Journal of N O Dental Sciences & I T I A Oral

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An Official Publication Of Institute Of Dental Sciences Bareilly, Uttar Pradesh, India

jdsorAvailable Online at

www.jdsor.com

Editor-in-chiefAnuraag Gurtu

Dental Sciences &Oral Rehabilitation

Journal of

January-June 2020 | Vol. 11| Issue 1

ISSN- 2231-1491ISSN- 2348- 6171(e)

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Editorial Board

Journal of Dental Sciences and Oral Rehabilitation

Volume 11 | Issue 1 | January-June 2020

CHIEF PATRONSKESHAV KUMAR AGARWAL

CHAIRMAN

ASHOK AGARWALPRESIDENT

KIRAN AGARWALVICE PRESIDENT

LATA AGARWALVICE CHAIRPERSON

EDITORSANURAAG GURTUEDITOR-IN-CHIEF

ASHISH AGGARWAL ASSOCIATE EDITOR

SUMIT MOHANASSOCIATE EDITOR

SMRITI SAXENAASSISTANT EDITOR

ARCHANA CHAURASIAASSISTANT EDITOR

SAUMMYA SINGHASSISTANT EDITOR

EDITORIAL BOARD MEMBERS

SATYAJITH NAIK SHIVALINGESH K K

MADHUSUDAN ASTEKARRAMAKANT DANDRIYAL

M K SINGHAL RASHMI BANSAL

R G SHIVAMANJUNATH D. K. AGARWAL

COORDINATOR

C. S. KANDPAL

ARTICLES COORDINATOR

MAYANK GANGWAR

ContentsORIGINAL ARTICLES

�Assessment of Impact of Oral Diseases on Oral Health Related Quality of Life among Institutionalized Elderly using OH1P-14: A Cross-sectional Study ��1Kratika Ajai, Vaibhav Seth, Smriti Saxena, Archana Chaurasia

�Adolescent Body Mass Index and Skeletal Maturation Assessed with Hassel and Farman’s Cervical Vertebrae Staging Method ��7 Sushila Sah, Preeti Bhattacharya, Ravi Bhandari, Taufique Anwer, Sumit Joshi, Akash Prakash Singh, Ahmad Muzaffar

�Knowledge, Attitude, and Practice of Hand Hygiene among Medical and Dental Undergraduates of Bareilly International University: A Cross-sectional Survey �� 11Swati Pathak, Shivalingesh K. K, Smriti Saxena, Henna Mir, Divya Srivastava, Adeeba Saleem

�The Assessment of Color Stability among the Four Base Resins in Different Edible Staining Solutions: An In vitro Study �� 18Kanupriya Agrawal, Mukesh Kumar Singhal, Smritashree Baruah, Hemendra Pratap

REVIEW ARTICLES

Efficacy of Silver Diamine Fluoride in Management of Caries: A Narrative Review �� 24Kanika Sharma, Sathyajith Naik, Pallavi Vashisht, Shivangi Shrma, Deepshikha, Shashank Kumar Singh

Mobile Phones: A Potential Source of Nosocomial Infection in the Hands of Health care Workers – A Narrative Review �� 28Divya Srivastava, Shivalingesh K K, Henna Mir, Adeeba Saleem, Swati Pathak, Supriya Naren

CASE REPORTS

��Third Generation Platelet Concentrate in Esthetic Management: A Case Report �� 32Rishabh Srivastava, Shiva Manjunath R.G, Geetika Kumar, Prerna Agarwa, Satyaki Verma

�Digital Computer-aided Design and Computer-aided Manufacturing Implant Titanium-Ceramic Screw Retained Prosthesis: A Wing Cantilever Design �� 35 Mukesh Kumar Singhal, Ankita Pal, Siddharth Vaish, Kanupriya Agrawal, Monal Mendiratta, A. Nikhilsingh

Enhancing Esthetics by the Carting of the Melanin: A Case Report with 1-Year Follow-up �� 39Bharti Chaudhary, Rika Singh, Geetika Kumar, S. S. Karthikeyan Sai, Shiva Shankar Gummaluri

Pinhole Surgical Approach in the Treatment Modality of Gingival Recession: A Case Report �� 42Anjali Gaba, Jaishree Garg, Manvi C Agarwal, Sunil Upadhayay

Journal of Dental Sciences and Oral Rehabilitation

Volume 11 | Issue 1 | January-June 2020

Journal of Dental Sciences and Oral Rehabilitation / Volume 11 / Issue 1 / Jan-Jun 2020

Dear Reader,

With immense pleasure as a team we bring forth the first issue (Jan-June) of 2020.

JDSOR publishes scientific papers based on original research, systematic reviews and case reports from all specialties of dentistry. The attempt is to make our journal a comprehensive reflection of all advances that are happening at a rapid pace in dentistry. This is our first issue with INS Publishers Pvt Ltd. I thank them for their immense cooperation and promptness to complete this issue on time.

Our Journal culminates with the due support from the Management, Principal Sir and the editorial team, I take this opportunity to thank them all. I also sincerely thank authors, reviewers and all members of Technical team for their dedicated service and support in culmination of every issue of this journal. Looking forward to more good articles in the future.

Warm RegardsDr�Anuraag Gurtu

Editor-in-Chief

Editorial

1Journal of Dental Sciences and Oral Rehabilitation / Volume 11 / Issue 1 / Jan-Jun 2020

Assessment of the Impact of Oral Diseases on Oral Health-related Quality of Life among Institutionalized Elderly using Oral Health Impact Profile-14: A

Cross-sectional Study

Kratika Ajai1, Vaibhav Seth2, Smriti Saxena3, Archana Chaurasia4

1Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 2Department of Oral Medicine and Radiology, Kothiwal Dental College, Moradabad, Uttar Pradesh, India, 3Department of Public health Dentistry, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 4Department of Oral and Maxillofacial Surgery, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

The elderly are characterized by unique conditions as a result of physiological changes characteristic of aging, as well as diseases and psychosocial and dietary factors that influence their nutritional status.[1]

In general, the elderly are at increased risk of malnutrition due to insufficient food intake (amount),[2] poor selection of food (quality), illnesses that may lead to nutrient loss, and also decrease nutrition absorption, also in elder people, the nutrition deficiency can be a cause of physiological, psychological, pathological, and social factors�[3,4] This situation is aggravated when institutionalized, the occurrence of nutritional disorders in institutionalized elderly ranging from 30% to 80%, with a consequent negative impact on their health�[5]

“Oral health is an essential element for general health and quality of life throughout an individual’s life course,” as written in a WHO report from 2006 about oral health in the elderly� Good oral health is a state of being free from oral diseases, infections, and pain that restrict normal function and quality of life� The world’s population is aging� Society will face a challenge in treating oral and general diseases in older individuals as to provide an appropriate treatment,

diagnosis of the disease at an early stage is required� According to Razak et al�, few factors such as illness and health-related factors, sociodemographic factors, service-related factors, and subjective factors are required for utilization of dental services�[6]

Due to remarkable increase in the geriatric population, the world is now facing a demographic revolution� According to 2011 census, according to Population Census 2011, there are nearly 104 million elderly persons (aged 60 years or above) in India; according to census, it is expected that by 2050, India’s population of the elderly may increase to 323 million�[7]

With increasing age, the problems related to health also increase� Oral health is an integral part of general health� Poor oral health consisting dental problems such as dental caries, periodontal diseases, mobile tooth, missing tooth, and many more lead to compromised general health�[8] Because if one cannot eat properly

ABSTRACT

Introduction: India is in a state of demographic transition with a geriatric population of about 80 million, which constitutes 7.2% of the total population. Poor oral health exerts a negative impact on the quality of life of geriatric population. Hence, the present study was conducted for the assessment of the impact of oral disease on daily activities and quality of life among the institutionalized elderly in Bareilly city. Materials and Methods: For the present study, a total of 100 patients were purposively selected from two old age homes through convenience sampling technique. Basic oral health survey form (1997) was used to assess the oral health status of the subjects and oral health-related quality of life using short version of oral health impact profile (OHIP-14). Statistical analysis was done using SPSS, 16. Independent t-test and ANOVA test were done to determine the relationship between the groups. Results: Independent t-test revealed that the presence or absence of grossly decayed teeth, chronic periodontitis, based on edentulism, and remaining sound teeth status produced no significant differences in any of the domains. Females experienced greater impact of oral diseases than males in mean OHIP-14 score; however, it was non-significant (P = 0.45). Conclusion: Oral health status of the institutionalized elderly in Bareilly city is poor, with edentulism and periodontitis. The impact of oral diseases on the lives of the elderly is relatively low and is non-significant.

Key words: Elderly, Oral health impact profile-14, Oral health-related quality of life, Impact of oral diseases

Original Article

Corresponding Author: Dr. Kratika Ajai, Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Ajai, et al. Assessment of the impact of oral diseases on oral health-related quality of life among institutionalized elderly using oral health impact profile-14: a cross-sectional study

2 Journal of Dental Sciences and Oral Rehabilitation / Volume 11 / Issue 1 / Jan-Jun 2020

their body suffers. Similarly, the different systemic problems also may have adverse effects on oral health. Poor oral health negatively affects the quality of life.

Also lately, the number of the elderly receiving institutional care has increased tremendously, such residents often have to depend on caregivers for their general and oral health care� Adequate access to dental care can affect there oral hygiene, oral health function that may led to compromised overall health and also can affect the quality of life.[9]

Surveys suggest limited utilization of dental services by geriatric population� This may be because of numerous considerable factors� Age-related compromised mobility is the main factor for limited use of oral health-care facility. Along with that financial dependence, physical dependence and physical health are other contributing barriers. The elderly living alone, who are financially deprived or abandoned from their houses look for alternative homes for living and some choose old age homes�[10] As per the National Oral Health Survey (2004), poor oral health among the elderly has resulted in a high level of tooth loss (29.3%), dental caries status (84.7%), periodontal disease (79.4%), mucosal lesions (10%), and oral cancer (0.5%).[11]

Such elderly do not have facilities for oral health care� This is partly due to the fact that we do not have much records regarding the oral disease burden and treatment needs of the elderly in India� In addition, the extent to which oral diseases affects the general health and quality of life of the elderly has not been extensively studied�

The aim of the study is to describe the oral health-related quality of life (OHRQoL), including the impact of oral diseases, in elderly people� Objective is to assess the impact that oral diseases have on their daily activities and quality of life�

MATERIALS AND METHODS

A cross-sectional study was conducted to assess the impact of oral diseases on daily activities and quality of life using basic oral health survey (1997) and short version of oral health impact profile (OHIP-14) among the institutionalized elderly in Bareilly. The study population comprised institutionalized elderly residing in old age homes in Bareilly�

For the present study, the residents of two old age homes aged 60 years or more and who gave the written informed consent were included in the study� Inmates with cognitive impairment and with severely debilitated and hearing and/or speech impairment were excluded� This list was arrived at, after short listing through convenience sampling technique� A total of 100 patients were purposively selected�

A self-administered questionnaire was given to the inmates’ who participated in the study� The information collected by the questionnaire included:1. OHRQoL using short version of OHIP-14.[12]

2� Oral health status of subjects using basic oral health survey form (1997).[13]

The OHIP-14 includes 14 questions, was prepared by Slade in 1997� The objective of the OHIP is to present certain types

of numerical data for different situations in terms of health and treatment consequences� It covers seven dimensions� The subjects covered are the following: Functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap� Each of the seven subscales has two questions graded on a 5-point Likert scale .Basic oral health survey was used to assess the oral health status of the subjects� The tool was translated to the local language Hindi by a panel of linguistic experts� The Hindi tool was then translated back in English to find out any errors and corrections were done and a final Hindi questionnaire was then constructed. The study protocol was reviewed and approved by Ethical board, IDS College, Bareilly�

The data were collected from the personal interview, by filling in the specially designed questionnaire� The interview included assessment of the impact of oral diseases on the daily living and quality of life of the participants using the sociodental indicator OHIP� The investigator introduced her to all subjects and appraised them about the study� The respondents were briefed about the study for respondents who had doubts, oral instructions were given to them and those who gave the consent were enrolled in the study�

The clinical examinations were conducted in a well-illuminated area at the old age homes using mouth mirror and CPI probe� The investigator was subjected to prior training and calibration in recording the basic oral health survey pro forma� The investigator was calibrated and intraexaminer reliability was calculated as κ ≥ 0.8.

Along with the oral health, the general health of the participants was also reviewed by the general physician� The medical records of the inmates were also examined to obtain information regarding the major systemic conditions that affected them and the treatment provided� The questionnaire required 25–30 min to be completed by each subject�

Statistical analysis was done using computer with the aid of the Statistical Package for the Social Sciences (SPSS), version 16, USA. In the present study, descriptive statistics were used to summarize the variables� Percentage was to describe the discontinuous variables� ANOVA test was done to determine the relationship between the groups�

RESULTS

In the present study, out of total six old age home, two were selected� A total 100 old people were examined aged between 71 and 80 years� From total population, 66 were men and 34 were women� The mean according to the domain functional limitation for male is 3.14 and for female it is 1.03 (t value −0.658). In physical pain, the mean value of male is 3�19, in female, it is 2�95 (t value 0.852). According to the physical discomfort, the mean value of male is 3.19 and female 1.03 (t value −0.852). In domain physical disability, the mean value for male is 3�24 and for female 3.05 (t value .787). According to the physiological disability, the mean value for male is 3.30 and for female is 3.16 (t value −0.502).



mean value for male is 3.30 and for female is 3.16 (t value −0.494). No statistical significance (P > 0.05) was observed between the domains [Table 1]�

In Table 2, Functional limitation was seen in 59 subjects with mean value of 3�03 +- 1�01 which was not found to be statistically significant at p value 0.718. Other tables domains such as physical pain, physical discomfort, physical disability was also not found to be statistically significant.

Table 3 shows that the impact of edentulism was more on functional limitation, physical pain, physical discomfort, social disability, and handicap (2.91±1.04) domain of OHIP-14.

In Table 4, when we see the age-wise comparison of OHIP-14, then the impact of all the domains was seen highest on people aged more than 80 years�

Mann–Whitney U-test was performed to find the domain-wise differences between and within groups according to the number of remaining sound teeth and it was found that having <12 sound teeth created a significant impact on the physical disability domain (3.38±0.87).

*Mann–Whitney U-test was used as these variables did not confer to equality of variance assumption and it was found that having <12 sound teeth created a significant and equal impact on psychological disability, social disability, and handicap domain (3.54±0.88) [Table 5].

Similarly, in Table 6, t-test and Mann–Whitney U-test were performed to find the comparison of domain of OHIP-14 and its domains based on decayed teeth and it was found that having <10 sound teeth created a significant and equal functional limitation, physical pain physical discomfort, and physical disability domain (3.1628±0.99834).

And having more than 10 sound teeth created significant effect on psychological disability, social disability, and handicap domain�

In the total study population, maximum people diagnosed with shallow pockets (42.8%) followed by people having calculus (19.6%) and deep pockets (16%).

On recording the DMFT index, it was found that maximum number of study subjects had sound teeth (9.12±4.12), followed by missing teeth (5.96±2.68), filled teeth (3.30±1.06), and decayed teeth (3.39±0.77).

On recording the DMFT index, it was found that maximum number of study subjects had sound teeth (9.12±4.12), followed by missing teeth (5.96±2.68), filled teeth (3.30±1.06), and decayed teeth (3.39±0.77). [Table 7]

Table 7: Descriptive statistics – DMFT�

In domain social disability, the mean value for male is 3�30 and for female 3.16 (t value 0.502). According to the handicap, the

Table 1: Gender-wise comparison of OHIP-14 scores and its domainsDomain Gender n Mean SD Mean

difft value P value*

Functional limitation

Male 66 3.14 1.00 0.19 0.658 0.514

Female 34 2.95 1.03

Physical pain Male 66 3.19 1.00 0.24 0.852 0.398

Female 34 2.95 1.03

Physical discomfort

Male 66 3.19 1.00 0.24 0.852 0.398

Female 34 2.95 1.03

Physical disability

Male 66 3.24 0.89 0.19 0.787 0.435

Female 34 3.05 78

Psychological disability

Male 66 3.30 97 0.14 0.502 0.618

Female 34 3.16 1.01

Social disability Male 66 3.30 0.97 0.14 0.502 0.618

Female 34 3.16 1.01

Handicap Male 66 3.30 0.97 0.14 0.494 0.624

Female 34 3.16 1.01

OHIP-14 Male 66 22.65 6.22 1.28 0.759 0.451

Female 34 21.37 5.46*P < 0.05, t-test was used as these variables confer to equality of variance assumption. OHIP-14: Oral health impact profile

Table 2: Comparison of OHIP-14 score and its domains based on periodontal statusDomain Gender n Mean SD Mean diff. t value P valueFunctional limitation

Present 59 3.0303 1.01504 −0.10013 −0.363 0.718

Absent 41 3.1304 1.01374

Physical pain

Present 59 3.0303 1.01504 −0.18709 −0.683 0.497

Absent 41 3.2174 0.99802

Physical discomfort

Present 59 3.0303 1.01504 −0.18709 −0.683 0.497

Absent 41 3.2174 0.99802

Physical disability

Present 59 3.0606 0.89928 −0.28722 −1.243 0.219

Absent 41 3.3478 0.77511

OHIP-14 Present 59 21.4242 6.29499 -1.92358 −1.193 0.238

Absent 41 23.3478 5.36494OHIP-14: Oral health impact profile

Domain Chronic periodontitis n Mean Std. deviation Mean diff. z value P value* Psychological disability Present 59 3.0909 1.01130 −0.38735 1.460 0.140

Absent 41 3.4783 0.89796 −0.38735

Social disability Present 59 3.0909 1.01130 −0.38735 1.460 0.140

Absent 41 3.4783 0.89796 −0.38735

Handicap Present 59 3.0909 1.01130 −0.38735 1.460 0.140

Absent 41 3.4783 0.89796 −0.38735 *P < 0.05, Mann–Whitney U-test was used as these variables did not confer to equality of variance assumption



Table 3: Comparison of OHIP-14 and its domain based on edentulism statusDomain Edentulism n Mean Std. deviation Mean diff. t value P valueFunctional limitation Present 20 2.91 1.04 −0.20 −0.593 0.555

Absent 80 3.11 1.01

Physical pain Present 20 2.91 1.04 −0.25 −0.727 0.470

Absent 80 3.16 1.00

Physical discomfort Present 20 2.91 1.04 −0.25 −0.727 0.470

Absent 80 3.16 1.00

Physical disability Present 20 2.91 0.94 −0.34 −1.170 0.247

Absent 80 3.24 0.83

Psychological disability Present 20 2.91 1.04 −0.42 −1.299 0.199

Absent 80 3.33 0.95

Social disability Present 20 2.91 1.04 −0.42 −1.299 0.199

Absent 80 3.33 .95

Handicap Present 20 2.91 1.04 −0.42 −1.299 0.199

Absent 80 3.33 0.95

OHIP-14 Present 20 20.36 6.61 −2.30 −1.153 0.254

Absent 80 22.67 5.78OHIP-14: Oral health impact profile

n Minimum Maximum Mean Std. deviation Decayed 100 2.00 4.00 3.3929 0.77878

Missing 100 2.00 12.00 5.9643 2.68981

Filled 100 2.00 5.00 3.3036 1.06035

DISCUSSION

Institutionalized elderly are found to have poorer oral health status than active elderly� Edentulism was calculated as the most significant problem among institutionalized elderly respondents in our study and has also been reported previously� These results are in accordance with the study conducted by Sujatha et al�[14] and Zhu and Hollis�[15]

Although the prevalence of edentulism reported in this study (19.6%) is similar to the prevalence of edentulism among the elderly in India according to the WHO Oral Health Data Bank (19%), other study done by Sonkesariya et al�, the prevalence of edentulism was 20�3%�[17]

Females experienced greater impact of oral diseases than males in all the domains of OHIP-14 and this is corroborating with the findings from a previous study conducted.[9,17]

In the present study, edentulous patients were excluded, leaving 80 only of the sample to be assessed� With periodontal pocket, 16% of these were deep, 42�8% were shallow, and dental calculus was present in 19�6% of the valid sextants� Bleeding on probing was found for 12�5% of the applicable sextants, and areas of health were represented by only 5�3% [Table 5]� Another study conducted by Agrawal et al� in 2015, total 599 elderly residing in old age homes were examined, the results showed, deep pocket 23�1%, shallow pocket 52�1%, and dental calculus was

Table 4: Age-wise comparison of OHIP-14 score and its domainsDomain Age n Mean SD F Sig.Functional limitation <70 years 41 2.78 1.00 1.770 0.180

71–80 years 41 3.22 1.00

>80 years 18 3.40 0.97

Physical pain <70 years 41 2.78 1.00 2.161 0.125

71–80 years 41 3.30 0.97

>80 years 18 3.40 0.97

Physical discomfort <70 years 41 2.78 1.00 2.161 0.125

71–80 years 41 3.30 0.97

>80 years 18 3.40 0.97

Physical disability <70 years 41 2.96 0.88 1.378 0.261

71–80 years 41 3.30 0.88

>80 years 18 3.40 0.70

Psychological disability <70 years 41 3.13 1.01 0.318 0.729

71–80 years 41 3.30 0.97

>80 years 18 3.40 0.97

Social disability <70 years 41 3.13 1.01 0.318 0.729

71–80 years 41 3.30 0.97

>80 years 18 3.40 0.97

Handicap <70 years 41 3.13 1.01 0.318 0.729

71–80 years 41 3.30 0.97

>80 years 18 3.40 0.97

OHIP-14 <70 years 41 20.70 6.15 1.341 .270

71–80 years 41 23.04 6.07

>80 years 18 23.80 4.89OHIP-14: Oral health impact profile



Table 6: Comparison of OHIP-14 and its domains based on decayed teethDomain Sound teeth n Mean Std. deviation Mean diff t value P valueFunctional limitation <10 teeth 23 2.7692 1.01274 −1.242 0.220 −0.39356

>10 teeth 76 3.1628 0.99834

Physical pain <10 teeth 23 2.9231 1.03775 −0.752 0.455 −0.23971

>10 teeth 76 3.1628 0.99834

Physical discomfort <10 teeth 23 2.9231 1.03775 −0.752 0.455 −0.23971

>10 teeth 76 3.1628 0.99834

Physical disability <10 teeth 23 3.2308 0.83205 0.249 0.804 0.06798

>10 teeth 76 3.1628 0.87097

OHIP-14 <10 teeth 23 22.4615 5.69525 0.169 0.866 0.32200

>10 teeth 76 22.1395 6.09676*t-test was used as these variables confer to equality of variance assumptionDomain Sound teeth n Mean Std. deviation Mean diff. z value P valuePsychological disability <10 teeth 23 3.5385 0.87706 1.220 1.220 .220

>10 teeth 76 3.1628 0.99834

Social disability <10 teeth 23 3.5385 0.87706 1.220 1.220 .220

>10 teeth 76 3.1628 0.99834

Handicap <10 teeth 23 3.5385 0.87706 1.220 1.220 .220

>10 teeth 76 3.1628 0.99834*Mann–Whitney U-test was used as these variables did not confer to equality of variance assumption. OHIP-14: Oral health impact profile

present in 24�5% of the valid sextants� Bleeding on probing was found for 0�26% of the applicable sextants, and healthy condition was represented by none�[18] Another study conducted by Sha et al�

among 320 elderly of Andhra Pradesh, shows deep pockets present in 66�2% of study subjects, whereas only 0�3% of subjects were reported to show no signs of periodontal pockets�[19]

Table 5: Comparison of OHIP-14 and its domains based on remaining sound teethDomain Sound teeth n Mean Std. deviation Mean diff. t value P valueFunctional limitation <12 teeth 77 3.02 1.01 −0.21 −0.648 0.520

>12 teeth 23 3.23 1.01

Physical pain <12 teeth 77 3.07 1.01 −0.16 −0.504 0.617

>12 teeth 23 3.23 1.01

Physical discomfort <12 teeth 77 3.07 1.01 −0.16 −0.504 0.617

>12 teeth 23 3.23 1.01

Physical disability <12 teeth 77 3.12 0.85 −0.27 −0.991 0.326

>12 teeth 23 3.38 0.87

OHIP-14 <12 teeth 77 21.77 5.92 -1.92 -1.021 0.312

>12 teeth 23 23.69 6.09 *t-test was used as these variables confer to equality of variance assumption Domain Sound teeth n Mean Std. deviation Mean diff. z value P valuePsychological disability <12 teeth 77 3.16 1.00 −0.37567 1.220 0.220

>12 teeth 23 3.54 0.88

Social disability <12 teeth 77 3.16 1.00 −0.37567 1.220 0.220

>12 teeth 23 3.54 0.88

Handicap <12 teeth 77 3.16 1.00 −0.37567 1.220 0.220

>12 teeth 23 3.54 0.88OHIP-14: Oral health impact profile



CONCLUSION

Oral health status of the institutionalized elderly in Bareilly city is poor, with edentulism and periodontitis� According to the OHIP-14, in edentulism, all the p values are non-significant. Moreover, in periodontitis, the p values of the following domains – functional limitation, physical pain, physical disability, and physical discomfort not found to be statistically significant.

LIMITATIONS

Majority of the participants shows a negative impact of the oral health on their quality of life but statistical significance could not be established which could be attributed to small sample size� Hence, further longitudinal study on large sample size of a large geographic region is advocated so as to assess the impact of oral diseases on OHRQoL of institutionalized elderly people and is wider implication on masses�

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17. Sonkesariya S, Jain D, Shakya P, Agrawal R, Prasad SV. Prevalece of dentulism, partial edentulism and complete edentulism in rural and urban population of Malwa region of India: A population-based study. Int J Prostodont Restor Dent 2014;4:112-9.

18. Agrawal R, Gautam NR, Kumar PM, Kadhiresan R, Saxena V, Jain S. Assessment of dental caries and periodontal disease status among elderly residing in old age homes of Madhya Pradesh. J Int Oral Health 2015;7:57-64.

19. Sha SK, Khan A, Eswara K, Suvarna DL, Kannaiyan K, Pottem N. Assessment of periodontal health and necessity of dental treatment in the institutionalized elderly population of East Godavari district, Andhra Pradesh. J Pharm Bioallied Sci 2019;11:S188-93.

Table 7: Percentage of subjects with healthy periodontal tissue, percentage of subjects with bleeding only, percentage of subjects with calculus, percentage of subjects with shallow pockets (4–5 mm), percentage of subjects with deep pocketsS. No. Codes n %1 0=HEALTHY 3 5.3

2 1=BLEEDING 7 12.5

3 2=CALCULUS 11 19.6

4 3=SHALLOW POCKETS 24 42.8

5 4=DEEP POCKETS 9 16

6 X/9=NOT RECORDED 2 3.5


Adolescent Body Mass Index and Skeletal Maturation Assessed with Hassel and Farman’s Cervical Vertebrae Staging Method

Sushila Sah1, Preeti Bhattacharya2, Ravi Bhandari3, Taufique Anwer4, Sumit Joshi5, Akash Prakash Singh6, Ahmad Muzaffar7

1Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 2Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 3Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 4Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 5Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 6Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 7Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

Obesity and underweight are two growing paradox problems in today’s world. The global disparity in terms of fat and hungry zones is the most visceral way, in which this inequality is lived, felt, and seen. Many ramifications and negative medical consequences are associated with obesity and underweight. The body weight and the level of fat accumulation depend on health status, basal metabolism, hormonal balance, physical exercise, diet, race, and heredity.[1] Body mass index (BMI) is usually used to describe the level of fatness classifying into underweight, normal, overweight, and obese. Raw BMI scores are practically pointless in growing children as the adiposity varies with age and gender during childhood and adolescence. BMI is age and gender-specific. BMI percentiles are a fast, non-invasive, and handy method to measure a child’s height-weight status.[2] According to the Center for Disease

Control (CDC) growth charts, a BMI over the 95th percentile is obese, 85th–95th percentiles are considered overweight, and those below the 5th percentile are underweight.[3]

Orthodontists frequently deal with children and adolescents for growth modulation therapy. Growth is an active process that commences right after conception. Complex interactions of genes, hormones, and nutrients regulate the postnatal craniofacial skeletal growth.[4] It is known that the growth velocity in obese shows faster linear growth in the 1st years of life which maintained till the beginning of puberty and later a growth spurt equal with the lean subjects.[5] It is understandable that by an obese body mass, growth

ABSTRACT

Introduction: Obesity and underweight are two growing paradox problems in today’s world. The global disparity in terms of fat and hungry zones is the most visceral way, in which this inequality is lived, felt, and seen. Body mass index (BMI) is normally used to describe of the level of fatness. Orthodontists frequently deal with children and adolescents for growth modulation therapy. Purpose: The purpose of this study was to investigate whether the increase or decrease in BMI influences the skeletal maturation in adolescent orthodontic patients. Material and Method: Four BMI groups: Group I (underweight), Group II (normal-weight), Group III (overweight), and Group IV (obese) with 25 subjects each and of 14–17 years of age were studied. Each subject’s lateral cephalogram was studied for cervical vertebrae (CV) as a skeletal maturation indicator using Hassel and Farman’s CV maturation index (CVMI) staging. Statistical Analysis: Analysis was performed using the SPSS version 20.0. Pearson product correlation was run to determine the relationship between BMI and CVMI. Linear regression and ANOVA was performed for finding the regression correlation between the BMI and CVMI. Results: The Pearson correlation test showed statistically significant linear relationship between BMI and CVMI (r = 0.423). The correlation was between BMI and CVMI, which was with 95% confidence with P < 0.001 (two-tailed). ANOVA test was used to find the regression correlation between BMI and CVMI, in which the beta (standardized regression coefficient) was 0.423. Conclusion: There was a significant positive linear relationship between CVMI and BMI, where an increase in BMI is likely to affect the CVMI and thereby the skeletal maturation.

Key words: Cervical vertebral maturation, skeletal maturation, body mass index, obesity, underweight

Original Research

Corresponding Author: Sushila Sah, Department of Orthodontics, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

mailto:[email protected]

Sah, et al.: Adolescent BMI and skeletal maturation assessed with hassel and Farman’s cervical vertebrae staging method


and development, will be affected but to what extent this occurs is presently unknown.[6] Thus, the objective of this study was to investigate whether the increase or decrease in BMI influences skeletal maturity in an adolescent orthodontic patient.

MATERIAL AND METHOD

Patients age 14–17 years, referred to the Department of Orthodontics and Dentofacial Orthopedics at the Institute of Dental Sciences, Bareilly, needing orthodontic treatment were considered to be a part of the study. As a part of the routine orthodontic investigation, each patient’s height and weight were recorded and a lateral cephalogram was taken. Subjects with any previous history of craniofacial trauma or congenital anomalies or any significant medical history that would affect physical development and growth were excluded from the study.

After the calculating, the BMI percentile for each patient, the records of 100 patients (25 subjects in each group) fulfilling the above-mentioned criteria were selected for the study and divided into four groups:• Group I – Underweight (<5th percentile)• Group II – Normal (5th–85th percentile)• Group III – Overweight (85th–95th percentile)• Group IV – Obese (>95th percentile).

For evaluating the cervical vertebrae (CV) stages, Hasseland Farman’s CV maturation index (CVMI) staging[7] was used [Table 1 and Figure 1]. CV C2, C3, and C4 were traced on each cephalometric film by one tracer on an acetate paper using a

0.3 mm 3H pencil. By identifying changes at the inferior border and body morphology of the cervical vertebrae: C2, C3, and C4, staging was done from CVMI 1 to CVMI 6.

Statistical analysis

The analysis was performed using the SPSS 20.0 version. A descriptive analysis of the qualitative variable is shown as a number and percentages. A Pearson product correlation was run to determine the relationship between BMI and CVMI. Linear regression was performed to predict the value of BMI on CVMI (if there is a relationship, is it dependent on each other). ANOVA was performed for finding the regression correlation between BMI and CVMI. P < 0.005 was considered statistically significant. All the data were reported with exact P-values and 95% confidence intervals. The present study was approved by the Ethical Committee of Bareilly International University, Bareilly.

RESULT

A total of 100 films were studied consisting of 25 subjects in each group. The Group I (underweight) comprised 14 (56.0%) males and 11 (44.0%) females, Group II (Normal), 14(56.0%) males and 11 (44.0%) females, Group III (overweight), 17 (68.0%) males and 8 (32.0%) females, and Group IV 18 (72.0%) males and 7(28.0%) females. Upon comparing the sex proportions (M/F) of four groups, revealed that these groups had statistically similar sex proportions (P=0.450).

The age of Group I (underweight), II (normal-weight), III (overweight), and IV (obese) groups ranged from 14 to 17 years with a mean (±SD) 15.04 ± 1.21 years, 15.08 ± 1.12 years, 14.80 ± 1.04 years, and 14.60 ± 1.04 years, respectively. When the mean age of four groups was compared using ANOVA, similar age among the four groups was found, that is, it did not differ statistically (P = 0.236).

The distribution of different CVMI stages among all 4 BMI groups are shown in Table 2. About 60% of underweights subjects were found to be in Stages 2 and 3, 80% of

Table 1: Hassel and Farman’s cervical vertebrae maturation indicators[7]

CVMI stages Characteristic changes on cervical vertebrae1 Initiation • Growth expected – Substantial

• The lower border of C2, C3, and C4 are flat• Upper borders are tapered posterior to anterior

2 Acceleration • Growth expected – Significant• The lower border of C2 and C3 starts developing

concavities• The C4 lower border is flat • Rectangular C3 and C4

3 Transition • Growth expected – Moderate• C2 and C3 lower borders with distinct concavities• The lower border of C4 starts to develop concavity• Rectangular C3 and C4

4 Deceleration • Growth expected – Little• The lower borders of C2, C3, and C4 with

distinct concavities• Nearly squarish C3 and C4

5 Maturation • Growth expected – Very little• The lower borders of C2, C3, and C4 with

accentuated concavities• Squarish C3 and C4

6 Completion • Growth expected – nil• The lower border of C2, C3, and C4 with deep

concavities• Height of C3 and C4 greater than the width

Figure 1: C3 as a guide for cervical vertebrae maturation indicators[7]



normal-weight subjects were found to be in Stages 4 and 5, and 64% of overweight subjects were found to be in Stages 5 and 6 and 60% of obese subjects were found to be in Stages 4 and 5.

The correlation between BMI and CVMI is represented in Table 3. The Pearson correlation test showed a statistically significant linear relationship between BMI and CVMI (r = 0.423). The correlation was between BMI and CVMI, which was with 95% confidence with P < 0.001 (2 tailed). The direction of the relationship was found to be positive and the magnitude of the association was strong with r = 0.423 with R2 = 0.179, thus, a total variation of 0.179 in <18% of the sample [Table 4]. ANOVA test was used to find the regression correlation between BMI and CVMI, in which the beta (standardized regression coefficient) was

0.423. Implying that with a change in the 1-unit change in BMI, an increase of 0.423 in CVMI will be noticed [Table 5].

DISCUSSION

Obesity is one of the significant public health problems in developed countries and results from multiple interactions between genes and the environment. The body weight and the level of fat accumulation depend on health status, basal metabolism, hormonal balance, physical exercise, diet, race, and heredity.[1] The prevalence of overweight and obese adolescents has increased rapidly in developed as well as developing countries. Meanwhile, the prevalence of underweight is also increasing in many regions of the world, leading to a “bidirectional crisis.”[8]

Various factors such as genes, nutrients, hormones, and epigenetic factors regulate craniofacial growth.[9] Perverted growth may result if there is an issue in any of these mechanisms. The general health of a child influences skeletal maturation and any prior knowledge of a certain type of skeletal predisposition can help in early diagnosis and treatment planning.

CDC growth charts were used to categorize underweight, normal weight, overweight, and obese constructed on the percentile-based data. CVMI was used as a skeletal maturation indicator for the participants. The orthodontists usually depend on the skeletal age more than the chronologic age as a gauge of growth modulation therapy. Although there has been criticism regarding the sensitivity of CVMI, there is no gold standard method. According to Wong et al.[10] in 2009, the CVMI method was considered sensitive for detecting growth maturity in too young or too old age ranges of subjects, but is quite helpful for precise detection of the growth maturity during the growth spurt period, that is, adolescence which comprises the test sample group of our study with age 14–17 years. Many studies Mack et al., Akridge et al., and Costacurta et al.[2,11,12] have reported accelerated skeletal growth in obese individuals. In our study too increased, BMI was associated with early skeletal maturation.

Our findings suggested that there is a positive linear relationship between BMI and CVMI. Furthermore, with every 1unit change in BMI for age and sex, there was an 0.432 increase in CVMI. This means that for a 14-year-old adolescent at a given time, with almost every 3 unit increase or decrease in the normal BMI, we could expect an increase/decrease 1 CVMI stage, respectively. The results of the study were consistent with the studies done by Akridge et al.,[11] Costacurta et al.,[12] Mack et al.,[2] and Kumar et al.[13]

Orthodontic treatment impacts the general health of children and adults. A recent study found that 55% of the orthodontists never collected any weight data, and only 4% weighed patients on a scale or recorded heights using a stadiometer.[2] Obesity was not assessed in any way by 73% of the orthodontists or dentists, and most of those who did not consider it to be significant.[14]

The craniofacial structures play an important role in facial esthetics; therefore, an orthodontist needs to know the possible changes in the craniofacial structures due to BMI in their growth period. Recording height and weight and considering, its likely effect on the treatment plan is recommended for the orthodontists.

Table 4: Regression analysis for BMI and CVMIModel R R square Adjusted R

squareStandard error of

the estimate1 0.423a 0.179 0.171 1.06,788a. Predictors: (Constant), BMI

b. Dependent variable: CVMI

Table 2: Frequencies of each maturation stage in BMI groupsCVMI stages Underweight Normal Overweight Obese.1 8% 0% 0% 0%

2 16% 0% 0% 0%

3 24% 12% 24% 16%

4 36% 40% 12% 28%

5 12% 40% 40% 32%

6 4% 8% 24% 24%

Table 3: Table showing the correlation between BMI and CVMICVMI BMI

CVMI

Pearson correlation 1 0.423**

Sig. (two-tailed) 0.000

N 100 100

BMI

Pearson correlation 0.423** 1

Sig. (two-tailed) 0.000

N 100 100**. Correlation is significant at the 0.01 level (two-tailed).

Table 5: Regression coefficient tableModel Unstandardized

coefficientsStandardized coefficients

t Sig.

B Standard Error

Beta

(Constant) 2.442 0.411 5.936 0.000

BMI 0.081 0.018 0.423 4.626 0.000a. Dependent variable: CVMI



Both obesity and underweight possesses a risk for many health-related issues and orthodontist being a health-care professional need to counsel the patients and the guardian regarding the ill-effects and should refer them to a nutritionist/diet counselor for weight management.

CONCLUSION

There was a significant linear relationship between CVMI and BMI, where an increase in BMI is likely to affect the CVMI, thereby the skeletal maturation. Thus, during adolescence when the growth changes take place, patients with lower BMI will have delayed skeletal maturation whereas, patients with higher BMI will have early skeletal maturation. A significant number of patients seeking orthodontic treatment are adolescents; so, it might be beneficial for the patient as well as the orthodontist to consider the BMI while making the treatment plan.

REFERENCES

1. Simopoulos AP. Obesity and carcinogenesis: Historical perspective. Am J Clin Nutr 1987;45:271-6.

2. Mack KB, Phillips C, Jain N, Koroluk LD. Relationship between body mass index percentile and skeletal maturation and dental development in orthodontic patients. Am J Orthod Dentofac Orthop 2013;143:228-34.

3. Kuczmarski RJ. CDC Growth Charts. United States: National Center for Health Statistics; 2000.

4. Salas-Flores R, González-Pérez B, Barajas-Campos RL, Gonzalez-Cruz B. Changes on craniofacial structures in children with growth-hormone-deficiency. Rev Méd Inst Mex Seguro Soc

2010;48:591-5.5. De Simone M, Farello G, Palumbo M, Gentile T, Ciuffreda M,

Olioso P, et al. Growth charts, growth velocity and bone development in childhood obesity. Int J Obes Relat Metab Disord 1995;19:851-7.

6. Neeley WW 2nd, Gonzales DA. Obesity in adolescence: Implications in orthodontic treatment. Am J Orthod Dentofac Orthop 2007;131:581-8.

7. Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod Dentofac Orthop 1995;107:58-66.

8. NCD Risk Factor Collaboration (NCD-RisC). Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: A pooled analysis of 2416 population-based measurement studies in 128.9 million children, adolescents, and adults. Lancet 2017;390:2627-42.

9. Van Limborgh J. Factors controlling skeletal morphogenesis. Prog Clin Biol Res 1982;101:1.

10. Wong RW, Alkhal HA, Rabie AB. Use of cervical vertebral maturation to determine skeletal age. Am J Orthod Dentofac Orthop 2009;136:484.

11. Akridge M, Hilgers KK, Silveira AM, Scarfe W, Scheetz JP, Kinane DF. Childhood obesity and skeletal maturation assessed with Fishman’s hand-wrist analysis. Am J Orthod Dentofac Orthop 2007;132:185-90.

12. Costacurta M, Sicuro L, Di Renzo L, Condò R, De Lorenzo A, Docimo R. Childhood obesity and skeletal-dental maturity. Eur J Paediatr Dent 2012;13:128-32.

13. Kumar V, Venkataraghavan K, Krishnan R, Patil K, Munoli K, Karthik S. The relationship between dental age, bone age and chronological age in underweight children. J Pharm Bioallied Sci 2013;5:S73.

14. Huang JS, Becerra K, Walker E, Hovell MF. Childhood overweight and orthodontists: Results of a survey. J Public Health Dent 2006;66:292-4.


Knowledge, Attitude, and Practice of Hand Hygiene among Medical and Dental Undergraduates of Bareilly International University: A Cross-

sectional Survey

Swati Pathak, Shivalingesh K. K, Smriti Saxena, Henna Mir, Divya Srivastava, Adeeba Saleem

Public Health Dentistry, Institute of Dental Sciences, Bareilly, India

INTRODUCTION

World Hand Hygiene Day takes place on May 5, 2019�[1]

According to the WHO, “hand hygiene is a general term referring to any action of hand cleansing, that is, it is the act of cleaning one’s hands with or without the use of water or another liquid, or with the use of soap, for the purpose of removing soil, dirt, and/or micro-organisms�”[2]

The healthcare workers’ hands play a major role in the transmission of pathogens linked to health care from one patient into the next�[3]

The hand which is considered the most contagious part of the body�[4] Infections that were acquired while receiving healthcare have increased thousands of death rates worldwide� Hands serve as the primary source of germ transmission. Health-care staff or others should be in a position to properly practice hand hygiene�[5]

Healthy hand hygiene can lessen the risk of disease associated with healthcare as these infections have been related to an unacceptably high level of cost of morbidity, mortality and healthcare�[6]

Maintaining good hand hygiene is a very easy step but the compliance is bad and to overcome this, continuous efforts are

being made. The WHO evidence-based concept of “My five moments for hand hygiene” is one of them [Figure 1]�

This concept has been appropriately used to make better understanding, training, monitoring, and reporting hand hygiene among healthcare workers�[7]

All health-care staff, or any person directly or indirectly involved in patient care, need to practice good hand hygiene�[8]

The most productive and realistic component of minimizing infections associated with healthcare is hand hygiene� The WHO has come up as a global effort with the launch of “SAVE LIVES: Clean Your Hands” campaign in 2009 for infection control as well as to assure patient safety and to reduce healthcare associated infections�[9]

Since previous reports demonstrated insufficient compliance by undergraduate students with hand hygiene practices�[10]

This study was conducted to assess the knowledge on hand hygiene practices among Indian medical and dental undergraduates�

ABSTRACT

Background: Hand hygiene is of utmost importance for the prevention and dissemination of antimicrobial resistance associated with health-care infections. Among interdisciplinary undergraduate students in healthcare, the definition of hand hygiene needs to be discussed.Materials and Methods: A cross-sectional observational study was conducted among the medical and dental undergraduate students of Bareilly International University. The questionnaire was adapted from the WHO hand hygiene awareness questionnaire for health workers, consisting of 13 questions and was distributed in print formats. P-value was calculated using Chi-square test. P = 0.05 or less was used as cut-off level for statistical significance.Results: Total 200 students were selected out of which 100 were medical and 100 were dental students. In our study, medical students had better knowledge, attitude, and practice toward hand hygiene as compare to dental students.Conclusion: None of the medical and dental students were fully aware of hand hygiene knowledge , attitude, and practices and the risk of infection associated with health care has increased.

Key words: Dental, Hand hygiene, Medical, Undergraduate

Original Article

Corresponding Author: Dr. Swati Pathak, Postgraduate Student, Public Health Dentistry, Institute of Dental Sciences, Bareilly, India. E-mail: [email protected]

Pathak, et al.: Knowledge, attitude and practices of handhygiene



A cross-sectional survey was conducted among 100 Indian medical and 100 dental undergraduates� The questionnaire consisting of 13 questions was adapted from the WHO hand hygiene knowledge, attitude, and practices questionnaire for healthcare workers and was distributed in print formats� Percentages were used to analyze the reaction to each question�[5]

The questions of the questionnaire were designed to assess their basic knowledge, attitude, and practice toward hand hygiene in clinics and hospitals� Data were collected and descriptive statistics were computed for each question’s responses� Statistical analysis was performed using SPSS version 22� Chi-square test carried out and value <0�05 was considered statistically significant.

RESULTS

A questionnaire study was conducted among 100 dental and 100 medical students of Bareilly international university (Uttar Pradesh), to determine their level of knowledge regarding hand hygiene� A pre-tested self-administered questionnaire consisting of 13 questions concerning their knowledge, attitude, and practices regarding hand hygiene was given to the students�

Figure 2 shows the distribution of data based on gender among the medical undergraduates� Nearly 53% of respondents were males and 47% were females�

Figure 3 shows the distribution of data based on gender among the dental undergraduates� Nearly 84% of respondents were males and 16% were females�

About 92% of medical students and 44% of dental students who took part in this study received formal hand hygiene instruction and 92% of medical and 47% of dental students claimed they routinely used alcohol-based hand rub for hand washing� About 69% of medical and 45% of dental students knew about percentage of hospitalized patients who would develop a healthcare associated infection� About 8% of medical and 16% of dental claimed that a healthcare-related infection had a very strong impact on the clinical outcome of a patient� Almost 66% of medical and 31% of dental students claimed that hand hygiene was very effective in preventing infections associated with health care� The majority of 61% medical students state very high priority of hand hygiene at their institution� Around 75% of medical and 35% of dental students knew about percentage of situations requiring hand hygiene where healthcare workers actually performed hand hygiene either by hand rubbing or hand washing�

When asked whether their leaders and seniors managers at institution support and openly promote hand hygiene 62% of medical and 32% of dental students agreed affirmatively.

When asked about the availability of alcohol based hand rub, 62% of medical and 33% of dental students strongly agreed on its easy availability� About 60% of medical students and 33% of

Figure 1: Five components of the WHO multimodal hand hygiene improvement strategy

Male

Female53%

47%

Figure 2: The distribution of data based on gender among the medical undergraduates

Figure 3: The distribution of data based on gender among the dental undergraduates



dental students also felt that adequate hand hygiene posters were displayed as reminders at point of cure�

About 61% of medical and 34% of dental students felt that they had received adequate education on hand hygiene� Similarly 64% of medical and 24% of dental students concurred on clarity and simplicity of hand hygiene instructions� When asked whether health workers received regular feedback on their hand hygiene performance, only 11% of medical and 19% of dental students agreed on the same� About 58% of medical and 29% dental students always performed hand hygiene as recommended� Only 18% of medical and 14% of dental students agreed that patients were asked to remind healthcare workers to do hand hygiene� About 58% of medical and 24% of dental students attached high importance to their head of their department in performing optimal hand hygiene� Interestingly, 12% of medical and 20% of dental students acknowledged that their patients had high priority regarding

optimal hand hygiene. When asked about the effort required to perform good hand hygiene during patient care, 13% of medical and 27% of dental students felt the effort required to perform hand hygiene was high� It was observed that 79% of medical and 42% of dental students actually performed hand hygiene either by hand rubbing or hand washing�

DISCUSSION

Hand cleaning can be done in hospitals in either way: Hand scrubbing and hand washing� Hand washing using water and soap and alcohol based hand rub for hand rub� Hands should be washed for at least 15 s to kill germs, ensuring that all parts of the hands are cleaned well� In a healthcare set up, hand rubbing is the best method for hand cleaning. It kills deadly germs more efficiently as compare

Response Percentage P valueMedical Dental

YesNo

928

928

0.676

YesNo.

928

4753

0.872

KnowI don’t know

6931

4565

0.680

Very lowLowHighVery high

1012708

3295216

0.398

Very lowLowHighVery high

4121866

2115631

0.717

Low priorityModerate priorityHigh priorityVery high priority

3122461

6184828

0.267

KnowI don’t know

7525

3565

0.276

a. Your institution’s leaders and senior managers support and openly promote hand hygiene.

1. Not effective2. Somewhat effective3. Moderately effective4. Effective5. Effective6. Effective7. Very effective

843

1184

62

4147

16121532

0.627

B. The health-care facility always makes hand rubbing based on alcohol available at every point of care.


5584

106

62

45

1320131233

0.753

(Contd...)




c. Hand hygiene posters are displayed as reminders at the point of cure.


417

12106

60

449

20161433

0.754

d. Healthcare worker receives hand hygiene training


3425

151061

766

25121034

0.376

e. For every healthcare worker, clear and simple instructions for hand hygiene are made visible.

1. Not effective.2. Somewhat effective.3. Moderately effective.4. Effective5. Effective6. Effective7. Very effective.

8527

104

64

568

25151724

0.017

f. Healthcare workers regularly receive feedback on the performance of their hand hygiene


2112925157

11

85

1018182219

0.168

g. Hand hygiene is always performed as prescribed (being a good example for your colleagues).


1298

121058

826

14232324

0.463

h. Patients are encouraged to remind healthcare workers to maintain hand hygiene.

1. Not effective.2. Somewhat effective.3. Moderately effective.4. Effective5. Effective6. Effective7. Very effective

112

17481318

139

1215172014

0.034

What importance does the head of your department attach to the fact that you carry out hand hygiene?

1. No importance.2. Somewhat important3. Moderately important4. Important5. Important6. Important7. Very high importance.

3313

161658

9769

192624

0.996

What importance do your colleagues attach to the fact that you carry out hand hygiene?


52196

6413

65

1015142921

0.673

(Contd...)



to soap and consumes less time� Hand rubbing is more convenient than hand washing as it does not irritate or dry the skin�[5]

The most significant factor in managing the spread of infections is considered to be good hand hygiene�[11]

This is the study where a integrative comparison was made in between medical and dental students�[10]

Many studies have examined the importance of hand hygiene among health-care professionals� The present study was done to assess the knowledge, attitude, and practice among 100 medical and 100 dental students of Bareilly International University. Regarding knowledge on hand infection, various questions were asked to the participants such as hand hygiene training, hand hygiene effectiveness in reducing the infection, and hand hygiene importance at the institution� The majority of the medical students had more knowledge than the dental students which was statistically significant. It is in accordance to a study conducted by Jagdish et al�[9] As far as attitude was concerned, in our study, medical students showed better attitudes toward hand hygiene than dental students which is in agreement with study conducted by Nair et al�[12] With respect to their practices like use of alcohol based hand rub, impact of infection associated with healthcare on clinical outcomes of patients, and medical students fared better than their dental counterparts�

Low knowledge, low attitude, and practice toward hand hygiene have been identified by individual studies focused on dental students�[13-15] However, there exists paucity on comparison studies regarding hand hygiene between dental students and medical students�[10]

The findings of this study indicate a need to instill formal training in hand hygiene at the undergraduate level� A systematic hand hygiene instruction can have a positive influence on undergraduate education attitude and practice� It is critical that undergraduate or health-care professionals maintain good hand hygiene because they

are directly involved in primary care for patients� Hand hygiene education, behavior, and the implementation of hand hygiene training modules should be emphasized in order to improve hand hygiene among undergraduates�[10]

Limitation of the Study

This study was conducted in single institute with a small sample size� To identify the possible gaps in hand hygiene among undergraduate health-care students, more multicenter studies and qualitative evaluations are required�

CONCLUSION

In our study, the knowledge, attitude, and practices regarding hand hygiene among medical and dental students was found to be insufficient.

Health-care students handle patients on regular basis so they must be educated regarding the hand hygiene and a formal training should be made compulsory to improve hand hygiene�

ACKNOWLEDGMENTS

The authors would like to thank all the study participants and all the faculty members of the Department of Public Health Dentistry, Institute of Dental Sciences, Bareilly�

REFERENCES

1. World Health Organisation. WHO Guidelines on Hand Hygienein Health Care: First Global Patient Safety Challenge Clean CareIs Safer Care. Geneva: World Health Organization Press; 2009.

2. Sultana M, Mahumud RA, Sarker AR, Hossain SM. Hand hygiene knowledge and practice among university students: Evidence from


What importance do patients attach to the fact that you carry out hand hygiene?


4213

146412

349

18172920

0.377

How do you consider the effort required by you to carry out good hand hygiene when caring for patients?

1. No effort2. Somewhat effort.3. Moderately effort.4. Effort5. Effort6. Effort7. A big effort

4213

146412

945

15132727

0.759

On average, in what percentage of situations requiring hand hygiene do you actually perform hand hygiene, either by hand rubbing or hand washing (between 0 and 100%)?

1. 0–30%2. 31–60%3. 61–100%

111079

144442

0.000



Private Universities of Bangladesh. Risk Manag Healthc Policy 2016;9:13-20.

3. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med 1999;159:821-6.

4. Shahin E, Al Dubaikhi K, Al Eissa N, Al Olah L, Al Saffan A,Baseer MA. Knowledge, attitudes, and practice of hand-washingamong dentists and dental students in Riyadh City, Kingdom ofSaudi Arabia. Oral Health Dent Sci 2017;1:1-3.

5. Modi PD, Kumar P, Solanki R, Modi J, Chandramani S, Gill N.Hand hygiene practices among indian medical undergraduates: Aquestionnaire-based survey. Cureus 2017;9:e1463.

6. AriyaratneMH, Gunasekara TD, Weerasekara MM, Kottahachchi J, Kudavidanage BP, Fernando SS. Knowledge, attitudes and practices of hand hygiene among final year medical and nursing studentsat the University of Sri Jayewardenepura. Sri Lankan J Infect Dis2013;3:15-25.

7. Al Kadi A, Salati SA. Hand hygiene practices among medicalstudents. Interdiscip Perspect Infect Dis 2012;2012:679129.

8. Gore CA, Bindu M, Saxena L. A study on knowledge about handhygiene among medical, dental and nursing students in Bangalore, Karnataka. Public Health Rev 2018;5:111-6.

9. Jagdish L, Naik TB, Gupta RK, Upadhya AK. Prevalence of handhygiene awareness among medical and dental students in ateaching hospital. Indian J Microbiol Res 2016;3:262-5.

10. Thakker VS, Jadhav PR. Knowledge of hand hygiene inundergraduate medical, dental, and nursing students: A cross-sectional survey. J Family Med Prim Care 2015;4:582-6.

11. Mathur P. Hand hygiene: Back to the basics of infection control.Indian J Med Res 2011;134:611-20.

12. Nair SS, Hanumantappa R, Hiremath SG, Siraj MA, Raghunath P.Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur,India. Int Sch Res Notices 2014;2014:608927.

13. Myers R, Larson E, Cheng B, Schwartz A, da Silva K, Kunzel C. Hand hygiene among general practice dentists: A survey of knowledge,attitudes and practices. J Am Dent Assoc 2008;139:948-57.

14. Thivichon-Prince B, Barsotti O, Girard R, Morrier JJ. Hand hygiene practices in a dental teaching center: Measures and improve. Eur J Dent 2014;8:481-6.

15. Abreu MH, Lopes-Terra MC, Braz LF, Rímulo AL, Paiva SM,Pordeus IA. Attitudes and behavior of dental students concerninginfection control rules: A study with a 10-year interval. Braz DentJ 2009;20:221-5.



QUESTIONNAIRE

1� Did you receive formal training in hand hygiene in the past 3 years? A� Yes B� No

2� Do you routinely use an alcohol-based hand rub for hand hygiene? A� Yes B� No

3. 3. In your opinion, what is the average percentage of hospitalized patients who will develop a healthcare-associated infection (between 0 and 100%)?

A� % B� I don’t know

4� In general, what is the impact of a health care-associated infection on a patient’s clinical outcome? A. Very low B. Low C. High D. Very high

5. What is the effectiveness of hand hygiene in preventing healthcare-associated infection? A. Very low B. Low C High D. Very high

6� 6� Among all patient safety issues, how important is hand hygiene at your institution? A. Low priority B. Moderate priority C. High priority D. Very high priority

7� 7� On average, in what percentage of situations requiring hand hygiene do healthcare workers in your hospital actually perform hand hygiene, either by hand rubbing or hand washing (between 0 and 100%)?

A� % B� I don’t know

8. In your opinion, how effective would the following actions be to improve hand hygiene permanently in your institution? Please tick one “ ” on the scale according to your opinion� A. Leaders and senior managers at your institution support and openly promote hand hygiene. Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective B� The health-care facility makes alcohol-based hand rub always available at each point of care� Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective C� Hand hygiene posters are displayed at point of care as reminders� Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective D� Each health-care worker receives education on hand hygiene� Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective E� Clear and simple instructions for hand hygiene are made visible for every health-care worker� Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective F� Health-care workers regularly receive feedback on their hand hygiene performance� Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective G. You always perform hand hygiene as recommended (being a good example for your colleagues). Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective H� Patients are invited to remind health-care workers to perform hand hygiene� Not effective 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very effective

9� What importance does the head of your department attach to the fact that you perform optimal hand hygiene? No importance 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very high importance

10� What importance do your colleagues attach to the fact that you perform optimal hand hygiene? No importance 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very high importance

11� What importance do patients attach to the fact that you perform optimal hand hygiene? No importance 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 Very high importance

12. How do you consider the effort required by you to perform good hand hygiene when caring for patients? No effort 0- - - 0- - - 0- - - 0- - - 0- - - 0- - - 0 A big effort

13� On average, in what percentage of situations requiring hand hygiene do you actually perform hand hygiene, either by hand rubbing or hand washing (between 0 and 100%)?

%


The Assessment of Color Stability among the Four Base Resins in Different Edible Staining Solutions: An In vitro Study

Kanupriya Agrawal, Mukesh Kumar Singhal, Smritashree Baruah, Hemendra Pratap

Department of Prosthodontics, Crown and Bridge and Implantalogy, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

Removable prosthesis partial or complete typically has acrylic resin bases to improve prosthesis sustenance and keep the simulated teeth in position�[1] These denture bases subsidize to esthetics and efficient rehabilitation.[2] Acrylic resin is thus considered as an efficient denture base material because of its cost-effectiveness, relining property and has a good esthetic appearance� It also has low density, easy to manipulate, biocompatible, as well as adequate physical and mechanical properties�[3,4] However, some undesirable physiognomies such as loss of elasticity, abrasion, porosity, and color changes might occur with time� One of the pointers of aging or damaging of materials is change in the color� It is one of the most imperative clinical possessions of dental materials�[5,6] The polymerization technique might persuade porosity inside the resin body during processing through short or long curing cycle[2,3,7,8] which may permit sorption of pigments of fluids such as tea, wine, grape juice, cola, and coffee, amid others.[2,3,9] This process of absorption and adsorption of fluids depends on environmental

circumstances and can quickly physical and mechanical properties of the material as well esthetics are challenged too�[9] Furthermore, various extrinsic factors can also cause discoloration such as thermal change, artificial dyes used in food, cleaning procedures, stain accumulation, and mishandling by the patient�[10]

To overawed some of the drawbacks of conventional compression processing technique, an injection-molded technique was endeavored for familiarizing non-polymerized acrylic resin into the mold� In this, a spring mechanism applies the continuous recommended hydraulic pressure to a reservoir of non-polymerized resin was used, to compensate for the polymerization shrinkage� Now, a number of dental trade corporations are introducing injection-molded systems, and

ABSTRACT

Aims and Objectives: The soul aim of this study is to assess the changes in color of different brands of commercially available heat cure denture base resins (Trevalon, DPI, Pyrax, and Ivoclar) processed by conventionally in long curing cycle and processed in injection molding flasks (Ivoclar) and the samples were compared by exposing them to various food beverages. Materials and Methods: Four varieties of heat cure base materials, namely, IVOCAP (HI), Trevalon (HI, DENTSPLY, Gurgaon [India], Pyrax [Roorkee, UK], and DPI [Dental Products, Mumbai]) were taken to prepare the desired samplings. The size of each cubical sampling was 20*20*2 mm. A total of 64 samplings (F) were prepared and out of which 48 samples were processed by compression molding technique using heat cure denture base resins Trevalon (HI, DENTSPLY, Gurgaon), Pyrax (Roorkee), and DPI (Dental Products, Mumbai). Rest, 16 samplings were set in special flasks with the injection unit (Dentsply). Injection of condensed heat-polymerizing resin was completed under a pressure of 6 × 105 N/m2. The pressure was maintained during a 45 min polymerization in hot water (100°C). All the samples are marked by their company name as I – Ivoclar, P – Pyrax, T – Trevalon, and D-DPI. Results and Statistical Analysis: The data were subjected to one factor analysis of variance and the significance of mean difference between (inter) the groups was done by Turkey’s honestly significance difference post hoc test. It was observed that significant changes in all the denture base resins were seen when observed after a period of 7–28 days. Conclusion: Minimum changes were seen in Ivoclar-based samples. Maximum staining was caused by turmeric and tobacco. Highly smooth and polished surface and significantly less amount of monomer content decrease the staining capacity of food colorants, thus making it more color stable.

Key words: Denture base resin, heat cure materials, color changes,injection moulding

Original Article

Corresponding Author: Dr. Kanupriya Agrawal, 22 Prabhat Nagar, Near Ram Janki Mandir, Bareilly - 243 001, Uttar Pradesh, India. E-mail: drkanupriyaagrawal92@ gmail.com

Agrawal, et al.: Staining of denture base resin


the method is more normally being used�[11] Injection-molded denture bases have the undue compensations of dimensional accuracy, low free monomer content, and good impact strength, low craze resistance, and the only drawbacks of high capital equipment costs initially�[12]

The color change of a polymeric substantial may be caused by various intrinsic or extrinsic factors� Intrinsic factors occur during the ripened process of the material due to physical and chemical circumstances resulting in resin discoloration and matrix changes� Color change is a result of changes in the matrix and aging procedure of the material occurring due to intrinsic factors but changes by extrinsic factors can be avoided with the help of an impervious, self-scrubbing, and scratch-resistant surface coating of titanium dioxide nanoparticles�[13,14] It is well recognized that brews such as tea, coffee, wine, and some artificial dyes used in food may increase the staining of both denture base polymers and the teeth� The research work focuses on the color constancy of denture base resins and their color perceivability for the food colorants commonly used in Indian diet�


Four varieties of heat cure denture base materials, namely, IVOCAP (HI), Trevalon (HI- DENTSPLY, Gurgaon), Pyrax (Roorkee, UK), and DPI (Dental Products, Mumbai) were taken to make the desired samplings� The size of each cuboidal specimen was 20*20*2 mm� Metal die was used for production the wax patterns of the sampling [Figure 1] which were processed according to the manufacturer’s instructions� A total of 64 specimens [Figure 2] were prepared and out of which 48 samples were processed by compression molding technique using heat cure denture base resins Trevalon (HI, DENTSPLY, Gurgaon), Pyrax (Roorkee), and DPI (Dental Products, Mumbai) (Manufacturer’s directions). They were equipped in conventional metal denture flasks and polymerized in a water bath for 9 h at 74°C (long curing cycle). For the injection molded method, HI-Ivocap (Ivoclar AG, Schaan, Liechtenstein), rest 16 samplings were equipped in special flasks with the injection unit (Dentsply). All the samplings were finished and polished using 200 grit sandpaper and followed by polishing from the lathe� All the samples are marked by their company name as I – Ivoclar, P – Pyrax, T – Trevalon, and D-DPI�

Solution preparation

Solutions of tea and turmeric were equipped using 200 ml of distilled water with the 10 ml of artificial saliva and 5 g of colorant for each and every sample� The solution was thoroughly mixed and heated to 100°C [Figures 3 and 4]� The obtained solutions were kept aside for 10 min and were then filtered through filter paper. Individually solution was then equally divided into four equal parts 55 ml into plastic containers�

Individually container with samplings was kept aside in an incubator at 37°C� Samples will be observed after the 1st week, 2nd week, 3rd week, and 4th week� The observation was made

using ultraviolet–visible (UV–Vis) spectrophotometer by setting (lambda max and min) to obtain the optical density (OD) of the immersed sample. The samples were kept in different solutions for different intervals and their individual readings were calculated, after leaching the samples in 30% hydrogen peroxide while hydrogen peroxide would be kept as the control group� This leached solution will be tested in spectrophotometer [Figure 5]�

Figure 1: Customized metal die

Figure 2: Prepared acrylic samples of Pyrax, DPI, Trevalon, and Ivoclar

Figure 3: Preparation of all the staining samples



Grouping of the samples

The study is divided into four groups as – Group A observes with Coca-Cola, Group B with tobacco, Group C with turmeric, and Group D with tea in Table 1 along with grouping and subgrouping of the samples which has been done� These groups are further divided into subgroups as follows:

Testing of samples

After conditional duration of time (1 week, 2 weeks, 3 weeks, and 4 weeks), each specimen was removed from the staining solution they were rinsed from hydrogen peroxide after removing the excess solution from the specimen by the tissue paper� Color changes of the specimen were determined from the leached solution of hydrogen peroxide solution in beaker which is kept for absorbent measurement over the UV spectrometer [Figure 5]� The absorbance of each specimen was determined using the wavelength of 200–700 nm. UV–Vis spectrophotometer and microplate readers differ fundamentally in their beam geometry. In spectrophotometer, samples are read through cuvette with a horizontal light path� The horizontal light beam and the customary 1 cm path length make assays based on extinction coefficients straight forward and allow easy comparison between them� Vertical light beam was dependent on volume filled which is, however, compensated in Spectramax where path length in each well of a microplate and automatically normalized the absorbance value to a 1 cm path length� The readings were recorded for each material and plotted in a graph�

For absorbance measurements, the OD is a logarithmic measurement of the percent transmission (%T) and it can be represented by the equation, OD = log 10 (Incident optical intensity/transmitted optical intensity).

= 10IO

OD logIT

If a sample has OD 3 that would mean that only

1 out of 1000 will be measured by the depicter�

RESULTS AND STATISTICAL ANALYSIS

The null hypothesis for the following study was used and nullified. It was observed that significant changes in all the denture base resins were seen when observed after a period of 7–28 days� Master values for investigations obtained after interpreting the graphs obtained in UV–Vis spectrophotometer Table 2.

Subsequently, from Graphs 1-4 show the effect of staining agent to all four samples�

In DPI, there was significant difference in mean in between all the four materials in DPI group (P = 0.007*).

In PYRAX group, there was a significant difference in mean in between all the four materials (P = 0.001*).

In TREVALON, there was a significant difference in mean in between all the four materials in TREVALO group (P = 0.011*).

Table 1: Grouping of samples used in methodologyGroup A (Coca-Cola)

Group B (tobacco)

Group C (turmeric)

Group D (tea)

Subgroup IA: 7 days

Subgroup IB: 7 days

Subgroup IC: 7 days

Subgroup ID: 7 days

Subgroup IIA: 14 days

Subgroup IIB: 14 days

Subgroup IIC: 14 days

Subgroup IID: 14 days

Subgroup IIIA: 21 days

Subgroup IIIB: 21 days

Subgroup IIIC: 21days

Subgroup IIID: 21 days

Subgroup IVA: 28 days

Subgroup IVB: 28 days

Subgroup IVC: 28 days

Subgroup IVD: 28 days

Figure 5: Spectramax 5

Figure 4: Prepared samples of the reagents

Graph 1: Effect of staining regents on DPI heat cure denture resin



In IVOCLAR, there was no noteworthy change in mean in between all the four materials in IVOCLAR group (P = 0.658). Analysis of variance (ANOVA) test was used to demonstrate the color change values, as dipping time increased, color changes became further intensive� All materials showed obvious color changes� These results are in agreement with the studies previously mentioned�[1,2,15,16] Color changes may be credited to excessive residual monomer, heat-polymerized acrylic material in tobacco the active reagents of nicotine started staining the resins in the 1st week 3�4 and raised as high as absorbance 4�1 seen in PYRAX, similarly, Group C reagent turmeric also started staining from the 1st week absorbance 3�4–4�2 in DPI� It was interpreted that DPI and PYRAX were highly color labile and got stained easily their absorbance started from observation

made in the 1st week and their staining continued till 28 days giving most unstable and esthetic denture bases, as shown in the following Table 4�

DISCUSSION

Acrylic resins are typically used as denture base material in dental practice. These are accessible in different forms according to the polymerization reaction as heat cure acrylic resin, rapid cure auto-polymerizing acrylic resin, light cure resin, and specialized form resins used for microwave processing� These materials have adequate strength to endure the masticatory forces, maintain the dimensional stability, adequate resiliency, biocompatibility, and high polish aptitude� Acrylic resins are imperiled to sorption and also the process of absorption and adsorption of the material and also the media which is in communication� Discoloring of the denture base polymers may be triggered by the oxidation of the amine accelerator or by the penetration of colored solutions� Discoloration of a dental material can be evaluated subjectively and using instruments such as spectrophotometer and colourimeter�[17]

Spectrophotometers measure OD, which is generally used to measure the concentration of bacteria in a suspension� As visible light permits through a cell interruption, the light is scattered� Greater scatter specifies that additional bacteria or other material is present� OD is not a physical density� It is ability of an optical component or material to retard the transmission of light or any EM wave� There are four diverse groups of acrylic resins which have been taken in the study to assess the absorption and staining physiognomies� Among the four groups, three groups were of heat cure acrylic denture which were the commonly used denture base resins processed by the conventional denture processing technique these materials were DPI, PYRAX, and TREVALON and fourth material was processed by injection molding technique (IVOCAP, high impact). Furthermore, the efficiency of the study was conducted on standardized disc samples in standardized environment� These study samples were incubated at 37ºC in an incubator throughout the study� This was done to simulate the discoloration in vivo which be contingent on the polar properties of the resin molecules and mechanism of diffusion that abide by the laws of diffusion. The diffusion coefficient for heat cure acrylic resins is 1.08 × 10-12 m/s2 at 37ºC (oral temperature).

All the four resins used in this study have the similar base chemical structures; though, each of them contained small quantities of dissimilar cross-linking agents and plasticizers, pigments, which may clarify the alterations in staining properties (hydrophilicity) of resins. To evaluate the stains of the samples, they were leached with hydrogen peroxide 30% w/v� This was done to obtain the concentrate of each soiled sample in separate beakers; they were then loaded on the spectrophotometer curette for the determination of absorbance of each sample� According to Nikawa et al�, a very high concentration of hydrogen peroxide is not used as it might cause hydrolysis and decomposition of denture resin itself�

Graph 3: Effect of staining regents on TREVALON heat cure denture resin

Graph 2: Effect of staining regents on PYRAX heat cure denture resin

Graph 4: Effect of staining regents on IVOCLAR heat cure denture resin



in any of the groups when observed from the 7th day to 28th day� The color sorption increased until the 16th day and was stagnant there, this might be because of the sorption property of the resins, however, and the color variations overtime were not statistically noteworthy in any staining solution� There also seemed to be some molecular interactions amid colorants and denture polymers that resulted in slight discoloration in acrylic resins�[18] The contributing factors that subsidize to the changes in color of esthetic restorative materials include stain accumulation, anhydration, water sorption, leakage, poor bonding and surface roughness, wear or chemical degradation, oxidation of the reacted carbon-carbon double bonds that produce colored peroxide compounds, and enduring development of the colored degradation products�[19,20]

Of all the resins, Ivoclar showed the most color stability among the four followed by Trevalon, DPI, and PYRAX� As this was an in vitro study of short duration, continuous immersion accelerated the study as compared to clinical conditions� In this study, turmeric and tobacco were seen to cause maximum staining of the samples, followed by tea� The acidic constituent of tobacco causes surface erosion of the acrylic which imparts it a rough surface morphology�[20] This rough morphology sustains more discoloration from the staining solutions� The pH of solutions was more toward the alkaline side causing less surface adsorption of the stain on denture resins hence reduced discoloration� Similar results were confirmed in a study by Crispin and Caputo who emphasized that the acidic nature of tea, coffee, and grapes erodes the polished surface layer of resin facilitating more stain uptake�[21] Although it was not statistically noteworthy, it was observed that the beverage tea and chemicals of tobacco caused most intense color alterations in the resins of PYRAX. IVOCLAR was found most color stable in turmeric, followed by Travelon-HI, DPI, and PYRAX�

One-way ANOVA analysis of alteration was useful to check the equality of means of color change amid the groups (PYRAX, DPI, Travelon-HI, and IVOCLAR) related to tea, Coca-Cola, turmeric, and tobacco solution. The difference among the groups related to three solutions after 7, 14, 21, and 28 days was established to be statistically significant because at a confidence level of 95%, P value obtained was <0�05� To further delineate the important difference among the means of color change between the four brands of acrylic resins in tea, Coca-Cola, tobacco, and turmeric solution, the Bonferroni (post hoc) test was performed [Table 3]� It was interpreted that DPI and PYRAX were highly color labile and got stained easily their absorbance started from observation made in the 1st week and their staining continued till 28 days giving most unstable and esthetic denture bases. In IVOCLAR material,

Table 4: The maximum stains in the most active reagents and the acrylic brand in DPI and PYRAXDPI Mean Minimum MaximumTOBACCO 3.9 3.7 4.1

Turmeric 3.8 3.4 4.2

PYRAX Mean Minimum MaximumTOBACCO 3.9 3.8 4.0

Turmeric 3.9 3.6 4.1

Table 2: Master chart: Values of all subjected groups from the 1st to 4th week of the acrylic samplesSample Coca-Cola Tobacco Turmeric Tea

1st week

2nd week

3rd week

4th week

1st week

2nd week

3rd week

4th week

1st week

2nd week

3rd week

4th week

1st week

2nd week

3rd week

4th week

DPI 3.3 3.3 3.3 3.3 3.7 3.8 4.0 4.1 3.4 3.8 3.9 4.2 3.4 3.5 3.7 3.7

PYRAX 3.2 3.3 3.3 3.3 3.8 3.8 3.9 4.0 3.6 3.7 4.0 4.1 3.6 3.7 3.8 4.0

TREVALON 3.0 3.4 3.4 3.1 3.6 3.7 3.7 3.8 3.5 3.5 3.8 4.0 3.3 3.5 3.5 3.7

IVOCLAR 2.8 3.2 3.2 3.1 2.9 3.5 3.6 3.7 3.1 3.5 3.5 3.5 2.9 3.5 3.6 3.6

Table 3: Depicting acrylic resins with their Mean and SD values in different groups namely Coca-Cola, tobacco, turmeric, and tea solutionBrand name Group name Mean±SD P-Value DPI A (Coca-Cola) 3.3±0.1 0.007

PYRAX A (Coca-Cola) 3.3±0.1 0.001

TREVALON A (Coca-Cola) 3.3±0.2 0.011

IVOCLAR A (Coca-Cola) 3.2±0.2 0.658

DPI B (tobacco) 3.9±0.2 0.007

PYRAX B (tobacco) 3.9±0.1 0.001

TREVALON B (tobacco) 3.7±0.1 0.011

IVOCLAR B (tobacco) 3.4±0.4 0.658

DPI C (turmeric) 3.8±0.3 0.007

PYRAX C (turmeric) 3.9±0.2 0.001

TREVALON C (turmeric) 3.7±0.2 0.011

IVOCLAR C (turmeric) 3.4±0.2 0.658

DPI D (tea) 3.6±0.2 0.007

PYRAX D (tea) 3.8±0.2 0.001

TREVALON D (tea) 3.5±0.2 0.011

IVOCLAR D (tea) 3.4±0.3 0.658

Moreover, a very less concentration of hydrogen peroxide would not have leached the sample adequately� Important color shifts occurred in each test group in each staining solution overtime� Furthermore, the color shift in different test groups was suggestively dissimilar when the magnitudes of color differences within the test groups were related in the 7th day and 28th day (P < 0.05). The most changes were observed in the staining solutions of tobacco and turmeric, significant changes were also seen in tea stained samples and the color changes were perceivable by the human eye, however, no significant changes were seen in Coca-Cola samples



least amount of changes were seen in all the reagents, there were no significant changes in all the groups, hence, it can be said that it is the most color stable denture base material, hence suggesting to be an effective denture base material, it is processed by injection molding technique, which results in less residual monomer content, in contrast to conventional processing techniques where 7% is ideal residual monomer content which is also a key reason for its porosity, surface roughness, and possibility of trapping surface reagents and these all possibilities are eliminated in the technique and material�

Color change in denture acrylic base resin is significantly (P < 0.05) and affected by denture base processing techniques, different commercial brands of acrylic used and staining materials. One-way ANOVA showed that significant difference was observed among all the groups (P < 0.001). It was further confirmed by post hoc Turkey test (Dennett test) which stated that significant difference was found.

LIMITATIONS

In the present study, the changes in color were examined in a saliva and diet free medium� This in vitro study only simulated a clinical condition in which many other factors can affect color; thus, it has its limitations�

CONCLUSION

It can be concluded least amount of the residual monomer content in the denture after processing least amount of staining in that material. As in the present study, IVOCLAR material denture was processed through injection molding technique leaving no monomer in between the polymer after curing� At the same time, patient should be explained the process of cleaning the denture regularly after every meal and usage of denture cleanser tablets after every 7 days� This will prevent the denture from having an unesthetic appearance�

The staining by the reagents was concluded by spectrophotometer in consistently decreasing order like Tobacco>Turmeric>Tea>Coca-Cola (P < 0.005) and the maximum amount of staining was also seen in DPI and PYRAX denture base resins� While, among the resins, the changes in their color were seen in the following order as DPI>PYRAX>TREVALON>IVOCLAR (P < 0.005).

Scope for further studies

No study can be flawless. In the present study, there is no comparison of different materials in injection molding technique and how to reduce their cost of production; this can be studied in further studies.

REFERENCES

1. Goiato MC, Santos DM, Haddad MF, Pesqueira AA. Effect of accelerated aging on the micro hardness and color stability of

flexible resins for dentures. Braz Oral Res 2010;3:3-29.2. Sepúlveda-Navarro WF, Arana-Correa BE, Borges CP, Jorge

JH, Urban VM, Campanha NH. Color stability of resins and nylon as denture base material in beverages. J Prosthodont 2011;20:632-8.

3. Anusavice KJ, Phillips RW. Phillips’ Science of Dental Materials. 2th ed. St. Louis, Missouri: Saunders; 2003. p. 73-758.

4. Carr AB, McGivney GP, Brown DT, McCracken WL. McCracken’s Removable Partial Prosthodontics. 2nd ed. St. Louis, Missouri: Elsevier; 2005. p. 37-242.

5. Hong G, Murata H, Li Y, Sadamori S, Hamada T. Influence of denture cleansers on the color stability of three types of denture base acrylic resin. J Prosthet Dent 2009;101:20522.

6. Goiato MC, Dos Santos DM, Baptista GT, Moreno A, Andreotti AM, Bannwart LC, et al. Effect of thermal cycling and disinfection on color stability of denture base acrylic resin. Gerodontology 2022;30:27682.

7. Yannikakis S, Zissis A, Polyzois G, Andreopoulos A. Evaluation of porosity in microwave-processed acrylic resin using a photographic method. J Prosthet Dent 2002;87:622-9.

8. Compagnoni MA, Barbosa DB, de Souza RF, Pero AC. The effect of polymerization cycles on porosity of microwave processed denture base resin. J Prosthet Dent 2004;91:281-5.

9. Keyf F, Etikan I. Evaluation of gloss changes of two denture acrylic resin materials in four different beverages. Dent Mater 2004;20:245-51.

10. Strohaver RA. Comparison of changes in vertical dimension between compression and injection moulded complete dentures. J Prosthet Dent 1989;62:716-8.

11. Imirzalioglu P, Karacaer O, Yilmaz B, Ozmen I. Color stability of denture acrylic resins and a soft lining material against tea, coffee, and nicotine. J Prosthodont 2010;19:11824.

12. O’Brien WJ. Dental Materials and Their Selection. 3rd ed. Chicago: Quintessence; 2002. p. 35-6, 30-224, 225-48.

13. Kado D, Sakurai K, Sugiyama T, Ueda T. Evaluation of clean ability of a titanium dioxide (TiO2)coated acrylic resin denture base. Prosthodont Res Pract 2005;4:6976.

14. Arai T, Ueda T, Sugiyama T, Sakurai K. Inhibiting microbial adhesion to denture base acrylic resin by titanium dioxide coating. J Oral Rehabil 2009;36:9028.

15. Smith LS, Saver JA. Sorbed water and mechanical behaviour of poly (methyl methacrylate). Plats Rubber Process Apple 1986;6:57-65.

16. Purnaveja S, Fletcher AM, Ritchie GM, Amin WM, Moradians S, Dodd AW. Color stability of two self-curing denture base materials. Biomaterials 1982;3:249-50.

17. Guler AU, Yilmaz F, Kulunk T, Guler E, Kurt S. Effects of different drinks on stainability of resin composite provisional restorative materials. J Prosthet Dent 2005;94:11824.

18. Phillips RW. Skinner’s Science of Dental Materials. 9th ed. Philadelphia, PA: WB Saunders; 1991. p. 197.

19. Ferracane JL, Moser JB, Greener EH. Ultraviolet light induced yellowing of dental restorative resins. J Prosthet Dent 1985;54:483-7.

20. Brewer JD, Wee A, Seghi R. Advances in color matching. Dent Clin North Am 2004;48:34158.

21. Keskin S. The Treatment of Prosthetic Dental Materials with Hypochlorite, MSc Thesis. Ankara, Turkey: Middle East Technical University; 2002.


Efficacy of Silver Diamine Fluoride in Management of Caries: A Narrative Review

Kanika Sharma, Sathyajith Naik, Pallavi Vashisht, Shivangi Shrma, Deepshikha, Shashank Kumar Singh

Department of Pediatric and Preventive Dentistry, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

The most common dental problem which is seen affecting all the age groups is dental caries� In India, the prevalence rate of dental caries ranges from 50�8% to 62�4% in children�[1]

American Academy of Pediatric Dentistry (AAPD) encourages health-care providers and caregivers to implement preventive practices that can be helpful in decreasing a child’s risk of developing this disease�[2]

A decrease in overall caries indicators has been reported, still prevention and control of dental caries in children is one of the difficult problems encountered by pedodontists. Although many advances in treatment and prevention of caries have come up, the various, biological, and environmental factors causing early childhood caries (ECC) make its prevention and control a very challenging task�[1]

Nowadays, silver diamine fluoride (SDF) is getting into limelight for caries prevention� It is a liquid mainly clear that has a combined effect of silver and fluoride, i.e, antibacterial and re-mineralizing effect� It can be used therapeutically for treating caries lesions in young children and also those with special care needs�[3] SDF application is 89% more effective compared to placebo and other treatments� It is simple, quick, painless, inexpensive, and non-invasive that can be readily learned by dental health professionals�[4] This review article aims to summarize the therapeutic effect on SDF in primary and permanent teeth, its adverse effect and technique of application�

HISTORY

The approval of the first SDF product, Saforide (Bee Brand Medico Dental Co, Ltd, Osaka, Japan) in 1970 was done by Drs Nishino and Yamaga in Japan� They combined F— and Ag+ and led to the development of ammoniacal silver fluoride, which could be used to arrest caries. Three hundred and eighty milligrams (38 w/v%) of Ag(NH3)2F are present in 1 ml of SDF. They described SDF as a product that could be used to desensitize open dentinal tubules and relief dentinal hypersensitivity, for prevention and arrest of dental caries in children and those with special health-care needs and also to prevent development of any secondary caries after restorations� It was reported that its penetration in sound enamel was 20 μm� In dentin, fluoride ion penetration was between 50 μm and 100 μm, Ag+ penetration was comparatively deeper than fluoride, which was found to be close to the pulp chamber�[5]

With its use in many clinical trials over the years, SDF is also believed to be effective in prevention of pit and fissure caries in the erupting permanent molar and root caries in elderly people�[1]

In 2014, SDF was approved by the US Food and Drug Administration as a treatment for dentinal sensitivity� SDF had been used off-label for caries arrest; however, it was recently approved (code D1354) as an interim caries arresting medicament.[6]

ABSTRACT

Dental caries is a microbial disease of the calcified tissues of the tooth, characterized by demineralization and leading to cavitation and is generally irreversible. Early involvement of pulp is associated with pain and loss of teeth as well as has negative impact on the quality of life. Hence, it is recommended to focus on preventive measures to limit the discomfort caused by caries. Silver diamine fluoride is one such medicament used to prevent and arrest dental caries and also helps in overcoming dentinal hypersensitivity. It is colorless or blue-tinted (which has advantage of arrest), odorless liquid composed of fluoride, ammonium, and silver. It is easy to use, efficient, accessible, cost effective, time saving, and patient centered.

Key words: Prevention, SDF, Dental Caries

Review Article

Corresponding Author: Dr. Kanika Sharma, Department of pediatric and preventive dentistry, Institute of Dental Sciences, Bareilly-243006, Uttar Pradesh, India E-mail: [email protected]

Sharma, et al.: Silver diamine fluoride and dental caries


MECHANISM OF ACTION

According to Yamaga and his coworkers, mechanism of action is due to presence of fluoride and silver ions.[5] They proposed that out of the 2 components, F ions acted on the tooth structure, while Ag ions were responsible for the antibacterial effect. Reaction of SDF with hydroxyapatite [Ca10(PO4)6(OH)2] in an alkaline environment forms calcium fluoride (CaF2) and silver phosphate (Ag3PO4). CaF2 leads to formation of fluoroapatite [Ca10(PO4)6F2], whose solubility is less than hydroxyl apatite in an acidic environment�[7]

The Ag3PO4 gets precipitated and forms an insoluble layer over the tooth surface� The transformation of hydroxyapatite to fluoroapatite is facilitated by this phosphate ion reservoir.[8] The overall reaction can be summarized by the following equation:

Ca10(PO4)6(OH)2 + Ag(NH3)2F → CaF2 + Ag3PO4 + NH4OH

Mei and her coworkers found that SDF creates an alkaline environment to render CaF2 less soluble and, therefore, serves as a fluoride reservoir for acid challenges by cariogenic bacteria. In vitro studies propose that SDF can prevent degradation of collagen and decrease demineralization of hydroxyl apatite�[9] In addition, SDF is believed to reduce collagen breakdown[10] and increase hardness of dentine�[7]

SDF has antibacterial properties which can be attributed to the fact that the silver ions bind to the negatively charged peptidoglycans in bacterial cell walls and lead to disruption of the membrane transport function, which further causes cellular distortions and loss of viability�[11] Binding to sulfhydryl groups (thiol group of cystine), which is essential for enzyme activities,[12] can inhibit bacterial enzyme activities, disrupt metabolic processes, and eventually cause death of the microbe� This was demonstrated by the inhibition of plaque formation on enamel and dextran-induced agglutination of Streptococcus mutans�[7] Ag ions can oxidize thiol groups and, therefore, reduce acidogenicity of dental plaque�[13] Moreover; silver ions inhibit bacterial DNA replications by attaching to guanine� In vitro studies show that silver ions can limit and reduce adherence of carcinogenic bacteria to enamel surfaces,[14] formation of Streptococcus mutans biofilm, and growth of Streptococcus mutans[15] and Lactobacilli acidophilus.

INDICATIONS FOR USE

1. High caries risk (xerostomia or severe ECC)2� Pre-cooperative and uncooperative children3. Difficult to treat dental carious lesions4� Patients with multiple carious lesions that may not all be treated

in one visit5� Patients with special needs6� Patients with dentinal hypersensitivity and active root caries�

CONTRA-INDICATIONS

1� Teeth with signs pulpal pathology2� Silver toxicity�

TECHNIQUE OF APPLICATION

SDF can be used as a part of restorative treatment or caries control therapy� According to AAPD, steps for clinical application include:• Removal of the debris from the caries affected area to facilitate

better contact of SDF with the tooth.• Caries dentin excavation maybe done, but is not mandatory�

The proportion of area which will become black after application of SDF will reduce if caries is excavated

• Application of protective coating (cocoa butter, Vaseline, etc.) on the soft tissue, lips and skin followed by isolation of the caries tooth with cotton rolls or other methods. (caution must be taken while applying protective coating on the adjoining gingiva� If it coats the caries lesion, contact of SDF with the tooth structure will be limited).

• Drying of lesion with compressed air.• Application of SDF using bent micro sponge brush. (one drop

is enough for one sitting� Furthermore, after dipping the brush into SDF, access should be removed by dabbing the brush on a dappen dish)

• Excess SDF from the lesion should be removed using sponge or cotton pellet to minimize systemic absorption

• Application time should be at least 1 min followed by gentle flow of compressed air to dry the medicament.

• After SDF treatment, the entire dentition should be treated with 5% sodium fluoride varnish to help prevent caries on sites not treated with SDF�

SAFETY

There are no studies that have reported about acute toxicity of SDF or its adverse effects. Some concerns have been raised over dental fluorosis, and accidental toxic overdose from the use of 40% SDF for arresting dental caries, although these concerns have been refuted�[4] Mild gingival and mucous irritation after SDF application might occur, but, generally, it heals spontaneously within 2 days�[16] Blackish discoloration of the carious lesions is the other side effect of SDF� Application of potassium iodide maybe helpful in decreasing the staining when applied immediately following SDF treatment; however, application of SDF is contraindicated in pregnant women and during the first 6 months of breastfeeding due to concern of overloading the developing thyroid with iodide�[16]

Even a small amount of SDF can cause a “temporary tattoo” to skin (on the patient or provider), similar to a silver nitrate stain or henna tattoo, but does not cause any harm� The natural exfoliation of skin leads to stain resolution, in 2–14 days� SDF stains clinic surfaces and clothes� The stain is permanent once it sets, so it is advised to immediately clean the surface if it spills accidentally�[16]

THE EVIDENCE BASE FOR SDF

The literature available indicates that SDF arrests caries in primary teeth as well as permanent teeth and may prevent formation of new caries� It has also shown to provide relief to dentinal sensitivity by blocking the open dentinal tubules�



Based on the Gao 2016 meta-analysis, the proportion of caries arrest on primary teeth treated with different application protocols (1 application, annual, and biannual), and followed from 6 to 30 months, was 81% (95% confidence interval, 68%–89% P < 0.001).[17] Fung et al�, in 2016, concluded that arresting rate of caries in primary dentition using SDF was greater at a 18-month follow-up when compared to 5% sodium fluoride varnish�[18]

A meta-analysis conducted on 8 studies, which used 38% SDF to arrest dentine caries in primary teeth in children (Chu et al�, 2002; Fukumoto et al., 1997; Llodra et al., 2005; Wang., 1984; Yang et al., 2002; Ye., 1995; Yee et al., 2009; and Zhi et al., 2012). The results showed that the caries-arresting rate of SDF treatment was 86% at 6 months, 81% at 12 months, 78% at 18 months, 65% at 24 months, and 71% at or beyond 30 months� The overall proportion of arrested dental caries after SDF treatment was found to be 81%�[17]

Braga et al. reported that a 38% SDF solution was significantly more effective for caries prevention in primary teeth (80% fewer new caries lesions; P < 0.05) and first molars (65% fewer new caries lesions; P < 0.001) compared to a control group.[19]

Zhi et al. found that the caries arrest rate was significantly higher (53%) when 38% SDF was applied semiannually than when 38% SDF (37%) or GIC (28.6) was applied annually (P < 0.001).[20] Chu et al� (2002) found that annual application of 38% SDF was more effective than quarterly application of 5% sodium fluoride varnish in arresting caries� Three monthly application of 12% SDF had been found to be more effective than once yearly application, but the difference between biannual and quarterly application was not significant (Llodra et al., 2005). SDF has been found to be most effective at higher concentration, that is, 38% % (Duangthip et al., 2018).

Trials have demonstrated the ability of SDF to block dentinal tubules and create this barrier (Craig et al�, 2012 and Castillo et al�, 2011). SDF had greater efficacy than either placebo or an oxalic acid-based preparation in reducing short-term sensitivity�[21]

Noriko et al., in 2010, studied the effect of 3.8% SDF and sodium hypochlorite on in vitro Enterococcus faecalis biofilm. They reported 100% efficiency of 3.8% SDF against E. faecalis�[22] Mathew et al� concluded the use of SDF as an endodontic irrigant to be feasible as it can effectively remove the microbes present in the canal and circumpulpal dentin�[23]

CONCLUSION

There is a strong evidence base for SDF as a safe and effective intervention for arresting caries as well as for reliving dentinal hypersensitivity� It has the potential to be useful in the community as primary and secondary care to arrest and prevent caries, thus reducing the overall burden of the disease�

REFERENCES

1. Jabin Z, Vishnupriya V, Agarwal N, Nasim I, Jain M, Sharma A.Effect of 38% silver diamine fluoride on control of dental caries in primary dentition: A systematic review. J Fam Med Prim Care

2020;9:1302-7.2. American Academy of Pediatric Dentistry. Policy on early

childhood caries (ECC): Classifications, consequences, andpreventive strategies. In: The Reference Manual of PediatricDentistry: Definitions, Oral Health Policies, Recommendations,Endorsements, Resources. Chicago, IL: American Academy ofPediatric Dentistry; 2020. p. 79-81.

3. Crystal YO, Niederman R. Evidence-based dentistry update onsilver diamine fluoride. Dent Clin North Am 2019;63:45-68.

4. Shounia TY, Atwan S, Alabduljabbar R. Using silver diaminefluoride to arrest dental caries: A new approach in the US. J Dent Oral Biol 2017;2:1105.

5. Yamaga R. Diammine silver fluoride and its clinical application. J Osaka Univ Dent Sch 1972;12:1-20.

6. American Dental Association. CDT 2020: Dental ProcedureCodes. Chicago, IL: American Dental Association; 2019.

7. Fung HT, Wong MC, Lo EC, Chu CH. Arresting early childhoodcaries with silver diamine fluoride-a literature review. J Oral Hyg Health 2013;1:117.

8. Suzuki T. Effects of diammine silver fluoride on tooth enamel. J Osaka Univ Dent Sch 1974;14:61-72.

9. Mei ML, Chu CH, Lo EC, Samaranayake LP. Fluoride and silverconcentrations of silver diammine fluoride solutions for dental use. Int J Paediatr Dent 2013;23:279-85.

10. Mei ML, Li QL, Chu CH, Yiu CK, Lo EC. The inhibitory effectsof silver diamine fluoride at different concentrations on matrix metalloproteinases. Dent Mater 2012;28:903-8.

11. Coward JE, Carr HS, Rosenkranz HS. Silver sulfadiazine: Effect on the ultrastructure of Pseudomonas aeruginosa. Antimicrob Agents Chemother 1973;3:621-4.

12. Bragg PD, Rainnie DJ. The effect of silver ions on the respiratorychain of Escherichia coli. Can J Microbiol 1974;20:883-9.

13. Oppermann RV, Rølla G, Johansen JR, Assev S. Thiol groups andreduced acidogenicity of dental plaque in the presence of metalions in vivo. Scand J Dent Res. 1980;88:389-96.

14. Espinosa-Cristóbal LF, Martínez-Castañón GA, Téllez-DéctorEJ, Niño-Martínez N, Zavala-Alonso NV, Loyola-Rodríguez JP.Adherence inhibition of Streptococcus mutans on dental enamelsurface using silver nanoparticles. Mater Sci Eng C Mater BiolAppl 2013;33:2197-202.

15. Knight GM, McIntyre JM, Craig GG, Zilm PS, Gully NJ. Inabilityto form a biofilm of Streptococcus mutans on silver fluoride-and potassium iodide-treated demineralized dentin. Quintessence Int2009;40:155-61.

16. Horst JA, Ellenikiotis H, Milgrom PM. UCSF protocol for cariesarrest using silver diamine fluoride: Rationale, indications and consent. J Calif Dent Assoc 2016;44:16-28.

17. Gao SS, Zhao IS, Hiraishi N, Duangthip D. Clinical trials of silverdiamine fluoride in arresting caries among children: A systematic review. JDR Clin Trans Res 2016;1:201-10.

18. Fung MH, Duangthip D, Wong MC, Lo EC, Chu CH. Arrestingdentine caries with different concentration and periodicity ofsilver diamine fluoride. JDR Clin Trans Res 2016;1:143-52.

19. Braga MM, Mendes FM, De Benedetto MS, Imparato JC. Effectof silver diammine fluoride on incipient caries lesions in erupting permanent first molars: A pilot study. J Dent Child (Chic)2009;76:28-33.

20. Zhi QH, Lo EC, Lin HC. Randomized clinical trial on effectiveness of silver diamine fluoride and glass ionomer in arresting dentine caries in preschool children. J Dent 2012;40:962-7.



21. Timms L, Sumner O, Deery C, Rogers HJ. Everyone else is usingit, so why isn’t the UK? Silver diamine fluoride for children and young people. Community Dent Health 2020;37:143-9.

22. Hiraishi N, Yiu CK, King NM, Tagami J, Tay FR. Antimicrobialefficacy of 3.8% silver diamine fluoride and its effect on root

dentin. J Endod 2010;36:1026-9.23. Mathew VB, Madhusudhana K, Sivakumar N, Venugopal T,

Reddy RK. Anti-microbial efficiency of silver diamine fluoride as an endodontic medicament - An ex vivo study. Contemp ClinDent 2012;3:262-4.


Mobile Phones: A Potential Source of Nosocomial Infection in the Hands of Health care Workers – A Narrative Review

Divya Srivastava1, Shivalingesh K K2, Henna Mir1, Adeeba Saleem1, Swati Pathak1, Supriya Naren3

1Department of Public Health Dentistry, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 2Department of Public Health Dentistry, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India, 3Department of Oral Medicine and Radiology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

In this modern world, there is a continuous progression in technology� We have personal computers, mobile phones, mobile handheld devices, and laptops� Mobile phones serve as an essential means of communication, so there is a widespread use of mobile phones by healthcare as well as non-health care workers� In the clinical setting, most health-care professionals use cell phones for urgent contact during emergencies, rounds, and also in operating theaters and intensive care units (ICUs).[1,2]

A hospital-acquired infection, also known as a nosocomial infection, is an infection that is acquired in a hospital or other health care facility� The infection can originate from the outside environment, another infected patient, staff that may be infected, or in some cases, the source of the infection cannot be determined� Physicians and other health-care personnel working in ICUs and operating units have high exposure to the deadly micro-organisms� Cell phones can function as infection reservoirs, allowing contaminating bacteria to be transported to several different clinical settings and directly encouraging the dissemination of potentially pathogenic bacteria to the population�[3]

Several bacterial species have been detected on mobile phone surfaces used in clinical as well as non-clinical settings and there

is no guidance on how to mitigate contamination, regardless of having evidence that these devices can harbor pathogenic micro-organisms� The mobile phones are rarely cleaned and are frequently contaminated during or after patient assessment and specimen handling without adequate hand washing�[4] These mobile phones can contain multiple potential pathogens and become an exogenous source of nosocomial infection for hospitalized patients and also a potential health hazard for the family members and mobile phone owners� In a study, the average mobile phone is found dirtier than either a toilet seat or the bottom of your shoe�[5]

Few studies have reported the presence of epidemic viruses such as influenza virus, rotavirus, metapneumovirus, and syncytial respiratory virus on healthcare workers’ mobile phones�[6]

Bacterial contamination of mobile phones

Studies suggest that the Staphylococcus aureus, (CoNS) coagulase negative Staphylococcus, Pseudomonas species, Micrococcus species,

ABSTRACT

Cell phones are nonmedical portable electronic devices that are widely used by the health care workers. It remains in close contact with the body but not cleaned properly, as health care workers’ may not wash their hands as often as they should and there are no guidelines regarding the cleaning of mobile phones. These mobile phones can contain multiple potential pathogens and become an exogenous source of nosocomial infection for hospitalized patients and also a potential health hazard for the family members and mobile phone owners. Studies have reported the presence of Methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus spp., Clostridium difficile, Acinetobacter spp., and norovirus. Colonized micro-organisms in the devices of health-care personnel may be transmitted to patient even if patients do not have direct contact with mobile phones. Nosocomial infection may be caused in patients with weak immune system. Hence, to prevent bacterial contamination of mobile phones, hand-washing guidelines must be followed by all the health-care workers and technical standards for prevention strategies should be developed. Regular disinfection of mobile phones is an important step in preventing cross infection.

Key words: Mobile phones, Health care workers, Nosocomial infections, Pathogens, Decontamination

Review Article

Corresponding Author: Dr. Divya Srivastava, Department of Public Health Dentistry, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. Phone: +91-9557100952. E-mail: [email protected]

Srivastava, et al.: Nosocomial infection is only a phone call away: A narrative review among healthcare workers


and Escherichia coli isolated from surfaces of mobile phone carried the most common health risk�[7,8] These organisms are known pathogens and cause various infections such as food poisoning, infections of the wound, and other types of infections� In one of the reports, 53 phones of orthopedic surgeons had 83% pathogenic bacteria the same as that found at the surgical site of the infection of the patients and it was observed that the bacterial contamination reoccurred after 1 week of disinfection with wipes�[9] The bacterium found on the cell phones of health-care personnel varies depending on the type of working ward and region� Such situations catalyze the cross-contamination in hospitals�[10-13]

Certain studies have reported the presence of drug-resistant pathogenic organisms over mobile phones� In a study, around 95% of the cell phones of health-care personnel from a hospital were contaminated with 52% of antibiotic-resistant species of bacteria� The bacterial composition on the phones was a reflection of the hand microbiota of the sampled health care workers�[14]

In a study conducted by Ustun and Cihangiroglu, bacterial contamination on screened phones was found to be 98%� About 10% of the collected samples were contaminated with methicillin-resistant Staphylococcus aureus (MRSA), while 11% with E coli�[15] These bacteria are primarily responsible for the spread of nosocomial infections and pose a major health hazard to infants and other patients with immune suppression, including old, diabetic patients, patients with burn, and cancer�[16]

Several studies have shown the bacterial contamination of preclinical students’ mobile phones at medical universities� Both pathogenic and non-pathogenic bacteria, including coagulase negative Staphylococcus (68%), Staphylococcus aureus (16.2%), Viridans streptococci, Bacillus species, and Pantoea species, were found�[16] The results of this study indicated a significantly higher proportion (three-fold) of contamination on the cell phones of clinical students with S. aureus (77.8%) and MRSA (20.0%) than the preclinical students� Furthermore, numerous other types of species of bacteria were isolated, including Acinetobacter species, Streptococcus pneumonia, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Candida albicans� The authors attributed the presence of MRSA and S. aureus to the hospital environment and emphasized the importance of phone hygiene�[17]

A variety of bacterial species associated with nosocomial infections have been isolated and tested for their resistance to antimicrobials� In most of the collected samples, coagulase negative Staphylococcus, S. aureus, Pseudomonas sp�, E. coli, and S. epidermidis, along with different patterns of drug resistance species, were predominant� Some authors said that if the mobile phones are not cleaned at regular intervals, they can serve as a source of hospital cross-contamination as they are highly contaminated�[18]

The pediatric wards have high morbidity and mortality rates due to cross-infection� To determine the bacterial contamination of mobile phones of health care workers operating in pediatric ICUs, a study was conducted� Out of 491 mobile phone samples from three hospitals, 104 phones were contaminated with Enterobacteriaceae, with a high prevalence of bacterial species developing antibiotic resistance genes and producing extended-spectrum β-lactamase

such as Klebsiella pneumonia and E. coli� These antibiotic-resistant bacteria are a major threat to the patients and play a major role in hospital-acquired infections in pediatric and neonatal ICUs.[19,20]

RISK OF NOSOCOMIAL INFECTION IN DENTAL PRACTICE

Oral cavity serves as a natural habitat for large number of microorganisms� Studies have shown that many infectious substances can survive for a long time if they are not removed by surface disinfection� In addition, the presence of saliva in dentistry and contamination with dangerous microbes has repeatedly exposed patients and doctors to several pathogenic microbes� Dental procedures involve use of a high-speed handpiece or ultrasonic instruments that produces a large number of droplets and aerosols generation with saliva and blood� As a result, dentists’ incidence of infectious diseases is higher than that of regular population and other medical staff.

Due to the high temperature and moisture content of the operatory, mobile phones are ideal for microbial growth� Mobile phones as a fomite can lead to community-acquired infections with potential consequences for public health� Many studies showed that coagulase-negative Staphylococcus spp�, Bacillus spp�, Pseudomonas spp�, Micrococci spp�, Acinetobacter spp�, and Staphylococcus citreus and Diphtheroids, as well as non-methicillin-resistant S. aureus and vancomycin-resistant Enterococci spp were the most commonly found bacteria on mobile phones� Opportunistic pathogens, such as Janthinobacterium spp�, and Pseudomonas spp� were isolated from the dentists’ and dental hygienists’ phones� Furthermore, Enterococcus spp� and Stenotrophomonas spp� known to cause severe nosocomial infections, Streptococcus species associated with oral disease and Acinetobacter, a multidrug resistant opportunistic pathogens have also been identified.[21]

Haemophilus spp�, which can cause a fatal respiratory infection, and Neisseria spp�, which can cause gonorrhea and septicemia, have been reported on the mobile phones� Besides this, Fusobacterium spp�, Actinomyces spp�, Streptococcus spp�, and Porphyromonas spp�, believed to be associated with different oral diseases, have been detected�[22]

DECONTAMINATION STRATEGIES

Antibacterial wipes

Several forms of antibacterial wipes are widely available to clean mobile devices� Wipes that are moistened with either plain water or saline can effectively reduce the bacterial count through mechanical removal�[19]

Wipes moistened with 70% isopropyl alcohol are remarkably effective in decontaminating cell phone surfaces.[23,24]

Antibacterial screens

Antibacterial silver-based glass for smartphones and other touch screen devices,[25] it can inhibit bacterial growth and activity and even cause the death of microbes�



Light-activated antimicrobial agents (LAAAs) are materials that exert an antimicrobial effect through the generation of reactive radical species on exposure to light of an appropriate wavelength� LAAAs have shown adequate efficacy in reduction of the bacterial load on screens of the mobile phone with minimal efforts of the user. However, as their disinfection efficiencies are not sufficiently effective for cases and covers of phones, they can offer protection to a certain degree only�

Ultraviolet (UV) light-based disinfection

Recently, the disinfecting effect of UV radiation on mobile phones has been investigated� To improve decontamination, the intrinsic antibacterial properties of UV light have been intensively investigated�[25]

In UV irradiation, an object is treated with light of a wavelength around 254 nm which terminates the reproduction and growth of the microbes by the destruction of nucleic acids�

Several commercially available UV-based phone sanitizers have been introduced, namely IQ MOBILE™ (LED Suutari), SETi (Sensor Electronic Technology Inc.), CleanSlate™ UV Sanitizer, PhoneSoap 2�0, Easycare®, Sonitech, LEAD YOUNG®, and Codonics D6000� These sanitizers consist of a compartment that is fitted with a UV light source; the mobile phone is positioned into this compartment for a few minutes to eliminate the microbes�

CONCLUSION

Today, mobile phones are essential equipment for doctors� Since restrictions on cell phone usage in hospitals are not a realistic solution� Daily and appropriate hand washing is the single most important aspect that can minimize cell phone contamination;[3] also, mobile phones can be decontaminated with alcohol disinfectant wipes (with 70% isopropyl alcohol).[23] Hence, it can be concluded that the isopropyl alcohol-based antibacterial wipes and advanced UV-cabinets can be used more regularly at certain time intervals for effective mobile phone disinfection�

REFERENCES

1. Brady RR, Wasson A, Stirling I, McAllister C, Damani NN. Is your phone bugged? The incidence of bacteria known to cause nosocomial infection on healthcare workers’ mobile phones. J Hosp Infect 2006;62:123-5.

2. Rafferty KM, Pancoast SJ. Brief report: Bacteriological sampling of telephones and other hospital staff hand-contact objects. Infect Control 1984;5:533-5.

3. Brady RR, Fraser SF, Dunlop MG, Paterson-Brown S, Gibb AP. Bacterial contamination of mobile communication devices in the operative environment. J Hosp Infect 2007;66:397-8.

4. Jayalakshmi J, Appalaraju B, Usha S. Cellphones as reservoirs of nosocomial pathogens. J Assoc Physicians India 2008;56:388-9.

5. Gurang B, Bhati P, Rani U, Chawla K, Mukhopodhyay C, Barry I. Do mobiles carry pathogens. Microcon 2008;23:45-76.

6. Pillet S, Berthelot P, Gagneux-Brunon A, Mory O, Gay C, Viallon A, et al. Contamination of healthcare workers’ mobile phones by epidemic viruses. Clin Microbiol Infect 2016;22:e1-6.

7. Al Momani W, Khatatbeh M, Altaany Z. Antibiotic susceptibility of bacterial pathogens recovered from the hand and mobile phones of university students. Germs 2019;9:9-16.

8. Al-Abdalall AH. Isolation and identification of microbes associated with mobile phones in Dammam in eastern Saudi Arabia. J Fam Community Med 2010;17:11-4.

9. Brady R, Hunt A, Visvanathan A, Rodrigues M, Graham C, Rae C, et al. Mobile phone technology and hospitalized patients: A cross-sectional surveillance study of bacterial colonization, and patient opinions and behaviours. Clin Microbiol Infect 2011;17:830-5.

10. Shakir IA, Patel NH, Chamberland RR, Kaar SG. Investigation of cell phones as a potential source of bacterial contamination in the operating room. J Bone Joint Surg 2015;97:225-31.

11. Anup N, Kahlon SS, Manchanda A, Narang RS, Singh B, Walia SS. Cellular telephone as reservoir of bacterial contamination: Myth or fact. J Clin Diagn Res 2014;8:50-3.

12. Corrin T, Lin J, MacNaughton C, Mahato S, Rajendiran A. The role of mobile communication devices in the spread of infections within a clinical setting. Environ Health Rev 2016;59:63-70.

13. Ulger F, Dilek A, Esen S, Sunbul M, Leblebicioglu H. Are healthcare workers’ mobile phones a potential source of nosocomial infections? Review of the literature. J Infect Dev Ctries 2015;9:1046-53.

14. Ustun C, Cihangiroglu M. Health care workers’ mobile phones: A potential cause of microbial cross-contamination between hospitals and community. J Occup Environ Hyg 2012;9:538-42.

15. Badr RI, Badr HI, Ali NM. Mobile phones and nosocomial infections. Int J Infect Control 2012;8:1-5.

16. Zakai S, Mashat A, Abumohssin A, Samarkandi A, Almaghrabi B, Barradah H, et al. Bacterial contamination of cell phones of medical students at King Abdulaziz university, Jeddah, Saudi Arabia. J Microsc Ultrastruct 2016;4:143-6.

17. Goh Z, Chung P. Incidence of meticillin-resistant Staphylococcus aureus contamination on mobile phones of medical students. J Hosp Infect 2019;101:482-3.

18. Morgan DJ, Lomotan LL, Agnes K, McGrail L, Roghmann MC. Characteristics of healthcare-associated infections contributing to unexpected in-hospital deaths. Infect Control Hosp Epidemiol 2010;31:864-6.

19. Nordberg V, Jonsson K, Giske C, Iversen A, Aspevall O, Jonsson B, et al. Neonatal intestinal colonization with extended-spectrum β-lactamase-producing Enterobacteriaceae-a 5-year follow-up study. Clin Microbiol Infect 2018;24:1004-9.

20. Agapito J, Gutierrez LR, Petersen K, Tamariz J, Rios P, Horna G, et al. Extended-spectrum β-lactamase-producing Enterobacteriaceae in cell phones of health care workers from Peruvian pediatric and neonatal intensive care units. Am J Infect Control 2016;44:910-6.

21. Singh S, Acharya S, Bhat M, Rao SK, Pentapati KC. Mobile phone hygiene: Potential risks posed by use in the clinics of an Indian dental school. J Dent Educ 2010;74:1153-8.

22. Lee SY, Lee SY. Assessment of bacterial contamination of mobile phones of dentists and dental hygienists by Illumina MiSeq. Oral Biol Res 2019;43:60-5.

23. Kiedrowski LM, Perisetti A, Loock MH, Khaitsa ML, Guerrero DM. Disinfection of iPad to reduce contamination with Clostridium difficile and methicillin-resistant Staphylococcus aureus. Am J Infect Control 2013;41:1136-7.



24. Brady RR, Chitnis S, Stewart RW, Graham C, Yalamarthi S, Morris K. NHS connecting for health: Healthcare professionals, mobile technology, and infection control. Telemed J E Health 2012;18:289-91.

25. Sumritivanicha A, Chintanavilas K, Apisarnthanarak A. Prevalence and type of microorganisms isolated from house staff ’s mobile phones before and after alcohol cleaning. Infect Control Hosp Epidemiol 2011;32:633-4.


Third Generation Platelet Concentrate in Esthetic Management: A Case Report

Rishabh Srivastava, R.G Shiva Manjunath, Geetika Kumar, Prerna Agarwal, Satyaki Verma

Department of Periodontology and Implantotology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

Gingival recession is an apical migration of the gingival marginal tissue relative to the cementoenamel junction characterized by the root surface exposure� There are several factors that are responsible for the marginal tissue recession including faulty tooth brushing, occlusal trauma, gingival inflammation, tooth alignment, overhanging restorations, and high frenal attachment�[1] The treatment of the facial gingival recession is the most common requirement for esthetic concern and root hypersensitivity�

There are several treatment modalities for the root coverage such as pedicle flaps, free soft-tissue grafts, or the combinations of the above with/without barrier membranes�[2] The coronally advanced flap (CAF) is one of the most predictable approaches for the root coverage when there is sufficient amount of keratinized tissue present just apical to the gingival recession defect� This procedure is based on the coronal movement of the gingival tissues on the exposed root surface�[3] Despite having several advantages, CAF alone has shown unstable results caused due to the formation of the long junctional epithelium which will cause recession in the future�

To improve the results, various regenerative materials are used with the CAF which will enhance the root coverage� Titanium platelet-rich fibrin (T-PRF) is one such modality which is used to eliminate the potential carcinogenic effect of silica from the dry glass tube which was used to make leukocyte platelet-rich fibrin.[4] T-PRF is a 3rd generation autologous platelet concentrate in which there is a polymerized matrix which consists of platelet, cytokines, leukocytes, and various growth factors that are entrapped and act

as a resorbable membrane� The growth factors with in the T-PRF upregulate the cellular activity and effective in the enhancement of early wound healing and are promoters of periodontal tissue regeneration� Because of various inherent factors present in autologous platelet concentrate which helps in the bone regeneration and also accelerate wound healing, so the gingival recession shown in this case report, was treated using autologous T-PRF membrane combined with CAF�

CASE REPORT

A 40-year-old male patient came to the department of periodontology and implantology with the chief complaint of hypersensitivity in upper front tooth region� Oral examination revealed Miller’s Class II gingival recession in the left upper central and lateral incisor [Figure 1]. Due to the presence of sufficient attached gingiva apical to recession, CAF along with T-PRF was planned�

T-PRF preparation

The T-PRF preparation was done according to Tunali’s protocol�[5] Briefly, 10 ml blood was collected by

ABSTRACT

Gingival recession is the most common problem affecting mostly the middle and older age patients to some degree. It may affect the healthy persons with good oral hygiene status as well as the persons with untreated periodontitis. Gingival recession can cause dental hypersensitivity, root caries, and unesthetic appearance. Various periodontal surgical procedures are available which includes coronally advanced flap (CAF), and this procedure having some advantages and disadvantages. To enhance the clinical outcome of such surgical procedures, different regenerative materials have been combined with it. In the present case report, we aimed for the root coverage in Miller’s Class II gingival recession by means of CAF along with titanium platelet-rich fibrin membrane.

Keywords: Gingival recession, Root coverage, Coronally advanced flap, Titanium platelet-rich fibrin membrane

Case Report

Corresponding Author: Geetika Kumar, Department of Periodontology and Implantotology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. E-mail: [email protected]

Srivastava, et al.: Titanium platelet rich fibrin with coronally advance flap in treatment of gingival recession


venipuncture in titanium tubes which were centrifuged at 2800 rpm for 12 min. With the help of sterile tweezer, fibrin clot was split from the RBC base [Figure 2] and then kept in a sterile dappen dish� Prior to use, PRF was slightly squeezed between the two gauze pieces to remove its serum content�

Surgical phase

The surgical area was anesthetized by giving 2% lignocaine� CAF was done according to de Sanctis and Zucchelli’s CAF technique�[6] In this technique, two vertical incisions were made on mesial and distal side to the affected area and are joined by giving a sulcular incision [Figure 3] and a full-thickness flap is reflected beyond the mucogingival junction followed by the partial thickness flap at the mucogingival junction. After the reflection of the flap, the exposed root surface is debrided by the curettes� T-PRF membrane was placed over the root surface [Figure 4]� Flap was coronally positioned to cover the membrane and the recession defect and sling sutures were given using non-resorbable silk suture [Figure 5]� Periodontal dressing was applied to protect the surgical area� Post-surgical medication was prescribed along with the proper post-operative instruction Patient recalled after 6 month for reevaluation [Figure 6]�

DISCUSSION

The present case report is aimed to treat Miller’s Class II gingival recession with the autologous T-PRF membrane along with CAF� CAF gives the most predictable results due to its various advantages such as it does not require a separate surgical site to obtain a graft, high color matching with the adjacent area and does not require any extended surgical or healing time� With these advantages, CAF alone can be used to successfully treat the sites but sometimes recurrence occurs as healing in CAF occurs by the formation of long junctional epithelium� T-PRF is a new platelet concentrate, the method of preparation of which is based on the hypothesis that

Figure 3: Incision

Figure 1: Pre-operative view Figure 4: Titanium platelet-rich fibrin placed over the tooth surface

Figure 2: Prepared titanium platelet-rich fibrin

Srivastava, et al.: Titanium platelet rich fibrin with coronally advance flap in treatment of gingival recession


titanium tubes may be more effective at activating platelets than the glass tubes. This material is used to avoid any adverse effects in the short or long term, or both, of dry glass or glass-coated plastic tubes and to eliminate any speculations about silica� In initial trials, it was found that titanium-induced platelet aggregation similar to that in glass tubes, and the clot produced in titanium tubes was clinically identical to that produced in glass tubes� However, the activation of platelets with titanium compared with activation with silica particles provides the distinctive characteristics of T-PRF, including its increased biocompatibility�[7] In the human study of T-PRF, it was confirmed that the basic histological structure of T-PRF is similar to L-PRF; however, the fibrin of T-PRF seemed more tightly woven and thicker than that of the classic L-PRF. This difference may be due to a better hemocompatibility of

titanium compared to glass, which could have potentially led to the formation of a more polymerized fibrin.[8] Due to this structure, we can hypothesize that T-PRF may remain for a longer time in the tissue� T-PRF also promotes regeneration by the various growth factors which was liberated from platelets and leukocytes within the membrane� T-PRF also stimulates angiogenesis through fibroblast growth factor and vascular endothelial growth fact. It has the property of reduced necrosis and shrinkage of the flap and contains thrombin which polymerizes fibrinogen into fibrin that favors wound healing� There are various factors which will determine treatment outcome such as root prominence, tooth position, vestibular depth, high frenal pull, gingival thickness and faulty brushing technique� Thus, proper examination of the recession site is very important for successful treatment�

CONCLUSION

The use of autologous platelet concentrates, such as T-PRF membrane, helps in the regeneration of the lost tissue by the local delivery of growth factors enhancing wound healing primarily by angiogenesis. This case report reflects the success of T-PRF for coverage of recession defects� However, long-term clinical and histological findings are required to state the nature of the attachment formed and success of the treatment outcome�

REFERENCES

1. Trott JR, Love B. An analysis of localized gingival recession in 766 Winnipeg high school students. Dent Pract Dent Rec 1996;16:209-13.

2. Roccuzzo M, Bunino M, Needleman I, Sanz M. Periodontal plastic surgery for treatment of localized gingival recessions: A systematic review. J Clin Periodontol 2002;29 Suppl 3:178-94.

3. Prato GP, Pagliaro U, Baldi C, Nieri M, Saletta D, Cairo, F, et al. Coronally advanced flap procedure for root coverage. Flap with tension versus flap without tension: A randomized controlled clinical study. J Periodontol 2000;71:188-201.

4. O’Connell SM. Safety issues associated with platelet-rich fibrin method. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:587-93.

5. Tunali M, Ozdemir H, Akman S, Yaprak E, Firatli E. In vivo evaluation of titanium-prepared platelet-rich fibrin (T-PRF): A new platelet concentrate. Br J Oral Maxillofac Surg 2012;51:438-43.

6. de Sanctis M, Zucchelli G. Coronally advanced flap: A modified surgical approach for isolated recession-type defects: Three-year results. J Clin Periodontol 2007;34:262-8.

7. Park JB. Metallic biomaterials. In: Bronzino JD, editor. The Biomedical Engineering Handbook. Boca Raton, Florida, USA: CRC Press; 1995. p. 537-51.

8. Takemoto S, Yamamoto T, Tsuru K, Hayakawa S, Osaka A, Takashima S. Platelet adhesion on titanium oxide gels: Effect of surface oxidation. Biomaterials 2004;25:3485-92.

Figure 6: Six months post-operative view

Figure 5: Suture placed


Digital Computer-aided Design and Computer-aided Manufacturing Implant Titanium-Ceramic Screw Retained Prosthesis: A Wing Cantilever Design

Mukesh Kumar Singhal1, Ankita Pal2, Siddharth Vaish3, Kanupriya Agrawal3, Monal Mendiratta3, A. Nikhilsingh3

1Department of Prosthodontics, IDS Dental College and Research Centre, Bareilly, Uttar Pradesh, India, 2Department of Prosthodontics and Implantology, School of Dental Sciences, Sharda University, Greater Noida, Uttar Pradesh, India, 3Department of Prosthodontics and Implantology, IDS Dental College and Research Centre, Bareilly, Uttar Pradesh, India

INTRODUCTION

Screw retained implant restoration with the computer-aided design and computer-aided manufacturing (CAD – CAM) systems has evolved over the last one decade� The CAD/CAM milled abutments present the advantages of being specific to each patient and providing a better fit than rest of available abutments. The current case report uses EXOCAD software�

Retrievability is the main advantage of screw retained crowns that make it more favorable to many clinicians� It allows better control on oral hygiene and surrounding mucosa while crowns can also be repaired easily in crown fracture�

Aglietta et al. (2009) done a systematic review to assess the survival rates of short-span implant-supported cantilever fixed dental prostheses (ICFDPs) and the incidence of technical and biological complications after an observation period of at least 5 years. ICFDPs represent a valid treatment modality; no detrimental effects can be expected on bone levels due to the presence of a cantilever extension per se�[1-3] The current paper presents a wing cantilever prosthesis design [Figure 1]� It is CAD-CAM titanium milled� This also shows the clinical steps for preparing a titanium screw retained crown for restoration of an anterior single implant�

Impression was made using open tray technique� Fabrication to delivery, titanium metal ceramic crown is presented by step to step manner and elucidated by detailed photographs�

UCLA stands for University Of California, Los Angeles. The abutment is made from a castable material such as plastic to gold base or titanium base. Plastic UCLA abutments are suitable for fabrication of a customized abutment for both screw and cement-retained restorations, through regular wax-up and casting techniques for single and multiple tooth restorations�

CASE REPORT

A 21 years old patient reported in the outpatient department of prosthodontics with a chief complaint of missing 41 and 42 [Figure 2]� On oral examination, right mandibular central incisor and lateral incisor were missing� The edentulous span was less, that is, 8�3 mm� This space was less to place two implants and to provide

ABSTRACT

Various types of cantilevers for fixed implant-supported prostheses have been suggested in the literature. The current paper presents a case report of wing cantilever prosthesis design in anterior mandibular right short span edentulous area. It is computer-aided design and computer-aided manufacturing (CAD-CAM) implant titanium milled metal ceramic restoration. The system has used dental EXOCAD software. The present paper also shows the clinical steps for preparing a titanium screw retained crown for restoration of an anterior single implant right from starting implant surgery to finally prosthesis fixation. Milled titanium implant coping framework is précised, light weight, and biocompatible. The CAD/CAM fabrication is more accurate than the lost wax/casting technique which is based on minimal human intervention and bypassing several fabrication steps such as waxing, investing, casting, and polishing. It also exhibits better bonding strength to ceramic. A small wing cantilever implants prosthesis, a good prosthetic option in mesio-distal length discrepancy. On follow-up, there is no bone loss after 6 months.

Key words: Wing cantilever design, Implant-supported cantilever fixed dental prostheses, Digital titanium computer-aided design and computer-aided manufacturing (Exocad software), Osseodensification

Case Report

Corresponding Author: Dr. Mukesh Kumar, Singhal, 17-B Prakashpuram, Opposite Private Ward Gate of Civil Hospital, Saharanpur, Uttar Pradesh - 247 001, India. E-mail: kdrcentre66@ gmail.com

Singhal, et al.: Wing CAD-CAM: Implant Prosthesis


two separate crowns� Hence, a single implant with two crowns prosthesis was decided� The both crowns will be wing cantilevered on both sides of the implant� The treatment plan was explained to the patient and a written consent was taken� A CBCT was planned to evaluate the bone height and width�

Procedures

Initially, an incision was made with a 13 number BP blade and the flap was reflected [Figures 3 and 4]� Pilot osteotomy was done using the lance drill. Then, the osseodensification was done

with the bone expander [Figure 5]� An implant of dimension 4�2 W/13L (Adin - S Touareg S, Isrel) was placed and cover screw was tightened. Bone grafting (G-bone, G. surgiwear Ltd. Sahajanpur, India) was done, the graft was covered with GBR membrane

Figure 4: Flap reflection

Figure 2: Pre-operative Figure 5: Osseodensification by bone expander

Figure 6: Bone graft with guided tissue regeneration membrane

Figure 1: Cantilever wing of airplane

Figure 3: Surgical armamentarium



[Figure 6]� The tissues were than approximated and sutured with no� 3�0 absorbable vicryl material� After 10 days, the patient was recalled and healing was checked� It was uneventful� After 3 months, when the implant has been osseointegrated, a second stage surgery was made and gingival former was placed� After 15 days, the tissue healing was complete and a healthy gingiva was formed around the gingival former� An implant level impression was made using an open tray transfer coping with a perforated tray and rubber base impression material [Figure 7]�

A second impression was made with irreversible sodium alginate (Algitex, DPI, Bombay) at abutment level and poured with dental stone type III� This cast was used for the fabrication of provisional crown, wing cantilever design [Figure 8] with self-cure Acrylic resin (SC-10 AV, Wazirpur Industrial Area Delhi). The impression was sent to the SP dental lab, YMN for the fabrication of CAD–CAM screw retained metal ceramic crowns [Figures 9 and 10]�

The final prosthesis was checked for high points on the excursive movements [Figures 11 and 12]� After, the satisfactory occlusion was achieved that the crowns were again glazed and

screwed to the implant fixture. The screw hole was blocked by putty and composite resin was cureds above it� The patient was recalled after 3 days and 1 month for checkup�

DISCUSSION

A cantilever is defined as a rigid structural element as a beam or a plate which is anchored at one end (usually vertical) support from which it protrudes� The Cantilevers could also be constructed with trusses or slabs� When it is subjected to a structural load, the cantilever carries the load to the support where it is strained against by a moment and shear strain�[4-6] Another use of the wing cantilever is in fixed-wing aircraft design, pioneered by Hugo Junkers in 1915. A wing cantilever design that uses no external struts or bracing� All support is obtained from the wing itself� The wing spars are built in such a way that they carry all the torsion and bending loads�

Eugenio et al. (2003) did a study on a sample of 38 partially edentulous patients treated between January 1994 and March 2001 with 49 partial cantilever fixed prostheses (range from 4 mm

Figure 8: Provisionalization

Figure 7: Open tray impression analogue in situ Figure 9: Roland digital computer-aided design and computer-aided manufacturing milling

Figure 10: Computer-aided design and computer-aided manufacturing wing prosthesis



to 7 mm) supported by 100 implants.[7-10] They had concluded a marginal bone resorption (marginal bone loss) and used as a reference parameter to define therapeutic success. Seven years after loading cantilever prostheses, the overall cumulative implant survival rate was 97%, and the prostheses success rate is 98%� Mesial cantilever prostheses registered a lower success rate (97.1%) than distal cantilever prostheses (100%). The current case report is the combination of wing as mesiodistal cantilever pattern�

CONCLUSION

Many past studies show that cantilever prosthesis survived well with a very high success rate of about 95%� The most frequent technical complications included veneer fractures, followed by screw loosening and loss of retention. No detrimental effects on

bone levels were observed around implants in the proximity of cantilever extensions� The present case report of 6 month follow-up of a patient, with two wing cantilevered crown over a single implant which are fabricated with titanium milled CAD-CAM ceramic anterior crown depicts a good clinical outcome� It is also concluded that a small wing cantilever implant prosthesis, a good prosthetic option in mesiodistal length discrepancy�

REFERENCES

1. Aglietta M, Siciliano VI, Zwahlen M, Brägger U, Pjetursson BE, Lang NP, et al. A systematic review of the survival and complication rates of implant supported fixed dental prostheses with cantilever extensions after an observation period of at least 5 years. Clin Oral Implants Res 2009;20:441-51.

2. Gastaldo JF, Cury PR, Sendyk WR. Effect of the vertical and horizontal distances between adjacent implants and between a tooth and an implant on the incidence of interproximal papilla. J Periodontol 2009;75:1242-6.

3. Jung RE, Pjetursson BE, Glauser R, Zembic A, Zwahlen M. A systematic review of the 5-year survival and complication rates of implant-supported single crowns. Clin Oral Implants Res 2008;19:119-30.

4. Hool GA, Nathan JC. Elements of structural theory-definitions. In: Handbook of Building Construction. 1st ed., Vol. 1. New York: McGraw-Hill; 2008. p. 2. Available from: https://www.books.google.com/books?id=wfddaaaaiaaj; https://www.books.google.com/books?id=wfddaaaaiaaj&pg=pa2. [Last accessed on 2008 Oct 01].

5. Wilfinger RJ, Bardell PH, Chhabra DS. The resonistor: A frequency selective device utilizing the mechanical resonance of a silicon substrate. IBM J Res Dev 1968;12:113-8.

6. Kosaka PM, Tamayo J, Ruz JJ, Puertas S, Polo E, Grazu V, et al. Tackling reproducibility in microcantilever biosensors: A statistical approach for sensitive and specific end-point detection of immunoreactions. Analyst 2013;138:863-72.

7. Eugenio R, Diego L, Emilio M, Marco G, Matteo C, Giorgio V. Implant-supported fixed cantilever prostheses in partially edentulous arches. A seven-year prospective study. Clin Oral Implants Res 2003;4:303-11.

8. Branemark PI, Zarb GA, Albrektsson T. Tissue-Integrated Prostheses: Osseointegration in Clinical Dentistry. Chicago: Quintessence Publishing Co. Inc.; 1985.

9. Buser D, Bragger U, Lang NP, Nyman S. Regeneration and enlargement of jaw bone using guided tissue regeneration. Clin Oral Implants Res 1990;1:449-54.

10. Buser D, Weber HP, Bragger U, Balsiger C. Tissue integration of one-stage ITI implants: 3-year results of a longitudinal study with hollow-cylinder and hollow-screw implants. Int J Oral Maxillofac Implants 1991;6:405-12.

Figure 11: Lingual view

Figure 12: Labial view


Enhancing Esthetics by the Carting of the Melanin: A Case Report with 1-Year Follow-up

Bharti Chaudhary, Rika Singh, Geetika Kumar, S. S. Karthikeyan Sai, Shiva Shankar Gummaluri

Department of Periodontology and Implantology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

Both pink (gingiva) and white (teeth) esthetics play a deciding role in determining an attractive smile� Pigmentation of gingiva is also a crucial factor along with contour, size, and shape in determining perfect smile�[1] Gingival color depends on the epithelium thickness, vascularization, degree of keratinization and pigmentation within the gingival epithelium�[2] The prime pigments that contribute to normal color of oral mucosa are melanin, carotene, oxy-hemoglobin, and reduced hemoglobin�[3] Gingiva is also considered as the most often pigmented tissue�[4] The most prevalent cause of gingival pigmentation is melanin, which is a non-hemoglobin-derived brown pigment known for the endogenous discoloration of gingiva present in the basal and suprabasal layers of the epithelium and is produced by melanocytes�[5] Increased pigmentation of gingiva beyond normal levels is noted to be hyperpigmentation� Positive correlation between skin color and gingival pigmentation is also reported by the investigators�[6] Gingival pigmentation varies in person to person, between different races and also with in the same mouth at different areas. Visibility of dark gums and presence of excessive gingival display is sometimes not pleasing to the patient� The procedure of depigmentation is not a medical need but is a patient’s treatment of choice� Considering various procedures such as lasers, electrosurgery for depigmentation in the literature,[7-10] the present case report describes scalpel surgical technique of gingival depigmentation for the correction of patient’s esthetics�

CASE REPORT

A 22-year-old female patient had a chief complaint of having unaesthetic, diffuse, and dark-brown to black gingival discoloration in the labial aspect of the maxilla and mandible reported to the Department of Periodontology and Implantology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. After intraoral examination, the patient was classified under Dummett moderate to severe physiologic hyperpigmentation [Figure 1] and scalpel technique was planned to be performed for gingival depigmentation�[11] The entire procedure is explained to the patient and written informed consent was obtained� To rule out any contraindication for surgery, complete medical history, family history, and investigations were carried out�

Local anesthesia is achieved by infiltration (2% lidocaine with adrenaline 1:200,000) in relation to surgical area, that is, area with in the smile line from 15 to 25� Split thickness excision was carried out with bard parker blade No� 15 involving the entire pigmented area from free gingival margin to mucogingival junction and from 15 to 25 extending beyond midline [Figure 2]� Blade was placed almost parallel to the long axis of the teeth, special care taken with frenum, free gingival margin and not to expose bone�

ABSTRACT

Esthetic smile is always desired by every individual and right amount of exposure, color and contour of gingiva plays a major role in achieving it. Gingival hyperpigmentation occurs by excessive accumulation of melanin. The degree of clinical pigmentation is depends upon melanin amount i.e. total number of melanosomes present in the suprabasal layer of the epithelium. Melanin pigmentation affects patient’s esthetics, it is not a medical disorder. There are various procedure for the correction of gingival depigmentation in which split thickness removal of gingival epithelium is carried out. Conventional scalpel surgical technique provides the maximum control over the instrument and therefore adequate depth penetration can be easily achieved during the surgical procedure. The scalpel surgical technique is simple, efficient, economical,convenient to perform and the need of sophisticated instrument is also not required.The present case report therefore describes conventional scalpel surgical technique of gingival depigmentation for the correction of patient’s esthetics with 1 year follow-up.

Key words: Gingiva, Esthetics, Depigmentation, Gingival Hyperpigmentation, Melanin

Case Report

Corresponding Author: Dr. Rika Singh, Department of Periodontology and Implantology, Institute of Dental Sciences, Bareilly, Uttar Pradesh - 243 006, India. Phone: +91-9458411133. E-mail: [email protected]

Chaudhary, et al. Enhancing esthetics by the carting of the melanin


The entire epithelium was removed in one piece� Any remaining tissue tags were removed by surgical scissors� The surgical area was then irrigated with betadine and normal saline and pressure was applied to control bleeding� After achieving hemostasis, periodontal dressing was applied� Post-operative instructions was given and post-operative mediation (Cap Amoxicillin 500 mg TDS, Tab Diclofenac sodium BD for 3 days and 0.12% chlorhexidine antiseptic mouth rinse BD for 2 weeks) was prescribed� The patient was recalled after 1 week� After 1 week, post-operative results were highly appreciated as there was no demarcation of the surgical area, the color of the gingiva was same as that of vestibular tissue [Figure 3], and there was no adverse event during post-surgical healing which is reported by the patient� The patient later visited after 1 year for follow-up and the results were favorably valued [Figure 4] as there was as such no sign of repigmentation�

DISCUSSION

Surgical gingival depigmentation also named as split-thickness epithelial excision and surgical stripping�[12,13] It is simple, efficient, most economical, convenient to perform, the need for sophisticated instrument is also not required�[14,15] Healing is faster with this technique in comparison to other surgical techniques as

reported by several researchers�[14,15] Therefore, we have used this technique in this case described above�

The pigmentation process involves three phases, activation of melanocytes (factors like stress hormone, sunlight causes the production of chemical messengers like melanocyte-stimulating hormone by stimulating melanocytes), and synthesis phase in which granules are formed by melanocytes like melanosomes, this process occurs when by the enzyme tyrosinase, amino acid tyrosine converts into a molecule known as dehydroxyphenylalanine� Tyrosinase then converts DOPA into secondary chemical dopaquinone� Dopaquinone then converted into either eumelanin i.e; dark melanin or pheomelanin i.e; light melanin after a series of reactions, lastly in expression phase (melanocytes are transferred from the melanocytes to the keratinocytes which are skin cells and melanin color becomes visible).[16] The degree of clinical pigmentation depends on amount of melanin, that is, amount of melanosomes, number of keratinocytes containing melanosomes, and the distribution of melanin loaded keratinocytes throughout the epithelium�[17] Hence, when melanocytes synthesize, melanin granules are synthesized by the melanocytes which are transferred to keratinocytes; then, only pigmented areas present and this close relationship is known as the “epidermal-melanin unit�”[18] Major advantage of conventional technique over other techniques is

Figure 2: Scalpel technique performed

Figure 1: Pre-operative view

Figure 4: One year post-operative view

Figure 3: One week post-operative view

Chaudhary, et al. Enhancing esthetics by the carting of the melanin


the maximum control over the instrument, and hence, adequate depth penetration can be easily achieved� Depigmentation by the conventional method has disadvantage of bleeding and pain as it allows the denuded connective tissue to heal by secondary intention�[19] Hence, new epithelium is formed without melanin pigmentation�[20] In addition, there is a requirement of periodontal dressing in the surgical technique of depigmentation�

Repigmentation is that the occurrence of pigmentation again at the previously treated site after a period of time�[13] The reason for repigmentation is unknown but attributed to the facts may active melanocytes migrate from the adjacent pigmented tissue to the treated area�[21] In the literature, there is a vast difference in the repigmentation time interval�[22-24] Perlmutter and Tal analyzed repigmentation of gingiva in two cases, and reported that in one patient repigmentation occurred after seven years� however in second patient, areas treated with scalpel technique remain depigmented even after 8 years follow-up period�[21] Surgical stripping completely removes the gingival epithelium and connective tissue along with the pigment, therefore, was associated with less recurrence in the majority of the studies�[22] In the present case report, there is no such sign of repigmentation even after 1 year and the outcome of color and healing results after 7 days is highly appreciated�

CONCLUSION

In the present scenario, patients are more pertaining toward gingival esthetics and smile designing, particularly patient with excessive gingival display and dark gums� Gingival depigmentation, therefore, has become common procedure as it gives immediate and esthetically pleasing results� There are various schools of thought regarding repigmentation; hence, we examined the patient for 1-year follow-up to rule out any recurrence of pigmentation� Gingival depigmentation is solely considered as an esthetic treatment as it is not a complication, but it is physiologic or pathologic is need to be determined�

REFERENCES

1. Bhusari BM, Kasat S. Comparison between scalpel technique and electrosurgery for depigmentation: A case series. J Indian Soc Periodontol 2011;15:402.

2. Müller S. Melanin-associated pigmented lesions of the oral mucosa: Presentation, differential diagnosis, and treatment. Dermatol Ther 2010;23:220-9.

3. Antony VV, Khan R. Management of gingival hyperpigmentation-2 case reports. J Dent Med Sci 2013;6:20-2.

4. Dummett CO. Physiologic pigmentation of the oral and cutaneous tissues in the Negro. J Dent Res 1946;25:421-32.

5. Patil KP, Joshi V, Waghmode V, Kanakdande V. Gingival

depigmentation: A split mouth comparative study between scalpel and cryosurgery. Contemp Clin Dent 2015;6:S97.

6. Rakhewar PS, Patil HP, Thorat M. Identification of gingival pigmentation patterns and its correlation with skin color, gender and gingival phenotype in an Indian population. Indian J Multidiscip Dent 2016;6:87.

7. Khalilian F, Nateghi Z, Janbakhsh N. Gingival depigmentation using lasers: A literature review. Br J Med Med Res 2016;12:1-7.

8. Kumar S, Bhat GS, Bhat KM. Comparative evaluation of gingival depigmentation using tetrafluoroethane cryosurgery and gingival abrasion technique: Two years follow up. J Clin Diagn Res 2013;7:389.

9. Suchetha A, Shahna N, Bhat DD, Apoorva SM, Sapna N. A review on gingival depigmentation procedures and repigmentation. IAJS 2018;4:336-41.

10. Kathariya R, Pradeep AR. Split mouth de-epithelization techniques for gingival depigmentation: A case series and review of literature. J Indian Soc Periodontol 2011;15:161.

11. Dummett CO, Gupta OP. Estimating the epidemiology of oral pigmentation. J Natl Med Assoc 1964;56:419.

12. Kumar S, Bhat GS, Bhat KM. Development in techniques for gingival depigmentation-an update. Indian J Dent 2012;3:213-21.

13. El-Shenawy H, Fahd A, Ellabban M, Dahaba M, Khalifa M. Lasers for esthetic removal of gingival hyperpigmentation: A systematic review of randomized clinical trials. Int J Adv Res 2017;5:1238-48.

14. Verma S, Gohil M, Rathwa V. Gingival depigmentation. Indian J Clin Pract 2013;12:801-3.

15. Almas K, Sadig W. Surgical treatment of melanin-pigmented gingiva; an esthetic approach. Indian J Dent Res 2002;13:70.

16. Lerner AB, Fitzpatrick TB. Biochemistry of melanin formation. Physiol Rev 1950;30:91-126.

17. Hedin CA, Larsson Ä. Large melanosome complexes in the human gingival epithelium. J Periodontal Res 1987;22:108-13.

18. Sanjeevni H, Pudakalkatti P, Saumya B, Aarati N. Gingival depigmentation: 2 case reports. World J Med Pharm Biol Sci 2012;2:1-4.

19. Dey SM, Nagarathna DV, Jacob C, Roy JS. Split mouth gingival depigmentation with scalpel and diode laser. A comparative study. IOSR J Dent Med Sci 2017;16:54-7.

20. Ribeiro FV, Cavaller CP, Casarin RC, Casati MZ, Cirano FR, Dutra-Corrêa M, et al. Esthetic treatment of gingival hyperpigmentation with Nd: YAG laser or scalpel technique: A 6-month RCT of patient and professional assessment. Lasers Med Sci 2014;29:537-44.

21. Perlmutter S, Tal H. Repigmentation of the gingiva following surgical injury. J Periodontol 1986;57:48-50.

22. Dummett CO, Bolden TE. Postsurgical clinical repigmentation of the gingivae. Oral Surg Oral Med Oral Pathol 1963;16:353-65.

23. Suragimath G, Lohana MH, Varma S. A split mouth randomized clinical comparative study to evaluate the efficacy of gingival depigmentation procedure using conventional scalpel technique or diode laser. J Lasers Med Sci 2016;7:227.

24. Ginwalla TM, Gomes BC, Varma BR. Surgical removal of gingival pigmentation. (a preliminary study). J Indian Dent Assoc 1966;38:147.


Pinhole Surgical Approach in the Treatment Modality of Gingival Recession: A Case Report

Anjali Gaba, Jaishree Garg, Manvi C Agarwal, Sunil Upadhyay

Department Periodontology and Implantology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India

INTRODUCTION

Gingival recession is defined as the displacement of marginal gingiva apical to the cement-enamel junction�[1] Gingival recession can cause by periodontal disease (gingivitis, periodontitis, and advanced periodontitis), abrasive habits when it comes to brushing the teeth. When a gingival recession occurs, the root structure of the tooth becomes exposed, and loss of the tissues covering the root�[2] This means that there are high chances of tooth decay and other problems can affect the teeth along the gingival line and beneath the gingiva.[3]

The concept of “minimally invasive surgery (MIS)” is one such approach which produces minimal tissue injury, reduced pain, minimal flap reflection, and gentle handling of the soft and hard tissues�[4] Wickham and Filtz described the techniques of using smaller incisions as “MIS” which was later defined by medical subject headings as those procedures that avoid the use of open invasive surgery in favor of closed or local surgery�[5] In recent years, a novel surgical approach of root coverage, called the pinhole surgical technique (PST), was introduced by Chao in 2012. Chao introduced it for Miller Class I and II, recession defects and reported favorable predictability for root coverage and defect reduction up to 18 months following procedure�[6] The purpose of this review was to examine the predictability and the effectiveness of PST.

METHODOLOGY

Initially, local anesthesia was given to the patient at the site of surgery, convexities and irregularities which were present on the root were removed and planed using rotary burs� A minimal horizontal incision of 2–3 mm was made in the alveolar mucosa near the base

of the vestibule using a no.12 scalpel (Bard-Parker). For the PST, a specially designed instrument (transmucosal papillae elevators) Figure 1 was inserted through the incision [Figure 2], and the full-thickness flap was elevated. The extension of the flap was coronally and horizontally to allow the elevation of the two adjacent papillae on each side of the denuded root� PRF membrane was placed into the sub-gingival space under the papilla and marginal soft tissue� Gentle digital pressure is applied over the flap for approximately 5 min� The entry incision was left without suturing in order to heal by the first intention. To stabilize the flap sling, suture was given at the opposite contacts allowed the sutures to be tightened and knotted from the facial aspect�[6] Postoperative instruction was given and recalled after 1 month for re-evaluation [Figure 3]�

MAIN OUTCOMES OF SELECTED STUDIES

This treatment is a more conservative and alternative to common periodontal treatments, such as coronally advanced flap. With the PST, the operator makes a small hole in the gingiva and then manipulates the tissue to correct the recession and other issues� In addition, for some cases, an additional agent is inserted, filling the space between gingival tissue and the roots, which helps heal the area and allows healthy tissue to attach to the teeth�[7]

Zucchelli and Sanctis conducted a case series to evaluate the root coverage treated with pinhole surgical approach and with coronally

ABSTRACT

The technique for the treatment of gingival recession has been a debated topic in dentistry in recent years. This paper consists of new technique for the treatment of gingival recession i.e Pinhole surgical technique (PST). Pinhole surgical technique is a minimal invasive surgical technique given by Chao et al. 2012. This paper shows that Pinhole surgical technique allows to reposition the gingiva quickly and easily, with the less invasive method, a decreased patient discomfort, a shorter treatment and recovery time, and much less pain.

Key words: Pinhole surgical approach, minimally invasive surgery, recession

Case Report

Corresponding Author: DR. Sanjog Narang, Department Periodontology and Implantology, Institute of Dental Sciences, Bareilly, Uttar Pradesh, India. Email:[email protected]

Gaba, et al.: Tratment of gingival recession by pinhole surgical technique


advanced flap procedure for the treatment of multiple gingival recession defects� The results showed 88% complete root coverage and greater reductions in gingival recession in cases with less amount of keratinized tissue apical to recession defect�[8] In 2005, Zucchelli and Sanctis conducted a long-term case series for the treatment of multiple gingival recession defects using envelope type coronally advanced flap and the 5-year follow-up showed increased in keratinized

tissue, and 85% of treated recession defects showed complete root coverage�[9] Chambrone et al� conducted a study of periodontal plastic surgery in the treatment of multiple gingival recession type defects and concluded that the mean width of keratinized tissue increased significantly and mean root coverage achieved ranged from 94% to 98% and the need for more randomized controlled trials to identify the indication for each surgical technique�[9,10] Another randomized controlled trial was conducted by Prato et al� in 2010 to compare the coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recession with a 5-year follow-up and concluded that 52% sites showed completed root coverage when treated with coronally advanced flap and connective tissue graft in comparison to 35% coverage in coronally advanced flap treated sites.[11]

A novel approach for the treatment of more than one recession defects using a pinhole surgical technique was introduced by Chao and stated that 94% mean defect reduction was obtained along with minimum post-operative complications� The Chao PST is a minimally invasive option for treating gingival recession. Unlike traditional grafting techniques, PST is incision and suture free� Gingival recession treatments involve the use of donor tissue or soft-tissue grafts to rebuild the gingival margin� During PST, a needle is used to make a small hole in the gingival tissue� Through this pinhole, special instruments are used to gently loosen the gingival tissue� These tools help to expand and slide the gingiva to cover the exposed root structure� There is no need for any grafts or sutures in the Chao PST� It simply involves the adjustment of the existing tissue�

Indications and contraindications of PST[11]

1� Miller Class I recession2� Thick biotype3. Localized gingival recession4� Esthetic concern5� Increased keratinized tissue width�

Contraindications[12]

1� Heavy smokers2. Uncontrolled or poorly controlled diabetes3. Under medication.

CHAO-CONDUCTED DIFFERENT ADVANTAGES AND DISADVANTAGES OF THE PST

Advantages

a. Less discomfort for the patient post-operativelyb� Faster healing of the tissuec� No need for surgical instrumentd� No need to take donor tissue from the patient’s palatee� Excellent, esthetic appearance, and long-lasting results�

Disadvantages

a� Result is unpredictable if recession height is moreb� Cannot be done in thin biotype�

Figure 2: Pre-operative

Figure 3: Post-operative

Figure 1: Transmucosal papilla elevator

Gaba, et al.: Tratment of gingival recession by pinhole surgical technique


The PST is an incision-free and suture-free procedure for treating gingival recession� Since there is no incision or suturing, patients can expect minimal post-operative symptoms (pain, swelling, and bleeding).[6]

CONCLUSION

PST is one such novel technique which is minimally invasive, predictable, efficient, time, and cost-effective procedure for recession coverage in Millers Class I and Class II recession defects mainly occurring in buccal areas� There is a need for more long-term research to be carried out to analyze the success of PST in management of single or multiple recession defects�

REFERENCES

1. Glossary of Periodontal Terms. American Academy of Periodontology. 4th ed. Chicago, USA: Glossary of Periodontal Terms; 1995. p. 53-6.

2. Lawrence HP, Hunt RJ, Beck JP. Three year root caries incidence and risk modelling in older adults in North Carolina. J Public Health Dent 1995;55:69-78.

3. Carvalho P, da Silva RC, Cury P, Joly JC. Modified coronally advanced flap associated with a subepithelial connective tissue graft for the treatment of adjacent multiple gingival recessions. J

Periodontol 2006;77:1901-6.4. Banthia R, Dongre M, Ritika R, Banthia P. Minimally invasive

techniques for regenerative therapy. J Interdiscip Dent 2016;6:56-9.5. Dannan A. Minimally invasive periodontal therapy. J Indian Soc

Periodontol 2011;15:338-43.6. Chao J. A novel approach to root coverage: The pinhole surgical

technique. Int J Periodontics Restorative Dent 2012;32:521-31.7. Miller PD. A classification of marginal tissue recession. Int J

Periodontics Restorative Dent 1985;5:8-13.8. Zucchelli G, de Sanctis M. Treatment of multiple recession-

type defects in patients with esthetic demands. J Periodontol 2000;71:1506-14.

9. Zucchelli G, de Sanctis M. Long-term outcome following treatment of multiple Miller Class I and II recession defects in esthetic areas of the mouth. J Periodontol 2005;76:2286-92.

10. Chambrone L, Lima LA, Pustiglione FE, Chambrone LA. Systematic review of periodontal plastic surgery in the treatment of multiple recessions-type defects. J Can Dent Assoc 2009;75:203a-f.

11. Pini-Prato GP, Cairo F, Nieri M, Franceschi D, Rotundo R, Cortellini P. Coronally advanced flap versus connective tissue graft in the treatment of multiple gingival recessions: A split-mouth study with a 5-year follow-up. J Clin Periodontol 2010;37:644-50.

12. Ozcelik O, Haytac MC, Seydaoglu G. Treatment of multiple gingival recession using a coronally advanced flap procedure combined with button application. J Clin Periodontol 2011; 38: 572-580.

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