BDJ Apr-june 2017 - Amazon S3 · 2017-12-21 · ISSN : 2278-6686 Issue 1 Volume 1 Jan-March 2016 BDJ BANGALORE DENTAL JOURNAL Official Publication of IDA Bangalore Branch Issue 2

ISSN : 2278-6686

Issue 1

Volume 1

Jan-March 2016

BDJBDJ

BANGALORE DENTAL JOURNAL

Official Publication of IDA Bangalore Branch

ISSN : 2278-6686

Issue 2

Volume 2

April - June 2017

Chair Side Screening Aids for early Detection of

Oral Cancer - A Review 6

Myofacial Pain Dysfunction Syndrome: A Review 10

Mucous Extravasation Cyst - A Case Report And Review of Literature 13

Contemporary paradigm shift of public health dentistry skills 17

Know Your Community – Build a Strong Bridge through 30Public Health Informatics

Medical management of Oral Submucous Fibrosis in a 34patient suffering from Alzheimer's disease. A case report with review of literature.

3

EDIT

OR

IAL

Review Board

Editorial Board

ORAL MEDICINE AND RADIOLOGY :Dr. JAIKRISHNADr. SHILPA PATIL ORAL PATHOLOGY :Dr. GIRISH H.CDr. SANJAY MURUGOD ORAL SURGERY :Dr. MADANDr. PREETHAM SHETTY

PEDODONTIA :Dr. PAVANDr. VENKATESH BABU

PERIODONTIA :Dr. SHYAM PADMANABHANDr. ANIERBAN CHATERJE

Associate Editor :Dr. CHETHAN.R

PROSTHODONTIA :Dr. PURUSHOTAM MANVIDr. SHILPA SHETTY

COMMUNITY DENTISTRY :Dr. MURALI IYERDr. PADMA BHAT

CONSERVATIVE :Dr. NAVEENDr. KAVITHA RANGANATH

ORTHODONTIA :Dr. HEMANTHDr. VINAY

I have been pleased and honored to serve you, the members and the Indian Dental Association Karnataka State Branch as President this year. The mission of IDA is

to advance increase knowledge for the improvement of oral health across the region ; to support and represent the oral health community; and tofacilitate the communication and application by Awarenesss among the public.

In support of the mission, the Association continued to provide professional

development and publication opportunities for members.Large number of attendees from all the branches allow delegatesopportunities to network with the community of clinicians and researchers while exploring the latest scientific discoveries in the field.

The IDA Karnataka StateJournal continued to serve this year, thanks to

the high quality of research that scientists and clinicians submitted for publication in the Journal. The high caliber of science of the Journal has had high impact and helped it achieve appreciationproviding increased opportunities for publication encompassedthe complete spectrum of oral, dental and craniofacial investigation with a focus onclinical and translational research.

The increasing importance of translating findings into clinical practice provided impetus for Research. Under the editorship of DrRajkumar. This groundbreaking new softcopy version of the print journal will be dedicated to publishing more original dental, oral and craniofacial research at the interface between scientific discovery and clinical application with the translation of research into healthcare delivery at the individual patient, clinical practice and community levels.

As scientists, we know that research discovery does not occur in isolation. Science is a continuum of knowledge that builds on the previous work of others, and today's discoveries will provide the foundation for further efforts. We must support our research community and extend our reach if we wish to further our science.

Also IDA continues to encourage members to collaborate with their fellow member colleagues and be active in the Association by participating in at least at the CDE for clinical and research updaesboth at the State and local branch meetings.

I encourage all Ida members to remainengaged so that together we can support the IDA mission and improve oral health Nationwide.

Sincerely,

B Nandlal

With Warm Regards,Dr. SATHEESHA REDDY B H

Editor-in-Chief, IDA BANGALORE

4

IDA BANGALORE BRANCHLIST OF OFFICE BEARERS FOR THE YEAR 2017-18

Hon. Treasurer:

Dr B K SrivastavaDr

Dr Tilak Raj T NDr Manjunath BDr Kumar NCDr Madhu KDr DhayakarDr Kishore HCDr Prashanth BRDr Manjunath VK

President Elect:

Imm. Past President:

Vice Presidents:

Dr. Girish Sharma

Dr. Ashwatharaju .P

Dr Annaji

Dr Sanjay Kumar

Dr Utkarsh .L

DrMurali .R

Hon. Joint Secretary:

Hon. Asst. Secretary:

Hon. Editor:

Chairman CDE:

Chairman CDH:

Dr Smitha T

Dr Sudarshan

Dr Satheesha Reddy B H

Dr Suresh .T

Dr Ramesh L

Executive Committee Members:

Dr Vidhya SagarDr Ramamurthy TKDr Sai RameshDr PremnathDr Chaithnya Babu NDr Raghu TNDr Rohith SDr Charan Shetty

Representatives to State:

Dr Veerendra KumarDr Hegde BTDr Sadanand MPDr Mohammed NoomanDr Madhusudhan ReddyDr Sudharshan KumarDr Ullhas AmasiDr Shivu ME

Dr Uma SRDr Prasad MGSDr Raghunatha KDr Akshay ShettyDr Chethan RDr Sandeep JNDr Dhanu

President

Dr. Nanda Kishore BHon. State Secretary

Mahesh Chandra

PR

ESID

ENT’

S M

ESSA

GE

President, IDA Bangalore Branch

SEC

RET

AR

Y’S

MES

SAG

E

Dr Mahesh ChandraHon. Secretary

IDA Bangalore Branch

5

Dr. Nanda Kishore

It is with great pride, enthusiasm, and anticipation that I invite you to read the inaugural issue of the IDA BANGALORE DENTAL JOURNAL, a new kind of research journal.

An enormous amount of work has gone into the development of this journal and I believe you will see that effort reflected in this journal and in the impact it will have on the field. It has been an interesting journey, the journey has not been one with a completely charted course. It could not have been, given our time constraints.

As we look at Journal, it is important to keep in mind that it represents the collective thinking of a group of innovative individuals with whom I am privileged to work. First, we want Journal to be the premiere scientific journal in Dental Sciences. We want it to look different, to be different, to be one journal that, with its related website, will be as dynamic as the work going on in our disciplines, a rarity in academic publishing. Second, we want it to be a vehicle for a new type of conversation about dental practice and its place in the academic review, tenure, promotion, and reward process. That’s a tall order, but with your help we will make it happen.

Over the past six years, having acquired considerable new experience in Indian Dental Association with such experienced and well informed colleagues from all the Dental Colleges , and papers of various qualities covering all fields of dental medicine, I believe this is the proper time to initiate some new activities. Setting a web site is such an activity; I believe quite an important activity, which will add to the Journals wider recognition and, consequently, better and more efficient communication and exchange of scientific ideas. Now, on the web site, the BDJ will be easily found, and I hope that this will enable the BDJ to become a well-known international scientific journal, covering all aspects of Dental Medicine.

Dear members,

It gives me immense pleasure to present to you the first issue of the current edition of BDJ for the year 2017.

It's been a very enriching and memorable journey as President, IDA Bangalore branch, which has given me an opportunity to evolve as a person and to serve our fraternity in my capacity.

I would like to thank all the office bearers of the IDA Bangalore branch and all the people who have supported me through this journey.

I would like to express my heartfelt thanks to Dr. Satheesha Reddy B H, our editor for his enduring efforts in ensuring the publication of this journal.

Dear respected IDA member,

6

ABSTRACT:

The World Health Organization has clearly identified prevention and early detection as major objectives in the control of the oral cancer burden worldwide there is strongavailable evidence to suggest that visual inspection of the oral mucosa is effective in reducing mortality from oral cancer in individuals exposed to risk factors. Simple visual examination, however, is well known to be limited bysubjective interpretation and by the potential, ableit rare, occurrence of dysplasia and early OSCCwithin areas of normal-looking oral mucosa. As a consequence, adjunctive techniques have beensuggested to increase our ability to differentiate between benign abnormalities and malignant changes as well as to identify areas of dysplasia/early OSCC that are not visible to nakedeye. These include the use of toluidine blue, brush biopsy, Chemiluminiscence and tissueauto fluorescence. These alternative screening aidsare non-invasive, easily performed and highlyaccurate are the norms for any test to accept as an alternative for histopathology. This articleFocuses on some screening techniques, which can be routinely adopt in adjuvant for histopathology.

Key words: Oral premalignant lesions (OPML). Oral cancer (OC), early diagnosis, VELscope, ViziLite.

(1) (2) (3) (4) (5)Authors: Dr. Sheela , Dr .Satheesha Reddy B.H , Dr Ramamurthy.T.K , Dr.Shilpa .B , Dr. R.Chethan

INTRODUCTION:

Oral cancer is the sixth most frequently occurring malignant tumour and is the major cause of morbidity

(1) and mortality with metastatic and invasive ability . The incidence of oral cancer world-wide is reported as 2- 10 /100,000 population per year. Highest incidence seen in South Asian countries like Srilanka, India, Pakistan, and Bangladesh. In India the incidence is 7-17/100,000 persons/year with 5,000-80,000 new

(2) cases registered annually Detecting oral cancer in its early stages dramatically affects survival rates compared with detecting it in later stages. Nevertheless, around 50% of diagnosed patients die

(3)within 5 years .Regular oral healthcheck-up is essential in the early detection of cancerous and pre-cancerous conditions. Unfortunately, early detection of oral precancerous and cancerous lesions has proved difficult, as the lesions are symptomatic, patient and dentist casual approach towards innocuous lesions and as well as the fact that 50% of patients have regional or distant metastases at time of

(4,5). diagnosis Hence a thorough knowledge of oral

examination and the available tools to detect cancer at an early stage is useful in reducing the morbidity and mortality caused by oral cancer.

1. ORAL SCREENING METHODS:

There are many advanced oral screening methods in dentistry to help early detection of Oral cancer; here we discuss few cost effective, easy to perform, well adaptable at routine dental practice

1.1 CONVENTIONAL ORAL EXAMINATION:

After eliciting the habit history, a thorough Oral examination should be performed under adequate incandescent light, carefully examining the oral cavity paying attention to any mucosal abnormalities, unhealed oral ulcer and local examination of regional lymph nodes plays an important role in early detection of OPML & conditions. 5-15% of the general population has oral mucosal abnormalities, which are

(6)clinically &biologically benign .COE may miss the detection of precancerous lesions that appear clinically normal; it does not identify all potentially premalignant lesions. The sensitivity and specificity

1. P. G Student, Department of Oral Medicine & Radiology. AECS Maaruti College of Dental sciences and Research Centre. Bangalore- 76.

2. Dr. Satheesha Reddy B.H, Professor & Head of the Department, Department of Oral Medicine & Radiology. AECS Maaruti College of Dental sciences and Research Centre. Bangalore- 76.

3. Dr Ramamurthy.T.K, Professor, Department of Oral Medicine & Radiology. AECS Maaruti College of Dental sciences and Research Centre. Bangalore- 76.

Dr. Sheela,

Chair Side Screening Aids for early Detection of Oral Cancer - A Review.

4. Reader, Department of Oral Medicine & Radiology. AECS Maaruti College of Dental sciences and Research Centre. Bangalore- 76.

5. Dr. R. Chethan, Senior Lecturer, Department of Oral Medicine & Radiology. AECS Maaruti College of Dental sciences and Research Centre. Bangalore- 76.

Dr. Shilpa .B,

8

7

IDA April - June 2017, Volume 2, Issue 2

varied between 58-94% and 76-98% respectively (7, 8, 9)

invarious studies . Hence the need arises for (9) adjunctive screening aids

2. ADJUNCTIVE ORAL SCREENING METHODS: Adjunctive Oral screening methods are those along with routine oral examination these help in ruling out suspicious areas for malignancy.

2.1 ORAL CYTOLOGY:

Cytology has been widely accepted as a tool in the early diagnosis of cancer which has gained popularity within a short period of time since its introduction by

(10)George Papanicolaou in 1942 . The concept of cytological studies is to study the cells, which are exfoliating due to pathologic or physiologic process, here we use cotton swabs, wooden or metal spatulas for collection of specimen stain it with Papanicolaou stain and look for any atypical cells this technique collects only cells of thesuperficial layers.

2.2 ORAL BRUSH BIOPSY:

Oral brush biopsy has an advantage over conventional cytology in collecting the specimen from the basal layer the basis for development of newer techniques for collection of cells is, dysplasia starts in basal layers

(12)and extends to all the layers of the epithelium. The ORAL CDxcytobrushclaims to collect the basal layer cells non-invasively and assess the dysplasia by computer-assisted neural network, inorder to

(11)eliminate subjective misinterpretations .A specially designed brush is the non-lacerational device used for epithelial cell collection and samples are eventually fixed onto a glass slide, stained with a modified Papanicolaou test and analysed microscopicallyvia a computer-based imaging system. Results are reported as "positive" or "atypical" when cellular morphologyis highly suspicious for epithelial dysplasia or carcinoma or when abnormal epithelial changes are ofuncertain diagnostic significance respectively. Results are considered as negative when

(13,14)no abnormalities can be found .

3. VITAL STAINING:

Vital staining is a procedure to stain a living cell without killing the cell. Toluidine blue, lugols iodine & methylene blue have been noted for their efficiency in

(15)staining the cancer cell .

3.1 TOLUIDINE BLUE (TOLONIUM CHLORIDE):

Vital dye that is believed to stain nucleic acids, instruct the patient to rinse the mouth thoroughly, apply an 1% acetic acid to the suspected area with a cotton applicator for 30 sec, then blot the area with 1% aqueous solution of toluidine blue stain for 30 sec, then examine for dye uptake .Dark blue stain is considered as positive for lesions suspicious malignancy,light blue retention is considered as positive for premalignant lesions unless proved otherwise by biopsyThe lesions without any retention

(16)of stain are considered as negative This test is highly sensitive but not specific might be useful in determining clinically evident oral lesion, which are

(17)more likely to progress to oral cancer .Not meant to be a diagnostic tool, it is a screening test procedure only as abrasions, ulcers, granulation tissue also take

(15)up the stain falsely .

3.2 LUGOL'S IODINE:

Consisting of 10 parts of potassium iodide to 5 parts of (17)

iodine to 85 parts of (distilled) water .Lugols Iodine stains Glycogen containing squamous epithelium

(18)which is fully differentiated .Application of iodine results in brown or black colour staining in areas containing glycogen in areas lacking glycogen, iodine is not absorbed and such areas remain colourless or

(19)turn yellow .

3.3METHYLENE BLUE: It is a heterocyclic aromatic chemical compound. At room temperature appears as a solid, odourless, dark-green powder, which yields a blue solution when dissolved in water. Methylene blue is beinginvestigated for the photodynamic

(19)treatment of cancer . Considering its low toxicity and the fact that it is cheaperthan TB, it may be convenient to substitute it for TB in large-scale oral

(20)screening in high-risk patients .

4. CHEMILUMINESCENCE:

Chemiluminiscence refers to the emission of light from a chemical reaction which is of varying degrees

of intensity with colours that span the visual spectrum(21)

.

4.1 VIZILITE SYSTEM:

The relevant technology (ViziLite system – Zila Pharmaceuticals, Phoenix, AZ), involves the use of an oral rinse with a 1% acetic acid solution for 1 min

8


followed by the examination of the oral mucosa under diffuse chemiluminescent blue/white l ight

(21,22)(wavelength of 490-510 nm) .The theory behind this technique is that the acetic acid removes the glycoprotein barrier and slightly desiccates the oral mucosa; the abnormal cells of the mucosa then absorb and reflect the blue/white light in a different way with respect to normal cells hence normal mucosa appears blue, whereas abnormal mucosal areas reflect the light (due to higher nuclear/ cytoplasmic ratio of epithelial cells) and appear more acetowhite with brighter, sharper and more distinct

(21,22)margins . In studies by Epstein, Huber, Kerr et al., and Oh et al.suggest that Chemiluminiscence may help identifying occult lesions that cannot be seen with incandescent light but this, however, is not

(23,24)supportedby any strong evidence . Rajmohanet al. assessed oral mucosa in normal, precancer and cancer patients usingViziLite and it was found 77.8 % sensitive for detecting dysplasia and 90 % sensitive for

(25) .detecting OSCC

5. TISSUE AUTO FLOUROSCENCE:

It is a phenomenon where by an extrinsic light source is usedto excite endogenous fluorophores such as certain aminoacids, metabolic products, and structural proteins. Within the oral mucosa, the most relevant fluorophoresare nicotinamide adenine dinucleotide (NADH) and Flavin adenine dinucleotide (FAD) in the epithelium and collagen cross-links in the stroma. The fluorophores absorb photons from the exogenous light source and emit lower energy photons which present clinically asfluorescence

5.1 VELscope (VISUALLY ENHANCED LESION SCOPE): VELscope is intended to be used by a dentist or health-care provider as an adjunct to traditional oral examination by incandescent light to enhance the visualization of oral mucosal abnormalities that may not be apparent or visible to the naked eye, such as

(26)oral cancer or premalignant dysplasia It is designed under the concept of all tissues fluoresce due to the presence of fluorescent fluorophores with in them (auto fluorescence).. Based on this it is stated that mucosa with normal cells appear apple green in colour whereas mucosa with abnormal cells appear

(27)dark green to black in colour .

6. TISSUE AUTOFLOUROSCENCE SPECTROSCOPY:

This also works under the concept of tissue auto fluorescence it is designed to overcome subjective errors of VELscope. The auto fluorescence spectroscopy system consists of a small optical fibre that produces various excitation wavelengths and a spectrograph that receives and records on a computer and analyses, via dedicated software, the spectra of reflected fluorescence from the tissue. Auto fluorescence spectroscopy seems to be very accurate for distinguishing lesions from healthy oral mucosa, withhigh sensitivity and specificity, especially when malignant tumours are compared to healthy mucosa. However, theability of the technique to distinguish and classify different types of lesion has

(28)been reported to be low .

CONCLUSION:

Detection of OPMDs before they advance to OSCC is necessary to improve survival rates for oral cancer. Evidence indicates that COE is a poor discriminator of oral mucosal lesionsand this has led to the development of several adjunctive visualisation aids. Hence a thorough knowledge of adjunctive chair side screening aids will definitely have an impact in early detection of premalignant lesions.

REFERENCES:

1)Ohnishi Y, Lieger O, Attygalla M, Iizuka T, Kakudo K. Effects of Epidermal growth factor on the invasion activity of the oral cancercell lines HSC3 and SAS. Oral Oncol 2008;44:1155-9.

2)Rajendran R, Sivapathasundaram P. Benign and malignant tumors of the oral cavity. Shafer's Text book of Oral Pathology. 6th ed. Delhi, India: Elsevier Pub; 2009. p. 101-2.

3) Greenlee RT, Hill-Harmon MB, Murray T, Thun M. Cancer statistics, 2001. CA Cancer J Clin 2001;51:15-36.

4)Lingen MW, Kalmar JR, Karrison T, Speight PM. Critical evaluation of diagnostic aids for the detection of oral cancer. Oral Oncol2008;44:10-22.

5)Monica Crooks. Early detection is your best weapon against oral cancer. Dental Care 2007;3:23-9.

6)Sankaranarayanan R, Ramadas K, Thomas G, MuwongeR,Thara S, Mathew B, et al. Effect of

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screening on oral cancermortality in Kerala, India: A cluster-randomised controlled trial. Lancet 2005;365:1927-33.

7)Wilson JM. Principles and practice of mass screening for disease. Public Health Pap 1968;8:14-32.

8)Downer MC, Moles DR, Palmer S, Speight PM. A systematic review of test performance in screening for oral cancer andprecancer. Oral Oncol 2004;40:264-73.

9)Kujan O, Glenny AM, Sloan P. Screening for oral cancer. Lancet 2005;366:1265-6.

10)Papanicolaou GN. A new procedure for staining vaginal smears. Science 1942;95:438-9.

11)Potter TJ, Summerlin DJ, Campbell JH. Oral malignancies associated with negative transepithelial brush biopsy. J Oral MaxillofacSurg 2003;61:674-7.

12)Potter TJ, Summerlin DJ, Campbell JH. Oral malignancies associated with negative transepithelial brush biopsy. J OralMaxillofacSurg 2003;61:674-7.

13)Driemel O, Dahse R, Berndt A, Pistner H, Hakim SG, Zardi L, et al. High-molecular tenascin-C as an indicator of atypical cells inoral brush biopsies. Clin Oral Investig 2007;11:93-9.

14)Hirshberg A, Yarom N, Amariglio N, Yahalom R, Adam I, Stanchescu R, et al. Detection of non-diploid cells in premalignantand malignant oral lesions using combined orphological and FISH analysis: A new method for early detection of suspicious orallesions. Cancer Lett 2007;253:282-90.

15 )Moyer GN, Taybos GM, Pelleu GB Jr. Toluidine blue rinse: Potential for benign lesions in early detection of oral neoplasms. J Oral Med 1986;41:111-3.

16)Ram S, Siar CH. Chemiluminescence as a diagnostic aid in the detection of oral cancer and potentially malignant epithelial lesions.Int J Oral MaxillofacSurg 2005;34:521-7.

17)Poh CF, Ng SP, Williams PM, Zhang L, Laronde DM, Lane P, et al. Direct fluorescence visualization of clinically occult high-riskoral premalignant disease using a simple hand-held device. Head Neck 2007;29:71-6.

18)Epstein JB, Scully C, Spinelli J. Toluidine blue and Lugol's iodine application in the assessment of oral malignant disease and lesions at risk of malignancy. J

Oral Pathol Med 1992;21:160-3.

19 )Olliver JR, Wild CP, Sahay P, Dexter S, Hardie LJ. Chromoendoscopy with methylene blue and associated DNA damage in arrett'soesophagus. Lancet 2003;362:373-4.

20)Redman RS, Krasnow SH, Sniffen RA Evaluation of the carcinogenic potential of toluidine blue o in the hamster cheek pouch. Oral Surg Oral Med Oral Patho1992;74:473-80.

21)Oh ES, Laskin DS. Efficacy of vizilite system in identification of oral lesions.J Oral Maxill Surg. 07;65:24-7.

22)Shedd DP, Hukill PB, Bahn S, Farraro RH. Further appraisal of in vivo staining properties of oral cancer. Arch Surg. 1967;95:16-22.

23)Microlux DL. Addent, 2012. Available from: http://www.addent. com.

24) Oh ES, Laskin DM. Efficacy of the ViziLite system in the identification of oral lesions. J Oral MaxillofacSurg 2007;65:424-6.

25)Rajmohan M, Rao UK, Joshua E, Rajasekaran ST, Kannan R.Assessment of oral mucosa in normal, precancer and cancer using chemiluminescent illumination, toluidine blue supravital staining and oral exfoliative cytology. J Oral MaxillofacPathol. 2012;16:325-9.

26) Patton LL, Epstein JB, Kerr AR. Adjunctive techniques for oral cancer examination and lesion diagnosis: A systematic review ofthe literature. J Am Dent Assoc 2008;139:896-905.

27 )Koch FP, Kaemmerer PW, Biestergeld S, Kunkel M, Wagner W.Effectiveness of autofluorescence to identify suspicious oral lesions– a prospective, blinded clinical trial. Clin Oral Investig. 2011;15:975- 82

28)Stefano Fedele,Diagnostic aids in the screening of oral cancer Head & Neck Oncology 2009, 1:5

10

ABSTRACT

Myofascial Pain Dysfunction Syndrome is the most common form of TMD, affecting principally women in 3

reproductive age. It is defined as pain that originates from myofascial trigger points in skeletal muscle.

This article gives a deeper

insight into the clinical features, diagnosis and management of MPDS which will help clinicians to better

understand this perplexing and mystifying condition.

KEYWORDS: Mpds ,Tmj, Muscles, Pain

The MPD

type ofTemporomandibular disorder is not associated with destructive changes in the temporomandibularJoint.

Usually anxious and stressed persons and those with bruxism are commonly affected.

(1) (2) (3) (4)Authors: Dr. Rekhaj , Dr. Satheesha Reddy B.H , Dr Ramamurthy .T.K , Dr. Meenakshi Prasad

Myofacial Pain Dysfunction Syndrome: A Review

1. Dr .RekhaJ Post Graduate Student,Dept Of Oral Medicine & Radiology, AECS Maaruti College Of Dental Sciences & Research Institute, Bangalore.

2. Dr. Satheesha Reddy B HProfessor & HOD ,Dept Of Oral Medicine & Radiology, AECS Maaruti College Of Dental Sciences & Research Institute, Bangalore.

3. Dr Ramamurthy T KProfessor, Dept Of Oral Medicine & Radiology, AECS Maaruti College Of Dental Sciences & Research Institute, Bangalore.

4. Dr. Meenakshi PrasadPost Graduate Student, Dept Of Oral Medicine & Radiology, AECS Maaruti College Of Dental Sciences & Research Institute, Bangalore.

INTRODUCTION:

MPDS (Myofascial Pain Dysfunction Syndrome) is the most common form of temporomandibular disorders.

Previous studies have shown muscular involvement in 90% of cases. MPDS is the most common cause of oro-facial chronic pains. In fact, MPDS is a psychological disorder which involves the masticatory muscles and results in pain, limitation in jaw movement, joint noise, jaw deviation in closing and opening the mouth and sensitivity in touching one or more masticatory

8muscles or their tendon .The main acceptable factors include occlusion disorders and psychological

5problems.

Myofascial pain tends to be dull, poorly localized, and deep, in contrast to the precise location of dental pain and cutaneous pain. Signs and symptoms suggestive of non-odontogenic pain include an inadequate local dental cause for the pain; a recurrence of pain in spite of reasonable dental therapy of the tooth or TMJ; poor lasting pain relief after local anesthetic blocking.

Patients with MPDS usually have a history of acute or chronic muscle overload. In dental practice, MPDS is commonly seen in patients with a history of bruxism

The pain is referred from trigger points from within myofascial structures or from distant area from pain.

CLINICAL FEATURES:

or clenching. There are four cardinal signs and symptoms of the syndrome viz. pain, muscle tenderness, clicking or crepitus noise in the TMJ and unilaterally or bilaterally limitation of jaw movement with deviation on opening

Pain: It can be either localized to the joint or referred to the head, neck or shoulders, it is usually unilateral and described as a dull ache in the ear or preauricular area which radiate to angle of the mandible, temporal area or lateral cervical area. Usually persistent in nature, often the pain is worse in the morning, in nocturnal bruxism or in the late afternoon if parafunctional clenching or bruxism are correlated with work stress.

Tenderness: It is present over the affected TMJ during normal opening and closing motions. It is best elicited by placing the examining f ingers at the posterosuperior aspect of both the condyles and expressing pressure.

Clicking or popping noises in the tmj: They are common and described as clicking, popping or crepitus. The nature of the click is still uncertain. It is usually bilateral. It can occur at any point of jaw movement and there maybe multiple clicks. It may be audible, palpable or both and usually noted on simple palpation directly over the condylar head during the

opening movement. Crepitus has been associated with perforations in the disk, which is usually followed by osteoarthritic change on the condylar surface followed by similar bony alterations on the opposing surface of the fossa.

Deviation of the jaw to the affected side during normal opening motion: It is a common finding, since muscle spasm frequently accompanies joint dysfunction and as such contributes to the pain. This restricts the motion of the condyle, impairing or completely eliminating the forward gliding motion so that all that remains is a simple hinge action, with the

5condyle remaining in the fossa.

Clinical features are the commonest way to diagnose MPDS. Other investigations include radiological imaging.

Imaging Studies: Imaging studies may provide useful anatomical information. However, MFP, TB, TRP and

7TS usually do not show up in these investigations

As it may be realised there is no distinctive radiographic feature of the MPDS. There is a great deal of emphasis on the “joint space”, however concentricity of the condyle in its fossa is quiet variable. When it appears displaced on radiographic examination such as tomography, arthrography, magnetic resonance imaging (MRI) the diagnosis is usually related to a disc displacement problem, and the clinical features are more consistent with that diagnosis than with MPDS. Several plain film techniques are useful in these cases, including:

1. Transcranial2. Transpharyngeal3. Transorbital4. Panaromic5. SpecialisedPanaromic

6. Tomography Ultrasonography has proven to be useful in studying the condition of the muscles. Muscle activity can be investigated by electromyo-

8graphy.

Differenial diagnosis may be cluster headache, migraine headache, post herpetic neuralgia, temporal cell arteritis, trigeminal neuralgia and middle ear

9infection.

INVESTIGATIONS

MANAGEMENT:

Injections into MTrPs(myofacial trigger points) are a common and effective treatment, presumably due to mechanical disruption by the needle and termination of the dysfunctional activity of involved motor endplates. MTrP injections may employ dry needling, short- or long-acting anesthetics, or steroids.

Dry needling has been traditionally used as one of the fastest and most-effective ways to inactivate MTrPs and help alleviate the accompanied pain.

Steroid injectionsinto MTrPs are controversial and without clear rationale because little evidence exists to s u p p o r t a n u n d e r l y i n g i n f l a m m ato r y pathophysiology. There are various sources in the literature, which have specifically described effective modalities, including deep-pressure massage, stretch therapy with spray (where a taut band is stretched immediately after cold spray), superficial heat, and myofascial release.

Ultrasound is a technique that has been proposed to treat myofascial pain by converting electrical energy to sound waves in order to provide heat energy to muscles. Treatment of MPDS using ultrasonography combined with massage and exercise was performed by DrArme Gam and Susan Warming.

Transcutaneous electric nerve stimulation (TENS) is a treatment modality that utilizes an electrical current to stimulate nerve fibers in order to provide pain relief.

Magnetic stimulation (MS) is a newer treatment that is being investigated for MPDS. Only a limited number of studies exist and the exact therapeutic mechanism of action remains uncertain.

Laser therapy has been used in the treatment of MPDS; however, its exact mechanism of therapeutic action remains elusive.

Exercise

After needling the TRP, it is essential to correct the muscle imbalance to achieve a good therapeutic result. It is important to try to restore normal length and flexibility to the muscles. The following neuromuscular relaxation techniques may be applied:

I. Muscle relaxation by exhalation.

ii. Muscle relaxation by eye movement, inferiorly and

11


5in the direction in which relaxation is desired.

Pharmacologic Treatment

Includes use of various drugs to reduce the pain and discomfort caused to the patient.

Analgesic Drugs - Nonsteroidal anti-inflammatory drugs (NSAIDs)

Cyclooxygenase-2 (COX-2) inhibitors

Tramadol an opioid pain medication

Tropisetron a serotonin 5-HT3 receptor antagonist ,

Muscle Relaxants -Tizanidine , Cyclobenzaprine

Anticonvulsants - Gabapentin 5

Antidepressants - Tricyclic antidepressants

EMOTIONAL SUPPORT:

In many cases it is essential to have a clinical psychologistavailable to support the patient emotionally.

The family practitioner must be ready to support the patientand help by preventing the re-occurrence of the sameproblems.

Continuous active exercises are necessary to maintainsupple muscles.

It is essential that the CORRECT diagnosis be made beforetreating Myofascial Pain Syndrome. The proper treatment of Myofascial Pain Syndrome maybe one of the most rewarding if handled correctly.

1. The Management Of Myofascial Pain Syndrome, ClO dendaal, Southern African Journal Of Anaesthesia& Analgesia - July 2003.

2. Myofacial Pain Dysfunction Syndrome: An Overview, ArunK.Garg,Heal Talk, Aug – Sep 2013,Volume 5, Issue 06.

3. Myofascial Pain Syndrome: A Treatment Review, Mehul J. Desai VikramjeetSaini ShawnjeetSaini, Pain Ther(2013) 2:21–36.

1

CONCLUSION:

MPDS is usually a selflimiting condition. Conservative treatments such as selfcare practices, rehabilitations to relieve muscle spasms are mostly sufficient. NSAIDS should be used for short term basis.

REFRRENCES:

4. Myofacial Pain Dysfunction Syndrome - A Review, N. ANITHA,Biomedical &Pharmacology Journal Vol. 9(2), 875-876 (2016).

9. Joanne Borg-Stein, David G Simons. Review- Myofascial Pain Archives of Physical Medicine And Rehabilitation, 83: Supplement 1; S40-S47 (2002).

5. Dr. Rhea Reji,Myofascial Pain Dysfunction Syndrome: A Revisit, IOSR Journal OfDental And Medical Sciences (IOSR-JDMS), Volume 16, Issue 1 Ver. V (January. 2017), PP 13-21.

6. Evaluation Of Malocclusion In Mpds.KvvPratap Verma Et Al,JContemp Dent Pract 2013;14(5): 939-943.

7. Eng-ChingYap.Myofascial Pain- An Overview. Ann Acad Med Singapore 2007;36:43

8. Carolina RoldánBarraza. Myofascial Pain: Etiological Factors and Therapeutical Methods. A Systematic Literature Review Of The Last Thirteen Years.Aus Santiago, Chile 2013 .

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13

ABSTRACT:

Mucous extravasation cyst or Mucoceles are benign mucous containing cystic lesions of salivary glands mainly of

traumatic origin, which is formed when the main duct of a minor salivary gland is torn with subsequent

extravasation of the mucus into the fibrous connective tissue. In due course a cyst like cavity is produced

which is filled with mucin. Most common location in oral cavity is lower lip followed by tongue, buccal mucosa,

soft palate, retromolar pad and lower labial mucosa. These are painless lesions which can be diagnosed clinically.

Hereby we present a case of 20 years old male patient with mucocele on the lower lip which was surgically

excised.

Key words: Mucocele, salivary gland, cyst, trauma.

Mucous Extravasation Cyst - A Case Report And Review of Literature

1 2 3 4Authors: Vijayalakshmi Venkat , Dr. Satheesha Reddy.B.H , Dr. Shilpa. B ,Dr.Rajeshwari kenchaiah

1. Vijayalakshmi VenkatPost graduate student, Department of Oral Medicine and RadiologyA.E.C.S Maaruticollege of dental sciences and research centreBangalore, Karnataka- 560076Email: [email protected] Ph: 9901548544.

2. Dr. Satheesha Reddy B.HProfessor and Head of the department, Department of Oral Medicine and RadiologyA.E.C.S Maaruticollege of dental sciences and research centreBangalore, Karnataka- 560076

3. Dr. Shilpa .BReader, Department of oral medicine and radiologyA.E.C.S Maaruticollege of dental sciences and research centreBangalore, Karnataka- 560076

4. Dr. Rajeshwari KenchaiahSenior Lecturer, Department of oral medicine and radiologyA.E.C.S Maaruticollege of dental sciences and research centreBangalore, Karnataka- 560076.

INTRODUCTION:

Mucocele is accumulation of mucus within minor 1

salivary glands resulting in benign cystic lesion. The word Mucocele is derived from latin,“muco” meaning mucous and “cele” meaning cavity, i.e.,cavities filled

2with mucous. Mucocele is seventeenth most common salivary gland lesions seen in the oral

3cavity. It usually presents as either a fluid filled blister or vesicle in the superficial mucosa or as a fluctuant

4nodule deep within the connective tissue. Initially it presents as small translucent discrete swelling which can gradually increase to larger size which is soft and painless mass ranging from normal pink to deep

4,5blue in color. Lower lip is the most frequent site for mucocele, tongue is the second most common

1,3,4,5location followed by the buccal mucosa. They may occur at any age, but are seen most frequently in children, adolescents and young adults and have no

1,2,3,4sex predilection.

Two types of mucoceles can appear - extravasation 3and retention cyst. Extravasation mucocele results

from trauma to salivary glands duct and the consequent spillage into the soft tissues around this gland whereas retention mucocele appears due to a decrease or absence of glandular secretion

produced by blockage of the salivary gland 3,6ducts. Extravasation mucoceles appear frequently on

the lower lip. In contrast, retention mucoceles appear 6at any site in the oral cavity. Clinically, two types of

mucoceles cannot be differentiated. However, they 1,7,8 can be distinguished histologically. Mucoceles are

usually asymptomatic but sometimes can cause discomfort by interfering with speech, mastication or

2,8swallowing.

CASE PRESENTATION:

A 20 years old male patient visited the department of oral medicine and radiology with the complaints of painless growth in the lower lip since 1 month. The growth was small initially and then was increasing gradually to attain the present size. The growth was seemed to interfere with speech and mastication. His medical history was insignificant.

On intraoral examination, a solitary, ovoid translucent swelling is seen on the inner aspect of lower lip, measuring approximately 1×1cm in relation to 32, 33 extending 2mm away from the vermillion border of lower lip to 1cm towards the lower labial vestibule.(Figure-1) Surface appears smooth and colour appears to be confluent with the surrounding normal mucosa. On palpation. The swelling was soft,

nontender and fluctuant. Patient gives positive history of habitual lip biting.

Considering the history and clinical examination, a provisional diagnosis of mucocele on lower lip was made. Differential diagnosis taken in to consideration wereirritational fibroma,lipoma and minor salivary gland tumours. Hematological investigations were carried out which was found to be within normal limits followed by excisional biopsy of the swelling.

An elliptical incision was placed on the most dependent part of the lesion. Flap was reflected cautiously and the Lesion was resected completely along with proper curettage to remove the residual minor salivary glands. The surgical site was irrigated thoroughly and closed primarily with 3-0 silk sutures. The specimen was placed in 10% formalin and sent for histopathological examination. Sutures were removed after a week with normal healing being observed.(Figure-2)

Microscopic examination of H&E stained soft tissue section shows cystic cavity with mucin surrounded by few histiocytes and chronic inflammatory infiltrates and dilated ducts. Few blood vessels with extravasated RBCsare seen. Normal salivary gland component seen. (F igure-3) C l in ica l and histopathological features are suggestive of Mucous extravasation cyst.Patient was recalled after 3 months or earlier in case of any recurrence.

DISCUSSION AND LITERATURE REVIEW:

Mucocele is defined as a mucus filled cyst that can appear in the oral cavity, appendix, gall

3bladder, paranasal sinuses or lacrimal sac. Oral mucocele represent lesions which affect the oral

1mucosa. Mucous is the exclusive secretory product of minor salivary glands and the major secretion of

6sublingual salivary gland. It is the second common

3benign soft tissue tumour of oral cavity. Incidence is 4around 0.4-0.8%.

Clinically, two types of mucoceles exist- Mucous 3extravasation type and Mucous retention type. Those

which develop due to partial obstruction of salivary ducts should be called as mucous retention cysts and those that develop as a result of a severance of salivary duct and escape of saliva into the tissue

6 should be called mucous extravasation cyst. Shear and Speight clarified that the term ''mucous

extravasation cyst'' is reserved for those lesions in which mucous has extravasated into the connective tissues and in which there is no epithelial

6,9lining. Mucoceles can be either superficial, classical and deep. Superficial mucocele are located under the mucous membrane, classical mucocele are seen in the upper submucosa and deep mucocelein the

3.10lower corium.

The two important etiological factor for mucoceles 3

are Trauma and ductal obstruction. Trauma may cause spillage of mucous in to the submucous tissue fol lowed by stagnant mucous leading to

11inflammation. Ata-Ali et.al., in 2010 proposed three phases of etiopathogenesis for mucoceles.First Phase will be spillage of mucus from salivary duct into the surrounding tissue in which some leucocytes and histiocytes are seen. In second phase, granulomas will appear due to the presence of histiocytes, macrophages and giant multinucleated cells associated with foreign body reaction. This second phase is called as resorption phase followed by third phase where there will be a formation of pseudocapsule without epithelium around the

12mucosa due to connective cells. In our case the patient had given the history of habitual lip biting which clearly states that the swelling is of traumatic origin.

They are clinically characterized as painless, asymptomatic swelling but can produce discomfort by interfering with speech, chewing or even

2,8swallowing. It can occur in patients of all ages predominantly children and young adults with peak incidence at 10-29 years and has equal sex

6predilection. It presents as rounded, dome shaped, well-circumscribed transparent, bluish coloured lesion of variable size. The bluish discoularation is mainly due to the vascular congestion and cyanosis of the tissue above and the fluid

3,4accumulation below. Size may vary from several millimeters to centimeters, single or can be bilateral. The swelling is fluctuant and has relatively rapid onset

3,4,5,6following trauma. Common locations are lower lip followed by buccal mucosa, floor of the mouth,

3,4,6,7,8tongue, retromolar area, palate and upper lip.

The diagnosis is made by proper history and careful examination as the appearaqnce of mucocele is pathognomonic. The history of trauma, rapid

14


15


appearance, fluctuancy, bluish hue will give a clue to 3

the diagnosis. In particular cases, the diagnosis may require traditional radiography, ultrasonography, or advanced diagnostic methods like computed tomography and magnetic resonance imaging. Ultrasonography shows mucocele as cystic masses that sometimes contain fibrillarprocesses produced by fibroblastsseen in minimal numbers within the mucinous area. Fine-needle aspiration is useful especially when differential diagnosis of

6,12angiomatous lesions is involved. FNAC of mucocele often reveals abundant minor salivary gland aciniwith many inflammatory cells, especially histiocytes but

3,13without any epithelial component. Chemical analysis of saliva shows high amylase and protein

3content. In this present case the history of trauma and the characteristic features confirmed mucocele, hence it was surgically excised and sent for histopathological examination.

The various differential diagnosis to be considered are Oral Lymphangioma, Oral Hemangioma, irritational fibroma, Gingival cyst, Benign or malignant salivary gland neoplasm, Venous varix, Soft tissue

2,5abscess. At times Superficial mucoceles may be confused with Cicatricialpemphigoid, Bullous lichen planus and Minor aphthous ulcers.Such cases may require biopsy in addition to direct immuno-fluorescence studies for immunoglobulins and

6,14complement. The most striking differential diagnosis of mucocele is from the low-grade mucoepidermoid carcinoma as both will have bluish hue and shows fluctuancyon palpation, the differentiating feature is mucoepidermoid carcinomas and mucous retention cyst are common on upper lip whereas mucous extravasation cyst is

15common on the lower lip.

The two types of mucoceles- extravasation and rete nt i o n ca n b e d i st i n g u i s h e d o n l y by

1,7,8histopathology. The retention mucocele contains viscous mucous material, always possess an epithelial demarcation and as a rule, show no inflammatory reaction compared with the extravasation mucoceles which is devoid of epithelial lining and contains

3,6,16,17inflammatory cells.

Various invasive and non invasive methods have been 18

proposed for the treatment of mucoceles. The most accepted treatment is surgical extirpation of the

surrounding mucosa and glandular tissue down to 19

the muscle layer. Small sized mucoceles are removed with marginal glandular tissue and in case of large lesions marsupialization will help to avoid damage to vital structures and decrease the risk of damaging the labial branch of mental

3nerve. Noninvasive methods include cryosurgery, laser micro marsupialization, Gluconate-Merucurius Heel Potentised Swine Organ Preparations, CO2 laser ablation, topical and

6,20intralesional injection of corticosteroids. The advantage in CO2 laser is it minimizes the recurrences and complications and allows rapid,

3simple mucocele ablation. Studies suggested that the initial cryosurgical approach or intralesional corticosteroid injection in the treatment of these lesions prove beneficial but chances of relapse is

19.20 more . According to García et al., it must be taken into account that typical minor salivary gland mucoceles rarely resolve on their own, thus surgical

20removal is required in most cases.

CONCLUSION:

Mucoceles are the most common benign self limiting lesions. Most reported literature shows that mucoceles arise from self inflicted traumas like habitual lip/ cheek bitng. Our present case highlights the history of habitual biting of lower lip with characteristic clinical features which reconfirms the literature. Since these are painless lesions, it is dentist who finds it on routine dental checkups. Thus the dentist should have good knowledge about the obstructive disorders and should be able to differentiate from various benign and malignant conditions which will further help in formulating a proper treatment plan and creating awareness among children and young adolescents towards avoidance of self inflicting habits.

Corresponding Author Details:

Dr. Vijayalakshmi Venkat

Post graduate student, Department of oral medicine

and radiology

A.E.C.S Maaruticollege of dental sciences and

research centre

Bangalore, Karnataka- 560076

Email: [email protected]

Contact number- 9901548544.

REFERENCES:

1. Pratik B. Kariya, KapilDagrus, ShrutiBohra, SeemaBargale. Oral mucocele in pediatric patient: A case report and review of literature. EJDTR, 2014 3(3), 234-236.

2. Shetty Urvashi A, Srikala Bhandary, Kumudha Rao, PushparajaShetty. Oral mucocele or mucous escape reaction an obstructive disorder: A report of 2 cases. IJDR 2017; 2(1): 15-17.

3. Prasanna Kumar Rao ,DivyaHegde, Shishir Ram Shetty , LaxmikanthChatra and PrashanthShenai. Oral Mucocele – Diagnosis and Management. Journal of Dentistry, Medicine and Medical Sciences Vol. 2(2) pp. 26-30, November 2012.

4 . D r. R i n i G a n g wa l B a d j at i a \ , D r. S o u ra b h B a d j at i a , Dr.VinayaKumarKulkarni, Dr. Divya S. Sharma. Oral Mucocele: A Case Report. NJDSR Number 2, Volume 1, January 2014.

5. Rajendran R and Sivapathasundharam B: Shafer's textbook of oral pathology, 6thed. India, Elsevier,2010.

6. Tandon A, Sircar K, Chowdhry A, Bablani D. Salivary duct cyst on lower lip: A rare entity and literature review. J Oral MaxillofacPathol 2014;18:151-6.

7. BoneuF, Vidal E, Maizcurrana A, Gonzalez J. Submaxillary glandmucocele: Presentation of a case. Med OralPatol Oral

Cir Bucal 2005; 10:180- 4.

8. Porter SR, Scully C, Kainth B, WardBooth P. Multiple salivary mucoceles in a young boy. Int JPediatr Dent 1998; 8:149-51.

9. Shear M, Speight P. Cysts of the Oral and Maxillofacial Regions.4th ed. Blackwell Munksgaard; 2007.

10.BaurmashH (2002). The etiology of superficial oral mucoceles. J Oral Maxillofac Surg. 60:237-8.

11.Yamasoba T, Tayama N, Syoji M, Fukuta M (1990). Clinicostatistical study of lower lip mucoceles. Head Neck. 12:316-20.

12.Ata-Ali J, Carrillo C ,Bonet C , Balaguer J, Peñarrocha M, Peñarrocha M (2010). Oral mucocele: review of the literature. J ClinExp Dent. 2:e18-21.

13.Guimarães MS, Hebling J, Filho VA, Santos LL, Vita TM, Costa CA (2006). Extravasationmucocele involving the ventral surface of the tongue (glands of Blandin-Nuhn). Int J Paediatr Dent. 16:435-39.

14.Khandelwal S, Patil S. Oral mucoceles-review of the literature. Minerva Stomatol 2012;61:91-9.

15.Carlson ER, Ord RA. Textbook and Color Atlas of Salivary Gland Pathology: Diagnosis And Management. Blackwell Munksgaard. p. 91-108.

16.Seifert G, Donath K, von Gumberz C. Mucoceles of the minor salivary glands. Extravasation mucoceles (mucus granulomas) and retention mucoceles (mucus retention cysts. HNO 1981;29:179-91.

17.Oliveira D.T, Consolaro A, Freitas F.J.G. Histopathological spectrum of 112 cases of mucocele. Braz Dent J, 1993; 4(1):29-36.

18.Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and maxillofacial pathology, 2nd p.389–91.

19.Baharvand M, Sabounchi S, Mortazavi H. Treatment of Labial Mucocele by Intralesional Injection of Dexamethasone: Case Series. J Dent Mater Tech 2014;3(3):128-33.

20.García JY, Tost AJE, Aytés LB, Escoda CG (2009). Treatment of oral mucocele - scalpel versus C02 laser. Med Oral Patol Oral Cir Bucal. 14 :e469-74.

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17

ABSTRACT

The transformation of Public Health Dentistry skills has emerged from the evolution of innovative and latest Public Health Dentistry skills. Newer Public Health dentistry skills are a contemporary application of a broad range of evidence based scientific, technological, and management systems implementing measures to improve the oral health of individuals and populations. Its main objectives are the political and practical application of lessons learned from past successes and failures in disease control and the promotion of preventive measures to combat existing, evolving and re-emerging oral health threats and risks. These skills are acquired skills and technological advancements over the past 50 years that have improved to address many new challenges. The tools at our disposal today are much more effective than they were even ten years ago, thus Promoting wider application of these tools. This approach includes health promotion, implementing technological advances and practicing gold standard methodologies.

Public Health Dentistry skills (Core Competencies) include developing Analytic Assessment Skills, Policy Development/Program Planning Skills, Communication Skills, Cultural Competency Skills, Community Dimensions of Practice Skills ,Basic Public Health Sciences Skills, Financial Planning and Management Skills, Leadership and Systems Thinking Skills using newer tools .

The New Public Health dentistry is a moving target, as the science and practice of public health grow in strength. It is an integrative approach to protect and promote the oral health status of both the individual and the society with social equity and efficient use of resources. Greater awareness of achievements and failures in Public Health Dentistry will improve the Public Health professionals to bring about better oral health for the population in future.

Keywords : Public Health Dentistry Skills; Health Promotion; Core Competencies.

1 2 3 4 5Authors : Dr. Chintakayala Mayuri , Dr. Sabiyata Khajuria , Dr. Mahesh Chandra K , Dr. Vanishree M.K , Dr. Guru Suhas

1. Dr. ChintakayalaMayuri, Post Graduate student

2. Dr. SabiyataKhajuria, Post Graduate student

3. Dr. Mahesh Chandra K, HOD and Professor

4. Dr. Vanishree M.K, Reader

5. Dr. Guru Suhas, Senior Lecturer

Department of Public Health Dentistry,

AECS Maaruti College of Dental Sciences and Research Centre,

Bengaluru, Karnataka.

INTRODUCTION

Dr. Cordell Neudorf, Chair of CPHA Board of Directors

said that “The best way to guarantee public health

capacity … is to ensure that the public health system

has a strong baseline capacity – a highly qualified

workforce with transferable skills or competencies 1

that can be called upon in times of need.”

Dental public healthis defined by the American Board

of Dental Public Health as: "...the science and art of

preventing and controlling dental diseases and

promoting dental health through organized

community efforts. It is that form of dental practice

which serves the community as a patient rather than

the individual. It is concerned with the dental

education of the public, with applied dental research,

and with the administration of group dental care

programs as well as the prevention and control of 2dental diseases on a community basis." Public Health

is a critical element in the health care system. The

services are population focused; for example, they are

services and interventions that protect entire 3populations from illness, disease and injury. This

population-based approach to professional practice is

quite different from the approach required for

individual patient care in private practice, though

both forms of practice are integral parts of the dental 2profession. Also in order for community health

workers (CHWs) to do their jobs effectively and to

grow personally and professionally through their

work, dental public health practice demands an

additional body of knowledge and also possess

Contemporary paradigm shift of public health dentistry skills

certain core skills. These competencies are NOT

discrete, nor ranked in order of importance, but rather

are the set of overlapping and mutually reinforcing

skills and knowledge essential for effective

community health work and advancement in the 4

field.

The Core Competencies for Public Health

Professionals (Core Competencies) are a consensus

set of skills for the broad practice of public health, as

defined by the 10 Essential Public Health Services.

Developed by the Council on Linkages Between

Academia and Public Health Practice (Council on

Linkages), the Core Competencies reflect

foundational skills desirable for professionals

engaging in the practice, education, and research of 5

public health. Core competencies are defined as …

the essential knowledge, skills and attitudes

necessary for the practice of public health. They

transcend the boundaries of specific disciplines and

are independent of program and topic. They provide

the building blocks for effective public health practice,

and the use of an overall public health approach.

Generic core competencies provide a baseline for

what is required to fulfill public health system core

functions. These include population health

assessment, surveillance, disease and injury

prevention, health promotion and health protection 6(Public Health Agency of Canada, 2007, p. 1).

Following an extensive literature search, review and

analysis, Sutcliffe, Snelling, and Laclé (2010) identified

competencies and organizational standards as one of

ten promising practices, at the local public health

level, with potential to contribute to reduction in

social inequities in health. The National Collaborating

Centre for Determinants of Health (NCCDH) reviewed

Core Competencies for Public Health in Canada:

Release 1.0 (PHAC, 2007), as well as selected core

competencies documents from the United States

(US), United Kingdom (UK) and Australia, to assess

how and to what extent the determinants of health

are described and reflected in the core competencies

and to make recommendations based on the findings.

The NCCDH encourages public health practitioners

and policy makers to consider this assessment during

a review of the Core Competencies for Public Health in 6

Canada: Release 1.0.

Because core competencies identify the essential

knowledge, skills and attitudes that public health

practitioners need, they benefit people who work in

public health by providing standards for staff

recruitment, development and retention. Core

competencies provide a basis for developing

curricula, training programs and professional

development tools, and they improve consistency in

job descriptions and performance assessments.

Benefits to organizations include identifying the

knowledge, skills and attitudes required across an

organization or program to fulfill essential public

health functions. Core competencies assist in

identifying the appropriate number and mix of public

health practitioners and in facilitating collaboration,

shared goals and interdisciplinary work. The use of

core competencies can contribute to improved health

of the public by encouraging evidence-based,

population-focused, ethical, equitable, standardized 6

and client-centered care. So the present review aims

to enlighten the core competencies of public health

which is required for a public health specialist to

promote health and well-being of the community.

WHAT ARE PUBLIC HEALTH CORE COMPETENCIES?

Core competencies are the essential knowledge, skills

and attitudes necessary for the practice of public

health. They transcend the boundaries of specific

disciplines and are independent of program and topic.

They provide the building blocks for effective public

health practice, and the use of an overall public health

approach. Generic core competencies provide a

baseline for what is required to fulfill public health

system core functions. These include population

health assessment, surveillance, disease and injury 7prevention, health promotion and health protection.

These are:-

Ø Set of skills desirable for broad practice of public

health

Ø Tool for assessment and workforce/training plan

development that meets accreditation standards

Ø Replicated across the country by public health

agencies of various sizes

Ø Created by the Public Health Foundation

specifically for public health professionals

18


WHY DO WE NEED PUBLIC HEALTH CORE

COMPETENCIES?

1. Core competencies may improve the health of the

public by:

• Contributing to a more effective workforce

• Encouraging service delivery that is evidence

based, population-focused, ethical, equitable,

standardized and client-centered

• Helping to create a more unified workforce by

providing a shared understanding of key concepts

and practices

• Helping to explain the nature of public health and

public health goals.

2. Core competencies will benefit the people who

work in public health by:

• Providing guidelines for the basic knowledge, skills

and attitudes required by individual practitioners in

public health

• Supporting the recruitment, development and

retention of public health practitioners

• Providing a rational basis for developing curricula,

training and professional development tools

• Improving consistency in job descriptions and

performance assessment

• Supporting the development of disciplineand

program-specific sets of competencies.

3. Core competencies can help public health

organizations to:

• Identify the knowledge, skills and attitudes required

across an organization or program to fulill public

health functions

• Help identify the appropriate numbers and mix of

public health workers in a given setting

• Identify staff development and training needs

• Provide a rationale for securing funds to support

workforce development

• Develop job descriptions, interview questions, and

frameworks for evaluation and quality assurance

• Facilitate collaboration, shared goals and 7interdisciplinary work.

PUBLIC HEALTH CORECOMPETENCIES REQUIRED

FOR?

Individuals with post-secondary training in public

health are expected to possess all of the core

competencies at least at a basic level of proficiency.

The core competencies primarily relate to the practice

of individuals, including front line providers,

consultants/specialists and managers/ supervisors.

They can also serve as a tool for assessing and creating

the best mix of competencies for a public health team

or organization. Individuals must be supported and

assisted by employers, professional organizations,

educational institutions, regulatory bodies, unions,

and governments at the federal, provincial/territorial 7

and local levels.

DEVELOPMENT OF THE PUBLIC HEALTH CORE

COMPETENCIES

Competency statements for dental public health, and

the performance indicators by which they can be

measured, were developed at a workshop in San

Mateo, California, on May 4-6, 1997. This was the third

in a series of such workshops conducted by the

American Association of Public Health Dentistry and

the American Board of Dental Public Health which set

up the knowledge and practice base by which the

specialty is recognized. The first such workshop was

held at Boone, NC, in 1974, and the second at

Bethesda, MD, in 1988. Social and technological

change and the evolution of the specialty make

periodic revisions essential. The Core Competencies

grew from a desire to help strengthen the public

health workforce by identifying basic skills for the

effective delivery of public health services. Building on

the Universal Competencies developed by the Public

Health Faculty/Agency Forum in 1991, the current

Core Competencies are the result of more than two

decades of work by the Council on Linkages and other

academic and practice organizations dedicated to

public health. Transitioning from a general set of

Universal Competencies to a more specific set of Core

Competencies began in 1998 and involved public

health professionals from across the country through

Council on linkages member organizations, the

council on linkages core competencies workgroup,

and a public comment period that resulted in over

1,000 comments. This extensive development process

19


was designed to produce a set of foundational

competencies that truly reflected the practice of

public health. These competencies were organized

into eight skill areas or “domains” that cut across

public health disciplines. The first version of the Core

Competencies was adopted by the Council on

Linkages in April 2001, and the Council on Linkages

committed to revisiting the Core Competencies every

three years to determine if revisions were needed to

ensure the continued relevance of the competency

set. The Core Competencies were reviewed in 2004,

with the Council on Linkages concluding that there

was inadequate evidence about use of the Core

Competencies to support a significant revision. At the

second review in 2007, the Council on Linkages

decided that revision was warranted based on usage

data, changes in the practice of public health, and

requests to make the Core Competencies more

measurable. Similar to the development process, the

revision process begun in 2007 was led by the Core

Competencies Workgroup and involved the

consideration of more than 800 comments from

public health professionals. A major focus of the

revision process was on improving measurability of

the competencies, and the revisions both updated the

content of the competencies within the eight domains

and added three “tiers” representing stages of career

development for public health professionals. The

Council on Linkages adopted a revised version of the

Core Competencies in May 2010. Review of the May

2010 Core Competencies began in early 2013, and the

Council on Linkages again decided to undertake

revisions. In addition to updating the content of the

competencies, this revision process was aimed at

simplifying and clarifying the wording of

competencies and improving the order and grouping

of competencies to make the competency set easier 5

to use.

Key Dates

Since development began in 1998, the Core

Competencies have gone through three versions:

· 2001 version – Adopted April 11, 2001 (original version)

· 2010 version – Adopted May 3, 2010

· 2014 version – Adopted June 26, 2014 (current 5

version)

ORGANIZATION OF THE PUBLIC HEALTH CORE

COMPETENCIES

The Core Competencies are organized into eight

domains, reflecting skill areas within public health,

and three tiers, representing career stages for public

health professionals.

Domains 1.Analytical/Assessment Skills 2.Policy Development/Program Planning Skills 3.Communication Skills 4.Cultural Competency Skills 5.Community Dimensions of Practice Skills 6.Public Health Sciences Skills 7.Financial Planning and Management Skills

58.Leadership and Systems Thinking Skills

Tier Definitions

Tier 1 – Front Line Staff/Entry Level

Tier 1 competencies apply to public health

professionals who carry out the day-to-day tasks of

public health organizations and are not in

management positions. Responsibilities of these

professionals may include data collection and

analysis, fieldwork, program planning, outreach,

communications, customer service, and program

support.

Tier 2 – Program Management/Supervisory Level


professionals in program management or supervisory

roles. Responsibilities of these professionals may

include developing, implementing, and evaluating

programs; supervising staff; establishing and

maintaining community partnerships; managing

t imelines and work plans; making pol icy

recommendations; and providing technical expertise.

Tier 3 – Senior Management/Executive Level


professionals at a senior management level and to

leaders of public health organizations. These

professionals typically have staff that report to them

and may be responsible for overseeing major

programs or operations of the organization, setting a

strategy and vision for the organization, creating a

culture of quality within the organization, and 5working with the community to improve health.

20


Eight domains have remained consistent in all

versions of the Core Competencies.

During the 2014 revision of the Core Competencies,

minor changes were made to clarify these tier

definitions. In general, competencies progress from

lower to higher levels of skill complexity both within

each domain in a given tier and across the tiers.

Similar competencies within Tiers 1, 2, and 3 are

presented next to each other to show connections

between tiers. In some cases, a single competency

appears in multiple tiers; however, the way

competence in that area is demonstrated may vary 5

from one tier to another.

1.Analytical/ assessment skills:- Identify and

understand data, Turn data into information for

action, Assess needs and assets to address

community health needs.

2.Policydevelopment/program planning skills:-

Determine needed policies. Effectively advocate for

policy. Plan, implement, evaluate and improve

programs.

3.C o m m u n i cat i o n s k i l l s : - i n c l u d e h e a l t h

literacy,community input, presentations, written/oral

communication. Also to listen and interpret.

Cultural competencyskills:- understand and

effectively respond to diverse needs, assess

organizational cultural diversity and competence,

ensure organizational cultural competence.

Community dimensions of practiceskills:-evaluate

and develop linkages and relationships within the

community, maintain and advance partnerships and

community involvement, defend public health

policies and programs, evaluate effectiveness and

improve community engagement.

Public health sciences skills:- history, scientific

foundation and evidence, ethical conduct of research,

research limitations

Financial planning and management skills:- leverage

community resources, manage partnership and

ensure programs are well managed, evaluate program

performance, motivation and establish performance

management system.

Leadership and systems thinking skills:-incorporate

ethical standards into the organization, integrate

systems thinking into public health practice,

monitoring, ensure continuous quality improvement;

adjust practice to address changing needs

andenvironment

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22


23


24


25


26


27


28


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CONCLUSIONThe practice of public health is both an art and a science. The common language and purpose of core competencies helps to define describe and standardize complex work in a complex environment. The Core Competencies support workforce development within public health and can serve as a starting point for public health professionals and organizations as they work to better understand and meet workforce development needs, improve performance, prepare for accreditation, and enhance the health of the communities they serve. More specifically, the Core Competencies can be used in assessing workforce knowledge and skills, identifying training needs, developing workforce development and training plans, crafting job descriptions, and conducting performance evaluations. The Core Competencies must be integrated into curricula for education and training; provide a reference for developing public health courses, and serve as a base for sets of discipline-specific competencies. Public health organizations are encouraged to interpret and adapt the Core Competencies in ways that meet their specific organizational needs.

REFERENCES 1. Public health association of British Columbia - https://phabc.org/ accessed on 12/11/2017

https://aaphd.memberclicks.net/assets/Education/competency%20statements-dental%20public% 20health%201.pdf

2. accessed on 12/11/2017

http://chfs.ky.gov/NR/rdonlyres/9B1E384C-40B7-444C-AA4F-7C9916C77D6C/0/ARVolIPublicHealth CoreFunctionsandCommunityHealthPlanning.pdf


http://www.machw.org/documents/CHWInitiative10CHWCoreCompetencies10.17.07.pdf


www.phf.org/.../Core_Competencies_for_Public_Health_Professionals_2014June


http://nccdh.ca/images/uploads/Core_competencies_EN_121001.pdf


http://www.phac-aspc.gc.ca/php-psp/ccph-cesp/pdfs/cc-manual-eng090407.pdf


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ABSTRACT With the availability of information technology in today's world and its integration in healthcare systems; the term “Public Health Informatics (PHI)” was coined and used. The main focus of PHI is the use of information science and technology for promoting population health rather than of individuals. PHI has a disease prevention rather than treatment focus in order to prevent chain of events or disease spread. Moreover, PHI often operates at the level of government rather than at the private sector. The current need for PHI arises from dramatic improvements in information technology, new pressures on the public health system, and changes in medical care delivery.The purpose of this article is to introduce the relatively new field of public health informatics and application of PHI principles provides unprecedented opportunities to build healthier communities.

Keywords- Public Health Informatics, surveillance, electronic Health Record, GIS and teledentistry.

Know Your Community – Build a Strong Bridge through Public Health Informatics

1 2 3 4 5Authors- Dr. Sabiyata Khajuria , Dr. ChintakayalaMayuri , Dr. Mahesh Chandra K , Dr. Vanishree M.K , Dr. Guru Suhas

1. Dr. Sabiyata Khajuria, Post Graduate student

2. Dr. ChintakayalaMayuri, Post Graduate student

3. Dr. Mahesh Chandra K, HOD and Professor

4. Dr. Vanishree M.K, Reader

5. Dr. Guru Suhas, Senior Lecturer

Department of Public Health Dentistry,

AECS Maaruti College of Dental Sciences and Research Centre,

Bengaluru, Karnataka.

INTRODUCTION

The emergence and rapid evolution of micro-processor technology enabled developments in Information and Communication Technologies (ICTs) that widened and transformed economic and social

1activities all over the world. The combination of the burgeoning interest in health, health care reform and the advent of the information represent a challenge and an opportunity for public health. For the effective development of public health, practitioners and researchers need reliable, timely information to make information-driven decisions, better ways to communicate, and improved tools to analyse and

2 present new knowledge.

Thus, amore systematic and informed approach is needed for the application of information science and technology so as to take full advantage of its potential

4to enhance and facilitate public health activities. In the recent past, this approach has emerged as a new and distinct specialty area in the global scenario within the broader discipline of health informatics, termed as public health informatics. It is an interdisciplinary profession that applies mathematics, engineering, information science, and related social sciences. (e.g, decision analysis) to important public

5health problems and processes. This article aims to review the principles, the scope, information and technology related tools of PHI and their application

for betterment of public.

What is Public Health Informatics?

Public Health Informatics is firstly defined by Yasnoff et al, in a paper published in 2000 as the systematic application of information and computer science and technology to public health practice, research and

6learning. Basically it is about using informatics in public health data collection, analysis and actions.

The scope of PHI includes the conceptualization, design, development, deployment, refinement, maintenance, and evaluation of communication, surveillance, and information systems relevant to

7public health.

Principles of Public Health Informatics

Public health informatics is related to medical informatics in several respects. Both disciplines seek to use information science and technology to improve human health. There are four principles that define, guide, and provide the context for the types of activities and challenges that comprise this new field:

1. As a discipline, public health focuses on the health of the population and the community, as opposed to that of the individual patient. Thus focus on application of information science and technology that promote the health of populations as opposed to the health of specific individuals.

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2. Focus on the information science and technology applications that prevent disease and injury by altering the conditions or environment that put populations at risk.

3. Explore the potential for prevention at all vulnerable points in the causal chains leading to disease, injury, or disability; applications should not be restricted to particular social, behavioural, or environmental contexts.

4. As a discipline, public health informatics should reflect the governmental context in which public health is practiced. Much of public health operates through government agencies that require direct responsiveness to legislative, regulatory, and policy directives, careful balancing of competing priorities,

8and open disclosure of all activities.

Recently this definition and the agenda have been updated to reflect four key drivers:

1) A global reduction in infectious disease rates in combination with a growth in non-communicable chronic diseases;

2) The broader implementation of health information systems across the world;

3) Continued rising costs of health care in nearly every nation; and

4) A greater emphasis on patient involvement in decision-making processes. The result is a complex scope for public health informatics that intersects with similarly expanding fields of Global Health Informatics (public health and health care in low-resource settings) and Population Health Informatics (healthcare and social services to clinical

9populations).

Work of public health informatics can be divided into three categories i.e. study and description of complex systems, identification of opportunities to improve the efficiency and effectiveness of public health systems through data collection or use of information and finally the implementation and maintenance of processes and systems to ach ieve such

10improvements.

Creating a Public Health Information System

The process involved in creating a public health information system has 5 steps:

1. Vision and System Planning,

2. Health Data Standards and Integration,

3. Data Privacy and Security,

4. Systems Design and Implementation,

5. Visualization, Analysis, and Reporting of Health 11

Data.

PUBLIC HEALTH SURVEILLANCE

Surveillance is another aspect of public health that could be dramatically transformed by application of information technology. Public health surveillance is the systematic, on-going collection, management, analysis, and interpretation of data followed by the dissemination of these data to public health programs

12to stimulate public health action. Through available data, early detection of outbreaks can be achieved through timely and complete receipt, review, and

13investigation of disease case reports. Worldwide, governments are strengthening their public health disease surveillance systems, taking advantage of modern information technology to build an integrated, effective, and reliable disease reporting

14system. The use of computerized global surveillance and data collection systems, such as health information exchange (HIE) and health information organization (HIO), could assist in population-level monitoring. This could help to avert the negative

15impact of a widespread global epidemic.

Applications of PHI

PHI could be considered one of the most useful systems in addressing disease surveillance, epidemics, natural disasters and bioterrorism.

1. During epidemics and natural disasters Data needs to be collected on a periodic basis to assess the prevalence and incidence of various diseases in a population as well as to keep a track on the trends. Public health reports are essential tools to estimate morbidity and mortality. In addition, surveillance data assist in the estimation of the resources and man power needed to handle these disasters.

2. Bioterrorism is another concern where the public is exposed to sudden and uncontrolled circumstances of the biological agents' release. PHI played a role in the collection and analysis of real-time data that were introduced right after the bioterrorism attack. The data is then sent, analysed and converted to

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information by the usage of statistical algorithms that detect anomalies that could help to identify outbreaks

16to the surveillance systems.

3. In worldwide and emergency disasters to collect data, threat detection and responding to that threat correctly and suitable time such as Hurricane Katrina

15and H1N1 influenza.

TOOLS OF DATA COLLECTION

World Health Organisation (WHO) has identified ICT related tools such as Geographical Information System (GIS), Teledentistry, Patient's Information System, Decision Support System, Electronic Health Records (EHRs), etc. form the basis of a public

17healthcare setup.

Electronic medical/health record

Electronic Medical Record (EMR) is the electronic record of the specific health-related event for a person whilst Electronic Health Record (EHR) is the electronic record for a person of all health-related events before birth till death (womb-to-tomb health record!). These terms describe systems that provide

18,19 “structured, digitized and fully accessible record.”

Advantages are:

(i) it helps in reduction of error in medical care, (ii) it is easy to maintain for a long period, (iii) it has low maintenance costs, (iv) it is easy to access from any corner of the world if linked to the world wide web, (v) it helps to make proper diagnosis and follow-up, (vi) it improves efficiency of health care, and (vii) it helps in research.

Geographical information system

Geographic information system (GIS) is a system designed to capture, store, manipulate, analyse,

17 manage, and present all types of geographical data.Public health applications of GIS include infectious disease surveillance and control, especially vector-borne diseases; to meet the demands of outbreak investigation and response, analysing spatial and temporal trends; mapping populations at risk; stratifying risk factors; assessing resource allocation; planning and targeting interventions and monitoring

20diseases and interventions over time.

Teledentistry

It is a relatively new field and due to the extensive

growth of technological capabilities and possesses the potential to fundamentally change the face of the current dental care. It increases patient access to dental care, improves quality of care and the cost

21 effectiveness. It has enormous scope but poverty, illiteracy, and lack of infrastructure, are major challenges in its implementation.

CONCLUSION

The confluence of improved information systems and technologies, new challenges to the public health system, and changes in health care system presents a unique opportunity, to not only improve the efficiency and effectiveness of public health practice, but to transform fundamentally some aspects of public health practice itself. This new and evolving discipline of public health informatics is the key to systematically and scientifically exploiting this opportunity to the benefit of the public's health. The revolution of information technology and the urge to incorporate it into different aspects of healthcare has become a required task for public health leaders. The adoption of new information systems by patients, healthcare professionals, and public health officials can help in reshaping public health.

REFERENCES

1. Chandrasekhar CP, Ghosh J. Information and communication technologies and health in low income countries: the potential and the constra ints . Bul l World Health Organ 2001;79:850-5.

4. R.D. Lasker, B.L. Humphreys, and W.R. Braithwaite, Making a Powerful Connection: The Health of the Public and the National Information Infrastructure. Washington, DC: Public Health Data Policy Coordinating Committee, U.S. Public Health Service, 1995

2. Friede A, Blum HL, McDonald M. Public health informatics: how information-age technology can strengthen public health. Annual review of public health. 1995 May;16(1):239-52.

3. Athavale AV, Zodpey SP. Public health informatics in India: The potential and the challenges. Indian journal of public health. 2010 Jul 1;54(3):131.

5. Savel TG, Foldy S. The role of public health informatics in enhancing public health

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surveillance. MMWR Surveill Summ. 2012 Jul 27;61(Suppl):20-4.

6. O'Carroll PW, Yasnoff WA, Ward ME. Public health informatics and information systems, Springer, 2002.

7. Choi BC. The past, present, and future of public health surveillance. Scientifica. 2012 Oct 23;2012.

8. Yasnoff WA, O'Carroll PW, Koo D, Linkins RW, Kilbourne EM. Public Health Informatics: Improving and Transforming Public Health in the Information Age. J Public Health Manag Pract 2000;6:67-75.

9. Dixon BE, Kharrazi H, Lehmann HP. Public health and epidemiology informatics: recent research and trends in the United States. Yearbook of medical informatics. 2015;10(1):199.

10. Lee LM, Teutsch SM, Thacker SB, St. Louis ME. Principles and Practice of Public Health Surveillance. New York, NY: Oxford University Press; 2010.

11. Centers for Disease Control and Prevention. Public health 101 series: Introduction to Public Health Informatics. Available from

https://www.cdc.gov/publichealth101/documents/introduction-to-public-health-informatics.pdf

12. Thacker SB, Qualters JR, Lee LM, Centers for Disease Control and Prevention. Public health surveillance in the United States: evolution and challenges. MMWR Surveill Summ. 2012 Jul 27;61(Suppl):3-9.

13. KraftMR, Androwich I.Informatics for health professionals. 1st ed. Burlington: Jones & Bartlett Learning, 2017. Chapter 17, Using Informatics to Promote Community/Population Health; 251-263

14. Wang L, Wang Y, Jin S, Wu Z, Chin DP, Koplan JP, Wilson ME. Emergence and control of infectious diseases in China. Lancet 2008; 372(9649): 1598-1605.

15. Aziz HA. A review of the role of public health informatics in healthcare. Journal of Taibah University Medical Sciences. 2017 Feb 28;12(1):78-81.

16. Lombardo JS , Bucker idge DL. Disease surveillance: a public health informatics approach. New Jersey: John Wiley & Sons; 2012.

17. Dani N, Sood SP, Prakash N, Mbarika V, Agrawal R. GIS and Telemedicine: Tools for Public Healthcare. e health 2006;1:11-5.

18. Pagett C. Clarifying the complex world of EHR. Health-e developments 2005;1:1-5.

19. Smolij K, Dun K. Patient Health Information Management: Searching for the Right Model. Perspectives in Health Information Management [serial on the internet]. 2006;3:10.

21. Chen JW, Hobdell MH, Dunn K, Johnson KA, Zhang J. Teledentistry and its use in dental education. J Am Dent Assoc 2003;134(3):342-346.

20. Shrinagesh B, Kalpana M, Kiran B. GIS for public health: A study of Andhra Pradesh. InIOP Conference Series: Earth and Environmental Science 2014 (Vol. 20, No. 1, p. 012024). IOP Publishing.

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ABSTRACT

Introduction:

Oral submucous fibrosis is a disabiling, potentially malignant condition of the oral cavity. The etiology is multifactorial but remains obscure. Areca nut is considered to be the most important causative agent. Various treatment modalities have been tried to treat this condition.

Case Report:

We hereby report a patient with Stage III OSMF suffering from Alzheimer's disease who showed a significant improvement in mouth opening of approximately 5 mm on usingintralesional Injection Hyanidase ( Hyaluronidase ) 1500 IU and Injection Dexona (Dexamethasone) 4mg , 2 times per week for 6 weeks along with SM Fibro 1 tablet per day for 6 weeks.

Conclusion :

A restricted mouth opening seen in the advanced stages of OSMF ,leads to a reduced food intake has a significant negative impact on the general health of the patient thus making its management essential. Cessation of the habit along with the medical line of treatment and proper diet though not curative helps to alleviate the symptoms to a large extent.

Key Words: Oral Submucous Fibrosis, Hyaluronidase, Dexamethasone, Antioxidants

Authors- 1 2 3 4 5 6

SrutiKalluri , Satheesha Reddy BH , Ramamurthy TK , Shilpa B , Rajeshwari K ,Dr R Chethan

Department of Oral Medicine & RadiologyAECS Maaruthi College of Dental Sciences & Research CentreBengaluru

1. Post Graduate Student2. Satheesha Reddy BH, Professor & Head of the Department3. Ramamurthy TK, Professor4. Shilpa B, Reader5. Rajeshwari K, Senior Lecturer

6. Dr R Chethan, Senior Lecturer

SrutiKalluri,

Medical management of Oral Submucous Fibrosis in a patient suffering from

Alzheimer's disease. A case report with review of literature.

INTRODUCTION

In this Modern era, as the evolution and civilization are progressing, human beings are subjected to various adverse habits. Most of which are tension relieving habits according to the patient which include smoking, pan, betel nut/ tobacco chewing and alcoholism which are addictive overtime. These habits do more harm than good to man. Oral Submucous fibrosis is one of such condition resulted from these adverse habits.

World Health Organisation defined OSMF as a “Slowly progressive disease characterized by fibrous bands in the oral mucosa, ultimately leading to severe restriction of mouth movement including the

1tongue”. In India the prevalence rate of OSMF is

2,3about 0.2 to 0.5%.

The etiology of OSMF is considered to be multifactorial, but remain obscure. several theories have been put forth to explain the etiology of OSMF, such as the use of areca nut, tobacco and allergy to

4chillies.

The etiopathogenesis of OSMF is complex and incompletely understood. Areca nut is the main agent involved in the pathogenesis of OSMF. Areca nut is made up of alkaloid and flavonoid components. Four alkaloids namely arecoline, arecaidine, guvacine, and guvacoline have been identifed in areca nut. Arecolinecauses an abnormal increase in collagen productionand is the most potent agent playing a

5major role in the pathogenesis of OSMF .

Many treatment protocols for oral sub mucous fibrosis have been proposed to alleviate its signs and symptoms . Patient is advised to completely quit the habit of betel nut chewing. The treatment of oral submucous fibrosis includes iron supplements, multivitamins including lycopene, pentoxifylline, local submucosal injections of steroids, hyaluronidase, aqueous extract of healthy human placenta, and

5surgical excision of the fibrous bands.

Hereby we report a case of Stage III OSMF which was successfully managed with intralesional injections of hyaluronidase 1500 IU , dexamethasone 4mg along with antioxidants and multivitamins.

35


CASE REPORT

A 62 year old male patient came to department of oral medicine and radiology with a chief complain of pain in left lower back tooth region since 2 days. On elicitnghistory of presenting illness patient gave a history of pain which is insidious in onset , moderate intensity, intermittent, throbbing in nature which aggravates on eating and lying down and subsides on medication ( Tab .Paracetamol 500mg). No other associated symptoms were present. Past dental history revealed a history of intralesional injectionsin right and left buccal mucosa along with Tab Lycopene 8 mg ( 1-0-1) for a reduced mouth opening ( 10 injections) before 1 year which resulted in significant increase in mouth opening ( 7mm). Patient's medical history revealed that he is diagnosed for Alzheimer's disease for the past 5 years and is under medication for the same (Tab .Donamem 10 mg 1-0-1, Tab .Procomet Am ( 50 + 5) and hypothyroidism for past 2 years and is under medication for the same ( Tab . Thyronom 25 micro grams , 1-0-0) . Personal history revealed that patient had a habit of chewing ghutka 10-12 packets / day , 1 packet at a time , for the past 20 years.Patient quit the habit 4 years ago.

Extraoral examination revealed , mouth opening of 24 mm.( Figure 1)Intraoral examination revealed diffuse blanched areas in the lower labial mucosa ( Figure 2) , right and left buccal buccal mucosa( Figure 3 , 4) and the faucial pillars (Figure 5 ). On palpation circular fibrous bands were felt in the labial mucosa and vertical fibrous bands were present in the posterior

r d2/3 of the buccal mucosaOther findings includedpartially erupted 38 with a grade II gingival recession and a 7mm pocket.Dental caries with pulpal involvement was seen in relation to 33, 34,35,36 with tenderness on percussion in relation to 34,35,36, 37,38. Based on the history and clinical examination a provisional diagnosis of periodontal abscess in relation to 38 and stage III Oral Submucous Fibrosis were considered. Panaromic imaging (Figure6) revealed anhorizontally impacted 38 with a diffuse radiolucency surrounding the entire crown and root. Dental caries with pulpal involvement was observed in relation to 34,35,36,37 with a diffuse radiolucency at the periapical region of 36, 37. Based on the history,clinical, radiographic examination a final diagnosis of Chronic Generalised Periodontitiswith periodontal abscess in horizontally impacted 38,

chronic periapical abscess in relat ion to 33,34,35,36,37and Oral Submucous Fibrosis Stage III were established. Extraction of 37, 38 was performed under local anesthesia. Patient was given intralesional injections of Inj.Hyaluronidase 1500IU, Inj dexamethasone 4mg along with local anesthesiain the right and left buccal mucosa and the lower labial mucosa for twice aweek for 6 weeks along with Tab. SM Fibro (a combination of carotenoids, lycopene, alpha lipoic acid minerals).Patient showed a significant improvement in the mouth opening from 24mm to 29mm ( Figure7)thus providing access for endodontic treatment in relation to 33,34,35,36.

DISCUSSION

Alzheimer's disease is a chronic neurodegenerative disease that usually starts slowly and worsens over

6,7time. It is the cause of 60% to 70% of cases of dementia. The most common early symptom is difficulty in remembering recent events (short-term

6memory loss). As the disease advances, symptoms can include problems with language , disorientation (including easily getting lost), mood swings , loss of motivation , not managing self-care, and behavioural

6,7issues. As a person's condition declines, they often withdraw from family and society.

Oral submucous fibrosis (OSMF) is an insidious, chronicdisease affecting any part of the oral cavity, and sometimespharynx. Although occasionally preceded and/or associatedwith vesicle formation, and always associated witha juxtraepithelial inflammatory reaction followed by fibroelasticchange of the lamina propria, with epithelial atrophy leading tostiffness of the mucosa and causing inability to open the mouthand difficulty ineating (Pindborg and Sirsat,

81966).

Theoverall prevalence rate in India is believed to be about 0.2–0.5% and prevalence by gender varying from 0.2 to 2.3% inmales and 1.2 to 4.57% in females

8(Yoithapprabhunathet al.,2013).

The onset of the condition is insidious and is often of 2 to 5 years duration. Most common initial symptom is a burning sensation in the mouth, often experienced when patient is eating spicy or hot foods.Other early symptoms are blisters, ulcerations or recurrent stomatitis. Excessive salivation, defective gustatory

9sensation and dryness of mouth. As the disease progresses, the oral mucosa becomes blanched,

36


slightly opaque and white and fibrous bands appear. Whitening often takes palce in spots giving a marble like appearance to the oral mucosa.The fibrous bands in the buccal mucosa run in vertical direction and fibrosis is sometimes so marked that cheeks are almost immovable. In soft palate, the fibrous bands radiate from pterygomandibular raphae or anterior faucial pillar and have a scar like appearance. The uvula shrinks and appears as a small fibrous bud. The faucial pillars become thick, short and extremely hard. The tonsils may get pressed between the fibrosed pillars. Sometimes the fibrosis spreads to the pharynx and down to the pyriform fossae. The lips are often affected and a circular band can be felt around the entire mouth called rima oris along with atrophy of vermillion border. There will be impairment of tongue

9movement and atrophy of tongue papillae.

Oral submucous fibrosis is diagnosed on clinical criteria including mucosal blanching, burning sensation, hardening and presence of characteristic fibrous bands and associated with limited mouth

9opening.

10Khanna and Dave R (1995) gave a clinical classification of OSMF.

Grade I: Very early or incipient stage

Burning sensation, dryness of mouth, irritation with spicy food, no changes in mucosal colour, no fibrous bands palpable, mouth opening 36-40mm, tongue protrusion normal.

Grade II: Early stage

Burning sensation and dryness of mouth, irritation with spicy food, oral mucosa blanched and loss of elasticity, no clear cut fibrotic band, slight restriction of mouth opening, tongue protrusion normal, mouth opening 26-35mm.

Grade III: Moderatly advanced stage

Burning sensation and dryness of mouth, irritation with spicy food, blanched, opaque leather-like mucosa vertical fibrotic bands on buccal mucosa making it stiff considerable restriction of mouth opening, tongue protrusion not much affected, difficulty in eating and speaking, poor oral hygiene, mouth opening 15-25mm.

Grade IV: Advanced stage

Burning sensation and dryness of mouth, irritation with spicy food, blanched, opaque, leather like mucosa, thick fibrous bands on both buccal mucosa, retromolar area and at pterygomandibularraphae, very little mouth opening, tongue protrusions, speech and eating very much impaired, very poor oral hygiene, mouth opening < 15mm.

Though the etiology of oral submucous fibrosis is well known , the treatment is still not totally curative. Recently intralesional injections steroids have come into focus for the treatment of oral submucous

11fibrosis.

The mechanism of action of steroids is by opposing the action of soluble factors generated by sensitized lymphocytes after activation by specific antigens. Steroids also act as an immunosuppressive agent and suppress inflammatory reactionswhich prevents fibrosis

by decreasing fibroblastic proliferation and collagen deposition. The initial relief of symptoms is due to anti-inflammatory action of steroids, which clears the

11juxtaepithelial inflammation.

Among the steroids, dexamethasone has a better local potency, longer duration of action and lesser

8systemic side effects . Hyaluronidase acts on hyaluronic acid, which plays an important role in the formation of the collagen. Hyaluronidase breaks of the fibrous bands providing relief form the restricted

11mouth opening.

Various studies have been performed to assess the use of intralesional injections of steroidsas well as antioxidants, multivitamins.

James L et al conducted a study 28 patients diagnosed with OSMF treated by administering an intralesional injection of dexamethasone1.5 ml, hyaluronidase 1500 IU with 0.5 ml lignocaine HCL injected intralesionally biweekly for 4 weeks. A significant mprovement in the patient's mouth opening with a net gain of 6 ± 2 mm (92%), the range being 4-8 mm. Definite reduction in burning sensation, painful ulceration and blanching of oral mucosa was observed

12in patients with a follow up of 9 months.

Ramesh DNVS et al conducted a study in 50 clinically diagnosed cases of OSMF tocompare the efficiency of antioxidant lycopene and a combination of

37


carotenoids, lycopene, minerals and alpha lipoic acid ( SM Fibro) along with intralesional injections of dexamethasone and hyaluronidase in the treatments of OSMF . Authors concluded that SM Fibro was more

8effective in treating OSMF.

AnjumAara et al conducted a study on 40 OSMF patients where 20 patients received oral Pentoxifylline 400 mg tablets twice daily for first 4 weeks and thrice daily for next 8 weeks while 20 others received biweekly intralesional injections of Dexamethasone (4mg/ml), Hyaluronidase 1500 IU and 0.5 ml of Lignocaine 2% for a period of 12 weeks. Authors concluded that a significant improvement in burning sensation, mouth opening, tongue protrusion and cheek flexibility was observed in dexamethasone

13group.

Shah PH et al conducted a study in 25 OSMF patients where they were divided into two

groups with group A receiving placental extract + dexamethasone and group B receiving hyaluronidase + dexamethasone. Authors concluded that both the treatment regimens studied were equally effective in the treatment of oral submucous fibrosis with average increase in

mouth opening from baseline record to 8th week of treatment was 3.53±1.26mm and 3.65±1.42mm respectively and average decrease in burning sensation, noted by VAS scale, was

5.13±1.13 and 4.90 ±1.29 respectively in group A and 14

group B.

Goswami R et al conducted a study on 80 clinically diagnosed patients of OSMF where 40 patients received oral administration of vitamin B complex, lycopene and topical triamcinolone for 4 months while 40 others received weekly intralesional injections of triamcinolone combined with hyaluronidase for 8 weeks along with vitamin B complex, lycopene and topical triamcinolone for 4 months.Intralesional injection of triamcinolone combined with hyaluronidase with oral antioxidants is more effective in treating the patients with OSMF

15than antioxidants alone.

The result obtained in our patient was similar to the above studies where a significant improvement in mouth opening of approximately 5 mm was obtained on using Injection Hyanidase( Hyaluronidase ) 1500 IU

and Injection Dexona ( Dexamethasone) 4mg , 2 times per week for 6 weeks along with SM Fibro 1 tablet per day for 6 weeks.

CONCLUSION

Oral Submucous Fibrosis is a chronic debilitating condition causing severe discomfort to the patient. Alzheimer's disease did not cause any oral manifestation in this patient but presence of such medical condition further adds to their difficulty making their treatment even more essential. Although medical management does not completely cure the disease but optimal doses of corticosteroid and hyaluronidase along with avoidance of predisposing factors and improvement of dietary habit is effective to some extent.

Figure 1 :Mouth opening of 24 mm before the start of treatment

Figure 2 : Lower labial mucosa showing diffuse blanched areas

Corresponding Author:

Dr. Sruti KalluriEmail : [email protected]

Phone : 7259719579

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Figure 3 :Right buccal mucosa showing diffuse blanched areas

Figure 4 :Left buccal mucosa showing diffuse blanched areas

Figure 5 :Diffuse blanched areas in relation to the right and left faucial pillars. Uvula appears apparently normal.

Figure 6 :Panaromic image of the patient.

Figure7 :Mouth opening of 29 mm after 6 weeks of injections.

REFERENCES

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BDJ Apr-june 2017 - Amazon S3 · 2017-12-21 · ISSN : 2278-6686 Issue 1 Volume 1 Jan-March 2016 BDJ BANGALORE DENTAL JOURNAL Official Publication of IDA Bangalore Branch Issue 2