Volume 2, Issue 1

Nov 2011 - Jan 2012

The Effect of CPP-ACP on Remineralization of Artificial Caries like

lesions: An Invitro study (Page 366)

Comparative Efficacy Evaluation of Articaine as Buccal Infiltration and Lignocaine as

IANB in the Mandibular first Molar with Irreversible Pulpitis (Page 370)

Pharmacovigilance: A tool for health safety (Page 374)

Sialolith: A Case Report with Review of Literature (Page 377)

Myth of Endodontics in Oral Focal Infection (Page 380)

The Scope and Limitations of Adult Orthodontics (Page 383)

Esthetic Enhancement of Discolored Teeth by Macroabrasion Microabrasion and

its psychological impact on patients - A case series (Page 388)

Roll Flap Technique for Anterior Implant Esthetics (Page 393)

Management of Frontal Sinus Outer Table Injury with Involvement of the Nasofrontal
Duct with Review (Page 396)

Capillary Heamangioma as a rare benign tumour of Gingival Origin : A Case Report (Page 399)

Prosthodontic Management of a Completely Edentulous Patient with Bell’s Palsy (Page 404)

Finger Prostheses - Overcoming a Social Stigma: Clinical Case Reports (Page 407)

Bordetella avium and Bacillus megaterium in Endodontic Infection (Page 411)

Peripheral Ossifying Fibroma - Report of a case (Page 415)

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Indian Journal of
Multidisciplinary Dentistry Volume 2, Issue 1
November 2011 to January 2012

IJMD’s Editorial Panel

Editor-in-Chief
KMK Masthan
Executive Editor Associate Editor
S Bhuminathan N Aravindha Babu
IJMD Advisory Board
Prosthodontics Oral and Maxillofacial General Medicine
Mahesh Verma Surgery Rajendran SM
Srinisha J Ramakrishna Shenoi
Raghavendra Jayesh S Vijay Ebenezer Periodontics
Raj Kutta (USA) Chandrasekaran SC
Sanjna Nayar Ash Vasanthan (USA)
Oral Pathology and
Conservative Dentistry/ Oral Medicine and
Microbiology
Endodontics Vinay K Hazarey Radiology
Sukumaran VG Nalini Aswath
Ipe Vargese V
Subbiya A Panjab V Wanjari
Puneet Ahuja
Praveen BN
Swaminathan S (Singapore) Sangeeta P Wanjari
Mubeen

Implantology Orthodontics Pedodontics

John W Thurmond (USA) Krishna Nayak US Krishan Gauba
Dhandapani G Ashima Gauba
Murali RV
Genetics
Deepak C Biochemistry
Aravind Ramanathan
Julius A
Pharmacology
Oncology Muthiah NS Microbiology
Abraham Kuriakose M Elumalai M Mahalakshmi K
IJCP’s Editorial Panel
Dr Sanjiv Chopra Dr KK Aggarwal
Prof. of Medicine & Faculty Dean CMD, Publisher and Group
Harvard Medical School Editor-in-Chief
Group Consultant Editor Dr Veena Aggarwal
Joint MD & Group Executive Editor
Dr Deepak Chopra Anand Gopal Bhatnagar
Chief Editorial Advisor Editorial Anchor

IJMD is included in the databases of Genamics JournalSeek along with Ulrich

International periodical directory and Index Copernicus International, Ltd. HINARI and EBSCO Publishing

Advisory Bodies
Heart Care Foundation of India, Non-Resident Indians Chamber of Commerce & Industry,
World Fellowship of Religions
From the Editor-in-chief
xxxxxxxxx

T
his issue denotes our successful completion
of six issues in one year i.e. First Volume
and the smooth sail of our journal into its
Second Volume. The topic I have chosen to discuss
in this editorial is the shift of trend of the dental and
medical academics towards research. When I attended
the Research Council Meet of Bharath University, I
realized that the universities, Governing Councils and Dr KMK Masthan
Professor and Head,
Ministries are intent upon implementing research as Department of Oral Pathology and Microbiology
part of the teacher’s life and that this mindset is not Sree Balaji Dental College and Hospital
Chennai
going to be blown away by the passage of time. The
slogans raised by the members,’’Publish or Perish’’ and
‘’If and only if you are a researcher you may continue
teaching. It is aimed to prove that a so called constant
as the HOD’’ were as explicit as a stick behind
is a variable. So how are we going to solve this tug with
the donkey. My discussions with the staff of other
teaching and research at two ends of the rope?
Universities revealed that they too had received severe
warnings and intended punishments if research works One way is to segment the faculty members into two
were not taken up immediately by the staff members. classes namely teachers or researchers. Another is to
It is quite right to expect us to produce something train the existing teachers into willing researchers in a
when they pay for it but not fair to expect us to get step by step manner. Let me indulge in a parable to
it done yesterday. elucidate what I try to convey. In a nearby state, my
friend in his early fifties works as a village medical officer.
I am not against research and, in fact, support it
He is quite busy managing routine cases, vaccinations
whole-heartedly, since I myself have agreed to take up
and minor trauma etc. Then the Health Ministry of
the responsibility of running Oral Cancer Research
that state had a brainstorm and wanted to sensitize
Centre at my college. But we entered into the teaching
all the state medical personnel in the identification
institutions with the intention of teaching because it
and diagnosis of HIV and AIDS. The concerned
gives us immense pleasure to be associated with the
officials tried several measures to make the medical
task of shaping the minds of a dental student and
and paramedical personnel to attend workshops and
his/her academics. Most of the teachers I know are
symposia with severe warnings for those who did not
extremely proud of teaching and I have seen several
attend. There was only marginal response. After due
of them foregoing golden opportunities of monetarily
deliberations and a frank dialogue with non-attendees,
gainful ventures just for the sake of continuing to teach.
they struck pay dirt. A scheme was announced wherein
Hence, in a way, no one should try to turn teachers
the attending medical personnel can come with his/her
away from teaching with the intention of converting
entire family, stay in government guest houses, attend
them into researchers. G.K.Chesterton’s saying’’ Do
the update workshops with an added remuneration
not free a camel of the burden of his hump; you may be
of eight hundred to three thousands per day. This
freeing him from being a camel’’ is to be remembered
workshop was held during weekends in the state
while attempting such radical endeavors.
capital, every week for the next three months or so.
In dentistry and medicine we teach established The response was tremendous. My friend shamelessly
protocols, time-tested procedures and conventional admitted it was the best holiday his family had had for
practice modalities. Research is, at its core values, years and he looked forward to attending more such
contradictory to what we cherish and convey in workshops. Hence I sincerely believe this attitude, if it

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 363
 From the Editor-in-chief
were to be adapted by Universities and Ministries will
produce much faster results regarding research. They
could offer to pay substantially, say about 50 thousands,
for every research paper submitted. When I proposed
this suggestion at a meeting held for improving research
activities, the responses were
 We will be flooded with too many papers.
 We can’t control the quality.
 Do we have to stoop down to pay to get research
done?
 We can’t pay that much, probably around one or
two thousands.
So the mindset of those who insist on research is not
to get research publications but to get them at little
or no cost and the teachers must feel it as a prestige
and not to consider it as a way to make money. My
opinion is you will get a stampede of researchers if the
authorities are ready to pay unconditionally for it. You
rephrase the terms of research into a paying job and, in
364 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
no time, you can see existing teachers infusing fervor
into it enthusiastically. If the incentives were adequate,
within one or two years a stage may be reached which
is better illustrated by the story of a wagon driver and
his passengers. As the wagon driver said when they
came to a long, hard hill,’ Them that is going with us,
get out and push. Them that ain’t,get out of the way’’.
Those of us who may opt not to enter research might
get pushed to the side in the stampede.
Some may feel differently to my Machiavellian views.
I also realize that it is not wise to attempt to throw
stones from within a glasshouse. But somebody has to
dare to touch the core issue and my suggestions reflect
the broad sentiments of dental and medical teachers
and are likely to definitely pave the way to get more
research works done. I leave the readers with this
thought and expect to hear their opinions at ijmdent@
gmail.com.
Best Wishes.
 From the Desk of IJCP Group Editor-in-Chief
xxxxxxxxx
Systemic conditions may affect oral health

S
ystemic conditions may affect oral health and/or the delivery
of dental care if the systemic condition increases the risk of
odontogenic infection

Conditions that are associated with increased risk of infection

Condition Oral manifestation Dental management
or complication
Childhood cancers Decreased immune Reduction of plaque and
Dr KK Aggarwal function, leading to microorganisms through
Padma Shri and Dr BC Roy National Awardee
Sr. Physician and Cardiologist, Moolchand Medcity gingival inflammation oral hygiene and use of
President, Heart Care Foundation of India and alveolar bone loss chemotherapeutic agents,
Group Editor-in-Chief, IJCP Group
Editor-in-Chief, eMedinewS such as chlorhexidine
Chairman Ethical Committee, Delhi Medical Council Chemotherapeutic Oral ulceration; Reduction of plaque and
Director, IMA AKN Sinha Institute (08-09)
Hony. Finance Secretary, IMA (07-08) immunosuppression infection by microorganisms through
Chairman, IMA AMS (06-07) opportunistic oral hygiene and use of
President, Delhi Medical Association (05-06)
emedinews@gmail.com organisms chemotherapeutic agents,
http://twitter.com/DrKKAggarwal such as chlorhexidine
Krishan Kumar Aggarwal (Facebook)
Graft-versus-host Mucositis, xerostomia, Artificial saliva,
disease oral pains chemotherapeutic agents to
reduce plaque, pain control
measures
HIV infection Severe acute and Reduction of plaque and
chronic gingival microorganisms through
and periodontal oral hygiene and use of
inflammation, chemotherapeutic agents,
exceeding that such as chlorhexidine
expected for local
irritants present
Diabetes mellitus Increased gingival Reduction of plaque and
and periodontal microorganisms through
inflammation and oral hygiene and use of
increased risk of chemotherapeutic agents,
odontogenic infections such as chlorhoxidine
Congenital heart Cyanotic friable oral Adherence to American
disease tissues; ingress of Heart Association guidelines
microorganisms for prevention of infective
implicated in subacute endocarditis [1]
bacterial endocarditis
In-dwelling catheters/ Risk of infection of Adherence to American
central lines device from oral Heart Association guidelines
bacteremia introduced for prevention of infective
by dental treatment endocarditis [1]
Sickle cell anemia Nonspecific oral Prophylaxis with appropriate
findings, but at antibiotic when needed for
increased risk for dental treatment
infection secondary
to dental treatment in
some cases
Casamassimo, PS. Pediatr Clin North Am 2000; 47:1149

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 365
 ORIGINAL RESEARCH

The Effect of CPP-ACP on Remineralization of

Artificial Caries like lesions: An Invitro study
Yoshaskam Agnihotri*, Namratha Lakshmi Pragada**, Gaurav Patri*, PK Thajuraj†

Abstract
The aim of the study was to investigate the efficacy of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP)
containing tooth mousse on the remineralization of enamel lesions and to compare its efficacy to fluoride containing tooth
paste. Thirty premolar teeth were placed in demineralizing solution for 96 hours to produce artificial caries-like lesions.
They were sectioned into half and ground sections were prepared. Samples were randomly assigned into three groups:
Group A: Nonfluoridated toothpaste (negative control), Group B: Fluoridated toothpaste and Group C: Tooth Mousse
containing CPP-ACP. Group C showed a significant decrease in lesion depth after the specified treatment followed by
Group B whereas, Group A demonstrated an increase in lesion depth. CPP-ACP containing tooth mousse remineralized initial
enamel lesions and showed a higher remineralizing potential than fluoridated toothpaste.

Key words: Remineralization, CPP-ACP, demineralization

D
ental caries a common tooth malady has The aim of this study was to investigate the efficacy
significantly declined over the past few of CPP-ACP containing tooth mousse on the
decades, largely due to the use of fluorides in remineralization of enamel lesions and to compare its
toothpastes. Fluoride has been proven to reduce caries remineralization ability with that of fluoride containing
in both the primary and permanent dentitions when tooth paste.
used in a variety of ways.1
Material and Methods
In recent years, casein phosphopeptide-amorphous
Thirty sound extracted premolars were cleansed of soft
calcium phosphate (CPP-ACP) nanocomplexes
tissue debris and inspected for cracks, hypoplasia and
has demonstrated anticariogenic properties in both
white spot lesions. The teeth were then coated with a
laboratory animal and human in situ experiments. 2
nail varnish, leaving a narrow window, approximately
CPP can stabilize calcium phosphate in amorphous
1 mm wide, on the sound, intact surface of the buccal
calcium phosphate solution and has been shown
enamel.6 Each tooth was subsequently immersed in
in vitro to localize on the tooth surface, preventing
the demineralizing solution7 (2.2 mM CaCl2, 2.2
demineralization and helping in remineralization.3
mM KH2PO4, 0.05M acetic acid having pH adjusted
CPP-ACP stabilized calcium phosphate solutions have
to 4.4 and 1 M KOH) for four days to produce
also shown remineralization of subsurface lesions and
lesions 120-200 µm deep.6 The teeth were sectioned
stabilization of free calcium and phosphate ions. CPP-
longitudinally through the lesions in two halves and
ACP (tooth mousse) has even shown a greater capacity
ground sections were made which was visualized
to neutralize acids than fluoridated toothpastes.4 The
under polarized light microscopy and the depth of
acid resistance of enamel exposed to CPP-ACP was
the lesions was measured using a microtome and
increased by the addition of fluoride. 4,5
image ‘J’ software.
Thirty sections were randomly assigned to three
treatment groups as follows: (1) Group A: Negative
*Senior Lecturer, Dept. of Conservative Dentistry and Endodontics control nonfluoridated toothpaste (Dabur promise,
**Senior Lecturer, Dept. of Prosthodontics
†
Professor and Head, Dept. of Conservative Dentistry and Endodontics India); (2) Group B: Fluoridated toothpaste (Pepsodent
Hi-Tech Dental College and Hospital, Bhubaneswar tooth paste, Hindustan lever, India); (3) Group C:
Address for correspondence
Dr Yoshaskam Agnihotri CPP-ACP as toothpaste (tooth mousse, GC Corp,
E-mail: drlee2@gmail.com Tokyo, Japan).

366 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
 original research

Toothpaste and tooth mousse supernatants in

Groups A, B, C were prepared by suspending 15 g
of the respective toothpaste⁄tooth mousse in 45 ml of
deionized water in order to achieve 1:3 (toothpaste:
Deionized water) ratio, these suspensions were then
thoroughly stirred and mechanically agitated. The
sections were placed in the pH cycling system on an Group A
orbital shaker for 10 days.8,9 Each cycle involved three
hours of demineralization twice-daily with two hours
of remineralization in between. The remineralizing
solution7 contained 1.5 mM CaCl2, 0.9 mM NaH2PO4,
0.15 M KCL and had a pH of 7.0. Specimens in
Groups A, B, and C were treated for 60 seconds with
toothpaste supernatant (5 ml/section) before the first Group B
demineralizing cycling, and both before and after the
second demineralizing cycles. After the 10-day pH
cycle the nail polish was carefully removed from the
specimens using acetone. Ground sections were re-
visualized under polarized light microscopy.10
After imbibition of the sections in water, polarized
light microscopy (PLM) was employed to qualitatively Group C
evaluate the body of the lesions in each of the enamel Figure 3. Group C, Images of demineralization and
sections. Depth of lesions was measured by using Remineralization under polarized light microscope.
microtome and image ‘J’ software and values were
compared with the previous ones.
Discussion
Results
The recent approach in caries management is the
The mean and standard deviation (SD) of pre- noninvasive method.11 Non-cavitated and cavitated
treatment lesion depth from each group ranged lesions extending up to dentinoenamel junction can
from 0.234 ± 0.043 mm to 0.244 ± 0.066 mm. be arrested if the cariogenic challenges of certain
No statistically significant difference was noted microenvironment are sufficiently controlled and if
among these pre-treatment lesion depths (p = 0.9996, therapeutic agents are applied for tissue healing.12
ANOVA). The paired ‘t’ test showed that Groups B
and C had a significant decrease in lesion depth after Professional fluoride-delivery methods, such as gels,
the specified treatment, whereas Group A demonstrated varnishes, fluoride releasing materials, are commonly
a significant increase in lesion depths (Table 1). applied to remineralize high-risk tooth areas. Bioactive
agents based on milk products have now been developed
to release elements that enhance remineralization of
Table 1.
the enamel and dentine, under cariogenic conditions.
Groups After After Change in
This agent (commercially available as Tooth Mousse,
demineralization remineralization size using
paired ‘t’ GC International, Itabashi-ku, Tokyo, Japan)
test is based on a nanocomplex of the milk protein
Group A 0.234 ± 0.043 0.262 ± 0.035 +0.028 CPP-ACP and has shown to promote remineralization
(95% conf.) of the carious lesions in ‘Invitro’ and ‘in vivo’ studies
Group B 0.244 ± 0.039 0.230 ± 0.044 -0.014 by maintaining a supersaturated state of enamel
(95% conf.) mineral.13 It has been proposed that the anticariogenic
Group C 0.242 ± 0.066 0.222 ± 0.050 -0.020 mechanism of CPP-ACP is due to localization of
(95% conf.) ACP at the tooth surface which then buffers the free

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 367
 original research
calcium and phosphate ion activities, thereby helping
to maintain a state of supersaturation with respect
to the enamel,14 thus depressing demineralization
and promoting remineralization. Studies have shown
that higher concentration of CPP-ACP elicit higher
remineralization.15,16
CPP-ACP can be incorporated into the pellicle
in exchange for albumin to inhibit the adherence
of S. mutans and S. sobrinus thus producing both
neutralization and enhancement of remineralization
(Schupbach et al). Therefore, CPP-ACP can be
expected to be effective in high-risk children who have
not developed good oral hygiene habits.17
Tooth mousse can be used to prevent root caries as
its application prevented demineralization of dentin
due to buffering capacity of the agent. Casein buffers
plaque acid directly or indirectly through bacterial
catabolism. This agent also releases basic amino acids
which accept proton ions thus when applied on root
dentin acts as an inert barrier preventing diffusion
of protons. This agent also has the ability to release
calcium thus depressing demineralization.18
CPP-ACP when used in combination with fluorides
showed better results and lower caries score than when
used individually. Our study also substantiates that
when CPP-ACP was used after fluoridated paste the
benefits of both the agents are enhanced.
The findings of our study shows that when CPP-
ACP was applied, the increase in remineralization and
decrease in lesion depth was greater as compared to
fluoridated paste and nonfluoridated paste showed an
increase in lesion depth and demineralization.
Conclusion
Based on the data obtained it can be concluded that
CPP-ACP effectively decreases the lesion depth better
than fluoridated toothpaste and nonfluoridated tooth
paste which showed no improvement in the lesion
size. Efficiency of remineralization can be increased
when CPP-ACP and fluoridated tooth pastes are used
together.
References
1. Wefel JS, Jensen ME, Triolo PT, Faller RV, Hogan
MM, Bowman WD. De/remineralization from sodium
fluoride dentifrices. Am J Dent 1995;8(4):217-20.
368 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
2. Reynolds EC. Remineralization of enamel subsurface
lesions by casein phosphopeptide-stabilized calcium
phosphate solutions. J Dent Res 1997;76(9):1587-95.
3. Iijima Y, Cai F, Shen P, Walker G, Reynolds C, Reynolds
EC. Acid resistance of enamel subsurface lesions
remineralized by a sugar-free chewing gum containing
casein phosphopeptide-amorphous calcium phosphate.
Caries Res 2004;38(6):551-6.
4. Kariya S, Sato T, Sakaguchi Y, Yoshii E. Fluoride effect
on acid resistance capacity of CPP-ACP containing
material. Abstract 2045 - 82nd General Session of the
IADR 2004, Honolulu, Hawaii.
5. Yamaguchi K, Miyazaki M, Takamizawa T, Inage H,
Moore BK. Effect of CPP-ACP paste on mechanical
properties of bovine enamel as determined by an
ultrasonic device. J Dent 2006;34(3):230-6.
6. Kumar VL, Itthagarun A, King NM. The effect of
casein phosphopeptide-amorphous calcium phosphate
on remineralization of artificial caries-like lesions: an in
vitro study. Aust Dent J 2008;53(1):34-40.
7. ten Cate JM, Duijsters PP. Alternating demineralization
and remineralization of artificial enamel lesions. Caries
Res 1982;16(3):201-10.
8. Itthagarun A, Wei SH, Wefel JS. Morphology of initial
lesions of enamel treated with different commercial
dentifrices using a pH cycling model: scanning electron
microscopy observations. Int Dent J 1999;49(6):
352-60.
9. Itthagarun A, Wei SH, Wefel JS. The effect of different
commercial dentifrices on enamel lesion progression: an
in vitro pH-cycling study. Int Dent J 2000;50(1):21-8.
10. Arends J, ten Bosch JJ. Demineralization and
remineralization evaluation techniques. J Dent Res
1992;71 Spec No:924-8.
11. Rahiotis C, Vougiouklakis G. Effect of a CPP-ACP agent
on the demineralization and remineralization of dentine
in vitro. J Dent 2007;35(8):695-8.
12. Burke FJ. From extension for prevention to prevention
of extension: (minimal intervention dentistry). Dent
Update 2003;30(9):492-8, 500, 502.
13. Reynolds EC, Cai F, Shen P, Walker GD. Retention in
plaque and remineralization of enamel lesions by various
forms of calcium in a mouthrinse or sugar-free chewing
gum. J Dent Res 2003;82(3):206-11.
14. Reynolds EC, Cain CJ, Webber FL, Black CL, Riley PF,
Johnson IH, et al. Anticariogenicity of calcium phosphate
complexes of tryptic casein phosphopeptides in the rat. J
Dent Res 1995;74(6):1272-9.
15. Reynolds EC. The prevention of sub-surface
demineralization of bovine enamel and change in plaque
 original research

composition by casein in an intra-oral model. J Dent Res streptococci. J Dent Res 1996;75(10):1779-88.
1987;66(6):1120-7.
17. Gagnaire V, Pierre A, Molle D, Leonil J. Phosphopeptides
16. Schüpb ach P, Neeser JR, Golliard M,
interacting with colloidal calcium phosphate isolated by
Rouvet M, Guggenheim B. Incorporation of
caseinoglycomacropeptide and caseinophosphopeptide tryptic hydrolysis of bovine casein micelles. J Dairy Res
into the salivary pellicle inhibits adherence of mutans 1996;63(3):405-22.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 369
 ORIGINAL RESEARCH
Comparative Efficacy Evaluation of Articaine as Buccal Infiltration and
Lignocaine as IANB in the Mandibular first Molar with Irreversible Pulpitis

A Subbiya*, AR Pradeepkumar**, P Vivekanandhan*, A Karthick†

Abstract
It has been shown that the inferior alveolar nerve block (IANB) has high failure rate especially in patients with irreversible
pulpitis. Newer local anesthetic, 4% articaine has shown superiority over 2% lignocaine when used as a primary buccal
infiltration of the mandibular first molar. This study compared the degree of pulpal anesthesia obtained with 1.7 ml 4%
articaine with 1:1,00,000 epinephrine when compared to 1.7 ml 2% lignocaine with 1:2,00,000 as a primary infiltration in
mandibular first molar with irreversible pulpitis. Sixty adults aged 18-65 years participated in this study. Twenty-two patients
out of 30 did not experience pain with 4% articaine (success = 73.33%) and 26 out of 30 patients did not experience pain in
2% lignocaine group (success = 86.66%). There was no statistically significant difference between the articaine and lignocaine
formulation with regard to anesthetic success.

Key words: Articaine, lignocaine, irreversible pulpitis

T
he inferior alveolar nerve block (IANB) is
the most frequently used injection technique
for achieving local anesthesia for mandibular
restorative and endodontic procedures. However, the
inferior alveolar nerve block does not always result in
successful pulpal anesthesia.1-4 It has been shown that
the IANB has high failure rate especially in patients
with irreversible pulpitis.5-7 Articaine has shown
superiority over 2% lignocaine when used as a primary
buccal infiltration of the mandibular first molar using
volumes ranging from ‘0.9 to 3.6 ml.8-12 Though the
exact mechanism of action of articaine’s efficacy is not
known, better penetration of bone owing to smaller size
of thiophene ring of articaine when compared to the
benzene ring of lignocaine and increased liposolubility
has been suggested to facilitate better diffusion of
the anesthetic solution to the teeth.13 Success rates of
articaine have ranged from 54 to 87% with an average
rate of 67%. Differences in populations may account
for the differences among studies. Racial differences
in bone mineral density are well-established. Bone
mineral density could be a factor that can affect the
dissociation of articaine into the mandible. Therefore,
the purpose of this study was to compare the degree of
pulpal anesthesia obtained with 1.7 ml 4% articaine
with 1:1,00,000 epinephrine when compared to
1.7 ml 2% lignocaine with 1:2,00,000 as a primary
infiltration in mandibular first molar with irreversible
pulpitis in an Indian population.
Material and Methods
The study included 60 subjects who had irreversible
pulpitis in mandibular first molar. None of them were
taking any medication that would alter pain perception
as determined by a written health history and oral
questioning. Exclusion criteria were subjects younger
than 18 or older than 65 years of age, allergies to local
anesthetics or sulfites, pregnancy, history of significant
medical conditions (American Society of Anesthesiology
Class II or higher), active sites of pathosis in area of
injection and unable to give an informed consent.

*Professor
The inclusion criteria for the study were active pain
**Senior Lecturer in a mandibular molar (>54 mm on Heft-Parker
Dept. of Conservative Dentistry and Endodontics
Sree Balaji Dental College and Hospital, Chennai
visual analog scale [HP VAS] of 170 mm) with
†
Professor and Head, Dept. of Conservative Dentistry and Endodontics prolonged response to cold testing with an ice stick
Thai Moogambigai Dental College and Hospital, Chennai
Address for Correspondence
and an electric pulp tester, absence of any periapical
Dr A Subbiya radiolucency on intraoral periapical radiographs and
Dept. of Conservative Dentistry and Endodontics,
Sree Balaji Dental College and Hospital, Chennai
a vital coronal pulp on gaining access to the pulp
E-mail: drsubbiya@gmail.com chamber. Patients were explained the treatment

370 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

Place a mark on the line below to show the amount of pain that you feel
0 mm 23 36 54 85 114 144 170 mm
None Faint Weak Mild Moderate Strong Intense Maximum
Figure 1. Heft-Parker visual analog scale used for the assessment of pain.
procedure and use of pain scales. Patients marked
their pre-treatment pain on a 170 mm HP VAS
(Fig. 1). To interpret the data, we divided the VAS
into the following four categories:
 No pain corresponded to 0 mm on the scale.
 Mild pain was defined as >0 mm and ≤54 mm.
A description of faint, weak and mild was included
in this category.
 Moderate pain was defined as >54 mm and
<114 mm.
 Severe pain was defined as ≥114 mm. A description
of strong and intense was included in this
category.
A topical anesthetic gel (20% benzocaine) was applied
at the site of injection for 60 seconds. For the first
group, which included 30 patients, 4% articaine with
1:2,00,000 adrenaline (Septanest, Septodont) was
administered as buccal infiltration injection adjacent to
the mandibular first molar, bisecting the approximate
location of the mesial and distal roots over a 1-minute
period. After 15 minutes, the patient was asked whether
his/her lip was numb. If profound lip numbness was
not recorded, the block was considered unsuccessful,
and the patients were excluded from the study. After
isolation with a rubber dam a conventional access
opening was done. Patients were instructed to raise
their hand if any pain was felt during the procedure. If
the patient experienced pain during the treatment, the
procedure was aborted. The patient was asked to rate
the pain on HP VAS.
For the second group 2% lignocaine was administered
as IANB and similar protocol of access opening was
performed and subject’s response was noted. For the
patients who experienced pain with articaine infiltration,
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
original research
possible
an additional IANB with 2% lignocaine was performed
with patients consent. If the patient experienced pain
during the access opening, the procedure was aborted.
The patient was asked to rate the pain on HP VAS.
Results
Sixty adults (30 men and 30 women) aged 18-65
years (mean age, 37 years) participated in this study.
Table 1 presents the subjects’ anesthetic success.
Twenty-two patients out of 30 did not experience
pain with 4% articaine (success = 73.33%) and
26 out of thirty patients did not experience pain in
2% lignocaine group (success = 86.66%). There was
no statistically significant difference between the
articaine and lignocaine formulation with regard to
anesthetic success. The degree of pain experienced
by the patient with articaine group and lignocaine
group was similar. One out of the failure cases in both
group experienced severe pain and the rest experienced
moderate pain.
Discussion
The complications associated with buccal infiltration is
minimal when compared to IANB. Since, the option
of buccal infiltration would be a better option for first
molar, it is better that the superiority be studied among
various races. This is because the penetration of articaine
on buccal infiltration, which is hypothesized to be the
reason for its success, may vary based on the bone density
and porosity which may vary among races.15 In previous
studies, the success of mandibular infiltration with 4%
articaine and epinephrine for first molar anesthesia was
found to be comparable to that of an inferior alveolar
nerve block with 2% lignocaine and epinephrine when
similar outcome measures are used.6-12
371
 original research
Table 1. Subjects who Experienced Anesthetic
Success
Tooth No. No. of subjects (n = 60)
Anesthetic solution
4% articaine 2% lidocaine
First molar 22 (30) 26 (30)
*There was no significant difference (p > 0.05) between the 4%
articaine (buccal infiltration) and 2% lignocaine (IANB) formulations.
The results of the current study confirm the results of
previous studies showing that 4% articaine was successful
as a buccal infiltration. The success of the infiltration of
4% articaine with 1:1,00,000 epinephrine was 73.33%
for the first molar when compared to 86.66% for 2%
lignocaine with 1:2,00,000 epinephrine as IANB
(Table 1). The success of mandibular first molar buccal
infiltrations has been studied by various authors using
asymptomatic subjects with 4% articaine containing
1:1,00,000 epinephrine and an electric pulp tester
to evaluate pulpal anesthesia. Kanaa et al,8 Robertson
et al9, Jung et al10 and Corbett et al11 demonstrated
64%, 87%, 54%and 64-70% success rates, respectively,
for the buccal infiltration of asymptomatic mandibular
first molar. Our success rate of 73.33% is similar to
that of Corbett et al but differs from the other authors.
The study also differs from the previous study by
Aggarwal et al7 where the success rate was only 58%,
where buccal infiltration with articaine was in addition
to IANB. Though a similar success rate was reported by
Haase et al,13 it was a combination of IANB and
supplemental buccal infiltration with articaine.
Although anesthesia of the lower lip on the side
of injection is assumed to be a sign of success of
mandibular nerve anesthesia, patients experienced
pain during access opening despite lip anesthesia.
This was similar to the observation in the study by
Aggarwal et al7 who reported pain on access opening
despite lip anesthesia. Furthermore, when 2%
lignocaine was given as IANB after a failure with
4% articaine for patients who consented for the
additional injection, pain was experienced in six out
of eight cases similar to the pain on access opening
with 4% articaine. This suggests that lignocaine may
not be successful in most of the cases where articaine
would be a failure, though this inference may be taken
with caution as the number of articaine failure cases
taken up for lignocaine IANB was limited. Based on
the manufacturer’s maximum recommended dose of
372
seven cartridges for 4% articaine and a maximum dose
of 13 cartridges of a 2% lignocaine for a healthy 70-kg
P value adult this additional dose is within the safety limits.14
As mentioned earlier, success of articaine [(4-methyl-3-
[1-oxo-2-(propylamino)-propionamido]-2-thiophene-
0.33* carboxylic acid methyl ester hydrochloride)] could be
because it contains a thiophene ring in its molecule
instead of the benzene ring seen in lignocaine, increasing
the liposolubility of the drug as well as its potency.
Robertson and colleagues suggested that buccal infiltration
of articaine might have resulted in penetration of the
solution through the mental foramen, leading to the
higher success rates in the premolars and first molar. But
a higher success rate can be expected in the premolars and
first molar than in the second molar for both articaine
and lignocaine formulations. This is because of a relatively
thicker bone in the buccal aspect of second molar region
which may prevent anesthetic diffusion.
Within the limitations of this study it can be concluded
that 4% articaine with 1:1,00,000 adrenaline can
be considered as an alternative for anesthetising
mandibular first molar instead of IANB with 2%
lignocaine with 1:2,00,000 adrenaline.
References
1. Nusstein J, Reader A, Nist R, Beck M, Meyers WJ.
Anesthetic efficacy of the supplemental intraosseous
injection of 2% lidocaine with 1:100,000 epinephrine in
irreversible pulpitis. J Endod 1998;24(7):487-91.
2. Reisman D, Reader A, Nist R, Beck M, Weaver J.
Anesthetic efficacy of the supplemental intraosseous
injection of 3% mepivacaine in irreversible pulpitis.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;84(6):676-82.
3. Cohen HP, Cha BY, Spångberg LS. Endodontic
anesthesia in mandibular molars: a clinical study. J
Endod 1993;19(7):370-3.
4. Kennedy S, Reader A, Nusstein J, Beck M, Weaver J. The
significance of needle deflection in success of the inferior
alveolar nerve block in patients with irreversible pulpitis.
J Endod 2003;29(10):630-3.
5. Tortamano IP, Siviero M, Costa CG, Buscariolo IA,
Armonia PL. A comparison of the anesthetic efficacy
of articaine and lidocaine in patients with irreversible
pulpitis. J Endod 2009;35(2):165-8.
6. Claffey E, Reader A, Nusstein J, Beck M, Weaver J.
Anesthetic efficacy of articaine for inferior alveolar nerve
blocks in patients with irreversible pulpitis. J Endod
2004;30(8):568-71.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

7. Aggarwal V, Jain A, Kabi D. Anesthetic efficacy
of supplemental buccal and lingual infiltrations of
articaine and lidocaine after an inferior alveolar nerve
block in patients with irreversible pulpitis. J Endod
2009;35(7):925-9.
8. Kanaa MD, Whitworth JM, Corbett IP, Meechan JG.
Articaine and lidocaine mandibular buccal infiltration
anesthesia: a prospective randomized double-blind cross-
over study. J Endod 2006;32(4):296-8.
9. Robertson D, Nusstein J, Reader A, Beck M, McCartney
M. The anesthetic efficacy of articaine in buccal
infiltration of mandibular posterior teeth. J Am Dent
Assoc 2007;138(8):1104-12.
10. Jung IY, Kim JH, Kim ES, Lee CY, Lee SJ. An evaluation
of buccal infiltrations and inferior alveolar nerve blocks
in pulpal anesthesia for mandibular first molars. J Endod
2008;34(1):11-3.
11. Corbett IP, Kanaa MD, Whitworth JM, Meechan JG.
Articaine infiltration for anesthesia of mandibular first
molars. J Endod 2008;34(5):514-8.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
original research
12. Abdulwahab M, Boynes S, Moore P, Seifikar S, Al-
Jazzaf A, Alshuraidah A, et al. The efficacy of six local
anesthetic formulations used for posterior mandibular
buccal infiltration anesthesia. J Am Dent Assoc
2009;140(8):1018-24.
13. Haase A, Reader A, Nusstein J, Beck M, Drum M.
Comparing anesthetic efficacy of articaine versus
lidocaine as a supplemental buccal infiltration of the
mandibular first molar after an inferior alveolar nerve
block. J Am Dent Assoc 2008;139(9):1228-35.
14. Katyal V. The efficacy and safety of articaine versus
lignocaine in dental treatments: a meta-analysis.J Dent
2010;38(4):307-17.
15. Patni R. ormal BMD values for Indian females aged 20-
80 years. J Midlife Health 2010;1(2):70-3.
16. Melamed A, Vittinghoff E, Sriram U, Schwartz
AV, Kanaya AM.BMD reference standards among
South Asians in the United States.J Clin Densitom
2010;13(4):379-84.
373
 Review artcle

Pharmacovigilance: A tool for health safety

N S Muthiah*, M Elumalai**, N P Murali †, Ramsundar Hazra ‡

Abstract
Pharmacovigilance is the pharmacological science activities relating to the detection, assessment, understanding and prevention
of adverse effects, particularly chronic and acute side effects of medicines. The aim of pharmacovigilance is to improve
public health and safety, to contribute to the assessment of benefit, harm, effectiveness and risk of medicines, to promote-
understanding, education and clinical training.

Key words: Health safety, pharmacovigilance, drugs

P
harmacovigilance is an important and integral part
of clinical research and these days it is growing in
many countries.1 A number of researchers have
studied about pharmacovigilance.2-4 Recently, its concerns
have been widened to include herbals, traditional and
complementary medicines, blood products, biologicals,
medical devices and vaccines.5 This applies throughout
the life cycle of a medicine equally to the pre-approval
stage as to the post-approval.
The scope of pharmacovigilance is to improve patient
care and safety in relation to the use of medicines, and
all medical and paramedical interventions. Improve
public health and safety in relation to the use of
medicines. Contribute to the assessment of benefit,
harm, effectiveness and risk of medicines, encouraging
their safe, rational and more effective (including cost-
effective) use, and promote understanding, education
and clinical training in pharmacovigilance and its
effective communication to the public.
Adverse Drug Reaction
A response to a drug which is noxious and unintended,
and which occurs at doses normally used in man for
the prophylaxis, diagnosis, or therapy of disease, or for
the modification of physiological function. Montastruc
et al6 have been studied to characterize the profile of
adverse drug reactions (ADRs) reported with selegiline,
a monoamine oxidase B (MAO-B) inhibitor used in
the treatment of Parkinson’s disease.
Adverse Event
Any untoward medical occurrence that may present
during treatment with a pharmaceutical product but
which does not necessarily have a causal relationship
with this treatment.
Side Effect
Any unintended effect of a pharmaceutical product
occurring at doses normally used in man which is
related to the pharmacological properties of the drug.
Serious ADRs
A serious adverse event (experience) or reaction
is any untoward medical occurrence that at any
dose: Results in death, is life-threatening, requires
inpatient hospitalization of prolongation of existing
hospitalization, is a congenital anomaly/birth
defect.

Unexpected Adverse Reaction

*Professor
Dept. of Pharmacology, Sree Balaji Medical College and Hospital, Chennai An adverse reaction, the nature, severity or outcome of
**Associate Professor which is not consistent with the summary of product
†
Lecturer
‡
UG Student characteristics.
Dept. of Pharmacology, Sree Balaji Dental College and Hospital, Chennai
Address for correspondence
Dr NS Muthiah
Adverse Reactions
E-mail: nsm.healingtouch@gmail.com Intrinsic factors of the drug

374 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
 Review Article

Pharmacological, idiosyncratic, carcinogenicity,  Change in frequency of a given reaction

mutagenicity, teratogenicity
Extrinsic Factors
Adulterants, contamination, underlying
conditions, interactions, wrong usage
Need for Pharmacovigilance  supplements such as glucosamine so that can be
Reason 1: Humanitarian concern - Insufficient evidence
of safety from clinical trials Animal experiments Phase
1-3 studies prior to marketing authorization.
Reason 2: Medicines are supposed to save lives Dying
from a disease is sometimes unavoidable; dying from a
medicine is unacceptable.
 ADRs to generics not seen with innovator products,
ADRs to traditional medicines.
 All suspected drug-drug, drug-food, drug-food
medical supplement interactions.
 Statement highlighting marine source of
avoided by those with allergy to sea food.
 ADRs associated with drug withdrawals, ADRs
due to medication errors.
 ADRs due to lack of efficacy or suspected
pharmaceutical defects.
Innovator Products 

Reason 3: ADR-related cost to the country exceeds the
cost of the medications themselves.
Reason 4: Promoting rational use of medicines and
adherence.
Reason 5: Ensuring public confidence.
Reason 6: Ethics, to know of something that is harmful
to another person who does not know, and not telling,
is unethical.
What should be Reported  whether the problem arose due to ADR or quality
 New drugs. Report all suspected reactions including
minor ones. For established or well known drugs.
If serious, unexpected, unusual ADRs
Limited information available at time when drug
is first marketed. Conduct intensive monitoring to
identify new, unlabeled adverse reactions, monitor for
‘rare’ reactions. Provide updates to prescribers on new
findings, labeling changes, safety issues.
Generic Products
Monitor efficacy, monitor adverse effect profile to study
differences in ADR pattern with respect to innovator
products. Help in improving quality of generics used
defects.
WHO Programmed for International Drug
Monitoring 

Active Ingredients Withdrawn Started 1968 Located in Uppsala, Sweden Collaborating

Thalidomide (1961) Congenital limb defects center for maintaining global ADR database -
Benoxaprofen (1982) Hepatotoxicity
Roles of WHO Collaborating Centre 
Phenformin (1982) Lactic acidosis
Fenfluramine (1997) Heart-valve abnormalities Identify early warning signals of serious adverse reactions
Astemizole Many drug interactions to medicines. Evaluate the hazard. Undertake research
Phenylpropanolamine (2000) Hemorragic stroke
into the mechanisms of action to aid the development
of safer and more effective medicines.
Kava Kava Liver abnormalities
Cerivastatin Rhabdomyolysis Pharmacovigilance in India 
Cisapride Cardiac arrhythmias
Pharmacovigilance is fastest emerging as an important
Rofecoxib (2004) Cardiovascular events
approach for the early detection of unwanted effects of
Valdecoxib (2005) Cardiovascular events,
serious skin reactions the drugs and to take appropriate regulatory actions if
Nephrotoxicity
necessary. National Pharmacovigilance Centre CDSCO
Comfrey, Senecio
Cardiovascular events
has initiated a country-wide pharmacovigilance
Tegaserod (2007)
program under the aegis of DGHS, Ministry of Health
Clobutinol (2007) Cardiac arrhythmia
and Family Welfare Government of India.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 375
 Review Article
National Pharmacovigilance Programme  identifying and correlating drugs and side effects and
The Program aims to faster the culture of ADR
notification in its first year of operation and
subsequently aims to generate broad-based ADR data
on the Indian population. Sponsored and coordinated
by the country’s central drug regulatory agency -
(CDSCO). Peripheral Pharmacovigilance Centre
(PPCs). Regional Pharmacovigilance Centers (RPCs).
Zonal Pharmacovigilance Centre (ZPCs).
“So…. What is our role?
Send not only quantity but …. Quality reports
How?”
Monitor clinical status of patients, identify the correct
ADRs not side effects, get more information, investigate
at hospital level, help doctors to fill-up the forms, keep
patient’s record if more information needed.
Conclusion
Pharmacovigilance looks at all available information to
assess the safety profile of a drug. Pharmacovigilance
should also take the benefit of the drug in account.
Pharmacovigilance required for systematically
376 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
taking corrective actions, especially for the product
launching first time in India.
References
1. Jeetu G, Anusha G. Pharmacovigilance: a worldwide
master key for drug safety monitoring. J Young Pharm
2010;2(3):315-20.
2. Prakash B, Singh G. Pharmacovigilance: scope for a
dermatologist. Indian J Dermatol 2011;56(5):490-3.
3. Chavant F, Favrelière S, Lafay-Chebassier C, Plazanet C,
Pérault-Pochat MC. Memory disorders associated with
consumption of drugs: updating through a case/noncase
study in the French PharmacoVigilance Database. Br J
Clin Pharmacol 2011;72(6):898-904.
4. Rahman SZ, Khan RA, Gupta V, Uddin M.
Pharmacoenvironmentology - a component of
pharmacovigilance. Environ Health 2007;6:20.
5. WHO (2002). Source: The Importance of
Pharmacovigilance.
6. Montastruc JL, Chaumerliac C, Desboeuf K, Manika
M, Bagheri H, Rascol O, et al. Adverse drug reactions
to selegiline: a review of the French pharmacovigilance
database. Clin Neuropharmacol 2000;23(5):271-5.
 Review artcle

Sialolith: A Case Report with Review of Literature

PE Chandra Mouli*, S Manoj Kumar**, S Kailasam†, S Shanmugam†, S Satish‡

Abstract
Sialoliths are calcified organic matter that forms within the secretory system of the major salivary glands. Salivary gland calculi
account for the most common disease of the salivary glands, and may range from tiny particles to several centimeters in
length. The majority of sialoliths occur in the submandibular gland or its duct and is a common cause of acute and chronic
infections. While the majority of salivary stones are asymptomatic or cause minimal discomfort, larger stones may interfere
with the flow of saliva and cause pain and swelling. The prevalence of sialoliths varies by location. Sialolith in the parotid
glands is less common when compared with that of submandibular gland. This case report describes a patient presenting with
submandibular gland sialolith and review of the literature regarding the salivary sialothiasis.

Key words: Submandibular gland; sialolith; nidus.

T
he deposition of calcium salts, primarily calcium
phosphate, usually occurs in the skeleton.
When, it occurs in an unorganized fashion in
soft tissue, it is referred to as heterotopic calcification.
Heterotopic calcification which results from deposition
of calcium in normal tissue despite normal serum
calcium and phosphate levels is known as idiopathic
calcification. Sialoliths belongs to the category of
idiopathic calcification.1 Sialoliths are calcareous
deposits in the ducts of major or minor salivary glands
or within the glands themselves. Sialolithiasis accounts
for more than 50% of diseases of the major salivary
glands and is thus the most common cause of acute
and chronic infections.2
Case Report
Mr. Nagarajan aged 44 years came to Ragas Dental
College with a chief complaint of pain on the left side
below the tongue region for the past three weeks. Pain
*Senior Lecturer
**Professor
†
Professor and Head
‡
Professor
Dept. of Oral Medicine and Radiology, Ragas Dental College and Hospital
Uthandi, Chennai
#
Senior Lecturer, Dept. of Oral Medicine and Radiology
Chettinadu College of Dental Sciences, Chennai
Address for correspondence
Dr PE Chandra Mouli
Senior Lecturer, Dept. of Oral Medicine and Radiology, Ragas Dental College
and Hospital, 2/102, East Coast Road, Uthandi, Chennai - 600 119
E-mail: mouli_7777@yahoo.co.in
is severe and intermittent. Pain is seen during mealtime
and reduces after half an hour by itself (Fig. 1).
On clinical examination, at the left floor of the mouth,
at submandibular gland, at the level of first molar, there
is a presence of a mass, measuring l × l cm in size and
round in shape with well defined borders. The mass is
hard in consistency and tender on palpation.
Orthopantomogram revealed (OPG), presence of radio-
opaque mass seen in the left body of the mandible at
submandibular fossa, measuring around 1 × 2 cm in
size, oval in shape extending superiorly from 1 cm
below the 35, 36 tooth and inferiorly to the lower
border of the mandible (Fig. 2).
Mandibular occlusal radiograph revealed presence of
radio-opaque mass seen in the left body of the mandible
at submandibular fossa, measuring around 1 × 2 cm
in size, oval in shape extending from anterior aspect of
35 to the distal aspect of 36 (Fig. 2).
Ultrasound showed an irregular border measuring
about 44 × 46 × 57 cm (Fig. 3).
Complete excision of the left submandibular sialolith
was done under local anesthesia, sutures placed. Post
surgical antibiotic regimen was given and healing was
satisfactory (Figs. 4 and 5).
Microscopically, the mass shows concentric laminations
around a central nidus of amorphous debris. Based
on history, clinical examination, radiographic and

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 377
 Review Article
Figure 1. Swelling present in left floor of the mouth
Figure 3. Ultrasound showed an irregular border measuring
about 44 x 46 x 57 cm.
microscopic features, the condition was finally diagnosed
as sialolithiasis - left submandibular salivary gland.
Discussion
Sialolithiasis is the most common disease of salivary
glands. It is estimated that it affects 12 in 1000 of the
adult population.3 Males are affected twice as much as
females.4 It involves most commonly the major salivary
glands. More than 80% of the sialoliths occur in the
submandibular gland or its duct, 6% in the parotid
gland and 2% in the sublingual gland or minor salivary
glands.2
The exact etiology and pathogenesis of salivary calculi
is unknown. They are thought to occur as a result of
deposition of calcium salts around an initial organic
nidus consisting of altered salivary mucins, bacteria
and desquamated epithelial cells.4,5
According to the literature, formation of sialolith
can occur in two phases: A central core and a
layered periphery.6 The central core is formed by the
378 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Figure 2. OPG and Mandibular occlusal view showing a
radio-opaque mass below 35, 36 region.
(a) (b)
Figure 4. (a) Surgically removed sialolith and (b) sialolith
seen on an IOPA radiographic film.
Figure 5. OPG and mandibular occlusal view after removal
of radio-opaque mass (sialolith) below 35, 36 region.
precipitation of salts, which are bound by certain
organic substances. The second phase consists of the
layered deposition of organic and inorganic material.7
Parotid stones are thought to form most often around a
nidus of inflammatory cells or a foreign body8 whereas
submandibular stones are thought to form around a
nidus of mucous. Another theory has proposed that
an unknown metabolic phenomenon can increase the
salivary bicarbonate content, which alters calcium
phosphate solubility leads to precipitation of calcium
and phosphate ions.9 A retrograde theory proposed
for sialolithiasis suggested that, substances or bacteria
within the oral cavity might migrate into the salivary
ducts and become the nidus for further calcification.6
Salivary stagnation, increased alkalinity of saliva,
infection or inflammation of the salivary duct or
gland, and physical trauma to salivary duct or gland
may predispose to calculus formation.3
Clinically, sialoliths are round or ovoid in shape,
rough or smooth in texture and yellowish in color.
Submandibular stones consist of 82% inorganic

material and 18% organic material, whereas parotid
stones are composed of 49% inorganic and 51% organic
material.2 The inorganic material comprises of calcium
phosphate, smaller amounts of carbonates in the form
of hydroxyapatite and smaller amounts of magnesium,
potassium, ammonia, whereas organic material consists
of various carbohydrates and amino acids.9
Sialoliths are usually unilateral. Sialolithiasis typically
causes pain and swelling of the involved salivary
gland by obstructing the salivary flow. Calculi may
cause stasis of saliva, leading to bacterial ascent into
the parenchyma of the gland resulting in sialadenitis.
Some sialoliths may be asymptomatic. Long-term
obstruction, in the absence of infection can lead to
atrophy of the gland with resultant lack of secretory
function and ultimately fibrosis.9
Careful history and examination are important in the
diagnosis of sialolithiasis. Pain and swelling of the
concerned gland at mealtimes and in response to other
salivary stimuli are important. Complete obstruction
causes constant pain, swelling and signs of systemic
infection may be present.10
Bimanual palpation of the floor of the mouth, in a
posterior to anterior direction, may reveal a palpable
stone in majority of the cases of submandibular calculi.
For parotid stones, careful intraoral palpation around
Stenson’s duct orifice may reveal a stone.9 Deeper parotid
stones are often not palpable. When minor salivary glands
are involved they are usually in the buccal mucosa or upper
lip, forming a firm nodule that may mimic tumor.
Imaging modalities, both conventional and advanced
are very useful in diagnosing sialolithiasis. Forty
percent of parotid and 20% of submandibular stones
are usually radiolucent. In such patients sialography
will be helpful. However, it is contraindicated in acute
infections or in patients having allergy to the contrast
agents.9
Patients presenting with sialolithiasis may benefit
from conservative management, especially if the stone
is small.9 The patient must be well-hydrated and the
clinician must apply moist warm heat and along with
massage of the gland.
Sialogogues are useful to promote production of saliva
and to flush the stone out of the duct. In case of
sialoliths associated with sialadenitis, a penicillinase-
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Review Article
resistant antistaphylococcal antibiotic will be preferable.
Most stones will respond to such a regimen, combined
with simple sialolithotomy when required.8,10
Alternative methods of treatment have emerged such as
the use of extracorporeal shock wave lithotripsy (ESWL)
and more recently the use of endoscopic intracorporeal
shock wave lithotripsy (EISWL), in which shockwaves
are delivered directly to the surface of the stone lodged
within the duct without damaging adjacent tissue
(piezoelectric principle). Salivary lithotripsy will be
more useful therapeutically than surgical removal of
the affected gland, as it prevents the risk of a general
anesthesia, facial nerve damage, surgical scar, Frey’s
syndrome, and causes little discomfort to the patient
with preservation of the gland.11
References
1. White SC, Pharoah MJ. Oral radiology principles and
interpretation. Chapter 27. In: Soft Tissue Calcification
and Ossification. Mosby, Missouri 2004:p597-614.
2. Zenk J, Benzel W, Iro H. New modalities in the
management of human sialolithiasis. Minimal Invas
Ther Allied Technol 1994;3(5):275-84.
3. Leung AK, Choi MC, Wagner GA. Multiple sialoliths
and a sialolith of unusual size in the submandibular
duct: a case report. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 1999;87(3):331-3.
4. Cawson RA, Odell EW. Essentials of oral pathology
and oral medicine. 6th edition, Churchill Livingstone:
Edinburgh 1998:p239-40.
5. Carr SJ. Sialolith of unusual size and configuration.
Report of a case. Oral Surg Oral Med Oral Pathol
1965;20(6):709-12.
6. Marchal F, Kurt AM, Dulguerov P, Lehmann W.
Retrograde theory in sialolithiasis formation. Arch
Otolaryngol Head Neck Surg 2001;127(1):66-8.
7. Rauch S, Gorlin R J. Disease of the salivary glands. In:
Thomas’ Oral Pathology. Gorlin RJ, Goldmann HM
(Eds.), Mosby-Year Book Inc: St Loius, Mo 1970:p997-
1003.
8. Pietz DM, Bach DE. Submandibular sialolithiasis. Gen
Dent 1987;35(6):494-6.
9. Williams MF. Sialolithiasis. Otolaryngol Clin North Am
1999;32(5):819-34.
10. Pollack CV Jr, Severance HW Jr. Sialolithisis: case studies
and review. J Emerg Med 1990;8:561-5.
11. Iro H, Schneider HT, Födra C, Waitz G, Nitsche N,
Heinritz HH, et al. Shockwave lithotripsy of salivary
duct stones. Lancet 1992;339(8805):1333-6.
379
 Review article

Myth of Endodontics in Oral Focal Infection

Jamuna Indramohan*, B Karthika**, Gouse Mohiddin†

Abstract
On clinical evidence there has been a belief in the past amongst the medical and dental practitioners that the presence of
bad teeth in the mouth can be a cause of some systemic diseases of unknown etiology. Examples of systemic conditions in
the above category include rheumatoid arthritis, some diseases of the eye, few cardiac conditions and some diseases of the
gastrointestinal region.1 It was felt that a circumscribed area infected with micro organisms due to dentoalveolar or periapical
abscess which may or may not give rise to clinical manifestation can initiate another infection in a distant organ through
the blood stream or the lymph channels. Based on this ‘focal infection theory’, all pulpless or non-vital teeth were extracted
hoping that the diseasae and symptoms will abate. But it was observed that the systemic disease continued in many cases
after removal of the infected teeth.2 Aim of this article is to emphasize the current concepts which advocate the belief that
with increasing knowledge, the number of conditions considered to be due to focal infection is decreasing and also disclose
the myth in relation between endodontic treatment and oral focal infection.

Key words: Endodontics, focal infection, focus of infection, sepsis

T
he concept that oral conditions can
significantly influence events elsewhere in
the body is not new, but it has undergone a
number of iterations over the years. Oral foci have
traditionally been ascribed to periodontitis, alveolar
abscesses, cellulitis, pulpless teeth, apical periodontitis,
general oral sepsis and endodontically-treated teeth
with viridians group streptococci being the principal
metastatic microbial culprits.
A frequently cited early publication is an 1891 report
by Miller entitled “The Human Mouth as a Focus of
Infection.” Miller was highly attuned to the role of
bacteria in disease causation, as he was working in
the laboratory of Robert Koch, whose postulates were
used to establish the microbial etiologies of infectious
diseases.3
*Professor, Dept. of Conservative Dentistry and Endodontics
Thai Moogambigai Dental College and Hospital, Chennai
**Senior Lecturer, Dept. of Oral Medicine and Radiology
Priyadarshini Dental College and Hospital, Thiruvallur
†
Reader, Dept. of Oral Pathology, Kalinga Dental college, Bhuvaneswar
Address for correspondence
Dr Jamuna Indramohan
Professor
Thai Moogambigai Dental College and Hospital
Golden George Nagar, Mogappair, Chennai
History
The journey began in 1674 when Antony von
Leeuwenhoek discovered microbes. He was an early user
of the microscope and analyzed small scrapings from
teeth. He described small ‘animalcules,’ which later were
named microbes and we call bacteria. Two hundred years
later in 1876, Robert Koch proposed the ‘germ theory of
disease,’ suggesting that bacteria may cause disease. At the
same time, Edward Jenner, Joseph Lister and Louis Pasteur
also implicated germs as a possible source of disease.
In 1879, Willoughby D. Miller, a recent graduate of
the University of Pennsylvania Dental School, heard
of Koch’s theory that germs might cause disease and
determined that he too wanted to study bacteria.
On completing his dental training, he traveled to Berlin
where he began work within Koch’s institute, looking at
the relationship of bacteria to disease.4 Miller became
convinced that the mouth was a focus of infection and
that bacteria in the mouth could explain most of
humankind’s illnesses and gave a speech on ‘Oral
Infection as a Cause of Systemic Disease.’ By 1911, the
term oral sepsis was replaced with the term focal infection
and the ‘era of focal infection’ was launched.5
Focal Infection Theory
A focus of infection is a confined area that contains
pathogenic microorganisms, can occur anywhere in the

380 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

body and usually causes no clinical manifestations. A
focal infection is a localized or generalized infection
caused by the dissemination of microorganisms or toxic
products from a focus of infection.6 These concepts
have led to the Focal Theory of Infection (or Theory
of Focal Infection) that postulates a myriad of diseases
caused by microorganisms (bacteria, fungi, viruses)
that arise endogenously from a focus of infection.
Miller proposed a role for oral microorganisms or their
products in the development of a variety of diseases
in sites removed from the oral cavity, including brain
abscesses, pulmonary diseases and gastric problems,
as well as a number of systemic infectious diseases.7
The role of oral sepsis as a cause of systemic disease
was championed by William Hunter, a prominent
British physician, in a publication and a 1910 talk
at McGill University, Montreal. He spoke, with
considerable hyperbole, of dental restorations “built in,
on, and around diseased teeth which form a veritable
mausoleum of gold over a mass of sepsis to which there
is no parallel in the whole realm of medicine.” In 1919,
Rosenow published a series of animal experiments
and human case reports supporting the concept of
focal infection. He emphasized the importance of
cooperation between dentists and physicians, as well
as the necessity of ensuring that the focus of infection
is eliminated completely, and he noted that tooth
extraction by itself might not be sufficient. Much of the
evidence presented in support of the concept of focal
infection proved, on closer inspection, to be anecdotal
or of questionable scientific merit. Nevertheless, it
became common practice in olden days to extract
all endodontically or periodontally involved teeth
to eliminate any possible foci of infection, with the
expectation that this would prevent or cure a whole
host of local or systemic problems.8
Endodontics and Focal Infection
Numerous studies have attempted to determine the
significance of various microbial pathogens in pulpal
and periapical infections. Efforts have been hampered
by small sample sizes, lack of randomization or use
of consecutive cases, varied case definitions and lack
of documentation regarding the presence/absence of
dental caries and periodontal disease, different expertise
in culturing techniques, varied health status of patients
and potential microbial contamination during sampling
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Review Article
procedures.9 In spite of these difficulties, sufficient data
exist to establish that all orofacial infections of whatever
origin share common major microbial pathogens:
Viridans group streptococci, Porphyromonas gingivalis,
Prevotella intermedia, Veillonella, Fusobacterium
nucleatum, Peptostreptococcus micros, Bacteroides
forsythus, Eubacteria, Lactobacilli and Actinomyces.
Oral pathogens with possibly greater relevance to
pulpal pathology include Dialister pneumosintes and
Eubacterium and Prevotella endodontalis. The relative
importance of these pathogens in pulpal, periapical
and periodontal infections or pericoronitis, peri-
implantitis and infectious spread to contiguous areas
(orbital, submandibular, mediastinal) are primarily
quantitative rather than qualitative. Any orofacial
infection spreading rapidly is likely to have a substantial
viridans group streptococci component. The precise
risk of bacteremia associated with endodontic lesions
and therapy is subject to some controversy. Apparently
no study exists that delineates the incidence/magnitude
of spontaneous bacteremias from neither infected root
canals with chronic periradicular lesions nor any with
acute periodontal abscesses.10 Such bacteremias may
occur during the management of infected root canals
and a good understanding of their incidence/magnitude
would be of importance.
Bender et al determined a 0-15% incidence of
bacteremia with none if the instrumentation remained
within the canal and 15% if it extended beyond the
apex. Baumgartner et al found a 3.3% incidence with
nonsurgical endodontics and a 83-100% incidence
with surgical endodontics. In a study that intentionally
instrumented beyond the apex, a 34-54% incidence of
bacteremia was detected. Al-Karaawi et al determined
that the ‘cumulative’ bacteremias with a rubber dam
clamp in children was 175 times greater than a tooth
extraction, while a matrix band was only four times
greater which conflicted with another study by the
same group that the incidence of bacteremia using a
rubber dam/wedge/matrix band model was 9-32%.11
One of the difficulties with comparing any given dental
procedure using cumulative data to dental extractions
is that no determination has ever been made of how
long dental extraction sites produce bacteremias
during their healing phase. Whether instrumentation
has occurred beyond the apex may not be readily
determined and antibiotic prophylaxis for endocarditis
prevention would be appropriate if the best clinical
381
 Review Article
judgment of the dentist is that such a determination
cannot be made. The question of bacteremias arising
from rubber dam application should be clarified
as the degree of trauma associated with its use is a
likely variable. It is reasonable to conclude from
the above data that nonsurgical endodontics is may
be the least likely of dental treatment procedures to
produce significant bacteremias in either incidence or
magnitude.
It is claimed that endodontically treated teeth are always
‘infected’ as it may be impossible to fill all lateral and
accessory canals or eliminate the ‘slime’ layers on root
canal surfaces. Whether this criticism is accurate or
not may be irrelevant as it does not recognize basic
microbiological principles of the inoculum effect
(the threshold level of bacteria necessary to produce
an infection), that the presence of bacteria does not
per se define an active infectious process and that most
microorganisms associated with the human body are
either innocuous or beneficial.12
Scientific Approach
By about 1930, the validity of the focal infection theory
began to be questioned, and investigators found, when
they considered the available real outcome data, that
there was no clear basis for ascribing the occurrence of
much systemic disease to the presence of oral foci
of infection.10 As a result, the focus of dental practice
changed such that restorative dental procedures re-
emerged as the mainstay of most dental treatment
plans due to the availability of successful methods of
treating endodontic lesions. The oral microorganisms
could in some way be responsible for diseases that
had a rather uncertain etiology.12 In considering the
existing data, it is important to differentiate between
those data supporting an association between two
diseases or conditions and those indicating a causal
relationship, so that the information can be interpreted
accurately.
382 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Conclusion
Studies must be performed to determine if endodontic
treatment in causing focal infection is inferior or not.
To date, these studies have not been performed and
there is no evidence to support the theory that modern
endodontic therapy is not safe and effective.
References
1. O’Reilly PG, Claffey NM. A history of oral sepsis as a
cause of disease. Periodontol 2000 2000;23:13-8.
2. Miller WD. The human mouth as a focus of infection.
Dental Cosmos 1891;33(9):689-706.
3. Hunter W. Oral sepsis as a cause of disease. Br Med J
1900;1:215-6.
4. Hunter W. The role of sepsis and antisepsis in medicine.
Lancet 1910;1:79-86.
5. Mayo CH. Focal infection of dental origin. Dental
Cosmos 1922;64:1206-8.
6. Cecil RL, Angevine DM. Clinical and experimental
observations on focal infection with an analysis of
200 cases of rheumatoid arthritis. Ann Intern Med
1938;12:577-84.
7. Editorial. Focal infection. J Am Med Assoc 1952;
4:150:490-1.
8. Mattila KJ, Nieminen MS, Valtonen VV, Rasi VP,
Kesäniemi YA, Syrjälä SL, et al. Association between
dental health and acute myocardial infarction. BMJ
1989;298(6676):779-81.
9. DeStefano F, Anda RF, Kahn HS, Williamson DF, Russell
CM. Dental disease and risk of coronary heart disease
and mortality. BMJ 1993;306(6879):688-91.
10. Pallasch TJ, Wahl MJ. Focal infection: new age or ancient
history? Endod Top 2003;4(1):32-45.
11. Barnett ML. The oral-systemic disease connection:
an update for the practicing dentist. J Am Dent Assoc
2006;137 Suppl 2:5S-6S.
12. Cugadasan V. Oral sepsis and focal infection. Singapore
Med J 1980;21(6):763-5.
 Review article

The Scope and Limitations of Adult Orthodontics

Nazeer Ahmed Meeran*, Madhuri**, MF Jaseema Parveen†

Abstract
The increased demand for orthodontic treatment by adults has increased the scope of orthodontics and widened the upper
age limit for orthodontic intervention. The main reason for this demand is the increasing patient awareness and the desire to
improve the facial esthetics. The necessity for tooth repositioning in ideal axial inclination to facilitate prosthetic replacement
is also another reason for seeking treatment. The marked limitation is the lack of growth in adults, which reduces the scope
for functional orthopedic intervention. Skeletal discrepancies have to be corrected by orthognathic surgery. The orthodontic
treatment is limited to tooth movement and related to remodeling of the alveolar process only. The limitations of orthodontic
treatment must be explained at the beginning of treatment, since adult expectations of orthodontics can be very high. It is
highly necessary to identify the expectations of this group of patients, in order to arrive at a realistic treatment plan. The
purpose of this article is to review the scope, effectiveness and limitations of orthodontic treatment in adult patients.

Key words: Adult orthodontics, root resorption, temporomandibular disorders

A
ccording to Ackerman,1 adult orthodontics is
defined as ‘The branch of orthodontics concerned
with striking a balance between achieving optimal
proximal and occlusal contact of the teeth, acceptable
dentofacial esthetics, normal function and reasonable
stability”.
The number of adults seeking orthodontic treatment
has increased considerably in the last 20 years. They fall
into two different groups:1 younger adults (under 35,
often in their 20’) who desired, but could not receive
orthodontic treatment during adolescent period.2
An older group, typically in their 40’s or 50’s who have
other dental problems and need orthodontics as part
of larger treatment plan. The major finding in adult
patient is that they are more concerned about improving
their appearance and social acceptance than function.
It has been proved that orthodontic treatment, besides
improving dental esthetics, also has a significant impact
on the psychosocial aspect of the patients’ life.2 It has also
been estimated that about 80% of orthodontic patients
seek treatment out of esthetic concerns rather than for
health and function.3 In general, many adults have not
*Assistant Professor
**Professor and Head, Dept. of Orthodontics and Dentofacial Orthopedics
Priyadarshini Dental College and Hospital Pandur, Tamilnadu
†
Dental Surgeon, India (Private Practice)
Address for correspondence
Dr Nazeer Ahmed Meeran
E-mail: nazeerortho@yahoo.co.in
been treated orthodontically at a younger age mainly
due to lack of awareness, funds or access to orthodontic
treatment providers. Adult patients in the age group
above 50 usually present complex oral problems which
need multidisciplinary treatment planning.4
Reasons for increased number of adults
patients are
 Availability of esthetic treatment options like
lingual orthodontics and clear aligners.
 Innovations in material research such as ceramic
brackets and tooth colored wires.
 More sophisticated and successful management of to
the symptoms associated with temporomandibular
joint (TMJ) dysfunction.
 More effective management of skeletal malocclusion
using advanced orthognathic surgical techniques.
 Increased desire of patients and restorative dentists
for treatment of dental mutilation problems using
tooth movement and fixed prostheses rather than
removable restorations.
 Reduced vulnerability to periodontal breakdown
as a result of improved tooth relationship and
occlusal function.
 Role of family dentist.
 Role of media and visual aids.
 Improved socioeconomic status.
 Greater awareness of health and esthetic concerns.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 383
 Review Article
Importance of Diagnosis in Adult Patients
Careful diagnosis and treatment planning on a
multidisciplinary approach is required to treat most adult
patients. The adult, unlike the child, is usually a patient
with high expectations from orthodontic treatment. He
presents with minimal or no growth potential and meager
accommodation to mechanics. In addition, the adult
may exhibit a potential for such pathological changes as
knife-edge ridges increased thickness of cortical plates,
buried roots, impactions, gingival recession, periodontal
breakdown, missing teeth, mesial tilting and extrusion
of molars due to nonreplacement of extracted posterior
teeth, TMJ problems, osteoporosis, osteomalacia and
diabetes mellitus. These conditions, which obtain as
a result of hormonal, vitamin or systemic disorders
common to the adult, necessitate more careful and
extensive diagnosis evaluations.
Orthodontic diagnosis involves development of a
comprehensive database of pertinent information.
The standard diagnostic aids such as case history,
clinical examination and study casts, radiographs and
photographs are mandatory.
Intraoral Periapical (IOPA), occlusal and TMJ films
should be obtained routinely in addition to the
panoramic radiograph and the cephalogram. The
“problem oriented diagnostic approach” as described
by Proffit and Ackerman,1 is strongly recommended to
ensure that no aspect of the patient need is neglected.
Additional diagnostic procedures that we should
consider in an adult patient are:
 A full series intraoral periapical radiographs and
TMJ X-rays.
 Muscle examination
 Splint therapy
General factors
• Family history of premature tooth loss due to periodontal
problems
• Evidence of chronic disease e.g, diabetes mellitus, bone
disorders
• Nutritional status
• Current stress factors
• Life stage of women
• Attitude of patient towards oral hygiene
384 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
 Diet evaluation
 Requirement of multidisciplinary approach towards
treatment.
Diagnostic steps involved in treating adult patients:
 Collection of accurate history and thorough patient
examination
 Analyze the database
 Develop a problem list and priority
 Prepare tentative treatment plan according to the
priorities
 Interact with other specialists involved. Acquire
patient acceptance for the proposed treatment
plan.
Periodontal Diagnosis
Periodontal status is important and must be evaluated
before contemplating orthodontic treatment in adult
patients. If the periodontal disease is not treated and
plaque control methods initiated before initiating
orthodontic treatment, then the orthodontic tooth
movement causes further periodontal destruction.
This is particularly true if the teeth are moved in the
direction of inflamed periodontal pockets that extend
beyond the alveolar crest.5 It is highly necessary to
assess the patients’ potential for bone loss and gingival
recession during orthodontic tooth movement. The
patient should be screened for the risk factors of
periodontal disease.
Pre-treatment consultation with the periodontist
should be routine and orthodontic objectives be
altered according to his advice. Movement of teeth in
the presence of periodontal inflammation will result in
an increased loss of attachment and irreversible crestal
bone loss.
Local factors
• Tooth alignment (e.g, marginal ridge, CEJ relationship,
crowding, plunger cusps, etc.)
• Plaque indices
• Occlusal loading
• Crown/Root ratio
• Bruxism
• Restorative status

Temporomandibular Disorders Diagnosis
Signs of symptoms of temporomandibular disorder
(TMD) often increase in frequency and severity
during adult treatment. So, it is imperative for the
orthodontist to be familiar with their diagnostic
and treatment parameters. Thorough evaluation of
the TMJ including signs and symptoms of disc and
joint problems is necessary before contemplating
any orthodontic intervention for adult patients.
Pre-existing TMD might get aggravated during
treatment, if not detected early.
Treatment Considerations and Limitations
 Reduced scope for growth modification:
The main treatment consideration in adults is
the limited scope for growth modification and
functional appliances. Skeletal malocclusions have
to be treated by camouflage and orthognathic
surgery.
 Social considerations: Adult patients exhibit
more desire for esthetic appliances and are more
concerned about social acceptance, with the
appliance in their mouth. Tayer and Burek6 found
that nearly 74% adult patients indicated that
they had initial fears concerning peer reaction to
their treatment. The patients who demand clear
aligners, esthetic brackets and lingual appliances
are usually adult patients who have hesitation in
accepting visibility of fixed appliances mainly for
social reasons. However, it has been found that the
expectations of adult patients are usually high and
the limitations of orthodontic treatment must be
explained at the beginning of treatment, in order
to arrive at realistic treatment objectives.7
 Limited adaptability to the appliance: Adult
Figure 1. Adult patient with missing lower first molar and
mesially tilted second molar.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Review Article
patients usually take a longer time to adapt to
the appliances. While anxiety about wearing
an orthodontic appliance may affect a person’s
psychological adjustment to treatment, the pain
experience is also a contributing factor.3 Ulceration
and soreness might be present in the first three
weeks of treatment, taking a comparatively longer
time to subside compared to younger patients.
The effects are usually temporary and subside after
four weeks of treatment. Studies have shown that
most patients’ reported only mild discomfort of
1-2 days duration and did not have any difficulty
in adapting to the appliance.8 However, some
patients might find it very difficult to tolerate
the appliance and might require early appliance
removal or even discontinuing the treatment.
 Requirement of interdisciplinary treatment
planning and execution: Adult patients usually
require adjunctive and comprehensive treatment
involving multidisciplinary treatment approach.
Correcting the malocclusion helps in improving
the quality of periodontal and restorative treatment
outcomes besides providing esthetic benefits. Molar
uprighting or molar intrusion might be needed in
some patients to facilitate prosthetic replacement
within the same arch or the opposing arch, which
might not be otherwise possible. The advent of
microimplants9,10 in orthodontics has improved
the scope, effectiveness and treatment success of
these procedures in adults. Space regaining in
the posterior region and achieving parallelism of
abutment teeth might be necessary for prosthetic
replacement of missing teeth. Interdisciplinary
treatment approach involving the entire concerned
specialty is needed in these situations.
 Age changes in bone: Cortical bone becomes denser
Figure 2. Molar intrusion with microimplants.
385
 Review Article
and the spongy bone reduces with age. Marginal
bone loss is more common in adults, which leads
to apical shifting of the center of resistance of
the involved tooth resulting in increased tipping
moment produced by the applied force.11 This
requires proper biomechanics utilizing adequate
counter moment to achieve bodily movement of
periodontally involved teeth.
 Periodontal considerations: A viable periodontal
ligament is important for cell proliferation on
application of mechanical force. There is a reduction
in the periodontal ligament vascularity with aging
and insufficient source of preosteoblasts, which
may explain the delayed response to orthodontic
forces described in adults.12 It is mandatory to
employ lighter force levels in adults as heavier
forces result in vascular compression and necrosis
of the blood vessels of the periodontal ligament.
There is high-risk of iatrogenic damage to the
periodontium with uncontrolled forces and it is
important to keep the periodontal status under
control during treatment.13
 Vulnerability for root resorption: Adults are
more vulnerable to root resorption on application
of orthodontic force.14 This is most commonly
seen during intrusion of anterior and posterior
teeth. Light continuous force must be employed
to minimize the risk of root resorption and the
patients must be informed of the potential risk
before starting the treatment. It is mandatory
to take periodical IOPA radiographs to evaluate
for signs of root resorption. In case resorption
is detected, active forces must be withdrawn for
7-8 weeks and further treatment can be continued
after cessation of root resorption.
 TMJ-related problems: Adults are more likely to
present with TMD and should be carefully evaluated
before contemplating any orthodontic treatment.15
 Biomechanical considerations: It is important
to remember that crestal bone loss is common
in adults and biomechanics must be modified
according to the situation. The center of resistance
of teeth shift apically due to the loss of attachment,
which in turn leads to increased tipping moment
produced by a given force.16 This necessitates the
requirement of greater counter moment to achieve
bodily translation of periodontally compromised
teeth. Molar extrusion should be avoided as a
method of deep bite correction in adults. Overbite
386 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
correction should rather be achieved by intrusion
of incisors, as extrusion of posterior teeth would
encroach in the freeway space, stressing the
TMJ. This is usually achieved by segmented arch
mechanics. Due to the lack of vertical growth in
adults, any deep bite correction achieved with
molar extrusion is relatively unstable, and prone
for relapse.
 Relapse: It is important to achieve a satisfactory
periodontal and functional condition before
finishing the treatment. Teeth might have to be
splinted and permanent retention is usually needed
to prevent spontaneous migration of teeth. This is
mainly due to the fact that, marginal bone loss
might have displaced the center of resistance of
the teeth further apically, resulting in absence of
equilibrium between the forces and the resistance.17
Adults exhibit higher relapse tendencies compared
to adolescents, requiring permanent retention in
most cases.18
Conclusion
The number of adult patients seeking orthodontic
treatment has increased in the recent years. These
patients are usually concerned about esthetics, but
may have other complications which could pose a
treatment challenge to the concerned orthodontist.
The limitations of adult orthodontics must be borne in
mind and explained to the patient before arriving at the
treatment decision. The patient must be evaluated for
systemic diseases, periorestorative problems, disorders
of the TMJ and vulnerability to root resorption apart
from routine diagnostic procedures. The biomechanics
must be customized for the individual treatment
requirement and multidisciplinary approach should
be employed when required in order to maximize the
treatment benefit.
Figure 3. Crestal bone loss seen in adult patients.

References
1. Proffit WR, Fields HW, Sarver DM. Contemporary
Orthodontics. 4th eition, Mosby: St Louis; 2007.
2. Gazit-Rappaport T, Haisraeli-Shalish M, Gazit E.
Psychosocial reward of orthodontic treatment in adult
patients. Eur J Orthod 2010;32(4):441-6.
3. Brown DF, Moerenhout RG. The pain experience and
psychological adjustment to orthodontic treatment of
preadolescents, adolescents, and adults. Am J Orthod
Dentofacial Orthop 1991;100(4):349-56.
4. Ackerman JL. The challenge of adult orthodontics. J
Clin Orthod 1978;12(1):43-7.
5. Wennström JL, Stokland BL, Nyman S, Thilander B.
Periodontal tissue response to orthodontic movement of
teeth with infrabony pockets. Am J Orthod Dentofacial
Orthop 1993;103(4):313-9.
6. Tayer BH, Burek MJ. A survey of adults’ attitudes toward
orthodontic therapy. Am J Orthod 1981;79(3):305-15.
7. Nattrass C, Sandy JR. Adult orthodontics - a review. Br J
Orthod 1995;22(4):331-7.
8. Buttke TM, Proffit WR. Referring adult patients for
orthodontic treatment. J Am Dent Assoc 1999;130(1):73-
9.
9. Park HS, Kyung HM, Sung JH. A simple method of
molar uprighting with micro-implant anchorage. J Clin
Orthod 2002;36(10):592-6.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Review Article
10. Park HS, Jang BK, Kyung HM. Maxillary molar
intrusion with micro-implant anchorage (MIA). Aust
Orthod J 2005;21(2):129-35.
11. Shei O, Waerhaug J, Lovdal A, Arnulf A. Alveolar bone
loss as related to oral hygiene and age. J Periodontol
1959; 26:7-16.
12. Cohn SA. Disuse atrophy of the periodontium in mice.
Arch Oral Biol 1965;10(6):909-19.
13. Melsen B. Tissue reaction following application of
extrusive and intrusive forces to teeth in adult monkeys.
Am J Orthod 1986;89(6):469-75.
14. Melsen B. Limitations in adult orthodontics. Current
controversies in orthodontics. Quintessence Publishing
Co 1991;147-80.
15. McNamara JA Jr, Seligman DA, Okeson JP. Occlusion,
Orthodontic treatment, and temporomandibular
disorders: a review. J Orofac Pain 1995;9(1):73-90.
16. Geramy A. Alveolar bone resorption and the center
of resistance modification (3-D analysis by means of
the finite element method). Am J Orthod Dentofacial
Orthop 2000;117(4):399-405.
17. Vanarsdall & Graber: Current principles and techniques.
1985; St Louis CV Mosby Co 791-856.
18. Bishara SE. Textnook of Orthodontics. WB Saunders Co
2001: 494-531.
387
 Case report

Esthetic Enhancement of Discolored Teeth by Macroabrasion

Microabrasion and its psychological impact on patients - A case series
Pratima Shenoi*, Archana Kandhari**, Mohit Gunwal**

Abstract
Art of dentistry has long been part of quest to achieve a beautiful smile. In today’s exceedingly competitive world, esthetics
plays a major role in personal grooming and presentation. The ‘first impression’ craze has continually impressed upon the
younger generation, the importance of a bright white smile. In this era of highly sophisticated technological marvels this
technique will help to fulfill our social obligation to the underprivileged with the improvement in the psychological status of
patient after treatment so as they can overcome low confidence in public appearance.

Key words: Esthetics, macro and microabrasion

A
rt of dentistry has long been part of quest to
achieve a beautiful smile. In today’s highly
competitive world, esthetics plays a major
role in personal grooming and presentation. The ‘first
impression’ craze has continually impressed upon the
younger generation, the importance of a bright white
smile. The need of this smile is no longer the privilege
of the rich. Even the commoner and also the rural
population have become increasingly aware of the
power of smile. The media has added fuel to fire and
the quest of a perfect smile goes on.
Discolored teeth are considered as major impairment
in esthetics. An array of treatment alternatives like
ceramics or composite veneering, bleaching, full
coverage crowns macroabrasion and microabrasion
are available. Most of these treatment modalities are
expensive, need exclusive materials and the need of
specialized laboratories.
In India discolored teeth with fluorosis are seen in village
population where drinking water is still consumed from
wells in the house. Though the revolution in media has
made them aware of beauty of white sparkling smile;
*Professor and Head
**PG Student
Dept. of Conservative Dentistry and Endodontics
VSPM’s Dental College and Research Centre, Digdoh Hill, Nagpur
Address for correspondence
Dr. Pratima Shenoi
301, Abhinav Residency, B-1, Laxminagar,
Nagpur-440022, Maharashtra
E- mail: prshenoi@gmail.com
most available treatment is much beyond their financial
limits and remains neglected coupled with the paucity
of experts in the neighborhood.
Macroabrasion along with microabrasion is been
in practice since early 19th century. It’s a combined
chemomechanical approach for esthetic management
of superficial enamel defects. It is least invasive esthetic
procedure which unfortunately has been over shadowed
by other means of restorations like composite, veneers
or crown. In our nation, it could serve as a magic wand
and help the fraternity to serve the poor and needy in
most esthetic, conservative and inexpensive way.
Review of Macro-and Micro-abrasion
Chapman in 1877, who was the first to bleach the
teeth affected with fluorosis using oxalic acid. The first
recorded use of hydrochloric acid to remove fluorosis
stains was done by Kane and Spring in 1916. Kane
applied hydrochloric acid on the affected surfaces and
applied direct flame from an alcohol torch to accelerate
acid penetration. Later, Kane dispensed with the use of
the flame and only applied the hydrochloric acid and
was able to eliminate the fluorosis stains.1
However, McCloskey continued the work taken up by
Kane and used 18% HCl with good results without any
damage to the teeth. Later, McCloskey used 18% HCl
with pumice applying the solution for five seconds and
then cleaning with water jet for 10 seconds. Croll and
Cavanacegh utilized McCloskey’s technique extensively
and achieved very good results with no deleterious
effects on the pulps or the surrounding tissues.1

388 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
 Case Report

Macro-and microabrasion Overview

Enamel macroabrasion is a controlled method for
removing enamel to improve discolorations limited
to the outer enamel layer. The technique of enamel
microabrasion involves application of hydrochloric
acid and pumice in a paste form to the affected
tooth surfaces to remove upto 100 m of surface Figure 1. Cleaning of tooth Figure 2. Macroabrasion.
surface.
enamel by use of a combination of erosion and
abrasion.2

Indications
 Brown stains
 Postorthodontic demineralization
 Localized hypoplasia due to infection or
trauma. Figure 3. Microabrasion.
 Idiopathic hypoplasia where the discolorations is
limited to outer enamel layer.
Technique

Step 1: Cleaning of tooth surface-teeth was cleaned of

debris and plaque to get rid of superficial staining of
tooth (Fig.1).
Step 2: Macroabrasion was done by 12-fluted carbide
or a fine grit finishing diamond bur. The bur was
moved along the anatomy of the tooth maintaining
the natural contour with reduction of 0.5 mm of
tooth (Fig. 2).
Step 3: Isolate the teeth to be treated with rubber
dam and either apply vaseline to the gingiva prior
to rubber dam application or paint Copalite varnish
around the necks of the teeth after dam application.
Mix 12% HCI with pumice into slurry and apply
a small amount to the labial surface with a slowly
rotating rubber cup, a wooden stick or flat plastic
instrument rubbed over the surface for five seconds.
Wash for five seconds directly into the aspirator.
Repeat until the stain is reduced, upto a maximum of
10 × 5 second applications per tooth. Any improvement
possible will have occurred by this time (Fig. 3)
Step 4: Polishing of tooth with graded Soflex discs or
proprietary polishing pastes (Fig. 4)
Step 5: Casein phosphopeptides-amorphous calcium
phosphate (CCP-ACP) application
Precaution - Protective shield or eyewear should beused
both by dentist and patient to avoid splatter.
Figure 4. Polishing of tooth.
Instruction to the patient
 Avoid staining beverages
 Proper brushing
 Topical fluoride applications
Case Report
In the year 2010, 220 patients reported to the Dept.
of Conservative Dentistry and Endodontics VSPM’s
Dental College and Research Center for the treatment
of discolored teeth. Patient selected were of age group
of 15-40 years.
In detailed case history, it was found that they all were
residing in the nearby rural area. They also gave history
of consumption of well water for drinking and cooking
purposes.
On the clinical examination, it was seen that the teeth
showed mild-to-moderate brownish discoloration of
teeth pitting and roughness of the surface. The teeth
showed positive response to vitality testing and IOPA
radiograph showed no pathologic changes. Diagnosis
of fluorosis was concluded and choice of treatment was
micro-and microabrasion.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 389
 Case Report

Figure 5a. Case 1 Pre- Figure 5b. Case 01 Post- Figure 10a. Case 6 Pre- Figure 10b. Case 6 Post-
treatment. treatment. treatment. treatment.

Figure 6a. Case 2 Pre- Figure 6b. Case 2 Post- Figure 11a. Case 7 Pre- Figure 11b. Case 7 Post-
treatment. treatment. treatment. treatment.

Discolored teeth reduce their self-confidence and they

are more hesitant to smile.
The color of tooth is influenced by a combination of
their intrinsic color and the presence of any extrinsic
stains. The cause of tooth discoloration is varied and
complex but usually classified as being either intrinsic
Figure 7a. Case 3 Pre- Figure 7b. Case 3 Post-
or extrinsic in nature. Extrinsic discoloration arises when
treatment. treatment.
external chromogens are deposited on the tooth surface.
On the other hand, intrinsic discoloration occurs when
the chromogens are deposited within the bulk of tooth,
usually in dentin and are often of systemic or pulpal origin.
A third category of stain internalization has recently been
described to include those conditions where extrinsic stains
enter tooth through defects in the tooth structure.3
Figure 8a. Case 4 Pre- Figure 8b. Case 4 Post- Intrinsic discoloration is that discoloration which is
treatment. treatment. incorporated into the structure of either enamel or
dentine and which cannot be removed by prophylaxis
with toothpaste or pumice. Intrinsic tooth discoloration
can be a significant cosmetic, and in some instances,
functional, problem. Loss of vitality secondary
to trauma or infection frequently results in tooth
discoloration which is not responsive to conventional
endodontic therapy. Similarly fluorosis, tetracycline
Figure 9a. Case 5 Pre- Figure 9b. Case 5 Post- staining, localized and chronological hypoplasia, and
treatment. treatment.
both amelogenesis and dentinogenesis imperfecta can
all produce a cosmetically unsatisfactory dentition.
Discussion
Fluorosis is hypoplasia or hyperminilerization of tooth
Esthetics of the teeth is of great importance to patients enamel or dentin proceed by chronic ingestion of
and the color of the teeth one of the prime concern. excessive amounts of fluoride during the period of

390 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

teeth development. Other causes of fluorosis are canned
floridated drinking water, commercially available
beverages, chewing vitamins, fluoride and oral care
products prescribed by dentists.
India lies within a geographical fluoride belt and
considered endemic in 15 states of India which accounts
for most of the fluoride in drinking water. This is one
of the major risk factor in the development of dental
flurosis.4 In recent decades, due to fluoridation of
drinking water and the addition of fluoride into milk
and salt, fluorosis has increased. This kind of pathology
leads to a whitish, opaque, unpleasant appearance of
enamel which is often visible at speaking distance. The
proposed treatments, depending on fluorosis severity,
range from expensive ceramic veneers to free hand
bonding restorations and abrasive chemical treatments.
In 1986, Croll and Cavanaugh advocated a regimen to
remove fluorosis like stains from the teeth that consisted
of upto 15 separate five second applications of a thick
paste made of 18% HCl mixed with a fine pumice
powder, followed by 10-second water rinses. In most
cases, they reported that distinct color improvement
occurred by the sixth or seventh application. If no
change was apparent after 12-15 applications, they
stopped microabrasion to avoid excessive enamel loss.
After the final application of the HCl-pumice paste,
they smoothed the tooth surface with a paste of
pumice and water in a rubber cup and then polished
the surface with sandpaper disks.5
Earlier it was McCloskey, Croll and Cavanaugh
advocated treating patients with the HCl of strength
18% but later on it was concluded that fluorosis stains
can be permanently corrected by using 12% HCI with
pumice.1
Microabrasion cover and reduces stained tooth
structure, improving tooth coloration, but the surface
layer created during treatment is highly polished,
densely compacted, mineralized structure. While the
exact reason for the color change that occurs after
microabrasion is not known, the microabraded surface
reflects and refracts light from the tooth surface in
such a way that mild imperfections in the underlying
enamel are camouflaged. The acid also may penetrate
and bleach the organic compounds within the enamel,
which might explain the improvement in tooth color.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
Mild surface abrasion of the enamel prisms with
simultaneous acid erosion compacts mineralized tissue
within the organic region of the enamel, replacing the
outer prism-free region. Light reflected off and refracted
through this new surface is thought to act differently
than light from an untreated enamel surface. In
addition, subsurface stains may be camouflaged by the
optical properties of the newly microabraded surface.
Croll has named this phenomenon the ‘abrasion
effect.’ Hydration of the tooth by saliva augments the
optical properties of this altered enamel surface, and
the application of topical fluoride further improves
these optical properties.5
This technique can be readily carried out in dental
practice. The treatment is ‘nondestructive’ in nature,
and should the result be unsatisfactory, for example,
with deep stains, treatments that involve removal of
enamel may then be considered. Local anesthetic is not
required, and the procedure is not time-consuming.
Patient satisfaction appears to be high, whereas
recurrence of the staining, postoperative sensitivity or
loss of vitality of treated teeth has not been reported.
The disadvantages of this technique are related to the
use of a strong acid intraorally.6 Use of the rubber dam
is mandatory, and petroleum jelly should be applied to
the cervical portion of the teeth to prevent leakage of
the solution around the margins of the rubber dam.2
Researchers have found that people believe that
beautiful individuals are happier, more outgoing, more
intelligent and more successful than their less attractive
counterparts.7
During the course of treatment of macroabrasion patients
were evaluated on a scale called as brief physiological
rating scale (BPRS) prior and after the treatment This
Psychiatric Rating Scale is an independent evaluator-
rated instrument that has been noted for its flexibility,
simplicity and usefulness8 and it was found 25%
improvement in psychological status two weeks and
40% improvement after four weeks of treatment.
In the current article patient reported were those from
rural area rural consuming water of nearby well in their
locality. All the patients were diagnosed with fluorosis
and treatment of macro-and microabrasion was done.
The amount of intrinsic stain and the initial tooth
color played a significant part in the ultimate treatment
outcome. Macro-and microabrasion ultimately leads to
391
 Case Report
the enhancement of patient compliance and satisfaction
as the results were with immediate effect of reduction
of staining of teeth.
Conclusion
The technique of macro-and microabrasion has faded
away from our list of treatment modalities. It is simple,
inexpensive conservative method and gives good results
without the need for mechanical tooth preparation. It
should be revisited and revived.
In this era of highly sophisticated technological marvels
this technique will help to fulfill our social obligation
to the underprivileged with the improvement in
the psychological status of patient after treatment
so as they can overcome low confidence in public
appearance.
References
1. Rahmatulla AA. Fighting fluorosis stains with
12% hydrochloric acid and pumice. Cairo Dent J
1998;14(2):83-8.
392 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
2. Lynch CD, McConnell RJ. The use of microabrasion to
remove discolored enamel: a clinical report. J Prosthet
Dent 2003;90(5):417-9.
3. Sulieman M. An overview of tooth discoloration:
extrinsic, intrinsic and internalized stains. Dent Update
2005;32(8):463-4, 466-8, 471.
4. Gopalakrishnan P, Vasan RS, Sarma PS, Nair KS,
Thankappan KR. Prevalence of dental fluorosis and
associated risk factors in Alappuzha district, Kerala. Natl
Med J India 1999;12(3):99-103.
5. Price RB, Loney RW, Doyle MG, Moulding MB.
An evaluation of a technique to remove stains
from teeth using microabrasion. J Am Dent Assoc
2003;134(8):1066-71.
6. Welbury RR, Shaw L. A simple technique for removal
of mottling, opacities and pigmentation from enamel.
Dent Update 1990;17(4):161-3.
7. Beall AE. Can a new smile make you look more intelligent
and successful? Dent Clin North Am 2007;51(2):289-
97, vii.
8. Lukoff D, Liberman RP, Nuechterlein KH. Symptom
monitoring in the rehabilitation of schizophrenic
patients. Schizophr Bull 1986;12(4):578-602.
 case report

Roll Flap Technique for Anterior Implant Esthetics

Jumshad B Mohamed*, Md Nazish Alam**, Gurdeep Singh†, SC Chandrasekaran‡

Abstract
The long-term clinical and esthetic success of implant-supported restorations is determined by osseointegration and optimal
remodeling of peri-implant soft tissues. Complications of soft-tissue management are often caused by fibrotic regeneration
of oral mucosa after multiple surgical procedures. Knowledge of the proliferative processes in wound healing is necessary
to attain adequate soft-tissue conditions. Successful reconstruction of peri-implant soft tissues is feasible even in fibrotic
conditions when appropriate surgical techniques are selected. Several surgical techniques may be applied to obtain an adequate
emergence profile of the restoration with sufficient keratinized gingiva. Improvement of the clinical situation and esthetics
can be achieved with a roll flap technique for closure of the defect. The advantage of this technique is the perfect blending
with the surrounding tissues.

Key words: Roll flap, keratinized gingiva, emergence profile

T
he long-term clinical and esthetic success of an
implant-retained restoration is determined by
stable peri-implant soft-tissue morphology in
harmony with the surrounding soft tissues and natural
dentition. In addition to successful osseointegration
of the implant, the surrounding soft tissues play
an important role in vascularization of the bone.1,2
Insufficient peri-implant tissues may cause a nutritive
undersupply of the bone resulting in implant loss due
to resorption.3 Proper gingival architecture is especially
important in relation to anterior esthetics.4
Several surgical techniques may be applied to obtain
an adequate emergence profile of the restoration with
sufficient keratinized gingiva :5,6
 To maintain an adequate amount of keratinized
gingiva:
 Crestal incision
 For local transposition of keratinized gingiva:
*Senior Lecturer
**PG Student
†
Professor
‡
Professor and Head
Dept. of Periodontology
Sree Balaji Dental College and Hospital, Pallikaranai, Chennai
Address for Correspondence
Dr Md Nazish Alam
E-mail: dr.naz.ish.alam@gmail.com
 Vestibular-oral transposition
 Pedicle graft/Roll flap techniques
 Split thickness flaps
 To reconstruct new keratinized gingiva:
 Free soft-tissue grafts in combination with
vestibuloplasty
 Future techniques (tissue engineering):
 Transplantation of autologous keratinocytes
cultivated Invitro, in combination with
vestibuloplasty.
Case Report: (Case 1 and Case 2)
Following the surgical protocol for stage two implant
surgery, local anesthesia and partial thickness
paracrestal incision was made and connective tissue was
undermined from the palate (Figs.1 and 2), which was
raised to the margin of the placed dental implant and
rolled to achieve required gingival contour. The implant
was covered with a healing cap so that the gingiva
augments according to the contour of the healing cap
(Fig. 3). The site was suture using 5-0 nonresorbable
suture. Postoperative instruction and medication
was advised. Regular recall was done to evaluate the
gingival status. One month postoperatively, excellent
emergence profile, gingival and papilla contour was
achieved.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 393
 Case Report

Discussion
The outcome achieved from this treatment was to achieve
emergence profile with adequate amount of gingival
tissue. Use of connective tissue graft (CTG) for gingival
augmentation is a common practice in periodontics.
Figure 1. Figure 2. Figure 3.

Case 1

Figure 1. Initial incision. Figure 2. Gingival roll flap.

Figure 3. Closure around healing cap. Figure 4. Gingival augmentation (occlusal).

Figure 5. Augmentation (Facial). Figure 6. Gingival final prosthesis.

394 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

Case 2
Figure 7. Initial incision.
Figure 9. Closure with temporary crown.
Figure 11. Augmentation (facial).
Although, it helps in achieving gingival augmentation
there are two surgical sites which have to be prepared
for the procedure. In this case, the second surgical site
is blended with the same surgical site extracting the
CTG for gingival augmentation. As mentioned earlier,
insufficient peri-implant tissues may cause a nutritive
undersupply of the bone resulting in implant loss due
to resorption.3 Proper gingival architecture is especially
important in relation to anterior esthetics.4
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
Figure 8. Gingival roll flap.
Figure 10. Gingival augmentation (occlusal).
References
1. Hurzeler MB, Weng D. Periimplant tissue management:
optimal timing for an aesthetic result. Pract Periodontics
Aesthet Dent 1996;8(9):857-69; quiz 869.
2. Weber HP, Cochran DL. The soft tissue response
to osseointegrated dental implants. J Prosthet Dent
1998;79(1):79-89.
3. Albrektsson T, Bränemark PI, Hansson HA, Lindström
J. Osseointegrated titanium implants. Requirements for
ensuring a long-lasting, direct bone-to-implant anchorage
in man. Acta Orthop Scand 1981;52(2):155-70.
4. Lazzara RJ. Managing the soft tissue margin: the key
to implant aesthetics. Pract Periodontics Aesthet Dent
1993;5(5):81-8.
5. Cranin AN. Implant surgery: the management of soft
tissues. J Oral Implantol 2002;28(5):230-7.
6. Heller AL, Heller RL, Cook G, D’Orazio R, Rutkowski J.
Soft tissue management techniques for implant dentistry:
A clinical guide. J Oral Implantol 2000;26(2):91-103.
395
 case report

Management of Frontal Sinus Outer Table Injury with

Involvement of the Nasofrontal Duct with Review
Abudakir*, Prakash Dhanavelu**, R Balakrishnan†, Vijay Ebenezer‡, Sarvana Kumar#

Abstract
Frontal sinus injuries are notorious for their early and late complications. Improper management can be potentially fatal
with development of meningitis or formation of mucopyoceles. Cosmetic defect is also considerable. We herewith present
our successful experience in the management of three cases of frontal sinus fractures with naso frontal duct involvement. All
three cases were exentrated of the mucous apparatus, obliterated, the duct patency obliterated and the outer table is fixed
rigidly. No early or late complications were encountered and the patients were symptom free, six months after the treatment,
establishing the success of the treatment procedure.

Key words: Frontal sinus, naso frontal duct, meningitis

T
he frontal sinus that lies between the
supraciliary arches is bound anteriorly and
posteriorly by thick bony plates named the
outer and inner tables, respectively. Posteriorly, it is in
close apposition to the cribriform plate, dura matter
and the frontal lobes. It drains through the frontonasal
duct located in the posteromedial floor of the sinus.
The mucosal lining is continuous with the ethmoid air
cells and the nasofrontal duct. Blunt or sharp injury to
the region results in fracture of the frontal sinus that
can result in brain injury, cerebrospinal fluid (CSF)
rhinorrhea, headaches, cosmetic defect depending on
the degree of penetration. Such fractures not only need
to be reduced but treated diligently to prevent long-
term sequelae. Repair of injury to the brain, meninges,
sagittal sinus, prevention of CSF leak and meningitis
are the immediate priorities. Prevention of mucocele
formation should be the next issue of importance and
the restoration of forehead contour the last.
Several materials autologous materials have been used
for the obliteration of the sinus including fat, muscle
and fascia.
*Reader
**Senior Lecturer
†
Professor
‡
Professor and Head
#
Reader
Address for correspondence
Dr Abudakir
Dept. of Oral and Maxillofacial Surgery
Sree Balaji Dental College and Hospital
Narayanapuram, Chennai -100
E-mail: drabu_dakir@yahoo.co.in
This study evaluates the usage of fat, muscle and fascia
together as an obliteration material for the prevention
of CSF leak and headache.
I am herewith presenting three cases of frontal sinus
injuries with the involvement of the nasofrontal duct,
that were treated by exploration, mucosal exenteration
to prevent any mucocele formation and obliteration of
the space to block the frontonasal duct.
Material and Methods
Three cases of frontal sinus injuries were referred to the
Dept. of Oral and Maxillofacial Surgery for management.
All patients were alert, ambulant and agile. All three of
them had presented with CSF rhinorrhea and depression
of the frontal region on admission and had been placed
on observation. None of the patients had a history of
projectile vomiting or exhibited any signs of neurological
injury. All patients had a transient anosmia and
complained of headaches. The patients were examined
to find a severe flattening of the forehead, lacerations
between the eyebrows, swelling, step deformities and CSF
rhinorrhea. Based in the findings, it was decided that the
frontal sinus be explored and reduced and oblitereated as
per the presence or absence of frontonasal duct patency.
Radiological examination revealed comminuted outer
table fracture with undisplaced inner table cortex.
Surgical Technique
After due investigation to ascertain the fitness of the
patient for frontal sinus surgery under general anesthesia,

396 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

the patients were posted for surgery, after administration
of general anesthesia, the surgical area was infiltrated with
local anesthetic solution with 1:20,000 adrenaline to
counter hemorrhage. A bicoronal incision was made upto
a depth beyond the galea, keeping the knife angulations
away from the hair follicles of the scalp, the flap was
rapidly retracted anteriorly, allowing the identification of
bleeding vessels and cauterizing them. Hemostasis at the
cut-edge of the flap was achieved by minimal cautery and
usage of minimal number of clips in order to prevent
loss of hair follicles at the incision site. The flap was
elevated below the pericranium and under the superficial
temporal fascia in order to avoid the frontal branch of
the facial nerve. The superior orbital nerve foramina was
outfractured in order the retract the flap enough to expose
the nasion and the orbits. The fractured fragments were
visualized, the fragments wer removed, debrides of the
mucosal lining and the sinus thoroughly irrigated with
saline. The posterior wall was explored for evidence of
any damage to the nasofrontal duct.
Since, all three cases had a possibility of nasofrontal
duct injury, the moucous membrane was thoroughly
exentrated. All mucosal elements were removed
carefully. The recesses of the frontal sinus were explored
and exentrated. Pneumatized sinuses were drilled using
high speed drills and trimmed. By removing a layer of
bone from the inner walls of the sinus, using magnifying
loupes, total removal of the mucosal elements was
ensured. The cavity was well-irrigated. The nasofrontal
duct was obliterated bilaterally using bone chips and
muscle and facia, harvested from the surgical site. The
frontal sinus was then obliterated using fat and fascia.
The bone fragments were reduced to anatomic position
and fixed using microplates. The flap was repositioned
and wound closed in layers. The patients were
administered antibiotics parenterally and kept under
observation for a period of seven days for the resolution
Figure 1. Panfacial trauma. Figure 2. 3D CT.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
of CSF rhinorrhea, development of any meningeal
irritation or infection.
Results
All three of the patients recovered uneventfully. The
cosmetic defect was totally corrected and the patients
were satisfied with the postoperative appearance. After
the suture removal and the healing of soft tissues,
the oedema subsided and the patients were weaned
off antiepileptic drugs. None of them complained of
headache or any symptoms of sinusitis during the
6-month follow-up period.
Discussion
Besides the cosmetic defect, the necessity of treating
the frontal sinus fracture arose from infection, frontal
sinusitis and its complications. In the preantibiotic
times, a frontal sinus injury posed a huge mortality
rate due to the intracranial spread of infections.
Wells in 1870, has recorded the first surgical procedure
for the treatment of a mucopyocele. Since, then the
management of frontal sinus fractures in order to prevent
its deleterious sequelae has undergone many changes.
Minimally invasive procedures involved trephination of
the outer table with limited removal of the mucosa and
the more elaborate procedures involved packing of the
cavity and creation of an external drain. 1
In 1898, Reidel described the ablation of the outer
table for the resolution of frontal sinusitis symptoms.
This involved the excision of the frontal bone and
the supraorbital wall totally to expose the posterior
wall. This radical surgery though highly effective, was
extremely disfiguring. Even when threatened with the
rate of high mortality of the lesion, patients refused to
undergo this facial disfigurement.1
Killian, in an attempt to reduce the disfigurement, tried
to preserve the supraorbital bar and collapsing the skin to
the inner table of the frontal sinus. Though this procedure
was less disfiguring, the limited ostectomy often retained
the troublesome nasofrontal duct and therefore the disease
was either persistent or recurred due to the incomplete
removal of the mucous membrane. This treatment was
then abandoned due to its morbidity.2,3
Lynch, in order to facilitate the drainage of the frontal
sinus, it was confluence with the anterior ethmoid cells
to establish a wide communication to the nasal cavity.
397
 Case Report
This surgery was performed through a medial periorbital
incision. 4 This technique ensued further complications of
herniation of orbital content into the nasal cavity and
restenosis of the nasofrontal duct. In order to prevent the
re-stenosis stents of silicone and mucoperiosteal flaps were
used. These techniques were moderately successful.4,5
Bergar and Itoiz reported the usage of an osteoplastic
flap hinged to the anterior sinus wall on an inferior
pedicle of pericranium. This technique enhanced
visualization of the sinus, improved appearance and
the replacement of the osseous structures.6
Goodale, 7 on realising that the failure lies in the
frontonasal duct patency, enhanced this technique further
by removing the sinus contents and obliterating the sinus
with autologous fat. This osteoplastic flap procedure has
been enhanced by elevating the pericranium with the
scalp flap and exploring the frontal sinus by removal
of the communited bone fragments. This yielded good
results and a <1% incidence of complications has been
reported after complete mucosal exentration, blocking
the nasofrontal duct and adipose tissue obliteration of
the dead space.8-10
Bone, muscle, fascia and hydroxyapatite have also been
successfully used to obliterate the frontal sinus.11-15
In our series of three cases, the headache, numbness
over the forehead resolved within three weeks. CSF
leak resolved by administration of acetazolamide and
the lumbar drain was removed within 48 hours after
the surgery. 16
Wound infections were contained by antibiotics.
None of the cases required a re-exploration. No late
complications were also encountered in the 6-month
follow-up. 17
References
1. Jacobs JB. 100 years of frontal sinus surgery. Laryngoscope
1997;107:1-36.
2. Logan-Turner A. The operative treatment of chronic
suppuration of the frontal sinus. J Am Med Assoc
1905;44:446-55.
3. Skillern RH. Untoward results following the external
398 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
operation on the frontal sinus: a critical review of twenty
cases. Laryngoscope 1913;23:1063-72.
4. Lynch RC. The technique of radical frontal sinus
surgery operation which has given me the best results.
Laryngoscope 31(1):1-5
5. Goodale RL. Some causes for failure in frontal sinus
surgery. Ann Otol Rhinol Laryngol 1942;51:648-52.
6. Bergara AR, Itoiz AO. Present state of the surgical
treatment of chronic frontal sinusitis. AMA Arch
Otolaryngol 1955;61(6):616-28.
7. Goodale RL. The use of tantalum in radical frontal sinus
surgery. Ann Otol Rhinol Laryngol 1945;54:757-62.
8. Stanley RB Jr. Fractures of the frontal sinus. Clin Plast
Surg 1989;16(1):115-23.
9. Weber R, Draf W, Keerl R, Kahle G, Schinzel S,
Thomann S, et al. Osteoplastic frontal sinus surgery
with fat obliteration: technique and long-term results
using magnetic resonance imaging in 82 operations.
Laryngoscope 2000;110(6):1037-44.
10. Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD.
Modern concepts of frontal sinus surgery. Laryngoscope
2001;111(1):137-46.
11. Donald PJ, Ettin M. The safety of frontal sinus fat
obliteration when sinus walls are missing. Laryngoscope
1986;96(2):190-3.
12. Weber R, Draf W, Kahle G, Kind M. Obliteration of
the frontal sinus--state of the art and reflections on new
materials. Rhinology 1999;37(1):1-15.
13. Petruzzelli GJ, Stankiewicz JA. Frontal sinus
obliteration with hydroxyapatite cement. Laryngoscope
2002;112(1):32-6.
14. Shumrick KA, Smith CP. The use of cancellous bone
for frontal sinus obliteration and reconstruction of
frontal bony defects. Arch Otolaryngol Head Neck Surg
1994;120(9):1003-9.
15. Snyderman CH, Scioscia K, Carrau RL, Weissman
JL. Hydroxyapatite: an alternative method of frontal
sinus obliteration. Otolaryngol Clin North Am
2001;34(1):179-91.
16. Wallis A, Donald PJ. Frontal sinus fractures: a review of
72 cases. Laryngoscope 1988;98(6 Pt 1):593-8.
17. Donald PJ, Bernstein L. Compound frontal sinus injuries
with intracranial penetration. Laryngoscope 1978;88(2
Pt 1):225-32.
 case report

Capillary Heamangioma as a rare benign tumour of

Gingival Origin : A Case Report
Kiran Kumar Ganji *, Arun B Chakki#, Jyothi Joseph**

Abstract
Introduction: Hemangioma is a relatively common benign proliferation of blood vessels that primarily develops during
childhood. Two main forms of hemangioma recognized: capillary and cavernous. The capillary form presents as a flat area
consisting of numerous small capillaries. Cavernous hemangioma appears as an elevated lesion of a deep red color, and consists
of large dilated sinuses filled with blood. The purpose of the study was to report the case of a capillary hemangioma in a
patient and to describe the successful treatment of this case. Case Presentation: The patient was a 16-year-old female who
presented herself to the Department of Periodontology, Guru Gobind Singh College of Dental Sciences & Research Centre,
Burhanpur with the complaint of bleeding and slowly enlarging mass on the upper central incisor region. The lesion was
diagnosed as capillary hemangioma after clinical examination and biopsy. Treatment consisted of scaling, root planning and
surgical excision. Four months after surgery healing was occurred and two years later area of the lesion appeared completely
normal as clinically. Conclusions: The surface is highly keratinized and no further growth was evidenced during the two
year of follow-up. Early detection and biopsy is necessary to determine the clinical behavior of the tumor and potential
dentoalveolar complications.

Key words: Capillary hemangioma, periodontitis, benign tumour

A
number of terms have been used to describe vascular
lesions, which are classified either as hemangiomas
or vascular malformations.1-3 Hemangioma is a
term that encompasses a heterogeneous group of clinical
benign vascular lesions that have similar histologic features.
It is bening lesion, which is a proliferating mass of blood
vessels and do not undergo malignant transformation.
There is a higher incidence in females than males.
Although a few cases are congenital, most develop in
childhood.2 Occasionally, older individuals are affected.2,3
The congenital hemangioma is often present at birth and
may become more apparent throughout life.2
Althought hemangioma is considered one of the most
common soft tissue tumors of the head and neck2, it
*Associate Professor,
Dept. of Periodontics,
College of Dental Sciences and Hospital, Rau, Indore (M.P)
#
 Professor
Dept. of Oral Pathology
**  Professor
Dept. of Periodontics
Guru Gobind Singh College of Dental Sciences and Research Centre,
Burhanpur, Madhya Pradesh
Address for correspondence
Dr.Kiran Kumar Ganji MD S (Periodontics)
R/o Staff Quarters No.2,
Guru Gobind Singh College of Dental Sciences and ResearchCentre,
Lal Bagh road, opp keer mansion, Burhanpur, Madhya Pradesh
E-mail: kiranperio@gmail.com
is relatively rare in the oral cavity and uncommonly
encountered by the clinicians. They may be cutaneous,
involving skin, lips and deeper structures; mucosal,
involving the lining of the oral cavity; intramuscular,
involving masticator and perioral muscles; or intra-
osseous, involving mandible and/or maxilla.4,5
Hemangiomas are also classified on the basis of their
histological appearance. Capillary and cavernous
hemangiomas are defined according to the size of
vascular spaces.2,6 Capillary hemangioma are composed
of small thin-walled vessels of capillary size that are lined
by a single layer of flattened or plump endothelial cells
and surrounded by a discontinuous layer of pericytes
and reticular fibres.6 To our knowledge, it was first
described in the literature by Sznajder et al.7 in 1973
under the term “Hemorrhagic hemangioma”. Cavernous
hemangiomas consist of deep, irregular, dermal blood-
filled channels.2 They are composed of tangles of thin-
walled cavernous vessels or sinusoids that are separated by
a scanty connective tissue stroma.6 Mixed hemangiomas
contain both components and may be more common
than the pure cavernous lesions.6
Clinically hemangiomas are characterized as a soft mass,
smooth or lobulated, sessile or pedunculated and may
be seen in any size from a few millimeters to several

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 399
 Case Report

centimeters.6 The color of the lesion ranges from pink on her gingiva with respect to palatal aspect of upper
to red purple and tumor blanches on the application of right central incisor & lateral incisor. The swelling in the
pressure, and hemorrhage may occur either spontaneously associated region had been increasing gradually since that
or after minor trauma. They are generally painless. time. She did not give any relevant past dental history.
These tumors are mostly seen on the face, fingers and The patient’s medical history was non-contributory and
occasionally seen on oral mucosa. Oral hemangiomas are she did not take any medications. She and her parents
usually seen on the gingiva and less frequently at other stated that, she had a lesion operated and diagnosed as
sites where it occurs as a capillary or cavernous type, congenital hemangioma on the right hand fingers.
more commonly the former. 6 Periodontally, these lesions
No other similar lesions were clinically visible in the
often appear to arise from the interdental gingival papilla
head and neck region. Moreover, no lymph nodes were
and to spread laterally to involve adjacent teeth.8
palpable.
Management of hemangiomas and the treatment of
Clinical evaluation revealed a mass of size 3 cm X 2.5
choice depend on several factors including the age of the
cm on the palatal surface involving both labial and
patient and the size and extent of the lesions, as well
palatal interdental papilla between upper right central
as their clinical characteristics. Some congenital lesions
and lateral incisor. (Figure 1). It was firm, pedunculated
may undergo spontaneous regression at an early age.9 If
and red mass, and was located in the attached gingiva
superficial lesions are not an esthetic problem and are not
in the right maxillary region, covering almost the entire
subject to masticatory trauma, they may be left untreated.3
coronal part of the 11 and 12 region. On the palatal side
Small and superficial lesions may be completely excised
the mass extended throughout the marginal and attached
with relative ease. However, excision of more deeply
gingival. The mass was painful and bleed easily upon
seated lesions usually involves a wider surgical approach,
palpation. Tooth 12,11 involved by the mass was mobile.
which may result in a disfigurement that is difficult to
Periodontal pocket (approximately 10 mm) was detected
accept for the treatment of these lesions. In addition,
in the associated region. Periodontal examination revealed
emergency surgery may become mandatory when arterial
a Severe generalized gingivitis due to bacterial plaque.
bleeding arises from intraosseous hemangiomas of the
There was a moderate accumulation of dental plaque
jaw following simple tooth extraction.4
and the gingival tissues were swollen. Other findings
Various treatments have been used in the management included a mild supragingival calculus around her teeth,
of hemangiomas, including oral corticosteroids, presence of carious lesions and tooth malpositioning. It
intralesional injection of fibrosing agents, interferon was provisionally diagnosed as a pyogenic granuloma.
α-2b, radiation, electrocoagulation, cryosurgery,
An orthopantomograph radiograph demonstrated that
laser therapy, embolization and surgical excision.11-13
there was localized crestal bone destruction in the area of
Recurrence has been reported.1,2
the tumor, missing tooth germs in upper third molars.
The purpose of the study was to report the case of a
capillary hemangioma in a patient and to describe the
successful treatment of this case.

Case Presentation
In October 2009, a 16-year-old female was referred by
her dentist to the Department of Periodontology, Guru
Gobind Singh College of Dental Sciences & Research
Centre, Burhanpur for evaluation and treatment of the
gingival bleeding and overgrowth.
According to the patient, she suffered from excessive
gingival bleeding during mastication that had started four
months ago, accompanied by elevated gingival reddish
colour. A short time later, she discovered a dark red swelling Figure1. Clinical view of capillary hemangioma.

400 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012

A gingival biopsy was taken from the tumor zone,
producing profuse hemorrhage controlled by pressure
with gauze. The biopsy tissue was rinsed in formalin
(10%), and sent for histopathologic examination.
Histopathologic examination of the excised tissue
revealed hyperplasia of squamous epithelium on
surface and beneath with numerous small capillaries
proliferation with RBCs in the lumen surrounded
by fibrous tissue septae with necrotic slough and
granulation tissue. (Figure 2) Lesion also revelaed with
unencapsulated tumor composed of many thin-walled
capillary channels. The capillaries were lined by a single
layer of endothelial cells. Some areas showed marked
endothelial cell proliferation. Sparse plasma cells and
lymphocytes were seen scattered throughout stroma.
After having undergone clinical and physical
examinations and laboratory evaluation in the
Figure 2a. Capillary lumen formation in deep connective
tissue. (x40 magnification H& E staining)
Figure 2b & 2c. Histological section showing capillary
hemangioma (hematoxylin-eosin, original magnification
3120). Immunohistochemical stains showing positivity for
factor VIII (original magnification 3120 [b]) and for CD34
(original magnification 3120 [c]).
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
pathology department, she was diagnosed as having
Sclerosing capillary hemangioma.
Periodontal therapy consisted of oral hygiene
instruction, full-mouth scaling and root planning, and
modified Widman flap surgery.
Written informed consent was obtained from the patient
after all treatment procedures had been fully explained.
Periodontal management
Before surgical treatment of the tumor, a thorough
scaling and root planning were done carefully to remove
any local irritating factors that may have been responsible
for the gingival inflammation. The patient was educated
regarding good oral hygiene maintenance practices.
Periodontal surgery was done under strict aseptic
conditions using local anesthesia. The modified
Widman flap surgical procedure was performed as
described by Ramfjord and Nissle.14 Initial incision was
performed in the regions of teeth 11. The tumor was
carefully removed the completely with the remaining
granulation tissue after elevating buccal and palatal
flaps. There was profuse intraoperative bleeding that
was controlled with the help of pressure packs. The
flaps were sutured with 3-0 non-resorbable silk sutures.
The excised tissue was kept in formalin (10%) and sent
for histopathologic examination. The histology was
similar to that seen in the first specimen.
The patient was prescribed analgesics and instructed to
rinse twice daily with 0.12% chlorhexidine rinse for 2
weeks postoperatively and to avoid trauma or pressure at
the surgical site. Toothbrushing activities in the operated
sites were discontinued during this time. The sutures
were removed 7 days after surgery, home care instructions
were given. Professional prophylaxis was done weekly for
the first month and then at 4-month interval.
Clinical observations
Four months following surgery, the affected area had
completely healed, and there were no complications.
Probing depth in the associated region was less than 2
mm. The patient’s plaque control was good, although
moderate tooth staining was apparent. The patient
was periodically observed until two years after our
treatment began. At that time there were no clinical or
radiographic signs of recurrence.
401
 Case Report
Discussion
Hemangiomas are a common soft tissue tumor that
often congenital or develop in the neonatal period
and grow rapidly. They usually cover a large site, may
be macular or raised and usually resolve progressively
in childhood.2,3 They may occur in the oral and
maxillofacial region including gingiva, palatal mucosa,
lips, jawbone, and salivary glands.1,2,7,10,15,16 Apart
from the oral cavity, capillary hemangioma developed
at other sites such as eyelid, cheek and cauda equine
were reported.1,17 The patient in this case report had
a congenital vascular lesion of face, was diagnosed
capillary hemangioma, but there were no similar lesions
of the other sites on the body.
The occurrence of hemangioma with its primary location
on gingival tissues seems to be extremely rare. There
are many clinical features of capillary hemangioma
such as asymmetry of the face, spontaneous bleeding,
pain, mobility of teeth, blanching of tissue, pulsation,
expansion of bone, paresthesia, early exfoliation of
primary teeth, delayed eruption, root resorption, and
missing teeth. 1,4,7,16
Hemangiomas may mimic other lesions clinically,
radiographically and histopathologically. The
differential diagnosis of hemangiomas includes
pyogenic granuloma, chronic inflammatory gingival
hyperplasia (epulis), epulis granulomatosa, varicocell,
talengectasia, and even with squamous cell carcinoma.
The most common vascular proliferation of the oral
mucosa is the pyogenic granuloma. This is a reactive
lesion that develops rapidly, bleeds easily and is
usually associated with inflammation and ulceration.
Clinically, it is often lobulated, pedunculated and red
to purple and it may be hormone sensitive.6 There
are two histological types of pyogenic granuloma of
the oral cavity: the LCH and non-LCH type. LCH
is characterized by proliferating blood vessels that are
organized in lobular aggregates although superficially
the lesion frequently undergoes no specific change,
including edema, capillaries dilation or inflammatory
granulation tissue reaction, whereas the second type
consists of highly vascular proliferation that resembles
granulation tissue.6,18 Histopathologically, the capillary
hemangioma exhibits a progression from a densely
cellular proliferation of endothelial cells in the early
stages to a lobular mass of well-formed capillaries in the
mature phase, often resembling the pyogenic granuloma
402 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
without the inflammatory features.2 The present case
has clinical features of a pyogenic granuloma, but
has not microscopic features of pyogenic granuloma.
Therefore, biopsy of tissue specimens is often necessary
for definitive diagnosis of hemangiomas. In the case
reported here, histopathological evaluation was made
before and after surgical removed, and the findings
correlated.
In addition, hemangiomas may be confused with the
vascular-appearing lesions of the face or oral cavity,
which may also represent the Sturge-Weber syndrome.19
They are often located in the territory of the branches
of the trigeminal nerve. Usually, they do not undergo
spontaneous involution like hemangiomas do. Ocular
and cerebral vascular lesions may be found in such
cases. These lesions may be further classified into flat,
telangiectatic, stellar and senile variants.6
Precise diagnosis of the type of vascular lesion
is important because it may influence treatment
considerably. Angiographic studies are not strictly
demonstrated for diagnosis of hemangiomas, and are
utilized only to define the size and the extent of the
lesion.1,16 These are more complicated procedures than
histopathological evaluation, have a higher morbidity,
and may cause undesirable side-effects. For these
reasons, no attempt to use angiography was made in
this case. CT and MRI of these lesions have more
recently been demonstrated, and have been successfully
utilized for the diagnosis of hemangiomas, as for other
lesions of soft tissues.19,20
In the case presented here, treatment of the capillary
hemangioma was done surgical periodontal treatment.
The treatment of capillary hemangiomas varies
considerably depending on the clinical features and the
anatomic considerations. Surgical excision is generally the
treatment of choice for capillary hemangioma.1,4,15,16 For
those lesions not amenable to surgery, other therapy such
as intralesional injection of fibrosing agents, interferon
α-2b, radiation, electrocoagulation, cryosurgery, laser
therapy, embolization may be used.1,11,12
Attempts to remove hemangiomas using surgical
excision may lead to serious medical problems such as
heavy bleeding. In addition, postoperative recurrence
may encounter.1,4,7 The case described here demonstrates
that there has been no subsequent hemorrhage or other
evidence of recurrence.

The present case is of periodontal interest in view of
the onset of the lesion on the gingival tissue, as well as
the conservative treatment used.
Conclusions
Early detection and biopsy is necessary to determine the
clinical behavior of the tumor and potential dentoalveolar
complications. Althought a rare bening tumor of the
oral cavity, capillary hemangioma is important to the
periodontist because of its associated gingival vascular
features and complications in the form of impaired
nutrition and oral hygiene, increased accumulation of
plaque and microorganisms, and increased susceptibility
to oral infections, which can impair the systemic health
of the affected individual. In addition, the periodontal
surgical management of hemangiomas should be
performed with caution because the tissues may bleed
profusely intraoperatively and postoperatively.
Abbreviations
CT: computerized tomography; LCH: lobular capillary
hemangioma; MRI: magnetic resonance imaging.
References
1. Van Doorne L, De Maeseneer M, Stricker C,
Vanrensbergen R, Stricker M: Diagnosis and treatment
of vascular lesions of the lip. Br J Oral Maxillofac Surg
2002 , 40:497-503.
2. Enzinger FM, Weiss SW: Soft tissue tumors. 3rd edition.
Mosby; 1995:581-586.
3. Silverman RA: Hemangiomas and vascular malformations.
Pediatr Clin North Am 1991 , 38:811-834.
4. Kocer U, Ozdemir R, Tiftikcioglu YO, Karaaslan O:
Soft tissue hemangioma formation within a previously
excised intraosseous hemangioma site. J Craniofac Surg
2004 , 15:82-83.
5. Açikgöz A, Sakallioglu U, Ozdamar S, Uysal A: Rare benign
tumours of oral cavity--capillary haemangioma of palatal
mucosa: a case report. Int J Paediatr Dent 2000, 10:161-165.
6. Neville BW, Damm DD, Allen CM, Bouquot JE: Oral
and Maxillofacial Pathology. 2nd edition. WB Saunders;
2002:447-449.
7. Sznajder N, Dominguez FV, Carraro JJ, Lis G:
Hemorrhagic hemangioma of gingiva: report of a case. J
Periodontol 1973 , 44:579-582.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
8. Carranza FA: Glickman’s Clinical Periodontology. 1st
edition. WB Saunders Co; 1990:335-351.
9. Tröbs RB, Mader E, Friedrich T, Bennek J: Oral tumors
and tumor-like lesions in infants and children. Pediatr
Surg Int 2003 , 19:639-645.
10. Yoon RK, Chussid S, Sinnarajah N: Characteristics
of a pediatric patient with a capillary hemangioma of
the palatal mucosa: a case report. Pediatr Dent 2007 ,
29:239-242.
11. Onesti GM, Mazzocchi M, Mezzana P, Scuderi N:
Different types of embolization before surgical excision
of haemangiomas of the face. Acta Chir Plast 2003 ,
45:55-60.
12. Burstein FD, Simms C, Cohen SR, Williams JK, Paschal
M: Intralesional laser therapy of extensive hemangiomas
in 100 consecutive pediatric patients. Ann Plast Surg
2000 , 44:188-194.
13. Deans RM, Harris GJ, Kivlin JD: Surgical dissection
of capillary hemangiomas. An alternative to intralesional
corticosteroids. Arch Ophthalmol 1992 , 110:1743-
1747.
14. Ramfjord SP, Nissle RR: The modified widman flap. J
Periodontol 1974 , 45:601-607.
15. Childers EL, Furlong MA, Fanburg-Smith JC:
Hemangioma of the salivary gland: a study of ten cases of
a rarely biopsied/excised lesion. Ann Diagn Pathol 2002
, 6:339-344.
16. Greene LA, Freedman PD, Friedman JM, Wolf M:
Capillary hemangioma of the maxilla. A report of two
cases in which angiography and embolization were used.
Oral Surg Oral Med Oral Pathol 1990 , 70:268-273.
17. Miri SM, Habibi Z, Hashemi M, Meybodi AT, Tabatabai
SA: Capillary hemangioma of cauda equina: a case report.
Cases J 2009 , 22:80.
18. Mills SE, Cooper PH, Fechner RE: Lobular capillary
hemangioma: the underlying lesion of pyogenic
granuloma. A study of 73 cases from the oral and nasal
mucous membranes. Am J Surg Pathol 1980 , 4:470-
479.
19. Bhansali RS, Yeltiwar RK, Agrawal AA: Periodontal
management of gingival enlargement associated with
Sturge-Weber syndrome. J Periodontol 2008 , 79:549-
455.
20. Panow C, Berger C, Willi U, Valavanis A, Martin E:
MRI and CT of a haemangioma of the mandible in
Kasabach-Merritt syndrome. Neuroradiology 2000 ,
42:215-217.
403
 case report

Prosthodontic Management of a Completely

Edentulous Patient with Bell’s Palsy
Sharmila Hussain*, Raghavendra Jayesh**, Sanjna Nayar†, U Aruna ‡, Ansu Mary Abraham#

Abstract
Bell’s palsy is the most common acute lower motor neurone (LMN) paralysis of face. Facial paralysis of permanent nature
affects the prosthetic outcome. In this clinical report, an attempt has been made to alter denture design and dimensions
to improve esthetics, function, retention and stability. A completely edentulous patient has been rehabilitated with denture
margins modified to support flaccid musculature. A hollow denture was fabricated with monoplane occlusal scheme for
improved retention and stability. The modification helped in improving overall appearance and function for the patient.

Key words: Bell’s palsy, complete edentulous patient, prosthodontic management, treatment options

B
ell’s palsy affects the unilateral facial muscles
with typical features like inability to blink,
absence of wrinkles on the forehead and
asymmetry of face.1 The problems encountered during
prosthodontic rehabilitation include uncontrolled flow
of saliva, a mask-like expressionless appearance and
cheek biting.2 All features may interfere with steps in
impression making, jaw relation and denture retention
and stability.
A combined approach of surgery and mechanical
support has been reported.3 Palliative treatment for
permanent facial paralysis includes, modifications of
denture to provide support to cheek like padding for
buccal flanges,1-7 spring loaded acrylic flanges8 and
magnet retained cheek plumpers.9
Case Report
A 61-year-old completely edentulous female patient
reported to the Dept. of Prosthodontics, Sree Balaji
Dental College, Chennai. Her chief complaint was
*Professor, Dept. of Prosthodontics
Saveetha Dental College and Hospitals, Chennai
**Principal and Professor, Dept. of Prosthodontics
†
Professor and Head
‡
Reader
#
Post Graduate Student, Dept. of Prosthodontics
Sree Balaji Dental College and Hospital, Chennai
Address for correspondence
Dr Sharmila Hussain
7f, Rear Block, Sai Subhoday Apartments,
57/2B, East Coast Road, Thriuvanmiyur, Chennai - 600 041
E-mail: hsharmi@yahoo.com
fractured mandibular complete denture. History
revealed that, the patient had suffered from fever
at the age of two years and subsequently developed
facial paralysis on the right side of the face. On
extraoral examination, asymmetry of face was
noticed with loss of muscle bulk on the paralyzed
side (Fig. 1). The face was drawn to the left side
during phonation with significant difficulty with
the bilabial plosives (p,b), labiodentals and fricatives
(f,v). There was buccolabial insufficiency causing
restricted lip movement.
The patient presented with reduced neuromuscular
control on jaw closure and phonation as classified
by House and Brackman as Grade V i.e.: Severe
dysfunction with only slight movement, asymmetrical
facial appearance at rest, no movement, incomplete
closure of eye and slight movement of the mouth.10
Her existing complete denture was examined and it
did not compensate for facial asymmetry or speech
limitation.
Techniques
 Modification of existing denture
 Fabrication of new modified denture
Modification of Existing Denture
The patient had an existing denture, which was modified
using low fusing compound. Low fusing compound
was added in the distosuperior margin of the vestibular
fornix of the affected site.5 The thickness of denture in

404 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
 Case Report

autopolymerizing acrylic resin replacing the low fusing

compound.

Fabrication of New Denture

The patient reported back with complaint of lack

of retention during functional movements. This was
attributed to increase in weight of denture due to
modified flange. It was then planned to fabricate new
hollow denture. Border molding was done to enhance
cheek support. Monoplane teeth11 were selected for
posterior replacement as they exerted no lateral stresses
on underlying structures and were deemed to be less
harmful during parafunctional movements. This form of
occlusion allowed wide range of movements which was
advantageous as the patient had poor neuromuscular
control on the affected side.
A 3D spacer using silicone putty12 was used to
fabricate the planned hollow cavity of the prosthesis.
The final denture had significant reduction in weight
thereby improving patient comfort and retention
(Fig. 3 and 4).
Discussion
Figure 1. Pre-treatment.
The prosthodontic management of patients with Bell’s
palsy should satisfy the esthetic and functional needs
of the patient. Treatment of permanent facial palsy
is usually palliative along with special modifications
of the prosthesis. Turnbull et al 7 advocated padding of
the buccal flanges as a modification for facial support.
Fickling et al8 advocated spring loaded acrylic flange
extensions. Vestibular extensions have been used as

Figure 2. Modification of existing denture.

this region was increased within physiological limits so

as to provide adequate lip support (Fig. 2). The addition
improved the esthetics as the lip was straightened and
also provided improvement in phonetics. The patient
was able to speak longer without fatigue with the
modified denture. The denture was processed with Figure 3. Hollow denture. Figure 4. Post-treatment.

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 405
 Case Report
a modification in this case.5 The advantage of the
procedure is that it is a simple technique to improve
function.
In patients with facial paralysis, there is poor
coordination of movements and increased
parafunctional movements. Monoplane occlusal
scheme allows greater possibility of functional contact
during wide range of mandibular movements. This
scheme has better chewing efficiency and stability in
these patients. Modifying the denture for these patients
has a drawback in that it increases the total weight of
the prosthesis. In order to overcome this limitation,
the hollow denture was fabricated. It has been shown
by previous studies13-15 that hollow dentures improved
retention by decreasing the weight of the prosthesis.
These modifications improved esthetics and function
with complete dentures.
Conclusion
In this case report, a conservative management of a
completely edentulous patient with facial palsy has
been described with modification of dentures. Along
with other palliative treatments (pharmacological,
physical, etc.), modification in prosthodontic treatment
improves patient’s sense of well-being.
References
1. Scully C, Felix DH. Oral medicine - update for the
dental practitioner. Disorders of orofacial sensation and
movement. Br Dent J 2005;199(11):703-9.
2. Emory L. The face in patient evaluation and diagnosis. J
Prosthet Dent 1976;35(3):247-53.
3. Elfenbaum A. Facial paralysis and denture construction.
Dent Dig 1967;73(2):78-9 passim.
406 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
4. Maxillofacial rehabilitation- John Beumer III, Thomas
A Curtis, David N Firell.
5. Larsen SJ, Carter JF, Abrahamian HA. Prosthetic
support for unilateral facial paralysis. J Prosthet Dent
1976;35(2):192-201.
6. Lazzari JB. Intraoral splints for support of lip in Bell’s
palsy. J Prosthet Dent 1955;5(4):579-81.
7. Turnbull MD. Support of orofacial musculature in Bell’s
palsy. Den Pract 1963;15:64-6.
8. Fickling BW. Buccal sulcus supports for facial paralysis.
Br Dent J 1951;90(5):115-7.
9. Riley MA, Walmsley AD, Harris IR. Magnets in
prosthetic dentistry. J Prosthet Dent 2001;86(2):137-
42.
10. House JW, Brackmann DE. Facial nerve grading system.
Otolaryngol Head Neck Surg 1985;93(2):146-7.
11. Winkler S. Essentials of complete denture prosthodontics.
2nd edition, Ishiyaku Euro America, Inc. Publishers.
12. O’Sullivan M, Hansen N, Cronin RJ, Cagna DR.
The hollow maxillary complete denture: a modified
technique. J Prosthet Dent 2004;91(6):591-4.
13. McAndrew KS, Rothenberger S, Minsley GE. 1997
Judson C. Hickey Scientific Writing Awards. An
innovative investment method for the fabrication of
a closed hollow obturator prosthesis. J Prosthet Dent
1998;80(1):129-32.
14. Chalian VA, Barnett MO. A new technique for
constructing a one-piece hollow obturator after partial
maxillectomy. J Prosthet Dent 1972;28(4):448-53.
15. Worley JL, Kniejski ME. A method for controlling the
thickness of hollow obturator prostheses. J Prosthet
Dent 1983;50(2):227-9.
16. Fauci et al. Harrison’s Principles of Internal Medicine.
17th edition.
 case report

Finger Prostheses - Overcoming a Social Stigma:

Clinical Case Reports
Dhruv Arora *, Shyam Singh**, R Shakila†, SK Jagdish*, Santosh Anand*, VR Arun Kumar*, J Balaji*

Abstract
Maxillofacial prostheses replace lost body parts using artificial substitutes like silicones. These prostheses support the patients
psychologically and enhance their social acceptance. The authors describe rehabilitation of two patients with missing fingers
using silicone prostheses. A 13-year-old boy with completely missing little finger and partially missing ring finger in his right
hand was treated by using silicone prosthesis. The prosthesis was retained by using a ring. A 9-year-old boy with partially
missing middle finger in his right hand was treated by using a silicone glove type of prosthesis. Implant retained prostheses
were not considered due to the cost of the treatment. Use of glove type prosthesis or mechanical aids such as rings provides
an easy and cost-effective alternative to implants. Such treatment can be opted for in cases of financial constraints.

Key words: Glove prosthesis, RTV silicone, finger prosthesis, mechanical retention

P
rosthesis refers to artificial replacement of an
absent part of the human body.1 These artificial
substitutes serve primarily to improve the patient’s
appearance and to support them psychologically. They
play an immense role in making the patient more
socially acceptable.2 Reconstructive surgery cannot
restore esthetics as much as prosthesis can and thus
has limited role in case of lost body parts. The major
role in rehabilitating the patient is thus played by the
maxillofacial prosthodontist and the anaplastologist.
Most of the prostheses are made from medical grade
silicones.3 These silicones can be rendered to match to
the skin color of the patient and give a more life-like
appearance. Most of the silicones used for this purpose
are room temperature vulcanizing silicones (RTV
silicones). The advantages of RTV silicones include
chemical inertness, flexibility and elasticity.4 They can
also be easily molded and colored. The prostheses
can be retained either by mechanical methods or by
*Junior Resident
** Director, Professor and Head
†
Associate Professor, Dept.
Address for correspondence
Dr Dhruv Arora
Junior Resident, Dept. of Prosthodontics and Implantology
Mahatma Gandhi Postgraduate Institute of Dental Sciences
Govt. of Puducherry Institution, Gorimedu, Puducherry,
Pondicherry - 605 006
E-mail: dhruv_doc1026@yahoo.co.in
the use of adhesives. Use of magnets for retaining
prostheses has also been tried.5 Implant retained
prostheses have proven to be satisfactory, provided they
are economically feasible.6,7
Retaining finger and hand prosthesis by using rings,
bracelets, etc. are some methods of mechanical
retention. Glove type prostheses are designed to snugly
fit over the remaining stumps to provide retention.8
This article describes rehabilitation of two patients
with finger prostheses using such mechanical modes
of retention.
Methods
Case Reports
Clinical Case 1
A 13-year-old boy reported to the Department of
Prosthodontics and Implantology for replacement
of a missing tooth in the mandibular posterior region.
During examination/the patient was found to have
missing fingers in his right hand. A detailed history
revealed that the patient lost his fingers 5-year-ago in a
road accident. The amputated stumps were well-healed
with completely missing little finger and partially
missing ring finger (Fig. 1). The advantages and
limitations of replacement of the finger were explained
to the patient and his parents. Since a part of the ring
finger was remaining, retaining the prosthesis by means
of a ring was chosen. A ring of suitable size and width

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 407
 Case Report
Figure 1. Pre-prosthetic photograph of case 1.
to mask the margin of the prosthesis was selected.
Clinical Case 2
A 9-year-old boy reported to the Dept. of
Prosthodontics and Implantology for replacement
of a missing middle finger in his right hand. The patient
said that he lost his finger one year ago while firing
crackers. Examination of the stumps revealed adequate
healing with two-thirds of the finger remaining. Only
the terminal one-third of the finger was lost (Fig. 2).
The treatment procedure was explained to the patient
and his parents. Retention of the prosthesis by using
a glove type of finger prosthesis was chosen for this
patient since two-thirds of the finger was remaining
to provide adequate retention. Use of a ring will be
unnatural in the terminal third of the finger or using
the ring near the lower third would make the prosthesis
longer, bulky and unesthetic.
Use of implant retained prosthesis was not considered
because both the patients could not afford such a
treatment.
Fabrication of the prosthesis
The basic steps in fabrication of the prostheses for
both the patients were the same and hence described
together. Attachment of the ring to the prosthesis for
case 1 was done after the prosthesis was fabricated.
408 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Figure 2. Pre-prosthetic photograph of case 2.
 Making the impressions and casts the impression
material chosen was alginate. A plastic container
of sufficient length and diameter was chosen to
confine the impression material. The containers
were tried on the patient’s hands to provide
adequate clearance of at least 5 mm around for
the impression material. Regular setting alginate
was mixed using cold water to increase the
working time and poured into the containers. The
patients were asked to dip their hands vertically
into the container without touching the sides or
the bottom of the container. The material was
allowed to set and the hand was removed quickly
in a jerking motion after the material was set.
Impressions of both the affected and normal
hands were made. The impressions were poured
in stone and casts were made. The normal hand
was used as a reference to duplicate the size, shape
and orientation of the fingers.
 Selection of a donor and making wax patterns
a donor hand for making the wax patterns was
essential to avoid the laborious task of sculpting.
Using the cast of the normal hand as reference,
a donor hand was selected for each patient from
among the patients visiting our department.
Impressions of the fingers of the donors were made
using condensation silicone in putty consistency.
Wax was molten and poured into the putty

Figure 3. Post-prosthetic photograph of case 1.
impressions. After the wax cooled down, it was
retrieved from the impression and tried on the
casts. Final carving and adjustments were made
to blend the margins with the respective casts.
The completed wax patterns were tried on the
patients.
 Color matching and incorporation of nail the
most critical step was to match the color of the
prostheses to the patient’s skin color. The basic skin
color was observed. The colors were mixed with the
silicone to obtain the base color. Maximum efforts
were made to match the color of the prostheses.
The nails were made from cold cure clear acrylic
resin. They were properly shaped and trimmed
to the required size. Around 1 mm of nail bed
was carved in the wax patterns and the nails were
incorporated in that space.
 Stump preparation in order to fabricate a glove
type prosthesis reduction of the stumps were
necessary. A reduction of 1-1.5 mm was done on
the stone casts.9 This would produce prosthesis with
a smaller diameter which can be stretched over the
amputated stumps to provide retention.
 Procesing and finishing the patterns were flasked
and a two part mould was obtained after dewaxing.
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
Figure 4. Post-prosthetic photograph of case 2.
RTV silicones mixed with colors were packed into
the moulds. Curing was done for 24 hours at room
temperature. Prostheses were finished using alpine
stones and silicone burs.
Methods of Retention
Clinical Case 1
The retention for this patient was by using a ring of
suitable size. The ring was attached to the prosthesis
by means of cyanoacrylate glue initially. The prosthesis
was tried on the patient and position was finalized.
The cyanoacrylate glue was later replaced by silicone
by flasking the prosthesis and adding silicone to attach
the ring (Fig. 3).
Clinical Case 2
Retention of the prosthesis for this patient was achieved
by fabricating glove type prosthesis as described (Fig 4).
Discussion
Successful prosthetic rehabilitation of these patients is a
challenging task, but it is our duty to make the best use
of the available materials and techniques to enable these
patients to re-enter the society as confidently as possible;
this may be considered every patient’s right. More
than functional and esthetic requirements, there is one
more dimension attached to these prostheses, which is
409
 Case Report
psychological well-being. It is worth remembering that
we cannot give the patient a living prosthesis of real
tissues. The day prosthesis behaves and looks like a real
tissue, will be the day when perfection is achieved.
References
1. The glossary of prosthodontic terms. J Prosthet Dent
2005;94(1):10-92.
2. Miglani DC, Drane JB. Maxillofacial prosthesis and its
role as a healing art. J Prosthet Dent 1959; 9(1):159-68.
3. Huber H, Studer SP. Materials and techniques in
maxillofacial prosthodontic rehabilitation. Oral
Maxillofac Surg Clin North Am 2002;14(1):73-93.
4. Kanter JC. The use of RTV silicones in maxillofacial
prosthetics. J Prosthet Dent 1970;24(6):646-53.
410 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
5. Javid N. The use of magnets in a maxillofacial prosthesis.
J Prosthet Dent 1971;25(3):334-41.
6. Pekkan G, Tuna SH, Oghan F. Extraoral prostheses
using extraoral implants. Int J Oral Maxillofac Surg
2011;40(4):378-83.
7. Manurangsee P, Isariyawut C, Chatuthong V,
Mekraksawanit S. Osseointegrated finger prosthesis: An
alternative method for finger reconstruction. J Hand
Surg Am 2000;25(1):86-92.
8. Kini AY, Byakod PP, Angadi GS, Pai U, Bhandari AJ.
Comprehensive prosthetic rehabilitation of a patient with
partial finger amputations using silicone biomaterial: A
technical note. Prosthet Orthot Int 2010;34(4):488-94.
9. Thomas KF. Prosthetic Rehabilitation. Quintessence,
London 1994:127-8.
 case report

Bordetella avium and Bacillus megaterium in

Endodontic Infection
Arunajatesan Subbiya*, Krishnan Mahalakshmi**

Abstract
Many microbiological studies on endodontic infections indicate a complex polymicrobial community. Different identification
methods used have revealed a diverse microflora in the endodontic niche. Recently 16S rRNA/DNA gene sequencing method
of identification is widely employed in dentistry which has discovered novel pathogens that may be uncultivable or possibly
slow growing and difficult to identify. In the present study, nested polymerase chain reaction (PCR) was performed with the
endodontic samples of the two patients with diffuse swelling and pain near the region of tooth with prosthetic crown as these
two samples were culture negative. 16S rRNA universal eubacterial primers were used for rapid identification. Unusually, the
organisms identified in both the cases were of single etiology. Bordetella avium was identified in the endodontic sample of
a tooth with prosthetic crown in a 56-year-old woman and Bacillus megaterium in a 65-year-sold man. The occurrence of
B. avium and B. megaterium on the teeth may be correlated to their ability to secrete collagenase. Direct screening of the
clinical samples by molecular approach has identified unusual human bacterial pathogens in tooth with prosthetic crown. In
addition, the results of this study also reveal that endodontic infection need not be polymicrobial all the time. Screening of
bacterial pathogens in the endodontic samples may help in treatment planning and treatment evaluation.

Key words: Bordetella avium, Bacillus megaterium, endodontic infection, prosthetic crown, 16S rDNA sequencing

B
ordetella avium is thought to be strictly an
avian pathogen. It is the etiologic agent of
bordetellosis, a highly contagious upper
respiratory disease of young poultry. Its prevalence
among domesticated turkeys is well-documented.1
B. avium is a gram-negative, nonfermentable, aerobic
and motile bacterium that colonizes the trachea of
chicken, turkeys, cockatiels, ostriches and many other
avian species. It is an opportunistic pathogen in
chicken.2 Human infections by B. avium is rare. Bacillus
megaterium, a gram-positive, rod-shaped endospore-
forming bacteria is a common soil saprophyte. It is
considered aerobic, but, it is also capable of growing
under anaerobic conditions when indispensable.
It finds wider applications in the environmental
and industrial needs. It can also survive in extreme
conditions such as desert environments due to the
spores it forms. The data regarding its association with
*
Professor, Dept. of Conservative Dentistry and Endodontics
**Associate Professor, Dept. of Microbiology
Sree Balaji Dental College and Hospital, Chennai
Address for correspondence
Dr Krishnan Mahalakshmi
Associate Professor
Dept. of Microbiology
Sree Balaji Dental College and Hospital, Velachery-Tambaram Road
Chennai - 600 100, Tamil Nadu
E-mail: kmag_1985@yahoo.co.in
dental infection in humans is lacking. The present
study reports of endodontic infection caused by
B. avium and B. megaterium in two different patient’s
teeth with prosthetic crown. In addition the present
study shows an unusual etiology as against usual
polymicrobial nature of endodontic infection reported
till date. To the best of our knowledge this may be the
first reported case in the tooth with prosthetic crown.
Case Description and Results
Case Report 1
A 56-year-old Indian woman visited a private dental
health centre in Chennai, with the chief complaint of
diffused swelling and pain in the periapical region of
right upper canine. Patient experienced a throbbing
pain for almost a week. On intraoral examination, the
concerned tooth had a PFM crown. The tooth was
serving as an abutment for a bridge. This bridge had
been in place for the past four years and 6 months.
The patient had history of generalized periodontitis
and extraction of posterior teeth, but gave no history
of caries. The patient is nonvegetarian by food habit.
The intraoral periapical (IOPA) radiograph showed a
periapical radiolucency of 2-3 mm diameter (Fig. 1).
A root canal treatment was planned and access opening

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 411
 Case Report
Figure 1. Preoperative IOPA radiograph of patient 1.
Figure 2. Preoperative IOPA radiograph of patient 2.
was done in #6. After administering local anesthesia,
the tooth to be sampled was isolated from the oral
cavity with a rubber dam. Disinfection of the crown
and operation field was performed as per the protocol
described by Ng et al.3 The pulp chamber and the root
canal were devoid of any pulp tissue or necrotic tissue.
Root canal orifice showed discharge of exudate. Two
paper points was placed in the root canal individually
to absorb the exudates draining from the canal and this
in turn was transferred into reduced transport media
and phosphate buffered saline (PBS), respectively. As
the discharge stopped after 20 minutes, closed dressing
was given with CaOH. The patient was put on
amoxycillin and metronidazole for five days. Rootcanal
was obturated after three weeks as the patient was
asymptomatic during this period. Patient was re-called
after four weeks for review. She was asymptomatic and
had no pain on palpation or percussion. Root canal
access was sealed with composite resin as permanent
access filling.
412 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report 2
A 65-year-old Indian man presented to a private clinic
in Chennai, with a complaint of pain in the right
lower molar region for 10 days. The pain had been
intermittent for the past 2-3 months with the intensity
slowly increasing with each episode of pain. On
intra-oral examination, both #30 and #31 had metal
crowns. Past dental history of the patient revealed that
crowns were placed in #30 and #31 as a treatment
for severe sensitivity, two years ago. The patient was
informed that the sensitivity was because of occlusal
wear and was advised to have full crown in both these
teeth. Patient was comfortable after placement of the
crowns. The pain had developed in this region only
10 days back. On percussion tooth #31 was tender.
IOPA radiograph revealed periapical radiolucency of
about 4-5 mm diameter in mesial root of tooth #31
Fig. 2). No pathology was evident in #30 both clinically
and radiographically. The metal crown was removed
and rubber dam was placed. Prior to the collection
of endodontic sample, the disinfection protocol was
followed as described earlier.3 There was no immediate
sign of any exudates from the mesial canals. The
mesial canals were enlarged to size 20K-file, with
saline irrigation between instruments. After enlarging
the mesial canals to size 20K-file, an endodontic
sample was collected from tooth #31 using paper
point and transferred to PBS for rapid microbiological
examination. Canal was enlarged and CaOH paste was
placed as an intracanal medicament. Patient was re-
called after three weeks for review. As the patient was
asymptomatic the root canal was obturated and a new
crown was placed after four weeks.
Microbiological Findings
The endodontic samples collected from the two
patients were processed for both aerobic and anaerobic
cultivation. As the samples were culture-negative after
five days of aerobic and anaerobic incubation, the
samples in PBS was processed for nested polymerase
chain reaction (PCR) using universal eubacterial
primers for rapid species level identification.4 The DNA
from the clinical sample was extracted by boiling-lysis
method in 100 μl of lysis buffer (10 mmol/l Tris-HCl,
1.0 mmol/l EDTA,1.0% Triton X-100, pH8.0) for PCR
assay.5 Simultaneously culture of diverse environmental
samples was also performed.

The PCR reaction mixture of 25 μl volume consisted
of 0.5 unit of Taq DNA polymerase (Bangalore genei,
India), 2.5 μl of 10× PCR buffer, 0.18 μM of each
primer (Sigma-Aldrich Pvt. Ltd., India), 100 μM of
each dNTP (Medox India Pvt Ltd, India) and 2.5 μl
of DNA template. One microliter of the first round
amplified product was used as DNA template in the
second round of amplification. Ten microliters of
each reaction product was mixed with 10 μl of 2×
loading buffer and fractionated in a 1.5% agarose
gel electrophoresis with Tris-Borate EDTA buffer
containing ethidium bromide (0.5 μg/ml), using a 100
bp DNA ladder (Medox India Pvt. Ltd., India) as a
size marker.
The first round and the second round PCR yielded 766
bp and 470 bp products, respectively in both the clinical
samples. The second round product was sequenced
and submitted to GenBank BLAST database. The
sequence from patient 1 (Case report 1) was genetically
identical to B. avium 197N, complete genome (430
bp evaluated, 95% sequence similarity) and the
sequence from patient 2 (Case report 2) was genetically
identical to B. megaterium DSM319 chromosome,
complete genome (458 bp evaluated, 99% sequence
similarity). The chromatogram of the 16S rRNA gene
sequencing of both the samples did not show a mixed
appearance with more than one fluorescent peak in
several positions, suggesting that the sample contained
single bacterial species. The sequences of B. avium and
B. megaterium were submitted to GenBank under
accession no’s HQ121265 and HQ158799, respectively.
None of the environmental samples yielded growth of
B. avium or B. megaterium, suggesting that the bacterial
species identified were solely from the patients clinical
sample.
Discussion
B. avium causes coryza or bordetellosis, a respiratory
disease affecting turkey. It is widespread in many
species of wild birds, with high prevalence in some
species.6 To our knowledge recent literature describes
two different incidences of human respiratory infection
and respiratory infection with cystic fibrosis by
B. avium.7,8 Till recently this bacterium has not been
identified in humans by phenotypic characterization.
16S rRNA gene sequence analysis provides accurate
identification at the species level and can clarify their
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
clinical importance.9 A study in USA has identified
B. avium in three patients showing symptoms of
respiratory tract infections with cystic fibrosis by using
a combination of bacterial genotyping and 16S rDNA
sequencing.8
An experiment in young poults demonstrates the
production of toxin(s) by B. avium that induces
serum proteases or collagenases to actively degrade
the connective tissue matrix thus, leading to decreased
elastin and collagen content of the aorta and trachea
in the birds.10 In the present study, the occurrence of
B. avium on the teeth may be correlated to its ability
to secrete collagenase. Its affinity for the collagen rich
tissues present in the pulp and the dentinal wall may
perhaps be a reason for pulp degeneration and the
resultant periapical lesion.
B. megaterium is one of those organisms, out of a
few in the bacillus group that produces high levels of
toxicity. Spores of B. megaterium is used in evaluating
efficacy of a dental unit.11 The study by Douglas et al
confirms their survival in harsh environment, which
could have been a reason for this endospore-forming
bacilli to survive and infect the tooth with prosthetic
crown. Dib et al has reported B. megaterium in a
40-year-old female patient with left ovarian mass torsion.12
Bruno et al study has reported 10.3% sporulated gram-
positive bacilli in the pulp of nonvital traumatized teeth
with intact crowns.13 Wu et al recently characterized
and purified a novel collagenase from Bacillus pumilus,
an organism that is genetically allied closely to
B. megaterium.14 Microbiological finding of the present
study as single etiology was unique as this does not
agree with many of the previous studies reviewed by
Siqueira and Rocas.15
Conclusion
Direct screening of the clinical samples by 16S rRNA
gene sequencing method appears to be a valuable tool
for the rapid and reliable diagnosis of oral infections.
The present case report highlights the need to consider
unusual human bacterial pathogens as potential cause of
infection in tooth with prosthetic crown. Identification
of bacterial pathogens in the endodontic samples may
help the clinicians in proper treatment strategy, and
treatment evaluation. The author(s) declare no conflict
of interests.
413
 Case Report
References
1. Jackwood MW, Saif YM. Bacterial Diseases: Pasteurellosis
and other respiratory bacterial infections. In: Diseases of
Poultry. Saif YM (Ed.), Bordetellosis (Turkey Coryza),
Blackwell Publishing, Inc.: Reino Unido 2008:pp. 774-
88.
2. Jackwood MW, McCarter SM, Brown TP. Bordetella
avium: an opportunistic pathogen in Leghorn chickens.
Avian Dis 1995;39(2):360-7.
3. Ng YL, Spratt D, Sriskantharajah S, Gulabivala K.
Evaluation of protocols for field decontamination before
bacterial sampling of root canals for contemporary
microbiology techniques. J Endod 2003;29(5):317-20.
4. Therese KL, Anand AR, Madhavan HN. Polymerase chain
reaction in the diagnosis of bacterial endophthalmitis. Br
J Ophthalmol 1998;82(9):1078-82.
5. Wu Y, Yan J, Chen L, Gu Z. Association between infection
of different strains of Porphyromonas gingivalis and
Actinobacillus actinomycetemcomitans in subgingival
plaque and clinical parameters in chronic periodontitis. J
Zhejiang Univ Sci B 2007;8(2):121-31.
6. Raffel TR, Register KB, Marks SA, Temple L. Prevalence
of Bordetella avium infection in selected wild and
domesticated birds in the eastern USA. J Wildl Dis
2002;38(1):40-6.
7. Harrington AT, Castellanos JA, Ziedalski TM, Clarridge
JE 3rd, Cookson BT. Isolation of Bordetella avium and
novel Bordetella strain from patients with respiratory
disease. Emerg Infect Dis 2009;15(1):72-4.
414 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
8. Spilker T, Liwienski AA, LiPuma JJ. Identification
of Bordetella spp. in respiratory specimens from
individuals with cystic fibrosis. Clin Microbiol Infect
2008;14(5):504-6.
9. Fredricks DN, Relman DA. Sequence-based identification
of microbial pathogens: a reconsideration of Koch’s
postulates. Clin Microbiol Rev 1996; 9(1):18-33.
10. Yersin AG, Edens FW, Simmons DF. The effects of
Bordetella avium infection on elastin and collagen content
of turkey trachea and aorta. Poult Sci 1998;77(11):1654-
60.
11. Douglas CW, Rothwell PS. Evaluation of a dental unit
with a built-in decontamination system. Quintessence
Int 1991;22(9):721-6.
12. Dib EG, Dib SA, Korkmaz DA, Mobarakai NK,
Glaser JB. Nonhemolytic, nonmotile gram-positive
rods indicative of Bacillus anthracis. Emerg Infect Dis
2003;9(8):1013-5.
13. Bruno KF, de Alencar AH, Estrela C, Batista Ade C,
Pimenta FC. Microbiological and microscopic analysis
of the pulp of non-vital traumatized teeth with intact
crowns. J Appl Oral Sci 2009;17(5):508-14.
14. Wu Q, Li C, Li C, Chen H, Shuliang L. Purification
and characterization of a novel collagenase from
Bacillus pumilus Col-J. Appl Biochem Biotechnol
2010;160(1):129-39.
15. Siqueira JF Jr, Rôças IN. Distinctive features of the
microbiota associated with different forms of apical
periodontitis. J Oral Microbiol 2009 Aug. 10;1.

Peripheral Ossifying Fibroma - Report of a case
G Sujatha*, G Sivakumar**, J Muruganandhan*, J Selvakumar†, M Ramasamy‡
Abstract
Peripheral ossifying fibroma is a gingival growth commonly seen in the maxillay anterior region occurring mainly due to
low-grade irritations. We report a case of a 20-year-old male patient who reported with a slow-growing gingival growth. The
clinical presentation, radiological and histological features along with the etiopathogenesis is been discussed.
Key words: Peripheral ossifying fibroma
P
eripheral ossifying fibroma (POF) is a
non-neoplastic gingival growth which is
relatively common. Among the two types central
and peripheral, the peripheral occurs only on the soft
tissue over the alveolar bone and is a reactive lesion.1
This reactive lesion usually occurs in response to
low-grade irritations such as trauma, plaque, calculus,
microorganisms, masticatory forces, ill fitting dentures
and poor quality restorations.2
POF appears as red to pink nodular mass that is either
pedunculated or sessile with a surface that is usually
ulcerated arising from the interdental papilla.3 Most
lesions are about 1.5 cm in diameter though some
reach the size of about 6 cm in diameter and the
diagnosis is based on clinical and histopathological
examination.4 Histologically, they appear as a mass of
nonencapsulated mass of celluar fibrous connective
tissue covered by stratified squamous epithelium which
may be ulcerated and with a areas of mineralization
varying between cementum like or bone like or
dystrophic calcifications.5
*Senior Lecturer, Dept. of Oral and Maxillofacial Pathology
** Professor and Head, Dept. of Oral and Maxillofacial Pathology
†
Reader, Dept. of Periodontics
‡
Reader, Dept. of Orthodontics
Sri Venkateswara Dental College and Hospital
Address for correspondence
Dr G Sujatha
Senior Lecturer
Dept. of Oral and Maxillofacial Pathology
Sri Venkateswara Dental College and Hospital
Off OMR Road, Near Navalur- Thalambur, Chennai
E-mail: gsuja@redifmail.com
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
case report
Treatment includes surgical removal of the lesion
including the periosteum which reduces the high
recurrence rate.6 This article presents a clinical case of
POF.
Case Report
A 20-year-old male patient reported to a private
clinic with a growth in the lower anterior region
measuring about 3 × 3cm for the past two months.
History revealed that the patient had an irritation in
the same area eight months back and had undergone
scaling. After scaling the growth had increased in size
with mild pain.
On examination, a reddish pink pedunculated growth
which was firm in consistency was present in the
marginal gingival of lower anteriors extending upto
1 mm below the occlusal plane. Treatment included
complete excision of the growth and removal of
irritating factors such as plaque and calculus. The
patient was reviewed after 10 days and healing was
uneventful. The patient was educated about his oral
hygiene and recalled after three months. The sectioned
tissue was sent for histopathological examination.
A differential diagnosis of pyogenic granuloma and
irritation fibroma was given.
The histopathological sections revealed a highly cellular
connective tissue with numerous plump fibroblasts
intermingled through out the vascular fibrous stroma.
Calcifications were in the form of globules resembling
cementum like material. This was seen with the
presence of overlying stratified squamous epithelium.
The histopathological diagnosis was given as POF. The
patient presented for follow-up after three months and
there was no evidence of recurrence.
415
 Case Report
Figure 1. Screener view of the lesion showing fibrocellular
stroma (4x).
Figure 3. Irregular basophilic calcifications resembling
cementum (10x).
Discussion
POF is a reactive growth of the oral cavity seen in
the gingiva. Menzel first described the lesion ossifying
fibroma in 1872, but its terminology was given by
Montgomery in 1927.7 Two types of ossifying fibroma
have been cited, the central and the peripheral.
However POF is not a counterpart of the central
ossifying fibroma but a reactive lesion of the gingiva.8
Eversol and Rovin were the first to describe the lesion
POF as a relatively uncommon, solitary, non-neoplastic
gingival growth.2 This entity was first reported as’
416 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Figure 2. Stroma is highly cellular with foci of inflammation
(10x).
Figure 4. Atrophic surface epithelium with areas of ulceration
(10x).
alveolar exostosis’ in 1844 by Shepherd.5,9 Various
terminologies like peripheral odontogenic fibroma,
peripheral cemento-ossifying fibroma, ossifying
fibroepithelial polyp, peripheral fibroma with
osteogenesis, peripheral fibroma with cementogenesis,
peripheral fibroma with calcifications, fibrous epulis,
calcifying or ossifying fibrous epulis, calcifying
fibroblastic granuloma have been used to describe
this lesion.10,11
Most of the reports suggest that POF is commonly seen
in the second decade of life, with a reduce in incidence

with age.2,5 There are two cases being reported at birth
and being presented as congenital epuli.12 There is a
increased predilection for maxillary arch with the
common site being the incisor-cuspid region and more
commonly seen in females.3,13 POF appears as a slow
growing solitary mass which is either pedunculated or
sessile, the surface is usually smooth or ulcerated and
the color ranging from red to pink.9,14 Involved teeth
are usually unaffected but in some cases migration,
mobility and delay in eruption of permanent teeth
may occur.3 Lesions range from 1-2 cm in diameter
usually but cases of > 2 cm have also been reported.1
Radiograpically POF varies from completely no changes
to areas of calcifications depending upon the degree of
mineralization. Superficial bone loss, cupping defect
and focal areas calcification have been reported in
some cases.1,13 Additional investigations like computed
tomography (CT) and magnetic resonance imaging
(MRI) are done in cases when required considering
the size. With administration of contrast agent, POF
appears as a mass with calcifications on CT and MRI
shows the area of calcification with a very low signal
on T2-weighted sequences.1
Histologically, POF appears as a noncapsulated fibrous
connective tissue with stratified squamous epithelium
which is ulcerated in most of the cases.15 Endothelial
proliferation can be more in areas of ulceration
misleading it to the diagnosis of pyogenic granuloma.16
Fibroblastic proliferation, mineralized component
varying from bone, cementum like material or
dystrophic calcifications, few endothelial proliferation
and few inflammatory cells is the usual presentation
of POF.13
POF presents as a reactive gingival growth with a
controversy whether it is a transitional growth or
a separate clinical entity. Bhaskar and Jacoway have
considerd it to be a separate entity in contrast to
Eversole and Rovin who highlighted the similarity in
sex and site predilection between pyogenic granuloma,
peripheral giant cell granuloma and POF. They also
stated that these histological variations could be in
response to irritation. Gardner has reported the highly
characteristic nature of the cellular connective tissue,
which makes the diagnosis of POF irrespective of the
presence of calcifications.
The role of hormones is also been put forward by
Kenney et al as it occurs more commonly in females and
Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
Case Report
its occurrence in the second decade and its decline with
old age.17 As POF occurs only in the gingival which is
close to the periodontal ligament, origin of cells from
the periodontal ligament (PDL) is considered. Also
relevant is the occurrence in interdental papillae and
presence of oxytalan fibers and other histopathological
similarities to gingival lesions.18 Kendrick and
Waggoner postulate that exuberant connective tissue
response to chronic irritation due to plaque, calculus,
restorative or orthodontic appliances is commonly
observed in gingival. Moreover, persistent irritation can
cause metaplasia of the mesenchymal cells resulting in
calcifications.6
Treatment includes local surgical excision and oral
prophylasis.16 Follow-up is essential because of the
recurrence rates varying from 8 to 20%. Recurrence is
due to incomplete excision, and or persistence of local
factors.2
Conclusion
POF is clinically often mistaken for pyogenic granuloma
and peripheral giant cell granuloma. Radiological and
histopathological diagnosis is required for confirmation.
Treatment is complete surgical excision and regular
follow-up is required due to the recurrence rate.
References
1. Moon WJ, Choi SY, Chung EC, Kwon KH, Chae SW.
Peripheral ossifying fibroma in the oral cavity: CT and
MR findings. Dentomaxillofac Radiol 2007;36(3):180-2.
2. Eversole LR, Rovin S. Reactive lesions of the gingiva. J
Oral Pathol 1972;1(1):30-8.
3. Neville, et al. Textbook of Oral and Maxillofacial
Pathology. 3rd edition 2009:p. 521-3.
4. Cuisia ZE, Brannon RB. Peripheral ossifying fibroma - a
clinical evaluation of 134 pediatric cases. Pediatr Dent
2001;23(3):245-8.
5. Bhaskar SN, Jacoway JR. Peripheral fibroma and
peripheral fibroma with calcification: report of 376 cases.
J Am Dent Assoc 1966;73(6):1312-20.
6. Kendrick F, Waggoner WF. Managing a peripheral
ossifying fibroma. J Dent Child 1996;63(2):35-138.
7. Eversole LR, Sabes WR, Rovin S. Fibrous dysplasia: a
nosologic problem in the diagnosis of fibro-osseous
lesions of the jaws. J Oral Pathol 1972;1(5):189-220.
8. Buchner A. Peripheral odontogenic fibroma. Report of 5
cases. J Craniomaxillofac Surg 1989;17(3):134-8
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9. Bodner L, Dayan D. Growth potential of peripheral Oral Pathol 1987;63(4):452-61.

ossifying fibroma. J Clin Periodontol 1987;14(9):551-4.
10. Zain RB, Fei YJ. Fibrous lesions of the gingiva: a
histopathologic analysis of 204 cases. Oral Surg Oral
Med Oral Pathol 1990;70(4):466-70.
11. Waldron CA. Fibro-osseous lesions of the jaws. J Oral
Maxillofac Surg 1993;51(8):828-35.
12. Yip WK, Yeow CS. A congenital peripheral ossifying
fibroma. Oral Surg Oral Med Oral Pathol 1973;35(5):661-
6.
13. Yadav R, Gulati A. Peripheral ossifying fibroma: a case
report. J Oral Sci 2009;51(1):151-4.
14. Buchner A, Hansen LS. The histomorphologic spectrum
of peripheral ossifying fibroma. Oral Surg Oral Med
15. Gardner DG. The peripheral odontogenic fibroma: an
attempt at clarification. Oral Surg Oral Med Oral Pathol
1982;54(1):40-8.
16. Farquhar T, Maclellan J, Dyment H, Anderson RD.
Peripheral ossifying fibroma: a case report. J Can Dent
Assoc 2008;74(9):809-12.
17. Kenney JN, Kaugars GE, Abbey LM. Comparison
between the peripheral ossifying fibroma and
peripheral odontogenic fibroma. J Oral Maxillofac Surg
1989;47(4):378-82.
18. Kumar SK, Ram S, Jorgensen MG, Shuler CF,
Sedghizadeh PP. Multicentric peripheral ossifying
fibroma. J Oral Sci 2006;48(4):239-43.

CORRIGENDUM:

Ref: Volume 1 Issue 6, Page 342, in authors details read are as follows:

J Muruganandhan*,  G Sivakumar**,  G Sujatha*

*Senior Lecturer, ** Professor & Head,
Dept. of Oral and Maxillofacial Pathology.
Sri Venkateswara Dental College and Hospital, Chennai

418 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012
 Indian Journal of
Multidisciplinary Dentistry Case Report

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For Editorial Correspondence
Dr KMK Masthan
Professor and Head
Department of Oral Pathology and Microbiology
Sree Balaji Dental College and Hospital
Velachery Main Road, Narayanapuram, Pallikaranai
Chennai - 600 100, E-mail: masthankmk@yahoo.com,
ijmdent@gmail.com, www.ijmdent.com

Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012 419
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420 Indian Journal of Multidisciplinary Dentistry, Vol. 2, Issue 1, November 2011 to January 2012