Dr. Deepesh K.Gupta JournalDr. Deepesh K.Gupta. An official publication of Ayush and Health Sciences...

An offical publication of Ayush and Health Sciences University ChhattisgarhCHHATTISGARH JOURNAL OF HEALTH SCIENCES

Patron Dr. G. B. Gupta

Vice Chancellor

Executive Editorial Board

Dr. K. L. Tiwari – Registrar Ayush & Health Sciences UniversityDr. N. Gandhi – Dean Faculty Medical

Dr. Anil G. Ghom – Dean Faculty, Dental Mrs. Abhilekha Biswal –Dean Faculty Nursing

Dr. D. Katariya – Dean Faculty Ayurvedic Dr. A. R. Rudrajwar –Dean Faculty Homoeopathy

Associate Editors

Dr. Raghavendra ShettyDr. Divya Sahu

Dr. A. K. Chandrakar Dr. S. Pawar Dr. A K Vishwakarma Dr. Rajendra Prasad Dr. Tripti Nagaria Dr. O. P. Khandelwal Dr. Rajendra K.Dubey Dr. Sanjay B.Nyamati Mrs. Sreelata Pillai Dr. Anand Sharma Dr. S. R. Inchulkar Dr.Vineeta Gupta Dr. R.P. Gupta Mrs. Uma Shendey Mrs. Preetha Sunil Ms. Bhuneshwari Sahare Dr. Rohit Rajput

Editorial Board

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An official publication of Ayush and Health Sciences University Chhattisgarh

CHHATTISGARH JOURNAL OF HEALTH SCIENCES

Volume 2 issue 1 ISSN 2348-4195

CONTENTS

REVIEW ARTICLE

Lasers in dentistry R.Mithra Rajan, C.A. Mathew,N. Vidya Sankari, Arul Kumar ........01

ORIGINAL ARTICLETo determine the antimicrobial property of MTA when mixed with triple antibiotic paste and

chlorhexidine gluconate: An invitro study

S. Naveen, A. Cicilia Subbulakshmi, Immanuel sathish solomon, Vineeta Gupta ........09

Pulmonary function test in chronic kidney disease patients : A study from tertiary care hospital

P. Gupta, Mukund G. ........14

Oral lichen planus : A diagnostic marker of chronic liver disease

Vaibhav Kumar Garg, Mayuri Garg ........20

A comparative evaluation of inter articulator reproducibility of protrusive condylar guidance

registration in four different semi adjustable articulators using two different recording materials

C.Dhinesh Kumar, Jayashree Mohan, N.Vidyasankari, Deepesh K. Gupta, S.Senthil kumar, Indumati ........29

Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane manipulated

with and without petroleum gel : An invitro study Adarsh Shetty, Jagadish Konchada, Balasubramaniyan R , Shailendra Sahu, Anurag Dani, Manikandan R. ........37

Dermatoglyphics in oral clefts Chinar Fating, Rolly Gupta, Anil Agrawal, Rana K. Varghese, Gopkumar Nair , Preeti Thakur ........42

Carcinoma cervix and renal failure : A study from central India

Sanjay Verma ,Punit Gupta, Prakash Khunte ........47

CASE REPORTImmediate denture as an immediate solution

N.Vidyasankari, S.Senthil kumar, Deepesh K. Gupta, Maheshwaren ........51

Unrecognized swallowing of a partial denture and surgical retrieval by cervical

oesophagotomy: A case report C. Sunil Kumar,B. M. M. Reddy, A. Samantaray, D. S. R. Reddy ........55

(ii)

“Great discoveries and achievement invariably involve co-operation of many minds”

The journal is very important mouth piece and advertisement for any society. It reflects a knowledge and research of our colleagues. What lies before us and what lies behind us is nothing compare to what lies within us. So this journal is giving an opportunity to the people of our faculty for their skills and achievement as it is said ‘when you are curious you find lots of interesting thing to do’.

It gives me immense pleasure to bring out the current issue of this year, “Chhattisgarh Journal Of Health Sciences”. This journal represents the brain of faculties of our university.

Our constant search of excellence in medicine remains the challenge. We are committed continuously to report new discoveries and research, finding and exploring new ideas, methods and advancement technology along with various dimension of learning. Besides the content we pirates around the numerous material, technique and technologies to enable our professionals to put the knowledge into immediate clinical use.

I will try to deliver my best in every issue of the journal. Your suggestions for the improvement of the journal will be accepted. The timely advice of the editorial board, advisors and review board has catalyzed the publication of this journal. The moral boost and the continuing support of all our colleagues help us to take out the journal in time.

I request all the authors to submit research and original articles which will be great help to us for indexing at higher level.

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

Editorial

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ABSTRACT

The word “laser” invokes many significant qualities like precision, efficiency, and innovation in the mind's eye. The

successful use of laser light has been proved in diverse branches of medicine and dentistry. The scope of laser in

dental procedure and number of dental professionals using them is steadily increasing. Based on recent

advancements and the minimum intervention principles, lasers has revolutionized various surgical, non surgical and

laboratory procedures of dentistry. Low level laser therapy (LLLT) can offer tremendous therapeutic benefits to

patients, such as painless as well as bloodless procedures, with more efficacy and accelerated healing. The purpose

of this article is to explain the basic principles of lasers and to explore the uses of lasers in general dental practice.

Key words: 2 Hard tissue lasers, Soft tissue lasers, Nd YAG laser, CO laser

Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) 1

INTRODUCTION

The field of dentistry have come a long way from just

drilling, filling or replacing teeth by simple mechanics to

the boundless era of modern technology. Over the past

several years, tremendous advances in the field of laser

have enormous impact in every disciplines of dentistry.

The word laser started as an acronym for "light

amplification by stimulated emission of radiation”. A

laser is a device that emits light (electromagnetic

radiation) through a process of optical amplification

based on the stimulated emission of photons. 1

Although Maiman first investigated the potential uses

of the ruby laser in dentistry in 1960, laser gained

popularity among the clinicians only after 1990s when

numerous studies were published on laser applications

in dentistry. The purpose of this article is to review the

literature on fundamentals of lasers and their

applications in various fields of dentistry.

2Components of a typical laser:

1. Active medium

This may be consists of a solid, liquid or gas that emits

laser light when stimulated. This is positioned within

the laser cavity, an internally-polished tube, with

mirrors co-axially positioned at each end and

surrounded by the external energising input, or

pumping mechanism. The 'active medium' (CO or 2

Nd:YAG) defines the type of laser and the emission

wavelength of the laser (10,600 nm and 1,064 nm

respectively). Other lasers of significance in dentistry

use rare earth and other metal ions within a 'doped' YAG

crystal lattice, eg. erbium (Er: YAG) and holmium

(Ho:YAG), together with another erbium and

chromium-doped garnet of yttrium, scandium and

gallium (Er,Cr: YSGG).

2. Pumping mechanism

1 2 3 4R.Mithra Rajan , C.A. Mathew ,N. Vidya Sankari , Arul Kumar1. PG Student, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)2. Professor & Head, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)3. Reader, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)4. PG Student, Department of Prosthodontics, K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)

Corresponding author : Dr.N. Vidya SankariReader, Department of Prosthodontics K.S.R. Institute of Dental Sciences and Research, Tiruchengode (TN)Mobile no- 09443940244, E-Mail ID: [email protected]

REVIEW

Ayush & Health Sciences University of Chhattisgarh

REV

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Lasers in dentistry

ISSN 2348 - 4195

Lasers in Dentistry

2

This is a source of primary energy that excites the active

medium. This is usually a light source, either a flashlight

or arc-light, but can be a diode laser unit or an

electromagnetic coil. Energy from this primary source is

absorbed by the active medium, resulting in the

production of laser light.

3. Optical resonator

Laser light produced by the stimulated active medium is

bounced back and forth through the axis of the laser

cavity, using two mirrors placed at either end, thus

amplifying the power. The distal mirror is totally

reflective and the proximal mirror is partly transmissive,

allowing light of sufficient energy to exit the optical

cavity. The parallelism of the mirrors insures that the

light is collimated.

4. Delivery system

Currently, two delivery systems are used (for surgical

lasers):

a) A flexible hollow waveguide/tube attached to a

handpiece (non-contact mode) or an accesory

tip of saphire or hollow metal (contact mode)

connected to the end of the wave guide.

b) A glass fiberoptic cable attached to a handpiece

(non contact mode) or a sapphire or quartz tip (contact

mode). Most of the times it is used in contact mode.

5. Cooling system

Heat production is a by-product of laser light

propagation. It increases with the power output of the

laser and hence, with heavy-duty tissue cutting lasers,

the cooling system represents the bulkiest component.

Co-axial coolant systems may be air- or water-assisted.

6. Control panel

This allows variation in power output with time, above

that defined by the pumping mechanism frequency.

Other facilities may allow wavelength change (multi-

laser instruments) and print-out of delivered laser

energy during clinical use.

Characteristics of laser:

With respect to the monochromatic nature of laser

light, a number of emission wavelengths have been

developed for the purposes of current clinical dentistry.

The wavelengths of commonly used lasers range from

the visible to the far infrared portions of the

electromagnetic spectrum (approximately 400 - 10,600

nm). Unlike visible light, laser is monochromatic and

coherent (all the waves are in the same phase & have

identical wave shapes). Collimation is another prime

property of laser light in that its acceptance is based

upon transmission through a vacuum.

3Photobiologic Effects of Laser

1. Photothermal effect

2. Photochemical effect

3. Photoacoustic effect.

Photothermal Effect

The principle effect of laser energy is photothermal, i.e.

the conversion of light energy into heat. The rate of

temperature rise plays an important role in this effect

and is dependent on several factors such as

- Cooling of the surgical site

- Ability of the surrounding tissues to dissipate heat

- Various laser parameters such as emission mode,

power density and the time of exposure.

Photochemical Effect

The laser light can stim ulate chemical reactions (e.g.

curing of composite resin) and breaking of chemical

bonds (e.g. using photosensitized drugs exposed to

Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)

Fig 1. The basic components of a typical laser cavity.

3

Commonly used lasers and their wavelength:

Ultraviolet (0.180 μm – 0.400 μm)

Laser Type Wavelength (μm)

Argon 0.275, 0.351, 0.363

Xenon Chloride 0.308

Xenon Fluoride 0.351

Neodymium:YAG (3rd harmonic) 0.355

Visible (0.400 μm – 0.700 μm)


Rhodamine 6G 0.450, 0.650

Argon 0.457, 0.476, 0.488, 0.514

Krypton 0.530

Neodymium:YAG (2nd harmonic) 0.532

Helium Neon 0.543, 0.632

Indium Gallium Aluminum Phosphide 0.670

Ruby 0.694

laser light to destroy tumor cells, a process called

photodynamic therapy).

Photoacoustic effect

The pulse of laser energy on a crystalline structure (e.g.

dental hard tissues) can produce an audible shock wave,

which could explode or pulverize the tissue with

mechanical energy creating an abraded crater. This

phenomenon is called the photoacoustic effect of laser

light.

Fig 2. Fotona laser (Slovenia, EU)

Lasers in Dentistry


Lasers in Dentistry

4

The shorter wavelengths (500–1,000 nm) are readily

absorbed in pigmented tissue and blood elements.

Argon is highly attenuated by hemoglobin. Diode and

Nd:YAG have a high affinity for melanin and less

interaction with hemoglobin.

The longer wavelengths (2,000–10,600 nm) are more

interactive with water and hydroxyapatite. The largest

absorption peak for water is at the Er:YAG wavelength

(just below 3,000 nm. Erbium is also well absorbed by

hydroxyapatite. CO (at 10,600 nm) is well absorbed by 2

water and has the greatest affinity for tooth structure.

Analgesic Effects of Laser :

Low-power lasers inhibit the release of mediators from

injured tissues. In other words, they decrease

concentration of chemical agents such as histamine,

acetylcholine, serotonin, H+ and K+, all of which are

pain mediators. Low-power lasers inhibit concentration

of acetylcholine, a pain mediator, through increased

acety lchol ine esterase act iv i ty. They cause

vasodilatation and increase blood flow to tissues,

accelerating excretion of secreted factors. Lasers

decrease tissue edema by increasing lymph drainage.

They also remove the pressure on nerve endings,

resulting in stimulation decrease. These lasers decrease

sensitivity of pain receptors as well as transmission of

impulses. They decrease cell membrane permeability

for Na + and K + and cause neuronal hyperpolarization,

resulting in increased pain threshold. Injured tissue

metabolism is increased by electromagnetic energy of

laser. This is induced by ATP production and cell

membrane repolarization. Low-power lasers increase

descending analgesic impulses at dorsal spinal horn and

inhibit pain feeling at cortex level. They balance the

Far-infrared (3.000 μm – 1 mm)


Helium Neon 3.390

Carbon Monoxide 5.000 – 5.500

Carbon Dioxide 10.6

Near-infrared (0.700 μm – 1.400 μm)


Ti-Sapphire 0.700 – 1.000

Gallium Aluminum Arsenide 0.780, 0.850

Gallium Arsenide 0.905

Neodymium:YAG 1.064

Helium Neon 1.180, 1.152

Mid-infrared (1.400 μm – 3.000 μm)


Erbium:Glass 1.540

Homium 2.100

Hydrogen Fluoride 2.600 – 3.000

Erbium 2.940


5

activity of adrenalin and noradrenalin system

(autonomous system) as a response to pain. Low-power

lasers increase the urinary excretion of serotonin and

glucocorticoids, increasing the production of β-4endorphin.

Diagnostic applications of laser:5

Laser fluorescence is commonly used for

a. Detection of dental caries (DIAGNOdent)

b. Detection of subgingival calculus

c. Detection of crown/root fractures

d. Assessment pulpal blood flow (Laser doppler

flowmetry)

e. Scanning of phosphor plate digital radiographs

/ conventional radiographs for teleradiology.

Laser as an in-vitro research tool:6

Nd:YAG (1064nm) is utilized for Raman spectroscopic

analysis of tooth structure and Terahertz imaging of

internal tooth structure. Er:YAG (2940nm) can be used

for breakdown spectroscopic analysis of tooth

structure. Argon (488 and 515nm) is useful in confocal

microscopic imaging of soft and hard tissues, flow

cytometric analysis of cells and cell sorting. Helium-

neon (633nm) and other diode lasers are proved to be

successful in profiling of tooth surfaces and dental

restorations.

LASERS IN ORAL MEDICINE

Laser vaporization offers a precise means of treating

oral lesions that reduces the potential for pain and

scarring. Oral lesions treated with laser surgery include

aphthous ulcers, lymphangiomas, hemangiomas and

verrucous carcinomas. Laser irradiation acts in the final

stage of HSV-1 replication by limiting viral spread from

cell to cell and that laser therapy acts also on the host

immune response unblocking the suppression of

proinflammatory mediators induced by accumulation

of progeny virus in infected epithelial cells.7

A more powerful laser-initiated photochemical reaction

is photodynamic therapy (PDT), which has been

employed in the treatment of malignancies of the oral

mucosa, particularly multi-focal squamous cell

carcinoma. Laser-activation of a sensitizing dye in PDT 8

generates reactive oxygen species. These in-turn

directly damage cells and the associated blood vascular

network, triggering both necrosis and apoptosis. There

is accumulating evidence that PDT activates the host

immune response, and promotes anti-tumour

immunity through the activation of macrophages and T

lymphocytes.

CO laser and diode laser has been found useful for the 2

treatment of vascular anomalies of the oral cavity and

concluded that laser is a suitable tool for the treatment

of these lesions and sometimes the laser cannot

remove the entire tumour in one treatment, so more

t re at m e nt s m ay b e n e e d e d . I n f ra re d l a s e r

photodynamic therapy over the projection of the

sinuses will lower the sensation of pressure and

tenderness. Irradiation into the nostrils will reduce the

mucosal swelling and open the nasal obstruction.9

LASERS IN PERIODONTICS:

The application of laser in periodontics was first

documented in 1985 when CO laser was used for the 2

removal of phenytoin hyperplasia. Early efforts were

l imited to those soft t issue procedures l ike

gingivoplasty, operculectomy, gingival troughing, crown

lengthening, Sulcular debridement (removal of

inflamed soft tissue in the periodontal pocket), flap

surgery and for guided tissue regeneration.10

Erbium lasers show potential for effective root

debridement. The Er:YAG laser has been shown, in vitro,

to remove calculus and to negate endotoxin. Clinical 11

data also exist that suggest the Er:YAG laser can result in

a superior calculated clinical attachment gain compared

with mechanical scaling and root planning.

LASERS IN CONSERVATIVE DENTISTRY AND

ENDODONTICS:

Er:YAG laser is used for caries removal, restoration

removal, hard tissue surface roughening and etching,

enameloplasty, excavation of pits and fissures for

placement of sealants, hypersensitive dentin. Esthetics

and smile has become important issues in modern

society. Bleaching has become the common method for

tooth whitening. Bleaching using diode lasers results in

immediate shade change and less tooth sensitivity and

is preferred among in office bleaching systems. 12

Lasers in Dentistry


Lasers in Dentistry

6

Lasers are also useful for access cavity preparation,

pulpotomy, cleaning and shaping of the root canal. In

periapical surgery, laser is used for incision of soft tissue

to prepare a flap and expose the bone, cutting bone to

prepare a window access to the apex (apices) of the

roots, apicoectomy – amputation of the root end, root

end preparation for retro filling, removal of pathological

tissues (i.e., cysts, neoplasm or abscess) and

hyperplastic tissues (i.e., granulation tissue) around the

apex.13

LASER IN ORAL AND MAXILLOFACIAL SURGERY:

A diode laser can be used for incision instead of a

scalpel. Hard tissue lasers are used for osteoplasty and

osseous recontouring (removal of bone to correct

osseous defects and create physiologic osseous

contours), ostectomy (resection of bone to restore bony

architecture, resection of bone for grafting, etc.),

osseous crown lengthening, vestibuloplasty, sinus lift

procedure. The yttrium-scandium-gallium-garnet

(YSGG) laser is the optimal choice for not cutting the

sinus membrane. The YSGG laser can also be used to

make the osteotomy for a ramal or symphyseal block

graft.

Diode lasers are attracted to pigments. Frena are

typically thicker fibrous tissue and have very little

pigment to them. The lack of pigment and more fibrous

nature of the tissue require higher energies to ablate

this tissue. Other wavelengths such as Er:YAG lasers

may ablate frena faster, and can be used in non contact

mode, but the drawback compared to diode lasers is an

increased risk of bleeding. 14

LASERS IN PROSTHODONTICS:

Fixed Prosthetics: 15

One of the essential elements of success of lasers in

fixed prosthodontics is the care and accuracy of the

component treatment stages and the laser often can

confer minimal collateral tissue damage through proper

consideration of the use of minimal laser energy of the

correct wavelength. Argon laser energy has peak

absorption in haemoglobin, thus lending itself to

providing excellent haemostasis and efficient

coagulation and vaporization of oral tissues. The

removal and recontouring of gingival tissues around

laminates can be easily accomplished with the argon

lasers.

Most commonly used in

i. Crown lengthening

ii. Soft tissue management around abutments

iii. Osseous crown lengthening

iv. Troughing

v. Formation of ovate pontic sites

vi. Altered passive eruption management

vii. Modification of soft tissue around laminates

Fig 3. Nd:YAG (200 μm laser fiber at 1.5 W and 15 Hz )

used for root canal disinfection.

Fig 4. Er:YAG Lasers for Fast and Precise

caries removal and tooth preparation.


7

viii. Bleaching

ix. Veneer removal

x. Laser etching of enamel, dentin, titanium,

zirconia

In pre-prosthetic surgery:16

i. Treatment of undercuts

ii. Tuberosity reduction

iii. Torus reduction

iv. Soft tissue modification

v. Epulis fissurata

vi. Denture stomatitis

vi. Residual ridge modification

In Implant dentistry: 17

i. Implant recovery

ii. Implant uncovering

iii. Implant site preparation

iv. Laser assisted cementation

v. Implant Surface Modification Using Laser

Guided Coatings

vi. Peri-implantitis

Laser applications in the dental laboratory: 18

I. Scanning of models for orthodontics.

II. Holographic interferometry.

III. Scanning of crown preparations for CAD-CAM

IV. Welding of alloys (Co-Cr,Ni-Cr,gold, titanium)

V. Sintering of ceramics

VI. Laser pointer surveyor

VII. CAD-sintering fabrication

VIII. CAD-polymer fabrication of splints or surgical

models Cutting of ceramics

Laser technology in fabrication of maxilla facial

prosthesis:19

i. Laser Digitizing Technology

ii. Selective Laser Sintering(SLS) technology 20

Laser Hazards and Laser Safety:21

The subject of dental laser safety is broad in scope,

including not only an awareness of the potential risks

and hazards related to how lasers are used, but also a

recognition of existing standards of care and a thorough

understanding of safety control measures.

Laser Hazard Class for according to ANSI and OSHA

Standards:

Class I - Low powered lasers that are safe to view

Class IIa - Low powered visible lasers that are

hazardous only when viewed directly for

longer than 1000 sec.

Class IIb - Low powered visible lasers that are

hazardous when viewed for longer than

0.25 sec.

Class IIIa - Medium powered lasers or systems that

are normally not hazardous if viewed for

less than 0.25 sec without magnifying

optics.

Class IIIb - Medium powered lasers (0.5w max) that

can be hazardous if viewed directly.

Class IV - High powered lasers (>0.5W) that

produce ocular, skin and fire hazards.

The types of hazards can be grouped as follows:

1. Ocular injury

2. Tissue damage

3. Respiratory hazards

4. Fire and explosion

5. Electrical shock

Proper training and education should be given for all the

dental personnel to follow standard operating

procedures. Personal protective equipment like

appropriate eye wear, clothing etc.

CONCLUSION :

It is most important for the dental practitioner to

become very familiar with the principles of recent

advances like laser and should have thorough clinical

experience. Although there is some overlap of the type

of tissue interaction, each wavelength has specific

qualities that will accomplish a specific treatment

objective. Laser energy requires some procedures to be

performed much differently than with conventional

instrumentation, but the indications for laser use

continue to expand and further benefit patient care.

Lasers in Dentistry


Lasers in Dentistry

8

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Accessed August 10, 2014.


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1 2 3 4 S. Naveen , A. Cicilia Subbulakshmi , Immanuel sathish solomon , Vineeta Gupta1. Senior Lecturer, Department of Conservative dentistry, VMS Dental college, Seeragapady Salem (TN)2. Senior Lecturer, Dept. of Oral Medicine and Radiology, KSR Institute of Dental Sciences, Trichengodu Namakkal (TN) 3. Professor, Dept. of Conservative Dentistry, R M Dental College & Hospital, Annamalai nagar, Chidambaram (TN)4. Reader, Department of Periodontics , Government Dental College, Raipur (C.G)

Corresponding Author :Dr. A. Cicilia subbulakshmiAddress: 6/3, Chaithanya Appartments, 5th cross, Brindhavan road, Fairlands, Salem-636016.Ph.no: 9488062382, E-mail: [email protected].

ABSTRACT

Context : Mineral trioxide aggregate [MTA] has several superior properties as a root end filling material but its

antibacterial property is not lethal against E.faecalis which is the main organism for endodontic treatment failure.

Hence antibacterial mixing agents was considered.

Aim : The aim of this in vitro study was to compare and determine whether the chlorhexidine gluconate[CHX] and

triple antibiotic agent(ciprofloxacin/metronidazole/minocycline) when used as a mixing agent for mineral trioxide

aggregate[MTA] would enhance the antimicrobial activity against E. faecalis.

Materials and methods : 30 single rooted tooth samples were endodontically treated, sterilized and divided into

three groups. Group A, B and C whose root ends were filled with MTA mixed in saline, CHX and antibiotic paste

respectively. The antimicrobial property was studied by placing MTA blocks in BHI (brain heart infusion broth) agar

plates suspended with bacteria and incubating it, after which the inhibition zones were measured.

Statistical analysis used : Kruskal Wallis test to ascertain the statistical significance.

Results : Group C showed enhanced antimicrobial property when compared to other groups.

Key words : MTA, antimicrobial property, CHX, triple antibiotic paste.

Key message : The properties of MTA will be enhanced when mixed with triple antibiotic paste or CHX.

INTRODUCTION:

When non-surgical endodontic treatment fails

periradicular surgery is advised. But the success of the

periradicular surgery depends on the root end sealing

material used. Ease of handling, dimensional stability,

radio opacity, insolubility and moisture resistance are

the properties of an ideal root end filling material .1

MTA which has several potential clinical applications

has all the above mentioned properties in addition has

the ability to stimulate osteoblastic activity. The original

study of Torabinejad et al found that MTA was effective

against some facultative microorganisms but not

“ To determine the antimicrobial property of MTA when mixed with triple antibiotic paste and chlorhexidine gluconate:

An invitro study”

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against other bacterial strains, including Enterococcus

faecalis .2

E.faecalis is a nonspore-forming, fermentative,

facultatively anaerobic, Gram-positive coccus. It can

penetrate deep into dentinal tubules and resist

bactericidal substances commonly used in endodontic

procedures.

Chlorhexidine (CHX) which is active against Gram

positive and Gram-negative bacteria, especially E.

feacalis facultative anaerobes and aerobes, moulds,

yeasts and viruses acts by adsorbing onto the cell wall of

the microorganism and causing leakage of intracellular

components and eventually leading to cell death . The 3

triple-antibiotic paste was first tested in vitro by Sato et

al. and was found to be effective in treating dentin

infected with E.faecalis .4

Hence this study was done to compare the

antimicrobial property of MTA when mixed with CHX

and triple antibiotic paste.

MATERIALS USED IN THE STUDY:

Extracted human lower premolars ( 30 ) Enterococcus faecalis strain Culture media (Pfizer selective Enterococcus agar) Culture media jar ( 1000 ml jar ) Culture plates ( Diameter 60mm;25 nos ) Distilled water Micropipette, micropipette tips ( 0.5µl ) Incubator, Autoclave Glass test tubes (5ml) Plastic test tubes (5ml),Swab and cotton Bunsen burner, Spirit Gloves and face mask Permanent marker Centrifuge tubes ( 3ML ) Test tube stand Diamond points ( round bur 08 ) Sterilization pouches and pouch sealer High speed air rotor hand piece.

K – files Size 10, Sizes 15 – 40, Sizes 45 – 80 . Sodium HypoChlorite 3% 5 ML irrigating syringe Mini Endo Block, PulpDent 17% EDTA, Saline Straight hand piece, Micro motor unit Carborundum disks with mandrel Lentulo spiral Ball burnisher Contra angle micromotor hand piece Epoxy glue Nail varnish. Digital Camera Pro root tooth colored MTA. Triple antibiotic (ciprofloxacin, metronidazole and minocycline) Chlorhexidine gluconate, Measuring scale

METHODOLOGY

Culturing of the bacterial strain

20 ml BHI broth was taken in a test tube and heated in a Bunsen burner for 60 seconds and allowed to cool to reach room temperature. The freeze dried vacuum sealed E.faecalis sample was opened from one end and the sample was mixed in the BHI broth by shaking followed by moving the test tube in circular motion. The test tube was then incubated for 4 hours before inoculation.

Preparation of the teeth samples

30 extracted human single rooted mandibular premolars[fig-1] were collected and stored in saline.

The diamond points used for access cavity were autoclaved. Access opening was performed with a high speed air rotor handpiece with water coolent. The initial

entry was made with a 0.08 round diamond abrasive point. The access cavity was extended with a non end cutting diamond point and the working length was estimated by visual method by deducting 1mm from the initial file visible beyond the apex. The canals were instrumented to an apical size of ISO file size #60 with step back technique with recapitulation after every instrument used. The canals were copiously irrigated

To Determine the Antimicrobial Property of MTA


Fig - 1


11

with 5ml of 3% sodium hypochloride between each instrument.

The smear layer was removed with a 2ml aqueous solution of 17% EDTA. The teeth samples were then flushed finally with saline as a final rinse. Then decoronation was done. The roots were kept on wet gauze to maintain humidity and autoclaved in sealed sterilization pouches sealed for 15 mins at 121º C.

After sterilization, 2 samples were inoculated in BHI broth and incubated anaerobically for 24 hours at 37º C to confirm sterility of the samples. After confirming the sterility of the broth, the study was performed in aseptic conditions and the 30 teeth were randomly divided into 3 groups with 10 samples in each group. Groups are Group A – MTA mixed with sterile water Group B – MTA mixed with chlorhexidine Group C – MTA mixed with triple antibiotic paste.

Preparation of MTA :

Tooth colored ProRoot MTA was used in this study. 100mg of MTA was taken for each Group.

In Group A MTA was mixed with sterile water according to the manufacture instructions. In this Group 100mg of MTA was mixed with 36μl of sterile water.

In Group B MTA was mixed with 36μl chlorhexidine 0.12% solution.

In group C triple antibiotic was mixed with saline and then 36μl test solution was mixed with MTA.

Placement of the root end filling material:

Root-end resections were made by removing 3 mm of the apex at a 90° angle to the long axis of the root with a cylindric carbide bur using a high-speed handpiece with coolent water spray.

The root experimental samples were randomly divided into 3 groups of 10 each (MTA with sterile water, MTA with 0.12% CHX, MTA with triple antibiotic paste). The material was mixed and placed into the root end with an amalgam carrier.

Agar diffusion test :

200 μl of bacterial s u s p e n s i o n (approximately 5 ×10 7

colony-forming units) were spread on BHI agar plates. Freshly mixed specimens of size 5mm diameter from each test material were prepared and placed in the agar p l a t e s . A f t e r incubation at 37°C for 24 hrs and 7 days under anaerobic conditions, the agar plates were examined for bacterial- inhibition zones. The diameter of the halo formed in the bacterial lawn was measured in millimeters. An independent observer who was blind to the study measured the zones of inhibition[fig-2].

RESULTS :

The zones of inhibition of the three groups MTA/sterile water, MTA/CHX, MTA/antibiotic paste were measured in millimetres after 7 days in anaerobic condition. The results obtained are shown in the Table-1.

The mean value of the individual groups was subjected to Kruskal Wallis test to ascertain the statistical significance.

The mean value obtained in Group A is 11.1mm. The mean value obtained in Group B was 13.6mm.The mean value obtained in Group C was 14.1mm. (Table-2).

Comparing the data obtained from the three Groups (Group A Versus Group B and Group C) shows (p<0.005) significance value. Group A was compared with Group B (p<0.011) showed significant difference. Group A was compared with Group C (p<0.002) showed significant difference. No significant difference was found when Group B was compared with Group C (p>0.529).

Coming to the sealing ability no turbidity was formed in the lower compartment of the test apparatus in any of the groups. Hence there was no significant difference in the sealing ability of the three groups.

Samples 1 2 3 4 5 6 7 8 9 10

MTA/sterile water 10 11 12 10 11 13 10 11 12 11

MTA/CHX 13 11 16 18 13 15 12 10 13 15

MTA/antibiotic 14 12 15 16 10 16 15 14 13 16

TABLE I: Zone of inhibition of three groups (in millimeters)

Fig -2


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TABLE II: Mean Zone of inhibition of three groups (in millimeters)

Material used Mean K.W value P value MultipleK.W test

MTA/sterile water 11.1

10.620 0.005 1 Vs 2,3 MTA/CHX 13.6

MTA/antibiotic 14.1

DISCUSSION:

Several different microorganisms play a key role in

endodontic treatment failures of which E.faecalis is the

most frequently recovered microorganism from

periapical periodontitis . Treatment outcome depends 5

on successful e l iminat ion of the associated

microorganisms and infected tissues as well as the

effective seal of the root-end site. The root-end filling

material used should also have certain anti-microbial

property to prevent future recontamination . 6

Cabiscol et al demonstrated that MTA in an aerobic

atmosphere can generate ROS [reactive oxygen

species], which have antimicrobial activity .The apical 6

third of the infected root canal is an anaerobic

atmosphere, hence the use of MTA does not favour the

formation of ROS. E.feacalis has high alkali tolerance

which might result in resistance to certain intracanal

medicaments and ability to survive conventional root

canal therapy .5

The original study of Torabinejad et al found that MTA

was not effective against E.faecalis . Hence this study 2

was done to compare the antimicrobial property of MTA

when mixed with CHX and triple antibiotic paste.

MTA itself has some antimicrobial property due to its

high PH of 11 to 12 which it can maintain for 78 days. E.

feacalis can survive in extra alkaline environment.

Perhaps the inherent, persistent high alkalinity of MTA

is just enough to overwhelm the E. faecalis , which could 7

have contributed to the zone of inhibition observed in

the Group I MTA/sterile water.

It has been proved that CHX has better antimicrobial

property, but Pucher states that CHX was shown to be

highly cytotoxic to human fibroblasts in vitro .8

Gabler et al concluded that serum present during the

initial healing period seems to provide significant

protection against these cytotoxic effects . Stowe et al 9 10

have demonstrated that MTA has better antibacterial

properties when mixed with 0.12% CHX instead of

water.

Luiz et al stated that When combined with calcium

hydroxide, production of ROS is increased .It is proved 11

that MTA on hydration produces calcium hydroxide. we

assume that this hydration of calcium hydroxide

combined with CHX increases the production of ROS

and has better antibacterial property than MTA mixed

with sterile water in this study.

The first reported local use of an antibiotic in

endodontics was in 1951, when Grossman used a

polyantibiotic paste known as PBSC (a mixture of

penicillin, bacitracin and streptomycin and caprylate

sodium) In this study the antibiotics used are 12

ciprofloxacin, metronidazole and minocycline pastes.

Metronidazole is a nitroimidazole compound that

exhibits a broad spectrum of activity against anaerobes

but it had no activity against aerobes. Tetracyclines, are

a group of bacteriostatic antimicrobials having broad

spectrum of activity against both gram-positive and

gram-negative microorganisms. In endodontics,

tetracyclines have been used to remove the smear layer

from instrumented root canal walls for irrigation of

apical root-end cavities during periapical surgical

procedures.

Ciprof loxacin is a synthet ic f loroquinolone.

Ciprofloxacin has very potent activity against gram-

negative pathogens but very limited activity against

gram-positive bacteria. Most anaerobic bacteria are

resistant to ciprofloxacin hence it is often combined

with metronidazole in the treatment of mixed

infections .13

In the present study the zone of inhibition was more for




13

MTA/antibiotic mixture than MTA/CHX and MTA/water.

Here the interaction between MTA and triple antibiotic

paste was not known. In this study E.faecalis was used,

which was a facultative anaerobe. The action of

metronidazole is more predominant for anaerobic

bacteria. The use of a combination of drugs was also

another reason for more antibacterial activity. Another

advantage of using a combination of drug is that, it will

decrease the likelihood of the development of resistant

bacterial strains. Sato et al evaluated the potential of 14

this mixture to kill bacteria in the deep layers of root

canal dentin in situ.

In present study it is noted that MTA/CHX mixture sets

more rapidly than MTA/water. This was concluded in

the study by Stowe et al, that MTA/CHX mixture seemed

to set more rapidly (1–2 min) than the MTA/water

mixture (5–6 min) and take on a more crumbly texture

at placement .10

REFERENCES:

1. Achristos Maltezos and Gerald N. Glickman.

Comparison of the Sealing of Resilon, Pro Root

MTA, and Super-EBA as Root-End Filling

Materials: A Bacterial Leakage Study.

JOE—2006; 32 ( 4) : 324-327.

2. Khalid Al-Hezaimi.MTA preparations from

different origins may vary in their antimicrobial

activity. OOOE 2009;107:e85-e88.

3. E. P. Hernandez et al. Effect of ProRoot MTA

mixed with chlorhexidine on apoptosis and cell

cycle of fibroblasts and macrophages in vitro.

IEJ 2005; 38 : 137–143.

4. Ozlem Marti Akgun et al. Use of triple antibiotic

paste as a disinfectant for a traumatized

immature tooth with a periapical lesion: A case

report. OOOE, 2009;108:e62-e65.

5. Hui Zhang et al. Dentin Enhances the

Antibacterial Effect of Mineral Trioxide

A g g r e g a t e a n d B i o a g g r e g a t e . J O E

2009;35:221–224.

6. Zio de Janeiro, Caroline S, Raphael H. The

antimicrobial activity of gray-colored mineral

trioxide aggregate (GMTA) and white-colored

MTA (WMTA) under aerobic and anaerobic

conditions. OOOE, 2010;109:e109-e112.

7. Dennis M. Holt, Thomas J. Beeson, Richard E.

The Anti-microbial Effect Against Enterococcus

faecalis and the Compressive Strength of Two

Types of Mineral Trioxide Aggregate Mixed

With Sterile Water or 2% Chlorhexidine

Liquid.JOE 2007; 33 ( 7) : 844-847.

8. P u c h e r J J , D a n i e l J C . T h e e f fe c t s o f

ch lorhex id ine d ig luconate on human

f i b r o b l a s t s i n v i t r o . J P e r i o d o n t o l

1992;63:526–32.

9. Gabler WL, Roberts D, Harold W. The effect of

chlorhexidine on blood cells. J Periodont Res

1987;22:150-153.

10. Ted J. Stowe. The effects of chlorhexidine

gluconate (0.12%) on the antimicrobial

properties of tooth-colored proroot mineral

trioxide aggregate. JOE 2004; 30 ( 6) : 429-431.

11. Luiz Eduardo Barbinet al. Determination of

para-Chloroaniline and Reactive Oxygen

Species in Chlorhexidine and Chlorhexidine

Associated with Calcium Hydroxide. JOE2008;

34: 1508 –1514.

12. Z. Mohammadi, P. V. Abbott. On the local

applications of antibiotics and antibiotic-based

a g e n t s i n e n d o d o n t i c s a n d d e n t a l

traumatology.IEJ 2009; 42:555–567.

13. Windley W, Teixeira F, Levin L, Sigurdsson A,

Trope M .Disinfection of immature teeth with a

triple antibiotic paste. JOE 2005; 31:439–43.

14. Sato I, Ando N, Kota K. Sterilization of infected

root-canal dentine by topical application of a

mixture of ciprofloxacin, metronidazole and

minocycline in situ. IEJ 1996; 29: 118 –24.


Pulmonary function test in chronic kidney disease patients : A study from tertiary care hospital

P. Gupta , Mukund .G1 2

1. Associate Professor, Nephrology Unit, Department of Medicine, Pt. J.N.M. Medical college, Raipur(C.G)2. MD Medicine, Private Practioner, Raipur

Corresponding author : Dr.Punit Gupta

Associate Professor, Nephrology Unit, Department of Medicine, Pt. J.N.M. Medical college, Raipur(C.G)Email : Mobile no- [email protected]

ABSTRACTContext: Malnutrition and inflammation are associated with impaired pulmonary function in pre-dialysis patients. Aims: To study variation in Spirometry due to malnutrition and inflammation. Methods and Material: Fifty Chronic Kidney Disease patients admitted in Pt.J.N.M medical college & GBG kidney care hospital, Raipur were studied. Pulmonary function test was performed as per ''ATS/ERS TASK FORCE Guidelines. Malnutrition and inflammation were assessed by Subjective Global Assessment scores (SGA) and CRP respectively. Statistical analysis used: Chi-square test, Student's t-test and Spearman's rank correlation. Results: Males were 70% and females were 30%. Restrictive pattern on pulmonary function test was present in 84%. Pulmonary restriction was severe in 43% males, and 8.3% females. Subjective global assessment score was B or C in 94% of which 20% were SGA C. Mean predicted Forced Vital Capacity was 37 ± 11% in SGA C and 82 ± 5% in SGA A. Mean predicted Forced Expiratory Volume in 1st second (FEV1) was 41 ± 13% in SGA C and 86 ± 3% in SGA A. Mean Peak Expiratory Flow Rate (PEFR) was 27 ± 9% in SGA C and 65 ± 23% in SGA A. Spearman's rank correlation (Rho) of CRP with percent predicted FVC, FEV1 and PEFR were Rho= -0.84, -0.60 and-0.35 respectively. Conclusions: Restrictive pattern was the most common pulmonary function anomaly. ( < 0.001) .Severe restriction Pwas significantly more common in males than in females ( < 0.01). Percent predicted FVC, FEV1 and PEFR were Psignificantly lower in severely malnourished than in well nourished. ( < 0.05). Severity of restriction on pulmonary Pfunction test increased in co-relation with increase in the level of CRP. Key-words: Malnutrition, Inflammation, Chronic Kidney Disease, pulmonary function, Subjective Global Assessment scores (SGA), CRP

INTRODUCTIONChronic kidney disease (CKD) is a devastating medical, social, and economic problem for patients and their families Prevalence CKD patients will continue to rise, 1.reflecting the growing elderly population and increasing numbers of patients with diabetes and hypertension. 2,3

Inflammation and malnutrition are common findings in patients of chronic kidney disease (CKD). Approximately 30-50% of patients with CKD have elevated serum levels of C-reactive protein (CRP). In CKD patients the acute phase response may be influenced by a number of

factors such as age, race, residual renal function and gender. Since malnutrition also occurs in pre-dialysis 4

patients, it is evident that dialysis-unrelated factors, e.g. infectious and inflammatory complications, as evidenced by increased levels of pro-inflammatory cytokines and CRP, is common in CKD patients and may cause malnutrition and progressive atherosclerotic cardiovascular disease. 5,6,7,8

SGA is a clinically useful measure of protein-energy nutritional status and is helpful in identifying patients with increased risk of morbidity and mortality in the setting of CKD. There is controversy over the degree to 9,10

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which albumin and nutrition are interrelated. 11

Physiologically, the lungs and kidneys are intricately related , Impairment of spirometric function in

12

patients with renal insufficiency is continual, with reduction of GFR, and thus small airways dysfunction may be expected not only in patients with end-stage renal failure, but also in those with moderate GFR reduction. This pulmonary dysfunction may be a direct 13

result of the circulation of toxins or, indirectly, from the excess volume due to the increased quantities of circulating body fluids, anemia, immunological suppression, drugs and deficient nutrition. 14

A low lung function has been associated with increased levelsof fibrinogen, C-reactive protein and white blood

cells. Several papers reported that inflammation 15

markers fibrinogen and C-reactive protein (CRP) were

inversely associated with lung function in cross-

sectional analyses. FVC is significantly and inversely 16

associated with plasma levels of inflammation sensitive plasma proteins. Impaired pulmonary function was associated with malnutrition and inflammation. 17

To best of our knowledge there is no Indian study regarding the association of CRP and SGA with impaired pulmonary function in pre-dialysis patients of CKD. Hence we have done this study to establish the relation between SGA , a marker of protein energy wasting and CRP, a marker of inflammation with lung function in CKD patients.

AIMS AND OBJECTIVESStudy of was conducted in the department of medicine, Dr.B.R.A.M hospital, Raipur (C.G) with the aims and objectives of:

1. To study Statistical correlation between various stages of CKD and pulmonary function anomalies (FVC, FEV1, FVC/FEV and PEFR) 1

2. To study Statistical correlation between Subjective global assessment score and pulmonary function anomalies (FVC, FEV1, FVC/FEV and PEFR) 1

3. To study Statistical correlation between Serum CRP with Pulmonary function anomalies (FVC, FEV1, FVC/FEV and PEFR) 1

4. To assess the Statistical correlation between Subjective global assessment score and serum CRP with pulmonary function anomalies (FVC, FEV1, FEV1/FVC and PEFR)

SUBJECTS AND METHODS

The study was conducted in the department of medicine, Pt. J.N.M. medical College and Dr. B.R.A.M. hospital, Raipur. In this study 50 chronic Kidney Disease patients, as per National Kidney Foundation, 2002 Kidney Disease outcome Quality Initiative (K/DOQI) guidelines, admitted in the wards of Medicine Department were selected as cases.Inclusion criteria for study group1. Patients with CKD according to the NFK-DOQI definition.2. Stage 0, I, II, III, IV and V CKD.3. Diabetics and non diabetics with CKD.4. Chest X ray showing absence of any active or old lung pathology.5. If Smoker then with <1 Cigarette pack per year.6. If Tobacco chewer then included in the study. 7. Age >15 years to ≤ 70 years. Patients were assessed by:a. History and physical examinationDetailed clinical history was recorded regarding age, sex, presenting complaints and duration of symptoms and significant past history of each patient. All patients underwent complete clinical examination including pulse, blood pressure, general examination and systemic examination. Height and weight were expressed in centimetres and kilograms respectively. b. Investigations: All routine investigation was done in all the cases.c. Assessment of Malnutrition, inflammation and pulmonary function abnormalities.i) Malnutrition: Malnutrition was assessed by Subjective global assessment, body mass index and serum albumin. Every patient was assessed and different SGA scores were given as per Detsky et al. 22

ii) Inflammation: Inflammation was assessed by measuring CRP (C reactive protein). The plasma concentrations of CRP were measured by CRP Latex

agglutination method.iii) Pulmonary Function Test: Pulmonary function test was performed three times and best of the three efforts were considered as appropriate .PFT was performed as per ''ATS/ERS TASK FORCE: STANDARDISATION OF LUNG FUNCTION TESTING'' 2005. Following activities were strictly avoided before the spirometry-Smoking within at least 1 h of testing-Consuming alcohol within 4 h of testing-Performing vigorous exercise within 30 min of testing-Wearing clothing that substantially restricts full chest

15


Pulmonary function test in CKD patients

and abdominal expansion-Eating a large meal within 2 h of testing -Lab records: Ambient temperature, barometric pressure and time of day were recorded. Statistical Analysis Chi-square test has been applied to find any association between two categorical variables. Student's t-test has been used to find any significant difference between the normal and abnormal groups of variables with respect to average values. Spearman's rank correlation was applied to find relation between the Level of CRP and FVC,FEV and FEV /FVC.1 1

RESULTS The number of male patients was 2.33 times higher than the number of female patients of CKD. Mean age for all patients was 42.58 ± 13.85 years. Mean age of male patients was 43.6 ± 13.8 years while that of female patients was 40.2 ± 14.14 years.The leading cause of chronic kidney disease in patients from urban areas (n=25) is diabetes mellitus accounting for 24% along with chronic glomerulonephritis (24%) of cases, followed by Hypertension (16%), Obstructive nephropathy(12%). UTI/Chronic pyelonephritis (8%) and sickle cell disease, renal stone and Polycystic Kidney disease in 4% each.Among patients from rural areas (n=25) chronic glomerulonephritis was the etiology of chronic kidney disease in 20% of cases followed by obstructive nephropathy in 16% of cases. While Renal stone, UTI and hypertension were observed in 12% each. In patients from rural areas diabetes mellitus was etiological factor responsible for CKD in 8% while in urban it accounted for 24% of cases. Diabetes was significantly more common in urban cases as compared to rural.( < 0.01)PRestrictive pattern on pulmonary function test was the most common anomaly accounting for 84% of the total cases followed by mixed pattern (6%) and obstructive pattern (4%). No anomaly was detected in 6% of the cases.Severe restriction was significantly more common in males as compared to females.Majority of patients who had restrictive pattern on PFT testing 38 (90.47%) were in stage III, IV and V (Overt nephropathy) while only 4 (9.53%) were in stage I and II (covert nephropathy).Severe restriction in stage V CKD was significantly more

common than in stage III and IV.There was no statistically significant difference between the mean hemoglobin in males and females in any stage of CKD. That Mean Hb was low in stage IV (6.62 ± 1.90) and stage V (6.68 ± 2.69) CKD as compared to other stages. Malnutrition in the form SGA B or C was present in 94% of the patients included in study. Out of which 20% were severely malnourished. More Co-morbidities in the form of diabetes, hypertension and smoking were present in SGA C as compared to SGA B. Mean Serum albumin was s ignif icant ly lower in severely malnourished (SGA C) as compared to well nourished (SGA A). Markers of inflammation were significantly more common in severely malnourished as compared to well nourished.Mean forced vital capacity was lowest (37 ± 11) in severely malnourished SGA C and highest (82 ± 5) in well nourished (SGA A). Mean forced expiratory volume in 1st

second (FEV ) was lowest (41 ± 13) in severely 1

malnourished (SGA C) and highest (86 ± 3 in well nourished (SGA A). Mean Peak Expiratory Flow Rate (PEFR) was lowest in SGA C (27 ± 9) and highest in SGA A (65 ± 23). Mean FEV /FVC is almost same in SGA A, SGA B 1

and SGA C . Severe restriction is seen in 70% of severely malnourished (SGA C).Mean Age of hs CRP positive patients was significantly more than hs CRP negative patients.The mean hsCRP level was 9.6 ± 10.8 (range 1.2-38.4)mg/l. Mean GFR in CRP positive patients were 29.4 while it was 40 in CRP negative patients. Lower GFR was present in CRP positive patients.Significant negative correlations were found between hs CRP and the percent predicted value of FVC%, FEV1and PEFR.

DISCUSSION Analysis of Subjective Global Assessment status in CKD There was no statistically significant difference as per the comorbid conditions are concerned between

23malnourished and wellnourished as per SGA. Various studies reported protein energy wasting in 19 to 20% 24,25. While other studies demonstrate prevalence of

8,26,15,27malnutrition in the range of 30 to 50%. In our study the total patients with malnutrition were 47 out of 50.that shows that 94%. The reason for this is that in Indian cases malnutrition is widely prevalent. In eastern India, overall prevalence of malnutrition was 65% in

28predialysis patients. The cause of such a high amount

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of malnutrition in our study can be because of its small sample size (n=50). Apart from that, most important is that the study is being done on low socioeconomic strata of the society. They are already malnourished in nature. If we consider severe malnutrition then our study demonstrated severe malnutrition in 20% (n=10). SGA is deficient in differentiating between mild to

55moderate malnutrition. Protein intake of Indian 29 patients on a vegeterian diet is normally low. With low

protein intake the wear and tear of the skeletal muscles is on stake, protein calorie malnutrition ensues and is responsible for the high SGA Score.In study done under the name of CANUSA (CANADA-30

USA (CANUSA) peritoneal dialysis study group under principal investigators Churchill DN, et al 1996 on patients of CKD, there were 30 patients (4.2%) with severe malnutrition, 364 (51 .2%) with mild to moderate malnutrition according to SGA. While in our study 20% (n=10) had severe malnutrition and 74% (n=37) had mild to moderate malnutrition. According to SGA, 70% of the patients had a normal nutritional status, 29% were classified as being mild to moderately malnourished and only 1% were classified as being severely malnourished in the study done by. Jansen 23

MAM, et al 2001 on behalf of NECOSAD Study Group.Prevalence of malnutrition in the form of SGA > 1 i.e SGA B or C was 36%. 13

Our results suggest that the prevalence of inflammation among the pre-ESRD population is high and that an

increased CRP in pre-dialysis patients predicts a

constant inflammatory state. And this result is in accordance of Barany P et al 2001 and Prakash J, et al 32 28

2007. On measuring the mean CRP level of 18 patients, the CRP level of which was documented by our laboratory. We found that the mean CRP level was 9.6 ± 10.8 (range 1.2-38.4). As compared to the result of Ortega O, et al 31

2002 the average CRP level in their study was 8.3 ± 14.2 mg/l (range 2-95 mg/l; median 2 mg/l). The mean value of hsCRP was 14.3 ± 11.4 mg/L (range 0.36-44.2 mg/L) in the study done by Abraham G et al 2009.14

Analysis of Pulmonary function on the basis of SGA status and CRP In this study difference in FVC (% predicted), FEV (% 1

predicted) and PEFR (% predicted) in SGA C as compared to SGA A was statistically significant [( < 0.001), ( < P P0.001) and ( < 0.05) respectively]. While in study done Pby Nascimento, et al in 2004 on pre dialysis patients 8

reported significant difference in mean FEV (% 1

predicted) and FVC (% predicted) in well nourished and malnourished but not regarding PEF (% predicted). The different spirometric parameter namely Spo2, FEV1, FVC, FEV1/FVC and PEFR was compared in between CRP positive and CRP negative group. Only statistically significant difference was found in mean FVC of the two groups. Nascimento MM, et al 2004 reported the difference in FEV , FVC, and FEV1/FVC and 1

mean PEFR. The Present study represents the restrictive pattern of intrapulmonary in nature . The reduction can be due to an increase in quantity of interstitial tissue in lung, for example interstitial pneumonitis, fibrosis, infiltration or edema. Altenatively the reduced lung compliance can be due to fibrosis of the visceral pleura and subpleural tissue. Any of these changes can increase the retractive force exerted on the walls of lung airways; the retraction reduces the airway resistance and increases the FEV1%. In this circumstance the peak expiratory flow can be well preserved or even supra maximal early in the disease process but, once lung volume becomes severely reduced the PEF also declines because it is then measured at a relatively small lung volume. 39

Spearman's rank correlation of different parameters of pulmonary function with level of hs CRPWe compared the level of hsCRP in hsCRP positive patients with that of % decrease in FVC, FEV and PEFR. 1

We applied Spearman's rank correlation for this variables and found significant degree of negative correlation of hs CRP with that of FVC%, FEV % but not 1

for PEFR. In the study done by Nascimento MM, et al they got 8

significant association between the CRP level and FVC%, FEV % and PEFR. Thus serum CRP assay must be 1

routinely done on pre-dialysis patients as there level negatively correlates with the degree of restriction in pulmonary function testing. Thus measures to curb high level of inflammation in these pre-dialysis patients such as higher antibiotic support and higher and proper nutrition be given to these patients thus preventing the fatal complication of high CRP level in these patients.

CONCLUSIONThe present study shows that chiefly malnutrition and inflammation are responsible for severe restriction encountered on pulmonary function in pre-dialysis



cases of CKD. Improvement in malnutrition by adequate nutrition to patients of CKD leads to a better outcome as far as pulmonary functions are concerned. Numerous studies have shown that there is a relation of FVC and cardiovascular mortality thus by improvising nutrition we can not only improvise the pulmonary function but also improve the cardiovascular profile even before starting dialysis.

REFERENCES

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2. Thomas R, Kanso A, Sedor JR. Chronic Kidney Disease and Its Complications. Prim Care. 2008 35(2): 329–332.

3. Bommer J. Prevalence and socio-economic aspects of chronic kidney disease. Nephrol Dial Transplant 2002: 17 [Suppl 11]: 8–12.

4. Nascimento MM, Qureshi AR, Stenvinkel P, Pecoits-Filho R, Heimburger O, Cederholm T et a l .Malnutr it ion and inf lammation are associated with impaired pulmonary function in patients of Chronic Kidney disease.Nephrol Dial Transplant 2004 : 19:1823-28.

5. Adey D, Kumar R, McCarthy JT, Nair KS. Reduced synthesis of muscle proteins in chronic renal failure. Am J Physiol Endocrinol Metab. 2000. 278: E219-E225.

6. Ikizler TA, Greene JH, Wingard RL, Parker RA, and Hakim RM. Spontaneous Dietary Protein Intake During Progression of Chronic Renal Failure. J. Am. Soc. Nephrol. 1995; 6:1380-91.

7. Stenvinkel P, Heimburger O, Lindholm B, Kaysen GA, Bergstorm J. Are there two types of malnutrition in chronic renal failure? Evidence for relationships between malnutrition, inflammation and atherosclerosis (MIA syndrome). Nephrol Dial Transplant .2000; 15: 953-60.

8. Abraham G, Sundaram V, Mathew M, Leslie N, Sathiah V. C-Reactive protein, a valuable predictive marker in chronic kidney disease. Saudi J Kidney Dis Transpl 2009;20:811

9. Asgarani F, Mahdavi-Mazdeh M ,Lessan-Pezeshki M, Kh. Makhdoomi A and Nafar M, Correlation Between Modified Subjective Global Assessment With Anthropometric M e a s u r e m e n t s A n d L a b o r a t o r y

Parameters.Acta Medica Irnica, ; 2004, 42(5): 331-7.

10. Lawson JA, Lazarus R, Kelly JJ.Prevalence and Prognostic Significance of Malnutrition in Chronic Renal Insufficiency.Journal of renal nutrition, 2001; 11(1):16-22 .

11. Jones CH, Newstead CG, Will EJ, Smye SW, Davison AM. Assessment of nutritional status in CAPD patients: serum albumin is not a useful measure. Nephrol Dial Transplant .1997; 12: 1406–13.

12. Hassan IS, Ghalib MB. Lung Disease in Relation to Kidney Diseases. Saudi J Kidney Dis Transpl 2005.16:282-7.

13. Tkácová R, Tkác I: Spirometric alterations in patients with reduced renal function. Wien Klin Wochenschr. 1993;105(1):21-4.

14. Engström G,Lind P, Hedblad B, Wollmer P,Stavenow L, Janzon L, Lindgärde F. Lung Function and Cardiovascular Risk :Relationship With Inflammation-Sensitive Plasma Proteins . Circulation. 2002;106:2555-60.

15. Jiang R, Burke GL, Enright PL, Newman AB, Margolis HG, Cushman M, Tracy RP, Wang Y, Kronmal RA and Barr RG. Inflammatory ,

Markers and Longitudinal Lung Function Decline in the Elderly. American Journal of Epidemiology 2008;168:602-10.

16. Yoon SH, Choi NW, Yun SR et al. Pulmonary D ys f u n c t i o n I s Po s s i b l y a M a r ke r o f Malnutrition and Inflammation but Not Mortality in Patients with End-Stage Renal Disease. Nephron Clin Pract 2009;111:c1-c6.

17. Detsky AS,Mclaughlin JR,Baker JP,Johnston N, whittaker S,Mendelson RA,Jeejeebhoy KN.What is Subjective Global Assessment of Nutritional Status?. Journal Of Parenteral And Enteral Nutrition. 1987. 11(1):8-13.

18. Jansen MAM,korevaar JC,Dekker FW,Jager KJ,Boeschoten EW,Krediet RT et al: Renal Function and Nutritional Status at the Start of Chronic Dialysis Treatment:J Am Soc Nephrol, 2001. 12:157-163.

19. Bruchfeld A, Qureshi AR, Lindholm B, Barany P, Yang L, Stenvinkel P, Tracey KJ. High Mobility Group Box Protein-1 Correlates with Renal Function in Chronic Kidney Disease (CKD). Mol Med. 2008 Mar–Apr; 14(3-4): 109–115.

20. Campbell KL, Susan A, Bauer JD and Davies



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PSW. Evaluation of nutrition assessment tools compared with body cell mass for the assessment of malnutrition in chronic kidney d i s e a s e . J o u r n a l o f R e n a l Nutrition.2007;17:189-95.

21. Caravaca F,Arrobas M,pizarro JL ,sanchez-casado E. Uraemic symptoms, nutritional status and renal function in pre-dialysis end-stage renal failure patients . Nephrol Dial Transplant 2001;16 : 776-82.

22. Cupisti A , D'Alessandro C, Morelli E, Rizza GM, Galetta F, Franzoni F, Barsotti G. Nutritional status and dietary manipulation in predialysis chronic renal failure patients. J Ren Nutr. 2004 Jul; 14(3):127-33.

23. Prakash J , Raja R , Mishra RN , Vohra R , Sharma N , Wani IA et al . High Prevalence of Malnutrition and Inflammation in Undialyzed Patients with Chronic Renal Failure in Developing Countries: A Single Center Experience from Eastern India. Renal Failure 2007;29: 811-816.

24. eheray SS.Dietary protein intake in Indian patients with chronic renal failure. Indian Journal of Nephrology. 1996 ; 6: 19-21.

25. Churchi l l DN,Taylor DW,Keshaviah PR. Adequacy of Dialysis and Nutrit ion in Continuous Peritoneal Dialysis: Association with Cl in ical Outcomes. CANADA-USA (CANUSA) Peritoneal Dialysis Study Group. J, Am. Soc. Nephrol. 1996; 7:198-207.

26. Ortega O,Rodriguez I,Gallar P,Carreño A, Ortiz M,Espejo B, et al . Significance of high C-reactive protein levels in pre-dialysis patients. Nephrol Dial Transplant .2002;17: 1105-09.

27. Bárány P.Inflammation, serum C-reactive protein, and erythropoietin resistance. Nephrol Dial Transplant.2001;16: 224-7.

28. Hekmat R, Boskabady MH, Khajavi A, Nazary A.The effect of hoemodialysis on pulmonary function tests and respiratory symptoms in patients with chronic renal failure. Pak J Med Sci .2007; 23:862-6.

29. Navari K, Farshidi H, Pour-Reza-Gholi F , Nafar M, Zand S, Pour HS, Eftekhaari TE. Spirometry P a r a m e t e r s i n P a t i e n t s U n d e r g o i n g Hemodialysis With Bicarbonate and Acetate Dialysates. IJKD 2008;2:149-53.

30. M e m o n M A , S a n d i l a M P, A h m e d S T. Spirometric reference values in healthy, non-smoking, urban Pakistani population. J Pak Med Assoc. 2007 Apr;57:193-5.

31. Utaka S, Avesani CM, Draibe SA, Kamimura MA, Andreoni S, Cuppari L. Inflammation is associated with increased energy expenditure in patients with chronic kidney disease. Am J Clin Nutr 2005; 82:801–5.

32. Gorek DA, Ulubay G, Bayraktar N, Eminsoy I, Öner Eyüboğlu F. The effects of cachexia and related components on pulmonary functions in Patients with COPD. Tüberküloz ve Toraks Dergisi 2009; 57: 298-05.

33. Nainani N, Panesar M. Nephrogenic Systemic Fibrosis. Am J Nephrol 2009;29:1–9.

34. Cotes JE, Chinn DJ, Miller MR .Lung function physiology, measurement and spplication in medicine. In:Patterns of abnormal function in lung disease.Massachusetts: Blackwell publishing ;6 th Edition. 2006:533-34.



1

ABSTRACT

Objectives: To correlate clinical presentation and gender of patients with oral lichen planus with chronic liver

disease by estimating the serum transaminase level.

Material & Methods: The present study included two groups; test group (patients with oral lichen planus) and

control group (normal healthy adults without any clinical evidence of oral mucosal lesions) of 45 patients each. Both

the groups were subjected to serum transaminase level test.

Results : At least one of two assays (either AST or ALT) showed altered results in 3 patients in the control group and

11(13.33%) patients in the test group. Both assays were raised in 2 patients in the control group and 6 patients in the

test group. Out of these, six (4 males and 2 females) patients with elevated transaminase levels had erosive lesions.

Conclusion: We conclude that the presence of oral lichen planus particularly the erosive variant should be seen as a

presentation of alteration in the functioning of the hepatocytes, which on further investigations might bring to light

an asymptomatic liver disease.

Key Words: Oral Lichen Planus, Alanine transaminase (ALT), Aspartate transaminase (AST), Chronic active hepatitis,

Primary biliary cirrhosis

INTRODUCTION

Lichen planus is derived from a Greek word LICHEN

which means ‘Tree moss’ and a Latin word PLANUS

which means ‘flat’. 1

The strange name of the condition was provided by the

British physician Erasmus Wilson, who first described

the lesion in 1869. 2

Lichen planus, one of the most common dermatologic

immunopathological diseases to affect the oral mucous

membrane, is a chronic, inflammatory, mucocutaneous

disorder of undetermined etiology. The care and 3

management of patients with oral lichen planus

continues to challenge even the most experienced

clinician, and strongly suspected associations with

chronic liver disease further complicate matters.

In recent years a number of case reports have drawn

attention to the possible association of mucocutaneous

lichen planus with chronic liver diseases – namely,

primary biliary cirrhosis and chronic active hepatitis

being the prime ones, followed by primary sclerosing

cholangitis, Wilson's disease, hemochromatosis and

alpha-1-antitrypsin deficiency. 4

The histological abnormalities of lymphocytic

infiltration of parenchymal tissue in liver disease and

oral l ichen planus, along with immunological

abnormalities, autoimmune phenomenon and humoral

immunity, are the factors that can be responsible for the

association between the two diseases.

In the initial stage of chronic liver diseases, where the

normal lobular architecture is preserved and the

patients often remain well without progression of their

1 2Vaibhav Kumar Garg , Mayuri Garg1. Reader, Oral Medicine & Radiology, Dr. B.R. Ambedkar Institute of Dental Sciences & Hospital, Patna, Bihar2. Senior Lecturer, Oral Medicine & Radiology, Dr. B.R. Ambedkar Institute of Dental Sciences & Hospital, Patna, Bihar

Corresponding Author : Vaibhav Kumar Garg,Reader, Oral Medicine & Radiology, Dr. B.R. Ambedkar Institute of Dental Sciences & Hospital, Patna, BiharMobile: 093591 04415, E-mail:[email protected]

Oral lichen planus : A diagnostic marker of chronic liver disease

ORIGINAL ARTICLE

Ayush & Health Sciences University of ChhattisgarhO

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20 Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) ISSN 2348 - 4195

21

disease over long periods, that is, patient is

asymptomatic and completely unaware of the hepatic

status, oral health care professionals, on a careful

examination of the oral cavity with oral lichen planus,

should be aware of possible existence and provide for

timely diagnosis and institution of proper treatment. 5

The present study has been undertaken to find out if

there exists any association with the type of clinical

presentation of oral lichen planus and the level of serum

transaminases.

PATIENTS AND METHODS

The present study comprised of two groups of patients.

A detailed case history performa was recorded for all

the patients.

Study Group : 45 patients of oral lichen planus were

recorded from the out patients attending the

department of Oral medicine. All the patients were

carefully examined for clinical assessment of OLP (their

type and clinical symptoms), subjected to incisonal

biopsy (for histopathological confirmation), and were

subjected to serum SGOT and SGPT levels using BASIC

version of clinical chemistry system manufactured by

SECOMAM, loaded with 2.0 software was used

Control Group: A control group of 45 normal healthy

subjects, without any clinical evidence of oral lichen

planus, were recorded from among the out patients

attending the department of Oral medicine. They were

tested for serum SGOT and SGPT levels.

Following patients were excluded from our study:

1. Patients with habit of alcohol, tobacco

consumption (clinically evident tobacco related

lesions namely leukoplakia, pre-leukoplakia,

erythroplakia, nicotina stomatitis, tobacco

pouch keratosis)

2. Patients with clinically compatible oral

lichenoid lesions who were diagnosed as

having following histopathological features : 6

· The sub epithelial infiltrate is more

diffuse and less bank-like, with deeper

extension in to the connective tissue,

and a more mixed cell population,

including eosinophils and plasma cells.

· Perivascualar infiltrate.

· Parakeratosis.

· Colloid bodies in the epithelial layer.

3. Patients, under medications( NSAIDS,

antibiotics, HMG Co-A-reductase inhibitors,

antiepileptic drugs, antituberculous drugs,

herbal medications, illicit drug use), Celiac

d i s e a s e ; E n d o c r i n e d i s e a s e l i k e

hypothyroidism, Addison's disease; suffering

from Congestive cardiac failure and ischemic

hepatitis, Diseases of striated muscle, Glycogen

storage diseases.

4. Patients with debilitating diseases which

render them unfit for taking biopsy, including

pregnant and lactating women.

5. Any soft tissue oral lesions that had obvious

etiology were excluded, such as cheek biting,

scar tissue, Fordyce's granules, or linea alba &

retro molar hyperkeratosis.

RESULTS AND FINDINGS

In the present study 45 patients with different types of

Oral lichen planus have been recorded. Out of the 45

patients 21 were males and 24 were females. The

mean age of the overall test group, being 38.22 years

with a standard deviation 38.31 9.22.

The test group contained only two types viz, reticular,

(66.67%), which dominated, and the erosive variety

(33.33%). The odds ratio was calculated which were

2.20. Although female patients were more affected with

oral lichen planus, the reticular form of oral lichen

planus was more common among the male patients

(76.20%), than in the female (58.33%) patients. On the

other hand the erosive form of oral lichen planus was

seen to affect female more (41.67%), than the males

(23.80%).

It was found that although reticular type dominated all

the age groups, erosive type was more prevalent than

the reticular type in the 51-60 years of age group.

Oral lichen planus: A diagnostic marker of CLD


Transaminase levels Control Group (n=45) Test Group (n=45)

Elevated AST levels (>35) 03 11 (M:6; F:5)

Elevated ALT levels(>45) 02 06 (M:4; F:2)

Elevated Transaminase levels (both

AST & ALT)

02 (4.44%) 06 (13.33%)

(M:4; F:2)

Table I

Only aspartate transaminase (AST) levels were elevated

in 11 patients (24.44%), and only alanine transaminase

(ALT) levels were elevated in 6 patients (13.33%) who

also had a raised aspartate transaminase (AST) level.

Therefore out of total of 45 test group 6 patients

(13.33%) had raised transaminase levels (both AST &

ALT). (Table 1). Elevated transaminase levels (both AST

& ALT) was seen more in male than female patients

(Table I, Graph I)

A t-Test was conducted which showed the mean of

aspartate transaminase (AST) level (p=0.035), mean of

the alanine transaminase (ALT) level (p=0.030) and the

mean of transaminase levels (both AST & ALT), for the

two groups viz, control group and the test group as

statistically significant (p=0.30, which was <0.05).

Graph I

The erosive variant was associated with a greater

alteration in transaminase levels (both AST & ALT) than

its reticular counterpart. A t-Test showed this as

statistically significant (p=0.032) (Table II & Graph II)

Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014)122


Type of OLP Elevated AST Elevated ALT

Elevated Transaminase levels

(both AST & ALT)

Reticular type 3 (6.67%) 0 0

Erosive type 8 (17.77%) 6 (13.33%) 6 (13.33%)

23

Table II- Elevated AST & ALT levels in the type of oral lichen planus

Graph II

All the cases of raised levels of AST & ALT had lesion of

lichen planus in buccal mucosa, while tongue was also

involved in two cases of raised levels of AST & ALT and

gingiva was also affected in one case each of raised

levels of AST & ALT.

Fig 1A &1B: Reticular Lichen Planus



24

Fig 2A & 2B: Erosive Lichen planus

Fig 3A &3B: Erosive Lichen planus

DISCUSSION

The present study has been conducted for clinical

analysis of oral lichen planus with specific reference to

its association with the levels of serum transaminase.

In analyzing 45 cases of oral lichen planus it was found

that incidence of oral lichen planus to be more in

females. This observation is in confirmation with the

previous studies. 7, 8, 9, 10, 11

Oral lichen planus can occur in the age group of 20-60

years, in both male and female sex, but in the present

study it was observed that lichen planus was

predominant in the middle age group, particularly

between 31-40 years age group which was followed by

41-50 years.

Oral lichen planus exists in many clinical forms, but in

the present study only two clinical forms viz; reticular

and erosive could be recorded. The incidence of

reticular lichen planus was the highest in the test group.

This finding matched with the study, where 95% of

patients belong to the reticular variant. 12

The erosive form was more prevalent in females; it was

double the number as compared to males. This finding

matched with a study of seven patients with erosive

lichen planus out of which five were females and two

were males 13

All the cases of lichen planus in the present study were

located on the buccal mucosa. This finding was

observed previously in many studies which stated the

involvement of buccal mucosa ranging from 80% to

94%. There was one case in the hard palate in a female 6

patient.

The present study included two groups viz; test group

(patients with oral lichen planus) and control group

(normal healthy adults) of 45 patients each. Both the

groups were subjected to serum transaminase level

test. At least one of two assays (either AST or ALT)



25

showed altered results in 3 patients in the control group

and 11 patients in the test group. Both assays were

raised in 2 patients in the control group and 6 patients in

the test group.

Out of the six patients with elevated transaminase

levels, all had erosive lesions. This is in accordance with

the following previous studies. A study in which five out

of seven patients having chronic liver disease had 14erosive type of lichen planus.

Another study stated that prevalence of liver disease 9 .was higher in erosive than the reticular variety Also

statistical correlation between erosive variant and 18hepatic damage was found . It was observed that

erosive variety occupied a central role in relation to 15

association with chronic hepatopathies. It was

co n c l u d e d t h at t h e e ro s i ve l e s i o n s c l e a r l y

predominated among patients with oral lichen planus 35 who had altered liver test results which also lends

support to the above finding.

In a study on 40 patients with different types of oral

lichen planus, showed that SGOT and SGPT levels, was

elevated in 19 cases (47.5%) and in 4 cases (10%) of

the study group and control group, respectively (P =

0.0002). In relation to the type of oral lichen planus,

out of 15 erosive cases, 80% (12 cases) showed

elevated SGOT/SGPT levels. They concluded that

elevated transaminase levels might be related to the

development of oral lichen planus lesions. There is a

strong association between elevated SGOT/SGPT levels

and detection of erosive type of such lesions 16

Results of a recent study regarding relationship

between transaminase level and type of OLP, about

87.5% patients with erosive forms showed elevated

SGOT/SGPT .These findings are suggestive enough to

indicate that in presence of severe liver pathologies

leading to change in SGOT/SGPT levels (increase) there

is greater tendency to development of aggressive OLP

lesions. From this it can be inferred that the association

of oral lichen planus with liver disorders is not a mere

coincidence17.

The results showed that in the erosive type the average

AST level was found to be 39 IU/L, while the average AST

level in the reticular type was 20.03 IU/L. On the other

hand the average level of ALT in the erosive type was

42.46 IU/L, while than in the reticular type was 23.23

IU/L. This data reinforced the findings of the above 6, 9, 15, 18, 12, 16, 17mentioned studies

Considering the gender involved, among the total of six

patients in which both assays were raised, 4 were males

and 2 females. This finding hits the bull's eye with two

separate studies, in which out of a total number of six

patients who had altered laboratory findings, four were 19, 20males and two were females

The site which was associated with raised levels of both

the assays, was buccal mucosa, which can be attributed

to the fact that the majority of the patients (95%), had

lesions on the buccal mucosa.

Although the aminotransferase levels are an excellent

marker of hepatocellular injury, it is alanine transferase

(ALT), more specific to the liver. Hepatocellular injury

and not necessarily cell death is the trigger for release of 21these enzymes in the circulation.

Since 6 cases (13.33%) of oral lichen planus, among the

test group, had raised levels of both the assays (AST &

ALT), as compared to the control group, in which only

two patients showed an elevated level of both the

assays, it can be safely said, that the proportion of cases

o f o r a l l i c h e n p l a n u s w i t h a l t e r a t i o n o f

aminotransferase were significantly higher than that of

controls (p value being less than 0.05)

In the past few years, several cases of oral lichen planus

with abnormal liver function tests have been observed.

This had prompted many to investigate the occurrence

of abnormal liver function test and / or liver disease in

patients with oral lichen planus and few of the studies 19, 22, 23, 20, 24, 25, have found some association between them.

26, 27, 29

Chronic liver disease comprising primarily of primary

biliary cirrhosis, chronic active hepatitis and hepatic

cirrhosis manifests clinically with signs such as jaundice,

hepatomegaly, splenomegaly, hyperpigmentation,

fatigue, pruritis and elevated serum amino – 27transaminase levels.

The association of chronic liver disease and oral lichen

planus may be derived on an immunological basis. The



26

immunopathogenesis is explained by expression of the

MHC class II antigen by the epithelial cells that are 28

attacked and destroyed by activated T cells.

It has been hypothesized that lesions of oral lichen

planus, occur as a part of an immune response to some

antigens presented to T-lymphocytes by epidermal

Langerhans cells that subsequently induce T cell

mediated responses directed against basal layer

24keratinocytes.

It is possible that factors altering keratinocyte

antigenicity may induce reactions that can damage

keratinocytes and to some extent, hepatocytes. It is also

possible that lichen planus is a nonspecific cutaneous

manifestation of certain internal diseases that may or 24may not be limited to liver disorders.

13, 30, 31, 32A simplified hypothesis for the pathogenesis is as follows:

Unknown antigenic change in OMM

Focal accumulation of Langerhans cells within the epithelium

Activated helper/inducer T lymphocyte in the lamina propria.

Expression of ICAM and HLA-DR on the surface of keratinocytes

Influx of cytotoxic/supressor T-cells within the epithelium

Keratinocyte damage

Basal cell degeneration

Pyknotic and shrunken basal cells (civatte bodies)

Pyknotic and shrunken basal cells (civatte bodies)

Apoptosis of Keratinocytes

Failure of Phagocytosis of Apoptotic cells

Colloid bodies (Underlying Dermis)



27

In discussing the overall observations of the present

study, it can be said that although, the raised levels of

serum transaminase (AST & ALT), are not specific

marker of chronic liver disease, but in the absence of

other common causes of raised transaminases, it

should raise an eye brow of suspicion, regarding the

hepatic status of that particular patient. The nature of

the clinical presentation of oral lichen planus, should

cast some light on the possible association of the two

diseases, which may turn it into an invaluable clue for

diagnosis, prognosis and monitoring the liver disorder,

as it was observed in the previous studies, where

alterations in at least one or both of the two assays (AST,

ALT), were diagnosed (liver biopsies) to be liver cirrhosis 26,29,16,17 19, 22, 20, 24, 26, 29, chronic active hepatitis primary biliary

cirrhosis 21,27

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epatopatie Croniche.Minerva Stomatol. 1989;

38:795-800.

19. Limdi J K and Hyde G M.Evaluation of abnormal

liver function tests. Postgrad. Med. J. 2003; 79:

307-312.

20. Powell F.C. et al.Lichen planus, primary biliary

cirrhosis and penicillamine. Br J Dermatology.



28

1982;107:616.

21. Kouroumal is E l ias and Notas George.

Pathogenesis of primary biliary Cirrhosis: A

unifying model. World J Gastroenterol

2006;12(15):2320-2327.

22. Rebora A et al. Chronic Active Hepatitis and

L i c h e n P l a n u s . A c t a D e r m Ve n e r o l

(Stockh),.1981;62:351-352.

23. Korkij Wiwat et al.Liver abnormalities in

patients with lichen planus. J Am Acad

Dermatol.1984: 11:609-615.

24. Alfredo Rebora and Rongioletti Franco.Lichen

planus and chronic active hepatitis – A

retrospective study. Acta Derm Venereol

(Stockh). 1984: 64:52-56.

25. Epstein O. Lichen Planus and Liver disease;

British Journal of Dermatologists.1984, 111:

473- 475.

26. Barry Monk Lichen planus and the liver.

J Am Acad Dermatol.1985:12(1):122-123.

27. Scully Crispian et al.Update on oral lichen

planus: Etiopathogenesis and management.

Crit Rev Oral Biol Med. 1988; 9(1):86-122.

28. Carmen Gheorghe; lelia mihai, loanina

parlatescu, serban tovanu. Medica-a Journal of

Clinical Medicine, 2014; 9(1):98-103.

29. Strauss A. Robert et al. The association of

mucocutaneous lichen planus and chronic liver

disease. Oral Surg Oral Med Oral Pathol.1989;

68:406-10.

30. Sugerman P.B., Savage N.W. et al. The

pathogenesis of oral lichen planus. Crit Rev Oral

Biol Med 13(4):350-365 (2002)

31. Sugerman PB, Savage NW. Oral lichen planus:

Causes, diagnosis and management. Australian

Dental Journal 2002;47:(4):290-297

32. Boorghani Marzieh, Gholizadeh Narges et al.

Oral Lichen Planus: Clinical Features, Etiology,

Treatment and Management; A Review of

Literature. JODDD 2010; 4 (1).



1 2 3 4 5C.Dhinesh Kumar , Jayashree Mohan , N.Vidyasankari , Deepesh K Gupta , S.Senthil kumar , 6

Indumathi1. Senior Lecturer, Department of Prosthodontics, JKK Nataraja Dental College, Salem (TN)2. Professor & HOD, Department of Prosthodontics, VMS Dental College, Salem (TN)3. Reader, Department of Prosthodontics, K.S.R Dental College, Salem (TN)4. Reader, Department of Prosthodontics, Govt. Dental College, Raipur (CG)5. Professor, Department of Restorative dentistry, JKK Nataraja Dental College, Salem (TN)6. Reader, Department of Prosthodontics, Bheemavaram (AP)

Corresponding Author:Dr. N.Vidyasankari, 12 S.S.D Road, Thiruchengodu (TN)Contact Number – 919443940244, E-Mail ID: [email protected]

ABSTRACT

The semi-adjustable articulators are being used in the fabrication of complete dentures are commonly programmed

using the interocclusal records. This study was conducted to evaluate the interarticulator reproducibility of

protrusive condylar guidance registration in four semi-adjustable articulators Hanau®Wide Vue ,WhipMix® Model

No.2240, Stratos® 300, Dentatus®ARH semi-adjustable articulators with two interocclusal recording materials in

completely edentulous patient. The Quick setting plaster and Luxabite (bisacrylic composite) was used as

interocclusal recording materials to program the protrusive condylar guidance angles in the articulators..The

reproducibility of protrusive condylar guidance registrations between materials and between articulators was

compared with the radiographically determined angle of inclination of articular eminence and protrusive condylar

path angles. The study was concluded that the Luxabite material demonstrated better reproducibility of protrusive

condylar guidance registration than the Quick setting plaster. The Non-arcon Dentatus® ARH semi-adjustable

articulator showed reliable registration of protrusive condylar guidance angulations when compared to the

radiographically determined angle of inclination of articular eminence to Frankforts horizontal plane. The Arcon

articulators – Hanau® Wide Vue ,Stratos® 300, WhipMix® Model No.2240 , showed better reproducibility of

protrusive condylar guidance angles when compared to the radiographically determined protrusive condylar path

angles obtained from Quick setting plaster record and Luxabite material record.

Keywords : Interoccclusal record, Protrusive condylar guidance, Semi-adjustable articulator.

A comparative evaluation of inter articulator reproducibility of protrusive condylar guidance registration in four

different semi adjustable articulators using two differentrecording materials

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29Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) ISSN 2348 - 4195

INTRODUCTION

The International Prosthodontic Workshop on

Complete Denture Occlusion at the University of

Michigan in 1972 classified articulators into four 1

classes Class I, Class II, Class III and Class IV based on

instrument's function.²The so called Semi-adjustable

articulators comes under Class III classification that

stimulates condylar pathways by using averages or

mechanical equivalents for all or part of the motion.

These instruments may be arcon or non arcon and

allow orientation of the casts relative to the TMJs. They

are more popularly used in construction of several

prosthesis for their simplicity in handling and

programming. Interocclusal records either protrusive or

lateral records are used to program the condylar

guidance values of the semi-adjustable articulators. In

this study the horizontal condylar guidance angles

obtained with the two interocclusal recording materials

Quick setting plaster and Luxabite-bisacryl composite in

all four semi-adjustable articulators Hanau® Wide Vue,

WhipMix® Model No.2240, Dentatus® ARH and

Stratos® 300 were compared with radiographically

determined protrusive condylar path and anatomic

angle of inclination of articular eminence to determine

the ideal interocclusal material and articulator for

obtaining the accurate horizontal condylar guidance of

the completely edentulous patient.

OBJECTIVES OF THE STUDY

1) To compare the effect of two interocclusal

recording materials namely Quick setting plaster,

a n d b i s a c r y l i c co m p o s i te ( L u xa b i te ) o n

reproducibility of protrusive condylar guidance

records.

2) To compare the inter articulator reproducibility of

protrusive condylar guidance records in four semi-

adjustable articulators (Hanau® Wide Vue,

WhipMix® Model No.2240, Dentatus® ARH and

Stratos® 300) in completely edentulous patient.

3) To compare the radiographic protrusive condylar

guidance values obtained in all four semi-

adjustable articulators from Quick setting plaster

record and Luxabite record with angle of inclination

of articular eminence in lateral cephalograph.

METHODOLOGY

The completely edentulous patient with ideal Class I

ridge relation, proper vertical dimension and

neuromuscular coordination was selected for the study.

Impressions and master cast for maxillary and

mandibular arches were fabricated and duplicated into

four pairs for articulating in four semi-adjustable

articulators. Four set of maxillary casts were mounted

onto four different semi-adjustable articulators with

facebow transfer (Fig-1) followed by mandibular casts

mounted in tentative centric relation. The Extraoral 16Gothic arch tracer with the pin was attached to the

maxillary occlusal rim and correspondingly the tracing

plate was attached to the mandibular occlusal rim. The

occlusal rims with the tracers were inserted into the

patient mouth and the centric, right lateral, left lateral

and protrusive movements were obtained in the form

of Arrow point tracing. The centre of the arrow

represents the centric position, the right and left arms

representing right and left lateral movements and the

central line represents the protrusive movement. The

interocclusal recording materials used in the study are

Bis-acrylic bite registration resin and Luxabite (DMG,

Germany), Quick setting plaster. The Quick setting 12 plaster was obtained by mixing the 50g of Dental

Plaster Type II with 30 ml of isotonic saline containing

sodium chloride (which accelerates the setting of the

plaster to 2%) and anti-expansion solution containing

4% potassium sulphate. Six interocclusal records were

made using each material and these records were used

to program the four semi-adjustable articulators.(Fig-

2). Two operators performed the articulator settings for

all the protrusive interocclusal records to prevent

operator bias. The horizontal condylar guidance angles

recorded in each articulator for each of the protrusive

interocclusal records was noted and tabulated. Total of

48 interocclusal records with 96 horizontal condylar

guidance readings are obtained. The values are

stastically analysed to compare the repeatability of

recordings within and between the articulators Lateral

Cephalometric radiographs were made with centric

position and protrusive position using Gothic arch

Inter articulator reproducibility of protrusive condylar guidance


31

tracers with interocclusal recording materials Quick

setting plaster, Luxabite (DMG, Germany) for both right

and left sides of the patient.(Fig-3,4,5,6). The tracings of

the radiographs were done. The tracings of the

protrusive condylar positions were overlapped onto the

tracing of centric positions for both right and left sides 4,5,10.The angle between the protrusive condylar path and

the Frankfort horizontal plane were measured for both

sides.The mean protrusive condylar guidance values of

both right and left sides obtained with two different

interocclusal recording materials in four different semi-

adjustable articulators was then compared with the

protrusive condylar path angles of right and left sides to

the Frankfort horizontal plane, obtained from

radiographic tracings.The angle formed between the

slope of the articular eminence and Frankfort

Horizontal plane may also be value in setting the 10,13condylar guidance in semi-adjustable articulators .

Fig-1-Semi-adjustable Articulators and Facebows used in the study.

Fig -2-Protrusive Interocclusal records made with Quick setting plaster and Luxabite

Fig-3&4- Lateral cephalometric radiograph and cephalometric tracing showing Centric position.



The condylar path from centric to protrusive position

follows the slope of the articular eminence.There exists

strong correlation between the protrusive condylar

path and the inclination of articular eminence which

was mathematically expressed and stastically

described. So in Lateral Cephalometric radiographs

made with centric position's the angle of inclination of

articular eminence was marked.i.e. the angle formed at

the intersection of the two lines-the slope of articular

eminence and tangent to Frankforts horizontal plane

was noted down which gives degree of inclination of

articular eminence to horizontal plane (34 ).This value

was used to compare the condylar guidance values

obtained from Cephalometric tracing with two

interocclusal recording materials Quick setting plaster,

Luxab i te (DMG, Germany) . Descr ipt ive and

comparative statistics are presented as Mean, Standard

Deviation and Coefficient of Variance.(Tables-1,2,3,4).

Two-way ANOVA was also carried out to know possible

interaction effect (interocclusal recording materials X

articulators) on protrusive condylar guidance

angles.Average deviations from the reference angles

obtained from radiographic tracings of protrusive

condylar path angle to the Frankfort horizontal plane

was also presented for determining the articulator

ability to simulate patient's protrusive condylar

guidance angle.(Fig-7,8).

Fig-5&6- Lateral cephalometric radiograph and cephalometric tracing showing protrusive position.

Fig-7-Arrticulators records made of Quick setting plaster to angle of slope of articular eminence.

Fig-8-Arrticulators records made of Luxabite to angle of slope of articular eminence.



33

Table.1..Comparison of Protrusive condylar guidance angles in four articulators with two interocclusal recording

materials to the reference condylar path angle to the Frankfort horizontal plane,obtained from radiographic tracings

using protrusive records of two materials Quick setting plaster and Luxabite .

Reference angle In

degrees

Hanau® Dentatus® Stratos® WhipMix®

Quick setting

plaster

41.5o

41.8o

▲ = 0.3

%=0.7

38.2o

▲ =-3.3

%=8

40.8o

▲ =-0.7

%=1.7

39.6o

▲ =-1.9

%=4.6

Luxabite

37o

36.6o

▲ =-0.4

%=1.1

35.6o

▲ =-1.4

%=3.8

36.7o

▲ =-0.3

%=1

36.1o

▲ =-0.9

%=2.4

RESULTS

1) The Luxabite recording material gave better

reproducibility than Quick setting plaster with less

variation of protrusive condylar guidance angle

value(1.4 – 0.3 more than radiographic value) in all

four semi-adjustable articulator with relation to

radiographically determined protrusive condylar

path angle with Luxabite record and of about only

3 more than radiographic value of angle of o

inclination of articular eminence(34 ).

2) The Non-arcon Dentatus® ARH semi-adjustable

articulator showed reliable registration of

angulations with minimumpercentage deviation of

4.7% than the Arcon articulators - WhipMix® Model

No.2240 , Hanau® Wide Vue ,Stratos® 300 when

compared to the radiographically determined

angle of inclination of articular eminence to

Frankforts horizontal plane i.e (34 ) which can be

taken as a guide in setting Protrusive condylar

guidance registrat ion in semi-adjustable

articulators.

3) The Arcon articulators - Hanau® Wide Vue ,Stratos®

300 WhipMix® Model No.2240 , showed better

reproducibility of protrusive condylar guidance

angles when compared to the radiographically

determined protrusive condylar path angles.The

Hanau® Wide Vue showed minimum percentage

deviation of 0.7%,Stratos® 300 (1.7%),WhipMix®

Table.2. Comparison of the reference condylar path angle to the Frankfort horizontal plane,obtained from

radiographic tracings using protrusive records of two materials Quick setting plaster and Luxabite to the

radiographically determined angle of slope of articular eminence.

Refernce angle-angle of slope of

slope of articular eminence Quick setting plaster Luxabite

34o

41.5o

▲ = -7.5

%=22

37o

▲ = -3

%=9



model no.2240(4.6%),Dentatus® ARH showed

maximum percentage deviation of 8% when

compared to the radiographic value.

DISCUSSION

Stimulation of jaw movements in an articulator

requires the articulation parameters to be registered at

the patient and transferred to the mechanical device

(articulator). These parameters comprise of the

protrusive condylar guidance angle, the Bennett angle,

the inter-condylar distance, and the spatial relations of

the dental arches with respect to the inter-condylar

axis. If articulator settings do not match the patient's

individual parameters, the developed occlusion in the

prosthesis may be of inaccurate and hampering the

function. According to Weinberhg (1963)². “neither

Arcon and nonArcon articulators has mathematical

advantage over the other and they produce the same

motion of condylar ball on the inclined plane”thus the

arcon as well as non-arcon articulators gave the same

registration of protrusive condylar guidance angle

irrespective of the materials and methods. Among the

articulators the Non-Arcon semi-adjustable articulator

showed significantly less reproducibility of protrusive

condylar guidance angle value than the Arcon semi-

adjustable articulators using both the materials Quick

setting plaster record and Luxabite record when

compared to the the radiographic value of protrusive

condylar path angles .But when compared to the

radiographically determined angle of inclination of

articular eminence to Frankforts horizontal plane i.e (34

) which can be taken as a guide in setting Protrusive

condylar guidance registration in semi-adjustable

articulators, the Nonarcon Dentatus® ARH articulator

showed reliable registration of angulations than the

Table.3.Comparison of Protrusive condylar guidance angles in four articulators obtained with Quick setting plaster

interocclusal records to the radiographically determined angle of slope of articular eminence.

Refernce angle –

Angle of slope of

articular

Hanau®

Dentatus®

Stratos®

WhipMix®

34o

41.8

Δ=-7.8

%=23%

38.2

Δ=-4.2

%=12.4%

40.8

Δ=-6.8

%=20%

39.6

Δ=-5.6

%=16.5%

Table.4. Comparison of Protrusive condylar guidance angles in four articulators obtained with Luxabite interocclusal

records to the radiographically determined angle of slope of articular eminence.

Refernce angle-

angle of slope of

articular eminence.

Hanau®

Dentatus®

Stratos®

WhipMix®

34o

36.6

Δ=-2.6

%=7.6%

35.6

Δ=-1.6

%=4.7%

36.7

Δ=-2.7

%=8%

36.1

Δ=-2.1

%=6%

%= Percentage deviations

▲= Mean deviations from reference angle-ve = negative sign indicated higher value compared to reference angle.



35

Arcon articulators - WhipMix® Model no.2240 , Hanau

Wide Vue Stratos® 300 . Brewka,Gilboa et al Norman

E.Corbett used cephalometric radiographic analysis 14

for their studies on protrusive condylar path

registrations in semi-adjustable articulators.Hence the

lateral cephalometric radiograph method of

comparative analysis was followed in this study.

Jankelson (1962), Ren YF, Isberg A, Westesson(1991),

Pammekiate S, Petersson A, Akerman S (1995), Gilboa.

Cardash, Kaffe, Gross(2008), Gilboa et al(2008) have 13

shown that the angle formed between the slope of the

articular eminence and Frankfort Horizontal plane may

also be value in setting the condylar guidance in semi-

adjustable articulators.Hence we determined the

inclination of articular eminence to Frankforts

horizontal plane in lateral cephalogram to predict the

horizontal condylar guidance value for programming

the articulator without using the protrusive

interocclusal records. Among the materials the Luxabite

recording material gives the nearly reliable protrusive

condylar guidance angle value in all four semi-

adjustable articulator with relation to radiographically

determined protrusive condylar path angle and also

with radiographically determined angle of inclination

of articular eminence to Frankforts horizontal plane.

Skurnik emphasized that the bisacrylic resin is easy to 11

handle and has reproductive accuracy and is rigid when

it sets; making it a good bite registration material for

fixed, removable, unilateral and bilateral restorations.

Although the angulations registered in each of the

articulator differ they may produce similar mandibular

movements as the condylar assemblies manufactured

by the different companies may vary and the

graduations will be given according to some relative

values. The articulators need to be more freely adjusted

to the interocclusal records so that they can be

programmed more easily and accurately.

CONCLUSION

From the analysis of this study the setting of protrusive

condylar guidance angle value in semi-adjustable

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

materials,methods and also the inclination of articular

eminence to Frankfort horizontal plane . So further

research and evaluation can be attempted to correlate

this inclination of articular eminence to protrusive

condylar path settings of the articulators.The

interocclusal recording materials Quick setting plaster

and Luxabite i.e from the oldest to recent materials was

compared in this study and the Luxabite material was

dimensionally stable and made more precise

protrusive interocclusal record in edentulous patients

for programming the horizontal condylar guidance of

the semi adjustable articulators. The ideal combination

of material and technique for making interocclusal

records along with proper articulator selection would

allow the fabrication of complete dentures in

edentulous pat ients with minimum occlusal

interferences and mandibular movements.

REFERENCES

1) Gysi, A. Some reasons for the necessity of using

adaptable articulators.Dent Dig.37 ; 224-1931.

2) Articulator development and condylar paths in

full denture prosthesis.-Balkwill., reviewed by

Gillis.J.Am.Dent.Assoc.1926.13;2.

3) Hanau®.R.L.DentalEngineering.Reprinted

from.J.Nat.Dent,Ass.July,1922

4) Olsson A,Posselt U.Relationship of various skull

reference lines.J Prosthet Dent.1961;11:1045-

9.

5) Posselt U, Skyttting, B.Registration of the

condyle path inclination:variations using the

Gysi technique.J Prosthet Dent.1960;10:243-

47.

6) Needles; J. W. Mandibular movements and

articulator design.J.A.DA.10;927;1923.

7) I l a n G i l b o a . H a r o l d S . C o n d y l a r

guidance.Correlation between articular



morphology and Panoramic images in Dry

Human Skulls.J Prosthet Dent.2008.pg no-477-

82.

8) Weinberg LA.Arcon principle in the condylar

mechanism of adjustable articulators.J

Prosthet Dent.1963; 13:263-68..

9) We i n b e rg L A . A N eva l u at i o n o f b a s i c

articulators and their concept parts.J Prosthet

Dent.1963;13-622-663,873-887.

10) Domagoj-Davor-Denis.Josip-comparative

study of condylar inclination settings in two

types of semi-adjustable articulators-J Prosthet

dent-2009-33(2).431-5.

11) J L Vivas, M Sierraalata ; Interocclusal record

fabricated with bisacrylic composite resin ans

vinyl polysiloxane registration material; J

Prosthet Dent 2009: 102:199-2008.

12) Anusavice; Philips science of Dental materials.

Eleventh Edition, India 2003; Saunders

Publication.

13) Norman E.Corbett.Robert Huffer.The Relation

of Articular eminence to Condylar Path in

Mandibular Protrusion.Vol.41.no.4.Journal of

orthodontics. Oct 1971.pg.no.286-292.

14) Brewka RE. Pantographic evaluation of

cephalometric hinge axis. Am J Orthod 1981;

79: 1-19. Analysis of the condyle/fossa

relationship in Kennedy class I and IIpartially

edentulous subjects*Nuran Yanikoglu1, M.

Ustun Guldag.OHDMBSC - Vol. V - No. 1 -

March, 2006.

15) Yoshiyuki Watnabe.Observation of Horizontal

mandibular positions in an edentulous patients

using digital gothic arch tracers.A Clinical

report.J Prosthet dent.2004.91;15-9.

16) Preti G, Scotti RS,Bruscagin C.A clinical study of

graphic registration of the condylar path

inclination .J Prosthet Dent 1982;48-461-6..



37

INTRODUCTION

A negative replica made with an impression material

must be securely attached to the tray to assure an

accurate impression resulting in dimensionally stable

cast. As the mechanical locking of the impression 1

material with the custom tray is minimal, some means

of bonding is to be provided to secure the same to the

tray. Hence the accuracy and consistency are best

maintained with the help of adhesive between custom

tray and impression. Metal and plastic trays are used 2

routinely for dental impressions with the putty

material, but chances of air entrapment are more and

hence not accurate as custom trays. The use of custom

tray is recommended to reduce the quantity of material

for making impression. Therefore, any dimensional

changes attributed to the materials can be minimized.3

Silicone impression materials used for border molding

require sufficient working time, especially while

1 2 3 4 5Adarsh Shetty , Jagadish Konchada , Balasubramaniyan R , Shailendra Sahu , Anurag Dani , 6Manikandan R

1. Senior Lecturer, Department of Prosthodontics, Yogita Dental College & Hospital, Khad (MH)2. Senior Lecturer, Department of Prosthodontics, C D C R I, Rajnadngoan, (CG)3. Professor, Department of Prosthodontics, Rajah Muthiah Dental Coleege & Hospital, Chidambaram, (TN)4. Reader, Department of Prosthodontics, C D C R I, Rajnadngoan, (CG)5. Reader, Department of Prosthodontics, C D C R I, Rajnadngoan, (CG)6. Senior Lecturer, Department of Prosthodontics, Rajah Muthiah Dental Coleege & Hospital, Chidambaram, (TN)

Corresponding author :Anurag Dani, Prosthodontist, Dani Hospital, Kelabadi, Civil Lines, Durg-491001,Chhattisgarh.Email: [email protected], Phone: 09893464987

ABSTRACT

Statement of problem: Clinicians tend to add petroleum gel with polyvinyl siloxane impression materials to extend

working time especially while doing border molding in mandibular arches.

Purpose: To know the effect of petroleum gel on tensile bond strength between tray adhesive and poly vinyl siloxane

impression materials

Material and Methods: a study was carried out in 120 identical specimens, out of which 60 were used as control

Group –A, impression material was manipulated as per manufacturer instructions. Remaining 60 were used as

Group- B in which petroleum gel (0.3ml) was included while manipulating impression material. The difference in

tensile bond strength between the groups is to be evaluated.

Results: The results revealed that tensile bond strength measured high for control group-A than the test group-B.

Conclusion: Addition of Petroleum gel, however, increased the working time, but decreased the effective tensile

bond strength between the tray adhesive and the resin custom tray.

Keywords: Tensile bond strength, Polyvinyl Siloxane impression material, Tray adhesive, Petroleum gel.

Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane manipulated with

and without petroleum gel : An invitro study

ORIGINAL ARTICLE


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Evaluation of tensile bond strength between tray adhesive and poly vinyl siloxane

38

working in mandibular arch. Clinicians tend to add

Petroleum gel with polyvinyl siloxane impression

materials to extend the working time. A pilot study was

conducted to evaluate the Effect of Petroleum gel on

working time and setting time of poly vinyl siloxane

(Aquasil, Dentsply) impression material. The results

obtained from the pilot study proved that the working

and setting time of the impression material is increased.

Further, this fact initiated us to know the effect of

petroleum gel on tensile bond strength between the

tray adhesive and poly vinyl siloxane impression

material. Studies have been done to evaluate the tensile

bond strength between poly vinyl siloxane impression

material and tray adhesive. The present study is aimed

at evaluating the difference in tensile bond strength

between tray adhesive and poly vinyl siloxane

impression material manipulated with and without

petroleum gel.

MATERIALS AND METHODS

The study was conducted on 120 identical specimens,

out of which 60 were used as control Group-A,

impression material was manipulated as per

manufacturer instructions. Remaining 60 were used as

Group-B in which Petroleum gel (0.3ml) was included

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

The difference in tensile bond strength between the

groups is to be evaluated. Acrylic resin specimens of

uniform size are made using metal mould (30mm ×

1.5mm) to standardize. Following the manufacturer's

recommendation acrylic resin was mixed and poured

into the metal mould. Hundred and twenty identical

round acrylic resin tray specimens were obtained

(Figure-1). The tray specimen was allowed to

polymerize and the excess material beyond the mold

was trimmed. A small (1 inch) attachment screw was

inserted into the tray specimen when it is in dough

stage, on the opposite side of the test surface. The test

surface was polished with 80 grit sand paper and tray

adhesive (caulk, Dentsply) was applied once uniformly

and allowed to polymerize for 15 minutes (Figure-2). A

standard round die stone mould of 30 mm inner

diameter and 3 mm depth without undercuts and

smooth inner surface was made ready for making

uniform sized impression material specimens (Figure-

3). Each test consists of two acrylic specimens with

impression material in between. The difference in

tensile bond strength between the tray adhesive and

poly vinyl siloxane in group A and group B was

evaluated.

To evaluate the bonding efficiency of the tray adhesive

on acrylic specimens, Universal testing machine is used.

The test side of the first tray specimen which was coated

with tray adhesive is attached to the PVS impression

material (Aquasil, Dentsply) (Figure-4). The optimum

technique for the use of poly vinyl siloxane impression is

to construct a custom tray and make the impression. 4

Thus the material used in this study was poly vinyl

siloxane -putty impression material (Aquasil, Dentsply).

In the mould and the impression material was taken

along with that. Adhesive coated free surface of the

second tray specimen is attached with the free end of

Figure-1: Acrylic Resin Specimens.

Figure-2: Tray Specimen Treated With 80 Grit Sand Paper And Tray Adhesive Applied.

Figure-3: Stone Mould.


39

the impression material. Excess material beyond the

tray specimens was carefully removed with sharp BP

blade. Care was taken not to compress the impression

material. The whole assembly was allowed to

polymerize for 5 minutes as recommended by the

manufacturer. (Group-A)

According to pilot study, 0.5 ml of petroleum gel added

to the impression material, increased the working time

by two folds. As our area of concern was regarding the

tensile bond strength such an extended working time

was not desired and so decided to add less amount of

Petroleum gel (0.3ml). To ensure homogenous mix of

Petroleum gel with putty impression material, polyvinyl

siloxane base material was mixed with Petroleum gel

(0.3ml) at the first instant, followed by the accelerator

with Petroleum gel mixed base. Thus 30 remaining

samples were prepared which formed the Test Group-B.

Adhesive applied tray specimens was attached to the

impression material in the mould as like control Group-

A. Each of the Group-A and Group-B assembled

specimens was attached to the Universal testing

machine (SERVO, UNITEK -94100, Crosshead speed:

0.5mm-250mm/min Load range: 0-100KN) (Figure-5)

with bigger size hooks. The specimens were tested for

its tensile strength using automated universal testing

machine which offered the facility of recording the

exact bond strength during the time of detachment of

the impression materials from the tray specimens.

RESULTS

Tensile bond strength between the tray adhesive and

poly vinyl siloxane impression materials are measured

in KN (Kilo Newton). In group-A (control group) the

minimum tensile bond strength measured as 0.070 KN

and a maximum as 0.120 KN (Table-1). In group-B (test

group) the minimum tensile bond strength measured as

Specimen No. Bond Strength Specimen No. Bond Strength Specimen No. Bond Strength

1 0.080 11 0.085 21 0.095

2 0.070 12 0.085 22 0.085

3 0.070 13 0.095 23 0.095

4 0.085 14 0.085 24 0.115

5 0.115 15 0.085 25 0.100

6 0.070 16 0.080 26 0.100

7 0.100 17 0.075 27 0.090

8 0.075 18 0.070 28 0.070

9 0.080 19 0.090 29 0.120

10 0.085 20 0.070 30 0.105

Table-1: Representing Control Group- A specimens (where bond strength is measured without addition of Petroleum gel with impression material)

Figure-4: Aquasil (dentsply) Putty And Tray Adhesive.

Figure-5: Universal Testing Machine.



40

0.050 KN and a maximum as 0.090 KN (Table-2). The

results thus obtained ( Table- 1and Table- 2 ) were

evaluated statistically for p-value as given in (Table-

3).Mean average values obtained for group A is 0.09 and

group B is 0.07 with a significant p-value 0.001

DISCUSSION

An impression made with an impression material must

be securely attached to the tray to assure an accurate

impression resulting in dimensionally stable cast. It has 1

been suggested that custom trays to be fabricated at

least 24 hours before the impressions are made,

allowing the material to become dimensionally stable.

Autopolymerising custom tray material is most

commonly employed for tray fabrication because of

ease in fabrication and is cost effective as compared to

visible light cured resin. Hence the samples in this study 1

were made with the auto-polymerising custom tray

material. As the mechanical locking of the impression

material with the custom tray is minimal, some means

of bonding is to be provided to secure the same to the

tray. Hence the accuracy and consistency are best

maintained with the help of adhesive between custom

tray and impression. Metal and plastic trays are used 2

routinely for dental impressions with the putty

material, but chances of air entrapment are more and

hence not accurate as custom trays. The use of custom

tray is recommended to reduce the quantity of material

for making impression. Therefore, any dimensional

changes attributed to the materials can be minimized. 3

The custom acrylic resin trays with occlusal stops ensure

a uniform distribution of impression material.5,6,7

Addition of petroleum gel when manipulating PVS putty

material is widely believed technique. It increases the

working and setting time. It provides sufficient time for

the intraoral procedures to be carried out. The tensile

bond strength between tray adhesive and poly vinyl

siloxane impression material showed a significant

difference in the values between Group A and B.

According to results obtained test specimen mixed with

Petroleum gel (Group-B) showed less bond strength

than the specimen without Petroleum gel (Group-A).

PVS material for the test specimens were hand mixed,

whereas it is strongly recommended that the materials 8should be automixed. Mixing time variation between

the samples could also be the reason for difference

within the test groups. Moreover when a auto mixing

dispenser is used, less chances of air entrapment is

been proved. In this study impression material was

Specimen No. Bond Strength Specimen No. Bond Strength Specimen No. Bond Strength

1 0.060 11 0.085 21 0.055

2 0.060 12 0.050 22 0.050

3 0.080 13 0.065 23 0.080

4 0.050 14 0.065 24 0.090

5 0.060 15 0.080 25 0.065

6 0.070 16 0.065 26 0.090

7 0.080 17 0.085 27 0.090

8 0.075 18 0.070 28 0.065

9 0.060 19 0.070 29 0.065

10 0.060 20 0.070 30 0.075

Table-2: Representing Test Group- B specimens (where bond strength is measured with

addition of Petroleum gel with impression material).

Groups N Mean SD t-value p value

Group A 30 0.09 0.01 5.792 0.001

Group B 30 0.07 0.02

Table-3: Mean comparison between Group-A and Group-B.



41

hand mixed and attached to the tray resin material, with

hand pressure and every effort was made to maintain

the even thickness between the test specimens. So

chances of air inclusions between the adhesive layer

and the PVS materials are always present. According to

the results obtained from the study it showed less bond 2,9,10strength when compared with previous studies.

Inclusion of Petroleum gel, may also be the reason for

decrease in bond strength.

Retention of an impression adhesive on a tray material

depends on the ability of solvent in the adhesive to

dissolve the tray material. Actually dimethyl

polysiloxane reacts with the tray material to create

micro porosities so that the adhesive bonds physically

and mechanically. Role of Petroleum gel on dimethyl

polysiloxane is not known .So this also could be the

reason for decrease in bond strength when Petroleum

gel is used.

CONCLUSION

The results revealed that tensile bond strength

measured high for control group than the test group.

Addition of Petroleum gel, however, increased the

working time, but decreased the effective tensile bond

strength between the tray adhesive and the resin

custom tray. Reasons for decrease in tensile bond

strength may be attributed to Inclusion of Petroleum

gel.

Impression materials were hand mixed; auto mixing is

preferred to avoid air inclusion and to ensure

homogenic mix.

Elastomeric impression materials should be stored in

23 C, whereas study was carried out in room 0

temperature of (30-32 C). 0

Further studies are required to know the role of

petroleum gel with impression material in altering the

working time and alteration of properties of the

impression material.

BIBILOGRAPHY

1. Abdhullah M A, Talic Y F. The effect of custom tray

material type and fabrication technique on tensile

bond strength of impression material adhesive

systems. Oral Rehabilitation 2003;30:312-17.

2. Anusavice K G. Impression materials: Science of

dental materials. Chapter 9: Craig R G, Powers J M

Editors. Philips science of dental materials.

Saunders publication;1995: p 205-54.

3. Bindra B, Heath JR. Adhesion of elastomeric

impression materials to trays. Oral Rehabilitation

1997; 24 (1):63-9.

4. Bolton LJ, Gage JP, Vincent PF, Basford KJE. A

laboratory study of dimensional changes for three

elastomeric impression materials using custom and

stock trays. Aust Dent J 1996;41(6);398-04.

5. Bomberg TJ, Goldfogel MH, Bomberg SE.

Consideration for adhesion of elastomeric

impression materials to impression trays. J Prosthet

Dent 1988:60(6):681-84.

6. Chai J Y, Jameson L M, Moser J B, Hesby R A.

Adhesive properties of several impression material

systems: Part2. J Prosthet Dent 1991:66(3):287-92.

7. Chai J Y, Jameson L M, Moser J B, Hesby R A.

Adhesive properties of several impression material

systems: Part1. J Prosthet Dent 1991:66(3):201-9.

8. Chee WWL, Donovan TE. Poly Vinyl Siloxane

Impression Materials: A Review Properties And

Techniques. J Prosthet Dent 1992: 68(5):728-32.

9. Chee WWL, Alexander ML. Impression technique

for arches requiring both implant and natural tooth

restorations. J Prosthodont 1998; 7(1):45-8.

10. Cho G C, Donovan T E, Chee W W L, White S N.

Tensile bond strength of polyvinyl siloxane

impressions bonded to a custom tray as a function

of drying time. Part time(1). J Prosthet Dent

1995;73(5):419-23.



1 2 3 4 5 6Chinar Fating , Rolly Gupta , Anil Agrawal , Rana K Varghese , Gopkumar Nair , Preeti Thakur1. Senior Lecturer, Department of Oral Medicine and Radiology, CDCRI, Rajnandgaon, Chhattisgarh, India.2. Senior Lecturer, Department of Oral Pathology and Microbiology, CDCRI, Rajnandgaon, Chhattisgarh, India. 3. Senior Lecturer, Community and Preventive Dentistry, New Horizon Dental College , Bilaspur , Chhattisgarh , India4. Prof. and Head, Department of Conservative Dentistry, New Horizon Dental College , Bilaspur , Chhattisgarh , India5. Prof. and Head, Deartment of Oral Medicine, New Horizon Dental College , Bilaspur Chhattisgarh , India 6. MS (Ayurved)

Corresponding Author: Dr. Chinar Fating, Senior Lecturer, Department of Oral Medicine and Radiology, CDCRI, Rajnandgaon, CG, India, Email : [email protected], Contact No: 9754550098

ABSTRACT

Objectives: To evaluate variations seen in the dermatoglyphic pattern between children with oral cleft and normal

children and to determine the significance of dermatoglyphics while studying the genetic etiology of oral clefts.

Study Design: Study was conducted on 60 children, 30 with cleft lip and palate (CL/P) and 30 control groups; and

dermal patterns were obtained using the Ink and Pad technique.

Results: The dermal pattern on the finger bulbs showed an increase in ulnar loops and the “atd” angle showed an

increase and fluctuating asymmetry was also noted.

Conclusion: Changes in the palmar patterns, “atd” angle and the asymmetry led to the conclusion that there is some

degree of genetic instability in Oral Cleft cases and dermatoglyphics can serve as a useful tool in diagnosis of such

cases.

Keywords: dermatoglyphics, oral clefts, ulnar loops, atd angle.

INTRODUCTION

Dermatoglyphics, is the study of dermal ridge

configurations on palmar and plantar surfaces of hands

and feet. It was first introduced by Cummins and Midlo

in 1926. They have been studied for fortune telling by

palmists and as a definitive and unalterable tool for

identification by forensic experts. From cradle to grave

until the body decomposes finger prints remain

unchanged i.e. the dermal patterns once formed

remain constant throughout the life. Dermatoglyphics

can be cons idered a window of congeni ta l

abnormalities and is a sensitive indicator of intrauterine

abnormalities.1,2,3.

Dermatoglyphic studies have gained scientific

acceptance in the recent years and were being used as

an adjunct to other diagnostic methods in identifying

specific syndromes of genetic origin. The current status

of dermatoglyphics is such that the diagnosis of some

illnesses can be done solely on dermatoglyphic analysis.

Several researchers claim high degree of accuracy in

their prognostic ability from the features of the hand.2,3.

Cleft of the lip and palate are inherited defects having a

broad phenotypic gamut and represent failure of the

facial and palatal processes to completely fuse during

embryonic development. Cleft of the lip and palate

account for about 65% of all congenital malformations.

They are observed with a frequency in about 1/500 to

1/2500 live births depending on geographic origin and 4.socioeconomic status. The study of congenital cleft lip

and palate anomalies has been the subject of

controversy regarding the etiology and mode of

transmission. While most of the cases have a polygenic

Dermatoglyphics in oral clefts

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Chhattisgarh Journal of Health Sciences (Vol-2, Issue-1: Jan-June 2014) ISSN 2348 - 4195

43

mode of inheritance, a certain proportion results from

rare mutant genes, chromosomal aberrations and

unknown exogenous factors. However, the exact

etiology and mechanism of transmission of these 5,6,7malformations is still obscure.

The development of the dermal ridges takes place along

with the development of the primary palate during 7 th

week of Intrauterine Life (IUL) and is completed by the

12 to 13 week of IUL and both are ectodermal in th th

origin. The genetic code that is deciphered for palate

and dermal ridges (normal/abnormal) is reflected in the

dermatoglyphics. 8

Hence this study was conducted to evaluate the

differences in dermatoglyphic pattern between

children with cleft and normal children and to

determine the significance of dermatoglyphics in

studying the genetic etiology of oral clefts.

MATERIALS AND METHOD

This study was performed in the Department of Oral

Medicine & Radiology, New Horizon Dental College,

Bilaspur after obtaining approval from the institutional

ethical committee. A total of 60 children were included

in this study that were between the ages of 5-9 years

with no difference between the sexes. The control

group consisted of 30 normal and healthy children

without any medical or congenital anomalies. The study

group consisted of 30 non-syndromic children with oral

clefts without any other external manifestations. After

informed verbal consent (as it is a non-invasive

procedure), bilateral palmar and fingerprints were

collected using the ink and pad technique. (Fig. 1)

Fig. 1---The patterns on the terminal phalange of the

digits were classified as either as loops, whorls, arches

or composite patterns ( Galton in 1892). The frequency 1.

of different patterns occurring on the terminal phalange

of the digits of oral cleft children were then compared

with that of the normal children. (Fig.2)

The triradius formed at the base of the fingers have

been designated as 'a,b,c and d' along the base of the

index finger to the base of the little finger respectively

(Fig.3). The triradius formed at the base of the palm, i.e.,

the thenar area is designated as't'. Figure – 1

a) Simple Arch b) Tented Arch

c) Ulnar Loop d) Double whorl

e)Spiral whorl

Figure - 2



Figure - 3

Figure – 4

For the present study the angle formed between 'atd'

along with the symmetry of the “atd” angle was taken

into consideration (Fig.4). The frequency of true

patterns of arches, loops and whorls were observed in

both groups.

The “atd” angle was measured on the palms of the oral

cleft and normal children and classified into four groups,

i.e., <40°, 40-45°, 45-50° & >50°. Statistical analysis was

done using the Chi-square test and Pearson's

correlation coefficient.

The fluctuating asymmetry of the “atd” angle between

the hands were seen in each individual and classified

into four groups 0°, between 1-4°, 4-7° and >8°

Results

On comparison of the fingerprint patterns on the distal

phalanges of the sixty children, it was observed that the

children with CL/P had greater frequency of ulnar loops

(24/30) as compared to control group who had ulnar

Diagram 1

The atd angle was greater (45-50˚) in children with cleft

(16/30) which was highly significant.

A higher frequency of normal children had the atd angle

<45° which was also highly significant. (diagram 2).

Asymmetry of the atd angle was higher in children with

cleft (4-7˚). The results showed significant p-value, and

Diagram 2



45

DISCUSSION

Cleft lip and palate are most common congenital facial

abnormalities. The etiology is complex and both

polygenic and multifactorial inheritance pattern has

been proposed. 3,4,9

It is known that the finger and palm prints are formed

during the first 6-7 weeks of the embryonic period and

are

completed af ter 15-20 weeks of gestat ion.

Abnormalities in these areas are influenced by a

combination of hereditary and environmental factors,

but only when the combined factors exceed a certain

level, can these abnormalities be expected to appear. 3,4,10.

The epidermal ridges of the fingers and palms are

formed from the same embryonic tissues (ectoderm)

during the same embryonic period (6-9 weeks) as is the

development of lip and palate. Since the facial

structures like lip, alveolus and palate also develop at 6-

9 weeks, the genetic and environmental factors that are

responsible for causing cleft lip and palate may also

cause peculiarities in the dermatoglyphic patterns. . 11,12

Fluctuating asymmetry is defined as the random

differences between two sides of quantitative traits in

an individual which increases in parallel to the

Table I. Pearson's correlation of the predominant pattern.

Pattern Cleft Normal

p- value

Loop 24 9

16.68

0.0008

p<0.05

Significant

Whorl 6 15

Arch 0 3

Composite 0 3

Table II. Pearson's correlation of the atd angle.

“atd” angle

(degree)

Cleft Normal

z- value p- value

35-40 4 5

27.57

0.0001

p<0.05

Significant

40-45 5 23

45-50 16 2

50-55 5 0

decreasing buffering ability of an organism and hence

inability to maintain developmental homeostasis. In the

case of dermatoglyphics, it is the degree of asymmetry,

which will already be present during the early fetal

stages, and the magnitude of fluctuating asymmetry

that will express the level of developmental

homeostasis of the individual. 13,14.

Isolated or non-syndromic CL/P is considered to be

multifactorial in origin with both genetic and

environmental factors playing a role.

In this study, we observed that the children with oral

clefts had an increasing frequency of ulnar loops

(24/30) on the distal phalanges of fingers whereas

normal children had an increased frequency of whorls

(15/30). On comparison of the add angles between the

children with oral clefts and the normal children, the

children with clefts were found to have an atd angle in

the higher ranges, i.e., 45-50˚ (16/30) as compared to

that of normal children (2/30). The asymmetry of the

atd angle was greater in children with cleft (4-7˚) than in

normal children.

The findings of the present study reveal statistically

significant difference between dermatoglyphic

patterns of controls and those of children with cleft

lip/palate. As the dermatoglyphics are genetically

determined and develop at the same time as the

development of the palate, any deviation in the

dermatoglyphic features indicates a genetic difference

in the study group and the controls. Thus indicating a

definite correlation between dermal ridge pattern and

cleft lip and palate. Considering the expenses involved

in chromosomal analysis; dermatoglyphics can prove to

be an extremely useful tool for prel iminary

investigations in subjects with suspected genetic

abnormality, by being non-invasive and cost effective

procedure. But further studies have to be done with a

larger sample size in order to evaluate the significance

of these variations in the dermatoglyphic features in

the oral cleft individual.

REFERENCES

1. Soni A, Singh SK, Gupta A. Implications of

Dermatoglyphics in Dentistry. journal of dento

facial sciences, 2013; 2(2): 27-30.



z- value

2 . B l a n k a S c h a u m a n n , M i l t o n , A l t e r.

Dermatoglyphics in medical disorders.

Springer- Verlage. New York, Heidel berg,

Berlin, 1976.

3. Elder D, Elenitsas R et al. Lever's Histopathology

of the skin. Lippincot William's & Wilkins (2001) th8 Edition. Pp 10-15.

4. Rajendran R, Sivapathasundaram B. Shafer's thTextbook of Oral Pathology. Elsevier (2009) 6

Edition Pg 16-17.

5. Balgir RS. Dermatoglyphic features in

congenital cleft lip and cleft palate anomalies.

JIMA 1986; 84:369-72.

6. Gorlin RJ, Pindborg: Syndromes of the Head and

Neck. New York, McGraw Hill (1964) page 97.

7. Lubs HA, Koeing EV, Brandt IK. Lancet

1961;2:1001-2.

8 . Ba lg i r RS . Congen i ta l o ra l c lef t s and

dermatoglyphics. J Med Sci 1984;20:622-4

9. Vaishali V Inamdar, SA Vaidya, Pratima Kulkarni:

Dermatoglyphics in carcinoma cervix. J Anat

Soc.India.

10. Natekar PE, DeSouza, Fatima M.: Fluctuating

asymmetry in dermatoglyphics of carcinoma of

breast. J Human Genetics. 2006; 12:76-81.

11. Noboru K, Yukiko Yoshida, N Kishi et al. Study on

abnormalities in the appearance of finger and

palm prints in children with cleft lip, alveolus

and palate.

12. Philip Stainer, Gudrun E. Moore: Genetics of

cleft lip and palate: Syndromic genes contribute

to non-syndromic clefts. Human molecular

Genetics. 2004; 13:

13 Mathew L, Hegde AM. Rai K: Dermatoglyphic .

peculiarities in children with oral clefts. J

Indian Soc Pedod. Prev Dent. 2005; 23:179-182.

14. Chintamani, Rohan Khandelwal.: Qualitative

and quantitative dermatoglyphic traits in

patients with breast cancer: a prospective

clinical study. BMC cancer. 2007; 7:44.



47

1 2 3Sanjay Verma ,Punit Gupta , Prakash Khunte1. Associate Prof., Pt.J.N.M.Medical College & Dr.B.R.A.M.Hospital Raipur (C.G.)2. Associate Prof., Nephrology Unit, Deptt.of Medicine, Pt.J.N.M.Medical College, Raipur (C.G.)3. PG Student, Dept. of Medicine, Pt.J.N.M.Medical College & Dr.B.R.A.M.Hospital Raipur (C.G.)

Corresponding Author :Sanjay VermaAssociate Professor, Department of Medicine, Pt.J.N.M.Medical College & Dr.B.R.A.M.Hospital Raipur (C.G)Mobile No.- 9826136022, E-Mail ID: [email protected]

ABSTRACT A total of 31 patients of Carcinoma Cervix was studied in Nephrology Unit at Dr.B.R.A.M Hospital Raipur C.G. An underlying malignant disorder was the cause of the obstruction in most of the patients. Carcinoma of the cervix was the most frequent malignant disorders, resulting in more severe renal failure.The mean age of presentation of Carcinoma of the cervix was 45.77 ± 11.25 years. Out of 31 patient 19 patient underwent hemodialysis . The mean urea level were 146.4 ± 47.6 mg/dl, creatinine level were 8.7 ± 4.7 mg/dl. Most patients were severely anaemic,mean hemoglobin level were 7.7 ± 2.1 gm%. Most patient have bilateral hydronephrosis obstructive uropathy in ultrasonographic finding resulting in severe renal failure.5 patients were dead before the hemodialysis. Most patient were hypoalbuminia and electrolyte abnormality. The overall prognosis was poor and most patient require hemodialysis.

INTRODUCTIONCancer of the uterine cervix is one of the leading causes of cancer death among women worldwide. The estimated new cancer cervix cases per year are 500,000 of which 79% occur in the developing countries. (Shanta V et al ).Cervical cancer is the most common female cancer in the developing countries and its incidence in India is about 32 per 100,000 women. (National Cancer Registry Programme 2005 ). Over 70% of the cases present in advanced stages of the disease with associated poor prognosis and high mortality rate Cancer cervix occupies either the top rank among cancers in women in the developing countries. The cervical cancer burden in India alone is estimated as 100,000 in the year 2001. The differential pattern of cervical cancer and the wide variation in incidence are possibly related to environmental differences. About 70% of them present as locally advanced disease, and one-third of them with renal failure. Such patients have dismal prognosis and are usually managed with palliative radiation or sometimes best supportive care. Kidney disease frequently complicates malignancy and its treatment. The spectrum of disease in this setting includes acute kidney

injury, chronic renal failure, and tubular disorders. Fortunately, these complications are often preventable or reversible with prompt diagnosis and treatment. ( Turka LA et al )

MATERIAL & METHOD: This study was conducted at Nephrology Unit , Dept of Medicine,Dr.B.R.A.M. Hospital & Pt.J.N.M.Medical College ,Raipur (C.G).Study was conducted among 31 patients and age between 30 years and 654 years.Complete laboratory investigation was were complete blood count, blood urea, serum creatine, serum lipid profile, thyroid profile, serum albumin level, ds. Chest Xray ,E.C.G ,ultrasonography was done in all patients.

RESULTS

All patient were female with minimum age was 30 years

and maximum age was 65 years .The mean age of

presentation of Carcinoma of the cervix was 45.77 ±

11.25 years.The most common presentation was

decrease urine out put followed by facial puffiness seen

in most patients , the mean blood pressure was

131.1+23.1/76.5+10.9 mmhg ,pulse rate was 96.9+10.3

Carcinoma cervix and renal failure : A study from central India.

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/min. Pallor,oedema seen in 100 % of cases. Mean

hemoglobin level was 7.7 ± 2.11 gms,total leucocyte

were 10900 ± 4972 /mm3. Renal failure seen in all cases

with mean blood urea and creatinine level 146.4 ± 47.6

and 8.7 ± 4.7 mg/dl. Grade + protienuria seen in 60 % of

cases. Hypocalcemia seen in 26 % cases followed by and

hyperkalemia ,hypernatremia in 22% & 8 % cases.

Hyponatremia and hypkalemia in 18 % and 22 % cases.

19 patients were underwent hemodialysis and 5 patient

died due to late presentation of diaseses. 70 % shows

bilateral hydronephrosis obstructive uropathy. Most

patient have hypoalbuminimia.

Graph 2 -shows symptoms presenting with the disease.

Graph -1 showing mean age of presentation of carcinoma cervix.

Carcinoma cervix and renal failure


49

DISCUSSIONAcute kidney injury (AkI) secondary to bilateral ureteric obstruction (BUO) is a common urological problem and the underlying etiology can be malignant or benign. Malignant obstruction is often from direct tumour compression of the distal ureters, most frequently from genitourinary most common carcinoma cervix cancers.(Nandakumar A et al )

Over 70% of the cases present in advanced stages of the disease and are associated with poor prognosis and high mortality rates. In many of them, it is difficult to offer definitive treatment as they present in uremia due to associated obstructive uropathy.. The results are unpredictable in terms of benefits achieved in these cases. (Vick CW et al )

Cervical cancer can spread to adjacent structures like the lower uterine segment, vagina and para cervical space along the broad and uterosacral ligaments. It can also have lymphatic and hematogenous spread. The parametrium is the connective tissue between the leaves of the broad ligament. Medially, it abuts the uterus, cervix, and proximal vagina. Laterally, it extends to the pelvic side wall. Inferiorly, it is contiguous with the cardinal ligament. The parametrium consists primarily of fat through which uterine vessels, nerves, fibrous tissues and lymphatic vessels run. The distal ureter is in the parametrium as it passes from the pelvic side wall to the bladder approximately two centimeters lateral to the margin of the cervix. When cervical cancer extends into the parametrium, the ureter can be encased by tumor and th i s leads to hydro ureteronephrosis and eventually renal failure. (Lee SK et al ) .

Ureteral obstruction due to malignancy carries a poor prognosis with a resulting median survival of three to seven months. Hence most patients are treated with b e s t s u p p o r t i v e c a r e o r s o m e p a l l i a t i v e diversionprocedure.

It is very important to select patients for curative treatment. Patients with features of uremia, frozen parametrium, non-functioning kidney are unlikely to show response and hence are best treated with supportive care.The non-recovery of renal function after the relief of hydro ureteronephrosis is dependent on age and renal cortical thickness. Age beyond 50 years

and decreased renal cortical thickness (less than 13 mm) indicate poor recovery of renal function. Use of cisplatin as radio sensitizer with radiation is avoided as it is a nephrotoxic drug and worsens the pre existing renal failure. Various other chemotherapeutic drugs like carboplatin and gemcitabine can be tried. (James M et al )

Crude mortality rates in critically ill patients with AKI are systematically higher in those with cancer than in those without. The performance status and associated comorbidities have an additional adverse impact on both short-term and long-term outcome in cancer patients.

Age and cancer characteristics by itself, with of extensive metastatic or uncontrolled recurrent disease in solid tumor patients, have only a minor impact on the 6-month mortality in critically ill cancern patients. (James M et al)

Furthermore, outcomes have been found to be worse in patients who experience further deterioration in renal function despite advanced life support in the ICU. AKI may also play an important role. Sepsis-induced AKI is often associated with protracted multiple organ dysfunction whereas this will be less or only rarely the case in AK I caused by nephrotox ic drugs . (Cohen E P et al )

In both the benign and malignant groups, the degree of renal impairment as measured by presenting serum creatinine was similar and did not serve as a differentiating variable. After relief of obstruction with percutaneous nephrostomy tubes or ureteric stents, renal function improved significantly and was decreasing on discharge in both groups. Multiple studies have shown both stents and nephrostomy tubes are effective methods to restore kidney function after ureteric obstruction

CONCLUSION

The overall prognosis is poor in patients requiring

hemodialysis and high mortality rate in carcinoma

cervix with renal failure patients. Early diagnosis of

disease is required for good prognosis of patients.



REFERENCES

1. Shanta V, Krishnamurthi S, Gajalakshmi CK, Swaminathan R, Ravichandran K. Epidemiology of cancer of the cervix: global and national perspective. J Indian Med Assoc 2000;98:49- 52. 2. Nandakumar A, Anantha N, Venugopal TC. Incidence, mortality and survival in cancer of the cerv ix in Bangalore, Ind ia . Br J Cancer 1995;71:1348-52 3. Vick CW, Walsh JW, Wheelock JB, Brewer WH. CT of the normal and abnormal parametria in c e r v i c a l c a n c e r. A J R A m J R o e n t g e n o l 1984;143:597-603. 4. Lutaif NA, Yu L, Abdulkader RC. Factors influencing the non-recovery of renal function after the relief of urinary tract obstruction in w o m e n w i t h c a n c e r o f c e r v i x . R e n F a i l 2003;25:215-23.

5. Lee SK, Jones HW., 3rd Prognostic significance o f uretera l obstruct ion in pr imary cer v ica l cancer. Int J Gynaecol Obstet. 1994;44:59–65 6. J a m e s M , Pa n n u N . M e t h o d o l o g i c a l cons iderat ions for observat ional studies of acute kidney injury using existing data sources. J Nephrol. 2009;22:295–305 7. National Cancer Registry Programme, Annual Report, ICMR, New Delhi: 2005 8. inshaw KA, Rao DN, Ganesh B. Tata Memorial H o s p i t a l C a n c e r R e g i s t r y A n n u a l R e p o r t , Mumbai, India: 1999 9. Cohen EP, Sobrero M, Roxe DM, Levin ML. R e v e r s i b i l i t y o f l o n g s t a n d i n g u r i n a r y obstruction requiring long term dialysis. Arch Intern Med 1992;152:177-9. 10. Turka LA, Rose BD. Clinical aspects of urinary tract obstruction. In acute renal failure. 2 nd ed. Lazarus JM, Brenner BM, editors. New York: Churchill Livingstone; 1988. p. 581-96.



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1 2 3 4N.Vidyasankari , S.Senthil kumar , Deepesh K. Gupta , Maheshwaren1. Reader, Department of Oral and Maxillofacial Prosthodontics, K.S.R Dental College, Salem (TN)2. Professor, Department of Restorative dentistry, JKK Nataraja Dental College, Salem (TN)3. Reader, Department of Prosthodontics, Govt. Dental College, Raipur (CG) India.4. Senior Lecturer, Department of Prosthodontics, K.S.R Dental College, Salem (TN)

corresponding Author :Dr. N. Vidyasankari, MDS, 12 S.S.D Road, Thiruchengodu – 637211, Tamil Nadu, India.Contact Number – 09443940244, E-Mail ID: [email protected]

ABSTRACT

An immediate denture is "a complete denture or removable partial denture inserted immediately after the removal

of natural teeth”. The primary advantage of an immediate denture is the maintenance of patient's appearance

because there is no edentulous period. Circum-oral support, muscle tone, vertical dimension of occlusion, jaw

relationship, and facial height can be maintained. Thus this article speaks about the needs and construction of an

immediate complete denture.

Key words – Denture, Surgical Templates, Extraction, Transitional Denture

INTRODUCTION

One of the most bewildering clinical problems to the

prosthodontist & general dentist is to encounter the

patients who are going for complete edentulism.

Immediate dentures are one of the options for the

patient facing the edentulous state. It provides

restoration of esthetics, phonetics and masticatory

function. Immediate dentures act as a bandage or

splint, promotes healing and protects blood clots,

patient gets used to the immediate dentures as sooner

than conventional dentures, can resume their daily

work early. Patients do not have to endure a long

healing process without teeth . In addition, it 1,2,3,4

facilitates the transition from dentulous to the

edentulous state.

Immediate dentures are more challenging to make than

routine complete dentures for both the dentist and the

patient, because anterior wax try-in is not possible

beforehand and the patient may not be completely

comfortable with the resulting appearance and fit of the

immediate denture when inserted . Hence the dentist 1,2,4

must explain the patient must about the limitations of

the procedure before the treatment begins.

CASE REPORT:A 46 year old female patient with

partially edentulous upper and lower arches was

reported to the Department of Prosthodontics for the

prosthesis. On examination the teeth present were

11,12,13,14,16, 21, 22, 23, 27, 34, 36, 41, 43 & 45. The

periodontal status of all the remaining natural teeth

was poor with grade III mobility and poor oral hygiene.

The treatment plan was total extraction of remaining

natural teeth followed by conventional complete

denture rehabilitation and was suggested to the

patient. However, the patient was so conscious about

her appearance & refused for the treatment because of

the fear of being edentulous for 3 months since

extraction. Hence, it was decided for Transitional

Immediate denture rehabilitation. All the remaining

lower teeth and the upper posterior teeth were

extracted except the upper six anterior teeth [fig 1].

Immediate denture as an immediate solution

CASE REPORT


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52

Initial phase - pre extraction procedures:

Initial impression was made with irreversible

hydrocolloid in a stock tray, and poured with dental

stone. A custom-made tray was fabricated with Auto-

polymerizing Acrylic resin by covering the remaining

teeth with a double thickness base plate wax. The

custom tray was placed in the patient's mouth and

evaluated for overextensions and borders refined by

using low fusing green stick compound. Perforations &

tray adhesives were placed in the tray to enhance the

retention of impression material. Light-bodied

polysiloxane rubber base impression material was used

for the final impression . 5, 6, 7

Record blocks were fabricated with temporary denture

base made of autopolymerizing acrylic resin. Jaw

relation was recorded [fig 2]. Appropriate shape, size and shade of the teeth were selected. The posteriors

were arranged first to provide multiple posterior

contacts in centric relation. The lower anteriors were

set according to the remaining upper natural teeth with

no contacts in centric relation. Posterior try-in was

scheduled to verify centric relation, vertical dimension

and the posterior palatal seal.

Preparation of surgical template:

The predetermined cross marked teeth to be extracted

were trimmed using a sharp knife and round bur up to

the level of gingival margin for cast modification [fig 3

and 4]. The gingival margins on the facial and lingual

surfaces of the cast were outlined. A pencil line 2mm

above and parallel to this gingival contoured line were

scribed on the cast. The stone cast was beveled from

labial to lingual aspect with the depth of 2mm at the

gingival margin areas. A duplicated cast was made on

which a clear acrylic surgical template was fabricated to

evaluate the surgical site latter . 6

The remaining anterior teeth were arranged in their

position. The contours of the dentures were waxed

properly. The dentures were processed using heat


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activated acrylic resin.

Surgical phase – extraction procedure:

The six anterior teeth were extracted under local

anesthesia following proper surgical protocol [fig 5].

Surgical template [fig 6] was used to check for any tissue

blanching. The hard tissue was trimmed at the blanched

area. Simple interrupted suture was placed without

tension [fig 7].

The maxillary denture was positioned and seated &

checked for pre-mature contacts. Only gross pre-

maturities were eliminated, the final correction was not

done to avoid further trauma to the extraction sites. The

denture adapts well and the labial undercut present

provides a better retention [fig 8,9,10].The patient was

discharged with the instruction of not removing the

denture for 24 hours, have fluid food and report the

dental clinic the next day.



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Post insertion review:

During follow-up review occlusion was verified and any

ulceration from denture pressure or over extension was

relieved. Dentures were cleaned for debris and the

patient was asked to rinse the mouth with mouthwash

gently. Denture reinserted & advised the patient not to

remove the denture for the next 24 hours.

The same procedures done on the first day was

repeated on the second consequent visit. Patient asked

to have soft cold baby feeds and chopped vegetables.

Patient asked to report after 5 days. After a week,

sutures were removed [fig 11]. Tissue surface was

examined with pressure indicator paste and there was

no soreness or irritation found. Hence the need for

tissue conditioner was eliminated.

After a month, the occlusion was refined. The patient

was told to report for checkup once in a month. Later

after 6 months, the interim denture can be replaced

with the conventional new denture.

CONCLUSION

Immediate dentures are a more challenging modality

than complete dentures because the presence of teeth

makes impressions and maxillomandibular positions

more difficult to record. An occlusal adjustment, or

even selective pretreatment extractions, may be

needed to make accurate records at the proper vertical

dimension of occlusion.

The most compelling reasons for the immediate

denture prescription are the patient wish not to live

without teeth for a day and consequently an

uninterrupted normal lifestyle of smiling, talking,

eating, and socializing. The patient is likely to adapt

more easily to dentures at the same time recovery from

surgery is progressing. Speech and mastication are

rarely compromised, and nutrition can be maintained.

Overall, the patient's psychological and social well-

being is preserved.

Thus a careful planning, operator experience,

attention to details of the technique and proper

motivation of the patient best address this inherent

problem of being edentulous.

REFERENCES:

1. Sheldon Winkler: Essentials of complete

prosthodontics – 2 edition P: 361-374.nd

2. Zarb – Bolender: Prosthodortic treatment for

edentulous patients – 12 edition P: 123 – 159.th

3. Farmer JB: Surgical template fabrication for

immediate dentures; J.Prosthet Dent 1983; 49: 579

– 580.

4. Heartwell CM & Salisbury FW: Immediate

Dentures: an evaluation J. Prosthet Dent 1965;

15(4): 616-618.

5. Seals RR, Kucbker WA, Stewart KL: Immediate

Complete dentures, Dent Clin North Am 1996;

40:151.

6. Stanley G.Standard: Preparation of casts for

immediate dentures. J. Prosthet. Dent 1988; 8 (7):

26 – 30.

7. Campagnia, S.J. An impression technique for

immediate dentures. J Prosthet Dent 1968; 20:196-

203.


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1 2 3 4C. Sunil Kumar, B. M. M. Reddy, A. Samantaray, D. S. R. Reddy1.Professor,Department of Conservative Dentistry ,C.K.S Theja Institute of Dental Sciences & Research, Tirupati, A.P 2.Professor, Department of Prosthodontics,C.K.S Theja Institute of Dental Sciences & Research, Tirupati, A.P 3.Additional Professor,Department of Anaesthesiology and Critical Care, SVIMS, Tirupati, A.P 4.Reader, Department of Conservative Dentistry & Endodontics.C.K.S.T. Institute of Dental Sciences & Research, Tirupati, A.P

Corresponding Author :Dr. C. Sunil Kumar, 1.Professor,Department of Conservative Dentistry ,C.K.S Theja Institute of Dental Sciences & Research, Tirupati, A.P Phone No :- 9849481124, E-Mail – [email protected]

ABSTRACT

Dental prosthesis may be swallowed or can be aspirated that may result in acute medical or life threatening

emergencies. A case of accidental swallowing of a four-unit removable partial denture by Dementia patient is

reported, and the important fact is that, the patient was unaware that the denture was ingested and came to the

clinic for a new partial denture. Patients with removable dental prosthesis should be informed of this potential risk of

swallowing and sometimes even unrecognised.

Key words :Removable dentures, Ingestion, Foreign body, Impaction, oesophagotomy

INTRODUCTION

Cases of impaction of foreign bodies in the upper part of the alimentary canal are not infrequently met within hospital practice, but the greater proportion are cases in which the foreign body is lodged in the pharynx, and can generally be dealt with from the mouth. Foreign bodies arrested in the oesophagus command attention because their presence is a source of great danger and their removal becomes immediately a very vital problem. Aspiration and accidental swallowing of foreign bodies is more common in children, because of their curiosity, habitual insertion of objects into their mouths while playing and speaking, and the lack of posterior dentition. Reviews from otolaryngology reports coins, marbles, buttons, batteries, safety pins, bottle tops and screws are the common objects ingested in children. In adults, about 62 % of the cases are due to chicken bones, fish bones, or poorly fitted

1artificial teeth. In regard to the situation at which foreign bodies may become lodged, it has been observed that small pointed bodies which easily penetrate the mucous membrane

may become fixed at any point in the oesophagus. Larger bodies usually cannot pass through the isthmus and remain in the pharynx. The larger variety of foreign body which has passed through the pharynx lodges at those places where, the oesophagus is constricted, just behind the crycoid cartilage, the middle constriction which is about opposite the bifurcation of the trachea at level of 7th cervical vertebra, and the inferior constriction, where the oesophagus passes through the

3diaphragm. Swallowing of dental objects may also occur away from the clinic and seems to be more common than aspiration in the elderly. In the older age group, the most common foreign body swallowed is a denture because of decreased sensation of the oral cavity in denture wearers, and poor motor control of

2laryngopharynx . Other reasons for aspiration can be maxillofacial trauma, dental treatment procedures, dementia or intellectual impairment, autism, Parkinson's disease, Cerebral palsy and mental retardation. Swallowing of dental materials and devices may be a serious complication during routine dental treatment.

Unrecognized swallowing of a partial denture and surgical retrieval by cervical oesophagotomy: A case report

CASE REPORT


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Surgical retrieval of a partial denture by cervical oesophagotomy

For example, screw driver or implant itself during implant placement, a cast crown, bands and brackets during orthodontic treatment, a file or a reamer during endodontic therapy has been reported in the literature1. Various measures have been proposed to prevent such occurrences such as using barriers (rubber dam, throat packs) and ligation of object (Eg. Files, Reamers, Rubberdam clamps etc) because they carry some risk of ingestion.The majority of foreign bodies entering the oropharynx will pass through the alimentary canal if they are small or they may cause perforation of the Gut if sharp, which may lead to serious complications and even death.4 If the denture is made of radiolucent material as in acrylic removable partial denture, endoscopic examination and removal is suggested in a symptomatic patient with positive history6. Surgery is rarely performed unless the foreign body is impacted, or failure to remove by routine endoscopic method. This report presents removal of an impacted removable partial denture with cervical oesophagotomy under general anaesthesia. The dangers of Oesophagotomy for foreign bodies are by no means negligible, chief causes being heamorrage,

4shock and infection resulting in death sometimes.

CASE REPORTA 78-year old dementia patient came to the clinic for replacement of maxillary anterior teeth. The patient was using removable acrylic partial denture since 5

years. Patient complains that the denture was missing since 1 month and they could not find the denture anywhere in the house. So she decided to get a new denture fabricated. Maxillary and mandibular impressions were made. During impression making patient complained of pain in the neck region. On proper enquiry about the patient's general health, her son revealed that she was complaining of pain and difficulty during swallowing solid food and was under liquid diet for the past 15 days that too with great difficulty.Correlating the symptoms of the patient, with missing denture a suspicion aroused about the swallowing of removable partial denture where the patient immediately denied the possibility. To confirm the suspicion the case was referred to Sri Venkateswara Institute of Medical Sciences, Tirupati. Preliminary radiological examination did not reveal anything but subsequent endoscopic examination showed a foreign body about 22 cm away from maxillary incisors in the midoesophageal region. Routine retrieval procedure was not successful because the denture was swallowed 1 month back and was deeply impacted in the mid oesophagus. The patient was subsequently posted for cervical oesophagotomy under general anaesthesia (fig.1,fig.2, fig.3). Impacted denture was removed successfully(fig.4) and absence of any fistulous tract into the trachea was confirmed. Intraoperative course was uneventful. The patient was extubated in the operation theatre and shifted to intensive care unit. In

Fig. 1: Initial incision at the mid oesophageal region. Fig. 2: Exposure of deeper structures at mid oesophageal region

Fig.4: Retrieval of partial denture


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I.C.U. the patient was kept under observation for 7 days and discharged on 7th postoperative day.The cause of aspiration in this case is because of old age with impaired cough reflexes and some degree of intellectual impairment as evidenced by the lack of a clear positive history of swallowing her own loose fitting denture during sleep one month back.

DISCUSSIONAccording to the National Health and Nutrition Examination Survey (NHANES) 1 of every 5 persons between the ages of 18 and 74 years has full or partial dentures. The inadvertent swallowing of a dental prosthesis is not uncommon in the adult population. In a study by Abdullah et al 2 out of 200 patients were with a known history of an impacted tracheal or oesophageal foreign body, dental prostheses accounted for 11.5% of t h e ca s es .E xa m in at io n o f t h e p at ient w i t h definite/suspected foreign body ingestion/entrapmentThis is often unhelpful, but careful examination should be carried out for acute clinical and medicolegal reasons:· Assess the airway and respiratory function to exclude any compromise.· Check vital signs, open the mouth and observe the oropharynx with a bright light.· Consider indirect laryngoscopy and/or fibre-optic examination of the pharynx.· Gently palpate the neck and assess tracheal position/compression.· Formally examine the chest and listen to the lungs.· Perform a cardiovascular examination.

7· Carefully examine the abdomenClinical history may be vague, and patients may or may not report a definite history of swallowing their dentures. Patients can present with vague symptoms of neck pain, dysphagia, odynophagia, and excessive salivation. Thus further reports may also be anticipated of sore throat, choking sensation, retrosternal pain, sweating and a raised temperature and coughing up blood. If not diagnosed early, progressive edema, infarction, ulceration and necrosis may lead to perforation and fistula formation. Fistulas can involve the trachea, oesophagus, mediastinum, aorta and bronchial tree in various combinations.Early diagnosis and treatment can avoid late complications that may require surgical intervention. The use of a unilateral removable partial denture to replace one or two missing teeth especially in elderly patients should be

avoided because small size makes it easy for a patient to ingest or aspirate this prosthesis, with potentially serious consequences. Difficulty has been reported in the identification and location of prosthesis when it is made of radiolucent acrylic resin (PMMA) with little or no metal framework. The inclusion of radiopaque materials into these types of prostheses is strongly advised3. Computerized tomography (CT) may be used to localize the offending object in 3-dimensions and also in locating the prosthesis because it has greater contrast resolution than conventional radiography and

8may reveal a radiolucent foreign body of dental origin .Differential diagnosiso This clinical scenario is unlikely to be confused with

another illness, with the possible exception of space-occupying oesophageal pathology – eg : oesophageal carcinoma causing obstruction of a normal food bolus.

o Always consider the possibility that a foreign body has been inhaled, particularly if a patient presents acutely with respiratory compromise or with chronic chest symptoms.

o An acute presentation of mediastinitis may be due to perforation by a swallowed foreign body, or the primary form of the disease.

o Retropharyngeal abscess can cause similar symptoms to impacted objects in the upper oesophageal area.

Investigations Blood tests are usually unhelpful, with the

exception of chronic presentations or febrile patients where FBC/ESR may provide useful clues as to the cause of symptoms

o Plain X-rays:Where there is a history of a swallowed radio-opaque object that may be located within the upper gastrointestinal (GI) tract, plain X-ray should be carried out to confirm or refute the possibility of oesophageal entrapment.Where the ingested object is not radio-opaque, X-ray investigations are unlikely to help and will probably only delay more relevant investigations such as upper GI endoscopy.

Very small children can be imaged using a mouth-to-anus radiograph. In adults, a PA and lateral chest radiograph and/or plain abdominal X-ray are more useful.Only about 20-50% of food bones will be

7visible on X-rays.o CT scans: - CT scanning of the thorax/abdomen is

highly useful for locating entrapped objects of various types and considered superior by many to plain X-ray imaging. CT scanning is the investigation



of choice if there is reason to suspect perforation or abscess formation.

o Endoscopy:Urgent endoscopy is mandatory in cases where there is airway obstruction or evidence of other severe complications.When there is a clear history of swallowing objects, such as toothpicks and/or aluminium bott le caps/can r ings, endoscopy is the investigation/procedure of choice, as there is a high risk of complications with such objects. Definite indications for endoscopy are objects that are sharp, non-radio-opaque, elongated, or when there are multiple swallowed

7objects or a high risk of oesophageal injury. Endoscopy is also indicated for gastric or proximal-duodenal foreign bodies that have a diameter of > 2 cm, and length of > 5-7 cm. Endoscopy is a relatively safe procedure in experienced hands, but expensive,and should therefore be avoided as a routine intervention if possible.

o Other tests:- Barium swallows are sometimes used to detect

non-radio-opaque items but CT is usually preferred, as there is a better yield and barium must be avoided when perforation is suspected.

- Hand-held metal detectors can be used to trace the passage of metallic objects through the GI tract and reduce exposure to ionising radiation.

CONCLUSIONSince foreign body ingestion may result in acute medical or life threatening emergency, prevention of such occurrence is therefore the best approach. Knowledge of the dental team of the signs and symptoms of a swallowed object, documentation and proper medical follow-up are all essential for better management of ingested objects.Configurations and overall dimensions of prosthesis are important and patients receiving small dentures should be informed of this potential risk of

swallowing. Fixed bridges with good cementation is preferred to removable prosthesis. However, fixed prosthesis may also be ingested if inadequately retained. So proper design and adequate retention of partial dentures is most important, either removable or fixed. Dentures also require proper fitting and checking on a regular basis to maintain an optimum fit. Elderly patients must be advised not to gulp large pieces of meat. Patients should be informed strongly to avoid wearing dentures during sleep. unilateral single tooth replacement should be avoided as it does not have cross arch stabilization and accidental ingestion will be easier.

REFERENCES:

1. Chua Y K D, See J Y, Ti T. Oesophageal-impacted denture requiring open surgery. Singapore Med J 2006; 47(9):820-821.

2. Carbery A, Provencal M. A case of swallowing a partial denture. J Can Dent Assoc 1993;59: 841-4.

3. Tsao DH, Guilford HJ, Kazanoglu A, Bell DH. Clinical evaluation of a radiopaque denture base resin. J Prosthet Dent 1984;51: 456-8.

4. Cooke LD, Baxter PW. Accidental impaction of p a r t i a l d e nta l p ro st h e s e s i n t h e u p p e r gastrointestinal tract. Br Dent J 1992;172: 451-2.

5. Green JG, Durham TM, King TA. Management of patients with swallowed dental objects. Am J Dent 1988;1: 147-50.

6. Brunello DL, Mandikos MN. A denture swallowed. Case report.Aust Dent J. 1995;40(6):349-51.

7. Munter D; Foreign Bodies, Gastrointestinal Foreign Bodies in Emergency Medicine, Medscape, Mar 2010.

8. Auluck A, Desai R. Accidental swallowing of prosthesis. Dent Update. 2008;35(8):577-9.



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