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Official Publication of IDA Karnataka State BranchOfficial Publication of IDA Karnataka State Branch

ISSN : 09733442

Issue 5

Volume 35

April - June 2017

Dear colleagues,

Season's greetings. As we look back in our professional and personal life's, there has been a phenomenal change in the past few years. The way we bought vegetables has changed, so is the way we are practicing dentistry today. The behavior of our patients has changed. Today patients are well aware of the global trends in dentistry that creates a demand on us to keep up with the changing times. Corporates and venture capitalists are on full swing to invest into the flourishing health care industry. Single unit clinics

have to face competition with swanky multifacility corporate setups. To keep your kitty intact, we need to transform ourselves as well as our clinical setups. There are few tips - be aware of latest technologies and trend in dentistry, be aware of the newer materials, keep up with the infrastructure, improve on payment facilities, plan your finances. Use the electronic media, be it e mail or social networking to keep in touch with your patients.

To conclude “change is the only constant thing in nature, so change before thechange changes you”.

With warm regards

EDITORIAL

Dr.Sudhakar M.CDr.Sadashiv ShettyDr.PruthvirajDr.Bharat ShettyDr.B. Sripathi RaoDr.Manjunath RaiDr.Veerendrakumar S.CDr.Sowmya B.Dr.Sumant GoelDr.Raghavendra KamatDr.B.S. BagiDr.C.JagadishDr.Sreenath ThankurDr.K.S GanapathyPradeepchandra ShettyDr.Ramesh ShenoyDr.Srinidhi D.Prabhuji M.L.V.Dr.Sateesh ReddyDr.Dayanand H.B.

Dr.Suraj HedgeDr.Moksha NayakDr.Padmaraj HedgeDr.B.Suresh ChandraDr.Tilak Raj T.N.Dr.Nandalal B.Dr.Jayakar ShettyDr.Ramchandra C.S.Dr.ShivaprakashDr.Veerendra B.Dr.Sreenivas VanakiDr.Sudeendra KumarDr.Beena Rani GoelDr.Ravi M.G.Dr.Krishna Nayak U.S.Dr.M.G. BhatDr.V.RanganathDr.ShivsharanDr.Pratap ShettyDr.Adarsh C.

Dr.Shashikhant RaiDr.Ramesh NadgirDr.K. UmeshDr.Asha M.LDr.Shivaprasad.S.Dr.Ramamurthy.T.KDr.Sanjay Mohan ChandraDr.Manjunath RaiDr.Uthkarsh Lokesh.Dr.Pradip RajuDr.Mohammed FaizuddinDr.Anirban ChatarjeeDr.Hemalatha SanjayDr.Anup Belludi.Dr.Santosh.RDr.Prithiv RajDr.Ravindra C. SavadiDr.Ramesh.T.RDr.Padma.K.BhatDr.Srivastava

Dr. RAJKUMAR.S.ALLEBDS, MDS, DNB, MFDS RCPS (Glasgow), FIMSA, FWFO

EDITOR-IN-CHIEF

EDITOR-IN-CHIEFDr. RAJKUMAR.S.ALLEBDS, MDS, DNB, MFDS RCPS (Glasgow), FIMSA, FWFO

Editorial Board

ASSOCIATE EDITORDr. KIRAN .H, MDS

Editorial Advisory Board

3

4

IDA KARNATAKA STATE BRANCHLIST OF OFFICE BEARERS FOR THE YEAR 2016-17

President:

My Dentist,Foundation of Preventive Dentistry118, Panchamantra RoadKuvempunagar, Mysore-570 [email protected]: 96866 77255

Dr. B. Nandalal

Mob: 98450 16003 Mob: 94481 75440

Dr. Sameer K PoteDr. Jagadish S KadamanarDr. Rithesh K BDr. Muralidhar Rai Dr. Srinivasulu P.Dr. Bharath S. V.Dr. Prashanth S Dr. Kirti Shetty Dr. M G Ravi Dr. Mahendra PimpaleDr. Kiran RaddarDr Manjunath RaiDr. Padmaraj HegdeDr. Shishir ShettyDr. Junaid AhmedDr. Roshan ShettyDr. Sanath ShettyDr. Prathap Kumar Shetty

Dr. Sudhindra Kumar NDr. Chaitanya BabuDr. SushanthDr. M L V Prabhuji Dr. Shridhar Sheelvant Dr. Sanjay KumarDr. Ashwath RajuDr. Deepak J R Dr. Satish Kumar Patil Dr. Raghunath ReddyDr. Utkarsha LokeshDr. Raghavendra N Dr. Sanjay Kumar D.Dr. Krishna PrabhuDr. Pramod ShettyDr. Smitha TDr. Jithesh NDr. Shivakumar Swamy

Dr. Tilakraj T.N.Dr. ShivasharanDr. Adarsh C.Dr. T K Ramamurthy Dr. Bhat M. G.Dr. H P Prakash Dr. Krishna NayakDr. Narendra Kumar M Dr. Bharath Shetty Y.Dr. Girish Sharma Dr. Mahesh ChandraDr. Raghavendra PidamaleDr. Veerendra Kumar S CDr. Ramachandra MallanDr. Sudhakar M. C.Dr. Jagadeesh C.Dr. Sanjay Mohan ChandraDr. Srinidhi D.Dr. Annaji A G

Dr. Ranganath V.Hon. Secretary, IDA Karnataka Branch

5

SECRETARY’S MESSAGE

Dear friends,

Greetings from the IDA, Karnataka State Office. It's a pleasure to speak to you again.

Hearty congratulations to the editorial team for bringing out the state journal in a timely fashion!

Past couple of months have been very hectic with us office bearers along with KSDC interacting positively with the health minister and pushing forward issues concerning us dentists. Efforts are on to abolish Trade license for dentists and to amend the KPA act with more powers to Dentists.

We are consistently working towards additional benefits to Dentists engaging with the Government of Karnataka. Looking forward to sharing more information in the near future….

Wishing you all a very Happy and prosperous Deepawali in advance….

CONTENTS

6

1.A review with Dental Implications- ,

2. Management strategies for dentinal hypersensitivity : A Review 11-Dr Souparna Madhavan, Dr . Mohammed Ali Habibulla, Dr . Haifa B,

Dr Lavanya Varma, Dr Rajesh shetty

3. Assessment of Perception of Smile Esthetics by Laypersons, 16Dental Students and Orthodontists-Dr Nirupama, Dr . Mithun

4. Evaluation of the effect of preparation taper, finish line and marginal configuration on extra oral scanning in CAD/CAM an in-vitro study

26

5. Knowledge and Practice of Pulp Therapy in Deciduous Teeth amongst General Dental Practitioners 28

Tobacco use Among School Personnel in Mangalore City, India - 32A Pilot Study

7. Evaluation of the effect of preparation taper, finish line and marginal 35configuration on extra oral scanning in CAD/CAM- an in-vitro study

Congenital insensitivity to pain – 7

Dr. Vidya K, Dr. Akshay Shetty Dr. Latha Anandakrishna

- Soundharya Aishwarya B, Ramesh TR, Shwetha Kumari Poovani, Niyati Shah, MavaniSoham V, Patel Brijesh M

1 2-Dr. N S VenkateshBabu , Dr. Purna B Patel

6.

1 2 3-Dr Shubhan Alva , Dr Amrithavarshini H , Dr Julie Elizabeth Lawrence

1 2 3- Dr. Soundharya Aishwarya B , Dr. Ramesh TR , Dr. Shweta Kumari Poovani ,

4 5 6 Dr. Niyati Shah , Dr.MavaniSoham V , Dr. Patel Brijesh M

7

Abstract

Congenital insensitivity to pain or congenital indifference to pain is a rare genetic condition in which patients do not respond to painful stimuli. Five different types of hereditary sensory and autonomic neuropathy (HSAN) have been identified till date. Each has different patterns of sensory and autonomic dysfunction, peripheral neuropathy, clinical features and underlying genetic etiology. Absence of pain and self mutilation are characteristic findings of this syndrome. Teeth in the oral cavity can cause damage to the oral tissues and tongue. When diagnosed, there should be co-ordination between dentist and the neurologist.

Key words: congenital insensitivity, neuropathy, dental implications

1.

2.

Dr. Vidya KSenior Lectuerer, Department of Pediatric and Preventive Dentistry, M.R.Ambedkar Dental College and Hospital, Bangalore.Dr. Akshay ShettyReader, Department of Prosthodontics, KGF Dental College, Kolar

3AUTHORS : Dr. Vidya K , Dr. Akshay Shetty Dr. Latha Anandakrishna1 2,

Dr. Latha AnandakrishnaProfessor and Head, Department of Pediatric and Preventive Dentistry, M.S.Ramaiah University of Applied Sciences, Bangalore.

Introduction

Pain is a protective mechanism for the body. Painful stimuli indicate tissue damage or potential damage and cause a reflex withdrawal from the source of

1such damage . It is an early symptom of a disease and is often the motivation for patient to seek medical or dental treatment. Absence of pain is a symptom in certain disorders which may be congenital or acquired. The Congenital types are present at birth, and the majority are diagnosed in early childhood and are collectively termed as Hereditary Sensory and Autonomic Neuropathies

2(HSAN) .

3pain .

Historical background

Congenital insensitivity to pain is a rare disorder, 1st described in 1932 by Dearborn as “Congenital

4pure analgesia” . After which various terms were used to describe these individuals, including “Congenital universal insensitiveness to pain” by Ford & Wilkins 1938, “Congenital universal indifference to pain” by Boyd & Nie 1949. “Congenital insensitivity to pain” McMurray, 1950. “Congenital absence of pain” by Winkelmann et al, 1962. Over time, two terms began to predominate in descriptions of these individuals - 'Congenital insensitivity to pain' (McMurray 1950) and 'congenital indifference to pain' (Jewesbury

51970) .

Congenital insensitivity to pain (CIP), also known as congenital analgesia, is one or more rare conditions in which a person cannot feel (and has never felt) physical

Congenital insensitivity to pain – A review with Dental Implications

Epidemilogy

Congenital insensitivity to pain and anhydrosis (CIPA) is a type of HSAN and most of the documented cases come under this variant. The incidence of this disorder has been estimated to be 1 in 25, 000 population with no predilection toward

6sex and race .

Current understanding of hereditary and congenital pain insensitivity syndromes

Children with underlying peripheral neuropathies have impairment in both the sensory- discriminative and affective –motivational components of pain perception. Collectively termed the hereditary sensory and autonomic neuropathies (HSAN), these disorders affect the number and distribution of small myelinated and nonmyelinated nerve fibers and are characterized by diminished or absent sensitivity to pain, touch and pressure on the extremities and varying parts

2of the trunk . At present, 5 types of HSAN have been identified. The various disorders within this group are classified according to the different patterns of sensory and autonomic dysfunction and peripheral neuropathy as well as the presence of additional

7-clinical features, such as learning disability13(table-1). The underlying pathology is due to mutation of respective genes, which result in defects in nerve growth factor signaling and hence leading to death of various nerve growth factor dependent neurons during embryonic period &

8

lack of maturation of small myelinated and un-myelinated fibers of the peripheral nerves, which convey sensation of pain.

Oral and Dental findings

Congenital insensitivity to pain is a rare disorder in which oral manifestations may be the presenting complaint. The frequent problems arising during the eruption of primary teeth are self mutilative injuries to teeth, tongue and lower lip. These biting injuries with resultant scarring of the finger tips and deformation of oral soft tissues were found in most patients. Such oral self mutilations were found to decrease with age and with intellectual, social and/or emotional development of the patients. The typical and common feature in the infantile patients with congenital insensitivity to pain was found to be a decubital ulcer on the ventral surface of the tongue. The incisal edges of erupting mandibular primary incisors cause this tongue injury during sucking or nursing. With eruption of maxillary and mandibular primary incisors, further oral trauma such as tongue or lip biting is induced. Repeated and uncontrolled tongue biting is one of the important diagnostic sign of HSAN. Self mutilative tooth luxation and multiple missing teeth because of autoextraction are other characteristic findings. Absence of fungiform and circumvallate papillae is an important specific clinical finding in HSAN type 4. Oral scalding could

14be an evidence of a lack of oral thermal sensation . There is a report that dental pulp infection resulting from dental caries caused osteomyelitis that led to mandibular bone fracture in a patient

15with HSAN type 4 .

Diagnosis

The confirmatory diagnostic tests include nerve conduction studies, nerve biopsy and histo-pathological examination under electron microscopy. Quantitative sweat tests and intra-dermal histamine tests are done to check for anhydrosis along with DNA studies to look for specific mutations.

Management

At present, there is no specific treatment for HSAN. Some reports in the literature describe a poor

16prognosis for these disorders . However, these mostly pertain to HSAN type 4, where patients also suffer from profound anhydrosis and learning disability. Due to painless injuries, the bones, joints

and soft tissues of the extremities as well as the orbits, nasal bones and oral cavity undergo mutilating effects. Bar-On et al have described preventive measures for orthopedic complications such as use of special shoe ware, periods of non weight bearing, surgical wide debridement and

17curative osteotomy for deformity .

Several methods for prevention of dental injuries have been suggested, including elimination of sharp surfaces of the teeth by grinding or addition of composites, the use of mouth guards and other appliances and extraction of teeth. The use of intraoral appliance is often difficult or impossible to implement because the mutilation may begin in

14infancy with the eruption of primary incisors . Thus extractions may be unavoidable in cases in

13which the mutilation is severe . Early loss of primary teeth for any reason is known to lead a significant increase in need for orthodontic treatment.

These patients are at higher risk because of late presentations of systemic and dental illnesses. Hence prevention of dental disease is very important in them, as dental caries can progress to pulpal involvement without causing pain and may lead to infection and tooth loss or even osteomyelitis. The dental team should therefore be involved in the management of these patients as soon as the diagnosis is made, and careful monitoring should continue throughout the life time of the patient.

Conclusion

Sense of pain is the precursor of a large variety of pathological conditions. Its elimination for any reason may cause a number of adverse conditions and result in injury. Congenital insensitivity to pain is a rare disorder in which oral manifestations may be the presenting complaint. It is important for clinicians to be aware of the potential complications caused by HSAN so that the appropriate treatment can be provided promptly, thus preventing the development of untoward complications. The dental team should be actively involved in the management of these patients as soon as the diagnosis is made. Moreover, careful monitoring should continue throughout the patient's life time, along with comprehensive dental care to maintain the patient's social, psychological and behavioural rehabilitation.

KSDJ / Vol 35/Issue 5/Apr - June 2017

9

Condition Inheritan

ce pattern

Clinical features Peripheral

nerve

abnormality

Genetic

abnormality

HSAN type 1 (hereditary

sensory

radicular

neuropathy)

Autosomal

dominant

Late onset (2nd -4th

decade) Progressive distal

sensory loss (pain and

thermal sensation)

Intermittent lancinating

pains in the lower

extremities Intelligence may be

mildly impaired

Hearing loss

Small

myelinated and

unmyelinated

fibers severely

diminished.

Large

unmyelinated

fibres

moderately

diminished

Mutation in

SPTLC1(serine

palmitoyltransfe

rase) gene at

locus 9q22.1-

q22.3

HSAN type 2

Autosomal

recessive

Onset in infancy; rare

disorder

Global distal sensory

loss/ minimal weakness

Self-mutilation

Usually no autonomic

dysfunction

Severe loss

of

myelinated

fibers

Some loss of

unmyelinated

fibers

Mutation in

HSN2

(hereditary

sensory

neuropathy type

2) gene at locus

12p13.33

HSAN type

3( Riley-Day

syndrome;

familial

dysautonomi

a)

Autosomal

recessive

Onset in infancy;

Ashkenazi Jewish

disease

Profound autonomic

dysfunction

Loss of pain and

thermal sensation

Absent deep tendon

reflexes

Absent fungiform

papillae on tongue

Total absence of

large myelinated

neurons

Severe loss of

unmyelinated

fibers

Mutation

in1KBKAP(inhib

itor of kappa

light polypeptide

gene enhancer

in B cells, kinase

complex-

associated

protein) gene at

locus 9q31

HSAN type 4

( congenital

autosomal

insensitivity

to pain with

anhydrosis;

CIPA)

Autosomal

recessive

Onset in infancy;

commonest HSAN

Profound insensitivity

to pain

Decreased or absent

thermal sensation

Impaired sweating with

episodic hyperpyrexia

Severe learning

disability/ self

mutilation

Virtual absence

of unmyelinated

fibers

Reduction of

small

myelinated

fibers

Mutation in

NTRK1

(neurotrophic

tyrosine kinase

receptor type 1)

gene at locus

1q21-q22

HSAN type 5

( congenital

insensitivity

Autosomal

recessive

Onset in infancy

Profound insensitivity

to pain

Severe

reduction of

unmyelinated

Mutation in

NGFB (nerve

growth factor B)


10

References

1. Rasmussen P. The congenial insensitivity-to-pain syndrome (analgesia congenital): report of a case. Int J Paediatr Dent 1996;6:117-22.

2. Littlewood SJ, Mitchell L. The dental problems and management of a patient suffering from congenital insensitivity to pain. Int J Paediatr Dent 1998; 8:47-50.

4. Dearborn G. A case of congenital pure analgesia. J Nerv Ment Dis 1932;75:612-5.

5. Nagasako EM , Oaklander AL and Dworkin RH. Congenital insensitivity to pain: an update. Pain 101(2003) 213-219.

6. Dave N, Sonawane A, Chanolkar S. Hereditary sensory autonomic neuropathy and anaesthesia - a case report.Indian J Anaesth. 2007; 51(6):528–30.

7. Nicholson GA, Dawkins JL et al. The gene for hereditary sensory neuropathy type 1 (HSN-I) maps to chromosome 9q22.1-q22.3. Nat Genet 1996; 13:101-4.

8. Axelrod FB, Hilz MJ. Inherited autonomic neuropathies. Semin Neurol 2003;23:381-90.

9. Verhoeven K, Coen K et al. SPTLC1 mutation in twin sisters with hereditary sensory neuropathy type 1. Neurology 2004; 62:1001-2.

10. Lafreniere RG, Mac Donald MLE et al. Identification of a novel gene (HSN2) causing h e re d i t a r y s e n s o r y a n d a u to n o m i c neuropathy type II through the study of Canadian genetic isolates. Am J Hum Genet 2004; 74:1064-73.

11. Slaughenhaupt SA, Blumenfeld A, Gill SP et al. Tissue specific expression of a splicing mutation in the 1KBKAP gene causes familial dysautonomia. Am J Hum Genet 2001; 68:598-605.

12. Einasdottir E, Carlsson A et al. A mutation in nerve growth factor beta gene causes loss of pain perception. Hum Mol Genet 2004; 13:799-805.

3. Steven Linton (2005). Understanding Pain f o r B e t t e r C l i n i c a l P r a c t i c e : A Psychological Perspective . Elsevier Health Sciences. p. 14. ISBN 0444515917.

13. Butler J, Fleming P, Webb D et al. Congenital insensitivity to pain – review and report of a case with dental implications. Oral Surg Oral Med Oral Path Oral Radiol Endod 2006; 101: 58-62.

14. Amano A, Akiyama S, Ikeba M et al. Oral manifestations of hereditary sensory and autonomic neuropathy type IV. Oral Surg Oral Med Oral Path Oral Radiol Endod 1998; 86: 425-31.

15. Kubo T, Kubota K, Banba S et al. A case report: mandibular osteomyelitis and morbid fracture of mandible caused by dental caries in patient with congenital insensitivity to pain with anhydrosis. Japanese Journal of Dental Handicaps 1997; 18:96.

16. Erdem TL, Ozcan I, Ilguy D et al. hereditary sensory and autonomic neuropathy: review and a case report with dental implications. J Oral Rehab 2000; 27:180-3.

17. Bar-On E, Weigl D, Parvari R et al. congenital insensitivity to pain. J Bone Joint Surg 2002; 84: 252-4.

Correspondence address: Dr. Vidya K#103, Jayalakshmi Residency

st st1 Main, 1 A Cross, T.K. Reddy LayoutBanaswadi, Bangalore – 560043Email : [email protected]


Management strategies for dentinal hypersensitivity : A Review

1. Dr Souparna Madhavan (Corresponding author), Reader Department of Conservative dentistry &EndodonticsSrinivas Institute of Dental Sciences, Mukka, Surathkal.

2. Dr . Mohammed Ali Habibulla, ReaderDepartment of Pedodontics and Preventive dentistrySrinivas Institute of Dental sciences, Mukka, Mangalore

3 . Dr . Haifa B, ReaderDepartment of Prothodontics & crown and bridge.Srinivas Institute of Dental sciences, Mukka, Mangalore

1 2 3 4 5AUTHORS : Dr Souparna Madhavan , Dr . Mohammed Ali Habibulla , Dr . Haifa B , Dr Lavanya Varma Dr Rajesh shetty

4. Dr Lavanya Varma, (Prof)Head of the department Department of Conservative dentistry &Endodontics

Srinivas Institute of Dental Sciences, Mukka, Mangalore

5. Dr Rajesh shetty, (Prof)Department of Conservative dentistry &Endodontics

D Y Patel Dental College Pune, India

ABSTRACTDentinal Hypersensitivity is a relatively common painful condition described as short sharp pain usually in response to stimulus in areas of dentinal exposure. Dentinal hypersensitivity is not life threatening, but it can be a particularly unpleasant sensation for patients dictating types of food and drinks ingested. Once sensitivity has become established the pulp may become irreversibly sensitive. Treatment is therefore aimed at not only restoring the original impermeability of the tubules by occluding them, but also controlling the neural elements within the pulp to dampen the external stimulatory effects.

Mild and responsive dentinal hypersensitivity may be managed by less complex treatments such as Over the counter desensitizers and in office treatment be reserved for more severe recalcitrant cases. Clinicians should consider predisposing factors, removal of etiologic factors and dietary modifications to prevent recurrence. This article aims to inform practitioners on various management strategies for dentinal hypersensitivity.

INTRODUCTION

Dentinal hypersensitivity(DH) is a relatively common painful condition described as short sharp pain usually in response to stimulus in areas of dentinal exposure. Essentially, exposure of the dentine results from one of two processes, either removal of the enamel covering the crown of the tooth, or denudation of

1the root surface by loss of cementum and overlying periodontal tissues .Painful symptoms arising from exposed dentine are a common finding in the adult population affecting 1 in 7 of patients seeking dental treatment (Graf & Galasse 1977).

Dentinal hypersensitivity is not life threatening, but it can be a particularly unpleasant sensation for patients dictating types of food and drinks ingested.

Prolonged exposure to the oral environment may cause the occlusion of dentinal tubules by the smear layer or pellicle. However this may not reduce DH. Once sensitivity has become established the pulp may become irreversibly sensitive. Treatment is therefore aimed at not only restoring the original impermeability of the tubules by occluding them, but also controlling the neural elements within the pulp to dampen the external stimulatory effects. Hence pain control is achieved by obliteration of the dentinal tubules or alteration of

5pulpal sensory activity, or both .

DIAGNOSIS

DH is characterized by short sharp pain arising from exposed dentin in response to stimuli typically thermal, evaporative, tactile, osmotic, or chemical and which can't be ascribed to any other form of dental defect or

6pathology . Therefore the diagnosis of DH should be considered only after the practitioner has excluded

The condition most commonly affects the canines and premolars 2 nd rd 3 peaking in incidence in the 2 and 3 decade of life and then again in the 50's .

Patients undergoing periodontal treatment are particularly susceptible to this condition due to gingival 4recession following periodontal surgery or loss of cementum following non-surgical periodontal therapy .

11

other possible causes of pain , such as cracked tooth syndrome, fractured restoration, dental caries, post

3, 6 restorative sensitivity, pulpitis . . The most common stimuli used in clinical studies are thermal and tactile . However widely used stimulus methods have differences that affect their reproducibility and therefore long term

monitoring of DH. Pain assessment presents another challenge in recording response as subjective feedback has to be translated to be objective data for recording. This involves the use of both unidimensional and multidimensional pain measurement systems.The most common unidimensional pain measurement system is the

7Visual analogue scale .

Visual analogue scale records a characteristic or attitude that is believed to range across a continuum of values. Pain is a continuous characteristic and doesn't take discrete steps, as a categorization of none, mild, moderate and severe would suggest. Operationally the VAS is usually a horizontal line,100mm in length, anchored by word

8descriptors at each end .The ends are defined as the extreme limits of the parameter oriented from

9 . the left (no pain) to the right (Unbearable pain) The patient marks on the line the point that they feel best represents the intensity of pain at that time. The VAS score is determined by measuring in millimeters from the left hand end of the line to the

point that the patient marks. However since such a method is subjective in nature, it is valuable in comparing changes in the same individual over a period of time but its use is limited when

8comparing a group of individuals .

MANAGEMENT OF DENTINAL HYPERSENSITIVITY

Management of Dentinal Hypersensitivity aims at elimination of pain or discomfort. This can be achieved by two means

· Occlusion of dentinal tubules

· Interefering with transmission of nerve impulse

Occluding agents physically block exposed dentinal tubules, preventing any external stimuli from triggering the movement of dentinal fluid and

10thereby blocking pain response .These agents can be delivered by OTC products that patient can use at home or may be applied professionally in the dental office.

The second method to manage DH is to interrupt the neural response to pain stimuli .This may be

9,10achieved by direct ionic diffusion. .World Health Organization recommends that mild and responsive DH be managed by less complex treatments such as OTC desensitizers and in office treatment be reserved for more severe recalcitrant

2cases (See Table 1 ) .

Sodium fluoride (NaF)

Home-use over-the-counter desensitizing agents that occlude the dentinal tubules are found in toothpastes, gels, and mouth rinses. One of the main active ingredients used in this manner is fluoride. The action of NaF may be attributed to the reaction that occurs between NaF and Calcium ions of dentinal fluid, and that leads to the formation of calcium fluoride crystals, which are deposited onto the openings of the dentinal tubules. However the crystal size of calcium fluoride (CaF2) being small,

11is diluted by saliva , a single application of NaF would be ineffective in narrowing down the diameter of dentinal tubules and multiple

12applications would be necessary .

Sodium mono fluorophosphates

It is effective in treating DH, however the 13mechanism of action is unclear .Scanning Electron

Microscopy failed to demonstrate any visual changes in the dentinal surface. Tubule occlusion , if

14any doesn't appear to be permanent .

Iontophoresis is one such procedure whereby the desensitizing agents are penetrated deep into the open dentinal tubules with the help of electric current. It is most often used in conjuction with fluoride pastes or solutions and reportedly reduces

15DH .

Stannous fluoride

It is effective in controlling DH either in aqueous solution or in glycerine gelled with carboxy methyl cellulose. Acts by tubule occlusion which may be partial or complete. Alternatively it may precipitate on dentin surface leading to occlusion of exposed

14dentinal tubules . An aqueous Stannous fluoride gel product has been granted ADA seal of acceptance for the therapeutic prevention of

16caries .

Potassium nitrate

Potassium nitrate is probably the most popular ingredient in OTC products for the treatment of DH.

12


5% Potassium nitrate is the concentration 17

recognized by the FDA for this agent .Potassium ions act by penetrating the dentinal tubules and block the repolarization of the myelinated A-fibers

18, 19 20 thus inactivating the action potential. .Hence desensitization is achieved . Importantly Potassium nitrate does not induce any pulpal changes and may be safely used in whitening trays to relieve hypersensitivity between whitening

21treatments .

Oxalates

Oxalates potentially offer an inexpensive and noninvasive chairside modality to treat DH. The potassium oxalate is a desensitizing agent which potentially obstruct the dentinal tubules and has been proven in a number of laboratory and clinical studies . This agent may act both by depolarization of the nerve endings (neural action) and by precipitation of calcium oxalate crystals in the

22dentinal tubules .

Calcium oxalates crystals formed on dentin surface are easily removed by daily brushing . However acid etching with 35% phosphoric acid increasing the penetration depth of oxalate buffer leading to long

23lasting relief .Oxalates have potential toxicity and are best avoided in generalized DH due to gingival

24and gastric irritation .

On the contrary Ben Balevi suggested that with the possible exception of 3 percent monohydrogen monopotassium oxalate alone, current evidence does not support the use of oxalates in the

25treatment of DH .

Resin based formulations

Resin-based materials have been reported to 26successfully reduce dentin hypersensitivity . An

aqueous solution of glutaraldehyde and HEMA (hydroxyethylmethacrylate) e .g . , G luma Desensitizer (Hereaus-Kulzer) and Calm-It (Dentsply-Caulk), has been reported to be an effective desensitizing agent . The mechansim for tubule occlusion appears to be due to the effect of glutaraldehyde mainly through coagulation of

27proteins inside the dentinal tubules .

Restorative treatment

Buccal cervical area is predisposed to DH since erosive and abrasive factors alone or in combination are most likely to impact at this site to

28expose dentine . In areas of significant tooth wear

restorative materials like glass ionomer cements, composite resins can be used . However this treatment modality is best reserved for cases that do not respond to less invasive desensitizing

5protocols .

Lasers

The first use of laser for the treatment of dentine hypersensitivity was reported by Matsumoto et al.

29(1985) .The lasers used for the treatment of dentine hypersensitivity are divided into two groups: low output power (low level) lasers [helium-neon (He-Ne) and Gallium/ Aluminum/ Arsenide (GaAlAs) (diode) lasers], and middle

30output power lasers (Nd:YAG and CO2 lasers) .

Nd:Yag

The mechanism of Nd:YAG laser effects on dentine hypersensitivity is thought to be the laser-induced occlusion or narrowing of dentinal tubules (Lan & Liu 1995, 1996, Yonaga et al1999) as well as direct

29nerve analgesia (Whitters et al. 1995) .

GaAIA

These lasers mediate an analgesic effect related to depressed nerve transmission and blocking of

31depolarization of C afferent fibres .The combined use of the GaAlAs laser (830 nm wavelength) with fluoridation enhances treatment effectiveness by

32more than 20% over that of laser treatment only .

He Ne lasers

The first use of He-Ne laser for the treatment of dentine hypersensitivity was reported by Senda et

29al . The mechanism involved is mostly unknown. According to physiological experiments, He-Ne laser irradiation does not affect peripheral A delta or C fiber nociceptors (Jarvis et al. 1990), but does affect action potential, which in the healthy nerve increased by 33% following a single trans-

33cutaneous irradiation .

Carbon dioxide ( CO2) Laser

The first use of this laser for the treatment of dentine hypersensitivity was reported by Moritz et al. CO2 laser effects on dentine hypersensitivity are due to the occlusion or narrowing of dentinal

34tubules .There have been no reports on nerve analgesia by CO2 laser irradiation. CO2 laser with stannous fluoride gel effect tubule occlusion for

29upto 6 months .

13


Casein phosphopeptides

Amorphous calcium phosphate (ACP) was developed by Tung et al in 2003, mimics the natural process of dentinal sclerosis and provides effective b i o c o m p a t i b l e t r e a t m e n t f o r d e n t i n hypersensitivity. ACP is precipitated under oral physiological conditions by the sequential application of calcium chloride (1.5mol/l) solution followed by potassium phosphate (1mol/l)

35maintained at a pH of 9.5 .

G.C. tooth mousse is a commercial preparation containing ACP and casein phosphopeptide (CPP) ,a product developed by Prof Reynolds at the

36University of Melbourne . CPP stabilizes ACP and forms nano complexes with ACP at the tooth surface thereby providing a reservoir of calcium

37and phosphate ions which favors mineralization . Calcium phosphate compounds occlude the tubules by forming a calcium phosphate precipitate, while calcium hydroxide occludes the tubules and promotes peritubular dentin

35, 38 formation. .The efficacy of CPP ACP reported in the literature have varied from a rapid reduction in

37sensitivity, with a prolonged desensitizing effect to insufficient effectiveness and short-term therapeutic effect in treating hypersensitivity of

39dentine .

Bioglass

This bioactive glass contains calcium sodium phosphosilicate which rapidly release calcium, sodium, and phosphorous ions which form hydroxycarbonate apatite (HCA) which occludes dentinal tubules . The use of Bioglass in the management of DH has been shown by some products such as Novamin . It has been successfully incorporated into prophylaxis pastes thus providing relief from DH while ensuring effective

40stain removal .

CONCLUSION

In clinical practice, the approach to the management of DH has been treatment based with little or no emphasis for the etiological and predisposing factors. Clinicians should evaluate the causes of DH and management strategies should include preventive measures.

Before embarking on any treatment protocol , it is necessary to consider operator knowledge and skill , patient preference , cost benefit ratio ,

severity of condition and number of teeth involved .As a general rule, treatment may initially involve non invasive and most cost effective modalities before considering complex and invasive procedures.

Removal or modification of etiological factors , dietary modification and oral hygiene will go a long way in ensuring a successful treatment . Regular reviews are recommended at appropriate intervals.

REFERENCES

1. Dowell.P, Addy.M. Dentin hypersensitivity A review. J clin peiodontol1983;10:341-350.

2. Ochardson R ,David .G. Managing dentin hypersensitivity. JADA;2006;137;990-998

3. Walter .P.A. Dentinal hypersensitivity : A review. J Contemporary Dent Practice 2005;6;110.

4.

Bartold. P.M. Dentinal hypersensitivity : a review. ADJ 2006;51;212-218

6. Addy. M .Dentine hypersensitivity: new perspectives on an old problem : IDJ 2002;52 ;5: 367-375.

7. Ide .M, Wilson.RF, Ashley.FP. The reproducibility of methods of assessment for cervical dentine hyper-sensitivity: J Clin Periodontol 2001; 28: 16–22.

8. Agnes Paul-Dauphin, Francis Guillemin, Jean-Marc Virion. Am J Epidemiol1999;150:1117-27

9. Gould. D. Visual analogue scale: Journal of clinical nursing 2001;10:697-706

10. Cummins D. Dentin hypersensitivity: From to a breakthrough therapy for everyday sensitivity relief. J Clin Dent 2009; 20 (Sp Is):1-9.

11. Everett FG, Hall WB, Phatak NM. Treatment of hypersensitive dentin. JOral Ther Pharmacol. 1966;2:300-10

12. Corona S AM, Do Nascimento TN, Catirse ABE et al. Clinical evaluation of low-level laser therapy and fluoride varnish for treating cervical dentinal hypersensitivity. J Oral Rehab 2003; 30: 1183-1189

13. Addy M, Dowell P. Dentine hypersensitivity – A review. Clinical and in vitro evaluation of treatments. J Clin Periodontol1983;10:351-363.

Curro F. Tooth hypersensitivity in the spectrum of pain. Dent Clin No Amer 1990;34; 429-37.

5.

Corresponding author:Dr Souparna Madhavan, Reader Department of Conservative dentistry &EndodonticsSrinivas Institute of Dental Sciences, Mukka, Surathkal.Pin code-574146Email ID- [email protected], [email protected] number- 09535649469

14


14. Tarbet WJ, Silverman G, Stolman JM, Fratarcangelo PA. Clinical evaluation of a new treatment for dentinal hypersensitivity. J Periodontol 1980;51:535-540.

15. Wilson JM, Fry BW, Walton RE, Gangarosa LP. Fluoride levels in dentin after iontophoresis of 2 % sodium fluoride. J Dent Res 1984;63(6):897-900

16.

Kim JL, Karastathis D. Dentinal hypersensitivity management. Dental Hygiene Theory and Practice.:3rd ed. St. Louis, MO: Saunders- Elsevier. 2010:726- 35.

Haywood VB, Caughman WF, Frazier KB, Myers ML. Tray delivery of potassium nitrate-fluoride to reduce bleaching sensitivity. Quintessence Int. 2001;32(2):105-9.

22. Orchardson, R.; Gillam, D.G. The efficacy of potassium salts agents for treating dentin hypersensitivity. J.Orofac. Pain,2000 ; 14 (1): 9-19.

23. Isabel C.C.M. Porto. Diagnosis and treatment of Dentinal hypersensitivity ; Journal of oral science ,2009 : 51; 3,323-332 .

24. Guo C , Mc Martin KE . The cytotoxicity of oxalates , metabolite of ethylene glycol, is due to calcium oxalate monohydrate formation . Toxicology 30:347 -355.

25. Oxalates may not be effective In treating dentin hypersensitivityn 2012 JADA :(6) ;143

26. Duran I, SengunA. The long term effectiveness of five current desensitizing products on cervical dentine hypersensitivity . J Oral Rehabil 2004;31: 351- 56.

27. Schupback P, lutz F . Closing of dentinal tubules by Gluma desensitizer . Eur J Oral Sci 1997 ;105;414 -421.

28. Addy M. Dentine hypersensitivity: new perspectives on an old problem; International Dental Journal 2002 :52; 5 (Supplement 1)

29. Kimura Y, Wilder-Smith P, Yonaga K, Matsumoto K Treatment of dentine hypersensitivity by lasers: a review.J Clin Periodontol 2000; 27: 715–721.

30. Shriprasad Sarapur, Shi lpashree H.S . Dent in Hypersensitivity: A Review international journal of dental clinics 2012 :4 ; 1

31. Wakabayashi, H., Hamba, M., Matsumoto, K. & Nakayama,T. Electro physiological study of irradiation of semi-conductor laser on the activity of the trigeminal subnucleues caudal neurons. 1992:Journal of Japanese Society for Laser Dentistry 3, 65–74.

32. Liu, H.-C. & Lan, W.H. The combined effectiveness of the semiconductor laser with Duraphat in the treatment of dentin hypersensitivity. Journal of Clinical Laser Medicine & Surgery 1994 :12;315–319.

Jacobsen PL, Bruce G. Clinical dentin hypersensitivity: understanding the causes and prescribing a treatment. J. Contemporary Dent Practice 2001;2(1):1-8.

17. Federal register ,vol 57 no 91 ,may 11,1992; 20114-20115.

18. Peacock J M, Orchardson R. Effects of potassium ions on action potential conduction in A and C fibers of rat spinal nerves: J Dent Res 1995; 74:634- 41.

19. Kim S Hypersensitive teeth. Desensitization of pulpal sensory nerves : Jendod 12, 482 -85

20

21.

.

33. Rochkind, S., Nissan, M., Barr-Nea, L.Response of peripheral nerve to He-Ne laser: experimental studies. Lasers in Surgery and Medicine 1987: 7, 441–443

34. Moritz, A., Gutknecht, N., Schoop, U., Wernisch, J., Lampert, F. & Sperr, W.Effects of CO2 laser irradiation on treatment of hypersensitive dental necks: results of an in vitro study. Journal of Clinical Laser Medicine & Surgery 1995:13; 397– 400.

Geiger S, Matalon S, Blasbalg J, Tung M, Eichmiller F. The clinical effect of amorphous calcium phosphate (ACP) on root surface hypersensitivity. Operative Dentistry 2003; 28 (5): 496-500

Reynolds E, Cain C, Webber E. Anticario-genicity of calcium phosphate complexes of tryptic casein phosphopeptides in the rat. Journal of Dental Research1995;74(6):1272-9.

Rosaiah.K, Aruna.K. Clinical Efficacy of Amorphous Calcium Phosphate, G.C. Tooth Mousse and Gluma Desensitizer in Treating Dentin Hypersensitivity. International journal of dental clinics 2011: 3 (1)

38. Tung MS, Bowen HJ, Derkson GD. Effects of calcium phosphate solution on dentin permeability J Endodont. 1993;19:283

39. Kowalczyk A, Botuliński B, Jaworska M, Kierklo A, Pawińska M, Dąbrowska E. Evaluation of the product based on RecaldentTM technology in the treatment of dentin hypersensitivity; Advances in Medical Sciences: 2006; 51 :1 ·

40. Jennings DT, McKenzie KM, Greenspan DC. Quantitative analysis of tubule occlusion using Novamin (sodium calcium phosphosilicate). J Dent Res. 2004; 83(Spec Iss A):2416.

TABLE 1

Management strategy for dentinal hypersensitivity a “hierarchial model”

General Guidelines

1. Improve awareness regarding risk factors in etiology of Dentinal Hypersensitivity

2. Suggest dietary modifications (Avoidance of dietary acids)

3. Recommend appropriate tooth brushing technique.

Level 1: Non invasive intervention (At home/ OTC)

1. Fluoride and Potassium nitrate dentifrices

35.

36.

37.

15


1 2AUTHORS : Dr Nirupama , Dr . Mithun

Assessment of Perception of Smile Esthetics by Laypersons, Dental Students and Orthodontists

ABSTRACT

Objective: To determine the factors influencing esthetic evaluations of the smile and to find out if there is homogeneity of the criteria between orthodontists, dental students and laypeople for diastema, buccal corridor and white spot lesions.

Materials and Methods: Patients were selected based on smile characteristics fulfilling standard norms. Photographs were taken with a digital camera with the head held in a natural head position. These photographs were manipulated to alter diastema, buccal corridor and white spot lesions and were arranged at random. A questionnaire and catalogue was designed including the set of smile images in color. The evaluation was done by 120 individuals (n= 60 men and n=60 women), belonging to one of three groups: 40 Layperson (20 men and 20 women); 40 Dental students (20 men and 20 women); 40 Orthodontist (20 men and 20 women). The responses was then analyzed and processed with SPSS.

Results: Perception of orthodontist of the ideal photographic characteristics was more precise than that of dental students and layperson in detecting deviations from ideal and had a narrower range of acceptability thresholds for Buccal corridor, Diastema and White spot lesions. Layperson and dental student had similar perception and were ignorant of the ideal smile characteristics.

Conclusions: The findings of this study showed that laypeople accept a wider range of deviation compared with dental students and orthodontists. Therefore, when aesthetic treatment to obtain a harmonious smile is performed, clinicians must be careful about imposing his/her own beauty norms upon patients.

KEYWORDS: Aesthetics, Smile, Orthodontists, Smile perception, White Spot Lesions.

INTRODUCTION

Smile is a greater recommendation than any letter of introduction. It is the most important facial expressions and is essential in expressing friendliness, agreement, and appreciation. Dale Carnige quoted the most important ways to win friends and influence people is to smile.1

Individuals within a given culture or society embrace common definitions for facial and physical attractiveness. It is also true that standards of beauty change over time and across cultures. There may be unique cultural preferences that identify the attractive smile, and perception of smile esthetics may vary in different populations. Patient's perceptions and expectations regarding their appearance play a significant role in treatment planning

A balanced smile, can be best described as an appropriate positioning of teeth and gingival scaffold within the dynamic display zone. Smile analysis is part of a facial analysis and allows

dentists to recognize positive and negative elements in each patient's smile. Various studies of facial features have been made with the aim of determining norms that might help us to evaluate facial characteristics given that while the rules defining esthetics can be difficult to determine, it might be possible to form some general guidelines for optimizing dentofacial esthetics.

There are two forms of smiles—the enjoyment or Duchenne smile and the posed or social smile. The posed smile is voluntary and not elicited by an emotion. In other words, it is reliably reproducible and can be sustained. Posed smiles, therefore have importance in orthodontic diagnosis and treatment planning. The unposed or social smile, however, is involuntary and is induced by joy or mirth. It is a natural response as it expresses authentic human emotion. Unlike the posed smiles, these smiles are not sustained. Both skeletal and dental relationships contribute to these smile components.

1. Dr NirupamaUndergraduate BDS student, A.J Institute of Dental Sciences, Mangalore.

2. Dr . Mithun Assistant Professor, A.J Institute of Dental Sciences, Mangalore.

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Hence, smile analysis and smile design have become a key element for dentists but the subjective perception of beauty makes it difficult to establish concrete esthetic objectives for guiding diagnosis and treatment planning.

The three parameters which will be evaluated are

1. Diastema

Diastema is the space between two teeth in the same dental arch not caused by the loss of a tooth between them. It occurs most commonly between the maxillary central incisors in adults. Also referred as a negative space, since diastema creates a dark spot within a smile as the darkness of the back of the mouth shows.

2. Buccal corridor space

Buccal corridor refers to dark space (negative space) visible during smile formation between the corners of the mouth and the buccal surfaces of the maxillary teeth and is measured from the mesial line angle of the maxillary first premolar to the interior portion of the commissure of lips. It is represented by a ratio of the intercommissure width divided by the distance from the first premolar to first premolar.2

3. White spot lesions

White spot lesion is the decalcification of the enamel surface adjacent to fixed orthodontic appliances. White spots that develop on tooth enamel are usually an indication of tooth decay formation. They're the first readily visible sign that an area is developing a cavity. Another term dentist's use for white spots is "incipient lesions," meaning areas of decay that are just beginning. The affected areas have an opaque, chalky-white appearance that's lighter in color than neighboring undamaged areas.

AIMS AND OBJECTIVES

Esthetic perception varies from person to person and is influenced by each person's personal experience and social environment. Trained and observant eye readily detects what is out of balance and out of harmony with its environment. For this reason, professional opinions regarding facial esthetics may not coincide with the perceptions and expectations of patients or lay people.

The objectives of the present study was to determine the factors influencing esthetic

evaluations of the smile such as diastema, buccal corridor and white spot lesions among orthodontists, dental students and laypeople, as well as to find out if there is homogeneity of the criteria by which smile esthetics are assessed between professionals (orthodontist and dental students) and lay person.

MATERIALS AND METHODS

Model selection and image manipulation:

Subjects will be selected based on smile characteristics that fulfilled standard norms. They had class I molar relation, well aligned anterior teeth, presence of all permanent teeth except third molars, no gross facial asymmetry, with no previous orthodontic treatment, and no history of facial trauma, plastic surgery or orthognathic surgery. Photographs will be taken with a digital camera with the head held in a natural head position. The distance between the camera and stool was fixed at 3 feet for all the subjects. The camera lens was adjusted parallel to the apparent occlusal plane and focused only on the dentofacial complex (corresponding to the area from the nose to the chin).

The two subjects selected one female (Fig: 1(A)) and one male (Fig: 1(a)) frontal smile photographs was taken. These photographs will be manipulated using Adobe Photoshop. Informed consent for manipulating the images was taken.

Fig: 1 Photographs of subject

a

b

The parameters which were manipulated are

1. Diastema: The midline diastema is a space (or gap) greater than 0.5mm between the mesial surfaces of maxillary central incisors. They were graded from 1mm, 2mm and 3mm (Figure 2 and 3)

17


Normal D1: Diastema of 1mm D2: Diastema of 2mm

D2: Diastema of 3mm

Figure : 2

Normal D1: Diastema of 1mm

D2: Diastema of 3mm

Figure : 3

2. Right and left buccal corridors: The horizontal distance from the distal aspect of the canine to the respective outer commissure. They were graded according to the negative space extending to molar, premolar and canine varied as 1mm, 2mm and 3mm respectively (Fig: 6 and 7)

NormalFigure : 6 B1: Buccal corridor space of 1mm B1: Buccal corridor space of 2mm

B1: Buccal corridor space of 3mm Figure : 7 Normal B1: Buccal corridor space of 1mm

B1: Buccal corridor space of 2mm B1: Buccal corridor space of 3mm

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3. White spot lesion: Decalcification of the enamel surface adjacent to fixed orthodontic appliances. They were graded as mild, moderate and severe. (Fig: 4 and 5)

Figure : 4 Normal W1: White spot lesion mild W2: White spot lesion moderate

W3: White spot lesion Severe Figure : 5 Normal W1: White spot lesion mild

W2: White spot lesion moderate W3: White spot lesion Severe

Questionnaire and catalogue:

A questionnaire and catalogue will be designed including the set of smile images in colour. The questionnaire gathered data on the subjects/ evaluators: age, sex and profession. The catalogue will contain image which has to be evaluated. The classification of the pictures will be done using the visual analogue scale (VAS), scored 1 to 5 with "1" indicating the least attractive smile and "5" the most attractive smile.

Evaluators:

It consists of 120 individuals (n= 60 men and n=60 women), belonging to one of three groups: 40 Layperson (20 men and 20 women); 40 Dental students (20 men and 20 women); 40 Orthodontist (20 men and 20 women) Manipulated pictures of the same smile will be arranged at random and the data obtained was entered into Microsoft Excel to evaluate smile.

STATISTICAL ANALYSIS:

The responses was then analyzed and processed with SPSS using tests of average equality and correlation. The presence of significant differences between the three groups of evaluators for individual assessment of each image and for order of preference was analyzed using non-parametric test Mann Whitney U test.

Methodological error:

To test the reproducibility of the test, 20 evaluators selected randomly in each group was asked to rate the photographs again after a 2-week interval.

RESULTS:

The difference in perception of smile and identification of malocclusion by orthodontists, dental students and lay persons was evaluated. The most frequent score given by orthodontists, dental students and lay persons for each photograph is given in (Table 1). Statistical analysis using Mann

19


Whitney U test showed a significant difference between orthodontists, dental students and lay persons in identifying malocclusions and their difference in smile perception (Table 2).

The evaluation of ideal smile of both male and female subjects by orthodontists, dental students and lay persons showed significant difference. The perception of smile by orthodontists differed significantly from lay persons and dental students (p < 0.001). There was no statistical difference between smile perception of ideal smile between lay persons and dental students (p = 0.617). The most frequent score given for ideal smile of female and male subjects by orthodontists was attractive, which differed from the average score given by dental students and lay persons.

Effect of midline diastema on smile attractiveness of female subject:

• 1 mm. There were statistically significant differences between lay people and orthodontists (P < 0.001) and between orthodontists and dental students (P < 0.001). Gender differences were found with significantly greater smile perception among males.

The most frequent score of average given by orthodontists, score of below-average by dental students and a score of attractive was given by lay persons.

• 2 mm. There were statistically significant differences between laypeople and orthodontists (P < 0.001) and between orthodontists and dental students (P = 0.001). There was no statistical difference between the genders on smile perception. The most frequent score given

by orthodontists was average, whereas, a score of below-average was given by dental students and lay persons.

• 3 mm. significant differences were observed between laypeople and orthodontist, and between lay persons and dental students. Males among dental students were more sensitive to the presence of a 3 mm midline diastema than females (P < 0.019). The most frequent score given by orthodontists and dental students was poor. The most frequent score given by lay persons was below-average.

Effect of midline diastema on smile attractiveness of male subject:

• 1 mm. There were statistically significant differences between lay people and orthodontists (P = 0.009) and between lay persons and dental students (P < 0.001). The most frequent score given by orthodontists was average. A score of poor and below-average was given by dental students and lay persons respectively.

• 2 mm. There were statistically significant differences between laypeople and orthodontists (P < 0.001) and between orthodontists and dental students (P = 0.001). there was no statistical difference between the gender on smile perception. The most frequent score given by orthodontists was average. A score of poor and below-average was given by dental students and lay persons respectively.

• 3 mm. There were statistically significant differences between laypeople and orthodontists (P < 0.001) and between orthodontists and dental students (P = 0.001). the most frequent score given by orthodontists and dental students was poor which differed from the score given by lay persons as below-average.

Effect of buccal corridor on smile attractiveness of female subject:

• 1 mm. There were statistically significant differences between lay people and orthodontists (P = 0.004) and between lay persons and dental students (P =0.025). The most frequent score given by orthodontists, dental students and lay persons was average.

• 2 mm. There were statistically significant differences between laypeople and orthodontists (P <0.001) and between orthodontists and dental students (P = 0.009). There was statistical difference between smile perception of dental students and lay persons (p=008). The most frequent score given by orthodontists and dental students was average which differed from a score of attractive given by lay persons.

• 3 mm. There were statistically significant differences between laypeople and orthodontists (P < 0.001) and between lay persons and dental students (P <0.001). The most frequent score given by orthodontists, dental students and lay persons was poor.

20


Effect of buccal corridor on smile attractiveness of male subject:

• 1 mm. There were statistically significant differences between lay people and orthodontists (P < 0.001) and between orthodontists and dental students (P =0.001).

There was statistical difference in smile perception between dental students and lay persons (p<0.001). The most frequent score given by orthodontists was average which differed from a below-average and attractive score given by dental students and lay persons respectively.

• 2 mm. There were statistically significant differences between lay people and orthodontists (P <0.001) and between orthodontists and dental students (P =0.008).

There was statistical difference in smile perception between dental students and lay persons (p=0.046). The most frequent score given by orthodontists and dental students was below-average compared to an average score given by lay persons.

• 3 mm. There were statistically significant differences between lay people and orthodontists (P <0.001) and between orthodontists and dental students (P =0.007).

21


22


DISCUSSION

Orthodontists, Dental professionals and Layperson share more differences when evaluating the smile esthetics. Subjects with ideal occlusions and Class I patients treated with or without extractions group were not differentiated in smile esthetics by 3 panels of judges when overall mean esthetic scores were taken.

Perception of orthodontist of the ideal photographic characteristics was more precise than that of dental students and layperson. Layperson and dental student had similar perception and were ignorant of the ideal smile characteristics.

Clinically, the midline diastema is a space (or gap) greater than 0.5mm between the mesial surface of maxillary central incisors. The space can be a normal growth characteristic during the primary and mixed dentition and generally is closed by the time the maxillary canines erupt. For most children, with the eruption of canine normal closure of this space occurs. For some individuals, h oweve r, t h e d i a s te m a d o e s n o t c l o s e spontaneously.19 Midline diastema's can be genetical, physiological, dentoalveolar, due to a missing tooth, due to peg shaped lateral, midline supernumerary teeth, proclination of the upper labial segment, prominent frenum and due to a self-inflicted pathology by tongue piercing.20 Midline spacing has a racial and familial background. Although no specific genes have been investigated for its genetic etiogenesis but there are many syndromes and congenital anomalies which contained midline diastema one of their component e.g. Ellis-van Creveld syndrome21, Pai Syndome22 ,lateral incisor agenesis 23 and cleft palate24 ,median cyst25 . Midline diastema may be considered normal for many children during the eruption of the permanent maxillary central incisors. When the incisors first erupt, they may be

separated by bone and the crowns incline distally because of crowding of the roots.

With the eruption of lateral incisors and permanent canines, midline diastema reduces or even closes (ugly duckling stage).

The outward pressure from prolonged oral habits (light continuous force over 6 hr) with inadequate lips seal can cause the maxillary incisors to flare out, which leads to the midline diastema. Examples include: lower lip biting and digit sucking.26 Conditions such as macroglossia, tongue thrust, improper tongue rest position, and/or flaccid lip muscles can caused midline diastema.27An open midpalatal suture or skeletal cleft may prevent normal space closure and present as midline diastema.28 Moyer's stated that imperfect fusion at the midline of premaxilla is the most common cause of maxillary midline diastema. The normal radiographic image of the suture is a V-shaped Structure.

The result of this study on midline diastema was rated as unattractive by orthodontist and dental students when compared to layperson. This is in agreement with Kokichet al.5 who suggested that orthodontists rated the smile as unattractive when the midline diastema width was 1–1.5 mm or more, while general practitioners and laypeople considered the smile as unattractive when the midline diastema width was 2 mm or more.

Buccal corridor of space

The ideal arch is broad and conforms to a U shape and is more likely to fill the buccal corridors than narrow and constricted arch. The result of this study on buccal corridor was rated as unattractive as it increased by orthodontist and dental students. The threshold of perception of layperson was 3mm which signifies this feature is not observed by layperson as an important feature in smile analysis. Moore et al recommended that having minimal

23


buccal corridors is a preferred esthetic feature in both men and women, and large buccal corridors should be included in the problem list during orthodontic diagnosis and treatment planning. Ioi et al found that narrow or intermediate buccal corridors are considered more esthetic.

White spot lesions

Dissolution and deposition of tooth enamel occurs regularly in all teeth. When the pH level in the mouth drops sufficiently, dissolution of calcium and phosphate ions occurs. As the pH returns to normal levels, deposition of these ions from the saliva occurs and the enamel is restored. If the pH stays low for an extended time, more dissolution than deposition occurs. When a net loss occurs, the enamel is defined as decalcified. When light hits an area of subsurface decalcification it scatters differently than when it hits sound enamel. As such, decalcified enamel appears as an opaque, white color and is referred to as a white spot lesion (WSL). Over time, the white spot may recalcify, but the opaque color usually remains, and often becomes stained, making it even less esthetic. The result of this study on white spot lesion was rated as unattractive as it increased by orthodontist and dental students. The layperson found moderate level of white spot lesion to be more attractive due to whiter appearance of the teeth. Thus indicating colour as main confounding factor in perception of smile.

In this study, we used a computer to alter dental and soft tissues to simulate natural dental anomalies. Although this is not a perfect method, at least by using the same image and only modifying 1 variable, we isolated and accurately compared the judgments of various groups of raters. However, therein lies a potential problem. We are not suggesting that the results of our research should be interpreted as anything other than the average assessment of each group of raters. The problem with using averages is that it is difficult to apply this information directly to a patient in your dental chair, when you are contemplating a change in his or her dental esthetics. Thus, you must interpret this information carefully and apply it cautiously. A better approach would be to customize this method of evaluation by allowing each patient to rate the same photos that were viewed by our raters. In this way, perhaps the clinician could determine each patient's level of awareness. This could result in a

more educated and informed approach in the treatment of each patient.

CONCLUSION

Among the three parameters. White spot lesion of severe variety was perceived as the least attractive by all three groups of evaluators followed by an increased buccal corridor of space. On a contrary moderate variety of white spot lesion was considered as more attractive by layperson.

The findings of this study showed that laypeople accept a wider range of deviation compared with dental students and orthodontists. Therefore, when aesthetic treatment to obtain a harmonious smile is performed, clinicians must be careful about imposing his/her own beauty norms upon patients. The type and degree of deviation from the norm and the opinion of the patient need to be taken into consideration.

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14. Nascimento DC, Santos ER, Machado AWL, BittencourtMAV. Influence of buccal corridor dimension on smile esthetics. Dental Press J Orthod. 2012 Sept-Oct;17(5):145-50.

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16.

17. Poorya Naik, Mala Ram Manohar, G.Shivaprakash, NazimaJabeen: Smile esthetics-evaluation of differential perception among laypersons,dental professionals and orthodontist. IOSR Journal of dental and medical sciences vol13; issue1: jan2014. 35-43.

18. Larissa Suzuki, André Wilson Machado, Marcos Alan Vieira Bittencourt. Perceptions of gingival display aesthetics among orthodontists, maxillofacial surgeons and laypersons. Rev. odontociênc. 2009;24(4):367-371

19. Proffit WR, Fields HW. Contemporary Orthodontics. 4th ed .Mosby.2007;99-100.

20. Ewards JG. The diastema, the frenum, the frenectomy a clinical study. Am J Orthod 1977; 71: 489–508

An, Seong-Mu et al. "Comparing Esthetic Smile Perceptions among Laypersons with and without Orthodontic Treatment Experience and Dentists. "Korean Journal of Orthodontics 44.6 (2014): 294–303

Cotrim ER, Vasconcelos ÁV, Haddad ACSS, Reis SAB. Perception of adults' smile esthetics among orthodontists, clinicians and laypeople. Dental Press Journal of Orthodontics. 2015;20 (1):40-44.

An S-M, Choi S-Y, Chung Y-W, Jang T-H, Kang K-H. Comparing esthetic smile perceptions among laypersons with and without orthodontic treatment experience and dentists . Korean Journal of Orthodontics. 2014;44(6):294-303.

21. Hattab FN, Yassin OM, Sasa IS. "Oral manifestations of Ellis-van Creveld syndrome: report of two siblings with unusual dental anomalies." The Journal of clinical pediatric dentistry 1998;22(2): 159-65.

22. Mishima K, Mori Y, Minami K, SakudaM ,Sugahara T. (1999). A case of Pai syndrome. Plastic and reconstructive surgery.1999;103(1): 166-70.

23. De Coster PJ, Marks LA, Martins LC, Hysseune A. Dental ageneses: Genetic and clinical perspective. J Oral Pathol Med 2009;38:1-17.

24. Tang EL, So LL. Prevalence and severity of malocclusion in children with cleft lip and/or palate in Hong Kong. The Cleft palate-craniofacial journal,1992; 29(3): 287-91.

25. Neville BW, Damm DD, Brock T. Odontogenic keratocysts of the midline maxillary region. J Oral MaxillofacSurg 1997;55:340-4.

26. Huang WJ, Creath CJ. The midline diastema: A review o f i t s e t i o l o g y a n d t r e a t m e n t . P e d i a t r i c dentistry.1995;17:171-77.

27. Attia Y: Midline diastemas: closure and stability. Angle Orthod.1993; 63:209-12.

28. Adams CP: Relation of spacing of the upper central incisors to abnormal frenumlabii and other features of the dentofacial complex. Am Dent J.1954; 74:72-86.

29. Kumar LN, Nagmode P. Midline Diastema: treatment Options. J Evolution of Medical and dental Science.2012; 1(6):1262-6.

30. Hiemstra R, Bos A, Hoogstraten J. Patients' and parents' expectations of orthodontic treatment. J Orthod. 2009;36: 219–228.

31. Moore T, Southard KA, Casko JS, Qian F, Southard TE. Buccal corridors and smile esthetics. Am J OrthodDentofacialOrthop 2005;127:208-13.

32. Ioi H, Kang S, Shimomura T, Kim SS, Park SB, Son WS, et al. Effects of buccal corridors on smile esthetics in Japanese and Korean orthodontists and orthodontic p a t i e n t s . A m J O r t h o d D e n t o f a c i a l O r t h o p . 2012;142(4):459-65.

33. Ogaard B. White spot lesions during orthodontic treatment: mechanisms and fluoride preventive aspects. SeminOrthod. 2008;3: 183–193.

34. Ogaard B. Prevalence of white spot lesions in 19 year olds: a study on untreated and orthodontically treated persons 5 years after treatment. Am J Orthod Dentofacial Orthop. 1989;96:423–427

25


Evaluation of the effect of Preparation Taper, Finish Line and Marginal Configuration on Extra Oral Scanning in

CAD/CAM- An In-vitro Study

AUTHORS : 4 5 6

Dr. Niyati Shah , Dr.MavaniSoham V , Dr. Patel Brijesh M

1 2 3Dr. Soundharya Aishwarya B , Dr. Ramesh TR , Dr. Shweta Kumari Poovani ,

ABSTRACT Purpose of the study: Many authors and some of the clinicians are of the opinion that tooth preparation is not the same for CAD-CAM restoration. There are some manufacturers who also recommend preparation taper of higher degree. Based on the above notion this study was conducted whether the tooth preparation has got any bearing in the scannability of gypsum models.

Aims and objectives:

Aim : The aim of the study is to scan the gypum models using extraoral scanners.

Objectives: The objective of this study is to evaluate whether the following feature of tooth preparation has any effect on scannability

Materials and methods:

Six standard metal dies are prepared with a crown length 8mm, diameter 5mm out of which

§ Three dies with 3º, 8º and 12ºtaper each with shoulder margin,

§ Two dies with shoulder and chamfer finish line &

§ One with marginal geometry in different planes.

Each die was duplicated ten times and a total 60 models will be obtained.

The stone cast models which are duplicated from the individual metal dies are scanned using extra oral model scanner INTELLIDENTA.

1. Different preparation taper.

2. Shoulder or chamfer margin.

3. Plane of marginal placement.

Results:

As far as extra oral scanning is concerned, there is no significant difference in scanning regarding preparation taper, finish line and marginal configuration.

Conclusion:

Currentlyextra oral scanners are capable of producing vitual model images irrespective of preparation taper, finish line and marginal geometry.

1. Soundharya Aishwarya B

Post graduate student, Department of Prosthodontics, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

2. Ramesh TR

HOD & Professor, Department of Prosthodontics Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

3. Shweta Kumari Poovani

Reader, Department of Prosthodontics, Raja Rajeshwari Dental College & Hospital, Bangalore, Karnataka, India

4. Niyati Shah

Senior Lecturer, Department of Prosthodontics Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

5. MavaniSoham V


6. Patel Brijesh M


Narsinhbhai Patel Dental College & Hospital, Visnagar, (Dist)Mahesana, Gujarat, India Pin 384315

INTRODUCTION

Automated restoration in the form of Computer Aided Designing and Computer Aided Manufacturing has become popular these days because of the quick, precise and bulk fabrication of restoration. CAD –CAM SYSTEM has got 3 components

1. A digitalisation tool/scanner that produces digital data

2. Software to produce virtual images

3. Milling system to produce the restorationScanners have digitalization tools that scans the prepared tooth and transform them into digital

1data sets.

26

Scanners are of two types: intra-oral and extra -oral scanners. Extra oral scanners are the most commonly used scanners for large scale production and cost effective. Both operates on the optical properties of light. The extraoral scanners can be classified based on thesource of light that it uses.They are Laser scanners and white light

2scanner . Laser scanners analyse line pattern and it produces speckle effect. White light scanner sanalyse multiple stripe pattern for obtaining

3three-dimensional data . The speed of laser is 10-500 kHz/s and that of white light is 3mHz/s.

In this study white light was employed from a professional CAD CAM laboratory.

4Some authors Castillo and Sanchez and manufacturers E4D have mentioned high degree of taper in their study for CAD-CAM scanning. It could be due to the scannability of extra oral scanners. This study was undertaken based on that notion.

Aims & Objectives:


Objectives : The objective of this study is to evaluate whether the following feature of tooth preparation has any effect on scannability

MATERIALS AND METHODS:

Six standard metal dies are prepared with the described preparation geometry of length 8mm, width 5mm out of which

§ Three with varying degrees of 3°, 8 and 12taper of preparation taper each,

§ Two dies with shoulder and chamfer finish line


Stone cast models are fabricated after duplicating the metal dies with putty impression material. A total of 60 samples of stone cast models are prepared of 10 each and are scanned in INTELLIDENTA model scanner.




° °

27


AUTHORS : Dr. N S VenkateshBabu Dr. Purna B Patel1 2 ,

Knowledge and Practice of Pulp Therapy in Deciduous Teeth

amongst General Dental Practitioners

1. Dr. N S VenkateshBabu, Professor and Head of the Dept of Pediatric& Preventive Dentistry, VS Dental College, Bangalore.

2. Dr. Purna B Patel, Post Graduate student, Dept of Pediatric & Preventive Dentistry, VS Dental College, Bangalore.

INTRODUCTION

The primary objective of pulp therapy is to maintain integrity and health of the deciduous tooth and its supporting tissues. Any primary tooth with an exposed pulp may require pulpotomy, pulpectomy, or extraction based on the vitality of the pulp, presence or absence of pathology, restorability, and the duration of time for normal

1tooth exfoliation.

Preservation of arch length is one of the principle objectives of Pediatric dentistry. Premature loss of primary teeth may cause aberration of the arch length, resulting in mesial drift of permanent teeth and consequent malocclusion. Thus, extraction would be the least preferred treatment in a deciduous tooth where space management would

1be an issue.

Pulpotomy and pulpectomy are the two main endodontic procedures performed in deciduous teeth.Medicaments and the obturation techniques used for pulp therapy in deciduous teeth differ from

2those used in permanent teeth. It is therefore important that general dental practitioners show interest in performing the procedure, familiarize themselves with the pulp medicaments to be used, do a proper final restoration and know when to

3refer.

AIM OF THE STUDY

To determine knowledge and practice of pulp therapy in deciduous teeth among general dental practitioners in South Bangalore city.

MATERIALS AND METHODOLOGY

A total of 100 general dental practitioners selected from private dental clinics in Bangalore city were asked to participate for the present study using a questionnaire. (Table 1) The participants were asked to choose from the answers provided in the questionnaire. The data was analysed using SPSS software version 11.0 and categorical outcomes were described with percentage.

RESULTS

The results of the present study showed that 15% dentists recommended pulpotomy as the first line of treatment 12% recommended pulpectomy and 73% referred the cases to Pediatric dentist where pulp therapy was indicated. None of the 100 dentists recommended extraction as the first line of treatment. 77% suggested primary reason for performing endodontic treatment in deciduous tooth was elimination of pain, whereas 18% thought space management should be the primary reason and 5% thought that pulp treatment should be performed in order to stop further progression of the disease. During pulpotomy procedure, 92% used Buckley's formocresol, while 1% used ferric sulfate and 3% used gluteraldehyde. 83% of the dentists squeezed the formocresol-dipped cotton pellet before placement on the vital pulp. For application time of formocresol during pulpotomy, 72% of the dentists applied it for 5 mins, 21% of the dentists applied for 4 mins, and 7% of the dentists applied for 1 min only. 79% of the dentists preferred zinc oxide eugenol (ZOE) as an obturating material for pulpectomy, followed by 13% calcium hydroxide paste and 5% preferred commercially available mixture of calcium hydroxide and iodoform. 63% dentists cited thatthe main reason for selecting ZOE as obturation material was its easy availability. 65% of the dentists preferred using handheld reamers for obturation of deciduous teeth, 3% slow-speed lentulospirals, 13% obturation paste syringes, and 19% preferred other techniques.48% of the dentists used glass ionomer cement as final restoration, followed by 36% used miracle mix, and 16% used composite resin. 35% of the dentists recommended stainless steel crowns followed by final restoration in pulp therapy treated tooth. (Table 1, Graph 1)

DISCUSSION

The type of pulp therapy depends on whether the pulp is vital or non-vital based on the clinical

4diagnosis. In the present study, the first line of

28

treatment for a tooth with pulp exposure, 15% of the dental practitioners recommended pulpotomy, 12% recommended pulpectomy, and 73% referred such cases to Pediatric dentist. None of the general dentists recommended extraction as the first line of treatment. It reflects awareness among the general dental practitioners about importance of maintaining the deciduous teeth in the dental arch.

A study done in Saudi Arabia by Togoo et al found that 64% and 30% of the general dentists preferred pulpotomy and pulpectomy respectively whereas

3only 6% referred such cases to Pediatric dentists. These results were comparable to the results obtained by Bowen et al. who found 45% of the general dentists selected pulpotomy as treatment of choice. Whereas in our study most of the dentists (73%) preferred to refer such cases to Pediatric

4dentist. Even though most recommended choice of treatment was pulpotomy which is a conservative approach to pulp therapy, may not always be the

3right option.

When enquired about the reason for performing endodontic treatment in deciduous tooth 77% of the dentists suggested elimination of pain as primary reason. However, 18% chose space management as primary reason for performing endodontic treatment which shows awareness amongst general dentists regarding maintenance of

6deciduous teeth in the dental arch.

During the pulpotomy procedure , 92% practitioners used Buckley's formocresol, while 3% used gluteraldehyde and 1% used ferric sulfate. Formocresolis the most commonly used material for pulp fixation among general dentists. Similar results were found by Togoo et al, who reported 88% of the dentists used formocresol for pulp

3fixation. Ideally, formocresol should be applied on the pulp for 5 mins, though it has been indicated in few studies that an application time of 1 min may

7also be sufficient. In the present study, 72% of the dentists applied formocresol for 5 mins and 7% applied it for 1 min. Majority of the dentists preferred traditional 5 mins application of formocresol for pulpotomy procedure.

It was found that 83% of the dental practitioners squeezed dry formocresol-dipped cotton pellet before applying it on the vital pulp. Excess amount of formocresol along with the inflammatory fluid may dissipate to local regional vascular vessels,

r e s u l t i n g i n s y s t e m i c d i s t r i b u t i o n o f formaldehyde.Therefore, the fact that majority of dental practitioners squeeze dry the cotton pellet before application on the pulp is a very significant finding. General dentists were aware about the complications associated with the use of excessive

8,9amount of formocresol.

Regarding the material of choice for obturation in primary teeth, 79% of general dental practitioners preferred Zinc oxide eugenolcement(ZOE), while 13% preferred calcium hydroxide paste. Very few dental practitioners were aware about the calcium hydroxide and iodoform combination, even though this material has superior properties than the other

10 materials. Most dentists selected ZOE because of its easy availability. For obturation of primary teeth the use of commercially available mixtures of iodoform, calcium hydroxide and ZOE should be encouraged. Use of these combination materials provide better prognosis than the use of ZOE

11alone.

The most commonly used obturation technique was the use of handheld reamers (65%). Whereas 19% dentists preferred using hypodermic syringes and pressure by cotton pellets to obturate deciduous canals. Commercially available obturation syringes were also used by 13% of the dentists. Very few (3%) dentists used slow speed lentulospirals.This may be due to lack of expertise among general dentists to use these techniques. Hands-on courses to train general dentists regarding different obturation techniques are recommended.

The final restoration after pulp therapy is a contributing factor to failure or success of the endodontic treatment.In our study, 48% of the general dentists preferred Glass Ionomer Cement (GIC) as final restoration, 36% preferred materials such as resin modified GIC or miracle mix and 16% preferred composite resin. None of the dentists recommended the use of amalgam for deciduous teeth. In a study done byhanes et al comparing the choice of final restoration by general and Pediatric dentistsfor primary teeth reported that general dentists frequently recommended restoring teeth

2with amalgam (61%). Whereas in our study all the general dentists were aware about the controversies regarding the use of amalgam for primary teeth and none of the dentists recommended its use.

29


Stainless steel crowns were recommended by 35% of the dentists followed by final restoration in pulpally treated teeth. This indicates lack of awareness amongst general dentists regarding the use of stainless steel crowns after pulp therapy. The relatively minimal use of stainless steel crowns may also be due to lack of expertise among general dentists.

CONCLUSION

The number of General dentists willing to provide treatment to young children are very few. Most of the dentists prefer to directly refer these cases to Pediatric dentist either due to their limited knowledge regarding the subject or due to the fear of non-cooperation on the part of the child.

Formocresol was the most common material used by the general dentists for pulp fixation. Most of the dental practitioners were aware about pulpotomy procedure, but lack knowledge when it comes to pulpectomy. Use of traditional obturation material such as Zinc oxide eugenol and technique such as handheld reamers were more popular amongst the general dentists. Very few general dentists were aware about the newer pulpectomy materials and techniques. Even though, Stainless steel crown is a must followed by pulp therapy very few dental practitioners have recommended its use.

Educational training programs like lectures and hands-on courses should be conducted to improve knowledge of the general dental practitioners regarding the endodontic treatment for primary teeth.

REFERENCES

1. Garcia-Godoy F. Evaluation of an iodoform paste in root canal therapy for infected primary teeth. ASDC J Dent Child. 1987;54:30–4.

2. Hanes CM, Myers DR, Dushku JC, Barenei JT. A comparison of general dentists' and pediatric dentists' treatment recommendations for primary teeth. Pediatr Dent. 1991;13:344–8. RATogoo

3. VS Nasim, M Zakirulla, SMYaseen. Knowledge and practice of pulp therapy in deciduous teeth among general dental practitioners in Saudi Arabia. Ann Med Health Sci Res 2012 Jul;2(2):119-23

4. Bowen JL , Mathu-Muju KR, Nash DA, Chance KB, Bush HM, Li HF. Pediatric and general dentists' attitudes toward pulp therapy for primary

1

teeth.Pediatr Dent. 2012 May-Jun;34(3):210-5.

5. Guideline on Pulp Therapy for Primary and Immature Permanent Teeth. AAPD Reference Manual. 2011-12;33:212–9.

6. Breakspear EK. Sequelae of early loss of deciduous molars. Dent Rec (London) 1951;71:127–34.

7. Garcia-Godoy F. Penetration and pulpal response by two concentration of formocresol using two methods of application. J Pedod. 1981;5:102–35.

8. Block RM, Lewis RD, Coffey J, Hirsch J, Langeland K. Histopathologic and Systemic Distribution of 14-C Pa ra fo r m a l d e hyd e i n c o r p o ra te d w i t h i n formocresol following pulpotomies in dogs. J Endod. 1983;9:176–89.

9. Myers DR, Pashley DH, Whitford GM, McKinney RV. Tissue changes induced by the absorption of formocresol following pulpotomy sites in dogs. Pedia Dent. 1983;5:6–8.

10.Bawazir OA, Salama FS. Clinical evaluation of root canal obturation methods in Primary Teeth. Pediatr Dent. 2006;28:39–47.

11.Huth KC, Paschos E, Hajek-Al-Khatar N, Hollweck R, Crispin A, Hickel R, et al. Effectiveness of 4 pulpotomy techniques- Randomized controlled trial. J Dent Res. 2005;84:1144–8.

Corresponding Author:Name: Dr N. S. VenkateshBabuAddress: V. S. Dental College, V. V Puram, K R Road, Bangalore-560004Phone : +919448710392E-mail : [email protected]

GRAPH 1: Graphical presentation of survey results

30


Questions

Total No. Of Dentists: 100

1.

First line of

treatment for

deciduous

tooth with

pulp exposure

Pulpotomy

15% Pulpectomy

12% Refer to

pedodontist

73%

Extraction

0%

2.

Reasons for

performing

endodontic

treatment in

deciduous

tooth

Pain

elimination

77%

Space

management

18%

Prevent

progression of

disease

5%

Other

reason

s

--

3. Materials used

for pulp

fixation

during a

pulpotomy

procedure

Buckley’s

formocresol

92%

Ferric sulphate

1% Gluteraldehyde

3% Others

4%

4. How many

minutes

formocresol is

retained on

the pulp

during a

pulpotomy

procedure

5 mins 72%

4 mins 21%

1 min 7%

--

5.

Squeeze

cotton pellet

dry before

placing it on

the vital pulp

Yes 83%

No 17%

6.

Materials

used for

obturation in

deciduous

teeth for

pulpectomy

Zinc oxide

eugenol

79%

Calcium

hydroxide

paste

13%

Combination of

CaOH2&Iodoform

5%

Other

materi

als

3%

7.

Reason for

selecting your

material of

Availibility

63%

Ease of use

37%

TABLE 1: Questionnaire

31


Tobacco use Among School Personnel in Mangalore City, India - A Pilot Study

1 2 3AUTHORS: Dr Shubhan Alva , Dr Amrithavarshini H , Dr Julie Elizabeth Lawrence

Authors:

1. Dr Shubhan Alva, Reader,

2. Dr Amrithavarshini H

3. Dr Julie Elizabeth Lawrence

Department of Public Health Dentistry, A.J. Institute of Dental SciencesMangaluru, Karnataka 575004

Background: Schools are in a uniquely powerful position to play a major role in reducing tobacco use among children. To plan effective interventions, it is essential to have information on the extent and the type of tobacco use among school personnel, their attitudes towards tobacco control, and the existence of school health polices about tobacco. Hence this study was conducted to obtain baseline information about knowledge, attitude and practice about tobacco use among school personnel in Mangalore city, India.

Methods:

A cross-sectional study was conducted among School Personnel of Mangalore city, India using anonymous self-administered Global School Personnel Survey (GSPS) questionnaire.

Results:

A total of 130 participants participated in the study, out of which 94.6% were females. Among them 5.4% smoked and 2.4% chewed tobacco.

Conclusion:

It can be concluded that School personnel have a favorable attitude towards tobacco control and are ready to work for it with proper training. Awareness programme regarding tobacco should be conducted for both teachers and students who can aid in implementation of tobacco control policies in schools.

Knowledge regarding the cause of lung cancer due to tobacco was known by 92.2% of the participants and 88.4% believed that teachers tobacco use influenced youth tobacco use. Among the study participants 69.3% said that they had a school policy prohibiting the use of tobacco inside school and 30.7% of them said that tobacco could be bought within 100 yards of their school premises.

Introduction:

Tobacco is the single most cause for premature death in the world. It is estimated that by 2030,

about 70% of deaths due to tobacco use will occur 1

in low and middle income countries. . Teachers form a very important component in shaping the behavior of the children. Continuous monitoring and appropriate action is required to curb this habit among children. Tobacco use among children in the age group of 13-15 years is conducted worldwide through GYTS. GSPS is also conducted at the same time as GYTS. The objectives of GSPS are 1) To obtain baseline information on Tobacco use.2) To evaluate the existence , implementation and enforcement of tobacco control policies in schools.3) to understand the knowledge and attitudes towards tobacco control policies.4)to assess training and material requirememts for implementing tobacco prevention and control interventions 5) to verify some information

2obtained from the GYTS. This study is the first report of school personnel from Mangalore,India. This can enable a coordinated action plan for tobacco control.

METHODOLOGY:

A cross sectional study was conducted among school personnel in Mangalore city for a period of 10 months. The school personnel involved both the teachers and the administrative staff of the school. The tool used for data collection was the Global School Personnel Survey (GSPS) form. Schools were selected based on convience sampling. All the school personnel who gave the informed consent were a part of the study. Ethical clearance was obtained from the Institutional Ethical Committee. The obtained data was analyzed using SPSS version 16.

Results:

Out of 42 sampled schools 30 participated in the survey. A total of 130 participants participated in the study out of which 39.5% belonged to the age group of 20-29 years, 94.6% were females.

Graph 1 shows the prevalence of tobacco use

32

among the school personnel. Cigarettes were used by 5.4% of the study participants. Smokeless forms of tobacco was used by 2.4% of the study participants.

Graph 2 shows that Knowledge regarding the cause of lung cancer due to tobacco was known by 92.2% of the participants. Tobacco as an addictive was known by 82.3% of the participants.

Graph 3 shows that among the participants 88.4% believed that teachers tobacco use influenced youth tobacco use. The harmful effect of second hand smoke was known by 96% of the participants. Regarding the ban of tobacco in public places was believed by 93.7%of the school personnel.

Graph 4 shows that 15.5% of the school personnel received training in tobacco control and 49.1% had access to teaching material.

Graph 5 shows that 69.3% and 60.7% of the study participants said that they had a school policy prohibiting the use of tobacco among students and personnel inside school . Regarding the purchase of Tobacco within 100 yards of school was agreed by 30.7% of the participants.

Discussion:

The World Health Organization and the Centers for Disease Control and Prevention initiated the GSPS

3in 2000 as a complement to GYTS. GSPS collects information regarding the Knowledge, Attitude towards tobacco among the school personnel and also provides information regarding the school curriculum related to tobacco. School teachers play a very important role for children, as majority of them take up the use of tobacco in their teens. The prevalence of Tobacco use was 5.4% among the school personnel and 2.4% of them used smokeless forms of Tobacco and snuff. This is very low when compared to a study conducted at Belgaum where

314.5% of them used tobacco.

Majority of the school personnel knew that tobacco was addictive and causes lung cancer and heart disease. This results is similar to a study done by Sharma Rameshwar where 78.4% of them knew that it causes cancer and 55.3% of them knew that

2tobacco was addictive.

Awareness regarding existence of tobacco control policy in the school was assessed through specific questions. Majority of the school personnel reported that their school policy prohibited them

from using tobacco among students as well as a m o n g s c h o o l p e r s o n n e l . Fo r e f fe c t ive implementation of tobacco control policy the school personnel opined that it should be banned in public. This result is in accordance to a study conducted at Bihar where the school policy prohibited the use of tobacco by the students and

4the school personnel.

Majority of the school personnel had access to teaching materials on tobacco. This was in contrast

to a study conducted by Sharma Rameshwar where only 18.7% of the school personnel had access, however 86.1% of the school personnel felt need

2for training.

The findings of this report are subjected to few limitations .First that this report is not preceded by GYTS survey. Secondly, school personnel participation was voluntary, therefore it may under or over report their knowledge and attitude on Tobacco. Thirdly other parameters like type of school (e.g government versus private) rural versus urban, and continuous monitoring of school staff behavior and knowledge should have been considered which may have helped for effective implementation of tobacco control policies in the school premises.

Conclusion:

The study concludes that the school personnel strongly support the tobacco control policies in the school premises and in public. Hence by targeting t h i s i n f l u e n t i a l g r o u p a n d s e t t i n g u p comprehensive smoking cessation programs is crucial for health policy makers to enforce appropriate legislations in the country.

References:

1) Farshad A A, Vesali S, Azaripour H, Rahimi Z, Akbari F. School Personnel Tobacco use in Iran: Results of Global School Personnel Survey. Primary Health Care 2012; 2:119.

2) Gupta R, Pednekar MS, Rehman AU, Sharma R. Tobacco use among school personnel in Rajasthan, India. Indian Journal of Cancer 2004; 41:162-166.

3) Savadi P, Wantamutte AS, Narasannavar A. Pattern of Tobacco use among Primary School Teachers in Belgaum City, India- A Cross Sectional Study. Global Journal of Medicine and Public Health 2013; 4:1-5

4) Sinha DN, Gupta PC, Warren CW, Asma S. Effect of School Policy on Tobacco Use by School Personnel in Bihar, India. Journal of School Health 2004; 74:13-5.

33


Graph 1: Graph showing Prevalence of tobacco use among School Personnel

PREVALENCE OF TOBACCO USECigarettes were smoked In School Premises by 4.8%

Graph 2: Graph showing Knowledge about ill effects of tobacco use among School Personnel

KNOWLEDGE Only 73.5% knew tobacco use causes heart diseases

Graph 3: Graph showing Attitude about tobacco use among School Personnel

Graph 4: Graph showing School Personnel's responses on incorporation of tobacco

control into the school curriculum

SCHOOL CURRICULUMOnly 15.5% of school personnel received training

in tobacco control

ATTITUDEAmong the participants 88.4% believed teachers

tobacco use influenced youth tobacco use

Graph 5: Graph showing the School personnel's responses on school policy on tobacco control

SCHOOL POLICYAround 30.7% said that tobacco could be

purchased within 100 yards of school

34


1 2 3AUTHORS: Dr. Soundharya Aishwarya B , Dr. Ramesh TR , Dr. Shweta Kumari Poovani , 4 5 6Dr. Niyati Shah , Dr.MavaniSoham V , Dr. Patel Brijesh M

Evaluation of the effect of preparation taper, finish line and marginal

configuration on extra oral scanning in CAD/CAM- an in-vitro study

Aims and objectives:


Objectives: The objective of this study is to evaluate whether the following feature of tooth preparation has any effect on scannability

Materials and methods:

Six standard metal dies are prepared with a crown length 8mm, diameter 5mm out of which

§ Three dies with 3º, 8º and 12ºtaper each with shoulder margin,

§ Two dies with shoulder and chamfer finish line


Each die was duplicated ten times and a total 60 models will be obtained.

The stone cast models which are duplicated from the individual metal dies are scanned using extra oral model scanner INTELLIDENTA.

Results:

As far as extra oral scanning is concerned, there is no significant difference in scanning regarding




ABSTRACT Purpose of the study: Many authors and some of the clinicians are of the opinion that tooth preparation is not the same for CAD-CAM restoration. There are some manufacturers who also recommend preparation taper of higher degree. Based on the above notion this study was conducted whether the tooth preparation has got any bearing in the scannability of gypsum models.

1. Soundharya Aishwarya BPost graduate student, Department of Prosthodontics, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

2. Ramesh TR HOD & Professor, Department of Prosthodontics Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

3. ShwetaKumari PoovaniReader, Department of Prosthodontics, Raja Rajeshwari Dental College & Hospital, Bangalore, Karnataka, India

4. Niyati Shah Senior Lecturer, Department of Prosthodontics Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

5. MavaniSoham VPost graduate student, Department of Prosthodontics, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India

6. Patel Brijesh M Post graduate student, Department of Prosthodontics, Narsinhbhai Patel Dental College and Hospital, Visnagar, (Dist)Mahesana Gujarat, India

preparation taper, finish line and marginal configuration.

Conclusion:

Currentlyextra oral scanners are capable of producing vitual model images irrespective of preparation taper, finish line and marginal geometry.

INTRODUCTION

Automated restoration in the form of Computer A i d e d D e s i g n i n g a n d C o m p u t e r A i d e d Manufacturing has become popular these days because of the quick, precise and bulk fabrication of restoration. CAD –CAM SYSTEM has got 3 components

1. A digitalisation tool/scanner that produces digital data

2. Software to produce virtual images

3. Milling system to produce the restoration

Scanners have digitalization tools that scans the prepared tooth and transform them into digital

1data sets.

Scanners are of two types: intra-oral and extra -oral scanners. Extra oral scanners are the most commonly used scanners for large scale production and cost effective. Both operates on the optical properties of light. The extraoral scanners can be

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classified based on the source of light that it uses. 2

They are Laser scanners and white light scanner . Laser scanners analyse line pattern and it produces speckle effect. White light scanner sanalyse multiple stripe pattern for obtaining three-

3dimensional data . The speed of laser is 10-500 kHz/s and that of white light is 3mHz/s.

In this study white light was employed from a professional CAD CAM laboratory.

4Some authors Castillo and Sanchez and manufacturers E4D have mentioned high degree of taper in their study for CAD-CAM scanning. It could be due to the scannability of extra oral scanners.This study was undertaken based on that notion.

Figure 1: Metal master die

Figure 2: Stone models duplicated for scanning

Figure3: INTELLIDENTA model scanner

PROCEDURE

All the models from each specified die are scanned using the white light scanner INTELLIDENTA. A total of 8 models can be scanned at a time with an average time of 1 ½ minute. The scanned models are shown in the fig2.Scanning data were exported to STL file format through proprietary conversion. The STL FILE viewer is used to open up the scanned images and compared. The scanned models with varying taper is shown in fig4,5,6

The scanned models with two different finish lines is shown in fig 7,8. The scanned models with varying marginal geometry is shown in fig 9

Figure 4: scanned models with 3 degree taper

Figure5: scanned models with 8 degree taper

Figure6: scanned models with 12 degree taper

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Figure7: scanned models with chamfer finish lines

Figure 8: Scanned models with shoulder margin

Figure 9: Scanned models with varying marginal geometry

STATISTICAL ANALYSIS

Similar to FEA study the scanning efficacy does not require statistical analysis as it is self -explanatory. The scanned image is compared directly with the prepared tooth and the successibility of scanning is determined.

RESULTS

As far as extra oral scanning is concerned, there is no significant difference in scanning regarding preparation taper, finish line and marginal configuration. The magnetic table in the extra oral scanner allows 360 degrees movement of the

individual model to allow the white light to pass in all the direction.

DISCUSSION

Inthe present study,white lightextraoral scanner is used to analyse the effect of scannability on the preparation taper, finish line and the plane of marginal placement.

Many clinicians and manufacturers like E4Dare of the opinion that little more taper is required for the CAD-CAM scanning. The purpose of this study is to determine whether the extraoral scanners can scan various degrees of preparation taper equally and different types of finish line margin without any difficulty.

PRINCIPLE OF DENTAL SCANNER

When the White light is projected on the object, the reflected patterns are registered in the digital camera which is present in the receptor unit.The relationship between thelight sources and the receptor unit is represented by a definite angle.This is based on the principle of Phase shifting optical

5triangulation.

When light is focussed on a parallel object the light projected and the light reflected travel in the same

6linear pathway. So the scanning requires a steep slope which can be achieved by using a higher degree of taper while scanning tooth preparations.

In this study,when the models with 3º,8 ºand 12ºtaper was placed in the scanning machine the virtual image produced after the white light reflection was same and there was no significant difference in the scanned image [Table/Fig-10].

Even though slight manual adjustment is required for preparation taper with lesser degree taper it was not so very significant.

Fig 10: Inter group Comparison of preparation taper in

scanability of extraoral scanner

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When the models with chamfer and shoulder finish line was placed in the scanning machine there was some difficulty in scanning the chamfer finish line margin when compared to the shoulder finish line. Some manufacturers recommend only shoulder finish line. But the modern day extra oral scanners can scan both the finish lines efficiently [Table/Fig-11].

Fig11:Inter Group Comparison of finish line margin in scanability of extraoral scanner

Similarly, when the models of varying marginal geometry are scanned the planes which goes deep into the sulcus are scanned with little difficulty and requires some manual adjustment when compared to that of the planes which are not so deep [Table/Fig-12].

Fig12:Intra group Comparison of varying Marginal Geometry in scannability of extraoral scanner

The reason behind this may be due to the uneven distribution of the titanium dioxide powder which is used for coating the models for scanning. The source of the white light which is used for scanning is projected from the sides of the scanner. The reflection of the light may not be sufficientto produce the virtual image. The software resistance which is present due to which the images has to be manually manipulated.But the difficulty in scanning and the difference in the virtual image formation is very minimal and is not considered significant.

Thewhite light extra oral scanner INTELLIDENTA which is used in this study can scan the various preparation taper 3,8,12 degrees without any significant difference. The difference in high degree taper may be attributed to the intra oral scanners due to limited space available, humid intra oral environment and salivary flow.

Regarding the finish line margin, shoulder margins and chamfer margins can be equally scanned and the marginal geometry in different planes can be manually adjusted. But the shoulder margins are better scanned.

The marginal geometry of the tooth preparation affects the fitting of the milled copings. If the preparation geometry is not uniform the fitting might not be proper. Butthe scanning with extra oral model scanners does not haveany significant effect in scanning different planes.

CONCLUSION

Within the limitation of this study the tooth preparation could be the same for CAD-CAM and conventional crown fabrication irrespective of preparation taper, finish line and marginal geometry.Extra oral scanners can scan any degree of preparation taper, finish line and plane of marginal geometry.Probably there might be some differencein the taper and sub-gingival margin placement when intra oral scanners are used. The optical properties are monolithic in case of stone models which are scanned by extra oral scanners.

REFERNCES:

1.Quaas S, Rudolph H, Luthardt RG. Direct mechanical data acquisition of dental impressions for the manufacturing of CAD/CAM restorations. J Dent 2007;35:903-8.

2. Persson A, Andersson M, Oden A, Sandborgh-Englund G. A three-dimensional evaluation of a laser scanner and a touchprobe scanner. J Prosthet Dent 2006;95:194-200.

3. Dental Lab 3D Scanners– How they work and what works best.Dr. Karl Hollenbeck, Dr. Thomas Allin, Dr. Mike van der Poel 3Shape Technology Research, Copenhagen January 2012

4.Influence of CAM vs. CAD/CAM scanning methods and finish line of tooth preparation in the vertical misfit of zirconia bridge structures.Castillo de Oyagüe R , Sánchez-Jorge MI , Sánchez Turrión A , Monticelli F , Toledano M , Osorio RAmerican Journal of Dentistry [2009, 22(2):79-83]

5. An introduction to dental digitizers in dentistry; systematic review.Ola Al-Jubouri1,2 and Abbas Azari Journal of Chemical and Pharmaceutical Research, 2015, 7(8):10-20

6. Azari A. and Nikzad S. Rapid Prototyping Journal, 2009. 15(3): p. 216-225.

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