International Healthcare Research Journal...

International Healthcare Research Journal (IHRJ)

E - I S S N : 2 4 5 6 - 8 0 9 0

Volume 1, Issue 7 (October 2017)

International Healthcare Research Journal

EDITOR-IN-CHIEF AND PUBLISHER Dr. Vatsul Sharma, MDS(Public Health Dentistry)

Consultant Dental Specialist Ex-Senior Lecturer

Department of Public Health Dentistry Sri Sukhmani Dental College

Dera Bassi (SAS Nagar) 140507 Punjab, India

PUBLICATION ADDRESS

66 A Day Care Centre

Housing Board Colony Kalka (Panchkula)

Haryana, India-133302 +91 8607700075

[email protected]

[email protected]

Co- Editor Dr. Sahil Thakar, MDS(Public Health Dentistry)

Senior Lecturer Department of Public Health Dentistry

Swami Devi Dyal Hospital and Dental College Panchkula, Haryana, India -134118

+91 9990036390, 8851436453

[email protected]

INTERNATIONAL EDITORIAL

BOARD

1. Dr. Richard J. Gray, DDS(Endodontics)

Private Practitioner

Ex-Assistant Professor

Virginia Commonwealth University

School of Dentistry

Apex Endodontics

1149 Jefferson Green Circle

Midlothian, VA 23113

USA

+1 804-378-9152

[email protected]

SENIOR EDITORS

1. Dr. Anil Sharma,[MBBS, MS(General

Surgery)]

Private Practitioner

Ex-Registrar, Ram Manohar Lohia

Hospital, New Delhi

Ex-Medical Officer Incharge (HCMS)

66 A

Day Care Centre

Housing Board Colony

Kalka (Panchkula)

Haryana, India-133302

+91 9416264986

[email protected]



BOARD

2. Dr. Arushi Khurana [MBBS,MD,PGY5 Fellow

(Hematology/Oncology)]

Virginia Commonwealth University

Massey Cancer Center

401 College Street

Box 980037

Richmond,Virginia 23298-0037

USA

+1804-828-9726

[email protected]

3. Dr. Naimatullah Habibi, [BSc(General

Medicine), MD(Doctor of Medicine),

MD(Family Medicine)]

General Practitioner

2, Merivale Drive

Truganina 3029

Melbourne

Victoria (Australia)

+61 424808900

[email protected]

4. Dr. Gordana Filipović, DDS, PhD

Professor

Chief of Department of Orthodontics

Medical Faculty University of Nis Bul. Zorana Djindjića 81

18000 Nis Serbia

+381 642182752 [email protected]

5. Dr. Syed Ameer Haider Jafri, MDS

(Pedodontics and Preventive Dentistry)

Registrar

King Salman Armed Force Hospital

Tabuk 47512

Saudi Arabia

+96 6534010567

[email protected]

SENIOR EDITORS

2. Dr. Nidhi Gupta, MDS(Public Health

Dentistry)

Professor and Head

Department of Public Health Dentistry

Swami Devi Dyal Hospital and Dental College

Panchkula (Haryana) 134118

+91 9876136514

[email protected]

3. Dr. Sulabh Puri, MD [MBBS, MD

(Radiodiagnosis)]

Senior Resident

Department of Radiodiagnosis

All India Institute of Medical Sciences

New Delhi 1100608

+917042202050

[email protected]

4. Dr. Bhuvandeep Gupta, MDS (Public Health

Dentistry)

Reader


ITS Dental College, Hospital and Research Centre

Greater Noida 201308

+91 9650757561

[email protected]

5. Dr. Sheetal Grover, MDS (Conservative

Dentistry and Endodontics)

Senior Lecturer

Seema Dental College and Hospital

Rishikesh 249203

+91 8477981601

[email protected]

6. Dr. Nitin Gorwade, MDS (Periodontics)

Senior Resident

PGIMER Chandigarh 160012

+91 7738477054

[email protected]

7. Dr. Abhishek Bansal, MDS (Prosthodontics)

Consultant Prosthodontist & Private Practitioner

H-32/62, Sector-3, Rohini, Delhi-110085

+91 9899236125

[email protected]



BOARD

6. Dr Mayank Gahlot (MDS Orthodontics)

Specialist Orthodontist

307, Block A

Al Attar Center

Karama 116440

Dubai

+971 558096897

[email protected]

7. Dr. Vivek Vijay Gupta (MDS Periodontics)

Senior Lecturer

Faculty of Dentistry, SEGi University

Jalan Teknologi 9, PJU5, Kota Damansara

Petling Jaya-47810

Malaysia

+60 102924549

[email protected]

8. Dr. Priti Gupta, MDS(Oral Medicine and

Radiology)

Lecturer

Department of Oral Medicine and Radiology

Nepal Medical College and Teaching Hospital

Attarkhel, Jorpati 44806

Kathmandu, Nepal

+977 9861316716

[email protected]

9. Dr. Ramya Madhuri, MDS(Oral Medicine

and Radiology)

Unit number 12

Building num 4277

Solumaniah

Riyadh

Saudi Arabia

+966 555740418

[email protected]

SENIOR EDITORS

8. Dr. Vinej Somaraj, MDS (Public Health

Dentistry)

Senior Lecturer


Rajas Dental College & Hospital

Thirurajapuram, Kavalkinaru Junction

Tirunelveli District, Tamil Nadu, India

+91 8105170815

[email protected]

9. Dr. Nikhil Prakash,MDS (Prosthodontics)

Senior Lecturer

Department of Prosthodontics

Yogita Dental College and Hospital

Khed, Ratnagiri- 415709

+91 7408814400

[email protected]

10. Dr. Khundrakpam Nganba MDS

(Pedodontics and Preventive Dentistry)

Senior Lecturer

Department of Pedodontics and Preventive

Dentistry

Maharana Pratap Dental College

Gwalior-475001, India

+91 8826355824

[email protected]

INTERNATIONAL HEALTHCARE RESEARCH JOURNAL


CONTENTS (VOLUME 1, ISSUE 7, OCTOBER 2017)

S.No TITLE AUTHOR NAMES PAGE NUMBERS

DOI

EDITORIAL COMMENT

1.

Osteoporosis: An Issue of Bone Strength

(World Osteoporosis Day Special Editorial )

Dr. Nitin Gorwade

1-2

10.26440/IHRJ/01_07/113

REVIEW ARTICLE(S)

2.

Dentistry at the Nano Level: The Advent of

Nanodentistry

Nikhil Seth, Khateeb Khan

3-9

10.26440/IHRJ/01_07/114

CASE REPORT(S)

3.

Odontogenic Submandibular Space Infection Complicated

By Temporal Space Abscess: Report Of A

Rare Case

Priyanka Razdan, Chanchal Singh, Jishnu Krishna

Kumar, Basavaraj Patthi, Ashish Singla, Ravneet

Malhi

10-13

10.26440/IHRJ/01_07/115

4.

Fibro-Epithelial Polyp: Case Report with Literature Review

Ratna Samudrawar, Heena Mazhar, Mukesh Kumar

Kashyap, Rubi Gupta

14-17

10.26440/IHRJ/01_07/116

5. Ameloblastic Fibroma Associated With

Impacted 3rd Molar: A Case Report

K Indira Priyadarsini, Karthik Raghupathy, KV Lokesh, B Venu Naidu

18-21

10.26440/IHRJ/01_07/117

ORIGINAL RESEARCH(S)

6.

Role of Laser Biostimulation in Treatment of Oral

Submucous Fibrosis: A Clinical Trial

Kesari Singh, Achint Garg, Mayank Jain, Mansimranjit

Kaur Uppal

22-26

10.26440/IHRJ/01_07/118

7.

Prevalence of Dental Anxiety among Patients Visiting the Out Patient Department (OPD) of a

Dental Institution in Panchkula, Haryana

Nishant Mehta, Vikram Arora

27-33

10.26440/IHRJ/01_07/119

IHRJ Volume 1 Issue 7 2017

It has been a privilege and an honour to write this editorial on the occasion of “World Osteoporosis Day”. I would like to thank the editorial team for giving me an opportunity to do so. The World Osteoporosis Day is celebrated on the 20th of October each year. Osteoporosis is a disease in which bones become fragile and are more likely to break (fracture). It is estimated that about half of all Indian women over the age of 50 will face a problem of osteoporosis with spine fractures being the most common.1 During one’s lifetime, the body continues to both resorb old bone and create new bone. As long as one’s body has a good balance of new and old bone, his/her bones shall stay healthy and strong, and once the loss of old bone overcomes the formation of new bone and/or if equilibrium between formation and resorption (bone remodelling) is disturbed, the bones become weak and fragile as seen in osteoporosis. The causes of osteoporosis include vitamin D deficiency, gastric bypass surgery, hormonal imbalance as age advances, prolonged illness leading to increased levels of pro-inflammatory cytokines in the body which ultimately affects bone remodelling, family history of osteoporosis, drinking large amounts of alcohol, low body weight, smoking and eating inadequate food or under nutritious diet.2

There are no symptoms in the early stage of osteoporosis. Many times, people will have a fracture before learning they have the disease. Osteoarthritis is also one of the earlier symptom before the major complications of osteoporosis arise. Many different diagnostic methods are available to check for bone density i.e bone density scan, CT bone, routine traditional radiography and DEXA scan. Among all the methods DEXA scan with its low dose radiation benefits the most with better

accuracy. Early detection with better accuracy is the need for the treatment of osteoporosis. Treatment of Osteoporosis includes:

Making lifestyle changes, such as changing your diet and exercise routine

Taking calcium and vitamin D supplements

Bisphosphonates (the main drugs used to prevent and treat osteoporosis in postmenopausal women)

Estrogen and estrogen receptor modulators

Teriparatide (a man-made form of a hormone that increases bone density)

Calcitonin/Denusomab (lessens bone loss and increases bone density)

Exercise also plays a key role in preserving bone density in older adults. Some of the exercises recommended to reduce your chance of a fracture include weight-bearing exercises such as walking, jogging, playing tennis, dancing, free weights, weight machines, stretch bands, Balance exercises such as tai chi and yoga and Rowing machines. Guidelines for getting enough calcium and vitamin D:

Natural sources are the most beneficial which include exposure to sun light, intake of cheese, butter, margarine, fortified milk, fish chicken, mutton and fortified cereals.

Adults under age 50 should have 1,000 mg of calcium and 400 to 800 International Units (IU) of vitamin D daily.

Women aged 51 to 70 years should have 1,200 mg of calcium and 400 to 800 IU of vitamin D daily.

Men aged 51 to 70 years should have 1,000 mg of calcium and 400 to 800 IU of vitamin D daily.

Adults over age 70 should have 1,200 mg of calcium and 800 IU of vitamin D daily.

It is advised that both males and especially females follow a diet that provides the proper amount of

Osteoporosis: An Issue of Bone Strength

(World Osteoporosis Day Special Editorial)

EDITORIAL COMMENT

ISSN: 2456-8090 (online) International Healthcare Research Journal 2017;1(7):1-2. DOI: 10.26440/IHRJ/01_07/113 QR CODE

Dr. NITIN GORWADE

1


calcium and vitamin D. To prevent osteoporosis, it is better to remember the quote “Prevention is better than cure”.

REFERENCES

1. Patwa P. One in every two middle-aged women suffers from low bone density: expert (Online Article). Available at http://www.deccanchronicle.com/lifestyle/health-and-wellbeing/010616/one-in-every-two-middle-aged-women-suffers-from-low-bone-

density-expert.html (Last Accessed 17th September 2017)

2. Kling JM, Clarke BL, Sandhu NP. Osteoporosis

Prevention, Screening, and Treatment: A Review. J Womens Health (Larchmt) 2014; 23(7): 563–72.

Senior Resident, PGIMER Chandigarh 160012 +91 7738477054 [email protected]

K

K

Cite this article as:

Gorwade N. Osteoporosis: An Issue of Bone Strength (World Osteoporosis Day

Special Editorial). Int Healthcare Res J 2017;1(7):1-2.

Osteoporosis: An Issue of Bone Strength Dr. Nitin Gorwade

2


INTRODUCTION The entire dental fraternity is witnessing the beginning of a truly ground breaking advancement- “Nanodentistry”; which is a rare opportunity. Described in simple terms, it implies engineering at the molecular scale.1 Nano is derived from the Greek word “nano” which means dwarf and a nanometer is 10–9 meter, or one-billionth of a meter. Since it is difficult to visualise the scale of a nanometer, it might be helpful to compare the scale with objects of appreciable dimensions. If the height of an average human being were scaled from the stretch from the earth to the moon, then each person’s atom would be about the size of a baseball (approx. 10 cms in diameter). A nanometer would then be about five baseballs in a row.2

As properties of dental materials often significantly change following the micro-to-nano shift, a new field was born to explain these rather strange phenomenon, named nanoscience; the application of its discoveries is dentistry being known as “nanodentistry”.3 Using nanocharacterization tools, a variety of oral diseases can be understood at the molecular and cellular levels and thereby be prevented. Nano-enabled technologies thus provides an alternative and superior approach to assess the onset and/or progression of diseases, to identify targets for treatment interventions as well as the ability to

design more biocompatible, microbe resistant dental materials and implants benefitting the entire human race. Many hopes are pinned on nanodentistry that it will likewise bring tangible benefits to dentistry, from diagnosis to the clinical level.3 This review stands in favour of the fact that the upcoming methodologies in dental sciences shall be substituted with finer, more precise and sensitive treatment techniques by the application of nanodentistry.

HISTORY OF NANODENTISTRY The history background of nanotechnology is blotted with a certain amount of skepticism among scholars. Some researchers believe that this is a brand new form of scientific evolution that did not develop until the late 1980s or early 1990s; while others have found evidence that the history of nanotechnology can be traced back to the year 1959. Interestingly, other researchers hold the belief that humans have unknowingly used practical nanotechnological methods for thousands of years (e.g. making steel, paintings and in vulcanization of rubber).4

1867:- The first mention of some of the early and distinguishing concepts in nanotechnology (but predating use of that name) was in 1867 by James

One of the revolutions in the filed of dentistry is nanodentistry. It has the power to completely revolutionized the field of dentistry through use of nano particles that shall guide and help maintain one’s overall oral health. Painful procedures shall be a thing of the past as nanomaterials shall reduce pain during various dental procedures, help remineralise tooth and associated structures and help maintain oral hygiene. This review focusses on the various aspects of nanodentistry and how it can revolutionize dentistry. KEYWORDS: Nanoscience, Nanomaterials, Nanorobots

K

Dentistry at the Nano Level: The Advent of Nanodentistry

REVIEW ARTICLE

A B STRACT

ISSN: 2456-8090 (online) International Healthcare Research Journal 2017;1(7):3-9. DOI: 10.26440/IHRJ/01_07/114

NIKHIL SETH1, KHATEEB KHAN2

QR CODE

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Clerk Maxwell when he proposed through a thought experiment that a tiny entity known as Maxwell’s Demon shall be able to handle individual molecules in the future.4

1914:- The first observations and size measurements of nano-particles was made during the first decade of the 20th century mostly associated with Richard Adolf Zsigmondy, who made a detailed study of gold sols and other nanomaterials with sizes down to 10 nm or less.4 He was also the first person who used the term “nanometer” explicitly for characterizing the size of a particle and determined it as 1/1,000,000 of millimeter. The credit for developing the first system of classification based on particle size in the nanometer range can be attributed to him.5

1959:- The topic of nanotechnology was again touched by the talk- ‘‘There’s Plenty of Room at the Bottom,’’ given by the Nobel prize winning physicist Prof. Richard Feynman at an American Physical Society meeting at Caltech on December 29, 1959.6 Prof. Feynman described atomic scale fabrication of nanomaterials using a bottom-up approach, as opposed to the top-down approach that manufacturers we are accustomed to at that time.4 He suggested nanomachines, nanorobots and nanodevices ultimately could be used to develop a wide range of atomically precise microscopic instruments and manufacturing tools and concluded his lecture by saying these often quoted lines on nanoscience- “This is a development which I think cannot be avoided.” 1974:- The word assigned to scientific advancement at the nano level is documented to have come from an article that was released in 1974 written from the Tokyo Science University. There, a student, Norio Taniguchi, coined the term ‘‘nanotechnology’’ in his article and the name gained popularity from then on. 4,7 1977:– Many researchers agree to the fact that the term “Nanotechnology” was coined by Prof. Kerie E. Drexler, a lecturer and researcher at MIT (Massachuehettes Institute of Technology).8 Researchers claim that that Prof. Drexler also introduced molecular nanotechnology concepts in the late 1970's, which he researched during his tenure at MIT.

NANODENTISTRY AND ITS APPLICATION Nanodentistry shall make the maintenance of near-perfect oral health through the use of nanomaterials, biotechnology (including tissue engineering), and nanorobotics. Trends in oral health and disease may change the focus on specific diagnostic and treatment modalities because of this technology. According to Baum BJ,9 the three main components of nanodentistry are:- 1. Nanomaterials 2. Biotechnology (including tissue engineering) 3. Nanorobotics

STATE OF THE FIELD OF NANODENTISTRY AT PRESENT:-10,11 Nanostructures that are in use at present are:- 1. Nanopores: They are tiny holes that allow DNA to pass through, one strand at a time and will make DNA sequencing more efficient. The size of the pores are so minute that separation of DNA might be attempted using this structure(s). As DNA passes through a nanopore, researchers can monitor the shape and electrical properties of each base, or letter on the strand and this can be used to decipher the encoded information in it, including discrepancies in the code known to be associated with cancer and/or other dental anomalies/diseases.12 2. Nanotubes: They are most common structures made of carbon atoms bonded into honeycomb-like shapes with enormous strength and electrical conductivity. These are carbon rods about half the diameter of a molecule of DNA that not only can detect the presence of altered genes, but may help researchers pinpoint the exact location of those changes. It helps to identify DNA changes associated with cancer.13

3. Quantum dots: They are miniscule molecules making up tiny crystals that glow when stimulated through UV light (of varying wavelengths) and are used to detectabsor cancer. Latex beads are filled with these crystals and are designed to bind to specific DNA sequences. By combining different sized quantum dots within a single bead, scientists can create probes that release distinct colours and

Dentistry at the Nano Level Seth N et al.

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intensities of light. When the crystals are stimulated by UV light, each bead emits light that serves as a sort of spectral bar code, identifying a particular region of DNA. To detect cancer, scientists can design quantum dots that bind to sequences of DNA that are associated with the disease. When the quantum dots are stimulated with light, they emit their unique bar codes, or labels, making the critical, cancer associated DNA sequences visible. 12,14

4. Nanoshells: These are miniscule beads that are coated with gold. By manipulating the thickness of layers that make the nanoshells, scientists can design these beads to absorb specific wavelengths of light. The most useful nanoshells are those that absorb near-infrared light, which can easily penetrate several centimeters of human tissue. UV light absorbed by the nanoshells creates localised heat which is intense and is lethal to cells. Researchers can already link nanoshells to antibodies that recognise cancer cells. Scientists envision letting these nanoshells seek out their cancerous targets, then applying neainfrared light. In laboratory cultures, the heat generated by the light-absorbing nanoshells has successfully killed tumor cells while leaving neighbouring cells intact. 15,16

5. Dendrimer: These are man-made molecules about the size of an average protein, and have a branching shape. This shape gives them a vast amount of surface area to which scientists can attach therapeutic agents or other biologically active molecules. Dendrimers are formed nanometer by nanometer, so the number of synthetic steps or generations dictates the exact size of particles in a batch. A dense field of molecular groups that serve as hooks for attachment of useful molecules, such as DNA is formed in a peripheral layer. Upon entering a living cell, dendrimers of a certain size trigger a process called endocytosis in which the cell's outer membrane deforms into a tiny bubble or vesicle. The vesicle encloses the dendrimer which is admitted into the cell's interior. Once inside the cell, DNA is released and migrates to the nucleus where it becomes part of cell's genome. It has been used in mammalian cell types and to be used in humans. An example is when Donald et al. reported using glycodendrimer "nanodecoys" to trap and deactivate influenza virus particles.16

6. Nanobelt: They have advantages over nanotubes in terms of price, flexibility and practicality. For making nanobelts, oxide is evaporated for 2 hours. The oxide contains zinc, tin, cadmium, gallium or indium. A Nanobelt is deposited as a wool like product and the little straps have a rectangular cross section, with a width of 30-300 nm and a thickness of 10-15 nm and each belt is a single crystal. Because the material is already an oxide, it does not undergo a chemical reaction and has a pure, flawless surface. To mainly differentiate between nanotubes and nanobelts, the lengh of nanotubes are a few millionths of a meter long, while the nanobelts are millimeters long. Also, while nanotubes are made of pure carbon, belts have been made from five oxides.16

TECHNIQUES APPLIED IN NANODENTISTRY Nanodentistry employs two main techniques namely:-17 a). Bottom up Technique. b). Top Down Technique. A). BOTTOM UP TECHNIQUE: This technique seeks to arrange smaller components into a more complex assembly.17 Nanodentistry as a bottom up approach (procedures using bottom up technique) :- The dental procedures employed are:- 1. Local anaesthesia 2. Hypersensitivity cure 3. Nanorobotic dentrifice (dentifrobots) 4. Dental durability and cosmetics 5. Orthodontic treatment 6. Photosensitizers and carriers 7. Diagnosis of oral cancer (nanodiagnosis)7 B). TOP DOWN TECHNIQUE: This technique seeks to create smaller devices by using larger ones to direct their assembly. Nanodentistry as a top down approach (procedures using top down technique):- The dental procedures employed are:- • Nanocomposites. • Nano Light-Curing Glass Ionomer Restorative. • Nano Impression Materials. • Nano-Composite Denture Teeth. • Nanosolutions. • Nanoencapsulation. • Plasma Laser application.


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• Prosthetic Implants. • Nanoneedles. • Bone replacement materials.2

NANOFORESIGHT Nanodentistry will make possible the maintenance of comprehensive oral health by employing nanomaterials, biotechnology including tissue engineering, and, ultimately, dental nanorobotics (nanomedicine).9 When the first micron-size dental nanorobots will be constructed in 10-20 years, these devices will allow, precisely controlled oral analgesia, dentition replacement therapy using biologically autologous whole replacement teeth manufactured during a single office visit, and rapid nanometer-scale precision restorative dentistry. New treatment opportunities may include dentition renaturalization, permanent hypersensitivity cure, complete orthodontic realignments during a single office visit, convalently - bonded and continuous oral health maintenance using mechanical dentifrobots. Freitas has described that how medical nanorobots might utilize specific motility mechanisms to crawl or swim through human body tissues doing mobile cell surgery carrying oxygen (Nano Respirocyte) 236 times more efficiently as compared to RBCs with navigational precision, acquire energy, sense and manipulate their surroundings, achieve safe cytopenetration (e.g., pass through plasma membranes such as the odontoblastic process without disrupting the cell),and employ any of a multitude of techniques to monitor, interrupt, or alter nerve impulse traffic in individual nerve cells, in real time. The functions of these nanorobots may be controlled by an onboard nanocomputer that executes pre-programmed instructions that are in response to local stimuli that are picked up by its sensors. Also, the dental operator may issue specific instructions by transmitting his orders through acoustic signals to nanorobots present in vivo.18

One of the most common procedures in dentistry is the injection of local anesthesia, which has varying degrees of efficacy, patient discomfort and infrequent complications. To induce oral anesthesia in the era of nanodentistry, a colloidal suspension containing millions of active analgesic micron - size dental nanorobots will be instilled on the patient's gingivae. After contacting the surface

of the crown or mucosa, the nanorobots shall reach the dentin by migrating into the gingival sulcus and passing painlessly through the lamina propria or 1 - 3 micron thick layer of loose tissue at the cemento -dentinal junction. After reaching the dentin, the nanorobots shall enter dentinal tubules sized 1 - 4 micron in diameter and slowly proceed towards the pulp, guided by a combination of temperature differentials, chemical gradients, specific and controlled positional navigation, all under the onboard nanocomputer control.13 Treatment options using nanodentistry may include techniques used to repair major tooth defects and dentition renaturalization procedures Renaturalization of dentition shall begin with patients desiring to have their old dental amalgam restoration(s) excavated and their teeth rebuilt with biological materials that mimic real tooth structure in terms of colour and hardeness.19 Dentin hypersensitivity is a pathologic phenomenon that may be amenable to a nanodental cure. This etiology(changes in pressure transmitted hydrodynamically to the pulp) is suggested by the finding that hypersensitive teeth have 8 times higher surface density of dentinal tubules; and affected tubules are with diameters twice as large than non-sensitive teeth. A wide availability of Over The Counter (OTC) drugs are available for the treatment of this common painful condition which provides temporary relief. In this particular case, dental nanorobots shall play a reconstructive role and shall selectively and precisely occlude selected pain causing tubules in minutes, offering patients a quick and permanent cure for their ailment.20

Orthodontic nanorobots could directly manipulate the periodontal tissues including gingiva, periodontal ligament, cementum and alveolar bone, allowing rapid painless tooth straightening, rotating, and vertical repositioning in minutes to hours, in contrast to current molar uprighting techniques which require weeks or months to proceed to completion.21 Effective prevention has reduced caries in children and a caries vaccine may soon be available, but a subocclusal dwelling nanorobotic dentifrice delivered by mouthwash or toothpaste could


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patrol all supragingival and subgingival surfaces at least once a day, metabolizing trapped organic matter into harmless and odorless vapors and performing continuous calculus debridement.22 Dentifrobots would also provide a continuous barrier to halitosis, since bacterial putrefaction is the central metabolic process involved in oral malodor. With this kind of daily dental care available from an early age, conventional tooth decay and gum disease will disappear into the annals of medical history.20 Private and public research efforts worldwide are developing nanoproducts aimed at improving health care and advancing medical research. Three applications of nanotechnology are particularly suited to biomedicine: diagnostic techniques, drugs, and prostheses and implants. Interest is also booming in biomedical applications for use outside the body, such as diagnostic sensors and "lab on-a-chip" techniques, which are suitable for analyzing blood and other samples, and for inclusion in analytical instruments for R&D on new drugs. For inside the body, many companies are developing nanotechnology applications for anticancer drugs, implanted insulin pumps, and gene therapy. ABI 007 is 130 nm long and consists of an engineered protein -stabilized nanoparticle that contains paclitaxel, which is used to treat breast, bladder, and more than a dozen other cancers. Such new delivery systems combine a drug with an artificial vector that can enter the body and move in it like a virus. If more advanced clinical tests are successful, ABI-007 is likely to enter the market in a few years. A project on nanotube based electronics biosensors is under process to develop a novel sensor technology platform based on carbon nanotube electronic sensor device, which could be integrated into a biochip and used for detection and analysis of biomolecules in samples from blood, saliva and other body fluids, as well as studies of protein - protein, and protein - small molecule interactions in the research laboratory. Nanotechnology is also being used to create a new family of "smart" orthopedic and dental implant coating materials that enhance new bone formation over exiting implants. "Smart" coating materials are necessary to selectively increase bone cell function while, at the same time, inhibit functions of competitive cells that lead to soft,

instead of bony, tissue formation. Such osseointegration provides mechanical stability to an implant in situ, minimizes motion- induced damage to surrounding tissues, and is imperative for the clinical success of bone implants. Increased bonding between an implant and juxtaposed bone so that a patient who has received joint or dental replacement surgery may quickly return to a normal active lifestyle.

BARRIERS TO OVERCOME The field of nanotechnology has certain barriers to overcome, if it wants to become a success in the future. These are- • Precise positioning and assembly of molecular scale part. • Economical nanorobot mass production technique. • Simultaneous coordination of activities of large numbers of independent micron scale robots. • Biocompatibility issues. • Funding and strategic issues. • Insufficient integration of clinical research. • Inefficient translation of concept to product because of inadequate venture capital, excessive bureaucracy and lack of medical input. • Social issues of public acceptance, ethics, regulation and human safety.22

PROBLEMS FOR RESEARCH IN NANOTECHNOLOGY IN INDIA •Painfully slow strategic decisions •Sub-optimal funding •Lack of engagement of private enterprises •Problem of retention of trained manpower.10

CONCLUSION Nanodentistry faces numerous critical difficulties in bringing its promises to realization. However, once the initial barriers are crossed and the production of nanoparticles in done on a large scale, it shall be of great benefit to the society and heal reduce the global burden that oral diseases carry.

REFERENCES 1. Satyanarayana T, Rai R. Nanotechnology: The

future. J Interdiscip Dentistry 2011;1:93-100. 2. Freitas RA Jr. Nanodentistry. J Am Dent Assoc

2000;131:1559–66.


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3. Uskoković V. Bertassoni LE. Nanotechnology in Dental Sciences: Moving towards a Finer Way of Doing Dentistry. Materials 2010;3:1674-91.

4. Kumar PS, Kumar S, Savadi RS, John J. Nanodentistry: A Paradigm Shift-from Fiction to Reality. Indian Prosthodont Soc 2011;1(1):1–6.

5. Zsigmondy RA. Colloids and the ultramicroscope- A manual of Colloid chemistry and ultramiscroscopy 1914. NY John Wiley and Sons Inc.

6. John G. Richard Feynman: A life in science 1997. Dutton, NY, p 170.

7. Norio Taniguchi, ‘‘On the Basic Concept of ‘Nano-Technology’,’’Proc. Intl. Conf. Prod. Eng. Tokyo, Part II, Japan Society of Precision Engineering, 1974:18–23.

8. Kaehler T. Nanotechnology: Basic concepts and definitions. Clinical chemistry. 1994, 15(9), 1797-9.

9. Baum BJ, Mooney DJ. The impact of tissue engineering on dentistry. J Am Dent Assoc. 2000 Mar;131(3):309-18.

10. Sarvanakumar R, Vijaylakshmi R. Nanotechnology in dentistry. Ind J Dent Res.2006;17( 2):62-5.

11. Rybachuk A.V., Chekman I.S., Nebesna T.Y. Nanotechnology and nanoparticles in dentistry. J. Pharmacol. Pharm. 2009;1:18–20.

12. Jhaveri H.M, P.R. Balaji. Nanotechnology: The future of dentistry. J of Indian Prosthodontic society:5(1);2005.

13. Bhuvaneswarri J, Alam N, Chandrasekaran S.C, Sathya M. S. Future impact of nanotechnology in dentistry – a review. Int J of nanotechnology and application 20130:3(2):15-20.

14. Titus L. Schleyer, Nano Dentistry Fact or Fiction. JADA 2000;131(11):1567-8.

15. Sheeparamatti BG, Sheeparamatti RB, Kadadevaramath JS, Nanotechnology: Inspiration from

16. nature. IETE Technical Review 2007;24(1):5-8.

17. Parak WJ, Gerion D. Biological applications of colloidal nanocrystals. Nanotechnology 2003;14:15-27.

18. Janes DB. What is Nanotechnology? Purdue University, The Janes Group Webpage, 2002. cobweb.ecn.purdue. edu/janes/prof_david_janes

19. Freitas RA Jr. Nanotechnology, Nanomedicine and Nanosurgery. Int J Surg 2005;3(4):243-6.

20. Abhilash M. Nanorobots. Int J Pharma Bio Sci 2010;1(1):1–10.

21. Mouli C, Kumar MS , Parthiban S. Nanotechnology in Dentistry - A Review. Int J Biol Med Res 2012; 3(2): 1550-3.

22. Gupta J. Nanotechnology applications in medicine and dentistry. Journal of Investigative and Clinical Dentistry (2011), 2, 81–88.

23. Chandki R, Kala M, N KK, Brigit B, Banthia P, Banthia R. ‘NANODENTISTRY’: Exploring the beauty of miniature. J Clin Exp Dent 2012;4(2):119-24.


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Corresponding Author: Dr. Nikhil Seth Senior Lecturer, Department of Public Health Dentistry, Ambedkar Dental College, Patna, Bihar, India +91 9810896450 [email protected]

AUTHOR AFFILIATIONS:

1. Senior Lecturer, Department of Public Health Dentistry, Ambedkar Dental College, Patna, Bihar, India

2. MDS (Public Health Dentistry), Private Practitioner

Source of support: Nil, Conflict of interest: None declared


Seth N, Khan K. Dentistry at the Nano Level: The Advent of Nanodentistry.

Int Healthcare Res J 2017;1(7):3-8.

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INTRODUCTION Infections of odontogenic origin are common cause of reporting to the dentist. They made lead to pain, discomfort and difficulty in opening mouth, thereby complicating the functional activities of oral cavity. In developing countries, lack of adequate nutrition, poor orodental hygiene, tobacco use, areca nut chewing and smoking has increased the prevalence of odontogenic infections. Odontogenic infections can also provide a channel to deep neck space infections. The most common cause of these infections is poor oral hygiene. Odontogenic infections are common and can be fatal or life threatening calling for an essential early diagnosis. Management of these infections mainly comprises of airway management, antibiotic therapy and surgical intervention. As always said, prevention is better than cure, prevention of odontogenic infections can be achieved by creating awareness regarding such complications of poor oral and dental hygiene and by conducting regular screening at community level. The current case report describes the management of a rare case of a submandibular space infection extending to temporal space in an eight years old male child.

CASE REPORT An eight years old male child reported with the chief complaint of pain and it was associated with swelling on the left side of face. The patient had visited local dentist in his area before 10 days and

was prescribed antibiotics (Amoxycillin 250 mg and Clavulanic acid 125 mg) and non-steroidal anti-inflammatory drugs (Diclofenac sodium 50 mg and Paracetamol 250 mg in combination) three times daily for three days. After three days, the swelling increased and he reported to another dentist who prescribed some medication again (which was unknown to the patient) for three days. There was no relief in the pain and swelling; so, he reported to the department of Pedodontics, Dental College and Hospital, Mathura. Upon examination, a gross asymmetry of face was found with palpable hard swelling in mandibular left posterior region of the jaw that had further extended to the temporal region (Figure 1).The swelling was hard and fluctuant in nature extending from 34 tooth region inferiorly to temporal region superiorly and below infra-orbital margin anteriorly to posterior auricular region posteriorly, measuring 8×5 cms (Figure 2). The subject presented with a temperature of 39ºC and had reduced mouth opening. On radiographic evaluation it was observed that the mandibular left first permanent molar (36) was grossly carious and there was widening of PDL space, suggestive of periapical abscess in relation to the affected, 36 (Figure 3) which was suspected to be the aetiology for the infection. With this the diagnosis of submandibular space infection extending to temporal region was made. Since the patient had already taken medication with no signs of relief, it

Cases of facial space infection of odontogenic origin are commonly reported in dentistry. Among them submandibular space infections are most common, but their extension to temporal region is seldom reported. Management of such infection is very challenging and requires expertise. This report describes the management of a rare case of a submandibular space infection extending to temporal space using incision and drainage in an eight years old male child. KEYWORDS: Antibiotic, Drainage, Suppuration

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Odontogenic Submandibular Space Infection Complicated By Temporal Space Abscess: A Rare Case Report

CASE REPORT

A B S T RA C T

PRIYANKA RAZDAN1, CHANCHAL SINGH2, JISHNU KRISHNA KUMAR3, BASAVARAJ PATTHI4, ASHISH SINGLA5, RAVNEET MALHI6

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was decided to incise and drain the abscess from the temporal region. The procedure was explained and written informed consent was obtained from the accompanying parent. Before the treatment, Otorhino-laryngologist was consulted to obtain an expert suggestion and to rule out any other possible aetiology. Under aseptic conditions, lignocaine spray was applied in the temporal region and using 18 gauge needle the abscess was drained slowly (Figure 4). Approximately 25 ml of the pus was drained using this method. Remaining abscess was not possible to drain with needle because of the presence of loculi. Hence incision and drainage was decided and the loculi were broken using artery forcep (Figure 5). Under Local anaesthesia, a 2 cm long stab incision was placed in the safe area of the temporal region (Keeping in mind vessels and nerves in that region) and the pus was drained by pressing it in downward direction towards the incision. A corrugated rubber sheet (as a drain) was placed in the stab incision deep into the temporal space and dressing was given and the patient was recalled after three days. Culture and sensitivity test of the drained abscess was carried out in the microbiology department and it came out as sterile. Postoperative medications for submandibular swelling (Tab. Amoxycillin 250mg and Clavulanic acid 125 mg, Tab metronidazole 200 mg and analgesics ibuprofen and paracetamol) were prescribed two times daily for three days and patient was also advised to perform mouth opening exercises and recalled after 3 days. There was improvement in mouth opening of up-to 20 mm width after 3 days. Because of poor prognosis the infected mandibular left permanent first molar was extracted followed by curettage. Some amount of abscess was drained again from the temporal region, rubber drain was changed and medication was continued for two more days. After 5 days, the swelling had regressed completely and the symmetry of the face was observed (Figure 6). Patient’s mouth opening was improved by regular physiotherapy. Post operatively healing was uneventful. At follow up examination patient’s clinical outcome was found to be satisfactory.

DISCUSSION The management of deep neck infections is troublesome due to the complex anatomy of the neck, polymicrobial etiology, and life-threatening complications that may arise. Intravenous high dose antibiotics (usually penicillin or cephalosporins and metronidazole), analgesic and fluid therapy in addition to establishment of surgical drainage and elimination of the source of infection stand-out to be the prime treatment plan of fascial space infections. Moreover, the inappropriate use of antibiotics, steroids, and nonsteroidal anti-inflammatory drugs may mask signs of infection and change the clinical presentation, making it more elusive, and also lead to a slow course of disease, delayed recovery, and the development of complications.1 Odontogenic infection was identified as the main source of fascial space infections in this case report while the cause is usually idiopathic in infants and young children.2 The causative bacteria are usually a mixture of aerobes and anaerobes including oral microorganisms such as streptococci or staphylococci.3 In the present case the patient had no relief with antibiotics initially and hence when he reported to us it was decided to drain the abscess. The culture of the sample was sterile which indicated the effectiveness of the previously taken antibiotics by the patient. In agreement with others reports, dental infection was the most common cause of submandibular space infection.4,5 Published literature pertaining to submandibular space infections, pointed out that in 28.4% of the cases the source of infection could not be found. Many of these patients might have had a long-standing suppuration of the deep lymph nodes not recognized in clinical and radiographic examination.6 In the present case the infected tooth was extracted at the second visit as there was limited mouth opening when patient reported to us. The spread of this submandibular space infection to temporal region is rare and its management is challenging because of the proximity of the swelling to various vital structures.7 Since submandibular space infections frequently have a dental origin, acquisition of high-resolution axial scans of the jaw together with curved and

Submandibular Infection Complicated By Temporal Space Abscess Razdan P et al.

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orthoradial multiplanar reconstructions (Dental scan) are advisable in order to identify periapical infections.8 The present case was carried out by surgical management supported by antibiotic coverage since, latter alone would not have moderated the pathology. Surgical drainage aided in removal of toxic purulent material, decompression of the oedematous tissues, allowed better perfusion of blood containing antibiotics and defensive elements and increased oxygenation in the infected area leading to postoperative uneventful healing.9, 10

CONCLUSION Pre-existing dental infections are the commonest causes of fascial space infections of the head and neck region. The extension of the submandibular space infection to temporal region could be dangerous if overlooked. Regular dental visits may enhance early detection and treatment of dental ailments, thereby preventing development of fascial space abscess.

REFERENCES

1. Syed MI, Baring D, Addidle M, Murray C, Adams C. Lemierre syndrome: two cases and a review. Laryngoscope 2007; 117(9): 1605-10. 2. Reynolds SC, Chow AW. Life-threatening

infections of the peripharyngeal and deep fascial spaces of the head and neck. Infect Dis Clin North Am 2007; 21(2): 557-76.

3. Schuknecht B, Stergiou G, Graetz K. Masticator space abscess derived from

odontogenic infection: imaging manifestation and pathways of extension depicted by CT and MR in 30 patients. Eur Radiol 2008; 18(9): 1972-9.

4. Akst LM, Albani BJ, Strome M. Subacute infratemporal fossa cellulitis with subsequent abscess formation in an immunocompromised patient. Am J Otolaryngol 2005; 26(1): 35-8.

5. Larawin V, Naipao J, Dubey SP. Head and neck space infections. Otolaryngol Head Neck Surg 2006; 135(6): 889-93.

6. Parhishar A, Har-El G. Deep neck abscess: a retrospective review of 210 cases. Ann Otol Rhinol Laryngol 2001; 110(11): 1051-4.

7. Schmitz, John P "Shooters Abscess" of the neck presenting as a temporal space infection and misdiagnosed as an odontogenic infection. Texas Dent J 2007; 124(12): 1188-91.

8. Gahleitner A, Watzek G, Imhof H. Dental CT: imaging technique, anatomy, and pathologic conditions of the jaws. Eur Radiol 2003; 13:366-76.

9. Boscolo-Rizzo P, Marchiori C, Montolli F, Vaglia A, Da Mosto MC. Deep neck infections: a constant challenge. ORL J Otorhinolaryngol Relat Spec 2006; 68(5): 259-65.

10. Bratton TA, Jackson DC, Nkungula-Howlett T, Williams CW, Bennett CR. Management of complex multi-space odontogenic infections. J Tenn Dent Assoc 2002; 82(3): 39-47.


Razdan P, Singh C, Kumar JK, Patthi B, Singla A, Malhi R. Odontogenic

Submandibular Space Infection Complicated By Temporal Space Abscess: A

Rare Case Report. Int Healthcare Res J 2017;1(7):10-13.

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Corresponding Author: Dr. Priyanka Razdan Senior Lecturer Dept of Pedodontics & Preventive Dentistry Yogita Dental College & Hospital Khed, Maharastra +91-8755114778 [email protected]


1. Senior Lecturer, Department of Pedodontics & Preventive Dentistry, Yogita Dental College & Hospital, Khed, Maharastra 2. Professor & Head, Department of Pedodontics & Preventive Dentistry, K.D Dental College & Hospital, Mathura, Uttar Pradesh 3. Senior Lecturer, Department of Public Health Dentistry, DJ College of Dental Sciences & Research, Ajit Mahal, Niwari Road, Modinagar 4. Professor & Head, Department of Public Health Dentistry, DJ College of Dental Sciences & Research, Ajit Mahal, Niwari Road, Modinagar 5. Reader, Department of Public Health Dentistry, DJ College of Dental Sciences & Research, Ajit Mahal, Niwari Road, Modinagar 6. Senior Lecturer, Department of Public Health Dentistry, BRS Dental College & Hospital, Sultanpur, Panchkula



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LEGENDS

Figure 1. Preoperative photograph showing submandibular space infection extending towards

temporal region

Figure 3. Orthopantomogram showing carious lower left 1st permanent molar

Figure 5. Breaking of loculi for drainage of remaining abscess

Figure 2. Preoperative photograph showing fluctuant swelling in temporal region

Figure 4. Draining abscess using needle

Figure 6. Post-operative photograph after 10 days


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INTRODUCTION Fibroma of the oral mucosa is the most common benign soft tissue tumor of the oral cavity derived from fibrous connective tissues (CTs).1 Its pathogenesis lies in the fact that due to continues local trauma, a type of reactive hyperplasia of fibrous tissue occurs.2 Thus, “Focal fibrous hyperplasia” (FFH) term was suggested by Daley et al. in 1990,3 for such type of reactive tissue response, rather than the term “fibroma.” It is also known as irritation fibroma (IF)/traumatic fibroma/fibro-epithelial polyp.4,5 The prevalence of such fibromas was found to 39.1% among the South Indian population.6 It presents clinically as sessile or occasionally pedunculated painless swelling that can be firm, resilient to soft, spongy in consistency.7 Cooke described such type of pedunculated swelling which arises from a mucosal surface as “polyp”.8 The tumor appears as elevated nodule of normal colour with smooth surface. The tumor is mostly small in size but, if larger in size and projecting above the surface, it may sometimes get inflamed and even may show superficial ulceration or hyperkeratosis.9 In this article we present a rare case of large size fibro-epithelial polyp associated with inflammation occurring on left alveolar region extending buccally and lingually. CASE REPORT A 42-year-old male reported to the Department of Oral and Maxillofacial Surgery with the chief

complaint of growth in left lower back region of the mouth since 4 months. History elicited that the a solitary, painless growth had been observed in his left mandibular molar region which was initially small in size and then it gradually enlarged to present size of oval shape, well-defined, pedunculated lesion. On intraoral examination 35 had been found missing and sharp cusp with respect to 25 was noted. The growth was smooth and associated with ulceration over superior surface of lesion, size was about 3.5 cm × 2 cm × 2 cm arising from extraction socket region of 35 and extending from the alveolar ridge 1 cm buccally and lingually and also above the level of occlusal plane (Figure 1). Grade 3 mobility of 34, 36 was present. On palpation, the growth was firm in consistency, non-tender and was attached to the underlying surface. Clinical diagnosis of fibro-epithelial polyp was given. Orthopantomograph was taken (Figure 2) to rule out other possible radiolucent lesions of jaw and to know extent of lesion radiographically. Under local anesthesia, surgical excision of lesion along with extraction of periodontally compromised tooth 34, 36 was done. Enemaloplasty of 25 was also done. After achieving homeostasis, primary closure was done. Specimen appeared fibrotic in consistency (Figure 3). Histopathological examination of H&E stained

Oral fibroma is the most common benign soft tissue tumor caused due to continuous trauma from sharp cusp of teeth or faulty dental restoration. It presents as sessile or occasionally pedunculated painless swelling which can be soft to firm in consistency. Its incidence occurs mostly during third to fifth decade and shows preference for female. Its occurrence corresponds with intraoral areas that are prone to trauma such as the tongue, buccal mucosa and labial mucosa, lip, gingiva. Even with conservative surgical excision, the lesion may recur until the source of continuous irritation persists. This article presents a case of large size oral fibroma on left alveolar region associated with ulceration along with literature review. KEYWORDS: Benign Connective Tissue Tumor, Fibro-epithelial Polyp, Irritation Fibroma, Traumatic Fibroma, Focal Fibrous Hyperplasia.

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Fibro-Epithelial Polyp: Case Report with Literature Review

CASE REPORT

A B S T RA C T

RATNA SAMUDRAWAR1, HEENA MAZHAR2, MUKESH KUMAR KASHYAP3, RUBI GUPTA4

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specimen showed hyperparakeratinized stratified squamous atrophic epithelium with the underlying fibrous connective tissue stroma along with mixture of acute and chronic inflammatory cells inflitrate in the areas of hyalinization. Histopathological diagnosis confirmed the clinical diagnosis. Post-operative healing was uneventful. No recurrence was reported at 6 months follow-up.

DISCUSSION Irritation or traumatic Fibromas are the most common connective tissue tumors occurring in the oral cavity caused due to trauma or local irritation.10,11 Rather than being a true neoplasm, they are merely fibrous overgrowths. Literature suggested the term fibro-epithelial polyp for such type of benign lesions.12

It is one of the most common sub-mucosal response to continuous irritation from sharp teeth or faulty dental prosthesis.13 Fibroma occurs as a result of chronic repair process that include granulation tissue and scar formation causing a fibrotic growth.14 The local irritation may includes calculi, sharp bony spicules remaining after extraction, overhanging margins of restorations, foreign bodies, habit of biting and over extended margins of dental appliances. Axell (1976) reported 3.25% prevalence among adult Swedish people for fibromas. It mostly occurs after fourth decade with no gender preference.15 The lesions are mostly seen in intraoral areas which are prone to trauma such as the lateral border of tongue, lip, buccal mucosa, retromolar region. Clinically, they appear as broad-based lesions, slightly paler than the surrounding normal mucosa, with the white surface due to hyperkeratosis or with surface ulceration caused due to trauma. The growth rate of fibroma is slow with no recurrence.16

The clinical presentations of oral fibroma are not unique and the differentiation of these lesions should be made from gaint cell fibroma, neurofibroma, peripheral ossifying fibroma, pyogenic granuloma or peripheral giant cell granuloma. The oral fibroma and peripheral ossifying fibroma both appear pale, firm and non-tender. However, peripheral ossifying fibroma appear exclusively on gingiva, and they may be firmer to palpate because of calcified material in

the stroma along with its greater tendency to displace adjacent teeth as compared to fibroma. On the other hand, lesions like pyogenic granuloma and peripheral giant cell granuloma are more vascular, so bleeds heavily on palpating or probing, thus, more difficult to achieve homeostasis as compared to Traumatic fibroma.17 Lipoma if considered in the differential diagnosis has a pale yellow color, soft and has slippery nature on palpation.18 The differential diagnosis of oral fibroma is mainly based on its location. If reported on the tongue, the chances of neurofibroma or granular cell tumor may be considered. Lesions occurring on the lower lip or buccal mucosa might be considered as mucocele. Traumatic Fibromas can also be differentiated from true fibromas on the basis of its etiology being presence of a continuous source of irritation. Histopathological examination shows that traumatic fibroma exhibits two patterns of collagen arrangement based on the amount of irritation and the site of the lesion: (a) Radiating pattern- associated with such sites which are immobile in nature (e.g. palate) and sustained a greater degree of trauma, (b) Circular pattern- associated with such sites which are flexible in nature and sustained a lesser degree of trauma (e.g. cheeks). As compared to this, true fibroma does not show any of the above mentioned specific patterns. They are capsulated with well-defined margins from the surrounding healthy tissue.19 Until the source of irritation has been removed, the chances of recurrences may persist. But, it does not hold a risk of malignant transformation.7 Mostly treated by conservative surgical excision along with removal of source of etiology. Literature suggested other treatment modalities like the use of electrocautery, Nd:YAG laser, pulsed dye laser, cryosurgery, intralesional injection of corticosteroids or sodium tetra-decyl sulfate for sclerotherapy.20 However, histopathological study of excised specimen should always be done to rule out other benign or malignant soft tissue tumors as it can also mimic the clinical appearance of a fibroma.2

Fibro-epithelial Polyp: Case Report with Literature Review Samudrawar R et al.

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CONCLUSION Traumatic fibroma being one of the most common benign soft tissue fibrous lesion should always be considered in cases of reactive hyperplastic lesions of oral cavity. As it causes difficulty during normal activities like eating and chewing, prompt surgical intervention along with removal of irritating source should be done to prevent recurrence.

REFERENCES 1. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 2nd ed. Philadelphia: Saunders; 2002. 2. Halim DS, Pohchi A, Pang EE. The prevalence of fibroma in oral mucosa among patient attending USM dental clinic year 2006-2010. Indonesian J Dent Res 2010;1:61-6. 3. Daley TD, Wysocki GP, Wysocki PD, Wysocki DM. The major epulides: Clinicopathological correlations. J Can Dent Assoc 1990;56:627-30. 4. Toida M, Murakami T, Kato K, Kusunoki Y, Yasuda S, Fujitsuka H. Irritation fibroma of the oral mucosa: A clinicopathological study of 129 lesions in 124 cases. Oral Med Pathol 2001;6:91-4. 5. Rangeeth BN, Moses J, Reddy VK. A rare presentation of mucocele and irritation fibroma of the lower lip. Contemp Clin Dent 2010;1:111-4. 6. Shamim T, Varghese VI, Shameena PM, Sudha S. A retrospective analysis of gingival biopsied lesions in South Indian population: 2001-2006. Med Oral Patol Oral Cir Bucal 2008;13:E414-8. 7. Yeatts D, Burns JC. Common oral mucosal lesions in adults. Am Fam Physician 1991;44:2043-50. 8. Cooke BE. The fibrous epulis & the fibro epithelial polyp: Their histogenesis & natural history. Br Dent J 1952;93:305-9.

9. Rajendran R, Sivapathasundharam B. Shafer’s Textbook of Oral Pathology. 6th ed. Elsevier; 2009. 10. Throndson RR, Johnson JM. Spontaneous regeneration of bone after resection of central giant cell lesion: A case report. Tex Dent J 2013;130:1201-9. 11. Ezirgan LS, Taşdemir U, Goze F, Kara Mİ, Polat S, Muderris S. Intraoral localized reactive hyperplastic lesions in sivas. ACU Saglık Bil Derg 2014;5:43-7. 12. Tyldesley WR. Oral medicine for the dental practitioner 7. Inflammatory overgrowths and neoplasms. Br Dent J 1974;136:111_6. 13. Alam MN, Chandrasekaran SC, Valiathan M. Fibroma of the gingiva: A case report of a 20 year old lesion. Int J Contemp Dent 2010;1:107-9. 14. Pedrona IG, Ramalhob KM, Moreirac LA, Freitas PM. Association of two lasers in the treatment of traumatic fibroma: Excision with Nd: YAP laser and photobiomodulation using in gaalp: A case report. J Oral Laser Appl 2009;9:49-53. 15. Axell T. A prevalence study of oral mucosal lesions in an adult Swedish population. Odontol Revy 1976;27:1-103. 16. Regezi JA, Sciubba JJ, Jordan RC, Abrahams PH. Oral Pathology: Clinical Pathologic Correlations. 5th ed. St. Louis, MO: WB Saunders; 2003. 17. Coleman GC, Nelson JF. Principles of Oral Diagnosis. St. Louis: Mosby; 1993. 18. Laller S, Saini RS, Malik M, Jain R. An appraisal of oral mucous extravasation cyst case-mini review. J Adv Med Dent Sci 2014;2:166-70. 19. Patil S, Rao RS, Sharath S, Agarwal A. True fibroma of alveolar mucosa. Case Rep Dent;2014:904098. 20. Bede SY. Gingival and alveolar ridge tumor-like overgrowth lesions. J Bagh Coll Dent 2013;25:110-4.


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LEGENDS


Samudrawar R, Mazhar H, Kashyap MK, Gupta R. Fibro-Epithelial Polyp -

Case Report with Literature Review. Int Healthcare Res J 2017;1(7):14-17.

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Corresponding Author: Dr. Heena Mazhar Consultant (Oral and Maxillofacial Surgery) Raipur, Chattisgarh +91- 9522915241 [email protected]

AUTHOR AFFILIATIONS: 1. Consultant (Oral Medicine and Radiology), Adilabad, Telangana 2. Consultant (Oral and Maxillofacial Surgery), Raipur, Chattisgarh 3. PG Student, Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhillai, Chattisgarh 4. PG Student, Department of Oral and Maxillofacial Surgery, Rungta College of Dental Sciences and Research, Bhillai, Chattisgarh


Figure 1. Intraoral view of lesion

Figure 3. Excised specimen of lesion

Figure 2. Surgical excision of lesion.

Figure 4. Post-Operative view


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INTRODUCTION

Odontogenic tumors are encountered frequently, therefore a comprehensive understanding of the embryology of these lesions will aid the clinician in formulating an accurate differential diagnosis and treatment plan.1 Ameloblastic Fibroma (AF) is a rare mixed odontogenic tumor that usually occurs in young patients, being diagnosed at a mean age of 15 years.2 AF was first described by Kruse in 1891 and it accounts for 2.5-4.5% of all odontogenic tumors.3,4 In 1946, Thoma and Goldman were the first to classify this tumor as a separate entity. WHO defined AF as “consisting of odontogenic ectomesenchyme resembling the dental papilla and epithelial strands and nests resembling the dental lamina and enamel organ, no dental hard tissues are present”.5

AF affects males more frequently when compared with females in a ratio of 1.4:1. Mandible is more commonly affected when compared to the maxilla. The majority of AF’s are found in the molar (posterior) area of mandible and are often associated with unerupted or displaced teeth. Clinically the tumor grows slowly and painless expansion of jaw and causing migration of adjacent teeth.6 There has been a long debate as to whether AF represents an anamolous hamartomatous growth or is a true benign neoplasm. This is due to difficulty in

differentiating between the histology of the neoplastic and hamartomatous lesions with the histologic features of AF.4

CASE REPORT

A 35 year old male patient came with a chief complaint of pain and swelling in the right lower back tooth region. Patient had identified the swelling 4 months back and his medical history was unremarkable. On intraoral examination, obliteration of the right lower buccal vestibule was seen due to the expansion of buccal cortical plate. The mucosa over the swelling was same as surrounding mucosa. It measured approximately 3x3 cm extending anteroposteriorly from mandibular 2nd molar to retromolar area on right side. On palpation swelling was bony hard in consistency and mild tenderness over the swelling was seen. Panoramic radiograph showed a unilocular radiolucent lesion with a scalloped borders measuring 5x3 cm, seen on the right side of the mandible extending from the 2nd molar to the whole ramus of the mandible. Internal structure was predominantly radiolucent and impacted 3rd molar was seen within the lesion and inferior alveolar canal was displaced inferiorly (Figure 1). Computed tomography revealed an osteolytic

Ameloblastic fibroma is an uncommon mixed neoplasm of odontogenic origin with a relative frequency between 1.5 – 4.5%. It can occur either in the mandible or maxilla, but predominantly seen in the posterior region of the mandible. It occurs in the first two decades of life. Most of the times it is associated with tooth enclosure, causing a delay in eruption or altering the dental eruption sequence. The common clinical manifestation is a slow growing painless swelling and is detected during routine radiographic examination. There is controversy in the mode of treatment, whether conservative or aggressive. Here we reported a 38 year old male patient referred for evaluation of painless swelling on the right posterior region of the mandible associated with clinically missing 3rd molar. The lesion was completely enucleated under general anesthesia along with the extraction of impacted molar. KEYWORDS: Ameloblastic Fibroma, Odontogenic Tumors, Jaw Tumors, Neoplasm, Hamartoma

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Ameloblastic Fibroma Associated With Impacted 3rd Molar: A Case Report

CASE REPORT

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K INDIRA PRIYADARSINI1, KARTHIK RAGHUPATHY2, KV LOKESH3, B VENU NAIDU4

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lesion involving the ramus of the mandible on right side (Figure 2). The lesion was completely enucleated under general anaesthesia and the impacted 3rd molar was extracted. The excised specimen was sent for histopathologic examination. The haematoxylin and eosin stained section showed both epithelial and mesenchymal elements. The mass was composed of embryonic mesenchyme, which was traversed by odontogenic epithelium in the form of elongated cords, islands (Figure 3). Epithelial islands were with peripherally placed row of columnar cells and centrally placed stellate cells. Juxta epithelial hyalinization of connective tissue resembling dentin was observed around some epithelial buds (Figure 4). The clinical, radiological and histopathological features confirmed the diagnosis as AF.

DISCUSSION Odontogenic tumors are uncommon lesions derived from specialized dental tissues.6 AF is a rare benign, true mixed odontogenic tumor in which both epithelial and the ectomesenchymal components are neoplastic without hard tissue formation.4,7,8,9 It is generally intraosseous, but can also occur in peripheral location.4,8 AF represents only 2% of odontogenic tumors.9,10 The precise etiology of AF is not known, however it is believed to arise de novo during a particular stage of odontogenesis, possibly as a result of overzealous elaboration of the basal lamina without further odontogenic differentiation.9

AF is mostly encountered in young patients especially during the first two decades of life with slight male predilection.1 AF exhibits slower growth than ameloblastoma and does not tend to infiltrate. Instead, it enlarges by gradual expansion so that the periphery of the lesion often remains smooth. The tumor frequently remains unnoticed by the patient and are discovered accidentally during radiographic examination.9 AF usually presents with a bony hard swelling, but intra oral ulceration, pain, tenderness or drainage may also be observed.5,11 In case of AF in a pericoronal location, the involved tooth may fail to erupt into the oral cavity as seen in our patient.11 An impacted tooth may be associated with the tumor in appropriately three quarter of the cases.4,5

Mandible is the predominant site of occurrence and the posterior mandible is affected more often than the maxilla by a factor of 3:1.4 Radiographically, AF are unilocular lesions, occasionally multilocular when larger, with smooth well demarcated borders. Cortical expansion may or may not be discernable on plain film. Because these lesions are frequently associated with unerupted teeth, they may initially be interpreted as dentigerous cysts.10 The radiological differential diagnosis includes ameloblastoma, odontogenic myxoma, KCOT, central granular cell tumor and histocytoma.6

Microscopically, AF comprises strands and islands of odontogenic epithelium in a loose and primitive connective tissue stroma characteristic of dental papilla. The odontogenic epithelial cells are similar to those of ameloblastoma. Tiny islands resembling the follicular stage of the developing enamel organ may be observed.4,5,11 Some recurrent cases developed dentin formation with or without enamel structure and subsequently differentiate over the time into odontoma.5,11 AF in young patient may resemble the primitive stage of odontoma.11 Mitoses should not be a feature of AF.5,7 The presence of mitosis should expand the differential diagnosis to include malignant entities like ameloblastic fibrosarcoma.11 In cases undergoing malignant transformation, there are unequivocal changes in the mesenchymal component and the odontogenic epithelium is completely disappeared.5,11

The preferred mode of treatment for AF is the conservative approach.1 Philipsen et al. proposed that the innocuous behavior of the lesion does not justify the aggressive initial treatment but rather meticulous surgical enucleation with close clinical follow up.5 In our case a conservative surgical approach was followed along with removal of impacted tooth. In general, a conservative approach such as enucleation with curettage of the surrounding bone should be applied for young patients. Conversely an extensive tumor and/or multiple reccurences necessitate more radical therapies.11 Recurrence rate of AF has been reported upto 18.3% by Zallen et al.3 and 43.5% by Trodahl et al.6,8,12,13,14 The literature showed the possible

Ameloblastic Fibroma Associated With Impacted 3rd Molar Priyadarshini KA et al.

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malignant transformation of AF to ameloblastic fibrosarcoma. Malignant transformation of AF is 4.5%, it may be due to untreated or surgical excision.1 Irrespective of the mode of treatment long term follow up is necessary for AF.

CONCLUSION

AF is a benign odontogenic mixed tumor, with a very good prognosis. A conservative approach including enucleation and mechanical curettage of the surrounding tissue is the mode of treatment. Recurrence of the lesion is common after excision, so long term follow up is necessary after the removal of the lesion.

REFERENCES 1. Gish JE, Lessin ME. Ameloblastic fibroma –

Diagnosis, treatment and propensity for misidentification. The New York State Dental Journal 2013;79(3):22-4.

2. Vasconcelos BCE, Andrade ESS, Rocha NS, Morais HHA, Carvalho RWF. Treatment of large ameloblastic fibroma: a case report. Journal of Oral Science, 2009; 51(2):293-6.

3. Dimitrakopoulos et al. Ameloblastic fibroma of the mandible associated with root resorption and unerupted teeth: A case report. Quintessence International 2009;39(6):523-7.

4. Jindal C, Bhola RS. Ameloblastic fibroma in six year old male: Hamartoma or a true neoplasm. J Oral Maxillofac Pathol 2011; 15:303-5.

5. Gupta S, Tandon A, Mehrotra D, Gupta OP. Ameloblastic fibroma: Report of 3 cases and

literature review. International Journal of Oral and Maxillofacial Pathology. 2011; 2(3):59-63.

6. Tuna EB, AK Gulsum, Genacy K. Ameloblastic fibroma: A case report with five years follow up. Acta Stomatol Croat. 2008; 4(2):185-191.

7. Basheer S, PM Shameena, Varghese V, S Sudha, Nair RG, N Sherin. Ameloblastic fibroma of anterior maxilla – A case report. Oral & Maxillofacial pathology Journal. 2010; 1 (1): 22-4.

8. Kulkarni RS, Sarkar A, Goyal S. Recurrent Ameloblastic Fibroma: Report of a rare case. Case reports in dentistry, April 2013. Article ID 565721.

9. Kim SW, Jang HS. Ameloblastic Fibroma: Report of a case. J Oral Maxillofac Surg 2002; 60: 216-8.

10. Nelson BL, Folk GS. Ameloblastic Fibroma. Head and Neck Pathol. 2009; 3: 51-3.

11. Pitak – Arnnop P, Chaine A, Dhanuthai K, Charles Bertrand J, Bertolus C. Extensive ameloblastic fibroma in an adolescent patient: A case report with a follow up of 4 years. European journal of dentistry. 2009; 3:224-228.

12. Dallera p, Bertoni F, Marchetti C, Bacchini P, Campobassi A. Ameloblastic fibroma: a follow up of six cases. Int J Oral Maxillofac Surg 1996: 25:199-202.

13. Bozic M, Hren NI. Ameloblastic fibroma. Radiol oncol. 2006; 40(1):35-8.

14. Prasad K, Ranganath K, Lalitha RM, Sreedivya B. Decompression followed by enucleation as treatment modality for ameloblastic fibroma: A case report. Oral Surgery 2011; 4:20-5.


Priyadarsini KI, Raghupathy K, Lokesh KV, Naidu BV. Ameloblastic Fibroma Associated

With Impacted 3rd Molar: A Case Report. Int Healthcare Res J 2017;1(7):18-21.

K

K

Corresponding Author: Dr. K. Indira Priyadarsini Reader, Dept. Of Oral Pathology C.K.S. Teja Institute of Dental Sciences and Research, Chandalawada Nagar Renigunta Road, Tirupati, Andhra Pradesh +91 8106179144 [email protected]

AUTHOR AFFILIATIONS: 1. Reader 2. Associate Professor 3. Senior Lecturer 4. Senior Lecturer

C.K.S. Teja Institute of Dental Sciences and Research, Chandalawada Nagar, Renigunta Road, Tirupati, Andhra Pradesh



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LEGENDS

Figure 1. Orthopantomograph reveals unilocular radiolucent lesion in the right ramus of the mandible with

an impacted 3rd molar

Figure 3. H&E Photograph 4x magnification showing elongated chords, strands and islands of odontogenic

epithelium (Red arrow) in a stroma of primitive connective tissue (black arrow)

Figure 2. CT axial section showing osteolytic lesion in the

mandible on the right side

Figure 4. The epithelial island in 40 x magnification showing peripherally placed row of columnar cells and

centrally placed stellate cells. Juxta epithelial hyalinization of connective tissue (black arrow)


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INTRODUCTION Oral Submucous Fibrosis (OSMF) has a well-known history, as it was known by Sushruta, one on India’s great physicians as ‘Vidari’.1,2 This condition is predominantly found in the Indian subcontinent. Joshi in 1953 was the first person to describe this entity in India.3 Oral Submucous Fibrosis is one of the most poorly understood and unsatisfactorily treated diseases with risk of malignant change in advanced cases of OSMF being 3 to 6%. JJ Pindborg defined it as “an insidious chronic disease affecting any part of the oral cavity and sometimes the pharynx. Although occasionally preceded by and /or associated with vesicle formation, it is always associated with juxta epithelial inflammatory reaction followed by a fibro elastic change of lamina propria, with epithelial atrophy leading to stiffness of oral mucosa and causing trismus and inability to eat”.4 The onset of the condition is insidious and the most common initial symptom is burning

sensation experienced on eating spicy hot food or on intake of hot beverages. Early signs are blisters, ulcerations or recurrent stomatitis. Excessive salivation, defective gustatory sensation, regurgitation and nasal resonance are rarely encountered. Restricted tongue movements are seen in advanced cases. The buccal mucosa, retromolar areas, soft palate and lips are commonly affected by OSMF. An occasional involvement of the pharynx and oesophagus is seen in some cases .5 There is no definite treatment for this condition. The various treatment modalities are mainly medical, surgical, or a combination of both with conservative/medical modality being the treatment of choice in patients having mild to moderate limitation(s) in opening their mouth. The Conservative, medical line of treatment includes usage of gold,6 iodides, hyluronidase, placental extract, and steroids (hydrocortisone, triamcinolone), iron in the form of supplements

AIM: To evaluate the efficacy of Low Level Laser Therapy (LLLT) in treatment of Oral Submucous Fibrosis (OSMF). MATERIAL & METHODS: 20 patients with a clinical diagnosis of OSMF were included in the study after informed consents and measurements of mouth opening (mm) and burning sensation (VAS) were made at day 0. Laser biostimulation was performed on right and left cheeks in anterior and posterior bands for 3 cycles of 10 seconds each. They were recalled for follow-up measurements and laser biostimulation at 3rd, 7th and 15th day. The paired t-test was applied for analysing significant differences, if any, using SPSS version 21.0. RESULTS: In the follow up recordings, generally, there was an increase in mouth opening after LLLT therapy and a significant difference was seen in males(p=.04) as well as the total population(p=0.02). Burning sensation(VAS Scale), on day zero was 5.5±1.20, which was reduced to 3.4±.084 on the 15th day with a significant difference seen in the entire study population(p=0.03). CONCLUSION: Biostimulation by laser in the treatment of OSMF is a good non-invasive, painless and quick alternative treatment modality for the management of the diseases. KEYWORDS: Oral Submucous Fibrosis (OSMF), LLLT, Laser Biostimulation

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Role of Laser Biostimulation in Treatment of Oral Submucous Fibrosis: A Clinical Trial

ORIGINAL RESEARCH

A B STRACT

KESARI SINGH1, ACHINT GARG2, MAYANK JAIN3, MANSIMRANJIT KAUR UPPAL4 2 Dr.Sameksha Arora

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and vitamins.7 In patients having marked limitation in opening his/her mouth, or failure to respond to the conservative management leads to surgical treatment of the lesion with dermal graft, tongue flap, nasolabial flap, Split Skin Graft (SSG) followed by Post-operative oral physiotherapy, dietary supplementation and other medications being routinely done in a dental setting.8 The word ‘LASER’ is an acronym for ‘Light Amplification by Stimulated Emission of Radiation’. Low-level laser therapy (LLLT) is also known as ‘soft laser therapy’ or bio-stimulation. The output for a low level laser device which is used for this therapy is in the order of 0.1 - 0.6 watts and is found to be quite effective.9 Laser has quite a few advantages as it provides better inflammatory responses with reduced oedema, pain reduction coupled with cellular biostimulation, as compared to current tissue regeneration modalities that present increased pain and inflammatory responses.10 Based on the above mentioned rationale, the present study was conducted with the aim of assessing the efficacy of LLLT in treatment of Oral Submucous fibrosis among patients visiting a dental setting in Greater Noida. The parameters which were assessed for evaluating the efficacy were limited mouth opening and burning sensation.

MATERIALS AND METHODS A total of 20 patients, each with clinically proven Oral Submucous Fibrosis, were included in the study. Exclusion criteria included patients who were already undergoing treatment for Oral Submucous Fibrosis, patients with Couagulopathies, Blood Disorders, Parkinson’s disease and Heart Disease. Ethical Clearance was duly taken from the Institutional Review Board, I.T.S. Dental College, Hospital and Research Centre, Greater Noida. Each patient was informed about the procedure and technique, and his/her written consent was obtained after duly explaining the study protocol. Pre-procedural evaluations were conducted for the following parameters in Oral Submucous Fibrosis:

1. Burning Sensation- Using Visual Analogue Scale (VAS). 2. Mouth Opening– Using Metric Vernier Caliper & ‘O’ Scale. The laser unit which was utilized in the current study was ‘Photon Plus Diode Laser’ (Zolar Technology and mfg. Co., Canada) which was duly calibrated prior to the commencement of the study (Figure 1). The laser unit was set at an output power of 0.8 W and a wavelength of 980 nm. Prior to starting with LLLT, the patient was seated comfortably on the dental chair and protective eyewear was adorned by the patient, the dentist and the assistant. (Figure 3) The treatment consisted of four sittings i.e. Day 0, 3, 7 & 15. Each sitting consisted of three cycles of low level laser applications, each cycle for 10-15 Seconds with a gap of about 20-30 seconds between each cycle, for a total laser application time of about three minutes. The application of the Laser was done in the non-contact mode with a distance of 2-3 cm between the Laser tip and the fibrous band surface/ mucosal surface. The laser beam was applied in a continuous sweeping, circular motion, so as to cover the lesion surface. Precautions were taken to prevent overheating of the mucosa and /or tissue surface, which were; a 20-30 seconds gap after each cycle, the continuous sweeping motion of the laser beam and the 2-3 cm distance between the laser tip and mucosal surface. The burning sensation scores (using VAS) and mouth opening (Figure 4) were evaluated immediately post the laser applications, at day zero, 3, 7 and 15th day. The patients were asked to refrain from using any medications for OSMF treatment over the next 15 days. Also, the patients were asked to keep a record of any post procedural adverse effects, such as a burning sensation, pain, bleeding, etc over the next 15 days. The responses of the patients were then captured into Microsoft excel, and then duly transferred to Statistical Package for Social Sciences (SPSS) version 21.0 for further analysis.11 After applying descriptive statistics, the data was analysed using paired t-test. Statistical significance was set as p≤.05.

Laser Biostimulation in Treatment of OSMF Singh K et al. Arora V et al.

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RESULTS

The present study, with the aim of assessing the efficacy of LLLT in treatment of Oral Submucous fibrosis enrolled 20 patients, out of which 8(40%) were females and 12 were males (60%)(Figure 2). Table 1. depicts the differences in mouth opening before and after LLLT therapy at 0, 3rd, 7th and 15th day. It was observed that generally, there was an increase in mouth opening after LLLT therapy and a significant difference was seen in males(p=.04) as well as the total population(p=.02). Upon comparison of the burning sensation based on the VAS Scale, it was again observed that there was a decreased burning sensation experience by the entire study population, as on day zero, it was 5.5±1.20, which was reduced to 3.4±.084 on the 15th day. A significant difference was seen among the entire study population (p=.03)(Table 2)

DISUSSION As compared to broadband light sources, lasers emit coherent, monochromatic, and collimated electromagnetic radiation with high intensity and display a high optical power per unit area for a given amount of energy, and hence, give laser the opportunity to be applied in both medical and dental field with unique applications.12

In the present study, the use of laser for treatment of OSMF vas found to be quite beneficial for the study subjects, with a reduction in pain and increased mouth opening. Such results are supported by findings of various authors2,12-16 across the globe who report better mouth opening, reduced discomfort and little inflammation of the treated lesion, making it a preferred treatment modality for treating lesions with OSMF.

CONCLUSION

A variety of treatment modalities for treatment of OSMF are easily available and are strongly supported by various authors, with each modality having its own pros and cons. However, there is still no universally acceptable protocol for the management of OSMF as the etiology of the disease is not fully understood.2 The results of the present study support the fact that laser treatment

is an acceptable, and a less painful method of treating OSMF with excellent results.

REFERENCES 1. Mukherjee AL. Oral submucous fibrosis. A

search for etiology. Ind J Otolaryngology 1972; 24: 1: 11- 5.

2. Saluja H, Asnani S, Mahindra U. Use of Diode Lasers in Treatment of Oral Submucous Fibrosis: A New Concept in Surgical Management. Indian Journal of Dental Education 2011 ;4(3-4):73-5.

3. Joshy SG. Submucous fibrosis of the palate and pillars. Indian J Otolaryngology 1952; 4: 110-3.

4. Gupta SC. “Mist” an etiological factor in oral submucous fibrosis. Ind J Otolaryngology 1978; 30: 1: 5-6.

5. Shahid R, Aziz. Oral submucous fibrosis: case report and review of diagnosis and treatment J Oral Maxillofac Surg. 2008; 66: 2386-9.

6. Yen DJC. Surgical Treatment of Oral submucous fibrosis. J Oral Maxillofac Surg 1982:269-72.

7. Canniff JP, Harvey W, Harris M. Oral submucous fibrosis: its pathogenesis and management. Br Dent J 1986;160(12):429-34.

8. Kamath VV. Surgical Interventions in Oral Submucous Fibrosis: A Systematic Analysis of the Literature. J Maxillofac Oral Surg 2015; 14(3): 521–31.

9. Walsh LJ. The current status of low level laser therapy in dentistry. Part 1. Soft tissue applications. Australian Dental Journal. 1997;42(4):247–54.

10. Lins RDAU, Dantas EM, Lucena KCR, Catão MHCV, Granville-Garcia AF, Carvalho Neto LG. Biostimulation effects of low-power laser in the repair process. An Bras Dermatol 2010;85(6):849-55.

11. IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.

12. Lokesh U, GCV, Jannu A, GKV, MRS.Application of Lasers for Oral Submucous Fibrosis: An Experimental Study. Arch CranOroFac Sc 2014;1(6):81-86.

13. Talsania JR, Shah UB, Shah AI, Singh NK. Use

of diode laser in oral submucous fibrosis with

trismus: prospective clinical study. Indian J


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Otolaryngol Head Neck Surg 2009; 61(Suppl

1): 22–5.

14. Chaudhary Z, Verma M, Tandon S. Treatment

of oral submucous fibrosis with ErCr: YSGG

laser. Indian J Dent Res 2011;22:472-4.

15. Tripathy R, Patnaik S, Acharya SA, Akheel M,

Diode Laser as a Treatment for Oral

Submucous Fibrosis- A Case Report. Arch

Cran Oro Fac Sc 2014;2(1):104-6.

16. Garde JB, Dadhe DP, Rajkumar S, Deshmukh

V. Diode laser in submucous fibrosis: A case

series with successful outcome. J Dent Lasers

2013;7:85-6.

Cite this article as: Singh K, Garg A, Jain M, Uppal MK. Role of Laser Biostimulation in

Treatment of Oral Submucous Fibrosis: A Clinical Trial. Int Healthcare Res J

2017;1(7):22-26.

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K Corresponding Author: Dr. Kesari Singh MDS (Oral Medicine and Radiology) B-27 Delta 1st, Silver Oak Estate Greater Noida U.P 201308 +91 9953168020 [email protected]


1. MDS (Oral Medicine and Radiology) 2. BDS, MS, Ph.D, Consultant Oral Oncologist and Maxillofacial Radiologist, Garg Dental Care, DLF Phase III, Gurgaon 3. Senior Lecturer, Department of Oral Medicine and Radiology, J N Kapoor DAV(C) Dental College, Yamuna Nagar, Haryana 4. Senior Lecturer, Department of Oral Medicine and Radiology, Swami Devi Dyal Hospital and Dental College, Barwala, Panchkula

LEGENDS

Figure 1. Diode laser unit used for LLLT


12, 60%

8, 40%

n=20

Males Females

Figure 2. Distribution of the study population

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Characteristic Mouth Opening at 0 days(in mm) (Mean±SD)

Mouth Opening at 3rd day(in mm) (Mean±SD)

Mouth Opening at 7th day(in mm) (Mean±SD)

Mouth Opening at 15th day(in mm) (Mean±SD)

p Value

Males 25.07±1.87 25.85±2.12 26.28±2.01 26.98±2.14 .04*

Females 22.25±0.83 22.75±0.82 24.10±0.93 24.65±0.86 1.6

Total 23.94±2.07 24.61±2.29 25.37±2.00 26.05±2.08 0.2*

Characteristic Burning Sensation at 0 days (in mm)

(Mean±SD)

Burning Sensation at 3rd day (in mm)

(Mean±SD)

Burning Sensation at 7th day (in mm)

(Mean±SD)

Burning Sensation at 15th day (in mm)

(Mean±SD)

p Value

Males 5.5±0.95 4.83±0.69 4.3±1.00 3.5±0.95 1.1

Females 5.5±1.5 4.75±0.82 4.25±0.43 3.25±0.43 0.7

Total 5.5±1.20 4.8±0.74 4.3±0.90 3.4±0.84 0.3*

Table 1. Differences in Mouth Opening among study subjects

Table 2. Differences in VAS Score among study subjects


Figure 3. Application of LLT therapy Figure 4. Measurement of Mouth Opening

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INTRODUCTION Anxiety, the reaction to unknown danger is a common problem experienced in dental practice. It can lead to treatment difficulties for both the patient as well as the practitioner. The degree of anxiety varies from patient to patient. It depends on age, gender, profession, intellect level, past experiences and other countless factors. Some patients experience only slight discomfort, while others experience a high level of anxiety. To a certain extent, little discomfort is obvious in both operative and non-operative procedures. The term Ódontophobia, literally meaning ‘fear of the dentist’ has been classified as an anxiety disorder as per the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).1 The pathophysiology behind dental anxiety is a bodily response which influences the sympathetic nervous system leading to an increase activity of the cardiovascular system, thereby stimulating the excretion of the excitatory neurotransmitters adrenaline/epinephrine and norepinephrine. The

development of dental anxiety in individuals has been explained by various theories. Ivan Pavlov’s theory of classical conditioning explains that previous negative or traumatic experiences may result in the development of acquired fear. It can be postulated that dental anxiety could be promoted due to the previous negative experiences during dental treatment. Locker et al reported that invasive or painful treatment could be related to dental anxiety.2 It is not necessary that all the patients who undergo through painful procedures develop dental anxiety. Moreover, it may also depend on how vulnerable an individual is. Abrahamsson et al proposed a theory of multifactorial etiology combining cognition and conditioning experiences as causative factors behind dental anxiety.3 It would be relevant to consider dental anxiety as one of the common and major reason for avoidance of dental care thus resulting in worsening of personal oral health. High levels of

INTRODUCTION: Anxiety is a common problem frequently experienced by patients undergoing dental procedures in every dental setting. The present study aimed to assess the prevalence of dental anxiety among the patients visiting the Out Patient Department (OPD) of a Dental Institution in Panchkula, Haryana. MATERIALS & METHOD: A sample of 600 adults (Females =298, Males = 302) with age ranging from 21 years to 65 years were enrolled in the study. The Modified Dental Anxiety Scale was used to measure dental anxiety among the study population. Chi Square test and ANOVA was used to find significant comparisons between the different variables assessed in the study. Further, Spearman’s Correlation was used to analyse these variables with the mean anxiety scores of the patients. RESULTS: The prevalence of anxiety among patients was found to be high. Reportedly the level of anxiety was found more in females than in males. It was revealed that with advancing age and higher education level, there was a decrease in level of anxiety, postponement of the dental treatment had a direct effect on dental anxiety. Previous unfavourable dental experience has a high impact on dental anxiety scores. CONCLUSION: Evaluation of anxiety levels in the subjects of this study suggests that majority of them are anxious towards dental treatment. Dental anxiety is one of the major barrier in the utilization of dental services. There is a strict need of directing efforts towards alleviation of this hindrance to provide a good quality dental care to the needy population. KEYWORDS: Dental Anxiety, Modified Dental Anxiety Scale, Negative Dental Experience.

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Prevalence of Dental Anxiety among Patients Visiting the Out Patient Department (OPD) of a Dental Institution in Panchkula, Haryana

ORIGINAL RESEARCH

A B STRACT

ISSN: 2456-8090(Online) International Healthcare Research Journal 2017;1(7):27-33. DOI: 10.26440/IHRJ/01_07/119

NISHANT MEHTA1, VIKRAM ARORA2 Dr.Sameksha Arora

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dental anxiety amongst those seeking dental care results in negative attitudes towards dental treatment and makes proper dental treatment difficult to achieve.4 Factors responsible for anxiety vary from person to person and hence, it is important to identify anxious patients and the reason behind their anxiety for successful management and satisfactory treatment. The aim of this study was therefore, to evaluate prevalence of dental anxiety among patients visiting the Out Patient Department (OPD) of a Dental Institution in Panchkula, Haryana.

MATERIALS & METHOD The present study was carried out among patients visiting the Out Patient Department (OPD) of a Dental Institution in Panchkula, Haryana from May,2014 to October,2014. The study was conducted to assess the level of dental anxiety by using the Modified Dental Anxiety Questionnaire. A total of 600 patients who gave informed consent and were aged between 21 to 65 years were enrolled in the study. Patients, who were uncooperative, suffering from any systemic disease or were on any anti-anxiety medication and those who did not give consent were excluded from the study. Data was collected using the Modified Dental Anxiety Scale (MDAS) originally given by Corah NL.5 It is the most commonly used scale for diagnosis of patients who suffer with dental anxiety and it was developed primarily from the Corah Dental Anxiety Scale (CDAS). Demographic details of the patients were recorded. This included patients age, gender, educational qualification, occupation, and any favourable/unfavourable past dental experience(s) prior to administration of the questionnaire. A pilot study was conducted to pre-test and pre-validate the questionnaire. The Cronbachs’ Alpha value was calculated and found to be 0.85 suggesting good internal consistency. The anxiety level was categorized into lowly anxious (5–10), moderately anxious (11–18), and severely anxious ≥19.A written, informed consent was obtained from the participants after explaining them the study protocol. An ethical clearance was duly obtained from the ethical committee of Dental Institution.

Statistical analyses of the data collected was done using Statistical Package for Social Science (SPSS) version 21.0. The Chi- square test was used to find significant differences between patients having a favourable/unfavourable previous dental experience while Analysis of Variance (ANOVA) was used to compare the level of significance of dental anxiety between different age groups. The correlation between the variables assessed in the study with their mean anxiety scores was determined using Spearman’s correlation. The level of significance was kept at 5%.

RESULTS A total of 300 patients participated in the study, out of which 298 were females and 302 were males. The age of the participants ranged from 21 to 65 years divided into three age groups with a majority (64% ) of the patients being 21-40 years old (Table 1). Age wise comparison between three age groups was in relation to their mean total anxiety scores. A significant difference in relation to their mean total anxiety scores (p=0.03) showed a decreasing trend as with advancing age of the patient. No significant differences were found between the anxiety scores of the patient and the educational status. The number of past dental visits and anxiety scores were also not found to be statistically different. However, a significant difference was seen (p=.001) when anxiety scores of patients who had been through a favourable previous dental experience, were compared to those who had an unfavourable previous dental experience (Table 1). Figure 1. highlights the mean dental anxiety scores of the study patients. The questionnaire contained 5 questions based on a 5 point likert scale ranging from “Not Anxious” to “Extremely anxious”. The range of the scores lied from 5 to 25 and according to the Corah NL, the cut-off point was set as 19, above which indicated a highly dentally anxious patient, possibly dentally phobic.5 There was a decrease in number of subjects with increase in anxiety score. Dental anxiety score greater than cut-off value was observed in only 3.10% of the study participants. Figure 2. depicts likeliness of postponement of dental visit in concern with anxiety. Out of total,

Dental Anxiety among Patients in Panchkula, Haryana Mehta N et al. Arora V et al.

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83% of the study subjects were willing to postpone their dental visit due to dental anxiety. A significant difference was seen in the mean anxiety score between patients with respect to their postponement of dental visit (p= 0.001). Table 2. depicts the Correlation between the variables assessed and the dental anxiety scores of the patients. Spearman’s correlation showed a significant correlation between the mean anxiety score when compared with gender and postponement of dental visit. In contrast, age showed a significant negative correlation with anxiety score. The r values again emphasised the results achieved above that while age depicts an inverse relationship, postponement of the dental treatment has a direct effect on dental anxiety.

DISCUSSION

In the past few decades, there has been a tremendous awareness regarding oral health due to great progress in the dental field owing to the development of new techniques, materials and infection control. However, dental anxiety has remained a major problem for both the patients as well as the clinicians.6 As per Hmud R and Walsh LJ, one out of every six adults suffers from some form of fear and anxiety.7 The present study, aimed to assess the prevalence of dental anxiety among patients visiting the Out Patient Department (OPD) of a Dental Institution in Panchkula, Haryana. The Cronbach alpha coefficient of MDAS in this study was 0.85 which in accordance with previous studies conducted by Serra-Negra J et al.,8 Gupta G et al.,9 Minja IK et al.,10 whose Cronbach alpha coefficient(s) were 0.80, 0.83 and 0.86 respectively. The demographic variables play a key role in the development of dental anxiety. In the present study, low levels of dental anxiety were found in aged persons when compared to subjects with younger age group. This was in agreement with the results of a few previous studies.11-14 It can be postulated that there is a decrease in level of anxiety with advancing age. It is greatest in children and adolescents, and possibly due to misrepresented views of dental treatment due to their own bad experiences and influence of the negative attitude of family and society.15 This can be explained by the fact that the tolerance capacity increases when a person goes through stressful

situations in life journey and the behavioural characteristics of the individual also gets shaped by countless life experiences.16 Prevalence of anxiety was found to be more in females in our study. Similar results have been reported by many authors.17-20 The reason behind this could be that due to orthodox gender roles, males tend to hide their fears.21 The other factor could be that generally the responsiveness of females to a specific stimulus is more than males. Moreover, physiological emotions (namely social phobia, panic, depression, stress and fear) are more common in females and high dental anxiety may be associated with the same.22,23 Anxiety levels were found to be reduced with increase in education level. Similar results were reported by Acharya S,11 Bjelland I et al.,24 Milgrom P et al.,25 and Do Nascimento DL et al.26 The results of our study revealed that dental anxiety was a potential factor for postponement of dental procedure, similar findings were also documented in literature.27,28 Patients who an unfavourable past dental experience had showed a higher level of anxiety & more negative attitude towards dental treatment, which was in concordance with several other studies.29-32 It is important to take into consideration the limitations of the present study. This is a cross-sectional study and it is important to note that dental anxiety is a subjective quality and its perception can change with time and circumstances. There is a need to carry out longitudinal studies with a bigger sample. Secondly, as it is a questionnaire study, chances of under-reporting, recall bias and social desirability bias are high.

CONCLUSION It can be concluded from the findings of the study that prevalence of dental anxiety among the study subjects was high. Amongst the various demographic variables, gender, age, education level and past negative dental experience were found to impact dental anxiety. Further research work is needed to address the dental anxiety levels in different populations, which will help the dental professionals to manage the anxious patients in a better way. Dental health education


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measures are required to control the levels of dental anxiety and thus improve patient attitude towards dental treatment.

REFERENCES

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-IV [Internet]. 4th ed. Washington (DC): American Psychiatric Association; 1994 [cited 2017 Mar]. 866 p. Available from: http://www.psychiatryonline.com/DSMPDF/dsm-iv.pdf 2. Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health.1996;13:86-92. 3. Abrahamsson KH, Berggren U, Hallberg L, Carlsson SG. Dental phobic patients’ view of dental anxiety and experiences in dental care: a qualitative study. Scand J Caring Sci.2002;16:188–196. 4. Lautch H. Dental phobia. Brit J Psych. 1971;119(549):151–8. 5. Corah NL. Development of a dental anxiety scale. J Dent Res. 1969;48:596. 6. Hutojac, Lj – editor. Psihijatrija. 1st ed. Zagreb: Medicinska naklada; 2006. p. 89-95. 7. Hmud R, Walsh LJ. Dental anxiety: Causes, complications and management approaches. J Minim Interv Dent. 2009; 2(1): 67-78. 8. Serra-Negra J, Paiva SM, Oliveira M, Ferreira E, Freire-Maia F, Pordeus I. Self-Reported Dental Fear among Dental Students and Their Patients. Int J Environ Res Public Health. 2012; 9(1): 44–54. 9. Gupta G, Shanbhag N, Puranik MP. Cross-Cultural Adaptation of Kannada Version of Modified Dental Anxiety Scale Among an Adult Indian Population. J Clin Diagn Res. 2015;9(9):ZC34-8. 10. Minja IK, Jovin AC, Mandari Gj.Prevalence and factors associated with dental anxiety among primary school teachers in Ngara District, Tanzania. Tanzan J Health Res.2016;18(1):1-10. 11. Acharya S. Factors affecting dental anxiety and beliefs in an Indian population. J Oral Rehabil. 2008;35:259–67. 12. Settineri S, Tati F, Fanara G. Gender differences in dental anxiety: Is the chair position important? J Contemp Dent Pract. 2005;6:115–22. 13. Yuan S, Freeman R, Lahti S, Lloyd-Williams F, Humphris G. Some psychometric properties of the Chinese version of the Modified Dental Anxiety

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Cite this article as: Mehta N, Arora V. Prevalence of Dental Anxiety among Patients Visiting the Out Patient Department (OPD) of a Dental Institution in Panchkula, Haryana. Int Healthcare Res J 2017;1(7):26-33.

K


K Corresponding Author: Dr. Vikram Arora B-2/11, Mandir Marg, Lal Quarter Krishna Nagar, Delhi, 110051 +91 9311111060 [email protected]

AUTHOR AFFILIATIONS 1. Senior Resident, Oral Health Sciences Centre, PGIMER, Chandigarh, Ex. Research Officer (National Oral Health Program, GoI), CDER, AIIMS,

New Delhi, Ex- Senior Lecturer, Department of Public Health Dentistry, Swami Devi Dyal Hospital And Dental College, Barwala, Panchkula, India

2. Ex- Senior Lecturer, Department of Public Health Dentistry, Swami Devi Dyal Hospital And Dental College, Barwala, Panchkula, India


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Variable Number of Subjects Percentage Statistical Analysis of Anxiety Scores

Age

21-35 years 384 64 ANOVA

36-50 years 156 26 F = 3.341

51-65 years 60 10 P=0.03*

Gender

Male 302 50.33 ANOVA

Female 298 49.67 F 1.437, p>0.05

Educational Qualification

Intermediate 242 40.33 ANOVA

Graduate 298 49.67 F 1.437

Post graduate 31 5.17 P value >0.05

Uneducated 29 4.83

Previous visit to dentist

Yes 406 67.67 Chi Square

No 194 32.33 p>0.05

Previous dental visit experience

Good (Favourable) 549 91.5 Chi Square

Bad (Unfavourable) 51 8.5 P=0.001*

24.30% 24.10%

20.50%

18.40%

9.60%

3.10%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

5-7 8-10 11-13 14-16 17-18 >19

LEGENDS

Figure 1. Mean dental anxiety scores of the study patients

Table 1. Demographic Details of the Subjects with statistical relation to anxiety scores


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Variables

Mean Anxiety Score

Spearman’s Correlation

P value

Gender 0.94 0.03*

Age -0.141 0.001*

Education 0.047 0.33

Postponement of dental visit 0.191 0.000*

83 %

17 %

YES NO

Table 2. Correlation between variables assessed in the study and their mean anxiety scores.

Figure 2. Likeliness to postpone dental visit (p=0.01)


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