Faculty of Dental Science

Dharmsinh Desai University

NADIAD

Volume - IX Issue - 1 2019

Volume - IX Issue - 1 2019
ANNUAL JOURNAL, - 2019
FACULTY OF DENTAL SCIENCE, DHARMSINH DESAI UNIVERSITY, NADIAD, GUJARAT.

INDEX
Page
Message.....................................................................................................................................[1]

Editorial....................................................................................................................................[6]
Conservative Dentistry and Endodontics

1. Sonic and ultrasonic irrigation: a review

Dr. Shivani Doshi, Dr. Jhanvi Vaviya, Dr. Dipti Choksi, Dr. Barkha Idnani .................[7]

2. Nanodentistry: Bioactive Glass and Nanoparticales as Intracanal Medicaments:

A Review
Dr. Prachi Maniar, Dr. Nihit Shah, Dr. Dipti Choksi, Dr. Barkha Idnani ........................[27]

Oral Medicine and Radiology

3. Transcutaneous electrical nerve stimulation therapy in temporomandibular joint

disorder –overview
Dr Priti P Shah, Dr. Hetul J Patel, Dr. Mona J Shah, Dr. Kevin Parikh ........................[41]

Oral and Maxillofacial Surgery

4. Sialolithiasis – a case report

Dr.Siddharth Deliwala, Dr. Hiren Patel, Dr. Haren Pandya,
Dr. Hitesh Dewan, Dr. Bijal Bhavsar, Dr. Urvi Shah, Dr. Kartik Dholakia ...................[48]

5. Epulis fissuratum of maxilla: consequences of ill-fitting prosthesis: a case report

Dr. Maitree P. Bavishi, Dr. Hiren Patel, Dr.Haren Pandya, Dr.Hitesh Dewan,
Dr. Bijal Bhavsar, Dr Urvi Shah, Dr. Kartik Dholakia ..................................................[55]

Oral and Maxillofacial Pathology

6. Patterns of rugae in gender identification

Dr. Divya Jay Makhija, Dr. Meghal Arpit Shah, Dr. Jigar Purani..................................[62]

Orthodontics & Dentofacial Orthopedics

7. Orthodontic space closure in carious 1st molar extraction case- a preferred

treatment option in young patients
Dr. Aakash Shah, Dr. Amit Mendiratta, Dr. Harsh Mandan .........................................[70]

Volume - IX Issue - 1 - 2019

ANNUAL JOURNAL, - 2019
FACULTY OF DENTAL SCIENCE, DHARMSINH DESAI UNIVERSITY, NADIAD, GUJARAT.

INDEX
Page

Periodontics and Oral Implantology

8. Association between diabetes mellitus and risk of peri-implant diseases

Dr. Anal Trivedi, Dr. Vasumati Patel, Dr. Shalini Gupta, Dr. Hiral Purani ................[77]

9. Amniotic-chorionic membrane: hype or hope

Dr. Deesha Chhaya, Dr. Shalini Gupta, Dr. Vasumati Patel ...................................... .[88]

10. Awareness amongst the gynecologists regarding the association between sex
hormonal changes and periodontal health/diseases: a questionnaire survey
Dr. Dhvani Valvai, Dr. Vasumati Patel, Dr. Shalini Gupta, Dr. Vishal Sahayat ……… [110]

11. Periodontal disease-systemic disease inter- relationship awareness study

Dr. Dhwani Patel, Dr. Vasumati Patel, Dr. Shalini Gupta, Dr. Hiral Purani,
Dr.Dhvani Valvai, Dr. Deesha Chhaya ....................................................................[121]

Prosthodontics & Crown and Bridgework

12. Soft tissue management in oral implantology

Dr. Shaili Ganatra, Dr. Somil Mathur, Dr. Rakesh Makwana, Dr. Nidhi Jathal,
Dr. Akanksha Dwivedi ...........................................................................................[132]

13. Milling Procedure in Prosthodontics

Dr. Manan Shah, Dr. Somil Mathur, Dr.Rakesh Makwana, Dr. Nidhi Jathal …........[137]

14. Minimally invasive post endodontic restorations

Dr. Thanmai Taduri, Dr. Meena Shah .......................................................................[144]

Volume - IX Issue - 1 - 2019

 Vice Chancellor's Message

We continually face challenges in life, how we view them defines us. I am proud to see
that Faculty of Dental Science, choose to see challenges as stepping stones and opportunities
that help them climb greater heights. I congratulate the editorial committee for coming up with
yet another issue of the annual journal, which brings out the master works of students and staff
members of the college, enriched with the scientifically reasoned information.

Dr. H.M Desai,

Vice Chancellor,
Dharmsinh Desai University,
Nadiad

1|Page
Volume - IX Issue - 1 - 2019
 Trustee's Message

Faculty of dental science has paved its path to a greater success. I have been part of it
ever since it was established and wish to look forward to its incremental success. My heartfelt
congratulations to each of the students as well as the faculty members who have poured their
strength into bringing out the current issue of the journal.

Mr. Ankur Desai

Trustee

Dharmsinh Desai University

Nadiad.

2|Page
Volume - IX Issue - 1 - 2019
 Coordinator's Message

Discoveries and inventions are a part of constantly growing world. With the innovative
ideas and procedures, we at the Faculty of Dental Sciences, provide a platform for the students
as well as for the Faculty members to showcase their scientific abilities, opening a new horizon
of knowledge. I, congratulate all the students and staff members for their active indulgence in
bringing out the current issue of the journal.

Dr. Bimal.S. Jathal,

University Co-Ordinator,
Dharmsinh Desai University,
Nadiad

3|Page
Volume - IX Issue - 1 - 2019
 Dean's Message

“If there is no struggle, there is no progress.”- Frederick Douglass

The progress in our communities, in our world can only happen when brilliant minds
decide to become engaged for the emergence of extraordinary work. We at the faculty of
dental science, provide a platform for the younger and creative minds to share the best of their
knowledge, creating an upgradation of an intellectual levels, leading to introduction of finer
techniques and an academic leap.
I congratulate all the students and the faculty members for adding yet another pearl to the
ocean of wisdom.

Dr. Hiren Patel

Dean
Faculty of Dental Science
Dharmsinh Desai University
Nadiad.

4|Page
Volume - IX Issue - 1 - 2019
 From the Editor's Desk

The documentation of clinical work is an important aspect of academic training. The journal of
dental science provides a platform for the faculty members and students to publish their work so
as to benefit the entire dental fraternity.
The editorial committee has been working hard in a hope to keep our readers updated and
motivated for the current and ever evolving trends in dentistry.
Looking forward for more knowledgeable articles in future too…

“Together we can.”

Dr. Shalini Gupta

Editor
Journal of Dental Sciences
Dharmsinh Desai University
Nadiad

5|Page
Volume - IX Issue - 1 - 2019
 Dharmsinh Desai University
Faculty of Dental Science
JOURNAL OF DENTAL SCIENCES
Editorial Committee Members

Editor Technical Advisor

Dr. Shalini Gupta Dr. Kartik Dholakia
Professor, Department of Periodontia, FDS, DDU. Lecturer, Department of Oral and Maxillofacial Surgery,
FDS, DDU.
EDITORIAL COMMITTEE MEMBERS
Dr. Khushali Patel
Dr. Heena Pandya
Tutor, Department of Prosthodontics, FDS, DDU
Reader, Department of Preventive and Community
Dentistry, FDS, DDU. ADVISORS

Dr. Jigar M. Purani Dr. Hiren Patel

Reader, Department of Oral and Maxillofacial Pathology, Dean, Professor & Head, Department of Oral and
FDS, DDU. Maxillofacial Surgery, FDS, DDU.
REVIEWER COMMITTEE MEMBERS Dr. B. S. Jathal
Dr. Vishal Patel Coordinator and Professor, Department of Periodontia,
FDS, DDU.
Reader, Department of Orthodontics, FDS, DDU.
ADVISORY BOARD
Dr. Hitesh Dewan
Dr. Amish Mehta
Professor, Department of Oral and Maxillofacial
Surgery,FDS, DDU. Professor & Head, Department of Orthodontics, FDS,
DDU.
Dr. Jyoti Mathur
Dr. Bhupesh Patel
Professor & Head, Department of Pedodontics, FDS,
DDU. Professor & Head, Department of Oral and Maxillofacial
Pathology, FDS, DDU.
Dr. Kevin Parikh
Dr. Dipti Choksi
Reader, Department of Oral Medicine, FDS, DDU.
Professor & Head, Department of Conservative Dentistry
Dr. Kunjal Mistry
and Endodontics
Reader, Department of Conservative Dentistry and
Dr. Preeti Shah
Endodontics, FDS, DDU.
Professor & Head, Department of Oral Medicine, FDS,
Dr. Snehal Upadhyay
DDU.
Lecturer, Department of Prosthodontics, FDS, DDU.
Dr. Somil Mathur
Dr. Vishal Sahayata
Professor & Head, Department of Prosthodontics, FDS,
Lecturer, Department of Periodontics, FDS, DDU. DDU.

Dr. Vasumati Patel

Professor & Head, Department of Periodontics,
FDS, DDU.

6|Page
Volume - IX Issue - 1 - 2019
 SONIC AND ULTRASONIC IRRIGATION: A REVIEW

*Dr. Shivani Doshi **Dr. Jhanvi Vaviya ***Dr. Dipti Choksi

****Dr. Barkha Idnani

ABSTRACT
Complete debridement of root canal system is a critical component of endodontic therapy.
Ultrasonic and sonic activation of endodontic instruments have been suggested as a means to
enhance canal debridement. When a file is ultrasonically activated and placed passively in canal,
a phenomenon called acoustic streaming produced. It may produce shear stresses that are capable
of disrupting biological cells and removing debris. Several studies have shown that ultrasonically
or sonically prepared teeth have significantly debris free canals. This may be due to the fact that,
when power driven files are used to instrument a canal, they can bind or contact the canal walls
in a way that restricts their vibratory motion and cleaning efficacy. This may be particularly true
for the fine and/or curved canals. Perhaps a more effective method for canal debridement would
be to passively activate a file, sonically or ultrasonically, inside the canal as a final step in root
canal preparation. Passive activation suggests that no attempt is made to instrument, plane, or
contact the canal walls with the file. This should enable maximum benefits from acoustic
streaming. The purpose of this review is to evaluate the cleaning efficacy of passive ultrasonic
activation and passive sonic activation.
Keywords: Ultrasonic irrigation, sonic irrigation, root canal, smear layer, irrigation, activation.

*Post Graduate Student Corresponding Authors:

**Post Graduate Student Dr. Jhanvi Vaviya
***Professor and Head of Department 3rd year Post Graduate Student,
Department of Conservative
****Professor
Dentistry and Endodontics,
Department of Conservative Dentistry and Faculty of Dental Sciences,
Endodontics Dharmsinh Desai University,
Faculty of Dental Science, College Road, Nadiad 387001, Gujarat.
Dharmsinh Desai University, Email: [email protected]
Nadiad – 387002 Gujarat (M) +91 9979862689
7|Page
Volume - IX Issue - 1 - 2019
 INTRODUCTION Throughout the history of endodontics,

The main aim of a Root Canal Treatment is ongoing efforts have been made to evolve

the complete elimination of the connective more effective systems to send and agitate

tissue and thedestruction of residual irrigant solutions in the canal system. These

microorganisms found in infected root systems can be categorized into manual and

canals and an effective seal in order mechanical agitation techniques. Machine-

toprevent recolonization of the root canal assisted procedures include using rotary

system with bacteria.1 Thus the primary brushes, simultaneous irrigation with rotary

endodontic treatment goal must be to ensure instrumentation of the canal, pressure

complete root canal disinfection and to alternation devices and sonic and ultrasonic

prevent re-infection. Irrigating solutions play systems.5 Several studies have shown that

a very important role in disinfecting the root ultrasonically or sonically prepared teeth

canals. Presence of numerous dentinal have significantly cleaner canals than teeth

tubules in the roots, the complexity of the prepared by hand instrumentation.6-8 Other
root canal system, invasion of the tubules by studies have failed to demonstrate the
microorganisms, presence of dentin as a superiority of ultrasonic or Sonics as a
tissue and formation of smear layer during primary instrumentation technique.9-13This
instrumentation are the major obstacles in may be due in part to the fact that, when
achieving the primary objectives of power-driven files are used to instrument a
complete cleaning and shaping of root canal canal, they can bind or contact the canal
systems.2 At present, no single irrigant walls in a way that restricts their vibratory
combines all the ideal characteristics, even motion and cleaning efficacy.14 Perhaps a
when they are used with an increased more successful technique for canal
temperature, lower pH, or added surfactants debridement would be to passively activate a
to increase their wetting efficacy.3,4 No file, sonically or ultrasonically, inside the
single irrigant has demonstrated an ability to canal as a final step in root canal
demineralize the calcified organic portion preparation.
and dissolve organic pulp material of canal
walls.

8|Page
Volume - IX Issue - 1 - 2019
 The purpose of this review is to evaluate the B.V.) and the EndoActivator® system with

cleaning efficacy of passive ultrasonic attached polymer tips (Dentsply Tulsa Dental

activation and passive sonic activation. Specialties)16

Desired functions of irrigating solutions15

• Washing action (helps remove
debris)
• Dissolve inorganic tissue (dentin)
• Penetrate to canal periphery
• Reduce instrument friction during
preparation (lubricant)
• Facilitate dentin removal (lubricant)
• Dissolve organic matter (dentin
collagen, pulp tissue, biofilm)
• Kill bacteria and yeasts (also in
biofilm)
• Do not irritate or damage vital
periapical tissue, no caustic or cytotoxic Illustrarion 1:
effects
• Do not weaken tooth structure (a) Micromega® Sonic Air® 1500
handpiece.
SONIC IRRIGATION: (b) Rispi-Sonic® fi le (Micromega)
Efficacy of sonic/subsonic activation Courtesy:John M. Nusstein. Sonic and
of irrigants has been evaluated as a manner Ultrasonic Irrigation,B. Basrani (ed.),
to improve overall canal cleanliness. By Endodontic Irrigation: Chemical
definition, sonic frequency is anything in the Disinfection of the Root Canal
audible hearing range of a human. The major System,2015:173-197
systems available to produce sonic/subsonic
agitation are the Micromega® Sonic
Air®1500 handpiece with an attached Rispi-
Sonic® file, the Vibringe® sonic irrigation
system (Vibringe
9|Page
Volume - IX Issue - 1 - 2019
 Endodontic Irrigation: Chemical
Disinfection of the Root Canal
System,2015:173-197

Conventionally, a Rispisonic file attached to a

MM 1500 sonic handpiece (Medidenta
International, Inc, Woodside, NY) is used to
perform sonic irrigation after canal shaping.
The Rispisonic files have a variable taper that
Illustration 2: increases with file size. Because they are
EndoActivator® system with polymer tips barbed, these files might inadvertently engage
(Dentsply Tulsa Dental) to the canal wall and damage the finished canal
Courtesy:John M. Nusstein. Sonic and preparation during agitation. A more recently
Ultrasonic Irrigation,B. Basrani (ed.), introduced sonically driven canal irrigation
Endodontic Irrigation: Chemical system is EndoActivator System (Dentsply
Disinfection of the Root Canal Tulsa Dental Specialties, Tulsa, OK).17 It
System,2015:173-197 consists of 3 types of disposable polymer tips
of different sizes and a portable handpiece.
These tips are claimed to be flexible and
strong and do not break easily. They do not cut
dentin,because they are smooth. The
EndoActivator System was reported to be able
to effectively remove the smear layer, clean
debris from lateral canals, and dislodge clumps
of simulated biofilm within the curved canals
of molar teeth.18The action of the
Illustration 3: EndoActivator tip frequently produces a cloud
Vibringe irrigation system (Vibringe) of debris during use, that can be observed
Courtesy:John M. Nusstein. Sonic and within a fluid-filled pulp chamber.
Ultrasonic Irrigation,B. Basrani (ed.),

10 | P a g e
Volume - IX Issue - 1 - 2019
 Vibrating the tip, in combination with endodontics in 1985. Sonic irrigation is

moving the tip up and down in short vertical different from ultrasonic irrigation in that it

strokes, synergistically produces a powerful operates at a lower frequency (1–6 kHz) and

hydrodynamic phenomenon.19 In general, produces smaller shear stresses.21 The sonic

10,000 cycles per minute (cpm) has been energy also generates significantly greater
shown to optimize debridement and promote back-and-forth tip movement or higher
disruption of the smear layer and amplitude. A minimum oscillation of the
biofilm.18Polymer tips used in the amplitude might be considered as an node,
EndoActivator system are radiolucent and it whereas a maximum oscillation of the
is a possible disadvantage of them. Although amplitude considered as an anti-node. They
these tips are designed to be disposable and have 1 nodenear the attachment of the file and
do not break easily during use, it would be 1 anti-node at the tip of the file.22The sideway
difficult to identify them if part of a tip oscillation disappears when the movement of
separates inside a canal. Apparently, these
the sonic file is constrained. This results in a
tips might be improved by incorporating a
pure longitudinal file oscillation. For root canal
radiopacifier in the polymer. The Vibringe®
debridement this mode of vibration is efficient,
irrigation system consists of a battery-
because it is largely unaffected by loading and
operated plunger and thumb ring which is
exhibits large displacement amplitudes.
placed into a disposable, 10 ml, nylon
syringe. An endodontic irrigating needle of
Debris and Smear Layer Removal:
varying size, depending on the root canal
Research into the improved cleaning
preparation, is attached. The reported
of the root canal walls, isthmuses, lateral
frequency of agitation is 150 Hz. As the
canals, and, as well as removal of pastes
irrigant is delivered into the root canal, the
(mainly calcium hydroxide) and smear layer
thumb ring is activated causing vibration of
removal, has provided rather mixed results
the irrigating needle.16
with sonic activation of irrigants. Stojicic et
al.23 reported on the effect sonic agitation of
Frequency and Oscillating Pattern of
NaOCl has on dissolution of tissue. They
Sonic Instrument:
reported that increasing the concentration of
20
Tronstad et al. were the first to
the NaOCl had the greatest impact and that
report the use o f a s onic i nstrument for
11 | P a g e
Volume - IX Issue - 1 - 2019
 agitation (sonic) had the second greatest and NaOCl. Rödig et al.30 found that the
effect (more than increasing the temperature addition of PUI/ UAI or EndoActivator® to
of the solution). DeGregorio et al.24reported activate the irrigants (NaOCl and EDTA) in
that sonic activationwith the curved canals resulted in superior smear
EndoActivator® equaled the effectivenessof layer removal, especially in the coronal
PUI/UAI in getting irrigant solution portion of the canal. Bolles et al.31compared
intolateral canals 2–4.5 mm from the root fluorescent dye-labeled sealer penetration in
apex whenEDTA was used.Merino et dentinal tubules following the use of
al.25found that Passive Ultrasonic Irrigation EndoActivator® and Vibringe® on 17 %
(PUI/ UAI) was superior to the EDTA. They stated that the use of the
EndoActivator® in getting irrigant to the activators did not improve sealer penetration
canal apex in variously (therefore smear layer removal was absent)
tapered, curved canals. They found that the in the apical 4 mm of the root canal
taper of the preparation had no impact on the compared to needle irrigation with 17 %
irrigant movement.Rödig et al.26 stated that EDTA. Calcium hydroxide and other paste
use of the Vibringe® resulted in a cleaner and sealer removal have also been evaluated
apical 1/3 of the canal as compared to needle utilizing sonic activation. Chou et al.32found
irrigation alone. Kanter et al.27found that the EndoActivator® resulted in more complete
use of the EndoActivator® removed more removal of the pastes as compared to needle
debris and cleaned lateral canals better than irrigation. There was no difference in
PUI/ UAI and needle irrigation. Johnson et calcium hydroxide removal. Grischke et al.33
al.28 stated that using Vibringe® cleaned evaluated the use of the EndoActivator® to
canals and isthmuses filled with artificial remove set AH Plus sealer from artificial
collagen to the same degree as needle grooves in roots. The group reported that the
irrigation although there were some EndoActivator® scored poorly in removing
differences at various levels of the canals. the sealer with PUI/UAI providing better
In removing smear layer, sonic activation results. Goode et al.34 and Khaleel et
has also had mixed results. Uroz-Torres et al.35also evaluated the efficacy of the
al.29 stated no differences between needle EndoActivator® to remove calcium
irrigation and the use of EndoActivator® in hydroxide from root canals, Khaleel reported
removing smear layer when using EDTA better results with the
12 | P a g e
Volume - IX Issue - 1 - 2019
 EndoActivator® and PUI/UAI (similar irrigant past the apex of the root canal.
results) than needle irrigation, while Goode’s Mitchell et al.40 stated that the use of the
group reported no difference between the EndoActivator® and MicroMega® Sonic
techniques. Air® 1500 systems did result in extrusion of
irrigant but that this occurred less frequently
Bacteria and Biofilm Removal: with the EndoActivator®. Boutioukis et al.41
Brito et al.36 stated that the use of the found that flow rate of the irrigant had a
EndoActivator® was similar to needle direct correlation with the amount of irrigant
irrigation (NaOCl as the irrigant) in reducing extrusion.
artificially placed Enterococcus faecalis
counts in extracted teeth. Tardivo et al.37 ULTRASONIC IRRIGATION Nature of
found no difference in removal of ultrasound:
Enterococcus faecalis between the Ultra-Sound (US) is a vibration or
EndoActivator® and PUI/UAI (Irrisafe™ acoustic wave of the same nature as sound
system) from the root canal system. Neither but at a frequency higher than the highest
technique could remove all the bacteria. frequency perceptible to the human ear
Shen et al.38 utilized infected hydroxyapatite (approximately 20,000 Hz).
discs to study chlorhexidine in killing There are two basic methods for producing
bacteria. They reported that the addition of ultrasound. Firstly, by magnetostriction that
EndoActivator® agitation improved the converts electromagnetic energy into
killing effect of the chlorhexidine, but did mechanical energy. Different strips of
not remove biofilm from the disc samples. In magnetostrictive metal in a hand-held piece
terms of biofilm removal, Ordinola- are joined to a stable, alternating magnetic
Zapataet al.39 stated that EndoActivator® field producing vibrations as a result. The
agitation and needle irrigation were similar second method is based on the piezoelectric
in results and were both inferior to PUI/UAI principle and uses a crystal which changes
and Photon. size when an electrical charge is applied.
Once the crystal deforms, it goes into
Safety: mechanical oscillation without producing
The safety of sonic irrigation has heat. Magneto strictive units create figures
been evaluated in terms of extrusion of the of eight (elliptical movement), which is not
13 | P a g e
Volume - IX Issue - 1 - 2019
 ideal for endodontic use and another evaluated. Most of these studies concluded
drawback with these units is that heat is that ultrasonics, together with an irrigant,
generated, so adequate cooling is required. contributed to a better cleaning of the root-
Piezoelectric unitsproduce more cycles per canal system than hand instrumentation and
second, 40 as against 24 kHz so they have irrigation alone.acoustic streaming and
some advantages over magnetostrictive cavitation of the irrigant contribute to the
units. The tips of these units work in a linear biologic chemical activity for maximum
movement from back to front like a piston effectiveness. Analysis of the physical
which is ideal for endodontic treatment.42 mechanisms of the hydrodynamic response
of an oscillating ultrasonic file suggested
Ultrasound Application: thattransient and stable cavitation of a file,
Ultrasound was first used in dentistry steady streaming, and cavitation
for cavity preparations. The concept of microstreaming all contribute to the cleaning
“Minimally Invasive Dentistry” meant a new of the root canal. Ultrasonic files must have
application of ultrasound for cavity free movement in the canal without making
preparation. Richman first introduced contact with the canal wall Several studies
ultrasonic instrumentation to endodontics in have shown the importance of ultrasonic
1957 for endodontic therapy with Cavitron© preparation for optimal debridement of
as irrigation and obtained good results. anastomoses between double canals, fins
However, ultrasonically activated K files and isthmuses.45-47The effectiveness of
were not used for preparing canals before ultrasonics in the elimination of dentin
43
filling until the study by Martin et al. The debris and bacteria from the canals has been
term “endosonic” was coined by Martin and shown by several studies.48-52 However, not
Cunningham44 and was defined as the all studies have supported these findings.
ultrasonic synergistic system of Van der Sluis and colleagues concluded in a
instrumentation and canal disinfection. The study that a smooth wire during ultrasonic
use of ultrasonic energy for facilitating irrigation is as effective as a size 15 K-file in
disinfection has a long history in the removal of artificially placed dentin
endodontics. In several earlier studies, the debris in grooves in simulated canals in resin
comparative effectiveness of ultrasonics and blocks. It is possible that preparation
hand-instrumentation techniques has been complications are less likely to occur with
14 | P a g e
Volume - IX Issue - 1 - 2019
 an ultrasonic tip with a smooth, inactive root canal by a syringe and replenished
surface.15 Two types of ultrasonic irrigation many times after each ultrasonic activation
is described in the literature. The first type cycle. The amount of irrigant flowing
referred to as combination of simultaneous through the apical region of the canal can be
ultrasonic instrumentation and irrigation controlled because both the volume of
(UI). The second type, is passive ultrasonic irrigantadministered and the depth of syringe
irrigation (PUI), operates without penetration are known. This cannot be
simultaneous instrumentation. UI devices possible with the use of the continuous flush
have significantly cleaner canals than teeth regime. Both flushing methods have been
prepared by conventional root canal filing shown to be equally effective in removing
alone.53 In addition, it is difficult to control dentin debris from the canal in an ex vivo
the cutting of dentin during ultrasonic model when the irrigation time was set at 3
irrigation and hence the shape of the minutes.57
prepared root canal. Highly irregular-shaped
canals as well as strip perforations were Continuous Ultrasonic Irrigation:
frequently produced.54 Therefore, UI is not A needle-holding adapter to an
generally perceived as an alternative to ultrasonic handpiece has been developed by
conventional hand instrumentation.51 On the Nusstein.58During ultrasonic activation, a
contrary, the endodontic literature supports 25-gauge irrigation needle is used instead of
that it is more advantageous to apply an endosonic file. This enables ultrasonic
ultrasonics after completion of canal activation to be performed at the maximum
preparation.55 power setting and does not cause needle
breakage. The main feature of this needle-
Irrigant Application Methods During holding adapter is that the needle is
PUI: simultaneously activated by the ultrasonic
Two flushing methods might be used handpiece, while an irrigant is delivered
during PUI, namely a continuous flush of from an intravenous tubing connected via a
irrigant from the ultrasonic handpiece or an Luer-lok to an irrigation-delivering syringe.
intermittent flush technique by using syringe The irrigant can thus be delivered apically
delivery.56In the intermittent flush technique, through the needle under a continuous flow
the irrigant is injected into the instead of being intermittently replenished
15 | P a g e
Volume - IX Issue - 1 - 2019
 from the coronal access opening.59 1 minute Brasseler file holder E12 (Brasseler)
of continuous ultrasonic irrigation produced Courtesy:John M. Nusstein. Sonic and
significantly cleaner canals and isthmi in Ultrasonic Irrigation,B. Basrani (ed.),
both vital and necrotic teeth.60It also resulted Endodontic Irrigation: Chemical
in a significantly greater reduction of Disinfection of the Root Canal
colony-forming unit. System,2015:173-197

Intermittent Flush Ultrasonic Irrigation:

In intermittent flushed UI, the
irrigant is delivered to the root canal by a
syringe needle. The irrigant is then activated
by an ultrasonically oscillating instrument.
The canal is then flushed with fresh irrigant
to
remove the dislodged or dissolved remnants
from the canal walls.

Illustration 5:
Satelec Acteon Irrisafe™ tips. Note
serrated wire with non-cutting sides and
irrigation port near attachment hub
(Satelec)
Courtesy:John M. Nusstein. Sonic and
Ultrasonic Irrigation,B. Basrani (ed.),
Endodontic Irrigation: Chemical
Disinfection of the Root Canal
System,2015:173-197

Illustration4:
16 | P a g e
Volume - IX Issue - 1 - 2019
 debris that is removed with the PUI/UAI file.
Rödig et al, however, found that apical size
had no impact on canal cleanliness when
utilizing PUI/UAI.16De Gregorio etal.61
reported that irrigant penetrated artificially
made lateral canals much better when
PUI/UAI was used than needle irrigation or
negative pressure irrigation. Liang et al.62
evaluating 86 patients 10–19 months after
Illustration 6:
root canal treatment, showed an improvement
Satelec Sonofi le with no irrigation port
in the reduction and resolution of apical
(Tulsa Dental Products)
pathosis following the use of PUI/UAI
Courtesy:John M. Nusstein. Sonic and
compared to needle irrigation. When NaOCl
Ultrasonic Irrigation,B. Basrani (ed.),
was used alone, studies have reported almost
Endodontic Irrigation: Chemical
complete smear layer removal from various
Disinfection of the Root Canal
levels of the root canal. When NaOCl was
System,2015:173-197
combined with EDTA, the research has shown
a marked improvement in smear layer
Debris and Smear Layer Removal:
removal.16 Studies looking at the use of
PUI/UAI has been reported to be
PUI/UAI to remove either calcium hydroxide
more effective than simple syringe and
or other paste fillers from the canals have
needle irrigation Goodman et al.45 and Lev at
given mixed results. The addition of PUI/UAI
al.59 reported that the addition of 3 min of
to remove calcium hydroxide and Ledermix
PUI/UAI per canal (using NaOCl as an
was found to improve overall removal, but did
irrigant) significantly enhanced the
not assure complete removal of all material.63
cleanliness of the isthmuses of the mesial
The effect of canal curvature on the
roots of mandibular molars in vitro at the 1
effectiveness ofPUI/UAI is also reported.
and 3 mm levels from the canal apex.
Significantly improved cleaning of isthmuses
Looking at the effect of the size of the canal
and canals occurred at the apical 5 mm in
preparation on cleaning with PUI/UAI, Lee
curved canals versus needle
et al. and van der Sluis et al. concluded that
the greater the taper of the canal, the more
17 | P a g e
Volume - IX Issue - 1 - 2019
 irrigation. Malki et al. report that the flow of kept at 3 and 5 mm from the apex. However,
irrigant beyond the ultrasonic file tip was not extrusion did occur when the file was placed
affected by curvature of the canal.16 within 1 mm of the apex.72

Bacteria/Biofilm Removal: CONCLUSION:

Bhuva et al.64 reported no Effective irrigant delivery and
improvement in removal when utilizing an agitation are prerequisites for successful
artificially produced biofilm of E.faecalis . endodontic therapy. This article presents an
Shen et al.65 reported an increase in killing of overview of the irrigant agitation methods
artificial biofilm when PUI/UAI was utilized and their debridement efficacy.
with chlorhexidine on dentin discs. Technological advances during the last
Gründling et al.66 reported that PUI/UAI decade have brought to fruition new
helped reduce E.faecalis biofilm only when agitation devices that rely on different
NaOCl was used as an irrigant. Joyce et al.67 mechanisms of irrigant transfer, soft tissue
looked at the mechanism of action of debridement, and, depending on treatment
ultrasonics on biofilm and stated that philosophy, removal of smear layers. When
PUI/UAI caused deagglomeration of the a file is passively activated in a canal by
biofilm via the cavitation effect. sonics or ultrasonics for 3 min after hand
instrumentation, it results in a significantly
Safety: cleaner canal than that for hand
There is potential risk of extrusion of instrumentation alone. There is no
debris and irrigants during the use of significant difference in cleaning efficacy
PUI/UAI. Fluid movement and cleaning between ultrasonically and sonically
extends 3 mm beyond the ultrasonic file activated files.
tip.68 The use of PUI/UAI does transport
irrigant solution to the apex of the root
canal.69More extrusion of irrigant and debris
out the apex of the root canal following the
use of PUI/UAI as compared to needle
irrigation.70,71 No extrusion of irrigant out
the root apex when the PUI/UAI file was
18 | P a g e
Volume - IX Issue - 1 - 2019
 techniques and devices. J Endod.

REFERENCES: 2009; 35:791–804.

6. Cunningham WT, Martin H. A

1. Garberoglio R, Becce C. Smear layer
scanning electron microscope
removal by root canal irrigants.A
evaluation of root canal debridement
comparative scanning electron
with the endosonic ultrasonic
microscopic study. Oral Surg Oral
synergistic system. Oral Surg 1982;
Med Oral Pathol. 1994; 78:359-67
53:527.

2. Torabinejad M, Handysides R, 7. Cunningham WT, Martin H.

Khademi A, Bakland LK. Clinical Endosonics—the ultrasonic
implications of the smear layer in synergistic system of endodontics.
endodontics: A review. Oral Surg Endod Dent Traumatol 1985; 1:201-
Oral Med Oral Pathol Oral Radiol 6.
Endod 2002; 94:658-66.
8. Stamos DE, Sadeghi EM, Haasch
3. Briseno BM, Wirth R, Hamm G,
GC, Gerstein H. An in vitro com-
Standhartinger W. Efficacy of
parison study to quantitate the
different irrigation methods and
debridement ability of hand, sonic,
concentrations of root canal
and ultra- sonic instrumentation. J
irrigation solutions on bacteria in the
Endodon 1987; 13:434-40.
root canal. Endod Dent Traumatol.
1992; 8:6–11.
9. Reynolds WA, Madison S, Walton

4. Al-Jadaa A, Paqué F, Attin T, RE, Krell KV, Rittman BRJ. An in

Zehnder M. Acoustic hypochlorite vitro histological comparison of the

activation in simulated curved step-back, sonic, and ultrasonic

canals. J Endod. 2009; 35:1408–11. instru- mentation techniques in small,

curved root canals. J Endodon 1987;
5. Gu LS, Kim JR, Ling J, Choi KK, 13:307- 14.
Pashley DH, Tay FR. Review of
contemporary irrigant agitation
19 | P a g e
Volume - IX Issue - 1 - 2019
 10. Goldman M, White R, Moser C, Endodontic Irrigation: Chemical

Tenca J. A comparison of three Disinfection of the Root Canal

methods of cleaning and shaping the System,2015:173-197

root canal in vitro. J Endodon

17. Ruddle CJ. Endodontic disinfection:
1988;14: 7-12.
tsunami irrigation. Endod Practice

11. Baker MC, Ashrafi SH, Van Cura JE, 2008. Feb:7–15.

Remeikas NA. Ultrasonic com- pared

18. Caron G. Cleaning efficiency of the
with hand instrumentation: a
apical millimeters of curved canals
scanning electron microscope study.
using three different modalities of
J Endodon 1988; 14:435-40.
irrigant activation: an SEM study.

12. Pugh RI, Goerig AC, Glaser CG, Paris VII University, Paris, France:

Luciano WJ. A comparison of four Master’s thesis; 2007.

endodontic vibratory systems. J Acad

19. Ruddle CJ. Cleaning and shaping the
Gen Dent 1989; 37:296-301.
root canal system. In: Cohen S,

13. Walker TL, del Rio CE. Histological Burns RC, eds. Pathways of the pulp.

evaluation of ultrasonic and sonic 8th ed. St Louis: Mosby, Inc;

instrumentation of curved root 2002:231–91.

canals. J Endodon 1989; 15:49-59.

20. Tronstad L, Barnett F, Schwartzben

14. Walmsley AD, Williams AR. Effects L, Frasca P. Effectiveness and safety

of constraint on the oscillatory of a sonic vibratory endodontic

pattern of endodontic files. J instrument. Endod Dent Traumatol

Endodon 1989; 15:189-94. 1985; 1:69–76.

15. Haapasalo M, Irrigation in 21. Ahmad M, Pitt Ford TR, Crum LA.

Endodontics,Dent Clin N Am 54 Ultrasonic debridement of root

(2010) 291–312. canals: an insight into the

mechanisms involved. J Endod 1987;
16. Nusstein J M. Sonic and Ultrasonic 13:93–101.
Irrigation,B. Basrani (ed.),
20 | P a g e
Volume - IX Issue - 1 - 2019
 22. Walmsley AD, Lumley PJ, Laird removing debris from simulated root
WR. Oscillatory pattern of sonically canal irregularities. J Endod. 2010;
powered endodontic files. Int Endod 36:1410–3.
J 1989; 22:125–32.

23. Stojicic S, Zivkovic S, Qian W, 27. Kanter V, Weldon E, Nair U, Varella

Zhang H, Haapasalo M. Tissue C, Kanter K, Anusavice K, Pileggi
dissolution by sodium hypochlorite: R. A quantitative and qualitative
effect of concentration, temperature, analysis of ultrasonic versus sonic
agitation, and surfactant. J Endod. endodontic systems on canal
2010; 36:1558–62. cleanliness and obturation. Oral
SurgOral Med Oral Pathol Oral
24. de Gregorio C, Estevez R, Cisneros
Radiol Endod. 2011; 112:809–13.
R, Heilborn C, Cohenca N. Effect of
EDTA, sonic, and ultrasonic
28. Johnson M, Sidow SJ, Looney SW,
activation on the penetration of
Lindsey K, Niu LN, Tay FR. Canal
sodium hypochlorite into simulated
and isthmus debridement efficacy
lateral canals: an in vitro study. J
using a sonic irrigation technique in a
Endod. 2009; 35:891–5.
closed canal system. J Endod. 2012;
38:1265–8.
25. Merino A, Estevez R, de Gregorio C,
Cohenca N. The effect of different
29. Uroz-Torres D, González-Rodríguez
taper preparations on the ability of
MP, Ferrer-Luque CM. Effectiveness
sonic and passive ultrasonic
of the EndoActivator System in
irrigation to reach the working length
removing the smear layer after root
in curved canals. Int Endod J. 2013;
canal instrumentation. J Endod.
46:427–33.
2010; 36:308–11.

26. Rödig T, Bozkurt M, Konietschke F,

30. Rödig T, Döllmann S, Konietschke
Hülsmann M. Comparison of the
F, Drebenstedt S, Hülsmann M.
Vibringe system with syringe and
Effectiveness of different irrigant
passive ultrasonic irrigation in
agitation techniques on debris and
21 | P a g e
Volume - IX Issue - 1 - 2019
 smear layer removal in curved root 35. Khaleel HY, Al-Ashaw AJ, Yang Y,
canals: a scanning electron Pang AH, Ma JZ. Quantitative
microscopy study. J Endod. 2010; comparison of calcium hydroxide
36:1983–7. removal by EndoActivator,
ultrasonic and ProTaper file agitation
31. Bolles JA, He J, Svoboda KK,
Schneiderman E, Glickman GN. techniques: an in vitro study. J
Comparison of Vibringe, Huazhong Univ Sci Technolog Med
EndoActivator, and needle irrigation Sci. 2013; 33:142–5.
on sealer penetration in extracted
36. Brito PR, Souza LC, Machado de
human teeth. J Endod. 2013; 39:708–
Oliveira JC, Alves FR, De-Deus G,
11.
Lopes HP, Siqueira Jr JF.
32. Chou K, George R, Walsh LJ. Comparison of the effectiveness of
Effectiveness of different intracanal three irrigation techniques in
irrigation techniques in removing reducing intracanal Enterococcus
intracanal paste medicaments. Aust faecalis populations: an in vitro
Endod J. 2014; 40:21–5. study. J Endod. 2009; 35:1422–7.

33. Grischke J, Müller-Heine A,

37. Tardivo D, Pommel L, La Scola B,
Hülsmann M. The effect of four
About I, Camps J. Antibacterial effi
different irrigation systems in the
ciency of passive ultrasonic versus
removal of a root canal sealer. Clin
sonic irrigation. Ultrasonic root canal
Oral Investig. 2014;18(7):1845–51.
irrigation. Odontostomatol Trop.
2010; 33:29–35.
34. Goode N, Khan S, Eid AA, Niu LN,
Gosier J, Susin LF, Pashley DH, Tay
38. Shen Y, Stojicic S, Qian W, Olsen I,
FR. Wall shear stress effects of
Haapasalo M. The synergistic
different endodontic irrigation
antimicrobial effect by mechanical
techniques and systems. J Dent.
agitation and two chlorhexidine
2013; 41:636–41.
preparations on biofilm bacteria. J
Endod. 2010; 36:100–4.
22 | P a g e
Volume - IX Issue - 1 - 2019
 39. Moorer WR, Wesselink PR. Factors 45. Goodman A, Reader A, Beck M, et
promoting the tissue dissolving al. An in vitro comparison of the
capability of sodium hypochlorite. efficacy of thestep-back technique
Int Endod J. 1982;15(4):187–96. versus a step-back ultrasonic
technique in human mandibular
40. Mitchell RP, Baumgartner JC,
molars. J Endod 1985; 11:249–56.
Sedgley CM. Apical extrusion of
sodium hypochlorite using different 46. Archer R, Reader A, Nist R, et al. An
root canal irrigation systems. J in vivo evaluation of the efficacy of
Endod. 2011; 37:1677–81. ultrasound after stepback preparation
in mandibular molars. J Endod 1992;
41. Boutsioukis C, Psimma Z,
18:549–52.
Kastrinakis E. The effect of flow rate
and agitation technique on irrigant 47. Sjogren U, Sundqvist G.
extrusion ex vivo. Int Endod J. 2014; Bacteriologic evaluation of ultrasonic
47:487–96. root canal instrumentation. Oral Surg
Oral Med Oral Pathol 1987; 63:366–
42. Plotino G, Pameijer CH, Grande
70.
NM, Somma F. Ultrasonics in
endodontics: a review of the 48. Spoleti P, Siragusa M, Spoleti MJ.
literature. J Endod. 2007; 33:81–95. Bacteriological evaluation of passive
ultrasonicactivation. J Endod 2002;
43. Martin H. Ultrasonic disinfection of
29:12–4.
the root canal. Oral Surg Oral Med
Oral Pathol. 1976; 42:92–9. 49. Sabins RA, Johnson JD, Hellstein
JW. A comparison of the cleaning
44. Martin H, Cunningham W.
efficacy ofshort term sonic and
Endosonic endodontics: the
ultrasonic passive irrigation after
ultrasonic synergistic system. Int
hand instrumentation inmolar root
Dent J. 1984; 34:198–203.
canals. J Endod 2003; 29:674–8.

23 | P a g e
Volume - IX Issue - 1 - 2019
 endosonic instruments. Endod Dent
50. Lee SJ, Wu MK, Wesselink PR. The Traumatol 1991; 7:84–9
effectiveness of syringe irrigation and
ultrasonics to remove debris from 55. Zehnder M. Root canal irrigants. J
simulated irregularities within prepared Endod 2006; 32:389–98.
root canalwalls. Int Endod J 2004;
37:672–8. 56. Cameron JA. The effect of ultrasonic
endodontics on the temperature of
51. Van der Sluis LW, Wu MK, the root canal wall. J Endod 1988;
Wesselink PR. A comparison 14:554–9.
between a smooth wireand a K-file in
removing artificially placed dentine 57. Vander Sluis LW, Gambarini G, Wu

debris from root canals in resinblocks MK, Wesselink PR. The influence of

during ultrasonic irrigation. Int volume, type of irrigant and flushing

Endod J 2005; 38:593– 6. method on removing artificially

placed dentine debris from the apical
52. Van der Sluis LW, Wu MK, root canal during passive ultrasonic
Wesselink PR. The evaluation of irrigation. Int Endod J 2006;39: 472–
removal of calciumhydroxide paste 6.
from an artificial standardized
groove in the apical root canalusing 58. Nusstein J. Ultrasonic dental device.

different irrigation methodologies. Washington, DC: United States

Int Endod J 2007; 40:52–7. Patent 6,948,935; 2005.

53. Cunningham WT, Martin H. A 59. Lev R, Reader A, Beck M, Meyers

scanning electron microscope W. An in vitro comparison of the

evaluation of root canal debridement step-back technique versus a step-

with the endosonic ultrasonic back/ultrasonic technique for 1 and 3

synergistic system. Oral Surg Oral minutes. J Endod 1987; 13:523–30.

Med Oral Pathol 1982; 53:527–31.

60. Gutarts R, Nusstein J, Reader A,

54. Walmsley AD, Murgel C, Krell KV. Beck M. In vivo debridement

Canal markings produced by efficacy of ultrasonic irrigation

24 | P a g e
Volume - IX Issue - 1 - 2019
 Following hand-rotary 64. Bhuva B, Patel S, Wilson R, Niazi S,
instrumentation in human mandibular Beighton D, Mannocci F. The
molars. J Endod 2005; 31:166–70. effectiveness of passive ultrasonic
irrigation on intraradicular
61. De Gregorio C, Estevez R, Cisneros
Enterococcus faecalis biofilms in
R, Paranjpe A, Cohenca N. Effi cacy
extracted single-rooted human teeth.
of different irrigation and activation
Int Endod J. 2010; 43:241–50.
systems on the penetration of sodium
hypochlorite into simulated lateral 65. Shen Y, Gao Y, Qian W, Ruse ND,
canals and up to working length: an Zhou X, Wu H, Haapasalo M. Three-
in vitro study. J Endod. 2010; dimensional numeric simulation of
36:1216–21. root canal irrigant fl ow with
different irrigation needles. J Endod.
62. Liang YH, Jiang LM, Jiang L, Chen
2010; 36:884–9.
XB, Liu YY, Tian FC, Bao XD, Gao
XJ, Versluis M, Wu MK, van der 66. Gründling GL, Zechin JG, Jardim
Sluis L. Radiographic healing after a WM, de Oliveira SD, de Figueiredo
root canal treatment performed in JA. Effect of ultrasonics on
single-rooted teeth with and without Enterococcus faecalis biofilm in a
ultrasonic activation of the irrigant: a bovine tooth model. J Endod. 2011;
randomized controlled trial. J Endod. 37:1128–33
2013; 39:1218–25.
67. Joyce E, Phull SS, Lorimer JP,
63. Rödig T, Hirschleb M, Zapf A, Mason TJ. The development and
Hülsmann M. Comparison of evaluation of ultrasound for the
ultrasonic irrigation and RinsEndo treatment of bacterial suspensions. A
for the removal of calcium hydroxide study of frequency, power and
and Ledermix paste from root canals. sonication time on cultured Bacillus
Int Endod J. 2011; 44:1155–61. species. Ultrason Sonochem. 2003;
10:315–8.

25 | P a g e
Volume - IX Issue - 1 - 2019
 68. Malki M, Verhaagen B, Jiang LM, 71. Mitchell RP, Baumgartner JC,
Nehme W, Naaman A, Versluis M, Sedgley CM. Apical extrusion of
Wesselink P, van der Sluis L. sodium hypochlorite using different
Irrigant flow beyond the insertion root canal irrigation systems. J
depth of an ultrasonically oscillating Endod. 2011; 37:1677–81.
fi le in straight and curved root
72. Malentacca A, Uccioli U, Zangari D,
canals: visualization and cleaning
Lajolo C, Fabiani C. Effi cacy and
efficacy. J Endod. 2012; 38:657–61.
safety of various active irrigation
69. Munoz HR, Camacho-Cuadra K. In devices when used with either
vivo effi cacy of three different positive or negative pressure: an in
endodontic irrigation systems for vitro study. J Endod. 2012; 38:1622–
irrigant delivery to working length of
mesial canals of mandibular molars.
J Endod. 2012;38(4):445–8.

70. Ambe VH, Nagmode PS, Vishwas

JR, P SK, Angadi P, Ali FM.
Evaluation of the Amount of Debris
extruded apically by using Conv-
entional Syringe, Endovac and
Ultrasonic Irrigation Technique: An
in Vitro Study. J Int Oral Health.
2013;5(3):63–6.

26 | P a g e
Volume - IX Issue - 1 - 2019
 NANODENTISTRY: BIOACTIVE GLASS AND NANOPARTICLES AS
INTRACANAL MEDICAMENTS: A REVIEW
*Dr. Prachi Maniar **Dr. Nihit Shah ***Dr. Dipti Choksi
****Dr. Barkha Idnani
ABSTRACT
The primary goal of endodontic therapy is thorough disinfection of the root canal
system through thermomechanical debridement. Intracanal medicaments have been widely
used for multipurpose like disinfection, regeneration, trauma, pain control. Newer research
has been focused to combat the drawbacks like antimicrobial resistance, dentin discoloration,
alteration in microhardness of dentin. Nanotechnology been the upcoming future scope
focuses on development of new such materials like bioactive glass and nanoparticles. These
materials not only are biocompatible but are target specific in their mode of action.

Keywords: intracanal medicaments, bioactive glass, nanoparticles, future scope.

INTRODUCTION

Several root canal irrigants have the root canal irrigant. Also, the protective
been used to eradicate the root canal layer formed by necrotic tissue, debris,
microbiota, however there exists no inhibit the penetration of the irrigant,
particular literature stating its complete thereby inhibiting the antibacterial activity
efficacy. Bacterial resistance, complex root of the irrigant.1
canal anatomy, leads to incomplete
efficiency of

*Post Graduate Student Corresponding Authors:

**Post Graduate Student Dr. Nihit Shah
***Professor and Head of Department 3rd year Post Graduate Student,
****Professor Department of Conservative Dentistry and
Department of Conservative Dentistry and Endodontics.
Endodontics Faculty of Dental Sciences,
Faculty of Dental Science, Dharmsinh Desai University,
Dharmsinh Desai University, College Road, Nadiad 387001, Gujarat.
Nadiad. (M) +91 9537712148

27 | P a g e
Volume - IX Issue - 1 - 2019
Regardless of single sitting or multiple visit against endodontic pathogens and has been

root canal treatment2, root canal disinfection evaluated in many in vitro studies.1

is time dependent, even if fast acting BIOACTIVE GLASS

biocides such as sodium hypochlorite are
used.3As such the standard treatment Biomaterials are the materials

protocol for treating apical periodontitis with which are either natural or manmade, that

two visit using interim root canal dressing is replace or supplement the functions of

followed. However, leakage of resident or living tissues.9 Biomaterials should

transient microbiota via temporary possess properties such as bioinert,

dressing/filling material into the canal space bioactive, biostable and biodegradable.10

intervenes the disinfection, which happens to The first bioactive material belonging to

be the disadvantage of this two-visit the SiO2-Na2O-CaO-P2O5system (Bio

protocol.4 Enterococcus. faecalis glass VR), was developed by Hench in

(E.faecalis), an enteric bacteria are hard to 1969, where he discovered that certain

eliminate once present. They can glass compositions could bond to the bone

recontaminate the pulp less root canal being and had excellent biocompatibility.11 A

the monoinfectants and/or an unsealed root bioactive material is synthesized such that

canal.5,6 Among the materials used aqueous it induces target specific biological

calcium hydroxide being used happens to be activity.12 This material acts upon

the most efficient. Nevertheless, it has its interaction once in the body with this

own disadvantages such as: Firstly, it could twostep process: First step, on interaction

alter the dentin strength of the tooth because with simulated body fluids (SBF) it

of its nonspecific proteolytic action of the undergoes specific surface reaction.

hydroxide ion. Hence decreasing the flexural Second step, interaction within hard and

strength of the dentin. Secondly, inefficient soft tissue through the formation of

action against alkali resistant microbiota such hydroxyapatite (HAp) like layer.13 The

as E. faecalis.7 Bioactive material is said to desired parameters for a bioactive

be one when it bonds the material and the glasses/glass–ceramics to function as

tissue and as an outcome provides the asuitable biomaterial are that they should

appropriate biological response.8 Recently, be nontoxic. They should promote cell

the use of bioactive glass and nanoparticles adhesion, causing cell proliferation, hence

as intracanal medicaments has been making biocompatibility an indispensable

suggested owing to their antibacterial action property. They should not cause any
28 | P a g e
Volume - IX Issue - 1 - 2019
 cytotoxic effect or hamper any The Mechanism of Hap Layer
bioactive process inside the cell/tissue. Formation on Bioactive Glasses
There must be a formation of a
Hydroxyapatite interacts with the
hydroxyapatite layer, when these glass
collagen fibrils of damaged bone to bond
contact the SBF, the bio glass scaffolds
with it, thus mimicking the bone mineral.
must exhibit mechanical properties that
Formation of HAp layer-bone bond
are comparable to those of the tissue to
involves incorporation of collagen fibrils,
be replaced for better compatibility to
protein adsorption, attachment of bone
withstand any kind of pressure or strain
progenitor cells, cell differentiation, the
in order to prevent any structural failure
excretion of bone extracellular matrix and
during handling of the material and
its mineralization. Dissolution products of
during the patient’s normal routine
the glass on osteoprogenitor cells,
activities. For bone engineering,
stimulates new bone growth causes
bioglass should possess controllable
osteogenesis.15 The mechanism of Hap
interconnected porosity to support
layer formation includes several stages:
vascularization so as to direct cells to
calcium ions dissolve from the bioactive
grow into the required physical
glass into the body fluid while a silica-rich
structure. Bioglass scaffold should have
interlayer forms on the glass surfaces. The
a porous three-dimensional (3D)
surrounding fluid is supersaturated with
structure for cell proliferation,
respect to HAp due to the dissolution of
vascularization and diffusion of
the calcium ions, hence nucleation of HAp
nutrients which provides a regulated
is possible. The reactions of the calcium,
microenvironment for new tissue
phosphate, and hydroxide ions leads to
synthesis, while still maintaining the
continuous process of nucleation and
desired features, bioactive glass should
be cost effective for growth of HAp layer.16

commercialization.14 Processing methods.

For years conventional glass

technology has been used to manufacture
bioactive glass. For the glass component,
mixture of oxides and carbonates are
homogenously melted at high temperatures

29 | P a g e
Volume - IX Issue - 1 - 2019
 0
up to 1250-1400 C in a platinum
crucible. Then the molten glass is cast
in a steel or graphite mold to form a
bulk mass. Finally, a final grind and
polish is necessary for the required
tolerance of the material. To produce
small fragments, the molten bulk is
poured in water or some other liquid
medium. Powdered bioactive glass is
implied in periodontal lesions.1
Bioactive glass produced by
conventional glass technology has the
(Courtesy: Dr. Julian Jones)
disadvantage such as that it requires
high temperature for production, Illustration 1: sol gel process
contamination can occur during the
Bioactive glass is indicated in various
processing, compositional limit due to
purposes such as repair of hard tissue, as
presence of SiO2 and increased
scaffolds, in dentinal hypersensitivity,
production cost.16,17
antimicrobial, dentin demineralization,
Sol Gel Process:18 removal of stains, caries removal. 8

Simply by changing the pH of the As Intracanal Medicament

process (illustration 1) bioactive glasses
During dissolution of bioactive
can be made as nonporous powders or
glass, the pH rises due to cation release
monoliths or as nanoparticles.
and such condition can kill the microbes.
Interconnected porous networks can now
For instance, S53P4, as one kind of
be non-destructively imaged and
bioactive glass, can kill pathogens
quantified by micro CT imaging and image
connected with enamel caries
analysis; and the atomic structure of
(Streptococcus mutans), root caries
glasses and hybrids can be understood
(Actinomycesnaeslundii, S. mutans) and
through nuclear magnetic resonance
periodontitis (e.g.
(NMR) spectroscopy, X-ray and neutron
Actinobacillusactinomycetemcomitas)
diffraction and particle-induced X-ray
emission (PIXE).
30 | P a g e
Volume - IX Issue - 1 - 2019
 Silver is one of the elements known as vascular density in and around
antimicrobial. Silver ions can easily be subcutaneously implanted allografts and
introducedinto a glass and then released hyaluronan based hydrogel.
during dissolution. The sol-gel derived
composition of 76 % SiO2, 19% CaO, 2%
P2O5 and 3% Ag2O (by weight) is the first
antibacterial glass which contains silver.
Less than 1 mg/ml of this glass in culture
is needed to kill bacteria such as
Escherichia coli, Pseudomonas
aeruginosa and Staphylococcus aureus.16
The antibacterial activity of BAG depends
on the following factors acting
simultaneously: High pH; An increase in
pH because of release of ions in an
aqueous environment, Osmotic effects; An
increase in osmotic pressure above 1% is Illustration 2: Approaches for BAG
inhibitory for many bacteria.Ca/P
(Courtesy: Abbasi Z, Bahrololoom ME,
precipitation as it induces mineralization
Shariat MH, Bagheri R)
on the bacterial surface. Furthermore, the
release of Ca2+, Na+, PO43, and Si4+ could (A) One approach BAGs that can change
lead to the formation of bonds with the the local physiological conditions when
mineralized hard tissues. Copper and its they areimplanted to produce a
alloys, such as brass, bronze, copper, bactericidal effect.(B) Another approach is
nickel and copper-nickel-zinc can also be to dope the BAG during its manufacture
used in antimicrobial applications. The with trace quantities of elements (e.g, Ag)
strong antimicrobial ions of copper can be that are known for their antibacterial
doped to different matrices such as activity, and, as the glass degrades, those
polymers or ceramics. Copper not only is elements are released at a clinically
an excellent antimicrobial agent but also desirable rate. (C) The third approach is
has an essential role in bone formation and to use BAG in conjunction with
healing. This metal can also stimulate antibiotics.16
wound healing responses and improves the
31 | P a g e
Volume - IX Issue - 1 - 2019
 Copper sulfate can induce the formation of Antibacterial Mechanisms of
cord-like and tubular structures and Nanoparticles
potentiate the effect of endogenous growth
The antibacterial activity of
factors, which makes it a perfect additive
nanoparticles are different against different
for blood vessel ingrowth. Zinc is another
microorganisms when compared to its
metal which is thought to have
original bulk form and may vary related to
antibacterial properties and beneficial
its different types of nanoparticles.23 The
cellular response, but it can also cause
two different mechanisms that attribute the
toxicity.16
efficacy of nanoparticles to eliminate
NANOPARTICLES bacterial cells is either they bind to the
bacterial cell membrane through the
Nanoparticles have different forms
electrostatic forces and change their
and shapes19 and are categorized according
electric potential causing disruption of
to their dimensions as: zero dimension
membrane thereby disturbing cell
such as nanoparticles, one dimension such 24
functions leading to cell death or by
as nanorods, two dimensions such as thin
production of oxygen free radicals such as
films and three dimensions such as
reactive oxygen species that influences the
nanocones. They show increased chemical
survival of bacterial cell.25
reactivity when compared to their bulk
form. 20
The term nanodentistry is defined Chitosan Nanoparticles.
as “the science and technology of
The deacetylated derivative of
diagnosis, treating and preventing oral
chitin- CHITOSAN is the second most
diseases, relieving pain, preserving and
abundant natural biopolymer. There are
improving dental health using
different methods to synthesis or assemble
21
nanostructured material. Nano dentistry nanoparticles of Chitosan depending on
can be used in different areas of dentistry the physical characteristics required or the
likemanufacturing of dental materials,
end of application in the Nanoparticles.26 It
prevention of oral diseases such as dental
has excellent antibacterial, antiviraland
caries and periodontal diseases, as
antifungal properties.Gram positive
therapeutic agents for the treatment of
bacteria were more susceptible than gram-
dentine hypersensitivity, oral cancer and
negative bacterias.27 Depending on the
endodontic diseases, in the technology of
organism, pH, degree of deacetylation
tissue engineering.22
32 | P a g e
Volume - IX Issue - 1 - 2019
 (DD), molecular weight, chemical CS-NPs can be delivered within the
modifications, and presence of lipids anatomic complexities and dentinal tubules of
and proteins. The minimum inhibitory an infected root canal to enhance root canal
ranges from 18–5000 ppm.28 disinfection.30 Biofilm bacteria are known to
express efflux pumps as a resistance
Clinical Implication:
mechanism to antimicrobials.31 The
Significantly reduced adherence antibacterial efficacy of CS-NPs was not
of Enterococcus faecalis was noted in affected against bacterial biofilms with
the dentin treated with Nanoparticles. known efflux pump inhibitors.32 The
These nanoparticles eliminated biofilm neutralizing effect of different tissue
on a concentrationand time-dependent inhibitors is another challenge in using
manner and also retained their antibacterial agents inside the root canal
antibacterial properties after aging for 90 space.33 Pulp and serum albumin inhibit the
days. 29 antibacterial effect of CS-NPs34 whereas
dentin, dentin matrix and lipopolysaccharides
do not affect the efficacy of CS-NPs.35

Silver Nanoparticles

Silver produces an antibacterial

effect by acting on multiple targets starting
from interaction with the sulfhydryl groups
of proteins and DNA, alter the hydrogen
bonding/respiratory chain, unwind DNA,
and interfere with cell-wall synthesis/cell
division.36,37 Silver Nanoparticles (Ag-
NPs) destabilize the bacterial membrane
and increases permeability that leads to
leakage of cell constituents.38

Clinical Implication:
(Courtesy: Dr. Annie Shreshta)
There is prolonged interaction
Illustration 3: Antibacterial
between positively charged Ag-NPs and
mechanism of chitosan.
negatively charged biofilm
33 | P a g e
Volume - IX Issue - 1 - 2019
 bacteria/structure resulting in this photosensitizer molecules offer unique
difference, when used as a medicament. physicochemical properties such as ultra-
When Ag-NP suspension is combined small sizes, large surface area/mass ratio and
with calcium hydroxide it shows increased physical/chemical reactivity. The
significantly reduced E. faecalis from combination of nanoparticles with
root canal dentin.39 In addition, these photosensitizers can be achieved by: 47
Ag-NPs were found to be
1. Photosensitizers supplemented with
cytocompatible to fibroblast cells.40
nanoparticles
The potential discoloration of dentin
and toxicity toward mammalian cells 2. Photosensitizers encapsulated
are two main issues associated with Ag- within nanoparticles
NPs.41
3. Photosensitizers bound or loaded to
Functionalized Antimicrobial nanoparticles

Nanoparticles
4. Nanoparticles themselves serving

The word functionalize means to as photosensitizers

organize (as work or management) into
An invitro test on E. faecalis
units performing specialized tasks.
biofilm and human dental plaque bacteria
Functionalization could alter the surface
in combination with PDT was done by
composition, charge and structure of the
Methylene blue–loaded poly (lactic-co-
material wherein the original bulk material
glycolic) acid (MB-PLGA) Nanoparticles.
properties are left intact.42 In a The cationic MB-PLGA nanoparticles
functionalized nanoparticle, the inorganic
exhibited significantly higher bacterial
or polymeric materials usually form the phototoxicity in both planktonic and
core substrate. Functionalized biofilm phases. It was concluded that
nanoparticles containing various reactive cationic MB-PLGA nanoparticles have the
molecules and decorated with peptides or
potential to be used as carriers of
other ligands have led to new possibilities
photosensitizer photodynamic therapy
43,44
of combating antimicrobial resistance.
(PDT) within root canals.48
Nanoparticle-based photosensitizers have
Photosensitizer-bound polystyrene beads
been considered to potentiate
with rose bengal (RB) were used after
45,46
photodynamic therapy efficacy. activation with light which improved
Functionalized Nanoparticles along with
34 | P a g e
Volume - IX Issue - 1 - 2019
 bacterial elimination with reactive References:
oxygen species.49 The Antimicrobial
1. A I O Ibrahim. Use of antibacterial
PDT Efficacy is enhanced by
nanoparticles in endodontics. SADJ
Combinations of Nanoparticles with
2017;72(3):105 - 112. Sathorn C,
Photosensitizer due to several factors
Parashos P, Messer HH. Effectiveness of
such as higher concentration of
single-versus multiple-visit endodontic
photosensitizer which thereby increases
treatment of teeth with apical
resultant ROS, reduced efflux of
periodontitis: A systematic review and
photosensitizer so drug resistance
meta- analysis. Int Endod J 2005;
reduces, greater possibility of targeting
38:347- 55.
bacteria,post conjugation stability of
photosensitizers increases.50,51
2. Bystrom A, Sundqvist G. The

CONCLUSION antibacterial action of sodium

hypochlorite and EDTA in 60 cases of
Antibacterial activity along with
endodontic therapy. IntEndod J 1985;
the potential of healing and regeneration of
18:35-40.
defect areas is the prime property of
bioactive glasses. Hence making it a 3. Siren EK, Haapasalo MP, Ranta K,
unique material in the field of dentistry. Salmi P, Kerosuo EN. Microbiological
Unique characteristics can be achieved by findings and clinical treatment
doping some elements to this composition procedures in endodontic cases
such as zinc, copper or silver. selected for microbiological
Nanoparticles via surface modifications investigation. IntEndod J 1997; 30:91-
provide target specificity by intimately and 5.
selectively targeting the bacteria and the
4. Engstrom B. The significance of
biofilms. Newer multifunctional
Enterococci in root canal treatment.
nanoparticles are being developed based
Odontol Revy 1964; 15:87-106.
on the clinical requirements in
collaboration with engineers, clinicians,
5. Bystrom A, Claesson R, Sundqvist
and biologists.
G. The antibacterial effect of
camphorated paramonochlorophenol,
camphorated phenol and calcium

35 | P a g e
Volume - IX Issue - 1 - 2019
 hydroxide in the treatment of 11. Williams DF, editor. Definitions in
infected root canals. Endod Dent Biomaterials. New York:
Traumatol1985; 1:170-5. Elsevier;1987.

12. Kokubo T, Takadama H. How useful

6. Prabhakar AR, Kumar SCH. is SBF in predicting in vivo bone

Antibacterial effect of bioactive bioactivity? Biomaterials 2006;

glass in combination with 27:2907–2915.

powdered enamel and dentin. 13. Kaur G, Pandey OP, Singh K,

Indian J Dent Res 2010; 21:30-4. Homa D, Scott B, Pickrell G. 2014.
A review of bioactive glasses:
7. Farooq I. Imraan Z. Bioactive
Their structure, properties,
glass. A material for future. World
fabrication, and apatite formation. J
J Dent 2012; 3(2): 199-201.
Biomed Mater Res Part A

8. Ramakrishna S, Meyer J, 2014:102A:254–274.

Wintermantel E, Leong KW.

14. Hench LL, Polak JM. Third-
Biomedical applications of
generation biomedical materials.
polymer-composite materials: A
Science. 2002; 295:1014-1017.
review. Comp Sci Tech 2001;
61:1189–1224. 15. Abbasi Z, Bahrololoom ME,
Shariat MH, Bagheri R. Bioactive
9. Hench LL. Bioceramics: from
Glasses in Dentistry: A Review. J
concept to clinic. J Am Ceram Soc
Dent Biomater, 2015;2(1):1-9.
1991; 74:1487–1510.
16. Li R, Clark AE, Hench LL. An
10. Hench LL, Splinter RJ, Allen WC,
Investigation of Bioactive Glass
Greenlee TK. Bonding
Powders by Sol-Gel Processing. J
mechanisms at the interface of
Appl Biomater. 1991; 2:231-239.
ceramic prosthetic materials. J
Biomed Mater Res 1972; 2:117– 17. Julian jones. Review of bioactive
141. glass. From Hench to hybrids.
ActaBiomaterialia 2013; 4457–
4486.

36 | P a g e
Volume - IX Issue - 1 - 2019
 23. Pelgrift RY, Friedman AJ.
18. Annie Shrestha. Antibacterial
Nanotechnology as a therapeutic tool
nanoparticles endodontics. A
to combat microbial resistance.
narrative review. J Endod 2016:1-
Advanced Drug Delivery Reviews
10
2013; 65:1803-15.

19. Tiwari JN, Tiwari RN, Kim

24. Valko M, Leibfritz D, Moncol J,
KS.Zero-dimensional, one-
Cronin MT, Mazur M, Telser J.
dimensional, two-dimensional and
Free radicals and antioxidants in
three-dimensional nanostructured
normal physiological functions and
materials for advanced
human disease. The International
electrochemical energy devices.
Journal of Biochemistry & Cell
Progress in Materials Science
Biology 2007; 39:44-84.
2012; 57:724-803
25. Agnihotri SA, Mallikarjuna NN,
20. Mantri SS, Mantri SP. The nano
Aminabhavi TM. Recent advances
era in dentistry. Journal of Natural
on chitosan-based micro- and
Science, Biology, and Medicine
nanoparticles in drug delivery. J
2013;4:39.
Control Release 2004; 100:5–28.

21. Neel EAA, Bozec L, Perez RA,

26. Rabea EI, Badawy ME, Stevens
Kim H-W, Knowles JC.
CV, et al. Chitosan as antimicrobial
Nanotechnology in dentistry:
agent: applications and mode of
prevention, diagnosis, and therapy.
action. Biomacromolecules 2003;
International Journal of
4:1457–65.
Nanomedicine 2015; 10:6371.
27. No HK, Park NY, Lee SH, Meyers
22. Beyth N, Houri-Haddad Y, Domb
SP. Antibacterial activity of
A, Khan W, Hazan R. Alternative
chitosan’s and chitosan oligomers
antimicrobial approach: nano-
with different molecular weights.
antimicrobial materials. Evidence-
Int J Food Microbiol 2002; 74:65–
Based Complementary and
72.
Alternative Medicine 2015;
2015:16.
37 | P a g e
Volume - IX Issue - 1 - 2019
 33. Shrestha A, Kishen A. The effect of
28. Shrestha A, Shi Z, Neoh KG,
tissue inhibitors on the antibacterial
Kishen A. Nanoparticulates for
activity of chitosan nanoparticles and
antibiofilm treatment and effect
photodynamic therapy. J Endod 2012;
of aging on its antibacterial
38:1275–8.
activity. J Endod 2010;
36:1030–5. 34. Barreras US, Mendez FT, Martinez
RE, et al. Chitosan nanoparticles
29. Shrestha A, Fong SW, Khoo enhance the antibacterial activity of
BC, Kishen A. Delivery of chlorhexidine in collagen membranes
antibacterial nanoparticles into used for periapical guided tissue
dentinal tubules using high- regeneration. Mater SciEng C Mater
intensity focused BiolAppl 2016; 58:1182–7.
ultrasound. J Endod 2009;
35. Lansdown AB. Silver in health
35:1028–33.
care: antimicrobial effects and
30. Lewis K. Multidrug resistance: safety in use. Curr Probl Dermatol
versatile drug sensors of bacterial 2006; 33:17–34.
cells. Curr Biol 1999;9: R403–7.
36. Sotiriou GA, Pratsinis SE.
31. Upadya M, Shrestha A, Kishen A. Antibacterial activity of nanosilver
Role of efflux pump inhibitors on ions and particles. Environ Sci
the antibiofilm efficacy of calcium Technol 2010; 44:5649–54.
hydroxide, chitosan nanoparticles,
37. Melo MA, Guedes SF, Xu HH,
and light-activated disinfection. J
Rodrigues LK. Nanotechnology
Endod 2011; 37:1422–6.
based restorative materials for
32. Portenier I, Haapasalo H, Rye A, et dental caries management. Trends
al. Inactivation of root canal Biotechnol 2013; 31:459–67.
medicaments by dentine,
38. Javidi M, Afkhami F, Zarei M, et
hydroxylapatite and bovine serum
al. Efficacy of a combined
albumin. Int Endod J 2001;
nanoparticulate/calcium hydroxide
34:184–8.
root canal medication on

38 | P a g e
Volume - IX Issue - 1 - 2019
 elimination of Enterococcus antimicrobial agent. Nat Nanotechnol
faecalis. Aust Endod J 2014; 2009; 4:457–63.
40:61–5.
44. Perni S, Prokopovich P, Pratten J, et
39. Fan W, Wu D, Ma T, Fan B. al. Nanoparticles: their potential use in
Ag- loaded mesoporous antibacterial photodynamic therapy.
bioactive glasses against Photochem Photobiol Sci2011;
Enterococcus faecalis biofilm in 10:712–20.
root canal of human teeth. Dent
Mater J 2015; 34:54–60. 45. Wilson RF. Nanotechnology: the
challenge of regulating known

40. Gomes-Filho JE, Silva FO, unknowns. J Law Med Ethics

Watanabe S, et al. Tissue 2006; 34:704–13. Kishen A.

reaction to silver nanoparticles Advanced therapeutic options for

dispersion as an alternative endodontic biofilms. Endod Topics

irrigating solution. J 2012; 22:99–123.

Endod2010; 36:1698–702.
46. Bezman SA, Burtis PA, Izod TP,

41. N, Marco MP. Multifunctional Thayer MA. Photodynamic

nanoparticles—properties and inactivation of E. coli by rose

prospects for their use in human bengal immobilized on polystyrene

medicine. Trends Biotechnol2008; beads. PhotochemPhotobiol1978;

26:425–33. 28:325–9.

42. Veerapandian M, Yun K. 47. Guo Y, Rogelj S, Zhang P. Rose

Functionalization of biomolecules Bengal-decorated silica

on nanoparticles: specialized for nanoparticles as photosensitizers

antibacterial applications. Appl for inactivation of gram-positive

MicrobiolBiotechnol2011; bacteria. Nanotechnology 2010;21:

90:1655–67. 065102.

43. Liu L, Xu K, Wang H, et al. Self-

assembled cationic peptide
nanoparticles as an efficient

39 | P a g e
Volume - IX Issue - 1 - 2019
 48. Perni S, Prokopovich P, Pratten
J, et al. Nanoparticles: their
potential use in antibacterial
photodynamic therapy.
Photochem Photobiol Sci2011;
10:712–20.

49. Guo Y, Rogelj S, Zhang P. Rose

Bengal-decorated
sil
ica nanoparticles as
photosensitizers for inactivation
of gram-positive bacteria.
Nanotechnology 2010;
21:065102.

40 | P a g e
Volume - IX Issue - 1 - 2019
 TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION THERAPY
IN TEMPOROMANDIBULAR JOINT DISORDER –OVERVIEW

*Dr. Priti P Shah **Dr. Hetul J Patel ***Dr. Mona J Shah ***Dr. Kevin Parikh

Abstract:
Temporomandibular joint disorder (TMD) is a term to describe a group of diseases
functionally affecting the masticatory system, especially masticatory muscles and the
temporomandibular joint (TMJ). It has different etiologies and specific treatments, including
transcutaneous electrical nerve stimulation (TENS). Hence the purpose of this article is to overview its
applications in dentistry for method of pain alleviation. Tens offers a modest, safe and noninvasive
technique, which has minimal or no side effect. It can be concluded that to achieve better response in
patients, combination of conventional (medication, soft diet and hot fomentations,) and TENS therapy
should be given
Keywords: TENS, TMJ, orofacial pain, TMJ disorder

Introduction
prevalence in the general population has
Temporomandibular joint disorder been reported as being as high as 12%3 It
(TMD) is a generic term to describe a group worsens with stress or may intensify with
of disorders or diseases affecting cold. It may be associated with bruxism,
masticatory muscles, the temporomandibular trauma from occlusion, and/or with jaw
joint (TMJ) and associated structures1 TMD manipulation in any form.4 Skeletal muscles
can be divided into two broad categories as are major sources of undiagnosed pain.
myogenous or muscle related TMD and There may be areas of hyperirritability
arthrogenous or joint related TMD2 They are called myofascial trigger points which are
the most common orofacial pain conditions sensitive sites in muscle bands, tendons or
of non-dental origin. That frequently ligaments which may generate local or
encountered in clinical practice, and them referred pain with atypical pattern.

*Professor and Head of the Department Corresponding Author:

**Senior Lecturer Dr. Priti Shah
***Reader Professor and Head
Department of oral medicine and radiology, Department of oral medicine and radiology
Faculty of dental sciences, Faculty of dental sciences,
Dharmsinh Desai University, Dharmsinh Desai University,
College road, Nadiad-387001, Gujarat College road, Nadiad-387001, Gujarat
41 | P a g e
Volume - IX Issue - 1 - 2019
 These motor end plates connect to a group of Transcutaneous electrical nerve
sensitized sensory neurons in charge of stimulation therapy:
transmitting pain information from the spinal (TENS) is defined as the application
cord to the brain. Temporomandibular joint of electrical stimulation to the intact surface
disorder patients present with a number of signs
of skin for pain control. 6 Maximal analgesia
and symptoms, including pain, malocclusion,
occurs when TENS generates a strong but non-
altered joint function with or without deviation,
painful electrical paranesthesia beneath the
clicking and/or restricted movement.6 Based on
1
electrodes 8 Shane and Kessler [1967], first
It is currently hypothesized that these trigger
described use of TENS in dentistry, yet to
points contain areas of sensitized low-threshold
gain the acceptance. It’s a safe, noninvasive,
nociceptors (free nerve endings) with
dysfunctional motor end plates. multifactorial effective and swift method of analgesia.7,9
etiology, treatment of TMD usually involves and produce a positive relaxing effect on the
more than one modality; main goal is pain masticatory muscals.2
reduction and restoration of normal jaw
fuction.7Dentists, physicians, psychologists and Principle: TENs works on the principle
physical therapists work together to cope with that, electrical stimulation is directed to pain
such condition afflicting patients. 1 Various areas via surface electrodes, and current
treatment modalities that have been tested passed through these areas which reduces or
over time are analgesic and anti-inflammatory eliminates pain. 7,9
medications, muscle relaxants, massage
therapy, occlusal splints, and cognitive
Method:
behavioral therapies2. Numerous physical This consists of a battery-powered hand-
therapy methods are moist heat, ultrasound, held stimulating device which generates pulsed
TENS, microwaves, laser, exercises and manual electrical currents which are delivered through
therapy techniques1 the skin using electrode pads. Users can adjust
Among these, transcutaneous electrical the pulse amplitude (mA), frequency (pulses per
nerve stimulation (TENS) deserves special second - pps), width or duration (μs) and pattern
attention, as it provides decreased pain and of the currents8.Electrodes are connected to
electromyography activity (EMG) of the skin surface aimed to unwind
masticatory muscles at rest in TMD hyperactive muscles and alleviate pain.
patients.1,6 In dentistry, though TENS has Electrodes may be silicone based that are
potential applications, it is not used that used either with gel application mechanism
frequently. Hence the purpose of this article or self-adhesive. They are placed at the
is to overview its applications in dentistry origin of pain or close to the site of highest
for method of pain alleviation so as to raise pain, within the same dermatome, myotome
awareness among dental fraternity regarding and/or myofascial trigger points. 6 There is
its applications. also the option of placing them on pathway of
peripheral nerves involved with pain genesis.1

42 | P a g e
Volume - IX Issue - 1 - 2019
 Types:
There are different pulse frequencies, Transcutaneous electrical nerve stimulation
intensities and durations. They are classified device
in two groups: high frequency, higher than
50 Hz and low frequency, lower than 10 Hz. Three main types of TENS are described in
Those used in dentistry are in generally the literature
mixed. In case of high frequency (50 to 150
Hz) and low intensity, the action seems to be 1. Conventional TENS
essentially central. Low frequency has 2. Acupuncture-like TENS [ALTENS]
essentially peripheral action being indicated 3. Intense TENS.
for muscle relaxation.10
Different TENS techniques are used to
selectively activate different afferent
nerve fibers:

1. Conventional TENS –Most

5
commonly used method. high
frequency and low intensity
characteristics of stimulation are
those which allow us to call this kind
of application “conventional”. The
mechanisms of pain relief with
conventional TENS are based on gate
control theory.8

Surface electode over pretragus region for 2. Acupuncture-like TENS [AL-TENS]

transcutaneous stimulation It uses low frequency; high intensity
pulsed currents AL-TENS can be
used for about 30 minutes at a time
as fatigue may develop with ongoing
muscle contractions. 11

3. Intense TENS It uses high frequency,

high intensity pulsed currents and
produces extra segmental analgesia
which has a rapid onset [< 30 min
after switch-on] and delayed offset
[>1 h after switch-off]. Intense TENS
can be used for about 15

43 | P a g e
Volume - IX Issue - 1 - 2019
minutes at a time as the stimulation may be medication costs. The greatest advantage of
uncomfortable.11 TENS is its ability to be used as an
outpatient treatment .12 16TENS has a superior
Mechanism of action: quality in reducing pain severity in a short
The mode of action of TENS has period of time even with a low voltage setting.2It
been attributed to neurological, can be used effectively throughout all the
physiological, pharmacological and stages of TMDs.4
psychological effect.
The neurologic action of TENS is based on Contraindication:
Melzack and Wall‟s gate control theory of The absolute contraindication for
TENS is patients with pacemaker or other
pain.6 It suggests that TENS stimulates the implanted electrical devices. Usage of TENS
thick, myelinated, and sensory f i b e r s (A- is also contraindicated in apprehensive
fibers) which in turn blocks the impulses of patients, epileptic patients, pregnant
thin pain-modulating fibers (C-fibers) and women’s and patient with cardiovascular
closes the gate to pain signals at their level
problem.5Skin irritation and contact dermatitis
of entry into spinal cord12 beneath the electrodes may occur8
Physiologically it affects muscle movements,
the fasciculation of muscle may result in Review of studies:
increased circulation, a decrease in oedema In his article Dr pal cited that TENS
and a decrease in resting muscle activity.13 was efficient in reducing pain intensity but
Pharmacologically it involves the stimulated not pain unpleasantness. TENS also
release of endorphins, which are endogenous produced a significant additive effect over
morphine like substances.13,14,12 repetitive treatment sessions.4Several types
TENS may have played a passive role in the of TENS, based on different combinations of
improvement of the patients’ pain. This frequency, pulse duration and intensity, exist.
would mean that the effect of TENS was The precise mechanism of action and the
limited to a placebo effect and the only relevance of combinations of stimulus
benefit of this treatment modality was to parameters are still unclear and do need
address the psychological aspect of the further study and evaluation 1
patient15 A placebo is defined as a positive Hina et al in her study stated that TENS is
response to unknown7 used as a main treatment modality for the
management of MPDS along with
Advantages: counseling and jaw exercises5 Grossman et
TENS is remarkably free from side al in his review article observed that TENS
effect. there is no potential for overdose and has improved mouth opening and decrease
has no known drug interactions.8 and so can pain immediately after therapy. there has been
be used in combination with significant decrease in electromyography levels
pharmacotherapy to reduce medication, for the group involving masseter muscle1
medication-related side effects and

44 | P a g e
Volume - IX Issue - 1 - 2019
 According to Rahman et al TENS has a tolerance to medications or poor
superior quality in reducing pain severity in gastrointestinal tolerance.
a short period of time even with a low Superior results may be expected if TENS is
voltage setting2 applied to reduce the pain severity and then
According to Bajjaragi et al they found low doses analgesics are prescribed to
encouraging results in their study. Active eliminate mild to moderate types of pain.
TENS therapy showed favorable results in
pain management in TMD patient, especially REFERENCES
in muscular or chronic pain and mouth
opening,7 In contrast various study
1. Eduardo Grossmann1, Joseane Steckel
recommended that in order to provide faster
Tambara2, Thiago Kreutz Grossmann3,
and longer lasting relief from pain, limited
José Tadeu Tesseroli de Siqueira4
mouth opening and muscle tenderness the
Transcutaneous electrical nerve
judicious combination of TENS therapy and
stimulation for temporomandibular
conventional therapy can be given. This will
Joint disorderRev Dor. São Paulo,
provide the patients with beneficial effects
2012; 13(3):271-6
of both the therapies.3,13,
TENS is a frequently applied therapy in
2. Basheer Rahman*, Mujeeb ur
chronic pain although evidence for
Rahman**, Qiam ud Din*Efficacy of
effectiveness is inconclusive. If a proper
transcutaneous electrical nerve
study and evaluation is done, patients might
stimulation in tmj pain-A
be benefitted by this non-invasive safer
nonpharmacologycal remedy for
device for alleviating pain.
immediate relief JKCD 2013; 3, (2):20-
23
Conclusion:
Pain reduction and masticatory
3. Muhammad Shanavas, Laxmikanth
muscles relaxation are the main goal in the
Chatra, [...], and Bilahari Naduvakkattu
treatment of TMDs.Tens offers a modest,
Transcutaneous electrical nerve
safe and noninvasive technique, which has
stimulation therapy: An adjuvant pain
minimal or no side effects. Proper use and
controlling modality in TMD patients —
monitoring would help the patients suffering
A clinical study Dent Res J(Isfahan)
from chronic pain.It can be concluded that to
2014; 11(6) 676-679
achieve better response in patients,
combination of conventional (medication,
4. Uma Shanker Pal, Lakshya Kumar1,
soft diet and hot fomentations,) and TENS
Gagan Mehta, Nimisha Singh, Geeta
therapy should be given which would
Singh, Mayank Singh, Hemant Kumar
provide patients the benefits of both the
Yadav2Trends in management of
therapy. TENS is good alternative for poor
myofacial pain 2014;5(2) 109-1167

45 | P a g e
Volume - IX Issue - 1 - 2019
 5. Hina Handa, Ashwini Deshpande, Silky 10. Delaine Rodrigues 1 Anamaria Siriani de
Punyani Value of transcutaneous electric Oliveira 2Fausto Bérzin 3 Effect of tens
nerve stimulation in the treatment of on the activation pattern of the
myofascial pain dysfunction syndrome masticatory muscles in TMD patients
Medical Journal of Dr. D. Y. Patil Braz J Oral Sci.2014, 3(10): 510-515
University 2017;10(3):314-318
11. Vikrant Kasat 1, Aditi Gupta 2, Ruchi
6. Kamran Habib Awan, Shankergouda Ladda 3, Mitesh Kathariya 4, Harish
Patil. The role of Transcutaneous Saluja 5, Anjum-Ara Farooqui 6
electrical nerve stimulation in Transcutaneous electric nerve
management of temporomandibular joint stimulation (TENS) in dentistry- A
disorder.Journal of contemporary dental Review J Clin Exp Dent. 2014;6(5):562-
practice 2015;16(12) 984-986 568.

7. Shobha Bijjaragi, Irfan Adil Majid, 12. Sunil Vasudev, Chinmay Dilip Vakade,
Saraswathi F. K, Sowbhagya B. Roshan Cherian Paramesh, Belgal
Malligere,Varsha Ajit Saangale and Priyanka Govind. Transcutaneous
Veerendra S. Patil. Pain Management in electric nerve stimulation: An adjuvant
Temporomandibular Joint Disorders by modality for pain relief in myofascial
Active and Placebo Transcutaneous pain dysfunction syndrome Journal of
Electric Nerve Stimulation: A Medicine, Radiology, Pathology &
Comparative Study American Journal of Surgery 2017;4(4) 9-11.
Drug Delivery and Therapeutics
2015;2(1)20-2819. 13. Dr. Harsha Puri1, Dr. Amit
Ramchandani2, Dr Sonali Kadam3, Dr.
8. Professor Mark Johnson Transcutaneous Hemant Umarji4 Conventional therapy
Electrical Nerve Stimulation: and Transcutaneous Electrical Nerve
Mechanisms, Clinical Application and Stimulation (TENS) therapy in the
Evidence (additional information). Rev treatment of Myogenous
pain 2007;1(1) 7-11) Temporomandibular Disorder- A study.
International journal of student’s
9. Shalu Rai1, Vikash Ranjan1, Deepankar research. 2015;2(4):5-10
Misra1, Sapna Panjwani1 Management
of myofascial pain by therapeutic 14. Altaf Hussain Chalkoo, Nusrat Nazir.
ultrasound and transcutaneous electrical Evaluation of conventional therapy,
nervestimulation: A comparative study transcutaneous electric nerve stimulation
European Journal of Dentistry, therapy, and placebo in management of
2016,10(1) :46-53 myofascial pain-dysfunction syndrome:
A comparative study. Journal of

46 | P a g e
Volume - IX Issue - 1 - 2019
 Advanced Clinical & Research Insights. maxillofacial surgery. SAJS 1996;36(1):
2016; 3(2) 51-55 36-38

15. L. R.kruger, W. J. Van Der Linden,P. E. 16. Varadarajan Usha.Transcutaneous

Cleaton- jones Transcutaneous electrical electric nerve stimulation in trigeminal
nerve stimulation in the treatment of neuralgia: A review of literature SRM
myofascial pain dysfunction Oral and Journal of Research in Dental Sciences
2014 ;5 (1) 36-41.

47 | P a g e
Volume - IX Issue - 1 - 2019
 SIALOLITHIASIS – A CASE REPORT

*Dr.Siddharth Deliwala ** Dr. Hiren Patel ***Dr. Haren Pandya

*** Dr. Hitesh Dewan **** Dr. Bijal Bhavsar **** Dr. Urvi Shah
*****Dr. Kartik Dholakia

ABSTRACT
Sialolithiasis accounts for the most common cause of diseases of salivary glands. The
majority of sialoliths occur in the submandibular gland or the Wharton's duct. This article
discusses the review of the literature, predisposing factors, signs and symptoms, diagnostic
methods and various modalities available for the management of sialolithiasis. This case report
presents a case of sialolith in the left Wharton’s duct, which was explored and removed via an
intra-oral approach.

Keywords: Sialolithiasis, Wharton’s duct, Transoral sialolithotomy

INTRODUCTION Salivary calculi are generally unilateral,

Salivary duct lithiasis refers to the clinically they are round or ovoid, rough or
formation of calcareous concretions or smooth with yellow in color. [5] Bilateral or
sialoliths in the salivary duct causing multiple gland sialolithiasis is occurring in
obstruction of salivary flow resulting in less than 3% of patients. [6] Sialolith
salivary ectasia, sometimes even dilatation consists of mainly calcium phosphate with
of the salivary gland.[1]Sialolithiasis is the smaller amounts of carbonates in the form of
most common (50%) disease of salivary hydroxyapatite, with minor amounts of
glands.[5] It is estimated to have a frequency magnesium, potassium, and ammonia. This
of 0.15% in the adult population with a mix is distributed evenly throughout.
slight male predilection. [3] Sialolithiasis Submandibular stones are 82% inorganic
usually appears between the age of 30 and and 18% organic material whereas parotid
60 years, and it is uncommon in children. [4] stones are composed of 49% inorganic and
51% organic material.

* 3rd year Post Graduate student, Corresponding Author:

**Dean and Head of the Department, Dr. Siddharth Deliwala
*** Professor, Department of Oral & Maxillofacial
**** Reader, Surgery,
***** Lecturer, Faculty of Dental Science,
Department of Oral & Maxillofacial Dharmsinh Desai University,
Surgery, Faculty of Dental Science, College Road, Nadiad – 387002, Gujarat
Dharmsinh Desai University, Email ID: [email protected]
College Road, Nadiad - 387002, Gujarat Contact: +91-9429575769

48 | P a g e
Volume - IX Issue - 1 - 2019
 The organic material is composed of several Surgery, Faculty of Dental Science,
carbohydrates and amino acids. There was Dharmsinh Desai University with a chief
no identification of bacterial elements at the complaint of pain and swelling in lower left
core of a sialolith.11 Sialoliths are always back region since 3-4 days. (Illustration 1)
found in the distal portion of the duct or at
the hilum of the submandibular gland with a
few in parenchyma’s. Commonly, sialolith
measures from 1mm to 1cm. They rarely
measure more than 1.5 cm. Giant sialoliths
are rare.3 About 40% of parotid and 20% of
submandibular stones are not radio-opaque
and sialography or other imaging techniques
(computed tomography scan, ultrasound)
may be required to locate them.5 Generally,
conservative techniques are recommended
for small sialoliths, such as patient's Illustration 1: Facial Profile
hydration, application of internal and
external heat, milking, massage of the gland
with acid fruit (lemon), and removal of small
stones close to the duct orifice through
dilating with the aid of a catheter. More
invasive techniques, such as surgical
removal via intraoral access are indicated for
greater salivary stones and/ or those located
in the gland parenchyma, mainly when the
stone is at the distal third of the gland, and it
can be easily touched. The affected duct is
exposed through an incision on the floor of
Illustration 2: Intraoral View Before
the mouth. Thus, the stone is seen and 1
1 /2-month patient had extraoral and intraoral
removed. The duct is sutured to the oral
mucosa, and left open for proper drainage. swelling (Illustration 2) on the left side. The
Also, tissue trans fixation or suture thread patient had difficulty in chewing, drinking,
anchorage involving the duct to promote the and speech at that time. He even had mild
obstruction prevents the sialolith and intermittent pain which got aggravated
[9] while eating. Detailed medical histories,
displacement towards the gland.
dental history, family history, history for
CASE REPORT: allergy or habit history were
A 43 years old male patient came to noncontributory. On examination non-
Department of Oral and Maxillofacial tender, about 2x2 cm round and hard
swelling was
49 | P a g e
Volume - IX Issue - 1 - 2019
present at the left side of the face below
the lower border of the mandible. Lymph
nodes were non-palpable. Intraorally firm
and tender swelling were seen at the floor
of the mouth on the left side, mesial to
the second premolar. Bleeding or
discharge from the site was absent.

INVESTIGATIONS:
Routine blood investigations,
ECG and chest X-Ray were carried out
and Mandibular Occlusal radiograph
(Illustration
3) and USG of the left submandibular
region (Illustration 4) was carried out.

Illustration 4: USG of Left Submandibular

Region

Mandibular Occlusal radiograph shows well-

defined radio opacity mesial to mandibular
left first molar. USG report suggested
slightly enlarge left submandibular gland
with reduced echogenicity and a small
hypoechoic focal lesion in the left
submandibular gland.

MANAGEMENT:
Approval for the management of the
lesion was taken from the patient in form of
Illustration 3: Mandibular Occlusal
View written consent. Physician and anesthetic
clearance were obtained. The patient was
deemed fit for surgery which was performed
under general anesthesia via the intra-oral
approach. Injection glycopyrrolate or
atropine was avoided during under general
anesthesia via the intra-oral approach as it
tended to dry up salivary secretions.

50 | P a g e
Volume-IX Issue – 1 2019
A deep stop suture was secured in the
floor of mouth distal to the last palpable
stone encircling the duct to avoid
slippage of stones posteriorly. A small
amount of local anesthesia was infiltrated
for hemostasis. A tongue suture, at the
tip, was taken to pull the tongue on
contralateral side and make it firm.
Incision of 2.5-3 cm was taken in the
floor of the mouth on left side
longitudinally to the submandibular duct
which was followed by blunt dissection Illustration 5: Sialolith
and tying of the duct at the second molar
region. Sialolith was palpated between DISCUSSION:
second premolar and first molar region Most sialoliths (80–90%) develop in
medially towards the tongue. After the submandibular gland. 5–10% develop
palpation of the sialolith, an incision was within the parotid gland and the remainder
taken and a 5mm sialolith was removed in the sublingual and minor salivary
(Illustration 5). Stop suture was removed. glands.[3] Several factors tend to favor
Ductal lavage was done with saline and submandibular gland stones: 6, 7, 13
clear flow of saliva was observed.
Reacannulation of the duct was done ➢ Longer submandibular duct and
with a small diameter polyethylene tube. larger duct caliber
One end of the tube was directed towards ➢ Tortuous course of Wharton’s duct
substance of gland and another end was ➢ The dependent position of the gland,
made to come out through the natural which leave them more prone to
ductal opening. On milking the gland, stasis.
salivary flow was confirmed and ➢ Saliva flows against gravity
established by aspirating through the tube ➢ Slower salivary flow rate compared
lumen with a hypodermic needle & to the other ducts.
syringe. The wound was closed primarily ➢ The presence of more alkaline saliva
with 3-0 silk interrupted sutures and ➢ Mainly mucous type of secretion
tongue tip suture was also removed ➢ Higher calcium and phosphate levels
finally. A ductal wall was left unsutured.
Use of sialagogues like citrus fruits and The right and left glands and ducts are
candy were advocated. Post-operative equally affected, although bilateral
healing was uneventful. Normal salivary occurrence is rare. However, multiple
flow was established after one weekend sialoliths in the same duct or gland are
was easily visualized on external common.2 Marchal et al. reported the
outcomes of analysis of 120 submandibular
pressure.
51 | P a g e
Volume-IX Issue – 1 2019
glands and the sphincter were situated results in calcification of a mucus plug. The
within the first 3mm of Wharton’s duct. second theory assumes that micro sialoliths,
Another special structure is a basin-like produced by autophagosomes in the salivary
structure within the submandibular gland, gland, form a nidus for calcium
which expands into the region of hilus on precipitation.10 Latest studies with sialo
sialo endoscopy. It is also called pelvis-like endoscopy revealed more chances of saliva
or coma area. It may slow down the flow of retention in the submandibular duct. The
saliva and cause the sediment of inorganic lining of the duct seen endoscopically is
substance to sink and induce the gradual white and avascular, and the duct could itself
formation of a sialolith if a nidus such as a cause partial obstruction. During sialo
mucus plug or a foreign body exists.3,13 endoscopy, some special features were
Submandibular gland sialoliths have been found in the lumen and wall of the duct by
reported to be radiopaque in 80–94.7% of Yu et al. One special structure is a sphincter-
cases.2 A study conducted by Sheman and like mechanism or muscle like structure.
McGurk indicated no link between water This has a valve-like function and can
hardness and sialolithiasis or sialadenitis, prevent the foreign body from entering the
suggesting that high calcium intake might duct, which is located on the anterior side of
not lead to sialolithiasis. Patients with gout the submandibular duct, which can be
and patients on diuretic therapy may be related to the formation of sialolith in the
predisposed to sialolithiasis.2 Gout is the submandibular gland.3 There are various
only systemic disease which can cause radiological methods for diagnosis of
calculi of uric acid composition 50% of submandibular sialolithiasis. The
parotid gland sialoliths and 20% of conventional methods for detecting
submandibular gland sialoliths which are obstructions in the salivary ductal system are
poorly calcified.7 Calcified concretions in occlusal films for the sialolith in the
salivary ducts or glands are formed by Wharton’s duct, lateral oblique mandibular
deposition of calcium salts around a central films or panoramic radiographs for sialoliths
nidus, which may consist of desquamated in the hilum or substance of the
epithelial cells, bacteria, foreign bodies or submandibular gland. In the early stages,
products of bacterial decomposition. The sialoliths may be too small or insufficiently
foreign bodies reported in association with mineralized to be evident radiographically.
sialolith formation include a toothbrush Sialoliths in ducts appear as elongated or
bristle, fingernail sliver, wood splinter, hair, smooth cylindrical radiopaque structures,
the blade of grass, and a fish bone. and round or oval when located within the
Generally, sialoliths are thought to begin gland. The reported incidence of radiolucent
from retention of saliva in the salivary duct.3 submandibular sialoliths is 20–43%. The
However, there are two main theories that other advanced imaging modalities also used
attempt to explain the formation of salivary include sialography, xeroradiography
stones. The first theory postulates that a (especially for radiolucent sialoliths),
local inflammatory process ultrasonography, scintigraphy, and
52 | Page
Volume-IX Issue – 1 2019 e
computerized tomography and magnetic rinsing with the aid of a catheter. The first
resonance imaging. The treatment depends report on the use of shock waves to fragment
on the number, size, and location of the sialoliths was in 1986 by Mammary. In
sialolith, or whether it is present in the duct ESW lithotripsy, the average size of
or the gland. There are various modalities of fragments produced was about 0.7 mm.
treatment employed. If the sialolith is small Sialendoscopy or Sialo endoscopy is a
and single, conservative management may minimally invasive technique, in which
be attempted with local heat, massage, and shock waves are delivered directly to the
sialagogues. Smaller sialoliths which are surface of the sialolith lodged within the
located sufficiently peripheral; near the duct without damaging the adjacent tissues.
orifice of the duct, are removed by Micro endoscopes are introduced into the
manipulation or milking of the gland. This duct systems, to allow direct visualization
can be done with the aid of lacrimal probes and evaluation of the intraductal and
and dilators for opening the duct. The intraglandular microanatomy.2
sialoliths in the anterior part of the duct are
treated under local anesthesia while in the CONCLUSION:
posterior part of the duct are treated Sialolithiasis is not an uncommon
preferably under general anesthesia. disorder of the ducts and parenchyma of
Multiple sialoliths in the duct, or below the salivary glands. The correct diagnosis
posterior edge of mylohyoid muscle, or at necessitates a careful history and use of
the hilum of the gland or within the gland, or correct imaging techniques to define the
if the gland has been damaged by recurrent position and size of sialolith. Although
infection and fibrosis, may require surgical several advanced diagnostic and treatment
removal, and those patients who do not modalities have developed in the
respond to conservative therapy. It is management of sialolith. The conventional
performed preferably through an extraoral modalities retain their popularity to date.
approach and under general anesthesia. This case report has illustrated a case of
There are two approaches to submandibular submandibular sialolith that was diagnosed
sialoliths that avoid the use of surgery. clinically and radiographically and treated
These are Extracorporeal Shortwave (ESW) surgically with no postoperative
lithotripsy, and Intracorporeal Endoscopic complications.
lithotripsy, or sialendoscopy or sialo
endoscopy. ESW lithotripsy refers to a non-
invasive method of application of shock
waves from an externally applied
lithotripter, which causes fragmentation of
the sialoliths. These fragments then pass
through the duct, as the saliva is stimulated
and enhanced by the use of sialogogues; or
are removed by normal salivary flow or

53 | Page
Volume-IX Issue – 1 2019 e
REFERENCES:

1. Srinivas Gadipelly, T. Srilatha, 7. Chandra S. Submandibular Sialoithiasis

B.S.Sheraz, N.Vijaykumar. Parotid Analysis of 4 Case Reports. JIMSA.
sialolith- a case report and review of 2010; 23(2):97-98
literature. International Journal of
Contemporary Medical Research 8. McCullom III C, Lee C, Blaustein
2016;3(4):1211-1213. D.Sialolithiasis in an 8-year-old child:
case report.Pediatric Dentistry.
2. Parkar M, Vora M, Bhanushali D. A 1991;13(4):231-33
Large Sialolith Perforating the
Wharton’s Duct: Review of Literature 9. Oliveira E, Coradette C, Marson G,
and a Case Report. Journal of Hasse P. Giant sialolith of
Maxillofacial and Oral Surgery. submandibular gland: case report.
2011;11(4):477-482. RSBO. 2016;13(1):55.

3. Mathew Cherian N, Vichattu S, Thomas 10. Soumithran D, Mathew D, Dev D,

N, Varghese A. Wharton’s Duct Mithilesh D, Fazmiya D. Parotid
Sialolith of Unusual Size: A Case Report Sialolithiasis: A Case Report. IOSR
with a Review of the Literature. Case Journal of Dental and Medical Sciences.
Reports in Dentistry. 2014; 2014:1-7. 2016;15(07):96-100.

4. Bilahari N, Kumari B, James B, 11. Sathish R, Chandrashekar L,Sachin

Kuruvila V. Submandibular G.Submandibular Salivary Calculi-A
sialolithiasis: Report of six cases. Case Report.Journal of Dental Sciences
Journal of Pharmacy and Bioallied & Research. 1(1):16-22
Sciences. 2013;5(3):240.
12. KaurH, Jain S, Kamboj R, et
al.Submandibular Salivary Sialolith: A
5. KT L, Jain M. Giant Submandibular Case Report with Review of
Sialolith: A Case Report and Review of Literature.OHDM. 2016;15(1):18-21
Literature. International Journal of Head
and Neck Surgery. 2011; 2:154-157. 13. Dewan H, Dewan S.K., Patel H, et al.
Multiple Sialoliths in Wharton's Duct: A
6. AlQudehy Z, Abdullah O. Giant Case Report. BUJOD. 2013;3(2):99-101
submandibular sialolith: A case report
and literature review. Indian Journal of
Otology. 2016;22(2):126.

54 | Page
Volume-IX Issue – 1 2019 e
 EPULIS FISSURATUM OF MAXILLA: CONSEQUENCES OF ILL-
FITTING PROSTHESIS: A CASE REPORT
* Dr.Maitree P. Bavishi ** Dr. Hiren Patel *** Dr.Haren Pandya *** Dr.Hitesh Dewan
**** Dr. Bijal Bhavsar **** Dr Urvi Shah ***** Dr. Kartik Dholakia

ABSTRACT
Epulis fissuratum, reactive fibrous hyperplasia/denture-induced fibrous hyperplasias are
the various names attributed to reactive tissue response to chronic irritation and trauma caused
by an ill-fitting prosthesis. Persistent trauma to oral mucosa may predispose the patient to
carcinoma. Mucosal lesions related to the wearing of poorly adapted dentures are frequent.
Chronic irritations with sharp or excessive edge lead to hyperplasic reaction. Epulis fissuratum
represents 15% of benign tumour of the jaws, is a pseudo tumour growth located over the soft
tissues of the vestibular sulcus. It has female predilection over males. Treatment indication for
these lesions is surgical excision with appropriate prosthetic rehabilitation. We present a case of
faulty denture and the resultant epulis fissuratum in a 62-year-old female patient.

Keywords: Epulis fissuratum, fibrous tissue, pre-cancerous, surgical excision, complete

denture.

INTRODUCTION:
Denture-induced hyperplasia otherwise Epulis fissuratum also known as Granuloma
called epulis fissuratum is a hyperplastic fissuratum is an oral pathologic condition
condition of the oral mucosa caused by low- thatappears in the mouth as an overgrowth of
grade chronic trauma from ill-fitting fibrous connective tissue. It is also known as
dentures.1 It is a reactive lesion of the oral inflammatory fibrous hyperplasia, denture
mucosa to excessive mechanical pressure on epulis, and denture fibrous hyperplasia.
the mucosa.2

*Third year Post- Graduate Student Corresponding Author:

**Dean, Head and Professor Dr. Maitree P. Bavishi
***Professor 3rd Year Resident Department of Oral and
****Reader Maxillofacial Surgery,
*****Lecturer Faculty of Dental Science,
Department of Oral and Maxillofacial Dharmsinh Desai University,
Surgery, Faculty of Dental Science, Nadiad – 387002 Gujarat
Dharmsinh Desai University, Email ID: [email protected]
Nadiad – 387001 Gujarat Contact No: +(91) 9825756426

Volume - IX Issue - 1 – 2019 55 | P a g e

 One of the major reasons for epulis to form is CASE REPORT:
the ill-fitting flanges of denture which A 62-year-old female patient visited
constantly traumatize the tissues of vestibule. Department of Oral and Maxillofacial
It may become very large and be composed Surgery, Faculty of Dental Science,
of several layers. The size of the lesion varies Dharmsinh Desai University, Nadiad with a
from localized hyperplasia which is less than complain of swelling and mild pain since last
1cm in size to larger lesions that involve most 15-20 days. Patient had a history of small soft
of the length of the vestibule, almost the tissue mass in relation to the upper arch
entire length of tissue around a denture. It is which has developed to the present size over
more common in women and it can appear in a 12-month period. The patient has been
either the mandible or maxilla but is more wearing upper removable complete denture
commonly found on the facial aspect of for 15 years. Pain was moderate and
alveolar ridge.3 When the cause (ill-fitting intermittent. The patient used to wear the
denture) is removed, a peculiar fissure denture during night at times. Patient had
bounded by hyperplastic soft tissue on both medical history of hypertension since last 7
sides is seen. The chronic nature of the years and was on medication for same.
process means that discomfort and pain is Intraoral examination revealed multiple
often not a prominent feature and therefore hyperplastic tissue folds in the right
the patient may continue to wear the maxillary buccal vestibule extending from
offending denture until hyperplastic lesions the right lateral incisor region to the third
of considerable size develops before the molar area with maxillary denture flange
patient becomes aware of the lesion and need fitting in between the tissue folds.
for treatment.4 However, the lesion may be (Illustration 1) Palatal mucosa was normal.
associated with discomfort and pain when The size of the lesion was 3x4cm
ulceration occurs.5,6 It occurs in 5-10% of approximately. Lesion was erythematous and
the jaws with patients wearing complete tender on palpation. Texture of the lesion was
dentures and more in maxilla.2 Denture- smooth with soft consistency. Provisional
induced hyperplasia can be treated in both the diagnosis was made to be denture induced
ways; conservatively or surgically depending epulis fissuratum/hyperplasia.
on the size of the lesion.1

Volume - IX Issue - 1 – 2019 56 | P a g e

 sutures were taken. Vestibule depth of
maxilla was preserved. Postoperatively,
antibiotics and analgesics were prescribed.
The patient was instructed not to wear the
denture. She was advised to rinse the mouth
with chlorhexidine (0.2w/v) mouthwash. The
excised specimen (Illustration 3) was sent for
histolopathological examination. It revealed
Illustration 1- Pre-Operative Picture hyperplastic epithelium in most of the areas,
and the underlying connective tissue was
fibrous, with moderate inflammatory
infiltrate consisting of predominantly
lymphocytes. The patient was recalled for
suture removal after a week.

Illustration 2-Lesion excision

using tissue forceps and vestibule was

retracted. Using a no. 15 surgical blade an
Illustration 3- Removal of lesion
outline for excision was made along the
length of the lesion. (Illustration 2) Complete
excision of the lesion was carried out.
Haemostasis was achieved through pressure
pack. The field was cleaned with betadine
and saline solution. A primary closure was
achieved using Mersilk suture material.
(Illustration 3 and 4) Simple interrupted
Volume - IX Issue - 1 – 2019 57 | P a g e
 DISCUSSION:
The term ‘epulis’ was coined by
Virchoff, and its dictionary meaning is ‘over
the gums’. However, the affected mucosa is
usually the oral mucosa of the vestibular
sulcus or of the palatal region and not the
gingival mucosa. Thus, another term,
‘denture-induced fibrous hyperplasia’ is
considered to be a much-preferred term.
Denture-induced fibrous hyperplasia is a
Illustration 4- Closure Done
reactive growth caused by chronic irritation
from badly adapted prosthesis with variable
hypertrophy and hyperplasia.7 Trauma and
irritation are the two main aetiological factors
responsible for occurrence of epulis.
Clinically, it presents as a raised sessile
lesion in the form of folds with a smooth
surface with normal or erythematous
overlying mucosa. Because of chronic
irritation, it may get traumatised and present
Illustration 5- Post-operative Picture with an ulcerated surface.2,8 Firoozmand et
al.6 reported that 78% of females had
The post-operative healing was satisfactory denture-induced hyperplasia which is mostly
after follow-up of 1 month. The new denture seen in maxilla. The size of the lesion has a
was fabricated after 3 months. The patient is wide range from being as small as few
on regular follow-up for 6 months and there millimeters to massive lesion involving the
was no recurrence of the lesion till date. entire vestibule. It is asymptomatic in nature
(Illustration 5) but sometimes severe inflammation and
ulceration can occur. Denture-induced
hyperplasia may be treated conservatively or
surgically. In the early stages of fibrous
Volume - IX Issue - 1 – 2019 58 | P a g e
 hyperplasia, when fibrosis is small in size of When areas of gross tissue redundancy are
few millimeters, nonsurgical treatment with a found, simple excision frequently results in
denture in combination with a soft liner is total elimination of the vestibule. In such
frequently sufficient for reduction or cases, excision of the epulae, with peripheral
elimination of this tissue. When the condition mucosal repositioning and secondary
has been present for some time and epithelialization, is preferable or secondary
significant fibrosis exists within the vestibuloplasty may be planned.9 A
hyperplastic tissue, this will not respond to surgical splint or denture lined with soft
nonsurgical treatment. Excision of tissue conditioner is inserted. This
hyperplastic tissue is the treatment of choice conditioner is worn continuously for the first
in such cases. Since the lesion was large it 5-7 days. Secondary epithelialization takes
was treated with surgical excision followed place and denture impressions can be made
1
by fabrication of new denture. Three within 4 weeks/1month.1 Laser excision of
techniques have been widely used large epulis allows complete removal without
successfully for the treatment of excessive scarring or bleeding.10 Most of
inflammatory fibrous hyperplasia. When the
the patients are not aware that dentures
area to be excised is minimally enlarged,
should be rectified on a regular basis because
electrosurgical or laser techniques provide
of the resorption of the alveolar bone, which
good results for tissue excision.1 If the tissue
is a continuous process, leading to unfitted
is extensive, simple excision and
denture that causes the growth of fibrous
reapproximation of the remaining tissue is
hyperplasia. It not only produces pain and
preferred. Electrosurgical techniques in such
discomfort but negatively affects the
cases may result in excessive vestibular
mastication, aesthetics and overall well-being
scarring. The redundant areas of tissue are
of the patient. Chronic trauma to oral mucosa
grasped with tissue forceps, a sharp incision
may predispose the patient to carcinoma.
is made at the base of the excessive fibrous
Bone loss and resorption are accelerated if
tissue down to the periosteum, and the
dentures are worn for 24 hours including
hyperplastic tissue is removed. The adjacent
night. Wearing dentures at night times, when
tissue is gently undermined and re-
the salivary flow is naturally diminished
approximated using interrupted or
leads to inflammatory reactions, which
9
continuous sutures.
Volume - IX Issue - 1 – 2019 59 | P a g e
 predisposes to hyperplastic conditions.11 N.Denture induced fibrous
Treatment includes immediate withdrawal of hyperplasia: A case report.SRM
the ill-fitting prosthesis followed by topical University J. Dental Sciences, 2010;
application of anaesthetics with local 1 (3) :256- 258.
analgesics.
4. Bhasker RM, Davenport JC,
CONCLUSION: Thomson JM. 5th ed. UK: Willy-
A case of successfully managed Blackwell; 2001. Prosthetic treatment
extensive denture-induced hyperplasia is of the edentulous patients.
presented. The need for regular maintenance
visits and good denture hygiene habits is also 5. Espinoza I, Rojas R, Aranda W,
highlighted. Patients with epulis fissuratum Gamonal J. Prevalance of oral
should be educated about the benign nature mucosal lesions in elderly people in
of the condition, treatment options, and Santiago Chile. J Oral Pathol Med.
importance of not to wear the dentures at 2003; 32:571–5.
night time.
6. Firoosmand LM, Almeide JD, Cabral
REFERENCES:
LA. Study of denture-induced fibrous
1. Kafas P, Upile T, Stavrianos C, hyperplasiacases
Angouridakis N, Jerjes W. diagnosedfrom1979-2001.
Mucogingival overgrowth in a QuintessenceInt. 2005; 36:825–9.
geriatric patient. Dermatol Online J.
2010; 16:7. 7. Removal of hyperplastic lesions of
the oral cavity. A retrospective study
2. Canger EM, Celenk P, Kayipmaz S. of 128 cases.
Denture-related hyperplasia: A
clinical study of a Turkish population 8. Regezi JA, Sciubba JJ, Jordan R.
group. BrazDent J. 2009; 20:243–8. Oral pathology: clinical
pathological correlations. 5th edn.
3. N. Kalavathy, Sridevi. J, P. Roshan Saunders, 2008.
Kumar, Sharmila. M. R, Jayanthi.
Volume - IX Issue - 1 – 2019 60 | P a g e
 9. Omal PM, Mathew SA. Denture-
induced extensive fibrous
inflammatory hyperplasia
(Epulisfissuratum) KeralaDent J.
2010; 3:154–5.

10. Naveen Kumar J, Bhaskaran

M.denture induced fibrous
hyperplasia. Treatment with carbon
dioxide laser and a two-year follow-
up. Indian J Dent Res. 2007; 18:135–
7.

11. Duyck J, Vandamme K, Krausch-

Hofmann S, Boon L, De
Keersmaecker K, Jalon E, et al.
(2016) Impact of Denture Cleaning
Method and Overnight Storage
Condition on Denture Biofilm Mass
and Composition: A Cross-Over
Randomized Clinical Trial. PLoS
ONE 11(1): e0145837. doi:10.1371/
journal. pone.0145837

Volume - IX Issue - 1 – 2019 61 | P a g e

 PATTERNS OF RUGAE IN GENDER IDENTIFICATION
* Dr. Divya Jay Makhija, * Dr.Meghal Arpit Shah ** Dr. Jigar Purani

Abstract:
Palatoscopy or palatal rugoscopy is the study of palatal rugae for person’s identification.
Aim:
The aim of the present study is to assess the pattern of palatal rugae to identify gender
using shape, length and number. Materials and methods: 30 casts of patients from age 10-60
years were made from type 3 plaster poured in alginate irreversible hydrocolloid impressions of
maxillary arch. The palatal rugae was examined based on shape, length and number. The rugae
were delineated using thin black marker pen. Results: Females had a greater number of rugae
compared to males. The length of palatal rugae was more in males compared to females. The
straight pattern was found most in both males and females while the circular pattern was found
the least. Conclusion: This study has showed significant difference in distribution of rugae
pattern among the genders, the uniqueness and stability of rugae makes it ideal forensic
identification marker and hence palatal rugae can be used to identify gender.

INTRODUCTION
Forensic odontology is a specialty in dentistry which deals with the appropriate
dentistry which occupies a primary niche handling and examination of dental evidence
within the total spectrum of methods applied and with proper evaluation and presentation
to medico-legal identification. Forensic of dental findings in the interest of justice.1
odontology can be defined as a branch of

* Dr. Divya Jay Makhija Corresponding Author:

* Dr. Meghal Arpit Shah
** Dr. Jigar Purani Divya Jay Makhija
*Interns
B-2, Ogad Nagar, Akashwani, Makkarpura
**Reader
Department of Oral and Maxillofacial Road, Vadodara. Postal Code-390018
Pathology, Email ID: [email protected]
Faculty of Dental Science
Dharamsinh Desai University. Contact Number: +91942879989
Nadiad-387001, Gujarat, India.

Volume - IX Issue - 1 – 2019 62 | P a g e

 The basis of forensic odontology is impressions of maxillary arch. The candidates
establishing individual identity by were randomly selected and were free of
identification of human remains. Positive congenital abnormalities, infectious diseases,
identification methods and exclusionary lesion causing mucosal or bony changes in
methods aid in personal identification.2 maxillary anterior region. Individuals with
Widely used methods to identify are analysis orthodontic treatment or history of palatal
of deoxyribonucleic acid, dactylogram, and surgeries were excluded. The stone models
comparing dental record ante and post were free of voids and discrepancies especially
mortem. When the body is burnt or in anterior two third of palate.
decomposed these methods are not helpful.2
At such instance palatine rugae come into METHOD OF IDENTIFICATION:
place in establishing identity. According to The rugae in each half were
glossary of prosthodontic terms, palatal rugae highlighted using thin black marker pen
are defined as anatomical fold or wrinkle under spot light. To reduce intra-observer
usually in pleural sense, irregular fibrous variation each cast were analyzed twice.
connective tissue ridges located in anterior The patterns of rugae were determined using
two-third of palate.3 They are also known as THOMAS AND KOTZE
5
“plica palatinae” or “rugae palatinae”.4 CLASSIFICATION. It is classified as
Palatoscopy or rugoscopy is the name given straight, circular, curved, unification, and
to the study of palatal rugae in order to wavy. The length was determined by
establish a person’s identity.4 Palatal rugae LYSELLL’S CLASSIFICATION.6 It
appear towards the third month of classifies rugae patterns into 3 categories
intrauterine life and its development and primary (5mm or more), secondary (3-5mm),
growth is controlled by epithelial- & fragmentary (2-3mm). Rugae smaller than
mesenchymal interactions. Due to stability 2mm were disregarded. The length of each
uniqueness it has been considered as one of rugae was measured using orthomax Vernier
the relevant parameters for human caliper in millimeters.
identification in forensic science.
Results:
AIM: The shape of rugae were recorded as
Aim is to assess the pattern of palatal straight, curved, circular, wavy and
rugae for gender identification using number, unification. Table 1 shows 93% wavy rugae
shape and length. pattern present in females and 80% in males.
Table 2 shows circular pattern was absent in
females and present in 13% males. Table 3
MATERIALS AND METHODS:
shows distribution of curved patterns where
This study consists of total number of
both males and females shared the same ratio
30 casts of patients from age 10-60 years.
by 93%. Table 4 shows 53% unification
Casts were made from type 3 plaster poured
rugae pattern present in males and 17% in
in alginate irreversible hydrocolloid
females. Table 5 shows straight patterns were

Volume - IX Issue - 1 – 2019 63 | P a g e

 equal in both males and females. The length the study performed by Ibeachu et al10 and
of rugae was measured with the help of contraindicates with the findings of a study
Vernier calipers which was further conducted by Nayak et al11, Kumar et al12,
categorized into primary, secondary and Kapali et al13 and Surekha et al14 in which
fragmentary. Table 6 shows 11 primary rugae wavy and curved pattern were predominant. In
are found in 27% males and 13% females our study the wavy pattern was higher in
which indicates that total number of primary females than in males which was similar to
rugae were more in males as compared to study conducted by Harjeet Kaur et al.15 In our
females. Table7 shows 6 secondary rugae are study curved pattern was equally present in
found in 21% of females and 8% males which both males and females which was
indicates that total number of secondary contradictory to study performed by Nayak et
rugae are more in females compared to males. al.11 In our study unifaction was higer in males
Table 8 shows absence of fragmentary rugae compared to females which was similar to
in males and 100% presence in females. study performed by Rani S Thaba et al.16
Table 9 shows the comparison of total Circular pattern was least common in both the
number of rugae between males and females genders. In our study total number of rugae
in which 15 rugae were found in 25% of were more in females than males which is in
females while male showed 20% of rugae association with the study performed by
which indicates that total number of rugae Dhoke and Osato who performed study among
were more in females compared to males. Japanese population.17 Similar study was
performed by Surekha et al. in which total
Discussion:
numbers of rugae were more in males
Palatal rugae facilitate personal
compared to females which was contradictory
identification procedures with its uniqueness,
to our study.13 According to present study
postmortem resistance and constancy;
length of rugae is higher among males
therefore, it is an ideal forensic parameter.7 In
compared to females these findings are
our study, stone models are used as ante-
contraindicated by the study performed by
mortem record due to simplicity in analysis
Selvamani et al. in which there was no
and minimum fabrication cost. Apart from
significant difference in length of rugae among
Thomas and Kotze classification used for the
males and females.18
study purpose, the other classification
devices are Silver, Carrea, Lysell Conclusion:
classification.8,9 The present study This study clearly shows that palatal rugae
investigated on difference in shape, number are unique to each individual and patterns of
and length of rugae pattern in 15 males and rugae with its different parameter can be used
15 females. The rugae pattern was classified successfully as a tool of identification. The
according to Thomas and Kotze for only limitation is that large scale studies are
difference in shape and Lysell for difference necessary. Besides that, research among
in length of rugae pattern. In our study different ethnic groups is essential for more
straight pattern was seen to be prevalent comprehensive understanding of palatal
inboth the genders this result confirms with rugae in forensic odontology.
Volume - IX Issue - 1 – 2019 64 | P a g e
 Table 1: Distribution of wavy rugae pattern

Gender Absence Presence Total

N % N %
Male 3 20% 12 80% 15
Female 1 7% 14 93% 15
Total 4 87% 28 13% 30

Table 2: Distribution of circular rugae pattern

Gender Absence Presence Total

N % N %
Male 13 87% 2 13% 15
Female 15 100% 0 0% 15
Total 28 93% 2 7% 30

Table 3: Distribution of curved rugae pattern

Gender Absence Presence Total

N % N %
Male 1 7% 14 93% 15
Female 1 7% 14 93% 15
Total 2 7% 28 93% 30

Volume - IX Issue - 1 – 2019 65 | P a g e

 Table 4: Distribution of unification rugae pattern
Gender Absence Presence Total
N % N %
Male 7 47% 8 53% 15
Female 11 73% 4 27% 15
Total 18 60% 12 40% 30
Table 5- Distribution of straight rugae pattern
Gender Absence Presence Total
N % N %
Male 0 0 15 100% 15
Female 0 0 15 100% 15
Total 0 0 30 100% 30

Table 6: Distribution of primary rugae pattern

Total no of Male Female Total
primary rugae
N % N % N %
5 1 7% 1 7% 2 7%
6 0 1 7% 1 3%
8 4 26% 3 20% 7 24%
9 2 13% 5 33% 7 23%
10 2 13% 2 13% 4 13%
11 4 27% 2 13% 6 20%
12 1 7% 0 1 3%
13 1 7% 1 7% 2 7%
Total 15 100% 15 100% 30 100%

Volume - IX Issue - 1 – 2019 66 | P a g e

 Table 7: Distribution of secondary rugae pattern
Total no of Male Female Total
secondary rugae
N % N % N %
1 1 8% 2 15% 4 15%
2 4 33% 1 8% 5 19%
3 1 8% 2 15% 3 12%
4 3 25% 3 21% 6 23%
5 1 8% 2 14% 3 12%
6 1 8% 3 21% 4 15%
7 1 8% 0 1 4%
Total 12 100% 13 100% 26 100%

Table 8: Distribution of fragmentary rugae pattern

Total no of Male Female Total
fragmentary
rugae
N % N % N %
1 0 0 5 63% 5 63%
3 0 0 3 37% 3 37%
Total 0 0 8 100% 8 100%

Volume - IX Issue - 1 – 2019 67 | P a g e

 Table 9: Comparison of total number of rugae pattern between males and
females
Total no of rugae Male Female Total
N % N % N %
7 1 7% 1 3%
9 1 7% 2 13% 3 10%
10 4 25% 1 7% 5 17%
11 3 20% 3 10%
12 1 7% 1 7% 2 7%
13 3 20% 3 10%
14 1 7% 2 13% 3 10%
15 3 20% 4 26% 7 23%
16 1 7% 1 3%
17 1 7% 1 3%
18 1 7% 1 3%
Total 15 100% 15 100% 30 100%

REFERENCES: 4. CV Mosby The Academy of

Prosthodontics. The Glossary of
1. Dayal PK textbook of Forensic Prosthodontic Terms. 8th ed. 2005.
Odontology. 1st ed. Paras Medical
Publishers; 1998. 5. Thomas CJ, kotze TJ. Palatal rugae
pattern: A new classification.
2. Subramanian P, Jagannathan N. J Den Assoc S Afr 1983; 38:153-7.
Palatal rugoscopy as a method of sex
determination in forensic science. 6. Lysell L. Plicae palatinae
Asian J Pharm Clin Res transversae and papilla incisiva in
2015;8(2):136-138. man: a morphologic and genetic
study. Acta Odont Scand 1955;13:
3. Nallaswamy D. Textbook of Suppl 18:1-137.
Prosthodontics. 1st ed. New Delhi:
Jaypee Brothers; Medical 7. Wichnieski C, Franco A, Ignacio
Publiction;2003. p. 226. SA, Batista PS. Comparative
analysis between dactyloscopy and

Volume - IX Issue - 1 – 2019 68 | P a g e

 rugoscopy. J Morphol Sci 2012 14. Surekha R, Anila K, Reddy VS,
Sep;29(3):174-177. Hunasgi S, Ravikumar S, Ramesh N.
Assessment of palatal rugae patterns
8. Thomas CJ, Kotze TJ. The palatal in Manipuri and Kerala population. J
rugae pattern in six southern African Forensic Dent Sci 2012; 4:93-6.
populations.human population , Part
II : Inter racial differences. J Dent 15. Sekhon HK, Sircar K, Singh S, Jawa
Assoc S Afr 1983; 38:166-72. D, Sharma P. Determination of the
biometric characteristics of palatine
9. Thomas CJ, Kotze TJ. The palatal
ruga pattern: A new classification. J rugae patterns in Uttar Pradesh
Dent Assoc S Afr 1983;38-153-7. population: A cross-sectional sudy –
Original Research. Indian Journal of
10. Ibeachu PC, Didia BC, Arigbede Dental Research. 2014;25(3);331-5.
AO. A Comparative Study of Palatal
Rugae Patterns among Igbo and 16. Thabhitha RS, Rajendra E, Reddy
M, Shreelakshmi N, Rajesh A,
Ikwerre Ethnic Groups of Nigeria: A Kumar V. Evaluation of palatal
University of Port Harcourt Study. rugae pattern in in establishing
Anat Res Int 2014; 2014:1-8. identification and sex determination
in Nalgonda children. Journal of
11. Nayak P, Acharya AB, Padmini AT, Forensic Dental Sciences. 2015;
Kaveri H. Differences in the palatal Vol 7; Issue3; 232-7.
rugae shape in two populations of
India. Arch Oral Biol 2007; 52:977- 17. Dhoke M, Osato S. Morphological
82. study of palatal rugae in Japanese. I.
Bilateral differences in the
12. Kumar S, Vezhavendhan N, Shanthi regressive evaluation of the Palatal
V, Balaji N, Sumathi MK, Vendhan Rugae. Jpn J Oral Biol 1994
P. Palatal rugoscopy among Jan;36(2):125-140.
Pudducherry population. J Contemp
Dent Pract 2012; 13:401-4. 18. Selvamani M, Hosallimath S,
Madhushankari, Basandi PS,
13. Kapali S, Towsend G, Richards L, Yamunadevi A. Dimensional and
Parish T. Palatal rugae patterns in morphological analysis of various
Australian aborigines and rugae patterns in Kerala sample
Caucassians. Aust Dent J 1997; population: a cross-sectional study. J
42:129-33. Nat Sci Biol Med 2015 Jul-
Dec;6(2):306-309.

Volume - IX Issue - 1 – 2019 69 | P a g e

 Orthodontic space closure in carious 1st molar extraction case- a
preferred treatment option in young patients
*Dr. Aakash Shah **Dr. Amit Mendiratta
**Dr. Harsh Mandan

ABSTRACT
Orthodontic treatments involving missing or compromised first permanent
molars are often challenging cases to treat considering the loss of potential anchor
tooth. The case presents orthodontic treatment in a patient with mutilated dentition &
carious first permanent molar. The treatment goals were to be accomplished by
extraction of compromised tooth and retention of healthy dentition. The diagnosis and
problem list needed extractions to accomplish the treatment goals. The possibility of
extracting compromised first permanent molars instead of other healthy teeth was
considered. Fixed appliances were used with simple mechanics without any
additional anchorage devices. Case‑based retention protocols were followed. The
patient achieved the predetermined treatment objectives of improved esthetics and
healthy and stable functional occlusion. This kind of treatment approach in young
patients has triple advantage- avoidance of an artificial prosthesis at a young age,
preserving healthy dentition as against a carious tooth and allowing more room for
the eruption of third molar.

Keywords: Space closure, Prosthetic replacement, Asymmetric extractions, Mutilated,

Molar extractions, Friction mechanics.

INTRODUCTION
Due to increased intake of time is elapsed, it may lead to supra-
processed, soft & sugary1 diet in the eruption of antagonist & tipping of
young population, incidence of caries adjacent teeth into edentulous area.
has increased. The 6-year molars are Prosthetic replacement of this
the early permanent teeth to erupt and mutilated condition is one treatment
they have high prevalence of caries. If alternative; & orthodontic ally
unattended, this may lead to eventual correcting supraeruption, tipping of
loss of the tooth & consequent teeth & closing the space without any
prosthetic replacement of the natural artificial teeth is another treatment
tooth. After the loss of tooth, if lot of alternative.

* Professor Corresponding Author:

** Senior Lecturer Professor Dr. Aakash Shah
Department of Orthodontics & Department of Orthodontics &
Dentofacial Orthopedics, Dentofacial Orthopedics,
Faculty of Dental Science, Faculty of Dental Science,
Dharmsinh Desai University,
Dharmsinh Desai University,
Nadiad 387002 Gujarat.
Nadiad 387002, Gujarat.

70 | P a g e
Volume - IX Issue - 1 - 2019
 Case report is presented in this article
in which patient reported to the clinic
with carious mandibular left first
molar. Detailed intraoral examination
revealed the presence of severe
imbrication, deep bite, proclination of
maxillary teeth, & supraeruption of
maxillary left 1st molar. Special
attention and precautions were taken as
it became an asymmetric extraction2,3,4
case involving one molar & three Illustration 1
premolar extractions. Orthodontic
space closure using simple Pretreatment extraoral & Intraoral
mechanics 5,6,7
& no skeletal photographs.
8,9
anchorage was used to treat the case.

Case Report:
Diagnosis & Problem list
A 14 year, 3 months old boy reported
with chief complain of crowding &
protruded teeth. He also had a
complain of occasional pain in relation
to mandibular left posterior region &
now is having difficulty in chewing on
left side. He had a convex profile with Illustration 2
incompetent lips. Lower lip was thick
& everted with deep mentolabial Pretreatment Lateral cephalogram &
sulcus (Illustration 1). The mandibular OPG xrays. including all developing
arch exhibited severe crowding in 3rd molars also; 37 had erupted
anterior region with Class II molars & partially. Cephalometric evaluation
canine relationships; 6mm of overjet & showed a Class II skeletal base,
5mm of overbite was present. Due to average growth pattern, & proclined
enormous amount of loss of the crown maxillary & mandibular incisors
structure in 36, supraeruption of 26 (Illustration 2).
was observed. 35 was in lingual
crossbite. Orthopentamogram(OPG) Treatment objectives:
showed full complement of teeth
1. Alignment of upper & lower
teeth
2. Correct overbite & overjet
relationship
71 | P a g e
Volume - IX Issue - 1 - 2019
 3. Retraction of anterior teeth to
improve facial profile
4. Camouflage the existing
skeletal deformity
5. Improve smile esthetics &
functional occlusion
6. Proper retention plan
7. Alignment of upper & lower
teeth
8. Correct overbite & overjet
relationship
9. Retraction of anterior teeth to
improve facial profile Illustration 3
10. Camouflage the existing
skeletal deformity Finishing & detailing stage (Stage-3)
11. Improve smile esthetics & extraoral & intraoral photographs.
functional occlusion
12. Proper retention plan.

Treatment alternatives:

1. Conventional orthodontic
treatment plan of Extraction of four
first premolars, one in each quadrant. Illustration 4
However, this plan would mean
extraction of healthy teeth and Finishing & detailing stage Lateral
retention of first molars on the cephalogram & OPG x-rays.
mandibular left side which is badly mandibular molar being bodily moved
carious and would need elaborate into the occlusion. Lateral cephalogram
endodontic treatment & prosthetic (Illustration 4) also shows reduced
crowns. proclination of maxillary & mandibular
anterior teeth.
2. Extraction of 14, 24, 36 & 44.
This plan inherently implies the Discussion:
closure of space of extracted 36; this Orthodontic treatment with
would mean no artificial prosthesis at a extraction of molars is technically
young age & also increase the chance more complex due to number of
of eruption of 38. Henceforth, patient factors. The space to be closed is
opted for this treatment alternative greater than premolar spaces but relief
of incisor crowding that can be
72 | P a g e
Volume - IX Issue - 1 - 2019
 achieved is less10 as evident from Retention in first molar extraction case
Table-1; also, amount of incisor should include a bonded wire on
retraction that can be achieved is buccal surface of second premolar and
much less rendering it to be a molar to avoid opening of extraction
critical anchorage case (Table-1). spaces in first molar region. This
The decision of asymmetric bonded wire is kept at least till the
extraction of molars on one side third molars erupt or even after.
versus premolars on the other was
taken in the above case as this Conclusion:
molar was broken down because Orthodontic space closure
of caries & had poor prognosis. treatment in patients with extracted or
Extraction of a compromised compromised first molars can be done
tooth than a healthy tooth was with simple mechanics to obtain good
aimed considering the longevity clinical results if the patient is young.
of dentition. The presence of This should be a preferred approach as
healthy third molars with normal it has an advantage of extracting
anatomy will compliment first carious teeth & hence avoiding
molar extractions to provide an lengthy, elaborate restorative treatment
occlusal table sufficient for along with a prosthesis in a young
function11. The ideal alveolar patient.
dimensions to succeed in closing
first molar space is 6 mm or less Declaration of patient consent:
in the mesio-distal direction and 7 The authors certify that they
mm in the bucco-lingual have obtained all appropriate patient
12
direction . A longstanding consent forms. In the form the patient’s
extraction space makes space guardian has given her consent for his
closure difficult due to multiple images and other clinical information
reasons viz. narrowing of alveolar to be reported in the journal. The
ridge bucco-lingually, supra- patients understand that their names
eruption of antagonist tooth & and initials will not be published and
change in axial inclination of teeth due efforts will be made to conceal
mesial & distal to the edentulous their identity, but anonymity cannot be
space. Hence, one can resort to the guaranteed.
temporary anchorage devices to
assist the tooth movements Conflicts of interest:
planned in cases with There are no conflicts of
longstanding extraction spaces interest.
which is commonly seen in adults.
A split‑ crest technique for narrow
ridge expansion can also be done
as for implant placement13,14.

73 | P a g e
Volume - IX Issue - 1 - 2019
 References: Dent Press J Orthod 2011; 16:130‑
57.
1. Touger-Decker, R., & van
Loveren, C. Sugars and 7. Jacobs C, Jacobs‑ Mü ller C
, Luley C,
dental caries. The Erbe C, Wehrbein H. Orthodontic
American Journal of space closure after first molar
Clinical Nutrition extraction without skeletal
2003;78(4):881S–892S. anchorage. J Orofac Orthop 2011;
72:51‑ 60.

2. Thirunavukkarasu VN, 8. Kyung SH, Choi JH, Park YC.

Miniscrew anchorage used to
Ramachandra SS, Dicksit DD,
protract lower second molars into
Gundavarapu KC. Extraction
first molar extraction sites. J Clin
protocols for orthodontic
Orthod 2003; 37:575‑ 9.
treatment: A retrospective
study. Contemp Clin Dent 9. Nagaraj K, Upadhyay M,
2016; 7:41-4. Yadav S. Titanium screw
anchorage for protraction of
3. Carlos de Oliveira RA, Martins mandibular second molars into
de Oliveira RR, Lourenço RF, first molar extraction sites. Am
Melo PM, Lacerda dos SR. J Orthod Dentofacial Orthop
Tooth extraction in
2008; 134:583‑ 91.
orthodontics: An evaluation of
diagnostic elements. Dent Press 10. Proffit, W. R., Fields, H. W., &
J Orthod 2010; 15:134‑ 57. Sarver, D. M. (2012)
Contemporary orthodontics. St.
Louis, Mo: Mosby Elsevier.
4. Travess H, Roberts‑ Harry D,
Sandy J. Orthodontics. Part 8: 11. Ay S, Agar U, Biçakçi AA,
Extractions in orthodontics. Br Köşger HH. Changes in
Dent J 2004; 196:195‑ 203. mandibular third molar angle
and position after unilateral
5. Ong DC, Bleakley JE. mandibular first molar
Compromised first permanent extraction. Am J Orthod
molars: An orthodontic Dentofacial Orthop
perspective. Aust Dent J 2010; 2006; 129:36‑ 41.
55:2‑ 14.

6. Schroeder MA, Schroeder DK,

Santos DJ, Leser MM. Molar
extractions in orthodontics.
74 | P a g e
Volume - IX Issue - 1 - 2019
 12. Hom BM, Turley PK. The
effects of space closure of the
mandibular first molar area in
adults. Am J Orthod 1984;
85:457‑ 69.

13. Blus C, Szmukler‑ Moncler S.

Split‑ crest and immediate
implant placement with
ultra‑sonic bone surgery: A
3‑year life‑table analysis with
230 treated sites. Clin Oral
Implants Res 2006; 17:700‑7.

14. Sethi A, Kaus T. Maxillary

ridge expansion with
simultaneous implant
placement: 5‑year results of an
ongoing clinical study. Int J
Oral Maxillofac Implants 2000;
15:491‑9.

75 | P a g e
Volume - IX Issue - 1 - 2019
 Table-1

SPACE FROM VARIOUS EXTRACTIONS

RELIEF OF
INCISOR INCISOR RETRACTION POSTERIOR FORWARD
EXTRACTION CROWDING MAXIMUM MINIMUM MAXIMUM MINIMUM
Central Incisor 5 3 2 1 0
Lateral Incisor 5 3 2 1 0
Canine 6 5 3 2 0
First Premolar 5 5 2 5 2
Second Premolar 3 3 0 6 4
First Molar 3 2 0 8 6
Second Molar 2 1 0 - -
Values in millimeters
With typical anchorage management (not skeletal anchorage)

76 | P a g e
Volume - IX Issue - 1 - 2019
 Association between diabetes mellitus and risk of peri-implant diseases
***
*Dr. Anal Trivedi **Dr. Vasumati Patel Dr. Shalini Gupta
****Dr. Hiral Purani

Abstract:
Dental implant surgery has developed to a widely used procedure for dental rehabilitation
and is a secure and predictable procedure. But some local and systemic risk factors can result in
higher failure rates and affect implant survival. Diabetes mellitus is a chronic disease that goes in
with hyperglycemia and causes multifarious side effects. India leads the world today with largest
number of diabetic patients in any given country. Along with all other complications diabetes
also affect the peri-implant tissue. Peri-implant diseases, namely peri-implant mucositis and peri-
implantitis, have been extensively studied in present era. However, little is known about the
association between diabetes and peri-implant diseases. Present review narrates role of diabetes
as a risk factor in developing peri-implant diseases, which may lead to implant failure in future.

Key words: diabetes mellitus, peri-implant mucositis, peri-implantitis.

Introduction: Under care and attention of indications,

Over the past few decades, oral anatomical and intra-individual limiting
osseointegrated implants have been widely factors, insertion of dental implants seems to
accepted as an effective treatment for represent a “safe” treatment option.
missing teeth.1


Lecturer, Department of Periodontics and
Oral Implantology, Faculty of Dental Correspondence Author:
Sciences, Dharmsinh Desai University,
Nadiad - 387001, Gujarat. Dr. Anal Trivedi, Lecturer

Head of The Department of Periodontics
and Oral Implantology, Faculty of Dental Department of Periodontics and Oral Implantology,
Sciences, Dharmsinh Desai University,
Nadiad - 387 001, Gujarat. Faculty of Dental Sciences, Dharmsinh Desai
***
Professor, Department of Periodontics University,
and Oral Implantology, Faculty of Dental
Sciences, Dharmsinh Desai University, Nadiad - 387 001, Gujarat.
Nadiad - 387 001, Gujarat.
*****
Reader, Department of Periodontics and Contact no.: +91- 9879286448
Oral Implantology, Faculty of Dental
Sciences, Dharmsinh Desai University, e-mail :[email protected]
Nadiad - 387 001, Gujarat.

Volume - IX Issue - 1 – 2019 77 | P a g e

Nevertheless, despite the high success and incidence increasing at an alarming rate.6
survival rates of dental implants, there are Along with five major complications of
several risk factors and complications that diabetes retinopathy, nephropathy,
could lead to their ultimate failure, such as neuropathy, macro vascular disease &
local and implant related factors like poor oral altered wound healing American Diabetes
hygiene, history of periodontitis, implant Association (ADA) has officially recognized
design (length and implant surface), lack of periodontitis as the “Sixth complication of
keratinized gingiva and smoking status.2-4 diabetes” and established a direct link
Moreover, numerous conditions including between diabetes and periodontitis.7 Present
general systemic diseases (diabetes, review, provides the information about
osteoporosis, immunosuppression and susceptibility of peri-implant diseases and
coronary heart disease) are also considered to thereby explains peri-implant tissue
affect the treatment outcome for patients with response to plaque in diabetics.
dental implants.5 Implant loss may occur as
“early implant loss” up to one year after Diabetes and peri-implant diseases:
implant insertion and “delayed implant loss” Peri-implant diseases include peri-
with a time period of more than one year after implant mucositis and peri-implantitis. Peri-
implant insertion. Diabetes mellitus is a implant mucositis has been described as a
chronic disease that goes in with disease in which the presence of
hyperglycemia and causes multifarious side inflammation is confined to the soft tissues
effects. Till date diabetes as a relative surrounding a dental implant with no signs
contraindication for implant surgery is of loss of supporting bone following initial
controversially discussed. Because the number bone remodelling during healing. Peri-
of patients suffering from diabetes increases, implantitis has been characterized by an
there are more diabetic patients demanding inflammatory process around an implant,
implant procedures. One fourth of total which includes both soft tissue inflammation
diabetic population of world is in India, and and progressive loss of supporting bone
beyond biological bone remodeling8

Volume - IX Issue - 1 – 2019 78 | P a g e

 (Illustration-1). The description of the suggested that plaque represents an initiator
inflammatory process of periimplant of pathologic events similar to those seen in
mucositis around an implant is quite similar gingival/ periodontal disease with soft tissue
to gingivitis around natural teeth. inflammation and crestal bone loss. In a
review of the literature, Meffert stated that
endotoxin producing pathogens will initiate
the same inflammation cascade leading to
both implant or tooth sites if left untreated.9
Crestal bone damage resulting from peri-
implant soft tissue inflammation could
progressively affect the bone implant
interface and ultimately leads to integration
failure. Depending on the configuration of
the bony defect,
Schwarz et al. distinguished between an
intraosseous class I defect and a supra-
alveolar class II defect in the
crestal implant insertion area. Spiekermann
Illustration: 1, Diagnostic criteria of peri-
characterized the type of bone resorption
implant diseases
into horizontal (class I), key-shaped (class
II), funnel- and gap-like (class III a, b) as
Plaque – bacterial biofilm induced peri-
well as horizontal-circular (class IV) forms.
implantitis has been implicated as one
However, it is not possible to conclude
etiological factor associated with long term
progression and prognosis criteria from
failure of endosseous implants. In contrast to
these classifications. In retrospective review
mucositis, peri-implantitis is a progressive
of data accumulated through the United
and irreversible disease of implant-
states department of Veteran affairs, Dental
surrounding hard and soft tissues and is
implant registry, peri-implant soft tissue
accompanied with bone resorption,
complications were associated with a
decreased osseointegration, increased pocket
significantly increased risk for implant
formation and purulence. It has been
failure.9-11, 17
Volume - IX Issue - 1 – 2019 79 | P a g e
There are some human studies which heterogeneity (P=0.872; I2=0%).
suggest effect of diabetes or glycemic Publication bias measured using Egger
control on osseointegration of implants, but (P=0.69) and Begg’s test (P=1.00) shows no
very few human trials give information evidence for diabetes bias in peri-
about soft tissue seal around implants. implantitis. A significant relationship
Shortly after implants are placed, between diabetes and peri-implantitis was
glycoproteins from saliva adhere to exposed revealed in this meta-analysis.15 According
titanium surfaces with concomitant to one another meta‐analyses, the risk of
microbiological colonization.12,13 The peri‐implantitis was about 50% higher in
formation of a biofilm plays a significant diabetes than in non‐diabetes (RR = 1.46;
role in the initiation and progression of peri- 95% CI: 1.21–1.77 and OR = 1.89; 95% CI:
implant diseases and is essential for the 1.31–2.46; z = 5.98; p < .001). Importantly,
development of infections around dental among non‐smokers, those with
implants.14 Soft tissue maintenance, in turn, hyperglycaemia had 3.39‐fold higher risk for
was associated with a number of variables peri‐implantitis compared with
that included oral hygiene levels. Thus, normoglycaemia (95% CI: 1.06–10.81).
elimination of the biofilm from the implant Conversely, the association between
surface is the prime objective when treating diabetes and peri‐implant mucositis was not
peri-implant mucositis. Peri-implantitis, like statistically significant (RR = 0.92; 95% CI:
periodontitis, occurs primarily as a result of 0.72–1.16 and OR = 1.06; 95% CI: 0.84–
an overwhelming bacterial insult and 1.27 ; z = 1.06, p = .29). This systematic
subsequent host immune response. Diabetes review suggests that diabetes
can disrupt collagen homeostasis in the mellitus/hyperglycaemia is associated with
extracellular matrix of periodontal tissue, greater risk of peri‐implantitis,
associated with neutrophil dysfunction and independently of smoking, but not with
imbalance of immune system, which may peri‐implant mucositis.16 According to one
lead to progression of peri-implant mucositis systematic review, which had included 22
to peri-implantitis. The meta-analysis clinical studies and 20 publications of
revealed a significant relationship between aggregated literature, conclude that patients
peri-implantitis and diabetes (OR, 1.89; 95% with poorly controlled diabetes suffer from
CI, 1.31-2.46) with no evidence of impaired Osseo integration, elevated
80 | P a g e
Volume-IX Issue – 1 2019
risk of peri-implantitis, and higher level of to the bacterial challenge and may increase
implant failure. When diabetes is under well the risk for periodontal disease. A number of
control, implant procedures are safe and epidemiologic studies have reported that the
predictable with a complication rate similar prevalence, severity and extent of
to that of healthy patients. The patients periodontal disease are higher in patient with
stratified by HbA1c levels as, well- diabetes mellitus (DM) than in non-diabetic
controlled (HbA1c 6.1–8 %), moderately controls.18-22 The association between
controlled (HbA1c 8.1– 10 %), and poorly diabetes mellitus and periodontitis has long
controlled (HbA1c ≥10 %). The healthy been discussed with conflicting conclusions.
control had HbA1c ≤6 %. So that, early Accumulation of AGEs (Advance Glycated
diagnosis and treatment by regular oral End Products) in alter collagen metabolism,
hygiene maintenance visits are utmost the collagen become less soluble and less
important for diabetic patients, which can likely to be normally repaired and replaced.
prevent the implant failure. (i.e. less resistant to destruction by
periodontal infections). AGE-modified
Diabetes with periodontitis – increased collagen accumulates in the walls of larger
risk of peri-implantitis: blood vessels, resulting in to thickening the
Zitzmann et al. quantified the vessel wall and narrowing the lumen. In
incidence of the development of peri- addition, AGE-modified vascular collagen
implantitis in patients with a history of has an affinity for low-density lipoprotein
periodontitis almost six times higher than in (LDL) and causes the accumulation of LDL
patients with no history of periodontal in the vessel wall, contributing to

inflammation.17 Based on an established atherosclerotic changes characteristic of

model of pathogenesis, the bacterial biofilm macrovascular complications of diabetes.

alone is insufficient to explain periodontal The basement membranes of endothelial

disease initiation and progression. Evidence cells also accumulate AGE-modified

suggests that periodontal tissues destruction collagen macromolecules, which can result

is mainly due to the host’s inflammatory in increased basement membrane thickness

response to the bacterial challenge. In in the microvasculature, altering normal

addition to other factors, diabetes mellitus homeostatic transport across the membrane.
has been shown to modify the host response This increased basement membrane
81 | P a g e
Volume-IX Issue – 1 2019
thickness is seen in the blood vessels of the deterioration of periodontal status was
periodontium in people with diabetes. associated with elevated serum levels of
Upregulation of proinflammatory cytokines AGEs.28 An analysis of the National Health
from monocytes/ polymorphonuclear and Nutrition Examination Survey
leukocytes and down regulation of growth (NHANES) III data set confirms the
factors from macrophages also present in previously reported significantly higher
diabetics.23-27 The alterations in periodontal prevalence of periodontitis in diabetics than
connective tissue carbohydrate metabolism in non- diabetics (17.3% versus 9%). The
uncouple the restorative and formative analysis of the data also shows that the
responses, and responsible for attachment prevalence of diabetics in patients with
loss. Degradation of collagen fibers periodontitis is double that seen in the non-
commonly seen in diabetics by MMPs periodontitis patients (12.5% versus 6.3%)
(MMP-8 & 9), which are elevated in and that, this difference is also statistically
diabetic tissues, including the periodontium. significant. Both of these diseases have a
Impaired osseous healing and bone turnover relatively high incidence in the general
are in association with hyperglycemia.25,26 In population (diabetes 1% to 6% and
subjects with diabetes, chronically elevated periodontitis 14%) as well as a number of
blood glucose levels lead to the accelerated common pathways in their pathogenesis
formation of advanced glycation end (both diseases are polygenic disorders with
products (AGEs). Endothelial cells and some degree of immunoregulatory
monocytes possess specific receptors for dysfunction). Endotoxin producing
AGEs (i.e. RAGEs) located on their cell pathogens will initiate the same
surfaces. There is strong indication that the inflammation cascade leading to both
interaction of AGEs with their receptors implant or tooth sites if left untreated.
plays an important role in the development Presence of diabetes in the patients with
of diabetic complications. The interaction of chronic periodontitis may also increase risk
macrophages with AGEs has been shown to of peri-implantitis.29 It is suggestive of the
stimulate increased secretions of pro- fact that diabetic patients with periodontitis
inflammatory mediators such as tumour form a specific group of patients, which are
necrosis factor a (TNF-α) and interleukin-1 not prefeferable candidates for implant
(IL-1). In subjects with type 2 diabetes, syrgey and have higher risk of developing
82 | P a g e
Volume-IX Issue – 1 2019
peri-implantitis in future. Crestal bone measure risk of peri-implantitis, in context
damage resulting from peri-implant tissue of type and duration of diabetes, glycemic
inflammation could progressively affect the control, role of antimicrobial rinses and
bone implant interface and ultimately leads systemic antibiotics. Specific continuous
to integration failure. But the risk of peri- check-ups with evaluation and elimination
implant mucositis can be decreased with of risk factors (e.g. smoking, systemic
proper oral hygiene maintenance in the such diseases and periodontitis) are effective
group of patients. precautions for the high success rate of
implant therapy. To that end, routine
Conclusion: monitoring of soft tissue around dental
Peri-implant inflammations represent implants as a part of a comprehensive
serious diseases after dental implant periodontal evaluation and maintenance is
treatment, which affect both the surrounding essential in patients with diabetes.
hard and soft tissue. And evidences suggest
that, in patients with diabetes mellitus, the References:
tissue repair ability and defensive
mechanisms against the insult of dental 1. Schwartz-Arad D, Kidron N and
plaque are impaired which may increase the Dolev E. A longterm study of
risk of peri-implantitis independently of implants supporting overdentures
smoking, but not of peri‐implant mucositis. as a model for implant success. J
The survival rate of implants in diabetics Periodontol 2005; 76: 1431-
does not differ from the survival rate in 1435.
healthy patients within the first 6 years, but
in the long-term observation up to 20 years, 2. Lindhe J, Meyle J; Group D of
a reduced implant survival can be found in European Workshop on
diabetic patients. Patients Periodontology. Peri-implant
with poorly controlled diabetes seem to have diseases: Consensus Report of
delayed osseointegration following the Sixth European Workshop on
implantation. Additional prospective cohort Periodontology. J Clin
studies are needed to clarify the implant Periodontol 2008; 35: 282-285.
survival rate in patients with diabetes and to
83 | P a g e
Volume-IX Issue – 1 2019
 3. Cosyn J, Vandenbulcke E, conditions.Michael G. Newman,

Browaeys H, Van Maele G and Henry H. Takei, Perry R.

Klokkevold and Fermin A.
De Bruyn H. Factors associated
Carranza.Carranza’s Clinical
with failure of surface-modified
implants up to four years of periodontology, 12th ed.

function. Clin Implant Dent Relat CanadaElseveir Saunders:

2015.p. 187.
Res 2012; 14: 347-358.

8. Dr.Paul Rosen,Dr.
4. Barfeie A, Wilson J and Rees J.
DonaldClem,David
Implant surface characteristics
Cochran,StuartFroum,
and their effect on
BradleyMcAllister,
osseointegration. Br Dent J 2015;
StefanRenvert,Hom-
218: E9.
LayWang.Peri
ImplantMucositisand Peri-
5. Roos-Jansaker AM, Renvert H,
Implantitis:ACurrentUnderst
Lindahl C and Renvert S. Nine-
andingofTheirDiagnosesand
to fourteen-year follow-up of
ClinicalImplications. J
implant treatment. Part III:
Periodontol2013; 84:436-43.
factors associated with peri-
implant lesions. J Clin 9. Meffert RM, Langer B, Fritz ME.
Periodontol 2006; 33: 296-301. Dental implants: a review. J
Periodontol. 1992;63(11):859-70.
6. SKWagnoo. Aetiopathogenesis
of Type 2 Diabetes mellitus- A
10. Benveniste R, Bixler D,
look in to Insulin deficiency.
Conneally PM. Periodontal
The Asian Journal of
disease in diabetics. J
Diabetology 2003;5: 29-34.
Periodontol 1967; 38:271-9.

7. Perry R. Klokkevold and Brian

L. Mealey. Influence of systemic

84 | P a g e
Volume-IX Issue – 1 2019
 11. S. E., Krall-Kaye, E. A., McCoy, Periodontol 2007; 78:1878-
L. C., Christiansen, C. L., 1886.
Rothendler, J. A. & Garcia, R. I.
Does periodontal care improve 15. Heitz-Mayfield LJA. Peri-

glycemic control? The implant diseases: diagnosis and

department of veteran’s affairs risk indicators. J Clin

dental diabetes study. Journal of Periodontol 2008; 35: 292–304.

Clinical Periodontology 2007;34:

46–52. 16. Kuan-Chi Tseng, Xin-Yi Zheng,
Xin-Hua Qu, Er-Yi Lu. Risk of
12. Momen A. Atieh, Nabeel
peri-implantitis in patients with
H.M.Alsabeeha, Clovis
diabetes mellitus: a meta-analysis
Mariano Faggion Jr., and
Int J Clin Exp Med
Warwick J.Duncan. The
2016;9(8):15986-15995
Frequency of Peri-Implant
Diseases: A Systematic Review 17. Alberto Monje , Andres Catena,
and Meta-Analysis. J Wenche S. Borgnakke.
Periodontol 2013; 84:1586- Association between diabetes
1598. mellitus/hyperglycaemia and
peri‐implant diseases: Systematic
13. Samuel J. DeAngelo, Purnima
review and meta‐analysis. J Clin
S. Kumar, Frank M. Beck,
Periodontol 2017; 44:636-48.
Dimitris N. Tatakis, and
Binnaz 18. Smeets et al. Definition, etiology,
prevention and treatment of peri-
14. Leblebicioglu.Early Soft Tissue implantitis – a review. Head &
Healing Around One-Stage Face Medicine 2014; 10:2-13.
Dental Implants: Clinical and
Microbiologic Parameters. J

85 | P a g e
Volume-IX Issue – 1 2019
 19. Benveniste R, Bixler D, 24. Perry R. Klokkevold and Brian
Conneally PM. Periodontal L. Mealey. Influence of systemic
disease in diabetics. J conditions. Michael G. Newman,
Periodontol 1967; 38:271-9. Henry H. Takei, Perry R.
Klokkevold and Fermin A.
20. Hove KA, Stallard RE. Diabetes Carranza. Carranza’s Clinical
and the periodontal patient. J periodontology, 12th ed. Canada
Periodontol 1970; 41:713-8. Elseveir Saunders: 2015.p. 188-
89.
21. Hugoson A, Thorstensson H,
Falk H, Kuylenstierna J.
Periodontal conditions in insulin- 25. Engebretson S, Chertog R,
dependent diabetics. J Nicholas A.Plasma levels of
ClinPeriodontol 1989; 16:215- Tumour necrosis factor – α in
patients with chronic
periodontitis and type 2
22. Emrich LJ, Shlossman M, Genco
diabetes.J ClinPeriodontol 2007;
RJ. Periodontal Disease in non-
34: 18- 24.
insulin- dependent diabetes
mellitus. J Periodontol 26. Theodosios G. Frantzis, Chrles
1991; 62:123-131 M. Reeve. The ultra-structure of
capillary Basement Membranes
in the attached Gingiva of
23. Safkan-Seppala B, Ainamo J.
Diabetic &Nondiabetic patients
Periodontal conditions in insulin-
with periodontal Disease. J
dependent
Periodontol 1973;42: 406-11.
mellitus.JClinPeriodontol
1992;19:24-9.
27. BediaSafkan-Seppälä,
TimoSorsa, TainaTervahartiala,
ArzuBeklen, and Yrjö T.
Konttinen. Collagenases in
Gingival Crevicular Fluid in

86 | P a g e
Volume-IX Issue – 1 2019
 Type 1 Diabetes Mellitus. J Odontologica Scandinavica
Periodontol 2006; 77:189-94. 2017; 75:319-24.

28. Kumar MS, Vamsi G, Sripriya R,

Sehgal PK.Expression of matrix
metalloproteinases (MMP-8 and
-9) in chronic periodontitis
patients with and without
diabetes mellitus. JPeriodontol
2006;771803-8.

29. LydieIzakovicovaHolla,KetrinaK
ankova. Distribution of the
receptor for advanced Glycation
End Products Gene
Polymorphisms in patients with
Chronic periodontitis: A
Priliminary Study. J Periodontol
2001; 72:1742-46.

30. Tariq Abduljabbar,Faisal Al-

sahaly,Mohammed Al-
kathami,Sibtain Afzal &Fahim
Vohra. Comparison of
periodontal and peri-implant
inflammatory parameters among
patients with prediabetes, type 2
diabetes mellitus and non-
diabetic controls. Acta

87 | P a g e
Volume-IX Issue – 1 2019
 AMNIOTIC-CHORIONIC MEMBRANE: HYPE OR HOPE

*Dr. Deesha Chhaya **Dr. Shalini Gupta ***Dr. Vasumati Patel

Abstract:
Periodontitis is a serious concern for clinicians. Several methods have been used for achieving
periodontal regeneration. Regenerative technique can be subdivided into two major types: non
bone graft associated, bone graft associated and combination of both. The placental membrane
used as a non-bone graft associated regenerative technique; possesses numerous growth
factors, proteins and stem cell reserves that accelerates wound healing and
regeneration. This review article unfolds placental membrane’s potential for regeneration
specially in the field of periodontal surgeries.

Keywords: Regeneration, fetal membrane, stem cell reserves.

INTRODUCTION

Regenerative medicinal therapy has highly proliferative and differentiative

emerged as a powerful tool to generate capacity to restore proper function and
biological substitutes and repair damaged provide better aesthetics.1
tissues, by either transplanting exogenous or
stimulating endogenous stem cells with

*Post Graduate Student, Corresponding Author:

**Professor and Head of Department, Dr. Deesha Chhaya
***Professor DEPARTMENT OF PERIODONTICS AND
DEPARTMENT OF PERIODONTICS AND ORAL IMPLANTOLOGY, FACULTY OF
ORAL IMPLANTOLOGY, FACULTY OF
DENTAL SCIENCE, DHARMSINH DESAI
DENTAL SCIENCE,
DHARMSINH DESAI UNIVERSITY, UNIVERSITY, COLLEGE ROAD,
COLLEGE ROAD,
NADIAD 387001, GUJARAT.
NADIAD 387001, GUJARAT.
(M) +91 97277 87605
[email protected]

Volume - IX Issue - 1 – 2019 88 | P a g e

 Three different methodological approaches membrane, separates the amnion from the
for regeneration can be distinguished: (1) decidua and the maternal uterus. Current
Cell-based therapy, (2) The use of research in the field of regenerative medicine
biomaterials or acellular scaffolds, and (3) and tissue engineering has suggested the
Cell-seeded scaffolds.2 The cells can be from potential role of human amniotic and
autologous, allogenic (same species, chorionic mesenchymal stromal cells
different individual), or heterologous (hAMSC) in mediating each phase of the
(different species) origin.2,3 Mesenchymal wound healing.6(Illustration:1) Advantages
stem cells (MSC) are one of the major cell of hAMSC over autogenously derived stem
populations, to mediate regeneration due to cells are: no morbidity in its procurement
their multipotential properties.4 They can be procedures, unlimited amount available7 and
obtained from various tissues such as bone isolation of hAMSC does not sacrifice the
marrow, periosteum, peripheral blood, embryo, as in the case of embryonic stem
adipose tissues and skin. MSC obtained from cells, thus no legal or ethical issues arise.8
these tissues have a few limitations, relatively Based on these factors amniotic membrane
invasive procedure and poor quality of cells (AM), can be preserved and used as a source
if taken from elderly or medically of stem cells in various tissue regenerative
compromised patients5. Therefore, newer modalities.1
developments in tissue engineering are
History:
focused on alternate sources of MSC. The
human placenta is a rich source of stem cells The use of placental tissue in treating

that are capable of differentiating into three the wound started more than 100 years ago

forms of germ layers. The fetal portion of the when Davis in 1910 first used these fetal

placenta is made up of the placental disk, the membranes as skin substitutes for treating

amniotic and chorionic membranes. The open wounds.9 Sabella and Stern in 1913

innermost of the two human fetal membranes described its use for burnt and ulcerated skin

is the amnion and it is in contact with the surfaces.10 In 1940, De Röth first reported use
contents of the amniotic sac, namely the of fetal membranes in the ocular surface11. He
amniotic fluid, the fetus and the umbilical
cord. The chorionic membrane, which is
attached to the outer surface of the amniotic
Volume - IX Issue - 1 – 2019 89 | P a g e
 used a biological dressing material made of maximal maintenance of biologic properties
fresh amnion and chorion for management of of membranes.12 In 1965, Dino et al
conjunctival defects. The use of these demonstrated for the first time that amniotic
membranes was very limited. Kim and Tseng membrane could be separated, sterilized and
in 1995 gave the preservation method for

Illustration :1 Composite diagram to illustrate the appearances of the layers of reflected

amnion and chorion when examined by both membrane preparations and routine cut sections.

safely used at a later date.13 The utilization of 1990’s and early 2000’s. Lawson in 1985 was
amniotic membrane waned in the early the first who studied the use of amniotic
1980’s because of increase in the membrane along with pectoralis major
communicable diseases such as muscle for oral cavity reconstruction.14 He
H.I.V./A.I.D.S., Hepatitis, etc. Amnion re- concluded that placement of amnion over the
appeared in the cryopreserved form for the deep aspect of the muscle that is exposed to
treatment of ophthalmic wounds in the late the oral cavity resulted in a more rapid
development of mucosa. Amniotic

Volume - IX Issue - 1 – 2019 90 | P a g e

 membrane (AM) is now used successfully in • Cryopreserved membrane.
the treatment of burns; creation of biologic
Frozen membrane:
surgical dressing; reconstruction of the oral
Amniotic membrane is frozen by
cavity, bladder, and vagina; tympanoplasty;
making it pass through liquid nitrogen at -
arthroplasty; abdominal surgery; and corneal
196°F. Cooling preserves the membrane for
transplantation. It has also been introduced in
an indefinite time, produces bacteriologically
dentistryas a suitable membrane for
pure and immunologically almost inert
vestibuloplasty. Currently it is also used in
material. Cryopreservation with dimethyl
regenerative procedures in periodontics. 15
sulphoxide (DMSO) at -80°C allows
retention cells in the AM at approximately
Preparation:
50% for several months. The several
Fresh membrane is obtained from the
angiogenic growth factors and cytokines are
placenta at the time of delivery, either vaginal
removed during cryopreservation of the AM.
or caesarian section. The membrane is rinsed
However, if the AM is cryopreserved in 50%
in a 0.025% solution of sodium hypochlorite
glycerol, the viability of Amniotic Epithelial
and stored at 4°C in sterile solution
Cells (AECs) is lost. It has been noted that
containing penicillin. Robson and Krizekl
storage of the AM in glycerol at 4°C results
showed that membranes remained sterile up
in immediate cell death.18
to 6 weeks. Dinno et al. performed cultures
to study the sterilization of amniotic
Freeze dried irradiated (lyophilized):
membranes. Preservation with 1:40 dilution
In this process, after obtaining
of sodium hypochlorite revealed no positive
membrane from placenta, it is freeze dried at
cultures until 30 days.16
-60°C under vacuum (atmospheric pressure
102) for 48 hours. It is then irradiated with
Processing:
2.5 mega rads (25 K Gray) in a batch type
For clinical use, amniotic membrane
cobalt-60 irradiator. By the method of freeze
can be prepared in the following forms-17
drying there is sublimation of liquid moisture
• Frozen membrane
of membrane to gaseous state without having
• Freeze dried irradiated membrane
undergone the intermediate solid stage. This
• Fresh membrane
• Stabilized amniotic membrane
Volume - IX Issue - 1 – 2019 91 | P a g e
 method helps the membrane to maintain its cesarean-section delivery in compliance with
original size and shape with minimum cell American Association of Tissue Banks
rupture. The freeze-dried membrane can be (AATB) standards and immediately stored at
readied for use by soaking it in normal saline -80°C for up to one year. Prior to processing,
for 1 minute.18 the frozen placenta was thawed at room
Fresh membrane: temperature for 8 hours in a Good Manufac-
The placenta was retrieved intact and turing Practice (GMP) facility before being
processed under sterile conditions. The placed at 8°C for an additional 16 hours. AM
chorioamnion was stripped from the placenta was affixed on a filter membrane and cut to 6
and, following antibiotic decontamination, x 6cm. The AM tissue was finally packaged
the amniotic membrane was separated from in a pouch containing 1:1 v/v Dulbecco
the chorion, cut into 2 cm squares and Modified Eagle Medium (DMEM) and
mounted on nitrocellulose backing paper. glycerol before storage at -80°C for up to two
The grafts were then stored individually in years.21
sterile CPTES (Corneal Potassium TES)
solution containing 2.5% chondroitin Preservation:
sulphate (CS) at +4°C.19 Glycerol has been used as a
cryoprotective agent for a long time. Because
Stabilized Amniotic Membrane: of its high osmotic pressure, it extracts
In this process, preservation and interstitial water from the amniotic
storage include spreading of AM on a plastic membrane. In this method, 80% glycerol is
sheet and allowing it to dry, passing through used for drying the amniotic membrane,
liquid nitrogen at -19°F, keeping at -60°C which can thereafter be preserved at 4°C for
under vacuum for 48 hours, then irradiated a long time, although it loses some of its
with 2.5 mega-rads and gluteraldehyde biologic properties. This type of preserved
fixation.20 amnion is used for dressing burn wounds.16

Cryopreserved Membrane: STRUCTURE AND COMPOSITION

To prepare cryopreserved AM tis- Amniotic membrane:
sues, donated full-term human placentas with It is about 10-15 micrometers thick
the umbilical cord were recovered after and consists of two fetal membranes; the
Volume - IX Issue - 1 – 2019 92 | P a g e
 inner amniotic membrane and the outer the basement membrane that serve as
chorion. It is normally 0.02 to 0.5 cm in adhesion ligands transmitting signals and
thickness and consists of five layers.6 interacting at cell surface receptors.24 An
array of growth factors is present in native
These are, from within outwards:6 human amnion/chorion membranes, which
• Epithelium. play critical roles in regulating tissue
• Basement Membrane. development and growth in utero. Epidermal
• Compact Layer. growth factor (EGF), basic fibroblast growth

• Fibroblast Layer. factor (bFGF), keratinocyte growth factor

• Spongy Layer. (KGF), transforming growth factors alpha

and beta (TGFα, β), nerve growth factor

There are two types of cells in (NGF), and hepatocyte growth factor (HGF)

amniotic membrane (AM) with different are some of the growth factors that have been

embryological origins: amnion epithelial identified in fresh and preserved amniotic

cells derived from embryonic ectoderm and membrane tissues.25

amnion mesenchymal cells from embryonic

mesoderm. It is from this layer that amniotic Chorion Membrane:
MSC (AMSC) are isolated from amniotic The chorion consists of four layers.
epithelial cells and stored to be used for These are, from within outward: Cellular
regenerating tissues. There are no nerves, Layer, Reticular Layer, Pseudo-basement
muscles, or lymphatics in the amniotic Membrane and Trophoblast. The reticular

membrane.22,23 The amniotic mesoderm layer layer is in contact with the spongy layer of the

consists of macrophages and fibroblast-like amnion and forms a majority of chorion’s

mesenchymal cells. These human amniotic thickness. The reticular network is composed
epithelial (HAE) cells and human amniotic of collagens I, III, IV, V, and VI. The
mesenchymal cells (HAM cells) express basement membrane anchors the trophoblasts
pluripotency and are potent stem cells to the reticular layer with collagen IV,
reservoirs.23 Amniotic epithelial cells (AEC) fibronectin, and laminin. The trophoblast
secrete collagen type III and IV and non- layer is the deepest layer, consisting of 2–10
collagenous glycoproteins like laminins, layers of trophoblasts which contact with the

nidogen, fibronectin and vitronectin within deciduas.26 The chorionic villi of human
Volume - IX Issue - 1 – 2019 93 | P a g e
 placenta is a rich source of mesenchymal of cell for future therapy.29 In addition, the
stem cells (PMSCs), also known as human chorionic villi contains abundant growth
chorionic mesenchymal stromal cells. The factors like insulin growth factor, Heparin-
Brescia Symposium has decided to call this binding EGF-like growth factor
type of cells from the placenta as “chorionic (HBEGF),Vascular endothelial growth factor
stromal mesenchymal cells”, not stem cells as (VEGF), Transforming growth factor-α
these cells have genetic and behavioural (TGF-α) and these factors work as
characteristics of both multipotent and adult endothelial cell mitogens and are required for
stem cells.27 The vascular niche of placenta cell signaling and prevent apoptosis of
harbors a pool of PMSCs that can give rise to cells.30
committed progenitors for tissue
maintenance and repair, and that PMSCs Properties Anti Inflammatory:
contribute to vessel maturation and The Mesenchymal Stem Cells
stabilization.28 The karyotyping analysis has (MSCs) in the AM decrease the secretion of
shown chorionic stem cells maintain proinflammatory cytokines like Tumor
chromosomal stability after serial passage, Necrosis Factor alpha (TNF-α) an
demonstrating chorion as a promising source

Table 1: Structure and composition of placental membranes31

Placental Layers of placental membrane Extracellular matrix component
membrane
1. Epithelium Single layer of cells
monolayer/amniotic Collagen types III, IV, and V, fibronectin, laminin,
epithelium and
2. Basement membrane nidogen
Amnion 3. Compact layer Collagen types I, III, V, and VI, fibronectin
4. Fibroblast layer Collagen types I, III, and VI, fibronectin, laminin,
5. Intermediate/spongy and
layer nidogen
Collagen types I, III, and IV, proteoglycans

Volume - IX Issue - 1 – 2019 94 | P a g e

 Chorion Reticular layer Collagen types I, III, IV, V, and VI, proteoglycans
Basement membrane Collagen type IV, fibronectin, and laminin
Trophoblasts

Illustration:2 Mechanisms of action of amniontic membrane.

Volume - IX Issue - 1 – 2019 95 | P a g e

 Interferon (INF) while increasing the Immunomodulatory:

production of anti-inflammatory cytokine, The unique molecular surface architecture

interleukin-10 and interleukin-4. The and biochemical properties of AM that is
inhibitors of matrix metalloproteinases derived from the layer of trophoblast cells
present in the amniotic membrane reduces renders it unsusceptible to maternal immune
matrix metalloproteinases (MMPs) released attack.14,32 These mesenchymal stem cells
by infiltrating neutrophils and macrophages. are different from other nucleated
Various tissue inhibitors of mammalian cells as they show little
metalloproteinases 1, 2, 3, and 4, allogenic reactivity when administered to
interleukin-10, and interleukin-1 receptor MHC unmatched adult immune competent
antagonists and endostatin which inhibit recipients.14 The cells of AM neither
endothelial cell proliferation, angiogenesis, express the programmed cell death receptor
and tumor growth are also expressed by 1 (PD1) (an inhibitory receptor that is
human amniotic epithelial and normally expressed on activated T and B
mesenchymal cells.32(Illustration:2) cells), nor its two ligands: programmed
death ligands 1 and 2 (PD-L1 and PD-L2)
and the immunoglobulin-like transcript
Angiogenesis:
receptors 2, 3, and 4 (ILT R-2, ILT R-3, and
The cells of the AM enhance the production
ILT R-4). Furthermore, they actively
of Vascular Endothelial Growth Factor
suppress T cell, dendritic cell and B cell
(VEGF) by activating the VEGF receptors 1
function that down-modulate exuberant
and 2. Extensive neovascularization after the
inflammation.14
application of AM is due to the liberation of
angiogenic factor like insulin derived
growth factor (IGF) that promotes Antimicrobial and Antiviral:

epithelialization and granulation tissue Amniotic membrane firmly adheres via

formation. The increase capillary blood flow fibrin and elastin linkages with the wound
to the lyophilized amniotic membranes that seals the wound and prevent
when used as graft material in contamination. This tight adherence helps in
vestibuloplasty promotes healing.33 restoring lymphatic integrity, protects
circulating phagocytes from exposure and

Volume - IX Issue - 1 – 2019 96 | P a g e

 allows faster removal of surface regulates TGF-beta and its receptor
debris and bacteria from the wound. expression by fibroblast that reduces fibrosis
The antimicrobial activity of the at the site. This also promotes tissue
MSCs in AM is mediated by two reconstruction by modulating the healing of
mechanisms: directly via the a wound. Various immune cells like T cell,
secretion of antimicrobial factors dendritic cell and B cell are also actively
such as LL-37 and indirectly via suppressed that prevents pathological
secretion of immunomodulative remodeling and excessive fibrosis.32
factors which will upregulates
bacterial killing and phagocytosis
Promotion of Epithelialization:
by immune cells. Defensins, mostly,
Amniotic membrane facilitates
secretary leukocyte proteinase
migration of epithelial cells, reinforces basal
inhibitor (SLPI), beta 3 defensins
cell adhesion, promotes epithelial
and elafin present in the amniotic
differentiation, prevents epithelial apoptosis,
cells act as components of the innate
and promotes epithelialization in healing of
immune system to provide
wounds. Brain natriuretic peptide and
protection from infection. Its
corticotrophin releasing hormone are also
antiviral properties are exhibited by
produced by membrane epithelial cells
the presence of a powerful antiviral
which play roles in increasing cellular
agent, Cystatin E which is an
proliferation and calcium metabolism.
analogue of cysteine proteinase
Sufficient oxygenation for epithelial cells is
inhibitors.15
provided by its good permeability in contrast
to other synthetic materials. Thus, amniotic
Anti-Scarring: membrane is an ideal tissue which facilitates
Vascular endothelial growth the growth of epithelial cells, helping in
factor (VEGF), hepatocyte growth their migration and differentiation.34
factor (HGF) are secreted by AM
that maintains a proper balance Reduction of Pain:
between TGF-1 and TGF-3 that
Reduction of pain by AM is because, it
prevents scarring. It also down-
diminishes inflammation and provides a
Volume - IX Issue - 1 – 2019 97 | P a g e
 better state of hydration that soothes should also have sufficient elasticity. Collagen and
the wound bed to promote faster elastin in extracellular matrix provide stiffness and
healing. The soft mucoid lining of elasticity for amniotic membrane, respectively. The
amniotic membrane also protects mechanical response of amniotic membrane is
the exposed nerve endings from viscoelastic in nature. Amniotic membrane is a
external irritant that help to decrease semipermeable membrane and is an immunotolerant
pain sensation.14,32 structure.16 The dehydrated amnion/chorion
membrane allograft can also be micronized, that
allows it to be used as a topical powder or mixed
Increased extracellular matrix deposition:
with saline to create an injectable solution or a
MSCs differentiation helps to topical gel.18 Mechanical testing reveals that the
regenerate the damaged tissue and regulate foetal membranes are elastic. Amniotic membranes
the local cellular responses to injury by have a tensile strength of 155 kPa and chorion
paracrine signaling. It helps in cell survival, membranes have a tensile strength of 95 kPa.35 In
proliferation, migration and gene expression vitro degradation revealed that up to three weeks
of epithelial cells, endothelial both the membranes resist degradation and maintain
cells, keratinocytes, and fibroblasts. MSC- their physical form. At end of 3 weeks foetal
conditioned medium acts as a membranes degraded completely. Amnion
chemoattractant for macrophages, membranes were not totally degraded even at the end
endothelial cells, epidermal keratinocytes, four weeks. The accumulated weight loss in
and fibroblasts which accelerate wound percentage for the amnion membrane was 21% of its
closure.14 initial weight at the end of the first week, 24% of the
initial weight at the end of second week, 31% at the
end of third week and 70% at the end of the fourth
MECHANICAL PROPERTIES:
week. Chorion membrane degraded 29% of its initial
Increase in stiffness enhances the stability
weight at the end of the first week, 35% at the end of
of scaffold and prevents displacement that
the second week, 42% at the end of the third week
leads to uninterrupted healing as well as
and 84% at the end of the fourth week.35
feasibility in exchange of metabolic
products of involving cells during the early
phase of healing. For maintaining the shear
stresses of surrouding tissue the scaffold
Volume - IX Issue - 1 – 2019 98 | P a g e
 AMNIOTIC MEMBRANE IN characteristics, anti-inflammatory, anti-
OPHTHALMOLOGY: angiogenesis, preventing collagen degradation and

Amniotic membrane can also promote promoting epithelialization which make AM an ideal

epithelialization of denuded areas of ocular biological skin substitute for the treatment of burn.42

surface.36 Amniotic membranes can be used Andonovska et al.43 showed that, use AM provide

in the treatment of persistent epithelial significantly better result than conventional method

defects as a single layer or multilayer graft in the treatment of dermal and sub-dermal burns.44
depending on the depth of lesions providing
USES OF CHORION AND AMNIOTIC
a substrate for epithelial cells to migrate and
MEMBRANES IN DENTISTRY:
adhere to the basement membrane.
The amniotic and chorion membrane
Multilayer AM is used to treat non-traumatic
have the biological properties such as
corneal micro perforation and
antimicrobial, anti-inflammatory, promotion of
descemetoceles.37 Using a non-healing
rapid vasculogenesis, epithelialization. Above
infective ulcers of ocular surface due to
all, as a source abundant stem cells these fetal
bacteria, fungi virus and protozoa, several
tissues a suitable choice in the field of
studies suggested that AM possesses
reconstructive and regenerative medicine. In the
inhibitory effects on several proteolytic
field of dentistry, these tissues find an
enzymes secreted by these
application especially in Oral maxillofacial
microorganisms.38 Partial Limbal Stem Cell
surgery and Periodontology.
Deficiency (LSCD) can be treated with
Antiinflammatory and antiscarring property of
AM.39,40 AM can be used to reconstruct
AM have shown decreased necrosis and rapid
the surface of the conjunctiva. It is also
healing of ulcers with herpes simplex virus
reported that AM can be used to
(HSV), varicella zoster virus–infected tissues,
reduce scarring at the time of filtering
erythema multiforme major (Stevens- Johnson
surgery, to repair early or late leaks in case of
syndrome) and cervical necrotizing fasciitis.45
41
glaucoma.
HAM (Human Amniotic Membrane) has been
tried in the reconstruction of TMJ ankylosis as
AMNIOTIC MEMBRANE IN BURN
it prevents fibrosis and reankylosis when used
HEALING:
as an interpositional material.46 AM is even
AM has several properties such as
used as a carrier for local delivery of the
non-immunogenicity, bacteriostatic
Volume - IX Issue - 1 – 2019 99 | P a g e
 various drugs like antibiotic netilmycin old rabbits. Amnion tissue grafts in this
(NTM) and antiviral drugs like study were made by layering 5 sheets (5
acyclovir (ACV) and trifluridine. × 5mm) of freeze-dried, human amniotic
Cryopreserved amniotic membrane membrane. Half of the wounds were covered
(CAM) has been known to promote with amnion grafts and the other half of the
periodontal soft tissue healing and is wounds served as the uncovered, control group.
also effective in helping cicatrization, Compared to the control group, the amnion
wound healing, epithelization, treated wounds had fewer polymorphonuclear
facilitated migration and reinforced cells at days 1 and 3; thicker epithelium and
adhesion. more fibroblasts at days 5, 7, and 10;
statistically significant greater new blood vessel
APPLICATIONS IN PERIODONTICS formation at days 7 and 10; and significantly
Preclinical Studies: more mature and dense collagen fibers at day
Gomes et al. (2001)47 studied 10.
the use of amnion grafts to line the
Clinical Studies:
floors of cortical bone defects of
Recently, the AM-based cell-culture
skull in rabbits and to cover the
system to culture PDL derived cells for
superficial surface of the defects. At
regenerative therapy of periodontal tissue has
90 days, amnion tissue was in direct
been developed. These cells are considered
apposition to newly formed bone.
capable of proliferation and potentially
At 120 days, the amnion tissue
maintaining their PDL-like properties even on
grafts were no longer present and
AM. Guler et al. (1997)49 studied the use of a
bone had completely filled the
single layer of lyophilized, gamma irradiated
defects. The authors concluded that
amnion for vestibuloplasty in 20 patients. The
the use of amnion tissue grafts did
graft was sutured in place and no stent was used
not inhibit repair in guided bone
to cover the graft. Observations of the graft
regeneration and may have been
sites 24 hours after amnion application
beneficial for its antibacterial
demonstrated a hyperaemic appearance of the
properties. Rinastiti et al. (2006)48
mucosal flaps. All patients showed some
histologically evaluated the use of
edema, which resolved by day 7. On day 10,
amnion tissue in thirty 3- 4-month-
epithelialization of the graft was observed and
Volume - IX Issue - 1 – 2019 100 | P a g e
 the amnion graft could not be allograft and bovine derived xenogeneic bone
differentiated. Smooth granulation graft with amniotic membrane in the treatment
tissue covered the grafted areas by day of human periodontal Grade II buccal furcation
14; and the amnion had completely defects. Results showed significant pocket
degraded. At day 21, the grafted areas depth reductions, clinical attachment level
were completely covered with oral gains, and significant improvement in bone fill
mucosa. In addition, blood flow to the and percentage gain with both of the materials.
alveolar mucosa was measured in Wallace (2010)53 evaluated clinically and
patients by clearance of intramucosal histologically the efficacy of a new resorbable,
injections of radioactive xenon gas. At immune privileged, self-adhering amniotic
day 10, a significant increase in blood membrane for ridge preservation following
flow in the graft was detected, tooth extraction. Quality of the histologically
compared with the preoperative state. evident bone formed at 4.5 months was
At 30 days, the blood flow decreased excellent. There was no evidence of resorption
and was not significantly different from of crestal bone height and inflammation, which
normal levels. Samandari et al. (2004)50 suggests the potential benefits of using amniotic
suggested that the amniotic membrane allograft in guided bone regeneration. Rosen
graft might be used as a potential graft (2011)54 used a combined approach for
material for vestibuloplasty. Gurinsky correcting both the hard- and soft-tissue
(2009)51 reported results of a series of deformities around a maxillary canine that
five patients treated with membranes included a mineralized bone allograft,
for shallow-to moderate Miller Classes recombinant platelet derived growth factor, and
I and II recession defects. At 12 weeks, a chorion amnion barrier covered by a
an increase in newly generated gingival subepithelial connective tissue graft.The
tissue of 3.2mm ± 1.7mm was advantages of this particular barrier are that it is
measured. Coverage was 100% in four extremely thin, measuring 300mm after full
out of five patients and 88% in the fifth hydration, with the major noncollagenous
patient.Kothiwale et al. (2009)52 components being laminins, proteoglycans, and
clinically and radiographically fibronectin, further enhancing its tissue friendly
evaluated and compared the efficacy of nature. Kothari et al. (2012)55 also concluded
demineralized freeze-dried bone that grafts of amniotic membrane are viable and

Volume - IX Issue - 1 – 2019 101 | P a g e

 reliable for covering of the raw surface, transmission with transplantation of amniotic
prevent secondary contraction after membranes is always an associated risk of
vestibuloplasty, and maintain the hence adequate precautions should be taken and
postoperative vestibular depth. A safety criteria should be included in application
clinical trial carried out by Suresh and of these biological membranes.59 Amniotic
Gupta (2013)56, on a 56-year-old male membranes are fragile membranes, so they need
with vertical recession depth of 2mm in to be dealt with care.59 Cryopreserved/ hyper
upper right canine for root coverage dry membranes are expensive.59 “zone of
and enhancement of gingival biotype altered morphology” (ZAM) includes structural
by using chorion membrane along with weaknesses and a marked disruption of the
coronally advanced flap, showed 100% connective tissue layers as well as a marked
root coverage and the soft-tissue reduction of the thickness and cellularity of the
biotype enhancement from thin to thick. membrane.60 Due to decreased integrity and
H. Singh and H. Singh (2013)57 increased apoptosis of cells in this region, use
presented a case report on bioactive of the ZAM is not preferred.
amniotic membrane as a membrane for
the treatment of isolated gingival THE FUTURE OF AMNIOTIC TISSUE:
recession. The results showed The benefits of novel allograft include
significant root coverage with reduction of surgery time, improving patient
uneventful healing. Shetty et al. outcomes with an affordable price tag. Amnion
58
(2014) compared usage of Platelet- tissue has many potentials uses across the field
rich Fibrin (PRF) and amniotic of medicine and dentistry. Third generation
membrane in bilaterally occurring amniotic membrane has been developed to
multiple Miller Class I recession. further optimize and simplify amniotic
100%root coverage was observed with membrane transplantation for ophthalmic and
both of the membranes but the results dental surgery as well.11 Many characteristics
were stable even after seven months in similar to stem cells are present in AECs, but
the amniotic membrane-treated site. one of the most important properties of stem
cells is that they survive freeze-thaw. Hence it
LIMITATIONS:
could be applied to the transplantation therapy
The use of amniotic membranes
for a wide variety of diseases. Technical
is technique sensitive Infection
Volume - IX Issue - 1 – 2019 102 | P a g e
 limitations with regards to suturing is 2. Feil G, Daum L, Amend B, Maurer S,
present as AM is a thin structure. A Renninger M, Vaegler M, Seibold J, Stenzl A,
new approach might include the use of Sievert KD. From tissue engineering to
glues as a substitute for suturing.61 regenerative medicine in urology—the potential
and the pitfalls. Adv Drug Deliv Rev.
CONCLUSION:
2011;63(4-5): 375–378.
Despite the few obstacles
mentioned above, the future of the
3. Dragin U, Kreft ME. Amniotic membrane in
Amniontic- chorionic membrane in
tissue engineering and regenerative medicine.
applications such as Tissue
Zdravn Vestn. 2010;79(10): 8707–8715.
Engineering and regeneration is
very exciting. Benefits of having
abundance of growth factors, having 4. Miki T, Lehmann T, Cai H, Stolz DB, Strom
anti-scarring properties, no SC. Stem Cell Characteristics of Amniotic
morbidity while procuring the Epithelial Cells. Stem Cells. 2005; 23: 1549-
membrane and its availability in 1559.
large amount makes it more material
of choice for its use. However, 5. Solomon A, Rosenblatt M, Monroy D, Ji Z,
further in vitro and clinical work is Pflugfelder SC, Tseng SCG. Suppression of
needed to determine the physical Interleukin 1 (Alpha) and Interleukin 1 (Beta)
properties and safety of the in Human Limbal Epithelial Cells Cultured on
Amniontic- chorionic membrane for the Amniotic Membrane Stromal Matrix.
the uses described in this review. British Journal of Ophthalmology. 2001; 85:
444-449
REFERENCES:

1. Thapliyal GK, Kumar V, Gour S; 6. Gupta S., Gupta R.; Placental Tissues- From
Amniotic Membrane: An Innovative Reproductive to Regenerative Biology;
Material for Repair and Regeneration International Journal of Science and Research
in Oral and Maxillofacial region- A (IJSR) ISSN (Online): 2319-7064 U. Human
Review; Rama Univ J Dent Sci 2016 Fetal Membranes: A Source of Stem Cells for
June;3(2):1-6 Tissue Regeneration and Repair Placenta. 2009;
Volume - IX Issue - 1 – 2019 103 | P a g e
 30: 2-10. reconstruction in severely damaged

rabbit corneas,” Cornea, vol. 14, no. 5, pp.473–

7. Toda A, Okabe M, Yoshida T, Nikaido 484, 1995.
T. The Potential of Amniotic
Membrane/Amnion- Derived Cells for 12. Dino BR, Eufemio GG, DeVilla M, Reysio-
Regeneration of Various Tissues. Cruz M, Jurado RA. The use of fetal membrane
Critical review. Journal of as homografts in local management of burns. J
Pharmacological Sciences. 2007; 105: Philipp Med Assoc. 1965; 41: 890- 898.
215-228.

13. Chopra A and Thomas BS. Amniotic

8. Davis J. Skin transplantation with a membrane: A novel material for regeneration
review of 550 cases at the Johns and repair. J Biomim Biomater Tissue Eng
Hopkins Hospital. Johns Hopkins Med 2013;18(1):106-13.
J. 1910; 15:307 312.

14. Rana M.P., Mehrotra N. Human Amniotic

Membrane: Hope in Periodontal
9. M. Stern, “The grafting of preserved Regeneration. International Journal of
amniotic membrane to burned and Science and Research (IJSR). Volume 5 Issue
ulcerated surfaces, substituing skin 4, April 2016
grafts: a preliminary report,” The
Journal of the AmericanMedical 15. Mohan R., Bajaj A, Gundappa M. Human
Association, vol. 60, no. 13, pp. 973– Amnion Membrane: Potential Applications in
974, 1913. Oral and Periodontal Field. Journal of
International Society of Preventive and
10. A. De R¨oth, “Plastic repair of Community Dentistry ¦ Volume 7 ¦ Issue 1 ¦
conjunctival defects with fetal January-February 2017.
membranes,” Archives of Ophthalmology, vol. 23, no. 3, pp. 522– 525, 1940.

16. Fernandes M, Sridhar MS, Sangwan VS, Rao

11. J. C. Kim and S. C. G. Tseng,
GN. Amniotic membrane transplantation for
“Transplantation of preserved human
ocular surface reconstruction. Cornea 2005;
amniotic membrane for surface
Volume - IX Issue - 1 – 2019 104 | P a g e
 24:643‑53. outcome of the first international Workshop on
Placenta Derived Stem Cells. Stem Cells ,2008
;26: 300-311.
17. Kala. S. Bhushan. Amniotic membrane
& its structure, features and uses in
dentistry – a brief review. International
22. Blackburn S (2003) Maternal, Fetal and
Journal of Advanced Research (2015),
Neonatal Physiology: a clinical prospective:
Volume 3, Issue 11, 354 – 360
Saunders: an imprint of Elsevier Science 345.

18. Philip J Adds. Amniotic membrane

23. Sniadecki NJ, Desai RA, Ruiz SA, Chen CS ()
grafts, “fresh” or frozen. A clinical and
Nanotechnology for cell- substrate interactions.
in vitro comparison. Br J Ophthalmol
Ann Biomed Eng, 2006;34: 59-74.
2001; 85:905–907.

24. Koob TJ, Rennert R, Zabek N, Massee M, Lim

19. Nargis Nizam Ashraf. Comparison of
JJ, Temenoff JS, Li WW, Gurtner G. Biological
Efficacy of Storage of Amniotic
properties of dehydrated human amnion/
Membrane at -20 and -80 Degrees
chorion composite graft: Implications for
Centigrade. Journal of the College of
chronic wound healing. Int Wound J,
Physicians and Surgeons Pakistan
2013;10:493– 500.
2015, Vol. 25 (4): 264-267.

25. Parry S, Strauss JF. Premature rupture of the

20. Cooke M. Comparison
fetal membranes. New Engl J Med,
of cryopreserved amniotic membrane
1998;338:663–670.
and umbilical cord tissue with
dehydrated amniotic membrane/
26. Parolini O, Alviano F, Bagnara GP, Bilic G,
chorion tissue. Journal of wound care
Bühring HJ, Evangelista M, et al. Concise
vol 2 3, no 1 0, octob er 2 0 1 4
review: isolation and characterization of cells
from human term placenta: outcome of the first
21. Parolini O, Alviano F, Bagnara GP,
international Workshop on Placenta Derived
Bilic G, Buhring HJ, et al. Concise
Stem Cells, Stem Cells, 2008, 26;2:300–311.
review: isolation and characterization
of cells from human term placenta:
Volume - IX Issue - 1 – 2019 105 | P a g e
 27. Castrechini NM, Murthi P, Gude NM,
Erwich JJ, Gronthos S, Zannettino A, 32. Samandari MH, Yaghmaei M, Ejlali M,
Brennecke SP, Kalionis B. Placenta. Moshref M, Saffar AS. Use of amnion as a
Mesenchymal stem cells in human graft material in vestibuloplasty: a preliminary
placental chorionic villi reside in a report. Oral Surg Oral Med Oral Pathol Oral
vascular Niche. 2010,31;3:203-12. Radiol Endod 2004; 97:574-8.

28. Fariha MM, Chua KH, Tan GC, Tan 33. Gupta A, Kedige SD, Jain K. Amnion and

AE, Hayati AR. Human chorion- chorion membranes: potential stem cell

derived stem cells: changes in stem cell reservoir with wide

properties during serial passage. applications in peridontics. Int J Biomater

Cytotherapy.2011,13;5:582-93. 2015;1-9.

29. Demetriou C, Abu-Amero S, Thomas 34. George A.K. Amnion and Chorion Membranes
AC, Ishida M, Aggarwal R, Al-Olabi L for Root Coverage Procedures: An In Vitro
Et al. Paternally expressed, imprinted Evaluation of its Physical Characteristics.
insulin-like growth factor- Periodon Prosthodon. 2018, Vol.4 No.2:07.
2 in chorionic villi correlates
significantly with birth weight. PLoS 35. Tsai, S.H., Y.W. Liu, W.C. Tang,
One. 2014,15;9(1): e85454.
Z.W. Zhou and C.Y. Hwang et al., 2007.
Characterization of porcine arterial endothelial
30. Gupta A. Amnion and Chorion
cells cultured on amniotic membrane, a
Membranes: Potential Stem Cell
potential matrix for vascular tissue engineering.
Reservoir with Wide Applications in
Biochem. Biophys. Res. Commun., 357: 984-
Periodontics. International Journal of
990.
Biomaterials. Volume 2015:9-15.

36. Lee S.H. and S.C. Tseng, 1997. Amniotic

31. Mishra S and Singh S. Human amniotic
membrane transplantation for persistent
membrane: Can it be a ray of hope in
epithelial defects with ulceration. Am. J.
periodontal regeneration. Indian J Res
Opthalmol., 123: 303-312
2014;3(9):118-21.
Volume - IX Issue - 1 – 2019 106 | P a g e
 atypia. Br. J. Ophthalmol., 85: 658- 661.
37. Malhotra C. and Jain A.K., 2014.
Human amniotic membrane 41. Fujishima, H., J. Shimazaki, N. Shinozaki and
transplantation: Different modalities of K. Tsubota, 1998. Trabeculectomy with the use
its use in ophthalmology. World J. of amniotic membrane for uncontrollable
Transplant., 4: 111-121. glaucoma. Ophthalmic Surg. Lasers, 29: 428-
431
38. Solomon, A., D. Meller, P.
Prabhasawat, T. John, E.M. Espana,
K.P. Steuhl and S.C. Tseng, 2002. 42. Andonovska, D., G.J. Dzokic, L. Spasevska, T.
Amniotic membrane grafts for Trajkovska and K. Popovska et al., 2008. The
nontraumatic corneal perforations, advantages of the application of amnion
descemetoceles and deep membrane in the treatment of burns. Prilozi, 29:
ulcers.Ophthalmology, 109: 694-703. 183-198.

39. Tseng, S.C.G., P. Prabhasawat, K.

43. Gabric, N., I. Mravicic, I. Dekaris, Z. Karaman
Barton, T. Gray and D. Meller, 1998.
and S. Mitrovic, 1999. Human amniotic
Amniotic membrane transplantation
membrane in the reconstruction of the ocular
with or without limbal allografts for
surface. Documenta Ophthalmologica, 98: 273-
corneal surface reconstruction in
283.
patients with limbal stem cell
deficiency. Arch. Ophthalmol., 116:
44. Mencucci R, Menchini U, Dei R. Antimicrobial
431-441.
activity of antibiotic- treated amniotic
membrane: An in vitro study. Cornea ,2006,
40. Paridaens, D., H. Beekhuis, W. van den
25: 428- 431.
Bosch, L. Remeyer and G. Melles,
2001. Amniotic membrane
45. Kothari CR, Goudar G, Hallur N, Sikkerimath
transplantation in the management of
B, Gudi S, et al. Use of amnion as a graft
conjunctival malignant melanoma and
material in vestibuloplasty: a clinical study. Br
primary acquired melanosis with
J Oral Maxillofac Surg ,2012,50: 545- 549.
Volume - IX Issue - 1 – 2019 107 | P a g e
 46. Gomes M. F., Anjos M. J. D., Nogueira 49. Samandari M. H., Yaghmaei M., Ejlali M.,
T. D., and Guimaraes S. A. C., Moshref M., and Saffar A. S., “Use of amnion
“Histologic evaluation of the as a graft material in vestibuloplasty: a
osteoinductive property of autogenous preliminary report.” Oral Surgery,
demineralized dentin matrix on surgical OralMedicine, Oral Pathology, Oral
bone defects in rabbit skulls using Radiology, and Endodontics, vol. 97, no. 5, pp.
human amniotic membrane for guided 574– 578, 2004.
bone regeneration,” International
Journal of Oral and Maxillofacial 50. Gurinsky B., “Anovel dehydrated amnion
Implants, vol. 16, no. 4, pp. 563–571, allograft for use in the treatment of gingival
2001. recession: an observational case series,” The
Journal of Implant & Advanced Clinical

47. Rinastiti M., Harijadi A. Santoso L. S, Dentistry, vol. 1, pp. 65–73, 2009.

and Sosroseno W., “Histological

evaluation of rabbit gingival wound
healing transplantedwith human 51. Kothiwale S. V., Anuroopa P., and Gajiwala A.

amnioticmembrane,” International L., “A clinical and radiological evaluation of

Journal of Oral and Maxillofacial DFDBA with amniotic membrane versus

Surgery, vol. 35, no. 3, pp. 247–251, bovine derived xenograft with amniotic

2006. membrane in human periodontal grade II

furcation defects,” Cell and Tissue Banking,
vol. 10, no. 4, pp. 317–326, 2009.
48. Guler R., Ercan M. T., Ulutunc¸el N.,
Devrim H., and Uran N.,
52. Wallace S., “Radiographic and
“Measurement of blood flow by the
histomorphometric analysis of amniotic
133Xe clearance technique to grafts of
allograft tissue in ridge preservation: a case
amnion used in vestibuloplasty,”
report,” The Journal of Implant & Advanced
British Journal of Oral
Clinical Dentistry, vol. 2, pp. 49–55, 2010.
andMaxillofacial Surgery, vol. 35, no.
4, pp. 280–283, 1997.

Volume - IX Issue - 1 – 2019 108 | P a g e

 53. Rosen P. S., “Comprehensive
periodontal regenerative care: 57. Shetty S. S., Chatterjee A., and Bose S.,
combination therapy involving bone “Bilateral multiple recession coverage with
allograft, a biologic, a barrier, and a platelet-rich fibrin in comparison with amniotic
subepithelial connective tissue graft to membrane,” Journal of Indian Society of
correct hardand soft-tissue Periodontology, vol. 18, no. 1, pp. 102–106,
deformities,” Clinical Advances in 2014.
Periodontics, vol. 1, no. 2, pp. 154– 58. Gupta I., Gupta R., Gokhale S. T., and Sharma
159, 2011. A., “Placental tissues: fixing smiles,”
International Journal of Innovation and
54. Kothari C.R., Goudar G., Hallur N., Scientific Research, vol. 7, no. 1, pp. 57–62,
Sikkerimath B., Gudi S., and Kothari 2014.
M. C., “Use of amnion as a graft 59. Malak TM, Bell SC (1994) Structural
material in vestibuloplasty: a clinical characteristics of term human fetal membranes:
study,” British Journal of Oral a novel zone of extreme morphological
andMaxillofacial Surgery, vol. 50, no. alteration within the rupture site. Br J Obstet
6, pp. 545–549, 2012. Gynaecol 101: 375-386.
60. Szurman P, Warga M, Grisanti S, Roters S,

55. Suresh D. K. and Gupta A., “Gingival Rohrbach JM, Aisenbrey S, Kaczmarek RT,

biotype enhancement and root Bartz Schmidt KU (2006) Sutureless amniotic

membrane fixation using fibrin glue for ocular
coverage using Human Placental
surface reconstruction in a rabbit model. Cornea 25:
Chorion membrane,” Clinical
460-466.
Advances in Periodontics, vol. 3, no. 4,
pp. 237–242, 2013.

56. Singh H. and Singh H., “Bioactive

amnion as a guided tissue regeneration
(GTR) membrane for treatment of
isolated gingival recession. A case
report,” Indian Journal of Dentistry,
vol. 4, no. 2, pp. 110–113, 2013.
Volume - IX Issue - 1 – 2019 109 | P a g e
 AWARENESS AMONGST THE GYNECOLOGISTS REGARDING THE
ASSOCIATION BETWEEN SEX HORMONAL CHANGES AND
PERIODONTAL HEALTH/DISEASES: A QUESTIONNAIRE SURVEY

*Dr. Dhvani Valvai **Dr. Vasumati Patel ***Dr. Shalini Gupta

****Dr. Vishal Sahayata

ABSTRACT:
Sex hormones play an important role in periodontal health and disease. For example,
puberty, menses, pregnancy, menopause, and oral contraceptives use, influence a
woman’s periodontal health. A survey was conducted among 50 gynecologists who are
practicing in private hospitals. In the form of questionnaire, 16 questions were framed
to evaluate the awareness among the gynecologists about female sex hormones on
periodontal health. 72% of them were aware that sex hormonal changes are correlated
with periodontal disease. Findings showed that most gynecologists were aware and
concerned about female patient’s oral health during various hormonal phases.

Introduction

The mouth serves as a It involves multiple substantial and

mirror to general health status hormonal changes that have a momentous
and also acts as a portal for the impact at the time of pregnancy.2
disease to the rest of the body.1
Oral health during pregnancy has
long been a focus of interest.

*3rd year post-graduate student Corresponding Author:

Dr. Dhvani Valvai (MDS Part 3 PG
**Professor & Head
Student)
***Professor T-6, Balaji Flates-1, Maruti Nagar,
****Lecturer Bamroli road, Godhra.
Department of Periodontics and
Oral Implantology, Faculty of Email: [email protected]
Dental Science, Dharmsinh Desai
University, Nadiad 387002, (M): +91-9537171483
Gujarat
Volume - IX Issue - 1 – 2019 110 | P a g e
 Oral health problems with pregnancy Materials and Methods:
primarily include gingivitis, pregnancy This cross-sectional study was
granuloma, and periodontitis.3-5 Pregnant conducted using a self-administered
women with periodontitis may be at a questionnaire among gynecologists of four
higher risk of preterm birth weight/low different cities Godhra, Santrampur,
birth weight.6,7 Studies showed 18.2% of Lunavada and Nadiad. 50 gynecologists
all preterm low birth weight (PLBW) cases were included in the survey.
may be attributable to the periodontal Questionnaires which included 16
disease.8 Most of the studies have shown questions were distributed to the
that individuals during pregnancy with participants through personal interview
severe periodontal diseases have a greater and were requested to fill the same.
risk to preterm birth and low birth weight.9 Participants were randomly selected and
Avoiding oral health during their assigned the questionnaire which
pregnancy causes many complications. So, contained: (a) Self-perception of
gynecologists should create an inimitable participant’s professional experience, their
opportunity to educate the women type of practice and periodontal health
throughout their pregnancy period. status; (b) assessing knowledge about
Assessment of oral health care at the time periodontal disease etiology and adverse
of pregnancy by gynecologists plays an influences on pregnancy outcome; (c)
important role in the entire issue. participant’s knowledge about periodontal
Gynecologists motivate pregnant women health and correlating it with the
to maintain good oral health and it pregnancy outcomes. Questionnaires
provides good welfare of mother as well as included multiple choice questions and yes
an opportunity to decrease adverse or no. Results on continuous
pregnancy outcomes10. So, together with measurements are presented on the
dental and medical practitioners should mean±standard deviation (Min-Max) and
recognize oral health care as an integral results on categorical measurements are
part of the overall prenatal care. Hence, it presented in number (%).
becomes important to evaluate the
knowledge of medical health professionals Statistical analysis:
about periodontitis and its association with Statistical analysis was performed
adverse pregnancy outcomes. using statistical univarient analysis
software. Gynecologist responses and
opinions regarding their clinical practice

Volume - IX Issue - 1 – 2019 111 | P a g e

 were calculated by qualitative analysis. experience their periodontal health status
Both univariant and multivariate analyzes and correlation of participants
are used according to sex, professional
Fisher man exact test and Chi-square test. Results:
Table 1 explains self-perception of
Standard backward P values were used to
professional experience, regarding given
compare the multiple variables. The
questions among 50 respondents. 50 out of
degree of significance was fixed to P =
50 gynecologists answered “YES”
0.05, and analysis of the results is
regarding the question “Is good oral
hygiene necessary for good
h e a l t h ?”

SR NO QUESTIONS YES NO YES NO

% %
1 Is good oral hygiene necessary for good health? 50 0 100 0%
%
2 Is there an association between oral disease and general 50 0 100 0%
health? %
3 During menstruation are there any problems in the 11 39 22% 78%
teeth /gums?
4 Do pregnant women complain of problems in their 27 23 54% 46%
teeth/ gums more often than other individuals?
5 Are pregnant women more susceptible to bleeding 24 26 48% 52%
from gums?
6 Do pregnant women complain of teeth mobility more 13 37 26% 74%
often than other individuals during the gestational
period?
7 Do pregnant women often complain of swelling/ any 20 30 40% 60%
unusual growth in the gums?
8 Any additional, oral hygiene maintenance necessary 39 11 78% 22%
during their pregnancy?
9 Can the dental treatment be carried out during 44 6 88% 12%
pregnancy?
10 Is local anesthesia with vasoconstrictors safe in 43 7 86% 14%
pregnancy?
11 Do gum infections during pregnancy result in the 34 16 68% 32%
preterm low birth weight deliveries?
Volume - IX Issue - 1 – 2019 112 | P a g e
 12 Do pregnant women need additional periodontal health 38 12 76% 24%
care during their gestations period to prevent adverse
pregnancy outcome?

13 Advising the patient to delay a visit to the dentist until 4 46 8% 92%

after pregnancy?
14 How much %(percentage) you refer the female patients 19 31 38% 62%
with puberty, pregnancy, menstruation, menopause and
oral contraceptive therapy to the periodontist for dental
concern in a month from your routine OPD?
15 What do you believe; gingival change (during these 33 17 66% 34%
various phases) needed treatment?
16 Which trimester is the safest for dental treatment? 2nd 3rd 2nd 3rd

30 20 60% 40%

Table 1: Shows how many gynecologists gave answers (“YES” or “NO”) and also shows
percentage of 16 answers (“YES” or “NO”) of 16 different questions.

Periodontal awareness among the comparison of answers of 16 questions.

gynecologists was detailed in Table 1. All Fewer gynecologists (11) noticed that

gynecologists correctly understand that there are problems in teeth/gums during

periodontal diseases are related with oral menstruation. Interestingly 27

as well as systemic inflammation and gynecologists’ opinioned, pregnant women

infection. 24 participants agreed that, complained in their teeth/ gums more often

gingival bleeding is the clinical signs of than other individuals. 39 of participants

periodontal disease. 13 of the participants estimated that there is a need of additional

opinioned, tooth mobility as a clinical sign treatment during pregnancy. Most of the

of the periodontal diseases. Table 1 also participants (44) believed that dental

explains the percentage of answers. Along treatment can be done during pregnancy.

with this 40% of participants believed 43 of them considered local anesthesia

gingival overgrowth as oral symptoms in with vasoconstrictors safe in pregnancy.

pregnant women. In addition, 68% 17 of respondents had never referred the

gynecologists’ opinioned that, periodontal patient for a dental checkup.

diseases cause preterm birth in pregnancy

50% of them believed that there is an The univariant analysis at the time of

association between Oral disease and finding out the influence of pregnancy on

general health. Bar diagram 1, 2 describes periodontal diseases showed that there is

Volume - IX Issue - 1 – 2019 113 | P a g e

 significant difference between participants professional experience at 5% showed
who are diagnosed and not diagnosed with there is significant difference pertaining to
the periodontal disease at 1° level of the oral health related information was
significance with 1° of freedom, hence P < given to the patient with a degree of
0.05. With regard to professional freedom 1 (P < 0.05). The importance of
experience, participants showed there is an periodontal care during pregnancy showed
insignificant difference between less than there is insignificant difference between
10 years and more than 10 years of 1% participants diagnosed with
professional experience at 5% level of periodontal disease and non-diagnosed
significance with 1 degree of freedom, with periodontal disease (P > 0.05). In
hence P > 0.05. Influence of periodontal another different study, regarding the
disease on pregnancy outcomes shows importance of periodontal care during the
there is significant Difference between, pregnancy showed that there is significant
diagnosed with the periodontal disease and difference between private and
non-diagnosed with periodontal disease government hospital practitioner,
about the periodontal status at 1% level of participants with a different type of
significance with 1 degree of freedom with practices 2 degrees of freedom (P <
P < 0.05. In addition, there is a significant 0.05)18.
difference between greater than 10 years
and less than 10 years of professional
experience at 1% level of significance with
1 degree of freedom with P < 0.05.
Multivariate analysis showed there is a
significant difference between the type of
practices at 1% level of significance with 2
degrees of freedom (P < 0.05). Oral
health-related information given to the
patient showed a significant difference
between diagnosed and non-diagnosed
periodontal disease with a 1% level of
significance with 1 degree of freedom
shows (P < 0.05). In addition, with regard
to the professional experience greater than
10 years and less than 10 years of

Volume - IX Issue - 1 – 2019 114 | P a g e

 50
50

45 45

40
40

35
35
30

30
25

20 25
YES YES
15 NO NO
20

10

15
5

0 10
QUESTION 6
QUESTION 7
QUESTION 8
QUESTION 1
QUESTION 2
QUESTION 3
QUESTION 4
QUESTION 5

0
QUESTION 9
QUESTION 10
QUESTION 11
QUESTION 12
QUESTION 13
QUESTION 14
QUESTION 15
QUESTION 16

Bar diagram 1: Describes the Bar diagram 2: Describes the

comparison of answers (“YES” or comparison of answers (“YES” or
“NO”) of 1-8 questions out of 16 “NO”) of 9-16 questions out of 16
questions questions

Volume - IX Issue - 1 – 2019 115 | P a g e

 Discussion: the present study, 68% gynecologists

This study indicates an awareness opinioned that periodontal diseases cause

of the association between periodontal preterm birth in pregnancy. Rocha et al.13
diseases and pregnancy outcomes among who is members of Brazilian Federation of
gynecologists. 50 respondents were chosen Gynecology and Obstetrics, did study on
for this study from Gujarat state. Among gynecologists, and results showed that
50 subjects, 100% of them were having 61% of the gynecologists were aware
knowledge that, good oral hygiene is about the influence of periodontal diseases
necessary for good health and there is an on pregnancy and that it causes preterm
association between oral disease and birth. This result was consistent with those
general health. McCann AL in 20011 did a reported in other studies.10,14-17 However,
study regarding “Maintaining women’s according to Tarannum et al. less numbers
oral health” and had a result that 100% of in the study reflect whose awareness or
them knew that; there is an interrelation attitude is not easily discernable.
between oral disease and general health. Participant’s answers to the question might
Annan in 20053 also did the same study indicate a lack of awareness of the
and got 95% results for same. 48% of association or it might reflect their
participants identified gingival bleeding as disagreement with the association despite
the clinical signs of periodontal disease in being aware of the evidence. This
this study. In other study,Tarannum et al.12 difficulty in distinction is inherent in
concluded that 50% of them were aware of survey-type studies, so they attempted to
clinical signs. In central North Carolina, frame the question to reflect awareness,
Page RC4 concluded 56% were aware that i.e., is there an association between
bleeding gums were the clinical signs in periodontal diseases and PLBW infants”
pregnancy. Rai et al.6 showed 51% of them rather than attitude, i.e., “Do you believe
were aware of clinical signs associated there is an association between periodontal
with periodontal disease in the general diseases and PLBW infants,” and results
population and pregnant women such as were considered more likely to reflect
gingival bleeding. Interestingly, they had awareness in his study.
also noted tooth loss, caries and alveolar This study showed (66%) gynecologists’
bone destruction as clinical signs opinioned that dental treatment is needed
associated with periodontal disease. This in pregnancy. 100% of participants
indicates participants were not aware of estimated that there is a possible
the pathogenesis of periodontal disease. In connection between the health

Volume - IX Issue - 1 – 2019 116 | P a g e

 of the teeth, gum, and pregnancy. McCann teeth/ gums more often than other
AL in 20011 did a study named individuals, because of lack of knowledge.
“Maintaining women’s oral health” and Moreu et al.9 in his study said that, 72%
had a result that 58.5% of them were gynecologists agreed that local anesthesia
having knowledge that, dental problems with vasoconstrictors is safe in pregnancy.
should be treated in pregnancy. On the In this study, 86% of participants knew
contrary, Page RC concluded in his study that local anesthesia with vasoconstrictors
that 64% gynecologists do not agree that is safe in pregnancy. There is no risk to the
dental treatment should be carried out fetus during the first trimester;
during pregnancy because they believe the pregnant mother may experience an
that, it is not safe and can lead to adverse increasing level of discomfort. So,
effects during pregnancy4. Hormonal it is safe to perform routine dental
changes lead to change in the microflora of treatment in the 2nd trimester, but from the
an oral cavity. In pregnancy, there are few third trimester routine dental
inflammatory changes like bleeding and treatment should be avoided. In this study,
swollen gums, plaque accumulation etc. 60% of participants said that 2nd trimester
occurs in an oral cavity. In this study, 78% is the safe period for dental treatment and
of participants answered positively that, 40% of the participants said that dental
“Any additional, oral hygiene maintenance procedure should be carried out in the only
is necessary during pregnancy?” And 54% 3rd trimester. In the present study, about
of them knew that pregnant women have 38% of participants suggested female
complained of problems in their teeth/ patients to visit the dental clinic when they
gums more often than other individuals. are at risk but not regularly. These results
Offenbacher S et al.8 also got the similar may indicate a strong need for
results, in their study 78.5% gynecologists interdisciplinary communication and
knew that additional maintenance is coordination to declare the provision of
required in pregnancy and 44% sufficient health care to pregnant females.
participants had knowledge that pregnant 62% of respondents never refer the patient
women have complained of problems in for a dental checkup. Cohen et al.11 found
their teeth/ gums more often than other that in his study 97.4% of them showed
individuals. But Krejci CB2 in his study consideration of dental treatment during
said that during his survey only 15% of pregnancy, 55.8% showed consideration
gynecologists knew that pregnant women when they are at risk. 66% of them refer
have complained of problems in them the patient for dental check. Rocha et al.13

Volume - IX Issue - 1 – 2019 117 | P a g e

 found that in Brazil, 58% of them pregnancy outcomes, especially in patients
systematically refer the patients to dental with severe periodontal disease.
care. According to Strafford et al.,10 64%
References:
of obstetricians reported that dental care
1. 1McCann AL, Bonci L.
was important to routine prenatal care,
Maintaining women’s oral
only 49% performed oral health
health. Dent Clin North Am
evaluations. Only 40% of them were
2001;45(3):571-601.
encouraged to seek dental care by health-
care professionals during pregnancy. Some
of the other studies showed many patients 2. Krejci CB, Bissada NF.
do not seek and are not advised to seek Women’s health: Periodontitis
routine dental care as part of their prenatal and its relation to hormonal
care.18, 19
Periodontal knowledge among changes, adverse pregnancy
the Gujarat gynecologists could be outcomes and osteoporosis.
considered as predictable. Clinical Oral Health Prev Dent
behavior regarding oral and periodontal 2012;10(1):83-92.
health did not correlate with such
knowledge. Therefore, training 3. Annan B, Nuamah K. Oral
gynecologists on how to provide a visual pathologies seen in pregnant
screening for oral health problems is also and non-pregnant women.
recommended. For practicing Ghana Med J 2005;39(1):24-7.
gynecologists, continuing education
courses on periodontal disease and
4. Page RC, Kornman KS. The
systemic conditions could be developed by
pathogenesis of human
the dental community in the Gujarat state.
periodontitis: An introduction.
Providing oral health referral sources to
Periodontol 2000 1997; 14:9-
gynecologists helps in referring pregnant
11.
women to oral health care that might
facilitate the process for better oral health
5. American Academy of
care for pregnant women and reduce
Periodontology. The
adverse pregnancy outcomes. Systematic
Pathogenesis of Periodontal
referral to the dentist during pregnancy can
Diseases, Chicago: The
cause a decrease incidence of negative
American Academy of
Periodontology; 1999.
Volume - IX Issue - 1 – 2019 118 | P a g e
 perceptions about dental care
6. Rai B, Kharb S, Anand SC. Is
during pregnancy. J Matern
periodontal disease a risk factor
Fetal Neonatal Med
for onset of preclampsia and
2008;21(6):63-71.
fetal outcome? Adv Med Dent
Sci 2008; 2:16-9.
11. Cohen L, Schaeffer M,
Davideau JL, Tenenbaum H,
7. American Academy of
Huck O. Obstetric knowledge,
Periodontology, Committee on
attitude, and behavior
Research, Science and Therapy.
concerning periodontal diseases
Periodontal Disease as a
and treatment needs in
Potential Risk Factor for
pregnancy: Influencing factors
Systemic Diseases, Chicago:
in France. J Periodontol
The American Academy of
2015;86(3):398-405.
Periodontology; 1998.

12. Tarannum F, Prasad S,

8. Offenbacher S, Katz V, Fertik
Muzammil, Vivekananda L,
G, Collins J, Boyd D, Maynor
Jayanthi D, Faizuddin M.
G, et al. Periodontal infection as
Awareness of the association
a possible risk factor for
between periodontal disease and
preterm low birth weight. J
pre-term births among general
Periodontol 1996;67 10
dentists, general medical
Suppl:1103-13.
practitioners and gynecologists.
Indian J Public Health
9. Moreu G, Téllez L, González- 2013;57(2):92-5.
Jaranay M. Relationship
between maternal periodontal
13. Rocha JM, Chaves VR,
disease and low-birth-weight
Urbanetz AA, Baldissera Rdos
pre-term infants. J Clin
S, Rösing CK. Obstetricians’
Periodontol 2005;32(6):622-7.
knowledge of periodontal
disease as a potential risk factor
10. Strafford KE, Shellhaas C, for preterm delivery and low
Hade EM. Provider and patient birth weight. Braz Oral Res
2011;25(3):248-54.
Volume - IX Issue - 1 – 2019 119 | P a g e
 18. Mangskau KA, Arrindell B.
14. Agueda A, Ramón JM, Manau Pregnancy and oral health:
C, Guerrero A, Echeverría JJ. Utilization of the oral health
Periodontal disease as a risk care system by pregnant women
factor for adverse pregnancy in North Dakota. Northwest
outcomes: A prospective cohort Dent 1996;75(6):23-8.
study. J Clin Periodontol
2008;35(1):16-22. 19. Wasylko L, Matsui D,
Dykxhoorn SM, Rieder MJ,
15. López NJ, Smith PC, Gutierrez Weinberg S. A review of
J. Higher risk of preterm birth common dental treatments
and low birth weight in women during pregnancy: Implications
with periodontal disease. J Dent for patients and dental
Res 2002;81(1):58-63. personnel. J Can Dent Assoc
1998;64(6)

16. Gibbs RS. The relationship

between infections and adverse
pregnancy outcomes: An
overview. Ann Periodontol
2001;6(1):153-63.

17. Muwazi L, Rwenyonyi CM,

Nkamba M, Kutesa A, Kagawa
M, Mugyenyi G, et al.
Periodontal conditions, low
birth weight and preterm birth
among postpartum mothers in
two tertiary health facilities in
Uganda. BMC Oral Health
2014; 14:42.

Volume - IX Issue - 1 – 2019 120 | P a g e

 PERIODONTAL DISEASE-SYSTEMIC DISEASE INTER-
RELATIONSHIP AWARENESS STUDY
*Dr. Dhwani Patel **Dr. Vasumati Patel ***Dr. Shalini Gupta
****Dr. Hiral Purani *Dr. Dhvani Valvai *Dr. Deesha Chhaya

Abstract:
Aim: To determine the awareness among patients about the inter-relationship between
periodontal and systemic diseases.
Material and method: A survey were conducted among 100 patients aged between 35 to 65
years who visited the Department of Periodontology and Oral Implantology, Faculty of Dental
Science, Dharmsinh Desai University, Nadiad. Assessment form comprised of a questionnaire
having 12 questions framed to evaluate the awareness among patients about periodontal and
systemic diseases inter-relationship.
Results: 100 patients were surveyed. About 69% of them were not aware that periodontal
disease is correlated with systemic diseases like diabetic mellitus, cardiovascular diseases,
hematological disorders, hormonal discrepancies and osteoporosis.
Conclusion: The awareness about the inter-relationship of periodontal and systemic diseases
among patients is very minimal.

Key Words: Periodontal disease, Systemic disease, Diabetes mellitus.

Introduction
For decades, close attention has been Currently, this gap between allopathic
paid by physicians and dentists to their own medicine and dental medicine is quickly
respective fields, specializing in medicine closing, due to significant findings
pertaining to the body and the oral cavity, supporting the association between
respectively. However, recent studies have periodontal disease and various systemic
strongly suggested that oral health may be conditions such as cardiovascular disease,
indicative of systemic health.

*3rd-year Post-graduate student Corresponding Author:

** Professor & Head Dr. Dhwani Patel
*** Professor
B-402, Simandhar Apt; Near Nehru Nagar,
**** Reader
Department of Periodontics and Oral Ichhanath Road, Surat.
Implantology, Email: dhavu.kaku @gmail.com
Faculty of Dental Science, Dharmsinh Desai (M): +91 9033188815
University, Nadiad – 387002 Gujarat

Volume - IX Issue - 1 – 2019 121 | P a g e

 type 2 diabetes mellitus, adverse pregnancy random sampling was done. All patients
outcomes, osteoporosis etc. Significant aged 35-65 years were included in the
effort has brought numerous advances in survey. The information was collected using
revealing the etiological and pathological a self-explanatory questionnaire. Twelve
links between the periodontal disease and questions were chosen to assess the patient's
systemic conditions like cardiovascular health problem and their awareness about
disease, type 2 diabetes, osteoporosis, inter-relationship between periodontal
adverse pregnancy outcome, hematological disease and systemic disease. The nature and
disorders etc. Therefore, there is a reason to purpose of the survey was explained to the
hope that the strong evidence from these patients and written consent was obtained.
studies may guide researchers towards The questionnaires were given to the
greatly improved treatment of periodontal patients during their regular visit to the
infection that would also ameliorate these dental hospital. This questionnaire was
systemic illnesses. It is important for the printed in English as well as a regional
general public to be aware of the association language. Patients were asked about their
between periodontal disease and systemic health status whether they have any systemic
conditions. Hence, a study was planned to problems like diabetes, heart problem, blood
evaluate the awareness of the common disorders, hormonal disease, and bone
people about the inter-relationship of the disease. Few questions were asked regarding
periodontal disease with systemic disease. their awareness, like do they know the oral
disease is an indicator of systemic disease or
Material and methods: not. Whether they have knowledge that

The aim of the study was to diabetic patients can have gum problems and

determine the awareness among patients same way severe gum problems can worsen

about the inter-relationship between glycemic control of the patients. Whether

periodontal and systemic diseases. A cross- they are known to the fact that long-term

sectional survey was conducted among 100 diabetes can increase the severity of gum

patients of all socioeconomic status visiting disease and if treated shows improvement in

the Department of Periodontics and Oral periodontal health and that untreated

Implantology, Faculty of Dental Science, diabetes can lead to worsening of

Dharmsinh Desai University. A simple periodontal health and loosening of teeth.

Volume - IX Issue - 1 – 2019 122 | P a g e

 Not only about diabetes, but they were also did not know that periodontal disease is an
asked questions about pregnancy, heart indicator of systemic disease (Chart - 1).
problems, bone disorders and hematological Only 21% were aware that there is a
disease, like do they know that gum disease correlation between diabetes mellitus and
is common during pregnancy and regular periodontal disease. 64% of patients did not
visit to the dentist is necessary during that know anything and 15% believed that there
period. Are they aware of the fact that gum isn't any correlation (Chart - 2). As shown in
problems lead to heart problem or whether (Chart – 3) 73% patients did not know that
blood disorders have any impact on gum diabetes increases the severity of periodontal
disease or have they ever noticed any bone disease. Only 9% of patients knew that
disease causing loosening of teeth? Three periodontal problem will worsen diabetes
options – “Yes”, “No” or “Don’t know” (Chart - 4). Treatment of diabetes cures
were given and the patients answered based periodontal disease- this fact was known to
on their knowledge. Then a brief knowledge 72% of patients only (Chart - 5). About 22%
was given to the patient about the correlation of patients had knowledge of the fact that
between periodontal disease and systemic loosening of teeth can occur because of
diseases like diabetic mellitus, diabetes (Chart - 6) and 15% believed that
cardiovascular diseases, hematological diabetes does not cause loosening of teeth.
disorders, hormonal discrepancies and As shown in (Chart - 7), 63% of patients
osteoporosis. were oblivious to the fact that periodontal
disease is common during pregnancy. About

Results: 22% of patients felt that it is necessary to

have a dental opinion during pregnancy
100 patients were taken up for the
whereas 66% of patients had no knowledge
study out of which 11% of patients had
about whether to have a dental opinion or
diabetes mellitus, 27% had heart disease and
not (Chart - 8). As shown in (Chart – 9),
6% had hormonal problems and 1% had
70% of the patients surveyed told they do
bone problems(osteoporosis). Following
not know that cardiovascular disease is
this, a questionnaire was given to the
related to periodontal disease and 25% of
patients to evaluate the awareness regarding
patients had wrong knowledge who
the association between periodontal diseases
answered ‘No’ when asked about the
and systemic diseases. Almost 69% patients

Volume - IX Issue - 1 – 2019 123 | P a g e

relationship between heart problems and gum
disease. Unawareness was there in 72%
patients about the correlation between Will long term diabetes
increase the severity of gum
hematological disorders and periodontitis disease? 73
80
(Chart - 10). 71% of patients participated in
60
the survey were ignorant of the relationship 40
between bone disorders and periodontal 20 13 14
disease and 9% of patients answered “No” to 0
Yes No Don’t know
the same question
(Chart - 11). Chart - 3

Will severe gum problem

Do you know oral disease is an
indicator of systemic disease? worsen diabetes? 76
80
80 69
60
60
40
40
19 12 20 9 14
20
0 0
Yes No Don’t know Yes No Don’t know

Chart - 4
Chart - 1

Do you think treating diabetes

Do you know diabetic patient
will cure gum problem?
will have gum problem? 72
80
80 64 60
60
40
40 15 13
21 15 20
20 0
0 Yes No Don’t know
Yes No Don’t know

Chart - 2 Chart - 5

Volume - IX Issue - 1 – 2019 124 | P a g e

 Will gum problem leads to
heart problem?
Will diabetes cause loosening of 80 70
teeth?
60
80 63 40 25
60
20 4
40 22 15 0
20 Yes No Don’t know
0
Yes No Don’t know
Chart - 9

Chart - 6 Do you think blood disorders

cause gum problem? 72
80
Is gum disease common during
pregnancy? 60
80 63 40
60 17 11
20
40
13 19 0
20
Yes No Don’t know
0
Yes No Don’t know
Chart - 10

Chart - 7

Will bone disease cause

loosening of teeth?
80 71
Do you think regular check up
to dentist is necessary during 60
pregnancy?
40
80 61 20
60 20 9
40 22 0
17
20 Yes No Don’t know
0
Yes No Don’t know Chart - 11

Chart - 8

Volume - IX Issue - 1 – 2019 125 | P a g e

 Discussion: of advanced glycation end products or

Periodontal disease is no longer just bacterial accumulation, respectively, which

about oral health. It is about the entire body. further leads to the production of

It is an immune inflammatory response to inflammatory mediators.2 Porphyromonas

microbial agent resulting from the interplay gingivalis 3, a member of a red complex
between periodontal pathogens and host. have the ability to invade deep vascular
500 different microorganisms are capable of endothelium associated with the
colonizing the oral cavity. Once an periodontium and can be found within
inflammatory lesion in the periodontium is pathological vascular plaques.4,5 The study
established, bacteria from the dental plaque by Grossi et al. indicated that the effective
can invade into the gingival tissue through control of periodontal infection in diabetic
the ulcerated sulcular epithelial lining of patients could improve the level of glycemic
periodontal pockets and then disseminate control.6 Efforts should be directed at
into the systemic circulation causing preventing periodontitis in patients who are

systemic disorders.1 Conversely, certain at the risk of diabetes, as well as in those

systemic disorders and conditions alter host patients with poor metabolic control.

tissues and physiology, which may impair Prevention and control of periodontal

host barrier integrity and host defense to disease must be considered an integral part

periodontal infection, resulting in a more of diabetes control.7,8,9 Taylor et al. reported

destructive disease. So, it is important to that severe periodontitis presents six times

know the two-way relationship between greater risk of a poor glycemic control

systemic and periodontal disease. Diabetes during a recall. Bangash et al.10 conducted a
mellitus is a metabolic disorder study among diabetic patients and concluded

characterized by hyperglycemia due to that 64% of patients knew the oral

defective secretion or activity of insulin. As complication of diabetes which is not in

diabetes is a metabolic disorder and accordance with this study. Preterm low

periodontal disease is an infectious disease birth weight (PLBW), is a birth weight of

of the oral cavity, the pathophysiological less than 2500g with a gestational age of

relationship between these two entities is lesser than 37 weeks. Buduneli et al. study

through the ability of both conditions to suggested that periodontal disease had a

induce an inflammatory response, because contributory role in PLBW.11 In a study by

Volume - IX Issue - 1 – 2019 126 | P a g e

 Zeba Rehman Siddiqui et al.12 less than 20% mediators in response to infection with
of people knew that periodontal disease can atherogenic effects.18 Investigating this by
be a cause of low birth weight babies which sampling carotid atheromatous plaques,
is in accordance with the study done by Cairo et al. detected T. Forsynthensis DNA
Nasir et al.13 which was conducted among in 79%, F. Nucleatum in 63%, P. Intermedia
the medical interns. In this study, 63% of in 53%, P. Gingivalis in 37%, and A.
patients were not aware that periodontal Actinomycetemcomitans in 5% of the
disease is common during pregnancy. samples from carotid atheroma patients.19
Habashneh et al.14 concluded that awareness P.Gingivalis have demonstrated the ability
on periodontal disease affecting pregnancy to interact with the endothelial surface and
outcomes was 36.1% which is less when to induce smooth-cell proliferation, causing
compared with a study done by Tarannum and damage and impairing the vasomotor
15
Faizuddin which was 54%. Fusobacterium functionality of the endothelial cells.20,21,22
nucleatum, a gram-negative anaerobe Arpita Gur found only 16% and 12%
ubiquitous to the oral cavity, was isolated respondents were aware that the periodontal
from amniotic fluid, placenta, and disease may be the possible risk factor for
chorioamnionic membranes of women coronary heart disease and cerebral
16
delivering prematurely. Case-control and infarction respectively.23 Similar results
prospective studies have shown preliminary were found by Zeba Rehman Siddiqui et
evidence of the treatment of periodontal al.12 in their study. In a study by AS
17
disease as a method for preventing PLBW. Anandakumar, 46.7% of medical practitioners
Cardiovascular disease is a common cause were not aware that antihypertensive drugs
of death, accounting for 29% of deaths cause gingival enlargement.24 Periodontal
worldwide.3 In this study, only 4% of diseases is characterized by the resorption of
patients were aware of the correlation a bone and the loss of soft tissue attachment
between cardiovascular diseases and of the tooth. Due to the commonality of
periodontal diseases. Etiologically, the bone loss between periodontal disease and
chronic presence of periodontal microbes osteoporosis the outcomes of both are
can lead to atherogenesis via two pathways: similar. Oral osteopenia and systemic
4
1) Direct invasion of the arterial wall and 2) osteopenia share risk factors including age,
The release of systemic inflammatory estrogen deficiency and smoking.25

Volume - IX Issue - 1 – 2019 127 | P a g e

 According to the result of Meenakshi et al, Conclusion:
75% of patients participated in the survey Periodontal disease is an associated
were not aware of the relationship between risk factor for various systemic diseases like
bone disorders and periodontal disease.26 In diabetes, cardiovascular disease,
this study only 20 % of patients had osteoporosis, adverse pregnancy outcomes
knowledge that bone disease can cause etc. Many types of researches and studies
loosening of teeth. Periodontal health is of have been conducted to establish the
critical importance in patients with bleeding relationship between periodontal disease and
disorders as inflamed and hyperemic systemic diseases. The awareness about the
gingival tissues are at increased risk of inter-relationship among patients is very
bleeding.27 Periodontitis may cause tooth minimal. Awareness should be spread
mobility and warrant extraction, which may among the public and steps should be taken
be a complicated procedure in patients with to prevent the periodontal disease, thereby
bleeding disorders. Patients with reducing the prevalence of systemic
hematological disorders may neglect their diseases.
oral health due to fear of bleeding during
tooth brushing and flossing, which leads to References:
increased gingivitis, periodontitis and caries. 1. Tomás I, Diz P, Tobías A, Scully C,
Patients undergoing periodontal treatment Donos N. Periodontal health status
may be at increased risk for bleeding. and bacteraemia from daily oral
Although the incidence of bleeding disorders activities: systematic review/meta-
is low in the general population, a analysis. Journal of Clinical
hemorrhagic episode during or after Periodontology. 2011;39(3):213-
periodontal procedures can lead to 228.
detrimental complications and can place the 2. Kim J, Amar S. Periodontal disease
patient’s life at risk.28 Meenakshi et al, and systemic conditions: a
found 84% of the study population did not bidirectional relationship.
know hematological disorders are correlated Odontology. 2006;94(1):10-21.
with the periodontitis.26 In this study 72% of 3. Amar S, Han X. The impact of
the population were unaware of the same. periodontal infection on systemic

Volume - IX Issue - 1 – 2019 128 | P a g e

 diseases. Med Sci Monit 2003; 9(12): patients with type 2 diabetes
291-299. mellitus. Journal of Clinical
4. Haraszthy V, Zambon J, Trevisan M, Periodontology. 2001;28(4):306-10.
Zeid M, Genco R. Identification of 9. Offenbacher S, Salvi G. Induction of
Periodontal Pathogens in Prostaglandin Release from
Atheromatous Plaques. Journal of Macrophages by Bacterial
Periodontology. 2000;71(10):1554- Endotoxin. Clinical Infectious
1560. Diseases. 1999;28(3):505-513.
10. Bangash YR, Khan Rasheed D,
5. Chun YH, Chun KR, Olguin D, Manzoor MA. Diabetes patients’
Wang HL. Biological foundation for level of awareness about oral health
periodontitis as a potential risk factor knowledge, attitude, and practices.
for atherosclerosis. J Periodontol Res Pakistan Oral and Dental Journal.
2005; 40: 87-95. 2011;31(2):292-595.
6. Grossi SG, Zambon JJ, Ho AW, 11. Buduneli N, Baylas H, Buduneli E,
Koch G, Dunford RG, Machtel EE, Turkoglu O, Kose T, Dahlen G.
et al. Assessment of risk for Periodontal infections and pre-term
periodontal disease. I. Risk low birth weight: a case-control
indicators for attachment loss. J study. Journal of Clinical
Periodontol 1994; 65:260-267. Periodontology. 2005;32(2):174-
7. Christgau M, Palitzsch K, Schmalz 181.
G, Kreiner U, Frenzel S. Healing 12. Zeba Rahman Siddiqui, Vivek
response to non-surgical periodontal Gupta, Vivek Kumar Bains, Rajesh
therapy in patients with diabetes Jhingram, Ruchi Shrivastava and
mellitus: clinical, microbiological, Rohit Madan. Awareness of systemic
and immunologic results. Journal of disease and periodontal disease inter-
Clinical Periodontology. relationship amongst the general
1998;25(2):112-4. people of Lucknow: A Cross-
8. Stewart J, Wager K, Friedlander A, sectional Survey. Asian journal of
Zadeh H. The effect of periodontal oral health and Aliied sciences.
treatment on glycemic control in 2014;4(2):32-8.

Volume - IX Issue - 1 – 2019 129 | P a g e

 13. Nasir N. Ali S, Ullah U. Extent of Birth Weight in Women With
awareness regarding systemic effects Pregnancy-Associated Gingivitis.
of periodontal disease among Journal of Periodontology.
medical interns. Ann Pak Inst Med 2005;76(11-s):2144-2153.
Sci. 2013; 9(4):188-190. 18. Loos B, Craandijk J, Hoek F, Dillen
14. Al Habashneh R, Khader Y, P, Velden U. Elevation of Systemic
Hammad M, Almuradi M. Markers Related to Cardiovascular
Knowledge and awareness about Diseases in the Peripheral Blood of
diabetes and periodontal health Periodontitis Patients. Journal of
among Jordanians. Journal of Periodontology. 2000;71(10):1528-
Diabetes and its Complications. 1534.
2010;24(6):409-414. 19. Cairo F, Gaeta C, Dorigo W,
15. Tarannum F, Prasad S, Muzammil, Oggioni M, Pratesi C, Pini Prato G et
Vivekananda L, Jayanthi D, al. Periodontal pathogens in
Faizuddin M. Awareness of the atheromatous plaques. A controlled
association between periodontal clinical and laboratory trial. Journal
disease and pre-term births among of Periodontal Research.
general dentists, general medical 2004;39(6):442-446.
practitioners and gynecologists. 20. Khlgatian M. Fimbria-Dependent
Indian Journal of Public Health. Activation of Cell Adhesion
2013;57(2):92-95. Molecule Expression in
16. Han Y, Redline R, Li M, Yin L, Hill Porphyromonas gingivalis-Infected
G, McCormick T. Fusobacterium Endothelial Cells. Infection and
nucleatum Induces Premature and Immunity. 2002;70(1):257-267.
Term Stillbirths in Pregnant Mice: 21. Schächinger V, Britten M, Zeiher A.
Implication of Oral Bacteria in Prognostic Impact of Coronary
Preterm Birth. Infection and Vasodilator Dysfunction on Adverse
Immunity. 2004;72(4):2272-2279. Long-Term Outcome of Coronary
17. López N, Da Silva I, Ipinza J, Heart Disease. Circulation.
Gutiérrez J. Periodontal Therapy 2000;101(16):1899-1906.
Reduces the Rate of Preterm Low

Volume - IX Issue - 1 – 2019 130 | P a g e

 22. Amar S, Gokce N, Morgan S, 27. Patton LL. Bleeding and clotting
Loukideli M, Van Dyke T, Vita J. disorders. In: Burket’s oral medicine:
Periodontal Disease Is Associated diagnosis and treatment. 10th ed.
With Brachial Artery Endothelial Hamilton: BC Decker; 2003. 454–
Dysfunction and Systemic 477.
Inflammation. Arteriosclerosis, 28. Shapiro N. When the Bleeding
Thrombosis, and Vascular Biology. Won’t Stop: A Case Report on a
2003;23(7):1245-1249. Patient with Hemophilia. The
23. Gur A, Majra J. Awareness regarding Journal of the American Dental
the systemic effects of periodontal Association. 1993;124(12):64-67.
disease among medical interns in
India. J Glob Infect Dis.
2011;3(2):123-127.
24. Amaranath J, Mishra S, Gupta R,
Srivastav R, Arora P, Kanodia S Et
al. Periodontal Disease and Its Bi-
Directional Relationship with
Systemic Disease: A Survey among
Medical Interns and Graduates.
Annals of International medical and
Dental Research. 2017;3(6):38-41.
25. Genco RJ, Grossi SG. Is estrogen
deficiency a risk factor for
periodontal disease? Compend
Contin Educ Dent Suppl 1998; 22:
23-29.
26. Meenakshi priyanka, jaiganesh
ramamurthy. Periodontal disease-
systemic disease inter-relationship
Questionnaire study. Int J Pharm Bio
Sci 2015; 6(3):16-21.

Volume - IX Issue - 1 – 2019 131 | P a g e

 SOFT TISSUE MANAGEMENT IN ORAL IMPLANTOLOGY

*Dr. Shaili Ganatra ** Dr. Somil Mathur *** Dr. Rakesh Makwana
****Dr.Nidhi Jathal *****Akanksha Dwivedi

Abstract
In the modern history of dental implants, the focus was to achieve osseointegration
however this has changed over a period of time. A soft tissue seal with structures around the
implants may contribute to protect the structural durability, functional harmony and aesthetics
of the tissues around the implant. An association exists between bone and soft tissue
preservation around implants, and this has a direct influence on aesthetics. The final outcome is
the result of a number of important parameters ranging from the periodontal to the prosthetic
point of view.

Key words: Dental implants, peri-implant soft tissue, grafting, guided tissue regeneration,
platform switching

INTRODUCTION
The goal of modern dentistry is to creation of the lost hard and soft tissues.
restore the patient to normal contour, The soft tissue that surrounds the dental
function, aesthetics, speech and health. implants is termed as the peri-implant
What makes implant dentistry unique is its mucosa. To the maximum possible extent,
ability to achieve this goal regardless of the the peri-implant soft tissue should have the
atrophy disease or injury of the same characteristic morphology as that of
stomatognathic system. The objective of the tissue surrounding the natural tooth
implant therapy has expanded from mimicking the architecture of the soft tissue
functional restoration of the missing around natural teeth.
dentition to include the re-

*3rd year postgraduate student Corresponding Author Name:

**Professor and Head of the Department Dr. Shaili Ganatra

***Reader****Senior Lecturer*****Senior Address of Correspondence:

LecturerDepartment of Prosthodontics, Faculty of Dental Science,

Crown and Bridgework and Oral Dharmsinh Desai University,

Implantlogy, Faculty of Dental Science, College Road, Nadiad. 387001, Gujarat.

Dharmsinh Desai University, Nadiad. [email protected] (M)+9197246234

Volume - IX Issue - 1 – 2019 132 | P a g e

 It is essential to recreate the volume of the
soft tissues which should appear in harmony The use of tissue punch in aesthetic implant
with the dental restoration. Hence this paper therapy is primarily indicated for exposure of
reviews biologic events associated with a submerged implant when the volume and
healing of the soft tissue for the architecture of the peri-implant soft tissue are
management of soft tissues in implant already ideal in area critical for prosthetic
therapy. emergence. This tissue punch is available in
a variety of sizes to accommodate various
MINIMALLY INVASIVE FLAP implants. 3
TECHNIQUES:
Papilla preservation flaps proposed
by Sclar in 2003 suggested that when mesial SURGICAL TISSUE GRAFTING AND
and distal papilla are present, they should be AUGMENTATION TECHNIQUES
left intact by giving a bevelled peri- crestal AROUND IMPLANTS 𝟒:
incision with facial vertical release incisions Dhir S and George P in suggested the
short of the muco-gingival junction, joining following surgical tissue grafting and
the crestal incision. This kind of technique augementation techniques.
increases the surface area for flap
coaptation, decreases the dehiscence of 1. Apically positioned flap /
wound margins and dramatically improves Vestibuloplasty (APF/V)
incision line aesthetics. 1 2. Free Gingival Graft (FGG)
The Curvilinear incision advocated by 3. Inter-positional Free Gingival Graft
Miller PD Jr in 1988 used the curvilinear 4. Sub-epithelial Connective Tissue Graft
incisions which allow a greater volume of (SCTG)
mucosal tissues to be incorporated in a flap, 5. Modified palatal roll technique
improving its overall elasticity. This 6. Vascularised Inter-Positional
facilitates passive flap coaptation and
Periosteal Connective Tissue Flap (VIP-
coronal advancement over a large volume of
CT)
hard and soft tissue grafts, without the
7. Papilla Regeneration
embarrassment of circulation to the flap
8. Modification of Soft Tissue
margin. It is easily camouflaged and
Augmentation Techniques
becomes less conspicuous with time
9. Combined techniques
compared to a linear incision. 2
The U-peninsula flap suggested by Miller PROSTHETIC CONSIDERATIONS
PD Jr in 1988 advocated the palatal or Implant position:
lingual based U-shaped peninsula flap for According to Kois. J the mesio-distal
access to an aesthetic implant site, when
position should be 1.5–2.0 mm between a
visualisation of the buccal aspect of the
alveolar ridge for tissue augmentation is tooth and an implant, and 3 mm between
unnecessary. Incisions through the buccal adjacent implants; 3.5–4.5 mm between the
tissues are avoided to minimize scarring and
upper central incisors. The bucco- lingual
to avoid soft tissue recession at the site by
preserving circulation and soft tissue position should be 2–3 mm inside from the
volume. 2 line joining the adjacent gingival margins

Volume - IX Issue - 1 – 2019 133 | P a g e

 and the apico-coronal position: 3 mm increases the horizontal component of the
apically from the gingival margin of the biological width, induces maintenance of the

implant site.5 Repeated connections and horizontal and vertical height of the

disconnections of healing or implant mesiodistal papilla, decreases cervical bone

abutments at different stages of surgery or resorption to the usual minimum amount of

prosthetic execution are the cause of the bone loss as far as the first thread of the

trauma of soft tissue attachment, which implant.

results in disruption of the bond between the

epithelial attachment and the connective PROVISIONAL AND FINAL

tissue, and in bacterial colonization that RESTORATION:

induces bone resorption, followed, in thin The provisional implant restoration

gingival biotypes, by gingival recession plays an essential role in the anterior sector

which can negatively impact soft tissue in the preservation or the shaping and

stability.6This would be particularly formation of peri-implant soft tissue. Clark et

important in the restoration of adjacent al suggested that the definitive restoration is

implants, where clinicians typically delivered following a 4–6-month

are challenged to conserve optimal provisionalization phase11. According to

papilla anatomy in the inter-implant region.7 Kinsel R, the cement line and preparation, it
should be ideally kept flush with the level of
SWITCH PLATFORM CONCEP𝟒𝟒,𝟒 the soft tissue margin at surgery, but it may
Wang et al in 2011 suggested that an later be extended to lie 0.5–1.0 mm
implant design with a platform diameter less subgingival following implant integration.12
than that of the implant body, with a tapered Wilson J conducted a prospective clinical
wall, and with a convergent or sloping study and concluded that clinical and
implant shaped module of the platform endoscopic signs of peri- implant disease are
shoulder, can be considered as the ideal absent in 74% of the test implants after the
implant design for homogenous occlusal removal of excess cement.13
force distribution, prevention of bone loss
around the implant collar and crestal bone,
and improvement of the gingival
aesthetics.10 Platform switching presents
several advantages like supracrestal fibers
are above the bone, implant/abutment
interface is located away from the bone,

Volume - IX Issue - 1 – 2019 134 | P a g e

 CONCLUSION: 3. Talwar B.S. A Focus on Soft Tissue in
Dental Implantology. J Indian
Implant dentistry has been Prosthodont Soc 2012; 12:137–142.
established as a predictable treatment
modality with high clinical success rates.
4. George JP, Dhir S. Soft tissue and
The replacement of missing teeth is only
esthetic considerations around implants. J
one part of the treatment. Another important Int Clin Dent Res Organ 2015; 7, Suppl
aspect of therapy consists of replacing the S1:119-31.
lost portion
5. Kois J, Predictable single-tooth peri-
of the alveolar process and the associated implant esthetics: five diagnostic keys.
soft tissue. The re-establishment of a normal Compend Contin Educ Dent 2004 Nov:
25(11):895- 6, 898, 900.
alveolar contour is a critical step in aesthetic
success. The long-term prognosis of the 6. Shah R, Aras M.Implant Abutment
function and the aesthetics of dental Selection:A Literature Review. Int J Oral
implants can be improved by correctly Implantol Clin Res 2014;5(2):43-49.

classifying alveolar ridge defects, by 7. Abrahamsson I, Lindhe J, Berglundh T.

adhering to proper techniques for alveolar The Mucosal Barrier Following
ridge and soft tissue augmentation, and by Abutment Dis/Reconnection: An
Experimental Study in Dogs. J Clin
ensuring the most appropriate mode of
Periodontol 1997; 24 (8): 568 –572.
implant placement in individual patients.14
All these factors contribute to the major 8. Leziy S, Miller B. Prefabricated Zirconia
Abutments: Surgical Advantages,
success of the implant treatment. However,
Indications and Handling Considerations.
if soft tissue management is not done Quintessence of Dental Technology 2008
appropriately the implant therapy may not ; 1: 68 – 80
give completely successful results.
9. Tabata F, Rocha P, Barao A, Assunçao
WG. Platform Switching: Biomechanical
Evaluation Using Three-Dimensional
Finite Element Analysis. Int J Oral
REFERENCES:
Maxillofac Implants 2011; 26:482 – 491.
1. Sclar AG. Soft tissue and esthetic
considerations in implant therapy. 10. Fu J, Lee A, Wang H. Influence of Tissue
Quintessence Publishing Co 2003 Biotype on Implants Esthetics. Int J Oral
Maxillofac Implants 2011; 26:499– 508.
2. Miller P.D. Regenerative and
Reconstructive Periodontal Plastic 11. Estafanous E, Clark S, Huynh-Ba
Surgery. Dent Clin North Am 1998; G. Platform Switching and Clinical
31:287–306. Science. Int J Oral Maxillofac Implants
2011; 26 (2): 655 – 658.
Volume - IX Issue - 1 – 2019 135 | P a g e
 12. Kinsel R, Capoferri D. A Simplified
Method to Develop Optimal Gingival
Contours for The Single Implant-
Supported, Metal ceramic Crown in the
Esthetic Zone. Pract Proced Aesthet
Dent 2008; 20 (4): 231 – 236.

13. Wilson Jr. G. The Positive Relationship

between Excess Cement and Peri-
Implant Disease: A Prospective Clinical
Endoscopic Study. J Periodontal 2009;
80: 1388 – 1392.

14. Berglund T, Lindhe J, Lang NP, et al.

Mucositis and Peri-Implantitis. In:
Clinical Periodontology and Implant
Dentistry 4th edition: 1014–23.
Blackwell Publishing Co, Munksgaard,
Copenhagen,2003

Volume - IX Issue - 1 – 2019 136 | P a g e

 Milling Procedure in Prosthodontics

*Dr. Manan Shah ** Dr. Somil Mathur ***Dr.Rakesh Makwana

*** Dr. Nidhi Jathal

ABSTRACT
In prosthodontics various indirect restorative methods like casting and heat sintering
procedures were used widely but they have limitations. To overcome these limitations milling
procedure was introduced. It is known as the process of braking down, sizing, separating or
classifying aggregate materials. In milling procedure any restoration can be fabricated by
subtractive manufacturing. Milling machine are classified into two type namely Horizontal
milling machine and Vertical milling machine

Keywords: Subtractive manufacturing, horizontal milling machine, vertical milling machine, dry
milling, wet milling

INTRODUCTION
Prosthodontics is one of the oldest surface roughness, irregularities and
dental specialties and has a long history of porosity1 advancement in the process was a
innovation and adaptability. Various indirect prime requirement. In order to overcome
restorations methods like casting and heat these limitations milling was introduced. In
sintering procedures were used widely but simple words,
due to limitations like distortion,

* 3rd year Post Graduate student, Corresponding Author:

** Professor and Head of the Department, Dr. Manan Shah
*** Reader, Department of Prosthodontics, crown and
****Senior Lecturer, bridgework & oral implantology,
Department of Prosthodontics, crown and Faculty of Dental Science,
bridge- Work & oral implantology, Dharmsinh Desai University,
Faculty of Dental Science, College Road, Nadiad
Dharmsinh Desai University,
Email ID: [email protected]
College Road, Nadiad - 387002
Contact: +91-7990969832

Volume - IX Issue - 1 – 2019 137 | P a g e

 All the milling processes that are to be titanium copings by spark erosion. He
carried out and all the final dimensions are introduced CAD/CAM technology for
fed into the computer via the program. The processing composite veneered restorations.
Milling refers to the process of breaking The Lava CAD/CAM System was
down, separating, sizing, or classifying introduced in 2002. It has been used for
aggregate material. It has advantages like fabrication of zirconia frameworks in all
better accuracy, reduced clinical visits, and ceramic restorations.
marginal integrity.2 computers thus knows
Type and components of milling machine:
what exactly is to be done and the
fabrication of restoration takes place.3 These Most of the milling machines are
restorations can be fabricated by two constructed of a column and knee structure
methods: and they are classified into two main types
namely Horizontal Milling Machine and
1. Subtractive manufacturing
Vertical Milling Machine. The name
2. Additive manufacturing horizontal or vertical is given to the machine
Historical Background: by virtue of its spindle axis. Horizontal
machines can be further classified into Plain
The CAD/CAM technology was
Horizontal and Universal Milling Machine.
introduced by Duret in 1971 however unlike
The main difference between the two is that
today, dental CAD-CAM was not very
the table of a Universal Milling Machine can
popular due to a number of factors that
be set at an angle for helical milling while
included: The cost of the equipment’s and
the table of a Plain Horizontal Milling
the time needed, the precision needed while
Machine cannot perform thus.5 Two types of
recording the details of the site of
milling machine are mainly being used
preparation of the restoration, precision in
the final milling of the accurate Horizontal Milling Machine:
restoration.10 The CEREC 1 system was the
The Horizontal Milling Machine is a
first to be introduced for dental purpose that
very robust and sturdy machine. A variety of
marked a landmark in the mid 1980’s. In
cutters are available to remove or shape the
1987 Dr. Andersson designed the Procera
material that is normally held in a strong
system.3 He attempted fabrication of
machine vice. This horizontal miller is used

Volume - IX Issue - 1 – 2019 138 | P a g e

 when a vertical miller is less suitable. For 3 – Axis milling devices:
instance, if a lot of material has to be
This type of milling device has degrees of
removed by the cutters or there is less of a
movement in the three spatial directions.
need for accuracy - a horizontal milling
Thus, the mill path points are uniquely
machine is chosen.6
defined by the X -, Y -, and Z- values.8
Vertical Milling Machine:
All 3-axis milling devices used in the dental
A vertical milling machine which is field can turn the component by 180° in all 3
of similar construction to a horizontal spatial directions, i.e. X, Y, Z, in the course
milling machine except that the spindle is of processing the inner and the outer
mounted in the vertical position.6 surfaces of the prosthesis.

Types of Milling Procedure: Some examples of 3 axis devices are as

following:8
Milling is the final phase of the
dental CAD/CAM process. It involves 1. in Lab (Sirona, Dentsply, USA)
developing a restoration from a CAD model
2. Lava (3M ESPE, USA)
into a physical part that undergoes
4– Axis milling devices:
processing, finishing, and polishing before
being inserted into the patient’s mouth.7 In this type of device, in addition to the three
spatial axes, the tension bridge for the
The construction data produced with the
component can also be turned infinitely
CAD software is converted into milling
variably.8 As a result, it is possible to adjust
strips for the CAM-processing and finally
bridge fabrications with a large vertical
loaded into the milling device. Processing
height displacement into the usual mold
devices are distinguished by the means of
dimensions. Hence, amount of material as
number of milling axes; which are listed
well as the milling time can be reduced.
thus: -
Some examples of 4 axis devices are as
3-axis devices following:8

4-axis devices 1. Zeno (Wieland-Imes, Germany)

5-axis devices 5 – Axis milling devices:

Volume - IX Issue - 1 – 2019 139 | P a g e

 With a 5-axis milling device there is also, in 1. Zeno 4030 (Wieland- Imes,
addition to the three spatial dimensions and Germany)
the rotatable tension bridge (4th axis), the
2. Lava (3M ESPA, USA) and Cercon
th
possibility of rotating the milling spindle (5 brain (Dentsply, USA)
8
axis).
Wet milling:
Some examples of 5 axis devices are as
Wet milling is also known as Green
following:8
milling. In this process the milling diamond
1. Everest Engine (KaVo, Germany) or carbide cutter is protected by a spray of

2. HSC Milling Device (etkon, cool liquid against overheating of the milled

Germany) material. This kind of processing is

necessary for all metals and glass ceramic
However, it should be noted that the
material in order to avoid damage through
increased quality of the restoration results
heat development. ‘Wet’ processing is
much more from the result of the
recommended, if zirconium oxide ceramic
digitalization, data processing and
with a higher degree of pre-sintering is
production process rather than increasing the
employed for the milling process. A higher
number of processing axes. degree of pre-sintering results in a reduction
of shrinkage factor and enables less sinter
Dry Milling:
distortion.22
The comminution of materials in a
suitablethe presence of a liquid, either by Some illustrations of wet milling are as

rods, balls, or pebbles, or autogenously, by following:

the material itself; used if the subsequent 1. Everest (KaVo, Germany)

process is a. Dry processing is applied
mainly with respect to zirconium oxide 2. Zeno 8060 (Wieland-Imes,
Germany)
blanks with a low degree of pre-sintering.22
Some illustrations of wet milling are as 3. inLab (Sirona, Dentsply, USA)
following:

Volume - IX Issue - 1 – 2019 140 | P a g e

 Applications, Advantages and Limitations Advantages of Milling:7,11-16
of Millig Procedures:
The use of Milling procedures for
Inlays, onlays, veneers, crowns, fixed dental restorations has numerous advantages
dental prostheses, implant abutments, and over traditional techniques. Speed, High
the full spectrum of implant prostheses, precision and accuracy, Application of new
when fabricated via milling procedures materials, Reduced labor, Cost
ensures a restoration with better accuracy, effectiveness, Quality control, Ease of
restorative quality, in term improving the retrieving the data.
life & prognosis of the treatment. The
Limitations of Milling Procedure:9,11,17,18
milling procedure was developed to solve
three challenges. The first challenge was to Time investment to master the
ensure adequate strength of the restoration, technique, initial high cost of CAD/CAM
especially for posterior teeth. The second equipment, Difficulty in recording details
challenge was to create restorations with a with some scanners. However, the
natural appearance. The third challenge was advantages of milling procedures outweigh
to make tooth restorations easier, faster, and these limitations and hence it has emerged
more accurate. In some cases, CAD/CAM as a successful treatment option.
technology provides patients with same-day
The Future of Milling:
restorations.10
Milling devices are expected to
Applications of Milling Procedure:
become increasingly simple and convenient
Procedure in fixed prosthodontics to use. In anticipation of future advances,
the CEREC AC is prepared for voice control
In complete denture prostheses
and voice output. Improvements in
In removable partial denture prostheses technology should avoid some of the back-
and-forth data information between the
In implant prosthodontics
dentist, the manufacturer, and the dental
In fabrication of surgical guides for implant laboratory. There are some areas of
placement: application for which milling is already
applied. In some production centers, so-
In maxillofacial prosthodontics

Volume - IX Issue - 1 – 2019 141 | P a g e

 called ‘laser sintering devices’ are used to References:
produce crown and bridge frames from
1. Kenneth Anusavice. Phillips’ Science of
chrome cobalt alloys. Since the productivity
Dental Materials. 12th edition. Elsevier;
of such devices is very high, dental
2012.
restorations can be produced very cost-
effectively. Basically, geometries are 2. Wimmer T, Gallus K, Eichberger M and

conceivable with this technology that cannot Stawarczyk B. Complete denture

be realized with grinding technology. fabrication supported by CAD/CAM. J

Prosthet Dent 2016; 115:541-546.
Conclusion:
3. Peter Liebhold. Cutting Tool
The introduction of milling in Engineering, October 1990, page 90.
dentistry and its extraordinary speed of
4. Tamakar A, Rathee M, Mallick R,
development in the industry affirms that it is
Dabas S. CAD/CAM in Prosthodontics
being rapidly accepted in the dental
– A futuristic overview. Annals of
profession. It allows application of newer
dental speciality 2014; 2:14-15.
high strength materials with outstanding
5. DeGarmo, E. Paul, et al, “Materials and
biocompatibility combined with adequate
Processes in Manufacturing”, McMillan
mechanical strength, provisions for esthetic
Publishing 2000.
designs and excellent precision of fit and
longevity. However, these advantages must 6. Groover, P. M., "Fundamentals of
be balanced against the high initial cost of Modern Manufacturing", WILEY Inc.,
milling machines and the need for additional 2. International Edition, 2002.
training. The future evolution of milling 7. Miyazaki T, Hotta Y, Kunii J,
procedures in dentistry could be spectacular Kuriyama S, Tamaki Y. A review of
considering its numerous possibilities. Its Dental CAD/CAM: Current status and
application is promising, not only in the future perspectives from 20 years of
field of dental prosthetics, but also in other experience. Dent Mat J 2009; 28:44-56.
fields of dentistry. It provides innovative,
state-of-the-art dental service, and
contributes to the health and the quality of
life in aging societies.

Volume - IX Issue - 1 – 2019 142 | P a g e

 8. Klim J, Corrales EB. Innovation in 15. Tinschert J, Na G, Mautsch W,
Dentistry: CAD/CAM Restorative Spiekermann H, Anusavice KJ.
Procedures J Prosthet Dent 2012; 6:1- Marginal fi t of alumina-and zirconia-
15. based fixed partial dentures produced by
a CAD/CAM system. Oper Dent 2001;
9. Beuer F, Schweiger J, Edelhoff D.
26:367-74.
Digital dentistry: An overview of recent
developments for CAD/CAM generated 16. Birnbaum N, Aaronson H, Cohen B. 3D
restorations. British Dental Journal digital scanners: A high-tech approach
2008; 204:505-511. to more accurate dental impressions.

10. Van Noort R. The future of dental Inside dentistry 2009; 5:70-77.

devices is digital. Dent Mater 2012; 17. Alghazzawi T. Advancements in

28:3–12. CAD/CAM technology: Options for
practical implementation. J
11. Mormann WH, Brandestini M, Lu F,
Prosthodontic Research 2016; 60:72-84.
Barbakow F. Chairside computer-
aided direct ceramic inlays. 18. Ting-Shu S, Jian S. Intraoral digital
Quintessence Int 1989; 20:329-39. impression technique: A review. J
Prosthodont 2015; 24:313–21.
12. Abduo J, Lyons K. Rationale for the use
of CAD/CAM technology in implant
prosthodontics. Int J Dent 2013; 10:1-8.

13. Freedman M, Quinn F, O’Sullivan M.

Single unit CAD/CAM restorations: A
literature review. J Ir Dent Assoc 2007;
53:38-45.

14. Reich S, Wichmann M, Nkenke E,

Proeschel P. Clinical fit of all ceramic
three-unit fixed partial dentures,
generated with three different
CAD/CAM systems. Eur J Oral Sci
2005; 113:174-79.

Volume - IX Issue - 1 – 2019 143 | P a g e

 MINIMALLY INVASIVE POST ENDODONTIC RESTORATIONS
* Dr. Thanmai Taduri **Dr. Meena Shah

Abstract
Endodontic therapy is routinely used in contemporary dentistry as a treatment
modality to avoid the loss of a tooth. Post endodontic treatment, a satisfactory restorative
solution is necessary to improve the longevity of a tooth. Restoring endodontically treated
teeth with a minimally invasive approach has become more successful lately because of the
improvement in the adhesive restorative technologies. Biomimetics or bio emulation makes
use of two key concepts: adhesion and tissue preservation. Following this concept helps us
to achieve maximum longevity and esthetics while preserving the remaining tooth structure.
The tooth – restorative bond is less likely to disrupt when the tooth is restored using the
concepts of biomimetics. The materials and the kind of adhesion used helps the restoration
to simulate the tooth so ultimately, the tooth and the restoration work in cohesion with each
other and chances of failures are reduced. This paper has reflected over the types of
minimally invasive post endodontic restorations that help us execute this form of treatment
to restore a tooth.

Key words: posts, core, inlays, onlays, biomimetic, minimally invasive, endocrowns

INTRODUCTION:
There are a variety of materials and treatment but also on the amount of
techniques advocated for restoring pulpless remaining dentine tissue, and the nature of
teeth, and hundreds of studies devoted to final restoration.2 The recent changes in the
this subject have been published in the methods available for restoring
dental literature.1 Scientific literature on the endodontically treated teeth depend on the
post-endodontic restoration is unanimous: improvement of the adhesive techniques,
the prognosis of root-filled teeth depends composite resin materials, fiber posts, and
not only on the success of the endodontic indirect ceramic materials.2

Correspondence:
*Postgraduate student
Dr. Thanmai Taduri
**Reader Postgraduate student
Department of Prosthodontics, Department of Prosthodontics,
Crown & Bridgework and Oral Crown & Bridgework and Oral
Implantology
Implantology Faculty of Dental Science,
Faculty of Dental Science, Dharmsinh Desai University,
Dharmsinh Desai University, College Road, Nadiad. 387001, Gujarat.
[email protected]
Nadiad.
(M): +919924165401

Volume - IX Issue - 1 – 2019 144 | P a g e

Biomimetic dentistry uses modern
materials to replicate the tooth’s biologic
and mechanical function.3 This technique
involves using dental adhesives and
sometimes fiber reinforcement to reproduce
the tooth’s natural hard tissues to facilitate
a secure bond.3 As Pascal Magne points out,
the concept of modern biomimetics can be
summarized into three distinct, but closely
linked, categories: Observation of nature,
biology, its role, its mechanical behavior, Illustration 1: The risk of fracture of
and its optical characteristics; respect of an endodontically treated tooth is
nature in preparing a minimal dental tissue directly related to the quantity of
tissues lost and to the specific cavity
and reproduction of nature using adhesion
and modern biomaterials (composites and
ceramics).4
RADICULAR RESTORATIONS:

NEED FOR MINIMALLY INVASIVE The loss of tooth structure makes

POST ENDODONTIC endodontically treated teeth more
RESTORATIONS: susceptible to fracture or so it is believed. A
Many classical indications for a post facilitates the retention of restorative
crown restoration are nowadays materials for fabrication of a foundation in
5
questioned. The largest reduction in tooth both posterior and anterior teeth.8
stiffness results from additional Consideration must be given to the
preparation, especially the loss of marginal variables involved: type of tooth, remaining
ridges; the literature actually reports 14% to tooth structure, periodontal support, root
44% and 20% to 63% reduction in tooth and pulp morphology, and occlusion.8
stiffness following occlusal and mesio-
occluso-distal (MOD) cavity preparations, INDICATIONS FOR POST
respectively.6 Minimally invasive PLACEMENT:
preparations, with maximal tissue 1. Type of tooth:
conservation, are now considered the gold Molars:
standard for restoring endodontically Posts are rarely required in
treated teeth.7 endodontically treated molars and when
required, because of lack of adequate
remaining coronal tooth structure, it
should generally be placed only in the
largest canal.9

Volume - IX Issue - 1 – 2019 145 | P a g e

Premolars: CRITERIA FOR POST
10
The decision regarding post PLACEMENT
placement is made based on the Post length:
remaining coronal tooth structure, the post length should reach two-thirds of the
entire root length. A crown-length/post-
functional requirements of the tooth,
length ratio of at least 1:1 should be
and an evaluation of the forces that act
provided.
on the tooth.9
Post diameter:
A diameter of one-third of the root diameter
Incisors: is postulated in many reviews. A minimal
Because of the shearing forces dentin thickness of 1 mm around the post
that act on them, anterior endodontically should be provided.
treated teeth are restored with posts Post fixation:
more often than posterior teeth.9 The Adhesive systems seem to be able to
decision to place a post is dictated by the stabilize the tooth. posts were adhesively
amount of coronal remaining tooth cemented were significantly more fracture
structure after the crown preparation is resistant than those using zinc phosphate
completed.9 cement.
Post design:
Parallel-sided posts and those
2. Amount of remaining tooth
surrounded by large amounts of cement had
structure:
lower fracture rates than tapered posts or
Class I: Describes the access preparation
tapered posts with maximal adaptation in
with all 4 axial cavity walls remaining.
the root canal. Tapered posts preserve more
Class II : Describes loss of 1 cavity wall,
tooth structure but tend to have a greater
commonly known as the mesio-occlusal
failure rate.
(MO) or the disto-occlusal (DO) cavity.
Class III: Represents an MOD cavity with 2
Post & core material:
remaining cavity walls.
With respect to the material used,
Class IV: Describes 1 remaining cavity
efforts should be made to make sure that the
wall, in most cases the buccal or oral wall.
Class V: Describes a decoronated tooth post and the core material should be the
same or an analog material should be used.
with no cavity wall remaining.10

TYPES OF POSTS:
Posts can be classified as
IMPORTANT PRINCIPLES FOR
➢ Active and passive posts
POSTS11
➢ Parallel and tapered posts
Retention and resistance, failure
➢ Prefabricated and custom made
mode, preservation of tooth structure, the
posts
ferrule effect and retrievability.
➢ According to material used:
• Metal posts
• Zirconia posts
• Carbon fibre posts

Volume - IX Issue - 1 – 2019 146 | P a g e

• Glass fibre posts composite resin liner-base to create an even
• Polyethylene fibre posts cavity geometry and fill undercuts.7
More than half of the coronal tooth
structure is missing:
THE POST/RESIN INTERFACE A post-and-core restoration is mandatory to
In addition to the interface between ensure tooth-restoration continuum
the resin cement and dentin, the post/resin strength and resistance to fracture. A ferrule
inter- face is also important. Several surface effect should also be attained. Occlusal
treatments of the post have been anatomy and function are usually restored
recommended for improving the bonding of with a full crown.7
resin cements or core materials to fiber Most of the coronal tooth structure is
posts.12 missing:
• Silane application This represents the least favorable
• Air abrasion biomechanical situation and cannot be
• Alternative etching techniques satisfactorily or safely approached in the
involving hydrogen peroxide or sodium long term. Extraction and implant therapy
ethoxide.12 can be considered an alternative to the
conventional treatment.7
CORONAL RESTORATIONS:
Coronal rehabilitation of Direct composite restorations:
endodontically treated teeth is required but This is the least invasive option
choosing the type of restoration depends on especially when restoring posterior teeth
a number of factors, most important of with conservative access preparation.
which is the amount of the tooth structure Developments in the adhesive restorative
remaining. The minimally invasive technologies enable construction of
restoration to elect range from direct debilitated tooth structure with a more
composite restorations, veneers, inlays, conservative non-invasive approach to
onlays and endocrowns. rebuild the integrity of the residual tooth
structure.
CLINICAL GUIDELINES:
Minimal loss of tooth structure:
Such teeth should be treated with only
adhesive restoration filling the access
cavity and pulpal chamber. The choice of
material should be limited to composite
resins, in combination with an effective
adhesive system, following the total
bonding concept.7
Upto one half of the coronal tooth structure
missing:
Complete occlusal coverage such as an
endocrown or indirect tooth-colored Illustration 2: Direct composite
restoration
overlay is suggested, overlying a bonded

Volume - IX Issue - 1 – 2019 147 | P a g e

Veneers:
Among indirect techniques, ceramic
laminate veneers represent a well-
documented, effective, and predictable
treatment option.13 Recently composite
veneers are also being used to restore the
anteriors. The main indication for using
veneers include in the anteriors where
discoloration cannot be masked with direct
restoration.

Illustration 4: Ceramic overlays

Illustration 3: Veneers

Posterior indirect adhesive restorations:

The typologies of cavities that have
to be restored in the posterior area are : Illustration 5: Endocrowns
inlay (a cavity that does not need cuspal
coverage), onlay (a cavity with coverage of
one or more cusps), overlay (a specific CONCLUSION:
onlay typology with complete cuspal The advances in material science
coverage), and veneerlay (an overlay with and adhesive dentistry have allowed us to
the involvement of the buccal wall and a use a more conservative minimally invasive
preparation combined with a laminate approach to restore endodontically treated
veneer).14 teeth. Preservation of tooth structure is of
utmost importance for ensuring success of
Endocrowns: these restorations. Advances in adhesive
The endocrown is a restorative dentistry have enabled us to use posts as a
option for endodontically treated teeth. It reinforcement factor rather than a retentive
consists of a circular butt-joint margin and element. Last, but not the least, proper
a central retention cavity inside the pulp treatment planning while restoring an
chamber and lacks intraradicular endodontically treated tooth is the key
7
anchorage. It is a conservative alternative factor that decides the success or failure of
to full crowns for the treatment of posterior a restoration.
nonvital teeth that require long-term
protection and stability.7

Volume - IX Issue - 1 – 2019 148 | P a g e

REFERENCES:
7. Lander E, Dietschi D. Endocrowns:
1. Morgano SM, Rodrigues AHC, A clinical report. Quintessence Int
Sabrosa CE. Restoration of 2008; 39:99–106.
endodontically treated teeth. Dent
Clin N Am 2004; 48:397–416.
8. Sorensen JA, Martinoff JT.
2. Polesel A. Restoration of the Intracoronal reinforcement and
endodontically treated posterior coronal coverage: a study of
tooth. Giornale Italiano di endodontically treated teeth. J
Endodonzia 2014; 28:2-16. Prosthet Dent 1984; 51:780–784.

3. Cohen RG. Biomimetic Perspective 9. Robbins JW. Restoration of the

on the Restoration of endodontically treated tooth. Dent
Endodontically Treated Teeth. Clin N Am 2002; 46:367–384.
Inside dentistry 2017; 13:1-4.
10. Peroz I, Blankenstein F, Lange KP,
4. Tirtlet G, Crescenzo H, Crescenzo Naumann M. Restoring
D, Bazos P. Ceramic adhesive endodontically treated teeth with
restorations and biomimetic posts and cores—A review
Quintessence Int 2005; 36:737–
dentistry: tissue preservation 
and
746.
adhesion. Int J Esthet Dent
2014; 9:354–369. 11. Schwartz RS, Robbins JW.
Restoration of Endodontically
Treated Teeth. J Endodon 2004;
5. Rocca GT, Krejci I. Crown and 30:289 -301.
post-free adhesive restorations for
endodontically treated 
posterior 12. Ree M, Schwartz RS. Endo-
Restorative Interface: Current
teeth: from direct composite to
Concepts. Dent Clin N Am 2010;
endocrowns. Eur J Esthet Dent
54:345–374.
2013; 8:156–179.
13. Veneziani M. Ceramic laminate
6. Dietschi D, Duc O, Krejci I, Sadan veneers: clinical procedures with a
A. Biomechanical considerations multidisciplinary approach. Int J
for the restoration of endodontically Esthet Dent 2017; 12:426–448.
treated teeth: A systematic review
of the literature—Part 1. 14. Ferraris F. Posterior indirect
Composition and micro and adhesive restorations (PIAR):
macrostructure alterations. preparation designs and
Quintessence Int. 2008; 39:117- adhesthetics clinical protocol. Int J
129. Esthet Dent 2017; 12:482–502.

Volume - IX Issue - 1 – 2019 149 | P a g e