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69
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
INDIAN JOURNAL OF DENTAL EDUCATION
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Dental Education. The Indian Journal of Dental
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are purely commercial.
The Indian Journal of Dental
Education (pISSN 0974-6099,
eISSN 2455-5355, Registered
with Registrar of Newspapers for
India: DELENG/2008/32281)
published quarterly, is dedicated
to the dissemination of new
knowledge and information on
all fields of dentistry. The IJDE
publishes original peer-reviewed
articles that examine all phases of
dental treatment, reports on
unusual and interesting case
presentations and invited review
papers. The aim of this journal is
to convey scientific progress in
dentistry for the benefit of the
dental health of the community.
The journal serves valuable tool
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practitioners, teachers and
administrators involved in the
prevention and treatment of
dental disease.
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
71
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Volume 10 Number 2
April - June 2017
Indian Journal of Dental Education
Contents
Original Articles
Early Childhood Caries Prevalence in Sudanese Preschool Children 73
Hiba S. Abdul-Jalil, Amal H. Abuaffan
Histochemical Demonstration of Ghost Cells in Calcifying Odontogenic Cyst 79
Dipti A Tharani, Ritesh B. Wadhwani
Establishment of a Casual Relationship between Hemoglobin
and Chronic Periodontitis 84
Shishir Shah, Shilpi S. Shah, Tejal Sheth
A Radiological Study on the Visualization of the Anterior Loop of
Mandibular Canal Using Panoramic Radiography 88
Saritha Maloth, Padmashree S., Pramod Krishna B.
Assessment of Smoking Habits, Oral Hygiene Practices and Self Perceived
Malodour among the College Students in Ahmedabad 93
Shishir Shah, Shilpi S. Shah, Tejal Sheth
Mandibular Ramus as Dimorphic Tool in Age and Sex Determination-A
Cross Sectional Radio-Anthropometric Study on Digital
Panoramic Radiograph 98
Akhilanand Chaurasia, Gaurav Katheriya
Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study 107
Akhilanand Chaurasia, Gaurav Katheriya
Review Articles
Foreign Body Reaction to Oral Tissue: Iatrogenic Factors 116
Vikram S. Amberkar, Nitya K., Madhushankari G.S.
Various Methods of Detecting Micro-Leakage in Restorative Dentistry 119
Pankaj Datta, Sonia S. Datta
Metals Used In Restorative Dentistry 125
Prashanth Kumar Katta
Success and Failure in Endodotics 128
Prashanth Kumar Katta
Case Reports
Maxillary Cemento-Ossifying Fibroma 132
Yousif I. Eltohami, Nour E. Alim, Amal H. Abuaffan
72
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Surgical Management of an Extra Oral Mandibular Cutaneous Sinus
Tract in a 23 Year Old Male Patient 135
Pathak Anjani K., Kumar V., Lal N., Singhal D., Goel K.
Parakeratinized Odontogenic Keratocyst 139
Vikram S. Amberkar, Yashavanth Kumar, Nitya K., Madhushankari G.S.
Giant Peripheral Ossifying Fibroma of Maxilla 142
Saranya George, Tinky Bose C.
Short Communication
Behçet’s Syndrome: Diagnosis of Exclusion 146
Rajasekharan Asish, A.K. Nabeel, Ramachandran Sunu
Guidelines for Authors 149
73
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Hiba S. Abdul-Jalil*, Amal H. Abuaffan*
Original Article
Early Childhood Caries Prevalence in Sudanese Preschool Children
Abstract
Introduction: Dental caries is one of the most important global oral health problems. The distribution and
severity vary in different parts of the world. This study aimed to determine the caries prevalence among a
sample of preschool children and to assess the relation between maternal variables (age, educational level,
occupation and family size) and the dental caries status of their preschool children. Subjects and Methods: A
cross-sectional pre-school based study for 419 preschool children aged 3-5 years old were selected randomly
from 21 kindergartens in Khartoum North, Sudan. Data were collected through clinical examination and
interviews. (dmft) were recorded according to WHO criteria. Face-to- face interviews mothers to determine
maternal variables. Results: The majority (71.4 %) of the children examined had caries. The mean dmft± SD
was 4.36 ± 4.40. A statistically significant association between dental caries status and child’s age was
found (P=0.00). No statistically significant correlations were observed between all maternal variables and
the prevalence of dental caries of their preschool children. Conclusion: The prevalence of early childhood
caries was high among preschool children in Khartoum North. School dental health programs; obligatory
dental examinations and tooth brushing exercises should be implemented in kindergartens and schools to
promote dental awareness and help in dental caries prevention.
Keywords: Early Childhood Caries; Preschool Children; Maternal Variables.
Auth or ’s Af fi li ation: *Department of Orthodontics,
Pedodontics and Preventive dentistry, Faculty of Dentistry,
University of Khartoum, Sudan.
Reprints Requests: Amal H. Abuaffan, Department of
Orthodontics, Pedodontics and Preventive dentistry, Faculty of
Dentistry, University of Khartoum, Sudan.
E-mail: amalabuaffan@yahoo.com
Received on 17.05.2017, Accepted on 13.06.2017
Introduction
Dental caries is one of the most important global
oral health problems worldwide, particularly in
developing countries [1].
Caries affecting preschool children known as
early childhood caries (ECC) which is defined as”
the presence of one or more decayed , missing (due
to caries), or filled tooth surfaces in any primary
tooth in a child less than 6 years old”. ECC imposes
significant threats to the physical, psychological and
social well-being of young children as dental pain
and subsequent tooth loss resulting in difficulty in
eating, speaking, sleeping and socializing [2].
The prevalence of ECC is especially high in many
low-income and socially disadvantaged populations
[3-7]. This is largely attributed to increasing
consumption of sugars, inadequate exposure to
fluorides and poor oral hygiene [4,5,8,9].
ECC
varies greatly between different studies which may
be due to several factors such as children studied;
their age and the accessibility for examination; socio-
economic status; ethnic and cultural factors and
criteria used for diagnosis [8]. Number of studies
had been carried out for the prevalence of dental
caries in preschool children, the dmft showed wide
variation among different populations ranging from
1.5 in Brazil up to 11 in Kosovo. [4,7-11]
There is a paucity of literature available regarding
prevalence of dental caries among preschool
children in Sudan. Raadal et al (1993) studied caries
prevalence among 4-5 years old preschool children,
the mean decayed, missed, filled teeth (dmft) was
1.68 [12]. To our knowledge, there is no study
exploring the prevalence of ECC among preschool
children. Therefore, this study aimed to assess the
prevalence of ECC and related risk indicators in a
sample of preschool Sudanese children.
Indian Journal of Dental Education
Volume 10 Number 2, April - June 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.1
74
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Subjects and Methods
First an ethical clearance was obtained from the
Research Committee, Faculty of dentistry,
University of Khartoum and the head ministries of
the selected kindergartens in order to conduct this
study. A consent letter was sent to the parents of
the selected children through the kindergarten’s
authorities. This was a descriptive, cross-
sectional, pre-school based study on a sample of
preschool children in Khartoum North locality,
Khartoum state, Sudan. A Sample of 419 children
was calculated based on the formula (1.96) 2 × pq
× dmft/d2 taking p = 0.26 from previous study
[13] with a relative error (d) of 6% and design
effect.
Khartoum North locality was divided into four
sectors. A list of all kindergartens was obtained
from the Administration of Preschool Education
at the State Ministry of Education/Khartoum
North. A multi-stage cluster sampling technique
was used to select 5 kindergartens randomly
from each sector. A random cluster consisting
of 21 children were chosen from se l e cted
kindergarten.
A request letter explaining the purposes of the
study was sent to the mothers of the selected
children through the kindergartens authorities.
Mothers were asked to attend the kindergarten and
direct interviewed questionnaires were completed
by the main researcher.
Medically fit Sudanese pre-school children
aged 3-5 years old were included in the study.
Exclusion criteria were children in early mixed
dentition and those whose mothers did not agree
to participate or fail to attend the day for interview.
Examination was carried out by the main
investigator according to WHO 1997 criteria for
caries detection in children [14]. The child was
seated in supine position on an ordinary chair under
day light in front of the examiner in the teacher‘s
office. Examination was carried out using a plane
dental mirror and probe, “dmft” (decayed, missing
and filled teeth index were used.
Statistical Analysis
Data were collected, summarized, cleaned and
coded. All statistical analyses were performed with
the Statistical Package for Social Sciences (SPSS)
program (version 20). Descriptive statistics;
frequency distribution tables, graph, means and
standard deviations were used. Chi square and
median tests were used to study the association
between dental health status and children’s age and
gender respectively. Chi square was applied for
testing the statistical significance of different
relationships between caries status of preschool
children and maternal variables (age, educational
level, occupation and number of children in the
family). For all tests, a level of probability of P
0.05 was considered significant.
Results
The majority 299 (71.4 %) of the children
examined had caries, the mean dmft ± SD was 4.36
± 4.40. A statistically significant association between
dental caries status and child’s age was found
(P=0.00) Figure1.
Fig. 1: Sample distribution according to caries prevalence
It was obvious that caries prevalence increased
with age, the percentage of caries among 3, 4 and 5
years of age was 48.9%, 72.5% and 80.8%
respectively Table1.
Table 1: The association between dental caries status and child’s age
P< 0.05 highly significant association
Age
(years)
Caries
Dmft
Caries Free With Caries Total
Mean
Std.
Deviation SD
P value X
2
N % N % N %
3
45
51.1
43
48.9
88
100
1.72
2.58
0.00*
30.3
4
38
27.5
100
72.5
138
100
4.57
4.45
5
37
19.2
156
80.8
193
100
5.40
4.55
Total
120
28.6
299
71.4 4
419
100
4.36
4.40
Hiba S. Abdul-Jalil & Amal H. Abuaffan / Early Childhood Caries Prevalence in Sudanese Preschool Children
75
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Concerning gender, no statistically significant
difference in dmft was found between boys and girls
Table 2.
No statistically significant correlations were
observed between all maternal variables (age,
educational level, occupation and number of
children in the family) and the prevalence of dental
caries of their preschool children (P < 0.05). It was
noticed that most mothers of caries free children
were between 20-40 years old, had university
educational level, housewives and had 2-5 children
Table 3.
Discussion
This was a cross sectional study, carried out to
determine the caries prevalence among preschool
children 3-5 years old in Khartoum North, Sudan,
and to assess the relationship between maternal
variables and dental caries status of the preschool
children.
In the current study, the mean dmft ± SD was
found 4.36 ± 4.40, only 28.6% of the examined
children were caries free. The result recorded high
caries level in comparison to previous Sudanese
studies where dmft was 1.68 [12]. the dmft was
recorded 3.1 and 3.95 among preschool children
in Uganda [15] and China [4] respectively. However,
dmft in Brazil and Trinidad, values among the same
age group were 1.53 and 1.40 respectively [5,7]. In
contrast, much higher dmft values 10.9 and 11 were
found in UAE and Kosovo respectively [8,9].
Difference in the mean dmft among preschool
children among different populations may be
partially attributed to insufficient dental health
knowledge and poor practices among mothers,
specially on-demand prolonged bottle feeding, high
sweet consumption, poor oral hygiene, lack of
adequate fluoride and irregular dental visits.
Table 2: The association between dental caries status and gender
Age in years Gender Number Mean dmft Std. Deviation T test P-value
3
Boy
37
1.76
2.74
0.097
0.928
Girl
51
1.71
2.48
4
Boy
65
5.28
5.22
1.786
0.079
Girl
73
3.93
3.56
5
Boy
81
4.93
4.46
1.243
0.215
Girl
112
5.75
4.60
Total
Boy
183
4.41
4.65
0.222
0.827
Girl
236
4.31
4.21
Table 3: Relationship between maternal variables and caries status of pre-school children
No statistically significant difference
Maternal
variables
Caries status P-value Χ
2
Caries Free Caries
Count (%) Count (%)
Mother’s age
< 20 yrs
4 (1)
6 (1.4)
20-40 yrs
111 (26.5)
274 (65.4)
0.508
1.35
>40 yrs
5 (1.2)
19 (4.5)
Mother' education level
Illiterate
3 (0.7)
7 (1.7)
Less than High school
4 (1)
20 (4.8)
Competed high school
23 (5.5)
86 (20.5)
University
69 (16.5)
152 (36.3)
Above university
21 (5)
34 (8.1)
0.194
7.89
Mother's Occupation
Professional
15 (3.6)
29 (6,9)
intermediate
20(4.8)
30 (7.2)
Non-manual-mamanual
skilled
17(4.1)
41 (9.8)
semi skilled
0 (0)
0 (0)
non skilled
0 (0)
0 (0)
0.163
5.124
housewife
68 (16.2)
199 (47.5)
Number of children in the
family
One child
19 (4.5)
48 (11.5)
2 -5 children
98 (23.4)
244 (58.2)
0.994
0.012
>5 children
3 (7)
7 (1.7)
P >0.05 statistically insignificant
Hiba S. Abdul-Jalil & Amal H. Abuaffan / Early Childhood Caries Prevalence in Sudanese Preschool Children
76
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Nevertheless, a socioeconomic and cultural
background plays a major role in this issue [1].
The relationship between dental caries and
maternal factors has been well documented in the
literature[4,7,16]. The current study failed to
demonstrate significant correlation between neither
maternal age (p=0.508), educational level (p=0.194),
occupation (p=0.163) nor family size (p=0.994) on
the dental health status of their preschool children.
Similarly, Naidu et al reported no significant
associations between child’s dental health status and
the socio-demographic variables in Trindad [5]. In
contrast, numerous studies reported that parent’s
educational level was critical factor which influence
the children’s dental health [15-19].
In the present study no significant correlation
existed between mother’s age, occupation and
family size with dental caries status of preschool
children. Similarly, the result obtained by Folayan
et al reported no significant association between
neither mother’s age nor family sizes with the child’s
dental caries status [20]. Whereas, Casthilo AR et al
in a systematic review concluded that parent’s age,
educational level and social class were important
factors directly influence their children’s dental
health [21]. Hooley et al descript that lower parent’s
age and level parental occupation was associated
with higher prevalence or severity of dental caries
[16]. Adeniyi A et al found that maternal age,
education were positively correlated with the child’s
caries and oral hygiene status [18].
In Norwegian and Chinese studies, increased
number of siblings was significantly associated
with ECC among preschool children [6, 22, 23]. The
association between financial, social, and
educational factors of mothers and dental caries had
complex interactions; this may explain the diversity
of results among different populations.
Conclusion
The majority of the participated children (71.2 %)
had caries. The mean dmft ± SD was 4.36 ± 4.40.
Dental caries was significantly associated with
children’s age (P=0.00). The data may be of meaning
in planning future oral health prevention and
treatment programmes intentionally preschool
children.
Strengths and Limitations of the Study
This was the second published study in Sudan in
concern to prevalence ECC among preschool
children. Single investigator for interviews and
clinical examination was involved in the current
study to provide best possible consistency and
reproducibility. All children included in the study
were given a written referral to dental clinic
University of Khartoum as needed. Using the WHO
criteria of caries detection without bitewing
radiographs may underestimate the actual
prevalence of dental caries.
Recommendations
School dental health programs, obligatory dental
examinations and tooth brushing exercises should
be implemented in all kindergartens and schools to
promote dental awareness and help in dental caries
prevention. The results of this study can be viewed
as preliminary findings. Further studies for more
representative sample size and different areas in
Sudan should be planned.
Conflict of Interest
We declare that there is no conflict of interest in
this paper
Acknowledgement
The authors gratefully acknowledge all the
children, mothers participated in the study and to
all kindergartens authorities for their cooperation.
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Hiba S. Abdul-Jalil & Amal H. Abuaffan / Early Childhood Caries Prevalence in Sudanese Preschool Children
78
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
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79
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Dipti A Tharani*, Ritesh B. Wadhwani**
Original Article
Histochemical Demonstration of Ghost Cells in
Calcifying Odontogenic Cyst
Abstract
Aim/Background: Ghost cells are seen in calcifying odontogenic cyst (COC) and some other odontogenic
and non-odontogenic lesions. There are varying opinions regarding their origin, nature, significance and
relation in different lesions. It has been stated that ghost cells represent an abnormal type of keratinisation.
This study was done with an aim to demonstrate the ghost cells in COC with one routine stain- hematoxylin-
eosin; and three special stains- Ayoub Shklar, Mallory and van Gieson. Materials and Methods: Four tissue
sections were made from paraffin embedded specimens of COC. Sections were stained with hematoxylin-
eosin stain, Ayoub-Shklar stain, Mallory stain and van Gieson stain respectively. The stained sections were
evaluated for efficacy of the four staining techniques to stain the ghost cells. Results: The ghost cells could
be identified in the sections stained by all the four different stains used in this study. When compared
among all the four stains, Ayoub-Shklar stain and Mallory stain appeared to be better than hematoxylin-
eosin stain and van Gieson stain to discern the ghost cells from rest of the cystic epithelium. Conclusion:
The ghost cells were stained positively by special stains used to demonstrate keratin. It indicates that they
accumulate keratin in their cytoplasm during the pathological transformation process.
Keywords: Ghost Cells; Calcifying Odontogenic Cyst; Keratin.
Author’s Affiliation: *Assistant Professor **Professor,
Department of Dentistry, Government Medical College and
Hospital, Latur, India.
Reprints Requests: Dipti A. Tharani, A1/2 Doctors quarters,
Government Medical College campus, Latur, Maharashtra, India.
413512. Email: diptitharani@gmail.com
Received on 20.05.2017, Accepted on 13.06.2017
Introduction
Ghost cells are the characteristic and distinctive
histologic feature of calcifying odontogenic cyst
(COC). The ghost cells, however, have been
reported to occur in several other odontogenic
lesions in addition to COC such as odontomas,
ameloblastic fibromas, ameloblasstic fibro-
odontomas, and solid/multicystic ameloblastomas.
Furthermore, ghost cells with similar
histomorphologic appearance to those in
odontogenic lesions are found in
craniopharyngiomas and the cutaneous calcifying
epithelioma of Malherbe (pilomatricoma) [1].
The ghost cells are enlarged, ballooned, ovoid or
elongated elliptoid epithelial cells. They are
eosinophilic and although the cell outlines are
usually well-defined, they may sometimes be
blurred so that groups of them appear fused. A few
ghost cells may contain nuclear remnants but these
are in various stages of degeneration and in the
majority all traces of chromatin have disappeared
leaving only a faint outline of the original nucleus.
The ghost cells represent an abnormal type of
keratinisation and have an affinity for calcification.
They have the same histological reactions as
keratin [2].
The nature and content of these cells have been
widely discussed over the years based on
histomorphologic, conventional histochemical, and
ultrastructural investigations. Consequently,
various theories have been proposed. The ghost cells
represent an abnormal type of keratinisation [3].
Some studies report that these cells may represent
the product of coagulative necrosis of odontogenic
epithelium [4]. Some investigators state that ghost
cells represent simple cell degeneration or a form
of enamel matrix. Takata et al have shown that ghost
cells in COCs contain enamel-related proteins in
their cytoplasm [5]. It has also been hypothesised
that they are derived from the apoptotic process of
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DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.2
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
odontogenic cells [6].
Ayoub-Shklar and Mallory are special
histochemical stains used to stain keratin
specifically. Van Gieson stain, a trichrome stain for
connective tissue, also stains keratinised epithelium.
As it is stated that the ghost cells represent an
abnormal type of keratinisation, we carried out this
study to demonstrate the ghost cells in COCs with
one routine stain- hematoxylin-eosin; and three
special stains- Ayoub-Shklar, Mallory and van
Gieson.
Materials and Methods
Four sections of 4 micron thickness were made
from paraffin embedded specimens of calcifying
odontogenic cyst. Sections were stained with
hematoxylin and eosin stain, Ayoub-Shklar stain,
Mallory stain and van Gieson stain respectively.
Hematoxylin-Eosin Staining Technique
1. The section was deparaffinised in xylene and
brought to water through decreasing grades of
alcohol.
2. Then it was stained in Harri’s hematoxylin for
5 minutes.
3. After water wash, the section was differentiated
with 1% acid alcohol.
4. Bluing was done by keeping the slide in running
tap water for 5 minutes.
5. It was then stained with eosin for 5 seconds.
6. Dehydrated with alcohol, cleared in xylene and
mounted.
Ayoub-Shklar Staining Technique
Materials used
1. 5% acid fuschin solution
2. Aniline blue orange G solution
Aniline blue (water soluble)- 0.5 gm
Orange G- 2gm
Phosphotungstic acid- 1 gm
Distilled water- 100 ml
Staining Procedure
1. The section was deparaffinised in xylene and
brought to water through decreasing grades of
alcohol.
2. The slide was then placed in 5% acid fuschin
solution for 3 minutes.
3. Then transferred to aniline blue orange G
solution for 45 minutes.
4. Section transferred to 95% alcohol, 3 changes.
5. Section was dehydrated in alcohol, cleared and
mounted.
Mallory Staining Technique
Materials used
1. 3% potassium dichromate solution
2. 0.1% acid fuschin solution
3. 1% phosphomolybdic acid
4. Mallory II solution
Staining Procedure
1. The section was deparaffinised in xylene and
brought to water through decreasing grades of
alcohol.
2. It was then placed in 3% potassium dichromate
solution for 2 hours.
3. Then rinsed in distilled water several times until
water remained clear.
4. The section was stained with 0.1% acid fuchsin
for 15 seconds.
5. It was rinsed properly in distilled water.
6. Section was stained in 1% phoshomolybdic acid
for 2.5 minutes.
7. Then rinsed properly in distilled water.
8. It was stained in Malory II solution for 25
seconds.
9. Then rinsed in distilled water, dehydrated,
cleared and mounted.
Van Gieson Staining Technique
Materials used
1. Weigert’s hematoxylin
2. van Gieson solution
Staining Procedure
1. The section was deparaffinised in xylene and
brought to water through decreasing grades of
alcohol.
Dipti A Tharani & Ritesh B. Wadhwani / Histochemical Demonstration of Ghost Cells in Calcifying Odontogenic Cyst
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
2. It was stained in Weigert’s hematoxylin for 1
min.
3. The section was then washed in tap water and
differentiated with 1% acid alcohol.
4. Bluing was done by washing the section in
running tap water.
5. Then it was stained with van Gieson solution
for 3 minutes.
6. Dehydrated in alcohol, cleared and mounted.
The stained sections were evaluated for efficacy
of the four staining techniques to stain the ghost
cells.
Results
The ghost cells could be identified in the sections
stained by all the four different stains used in this
study. In hematoxylin and eosin stained section the
ghost cells appeared as enlarged, elongated
epithelial cells which were eosinophilic in
appearance with well defined cell outlines and loss
of nucleus in some cells (Figure 1,2).
When stained with Ayoub-Shklar stain, the ghost
cells appeared as brilliant red with well defined cell
outlines. The ghost cells could be differentiated from
rest of the epithelial cells which were stained as blue
(Figure 3,4).
In sections stained with Mallory stain, the ghost
cells appeared as orange in colour and could be
differentiated from rest of the non-keratinised
epithelial lining which appeared blue in colour
(Figure 5,6).
van Gieson stained sections showed ghost cells
appearing yellow in colour with well defined cell
outlines. They could be differentiated from rest of
the non-keratinised epithelium and the underlying
connective tissue component (Figure 7,8).
When compared among all the four stains, Ayoub
Shklar stain and Mallory stain appeared better than
hematoxylin-eosin stain and van Gieson stain to
discern the ghost cells from rest of the cystic
epithelium in COC.
Fig. 1: H and E stain. Eosinophilic ghost cells appearing as
enlarged, elongated epithelial cells (10x magnification)
Fig. 2: H and E stain. High power view of ghost cells as seen in
figure 1 (40x magnification)
Fig. 3: Ayoub-Shklar stain. Ghost cells appearing as brilliant red
in distinction to the rest of the blue staining epithelium (10x
magnification)
Fig. 4: Ayoub-Shklar stain. High power view of ghost cells as seen
in figure 3 (40x magnification)
Dipti A Tharani & Ritesh B. Wadhwani / Histochemical Demonstration of Ghost Cells in Calcifying Odontogenic Cyst
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Fig. 5: Mallory stain. Ghost cells appearing as orange in distinction
to the rest of the blue staining epithelium (10x magnification)
Fig. 6: Mallory stain. High power view of ghost cells as seen in
figure 5 (40x magnification)
Fig. 7: van Gieson stain. Ghost cells appearing yellow in colour.
Underlying connective tissue appearing red. (10x magnification)
Fig. 8: van Gieson stain. High power view of ghost cells (40x
magnification)
Discussion
Ghost cells are seen in COC and few other
odontogenic and non-odontogenic lesions. They
have been a topic of controversy since a long time.
Controversy arises because of the fact that there are
varying opinions regarding their origin, nature,
significance and relation in different neoplasms.
Various theories have been put forward
regarding the nature of ghost cells. There are
different reports suggesting ghost cells as a form of
true keratinisation [7], abnormal/aberrant
keratinisation [3], cells which have lost their
developmental and inductive effect [8], special form
of degeneration [9], or formed as a result of
coagulative necrosis of odontogenic epithelium [4].
Few investigators state that ghost cells represent
enamel matrix which probably could not completely
calcify because of the absence of odontoblasts and
dentin [10].
Special stains are the stains that are used to
visualize specific tissues and cellular structures.
These are the dyes that bind to the cellular
components either physically or by chemical bonds.
Special stains for keratin are indicated to
differentiate and emphasize small foci of abnormal
keratinization. Examples include Ayoub-Shklar and
Mallory. Trichrome stain such as van Gieson, used
to stain connective tissue elements can differentiate
epithelium from the underlying collagenous
connective tissue.
In our study the ghost cells present in COCs were
stained by hematoxylin-eosin stain and all the three
special stains. The ghost cells were better seen in
sections stained with Ayoub-Shklar and Mallory
stains as compared to hamatoxylin-eosin and van
Gieson stains.
As the former two stains are used specifically to
stain keratin, the results of our study emphasise the
fact that the ghost cells accumulate keratin in their
cytoplasm during the pathological transformation
process. This is in accordance with the previous
literature on this particular kind of cell.
Thus the staining reaction of ghost cells appeared
to be similar to keratin. But certain immunohisto-
chemical investigations on cytokeratins in the ghost
cells of COCs failed to demonstrate positive staining
for different kinds of keratin [4, 11].
Hong et al expressed the opinion that the
characteristics of ghost cells are compatible with the
features of coagulative necrosis of odontogenic
epithelium [4]. Based on immunohistochemical
Dipti A Tharani & Ritesh B. Wadhwani / Histochemical Demonstration of Ghost Cells in Calcifying Odontogenic Cyst
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
investigations Takata et al concluded that ghost cells
in COCs contain enamel-related proteins in the
cytoplasm accumulated during the process of
pathologic transformation [5]. Ultrastructural
findings have revealed that these cells represent an
aberrant or unusual form of keratin and not true
keratin [12].
To gain insight into the true nature of ghost cells
further studies at molecular level can be done.
References
1. Reichart PA, Philipsen HP. Odontogenic tumors and
allied lesions. Quintessence Publishing Co. Ltd.,
London, UK, 2004.
2. Shear M, Speight P. Cysts of the oral and
maxillofacial regions. 4
th
ed. Blackwell Munksgaard,
Oxford UK, 2007.
3. Gorlin RJ, Pindborg JJ, Clausen FP, Odont, Vickers
RA. The calcifying odontogenic cyst: A possible
analogue of the cutaneous calcifying epithelioma of
Malherbe. An analysis of fifteen cases.Oral Surg Oral
Med Oral Pathol.1962;15:1235–43.
4. Hong SP, Ellis GL, Hartman KS. Calcifying
odontogenic cyst. A review of ninety-two cases with
reevaluation of their nature as cysts or neoplasms,
the nature of ghost cells, and subclassification. Oral
Surg Oral Med Oral Pathol.1991;72:56–64.
5. Takata T, Zhao M, Nikai H, Uchida T, Wang T. Ghost
cells in calcifying odontogenic cyst express enamel-
related proteins. Histochem J. 2000;32:323-9.
6. Kim J, Lee EH, Yook JI, Han JY, Yoon JH, Ellis GL.
Odontogenic ghost cell carcinoma: A case report with
reference to the relation between apoptosis and ghost
cells.Oral Surg Oral Med Oral Pathol Oral Radiol
Endod.2000;90:630–5.
7. Smith JF, Blankenship J. The calcifying odontogenic
cyst. Report of a case.Oral Surg Oral Med Oral
Pathol.1965;20:624–31.
8. Kerebel B, Kerebel LM. Ghost cells in complex
odontoma: A light microscopic and SEM study.Oral
Surg Oral Med Oral Pathol. 1985;59:371-8.
9. Chaves E, Pessôa J. The calcifying odontogenic cyst.
Report of two cases.Oral Surg Oral Med Oral
Pathol.1968;25:849–55.
10. Freedmen PD, Lumerman H, Gee JK. Calcifying
odontogenic cyst. A review and analysis of seventy
cases.Oral Surg Oral Med Oral Pathol.1975;40:
93–106.
11. Lukinmaa P-L, Leppaniemi A, Hietanen A, et al.
Features of odontogenesis and expression of
cytokeratins and tenascin-C in three cases of
extraosseous and intraosseous calcifying
odontogenic cyst. J Oral Pathol Med. 1997;26:
265-72.
12. Regezi JA, Courtney RM, Kerr DA. Keratinization
in odontogenic tumors. Oral Surg Oral Med Oral
Pathol. 1975;39:447-55.
Dipti A Tharani & Ritesh B. Wadhwani / Histochemical Demonstration of Ghost Cells in Calcifying Odontogenic Cyst
84
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Shishir Shah*, Shilpi S. Shah**
Original Article
Establishment of a Casual Relationship between Hemoglobin and
Chronic Periodontitis
Abstract
“What is the 1
st
diagnostic finding that a periodontist looks in his patient’s mouth”? Bleeding on probing
and “what are the most important diagnostic tests which he tends to miss? Erythrocyte counts, Hb levels,
microhematocrit values. These are the diagnostic tests which are missed by dentist and are of paramount
importance in medicine for providing multifactorial measures of systemic response to infections/
inflammatory diseases. Epidemiological studies suggest that periodontitis is associated with increased
risk of systemic diseases like cerebrovascular disease, cardiovascular ischemia, atherosclerosis. A lot of
association of chronic systemic disorders leading to anemia has been totally proven in medicine. In chronic
diseases like parasitic infections, bacterial and fungal infections, neoplastic illnesses anemia has been noted
and hence it has been given the term anemia of chronic disease. Also periodontitis patients show various
acute/ chronic immune activation and may develop anemia called anemia of chronic disease. Despite a lot
of association of periodontitis and various systemic conditions very little work has been attempted at
association between periodontitis, hemoglobin levels and erythrocyte counts with very few available reports
by Scannapieco, Philip et al., JW Hutter. Hence this original research study was undertaken to investigate
the possible relation between periodontal disease and Hb levels in systemically healthy subjects compared
to chronic severe periodontitis subjects.
Keywords: Periodontitis; Hemoglobin; Anemia of Chronic Disease.
Author’s Affiliation: *Associate Professor, Department of
Dentistry, GMERS Medical College and Hospital, Sola,
Ahmedabad, Gujarat. **Reader, Dept of Periodontology and
Implantology, Ahmedabad Dental College and Hospital,
Ahmedabad, Gujarat.
Reprints Requests: Shilpi S. Shah, J3, Birju Appts, Opp. Azad
Society, Polytechnic, Satellite Area, Ahmedabad-380015.
E-mail: drpiyushpujara@gmail.com,
smilecostsnothing@gmail.com
Received on 25.04.2017, Accepted on 08.04.2017
Introduction
Periodontitis is a multifactorial disease. Since time
immemorial dentists have known and tried to
achieve a healthy mouth as a window to healthy
body. In the 1
st
half of 20
th
century the evidence of
interrelationship between periodontitis and
systemic conditions was primarily anecdotal but
dentistry has come a long way and a new paradigm
in dentistry in general and periodontology in
particular has arrived. A lot of association of chronic
systemic disorders leading to anemia has been
totally proven in medicine e.g. mild to moderate
anemia has been reported as a frequent
manifestation of rheumatoid arthritis [6,7,8]. In
chronic diseases like parasitic infections, bacterial
and fungal infections, neoplastic illnesses anemia
has been noted and hence it has been given the term
anemia of chronic disease [8,9,10].
Also periodontitis patients show various acute/
chronic immune activation and may develop
anemia called Anemia of Chronic Disease.
Despite a lot of association of periodontitis and
various systemic conditions very little work has
been attempted at association between periodontitis,
hemoglobin levels and erythrocyte counts with very
few available reports by Scannapieco, Philip et al.,
JW Hutter et al [11,12]. In a study by J.W. Hutter
he suggested that proinflammatory cytokines from
chronic disease process like periodontitis down
regulate the erythropoiesis in bone marrow. In
particular interleukin-1, interleukin-6, tumor
necrosis factor-a have been implicated as cytokines
responsible for suppressing erythropoiesis.
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DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.3
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Similarly in other studies also, periodontitis patients
showed decreased levels of hemoglobin and
erythrocyte counts leading to anemia in
periodontitis patients. But still there is a paucity of
literature to correlate between hemoglobin levels
and chronic periodontitis patients.
Hence this original research study was
undertaken to investigate the possible relation
between periodontal disease and Hb levels in
systemically healthy subjects compared to chronic
severe periodontitis subjects.
Materials and Methods
The Present study was conducted in the outdoor
patient department of Ahmedabad dental college
and hospital, GMERS Medical College and Hospital,
Sola. A total of 60 subjects were included in the
study. The subjects were divided into 2 groups
consisting of 30 subjects in each group.
Inclusion Criteria Were
1. Controls: 30 patients with healthy periodontal
condition with all teeth present (except 3
rd
molar).
2. Cases: 30 subjects with severe chronic
periodontitis with probing attachment loss of
more than 7 mm (Figure 7).
3. Age Group: 35-44 years (W.H.O.).
4. Only Patients with normal microhematocrit
values (MCV, MCH, and MCHC) were
included in the study.
Exclusion Criteria Were
1. Patient who suffered with any acute / chronic
medical condition apart from periodontitis.
2. Any viral, fungal and bacterial infection apart
from periodontitis.
3. Pregnant women.
4. Habits like smoking, tobacco etc.
5. Any other systemic disease.
Methodology
Blood from EDTA bulb is aspirated from sample
probe into sample rotor value. 4.0 ml of blood
measured by sample rotor value is diluted into 1:500
with 1.996 ml of diluent and brought to the mixing
chamber as diluted sample (1
st
step dilution). Out
of 1:500 dilution sample, 40 mL is measured by the
sample rotor value, diluted into 1:25000 with 1.960
ml of diluent, then transferred to the RBC
transducer (2
nd
step dilution). 250 mL of sample in
the RBC transducer chamber is aspirated through
aperture. At this time RBC is counted through DC
detection method. At the same time hematocrit
(HCT) or packed cell volume is calculated by RBC
pulse height detection method.
Statistical Analysis
Data The data was coded and entered into
Microsoft Excel spreadsheet. Analysis was done
using SPSS version 15 (SPSS Inc. Chicago, IL,
USA) Windows software program. Descriptive
statistics included computation of percentages.
For all tests, confidenc e level and level of
significance were set at 95% and 5% respectively.
Means of both groups were compared by
independent student t-test.
Results
Average mean age of cases is 40.46±2.92 and for
controls is 41.93±2.82 (Table 1). Mean values of four
parameters in severe chronic periodontitis are as
follows. MCV: 82.61±1.7, MCHC: 31.85±1.7, MCH:
28.48±2.29, HB: 14.66±2.1. Mean values of four
parameters in Healthy Subjects are as follows.
MCV: 83.11±2.1, MCHC: 32.16±2.21, MCH:
26.9±1.7, HB: 10.8±1.22 (Table 2). In our study,
overall data analysis showed that periodontitis
patients have lower hematorcit values (Table 3 and
Table 4).
Table 1: Mean and standard deviation of age group between the 2 groups (severe chronic periodontitis)
cases and controls (healthy subjects)
Controls Cases
Mean SD Mean SD
Age 40.467 2.921 41.93 2.815
SD: Standard Deviation
Shishir Shah et. al. / Establishment of a Casual Relationship between Hemoglobin and Chronic Periodontitis
86
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Discussion
Epidemiological studies suggest that
periodontitis is associated with increased risk for
systemic diseases like cardiovascular disease,
cerebrovascular ischemia, atherosclerosis and
preterm low birth weight [1].
In previous studies, it
has also been shown that periodontitis has elevated
WBC levels, elevated C-reactive protein levels,
which indicates that periodontitis has systemic
effects. Very few studies have been done considering
periodontitis red blood cell interrelationship
[2,3,4,5].
Chronic infections and subgingival microbiota
have been observed as factors affecting the red blood
cell counts in periodontitis patients. The association
of anaemia with infection and chronic systemic
disorders has been well established. But anaemia
has not been identified as a systemic consequence
of periodontitis. In our study, overall data analysis
showed that periodontitis patients have lower
hematorcit values (Table 3 and Table 4).
Consequently, in the study lower levels of
hemoglobin was noted although Hemoglobin per
erythrocyte (MCH and MCHC) is comparable
between controls and periodontitis. A few early
reports in literature have observed anemia in
periodontitis patients [11,12,13].
On the contrary, a
study by Siegel have led to believe that anemia was
one of the causes of destructive periodontitis rather
than to regard this phenomenon as a consequence.
Table 2: Mean and standard deviation (SD) of 4 parameters in severe chronic periodontitis and healthy subjects
Controls Cases
Mean SD Mean SD
MCV
82.613
1.767
83.11
2.01
MCHC 31.85 1.705 32.16 2.21
MCH
28.487
2.293
26.9
1.7
Hb
14.667
2.108
10.8
1.22
SD: Standard Deviation
Table 3: Intercomparison of microhematocrit levels using students unpaired‘t’ test
MCV MCHC MCH
Healthy
Chronic severe periodontitis
P=0.31
NS
P=0.54
NS
P = 4.0 x 10
-3
S
Hb
Healthy
Chronic severe periodontitis
P=3.4 x 10
-12
HS
Statically significant difference at p=0.05
Test of significance- unpaired‘t’test
Table 4: Intercomparison of Hb counts using students unpaired ‘t’ test
Statically significant difference at p=0.05
Test of significance- unpaired‘t’test
Also in our study, the lower number of lower levels
of hemoglobin in chronic severe periodontitis
subjects compared to controls are not due to iron
or vitamin deficiencies as the MCV levels are nearly
the same between periodontitis and control groups.
This has been supported by earlier studies done by
Ward, Samson who have reported that depressed
MCV levels (microcytosis) or elevated levels of
MCV (macrocytosis) relate anemia to iron or
vitamin deficiencies respectively.
Mild to moderate anemias have been reported
as a frequent manifestation of rheumatoid arthritis
[7,8,15] and chronic diseases like parasitic diseases
hence the name anemia of chronic disease (ACD),
is one of the most common syndromes in medicine
[8,16].
Recent literature has also considered Periodontitis
as a chronic disease and therefore has been grouped
under the syndrome of “anemia of chronic disease”.
The anemia of chronic disease is multifactorial.
However, it is currently thought that
proinflammatory cytokines from given chronic
disease process may downregulate erythropoiesis
in bone marrow [13]. In particular IL-1, IL-6 and
Tumour necrosis factor –alpha have been implicated
as cytokines responsible for suppressing
erythropoiesis. The pathogenesis of periodontitis
having an effect on red cell counts is most likely
similar as reported for rheumatoid arthritis.i.e.,
depressed erythopoiesis by systemically circulating
proinflammatory cytokines resulting from chronic
Shishir Shah et. al. / Establishment of a Casual Relationship between Hemoglobin and Chronic Periodontitis
87
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
inflammatory process. In support of this concept is
the observed systemic levels of IL-6 in about 1/3
rd
of patients with localized periodontitis and half of
patients with generalized periodontitis [5,14].
The two factors chronic Infection and
Subgingival microbiota may be considered as
factors that lead to increased levels of
proinflammatory cytokines in the plasma of chronic
periodontitis patients. These factors acting together
lead to suppression of HEMOGLOBIN,
erythropoeisis and anemia.
But still there is paucity of literature to see the
correlation between erythrocyte count, Hb and
periodontal diseases and also the specific processes
in the pathogenesis. Additional studies are
necessary to better define the relationship between
periodontal conditions and red cell parameters.
Conclusion
Chronic infection and sub gingival microbiota
have been observed as factors affecting the red blood
cell counts in periodontitis patients. The factors
acting in conjunction lead to suppression of
Hemoglobin,erythropoiesis and thus leading to
anemia.
Nonetheless, further longitudinal studies and
applied research is required in this area to unveil
the exact mechanism underlying the causation of
anemia in chronic periodontitis and also to provide
a better understanding of the relationship between
periodontal conditions and red cell parameters.
Thus chronic periodontitis like other chronic
conditions may tend towards anemia therefore
improvement in periodontal status may tend
towards an improvement in the anemia to some
extent.
References
1. Scannapieco FA. Position paper. Periodontal disease
as a potential risk factor for systemic diseases. J
Periodontol 1998; 69:841-850.
2. Kweider M, Lowe GDO, Murray GD, Kinane DF and
McGowan DA. Dental disease, fibrinogen and white
cell count; Links with myocardial infarction? Scottish
Medical Journal 1993; 38:73-74.
3. Ebersole J, Machen RL, Steffen M and Willman D.
Systemic acute phase reactants, C-reactive protein
and haptoglobulin, in adult periodontitis. Clinical
Experimental Immunology 1997; 107:347-352.
4. Wakai K, Kawamura T, Umemura O, Hara Y,
Machida J, Anno T, Ohno Y. et al. Associations of
medical status and physical fitness with periodontal
disease. J Clin Periodontol 1999; 26:664-672.
5. Loos BG, Craandijk J, Hoek FJ, Werthim-Van Dillen
PME and Vander Velden U. Elevation of systemic
markers related to cardiovascular diseases in the
peripheral blood of periodontitis patients. J
Periodontol 2000; 71:1528-1534.
6. Mowat AG. Anaemia of rheumatoid arthritis –
Modern trends in rheumatology 1971; 2:106-116.
7. Hansen NE. The anemia of chronic disorders.
Scandinavian Journal of Hematology 1983;
31:397-402.
8. Lee GR. The anemia of chronic disease. Seminars in
Hematology 1983; 20:61-80.
9. Barrett-Connor E. Anemia and infection. The
American Journal of Medicine 1972; 52:242-253.
10. Samson D. The anemia of chronic disorders.
Postgraduate Medical Journal 1983; 59:543-550.
11. Phillip A. Lainson, Patrik P. Brady, Claud M.
Fraleigh. Anemia – A systemic cause of periodontal
disease? J Periodontol 1968; 39:35-38.
12. JW Hutter, U Vandervelden, A aroufaki, RAM
Huffels, FJ Hoek and BG Loos. Lower number of
erythrocytes and lower levels of hemoglobin in
periodontitis patients compared to control subjects.
J Clin Periodontol 2000; 28:930-936.
13. Siegel EH. Total erythrocyte, leukocyte and
differential white cell counts of blood in chronic
periodontal disease. J Dent Res 1947; 24:270.
14. Loos BG. Systemic markers of inflammation in
periodontitis. J Periodontol 2005; 76(11):2106
15. Vreugdenhil G, Baltus CAM, Van Eijk HG and Swaak
AJG. Prediction and evaluation of the effect of iron
treatment in anemic RA patients. Clinical
Rheumatology 1989; 8(3):353-362.
16. Guenter Weiss and Lawrence T. Goodnough.
Anemia of chronic disease. Review 2005; 352(10):
1011-1023.
Shishir Shah et. al. / Establishment of a Casual Relationship between Hemoglobin and Chronic Periodontitis
88
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Saritha Maloth*, Padmashree S.**, Pramod Krishna B.***
Original Article
A Radiological Study on the Visualization of the Anterior Loop of
Mandibular Canal Using Panoramic Radiography
Abstract
Background: The anterior loop is a prolongation of the neurovascular bundle of mandibular canal anterior
to the mental foramen. This structure cannot be seen clinically but can be detected in radiographs. It is an
important presurgical landmark of the mental interforaminal area during radiographic analysis. Aims: To
determine the visibility of anterior loop in the mandible on panoramic radiographs. Material and Methods:
Total 480 Panoramic radiographs of dentate patients with completely erupted lower premolars and molars
were selected for the study. Subjects were divided into five different age groups. The radiographs were
assessed for visibility of anterior loop. Anterior loop status was categorized as present on both sides,
present on right side only and present on left side only. Statistical Analysis: Cross tabulations followed by a
chi-square test were performed to compare the significance of categorical findings with respect to age
group and gender. A P-value of less than 0.05 was considered as statistically significant. Results: One or
more anterior loops were visible in 41% of radiographs. Anterior loops were most commonly visible
bilaterally in 29.2% of radiographs followed by right side 7.5% and left side 4.3%. Visibility of anterior
loop reduced with increased age of the subjects. There was no association between visualization of the
anterior loop and subject gender. Conclusion: In our present study, the radiographic appearance of anterior
loop was present in significant percentage of cases. Prevalence of the anterior loop can be overlooked and
should be carefully identified before any surgical procedures in the mental interforaminal region.
Keywords: Anterior Loop; Mental Foramen; Panoramic Radiographs.
Author’s Affiliation: *Associte Professsor, Department of
Dentistry, KIMS, Koppal, India **Professor and Head, Dept of Oral
Medicine and Radiology, Vydehi institute of dental sciences,
Bangalore, India. ***Professor, Dept of Oral and Maxillofacial
surgery, Farooqia Dental College and Hospital, Mysore, India.
Reprints Requests: Saritha Maloth, Associate Professor,
Department of Dentistry, Koppal institute of medical sciences,
Koppal, Karnataka, India.
E-mail – saritha.maloth@gmail.com
Received on 06.02.2017, Accepted on 13.02.2017
Introduction
One of the common complications that can occur
following surgical procedures in the mental
interforaminal region of anterior mandible is
neurosensory alterations in the chin and lower lip.
This complication can occur if vital structures such
as mental foramen and anterior mental loop are not
properly identified and protected [1]. The mental
nerve extends beyond the mental foramen boundary
as intraosseous anterior loop that can be detected
using appropriate radiographic techniques [2].
Anterior loop is referred as the mental canal which
rises from the mandibular canal and runs outwards,
upwards and backwards to open at the mental
foramen (Sichers oral anatomy) [3]. Very few studies
have been undertaken to recognize anterior loop
radiographically. Panoramic radiographs are
routinely used to locate anatomical landmarks for
planning surgical procedures in interforaminal
regions to avoid post operative complications [4].
Hence this study was undertaken to determine the
visibility of anterior loop in the mandible on digital
panoramic radiographs and to determine the effect
of aging and gender on visualization of the anterior
loop on panoramic radiographs.
Materials and Methods
A total of 480 dental panoramic radiographs
taken for routine diagnostic purposes in the
department of Oral Medicine and Radiology were
selected for the study. All panoramic radiographs
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DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.4
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
were taken using Planmeca machines. Only good
Quality radiographs of dentate patients with
completely erupted lower premolars and molars
were selected for the study. The magnification
factors reported by the manufacturers were 1.2 and
1.25 respectively. The planmeca X- ray machine was
operated at 66 kvp, 10 ma for 13 sec. All the subjects
or patients were divided into five different age
groups as follows: 14-24 yrs, 25-35yrs, 36-46yrs, 47-
57 yrs and 58 yrs and older. The radiographs were
selected based on the following criteria.
1. High quality radiographs with respect to
geometric accuracy and contrast of the image.
2. Teeth present between lower first molars on
right and left side.
3. Radiographs with no deep caries,
endodontically treated tooth or various large
restorations in lower teeth.
4. Radiographs free from any radiolucent or
radioopaque lesions in the lower arch /
mandible and with no evidence of jaw fracture
around the mental foramen and mandibular
canal region.
5. Radiographs with no supernumerary
unerupted teeth in the mental foramen region.
6. Radiographs devoid of any radiographic
exposure or processing errors and artifacts.
The radiographs were placed on a well
illuminated view box and viewed with a magnifying
lens. The radiographs were interpreted
independently by two observers and differences in
the results were discussed and reabsorbed for
conclusion. If there was any difference in the results
then a third observer with experience in Oral
Radiology would make the final evaluation. We first
identified the mental foramen according to the
description of Yosue and Brook [5] and then
determined whether an anterior loop was present
or absent. The typical appearance of the anterior
loop on a dental panoramic radiograph is shown in
Figure 1.
Anterior loop status was divided into four
categories such as
I. Present on both sides
II. Present on right side only
III. Present on left side only
IV. Absent
Data and Statistical Analysis
All calculations were processed using SPSS
statistical software. Cross tabulations followed by
a chi-square test were performed to compare the
significance of categorical findings with respect to
age group and gender. A P-value of less than 0.05
was considered as statistically significant.
Results
A total of 480 panoramic radiographs that fulfilled
the criteria were selected. They were divided
according to age group into five subgroups (Table
1). This study included 257 male and 223 female
subjects and their distribution according to age
groups is shown in Figure 2. Table 2 shows
visibility of anterior loops according to age groups
and subject gender. The number of subjects (and
hence the radiographs) that fulfilled the criteria
reduced as the age of subjects increased. At least
one anterior loop was visualized in 41% of
radiographs. Most of the anterior loops were
visible bilaterally (29.2%) followed by on right side
( 7.5% ) and only 4.3%. on left side It was not visible
in 59% of cases. More than 30% of subjects aged
14-35yrs had bilaterally visible anterior loop and
this gradually reduced to only 3.5% in subjects
aged above 58yrs. It was more c ommonly
identified in males (51%) than in females (49%).
The anterior loop was most frequently visible
bilaterally in both the gender. There was no
significant difference in visibility of anterior loop
by gender.
Table 1: Distribution of the number of subjects according to age groups
Age Group(yrs) Number of subjects ( Radiographs ) Percentage
14-24
25-35
36-46
47-57
>58
168
151
69
48
44
35.00
31.46
14.38
10.00
9.17
Total 480 100
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Canal Using Panoramic Radiography
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Discussion
The inferior alveolar nerve is a major sensory
branch of mandibular division of trigeminal nerve.
It runs through the mandibular canal and divides
Age Groups (yrs) Gender (n) Present (frequency) Absent (frequency)
Both side(I)
Right (II)
Left (III) ( IV)
14-24
F (89)
28
7
5
49
M(79)
30
5
3
41
25-35 F(66) 24 3 4 35
M(85)
27
4
3
51
36-46
F(32)
8
5
0
19
M(37)
10
3
2
22
47-57
F(25)
4
4
2
15
M(23)
5
3
1
14
Above 58y
F(11)
2
0
0
9
M(33)
2
2
1
28
Table 2: Visibility of anterior loops according to age groups and gender of the subjects on panoramic radiographs
M=Male; F= Female
Fig. 1: The appearance of the anterior loop on a dental panoramic
radiograph
Fig. 2: Gender distribution of subjects according to age groups.
The total number of subjects 480; male and female subjects were
257 and 223, respectively.
into terminal branches in the premolar region as
mental nerve and incisive nerve.
The mental nerve is the largest branch of inferior
alveolar nerve. Usually three mental nerve branches
emerge out of mental foramen [6]. It passes through
the mental canal as an intraosseous anterior loop
and emerges from the mental foramen to supply
sensory innervations to skin of the lower lip, mucous
membrane and gingiva of mental region. The
incisive neurovascular bundle continues within the
incisive canal to supply lower anterior teeth.
Anterior loop cannot be seen clinically but can
be detected in radiographs such as dental panoramic
radiographs, Computed Tomography, CBCT and
MRI. Several studies on cadaveric mandible have
shown that the prevalence of anterior loop is 61.5 –
96% with symmetric occurrence in 76.2% [1].
Radiographic studies by Yosue and Brooks
5
revealed presence of anterior loop in 21% of 297
radiographs. While Jacobs et al [8] noticed 11% of
anterior loop visible in panoramic radiographs but
only 3% were well visualized. Similarly, about 12%
was reported in a study by Arzouman et al as
viewed on dental panoramic radiograph [3].
Various studies have shown wide variation in
anterior loop length [9]. Due to variation in length,
a fixed distance mesially from mental foramen
cannot be assumed even with current
recommendation of a safety margin of 4-6mm [10].
No consistent results on visualization of anterior
loop on panoramic radiographs are found. Study
done by Iyengar et al showed a visibility of anterior
loop on at least one side in only 21% of total
radiograph examined [4]. In a study by Neha singh
et al, only 10% cases showed presence of anterior
loop [4]. The visibility of the anterior loop was noted
in 49% males and 51% in female subjects. Studies
by Kuzmanovic et al (27%)
[11], Yosu and Brooke
(21%) [5], Jacob et al (11%) [8] and Arzouman et al (
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Canal Using Panoramic Radiography
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
12%) [3] reported variation in incidence of visibility
of anterior loop in panoramic radiographs. Failure
to view anterior loop does not definitively mean it
is absent and it may be due to limitation in the ability
to visualize the anterior loop. We performed our
study using panoramic radiograph as it is the most
routinely used imaging technique.
Many reasons attribute to under examination of
anterior loop on plain films. Poor radiographic bone
quality, distorted images or obscured images [12],
inability to distinguish anterior loop from trabecular
pattern because anterior loop is an intramedulary
structure that is located in an area with thick cortical
plates [3]. Studies have shown that the identification
of anterior loop reduced with increased age of the
subjects. Results were similar to our study. This
could be attributed to reduced calcification of cortex
and enlarged marrow spaces and disordered
trabeculae [13]. Percentage of absence of anterior
loop in older subjects was high due to quantitative
and qualitative changes in bone [7].We selected
dentate subjects for our study as alveolar bone
undergoes resorption as reported [14] following loss
of teeth
thus affecting visualization of the anterior
loop of the mental canal. We used panoramic
radiographs in our study as it is the most commonly
used diagnostic tool in preoperative evaluation of
implant site and not much study has been
undertaken in Indian population. In a comparative
study using panoramic radiographs and CBCT
using human cadaver heads by Hu et al [15]
concluded that the mandibular panoramic
radiographs can be used safely. Different studies
have shown that the panoramic radiographs are
unreliable in assessing anterior loop due to inherent
limitations of tomographic layer to capture the
entire areas appropriately [4].
Ngeow et al [16]
showed that the anterior loop
was visible in 40.2% dental panoramic radiographs
and was often observed bilaterally followed by right
side only similar to our study. Arzouman et al
identified anterior loop on panoramic radiographs
in 56-76% using different panoramic machines [3]
.
Many authors have concluded that panoramic
radiography is not sufficient for presurgical implant
planning in the mental region and may need to be
supplemented with other modalities such as CT,
CBCT for better visualization of the area [2].
Dissimilar diagnostic technique may be the reason
for diverse findings. In case the AL of the mental
nerve cannot be determined definitely, a safe
guideline of about 6 mm to the most anterior point
of the mental foramen need to considered to avoid
any neurological complication.
References
1. Walton JN. Altered sensation associated with
implants in the anterior mandible: a prospective
study. J Prosthet Dent. 2000; 83(4):443-9.
2. Anatomy of mandibular vital structures. Part II:
Mandibular incisive canal, mental foramen and
associated neurovascular bundle in relation with
dental implantology. J Oral Maxillofasc Res. 2010;
1(1):e3, 1-10.
3. Arzouman MJ, Otis L, Kipnis V, Levine D.
Observation of the anterior loop of the inferior
alveolar canal. Int J Oral maxillofac implants. 1993;
8:295-300.
4. Neha Singh, Prashant P Jain, Sushma Jaju, Rohit
Agarwal. Detection of anatomical variations in
mandible by panoramic radiography. Journal of
cranio- maxillary diseases. 2014; 3(2);95-100.
5. Yosue T, Brooks SL. The appearance of mental
foramina on panoramic radiographs. I. Evaluation
of patients. Oral Surg Oral Med Oral Pathol. 1989;
68: 360-364.
6. Mraiwa N, Jacobs R, Merman P, Lambrichts I, Van
Steenberghe D, Quirynen M. Presence and course of
the incisive canal in the human mandibular
interforaminal region: two dimensional imaging
versus anatomical observations. Surg Radiol Anat.
2003; 25(5-6)416-23.
7. Wei Cheong Ngeow, Dionetta D Dionysius, Hayati
Ishak, Prabhakaran Nambiar. A radiographic study
of the visualization of the anterior loop in dentate
subjects of different age groups. Journal of Oral
Science. 2009; 51(2):231-237.
8. Jacobs R, Mraiwa N, Van Steenberghe D, Sanderink
G, Quirynen M. Appearance of the mandibular
incisive canal on panoramic radiographs. Surg Radiol
Anat. 2004; 26:329-333.
9. Lamia H Al-Nakib, Sarkawt Khidhir Rasul.
Evaluation of the anterior loop of the mental nerve
incidence and extension in different age groups in
sulaimania city using digital imaging system. J Bagh
College Dentistry 2013; 25(1):99-104.
10. Dusan V Kuzmanovic, Alan GT Payne, Jules A
Kieser, George J Dias. Anterior loop of the mental
nerve: a morphological and radiographic study. Clin
Oral Impl.Res. 2003; 14:464-471.
11. Kuzmanovic DV, Payne AG, Kieser JA, Dias GJ.
Anterior loop of the mental nerve: a morphological
and radiographic study. Clin oral implants Res. 2003;
14:464-471.
12. Dharmar S. Locating the mandibular canal in
panoramic radiographs. Int J Oral Maxillofacial
Implants. 1997; 12:113-117.
13. Kingsmill VJ, Boyde A. Variation in the apparent
dentistry of human mandibular bone age and dental
status. J Anat. 1998; 192(2):233-244.
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14. Kieser J, Kuzmanovic D, Payne A. Dennison J,
Herbison P. Patterns of emergence of the human
mental nerve. Arch Oral Biol. 2002; 47:743-747.
15. Hu KS, Choi DY, Lee Wj, Kim HJ, Jung Uw, Kim S.
Reliability of two different presurgical preparation
methods for implant dentistry based on panoramic
radiography and cone beam computed tomography
in cadavers. J Periodontal Implant Sci. 2012; 42:
39-44.
16. Ngeow WC, Dionysius DD, Ishak H, Nambiar P. A
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anterior loop in dentate subjects of different age
groups. Oral Sci. 2009; 51(2):231-7.
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Canal Using Panoramic Radiography
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Shishir Shah*, Shilpi S. Shah**
Original Article
Assessment of Smoking Habits, Oral Hygiene Practices and Self
Perceived Malodour among the College Students in Ahmedabad
Abstract
Background and Aim: Halitosis or oral malodor affects a large proportion of the population and is often
associated with poor oral hygiene practices, smoking habits, oral and systemic diseases. present study was
carried out to assess the effect of smoking habits, oral hygiene practices on halitosis and even to evaluate
self perceived malodour among college community in Ahmedabad. Materials and Methods: A survey was
carried out in a college community of Arts and Science students in Ahmedabad in order to assess smoking
habits, oral hygiene practices and self perceived malodour. All the 1200 students were invited to participate
in the study but only 650 volunteers participated and a self administered close ended questionnaire was
distributed. Descriptive statistics were used to describe the data. Results: Out of 650 students, only 31
(4.8%) had a habit of smoking and 619 (95.2%) were aware of the ill effects of smoking. 464 (71.3%) brushed
once daily, 456 (70.1%) rinsed their mouth after eating anything and self perceived malodour was expressed
by 59(9%). Conclusion: The habit of smoking was seen in a very small percentage of study subjects and
majority of them were aware of its ill effects. There is a need to educate them on brushing techniques and
encourage them to visit a physician/dentist whenever they perceive a malodour.
Keywords: Smoking; Oral Hygiene; Oral Malodour; College Community.
Author’s Affiliation: *Associate Professor, Department of
Dentistry, GMERS Medical College and Hospital, Sola,
Ahmedabad, Gujarat. **Reader, Dept of Periodontology and
Implantology, Ahmedabad Dental College and Hospital,
Ahmedabad, Gujarat.
Reprints Requests: Shilpi S. Shah, J3, Birju Appts, Opp. Azad
Society, Polytechnic, Satellite Area, Ahmedabad380015
E-mail: drpiyushpujara@gmail.com,
smilecostsnothing@gmail.com
Received on 13.04.2017, Accepted on 18.04.2017
Introduction
Smoking has health implications for young people
and is associated with other high-risk behaviors
among young people including abuse of other
drugs, fighting and high-risk sexual behavior [1].
Young adults smoke fewer cigarettes daily and are
less likely to smoke every day than the general
population of adults [2].
Various factors affect tooth
loss including cigarette smoking; however, evidence
regarding the association between smoking and
tooth loss during young adulthood is limited.
3
Many
studies tell that cigarette smoking leads to excess
mortality risk [4-7].
Many methods are available for maintaining
opt imal oral hygiene, among which tooth
brushing is the most widely accepted method for
the prevention and control of periodontal
diseases. Most researchers recommend tooth
brushing twice a day and agree that when
performed with fluoride toothpaste, it could also
reduc e dental caries. Howeve r ; a recent
systematic review of the available evidence has
shown that tooth brushing plays a limited role in
caries prevention because brushing alone is not
sufficient in cleaning the proximal surfaces of
teeth. As such, using dental floss is therefore also
recommended to further help in preventing both
dental caries and periodontal disease [8].
Other oral
hygiene tools include woodsticks, rubber tips and
interdental brushes, these also aid in interdental
cleansing [9].
Mouthwashes are adjuvants to
brushing and flossing, it has been observed that they
add advantages to mechanical control [10].
Oral malodour affects a large proportion of the
population and is often associated with poor oral
hygiene practices, smoking habits, oral and
systemic diseases. Halitosis is a general term used
to describe an unpleasant or offensive odor
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Volume 10 Number 2, April - June 2017
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
emanating from the oral cavity. Although several
non-oral sites have been related to oral malodour,
including the upper and lower respiratory tracts,
the gastrointestinal tract, and some diseases
involving the kidneys or the liver, it is thought that
around 90% of all bad breath odors emanate from
the mouth itself. Oral halitosis is the specific term
used to define halitosis with an origin within the
oral cavity [11].
Oral halitosis is a very common problem in
dental patients [12]. In fact; most adult subjects
have socially unacceptable bad breath when
waking up in the morning. This problem is
transitory and attributed to physiologic causes
such as reduced saliva flow during sleep. Although
these transitory problems are easily controlled,
persistent bad breath may be indicative either of
oral diseases (i.e., periodontal diseases, oral
ulceration, pericoronitis, gingivitis, acute
ulcerative gingivitis, oral carcinoma, the presence
of bacterial reservoirs in the mouth) or indicative
of systemic diseases (i.e., hiatus hernia, hepatic
cirrhosis, or diabetes mellitus). Along with these
food impaction, dry socket, dentures and
prosthesis are other etiologic factors behind
halitosis [13].
In healthy subjects, tongue coating is by far the
most important source of malodour, most of the
odor coming from the dorso-posterior surface of the
tongue where the crypts are the favored sites for
growth of the anaerobic bacteria responsible for
halitosis. Some investigators believe that besides
VSC (Volatile Sulphur Compounds), other volatiles
produced by oral putrefaction processes such as
organic acids, ammonia, and amines may also cause
oral malodour [14].
As the young adults of today are indulging in
unhealthy habits like smoking, drug abuse, poor
oral hygiene practices, consumption of fast foods,
a study was carried out to know the smoking
habits, oral hygiene practices, and self perceived
malodour among arts and science students of
Ahmedabad.
The aim of the current study was to evaluate the
Smoking habits, Oral hygiene practices and
perceived Malodour among the college community
of Arts and Science students in Ahmedabad. It has
been observed that self-reporting questionnaire are
a valid tool to gather information on the level of
discomfort and personal habits of the patient
because it provides not only an objective measure
of the influence of oral hygiene habits followed by
the patient but basically a view on patient’s
perception of health [15,16].
Materials and Methods
An epidemiological survey was carried out to
assess the Smoking Habits, Oral Hygiene Practices,
and Self Perceived Malodour among the College
community of Arts and Science Students,
Ahmedabad. Ethical clearance was obtained from
the institute.
Sample Size
All the 1200 students were invited for the study
but only 650 students participated. The students
belonged to Ahmedabad, and from educated and
wealthy background. The inclusion criteria included
male and female students in the age group of 17-25
years, having no previous medical history, under
no medication. The exclusion male and female
students having age more than 25 years and less
than 17 years, having previous medical history and
under some medication.
Study Design
A specially designed closed ended questionnaire
in Guajarati which consisted of 15 questions was
used to assess the smoking habits, oral hygiene
practices and self perceived malodour Arts and
Science College students in Manimangalam,
Chennai. Study questionnaire was tested and
validated before the study, through a pilot study. It
was tested on a small group of (50) students who
were requested to complete it and to indicate any
questions that they found unclear to answer. The
pilot study proved that moving ahead with the
study was beneficial and the survey outcome would
be positive. The students were approached class
wise and the purpose of the study was explained to
them and informed consent was obtained. The
questionnaire was distributed to them and was
assured of the confidentiality. The filled questionnaire
was collected on the same day immediately after
completion. The resulting data was coded and
statistical analysis was done using SPSS (Statistical
Package for Social Sciences) version 17.0 software, Chi-
square test was applied to compare the percentages
and the level of significance was set at 0.05.
Results
The subjects consisted of 63.8% (415) males and
36.2% (235) females which totally comprises of 650
participants.
Shishir Shah et. al. / Assessment of Smoking Habits, Oral Hygiene Practices and Self Perceived Malodour
among the College Students in Ahmedabad
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
• Responses of College Students on Smoking Habits
Among the study subjects 4.8% (i.e. 31) were
smokers in which 2.6% (i.e. 17) were smoking daily,
2.1% (i.e.13) were smoking weekly, 0.1% were
smoking occasionally which is represented in Table
1. Among smokers 64.5% (i.e. 20) were smoking less
than 5 cigarettes, 22.5% (i.e 7) were smoking 5-10
cigarettes, and 13% (i.e. 4) were smoking more than
10 cigarettes per day. Among smokers 25.8% (i.e.
8) were smoking for 1-3 years, 29% (i.e. 9) were
smoking for 1-2 years, and 19.4% (i.e. 6) were
smoking more than 3 years. 65.5% (i.e. 212) of males
and 78.8% (i.e. 185) of females responded that all
the ill effects of smoking. These difference noted
between the sexes were statistically significant
(P=0.001) which is represented in Table 2. 70.9% (i.e.
22) of smokers had attempted to stop smoking and
29.1% (i.e. 9) smokers had not attempted to stop
smoking.
• Responses of College Students on Oral Hygiene
Practices
20% (i.e. 83) of males and 46% (i.e. 108) of females
brushes their teeth twice a day. These difference
noted between the sexes were statistically significant
(P=.000). 41% (i.e. 170) of males and 63.4% (i.e. 149)
females brush their teeth circularly. These difference
noted between the sexes were statistically significant
(P=.000). 38.5% (i.e. 160) of males and 51.9% (i.e.
122) of females change their toothbrush once in a
month. These difference noted between the sexes
were statistically significant (P=.002) which is
represented in Table 3. 53.7% (i.e. 223) of males and
61.7% (i.e. 145) of females snack once in between
meals in a day. These difference noted between the
sexes were statistically significant (P=.001) which
is represented in Table 4. 67.7% (i.e. 280) of males
and 74.9% (i.e. 176) of females rinse their mouth
after eating. 32.4% (i.e 134) of males and 25.1%
(i.e. 59) of females do not rinse their mouth after
eating. These difference noted between the sexes
were statistically significant (P=0.54).
• Responses of College Students on Self Perceived
Malodour
9.8% (i.e. 40) of males and 0.5% (i.e. 11) of females
responded they have bad breath. These difference
noted between the sexes were statistically significant
(P=.000).3.07% (i.e. 12) of males and 0.4% (i.e. 9) of
females had visited dentist or physician for bad
breath. 95.2% (i.e. 395) of males and 99.6% (i.e. 234)
of females had not visited dentist or physician for
bad breath. These differences noted between the
sexes were statistically significant (P=.002). 10.6%
(i.e. 44) of males and 0.5% (i.e. 1) of females had
received treatment from dentist or physician for bad
breath. 89.4% (i.e. 371) of males and 99.5% (i.e. 233)
females had not received any treatment from dentist
or physician for bad breath. These difference noted
between the sexes were statistically significant
(P=.000). 9.8% (i.e. 40) of males and 0.05% of females
responded that their bad breath interfere with their
social life. These difference noted between the sexes
were statistically significant (P=.000). 8% (i.e. 33) of
males and 0.4% (i.e. 1) of females had self medicated
themselves for bad breath. 92% (i.e. 381) of males
and 99% (i.e. 232) of females had not self medicated
themselves for bad breath. These difference noted
between the sexes were statistically significant
(P=.000).
Smokers 31(4.8) Non smokers Total
Daily Weekly Occasionally
17 (2.6%)
13 (2.1%)
1 (0.1%)
619 (95.2%)
650 (100%)
Table 1: Frequency of smoking among study subjects
Gender Oral cancer Bad breath and staining of teeth Respiratory problems Total
Male
120 (29%)
3 (0.7%)
20 (4.8%)
272 (65.5%)
415 (100%)
Female
47 (20%)
2 (0.8%)
1 (0.4%)
185 (78.8%)
235 (100%)
Gender Once in one
month
Once in three
month
Once in 6 month Whenever I feel like
changing
Total
Male
160(38.5%)
116(28%)
15 (3.6%)
124 (29.9%)
415 (100%)
Female
122 (51.9%)
63 (26.8%)
3 (1.3%)
47 (20%)
235 (100%)
Table 2: Knowledge on ill effects of smoking among study subjects
P=0.01
Table 3: Frequency of changing tooth brush among study subjects
P=0.02
Shishir Shah et. al. / Assessment of Smoking Habits, Oral Hygiene Practices and Self Perceived Malodour
among the College Students in Ahmedabad
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Discussion
This was a cross sectional study conducted
among College community of Arts and Science
Students, Ahmedabad. It was a questionnaire
survey in which 415 (63.8%) males and 235 (36.2%)
females participated and responded to questions on
smoking habits, oral hygiene practices and self
perceived malodour.
Only 4.8% were smokers in the study, which are
very low when compared with a study conducted
by, Eldarrat A et al in 2008 [17] among Libyan
students (schools and universities) and employees
in which 17% of them were smokers The smoking
attitudes, behaviors of family members and close
friends would have influenced the increased
frequency of smoking among them.
According to above findings, 64.5% smoke less
than 5 cigarettes, 22.5% smokes 5-10 cigarettes, 13%
smokes more than 10 cigarettes per day which is
similar to a study conducted by William Kasapila
in 2010 [18], among students specializing in Nursing
and Agriculture in which 61.8% smokes less than 5
cigarettes and 26.5% smokes less than 10 cigarettes.
In the present study 65.5% of males and 78.8% of
males were aware of ill effects of smoking which is
similar to a study conducted by Talal J. Hashim in
2000 [19] among students of Applied Medical
Sciences in which 73% of the respondents were
aware of ill effects of smoking.
Around 71% have attempted to stop smoking in
the current research, which is similar to that of study
conducted by Talal J. Hashim in 2000 [19], Saudi
Arabia in which 70% have attempted to stop
smoking. In the present study 80% of the males and
54% of the females brushes their teeth once daily,
20% of the males and 46% of the Females brushes
their teeth twice daily. In a study conducted by R.
Al-Hussaini et al in 2003 [8], among students of
Kuwait University Health Sciences Centre, 94% of
the students brushes their teeth once a day and 79%
of the girls brushes their teeth twice a day which is
comparatively higher than our study.
In the present study 28% of the males and 26.8%
of the females changed their tooth brush once in
three months, 3.6% of the males and 1.3% of the
females changed their tooth brush once in six
months. In a study conducted by Hossain
Neamatollahi et al in 2009 [20] in Iran and noticed
33% of them changed their tooth brush once in three
months, 43% of them changed their tooth brush once
in three to six months which is less than our study.
In the present study 9.8% of the males and 0.5% of
the females responded for self perception on
malodour which is comparatively low to a study
conducted by Khalid Almas et al in 2000
21
, among
dental students in which 44% of the males and 32%
of the females responded for the self perception of
malodour. This difference would be because the
subjects of the above mentioned study were dental
students who could have perceived malodour better
because of their awareness about it.
Results from above findings suggested that 10.6%
of the males and 0.5% of the females had received
treatment for malodour from the dentist or
physician which is comparatively low to a study
conducted by Aziza H. Eldarrat(2011) [22] in Libya
among University students in which 27% 0f students
received treatment for malodour from the dentist
(24%) or physician (3%). The positive attitudes
among Libyan college students as mentioned by the
authors in the study would have encouraged them
to take treatment for malodour. In the present study
9.8% of the males and 0.5% of the females responded
that their bad breath interfere with their social life.
Khalid Almas et al in 2000 [21] conducted a study
among dental students in Saudi Arabia. 5.8% of the
males and 44% of the females responded that their
bad breath interfere with their social life.
In the current findings it was observed that 8%
of the males and 0.4% of the females had self
medicated themselves for malodour which is
comparatively low to the study conducted by Khalid
Almas et al in 2000 [21], among dental students in
which 12% of the males and 26% of the females have
self medicated themselves probably due to the
awareness from their educational training.
Conclusion
The present study indicates that the habit of
smoking was seen in a very small percentage of
Gender Once Twice Thrice
More than Thrice
Total
Male
223 (53.7%)
82 (19.7%)
53 (12.8%)
57 (13.8%)
415 (100%)
Female
145 (61.7%)
59 (25.2%)
11 (4.6%)
20 (8.5%)
235 (100%)
P=0.01
Table 4: Frequency of snacking in between meals in a day among study subjects
Shishir Shah et. al. / Assessment of Smoking Habits, Oral Hygiene Practices and Self Perceived Malodour
among the College Students in Ahmedabad
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
study subjects and majority of them were aware of
its ill effects. A good proportion of smokers had
attempted to stop smoking. Majority of them
brushes their teeth once daily using circular motion
and rinse their mouth after eating. Majority of them
had no self perception on their bad breath and who
responded for malodour also accepted that it
interfere with their social life.
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Oncol. 2009; 20(12):1929-35.
16. Ashwath B, Vijayalakshmi R, Malini S. Self-perceived
halitosis and oral hygiene habits among
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Periodontol. 2014; 18(3):357-60.
17. Eldarrat A, Alkhabuli J, Malik A. The prevalence of
self-reported halitosis and oral hygiene practices
among Libyan students and office workers. Libyan
J Med 2008; 3(4):170-6.
18. William Kasapila, Tapiwa Susan Mkandawire
Drinking and Smoking Habits Among College
Students in Malawi. Eur Jour Soc Sci 2010; 15(3):
441-48.
19. Talal J. Hashim. Smoking habits of students in
College Of Applied Medical Science, Saudi Arabia .
Saudi Med J 2000; 21(1):76-80.
20. Hossain Neamatollahi, Masoumeh Ebrahimi. Oral
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Khamis Oral Hygiene.Practices, Smoking Habits,
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Shishir Shah et. al. / Assessment of Smoking Habits, Oral Hygiene Practices and Self Perceived Malodour
among the College Students in Ahmedabad
98
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Akhilanand Chaurasia*, Gaurav Katheriya**
Original Article
Mandibular Ramus as Dimorphic Tool in Age and Sex Determination-A
Cross Sectional Radio-Anthropometric Study on Digital Panoramic
Radiograph
Abstract
Objective: This research article focuses on prediction of age on the basis of maximum ramus breadth,
minimum ramus breadth, condylar height, projective height of ramus and coronoid height. (Linear regression
analysis). However it also determine sex of individual on the basis of discriminant function analysis using
Fischer exact test using maximum ramus breadth, minimum ramus breadth, condylar height, projective
height of ramus and coronoid height. Material and Methods: The orthopantomograms of 200 subjects were
taken from planmeca promax-dimax4 OPG machine at 66 Kvp, 8mA and exposure time 16 sec. All the
measurements are done on digital orthopantomograms using planmeca Romexis 3.2.0R software. The
measurements of the mandibular ramus will be subjected to Discriminant function analysis. Results: The
study sample consists of 200 subjects aged between 8 to 82 years with a mean age of 38.21±17.12 years. The
persons correlation coefficient (r) between age and minimum ramus breadth was not significant correlation
however the maximum ramus breadth, condylar height, coronoid height and projective height were directly
associated with age and demonstrate a significant positive relation in maximum ramus breadth, condylar
height, coronoid height and significant positive relation in projective height. The maximum ramus breadth,
min ramus breadth, condylar height, coronoid height and projective height values were greater in males
than females. The difference in maximum ramus breadth, minimum ramus breadth, condylar height,
coronoid height and projective height values in males and females were statistically significant (P<0.05).
Conclusion: Mandibular ramus can be a useful tool for age and sex determination in forensic science.Thus
medicolegal cases having age and sex issues can be resolved with measurements of mandibular ramus if
panoramic radiograph is available.
Keywords: Mandibular Ramus; Ramus Breadth; Condylar Height; Projective Height of Ramus and
Coronoid Height.
Author’s Affiliatio n: *Assistant Professor ** Resident,
Department of Oral Medicine & Radiology, Faculty of Dental
Sciences, King George’s Medical Unniversity Lucknow.
Rep rints Requ ests: Akhilanand Chaur as ia, Assi stant
Professor, Department of Oral Medicine & Radiology, Faculty of
Dental Sciences, King George’s Medical Unniversity, Lucknow.
E-mail-chaurasiaakhilanand49@gmail.com
Received on 16.02.2017, Accepted on 23.02.2017
Introduction
Dentofacial radiography has become a routine
procedure in the dental, medical and hospital
clinics.Where in radiographs are taken at different
periods during the lifetime of large segments of the
population [1]
.Whereas the determination of sex is
an important aspect of forensic anthropology and
vital in medicolegal investigations. Among various
measures mandibular ramus can be used to
differentiate between male and female strongly
expresses univariate sexual dimorphism. When
skeletal sex determination is considered, metric
analyses on the radiographs are often found to be
of superior value owing to their objectivity, accuracy
and reproducibility.
Mandible is the largest, strongest and movable
part of the skull. Mandible identification is
important in medicolegal and anthropological work
[2]. The teeth along with skull are best preserved
part of human remains. Sex can be more accurately
determined after the attainment of puberty. The
differences are well marked in bony pelvis and skull.
Mandible next to the pelvis in human remains will
help us in identification of age, sex and race [3,4].
To evaluate the mandibular angle and to analyze
the relationship of the angle and height and breadth
Indian Journal of Dental Education
Volume 10 Number 2, April - June 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.6
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
of the ramus of the mandible to the gender so as to
study its role in the anthropological diagnosis [5].
Sex determination based only on characteristics of
teeth and their supporting structures had been a
difficult task where as X-ray examination of the
mandible gives definitive information about the sex.
The mandibular condyles are smaller in females.
By radiological examination sex determination of
skull is possible to the extent of 88 percent [6].
Mandible and its variations in age, sex and race will
help physicians, surgeons, medico-legal authorities
and anthropologists to give correct interpretations
for the results of diagnostic procedures in living
[2,4].
Panoramic radiography is a very popular and
most widely accepted that conveniently provides
the clinician with a comprehensive view of
maxillofacial complex with relatively reduced
radiation dose [7,8]. However the limitation being
is its inability to confirm the dimensions of the
structures shown on the radiographs correspond
to real dimensions of the exposed structures [8-10].
The inherent property of panoramic radiographs is
magnification and distortion. Distance of the object
between the X-ray source and film is responsible
for the magnification of the filmed structures. In the
sharply depicted layer, the image is free of distortion
[9-11].
The identification of human skeletal remains is
considered an initial step in forensic investigations
and is crucial for further analysis [12]. In the adult
skeleton, sex determination is usually the first step
of the identification process as subsequent methods
for age and stature estimation are sex dependent.
The reliability of sex determination depends on the
completeness of the remains and the degree of
sexual dimorphism inherent in the population [13].
When the entire adult skeleton is available for
analysis, sex can be determined up to 100%
accuracy, but in cases of mass disasters where
usually fragmented bones are found, sex
determination with 100% accuracy is not possible
and it depends largely on the available parts of
skeleton [12,13].
As evident from the earlier studies, skull is the
most dimorphic and easily sexed portion of skeleton
after pelvis, providing accuracy up to 92%.
12
But in
cases where intact skull is not found, mandible may
play a vital role in sex determination as it is the most
dimorphic, largest, and strongest bone of skull [12-
15].
Presence of a dense layer of compact bone makes
it very durable, and hence remains well preserved
than many other bones. Dimorphism in mandible
is reflected in its shape and size [12].
Male bones
are generally bigger and more robust than female
bones [13].
The relative development (size, strength, and
angulation) of the muscles of mastication is known
to influence the expression of mandibular
dimorphism as masticatory forces exerted are
different for males and females [16].
Humphreyet
al. showed that the sites associated with the greatest
morphological changes in size and remodeling
during growth, mandibular condyle, and ramus in
particular are generally the most sexually
dimorphic. Measurements of the mandibular ramus
tend to show higher sexual dimorphism, and
differences between the sexes are generally more
marked in the mandibular ramus than in the
mandibular body [17].
Methods based on
measurements and morphometry are accurate and
can be used in determination of sex [18].
Dentofacial radiography has become a routine
procedure in the dental, medical, and hospital
clinics. The radiographs are taken at different
periods during the lifetime of large segments of the
population [19].
Rotational panoramic radiography
is widely used for obtaining a comprehensive
overview of the maxillofacial complex [20]. In
forensic anthropology, comparison of antemortem
and postmortem radiographs is one of the
cornerstones of positive identification of human
remains. Antemortem orthopantomograms may be
of great value in the identification of human remains
[21]. Several studies have been conducted on dry
adult mandibles for sex determination [12,15-18],
but a literature search did not reveal any studies
with regard to measurements on ramus of the
mandible using a digital panoramic radiograph.
Materials and Methods
The orthopantomograms of 200 subjects were
taken from planmeca promax-dimax4 OPG machine
at 66 Kvp, 8mA and exposure time 16 sec. All the
measurements are done on digital
orthopantomograms using planmeca Romexis
3.2.0R software.The subject was positioned properly
in the panoramic machine set up so that the jaws
were within the focal trough as per the methodology
described by Langland, Langlais and Morris (1982).
The subject was made to stand erect with back
straight. The height was adjusted by pressing the
adjustable knob. The subjects were explained about
the working of the machine. The operation of the
panoramic machine was demonstrated to the
subjects and the subjects were appraised of the need
Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
to be still during the procedure.Jacket, sweater and
bulky dress materials were removed so that there
could be sufficient space between the bottom of the
cassette holder and patients shoulder. The subject
was made to wear a lead apron and was positioned
carefully in the focal through with the help of bite
block covered with occlusal disposable envelope
and head holder of the machine so that the lower
border of mandible was equidistant on each side
from the chin support and perpendicular to the
Frankfurt horizontal plane.Frankfurt horizontal
plane was maintained parallel to the floor of the
clinic. The patient’s midsagittal plane was
positioned in the center of the focal trough of the x-
ray unit by asking the patient to bite with his central
incisors (upper and lower). The patient was asked
to close the lip and place the tongue against the
palate. Automatic exposure parameters were
selected. After all the adjustments were made,
appropriate 66 Kvp and 8mA were selected and
exposure were made at 16 sec of exposure time by
depressing the control switch of the panoramic
machine. The orthopantogram is displayed on
console computer. The image is saved and stored
in computer. Then image of orthopantogram is
opened with inbuilt planmeca Romexis 3.2.0R
software for measurement of study parameters. The
study parameters are measured using mouse-driven
method by moving the mouse and drawing lines
using chosen points on the digital panoramic
radiograph as follows (Figure 1& Figure 2)-
• Maximum ramus breadth: The distance
between the most anterior point on the
mandibular ramus and a line connecting the
most posterior point on the condyle and the
angle of jaw.
• Minimum ramus breadth: Smallest anterior–
posterior diameter of the ramus.
• Condylar height/maximum ramus height:
Height of the ramus of the mandible from the
most superior point on the mandibular condyle
to the tubercle, or most protruding portion of
the inferior border of the ramus.
• Projective height of ramus: Projective height of
ramus between the highest point of the
mandibular condyle and lower margin of the
bone
• Coronoid height: Projective distance between
coronion and lower wall of the bone.
Statistical Analysis
Categorical variables will be presented in number
and percentage (%) and continuous variables will
be presented as mean and SD. Qualitative variables
will be compared using Chi-Square test /Fisher’s
exact test as appropriate. The data were analyzed
by the discriminant function analysis using Fischer
exact test. Pearson correlation coefficients were used
to determine the relationship between two scale
parameters, while correlation was defined as a
measure of the strength of a linear relationship
between two variables. A p value of <0.05 will be
considered statistically significant. The data will be
entered in MS EXCEL spreadsheet and analysis will
be done using Statistical Package for Social Sciences
(SPSS) version 21.0.
Results
The study sample consists of 200 subjects aged
between 8 to 82 years with a mean age of
38.21±17.12 years (Table 1). Majority of the study
subjects were between 18 to 35 years of age(Table
2). The sex ratio in our study population showed
that male patient proportion was higher than female
i.e. 51.0 % and 49.0% respectively (Table 3). The
pearsons correlation coefficient (r) between age and
minimum ramus breadth shows no obvious
significant correlation(r=-.040) however the
maximum ramus breadth, condylar height,
coronoid height and projective height were directly
associated with age and demonstrate a significant
positive relation in Maximum ramus
breadth(r=0.182, p=0.010), condylar height(r=0.192,
p=0.006), coronoid height(r=0.274, p=<0.001) and
significant positive relation in projective
height(r=0.193, p=0.006) (Table 4). On the basis of
strong positive correlation between maximum
ramus breadth, condylar height, coronoid height
and projective height and age it was concluded that
age plays an important role in determination of
maximum ramus breadth, condylar height,
coronoid height and projective height. The linear
regression analysis has been done for all parameters
in relation to age and mathematical equation
derived are used in prediction of age if value of any
study parameter is known (Figure 1,2,3,4). Table 5
shows the mean comparison of study parameters
according to gender of study population using
discriminant function analysis and Fisher exact test.
Higher mean values were observed in male
population in comparision to females i.e the
maximum ramus breadth, min ramus breadth,
condylar height, coronoid height and projective
height values were greater in males than females.
The difference in maximum ramus breadth,
Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
minimum ramus breadth, condylar height, coronoid
height and projective height values in males and
females were statistically significant (P<0.05). The
standard deviation was greater in females than
males. The F-statistic values indicated that highest
sexual dimorphism was seen with condylar height
and least with minimum ramus width. The sex
could be determined from calculations using the
equations given below(Table 6).
D of Male: 82.455+ 1.173 (Max Ramus breadth) +
.315 (Min Ramus breadth) - 0.569 (Condylar
Height)+ .802 (Coronoid Height) + 1.345 (Projective
Height)
D of Female: 73.158+ 1.075 (Max Ramus breadth)
+ .320 (Min Ramus breadth) - 0.732 (Condylar
Height)+ .772 (Coronoid Height) + 1.435 (Projective
Height)
The sex was accurately determined in 74 cases
out of 102 male mandibular measurements with
prediction accuracy rate of 72.5% and sex was
accurately determined in 66 cases out of 98 female
mandibular measurements with an accuracy rate
of 67.3%.
N Range Minimum Maximum Mean Std. Deviation
Age
200
74
8
82
38.98
17.116
Age Intervals
N %
<18 years
26
13.0
18 to 35 years
66
33.0
36 to 50 years
60
30.0
51 to 65 years
33
16.5
>65 years
15
7.5
Total
200
100.0
Sex N %
Male 102 51.0
Female
98
49.0
Total
200
100.0
Pearson Correlation Coefficients (R) P value Equations Derived by Linear Regression Analysis
Max Ramus breadth
.182
**
.010
Age =10.320+0.808*(Max Ramus breadth)
Min Ramus breadth
-.040
.574
Age =43.898+(-0.164)*(Min Ramus breadth)
Condylar Height
.192
**
.006
Age =10.408+(0.430)*( Condylar Height)
Coronoid Height .274
**
<0.001 Age =(-6.947)+(0.779)*( Coronoid Height)
Projective Height
193
**
.006
Age =6.813+(0.440)*( Projective Height)
Male Female F value P value
Mean Std. Deviation Mean Std. Deviation
Max Ramus breadth
36.302
3.7023
34.558
3.8297
10.720
0.001
Min Ramus breadth
30.642
4.7322
29.202
3.3391
6.139
0.014
Condylar Height
69.149
6.9221
63.740
7.4105
28.482
<0.001
Coronoid Height
60.941
5.8306
56.810
5.4894
26.568
<0.001
Projective Height
75.700
6.6853
70.529
7.4265
26.831
<0.001
Table 1: Descriptive Statistics
Table 2:
Table 3:
Table 4: Pearson correlation with age of study subjects
** Correlation is significant at the 0.01 level (2-tailed)
Table 5:
Sex
Male
Female
Max Ramus breadth
1.173
1.075
Min Ramus breadth
.315
.320
Condylar Height
-.569
-.732
Coronoid Height
.802
.772
Projective Height
1.345
1.435
(Constant)
-82.455
-73.158
Table 6: Fisher’s linear discriminant functions
Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Sex
Predicted Group Membership
Total
Male
Female
Original
Count
Male
74
28
102
Female
32
66
98
%
Male
72.5
27.5
100.0
Female
32.7
67.3
100.0
Cross-validated
a
Count
Male
72
30
102
Female
33
65
98
%
Male
70.6
29.4
100.0
Female
33.7
66.3
100.0
a. Cross validation is done only for those cases in the analysis. In cross validation, each case is classified by the functions derived from all
cases other than that case.
b. 70.0% of original grouped cases correctly classified.
c. 68.5% of cross-validated grouped cases correctly classified.
Table 7: Classification Results
a,b,c
Graph 1:
Graph 2:
Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Graph 3:
Graph 4:
Fig. 1: Measurements of study
parameters on right side of
mandibular ramus
Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Fig. 2: Measurements of study parameters on left side of mandibular ramus
Discussion
Determination of sex by morphological
assessment has remained as one of the oldest
approaches in forensic anthropology and medico
legal examinations. The method may vary and
depend on the available bones and their conditions.
The identification of sex is of significance in cases
of mass fatality incidents where bodies are damaged
beyond recognition. When entire adult skeleton is
available for analysis, sex can be determined up to
100% accuracy (pelvis). However in cases of mass
disasters where usually fragmented bones are
found, sex determination with 100% accuracy is not
possible and it depends largely on the available
parts of skeleton [22]. Skull is the most dimorphic
and easily remarked portion of skeleton after pelvis.
However in cases where intact skull is not found
mandible may play a vital role in sex determination
as it is the most dimorphic bone of skull.
Anthropometry of the face and intraoral regions can
help in the field of forensic odontology when
common forensic data are unavailable [23]. The
disadvantages OPG technique is unequal
magnification and geometric distortion which
causes many problems.The vertical dimension as
compared to the horizontal dimension is little
altered. These distortions are the result of the
horizontal movement of the film and X ray source
[24,25].
A study conducted by Kambylafkas et al [26]
concluded that the evaluation of total ramal height
is reliable and an asymmetry of more than 6% is an
indication of a true asymmetry using panoramic
radiograph. Dayal et al [27] found mandibular
ramus height to be the best parameter in their study
with 75.8% accuracy. A study conducted by Saini
et al [28] showed that coronoid height possessed
the best potential for sex determination in Indian
people with the accuracy of 74.1% and the
combination of it with minimum ramus breadth,
maximum ramus breadth and/or mandibular
ramus length will show significant sexual
dimorphism with an overall accuracy of 80.2%.
Another study conducted by Indira et al [29] on
mandibular ramus measurements were subjected
to discriminant function analysis. Each of the five
variables measured on mandibular ramus using
orthopantomograph showed statistically significant
sex differences between sexes indicating that ramus
expresses strong sexual dimorphism. The
mandibular ramus demonstrated greatest
univariate sexual dimorphism in terms of minimum
ramus breadth, condylar height, followed by
projective height of ramus. Overall prediction rate
using all five variables was 76%.
D. N Kawale et al [30]
concluded that minimum
ramus breadth of mandible in males having mean
3.1346 cm, standard deviation 0.3243,standard error
of mean is 0.0463 with values of female mandible
have mean 2.9 cm, standard deviation 0.23,standard
error of mean 0.0542.The p value is 0.006 which
decreases the importance of minimum ramus
breadth in sex determination of mandible.He also
stated that maximum ramus breadth in males
having mean 3.8938 cm, standard deviation 0.335,
standard error of mean 0.0478 while in females
mean is 3.6666 cm, standard deviation 0.3067 and
standard error of mean is 0.0723 and p value is
0.013.He also deduced that maximum ramus height
of mandible in males is having mean 6.0061 cm,
standard deviation 0.5249 and standard error of
mean is 0.0749 while in females mean is 5.0888 cm,
Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
105
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
standard deviation is 0.3878 and standard error of
mean 0.0914. Sexual dimorphism of mandible with
help of maximum ramus height is highly significant
as p value is 0.000. Skull and pelvis are the
exclusively studied bones for determination of sex.
Although mandible is a part of skull, it is not
investigated as vigorously as the rest of the cranium
[31]. Sex differences in the mandible have been
described based on traditional morphological and
features or statistical analysis of metrical system.
However in recent times Franklinet al [32] have
tried to utilize the principles of geometric
morphometric method and data were analyzed
using specific software and three-dimensional
configuration. While the study appears modern and
valuable it requires highly technical and expensive
morphometric equipment and therefore the results
are less helpful at most of the forensic or
anthropologic centers. Consequently it is imperative
to use the conventional morphological or
anthropometric measurements to arrive at a
conclusion.
Giles et al [33] measured mandibles of known sex
using anthropometric measurements and reported
mandibular ramus height, maximum ramus breadth
and minimum ramus breadth as highly significant
with an accuracy of 85% in American Whites and
Negroes.
Whereas in our study we concluded that the
pearsons correlation coefficient (r) between age and
minimum ramus breadth shows no obvious
significant correlation(r=-.040) however the
maximum ramus breadth, condylar height,
coronoid height and projective height were directly
associated with age and demonstrate a significant
positive relation in maximum ramus breadth
(r=0.182, p=0.010), condylar height(r=0.192,
p=0.006), coronoid height (r=0.274, p=<0.001) and
significant positive relation in projective height
(r=0.193, p=0.006).
On the basis of strong positive correlation
between maximum ramus breadth, condylar height,
coronoid height and projective height and age it was
concluded that age plays an important vital role in
determination of maximum ramus breadth,
condylar height, coronoid height and projective
height.
We compared the study parameters according to
gender of study population using discriminant
function analysis and Fisher exact test. We observed
higher mean values in males in comparision to
females i.e the maximum ramus breadth, minimum
ramus breadth, condylar height, coro noid height
and projective height values were greater in males
than females. The difference in maximum ramus
breadth, minimum ramus breadth, condylar height,
coronoid height and projective height values in
males and females were statistically significant
(P<0.05). The standard deviation was greater in
females than males. The F-statistic values indicated
that highest sexual dimorphism was seen with
condylar height and least with minimum ramus
width.We accurately determined the sex in 74 cases
out of 102 male mandibular measurements with
prediction accuracy rate of 72.5% and sex was
accurately determined in 66 cases out of 98 female
mandibular measurements with an accuracy rate
of 67.3%.
Conclusion
Mandibular ramus can be a useful tool for age
and sex determination in forensic science.Thus
medicolegal cases having age and sex issues can be
resolved with measurements of mandibular ramus
if panoramic radiograph is available.
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Akhilanand Chaurasia & Gaurav Katheriya / Mandibular Ramus as Dimorphic Tool in Age and Sex
Determination-A Cross Sectional Radio-Anthropometric Study on Digital Panoramic Radiograph
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Akhilanand Chaurasia*, Gaurav Katheriya**
Original Article
Morphometric Evaluation of Nasolacrimal Canal in Indian Ethinics: A
Cone Beam Computed Tomography Study
Abstract
Objective: This study aims at age and sex related changes in mediolateral diameter,antero-posterior
diameter and length of nasolacrimal duct. The mathmetical equations derived from linear regression analysis
on the basis of mediolateral diameter,antero-posterior diameter and length of nasolacrimal duct is used in
determination of age of study subjects however sex of study subjects can be predicted on the basis of
length of nasolacrimal duct by discriminant function analysis using Fischer’s exact test. Material and Methods:
The CBCT images of 216 study subjects were analysed prospectively. All the CBCT images are obtained at
90 Kvp,4 mA for 11.3 seconds at FOV(17"x13.5") voxel size of 300. The mediolateral diameter, antero-
posterior diameter and length of nasolacrimal duct are measured by using Trophy Dicom Ink software
programme on axial and mid-sagittal images (DICOM images). Results: The study population consists of
216 study subjects aged between 10 and 84 years with a mean age of 34.28±17.357 years.The t test showed
that the length of nasolacrimal duct is statistically significantly (p<0.001). The mean of length of nasolacrimal
duct is slightly higher in males than females. The mean of length of nasolacrimal duct is slightly higher in
males than females. The mediolateral diameter, length of nasolacrimal duct, antero-posterior diameter
were not significant (p>0.05) in the age groups. Conclusion: The age and sex issues in medico-legal cases
and forensic anthropology can be resolved by measurements of nasopalatine duct.
Keywords: Nasopalatine Duct; Cone Beam Computed Tomography; Maxilla.
Author’s Affiliatio n: *Assistant Professor ** Resident,
Department of Oral Medicine & Radiology, Faculty of Dental
Sciences, King George’s Medical Unniversity Lucknow.
Rep rints Requ ests: Akhilanand Chaur as ia, Assi stant
Professor, Department of Oral Medicine & Radiology, Faculty of
Dental Sciences, King George’s Medical Unniversity, Lucknow.
E-mail-chaurasiaakhilanand49@gmail.com
Received on 16.02.2017, Accepted on 23.02.2017
Introduction
The nasopalatine canal (NPC) also known as the
incisive canal or anterior palatine canal is a long
slender passage present in the midline of the anterior
maxilla that connects the palate to the floor of the
nasal cavity. The canal continues in the oral cavity
as a single incisive foramen posterior to the central
incisor teeth and in the nasal cavity as the foramina
of Stenson, which are usually two in number.
Through each of them passes the terminal branch
of the descending palatine artery and the
nasopalatine nerve, to communicate with the
posterior septal branch of the spheno-palatine artery
and greater palatine nerve, respectively. Thorough
knowledge of the anatomical appearances and
variation of the NPC is essential prior to surgical
procedures like implant placement and local
anesthesia in the anterior maxilla. Difficulties and
anatomic limitations regarding the location of the
nasopalatine canal in relation to the maxillary
central incisor implants have been reported [1].
The nasopalatine canal commences towards the
front of the floor of each nasal cavity. Each canal
opens into the midline incisive foramen on the
median plane of the palatine process of the maxilla,
posterior to the central incisors and transmits
nasopalatine vessels and nerves, branches of the
maxillary division of the trigeminal nerve and the
maxillary artery. The nasopalatine canal exists of
one, two or multiple canals [2,3].
The maxillary incisive canal (IC) is a Y-shaped
passage that is between 4 and 26mm in length,
depending on the surrounding maxillary bone
height [2,4]. It develops from the fusion of the right
and left IC respectively with the anterior palatine
Indian Journal of Dental Education
Volume 10 Number 2, April - June 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.7
108
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
canal to form the common IC [5]. It is located about
12–15 mm from the anterior nasal spine, usually
closer to the nasal septum [4]. It connects the roof
of the oral cavity with the floor of nasal cavity [5].
The IF and the incisive fossa form the inferior part
of this canal while superiorly, the nasal septum in
the nasal floor divides the opening into 2 foramina,
namely the nasopalatine foramen or the foramen of
Stensen [6,7]. Two accessory minor openings,
termed the foramina of Scarpa are sometimes seen.
These additional canals may also transmit the
nasopalatine nerve [2]. Nasal foramen (NF) is the
collective term that is usually used to describe the
nasal openings located on the nasal floor. In addition
to nerve bundles, the naso-(spheno) palatine artery
also shares a course along this canal to supply the
oral cavity [5]. The maximum width and standard
deviation of the NF was reported to be 4.9 (1.2) mm.
2
Anatomy of the NPC. The paired NPC is localized
in the anterior maxilla, close behind the central
incisors [8]. The NPC forms a tube connecting soft
tissues of the nasal and oral cavities [9,10]. The oral
aperture of the NPC lies in the anterior palatine
bone, just dorsal to the roots of the upper central
incisors [10]. The funnel-shaped opening to the oral
cavity is defined as the incisive foramen or fossa
[8]. Inside the bone, the NPC divides in the cranial
course into two tubes that run separately to the nasal
aperture, termed nasal foramina [11-14]. The NPC
contains fibrillary connective and adipose tissues
[13], minor salivary glands [15,16], and the
nasopalatine nerve and artery [17,18]. During its
osseous passage, the artery maintains anastomoses
with the major palatine artery [19]. Occasionally,
two additional small channels are found in the
incisive bone medial to the NPC (canals of Scarpa).
These channels carry further nerve filaments of the
nasopalatine nerve, terminating in the incisive
foramen as Scarpa’s foramina. In the oral cavity,
the left supplementary channel opens anteriorly and
the right posteriorly to the oral opening of the NPC
[10,20].
Materials and Methods
This study was an observational study in which
CBCT images of Head of 216 subjects aged between
10 and 84 years were chosen. The CBCT images of
subjects having no history of trauma, pathology
diagnosed as normal have been included in study.
Any CBCT with obvious pathology, trauma and
facial asymmetry were excluded from this study.
All the patients were examined on CS9300
carestream CBCT machine. The axial and mid-
sagittal images were obtained at 90 Kvp,4 mA for
11.3 seconds at FOV(17"x13.5")voxel size of 300. .
Linear measurements of nasopalatine duct in the
mid-sagittal plane and axial planes were done by
using Trophy Dicom Ink software programme. All
the measurements are done in millimeters. The
medio-lateral diameter of the incisive fossa and
foramen of Stenson and the number of openings at
the nasal fossa were evaluated in the axial sections
while the shape of the canal, curvature of the canal,
angle of curvature, length of the canal and antero-
posterior diameters were assessed in the sagittal
slices (Figure 1,2,3,4).
Statistical Analysis
Categorical variables will be presented in number
and percentage (%) and continuous variables will
be presented as mean and SD. Qualitative variables
will be compared using Chi-Square test/Fisher’s
exact test as appropriate. Quantitative variables will
be compared using Unpaired t-test between two
groups and ANOVA between three groups. The
data were analyzed by the discriminant function
analysis using Fischer exact test. Pearson correlation
coefficients were used to determine the relationship
between two scale parameters. A p value of <0.05
will be considered statistically significant. The data
will be entered in MS EXCEL spreadsheet and
analysis will be done using Statistical Package for
Social Sciences (SPSS) version 21.0.
Results
The study population consists of 216 study
subjects aged between 10 and 84 years with a mean
age of 34.28±17.357 years (Table 1). Majority of the
study subjects were between 18 to 35 years of age
(Table 2). The sex ratio in our study population
showed that male proportion was higher than
female i.e. 65.7 % and 34.3% respectively (Table 3).
The study parameters i.e mediolateral diameter,
length of nasolacrimal duct, antero-posterior
diameter (canine Fossa, at mid level and palatal)
characteristics of males and females are
summarised in Table 5. Comparing the mean of
clinical characteristics of two groups (males and
females), t test showed that the length of
nasolacrimal duct is statistically significantly
(p<0.001). The mean of length of nasolacrimal duct
is slightly higher in males than females. However,
rest of study parameters were not differed (p>0.05)
between the males and females i.e. found to be
Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study
109
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
N
Range
Minimum
Maximum
Mean
Std. Deviation
Age
216
74
10
84
34.28
17.357
Sex
N %
Male
142
65.7
Female
74
34.3
Total
216
100.0
Age intervals
N
%
Below 18 years
34
15.7
18 to 35 years
106
49.1
36 to 50 years
30
13.9
51 to 65 years
32
14.8
More than 65 years 14 6.5
Total
216
100.0
Sex
N
Mean
Std. Deviation
P value
Mediolateral diameter Male 142 3.837 1.1848 0.738
Female
74
3.782
1.0560
Length of nasolacrimal duct Male 142 11.662 2.4287 0.001
Female
74
10.573
2.1787
AP Canine Fossa Male 142 4.557 5.4021 0.538
Female
74
4.128
3.5371
AP Mid level Male 142 2.837 2.5241 0.668
Female
74
2.705
1.0616
AP Palatal
Male
142
4.632
7.9576
0.223
Female
74
3.518
1.7014
Table 1: Descriptive Statistics
Table 2:
Table 3:
Table 4: Group Statistics
N
Mean
Std.
Deviation
Std.
Error
95% Confidence Interval for Mean
P value
Lower Bound
Upper Bound
Mediolateral
diameter
Below 18 years
34
3.571
1.0356
.1776
3.209
3.932
18 to 35 years
106
3.791
1.3331
.1295
3.534
4.047
36 to 50 years
30
3.710
.7993
.1459
3.412
4.008
.226
51 to 65 years 32 4.097 .9400 .1662 3.758 4.436
More than 65 years
14
4.229
.5690
.1521
3.900
4.557
Total
216
3.819
1.1401
.0776
3.666
3.971
length of
nasolacrimal
duct
Below 18 years 34 11.291 2.2723 .3897 10.498 12.084
18 to 35 years
106
11.324
2.3910
.2322
10.863
11.784
36 to 50 years
30
10.567
2.2905
.4182
9.711
11.422
0.208
51 to 65 years
32
12.003
2.4730
.4372
11.112
12.895
More than 65 years 14 10.936 2.6270 .7021 9.419 12.452
Total
216
11.289
2.3976
.1631
10.967
11.610
AP Canine
Fossa Below 18 years 34 4.838 8.9005 1.5264 1.733 7.944
18 to 35 years
106
4.315
4.7079
.4573
3.408
5.222
36 to 50 years
30
4.150
1.0126
.1849
3.772
4.528
.946
51 to 65 years
32
4.203
1.0353
.1830
3.830
4.576
More than 65 years
14
5.121
1.0678
.2854
4.505
5.738
Total
216
4.410
4.8402
.3293
3.761
5.059
AP Mid level
Below 18 years
34
2.682
1.1730
.2012
2.273
3.092
18 to 35 years 106 2.579 1.0365 .1007 2.380 2.779
36 to 50 years
30
2.860
1.0849
.1981
2.455
3.265
0.376
51 to 65 years
32
3.428
4.9316
.8718
1.650
5.206
More than 65 years
14
3.071
1.1006
.2942
2.436
3.707
Total
216
2.792
2.1365
.1454
2.506
3.079
AP Palatal
Below 18 years
34
6.865
15.8673
2.7212
1.328
12.401
18 to 35 years
106
3.697
1.8754
.1822
3.336
4.058
36 to 50 years 30 4.463 1.8341 .3349 3.778 5.148 0.133
51 to 65 years
32
3.681
1.7578
.3107
3.047
4.315
More than 65 years
14
2.929
1.4725
.3936
2.078
3.779
Total
216
4.250
6.5415
.4451
3.373
5.127
Table 5:
Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study
110
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Correlations
Age Mediolateral
diameter
length of
nasolacrimal duct
AP diameter at
Canine Fossa
level
AP diameter at
AP Mid level
AP diameter
at Palatal
level
Age
Pearson
Correlation
1
.166
*
-.005
.017
.147
*
-.087
Sig. (2-tailed)
.015
.938
.801
.030
.201
N
216
216
216
216
216
216
*. Correlation is significant at the 0.05 level (2-tailed).
Table 6:
Table 7: Pearson correlation with Age of patients
**. Correlation is significant at the 0.05 level (2-tailed)
Pearson correlation
coefficients (r)
P value Linear Regression analysis equations
Mediolateral diameter
.166
*
.015
Age =24.653+2.521*( Mediolateral diameter)
Length of nasolacrimal duct
-.005
.938
Age =34.715+(-.039)*( length of nasolacrimal duct)
Antero-posterior diameter at
canine fossa level
.017
.801
Age =34.006+(.062)*( AP diameter Canine Fossa)
Antero-posterior diameter at
at mid level
.147
*
.030
Age =30.933+(1.198)*( AP diameter Mid level)
Antero-posterior diameter at
palatal level
-.087
.201
Age =35.262+(-.232)*( AP diameter Palatal)
Table 8:
Male Female F value
P value
Mean Std.
Deviation
Mean Std.
Deviation
Mediolateral diameter
3.837
1.1848
3.782
1.0560
.112
.738
length of nasolacrimal duct
11.662
2.4287
10.573
2.1787
10.479
.001*
statistically the same. The mediolateral diameter,
length of nasolacrimal duct, antero-posterior
diameter( canine fossa , at mid level and at palatal
level are compared in age groups shows that study
parameters were not differed (p>0.05) between the
age groups i.e. found to be statistically the same
(Table 5).
The pearsons correlation coefficient (r) between
age and study parameters shows no significant
correlation between age with length of nasolacrimal
duct, antero-posterior diameter at canine fossa level
and antero-posterior diameter at palatal level.
However mediolateral diameter and antero-
posterior diameter at mid level were directly
associated with age and demonstrate a significant
positive relation (r=0.166, p=0.015) in mediolateral
diameter, significant positive relation (r=.147
*
,
p=030) in antero-posterior diameter at mid level
(Table 6). The equations derived by linear regression
analysis is used in determination of age of an
individual if any of study parameters is known
(Table 7). The mean comparison of parameters
according to their gender using discriminant
function analysis using Fisher exact test was
done.Higher mean were observed in mediolateral
diameter and length of nasolacrimal duct of males
in compariosion of females however statistically
significant difference were observed in length of
nasolacrimal duct (P<0.05) (Table 8). The sex could
be determined from calculations using the equations
given below(Table 9).
D of Male
22.076+ 3.837 (Mediolateral diameter) + 2.451
(length of nasolacrimal duct)
D of Females
19.964+ 3.719 (Mediolateral diameter) + 2.243
(length of nasolacrimal duct)
Sex was accurately determined in 139 cases out
of 142 male with prediction accuracy rate of 97.9%
in male population however in female population
sex was accurately determined in 5 cases out of 74
female with an accuracy rate of 6.8% (Table 10).
Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Table-10
Sex Predicted Group Membership Total
Male Female
Original
Count
Male
139
3
142
Female
69
5
74
%
Male
97.9
2.1
100.0
Female
93.2
6.8
100.0
a. 66.7% of original grouped cases correctly classified.
Table 9: Classification Function Coefficients
Sex
Male Female
Mediolateral diameter
3.837
3.719
length of nasolacrimal duct
2.451
2.243
(Constant)
-22.076
-19.964
Fisher's linear discriminant functions
Table 10:
a. 66.7% of original grouped cases correctly classified
Fig. 1: Axial section (CBCT) showing mediolateral diameter of
nasopalatine fossa in male subject.
Fig. 2: Axial section (CBCT) showing mediolateral diameter of
nasopalatine fossa in female subject
Fig. 3: Sagittal section (CBCT) showing length of nasopalatine duct
and anteroposterior diameter at 3 levels(Hard palate level, mid-
level, Canine fossa level) in male subject.
Fig. 4: Sagittal section (CBCT) showing length of nasopalatine duct
and anteroposterior diameter at 3 levels (Hard palate level, mid-
level, Canine fossa level) in female subject.
Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Graph 1
Graph 2
Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Discussion
Several previous reports have dealt with the
pathology of the nasopalatine canal region. The
anatomical variations in the dimensions and
morphology of this canal remain poorly
documented. The present study indicated that the
nasopalatine canal showed a great deal of variability
with regard to its dimensions as well as to its
morphological appearance.
Thakur A et al [21]
stated that the mean inner
diameter of the incisive foramen was 3.61 (±0.94).
These values were lower than those reported in the
previous study by Mraiwa et al [22](4.6 mm) but
comparable to those reported by Liang et al [23]
(3.4 mm). He also stated that the diameter of the
incisive fossa ranged from 1.40 mm to 5.90 mm.
Mraiwa et al [22]
also stated the diameter of the
incisive foramen is usually considered to be below
6 mm; when it exceeds 10 mm,pathological
conditions should be considered.
Song et al [24] have reported the length of the
NPC to be 12.0 mm (8.4-15.8 mm) in dentulous
maxillae, Mraiwa et al [22] have reported a mean
length of 8.1 (±3.4) mm, and Liang et al [3] in their
study assessed the length of the NPC as 9.9 (±2.6)
mm.Thakur et al [1]
had reported that the mean
length of the NPC was found to be 10.08 mm (±2.25).
Liang et al [23] stated that there were some
dimensional variabilities related to the samples’ age,
gender and dental status. The canal diameter
enlarged with age. But as the number of edentulous
cases was also significantly increased by age, the
enlarged diameter might also be caused by
edentulism and bone resorption, even if there was
no obvious significant difference on the canal
diameter between the dentate and the edentulous
group. The latter is confirmed by Mardinger et al
[25]
who detected a significant enlargement of the
nasopalatine canal diameter by tooth loss.
Iordanishvili et al [26] found evidence of age- and
gender-linked differences in the mean length of the
nasopalatine canal using craniometric investigation
on human skulls.
Guler et al [27] reported that men had
significantly bigger canals by measuring on
panoramic radiographs.S M Al -Amery et al [28]
stated that the mean labiopalatal and mesiodistal
widths of the IF were 2.80mm and 3.49mm
respectively. This was close to the average of
2.90mm reported for the Caucasians/Arabs
population conducted by T.F Tozum et al [29] and
3.49mm for the Korean population that was
conducted by GT Kim et al [30] on the same
parameters measured. However, it was lower than
the 3.8mm size for labiopalatal width and 3.7mm
for mesiodistal width reported for the Japanese
population that was conducted by R Asaumi et al
[31]. Bornstein et al [32] and Güncü et al [33]
reported that male had significantly larger mean
canal diameter as compared to female.
Where as in our study we compare the mean of
clinical characteristics of two groups (Males and
Females), t test showed that the length of
nasolacrimal duct is statistically significantly
(p<0.001). The mean of length of nasolacrimal duct
is slightly higher in males than females. However,
rest of study parameters were not differed (p>0.05)
between the males and females i.e. found to be
statistically the same. The mediolateral diameter,
length of nasolacrimal duct, Antero-posterior
diameter (canine fossa, at mid level and at palatal
level are compared in age groups shows that study
parameters were not differed (p>0.05) between the
age groups i.e. found to be statistically the same.
We found that there was no significant correlation
between age with length of nasolacrimal duct,
antero-posterior diameter at canine fossa level and
antero-posterior diameter at palatal level. However
mediolateral diameter and antero-posterior
diameter at mid level were directly associated with
age and demonstrate a significant positive relation
(r=0.166, p=0.015) in mediolateral diameter,
significant positive relation (r=.147
*
, p=030) in
antero-posterior diameter at mid level.
We derived the equations by using linear regression
analysis that was used in determination of age of an
individual if any of study parameters is known.
We observed the higher mean in mediolateral
diameter and length of nasolacrimal duct of males
as compare to females however statistically
significant difference were observed in length of
nasolacrimal duct (P<0.05). We also stated that sex
was accurately determined in 139 cases out of 142
male with prediction accuracy rate of 97.9% in male
population however in female populationsex was
accurately determined in 5 cases out of 74 female
with an accuracy rate of 6.8%.
Conclusion
The Nasopalatine duct is a good dimorphic tool
to assess the age and sex of an individual in forensic
anthropology and medicolegal cases having dispute
of identification and age.
Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study
114
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
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1. Mardinger O, Namani-Sadan N, Chaushu G,
Schwartz-Arad D. Morphologic changes of the
nasopalatine canal related to dental implantation: a
radiologic study in different degrees of absorbed
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2. Mraiwa, N., Jacobs, R., Van Cleynenbreugel, J.,
Sanderink, G., Schutyser, F., Suetens, P., van
Steenberghe, D. & Quirynen, M. The nasopalatine
canal revisited using 2D and 3D CT imaging.
Dentomaxillofacial Radiology 2004; 33:396–402.
3. White, S.C. & Pharoah, M.G. Oral Radiography
Principles and Interpretation, 5th edition. St. Louis:
C.V. Mosby Company, 2004.p.174.
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K.U. eds. Implants and Restorative Dentistry.
London: Martin Dunitz. 2001.p.265–310.
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landmarks. Dental Roentgenology. Philadelphia: Lea
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6. Jacobs R, Lambrichts I, Liang X, Martens W, Mraiwa
N, et al. Neurovascularization of the anterior jaw
bones revisited using high-resolution magnetic
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Oral Radiol Endod 2007; 103:683–693.
pmid:17320428.
7. Standring S, Ellis H, Healy J, Jhonson D, Williams
A, et al. Gray’s anatomy: the anatomical basis of
clinical practice. Edinburgh: Churchill Livingstone.
2005.p.538–584. pmid:2527521.
8. von Lanz T and Wachsmuth W: Praktische
Anatomie. Vol. 1. Springer, Berlin-Heidelberg-New
York, 1985.p.186-188.
9. Knecht M, Kittner T, Beleites T, Hüttenbrink KB,
Hummel T and Witt M: Morphological and
radiologic evaluation of the human nasopalatine
duct. Ann Otol Rhinol Laryngol 2005; 114:229-232.
10. Jacobs R, Lambrichts I, Liang X, Martens W, Mraiwa
N, Adriaensens P and Gelan J: Neurovascularization
of the anterior jaw bones revisited using high-
resolution magnetic resonance imaging. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2007; 103:
683-693.
11. Abrams AM, Howell FV and Bullock WK:
Nasopalatine cysts. Oral Surg 1963; 16:306-332.
12. Krüger E: Lehrbuch der chirurgischen Zahn-, Mund-
und Kieferheilkunde. Quintessenz, Berlin, 1988;
1:132.
13. Meyer W: Die Zahn-, Mund- und Kieferheilkunde,
Histologie der Mundhöhle. Urban, München,
1958.p.247.
14. Pasler FA and Visser H. Taschenatlas der
Zahna¨rztlichen Radiologie, Thieme, Stuttgart,
2003.p.72.
15. Keith DA: Phenomenon of mucous retention in the
incisive canal. J Oral Surg 1979; 37:832-834.
16. Noyes HJ: Nasopalatine duct and Jacobson’s organ
in newborn infants. J Dent Res 1935; 15:155.
17. Hill WC and Darlow HM: Bilateral perforate
nasopalatine communication. J Laryngol 1945; 60:
160-165.
18. Sieglbauer F: Lehrbuch der normalen Anatomie des
Menschen. Urban, München, 1963.
19. Schumacher GH: Anatomie für Zahnmediziner,
Lehrbuch und Atlas. Third Edition, Hüthig,
Heidelberg, 1997.p.524.
20. Bornstein MM, Balsiger R, Sendi P and von Arx T:
Morphology of the nasopalatine canal and dental
implant surgery. A radiographic analysis of 100
consecutive patients using limited. Clin Oral
Implants Res 22: 295–301
21. Thakur, A. R., Burde, K., Guttal, K., & Naikmasur,
V.G. Anatomy and morphology of the nasopalatine
canal using cone-beam computed tomography.
Imaging Science in Dentistry, 2013; 43(4):273–281.
22. Mraiwa N, Jacobs R, Van Cleynenbreugel J,
Sanderink G,Schutyser F, Suetens P, et al. The
nasopalatine canal revisited using 2D and 3D CT
imaging. Dentomaxillofac Radiol 2004; 33:396-402.
23. Liang X, Jacobs R, Martens W, Hu Y, Adriaensens P,
Quirynen M, et al. Macro- and micro-anatomical,
histological and computed tomography scan
characterization of the nasopalatine canal. J Clin
Periodontol 2009; 36:598-603.
24. Song WC, Jo DI, Lee JY, Kim JN, Hur MS, Hu KS, et
al. Microanatomy of the incisive canal using three-
dimensional reconstruction of microCT images: an
ex vivo study. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2009; 108:583-90.
25. Mardinger, O., Namani-Sadan, N., Chaushu, G. &
Schwartz-Arad, D. Morphologic changes of the
nasopalatine canal related to dental implantation: a
radiologic study in different degrees of absorbed
maxillae. Journal of Periodontology 2008; 79:1659–
1662.
26. Iordanishvili, A.K. Age-related characteristics and
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incisive canal. Stomatologiia 1991; 71:25–27.
27. Guler, A. U., Sumer, M., Sumer, P. & Bic¸er, I. The
evaluation of vertical heights of maxillary and
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patients for implant dentistry. Journal of Oral
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28. Al-Amery, S. M., Nambiar, P., Jamaludin, M., John,
J., & Ngeow, W.C. Cone beam computed
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ONE, 2015; 10(2). https://doi.org/10.1371/
journal.pone. 0117251.
29. Tözüm TF, Güncü GN, Yildirim YD, Yilmaz HG,
GalindoMoreno P, et al. Evaluation of maxillary
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doi: 10.1902/jop.2011. 110326. pmid:21910596.
30. Kim GT, Hwang EH, Lee SR. A study of incisive
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Korean J Oral Maxillofac Radiol 2004; 34:7–12.
31. Asaumi R, Kawai T, Sato I, Yoshida S, Yosue T.
Threedimensional observations of the incisive canal
and the surrounding bone using conebeam
computed tomography. Oral Radiology 2010; 26:20–
28.
32. Bornstein MM, Balsiger R, Sendi P, von Arx T.
Morphology of the nasopalatine canal and dental
implant surgery: a radiographic analysis of 100
consecutive patients using limited cone beam
computed tomography. Clin Oral Implants Res 2011;
22:295–301.
33. Güncü GN, Yýldýrým YD, Yýlmaz HG,
GalindoMoreno P, Velasco Torres M, et al. (2013) Is
there a gender difference in anatomic features of
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Akhilanand Chaurasia & Gaurav Katheriya / Morphometric Evaluation of Nasolacrimal Canal in Indian
Ethinics: A Cone Beam Computed Tomography Study
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Vikram S. Amberkar*, Nitya K.**, Madhushankari G.S.***
Review Article
Foreign Body Reaction to Oral Tissue: Iatrogenic Factors
Abstract
Foreign body reaction is a response of biological tissues to any foreign material when it comes in contact.
These reactions can be due to either trauma or any foreign material used for treatment purposes. The
various foreign body reaction due to iatrogenic causes includes due to suture material, prosthetic implants,
glove powder, gauze piece etc. The events for foreign body reaction include protein adsorption, monocyte
adhesion, macrophage adhesion and activation, macrophage fusion and foreign body giant cell formation.
Keywords: Foreign Body; Foreign Body Giant Cell; Gauze; Glove Powder; Prosthetic Implants; Suture
Material.
Author’s Affiliation: *Professor **Post Graduate Student
***Professor and Head, Department of Oral Pathology and
Microbiology, College of Dental Sciences, Davangere, Karnataka
577004, India.
Reprints Requests: Nitya K., Post Graduate Student, Room
no: 7, Department of Oral Pathology and Microbiology, College
of Dental Sciences, Davangere - 577004.
E-mail: nitya.aytin@gmail.com
Received on 06.02.2017, Accepted on 23.02.2017
Introduction
Foreign body ingestion in oral cavity are
uncommon, but it can be deposited either due to
trauma or iatrogenic. Motor vehicle accidents,
assaults bullet wounds and iatrogenic surgical faults
are the most common causes of tissue reaction to
foreign materials when embedded in the oral cavity
that leads to a granuloma formation. Tissue
reactions to foreign bodies are commonly
encountered in the oral cavity [1].
The oral cavity is very sensitive and easily
approachable for the accidental penetration of the
foreign bodies. These foreign substances when
introduced into oral cavity or any part of human
body may elicit inflammatory and foreign body
reaction. It can also be introduced during any
sur gical procedure which includes suture
material, glove powder, gauze and prosthetic
implants [2].
Introduction of foreign body into oral cavity may
cause local pain, stay inert (asymptomatic), induce
local abscess formation or spread down to produce
deep infections (Danforth &Brown1963).
Etiopathogenesis
Unlike the pathogenesis of other inflammatory
processes, foreign body reactions are dynamic in
nature. It seems that the initial response against a
foreign substance in the skin involves a neutrophilic
infiltrate, which usually fails to deal with the foreign
body. This neutrophilic infiltrate is later replaced
by histiocytes and macrophages that engulf the
foreign material [3].
Sometimes macrophages are successful in
digesting the foreign body, but more often the
foreign material resists degradation and remains
within the cytoplasm of macrophages. Macrophages
containing foreign body material within their
cytoplasm are activated leading to secretion of
different cytokines, which attract additional
macrophages to the inflammatory focus. This result
in the formation of a granuloma around the foreign
body,which attempts to isolate the rest of the body
from the sequestered indigestible material.
Individual macrophages coalesce to form
multinucleated foreign body giant cells, and T
lymphocytes and fibroblasts are also components
of the inflammatory response [3].
Foreign Body Reaction to Suture Material
The use of appropriate suture material and
Indian Journal of Dental Education
Volume 10 Number 2, April - June 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.8
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
technique assist wound closure in any surgery. The
aim of wound closure is to assist efficient healing
and return to their original function as well as to
maintain the esthetics of surgical site [4]. Sutures
play an important role in wound healing after the
surgical interventions and thus selection of suture
material, especially in oral procedures should be
made carefully.
The selection of suture materials for any oral
procedures should be made carefully as this location
differs from the other body sites due to constant
presence of saliva, specific microbiota, high
vascularization as well as its functions related to
speech, mastication and swallowing. The search for
more appropriate suture material has resulted in a
variety of natural and synthetic, absorbable and non
absorbable sutures that are available commercially.
These features influence the biological reactions to
the suture, permitting a great diversity of clinical
application [5].
The basic property of an ideal suturing material
includes biocompatibility, ease to handle and
presence of smooth surface to prevent the wicking
effect of oral fluids & bacterial overgrowth [6].
Researchers have shown that reduced
accumulation of inflammatory cells around the
suture material will accelerate wound healing.
Tissue reaction to suture material is very important
particularly in patients who are susceptible to
infection (like diabetic patients or patients taking
immunosuppressive drugs)[6].
Foreign Body Reaction to Prosthetic Implants
When an oral implant is to be placed in bone, the
sequence starts by preparing the defect. Surgical
preparation results in breakage of blood vessels,
destruction of bone tissue with a necrotic border
developing inevitably, and an acute inflammatory
response.The latter is an important step in the
healing cascade leading to the preferred bony
anchorage of the implant [7].
Thereafter, possible events follow the placement
of the implant: Either a foreign body response
develops, characterized by a chronic inflammatory
response with the implant shielded off from the
rest of the organism by an enveloping bone tissue
layer that gradually condenses or the foreign body
response results in the implant being embedded
(enc a psulated) in soft tissues, thereby
representing a primary clinical failure are with
modern implants placed by trained clinicians but
was a more common problem in the infancy of
osseointegration [7].
Foreign Body Reaction to Gauze
Forgotten or missed foreign bodies, such as cotton
sponges, gauze or instruments, after any surgical
procedures are considered a misadventure and is
associated with several legal problems. The term
“gossypiboma” denotes a mass of cotton retained
in the body after any intervention [8].
This term is derived from the latin, gossypium
for “cotton” and the Swahili word boma for “a place
of concealment.” Other terms used for gossypiboma
include “textiloma”, “cottonoid”, “cottonballoma”
“muslinomas” or “gauzeoma”. Gossypiboma is
rarely reported in literature and the reports of this
technical oversight are the tip of an iceberg because
the symptoms of gossypiboma are usually
nonspecific and some patients remain
asymptomatic. Some textilomas cause infection or
abscess formation in the early stage, whereas others
remain clinically silent for many years [8].
However, some remain clinically asymptomatic
for many years, and then cause a foreign body
reaction in the surrounding tissue, with new clinical
signs indicating significant mass effect. Foreign
bodies that are left behind during operations may
organize and increase in size but such changes are
not correlated with time [9].
In such cases, the diagnosis of gossypiboma and
the second surgical operation needed for removal
of medical problem can lead to start of legal problem
between the patient and the surgeon at fault.
Foreign Body Reaction to Glove Powder
Gloves containing Natural Rubber Latex (NRL)
represent an important hand barrier and their use
is an integral part of dental practice. Although they
provide excellent protection against the
transmission of infectious agents, they have been
associated with adverse reactions when used [10].
Glove powders are modified corn starches used
to assist in the donning of the glove. Powder in
manufacturing process are used to prevent blocking
or adherence of NRL surface.
The introduction of glove powder into body can
impair normal physiological functions causing
complications associated with the introduction of
foreign body like contamination of implants or
transplant organs.
The presence of glove powder can result in many
other undesirable effects, such as interference in
laboratory testing causing false results (i.e. PCR –
Polymerase Chain Reaction, enzyme immunoassay
or some HIV tests) and powder granulomas being
Vikram S. Amberkar et. al. / Foreign Body Reaction to Oral Tissue: Iatrogenic Factors
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
misdiagnosed as metastatic carcinoma [11].
Researchers have also shown powdered gloves
to be a risk factor for post-operative wound
infections. As with most foreign bodies, glove
powder decreases the inoculums of bacteria
required to produce abscesses. In addition, powder
also delays wound healing and alters the normal
reparative process while at the same time increases
the wounds inflammatory response.
However glove powder can act not only as a
vehicle for latex antigens but also for opportunistic
and pathogenic microorganisms, which increase the
occupational risks to both health care workers and
patients.
Diagnosis
Although foreign body reactions are commonly
associated with trauma related events and
sometimes due to iatrogenic, it is important to
investigate and evaluate them with utmost care. A
proper history, clinical evaluation and the
appropriate investigation will help us in diagnosis
and treatment of these conditions with accuracy.
Radiographically these foreign bodies appear as
radio opaque areas surrounding the particular tissue
[12].
Histologically abundant chronic inflammatory
cell infiltrate, presence of foreign material which
appear as eosinophilic areas and few giant cells
surrounding the foreign material [13].
Treatment
Surgical excision of the foreign material is the
treatment of choice.
Conclusion
Clinical evaluations and diagnosis of foreign body
reactions pose a challenge as they mainly depend
on the type of foreign body involved, the duration
of its presence, symptoms associated and the clinical
picture. Although foreign body reactions are
commonly associated with trauma related events it
is important to investigate and evaluate them with
utmost care and iatrogenic cause of foreign body
reaction must be prevented.
References
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Vikram S. Amberkar et. al. / Foreign Body Reaction to Oral Tissue: Iatrogenic Factors
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Pankaj Datta*, Sonia S. Datta**
Review Article
Various Methods of Detecting Micro-Leakage in Restorative Dentistry
Abstract
Micro-leakage testing has been used to determine the possible clinicalperformance of a restorative material.
A large number of different techniques have been developed for the investigation of micro-leakage. Many
micro-leakage testing materials have been developed andperformed through the years. There has been no
agreement as to which testing methodology would give the most accurate results. Attempts have been
made to simulate the oral conditions and to give a more quantitative representation of micro leakage. The
different micro leakage testing methodologies are presented in this paper.
Keywords: Micro-Leakage Testing; Clinical Relevance.
Author’s Affiliation : *Dean and Head, Department of
Prosthodontics **Reader, Department of Public Health Dentistry,
Inderprastha Dental College & Hospital, Sahibabad-Ghaziabad
(U.P.).
Reprints Requests: Pankaj Datta, Dean and Head, Department
of Prosthodontics, Inderprastha Dental College & Hospital, 46/1,
Site IV, Industrial Area, Sahibabad, Ghaziabad, Uttar Pradesh –
201010.
E-mail: pankajdatta97@gmail.com
Received on 13.05.2017, Accepted on 27.05.2017
Introduction
Restorative dentistry has modified in several
aspects due to the myriad of options available for
fabricating indirect restorations which have come
up over the past few decades, especially pertaining
to ceramics [1] and resin cements.
The objective of restorative dentistry is to restore
the tooth to its form and function with fair amount
of longevity to determine its clinical success. No
restorative work can be done without creating an
interface with the tooth structure. For a true
restorative material or a luting agent one of the
many requisites is its adaptability and bonding or
chemically joining to the tooth structure. Failure to
do so leads to the gap left between the prepared
tooth and the luting cement. Further damage is done
by the thermal contraction of the luting cements;
masticatory load induced volumetric changes which
enhance this gap causing micro - leakage between
the interfaces. It has been established that bacterial
leakage and its toxins are a greater threat to the pulp
there by to the tooth as well as the restorative work.
Most of the indirect restorations in the oral cavity
are meant to provide function and aesthetic without
causing any damage to the biological tissues. Three
main factors, which determine the success of an all-
ceramic restoration is; esthetics, resistance to
fracture and marginal adaptation [2]. One of the
critical parameter for the indirect restorations to be
successful in the patient’s mouth is marginal
adaptation.
The weakest link in the fixed partial denture
treatment is the tooth restorative margin interface.
Thus, marginal fit and its evaluation is a critical
parameter needed for longitudinal success. McLean
has given a clinically acceptable, marginal fit to be
within 120 m
3
. Any gap (horizontal or vertical)
exposes the luting agents to the oral cavity which
may cause degradation, dissolution, micro-leakage
[4] increase plaque accumulation, periodontal
inflammation, and secondary caries [5].
Poor marginal adaptation and cementation failure
leads to abutment and restoration failure. Studies
have stated that All-ceramic restorations failed by
10.9% and 21.7% due to secondary caries [6].
Micro-leakage is an unwanted passage of oral
fluid with micro-organisms and ions between the
tooth and restorations. Micro-leakage cause the
pulpal damage, discoloration, hypersensitivity,
recurrent caries, hastening of marginal break down,
all of which lead to pulpal pathology and failure of
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Volume 10 Number 2, April - June 2017
DOI: https://dx.doi.org/10.21088/ijde.0974.6099.10217.9
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the restoration.
Micro - leakage may be caused due to various
reasons; some of them are:
• Poor adaptation of restorative materials
• The contraction of restorative or luting agents
during setting
• Non adherence of these materials to tooth
structure
• Deformation under load and
• Temperature induced volume changes
Micro-Leakage Tests
One of the important methods of testing the
clinical performance of a restoration as well as the
luting materials has been to determine the micro -
leakage. Techniques to detect micro - leakage have
been classified in to various categories.
• Air pressure method
• Penetration studies with the help of dyes,
chemical tracers, radio isotopes, neutron
activated analysis and bacterial studies
• Fluid conduction studies
• Electronic methods
• Microscopic examination
Direct Observation
One of the simplest methods of detecting micro -
leakage is direct observation without the help of any
agent or tracer. It is based on visual and tactile
examination like discoloration of enamel or explorer
exposing the lack of marginal integrity finding the
gap between the tooth and restoration. However,
there is no direct correlation between visible
marginal gap and the depth of leakage.
Air Pressure Method
The principle of this technique is to take the tooth
with the restoration to be evaluated for micro -
leakage and to deliver the air at the junction or the
interface between the two and place this whole
assembly under water. The detection of air bubbles
from any of the margin of the restoration indicates
micro - leakage. The technique was evolved by
Harper 1912 but is now rarely used.
Penetration Technique (Tracers)
Currently, principle of penetration is utilized to
assess the micro - leakage; it involves luting the
indirect restoration over the prepared tooth,
followed by immersion of the specimen in a
penetrant solution for a specific period of time [7].
Later, the specimen is cleaned, sectioned and
examined under magnification to determine the
extent of the penetration. A standard criterion is
used to determine the extent of micro - leakage.
Organic Dyes
They are also known as organic tracers which are
used in dentistry to detect micro - leakage. They
may be used as solutions or particles of suspension.
One of the most popular as well as oldest techniques
using this principle is by making use of organic dyes.
These dyes may be used in many ways with the
specimen under examination. If the specimen is
dipped in the dye for a specific period of time it is
known as passive method. The phenomenon of
capillarity is very important to determine leakage.
Similarly, the specimen may be dipped in the dye
under vacuum/negative pressure or positive
pressure (specimen is dipped in epoxy resin and
kept in an autoclave under desired pressure).
Amongst the commonly used organic dyes basic
fuchsin is the most common [8]. However, there are
other dyes also which are made use of like
methylene blue, aniline blue, eosin, and crystal
violet. The aniline blue dye has a drawback as it
becomes transparent at an elevated pH with calcium
hydroxide [9].
Most of the dyes are used in the concentration
range of 0.5 to 2.0 percent [10,11]. Basic fuchsin dye
is commonly used at 0.5 percent solution. It is also
used as caries disclosing agent in combination with
propylene glycol. Some of these dyes were initially
toxic, due to which they were not used in vivo
studies. Further, some of these dyes diffused
profusely to the enamel or dentin which discolored
the tooth, making it difficult to interpret. Despite of
having drawbacks, the popularity of the organic
dyes has not gone down due to ease of use and low
cost.
Many a times the standard criteria are used for
evaluation of the results. This has been criticized
for being subjective and qualitative.In order to
remove this drawback, spectrophotometry was
introduced to quantify the results. Dye penetration
can also be assessed with the help of
stereomicroscope linked to image analysis software
[12]. Digital imaging microscopy can also be made
use of along the interface to record the actual length
of the dye penetration.
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Fluorescent Dyes
With the advent of fluorescent dyes many
researchers shifted to them for the following
reasons:
Fluorescent dyes are non-toxic in nature;
therefore they are safer to be used in vivo studies
as well as topical applications [13].
They are also detectable in dilute concentrations,
as well as sensitive to ultraviolet light. This makes
them more popular as it is easy to take photograph
and produce reproducible results. The contrast
provided by the fluorescent dye against the natural
fluorescence of the tooth makes it easy to detect the
path of dye penetration under ultraviolet light.
Criticisms have been raised against laboratory
testing because of the absence of the effect of pulpal
hydrostatic pressure on the dye. The scores obtained
from in vivo studies for micro - leakage are much
lower than the in vitro studies [14].
Radioisotopes
Radioisotopes became popular primarily for two
reasons; their ability to penetrate more deeply than
the dyes and due to autoradiography technique
which detected even minute amounts of tracers that
otherwise was not possible. Commonly used
isotopes are Ca45, c14, I31, S35, Na22, P32, Rb86
and C14. Radioisotopes of 45Ca are being used in
autoradiography for detecting micro - leakage [15].
Only the part of the tooth structure with the
restoration is left unpainted with varnish. Then the
sealed teeth (except the interface to be tested) are
immersed in the isotope solution for several hours
just like it is done with dyes. Later, the tooth-
restoration assembly is rinsed with water and cut
into longitudinal sections through the restoration.
The cut (flat) surfaces are applied to a photographic
film making good contact. After development the
film shows the radiolucency around the restoration
(due to the presence of radioactive isotopes) if the
micro - leakage is present.This technique offers
many advantages over the conventional dye
technique.
Radioisotope technique requires an exposure
time of two hours in comparison to a day required
by the dye.
The differences between in vivo and in vitro
results are minimal which supports the use of this
technique in vitro testing.
However, special training is required to handle
and master this technique. Further, the results of
this method are always qualitative.
Bacterial Studies
The more realistic method with more clinical and
biological relevance in detecting micro - leakage is
with the help of bacterial studies. Usually bacteria’s
have larger size than the molecular size of dye or
isotope, thereby giving more real life results of micro
- leakage. The specimen with the interface to be
checked is placed in a broth inoculated with
bacterial culture. Later this specimen is kept in a
sterile broth for culture; if the sterile broth turns
cloudy micro - leakage is diagnosed. Commonly
Enterococcus and streptococcus bacteria are used
as tools in this method. Enterococcus fecalis is used
because it is a part of normal oral flora and exists
with other aerobic and anaerobic microorganisms.
This technique is qualitative rather than
quantitative.
Silver Nitrate Technique
Silver nitrate is also very commonly used as a
stain to detect micro - leakage because it provides a
good optical contrast because of silver [16]. A 50%
solution of silver nitrate is used to keep the specimen
dipped in it for two hours. Later, they are washed
and exposed to developing solution to precipitate
the silver particles. Specimens are cut in the desired
section to detect the micro - leakage. The degree of
micro - leakage is determined in a similar fashion
to one used for organic dyes.
Neutron Activation Analysis
Micro - leakage can also be quantified by using
neutron activation analysis [17]. This technique may
be used for determining micro - leakage in vivo and
in vitro. However, the in vitro uptake is always
greater than the in vivo uptake. 55Mn was used for
neutron activation but the presence of manganese
in the tooth or the restorative material can alter the
results. Therefore, it has been replaced now by
dysprosium as tracer.
For in vivo testing the teeth are soaked in an
aqueous solution of a nonradioactive 55Mn salt after
isolating for one hour. Later, they are extracted and
placed in a nuclear reactor and irradiated at 1
megawatt for two minutes where the 55Mn is
activated to 56Mn. The gamma-ray emission of
56Mn is measured with a scintillation detector and
a germanium crystal linked to a gamma-ray
spectrometer.
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Fluid Conduction Studies
This technique was evolved by Pashley to
quantify the micro-leakage. The restoration is placed
on the tooth and sectioned. The sectioned tooth with
the restoration forms a working model are
connected to a plastic tube. The working in this
model is based on the fluid transport under positive
pressure, which displaces the air bubble in a
capillary tube filled with deionized water between
the model under test and the pressurized
chamber.The air bubble is created and adjusted in
the capillary by sucking the water. The model with
the attached capillary are kept in water bath at a
contrast temperature. Now the pressure is applied
from the inlet to force the water through the void
along the restoration, which displaces the air bubble
in the capillary. The volume of fluid transported is
measured by observing the displacement of the air
bubble which is expressed in ml/day
Electronic Monitoring
This technique permits the quantification of the
micro - leakage. It allows the micro - leakage to be
recorded over a period of time during which several
reading may be taken. Hence, leakage as a function
of time can also be recorded.
The micro - leakage detecting device consists of
two main parts.
• Constant pressure reservoirs
• Micro-pressure sensor
Constant pressure is maintained in the steel
reservoir by means of manual air pump and
electronic micro-pressure sensor. With the help of
a valve a constant pressure is supplied to the
specimen to be tested. The sensor is sensitive to the
pressure changes as small as 0.05 mm of Hg. A
polyvinyl chloride tubing with known inner and
outer diameter is connected between a pressure
reservoir and the pressure sensor and calibrated
with 1 ml if water to check the variation in the
pressure.
Water and specimen to be tested is injected into
the sensor end of the tube. A constant air pressure
is then applied to the water bolus and changes in
air pressure on the sensor side of the specimen are
recorded. With the help of proportionality factor,
the changes in pressure measures as the result of
micro - leakage can be converted to volume of
leakage per unit time.
Microscopic Examination
Scanning Electron Microscopy (SEM)
With advancement scanning electron microscopy
(SEM) was made use of to observe the accuracy of
marginal integrity between the tooth and the
restoration. This technique had the advantage over
the microscopic examination like introduction of
artifacts during its preparation for imaging
18
.SEM
works with a very thin layer of heavy metal like
gold or palladium being coated o the surface of the
specimen to be examined. Before that the specimen
is coated with carbon which provides a conducting
base. These heavy metal alloys usually serve as
secondary source of secondary electrons. An
electron beam is focused into a fine probe. The probe
is scanned over the surface of the specimen. When
a beam of electron hits the surface of the specimen
it interacts up to 1 µm of the surface, some electrons
are reflected (scattered back) and others are ejected
(Secondary electrons) released from the heavy
metal. The secondary electrons are collected by
detectors and interpreted and displayed as a 3D
image on a monitor. SEM is commonly used to
measure gap which occurs between the restorations
and the axial walls or the floor of the reparations.
The defects can be observed at required
magnification such as 200 x or 1000 x at the
submicron level.
Replication Scanning Electron Microscopy
In replication SEM replicas are used which permit
marginal defects to be evaluated on a longitudinal
basis clinically as well as in vitro. In vivo technique
replicas are prepared of the experimental restoration
after finishing or at any desired intervals of time.
The surfaces are cleaned with a 5% of NaOCl
solution for the impression to be made with silicone.
The replicating material should be fluid enough to
record all the fine details, shouldn’t react with the
material used to fabricate the positive and also it
should be able to record the details of wet as well
as dry surfaces. These impressions are used to make
cast with epoxy resin. The casts are prepared for
SEM by coating of gold and examined. For in vivo
assessment of marginal gap and associated micro -
leakage replica technique provides a satisfactory
way.
Confocal Microscopy
This is a Laser Scanning microscope, through
which multiple scanning of the specimen is achieved
which helps in creating a 3-D image. It differs from
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the fluorescent microscopy which uses UV
radiations, of which a wavelength is absorbed and
emitted at different wavelength which is collected
by the objective lens. It has limitations like lack of
contrast, sharpness and the thickness. On the
contrary, confocal microscope enables the imaging
of volume objects in a 3-dimensionally.
Specimen Evaluation
The most critical factor in evaluating the micro -
leakage is the scoring method or the number of
surface to be considered when used with dyes or
tracers. Most of the studies are done including two
surfaces scoring by sectioning the specimen
longitudinally from its centre [8,19]. However, some
researchers also propagate the inclusion of all
marginal interfaces for the evaluation of micro-
leakage, as it reduced the chances of getting false
negative results [13]. As far as the scoring is concerned
the most standard method is assigning a numerical
value to represent the extent of dye penetration
signifying micro – leakage [20,21]. The use of
radiographs for evaluation with radioisotopes is based
on the subjective analysis which is not very reliable.
Leakage Patterns
It has been an established fact that the micro -
leakage is generally more at the cervical margin of
the restorations in comparison to the occlusal
margins [11,22].
Such a behavior has been attributed to
permeability of dentin and the prismatic pattern of
enamel at cervical and occlusal surface [22].
The temperaturethroughout the test specimen
may be calculated once the thermal parameters like
thermal conductivity, specific heat, density of the
material and coefficient of heat transfer of the test
are known.
Thermocycling
All the specimens to be tested for micro - leakage
must undergo thermal cycling or load cycling or
both in order to stimulate the oral conditions.
Thermocycling is an in vitro method of exposing
the test specimens artificially to hot and cold
temperatures simulating the oral conditions.
It is a well-known fact that at the interface of two
materials percolation takes place due to the
difference in the CTE of these materials when
exposed to fluctuating temperatures. In the case of
a crown cemented on to the prepared tooth two
interfaces are created; tooth-cement and cement-
restorative material through which marginal
percolation takes place and fluid drops extrude from
the margins of the restorations with the increase in
temperature which indicates, micro - leakage of the
restorations. Such situations are similar to faced by
the natural teeth [23] when taking food items
simultaneously at different temperatures. Therefore,
it is important to study the behavior of different
materials when exposed to the extremes of
temperatures (with in physiological tolerance). The
tolerance limit in humans have been found to be
4°C for the lower thermal limit and 60°C for the
upper thermal limit [24]. Along with temperature
another equally important parameter is the dwell
time; that is the time for which the material is
exposed to a temperature. It has been generally
agreed upon to expose the specimens for a
maximum of 10 seconds as dwell time. It is relevant
since it determines the ability of the material to
conduct heat in relation to its mass [25].
Thermocycling requirestwo important things;
equipment to ensureconstant temperatures inthe
water baths and shifting of the specimens at the
appropriate time.
Thermo-Cycler
Thermo-cycler is particularly designed to conduct
laboratory testing of micro leakage in composite
filling and adhesive bonding materials in and on
tooth structures. Specimens to be tested are
submerged in hot and cold baths for a definite
duration of time for numbers of cycles. The
temperature of the water bath is accurately
controlled with microprocessors.
International standardsspecify immersion times
(dwell time, 10 seconds to 30 seconds) and
temperatures (5 °C cold water and then in 55 °C
hot water) for a defined number of cycles for a
specimen to be tested. Thermocycling is a useful
method of ageing thematerials. The result
ofsubsequent testing invariably shows degradation
in adhesive strength. It is important thatthis loss of
bonding is limited. Thermocycling is based on the
diffusion of heat, movement of moisture in and out
of the porous test materials. A diffusion process
always acts to even out differences of temperature
gradients or moisture content. It also produces
transient mechanical and chemical stresses on the
test material.
Conclusion
A variety of methods are currently available to
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detect and determine the micro - leakage to the
researchers. As mentioned earlier all techniques
have their advantages and disadvantages. The goal
of all these studies is to make testing clinically
relevant. However, the in vitro results do not
necessarily correlate to the clinical performance. It
has been observed the results of various studies on
the same materials do not match some times because
of the variation in the testing techniques used in
the research.
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© Red Flower Publication Pvt. Ltd
Prashanth Kumar Katta
Review Article
Metals Used In Restorative Dentistry
Abstract
Dentistry without metals is impossible. It is used for various reasons like posts, crowns, orthodontic
braces and brackets. Tooth coloured materials like ceramics also have different metallic oxides as part of
their composition. Even the so called resin composites used in dentistry as tooth coloured restorative
materials have traces of metals in them which serve various purposes. It is impossible to imagine metal
free dentistry. This article provides an in detail review of the various metals and alloys used in dentistry.
Keywords: Alumina; Alloys; Metals; Zinc Oxide.
Author’s Affiliation: Assistant Professor, Department of
Restorative Dental Sciences, Al Farabi Dental College, Jeddah,
Kingdom Of Saudi Arabia.
Reprint s Requests : Prashan th Kumar Katta, Assistant
Professor, Department of Restorative Dental Sciences, Al Farabi
Dental College, Jeddah, Kingdom of Saudi Arabia.
E-mail:drprashanthkumar@yahoo.com
Received on 18.03.2017, Accepted on 07.04.2017
Introduction
Porcelain
Lithium is an alkaline metal which is a component
of porcelain mixture used in dentistry; it is a
hardmetal, Zirconium resistant to corrosion and
similar tosteel. Alkaline Glasses is composed
primarily of silicon dioxide, but also includes a
fraction of alkaline oxides such as barium oxide
(BaO) and strontium oxide (SrO), which integrate
into the silica network. Aluminum oxide (Al2O3),
titanium dioxide (TiO2), zinc oxide (ZnO), and
zirconium oxide (ZrO2) [1].
Fluxes
Fluxes are alkaline metal oxides such as sodium,
potassium, lithium, boron, and lead. They dissolve
silica. Pure quartz melts at 1713°C. The addition of
25 % sodium oxide lowers the melting temperature
of quartz to 793°C.
Alumina Alumina (aluminum oxide) is found
combined with silicon in naturally-occurring glasses
called feldspars. It is used as a stabilizer to toughen
glass. Alumina acts as a sort of framework or
skeleton. This framework stiffens glass during firing
and makes it less likely to slump. The inclusion of
crystalline structures transforms glass into porcelain
which is much tougher and less prone to fracture
than glass without such a matrix. Alumina is in clay
and nearly all ceramic products such as dinnerware
and china. It is added to dental porcelain in the form
of aluminum oxide. Trace metals give glass color.
Cobalt imparts a blue color; gold imparts red, and
copper, green. These metals are added as oxides.
They have fluxing qualities, but they are not alkaline
metals.
Cobalt, gold, and copper are added in such small
amounts that they are not considered fluxes for
purposes of calculating glass formulas. Zirconium
and titanium oxides add opacity to glass. They form
a crystalline structure within otherwise translucent
glass. This structure diffuses light and creates a
milky or pure white appearance depending on the
amount of zirconium or titanium oxide used [3].
How Metals Affect the Properties of Dental
Materials?
Metal oxide nanoparticles were synthesized from
tantalum ethoxide and zirconium isopropoxide and
subsequently surface grafted with vinyl silane and
silyl methacrylate coupling agents. The
nanoparticles were then dispersed into a
commercial dental resin, and the composite was
photocured into rigid three-point bend and fracture
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toughness specimens. The optically transparent/
translucent cured composites demonstrated
strength, toughness, and elastic modulus inferior
to the unfilled material.
Ceramic Stains
Metal oxides are often added into porcelain
powders as pigments for them to be tooth coloured,
as metal oxides are stable during fusion
temperature. This gives porcelain an advantage over
other materials as they can match the shade of the
adjacent tooth closely and gives a realistic
appearance.
Some feldspathic porcelain is supplied as
opalescent porcelains, which contains small
amounts of metallic oxides. These metallic oxides
have high refractive index and particle size near to
that of the wavelength of light, thus, they have a
light scattering effect. This resembles the natural
teeth, which is also display some degree of
opalescence, and further improves the aesthetics of
the fabricated prostheses.
Metals in GIC
Alumina is considered to be a ‘‘conditional
network former’’ in glasses. This means that it will
not form a glass on its own, but will do so in
association with sufficient amounts of another
oxide. In alumina containing glasses, aluminum ions
may be found in 4-, 5- and 6-coordination. The 4-
co-ordinate structures correspond to those forced
on aluminum by the presence of large amounts of
silica 1, but the existence of the 5- and 6-coordinate
units shows that not all the aluminum ions are
forced into silica-like tetrahedra. For those Al ions
forced into aluminate tetrahedral, mutual sharing
of corners is unfavorable because of the instability
of the AlO4 species. Hence they are found only in
association with SiO4 tetrahedra [2].
Adverse Effects of Aluminium
Aluminum needs to be excluded from cells
because of its affinity for phosphate species 3. It is a
small ion of high charge density and consequently
binds strongly to anionic O-donor ligands, such as
HPO2 [4]. Were it to do this inside the cells, it would
interfere with energy transduction, a process that
involves the phosphate species adenosine
triphosphate (ATP) and adenosine diphosphate
(ADP). Complexation with aluminum ions would
slow down reactions of these compounds to rates
that could not sustain life. Hence aluminum is toxic
to a wide range of animals and plants [4].
Zinc oxide is present in dental amalgam, zinc
phosphate cement, zinc polycorboxylate cement,
zinc oxide eugenol cement, and even dental
composites. It gives hardness, improves physical
properties and has antibacterial properties [5,6].
Composites containing ZnO-NPs were found to
moderately inhibit S. sobrinus biofilm formation for
periods of three days when compared to composites
without ZnO nanoparticles [5].
Apart from alumina and zinc oxide magnesium
oxide is also a part of composition of various dental
cements and ceramics used in dentistry. Not just
these, traces of other metal oxides like bismuth and
barium oxides are part of various cements, ceramics
and composites used in dentistry.
Dental Composites
Many metals have been used as fillers in dental
composites. Thes include barium, quartz and silica
[7]. Barium-containing glasses were re prone to
leaching of this ion from well polymerized
composite resin in water, but quartz fillers were
substantially stronger and remained steadfast in an
aqueous environment [8,9,10,11].
Conclusion
The bottom line is that, there is nothing called as
metal free dentistry. Metals and metal oxides are
part of the composition of all the materials used in
dentistry. These metals significantly improve the
physical properties of the material without which
the material would be too weak to sustain the forces
of mastication. But the percentage of the metal used
must be carefully chosen so that it does not
adversely affect the biocompatibility of the material.
Conflict of Interest
None
Source of Funding
Self
Acknowledgements
None
Ethical Clearance
Not applicable
Prashanth Kumar Katta / Metals Used In Restorative Dentistry
127
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
References
1. Paul, A. The Chemistry of Glasses, London,
Chapman and Hall, 1982.p.5–9.
2. Fyfe, C.A., Thomas, J.M., Klinowski, J. and Gobbi,
G.C. Magic-AngleSpinning NMR (MAS-NMR)
Spectroscopy and the Structure of Zeolites, Angew.
Chem. Int. Edit. Engl., 1983: 22:259–275.
3. Williams, R.J.P. What is Wrong with Aluminium? J.
Inorg. Biochem., 1999: 76:81–88.
4. Swaddle, T.W. Silicate Complexes of Aluminium (III)
in Aqueous Systems, Coord. Chem. Revs., 2001: 219–
221, 665–686.
5. Antibacterial Activity of Dental Composites
Containing Zinc Oxide Nanoparticles Berdan Aydin
Sevinç and Luke Hanley, J Biomed Mater Res B Appl
Biomater. 2010 July; 94(1):22–31.
6. Metal-oxide nanoparticles for the reinforcement of
dental restorative resins. Furman B
1
,Rawls
HR,Wellinghoff S,Dixon H,Lankford J,Nicolella D.
Crit Rev Biomed Eng.2000; 28(3-4):439-43.
7. Schweiz Monatsschr Zahnmed, Composite materials:
Composition, properties and clinical applications A
Literature Review, 2010; 120(11).
8. Ohsaki A, Imai Y. Analysis of major components
contained in Bis- GMA monomer.Dent Mater.1999;
18:425–9.
9. Soderholm KJ, Zigan M, Ragan M, Fischlschweiger
W, Bergman M. Hydrolytic degradation of dental
composites.J Dent Res.1984; 63:1248–54.
10. Oysaed H, Ruyter IE. Water sorption and filler
characteristics of composites for use in posterior
teeth.J Dent Res.1986; 65:1315–8.
11. Mousavinasab SM. Biocompatibility of composite
resins.Dental Research Journal. 2011; 8(Suppl1):
S21-S29.
Prashanth Kumar Katta / Metals Used In Restorative Dentistry
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Prashanth Kumar Katta
Review Article
Success and Failure in Endodotics
Abstract
The criteria for considering a root canal treatment as success or failure many. Just because the clinical
symptoms have subsided that doesn’t mean that the treatment is success, its just the severity of the disease
has come down. The clinical, radiographic as well as the time factor after the treatment should be considered
in the progress of the treatment. This article highlights the cause of success and failure of endodontics.
Keywords: Endodontics; Failure; LASERS; Success; Surgery.
Author’s Affiliation: Assistant Professor, Department of
Restorative Dental Sciences, Al Farabi Dental College, Jeddah,
Kingdom Of Saudi Arabia.
Reprint s Requests : Prashan th Kumar Katta, Assistant
Professor, Department of Restorative Dental Sciences, Al Farabi
Dental College, Jeddah, Kingdom of Saudi Arabia.
E-mail:drprashanthkumar@yahoo.com
Received on 14.04.2017, Accepted on 24.04.2017
Introduction
Endodontic treatment unlike esthetic dentistry,
orthodontics or prosthodontics needs removal of the
existing disease. The tooth anatomy can vary with
race, age and gender. The cause of the disease can be
carious or non carious like trauma. It can also be
previous endodontic treatment that has failed. Proper
diagnosis of the case will help in better treatment
and eventually help in complete removal of the
disease. The failure of initial treatment can be various
including missed canals, inadequate enlargement and
incomplete obturation. Now the real challenge is to
remove the disease and ensure that the case doesn’t
fail for the second time. The astute clinician must
diagnose properly using latest imaging techniques
and use latest canal disinfection techniques based on
evidence to ensure the success [1,2].
Criteria for a Failed Endodontic Treatment [3]
Most common cause of failure of endodontic
treatment is residual infection within the root canal
system. It might remain in uninstrumented surfaces
of the root canal, missed canal, apical ramifications
or periapical biofilms.
1. When the presenting clinical signs like sinus,
swelling or the pain does not subside even after
1year
2. The size of the periapical lesion does not come
down even after 1 year
The most common causes of endodontic
treatment failure include (Thiele et al. 2003):
• Incomplete apical obturation
• Incomplete coronal obturation
• Incomplete disinfection of the root canal (extra
canals, ramification, aberrant dentin tubes)
• Precise microbial infection (enterococcus
faecalis and candida albicans, for example, are
very meagerly susceptible to the effects of
calcium hydroxide.)
• Protracted course of treatment
• Iatrogenic damage of integrity of the tube’s
anatomy (excessive instrumentation/over
filling/false route)
3. According to Ray and Trope (1995) [4], good
apical and coronal closure resulted in 91.4% of
cases in complete resolution of the endodontic
infection. If only good apical obturation is guaranteed
but a tight coronary closure is refrained from,
the rate of success is reduced to 44.1%.
Criteria for A Successful Endodontic Treatment [5]
1. There is no swelling and other sign of infection
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
and inflammation
2. Complete healing of sinus tract in case it was
present before starting the treatment or healing
of narrow, isolated probing defect
3. No clinical proof of soft tissue destruction,
including probing defects
4. The tooth is back in form and function.
Radiographic Criteria [6,7]
There is regeneration of periapical bone
following endodontic treatment. But this will take
time at least 6 months to 1 year depending upon
the extent and size of periapical lesion. However,
periapical radiographs may not be accurate enough
in giving a 3 dimensional picture of the lesion hence
CBCT (cone beam computed tomography) or micro
computed tomography must be used to get
accurate picture of the progress of the bone
formation.
Quality of obturation of the root canal achieved
with regard to the density, filling material,
regularity and anatomical form of the mechanical
preparation,degree of enlargement of the root canal
and condition of the periapical tissue.
How to Increase the Success Rate [4]
1. Determine and diagnose the condition
accurately
2. Use advances diagnostic techniques like micro
CT to know the internal anatomy of the pulp
chamber and root canal. Check for extra canals
or bifurcations in the apex.
3. Use of rubber dam and other isolation
techniques during the treatment phase
As an alternative to the terms “success” and
“failure,” the American Association of Endodontists
has proposed the following terms:
1. Healed —Functional, asymptomatic teeth with
no or minimal radiographic periradicular
pathosis.
2. Nonhealed —Nonfunctional, symptomatic
teeth with or without radiographic
periradicular pathosis.
3. Healing —Teeth with periradicular pathosis
that are asymptomatic and functional, or teeth
with or without radiographic periradicular
pathosis that are symptomatic but for which the
intended function is not altered.
4. Functional —A treated tooth or root that is
serving its intended purpose in the dentition.
Single Visit vs. Multiple Visit Endodontics
Several studies have proven that the success rate of
single visit is equally good as multiple visit endodontics
when calcium hydroxide was used as inter-appointment
dressing to reduce the intracanal infection [1]. The
advantages of single visit treatment includes
avoiding microleakage during the inter
appointment visits, less flare up and better patient
acceptance [2, 8]. Few studies have shown that even
though success with single visit treatment is more
comparatively the difference in healing rate between
these two treatment regimens was not statistically
significant [9].
Influence of Calcium Hydroxide Intracanal
Dressing
Studies and meta-analysis of literature has shown
that Calcium hydroxide has limited effectiveness
in eliminating bacteria from human root canal when
assessed by culture techniques [10]. Few other
evidence based studies have shown that calcium
hydroxide has limited effectiveness in eliminating
bacteria from human root canals, when assessed by
culture techniques [11].Also, few studies have
refuted the medicinal effects of calcium hydroxide
and concluded that calcium hydroxide did not show
the expected effect despite following up the case
for 1 year in disinfecting the root canal system and
treatment outcome despite there were cultivable
microorganisms in the canal,and there is a need
for better medicament that can be used as intracanal
medicine [12,13]. When calcium hydroxide was
used in non vital teeth with periapical lesions, it
could only limit the microorganisms but not totally
eliminate the infection [14].
Surgical vs. Non Surgical Root Canal Treatment
When conventional orthograde treatment fails
with the periapical lesion intact, people resort to
apicoectomy before more extensive treatment like
extraction. The doctor must diagnose the case
properly before taking any step. He should use
diagnostic aids like CBCT or micro CT to check for
any missed canals which may be the cause for failure
of initial treatment. Cases have been reported which
have undergone surgery in the past but failed and
it was retreated in orthograde way and lesions
healed [15,16].
Prashanth Kumar Katta / Success and Failure in Endodotics
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Use of Ultrasonics, LASERS and Sonics
Several advancements have been made with
regard to disinfection of the root canal. WaterLase
Er,Cr:YSGG 2,780nm laser energy can penetrate
deep into dentinal tubules to culminate bacteria,
without any potential toxicity of sodium
hypochlorite (NaOCl) irrigating solutions [17].
Research has proven that use of LASERS
potentially improved the success rate when
compare to cases that were not treated without
using them [18].
Photo-activated disinfection (PAD) has also been
used in disinfecting root canals. Research has shown
that The PAD and EndoActivator system were more
successful in reducing the root canal infection than
the diode laser and NaOCl syringe irrigation alone
[19].
E. Faecalis is the most commonly found bacteria
in failed root canal treated cases. Studies have not
been so conclusive about eliminating this bacterium
from root canal. Photodynamic therapy killed E.
Faecalis in experimental primary endodontic
infections and retreated human root canals. PDT is
an effective supplement in root canal disinfection;
especially in endodontic retreatments [20].
Other studies have shown that efficacy of PDT in
eliminating E. Faecalis from infected root canals
remains questionable [21].
Ultrasonic irrigation of the root canal can be done
with or without simultaneous ultrasonic
instrumentation. Passive ultrasonic irrigation (PUI)
can be used When canal shaping is not being done.
PUI is more effective in disinfecting canals than
ultrasonic irrigation along with simultaneous
ultrasonic instrumentation. But factor like canal
shape and diameter, irrigation frequency, intensity
on the streaming pattern as well as the complicated
interaction of acoustic streaming with the adherent
biofilm needs [22].
Discussion
The root canal anatomy is never standard for a
particular tooth. Cause for failure include
perforation, overextension of obturating material,
violation of the anatomical apex, Studies have
shown that the most common microorganism
involved in failure is Candida albicans, as it has been
isolated in the failed cases [3].
With the advent of imaging techniques like cone
beam computed tomography, micro CT, the
practitioner should be able to better detect
additional canals in case doubt arise [5].
The possibility of periapical surgery must be
considered in case there is a frank cystic lesion or
multiple failures of the same case [22].
Conclusion
An astute practitioner must take the aid of the
latest technology right from diagnosis through
treatment phase to avoid any pitfalls and ensure
the best treatment. The treating dentist must
diagnose the condition properly particularly while
treating retreatment cases, identify the cause of
failure, look for any deviation in the root canal
anatomy like apical ramifications or additional
canals, and ensure that the disease will subside
completely both radiographically and clinically.
Conflict of Interest: None
Source of Funding: Self
Acknowledgements
None
Ethical Clearance: Not applicable
References
1. C. Sathorn, P. Parashos & H. H. Messer, Effectiveness
of single- versus multiple-visit endodontic treatment
of teeth with apical periodontitis: a systematic review
and meta-analysis, International Endodontic Journal,
2005; 38:347–355.
2. Walton R, Fouad A. Endodontic interappointment
flareups: a prospective study of incidence and related
factors. Journal of Endodontics 1992; 18:172–7.
3. Tabassum S,Khan FR. Failureof endodontic
treatment: Theusualsuspects. Eur J Dent.2016 Jan-
Mar; 10(1):144-7.
4. Ray HA,Trope M. Periapical status of
endodontically treated teeth in relation to the
technical quality of the root filling and the coronal
restoration. Int Endod J.1995 Jan; 28(1):12-8.
5. Carlos Estrela, Roberto Holland, Cyntia Rodrigues
de Araújo Estrela, Ana Helena Gonçalves Alencar,
Manoel Damião Sousa-Neto, Jesus Djalma Pécora,
Characterization of Successful Root Canal Treatment,
Brazilian Dental Journal 2014; 25(1):3-11
6. Akbar I, Radiographic study of the problems and
Prashanth Kumar Katta / Success and Failure in Endodotics
131
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
failures of endodontic treatment, Int J Health Sci
(Qassim). 2015 Apr; 9(2):111–118.
7. A Iqbal, The Factors Responsible for Endodontic
Treatment Failure in the Permanent Dentitions of the
Patients Reported to the College of Dentistry, the
University of Aljouf, Kingdom of Saudi Arabia, J Clin
Diagn Res. 2016 May; 10(5):ZC146–ZC148.
8. Imura N, Zuolo ML. Factors associated with
endodontic flare-ups: a prospective study.
International Endodontic Journal 1995; 28:261–5.
9. Sathorn C
1
,Parashos P,Messer HH. Effectiveness of
single- versus multiple-visit endodontic treatment of
teeth with apical periodontitis: a systematic review
and meta-analysis. Int Endod J.2005 Jun; 38(6):347-
55.
10. Sathorn C
1
,Parashos P,Messer H. Antibacterial
efficacy of calcium hydroxide intracanal dressing: a
systematic review and meta-analysis. Int Endod J.
2007 Jan; 40(1):2-10.
11. Balto KA.Calcium hydroxide has limited
effectiveness in eliminating bacteria from human root
canal.Evid Based Dent. 2007; 8(1):15-6.
12. Waltimo T
1
,Trope M,Haapasalo M,Ørstavik D.
Clinical efficacy of treatment procedures in
endodontic infection control and one year follow-
up of periapical healing. J Endod.2005 Dec;
31(12):863-6.
13. Peters LB,Wesselink PR. Periapical healing of
endodontically treated teeth in one and two visits
obturated in the presence or absence of detectable
microorganisms. Int Endod J.2002 Aug; 35(8):660-
7.
14. Peters LB
1
,van Winkelhoff AJ,Buijs JF,Wesselink
PR. Effects of instrumentation, irrigation and
dressing with calcium hydroxide on infection in
pulpless teeth with periapical bone lesions. Int Endod
J.2002 Jan; 35(1):13-21.
15. Kapoor V,Paul S. Non-surgical endodontics in
retreatment of periapical lesions - two representative
case reports. J Clin Exp Dent.2012 Jul 1; 4(3):e189-
93.
16. Cali kan MK. Nonsurgical retreatment of teeth with
periapical lesions previously managed by either
endodontic or surgical intervention. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod.2005 Aug;
100(2):242-8.
17. Wanda Gordon, DMD, Vahid A. Atabakhsh, DDS,
Fernando Meza, DMD, Aaron Doms, DDS, Roni
Nissan, DMD, Ioana Rizoiu, MS and Roy H. Stevens,
DDS, MS. The antimicrobial efficacy of the erbium,
chromium: yttrium-scandium-gallium-garnet laser
with radial emitting tips on root canal dentin walls
infected with Enterococcus faecalis. JADA 2007;
138(7):992-1002.
18. Asnaashari M,Safavi N. Disinfection of
Contaminated Canals by Different Laser
Wavelengths, while Performing Root Canal Therapy.
JLasersMed Sci.2013 Winter; 4(1):8-16.
19. Bago I,Pleèko V,Gabriæ Panduriæ D,Schauperl
Z,Baraba A,Aniæ I. Antimicrobial efficacy of a high-
power diode laser, photo-activated disinfection,
conventional andsonicactivated irrigation during
root canal treatment. Int Endod J.2013 Apr; 46(4):339-
47.
20. Bago I,Pleèko V,Gabriæ Panduriæ D,Schauperl
Z,Baraba A,Aniæ I. Antimicrobial efficacy of a high-
power diode laser, photo-activated disinfection,
conventional andsonicactivated irrigation during
root canal treatment. Int Endod J.2013 Apr; 46(4):339-
47.
21. Siddiqui SH,Awan KH,Javed F. Bactericidal efficacy
of photodynamic therapy against Enterococcus
faecalis in infected root canals: a systematic literature
review. Photodiagnosis Photodyn Ther.2013 Dec;
10(4):632-43.
22. van der Sluis LW,Versluis M,Wu MK,Wesselink
PR. Passive ultrasonic irrigation of the root canal: a
review of the literature. Int Endod J.2007 Jun;
40(6):415-26. Epub 2007 Apr 17.
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Yousif I. Eltohami*, Nour E. Alim*, Amal H. Abuaffan*
Case Report
Maxillary Cemento-Ossifying Fibroma
Abstract
Maxillary cemento-ossifying fibroma is a rare, benign fibro-osseous lesion; belong to the odontogenic
lesions, characterized by replacement of the bone by fibrous tissue and cementum like material. It occur
most commonly in the 3
rd
and 4
th
decade with a female predilection. The current case report represent a 26-
year- old female patient, who had cement-ossifying fibroma in the maxilla that extend to the left orbital
rim and treatment is successfully perform by enucleating.
Keywords: Fibro-Osseous Lesions; Cement-Ossifying Fibroma; Benign Odontogenic Tumor; Maxilla.
Author’s Affiliation: *University of Khartoum Faculty of
Dentistry, Sudan.
Rep rints Request s: Am al H. Abuaffa n, University of
Khartoum, Faculty of Dentistry, Sudan.
E-mail amalabuaffan@yahoo.com
Received on 11.04.2017, Accepted on 16.05.2017
Introduction
Cemento-ossifying fibroma is one of the fibro
osseous lesions that commonly affect the head and
neck region; it is a rare, benign, odontogenic tumor
that commonly affects the mandible [1]. Frequently
affect the posterior area of the lower jaw [2]. It may
occur in the maxilla, particularly in the canine fossa
and the zygomatic arch area and has a female
predilection [3]. The peak incidence in the third
and fourth decades of life [4]. Clinically, appear as
a slow-growing intra bony tumor, normally well
delimited and asymptomatic–though over time, the
lesion may become adequate large to cause facial
deformation [5]. Radiologic ally, they show a
number of patterns according to the degree of lesion
mineralization. The more advanced lesions manifest
a well delimited unilocular lesion containing
variable amounts of radio-opaque material [5,6].
Cemento-ossifying fibroma is characterized by
proliferation of fibrous cells, new bone formation
and a cementum like tissues in replacement to the
normal bone [7]; that formed from pluripotent
mesenchymal cells, originate from the periodontal
ligament and capable of forming bone tissue and
cement [8].
Cemento-ossifying fibroma clinically resembles
fibrous dysplasia, cemetifying periapical dysplasia
or cemento-osseous florid dysplasia. It originates
from the periodontal membrane [9]. The treatment
choice is complete excision of the tumour, along
with the involved site., they are insensitive to
radiotherapy and recurrences are uncommon [10].
The current case report, for 26 years old Sudanese
female with cemento-ossifying fibroma in the
maxilla, extend to the orbital rim and it is excised
by enucleating.
Case Scenario
A 26 years old Sudanese female came to the Oral
and Maxillofacial Surgery Clinic complaining from
painless hard swelling in the left side of the upper
jaw with difficulty in biting which started 3 years
ago and increase gradually in size. There was no
significant medical or social history.
A clinical examination shows a bony hard well
defined maxillary swelling with intact and normal
colored mucosa, without apparent discharge. The
lesion had a bucco-palatal extension and the
associated teeth were firm and vital (Figures 1-2).
CT scan showed a spherical shaped well defined
radiolucent with sclerotic margins in the left maxilla
with involvement of left orbital rim (Figure 3).
Incisonal biopsy result was revealed fibro osseous
lesion (foci of calcified materials and cementum like
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
spherules) with characteristic osteoblastic rim
surrounding the fibrous stroma.
Patient was Treated by Enucleation
Discussion
Cemento- ossifying fibroma belong to the fibro-
osseous lesions, it was benign and rare, commonly
occurs in the premolar and molar regions of the
lower jaw during the third and fourth decades of
life. Females are affected more and black patients
tend to have multiple lesions. The lesion usually rise
as a painless swelling [12,13] the most common
clinical sign; the bony swelling or the buccal and/
or lingual cortical plates expansion [14,15]. In our
case the patient age, in the 3
rd
decade and it within
the common range for appearance of COF, as well
the gender predilection and the clinical presentation.
The origin of the cemento-ossifying fibroma not
well defined and in the previous literature, it has
found that, history of trauma can exaggerate it.
However, it was not the reason in the present case
report. Few studies have considered that these
lesions develop either by reactive or developmental
origin, from the periodontal membrane [11].
Ossifying fibroma was usually solitary. Bilateral
as well as multiple familial ossifying fibromas also
had been reported [16]. In this case it was a solitary
lesion in the left maxilla.
Regarding the radiographic appearance, COF
can present in three stages; in early stages the lesion
is radiolucent (osteolytic), which then becomes
progressively radiopaque as the mineralization of
the stroma start, thus it appears as mixed lesion. In
late stages, the radiopacities coalesce to the extent
that the mature lesion may appear sclerotic or
radiopaque lesion [17]. In this case CT scan shows
well defined radiolucency with a sclerotic margins
in the left maxilla extends to the orbital rim
superiorly.
Due to the circumscribed nature of the ossifying
fibroma; the treatment of choice is Surgical curettage
or enucleating for most small ossifying firomas [18].
Larger lesions that caused bone destruction may
require surgical resection and reconstruction by a
bony graft. The prognosis was very good, and
recurrence was rare [12,18]. The Sudanese case was
treated by enucleating of the lesion and it was
successful with no evidence of recurrence in the
follow up appointments.
Conclusion
In this case we report Cemento ossifying fibroma
for 26-year old female patient who came with a
maxillary swelling on the left side of the maxilla.
Fig. 3: Shows axial cut of CT scan which reveals a spherical shaped
well defined radiolucency with sclerotic margins in the left maxilla
Fig. 1: Shows a well-defined maxillary swelling with intact
overlying mucosa
Fig. 2: Shows the bucco-palatal extenstion of the maxillary
swelling
Yousif I. Eltohami et. al. / Maxillary Cemento-Ossifying Fibroma
134
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
We concluded that a good correlation of the clinical,
radiological and the histological features is
mandatory for determining a definitive diagnosis,
and classification of all fibro osseous lesions.
Surgical resection and follow-up of the patients is
obligatory to avoid recurrent of the lesion..
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8. Saiz-Pardo-Pinos AJ, Olmedo-Gaya MV, Prados-
Sánchez E, Vallecillo-Capilla M. Juvenile ossifying
fibroma: a case study. Med Oral Patol Oral Cir Bucal.
2004; 9(5):456–8, 454–6.
9. Sarwar HG, Jindal MK, Ahmad SS (2008) Cemento-
ossifying firoma-a rare case. J Indian Soc Pedod Prev
Dent. 2008; 26:128-131.
10. Sanchis JM, Peñarrocha M, Balaguer JM, Camacho
F. Cemento ossifying mandibular firoma: a
presentation of two cases and review of the literature.
Med Oral. 2004; 9:69-73.
11. Rangil JS, Silvestre FJ, Bernal JR. Cemento-ossifying
firoma of themandible: Presentation of a case and
review of the literature. J Clin ExpDent. 2011;
3:66-69.
12. Neville BW, Damm DD, Allen CM, Bouquot JE Text
Book of Oraland Maxillofacial Pathology (3
th
.edn),
2009; Philadelphia, PA: Sanders.
13. Serra-Serra G, Berini-Aytés L, Gay-Escoda C. Erupted
odontomas:a report of three cases and review of the
literature. Med Oral Patol OralCir Bucal. 2009; 14:
299-303.
14. Mintz S, Velez I Central ossifying firoma: An analysis
of 20 casesand review of the literature. Quintessence
Int. 2007; 38:221-227.
15. Chia Chuan C, HsienYen H, Julia YC, ChuanHang
Y, YiPing W, et al.Central ossifying fibroma: A
clinicopathologic study of 28 cases. JFormos Med
Assoc. 2008; 107:288–94.
16. Emin MC, Peruze C, Saadettin K, Alper A, Omer G.
Familialossifying firomas: Report of two cases. J Oral
Science. 2004; 46:61-64.
17. Mac Donald Jankowski DS. Cemento-ossifying
firomas in the jawsof Hong Kong Chinese. Dento
maxilla fac.Radiol, 1998; 27:298-304.
18. Regezzi JA, Sciubba JJ, Jordan RC. Benign non
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© Red Flower Publication Pvt. Ltd
Pathak Anjani K.*, Kumar V.**, Lal N.***, Singhal D.****, Goel K.****
Case Report
Surgical Management of an Extra Oral Mandibular Cutaneous Sinus
Tract in a 23 Year Old Male Patient
Abstract
Chronic alveolar abscess, as a sequelae of pulpal necrosis, can drain through a sinus tract, which may be
intra-oral or extra-oral, though the intra-oral drainage is much more common. The extra oral sinus tract
can be often misdiagnosed as an exclusive cutaneous lesion and get maltreated by systemic antibiotics.
This case report demonstrates that if the general health of the patient allows, such ill-treated conditions
can be managed by performing single visit endodontic therapy of the involved tooth followed by surgical
excision of sinus tract so as to minimize the residual scar formation and therefore, aesthetically more
acceptable for the patient.
Keywords: Chronic Alveolar Abscess; Pulpal Necrosis; Cutaneous Sinus Tract.
Author’s Affiliation: *Assistant Professor **Junior Resident
***Professor and Head ****Senior Resident, Department of
Periodontology, Faculty of Dental Sciences, King George’s
Medical University, Lucknow-226003, Uttar Pradesh, India.
Reprints Requests: Pathak Anjani K., Assistant Professor,
Department of Periodontology, Faculty of Dental Sciences, King
George’s Medical University Lucknow-226003, Uttar Pradesh
India.
E-mail: dr.anjanipathak@gmail.com
Received on 07.03.2017, Accepted on 17.03.2017
Introduction
The term sinus tract is defined as a blind ending
tract, usually lined with granulation tissue that leads
from an epithelial surface into the surrounding
tissue, often into an abscess cavity. A chronic pulpal
inflammation is one of most common etiologies for
an extra oral sinus of dental pathology [1]. The
periradicular microorganisms and related bacterial
by-products present there, may perforate the buccal
cortical bone with the infection finally draining onto
the mucosal or cutaneous surface following the path
of minimum resistance, after exiting a persistently
infective and necrotic pulp-canal system [2].
After the formation of a sinus tract, the periapical
inflammation may persist for a significant time
period as in the case of chronic abscess where
because of the continuous drainage, it remains
asymptomatic and becomes symptomatic when
there is drainage obstruction [3]. Misdiagnosis often
adds to the chronicity of the lesion and has
deleterious effects on facial aesthetics due to
unnecessary scarring and dimpling. For this reason,
differential diagnosis followed by a thorough
clinical and radiographic examination is of
paramount importance.
The case presented here is of a young,
systemically healthy patient having an extra-oral
cutaneous sinus tract in relation to mandibular
symphyseal (chin) area, which is more common as
compared to other regions like submandibular or
sublingual. The management was initiated
conservatively by nonsurgical endodontic treatment
of the involved teeth followed by the surgical
excision of the sinus tract so as to minimize the
residual scar formation and dimpling as esthetics
was one of the prime concerns of the patient.
Case Report
A 23 year old male patient reported to the
department of periodontology with chief complaint
of a painless, small nodular mass in the chin region
with occasional pus discharge from it (Figure 1).
The patient recalled that the complaintstarted 2
years back, when he started noticing a small
swelling in the mid symphyseal area, which soon
after, resulted in a small skin lesion with
spontaneous pus discharge from it. Along with that,
he was experiencing mild pain in the lower front
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
teeth while biting. Following that, he went for
medical consultation from a physician who started
systemic antibiotics and anti-inflammatory drugs for
the same. The complaint used to reappear after every
few months following the therapy. Finally the patient
was referred to our institute for opinion and needful.
On the day of examination, the patient was
afebrile and devoid of any systemic diseases. On
extra oral examination, an erythematous nodule of
size 6mm × 4mm × 3mm is seen (Figure 1). The
nodule was firm on palpation and occasional pus
discharge was elicited when pressed. Intraoral
examination and vitality tests revealed non-vital
mandibular central incisors which were not tender
on percussion (Figure 2). Patient also gave the history
of traumatic injury to the lower incisors while
playing. Radiographic examination showed presence
of diffused periapical radiolucency involving the
apical 1/3
rd
if the root of 31 and 41 (Figure 3). Chronic
alveolar abscess with extraoral draining sinus
following pulpal necrosis was set as definitive
diagnosis. Root canal treatment of 31 and 41 was
performed. Surgical excision of sinus tract was
planned as to prevent dimpling and to minimize
the residual scar formation. The sinus was traced
intra orally by raising a full thickness flap between
the mesio facial surfaces of lower canines, providing
better access. Also, it served the dual purpose of
Miller‘s class 1 recession coverage in relation to 31
and 41 when advanced coronally as shown in the
picture (Figure 4).
Simultaneously extra orally, under local
anesthesia, primary incision was made around the
lesion. The area was dissected to surgically remove
the cord like tract of approx. 3.8cm- 4cm (Figure 5-
9). The skin was undermined to relax the affected
area and restore the normal facial contour.
Interrupted sutures were placed extra as well as
intra orally (Figure 7-8). After 3 months of follow
up, the cutaneous lesion has healed completely with
neat linear scar formation, which is esthetically
satisfactory for the patient.(Fig 9-10)
Fig. 1: Pre op extraoral
Fig. 2: Pre op intraoral
Fig. 3: Pre op IOPA
Fig. 4: Intra op
Pathak Anjani K. et. al. / Surgical Management of an Extra Oral Mandibular Cutaneous
Sinus Tract in a 23 Year Old Male Patient
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Fig. 5: Intra op
Fig. 6: Intra op
Fig. 7: Post op
Fig. 8: Post op
Fig. 9: Sinus tract
Fig. 10: Follow up(3months)
Discussion
Cutaneous sinus tract of dental origin have been
documented extensively [4,5,6]. Because of its
clinical appearance being very similar to many other
cutaneous lesion, it can pose a diagnostic challenge.
The differential diagnosis should include traumatic
lesions, bacterial and fungal infections, neoplasms,
presence of foreign body, local skin infections
(carbuncle and infected epidermoid cyst), pyogenic
granuloma, chronic tubercular lesion, osteomyelitis,
Pathak Anjani K. et. al. / Surgical Management of an Extra Oral Mandibular Cutaneous
Sinus Tract in a 23 Year Old Male Patient
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
actinomycosis and gumma of tertiary syphilis. Also
the less common ones like the developmental
defects of throglossal duct cyst origin or brachial
cyst, salivary gland and duct fistula, dacryocystitis,
and suppurative lymphadinitis [7]. The examination
of a cutaneous sinus tract must begin with a
thorough history and awareness that any cutaneous
lesion of neck and face could be of dental origin.
Winstock [8]described cutaneous lesions with dental
infections. Kaban [9] elaborated the path of spread
of chronic dental infection. Approximately 80% of
the reported cases are associated with mandibular
teeth.
If the tooth is restorable, single or multi visit root
canal treatment is preferred over extraction in such
cases.In case of a chronic odontogenic sinus tract,
the cord like tract must be eliminated by either
cutting it off its insertion in the alveolar bone or by
removed by complete excision. Antibiotic therapy
is indicated when there are signs of systemic
involvement (fever or lymphadenopathy) [10].
In this case report, the cord was removed from
its origin to the point of skin attachment, which
allowed relaxation of facial skin, elimination of skin
dimpling in the affected area and restoration of
normal facial contour.
Conclusion
Resolution of sinus tract can be achieved by
elimination of the source of infection by endodontic
treatment or tooth removal. But in case of an older
sinus tract, wound contraction and scar tissue
formation may require surgical excision of cord like
tract.
The aim of this paper is to present a dental as
well as medical literature review of cutaneous sinus
tract of odontogenic origin, and to present the
surgical technique used to eliminate the cord like
tract and dimpling of the skin for esthetic concerns.
References
1. Bender IB, Seltzer S. The oral fistula: its diagnosis
and treatment. Oral Surg Oral Med Oral Pathol. 1961;
14:1367-76.
2. Kotecha M, Browne MK. Mandibular sinuses of
dental origin. Practitioner. 1981; 225:910-5.
3. Swales KL, Rudralingam M, Gandhi S. Extraoral
cutaneous sinus tracts of dental origin in the
paediatric patient. A report of three cases and a
review of the literature. [Int J Paediatr Dent. 2015;
22. doi: 10.1111/ipd.12205.
4. Cioffi GA, Terezhalmy GT, Parlette HL. Cutaneous
draining sinus tract: an odontogenic etiology. J Am
AcadDermatol. 1986; 14(1):94-100.
5. Caliskan MK, Sen BH, Ozinel MA. Treatment of
extraoral sinus tracts from traumatized teeth with
apical periodontitis. Endod Dent Traumatol. 1995;
11(3):115-20.
6. Barrowman RA, Rahimi M, Evans MD, Chandu A,
Parashos P. Cutaneous sinus tracts of dental origin.
Med J Aust. 2007; 186(5):264-5.
7. Tidwell E, Jenkins JD, Ellis CD, Hutson B, Cederberg
RA. Cutaneous odontogenic sinus tract to the chin:
a case report. IntEndod J. 1997; 30(5):352-5.
8. Winstock D. Four cases of external facial sinuses of
dental origin. Proc R Soc Med. 1959; 52:749-51.
9. Kaban LB. Draining skin lesions of dental origin: the
path of spread of chronic odontogenic infection.
PlastReconstr Surg. 1980; 66(5):711-7.
10. Witherow H, Washan P, Blenkinsopp P, Midline
odontogenic infections: a continuing diagnostic
problem. Br J Plastic Surg. 2003; 56(2):173-5.
Pathak Anjani K. et. al. / Surgical Management of an Extra Oral Mandibular Cutaneous
Sinus Tract in a 23 Year Old Male Patient
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© Red Flower Publication Pvt. Ltd
Vikram S. Amberkar*, Yashavanth Kumar**, Nitya K.***, Madhushankari G.S.****
Case Report
Parakeratinized Odontogenic Keratocyst
Abstract
The odontogenic keratocyst (OKC) is a commonly encountered developmental cyst of considerable
importance because of its potential for aggressive clinical behavior and recurrence. Also, it may be a
component of the nevoid–basal cell carcinoma (Gorlin) syndrome. Histologic features of OKC are
pathognomonic. The common site of involvement is the mandibular ramus region but this case represents
odontogenic keratocyst involving the mandibular anterior region. Most odontogenic keratocyst (60%) arise
from dental lamina rests or from the basal cells of oral epithelium and are thus primordial-origin odontogenic
keratocysts. The remaining 40% arise from the reduced enamel epithelium of the dental follicle and are
thus dentigerous-origin odontogenic keratocysts.
Keywords: Corrugated parakeratinized epithelium; Mandibular anterior region; Odontogenic Keratocyst.
Author’s Affiliation: *Professor ***Post Graduate Student
****Professor and Head, Department of Oral Pathology and
Microbiology, **Reader, Department of Oral Surgery, College of
Dental Sciences, Davangere, Karnataka, India.
Reprints Requests: Nitya K., Post Graduate Student, Room
No. 7, Department of Oral Pathology and Microbiology, College
of Dental Sciences, Davangere - 577004, Karnataka, India.
E-mail: nitya.aytin@gmail.com
Received on 10.05.2017, Accepted on 27.05.2017
Introduction
The odontogenic keratocyst (OKC) was first
described in 1876 and named by Phillipsen in 1956.
It is one of the most aggressive odontogenic cysts
of the oral cavity. OKC is known for its rapid growth
3-5 and its tendency to invade the adjacent tissues
including bone.
Odontogenic keratocysts are generally thought
to be derived from either the epithelial remnants of
the tooth germ, or the basal cell layer of the surface
epithelium [1,9]. The majority of patients are in the
age ranges of 20-29 and 40-59, but cases ranging
from 5 to 80 years have been reported.
It has a high recurrence rate and is associated with
the basal cell nevus syndrome [2].
Odontogenic keratocysts may occur in any part
of the upper and lower jaw with the majority
occurring in the mandible, most commonly in the
angle of the mandible and ramus region.
Case Report
A 40 year old male patient reported with a chief
complaint of discomfort and mild swelling in his
lower front tooth region since 2 weeks, swelling was
insidious in onset and gradually increased to the
present size. Past dental history revealed , trauma
to the lower front teeth region 25 years back and
for which root canal treatment was done. No other
associated symptoms were observed. Intra oral
examination revealed , non tender swelling , which
was roughly oval in shape approximately
measuring around 3x4.5 cms crossing the midline
extending from 35 to 44 causing buccal cortical
expansion. There was no signs of bleeding, pus
discharge or pain and had normal temperature. The
patient was advised for orthopantomogram . The
panoramic radiograph revealed a well defined
unilocular radiolucency extending from the distal
root of 43 to the mesial root of 35 with well defined
cortical border.. Aspiration was done which was
initially a straw coloured fluid but was not positive.
On the basis of clinical and radiographic findings
, a provisional diagnosis of Radicular cyst was given.
The patient was adviced for biopsy , for which
routine blood investigation was carried out. All the
hematological values were in normal limits.
Enucleation of the cystic lesion was done under local
anesthesia along with chemical curettage was done
by applying Carnoy’s solution to the enucleated
cavity and the tissue was sent for histopathological
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examination.
Hematoxylin and Eosin stained tissue section
revealed corrugated parakeratinized stratified
squamous epithelium of uniform thickness without
any retepeg formation. Basal cells shows
hyperchromatic nuclei arranged in a palisaded
manner.
Connective tissue also shows numerous needle
like spaces / Cholesterol clefts and chronic
inflammatory cells predominantly of lymphocytes.
On the basis of histopathological features, a final
diagnosis of Parakeratinized Odontogenic
Keratocyst was made.
Discussion
The odontogenic keratocyst is derived from the
remnants of the dental lamina with a biologic
behaviour similar to a benign neoplasm. Because of
this aggressive nature, recently World health
organization used the term “keratocystic odontogenic
tumor” to describe this cyst [3].
It is named keratocyst because the cystic lining
produces keratin. The cyst occurs in any age group,
but most commonly seen in the second and third
decades of life with male predilection. The most
common features are pain, soft tissue swelling,
expansion of bone and parasthesia .
The odontogenic keratocyst may occur due to
traumatic implantation or down growth of the basal
cell layer of surface epithelium or reduced enamel
epithelium of the dental follicle. Nohl and
Gulabivala reported two cases of OKCs, and in their
first case, tooth associated with OKC had history
of trauma twenty years ago [4,5].
The most common site includes the posterior
mandible but cases have been reported in anterior
region also. Radiographically, most OKCs are
unilocular with scalloped margin when presented
at the periapex and can be mistaken for radicular
or lateral periodontal cyst. When the cyst is
multilocular and located at the molar ramus area it
may be confused to ameloblastoma.
Multiple OKC’s are usually associated with
Nevoid basal cell syndrome, Gorlin-Goltz syndrome
[6,10].
Recurrence rate ranges from 2.5 to 62% [7], in
KCOTs and they occur due to incomplete removal
Fig. 1: Flap elevated in lesional area
Fig. 2: Well defined Unilocular radiolucency in the mandibular
anterior region
Fig. 3: Hematoxylin and eosin stained tissue section showing
numerous cholesterol clefts
Fig. 4: Hematoxylin and eosin stained section showing corrugated
parakeratinized epithelium without any reteridges
Vikram S. Amberkar et. al. / Parakeratinized Odontogenic Keratocyst
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
of the original cyst’s lining, thin friable cystic lining,
growth of the new OKC from small satellite cyst of
odontogenic epithelial cell rests left behind by
surgical treatment, or by development of an
unrelated OKC in an adjacent region of jaw which
is interpreted as a recurrence. Resection despite a
recurrence rate of nil is not significantly better at
elimination recurrences than enucleation plus
Carnoy’s solution or marsupialization plus
cystectomy [8].
A case reported by Sulabha et al on Keratocystic
OdontogenicTumour of mandible crossing the
midline in a 11 year child has shown the various
treatment modalities for the management of
Odontogenic keratocyst [6].
In the present case, massive OKC was seen in
mandibular anterior region crossing the midline and
this case is different from others in relation to its
site and etiology. To conclude, there is a need for
further studies to better understand its
characteristics for more accurate diagnosis and for
the development and adoption of less aggressive
therapeutic approaches that are perfectly adequate
for each case in order to prevent its recurrence
References
1. Oda D, Rivera V, Ghanee N, Kenny EA, Dawson KH.
Odontogenic Keratocyst : The North-Western USA
Experience. The Journal of Contemporary Dental
Practice 2000; 1(2):1-10.
2. Browne RM. The odontogenic keratocyst - clinical
aspects. Br Dent J 1970; 128:225-31.
3. Rajkumar CG, Hemalath M, Shashikala R, Sonal P.
Massive keratocystic odontogenic tumor of the
mandible: A case report and review of literature.
Indian J Dent Res 2011; 22:181, 205-9.
4. Veena KM, Rao R, Jagadishchandra H, Rao PK. Case
Report - Odontogenic Keratocyst looks can be
Deceptive causing Endodontic Misdiagnosis .
Hindawi Publishing Corporation , Case Reports in
Pathology 2011.p.1-3.
5. Mufeed A, Vengal M, Issac JK, Vazhagan V, Noufal
A. Keratocystic Odontogenic Tumour occurring in the
Anterior Mandible. Annals Medicus 2014; 1(1):30-7.
6. Sulabha AN, Choudhari S, Kenchappa U, Totad S.
Massive Keratocystic Odontogenic Tumour of
Mandible crossing midline in 11 year child : An
unusual case report and its management. Dental
Hypotheses 2013; 4(1):20-32.
7. Moeini M,Anvar SE, Bafghi RB. A case report of
Odontogenic Keratocyst in anterior mandibule
position. American Journal of Research Communication
2013; 1(9):286-91.
8. Ramadevi S, Naveen Kumar M, Khartik K.
Odontogenic Keratocyst – A case report. Indian
Journal of Mednodent and Allied Sciences 2015;
3(2):127-30.
9. Belmehdi A, Chbicheb S, Wady WE. Odontogenic
Keratocyst Tumour : A case report and Literature
Review . Open Journal of Stomatology 2016; (1):
171-78.
Vikram S. Amberkar et. al. / Parakeratinized Odontogenic Keratocyst
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© Red Flower Publication Pvt. Ltd
Saranya George*, Tinky Bose C.**
Case Report
Giant Peripheral Ossifying Fibroma of Maxilla
Abstract
Peripheral ossifying fibroma (POF) is a reactive lesion of the gingival tissues that predominantly affects
women and is usually located in the maxilla anterior to the molars. It is considered to origin from the cells
of the periodontal ligament in response to local irritating factors.The definitive diagnosis is established by
histological examination, which reveals the presence of cellular connective tissue with focal calcifications.
Complete surgical excision is the treatment of choice. Here we report a case of a large peripheral ossifying
fibroma in a 52 year old female.
Keywords: Gingival Growth; Epulis; Fibrosed Pyogenic Granuloma; Peripheral Ossifying Fibroma.
Author’s Affiliation: *MDS **Professor and Head, Department
of Oral Medicine and Radiology, Government Dental College,
Thiruvananthapuram, Kerala-695011, India.
Reprints Requests: Saranya George, Department of Oral
Medicine an d Radiology, Government Dent al College,
Chalakkuzhi, Thiruvananthapuram, Kerala-695011, India.
E-mail: sanu280387@gmail.com
Received on 12.05.2017, Accepted on 27.05.2017
Introduction
Peripheral ossifying fibroma (POF)accounts for
around 9.6 % of all gingival lesions and 3.1% of all
oral tumours [1].
It is a reactive lesion of the oral
cavity which occurs as an overgrowth of gingiva
due to factors like trauma or irritation.This lesion
is included under term “epulis” which refers to a
series of reactive gingival lesions often produced
by irritating agents [4]. Peripheral ossifying fibroma
is known by various names in the literature such as
peripheral cementifying fibroma, calcifying or
ossifying fibroidepulis, and peripheral fibroma with
calcification [2].
POF mainly affects women in the second decade
of life [3].
The lesions are most located anterior to
the molars in the maxillary gingival region [6].
POF
usually manifests as a well defined and slow
growing gingival mass measuring under 2 cm in
size and located in the interdental papilla region.
Base of the lesion may be sessile or pedunculated
[5].
Radiographic examination may show the
presence of soft tissue shadow, interspersed with
radiopaque areas suggestive of calcification [1].
The
definitive diagnosis is based on the histological
examination, with the identification of cellular
connective tissue and the focal presence of bone or
other calcifications [5,7].
Case Report
52 year old female patient presented to the
department of Oral Medicine and Radiology with
the complaint of a painless soft tissue growth in the
upper anterior region of three months duration. She
gave a history of fall three months back hitting on
anterior maxillary region. There was associated
loosening of upper anterior teeth. Since then patient
noticed a growth in relation to the anterior teeth
which was gradually increasing in size. She reports
occasional mild pain associated with upper anterior
teeth.
Extraoral examination revealed a swelling in
relation to the upper anterior teeth which was visible
extraorally as the patient was unable to close her
lips properly (Figure 1). Intraorally a solitary
localized growth with well-defined borders in
relation to labial aspect of maxillary central incisors
was noted (Figure 2). Lesion was measuring
approximately 3x3 cm. Growth seemed to arise from
the interdental papilla displacing the central incisors
laterally (Figure 3). The interdental papilla on the
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palatal aspect was continuous with the lesion which
exhibited mild thickening. Lesion grossly appeared
smooth surfaced. Colour of overlying mucosa
varied from pink to slightly blanched appearance
along the surface of the lesion. The swelling was
mildly tender and firm in consistency. On the basis
of these findings a provisional diagnosis of a benign
connective tissue neoplasm was made.The patient
was referred for routine hematological and
radiological investigations. The hemogram was
within normal limits.
Intraoral radiograph shows laterally displaced 11
and 21 with severe interdental bone loss. Minute
flecks of radiopacity were noted in the interdental
region of 11 and 12 suggestive of calcification (Figure
4). Panoramic radiograph shows laterally displaced
11 and 21. Severe interdental bone loss noted.
Minute flecks of radiopacitywere seen overlapping
maxillary anterior region (Figure 5). Lateral skull
radiograph revealed the soft tissue outline of the
lesion with an irregular central mass of
calcificationin relation to the labial aspect of upper
incisors (Figure 6).
The histopathological examination of the excised
lesion using haemotoxylin and eosin (HE) staining
method at 10X magnification showed stratified
squamous epithelium with psuedoepitheliomatous
hyperplasia in many areas. Just beneath the
epithelium there is condensation of connective tissue
and proliferating plump fibroblasts in the form of a
capsule. Presence of a cementoid like hematoxyphillic
calculi as well as osteoid tissue noticed. These
findings were suggestive of peripheral ossifying
fibroma.At the one-year postsurgical follow-up the
patient was asymptomatic, and there was no
evidence of recurrence.
Fig. 1: Extra oral view showing lip incompetence due to the lesion
on maxillary gingiva.
Fig. 2: Intra oral view showing the lesion in relation to the labial
gingiva of 11 and 12.
Fig. 3: Intra oral view showing lateral displacement of incisors
and the lesion continuous with the interdental gingiva.
Fig. 4: Occlusal radiograph showing the flecks of radiopacity
interdentally between 11 and 21.
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Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Fig. 5: Panoramic radiograph depicting the lateral displacement
of 11 and 12 and irregular radiopacity overlapping them.
Fig. 6: Lateral skull view showing the soft tissue outline of the
lesion. An irregular calcified mass noted in the center of the
lesionlabial to the incisors.
Fig. 7: Histopathology image showing fibrous connective tissue
with varying fibroblast, myofibroblast and collagen content,sparse
to profuse endothelial proliferation and mineralized material.
Discussion
Eversole and Rovin first coined the term
Peripheral ossifying fibroma .They stated that, with
the similar sex and site predilection of pyogenic
granuloma, peripheral giant cell granuloma(PGCG)
and POF, as well as similar clinical and histologic
features, these lesions may simply be varied
histologic responses to irritation [8].
However,
recent reports suggest that the POF is totally a
separate clinical entity [9].
The etiology of POF is
attributed to the inflammatory hyperplasia of cells
of periodontal ligament. This is supported by the
fact that POF occurs exclusively in gingiva and by
thepresence of oxytalan fibreswithin
themineralizedmatrix [5].
Chronic irritation of the
periosteal and periodontal membrane causes
metaplasia of the connective tissue and result in
initiation of formation of bone or dystrophic
calcification [11].
The inflammatory reaction is said
to occur due to trauma or other local irritants such
as plaque, calculus, restorations or ill fitting dental
appliances [2].
The highest incidence of peripheral ossifying
fibroma is during second and third decades of life
and females account for almost two-third of the
cases reported [1].
Most cmmonly it occurs in the
maxillary incisor region [5].
In our case, the lesion
occurred in a 52-year-old female in the maxillary
incisor region.
POF may present as a pedunculated nodule, or it
may have a broad attachment base. The colour can
range from pink to red. Ulcerations may be present
but are not frequent [10].
Most of these lesions range
from 1 to 2 cm in size, but there are fewreports of
casesmore than 2 cms [11].
In our case, the lesion
was 3X3cms in size. The teeth involved are usually
unaffected but may show migration, mobility and
delay in eruption of permanent teeth [1].
Tooth
migration was seen in our case. Peripheral ossifying
fibromas are usually solitary. Syndromes associated
with multicentric POF are nevoid basal cell
carcinoma syndrome, Multiple endocrine neoplasia
type II, neurofibromatosis andGardner’s syndrome
[11].
The radiographic features may range from mild
or no changes to destructive changes. In certain
cases the lesioncould cause superficial erosion of
underlying bone, cupping defect and focal
calcifications at centre of lesion [12].
In our case well
defined calcified mass was noted radiographically
labial to maxillarycentralincisors within the lesion.
The common lesions considered in the differential
Saranya George & Tinky Bose C. / Giant Peripheral Ossifying Fibroma of Maxilla
145
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
diagnosis include pyogenic granuloma, peripheral
giant cell granuloma,osteoma. Diagnosis was
confirmed by histopathological evaluation.
The histopathological examination usually shows
featuressuch as benign fibrous connective tissue
with varying fibroblast, myofibroblast and collagen
content, sparse to profuse endothelial proliferation
and mineralized material that may represent mature
lamellar or woven bone or dystrophic calcifications
[10,13].
Occasionally inflammatory cell infiltration
can also be seen. The histopathological picture was
similar to the above in our case.The
immunohistochemical profile of POF indicated that
the proliferating cells are of a myofibroblastic nature
i.e., cells sharing morphological characteristics with
fibroblasts and muscle cells [5].
The most preferred
choice of treatment for peripheral ossifying fibroma
is conservative surgical excision.The rate of
recurrence has been reported to range from 8.9 to
20% [9].
Recurrences can be treatedwith surgical
excision.
Conclusion
In the present case report the clinical,
radiographic and histopathologic features of POFis
discussed. Clinically the lesion can be confused with
other reactive gingival lesions of oral cavity.
Radiography can be of some help in the diagnosis
of POF but confirmatory diagnosis requires
histopathologic examination. This report adds to the
existing literature about the presentation of POF as
a gingival mass from interdental papilla alongwith
appearance of radiopacity in the anterior maxillary
region.
References
1. Mishra AK, Bhusari P, Kanteshwari K. Peripheral
cemento-ossifying fibroma -Acase report. Int JDent
Hygiene 2011; 9:234–7.
2. MithulaNair S,VidyaAjila ,ShruthiHegde ,G.
SubhasBabu&RumelaGhosh. Peripheral Ossifying
Fibroma of the Posterior Maxilla : A Case Report.
NUJHS 2016 June; 6(2).
3. Kumar SK, Ram S, Jorgensen MG, Shuler CF,
Sedghizadeh PP.Multicentric peripheral ossifying
fibroma. J Oral Sci 2006; 48:239 43
4. Lata Kale, Neha Khambete, Sonia Sodhi, Sushma
Sonawane. Peripheral ossifying fibroma: Series of
five cases. Journal of Indian Society of Periodontology
2014 Jul-Aug; 18(4).
5. García de Marcos JA, García de Marcos MJ, Arroyo
Rodríguez S, Chiarri Rodrigo J, Poblet E. Peripheral
ossifying fibroma: A clinicaland immunohisto-
chemical study of four cases. J Oral Sci 2010; 52:95 9.
6. Zhang W, Chen Y, An Z, Geng N, Bao D. Reactive
gingival lesions: A retrospective study of 2,439 cases.
Quintessence Int 2007; 38:103-10
7. Moon WJ, Choi SY, Chung EC, Kwon KH, Chae SW.
Peripheral ossifying fibroma in the oral cavity: CT
and MR findings.
8. Kenney JN, Kaugars GE, Abbey LM. Comparison
between the peripheral ossifying fibroma and
peripheral odontogenic fibroma. J Oral Maxillofac
Surg 1989; 47:378 82.
9. Farquhar T, Maclellan J, Dyment H, Anderson RD.
Peripheral OssifyingFibroma:Acase report. J
CanDentAssoc 2008; 7:809-12.
10. Neville, et al. Textbook of Oral and Maxillofacial
Pathology. 3rd edition 2009.p.521-3.
11. HimanshuKapoor, RitikaArora. A Massive
Peripheral Ossifying Fibroma–Uncommon Presentation
of a Common Lesion. OHDM 2014 Dec; 13(4).
12. Yadav R, Gulati A. Peripheral ossifying fibroma: a
case report. J Oral Sci 2009; 51(1):151-4.
13. Eversole LR, Leider AS, Nelson K. Ossifying
fibroma:A clinicopathologic study of sixty four cases.
Oral Surgery, Oral Medicine, Oral Pathology. 1985;
60: 505-511.
Saranya George & Tinky Bose C. / Giant Peripheral Ossifying Fibroma of Maxilla
146
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
© Red Flower Publication Pvt. Ltd
Rajasekharan Asish*, A.K. Nabeel**, Ramachandran Sunu*
Short Communication
Behçet’s Syndrome: Diagnosis of Exclusion
Abstract
Behçet’s syndrome is a rare immune-mediated disease often presents with mucous membrane ulceration
and ocular problems. Nearly all patients with Behçet’s syndrome present with some form of painful oral
mucocutaneous ulcerations in the form of aphthous ulcers. The cause is not well-defined; the primary
mechanism of the damage is autoimmune. Treatment is aimed at easing the symptoms, reducing
inflammation, and controlling the immune system. Here we present a case of Behçet’s syndromewith 2
week follow up.
Keywords: Behçet’s Syndrome; Autoimmune Disorder; Oral Ulcers; Patehrgy Reaction.
Author’s Affiliation: *Assistant Professor **Junior Resident,
Department of Oral Medicine & Radiology, Government Dental
College, Thiruvananthapuram, Kerala, India.
Reprints Requests: Ayappali Kalluvalappil Nabeel, Junior
Resident, Department of Oral Medicine & Radiology, Government
Dental College, Thiruvananthapuram- Kerala 695011, India.
E-mail: nabeelsabeel@gmail.com
Received on 20.03.2017, Accepted on 07.04.2017
Behçet’s Syndrome- Diagnosis of Exclusion
Behçet’s syndrome is a rare immune-mediated
disease often presents with mucous membrane
ulceration and ocular problems. In 1937 Turkish
dermatologistHulusi Behçet, who first described
the triple-symptom complex of recurrent oral
aphthous ulcers, genital ulcers, anduveitis [1].
As a
systemic disease, it can also involvevisceral
organssuch as the gastrointestinal tract, pulmonary,
musculoskeletal, cardiovascular and neurological
systems [1,2].
Nearly all patients with Behçet’s syndrome
present with some form of painful oral
mucocutaneous ulcerations in the form of aphthous
ulcers.The sores usually heal in one to three weeks.
Painful genital ulcerations usually develop around
the anus, vulva, or scrotum. Inflammation in blood
vessels (veins and arteries) may occur in Behcet’s
disease, causing redness, pain, and swelling in the
arms or legs [2,3,4].
The cause is not well-defined, the primary
mechanism of the damage is autoimmune. For a
patient to be diagnosed with Behçet’s disease, the
patient must have oral (aphthous) ulcers (any shape,
size, or number at least 3 times in any 12 months
period) along with 2 out of the following 4 hallmark
symptoms [1,4]:
• Eyeinflammation (iritis,uveitis, retinal
vasculitis,)
• Genital ulcers (analulcers and spots in the
genital region and swollentesticlesor
epididymitisin men)
• Pathergy reaction(papule >2mm dia. 24-48 hrs
or more after needle-prick).
• Skinlesions(papulo-pustules,folliculitis,
erythema nodosum,acne)
The diagnosis can sometimes be reached by
pathologic examination of the affected areas. A large
number of serological studies show a linkage
between the disease andHLA-B51 [5].
Complications of Behcet’s syndrome depend on
your signs and symptoms. For instance, untreated
uveitis can lead to decreased vision or even
blindness.
Treatment is aimed at easing the symptoms,
reducing inflammation, and controlling the immune
system. High-dosecorticosteroidtherapy is often
used for severe disease manifestations.
Topical antifungal therapy is also advised.
People with oral, genital and eye signs and
Indian Journal of Dental Education
Volume 10 Number 2, April - June 2017
147
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
symptoms of Behcet’s disease need to visit doctor
regularly to prevent complications. Here we present
a case of Behçet’s syndromewith 2 week follow up.
Fig. 1: Multiple ulcers on palate
Fig. 2: Major aphthous ulcer ulcers on left buccal muccosa
Fig. 3: Candidiosis on tongue
Fig. 4: Healing lesions over lip & left buccal mucosa ( 1 week)
Fig. 5: Healing lesions over lip & left buccal mucosa ( 1 week)
Fig. 6: Healing lesions over palate ( 1 week)
Fig. 7: Healing lesions over palate ( 1 week)
Rajasekharan Asish et. al. / Behçet’s Syndrome: Diagnosis of Exclusion
148
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
Fig. 8: Healed lesions (2 week)
Fig. 11: Healed lesions (2 week)
Fig. 9: Healed lesions on lips (2 week)
Fig. 10: Healed lesions on buccal mucosa
(2 week)
Key Messages
The diagnosis can sometimes be reached by
pathologic examination of the affected areas. A large
number of serological studies show a linkage
between the disease andHLA-B51.
Conflict of Interest: nil
References
1. Neville B, Damm D, Allen C, Bouquot J. Oral &
maxillofacial pathology. 3rd ed. Philadelphia:
W.B.Saunders; 2008.p.336.
2. Hatemi G, Seyahi E, Fresko I, Hamuryudan V.
Behçet’s syndrome: A critical digest of the recent
literature. Clin Exp Rheumatol. 2012; 30:S80–9.
3. Ohno S, Ohguchi M, Hirose S, Matsuda H, Wakisaka
A, Aizawa M. Close Association of HLA-Bw51 With
Behçet’s Disease. Arch Ophthalmol. 1982; 100(9):
1455–8.
4. International Study Group for Behçet’s Disease.
Criteria for diagnosis of Behçet’s disease. Lancet.
1990; 335(8697):1078–80.
5. Ahn JK, Park YG. Human Leukocyte Antigen B27
and B51 Double-Positive Behçet Uveitis. Arch
Ophthalmol. 2007; 125(10):1375–80.
Rajasekharan Asish et. al. / Behçet’s Syndrome: Diagnosis of Exclusion
149
Indian Journal of Dental Education, Volume 10 Number 2, April - June 2017
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35: 540-7.
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27.
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