From the Editor’s Desk

Dear Readers,

On behalf of, the Editorial Board and the Editorial Team of our journal, I would like to
wish all authors, patrons and readers a wonderful and prosperous year ahead.

With a thought that has been enduring in mind becomes real, it is truly an interesting and
exciting experience. Our journal continues to enjoy a pan India reach and also excellent
international presence. In the year that has gone by, our publications continued to maintain
a subscriber base that is unparalleled by any other journal.

I shall assure all our readers that our consistent efforts will be aimed toward increasing the
visibility, impact, editorial cycle time, citations and the overall quality of our journals. We
very much look forward to strengthening the reputation of our publications, and we want
to attract more higher-quality submissions. I hope our readers and patrons share a similar
vision, and we look forward to a productive, challenging and successful year ahead. In the
spirit of continuous improvement, any constructive input on streamlining our processes
is very welcome.

Dr. Bhagwant Singh

Editor

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 Council Members APDF/APRO
Executive Officers (2018-2019)
President Dr Fernando Fernandez (Philippines)
President Elect Dr Cheol- Sooo Kim (Korea)
Secretary General Dr Oliver Hennedige (Singapore)
Chairman College Dr Jeffrey Y S Tsang, MBE (Hong Kong)
Treasurer Dr Yang Chun-Chieh (Chinese Taipei)

Council Officers (2018-2019)

Vice Presidents Dr Asif Arain (Pakistan)
Vice Presidents Prof Chia Tze Kao (Chinese Taipei)
Vice Presidents Dr Seung-Mok Na (Korea)
Vice Presidents Dr Carlos Buendia (Philippines)
Vice Presidents Dr Kenny Lau (Hong Kong)

Imm Past President Dr Cristina Antonio (Macau)

Editor Dr Bhagwant Singh (India)
Chairman, Dental Education Commission Dr Mark Villalobos (Philippines)
Chairman, Oral Diseases Commission Dr Mahmood Shah (Pakistan)
Chairman, Dental Public Health Dr Lin-Yang Chi (Chinese Taipei)
Chairman, General Dental Practice Dr Sudin Shakya (Nepal)
Chairman, Defence Forces Dentistry Air Vice Marshall (Retired) Dr A M B Amunugama (Sri Lanka)

ICCDE Board Members

President Dr Jeffrey Y S Tsang
Executive Director Dr Oliver Hennedige
Vice-President Dr Cristina Antonio
Prof Dr S M Balaji
Prof Dr Amish Mehta
Dr Sudin Shakya
Dr Kuan Chee Keong
Dr Century Tsang
Finance Director Dr Yang Chun Chieh
Editor Dr Bhagwant Singh
Board of Directors Dr Asif Niaz Arain
Dr Hermogenes P Villareal
Dr Mahmood Shah
Dr Fernando “Andy” Fernandez
Dr S P Aggarwal
Dr Floren Ly
Dr Roberto M Tajonera
Dr Mui Sau Fung Michael
Dr Chan Chi Chun Andrew
Dr Ritika Arora
Dr Anusak Sintapnont
Dr Saurabh Arora
Dr Vikash J. Singh
Dr Kelvin Chuan Hee Chye
Dr Hilary W.M. Cooray
Regent For South Asia Dr Bhagwant Singh
Regent For East Asia Prof. Allen Ming-Lun Hsu
Regent For Middle East Dr Aisha Sultan Alsuwaidi
Regent For South East Asia Dr Mirza Zamzami Djasri M A
Regent for Australiasia Dr Patrick J Colgan

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 ASIA PACIFIC DENTAL JOURNAL
Editor
Dr. Bhagwant Singh
A-6, Gurudwara Shaheedan Road, Model Town Ludhiana (Pb.), India – 141002
M. +91-98142-45608
Email : dr.bs_ldh@rediffmail.com

Associate Editors
Dr. Saurabh Arora Dr. Amish Mehta Dr. Vikas Jindal

Assistant Editors
Dr. Ravneet Arora Dr. Pallvi Goomer Dr. Arpit Sikri

Advisory Editorial Board

Dr. Aisha Sultan (U.A.E.) Dr. Oliver Hennedige (Singapore) Lt. Gen. Vimal Arora (India)
Jeffre Y.S. Tasang (Hong Kong) Dr. Anil Kohli (India) Dr. Keki Mistry (India)
Dr. Boy Vallareal (Philippines) Dr. James Lee (Chinese Taipei) Dr. Arturo De Leon (Philippines)

Community Dentistry Esthetic Dentistry Oral Medicine

Dr. R.K. Bali Dr. Sandesh Mayekar Dr. S.Y. Rajan
Dr. Ajith Krishnan Dr. Rumpa Wig Dr. Soheyl Sheikh
Dr. Ankur Singh (Australia) Dr. Sushant Umre Dr. Ankur Aggarwal
Dr. Sanjeet S. Risam
Pedodontics Periodontics
Dr. S.G. Damle Dr. Arunachalam Orthodontics
Dr. I.K.Pandit Dr. Ritika Arora Dr. D.N. Kapoor
Dr. Neru Singh Dr. Pradeep Shukla Dr. Krishna Nayak
Dr. Nikhil Sivastava Dr. Mayur Kaushik Dr. O.P. Kharbanda
Dr. Vivek Gaurav Dr. Chandresh Shukla
Gen. Dentistry Dr. Diki Tsering Lasquite (Philippines)
Conservative Dentistry Dr. Asif Niaz Arian Dr. Mauricio Gonzalez Balut (Mexico)
Dr. Vimal Sikri Dr. Christina Antonio Dr. Anand Marya (Philippines)
Dr. Rajiv Bali Dr. Anwar Saeed
Dr. Parvin Kumar Dr. Sudin Shakya Oral Pathology
Dr. Jaidev Singh Dhillon Dr. Amar Singh Dr. R.M. Mathur
Dr. Vijita Mehta Dr. K.S. Ghai Dr. Ish Paul Singh
Dr. Nikhil Bahuguna Dr. Vivek Vij (New York)
Oral Surgery
Dr. R. Vemareddy Dr. Shikha Kanotra (Boston)
Dr. S.P.S. Sodhi
Dr. Sachin Dev Mehta Dr. Anureet Dhillon
Dr. Vimal Kalia
Dr. Sukhpash Sandhu
Dr. Rahul Thakkur
Prosthodontics
Dr. Puneet Girdhar
Implants Dr. Mahesh Verma
Dr. Amreen Kaur
Dr. Sanjay Kalra Dr. Padmanabhan
Dr. S.P. Aggarwal Dr. Himanshu Aeran Allied Medical Sciences
Dr. Minas Leventis (Greece) Dr. Ramanpreet Ranauda Dr. L.S. Chawla (Medicine)
Dr. Rohan Sikka Dr. Rajesh Bhanot Dr. Robert Patricia (Dermatologist, Sweden)
Dr. Andrea Mastrorosa (New York) Dr. Manu Rathee Dr. Rohan Arora (Neurologist, USA)
Dr. Sunil Arora Dr. Carl Brown (Cardiologist, Canada)
Dr. R.S. Bhatia (Pulmonologist)

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 Contents

Two Phase Treatment for the correction of Skeletal Class II Malocclusion – A Case Report 1
Prof. (Dr.) U.S. Krishna Nayak, Dr. Rajshekhar Banerjee, Dr. Megha Parikh, Dr. Adarsh N.K.,
Dr. Harshit Atul Kumar, Dr Upasak Mukherjee 1

Changing face of history-virtual anthropology 4

Dr Saurabh Arora, Dr Ravneet Arora

Shear bond strength assessment of composite – tooth interface following caries excavation by different 7
chemomechanical caries removal agents
Dr. Jyotika Grover

Ill effects of technology: dehiscence encountered following laser depigmentation: A case report 11
Dr Anamika Sharma

Recent trends in regenerative dentistry: A review 14

Dr. Jyotsana Sikri and Dr. Arpit Sikri

Biofilms in endodontics 24
Dr. Nikenlemla, Dr. Naman Vaidya, Dr. Rucha Shinde, Dr. Swati Bali

Mandibular canine index 35

Dr Ravneet Arora, Dr Saurabh Arora

A Paradigm shift from micro to nano in dentistry 37

Dr. Atulana Roy and Dr. Arpit Sikri

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 Two Phase Treatment for the correction of Skeletal
Class II Malocclusion – A Case Report
Prof. (Dr.) U.S. Krishna Nayak, Dr. Rajshekhar Banerjee, Dr. Megha Parikh,
Dr. Adarsh N.K., Dr. Harshit Atul Kumar, Dr Upasak Mukherjee

Case Report: Diagnosis:

A 12 year old male patient presented with a chief complaint of From clinical and cephalometric analysis, the case was
forwardly placed upper front teeth. diagnosed to be a case of

Extraoral Examination 1. Skeletal and Dental Class II with a retrognathic

mandible and a normal maxilla
Patient had a Brachycephalic skull type and a Mesoprosopic
facial type with a convex facial profile, posterior facial 2. Horizontal growth pattern
divergence, Class II relation of apical bases and a flat 3. Proclined Maxillary and
mandibular plane angle. [Figures 1A-1E] Mandibular Incisors
4. Generalised upper and lower
anterior spacing
5. Procumbent lips
Visual Treatment Objective
The Visual Treatment Objective
(VTO) was positive. Hence a
treatment plan involving mandibular
advancement using a functional
appliance was considered. (Figure 3) Figure 3: Visual
Treatment Objective
(VTO)
Treatment Objectives:
1. To achieve Class I skeletal relation.
2. To achieve Class I molar and canine relation
3. Closure of spaces
Figure 1: Extraoral Photographs 4. Uprighting of the anteriors
Intraoral Findings 5. To achieve harmonious soft tissue profile.
Patient had a Class II molar and canine relation with Treatment Plan:
generalised spacing. An overjet of 10 mm and overbite of A Two=Phase treatment was considered to achieve the
5mm was present. Distolingual rotation with respect to 14 and treatment objectives
24 was also present. (Figures 2A-2D)
1. Phase I: Forward repositioning of the mandible by Twin
Block with incisor capping
2. Phase II: Fixed orthodontic therapy with 0.022 Slot
MBT prescription
Closure of Anterior spacing
Finishing and Detailing.
Phase I Therapy
The Twin Block functional appliance consists two bite
blocks, upper and lower (twin-block) with inclined planes
interlocking at 70 degrees. The interlocking of the two blocks
positions the mandible in a protrusive manner.1 It is designed
Figure 2: Intraoral Photographs

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 1

to be worn full time. The appliance works by transmitting
occlusal forces to the occlusal inclined planes covering the
posterior teeth.2 It induces supplementary lengthening of the
mandible by stimulating increased growth at the condylar
cartilage.3 For children with skeletal Class II discrepancy, a
two phase therapy can be beneficial as skeletal growth can
be modified and subsequent fixed appliance therapy can be
simplified when compared to a one phase treatment.4 Not Figure 6: Fixed Orthodontic Therapy
addressing the skeletal discrepancy in childhood may result
in the need arising for surgical treatment later in life.
The twin block appliance was cemented in place and kept for
8 months. The mandibular incisors were capped by extending
the acrylic of the twin block over their incisal edges onto
the buccal surface, thereby preventing them from further
proclination. (Figure 4) Figure 7: Anterior Space closure and Class II elastics

Figure 8: Intrusion Utility Arch

Following this, an Intrusion Utility Arch was attached from

Figure 4: Twin Block with Incisor Capping
Occlusion at the end of Functional Therapy (Twin Block
Appliance)
Post Twin Block therapy, the mandibular arch was visibly
placed forward. A Lateral Open Bite was present. (Figure 5)
the auxiliary tubes of the maxillary molar tubes and was used
to intrude 12-22. Class II elastics were continued in this stage
as well. (Figure 8)
Subsequently 0.019x0.025” SS wires were engaged in both
upper and lower arches. A Reverse Curve of Spee was
incorporated in the mandibular archwire.
Anterior crown build-ups were done utilizing the spacings
remaining at the end of Fixed Orthodontic therapy.

Phase II Therapy: Fixed Orthodontic Therapy

MBT 0.022” slot pre-adjusted edgewise appliance was used
for the fixed orthodontic therapy. Initial levelling and aligning
was done using NiTi wires. (Figure 6A and 6B) The wires
Figure 9: Post treatment
were progressively stepped up to 0.017x0.025” Stainless
Steel. Class II elastics were engaged. The anterior space
closures were done using E-Chains from 13 to 23 and 33 to
43. (Figure 7A and B)
2 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
 the fact that full time wear of the appliance was essential to
elicit its maximum therapeutic effect.7

References.
Rondeau B. Twin Block appliance. Part II. The Functional
orthodontist. 1996;13(2):4-10.
Clark W. Twin block functional therapy. JP Medical Ltd; 2014 Sep
30.
Baccetti T, Franchi L, Toth LR, McNamara Jr JA. Treatment timing
for Twin-block therapy. American Journal of Orthodontics and
Figure 10: Intraoral - Pre and Post treatment Dentofacial Orthopedics. 2000 Aug 1;118(2):159-70.
Tulloch JC, Phillips C, Proffit WR. Benefit of early Class II
treatment: progress report of a two-phase randomized clinical
trial. American Journal of Orthodontics and Dentofacial
Orthopedics. 1998 Jan 1;113(1):62-74.
Gianelly AA. One-phase versus two-phase treatment. American
Journal of Orthodontics and Dentofacial Orthopedics. 1995
Nov 1;108(5):556-9.
McNamara Jr JA. Neuromuscular and skeletal adaptations to altered
function in the orofacial region. Am J Orthod 1973;64:578-606.
Aggarwal P, Kharbanda OP, Mathur R, Duggal R, Parkash H. Muscle
response to the twin-block appliance: an electromyographic
study of the masseter and anterior temporal muscles. American
journal of orthodontics and dentofacial orthopedics. 1999 Oct
1;116(4):405-14.

Prof. (Dr.) U.S. Krishna Nayak

Principal and Professor
Dept. of Orthodontics and Dentofacial Orthopaedics, A.B.
Comparison of Pre and Post treatment - Intraoral Shetty Memorial Institute of Dental sciences, Mangalore

Comparison of Pre and Post treatment - Extraoral Dr. Rajshekhar Banerjee

Post Graduate Student
Summary Dept. of Orthodontics and Dentofacial Orthopaedics, A.B.
The current case presented at a stage when the patient was Shetty Memorial Institute of Dental sciences, Mangalore
still in the growing phase and the remaining growth could
Dr. Megha Parikh
be harnessed. Skeletal discrepancies such as this with a
Ex-Post Graduate Student
mandibular retrognathism are well indicated for a two-phase
Dept. of Orthodontics and Dentofacial Orthopaedics, A.B.
therapy.5 The first phase of the therapy not only substantially
Shetty Memorial Institute of Dental sciences, Mangalore
minimizes the skeletal problem, but also reduces the
complexity of the phase of the fixed orthodontic treatment. Dr. Adarsh N.K.
Further, failure to correct the skeletal discrepancy during the Post Graduate Student
time when growth is still remaining will warrant a surgical Dept. of Orthodontics and Dentofacial Orthopaedics, A.B.
correction of the problem. The option of orthognathic surgery Shetty Memorial Institute of Dental sciences, Mangalore
was presented more often in the cases of children who did not
undergo early treatment.4 Dr. Harshit Atul Kumar
Post Graduate Student
The mode of action of functional therapy is linked to Dept. of Orthodontics and Dentofacial Orthopaedics, A.B.
neuromuscular and skeletal adaptations to altered function Shetty Memorial Institute of Dental sciences, Mangalore
in the orofacial region.6 Aggarwal, in a study in 1999 studied
the muscle response to twin block therapy and concluded Dr Upasak Mukherjee
that the main force for Twin-block treatment was provided Post graduate student
through increased active tension in the stretched muscles and Dept of Orthodontics,AB Shetty Memorial Institute of
initiation of myotatic reflex activity and not through passive Dental Sciences
tension (viscoelastic properties) of jaw muscles. It reaffirmed

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 3

 Changing face of history-virtual anthropology
Dr Saurabh Arora, Dr Ravneet Arora
Cadavers speak their own language. Moving back in history
human identification was one of the most challenging subjects
that man had confronted. The concept of identity, with few
significant variations, is the same as the assertion of Alves1
that identity is a set of physical characteristics, functional or
psychic, normal or pathological, that define an individual.
The determination of race, sex, age, and stature of the bone
gives valuable information in establishing the identity of a
person.
Another skill that is receiving increasing attention is the
virtual anthropology
Early methods used were
 Anthropometry; ‘measurement of mankind’
 Osteometrics; measurements of skeleton
 Craniometrics; measurements of skull
 Anthroposcopy: visual differences
Now Virtual anthropology is becoming a fundamental tool
for anthropological analysis, it allows researchers to deal
with problems that could not be resolved using traditional
anthropological approaches without compromising the
integrity of the physical remains (i.e., analysis of mummies,
reconstruction of deformed fossils, etc.). Models of the
physical object allow for virtual manipulation, simulation, and
bone sectioning, etc., in a virtual space, therefore preserving
the original object from invasive procedures.
Facial imaging technologies for virtual antropology
Imaging modalities for clinical evaluation of the face, such
as photographs and two-dimensional radiographic films
(used since 1931) were developed decades ago and are still
in mainstream clinical use. However, the information they
provide is limited in perspective, accuracy, and contains
information voids. For these reasons, in the last decades,
threedimensional techniques such as 3D CT, laser surface
scanning, photogrammetry (conversion of photographs taken
from different views into 3D models), Moire’ stripes18, and
Computer Assisted Design (CAD) manipulation of these
models have been explored.5
CT Scans: Computed tomography (CT scan) has much of
its history in general medicine while its use in craniofacial
assessment is more recent. In this area, the bulk of the research
work is focused upon bony cranial landmarks. Previous
work reported the use of 3D CT for craniofacial surgical
planning and comprehensive assessment. Richtsmeier and her
research group6 developed mathematical tools such as EDMA
(Euclidean Distance Matrix Analysis) to assess asymmetry
4 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
in human skulls, detection of influencial landmarks7and
confidence intervals8.
Laser facial scanning: Technologies for generating a
3-dimensional model of a human face with registered texture
include laser scanning and visible light techniques. The laser
scanners produce a detailed model Researchers have explored
the use of laser surface scanning for assessment of facial
asymmetry9. The authors divided the face in different regions
and then classified the pre-surgical and post-surgical areas
according to different surface type primitives: valley, ridge,
saddle surface, etc. The quantitative changes per region are
expressed in terms of area size changes and their movement
on the face9.
Stereo-photogrammetry: In 1960 dot stereograms and the
idea that stereoscopic vision is a cooperative process were
introduced10. A algorithm for stereo reconstruction followed.
Stereo-photogrammetry has also been used to find the optimal
plane of reference for assessment of craniofacial anomalies
Commercial visible-light imaging systems: Fixed viewpoint
depth maps are created from stereo-photogrammetry systems
(Geometrix’s Face 200 and 800) and structured-light camera
systems (such as Eyetronics, 3DMD and Inspeck requiring a
slide projector and one or more cameras). To produce a full
face model (from ear to ear) with these systems, two or three
depth maps are obtained for a subject from varying view
points (e.g., left-side, right-side, and frontal) and stitched
together with manual assistance. The only commercially
available system that acquires an ear-to-ear model is Face
1200 from Geometrix with 12 cameras. Given the current
state, a fast, efficient, reliable, non-invasive solution to 3-D
facial image acquisition would be a very significant step
forward. A system such as this would eliminate many of the
barriers for clinicians to obtain and use such as system. Today,
no 3-D systems are in common clinical use, while traditional
photography is the standard.
Cranial form analysis
Landmarks have been used for over a century by
anthropometrists interested in quantifying cranial variation.
A new field, morphometrics, has grown around the statistical
analysis of shape and size for comparison of biological shapes11
A great body of work in craniofacial anthropometry is that of
Farkas12 who established a database of anthropometric norms
by measuring and comparing more than 100 dimensions
(linear, angular and surface contour’s) and proportions
in hundreds of people over a period of many years. These
measurements include 47 landmark points to describe the
face (Figure 1 shows some of the Farkas’ landmarks)
 Figure 1: Subset of Farkas’s anthropometric landmarks (frontal and side picture of the mannequin).
Farkas’s inventory of facial measurements has been used in
computer graphics to automatically create new “plausible”
computer graphic faces12.
Steps for reconstruction
1. Click photograph and digitize it using digital camera
2. Place digitized markers on anthropometric landmarks
• Head: g – glabella, tr – trichion, ft – frontotemporale.
• Face: zy – zygion, go – gonion, sl – sublabiale, pg–
pogonion, gn – gnathion (or menton, not visible), cdl –
condylion laterale.
• Orbits: en – endocanthion, ex – exocanthion.
• Nose: n – nasion, prn – pronasale, sn – subnasale, sbal –
sub-alare (sbal’), ac – alar curvature (ac’).
• Lips and mouth: cph – crista philtri (cph’), ch –
cheilion (ch’), sto – stomion, ls – labiale superius, li–
labialeinferius.
• Ears: obi – otobasion inferius, obs – otobasion superius,
sa – superaurale, sba – subaurale, pa – postaurale,pra –
preaurale. 12
3. Depth of skin that overlays the skull is estimated.
4. Small pegs are used as facial depth indicators & are fixed
into the skull.
5. The mimic muscles are made of plastilin or clay, eyes are
of marble & the nose is formed from paraffin or wax.
6. Started with 20-35 tissue layers usually, scattered all over
the face. Main heavily concentrated depths are situated
around the mouth & in between the eyes
7. Work on the eyes, mouth, ears, nose, chin, jaws & cheeks
is now started.
8. Next a mould from clay head is made using plaster of
paris
9. Muscles are approximated by noting the shape & size
of certain facial bones. Shaping & fixing of each muscle
onto the skull in it’s place is important criteria.
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
10. The final step is to cover the clay muscles with a layer
of clay skin ,which is smoothened over such that it
resembles the real skin.
11. Color :
12. - Hair, skin & eye color are added by borrowing the
physical features of a living person of similar age, racial
qualities & built by a process called “3-D mapping.”
F.A.C.E.S & C.A.R.E Softwares.
Conclusion
Forensic arts has to deal with many ambiguous variables (such
as the shape of the eyes, the lips and the nose), cranio-facial
reconstruction cannot claim to provide with absolute certainty
the look of the personage. On the other hand, we can assume
that facial reconstruction based on forensic procedures is the
most scientific approach to obtain an approximated aspect of
the face, at least regarding the overall shape.
References
Alves ES – Medicina Legal E Deontologia. Curitiba, Ed. Do Autor,
1965.
Aulsebrook AW, Iscan MY, Slabbert JH and Becker P. Superimposition
and reconstruction in forensic facial identification - A survey:
Forensic Sci Int. 1995; 75: 101-120.
Phillips VM, Rosendorff S, Scholtz HJ. Identification of a suicide
victim by facial reconstruction: Forensic Odontostomatol.
1996; 14: 34-38.
Vanezis M, Vanezis P. Cranio-facial reconstruction in forensic
identification - Historical development and a review of current
practice. Med Sci Law. 2000; 40 : 97- 205.
T. Kawai, N. Natsume, H. Shibata, and T. Yamamoto, “Three-
dimensional analysis of facial morphology using moire
stripes.Part I. Methods,” Int J Oral Maxillofac Surg, 19, 356-358,
1990.
S. Lele and J. T. Richtsmeier, “Euclidean Distance matrix analysis:
a coordinate-free approach for comparing biological shapes
using landmark data,” Am J Phys Anthropol, 86, 415-427, 1991.
S. Lele and J. T. Richtsmeier, “On comparing biological shapes-
detection of influential landmarks.,” Am J Phys Anthropol,
5
S. Lele and J. T. Richtsmeier, “Euclidean Distance Matrix Analysis:
confidence intervals for form and growth comparison.Amer. J. Dr Saurabh Arora
Phys. Anthropol. 98: (1) 73-86, 1995 Reader
J. P. Moss, A. Linney, S. Grindrod, A. SR, and C. JS, “Three- Department of Conservative and Endodontics
dimensional visualization of the face and skull using Vananchal Dèntal College and Hospital
computerized tomography and laser scanning techniques,” Garwa, Jharkhand
European Journal of Orthodontics, 9, 247-53, 1989.
Dr Ravneet Arora
D. Marr and T. A. Poggio. Cooperative Computation of Stereo
Disparity. Science, 194[4262], 283-287, 197 Reader
Department of Oral Medicine and Radiology
F. Rohlf, “Morphometrics,” Annual Rev Ecol Syst, 21, 299-316,
1990.
Vananchal Dèntal College and Hospital
Garwa, Jharkhand
L.Farkas,Anthropometry of the Head and Face, Raven Press, New
York, 1994.

6 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 Shear bond strength assessment of composite – tooth
interface following caries excavation by different
chemomechanical caries removal agents
Dr. Jyotika Grover

ABSTRACT
Background: Chemomechanical agents are routinely used in the excavation of caries in primary teeth. However, to
achieve clinical success of the final restoration, the bond strength of the affected dentin to the composite is essential.
Aim: The purpose of this study was to assess the shear bond strength between composite and caries affected dentin
after caries excavation by different chemomechanical caries removal agents. Settings and Design: Thirty human primary
molars with moderate caries were selected and randomly divided into 3 groups according to the CMCR agent used for
caries excavation; Group I Carisolv, Group II Cariecare and Group III Papacarie. The teeth were then restored with light
cured microhybrid composite and sectioned at tooth restoration interface for the assessment of shear bond strength using
universal testing machine. Results: The observations were put to descriptive statistics to find out the mean and standard
deviation of all 3 Groups. Further, independent t-test was used for intergroup comparisons. Conclusion: Maximum shear
bond strength was found in Group II (Cariecare - 15.21 + 4.45 N/mm2) while minimum shear bond strength was observed
in Group I (Carisolv). There was statistically significant difference in shear bond strength between Group I and Group III.
Keywords: Cariecare, Papacarie, Carisolv, Shear bond strength.

Introduction Several restorative materials have been compared (nanohybrid,

The peculiarity of pediatric dentistry is that it focuses on
eradicating anxiety, pain, and fear from the child towards
dental treatment and inspiring the child towards it by behavior
modification and by providing comfort and relief environment
in dental office.
Traditional methods which were based on the ideology of
extension for prevention have been shifted to minimally
invasive technique due to which less tooth cutting is achieved.1
Several new technologies came into light which supported
minimal intervention technique such as ozone therapy,
ultrasonic instrumentation, lasers, air abrasions and
chemomechanical caries removal agents. Out of all,
chemomechanical caries removal agent fitted best for caries
removal without any excessive tooth cutting and preventing
from causing any anxiety or fear for dental treatments in
patient.2
Carisolv, Papacarie and Cariecare are some of the
chemomechanical caries removal agents used to excavate
unmineralized infected dentin which is rich in bacteria. These
also help in removal of smear layer of varying degree, leaving
behind affected dentin which is the remineralizable.3-5
The presence of smear layer has been known to act as a
barrier between restorative material and prepared cavity
compromising the bond strength as it prevents the formation
of resin tags. The type of restorative material used is another
factor which contributes to bond strength with the prepared
cavity walls.6
microhybrid, and microfilled), out of which microhybrid resin
based composite demonstrated highest shear bond strength.7
However the literature is scarce regarding the studies on the
bonding of resin composite (microhybrid) to affected dentin
following caries removal through various chemomechanical
caries removal agents. Hence, the present study was aimed
to evaluate and compare shear bond strength of new hybrid
composite to affected dentin following caries excavation with
Carisolv, Cariecare and Papacarie.
Methodology
A total of 90 extracted human primary teeth (samples) with
moderate caries were included in the study and stored in
deionized water with 0.1% thymol. Roots were removed
perpendicular to the long axis of the tooth at CEJ with a
0.3mm thick diamond blade. The crowns were washed in
distilled water and dried with a triplex syringe.
The collected samples were equally and randomly divided
into 3 groups according to CMCR agents were to be used for
caries excavation.
a. GROUP 1 : 30 samples, caries excavation using Carisolv
b. GROUP 2 : 30 samples, caries excavation using Cariecare
c. GROUP 3 : 30 samples, caries excavation using Papacarie
In group I (Carisolv), caries was excavated using instruments
provided by manufacturer. Required amount of gel was
dispensed into dappen dish and was applied to carious lesion
using multistar instrument and left it over for 30 seconds
for chemical process to soften the caries, which was then

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 7

excavated with the multi star instrument and the process was
repeated until the solution remained clear without turning
cloudy. After completion of excavation, the surface was
wiped out with a moist cotton pellet.
In Group II (Cariecare), gel was applied directly into cavity
using disposable applicator tip; soon gel changed the color in
the affected area. After 1 minute using sharp spoon excavator
the gel along with dissolved caries was removed. The
procedure was repeated until caries was completely removed.
In Group III (Papacarie), the gel was dispensed in dappen
dish and was dispersed over the carious lesion using spoon
excavator and was left in place for 30 seconds undisturbed.
When gel became cloudy, without applying pressure it was
removed gently by scraping with the spoon excavator. The
removal of carious dentin was continued until the gel was no
longer cloudy. The gel was then removed and the cavity was
wiped with a moistened cotton pellet and rinsed.
After excavation of caries from each sample, the crowns
were sectioned parallel to the occlusal plane to provide a flat
coronal dentinal surface and each sample was then segmented
vertically in buccolingual and mesiodistal directions to get 4
segments of each sample, using diamond disc (Fig 1). These
segments were mounted on dental stone for convenient
handling.
All the segments were stored in 0.1% Thymol in deionized
water until preparation for bonding. After dentinal etching
with 37% phosphoric acid for 10 seconds (Scotchbond; 3M
ESPE), washing and minimal drying, an adhesive dentinal
bonding agent, 3M ESPE Single Bond (SB; 3M ESPE, St
Paul, Minn) was applied to all prepared areas of segments
according to the manufacturer’s directions and restored with
resin composite (GC solare x microfine hybrid resin, A2
shade).
A PVC tube (internal diameter= 1 mm, 2 mm high) was
placed on the restored composite surface and light-cured
together with the adhesive. The tube was filled with resin
composite (GC solare x microfine hybrid resin, A2 shade)
and light-cured for 40 seconds. After that the tube was cut
Fig. 3 Fig. 4
Fig. 3, 4 and 5: Comparison of Shear bond strength (N/mm2) using independent t-test.
8 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
to remove with an 11 no. scalpel blade, leaving a 2 mm high
resin composite rod (diameter= 1 mm) bonded on the restored
composite. All segments were then stored in tap water at 37°C
for 12 hours prior to testing.
The bonded interface was subjected to shear bond strength
testing in a universal testing machine. A metal intender was
used to deliver a force parallel to the bonded surface at a
crosshead speed of 4.0 mm/minute (Fig 2).The microshear
bond strength value in megapascals (MPa) at fracture site was
calculated for each segment using the formula:
Microshear bond strength (MPa) = Shear force (N)/Cross-
sectional area (mm^)
Results
The 30 segments of each Group (I, II and III) were evaluated
for shear bond strength. The shear bond strength was found to
be highest in Group II (15.21 + 4.45) and was lowest in Group
I (12.88 + 3.20) but difference in shear bond strength amongst
groups was statistically not significant according to one way
ANOVA test.
When intergroup comparison was made using independent
t test (Table 1) between Groups I and II (Fig: 3), the shear
bond strength was found to be more in group II (Cariecare)
compared to group I (Carisolv) and the difference was
statistically significant (p= 0.023). When shearbond strength
between Group I and III were compared, the difference was
not statistically significant (p= 0.098) though the shear bond
strength of Group III (Papacarie) was more than Group I
(Carisolv) (Fig: 4). In intercomparison between Group III
and Group II (Fig: 5), the shear bond strength of Group II
(Cariecare) was more compared to Group III (Papacarie),
though here also the difference was statistically non significant
(p= 0.574).
Discussion
Frank carious lesions are restored with various esthetic and
non esthetic materials with varying degree of success and
failures but with the advent of adhesive dentistry, composites
have become material of choice owing to their esthetics,
Fig. 5
Table 1: Mean shear bond strength of microfilled hybrid composite to affected dentin following excavation using CMCR
agents.
Measure
No. of specimen tested
Mean microshear bond strength
(MPa) ± (SD)
P values:
Group I vs Group II
Group I vs Group III
Group II vs Group III
* Statistically significant
** Statistically non significant
strength and ease of restoring the teeth. Restorative material
which was used in this study was microfilled hybrid composite
material, due to its good strength, wear resistance and for
permitting excellent esthetics.
Complete excavation of infected dentin, moisture free
environment, proper isolation and restorative material having
good adhesion properties are some of the factors which
determine the success of restoration.8 Another important factor
that can affect bond strength is the presence of smear layer.
Whenever dentin is cut using hand or rotary instruments, the
mineralized tissues are not shredded or cleaved but shattered to
produce considerable quantities of debris. Much of this, made
up of very small particles of mineralized collagen matrix,
spread over the surface to form what is called the smear layer.
Smear layer consists of organic and hydroxyapatite particles
that cover dentin which interferes with adhesion between
bonding resin and underlying dentin.9
In our study, Cariecare showed highest shear bond strength
out of the 3 chemomechanical caries removal agents used.
Similar results were found in the study by Shehab FAHE
and El-Tekeya et al who found that shear bond strength after
excavating with Carisolv agents was less when compared with
other chemomechanical caries removal agent like Papacarie
and traditional techniques.10,11 The reason attributed was
that both Caricare and Papacarie contain an active ingredient
Papain which dissolves the infected dentin along with
complete removal of smear layer resulting in higher shear
bond strength.
When the shear bond strength of Carisolv and Papacarie were
compared, Papacarie showed better results. Similar results
were also seen in the studies done by Hamama HH et al12 and
Viral PM et al.13 The better shear bond strength of Papacarie
group could be explained by the fact that Papacarie has the
ability to remove complete smear layer with less marked
destruction to dentinal tubules resulting in better shear bond
strength.14 Papacarie also has an active ingredient, papain
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
Distribution of primary tooth dentin segments
Group 1: Group 2: Group 3:
Carisolv Cariecare Papacarie
30 30 30
12.88 + 3.20 15.21 + 4.45 14.56 + 4.46
0.023*
0.098**
0.574**
which acts only on damaged tissues due to the absence of
an antiplasmatic protease, alpha-1-antitrypsin, which hinders
its proteolytic action on the normal tissues. The absence
of alpha-1-antitrypsin in infected tissues allows Papain
to break down partially degraded molecules. It contains
Chloramine which acts as a disinfectant and softens the
carious dentin due to chlorination of the partially degraded
collagen because of which the smear layer is completely
removed. Jawa et al pointed out that due to thorough removal
of smear layer, highly irregular surface or high roughness is
achieved, providing a suitable surface for strong bonding with
restorative materials.14
Various other studies have shown that dentin surfaces
undergoing excavation by bur and Co2 laser result in a
surface characterized by crazing, undercuts, irregularities
and presence of smear layer which influence the strength
required for bonding of resin adhesion to prepared cavity.
Chemomechanical caries removal agents, used in the study
has been found effective in removing smear layer partially or
completely.15,16
Conclusions
Based on the results of present study, the following conclusions
were drawn:
1. All the 3 chemomechanical caries removal agents used in
the study; Carisolv, Cariecare and Papacarie were found
to be effective in removing infected carious dentin.
2. Shear bond strength was found to be maximum between
composite restoration and tooth dentin when caries was
excavated using Cariecare (Group II).
3. Minimum shear bond strength was observed between
composite restoration and tooth dentin when caries was
removed with Carisolv (Group I).
4. Caries excavation using Cariecare and Papacarie did not
result in any significant change in the shear bond strength
of composite restoration with tooth dentin.
9
However, further studies should be conducted using a larger Yazici AR, Atílla P, Ozgünaltay G, Müftüoglu S. In vitro comparison
sample size to evaluate the shear bond strength of composite of the efficacy of Carisolv and conventional rotary instrument
with caries affected dentin following excavation by various in caries removal. J Oral Rehabil. 2003 Dec;30(12):1177-82.
chemomechanical caries removal agents and to authenticate Moshonov J, Stabholz A, Bar-Hilel R and Peretz, B: Chemical
the results of the present study. analysis and surface morphology of enamel and dentin
following 9.6 micron CO2 laser irradiation versus high speed
References drilling. J Dent. 2005;33(5):427-32.
Bijle MNA, Patil S, Mumkekar SS, Arora N, Bhalla M, Murali
KV. Awareness of Dental Surgeons in Pune and Mumbai,
India, regarding Chemomechanical Caries Removal System. J
Contemp Dent Pract 2013;14(1):96-9.
Rajakumar S, Mungara J, Joseph E, Philip J, Guptha V, Mangalan
Pally SP. J Clin Pediatr Dent. 2013 Nov;38(1):23-6.
Shehab FAHE. Morphological and structural changes of dentin after
caries removal by different caries removal techniques and their
effect on the Shear bond strength to poly acid modified resin
composite. Cairo Dental Journal.2008 Jan;24 (I):99-110.
Corrêa FN, Filho LE, Rodrigues CR. Evaluation of residual dentin
after conventional and chemomechanical caries removal using
SEM. J Clin Pediatr Dent. 2008 Winter; 32(2):115-20.
Ramamoorthi S, Nivedhitha MS, Vanajassun PP. Effect of two
different chemomechanical caries removal agents on dentin
microhardness: An in vitro study. J Conserv Dent. 2013
Sep;16(5):429-33.
Violich DR, Chandler NP. The smear layer in endodontics - a review.
Int Endod J. 2010 Jan;43(1):2-15.
Moncada G, Angel P, Fernandez E, Alonso P, Martin J, Gordan VV.
Bond strength evaluation of nanohybrid resin-based composite
repair. Gen Dent. 2012 May-Jun;60(3):230-4.
Shono Y, Ogawa T, Terashita M, Carvalho RM, Pashley EL, Pashley
DH. Regional measurement of resin-dentin bonding as an array.
J Dent Res. 1999 Feb;78(2):699-705.
Yamada Y,  Kimura Y,  Hossain M,  Kinoshita JI,  Shimizu
Y, Matsumoto K. Caries removal with Carisolv system: criteria
evaluation and microleakage test. J Clin Pediatr Dent. 2005
Winter; 30(2):121-6.
Shehab FAHE. Morphological and structural changes of dentin after
caries removal by different caries removal techniques and their
effect on the Shear bond strength to poly acid modified resin
composite. Cairo Dental Journal.2008 Jan;24 (I):99-110.
El-Tekeya M, El-Habashy L, Mokhles N, El-Kimary E. Effectiveness
of 2 chemomechanical caries removal methods on residual
bacteria in dentin of primary teeth. Pediatr Dent. 2012 Jul-
Aug;34(4):325-30.
Hamama HH, Yiu CK, Burrow MF, King NM. Chemical,
morphological and microhardness changes of dentine
after chemomechanical caries removal. Aust Dent J. 2013
Sep;58(3):283-92.
Viral PM, Nagarathna C, Shakuntala BS. Chemomechanical Caries
Removal in Primary Molars : Evaluation of Marginal Leakage
and Shear Bond Strength in Bonded Restorations” - An  in
Vitro Study. J Clin Pediatr Dent. 2013 July;37(3):269-74.
Jawa D, Singh S, Somani R, Jaidka S, Sirkar K, Jaidka R. Comparative
evaluation of the efficacy of chemomechanical caries removal
agent (papacarie) and conventional method of caries removal:
An in vitro study. J Indian Soc Pedod Prev Dent 2010;28:73-7.

10 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 ILL EFFECTS OF TECHNOLOGY: DEHISCENCE ENCOUNTERED
FOLLOWING LASER DEPIGMENTATION: A CASE REPORT
Dr Anamika Sharma

ABSTRACT
Deformities of the alveolar process discovered during mucogingival procedures can present surgical dilemmas which
may seriously affect the outcome of treatment Fenestration and dehiscence are localized defects of the cortical bone which
covers the teeth. Etiologic factors include developmental anomalies, frenum attachments, orthodontic tooth movement,
periodontal and endodontic pathosis, trauma from occlusion, tooth size, and tooth position. The present report describes a
case of alveolar dehiscence in relation to maxillary canine encountered three months following diode laser depigmentation

INTRODUCTION: of pain (Fig 5).

An alveolar dehiscence denotes a lack of the facial or lingual
alveolar cortical plate resulting in a denuded root surface,
while an alveolar fenestration is a circumscribed defect
of the cortical plate which exposes the underlying root
surface, not involving the marginal bone1. Deformities of the
alveolar process can present surgical dilemmas which are
technically demanding and may seriously affect the outcome
of treatment.2
The overall prevalence ranges from 0.99 to 13.4% for
dehiscences and 0.23% to 16.9% for fenestrations. Elliott and
Bowers3 reported that alveolar dehiscences and fenestrations
were associated with 9.19% and 10.93%, respectively.
CASE REPORT:
A 25 year old male patient reported with the complaint of
dark coloured gums. Gingival depigmentation was performed
with diode laser in both maxillary and mandibular arches
in the intercanine region. Three months postoperatively,
the patient reported with pain in the attached gingiva of the
maxillary right lateral incisor and canine. On examination, a
bony sequestrum surrounded by erythema was observed in
the gingiva overlying the maxillary right lateral incisor and
canine. (Fig 1)
A submarginal incision was given with a 15 no.B.P.blade in
the attached gingiva extending from the maxillary right lateral
incisor to the maxillary right first premolar. A full thickness
flap was reflected to perform alveoloplasty for removal of
the bony sequestrum and reshaping of the underlying bone.
On removal of the sequestrum, an alveolar dehiscence was
found in relation to the maxillary right canine, measuring
upto 6 mm from the gingival margin (Fig 2). Alveoloplasty
was performed; the flap was repositioned and sutured with
5-0 black silk and postoperative instructions given (Fig 3).
Antibiotic and analgesic was prescribed for 5 days. Erythema
was absent one week postoperatively but slight pain was
reported (Fig 4). On one month follow up, the gingiva was
pink, firm and resilient with stippled appearance and absence
DISCUSSION:
Alveolar bone architecture may vary from patient to patient
in point of thickness, contour and configuration, and all
these variations may be both normal and healthy1. The cause
of these differences is the unique dependence between the
morphology of the alveolar process and the teeth. The bone
contour normally conforms to the prominence of the roots
with intervening vertical depressions that taper toward the
margin4.
Previous studies have reported the prevalence of alveolar
dehiscences and fenestrations in human skulls and autopsy
specimens from a variety of populations including Japanese4,
Bedouins5, Italians & Australians6, Mexican Indians7,
Egyptians1, Britons8 and South African Blacks9.
Clinical predictors of dehiscences and fenestrations have not
been well defined. A number of possible etiologic factors have
been examined, including developmental anomalies, frenum
attachments, orthodontic tooth movement, periodontal and
endodontic pathosis, trauma from occlusion, tooth size,
and tooth position2. Davies et al9found dehiscences and
fenestrations in 5.36% and 8.45% in teeth of 398 nineteenth
century British skulls. Dehiscences were most commonly
associated with mandibular canines and first premolars and
maxillary canines and first molars. Fenestrations were most
frequently associated with maxillary first molars. Edel6
evaluated 87 dry Bedouin jaws and found the prevalence
of dehiscences and fenestrations to be 4.40% and 9.70%,
respectively, in 990 teeth examined. Our patient presented a
dehiscence in the maxillary canine. Possible etiologic factor
for the existence of this defect may be the prominent root
of canine in combination with a thin alveolar bone plate.
This observation is consistent with previous reports by
Abdelmaleket al1 and Edel6.
Presence of the alveolar defect observed in our patient may
also be attributed to the use of laser beam deep into the
connective tissue in an attempt to remove the pigmented

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 11

 Figure 1. Preoperative Figure 2. Alveolar Dehiscence Seen on
Flap Reflection
Figure 4. 1 Week Postoperative
tissues completely. Also the soft tissues overlying the canine
region are thin, therefore laser ablation may have been
inadvertently carried out in close proximity of bone, leading
to necrosis and eventually sequestration of bone. Similar
findings were reported by Atsawasuwan et al11 in 4 cases of
gingival pigmentation treated with Nd:YAG laser.
Lost12 reported that in most cases the bone crest was found
to be about 3 mm from the position of the gingival margin;
however, in 14% of instances, the bone crest was observed
located more than 4 mm from the position of the pre-surgical
soft tissue margin, most often associated with mandibular
canines. Similarly, in our patient, the distance of crestal bone
from gingival margin was 6 mm, though no recession was
present over the canine.
Clinically, the intraoperative discovery of an alveolar
dehiscence or fenestration requires special consideration. If a
defect is unintentionally exposed, root instrumentation which
may remove radicular connective tissue fibers should be
avoided, the root surface should not be permitted to become
desiccated, and soft tissue coverage of the defect must be
ensured. The soft tissue used to cover these defects, whether
obtained by use of a free autogenous graft or mobilized soft
tissue flap, must have an adequate blood supply to overcome
the lack of perfusion from the avascular root surface. The
absence of crestal bone reduces support for the soft tissue flap
and may increase the likelihood of undesirable post-operative
gingival recession. Flaps must be carefully positioned and
sutured to optimally support the flap margin in the desired
position2.
12
Figure 3. Sutures Placed
Figure 5. 1 Month Postoperative
CONCLUSION:
Alveolar dehiscence is a defect which may be encountered
over the maxillary canine as an intraoperative discovery.
Possible etiologic factors include malpositioned tooth
with thin alveolar bone which may undergo necrosis and
eventually sequestration of bone by laser ablation carried
deep into connective tissue.
BIBLIOGRAPHY
AbdelmalekRG, Bissada NF. Incidence and distribution of alveolar
bone dehiscence and fenestration in dry human Egyptian jaws.
J Periodontol 1973;44:586-588.
Rupprecht RD, Horning GM, Nicoll BK and Cohen ME.
Prevalence of Dehiscences and Fenestrations in Modern
American Skulls. J Periodontol 2001;72:722-729.
Elliott JR, Bowers GM. Alveolar dehiscence and fenestration.
Periodontics 1963;1:245-248.
Nimigean VR, Nimigean V, Bencze MA, Dimcevici-Poesina
N, Cergan R, Moraru S. Alveolar bone dehiscences and
fenestrations: an anatomical study and review. Romanian
Journal of Morphology and Embryology2009, 50(3):391–397
Ezawa T, Sano H, Kaneko K, Huruma S, Fufikawa K, Murai
S. The correlation between the presence of dehiscence or
fenestration and the severity of tooth attrition in contemporary
dry Japanese adult skulls. Part I. Nihon UnivSch Dent
1987;29:27-34.
Edel A. Alveolar bone fenestrations and dehiscences in dry Bedouin
jaws. J ClinPeriodontol 1981; 8: 491-499.
Larato DC. Alveolar plate fenestrations and dehiscences of human
skull. Oral Surg Oral Med Oral Pathol1970;29: 816-819.
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
Davies RM, Downer MC, Hull PS, Lennon MA. Alveolar defects
in human skulls. J Clin Periodontol 1974; 1: 107-111.
Dr Anamika Sharma
Professor and HOD, Department of Periodontology,
Tal H. Alveolar dehiscence and fenestrae in dried South African
Subharti Dental College and Hospital, Meerut, U.P., India
Negro mandibles. Am J Phys Anthropol1983;61:173-179.
Email: prof_anamika@hotmail.com
Atsawasuwan P, Greethong K, Nimmanon V. Treatment of
gingival hyperpigmentation for esthetic purposes by Nd:YAG
laser: Report of 4 cases. J Periodontol 2000; 71: 315-321.
Lost C. Depth of alveolar bone dehiscences in relation to gingival
recessions.J Clin Periodontol 1984; 11: 583-589.

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 13

 RECENT TRENDS IN REGENERATIVE DENTISTRY: A REVIEW
Dr. Jyotsana Sikri and Dr. Arpit Sikri

ABSTRACT
Although humanmouth benefits fromremarkable mechanical properties, it is very susceptible to traumatic damages,
exposure to microbial attacks, and congenital maladies. Since the human dentition plays a crucial role in mastication,
phonation and esthetics, finding promising and more efficient strategies to reestablish its functionality in the event of
disruption has been important. Dating back to antiquity, conventional dentistry has been offering evacuation, restoration,
and replacement of the diseased dental tissue. However, due to the limited ability and short lifespan of traditional restorative
solutions, scientists have taken advantage of current advancements in medicine to create better solutions for the oral health
field and have coined it “regenerative dentistry.” This new field takes advantage of the recent innovations in stem cell
research, cellular and molecular biology, tissue engineering, and materials science etc. In this review, the recently known
resources and approaches used for regeneration of dental and oral tissues were evaluated using the databases of Scopus
and Web of Science. Scientists have used a wide range of biomaterials and scaffolds (artificial and natural), genes (with
viral and non-viral vectors), stem cells (isolated from deciduous teeth, dental pulp, periodontal ligament, adipose tissue,
salivary glands, and dental follicle) and growth factors (used for stimulating cell differentiation) in order to apply tissue
engineering approaches to dentistry. Although they have been successful in preclinical and clinical partial regeneration of
dental tissues, whole-tooth engineering still seems to be far-fetched, unless certain shortcomings are addressed.

1. Introduction from congenital maladies to chemical, physical, and microbial

After the first successful kidney transplant between two
nongenetically identical patients was performed by Murray,
the Nobel prize winner and scientist in the early 1960s [1],
transplantation has been the treatment for most of organ
injuries and failures. However, transplantation has major
drawbacks such as severe shortage in organ donors, gradual
crescendo in the number of organ failure cases, indeterminate
immune responses, and unreliable organ acceptability [1].
Therefore, scientists with backgrounds in cellular and
molecular biology, materials science, and stem cell
engineering came together and developed a newfield called
Tissue Engineering and RegenerativeMedicine (TERM).
As a rapidly growing field of research, TERM offers novel
treatments for patients suffering fromslight injuries to end-
stage organ failure for nearly every type of human body tissue
and organ. The clinically available treatments include but are
not limited to strategies for urethral tissue [2], bladder wall
tissue [3], genital tissues and organs [4], female reproductive
tissue [5], blood vessel [6], heart valves [7], liver [8]
and tracheal tissue [9]. In all of these cases, there are still
substantial problems which need to be resolved; however,
the recent advancements and their potential benefits seem to
be revolutionary. In dentistry, scientists have always placed
significant emphasis on the study of novel strategies that
apply TERM to the dental practice [10]. Human teeth and
orofacial tissues are responsible for phonation, mastication,
esthetics, respiration, and emotional and facial expressions.
Although teeth have high abrasion resistance and lifelong
architectural durability, oral tissue, as one of the excessively
used parts of the body, is prone to several common diseases
attacks [11]. While the oral cavity plays an essential role in
daily life, it is severely exposed to microbial infections—
therefore, any defect, induced by infections, decay or
trauma and all other oral diseases including autoimmune and
malignancies in the dental tissue should be addressed quickly
[12]. More specifically, any large size defect that is close to
pulp exposure, including moderate to advance decay, needs
to be treated urgently. Often, trauma induced by mastication,
accidents or even pathogens can disrupt the oral epithelium
protective barrier.
The reports outline that 41% of the children aged 2–11 years
(in their primary teeth), 42% of children and adolescents
aged 6–19 years, and approximately 90% of human adults (in
their permanent teeth) suffer from at least one of the dental
diseases, such as caries [13], which makes it important to
find approaches that can restore oral tissue to normal function
and form. Although the techniques used in conventional
dentistry—such as restoration with filling materials, whole
tooth replacement with synthetic restorative materials, and
teeth removal—date back to antiquity, they havemajor
drawbacks that necessitate exploration of more effective
approaches and novel technologies in modern dentistry
[14]. The current efforts are focused on the investigation of
the possibility of engineering the whole tooth, as well as all
of the individual dental structures separately. Both of these
routes require utilization and development of stem cells,
biomaterials, scaffolds, and growth factors. However, before
outlining the details, grasping a better understanding of the
human tooth structure and development is necessary.

14 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

2. Current approaches in regenerative dentistry
The recent scientific advancements in reprogramming
and guideddifferentiation of human embryonic and adult
stemcells, producing biocompatible materials, and scaffolding
systems that support cell growth have convinced scientists to
apply these technologies to modern dentistry.
Here, the major approaches recently used are discussed.
2.1. Dental stem cells and growth factors
In the past few decades, a lot of progress has been made in
understanding, extracting and utilizing human embryonic
and adult stem cells [17]. Self-renewal, programmability,
and the potential to produce various cell types are the main
factors which make these cell types attractive for any field of
medicine [18]. In RD, scientists have used both pluripotent
and adult stem cells derived from embryo, bone marrow,
dental tissues, oral tissues, and glands. They have also used
induced pluripotent stem (iPS) cells [19]. After discovery
of the potential of extracting stem cells from dental pulp by
Gronthos et al. [20], dental pulp stem cells (DPSCs) and stem
cells from human exfoliated deciduous teeth (SHED) were
the first cell lines derived from human dental pulp [20,21].
They are both favored because of their non-invasive harvest
and potential for multi-lineage differentiation [22]. Shi et al.
[23] compared human dental pulp stem cells and bone marrow
mesenchymal stromal stem cells (BMSCs) and showed
distinct gene expression patterns for DPSCs [23]. In 2008
stem cells derived from apical papilla (SCAP), which were
harvested from wisdom teeth, were shown to have potential in
dentin regeneration [24,25]. Although the abundant presence
of progenitor cells in the periodontal ligament was proven a
long time ago [26], Seo et al. [27] investigated the stem cells
harvested from the periodontal ligament (PDLSCs) of the
third molar and found out that these stem cells are capable
of developing a tissue similar to their extraction site [27].
Morsczeck et al. [28] isolated precursor cells from the dental
follicle (DFSCs) of wisdom teeth and developed them into a
mature periodontium [28]. Honda et al. [29] studied DFSCs
and showed their osteogenic potential [29]. The progenitor
cells extracted from the tooth germ of the third molar during
the bell stage (TGPCs), by Ikeda et al. [30] demonstrated the
ability to differentiate into osteoblasts, hepatocytes, and neural
cells [30]. Scientists have also reported the extraction of stem
cells from human dental epithelium tissue. Oral epithelial
stem cells [19], gingiva-derived mesenchymal stromal cells
(GMSCs) [31], and periosteum-derived stem cells (PSCs)
[32] have shown the potential to differentiate into lineages of
all three germ layers. On the other hand, stem cells derived
from human salivary glands have not shown the potential to
proliferate into all forms of epithelial cells [33]. Fig. 2 [19]
depicts the various oral and dental sources of adult stem cells.
Adipose is loose, connective tissue which controls body
energy resources in order to keep the body warm against cold
environments[34]. Adipose-derived stromal cells (ADSCs),
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
which can be harvested through relatively less-invasive
procedures, have shown the capacity for multi-lineage
differentiation [35]. One-hundredth of white adipose cells are
ADSCs with mesenchymal properties [36]. Tobita et al. [37]
has shown the possibility of periodontal tissue regeneration
using ADSCs [37]. Before the discovery of iPS by Takahashi
et al. [38], embryonic stemcells were the only available
pluripotent cells used in dentistry. Research on human and
mouse embryonic stem cells led to great accomplishments
in differentiation of stemcells into oral tissues and organs
[39,40]. Dental iPS cells have shown to be readily accessible
from various dental stem cells [41,42] and fibroblasts [43,44].
The aim in using stem cells is to explore the possibility of
craniofacial, tooth, pulp, periodontal ligament, enamel, and
dentin regeneration[45]. So far extensive studies on cementum
matrix by Handa et al. [46], periodontal ligament by Lin et al.
[47], soft dental pulp regeneration by Cordeiro et al. [48] and
Huang et al. [48,49], and enamel regeneration by Honda et al.
[50] have shown great promise in the future of stem cells in
RD. Recently, Iglesias-Linares et al. [51] have investigated the
revascularization and apexogenesis induced by stem cells and
demonstrated the latest advancements in apical regeneration
[51]. Although the scientists have established the preclinical
safety, efficacy and feasibility of pulp regeneration derived
fromdental stemcells [52], clinical trials cannot be launched,
until certain challenges, such as the difficulty to handle
critically-sized defects, are addressed [53].
Growth factors can help tissue regrowth by regulating the
signaling between the cells, their environment, and their
neighbors [54]. Through making an information-conducive
and extra-cellular matrix, growth factors play a crucial
role in the regeneration of dental tissues [55]. Tayalia et al.
demonstrated howscientists can take advantage of growth
factors to improve specifically guided differentiation of cells
[56]. It is extremely important to knowwhich growth factors
are suitable for specific types of cells and have the ability to
orchestrate the cell type’s proliferation and differentiation
into the anticipated cell lineage [57]. A wide spectrum of
growth factors is required in order to control each step of
tissue regeneration and the fate of the stemcell [58]. The
growth factors entrapped in the dentin matrix, which are
actively protected in the dentinmatrix, are responsible
for the stimulation of processes—such as odontoblast
differentiation—that lead to dentin formation [59]. Dental
growth factors are also in charge of differentiation of adult pulp
stem cells [60] and dentin bridging [61]. Although important
prerequisite steps for utilizing growth factors—delivery,
immobilization, and release—are currently undergoing active
investigations, preclinical and stage I/II clinical trials have
demonstrated howgrowth factors can accelerate and improve
periodontal and bone regeneration [62,63].
2.2. Biomaterials and scaffolds
Scientists have used three major categories of materials in
TERM: namely, naturally derived materials (such as chitosan,
elastin, and collagen), acellular tissue matrices, and synthetic
15
materials [1]. Since application of natural materials is limited, metallic implants have beenwidely used for medical and
FDA-approved synthetic polymers, such as polylactic acid dental applications and have been tailored for specific
(PLA), polyglycolic acid (PGA), and poly(lactic-co-glycolic reconstruction of small or large hard-tissue defects [102,103].
acid) (PLGA) have wide applications in many TERM However, scaffolds are suggested to be made of biodegradable
fields including RD [64,65]. Pre-clinical studies on animal materials with a degradation rate close to the tissue generation
models using all of the aforementioned categories have rate [11,104–106]. Therefore, the utilization of metallic
shown promising results in dental tissue regeneration [66]. scaffolds can be limited as they are mostly non-degradable,
Besides the conventional mechanical and chemical routes for and thus may require second surgery to be removed from the
synthesizing materials with biomedical applications [67–72], body. Scaffolds can be used in RD as structural templates for
scientists have always tried to explore innovative biomaterial stemcell differentiation and proliferation. Recently, Song et
synthesis techniques, such as green in situ synthesis of al. demonstrated the successful production of hard
silver particle encapsulated gelatin-based scaffolds, in situ
dental tissues on the periphery of macro-porous biphasic
encapsulation of iron nanoparticles in hydroxyapatite/chitosan
calcium phosphate scaffolds. Synthetic polymeric scaffolds
matrix, and particulate sol–gel and cellulose templating of
have shown great potential in promoting dental pulp tissue
nanostructured zirconium titanate fibers [73–77]. Recently,
regeneration [107]. Recent experiments on platelet-rich
novel biomaterials with more sophisticated designs that
plasma scaffolds have demonstrated that they can effectively
can be reinforced by bioactive elements have appealed to
improve the healing induction and tissue regeneration
scientists [78–81]. Some examples include coating of bone
in regenerative endodontic treatments [108,109]. Useful
scaffolds with fluoridated hydroxyapatite [80], adding various
implications of these scaffolds have been shown on a group
ion substitutes to bioactive glasses [79], and incorporation
of pediatric patients clinically or radiographically, although
of bonemorphogenetic protein into various bio-matrices
not significantly better than conventional blood clot scaffolds
to enhance osteogenesis[82]. Moreover, biodegradable
[110]. These studies can justify the investigations that are
hydrogels that profit from their tissuelike properties and cross-
currently being carried out for the design and improvement
linking potential can also be used for efficient incorporation
of dental scaffolds. Marine sponge skeletons [111], diatom
of biological agents [83,84]. In general, biomaterials that
skeletons [112], and Foraminifera micro-skeletons [113] have
are used in RD are artificial and must be able to promote the
been used as scaffolds, bioactive molecule delivery devices,
epithelial and mesenchymal interactions [85]. Trombelli and
and bone substitutes. These biomimetic structures can be
Farina [86] demonstrated how using calcium phosphate bone
interesting options for dental bone regeneration. Several
substitutes and collagen derivatives can encourage alveolar
pre-clinically successful collagenbase periodontal tissue
bone tissue rebuilding [86]. Marine biomaterials have also
regeneration strategies and also clinically available scaffold
started to attract a lot of attention in TERM and RD. A broad
materials have shown promising results to be used in RD
spectrum of biomaterials with high bio-availability can be
[114–116].
extracted from marine products. In 2011, Addad et al. isolated
collagen from jellyfish [87]. Two years later, Wysokowski 3.3. Other approaches
et al. extracted chitin from marine sponges [88]. Marine
There are over 700 genetic syndromes that cause approximately
biomimetics can be put into action in RDthrough either
75% of the congenital defects occurring in the United States.
deploymentwithout cellular content or in vitro culturing of
Beside the significant impact of these genetic disorders on
mature tissues inside their matrices [89]. Another approach
the quality of life, the estimated yearly treatment cost for
in delivering bioactive factors is called small molecule
these patients is more than $750 million [117]. For a long
technique, which involves utilizing carbon-based compounds
time, transferring manipulated genes for clinical applications
comprising only a small sequence of natural protein ligands
has been a dream, but nowadays with the recent advances in
[90]. In the past fifteen years, several small molecules have
biotechnology, gene therapy has shown promising preclinical
been designed and investigated for their osteoblast-promoting
results in curing non-hereditary and hereditary diseases [118].
and osteoclast-inhibiting properties [91–93].
In gene therapy, by either using a viral or non-viral vector
Due to their relatively smaller molecular size (b1000 Da),
as a carrier molecule, functional genes replace the abnormal
these molecules neither induce unwanted immune responses,
and malfunctioning mutant alleles after the insertion into
nor necessitate structural integrity for bioactivity [94].
the patient’s cells [119]. Unlike somatic gene therapy, in
Researchers have performed a number of preclinical animal
which functional genes are inserted into the patient’s somatic
studies on bone defects in order to reduce the nonspecific
cells, germline gene therapy targets genetic modification
adverse effect of small molecules [95–98]. Scaffolds provide
of spermand egg and would be heritable to the offspring
3-D support for cells, biological agents, and biomaterials
[120,121]. When using viral vectors, namely retroviruses,
in order to accomplish different missions—such as cell
adenoviruses, adenoassociated viruses, or herpes simplex
adhesion, stem cell differentiation, guided tissue regeneration,
virus—even though the forms of the genetic materials are
and permanent mechanical support [99–101]. For decades,
different—the transportation takes place after the virus

16 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

infects the host cell. For non-viral gene transfection, scientists
have tried direct transfer of naked DNA [122], inactivation
of diseased genes using oligonucleotides [123], liposomal
delivery of plasmid DNA [124], application of cationic
dendrimers and endocytosis [125], and the combination of
two or more techniques [126]. Over the past two decades,
scientists have passionately worked on applying gene therapy
to dentistry and as a result they have made tremendous
progress in periodontal bone regeneration [127]. The salivary
gland is another target of gene therapy and this area has shown
promising results in both curing salivary gland diseases and
even serious systemic pathologies [128]. Recently, genetically
modified cell therapy, by combining the benefits of direct
gene delivery and cell therapy [129], has been explored for
periodontal ligament in rabbits [130,131]. Showing good
patient specific adaptability, this novel therapy has potential
for a bright future in this field.
Dental tissues have complex architecture, anisotropic
mechanical properties, and heterogeneous cell distribution;
hence, it is hard to mimic their complex 3-D structure using
the conventional techniques. To overcome this challenge,
recently 3-D bio-printing of dental and craniofacial tissues
has been proposed [132,133]. 3-D bio-printed scaffolds
can be designed for each individual patient and have
shown remarkable controllability over cell and biomaterial
positioning, while maintaining great accuracy in internal
and external details [134]. In general, printers use computed
designs and follow the basic concept of layer-by-layer
deposition of materials to produce 3-D volumetric structures.
Based on the type of their ink dispenser, bio-printers
can be grouped into three categories: Inkjet 3-D printers
(capable of applying low-viscosity bio-inks using thermal
or piezoelectrical controlling system), laser-assisted printers
(capable of using cell and biomaterial sources with various
viscosities for pulse laser deposition of 3-D structures), and
extrusion printers (capable of extruding high-viscosity and
stiff polymeric sources at relatively high temperatures) [133].
Due to their excellent biocompatibility and outstanding
tenability, polymeric hydrogels have been the best nominees
to be used as materials for 3-D bio-printing [135]. As the
bio-printing process usually involves high-temperature steps,
cells and growth factors (temperature susceptiblematerials)
are not initially amalgamated in the polymeric mixture [136].
Both ceramic (such as hydroxyapatite) [137] and composite
materials (such as polymer composite hydrogels) [138] are
considered as alternative bio-ink materials.
Applying this novel technique to TERM, Reichert et al. [139]
used 3-D bio-printed scaffolds to study the bone formation
in a sheep model in which the sheep was suffering froma
critically-sized bone defect and eventually showed significant
bone formation improvement [139]. In RD, scientists have
made several attempts to mimic the intricate architecture of
the periodontium in order to improve the regeneration of
the periodontal complex [140,141]. In an investigation on
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
scaffolds for cartilage regeneration, Schek et al. [142] used
composite bio-printed scaffolds seeded with fibroblasts and
reported a remarkable growth of cartilaginous tissue in the
craniofacial region [142]. Kimet al. [143] made a 3-D printed
tooth replica to performin vitro and in vivo experiments on
thewhole-tooth regeneration process [143]. Other groups
have also tried the same route of research and have narrowed
down the fundamentals of whole-tooth regeneration via 3-D
bio-printing [144, 145]. All of these technological advances
showpromise for a hopeful future in 3-D bio-printing of the
whole tooth and other oral tissues for future generations.
In the last fifteen years, scientists have started to apply
their knowledge of micro-electronics and achievements in
semiconducting materials to cellular differentiation and its
microenvironment [146]. These technologies can potentially
solve some of the challenges that other TERM approaches
face—for example, they can shed light on the reconstruction
of ectodermal and mesodermal interactions. They can provide
nano-resolution for building patterns to develop various cell
types; hence, making these technologies useful for producing
scaffolds carrying several stem cells. Moreover, microscale
technologies provide the possibility of isolating, seeding, and
combining various cell types, which makes them suitable
for in vitro assessments of cell behaviors inwell-controlled
environments [147]. This can enable rapid evaluation of
the effects of biomaterials, drugs, and biological agents as
a result of performing patterned single or multi-culturing
in vitro experiments. Flaim et al. [148] investigated the
potential synergistic effects of the simultaneous utilization
of growth factors and extracellular matrix proteins on stem
cell activity [148]. These novel technologies have improved
growth factor delivery by offering precise cell control and
regulation. For example, Ennett et al. [149] performed long-
lasting growth factor release using PLGAmicro-spheres in
vitro and in vivo [149]. The so called “microscale technology
approach” can be carried out through either soft lithography
or photolithography [15]. Kane et al. [150] and Rozkiewicz et
al. [151] used soft lithography tomold templates and pattern
selective cells [150,151]. Zhang et al. [152] and Kimet al. [153]
used photolithography to fabricate 3-D micro-vascularized
scaffolds and structures [152,153]. These techniques’ ability
to form 3-D microchannels can help in supporting the cell
metabolism [154]. This advantage can play a crucial role
in achieving a reliable technique for tooth regeneration.
Hydrogels, with approximately 99% water content, are
the best materials to use in the microscale approach [155].
These materials can provide controllability in the structural
formation with great detail. Microscale technologies can
fabricate micro-structures, provide open channels, support
vascularization, enhance diffusion, help regulate the cell
activity, and facilitate high-throughput approaches; hence,
they have a huge potential for both the in vitro and in vivo
constructions of tooth-like structures [156].
17
Even after reaching the advanced technology of building
patientspecific tooth substructures, the major challenges
of the application of TE in dentistry range from the cost-
efficiency of these approaches to their availability to public
(in terms of well-equipped health centers and institutes).
Moreover, RD inherits the controversial ethical challenge of
choosing which cell source (patient’s own or donors’) and cell
type (adult or fetal) for TE. However, the ongoing research on
TE and RD opens the venue to future investigations toward
the development of whole-tooth structure during the next
decades; which furtherly can shed light on the regeneration
of other organs.
4. Conclusion
Although a lot of advancements in RD have revolutionized
modern dentistry, there are still several steps left to take
before declaring RD as a reliable alternative to conventional
dentistry. RD owes plenty to stem cell science and growth
factor engineering. However, a good source of totipotent
stem cells is not yet readily accessible and extracting human
embryonic stem cells is a problematic and controversial issue.
Moreover, it is not easy to control the stemcell differentiation.
Delivery of active growth factor to the desired site is
challenging and might provoke side effects. Biomaterials and
scaffolds have played fundamental roles in facilitating partial
dental tissue regeneration, but until today, none of thematerials
have met all the mechanical and biological standards required
for RD. Gene therapy has opened up new directions to curing
dental congenital diseases in individuals and their offspring;
however, viral vectors used in this technique might trigger
immune responses and side effectswith irreversible damage.
These genes live for a short period of time, which makes them
ineffective in some cases. Furthermore, 3-D bio-printing and
microscale technologies are pushing the boundaries of RD,
but both are costly and are still in their early developmental
stages. Though there is much work left, these are areas with
great promise for the future of RD. The future of dentistry
is in the hands of cellular biologists, geneticists, biomedical
engineers, and materials scientists that strive to find and
perfect novel approaches and techniques to address the
aforementioned issues. Although the partial regeneration of
human dental tissues and structures seems to be attainable near,
considering the obstacles ahead,whole-tooth regeneration
may be achievable in the farther future.
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 BIOFILMS IN ENDODONTICS
Dr. Nikenlemla, Dr. Naman Vaidya, Dr. Rucha Shinde, Dr. Swati Bali
“Biofilm can be defined as a sessile multicellular microbial
community characterized by cells that are firmly attached
to a surface and enmeshed in a self-produced matrix
of extracellular polymeric substance (EPS), usually a
polysaccharide.”[1]
The term biofilm was introduced to designate the thin layered
condensations of microbes (e.g. bacteria, fungi, protozoa)
that may occur on various surface structures in nature. Free-
floating bacteria existing in an aqueous environment, so-called
planktonic microorganisms, are a prerequisite for biofilm
formation. In dental contexts, a well-known and extensively
studied biofilm structure is established during the attachment
of bacteria to teeth to form dental plaque. Here, bacteria free
in saliva (planktonic organisms) serve as the primary source
for the organization of this specific biofilm.[2]
Development of biofilm is influenced by physiochemical
property of components involved in the biofilm. pH,
temperature, surface energy of substrate, nutrient availability,
and length of the time the bacteria is in contact with the
surface and bacterial cell surface charge may play a key role
in biofilms. Studies have shown that biofilm is made up of
single cells and microcolonies, all embedded in a highly
hydrated, predominantly anionic exopolymer matrix. [3]
Biofilm formation is a step-wise procedure its formation
occurs in the presence of microorganisms, fluid and solid
surface. Biofilm is considered as community as it possesses
following criteria: Autopoiesis; Haemostasis; Synergy;
Communality[4]
Stages in the Development of Biofilm
1. First step is the interaction and adsorption of inorganic
and organic molecules to solid surface creating the
conditioning layer
2. Once the conditioning layer is formed; finally, it
undergoes adhesion of microbial cells to this layer.
In addition, the microbial adherence to substrate is also
mediated by bacterial surface structure such as fimbriae, pili,
flagella, and extra polymeric substances (EPS). The bacterial
cell surface structures form bridges between the bacteria and
conditioning layer. Initially, the bond between the bacteria
and the substrate may not be strong. However with time,
these bonds gains in strength, making the bacteria substrate
attachment irreversible.[3]
Ultrastructure of Biofilm
A fully developed biofilm is described as a heterogeneous
arrangement of microbial cells on a solid surface. Basic
24
structural unit microcolonies or cell clusters formed be
surface adherent bacterial cells. Microcolonies comprises a
discrete unit of densely packed bacterial cells aggregates.
Three factors essential for biofilm are:
1. Microorganisms
2. Solid substrate
3. Fluid channels.
Composition of biofilm
Biofilm consists of matrix material 85% volume and 15%
cells. A fresh biofilm is made up of biopolymers such
as polysaccharides, proteins, nucleic acids, and salts. A
glycocalyx matrix is made up of EPS, which surrounds the
microcolonies and anchors the bacterial cells to the substrate.
Tower or mushroom shaped structure is typically characteristic
feature of a viable fully hydrated biofilm.
There is an important aspect when we see the composition
of biofilm these are water-filled channels which act as
a primitive circulatory system in a biofilm, intersect the
structure of biofilm to establish connections between the
microbial colonies. Biofilm community comprises efficient
exchange between bacterial cells and fluid. Detachment has
been understood to play an important role in shaping the
morphological characteristics. It is also an “active dispersal
mechanism” or “seeding dispersal” where a detached cell
forms resistance traits which is the source of persistent
infections.[3]
Oral diseases as consequences of ecological changes in
biofilms
While seemingly a contradictory quality, dental biofilms are
essential for maintenance of both oral health and oral disease
conditions. Indeed, caries, gingivitis and chronic periodontitis
are caused by commensal microorganisms and not by
classical microbial pathogens. Currently their development
is considered to be a consequence of ecologically driven
imbalances in dental microbial biofilms . In the case of caries
for example, a low pH environment caused by microbial
fermentation of carbohydrates selects populations of acid-
tolerant and acid-producing strains that in turn increase acid
formation and may result in demineralization of the tooth
structure. As far as endodontic infections are concerned the
flare-up lesion could have a similar mechanism. Hence, acute
exacerbations of endodontic lesions may be explained by a
shift in the flow of nutrients to the root canal space, giving rise
to ecological changes, which promote growth of proteolytic
bacteria.
Example, following the initial instrumentation of a primary
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
infected root canal, injury of the periapical tissue by over-
instrumentation may release entry of inflammatory exudates
into the root canal and cause growth of proteolytic bacteria
that may have survived the endodontic treatment procedure.
The necrotic pulp tissue becomes a favorable environment
for microbial proliferation due to the presence of organic
residue or nutrients, which act as substrate or culture medium.
Gram-negative bacteria are more frequent than Grampositive
bacteria. Facultative or strict anaerobic microorganisms are
more frequent than aerobic microorganisms, and the presence
of bacilli and filaments is equivalent to that of cocci.[2]
BIOFILMS IN ENDODONTIC INFECTIONS
Biofilm formation in root canals is probably initiated at some
time after the first invasion of the pulp chamber by planktonic
oral organisms after some tissue breakdown.[4]
An ischemic injury by trauma, leading to pulpal necrosis,
is likely to provide totally different prerequisites for the
colonization phase than in a caries exposure of the pulp. In
the latter case, the inflammatory lesion front may recede
successively towards the apex, possibly in bursts, and provide
the fluid vehicle by which invading planktonic organisms can
multiply and start attaching to the root canal walls.
Quorum sensing, a bacterial cell-to-cell communication
mechanism for controlling cellular functions, is of particular
interest because of the presence of dense aggregates of bacteria
in biofilms. The signaling is mediated by diffusible molecules
which, when present in sufficient concentrations, serve to
modify gene expression in neighboring microorganisms.
Quorumsensingsignaling is known to be involved in the
regulation of several microbial properties, including virulence
and the ability to form biofilms, incorporate extracellular
DNA and cope with environmental stress. The known peptide-
signal molecules produced by oral streptococci are primarily
used for intra-species communication. However, other
signals of unknown nature and actual function released by
oral microorganisms serve as inter-species communication.
Because many of the oral bacteria found in root canals, e.g.

Table 1: Bacterial species/phylotypes commonly detected in endodontic infections

Species Gram staining Phylum Type of infection
Bacteroidetes oral clone X083 Gram negative Bacteroidetes Primary
Campylobacter rectus Gram negative Proteobacteria Primary
Dialister invisus Gram negative Firmicutes Primary; persistent/secondary
Fusobacterium Nucleatum Gram negative Fusobacteria Primary; persistent/secondary; extraradicular
Porphyromonas Endodontalis Gram negative Bacteroidetes Primary; extraradicular
Porphyromonas Gingivalis Gram negative Bacteroidetes Primary; extraradicular
Prevotella intermedia Gram negative Bacteroidetes Primary; extraradicular
Prevotella nigrescens Gram negative Bacteroidetes Primary
Prevotella baroniae Gram negative Bacteroidetes Primary
Pyramidobacter Piscolens Gram negative Synergistetes Primary; persistent/secondary
Tannerella forsythia Gram negative Bacteroidetes Primary
Treponema denticola Gram negative Spirochaetes Primary
Treponema socranskii Gram negative Spirochaetes Primary
Treponema maltophilum Gram negative Spirochaetes Primary
Veillonella parvula Gram negative Firmicutes Primary
Actinomyces israelii Gram positive Actinobacteria Primary; persistent/secondary; extraradicular
Enterococcus faecalis Gram positive Firmicutes Persistent/secondary
Filifactor alocis Gram positive Firmicutes Primary; persistent/secondary
Olsenella uli Gram positive Actinobacteria Primary; persistent/secondary
Parvimonas micra Gram positive Firmicutes Primary; persistent/secondary
Propionibacterium acnes Gram positive Actinobacteria Primary; persistent/secondary
Propionibacterium Propionicum Gram positive Actinobacteria Primary; persistent/secondary; extraradicular
Pseudoramibacter alactolyticus Gram positive Firmicutes Primary; persistent/secondary
Streptococcus anginosus Gram positive Firmicutes Primary; persistent/secondary
Streptococcus constellatus Gram positive Firmicutes Primary; persistent/secondary
Streptococcus intermedius Gram positive Firmicutes Primary; persistent/secondary
Streptococcus mitis Gram positive Firmicutes Primary; persistent/secondary

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 25

 Fig 1: Stages of biofilm Formation

Fig 3: Variable thickness of biofilm adherent to the root canal Fig 2: Scanning electron microscope showing biofilm (a) on
predentine with moribound pulp tissue towards the canal the root canal wall (b) within dentinal tubules
lumen

Fig 4: Microorganisms observed in biofilms on root canals walls of teeth with primary endodontic infections. Cocci (a), spirochetes (b),
filaments (c), and bacilli (d) could be observed, although a direct correlation between bacterial morphological differences and clinical/radio-
graphic findings was not established by means of SEM evaluation

26 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

Fig 5:. Biofilm within the root canal. (a) Radiograph showing maxillary left first premolar. Crown delivered 3 years previously.
Patient presented with intermittent pain, particularly upon chewing, and absence of deep probing. Diagnosis: necrotic pulp and
symptomatic apical periodontitis. Patient elected extraction. (b) SEM image of middle section of the root canal wall showing
necrotic pulp tissue and debris covering dentinal tubules; (c) Close-up of circled area in (b); (d) Close-up of circled area in (c)
showing dentinal collagen fibers and bacteria inside the dentinal tubule; (e) Close-up of circled area in (d) showing bacteria
inside dentinal tubule.

Fig 6:. Biofilm within the root canal. (a) Radiograph showing mandibular left second molar. Patient presented with no symptoms
and absence of deep probing. Diagnosis: necrotic pulp and asymptomatic apical periodontitis. Patient elected extraction. (b)
SEM image of middle section of the root canal wall showing dentinal wall as a niche for biofilms; (c and d) Close-up images of
left circled area labeled in (b) showing dentinal collagen fibers and bacteria inside dentinal tubules; (e and f) Close-up images
of right circled area in (b) showing multi-species biofilms with cocci, rods, and long filaments

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 27

Fig 7:External surface of the root apex of tooth with pulp necrosis and chronic periapical lesion. (a) Morphological changes in
the radicular cementum close to the apical foramen showing areas of intact cementum (arrowhead) between areas of resorption
(arrow) (_400). (b) Higher magnification of cementum resorption in (a) with areas of microorganisms (arrow) (_1650); (c)
Higher magnification of (b) (arrow), showing the presence of cocci forming apical biofilm (_6000)

Fig. 8 : Bacteria forming dense biofilms on the root canal walls of a lower canine with extensive caries and a periapical lesion.
Biofilm, mainly comprised of cocci and rods (*), can be observed at cervical (a), middle (b), and apical (c, d) thirds of the canal.
In some areas, bacteria could also be detected into dentinal tubules (~). (DC refers to defense cells.)

28 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

Fig 9 : Biofilm on extruded gutta-percha cone recovered from previously treated tooth with refractory periapical periodontitis.
(a) Radiograph of tooth. Filling material (gutta-percha point) is observed outside the palatal root canal; (b) SEM image of gutta-
percha specimen after removal. The apically extruded material (arrows) is approximately 2 mm in length (original magnification
_50; bar¼500 um); (c) SEM image of extruded gutta-percha (original magnification _350; bar¼50 um); (d) High magnification
of arrowhead area in (c). Glycocalyx structure is present in the upper right area but not in lower left area. Filamentous or
spirochete-shaped bacteria are observed in lower left

Fig 10 : Schematic diagram showing different methods by which bactaria in a biofilm gain resistance against antimicrobials

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 29

Fig 11 : Comparison of ESEM (a) and SEM (b) images demonstrating differences in resolution. (a) Fusobacterium nucleatum
species (arrows) in mixed culture with Enterococcus faecalis; (b) Colonies of F. nucleatum and E. faecalis. Both species could
clearly be distinguished

Fig 12 : Schematic diagram showing different antibiofilm stratergies

30 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

S. gordonii, Streptococcus mitis, Porphyromonas gingivalis,
Fusobacterium nucleatum and Prevotella intermedia possess
the ability to communicate through quorum sensing, it is likely
that signal molecules operate as additional environmental
factors that alter gene expression to optimize phenotypic
properties of biofilm bacteria in root canals.[2]
Types of Endodontic Infections
Endodontic infections can be classified as intraradicular and
extraradicular according to the anatomic location of infection
in relation to the root canal.
I] Intraradicular Infection
Primary intraradicular infections:
Microorganisms that initially invade and colonize the necrotic
pulp tissue cause primary intraradicular infection. Primary
infections are characterized by a mixed consortium composed
of 10 to 30 bacterial species and 10 to 108 bacterial cells per
canal. The involved microbiota is conspicuously dominated
by anaerobic bacteria, but some facultative or microaerophilic
species can also be commonly found in primary intraradicular
infections.
Secondary Intraradicular Infections:
Microorganisms that were not present in the primary
infection but that were introduced into the root canal system
at some time after professional intervention cause secondary
intraradicular infections. The entry can be during treatment,
between appointments, or even after root canal filling. Species
involved can be oral or nonoral microorganisms, depending
on the cause of infection.
Persistent Intraradicular Infection:
Microorganisms that can resist intracanal antimicrobial
procedures and endure periods of nutrient deprivation in a
prepared canal cause persistent intraradicular infections. This
is also termed recurrent infection. Involved microorganisms
are remnants of a primary or secondary infection. E faecalis
are predominant and is a persistent organism. It is commonly
found in a high percentage of root canal as a single organism
or as a major component of the flora. Persistent and
secondary infections are clinically indistinguishable and are
responsible for persistent exudation, persistent symptoms
interappointment exacerbation and failure of endodontic
treatment characterized by persistent apical periodontitis.
II] Extraradicular Infection:
Microbial invasion of the inflamed periradicular tissue is
invariably a sequel of interradicular infection. Acute alveolar
abscess is an example of extraradicular extension or a sequel
to interradicular infection. Sometimes extraradicular infection
can be independent of intraradicular infections. For example,
apical actinomycosis caused by Actinomyces species and P.
propionicum is a pathological disease which can be treated
only by periapical surgery.[7]
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
III] Periapical microbial biofilms
These are isolated biofilms found in the periapical region of an
endodontically infected tooth. The microbiota in the majority
of teeth associated with apical periodontitis is restricted to
root canal as most of the microbial species that infect the root
canal are opportunistic pathogens that do not have the ability
to survive the host defense mechanisms in periapical tissues.
Rarely, microbial species or even strains within species may
possess strategies to survive and thus infect periapical tissues.
IV] Biomaterial centered infection (BCI)
It is caused when microorganisms adhere to an artificial
biomaterial surface and form biofilms structures.
Biomaterials play an important role, and hence presence
of biomaterials in close range to host immune systems can
increase the susceptibility to biofilms. BCI is one of the major
complications associated with prosthesis and or implant
related infections. [3]
Mechanisms of antimicrobial resistance
There are several mechanisms for biofilm/s to resist
antimicrobial agents. The polysaccharide matrix of biofilms
can retard diffusion of the antibiotics. In addition, extracellular
enzymes such as β‑lactamase may become trapped and
concentrated in the matrix, thereby inactivating β‑lactam
antibiotics. Furthermore, quorum sensing (communication
with one another) can influence the structure of the biofilm by
encouraging the growth of species beneficial to the biofilm.
It has been shown that subpopulations of bacteria in biofilm
form a phenotypic state (altered gene expression) where
they are highly protected. Bacterial cells protect themselves
by being located within the interior part of a biofilm; hence,
medicaments will only act on the microorganisms in the
peripheral portion of the biofilm. Additionally, bacterial cells
residing within a biofilm grow more slowly than planktonic
cells, and as a result, antimicrobial agents act more slowly.
Depletion of nutrients or accumulation of waste products can
result in bacteria entering a non‑growing state which protects
the bacteria from the antibiotics. Pajkos et al. revealed that
biofilm bacteria exist in a low metabolic state, with a slower
growth rate and production of exopolysaccharides. Chemical
changes to the environment in the biofilm are lack of oxygen
inhibits some antibiotics and accumulated acidic waste leads
to a difference in pH which has an antagonizing effect on the
antibiotic.[5]
ROLE OF ENTEROCOCCUS FAECALIS IN BIOFILM:
Enterococcus faecalis are Gram positive cocci, facultative
anaerobes. They produce various infections in human and
most commonly infect urinary tract, blood stream, biliary
tract, endocardium , burn wounds and also associated with
foreign body induced infections. They are associated with
infections in root canal and also they are seen in chronic
periapical pathology, failed root canal cases.
31
They have many survival and virulence factors: they physically removing the biofilm.
are capable of causing mono-infection, opportunistic
Chavez de Paz et al. found that 1% NaOCl affected the
microorganisms which can withstand nutritional deprivation,
membrane integrity of E. faecalis, Lactobacillus paracasei,
they utilize serum as nutritional source, binds to dentinal
Streptococcus anginosus, and Streptococcus gordonii, and
tubules, produces collagen –binding protein and serine
removed most biofilm cells. Exposure to EDTA (50 mmol/l)
protease alter host responses, suppresses the action of
affected the membrane integrity in all organisms, but failed to
lymphocytes, possesses lytic enzymes, cytolysin, aggregation
remove more than a few cells in the biofilms of E. faecalis,
substance ,phenomones and lipoteichoic acid,maintains pH
L. paracasei, and Str. anginosus. Chlorhexidine (2.5%) had
homeostasis due to proton pump mechanism and they resist
a mild effect on the membrane integrity of E. faecalis and
the activity of antimicrobial agents due to biofilm formation.
removed only 50% of its biofilm cells. The effects were
Among all the survival and virulence factors Enterococcus substratum‑dependent, and most organisms displayed
faecalis the unique property of this organisms is biofilm increased resistance to the antimicrobials on collagen‑coated
formation and the physiochemical properties of organisms surfaces. Furthermore, Triphala, green tea polyphenols (GTP)
help them to modify according to the prevailing environmental and MTAD showed statistically significant antibacterial
and nutrient conditions. Biofilms formed by Enterococcus activity.
faecalis are able to resist destruction by enabling the bacteria to Table 2: Relative efficacy of root canal irrigant agents in their
become 1000 times more resistant to phagocytosis, antibodies different properties
and antimicrobials than nonbiofilm producing bacteria.
Action/ Sodium Iodine Chlorhex- EDTA
Enterococcus faecalis forms biofilm in various stages which agent hypochlo- idine
includes adherence of the organisms and formation of rite
microcolonies followed by bacterial mediated dissolution of
Bacterial +++++ +++++ +++ +
the mineral fraction from the dentin which results in release
killing
of calcium and phosphate ions leading to initial calcification.
Dissolution +++++ + – –
At later stages E. Faecalis biofilm shows carbonated –apatite
Biofilm +++++ ++++ ++ ++
structure as compared to natural dentine which contains
penetration
carbonated flor-apatite structure which are more resistant
and difficult to eradicate.Enterococcus faecalis can inactivate Biofilm +++++ – – ++++
antimicrobial agents such as metronidazole and also can break-up
protects organisms like B. Fragilis found in multispecies +relative degree of potency, – no potency
biofilm producing synergistic effect. Enterococcus faecalis ERADICATION OF BIOFILM:
coaggregates with F.nucleatum which results in further The structural dense organization of the biofilm within the
aggravate endodontic infection. polymeric matrix restricts the penetration of any agent
A recent study conducted showed that Enterococcus faecalis, into them. Biofilm are found to be resistant to amoxicillin,
S. sanguinis,S. intermedius, S.pyogenes and S. aureus were doxycycline and metronidazole. Sodium hypochlorite is an
capable of producing biofilm on gutta percha. Enterococcus effective irrigant to destroy all forms of Enterococcus faecalis
faecalis, S. sanguinis biofilm were thicker than other biofilms including its biofilm form. Chlorhexidine 2% gel or liquid
produced by other organisms[6] form is effective to eliminate Enterococcus faecalis from the
superficial layers of dentinal tubules up to 100micrometer.
Effects of endodontic irrigants and medicaments on
The new techniques include use of ultrasonic irrigation,
biofilms
ozone, plasma dental probe, photoactivated disinfection with
Spratt et al. evaluated the effectiveness of NaOCl (2.25%), low-energy laser for biofilm removal.
0.2% chlorhexidine gluconate (CHX), 10% povidone
iodine, 5 ppm colloidal silver, and phosphate‑buffered saline Ultrasonic Irrigation
(PBS) solution (as control) against monoculture biofilms 1-minute use of ultrasonically activated irrigation, followed
of five root canal isolates including Prevotella intermedia, by root canal cleaning and shaping has been shown to
Peptostreptococcus micros, Streptococcus intermedius, improve canal and isthmus cleanliness in terms of necrotic
Fusobacterium nucleatum, and E. faecalis. Results showed debris/biofilm removal.
that NaOCl was the most effective antimicrobial, followed by
the iodine solution. Clegg et al. evaluated the effectiveness Ozone
of three concentrations of NaOCl (6%, 3%, and 1%), 2% High concentrated gaseous and aqueous ozone is strain,
CHX, and BioPure MTAD on apical dentin biofilms in dose and time dependently effective against the tested
vitro. Their findings indicated that 6% NaOCl was the only microorganisms in suspension and biofilm test model.
irrigant capable of both rendering the bacteria nonviable and However, NaOCl was the only method that eliminated biofilm.

32 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

Plasma Dental Probe
Plasma dental probe is effective for tooth disinfection.
Scanning electron microscopy shows complete destruction
of endodontic biofilms for a depth of 1 mm inside a root
canal after plasma treatment for 5 min. Plasma emission
spectroscopy identifies atomic oxygen as one of the likely
active agents for the bactericidal effect.
Laser
The Er:YAG laser have produced excellent results due to its
capacity for ablating hard tissue with very less thermal effects.
They are considered to be effective tool for the removal of
apical biofilm.
Photoactivated disinfection
Photodynamic therapy/ Light Activated Therapy is the latest
method used to destruct endodontic biofilm. It involves the
killing of microorganisms when a photo sensitizer selectively
accumulated in the target is activated by a visible light of
appropriate wavelength.
PAD is a unique combination of a photosensitizer solution
and low-power laser light. The photosensitizer, which is
mostly colored, adheres to or gets absorbed by microbial
cells. The low-power laser will destruct the target area and
inactivate the microbial invaders. The photosensitizer then
binds to microbial cell walls or even enters the cells. Further,
the Laser light activates the photosensitizer and creates a
cascade of energy transfer and variable chemical reactions in
which singlet oxygen and free radicals play an important role.
The other advantage is the time taken. Usually sodium
hypochlorite, antibiotics and other methods against microbial
threats need a lot of time to inactivate the microbes.
PAD needs a maximum of 150 seconds. PAD is effective
against Enterococcus faecalis, Streptococcus intermedius,
Fusobacterium nucleotum, Peptostreptococcus micros,
Prevotella intermedia)[6]
Nanoparticles
Nanoparticles are microscopic particles with one or more
particle dimensions in the range of 1–100 nm. Nanoparticles
are recognized to have properties that are very unique compared
to their bulk or powder counterparts. In root canal therapy,
nanoparticles may be applied as slurry or in combination
with sealers. They have the ability to diffuse antimicrobial
components deep in dentin tissue. The successful application
of nanoparticles in endodontics will depend on both the
effectiveness of antimicrobial nanoparticles and the delivery
method used to disperse these particles into the anatomical
complexities of the root canal system.
Bioactive glass
Bioactive glass (BAG) consists of SiO2, Na2O, CaO2, and
P2O5 at different concentrations. It has received considerable
interest in root canal disinfection due to antibacterial
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
properties. Previous authors attributed the antibacterial
mechanism of BAG to its high pH, osmotic effects and Ca/P
precipitation. Another author demonstrated that compared
CH, BAG showed significantly less antibacterial effects as an
intracanal medicament. In addition, another author showed
that BAG did not effectively prevent recontamination of
instrumented root canals.[4]
CONCLUSION
Current understanding emphasizes that endodontic disease
is a biofilm-mediated infection and that elimination of
bacterial biofilm from the root canal system and the exterior
root surface may be necessary to maximize the prospects
for a favorable treatment outcome in the management of
this disease. Unfortunately, the root canal environment is a
challenging locale to accomplish this goal. It has been for
this reason that different protocols ranging from antimicrobial
root canal irrigation to advanced methods that incorporate
lasers, photoactivated disinfection, and nanoparticles have
been tried. While several of the advanced antimicrobial
protocols have shown a significant inhibitory effect against
several types of microbial biofilms under in vitro conditions,
more in vivo studies are required to evaluate whether they
are clinically practical and effective.. In bringing this new
technology to the marketplace, it is important to combine
potent antibiofilm strategies with an effective and easy-to-use
delivery system, if it is to enjoy broad acceptance.
References:
Cohen’s Pathways of the Pulp 11th edition.
Gunnel Svensa¨Ter & Gunnar Bergenholtz. Biofilms in endodontic
infections.Endodontic Topics 2004, 9, 27– 36
Sindhu Haldal, K P Muhammed Yazar Arafath, K Subair, Kiran
Joseph, Rajesh. Biofilms in Endodontics. Journal of
International Oral Health 2016; 8(7):827-829
Shruti Sharma, Varun Rajkumar, Sipra Sarin, Sahil Sarin, Charanpreet
Singh Chugh, Harmeet Kaur. Root canal biofilms: review. Hecs
int j com health and med res 2017;3(3):93-95
Magar S, Palekar A , Magar S. , Mosby S. Endodontic Biofilm: A
Review. NJDSR Number 2, Volume 1, January 2014
Usha H.L, Anjali Kaiwar, Deepak Mehta. Biofilm In Endodontics:
New Understanding To An Old Problem. IJCD • December,
2010 • 1(3)
Luis E. Chavez de Paz ,Christine M. Sedgley ,Anil Kishen. The Root
Canal Biofilm.
Gary B. Carr, DDS, Richard S. Schwartz, DDS, Christoph Schaudinn,
PhD,Amita Gorur, MSc,and J. William Costerton, PhD.
Ultrastructural Examination of Failed Molar Retreatment with
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Biofilms in an Endodontic Retreatment Failure. American
Association of Endodontists. doi:10.1016/j.joen.2009.05.035
Francisco Correa Toral1, Leylin Delgado Hernández1, Carolina
Echavarría González1, Fátima Serna Varona1, Adriana
Rodríguez Ciodaro1, Hugo Díez Ortega2, .Ex vivo model for
studying polymicrobial biofilm formation in root canals. Univ.
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L Lakshmi Narayanan, Vaishnavi C. Endodontic microbiology. Dr. Nikenlemla
Journal of Conservative Dentistry.Oct-Dec 2010. Vol 13.Issue 4 (Asst. Professor)
Pankaj Yadav 1, Sarika Chaudhary 2, Rajendra K. Saxena 3, Sangeeta Department of Conservative Dentistry and Endodontics,
Talwar 4, Sudha Yadav 5.Evaluation of antimicrobial and Darshan Dental College, Loyara, Udaipur, Rajasthan
antifungal efficacy of chitosan as endodontic irrigant against
Dr. Naman Vaidya
enterococcus faecalis and candida albicans biofilm formed on
tooth substrate J Clin Exp Dent. 9(3):e361-7. 2017.
(III yr. Post Graduate Student)
Department of Conservative Dentistry and Endodontics,
Kim Lewis. Riddle of Biofilm Resistance. Antimicrobial agents and
Darshan Dental College, Loyara, Udaipur, Rajasthan
chemotherapy. 45( 4) . 2001,
Vytaute Peciuliene, Rasmute Maneliene, Estera Balcikonyte, Saulius Dr. Rucha Shinde
Drukteinis, Vygandas Rutkunas. Microorganisms in root canal (II yr. Post Graduate Student)
infections: a review. Baltic Dental and Maxillofacial Journal, Department of Conservative Dentistry and Endodontics,
10:4-9, 2008 Darshan Dental College, Loyara, Udaipur, Rajasthan
Zahed Mohammadi, Flavio Palazzi, Luciano Giardino, Sousan
Shalavi. Microbial Biofilms in Endodontic Infections: An Dr. Swati Bali
Update Review. Biomed J 2013;36:59-70) (II yr. Post Graduate Student)
Santos AL, Siqueira JF Jr, Roˆ c¸as IN, Jesus EC, Rosado AS, et al. Department of Conservative Dentistry and Endodontics,
Comparing the Bacterial Diversity of Acute and Chronic Dental Darshan Dental College, Loyara, Udaipur, Rajasthan
Root Canal Infections. PLoS ONE 6(11): (2011)
Kapil Jhajharia,  Abhishek Parolia,  K Vikram Shetty,  and  Lata
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H. J. Rolph, A. Lennon, M. P. Riggio, W. P. Saunders, D.
Mackenzie, L. Coldero, And J. Bagg.molecular identification
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1 No 2, July 2014

34 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 MANDIBULAR CANINE INDEX
Dr Ravneet Arora, Dr Saurabh Arora
The mandibular canines are not only exposed to less plaque,
calculus, abrasion from brushing, or heavy occlusal loading
than other teeth, they are also less severely affected by
periodontal disease and so, usually are the last teeth to be
extracted with respect to age. These findings indicate that
mandibular canines can be considered as the key teeth for
personal identification.115
Gran et al in 1967, Dekock in 1972 have found that male
canines were larger than the females and the inter canine arch
width was larger in males when compared to females and
that those dimensions could be utilized for the purpose of sex
determination.116 Sherfuddin, Abdullaah and Khan in 1996
and Harris and Mohammed Q Al Rifaiy in 1997, Yadav et al in
2002, Kaushal et al in 2003,Vandana M Reddy in 2008,Aliaa
Omar et al , Karen Boaz and Chavi Gupta, Ashith B. Acharya
et al in 2009, Maneesha Sharma and R. K Gorea , Irfan
Ahmed Mughal, Bindu Aggarwal et al in 2010, KS Nagesh et
al, Dhara Parekh et al, Rishabh Kapila et al, in 2011, Carlos
Sassi et al in 2012 conducted their studies and have found that
male canines were larger than the females and the inter canine
arch width was larger in males when compared to females and
that those dimensions could be utilized for the purpose of sex
determination
Mandibular Canines
It is the third tooth in the mandibular dental arch from the
midline. It bears a close resemblance the maxillary canine.
The mesiodistal diameter of the crown is smaller than that of
its maxillary counter.
LABIAL ASPECT
When the tooth is viewed from the labial aspect, the crown of
the Mandibular teeth resembles maxillary canines except for
the crown appearing longer and narrower mesio-distally. The
mesial outline is more or less straight and is in line with the
mesial outline of the root. The distal contact point is placed
more incisally than the maxillary canine.101
PALATAL ASPECT
The lingual surface of the mandibular canine crown is
relatively flat when compared to the maxillary canine. This
is a result of the poorly developed cingulum and marginal
ridges. The lingual aspect of the root is relatively more is
relatively narrower than the maxillary canine.101
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
TABLE IX – MEASUREMENTS OF MANDIBULAR
CANINE
Cervicoincisal length of crow 11mm
Length of root 16mm
Mesiodistal diameter of crown 7mm
Mesiodistal diameter of crown at cervix 5.5mm
Labiolingual diameter of crown 7.5mm
Labiolingual diameter of crown at cervix 7mm
Curvature of cervical line mesially 2.5mm
Curvature of cervical line distally 1mm
The dimensions of canine teeth have been studied by several
methods, including Fourier analysis, Moire topography and
the measurement of linear dimensions such as mesiodistal
width, buccolingual width, and inciso cervical height. The
uses of Fourier analysis and Moire topography are limited to
small sample where as measurements of linear dimensions of
canine teeth are used in large population.105
These methods can be applied directly on the Mandibular
canine within the oral cavity, and also they can be best applied
on the cast models. Dimorphism in right and left mandibular
canines can be calculated using formula given by Garn &
Lens (1967) as follows.
Sexual Dimorphism = Xm/Xf x 100
Where, Xm = Mean value of males
Xf = Mean value for females
Further the mandibular canine index was calculated based on
the formula used by Rao et al
Mandibular Canine Index (MCI) = Mesio - distal crown width
of mandibular canine / Mandibular canine arch width or inter
- canine distance
Standard Mandibular Canine Index
The standard Mandibular Canine Index of the population
studied was obtained from the measurements taken in the
sample by applying the following formula Std. MCI = (Mean
male MCI SD) + (Mean female MCI +SD) / 2
According to Rao et al if the calculated Mandibular Canine
Index for the individual was higher than the Standard
Mandibular Canine Index the individual was considered to
be male. If it was the other way round the subject was taken
as females.
35
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index as a sex determinant: A study on the population of western Reader
Uttar Pradesh. Journal of Oral and Maxillo Facial Pathology Department of Oral Medicine and Radiology
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Shishir Yadav, Nagabhushana D, B. Balaji Rao, G. P. Mamatha.
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2002; 13(3&4):143-146. Dr Saurabh Arora
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Kaushal, S., Patnaik, V.V.G., Agnihotri, G. Mandibular Canines in
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S. Kaushal, V.V.G Patnaik, V. Sood, and G Agnihotri. Sex
determination in north Indians using Mandibular canine index.
JIAFM, 2004; 26(2):45-49.
Aliaa Omar and Sonia Azab. Applicability of Determination of
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a Sample of Adult Egyptian Population. Cairo Dental Journal
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Karen Boaz and Chhavi Gupta. Dimorphism in human maxillary
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Ashith B. Acharya, and Sneedha Mainali. Limitations of the
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Maneesha Sharma and R. K. Gorea. Importance of Mandibular and
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P. C. Srivastava. Correlation of Odontometric Measures in Sex
Determination. J Indian Acad Forensic Med 2010 32(1):56-61.
Irfan Ahmed Mughal, Anwar Saood Saqib, Farida Manzur.
Mandibular Canine Index; its role in determining gender.
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Bindu Aggaewal, Subhash Kaushak, Kamlesh Vasudeva, Usha
Chhabre, Sanjay Singla. Significance of mandibular canine
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KS Nagesh, Asha R Iyengar, Rishabh Kapila, Sushma Mehkri.
Sexual Dimorphism in Human Mandibular Canine Teeth: A
Radiomorphometric Study. JIOMR 2011; 23(1):33-35.
Dhara Parekh, Ankur Zalawadia, Srushti Ruparelia, Shailesh Patel,
S. P. Rathod, S. V. Patel. Study of Mandibular Canine Teeth
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36 ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018

 A Paradigm shift from micro to nano in dentistry
Dr. Atulana Roy and Dr. Arpit Sikri

ABSTRACT
The concept of “nanomaterials” formed in the early 1980’s, has captured a considerable amount of attention because of its
unique structures and properties. At present, the revolutionary development of nanotechnology has become the most highly
energized discipline in science and technology. The word ‘nano’ originates from the Greek word “dwarf”. The concept of
nanotechnology was first elaborated in 1959 by Richard Feynman . Nanometer is defined as ‘unit of length used to measure
the wavelength of light. It is equivalent to 1ˣ 10-9 m or 1 angstroms.’ As the size of the system decreases there is increase
in the ratio of surface area to volume and a number of physical phenomena becomes noticeably pronounced which tends
to alter the macroscopic properties of the material. Nanomaterials produced by using nanotechnology have revolutionized
dentistry by providing us with ‘nanofillers’.

HISTORICAL BACKGROUND OF cobalt-chromium alloy or cobalt-chromium-molybdenum

NANOTECHNOLOGY
Even long before the start of “nanoera”, people were coming
across various nanosized objects and the related nanolevel
processes and used them in practice. Thousands of years BC
people knew and used natural fabrics: flax, cotton, wool,
silk. They were able to cultivate them and process them into
products. What makes these fabrics special is the fact that
they have a developed network of pores with the size of 1-20
nanometers, i.e., they are typical nanoporous materials. Due
to their nanoporous structure, natural fabrics possess high
utilities: they absorb sweat well, quickly swell and dry.
The word “nanotechnology” was introduced for the first time
into a scientific world by N. Taniguchi at the international
conference on industrial production in Tokyo in 1974 so as to
describe the super thin processing of materials with nanometer
accuracy and the creation of nano-sized mechanisms.
Ideas of nanotechnological strategy, which were put forward
by Feynman, were developed by E. Drexler in his book
“Vehicles of creation: the arrival of the nanotechnology era”
published in 1986.
In 1991, the first nanotechnological program of National
Scientific Fund started to Operate in USA.
In 2001, the National Nanotechnological Initiative (NNI) of
the USA was approved. In this way, according to the definition
of the National Nanotechnology Initiative, nanotechnology is
the manipulation of different materials for different purposes
at the nanoscale. The ability to arrange atoms as we desire
and subsequently to achieve effective, complete control of the
structure of matter is possible through nanotechnology.
NANOMATERIALS WITH THEIR CHARACTERISTIC
PROPERTIES
1. Nanometals :
Currently, most metal stents of partial denture are applying
alloy and titanium alloy. The initial cobalt-based alloy is
cobalt –chromium binary alloy which was then developed
into cobalt chromium- tungsten alloy and later developed
into cobalt chromium-molybdenum alloy. Its mechanical
properties and corrosion resistance are better than stainless
steel or gold alloy.
Another metal that is often used in dentistry are titanium
alloys because of its outstanding properties which are close
to natural human bones, such as high specific strength, good
biological security, high corrosion resistance, and elastic
modulus.
Modification of titanium implant surfaces into nanostructures
has been found to be able to improve their biological
integration with surrounding soft tissues.
Yao et al. created nanometer surface features on titanium
and Ti6Al4V implants by anodization, which was a quick
and relatively inexpensive electrochemical method.It
demonstrated that anodization of Ti-based metals might create
nanometer surface features that could promote osteoblast
adhesion.
2. Nanocomposites
Addition of nanoparticles in composite resin can increase
strength and toughness of the composite resin. Due to
small particle size, composite resins with nanoparticles
significantly reduce the effect of polymerization shrinkage
and dramatically improve physical properties. In addition
composites containing nanofillers resulted in smooth surfaces
with their ease of polish ability, increased abrasion resistance
and surface hardness.
Nanofilled composite resins provide a better finish on the
surface. This characteristic could improve surface texture and
material biodegrading over time in this way, may be reduced.
These composite resins have also achieved good mechanical
properties, indicating possible use in the anterior and posterior

ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 37

teeth.
3. Nanorobotic dentrifices
Effective prevention has reduced caries in children, and a
caries vaccine may soon be available but a subocclusal-
dwelling nanorobotic dentifrice delivered by mouthwash or
toothpaste could patrol all supragingival and subgingival
surfaces at least once a day, metabolizing trapped organic
matter into harmless and odorless vapors and performing
continuous calculus debridement.
These invisibly small (1-10 μ) dentifrobots(FIGURE 1),
perhaps, numbering 103-105 nanodevices per oral cavity and
crawling at 1-10 μ/s would be inexpensive purely mechanical
devices that would safely deactivate themselves if swallowed
and would be programmed with strict occlusal avoidance
protocols.
FIGURE1: Nanorobotic dentrifice acting on oral microflora
4. Nanotoothpaste
Metals have been used for centuries as antimicrobial agents
such as Ag, gold (Au) and metal oxides, such as zinc oxide
(ZnO) and titanium dioxide and amorphous calcium phosphate
nanoparticles which have gained significant interest over the
years due to their remarkable antimicrobial properties.
Nano whitening toothpaste is a toothpaste that contains
synthesized hydroxyapatite, a key component of tooth enamel,
as nanosized crystals. It has been proven to freshen breathe
as well as whiten teeth. Ag nanoparticles are incorporated
in these toothpastes which has a broad spectrum of activity
against bacteria, fungi, viruses, and even some protozoa.
Its antimicrobial action becomes even greater when in the
form of nanoparticles. Ag nanoparticles have been used to
inactivate enzymes and prevent the replication of bacterial
DNA and its action occurs because the nanoparticles adhere
to the outer membrane and so, promote changes in bacterial
cell structures, modifying its permeability.
5. Nanoparticles on dental implant interface
Recently three different nanostructured implant coatings have
been developed:
I. Nanostructured diamond: This kind of coating
38
shows very high hardness,improved toughness over
conventional microcrystalline diamond, low friction and
good adhesion to titanium alloys.
II. Nanostructured processing of HA coatings: This
coating material is used to provide the desired mechanical
characteristics and enhanced surface reactivity and has
been shown to increase osteoblast adhesion, proliferation,
and mineralization.
III. Nanostructured metalloceramic coatings: These
coatings provide continuous variation from a
nanocrystalline metallic bond at the interface to the hard
ceramic bond on the surface.
Nanostructured ceramics, carbon fibers, polymers, metals,
and composites enhance osteoblast adhesion and calcium/
phosphate mineral deposition. Studies have suggested that
nanophase ZnO and TiO2 may reduce Staphylococcus
epidermidis adhesion and increase the osteoblast functions
that are necessary to promote the efficacy of orthopedic
implants.
CONCLUSION
Although at present the impact of nanotechnology on dentistry
is somewhat limited due to the necessity to use materials
that are currently available, such as composite resin-based
materials, ongoing and future investigations will ensure that
developments that seem unbelievable today are possible
during the following years. The utilization of nanotechnology
in the future could facilitate improvements for the oral
health. Modified restorative materials, new diagnostic and
therapeutic techniques, and pharmacologic approaches will
improve overall dental care.
Nanotechnology and its restless struggle for developing new
better nanomaterials with applications in the biomedical
field has had an impact upon dentistry in terms of improving
the quality of materials and also in the conceptualizing
of upgraded shaping technologies used for implant
manufacturing. Sequentially, oral health will probably be
maintained through an advanced level of biotechnology and
nanorobot-assisted life-long processes. Nonetheless, despite
the advantages of nanotechnology, it does not come without
risks when employed.
It remains yet to be established whether the nano patterning
or micron-scale patterning is the most convenient choice,
taking into account that nanopillars have been shown to
increase the hydrophobicity to an extent that might not favor
their use in implantology. Hence, further studies should be
performed for establishing adequate coating composition
and a correlation between the composite features and the
specifics of implantation area, in terms of thickness, surface
topography and cell response.
Straightforward directions should be established when the
scientific community reaches a high level of understanding of
the processes that happen and can be strictly controlled at the
ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018
nanoscale, when there is undoubted proof of its safe use for 11. Elias, KL, Price, RL & Webster, TJ 2002. ‘Enhanced functions
the benefits of human health. of osteoblasts on carbon nanofiber compacts.’ Biomaterials, 23,
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Nanotechnology can be applied in almost all fields of human
12. Feynman RP. There’s plenty of room at the bottom. Eng Sci
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Actually, it may be concluded that among these, the most
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substantial contribution of nanotechnology to dentistry is the of dentistry.’ Journal of Indian Prosthodontic Society, 5(1).
enhancement in tooth restoration with nanocomposites.
17. Ji, B & Gao, H, 2004. ‘Mechanical properties of nanostructure
As final words, the combination of philosophies of science of biological materials.’ Journal of the Mechanics and Physics
and art will come together in this scene. In nanotechnology, of Solids, 52(9), pp.1963-1990.
someone will imagine it and then someone will do it. As an 18. Karimi, M, Ghasemi, A, Zangabad, PS, Rahighi, R, Basri,
example, Jules Gabriel Verne imagined the moon trip and SMM, Mirshekari, H, Amiri, M, Pishabad, ZS, Aslani, A,
Neil Armstrong and other scientists did it. Bozorgomid, M & Ghosh, D 2016. ‘Smart micro/nanoparticles
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ASIA PACIFIC DENTAL JOURNAL, Vol. 5, issue 3, October to December 2018 39

About the Journal
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