Professional Documents
Culture Documents
IDJSR Special Periodontology Issue
IDJSR Special Periodontology Issue
Founders
Dr. Kumar Anshul Manipal College of Dental Sciences, India
Dr. Harsh Rajvanshi - I.T.S Dental College, India
Dr. Ayesha Zaka - Margalla College of Dentistry, Pakistan
Dr. Joharia Azhar Saadat, BDS, MSc (Oral Path) (London), Mphill
(NUST) Pakistan
Indexed In
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Scientific Indexing Services
Editorial Board
Dr. Kumar Anshul - Editor In Chief
Dr. Harsh Rajvanshi - Executive Editor
Dr. Ayesha Zaka - Executive Editor
Dr. Muhammad Sohail Zafar, BDS, PhD (UK), MSc (UK), F.I.C.D
(USA), F.A.D.I (USA) Kingdom of Saudi Arabia
ii
TITLE
Title Page
A Foreword
GUEST EDITORIALS Dr. Zeeshan Sheikh & Dr. Zohaib Khurshid
Page No.
4.
EDITORIAL FOUNDERS
42
5.
ORIGINAL RESEARCH
In-vitro properties of calcium phosphate cement as a bone grafting material
43-45
40
41
6.
46-48
7.
49-51
8.
52-55
9.
56-57
10.
Thomas T. Nguyen
CLINICAL CASE REPORT
Periodontal Disease and Diabetes Mellitus: Case Report
58-65
11.
66-71
12.
Dr. Kashif Hafeez, Dr. Aiyesha Wahaj, Dr. Muhammad Sohail Zafar , Dr. Sana Shahab
SYSTEMATIC REVIEW
Laboratorial and clinical impacts of tobacco on periodontal health: A systematic review
72-78
13.
Fahad Sikander Khan, Aisha Aziz , Dr. Sana Shahab, ,Dr. Muhammad Sohail Zafar
SHORT COMMUNICATION
A review of the use of laser in periodontal therapy
79-82
14.
Dr. Amir Manzoor Shah , Dr. Khurram Khan , Dr.Fahd Ahmed , Dr.Nida Amir
ORIGINAL RESEARCH
Prevalence of bleeding gums while tooth brushing among betel nut chewers vs non betel nut chewers in
school going children
83-87
15.
Dr. Syed Misbahdduin, Dr. Mansoor Ul Aziz, Dr. Asma Fazal, Dr. Tayyaba Khairuddin, Dr. Safia Khairuddin
SHORT COMMUNICATION
Short communication: Stem Cells for Periodontal Tissue Regeneration
88-92
16.
93-104
17.
105-108
{40}
It is very hard to find somebody who does not agree that periodontology and its related sciences were the focus of
dental research in the last few decades thanks to its unique and special mix of biology, basic sciences, medicine, and
surgery. Interest in periodontology as a science and periodontics as a clinical practice was heightened even more
after the proven and suggested links between periodontal disease and a host of relatively common systemic
conditions, such as cardiovascular diseases, diabetes, arthritis, pneumonia, Alzheimers disease and gestation
outcome complications among others. Therefore, it was not surprising to dedicate this issue of the International
Dental Journal of Students' Research (IDJSR) to periodontology in order to shed more light on what do university
academics and their trainees contribute to this interesting and quickly progressing field.
This periodontology issue, which is the first special edition of IDJSR, includes studies originating from reputable
university research centers in the east and the west (Malaysia, Pakistan, Ireland, UK, USA, and Canada) offering
different perspectives and providing different levels of evidence ranging from case reports to systematic reviews in
addition to reports of original research and short communications. The material presented covers appealing topics
and addresses important questions of clinical relevance adding value to this issue through offering knowledge that
could be directly translated into clinical practice.
Since it was first established, IDJSR took big strides towards achieving its goal as the students committed researchdissemination hub and their exclusive vehicle to present scientific work and share intellectual output in the most
pertinent topics. This special edition on periodontology is just another example of that commitment and will mark an
important step forward for the IDJSR.
I hope you enjoy this issue as much as I enjoyed going over its versatile material. I would like to extend special
thanks to the authors who participated. My thanks also go to the guest editor Dr. Zeeshan Sheikh who devoted this
edition of the IDJSR to periodontology and honored me with the kind invitation to provide the foreword section as
my humble contribution!
Best Wishes!
{41}
GUEST EDITORIAL
Dear Colleagues,
It is an honor for me to be the guest editor for the periodontology special edition issue by the IDJSR. The primary
purpose of this special edition is to present the research and clinical case reports in the field of periodontology in
order to stimulate a critical analysis and a discussion on the future of the periodontal practice and research. The
initiatives being taken by this journal paves the way for dental students/clinicians/researchers from all over the
world to contribute and share their research. I can only see this journal go from strength to strength and I wish the
whole team of IDJSR the very best and look forward to being associated with them in the future.
We know from the current data from USA alone that about 46% of the population has some form of periodontitis.
This when coupled with an increase in life-expectancy leading to an aging population, means that the importance of
managing and treating periodontal disease is more important than ever. There is a need to develop more effective
strategies for periodontal therapy to achieve optimal outcomes with high levels of clinical success. Most of the
activities within the field of periodontology are largely focused on the development of implant placement
techniques, implant-related materials and state-of-the-art implant systems. As dentists, we treat patients by
acknowledging the importance of prevention by maintenance of oral hygiene, early diagnosis and intervention for
appropriate management of periodontal health. The same approach must be adopted for implant patients and a risk
assessment should be performed. Presence of different medical conditions, susceptibility to periodontal disease and
use of certain drugs can limit the success of implants. Implant loss, mucositis, marginal bone loss and periimplantitis are the more common types of complications reported in implant therapy. With the increasing number of
implants being placed currently, it can be expected that the frequency with which we encounter peri-implant lesions
will increase as well. There are constant advances being made in periodontal regenerative therapy,
immunoregulation, vaccination and community based approach to prevention. The knowledge and technology that is
available today makes it an exciting time in the field of periodontology. It is imperative that we decide wisely how
these professionals aids are going to be of benefit to our patients.
Dr Zohaib Khurshid Co Guest Editor
B.D.S, MRes in Biomaterials (Student)
Cert. in Aesthetic Dentistry (Kings College London)
Cert. in Laser Dentistry (BACD, UK)
Senior Lecturer
Department of Dental Materials and Oral Biology
Altamash Institute of Dental Medicine
Karachi, Pakistan
Consultant Dental Advisor
Paramount Book Publisher, Pakistan
Email: drzohaibkhurshid@gmail.com
It is extremely difficult to ignore the research done on periodontal tissue in relation to its physiology and pathology,
diagnosis, epidemiology and prevention and therapy of periodontal disease. In present scenario where almost half of
the population is effected by some level of periodontal problem it is difficult to its importance. Therefore special
volume of this journal emphasises on publishing the original contributions of high merit from different part of
world.
International Dental Journal of Students Research, April - June 2015;3(2):41
{42}
EDITORIAL
My family is like a sanctuary to me.I turn to them for support and strength. I take comfort in knowing no matter
which path I choose, my family stands behind me.
Anonymous
Family is our support system. We rely on our family for everything they are our pillars of strength. Same way for
the tooth the periodontal structures are its family. No matter how much stress the tooth bears, family backs it up.
The care of these periodontal structures is necessary, for without it; the tooth cannot stand alone.
This is the era of Periodontology and as promised, the editorial board of IDJSR brings to you the dessert from the
Editorial Kitchen The Special Issue on Periodontology. This delicacy is topped with creamy articles with
ingenious stuffing. With modernization, focus is being shifting to more prophylactic and conservative approaches
&Periodontics deals with the very same concept.
In this issue, we have two great researchers Dr. Zeeshan Sheikh as the Guest Editor and Dr. Zohaib
Khurshidas the Co-Guest Editor who have kindly worked with us on this issue. We have articles from around the
world - Malaysia, Pakistan, Saudi, Canada, Egypt, Ireland, UK, USA with the stalwarts sharing their
experiences with us.
Readers, authors and peers We shall be coming up with another regular issue hot off the press in the month of
August, 2015. The call for papers is open!
At IDJSR, we have always strived to bring something fresh and new to the field of Dental Literature. We hope that
this issue helps both the clinicians and researchers at large.
Happy Reading!
{43}
ORIGINAL RESEARCH
Abstract
In 1980s researchers discovered CPCs (calcium
phosphate crystals) which are a bioactive and
biodegradable bone grafting material. Phases form
after mixing in different compositions with different
end products which are mainly two types; Brushite,
and a Apatite. Bioactive glass can undergo
dissolution in physiological solutions and form a
hydroxycarbonated apatite like phase (this includes
Octacalcium or Flouroapatite). Novel material can be
made by mixing bioglass and Ca(H2PO4)2 and have
cements set to form hydroxyapatite or brushite
produce HAP, brushite and fluorapatite forming
cements. The aims and objectives of this study were
to investigate the influence of storage media on the
Calcium Phosphate Cements combined with
bioactive glass, with respect to properties and phase
formed and strength of development. Would the
outcomes of storing in a media enriched in calcium
Introduction
One of the prerequisites of periodontal regeneration
is the formation of bone. Bone grafting is possible
because the bone tissue, unlike many other tissues,
has the ability to regenerate completely if there is
sufficient space to grow into. As bone grows, it will
generally replace the graft material completely, and
result in a totally integrated region of new bone. The
biological mechanisms providing a rationale for bone
grafting are the following osteoconduction,
osteoinduction, osteopromotion and osteogenesis.1
Osteoconduction phenomena occurred when the bone
graft material served as a scaffold for new bone
growth and therefore it was perpetuated by the native
bone. Osteoblast from the margin of the defect being
grafted utilized the bone graft material as a
framework upon which to spread and to synthesize
new bone.1 Bone grafting is a surgical procedure that
was performed to replace the missing bone with a
material from a patient's own body, an artificial,
synthetic, or a natural substitute. Bone grafting was
possible when the bone tissue had the ability to
regenerate completely if sufficient space was
{44}
provided into which the bone can grow. As natural
bone grows, it can generally replace the graft material
completely, and result in a fully integrated region of
new bone. Classification of the bone grafts based on
various material groups are2 Allograft-based bone
graft entails allograft bone, can be used alone or
incombination with other materials (e.g., Grafton,
OrthoBlast).
Factor-based bone graft are natural and recombinant
growth factors, which are used alone or in either in
merging with other materials, such as transforming
growth factor-beta (TGF-beta), Platelet-derived
growth factor (PDGF), fibroblast growth factors
(FGF), and bone morphogenetic protein (BMP). Cellbased bone grafts use cells to generate new tissue
alone or are added onto a support matrix, for
example, haemapoetic stem cells. Ceramic-based
bone graft substitutes which include material likes
calcium phosphate, calcium sulphate, and Bioglass
used alone or in combination; for example,
OsteoGraf, ProOsteon, OsteoSet. Polymerbased bone graft used degradable and nondegradable
polymers alone or in combination with other
materials, for example, open porosity polylactic acid
polymers Flexible hydrogel-hydroxyapatite (HA)
composite has a mineral to organic matrix ratio,
which approximates that of the human bone.
Artificial bone can be created from ceramics, like
calcium phosphates (e.g., HA and tricalcium
phosphate), bioglass, and calciumsulphate are
biologically active depending on the solubility in a
physiological environment 3Alloplastic grafts can be
manufactured from hydroxyapatite, and was a
naturally occurring mineral (a main mineral
component of bone), made from bioactive glass.
Hydroxyapatite was a synthetic bone graft, which
was commonly used now due to its properties e.g.,
osteoconduction, hardness, and acceptability by bone.
Calcium orthophosphates have been studied as bone
repair materials for the last 80 years. Calcium
phosphates are part of a group of bioactive synthetic
materials and the most frequently used are the
hydroxyapatite and the tricalcium phosphate
materials. They are commonly used due to their
osteoconductivity, crystallographic structures, and
chemical composition similar to the skeletal tissue.
They are therefore classified according to their
'resorbability' which was that extent of degradation in
vivo. Hydroxyapatite in turn hasbeen described as
non resorbable and tricalcium phosphate has been
described as resorbable4,5. Calcium phosphate
materials demonstrate a positive interaction with
living tissue that included also the differentiation of
the immature cells towards bone cells5,6. Calcium
Orthophosphate cements (CPC) have been reported
to form two major end products: a precipitated poorly
crystalline HA or CDHA and DCPD (also called
brushite) and apatite cements. The final setting
{45}
hydroxyapatite and higher mineral contents.
Mechanical; does it result in a higher compressive
strength of the new material calcium phosphate and
bioactive glass.Functional; does it aid the conversion
of Octacalcium phosphate to Hydroxyapatite.
The CPC/Bioglass composition was formulated by
measuring 0.98 gm of calcium phosphate and mixing
with 1.02 gm. of bioactive glass. The cement paste
was mixed and packed into 6 by 4 cylindrical steel
moulds and placed in an incubator at 370c for 120
minutes. The cylinders were removed from the
moulds and immersed in 50 ml of either TRIS buffer
solution or SBF at 370c for 1hour, 24 hours, 7 days
and 28 days The testing of the compressive strength
(Mpa) of the samples (n=8) was by an Instron
universal testing machine type 5567 and
characterization of the different phases of the samples
was by FTIR spectrum and X-rayDiffraction in order
to determine the quantitative measurements of the
mineral concentration in hard tissue.
Results
{46}
Discussion
There are limited data with regard to the novel
materials used in the present study although a recent
study by Sadiasaet al.9 in which the investigators
{47}
responses of the osteoblasts and the in vivo tissue
responses following the implantation of calcium
phosphate cement and bioglass in the femoral
condyle defects of rabbits was also investigated by
Yu et al.10 As mentioned previously the present study
did not undertake any similar procedures in an animal
model to determine whether the product would be
suitable in terms of biocompatible which in retrospect
would have been an important component to the
investigation. In the Yu et al. study CPC-BG was
observed to have a retarded setting time and also an
improved injectability and mechanical properties than
CPC alone. It was also observed that a new Cadeficient apatite layer was deposited on the
composite surface after it was placed in SBF for 7
days. It was also observed that the CPC-BG samples
demonstrated a significantly improved degradability
and bioactivity compared to CPC in the simulated
body fluid (SBF). The improvement in cell
attachment, proliferation and differentiation on CPCBG were superior to cells observed on CPC.
Macroscopic evaluation, histological evaluation, and
micro-computed tomography (micro-CT) analysis
observations also demonstrated that CPC-BG
enhanced the efficiency of new bone formation in
comparison with CPC alone. No histological
evaluation or proliferation studies were undertaken in
the present study. The Yu et al.10study concluded that
a novel.HydroSet represented the next generation in
bone substitute technology and was reported to be an
excellent bone substitute solution for a number of
clinical applications and surgical specialties.
HydroSet was a self-setting calcium phosphate
cement and contained apatite which converted to
hydroxyapatite (the principal mineral component of
bone).
The crystalline structure and porosity of hydroSet
indicated that it was an effective osteoconductive and
osteointegrative material, with good biocompatibility
An Ovine Implant study in Britain was undertaken by
Hill et al.11 on bioactive glass (with three kinds of
glasses) plus Calcium phosphate and Hydroset. The
research group implanted the material into femur
sites both right and left sides distal and proximal. The
implantation was placed in one animal for six weeks
and in six animals for twelve weeks. Scattered SEMs
demonstrated that for the 6 weeks ovine implanted
there was relatively little resorbtion of the cement for
all cements including Hydroset. No thermal
emissions (isothermic) were observed during the
hardening phase at 6 weeks and three months.
Analysis was done using XMT, Histology, Peripheral
quantitative computed tomography (pQCTBack). It
was
observed
that
there
was
excellent
osseointegration with bioglass cements and that
HydroSet was more radio opaque due to higher
density at 6 weeks. New bone growth surrounded all
thecements and interdigitation of cements with the
host bone The novel cements were observed to set invivo and wash out of the cement was not witnessed
and excellent osseointegration of all cement
compositions was evident. New bone formation
surrounding implanted cement high level of
resorption and remodeling at twelve weeks
octacalcium phosphate & hydroxyapatite forming
cements brushite Cements was observed.
Conclusion
The results from the present study demonstrated that
the media influenced how compressive strength
changes and storage in SBF resulted in an increase in
the compressive strength initially compared to a
reduction in Tris buffer. The presence of strontium
inhibited the formation of brushite probably because
the Sr2+ cation cannot replace Ca2+ ions in the
Brushite crystal lattice. It would therefore appear
according to the results obtained that storing the
combined CPC/Bioglass composition in Tris buffer
solution and Simulated Body Fluid had an influence
on both the compressive strength and the phase
formed over the media used to store the cements
influenced the phases formed and in particular the
conversion.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
{48}
Z. 2013. A novel injectable calcium phosphate cementbioactive glass composite for bone regeneration. PLoS
One, 8, e62570
11.
Karpukhina D.N., Kent &Hill (2013 submitted) highly
bioactive glass reacts to form in vitro setting calcium
phosphate bone cement.
__________________________________________________
{46}
SHORT COMMUNICATION
Corresponding Author
Dr. Marco Laurenti
Email: marco.laurenti@mail.mcgill.ca
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{47}
structural integrity of the tissue [4a, 4c]. These
scaffolds should be biocompatible facilitating cell
attachment and proliferation, and biodegradable so
that they do not require any surgical procedure for
removal[5]. Hydrogels are highly hydrated polymeric
biomaterials composed of hydrophilic polymeric
network, either of synthetic or natural origin, and
used as 3D scaffolds for periodontal tissue
engineering
applications[6].
Hydrogels
are
biodegradable, can be tailored to confer mechanical
and structural properties similar to many ECM
tissues, processed under mild conditions required to
encapsulate biological moieties, and delivered in a
minimally invasive manner[7].
Natural biomaterials have been extensively used in
the development of matrix-based regenerative
therapies that aim to accelerate clinical application
due
to
their
excellent
biocompatibility,
biodegradability, affinity for biomolecules and
wound healing activity [8]. Materials such as
collagen, hyaluronic acid, alginate and chitosan
scaffolds have been used in periodontal regenerative
research for more than two decades. The natural
origin of these materials allows the design and
engineering of biomaterial systems that function at
the molecular level, often minimizing chronic
inflammation. They can also be easily chemically and
physically modified to form desired structures. The
use of natural polymers in the form of hydrogels
allows for the incorporation of biological agents by
promoting cross-linking when the growth factor is
dispersed in the polymer solution. Because natural
polymers are often soluble in water, the creation of
hydrogels may occur under mild fabrication
conditions that are relatively harmless to the
bioactivity of the growth factors. Normally, these
hydrogels are degraded by enzymes and/or acid
hydrolysis at a rate depending on the degree of
crosslinking or the molecular weight [8].
Collagen is one of the most used biomaterials due to
its excellent biocompatibility, weak antigenicity,
biodegradability, and safety. Collagen hydrogel fits
well with injectable cell delivery and highly porous
cross-linked scaffolds provide good mechanical
stability. For these reasons, collagen hydrogels have
been used as support for in vitro growth of many
types of tissues and to deliver different kinds of
growth factors. Following the clinical use of collagen
carriers delivering bone morphogenetic proteins for
tibial shaft fractures [9], spine fusions and long-bone
nonunions [10], collagen is currently being evaluated
for widespread clinical periodontal regeneration. For
example, there are commercially available collagen
composite scaffolds such as Formagraft and
OssiMend for periodontal regeneration currently
used in animal studiesand clinical trials [11].
Chitosan is biodegradable natural polymer and it has
{48}
hydroxyapatite on their surface, and they can
facilitate odontoblastic cell growth with the
integration of host mineralized tissue. Hybrid
P(EMA-co-HEA)/SiO2nanocomposite
matrix
incubated in simulated body fluid for 14 days showed
the best cellular distribution and neo-dentin like
pattern. These constructs also showed enhanced
mechanical properties to withstand functional stresses
[20]. All these results indicate that the nanohybrid
matrix scaffolds could be promising potential sources
for dentin repair and regeneration.
Acknowledgment
The authors would like to acknowledge the Network
of Oral and Bone Health Research, and the Faculty of
Dentistry of McGill University for their financial
support.
References
1.
2.
3.
4.
5.
6.
{49}
CLINICAL CASE REPORT
Abstract
The term fenestration refers to a circumscribed defect
that creates a "window" through the bone over the
prominent root. This lesion will be seen when the
alveolar bone is exposed by a flap surgery, its
associated with localized periodontal destruction.This
case reports a 62year-oldmale patient who presented
with persistent tooth pain at the lower right 2ed
incisor, despite repeated root canal treatments by a
general practitioner. When the patient visited our
clinic, a CT examination was performed and apical
fenestration was diagnosed. The tooth was not
restorable due to a fracture in the apical third from a
previous root canal therapy. Suggested treatment plan
was to extract the tooth, perform bone grafting and a
future implant.
Incidence
The incidence of apical fenestration is between 7.5%
and 20%, and is higher in the maxillary than in the
mandibular teeth. It has also been reported that the
incidences higher in the anterior than in the posterior
teeth. The most commonly observed regions are the
canine root and the mesio-buccal root of the
maxillary first molar. Although the cause of apical
fenestration is still unclear, it has been suggested that
anatomical factors such as age-related changes and
the positional relationship between the tooth and the
alveolar bone might be involved. Moreover, occlusal
dysfunction should also be considered.[4]
Management
{50}
demonstrates coverage of an implant dehiscence
using a barrier membrane. Admittedly, without a
biopsy, it cannot be determined whether the tissue
covering the implant is bone or firm connective
tissue.[5,6]
A one-year multicenter study evaluating 55
Brnemark implants (i.e., machined-surface, external
hex) with bone dehiscence in 45 patients, treated by
ePTFE membrane alone, demonstrated an average
bone fill of 82%.12. The average initial defect height
was 4.7 mm. The 1-year follow-up of these implants
demonstrated a favorable response to loading. Of the
55 implants, a total of 6 failed, corresponding to a
cumulative survival rate of 84.7% in the maxilla and
95.0% in the mandible, which is similar to previously
published results for this implant design. A clinical
report on the use of TR membranes demonstrated the
biologic potential to fill a large protected space in
four patients. 24Bone dehiscence at implant sites
ranged from 5 to 12 mm (mean:8.2 mm). They were
covered with a TR membrane alone (no graft).
Re-entry after 7 to 8 months of submerged healing
found complete bone coverage over all the implants.
Radiographic evaluation demonstrated that the
implants were functioning with normal crestal bone
support after 1 year.
No clinical comparisons are available in the literature
evaluating the placement of bone grafts with or
without barrier membranes on implant dehiscence
defects. Most evidence supports the use of graft
materials in conjunction with membrane treatment,
particularly the use of FDBA in conjunction with
GBR. In a study with 40 patients, 110 implants were
placed in conjunction with barrier membranes and
FDBA; a success rate of 96.8% was achieved with
complete bone fill (defined as >90% fill of
dehiscence)[7].This study reported a membrane
exposure rate of 29%, but noted little adverse effect
on the bone regeneration.
Case report
A 62 years male patient presented to our clinic with
persistent pain related to the lower 2ed right incisor
tooth. Patient wanted the tooth extracted and implant
placed. Patient medical history was normal. Upon
oral examination, tooth 4.2 was positive to percussion
with possible horizontal fracture. Mobility class II
was noticed and upon radiographic examination, well
circumscribed radiolucent lesion surrounding the
apex of tooth 4.2 was notices, which turned to be a
periapical granuloma after a biopsy.Fig 1,2
Figure 3. Intraoral view showing the alveolar bone
loss and fenestration
Curettage of the lesion was completed and was sent
for biopsy. Next step was to graft the socket using 2
International Dental Journal of Students Research, April - June 2015;3(2):49-51
{51}
types of bone. We used a mix of allograft material
which is composed of 50% mineralized cortical and
50% mineralized cancellous size 0.25 mm with the
4bone bch composed of 60 % hydroxyapatite and
40% beta-Tricalcium Phosphate that was covered
with a resorbable membrane. Fig4
References
1.
The flap then was closed using silk sutures size 3.0.
An antibiotic course was started and analgesics were
prescribed to patient and he was scheduled for
follow-ups.Fig5
Conclusion
The etiology of bone fenestration is still unclear. In
most cases, early diagnosis and treatment can lead to
successful management and do not require extensive
treatment. In this case, we were able to preserve the
socket for a future implant and give patient more
options to restore the missing tooth.
International Dental Journal of Students Research, April - June 2015;3(2):49-51
{52}
CLINICAL DIAGNOSIS & GUIDELINES
{53}
measurements are accurate to within 1mm 90% of the
time [7], we can expect healthy probing depths to
range between 0.11mm-3.21mm (0.11mm = 1.11mm
- 1mm ; 3.21 mm = 2.21mm + 1mm) or simply up to
3mm(Figure 2A).
To understand why PD values increase with
periodontal disease progression, one has to examine
the pathophysiology of gingivitis and periodontitis.
Gingivitis is defined by the presence of gingival
inflammation without the loss of periodontal
attachment [8]. Histologically, gingivitis is
characterized by an increase in blood flow, an influx
of inflammatory cells and breakdown of perivascular
connective tissue (Figure 2B)[9]. All together, these
changes lead to clinical features consisting of
edematous, erythematous and friable gingival tissues
that typically extend coronal to the cement enamel
junction (CEJ) and readily bleed upon probing. Even
without periodontal attachment loss, clinical PD
values are increased in gingivitis when compared to
clinically healthy sites. The increased PD during
gingivitis is explained partly by the gingival
enlargement and partly by increased penetration of
the periodontal probe in inflamed tissues. Studies
have shown that the tip of a periodontal probe
penetrates the full length of the junctional epithelium,
stopping 0.1mm to the apical termination of the
junctional epithelium in an inflamed site[6],
compared to 0.4mm in healthy periodontium as
discussed above. Together, these two factors explain
why increased PD values are often associated with
gingivitis in the absence of concurrent loss of
periodontal attachment or loss of alveolar bone.
Unlike gingivitis, periodontitis is characterized by the
pathological loss of collagen fibers, apical migration
of the junctional epithelium, loss of alveolar bone and
periodontal attachment (Figure 2C). Histologic
studies of the progression of periodontitis have
shown that early periodontal lesions are initially
localized to the gingival sulcus and later progress to
the periodontium proper, the periodontal ligament,
cementum and alveolar bone. Histological studies in
more advanced periodontal disease have shown that
during probing, the probe tip penetrates the full
length of the junctional epithelium and extends deep
into the connective tissue attachment[6,10], resulting
in progressively increased probing depth proportional
to the degree of attachment loss. For this reason, deep
PDs are seen in tissues undergoing periodontal
breakdown due to the concurrent apical migration of
the junctional epithelium, the inflamed nature of the
connective tissues and the loss of alveolar bone.
Clinical studies routinely classify pockets into three
groups: 1-3mm, 4-6mm and 7mm and greater [1113].The reason for this common classification system
is twofold. Firstly, this classification system stratifies
diseased sites and helps determine the aggressiveness
of treatment including the need for surgical
{54}
disease [27]. Nonetheless, periodontal probing
provides clinicians with a useful estimate of the
location of the most coronal insertion of the intact
connective tissue fibers and thereby verifying the
presence or absence of periodontal disease.
References
1.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
___________________________________________
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CLINICAL DISCUSSION
Thomas T. Nguyen
DMD, MSc, Resident in Periodontology,
University of Minnesota, School of Dentistry,
Minnesota, USA.
Corresponding author:
Dr. Thomas T. Nguyen
Email: nguy2292@umn.edu
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Clinical Question
How can we minimize mandibular nerve injury
during dental implant placement?
One of the common complications after implant
placement is nerve injury. This complication usually
results in the altered sensation of the lower lip, chin,
mucosa, alveolar gingiva, teeth and/or tongue. The
mandibular nerve injury is the most frequent due to
the reabsorption of the alveolar ridge after its atrophy
due to lack of stimuli after extraction.
Pre-operative recommendations
Informed consent for implant placement must be
given to the patient. The surgeon should
forewarn the patient regarding the possibility of
postoperative impaired sensation.
A thorough clinical examination and treatment
planning must be performed.
Radiographic examination to assess the location
of the inferior alveolar canal (IAC) of the
mandibular nerve and the mental foramen:
The panoramic radiograph, preferably
digital, is useful as the primary image study
to assess the vertical distance from the crest
of the edentulous mandibular alveolar ridge
to the superior aspect of the IAC.
Intra-operative recommendations
Intra-operative radiographs during implant
preparation and after implant placement are
required in order to assess the position and
angulation of the implant.
Surgical equipment with predetermined depth
stops as well as careful surgical technique is
necessary.
During implant placement, cancellous bone may
be compressed against the contents of the IAC,
possibly causing mandibular nerve damage.
If the post-operative radiograph indicates
encroachment on the IAC:
The implant should be removed;
Dexamethasone should be introduced into the
osteotomy site as follows3:
Dexamethasone liquid 4 mg./ml. applied
topically for 1 minute and repeated once.
Followed by a 7day day regimen of
dexamethasone orally as follows:
Days one and two: 8mg. per day
Days three and four: 6 mg. per day
Days five and six: 4 mg. per day
Day seven: 2 mg.
An appropriate antibiotic must be
prescribed.
Oral dexamethasone must be voided in
patients
with
preexisting
cardiac,
hypertensive and/or renal issues since such
high doses may lead to a hypertensive crisis.
A shorter implant should be considered and no
bone grafting materials should be placed in order
to avoid migration into IAC.4
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Conclusion
One of the serious complications of posterior
mandibular implant placement is nerve injury. Proper
understanding of the involved anatomy and the
surgical procedures, along with proper treatment
planning, will reduce the chances of such morbidity
to the patient. If nerve injury occurs, early and proper
management is the key to maximizing the chances of
recovery.
References
1.
{58}
CLINICAL CASE REPORT
Medical History
Introduction
The mechanisms linking oral and systemic health are
of utmost importance in patients with chronic
inflammatory disease. In this particular case, the
patient presented with chronic poorly diabetes
mellitus, which is known to have a negative impact
on periodontal health. Periodontal pathogens have
been found to illicit biomolecular responses that
result in poor glycemic control. Aside from diabetes
the patient was also being treated for cardiovascular
disease; hypertension and also for hyperlipidemia.
Patients with diabetes have a greater chance of
cardiovascular complications than those without
diabetes(1). Periodontitis and cardiovascular disease
are linked through several biomolecular pathways,
including the inflammatory response to bacteremia.
The patient also presented a 10 pack-year history of
smoking.
Patient History
The present case report is about a 65-year-old female
patient who was admitted to the Dalhousie University
Dental Clinic for an initial screening and treatment
planning. The patient had a chief complaint of, My
teeth are getting loose and my private dentists fees
are too expensive, so I cannot afford my needed
dental treatments. Detailed history of her medical
Dental history
The patient stated that in the last 4 years her teeth had
become progressively looser. She also reported
sensitivity to hot and cold of the remaining maxillary
teeth.
Prior to being treated at the dental school, the patient
reported no flossing and brushing once per day with a
manual toothbrush. The last time she had seen a
dentist was 6 years prior.
Social habits
The patient does not currently smoke but reported
that she quit smoking over 20 years ago. She
confessed to smoking about a half pack of cigarettes
a day for 20 years. The patient does not consume
alcohol.
{59}
appointment (September 2013) (see Appendix
A).Gingival margins were red and edematous and
generalized heavy calculus and plaque accumulation
(PI=100%) were noted. The following teeth were
missing: 3-8, 3-6, 4-5 and 4-6. Full mouth probing
depths, recession, clinical attachment level, mobility,
and furcation involvement were recorded. The
deepest pockets were present at 4-3, 4-4, and 4-7.
More than half of her teeth showed generalized
advanced bone loss with CAL ranging from 8mm to
12mm plus mobility of grade 2 or 3.The 4 lower
incisors were splinted with a composite periodontal
splint. The maxillary teeth were especially sensitive
to cold, air, and water. (See Appendix B for
periodontal
charting).
There
was
sinus
pneumatization due to loss of the posterior maxillary
teeth (2-6) as well.
Diagnosis
Upon completion of the initial comprehensive
examination a diagnosis of generalized advanced
chronic periodontitis was made for her based on
Armitage classification (2). Modifying factors
included diabetes mellitus and a history of smoking.
Prognosis
Initial comprehensive examination determined the
prognosis of all maxillary teeth, 4-1, 3-1, 4-3 and 4-7
to be hopeless, according to McGuires classification
system(3), and teeth4-2 and 3-2 had questionable
prognosis as well.
Two major factors contributing to the patients
periodontal status could be due to her poor oral
hygiene and systemic medical condition besides
being a former smoker. The patient mentioned that
her diabetes was recently controlled, however, her
fasting blood glucose level was still greater than the
normal range (7.5mmol/L) on the morning of most of
her appointments.
Treatment Plan
Initial periodontal therapy; included full arch scaling
and root planing (SRP) with hand instruments and
ultrasonics under local anesthetic in 2 separate
appointments, following by a reevaluation after 6
weeks. At the time of the reevaluation (Appendix B),
periodontal and prosthodontics consultations were
done. Because of the hopeless prognosis of the
maxillary teeth, clearance was planned for the
maxillary arch followed by fabrication of a complete
upper denture. In the mandibular arch, teeth with
hopeless prognoses were extracted. The prognoses of
teeth 48, 44, 33, 34, 35 and 37 had improved from
questionable to poor, so it was decided to maintain
these teeth (Fall 2013). Since the patients oral
hygiene was still not acceptable (PI>25%) a second
round of scaling and root planning was completed
under local anesthesia with the hope of patients selfperformed oral hygiene (including brushing and
flossing) would improve. After each appointment oral
hygiene instructions were reviewed, following by
emphasizing the important association between her
periodontal status and her medical systemic condition
(4). Oral hygiene instruments that were suggested to
the patient were manual or electric tooth brushing,
and the use of floss, super floss, Sulcabrush, and
interproximal brush. Oral hygiene effectiveness was
recorded at each appointment. Unfortunately, the
BOP and plaque index measurements at all reevaluations and recall examinations were not ideal.
After eight weeks a the second reevaluation was done
(Winter 2014) (Appendix B) at which time better oral
hygiene status was noted with decreasing probing
pocket depths so we were able to proceed with the
prosthodontic treatment including fabrication of the
lower removable partial denture that was planned for
her at the initial reevaluation. The splint was also
removed from the lower incisors at the end of the
second round of SRP, so they could be extracted.
Oral hygiene was again stressed with the patient as
she was planned for a L-RPD; which itself may cause
plaque accumulation.
The patients diagnosis after the extraction of all
hopeless teeth was generalized moderate chronic
periodontitis. Due to inadequate width of keratinized
gingiva on the facial aspect of teeth 33, 34, 35 and44
(<2mm)(5), after the periodontal consultation by one
of the periodontics instructors two free gingival grafts
(FGG) were planned for her prior to the L-RPD
treatment. In the meantime, we proceed with the
CUD. Upon completion of the treatment in the
graduate periodontics clinic by a periodontics
resident (SD) (Appendix C for clinical photographs),
the L-RPD treatment started.
During the fabrication of the CUD, due to the curve
of Spee of the lower teeth and the mobility associated
with the 3-2 and 4-2, it was determined that these two
teeth should also be extracted prior to RPD
fabrication. Extractions were completed on April 16,
2014.
In Fall 2014 the patient was seen for a recall
examination including complete periodontal charting.
BOP and plaque index had again improved since the
last appointment. It was decided that the patient
should continue to be seen on 3-monthperiodontal
recalls and fabrication of the L-RPD could now
begin. Three-month recall was suggested because of
the patients periodontal status (moderate chronic
periodontitis) and the presence of modifying factors
(diabetes). Recall intervals that are 3months apart
will allow for removal of subgingival plaque
containing periodontal pathogens, close monitoring
of periodontal condition to prevent further attachment
loss, and to reinforce optimal oral hygiene(6). Also,
since the patient will be wearing a partial denture in
{60}
the near future it is especially important to ensure that
the patient is keeping up with oral hygiene, as partial
dentures are known to act as a plaque trap.
Discussion
Modifying factors
Diabetes mellitus
Poorly controlled diabetes is linked to a variety of
oral health complications. Patients with poorly
controlled diabetes have an increased risk of oral
infections, decreased salivary flow and impaired
wound healing (7). They also respond differently to
bacterial plaque due to increased levels of cytokines
in the gingival tissues. Also increased glucose
concentration in the crevicular fluid may change the
bacterial composition of the oral microbiota(8).
Periodontal disease can also have systemic effects.
Systemic response to periodontal disease results in an
increase in inflammatory mediators such as tumor
necrosis factor-alpha and interleukins (6). These
inflammatory mediators may result in increased
insulin resistance and therefore make it more difficult
for the patient to maintain glycemic control (1, 7, 9).
Some studies have indicated that periodontal therapy
may decrease HbA1c levels by approximately 0.4%
(7, 10).
Cardiovascular Disease: Hyperlipidemia
&Hypertension
Periodontitis and cardiovascular disease are linked
through their inflammatory effects. Both diseases
lead to chronic states of inflammation and have
effects on the vasculature if appropriate treatment is
not initiated. Stimulation of inflammatory
mechanisms by periodontal pathogens has been
shown to have negative effects on atherosclerotic
pathogenesis (1, 9).
Former smoker
The impacts of smoking on oral health are numerous.
Smoking results in an increased risk for periodontitis
due to impaired microcirculation, inhibition of
neutrophil function, and increased calculus
formation. Patients who smoke present with greater
bone loss than those that dont and have decreased
response to periodontal therapy (11). The cessation of
smoking can decrease the progression of
periodontitis, however attachment loss will not be
regained (11).
In order to see the most optimal results following
initial therapy coronal and root surfaces need to be
completely debrided and free of calculus and plaque
deposits (12). When initial probing depths are greater
than 6mm, then surgical debridement is favoured and
greater clinical attachment gain can be achieved
along with a greater reduction in probing depths (12).
When pockets are greater than 6mm, instrumentation
of deeper root surfaces may not be achievable and,
therefore, flap surgery provides better access (12).
Unfortunately, in this patients case due topoor oral
hygiene and constant high PI (>25%) we did not
proceed with surgical debridement due to the need for
a low plaque score for optimal healing to occur (12).
Limitations of patient treatment in the
undergraduate clinic:
Unfortunately, due to the academic schedule it is
difficult for treatment in undergraduate clinics in
dental faculties to permit ideal timing in terms of
periodontal treatment. At Dalhousie, in the summer
only the third year students provide treatments in the
clinic. This may contribute to longer wait times for
patient treatment. In this case, more than half the
patients teeth had hopeless prognoses and were
ultimately be extracted. The patients oral health
condition was extremely poor and she also had a
large draining periodontal abscess distal to the 4-3.
Ideally, the patient should have been seen
immediately in the clinic after treatment planning
instead of having waited nearly 6 months for removal
of the hopeless teeth.
{61}
Appendix A
March 27, 2013
{62}
Appendix B
September 19, 2013
March 4, 2014
{63}
Appendix C
May 29, 2014
44 graft site
Pre-treatment donor site (palate)
44 graft in place
{64}
June 5, 2014
March 2015
{65}
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
__________________________________________________
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SYSTEMATIC REVIEW
Abstract
Sinus lift is one of the intricate methods of increasing
bone height in the posterior maxilla. Graft materials
are used to provide the height and hence increase the
implant support and success rate. Successful
osseointegration of dental implants required a stable
and sufficient amount of bone. There are different
types of bone grafting materials including autogenous
bone grafts, allografts and xeno grafts. Other newly
used materials such as platelet rich plasma is also
found to have optimal results. The current study was
aimed to assess the implications of dental implants
after immediate sinus augmentation and type of graft
materials which are suitable to support the sinus lift
Introduction
Surgical placement of dental implant is a demanding
technique particularly if alveolar bone height is
compromised in the posterior maxillary region.
Multiple surgical methods have continuously been
adopted to encounter these clinical problems
including reduced alveolar ridge height and density13
.The most common surgical procedure for obtaining
clinically adequate bone height before the placement
of endosseous implants in the maxilla is grafting of
the maxillary sinus floor. The sinus augmentation
technique was discovered about forty years ago. This
was achieved using the autogenous cancellous bone
material from the lateral iliac crest and repaired
though Caldwell-Luc yechnique. Later on, various
methods were discovered in the precision of the sinus
grafting techniques1-6. This was performed to make
the procedure more comprehensive yet clinically an
effective way to increase bone height.
A wide range of materials including allografts,
xenografts and alloplastic grafts have been used for
bone substitution to make implantation more
predictable and successful clinically5,7-9. Implant
success is found to have dictated by primary stability
factors such as implant diameter, shape, thread forms
and pitch values. Secondary stability factors included
the host environment where bone density plays a vital
role
in
their
placement
and
successful
osseointegration. For example, osseointegration can
be enhanced using osteogenic surface coated dental
implants10.
Radiographic techniques including cone beam
tomography is frequently used for anatomic
assessment of orodental tissues11-13. For example,
computed tomography is used to assess the core basal
value and density of alveolar bone in order to make
sinus augmentation valuable in long term. This
{67}
review discusses the significance of sinus lift
procedures with immediate dental implant placement
in combinations with different graft materials. Based
on previous clinical studies, clinical survival
predictability of graft materials and implant success
rate has been discussed.
Results
Initial search recovered 3510 peer reviewer papers
(figure 1) and reduced to 1724 after filtering out
duplicate papers. After going through the titles,
abstracts and full texts of 279 papers we excluded
151 papers because of high risk of bias. Considering
the inclusion criteria carefully, only 40 papers were
included in the review.
Figure 1: Article screening criteria used in this study. PubMed/MEDLINE and Cochrane electronic databases
were searched for articles published from 2000 to 2013.
{68}
The key outcome of inclusive research studies including the type of graft augmentation has been summarized (table2).
Table 2: Reviewed studies with basic research outcome
Researcher
Graft type for augmentation
Cochrane1
Not specified
Lazzara et al2
Not mentioned
Khang et al3
Not specified
Wallace et al4
Del et al5
Stach et al6
Peleg et al15
Not specified
Winter et al16
Not specified
Peleg et al17
Lozada et al18
Hallman et al19
Engelke20
Not specified
Autogenous
Bovine HA and autogenous bone
Particulate alloplastic bone
(autogenous) and blood
Autogenous
Autologous calvarial bone, human
recombinant tissue factor, platelet
plasma & tetracycline.
Deproteinated bovine bone +
platelet rich plasma
Autogenous
Iliac corticocancellous bone
Autogenous & ePTFE membrane
Alloplastic
Autogenous
Autologous
Autogenous
Organic bovine bone with/without
autogenous bone.
Autogenous
Autogenous/allograft/Gore-Tex
membrane
Autogenous cancellous bone/HA
Autogenous
Autogenous bone/xenograft
mixture 2:1
Resorbable membrane, collagen
and inorganic bone mineral
McCarthy et al21
Philippart et al22
Rodriguez et al23
Stricker et al24
Bloomqvist et al25
Hurzeler et al26
Zinner et al27
Block et al28
Daelemans et al29
Block et al30
Wallace et al31
Karabuda et al32
Fugazzotto33
Kaptein et al34
Van et al35
Hatano et al36
Schwarz et al37
Valentine et al38
Emmerich et al39
Leonardis et al40
Khoury et al41
Lekholm et al14
Peleg et al42
Lovenzoni et al43
Autogenous
Autogenous
Main Outcome
Sand blasted/acid etched titanium implants promote
osseous contact than plasma sprayed.
Cumulative implant survival rate 99.8% at 10.5 months
loading in non-complicated implants. Clinically
investigation suggested that functional loading is possible
at 2 months.
Cumulative success rate for post loading three year 96.8%
(acid etched) and 84.8% (machined surface).
Survival rate of implant in augmented sinus ~92.6%.
Bone substitutes are successful for sinus augmentation.
Cumulative success rate (4 years) for machined implants
92.7% (dense bone) & 88.2% (poor bone)
Immediate implant insertion can be a likely choice for
patients with 1-2mm of vertical residual bone height.
In atrophic posterior maxilla, primary stability was
achieved with tapered implants.
Simultaneous implant placement favorable results.
Less dense bone required large diameter implants.
Acceptable short term results and less resorption.
Adequate bone height achieved.
Sufficient bone volume achieved.
High bone regeneration capacity.
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Pal et al44
Butz et al45
Guers et al46
Kahnberg et al47
Autogenous
Alloplastic
Autogenous
Autogenous
Discussion
There are various techniques for sinus augmentation
such as lateral window, crestal approach, summers
osteotomy, bone aided augmentation. The most
popular technique for sinus lift is found to be lateral
window with autogenous corticocancellous grafts.
Autogenous bone grafts have always been considered
the most effective standardized grafting material due
toosteoinductiveand osteoconductive potential 1-6,15,16.
Various alternative materials havealso been used in
this
context,
however
compromising
the
osteoinductive potential. The property of biomaterials
in providing graft maturation and effective provision
to the endosseous implants is the most significant
element believed for the success of sinus graft
augmentation procedures17-24.
Implants placed in grafts composed of a combination
of autogenous bone and synthetic materials found to
have better survival rates than implants placed using
the autogenous graft only17-24. Such response is
probably due to its high resorption values. The
reviewed studies explained that a majority of
implants had textured surface followed by machined
surface. Textured surface implants have shown
significant results (p<0.05) contrast to machined
(p>0.05). No association was observed in context to
bone graft materials. This might refer to the adequate
results with rough surfaced implants in
immunological risk patients or those who have
insufficient bone this seems regardless in bone with
adequate height and density1-5.Direct implant
placement is usually a recommended protocol in such
cases25-31. Primary implant stability and graft is
related to adequate bone height. Delayed implant
placement is not recommended for badly destructed
alveolar ridge with no proper implant base.
{70}
regeneration48. From biomaterials prospective, there
is an intense need of new materials for these
applications. The limitations of clinical studies
included inadequate sample size, lack of integrated
systemized similar approaches and variability in data
collection. All accounts towards the specific need of
more rational case control and randomized clinical
trials. This approach can further encompass the
various human physiologically mediated conditions
required to be discussed. There is also found to have
constant need of long term follow up related to
implant stability.
Conclusion
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
References
1.
2.
3.
4.
5.
6.
7.
18.
19.
20.
21.
22.
23.
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24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
{72}
SYSTEMATIC REVIEW
Abstract
Use of tobacco has been documented a significant
risk factor for the progression of periodontal
conditions. The consumption of tobacco is related to
intensified depth of periodontal pockets and ligament
detachment, alveolar bone loss and susceptible to
tooth loss. The main aggravating part in development
of periodontal disease is contributed by nicotine that
is pharmaceutically active component and a primary
constituent of tobacco. It have been documented that
negative impact on periodontal tissues is due to
hindrance in connective tissue proliferation as a result
of affected gingival blood circulation and neutrophil,
cytokine production caused by nicotine. Thus,
abeyance of tobacco is most important part of
periodontal treatments as this renders positive
influence on the patients' oral and systemic
wellbeing. Tobacco cessation has been included as a
Introduction
It has been known since late 1040's that tobacco
exhibits detrimental effects on periodontal tissues
health when association of ANUG (Acute
Necrotising Ulcerative Gingivitis) was noticed with
smoking1. A diverse range of periodontal diseases
have been investigated observing their relationship
with smoking. A substantial amount of scientific
literature is available on the basis of which this
review has been formulated. The basic aim and
objective of this review is to conduct effective review
for having clear idea of tobaccos effect on
periodontal health from the perspective adopted in
clinical trial and error and to analyse the effect of
tobacco consumption on periodontitis and its types
(Chromic periodontitis, Aggressive periodontitis).
Cross-sectional studies prove that smokers exhibit
prevalence and severity of periodontal disease more
than twice as compared to individuals who do not
smoke. This is evidence that smoking exhibits a
major connection with periodontal diseases. More
cases of tooth loss are also reported in smokers with
periodontal disease as it aggravates the pathological
condition.
According to research conducted in 19972, observe
that negligence of oral hygiene among youth is
ironical because they tend to be more health
conscious, as the number of people visiting gyms and
health clubs has increased with the onset of the new
millennium. While awareness on diseases like obesity
has received widespread awareness, the issues in
relation to maintenance of oral health have not come
into limelight. Life threatening diseases like cancer
have been the chief concern of medics in relation to
tobacco addiction.
The knowledge on maintaining proper oral hygiene
among general people is very limited. From the onset
of childhood pupils are taught about brushing twice
{73}
and dental flossing to keep the menace of tooth decay
at bay. However, importance of food habit and
lifestyle in relation to oral health remains ignored.
Observing the adverse influence of smoking on
periodontal health, the aim of this review is to
highlight the unfavorable impact of smoking in
relation to periodontal conditions and focus on
cessation of smoking, highlighting its significance on
periodontal health and outcomes of diseased
periodontal tissues' treatment.
Literature review
Epidemiological literature provides various evidences
related to connection of smoking with detrimental
periodontal diseases when studies of about more than
two decades are reviewed3-5. The conclusions
provided by Asmaand Tomar6 based on statistics
from the NHANES III study, may be considered a
sturdy body of evidence of nicotine as a peril factor
for periodontal diseases. Authors proposed that in
USA almost fifty percent of patients suffering from
periodontal pathologies were smokers. It was also
noted that susceptibility of periodontal disorder was
directly related to rate of smoking intensity of an
individual and prevalent smokers were more than 3
times susceptible to periodontal diseases in
comparison to non-smokers.
Literature based in clinical studies clearly reveals that
smoking has deleterious effects on periodontal tissue;
it causes quick and greater loss of periodontal
attachment, gingival recession, pocket formation and
bone loss in diseased condition7. Clinical study
conducted by Mullally et al. in 2004 reviled that odds
ratio between periodontal disease was as high as 14.1
for patients who smoked, exhibiting that smoking
acts as the strong predator of progressive
periodontitis, causing early loss of periodontal
attachments and progression of other signs and
symptoms.8
Connection between smoking and periodontal disease
is known very clearly and proved by epidemiological
studies but the true mechanism by which smoking
causes deleterious effects on progression of
periodontal pathology are still unknown.
Methodology
To obtain the desire article following database will be
use like Pub Med, Medline, Lancet, Google scholar,
Cochrane library and from different organization who
are actively working on tobacco like TTAC (tobacco
technical assistance consortium America).
The following keywords will be used during
searching; effects, role, tobacco, smoking, oral,
mouth and periodontium or gingivitis. Articles
published between 2000 and 2012 and in English
{74}
able to critically evaluate the qualitative and
quantitative methods. As per CASP or Critical
Appraisal Skills Programme, the framework consists
of several questions that are keenly analysed to meet
up factors like relevance of the study, the results,
validity, reliability and similar such 13. Through the
aid of the questions for study assessment, the
following segments of the entire study for instance,
study design, objective of the research, target
population sample, concerns related to research
ethics, data analysis and findings and many such.
Results
After analyzing literature, we concluded different
tables (1, 2 and 3) with authors details, year of
reporting, title of study, study design, which
population targeted, country of study, their aims with
result outcomes.
Author
Year of
Publication
D.F.
Kinane and
I.G.
Chestnutt14
Title of
Study
Study
Design
Smoking and
Periodontal
Disease
Cross
Sectional and
Longitudinal
Study on
Patients
1361 Case
(n= 873)
Target Age
Group 25-74
Erie
County,
New
York State
Strength of
Association
between
Tobacco and
Periodontal
Brian H.
Mullally15
The
Influence of
Tobacco
Smoking on
the Onset of
Periodontitis
in Young
Persons
Tobacco Use
and Its
Effects on
the
Periodontium
and
Periodontal
Therapy
Hospital
Case Study
17, 22 Case,
Target Age
Group 17-34
years.
Africa
Prevalence of
early onset or
aggressive
periodontitis
in young
adults.
Cross
sectional
12,329 Case,
Target Group
18 years and
above
USA
Reviewing
potential
biological
mechanisms
related to
effects of
tobacco on
periodontal
disease.
Vandana
K. Laxman
and
Sridhar
Annaji16
Results
Tobacco smoking
significantly contributes
to the development of
periodontal disease.
{75}
NurcanBud
uneli17
Jose
LopezLopez et al
18
Effects of
Tobacco
Smoking on
Chronic
Periodontitis
and
Periodontal
Treatment
Tobacco
Smoking and
Radiographic
Periapical
Status
Cross
Sectional
Study
550 Case
Target Group
18 to 45
Turkey
Impact of
Tobacco
Smoking on
Chronic
Periodontitis
A positive association
between smoking and
various biochemical,
clinical signs of
periodontitis and
chances of periodontitis
among smokers.
Case Control
Study
79 Case,
Target Group
18 and
above
UK
Radiographic
investigating
the
relationship
between
tobacco
smoking and
periapical
status.
Author
Name and
Year of
Publication
Cristina
Cunha Villar
and Antonio
Fernando
Martorelli
de Lima 19
Title of Study
Smoking Influences on
the Thickness of
Marginal Gingival
Epithelium
Brazil
Evaluation of the
thickness of marginal
gingival oral
epithelium and
non0smokers who
have clinically healthy
gingivae.
FlonaM.Coll
ins20
United
States
GirishParma
r, et al 21
Effect of Chewing a
Mixture of Areca Nut
and Tobacco on
Periodontal Tissues and
Oral Hygiene Status
Prevalence of and Risk
Indicators for Chronic
Periodontitis in Males
from Campeche.
India
MirnaMinay
a-Sanchez et
al22
Brazil
Results
{76}
Author Names
and Year of
Publication
ZHS Lung,
MGD
Kelleher, R W
J Porter, J
Gonzalez and
R F H Lung. 23
Poor Patient
Awareness of the
Relationship
between Smoking
and Periodontal
Diseases.
Cross Sectional
Survey based
on wellstructured
interview
Smoker
patients
attending
dental clinic
London,
UK
Investigating
patients
knowledge of
the effects of
smoking on
periodontal
disease.
Yuval Vered
and Harold D
Sgan-Cohen.24
Self-perceived
and clinically
diagnosed dental
and periodontal
health status
among young
adult and their
implications for
epidemiological
surveys.
Cross Sectional
Survey based
on wellstructured
interview
21 year old
Israeli
Defense
Forces after
being
released
from
military
services.
Israel
Investigating
parity
between selfperceived
and clinically
diagnosed
dental and
periodontal
health status.
ShaileeFotedar
et al, et et al 25
Knowledge of
Attitude Towards
and Prevalence of
Tobacco Use
Among Dental
Students in
Himachal
Pradesh.
Cross Sectional
Survey based
on wellstructured
interview
Third year
Students of
Bachelor of
Dental
Surgery.
India
Assessing
prevalence of
tobacco and
its use along
with
knowledge of
cessation
counseling
among dental
students in
the state of
Himachal
Pradesh,
India.
Discussion
Results
The patients
were found to be
less aware of the
relationship
between
smoking and
periodontal
diseases as only
6% of the total
were aware of
the fact.
The selfassessment of
individuals was
found to have
been low. The
low level
awareness will
directly impact
care-taking
behavior and
need for public
health action.
The prevalence
of tobacco use
among the
students is found
to be low.
Though, use of
skills to support
quitting of
smoking is
necessary.
{77}
consequences of smoking on periodontal health. By
this mode dental department will also be playing a
major role in the general health and well-being of the
youth.
By the epidemiological study about the treatment of
the individuals addicted to cigarettes, the theorists
have suggested that non-surgical treatment will
generally be productive in requisites of penetrating
depth reduction and gingivitis. Thus the
consequences of smoking on the result of
periodontitis treatment may be concluded as Short
term effects in terms of less gingivitis resolution, less
probing depth reduction, less attachment gain among
the smokers.
It has been noticed and stated by Lpez-Lpez, J.,18
80 to 90% of the cases in long term effects are
treatment failures among the smokers. He has also
stated that 70-80% of the cases are not successful in
the implantation among the smokers. Thus smoking
does have a negative effect on the treatment
procedure of the periodontitis diseases. Keeping this
in mind, the patients suffering from periodontitis
diseases need to be advised and counselled about the
consequences of smoking.
Study on effects of tobacco use on periodontal health
and treatment has made evident that over the past 50
years, knowledge and concern about obnoxious
effects of tobacco smoking on periodontal health has
progressed significantly. Hence, in todays world
there is little doubt on the fact that tobacco smokers
are at a high risk of getting affected by periodontitis.
They are also found to be slow responders to
periodontitis treatment.
Tobacco smoking in fact, is found to have wide
spread effects on oral health. The mechanisms of
tobacco smoking for increased level of susceptibility
to periodontitis and poorer response to remedial
treatments are some of the ill-effects on over all oral
health and recovery process. Another, significant
outcome of the tobacco smoking is that it acts as a
strong environmental factor. Smoking of tobacco
interacts with the body of host and bacterial growth
associated with the disease periodontitis 14. The
genetic built of the host and interaction with the
environmental factors like cigarette smoking makes
way to further exploration of the relationship between
tobacco smoking and related genetic factor of the
host.
The effects of tobacco smoking on formation of
chronic periodontitis have also been found to impair
the microcirculatory system and changes on the
vascular formation system. This in turn leads to
negatively influence the immune system and
inflammatory reactions on healthy periodontal
tissues. It is found that smokers have less number of
vessels and existence of highly inflamed gingival
tissues as compared to non-smokers. According to
researchers it has been found that smoking of tobacco
Conclusions
Smoking is a well-known causing and aggravating
factor for periodontal problems. Smokers exhibited
more than twice chances of having periodontitis.
Therefore, cessation of smoking plays a significant
role in the cure of periodontal diseases. Patients
should be educated and motivated by their dentists to
quit smoking. Dentists can have very effective and
influential position, as patients tend to visit them
more regularly in comparison to their physicians.
However, success in cessation of smoking may be
{78}
certainly influence by mutual coordination among
dentists and physicians.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
{79}
SHORT COMMUNICATION
Corresponding Author:
Dr. Amir Manzoor Shah
E-Mail: amir.shah@mail.mcgill.ca
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Abstract
The use of lasers has significantly developed in
modern dentistry, however the clinical value and
awareness on the benefits of their use is limited.
Lasers have made their way in dental treatment since
1994. They have been granted Food and Drug
Administration (FDA) approval, however the
American Dental Association (ADA) is still
researching on the outcomes of laser therapy1. This
article reviews the use of laser therapy in the initial
non-surgical phase of periodontal therapy.
Introduction
{80}
filling materials such
composite resins7,8.
asphotopolymerizationin
{81}
Modern techniques using lasers can control the
spread of harmful bacteria and limit tooth loss
compared to standard periodontal treatment options.
Some benefits of laser treatment for gum disease
include: elimination of cutting and bleeding, soreness
and discomfort of the gums. Isolation of deep
periodontal pockets. Reduction in tooth loss.
Regeneration of bone and ligament tissues. Lastly,
increased chances of success with a solution in case
of setbacks that may occur19.
As compared to a dental hand piece, lasers are
advantageous in certain conditions causing less pain,
anxiety and discomfort for the patient. In addition,
soft tissue damage is minimized and the need for
anesthesia may be avoided in less invasive
procedures.
References
1.
2.
Conclusion
With all the benefits of laser therapy outlined in this
review, we point out the lack of studies supporting its
use alone. There is no evidence in the literature to
suggest it may control adult chronic periodontitis
without conventional SRP and surgical treatment.
The advantage of laser therapy in conjunction with
traditional therapy are of benefit, yet current
challenges include increased operating costs for the
dentists and patients coupled with technique
sensitivity for operators.
The main advantages of laser therapy over
conventional
methods
are
reduced
tissue
inflammation and bleeding. Sterilization of the
affected area leading to a reduction in post-treatment
discomfort with higher patient satisfaction. With this
in mind, are lasers considered more advantageous
than traditional therapy? Current literature is
inconclusive.
In order to come up with a final conclusion,
evidence-based science provides strict research
protocols and parameters to make fair comparisons
between various treatments. Studies should have an
adequate sample size, be randomized with controls
and have specific treatment goals and criteria. To
show effectiveness and long-term results, an
appropriate time-line should be set.
In a systematic review of the literature on the use of
lasers in periodontal therapy, only 8 of 300 studies
met the criteria above. Researchers in only 5 out of 8
studies assessed the tissue attachment after treatment,
a gold standard in assessing periodontal treatment
outcome. The results of the review could not point to
any advantages of Nd:YAG lasers over conventional
periodontal therapy in the treatment of initial
periodontitis.
Initial non-surgical therapy of periodontitis remains
the treatment of choice with growing interest in lasers
as an adjunct treatment option for gum disease. The
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
{82}
on fibroblast attachment to root surfaces. A scanning
electron
microscopy
analysis. Journal
of
periodontology, 73(11), 1308-1312.
18. Yukna, R. A., Carr, R. L., & Evans, G. H. (2007).
Histologic evaluation of an Nd: YAG laser-assisted new
attachment procedure in humans. The International
journal of periodontics & restorative dentistry, 27(6),
577.
19. White, J. M., Goodis, H. E., & Rose, C. L. (1991). Use of
the pulsed Nd: YAG laser for intraoral soft tissue
surgery. Lasers in surgery and medicine, 11(5), 455-461.
__________________________________________________
{83}
ORIGINAL RESEARCH
Corresponding Author:
Dr. Syed Misbahuddin
Email: Syedmisbahuddin22@yahoo.com
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Abstract
Betel nut (BN) also referred to as Chalia/Supari has
been used for thousands of years. BN chewing is an
important and popular cultural habitin India,
Bangladesh and Pakistan (the subcontinent).It is
being used regularly on individual and family basis.
The use of BN is prevailing in the rural and urban
areas of Pakistan. In several studies, an association
between BN chewing and oral health problems like
bleeding gums, sore gums have been identified.
These lesions are reported in children and
adolescents. This is of great concern not only because
of the high cost involved in their management but the
morbidity and mortality associated with it. Low cost,
easy availability, advertising, role modelling, social
Introduction
The chewing of betel nut (BN) is an old practice in
South-East Asia, especially in the Indian
subcontinent1. This tradition is inherited by
generation after generation and has become a popular
cultural activity among people of Pakistan, India, Sri
Lanka, and Bangladesh2. BN is a fruit of areca tree
that widely grows in tropical Pacific, Asia and east
Africa3. It is a small feathery plant that grows to the
height of 1.5 m. The most common method of using
BN is to chop it into very small pieces with the help
of an especial instrument known in local language Urdu as sarota. Slurry of slaked lime and catechu
boiled in water is applied on a betel leaf and the
chopped pieces of BN are rolled in it to be kept in
mouth4,5.
BN contains the alkaloid arecoline in addition to
nitrosamines, which is carcinogenic.Various studies
have been conducted to determine the relation of BN
and other alternative chewing material to oral and
other associated cancers6,7. It has been proved that
BN, Gutka and Paan cause oral cancers8,9and alone in
India, out of 700,000 cancers diagnosed each year
{84}
300,000 cases are related to tobacco smoking and BN
chewing10,11.
Although, the use of BN and Gutka is associated with
certain oral conditions; the prevalence and effect on
oral health of school going children of 12-16 years of
age is not clearly known in local context. This study
was conducted to identify the prevalence of oral
lesions and to investigate association which may exist
between the oral conditions and BN/Gutka chewing
among the school going children.
Methodology
A cross sectional study was conducted in City
District, Karachi. A research questionnaire was
prepared, and sent along with the parental consent
and student assent forms to the Clinical Research
Ethics Committee of the Cork Teaching Hospital,
University College Cork for ethical approval, which
approved it. Ethical approval was also granted from
Baqai Dental College, Karachi for this study. The
questionnaire was scrutinized by the subject
specialists and was coded for statistical purposes. The
research questionnaire consisted of chewing habits,
clinical interview and findings of the clinical
examination.
The sample comprised of 360 students from 17
different schools in CD, Karachi. The age range of
sample population was 12 - 16 years. The authors
was trained and calibrated for the examination of oral
health and identification of oral lesions at Cork
University School and Dental Hospital. In Karachi,
the author hired qualified dental assistants and trained
and calibrated them. The subjects had their oral
examination done on the specified date by the author
and the trained dental staff.
Individuals were examined in the natural day light on
a chair in a separate room to maintain privacy. A
hand torch was also used in some cases, where natural
daylight was insufficient. A sterile CPITN probe was
used to observe bleeding on gentle probing. When
required the teeth were dried using cotton wool rolls.
Universal precautions were followed. Personal
protective clothing and equipment was worn by all
the examiners and recorders in attendance. Latex free
examination gloves were used for the examination of
each child and were changed before examining the
next child. A facemask was worn and changed at
frequent intervals. A disposable paper sheet was used
under each set of instruments and disposed after each
Statistical Analyses
SPSS Version 18 was used for statistical analysis.
The following information was obtained and
analysed:
The number of children examined by gender and
age.
The mean age in years of children that
participated in the study.
Habit of BN chewing and its association with
gender.
Frequency of tooth brushing habit.
Distribution of subjects by gender and tooth
brushing habit
Association of gender with the frequency of
bleeding gums while brushing teeth
Results
The distribution of males and females by the status of
betel nut chewing:
As illustrated in the table below, 61.61% of males
and 38.39% of females chewed betel nut (Table 1.1).
Table 1.1 BN chewing and gender distribution
Betel nut
Males% (n)
Females% (n)
chewing
Yes
61.61 (130)
38.39 (81)
No
36.91 (55)
63.08 (94)
{85}
twice the numbers of males (61.61%) chewed betel
nut as compared to females (38.39%).
Never
Once a day
53.71%
38.37% 37.83%
29.16%
16.75%
12 years
13 years
14 years
15 years
16 years
Male
37
39
49
34
26
Female
32
44
40
34
25
14.85%
7.05%
Males
2.28%
Females
Brushing frequency
BN chewing %
53.69%
42.65%
40.28%
45.83%
33.61%
15.85%
21.47%
20.80%
4.71%
11.86%
Never
Once a
day
Twice a
day
5.21%
4.04%
More
Never
Once a
day
Twice a
day
More
{86}
Female
81.14%
67.02%
14.59%
18.39% 14.86%
Never
Occasional
4%
Frequently
Discussion
In our study, we found out that twice a number of
males were indulged in Betel nut chewing as
compared to females. Females had the highest
percentage of brushing teeth but males predominated
in brushing teeth twice a day. It was also noticed that
tooth brushing was more common among BNC as
compared to Non BNC. In contrast to males, bleeding
gums was less common in females.
It is seen that mostly periodontal diseases progress
un-noticed. People commonly recognize it at an
advance stage. It is therefore important to make
dental health education mandatory for control and
maintenance of periodontal health.
Early recognition of periodontal conditions is not so
common because people do not understand the
connection between gum bleeding and gum disease.
According to Brady, 73% of patients with periodontal
disease did not know that they had it12. Almas et al
reported 42% of Saudis with bleeding gums13.
Khawamura and Eva Motto found that 3 quarters of
Japanese employees had bleeding gums14.
Gingivitis with bleeding gums is the first symptom of
periodontal disease. This symptom of disease is selfdetected and is the most reliable indicator of the
condition15. In order to prevent progression of
periodontal disease, the public needs dental health
education to connect gingival bleeding with gum
disease16. The aspect of dental health education
therefore has a key role in the awareness of
periodontal disease among different groups of
society.
{87}
Self-Reporting
Research conducted in Dundee dental hospital and
school revealed astonishing results about the
knowledge and understanding of periodontal disease
among the people who took part in the study. People
were unable to recognize that they have periodontal
disease while having gingival bleeding17. Although
people were aware of bleeding gums at times, there
were other times when it went unnoticed A.D. Gilbert
& N.M. Muttall. Radiographs were not used in order
to validate the self-reporting instrument and also to
avoid unnecessary radiation. The CPITN method
was normally used to determine periodontal
treatment needs and was considered more appropriate
to make patient realize that they have gum disease.
Conclusion
11.
12.
13.
14.
15.
16.
17.
___________________________________________
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
{88}
SHORT COMMUNICATION
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Introduction
Periodontal disease is an inflammatory condition that
causes pathological alterations in the periodontium,
potentially leading to tooth loss [1]. In the world,
35% of adults in the population suffer from moderate
periodontal disease, while up to 15 % were affected
by a more severe form at some stage of their life [2,
3].The periodontium has always proved to be one of
the structures with inherent regenerative capacities. It
gives rise to osteoblasts, periodontal ligament (PDL)
fibroblasts, and cementoblasts[4]. However, the
periodontium which includes the periodontal
ligament, root cementum, alveolar bone and gingiva has a limited ability to regenerate once damaged [4].
For decades, periodontists have sought to repair the
damage from periodontitis and to achieve
regeneration through a variety of non-surgical
procedures and surgical procedures that include root
surface conditioning, bone graft placement, guided
tissue regeneration and the application of growth
factors [5-7]. However, current procedures allow the
periodontal tissue to be repaired rather than
regenerated with some approaches showing some
limited unpredictable regenerative outcome [8-12].
Recent advances in tissue engineering and stem cell
biology have paved the way to develop novel
{89}
Stem cells
By definition, a stem cell is a clonogenic, relatively
undifferentiated cell that is capable of self-renewal
and multi-lineage differentiation depending on
intrinsic signals modulated by extrinsic factors in the
stem cell niche[20, 21]. Stem cells (SCs) are
classified according to their origin and their
differentiation potential[16, 22]. They can be broadly
classified into three categories: (1) embryonic stem
cells (ESCs); (2) induced pluripotent stem cells
(iPSCs); (3) adult or postnatal SCs. ESCs are
totipotent or pluripotent cell, which means that they
possess the capacity to proliferate extensively and
differentiate into almost all possible cell types.
However, using embryos to obtain human embryonic
stem cells has raised many ethical concerns and
limited their usage. These concerns pushed
researchers to investigate the possibility of
genetically reprogramming somatic cells back to the
pluripotent phase, which lead to the generation of
iPSCs[23, 24]. They are comparable to the ESCs in
their function, morphology, gene expression and wide
differentiation capacity[23, 24]. Efforts were also
made to obtain iPSCs from gingival and periodontal
fibroblasts[25-27]. In general, the behaviour of iPSCs
can be unpredictable because the genetic
manipulations may alter their development and
growth characteristics, thus, limiting their in tissue
engineering[16]. Moreover, both the ESCs and the
iPSCs convey tumorigenic properties that raise
serious safety concerns that further limit their use in
regenerative therapies.
Somatic adult or postnatal stem cells can be derived
from the majority of fetal and adult tissues that
continually replenish themselves (e.g. dermis,
peripheral blood) [20, 28, 29]. They are multipotent
and can differentiate into limited number of cell
lineages such as endothelial, perivascular, neural,
bone or muscle cells [30]. It is thought that they
function in long-term tissue maintenance and
replacing cells that are either lost or injured [31].
Despite their limited life span, SCs have extensive
self-renewal capacity [32]. Even though adult SCs
exhibit more restricted capabilities compares to
ESCs, they are immunocompatible and are not
associated with any ethical concerns (Han). Their
most common sources are the bone marrow
(hematopoietic stem cells) and bone marrow stromal
cells (mesenchymal stromal stem cells) [33-35].
Hematopoietic stem cells were the first cells to be
used in regenerative therapies, mainly in the
treatment
of
blood
malignancies
and
immunodeficiency syndromes, but they lack the
ability to give rise to supporting connective tissues
[36]. On the contrary, mesenchymal stem cells
(MSCs) have been used to treat a range of
{90}
the immune response without an induction of an
inflammatory response, thus enabling the use of
allogenic
PDL
sources
for
periodontal
regeneration[48, 49]. Animal studies showed that
implanted PDLSCs in periodontal defects resulted in
the new formation of cementum and alveolar bone,
and new attachment apparatus[50-55]. Furthermore,
a study conducted on mini-pegs demonstrated the
formation of PDL- like tissue mimicking the
orientation of the fibre bundles similar to Sharpeys
fibers within four weeks[51]. The results from human
clinical studies using PDLSCs are encouraging yet
still very limited and variable [56-58].Recent studies
even showed that MSCs can be derived from normal
and inflamed gingival tissues which might be a more
abundant potential source compared to PDL[59, 60].
More future studies are required to assess the benefits
and safety of using MSCs from dental origin and
important challenges need to be addressed before
applying such treatment protocols to standard clinical
practice[56].
3.
Final remarks
10.
4.
5.
6.
7.
8.
9.
11.
12.
13.
14.
15.
16.
17.
18.
References
19.
1.
2.
20.
{91}
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
{92}
58.
{93}
CLINICAL DIAGNOSIS & GUIDELINES
Morvarid Oveisi1,
Oriyah Barzilay2,
Ahmed A. Hanafi3
1,2,3
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Abstract
Primary immunodeficiency diseases are rare
hereditary conditions that usually occur at a young
age; however, secondary immunodeficiency is
acquired due to disease, drug treatment and is
increasing in frequency among the population.
Although periodontal diseases related to these
conditions are secondary to other life threatening
manifestations, they are very common and easily
detectable by the patient, patient guardians and
periodontists. Periodontists have a major role in both
helping to detect undiagnosed diseases, as well as
improving the oral care of diagnosed patients, thus a
thorough knowledge of these conditions, causes,
local and systemic involvement, diagnostic tools and
proper management is very important. This article
summarizes selected primary and secondary
immunodeficiency conditions such as neutropenia,
leukocyte adhesion deficiency (LAD) and ChediakHegashi syndrome, and places schematic, diagnostic,
and management steps that may help periodontists
manage unexplained severe periodontal diseases
related to immunodeficiency.
Neutropenia
Neutropenia is defined by a low absolute neutrophil
count (ANC) in the blood lasting more than 6
months, which can cause recurrent infections to a
patient [10] with varying severity from stomatitis
{94}
and gingivitis, to more severe pneumonia and sepsis.
[11] Different forms of neutropenia such as cyclic
neutropenia, chronic benign neutropenia and severe
congenital neutropenia (Kostmann syndrome) can all
cause periodontal disease.[10, 12]
Kostmann Syndrome
Severe congenital neutropenia (Kostmann Syndrome)
is a rare hereditary syndrome characterized by a very
low ANC (less than 0.2x109/l) [18] due to maturation
arrest during myelopoiesis process [4]and increased
apoptosis of myeloid progenitor cells in bone
marrow.[19]
Initial symptoms can be summarized as recurrent
bacterial infections of the skin, mucosa leading to
cellulitis, perirectal abscess, stomatitis, meningitis,
pneumonia, and sepsis [20] . Long term symptoms
are periodontitis, splenomegaly and hepatomegaly,
osteoporosis and myelodysplastic syndrome/acute
myeloid leukaemia (MDS/AML) [19].
Oral findings are usually more severe than other
forms of neutropenia, with recurrent painful
ulceration, [21] diffuse gingival inflammation,
alveolar bone loss, teeth mobility and loss of both
dentition [22]
Persistent ANC less than 0.5x109/l is a significant
laboratory finding and diagnosis is confirmed with
bone marrow aspiration showing an arrest of
neutrophil
hematopoiesis
at
the
promyelocyte/myelocyte stage.[10]
Cyclic neutropenia
Cyclic Neutropenia is characterized by the repetitive
occurrence of neutropenia at average of 21 day
period and last for approximately 3-6 days[23].The
mutation is passed along in an autosomal dominant
manner. It has been observed that this disease is
associated with the mutation in ELA2 gene mapped
to chromosome 19p13.3 which encodes neutrophil
elastase. Mutations in this gene lead to a shortened
neutrophil life[24] .
It is characterized by fever, mouth ulcers,
lymphadenopathy, multiple abscess formation,
exhaustion and susceptibility of infection which can
be lethal [25-29]. Reduction in the number of
polymorph nuclear leukocytes (PMNs) can be
associated with rapid and destructive periodontal
disease including aphthous-like lesions[10].
The initial oral characterization of patient includes
repetitive ulceration showing little evidence of an
inflammatory halo[30], severe gingival inflammation
and recession[14, 25],which extended from the
gingiva into the alveolar mucosa[25].Recurrent
gingival bleeding along with fever was noted as a
sign of this disease [25, 31],pocket depths exceeded
the 6- to 8-mm range[25] with various levels of tooth
mobility [31].
Diagnosis requires serial measurements of the ANC
(<1,500) daily or at least three times per week for
four to six weeks[32].
It has been demonstrated that Granulocyte ColonyStimulating Factor(GCSF) can be an efficient
treatment for neutropenia[33], as it can lead to a 10
fold increase in ANC and result in a higher life
expectancy[34].
Dental management is necessary for these patients to
control infections.
LAD
LAD is a rare, autosomal recessive, primary
immunodeficiency syndrome; characterized by
impaired phagocytic functions[35]. LAD is classified
{95}
according to causative gene mutation into 3 types:
LAD I, LAD II and LAD III [36-38].
LAD I is caused by mutation in gene ITGB2 which
encodes for CD11/CD18 [39, 40] and ultimately
decreases the expression of three integrins on
leukocyte surfaces CD11a,CD11b and CD11c and
preventing the adhesion of neutrophils to endothelial
cells)[41]. Characterized delayed separation of
umbilical cord, major bacterial infections with no pus
formation [35] and impaired wound healing [40], the
severity of clinical features are directly related to
degree of CD18 deficiency and can be divided into
severe (less than 1% CD18 expression) and moderate
( 2.5% to 10% CD18 expression) [42, 43].
Morbidity rate of severe LAD I is high before the age
of 5 [44].
In LAD II, different gene mutations cause defects in
the specific Golgi GDP-fucose transporter [45, 46]
which reduce CD15s (Sialyl-Lewis X) on the
leukocyte surface, thus affecting the rolling phase of
neutrophil adhesion [35]. This is characterized by
mental retardation and less severe infections in
{96}
Figure 1: Schematic laboratory tests for diagnosis of listed diseases. LAD, Leukocyte adhesion Deficiency.
DHR, Dihydrorhodamine. HIES, Hyper immunoglobulin E syndrome. CVID, Common Variable
Immunodeficiency.
Bone marrow transplant is the treatment of choice for
young LAD patients [53, 54].However if not
possible, several maneuvers to adjust host response
can be achieved such as white blood cell transfusion,
antibiotics, interferon and allogenic stem cell
transplant [55]. Periodontal treatment usually ends
with tooth loss [10] however maintaining the teeth is
advocated with the goal of improving patients
physiologic and psychological health by
Periodic oral prophylaxis [56]
Prophylactic Antimicrobial
Fluoride application and diet counseling
Extraction should be avoided (due to delayed
wound healing)
Chediak-Hegashi Syndrome
Chediakhigashi is a rare condition which is inherited
in an autosomal manner. This disease is usually fatal
and appears with the irregularly enormous lysosomal
granules in the leukocytes [57, 58]. This disorder is
characterized by numerous repetitive bacterial
infections, oculocutaneous albinism, susceptibility to
bruising, and mucosal bleeding as well as peripheral
neuropathy. In addition, patients may show
neurologic dysfunction and movement disorders[3].
Furthermore, the accelerated phase of CHS named
Hemophagocyticlymphohistiocytosis (HLH) can be
recognized
by
cytopenia,
fever,
bleeding,
lymphadenopathy and hepatosplenomegaly [59-61].
This disorder is connected to the fusion of
cytoplasmic granules which can take place in the
myelopoieses and can lead to the death of myeloid
precursors in the marrow and cause neutropenia. Also
neutrophils can have a problem in phagocytosis,
chemotaxis and killing bacteria[62].
Intraoral examination showed a full mouth plaque
score of 85% [63], gingival bleeding and teeth
mobility [3, 58] , high frequency of periodontal
pockets and bone loss at an early age [10, 64, 65],
probing showed more than 30% of the sites 5-8mm
deep with concomitant recession defects [66]
Blood testing and examination of giant granules
within neutrophils, lymphocytes and natural killer
cells using nitrobluetetrazolium dye [10] are essential
for diagnosis. Bone marrow aspiration and
examination of giant eosinophilic or azurophilic
cytoplasmic inclusion bodies within the myeloid
lineage cells show a positive reaction to peroxidase
staining
People with Chediak-Higashi disorder can be
recognized at a young age, and bone marrow
{97}
Variations of oral findings in CGD patients [72, 89,
90], and Neutrophil dysfunction[10, 91] are probably
due to immunosuppressive therapy specially steroids
[92].
Patients with CGD can be diagnosed through
flowcytometery, dihydrorhodamine 123 (DHR)
assay[93] and the nitrobluetetrazolium Test [94]
Treatment:
Regular dental care and frequent follow-up.
Antibacterial mouth washes.
Antibiotics such as clavulanic acid and
amoxicillin is needed for any dental work and
surgery related to bacteremia[95]
Antimycotic prophylaxis[95]
{98}
Table 1: Grimbacher et al[105] Scoring System for HIES
0
<200
200-500
Skin abscesses
None
Pneumonia (episodes)
None
Absent
None
10
501-1000
1001-2000
>2000
1-2
3-4
>4
>3
Bronchiectasis
Pneumatocele
15-20
>3
o
Scoliosis
<10
None
<700
Characteristic face
Absent
Midline anomaly
Absent
Eczema
Absent
Mild
Moderate
Sever
1-2
4-6
>6
Candidiasis
None
Oral
Finger Nails
Systemic
Fatal infection
Absent
Present
Hyperextensibility
Absent
Present
Lymphoma
Absent
Present
High palate
Absent
Present
>20o
1-2
>2
700-800
>800
Mild
Present
Present
Present
<15 points: patient not affected; 15 to 39 points: possible diagnosis; 40 to 59 points: probable diagnosis; >60 points definitive diagnosis
{99}
Common Variable Immunodeficiency
Common variable immunodeficiency (CVID) is a
common heterogeneous primary immune deficiency.
Patients with CVID have a deficiency in humoral
immunity leading to a defective antibody response,
causing repetitive infections of the gastrointestinal
and upper respiratory tracts, and susceptibility to
some cancers such as lymphoma and autoimmune
diseases. Hypogammaglobulinemia has also seen in
these patients.
Although normal B-cell numbers have been
identified in lymphoid tissue and peripheral blood of
patients, it has been noted that B-cells of these
individuals have difficulty in differentiating into
immunoglobulin-secreting plasma cells. Furthermore,
it should be mentioned that the deficiency in
monocyte and macrophage function has also been
recognized. In addition, in some CVID patients, Tcell malfunction has been identified with decreased
CD4 lymphocytes and T-cell receptors, loss of
antigen-specific and quick death of T-cells.[4]
Individual suffering from CVID have been diagnosed
by having a low level of IgG and IgA[106].
Mutations in a group of genes asTNFRSF13B
gene[107] involved in B-cells result in having a
defected immunity in CVID[108]
Clinical examinations show dental problems such as
gingivitis and lichenoid lesions with Wickham
striae,[109] necrotizing ulcerative periodontitis
(NUP) [109, 110] , severe periodontitis and gingival
pain along with bleeding and tooth mobility was
demonstrated in a case report.[110]
In order to treat CVID, the primary method used is to
replace the antibody by an intravenous or
subcutaneous means. This occurs in doses of 400600mg of antibody per kilogram of the patients
weight per month.[111]
Dental management as reported in some case reports
include
Regular oral prophylaxis with crown polishing
[109]
Chlorhexidinedigluconate rinse is recommended
twice a day.
Antibiotic
therapy[109,
110]
such
as
Amoxycillin and clavulanic acid[109]
Leukemia
Leukemia is a type of a cancer caused by an
uncontrolled differentiation and proliferation of blood
cell precursors resulting in the production of
immature cells.Clinically, leukemia is classified into
two types: chronic and acute, with the acute phase
possibly being fatal. In addition, according to
histogenicity, leukemia is divided in to lymphocytic
or myelocytic depending on the origin of the
cells[126-128].
Acute myeloid leukemia(AML) is more common in
adults and acute lymphoid leukemia (ALL) is mostly
seen in children[128-130]. Acute myeloblastic
leukemia (AML) is characterized by symptoms of
{100}
pancytopenia including
fatigue, weaknesses,
infection,
gingival
bleeding,
ecchymoses,
menorrhagia, and epistaxis [131, 132]. The direct
penetration of leukemic cells in lymph nodes, spleen,
central nervous system and gingival has been
reported [126, 129, 133-135].
Oral complication can be observed in all types of
leukemia[136]. Individuals having leukemia are
suffering from extreme enlargement of the gingiva
along with bleeding[127, 135-139], bulbous
enlargement in the interdental papillae [126, 127] a
pale blue gum with glazed texture ,and loss of
stippling is one the symptoms of leukemia[126, 127],
generalized horizontal bone loss was reported[127]
however in some cases bone loss is not
recognized[126] Ulceration and petechiae was noted
as a frequent sign[135]. In patient with acute
monocytic leukemia and acute myelomonocytic
leukemia, gingival infiltration of leukemic cells are
commonly seen[140].
Diagnosis by complete blood count peripheral blood
smear, shows the presence of blast cells and reveals
the type and quantity of white blood cells[126], and
flow cytometry of peripheral blood are used for
leukemia diagnosis[126, 127], biopsy such as bone
marrow aspiration also can be used to confirm
diagnosis and type of leukemia[126, 127, 135]
Regular oral prophylaxis is needed. Antibacterials
can be used in conjugation with scaling and sub
gingival debridement to lower the risk of dental
infection during the chemotherapy. Tooth extraction
of hopeless teeth can eliminate the infection.[141]
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Conclusion
16.
References
1.
2.
3.
17.
18.
19.
20.
21.
22.
{101}
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
61.
{102}
62.
63.
64.
65.
66.
67.
68.
69.
70.
71.
72.
73.
74.
75.
76.
77.
78.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
94.
95.
96.
97.
{103}
98.
99.
100.
101.
102.
103.
104.
105.
106.
107.
108.
109.
110.
111.
112.
113.
114.
115.
116.
117.
118.
119.
120.
121.
122.
123.
124.
125.
126.
127.
128.
129.
130.
131.
132.
133.
134.
135.
{104}
136.
137.
138.
139.
140.
141.
{105}
CLINICAL CASE REPORT
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Article Code: IDJSR SE 0173
Quick Response Code
Introduction
Gingival recession is defined as the apical migration
of the gingival margin in relation to the cementoenamel junction causing root exposure. The negative
effects of exposed roots may lead to dentine
hypersensitivity, root caries, and poor esthetics(1).
One of the reasons of mucogingival surgery is to gain
root coverage with procedures that warrant sound
predictability and good esthetics.
There are several periodontal plastic surgery
proceduresto cover exposed root surfaces which
include pedicle grafts (2), free gingival grafts (3),
connective tissue grafts (4, 5), membrane barrier
guided tissue regeneration technique (6), and
acellular dermal matrix allografts (7, 8). However,
the predictability of such surgical procedures may be
associated with different conditions. Out of number
of procedures, subepithelial connective tissue graft
can be considered as the gold standard technique for
treating teeth with gingival recessions (9). A number
of systematic reviews (9-11)have validated the use of
Case Report
Clinical case presentation
A 28-year-old male with no medical problems was
referred to the Department of Periodontology with
complain of an un-aesthetic mandibular incisor tooth
(tooth #41) with sensitivity to hot and cold stimulus
from approximately 12 months. Clinical evaluation
revealed gingival recession on the labial surface
extending 2 mm apical to the cemento-enamel
junction (CEJ) and narrow zone of attached gingiva
measuring approximately 1 mm (Fig 1). There was
no loss of interdental papillary height on the distal
aspect of the incisor and mild loss of papilla on the
mesial aspect. Plaque control and oral hygiene was
good with no apparent staining on the teeth. There
was no evidence of interdental bone loss (i.e. the
distance between the crestal bone and CEJ was not
greater than 2 mm). The case was diagnosed to be
sensitivity associated with Class II Miller recession.
The goal of the treatment was to restore harmonious
appearance of the gingiva by covering the root
surface to the height similar to the adjacent tooth and
to increase the zone of attached gingiva.
{106}
Autogenous Connective Tissue Graft
(ACTG)
Following local anesthesia with 2% lidocaine,
epinephrine 1:100,000, the exposed root surface was
thoroughly planed and scaled first with ultrasonic
instrument and then manually with the use of hand
instruments to remove plaque, accretions and root
surface irregularities. The exposed root surface was
then conditioned with a saturated solution of
tetracycline-HCL for 2 minutes (100mg tetracyclineHCL/1 ml of sterile distilled water). A sulcular
incision was made at both sides through the bottom
of the crevice allowing dissection of the papillae
adjacent to the site of recession defect until the
proximal line angles of the adjacent teeth. Afterwards
two vertical releasing incisions were placed both
mesial and distal involving adjacent teeth, distant
from the main defect. A full thickness flap providing
a broader surgical bed was elevated in an apical
direction exposing the alveolar plate of bone until the
mucogingival junction (MGJ). The periosteum was
released and blunt dissection into the vestibular lining
mucosa was performed to eliminate tension to help
re-position the flap coronal at the level of CEJ. The
interdental papilla of the adjacent teeth were not
involved (Fig 2).
The donor site for the sub-epithelial connective tissue
graft was the palate in the bicuspid region of the same
subject (Fig 3). Donor palatal tissue was harvested in
the following way: a horizontal incision was placed
in the palate 2 to 3 mm from the free gingival margin,
and two parallel internal vertical incisions, one
superficial and one deep, were made and connected
mesially and distally. The underlying connective
tissue was released at its base and removed (Fig 4).
The wound was closed with simple interrupted 3-0
silk sutures. The donor site on the palate healed by
primary intention after two week of suture removal.
The graft was shaped to fit the recipient site and
secured to the wound bed (Fig 5) with a continuous
sling suture using 5-0 vicryl material to the papilla on
either side of the graft. Silk sutures were removed
after 15 days; visible portions of the vicryl suture
were removed after 3 weeks.
{107}
Postsurgical Care
Patient was instructed to avoid trauma and to
discontinue tooth brushing at the surgical site during
the first 15 days. Patient was instructed to use 0.12%
chlorhexidinedigluconate solution rinse for 60
seconds twice daily for 2 weeks. After 15 days, a
modified brushing technique was advised in order to
minimize apically directed trauma to the soft tissue
around the surgical site. Throughout the treatment,
recall visits for prophylaxis treatment were arranged
at 1, 3, 5, 8, 12, 16 and 32 weeks.
Healing was uneventful. At 2nd week, the gingiva at
the surgical site was still edematous (Fig 6). Only
erythema could be observed along the border of
attached gingiva which improved at 8th week of
follow-up. At 9 months postoperatively, the amount
of attached gingiva was approximately 3 mm, and the
gingiva was firmly attached. Probing depth at the mid
buccal site was less than 1 mm and the free gingival
margin was located less than 1 mm apically to the
apical border of the CEJ (Fig 7).
Discussion
This case report evaluated the treatment of localized
gingival recession by using palatal connective tissue
graft for the treatment of Class II Miller recession.
The present clinical result is encouraging and
indicates significant coverage of the exposed root
with the palatal connective tissue graft that has
provided restoration of clinical attachment. Overall
surgical procedure was aimed to reduce any risks
involved with no harmful events in the healing
process along with patient comfort. The connective
tissue graft for the restoration of root defect was
harvested from the palate of the same subject.
Horizontal incisions were placed in the palatal tissue
with two parallel vertical incisions along each side of
the horizontal incision to remove adequate tissue
from the underlying connective tissue. The incisions
were placed to ensure primary intention healing and
comfort for the patient.
Multiple factors can effect the degree of root
coverage including, biocompatibility of root surface,
sufficient vascularization of the surgical bed, surgical
manipulation, tissue width and ideal plaque control
(12). Meticulous root planing on the exposed root
surface was performed with the use of hand
instruments to remove plaque and accretions and
further increasing the surface biocompatibility.
Special care was taken to prepare recipient surgical
bed. Sutures were performed without stretching the
graft tissue, preventing the displacement of graft
without tension, thereby avoiding impaired
vascularization. The grafts were also compressed to
promote the tensile strength and stability of the
wound.
Coronally advanced flaps (CAF) with or without
enamel matrix derivatives have been recommended
as an alternative to CTG in the management of Class
I & II recession lesions. Nemcovsky et al, (13)
compared the clinical outcome of CAF and CTG in
the management of recession defects, concluding that
CTG was superior to CAF in the percentage of
coverage and increase in width of keratinized tissue.
{108}
In addition, soft tissue allografts have been used as an
alternate to autogenous CTG to provide root coverage
without the need of a second surgical site intra-orally
(14).However CTG additional increases the gingival
tissue thickness and width of keratinized tissue, two
critical features, which warrant the use of connective
tissue graft over allografts (15).
Conclusion
This surgical technique aided complete root coverage
as well as improved the thickness of attached gingiva.
The interpretations made in the present case report
indicate that connective tissue graft can be a
successful treatment option in achieving soft tissue
root coverage and gain of clinical attachment in
Millers class II root defects.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.