or as bars which connect the prosthesis to the splinted abutment teeth. They are further classified as rigid or resilient. However, since edentulous ridges and the remaining roots are often compromised, the prosthesis that relies on resilient attachments is better able to divert occlusal forces away from weak abutment teeth. The metal O-ring attachment system, is considered to be a good

9,10resilient attachment for overdentures.Radicular attachments are commonly used for overdentures. They provide the stability and retention to the prosthesis. This clinical report describes mandibular overdenture retained with the help of O-ring stud attachments.

RADICULAR ATTACHMENT RETAINED

OVERDENTURE-CASE REPORT


CASE REPORT

1)Pre prosthetic phase:

2)Prosthetic phase:

A 45years old male patient was reffered to the Department of Prosthodontics Ahmedabad Dental College and Hospital, Ahmedabad with a chief complaint of difficulty in chewing because of absence of many lower teeth. A detailed medical, dental and social history was obtained. The patient d id not have any pros thes is . Pr imary impressions(ALGINATE, MARIEFLEXand diagnostic casts(DENTAL STONE,ASIAN) were made.On Intraoral Examination:Teeth present in maxillary arch 11, 12, 13, 14, 21, 22, 23Teeth present in mandibular arch 33,34,43 Grade I mobility in 11,12,21A treatment plan was developed with the following aims: to reduce effect of loss of teeth and function, to improve the esthetics and to restore masticatory function.A treatment plan was carried out with 3 phases:

The periodontal therapy- The periodontal health of each tooth was checked, and the tooth was treated by curettage. Splinting was done for maxillary teeth. In maxillary arch cast partial denture was planned.The endodontic therapy-Endodontic therapy was routinely done to create a more favorable crown-root ratio. The decreased crown size reduced the torquing forces and aided in maintaining the

11periodontal health of the abutments. In this case periodontal health of the teeth were improved with the scaling and endodontic therapy was done i.r.t 33,34 and 43( figure 1).

Abutment teeth were prepared in a dome-shaped contour and hemispherically rounded in all dimensions. The height of the abutment teeth was 3-

4 mm projecting just above the gingiva. The exposed dentin of the abutment was polished. Metal coping was done with routine casting procedure on a primary cast on 34. Cementation( GIC, 3M ESPE) was done on 34 with metal coping ( figure 2). After cementation of metal coping a rubber base (Photosil, Dental Impression Material) impression (Figure 3) was made and a cast poured in die stone(DIE STONE IV , PEARL STONE ).

The preci-clix radicular attachment kit comprises of 3 drills, insertion tool, metal analogue, 3 flexible cap red, yellow and white according to resilience, tin foil( figure 4), metal housing with yellow medium resilient flexible cap and male attachment with black ring(figure 5).

Figure :1 Mandibular retained teeth in 33, 34 and 43.

Figure:2 Dome shaped teeth preparation on 33, 34, 43 andmetal coping 34.

Figure :3 Final impression

Figure :4 Preci-clix radicular attachment kit.


Canal preparation was done for the attachment in teeth 33 and 43.Sequencial drilling was carried out with access drill, counter shink drill and final drill. The adequate length of male attachment determination was done and its confirmed by radiographs after that cementation(GIC,3M ESPE) of attachment was carried out. (figure 6).

Flexible cap press in the metal housing with the help of insertion tool and place on the male attachment with tin foil spacer(figure 7).Tin foil spacer create space between denture and male attachment for resilience effect during function.

Create space for the pickup of metal housing with flexible cap(female attachment) in the final complete removable denture(figure 8).

Female attachment pick up with cold cure resin (RAPID REPAIR, Pyrax)in complete denture. After that excess resin was trimmed and final finishing and polishing of prosthesis was carried out(figure 9).Reinsert the denture and is checked for its easy insertion.

The instruction was given regarding oral hygiene maintenance and prosthesis maintenance to the patient. Patient is recalled every 6 months and is checked for the resiliency of the flexible cap and prosthesis.

The use of teeth as overdenture abutments is beneficial to the patients. The psychological aspect of Patients losing teeth should not be underestimated and this has been well

12documented. Careful selection of strategic abutment is important. The decision must, first be made to retain the teeth as overdenture abutments and then the attachment should be planned. The attitude of the patient to the treatment should be assessed. Only those who understand the limitations and benefits of attachments should be treated with attachment retained overdentures. Hence, patient selection is critical to the success of the treatment.

3)Maintenance phase :

DISCUSSION

Figure :5 Metal housing, yellow medium resilient flexible capand male attachment with black ring.

Figure :6 Male attachment in 33 and 43.

Figure :7 Metal housing with flexible cap and tin foil spaceron the male attachment

Figure :8 Complete denture ready for pick up the femaleattachment.

Figure:9 Final prosthesis with female attachment.


In the present report, flexible cap with metal housing attachment retained mandibular denture was fabricated. The attachment used was basically the implant prosthetic component. It is functionally classified as a resilient attachment. It does not transfer forces to the root and only acts as a retentive devices. Hence, the system is considered to be the best attachment that acts passively on the remaining abutment teeth. It also provides the adequate retention, so that it is easy to insert/remove, and is comfortable to the patient. There are however, some disadvantages such as the gradual loss of retention, due to the wear of flexible cap, and the need for periodic replacement but the presence of metal housing give ease for replacing the flexible cap, With the help of insertion tool we can place the another flexible cap directly in metal housing, which is already present in complete denture.

CONCLUSIONLack of retention of complete mandibular dentures is a common complaint among the complete denture patients. With the inception of ossteointegrated implants, the concept of overdentures has become more popular, but not all patients are able to afford the treatment costs. A tooth-borne overdenture may be advised whenever several good teeth remain in the arch. The different attachment designs are suggested in the literature for implant overdentures, also hold true for tooth-borne overdentures. The incorporation of attachments in overdentures into everyday dental practice will open up another dimension in dental treatment planning and patient satisfaction. Teeth that might be considered for extraction, may be considered as long or short term alternatives to implant or total edentulousness.

REFERENCES1. Tallgren A. Changes in adult face height due to aging, wear, loss of

teeth and prosthetic treatment. Acta Odontol Scand 1957;15:24.2. Brill N. Adaptation and the hybrid prosthesis. J Prosthet Dent

1955;5:811-823.3. Miller PA. Complete dentures supported by natural teeth. J Prosthet

Dent 1958;8:924-928.4. Prince JB. Conservation of the supportive mechanism. J Prosthet

Dent 1965;19:327-338.5. Rissin L, House JE, Manly RS, Kapur KK. Clinical comparison of

the masticatory performance and electromyographic activity of patients with complete dentures, overdentures and natural teeth. J Prosthet Dent 1978;39:508.

6. Crum RJ, Rooney GE. Alveolar bone loss in overdentures; a 5-year study. J Prosthet Dent 1978;40:610-613.

7. Lovdal A, Schei O, Waerhaug J. Tooth mobility and alveolar bone resorption as a function of occlusal stress and oral hygiene. Acta Odontol Scand 1959;17:61-75.

8. Renner RP, Gomes BC, Shakeen ML. Four year longitudinal study of the periodontal health status of overdenture patients. J Prosthet Dent 1984;51:593-598.

9. Tokuhisa M, Matsushita Y, Koyan K. In vitro study of a mandibular implant overdenture retained with ball, magnet, or bar attachment: comparison of load transfer and denture stability. Int J Prosthodont 2003;16:128-134.

10. Ben-Ur Z, Gorfil C, Shifman A. Anterior implant support overdentures. Quintessence Int 1996;27:603-606.

11. Wayne R Frantz: The use of natural teeth in overdentures. J Prosthet Dent 1975;34:135-140.Fiske J, Davis DM, Frances C, Gelbier S. The emotional effects of tooth loss in edentulous people. BDJ 1998;184:90-93.


CANCER THERAPY INDUCED ORAL MUCOSITIS:

PREVENTION AND MANAGEMENT PROTOCOL

* Parul Bhatia, **A.R. Chaudhary,***Yesha Jani, ****Suresh Ludhwani



* Professor, ** *** Professor, Senior Lecturer, ****P.G.Student

ABSTRACTOral mucositis also called stomatitis, is one of the most common and troublesome occurrence in individuals undergoing chemotherapy and radiotherapy. Oncology treatment cannot distinguish between healthy and malignant cells. Thus, the mucosa becomes atrophic and more susceptible to trauma, allowing the development of inflammation followed by secondary infection, which increases patient discomfort and hampers quality of life. The clinical management of mucositis includes preventive and palliative strategies. Role of an oral physician in prevention and management of chemotherapy and radiotherapy induced mucositis is critical.

Introduction

Pathophysiology

Oral mucositis may be defined as inflammation of oral mucosa with extensive ulceration and painful irritation caused by the necrosis of the basal layer of

1the oral mucosa . Mucositis has received significant attention from the physician community in the last two decades of life. It is estimated that oral mucositis affects 40% of the patients undergoing chemotherapy, 75% of the patients undergoing chemotherapy and bone marrow transplantation and more than 90% patients undergoing

2radiotherapy for head and neck cancer . Oral mucositis is a complex biological process divided

3into four phases , which are interdependent and can occur due to action of cytokines on epithelium. These phases are1. Inflammatory or vascular phase: days 0-42. Epithelial phase: days 4-63. Ulcerative or bacteriologic phase: days 6-124. Healing phase: days 12-16 The more important clinical features are erythema

4and/or ulceration , which may extend from the 5mouth to the rectum . It can induce several life-

threatening complications, such as intestinal 6obstruction and perforation , compromising the

patient's quality of life and leading to severe 7infections .

Firstly, the chemotherapy drugs induce the death of the basal epithelial cells, which may occur by the generation of free radicals. These free radicals activate second messengers that transmit signals

from receptors on the cellular surface to the inner cell environment, leading to up-regulation of pro-inflammatory cytokines, tissue injury, and cell death. The anti cancer drugs most commonly associated with oral mucositis include bleomycin, doxorubicin, fluorouracil, methotrexate, vincristine and daunorubicin. Either the use of these drugs or the cancer itself leads to neutropenia, which predisposes the mucosa to inflammation and also enables bacterial invasion of the submucosa and vascular walls, leading to bacteraemia.In radiotherapy, an inflammatory response is influenced by the depth and volume of radiation, total grays of radiation delivered and the number and frequency of treatments. The onset, duration and intensity vary with the individual but most often the onset starts with second week of therapy or after

11a dose of about 2000cGy . Later, the mucous membrane tends to become atrophic, thin and relatively avascular. This long term atrophy results from progressive obliteration of the fine vasculature and fibrosis of underlying connective tissue. These atrophic changes complicate denture wearing because they may

11cause oral ulceration of compromised tissue .

The first symptoms reported by patients with oral mucositis are burning mouth and color changes in the mucosa, which becomes white because of insufficient keratin desquamation. Later, this epithelium is replaced by atrophic, edematous, erythematous, and friable mucosa, allowing the

CLINICAL MANIFESTATION

Review Article


development of ulcerated areas with the formation of a pseudomembrane, characterized by the presence of a fibrinopurulent yellow colored layer 7,12. The ulcerated lesions are painful and compromise patient nutrition and oral hygiene. They are also favorable sites for the development of local and systemic infections. In the oral mucosa, this condition involves the ventral surface of

13tongue, floor of the mouth and soft palate .Various grading systems for oral mucositis have been suggested.

The WHO scale [1979] was employed, which ranges from 0 to 4 and does not measure different aspects in the different sites analyzed.

(An assessment guide such as the table 2 provides a tool to quantify the intensity of mucositis. It is clinically useful to translate the scores into rating mild (score of 4-5), moderate (score of 5--8) and

16severe (score 8-12) .

MANAGEMENT OF ORAL MUCOSITIS

PREVENTIVE PROTOCOL

Treatment modalities for Oral mucositis-

· Preventive protocol (Assessment and prevention for oral cavity before cancer therapy)

· Treatment protocol (Management of mucositis)· Post treatment protocol (Prevention of

suprainfection)

Prior to cancer therapy, the patients should be submitted for an assessment of the oral cavity. Dental caries or periodontal disease associated with inadequate oral hygiene may lead to a greater risk for oral complications during the course of cytotoxic therapy. These risk factors underscore the importance of an inspection of the oral environment before and during treatment as prior assessment allow differentiating oral mucositis from other pre-existing lesions as well as the elimination of potential sources of infection and sites of chronic

16irritation . This protocol should be followed by an oral physician for the patients.

16Preventive protocol .Grade 1Ö Brush with soft bristled nylon brush and floss

dailyÖ Rinse with salt and soda or 15% hydrogen

peroxideÖ Apply a moisturizer.

Ö Promote oral hydration and nutritional intake

Ö Remove and clean dentures regularly (in denture wearer patients)

Grade 2 & 3Ö Increase frequency of oral hygiene to every 2-3

hoursÖ Use foam oral wash if brushing is too painful

Ö Use agents to protect mucosa (mucosal barrier)

Ö Apply topical agents for pain control

Ö Supplement oral intake with proper analgesics and/or antibiotics if indicated

Grade 4Ö Continue frequent oral hygiene

Ö I.V antibiotics

Ö Laser therapy

Ö Cryotherapy

Many different treatment protocols are available to reduce the severity of oral mucositis, although there is little evidence to recommend one or any approach as a gold standard procedure. The following have

Table 1- W.H.O has proposed the following grading system for assessment of oral mucositis

with regard to severity of symptoms (14):

Grade 0 Asymptomatic

Grade 1 Soreness, erythema, no ulceration

Grade 2 Erythema, ulceration, but ability to swallow solid food

Grade 3 Extensive erythema, ulceration, and solid food cannot be swallowed.

Grade 4 Mucositis to the extent of impossible alimentation

Table 2-Modified oral mucositis assessment index (source-from Beck SL, Yasjo, JM: guidelines for

oral care).

CATEGORY 1 2 3 4

Oral mucosa

including lip

& tongue

Smooth, pink,

moist and intact

Pale and slightly

dry; one or two

isolated lesions,

blisters or

reddened areas.

Papillae

prominent,

particularly at base

of tongue.

Dry and somewhat

swollen, generalized

redness; more than two

isolated lesions,

blisters or reddened

areas. generalized

redness on tongue but

tip and papillae are

more red in

appearance

Very dry and

edematous; thick

and engorged;

multiple blisters or

ulcers. Entire

tongue very

inflamed; tip very

red and

demarcated with

coating.

Teeth Clean; No debris Minimal debris;

mostly between

teeth

Moderate debris

clinging to one-half of

visible enamel

Teeth covered

with debris

Saliva Thin, watery,

plentiful

Increase in amount Saliva scanty and

maybe somewhat

thicker than normal

Saliva thick and

ropy, viscid or

mucus. Mouth

mirror test positive

Oral

dysfunction

No dysfunction Mild dysfunction Moderate dysfunction Severe

dysfunction


been used in the treatment of radiation-induced and chemotherapy-induced mucositis,Pharmacological modalities Non-Pharmacological modalities-Analgesics - Anti inflammatory - Low intensity laser

drugs-Antioxidants - Growth factors - Cryotherapy -Steroids - Others-Immunomodulators

– They can be administrated in local application, mouthwash and systemic form.

Treatment should be arranged according to WHO ladder and pain killers should be given in liquid or transdermal form as swallowing is usually severely altered in patient undergoing cancer therapy. Initial paracetamol soluble tablets (500-1000mg QDS), usually followed by soluble codeine (300 or 500 mg 1-2 tablets QDS) are given. In severe cases, usually liquid modified release morphine 12 hourly preparations or fentanyl patches in increasing doses are used with the choice based on the patient's tolerance. Oral solution of oramorph is used for

17breakthrough pain . It is found in chilli peppers and acts

upon nerve endings to provide temporary pain 18

relief. The exact mechanism of action is unknown . Recipe for capsaicin candies are available & they are prepared according to ICCR's Research Kitchen. The dosage schedule of 1 candy every 4-6 hours was determined based on Berger's observation that most patients required 4-6 candies per day to maintain pain relief

It is a central nervous system analgesic which depresses pain impulse transmission. It is effective for managing mucositis pain in cancer patients, but dry mouth is one of its adverse

18reactions . A very potent

short acting opioid, it is used primarily as an anaesthetic especially useful in patients unable to take oral medicine. It is available in a sustained-release transdermal delivery system (duragesic)

18with a half-life of 22 hours .

Antioxidants may be particularly important since cancer treatment is an oxidative process. Radiotherapy and chemotherapy generate free radicals, which require antioxidants to be neutralized

Pharmacological modalities

Analgesics

Capsaicin-

Morphine-

Fentanyl (transdermal patch) -

Antioxidants

Vitamins-

Beta-carotene-

Glutamine-

Allopurinol-

Lysofylline -

Leucovorin -

Pentoxifylline -

Vitamins such as A,E,C & beta-carotene are involved in detoxification of the reactive oxygen species (ROS). Vitamin E and betacarotene are lipophilic antioxidants whereas vitamin C is hydrophilic antioxidant. Vitamin E functions as a free radical chain breaker particularly interferes with the propagation step of lipid peroxidation. The vitamin A and beta-carotene act by quenching both singlet oxygen and other free radicals generated by

19photochemical reactions .

The pro-vitamin A (beta-carotene) when used as an adjunct to radiotherapy in the treatment of transplantable adenocarcinoma in mice significantly improved tumour reduction, survival and wound healing. This has also been proven to be useful in chemotherapy-induced mucositis. In one trial, chemotherapy patients were given 400,000 IU per day for 3 weeks followed by 125,000 IU for an additional 4 weeks. Significant

18result was seen .

A precursor of glutathione, this is the most abundant amino acid in the human body, and it is now considered a conditionally essential amino acid during periods of catabolism. Early studies show that glutamine has a positive effect through three mechanisms: (1) as a cellular fuel; (2) as a precursor for nucleotides needed for cell regeneration; and (3) as a source of glutathione, which is a potent antioxidant. The use of 4 grams of powdered glutamine in the form of a swish and swallow suspension, twice daily, decreases the

21intensity and duration of the mucositis . Allopurinol, a xanthine oxidase

inhibitor, has been studied for both prophylaxis and treatment of fluorouracil-induced mucositis. Two primary mechanisms have been proposed for such activity: nonspecific free-radical scavenging and specific inhibition of fluorouracil activation.

A protectant that reduces lipid peroxidation and also decreases oxidative injury. It is presently being tested in chemoradiation trials of

22head and neck cancer .Leucovorin, or folinic acid, in

combination with hydration is well established as a rescue agent to reduce mucositis and myelotoxicity

14of high-dose methotrexate . Pentoxifylline (PTX) is a

hemorrheologic agent indicated for treatment of intermittent claudication. PTX has been shown to reduce the production of tumor necrosis factor- alfa


(TNF-a) possibly by inhibiting TNF-messenger-14RNA transcription .

As a topical corticosteroid, it plays a role in inflammation and immunosuppression. It is contraindicated in presence of infection.

These may be beneficial but are contraindicated if the patient has a bacterial or viral infection. Triamcinolone acetonide 0.2% aqueous suspension can be used as a rinse for 1 minute twice a day and expectorated.

An immunomodulatory and antiangiogenic agent, it inhibits tumor necrosis factor-alpha (TNF-a), which is associated with

23,24oropharyngeal ulcers . In multiple studies, the efficacy of this medication against oral and esophageal ulcers bas been demonstrated. In one trial, 92% of patients had complete healing after 4

24weeks by taking 200 mg by mouth at bedtime .

It is used as a mouthwash and topical application agent. Topical application of benzidamine, a non-steroidal anti-inflammatory drug with cytoprotective, antimicrobial, and analgesic action, relieves the pain and reduces the use of opioid analgesics ; it also inhibits pro-inflammatory cytokines, including TNF-a and is considered a safe product, although its effectiveness for prevention of mucositis induced by chemotherapy agents is still unknown. As an oral rinse, this has been shown to be effective, safe and well tolerated in ameliorating the symptoms of cancer treatment induced mucositis. Rinsing and expectorating 15 ml of 0.15% solution every 2 hours will help in reducing painful inflammation of

25the mouth and throat .

The amniotic membrane was shown to be a biocompatible product with the capacity to adhere to ulcerated mucosal surfaces, accelerating the healing process by its anti-inflammatory activity. In a pre-clinical study by Goulart et al. it also was found that the amniotic membrane promotes rapid cell proliferation, especially of fibroblasts and epithelium cells, and

SteroidsClobetasol (0.05% ointment 1:1 with Orabase) -

Corticosteroid mouthwashes -

Immunomodulators Thalidomide-

Anti Inflammatory drugsBenzydamine hydrochloride-

Growth factorsAmniotic membrane-

stimulates vascular neoformation that positively influences the repair process. This proliferative capacity is probably due to the presence of stem

26cells and growth factors .

It is known to influence the growth, development, and repair of epidermal tissues. It also accelerates wound healing, increases the number of stem cells that survive a dose of radiation therapy and reduces the incidence and duration of oral mucositis due to cancer treatment. This therapy, however, requires

27further studies .

This is present in biologic fluids including saliva. Its level decreases in patients receiving radiation therapy. EGF plays a role in healing damaged mucosa. In recent studies it was demonstrated that less tissue damage is

27associated with a higher EGF level in saliva .

Sucralfate is a nonabsorbable, basic aluminum salt of sulfated sucrose indicated for the treatment of peptic ulcer disease. Sucralfate forms an ionic bond with proteins in ulcerations, which produces a protective barrier that promotes healing. In addition, local production of the cytoprotectant

25 27prostaglandin E2 is stimulated . Pfeiffer et al performed a randomized, double-blind cross-over study of patients receiving a cisplatin/ fluorouracil regimen for various solid tumors. Patients were instructed to swish and expectorate or swallow sucralfate suspension (1 g) or placebo four times per day for 14 days starting on the first day of chemotherapy. The objective evaluation revealed less mucositis with the sucralfate treatment.

These have been used to improve mucosal healing with controversial results. However, rinsing with 15 drops of chamomile in 10 ml of warm water, thrice a day, has reduced the incidence and severity of mucositis in

28cancer patients . These may help

to relieve pain on a temporary basis.Other- Rinsing with bland solutions such as normal saline with sodium bicarbonate (1 L water with 1/2 teaspoon baking soda and 1/2 teaspoon salt) has

16shown to reduce the severity of mucositis .

Recombinant keratinocyte growth factor-

Epidermal growth factor (EGF)-

OthersSucralfate -

Chamomile mouthwashes-

Local anesthetic mouthwashes-


Non pharmacologic approachCryotherapy-

Low-intensity Laser therapy-

Post treatment protocol -

This produces vasoconstriction, which reduces blood flow and diminishes the distribution of the chemotherapeutic agent to the oral mucosa. Ice swishing for 30 minutes following cancer therapy has been shown to be beneficial for

29these patients .

This may improve wound healing and accelerate replication of the cells. Low-energy helium-neon (He-Ne) laser seems to be a safe, simple, atraumatic, and efficient method for the prevention and treatment of

30chemotherapy/radiotherapy- induced mucositis .

Patients with complications should be treated with empiric antimicrobial therapy usually with fluconazole 50 mg OD in case of fungal infection or

penicillin derivates in case of bacterial infection. Culture and sensitivity evaluation is recommended when feasible to provide patient with targeted

16evidence-based antibiotic therapy .

Mucositis is a common side effect of radio and/or chemotherapy anticancer treatments, but it has a complex pathophysiology and requires standardized management strategies. There are many agents used for the treatment of mucositis with different mechanisms of action. However, there are no conclusive evidences on their effectiveness to establish protocols for patients undergoing radio and/or chemotherapy. Further studies are required in future to establish a widely accepted protocol for treatment of these patients.

Conclusion

References-1. Implications for evidence-based research in alternative and

complementary palliative treatments. Evidence Based Complement Alternative Med 2005; 2:489-94.

2. Herrstedt J. Prevention and management of mucositis in patients with cancer. International Journal of Antimicrobial Agents 2000; 16:161-3.

3. Raman kapur, ravi kapur, mannat dagura, rajat kapur. "Oral Mucositis: A Sequel to Cancer Therapy" Prevention and Management. Indian journal of dental science March 2011; 1(3):23-25

4. Keefe DM, Schubert MM, Elting LS, Sonis ST, Epstein JB, Raber- Durlacher JE et al. Updated clinical practice guidelines for the prevention and treatment of mucositis. Cancer 2007; 109: 820-31.

5. Epstein JB, Schubert MM. Oral mucositis in myelosuppressive cancer therapy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 88:273-6.

6. Gibson RJ, Bowen JM, Keef DM. Technological advances in mucositis research: new insights and new issues. Cancer Treat Rev 2008; 34:476-82.

7. Volpato LE, Silva TC, Oliveira, TM, Sakai VT, Machado MA. Radiation therapy and chemotherapy-induced oral mucositis. Rev Bras Otorrinolaringol 2007; 73:562-568.

8. Arora H, Pai KM, Maiya A, Vidyasagr MS, Rajeev A. Efficacy of He- Ne Laser in the prevention and treatment of radiotherapy-induced oral mucositis in oral cancer patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105:180-6.

9. Lalla RV, Sonis ST, Peterson DE. Management of oral mucositis in patients who have cancer. Dent Clin North Am 2008; 52: 61-77.

10. Volpato LE, Silva TC, Oliveira, TM, Sakai VT, Machado MA. Radiation therapy and chemotherapy-induced oral mucositis. Rev Bras Otorrinolaringol 2007; 73:562-568

11. Oral radiology-Principle and Interpretation – edition 5th pg 3312. Chemotherapy-induced oral mucositis in a patient with acute

lymphoblastic leukaemia; European Archives of Paediatric Dentistry 2011; 12 (2).

13. Sloan JA, Loprinzi CL, Novotny PJ etal. Sex differences in Fluorouracil induced stomatitis. J Clin Oncol. 2000; 18(2):412-20.

14. Rod Quilitz, PharmD, Oncology Pharmacotherapy: Modulation of Chemotherapy-Induced Mucositis, cancer control journal; 2(5)

15. Cancer symptom management, jones & barlett publishers; 3rd edition, 276-287

16. HYCCN Guidelines for the management of chemotherapy and/or radiotherapy induced acute mucositis Version 1.1 September 2011

17. Gage TW, Pickett FA, Dental Drug Reference, ed 5, St Louis: Mosby, 2002

18. Mills EED. The modifying effect of beta carotene on radiation and chemotherapy induced oral mucositis. Brit J Cancer 1988; 57:416-417

19. Antioxidant in cancer treatment, current cancer treatment-novel beyond conventional approach, edited by oner ozdemir, Intech December 2011

20. Wadleigh RG. Vitamin E and chemotherapy induced oral mucositis. Amer J Med 1992 ; 92:481-482.

21. KJimberg VS, How glutamine protects the gut during irradiation. ICCN 1996; 3:21.

22. Chao KSC, Perez CA, Brady LW, Radiation Oncology. Management Decisions, ed 2, Philadelphia: Lippincott Williams & Wilkins, 2002; 1

23. Jacobson JM, Greenspan JS, Spritzler J, et a!, Thalidomide for the treatment of oral ulcers in patients with human immunodeficiency virus infection, N EngI J Med 1997; 336:1487-1493

24. Alexander LN. Wilcox CM. A prospective trial of thalidomide for the treatment of HIV associated idiopathic esophageal ulcers. AIDS Res Hum Retroviruses 1997; 13:302-304.

25. Epstein JB, Silverman S Jr, Paggiarino DA, et al. Benzidamine HCl for prophylaxis of radiation-induced oral mucositis: Results from a multicenter, randomized, double-blind, placebo controlled clinical trial. Cancer 2001 ;92:875-885

26. Vilela-Goulart MG, Teixeira RT, Rangel DC, Niccoli-Filho W, Gomes MF. Homogenous amniotic membrane as a biological dressing for oral mucositis in rats: histomorphometric analysis. Arch Oral Biol 2008;53:1163-71.

27. Verdi CJ. Cancer therapy and oral mucositis. Drug Saf. 1993; 9: 185-195.28. Carl W, Emrich LS, Management of oral mucositis during local radiation

and systemic chemotherapy: A study of 98 patients, J Prosthet Dent 1991:66:361-369

29. Pfeiffer P, Madsen EL, Hansen O, et al. Effect of prophylactic sucralfate suspension on stomatitis induced by cancer chemotherapy: a randomized, double-blind cross-over study. Acta Oncol. 1990; 29: 171-173.

30. Bensadoun RJ, Franquin JC, Ciasis C, et al. Low energy He-Ne laser in the prevention of radiation-induced mucositis: A multicenter phase III randomized study in patients with head and neck cancer. Support Care Cancer 1999; 7:244-252


INTRODUCTION

CASE REPORT

The radicular cyst is the most frequent cyst found in the jaw (between 38% and 68 % of all the jaw cysts). The prevalence of periapical cysts varies between 8.7% and 37.7% of chronic inflammatory periapical

1lesions . It is not uncommon, to find periapical lesions to extend to the surrounding tissues and not limit themselves to the apex of the involved tooth. In the literature most cases of unusually large periapical lesions of odontogenic origin are found

1in the maxilla where the bone is spongy . Because of the bone consistency, it is easier for the lesion to occupy bony space and expand. Lesions have been found to occupy the entire sinus and even the floor

2of the nasal cavity .

A 35 year old male patient came to the department of oral & maxillofacial surgery with chief complain of swelling in upper left back jaw region since 6-7 months. Swelling was asymptomatic & gradually increase in size since 6-7 months. Clinically, there was a well-defined 3x3 cm ovoid shape swelling present over left side of mid face region extending superioinferioraly infra orbital rim to line joining corner of mouth to tragus & anterioposterioraly from left side ala to the line joining outer canthus to inferior border of mandible with a smooth surface and no any sign of sinus opening. The swelling was soft, fluctuant, non-tender on palpation. On intraoral examination, the upper left first molar was

decayed and nonvital. Intraoral examination shows roughly oval, 2x2 cm size swelling with pink shiny overlying surface in upper left buccal vestibule in relation to 26, 27. On palpation swelling is soft, fluctuant, non-tender, non-redusible (Figure 1).

Also, external examination revealed that eye movements and visual acuities were normal. On bases on clinical examination patient was provisionally diagnose as radicular cyst in relation to 26. For final diagnosis we advised patient for radiographic examination, in which IOPA of 26 & radiographs panoramic view (Figure 2) showing

RADICULAR CYST ENCHROCHING UPON THE MAXILLARY SINUS –A DIAGNOSTIC DILEMMA

CASE REPORT

* Purnima Jethwa, **Mitesh Patel,***Nitu Shah, ****Neha Vyas



* Reader, ** *** PG Student, Professor, ****Professor & HOD

ABSTRACTMaxillary sinus, being one of the paraoral structures, is commonly encroached upon by Odontogenic & Non-odontogenic cysts and tumours. Here we are presenting a case of an unusually large cystic lesion in relation with left maxillary first molar, which has encroached upon the maxillary sinus displacing it up to superior border which clinically favoured radicular cyst but radiographically it was more likely to be mucocele of maxillary antrum creating a diagnostic dilemma. Provisional diagnosis of radicular cyst was made by history and examination, correlating it with various radiographic investigations and aspirational cytology. Enucleation was done under general anesthesia and final diagnosis was made by histopathologic examination of enucleated specimen.

Keywords:Radicular Cyst, Carious Tooth, Maxillary Sinus

Figure 1 :Photograph of Patient's oral cavity showing

swelling in relation to molar & premolar region. buccally.


well define radiolucency in relation to 26 more favour to cyst in relation to but when taken Paranasal Sinus view(Figure 3) is more likely to mucocele of maxillary sinus.

CT Scan (Figure 4)revealed an osteolytic radiolucency well delineated around the roots of the upper left first molar, the large lesion measured 35mm antero-posteriorly, 24mm medio-lateraly and 28mm supero-inferiorly which has elevated mucosal lining of floor of left maxillary sinus & pushed it to posteriosuperiorly. Coronal CT image shows expansive process displacing part of nasal cavity, with intact and sclerotic border, occupying most of right maxillary sinus. Transverse CT image shows loss of anteriolateral wall of maxillary bone with posteriorly displacing maxillary sinus. Sagittal CT image shows osteolytic radiolucency around the root of 26 to extending whole maxillary sinus.

Figure 3 :Panoramic Radiograph of patient revealed an unusual large lesion invading large maxillary sinus.

From history, clinical and radiographic examinations, a provisional diagnosis of radicular cyst was made. It was decided to surgically enucleate the lesion under general anesthesia. Incision was given teeth in relation to 22,23,24,25,26,27,28 with releasing incision at 22 & Reflection of a mucoperiosteal flap, followed by removal of bone and exposure of the lesion membrane was carried out (Figure 5).

A spiration of the contents of the cystic lesion was a valuable diagnostic aid (Figure 6); it revealed a yellow semi-viscous fluid. The lesional wall was hypertrophic and adhered partly to the mucosa of the base of the maxillary sinus; therefore, the lesional mass was totally curetted to a maximum extent. Enucleation of the cystic lesion and extraction of the 26 with care of the wound and suturing were done with 3-0 vicryl.

Figure 2:Panoramic Radiograph of patient revealed an

unusual large lesion invading large maxillary sinus with loss

of lamina dura& no displacement of surrpundin teeth.

Figure 4: Respectively transverse, Coronal &Sagital CT image shows osteolytic radiolucency attach to teeth

26 to extend into left sinus

Figure 3 :Paranasal sinus view of patient's radiograph revealed

an unusual large lesion invading large maxillary sinus.

Figure 5: Enucleation of cyst


Enucleating biopsy of the periapical lesion (Figure 7) was diagnosed histologically as radicular cyst with a layer of nonkeratinised stratified squamous epithelium and at some place Pseudostratified ciliated columnar epithelium is also seen. Connective tissue capsule shows large numbers of chronic inflammatory cells, Dilated capillaries & RBCs .The healing was uneventful without swelling or other complications. Sutures were removed 1 week pos1toperatively, at the 8 months follow-up, no complications or recurrence were noticed with complete bone healing and repneumatization of the antrum.

The etiopathogenesis of cysts is particularly

controversial; the formation has been explained by

diverse theories, such as epithelial colonization,

epithelial cavitationsor the formation of

microabscesses. The theory of microabscess

formation is based on the degeneration of the

connective tissue leading to the development of the

cyst; the formation of a microabscess in the nucleus

of the granuloma, with the presence of stimulated

epithelial cells, would lead to their growth in an 3

attempt to line the created cavity.

DISCUSSION

The pathogenesis of cysts has been described in three phases. During the firstphase, the epithelial cell rests of Malassez begin to proliferate as a direct result of the inflammation and influenced by bacterial antigens, the epidermal growth factors, metabolic and cellular mediators. In the second, a cavity is formed, lined by epithelium (according to the above described theories), and in the third phase

1the cyst grows, probably by osmosis.Radiographically, the radicular cyst is a unilocular radiolucent lesion with wellcircumscribed sclerotic borders that are often radiopaque. The lesion is associated with the apex of the tooth and a diameter of at least 1 cm is postulated to be necessary to differentiate it from that of a normal follicular

4space .Natkin and el.related radiographic lesion size to histological findings and concluded that with

2a radiographic lesion size of 200 mm or larger, the 5

incidence of cysts was almost 100% . Other odontogenic cysts like dentigerous cysts, odontogenic keratocysts, and odontogenic tumors such as ameloblastoma, Pindborg tumor, odontogenic fibroma, and cementomas may share the same radiologic features as radicular cysts. Microscopic evaluation is necessary most of the

6 time to define the type of lesion .Our specimen was diagnosed histologically as radicular cyst with a layer of nonkeratinised stratified squamous epithelium, in fact all radicular cysts are lined partially or completely by nonkeratinized stratified squamous epithelium. Keratinization is seen in approximately 2% of cases, and when present orthokeratinization is more common than

7parakeratinization .When cysts are especially large, with maxillary sinus involvement as in our patient, the panoramic radiograph is often not of great aid. CT scans provide superior bony detail, allowing for the visualization of the size and extent of the lesion with determination of orbital or nasal invasion or involvement. Again, with larger lesions, it also aids in planning of a surgical approach. Mucoceles, retention cysts, and pseudocysts are also included in the differential diagnosis when a maxillary sinus cyst is visualized involving maxillary expansion; this is in addition to the array of radiolucent lesions mentioned above that can also be visualized on

8CT .The treatment of pariapical cysts are still under discussion and many professionals opt for a conservative treatment by means of endodontic. However, in large lesions the endodontic treatment alone is not sufficient and it should be associated to

Figure 6: Enucleated of cyst, Extracted tooth, Aspirated Fluid

Figure 7: Histological Section


a decompression or a marsupialisation (indicated when cyst is in close proximity to vital structures and where there is significant risk of injury with enucleation) or even to enucleation and extraction of the associated tooth.A large maxillary cyst may involve the whole sinus and can transmit pressure to the wallsof the sinus; consequently, ophthalmologic and nasal symptoms may develop. With extensive lesions, it is important to carefully plan the surgical approach. The choice of treatment may be determined by some factors such as the extension of the lesion, relation with noble structures, evolution, origin, clinical characteristic of the lesion, cooperation and systemic condition of

9the patient . Some authors suggested a nasal approach; however, in keeping with the law of gravity, it is reasonable to surmise that the content from maxillary cysts can be drained much more

easily into the oral cavity. An oral vestibular approach is therefore more preferable than a nasal approach. (10-11)CONCLUSIONIt must be kept in mind that chronic periapical lesions (granuloma, cyst, and scar tissue) are usually asymptomatic and do not create soft tissue alterations. However, they can deteriorate, producing pain and fistulization. Clinician should be very careful on clinical examination and should not omit any details. Before beginning any treatment a careful and complete clinical and radiographic examination is needed to supply all the required information. In extensive cases, near to vital structure routine radiography alone may not be sufficient to show the full extent of the lesions, and advanced imaging may be needed.

REFERENCES

1- Açikgöz A, Uzun-Bulut E, Ozden B, Gündüz K. Prevalence and distribution of odontogenic and nonodontogenic cysts in a Turkish Population. Med Oral Patol Oral Cir Bucal 2012; 17(1):e108-115.

2- Gibson GM, Pandolfi PJ, Luzader JO. Case report: a large radicular cyst involving the entire maxillary sinus. Gen Dent 2002; 50(1):80-1.

3- García CC, Sempere FV, Diago MP, BowenEM. The post-endodontic periapical lesion: histologic and etiopathogenic aspects Med Oral Patol Oral Cir Bucal 2007; 1; 12(8):E585-590.

4- Ricucci D, Mannocci F, Ford TR. A study of periapical lesions correlating the presence of a radiopaque lamina with histological findings. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101(3):389-394.

5- Natkin E, Oswald RJ, Carnes LI. The relationship of lesion size to diagnosis, incidence, and treatment of periapical cystsand granulomas. Oral Surg Oral Med Oral Pathol 1984;57:82-93.

6- FN Pekiner, O Borahan, F Ugurlu, S Horasan, B.M Sener, V Olgaç. Clinical and radiological reatures of a rarge radicularcyst involving the entire maxillary sinus. Journal of Marmara University Institute of H e a l t h S c i e n c e s Vo l u m e : 2 , N u m b e r : 1 , 2 0 1 2 -http://musbed.marmara.edu.tr

7- Joshi.N, Sujan.S, Rachappa.M. An unusualcase report of bilateral m a n d i b u l a r r a d i c u l a r c y s t s . C o n t e m p o r a r y C l i n i c a l Dentistry.2011;2(1):59-62.

8- AS Tournas, MA Tewfik, PJ Chauvin, JJManoukian Multiple unilateral maxillary dentigerous cysts in a non-syndromic patient: A case report and review of the literature. Int J Pediatric Otorhinol Extra1,(2) 2006; 100-106.

9- Ribeiro, Paulo Domingos Jr. et al. Salusvita, Bauru. Surgical approaches of extensive Periapical cyst. Considerationsabout Surgical technique., v. 23, n. 2, p. 317-328, 2004.

10- Chaine A, Pitak-Arnnop P, Dhanuthai K,et al. An asymptomatic radiolucent lesion of the maxilla. Clear cell odontogenic carcinoma. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:452–7.

11- Pitak-Arnnop P, Chaine A, Oprean N, etal. Management of odontogenic keratocysts of the jaws: a ten-year experience with 120consecutive lesions. J Craniomaxillofac Surg 2010;38:358–64.


ORTHOKERATINIZED ODONTOGENIC KERATOCYST Case Report

* Minal Bakshi, ** Manisha singh, ***Richa Vasant, ****Riya Achu Rajan



* Reader, **Senior Lecturer, ***PG Student, ****PG Student

ABSTRACTOrthokeratinized Odontogenic Cyst (OOC) is a developmental cyst that can occur in the maxilla or mandible and was initially defined by the World Health Organization as the uncommon orthokeratinized type of Odontogenic Keratocyst (OKC). However, studies have shown that OOC has atypical clinicopathologic aspects when compared with other developmental odontogenic cysts, especially OKCs. The purpose of the article is to present a case report of OOC arising in the posterior mandible and highlight the importance of distinguishing it from the more commonly occurring Keratocystic Odontogenic Tumor (KCOT).

Key words: Orthokeratinized odontogenic cyst (OOC) and Odontogenic Keratocyst(OKC)

INTRODUCTION

CASE REPORT

The term Odontogenic Keratocyst (OKC) was first introduced by Philipsen in 1956 to describe a particular pathological entity characterized by a fibrous cystic wall lined by keratinized epithelium. Thus, all cystic lesions of the jaws that had aspects of odontogenic keratocysts were considered, regardless of the clinical and other histological

1-4features . Currently, significant differences between keratinized cystic lesions are recognized and orthokeratinized odontogenic cyst (OOC) is no longer part of the spectrum of odontogenic

3,5-7keratocyst . Li et al suggested a descriptive term ''orthokeratinized odontogenic cyst,'' which also reflected its most plausible histogenic origin. The World Health Organization new classification (2005) for head and neck tumors has designated OKC as Keratocystic Odontogenic Tumor (KCOT) and reclassified it as a neoplasm in view of its intrinsic growth potential and propensity to recur. According to this new classification, OOC should not be part of the spectrum of KCOT and should be

8,9,10distinguished from the latter .

A 27 years old male patient reported to the OPD of ACDH, Ahmedabad. He presented with swelling of the lower left side of face since 2 months. On examination, the region corresponding to the lesion was located in the premolar region, extending into the molar region, and was covered by normal

mucosa. On palpation it was found that swelling was non-fluctuant and non-tender in nature and radiograph revealed a unilocular radiolucency with a well defined scalloped rim. Thus, a clinical diagnosis of ameloblastoma or odontogenic keratocyst was established. A biopsy was conducted and the tissue was sent to the department of Oral Pathology to arrive at final diagnosis. On histopathological examination, we found orthokeratinized stratified squamous epithelium of varying thickness lining a thin fibrous wall. A hypocellular spinous cell layer was made up of polyhedral to flattened cells with eosinophilic cytoplasm. The basal layer cells were low cuboidal and exhibited little tendency of nuclear hyperchromatism and palisading.

The orthokeratinized odontogenic cyst was clearly identified as an orthokeratinized variant of the odontogenic keratocyst for the first time by Wright in 1981 owing to it's different histopathology and

8reduced likelihood to recur . Although the first two editions of the World Health Organization's histological classification of odontogenic tumors recognized cases with orthokeratosis, the WHO's 2005 edition excluded it from its definition of a

9KCOT . The 2005 edition reclassified the parakeratotic type as a Keratocystic Odontogenic Tumour and stated ''Cystic jaw lesions that are lined by orthokeratinizing epithelium do not form part of

DISCUSSION


the spectrum of a KCOT. Three histologic variants were recognized initially: a parakeratinized variant, an orthokeratinized variant, and combination of the two. The less aggressive clinical behavior and recurrence pattern of the orthokeratinized variant ultimately warranted the designation of the orthokeratinized variant as a separate entity,

9,11"Orthokeratinized Odontogenic Cyst” .The association with unerupted teeth suggests that many OOCs may have first developed during adolescence, when the third molars were developing, and were only noticed later either owing to the development of symptoms or as an incidental discovery during investigation of another

12dental problem . Clinically the two entities (OOC & KCOT) exhibit an overlap in clinical and radiographic presentation. KCOTs also exhibit similar findings regarding age, sex and site of occurrence but they are associated with NBCCS patients and thus tend to exhibit multiple lesions. Radiographically OOCs tend to be unilocular lesions and are more often associated with impacted

12teeth as compared to KCOTs .Histologically, there are several striking differences between the epithelial lining of orthokeratinized and parakeratinized cysts. The typical KCOT exhibits a highly cellular parakeratinized epithelial lining with surface corrugations and a palisaded layer of basal cells. In contrast the OOC lacks these features and instead the thin, uniform, orthokeratinized lining epithelium is characterized by onion-skin–like luminal surface keratinization, prominent stratum granulosum and low cuboidal or flattened basal cell layer with minimal tendency for

8nuclear palisading .

Clinical picture of patient Figure 1

Figure 2 Gross specimen

Histopathologic picture (10 x)

Figure 3

Figure 4 Histopathologic picture (40 x)


CONCLUSIONThe significant clinicopathologic differences between orthokeratinized and parakeratinized odontogenic cysts make it essential that the orthokeratinized cyst should be recognized as a distinct entity. Historically, these cysts have been

REFERENCES1. Da Silva MJ, de Sousa SO, Corrêa L, Carvalhosa AA, De Araújo VC.

Immunohistochemical study of the orthokeratinized odontogenic cyst: a comparison with the odontogenic keratocyst. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;94:732-7.

2. Li TJ, Kitano M, Chen XM, Itoh T, Kawashima K, Sugihara K, Nozoe E, Mimura T. Orthokeratinized odontogenic cyst: a clinicopathological and immunocytochemical study of 15 cases. Histopathology 1998;32:242-51.

3. Vuhahula E, Nikai H, Ijuhin N, Ogawa I, Takata T, Koseki T, Tanimoto K. Jaw cysts with orthokeratinization: analysis of 12 cases. J Oral Pathol Med 1993; 22:35-40.

4. Rangiani A, Motahhary P. Evaluation of bax and bcl-2 expression in odontogenic keratocysts and orthokeratinized odontogenic cysts: A comparison of two cysts. Oral Oncol 2009;45:41-4.

5. Fregnani ER, da Cruz Perez DE, Soares FA, Alves FA. Synchronous ameloblastoma and orthokeratinized odontogenic cyst of the mandible. J Oral Pathol Med 2006 35:573-5.

6. González-Alva P, Tanaka A, Oku Y, Yoshizawa D, Itoh S, Sakashita H et al. Keratocystic odontogenic tumor: a retrospective study of 183 cases. J Oral Sci 2008;50:205-12.


diagnosed as odontogenic keratocyst. Therefore, in order to avoid confusion, it is suggested that the term “orthokeratinized odontogenic keratocyst” should be used for the cases diagnosed histopathologically exhibiting the above stated features.

7. Thosaporn W, Iamaroon A, Pongsiriwet S, Ng KH. A comparative study of epithelial cell proliferation between the odontogenic keratocyst, orthokeratinized odontogenic cyst, dentigerous cyst, and ameloblastoma. Oral Dis 2004;10:22-6.

8. Wright JM. The odontogenic keratocyst: orthokeratinized variant. Oral Surg Oral Med Oral Pathol 1981;51(6):609-18.

9. Philipsen HP. Keratocystic odontogenic tumor. In: Barnes L, Eveson JW, Reichart PA, Sidransky D, eds. World Health Organization Classification of Tumours: Pathology and Genetics Head and Neck Tumours. Lyon, France: IARC Press; 2005. P 306-7.

10. Barnes L, Eveson J, Reichart P, Sidransky D, eds. Pathology and Genetics of Head and Neck Tumours. Lyon. France: IARC Press; 2005. World Health Organization Classi?cation of Tumours.

11. Crowley TE, Kaugars GE, Gunsolley JC. Odontogenic keratocysts: a clinical and histologic comparison of the parakeratin and orthokeratin variants. J Oral Maxillofac Surg 1992;50(1):22-6.

12. Onuki M, Saito A, Hosokawa S, Ohnuki T, Hayakawa H, Seta S, et al. A case of orthokeratinized odontogenic cysts suspected to be a radicular cyst. Bull Tokyo Dent Coll. 2009;50(1):31-5.

92

Dr. Medha Jain

Dr. Kiran DesaiProfessor & Head,Dept. of Oral Surgery, K.M. Shah Dental College & Hospital,Vadodara, Gujarat.

Dr. Babu ParmarProfessor & Head,Dept. of Oral Surgery, Government Dental College & Hospital,Ahmedabad, Gujarat.

Dr. Bela DaveProfessor & Head,Dept. of Periodontology, Swarnim Jayanti Dental College & Hospital, Ahmedabad, Gujarat.

Dr. Rajesh SeturamanProfessor, Dept. of Prosthodontics, K.M. Shah Dental College & Hospital, Vadodara, Gujarat.

Dr. Saumil MathurProfessor & Head, Dept. of Prosthodontics, K.M. Shah Dental College & Hospital,Vadodara, Gujarat.

Dr. Janki ShahAsst. Professor, Dept. of Public Health Dentistry, Government Dental College & Hospital,Ahmedabad, Gujarat.

Second Artical 2014-2

Documents

Transcript of Second Artical 2014-2