v2 i2 15 - pt. deendayal upadhyay memorial health sciences and...

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ISSN 2348 - 4195

CHHATTISGARH JOURNAL OF HEALTH SCIENCESAn official publication of Ayush and Health Sciences University, Chhattisgarh

PatronDr. G. B. Gupta Vice Chancellor

Executive Editorial BoardDr. K. L. Tiwari– Registrar Ayush & Health Sciences University

Dr. N. Gandhi – Dean Faculty Medical

Dr. Anil G. Ghom – Dean Faculty, Dental

Mrs. Abhilekha Biswal –Dean Faculty Nursing

Dr. D. Katariya – Dean Faculty Ayurvedic

Dr. A. R. Rudrajwar –Dean Faculty Homoeopathy

Associate EditorsDr. Raghavendra Shetty

Dr. Divya Sahu

Dr. A. K. Chandrakar Dr. S. Pawar

Dr. A K Vishwakarma Dr. Rajendra Prasad

Dr. Tripti NagariaDr. O. P. Khandelwal

Dr. Rajendra K. DubeyDr. Sanjay N

Mrs. Sreelata Pillai Dr. Anand Sharma

Dr. Deepesh K. GuptaDr. S. R. Inchulkar Dr. Vineeta Gupta

Dr. R.P. Gupta Mrs. Uma Shendey Mrs. Preetha Sunil

Ms. Bhuneshwari Sahare Dr. Rohit Rajput

Editorial Board

REVIEW ARTICLE

Intensity modulated radiotherapy in head and neck cancer : A review

J ....... aideep Sur, Rachita Jain, Latha.S, Fatima Khan, Fiza Khan, Divya Chaurasia 01

Diagnosis & management of the pathological temporomandibular joint

M.S. Senthil kumar, Senthil kumar S., Deepesh Gupta, N.Vidyasankari .......06

ORIGINAL ARTICLE

Sex determination using dental pulp in permanent & deciduous dentition

N.Mohan, Sukriti Kumar, Jayashree Mohan .......10

Evaluation of pentraxin-3 inflammatory Marker level in generalized chronic periodontitis

before and after mechanical therapy (scaling and root lanning)

Kokila G, Renuka Devi R, Vineeta Gupta .......15

Study of serum phosphate levels and risk of infection in hemodialysis patients

P. Gupta, S. Verma, P. Dubey .......22

Edentulousness , prosthetic status and prosthetic need ofinstitutionalized elderly people

in old age homes of Chhattisgarh

R. K. Dubey, P. Shetty, D. K. Gupta, S. Pandey .......25

Trends in epidemiology of oral cancer in central part of India in Madhya Pradesh : An

institutional study

Vanita Rathod, Chandan Rathod .......32

Assessment of dental aesthetic index among school children of Bilaspur, Chhattisgarh : A pilot study R S Makkad, Madhu Pandey, S Hamdani, V. Agrawal, M Motlani , Gunjan Agrawal .......37

CASE REPORT

Neurofibroma of spindle cell origin, a diagnostic dilemma to general dentist

Swapnil Moghe, Ajay Kumar Pillai, Vineeta Gupta, Geeta Mishra .......42

TMJ ankylosis associated with odontogenic keratocyst of mandibular ramus : A rare case report

Biju Pappachan, R K Dubey, Manish Raghani, Raghav Agrawal .......45

Wilckodontics demystified : A case report

Sumit Gandhi, Lokesh Advani, Javed Sodawala, G. Anita, Srinias T.S., Parul Agrawal .......48

Volume 2 issue 2

CONTENTS

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CHHATTISGARH JOURNAL OF HEALTH SCIENCESAn official publication of Ayush and Health Sciences University, Chhattisgarh

ISSN 2348-4195

It is my proud privilege to present you the “Chhattisgarh Journal Of Health Sciences” that reflects voice of medicine professionals in Chhattisgarh. As, an Editor, I humbly accept the responsibilities entrusted to me and assure you that I will do my best to prove worthy of it. I vow that I will do everything to uphold the standard of our quarterly bulletin. All the advances in medicine field are meaningless if the masses do not have the access to healthcare facilities and get the benefit of these advances. To move forward with this vision, it is wise to look backward with a perception not to blame ourselves or our predecessors but to learn from history and plan for the future. You have precious skill & abilities to make a lot many lives in the community happier.I invite your valuable articles, suggestions, write-ups, views, book reviews, achievement & classified advertisement to make the journal adequately interactive and interesting one.Our quarterly bulletin is a complete scientific publication for the benefit of our members.Once again thanks to all for motivation and co-operation.

Anil G Ghom(Editor-in-Chief)e-mail: [email protected]@gmail.com

Editorial

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Ayush & Health Sciences University of Chhattisgarh

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REVIEW

1 2 3 4 5 6Jaideep Sur , Rachita Jain , Latha.S , Fatima Khan , Fiza Khan , Divya Chaurasia1. Jaideep Sur, Associate Professor, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)2. Rachita Jain, Post Graduate Student, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)3. Latha.S, Professor & HOD, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)4. Fatima Khan, Senior Lecturer, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)5. Fiza Khan, Post Graduate Student, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)6. Divya Chaurasia, Post Graduate Student, Department of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)

Corresponding Author :Dr. Jaideep SurDept of Oral Medicine & Radiology, RCDSR, Bhilai (C.G.)Email: Mobile No: 93029 [email protected],

ABSTRACT:Radiation therapy is a principal modality in the treatment of head and neck cancer. Its capabilities have steadily progressed with the increase in clinical knowledge and technological development. Intensity-modulated radiotherapy (IMRT) concept had been described back in 1978, but it was not until the 90's that it was applied in practice, following improvement and development of computer equipment. A big step forward was made in the past decade by constructing a device with Multi Leaf Collimators. IMRT appears to be clinically justifiable for cancers in the nasopharynx, sinonasal region, parotid gland, tonsil, buccal mucosa, gingiva, and thyroid. IMRT may also be useful in the re-treatment of previously irradiated head and neck cancers, due to its ability to spare adjacent normal tissues with acceptable target dose uniformity. IMRT represents a significant advance in conformal radiotherapy. In particular, it allows the delivery of dose distributions with concave isodose profiles such that radiosensitive normal tissue close to, or even within a concavity of, a tumour may be spared from radiation injury. Key words: IMRT, head and neck cancer, Multi Leaf Collimators.

INTRODUCTIONOverall 57.5% of global head and neck cancers occur in Asia, especially in India. The greatest challenge for

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radiation therapy or any cancer therapy is to attain the highest probability of cure with the least morbidity. The simplest way in theory to increase this therapeutic ratio with radiation is to encompass all cancer cells with sufficient doses of radiation during each fraction, while simultaneously sparing surrounding normal tissues. In practice, however, we have been hampered by our abilities to both identify the cancer cells and target them with radiation. Over the past decade, enormous progress has been made on both fronts. Technical improvements in the application of X-rays, computed tomography scans, magnetic resonance imaging with and without spectroscopy, ultrasound, PET scans, and electronic portal imaging—and our understanding of

their limitations— have greatly improved our ability to identify tumors.2

In 1960, Professor Shinji Takahashi developed a method of conformation radiotherapy that used multileaf collimators. In 1967, a 6-MV linear accelerator at the Aichi Cancer Center became the first in Japan to be equipped with a multileaf collimator. This unit was used in conformational radiotherapy for various types of cancers. In the 1980s, rotation radiography devices used for conformational radiotherapy were replaced by CT devices. Moreover, conformational radiotherapy evolved into intensity-modulated radiation therapy (IMRT), which gained widespread use in the 1990s.

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Three-dimensional (3D), or CT-based, planning was a major advance because it took into account axial

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Intensity modulated radiotherapy in head and neck cancer : A review

Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014)ISSN 2348 - 4195

mailto:[email protected],

mailto:[email protected],

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anatomy and complex tissue contours such as the hourglass shape of the neck and shoulders. While 3D planning allowed for accurate dose calculations to such irregular shapes, we were still limited in the corrections we could make. As its name implies, intensity-modulated radiation allows us to modulate the intensity of each radiation beam, so each field may have one or many areas of high intensity radiation and any number of lower intensity areas within the same field, thus allowing for greater control of the dose

2distribution with the target. Two opposing beams of single intensities, represented by the yellow arrows, create a single-dose distribution through a nasopharynx tumor (GTV in red, CTV in purple) and normal tissue alike in two-dimensional radiotherapy, whereas IMRT creates a highly sculpted dose distribution with relative sparing of the brain, brainstem, and parotid glands by delivering beams of

2different intensities as shown in figure 1.

Advanced treatment planning software has furthered our ability to modulate radiation dose. Instead of the clinician choosing every beam angle and weighting, computer optimization techniques can now help determine the distribution of beam intensities across a treatment volume, which often include a non-intuitive distribution of “beamlets,” or 1 cm2 areas of isointensity. IMRT for head and neck tumors refers to a

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new approach that aims at increasing the radiation dose gradient between the target tissues and the surrounding normal tissues at risk, thus offering the prospect of increasing the locoregional control probability while decreasing the complication rate.

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PRODUCTION OF INTENSITY MODULATED BEAMSTechniques for generation of intensity modulated beams:Metal compensators: A specifically manufactured metallic compensator is milled or moulded so that a variable thickness of the absorber is presented before the radiation beam.6Multiple segments per field: Each treatment field is divided into several smaller segments or subfields,

which are delivered sequentially (the “step and shoot'' method). Each segment shape is defined by a MLC or by shaped blocks. Addition of several segments produces an IMB.

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Dynamic MLC (dMLC): Modulation of beam intensity by pairs of moving MLC leaves characterizes this technique (also known as the ̀ `sliding window'' technique).

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Tomotherapy: Tomotherapy descr ibes IMRT techniques that irradiate the target slice by slice. The NOMOS Corporation developed the first commercially available tomotherapy machine, the multivane intensity modulating collimator (MIMiC), which is in use in several centre.5 This device attaches to the head of the linear accelerator (LINAC), which arcs about the craniocaudal axis of the patient.6,7

ADVANTAGES OF IMRT:IMRT has attracted wide spread interest because of its dosimetric and potential clinical advantages.8 Numerous dosimetry studies on linear accelerator based IMRT treatments of different anatomical sites

FIGURE 1: Beam Delivery in radiotherapy A: Two dimensional Radiotherapy B: IMRT

Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014)

IMRT in head and neck cancer

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have been reported, and all of them show that IMRT can have definite dosimetry advantages over 2D and conventional 3DCRT treatments. Whether the

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dosimetric advantages of IMRT can be realized clinically would depend on a number of factors, including (a) the accuracy in localisation and delineation of the tumour and the adjacent critical tissue structures, (b) understanding of the optimum relationship between dose and response for the individual tumour, and (c) delivery of the prescription doses according to the treatment plans.

IMRT's high conformity with dose facilitates escalation of dose and better protection of normal tissue structures. These features make it particularly 11,12

suitable for the treatment of diseases that involve high rates of local recurrence and toxicity and complications related to treatment.

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Radiotherapy plays an important role in head and neck tumor treatment because of the cosmetic and functional preservation that becomes possible. IMRT 15

significantly improves broad aspects of health related quality of life in head and neck cancer survivors. 16

It highly reduces parotid irradiation and thus reduces post radiotherapy xerostomia. With the advent of

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IMRT and its capability to treat multiple targets simultaneously to different doses, a new accelerated fractionation scheme is introduced. It is known as simultaneous modulated accelerated radiation therapy (SMART) boost. SMART boost can be applied to

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various sites including head and neck, brain and prostate. The principle is to treat two different targets with different fraction sizes to different total doses.19

According to a study done by Beadle et al on 3172 patients with head and neck cancers IMRT treated patients experienced significant improvements in cause specific survival (CSS) compared with patients treated with non-IMRT techniques. IMRT improves the overall survival rate in patients.

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CLINICAL APPLICATIONS OF IMRT IN HEAD AND NECK CANCER:The management of head and neck cancer in recent years has involved increasingly complex, combined-modality programs, as well as the integration of new diagnostic and therapeutic technologies. That head and neck cancer is the most complex “organ site” for treatment decision making is not an overstatement,

and supports a best practices model of multidisciplinary team involvement. Intensity-modulated radiotherapy (IMRT) has been widely adopted as a standard technology for head and neck cancer. IMRT therefore offers a significant advance in conformal therapy, by improving conformality and reducing radiation dose to radiosensitive normal tissues close to the tumour even if they lie within a concavity in the planning target volume (PTV).

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In radiotherapy there are many clinical situations where radiosensitive normal tissues lie within a concavity surrounded by the PTV. Treatment of patients with tumours of the larynx, pharynx or thyroid offers a good example. The CTV often includes a midline target and bilateral cervical lymph nodes producing a horse- shoe shaped PTV with the spinal cord within the concavity. Homogenous irradiation of these PTVs to radical doses (50-66 Gy) with the conventional external beam radiotherapy is difficult. Typically, parallel-opposed photon portals are matched to electron beams. This technique leads to dose inhomogenity at the photon-electron match line, and also underdoses posterior cervical lymph nodes close to the spinal cord. Figure 2 shows, an intensity modulated radiotherapy dose distribution produced by inverse planning to treat the thyroid bed and adjacent lymph nodes (minimum dose 60 Gy, red isodose line) and spinal cord dose less than 30 Gy (light blue circular isodose line).6

Significant normal tissue sparing using IMRT has also

been demonstrated in planning studies for tumours of the maxillary antrum and nasopharynx.6 The treatment of nasopharyngeal carcinoma with minimal dose

FIGURE 2: Inverse planning IMRT to treat carcinoma ofthyroid bed and adjacent lymph nodes



Complex dose distributions can be delivered that avoid a number of radiosensitive normal tissues close to a t u m o u r. Fo r exa m p l e , i n t h e t re at m e nt o f nasopharyngeal cancer, large parallel-opposed lateral portals are used to encompass macroscopic disease and sites of occult metastases. With this technique parotid glands, spinal cord and brainstem are inevitably included in the irradiated volume although these structures do not need to be included in the target volume. . By defining concavities in the PTV, IMRT can

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produce a dose distribution that reduces the radiation dose to these organs and this promises a significant reduction in treatment morbidity. IMRT could be used for the whole duration of a radiotherapy treatment, or

simply as a boost after more conventional treatment. The appropriateness of these two approaches is likely to depend on the tolerance doses of surrounding radiosensitive normal tissues. IMRT also reduces

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parotid dose to less than 15Gy in treatment of nasopharyngeal carcinoma as shown in figure 4.6,11

Issues in clinical application of IMRT includes, increased risk of a marginal miss because of intrafraction target movements, accurate determination of the target volume and the geometry of the organs at risk (OAR) is difficult. Another issue is the high cost, which limits 21,22

the large scale implementation of IMRT.23

CONCLUSION:Head and neck sites have always been among the most challenging, complex and time consuming to plan because of their complex anatomy. IMRT is designed to deliver more dose to the cancer and less to surrounding healthy tissues. This allows for less normal tissue toxicity, which maintains the patient's quality of life and also improves survival rate. Excellent disease control can be achieved by IMRT with minimum complications like xerostomia, mucositis, dysphagia. The future of head and neck radiotherapy lies in optimally using targeted therapy (IMRT) in order to maximize the therapeutic ratio with minimal morbidity.

delivery to parotid gland bilaterally (26 Gy) and sparing of optic structure with a minimum dose of 30 Gy in a

patient with sinonasal carcinoma can be achieved using IMRT6 as shown in figure3.

FIGURE 3: IMRT in A: Nasopharynx cancer, B: Sinonasal cancer.

B

FIGURE 4: Inverse planning in carcinoma of nasopharynx.

A

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REFERENCES:1. Kulkarni RM. Head and Neck Cancer Burden in India. International Journal of Head and Neck Surgery 2013;4:29-35.2. Bucci MK, Bewan A, Roach M. Advances in radiation therapy: Conventional to 3D, to IMRT, to 4D, and beyond. CA Cancer J Clin 2005;55:117-34.3. Doi K, Morita K, Sakuma S, Takahashi M. Shinji Takahashi, M.D. (1912–1985): pioneer in early development toward CT and IMRT. Radiol Phys Technol 2012;5:1–4.4. Bourhis J AC, Pignon JP. Update of MACH-NC (Meta- analysis of chemotherapy in head and neck cancer) database focussed on concomitant chemotherapy. J Clin Oncol 2004;22:5505.5. Vincent G, Awilfried N. Intensity modulated radiotherapy for head and neck carcinoma. The Oncologist 2007;12:555-64.6. Nutting C. Intensity modulated radiation therapy: a clinical review. The British Journal of Radiology 2000;73: 459-69.7. Woo SY, Sanders M, Grant W, Butler EB. Does the ``Peacock'' have anything to do with radiotherapy? Int J Radiat Oncol Biol Phys 1994;29:213-14.8. Lanceford M, Hunt CA. IMRT For Head And Neck Cancer, A Practical Guide to Intensity-Modulated Radiation Therapy. Madison,Wis: Medical Physics Pub,c2003. 191-216.9. Kam MK, Chau RM, Suen J. Intensity-modulated radiotherapy in nasopharyngeal carc inoma: Dosimetric advantage over conventional plans and feasibility of dose escalation. Int J Radiat Oncol Biol Phys 2003;56:145-57.10. Hunt MA, Zelefsky MJ, Wolden S. Treatment planning and delivery of intensity-modulated radiation therapy for primary nasopharynx cancer. Int J Radiat Oncol Biol Phys 2001;49:623-32.11. Wu Q, Manning M, Schmidt RU. The potential for sparing of parotids and escalation of biologically effective dose with intensity-modulated radiation treatments of head and neck cancers: a treatment d e s i g n st u d y. I nt J R a d i at O n co l B i o l P hys 2000;46:195-205.12. Nutting CM, Rowbottom CG, Cosgrove VP. Optimisation of radiotherapy for carcinoma of the parotid gland: A comparison of conventional, three- dimensional conformal, and intensitymodulated techniques. Radiother Oncol 2001;60:163-72.13. Pirzkall A, Carol M, Lohr F, Höss A, Wannenmacher M, Debus J. Comparison of intensity modulated ra d i o t h e ra p y w i t h co nve nt i o n a l co nfo r m a l

radiotherapy for complex-shaped tumors. Int J Radiat Oncol Biol Phys 2000;48:1371-80.14. KY Cheung. Intensity modulated radiotherapy: advantages, limitations and future developments Biomed Imaging Interv J 2006;2:1-19.15. Obinata K, Nakamura M, Carrozzo M, Macleod L, C a r r A , S h i ra i S . C h a n ge s i n p a ro t i d g l a n d morphology and function in patients treated with i n t e n s i t y - m o d u l a t e d r a d i o t h e r a p y f o r nasopharyngeal and oropharyngeal tumors. Oral Radiol 2014;30:135–41.16. Leung S, Lee T, Chien C. Health-related Quality of life in 640 head and neck cancer survivors after radiotherapy using EORTC, QLQ-C30 and QLQ-H & N35 questionnaires. BMC Cancer 2011;11:128-38.17. Anand AK, Jain J, Negi PS, Chaudhoory AR, Sinha SN, Choudhury PS. Can dose reduction to one parotid gland prevent xerostomia? A feasibility study for locally advanced head and neck cancer patients

treated with intensity modulated radiotherapy. C l i n -Oncol 2006;18:497-504.18. Butler EB, Teh BS, Grant WH et al. SMART (Simultaneous Modulated Radiation Therapy) boost-a new accelerated fractionation schedule for the treatment of head and neck cancer with intensity modulated radiotherapy. Int J Radiat Oncol Biol Phys 1999;45:21-32.19. Teh BS, Woo SY, Butler EB. Intensity Modulated Radiation Therapy ( IMRT): A New Promising Technology in Radiation Oncology. The Oncologist 1999;4:433-42.20. Beadle BM, Liao KP, Elting LS, , Ang KK, Garden AS, Guadagnolo BA. Improved survival using in h e a d and neck cancer: a SEER-Medicare analysis . Cancer 2014;20:702-10. 21. Mendenhall WM, Amdur RJ, Palta JR. Intensity- m o d u l a t e d r a d i o t h e r a p y i n t h e s t a n d a r d management of head and neck cancer: promises a n d pitfalls. J Clin Oncol 2006;24:2618-23.22. Sankaralingam M, Glegg M, Smith S, James A, R izwanul lah M. Quant itat ive comparison of volumetric modulated arc therapy and intensity modulated radiotherapy plan quality in sino nasal cancer. J Med Phys 2012;37:8-13.23. Verbakel WF, Cuijpers JP, Hoffmans D, Bieker M, S l o t m a n B J , S e n a n S . V o l u m e t r i c intensity-modulated arc therapy vs. conventional I M R T i n h e a d a n d n e c k c a n c e r : A comparative planning and dosimetric study. Int J Radiat Oncol Biol Phys 2009;74:252-9.




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ABSTRACT

Temporomandibular joint (TMJ) is a unique joint for the practitioner not by its anatomy and function but by the

complexity in the diagnosis and treatment. It is widely accepted that palliative and conservative therapy is the best

treatment choice. This discussion is about the importance of documenting all the clinical signs, symptoms and

findings that are not so common to the internal derangement of the temporomandibular joint. Pathological

temporomandibular joint requires simple biochemical and radiological investigations in addition to an altered

medical and occlusal therapy as discussed here.

INTRODUCTION

Temporomandibular joint (TMJ) pain involves the joint

and the muscles of mastication. The pain involves the

lateral face region that radiates to the neck and the ear

region. Patients usually visit or treated by other

specialities before being referred to a dental

pract it ioner. Most patients can identify the

predisposing factor that leads to the pain in their

questionnaire or during examination. The predisposing

factors usually are trauma, sports injury, dietary habits,

chewing pattern, prolonged dental treatment etc.

Dental practitioners first priority is to identify the

occlusal harmony of the mouth.

Any missing tooth or dental filling or prosthesis leads to

the habit of chewing on one side which is identified by

the timing of the clicking noise in the TMJ or irregular

movement of the joint as whole. Severe pain will be

experienced by the individuals who try to change their

chewing pattern. These are patients who broadly fall

under the category of internal derangement of the TMJ1,

2. These patients are usually treated conservatively with

soft diet, stabilization splints, occlusal rehabilitation

and modification in the chewing pattern. Patients who

understand that medical and surgical management is of

no use usually accept life style changes and respond

well to treatment.

Patient without occlusal disharmony fall under the

broad category of myofacial group with or without

etiological factors . These patients are usually treated 3

with occlusal splints to relieve the pressure on the disc

and analgesics for a short period of time. Both

categories of patients need long term follow up. A

modification in the regular protocol is indicated if it

involves psycho social factors, with opinion from other

specialities.

The third category of patients includes inflammatory

TMJ who exhibits the same clinical signs and symptoms

but do not respond for the regular treatment protocol.

Failure to identify the etiological and clinical factors will

worsen the disease.

DISEASE DIAGNOSING AND IMAGING

Much has been written and documented about the

management of diagnosis and treatment of the joint. A

basic understanding of the anatomy, diagnosis,

classification and the routine protocol in the

management of the Temporomandibular disorders is

1 2 3 4M.S. Senthil kumar , Senthil kumar S. , Deepesh K Gupta , N.Vidyasankari1. Associate Professor, Department of Oral and Maxillofacial Surgery, SRK Dental College, Coimbatore (TN)2. Professor, Department of Restorative dentistry, JKK Nataraja Dental College, Salem (TN)3. Reader, Department of Oral and Maxillofacial Prosthodontics, Govt. Dental College, Raipur (CG)4. Reader, Department of Oral and Maxillofacial Prosthodontics, K.S.R Dental College, Salem, (TN)

Correspondence Author :Dr. M.S.Senthil kumar, Sri Ramakrishna Dental Colloge, Coimbatore (TN)Contact Number – 09443505060

Diagnosis and management of the pathological temporomandibular joint

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needed to treat a case successfully. Various protocols

have been suggested from the diagnosis and treatment

point of TMJ. Pain on palpating in relation to the

temporal and massetric region, intra oral palpation of

the coronoid region which is usually very tender is a

single indication of the non harmonious muscle

movements.

Routine radiological investigations include an

orthopantomogram and open/closed mouth view of

the bilateral Temporomandibular joint . An asymmetry 4

or change in the long axis of the condyle when

compared with the other side in an open mouth view

indicates a internal derangement.(Fig1) A radiological

discontinuity in the head of the condyle indicates

pathological changes usually osteoarthritis. However

not all pathological joints are arthritic as age,

development and systemic changes play a role in the

pathological classification. The other pathologies

include rheumatoid arthritis, arthrosis, Stills disease

(Juvenile osteoarthritis) and Metabolic disorders .5

Inflammatory or degenerative joints exhibit a

disocclusion or an open bite apart from the pain,

difficulty in mouth opening, clicking or hyper mobility of

the joint. (Fig2) Arthritic changes in the joint are elicited

by the presence of osteophytes and erosion with a good

radiologic imaging.(Fig 3) The structural damages to the

disk and perforations if any are better diagnosed by an

MRI . Biochemical investigation for rheumatoid arthritis 6

is elicited by the presence of Rheumatoid factor. A

broader understanding is achieved by complete

systemic evaluation and an opinion from the

orthopaedic surgeon if needed. If the patient is already

on medical management, only a conservative approach

is advised.

MANAGEMENT

The inspection, palpation and auscultation of the TMJ is

followed by the recording of the clinical findings like

Fig - 1

Fig - 2

Fig - 3


Diagnosis & management of the pathological TMJ

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maximum mouth opening, relationship of the dental

midline (upper maxillary incisor midline) to the facial

midline on opening and closing. Deviation, dislocation

and deflection of the mandible (with reference to the

dental midline) on opening and closing, timing of the

clicking on opening and closing are to be documented.

As these finding play an important role in evaluating the

prognosis. The authors follow the below mentioned

protocol in their line of management.

Initial/Pain management:

1. Ice pack on the affected side

2. Soft diet

3. Analgesics and anti depressants

After pain reduces :

4. Mouth opening exercises- regular opening and

closing

5. Conscious bilateral chewing on both sides

(practiced with mirror in front)

6. Conventional Occlusal splint- to relieve stress at the

TMJ- to be worn at nights, travel, watching TV

Patients with reduced mouth opening :

7. Warm fomentation bilaterally on the lateral side of

the face, temporal region and neck regions.

8. Physiotherapy- ultra shortwave diathermy or TENS

9. Low level laser therapy

Further management:

10. Occlusal rehabilitation to aid in bilateral chewing-

replacement of missing teeth, extraction of supra

erupted maxillary wisdom teeth, to check

functional occlusion if all teeth are present.

Pathological management:

11. Tricyclic antidepressants

12. Glucosamine and chondroitin sulphate

13. Steroids

14. Patients who do not respond to this protocol are

further evaluated with MRI and minimally invasive

surgical therapy.

Evaluation of the occlusal splint and the treatment as a

whole can be assessed by the timing of the clicking in

the opening and closing movements. The deviation of

the mandible from the dental midline reduces. Anterior

repositioning appliance has also been documented of

good use if properly made . Medical management is not 7

a long term option, it should be reduced or

discontinued as needed. As mentioned earlier the

treatment protocol will not be effective if appropriate

care is not given to the occlusal rehabilitation. Often

patients do not report to the dentist after their acute

phase subsides. Hence the need for occlusal harmony

should be stressed during every visit.

DISCUSSION

Pain and pathology of TMJ is multi factorial which

makes the diagnosis and treatment more complex. It

requires a multi disciplinary approach . Occlusal 8

rehabilitation should be the prime target for the dental

practitioner as various studies has pointed out. One

should also understand occlusal splint therapy is a

supportive splint therapy. During occlusal rehabilitation

the endodontic procedures should not be for long

duration and the prosthodontic aim should be focused

on achieving good functional occlusion. The supportive

occlusal splints can be hard, soft or functional as

needed.

The role of surgery is always indicated for those patients

w i t h l i m i t e d o r n o m o u t h o p e n i n g a t a l l .

S imple invas ive surg ica l therapies l ike TMJ

arthrocentesis should be considered before an open 9

surgery . Conservative and palliative management 10

seems to provide better and long term results with less

or no morbidity.

CONCLUSION

Fo l lowing the bas ic protoco l w i th min imal

investigations and occlusal therapies which are aimed

at patient education and long term follow should be the

g o a l s i n t h e t r e a t m e n t o f p a t h o l o g i c a l

Temporomandibular joints.

REFERENCES

1. Dworkin SF, LeResche L. Research diagmostic

criteria for temporomandibular disorders: review,

criteria, examinations and specifications, critique. J

Craniomandib Disord. 1992;6:301–355

2. Wilkes CH. Internal derangements of the

temporomandibular joint: pathological variations.

Arch Otolaryngol Head Neck Surg. 1989; 115:

469–477

3. In: de Leeuw R editors. Orofacial pain: guidelines

for asssessment, diagnosis, and management. 4th



ed.. Chicago: Quintessence Publishing; 2008

4. Inclination of the temporomandibular joint

eminence and anterior disc displacement. Int J of

Oral Maxillofac Surg.1989;18:229-232

5. Gynther GW, Holmlund AB, Reinholt FP, Lindblad S.

Temporomandibular joint involvement in

generalized osteoarthritis and rheumatoid arthritis:

a c l i n i ca l , a r t h ro s co p i c , h i s to l o g i c , a n d

immunohistochemical study. Int J Oral Maxillofac

Surg. 1997;26:10–16

6. L.M.J. Helenius, P. Tervahartiala, I. Helenius, J. Al-

Sukhun, et al. Clinical, radiographic and MRI

findings of the temporomandibular joint in patients

with different rheumatic diseases International

Journal of Ora l & Maxi l lofac ia l Surgery.

2006;35:11:983-989

7. Roger A. Solow. Customized anterior guidance for

occlusal devices: Classification and rationale.The

Journal of Prosthetic Dentistry, 2013;110:4:259-

263

8. Epidemiology, Diagnosis, and Treatment of

Temporomandibular DisordersReview Article.

Dental Clinics of North America 2013;57: 465-479

9. F.A. Al-Belasy, M.F. Dolwick. Arthrocentesis for the

treatment of temporomandibular joint closed lock:

a review article. International Journal of Oral &

Maxillofacial Surgery 2007;36:773-782

10. Dolwick MF, Dimitroulis G. Is there a role for

temporomandibular joint surgery. Br J Oral

Maxillofac Surg. 1994;32:307–313


9Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014)

10

1 2 3N.Mohan , Sukriti Kumar , Jayashree Mohan1. Professor & HOD, Department of Oral Medicine & Radiology, VMS Dental college, Salem (TN)2. Post Graduate Student, Dept. of Oral medicine & Radiology, VMS Dental college, Salem (TN)3. Professor & HOD, Department of Prosthodontics, VMS Dental college, Salem (TN)

Corresponding Author:Dr. N. Mohan, Professor, Department of Oral Medicine & Radiology, VMS Dental college, Salem (TN)Email : [email protected], Mobile: 09843082608

ABSTRACT

Objective : This study was carried out to determine the reliability of sex determination from tooth pulp tissue.

Methods : This study was carried on 30 teeth samples. Out of which 15 were permanent and 15 were deciduous

teeth. (8 male teeth and 7 female teeth in each group) which were indicated for extraction advised for orthodontic

treatment, Retained deciduous& Periodontally compromised tooth. Teeth was extracted and pulp taken out after

access opening was transferred in to fixative solution for 24 hours. the pulp cells were stained with harris's

hemotoxylin and eosin stains which was examined under oil immersion lens of light microscope to study the barr

body.

Results : Study of sex determination with tooth pulp proved to be reliable for deciduous teeth when association of

barr body and sex of permanent and deciduous teeth were tested. And also the overall statistical analysis of sex wise

estimation of barr bodies involving both deciduous and permanent teeth showed significant results for female

group.

Conclusion : The Barr body test is shown to be a reliable, simple, and cost-effective technique for sex identification.

Keywords : Barr bodies, sex determination, tooth pulp tissue,odontology

INTRODUCTION:

Forensic odontology can be defined in many ways . The 1

Federation Dentaire Internationale (FDI) defines

forensic odontology as that branch of dentistry which,

in the interest of justice, deals with the proper handling

and examination of dental evidence and with the

proper evaluation and presentation of dental findings.

According to the American Society of Forensic

Odontology, forensic odontology is by definition, the

application of dental science to the law, i.e. the use of

dental evidence in the interest of justice.Human

identification is one of the major fields of study and

research in forensic science because it deals with the

human body and aims at establishing human identity 2

Tooth enamel is the hardest tissue in the body, and the

teeth remain intact after death, thus making them

useful for forensic identification of sex with respect to

morphological characteristics (Haga, 1959; Gonda,

1959;Garm, 1964) and soft tissues (Das et al., 2004) 2

Determining the sex from either dental pulp or dentin of

Figure 1. showing diagrammatic representation of

barr body in the cell nucleus.

Sex determination using dental pulp in permanent and deciduous dentition

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ORIGINAL ARTICLE

Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195

11

tooth can also provide criminal investigators with useful

intelligence and can aid the identification of missing

persons and disaster victims. Forensic odontology is

useful in identification of age and sex of patients Sex of 3

the individual can be determined by using X and Y

chromosomes in the cells which are inactive. X

chromatin in its inactivated form is present as a mass

against the nuclear membrane in females is known as

Barr body as it was first named by Barr and Bertem

(1949)(Fig 1). These Barr bodies are present in 40% of

females who are considered as chromatin positive and

absent in males who are considered as chromatin

negative.

MATERIAL AND METHODS:

A total of 30 teeth were collected and were grouped in

to permanent and deciduous. Each group comprised

of 15 teeth . Out of 15 teeth (7 males and 8 females)

were selected out of patients who came for treatment

in vinayaka missions sankarachariyar dental college

salem .Eligibility criteria included was extractions

advised for orthodontic treatment. Retained

deciduous.,Periodontally compromised tooth, age

criteria:-up to 45 years .and those Teeth with dental

caries,Grossly destructed teeth, Non vital tooth were

excluded from the study.

An ethical committee clearance was taken and

informed consent was obtained .Either the patients or

their guardians, if they are minors, were informed

about the objectives of the investigation.

The teeth were removed by conventional technique,

washed with sterile water to remove residual blood,

The pulp was conventionally obtained through the

normal access cavity on the occlusal surface of the

teeth; dental pulp tissues were obtained using

standardized K-files(Fig 5). The pulp tissue was then

transferred to the dry and clean conical centrifuge tubes

containing 5 ml. of fixative (3 Methanol: 1 Glacial acetic

acid) and left as such for about half an hour to 24 hours

for the fixation of the pulp cells. It was then crushed /

teased with the glass rod sufficiently to isolate the pulp

cells. A suspension thus obtained was centrifuged for 10

Figure 5. Pictures showing material and method involved in the study

Sex Determination Using Dental Pulp



12

minutes at 1000 rpm. The supernatant was discarded,

leaving behind the pellet in the centrifuge tube. 5ml of

fresh fixative was then added to re-suspend the pellet

and the process was repeated thrice till a clear

suspension of the pulp cells was obtained.

Thin smears were prepared on chilled microscope slides

of 1 mm thickness by the air drying method i.e. by

dropping 2 –3 drops of the above suspension on the

slide from a distance of inches to get a homogenous

population of cells. Two smears were made from each

suspension of the specimen; one slide was stained with

Harris's Hemotoxylin and Eosin stain to study the Barr

bodies 3

RESULTS:

When association of barr body and sex of permanent

and deciduous teeth were tested with chi square test

and compared it was observed that p-value was highly

significant in deciduous (Table 2) and significant in

permanent teeth(Table1). Hence,suggesting study to be

more reliable for the deciduous teeth.

Overall statistical analysis of sex wise estimation of barr

bodies involving both deciduous and permanent teeth

(Table3) showed p-value 0.001 which was highly

significant at 1% therefore more percentage of barr

bodies was observed in female group.

And finally, the association between the type of teeth

and presence of barr bodies were tested with chi square

test , Table 4 showed that the p-value is less than 0.5

hence the result is significant at 5%,Therefore it is

concluded that there is significant association found

between the type of teeth and barr bodies.It was

observed from the study that deciduous teeth is

showing more percentage towards barr bodies than

permanent teeth. Estimation of barr bodies in

deciduous teeth were more significant when compared

to permanent teeth

Table 1 . Association between sex and Barr Bodies - Permanent Teeth

Sex

Barr bodies

Total Chi

square p Positive Negative

N % N %

Male 8 100.00 8 4.28 0.038*

Female 3 42.86 4 57.14 7

Total 3 20.00 12 80.00 15

* Significant at 5 %

Table 2 . Association between sex and Barr Bodies - Deciduous Teeth

Sex

Barr bodies

Total Chi


N % N %

Male 1 14.29 6 85.71 7 11.43 0.001**

Female 8 100.00 - - 8

Total 9 60.00 6 40.00 15

** Significant at 1 % (Highly Significant)


13

DISCUSSION:

In the study we were able to differentiate the sex of an

individual by observation of barr bodies in both

deciduous and permanent teeth.(Fig 2,Fig 3)

The association between sex and barr bodies in

permanent teeth showed 42.86% positive result for

females and 100% negative result in males.

And the association between sex and barr bodies in

deciduous teeth showed 85.71% negative result for

males whereas in females it showed 100% positive

results. Figure 3. Picture showing positive barr body along

the nuclear membrane observed in 100x magnification of

light microscope under oil immersion.

Figure 2. Picture showing positive barr body along the nuclear membrane observed in 100x magnification of

light microscope under oil immersion.

Figure 4. Picture showing cell without a barr body.

observed in 100x magnification of light microscope

under oil immersion

Table 4 . Association between sex and Barr Bodies - Deciduous Teeth

Sex

Barr bodies

Total Chi


N % N %

Male 1 6.67 14 93.33 15 13.89 <0.001**

Female 11 73.33 4 26.67 15

Total 12 40.00 18 60.00 30

Type of Teeth

Table 3 . Association between sex and Barr Bodies - Deciduous Teet3

Barr bodies

Total Chi


N % N %

Permanent Teeth 3 20 12 80 15 5.00 0.025*

9 60 6 40 15

Total 12 40 18 60 30

Deciduous Teeth




14

The overall association between sex and barr bodies

revealed 73.33% positive results in females and 6.67 %

in males with 93.33% and 26.67% negative results

respectively in males and females .

The most significant association was observed between

the type of teeth and barr bodies. Here deciduous teeth

showed 60% positive result and 20% negative results

was seen in permanent teeth.

Das et al., reported that 24.92% of women pulp cells

were positive for Barr body observation 2

Yunis & Chandler (1979) indicated that in women with a

normal karyotype, Barr bodies were observed in

approximately 30% of cellular nuclei, with a range

between 15% and 40% 4

Gajendra veeraraghavan et al stated that freshly

extracted teeth which were examined one month later

showed posit ive 100% results in sensit iv ity,

specificity,positive predictive value and efficiency 3

Our study involved permanent as well as deciduous

teeth and the results were more reliable in female

deciduous tooth pulp than the female permanent tooth

pulp. Though the determination of sex does not give

100 % of results in its predictive value and efficiency

every time we perform the study, still it has got some

advantages like it is Rapid and is easily implemented

because it requires little equipment in contrast to

techniques, such as PCR (Murakami et al.) and LAMP

method (Nogami et al., 2008).And IT can be observed

with most of the nuclear stains, such as hematoxylin-

eosin, Papanicolaou, Feulgen, cresyl violet, aceto-

orcein, carbol-fuchsin, and fluorescence 5

Alterations at the chromosomal level in patients with a

bnormalities can yield false negatives or false positives .

CONCLUSION

Along with forensic investigations, antemortum records

also have equal importance for identification of the

individual. Forensic odontology has a prime role in

identification of the individual even in a critical situation

where the obtained sample is severely damaged and

decomposed.

REFERENCES:

1. Ivan Suazo Galdames et al. Sex Determination

by Observation of Barr Body in Teeth Subjected

to High Temperatures. Int. J. Morphol 2011;

29(1):199-203.

2. Dr. Nirmal Das et al. Sex determination from

pulpal tissue. Jiafm 2004; 26(2): 50-54.

3. Gajendra Veeraraghavan1, Ashok Lingappa et

al. Determination of sex from tooth pulp tissue.

Libyan J Med 2010, 5: 5084

4. Bar MC, Bertam LF and Lendsay HA. The

morphology of the nerve cell nucleus according

to sex. Anat Rec 1950: 107 -283

5. Dufy JB, Waterfield JD and Skinner MF.

Isolationof Tooth pulp cells for sex chromatin

studies inexperimental dehydrated and

c r e m a t e d r e m a i n s . F o r e n s i c S c i e n c e

International. 191; 49: 127-141.

6. Shamim T, Ipe Varughese V, Shameena PM,

Su d h a S . Fo ren s i o d o nto lo gy : a n ew

perspective. Medicolegal Update 2006; 6:1-4.


15

1 2 3Kokila G , Renuka Devi R , Vineeta Gupta1. Lecturer, Department of Periodontics, KSR Institute of Dental Science and Research, Tiruchengode, (TN) India

2. Reader, Department of Periodontics, KSR Institute of Dental Science and Research, Tiruchengode, (TN) India

3. Reader, Department of Periodontics , Government Dental College Raipur (C.G)

Corresponding Author :Dr. G. Kokila

Lecturer, Department of Periodontics, KSR Institute of Dental Science and Research Tiruchengode – 637215,

email: [email protected]

ABSTRACT :

Background : Pentraxins are acute phase proteins which belong to a family of evolutionarily conserved proteins,

considered as markers of inflammation. Pentraxin 3 (PTX3) is a prototype of the long pentraxin group. It is suggested

to play an important role in innate immunity, regulation of inflammation and clearance of apoptotic cells. Hence this

study was planned and designed to estimate the level of pentraxin-3 in chronic periodontitis before and after non

surgical periodontal therapy and correlate its level with disease severity (healthy, gingivitis and periodontitis).

Materials and methods : A total of 45 individuals both males and females of age group (23-50yrs) were included in

the study and they were divided into three groups of 15 in each. Control group A (group I, = 15) healthy, Control group

B (group II = 15) gingivitis, Test group (group III =15) generalized chronic periodontitis.3weeks after intervention

(scaling and root lanning), the 15 subjects from Group III were categorized as fourth group (Group IV). GCF and

plasma samples obtained from each subjects were quantified for pentraxin-3 using sandwich enzyme linked

immunosorbent assay (ELISA) technique.

Statistical analysis : Chi-square test, ANOVA, ANCOVA, Spearman correlation coefficient and Paired t test were used

for statistical analysis of this study. P value of less than 0.05 was considered to be statistically significant.

Results : The mean GCFPTX3 concentration increased from healthy to gingivitis groups and then from gingivitis to

periodontitis groups (1.402 ng/ml <2.299 ng/ml <3.184 ng/ml). Similarly the mean plasma PTX3 concentration was

highest in periodontitis group (2.885ng/ml) followed by the gingivitis group (2.118 ng/ml) and lowest in the healthy

group (0.983 ng/ml). The mean differences between the groups were also statistically significant (p<0.001). The GCF

and plasma PTX3 concentrations in chronic periodontitis decreased (2.14 ± 0.57, 1.95 ± 0.58) after treatment.

Conclusion : Pentraxin3 level increases in GCF and plasma, from periodontal health to the diseased condition, as well

as there is distinct decrease in the level after periodontal therapy. This data indicates that pentraxin-3 plays a key role

in periodontal disease and could be considered as a biomarker in periodontal disease progression.

Key Words : Chronic periodontitis, Enzyme linked immunoabsorbent assay, Gingival crevicular fluid, Pentraxin-3.

Evaluation of pentraxin-3 inflammatory Marker level in generalized chronic periodontitis before and after mechanical

therapy (scaling and root planing)

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INTRODUCTION

Chronic periodontitis is an infectious disease of bacteria

characterized by the inflammatory breakdown of tooth

supporting structures including hard and soft tissues.

The initiation and progression of periodontal disease is

caused by interaction between periodontal pathogens

and host immune system. The periodontal pathogens

contains a number of potential virulence factors like

antigens, lipopolysaccharide and heat shock proteins,

which trigger the local and systemic immune and

inflammatory response. The local inflammatory

response stimulates hepatocytes and the other cells

including neutrophils, monocytes, macrophages,

vascular endothelial cells, fibroblast and smooth

muscle cells to release various acute phase proteins

(APR).1, 2, 3

Pentraxins, a super family of acute phase proteins are

identified as biomarkers in inflammatory conditions. It

has an important role in the innate immune system.

Pentraxins are divided into two groups based on

primary structure of the subunit: short pentraxin (C-

reactive protein and serum amyloid protein), long

pentraxins (pentraxin-3 [PTX3] and PTX4), and several

neuronal pentraxins. 4, 5

Pentraxin-3 is identified as first member of the long

pentraxin super family. It is produced by macrophages

and other cell types in response to IL-1 , tumour β

necrosis factor-alpha [TNF- ] and microbial α

components including lipopolysaccharides.6, 7

Measurement of pentraxin-3 in GCF or plasma may help

in the identification of a subset of patients who are at a

higher risk for destructive disease or those who are

undergoing the process of periodontal breakdown.8

To date, this is the second study to examine the

effect of nonsurgical periodontal therapy on GCF and

serum level of pentraxin-3. The aim of study was to

estimate the level of pentraxin-3 in GCF and blood

before and after non surgical periodontal therapy in

chronic periodontitis and correlate its levels with

disease severity.

MATERIALS AND METHODS

The study protocol was analyzed and approved by the

Institutional Ethical Review Board. Written and verbal

informed consent was obtained from the subjects

participating in the study. A total of 45 subjects (20

males and 25 females) were participated in the study.

Inclusion criteria:

1. Age group 23 to 55yrs

2. At least 20 natural teeth

3. Good general health without any history of systemic

disease

Exclusion criteria:

1. Any autoimmune disease or other systemic

diseases that could change the course of

periodontal disease.

2. Subjects having history of smoking or any form of

tobacco use previously

3. Use of a medication like antibiotic drugs or anti

inflammatory drugs in the past 3 weeks

4. History of periodontal therapy in the past 6 months

5. Pregnant/ lactating women

6. Unwillingness to join in the study.

Each subject underwent full mouth periodontal probing

and charting, along with digital OPG.

The subjects were divided into 3 groups of 15 each

based on scores of plaque index (Sillness and Loe 1964),

gingival index (Loe and Sillness 1963), sulcus bleeding

index (Muhlemann 1971), probing depth (PD), clinical

attachment level (CAL) and radiographic evidence of

bone loss. Control group (Group 1 = clinically healthy

[n=15 (no bleeding on probing, gingival index = 0

probing depth 3mm, CAL=0, radiographically no bone ≤

loss). Control group (Group 2 = gingivitis [n=15

(clinically, signs of gingival inflammation and bleeding

on probing present, gingival index >1, probing depth ≤

3mm and no CAL or radiographic bone loss). Test group

(Group 3= generalized chronic periodontitis [n=15

(clinically, signs of gingival inflammation and bleeding

on probing present, gingival index >1, probing depth ≥

5mm, CAL 3mm and radiographic evidence of ≥

bone loss). Group 4 = Group 3 patients [n=15

(generalized chronic periodontitis) receiving non

surgical therapy (scaling and root planning) are

converted into Group4.


Pentraxin-3 in periodontal diseases

17

EXAMINATION METHOD

The clinical and radiographic examinations, group

allocations were performed by single examiner for all

patients. Samples were collected from predetermined

sites in each patient on the following day by same

examiner. This was carried out to avoid the

contamination of GCF with blood associated with the

probing of inflamed sites. Only one site per subject was

selected as sampling site in group 2 (gingivitis) and

group 3 (generalized chronic periodontitis) whereas, in

group 1 (healthy), many sites were sampled. Probing

depth and clinical attachment levels were measured by

using a William graduated periodontal probe.

GCF Collection

After drying the selected area, supragingival plaque was

removed by using the Gracey curettes. Care was taken

not to touch the gingival margins after which the area

was isolated with cotton rolls to prevent saliva

contamination. GCF was collected by gently placing the

microcapillary tube at the entrance of the gingival

sulcus. A standardized volume of 1μl was collected in

each group by ibration on black using the cal

colour–coded 1- to 5-μL calibrated volumetric

microcapillary tubes. Maximum of 10-15 minutes were

allotted for each sample. If GCF is not expressed within

the allotted time, that sites were excluded. This was

done to ensure atraumatism. The micropipettes that

were suspected to be contaminated with blood or saliva

were also excluded. Collected GCF samples were

immediately transferred to airtight plastic vials and

were diluted with phosphate buffer saline up to 100μl 0and immediately transferred and stored at -70 C until

assayed.

Blood Collection

2ml of blood was collected from anticubital fossa by

venipuncture using a graduated syringe with 20 gauge

needle. The collected blood was transferred to a test

tube containing EDTA. Immediately the collected

samples were sent to laboratory for processing. Plasma

was separated within 30 minutes from collected blood

by centrifuging at 1000 x g for 15 minutes and

immediately transferred to a plastic vial and stored at -

70 C until assayed.◦

Non surgical periodontal therapy

The patient in group 3 received non surgical periodontal

therapy (scaling and root planning) within 1 or 2 visits

according to patient needs. Oral hygiene instructions

were given which included, tooth brushing techniques

and the use of dental floss. If patient reported any

sensitivity, instruction was given to use desensitizing

tooth paste (Thermoseal). The patients were recalled

after 21 days for recording of plaque index, gingival

index, sulcus bleeding index, probing depth and CAL.

GCF and blood samples were collected and sent to

laboratory and stored at -70 C ◦

Assay Procedure

The pentraxin-3 levels in collected GCF and blood

sample were assayed using an enzyme-linked

immunosorbent assay (ELISA KIT). The assay employed

the quantitative sandwich enzyme immunoassay

technique. Antibody specific for PTX3 was pre-coated

onto a microplate and antigen samples to be tested was

added into the wells and any PTX3 present was bound

by the immobilized antibody. After removing any

unbound substances, a biotin-conjugated antibody

specific for PTX3 was added to the wells. After washing,

avidin conjugated Horseradish Peroxidase (HRP) was

added to the wells. Following a wash to remove any

unbound avidin-enzyme reagent, a substrate solution

was added to the wells and color developed in

proportion to the amount of PTX3 bound in the initial

step. Once pentraxin-3 binds with antibody completely,

the color development stops and the intensity of the

color was measured. The absorbance of each well is

read on an ELISA reader using 450 nm as the primary

wavelength. The concentration of PTX3 in the tested

samples was estimated using the standard curve.4

Statistical Analysis

Statistical analysis was done using software program.

One way ANOVA was carried out to compare the mean

clinical parameters between the groups. In addition,

Chi-square test was done to assess sex distribution of

subjects in groups. Pearson's correlation coefficient has

been applied to find out the relationship between the

pentraxin-3 level and the selected variables. Paired t

test was used to analyze mean and standard deviation



18

of clinical parameters and pentraxin-3 levels before and

after SRP for group III patients. P <0.05 was considered

to be statistically significant.

RESULTS

Descriptive statistics of baseline parameters of the

study population are shown in Table1.

The results of the present study indicated that the mean

PTX3 concentration in GCF was highest in group III

(3.184ng/ml).The mean GCFPTX3 concentration

increased from healthy to gingivitis groups and then

from gingivitis to periodontitis groups (1.402 ng/ml

<2.299 ng/ml <3.184 ng/ml) (Table 2). Similarly the

mean plasma PTX3 concentration was highest in

periodontitis group (2.885ng/ml) followed by the

gingivitis group (2.118 ng/ml) and lowest in the healthy

group (0.983 ng/ml). The mean differences between

the groups were also statistically significant (p<0.001)

(Table 3).

Paired t test showed a statistically very highly significant

reduction of clinical parameters and CF and plasma G

PTX3 levels of group III after SRP. The clinical parameters

has been reduced from (1.65 ± 38, 2.16 ± 0.36, 3.06±

0.57, 5.91± 1.01 and 5.49 ± 0.81) at baseline to (0.85

±0.10, 1.34 ±0.64, 1.84 ± 0.89, 5.37 ±1.19 and 4.82 ±

0.91) at the end of 3 weeks (Table 4).

Result of group III revealed that there was a very highly

statistically significant (p < 0.001) reduction of GCF

pentraxin-3 from (3.18 ± 0.64) at baseline to (2.14 ±

Table 1: Descriptive statistics of baseline parameters in the study population

PI (Mean±SD) GI (Mean±SD) SBI (Mean±SD) CALMean±SD)

PPDMean±SD)

Group I 0.338 ± 0.11 0.216 0.226 1.402 ± 0.29 0.938± 0.29

Group II 0.675 ±0.21 0.964 1.224 2.299± 0.36 2.118± 0.41

Group III 1.654 ±0.38 2.162 3.064 3.184± 0.64 2.885± 0.49

Table 2: Descriptive statistics of pentraxin-3 inflammatory marker level in GCF

Pentraxin-3

in GCF

Mean Standard

deviation

Minimum Maximum ANOVA- X² - value

P-value Scheffe’s

multiple

comparison

test result

Group I 1.402 0.29 0.87 1.87 56.76 <0.001 GI<GII<GIII

Group II 2.299 0.36 1.54 2.83

Group III 3.184 0.64 1.98 4.25

Table 3: Descriptive statistics of pentraxin-3 inflammatory marker level in plasma

Pentraxin-3

in plasma

Mean Standard

deviation

Minimum Maximum ANOVA- X²- value

P-

value

Scheffe’s

multiple

comparison

test result

Group I 0.938 0.29 0.32 1.56 84.90 <0.001 GI <GII <GIII

Group II 2.118 0.41 1.35 3.00

Group III 2.885 0.49 1.63 3.56



19

0.57) at the end of 3 weeks and serum pentraxin-3 from

(2.88 ± 0.49) at baseline to (1.95± 0.58) at the end of 3

weeks (Table 4).

DISCUSSION

Periodontal disease is a multifactorial infectious disease

characterized by inflammatory breakdown of tooth

supporting structures; although the most important

cause of periodontal disease is the presence of

periodontal microorganisms. Consequent progression

and disease severity are considered to be determined

by the host immune response. Mediators formed as a

part of host response that contribute to tissue

destruction comprise of acute-phase proteins,

cytokines, and prostaglandins. Pentraxin 3 is the first

long pentraxin to be identified and is produced by a

variety of cells like the dendritic cells, endothelial cells,

fibroblasts and neutrophils. It has an important role in

innate immunity, regulation of inflammatory reaction

and the clearance of apoptotic cells. Plasma levels of 9, 6, 7

PTX3 are raised in inflammatory conditions resulting

from a wide range of diseased states from infection to

autoimmune and/or degenerative disorders.10

In the past, few studies showed that there was an

increase in the levels of PTX3 in GCF and serum in

periodontal disease conditions. These studies

suggested that level of PTX3 were directly related to

amount of inflammatory condition and therefore it can

be considered as a marker of inflammation in

periodontal diseases.4, 9, 11

The main objective of this study was to estimate the

level of pentraxin-3, in chronic periodontitis patients

before and after non surgical periodontal therapy and

to correlate the levels of pentraxin-3 with disease

severity (healthy, gingivitis and periodontitis).

This study was initiated to determine, whether PTX3

levels were altered after non surgical therapy.

In our study, GCF and serum PTX3 levels were found to

be significantly higher in periodontitis group compared

with healthy and gingivitis groups. This indicates that

the severity of the inflammation is more in patients with

generalized chronic periodontitis than in healthy and

gingivitis. As the disease progresses from healthy to

gingivitis and then periodontitis, there is more

accumulation of neutrophils and monocytes at disease

sites and augmentation of cytokines such as IL-1 and 4,12

TNF-β for PTX3 synthesis.

In the present study, the GCF was collected by using

micro-capillary tube to avoid non-specific attachment

of PTX3 to filter papers, which can lead to a false decline

in measurable PTX3 levels and thus can miscalculate the

correlation of PTX3 levels of disease severity and

progression.

The sandwich ELISA, known for sensitivity and

specificity, is used in this study for accurate

quantification of PTX3. As per various studies

immunohistochemistry can also be used for PTX3

analysis.13

Pradeep et al (2011) recently reported the levels of

PTX3 in GCF and serum in chronic periodontitis patients

as 3.378 ± 1.45003 ng/ml and 3.074 ± 0.71829 ng/ml

Table 4: mean and standard deviation of the dental parameters before and after SRP for chronic periodontitis patients.

Variable Before SRP After SRP Paired t-

test

P-value

Mean Standard

Deviation

Mean Standard

Deviation

Plaque Index 1.654 0.38 0.856 0.10 8.154 <0.001

Gingival Index 2.163 0.36 1.340 0.65 5.938 <0.001

SBI 3.064 0.57 1.849 0.89 6.392 <0.001

CAL 5.912 1.01 5.375 1.19 6.255 <0.001

PPD 5.493 0.81 4.821 0.91 4.846 <0.001

Pentraxin-3 in GCF 3.184 0.64 2.141 0.57 5.334 <0.001

Pentraxin-3 in plasma 2.885 0.49 1.956 0.58 5.552 <0.001



20

respectively using the ELISA technique. The deepest

probing sites were used for sample collection. In our 4

study, the samples were obtained from sites with

deepest probing depth and PTX3 values in the GCF and

serum from patients with chronic periodontitis were

estimated at 3.184 ± 0.64 ng/ml and 2.885 ± 0.49 ng/ml

respectively.

In our study, PTX3 concentrations positively correlate

with clinical parameters in the periodontitis group. The

positive correlation between clinical parameters and

PTX3 levels can be attributed to the production of

cytokines at tissue injury sites. Neutrophils appear early

at sites of infection and injury. They represent a

reservoir of pre-stored PTX3 that are ready for rapid

release. These specific granules of PTX3 are released

from neutrophils in response to inflammatory signals.4

A study by Yuzo Fugita et al in 2012 reported GCF PTX3

levels to be significantly higher in patients with

periodontal disease site (0.64 ± 0.39 ng/ml) than

periodontal healthy sites (0.06 ± 0.10ng/ml) in patients

with chronic periodontitis. A strong positive correlation

was also observed between mean gingival index, pocket

depth, bleeding on probing, GCF levels and PTX3

levels. The GCF PTX3 level in the above study is almost [11]

6 times lower than the level obtained in our study

(3.184±0.64ng/ml).

The result of the present study revealed statistically

significant (p < 0.001) increase in the mean

concentration of PTX3 in GCF as the diseases

progressed from healthy (1.402 ± 0.29) to gingivitis

(2.299 ± 0.36) to periodontitis (3.184 ± 0.64). The results

were in accordance with the result of a study done by

Yuzo Fugita et al (2012) which showed that the mean

concentration of PTX3 was significantly higher (p < 0.01)

in diseased sites (0.64 ± 0.39) as compared to healthy

sites (0.06 ± 0.10).

Enas Ahmed Elgand et al (2013) study was conducted to

evaluate the effectiveness of SRP (Group I) and SRP with

adjunct treatment of tea tree oil (Group II) on clinical

parameters and level of pentraxin-3 in chronic

periodontitis. Serum samples were collected to

measure the serum PTX3 levels by using ELISA. This

study showed statistically significant reduction in

clinical parameters PTX3 levels in group II compared

with group I.14

The patients after non surgical periodontal therapy

(scaling and root planning) showed reduced GCF and

serum PTX3 levels and clinical parameters. Serum PTX3

was reduced from 2.885 ± 0.49 to 1.956 ± 0.5 at the end

of 3 weeks and GCF PTX3 also reduced from 3.184 ± 0.64

to 2.141 ± 0.57.

Mean pentraxin 3 values in comparison were analysed

before and after non surgical therapy in GCF and plasma

by using paired t test. Mean values shows statistically (p

< 0.001) significant differences. The result of our study

revealed that there was a highly statistically significant

(p < 0.001) reduction of clinical parameters and GCF

PTX3 levels in patient with chronic periodontitis after

nonsurgical therapy.

Clinical improvement after periodontal therapy was

associated with significant reduction in PTX3 in GCF and

plasma. Non surgical therapy (Scaling and root

planning) controls the local bacterial infection and leads

to minimum influx of PMN into GCF and reduces PTX3

expression in GCF. At the same time it decreases the

entry of bacteria into systemic circulation, thus

reducing PTX3 expression in serum.15, 16

To date, only one study by Enas Ahmed Elgend et al

(2013) showed effect of non-surgical therapy on

pentraxin-3 level in GCF samples of patients with

periodontal diseases.14

Limitations of our study were, Gingivitis patients did not

receive any SRP, because the aim of our study was to

check the impact of SRP on inflammatory marker PTX3

in GCF and plasma samples and for that the most

destructive periodontal disease was selected to obtain

better results. Other systemic inflammatory markers

were not analysed.

CONCLUSION

Quantitative sandwich enzyme immunoassay

techniques revealed the GCF and plasma PTX3 levels are

higher in pat ients with general ized chronic

periodontitis than healthy patients and those with

gingivitis. After non surgical therapy the PTX3 levels

reduced in both GCF and plasma. PTX3 concentration

was elevated with increasing severity of periodontal

d iseases and decreases with lower level of

inflammatory conditions.



21

REFERENCES:

1. Newman MG, Takei H, Klokkevold PR, Carranza

FA. Microbial interactions with the host in

periodontal diseases. Clinical Periodontology

2006; 10 edition: 228-246.th

2. Sema Becerik, Veli Ozgen Ozturk, Harika

Atmaca, Gul Atilla, Gulnur Emingil. Gingival

crevicular fluid and plasma Acute-phase

cytokine levels in different periodontal

diseases. J Periodontol 2012; 83: 1304-1313.

3. Farah Az iz Khan, Mohd Fareed Khan.

Inflammation and acute phase response.

International Journal of Applied Biology and

Pharmaceutical Technology 2010; I (2): 312-

321.

4. Pradeep A.R, Rahul Kathariya, Raghavendra

N.M, Anuj Sharma. Level of pentraxin-3 in

gingival crevicular fluid and plasma in

periodontal health and disease. J Periodontol

2011; 82:734-740.

5. Alok Agrawal, Prem Prakash Singh, Barbara

Bottazzi, Cecilia Garlanda, Alberto Mantovani.

Pattern Recognition by pentraxins. Adv Exp

Med Biol 2009; 653: 98-116

6. Alberto Mantovani, Cecilia Garlanda, Andrea

Doni, Barbara Bottazzi. Pentraxins in innate

immunity; From C-reactive protein to the long

pentraxin PTX3. J Clin Immunol 2008; 28: 1-13

7. Cecilia Garlanda, Barbara Bottazzi, Antonio

Bastone, Alberto Mantovani. Pentraxins at the

crossroads between innate immunity,

inflammation, matrix deposition and female

fertility. Annu Rev Immunol 2005; 23: 337-66.

8. Newman MG, Takei H, Klokkevold PR, Carranza

FA. Defence mechanism of gingiva. Clinical

Periodontology 2006; 10 edition: 344-354. th

9. Gonca Cayir Keles et al. Biochemical analysis of

p entrax in - 3 an d f ib r in o gen leve l s in

experimental periodontitis model. Mediators

of Inflammation 2012; 1-7.

10. Pawel Cieslik and Antoni Hrycek. Long

pentraxin 3 in the light of its structure,

mechanism of action and clinical implications.

Autoimmunity 2012; 45(2):119-128.

11. Yuzo Fujita, Hiroshi Ito, Satoshi Sekino, Yukihiro

Numabe. Correlations between pentraxin 3 or

cytokine levels in gingival crevicular fluid and

clinical parameters of chronic periodontits.

Odontology 2012; 100: 215-221.

12. Pradeep A.R, Rahul Kathariya, Arjun Raju P,

Sushma Rani R, Anuj Sharma, Raghavendra

N.M. Risk factors for chronic kidney diseases

may include periodontal diseases, as

estimated by the correlations of plasma

pentraxin-3 levels: a case-control study. Int Urol

Nephrol 2012; 44: 829-839.

13. Luchetti M.M et al. Expression and production

of the long pentraxin PTX3 in rheumatoid

arthritis. Clin Exp Immunol 2000; 119:196-202.

14. Enas Ahamed Elendy, Shereen Abdel Moula,

Doaa Hussien Zineldeen. Effect of local

application of tea tree oil gel on long pentraxin

level used as an adjunctive treatment of chronic

periodontitis: A randomized controlled clinical

study. Indian society of periodontology 2013;

17: 444-448.

15. Barbara Noack, Genco J, Maurizio Trevisan,

Sara Grossi, Zambon J, Ernesto De Nardin.

Periodontal infections contribute to elevated

systemic C- reactive protein level. J Periodontol

2001; 72: 1221-1227.

16. Chung RM, Grbic JT, Lamster IB. Interleukin-8

and β-glucuronidase in gingival crevicular fluid.

J Clin Periodontol 1997; 24: 146-152.



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LE 1 2 3P. Gupta , S. Verma , P. Dubey1 Associate Professor, Nephrology Unit, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur2 Associate Professor, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur3. PG Student, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur

Corresponding Author: Dr. P. GuptaAssociate Professor, Department of Medicine, Pt.J.N.M. Medical College & Dr. B.R.A.M. Hospital, Raipur, Email : [email protected], Mob: 9009200001

ABSTRACT

Objectives: Hyperphosphatemia is highly prevalent in dialysis patients and may be associated with immune

dysfunction. The association of serum phosphate level with infection remains largely unexamined.

Material and method: A study group contain total of 100 patients, out of which 15 patients blood culture and central

venous catheter tip culture was positive. All Patients were underwent investigation in form of renal function test, c

reactive protein level, serum phosphorus, blood culture,urine culture, central line tip culture.

Results: Out of 15 patients of renal failure on hemodialysis with sepsis none had serum phosphate level less than 3.5

mg /dl, 4 (26.67%) had serum phosphorus level between 3.5 – 5.5 mg/dl and 11 (73.33%) patients had serum

phosphorus level > 5.5 mg/dl. Infections of any type were more frequent among patients with high phosphate levels

at baseline, relative to normal. Male sex, advanced age, diabetes, anemia, hypoalbuminemia were found to be risk

factors for infections.Gram positive cocci (Staphylococcus aureus) was the most common organism found in blood of

80% patients of renal failure on haemodialysis with sepsis. Incidence of sepsis was high with femoral vein (66.67%)

usage and prolonged hemodialysis (more than 21 days). Serum Phosphorus level was high in 73.33% patients and

CRP was raised in all 15 patients with sepsis. Most of the patients were euthyroid and their lipid profile was normal.

Conclusions: High phosphate levels may be associated with increased risk for infection, contributing further to the

rationale for aggressive management of hyperphosphatemia in dialysis patients.

INTRODUCTION

Hyperphosphatemia is highly prevalent in dialysis

patients and may be associated with immune 1

dysfunction . The association of serum phosphate level

with infection remains largely unexamined. Disorders of

bone mineral metabolism, including hypo- and

hyperphosphatemia, have been shown to be associated

with increased risk for all-cause and cardiovascular 2-5

mortality and morbidity in dialysis patients . The risk

for infectious morbidity and mortality has also been

shown to be increased in patients with increased 6

phosphate levels .

Hyperphosphatemia could be associated with the risk

for infection in dialysis patients through other

mechanisms. Phosphate may act purely as a surrogate

for the uremic state, which has also been associated 8

with immune dysfunction . 7Yoon et al. showed that hyperphosphatemia was

directly associated with diminished populations of

naive and central memory T lymphocytes. This

observation may in part contribute to the acquired

impaired immune response of this population, leading

to an increased risk for infection.

MATERIAL METHOD

This study was conducted in Department of Medicine,

Dr. B. R. A. M. Hospital Raipur (C.G.) from 2013 to 2014.

100 Indoor patients of both sexes who were diagnosed

Study of serum phosphate levels and risk of infection in hemodialysis patients

22


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23

as a case of renal failure that include both Acute Kidney

Injury and Chronic Kidney Disease on basis of clinical

history, examination, biochemical markers and who

were advised for hemodialysis were included in the

study. The criteria used for AKI in the study was RIFLE

criteria and CKD is diagnosed by KDOQI guidelines.

A im of our study to f ind of assoc iat ion of

hyperphosphatemia in hemodialysis patients and its

relation with sepsis.

All patients will undergo complete clinical examination

including pulse, blood pressure, general examination,

systemic examination including Local examination at

catheter site. Following investigations were done in all

the patients whom included: Haematological test (Hb%,

TLC, DLC, Platelet count) , RFT (S.creatinine, Blood urea,

S.electrolyte), CRP, Serum Phosphorus, LFT (SGOT,

SGPT, S.Bilurubin ,S. Total Protein, S. Albumin, Alkaline

phospatase), TFT (T3, T4, and TSH) , Viral markers

(HBsAg, HCV, HIV), Blood Culture,Central Line Tip

Culture , Urine Routine/Microscopy, CXR P/A view, USG

Abdomen and KUB.

RESULTS

Total 100 patients were taken for our study, 15 patients

have signs and symptoms of sepsis and their blood

culture was positive.

Out of these 15 patients, 11 (73.33%) patients have

raised serum phosphorus level. In this study group were

63.33 % males and 36.67% were females patients

suffering from catheter related infection in the form of

fever with chills and rigors, redness and induration over

the site of catheter insertion and their blood culture

was positive. Mean age in our study was 41.78 ± 13.61

year. 30% patients were diabetic. Among these 11

patients 27.28% patients has mild anemia (Hb 9 – 11

gm%), 36.36% has moderate anemia( Hb 7 - 9 gm%) and

36.36% (Hb < 7gm%) has severe anemia. Mean Hb was

8.18 ± 1.91 m %. Hypoalbuminemia found in 55.55%.

Hypothyroidism found in 18.19% patients.

63.37% patients have femoral catheter and 36.63%

patients have internal jugular catheter. None has

subclavian catheter. Mean duration of dialysis was

15.86 ± 7.19 days. Most common organism found was S.

aureus.

CRP was high in all these patients. All patients have

creatinine level more than 6 mg/dl.

On statistical analysis of above observation, data found

significant. (P value < 0.005) suggest strong association

of serum phosphorus level and infection.

Fig showing serum Phosphorus level in Renal Failure

patients on hemodialysis

DISCUSSION

Phosphorus is essential for life. As phosphate, it is a

component of , , , and also the DNA RNA ATP

phospholipids that form all cell membranes.

In addition to being essential for the structural stability

of bones and teeth, cell membranes (phospholipids),

and nucleic acid molecules, phosphorus plays an

important role in metabolic activity such as

carbohydrate and energy metabolism that inherently

depends on the capacity to phosphorylate intermediate

metabolites and to store energy released during

oxidation in high-energy phosphate bonds such as ATP

or phosphocreatine. Phosphorus is an integral

component of 2,3-DPG, a compound that regulates

oxygen release from hemoglobin and therefore is

critical for oxygen delivery to tissues. Inorganic

phosphorus (phosphate, PO , or Pi) is also an important 4

buffer in the body. Quantification of phosphate levels is

useful for diagnosis and management of bone,

parathyroid, and renal disease, as well as various other

disorders. Refferance range is Age 18 years or older -

Serum phosphate levels and infection risk in hemodialysis patients


24

112.5-4.5 mg/dL(Walter Gruenberg 2014)

Laura C Plantinga et al (10) conducted a prospective

cohort study found that high levels of phosphate i.e >

5.5 mg/dl in 37.3% early in the course of dialysis were

associated with increased risk for subsequent infection.

This association was not explained by evidence of

secondary hyperparathyroidism or uremia as a result of

poor dialysis, suggesting that phosphate may be an

independent risk factor for infection. They Found sepsis

is associated with high level of phosphate level.

CONCLUSISON

High levels of phosphate early in the course of dialysis

were associated with increased risk for subsequent

infection. Thus phosphorus can be use as a significant

marker of infection in dialysis patients, And More

aggressive management of hyperphosphatemia in

dialysis patients could result in decreased infectious

morbidity among dialysis patients.

REFERENCES

1. National Kidney Foundation: Kidney Disease

Outcomes Quality Initiative (K/DOQI).Accessed

December 15, 2007

2. Block GA, Hulbert-Shearon TE, Levin NW, Port

FK: Association of serum phosphorus and

calcium x phosphate

3. product with mortality risk in chronic

hemodialysis patients: a national study. Am J

Kidney Dis 31: 607–617, 1998.

4. 3. Block GA, Klassen PS, Lazarus JM, Ofsthun N,

Lowrie EG, Chertow GM: Mineral metabolism,

mortality, and

5. morbidity in maintenance hemodialysis. J Am

Soc Nephrol 15: 2208–2218, 2004.

6. Melamed ML, Eustace JA, Plantinga L, Jaar BG,

Fink NE, Coresh J, Klag MJ, Powe NR: Changes in

serum calcium, phosphate, and PTH and the

risk of death in incident dialysis patients: A

l o n g i t u d i n a l s t u d y. K i d n e y I n t 7 0 :

351–357,2006.

7. Ganesh SK, Stack AG, Levin NW, Hulbert-

Shearon T, Port FK: Association of elevated

serum PO(4), Ca x PO(4) product, and

parathyroid hormone with cardiac mortality

risk in chronic hemodialysis patients. J Am Soc

Nephrol 12:2131–2138, 2001.

8. Lange LG, Hartman M, Sobel BE: Oxygen at

physiological concentrations: A potential,

paradoxical mediator of reperfusion injury to

mitochondria induced by phosphate. J Clin

Invest 73: 1046–1052, 1984.

9. Yoon JW, Gollapudi S, Pahl MV, Vaziri ND: Naive

and central memory T-cell lymphopenia in end-

stage renal disease. Kidney Int 70: 371–376,

2006.

10. Laura C. Plantinga, Nancy E. Fink, Michal L.

Melamed, William A. Briggs, Neil R. Powe, and

Bernard G. Jaar CJASN Clin J Am Soc Nephrol.

Sep 2008; 3(5): 1398–1406.

11. Walter Gruenberg, DrMedVet, MS, PhD,

DECAR, DECBHM April 2014


Serum phosphate levels and infection risk in hemodialysis patients

25

1 2 3 4R. K. Dubey , P. Shetty , D. K. Gupta , S. Pandey1. Professor, Department of Prosthodontics, Government Dental College, Raipur (C.G.)2. Professor, Department of Prosthodontics, TIDS, Bilaspur 3. Associate Professor, Department of Prosthodontics, GDC, Raipur4. Lecturer, Department of Prosthodontics, TIDS, Bilaspur

Corresponding Author :Dr. R. K. Dubey

Professor, Department of Prosthodontics, Government Dental College, Raipur (C.G.)Mob. No.- 9229927756, E-mail ID – [email protected]

ABSTRACT: Objectives: A descriptive cross-sectional study was conducted among institutionalized geriatric individuals in cities

of Chhattisgarh to assess their oral health status primarily concerned with prosthetic status and needs that would

aid in formulating plan for oral health service programs.

Materials and methods: The oral examination of the study subjects was carried out using Basic Oral Health Surveys

WHO 1997 guidelines.

Results: A total of 125 individuals were included in the study out of which 68 were males and 57 were females.

11(8.8%) study participants had some prosthesis at the time of examination, whereas 119 (95.2%) were in need of

prosthesis. 51(40.8%) people, with all or more than 20 teeth missing/root stumps, had intense prosthetic need to

restore oral function and consequently the general health. 48(39.2%) residents had need of U/L RPD followed by

need of U/L CD among 37(29.6%) persons. 15.2%(19) people requires combination of RPD and CD in upper and

lower dental arch while 11.2%(14)of residents had need of either FPD or combination of RPD and FPD.

Conclusions: The prosthetic status of the institutionalized geriatric individuals in cities of Chhattisgarh is poor with

higher unfulfilled prosthetic needs. A planed strategy is needed to address this problem of elderly people.

INTRODUCTION:Though aging is an inevitable natural phenomenon, the advancement in medical discoveries and improving socio economic condition has created possible environment of enhanced lifespan throughout the world . The consequences strengthen the expectation 1

and reflected in literature that there will be 1.2 billion elderly peoples worldwide by 2025 and will reach to the mark of 2 billion by 2050 out of which 80% will belong to developing nation . Mission of the health professional

1, 2

is not merely to increase the life span but also perhaps more importantly to make the later life more productive and enjoyable .3

The joint family system and traditional Indian society have been instrumental in safe guarding the social and economic securities of older peoples in country.

However, the rapid change in social scenario and emerging trend of nuclear family set up in India, the elderly people are likely to be exposed physical, emotional and financial insecurities in years to come . 4

Government of India has adopted 'National policy on senior citizens 2011 to help such elderly peoples and '

number of programs are being efficiently implemented by various state governments to provide shelter and support to the elderly peoples.The loss of teeth is an end product of oral disease and reflects the attitudes of the patients, the dentists in a society, the availability and accessibility of dental care as well as the prevailing philosophies of care . The lower 5

socioeconomic condition, cultural misbelieves, unfavorable environmental and demographic situation may further aggravate the causative factors of tooth

Edentulousness , prosthetic status and prosthetic need ofinstitutionalized elderly people in old age homes of Chhattisgarh

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loss.The barriers to oral health care like, impaired mobility that impedes access to oral health care, financial hardship following retirement, the cost or perceived cost of dental treatment, together with poor attitudes to oral health, may further exaggerated the

6edentulousness in institutionalized elderly people . Improved oral health maintains nutritional status of geriatric person and consequently improves their self confidence, ability to contribute their possible services to society and active happy social contacts. Numerous Old age Homes are delivering their sincere help to such elderly with credible support of state government across the whole Chhattisgarh. Oral health care needs of these elderly living in such care facilities has been least addressed till date.In order to promote oral health and formulating a plan fo r a n o ra l h e a l t h c a r e p r o g ra m fo r s u c h institutionalized elderly, we need to acquire the baseline information regarding their oral health status, prosthetic status and prosthetic needs. As of today no data available for state of Chhattisgarh. Hence, an effort was performed to collect this baseline information.

MATERIAL AND METHOD:The present study was conducted among elderly peoples residing in old age home of Chhattisgarh with prior written permission of concerned authority and informed verbal &written consent of all individual examined. The examiners were trained and intra-examiner calibration showed a good agreement statically. All the available residents of 5 old age homes of Chhattisgarh had interviewed for their socio-demographic factors like age, sex, education, habits. Clinical examination of dentition status and treatment needs has been performed using a mouth mirror and a Community Periodontal Index Probe in proper light. The assessment of dentition status and treatment needs

were the recording of the number of teeth lost by dental caries/periodontal diseases, number of existing prostheses (if any) and a detailed prosthodontic treatment requirement (Complete removable dental prosthesis, Partial removable dental prosthesis, Fixed dental prosthesis) based on the clinical assessment of the operator and patient's acceptability of the type of treatment. Primary aim was to record all information advocated in 'WHO oral health status assessment form' approved for such investigation in 1997. But, due to practical problems like diminished co-operation for detail examination in older age and inadequate seating arrangement for comfortable periodontal examination with probe, all information as per WHO Performa 1997 had not been recorded. Only status of dentition (decayed, missing, and level of abrasion and attrition) and superficial periodontal health observation (gingival recession, periodontal condition) had been performed. Prosthodontic status and needs were recorded as per WHO oral health status assessment form 1997.The extract of observation was tabulated. Simple statistical analysis was done to draw prosthodontic treatment requirements and prosthetic status in residents of old age homes.

RESULTS:Total 125 residents were examined from 5 old age home of Chhattisgarh (two from Raipur, one from Durg, Rajnandgoan and Bilaspur). Few residents from each center were not examined due to unavailability on date of examination, not interested for examination or their much compromised general health. Among the examined people, 68(54.4%) and 57 (45.6%) were male and female respectively (Table -1). 52residents (41.6%) were of age group 70-80 yrs followed by 48(38.4%) of 60-70 yrs and 20% (25 residents) were above the age of 80 yrs (Table- 2).

Table-1. Total number of residents examined = 125 Male subjects = 68 (54.4%) Female subjects = 57 (45.6%)

Table-2. Distribution of subjects by age

Age (years) Number of subjects Percentage60-69 48 38.470-79 52 41.6> 80 25 20.0Total 125 100.0


Prosthetic status and prosthetic need of institutionalized elderly of CG

27

Only 09(7.2%) of the examined residents had fully intact dentition. Among 116(92.8%) of the subjects having 01 or more than 01 teeth loss, 40(32%) person had lost 20 or more than 20 teeth in both arches (Table-3). 17(13.6%) people were fully edentulous. When root

stumps were also added with missing teeth it was found that only 7(5.6%) had no tooth mortality. Large number of people (40.8%) had 20 or more than 20 missing teeth and root stump (Table-4).

Table-3. Subjects by Number of missing teeth and sex

No. of missing teeth Male Female Total

0 04(5.88%) 05(8.77%) 09(7.2%)

01-09 25(36.76%) 24(42.1%) 49(39.2%)

10 -19 16(23.53%) 11(19.2%) 27(21.6%)

?20 14(20.58%) 09 (15.7%) 23 (18.4%)

Fully Edentulous 09(13.23%) O8 (14.03%) 17(13.6%)

Total 68(100%) 57(100%) 125(100%)

Table-4. Subjects by Sex and Tooth mortality in form of missing and root stump

Prosthetic need were evaluated on the basis of missing teeth, root stumps, tooth/teeth to be extracted due to mobility or gross mutilation of coronal part due to caries, abrasion or attrition . It was observed that 119(95.2%) residents had need of some kinds of dental prosthesis. The overall prosthetic needs in females (96.4%) were little higher than males (94.1%) but statical ly

insignificant (table-5). Need for dental prosthesis was slightly higher in lower arch (92.0%) compared to upper arch (87.2%) both among male as well as female subjects but statistically insignificant. Need of multiunit prosthesis in upper [50(40.0%)] or lower arches [52(41.6%)] of the subjects surveyed was highest followed by full prosthesis in upper [45(36.0%)] or lower arches [48(38.4%)] (table-6).

Table -5.Correlation between overall prosthetic need and sex

The surveyed male subjects had highest need of multiunit prosthesis [44.11% in Upper & lower arches respectively] followed by full dental prosthesis in both upper (32.35%) and lower arches (33.82%). Whereas the female subjects

experienced highest need of full dental prosthesis [U (40.35%) & L (43.85%)] followed by multiunit prosthesis in upper (35.01%) or lower arches (38.59%) [table-6].


No. of missing teeth + root stump Male Female Total 0 04(5.88%) 03(5.2%) 07(5.6%)01-09 18(26.47%) 22(38.59%) 40(32.0%)10-19 19(27.94%) 08(14.03%) 27(21.6%)?20 27(39.7%) 24(42.1%) 51(40.8%)Total 68(100%) 57(100%) 125(100%)

Male Female Total n % n % n % Prosthetic needs 64 94.1 55 96.4 119 95.2Total 68 100.0 57 100.0 125 100.0 P-value > 0.1

2 X = 0.539


28

In terms of need for RPD, FPD, CD and Combination of RPD& FPD the surveyed subjects experienced highest need of RPD followed by CD. The male subjects had same pattern of need as the overall subjects. But the females entailed more need of CD compared to RPD in both upper and lower arches (table-7).It has been observed that only 11(8.8%) residents have

availed opportunity to get dental prosthesis fabricated, however only 06(4.8%) subjects were wearing the prosthesis successfully. Prosthetic status in females (7.02%) was poor compared to males (12.3%) [table-08] . The prosthetic status in surveyed subjects was nearly same in both and upper arches.

Table -6. Prosthetic needs in Subjects by jaw type and sex (oral health assessment criteria 1997)

Prosthetic needs Upper Arch Lower Arch

Male Female Total Male Female Total

No prosthesis needed 10 (14.71%)

06 (10.52%)

16 (12.8%)

06 (8.82%)

04 (7.01%)

10 (8.0%)

Need for one unit prosthesis

04 (5.88%)

04 (7.01%)

08 (6.4%)

04 (5.88%)

03 (5.26%)

07 (5.6%)

Need for multi unit prosthesis 30 (44.11%)

20 (35.01%)

50 (40.0%)

30 (44.11%)

22 (38.59%)

52 (41.6%)

Need for combination of one-and/or multi unit prosthesis

02 (2.94%)

04 (7.01%)

6 (4.8%)

05 (7.35%)

03 (5.26%)

08 (6.4%)

Need for full prosthesis 22 (32.35%)

23 (40.35%)

45 (36.0%)

23 (33.82%)

25 (43.85%)

48 (38.4%)

Total 68 (100%)

57 (100%)

125 (100%)

68 (100%)

57 (100%)

125 (100%)

Table -7.Prosthetic need in Subjects by sex and jaw type (In terms of RPD, CD and FPD)

Prosthetic needs MALE FEMALE TOTAL

UPPER ARCH

LOWER ARCH

UPPER ARCH

LOWER ARCH

UPPER ARCH

LOWER ARCH

No need 10(14.71%) 06(8.82%) 06(10.52%) 04(7.01%) 16(12.8%) 10(8.0%)

RPD 28(41.17%) 33(48.52%) 20(35.08%) 22(38.59%) 48(38.4%) 55(44.0%)

FPD 06(8.82%) 01(1.47%) 04(7.01%) 03(5.26%) 10 (8.0%) 04(3.2%)

Combination of RPD& FPD

02(2.94%) 05(7.35%) 04(7.01%) 03(5.26%) 06(4.8%) 08(6.4%)

CD 22(32.35%) 23(33.82%) 23(40.35%) 25(43.86%) 45(36.0%) 48(38.4%)

Total 68(100%) 68(100%) 57(100%) 57(100%) 125(100%) 125(100%)

Table -08 Overall Prosthetic Status by sex

Prosthetic Status Male Female Total

Number of subjects

% Number of subjects

% Number of subjects

%

No prosthesis

61 89.7 53 92.98 114 91.2

Prosthesis ( RPD, FPD or CD) wearer in U/L or U and L both arch

7 12.3 4 7.02 11 (5 US*)

8.8 (4.0)

Total 68 100.0 57 100.0 125 100

*Unsatisfied with dental prosthesis and not wearing the prosthesis



29

DISCUSSION-119(95.2%) people residing in old age homes of Raipur, Bilaspur, Durg and Rajnandgoan (Chhattisgarh) had one or more than one teeth missing / root stumps and they had need of dental prosthesis. This result is a little higher but nearly accordance with similar studies

7conducted by and Suryakant C. S. Chaware et.al. 8

Deogade et.al. among subjects of old age homes of Nasik (MH) and Jabalpur(MP) respectively. But it is

9-11much higher than some like studies carried out in Indian places reporting prosthetic needs within range of

12-1670-80%. Almost all the current studies from places of world other than India reported edentulousness more than 70% in elderly peoples. Reason for higher prosthetic needs among institutionalized elderly may ascribe to old age and factors associated with old age such as reduced salivary flow rate, quality and quantity, lowered immunity and the reduced ability of the body

17to repair itself . Several other factors such as multiple chronic diseases, intake of several medications and their side effects, psychological factors such as depression and isolation (because of gradual loss of spouse and friends and feeling of being unwanted by family members), feeling of low self worth owing to loss of earning power and social recognition which leads to

18, 19 poor oral hygiene health , may result into higher edentulousness and prosthetic needs.

51(40.8%) of the surveyed people had all or more than 20 teeth missing/root stumps out of which 17(13.7%) subjects were fully edentulous. The prevalence of edentulism apparently looks lower than the report of

o World Oral Health 2003 i.e.19% in Indian population

but it appeared much higher in terms of need of full dental prosthesis in our study. The reason might be the involvement of the socio economically disadvantaged elderly subjects who were deficient to avail the already scant dental facilities for extraction of the mobile / grossly decayed teeth. The loss of more than 20 teeth badly affects oral function and consequently the general health of these people. Thus, they have intense call for restoration with dental prosthesis as early as possible.

The examined men had little lower overall dental prosthetic need compared to women. The women experienced more need of full dental prosthesis compared to men whereas the men were in more need of multiunit prosthesis compared to women. These

8findings are supported in an analogous study performed. However results are contrast to the similar

7,10,11 studies conducted at other places in India. The social & economical dependency since the beginning and much higher illiteracy in the women surveyed in this study may be one reason for such results. The post menopausal osteoporotic changes in the women may also be a contributory factor.

The prosthetic status observed among residents of old age homes of Chhattisgarh is very poor. Only 11(8.8%) persons had availed the facility of dental prosthetic treatment out of which 5(4.0%) were unsatisfied with their prosthesis and not using the prosthesis. Thus, merely 4.8% (6) of the examined old age home dwellers had successful dental prosthesis. The prosthetic status in females was more worrying compared to males.

Table -09 Prosthetic Status by sex and jaw type

Prosthetic status

MALE FEMALE TOTAL

UPPER ARCH

LOWER ARCH

UPPER ARCH

LOWER ARCH

UPPER ARCH

LOWER ARCH

No prosthesis 61(89.7%) 61(89.7%) 54(94.3%) 53(92.9%) 115(92.0%) 114(91.2%)

Bridge/ Crown 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%)

>one Bridge 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%)

Partial denture 00(0.0%) 00(0.0%) 01(.17%) 02(.34%) 01(0.8%) 02(1.6%)

Both Bridges & Partial Denture

00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%) 00(0.0%)

Full mouth Removable denture

7(32.35%) 7(33.82%) 2(40.35%) 2(43.86%) 09( 05US*) (7.2%)

09( 05US*) (7.2%)

Total 68(100%) 68(100%) 57(100%) 57(100%) 125(100%) 125(100%)

*Unsatisfied with dental prosthesis and not wearing the prosthesis



30

Comparable outcome were observed by R P Shenoy 10 11et.al. (12%) , A Srivastava et.al. (~11.5%) and V Bansal

9et.al.(13.8%) in institutionalized elderly. A little better

prosthetic status( 30%) was noticed in like studies by S ≥7 8 20Chaware et.al. ,S C Deogade et.al . and V Thakare et.al.

All the like mentioned studies were reported poor prosthetic status in females compared to males as recognized in our study. The poor prosthetic status among subjects of present study may be due to the fact that institutionalized elderly underuse the available dental facilities due to lack of awareness, financial constraint, lack of interest, reduced mobility and components of dental care like poor access to services and higher costs of dental care. The dependency on their counterpart (males), higher level of illiteracy and lack of self earning in our society may further worsen the prosthetic status in females.

CONCLUSION:The findings of this survey demonstrate a high unmet need for prosthetic care among the population of old age homes of Raipur, Bilaspur, Durg and Rajnandgoan. Most of the institutionalized elderly also requires extraction. The Study demonistrates that most of the residents have lack of knowledge as well as priority for

oral health. Thus it is suggested to initiate immediate p r e v e n t i v e m e a s u r e p r o g r a m s t o r e d u c e edentulousness and provide oral health care & rehabilitation facilities to these residents with help of state government, non-government organization, nearby dental institution and private institutions.

Acknowledgment; Sincere thanks to Department of Social and Family welfare, Chhattisgarh for the permission to perform the study, especially Rajesh Tiwari, Deputy Director and Mr. M. L.Pandey, Joint Director for their kind support throughout the survey. We would also like to thanks all participants who have contributed to the completion of this study.

REFERENCES;1. United Nations Population Division. World

population prospects: 332 the 2002 revision, New York, 2003. http://www.un.org/esa/ 333 population/publications/wpp2002/WPP2002-HIGHLIGHTSrev1. 334 PDF.

2. World Health Organization (2002) Active ageing: a policy 344framework. WHO, Geneva

3. Goel P, Singh K, Kaur A, Verma M . Oral health care for 339 elderly: identifying the needs and feasible strategies for service 340 provision. Indian J Dent Res2006; 17:11–21

4. N a t i o n a l p o l i c y o n o l d e r persons.www.social justice.nic. in/hindi 342/pdf/npopcomplete.pdf. Accessed on 24.05.2014

5. Burt BA and Eklund SA. Tooth loss. Dentistry, Denta l Pract i ce and the Community. W.B.Saunder Company. Philadelphia. 5th edition: 203-211

6. Zarb GA, Bolender CL. Prosthodontic th

treatment for edentulous patients. 12 ed. St. Louis: Mosby, 2004:6–23.

7. Chaware S, Ghodpage SL, Sinha M, Chauhan V, Thakare V. Prosthetic Status and Prosthetic Needs among Institutionalized Geriatric Individuals in Nashik City,Maharashtra: A Descriptive Study. J Contemp Dent Pract 2011;12 (3):192-195.

8. Suryakant C. Deogade, S. Vinay, S. Naidu Dental Prosthetic Status and Prosthetic Needs of Institutionalised Elderly Population in Oldage Homes of Jabalpur City, Madhya Pradesh, India. J Indian Prosthodont Soc.2013 .

9. Bansal, GM Sogi, KL Veeresha Assessment of oral health status and treatment needs of elders associated with elders' homes of Ambala division, Haryana, India Indian J Dent Res 2010;21:244-7

10. R. P. Shenoy and V. Hegde Dental Prosthetic S t a t u s a n d P r o s t h e t i c N e e d o f t h e Institutionalized Elderly Living in Geriatric Homes in Mangalore: A Pilot Study ISRN Dent. 2011;

11. A. Shrivastav, A. Bhambal, V. Reddy,M. Jain Dental prosthetic status and needs of the residents of geriatric homes in Madhya

Pradesh, India J. Int Oral Health 2011;3(4):9-14

12. Bonakdarchian M, Ghorbanipour R, Majdzadeh F, Hojati T. Prevalence of edentulism among adults aged 35 years and over and associated factors in Yasooj (Iran). Journal of Isfahan Dental School 2011; 7(1):101-4

13. Mamai-Homata E, Margaritis V, Koletsi-Kounari H, Oulis C, Polychronopoulou A, Topitsoglou V. Tooth loss and oral rehabilitation in Greek



31

middle-aged adults and senior citizens. Int J Prosthodont. 2012;25(2):173-9.

14. Nadia Khalifa, Patrick F. Allen, Neamat H. Abu-bakr, and Manar E. Abdel-Rahman4. Factors associated with tooth loss and prosthodontic status among Sudanese adults Journal of Oral Science2012; 54(4):303-312.

15. Adrienne Nickles, Dr. Sheila Vandenbush et. al. Results from a 2010 Oral Health Screening and Needs Assessment of Michigan Residents and Managers of Alternative Long-Term Care F a c i l i t i e s . http//www.michigon.gov./senior_smile_report_final_050311_355 assesed on Accessed on 24.05.2014

16. Kethy Phipps, Nicole Laws et. al . The Commonwealth's High-Risk Senior Population; Results and Recommendations from 2009 Statewide Oral Health Assessment in

M a s s a c h u s e t t s . www.mossgov/eohhs/doc/../senior-oral-health-assessment-report pdf

17. Navazesh M. Dry mouth: aging and oral health. Compend Contin Educ Dent2002;23(10):41–48

18. Ganguli M, Dube S, Johnston JM, Pandav R,Chandra V, Dodge HH. Depressive symptoms,cognitive impairment and functional impairment in a rural elderly population in India: a Hindi version of the geriatric depression scale (GDS-H). Int J Geriatr Psychiatry 1999; 14: 807–820.

19. Shah N. Geriatric oral health issues in India. Int Dent J 2001; 51: 212–218.

20. Thakare V, Ajith Krishnan CG. Periodontal status, prosthetic status and prosthetic needs among institutionalized geriatric individuals in Vadodara City, Gujarat—A descriptive study. J Ind Asso Public Health Dentistry 2010(15):153-57.



32

1 2Vanita Rathod , Chandan Rathod1. Professor, Department of Oral Pathology, Rungta College of Dental Sciences & Research Centre, Bhilai (CG)2. Lecturer, Department of Prosthodontics, Rungta College of Dental Sciences & Research Centre, Bhilai (CG)

Corresponding Author :Dr. Vanita RathodProfessor, Department of Oral Pathology, Rungta College of Dental Sciences & Research Centre, Bhilai (CG)E: mail: [email protected]

ABSTRACT

Objective: The purpose of the study was to identify trends in incidence rates of oral squamous cell carcinoma (OSCC)

at specific anatomic sites or within specific age or sex groups in the central Madhya Pradesh population.

Materials and Methods: The study covers the period of January 2007 through July 2011. OSCC cases were

retrospectively analyzed for site, age, gender, habits and histopathological grading. And the findings were

formulated to chart the trends in Madhya Pradesh.

Results: The study revealed a male to female ratio of 2:1 with the largest number of OSCCs developing in the peak

age of 46-55 years. Overall, the most common site was the alveolar mucosa and buccal mucosa followed by tongue,

palatal mucosa, floor of mouth, retro molar area. Smokeless tobacco habit was more prevalent than smoking

tobacco in both men as well as women. Smokeless tobacco in the form of gutkha is more prevalent in this region.

Conclusion: OSCC is significant cause of mortality and morbidity worldwide with an incidence rate that varies widely

by geographic location. Even within one geographic location, the incidence varies among group categorized by age,

sex, site or habits.

Key words : epidemiology, oral squamous cell carcinoma, trends.

INTRODUCTION

Squamous cell carcinoma is the most common

malignant neoplasm of the oral cavity and represents

about 90% of all oral malignancies. Oral squamous cell 1

carcinoma (OSCC) is significant cause of morbidity and

mortality worldwide with an incidence rate that varies

widely by geographic location. In India, oral cancer 2

represent a major health problem constituting up to

40% of all cancer in males and the third most prevalent

in females. Even within one geographic location, the

incidence varies among groups categorized by age, sex,

or race. Recent publications have highlighted 1,2

variations in oral cancer trends by geographic area are

vital for many reasons including understanding the

extent of the problem , determining which groups

within the population are at highest and lowest risk, and

relating the burden of oral cancer, consequently it helps

in evaluating the allocation of resources for research,

prevention, treatment and support services Despite 3,4

several diagnostic and therapeutic advances, the

overall incidence and mortality associated with OSCC

are rising. The current estimates of age-standardized

incidence and mortality is and 3.1/100,000 and

2.9/100,000 in men and women respectively. 5

Trends in epidemiology of oral cancer in central part of India in Madhya Pradesh : An institutional study


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Table 1: OSCC trends in central part India in M.P. population according to age, sex, site and habits.

SEX

male

female SITE

BM

AM

PM

LM

FM

RA HABITS

SL

ST

NH

25-35 5 7 4 4 7 4 1

36-45 5 11 5 7 11 3 2

46-55 20 10 13 11 2 1 2 1 20 6 4

56-65 10 4 4 2 - 2 1 1 9 3 2

66-75 4 3 3 3 1 1 1 5 2

76-85 - 2 1 1 1 1

86-95 1 2 1 Total 45 37 30 30 2 4 4 3 53 20 9

Sites S: BM-Buccal mucosa, AM-Alveolar mucosa, PM-Palatal mucosa, LM- Labial mucosa, FM- Floor of mouth, RA-

Retro molar area.

Habits : SL- Smokeless Tobacco (gutakha & quid chewing), ST- Smoking tobacco and NH- No habits .

33

Studies reported on the incidence and pattern of OSCCs

from various parts of the world is 4.7./100000.

However, very few studies have reported on the

incidence and trends of OSCCs in Madhya Pradesh

(M.P.) population. The purpose of this retrospective

study was to identify trends in the number of cases or

incidence rates of OSCCs at specific anatomic sites or

within specific age or sex groups in the Madhya Pradesh

population.

MATERIALS AND METHODS

82 Histologically proven in cases of OSCCs verified in the

oral pathology and microbiology from January 2007 to

July 2011 were extracted from the archives of Hitkarini

dental college Jabalpur. The anatomic sites included in

the study were alveolar mucosa, buccal mucosa, floor

of mouth, retro molar area, tongue and hard palate. As

the pathophysiologic and epidemiologic behavior of the

lip cancer is believed to be substantially different from

the oral cavity sites, cancers originating in the lip were

not included in this study. Charts were made listing the

age, sex, site, habits and histopathology grading of

eighty OSCC patients. A comprehensive analysis was

done on the data collected and the results were

formulated.

RESULTS:

Of the 82 OSCC patients, males represented a higher

proportion (66%) of squamous cell carcinomas than

females (33%) {Diagram 1}. Larger numbers of cases

were seen to develop in 46-56 years followed by 36-45

and 25-35 years. Over all alveolar mucosa and buccal

mucosa were the most common sites involved 42.5%,

and 37.5% respectively. While the floor of the mouth,

retromolar areas showed least incidence in this region

of India (3.7%) {Diagram 2}. The study also revealed that

larger number of patients had the smokeless tobacco in

the form of gutkha and quid chewing than the bidi and

cigarette smoking habit. {Diagram 3}


Trends in epidemiology of oral cancer in central part of India

34

Diag. 1: OSCC in 82 patients (Gender with respect to age)

Diag. 2: OSCC in 82 patients (Sites with respect to age)

Diag. 3: OSCC in 82 patients (Habits with respect to age)

DISCUSSION:

The incidence of OSCC seems to be increasing and is

global health problem with increasing incidence and

mortality rates. Around 3,00,000 patients are annually

estimated to have oral cancer worldwide. OSCC is 4,7,8

known to show geographic variation with respect to

the age, site, sex and habits of the population. The 1,2,4,8,9

present study revealed a male to female ratio of 2:1

with the largest number of OSCCs developing in peak

age of 46-55 years. This is consistent with an earlier

report by Mehrotra and coworkers confirming that 8

oral cancer in Northern India was a disease of the

middle aged men. An epidemiologic study on palatal

changes in reverse smokers conducted in Andhra

Pradesh (Southern India) by Mehta et al. showed a 10

predominance of females in the middle age group (35-

54years).

Regarding the site of preference for intra-oral SCC, our

study showed some degree of variation from most of

the studies conducted at Spain, Canada, Scandianavia

and some part of India. A retrospective study 11-13

conducted by S. manuel and co-workers, in 2003, at 14

the regional Cancer (RCC), Thiruvananthapuram

Kerala analyzed one of the largest series of young

patients under the age of 45 years having SCC of the

oral tongue.

In the present study, the alveolar mucosa and buccal

mucosa were the most frequent involved sites (41 and

37.5% respectively) while the floor of mouth was the

least commonly involved site (3.75%). These regional

difference may be attributed to the exclusive use of

chewing tobacco in the India subcontinent compared

to smoking in the west. SCC of buccal mucosa is one 12-14

of the most common cancers along the geographical

belt extending from central to south east asia because

of practice of chewing pan a combination of tobacco,

nut and lime. In contrast, the lateral tongue and floor 15

of mouth are the more commonly involved site in the

West. The anterior 2/3 of the tongue is commonly 11-13 rd

involved in India, while the posterior lateral border

and ventral surfaces are frequently involved in the

United State.(8

In 1969,the result of first epidemiologic survey of



35

palatal changes in reverse smokers in the Srikakulam

district of Andra Pradesh in India was reported by

Mehta FS et al, who later emphasized that the palatal 10

changes seen in reverse smokers exhibited greater

clinical variation than the leukokeratosis nicotina palate

known from the Western countries. Earlier, OSCC was

thought to be a disease primarily of the elderly. Some 1,2

recent studies conducted in united states, South East of

England, Spain and Scandinavia have , however, shown

that the incidences of oral cancer are increasingly being

reported in the young (<40 years of age) also

particularly younger male patients. Our study 13,14,16,17

finds increasing number of OSCC cases being recorded

in the 4 and 5 decades of life. This may be related to th th

the habits like tobacco and alcohol.

Men represented a higher proportion of OSCCs than

women simulating the trends in many recent

publications. Some studies show the opposite 3,6,11,18

trend with the increased incidence among women,

which may be due to the changing social habit in the

high socioeconomics groups or cultural habits of some

rural area of India. Interestingly, 3.75% of the patient 10,16

were not associated with any habits like tobacco

smoking or chewing in our study, Probably attributed to

other etiological factors of OSCCs like certain viruses

(such as human papilloma virus), low consumption of

fruits and vegetables, genetic predisposition ,etc. 16

Gutkha chewing or Pan chewing were the most

prevalent habits recorded in the study. The incidence

was highest at mucosal sites with prolonged contact

with carcinogens. There has been strong evidence that

smokless tobacco can cause oral cancer and

precancerous oral lesions like leukoplakia. smokeless 8

tobacco is thought to induce cancer in regions where it

is held in direct contact, such as the cheek or gum. The 8

clinicopathological profile of Indian oral cancers shows

significant differences from oral cancer in several

developed countries of world, including the USA, UK,

France and Japan, where it is associated with tobacco

smoking with or without alcohol consumption 19

CONCLUSSION:

As useful clinical information on the trends of OSCCs

among mid of the central part of India in Madhya

Pradesh population is limited, this retrospective study

was undertaken to present a compressive data on the

trends of OSCC in M.P. population. Different levels of

tobacco and alcohol exposure, diet, socio economic

circumstances factors in the diff age, gender and sites

are the causative factors in the difference seen in the

incidence rates of OSCC in various populations globally.

Because of the magnitude of the oral cancer problem

and trends reported serious thought should be given to

plans for prevention and early detection of

premalignant and malignant oral diseases in central

part of India in M.P. race, ethnicity and age cannot be

altered; however, lifestyle behavior such as use of

tobacco and alcohol are amenable to change and

increased intake of fruits and vegetables must be

addressed. The dental profession has a well deserved

reputation for preventing other oral diseases. Now is

time to focus on the prevention and early detection of

oral cancer.

REFERENCES:

1. Lawoyin JO, Lawoyin DO,Aderinokun G. Intra-

Oral squamous cell carcinoma in Ibadan: a

review of 90 cases. Afr J Med Sci 1997; 26:187-

8.

2. Howell RE, Wright BA, Dewar R. Trends in oral

cancer in Nova scotia from 1983 to 1997. Oral

Surg Oral Med Oral Pathol Oral Radiol Endod

2003; 95:205-12.

3. Schantz SP, Yu Gp, Head and Neck cancer

incidence trends in young American, 1973-

1997, with aa special analysis for tongue cancer.

Arch Otolaryangol Head Neck SURG 2002 ;

128:268-74.

4. Rautava J, Luukkaa M, Heikinheimo K, Happone

RP. Squamous cell carcinomas arising from

different types of oral epithelia differ in their

tumour and patient characteristics and

survival. Oral Oncol 2007; 43:911-9.

5. Carvalho AL, Singh B, Spiro RH, Kowalski LP,

Shah JP. Cancer of the oral cavity: a comparison

between institutions in a developing and a

developed nation, Head Neck 2004; 26:31-8.



36

6. Llewelly3n CD, Linklater K,Bell J, Johnson NW,

Warnakulasuriya KA. Squamous cell carcinoma

of the oral cavity in the patients aged 45 years

and under: a discriptiveanalysis of 116 cases

diagnosed in the south east of England from

1990 to 1997. Oral Oncol 2003; 39:106-14.

7. Funk GF, Karnell LH, Robinos RA, Zhen WK,

Trask DK, Hoff iman HT. Presentat ion,

treatment, and outcome of oral cavity: a

national cancer data base report. Head Neck

2002; 24:165-80.

8. Mehrotra R, Singh MK, Pandya S, Singh M. The

use of an oral brush biopsy without computer-

assisted analysis in the oral lesions. A study of

94 patients. Oral Surg Oral Pathol Oral Radiol

Endod 2008; 106:204-53.

9. Shiboski CH, Shiboski SC, Silverman S Jr.Ttrends

in oral cancer rates in the united states, 1973-

1996. Community Dent Oral Epidemiol 2000;

28:249-56.

10. Mehta FS, Jalnawalla PN, Daftary DK,Gupta

PC,Pindborg JJ. Reverse smoking in Andhra

Pradesh, India: variability of clinical and

histologic appearance of palate changes. Int J

Oral Surg 1997; 6:75-83.

11. Martin-Granizo R, Rodriguez-Campo F, Naval l,

Diaz Gonzalez FJ. Squamous cell carcinoma of

the oral cavity in patients younger than 40

years. Otolaryngyol Head Neck Surg 1997;

117:268-75.

12. Gorsky M, Epstein JB, Oakley C, Le ND, Hay J,

Stevenson- Moore P. Carcinoma o f tongue : a

series analysis of clinical presentation, risk

factors, staging, and outcome. Oral Surg Oral

Med Oral Pathol Oral Radiol Endod 2004;

98:546-52.

13. Annertz K, Anderson H, Biorklund A, Moller T,

Kantola S, Mork J, et al. incidence and survival

oral squamous cell carcinoma of the tongue in

Scandinavia, with spcial reference to young

adults. Int J Cancer 2004; 101:95-9.

14. Manuel S, Raghavan SK, Pandey M, Sebastian P.

Survival in patients under 45 tears with

squmaous cell carcinoma of the tongue. Int J

Oral Maxillofac Surg 2003; 32:167-73.

15. Diaz EM Jr, Holsinger FC, Zuniga ER, Robert DB,

Sorensen DM. Squamous cell carcinoma of the

buccal mucosa: one institution's experience

with 119 previously untreated patients. Head

Neck 2003; 25:267-73.

16. Silverman S Jr. demographic and occurrence of

oral and pharyngeal cancers. The outcomes,

the trends, the challenge. J AM Dent Assoc

2001; 132:57-11.

17. Rodriguez T Altieri A, Chatenoud L, GallusS,et

al. risk factors for oral and pharyngeal cancer in

young adults. Oral Oncol 2004; 40:207-13.

18. Shiboski CH, Schmidt BL, Jordan RC. Tongue and

tonsil carcinoma increasing trends in the U.S.

population ages 20-44years. Cancer 2005;

103:1843-9.

19. Jane C, Nerurkar AV, Shirsat NV, Deshpande RB,

Amrapurkar AD, Karjodkar FR. Incresed

surviving expression in high grade oral

squamous cell carcinoma: a study in Indian

tobacco chewers. J Oral Pathol Med 2006;

35:595-601.



37

INTRODUCTION

Dento-facial appearance has a lot to do with the 1way the people are perceived in the society.

People equate good dental appearance with 2success in many aspects. Social interactions that

have a negative effect on self-image, career

advancement and a peer group acceptance have

been associated with an unacceptable dental 3

appearance. The prevalence of malocclusion

varies from country to country and among different 1

races. The reasons to develop malocclusion could

be genetic or environmental and/or combination

of both the factors along with various local factors

such as adverse oral habits, tooth anomalies, form

and developmental posit ion of teeth can cause

malocclusion. Orthodontics has traditionally 4focussed on children and adolescents. There is an

increases concern for dental appearance during 2adolescents to early childhood has been observed.

Malocclusions are 3rd in the ranking of priorities

among the problems of dental public health

worldwide, surpassed only by dental cavity and 5

periodontal diseases. The benefits of taking

orthodontic treatment are to prevention of tissue

damage and correction of aesthetic component, 2

improve the physical function . A variety of indices

have been developed to assist professionals in

categorizing malocclusion according to the

1 2 3 4 5 6R S Makkad , Madhu Pandey ,S Hamdani , V. Agrawal , M Motlani , Gunjan Agrawal1. Lecturer, Department of Oral Medicine & Radiology, New Horizon Dental College and Research Institute, Bilaspur, (CG)2. Lecturer, Department of Orthodontics, Rungta Dental College and Hospital, Bhilai, (CG)3. Post Graduate, Department of Orthodontics, Rungta Dental College and Hospital, Bhilai, (CG)4. Lecturer, Department of Oral and Maxillofacial Surgery, Maitri Dental College, Anjora, Durg (CG)5. Lecturer, Department of Endodontics, Chhattisgarh Dental College and Research Institute, Rajnandgaon (CG)6. Lecturer, Department Oral and Maxillofacial Surgery, (CG)Pt. Jawaharlal Nehru Medical College, Raipur

Corresponding Author: Dr. Ramanpal Singh Makkad Lecturer, Department Oral Medicine & Radiology, New Horizon Dental College and Research Institute, Bilaspur, (CG)Mobile no- 090986 99300 email: [email protected]

ABSTRACT

Objectives-This study is to know the prevalence of malocclusion and orthodontic treatment needs among 12-15yr

old school children of Bilaspur.

Materials and Methods-A total of 351 study subjects were selected based on convenience sampling and

examination was carried out under natural light and data was recorded using WHO Proforma 1997. The collected

data was subjected to statistical analysis using SPSS16.

Results-Out of the 351 children examined, 46.2% were boys & 53.8% were girls and their mean age was 13.89yrs.

One and two segment crowding was seen in 24.5% & 11.4% respectively. Normal molar relation was seen in 80.3% of

children. Definite, severe and very severe or handicapping malocclusion was seen in 9.7%, 4.3% & 3.4% of children

respectively. There is no statistically significant difference in malocclusion status between boys and girls.

Conclusion- needs.Only 4.3% and 3.4% of children required highly desirable and mandatory orthodontic treatment

KEYWORDS- Malocclusion, Dental Aesthetic Index, OrthodonticTreatment needs.

Assessment of dental aesthetic index among school children of Bilaspur, Chhattisgarh : A pilot study

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TABLE 1. AGE WISE DISTRIBUTION OF STUDY POPULATION

AGE FREQUENCY PERCENTAGE

12 13 3.7

13 95 27.1

14 133 37.9

15 110 31.3

TOTAL 351 100

6treatment needs . Dental Aesthetic Index (DAI)

introduced by Cons et al(1986), which links clinical

and aesthetic components. It was developed

originally based on North American Caucasian 7

sample. The World Health Organizat ion

concerning to acknowledge the real malocclusions

conditions in different countries, adopted it as a

cross cultural index and advocated it in the 4th

Edition of the Manual of Basic Oral Health Survey,

so there would be a suitable instrument to gather

epidemiological data collection and assessment of 5,7-9

orthodontic treatment needs . DAI is proven to

be reliable, valid, versatile, simple and easily 7,9

applied index . Most of the malocclusion can be

corrected if detected early by correctional 1methods. This study was intended to evaluate the

prevalence of malocclusion, its severity and the

orthodontic treatment needs using DAI, among 12-

15yr old school children of Bilaspur, Chattishgarh.

MATERIALS AND METHODS:

The present study was conducted among 12-15yr

old school children of Bilaspur, Chattishgarh. The

schools were selected based on convenience

sampling. A total of 351 school children of both

sexes were selected for the study based on

convenience sampling. Approval was obtained

from the concerned authorities before the start of

the study. All examinations were performed at

schools while children were seated on chair under

normal illumination. The examiners were trained

and intra-examiner calibration was done. Kappa

statistics showed a good agreement. Sufficient

number of autoclaved instruments was taken to

the examination site. The WHO Proforma (1997)

was used to assess the malocclusion. Data

collected was coded, processed and subjected to

statistical analysis using SPSS version16.

RESULTS

The study population consisted of about 351

school children aged 12-15years in Bilaspur city,

out of which 46.2% were males and 53.8% were

females (Table 1). Table 2 shows the distribution of

DAI components. Out of 351 school children, 24.5%

had one segment crowding and 11.4% had two

segments crowding. One and two segment spacing

was seen in 8.5% and 1.7% school children

respectively. Diastema of 1-3mm was seen among

5.7% of the study subjects. Largest maxillary

irregularity of 0, 1-3 and >3mm was seen among

80.9%, 17.1% and 2% of school chi ldren

respectively. Largest mandibular irregularity of 0,

1-3 and >3mm was seen among 72.1%, 27.6% and

0.3% of school children respectively. Maxillary

over-jet of 0-3mm is considered normal and was

seen among 76.4% of school children and >3mm

was seen among 23.6%of school children.

Mandibular overjet of 0-3mm was among 99.4% of

school children and 0.6% of them had >3mm of

overjet. Open bite of >3mm was seen among 0.9%

of study subjects. Molar relation was normal

among 80.3% of school children whereas half cusp

and full cusp molar relation was seen among 14.8%


Assessment of dental aesthetic index

TABLE 2: DISTRIBUTION OF DAI COMPONENT

TABLE 3: DISTRIBUTION OF THE SUBJECTS ACCORDING TO DAI SCORES,

SEVERITY OF MALOCCLUSION, TREATMENT NEEDS AND GENDER (P=3.946).

DAI COMPONENTS PERCENTAGE (%)

CROWDING 0 64.1

0NE SEGMENT 24.5

TWO SEGMENT 11.4

SPACING 0 89.7

0NE SEGMENT 8.5

TWO SEGMENT 1.7

DIASTEMA 0 94.3

1-3 5.7

LARGEST MAXILLARY 0 80.9

IRREGULARITY(mm) 0-3 17.1

>3 2

LARGEST MANDIBULAR 0 72.1

IRREGULARITY(mm) 0-3 27.6

>3 0.3

MAXILLARY OVERJET (mm) 0-3 76.4

>3 23.6

MANDIBULAR OVERJET(mm) 0 99.4

>3 0.6

OPEN BITE(mm) 0 99.1

>3 0.9

MOLAR RELATION NORMAL 80.3

HALF CUSP 14.8

FULL CUSP 4.8

DAI SCORE Severity Of Treatment MALE (%) FEMALE (%) TOTAL (%) Malocclusion Indicated<25 No/ minor No/slight 84 81.5 82.6 Malocclusion Treatment 26-30 Definite Elective 8 11.1 9.7 Malocclusion 31-35 Severe Highly 3.1 5.3 4.3 Malocclusion Desirable>35 Very severe or Mandatory 4.9 2.1 3.4 handicapping malocclusion TOTAL 100 100 100

ASSESSMENT OF DENTAL AESTHETIC INDEX



and 4.8% of school children. There was no

statistically significant difference between the DAI

scores and the gender. Table 3 shows the

distribution of according to DAI score, severity of

malocclusion, treatment indicated and gender.

4.3% and 3.4% of the study subjects had severe and

very severe malocclusion respectively and required

highly desirable and mandatory orthodontic

treatment needs.

DISCUSSION

Many epidemiological studies have been

conducted worldwide utilizing various indices for

quantifying the extent of malocclusion. Crowding 1

of incisal segment affects half of all children in

mixed dentitions and it worsens in adolescent

years as the permanent teeth erupt and continues

to increases as the age progresses. In the current 2

study, 35.9% of the study population had incisal

crowding. The results of the current study are in

correlation with the study conducted by

Shivakumar et al and in contrast with a study 2

conducted by Bhardwaj et al . Both the upper and 1

lower incisal segments were examined for spacing.

In the present study, 10.2% had incisal segment

spacing either in one or both the arches which was

in correlation with the study conducted by Artenio

Jose Isper Garbin et al . Diastema>1mm was seen 5

among 5.7% of school children and this result was

in correlation to the study conducted by Artenio

Jose IsperGarbin et al . Irregularity may occur with 5

or without crowding. In the current study, 19.1% of

the children had maxillary anterior irregularity of

>1mm, and the results are in correlation with the

study conducted by Shivakumar et al and Artenio 2

Jose IsperGarbin et al . 27.9% had mandibular 5

anterior irregularity >1mm and the result were in

contrast with the study conducted by Bhardwaj et

al , DS Rwakatema et al , B. Eduardo and F.M 1 8

Carlos . 9

In the present study, maxillary overjet of >3mm

was seen in 23.6% and it was similar to the study

conducted by B. Eduardo and F.M Carlos and 9

Bhardwaj et al and in contrast to a study 1

conducted by Matilda Mtaya et al . 10

Mandibular overjet of >3mm was seen in 0.6% of

school children and it was in correlation with

studies conducted by Shivakumar et al , DS 2

Rwakatema et al , Bhardwaj et al and Artenio Jose 8 1

IsperGarbin et al .5

An anterior openbite of >3mm was seen in 0.9% of

school children which was similar to studies

conducted by Bhardwaj et al and B. Eduardo and 1

F.M Carlos . Normal molar relation was seen in 9

80.3% of the school children and which was similar

to the study conducted by Bhardwaj et al and was 1

in contrast with the study conducted by Artenio

Jose IsperGarbin et al . Definite malocclusion was 5

seen in 9.7% of the school children, severe

malocclusion was seen in 4.3% of school children

and very severe or handicapping malocclusion was

seen in 3.4% of children. Similar results were found

in the study conducted by Vijaya Hedge and

RekhaShenoy , Bhardwaj et al and Shivakumar et 11 1

al , whereas it was in contrast with the study 2

conducted by B. Eduardo and F.M Carlos and D.S 9

Rwakatema et al . 8

CONCLUSION

Thus the present study concluded that out of 351

study subjects, 4.3% and 3.4% of school children

required highly desirable and mandatory type of

orthodontic treatment needs respectively. The

information from this study forms a part of the

basis not only for further research, but also for

planning orthodontic care.



REFERENCES

1. VK Bhardwaj, KL Veeresha and KR Sharma.

Prevalence of malocclusion and orthodontic

needs among 16 and 17year old school going

children in Shimla city, Himachal Pradesh.

Indian Journal of Dental Research 2011;22(4):

556-560.

2. Shivakumar KM, Chandu GN, Subba Reddy VV,

e t a l . P r e v a l e n c e o f m a l o c c l u s i o n a n d

orthodontic treatment needs among middle a n d

high school children of Davangere city, India

b y D e n t a l A e s t h e t i c I n d e x . J I n d i a

SocPedodPrev Dent 2009; 27:211-218.

3. H. Nihal, B. Guvenc and U. Ersin.Dental

Aesthetic Index scores and perception of

personal dental appearance among Turkish

university students. European Journal of

Orthodontics 2009; 31: 168-173.

4. B.A Carlos, M.C Jose-Maria, M.P David, et al.

Orthodontic treatment need in Spanish young

adult population. Med Oral Patol Oral Cir Bucal

2012; 17(4):638-643.

5. I.G Artenio Jose , P.P Paulo Cesar, S.G CleaAdas,

et al. Malocclusion prevalence and comparison

between the Angle classification and the

Dental Aesthetic Index in scholars in the

interior of Sao Paulo state- Brazil. Dental Press J

Orthod 2010; 15(4):94-102.

6. Poonacha KS, Deshpande SD, Shigli AL. Dental

Aesthet i c Index , app l i cab i l i ty in Ind ian

population: a retrospective study. J Indian

PedodPrev Debt 2010; 28: 13-17.

7. B. Venkatesh, Gopu H. Assessment of

Orthodontic treatment needs according to

Dental Aesthetic Index. Journal of Dental

Sciences and Research 2011; 2(2):9-13.

8. D.S Rwakatema, P.M. Ng'ang'a and A.M.

Kemoli. Orthodontic treatment needs among

12-15 year olds in Moshi, Tanzania. East African

Medical Journal 2007; 84(5): 226-232.

9. B. Eduardo and F.M Carlos. Orthdontic

treatment need in Peruvian young adults

evaluated through Dental Aesthetic Index.

Angle Orthodontist 2006; 76(3): 417- 421.

10. M Matilda, B. Pongsri and A. Anne Nordrehaug.

Prevalence of malocclusion and its relationship

with socio-demographic factors, dental caries

and oral hygiene in 12 to 14 year old Tanzanian

s c h o o l c h i l d r e n . E u r o p e a n J o u r n a l o f

Orthodontics 2009; 31: 467-476.

11. H. Vijaya and S. Rekha.Dentition status,

treatment needs and malocclusion status

a m o n g 1 5 y e a r o l d s c h o o l c h i l d r e n o f

Mangalore- a pilot study. JIDA 2010; 4 (12): 568-

569.



42

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CASE REPORT

ABSTRACT

Neurofibroma is a benign tumor of neural origin derived from peripheral nerve sheath. Nerve sheath tumors are

extremely rate. There is no sex predilection and average age of occurrence is 28 years. In the present case it was 22 yr.

old patient . The surgical removal of tumor mass was done under GA and histological confirmation was done.

Key Words: Neurofibroma, Spindle cell, Tumor

1 2 3 4Swapnil Moghe , Ajay Kumar Pillai , Vineeta Gupta , Geeta Mishra1. Reader, Department of MaxilloFacial Surgery, Peoples Dental Academy, Bhopal (MP)2. Reader, Department of MaxilloFacial Surgery, Peoples Dental Academy, Bhopal (MP)3. Reader, Department of Periodontics, Govt. Dental College, Raipur (CG)4. Assistant Professor, Department of Dentistry, Govt.Medical College. Rewa (MP)

Corresponding author : Dr. Ajay Kumar Pillai

Reader, Department of Maxillofacial Surgery, Peoples Dental Academy, Bhopal (MP)Contact No: 98932 60776, Email : [email protected]

INTRODUCTION:

Neurofibromas arise from a mixture of cell types

including Schwann cells and perineural fibroblasts. They

may occur as solitary lesions or in association with

neurofibromatosis. Although most commonly reported

in soft tissues, neurofibromas do occur in bone. And

very few cases have been reported in association with

the inferior alveolar nerve. We report a case of neuro-

fibroma of spindle cell origin associated with the

inferior alveolar nerve in a 22 year old man. Pain or

paresthesia may result from lesions of the inferior

alveolar nerve. Patients presents with cortical

expansion. Intra-osseous lesions may produce a well

demarcated or poorly defined unilocular or multilocular

radiolucency. Adjacent soft tissue neurofibromas may

produce cortical erosion. Solitary neurofibromas and

those found in association with neurofibromatosis

share the same microscopic features . The tumor is 1

composed of spindle-shaped cells with fusiform or

wavy nuclei in a delicate connective tissue matrix. It is

not encapsulated and may blend with the adjacent

connective tissues. The normally recommended

treatment of solitary lesions following biopsy is

localized excision.

CASE PRESENTATION

The patient reported a slow growing lesion in lower left

mandibular region extending from canine to 2 molar nd

region. A 22-year-old man presented to the department

of the Oral and Maxillofacial Surgery with a 1 month

history symptom of paraesthesia of lower left side of

mandible extending from corner of mouth to angle of

mandible. His medical history was unremarkable and

there was no history of gum-related disease or trauma

to the maxillofacial complex. Mobility of teeth was

absent, also, a history of numbness of the lower lip since

2 months with no history of extraoral swelling was

significant. An intraoral examination revealed a

obliteration of muco-buccal fold of about 3 × 1 cm in the

left lower canine- molar region with no signs of

ulceration (Figure 1). On palpation, the swelling was

firm in consistency with underlying bone from left

canine to molar region. No neck nodes were palpable

and the cranial examination was normal. Funelling &

widening of inferior alveolar canal was evident on OPG.

(Figure 2)

Neurofibroma of spindle cell origin, a diagnostic dilemma to general dentist


Figure 3: Exposed tumor mass Figure 4: Excised Tumor mass.

Figure 5: Histopathology shows a tumor of Proliferative spindle cells with a stroma of

Irregular collagen fibers (HE, × 100).

Figure 6: Post -operative OPG after 6 months.

Not many cases have been reported in the literature for

the same. Under all aseptic conditions, the patient was

intubated under G.A. & local anesthetic was infiltrated

around lower anterior & posterior mandibular region

on the left side. A crevicular incision was placed from

the lower left side central incisor till second molar with

bilateral releasing incisions. A full thickness muco-

periosteal flap was raised, the tumor mass was exposed

(Figure 3) & through the opened window, the tumor

mass was removed (Figure 4). Nerve avulsion was done

to remove the remnants of IAN. The surgical site was

irrigated with betadine & saline. Hemostasis was

achieved & closure was done with 3-0.

Figure 1: Obliteration of muco-buccal fold with 33-36 region. Figure 2: Funelling & widening of inferior alveolar canal.


Neurofibroma of spindle cell origin

Investigations

Orthopantamogram revealed an osteolytic scalloped

lesion extending from the lower left canine region to the

second molar. The lesion also shows erosion of buccal

cortical plate.

Microscopically the tumor is composed of an irregular

pattern of proliferative spindle cells (Figure 5). The

stroma is composed of collagen fibers and mucoid

masses. Small axons all over the tumoral tissue are

demonstrated with silver staining.

Treatment & follow up:

The patient was followed up for 6 months (Figure 6).The

postoperative OPG showed good healing with no signs

of recurrence at the surgical site.

DISCUSSION:

Neurofibroma (NF) is a benign tumor of neural origin

derived from the peripheral nerve sheath that may

have variable histology. Nerve sheath tumors located in

the jaw are extremely rare, having published only a few

cases of central neurofibroma of the mandible. There is

no sex predilection and average age of occurrence is 28

years. In our case it was 22 years old man.

Ninety percent of the neurofibromas are associated

with neurofibromatosis type 1, so the physical 2

examination and family history should be elicited to

exclude the disease. In this case, there were no clinical

signs or family history suggestive of neurofibromatosis.

The lesion was a solitary one.

Hubner and Lewis developed an animal model to 3

investigate the causative factors in the development of

the lesion. They reported that the peripheral nerve

section resulted in the formation of an expanded

connective tissue cap at the end of the proximal

segment. Nerve fibers attempting to re-establish

continuity with the distal segment penetrated into and

beyond the cap, becoming tangled and entrapped in the

soft tissue. But in our case, there was no history of

trauma.

In the mandible, the lesions most commonly arise from

the mandibular nerve with accompanying pain and par

aesthesia. In such cases the radiograph shows flaring of

mandibular foramen, the so called “blunderbuss'

foramen or fusiform enlargement of the mandibular

canal, as was seen in our case .4

Histologically the tumor is composed of spindle cells

a r r a n g e d i n b u n d l e s w i t h i n c o l l a g e n a n d

mucopolysaccharides matrix that makes the tumor soft

& even gelatinous. The nerve fibres are within the

lesion. The tri-chrome stains like Mallory's or Masson's

may be useful in identifying collagen. Alcian blue stain is

helpful in staining perineural mucin which is not present

in scar tissue.

The lesion should be differentiated with schwanomma

(Antoni A and Antoni B areas) and perineuroma (pattern

similar to onion bulbs), as proposed by Ide .5

The solitary intraosseous neurofibroma may be the first

manifestation of neurofibromatosis. It is important to

put patient on regular follow-up & correlating clinically

& radiographically, since recurrence and malignant

changes have been reported .6

REFERENCES:

1. Zachariades N, Mezitis M, Vairaktaris E,

Triantafyllou D, Skoura- Kafoussia C, Konsolaki-

Agouridaki E, Hadjiolou E, Papavassiliou D:

Benign neurogenic tumors of the oral cavity. Int

J Oral Maxillofac Surg 1987, 16:70-76.

2. Sharma P, Narwal A, Rana AS, Kumar S.

Intraosseous neurofibroma of maxilla in a child.

J Indian Soc Pedod Prev Dent. 2009; 27: 62-4.

3. HUB E . Amputat ion neuromas: The i r

development and prevention. Archives of

Surgery 1920; 1(1):85.

4. Rajendran R, Sivapada Sundaram B. Benign and

malignant tumors of the oral cavity. Shafer,

Hine, Lavy, editors Shafer's Text book of Oral

Pathology India: Elsevier2009:120-7.

5. Ide F, Shimoyama T, Horie N, Kusama K.

C o m p a r a t i v e u l t r a s t r u c t u r a l a n d

immunohistochemical study of perineurioma

and neurofibroma of the oral mucosa. Oral

Oncol. 2004; 40: 948-53.

6. Mori H, Kakuta S, Yamaguchi A, Nagumo M.

Solitary intraosseous neurofibroma of the

maxilla: report of a case. J Oral Maxillofac Surg.

1993; 51:688-90.

Neurofibroma of spindle cell origin


45

1 2 3 4Biju Pappachan , R K Dubey , Manish Raghani , Raghav Agrawal1. Professor, Dept of Oral And Maxillofacial Surgery Govt Dental College, Raipur, Chhattisgarh,India.2. Professor, Dept Of Prosthodontics, Govt Dental College Raipur3. Lecturer, Govt Dental College, Raipur, Chhattisgarh, India.4. Private Practioner, Raipur, Chhattisgarh, India.

Corresponding Author :Biju Pappachan572/10-47, Lane No-6, New Shanti Nagar, Raipur Chhattisgarh E MAIL- [email protected], Tel- 00918109006001

ABSTRACT

A range of disorder affects temporomandibular joint(TMJ) and structures associated to limit its motion. If the restriction is because of fusion in TMJ, it may be complete or incomplete. We present here a case of incomplete fusion of TMJ where complete restriction in mobility was noted following appearance of odontogenic keratocyst in the ramus. The treatment here was a gap arthroplasty which included the pathology in the block of bone which was resected.

Key-words: Temporomandibular Joint Ankylosis, Odontogenic Keratocyst

INTRODUCTION

Temporomandibular joint (TMJ) ankylosis is a disorder

that leads to a restriction of the mouth opening from

partial reduction to complete immobility of the jaw.

Ankylosis is most commonly associated with trauma

(31% to 98%), local or systemic infection (10% to 49%),

or systemic disease(10%). Infection is most commonly 1-4

secondary to spread from otitis media or mastoiditis,

but may also result from hematogenous spread,

including tuberculosis, gonorrhea, and scarlet fever.

Systemic causes of TMJ ankylosis include ankylosing

spondylitis, rheumatoid arthritis, and psoriasis.5,6

TMJ ankylosis may be classified by a combination of

location (intra- or extra- articular), type of tissue

involved (boney, fibrous, or fibro-osseous), and extent

of fusion (complete or incomplete). Literature classifies

ankylosis as true and false.Any condition that gives rise

to osseous or fibrous adhesion between the surfaces of

the TMJ is true ankylosis. False ankylosis results from

pathological condition not directly related to the joint. 7

This case report presents a unique case of fibrous

Temporomandibular joint ankylosis associated with

odontogenic keratocyst.

CASE REPORT

A 48 years old male patient reported to the department

of Oral and Maxillofacial Surgery with chief complaint of

Inability to open the mouth since –2 years, Pain and

swelling over left mandibular posterior region since – 2

years.

Patient was apparently all right 2 years back when he

noticed swelling over left mandibular posterior region

(Angle and Ramus) accompanied with pain. Pain was

dull in nature and intermittent. The swelling was initially

small but gradually increased in size. Mouth opening

was around one and half finger width, which gradually

reduced to nil.

Extra- orally – small swelling was present over left

mandibular angle and ramus region. Deep antegonial

notch present over left angle of mandible. Chin was

retruded with slight deviation towards left. TMJ

movements were not palpable in left side with slight

movement of right side. Intra-orally – Mouth opening

was NIL.

OPG shows unilocular radiolucency over left ramus

region involving the coronoid process ( Fig-1). Lower

left third molar was displaced upwards and inverted

TMJ ankylosis associated with odontogenic keratocyst of mandibular ramus : A rare case report

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CASE REPORT


inside the radiolucent cavity. Second molar displaced

and involved in the radiolucent cavity. Left TMJ region,

joint space was partially obliterated with incomplete

fusion; condylar demarcation was not clear in left side.

The length of ramus and body were comparable both

sides. Aspiration with wide bore needle was negative.A

provisional diagnosis of left sided TMJ ankylosis

a s s o c i a te d w i t h O d o n to g e n i c Ke ra to c yst /

Ameloblastoma was made. Histopathology confirmed

Odontogenic keratocyst.

Patient was planned for excision of the lesion which

consequently would create gap arthroplasty.

Under G.A. the left Temporomandibular Joint was

approached through Risdon incision. The lesion and the

ankylotic mass was resected in a block (Fig-2).

DISCUSSION:

TMJ ankylosis commonly presents as facial asymmetry,

chin deviation to the affected side, elongation and

flatness on the non affected side with roundness and

fullness on the affected side when observed from a

frontal view. A bony thickening is often felt in the

preauricular area of the affected TMJ. Mandibular

morphology is severely influenced in terms of size, and

shape with marked antegonial notch, enlarged

coronoid process, reduced vertical ramus height on the

affected side, and flattened mandibular body and

ramus on the non affected side. The ankylosed

mandibular condyle can be hyperplastic with irregular 8

contours and absent joint spaces.

This case of our clinically had features similar to TMJ

ankylosis, but further investigation suggested that the

features were secondary to an underlying pathology

which is dreaded for it notorious presentation and high

rate of recurrence.

This case is unique because there was only a minimum

restriction before the pathology appeared. With

expansion of the pathology in the bone the boney

interfaces moved towards each other increasing the

degree of ankylosis. This later progressed to full

hypomobility with the appearance of odontogenic

keratocyst. The pathology here itself may have not

primarily caused ankylosis but was the reason for

complete hypomobility of the joint.

This case is again unique because there was only a

minimum restriction before the pathology appeared.

This later progressed to full hypomobility with the

appearance of odontogenic keratocyst. The pathology

here itself may have not primarily caused ankylosis but

was the reason for complete hypomobility of the joint.

All cysts in the angle of the mandible with extension into

the ascending ramus, or completely located in the

ramus, should be treated as potentially aggressive 9cysts .

Many operative techniques have been described in the

literature. The most frequently reported operations

include gap arthroplasty,interpositional arthroplasty, 10and excision and joint reconstruction. Gap

arthroplasty has fallen out of favour because of

p o te nt i a l c h a n c e o f re a n k y l o s i s a n d o t h e r 5,10,11

disadvantages and complications. However in

specific cases like this it is useful as a larger block of

fig-1 OPG showing ankylosed mass withodontogenic keratocyst of ramus mandibularis

fig-2 showing the osteo-arthrectomy withcystic lesion within the resected mass


TMJ ankylosis associated with odontogenic keratocyst

bone is removed and chances of reankylosis is none.This

particular case was unique in the sense that, the bone

required to be removed for creating the gap in itself

contained an aggressive cyst.

Recently distraction osteogenesis has been used

successfully to reconstruct ramus and condylar portions 12-15. of mandible. In this case patient refused for any

reconstructive procedure.

CONCLUSION

In such cases where multiple pathologic findings are

observed, a well planned treatment is to be performed

following all basic principles of treatment. A group of

findings in same patient does not rule out possibility of

syndrome or the reason of one or more incidental

findings can be because of the effect of the present

pathology. Proper case study, advanced investigations

and basic principle of surgery with periodic follow up

are key to manage such pathologies.

REFERENCES:

1. MM Chidzonga. Temporomandibular joint

ankylosis: review of thirty-two cases. British Journal

of Oral and Maxillofacial Surgery 1999;37: 123–126

2. Guralnick WC, Kaban LB: Surgical treatment of

mandibular hypomobility. J Oral Surg 1976; 34:343-

45

3. Topazian RG. Etiology of ankylosis of the TMJ:

Analysis of 44 cases. J Oral Surg Anesth Hosp Dent

Serv1964; 22:227-31

4.. Sawhney CP. Bony ankylosis of the TMJ: Follow up

of 70 patients treated with arthroplasty and acrylic

spacer interposition. Plast Reconstr Surg1986;

77:29-33

5. Moorthy AP, Finch LD: Interpositional arthroplasty

for ankylosis of the temporomandibular joint. Oral

Surg 1983;55:45-47

6. K Su-Gwan: Treatment oftemporomandibular

joint ankylosiswith temporalis muscle and fascia f l a p .

International journal of oral and maxillofacial

surgery2001; 30: 189–193

7. M Jagannathan: Temporomandibular joint

ankylosis. Indian journal of plastic surgery2009; 42(2):

187–188.

8. Belmiro Cavalcanti Do Egito V, Ricardo V, Bessa-

N o g u e i r a , R a f a e l V C , T r e a t m e n t o f

Temporomandibu lar Jo int Anky los i s by gap

Arthroplasty. Med Oral Patol Oral Cir Bucal

2006;11:E 66-69

9. Paul J.W. Stoelinga :The management of aggressive

cysts of the jaws. J Maxillofac.oral surg2012

11(1):2-12-16.

10. Topazian RG: Comparison of gap and interposition

arthroplasty in the treatment of TMJ ankylosis. J O r a l

Surg 1966; 24:405-08.

11. Hili G, Kaneda T, Oka T: Indication and appreciation

of operative procedures for mandibular ankylosis.

Int J Oral Surg 1978;7:333-36

12. A Roychoudhury, H Parkash, A Trikha -. Functional

r e s t o r a t i o n b y g a p a r t h r o p l a s t y i n t e m

poromandibular joint ankylosis: a report of 50 cases.

Oral Surgery, Oral Medicine, Oral pathology 1999;

87: 166–169

13. Stucki-McCormick SU: Reconstruction of the

mandibular condyle using transport distraction

osteogenesis. J Craniofac Surg1997;8:48-51

14. Dean A, Alamillos F: Mandibular distraction in

temporomandibular joint ankylosis. Plast Reconstr

Surg1999; 104:2021-26

15. Piero C, Alessandro A, Giorgio S, et al: Combined

surgical therapy of temporomandibular joint

ankylosis and secondary deformity using intraoral

distraction. J Craniofac Surg2002 13:401-5


TMJ ankylosis associated with odontogenic keratocyst

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CASE REPORT

INTRODUCTION

The number of adult patients seeking orthodontic

treatment has been increasing in the recent years.

There are several psychological, biological and clinical

differences between the orthodontic treatment of

adults and adolescents. Adults have more specific

objectives and concerns related to facial and dental

aesthetics, the type of orthodontic appliance and the

duration of treatment. Growth is an almost insignificant

factor in adults compared to children, and there is

increasing chance that hyalinization will occur during

treatment. In addition, cell mobilization and conversion

of collagen fibers is much slower in adults than in

children. Finally, adult patients are more prone to

periodontal complications since their teeth are

confined in non-flexible alveolar bone .All these factors 1

make adult orthodontic treatment a challenging

therapeutic modality in dentistry, which necessitates

the need for an improvised concepts and procedures for

the purpose of creating a functional dentition in a

healthy periodontal environment.

Corticotomy assisted orthodontic treatment and -Periodontally Assisted Osteogenic Orthodontics (PAOO)

opened doors and offered solutions to many limitations

in the orthodontic treatment of adults, that included

increased anchorage control,reduced treatment

duration and lesser chances of relapse.2

This paper highlights a case report of an adult patient

who was treated with Cort icotomy Assisted

Orthodontic Treatment.

CASE REPORT

A 19 year old adult male patient reported to the OPD of

Department of Orthodontics, Rungta College Of Dental

Sciences & Research with a chief complaint of forwardly

placed upper and lower front teeth and spacing

between the teeth.

Pretreatment Evaluation. Extra oral examination

revealed that patient had a convex profile with

protrusive and potentially competent lips & reduced

Nasolabial angle (Fig.1).

Intra oral examination revealed a Angle's Class II molar

1 2 3 4 5 6Sumit Gandhi , Lokesh Advani , Javed Sodawala , G. Anita , Srinias T.S. , Parul Agrawal1 Reader, Department of Orthodontics, Rungta College of Dental Sciences and Research.2. Post Graduate student, Department of Orthodontics, Rungta College of Dental Sciences and Research.3. Reader, Department of Orthodontics, Rungta College of Dental Sciences and Research.4. Proffessor and H.O.D, Department of Orthodontics, Rungta College of Dental Sciences and Research.5. Reader, Department of Periodontics, Rungta College of Dental Sciences and Research.6. Post Graduate student, Department of Periodontics, Rungta College of Dental Sciences and Research.

Corresponding author :Dr. Sumit GandhiDept. of Orthodontics & Dentofacial Orthopedics, Rungta College of Dental Sciences and ResearchKohka kurud Road, Bhilai- 490023Contact no.- 9826992112, Email id.- [email protected]

ABSTRACT:

This paper illustrates the combined nonextraction orthodontic treatment with the corticotomy technique in an

adult patient with severely spaced arches to accelerate tooth movement and shorten the treatment time. Initial

fixed orthodontic appliances were bonded and three months later corticotomy procedure in the maxilla and

mandible was performed. The space closure was performed in 10 weeks with elastics (sliding mechanics).

Key words: Corticotomy, Adult orthodontics, PAOO

Wilckodontics demystified : A case report

48 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-2: July-Dec. 2014) ISSN 2348 - 4195

Wilckodontics demystified

Fig 1: Pre Treatment Extraoral Photographs.

Fig. 2: Pre Treatment Intraoral Photographs.


and Class II canine relationship with 8 mm overjet and

1 mm overbite. Maxillary arch had spacing of 10 mm

and mandibular arch had spacing of 6.5 mm with

severely proclined upper anterior teeth & lower

anterior teeth (Fig.2). Upper midline was deviated to

the left side of facial midline by 2mm.

Orthopantogram of the patient revealed normal hard

tissue structures and absence of pathology (Fig.3).

Pre Treatment Lateral Cephalogram (Fig.4) and

Cephalometric measurements showed a skeletal class II

pattern, hypodivergent mandibular plane with

proclined upper and lower incisors.(Table 1)

Treatment Plan. As the patient only desired the space

closure within a shorter duration of time, a

nonextraction orthodontic treatment plan with fixed

appliances (Pre adjusted edgewise MBT .018 slot) along

with the corticotomy procedure in both the arches was

decided.

Treatment Progress. 018 MBT fixed appliance (Ormco)

was bonded and .014 inch NiTi arch wire was inserted

for initial leveling and alignment, which was followed by

.018NiTi, .016 X .022 NiTi & .017 X .025 SS.

Surgical Procedure. Corticotomy technique as 1described by Wilcko was performed by the

periodontist (fig.5). After administering the proper local

anesthetic dose, a full thickness flap was reflected

sharply facially, from canine to canine in the maxilla and

between the central incisors in the mandibular arch.

The flap was released with a sulcular incision and with

papillary preservation technique. No vertical releasing 3

incisions were used. Cuts in the alveolus that penetrate

the entire thickness of the cortical plate and penetrate

just barely into the medullary bone were performed 4,5,6

buccally & lingualy around the teeth in both arches.

Vertical decortication cuts were made between the

roots of the teeth and they were stopped 2-3mm shy of

the alveolar crest. Horizontal cuts were used to connect

the vertical cuts along with perforations in the cortical

Fig 3 Pre Treatment Panoramic Radiograph.

Fig. 4: Pre Treatment Lateral Cephalogram.

SNA 870

SNB 820

ANB 50

Wits 5mm

FMPA 130

UI-NA 330, 11 mm

LI-NB 420, 11 mm

IMPA 1250

Nasolabial angle 900

S LINE UL

LL

6 mm ahead

7 mm ahead

Table 1: Cephalometric values (Pre treatment)



(a) (b) (c)

(d) (e)

(f)

Fig.5: Corticotomy in maxillary and mandibular arch.

(g) (h) (i)

(j) (k)

plate. Flaps were repositioned to their presurgical

positions and sutured with interrupted loop sutures.

The sutures were removed after 7 days from the

procedure. The patient was kept under antibiotic

regimen for 5 days following the surgery.

After removal of sutures, 0.017 × 0.025-inch SS

Fig. 6: Comparison of Pre Treatment and Post space closure Profile photographs



archwires with power arms were inserted in both the

arches. Short clear E chain (Rabbit Force, Libral) was

used for the enmass retraction of the anteriors & 150 g

force was applied. Post space closure profile

photographs showed reduced convexity and

competent lips (fig.6). After the active treatment of 10

Fig.7: Extraoral photographs (Post space closure)

weeks, space closure was achieved. (fig 7)

DISCUSSION

The corticotomy was planned as an adjunct to the

treatment in this case to achieve a better anchorage

control.5

Another reason why corticotomy was planned was the

desire of the patient to get the treatment finished in a

shorter duration. The chances of relapse in patients 6

with spacing is reduced with corticotomy as the

procedure require incisional cuts that are extended to

the bone level that sever the periodontal fibres in

particular the transeptal fibres.7

The space closure in this patient was achieved in 10

weeks, which is significantly less than the normal

duration which is (6 months) required by conventional

orthodontic treatment. 8

Intraoral photographs showed that arches were well

aligned and spacing have been closed (fig.8).



PARAMETERS PRE-TREATMENT POST SPACE CLOSURE

SNA 870 860

SNB 820 840

ANB 50 40

WITS 5 mm 4 mm

FMPA 130 120

U1-NA 330,11 mm 240,6.5 mm

L1-NB 420,11 mm 380,7 mm

IMPA 1250 1180

Nasolabial Angle 900 990

S Line UL

LL

6 mm ahead

7 mm ahead

4 mm ahead

3 mm ahead

Table 2: Comparison of Pre treatment and Post space closure cephalometric values.

Fig.8: Intraoral photographs (Post space closure)

Pretreatment and post space closure values when

compared showed that there was a reduction in the

proclination of anteriors in the maxillary and

mandibular arches (Table 2).

CONCLUSION

Corticotomy Assisted Orthodontic Treatment is a

promising technique that has many applications in the

orthodontic treatment of adults because it helps to

overcome many of the current limitations of this

treatment including lengthy duration, potential for

periodontal complications, lack of growth and the

limited envelope of tooth movement.

REFERENCES

1. Murphy KG, Wilcko MT, Wilcko WM, Fergusson WJ.

Periodontal Accelerated Osteogenic Orthodontics:

A Description Of The Surgical Technique. J Oral

Maxillo Surg 2009; 67:2160-2166.

2. Aljhani AS, Zawai KH Nonextraction Treatment of

Severe Crowding with the Aid of Corticotomy-



Assisted Orthodontics. Case Reports In Dentistry

2012;2012:694527(1-8).

3. Thakur A. Halwai H,Corticotomy Assisted

Orthodontic Treatment Journal of Universal College

of Medical Sciences 2013;1(1):1-6

4. Goyal A et al. Periodontally accelerated osteogenic

orthodontics (PAOO) - A review. J Clin Exp Dent

2012;4(5):292-6.

5. Bhat SG, Singh V. PAOO technique for the

b i m a x i l l a r y p r o t r u s i o n : P e r i o - o r t h o

interrelationship. Journal of Indian Society of

Periodontology 2012;16 (4):584-87

6. Karanth S ,Ramesh A ,Thomas B, John AM.

Periodontally accelerated osteogenic orthodontics:

Review on a surgical technique and a case report.

J o u r n a l o f I n t e r d i s c i p l i n a r y D e n t i s t r y

2012;2(3):179-185.

7. Ali H, Ahmed A. Corticotomy-Assisted Orthodontic

Treatment: Review. The Open Dentistry Journal

2010;4: 159-164.

8. Fischer TJ. Orthodontic Treatment Acceleration

with Corticotomy-assisted Exposure of Palatally

Impacted Canines. Angle Orthodontist 2007; 77(3 ):

417-420.



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