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Journal of Dental Herald
E ISSN : Awaited
P ISSN : Awaited
Affiliated to Indian Dental Association, Jammu Branch
Editorial Board
Patron
Dr. Mahesh Verma
Vice President, Dental Council of India
Editor-in-chief
Dr. Bhanu Kotwal
Chief Patron
Dr. Dibyendu Mazumder
President, Dental Council of India
Editorial Advisor
Dr Mark Bartold
Editor-Australian Dental Journal,
Director-Australian Clinical Dental Research Centre,
University of Adelaide, Australia.
Associate Editor
Dr. Ritesh Gupta
Assistant Editor
Dr. Nanika Mahajan
Editorial Coordinator
Dr. Rakesh K. Gupta. H.O.D., Deptt. of Pedodontics, IGGDC, Jammu.
Co-Editors
Dr. Rajesh Ahal, Dr. Satish Sharma, Dr. Rajiv Mengi, Dr. Arvind Mengi, Dr. Gautam Sharma, Dr. Neetu Gupta
Dr. Vikas Jindal
Principal, Himachal Dental College, Sundernagar, HP.
Dr. Romesh Singh
Principal, Indira Gandhi Govt. Dental College, Jammu.
Dr. Vinod Sachdev
Principal, ITS Dental College, Muradnagar.
Dr. Virender Goyal
Professor, Deptt of Pedodontics, Dashmesh Institute
of Research and Dental Sciences, Faridkot.
Dr. Vivek Hegde
Professor, Deptt.of Conservative Dentistry and
Endodontics, M. A. Rangoonwala Dental College,
Pune.
Dr. Manesh Lahori
Professor & Head, Deptt. of Prosthodontics, K.D.
Dental College & Hospital, Mathura.
Dr. Sharath Kumar Shetty
Director (PG studies), Professor & HOD, Deptt.of
Orthodontics, KVG Dental College, Sulli, Karnatka.
Dr. Mahesh Kumar Y.
Professor, Deptt of Orthodontics, KVG Dental College,
Sulli, Karnatka.
Dr. Suvarna Nene
B.D.S. D.U. (France)
Dr. Robert L. Ramus
DDS Ohio, USA
Dr. Souheil R. Hussaini, MS
President, Chairman of scientific committee - CDE
Implant Dentistry - Study Consortium (ID-SC),
Columbia University School of Dentistry, Assistant
professor, College of Dentistry, University of Sharjah,
UAE.
National Editorial Board
Dr. Vimal Sikri
Principal, Punjab Govt Dental College, Amritsar
Dr. Riyaz Farooq
Principal, Govt. Dental College, Srinagar.
Dr. Gurkeerat Singh
Professor, Deptt.of Orthodontics, SudhaRustagi
College of Dental Sciences and Research, Faridabad.
Dr. Sridevi Padmanabhan
Professor, Deptt.of Orthodontics, Sri Ramachandra
Dental College, Chennai.
Dr. Sanghmitra Das Gupta
Director: CORE; Former Professor & Head. Deptt. of
Oral and Maxillofacial Surgery, Vydehi Dental College,
Bangalore.
Dr. Himanshu Aeran
Director PG Studies, Seema Dental College, Rishikesh.
Dr. Ankur Rustagi
MDS, Oral & Maxillofacial Surgery AIIMS; Senior
consultant & Maxillofacial Surgeon. Delhi Heart & lung
Hospital, New Delhi.
Dr. Manish Khatri
Professor& Head, Deptt.of Periodontics, IDST,
Modinagar.
International Editorial Board
Dr. Ramon J.Baez
DDS, MPH Boerne, TX USA
Dr. Shiva Mortazavi, DDS, MS,
Assistant Professor, Dental School & Research Center,
Isfahan University of Medical Sciences Isfahan, Iran.
Dr. Mohammad Altamash
Dr. Med. Dent. (Germany), FACD
(USA),President.Principal, Altamash Institute of Dental
Medicine, Karachi. Pakistan.
Dr. Anil Singla
Director, Himachal Dental College, Sundernagar, H.P.
Dr. Gaurav Gupta
Director, Institute of Dental Sciences, Paonta Sahib.
Dr. Anil Chandra
Professor, Deptt. of Conservative Dentistry and
Endodontics, Faculty of Dental Sciences, K.G's
medical University, Lucknow.
Dr. Ashok Kumar Jena
Deptt.of Dental Surgery, AIIMS, Sijua, Dumduma,
Bhubaneswar.
Dr. Neeraj Mahajan
Professor & Head, Deptt.of Pedodontics, Guru Nanak
Dev Dental College and Research Institute,Sunam,
Punjab.
Dr. D. K. Gautam
Professor& Head, Deptt. of Periodontics, Himachal
Dental College, Sundernagar, H.P.
Dr. Ramesh Reddy
Professor, Deptt. of Periodontology, Narayana Dental
College, ChintareddyPalem, Nellore, A.P.
Dr. Vinay Kumar Bhardwaj
Assistant Professor, Deptt. of Public Health Dentistry),
Govt. Dental College, Shimla.
Dr. Suchetan Pradhan
M.D.S. (Prosthodontics) M.Sc. Laser Dentistry
(Aachen Univ., Germany), EMDOLA(European Union,
Mumbai, India.
Dr. Mohammed Mustafa
Assistant Professor, Head of Endodontic Division,
Coordinator for Quality & Development,College of
Dentistry & Hospital, Saudi Arabia.
Executive Committee
Dr. K. S. Kotwal
Dr. Parveen Lone
Dr. Akshay Gupta
Dr. Nikhil Dev Wazir
Dr. N. P. Gupta
Dr. Reecha Gupta
Journal of Dental Herald. ( Issue:2, Vol.:1, April 2014) All rights are reserved
Dr. Azhar Malik
Dr. Sarbjeet Singh
Dr. Gautam Mengi
Dr. Rubina Anjum
Dr. Satvinder Singh
Dr. Chander Joshi
A
E ISSN : Awaited
P ISSN : Awaited
Affiliated to Indian Dental Association, Jammu Branch
1st Dental Journal from the State of Jammu & Kashmir, India.
General Information
Journal of Dental Herald is a peer-reviewed journal published by likeminded well-wishers of Dental fraternity of Jammu through the dais of prestigious Indian Dental
Association Jammu Branch. The journal publishes information related to all the fields of Dentistry with emphasis on clinical point of view so as to help the young and budding
dentist& to bridge the gap between under graduate & post graduate. The journal is published quarterly in January, April, July and October.
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D
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E
Editorial
On behalf of the Journal of Dental Herald, as Editor-in-Chief it is my distinct honor and
privilege to welcome all dental scientific community to our journal. Let me start by
conveying my sincere gratitude to all of our many authors and reviewers who have
submitted papers and/or provided valuable service as a reviewer for Journal of Dental
Herald.
Our editorial board and the reviewers have spent countless hours reviewing manuscripts
for the Journal and we continue to excel as a direct result of your efforts.As
editor of the Journal, I consider the job seriously. It requires knowledge and
ateam effort. The multiple disciplines and specialties that make up the
scienceof dentistry make the journal appealing to a wide range of
clinicians.The journal will emphasize high-level research of clinical relevance
and excitingeducation. Therefore, we welcome any clinical and basic science
research, as longas the study has clinical relevance to the benefit of our
Dr. Bhanu Kotwal
Editor-in-Chief
readers and authors.
We are delighted that you are joining us as readers and hope you will also join us as
contributors. Any comments or suggestions you may have that would improve the
Journal are welcome.
Dr. Bhanu Kotwal
Editor-in-Chief
E-mail: editordherald@gmail.com
F
www.dherald.in
(April 2014) Issue:2, Vol.:1
E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
Original Article
Association Between The Prevalence Of First Permanent Molar Caries Experience And Oral
Health Knowledge Perception And Behavior Among School Children Aged 9-12 Years In
Bangalore City, India
Kadambari Ambildhok1, H.L Jayakumar2, Rohini Patil3, Mudit Gupta4, Manu Batra5
1
Assistant Professor, Dept. Of Public Health Dentistry, Sinhgad Dental College And Hospital, Pune, Maharashtra, India
Professor & Head, Dept. Of Public Health Dentistry, AECS Maruti Dental College, Bangalore, Karnataka, India
Assistant Professor, Dept. Of Public Health Dentistry, CSMSS Dental College, Aurangabad, Maharashtra,India
4
Assistant Professor, Dept. of Oral Medicine and Radiology, Uttaranchal Dental & Medical Rasearch Institute, Dehradun, Uttarakhand, India
5
Assistant Professor, Dept. Of Public Health Dentistry, Teerthankar Mahaveer Dental College & Research Centre, Moradabad, Uttar Pradesh, India
2
3
Abstract
Objectives: To assess the association between first permanent molar caries experience and Oral health knowledge, perception and behavior.
Method: The caries status of first permanent molar (FPM) was studied in 200 school children aged (9-12 years) from randomly selected primary
schools from south Bangalore area, India. The sample consists of 50 children from each age group of 9, 10,11 and 12 years old. A questionnaire was
administered to the children consisting of questions regarding knowledge, behavior and perception pertaining to oral hygiene practices.
Results: The prevalence of caries in four first permanent molars varies according to age with highest among the twelve year old and lowest among
the 9 year old children. The children who exhibited good oral hygiene behavior with good knowledge and perception had more sound first
permanent molars compared to other children. The number of caries FPM increased with age.
Conclusion: The level of knowledge had a positive correlation with the caries level amongst this cohort of schoolchildren.
Key Words
dental caries, children, molar, knowledge
Introduction
While the eyes may be the window to the soul, our mouth is a
window to our general health[1]. The global distribution of
dental caries suggest a varied picture. The frequency of
involvement of dental surfaces by caries lesion varies with age
and peak of intensity occurs during certain stages of life.
Previous studies conducted showed that First Permanent
molars accounted for 30-40% of all extractions due to caries
which is the highest when compared to other teeth[2].
In Bangalore similar to other Indian cities the prevalence of
dental caries is high and it is essential to obtain base line data
regarding the condition of first permanent molars so that
appropriate preventive and Therapeutic options can be planned
and implemented. The aim of this study is to;
?
Determine the prevalence of Dental caries in the first
permanent molars among 9-12 year old school children
from Bangalore city, India.
?
To correlate the prevalence of caries in relation to oral
health knowledge, perception, behavior and age of the
study participants.
Materials and Methods
It is a cross-sectional study used to determine the prevalence of
dental caries in the First Permanent molars. Examination was
conducted in a class room within the school premises on an
Quick Response Code
Address For Correspondence:
Dr. Manu Batra,
Assistant Professor, Dept. Of Public Health Dentistry,
Teerthankar Mahaveer Dental college, Moradabad,
Uttar Pradesh, India,
Email – drmanubatra@aol.com,
Phone number – 91 9719522272
©Journal of Dental Herald (April 2014, Issue:2, Vol.:1).
ordinary sitting chair with the help of a mouth mirror, CPITN
probe and artificial illumination. A total of 216 school children
were examined from randomly selected two schools from
South Bangalore region. The participants were stratified into
four subgroups dependent on their age 9, 10, 11 and 12 years.
Amongst each subgroup participants were randomly selected
using lottery method such that each subgroup consisted of 54
students.
Oral examination
The school children were examined by a trained and calibrated
examiner (KA). WHO criteria was utilized to diagnose the
carious status of first permanent molars. Fissure sealants were
excluded from the study.
Questionnaire
Was developed and was pilot tested amongst 30 school
children. Questionnaire consists of 17 closed ended questions
consisting of three domains related to knowledge, perception
and behavior. The children who required dental treatment were
referred to AECS Maaruti College of Dental Science and
Research centre, Bangalore. Those who had sound molars, but
belonging to high risk categories were referred for preventive
treatment. All the children received oral hygiene instructions
and received and oral hygiene hamper consisting of a
fluoridated toothpaste and a toothbrush.
Statistical software for social sciences (Window version 21)
was used to generate descriptive statistics and inferential data.
Chi-square test is used in order to find out significance
between the subgroups divided according to age (9,10,11,12)
in years. Knowledge, attitude, behavior and perception
regarding oral health when associated with the corresponding
first permanent molar experience in the children. The P<0.05
001
Table 1: Number (%) of children who presented with and without caries of the first
permanent molar in relation to age (N = 216)
was considered significant
Results
Out of total 216 children, 91 (46%) were males and 115 (54%)
were females. In total 53 (24.5%) had all First permanent
molars sound. The remaining 163 (75.5%) children had one or
more carious first permanent molars. The carious status of all
FPMs increased significantly with an increase in age (P <
0.05). (Table 1.) (Fig. 1.)
When knowledge regarding oral health was assessed 40 (22%)
showed good knowledge component , among them 13 (32%)
had all 4 FPMs sound and 2 (7%) had all FPMs carious. From
the remaining 176 (78%) children who showed poor
knowledge regarding oral health 40(23%) had all FPMs sound
and 11(7%) had all 4 carious molars, the difference is not
statistically significant (P > 0.05) (Table 2.) (Fig. 2.)
When behavior regarding oral health maintenance was
assessed among the study participants 111 (47%) showed good
Oral hygiene behavior, among them 33 (29.5%) had all FPMs
sound and only 3% had all FPMs carious. Of the remaining
children 19% had sound FPMs and 9.5% had all FPMs carious
(Table 3.) (Fig. 3.) The difference between the two groups was
statistically significant (P<0.05).
When perception in relation to oral health was assessed , 27
(19%) showed positive perception, among them 37.5% had all
FPMs sound (Table 4) (Fig. 4.) From the remaining 81% did
not get any advice, 45 (23%) had sound permanent molars and
23 (6%) had all permanent molars decayed. The difference was
statistically significant. (P<0.05).
Discussion
It is revealed from this study that carious process in the FPMs ,
Age in All molars 1 or more carious 1 molar
molars n (%)
2 molar
3 molar
All molar
Total n (%)
years
sound
9
18 (33%) 36 (67%)
14 (26%)
14 (26%)
7 (13%)
1 (2%)
54 (100%)
10
16 (30%) 38 (70%)
18 (34%)
13 (24%)
4 (7%)
3 (3%)
54 (100%)
11
10 (19%) 44 (81%)
12 (22%)
18 (34%)
11 (19%)
4 (3%)
54 (100%)
12
9 (17%)
12 (23%)
15 (28%)
13 (23%)
5 (9%)
54 (100%)
Total
53 (25%) 113 (75%)
56 (26%)
60 (28%)
28 (15%)
13 (6%)
216 (100%)
45 (83%)
carious n (%) carious n (%) carious n (%) carious n (%)
Fig 1: Number (%) of children who presented with and without caries of the first permanent
molar in relation to age (N = 216)
Chi-square (?2) = 25.8, P < 0.05 Statistically significant
Table 3: Caries status of first permanent molars in relation to behavior regarding oral health
maintenance among the participants
The behavior
All molars
One molar
Two molar
Three molar
Four molar
component
sound
carious
carious
carious
carious
Total
Good
111 (47%)
33 (29.5%) 36 (32%)
21 (18%)
19 (17%)
4 (3%)
111 (100%)
Poor
105 (53%)
20 (19%)
21 (20%)
39 (37%)
15 (14%)
10 (9.5%)
105 (100%)
Total
216 (100%) 53 (25%)
56 (26%)
60 (27%)
33 (16%)
14 (6%)
216 (100%)
Table 2: Caries status of first permanent molars in relation to knowledge regarding oral
health maintenance among the participants
The knowledge
All molars
One molar
Two molar
Three molar
Four molar
component
sound
carious
carious
carious
carious
Total
Good
22%
13 (32%)
8 (20%)
10 (25%)
7 (16%)
2 (7%)
40 (100%)
Poor
78%
40 (23%)
48 (27%)
50 (28%)
27 (15%)
11 (7%)
176 (100%)
Total
100%
53 (24.5%)
56 (26%)
60 (27.5%)
34 (15%)
13 (7%)
216 (100%)
Fig 3: Caries status of first permanent molars in relation to behavior regarding oral health
Fig 2: Caries status of first permanent molars in relation to knowledge regarding oral health
Chi-square (?2) = 3.8, P > 0.05 statistically not significant
Table 4: Caries status of first permanent molars in relation to perception regarding oral
health services
The perception
All molars
One molar
Two molar
Three molar
Four molar
component
sound
carious
carious
carious
carious
Positive 19%
7 (37.5%)
4 (25%)
3 (19%)
1 (8%)
1 (6%)
14 (100%)
Negative 81%
45 (23%)
25 (28%)
28 (29%)
15 (17%)
12 (8%)
98 (100%)
Total
27 (25%)
28 (26%)
31 (27%)
17 (16%)
23 (6%)
112 (100%)
100%
Total
Fig 4: Caries status of first permanent molars in relation to perception regarding oral health
services
002
starts as soon as they erupt and as the age increases the severity
of caries also increases. In one previous study Noronha et al
and Wyne reported that 87% 12 year old children had first
permanent molar affected by caries. Many previous studies
have reported that aging is accompanied by increased caries
prevalence among children the findings are similar to our
study[3],[4]. More than 50% of the respondents showed good Oral
hygiene behaviour, among them 33% had sound FPM. Other
studies have also confirmed that if good oral hygiene practices
are initiated and maintained at home, it is more likely to result
in lower caries prevalence[5]. In a study reported brushing teeth
at least once a day and having received preventive dental care
in the last year before data collection were associated with
declines in the expected mean dmft by 19.5% and 69.6%,
respectively[6]. Previous studies have shown that imparting oral
health education may lead to better behaviour and perception
regarding oral health[5]. The present study suggests that good
oral health knowledge and perception is associated with better
oral health status. These findings support the previous studies[7]
suggesting that knowledge acquired by the subjects generate a
positive attitude that in turn gives rise to changes in
practice[8],[9].
Moreover, it is well documented that shortages in the dental
workforce (general and pediatric dentists) pose a barrier to
access to care for large portions of the population, particularly
those enrolled in public insurance and residing in rural
areas[10],[11]. In an environment with limited resources, it appears
reasonable to support a need- and risk-based prioritization of
early preventive dental treatment[12],[13], as low-risk groups may
benefit the least from early dental office-based visits[14]. Thus
spreading awareness and building positive perception among
the school children may lead to better compliance and
behaviour regarding oral health.
Conclusions
Prevalence of caries in first permanent molars was high. It
increased as the age of the child increased . Oral health
knowledge, perception and behavior has an remarkable
influence on oral health status and prevalence of first
permanent molar caries among children. Hence in a country
like India with limited resources and manpower the most
feasible method in preventing oral disease should be
community based, tailor-made directed towards school
children to improve various oral health education and
preventive programs.
Recommendations
1. Early visits to the dental office will ensure effective
preventive programs including sealant application and
fluoride application along with oral health education.
2. Parents should be invited regularly for presentation on oral
and general health.
3. Teachers must be involved in the school brushing and
educational programs as school children are largely
influenced by their teachers.
4. Periodic reinforcing of Oral Health education programs
thereby improves knowledge and improves skill based
technique of tooth brushing and dental flossing.
5. Perception of children regarding Oral health needs to be
positively reinforced will enable them to understand and
seek early professional dental care behavior and
relationship between oral and general health.
References
1. Janice S Paula, Isabel CG Leite, Anderso B Almeida,
Glaucia MB Ambrosano, Antonio C Pereira and Fabio L
Mialhe. The influence of oral health conditions,
scioeconomic stutus and home environment factors on
schoolchildren’s self-prception of quality of life. Health
and quality of life outcomes. 2012;10(6).
2. Khalid H.M. Al-Samadani and Mohammad Sami Ahmad.
Prevalence of First Permanent Molar Caries in and Its
Relationship to the Dental Knowledge of 9–12-Year Olds
from Jeddah, Kingdom of Saudi Arabia. ISRN 2012;
Article ID 391068, 6 pages.
3. A. H. Wyne, “The bilateral occurance of dental caries
among 12-13 and 15–19 years old school children,”
Journal of Contemporary Dental Practice, vol. 5, no. 1, pp.
42–51, 2004.
4. Nina Markovic, Amra Arslanagic Muratbegovic. Caries
prevalence of children and adolescents in Bosnia and
Herzegovina. Acta Medica Academica 2013;42(2):108116
5. J.C.Noronha, M. L. Massara, B. Q. Souki, and A.
P.Nogueira,“First permanentmolar: first indicator of dental
caries activity in initial mixed dentition,” Brazilian Dental
Journal, vol. 10,no. 2, pp. 99–104, 1999.
6. Miriam del Socorro Herrera et al. Dental plaque,
preventive care, and tooth brushing associated with dental
caries in primary teeth in schoolchildren ages 6–9 years of
Leon, Nicaragua. Med Sci Monit, 2013; 19: 1019-1026.
7. M. Ghandehari Motlagh and A. Kohestani, “An
investigation on DMFT and DMFS of first permanent
molars in 12 yearsold blind children in residential institutes
for blind in Tehran (2000-2001),” Journal of Dentistry, vol.
1, no. 3, pp. 101–106, 2004.
8. Chachra S, Dhawan P, Kaur T, Sharma AK. The most
effective and essential way of improving the oral health
status education. Journal of Indian Society of Pedodontics
and Preventive Dentistry. 2011; 29 (3):216-221.
9. Ernesto Smyth, Francisco Caamano, Paula FernandezRiveiro. Oral health knowledge, attitude and practice in 12year old schoolchildren. Med Oral Patol Oral Cir Bucal.
2007;12(8):614-20.4)
10. Okunseri C, Pajewski NM, Brousseau DC, TomanyKorman S, Snyder A, Flores G. Racial and ethnic
disparities in nontraumatic dental-condition visits to
emergency departments and physician offices: a study of
the Wisconsin Medicaid program. J Am Dent Assoc.
2008;139(12): 1657–1666.
11. Logan HL, Guo Y, Dodd VJ, Seleski CE, Catalanotto F.
Demographic and practice characteristics of Medicaidparticipating dentists. J Public Health Dent. Epub
September 18, 2013.
12. Beil H, Rozier RG, Preisser JS, Stearns SC, Lee JY. Effects
of early dental office visits on dental caries experience. Am
J Public Health. Epub October 17, 2013.
13. Beil H, Rozier RG, Preisser JS, Stearns SC, Lee JY. Effect
of early preventive dental visits on subsequent dental
treatment and expenditures. Med Care.
2012;50(9):749–756.
14. Shenkin JD. Early preventive dental visits for low risk
children may have limited benefit. J Evid Based Dent
Pract. 2013;13(1):31–32.
Source of Support : Nill, Conflict of Interest : None declared
003
www.dherald.in
Original Article
E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
Oral Hygiene Practices, Smoking Habits, And Self- Perceived Oral Malodor Among Dental
Students Of Udaipur City, Rajasthan
Surekha Bhat1, Rupam Gupta2, Neeldipsinh Jadeja3, Rahul Krishan Sharma4, Mandeepsinh Gohil5, Snehal6
1
Professor, Department Of Conservative Dentistry And Endodontics, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan
Post Graduate Student, Department Of Public Health Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan
Postgraduate Student, Department Of Oral Medicine And Radiology, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan
4
Postgraduate Student, Department Of Orthodontics, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan
5
Postgraduate Student, Department Of Public Health Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan
6
Undergraduate Student, Department Of Public Health Dentistry, Darshan Dental College and Hospital, Loyara, Udaipur, Rajasthan
2
3
Abstract
Background: The behavior of the oral health providers and their attitudes towards their own oral health reflect their understanding of the
importance of preventive dental procedures and improving the oral health of their patients. Despite acquiring an increased knowledge about risk
factors and the pathogenesis of tobacco related diseases during their health care professional education period, students begin or continue to
smoke during their studies at universities. Dental students as the future providers of dental care are expected to be a role model for their patients,
family members and their friends and ensure their awareness of oral health maintenance.
Materials and Methods: A self administered questionnaire was developed to evaluate the oral hygiene practices, smoking habits and self
perceived oral malodor among dental students of Darshan Dental College and Hospital in Udaipur city of Rajasthan, India. The questionnaire
consisted of 14 questions which could derive the information related to the oral hygiene practices, smoking habits and self perceived oral malodor of
the dental students.
Results: Almost 10.5% of male and 4.6% of female had self perception of oral bad breath (p < 0.05). 40.7% of male and 4.1% of females were
smokers. 20.6% of male and 10.5% of female dental students said that their tongue was coated with yellowish or white deposits.
Conclusions: The female dental students had better oral hygiene practices and its care in comparison to the male dental students.
Key Words
Oral hygiene practices, Halitosis, Smoking habits, Oral Malodor
Introduction
The behavior of the oral health providers and their attitudes
towards their own oral health reflect their understanding of the
importance of preventive dental procedures and improving the
oral health of their patients.[1] Dental students are generally
motivated to maintain good oral health.[2],[3] Researchers have
found that the oral health attitude and behavior of dental
students differed in their preclinical and clinical years.[2],[4]
Despite acquiring an increased knowledge about risk factors
and the pathogenesis of tobacco related diseases during their
health care professional education period, students begin or
continue to smoke during their studies at universities.[5] The
study[2] conducted showed that the dental students in India had
a poorer oral health awareness compared to other countries.
Another study showed that the dental students did not exhibit
any particular exemplary behaviors which generally fell below
the recommended standards. Indications from the published
studies are that health professionals who smoke may not be as
effective in counseling patients to quit smoking as health
professionals who do not smoke.[5],[6],[7] Smoking prevalence
Quick Response Code
Dr. Rupam Gupta, BDS, (MDS)
Postgraduate student,
Department of Public Health Dentistry,
Darshan Dental College and Hospital.
Loyara, Udaipur, Rajasthan, India-313003.
e-mail: dr.rupamgupta11@gmail.com
Tel: +919636206369
©Journal of Dental Herald (January 2014, Issue:1, Vol.:1).
among male dental students was 7 times higher than females.5
Another study conducted reported that the female students had
better oral hygiene practices; significantly less reported oral
bad breath and smoked less compared to male students.[8]
Available evidence suggests that risk of diseases increases
with greater use of tobacco where as quitting smoking can
result into decrease in that risk.[5]
Halitosis is the general term used to describe any disagreeable
odor in exposed air. Other names used for it are: Fetor exore,
fetor oris, bad breath, foul, oral malodor, breath malador. It
originates in the oral cavity where anaerobic bacteria degrades
sulphur containing aminoacids to foul smelling volatile
sulphur compounds (VSC) namely hydrogen sulphide and
methyl mercaptan.[8] Available reports in the literature
conclude that oral malodor is a social stigma. Reviews in
research reports agree that halitosis (80-90%) originates
within the oral cavity. and an estimated 10-20% of halitosis has
non-oral causes.[8],[9],[10]
Dental students as the future providers of dental care are
expected to be a role model for their patients, family members
and their friends and ensure their awareness of oral health
maintenance.[11] There is a lot of published data related to
motivation of patients to follow an effective oral health care
program but only little is known about the influence of clinical
training and course content on the development of oral health
behavior of dental students. Hence the present study was
undertaken to assess the oral hygiene practices, smoking habits
and self perceived oral malador among dental students.
004
Materials and methods
The descriptive cross sectional study was conducted among
the students of Darshan Dental College and Hospital,
Rajasthan, India. Ethical clearance was obtained from the
ethical committee of Darshan Dental College and Hospital.
The study was conducted during the period of July 2013.
Under graduate students from all five academic years and post
graduate students of the same college were selected as the
sample. Students absent on that particular day were excluded
from the study. Participation was voluntary. The students were
asked to fill the questionnaire at the end of their lecture inside
the classrooms rather outside the class. Students were asked to
not to mention their names on questionnaire to maintain the
confidentiality of the information.
A self administered questionnaire was developed to evaluate
the oral hygiene practices, smoking habits and self perceived
oral malodor among dental students of Darshan Dental College
and Hospital in Udaipur city of Rajasthan, India. The
questionnaire consisted of 14 questions which could derive the
information related to the oral hygiene practices, smoking
habits and self perceived oral malodor of the dental students.
Data entry was done using SPSS software version 19.0 and the
comparison of the variables was done using Chi-square test.
The P value < 0.05 was set as statistically significant.
Table 1: Frequency Of Self Perception Of Oral Breath
Gender
Yes
No
Don’t know
Total
Male
130 (65.3%)
48 (24.1%)
21 (10.6%)
199 (100%)
Female
111 (50.7%)
87 (39.7%)
21 (9.6%)
219 (100%)
X2 = 11.83 p = <0.05
Table 2: Treatment Received For Bad Breath From The Dental Practitioners
Gender
Yes
No
Total
Male
0 (0%)
199 (100%)
199 (100%)
Female
12 (5.5%)
207 (94.5%)
219 (100%)
X2 = 15.43 p = < 0.05
Table 3: Self Treatment Of Oral Malodor
Gender
Yes
No
Total
Male
134 (5.3%)
65 (94.7%)
199 (100%)
Female
90 (21.1%)
129 (78.9%)
219 (100%)
Total
224
194
418
X2 = 59.77 p = < 0.05
Table 4: Interference Of The Bad Breath At Work
Results
65.3% of male and 50.7% of female reported the self
perception of oral breath. The results were statistically
significant with p < 0.05.
No male had received treatment for the bad breath while only
5.5% of the female received treatment from the dental
practitioners for their bad breath. The result was statistically
significant (p < 0.05).
67.3% of male and 41.1% of female had received the treatment
of oral malodor by their own means. The result was statistically
significant (p < 0.05).
32% of male and 8.7% of female did experience the
interference of the bad breath in their social life at work place.
The result was statistically significant (p < 0.05).
Almost 10.5% of male and 4.6% of female had self perception
of oral bad breath (Hand on Mouth Technique). The difference
between the two groups was statistically significant (p < 0.05).
Only 1% of the male dental students did not brush their teeth
regularly. Females used mouthwash regularly almost more
than twice than that of males. 49.2% of males and 30.6% of
females had tooth decay. 5% of males and 3.7% of females
suffered from bleeding gums. 20.6% of male and 10.5% of
female dental students said that their tongue was coated with
yellowish or white deposits.
40.7% of male and 4.1% of females were smokers. Almost all
the students were aware regarding the ban of smoking in public
places
Discussion
A descriptive cross sectional study was conducted among the
499 students of Darshan dental college of Udaipur city,
Rajasthan, India. Being the health care professionals of the
future, they must adopt accurate oral health attitudes and
behavior right from the period of their study courses in order to
direct their patients properly. In the present study 65.3% of
male and 50.7% of female reported the self perception of oral
breath. This supports the statement that the males have more
Gender
Yes
No
Total
Male
64 (5.2%)
135 (94.8%)
199 (100%)
Female
19 (3.7%)
200 (96.3%)
219 (100%)
Total
83
335
418
X2 = 36.13, p = < 0.05
Table 5: Frequency Of The Self Perceived Bad Breath Among The Dental Students
Gender
Yes
No
Total
Male
21 (10.5%)
178 (89.5%)
199 (100%)
Female
10 (4.6%)
209 (95.4%)
219 (100%)
Total
126
294
418
X2 = 176.69, p = < 0.05
Table 6: Questions Pertaining To Oral Hygiene Practices Among The Dental Students
Questions
Male
Yes
Female
No
Yes
Total
p value
No
1. Do you brush your teeth every day?
197 (99%) 2 (1%)
2. Do you use mouthwash regularly?
39 (19.6%) 160 (80.4%) 100 (45.7%) 119 (54.3%) 418 (100%) <0.05
219 (100%) 0 (0%)
3. Do you use toothpick regularly?
34 (17.1%) 165 (82.9%) 51 (23.3%) 168 (76.7%) 418 (100%) >0.05
418 (100%) <0.05
4. Do you have tooth decay (dental caries)? 98 (49.2%) 101 (50.7%) 67 (30.6%) 152 (69.4%) 418 (100%) <0.05
5. Do you have bleeding gums?
10 (5%)
190 (95%) 8 (3.7%)
6. Do you have dryness of the mouth?
9 (4.5%)
190 (95.5%) 10 (4.6%) 209 (95.4%) 418 (100%) >0.05
211 (96.3%) 418 (100%) <0.05
7. Is your tongue coated with white or
41 (20.6%) 158 (79.4%) 23 (10.5%) 196 (89.5%) 418 (100%) <0.05
yellowish deposits?
Table 7: Questions Pertaining To Smoking Habits Among Dental Students
Questions
Male
Yes
Female
No
Yes
1. Do you smoke?
81 (40.7%) 118 (59.3%) 9 (4.1%)
2. Are you aware regarding ban of
185 (93%) 14 (7%)
Total
p value
No
210 (95.9%) 419 (100%) <0.05
211 (96.3%) 8 (3.7%)
419 (100%) >0.05
smoking in public places?
005
self perception of the oral breath as compared to females.
Halitosis could be a social handicap and therefore its self
perception is very much important for its diagnosis and
control.[8]
No male had received treatment for the bad breath while only
5.5% of the female received treatment from the dental
practitioners for their bad breath which was in contrast to the
study[8] done by Almas K. which reported that more males (7%)
had received treatment for bad breath than females (2%).
A large variety of products are readily available to treat the
halitosis temporarily. So 5.3% of male and 21.1% of female
had received self treatment to eradicate oral malodor.
5.2% of males and 3.2% of females experienced the
interference of the bad breath during their work in last month.
Regarding the diagnosis for the bad breath students were asked
to put their right palm in front of their mouth and was asked to
exhale (Hand on Mouth technique).10.5% of males and 4.6%
of females reported to have bad breath using this technique. A
similar technique used in study8 done by Almas K showed that
8.9% of males and 4.7% of females had self perceived oral
malodor. Eli et al concluded that the self perception of breath
odor is a multifactorial, psycho-physiological issue related
closely to one’s body image and psychopathological profile.[12]
A study[13] has shown that 10-30% population of United States
of America suffers from halitosis on regular basis. A survey[14]
done in Japan showed that 24% of the individuals suffered
from the bad breath while in Sweden only 2.4% of the study
subjects suffered from oral malodor.[15] The study[16] done in
French general population showed prevalence of halitosis
around 22%. This shows that the oral malodor is a universal
hitch perceived in different cultures and societies.
Except 1% of male dental students rest all the students brushed
their teeth on daily basis. A study[8] done in Riyadh showed that
the large percentage of female dental students had a daily tooth
brushing as compared to males. 45.7% of female dental
students and 19.6% of male dental students used mouth wash
regularly which was corresponding to the study by Almas K[8]
who reported that compared to males, females used
mouthwash twice.
The prevalence of dental caries in male and female dental
students was 49.2% and 30.6% respectively. Al-Motairy EA et
al[17] reported 90% prevalence of dental caries among male
dental students while Almas K[8] showed 57% prevalence of
dental caries among male dental students.
5% and 3% of male and female dental students reported of
having bleeding gums respectively. Almas K[8] reported the
prevalence of bleeding gums amongst males almost twice than
that of females. Another study done[18] on secondary school
boys in Riyadh showed that 24% of male students had bleeding
gums. 4.5% and 4.6% of male and female dental students had
dryness of mouth. Study[19] done by Saurez F showed that the
decrease in salivary flow at night favors the putrefaction of
anaerobic bacteria giving rise to ‘morning breath” a transient
condition which disappears after meal. Meskin LH[13] reported
that 10-30% of USA population suffered from the problem of
dry mouth.
Male students (20.6%) suffered from tongue coating twice as
compared to female students (10.5%). Miyazaki et al[20]
suggested that halitosis in younger generation could be
attributable to tongue coating. Morita M[21] demonstrated a
correlation between the levels of volatile sulphur compounds
on the dorsum of the tongue and oral malodor.
Smoking has adverse impact on oral and systemic health.
40.7% and 4.1% of male and female dental students were
smokers. The study done[11] on Turkish dental students showed
that 26% of the examined students were smokers. The
prevalence of the smoking rate in the previous studies done on
the dental students in Greece, Serbia, Hungary, France, and
Italy were 47%, 43%, 34%, 33% and 33% respectively.[11]
Majority of the dental students were aware regarding the ban of
smoking in public places. Dentists adapted to the smoking
habits are less likely to counsel their patients to quit the habit.
Health care providers play an important role in educating
patients about the health risks of tobacco use and in promoting
tobacco cessation thus a role model image to them. The high
percentage of smoking habits amongst dentist may lead to the
downfall of this image in future.
In the conclusion, the female dental students had better oral
hygiene practices and its care in comparison to the male dental
students. The prevalence of smoking was more in males as
compared to females. As a health care provider dental students
should be a good model to their family members, friends and
especially to their patients for oral health behavior. The
improvement of personal oral health among dental students
has shown to be linked to their dental education experience, so
emphasis on the preventive and health education should be
made right from their preclinical courses. Curriculum
involving the tobacco risks and its cessation should be
involved throughout 5 years of their education.
The self-perception and self-reported data needs to be
evaluated carefully due to the concerns about the reliability of
the information. Estimation of oral malodor using standard
technique is recommended in further studies.
References
1. Peker I, Alkurt MT. Oral health attitudes and behavior
among a group of Turkish dental students. Eur J Dent 2009;
3: 24-31.
2. Dagli RJ, Tadakamadla S, Dhanni C, Duraiswamy P,
Kulkarni S. Self reported dental health attitude and
behavior of dental students of India. J Oral Sci 2008; 50:
267-272.
3. Cortes FJ, Nevot C, Roman JM, Cuenca E. The evolution
of dental health in dental students at University of
Barcelona. J Dent Educ 2002; 66: 1203-1208.
4. Polychronopoulou A, Kawamura M, Athanasouli T. Oral
self care behavior among dental students in Greece. J Oral
Sci 2002; 44: 73-78.
5. Alomari Q, Nusair KB, Said K. Smoking prevalence and
its effect on dental health attitudes and behavior among
dental students. Med Princ Pract 2006; 15: 195-199.
6. Olive KE, Ballard JA. Attitudes of patients toward
smoking by health professionals. Public Health Rep 1992;
107: 335–339.
7. Puska PM, Barrueco M, Roussos C, Hider A, Hogue S. The
participation of health professionals in a smokingcessation programme positively influences the smoking
cessation advice given to patients. Int J Clin Pract 2005; 59:
447–452.
8. Almas K, Al-Hawish A. Oral hygiene practices, smoking
habits and self perceived oral malodor among dental
006
students. J Contemp Dent Pract 2003; 4: 77-90.
9. Tonzetich J. Production and origin of oral malodor: a
review of mechanisms and methods of analysis. J
Periodontol 1977; 48(1):13-20.
10. Durham TM, Malloy T, Hodges ED. Halitosis: knowing
when ‘bad breath’ signals systemic disease. Geriatrics
1993; 48(8):55-59.
11. Yildiz S, Dogan B. Self reported dental health attitudes and
behavior on dental students in Turkey. Eur J Dent 2011; 5:
253-259.
12. Eli I, Baht R, Koriat H. Self-perception of breath odor. J
Am Dent Assoc 2001;132(5): 621-626.
13. Meskin LH. A breath of fresh air. J Am Dent Assoc 1996;
127(9):1282-1286.
14. Miyazaki H, Sakao S, Katoh Y, et. al. Oral malodor in the
general population of Japan. In: Bad breath: research
perspectives, eds. Rosenberg , M. pp. 119-136. Tel Aviv:
Ramot Publishing.
15. Söder B, Johansson B, Soder PO. The relation between
foetor ex ore, oral hygiene and periodontaldisease. Swed
Dent J 2000; 24(3):73-82.
16. Frexinos J, Denis P, Allemand H, et. al. Descriptive study
of digestive functional symptoms in theFrench general
population. Gastroenterol Clin Biol. 1998; 22(10):785-
791.
17. Al-Motairy EA, Al Ghizzy SA, Chohan AN, et. al. Caries,
oral hygiene and smoking among the maleundergraduate
dental students of King Saud University, College of
Dentistry, Riyadh, Interns ResearchSeminar, 16 April
2001.
18. Almas K, Maroof F. Prevalence of smoking and oral
hygiene habits among secondary school boys inRiyadh. J
Dent Res 2001; 80: Special issue; 636 (Abstr # 0789).
19. Suarez F, Furne J, Springfield J, et. al. Morning breath
odor: influence of treatments on sulfur gases. JDent Res
2000; 79(10): 1773-1777.
20. Miyazaki H, Sakao S, Katoh Y, et. al. Correlation between
volatile sulphur compounds and certain oral health
measurements in the general population. J Periodontol
1995; 66(8): 679-684.
21. Morita M, Wang HL. Relationship between sulcular
sulfide level and oral malodor in subjects with periodontal
disease. J Periodontol 2001; 72(1): 79-84.
007
www.dherald.in
E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
Original Article
Comparison Of Dentin Caries Excavation With Polymer Bur, Diamond Bur And Conventional
Tungsten Carbide Burs - An In Vivo Study
Shashi Paul1, Ajay Chhabra2, Varun Jindal3, Bhavna Sharma4, Gurkirat Grewal5
1
PG Student, Deptt Of Conservative & Endodontics, Bhojia Dental College Distt Solan. Baddi (HP)
Professor & Hod, Deptt Of Conservative & Endodontics, Bhojia Dental College Distt Solan. Baddi (HP)
Reader, Deptt Of Conservative & Endodontics, Bhojia Dental College Distt Solan. Baddi (HP)
4
PG Student, Deptt. Of Prosthodontics, Bhojia Dental College Distt Solan. Baddi (HP)
5
PG Student, Deptt Of Conservative & Endodontics, Bhojia Dental College Distt Solan. Baddi (HP)
2
3
Abstract
To compare the effectiveness of polymer burs (Smart Prep, SS White) and conventional carbide & diamond burs in removing dentin caries.
Method and Materials : Fifteen patients with carious permanent teeth were assigned to 3 groups according to the caries removal technique. Green
staining by the dye indicates caries, whereas no staining indicates exposed inner dentin or normal dentin. Using the dye as a guide, sequential thin
layers are removed with burs until the excavated surface is no longer stained. Tactile and visual judgments have been used to evaluate whether
infected dentin was removed after cavity preparation.
Result : No significant differences were observed in the mean dentin caries removal with diamond and carbide bur .The mean values for the carious
surface areas differed minimally between polymer bur with carbide and diamond bur.
Key Words
Polymer Bur, Carbide Bur, Diamond Bur, Caries Revealing Dye.
Introduction
The techniques used in carious dentine removal have
developed since GV Black, in 1893, initially proposed the
principle of ‘extension for prevention’ in the operative
treatment of carious lesions. He proposed that the removal of
sound tooth structure and anatomical form at sites that might
otherwise encourage plaque stagnation (eg occlusal fissures,
approximal contact points) would help minimise caries onset
and progression. These principles of cavity preparation were
based on the clinical presentation of caries and constrained by
the knowledge of the disease process and the restorative
materials available at that time. [1]
A number of excavation techniques are available to the dentist.
It has been suggested that during the operative treatment of
carious dentine, only the heavily infected, softened and wet
dentine require removal prior to restoration placement.[2] The
outer layer of carious dentin, which is 1 of the 2 distinct carious
layers, is highly infected with bacteria, and collagen fibrils are
irreversibly denatured. The inner caries-affected layer,
invaded by fewer bacteria, has limited collagen denaturation
and is capable of remineralisation. Thus the goal is to preserve
the potentially remineralizable inner layer as much as
possible.[3]
When removing demineralized dentin, it is not always easy to
Quick Response Code
Dr. Shashi Paul,. PG Student
Deptt Of Conservative & Endodontics.
Bhojia Dental College Distt Solan. Baddi (HP)
know when to stop excavation because there is an apparent
lack of objective clinical markers.[1],[2],[3] Traditionally, tactile
and visual judgments have been used to evaluate whether
infected dentin was removed after cavity preparation.[4]
The introduction of caries detector dyes for clinical use can be
a means to overcome the inherent problem of classical visual
and tactile techniques to ensure acceptable clinical excavation
without persisting bacteria.[5] Staining by the dye indicates
caries, whereas non staining indicates exposed inner carious
dentin or normal dentin. Using the dye as a guide, sequential
thin layers are removed with burs until the excavated surface is
no longer stained. A disadvantage of the technique is that non
carious dentin may be stained.[6]
Traditionally, carious dentin may be removed mechanically
with burs, hand excavators, and air-abrasion. Since diamond
and tungsten carbide burs are indiscriminate in their removal
of carious tissues, they can remove caries-infected and cariesaffected dentin simultaneously, with possible extension into
the underlying sound dentin.[7] This may be accompanied by
pain and necessitates the application of local analgesia during
treatment. A novel, recently proposed, self-limiting concept in
mechanical caries removal has been brought to fruition by the
introduction of a polymer bur (Smart Prep, SS White Burs,
Inc., Lakewood, NJ, USA). The paddle-shaped bur has a
unique flute design, and is constructed from a medical-grade
polyether-ketone- ketone, with a particular hardness and wear
resistance that reportedly enable it to remove only the soft
caries-infected dentin, leaving the caries-affected dentin
intact. Utilized exclusively at low speed (500-800 rpm), the
bur quickly dulls and vibrates when it encounters the more
highly calcified caries-affected dentin. Although the selflimiting concept of caries removal appears to have potential
008
merits, and its use without local anesthetic is accepted by
patients, the ability of the polymer bur to remove infectious
carious tissues and produce optimal bonding substrates in the
remaining dentin has not been established. [8],[9]
The Objective of this study is to compare the effectiveness of
polymer burs (Smart Prep, SS White) and conventional
carbide & diamond burs in removing dentin caries with the
help of Tactile sensation, visual appearance, acoustic
characteristics (a sharp scratching sound), and/or caries
detector dyes .
Materials and Method
This study was conducted in Department of Conservative and
Endodontics, Bhojia Dental College and Hospital, Baddi.
(H.P)
Materials
?
Polymer burs (no4,Smart Prep, SS White)
?
Round carbide bur (no. 4, SS White Co)
?
Round diamond burs(BR 41, SS White Co)
?
Sterile spoon excavator.
?
LA (LIGNOCAD ADR, CADILA phrm.)
?
Air Rotor (NSK)
?
Suction tip
?
Micro motor and contra angle ( Marathan, NSK,JAPAN)
?
Caries Revealing dye (PREVEST DENPRO LIMITED)
Method
Fifteen patient who attended as outpatients in the Department
of conservative and endodontics, Bhojia dental college Baddi,
Himachal , India, were selected. All teeth with occlusal
dentinal carious lesions without pulpal involvement were
chosen. Caries diagnosis was done both clinically and
radiographically using intraoral periapical radiograph (IOPA)
in addition to visual and tactile assessment to judge the depth of
the teeth’s carious lesions. Ethical clearance was obtained
from the institution’s research ethics committee, Bhojia dental
college Baddi, Himachal, India and each patent was signed an
informed consent form.
The criteria for inclusion in the sample stipulated that each
patient must have occlusal carious lesions on with softened
dentin involvement.
The exclusion criteria were: Teeth following clinical or
radiological signs and symptoms: pulpal, periodontal, and soft
tissue pathology in the involved tooth. Also excluded were
nonvital teeth and teeth with pit and fissure caries.
Caries excavation was done by a single operator in all teeth,
which were divided into 3 groups. All teeth in each group were
isolated with a rubber dam, and surface debris and the
outermost layer of carious dentin were removed using a sterile
excavator. Cavities were rinsed with saline and dried with a
sterile cotton pellet. If there is any hard enamel covering the
soft caries was removed by air-Rotor.
Group 1-Carbide Bur (n=5), caries was excavated using a new
round carbide bur (no. 4, SS White Co) with a slow-speed
handpiece at 800 rpm from the occlusal aspect until hard dentin
was detected using straight probe. Caries removal was verified
with a dental explorer and then with the caries detector dye
(PREVEST DENPRO LIMITED, as recommended by the
manufacturer. The caries detector dye was dropped onto a
sterile cotton pellet, and then the pellet was placed into the
cavity and removed after 10 seconds. The solution was rinsed
off with sterile saline. When small areas of carious dentin were
observed with the help of the dye, caries removal was again
carried out.
For Group 2-Smartburs (n=5): New polymer burs (Smart bur,
nos. , 4, SS White Co) were used with slow speed handpiece at
800 rpm. Caries was excavated with circular movements
starting from the center of the lesion to the periphery, as
recommended by the manufacturer. Caries removal was
verified with a dental explorer and then with the caries detector
dyes (PREVEST DENPRO LIMITED), as recommended by
the manufacturer. The caries detector dye was dropped onto a
observed at the undercuts with the help of the dye, caries
removal was again carried out.
Excavation was stopped when the instrument became
macroscopically abraded and blunted and was no longer able
to remove tissue.
For group 3-diamond bur 3 (n=5) Caries was excavated using a
new round diamond bur (no.BR 41, SS White Co) with a slowspeed handpiece at 800 rpm from the occlusal aspect until hard
dentin was detected using straight probe Caries removals was
verified with a dental explorer and then with the caries detector
dye (PREVEST DENPRO LIMITED), as recommended by
the manufacturer. The caries detector dye was dropped onto a
observed with the help of the dye, caries removal was again
carried out.
Results
No significant differences were observed in the dentin caries
removal with diamond and carbide bur. The carious surface
areas differed minimally between polymer bur with carbide
and diamond bur. As the caries removal was verified with a
dental explorer and then with the caries detector dye was found
that small amount of discoloured surface was left in case of
polymer bur used but in diamond and carbide group all the
discoloured surfaces was removed. (Fig 1, 2, 3)
Discussion
Dentinal caries removal is normally accomplished using rotary
carbide burs and hand excavators. Carbide burs, which
perform better than steel burs, are superior at a higher speed but
mostly are associated with noise, pain, overheating, vibration,
and discomfort.[10],[11] Recently, special burs made of polymer
material were introduced and the hardness of this bur is less
than that of healthy dentin but more than infected dentin.[12]
After caries removal under in vitro study conditions, a slightly
but clinically irrelevant greater amount of residual caries was
found using the polymer burs compared to that obtained with
carbide burs and diamond bur. The method can apparently
differentiate between soft and hard tissue, but, as conventional
carbide and diamond burs do, polymer burs may not be able to
differentiate softened but still remineralizable hard tissue with
minimal collagen degradation. [13]
In a recent in vitro study, Celiberti et al [14] assessed the speed
and caries removal effectiveness of 4 different dentin
009
[a]
[b]
[c]
[a]
[b]
[c]
[d]
[d]
Fig 1(A, B, C, D) Caries Excavation With Polymer Bur
Fig 3(A, B, C, D) Caries Excavation With Carbide Bur
[a]
[c]
[b]
[d]
Fig 2(A, B, C, D) Caries Excavation With Diamond Bur
excavation methods in primary molars. The procedure of
determining the dentin hardness during caries removal with an
explorer is seen clinically as a good standard prerequisite for
future treatment success.
Kidd et al[15] found significantly less cariogenic bacteria in hard
dentin than in softened dentin. However, clinical hardness
does not necessarily correspond with the amount of carious
dentin that should strictly be removed. The distinction must be
made between infected carious dentin, which should always be
removed, and affected carious dentin, which may be left. Intact
collagen forming the demineralized, slightly softened inner
dentin layer of a caries lesion can be remineralized, ie,
hardened,[16] and therefore, from a biologic and therapeutic
point of view, must not necessarily be eliminated.
Several studies also showed that caries detector dyes cannot
discriminate affected, non infected, sclerotic (translucent), or
reparative dentin.[17]
These facts have to be considered in studies like the present one
that use caries-detector dyes, because the results may lead to
overestimation of the real amount of affected carious dentin
tissue that must be eliminated. Thus, the minimal amount of
residual caries found for method using burs could be
considered clinically irrelevant, but the exact contribution of
each of these factors needs to be clarified in future studies.
Conclusion
Under the presented in vivo study conditions, diamond and
tungsten carbide burs were similarly effective for stained
dentin removal but some time single polymer bur was not able
to remove all the stained dentin.
References
1. A. Banerjee,1 t. F. Watson,2 and e. A. M. Kidd: dentine
caries excavation: a review of current clinical techniques ;
British dental journal ; volume 188. No.9 may 13, 2000
2. Banerjee, E.A.M. Kidd, T.F. Watson :Scanning electron
microscopic observations of human dentine after
mechanical caries excavation: Journal of Dentistry 28
(2000) 179–186
3. Banerjee A, Watson TF, Kidd FA. Dentin caries: Take it or
leave it? Dent Update 2000;27: 272-6.
4. Banerjee A, Kidd EA, Watson TF In vitro evaluation of five
alternative methods of carious dentin excavation. Caries
Res 2000:34:144-50.
5. M. Zakirulla, K.S. Uloopi , V.V. Subba Reddy: In Vivo
Comparison of Reduction in Bacterial Countafter Caries
Excavation with 3 Different Techniques Journal of
Dentistry for Children-78:1, 2011
6. Fusayama T. Clinical guide for removing caries using a
caries-detecting solution. Quintessence Int 1988; 19: 397401.
7. Yip HK, Samaranayake LP Caries removal techniques
andinstrumentation: a review. Clin Oral Invest 2:148-154.
(1998).
8. Boston DW New device for selective dentin caries
removal. Quintessence Int 34:678-685. (2003).
9. Allen KL, Salgado TL, Janal MN, Thompson VP
010
Removing carious dentin using a polymer instrument
without anesthesia versusa carbide bur with anesthesia. J
Am Dent Assoc 136:643-651. (2005).
10. Banerjee A, Kidd EAM, Watson TF. Dentin caries
excavation: A review of current clinical techniques. Br
Dent J 2000;188:476-82.
11. Anusavice KJ, Kincheloe JE. Comparison of pain
associated with mechanical and chemicomechanical
removal of caries. J Dent Res 1987;66:1680-3.
12. Celiberti P, Francescut P, Lussi A. Performance of four
dentin excavation methods in deciduous teeth. Caries Res
2006;40:117-23.
13. Christian Meller,Alexander Welk,Thomas Zeligowski,
Christian Splieth. Comparison of dentin caries excavation
with polymer and conventional tungsten carbide burs.
Quintessence Int 2007;38:565–569
14. Celiberti P, Francescut P, Lussi A. Performance of four
dentine excavation methods in deciduous teeth. Caries Res
2006;40:117–123.
15. Kidd E, Joyston-Bechal S, Beighton D. Microbiological
validation of assessments of caries activity during cavity
preparation. Caries Res 1993;27: 402–408.
16. Kato S, Fusayama T. Recalcification of artificially
decalcified dentin in vivo. J Dent Res 1970;49: 1060–1067
17. HK, Stevenson AG, Beeley JA. The specificity of caries
detector dyes in cavity preparation. Br Dent J
1994;176:417–421.
011
www.dherald.in
E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
Original Article
Comparative Study Of Physicochemical Properties Of Mta, Portland Cements And Modified
Portland Cement
Rachna Dhani1
1
Department of Conservative Dentistry & Endodotics, Indira Gandhi Government Dental College and Hospital, Jammu
Abstract
Aim: To evaluate and compare chemical composition of white ProRoot MTA with gray and white Portland cements and a novel composition of
Portland cement with bismuth oxide.
Methods: The Chemical Composition and surface characteristics of both in powder and bound form of samples were analyzed by energy
dispersive X-ray analysis (EDX) and Surface electron microscopy respectively.
Results: The chemical composition of white Portland cement, gray Portland cement, modified Portland cement and MTA were very similar in
powder and bound form. The only difference was the presence of bismuth ions in MTA and modified Portland cement and iron in gray Portland
cement.
Conclusion: The MTA and Modified Portland cements showed similar physico-chemical properties and EDX study showed similar chemical
composition but not same.
Key Words
MTA (Mineral Trioxide Aggregate), Portland cement(s)
Introduction
Many significant advancements in health care occurred in the
20th century which have direct impact on dental practice
through the development of new treatments and preventive
modes, new biomaterials applicable to dental practice and
more sophisticated techniques to measure the health status of
individuals. The ultimate goal of dentistry is to maintain and
improve the quality of life of dental patients. This goal can be
achieved by preventing disease, relieving pain, improving
mastication, enhancing speech and improving appearance.
Because many of these objectives require the replacement or
alteration of tooth structure, the main challenges for the
centuries have been to develop biocompatible, long lasting
restorative materials which can withstand the adverse
challenges of the oral environment.[1] The first publication on
the use of the material to seal root perforation was published in
1993. MTA was described for the first time in the dental
literature by Lee et al., 1993.[2] As an endodontic repair cement,
it was applied for patent in the mid 1990.[3] Clinically, MTA is
being used in dental procedures such as vital pulp therapy,
apexification, repair of root perforation, root end filling,
internal bleaching and resorption repair. In a series of tests,
MTA has demonstrated excellent sealing ability.[4] It has been
successfully used for direct pulp capping and repair of furcal
perforations.[5] Mohmoud Torabinejad in 1995 determined the
chemical composition, pH, radiopacity, setting time,
compressive strength and solubility of MTA and compared
Quick Response Code
Dr. Rachna Dhani
Department of Conservative Dentistry & Endodotics,
Indira Gandhi Government Dental College and
Hospital, Jammu
with those of amalgam, super-EBA and Intermediate
Restorative Material (IRM).[5] Ford et al., in 1996 examined the
dental pulp responses in monkeys to mineral trioxide
aggregate, or MTA, and a calcium hydroxide preparation when
used as pulp capping materials. Based on his results, it appears
that MTA has the potential to be used as a pulp-capping
material during vital pulp therapy.[5],[6] Studies were conducted
to examine the periradicular tissue response of monkey to
MTA as a root end filing material in man. Koh et al., 1998
studied the cytomorphology of osteoblasts in the presence of
Mineral Trioxide Aggregate (MTA) and examined cytokine
production. His studies revealed that MTA offers biologically
active substrate for bone cells and stimulates IL production.[7]
Zhu et al., 2000 conducted a study to observe the adhesion of
human osteoblast on root end filling materials (MTA, IRM,
composite and amalgam). The result indicated that osteoblast
have a favourable response to MTA and composite resin
compared with IRM and amalgam.[8] Roy et al., 2001 in an in
vitro study evaluated the effect of an acid environment on
leakage of amalgam, Geristore, super EBA mineral trioxide
aggregate (MTA), calcium phosphate cement (CPC) or MTA
with CPC matrix. Author concluded that an acid environment
did not hinder the sealing ability of any of the materials
tested.[9] Giuliani et al.,in 2002 evaluated three clinical cases
treated an apical plug of MTA for apexification. MTA appears
to be a valid option for apexification with its main advantage
being the speed at which the treatment can be completed.[10]
Steinig TH et al., 2003 proposed a one visit apexification
protocol with MTA as an alternative to the traditional treatment
practices with Ca (OH)2. One visit apexification may shorten
the treatment time between the patient’s first appointment and
the final restoration. Compared the major constituents present
in ProRoot MTA, PMTA (tooth coloured formula), ordinary
Portland cement and white Portland cement using X-ray
diffractometery and found that tricalcium silicate, tricalcium
012
aluminate, calcium silicate, and tetracalcium aluminoferrite
were the main constituents in all the four cements with the
additional presence of Bismuth oxide in ProRoot MTA and
ProRoot MTA (tooth coloured formula).[11] Oliveira, 2007
compared the components of a Portland cement to two
commercial branch of MTA. He concluded that tested cements
have similar components, (except Bismuth was present only in
MTA cements) which supports, as far as composition is
concerned, the possible clinical use of Portland cements as an
option to MTA.[12]
Materials and methods
Materials
MTA (ProRoot), White Portland Cement (IS : 80421989),Bismuth Oxide (99% pure),Distilled Water, Glass Slab,
Stainless Steel Spatula, Stainless Steel die, Pipette, Borosil
China Dish, Butter Paper, 600 Grit Silicon Paper, Modeling
Wax, Syringe, Scanning electron Microscope (Leo 1430
VP),Electronic Balance (Sertorious) ,Vibrator, Mixing
Machine, Microhardness Tester (Micromet 2101) .White
Portland cement (IS: 8042-1989 was selected with Blaine
number 390 to 410), Bismuth Oxide (99% and other ingredient
NO3 & Arsenic 1 ppm. Arsenic level is far below the level of
toxicity acceptable level of Arsenic is food in 3.5 ppm), MTA
(ProRoot) Tooth Coloured formula (Blaine number 450 – 460),
Mineral trioxide Aggregate (80% white Portland cement and
20% of Bismuth oxide by weight), Modified Portland Cement
(mixture of white Portland cement and Bismuth Oxide in the
ratio of 4 : 1 by weight.
Preparation of Samples
Prepared modified Portland cement by mixing of white
Portland cement and Bismuth Oxide in the ratio of 4: 1 by
weight) to keep ratio similar to MTA i.e. 80:20. This ratio was
chosen because in both commercially available MTA i.e.
ProRoot MTA and MTA Angelus the have percentage by
weight of Bismuth oxide is 20. The mixing was done in a
milling machine with metal balls for two and half hours and
immediately sealed in airtight plastic bag to protect the mixed
material from moisture.
Chemical Composition & Surface Morphology
Energy dispersive x-ray spectrometer system was used to
determine the chemical composition of the examined
materials. Scanning electron microscopy was performed to
study surface characteristics of MTA, white Portland cement,
and gray Portland cement and modified Portland cement for
both powder and bound form of cements. Bound form was
prepared by mixing the powder form with distilled water in the
ratio prescribed by Dentsply. Tulsa Dental i.e. 3: 1 on clean, dry
glass slab with stainless steel spatula. To make same size of
samples, a steel die was taken and material was allowed to set
for 24 hrs. To observe them under SEM, for the surfaces were
made smooth with 600 grit silicon papers. For this cylindrical
Aluminum stubs with adhesive i.e. double-coated conductive
carbon tape was taken, on which the samples were mounted.
As the study material was non-conductive so to make it
conductive Gold coating was done as the surface of powder
form was irregular. Gold coating was applied at a thickness of
20 nanometers. This thickness was too thin to interfere with
dimensions of surface features. The mounted aluminum stubs
were placed in the vacuum chamber of SEM for analysis. For
Table 1 Chemical composition of (a) White Portland cement (b) Grey Portland
cement,(c)MTA,(d) Modified Portland cement.
Elements White Portland Cement
Powder
Bound
Grey Portland Cement
Mta
Powder
Powder
Bound
Modified Portland Cement
Powder
Bound
Bound
Wt % At % Wt % At % Wt % At % Wt % At % Wt % At % Wt % At % Wt % At % Wt % At %
OK
50.18 72.79 55.56 75.01 49.26 67.65 52.08 71.09 48.26 69.85 44.24 67.08 36.21 61.54 50.18 72.79
Al K
1.27 1.10 -
Si K
3.98 3.29 4.38 3.37 14.73 11.52 9.61 7.47 8.88 7.32 8.76 7.57 8.62 8.34 3.98 3.29
KK
5.05 3.00 2.41 1.33 0.95 0.53 0.76 0.43 -
Ca K
33.00 19.11 37.65 20.29 25.27 13.85 31.59 17.21 37.09 21.42 39.18 23.71 39.44 26.76 33.00 19.11
Bi M
6.51 0.72 -
-
-
Fe
-
-
3.64 1.43 2.45 0.96 -
-
-
-
6.16 5.01 3.51 2.84 1.03 0.88 0.93 0.84 1.49 1.50 1.27 1.10
-
-
-
-
-
-
0.00 0.00 5.05 3.00
4.74 0.52 6.88 0.80 14.25 1.85 6.51 0.72
-
-
-
-
-
-
-
morphological view the samples were viewed at the
magnification of 400x, with energy dispersive spectroscopy
the chemical compositional analysis was done in both atomic
and weight percentage.
Results
Chemical Composition & Surface Morphology The chemical
composition of white Portland cement, gray Portland cement,
modified Portland cement and MTA were very similar in
powder and bound form. The only difference observed
between white Portland cement and MTA was presence of
bismuth in MTA. Modified Portland cement was similar to
MTA. Table (1). Gray Portland cement was similar to white
Portland cement except for presence of iron is gray Portland
cement. Potassium was absent in MTA but present in rest of
materials. Observing the morphological characteristic of
samples under SEM. White Portland cement bound form
showed Crystals size 10 - 30 µm in size (Fig.6). Crystals were
irregularly rounded in shape and Surface appearance of
aggregate was smooth. Modified Portland cement bound form
Crystal size was less than 10 µm (Fig. 7) Crystals were
rounded in shape. Surface appearance of aggregate was
smooth. Gray Portland cement bound form crystals were 10-30
µm in size. (Fig. 8) Crystals were irregular in shape, some are
round and some are square shaped. Surface appearance of
aggregate was smooth. White Portland cement powder form
Particle size - 5 - 25 µm. Particles were irregularly rounded and
some are long. Particles shape and distribution was not
homogeneous (Fig. 4). Modified Portland cement powder
form Particle size was 2 - 20 µm and rounded smaller size
particles were more in number, more homogeneous particles
shape and distribution (Fig. 3). Gray Portland cement powder
form Particle size was 3-30 µm Particles were rounded; needle
EDX Spectrum of MTA
EDX Spectrum of White Portland cement
EDX Spectrum of Modifies Portland Cement
EDX Spectrum of Grey Portland
013
MTA bound form
White Portland bound form
Modified Portland bound form
Grey Portland bound form
Gray Portland powder form
Modified Portland powder
White Portland powder
MTA powder
like and some are large irregular shaped, less homogeneous
particles shape and distribution (Fig. 5). MTA bound form
Crystals were less than 10 µm and crystals were rounded and
closely adhered Surface appearance of aggregate was smooth
(Fig. 1). MTA power form Particle size was 5 - 25 µm Particle
were irregularly rounded & some needle shaped particle were
also present, more homogeneous particles shape and
distribution. (Fig. 2)
Statistics
Posthoc test was done for multiple comparisons when
compared the groups with each other using post HOC test. The
level of significance was established at 5%. ANOVA is
performed to compare the means. The statistic was carried out
using graph pad prism.
Discussion
Mineral Trioxide Aggregate (MTA) has been investigated as a
potential compound to seal off the pathways of communication
between the root canal system and the external surface of the
tooth. MTA is a new class of water based cement that has been
added to biomaterials. Most important advantages associated
with it are biocompatibility; good sealing ability and it
promote regeneration of body tissues i.e. bone, cementum,
dentinal bridge. MTA was first developed as a root end filling
material. Although MTA is popular, there have been concerns
about its cost, difficult handling characteristics and long
setting time MTA is a fine powder consisting of hydrophilic
particles of tricalcium silicate, tricalcium aluminate,
tricalcium oxide and silicate oxide (Schwartz et al., 1999).
MTA is marketed as, Gray MTA (GMTA) - Proroot MTA
(Dentsply Tulsa, OK); MTA - Angelus (Angelus - Brazil);
White MTA (WMTA) - Tooth colored Proroot MTA (Dentsply,
Tulsa, OK). According to material safety data sheet proroot
MTA (Mineral Trioxide Aggregate) root canal repair material
is in powder state, off white in colour and consists of Portland
cement clinker 75% by weight, gypsum 5% by weight,
bismuth oxide 20% by weight. Major compounds so present
are Tricalcium silicate (3CaOSiO2); Bismuth Oxide (Bi2O3);
Dicalcium silicate (2CaOSiO2); Tricalcium aluminate
(CaO.Al2O3) Calcium sulfate dihydrate or Gypsum
(CaSO42H2O). Major component of MTA is Portland cement
clinker Portland cement clinker is composed of Tricalcium
silicate (CaO)3.SiO2; Dicalcium silicate (CaO)2.SiO2;
Tricalcium Aluminate (CaO).Al2O3. Gypsum (CaSO42H2O)
In gray Portland cement one additional compound is present
i.e. Tetracalcium aluminoferrite (CaO)4.Al2O3.Fe2O3. The
United States Patent no 5,415,547 and 5,769,638 for MTA
states that the base material for MTA is Portland cement and
bismuth oxide has been added to make the mix radiopaque
Torabinejad et al., 1995, 1998.[6],[14] Roberto Brandao, et al
2006 compared different type of Portland cements with
bismuth oxide, which has generated interest in the evaluation
of Portland cement as an alternative to MTA, as Portland
cement is less costly and widely available. When a material is
used as a substitute for other then it should have similar
physical, mechanical and biological properties. Although the
mechanical tests do not necessarily represent their actual
clinical performance, they are used to guide the effects of
changes in their composition or processing on their
properties.[15] Also, these mechanical tests might help some
how the clinician to choose once comparisons between former
formulations and new ones, as well as, with the leading brand,
as highlighted by manufacturer Linda Wang et al., 2003. So
here in this paper composition and some of the clinically useful
physical properties have been compared i.e. pH, hardness and
setting time of white Portland cement and WMTA.[16]
Considering morphological characteristics, the particle size or
granulation of cement is an important characteristic feature of
the physical properties and therefore it has been studied using
SEM. It is known that the materials physical structure and
surface characteristics in addition to its cytotoxicity is an
indication for the materials biocompatibility.[17]
The difference in the particle size of the four materials tested
are of great importance for the mechanical characteristics of
the bound cements. With a similar particle size a higher
mechanical strength is designed by a reduced spreading in grit
size (Locher et al., 1973)[18] which could be observed in white
Portland cement, modified Portland cement and Proroot MTA.
Similar morphology in bound from of modified Portland
cement and MTA had been seen. Particle size measurement
from scanning electron micrographs showed gray Portland
cement to be the most coarse having a mean particle size of 10 30 m. White Portland cement and MTA had similar particle
014
size of 2 - 20 m. Modified Portland cement showed similarity
to white Portland cement & MTA but it was more finer (2 - 15
m) in powder from. Camilleri et al., (2004), studied the
chemical constitution and biocompatibility of accelerated
Portland cement and found the similar finding under SEM.[19]
Though similar type of morphology of particles observed with
all four materials but some difference exist, in gray Portland
cement particles were more irregular, coarse and vary greater
in size. The white Portland cement particles were rounded and
uniform in size. MTA was similar to white Portland cement
except needle shaped particles were present and these needle
shaped particles were bismuth oxide. In modified Portland
cement, the particles were round and more uniform in size and
needle shaped particles were not present though bismuth oxide
was added. This may be because Portland cement & bismuth
oxide were mixed in a milling machine for two and half hours
which might reduced the size of particles of Portland cement
and bismuth oxide and long milling of particles made it
rounded. Camilleri et al. (2004) compared the MTA and
accelerated Portland cement (white Portland cement clinker
inter-ground without the gypsum and mixed with 4:1
proportion bismuth oxide and found the same results regarding
the morphology of particles of MTA and Portland cement.[19]
For checking material properties and interactions in the
biological systems like biocompatibility and cytotoxicity, it is
necessary to understand the materials surface. Further more,
the analysis of the surface composition helps to understand the
interaction of materials in biological systems. The surface of
bound forms of MTA, white and gray portland and modified
Portland cement were smooth.
Regarding the composition of powder and set from of four
material EDX was done. EDX of powder and bound form of all
material showed that the main constituent were calcium,
oxides, silicate and aluminate. Iron was present only in gray
Portland cement and it is responsible for providing gray colour
to gray Portland cement. Bismuth was present in modified
Portland cement and MTA. Potassium was absent in MTA but
in rest of the materials it was present. Bismuth so present in
MTA is mainly responsible for providing radiopacity. Bismuth
oxide is yellow colour powder or crystal that is insoluble in
water. It has molecular formula of Bi2O3 and molar mass of
465.959 g/mol. The melting point of Bismuth oxide is 8170C,
density 8.9 g/cm3 (solid) and pH is in the range of 9.5 to 115.
Bismuth oxide is present in 20 wt.% in Proroot MTA and MTA
Angelus. In this study bismuth oxide is added in 20 wt.% to
white Portland cement that was named as modified Portland
cement. Portland cement was white in colour but when
bismuth oxide was added to Portland cement then it became
off-white in colour, which was similar to MTA in colour.
In a comparative analysis of mineral trioxide aggregate and
Portland cement using plasma emission spectroscopy (ICPES), Funteas et al. (2003) evaluated 15 elements of MTA and
Portland cement composition. The results showed similarities
between the materials, except for the fact that there was no
detectable quantity of bismuth in Portland cement.[20] Estrela et
al. (2000), investigated the chemical and antimicrobial
properties of various materials including Portland cement and
MTA and found that both cements are constituted of the same
elements except for bismuth.[21] It was also concluded that
Portland cement differed from the MTA by the absence of
bismuth ions and presence of potassium ions. Gray MTA
contained a significant amount of iron when compared with
white MTA.
Hydration of MTA powder results is a colloidal gel that
solidifies to a hard structure in less than 3 hrs. The
characteristics of the aggregate depend on the size of the
particles, powder to water ratio, temperature, presence of
water, and entrapped air. It has generally been considered that a
potential root end filling material should set as soon as it is
placed in the root end cavity without significant shrinkage.
This condition would allow dimensional stability of the
material after placement and less time for an unset material to
be in contact with vital tissues. However, in general terms, the
quicker a material sets the more it shrinks. This phenomenon
may explain why MTA in previous experiments had
significantly less dye and bacterial leakage than other
materials tested as root end filling materials.[5],[6]
Portland cement has great similarity to MTA and offers
significant economical incentives if applicable in biological
systems. However, a major concern regarding use of waterbased cements is the amount of leachable arsenic and lead
present in the material. Arsenic and lead are impurities of
limestone that is used in the manufacture of Portland cement.
Duarte et al. (2005) determined the release of arsenic from gray
Portland cement, white Portland cement, PMTA and MTAAngelus. The results of their study showed very low levels of
arsenic released by the materials, with all values recorded
being well below the toxic levels.[22] (ISO 9917-1:2003
recommends that water based dental cements should contain
less than 2 mg/kg of acid soluble arsenic and less than 100
mg/kg of acid soluble lead). They concluded that the Portland
can be used in clinical practice, as far as the content of arsenic
is concerned. However, no study has compared the lead
content in these cements.
Portland cement can be easily sterilized either by gas or by
autoclaving (Islam et al., 1995, 1998). However this by no
means suggests that Portland cement in its native state is ready
to be used clinically. Medical devices are usually
manufactured under strict regulations, conforming to the FDA
good manufacturing practices and the European Medical
Device Regulations. Industrially manufactured Portland
cement in not approved currently for use in the United States
and therefore no clinical recommendation can be made for its
use in the human body. PMTA has undergone extensive tests
before approve for clinical use by FDA. Similarly, further in
vitro and in vivo tests should be conducted to determine the
suitability of Portland cement, whether in its native or
modified form for use clinically.
References
1. Kallus T, Major IA. Incidence of adverse effect of dental
materials. Scand J Dent 1991; 19:236-240.
2. Lee SJ, Monosef M, Torabinejad M. Sealing ability of a
mineral trioxide aggregate for repair of laterial root
perforations. J End1993;19:541 – 544.
3. White DJ, Torabinajad. Tooth filling material and use. US
patent number 5,769,638 1995.
4. Adamo HL, Buruiana R, Schertzer L, Boylan RJ. A
comparison of MTA, Super-EBA, composite and amalgam
as root-end filling materials using a bacterial microleakage
model. Int J End 1999;32: 197-203.
5. Pitt Ford TR, Torabinejad M, Abedi H.R., Bakland L.K.,
Kariyawasom SP. Using mineral trioxide aggregate as a
pulp capping material JADA 1996;127:1491 - 1494.
015
6. Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR,
Miller DA, Kariyawasam SP. Histologic assessment of
mineral trioxide aggregate as a root end filling in monkeys.
J End. 1997; 23(4):225-8.
7. Koh ET, Torabinejad M, Pitt Ford TR, Brady K, Mc Donald
F. Mineral trioxide aggregate stimulates a biological
response in human osteoblast. J Biomed Mat Res
1997;5:432 -439.
8. Zhu Q, Haglund R, Safavi KE, Spangberg LS. Adhesion of
human ostmmmmbeoblasts on root-end filling materials. J
End. 2000; 26:404-406.
9. Roy CO, Jeansonne BG, Gerrets TF (2001) Effect of an
acid environment on leakage of root end filling materials.
Journal of Endodontic 27,7-8
10. Giuliani V, Baccetti T, Pace R. Pagavino (2002) The use of
MTA in teeth with necrotic pulps and open apices. Dental
Traumatology 18, 217-21.
11. Steinig TH, Regan JD, Gutmann JL (2003) The use and
predictable placement of Mineral Trioxide Aggregate in
one-visit apexification cases. Australian Endodontic
Journal 29 34-42.
12. Oliveira M.G.,Xavies CB, Demasco.F, Comparative
chemical study of MTA and Portland cements. Braz Dent J.
(2007) ; 18:3-7.
13. Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd
mineral trioxide aggregate; a new material for endodontics.
J Am Dent Assoc. 1999; 130: 967-75.
14. Torabinejad M, Kettering JD (1995), Mutagenecity of
mineral trioxide aggregate Journal of Endodontic, 21 537 –
42.
15. Roberto Brandao, Ivaldo Games de M et al (2006) Healing
of root perforations treated with mineral trioxide aggregate
(MTA) and portland cement Journal of Applied Oral
Science 2006;14 305-11
16. Linda Wang, Paulo Henrique, Lawrence, Jose Carlos.
Mechanical properties of dental restorative materials
relative contribution of laboratory tests. J App oral Sci.
2003; 11: 567-89.
17. Till Dammaschke, Hans UV Gerth, herald Zuchner, Edgar
Schafer. Dental materials. 2005; 21: 731-738.
18. Locher FW, Sprung S, Korf P.Effects in grinding on cement
properties. ZKG Int.1973;26:349-55.
19. Camiller J, Montesin FE, Papaioannou S, Ms Donald F, Pitt
Ford TR. Biocompatibility of two commercial forms of
mineral trioxide aggregate. Int endo J. 2004; 37:699-704.
20. Funteas UR, Wallace JA, Fochtman EW. A comparitive
analysis of mineral trioxide aggregate and Portland
cement. Aust Endod j 2003;29:43-44.
21. Estrela C, Bammann ll, Estrela CR, Silva RS, Pecora
JD.Antimicrobial and chemical study of MTA, Portland
cement, calcium hydroxide paste, sealapex and dycal. Braz
Dent J. 2000;11:19-27.
22. Daurte MAH, Demarchi ACCO, Yamashita JC, Kuga MC,
Fraga SCF. pH and calcium ion release of 2 root-end filling
materials. Oral Surg Oral Med Oral Path 2003;95:345-47.
016
www.dherald.in
E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
Original Article
Awareness And Preference Of Needs Among Dental Patients Towards Artificial Prosthesis
Jasjit Kaur1, Navneet Sharma2, Parikshit Gupt3, Amit Kumar Babbar4
1
Senior lecturer – Department of Prosthodontics and Crown & Bridge, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India.
Reader - Department of Oral Medicine and Radiology, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India.
PG student-1st year Department of Prosthodontics and crown & bridge, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India.
4
PG student-1st year Department of Prosthodontics and crown & bridge, Himachal Dental College, Sunder Nagar, Himachal Pradesh, India.
2
3
Abstract
The face and smile plays an important role in the maintenance of positive attitudes about one’s self. Teeth play an important role in the maintenance
of positive self image. The loss of teeth results in significant disabilities, which can profoundly, disrupts social activities. Tooth Loss is very traumatic
and serious life event that requires social and psychological readjustment. The attitudes towards tooth loss are changing now days. The patients
are more aware about the dental treatment. Thus it is essential to evaluate awareness and preference of need before starting treatment as
treatment expectations may influence treatment modalities.A study was conducted among 250 edentulous and partially edentulous patients using
self supervised questionnaire containing questions regarding the knowledge towards artificial prosthesis among new patients at Department of
Prosthodontics and Crown & Bridge at Himachal Dental College,Sundernagar. Results of this study shows that majority of subjects realized that
fixed prosthesis are esthetically more attractive than removable prosthesis and less annoying in the mouth. Most of the subjects were having lack of
awareness and knowledge about implants. Results regarding the preference of need of artificial prosthesis shows that male subjects are more
aware of mastication and phonetics as function of denture while female subjects prefers dentures for esthetics.
Key Words
knowledge, attitude, edentulism, replacement of teeth, patient education
Introduction
Teeth and their supporting structures are an integral part of the
facial skeleton. They support and interact sensitively with
other parts of the skull to provide a biological system to interact
for chewing, speaking and expressing emotions. The loss of
teeth, until very recently, was accepted as a normal and
inevitable part of ageing, and old age was endured ‘sans teeth,
sans eyes, sans taste, sans everything.[1] Perception of
edentulous state may range from feeling of inconvenience to
the feeling of severe handicapped, because many individuals
regard tooth loss equivalent to loss of a body part.[2] Tooth Loss
is very traumatic and serious life event that requires social and
pschycological readjustment.[3]
Loss of teeth can result in significant disabilities such as
mastication, phonetics and aesthetics. Edentulism limits the
intake of favourite foods. Poor oral health not only affects the
dietary intake but also compromises the nutritional status and
general health of the patients.[4]
Edentulism affects the speech and appearance of the well being
and few patients are not at ease and comfort to interact in the
society. Desire for an esthetics is a major motivating factor for
persons seeking new dentures,as society places considerable
Quick Response Code
Dr. Jasjit Kaur
Senior Lecturer,
Department of Prosthodontics and Crown & Bridge
Himachal Dental College, Sunder Nagar, Himachal
Pradesh.
Mobile: 09418421528.
Email : drjasjitkaur@gmail.com
emphasis on physical appearance.[5] It has been suggested that
adverse reactions towards edentulism as well as the
individual’s feeling about dentures are important for the
acceptance of the new dentures.[6]
Bjorn and Owell noted that missing teeth are replaced
primarily for social and esthetic reasons and that treatment
decisions cannot be based solely on professional factors.[7]
Perceived need for tooth replacement are based on esthetics,
social, functional and cultural factors.[8] According to data
gathered in previous studies, many patients find the six
anterior indispensable but will accept edentulous spaces in the
posterior regions of the mouth.[9] Several studies have reported
that patients underestimate their treatment needs.[10] However
there is not much evidence about awareness among edentulous
or partially edentulous subjects about impairment of oral
functions followed by tooth loss and preference of need
towards artificial prosthesis in literature. Therefore a study
was planned using questionnaire to evaluate awareness and
preference of needs towards artificial prosthesis in individuals
who have reported first time in the dental institute.
Aims and objectives:
The aims and objectives of the study were to conduct clinical
survey using questionnaire to assist awareness towards
artificial prosthesis and regarding preference of needs of
prosthesis among edentulous and partially edentulous
subjects.
Material and methods:
A study was conducted to determine patient’s awareness
towards artificial prosthesis and preference of need of
prosthesis. A pilot study was carried out on 10 patients to
017
Table.1 : Characteristic feature of the studied subjects regarding awareness and preference
of needs among dental patients towards artificial prosthesis.
Questionnaire
Knowledge of subjects
Male (112)
Female (138 )
Que 1 Do you think the lost teeth can be replaced by artificial means?
Yes
110 (98.21%)
105 (76.08%)
Que 2 Mention your preferable method of teeth replacement?
Removable Partial Denture
Fixed Partial Denture
Implants
++
46 (41.07)%
54 (39.13)%
+++
62 (55.35)%
80 (57.97)%
+
4 (3.57) %
4 (2.89%)
88 (78.57)%
136 (98.55)%
Que 3 Do you think lost teeth had affected their appearance?
Yes
Que 4 Do you think that lost teeth had affected their ability to chew food?
Yes
105 (93.75)%
95 ( 68.84)%
Que 5 Do you think that lost teeth had affected their ability to speak?
Yes
71 ( 63.39) %
60 (43.47)%
Que6 Do you think prosthesis need oral hygiene maintenance every day?
Yes
76 (67.85)%
75 (54.34) %
Que 7 Do you think prosthesis should be removed at night while sleeping?
Yes
54 (48.21) %
84 (60.86)%
check the feasibility of the study and validation of
questionnaire. Following the successful pilot study, main
study was conducted on 250 patients between ages 26 and 65
years reported first time to Department of Prosthodontics,
Himachal Dental College, Sundernagar.
Clinical examination was followed by questionnaire. A
questionnaire which sought patient’s awareness and
preference of needs of prosthesis was prepared. Questionnaire
consists of questions related to socio demographic factors and
awareness of patients regarding need of prosthesis.
Among these 250 subjects 80 were completely edentulous and
rest were partially edentulous. In completely edentulous
subjects 40 were female subjects and 40 were male subjects. In
partially edentulous cases 72 were male subjects and 98 were
female subjects. These subjects were informed of the nature of
study and they had given their consent for the study. The
questionnaire was completed personally for each patient who
gave consent to participate in the study in the form of interview
to allow them to express their ideas. Then the collected data
was analyzed.
Results:
As shown in Table no.1 among the 250 subjects surveyed,
68.0% were dentate and 32% were edentulous either in both
arches. 98.21% male and 76.08% female subjects were aware
that teeth can be replaced by artificial prosthesis. When
subjects were asked about the preferable methods of treatment
modality then 41.07% male and 39.13% female subject’s
preferred removable prosthesis and 55.35% male and 57.97 %
female subjects preferred fixed prosthesis and 3.57%male and
2.89% female subjects preferred implant prosthesis.
When these subjects were asked about the preference of need
for treatment 78.57% male and 98.55% female agreed that lost
teeth had affected their appearance. On the other hand 93.75%
male and 68.84% female subjects realized that lost teeth had
affected their ability to chew food, 63.39% male and 43.47%
female subjects realized that lost teeth had affected their ability
to speak.
When subjects were asked about their awareness that
prosthesis need oral hygiene maintenance every day, 67.85%
male and 54.34% female subjects showed their awareness that
prosthesis needs oral hygiene maintenance every day. On the
other hand 48.21% male and 60.86 % female subjects were
having knowledge regarding removal of artificial prosthesis at
night.
Discussion:
The oral health being an integral part for the healthy living,
necessity of disability limitation and rehabilitation in oral
health has taken a paramount role[11]. Rising knowledge of
treatment modalities in the society paves way for its ready
acceptability. But for this a baseline data on their level of
awareness is required. Thus a study was conducted to assess
the patient’s awareness towards artificial prosthesis. This kind
of survey provides data on patient’s awareness level,
knowledge, acceptance, mind set towards an artificial
prosthesis which can be used to formulate patient’s education
and motivation strategies, treatment policies and guidelines for
treatment modalities in this region. From the present study it is
observed that subjects are aware that artificial prosthesis are
used to replace the missing teeth.
The present study gives information about subject’s
knowledge towards artificial prosthesis and their needs. Most
of the subjects felt that the fixed prosthesis gives better feeling
in the mouth and appears natural. This result was similar to a
study conducted by Tepper et al and Zimmer et al[12], [13] that
fixed prosthesis is esthetically more attractive than removable
prosthesis and less annoying in the mouth.
As 41.07% male and 39.13 % female subjects felt removable
partial dentures are better means of replacing missing teeth.
These findings differ significantly from that reported by
Sulieman Al-Johany[14] and closely related to study done by
Kumar CR[15] where 37.64 % subjects chose removable
treatment as best treatment in replacing missing teeth. Most of
the patients were not interested in having removable prosthesis
as the treatment modality in replacing missing teeth, which
confirms the fact that most patients prefers fixed prosthesis
regardless of the situation they have. This result was in
accordance with study conducted by Tepper and Zimmer
etal.[12], [13]
This study showed that only 2.89% female and 3.57% male
subjects preferred implants as the treatment modality as they
were aware of implants. These findings differ significantly
from study conducted by Satpathy et al.[16] This shows their
lack of awareness and knowledge about implant. Majority of
questioned subjects were not aware about dental implants and
its advantages. They should be informed about implants by
conducting various public awareness campaigns, and
counselling centres should be established in patient outpatient
ward in Prosthodontic Departments of Dental College.
Data in this study regarding the preference of need of artificial
prosthesis shows that male subjects are more aware of
mastication as a function of denture, this is also evident in
study done by Szentpetry AG etal[17], they are less aware of the
018
esthetics. This study shows that female subjects are more
concerned with esthetics, this is in accordance with the result
of a study done by Davis DM et al 2000.[18] Osterberg et al [19]
reported that esthetics rather than functional factors
determined an individual’s subjective need for replacement of
missing teeth which is in agreement with the finding of several
other studies.[20], [21], [22], [23] When subjects were asked about the
most preferable method of replacement.
More than half of the subjects knew that the dentures should be
cleaned everyday as they had probably heard from other
patients and their relatives who had undergone prosthetic
treatment. The findings of this study are comparable to study
conducted by Dikbas[24] et al who reported that dentures were
cleaned by the 70% of the patients.
A study conducted by Marcus et al[25] reported that one third of
the participants slept with both dentures and 12% slept with
only maxillary dentures in place. Dental education should be
encouraged to remove dentures before retiring at night, or for
several hours each day to allow relief of the underlying soft
tissues.
Limitations of the study
Majority of the patients were unskilled and educated only till
secondary level of education or less. Socioeconomic status is
major factor affecting the preference of artificial prosthesis
which has not been taken into account in this study. Age
distribution was chosen randomly.
Summary and conclusions
The present results may serve as a baseline for the future
evaluation of attitudes towards replacement of teeth. These
findings indicate that awareness needs to be created regarding
the other functions of the teeth like phonetics, mastication. So
awareness regarding prosthodontic treatment needs and their
usage should be increased among the local population through
oral health education programmes.
Apart from this, community based oral health education
programmes should be conducted to improve patient’s oral
health knowledge and these programmes can be organized by
the government and the dental profession. They could be
implemented with mass media as they are powerful and
influential forces in modern society.[1] For this television, radio
and printed media like newspaper and magazines could be
appropriate ways to disseminate oral health messages to
population.[26]
References
1. Shigli K,Angadi GS and Hebbal M. Knowledge of
Prosthodontic treatment among denture wearer and non
denture wearers attending a dental institute in India: A
survey report. Gerodontogy 2007; 24:211-216.
2. Suresh S and Swati Sharma. A clinical survey to determine
the awareness and preference of needs of a complete
denture among complete edentulous patients. J Int Oral
Health 2010
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treatment within a Swedish population.Swed Dent J 1979;
3:15-25.
8. Schuurs AH, Duivenvoorden HJ, Thoden van Velzen SK,
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Cuttack.International journal of public Health
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019
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020
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E ISSN No. : 2348 – 1331
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Case Report
Non-surgical Management Of External Inflammatory Root Resorption Using Mineral
Trioxide Aggregate
Chandki Rita1, Sai Kalyan S2
1
Assistant professor, Department of Conservative Dentistry and Endodontics, Index Institute of Dental Sciences, Indore, Madhya Pradesh, India.
Assistant professor, Department of Conservative Dentistry and Endodontics, Rural Dental College, Loni, Maharashtra, India.
2
Abstract
This case report presents management of a severe Inflammatory External root resorption in a mandibular molar tooth. The condition developed as
a sequelae to pulpal infection. Treatment comprised of endodontic therapy with interim dressing of Calcium hydroxide paste followed by obturation
of the affected root canal with Mineral Trioxide Aggregate. A six-month follow-up clearly showed that the resorptive process had ceased and the
patient was asymptomatic. This case was thus a clinical and radiographic success.
Key Words
Root Resorption, External Root Resorption, Apical root resorption, Mineral Trioxide Aggregate.
Introduction:
Root resorption can either be a physiologic or a pathologic
process, mainly occurring due to the action of activated clast
cells and is characterized by progressive or transitory loss of
cementum or cementum/dentin[1].
Andreasen[2] in 1985 classified Pathologic Root Resorption
into External and Internal Root Resorption. Internal
Resorption was further subclassified into replacement and
Inflammatory Internal resorption. External root resorption was
subdivided into three classes; namely Superficial,
Replacement and Inflammatory.
External resorption is a process that leads to an (ir) reversible
loss of cementum, dentin and bone[3]. The frequency of
occurrence is more in patients aged between 21 and 30 years
and the condition is more common in females than males[4].
In contrast to Replacement External root resorption; wherein
lost cementum and dentin is eventually replaced by osseous
tissue, an Inflammatory External root resorption must undergo
an endodontic therapy for removal of necrotic pulp and
stabilization of resorptive process[5].
In treating teeth with open apices, obtaining an optimum root
canal sealing following complete debridement and
disinfection of root canal system is a challenging task[6]. In
recent times, Mineral Trioxide Aggregate (MTA) has gained
popularity in treating teeth with open apex[7]. Though several
cases of MTA apexification [8],[9],[10] have been reported,
obturation of entire canal with MTA is relatively uncommon.
This case reports successful management of a case of External
Inflammatory root resorption in a mandibular molar tooth
Quick Response Code
wherein the affected root was obturated with MTA to promote
periapical healing.
Case Report:
An 18 year old female patient reported with a chief complaint
of pain in her lower right back tooth since 6 months. The
medical history was non-contributory.
Clinical Examination revealed deep mesioproximal caries
with tooth #47. The tooth was tender on vertical percussion. No
signs of mobility or periodontal pockets were present in
relation to tooth #47.
Pulp testing with an electric pulp tester (Parkell Inc.
Edgewood,NY, USA) and thermal test using hot gutta percha
elicited non-responsiveness from the suspect tooth when
compared to the control teeth.
Intraoral periapical radiograph using radiovisiography (Kodak
5100, Trophy, France) revealed short distal root with external
resorption in relation to tooth # 47. Small areas of periradicular
radiolucency associated with both mesial and distal roots were
also evident (Fig.1)
Corroborating the clinical and radiographic findings, a
Dr. S.Sai Kalyan,
Assistant professor, Department of Conservative
Dentistry and Endodontics, Rural Dental College,
Pravara Institute of Medical Sciences(Deemed
University), Loni, Maharashtra, India.
Email: s_saikalyan@rediffmail.com
Tel: +91-9890785288
Figure.1 Preoperative Radiograph
021
diagnosis of inflammatory external root resorption secondary
to chronic apical periodontitis with tooth # 47 was made.
The options for root-end management included the placement
of an artificial apical plug or barrier of MTA or periapical
surgery with placement of a root-end filling. Considering the
extent and severity of root resorption, orthograde obturation of
root canal space with MTA was planned in order to arrest the
process of resorption. Informed consent was obtained from the
patient and Conventional Endodontic therapy initiated.
Following isolation with rubber dam, an endodontic access
opening was made under magnification of an operating
microscope (20x Seiler precision microscopes, St.Louis, MO,
USA) using an Endo-Access bur (Dentsply
Maillefer,Ballaigues, Switzerland) .The contents of the pulp
chamber were removed with long shank spoon excavator. The
root canal was copiously irrigated with 3% sodium
hypochlorite and 17% EDTA solution. Working length was
determined by Root ZXR (J. Morita Corporation, Kyoto,
Japan). The electronically determined working length was
confirmed radiographically using a size 15 K-file (Sybron
Endo Glendora CA, USA) in the intact mesial root and by
using paper point method in distal root affected by resorptive
process. The root canal was cleaned and shaped by rotary
nickel-titanium ProTaper instruments to the size F5 (Dentsply
Maillefer) using Glyde (Dentsply Maillefer) as a lubricant. An
X-smartTM dual endodontic motor (Dentsply Maillefer) was
used to control the speed and torque of rotary files. The root
canal was again irrigated with 3% sodium hypochlorite
followed by a final saline rinse and dried using sterile
absorbent paper points (Dentsply Maillefer). Calcium
hydroxide paste (Calcigel, Prevest Denpro Limited, India) was
placed as an intra-canal medicament and the access cavity was
temporized (Cavit GTM, 3M ESPE, Seefeld, Germany). The
patient was recalled 1 week later. On recall visit, the tooth was
asymptomatic. The temporary restoration was removed,
canals were cleaned and dried and mesial canal was obturated
using Gutta-percha and sealer. For distal canal which exhibited
apical root resorption, MTA PLUS (Prevest Denpro Limited,
India) was used as an obturation material. The material was
mixed according to manufacturer’s instructions and delivered
in situ using a 20 gauge spinal tap needle and condensed using
ultrasonic endodontic tip (Satelec, Acteon, France).
Care was taken to prevent extrusion of the material in to the
peri-radicular area. The final adjustment was done with the
light force using the butt end of sterilized greater taper paper
points (Dentsply Maillefer). With the aid of the radiograph, the
access cavity was then restored with Glass Ionomer Cement
(Micron Superior, Prevest Denpro Limited, India) (Fig.2)
The patient was then scheduled on a 3-month regular recall.
The tooth remained asymptomatic and functional. Follow up
radiograph after 6 months showed that apical root resorption
had stabilized and periapical healing ensued. (Fig.3)
Discussion:
External inflammatory resorption is a progressive condition
and the major culprit is usually a necrosed pulp. To avoid
compromising the longevity of tooth, the clinician intervention
is must to hault the process through elimination or reduction of
the maintenance factor i.e. necrosed pulp[11].
The treatment protocol suggested for such a condition should
Figure.2 Post Operative Radiograph
Figure 3. Follow up Radiograph after 6 months
involve removal of bacteria and their by-products from the root
canal system to arrest the inflammatory processes involving
the root surface and hence to allow the regeneration of
periodontium[12].
Since its first description in the dental literature by Lee and
colleagues[13] in 1993, and its first use as root end filling
material,[14] the development of Mineral Trioxide Aggregate
(MTA) material has truly been a landmark event in dentistry
and in Endodontics in particular. This event dramatically
increased the success rate of many complex cases that used to
have high failure rates. The superior physicochemical and
bioactive properties of MTA may be an advantage when used
as an obturation material[15]. In addition to being sterile,
dimensionally stable, radio-opaque, moisture insensitive, it
also provides an effective seal against dentin and cementum
and promotes biologic repair and regeneration of the periapical
tissues.[13],[14],[16]
In the present case, calcium hydroxide was applied as an
interim dressing before the placement of MTA because
calcium hydroxide is the intracanal medicament preferred in
cases of inflammatory resorption[17]. Its alkaline pH (12.2)
neutralizes the action of the clastic cells, hence inhibiting the
resorption process.[5],[18],[19]
A decision to obturate the entire canal affected with apical root
resorption with MTA instead of just using an apical plug was
made. This was in accordance with the literature[6],[15],[20],[21]
reporting several successful cases of MTA being used as a root
canal filling material.
It has been suggested that the root canal treated teeth, obturated
022
with MTA exhibit higher fracture resistance[22]. It has been
proposed that MTA as a root canal filling material can induce
biologic repair mechanisms in a more consistent and
predictable manner than other traditional obturation materials
like gutta-percha.15 Further the antiwashout MTA (MTA plus)
used in this case improved the handling properties and
condensability.
Orthograde obturation of the root affected with apical root
resorption with MTA in present case proved to be very
conservative approach with predictable outcome.
Conclusion:
Undeterred by the substantial root damage caused by
resorptive process, non-surgical root canal therapy with MTA
obturation of the affected root stabilized the external root
resorption and regenerated the periapical tissue. Owing to its
superior properties, MTA appears to be a viable alternative as a
root canal filling material in teeth requiring complex
endodontic treatment which might be otherwise doomed to
extraction.
References:
1. Lopes HP, Siqueira Jr JF. Endodontia. Biologia e técnica. 2.
ed. Rio de Janeiro: Guanabara Koogan/ Medsi; 2004
2. Andreasen, J. O. External root resorption: its implications
in dental traumatology, paedodontics, periodontics,
orthodontics and endodontics. Int Endod J. 1985
Apr;18(2):109-18.
3. Bergmans L, Van Cleynenbreugel J, Verbeken E, Wevers
M, Van Meerbeek B, Lambrechts P. Cervical external root
resorption in vital teeth. X-ray microfocustomographical
and histopathological case study.J Clin Periodontol 2002:
29: 580–585
4. Opaci-GaliV, Zivkov S. Frequency of the external
resorptions of tooth roots. Srpski Arhiv za Celokupno
Lekarstvo 2004; 132 (5-6):152–6
5. Heithersay GS. Calcium hydroxide in the treatment of
pulpless teeth with associated pathology.J Br Endod Soc
1975; 8 (2):74-93.
6. Raldi DP, Mello I, Habitante SM, Lage-marques JL, Coil J.
Treatment options for teeth with open apices and apical
periodontitis. J Can Dent Assoc 2009; 75: 591-596.
7. Parirokh M, Torabinejad M. Mineral trioxide aggregate: a
comprehensive literature review-part III: clinical
applications, drawbacks, and mechanism of action. J
Endod. 2010 Mar;36(3):400-13.
8. Mente J, Hage N, Pfefferle T, Koch MJ, Dreyhaupt J,
Staehle HJ, Friedman S. ineral trioxide aggregate apical
plugs in teeth with open apical foramina: a retrospective
analysis of treatment outcome. J Endod. 2009 Oct;
35(10):1354-8.
9. Pace, R., Giuliani, V., Pini Prato, L., Baccetti, T. and
Pagavino, G. Apical plug technique using mineral trioxide
aggregate: results from a case series. International
Endodontic Journal 2007, 40: 478–484.
10. Ghaziani P, Aghasizadeh N, Sheikh-Nezami
M.Endodontic treatmet with MTA apical plugs: a case
report. J Oral Sci. 2007 Dec; 49(4):325-9.
11. Fuss Z, Tsesis I, Lin S. Root resorption – diagnosis,
classification and treatment choices based on stimulation
factors. Dent Traumatol. 2003 Aug;19(4):175-82
12. Levin and M. Trope, “Root resorption,” in Dental Pulp, K.
Hargreaves and H. Goodis, Eds., pp. 425–448,
Quintessence, Chicago, Ill, usa, 3rd edition, 2002.
13. Lee SJ, Monsef M, Torabinejad M. Sealing ability of a
mineral trioxide aggregate for repair of lateral root
perforations J Endod 1993 Nov;19(11):541-4.
14. Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of
a mineral trioxide aggregate when used as a root end filling
material. J Endod 1993 Dec; 19(12):591-5.
15. Bogen G, Kuttler S. Mineral Trioxide Aggregate
Obturation: A Review and case Series. JOE volume 35;
6.June 2009.777-790
16. Torabinejad M, Wilder Smith P, Pitt Ford TR. Comparative
investigation of marginal adaptation of mineral trioxide
aggregate and other commonly used root end filling
materials. J Endod 1995; 21: 295-9.
17. Andreasen JO, Andreasen FM. Traumatismo d e n t á r i o : s
o l u ç õ e s c l í n i c a s . S ã o P a u l o : Panamericana; 1991
18. Fava LR, Saunders WP. Calcium hydroxide pastes:
Classification and clinical indications. Int Endod J 1999;
32(4):257-282.
19. Foreman PC, Barnes IE. Review of calcium hydroxide.Int
Endod J 1990; 23(6):283-297.
20. Mohammadi Z. Orthograde root filling of an immature
nonvital tooth using MTA. Dent Today 2008; 27:102, 104105.
21. Mohammadi Z, Yazdizadeh M, Obturation of immature
nonvital tooth using MTA. Case report N Y State DentJ
2011; 77: 33-35.
22. Bortoluzzi EA, Souza EM, Reis JM, Esberard RM,
Tanomaru-Filho M. Fracture strength of bovine incisors
after intra-radicular treatment with MTA in an
experimental immature tooth model.Int Endod J 2007; 40:
684-91
023
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P ISSN No. : 2348 – 134X
Case Report
Hidden Canals: A Case Series
Amrit Singh Ahluwalia1, Navneet Kaur2, Deept Jain3, Rohan Sikka4, Dhruv Arora5
1
Post Graduate Student, Department Of Conservative Dentistry And Endodontics, Vyas Dental College And Hospital, Jodhpur (Raj.)
Post Graduate Student, Department Of Oral And Maxillofacial Pathology, Vyas Dental College And Hospital, Jodhpur (Raj.)
3
Senior Lecturer, Department Of Periodontics, Institute Of Dental Studies & Technologies, Modinagar,Ghaziabad,Uttar Pradesh, India.
4
Senior Lecturer, Department Of Prosthodontics, Institute Of Dental Studies And Technologies Modinagar, Ghaziabad, Uttar Pradesh, India
5
Senior Lecturer, Department Of Prosthodontics, Institute Of Dental Studies And Technologies Modinagar, Ghaziabad, Uttar Pradesh, India.
2
Abstract
Clinicians need to completely understand and fully appreciate the anatomy of human teeth, its complexities and use this knowledge to locate
calcified, aberrant, or previously missed canals. One of the common causes of failure in endodontics is missed/eluded canals which hold tissue,
and at times bacteria and their related irritants. These breakdown products inevitably contribute to clinical symptoms and lesions of endodontic
origin. There are multiple concepts, armamentarium and instruments that are useful to locate canals. This article describes in detail the various
techniques to identify such commonly missed canals by giving a thorough hindsight of the complex anatomy seen in various categories of teeth,
backed with clinical cases.
Key Words
bacteria, missed canals, irritants
Introduction
The main objective of endodontic therapy is toeliminate the
microorganisms, which if left untreated, can leadto apical
periodontitis.[1],[2] This can be achieved by:
-Proper shaping and cleaning of the root canal space by means
of instrumentation and use of irrigants,[3] and
-A tight three- dimensional seal with an inert filling material.[4]
To achieve this objective, a clear understanding of the pulp
anatomy and its variations is essential.With the aid of
magnification, there has been a tremendous increase in the
number of additional canals reported in various categories of
teeth. Hence, the clinician should be aware of the variations in
each tooth. Prior to initiating endodontic therapy, it is
absolutely essential to take radiographs with different
angulations to assess the root canal anatomy and suspect
additional roots/canals if any.This would minimize the risk of
missed anatomy of the root canal system.[5]
This article describes the various canal configurations, its
variations and the most commonly missed/elusive canals in
both the maxillary and mandibular teeth which will help
clinicians to successfully recognize and treat these difficult
cases. Also the various clinical cases with elusive canals which
were successfully found and treated are presented in this
article.
Variations in canal morphology: risk of missingcanals in
maxillary and mandibular teeth
Maxillary incisors and premolars
The endodontic anatomy of maxillary incisors and canine is
generally simple with one canal and one root in almost 100%
Quick Response Code
cases.[6],[7] Out of these teeth most commonly variations are
seen in the lateral incisor where dens invaginatus is a common
finding. In maxillary premolars also normal root morphology
is seen in most of the cases. Only 1.2 to 1.4% cases have been
reported to have an aberrant morphology.[8]
Maxillary first and second molars
There is a wide range of variation in the literature on maxillary
first molars with respect to the number of canals in each root,
the number of roots, and the incidence of root fusion. In molars
the incidence of extra canals varies with each root. In the
mesio-buccal root two or more canals have been reported in
57.1% cases in first molars and 47.1% in second molars. For
the disto-buccal root two or more canals were found only in
1.7% cases and in second molars only 0.3% cases. The
incidence of two or more canals in the palatal root is 1% and
0.1% for first and second molars respectively.[8]
Second Mesiobuccal Canal: (Case Report 1)
An18 year old female patientreported to our department with a
complaint of pain in right back region of upper jaw. The patient
had a faulty root canal treatment done and tenderness to
percussion in relation to 16. A chronic periapical abscess was
diagnosed and the patient was advised re-root canal treatment
in relation to 16. During the operative procedure a second canal
was found in the mesio-buccal root.
Dr. Amrit Singh Ahluwalia,
Post Graduate Student, Department Of Conservative
Dentistry And Endodontics, Vyas Dental College And
Hospital, Jodhpur (Raj.)
E-mail: rohan67@gmail.com
Phone no.: 09871048800
Pre Operative
Post Operative
028
Case Report 2
A 33 year old male patient reported to our department with the
had tenderness to percussion in relation to 16. The patient was
diagnosed with acute apical periodontitis and advised root
canal treatment in relation to 16. During the operative
procedure a second canal was found in the mesio-buccal root.
Pre Operative
Post Operative
Second Distobuccal Canal (Case Report 3)
A 23 year old female patientreported to the department with the
complaint of pain and swelling in left back region of upper jaw.
The patient had tenderness to percussion in relation to
25,26,27. The patient was diagnosed with chronic irreversible
pulpitis and advised root canal treatment in relation to all three
teeth. During the operative procedure two canals were found in
the disto-buccal rootin relation to 27.
Pre Operative
Case Report 5
A 30 year old female patientreported to the department with the
complaint of pain in right front region of lower jaw and was
diagnosed with apical periodontitis in relation to 41,42,43. The
patient was advice root canal treatment in relation to 41,42,43.
The second canal was foundin relation to 42 during the
operative procedure.
Post Operative
Second Palatal Canal (Case Report 4)
A 45 year old male patientreported to the department with the
had tenderness to percussion in relation to 16. The patient also
had deep proximal caries on mesial and distal aspects in
relation to 17. The patient was diagnosed with chronic
irreversible pulpitis and advised root canal treatment in
relation to 16,17. During the operative procedure two canals
were found in the palatal root of 16.
Pre Operative
Mandibular molars
In mandibular molars the number of extra canals is also
influenced by the number of roots, as a two rooted mandibular
first molar shows the presence of two or more canals with an
incidence of 95.8% in the mesial root and 31.7% in the distal
root. In three rooted mandibular first molars the mesial root
shows two or more canals in almost 100% of cases and about
2.4% in the disto-buccal root. Mandibular second molars show
two or more canals with an incidence of 86% in mesial root and
14.9% in the distal root.[4],[6],[7]
Second Distal Canal (Case Report 6)
A 45 year old patient reported to our department with the
complaint of pain and sensitivity in left back region of lower
jaw. The patient had generalized attrition, severe sensitivity to
cold and hot and tenderness to percussion in relation to 36, 37
and 38. The patient was diagnosed with chronic irreversible
pulpitis and advised root canal treatment in relation to all three
teeth. During the operative procedure two canals were found in
the distal root of 36.
Pre Operative
Pre Operative
Post Operative
Mandibular anteriors and premolars
Amongst the anterior teeth the highest prevalence of extra
canals is found in the mandibular incisors (22.5%),followed by
the mandibular canines (10.6%). For mandibular premolars
the incidence for two or more canals is as high as 27.8%.[9],[10]
Post Operative
Post Operative
Discussion
In an extensive study done by Vertucci in 19846, he classified
and described the root canal systems of human permanent teeth
into eight different types.
029
Later a few additions were made to this classification by
Gulabivala in 2001.[11]
It is generally accepted that a major cause for the failure of the
rootcanal therapy is an ability to recognize the presence and to
adequately treat all of the canals. The consensus that the tooth
has only a fixed number of tooth and root canals is now an
ideology of the past. The clinician should be aware of the
additional canals and should be able to identify and treat them.
Multiple preoperative radiographs with different angulations
would be most desirable, before initiating treatment.[12]
Apart from the radiographic methods, there are various
techniques which can be utilized to detect the additional canals
present. These include
1. Modification of access for better visualization: the access
can be modified in the following ways:
a. Straight line access
b. Remove Mesial Shelf- For cases where extra canals are
present in mesiobuccal root, remove the mesial dentine
shelf which represents the roof of the pulp chamber
overlying the second mesiobuccal orifice.
c. Troughing- Trough and search with low-speed burs or
ultrasonic tips, beginning from the orifice. Also try not
to exceed a depth of 2 mm to 3 mm as this could weaken
the mesial furcation.[13]
2. Dentin map – the road to canal orifices- Using a rhomboid
access, follow the road map that the developmental
grooves form on the pulpal floor.[13]
3. Use of ultrasonics- ultrasonic tips can be used for
troughing, removing coronal obstructions and creating
better access.[12]
4. Use of endodontic explorer(DG – 16)- judicious use of the
endodontic explorer helps in removing minor obstructions
present over orifices, as it is stiffer than the regularly used
files.[8]
5. Champagne / bubble test- A bubble test with sodium
hypochlorite in the pulp chamber may be helpful in
detecting organic tissue within the hidden canal.[12]
6. Chelate- Chelating agents (EDTA) can assist in removing
the smear layer and softening calcifications inside the pulp
chamber, allowing for easier access to canal openings.[8]
7. Transillumination- it helps in revealing dystrophic
calcifications in the pulp chamber. Also aids in locating
missed canals.[12]
8. Highlight using stains- Use stains (eg, 1% methylene
blue)or dentin powder(white line test)/ bleeding points (red
line test) to highlight the pulp chamber anatomy.[8],[12],[13]
9. Remember the Isthmus- Maxillary roots are not perfectly
round in cross-section. Different anatomic configurations
are present at different levels of the same root, especially in
the apical 4 mm.[13]
10. Laws given by Krasner et al- Krasner gave nine laws for
identification of missed canals.[14]
For these intra-operative procedures, to identify and locate
such elusive canals, magnification aids help in better
visualization. Common magnification aids include surgical
operating microscopes and loupes.[5],[8],[12],[14]
Apart from these regularly used methods, a commonly
developing field is the use of Cone-beam computed
tomography(CBCT) in detecting not only extra canals but also
extra roots and root canal aberrations.[15]
Conclusion
The idea that a tooth has only a fixed number of roots and
canals is now obscure and it is the responsibility of the
clinician to locate and treat the extra canals. Awareness of the
common canal morphology and location is essential. The
variability of symptoms and diagnostic and therapeutic
difficulties make the treatment of missed anatomy a challenge
for the general dentist. Consequently the knowledge, skill and
the time devoted by the clinician are the factors which
influence a successful endodontic outcome.
References
1. Ørstavik D. Time-course and risk analyses of the
development and healing of chronic apical periodontitis in
man. IntEndod J 1996; 29: 150–155.
2. Friedman S. Considerations and concepts of case selection
in the management of post-treatment endodontic disease
(treatment failure). Endod Topics 2002; 1: 54–78.
3. Kirkevang LL, Horsted-Bindslev P. Technical aspects of
treatment in relation to treatment outcome. Endod Topics
2002; 2: 89–102.
4. Vertucci FJ. Root canal morphology and its relationship to
endodontic procedures. Endod Topics 2005; 10: 3–29.
5. Cantatore G, BeruttiE. Missed anatomy: frequency and
clinical impact. Endodontic Topics 2009; 15: 3–31.
6. Vertucci FJ. Root canal anatomy of the human permanent
teeth. Oral Surg Oral Med Oral Pathol Oral
RadiolEndod1984; 58: 589–599.
7. P i n e d a F , K u t t l e r Y. M e s i o d i s t a l a n d
buccolingualroentgenographic investigation of 7275 root
canals. OralSurg Oral Med Oral Pathol 1972; 33:101–10.
8. Ingle JI, Bakland LK, Baumgartner JC. Endodontics. 6th
edition, Morphology of teeth and their root canal systems,
Dc Becker, Pg No.151-220
9. Kartal N, Yanikoglu FC. Root canal morphology of
mandibular incisors. J Endod 1992; 18: 562-564.
10. Miyashita M, Kasahara E, Yasuda E, Yammamoto A,
Sekizawa T. Root canal system of mandibular incisor. J
Endod 1997; 23: 479-484.
11. Gulabivala K, Aung TH, Alavi A, et al. Root and canal
morphology of Burmese mandibular molars. IntEndod J
2001; 34: 359–70.
12. Rajan RR, Kumar S, Kumar M, Karunakaran JV. Elusive
canals in endodontics. JIADS vol-2, Issue 2, April-June
2011.
13. Davich MH. The MB2 canal: Following the map of the
pulpal floor. Endodontic Therapy 2007; 5: A-C.
14. Krasner P, Rankow HJ. Anatomy of the pulp-chamber
floor. J Endod 2004; 30: 5-16.
15. Neelakantan P, Subbarao C, Subbarao CV. Comparative
Evaluation of Modified Canal Staining and Clearing
Technique, Cone-Beam Computed Tomography,
Peripheral Quantitative Computed Tomography, Spiral
Computed Tomography, and Plain and Contrast
Medium–enhanced Digital Radiography in Studying Root
Canal Morphology. J Endod 2010; 36:1547–1551
030
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E ISSN No. : 2348 – 1331
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Case Report
Amlodipine - Induced Gingival Enlargement - A Clinical Report
Isha Bhardwaj1, Anoop Bhushan2, Priyanka Aggarwal3
1
2
3
Sr.Lecturer, Deptt Of Periodontics, Sudharustogi College Of Dental Sciences And Research, Faridabad
Hod And Professor, Deptt Of Periodontics, Santosh Dental College,Ghaziabad
Sr Lecturer, Deptt Of Periodontics, Santosh Dental College,Ghaziabad
Abstract
Objective: Among the calcium channel blockers, gingival enlargement has most frequently been described as a side effect following administration
of nifedipine. The incidence with amlodipine is much lower.This case report aims to make dentists aware of the adverse effects of amlodipine as well
as offers a brief review.Themanagement of gingival overgrowth seems to be directed at controlling gingival inflammation through a good oral
hygiene regimen.However in severe cases, surgical excision is the most preferred methodof treatment, followed by rigorous oral hygiene
procedures. This casereport describes the management of gingival overgrowth in a hypertensivepatient taking amlodipine.
Methods: This case report was carried out in post graduate department of Santosh Dental College and Hospitals, Ghaziabad on a 33 year old
female patient with gingival overgrowth due to drug amlodipine (for hypertension) which she was taking for the past 6 months.
Results: After thorough scaling and root planning,inflammatory component of gingival overgrowth got subsided and 2 weeks later, sugery was
performed.After surgery, fibrotic component reduced to a major extent and normal contour with firm and resilient gingiva was noticed 4 weeks post
surgery.
Conclusion: Drug induced enlargement with amlodipine does occur.Substitution with another drug and performing thorough scaling and root
planning simultaneously reduced the gingival overgrowth.However, after surgery result achieved was satisfactory.
Key Words
Calcium channel blocker, hypertension, drug-induced gingival overgrowth, gingivectomy
Introduction:
“Gingival enlargement” or “gingival overgrowth” arethe
preferred terms for all medication-related gingival lesions
previously termed “gingival hyperplasia” or “gingival
hypertrophy.” These earlier terms did not accurately reflect the
histologic composition of the pharmacologically modified
gingiva. Gingival enlargement is a well-known consequence
of administration of some anticonvulsants, the
immunosuppressant drug cyclosporine A (CsA), and calcium
channel blockers, and it may create speech, mastication, tooth
eruption, and esthetic problems.[1] Calcium channel blockers
are used in the management of various cardiovascular
disorders such as angina and hypertension. These drugs have
been reported to be associated with gingival enlargement since
1984.[2] Of this large group of drugs, the
dihydropyridines—especially nifedipine—are most
frequently implicated in gingival enlargement. The prevalence
with amlodipine, 33.3%, is much lower.[3] Seymour et. Al[4]
were the first to report on amlodipine-induced gingival
overgrowth, and there have been only few reported
associations of gingival overgrowth with this drug.
Materials And Methods:
Case was carried out in the postgraduate department of
Santosh Dental college,Ghaziabad. A 35 year old hypertensive
Quick Response Code
Dr. Isha Bhardwaj
Sr.Lecturer, Deptt Of Periodontics, Sudharustogi
College Of Dental Sciences And Research, Faridabad
female patient diagnosed hypertension 6 months back and was
put on amlodipine since then. Intra oral examination revealed
generalized pink gingiva with deep red, smooth and shiny
rolled gingival margins, lobulated papillae and soft and
edematous gingiva with respect to mandibular anterior teeth,
particularly on the labial side.
A prominent nodular growth was also seen on the labial of the
mandibular left and right incisors, which was approximately
1.5 cm x 1.0 cm in size. Generalized deep pocket and bleeding
on probing was noted. The oral hygiene status of the patient
was poor, accompanied by marked plaque and calculus
accumulation around all teeth. Clinically, the differential
diagnosis for the localized growth included pyogenic
granuloma, fibroma, and peripheral ossifying fibroma. A
provisional diagnosis of drug-induced gingival enlargement
was made for the patient.
At the first visit, after complete medical history,scaling and
031
root planning was performed. The patient was given proper
instructions for maintaining home care oral hygiene and
simultaneously asked for substitution of the drug by the
physician .The patient was recalled after 2 weeks.
At the 1-month recall, the patient showed significant
resolution of gingival inflammation on the buccal aspect and
uneventful healing.
Histologic examination of the specimen demonstrated
hyperkeratotic stratified squamous epitheliumwith prominent
rete ridges and underlying connective tissue. The underlying
connective tissue showed dense fibrocellularstroma, thick
bundles of collagen fibre plump and proliferating fibroblasts,
afew blood vessels and extravasated RBC’s. Histologically,
the lesion was diagnosed as fibroepithelial hyperplasia.
It was observed that inflammatory component was almost
subsided 1 week post scaling and root planning. However,
fibrotic component of drug- induced enlargement was still
persisting.
Two weeks later, the growth was excised by undisplaced flap
from the mandibular incisors and sent for histopathologic
examination , after which the area was given sling suture 3-0
silk.
The patient was recalled after 1 week for suture removal.
Treatment
The clinician should emphasize plaque control as the first step
in the treatment of drug-induced gingival enlargement, as it
may regress with time in patients undergoing a vigorous oral
hygiene program.[5] Usually, a 3-month interval for periodontal
maintenance therapy has been recommended for patients
taking drugs associated with gingival enlargement.[6] Further
consideration should be given to the possibility of medication
withdrawal or substitution in patients for whom the new
medication can offer some advantage for the control of their
hypertension, or in patients who present with clinically
significant overgrowth and are at high risk of corrective
surgery or recurrence after gingivectomy. Reduction of
gingival overgrowth has been reported where substitution is
made by a structurally different antihypertensive drug,
including the angiotensin-converting enzyme inhibitor,
enalapril; the β-blocking drug, atenolol; or thiazide diuretics.[7]
With this form of treatment, it may take from 1 to 8 weeks for
resolution of gingival lesions.[8]
Discussion:
The pathogenesis of gingival overgrowth is uncertain and
thetreatment is still largely limited to the maintenanceof an
improved level of oral hygiene and surgicalremoval of the
overgrown tissue. Several factorsmay influence the
relationship between the drugsand gingival tissues.[9] These
factors include age,genetic predisposition, pharmacokinetic
variables,alteration in gingival connective tissuehomeostasis,
histopathology, ultra structuralfactors, inflammatory changes
and drug action ongrowth factors.
Most studies show an association betweenthe oral hygiene
032
status and the severity of druginducedgingival overgrowth.
This suggests that plaque-inducedgingival inflammation may
be an important risk factorin the development and expression
of the gingivalchanges.[10] In this presentcase the local
environmental factors such as poorplaque control may act as
risk factors that hadcontributed to worsen the existing
gingivalenlargement and therefore complicate the oralhygiene
procedures.[11]
The treatment options for drug-induced gingival enlargement
should be based on the medication being used and the clinical
presentation of the individual case. First, consideration should
be given to the possibility of discontinuing or substituting the
drug. Either of those scenarios should be examined in
consultation with the patient's physician. Simple
discontinuation of the offending agent is usually not a practical
solution. However, its replacement with another medication
might be the practical solution. It may take from 1 to 8 weeks
for resolution of gingival overgrowth. Consideration may be
given to the use of another class of antihypertensive
medications, which are known to be non-associated with the
gingival enlargement. In the present case, substitute drug, that
is, Normadate 100 mg along with Phase-1 therapy resulted in
clinically significant improvement in six weeks time.
The need for, and timing of, any surgical intervention needs to
be carefully assessed. Surgery is normally performed for
cosmetic/aesthetic needs before any functional consequences
are present. The classical surgical approach has been the
external bevel gingivectomy. However, a total or partial
internal gingivectomy approach has been suggested as an
alternative. In the present report, as the gingival overgrowth
was associated with the true periodontal pockets, internal
bevel gingivectomy followed by gingivoplasty was carried
out. The postoperative results were found to be extremely
satisfactory both esthetically and functionally.
Newman MG, Takei HH, Klokkevold PR, Carranza FA.
Carranza’s Clinical Periodontology. 10th ed. St. Louis,
MO: Saunders; 2006: 375-376.
2. Lederman D, Lumerman H, Reuben S, Freedman PD.
Gingival hyperplasia associated with nifedipine therapy.
Report of a case.Oral Surg Oral Med Oral Pathol.
1984;57(6):620-622.
3. Jorgensen MG. Prevalence of amlodipine-related gingival
hyperplasia. J Periodontol. 1997;68(7):676-678.
4. Seymour RA, Ellis JS, Thompson JM, e al. Amlodipine
induced gingival overgrowth. J ClinPeriodontol.
1994;21(4):281-283
5. Montebugnoli L, Servidio D, Bernardi F. Role of time in
reducing gingival overgrowth in heart transplanted
p a t i e n t s f o l l o w i n g c y c l o s p o r i n e t h e r a p y. J .
ClinPeriodontol. 2000;27(8):611-614.
6. Hall EE. Prevention and treatment consideration in
patients with drug-induced gingival
enlargement.CurrOpinPeriodontol. 1997;4:59-63.
7. Mavrogiannis M, Ellis JS, Thomason JM, Seymour RA.
The management of drug induced gingival overgrowth. J
ClinPeriodontol. 2006;33(6):434-439.
8. Khocth A, Schneider LC. Periodontal management of
gingival overgrowth in the heart transplant patient: a case
report. J Periodontol. 1997;68(11):1140-1146.
9. Seymour RA, Thomason JM and Ellis JS (1996). The
pathogenesis of drug-induced gingival overgrowth.J
ClinPeriodontol, 23: 165-175
10. Barclay S, Thomason JM, Idle JR and Seymour RA.
(1992). The incidence and severity of nifedipineinduced
gingival overgrowth.J ClinPeriodontol, 19: 311-314
11. Ikawa K, Ikawa M, Shimauchi H, Iwakura M and
Sakamoto S (2002). Treatment of gingival overgrowth
induced by manidipine administration: a case report. J
Periodontol, 72: 115-122
References:
1. Carranza FA, Hogan EL. Gingival enlargement. In:
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E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
A Review
Piezosurgery – A True Revolution In Periodontics & Implantology
VineshKamath K1, B S JagadishPai2, Padma R3, NamitaJaiswal4
1
Senior Lecturer, Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet 571218
Professor, Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet 571218
3
Professor & HOD, Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet 571218
4
Post Graduate Student, Department of Periodontics, Coorg Institute of Dental Sciences, Virajpet 571218
2
Abstract
The piezosurgery instrument, developed in 1988, uses a modulated ultrasonic frequency that permits highly precise and safe cutting of hard tissue.
Nerves, vessels, and soft tissue are not injured by the microvibrations (60 to 200 mm/sec), which are optimally adjusted to target only mineralized
tissue. The selective and thermally harmless nature of the piezosurgery instrument results in a low bleeding tendency. The precise nature of the
instrument allows exact, clean, and smooth cut geometries during surgery. Postoperatively, excellent wound healing, with no nerve and soft tissue
injuries, is observed. Because of its highly selective and accurate nature, with its cutting effect exclusively targeting hard tissue, its use may be
extended to more complex oral surgery cases, as well as to other interdisciplinary problems.
Key Words
Ultrasonic, microvibrations, piezoelectric, osteotomies, macrovibration
Introduction:
Ultrasound has been used for many years in periodontics to
remove tartar, debride root surfaces, and to degranulate
periodontal defects. In the last decade a novel family of
ultrasonic powered devices has been developed that is
revolutionizing maxillofacial bone surgery.
In 1997, TomasoVercellotti first introduced the idea to use an
ultrasonic device for ablation fitted with a sharpened insert,
such as a scalpel blade, to perform periradicular osteotomy to
extract an ankylosed root of a maxillary canine. The implant
positioned at the moment of the extraction worked perfectly
and this gave rise to a series of experimental techniques using
ultrasound for bone cutting.
The most compelling characteristics of piezoelectric bone
surgery are low surgical trauma, exceptional control during
surgery, and a fast healing response of tissues. Clinical studies
have demonstrated that the specificity of operation and the
techniques employed with piezoelectric bone surgery make it
possible to advantageously exploit differences in hard and soft
tissue anatomy. This not only increases treatment effectiveness
but it also improves postoperative recovery and healing.
Ideally, surgical trauma should be minimized to obtain the
optimal healing, which depends on gentle management of soft
and hard tissues. Surgery, by definition, alters normal
physiology by interrupting the vascular supply of tissues. The
degree of surgical invasiveness is extremely important for the
quality of tissue healing and may affect whether wounds heal
by repair or regeneration. Indeed, when surgical trauma is kept
to a minimum it generates enough stimulation to favor healing
mechanisms that lead to regeneration. On the other hand,
Quick Response Code
Dr. VineshKamath K,
Senior Lecturer, Department of Periodontics, Coorg
Institute of Dental Sciences, Virajpet 571218
Email id: drkamath84@gmail.com
Mobile No: 09481842243
surgical techniques that are more traumatic often lead to
greater inflammatory responses with slow healing that may
lead to repair and scarring rather than regeneration. For this
reason, it is desirable to choose the least traumatic surgical
instruments and techniques for any surgical procedure.
Piezoelectric bone surgery is conceived and developed
precisely to overcome the limits of traditional bone cutting
instruments and to achieve the most effective treatment with
the least morbidity.
Birth Of Piezoelectric Bone Surgery
TomasoVercellotti carried out extensive scientific research in
veterinary orthopedic surgery, which enabled him to determine
the properties of ultrasonic cutting and obtain the first
favorable results of tissue healing. He immediately understood
the clinical importance of this new technology could have for
all bone surgery; thus, he set up a research group with
orthopedists, neurosurgeons, maxillofacial surgeons, and earnose-throat surgeons. In addition, encouraged by the research
conducted on animals, began the clinical pioneering phase by
developing new surgical protocols in oral, periodontal, and
maxillofacial surgery, and by the invention of two new surgery
techniques (Ultrasonic Implant Site Preparation and
Orthodontic Microsurgery -New-Surgically-Guided Dental
Movement). It was realized that a new bone discipline was
arising with important clinical and histological features. In
1999, in order to distinguish it from traditional and insufficient
ultrasonic bone surgery, it was decided to call it "Piezoelectric
Bone Surgery".
This review article has been presented to provide a brief
description of certain applica-tions and the clinical benefits of
piezoelectric bone surgery.
Philosophy Of Piezoelectric Bone Surgery
The philosophy behind the development of Piezoelectric Bone
Surgery is based on two fundamental concepts in bone
microsurgery.
The first is minimally invasive surgery, which improves tissue
healing and reduces discomfort for the patient. The amount of
034
post-operative pain and swelling is always much lower than
with traditional techniques.
The second concept is surgical predictability, which increases
treatment effectiveness. Indeed, the ease in controlling the
instrument during the operation combined with reduced
bleeding, the precision of the cut, and the excellent tissue
healing make it possible to optimize surgical results even in the
most complex anatomical cases.[1],[2],[3],[4],[5],[6]
The Technological Development Of Low-frequency
Ultrasound: From Scaling To Bone Cutting
Starting in the 1950s, the development of ultrasonic
transducers (out of hearing range, ie, higher than 20,000 Hz)
attracted increasing interest in several sectors, both industrial
and nonindustrial, which considered this "new" form of energy
transduction to have important application opportunities.
Among the many sectors, the medical sector is without a doubt
the one that over the years has gained the most benefits from
developments in this technology. For instance, in the last 20
years, the field of dental scaling has undergone a revolution,
passing from the manual use of curettes to the use of
sophisticated electromechanical transducers. The basic
technology of these ultrasonic devices uses the piezoelectric
phenomenon, an intrinsic property of certain materials. The
ultrasound is generated artificially by exploiting the
mechanical deformations of quartz or a piezo-ceramic disk.
By applying electrical charges to the face of a quartz plate, the
result is crystal compression, and by inverting the direction,
expansion results. When the quartz (or piezo-ceramic disk) is
placed under an alternating electrical field, it is possible to
alternate between compression and expansion of the crystal,
thus producing a series of vibrations.
When these are conducted through a system (transducer), they
generate micrometric movements that can be used for delicate
mechanical operations, such as the removal of calculus.
Another field initially investigated for the generation of
ultrasonic vibrations is related to the magnetostriction
phenomenon. This is a decisive cause of micrometric
deformation in the structure of materials, and in this case, the
application of an alternating magnetic field. However, over the
years, the piezoelectric transducer was preferred due to its
higher efficiency, mainly because of the fact that the
magnetostriction transducer requires dual conversion of
energy from electric to magnetic and then from magnetic to
mechanical. Some efficiency is lost with every conversion. At
the beginning of the 1980s, Mectron Medical Technology
developed and launched an ultrasonic dental scaling device
with a highly efficient handle, achieved after carrying out
extensive studies on materials and design.
For the first time, the transducer had a titanium component and
fully exploited the considerable mechanical potential. The
stability of the ultrasonic generation system guaranteed 3
degree of reliability and mechanical resistance that was
unknown in the past. It enabled an extensive range of
vibrations and excellent management of thermal dissipation,
which is fundamental to achieve a high ratio between electrical
energy provided to the handle and mechanical energy as
vibrations.
Characteristics Of Piezosurgery Surgical Instruments
The piezosurgery unit is composed of the main body, activated
with a pedal, a handle, and number of inserts with different
shapes depending on the surgical need.
Main Body
The main body has a display, an electronic touchpad, a
peristaltic pump, one stand for the handle and another to hold
the bag containing irrigation fluid.
The interactive touchpad has four keys that enable to select the
feature mode, the specific program and the flow of the flowing
cooling liquid. Every command is shown on the display.
There are two primary operating modes:
a. Bone Mode
b. Root Mode
Root Mode
The vibrations generated by selecting root mode are
characterized by average ultrasonic power without frequency
over modulation.
Two different programs:
a. ENDO Program: a limited level of power provided by
applying reduced electrical tension to the transducer,
which generates insert oscillation by a few microns. These
mechanical microvibrations are optimal for washing out
the apical part of the root canal in endodontic surgery.
b. PERIO Program: an intermediate level of power between
the endo program and the bone program. The ultrasonic
wave is transmitted through the transducer in continuous
sinusoidal manner characterized by a frequency equal to
the resonance frequency of the insert used.
Bone Mode
The vibrations generated by selecting bone mode are
characterized as follows: extremely high ultrasonic power
compared to root mode. Its performance is monitored by
several sophisticated software and hardware controls.
Frequency over modulation gives the ultrasonic mechanical
vibrations its unique nature for cutting different kinds of bone.
The selection recommended is:
- Quality 1: for cutting the cortical bone or high density
spongy bone.
- Quality 3: for cutting low density spongy bone.
Special Program: was designed with a standard power level
slightly lower than the bone programs and is characterized by
the same frequency over modulation. The special program is
dedicated to a limited series of surgical inserts that are
particularly thin and delicate. The latter are recommended only
for surgeons who have experience using piezosurgery and
would like an extremely thin and effective cut.
Handle
The cutting action is based on the generation of ultrasonic
waves by piezoelectric ceramic disks inside.
These ceramic plates are subjected to an electrical field
produced by an external generator and vary their volume to
generate ultrasonic vibrations. These are channeled into the
amplifier, which transmits them to the sharp end of the handle.
The insert is tightened with a special key for that purpose.
In this manner, the highest degree of efficiency is obtained for
the cut and duration of the inserts.
Inserts
The design and features of all inserts used in Piezoelectric
035
Bone Surgery have been conceived and developed by the
Mectron Medical Technology.
The prototype of each specific insert was developed to satisfy
the specific clinical needs of each surgical technique.
The inserts have been defined and organized according to a
dual classification system, taking into consideration
morphological-functional and clinical factors. This system
helps understand the cutting characteristics and clinical
instructions for each insert.
Morphological-Functional Classification:
The morphological description defines the structural
properties of the insert, while the functional description
outlines the cutting characteristics:
?
Sharp - Cutting
?
Diamond-coated - Abrasive
?
Rounded – Smoothing
Clinical Classification
The clinical classification sorts the inserts (sharp, abrasive,
smoothing) according to basic surgical technique: osteotomy,
osteoplasty, extraction.
1. Osteotomy (OT)- OT1 - OT2 - OT3 - OT4 - OT5 - OT6 OT7 - OT7S4 - OT7S3 - OT8R/L
2. Osteoplasty (OP)- OP1 - OP2 - OP3 - OP4 - OP5 - OP6 OP7
3. Extraction (EX)- EX1 - EX2 - EX3
4. Implant site preparation (IM)- IM1 (OP5) - IM2A - IM2P OT4 - IM3A - IM3P
5. Periodontal Surgery- PS2-OP5-OP3-OP3A- Pp1
6. Endodontic Surgery- OP3-PS2-EN1-EN2-OP7
7. Sinus Lift- OP3-OT1 (Op5)- EL1 - EL2 - EL3
8. Ridge Expansion- OT7 - OT7S4 - OP5 (IM1) - IM2 - OT4 Im3
9. Bone Grafting- OT7 - OT7S4 – OP1 - Op5
10. Orthodontic Microsurgery- OT7S4 - OT7S3
The inserts for basic osteotomy, osteoplasty, and extraction
techniques are used in combi-nation with each other and with
specific inserts in the surgical protocol for each technique.
Advantages
1. Micrometric cutting action
2. Selective cutting action: minimum soft tissue damage ultrasonic frequency used does not cut soft tissue
3. Maximum intra-operative visibility (cavitation effect)
4. Minimum surgical stress - Excellent tissue healing .The
cutting action is less invasive, producing less collateral
tissue damage, which results in faster healing.
5. Sterile water environment for better asepsis (free from
contamination).
Indications
Oral surgery
- Dental extraction,
- Third molar extraction
- Osteogenic distraction,
- Cyst removal
- Endodontic surgery,
- Bone harvesting (chips and blocks),
Implantology
- Maxillary sinus lift
-
Ridge expansion (crestal splitting),
Alveolar nerve decompression,
Harvesting techniques
Periodontology
- Crown lengthening technique.
- Resective and Regenerative Surgery
Orthodontic Surgery
- Osteotomy and Corticotomy.
Applications In Periodontology And Implantology
The removal of supra and subgingival calculus deposits and
stains from teeth, periodontal pocket lavage with simultaneous
ultrasonic tip movement, scaling, root planing and crown
lengthening, periodontal ostectomy and osteoplasty
procedures requires careful removal of small quantities of
bone adjacent to exposed root surfaces to avoid damaging the
tooth surface.[7] The piezosurgery device is used to develop
positive, physiologic architecture of bone support of the
involved teeth.
The piezosurgery device can be used for soft-tissue
debridement to remove the secondary flap after incision
through retained periosteum. By changing to a thin, tapered tip
and altering the power setting, the piezosurgery device can be
used to debride the field of residual soft tissue and for root
surface scaling to ensure thorough removal of calculus.
Osteoplasty and ostectomy is performed using the
piezosurgery device to create positive architecture for pocket
elimination surgery.[7] The device allows for precise removal of
bone, with minimal risk of injury to underlying root surfaces.
Final smoothing of root surfaces and bony margins using a
specific ultrasonic insert, PP1, creates a clean field, with ideal
bony architecture ready for flap closure. The piezosurgery
device is used in bone grafting of an infrabony periodontal
defect. Autogenous bone can be readily harvested from
adjacent sites with minimal trauma and therefore minimal
postoperative effects.[8] Implant site preparation, implant
removal[9] and bone harvesting, bone grafting and sinus lifts
can be done with much ease and less soft tissue trauma.
Biological Effects On Bone Cut By A Piezoelectric Device
The effect of mechanical instruments on the structure of bone
and the viability of cells is important in regenerative surgery.
Relatively high temperatures, applied even for a short time, are
dangerous to cells and cause necrosis of tissue. There have
been several studies about the effect of piezoelectric surgery on
bone and the viability of cells.[10],[11] Recently autologous bone
that had been harvested by different methods (round bur on
low and high-speed handpiece, spiral implant bur on lowspeed hand-piece, safe scraper, Rhodes back action chisel,
rongeur pliers, gouge shaped bone chisel, and piezoelectric
surgery) was examined using microphotography and
histomorphometric analysis that evaluated particle size,
percentage of vital and necrotic bone, and the number of
osteocytes /unit of surface area. The results showed that the
best methods for harvesting vital bone are: gouge-shaped bone
chisel, back action, enblock harvesting, rongeur pliers, and
piezoelectric surgery. It confirmed earlier studies the effects of
piezoelectric devices on chip morphology and cell viability
when harvesting bone chips.[12],[13] Bone that has been harvested
with a round bur on low and high speed hand-pieces, a spiral
036
implant bur, or safe scrapers, is not suitable for grafting
because of the absence of osteocytes and the predominance of
non-vital bone.
Discussion
Piezosurgery is a relatively new surgical technique for
periodontology and implantology that can be used to
complement traditional oral surgical procedures, and in some
cases, replace traditional procedures.[1] Useful in a variety of
surgical procedures, piezosurgery has therapeutic features that
include a micrometric cut (precise and secure action to limit
tissue damage, especially to osteocytes), a selective cut
(affecting mineralized tissues, but not surrounding soft
tissues), and a clear surgical site (the result of the cavitation
effect created by an irrigation/cooling solution and oscillating
tip). Because the instrument's tip vibrates at different
ultrasonic frequencies, since hard and soft tissues are cut at
different frequencies, a selective cut enables the clinician to cut
hard tissues while sparing fine anatomical structures (e.g.,
schneiderian membrane, nerve tissue). An oscillating tip
drives the cooling-irrigation fluid, making it possible to obtain
effective cooling as well as higher visibility (via cavitation
effect) compared to conventional surgical instruments
(rotating burs and oscillating saws), even in deep spaces. As a
result, implantology surgical techniques such as bone
harvesting (chips and blocks), crestal bone splitting, and sinus
floor elevation can be performed with greater ease and safety.
Piezoelectric bone surgery seems to be more efficient in the
first phases of bony healing; it induces an earlier increase in
bone morphogenetic proteins, controls the inflammatory
process better, and stimulates remodelling of bone as early as
56 days after treatment.[14] The low pressure applied to the
instrument enables a precise cut; additionally, the selective cut
characteristically protects soft tissues. Nerve transpositioning,
sinus floor elevations, distraction osteogenesis, and a number
of other sensitive procedures are easier and safer to perform
with Piezosurgery.[1]
There are few limitations. Operating time for osteotomies is
slightly longer than with traditional saws,[15] and increasing the
working pressure impedes the vibration of devices that
transform the vibrational energy into heat, so tissues can be
damaged.[16],[17]
Conclusion
Piezoelectric devices are an innovative ultrasonic technique
for safe and effective osteotomy or osteoplasty compared with
traditional hard and soft tissue methods that use rotating
instruments because of the absence of macrovibrations, ease of
use and control, and safer cutting, particularly in complex
anatomical areas.
References
1. Boyne PJ, James RA. Grafting of the maxillary sinus floor
with autogenousmarroe and bone. J. Oral Surg 1980; 38:
613-616.
2. McFall TA, Yamane GM, Burnett GW. Comparison of the
cutting effect on bone of an ultrasonic cutting device and
rotary burs. J Oral Surg, Anesth& Hosp D Serv 1961; 19:
200-209.
3. Stubinger S, Robertson A, Zimmerer SK, Leiggener C,
Sader R, Kunz C. Piezoelectric Harvesting of an
autogenous bone graft from zygomaticomaxillary region:
Case report. Int J Periodontics Rest Dent. 2006; 26: 453457.
4. Vercellotti T, Majzoub Z, Trisi P. Valente ML, Sabbini E,
Cordioli G. Histologic evaluation of bone response to
Piezoelectric, surgical saw and drill osteotomies in the
rabbit calvaria. Int J oral and Maxillofac implants.
(submitted).
5. Vercellotti T. The piezoelectric bone surgery: New
Paradigm. Quintessence Publisher.
6. Preti G, Martinasso G, Peirone B, Navone R, Manzella C,
Muzio G et al. Cytokines and Growth factors involved in
the Osseointegration of oral titanium implants positioned
using piezoelectric bone surgery versus a drill technique: A
pilot study in minipigs. J Periodontol 2007; 78:716-722.
7. Sherman JA, Davies HT. Ultracision: the harmonic scalpel
and its possible uses in maxillofacial surgery. Br J Oral
MaxillofacSurg2000;38:530–2.
8. Sivolella S, Berengo M, Fiorot M, Mazzuchin M. Retrieval
of blade implants with piezosurgery: two clinical cases.
Minerva Stomatol2007;56:53–61.
9. Lambrecht JT. Intraoralepiezo-chirurgie (Intraoral
p i e z o s u r g e r y ) .
SchweizMonatsschrZahnmed2004;114:28–36.
10. Gleizal A, Bera JC, Lavandier B, Beziat JL. Piezoelectric
osteotomy: a new technique for bone surgery—advantages
in craniofacial surgery. Childs NervSyst2007;23:509–13.
11. Stubinger S, Kuttenberger J, Filippi A, Sader R, Zeilhofer
HF. Intraoral piezosurgery: preliminary results of a new
technique. J Oral MaxillofacSurg2005;63:1283–7.
12. Schaller BJ, Gruber R, Merten HA, et al. Piezoelectirc
bone surgery: a revolutionary technique for minimally
invasive surgery in cranial base and spinal surgery?
Technical note. Neurosurgery 2005;57:E410.
13. Vercellotti T. Technological characteristics and clinical
indications of piezoelectric bone surgery. Minerva
Stomatol2004;53:207–14.
14. Hoigne DJ, Stubinger S, Von Kaenel O, Shamdasani S,
Hasenboehler P. Piezoelectic osteotomy in hand surgery:
first experiences with a new technique. BMC
MusculoskeletDisord2006;7:36.
15. Vercellotti T, De Paoli S, Nevins M. The piezoelectric bony
window osteotomy and sinus membrane elevation:
introduction of a new technique for simplification of the
sinus augmentation procedure. Int J Periodontics
Restorative Dent 2001;21:561–7.
16. Schlee M. UltraschallgestützteChirurgie-grundlagen und
Möglichkeiten. Z ZahnärztlImpl 2005: 48–59.
17. Happe A. Use of a piezoelectric surgical device to harvest
bone grafts from the mandibular ramus: report of 40 cases.
Int J Periodontics Restorative Dent 2007;27:241–9.
037
www.dherald.in
E ISSN No. : 2348 – 1331
P ISSN No. : 2348 – 134X
A Review
Abutment Evaluation – A Boon To Success Of Fixed Partial Denture
Sharma Sumeet1, Sethuraman Rajesh2, Singh Harvinder3, Singh Sarbjeet4, Wazir Dev Nikhil5
1
Senior lecturer, Department of Prosthodontics, Institute of Dental Sciences, Sehora, Jammu, India.
Professor, Department of Prosthodontics, K.M. Shah Dental College & Hospital, Vadodara, India.
3
Professor, Department of Prosthodontics,Institute of Dental Sciences, Sehora, Jammu, India.
4
Reader, Department of Oral Medicine & Radiology, Institute of Dental Sciences, Sehora, Jammu, India.
5
Professor & HOD, Department of Conservative & Endodontic, Institute of Dental Sciences, Sehora, Jammu, India.
2
Abstract
Fixed partial dentures transmit forces through the abutments to the periodontium. Failures are due to poor engineering, the use of improper
materials, inadequate tooth preparation, and faculty fabrication. Of particular concern to dentists is the selection of teeth for abutment. They must
recognize the force developed by the oral mechanism, and the resistance of the tooth and its supporting structures to them.
Successful selection of abutments for fixed partial dentures requires sensitive diagnostic ability. Through knowledge of anatomy, ceramics, the
chemistry and physics of dental materials, metallurgy, periodontics, phonetics, physiology, radiology and the mechanics of oral function is
fundamental1. This article review diagnostic procedures and requisities for the selection of abutments.
Key Words
Biomechanics, FPD, Pontics, Retainer, Span length, Clinical crown, Anatomical crown.
Introduction
Fixed prosthodontic treatment can range from the restoration
of a single tooth to the rehabilitation of the entire occlusion.
Single teeth can be restored to full function, and improvement
in cosmetic effect can be achieved. Missing teeth can be
replaced with prostheses that will improve patient comfort and
masticatory efficiency, maintain the health and integrity of the
dental arches, and, in many instances, elevates the patient’s
self-image.
Every restoration must be able to withstand the constant
occlusal forces to which it is subjected. This is to particular
significance when designing and fabricating a fixed partial
denture, since the forces that would normally be absorbed by
the missing tooth are transmitted, through the pontic,
connectors and retainers, to the abutment teeth. For example,
to evaluate the significance of a simple full crown on a
mandibular molar tooth in a patient with relatively normal
occlusion, a full complement of teeth and normal bone support.
We see that the following parameter of form and forces are
within the control and responsibility of the operator:
a) Number and area of occlusal contacts.
b) Inclination and length of cusps.
c) Axial contours.
Abutment teeth are called upon to withstand the forces
normally directed to the missing teeth, in addition to those
usually applied to the abutments.
If a tooth adjacent to an edentulous space needs a crown
because of damage to the tooth, the restoration usually can
Quick Response Code
Dr. Sumeet Sharma,
Senior Lecturer,
Department of Prosthodontics,
Institute of Dental Sciences,
Sehora, Jammu, India.
Phone no. 09419148335.
E-mail: drsumit02@gmail.com
double as an FPD retainer. If several abutments in one arch
require crowns, there is a strong argument for the selection of a
fixed partial denture rather than a removable partial denture[1].
Diagnostic Casts
Accurate diagnostic cast must be correctly oriented to the
transverse hinge axis and the plane of occlusion on an
articulator to permit eccentric movements similar to those that
take place in the mouth. This procedure allows a simple
evaluation of the occlusal relationships of the dental arches and
the abutment teeth.
Roentgenographic Examination
Periapical and bite-wing films are most important in selection
of abutment teeth. The primary purpose of roentgenograms is
to disclose hidden areas and structures such as the root
morphology, pulp outline, the periodontal ligament space, the
alveolar bone, infrabony defects, residual roots, impacted or
supernumerary teeth, and the extent of present or past caries.
Definite rules of treatment planning cannot be formulated.
However, an understanding of the favourable indications and
reasonable limitations of abutments for fixed partial dentures
is essential[2].
Factors Governing Abutment Selection
Crown
Gottlieb has suggested a special terminology, anatomic crown
and clinical crown. He calls the enamel covered portion of the
tooth the anatomic crown, and the cementum covered portion,
the anatomic root. Clinically, that portion of the tooth which is
actually erupted (exposed) is called the clinical crown, and the
remainder of the tooth, which is still united with the investing
tissues, the clinical root. Thus, it may be said that in youth the
clinical crown is smaller than the anatomic crown, and in old
age the clinical crown is greater than the anatomic. In certain
mouths, all of anatomic crowns are exposed at the age of 40; in
others, at least for some teeth, there is an epithelial attachment
038
to the enamel at 50 years or even later.
Size of crown: The combined existing surface area of the
periodontal ligaments of the abutment teeth should be equal or
exceed the normal area of the periodontal ligament of the teeth
to be replaced.[3] The surface area of the periodontal ligaments
of normal teeth has been measured by several investigators.[4],[5]
The total mesio-distal width of the cusps of abutments should
equal or exceed the width of the cusps of pontics.
Occlusal anatomy: Occlusal anatomy has an indirect
influence on the loads transmitted to the teeth. The occlusal
surfaces of natural posterior teeth have distinct cusps with
many primary and supplemental ridges. The cusps are convex
in both directions with grooves interspersed between the
rigdes. Stallard[6] points out that worn-down teeth need more
muscular power and longer and more masticatory strokes in
order to chew food enough. Much of this force is directed at
right angles to the long axis of the teeth.
Buccolingual dimension of the teeth: The occlusal surface of
the pontics should harmonize with the buccolingual dimension
of the natural unmutilated teeth, and recreate the normal buccal
and lingual form to the height of contour. Reducing the width
of the pontics does not materially reduces the force transmitted
to the abutments, but merely places heavier per unit stress on
the restoration and produces conditions in the pontic.
Roots
The forces acting on a tooth are transferred to the supporting
bone through the root. The shape of the root determines the
ability of the abutment to transfer the masticatory load to the
supporting bone.
a) Number: Multirooted posterior teeth with widely
separated roots will offer better periodontal support than
roots that converge, fuse, and generally present a conical
configuration.
b) Size: Teeth with longer root are stronger abutment than
compared to the shorter ones.
c) Width: Roots with greater labio-lingual width are
preferred.
d) Shape: Roots with irregular curvature are preferred. Teeth
with conical roots can be used for short span fixed partial
dentures.
Crown: root ratio: Poor crown-to-root ratio can result from
improper dental treatment as well as from traumatic or
pathologic changes that either increase the length of the
clinical crown or decrease the length of the clinical root. In
1955, Marshall-Day and associates[7] found crestal loss of
alveolar bone in 98% or more of a sample of individuals 35
years of age or older. In 1962, examination of a random sample
of Americans revealed the increased prevalence of
periodontitis and advanced tissue destruction associated with
older age groups.[8]
Mobility, as related to crown-to-root ratio, occurs when
alveolar support is no longer adequate to withstand the forces
encountered in the oral cavity. Tooth mobility becomes
significant when the re-quirements of comfort and masticatory
function are compromised.[9] Development of dental caries on
exposed root surfaces is a potential problem. A recent study
revealed increased amount of caries on exposed root surfaces
in the mandibular arch, most frequently in premolars.[10] In
these patients the prevalence of root surface caries did not
correlate with the degree of oral hygiene or with evidence of
previous coronal caries. "These data suggest that the incidence
of root surface caries may be a function of diet rather than an
inevitable sequelae of root exposure. The root surface
concavities and increased surface area associated with
exposed roots also complicate oral hygiene efforts, thus
favoring an increased incidence of caries. Sensitivity from
exposed root surfaces is also a common problem. A variety of
techniques and substances are available for desensitization."
Unfortunately, no one approach is uniformly successful.
The early guidelines on crown-to-root ratio for abutment teeth
were conservative, but they still serve as a standard in many
texts.[11] Ante's Law[11] states that "The combined pericemental
area of the abutment teeth should be equal to or greater in
pericemental area than the teeth to be replaced." Removal of all
teeth or roots that are "unfit" for further service was also
recommended.
Definition and measurement technique:
The level of supporting bone is rarely coincident with the
cementoenamel junction or dentogingival junction(Fig. 1).
Evaluation is best performed using the clinical crown-to-root
ratio. Further use of the term crown-to-root ratio will refer to
Figure 1
the clinical ratio unless otherwise specified.
Jepsen[5] compared root surface areas and radio-graphic root
areas and established that they could be correlated within a
10% to 15% margin of error, thereby demonstrating the
validity of radiographic evaluation. Workers usually
recommend the use of Ante's Law when allowances for a 15%
to 20% variation in computations of the pericemental area are
made." Other textbooks proposed the use of actual crown-toroot ratio in determining prognosis. Presumably these are
based on linear measurements from radiographs. A ratio of 1:2
was considered ideal. 1:1.5 was acceptable, and a crown-to-
039
root ratio of 1:1 was considered minimal or doubtful.[12],[13]
Crown-to-root ratio was also discussed in terms of the linear
amount of bone loss although the importance of this approach
varies with root form and length. Teeth exhibiting extensive
bone loss, with pocket depth greater than 6 to 7 mm from the
cementoenamel junction, are sometimes considered hopeless
because of the compromises encountered in periodontal
surgery[13]. Tylman[14] recommended that teeth with a normal
amount of bone be used for abutments. However, he stated that
teeth lacking one third to one half of their normal periodontal
attachment. Beube[15]," discussing the retention or extraction of
teeth, assigned a poor prognosis to teeth with only one third of
the apical bone remaining, advanced mobility, and poor root
morphology. Goldman and Cohen[16]* advocated the retention
of teeth based on their ability to return to health and maintain
themselves in function.
Treatment considerations for teeth with poor crown-root
ratio
Plaque: Plaque control and adequate oral hygiene are of
primary concern in teeth having poor crown-to-root ratio.
Continued progression of periodontitis due to inadequate
plaque control invites treatment failure. Examples are the
addition of margins and solder joints and the exposure of less
accessible, concave crown and root surfaces.
Periodontal surgery: Periodontal surgery can affect the
crown-to-root ratio. Complete: osseous resection of
periodontal bony defects to create physiologic contours may
result in loss of surrounding bone. Selipsky[17]" noted that the
decreased mobility obtained in initial therapy was not
compromised in the long-term (1 year) by definitive surgery
within "clinically operable limits.”
Periodontal support regeneration: Regeneration of lost
periodontal support is the most logical approach to improve
poor crown-to-root ratio, and bone grafting is the most reliable
method. Ingber[18] presented the rationale and technique of
forced eruption as a method of treating one- and two-wall
infrabony defects.
Occlusal reduction: Reducing clinical crown length by
occlusal reduction of extruded teeth is a valid approach to
improving the crown-to-root ratio. Bohannan and Abrams
discussed crown shortening in conjunction with intentional
pulp extirpation. They noted an improved crown-to-root ratio
but encountered complications. For each millimeter of
posterior tooth reduction and resultant decrease in the vertical
dimension of occlusion, an increase of 3 mm of anterior
vertical overlap (overbite) will occur. Overdentures represent
an extreme approach to crown shortening and crown-to-root
ratio improvement, providing a new treatment alternative.
Increasing stability: The mobility seen in teeth with poor
crown-to-root ratio can be reduced by selectively grinding
occlusal surfaces and minimizing horizontal forces in the
existing dentition.[9] Teeth which have poor crown-to-root ratio
and exhibit mobility can be retained through splinting.
Dawson[19] emphasized the difficulty in maintaining good oral
hygiene in splinted areas and suggested splinting only when it
is needed.
Restorative consideration: Cast restorations for teeth with poor
crown-to-root ratios place greater demands on the dentist.
Ideal margins of restorations are essential, since inflammation
has been associated with restorations having excellent
margins.[19]
Design of the preparations for cast restorations are dictated by
the anatomy of the root surfaces, which may necessitate
endodontic therapy.
Contours must be consistent with existing root contours and
clinical crown form to permit essential hygiene.
Extraction: Extraction must be considered as a treatment
alternative. Removal or retention of molar teeth related to
furcation involvement was reviewed by Saxe and Carmen.[17]
These considerations also applied to teeth with poor crown-toroot ratio.
These authors suggested that the indications for removal of
problem teeth are
(1) An unopposed terminal tooth in an arch.
(2) A periodontally involved tooth with sound adjacent teeth
providing other treatment alternatives.
(3) A solitary distal abutment that exhibits mobility.
Periodontal factor
Inflammation: A diagnosis of periodontitis is not uncommon
for the patient requiring prosthodontics because one or more
teeth may already have been lost to periodontal disease.
The goals of periodontal therapy for the prosthodontic patient
are: to resolve the inflammation; convert periodontal pocket
depths to clinically normal sulcular depths; establish
physiologic gingival architecture; and provide an adequate
zone of attached gingiva. Adequate oral hygiene is
fundamental to the maintenance of a healthy periodontium.
If surgical intervention is required to achieve therapeutic
goals, approximately six to eight weeks of healing is
recommended before the gingival termination of the tooth
preparations is completed.
Furcation invasions: Teeth with furcation invasions require
special consideration.
Margin placement: G.V. Black's original concepts of
"extension for prevention"[20] have been modified. Broad
extension of cavity preparations to place margins in "caries
immune" areas is not universally advocated. The
recommendation that all gingival finish lines be developed
within the gingival crevice has been challenged.[20],[21]
The gingivae are healthiest when margins are placed well
above (i.e., 1 to 2 mm) the gingival crest[22], and intracrevicular
margin placement is not the universal solution to dental caries.
Biologic width: Histologic studies by Gargiulo, et al[23] have
demonstrated a band of soft tissue attach-ment between the
base of the gingival sulcus and the alveolar crest that is
composed of approximately 1 mm of junctional epithelium
(attachment epithelium) and 1 mm of connective tissue fibers.
This dento-gingival attachment, referred to as the "biologic
width"[24] (Fig.2), has significant implications in treatment
planning. The presence of caries, fractured root structure, or
previous restorations apical to the gingival crest maypredispose to violation of the biologic width during tooth
preparation. A short clinical crown may induce the dentist to
overextend the preparation apically in an attempt to enhance
retention.[25]
Location in the arch
Parfitt GJ (1960), have shown that the faciolingual movement
ranges between 56-108 µm, and intrusion of 28 µm. Teeth in
different segments of the arch move in different directions.
Because of the curvature of the arch, the faciolingual
040
Figure 2
movement of an anterior tooth occurs at a considerable angle to
the faciolingual movement of the molar(Fig.3).
Figure 4
ARCH CURVATURE: There is a common problem in
replacing all four maxillary incisors with a fixed partial
denture and the problem is more pronounced in the arch that is
pointed in the anterior. This occurs because the pontics lie
outside the interabutment axis line and thus acts as a lever arm,
which can produce a torquing movement. In order to offset the
torque, additional retention is obtained in the opposite
direction of the lever arm and at a distance from the
interabutment axis equal to the length of the lever arm.
The first premolars sometimes are used as secondary
abutments for a maxillary four-pontic canine to canine fixed
partial denture. Because of the tensile forces that will be
applied to the premolar retainers, they must have excellent
retention(Fig.3).
Figure 3
Angulation
A common problem that occurs with some frequency is the
mandibular second molar abutment that has tilted mesially into
the space formerly occupied by the first molar. It is impossible
to prepare the abutment teeth for a fixed partial denture along
the long axes of the respective teeth and achieve a common
path of insertion. There is further complication if the third
molar is present. It will usually have drifted and tilted with the
second molar. Uprighting is best accomplished by the use of a
fixed appliance.[27] Both premolars and canine are banded and
tied to a passive stabilizing wire.A helical uprighting spring is
inserted into a tube on the banded molar and activated by
hooking it over the wire on the anterior segment.[27],[28] The
average treatment required is 3 months.[29] A proximal half
crown sometimes can be used as a retainer on the distal
abutment.(Fig.4)[33] This preparation design is simply a three©Journal of Dental Herald (April 2014, Issue:2, Vol.:1).
quarter down that has been rotated 90 degrees so that the distal
surface is uncovered. A telescope crown and coping can also be
used al a retainer on the distal abutment.[34] A full crown
preparation with heavy reduction is made to follow the long
axis of the tilted molar. An inner coping it made to fit the tooth
preparation, and the proximal half crown that will serve as the
retainer for the fixed partial denture it fitted over the coping.
Conclusion
Competent treatment depends upon the careful examination of
all available information, a definitive diagnosis, and a realistic
treatment plan that offers a favourable prognosis. A
comprehensive, sequential approach to treatment planning is
essential. Planning for fixed prosthodontics must not be
independent of other disciplines of dentistry. Hasty, segmented
planning that ignores major aspects of needed treatments
defies modern concepts of treating “the whole patient” rather
than individual teeth.
When planning and treating cases involving fixed
prosthodontic restorations, it is important that all the
applicable parameters are taken into account. The
prosthodontist must not focus too much on the finer details of
constructing a “perfect” restoration, or risk creating a failure
because proper engineering principles was not used. If success
is to be attained the prosthodontist must take into account the
length of span, attachment apparatus, periodontal bone loss,
inclination of teeth, position in the arch, opposing occlusion to
examine and comes to a specific treatment planning and one
must make use of modern diagnostic tools. One such
indispersible tool at the hand of the operator is the radiograph.
A thorough analysis of the radiograph often reveals that the
abutment teeth may not satisfy the requirement of Ante’s law.
However, long term studies have proved that treatment
regimen & maintainence can convert questionable abutments
into ideal abutments.
Radiographs are made, and pulpal health is assessed by
evaluating the response to thermal and electrical stimulation.
Existing restorations, cavity liners, and residual caries are
removed, and a careful check is made for possible pulpal
exposure. Teeth in which pulpal health is doubtful should be
endodontically treated before the initiation of fixed
prosthodontics. Although a direct pulp cap may be an
acceptable risk for a simple amalgam or composite resin,
conventional endodontic treatment is normally preferred for
041
cast restorations, especially when the later need for endodontic
treatment would jeopardize the overall success of treatment.
References
1. Shillingburg H.T, Hobo Sumiya, Whitsett L.D, Jacobi
Richard, Brackett S.E. Fundamental of Fixed
Prosthodontics, ed. 3, Quintessence Publishing Co,
Inc.2010.
2. Johnston J.F., Phillips R.W., Dykema R.W. Modern
Practice in Crown and Bridge Prosthodontics, ed. 2,
Philadephiah,1965. W.B. Saunders Company, p. 5.
3. Reynold J.M. : Abutment Selection for fixed
Presthodontics J. Prosthet Dent.. 19:483, 1968.
4. Ante, I.H: J. Canadian D.A. 2: 249-260, 1936.
5. Jespen, A: Root surface Measurement and A method for Xray Determination of Root surface area, Acta. Odont.
Scandinav. 21: 35-46,1965.
6. Stallard, H.: The Good Mouth- A syallabus on Oral
Rehabilitation and Occlusion , University of California,
San Fransisco, Calif., Vol.1, p- 13.
7. Marshall-Day, C.D., Stephens, R.G., and Quigley, L.F., Jr.:
Periodontal disease: Prevalence and incidence. J.
Periodontal 26: 185,1955.
8. Johnson, E.S., Kelly, J.E., and Vankirk, L.E.: Selected
Dental findings for adults. National center for health.
Statistics, Series 11, No. 7, Washington, D.C, 1965. U.S.
Public Health Service.
9. Nyman, S. Lindhe. J, and Lundgren. D.: The role of
occlusion for the stability of fixed bridges in patients with
reduced periodontal tissue support., J. Clin. Periodontal, 2 :
53, 1975.
10. Sumney, D.L. Jordon, H.V., and Englander H.V.: The
Prevalence of root surface caries in selected population.
J.Periodontal 44: 500, 1973.
11. Ante, I.H.: The Fundamental Principles of Abutment,
Mich. Dent. Soc Bull. 8: 14, 1926.
12. Johnston, J.E, Phillips, R.W., and Dykema, R.W: Modern
Practice in Crown and Bridge Prosthodontics, ed. 3,
Philedelphia, 1971, W.B Saunders Co.
13. Dykema, R.W: Fixed Partial Prosthodontics, J. Tenn Dent
Assoc. 43: 309, 1962.
14. Tylman, S.D: Theory and Practice of Crown and Bridge
Prosthodontics, ed.5, st. Louis,1965, The C.V. Mosby
Company, p- 173.
15. Beube, F.E: Correlation of the degree of alveolar bone loss
with other factors for determining the removal or retention
of teeth. Dent. Clin. North Am. 13: 801,1969.
16. Goldman, H.M, and Cohen, D.W.: Periodontal Therapy,
Ed. 5, St. Louis, 1973, C.V. Mosby. Co.
17. Prichard, J.F: Advanced Periodontal Disease. Surgical and
Prosthetic Management, ed.2, Philadelphia, 1972, W.B
Saunders Co.
18. Robert E. Penny., crown-to-root ratio: its significance in
resforative Dentistry, J. Prosthet Dent Vol 42; Number, July
1979.
19. Dawson PE. Evaluation, Diagnosis and Treatment of
occlusal Problems,ed 1 ST.Louis, 1974.
20. Blackwell, R.E. G.V. Black’s operative Dentistry, Vol. II,
ed.9, South Milwankee, 1955, Medico-Dental Publishing
Co.P-110-111.
21. Reynold J.M.: Abutment Selection for fixed
Presthodontics J. Prosthet Dent.. 19:483, 1968.
22. Romanelli, J.H.I. Periodontal considerations in tooth
preparation for growth and Bridge, Dent Cli. NorthAm.
24:2,271-283, 1980.
23. Marcum, J.S. : The effect of crown marginal depth upon
gingival tissue, J. Prosthet Dent. 17:2,271-283, 1980.
24. Glickman, I.: Clinical Periodontology, ed. 4, Philedelphia,
1972, W. B. Saunders Co., p- 879-898.
25. Miller, C.: A Clinical interpretation of tooth preparation
and design of metal substructures for metal ceramic
restorations. In Mclean, J.W., editor; Dental Ceramics,
Chicago, 1983, Quintessence Publishing co, Inc., P-169170.
042

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