Indian Journal of

Multidisciplinary Dentistry Volume 1, Issue 5

July-August 2011

IJMD’s Editorial Panel

Editor-in-Chief
KMK Masthan
Executive Editor Associate Editor
S Bhuminathan N Aravindha Babu

IJMD Advisory Board

Prosthodontics Oral and Maxillofacial General Medicine

Mahesh Verma Surgery Rajendran SM
Srinisha J Ramakrishna Shenoi
Raghavendra Jayesh S Vijay Ebenezer Periodontics
Raj Kutta (USA) Chandrasekaran SC
Sanjna Nayar
Ash Vasanthan (USA)
Oral Pathology and
Conservative Dentistry/ Oral Medicine and
Microbiology
Endodontics Vinay K Hazarey Radiology
Sukumaran VG Nalini Aswath
Ipe Vargese V
Subbiya A Panjab V Wanjari
Puneet Ahuja
Swaminathan S (Singapore) Praveen BN
Sangeeta P Wanjari
Mubeen

Implantology Orthodontics Pedodontics

John W Thurmond (USA) Krishna Nayak US Krishan Gauba
Dhandapani G Ashima Gauba
Murali RV
Genetics
Deepak C Biochemistry
Aravind Ramanathan
Julius A
Pharmacology
Oncology Muthiah NS Microbiology
Abraham Kuriakose M Elumalai M Mahalakshmi K

IJCP’s Editorial Panel

Dr Sanjiv Chopra Dr KK Aggarwal
Prof. of Medicine & Faculty Dean CMD, Publisher and Group
Harvard Medical School Editor-in-Chief
Group Consultant Editor Dr Veena Aggarwal
Joint MD & Group Executive Editor
Dr Deepak Chopra Anand Gopal Bhatnagar
Chief Editorial Advisor Editorial Anchor
IJMD is included in the databases of Genamics JournalSeek along with Ulrich
International periodical directory and Index Copernicus International, Ltd.
Advisory Bodies
Heart Care Foundation of India, Non-Resident Indians Chamber of Commerce & Industry,
World Fellowship of Religions
Contents
From the Editor-in-chief 244

From the Desk of IJCP Group Editor-in-Chief

Chlorhexidine and Tooth-brushing as Prevention Strategies in Reducing Ventilator-associated
Pneumonia Rates 245

original research
Incidence of Oral Tuberculosis Lesions in Patients with Pulmonary Tuberculosis 246
Comparison of Efficiency of Various Cleansing Techniques on Dentin Wettability Using Contact Angle Test 250

clinical study
Effect of Surface Treatments on Push-out Strength of Three Glass Fiber Posts: An in vitro Study 255
Prevalence of Facial Neuropathy among Diabetic Peripheral Neuropathy 260

review article
Upsurge of Nanotechnology in Dentistry and Dental Implants 264
Pre-eclampsia: An Oral Infectious Etiology? 269
Oral Lichen Planus: A Review on Current Medical Management 274
Role of Gene in Palate Formation 279

clinical practice
A Technique to Locate Implants during Second Stage Surgery 283

Case report
Extensive Nasopalatine Duct Cyst Causing Nasolabial Protrusion 285
Full Mouth Rehabilitation with Unilateral Distal Extension Prosthesis Attached to Splinted 289
Fixed Partial Denture
Ossifying Fibroma of Maxilla: A Case Report with Review of Literature 293
Dentigerous Cyst Associated with Mandibular First Premolar: A Rare Case Report 296

IJCP’S Editorial & Business Offices

Delhi Mumbai Kolkata Bangalore Chennai Hyderabad
Dr Veena Aggarwal Mr. Nilesh Aggarwal Sr. BM Sr. BM Sr. BM Sr. BM
9811036687 9818421222 Ritu Saigal H Chandrashekar Chitra Mohan Venugopal
E - 219, Greater Building No. D-10 9831363901 9845232974 9841213823 9849083558
Kailash, Part - 1 Flat No 43, 4th Floor Flat 5E Arora Business Centre 40A, Ganapathy- H. No.
New Delhi - 110 048 Asmita Co-operative Merlin Estate 111/1 & 111/2 puram 16-2-751/A/70
Cont.: 40587513 Housing Society Geetanjali Dickenson Road Main Road First Floor
editorial@ijcp.com Marvey Road 25/8 Diamond (Near Manipal Centre) Radhanagar Karan Bagh
drveenaijcp@gmail.com Near Charkop Naka Harbour Road Bangalore - 560 042 Chromepet Gaddiannaram
Subscription Malad (W) Kolkata - 700 008 Cont.: 25586337 Chennai - 600 044 Dil Sukh Nagar
Dinesh: 9891272006 Mumbai - 400 095 Cont.: 24452066 chandra@ijcp.com Cont.: 22650144 Hyderabad -
subscribe@ijcp.com nilesh.ijcp@gmail.com ritu@ijcp.com chitra@ijcp.com 500 059
Ritu: 09831363901 Cont.: 65454254
ritu@ijcp.com venu@ijcp.com

Sr.: Senior; BM: Business Manager

 From the Editor-in-chief
xxxxxxxxx

O
ur fourth issue carried some innovative and enthusiastic
articles for which I received several positive and productive
comments. Medicine and Dentistry both have advancing
fronts into modern concepts and techniques, but are still hampered by
the hesitation of the executive arm i.e. physicians and surgeons to adapt
to these newer techniques and concepts, their explanation being that
time-tested methods are safer and long term results of newer methods
and medicines are yet to be seen. Their caution is greatly justified. Dr KMK Masthan
However, my perception is that they hesitate to implement these newer Professor and Head,
Department of Oral Pathology and Microbiology
technologies mostly because they do not update themselves and have Sree Balaji Dental College and Hospital
lost the enthusiasm to learn and do not care to spend their productive Chennai
time in learning the latest methods and medicines. We are in the era
of evidence-based medicine and in spite of the lobbying/promotional maneuvers of pharmaceutical and medical
equipment manufacturers, we get to reach/prescribe/utilize the safest medications and surgical procedures. Hence,
we must update our minds and hands to extend the latest medical/surgical care to our patients. One step you can
take in that direction is to subscribe to journals like this so that you get an uninterrupted flow of knowledge.
A month back I had an opportunity to discuss chronic pain management with an aged doctor working in a
cancer hospice. This institution is a terminal care centre offering free care for the abandoned cancer patients. He
told me he achieves more pain relief for his patients through biofeedback than through all painkillers including
morphine. I was skeptical as I do not know how to teach biofeedback and had never bothered to learn any such
psychotherapy modalities. I thought he was making a tall claim as to the results. So I met several of his patients
and spoke/enquired/literally interrogated them. These patients are not your usual type of people who suffer from
minor ailments, who know that they are going to get well in due course and hence carry the ‘’nothing serious’’
attitude. These are the terminally-ill cancer patients abandoned by medical fraternity; some of them by the society
too and are awaiting death so that their suffering ends. I could not believe my eyes and ears when they spoke
highly about the biofeedback and how it helps to tune their mind away from their pain. This is evidence-based
medicine demonstrated to me raw and in spite of my bias and prejudice, I had to accept that the biofeedback
works. So a mental block within me had prevented me from learning a valid treatment option which I could have
provided to several of my patients. They say a wise man learns from other people’s mistakes and hence let us shed
our misconceptions and learn newer treatment modalities.
Another interaction I had with my student who just passed his examination deserves mention. I asked him what
his plans for the future were. He blinked for a moment and said ‘’No plans’’. Then he added ‘’Why plan? Future
will unfold itself ’’. I was unable to digest this philosophical reply. I was reminded of a poem I had read as a
schoolboy.
Only as high as I reach can I grow
Only as far as I seek can I see
Only as deep as I look can I see
Only as much as I dream can I be
Hence I feel in our profession, irrespective of being a budding doctor or roaring practitioner, we need to set goals/
targets and work towards them. For example, the reader could set a target of writing one case report or a review
article within the next month and mail it to ijmdent@gmail.com.
Best Wishes.

244 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

 From the Desk of IJCP Group Editor-in-Chief
xxxxxxxxx
Chlorhexidine and Tooth-brushing as Prevention
Strategies in Reducing Ventilator-associated
Pneumonia Rates

V
entilator-associated pneumonia (VAP) is a common
complication of mechanical ventilation after
endotracheal intubation. The role of chlorhexidine
and tooth-brushing is considered as a clinical intervention to
reduce infection rates.
A paper from Department of Health and Social care, University
of the West of England, Bristol, Avon, UK has shown that
Dr KK Aggarwal
the chlorhexidine is of some value in reducing VAP and is Padma Shri and Dr BC Roy National Awardee
more effective when used with a solution which targets gram- Sr. Physician and Cardiologist, Moolchand Medcity
President, Heart Care Foundation of India
negative bacteria. Group Editor-in-Chief, IJCP Group
Editor-in-Chief, eMedinewS
Chairman Ethical Committee, Delhi Medical Council
Tooth-brushing is recommended in providing a higher standard Director, IMA AKN Sinha Institute (08-09)
Hony. Finance Secretary, IMA (07-08)
of oral care to mechanically ventilated patients and reducing Chairman, IMA AMS (06-07)
President, Delhi Medical Association (05-06)
VAP when used with chlorhexidine. emedinews@gmail.com
http://twitter.com/DrKKAggarwal
The study showed that CHX was successful in reducing the Krishan Kumar Aggarwal (Facebook)

rate of VAP and using a combination of CHX and colistine

resulted in better oropharyngeal decontamination which
reduced and delayed VAP.
Chlorhexidine was also effective in reducing dental plaque in patients cared for in intensive care and had the
potential to reduce nosocomial infections.

Reference
1. N Roberts, BSc (HONS), Y Plas, Ymwlch Fawr, Criccieth, N. Wales LL52 0PW, Gwynedd, UK, Department of Health
and Social care, University of the West of England, Bristol, Avon, UK Dr P Moule, Roberts N, Moule P. Nurs Crit Care
2011 Nov;16(6):295-302. doi: 10.1111/j.1478-5153.2011.00465.x. Epub 2011 Jul 26.

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 245

 original research

Incidence of Oral Tuberculosis Lesions in Patients

with Pulmonary Tuberculosis
M Sathish Kumar*, TS Thirugnanasambandan**, J Jananee†, M Preethi†, Gouse Mohiddin‡

Abstract
Tuberculosis (TB) is a specific infectious granulomatous disease that most commonly affects lungs but it can also affect
the intestines, meninges, bone, joints, lymph glands, skin and other tissues of the body. Primary TB of the mouth can be
an invaluable aid in clinical diagnosis and patient management and this article emphasizes the significance of this early
diagnosis.

Key words: Tuberculosis, granulomatous, meninges, Mantoux test

T
uberculosis (TB) is a specific infectious
granulomatous disease caused by Myco-
bacterium tuberculosis. It commonly affects
lungs but can also affect the intestines, meninges,
bone, joints, lymph glands, skin and other tissues of
the body. The tubercle bacilli spread via:
l Droplet infection
l Inhalation
l Unpasteurized cow’s milk
On March 24, 1882, Robert Koch discovered the
tubercle bacillus. Anti-TB treatment has been available
since the 1940s and 1950s, making TB 100% curable;
yet, in 1993, the World Health Organization (WHO)
had declared TB a global emergency.10
The case rate varies from one region to another
and is dependent on factors that favor spread of
communicable disease, such as poor living conditions,
low socioeconomic status, low native resistance
and compromised immunity from debilitating or
immunosuppressed conditions. Of particular concern
is the sharp rise of this disease in people with AIDS
and the implications for further control.
*Professor and Head, Dept. of Oral Pathology
Madha Dental College, Chennai
**Professor, Dept. of Oral Pathology
Raja Muthaiah Dental College, Annamalai University, Chennai
†
Senior Lecturer, Dept. of Oral Pathology
Madha Dental College, Chennai
‡Reader, Dept. of Oral Pathology
Kalinga Dental College, Bhuvaneswar
Address for correspondence
Dr M Sathish Kumar
Madha Dental College, Chennai
E-mail: samanander@yahoo.co.in
The HIV pandemic provides further evidence of
the interplay between TB infection and immunity.
Exposure to TB carries a 10% annual risk of disease in
HIV-positive individuals, compared to a 5% lifetime
risk in the absence of HIV.10
The emergence of multiple drug-resistant forms of TB
has also raised concerns among health officials in many
cities.
The purpose of this article is to emphasize the
importance of early diagnosis of primary TB of the
mouth, which may be misdiagnosed when oral
lesions are not associated with any apparent systemic
infection. This not only helps in understanding the
disease process but also provides an invaluable aid in
the clinical diagnosis and patient management.
Human TB is principally transmitted by inhalation of
bacilli in moist droplets coughed out by individuals
with open pulmonary TB. Dried bacilli in dust appear
to be less of a health hazard. As a general rule, only
sputum smear-positive individuals are infectious;
l ml of sputum from these individuals contains at least
5,000 tubercle bacilli. Most transmission of the disease
occurs within households, or other environments,
where individuals are close together for long periods
of time.
Primary Tuberculosis
Primary TB is usually symptomless and passes
unnoticed and undiagnosed. Diagnosis is usually made
after a routine chest X-ray or Mantoux test, often as part
of the process of tracing contacts of known patients or

246 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

 original research

during pre-employment health screening. Occasionally,

the primary infection may cause a mild febrile illness,
with or without cough that lasts for about one week.
Medical help is usually not sought and the symptoms
resolve spontaneously (Fig. 1).

Post-primary Tuberculosis
The onset of pulmonary post-primary TB is usually
insidious with no specific symptoms. It is often
diagnosed by chance after a routine chest X-ray. Post-
primary TB is a disease with many variants. When
patients become symptomatic, they often complain of
nonspecific symptoms such as malaise, fever, weight Figure 1. Patient with pulmonary TB.
loss and night sweats. The most commonly presenting
feature is cough which may be either dry or purulent
and blood-stained. Hemoptysis is rare and is usually a
sign of more advanced disease.

Investigations
For control of the disease to be successful, it is
important not only to diagnose TB, but also to identify
those with asymptomatic infection, who may require
treatment so that they do not infect others. The three
main investigation6 used are: Figure 2. Materials for biopsy.
l Chest X-ray
l Tuberculin testing
l Bacteriological examination

Incidence of Oral Tuberculosis

Komet (1965),8 Stephen (1977),9 Addlestone (1979)1
have stated that the occurrence of TB in the oral cavity
and jaw bones is rare.
Literature has shown considerable variation in the
incidence of oral TB. The reported incidence of
Figure 3. Material for Ziehl-Neelsen staining.
clinical oral involvement, particularly as a secondary
manifestation of the disease by Rubin (1975),2 Brodsky
(1942),7 Komet (1965),8 Gupta KB (1977),4 Rauch
(1978),5 Purohit et al (1985),3 ranged from 0.05 to
1.44%. However, performed autopsies on 141 patients
who died of TB and found oral lesions in 19.9% of
cases. Although oral TB can affect all age groups, the
majority of patients are middle-aged and older persons.
Males are affected more frequently than females.

Predisposing Factors
The onset of oral TB infection depends on certain Figure 4. Material for hemoglobin estimation.

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 247

 original research

systemic and local factors including lowered host

resistance and increased virulence of the organisms.
l Poor oral hygiene
l Local trauma
l Pre-existing lesions such as leukoplakia
l Periapical granulomas
l Dental cysts
l Dental abscess
l Jaw fractures Figure 5. Material for ESR.

l Periodontitis

Aims and Objectives

The objective of this study was to inform the
professionals about the oral manifestations of TB.

Material and Methods

We recruited 227 patients with pulmonary TB
belonging to both sexes (136 males and 91 females).
They were examined for lesion of oral TB. Hematological
and radiological investigations were done, including
sputum smears by Ziehl-Neelsen (ZN) and Fite’s Figure 6. Histopathology of periapical granuloma.
staining techniques to detect tubercle bacilli. Suspected
lesions were biopsied. The material for biopsy, material
for ZN, material for hemoglobin estimation, material
for erythrocyte sedimentation rate (ESR) are shown in
the Figures 2-5.

Observations
The following observations were made.
l Oral manifestations were seen in 0.88% of patients
with pulmonary TB.
l The incidence of oral lesions in males was 0.7%
and that in females was 1.09%. Figure 7. Histopathology of osteomyelitis.
l The oral manifestations occurred most commonly
in the age group of 31-45 years (0.88%).
l The mean hemoglobin (g/dl) was 10.4 ± 15.01 in
males and 9.71 ± 14.23 in females. was 56.77 ± 30.69 in males and 60.11 ± 18.8 in
females.
l ESR was raised in all patients. The mean of ESR
was 22.6 ± 80.44 in males and 10 ± 21.5 in l The mean value of eosinophil (%) was 0.69 ±
females. 47.24 in males and 0.91 ± 33.5 in females.
l The mean total leukocyte count (per cumm) was l The mean value of basophil (%) was 0.55 ± S9.1
7,507 ± 15.26 in males and 9,451.53 ± 14.27 in in males and 0.54 ± 40.9 in females.
females. l The mean value of monocyte (%) was 1.12 ± 29.08
l The mean value of lymphocyte count (%) observed in males and 1.13 ± 20.2 in females.

248 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


The sputum smear of all the subjects was positive by
both ZN and Fite’s staining methods. Sputum smear by
ZN method revealed a mean bacilli count of 43.17%,
33.48%, 23.34% in field of 1, 10, 30 and respectively.
The overall mean was 4.8 ± 2.4. Histopathology
pictures of periapical granuloma and osteomyelitis are
shown in the Figures 6-7.
Conclusion
It needs to be pointed out that not all patients with
pulmonary TB had oral manifestations. The incidence
of oral lesions was less. However, most patients in
the study were treated patients or under treatment.
Of particular concern is the sharp rise of pulmonary
TB within the AIDS affected population and the
implications for further control. The HTV pandemic
provides further evidence of the interplay between TB
and immunity. Hence, early diagnosis of oral lesions
not only helps to prevent needless delays in treatment,
it also helps to eliminate the expense of unnecessary
laboratory tests and consultations.
References
1. Addlestone RB, Witt WS, Kaiser AB. Tuberculosis
of the mandible presenting as ‘lumpy jaw’. JAMA
1979;241(23):2544-5.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
original research
2. Rubin CH. Tuberculosis of tongue. J Oral Surg
1975;32:311-5.
3. Purohit SD, Mathur BB, Gupta PR, Agarwal KC, Hathi
HH. Tuberculous fistula of cheek. Report of a case. Oral
Surg Oral Med Oral Pathol 1985;60(1):41-2.
4. Strull GE, Dym H. Tuberculosis: diagnosis and
treatment of resurgent disease. J Oral Maxillofac Surg
1995;53(11):1334-40.
5. Rauch DM, Friedman E. Systemic tuberculosis initially
seen as an oral ulceration: report of case. J Oral Surg
1978;36(5):387-9.
6. Cotran, Kumar, Robbins. Robbins Pathologic Basis of
Disease. 4th edition, WB Saunders Co, 1989:p63-8.
7. Brodsky RH, Klattel JS. The tuberculous dental
periapical granuloma. Am J Orthod Oral Surg
1943;29(9):B498‑B502.
8. Komet H, Schaefer RF, Mahoney PL. Bilateral
tuberculous granulomas of the tongue. Arch Otolaryngol
1965;82(6):649-51.
9. Stephen AS, Eisenbud L. Tuberculous osteomyelitis
of the mandible. Oral Surg Oral Med Oral Pathol
1977;44(3):425-9.
10. Styblo K. Overview and epidemiologic assessment of the
current global tuberculosis situation with an emphasis on
control in developing countries. Rev Infect Dis 1989;11
Suppl 2:S339-46.
n n n
249
 Original research

Comparison of Efficiency of Various Cleansing Techniques

on Dentin Wettability Using Contact Angle Test
M Dilipkumar*, Shafath Ahmed**, M Dhivya†

Abstract
Aim: To evaluate the effect of different cleansing techniques in removing the residual provisional cement on prepared abutment
teeth and their influence on wetting properties of dentin. Materials and Methods: Forty coronal portions of human third
molar were mounted in acrylic resin blocks and prepared until dentin was exposed. Specimens were divided into two groups:
Group A and Group B. To simulate the Provisional restoration, discs were made with autopolymerizing resin and specimens
in Group A were luted with Zinc oxide eugenol and Group B with Freegenol cement. All specimens were stored in distilled
water at room temperature for 24 hrs and provisional cements were mechanically removed with explorer and rinsed with
water. Subsequently each group was further divided into four subgroups depending upon the various surface treatments
(Control-air-water spray, Pumice prophylaxis, Ultrasonic scaler with 0.2% Chlorhexidine gluconate, 17% EDTA). Contact
angle measurements were performed to assess wettability of various cleansing agents using the Axisymmetric Drop Shape
Analysis - Contact Diameter (ADSA-CD) technique. Results: Specimens treated with EDTA showed the lowest contact angle
for both the groups. SEM showed that EDTA was most effective solution to remove the smear layer, and pumice prophylaxis
leaves large remnant particles.

Key words: Contact angle, axisymmetric drop shape analysis - contact diameter (ADSA-CD) technique

R
esidual provisional cements and debris on
prepared abutment teeth may negatively
influence the performance of the definitive
luting agent1. Apart from the choice of restorative
materials, clinical outcome may be influenced
by factors such as tooth preparation, preparation
coarseness, type of luting agent, fit of restoration, type
of provisional cement and also cleansing techniques
used to remove the remnants of provisional cements.
Indirect restorations usually require temporization
for protection of the pulp and to restore the patients
esthetic and functional needs. Terata et al2 showed that
both residual Zinc Oxide Eugenol and Non Eugenol
containing temporary cements reduced the tensile bond
*Senior Lecturer
**Reader
Dept. of Prosthodontics
SRM Kattankulathur Dental College, Chennai
†
Reader
Dept. of Orthodontics
SRM Kattankulathur Dental College, Chennai
Address for correspondence
Dr Dilip Kumar
Senior Lecturer
Dept. of Prosthodontics, SRM Kattankulathur Dental College
Kanchipuram, Chennai
E-mail: dilipcanine@gmail.com
strength of resin luting agents. For this reason, it is
imperative to remove any remnants of the provisional
luting agent.
Several investigators have studied removal of
provisional cements in vitro. Grasso et al3 showed that
pumice cleansing was known to be more effective than
other cleansing techniques such as explorer/air-water
technique or with 0.12% chlorhexidine gluconate.
Others4,5 showed that removal of provisional cement
with explorer and use of soap was incomplete and
not recommended for clinical use. Adhesion involves
intimately joining two materials and the contact may
be physical or chemical. For this reason, the resin must
wet the dentinal surface to produce sound adhesion. The
manner in which liquid spreads on a surface expresses
the wettability of the surface. High wettability provides
intimate contact and enhanced adhesion.6
The newer generation resin cements offer numerous
advantages over conventional cements like good
bonding to dentin, thereby reducing microleakage,
reduced film thickness and almost negligible water
solubility.
The inherent drawbacks associated with resin cements
like microleakage (due to inadequate bonding), higher

250 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


film thickness and colour instability have been largely
superceded in the newer generation resin luting agents,
thus making their use universal and widespread.
Provisional cements contamination on dentin surface
may interfere with the spreading and penetration of
resin through the dentinal tubules. To increase the bond
strength of resin, acids have been used to demineralize
the dentin surface and to remove the subsequent debris
and remnants of provisional cements present in it.
This In-vitro study is aimed to evaluate
l The influence of these cleansing methods on
wetting properties of the dentin by Axisymmetric
drop Shape Analysis – Contact Diameter technique
(ADSA-CD).
l Cleanliness of resulting dentin surfaces under a
field emission scanning electron microscope.
Materials and Methods
Forty freshly extracted unrestored, caries-free third
molars were cleaned and stored in normal saline at room
temperature. The roots were sectioned at the cemento-
enamel junction and the coronal portion were separated
mesiodistally with a water cooled diamond coated
disc. Specimens were then mounted with the buccal or
lingual surfaces facing upward with autopolymerizing
resin (Denture base polymer resin, DPI-RR Cold cure,
India). The buccal and lingual surfaces were prepared
with a standard-grit diamond rotary cutting instrument
until the dentin surface was reached and preparation
was finished with a fine-grit diamond instrument.
To simulate the provisional restoration, discs (3 mm ×
1 mm) were made with autopolymerizing resin (DPI,
Self cure tooth moulding powder, India) and luted
with provisional cement.
All specimens were stored in distilled water at room
temperature for 24 hours. After that, provisional
cements were mechanically removed with explorer until
the dentin surface appeared macroscopically clean and
then dentin surface was thoroughly rinsed with water.
The specimens were divided into two groups (n = 20)
as follows:
l Group A: Specimens cemented with Zinc oxide
Eugenol cement (Dental products of India Ltd).
l Group B: Specimens cemented with Freegenol
cement (Rely X Temp NE, 3M ESPE, Germany)
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
original research
Subsequently each group was further divided into
4 subgroups (n = 5) according to different surface
treatments as follows:
Subgroup I: Control group - Air water spray
Subgroup II: Cleaned with pumice prophylaxis
Subgroup III: Cleaned with ultrasonic scaler using
0.2% chlorhexidinegluconate as irrigant
Subgroup IV: Scrubbed with cotton pellet soaked in
17% EDTA for 15 seconds (Glyde, Dentsply, USA)
Contact angle test
For contact angle measurement, the Axisymmetric
Drop Shape Analysis – Contact Diameter technique
(ADSA – CD) was used. This technique permits
measurement of the contact angle of sessile drops
when they have a flat profile. This measurement was
made on an anti-vibrational table. One 10µL drop
of deionised water was placed on the cleansed dentin
surface of the prepared specimen and the Scontact angle
was measured. The drop image was captured with a
micro video system when the drop was in equilibrium.
The video signal was transmitted to a computer that
provided the contact angle values.
SEM Observation
Composite (Esthet X Micromatrix restorative
Dentsply, USA) was placed into a plastic transparent
mould of 3 mm diameter and 1mm height and cured
for 20 seconds. Dentin surfaces were etched, dentin
adhesive and dentin bonding agent were applied
according to manufacturer’s instructions. Resin luting
agent (Variolink II, Ivoclar Vivadent, Liechtenstein)
was placed in between composite and dentin surface.
Each specimen was polymerized for 40 seconds at a
distance of 1mm using visible light polymerizing unit
and specimens were stored in distilled water at room
temperature for 24 hours. All specimens were allowed
to dry overnight and were then gold – sputtered and
examined under scanning electron microscope (SEM)
at 15 Kv. The SEM photomicrographs were observed
with 1000x magnification.
Results
The readings are tabulated and the mean, standard
deviation and test of significance of mean values
between the groups were studied using
251
 original research

SEM Observation: Table 1. Contact angle values for Zinc-oxide Eugenol

(Group A)
Sub Group Mean ± SD p-value Significance
group at 5% level
I 69.041 ± 0.412
II 63.15 ± 0.845
III 67.389 ± 1.05 0.001 IV Vs I, III

Plate 1A. Group A , Plate 1B. Group B, IV 62.609 ± 0.635

Subgroup I Subgroup I
Table 2. Contact Angle Values for Freegenol group
(Group B)
Sub Group Mean ± SD p-value Significance
group at 5% level
I 68.459 ± 0.599 I Vs II, III, IV
II 64.271 ± 0.083 II Vs I, III, IV
III 65.786 ± 0.639 III Vs I, II, IV
Plate 2A. Group A , Plate 2B. Group B, IV 62.686 ± 0.736 0.001 IV Vs I, II, III
Subgroup II Subgroup II

Plate 3A. Group A , Plate 3B. Group B, Plate 4A. Group A , Plate 4B. Group B,
Subgroup III Subgroup III Subgroup IV Subgroup IV

l One way ANOVA - to calculate the p value
l Multiple range Tukey HSD procedure - to identify
the significant groups at 5% level.
In Group A, the mean contact angle of Sub group IV is
significantly lower than the Sub group I and Sub group
III (Table 1) In Group B, the mean contact angle value
of Sub Group IV is significantly lower than the mean
contact angle of Sub group II followed by Sub group
III and Sub group I (Table 2).
Under SEM Observation, widespread remnants of the
provisional cements were seen on the micrograph of
the untreated dentin surface (Plate 1. A and B). The
use of pumice prophylaxis for both zinc oxide eugenol
and freegenol groups produced a smoother and cleaner
surface than for other groups, despite formation
of large remnant particles (Plate 2. A and B). The
remnants smeared to the surface were more evident
on the dentin cleansed with the ultrasonic scaler with
0.2% chlorhexidine gluconate irrigant (Plate 3. A
and B). According to Plate. 4 A and B, which shows
that 17% EDTA was most effective solution to
remove the smear layer.
Discussion
The adverse effects of residual eugenol from the
provisional cements on the bonding characteristics of
subsequent restorations have been well documented.7,8,9,10
Several investigators2,3 have hypothesized that different
cleaning techniques for the removal of the provisional
cement remnants from the dentin, like air-water spray,
pumice prophylaxis, and use of cleansing agents affect
the bond strength of resin luting agent to the dentin
and the water contact angle of the dentin surface. After
tooth preparation, the dentin is covered with a smear
layer that is composed primarily of cut, mineralized
collagen fibrils. There is no structural continuity
between the smear layer particles and the underlying
dentin.11 However the smear layer forms a barrier

252 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


that covers the dentin surface, blocking the orifices of
dentin tubules and forming smear plugs.
When Eugenol containing provisional cement is applied
on the smear layer, eugenol leaches into and through
the smear layer to the dentin tubules, contaminating
the dentin surface.12 After the removal of the provisional
cements, the dentin surface is still covered by the smear
layer, which contains the absorbed eugenol and cement
remnants.
Various techniques of removing the smear layer have
been used in literature.13,14,15 In comparison, EDTA
and pumice prophylaxis have been found to be more
effective in cleaning the remaining dentinal surface of
residual debris and the smear layer.16,17,18 Cameron19
claimed that cleanliness is achieved following
ultrasonically agitated irrigation with distilled water.
For this reason the effectiveness of pumice prophylaxis,
ultrasonic scaler with 0.2% chlorhexidine gluconate
irrigant and cleaning the dentin surface with 17%
EDTA were used in this study to remove the remnants
of the provisional cement from the dentin surface and
the performance of the definitive luting agent was
investigated.
Scleza et al20 showed that irrigation with 17% EDTA
solution has a good cleaning effect on the dentinal
tubules. Hulsmann21 et al have reported that 17%
EDTA has a good cleansing effect on dentin and
removes the smear layer by dissolving the inorganic
compounds. This ensures better penetration of resin
and subsequently increases the shear bond strength
values.
The presence of any remnants of provisional luting
agent could interfere with dentin wetting.22 The result
of the present study showed that the different cleansing
techniques altered the dentin wetting characters. The
extent to which a liquid drop will wet the dentin
surface depends on the chemical interactions between
the liquid and the dentin, physical considerations such
as capillary action, the roughness of the dentin and the
surface energy.12,23
According to Table 1 and 2, the lowest contact angle
were obtained with 17% EDTA for both Zinc-oxide
Eugenol and Freegenol groups, which indicates that
EDTA is more effective at removal of the remnant of
the provisional cement and the smear layer, so EDTA
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
original research
creates appropriate physical and chemical interactions
between the resin cement and dentin.
In the present study, all specimens were contaminated
with the provisional cements. However the results of
contact angle analysis showed significant differences
(p <0.001) between the cleansing techniques.
The SEM observation of the specimen reveals that
dentinal tubules were completely covered by the smear
layer and the remnants of the provisional cements on
the dentin surface.
The results of the SEM study showed that 17% EDTA
was most effective solution to remove the smear layer.
Also EDTA leaves the surface rough for better resin
penetration. Abott et al17 and Brammstrom18 also
showed similar results.
Kielbasa and others12 showed that diffusion of eugenol
may be more than 200 μm in depth, so that acid
etching may not eliminate the effects of eugenol. It
is interesting to note from this study that negative
effects of eugenol on dentin adhesion are not based on
the wetting process but on adhesion test results6. So
the diffusion of eugenol and other contamination of
dentin did not interfere with dentin wetting by water
or a hydrophilic resin on dentin.
The result of this present study suggests that the
wettability of dentin were affected not only by the acid
etching and or dentin primers but also dentin cleansing
techniques. In this study, EDTA has been used as an
effective dentinal cleansing agent even in the presence
of eugenol in an invitro situation. An effectiveness of
EDTA with different luting agents requires special
consideration. The contact angle measurement, in
an in-vivo situation, would consider various factors
like thermal and mechanical changes, oral fluid
contaminations, organic and inorganic residues, etc.
Further, a three dimensional model of the bonding
surfaces would better reflect the failures which occurs
as a combination of various compressive, tensile and
shearing forces.
Future advancements in research methodologies
including the finite element method (FEM) for a
3D model and a digitized Axisymmetric Drop Shape
Analysis-Contact Diameter (ADSA-CD) technique
could be incorporated to achieve higher levels of
accuracy and relevance.
253
 original research
Conclusion
Within the limitation of this study, it was concluded
that
l Significant differences were found with the different
cleansing techniques evaluated.
l EDTA showed the lowest contact angle for both
the groups.
l SEM showed that EDTA was most effective
solution to remove the smear layer, and pumice
prophylaxis leaves large remnant particles.
References
1. Ayad MF, Rosensteil. Surface roughness of dentin after
tooth preparation with different rotary instrumentation.
J. Prosthet Dent 1996;75:122-8.
2. Tereta et al. Characterization of enamel and dentin
surfaces after removal of temporary cement. Dent
Mater. J 1993;12:18-28.
3. Grasso et al. In vivo evaluation of three cleansing
techniques for prepared abutment teeth. J Prosthet
Dent 2002;88:437-41.
4. Bachmann et al. Effect of cleansing dentin with soap
and pumice on shear bond strength of dentin - bonding
agents. J Oral Rehab 1997;24:433-8.
5. Rodrigo et al. Influence of provisional cements on
ultimate bond strength of indirect composite restoration
to dentin. J Adhes Dent 2005;7:225-30.
6. Rosales et al. Influence of eugenol contamination on
the wetting of ground and etched dentin. Oper. Dent
2003;28:695-9.
7. Hansen EK et al. Influence of temporary filling
materials of effect of dentin bonding agents. Scand
J Dent Res 1987;95(6):516-20.
8. Meyerowitz JM et al. The effect of eugenol containing
and non-eugenol temporary cements on the resin enamel
bond. J Dent Assoc S Africa 1994;49(8):389-92.
9. Ngeh EC et al. Effects of eugenol on resin bond strengths
to root canal dentin. J Endod 2001;27(6):411-4.
254
10. Yap et al. Influence of eugenol – containing temporary
restorations on bond strength of composite to Dentin.
Oper. Dent 2001;26:556-61.
11. Dugu sarac et al. Effect of the dentin cleaning technique
on dentin wetting and on the bond strength of a resin
luting agent. J Prosthet Dent 2005;94:363-9.
12. Kielbasa et al. Diffusion behaviour of eugenol from zinc
oxide eugenol mixtures through human and bovine
dentin invitro. Oper. Dentistry 1997;22(1):15-20.
13. Duke E.S. et al. Effect of various agents in cleaning cut
dentin. J Oral Rehab. 1985; 12(4): 295-302.
14. Takeda FH et al. A comparative study of the removal of
smear layer by three endodontic irrigants and two types
of laser. Int Endod J 1999;32(1):32-9.
15. Peters D et al. Effect of eugenl-containing sealer on
marginal adaptations of dentin-bonded resin fillings. Int.
Endod. J 2000;33(1):53-9.
16. Grasso et al. In vivo evaluation of three cleansing
techniques for prepared abutment teeth. J Prosthet Dent
2002;88:437-41.
17. Abatt et al. An SEM study of the effects of different
irrigation sequences and ultrasonics. Int Endod J 1991;
24(6):308-16.
18. Brammstrom et al. The effect of EDTA containing
surface-active solvents on the morphology of prepared
dentin : an invivo study. J Dent Res 1992;59:1127-31.
19. Cameron. Factors affecting the clinical efficiency of
ultrasonics endodontics. A scanning electro microscopy
study. International Endodontic J 1995;28:47-53.
20. Scleza et al. Efficacy of funal irrigation - A scanning
electron microscopic evaluation. J Endodontics 2000;
26:355-8.
21. Hulsmann et al. Chelating agents is root canal treatment
mode of action and indications for their use. Int End
J 2003;36:810-30.
22. Aykent F et al. Effects of provisional restorations on
the final bond strengths of porcelain laminate veneers.
J Oral Rehab 2005;32:46-50.
23. Kenneth J. Anusavice. In: Philips science of Dental
Materials. 11th Ed: 38-9.
n n n
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 clinical study

Effect of Surface Treatments on Push-out Strength

of Three Glass Fiber Posts: An in vitro Study
AVK Narene*, P Shankar**, R Indira**

Abstract
This in vitro study evaluated whether surface treatment for glass fiber posts has an effect on the push-out strength bonded to
human root dentin. Fifty freshly extracted maxillary central incisors were endodontically-treated and post space preparation
was done. A total of 50 FRC Postec, randomly divided into five groups (10 teeth each) were subjected to four different surface
treatments: Silane only (II), Cojet and Silane (III), 10% sodium ethoxide and silane (IV) and 10% hydrogen peroxide (V). The
control group (I) did not receive any surface treatment. The root canals were treated with 37% phosphoric acid and Excite
DSC and all the posts were luted with Variolink II dual cure resin. A push-out test was done to measure bond strength at
different levels of the root. Data were analyzed with one-way ANOVA and post-hoc Tukey HSD test. The results showed no
significant differences between control group and silane treatment. Cojet and Silane (III) showed the highest bond strength
of 15.50 ± 4.2 MPa, which was statistically significant than all the other group (p < 0.001). The coronal segment showed the
highest mean bond strength of 13.74 ± 6.1 MPa (p < 0.001).

Key words: Post, push-out bond strength, surface treatment

T
he challenge of restoring endodontically-treated
teeth has spawned a considerable diversity
in foundation restorations and a plethora of
publications in dental literature.1 Pulpless teeth pose
several challenges due to the loss of tooth structure as
a result of caries, defective restoration and endodontic
access preparations.
Use of post system for the rehabilitation of
endodontically-treated teeth requires planning in order
to restore function of the tooth as well as structural
and esthetic strategies. Currently, increasing demand
for esthetic posts and cores has led to the development
of zirconia and fiber posts.2 These post systems have
been developed to improve the optical effect of esthetic
restorations.3 Newer adhesive systems and resin-based
luting agents create a genuine adhesive continuum
between the tooth and the post core complex. The use
of these bondable materials allows the practitioner to
unify the structure and morphology of root systems.4
Zirconium oxide posts demonstrate high fracture
resistance due to high flexural strengths, which is
comparable to that of cast gold and titanium posts.
But the fracture of zirconium oxide posts often results
in unrestorable damage to the tooth, whereas in vitro
studies on fracture strength of FRC posts show more
favorable mode of failure. The modulus of elasticity of
FRC posts is closer to that of dentin and distributes
stress evenly over a broad surface area.5,6
Fiber posts are bonded with resin-luting cements,
which allow the formation of a single unit where
tooth, post and core function as a cohesive unit-
Monobloc configuration.7 The clinical success of post
retention depends on the bonding of post to the luting
cement and luting cement with the dentin.8 Surface
treatments are methods by which general adhesive
properties of a material are enhanced by facilitating
chemical and micromechanical retention between
different constituents.9,10 Various methods of surface
treatments for fiber posts are sand blasting, hydrogen
peroxide (H2O2), Silane, potassium permanganate,
sodium ethoxide, etc.
Aims and Objectives

*Senior Lecturer, Dept. of Conservative and Endodontics
Sree Balaji Dental College and Hospital, Chennai
**Professor, Dept. of Conservative and Endodontics
Ragas Dental College and Hospital, Chennai
Address for correspondence
Dr AVK Narene
8/4, East Tank Street, Thiruvottiyur, Chennai - 600 019
In view of the fact that the primary cause of failure of
fiber posts is debonding, the objective of this study was
to test the effect of various surface treatments on the
push-out bond strength of glass fiber posts. The null
hypotheses tested in this study were:

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 255

 CLINICAL STUDY
l The use of Silane coupling agent alone does not
have effect on the bond strengths of fiber posts.
l There is no measurable difference in bond strength
after different surface treatment.
l There is no measurable difference in bond strength
at different levels of root.
Methodology
Fifty freshly extracted single rooted human maxillary
central incisors, free of caries and fractures without
any significant canal curvatures and with type 1
canal configuration, were selected and stored in 0.9%
physiologic saline until root canal treatment was
performed. Crowns were decoronated to the level
of cementoenamel junction for all samples using a
diamond disc and pulp was extirpated using barbed
broaches.
An initial 10 size K-file was passed in the canal till its tip
could be seen at the apex and the length was measured.
Working length was calculated by subtracting 1 mm
from the measured length of the initial 10 size K-file.
The coronal third of the canal was prepared using GG
drills from sizes 4 to 1, while apical- and middle-third
were prepared manually with Kfiles using step back
technique. The standard irrigants used in the study
were 3% sodium hypochlorite, 17% EDTA (ethylene-
diaminetetraacetic acid) and 0.9% physiological
saline. Master apical size of #35 was standardized and
obturation was done by lateral condensation technique
with AH Plus sealer.
Post space preparation was done using the corresponding
drill supplied by the manufacturer leaving 5 mm of
apical gutta-percha for all the samples. The canals
were then irrigated with distilled water and dried with
paper points. The canal walls of all the experimental
samples were then etched with 37% orthophosphoric
acid gel for 15 seconds using an applicator tip. The
canal walls were then irrigated with distilled water to
remove the excess etchant from the canal and dried
with paper points. The bonding agent Excite DSC
(Ivoclar Vivadent) was applied with Microbrush all
over the prepared post space of the root canal and light
cured for 20 seconds from the orifice. All the samples
were randomly assigned into five experimental groups
of 10 teeth each.
256
Box 1. Surface Treatment of Posts
l Group I (n = 10): No surface treatment
l Group II (n =10): Silane treatment only (The posts were
surface-treated with Silane coupling agent (Monobond-S)
for 60 seconds and then gently air-dried)
l Group III (n = 10): Cojet and Silane treatment (The posts
were sandblasted (Cojet) for 30 seconds and then treated
with Silane coupling agent for 60 seconds and then gently
air-dried)
l Group IV (n = 10): 10% H2O2 and Silane treatment (The
posts were immersed in 10% H2O2 for 5 minutes, washed
with distilled water and treated with Silane solution for 60
seconds and then gently air-dried)
l Group V (n = 10): Sodium ethoxide and silane treatment
The fiber post FRC Postec (Ivoclar Vivadent) - 1.0
mm diameter (Tip) (n = 50) were grouped as shown
in Box‑1.
The posts were immersed in freshly prepared solution of
sodium ethoxide for five minutes, washed with distilled
water and treated with Silane solution (Monobond-S)
for 60 seconds and then gently air-dried. All the posts
were then luted with Variolink II (Ivoclar Vivadent)
dual cure resin cement. After luting, the samples were
stored in 100% humidity at 37°C and were subjected
to a temperature of 45°C for three minutes, 5 times a
day for 15 days.
Push-out Bond Strength Testing
The apical 5 mm of the samples containing gutta-
percha was cut-down with a diamond disc. From
the remaining coronal segment of the samples, three
cross-sections of 2 mm thickness from apical area were
obtained and the thickness was checked with a digital
vernier calipers. The specimens were then placed in an
acrylic mold of 2 mm diameter and then subjected
to push-out bond strength testing. Each section
was attached to the acrylic mold with cyanoacrylate
adhesive ensuring that the coronal surface faces
the mold and the post was centered over the hole of
2 mm diameter in the mold.
The push-out mold was then placed in Lloyds Instron
Universal Testing Machine. The cross-head was lowered
at a speed of 1 mm/min until the post was dislodged.
Push-out bond strengths were calculated for each
section. All the values obtained were tabulated and
subjected to statistical analysis.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

Results
The highest mean push-out strength values were
recorded in Group III (Cojet and Silane treatment):
15.50 ± 4.2 MPa followed by Group V (Sodium
ethoxide and Silane treatment): 12.04 ± 3.9 MPa
and Group IV (10% H2O2 and Silane treatment):
11.9 ± 3.5 MPa as shown in Table 1. These results were
analyzed using one-way ANOVA and post-hoc Tukey
HSD test. Group III (Cojet and Silane treatment)
was significant with all the other groups at p < 0.001
level. There was no significant difference between
Group I (No surface treatment) 10.43 ± 3.8 MPa and
Group II (Silane treatment) 10.73 ± 3.5 MPa at p
< 0.05 proving that there was no increase in bond
strength of fiber posts that had undergone only Silane
treatment.
In all the experimental groups, the coronal segment
showed the highest mean bond strength of
13.74 ± 6.1 MPa. The lowest bond strength was
observed with the apical segments (10.58 ± 5.1
MPa). Coronal segments show a statistical significance
(p < 0.001) when compared with the apical and middle
segments.
Discussion
The restoration of endodontically-treated teeth is one
of the extensively studied topics in endodontics and
yet remains controversial from many perspectives.
Today, a variety of posts are available that vary in
composition, mechanical properties and structural
geometry (Custom made cast post, prefabricated
post, titanium post, zirconia and fiber posts).11 Fiber-
reinforced technology is already used for a wide range
of applications in dentistry - splints, complete dentures,
fixed dentures, retainers, etc. Fibers have also been used
for endodontic post build-up restorations to reinforce
composite resins.
Surface treatments are methods by which general
adhesive properties of a material are enhanced by
Table 1. Push-out Bond Strength of Coronal, Middle and Apical Specimens
Groups I II
Subgroups (MPa) (MPa)
Coronal 11.9 ± 6.3 12.5 ± 7.2
Middle 10.5 ± 5.5 10.7 ± 6.9
Apical 8.9 ± 7.3 9.0 ± 6.8
Mean 10.43 ± 3.8 10.73 ± 3.5
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
CLINICAL STUDY
facilitating chemical and micromechanical retention
between different constituents. As it has been
hypothesized that the primary mode of failure of fiber
posts is debonding, various surface treatment methods
have been suggested to improve the bond between
the post and the luting cement like sandblasting,
silanization, hydrogen peroxide, sodium ethoxide
etching, etc.12,13
Silanes are hybrid organic-inorganic compounds
that can mediate adhesion between matrices through
their intrinsic dual reactivity. Although the use of
Silane coupling agents as adhesion promoters in fiber
reinforced materials is well-established, their use in pre-
treatment of fiber posts still remains controversial.14,15
Bond integrity is challenged by the limited capacity to
dissipate polymerization shrinkage stresses (C factor) in
long narrow post spaces that exhibit highly unfavorable
cavity geometry.16-18
The efficacy of one step (self-etch) adhesives in forming
a durable bond with root dentin has been questioned.19
It was shown that the hybrid layers created by self-etch
adhesives are not uniform and contain nanovoids that
are permeable to water. This may adversely affect the
longevity of bonded root canal fillings and posts. The
increased collagenolytic activity in root dentin due to
the less acidic primers of self-etch adhesives has also
been recently demonstrated.20 Therefore, a total etch
technique was used in this study.
Excite DSC, dual polymerizing single bottle agent was
used as the bonding agent. The uniform formation of
hybrid layer lies in the wetting of the adhesive entirely
over the etched surfaces. The importance of microbrush
in reaching the narrowest and deepest portion of root
canal preparations has been shown by Vichi et al21 and
Ferrari et al.8 This results in a deep diffusion of resin
into the tubules and the formation of uniform hybrid
layer and lateral branches. In an attempt to simulate
the oral condition, a thermocycling protocol was done
to all the test samples.
III IV V
(MPa) (MPa) (MPa)
17.1 ± 7.0 13.5 ± 4.9 13.7 ± 5.5
15.2 ± 5.8 11.9 ± 5.2 12.0 ± 7.2
14.2 ± 4.9 10.3 ± 6.6 10.5 ± 7.3
15.5 ± 4.2 11.9 ± 3.5 12.04 ± 3.9
257
 CLINICAL STUDY
In a recent study of bonding of resin cements to fiber
posts, it was found that the strength of the bond
depended on the post material, the surface treatment
of the post and the resin cement.22 The role of Silane
in the bonding of ceramics and composites has
been established but its role in fiber post adhesion
yet remains controversial. Silane due to its low
viscosity would assist substrate wetting, and once an
intimate contact between the interfacing materials is
established, the van der Waals forces would become
effective providing physical adhesion, which may lead
to a tertiary monoblock structure from the existing
secondary monoblock.
The results showed no significant differences between
Groups I and II (No surface treatment and Silane
(10.43 ± 3.8 MPa and 10.73 ± 3.5, respectively)
proving no increase in bond strength of fiber posts
that had undergone only Silane treatment. Hence,
the first null hypothesis tested holds good. These
results were in accordance with the study by Perdigão
et al23 and Newman et al.24 The highest mean push-
out strength values were recorded in Group III (Cojet
and Silane): 15.50 ± 4.2 MPa followed by Group V
(Sodium ethoxide and Silane): 12.04 ± 3.9 MPa and
Group IV (10% H2O2 and Silane): 11.9 ± 3.5 MPa.
These results show a statistically significant difference
at p < 0.001.
The highly crosslinked polymers of the matrix of the
glass FRC posts used in this study do not have any
free functional group for reaction.22,23 This could be
the possible reason for insignificant effect of the Silane
when no surface treatment was done. Etching solutions
such as sodium ethoxide, hydrogen peroxide, potassium
permanganate have been commonly employed to
partially remove the resinous superficial layer of the
fiber posts containing epoxy resin matrix. Increased
bond strength has been observed after the combined
etching and silanization coupling from various studies
than Silane treatment alone.
In the present study, mechanical roughening using
Cojet followed by Silane treatment achieved the
highest bond strength of 15.5 MPa compared to
chemical etching (10% H2O2, sodium ethoxide) and
Silane treatment. These were significant at p < 0.001.
Additionally, etching with chemical solutions yielded
higher bond strength values than Groups I and II
(Silane and non-Silane). Thus second null hypothesis
tested was proven to be false.
258
The coronal segment showed the highest mean bond
strength of 13.47 ± 6.1 MPa. The lowest bond strength
was observed with the apical segments. Coronal
segments show a statistical significance (p < 0.001)
when compared with the apical and middle groups.
But no statistical difference was observed between the
middle and apical segments (p > 0.001). These results
were in consistent with the studies of Boff et al,6 Kalkan
et al16 and Perdigão et al.23
Adhesion to root dentin is a viable procedure; but,
structural differences exist between coronal and
radicular dentin. Tubule density is greatest in the
coronal- and middle-third than the apical-third of the
root. As adhesion is enhanced by the penetration of
resin into the tubules, if there were a greater number of
tubules per mm2, a stronger bond would be expected.
Moreover, the coronal portion of the canal is the most
accessible part for the canal space, making it easier for
thorough application of the adhesive and therefore
formation of resin tags is more uniform than the deeper
areas of the canal. Hence, the third null hypothesis
tested was proven to be false.
Thus, mechanical roughening of the post (Cojet) and
silanization was proven to be more effective than the
use of the etching solutions and Silane.
Conclusion
Within the limitations of the present study it was
found that:
l Silanization without any surface treatment has
negligible effect on the bond strength of fiber
post.
l Cojet with Silane treatment was proven to be
more effective than silanization done along with
etching solutions.
l There is a marginal increase in bond strength
when the posts were silanated after etching with
10% H2O2 and sodium ethoxide.
l Highest push-out strength was achieved at the
coronal-third of the root when compared with
the middle- and apical-third.
Further studies on these fiber post systems are
required to validate the results of the present study.
More parameters like microleakage, flexural strength,
modulus of elasticity, etc. needs to be evaluated.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

References
1. Bateman G, Ricketts DN, Saunders WP. Fibre-based
post systems: a review. Br Dent J 2003;195(1):43-8;
discussion 37.
2. Berekally T. Contemporary perspectives on post-
core systems. Aust Endod J 2003;29(3):120-7.
3. Gluskin AH, Ahmed I, Herrero DB. The aesthetic post
and core: unifying radicular form and structure. Pract
Proced Aesthet Dent 2002;14(4):313-21; quiz 322.
4. Qualtrough AJ, Mannocci F. Tooth-colored post
systems: a review. Oper Dent 2003;28(1):86-91.
5. Balbosh A, Kern M. Effect of surface treatment on
retention of glass-fiber endodontic posts. J Prosthet
Dent 2006;95(3):218-23.
6. Boff LL, Grossi ML, Prates LH, Burnett LH Jr, Shinkai
RS. Effect of the activation mode of post adhesive
cementation on push-out bond strength to root canal
dentin. Quintessence Int 2007;38(5):387-94.
7. Tay FR, Pashley DH. Monoblocks in root
canals: a hypothetical or a tangible goal. J Endod
2007;33(4):391‑8.
8. Ferrari M, Grandini S, Simonetti M, Monticelli F,
Goracci C. Influence of a microbrush on bonding
fiber post into root canals under clinical conditions.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2002;94(5):627-31.
9. Ferrari M, Vichi A, Grandini S, Goracci C. Efficacy of a
self-curing adhesive-resin cement system on luting glass-
fiber posts into root canals: an SEM investigation. Int
J Prosthodont 2001;14(6):543-9.
10. Monticelli F, Toledano M, Tay FR, Cury AH, Goracci
C, Ferrari M. Post-surface conditioning improves
interfacial adhesion in post/core restorations. Dent
Mater 2006;22(7):602-9.
11. Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NH.
A structured analysis of in vitro failure loads and failure
modes of fiber, metal, and ceramic post-and-core systems.
Int J Prosthodont 2004;17(4):476-82.
12. Goracci C, Fabianelli A, Sadek FT, Papacchini F,
Tay FR, Ferrari M. The contribution of friction to the
dislocation resistance of bonded fiber posts. J Endod
2005;31(8):608-12.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
CLINICAL STUDY
13. Goracci C, Raffaelli O, Monticelli F, Balleri B,
Bertelli E, Ferrari M. The adhesion between prefabricated
FRC posts and composite resin cores: microtensile bond
strength with and without post-silanization. Dent Mater
2005;21(5):437-44.
14. Matinlinna JP, Lassila LV, Ozcan M, Yli-Urpo A,
Vallittu PK. An introduction to Silanes and their
clinical applications in dentistry. Int J Prosthodont
2004;17(2):155-64.
15. Goerig AC, Michelich RJ, Schultz HH. Instrumentation
of root canals in molar using the step-down technique.
J Endod 1982;8(12):550-4.
16. Kalkan M, Usumez A, Ozturk AN, Belli S,
Eskitascioglu G. Bond strength between root dentin
and three glass-fiber post systems. J Prosthet Dent
2006;96(1):41-6.
17. Le Bell AM, Tanner J, Lassila LV, Kangasniemi I,
Vallittu P. Bonding of composite resin luting cement
to fiber-reinforced composite root canal posts. J Adhes
Dent 2004;6(4):319-25.
18. Monticelli F, Toledano M, Tay FR, Sadek FT,
Goracci C, Ferrari M. A simple etching technique for
improving the retention of fiber posts to resin composites.
J Endod 2006;32(1):44-7.
19. Monticelli F, Osorio R, Toledano M, Goracci C, Tay
FR, Ferrari M. Improving the quality of the quartz
fiber postcore bond using sodium ethoxide etching
and combined Silane/adhesive coupling. J Endod
2006;32(5):447-51.
20. Tay FR, Pashley DH, Loushine RJ, Weller RN,
Monticelli F, Osorio R. Self-etching adhesives increase
collagenolytic activity in radicular dentin. J Endod
2006;32(9):862-8.
21. Vichi A, Grandini S, Ferrari M. Clinical procedure for
luting glass-fiber posts. J Adhes Dent 2001;3(4):353-9.
22. Qualtrough AJ, Chandler NP, Purton DG. A comparison
of the retention of tooth-colored posts. Quintessence Int
2003;34(3):199-201.
23. Perdigão J, Gomes G, Lee IK. The effect of Silane
on the bond strengths of fiber posts. Dent Mater
2006;22(8):752-8.
24. Newman MP, Yaman P, Dennison J, Rafter M,
Billy E. Fracture resistance of endodontically treated
teeth restored with composite posts. J Prosthet Dent
2003;89(4):360‑7.
n n n
259
 clinical study

Prevalence of Facial Neuropathy among Diabetic

Peripheral Neuropathy
R Senthil Nathan*, B Vinodkumar**, K Satheesh†, D Sangeetha‡, SM Rajendran#

Abstract
Diabetes mellitus (DM) has a severe influence on the nervous system and it is more likely to occur on the nerves of the upper
and lower extremities than on the cranial nerves. According to the statistics, the incidence of cranial nerve involvement ranges
from 3% to 14%. Aim: To perform facial nerve conduction studies in diabetic patients with peripheral neuropathy, confirmed
by electrophysiological methods, to determine the frequency of affection of cranial nerve conduction in a neuropathy which
mainly occurs in a distal, symmetric fashion. Material and methods: The study was conducted in a group of 30 diabetics who
had electrophysiologically-confirmed polyneuropathy. All of the patients had type 2 DM. Facial nerve conduction was done in
these patients. Results: We found 46% of patients had decreased amplitude, which is suggestive of axonopathy of metabolic
cause. Amplitudes of muscle responses to facial nerve stimulation showed a statistically significant difference from controls
(p < 0.000). Conclusions: This study has shown that proximal nerves like cranial nerves are affected in a high proportion of
cases in a neuropathy which mainly occurs in a distal symmetric fashion. The facial nerve is one of the most easily accessible
nerves in the proximal part of the body (head-face) and makes it suitable for routine evaluation. We believe this conduction
abnormality may give us the chance to classify these neuropathies as more severe than the ones that only have limb conduction
abnormalities. Further studies should be performed in order to confirm these findings.

Key words: Diabetes mellitus, facial conduction time, polyneuropathy

I
t is a well-known fact that diabetes mellitus (DM)
has a severe influence on the nervous system
and it is more likely to occur on the nerves of
the upper and lower extremities than on the cranial
nerves. According to statistics, the incidence of cranial
nerve involvement ranges anywhere between 3-14%.
Irkeç C, Nazliel B, Yetkin I, Koçer B. Facial nerve
conduction in diabetic neuropathy. Acta Neurol Belg
2001;101(3):177-9. (Mazzotta et al., 1988)
The most common disturbance is an isolated third nerve
lesion, the sixth nerve being affected less frequently. It is
a well-recognized fact that the pupillary innervation is
frequently unaffected in diabetic third nerve palsy. The
fourth nerve is rarely involved alone, but sometimes in
combination. Other cranial nerves may also be affected
but less frequently than those to the external ocular
muscles. Besides the third, fourth and sixth nerves,
the seventh cranial nerve is most frequently involved.
(Thomas et al., l993)
Electrophysiological testing of cranial nerves in diabetes
has rarely been performed.
Aims and Objectives
To perform facial nerve conduction in elecrophysio-
logically-confirmed diabetic peripheral neuropathy
patients to determine the frequency of affection of
cranial nerve conduction in a neuropathy, which
mainly occurs in a distal symmetric fashion.

Material and methods

*Lecturer Selection Criteria
Oromaxillofacial Surgery, Sri Meenakshi Ammal Dental College
**Postgraduate Cases
Dept. of General Medicine, Sree Balaji Medical College and Hospital, Chennai
†
Postgraduate, Dept. of Pharmacology, Sree Balaji Medical College and Diabetic patients were included if they had symptoms
Hospital, Chennai
‡
Post Graduate, Dept. of General Medicine, Sree Balaji Medical College or clinical signs of diabetic neuropathy. Physical
and Hospital, Chennai examination included evaluation of muscle atrophy,
#
Professor, Dept. of General Medicine, Sree Balaji Medical College and
Hospital, Chennai tendon reflexes and sensory deficit. Sensory deficit
Address for correspondence evaluation included touch, vibration position, pain,
Dr R Senthi Nathan
E-mail: shanmugamrajendran@hotmail.com aching, numbness, cramps paresthesia and definable

260 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


complaints such as restless legs, faintness on standing,
frequent episodes of intermittent diarrhea and hesitancy
before micturition.
Control
Patients with earlier cranial nerve lesions, stroke,
alcohol abuse, chronic renal failure, clinical or
electrophysiological evidence of a hereditary or acquired
neuromuscular disease, patients with edematous limbs
which could make recording or stimulation difficult
during nerve conduction studies and patients treated
with drugs recognized as potentially causing neuropathy
were excluded.
Methodology
Nerve conduction studies were performed in a warm
room, with extremity skin temperature of 32°C or
above, at the side where nerve conduction velocity
measurement (NCV) was done. Median motor and
sensory nerve conduction velocities were obtained in
one upper extremity, posterior tibial, peroneal motor
conduction velocities in one lower extremity and sural
nerve sensory conduction in both lower extremities
were performed by the method described by Oh
(1984). Abnormality was defined as slowed velocity or
an absence of response in at least two nerves. Only
patients with abnormal results were included in the
study for the evaluation of distal latency of muscle
responses to facial nerve stimulation (DML VII).
For the facial nerve, an active electrode was placed over
the midpoint of the lower portion of the orbicularis
oculi and a reference electrode was placed above the
eyebrow along the same vertical plane of the active
electrode. The zygomatic branch of the facial nerve was
stimulated anterior and inferior to the tragus of the
earlobe with a standard distance of 8 cm. Both sides
were tested consecutively. The latency was measured
from the stimulus onset to the first deflection of
the compound muscle action potential (CMAP).
Amplitudes were measured from peak to peak.
Only delays above the average latency ± 3 SD (standard
deviation) of the mean of control subjects, or the
absence of CMAP was considered abnormal.
Study Design
Cross-sectional study
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
CLINICAL STUDY
Study Area
Sree Balaji Medical College and Hospital, Chennai,
India.
Study Period
October 2009 to March 2010.
Study Participants
Case group: The study was conducted in a group of
30 diabetic patients, (11 females, 19 males) in the age
range of 45-69 (mean: 58.95) years. The mean duration
of DM was 9.6 ± 0.82. All patients had type 2 DM
according to WHO criteria (The Expert Committee,
2000). The mean glycosylated hemoglobin (HbA1C)
value was 7.6 ± 2.0% (normal values: 4.4-5.7%).
Control group: The control group consisted of 20
subjects, (11 males, 9 females), age range 45-72 (mean
58.95) years who were attending the EMG laboratory
for nonspecific complaints. Subjects with central or
peripheral nerve diseases, or those treated with drugs
recognized as potentially causing neuropathy were
excluded. All subjects had a normal neurological
examination.
Statistical Evaluation
The statistical evaluation was performed using
nonparametric Mann-Whitney test and Pearson and
Sperman’s correlation coefficient when appropriate.
The software used for all statistical evaluations was
SPSS 8.0 statistical package program.
Results
Table 1 presents DML VII in normal subjects and
in diabetics. In control subjects, the mean amplitude
of muscle responses to facial nerve stimulation was
2.11 ± 0.09 mV with a range of 1.85-2.30 mV;
it was 1.85 ± 0.44 mV in diabetics with a range of
1.00-2.09 mV. The difference between the two groups
was statistically significant (p < 0.000).
Based on these data, criteria were established for
abnormal response using the mean amplitude plus
3 SD of the lower limit of normal: A facial conduction
time with amplitude <2 mV is defined as abnormal.
Fourteen (46%) of our patients had an abnormal
response at least on one tested side. In control subjects,
DML VII mean latency was 3.24 ± 0.17 ms with a
261
 CLINICAL STUDY

Table 1. Facial Nerve mean CMAP Amplitude in

60 53.33
Normal Subjects and in Diabetics 46.67
50

Percentage (%)
Normal Diabetics <p
40
(n = 20) (n = 30)
30
Age (mean and range) 58.95 (45-72) 59.06 (45-69)
20
Mean duration of DM – 9.6 ± 0.82 10
(years) 0
Mean CMAP amplitude 2.11±0.01 1.85±0.04 0.000 Amplitude <2.0 Amplitude >2.0
of CN VII (mV)
Conduction time of CN 3.24 ± 0.17 3.27±0.04 0.578 Figure 1. Comparison of amplitude between diabetes and
VII (ms/8.0 cm) normal subject.

range of 2.90-3.96 ms, and was 3.27 ± 0.04 ms with a

100 93.33
range of 2.24-5.80 ms in the diabetics. The difference
between the two groups was not statistically significant 80

Percentage (%)
(p < 0.578) (Fig. 1).
60
A facial conduction time with latency >3.3 msec is
40
defined as abnormal. Two (6.6%) of our patients only
had an abnormal response (Fig. 2). Latency of muscle 20
6.67
responses to facial nerve stimulation in both groups 0
did not vary greatly. Therefore, the latency of muscle Latency >3.30 Latency <3.30
responses to facial nerve stimulation was not used as an
index of abnormality. Figure 2. Comparison of latency among diabetic and normal
subjects.
In case group, among 30 subjects, 18 were found to
be diabetic of <10 years of which only two (11%) got
affected. Whereas all the 12 (100%) subjects who had Presence
Absence
diabetes of more than 10 years duration showed facial 100
neuropathy (Fig. 3). This showed a strong correlation 100 88.89
between subclinical facial neuropathy and duration of
Percentage (%)

80
diabetes. 60
40
No correlation was found between DML VII and sural
20 11.11
nerve sensory conduction velocity or between DML 0
VII and peroneal nerve motor conduction velocity. 0
<10 years >10 years
Sixteen (54%) diabetic subjects demonstrated no
Figure 3. Prevalence of facial neuropathy in diabetic
abnormalities.
subjects.
Discussion
The possibility of subclinical involvement of the facial Neuropathies can occur in mild diabetics of recent
nerve in different generalized neuropathies was reported onset and may be independent of other types of
in the past by some authors. The degree of involvement diabetic complications. There are only a small
depends on the type of neuropathy. The correlation number of studies on the frequency of clinically
between the degree of involvement of the facial nerve apparent cranial nerve lesions associated with DM.
and peripheral nerves varies greatly in different types A large retrospective series revealed 0.97% incidence
of neuropathies. The most pronounced prolongation of oculomotor and facial nerve palsies in diabetic
of DML VII was found in demyelinating hereditary patients over a 25-year period, which was 7.5-fold
sensorimotor neuropathy (HSMN I) (Hausmanowa- more frequent than in the nondiabetic control group
Petrusewicz et al., l987). (Urban et al., 1999).

262 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


Hausmanowa-Petrusewicz et al. (l987) found no
changes of the distal motor latency of the facial nerve
in 22 diabetics, who were not further characterized,
but showed only very mild signs of neuropathy. But
they stated that the negative results they reported may
be due to mild nature of DM in their patients.
This procedure evaluates polyneuropathy, not
mononeuropathy, which develops with acute onset
possibly due to vascular involvement of the facial
nerve. In view of length-related involvement of
polyneuropathy, facial nerve conduction may be less
impaired than limb nerve conduction.
Rarely, some patients with severe lower limb edema may
require the use of needle electrodes instead of surface
recording techniques, which is hard and sometimes
unbearable for the patient. We believe that under these
circumstances, this noninvasive conduction abnormality
will give us additional diagnostic information.
Our findings indicate that subclinical facial nerve
involvement is not unusual in DM, although it is
significantly less frequent than the involvement of
limb nerves. This study has revealed that the facial
nerve is affected in a high proportion in a neuropathy
which mainly occurs in a distal symmetric fashion.
Of course, this test is not a gold standard for the
evaluation and confirmation of a neuropathy. But
the facial nerve is one of the most easily accessible
nerves in the proximal part of the body (head-face)
suitable for routine evaluation. In demonstrating the
sensory disturbances of diabetic neuropathy Thomas
and Tomlinson (1993) reported that only in most
severe instances of ‘length-related’ progression of
the distal symmetric neuropathic forms the vertex
of the head may be reached.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
CLINICAL STUDY
Conclusion
We believe this conduction abnormality may give
us the chance to classify these neuropathies as more
severe than the ones that only have limb conduction
abnormalities. Further studies on this subject with
more patients should be performed in order to confirm
these findings.
References
1. Hausmanowa-Petrusewicz I, Ryniewicz B, Rowińska-
Marcińska K, Emeryk B, Kopeć A. The subclinical
facial nerve involvement in generalized neuropathies.
Electromyogr Clin Neurophysiol 1987;27(4):229-34.
2. Mazzotta G, Del Gatto F, Firenze C, Gallai V. The
blink reflex in diabetic patients. Electromyogr Clin
Neurophysiol 1988;28(6):291-4.
3. OH S. Anatomical guide for common nerve conduction
studies. In: Clinical Electromyography: Nerve conduction
studies. Park Press, Baltimore, Maryland 1984:p65-85.
and mononeuropathy multiplex in diabetes mellitus. N
Engl J Med 1968:17-22.
4. The Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus. Report of the Expert
Committee on the diagnosis and classification of diabetes
mellitus. Diabetes Care 2000;23 Suppl 1:S4-19.
5. Dyck PJ, Thomas PK, (Eds.), Thomas PK, Tomlinson
DR. Diabetic and hypoglycemic neuropathy. In:
Peripheral Neuropathy. WB Saunders: Philadelphia
1993:1219-50.
6. Urban PP, Forst T, Lenfers M, Koehler J, Connemann
BJ, Beyer J. Incidence of subclinical trigeminal and facial
nerve involvement in diabetes mellitus. Electromyogr
Clin Neurophysiol 1999;39(5):267-72.
7. Waylonis GW, Johnson EW. Facial nerve conduction
delay. Arch Phys Med Rehabil 1964;45:539-47.
n n n
263
 review article

Upsurge of Nanotechnology in Dentistry and

Dental Implants
Sanjna Nayar*, S Bhuminathan**, J Muthuvignesh†

Abstract
Nanotechnology has been defined as “the creation of functional materials, devices and systems through control of matter on
the nanometer scale (1-100 nm), and exploitation of novel phenomena and properties (physical, chemical and biological) at
that length scale”. The article discusses from the inception of nanotechnology, its advantages, disadvantages and its application
in the field of dentistry. The role of nanotechnology in the field of implantology and ceramics cannot be underestimated. The
different types and classification systems of nanotechnology have also been exemplified. Nanotechnology has enhanced the
implant bone contact and hence osseointegration. The article also reviews the role of nanoparticles on the implant surface.

Key words: Nanotechnology, nanomaterials in dentistry, nano in dental implants, biomimetics, osseointegration, hazards,
nanorobots

C
urrent developments during the past decade
in physics, and engineering have resulted
in a tremendous upsurge of interest in the
properties of very minute particles and their possible
applications in different fields. In nanotechnology
the reductions in the size of any particles is upto a
nano scale. The term “Nanotechnology” was coined
by Prof. Kerie E. Drexler, a lecturer and researcher of
nanotechnology. ‘Nanotechnology’ influences almost
every facet of everyday life from security to medicine.
Nanotechnology has been defined as “the creation
of functional materials, devices and systems through
control of matter on the nanometer scale (1-100 nm),
and exploitation of novel phenomena and properties
(physical, chemical and biological) at that length scale
(NASA).1 The potential of nanosized particles was
speculated as early as in 1959 by the physicist Richard
P Feynman.
Nanotechnology is an interdisciplinary field such
as physics, biology, microbiology engineering,
chemistry, computer science and more. The concept of
* Professor and Head,
**Professor,
†
Senior Lecturer
Dept. of Prosthodontics
Sree Balaji Dental College, Chennai
Address for correspondence
Senior Lecturer, Dept of Prosthodontics
Sree Balaji Dental College-Chennai
E-mail: jayamvignesh@gmail.com
nanotechnology is: when one goes down to the bottom
of things one can discover unlimited possibilities and
potential of the basic particle. In Nanotechnology one
analyzes to the level of manipulating atoms, molecules
and the chemical bonds between them.
Technological innovations have enabled the
manipulation of tiny structures called nanopores,
nanotubes, quantum dots, nanoshells, nanospheres,
nanowires, nanocapsules, dendrimers, nanorods,
etc.2 More recently, tiny machines, known as
nanoassemblers, which can be controlled by computer
to perform specialized jobs have been invented. The
nanoassemblers could be smaller than a cell nucleus so
that they could fit into places that are hard to reach
by hand or with any other technologies. For example,
in dentistry, it can be used to destroy bacteria in the
mouth that cause dental caries or even repair spots on
the teeth where decay has set in, by use of computer to
direct the nanoassemblers in their tasks.
Nanotechnology is also applied to various medical and
biological fields like pharmacological research, clinical
diagnosis, mechanically reversing artherosclerosis,
Improving respiratory capacity, cryogenic storage of
biological tissues, In enabling instantaneous hemostasis,
vasculoids, detection of proteins, probing of DNA
structure, tissue engineering, tumour destruction via
heating (hyperthermia), separation and purification
of biological molecules and cells, magnetic resonance
imaging (MRI) contrast enhancement, phagokinetic
studies, etc.3

264 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


Products which use nanotechnology are: Burn and
wound dressings, bumpers and catalytic converters
on cars, sunscreens and cosmetics, longer-lasting
tennis balls and lightweight stronger tennis racquets,
protective and glare-reducing coatings for eyeglasses
and stain-free clothing.
Nanotechnology can be classified in terms of application
in three broad and extensively overlapping categories:4
l Nanoelectronics
l Nanomaterials/particles
l Nano-biotechnology
Nanoelectronics: Refers to the use of nanotechnology
on electronic components, especially transistors,
computer processors, etc.
Nanomaterials are essentially polymers reinforced by
nanoparticles resulting in novel materials which can
be used as light weight replacements for metals. When
brought into a bulk material nanoparticle can strongly
influence the mechanical properties of the materials
like stiffness or elasticity. Nanomaterials are of utmost
significance in dentistry and can be used for better
efficiency of dental materials.
Classification of Nanomaterials5
Nanomaterials could be classified into four major
types: Carbon-based materials, metal-based materials,
dendrimers and composites.
Methods of Synthesis of Implant
Nanomaterials5
Numerous techniques are used to fabricate different
nanomaterials that are used to coat the implant surfaces.
Mainly they can be processed by two methods: Top-
down and bottom-up.
Top-down: In this method nanoparticles are produced
from larger structures by use of ultrafine grinders, lasers
and vaporization followed by cooling.
Bottom-up In this method nanoparticles are produced
by arranging molecules to form complex structures
with new and useful properties.
Imaging of Nanomaterials6
Imaging is an important procedure in nanotechnology
because the coating of nanomaterials should be checked
for their sizes and thickness. Various imaging techniques
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Review Article
involved in nanotechnology are: X-ray diffraction
(XRD), atomic force microscopy (AFM), scanning
electron microscope (SEM), transmission electron
microscopy (TEM), magnetization measurements,
nuclear magnetic resonance (NMR), spectroscopy,
2-D electrophoresis and mass spectrometry of proteins
and confocal microscopy.
Nanomaterials can be used in various fields of dentistry
as nano impression materials, nano bonding agents,
nano drug releasing systems, nano composites,7 nano
ceramics, nano sterilizing agents8 and as well in dental
implants.
Nanotechnology in Dental Implants
The application of nanotechnology in dental implants
can be made by coating of nanoparticles over the dental
implants. It has been demonstrated that different cell
types respond positively to nanotopography.
The surface of the implant plays a critical role in
determining biocompatibility and biointegration
because it is in direct contact with the tissues. Implant
surface composition, surface energy, surface roughness
and surface topography are the four material related
factors which can influence events at bone-implant
interfaces. Various surface textures have been created
and used to successfully influence cell and tissue
responses. Surface textures are of three types’ macro,
micro and nano.1 The ‘nanostructured’ materials can
exhibit enhanced mechanical, electrical, magnetic and/
or optical properties compared with their conventional
micron-scale or macro-scale (larger) counterparts.
Nanostructured (NS) materials contain a large volume
fraction (>50%) of defects such as grain boundaries,
inter phase boundaries, and dislocations, and this
strongly influences their chemical and physical
properties.
In many cases, the intended implant site is compromised
because of poor bone quality or insufficient bone
quantity. Lack of sufficient alveolar ridge height is
often related to the proximity of the implant site to
other anatomical structures. In these situations separate
preparatory procedures may be required to augment the
available volume of bone before the implant placement,
which may result in longer treatment time, greater
risk of complications and higher costs. Alternatively,
orthodontic procedures have been used to extrude and
265
 Review Article
eventually extract ‘hopeless’ teeth. However, as effective
as these procedures may be, the risks of complications
are greater than for single site procedures, treatment
time and costs are also increased. Biomimetic dental
implants may be the next development in the field.9
A variety of biomimetics coatings may be helpful for
application in individual patients. For example, coating
implants with nanotextured titanium, hydroxy apatite,
and pharmacological agents such as bisphosponates
may induce cell differentiation and proliferation and
may promote greater vascularity in highly cortical bone,
thereby improving conditions for early and long-term
(in response to functional loading) bone remodeling.
Nanoscale modification of an implant surface could
contribute to the mimicry of cellular environments to
favor the process of rapid bone accrual. Cell adhesion
to basement membranes is an often cited example of
nanoscale biomimetics.9
Successful osseointegration is influenced by both the
chemical composition and the surface geometry or
topography of the implant.10 Literature indicates that
degradation of an implant surface coating may help
to promote de novo bone formation, as a result of
either enhanced osteoconductivity due to the resulting
changes in surface topography or enhanced osteogenesis
due to local release of calcium or other elements that
may promote bone formation.
Surface nanotopography affects cell interactions at
surfaces and alters cell behavior when compared to
conventional sized topography.11,12 Different physical
relationships exist between cells at micron scale
level and nanoscale level. Nanotopography-specific
effects on cellular behavior have been demonstrated
using a wide range of different cell types including
epithelial cells, fibroblasts, myocytes and osteoblasts.
Nanostructured surfaces possess unique properties that
alter cell adhesion by direct10 (cell-surface interactions)
and indirect (affecting protein-surface interactions)
mechanisms.
Nanoscale topography is a powerful way of altering
protein interactions with the surface. Surface profiles
in the nanometer range play an important role in the
adsorption of proteins, adhesion of osteoblastic cells
and thus the rate of osseointegration. There is an
increased vitronectin adsorption on nanostructured
surfaces when compared to conventional surfaces.13
266
This leads to increased osteoblasts adhesion when
compared to other cell types such as fibroblasts, on the
nanosurfaces.
Cell–matrix-substrate interactions associated with cell
signaling occur in the nanoscale level. Such signaling
regulates cell attachment, spreading, migration,
differentiation and gene expression. The cells also
respond differently to the scale of nano roughness.
There is an increased cell integrin signaling in
14-29 nm pits than 45 nm pits, Since, the surface
roughness of bone is approximately 32 nm.14 Increased
cellular responses have been reported in cell cultures
grown on nanophase ceramics. These types of coatings
onto the surface of implants stimulate cells in the
early stage of bone formation and accelerate the bone
formation around the implant site, thereby enhancing
the primary implant stabilization.
In addition to the dimensional similarity to bone/
cartilage tissue, nanomaterials also exhibit unique
surface properties (such as surface topography, surface
chemistry, surface wettability and surface energy) due to
their significantly increased surface area and roughness
compared to conventional or micron structured
materials. As is known, material surface properties
mediate specific protein (such as fibronectin, vitronectin
and laminin) adsorption and bioactivity before cells
adhere on implants, further regulating cell behavior
and dictating tissue regeneration. Furthermore, an
important criterion for designing orthopedic implant
materials is the formation of sufficient osseointegration
between synthetic materials and bone tissue. Studies
have demonstrated that nanostructured materials
with cell favorable surface properties may promote
greater amounts of specific protein interactions to
more efficiently stimulate new bone growth compared
to conventional materials. This may be one of the
underlying mechanisms why nanomaterials are superior
to conventional materials for bone growth.
Modifying the surface characteristics of the implant
in nanoscale can promote migration of mesenchymal
cells to the implant surface, enhance attachment and
proliferation of these cells, and, in some instances,
stimulate osteoblastic differentiation.15
Some reports have suggested that in designing a
biomimetics implant one should choose a surface
texture of high roughness (presumably with some
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

optimum value) and ensure a high surface area, to
optimize the ability of the implant to act as a ‘carrier’
for the planned biomimetics coatings.16-18 Such a design
might also enhance osteoconductivity and osteogenesis,
and thereby improve long-term fixation of the implant
through more effective mechanical interlock at the
bone-to-implant interface after osseointegration.
The so-called bioactive implants (devices capable
of implant to bone chemical bonding) will become
popular because such implants combine biomechanical
and chemical bonding of the surfaces.19 The advantage
of chemical bonding is primarily that it is rapid, in
contrast to biomechanical bonding (typical of implants
of today), which develops gradually as bone forms and
invades implant surface irregularities. In time, doped
surfaces containing nano bone morphogenetic proteins
that are gradually released from the surfaces will be
developed. Doped surfaces will improve the outcome
of implants in grafted bone or where implants might
otherwise be unstable, but they will be of little use in
the ordinary stabilized implant situation.
In basic science, there is currently considerable interest
in nanostructures. With respect to surface roughness,
it is unknown whether nanometer-sized irregularities
will affect the bone response. Changes in implant
roughness at the micrometer level of resolution may
simultaneously result in changes at the nanometer
level. It is therefore difficult to reliably exclude the
possibility that nanometer-sized surface irregularities
may influence the bone response to an implant.
One study showed that macrophage cell lines react
to microgrooves at the nanometer level, whereas
another investigation saw no significant effects in cell
adhesion to different nanotopographies.20 There is a
need for more in vitro and of course in vivo, data to
decide on the potential importance of nanostructures.
Nevertheless, for clinical purposes, the relevant way to
describe an oral implant surface is by referring to its
micrometer-sized irregularities.
Nanobiotechnology
Nanorobots play an important role in nanobiotechnology.
They can be used for cell repairs in the human body.
Nanorobotics
Nanorobots are theoretical microscopic devices
measured on the scale of nanometers (1 nm equals
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Review Article
one millionth of 1 mm).21 When fully released from
the hypothetical stage, they would work at the atomic,
molecular and cellular level to perform tasks in both
the medical and industrial fields that have heretofore
been the stuff of science fiction. Feynman has
mentioned how these nanotechnologies can be applied
to nanomedicine. He offered the first known proposal
for nanomedical procedure to heart disease.
Nanorobotics in Dentistry
The growing interest in the future of dental applications
of nanotechnology is leading to the emergence of a
new field called nanodentistry. Nanorobots induce
oral analgesia, desensitize tooth; manipulate the tissue
to realign and straighten irregular set of teeth and to
improve durability of teeth. Further, it is explained that
how nanorobots are used to do preventive, restorative,
curative procedures, major tooth repair, tooth durability
and appearance, anesthesia, surgery and orthodontic
treatment has been documented.
Hazards of Nano
The potential deleterious effect that these materials
can produce on humans or the environment should
be analyzed so that expanded development and use
of nanotechnology can proceed. There has been one
reported rapid withdrawal of a nanotechnology-based
product, Magic Nano, a spray-on ceramic sealant to
repel dirt.22 Over 110 consumers in Europe reported
respiratory symptoms after using the spray. The product
was withdrawn in March 2006.
Potential Risks of Nanomaterialsto
Human Exposure8
Skin
Skin consists of several layers of dead keratinized cells
which, when intact, prevent entry of most ionic and
water soluble substances. There is no adequate data
available on penetration of the skin by nano particles.
Micrometer-sized particles of titanium dioxide can
penetrate the surface of the skin and get into hair follicles
but are not thought to react with living tissues. But
some smaller particles were reported to penetrate deeply
enough to be taken up by macrophages. Currently, it
is impossible to predict whether nanoparticles will pass
through the skin to a significant extent.
267
 Review Article
Lungs
Most dust particles get entrapped by the mucus
lining during inhalation. Nanoparticles can penetrate
deep into the lungs, into the alveoli because of their
size. Higher concentrations of these particles can
cause inflammation, as they cannot be engulfed by
macrophages. They can also produce nervous and
cardiovascular adverse effects.
Gastrointestinal Tract/Circulatory System
Nanoparticles can be absorbed from the gastrointestinal
tract and enter the circulatory system. Nanoparticles
are readily taken up by many types of cells in vitro and
are expected to cross the blood-brain barrier (BBB) that
excludes many substances that are harmful to the brain.
Some reports suggest that nanoparticles cause oxidative
stress in the liver, precipitate lung inflammation and
activate blood platelets that may contribute to clot
formation. Certain in vitro studies have proved that
fullerenes can cause morphological changes in vascular
endothelial cells and in high concentrations induce
cytotoxicity. Further in vivo studies are required to
evaluate and overcome these hazards.
Conclusion
This article demonstrates the modern and upcoming
technology. The article features the type, mode of action
and drawbacks of nanotechnology in general and in
the field of dentistry specifically. Nanotechnology has
made numerous strides to improve the bone-implant
contact thus opening the avenues of successful implant
therapy. Clinical trials need to be evaluated over a
longer period of time and to interpret the success and
hazards of nanotechnology. The benefits provided by
the nanotechnology overrun its shortcomings. No
wonder as Richard P Feynman Said “This is a
Development Which Cannot Be Avoided”.
References
1. Gustavo mendonça et al. Advancing dental implant
surface technology – from micron to nanotopography.
Biomaterials 3822-3835.
2. Nanotechnology and nanoparticles in dentistry. Anna V.
Rybachuk, Ivan S. Chekman, Tetyana Yu. Nebesna.
3. Salata OV. Applications of nanoparticles in biology and
medicine. Journal of Nanobiotechnology
4. Majumder DD, et al. IETE technical review. 2007;
24:#1: 9-25. 36:R167-R181.
268
5. Singh DN. IETE technical review nanotechnology: an
Indian perspective 2007; 24:#1: 43-49.
6. Bhatnagar K, Varma A. IETE technical review-
nanobiogenomics. education and research. 2007;
24:#1:27-30.
7. Sumita B, Mitra, et al. An application of nanotechnology
in advanced dental materials. JADA 2003;134:1382-90.
8. Nanotechnology: a brief literature review. M. Ellin
Doyle, Ph.D.
9. Ziv Simon,.Biomimetic Dental Implants - New Ways
to Enhance Osseointegration. DMD: J Can dent Assoc
2002:286-8.
10. L Le Gu´ehennec. Surface treatments of titanium
dental implants for rapid osseointegration. Biomaterials
2007:844-54.
11. Meyer U, Buchter A, et al. Basic reactions of osteoblasts
on structured material surfaces. Euro Cells Mater
2005;9:39-49.
12. Possible medical applications of nanotechnology.
Nanotechnology research and perspectives. MIT press
1992:p251
13. Wennerberg A, Alberektsson T. Implant surfaces beyond
micron roughness. Experimental and clinical knowledge
of surface topography and surface chemistry. Inte Dent
SA vol 8, #6 :14-17.
14. Hansen JC, Lim JY, et al. Effect of surface nanoscale
topography on elastic modulus of individual osteoblastic
cells as determined by atomic force microscopy. J
Biomech 2007;40:2865-71.
15. Lyndon F. Cooper, DDS, PhDa. A role for surface
topography in creating and maintaining bone at titanium
endosseous implants. : JPD vol 84 #5.
16. Adriane Yaeko Togashi. The role of implant surface
chemistry in the biological bone response. RPG Rev Pós
Grad 2007;13(4):340-4.
17. Nanodentistry: Freitas RA. American Dental Association.
2000;131:1559-66.
18. JS Kadadevaramath. IETE technical review. vol 24:#1;
2007:5-8
19. Parak WJ, Gerion D, et al. Biological applications of
colloidal nanocrystals. Nanotechnology 2003;14:R15-
R27.
20. Brite Groessener, et al: Fibroblast growth on surface-
modified dental implants- in vitro study. J biomed
materials research. -64a: 591-593.
21. Nanorobots: Abhilash M: International Journal of
Pharma and Bio Sciences: 2010.
22. Pankhurst QA, et al. Applications of magnetic
nanoparticles in biomedicine. J Phys D: Appl Phys 2003,
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 review article

Pre-eclampsia: An Oral Infectious Etiology?

Jaideep Mahendra*, Khushbu Desai**, Little Mahendra†

Abstract
Pre-eclampsia is a common hypertensive disorder of pregnancy, affecting 5-10% of pregnancies and contributing significantly
to natural and periodontal morbidity and mortality. It has been recently studied that women were at higher risk for pre-
eclampsia, if they had severe periodontal disease at delivery. Periodontal disease may provide a chronic burden of endotoxin
and inflammatory cytokines, which serve to initiate and exacerbate atherogenesis and thrombogenesis. It is possible that
the placenta may be similarly burdened in pregnant women who develop pre-eclampsia. Pre-eclampsia and periodontitis are
both mutlifactorial diseases and obtaining a good oral hygiene measures can reduce the risk for periodontal disease thereby
also reducing the further risk for pre-eclampsia in the pregnant women.

Key words: Pre-eclampsia, periodontitis, hypertension, pregnancy

P
eriodontitis is an inflammatory disease that
affects the supporting tissues of the teeth,
causing progressive destruction of connective
tissue attachment and loss of alveolar bone. This
causes formation of a periodontal pocket defined as
apical migration of junctional epithelium as well as
deepening of gingival sulcus, along with production
of proinflammatory cytokines. Due to its chronic
inflammatory nature, periodontitis can be considered
as a systemic exposure leading to a variety of systemic
illnesses.1 Periodontitis causes bleeding gingiva
when brushing, spacing of teeth due to pathologic
migration, mobility and areas of localized pain.2 This
disease, characterized as a chronic low-grade systemic
stressor, is associated with various systemic illness such
as atherosclerosis, diabetes and respiratory disorders.1
Detection of oral pathogens in atherosclerotic plaque
confirms their role in development and progression of
atherosclerosis leading to coronary heart disease.1
Pre-eclampsia is a dangerous disease of human
pregnancy, which affects both the mother and
*Professor, Dept. of Periodontics
**Postgraduate Student
Meenakshi Ammal Dental College, Chennai
†
Senior Lecturer
Raja Muthaiah Dental College, Annamalai University, Chennai
Address for correspondence
Dr Jaideep Mahendra
Professor, Dept. of Periodontics
Meenakshi Ammal Dental College, Chennai
E-mail: jaideep_m_23@yahoo.co.in
her fetus. It is defined as blood pressure (BP)
>140/90 mmHg on two separate occasions after
Week 20 of gestation and >1+ proteinuria.3 It is a
common obstetric syndrome that affects approximately
7-10% of pregnant women and remains one of the
two most common causes of maternal mortality in
the developed world. There are two syndromes in
pre-eclampsia. The first is maternal, characterized
by endothelial cell activation, hypertension and
proteinuria. The second is fetal, manifested primarily by
intrauterine growth restriction (IUGR). The symptoms
of this syndrome appear during the second and third
trimesters of pregnancy. Although this disease is of
major obstetric importance throughout the world, it
remains an enigma. Despite extensive research, neither
its cause nor possible mechanism have been clearly
defined.4 It is characterized by abnormal vascular
response to placentation, reduced organ perfusion,
vasospasm, activation of the coagulation system,
inflammatory-like responses, oxidative stress and some
perturbations in volume and BP control, affecting
the placenta, kidney, liver and brain. Recent studies
suggest that periodontal inflammation plays a key role
in causing pre-eclampsia or its manifestations. Normal
pregnancy evokes a mild increase in the systemic
inflammatory response that becomes considerably
greater in pre-eclampsia.5 Periodontal disease may
also serve primarily as a vascular stressor and bring
an additional infectious/inflammatory burden to the
placental-fetal unit, thereby increasing the risk of

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 269

 Review Article
preterm delivery in preeclamptic women.6 Based on
this concept, some authors have hypothesized that
infection might be involved in the etiology and
pathogenesis of pre-eclampsia, both in terms of its
initiation (by increasing the risk of acute uteroplacental
atherosis) and/or its potentiation (by amplifying the
maternal systemic inflammatory response).5
Incidence of Pre-eclampsia
The incidence of pre-eclampsia in India is around
10% and around 2-5% in the US.7 It occurs mostly in
the second or third trimester i.e., around 32nd week
or as early as 20 weeks, though it is rare. It is more
common in women with first pregnancies, pre-existing
hypertension, diabetes, autoimmune diseases like
lupus, inherited thrombophilias like Factor V Leiden
or renal disease, family history of pre-eclampsia, obese
women and in women with multiple gestations.8 The
single most significant risk factor for developing pre-
eclampsia is women who have suffered from the same
disease in their earlier pregnancy.9
Degree of Severity
Pre-eclampsia can be divided based on its degree of
severity into mild and severe. Mild pre-eclampsia
is characterized by diastolic BP >90 mmHg but
<110 mmHg; the diastolic BP is 20 mmHg above the
reading in early pregnancy and mean arterial pressure
exceeds 105 mmHg. In severe pre-eclampsia, the systolic
BP is >160 mmHg or diastolic BP is ≥110 mmHg on
at least two occasions at least four hours apart;
proteinuria ≥5 g in 24 hours; oliguria ≤400 ml in
24 hours, cerebral or visual disturbances and severe
headache or epigastric pain.10
Predisposing Factors
Some of the general predisposing factors of pre-
eclampsia are:
l Pre-eclampsia in an earlier pregnancy, family
history of mother or sister suffering from pre-
eclampsia8
l Immunological: Primigravida, new partner3
l Vascular disease: Essential hypertension, family
history of hypertension, renal disease, diabetes
mellitus, connective tissue disease like systemic
lupus erythematosus11
l Hyperplacentosis: Multiple pregnancy, diabetes
270
mellitus, uterine malformation, molar pregnancy
and hydrops fetalis10
l Inflammatory diseases: Periodontitis
Major predisposing factors given to explain cause of
pre-eclampsia could be as:9
l Endothelial cell injury
l Immune reflection of placenta
l Compromised placental perfusion
l Altered vascular reactivity
l Imbalance between prostacyclin and thromboxane
l Decreased glomerular filtration rate (GFR) with
salt and water retention
l Decreased intravascular volume
l Increased central nervous system irritability
l Disseminated intravascular coagulation
l Uterine muscle stretch (ischemia)
l Dietary factors including vitamin deficiency
l Genetic factors
l Elevated serum lipid ratio
l No prenatal care
Pathophysiology of Pre-eclampsia
There are alternate segments of vasodilatation and
vasoconstriction throughout the body causing vasospasm.
The constricted segments contribute to the heightened
peripheral resistance and hence to hypertension.12 In
the dilated segments, there are endothelial cell breaks
in the capillary wall and exudation of plasma proteins
occurs through these breaks leading to cardiovascular
changes. Due to extravasation, there is increased
hematocrit, low platelet count and decreased fibrinogen.
Hemolytic anemia may also be present.10
Various organs of the body undergo certain
morphological changes in preeclamptic women. In
kidneys, the GFR decreases, blood urea, nitrogen,
creatinine and uric acid increase, nonselective
proteinuria comprising albumin and globulin occurs.
In severe pre-eclampsia, acute renal failure may develop
due to acute tubular necrosis, which is reversible after
delivery. Liver may undergo periportal hemorrhagic
necrosis giving rise to elevated enzyme levels.13 These
microhemorrhages may then coalesce to give rise
to a subcapsular hematoma that causes epigastric
pain. Similarly, brain undergoes changes like edema,
hyperemia, infarcts, thrombosis and hemorrhage.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

The CNS manifestations of pre-eclampsia include
seizures, blindness or unconsciousness. In retina
there could be localized vascular spasm, generalized
narrowing, hemorrhage and papilledema.10
Vasospasm and hypovolemia compromise the
uteroplacental perfusion. In pregnancy, the trophoblasts
erode into the maternal blood vessels and form the
uteroplacental bed. But, this process is incomplete in
pre-eclampsia causing intact maternal blood vessels to
respond to any circulating vasoconstrictor substances
compromising the placental blood flow and in the long
run leading to IUGR.10
Prostaglandins: The Key Factor in Pre-
eclampsia
In pre-eclampsia, there is an imbalance in the
levels of prostacyclin and thromboxane A2. The level
of latter is much more than the former.14 Prostacyclin is
vasodilatory, uterine relaxant and platelet deaggregating
substance as opposed to thromboxane A2, the actions of
which are just the opposite. In pre-eclampsia, the levels
of thromboxane A2 are raised leading to proteinuria,
decreased glomerular filtration rate and altered liver
function.14
Oral Infection Contributing Towards Pre-
eclampsia: Recognizing the New Risk
Factor
Periodontal disease is the most common chronic gram-
negative anaerobic infection. Periodontium affected
with the periodontal disease acts as a toxic reservoir of
pathogenic gram-negative bacteria. The toxins produced
by the bacteria attack the gums, ligaments and bone
surrounding the teeth to produce infected pockets that
are similar to large infected wounds in the mouth.15
These bacteria gain access to the bloodstream and
travel throughout the body; they even enter the cervix
causing increase in prostaglandin E2 in the placenta.16
Fluid that bathes the tooth at the gingival margin,
known as gingival crevicular fluid, often contains
inflammatory mediators and the oral pathogens
associated with periodontitis. The mechanisms
underlying this destructive process involve both direct
tissue damage resulting from plaque bacterial products,
and indirect damage through bacterial induction of
the host inflammatory and immune responses. While
periodontitis is a chronic, local oral infection, there is
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Review Article
evidence that both local and systemic inflammation
may occur.15
The biological mechanisms involve bacterially-induced
activation of cell-mediated immunity, which lead to
production of cytokines, synthesis of tumor necrosis
factor (TNF)-α and release of prostaglandins. During
normal pregnancy, when the intra-amniotic levels are
reached, cervical dilatation and delivery are induced.
Abnormal production of these mediators during the
pregnancy in the setting of infection triggers preterm
labor and low birth weight. Cytokines like interleukins
(IL)-1, IL-6 and TNF-α can cross human fetal
membranes.
Active periodontal disease during pregnancy may
have transient translocation of oral organisms to the
uteroplacental unit, inciting placental inflammation or
oxidative stress early in pregnancy, which may ultimately
produce placental damage and clinical manifestations
of pre-eclampsia.17 Subgingival microorganisms like
Porphyromonas gingivalis, Tannerella forsythia and
Treponema denticola occur more frequently or in
higher levels in periodontitis sites.18 Bacteria known as
Fusobacterium nucleatum have been linked with adverse
pregnancy outcomes. Since F. nucleatum is associated
with periodontal infection rather than genital or
uterine infections, it is hypothesized that the infection
does not enter the womb by an ascendant route
coming through the genital tract; instead it enters the
mother’s bloodstream from the oral cavity making it
way down.19 The virulence factors of P. gingivalis have
been linked to various complications in pregnancy
outcome and pathogenesis of atherosclerosis.19
This gram-negative periodontal pathogen found in
periodontal disease may find its way into the patient’s
bloodstream through oral hygiene procedures or even
chewing.18 The cysteine proteinases produced by
P. gingivalis termed ‘gingipains’ have deleterious effects
in activating coagulation factors and platelet aggregation
and in altering the cytokine response in human
umbilical-vein-endothelial cells.20 Other virulent factors
like fimbriae and lipopolysaccharides that can activate
spleen cells and peripheral blood monocytes result
in the release of proinflammatory cytokines like IL-1,
IL-6 and TNF-α.18 T. forsythia possesses virulence
traits, including the production of LPS and a trypsin-
like protease as well as the ability to penetrate and induce
apoptosis in host cells.21 This may explain the possible
271
 Review Article
mechanisms of P. gingivalis and T. forsythia virulence
factors involved in pre-eclampsia development.18
Endothelial cell dysfunction is the key feature of pre-
eclampsia, potentially explaining the multi-organ nature
of the disorder. This dysfunction is demonstrated by
the structural changes in the placental bed and uterine
boundary vessels and the high maternal blood levels
of markers of endothelial damage like fibronectin,
von Willebrand factor, endothelin, tissue plasminogen
activator and thrombomodulin.22 Endothelial cell
dysfunction may be because of increase in oxidative
stress due to reduced placental perfusion. Placental
ischemia is a common feature of pre-eclampsia and
enhances the synthesis of inflammatory cytokines like
TNF-α, which induces oxidative damage.23 Under
hypoxic conditions, free radicals are formed that can
stimulate lipid peroxidation of free-fatty acids, leading
to the injury of endothelial cells.24 The consequence of
this oxidative stress includes activation of microvascular
coagulation, increased capillary permeability and the
production of lipid-laden macrophage foam cells,
which are the characteristic features of atherosis.
Acute atherosis, the placental lesion of pre-eclampsia,
shares a similar pathology, pathogenesis (inflammation)
and clinical setting (endothelial cell damage) with
atherosclerosis. It is characterized by infiltration of
the perivascular spaces by mononuclear cells, an
accumulation of lipid-laden macrophage foam cells
and lipoprotein deposition.19 Increased plasma levels of
free 8-isoprostane, a marker of lipid peroxidation and a
potent vasoconstrictor, have been found in preeclamptic
women.25 It is also found that periodontal disease is
a vascular stressor as evidenced by increase in serum
levels of soluble intercellular adhesion molecules.26
Periodontal disease may burden pregnant women
systemically with endotoxin, inflammatory cytokines
and oxidative stressors at the maternal-fetus interface.18
It is suggested that oral infection could also be an
important trigger of the chronic inflammatory response
that characterizes pre-eclampsia and could also initiate
the preeclamptic process by increasing the risk for
acute uteroplacental atherosis.27
Conclusion
Association between pre-eclampsia and chronic
periodontal diseases should be interpreted with
272
prudence, as the etiology of both events is likely
multifactorial. Various longitudinal and cross-sectional
studies in future are necessary to further elicit the role of
periodontal infection in pre-eclampsia. It is important
to emphasize that primary healthcare services must
be able to diagnose and control periodontal disease
during pregnancy. Managing periodontal disease may
represent a novel strategy to reduce the incidence
and/or complications from this pregnancy hypertensive
disorder. Thus periodontal treatment during pregnancy
could be one of the future aspects in giving better
prenatal care.1
References
1. Cota LO, Guimarães AN, Costa JE, Lorentz TC,
Costa FO. Association between maternal periodontitis
and an increased risk of pre-eclampsia. J Periodontol
2006;77(12):2063-9.
2. Michael G. Newman, Henry H. Takei, Perry R.
Klokkevold, Fermin A. Carranza: Clinical Periodon-
tology. 10th edition, Chapter 31:p494-9.
3. Siqueira FM, Cota LO, Costa JE, Haddad JP,
Lana AM, Costa FO. Maternal periodontitis as a
potential risk variable for pre-eclampsia: a case-control
study. J Periodontol 2008;79(2):207-15.
4. Canakci V, Canakci CF, Canakci H, Canakci E,
Cicek Y, Ingec M, et al. Periodontal disease as a risk
factor for pre-eclampsia: a case control study. Aust N Z J
Obstet Gynaecol 2004;44(6):568-73.
5. Conde-Agudelo A, Villar J, Lindheimer M. Maternal
infection and risk of pre-eclampsia: systematic review and
metaanalysis. Am J Obstet Gynecol 2008;198(1):7‑22.
6. Riché EL, Boggess KA, Lieff S, Murtha AP, Auten RL,
Beck JD, et al. Periodontal disease increases the risk
of preterm delivery among preeclamptic women. Ann
Periodontol 2002;7(1):95-101.
7. National High Blood Pressure Education Program
Working Group Report on High Blood Pressure
in Pregnancy. Am J Obstet Gynecol 1990;163
(5 Pt 1):1691‑712.
8. Cincotta RB, Brennecke SP. Family history of pre-
eclampsia as a predictor for pre-eclampsia in primigravidas.
Int J Gynaecol Obstet 1998;60(1):23-7.
9. Taylor DJ. The epidemiology of hypertension during
pregnancy. In: Hypertension in Pregnancy. Rubin PC,
(Ed.), Elsevier Science: Amsterdam 1988:233-40.
10. Shirish N. Daftary, Sudip Chakravarti. Manual of
Obstetrics. 2nd edition, Chapter 11:p99-111.
11. Dekker GA. Risk factors for pre-eclampsia. Clin Obstet
Gynecol 1999;42(3):422-35.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

12. Pascoal IF, Lindheimer MD, Nalbantian-
Brandt C, Umans JG. Pre-eclampsia selectively impairs
endothelium-dependent relaxation and leads to
oscillatory activity in small omental arteries. J Clin Invest
1998;101(2):464‑70.
13. Sibai BM. Diagnosis, controversies, and management
of the syndrome of hemolysis, elevated liver enzymes,
and low platelet count. Obstet Gynecol 2004;103
(5 Pt 1):981-91.
14. Ylikorkala O, Mäkilä UM. Prostacyclin and thromboxane
in gynecology and obstetrics. Am J Obstet Gynecol
1985;152(3):318-29.
15. Boggess KA. Is there a link between periodontal
disease and preterm birth? Contemporary Ob/Gyn
2003;48:79‑84.
16. Hill GB. Preterm birth: associations with genital
and possibly oral microflora. Ann Periodontol
1998;3(1):222‑32.
17. Oettinger-Barak O, Barak S, Ohel G, Oettinger M,
Kreutzer H, Peled M, et al. Severe pregnancy complication
(pre-eclampsia) is associated with greater periodontal
destruction. J Periodontol 2005;76(1):134-7.
18. Contreras A, Herrera JA, Soto JE, Arce RM, Jaramillo A,
Botero JE. Periodontitis is associated with pre-eclampsia
in pregnant women. J Periodontol 2006;77(2):182-8.
19. Barak S, Oettinger-Barak O, Machtei EE, Sprecher H,
Ohel G. Evidence of periopathogenic microorganisms
in placentas of women with pre-eclampsia. J Periodontol
2007;78(4):670-6.
20. Baba A, Kadowaki T, Asao T, Yamamoto K. Roles for
Arg- and Lys-gingipains in the disruption of cytokine
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Review Article
responses and loss of viability of human endothelial
cells by Porphyromonas gingivalis infection. Biol Chem
2002;383(7-8):1223-30.
21. Moncla BJ, Braham P, Rabe LK, Hillier SL. Rapid
presumptive identification of black-pigmented
gram-negative anaerobic bacteria by using
4-methylumbelliferone derivatives. J Clin Microbiol
1991;29(9):1955-8.
22. Aydin S, Benian A, Madazli R, Uludag S, Uzun H,
Kaya S. Plasma malondialdehyde, superoxide dismutase,
sE-selectin, fibronectin, endothelin-1 and nitric oxide
levels in women with pre-eclampsia. Eur J Obstet
Gynecol Reprod Biol 2004;113(1):21-5.
23. Hubel CA. Oxidative stress in the pathogenesis
of pre-eclampsia. Proc Soc Exp Biol Med 1999;
222(3):222‑35.
24. Conrad KP, Benyo DF. Placental cytokines and the
pathogenesis of pre-eclampsia. Am J Reprod Immunol
1997;37(3):240-9.
25. Staff AC, Halvorsen B, Ranheim T, Henriksen T.
Elevated level of free 8-iso-prostaglandin F2alpha in
the decidua basalis of women with pre-eclampsia. Am J
Obstet Gynecol 1999;181(5 Pt 1):1211-5.
26. Beck JD, Offenbacher S. The association between
periodontal diseases and cardiovascular diseases: a state-
of-the-science review. Ann Periodontol 2001;6(1):9-15.
27. von Dadelszen P, Magee LA. Could an infectious trigger
explain the differential maternal response to the shared
placental pathology of pre-eclampsia and normotensive
intrauterine growth restriction? Acta Obstet Gynecol
Scand 2002;81(7):642-8.
n n n
273
 review article

Oral Lichen Planus: A Review on Current Medical

Management
D Anusha*, KT Magesh**, T Elangovan†, Yakob Martin‡

Abstract
Lichen planus is a chronic inflammatory mucocutaneous disease of unknown etiology. The prevalence of lichen planus is
unknown, but it is estimated to occur in <1% of the population. It is thought to be significantly less frequent than the
exclusive oral lichen planus (OLP) that affect approximately 1-2% of the population. Malignant transformation of OLP has
been reported in a number of studies and the actual overall frequency varies between 0.3-3%. There are no effective means
to predict or prevent such malignant transformation. The aim of treatment of OLP is to eliminate mucosal erythema and
ulceration, alleviate symptoms and reduce risk of malignant transformation. The main objective of this paper is to review the
current literature regarding the treatment of OLP.

Key words: Oral lichen planus, autoimmune, corticosteroids, stress

L
ichen planus is an inflammatory mucocutaneous
condition which most commonly affects
middle-aged adults of both sexes, with a slight
predominance in women. Although the etiology has
not been fully elucidated, an immunologically-induced
degeneration of the basal cell layer has been suggested.
The mechanism of basal cell damage is related to
cell-mediated immune process involving Langerhans
cells, T lymphocytes and macrophages. In contrast to
cutaneous lichen planus in which the clinical course
is often mild and resolve, mucosal oral lichen planus
(OLP) tends to follow a chronic course, rarely undergo
spontaneous remission, are potentially premalignant
and are frequently associated with morbidity.
Existing data suggest that OLP is a T-cell mediated
autoimmune disease in which autocytotoxic CD8+
T cells activate apoptosis of oral epithelial cells.1
OLP can be divided into six clinical types namely
reticular, papular, plaque-like, erosive, atrophic and
bullous.2 The reticular, papular and plaque-like forms
are usually painless and appear clinically as white
keratotic lesions. The erosive, atrophic and bullous
forms are often associated with burning sensation and
pain. Less than 5% of OLP patients who do not use
tobacco products develop oral squamous cell carcinoma,
most frequently in atrophic, erosive and plaque lesions.
The cause of increased oral cancer risk in OLP patients
is still unknown, the possible mechanism could be that
the affected oral mucosa may be compromised to the
extent of being more sensitive to exogenous mutagens;
alternatively the chronic inflammatory response and
simultaneous epithelial wound healing response in
OLP may increase the likelihood of cancer forming
gene mutations.3 The management of OLP is primarily
aimed at alleviating the symptoms, avoiding the
possible contributing factors and reducing the chances
of malignant transformation. The various modalities
of medical management, their applications, advantages
and disadvantages are discussed in detail.

*Assistant Professor Drugs/regimen used to treat OLP include:

Dept. of Pharmacology, Sri Ramachandra University, Porur, Chennai l Corticosteroids
**Professor
†
Reader l Retinoids
‡
Senior Lecturer
Dept. of Oral and Maxillofacial Pathology l Immunosuppressants
SRM Kattankulathur Dental College, SRM University
Address for correspondence l Phototherapy
Dr D Anusha
Assistant Professor
l Antifungal drugs
Dept. of Pharmacology l Other modalities
Sri Ramachandra University, Porur, Chennai
E-mail: ktmagesh@yahoo.com l Stress management

274 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


Corticosteroids
These agents have profound anti-inflammatory
properties, they induce varied metabolic effects,
modify the body’s immune response to diverse
stimuli and decreases inflammation by reversing the
increased capillary permeability and by suppressing
polymorphonuclear neutrophils (PMN) activity. They
are available in both systemic and topical forms.
Steroids in ointment form reduce pruritus in cutaneous
lichen planus, but they have not been proven to induce
remission.3
Topical Corticosteroids
Several topical agents have been employed in the
management of OLP by different authors with varying
degree of success.
Betamethasone is one of the most widely used topical
corticosteroid. In a study by Malhotra et al,4 it was
shown that betamethasone oral therapy improves the
clinical outcome in patients with moderate-to-severe
OLP, and its efficacy was comparable with that of
topical triamcinolone acetonide. It should be used in
pediatrics with extreme caution since children have a
larger skin surface area to body weight ratio and less
developed, thinner skin, which may result in greater
amounts of topical steroid being absorbed compared
with adults. For OLP, the gel has to be applied to the
affected area q 4-6 hour for 2-3 months.
Mometasone is a potent synthetic glucocorticoid and
has demonstrated a greater anti-inflammatory activity
and longer duration of action than betamethasone with
less side effects. To avoid the difficulty of application of
topical corticosteroids in the oral cavity, to increase the
ability to reach posterior areas and to cover extensive
and multiple areas, mometasone furoate 0.1% is used
in new form as microemulsion mouth wash (5 ml for
5 minutes 3 times a day). It is safe and effective in the
treatment of erosive-ulcerative OLP.2
Carrozzo and Gandolfo in their study5 have shown
topical clobetasol to be successful in 50-65% of
patients, bringing about total reduction of symptoms,
in comparison with other topical steroids. Thongprasom
et al in their 2-year clinical evaluation follow-up6 have
shown that topical fluocinolone acetonide in either
orabase or solution form can produce improved results
in the management of OLP.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Review Article
Topical steroids unlike systemic steroids do not cause
adrenal suppression even if administered for a long
time. Patients are instructed to apply a small amount
of the drug on the lesional area, abstain from speaking
or eating for about an hour and then to rinse the
mouth thereafter to prevent systemic absorption;
the only adverse effect could be the occurence of
pseudomembranous candidiasis which can be prevented
by concomitant use of antifungal gels or chlorhexidine
mouthwash.7
Systemic Corticosteroids
Indicated at high dose (1.5-2 mg/kg/day) for
patients with recalcitrant severe erosive atrophic OLP
where topical approaches have failed or for diffuse
mucocutaneous involvement. Systemic triamcinolone
available as parental injections has been reported to be
effective. Oral lesions can be treated with intralesional
injection of 5-10 mg/ml. Systemic prednisone
also proved to be very effective for severe OLP. It
should be administered for adult with dosage of
30-60 mg/day PO for 4-6 weeks followed by gradual
taper.8 For pediatric purpose 4-5 mg/m2/dday PO;
alternatively, 0.05-2 mg/kg PO divided b.i.d/q.i.d and
should be tapered over two weeks as the symptoms
resolve. Systemic steroids are contraindicated in
hepatitis C virus (HCV)-related lichen planus as it
increases HCV viremia leading to a worsening of liver
damage.9
Retinoids
Retinoids are a class of chemical compounds that are
related chemically to vitamin A and are used in medicine
primarily due to the way they regulate epithelial
cell growth. These agents regulate cell proliferation
and differentiation, growth of bone tissues, immune
function and activation of tumor suppressor genes.
Drug isotretinoin, a first-generation retinoid is used as
an oral agent to treat serious dermatologic conditions.
It is a synthetic 13-cis isomer of the naturally occurring
tretinoin (trans-retinoic acid). Both agents are
structurally-related to vitamin A. It decreases sebaceous
gland size and sebum production and inhibit sebaceous
gland differentiation and abnormal keratinization.
Topical tretinoin 0.1% in an adhesive gel used
4 times a day for two months completely or partially
heals atrophic-erosive and reticular plaque lesions.
275
 Review Article
Both topically and systemically applied retinoids are
used as adjuvant therapy when steroids fail to be
effective.10
Toxicities that may occur with vitamin A are pseudotumor
cerebri or papilledema, it may reduce plasma levels
of carbamazepine, increases toxicity of methotrexate
(avoid concomitant use), interferes with effects of
microdose progestin minipill, coadministration with
alcohol may result in formation of etretinate, which has
much longer half-life than acitretin (>120 days) and it
also increases toxicity of phenytoin. Moreover, these
analogs may decrease night vision, cause inflammatory
bowel disease, may be associated with development of
hepatitis and pancreatitis and diabetic patients may
experience problems in controlling blood glucose.
The drug should be discontinued if rectal bleeding,
abdominal pain or severe diarrhea occurs. Drug should
be administered with extreme precaution in patients
with history of depression since the drug can induce
mood swings and depression.
Immunosuppressants
These agents modulate the immune system. It induces
a substantial decrease of T cells and a corresponding
reduction in activated CD25-positive cells and in
antigen presenting cells possibly by inhibition of
interferon-gamma production.
Cyclosporine mouthwash solutions have been effective
for OLP but seem to be no better than corticosteroids.11
Systemic treatment has been used for severe resistant
cutaneous disease, oral or ulcerative foot involvement
and lichen planopilaris of the scalp. Pediatric
population may require higher or more frequent
dosing because of accelerated clearance but should be
used with extreme caution. For adults 1-2 mg/kg/day
PO is the recommended starting dosage and if no
response in disease pattern, dosage can be increased
to 5 mg/kg/day. Renal and liver functions have to be
assessed before usage, since the drug is hepatotoxic
and nephrotoxic. IV use is reserved only for those
who cannot take PO. Other adverse effects include
hypertension, gingival enlargement, hyperkalemia,
hypomagnesemia, pancreatitis and paresthesia. Due
to the severe adverse effects and the oral lesions being
often chronic in nature, the usage is limited.
Drug tacrolimus has a powerful immunosuppressive
activities by inhibiting T-cell production of
276
proinflammatory cytokines. Topical application induce
a rapid improvement in OLP.12 Recent studies have
showed tacrolimus has an impact on cancer signaling
pathways such as MAPK and the P53 pathways. This
suspected causal relation ship and development of
squamous cell carcinoma suggest that carcinogenicity
go beyond immunosuppression.13
Levamisole is another effective immunomodulating
agent that can restore the normal phagocytic activity
of macrophages and neutrophills. Levamisole
monotherapy is effective for treating OLP patients who
are unable to use steroids and who had no response to
convetional treatment.14 Topical rapamycin (sirolimus)
impedes the response of interleukin-2 (IL-2), and thus
prevents T and B cell activation. Rapamycin has both
immunomodulatory and tumor inhibitory nature and
hence blocks malignant transformation of OLP to some
extent. In a study by Soria et al, 3-month application
of rapamycin showed complete remission in 57% and
partial remission in 30% of cases.15
Psoralen and Ultraviolet A (PUVA)
PUVA (psoralen + ultraviolet A) are photosensitising
agents found in plants. They are applied or taken
orally to sensitise the skin, before exposing the latter to
UVA. PUVA has been effectively used to treat several
dermatological conditions like eczema, psoriasis, mycosis
and vitiligo. Ultraviolet irradiation in combination
with psoralens is indicated in the treatment of OLP as
it reduces T suppressor cell function.
In a study by Gonzalez et al16 80% of the lichen planus
patients treated with PUVA showed positive response.
The major concern in using PUVA therapy is its
carcinogenic potential and its use in the premalignant
lesion like lichen planus, could theoretically increase
the risk of cancer. In India, photochemotherapy with
solar radiation (PUVASOL) has been found to be
effective and a cheaper alternative. Sharma and Mishra
in their study have shown PUVASOL therapy to be
more effective than other regimen,17 with nausea and
sunburn occurring as side effects in few cases.
Antifungal Agents
Topical antimycotic drugs-like griseofulvin and
amphotericin have shown good results in patients with
and candidiasis and OLP. It is used as an adjunctive
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

therapy along with steroids. Dexamethasone is given
in combination with nystatin, and clobetasol with
miconazole.18
Other Modalities
Adalimumab, infliximab, etanercept monoclonal antibody
(TNF antagonist), basiliximab (anti IL-2 receptor),
alefacept, efalizumab (LFA fusion proteins) with its anti
inflammatory activity have shown almost fully resolved
response but safety and efficacy is in trial.19
Aloe vera is a stem-less or very short-stemmed
succulent plant. There is some preliminary evidence
that Aloe vera extracts may be useful in the treatment
of wound, burn healing and minor skin infections. Aloe
vera extracts have also been used to produce symptomatic
relief and improve the quality-of-life in patients
with OLP.20
Hyaluronic acid is an anionic nonsulfated
glycosaminoglycan distributed widely througout
connective, epithelial and neural tissues and is a major
component of both the skin and cartilage. It appears to
be of some benefit in the management of erosive lichen
planus but its action is not long-lasting. It also needs
frequent applications.21
Lasers have been used in patients whose condition
is unresponsive to topical corticosteroids. CO2 laser
evaporation can cause long-term remission of symptoms,
and may be the treatment of choice in patients suffering
from painful OLP.22 Diode laser treatment is effective
for plaque like-lichen planus lesions.23
Stress and Lichen Planus
Stress epidemic in modern life has been proved to trigger
inflammatory skin diseases. Skin and nervous system
develop side by side in ectoderm of fetus and remain
intimately interconnected through the cutaneous
sensory hormone. Skin is the largest sense organ of
body and vital to protection and health. Significant
psychosomatic or behavior component may lead to
skin disorders. Relaxation, meditation and hypnosis
have positive impact on many cutaneous diseases and
helps to calm and rebalance the inflammatory response
which can ameliorate inflammatory skin disorders.
Breath relaxation in traditional yoga with slow and
deepen breathing over rapid and shallow one, and
slower diaphragmatic abdominal breathing improve
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Review Article
psycshostomatic aspects of skin disorders. Hypnosis
is the intentional inducing, deepening, maintenance
and termination of trance state for a specific purpose.
It promotes healing, regulates blood flow and other
autonomous function not usually under conscious
control.24
Summary and Conclusion
The management of OLP should begin by taking
proper history and clinical examination. Elimination
of any form of irritants-like maloccluded teeth, ill-
fitting dentures, amalgam fillings should be removed.
Biopsy should be done to confirm the diagnosis. After
establishment of diagnosis topical corticosteroid in
an adhesive medium is the first drug of choice. For
recalcitrant lesions systemic corticosteroid could be
used. In steroid unresponsive cases immunosuppresants-
like cyclosporines and tacrolimus should be considered.
Topical Antimyotic drugs should be used in patients
with candidiasis and OLP. Both topically and
systemically applied retinoids can be considered when
steroids and immunosuppresants fail to be effective.
CO2 laser evaporation can also be considered when
the lesions fail to respond for systemic and topical
therapies. One should not forget the relationship
of stress and inflammatory skin diseases. Regular
relaxation exercises, meditation and hypnosis help to
calm and rebalance inflammatory response which can
ameliorate inflammatory skin disorders.
References
1. Sugerman PB, Savage NW, Walsh LJ, Zhao ZZ, Zhou
XJ, Khan A, et al. The pathogenesis of oral lichen planus.
Crit Rev Oral Biol Med 2002;13(4):350-65.
2. Aguirre JM, Bagán JV, Rodriguez C, Jimenez Y,
Martínez-Conde R, Díaz de Rojas F, et al. Efficay of
mometasone furoate microemulsion in the treatment of
erosive-ulcerative oral lichen planus: pilot study. J Oral
Pathol Med 2004;33(7):381-5.
3. Sugerman PB, Savage NW. Oral lichen planus:
causes, diagnosis and management. Aust Dent J
2002;47(4):290‑7.
4. Malhotra AK, Khaitan BK, Sethuraman G, Sharma VK.
Betamethasone oral mini-pulse therapy compared with
topical triamcinolone acetonide (0.1%) paste in oral
lichen planus: a randomized comparative study. J Am
Acad Dermatol 2008;58(4):596-602.
5. Carrozzo M, Gandolfo S. The management of oral lichen
planus. Oral Dis 1999;5(3):196-205.
277
 Review Article
6. Thongprasom K, Leuengvisut P, Wongwatanakij A,
Boonjatturus C. Clinical evaluation in treatment of oral
lichen planus with topical fluocinolone acetonide: a
2-year follow up. J Oral Pathol Med 2003:32(6):
315‑22.
7. Lodi G, Tarozzi M, Sardella A, Demarosi F, Canegallo L,
Di Benedetto D, et al. Miconazole as adjuvant therapy
of oral lichen planus: a double-blind randomized control
trial. Br J Dermatol 2007;156(6):1336-41.
8. Carbone M, Gross E, Carrozzo M, Castellano S,
Conrotto D, Broccoletti R, et al. Systemic and topical
corticosteroid treatment of oral lichen planus: a
comparative study with long-term follow-up. J Oral
Pathol Med 2003;32(6):323-9.
9. Bechade D, Oui B, Mayet F, Trouette H, Schouler L,
Jouglen J, et al Appearance of hepatitis C virus replication
and increase in serum aminotransferase levels after
corticoid therapy of presumed autoimmune hepatitis. 2
cases. Gastroenterol Clin Biol 1996;20(8-9):696-9.
10. Camisa C, Allen CM. Treatment of oral erosive lichen
planus with systemic isoretinoin. Oral Surg Oral Med
Oral Pathol 1986;62(4):393-6.
11. Conrotto D, Carbone M, Caorrozzo M, Arduino­ P,
Broccoletti R, Pentenero M, et al. Ciclosporin vs.
clobetasol in the topical management of atrophic and
erosive oral lichen planus: a double-blind randomized
controlled trial. Br J Dermatol 2006;154(1):139-45.
12. Shichinohe R, Shibaki A, Nishie W, Tateishi Y,
Shimizu H. Successful treatment of severe recalcitrant
erosive oral lichen planus with topical tacrolimus. J Eur
Acad Dermatol Venereol 2006;20(1):66-8.
13. Becker JC, Houben R, Vetter CS, Brocker EB. The
carcinogenic potential of tacrolimus ointment beyond
immune suppression: a hypothesis creating case report.
BMC Cancer 2006;6:7.
14. Won TH, Park SY, Kim BS, Seo PS, Park SD. Levamisole
278
monotherapy for oral lichen planus. Ann Dermatol
2009;21(3):250-4.
15. Soria A, Agbo-Godeau S, Taieb A, Francés C. Treatment
of refractory oral erosive lichen planus with topical
rapamycin: 7 cases. Dermatology 2009;218(1):22-5.
16. Gonzalez E, Momtaz-T K, Freedman S. Bilateral
comparison of generalized lichen planus treated with
psoralens and ultraviolet A. J Am Acad Dermatol
1984;10(6):958-61.
17. Sharma L, Mishra MK. A comparative study of
PUVASOL therapy in lichen planus. Indian J Dermatol
Venereol Leprol 2003;69(3):212-3.
18. Thongprasom K, Carrozzo M, Furness S, Lodi G.
Interventions for treating oral lichen planus. Cochrane
Database Syst Rev 2011;(7):CD001168.
19. Chao TJ. Adalimumab in the management of cutaneous
and oral lichen planus. Cutis 2009;84(6):325-8.
20. Choonhakarn C, Busaracome P, Sripanidkulchai B,
Sarakarn P. The efficacy of aloe vera gel in the treatment
of oral lichen planus: a randomized controlled trial. Br J
Dermatol 2008;158(3):573-7.
21. Nolan A, Badminton J, Maguire J, Seymour RA.
The efficacy of topical hyaluronic acid in the
management of oral lichen planus. J Oral Pathol Med
2009;38(3):299‑303.
22. van der Hem PS, Egges M, van der Wal JE, Roodenburg
JL. CO2 laser evaporation of oral lichen planus. Int J
Oral Maxillofac Surg 2008;37(7):630-3.
23. Sivolella S, Berengo M, Cernuschi S, Valente M. Diode
laser treatment is effective for plaque-like lichen planus
of the tongue: a case report. Lasers Med Sci 2011 Jul 31.
[Epub ahead of print].
24. Shenefelt PD. Relaxation, meditation, and hypnosis
for skin disorders and procedures. In: Mind-Body and
Relaxation Research Focus. deLuca BN, (Ed.), Nova
Science Publishers: Hauppauge, NY 2008:p45-63.
n n n
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 Review Article

Role of Gene in Palate Formation

Subrata Sarkar*, Soumyabrata Sarkar**, Gargee Maitra†

Abstract
Genes are the ultramicroscopic structure of DNA. Genes and their products i.e. enzymes, control various metabolic processes.
There are two types of genes: Structural genes and control or regulatory genes. Without the help of the genes, palate formation
cannot take place.

Key words: Palate formation, genes

P
alate, a natural bony separator, is a part of tongue. After neural connection with hyoglossal and
orofacial structure that separates the oral cavity hypoglossal nerves, the downward pulling of tongue
and the nasal cavity. Palate is divided into two takes place. At that time palatal shelves transposition
parts: Anterior and posterior. The anterior part is made occurs as a result of which fusion of 2 ‘L’ shaped
up of bony structure and the posterior part is made up palatine processes takes place. During this period
of soft tissue structures.1-4 At one stage of development, premaxilla and the two palatine processes join together
the oral cavity communicates with the nasal cavity. and ultimately palate forms.5-7,10
According to anatomists development of palate occurs l The anterior three-fourth of the mesodermal
as follows: partition becomes cartilaginous and helps to form
the hard palate.
l A partition grows backward from the frontonasal
process to meet the buccopharyngeal membrane. l Posterior one-fourth forms the fibrous part of the
This partition is called the bucconasal membrane soft palate. All muscles of the soft palate migrate
(or the primitive palate), the anterior part of which from the sixth arch myotome except the tensor
only persists to form the premaxilla. palate which comes from the first arch myotome
(Figs. A-E).
l Horizontal process, one on either side, grows from
the maxillary process of the mandibular arch to Anatomists have described the time schedule of the
form the definitive palate. These two horizontal formation of various structures as shown below:
processes cannot meet the premaxilla due to the
position of the tongue. Structures Time (intrauterine period)
At this stage, the entire oral cavity is filled up by the Stomodium 3rd week
tongue. During 7th week of intrauterine period, two Frontal process 4th week
tubercles develop in the lingual side of mandible i.e.
Mandibular process 5th week
genial tubercles. From here, the genioglossus and
geniohyoid muscles develop and then attach with the Maxillary process 5.5th week
Lateral nasal process 6th week
*Professor and Head Globular process 7th week
Dept. of Pedodontics and Preventive Dentistry
**Senior Lecturer Face formation 8th week
Dept. of Oral Diagnosis, Oral Medicine and Oral Radiology
†
Intern, Dept. of Pedodontics and Preventive Dentistry
GNIDSR, Kolkata Various genetic engineers have suggested that genes
Address for correspondence play an important role in palate formation. According
Dr Subrata Sarkar
Professor and Head to them genes are of two types:
Dept. of Pedodontics and Preventive Dentistry
GNIDSR, 114/F, Nilgung Road, Panihati, Sodepur, Kolkata -700 114 l Structural genes, which synthesize specific protein
E-mail: drssarkar44@yahoo.com molecule

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 279

 Review Article

A
Lateral nasal
process
Medial nasal
process
Maxillary process
Area of secondary
palate

Figure A. At the completion of primary palate formation.

B C

Primary palate
Primary palate

Palatal shelves
Palatal shelves after elevation

Figure B. Before elevation of palatal Figure C. Shelves during elevation.

shelves.

D E

Incisive foramen

Point of incisive Odontogenic

foramen epithelium

Line of fusion
Point of initial
fusion

Figure D. Initial fusion of the Figure E. Secondary palate after

shelves. fusion.

From Contemporary Orthodontics, 2008 edition, Proffit R. William, Elsevier.

280 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

 Review Article

l Control or regulatory genes, which regulate

the synthesis and activity of structural gene and Retinoid acid Frontonasal process
also promote or inhibit steps of transcription of FGF-8
SHH Stomodium
structural gene and protein.8,9 FGF-8 Maxillary process

The frontonasal process is formed by synthesis of FGF-8 Mandibular process

retinoid acid which is present in ectoderm. Retinoid 2nd branchial arch
acid helps fibroblast growth factor-8 (FGF-8) and 3rd branchial arch
Sonic hedgehog (SHH) gene to stimulate neural crest
cell and helps to form frontonasal process. During Figure F. Early development of face.
4.5-5th weeks of intrauterine period, the proliferation
of frontonasal process takes place. During this period
maxillary, mandibular, medial and lateral nasal processes -8 Eye
start growing (Figs. F-H). -1 Medial nasal process
Lateral nasal process
It is clear that without the help of genes, no growth -8 Maxillary process
Stomodium
and development of various facial processes and sutural -1
-2 Mandibular process
growth of palate can occur. At the time of suture
morphogenesis (before birth), the following genes
become very active:
Figure G. Development of medial and dateral nasal
l MSX-2 processes.
l FGF-1
l TGF-2
l TGF-3
SHH Nasal septum
These genes help in sutural growth of palate. Thus Nasal cavity
EGF
formation of palate along with formation of face Lateral palatine process
MAX-1 Oral cavity
occurs. Tongue
BMP-4
Various anatomists and dental scientists have observed BMP-2

improper formation and fusion of palatine processes

as a result of which various types of cleft palate are Figure H. Various genes help in palate growth.
formed.
The functions of various genes are given below:
l FGF-8 is the molecular centre of maxillary The following genes are required for palate formation:
processes. l Retinoid acid
l MSX-1 (Muscle segment homeobox gene 1) gene l FGF-8
helps to grow mesenchyme of all facial processes. l SHH
l OTX-2 gene is the precursor of first branchial l MSX-1
arch.
l OTX-2
l FGF-2 and FGF-4 are signaling centers of
l DLX-1 and DLX-2
epithelium, which help in the growth of
mesenchyme. Conclusion
l DLX-1 and DLX-2 are important genes present in Palate is the bony separator between oral cavity
maxillary process. and nasal cavity. Palate formation takes place in the

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 281

 Review Article
intrauterine period, which is formed by premaxilla and
two palatal processes of maxilla (right and left). Dental
anatomists and general anatomists have observed that
transposition of palatine shelves has a major role in
palate formation.
Genetic engineers have stated that different genes
have important role in formation of palate along with
fusion of bones. Improper formation and fusion causes
various types of palatal clefts.
References
1. Peter WL, Gray’s Anatomy. 38th edition, Churchill
Livingstone, 200;1688-1691.
2. Mahindra AK, Anand’s Human Anatomy. 1st edition,
The Arora Medical Book Publisher’s Pvt. Ltd, 2002:
279.
3. Chaurasia BD. Chaurasia’s Human Anatomy. 3rd edition,
282
CBS Publishers and Distributors 2002:178-9, 313.
4. Singh I. Human Embriology. 7th edition, Macmillan,
2001:147.
5. Antonio N, Ten Cate’s Oral Histology, Development,
Structure and Function. 4th edition, Mosby, Page No:
22, 24-27,418,424.
6. Bhaskar SN Orban’s Oral Histology and Embryology.
11th edition, Elsevier, 2004:283-9.
7. Avery K James. Oral Development and Histology, 3rd
edition, Thieme, 2007;26, 28-31, 252-4, 417.
8. Pal GP, Niladri M, Genetics In Dentistry. 1st edition,
Jaypee Brothers, New Delhi, 2010:120-5.
9. Peter T & Ellard Sian, Emery’s Elements of Medical
Genetics, 13th edition, 2007, Churchill Livingstone,
Page No: 139, 238, 246, 393, 410.
10. Stewart RE, Prescott GH. Orofacial Genetics. C.V
Mosby Company, 1976:475-7, 494.
n n n
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 clinical practice

A Technique to Locate Implants during Second Stage

Surgery
CJ Venkatakrishnan*, M Narasimman**

Abstract
This article describes a technique of uncovering implants during the second stage surgery. This technique was done with a
surgical stent which is used during the implant placement.

Key words: Implant placement, surgical stent

D
ental implants have been considered as a l Using the diagnostic waxup a surgical stent was
standard of treatment for partially edentulous made.
and completely edentulous patients for l Under local anesthesia full thickness flap was
several decades. The accurate placement of implants is elevated and the endosteal implant is placed using
done with the help of a surgical stent. Various surgical the surgical stent.
stents have been used in the literature.1-10 The implant l After three months of healing period the surgical
placement can be a single or two stage procedure. In stent was repositioned (Fig. 1).
single stage procedure the implant is accessible in the
oral cavity by placing the healing cap or prosthesis or
the implant design itself. In two stage procedure the
first stage will be placement of implant and the second
stage will be uncovering the implant by opening the
mucoperiosteal flap.
The implant is uncovered after a healing period of
three months in the conventional method. In this two
stage procedure the second stage generally requires
elevation of mucoperiosteal flap followed by suture
placement. This conventional procedure requires
suture placement and an extended period of healing
time. This article describes a technique to locate the
implants during second stage surgery by the use of Figure 1. Repositioning of the surgical stent.
surgical stent which does not need suture placement
and requires less healing time.

Technique
l Diagnostic waxup was made using the diagnostic
impression.

*Professor and Head

**Senior Lecturer
Dept. of Prosthodontics and Crown and Bridge
Tagore Dental College and Hospital, Chennai
Address for correspondence
Dr CJ Venkatakrishnan
Dept. of Prosthodontics and Crown and Bridge
Tagore Dental College and Hospital, Chennai
E-mail: drvenkat93@gmail.com Figure 2. Implant site marked with periodontal probe.

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 283

 CLINICAL practice
Figure 3. Mucoperiosteum removed.
Figure 4. Use of rotary punch.
l Periodontal probe was used to mark the implant
site through surgical stent access hole (Fig. 2).
l A rotary punch was used (Fig. 3) to remove the
mucoperiosteam overlying the cover screw of the
implant (Fig. 4).
l Cover screw was removed and the suitable healing
cap was placed (Fig. 5).
Discussion
This technique eliminates the need of full thickness flap
elevation, reducing the healing period, thus increases
the patient comfort during and after the second stage
surgery. The implant or abutment level impression
can be made immediately after this technique. This
technique can be used in single and multiple implants
and it will be more ideal in uncovering implants for
mandibular retained over denture. ‘This technique
284
Figure 5. Cover screw removed.
Figure 6. Healing cap placed.
cannot be used if, there is any change in the remaining
dentition or prosthesis after the surgical stent has been
fabricated, since the stent cannot be repositioned.’
References
1. Ganz SD. Techniques for the use of CT imaging for the
fabrication of surgical guides. Atlas Oral Maxillofac Surg
Clin North Am 2006;14(1):75-97.
2. Marchack CB. An immediately loaded CAD/CAM-
guided definitive prosthesis: a clinical report. J Prosthet
Dent 2005;93(1):8-12.
3. van Steenberghe D, Glauser R, Blomback U,
Andersson M, Schutyser F, Pettersson A. A computed
tomographic scan-derived customized surgical
template and fixed prosthesis for flapless surgery and
immediate loading of implants in fully edentulous
maxillae: a prospective multicenter study. Clin
Implant Dent Relat Res 2005;7 Suppl 1:S111-20.
Continued page 287...
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 Case report

Extensive Nasopalatine Duct Cyst Causing

Nasolabial Protrusion
AR Tariq Salamm*, Vijay Parthiban*, Gopinath**, R Karpagam†

Abstract
The nasopalatine duct cyst (NPDC), also known as nasopalatine cyst or elevator shaft cyst, is a developmental, non-neoplastic
cyst that is considered to be the most common nonodontogenic cyst. It is one of many pathologic processes that may occur
within the jawbones, but it is unique in that it develops in only a single location, in the midline anterior maxilla. Nasopalatine
cysts are usually asymptomatic, but may sometimes produce an elevation in the anterior portion of the palate, and are
discovered incidentally during routine radiological examination. Radiographically, it appears as a heart-shaped radiolucency.
In this article, we report a case of nasopalatine duct cyst along with a review of its epidemiology, etiology, diagnostic
work-up, differential diagnosis and therapeutic strategies.

Key words: Elevator shaft cyst, non-neoplastic, nonodontogenic cyst

T
he nasopalatine cyst was first described by
Meyer in 1914.1 It is believed to arise from
remnants of nasopalatine duct, an embryologic
structure connecting the oral and nasal cavities in the
area of incisive canal.2 It is one of the most common
nonodontogenic cysts,3 comprising 10% of jaw cysts
and occurring in one of every 100 persons with slight
male predilection, the mean age being 42.5 years.4
These cysts are usually asymptomatic, unless they are
secondarily infected.27 The most commonly reported
clinical symptom, if at all present, is swelling in the
anterior part of the palate. These entities are usually
treated by surgical enucleation.5,25
Case Report
A 55-year-old female patient reported to the outpatient
department with a complaint of swelling in the upper
lip for the past three months. The patient noted the
swelling along the upper lip, which gradually increased
to the present size. The swelling was associated with
a dull aching intermittent pain. Extraorally, there
was a swelling in the anterior part of the upper lip
measuring about 2 × 2 cm, causing the floor of the
nose to bulge. There were no palpable lymph nodes
present. Intraoral examination revealed a well-defined
oval-shaped bluish swelling measuring approximately
2 × 2 cm, located along the labial vestibule. The swelling
was fluctuant and nontender. The teeth in relation, 12
and 21, were mobile with severe periodontal problems.
Intraoral periapical and occlusal radiographs revealed a
well-defined radiolucency located anteriorly, between
the apical third of roots of maxillary central incisors
with an impacted supernumerary tooth (Fig. 1). The
radiolucency extending laterally along the apex of the
roots of the lateral incisors, then extending superiorly
and medially to give ‘heart-shaped’ radiolucency, which
is the characteristic feature of a nasopalatine cyst. The
periphery of the lesion was well-defined. There was an
evidence of resorption and displacement of the tooth
roots. The teeth in relation to 11 and 21 were extracted
one week prior to surgery.
Treatment Done

On the basis of the clinical and radiographic findings,

*Dept. of Oral Surgery a provisional diagnosis of nasopalatine cyst was made
**Dept. of Periodontia
Chettinad Dental College and Research Institute, Chennai (Figs. 2 and 3). Cyst was enucleated along with the
†
Dental Surgeon
Address for correspondence impacted supernumerary teeth and the specimen with
Dr R Karpagam the mesiodens (Fig. 5) was sent for histopathological
Dental Surgeon
E-mail: mailkarpu@yahoo.com examination.

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 285

 Case Report
Figure 1. OPG showing a ‘heart-shaped’ radiolucency with
a supernumerary teeth.
Figure 2. Lesion exposed.
Histopatholog ical Examination
On microscopic examination, the cyst was lined with a
cuboidal epithelium and the cyst wall contained small
muscular arteries lined by endothelial cells, veins;
features of hemorrhage were also seen.
Differential Diagnosis
Periapical cyst, dentigerous cyst, adenomatoid
odontogenic tumor
Discussion
The nasopalatine duct cyst (NPDC) is a developmental,
non-neoplastic cyst. It is the most common of the
nonodontogenic cysts of the oral cavity, occurring in
about 1% of population.8,9,13 Most studies show a higher
incidence of NPDC among males than females with
286
Figure 3. After enucleation.
Figure 4. Closure.
the ratio being 1.7:15. The age distribution is broad,
with most cases being discovered in the fourth through
sixth decade. In spite of being a developmental cyst, it
is rarely seen in the first decade of life. Nasopalatine
cysts are believed to develop from epithelial remnants
of paired embryonic nasopalatine ducts within the
incisive canal.8,9,13 The stimulus for cyst formation
from the epithelial remnants of the nasopalatine canal
is uncertain, although trauma and bacterial infection
are thought to have a role. It has also been suggested
that the mucous glands within the lining may cause
cyst formation as a result of mucin secretion.18,24
Most of these cysts are asymptomatic or cause such
minor symptoms that they are tolerated for very
long periods. Usually patients complain of a small
asymptomatic swelling just posterior to palatine
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

Figure 5. Excised lesion with the supernumerary tooth.
Figure 6.
papilla. If the cyst is near the surface, the swelling will
be fluctuant and blue. The deeper cyst is covered with
normal appearing mucosa, which may be ulcerated
due to masticatory trauma.11,12 In some cases, the
swelling may occur in the midline on the labial aspect
of the alveolar ridge and in some patients through and
through fluctuation can be palpated between the labial
and palatal swellings. The cyst may produce bulging
of the floor of nose.15 In various cases, the swelling
is associated with a burning sensation, numbness over
the palatal mucosa and pain as a result of pressure
on the nasopalatine nerves. Various combinations of
swelling, discharge and pain may occur.10,14 Discharge
may be mucoid, in which case the patients describe
a salty taste, or it may be purulent and the patient
may complain of a foul taste. A cyst with a mesiodens
or bilateral mesiodens and displacement of teeth as in
this case is a rare finding.16
Even though definitive diagnosis of a nasopalatine cyst
is more easily made on plain films, other advanced
imaging modalities such as computed tomography
(CT) and magnetic resonance imaging (MRI) are being
used to differentiate this entity from other lesions.21
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Case Report
CT findings of a nasopalatine cyst reveal a midline
location, smooth expansion with sclerotic margins.
As the incisive canal and foramen may normally vary
greatly in size, the clinician may have some difficulty
in distinguishing between a large incisive foramen and
a small asymptomatic incisive canal cyst on the basis of
radiographic evidence alone.26 Some clinicians follow
the rule of thumb that radiolucencies of the incisive
canal measuring <0.6 cm in diameter should not be
considered cystic in the absence of other symptoms.20,22
A radicular cyst or a granuloma associated with the
central incisor should also be considered in differential
diagnosis as these entities may be similar in appearance
to an asymmetric NPDC.17,23 The presence or absence
of the lamina dura and enlargement of the periodontal
ligament space around the apex of the central incisor
indicates an inflammatory lesion. NPDC and radicular
cysts can also be differentiated by taking a second
periapical view at a different horizontal angle, which
show an altered position of the image of a NPDC,
whereas a radicular cyst should remain centered
about the apex of involved tooth. A vitality test of
the regional teeth may also be useful. Nasopalatine
cysts are usually treated by enucleation.7,19 In case
of large cysts, marsupialization may be considered
before definitive enucleation. Recurrence rate ranges
from 0% to 11%.
Conclusions
Nasopalatine duct cysts occur in approximately 1%
of the population with mean age of 42.5 years. The
lesions may be asymptomatic or may manifest as
swelling, pain and drainage from the hard palate. A
well-circumscribed, round, ovoid or heart-shaped
radiolucency is seen on radiograph. Enucleation is the
preferred treatment with low recurrence rates.
References
1. Allard RH, van der Kwast WA, van der Waal I.
Nasopalatine duct cyst. Review of the literature and
report of 22 cases. Int J Oral Surg 1981;10(6):447-61.
2. Curtin HD, Wolfe P, Gallia L, May M. Unusually large
nasopalatine cyst: CT findings. J Comput Assist Tomogr
1984;8(1):139-42.
3. Damm DD, Lu RJ, Rhoton RC. Concurrent nasopalatine
duct cyst and bilateral mesiodens. Oral Surg Oral Med
Oral Pathol 1988;65(2):264-5.
287
 Case Report
4. Elliott KA, Franzese CB, Pitman KT. Diagnosis and
surgical management of nasopalatine duct cysts.
Laryngoscope 2004;114(8):1336-40.
5. Hegde RJ, Shetty R. Nasopalatine duct cyst. J Indian
Soc Pedod Prev Dent 2006;24 Suppl 1:S31-2.
6. Ely N, Sheehy EC, McDonald F. Nasopalatine duct cyst:
a case report. Int J Paediatr Dent 2001;11(2):135-7.
7. Gnanasekhar JD, Walvekar SV, al-Kandari AM,
al-Duwairi Y. Misdiagnosis and mismanagement of a
nasopalatine duct cyst and its corrective therapy. A case
report. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1995;80(4):465-70.
8. Harris IR, Brown JE. Application of cross-sectional
imaging in the differential diagnosis of apical radiolucency.
Int Endod J 1997;30(4):288-90.
9. Herráez-Vilas JM, Gay-Escoda C, Berini-Aytés L. Quiste
del conductonasopalatino. Revisión de la literatura y
aportación de 14 casos. Rev Eur Odonto-Estomatol
1994;6(4):231-6.
10. Hisatomi M, Asaumi J, Konouchi H, Shigehara H, Yanagi
Y, Kishi K. MR imaging of epithelial cysts of the oral and
maxillofacial region. Eur J Radiol 2003;48(2):178-82.
11. Hisatomi M, Asaumi J, Konouchi H, Matsuzaki H,
Kishi K. MR imaging of nasopalatine duct cysts. Eur J
Radiol 2001;39(2):73-6.
12. Kreidler JF, Raubenheimer EJ, van Heerden WF.
A retrospective analysis of 367 cystic lesions of the
jaw - the Ulm experience. J Craniomaxillofac Surg
1993;21(8):339-41.
13. Mermer RW, Rider CA, Cleveland DB. Nasopalatine
canal cyst: a rare sequelae of surgical rapid palatal
expansion. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 1995;80(6):620.
14. Moss HD, Hellstein JW, Johnson JD. Endodontic
considerations of the nasopalatine duct region. J Endod
2000;26(2):107-10.
15. Neville BW, Damm DD, Brock T. Odontogenic
keratocysts of the midline maxillary region. J Oral
Maxillofac Surg 1997;55(4):340-4.
16. Neville BW, Damm DD, Allen CM, Bouquot JE.
Oral and maxillofacial pathology. In: Developmental
288
defects of the oral and maxillofacial region. 2nd edition
Saunders 2005:p27-30.
17. Pevsner PH, Bast WG, Lumerman H, Pivawer G. CT
analysis of a complicated nasopalatine duct cyst. N Y
State Dent J 2000 Jun-Jul;66(6):18-20.
18. Regezi JA, Sciubba JJ, Jordan RCK. Oral pathology
clinical pathologic correlations. In: Cysts of the jaws and
neck.4th edition, Saunders 2003:p256-7.
19. Righini CA, Boubagra K, Bettega G, Verougstreate G,
Reyt E. Nasopalatine canal cyst: 4 cases and a review of
the literature. Ann Otolaryngol Chir Cervicofac 2004
Apr;121(2):115-9.
20. Robertson H, Palacios E. Nasopalatine duct cyst. Ear
Nose Throat J 2004;83(5):313.
21. Swanson KS, Kaugars GE, Gunsolley JC. Nasopalatine
duct cyst: an analysis of 334 cases. J Oral Maxillofac
Surg 1991;49(3):268-71.
22. Tanaka S, Iida S, Murakami S, Kishino M,
Yamada C, Okura M. Extensive nasopalatine duct cyst
causing nasolabial protrusion. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2008;106(4):e46-50.
23. Vasconcelos R, de Aguiar MF, Castro W, de Araújo
VC, Mesquita R. Retrospective analysis of 31 cases of
nasopalatine duct cyst. Oral Dis 1999;5(4):325-8.
24. Velasquez-Smith MT, Mason C, Coonar H, Bennett J.
A nasopalatine cyst in an 8-year-old child. Int J Paediatr
Dent 1999;9(2):123-7.
25. Wood NK, Goaz PW. Differential diagnosis of oral and
maxillofacial lesions. In: Interradicular radiolucencies.
5th edition Mosby 1997:p303-5.
26. White SC, Pharoah MJ. Oral radiology principles and
interpretation. In: Cyst of jaws. 5th edition, Mosby
2000:p400-1.
27. Yih WY, Krump JL. Odontogenic keratocyst in the
nasopalatine duct associated with mural cartilaginous
metaplasia. J Oral Maxillofac Surg 2005 Sep;63(9):
1382-4.
n n n
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 case report

Full Mouth Rehabilitation with Unilateral Distal Extension

Prosthesis Attached to Splinted Fixed Partial Denture
N Gopi Chander

Abstract
This article describes the design of a unilateral distal extension removable partial denture attached to a splinted fixed partial
denture (FPD) with a semi-precious attachment. The clinical results of the dentures used in selected situations are admirable,
however, it is emphasized that a unilateral denture is only an alternative rather than a routine.

Key words: Splinted fixed partial denture, unilateral denture

T
he clinical use of a unilateral removable
partial denture (RPD) is limited because of
its poor stability and retention.1,2 A regular
problem faced by the partially edentulous patients is
the intricacy of adapting to a removable prosthesis.
A unilateral prosthesis is always less stable, because it
lacks the effect of cross arch stabilization.3,4 There is
also an emotional component for some patients who
do not like that their teeth are removable. The stability
can be improved by re-basing the edentulous area of
the removable prosthesis on needed occasions. This
requires recall of patient for scheduled visits and it
may not create a high level of comfort and function
for many patients. Alternative treatments for partially
edentulous patients include a conventional cast partial
denture to an implant-supported prosthesis.5-10 These
procedures are not always acceptable treatment options
for the patient. The disadvantages of a implant-
supported prosthesis could be functional, economical
and biomechanical.11,12
An alternative reconstructive option that does not involve
complex procedures for the patient is combination
prosthesis with fixed and removal partial denture
connected with attachments. This prosthetic option,
in addition to the esthetics and functional advantage
Professor
Dept. of Prosthodontics
SRM Dental College, Ramapuram, Chennai
Address for correspondence
Dr N Gopi Chander
496, 3rd Main Road
TNHB Colony, Velachery, Chennai - 600 042
E-mail: drgopichander@gmail.com
of a fixed denture, gives a decreased compression of
the edentulous ridge and enhanced mastication and
phonetics. This clinical report describes the treatment
of a patient with this prosthetic solution of fixed
removable prosthesis with semi-precision attachment.
Clinical Report
A 75-year-old man was evaluated for treatment. His
chief complaint was missing teeth and he wanted a
stable retained prosthesis. The patient’s medical history
was evaluated and was found to be noncontributory.
The missing teeth were 14, 15, 16, 24, 25, 26, 27, 32, 34,
35, 44, 45, 46 Several treatment options were offered
to the patient: a removable partial denture, an implant-
supported prosthesis, combination of a fixed prosthesis
with RPD and combination denture with fixed and
removal prosthesis with attachments. After reviewing
the options, the patient accepted the latter treatment
option. Diagnostic models made with the primary
impression. The treatment plan was charted for fixed
prosthesis and the maxillary attachment denture.
Procedure
l Abutment teeth 11, 12, 13, 17, 21, 22, 23, 31, 33,
36, 37, 41, 42, 43, 47 were prepared for full veneer
metal ceramic retainers for mandibular fixed partial
denture and maxillary fixed-removal attachment
denture. Regular precautions of preparation were
followed.
l Conventional tissue management procedures were
pursued and single step putty reline impression was
made. Cast was made and the maxillary anterior

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 289

 Case Report

Figure 1. Preoperative. Figure 5. Buccal view of denture in occlusion.

Figure 2. Attachment for distal extension. Figure 6. Palatal view of denture in occlusion.

Figure 3. Patrix attached to the cast partial denture. Figure 7. Postoperative in occlusion.

Figure 4. Buccal view of denture in occlusion. Figure 8. Postoperative occlusal view.

290 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


Fixed partial denture (FPD) and mandibular FPD
were fabricated. Dalbo attachment was attached to
maxillary anterior FPD.
l Metal try-in of the coping was done to evaluate
the fit of the casting. Ceramic layering was done
on the metal frame work tried.
l The fabricated metal ceramic FPD was provisionally
cemented with the patrix attached to the casting and
picked up using putty impression for fabricating
the removal partial denture.
l Cast was made from the impression and the regular
fabrication of removal denture was done.
l Once the framework was fabricated, it was tried
on the patient; maxillo-mandibular relationship
was recorded, teeth arrangement was done and the
denture fabricated.
l Mandibular FPD was cemented with glass ionomer
cement. Maxillary FPD was cemented with glass
ionomer with the RPD. After the cement was set,
the RPD was separated and excess cement from all
areas was removed.
Discussion
For the patient described, the maxillary RPD was
connected to an FPD with an attachment system. The
disadvantages reportedly associated with RPD such as
patient discomfort, ill-fitting, loose prosthesis, decreased
phonetics and masticatory efficiency were avoided.13-15
The recommended procedure has several advantages
over the conventional prosthesis. The advantages of
attachment denture are beneficial and the limitation
of RPD are reduced. Patient comfort and psychology
are drastically improved. Being attachment prosthesis,
the RPD can be removed and maintained as a regular
denture. Added to this the laboratory procedures are
simple, and treatment is economical compared to the
more complex treatment options.16-19
The extracoronal precision attachments for RPDs are
recommended to this clinical situation because all teeth
were involved as primary and secondary abutments for
RPD tooth preparation. Splinting of maxillary teeth
was possible with single unit casting of all teeth, and
the partially edentulous teeth present close this splinted
FPD aided to attach semi-precision attachment.20-22
Extracoronal semi-precision attachments are easier to
insert and remove. It is also esthetic and can be used
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Case Report
for patients with limited manual dexterity, or when the
prosthesis has a difficult path of insertion and removal.
Extracoronal precision attachments are normally
resilient and allow free movement of the prosthesis to
distribute potentially destructive forces or loads away
from the abutments to supportive bone and tissue.23-26
Though limitations exist with the attachment system,
this Kennedy Class 2 partially edentulous situation
attached with fixed or removable prosthesis has greater
advantage clinically as discussed earlier.
Summary
This clinical report illustrates the option of achieving
encouraging results with a removable prosthesis
attached to a fixed prosthesis. The support of the RPD
and its connection with the fixed prosthesis generate
stability throughout masticatory activity and permit
a functional action similar to that involving a fixed
denture. The execution of the stress-director system
is effective and decreases the risk of loss of function.
Further long-term follow-up studies with a larger
patient population are needed to confirm the clinical
and biomechanical validity of the prosthetic solution
described in this clinical report.
References
1. Redford M, Drury TF, Kingman A, Brown LJ. Denture
use and the technical quality of dental prostheses among
persons 18-74 years of age: United States, 1988-1991.
J Dent Res 1996;75Spec No.:714-25.
2. Gunne HS. The effect of removable partial dentures on
mastication and dietary intake. Acta Odontol Scand
1985;43(5):269-78.
3. Bertram U. A clinical survey of removable partial dentures
after ten years usage. J Dent Res 1979;58 (Special Issue
A):IADR Abstr. No. 234.
4. Scott BJ, Maillou P. The distal extension base denture.
Dent Update 2003;30(3):139-44.
5. Rubel B, Hill EE. Unilateral semi-precision removable
partial denture utilizing Bredent VKS-SG attachment
system. N Y State Dent J 2009;75(4):36-8.
6. Preiskel HW. Precision attachments in dentistry. London:
Henry Kimpton, 1973:p337-9.
7. Ku YC, Shen YF, Chan CP. Extracoronal resilient
attachments in distal-extension removable partial
dentures. Quintessence Int 2000;31(5):311-7.
8. Goto Y, Brudvik JS. Custom precision attachment
housings for removable partial dentures. J Prosthet Dent
2002;88(1):100-2.
291
 Case Report
9. Marxkors R. Mastering the precision removable partial
denture. Part Two. Connection of partial dentures to the
abutment teeth. J Dent Technol 1997;14(2):24-30.
10. Donovan TE, Cho GC. Esthetic considerations
with removable partial dentures. J Calif Dent Assoc
2003;31(7):551-7.
11. Ohkubo C, Kobayashi M, Suzuki Y, Hosoi T. Effect of
implant support on distal-extension removable partial
dentures: in vivo assessment. Int J Oral Maxillofac
Implants 2008;23(6):1095-101.
12. Kuzmanovic DV, Payne AG, Purton DG. Distal
implants to modify the Kennedy classification of a
removable partial denture: a clinical report. J Prosthet
Dent 2004;92(1):8-11.
13. Aviv I, Ben-Ur Z, Cardash HS, Fatael H. RLS - the
lingually retained clasp assembly for distal extension
removable partial dentures. Quintessence Int
1990;21(3):221-3.
14. Owall B. Precision attachment-retained removable partial
dentures: Part 2. Long-term study of ball attachments.
Int J Prosthodont 1995;8(1):21-8.
15. Zinner ID, Pines MS, Markovits S, Neurohr FG
3rd. A stress-releasing intracoronal attachment for
extension base removable partial dentures. Gen Dent
1998;46(4):398‑402.
16. Zitzmann NU, Rohner U, Weiger R, Krastl G. When
to choose which retention element to use for removable
dental prostheses. Int J Prosthodont 2009;22(2):161-7.
Erratum in: Int J Prosthodont 2009;22(3):286.
17. Yamaga T, Soga K, Nokubi T. A new sectional partial
denture utilizing lock mechanism for an upper removable
partial denture. J Osaka Univ Dent Sch 1993;33:34-8.
...Continued from page 279
4. Lal K, White GS, Morea DN, Wright RF. Use
of stereolithographic templates for surgical and
prosthodontic implant planning and placement. Part I.
The concept. J Prosthodont 2006;15(1):51-8.
5. Lal K, White GS, Morea DN, Wright RF. Use
of stereolithographic templates for surgical and
prosthodontic implant planning and placement. Part II.
A clinical report. J Prosthodont 2006;15(2):117-22.
6. Simon H. Use of transitional implants to support a
surgical guide: enhancing the accuracy of implant
placement. J Prosthet Dent 2002;87(2):229-32.
7. Cehreli MC, Aslan Y, Sahin S. Bilaminar dual-purpose
292
18. Livaditis GJ. Repair with a surveyed cast clasp while
patient retains the partial denture. J Prosthet Dent
1997;77(6):624-9.
19. Brudvik JS, Palacios R. Lingual retention and the
elimination of the visible clasp arm. J Esthet Restor Dent
2007;19(5):247-54; discussion 255.
20. Lynch CD, Allen PF. The swing-lock denture: its use in
conventional removable partial denture prosthodontics.
Dent Update 2004;31(9):506-8.
21. Saito M, Miura Y, Notani K, Kawasaki T. Stress
distribution of abutments and base displacement
with precision attachment- and telescopic crown-
retained removable partial dentures. J Oral Rehabil
2003;30(5):482-7.
22. Grasso JE. A new removable partial denture clasp
assembly. J Prosthet Dent 1980;43(6):618-21.
23. Givan DA, Kolodney H Jr. Removable partial denture
design with a splint bar and precision attachments.
Compendium 1993;14(5):670, 672, 674-6; quiz 678.
24. Grageda E. Achieving an aesthetic anterior-posterior
rotational path partial denture: case report. Dent Today
2007;26(4):130, 132-5; quiz 135.
25. Colt SG, Millstein PL. A prefabricated semi-precision
intracoronal attachment for removable partial dentures:
the P.D. attachment. Quintessence Int Dent Dig
1979;10(11):19-24.
26. De Rossi A, Albuquerque RF Jr, Bezzon OL. Esthetic
options for the fabrication of removable partial dentures:
a clinical report. J Prosthet Dent 2001;86(5):465-7.
n n n
stent for placement of dental implants. J Prosthet Dent
2000;84(1):55-8.
8. Al-Harbi SA, Verrett RG. Fabrication of a stable surgical
template using staged tooth extraction for immediate
implant placement. J Prosthet Dent 2005;94(7):394-7.
9. Kuzmanovic DV, Waddell JN. Fabrication of a self-
retaining surgical template for surgical placement of
dental implants for the partially edentulous patient.
J Prosthet Dent 2005;93:95-6.
10. Meitner SW, Tallents RH. Surgical templates for
prosthetically guided implant placement. J Prosthet
Dent 2004;92:569-74.
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 case report

Ossifying Fibroma of Maxilla: A Case Report with

Review of Literature
V Sathyabama*, C Saravanan**, SS Sharma†, R Kamal Kanthan*

Abstract
Fibro-osseous lesions of bone have evolved over several decades to integrate two major entities: Fibrous dysplasia and ossifying
fibroma along with the other entities such as periapical dysplasia, osteitis deformans, hyperparathyroidism and Paget’s disease
with hypercementosis in the late stages. A case of a young adult male with maxillary ossifying fibroma measuring about
12 × 6 cm in the upper right quadrant is presented herein. The patient was managed surgically by a conservative intra-oral
approach preserving the median nasal base, orbital floor and the palatal shelf. The patient was later rehabilitated by a tooth-
supported removable dental prosthesis. A review of literature regarding the course, prognosis and the management of maxillary
cemento-ossifying fibroma is also discussed.

Key words: Fibro-osseous lesion, ossifying fibroma, odontogenic tumor, maxilla

O
ssifying fibroma of the maxilla is an
uncommon tumor. It is a well-circumscribed
tumor, which grows exponentially with
clear and defined margins. It occurs in middle-aged
adults with a marked predilection for females. Though
generally a benign tumor, it can explicitly present an
aggressive behavior.
In the early stages, the lesion is totally radiolucent.
Intermediate stages of the lesion exhibit mixed
radiolucent and radiopaque densities depending on
the amount of the calcified material. It can appear as
ground glass (similar to the pattern seen on fibrous
dysplasia), cotton wool, or present a flocculent
appearance (similar to large snowflakes). Cementum-
like structures called ‘cementicles’ (similar to those
seen on cemental dysplasia) can also be present.
Histopathologically, a large number of fibroblasts and
cementoblasts with flat elongated nuclei are present
within a network of interlacing collagen fibers. At the
later stages, the cementoblasts coalesce to present as
*Senior Lecturer
**Reader
†
Professor
Dept. of Oral and Maxillofacial Surgery
SRM Kattankulathur Dental College and Hospital
Potheri, Kancheepuram, Tamil Nadu
Address for correspondence
Dr V Sathyabama
Senior Lecturer
Dept. of Oral and Maxillofacial Surgery
SRM Kattankulathur Dental College
Potheri, Kanchipuram, Tamil Nadu
the common islands of bony calcification. These appear
woven at the center while they appear lamellar at the
periphery.
Surgery is the treatment of choice including aggressive
curettage, localized surgical resection and segmental
resection. When the tumor is present in association
with the craniofacial complex, treatment is more
aggressive to protect the vital structures.
Case Report
A 29-year-old young male presented with a complaint
of progressively increasing extraoral mass of the right
maxilla obstructing his right nostril and causing
disfigurement of the right upper lip.
According to the patient, the mass had been slowly
expanding over the last six years. Though pain was
not a presenting feature, he underwent extraction of a
single tooth in the region by a local dental practitioner
suspecting it to be the reason for the swelling. He
had repeated nasal obstructions, and an increasing
paresthesia of the right infraorbital region. He also had
intermittent epiphora on the affected side. There was
no regional lymphadenopathy. The patient’s general
health was good with no co-morbid conditions. There
was no associated family history of similar type of
tumors.
Clinical examination revealed a well-circumscribed
slow-growing lesion causing massive bony expansion.

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 293

 Case Report
Figure 1. CT scan pre. Figure 2. En mass
enucleation.
Figure 3. Intra operative Figure 4. Ossifying fibroma.
obturator.
The mass was firm to hard in consistency. The mass
caused a facial disfigurement with the swelling extending
from the angle of the mouth to the malar region. Intra-
orally, the buccal vestibule was completely obliterated
with the mass extending from the canine fossa region
on to the maxillary tuberosity region. Palatally, the
soft tissue was healthy with minimal expansion of
the palatal alveolus. The vault of the palate was not
involved and the midline was not violated.
The maxillary right first bicuspid was missing, which
was apparently extracted a few months ago. There was
paresthesia on the infraorbital region on the right side.
The nasal passage was partially obstructed on the right
side.
On radiographic evaluation, orthopantomogram
(OPG) revealed a well-circumscribed mixed, radiopaque
lesion obliterating the entire maxillary sinus. CT scan
confirmed the extent of the mass. It also established
that in spite of the massive expansion, there were no
noticeable perforations and soft tissue infiltrations into
the adjacent infratemporal and pterygopalatine fossae
with the nasal turbinates and the palate being intact
(Fig. 1). Incisional biopsy was performed under local
anesthesia via a buccal sulcus approach. The tumor had
cheesy firm consistency. Histopathology confirmed the
lesion to be cemento-ossifying fibroma (Fig. 4).
Management
After routine work-up and obtaining anesthetic
fitness, the patient was taken to the operating theater.
Under general anesthesia, the tumor was surgically
294
Figure 5. Specimen.
removed through a transoral approach instead of
the regular Weber-Ferguson maxillectomy approach.
Intraoperatively, the tumor was found to be well-
encapsulated with a cleavage plane to allow it to be
shelled out from its surrounding structures. The orbital
and the nasal floors were preserved and maintained.
The palatal mucoperiosteum was preserved and the
tumor was removed en masse in one piece with no
perforations. Surgical cavity was debrided and a
surgical obturator with a bismuth iodoform paraffin
paste (BIPP) pack was secured in place using
circumzygomatic wiring (Figs. 2-5).
Post-op recovery was uneventful. The surgical cavity
was debrided periodically with change of the BIPP
pack. After epithelialization of the defect, a final
obturator with teeth and hollow bulb was fabricated
after six weeks. Patient remains asymptomatic for the
past eight months with minimal facial disfigurement
and no visible facial scar. Clinical and radiographic
evaluation of the upper left quadrant shows no change
of the lesion, which we are planning to follow-up
periodically.
Review of Literature
Ossifying fibroma of the jaws is a benign fibro-osseous
lesion. The origin is supposed to be from periodontal
ligament.
In 1968, Hamner et al1 analyzed 249 cases of fibro-
osseous jaw lesions of periodontal membrane origin
and classified them.13 In 1973, Waldron and Giansanti2
reported 65 cases (of which 43 cases had adequate
clinical histories and radiographs) and concluded that
this group of lesions was best considered as a spectrum
of processes arising from cells in the periodontal
ligament. In 1985, Eversole et al3 described the
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011

radiographic characteristics of central ossifying fibroma
and two major patterns were noted, expansile unilocular
radiolucencies and as a multilocular configuration.
Various studies conducted have elicited that females
were twice affected than males.4,6,7 Age group between
second and fourth decades5,7,10 are usually affected.
These lesions are more commonly present in the
mandible and commonly diagnosed accidentally on
a radiograph.7 When left untreated, the resultant
expansion presents with cosmetic facial asymmetry.2,11
Radiographically, the lesion presents different stages
of development14 with a centrifugal growth pattern.
Therefore, lesions grow by expansion equally in all
direction and present as round tumor masses. A
thin fibrous capsule demarcates the lesion from the
adjoining normal bone.11
A variable presentation is the juvenile ossifying fibroma.
Children below the age group of 15 were affected
with this aggressive tumor that requires an aggressive
surgical resection and a long-term follow-up due to its
high recurrence rate of 30-58%.3,8,12,15
However, the adult variant has shown recurrence in one
of the 20 cases followed up by Liu et al demonstrating
that a surgical intervention might stimulate the growth
of the tumor.13 This warrants a thorough follow-up of
the cases with the surgical enucleation being mandatory
for the cosmetically disfiguring lesions.
References
1. Hamner JE 3rd, Scofied HH, Cornyn J. Benign fibro-
osseous jaw lesions of periodontal membrane origin. An
analysis of 249 cases. Cancer 1968;22(4):861-78.
2. Waldron CA, Giansanti JS. Benign fibro-osseous lesions
of the jaws: a clinical-radiologic-histologic review of
sixty-five cases. II. Benign fibro-osseous lesions of
periodontal ligament origin. Oral Surg Oral Med Oral
Pathol 1973;35(3):340-50.
3. Eversole LR, Merrell PW, Strub D. Radiographic
characteristics of central ossifying fibroma. Oral Surg
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Case Report
Oral Med Oral Pathol 1985;59(5):522-7.
4. Summerlin DJ, Tomich CE. Focal cemento-osseous
dysplasia: a clinicopathologic study of 221 cases. Oral
Surg Oral Med Oral Pathol 1994;78(5):611-20.
5. Langdon JD, Rapidis AD, Patel MF. Ossifying Fibroma-
one disease or six? An analysis of 39 fibro-osseous lesions
of the jaws. Br J Oral Surg 1976;14(1):1-11.
6. Hamner JE 3rd, Lightbody PM, Ketcham AS,
Swerdlow H. Cemento-ossifying fibroma of the maxilla.
Oral Surg Oral Med Oral Pathol 1968;26(4):57-87.
7. Jayachandran S, Meenakshi R. Cemento ossifying
fibroma. Indian J Dent Res 2004;15(1):35-9.
8. Breheret R, Jeufroy C, Cassagnau E, Malard O.
Juvenile ossifying fibroma of the maxilla. Eur Ann
Otorhinolaryngol Head Neck Dis 2011 May 17. [Epub
ahead of print]
9. Ayub T, Katpar S, Shafique S, Mirza T. En bloc resection
of huge cemento-ossifying fibroma of mandible:
avoiding lower lip split incision. J Coll Physicians Surg
Pak 2011;21(5):306-8.
10. Alsharif MJ, Sun ZJ, Chen XM, Wang SP, Zhao YF.
Benign fibro-osseous lesions of the jaws: a study of 127
Chinese patients and review of the literature. Int J Surg
Pathol 2009;17(2):122-34.
11. Su L, Weathers DR, Waldron CA. Distinguishing
features of focal cemento-osseous dysplasia and cemento-
ossifying fibromas. II. A clinical and radiologic spectrum
of 316 cases. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1997;84(5):540-9.
12. Patil K, Mahima VG, Balaji P. Juvenile aggressive
cemento-ossifying fibroma. A case report. Indian J Dent
Res 2003;14(2):111-9.
13. Liu Y, Wang H, You M, Yang Z, Miao J, Shimizutani
K, et al. Ossifying fibromas of the jaw bone: 20 cases.
Dentomaxillofac Radiol 2010;39(1):57-63.
14. Sarwar HG, Jindal MK, Ahmad S. A case report of
cemento-ossifying fibroma. J Maxillofac Oral Surg
2010;9(2):178‑81.
15. Shekhar MG, Bokhari K. Juvenile aggressive ossifying
fibroma of the maxilla. J Indian Soc Pedod Prev Dent
2009;27(3):170‑4.
n n n
295
 Case Report

Dentigerous Cyst Associated with Mandibular First

Premolar: A Rare Case Report
R Sathish Muthukumar*, S Vijay Parthiban**, M Alagappan†, Sandhya Arunkumar‡

Abstract
Dentigerous cysts are benign odontogenic cysts associated with crowns of unerupted or impacted teeth. They are usually
solitary in occurrence and mostly associated with the mandibular third molars. Dentigerous cysts involving impacted first
premolars are rarely reported in the literatures. We present a rare case of dentigerous cyst in a 62 year old female patient
associated with an impacted mandibular first premolar.

Key words: Dentigerous cyst, odontogenic cyst, impacted teeth

D
entigerous cyst is the second most common
cyst of odontogenic origin. They are mostly
associated with an impacted mandibular third
molar and rare lesions of dentigerous cyst involving
the maxillary and mandibular premolars have been
reported in the literature.1 The prevalence rate of this
cyst is more in males than females, mostly unilateral in
the second and third decade2,3 whereas bilateral lesions
occur between first to sixth decade.4 In this article we
present a rare case of dentigerous cyst associated with Figure 1. Orthopantomogram showing the unilocular
an impacted mandibular right first premolar in a sixty- radiolucency with scelerotic border inrelation to the crown
two year old female patient. of impacted mandibular right first premolar.

Case Report
A 62-year-old female patient reported with a gradually
increasing swelling with dull pain on the right side of the
lower jaw for the past two to three months. Extra oral
examination revealed mild asymmetry of the lower jaw
and palpable submandibular lymph nodes on the right
side. Intraoral examination presented a well defined

*Professor and Head

Dept. of Oral and Maxillofacial Pathology
Chettinad Dental College and Research Institute, Kelambakkam, Chennai
**Senior Lecturer
†
Reader
Dept. of Oral and Maxillofacial Surgery Figure 2. Photomicrograph showing non-keratinized
Chettinad Dental College and Research Institute
‡
Reader epithelium lining supported by loose connective tissue
Dept. of Oral and Maxillofacial Pathology stroma (H&E, x5).
Chettinad Dental College and Research Institute, Kelambakkam, Chennai
Address for correspondence
Dr Sathish Muthukumar R bluish tinged, ovoid swelling causing expansion of the
Chettinad Dental College and Research Institute, Padur, Kanchipuram, buccal cortex. On palpation, the lesion was soft and
Tamil Nadu
E-mail: drsmkop@gmail.com tender. FNAC revealed a blood tinged fluid and non-

296 Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011


Figure 3. Photomicrograph showing focal area of epithelial
hyperplasia (H&E, x10).
specific inflammatory cells on cytological examination.
Orthopantomogram demonstrated a well defined
unilocular radiolucent lesion with sclerotic border, in
relation to the crown of impacted mandibular right
first premolar (Fig. 1). The radiographic appearance
was characteristic of dentigerous cyst associated with
mandibular first premolar. The lesion was enucleated
along with the impacted tooth. Histopathological
examination revealed non-keratinized epithelium
consisting of 3-5 layers of flat to cuboidal cells lining
the cystic lumen with focal area of epithelial thickening
(Fig. 2 and 3). The connective tissue wall was composed
of loosely arranged collagen fibers, young fibroblast and
infiltrated with chronic inflammatory cells. The patient
is under routine follow up and has no complication.
Discussion
Dentigerous cysts are developmental cyst of
odontogenic orgin and the most prevalent, comprising
14-24% of the entire jaw cyst.2,5 They are caused by
the accumulation of fluid between the crown and
reduced enamel epithelium, attached at the cemento-
enamel junction of an impacted or unerupted tooth.4,6
Whites are more affected than blacks.4 They are seen
in a wide age range but usually common between the
ages of 10 and 30 years.7 The sex predilection is 1.6:1
in favor of male. Our case is a rarity as it occurred in
a 60-year-old female patient.
Dentigerous cysts are usually solitary, slow growing,
asymptomatic lesions that are incidentally found
during routine radiographs taken to identify a missing
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
Case Report
tooth. They can occur at any location of the jaw but
frequently seen in relation to impacted mandibular
third molars followed by the maxillary canines and
maxillary third molars.4,6,8 Occasionally these cysts
become painful when infected causing swelling and
erythema. The cyst is usually small but when large,
results in the expansion and thinning of the cortex
leading to pathological fracture.4,7 Although the clinical
presentations are classical of a dentigerous cyst, in our
case it is associated with mandibular first premolar
which has not been reported.
Radiographic features are specific to the lesion
characterized by a well defined radiolucency
circumscribed by a sclerotic border, associated with the
crown of an impacted or unerupted tooth. The borders
may be ill-defined when infected. Rarely may they be
found with odontoma or a supernumerary tooth.7,8
Although they mimic a normal tooth follicle, literatures
suggest any follicular space of more than 4 mm to be a
dentigerous cyst.4 Radiographically the cyst is classified
according to its relation with the involve tooth crown
as central, lateral and circumferential type. The central
type is the most common and presents surrounding
the crown. The lateral dentigerous cyst is that, which
partially surrounds the crown and extends along the
side of the root. The circumferential variant surrounds
both the crown and the root of the involved tooth.7
Histologically, the lumen is lined by 2 to 4 cell layers
of cuboidal to flattened non-keratinized epithelial cells
but may form keratin by metaplasia.9 The epithelium
may be hyperplastic with the presence of hyaline bodies
associated with inflammation. The connective tissue is
more collagenous when inflamed and contain varying
degree of chronic inflammatory cell infiltration.4,7
Occasionally the cyst lining may contain ciliated and
mucous secreting cells.4
Dentigerous cysts are treated most commonly by
Enucleation5, Marsupialization3 and decompression
of cyst by fenestration.10 Motamedi et al suggested
the criteria for selecting the treatment modality based
on the age, size, location, stage of root development,
position of the involved tooth and relation of the lesion
to the adjacent tooth and vital structure.11 The most
preferred treatment is enucleation with the removal of
unerupted or impacted tooth. If the cyst is associated
with the canine or premolar with favorable eruptive
297
 Case Report
position, then extraction of the associated tooth
is deferred. Large dentigerous cyst may be treated
with marsupialization followed by enucleation. The
prognosis is excellent when the cyst is enucleated in
toto and recurrence is rare. As the lining epithelium has
the pluripotential capacity, these lesions may progress
to ameloblastoma, mucoepidermoid carcinoma and
squamous cell carcinoma.4
Conclusion
Dentigerous cyst associated with an impacted first
premolar is extremely rare. As the clinical finding of
unerupted tooth may be the only presenting symptom of
a dentigerous cyst, a thorough radiographic evaluation
is mandatory for all unerupted teeth that have well past
their expected eruption date. These lesions demand an
early detection and surgical elimination in order to
avoid the potential morbidity.
References
1. Miyakawi S , Hyomoto M, Kirita J, Sugimura M.
Eruption speed and rate of angulation change of a
cyst associated mandibular second premolar after
marsupialization of a dentigerous cyst. AM J Ortho
Dentofacial Orthop 1999;116:578-84.
2. Regezi AJ , Sciubba JJ. Cysts of the oral region, In Oral
pathology: Clinical Pathologic Correlations, 3rd edition
Philadelphia: WB Saunders 1999:288-321.
3. Murakami A, Kawabata K, Suzuki A, Murakami S,
298
Ooshima T. Eruption of an impacted second premolar
after marsupialization of a large dentigerous cyst: A case
report. Pediatr Dent 1995;17:372-4.
4. Sumita M, Vineet R, Karen B, Thomas G. Non-
syndromic bilateral dentigerous cysts of mandibular
premolars: a rare case and review of literature. Hong
Kong Dental Journal 2006;3:129-33.
5. Rubin DM, Vendrenne D, Portnof JE. Orthodontically
guided eruption of mandibular second premolar
following enucleation of an inflammatory cyst: A Case
Report. J Clinical Pediatr Dent 2002;27:19-24.
6. Shah N, Thuau H, Beale T. Spontaneous regression of
bilateral dentigerous cysts associated with impacted
mandibular third molars. British Dental Journal 2002;
192:75-76.
7. Aziz SR, Dourmas MA, Roser SM. Inferior alveolar nerve
paresthesia associated with a mandibular dentigerous
cyst. J Oral Maxillofac Surg 2002;60:457-9.
8. Pradeep KM, Namita J. Conservative management of a
dentigerous cyst associated with an impacted mandibular
second premolar in mixed dentition: A case report. J
Dent Res Dent Clin Dent Prospect 2009;3(3):98-102.
9. Shear M. Dentigerous cyst. In: Shear M, editor. Cysts of
the oral regions. Mumbai: Varghese Publishing House;
reprinted in 1996; originally published in 1992.
10. Ziccardi, Eggleston TI, Schneider RE. Using a
fenestration technique to treat a large dentigerous cyst.
J Sm Dent Assoc 1997;128:201-5.
11. Motamedi M, Talesh KT. Management of extensive
dentigerous cyst. Br Dent J 2005;198:203-6.
n n n
Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011
 Indian Journal of
Multidisciplinary Dentistry Case Report

Information for Authors

Manuscripts should be prepared in accordance with the ‘Uniform
requirements for manuscripts submitted to biomedical journals’ compiled
by the International Committee of Medical Journal Editors (Ann. Intern.
Med. 1992;96:766-767). The Journal strongly disapproves of the submission
of the same articles simultaneously to different journals for consideration as
well as duplicate publication and will decline to accept fresh manuscripts
submitted by authors who have done so.
The boxed checklist will help authors in preparing their manuscript
according to our requirements. Improperly prepared manuscripts may be
returned to the author without review. The checklists should accompany
each manuscript.
Covering Letter: The covering letter should explain if there is any
deviation from the standard IMRAD format (Introduction, Methods,
Results and Discussion) and should outline the importance of the
paper. Principal/Senior author must sign the covering letter indicating
full responsibility for the paper submitted, preferably with signatures of
all the authors. Articles must be accompanied by a declaration by all
authors stating that the article has not been published in any Journal/
Book. Authors should mention complete designation and departments,
etc., on the manuscript.
Manuscript: Three complete sets of the manuscript should be submitted
and preferably with a CD; typed double spaced throughout (including
references, table and legends to figures). The manuscript should be
arranged as follow: Covering letter, Checklist, Title page, Abstract,
Keywords (for indexing, if required), introduction, Methods, Results,
Discussion, References, Tables, Legends to Figures and Figures. All pages
should be numbered consecutively beginning with the title page.
Types of Submission: Original Research articles, Review articles, Case
reports and Clinical study
Title Page: Should contain the title, short title, names of all the authors
(without degrees of diplomas), names and full location of the departments
and institutions where the work was performed, name of the corresponding
authors, acknowledgement of financial support and abbreviations used. The
title should be of no more than 80 characters and should represent the
major theme of the manuscript. A subtitle can be added if necessary.
A short title of not more than 50 characters (including inter-word spaces)
for use as a running head should be included. The name, telephone
and fax numbers, e-mail and postal addresses of the author to whom
communications are to be sent should be typed in the lower right corner
of the title page.
Abstract: The abstract of not more than 200 words. It must convey the
essential features of the paper. It should not contain abbreviations, footnotes
or references.
Introduction: The introduction should state why the study was carried out
and what were its specific aims/objectives were.
Material and Methods: Theses should be described in sufficient details to
permit evaluation and duplication of the work by others. Ethical guidelines
followed by the investigations should be described.
Results: These should be concise and include only the tables and figures
necessary to enhance the understanding of the text.
Discussion: This should consist of a review of the literature and relate
the major findings of the article to other publications on the subject. The
particular relevance of the results to healthcare in India should be stressed,
e.g., practically and cost.
References: These should conform to the Vancouver style. References
should be numbered in the order in which they appear in the texts and
these numbers should be inserted above the lines on each occasion the
author is cited.
Tables: These should be typed double spaces on a separate sheet and
figure number (in Roman Arabic numerals) and title above the table and
explanatory notes below the table.
Legends: These should be typed double spaces on a separate sheet and
figure numbers (in Arabic numerals) corresponding with the order in which
the figures are presented in the text. The legend must include enough
information to permit interpretation of the figure without reference to the
text.
Figures: Two complete sets of glossy prints of high quality should be
submitted. The labeling must be clear and neat. All photomicrographs
should indicate the magnification of the print. Special features should be
indicated by arrows or letters which contrast with the background. The
back of each illustration should bear the first author’s last name, figure
number and an arrow indicating the top. This should be written lightly
in pencil only. Please do not use a hard pencil, ball point or felt pen.
Color illustrations will be accepted if they make a contribution to the
understanding of the article. Do not use clips/staples on photographs and
artwork. Illustrations must be drawn neatly by an artist and photographs
must be sent on glossy paper. No captions should be written directly on
the photographs or illustration. Legends to all photographs and illustrations
should be typed on a separate sheet of paper. All illustrations and figures
must be referred to in text and abbreviated as ‘Fig’.
Please complete the following checklist and attach to the manuscript:
1. Classification (e.g. original article, review, etc.)_________________
2. Total number of pages____________________________________
3. Number of tables________________________________________
4. Number of figures_______________________________________
5. Special requests_________________________________________
6. Suggestions for reviewers (name and postal address)
Indian 1.______________ Foreign 1. _______________
2._____________________ 2._______________
7. All author’s signatures____________________________________
8. Corresponding author’s name, current postal and e-mail address and
telephone and fax numbers
__________________________________________________________
For Editorial Correspondence
Dr KMK Masthan
Professor and Head
Department of Oral Pathology and Microbiology
Sree Balaji Dental College and Hospital
Velachery Main Road, Narayanapuram, Pallikaranai
Chennai - 600 100, E-mail: masthankmk@yahoo.com,
ijmdent@gmail.com

Indian Journal of Multidisciplinary Dentistry, Vol. 1, Issue 5, July-August 2011 299