Print ISSN 2393-8692 Indian Journal of Oral Health and Research · 2017-08-10 · Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017 I Editorial

Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017 I

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Print ISSN 2393-8692

Patrons Dr. D. Y. Patil (Founder President) Dr. Vijay D. Patil (President)

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Indian Journal of Oral Health and Research

Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017II

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General Information

Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017 III

CONTENTS

Volume 3 | Issue 1 January-June 2017

REviEw ARTiClEPeriodontal Considerations during Orthodontic TreatmentSuma Shekar, A. Bhagyalakshmi, B. R. Chandrashekar, B. S. Avinash ...................................................................1

ORigiNAl ARTiClESKnowledge, Attitude, and Practices Related to Orthodontic Treatment among College Students in Rural and Urban Areas of Mysore, india: A Cross‑sectional Questionnaire StudySuma Shekar, B. R. Chandrashekar, A. Bhagyalakshmi, B. S. Avinash, M. S. Girish ..............................................9

Assessment of the Efficacy of Licorice Versus 0.2% Chlorhexidine Oral Rinse on Plaque‑induced gingivitis: A Randomized Clinical TrialPrateek Jain, Priyanka Sontakke, Satinder Walia, Pramod Yadav, Gautam Biswas, Diljot Kaur ........................... 15

The Acidogenicity of Crispy Snacks Available in Indian Market: A Comparative StudyAshveeta J. Shetty, Farhin Katge, Debapriya Pradhan, Mayur Wakpanjar .............................................................19

Knowledge, Attitude, and Practice among Pediatric Dentists Regarding the Use of Rotary Endodontic instruments for Endodontic Treatment in indiaDevanshi Nareshkumar Mehta, Bhavna Haresh Dave, Seema S. Bargale, K. S. Poonacha, Vinay Mulchandani, Princy S. Thomas ....................................................................................................................23

CASE REPORTSEsthetically Displeasing and Recurrent gingival Enlargement: A Report of Two CasesClement Chinedu Azodo, Ifeyinwa E. Uche, Patrick I. Ojehanon, Adebola O. Ehizele, Osawe F. Omoregie ............ 27

Oral Cysticercosis: Mimicking Mucocele of the CheekSimrata Ajrawat, Jatin Kharbanda, Susmita Saxena ...............................................................................................32

Adenoid Cystic Carcinoma of the Base of the Tongue: Case Report and literature ReviewGozde Serindere, Gul Soylu Ozler, Sibel Hakverdi, Mehmet Serindere .................................................................36

glandular Odontogenic Cyst: Analysis of Clinicopathological Features of Five CasesSarita Yanduri, K. K. Deepa, B. Veerendra Kumar, S. Suma, M. G. Madhura, Chinmay Dilip Vakade .................. 40



Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017IV

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Review Article

IntroductIon

The goal of orthodontic treatment is not only to improve facial esthetics and function but also to address the health of supporting structures and how teeth are placed in them. Nomatter how talented an orthodontist is, amagnificentorthodontic correction can be destroyed by failure to recognize periodontal susceptibility. Both the short‑ and long‑term successfuloutcomesoforthodontictreatmentareinfluencedby the patient’s periodontal status before, during, and after active orthodontic therapy, which also includes posttreatment maintenance by the patient.[1]

Periodontal pathogenesis is a multifactorial etiologic process, and the orthodontist must recognize the clinical forms of inflammatory periodontal diseases. Cooperation betweendifferent specialties in dentistry is extremely important in establishing diagnosis as well as in treatment planning. One such interaction exists between orthodontics and periodontics.[2]

The interrelationship between orthodontics and periodontics often resembles symbiosis. In many cases, periodontal health is improved by orthodontic tooth movement, whereas orthodontic tooth movement is often facilitated by periodontal therapy. The purpose of this article is to provide a dental practitioner with basic understanding of the interrelationship between periodontics and orthodontics and also to highlight

the orthodontics and periodontics interface in clinical practice for optimized treatment outcomes.[3]

GInGIval and PerIodontal Problems

Gingivitis[4‑9]

Accumulation of microorganisms around teeth can cause gingival redness, bleeding and edema, changes in gingival morphology, reduced tissue adaptation to the teeth, increase in the flow of crevicular fluid, and other clinical signs of inflammation. Mechanical removal of plaque reduces gingivitis, but many orthodontic patients are not motivated to remove plaque. Removal of supragingival plaque has been shown to have an inhibitory effect on the formation of subgingival plaque.

Gingivitishasbeenclassifiedasgivenbelow.1. Initial2. Early3. Established lesions.

Periodontal Considerations during Orthodontic TreatmentSuma Shekar, A. Bhagyalakshmi, B. R. Chandrashekar1, B. S. Avinash2

Departments of Orthodontics, 1Public Health Dentistry and 2Periodontics, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka, India

Orthodontic treatment aims at providing an acceptable functional and esthetic occlusion. Tooth movements are strongly related to interactions of teeth with their supportive periodontal tissues. In recent years, due to the increased number of adult patients seeking orthodontic treatment, orthodontists frequently face patients with periodontal problems. Esthetic considerations, such as uneven gingival margins or functional problemsresultingfrominflammatoryperiodontaldiseases,shouldbeconsideredintheorthodontictreatmentplanning.Thepurposeofthisarticle is to provide a dental practitioner with basic understanding of the interrelationship between periodontics and orthodontics and also to highlight the orthodontics and periodontics interface in clinical practice for optimized treatment outcomes.

Keywords: Orthodontic treatment, periodontal considerations, review

Access this article online

Quick Response Code:Website: www.ijohr.org

DOI: 10.4103/ijohr.ijohr_25_17

Abstract

Address for correspondence: Dr. Suma Shekar, Department of Orthodontics, JSS Dental College and Hospital,

Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka, India.

E‑mail: [email protected]

How to cite this article: Shekar S, Bhagyalakshmi A, Chandrashekar BR, Avinash BS. Periodontal considerations during orthodontic treatment. Indian J Oral Health Res 2017;3:XX‑XX.

This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

Shekar, et al.: Periodontal consideration in orthodontic treatment

Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 20172

Only the established lesion can be observed as clinical gingivitis. The important point is that alveolar bone loss has not yet occurred and it is hoped that the lesion can be prevented from spreading onto the surrounding structures. It is therefore crucial to determine the appropriate plaque control intervals for the patient which will prevent bone loss. Pseudopockets or gingival overgrowth or enlargement of the gingival margin and the papilla, whether it is drug induced or primary plaque related, are exacerbated by poor hygiene.

The risk factors for development of gingivitis include uncontrolled diabetes, pregnancy, systemic illness, and poor oralhygiene.Malalignedteeth,roughedgesoffillings,andunclean oral appliances can irritate the gingiva and increase the risk of gingivitis. Medications such as phenytoin, oral contraceptive pills, and ingestion of heavy metals such as lead and bismuth can also be considered as risk factors.

Periodontitis[5‑7]

Periodontitis has been defined as an inflammatory diseaseofspecificbacterialoriginthatprogresseswiththeepisodicattachment loss of periodontium. Although gingival inflammationmaybeaprerequisite,theactualmechanismforconversion of gingivitis to periodontitis is still being debated. Adult periodontitis is the most common form of periodontitis. The organisms most often reported to be associated with adult periodontitis are Porphryomonas gingivalis, Prevotella intermedia, and Bacteroides forsythus. The periodontitis is of differenttypesandfewimportantonesarebrieflyexplained.

Prepubertal periodontitisIt is a rare form that appears soon after eruption of primary teeth. It can occur in either the localized or the generalized form.

Localized or generalized juvenile periodontitisIt occurs in the circumpubertal period. These patients have little plaque and calculus and they respond well to local debridement and supplemental tetracycline therapy. Juvenile periodontitis is characterized by a rapid loss of alveolar bone and periodontal attachment in otherwise healthy adolescents, with onset thought to occur after puberty. It is generally localized to the permanent firstmolars and incisors,withlittlegingivalinflammation.Thecorrectionofmalocclusionin juvenile periodontitis patients after periodontal therapy is a problem if increasing clinical concern since many teeth with severe alveolar bone loss in these patients can now be treated successfully without extractions.

These findings have led to a general consensus that orthodontic treatment has the potential to aggravate preexisting plaque‑induced periodontal diseases and cause further loss of alveolar bone and attachment. However, it has been demonstrated that if excellent plaque control is achieved during orthodontic treatment, including uprighting and intrusion procedures, then periodontally compromised teeth can be successfully repositioned without further loss of periodontal attachment. The orthodontic patient may be at a greater risk

of attachment loss after teeth have become mobile because of toothmovement.Theclinicalsignsofinflammationandtoothmobility must be recognized and controlled during treatment to prevent extensive bone loss. Periodic monitoring of the periodontal status with probing, microbiologic assessment with immunologic assays, DNA probes, and culturing, as well asclinicalfindingsareusefulindeterminingscalingintervalsand detecting potential sites for increased risk of attachment loss. These methods may be used to assess the endpoint of the effectiveness of scaling and root planing before orthodontic treatment to ensure that no putative pathogen exists.

Rapidly progressive periodontitisThis occurs commonly in young adults, and the cause of pathogenesis appears to share many of the features of generalized juvenile periodontitis, such as rapid bone loss and depressed neutrophil functions.

Refractory periodontitisThis is a disease condition used to define sites present in patients who continue to be infected with periodontal pathogens and who have a high rate of loss of attachment and tooth loss, despite intensive treatment to prevent bone loss.

Mucogingival problems[7,8]

It is suggested that some cases of potential or actual mucogingival deficiencies may be improved by tooth movement. Since orthodontic and conservative periodontal therapy may induce changes in the character and level of attached gingiva, surgical grafts may be unnecessary.

Mucogingival deformities in children and adults have been described as recession, gingival clefts, and localized pathologic recession. Inadequate keratinized gingiva, minimally attached gingiva, coronally attached frenal and muscle attachments, abnormal tooth position, fenestrations or bony dehiscence in the alveolus, and other factors have been predisposing and etiologically related pathosis.

Lang and Loe concluded that gingival health is compatible with a very narrow gingiva and that 2 mm of keratinized gingiva is adequate to maintain gingival health. Minimally attached gingiva, apically positioned gingival margins, and apparently high muscle attachments have been treated surgically to prevent development of localized gingival recession.Alocalizedpathologicrecessionmaybeidentifiedwhen the gingival attachment is apical to the cementoenamel junction (CEJ). Factors that may be etiologic or predisposing to mucogingival problems of the mandibular incisors may be developmental or acquired.

Abnormal frenal and muscle attachments[8]

Abnormal frenum and muscle pull has been considered detrimental to periodontal health by pulling away the gingival margin from the tooth, contributing to accumulation of plaque andcalculusandleadingtoinflammationandpocketformation.Adequate depth of the vestibule has been similarly held significant.Severalsurgicalprocedurestodeepenthevestibule


Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017 3

as well as to reduce the height of frenal attachments have been developed as preventive therapeutic measures.

Occasionally, in the developing dentition, abnormal frenal or muscle attachments may extend onto the crest of the alveolar ridge. The erupting tooth may pass through the alveolar gingiva andbedeficientinkeratinizedtissue.Surgicalrecessionwillensure normal eruption of the tooth with adequately attached gingiva.

Interdental recession[10‑13]

Causes of open gingival embrasures• Severelymalalignedmaxillaryincisors• Dimensionalchangesintheinterdentalpapilla• Locationandsizeofinterproximalcontact• Divergentrootangulations• Triangular‑shapedcrowns.

Interdental recessions manifest as dark triangles between teeth. Main indication of correction of interdental recession is esthetics.

Options available for treatment of interdental recessions are• Mucogingivalsurgerieswithcoronallypositionedgrafts

and guided tissue regeneration• Provisionofgingivalprosthesis• Orthodonticparallelingoftherootsofneighboringteeth• Mesiodistalenamelreduction.

The principle involved in stripping is to recontour the teeth which have an abnormal shape. By this procedure, a good occlusion with optimal tooth contact point relationships and normal interdental gingival papillary contours will be achieved. When crowding is unraveled in orthodontic patients, the contact points are located in the incisal thirds. The amount of tooth material to be removed by enamel reduction will be around 0.5–0.75 mm. After diastema is created, space is closed orthodontically. As this takes place, roots of neighboring teeth come closer and the contact point is lengthened and the reduced papillacanfilltheembrasure.

Missing interdental papilla[14‑16]

Usually, when the papilla is lost as a result of advanced periodontal disease which involves loss of interdental alveolar crest, the esthetic improvement in the situation requires a combination of enameloplasty (interproximal reduction), tooth movement, and selective addition of composite resin. If this is not enough for the remodeled tissue to cover the area of the papilla, direct bonding resin can be added to lower the contact point and create the illusion of a healthier papilla. Interproximal enamel reduction along with the closure of the resultant diastema is sufficient inmost cases to restore themissing papilla.

basIc tooth movements and PerIodontal chanGes

Orthodontic treatment is based on the premise that when force is applied to a tooth, it is transmitted to the adjacent investing

tissues, and certain structural alterations take place within these tissues which allow for and contribute to tooth movement.

Intrusion[17‑22]

Intrusion alters the CEJ and angular crest relationships and creates only epithelial root attachment. therefore, a periodontally susceptible patient is at greater risk of future periodontal breakdown. Tooth movement, when properly executed, improves periodontal condition and is beneficialto periodontal health. Orthodontic forces, when kept within biological limits, do not induce tissue alterations leading to loss of connective tissue attachment and periodontal pocket formation. The gingiva moves in the same direction as that of tooth intrusion, but it moves only by about 60%. Gingival sulcus gets deepened by about 40% of tooth intrusion.

Indications• Teethwithhorizontalboneloss• Toincreaseclinicalcrownlength.

Clark et al. studied the effect of intrusion on the microvascular bed and fenestrae in the apical periodontal ligament (PDL) of rat molar. They found that the decrease in fenestrae numbers per square micrometer of endothelium was most marked in the venous capillaries, which had the greatest density of fenestrae per square micrometer of endothelial surface. With intrusive loading, the small arterial fenestrae population was unchanged.

Zachrisson et al. measured the gingival pocket depth during treatment and retention in orthodontic patients treated with edgewise appliance and found that pocket depth increased during the tooth movement. They reported that the increase was caused by edematous swelling in the gingiva and by tissue accumulation during tooth movement, not by deepening of the pocket. Gingival sulcus deepened with tooth intrusion. Further, dentoperiostealanddentogingivalfiberswerepartedfromthecementum gradually as tooth intrusion increased.

Melsen et al. studied the tissue reaction related to orthodontic intrusionof teethand the influenceoforalhygieneon thisreaction. They found that alveolar bone height was gained through forced eruption and that this bone may be maintained even during an intrusion applied following extrusion. Intrusion can therefore constitute a reliable therapeutic method in the orthodontic treatment of adult patients with a healthy periodontal condition. Intrusion of teeth does not result in a decrease in marginal bone level in periodontally healthy patientsprovidedgingivalinflammationiscontrolled.

Nanda et al. studied the extent of root resorption due to intrusion. Results indicated that intrusion with low forces can be effective in reducing overbite while causing only a negligible amount of apical root resorption. McFadden et al. found an average root shortening of 1.8 mm per tooth, irrespective of the amount of intrusion.

Sinceorthodonticmovementofteethintoinflamedinfrabonypockets may create an additional periodontal destruction, and



because infrabony pockets are frequently found at teeth that have been tipped or elongated as a result of periodontal disease, it is essential that periodontal treatment with elimination of the plaque‑induced lesion should be performed before the initiation of orthodontic treatment. Maintenance of excellent oral hygiene during the treatment is equally important.

Extrusion[23‑25]

Extrusion or eruption of a tooth or several teeth, along with reduction of the clinical crown height, is reported to reduce infrabony defects and decrease pocket depth. Extrusion of an individualtoothisusedspecificallyforcorrectionofisolatedperiodontal osseous lesions. Studies have shown that extrusion intheabsenceofgingivalinflammationreducesbleedingonprobing, decreases pocket depth, and even causes formation of new bone at the alveolar crest as the tooth erupts, with no occlusal factor present.

Raymond Yukna et al. in animal experiments studied the effects of extrusion of single‑rooted teeth with advanced periodontal disease. Extruded teeth had shallower pocket depths, less gingivalinflammation,andnobleedingonprobing.Earlyinthe extrusion process, the teeth appeared to be avulsed, with more than three‑fourths of the root coronal to the alveolar crest. After stabilization, approximately 2 mm of new bone was seen coronal to the original alveolar crest, and the periapical areashadfilledinwithbone.Theextrudedteethhadanintactattachment apparatus.

The improved periodontal condition resulting from extrusion may have been due to both physiologic and microbiologic changes in the local environment. The subgingival microbial plaque may have been converted to a supragingival plaque by the extrusive tooth movement, thereby lessening its pathogenicity and effect on gingival tissues. This is the reverse finding of Ericsson et al., who reported that orthodontic treatment which involves intrusion of a tooth in a plaque‑infected dentition may shift a supragingivally located plaque into a subgingival location.

Marc Quirynen et al. studied the periodontal health of orthodontically extruded impacted teeth. Most impacted teeth were extruded after minor periodontal surgery. They found no difference between test and control teeth, except gingival width, which was 1 mm larger for the spontaneously erupted teeth. This study demonstrated that orthodontic extrusion of impacted teeth does not jeopardize their periodontal health

Forced eruption[26,27]

1. It helps save an isolated tooth in which caries, trauma, or iatrogenesis has destroyed the clinical crown by bringing the fractured, diseased, or prepared margins of the neck of the tooth more coronally to reestablish biological width

2. Although forced eruption is associated with an increase in the width of attached gingiva, mucogingival junction remains unaltered

3. Fiberotomy, which is done before active eruption, is essential for success of the procedure

4. For shallowing out of isolated intraosseous defects5. Increase clinical crown length of single teeth.

ForcederuptionwasfirstintroducedbyIngberin1974forthetreatment of one‑walled and two‑walled defects. Extrusion results in a coronal position of the connective tissue attachment and the bony defect are shallowed out. Because of extrusion, the tooth is in supraocclusion and will need to be shortened. During the elimination of an intraosseous defect by means of extrusion, the relationship between CEJ and the crest of alveolar bone is maintained. When the goal of treatment is to extrude the tooth out of periodontium as required during crownfractures,extrusionhastobecombinedwithfiberotomy.

The supporting soft tissue structures will also follow the bone duringextrusionwithoutfiberotomy.Kajiyamaet al. found that in experimental animals, the free gingiva moved about 90% and the attached gingiva about 80%of the extrudeddistance. The width of the attached gingiva and the clinical crownlengthincreasedsignificantly,whereasthepositionofthe mucogingival junction remained unaltered.

Rotation[28]

Relapse tendencies exist in a fairly high percentage of treated malocclusion and it is greatest for rotation corrections. The fibrous elements of the PDL adapt to toothmovement inpossibly three mechanisms:• Progressiveosteogenicandcementogenicactivityplaysan

activeroleintheshorteningoftheextendedfibersduringtooth movement

• Thestretchingofthewavycollagenfibersandreorientationof their directional morphology permit a certain amount of tooth movement

• Theexistenceofatypeofintermediateplexusmightallowanelongationoffiberbundlesbyslippageofthefibersover one another and a subsequent reorientation of the fibersinanewposition.

Brauer et al. found that transsecting the supracrestalfiberswith vertical incisions mesial and distal to the rotated teeth mayreducethedangerofrelapse.Theyreportedasignificantreduction in relapse after an initial retention of 4–8 weeks. Edwards et al. concluded that a simple surgical method of severingallsupracrestalfibersattachmentofarotatedtoothcansignificantlyalleviaterelapsefollowingrotation,withoutapparent damage to supporting structures of the tooth.

Space closure[29,30]

Wennstrom et al. evaluated, in animal experiments, the effect of orthodontic tooth movement on the level of the connective tissue attachment in sites with infrabony pockets. Orthodontic therapy involving bodily movement of teeth with inflamed, infrabony pocketsmay enhance the rate ofconnective tissue loss. They found that orthodontic movement of teeth into infrabony pockets may be detrimental for the periodontal attachment when realignment of teeth that have been tipped and/or elongated as a result of periodontal disease being considered. Hence, periodontal treatment directed at



elimination of the plaque‑induced lesion should precede the initiation of orthodontic therapy and proper oral hygiene maintained during the orthodontic treatment.

Studies demonstrate that provided periodontal health and a proper oral hygiene standard are maintained during the phase of orthodontictherapy,noinjuries,oronlyclinicallyinsignificantinjuries will occur. If oral hygiene is less effective and periodontalinflammationispresentduringtoothmovement,an increased risk for attachment loss was found.

Camilla Tulloch et al. undertook a study to determine the incidence and possible association of gingival invaginations seen during space closure with gingival health and stability of extraction space closure. An infolding or invagination of gingival tissue commonly forms during the orthodontic approximation of teeth. The clinical appearance of these invaginations ranges from a minor one‑surface crease in the attached gingiva to a deep cleft that extends across the interdental papilla from the buccal to the lingual alveolar surface. The precise cause of these invaginations remains unclear.

The study revealed that:1. Gingival invaginations occur commonly during

orthodontic treatment that involves first premolar extraction and space closure. Although they may decrease in size or even resolve, many invaginations persist for years after treatment

2. Invaginations are more common, complex, severe, and persistent in the mandibular arch than in the maxillary arch

3. Their formation is not related to the width of the attached gingiva, canine inclination, or overall gingival health

4. Gingival invaginations do not seem to be associated with extraction space reopening

5. The presence, severity, and complexity of invaginations appear to impair the patient’s ability to maintain adequate gingival health in the extraction area.

Traumatic occlusion and orthodontic treatment[31]

Studies indicate that traumatic occlusion forces:1. Do not produce gingival inflammation or loss of

attachment in patients with healthy periodontium2. Do not aggravate and cause spread of gingivitis3. May aggravate an active periodontitis lesion, i.e., may be

a co‑destructive factor4. May lead to less gain of attachment after periodontal

treatment.

Some studies conclude that occlusal adjustments should be carried out in the evidence of trauma after the control of inflammation.Burgettet al. have demonstrated that there is a significantgaininattachmentinpatientswhoreceivedocclusaladjustment as part of treatment plan.

Periodontal considerations in surgical exposure[32,33]

It is often seen that teeth have a delayed eruption and at times do not erupt at all. In such conditions, management of the

periodontal tissues is very much vital. According to the current concepts, electrosurgery or lasers should be avoided for such cases, but their use could be restricted toward removing the overlying tissue.

Prato et al. compared the width of keratinized gingiva after orthodontic therapy for buccally erupting premolars that had been pretreated by extraction of deciduous teeth alone versus interceptive mucogingival surgery. It was noted that there was nosignificantdifferenceinthemeanwidthofkeratinizedtissueat the start of treatment. By the end of treatment, mean width at the site where mucogingival surgery was performed was found tobesignificantlyhigher(2.3mm)thanthesitewhereextractionalone was performed (1.3 mm). This proved conclusively that mucogingival surgery was an effective technique to maintain keratinized tissue in correspondence with buccally erupted teeth. Mucogingival interceptive therapy in patients with buccally erupting teeth is performed to prevent the ectopic permanent tooth from developing periodontal lesions.

Christina Hansson reviewed the periodontal status of patients who had unilateral palatal impacted canines and their adjacent incisors 1–18 years post treatment. The results showed greater mesial probing depth of the canines on the treated side, on the adjacent lateral incisors distolingually, and on thefirstpremolars mesiolingually. In general, the results showed a good gingival and periodontal status with slight differences between treated and untreated sides.

Orthodontic force and labial recession[34,35]

Teeth having adequately attached gingiva occasionally develop localized recession during treatment. It has generally been assumed that such destruction has been associated with excessive force that has not permitted repair and remodeling of alveolar bone. It is more likely that the direction and extent of tooth movement have forced the tooth through the cortical plate. This concept is supported in cases of severe gingival recession consequent to tooth movement, in which remaining gingivalattachmentappearsrelativelyfreeofinflammation.Such sequelae may be readily explained if the direction of tooth movementhasbeen towardareasofattachmentdeficiency.When adverse forces and local factors do not exist, however, the prior presence of an unseen dehiscence should be suspected. Chronic marginal gingivitis may rapidly destroy the marginal alveolar bone and gingival attachment during the application of modest forces normally well tolerated by the periodontium.

Mandibular incisors with minimally attached gingiva may be particularly susceptible to the adverse effect of a cross bite or an edge to edge occlusion. If the resulting occlusal forces are in the direction of the inadequate gingival attachment, they may accentuatethedestructivecapacityoftheinflammatoryprocessand crestal alveolar bone may be lost. Orthodontic correction of malaligned teeth may induce a spontaneous improvement in periodontal health. Inflammation andmobility decreasewith the improvement in hygiene and occlusal function. Such changes can occur with minimally attached gingiva or localized recession, regardless of the age of the patient.



Sabine Ruf et al. studied the effect of orthodontic proclination of lower incisors in children and adolescents on the possible development on gingival recession. In all patients, Herbst treatment resulted in varying degrees of lower incisor proclination. Either no recession developed or preexisting recession remained unchanged during Herbst therapy. No interrelationship was found between the amount of incisor proclination and recession.

Artun and Kronstad found that gingival recession in adults developed mostly during the active phase of orthodontics and thefirst 3 years after appliance removal of onlynegligiblerecession took place.

Handelmann et al. in a review of nonsurgical rapid palatal expansion cases have shown that buccal attachment loss was notstatisticallysignificantformaleswhentheadultexpansiongroup was compared to the adult control group. The average increase in crown length was 0.5 mm. They suggested that patients who demonstrated the largest increase in gingival recession following RME would be the oldest, those who had the greatestmaxillary transarch deficiency, thosewith thegreatest amount of transarch expansion, and those who initially had the longest crown heights.

Molar uprighting[36]

Orthodontic uprighting of mesially tipped molars is accompanied by the elimination of osseous defects and improvement in pocket probing depth and in crown‑root ratio. However, in molars with furcation involvement, there is an increased risk of aggravation of the periodontal problem during the orthodontic uprighting procedure. Orthodontic movement of teeth in edentulous areas with reduced alveolar ridge height is, usually, possible with minimal loss of alveolar bone. The movement should be parallel and performed with low orthodontic forces.

Gummy smile[37,38]

In conformity to the present esthetic standards, maxillary gingival display in an attractive adult smile will range between 1 and 2 mm. Increased gingival exposure may be attributed to different causes, which designate the appropriate management: vertical growth of the maxilla, retardation of the physiological apical migration of gingival margins, extrusion of maxillary anterior teeth and anatomical considerations.

Patients with excessive vertical growth of the maxilla, generally, present normal clinical crowns dimensions and healthy gingiva. In growing patients, growthmodificationshould be considered to inhibit vertical growth with orthopedic forces, while management of this condition in adults possibly demands orthognathic surgery including LeFort I osteotomy and maxillary impaction.

Certain patients present a significant retardation of the physiological apical migration of gingival margins, with thick gingivalbiotypeorfibroidgingivaltissuesandprobingdepthof gingival sulcus of approximately 3–4 mm, sometimes even withoutclinicalsignsofinflammation.Mainclinicalfeaturesof

this type of a gummy smile are the short clinical crowns and the apparently increased labiolingual thickness of gingival tissues. This condition is an indication for mucogingival esthetic surgery.

PerIodontal surGIcal Procedures commonly requIred durInG orthodontIc Procedure[39‑43]

Gingival curettageCurettage means scraping of the gingival wall of a periodontal pocket to remove infected and necrotic tooth substance. It removes the inflamedsoft tissue lateral to thepocketwall.The aim of curettage is to reduce pocket depth by enhancing gingival shrinkage and new connective tissue attachment.• Itcanbeperformedaspartofnewattachmentattemptsin

moderately deep infrabony pockets located in accessible areas where a type of closed surgery is deemed advisable

• It can be done as a nondefinitive procedure to reduceinflammation before pocket elimination using other methods or in patients in whom more aggressive techniques are contraindicated

• It is also performed on recall visits as amethod ofmaintenancetreatmentforareasofrecurrentinflammationand pocket deepening.

GingivectomyGingivectomy means excision of the gingiva. By removing diseased tissue and local irritants, it creates a favorable environment for gingival healing and the restoration of a physiological gingival contour.

Indications• Eliminationof suprabonypockets if thepocketwall is

firmandfibrous• Eliminationofgingivalenlargements.

Contraindications• Whenosseoussurgeryisneeded• Bottomof pocket located apical to themucogingival

location• Estheticconsiderationsparticularlyintheanteriormaxilla.

According to Kokich et al. in SEMOrthod 1996, therelationship of the gingival margin of the six maxillary anterior teeth plays an important role in esthetic appearance of teeth. In some instances, it may be necessary to increase the clinical crown length of one or several teeth during or after orthodontic treatment. If a gingival margin discrepancy exists and the patient’s lip does not move to expose the discrepancy, then no treatment is required. If the discrepancy is apparent, one of the four possible treatment modalities may be undertaken:• Gingivectomy• Intrusionandincisalrestoration• Extrusionwithfiberotomyandporcelaincrown• Surgicalcrownlengthening.

GingivoplastyGingivoplasty is the reshaping of gingiva to create physiologic gingival contours, for the sole purpose of recontouring the



gingiva in the absence of pockets. Gingival and periodontal diseases often produce deformities in the gingiva that interferes with normal food excursion, collect plaque and food debris, and aggravate the disease process.

FiberotomyMethods to reduce of relapse of orthodontically treated teeth, especially rotated teeth, include:• Completecorrectionorovercorrectionofrotatedteeth• Stablelong‑termretentionwithbondedlingualretainers• Useoffiberotomy.

Periodontalfiberbundlesthatinfluencestabilityaretheprincipalfibers of PDL and the supraalveolarfibers. Fibers of PDLremodel completely only after 2–3 months. The supraalveolar fibersarestableandhaveaslowerturnover.Thesupracrestalgingival tissues contribute to rotational relapse and hence the techniqueof “circumferential supracrestalfiberotomy.”ThetransseptalfibersarecutinterdentallybyenteringthePDLspace.Clinicalhealingoccursin7–10days.Thefiberotomyprocedureis not indicated during active tooth movement or in the presence ofgingivalinflammation.Whenperformedinhealthytissuesafter orthodontics, there is minimal attachment loss.

Edwards studied the long‑termeffectoffiberotomy. Itwasfound that cerebrospinal fluid was more effective in the maxillary anterior than the mandibular arch. It was more effective in alleviating rotational than labiolingual relapse. Therewasnoclinicallysignificant increase insulcusdepthnor any gingival recession that was observed.

FrenotomyHyperplastic types of frenum with fan‑shaped attachment may obstruct diastema closure and hence surgical intervention is desirable. In the past, frenectomy was undertaken. The complication with frenectomy is that the complete removal of the frenum may result in gingival recession between the central incisors. Hence, frenotomy with only partial removal of the frenum with the purpose of relocating the attachment in a more apical direction is currently undertaken. Tissue healing is uneventful although some scarring may occur.

Removal of gingival cleftsIncomplete adaptation of supporting tissues during space closure may result in invaginations or infolding or clefts in the gingiva. A simple removal of only the excess gingiva in the buccalandlingualareaswouldbesufficienttoalleviatethetendency of teeth to separate after space closure.

Crown lengtheningA simple localized gingivectomy to the bottom of the clinical gingival sulcus will increase the crown length. As shown in a human experimental model, nearly 50% of the excised tissue will regenerate and become clinically and histologically indistinguishable from normal gingiva. This means that if a labial probing pocket depth of 4 mm is recorded on the cuspid, a gain of 2 mm in crown length can be anticipated. Electrosurgery can be used but is no more effective than a scalpel. Even if

the excision is extended into the alveolar mucosa, the coronal part of the regenerated gingiva will still become keratinized. Careful oral hygiene procedures, using single‑tufted brushes, are required for 2 months after the gingivectomy so that the regenerated gingiva will appear entirely normal.

Distraction osteogenesis of the periodontal ligamentDistraction osteogenesis is the process of growing new bone by mechanical stretching of preexisting bone tissue. A new concept of distracting the PDL is proposed to elicit canine retraction in 3 weeks. This is called dental distraction. The PDL acts as a suture between the bone and the tooth.

Liou and Hang studied patients who needed canine retraction andfirstpremolarextractions in themaxillaandmandible.Atthetimeoffirstpremolarextraction,theinterseptalbonedistal to canine is undermined grooving vertically inside the extraction socket both buccally and lingually. Activation of 0.5–1 mm/day can be carried out immediately after extraction. Although some tipping was seen, most of the canines were moved bodily. Apical and lateral root resorption of the canine was minimal and there were no periodontal or endodontic complications by this method. It was observed from this study that the PDL can be rapidly distracted without complications.

Changes in the PDL on the mesial side of the canine can be classifiedinto:1. Stretching and widening of the PDL2. Active growth of new bone spicules in the distracted PDL

during the 2nd week3. Recovery of the distracted PDL during the 4th week4. Remodeling of striated bone from the 4th week to the

3rd month after distraction5. Maturation of the striated bone.

conclusIon

The main objective of periodontal therapy is to restore and maintain the health and integrity of the attachment apparatus of teeth. Orthodontic treatment can often correct these problems, or at least prevent them from progressing. In addition, orthodontic therapy can facilitate management of several restorative and aesthetic problems relating to fractured teeth, tipped abutment teeth, excess spacing, inadequate pontic space, malformed teeth, and diastema. Orthodontic treatment may improve periodontal health in these circumstances, but it also holds some potential for harm to the periodontal tissues. Thus, orthodontic treatment can be referred to as a two‑edged sword, which may be sometimes very meaningful in increasing the periodontal health status and may be sometimes a harmful procedure, which can be followed by several types of periodontal complications.

AcknowledgmentsWe extend our sincere thanks to all college authorities for permitting us to undertake this project and volunteers for extending their valuable support in completing the questionnaire.



Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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© 2017 Indian Journal of Oral Health and Research | Published by Wolters Kluwer - Medknow 9

Original Article

IntroductIon

Unacceptable dental appearance has been found to exert a negative impact on self‑image, career advancement, and peer‑group acceptance. This in turn will have an adverse influenceonanindividual’slevelofsocialinteractions.Suchesthetic concerns and adverse influence on psychosocial well‑being are the primary factors for decision to start orthodontic treatment.[1] Changes in morphogenesis and physiology of dentofacial structure over time and an increased concern for dental appearance and orthodontic treatment with age have become apparent rather than inadequate decisions and a provision of care during childhood and adolescence.[2] Orthodontists traditionally have considered oral health and function as the principal goals of treatment. However, recently, there has been growing acceptance of esthetics and its psychosocialimpactasanimportanttreatmentbenefit.[3]

In the past three decades, a major reorientation of orthodontic thinking has occurred regarding adult patients, the reasons may be changed lifestyle, patient awareness, and multidisciplinary dental therapy that have allowed better management of the more complicated patient population, thereby greatly improving the quality of care and treatment prognosis. There are many reasons why adult orthodontic therapy should be encouraged, including the improvement of function and occlusion, and improvement of

Knowledge, Attitude, and Practices Related to Orthodontic Treatment among College Students in Rural and Urban Areas of

Mysore, India: A Cross‑sectional Questionnaire StudySuma Shekar, B. R. Chandrashekar1, A. Bhagyalakshmi, B. S. Avinash2, M. S. Girish3

Departments of Orthodontics, 1Public Health Dentistry, 2Periodontology and 3Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, Mysore, Karnataka, India

Objectives: The objective of this study was to assess knowledge, attitude, and practices (KAPs) related to orthodontic treatment among college students in rural and urban areas of Mysore, India. Materials and Methods: This was a cross‑sectional questionnaire study conducted among college students in rural and urban areas of Mysore, India, over 2 months from August to September 2015. The sample size was estimated using nMaster software. One government and one private college each in rural and urban areas of Mysore were selected based on administrative convenience. All eligible participants from these colleges were recruited. A sixteen‑item questionnaire was developed and validated. This predesigned and validated, self‑administered, structured questionnaire was used for data collection. The statistical analysis was done using SPSS. Results:Fourhundredandforty‑onecollegestudentsparticipatedinthepresentstudy.89.3%oftheparticipantswereawareaboutmalalignmentof teeth.Theawarenesswassignificantlyhigheramongfemalesand those inurbanareas.39.2%of thestudyparticipantsexpressedwillingnesstoundergoorthodontictreatmenteveniftreatmentdurationextendsupto1–2yearswithnosignificantdifferenceinrelationtogenderandareaofresidence.14.1%ofthestudyparticipantshaveundergonetreatmentformalalignmentofteethwithnosignificantdifferencebetweenmalesandfemales.However,asignificantlyhigherpercentageofparticipantsfromurbanareashaveundergonetreatment.Conclusion:TheKAPrelatedtoorthodontictreatmentwassignificantlyhigheramongfemalesandthoseinurbanareas.Thishighlightstheneed to augment orthodontic awareness programs in rural areas.

Keywords: Awareness, college students, malalignment, orthodontic treatment, rural and urban




Address for correspondence: Dr. Suma Shekar, Department of Orthodontics, JSS Dental College and Hospital,

Jagadguru Sri Shivarathreeshwara University, JSS Medical Institutions Campus, SS Nagar, Mysore, Karnataka, India.




How to cite this article: Shekar S, Chandrashekar BR, Bhagyalakshmi A, Avinash BS, Girish MS. Knowledge, attitude, and practices related to orthodontic treatment among college students in rural and urban areas of Mysore, India: A cross‑sectional questionnaire study. Indian J Oral Health Res 2017;3:XX‑XX.

Abstract

Shekar, et al.: KAP‑related orthodontics among college students


esthetics as well as the psychological aspects.[4] The literature on the prevalence of malocclusion in relation to area of residence isconflicting.Somestudies revealedahigherprevalence inurban areas,[5,6]whileothersfoundnosignificantdifferences.[7] The malocclusion prevalence is related to knowledge, attitude, and practices (KAPs)‑related orthodontic treatment. Literature assessing the KAP related to orthodontic treatment among adolescents in rural and urban areas of Mysore was nonexistent. In this background, the present study was undertaken to assess KAPs related to orthodontic treatment among college students in rural and urban areas in Mysore, India, as well as to identify key factors related to utilization of orthodontic services among the study participants.

materIals and methods

This questionnaire survey was conducted among college students in rural and urban areas of Mysore, India, over 2 months from August to September 2015. The ethical clearance for the study was obtained from the Institutional Ethics Committee, JSS Dental College and Hospital, Mysore.

Sample sizeThe sample size was estimated using nMaster 1.0 software (Biostatistics Resource and Training Center, Christian Medical College, Vellore, India) software assuming an expected proportion of 0.5 to be having good KAP on oral health witharelativeprecisionof10%,95%confidencelevel.Thesample size was computed to be 430 with an anticipated 10% nonresponse in the form of incomplete data.

A convenient sampling was used for selecting required number of eligible participants from rural and urban areas of Mysore. Among the various colleges in Mysore, one government and one private college each in rural and urban areas of Mysore were selected based on administrative convenience. The selection of participants in these four colleges was done according to the following eligibility criteria.

Inclusion criteria1. College students in the selected colleges willing to

participate in the study by offering informed consent were included in the study.

Exclusion criteria1. Incomplete questionnaires were excluded from the study.

Questionnaire developmentAfter reviewing previous published literature assessing KAP related to orthodontic treatment in different settings, all questionswerepooledasafirststep.Atotalof22itemswereinitially listed. Then, eight redundant questions were deleted. Thequestionnairewasfurthermodifiedwithadditionofsixitemsthoughttoberelevant.Themodifiedquestionnairehad20 items. The questionnaire was scrutinized independently by two orthodontists and one public health dentist to assess relevance, accuracy, and appropriateness of each item.

Each expert was instructed to grade the items for relevance, accuracy, and appropriateness on afive‑pointLikert scale.Three questions having low scores for relevance, accuracy, and appropriateness from all three experts were removed from the questionnaire. The questionnaire having 17 items wastranslatedtoKannadabyanexperthavingproficiencyinEnglish and Kannada. The translated Kannada questionnaire was again back translated to English by another language expert. The back‑translated English questionnaire was compared with original 17‑item English questionnaire.

The reliability of questionnaire was assessed using test‑retest reliability assessment. Questionnaire was administered to a group of 20 college students. The same questionnaire was distributed to these 20 students after a gap of 1 month. Kappa coefficientforeachitemwasassessed.Thekappacoefficientrangedfrom0.89to0.92forallitemsexceptforonequestionon knowledge which had a reliability score of 0.51. This itemwas removed from thequestionnaire.Hence, thefinalquestionnaire had 16 items with either yes, no, or don’t know options [Annexure 1].

Data collectionThe study protocol was explained to the participants in a meeting organized in each college. The participants were requestedtofillthequestionnairethathadatotalofsixteenquestions on KAPs‑related orthodontic treatment. The instructionsforfillingthequestionnaireweregivenandfilledquestionnaires were collected after 20 min following the administration of the questionnaire. The data from completed questionnaires were entered into a personal computer.

Statistical analysisThe statistical analysis was done using SPSS (Statistical Package for Social Sciences) version 20 (IBM, Chicago, IL, USA). The association between KAP on orthodontic treatment and various sociodemographic factors was assessed using Chi‑squaretest.Thestatisticalsignificancewasfixedat0.05.The research protocol is diagrammatically depicted in Figure 1.

results

A total of 441 college students participated in the present study. Amongthem,219werefromruralareasand222werefromurban areas. Two hundred and forty‑four were females and 197weremales.197werebelow20yearswhiletheremaining244 were 20 years and above [Table 1].

Overall, 65.8% of the study participants had heard of the term malalignment of teeth. The awareness on malalignment of teeth wassignificantlyhigheramongfemales,thoseinurbanareaswithnosignificantdifferencebetweenindividualsagedlessthan and more than 20 years [Table 2].

40.4% of the study participants expressed willingness to undergo correction of malalignment even if the treatment extended for a duration of around 1–2 years. The willingness toundergotreatmentwassignificantlyhigheramongfemales,those aged <20 years and those in urban areas [Table 3].



dIscussIon

The knowledge onmalocclusionwas significantly higheramong females, those in urban areas with no significant difference between individuals aged <20 years compared to those aged >20 years. The increase in knowledge facilitates the development of positive attitude which in turn leads to adoption of healthy practices. The higher levels of knowledge related to malocclusion among females may be attributed to higher concerns among females on oral health.[8,9] These resultswereconsistentwiththefindingsofChopraet al.[10] The participants in urban areas will have more access to dental care compared to their rural counterparts. This could beresponsibleforsignificantlyhigherlevelsofknowledgeonmalocclusion among participants in urban areas. A study by Chand and Arfan (2014)[11] found oral health‑related KAP to besignificantlyhigheramongfemalechildrenandthosefromurban areas similar to the results of the present study.

The attitude of continuing with the orthodontic treatment even when it caused pain or discomfort was higher among females, those in urban areas with no difference between those aged <20 years compared to those aged >20 years. In supportofthepresentstudy,variousstudiesidentifiedfemaleorthodontic patients as more cooperative than males.[12‑15] The willingness to undergo treatment even when it extended for a longdurationwassignificantlyhigheramongfemales,thoseaged <20 years, and those in urban areas. The concern‑related esthetics and social pressure of maintaining pleasing appearance drive females to undergo orthodontic treatment. The eagerness to achieve that pleasing appearance may motivate females to bear with any slight pain and discomfort associated with treatment of malocclusion. These factors may be responsible for favorable attitude among females for undergoing orthodontic treatment in comparison with males. The younger individuals and those in urban areas will strive hard to have gratifying appearance which in turn may be responsible for favorable attitude toward malocclusion treatment.

Higher percentage of females and those in urban areas had undergone treatment formalocclusionwith no significantdifference with regard to those aged <20 and >20 years. This result is in accordancewith studybyRafighiet al.[16] and Wedrychowska‑Szulcet al. (2010)[17] who stated that girls, in general, undergo orthodontic treatment more frequently than boys as they are more sensitive to dentofacial attractiveness. The higher levels of knowledge and favorable attitude toward malocclusion treatment among females and those in urban areas might have led to favorable practices. Moreover, the necessity to maintain an attractive appearance in social gatherings is high among females and those in urban areas which might have compelled them to undergo orthodontic treatment more than their counterparts.

The KAP related to malocclusion was higher among females, those in areas. This highlights the need to augment orthodontic awareness programs in rural areas. We could not precisely

Figure 1: Research protocol

42.4% of the study participants expressed their willingness to continue with the treatment for malalignment even if there is any possibility of pain, ulcerations, or some discomfort during treatment. This willingness was significantly higher among females, those in urban areas with no difference between those aged <20 years compared to those aged >20 years [Table 4].

16.1% of the study participants had undergone treatment formalalignmentteeth.Asignificantlyhigherpercentageoffemales and those in urban areas had undergone treatment for malocclusionwith no significant differencewith regard tothose aged <20 and >20 years [Tables 2‑4].

Table 1: Demographic details of study participants

College Gender Age groups n (%) Statistical inference (χ2, df, P)

Rural Males 19yearsandless 49(59.0) 1.976,1,0.16020 years and above 34 (41.0)

Females 19yearsandless 67(49.3)20 years and above 69(50.7)

Total 219(49.7)Urban Males 19yearsandless 76 (54.3) 1.306, 1,

0.25320 years and above 38 (46.3)Females 19yearsandless 64 (45.7)

20 years and above 44 (53.7)Total 222 (51.3)Overall 441 (100)



compare our results with previous published literature as studies comparing KAP in relation to gender, age, and area of

residence are scanty. Hence, further studies are recommended to validate the results of present study.

Table 2: Responses to various questions in relation to gender

Question Males, n (%)

Females, n (%)

Total, n (%)

Statistical inference (χ2, df, P)

Have you heard of the term malalignment of teeth? 89(45.2) 201 (82.4) 290(65.8) 66.987,1,<0.001Doyouthinkhereditycaninfluencetheoccurrenceofmalalignmentofteeth? 72 (36.5) 120(49.2) 192(43.5) 7.075, 1, 0.008Do you think habits such as thumb sucking, tongue thrusting, and mouth breathing can cause malalignment of teeth?

80 (40.6) 150 (61.5) 230 (52.2) 19.018,1,<0.001

Do you think malaligned teeth can affect appearance? 79(40.1) 144(59.3) 223 (50.7) 15.975,1,<0.001Do you think malaligned teeth can affect chewing ability? 81 (41.1) 176 (72.1) 257 (58.3) 43.119,1,<0.001Do you think malaligned teeth can affect speech? 88 (44.7) 150 (61.5) 238 (54) 12.391,1,<0.001Do you think malaligned teeth can affect oral hygiene? 67 (34) 153 (62.7) 220(49.9) 35.899,1,<0.001Do you think dental checkup and treatment of malalignment is essential in early childhood and adolescent?

76 (38.6) 180 (73.8) 256 (58) 55.433, 1, <0.001

If the correction of malalignment extends for duration of around 1‑2 years, would you like to undergo treatment?

64 (32.5) 114 (46.7) 178 (40.4) 9.174,1,0.002

If some teeth have to be removed in the course of your treatment of malalignment teeth, will you agree for the removal of healthy teeth?

44 (22.3) 109(44.7) 153 (34.7) 24.003, 1, <0.001

If the doctor instructs you to wear an appliance for additional 6 months to 1 year even after the completion of your treatment, will you wear that appliance?

51(25.9) 139(57) 190(43.1) 42.934,1,<0.001

If you experience slight pain, ulcerations, or some discomfort during the treatment for malalignment, will you still continue with the treatment?

59(29.9) 128 (52.5) 187 (42.4) 22.613, 1, <0.001

Have you undergone any treatment for malalignment teeth in the past? 20 (10.2) 51(20.9) 71 (16.1) 9.324,1,0.002If yes

Was the treatment complete as planned? 22 (78.6) 13 (44.8) 35 (61.4) 6.844,1,0.009Didyouweartheremovableretentionplatefortheentiredurationspecifiedbyyour doctor?

10 (35.7) 22(75.9) 32 (56.1) 9.325,1,0.002

Did you consult your doctor for any suggestion after completion of treatment? 21 (75) 13 (44.8) 34(59.6) 5.388, 1, 0.020

Table 3: Responses to various questions in relation to age

Question <19 years, n (%)

>20 years, n (%)

Total, n (%)


Have you heard of the term malalignment of teeth? 162 (63.3) 128(69.2) 290(65.8) 1.665,1,0.197Doyouthinkhereditycaninfluencetheoccurrenceofmalalignmentofteeth? 120(46.9) 72(38.9) 192(43.5) 2.765,1,0.96Do you think habits such as thumb sucking, tongue thrusting, and mouth breathing can cause malalignment of teeth?

120(46.9) 110(59.5) 230 (52.2) 6.816,1,0.009

Do you think malaligned teeth can affect appearance? 145(56.9) 78 (42.2) 223 (50.7) 9.270,1,0.002Do you think malaligned teeth can affect chewing ability? 146 (57) 111 (60) 257 (58.3) 0.389,1,0.533Do you think malaligned teeth can affect speech? 142 (55.5) 96(51.9) 238 (54) 0.553, 1, 0.457Do you think malaligned teeth can affect oral hygiene? 136 (53.1) 84 (45.4) 220(49.9) 2.560, 1, 0.110Do you think dental checkup and treatment of malalignment is essential in early childhood and adolescent?

155 (60.5) 101 (54.6) 256 (58) 1.562, 1, 0.211


117 (45.7) 61 (33) 178 (40.4) 7.230, 1, 0.007


99(38.7) 54(29.2) 153 (34.7) 4.262,1,0.039


97(37.9) 93(50.3) 190(43.1) 6.712, 1, 0.010


105 (41) 82 (44.3) 187 (42.4) 0.481, 1, 0.488

Have you undergone any treatment for malalignment teeth in the past? 41 (16) 30 (16.2) 71 (16.1) 0.003,1,0.955If yes

Was the treatment complete as planned? 15 (50) 20 (74.1) 35 (61.4) 3.475, 1, 0.062Didyouweartheremovableretentionplatefortheentiredurationspecifiedby your doctor?

20 (66.7) 12 (44.4) 32 (56.1) 2.850,1,0.091

Did you consult your doctor for any suggestion after completion of treatment? 19(63.3) 15 (55.6) 34(59.6) 0.357, 1, 0.550



conclusIon

Majority of the subjects in the study were aware about the term orthodontics. Despite having good knowledge on orthodontic treatment, patient’s attitude and practice toward orthodontic treatment was moderate. Adult patients provide us the prospect to render the greatest service doable in orthodontics. Continuing education of the general public will result in an increasing claim for this type of service. Adjunctive and comprehensive orthodontic treatment is practicable for adults owing to the growing emphasis on cosmetic dentistry. Furthermore, correction of malocclusion makes it possible to improve the quality of periodontal and restorative treatment outcomes in addition to providing psychosocialbenefits.Werecommendfurtherstudieswithalarger sample size to create awareness in the general public on recent technologies as well as to assess the future requirement of treatment needs.

AcknowledgmentsWe extend our sincere thanks to all college authorities for permitting us to undertake this project and volunteers for extending their valuable support in completing the questionnaire.



references1. Hamamci N, Basaran G, Uysal E. Dental Aesthetic Index scores and

perception of personal dental appearance among Turkish university students.EurJOrthod2009;31:168‑73.

2. Urtane I, Pugaca J, Liepa A, Rogovska I. The severity of malocclusion and need for orthodontic treatment in correspondence with the age. Stomatologija 2006;8:35‑8.

3. Klages U, Claus N, Wehrbein H, Zentner A. Development of a questionnaire for assessment of the psychosocial impact of dental aesthetics in young adults. Eur J Orthod 2006;28:103‑11.

4. Rastogi S, Jatti RS, Keluskar KM. Assessment of awareness and social perceptions of orthodontic treatment needs in adult age group: Aquestionnairestudy.JOralHealthCommunityDent2014;8:95‑100.

5. Shekar BR, Suma S, Kumar S, Sukhabogi JR, Manjunath BC. Malocclusion status among 15 years old adolescents in relation to fluoride concentration and area of residence. Indian J Dent Res2013;24:1‑7.

6. Chandra Shekar BR, Suma S, Kumar S, Sukhabogi JR, Manjunath BC. Prevalence of malocclusion among 15 year old school children using dental aesthetic index in Nalgonda district, Andhra Pradesh, India: A cross sectional study. J Indian Assoc Public Health Dent 2014;12:173‑8.

7. Gupta R, Chandrashekar BR, Goel P, Saxena V, Ganavadiya R, Verma N. Prevalence of malocclusion in relation to area of residence among 13‑15 years old Government and Private school children in Bhopaldistrict,MadhyaPradesh,India.IntJAdvRes2015;3:918‑25.

8. El‑Qaderi SS, Taani DQ. Oral health knowledge and dental health practices among schoolchildren in Jerash district/Jordan. Int J Dent Hyg 2004;2:78‑85.

9. KassakKM,DagherR,DoughanB.Oralhygieneandlifestylecorrelatesamong new undergraduate university students in Lebanon. J Am Coll Health 2001;50:15‑20.

10. Chopra K, Kathariya MD, Kathariya R, Mohammed IB, Patil SK, Kasat V. Knowledge, attitude and practices regarding oral health among orthodontic and non‑orthodontic patients in a dental institute. Int J Dent

Table 4: Responses to various questions in relation to area of residence

Question Rural, n (%)

Urban, n (%)

Total, n (%)


Have you heard of the term malalignment of teeth? 119(54.3) 171 (77) 290(65.8) 25.206, 1, <0.001Doyouthinkhereditycaninfluencetheoccurrenceofmalalignmentofteeth? 77 (35.2) 115 (51.8) 192(43.5) 12.421, 1, <0.001Do you think habits such as thumb sucking, tongue thrusting, and mouth breathing can cause malalignment of teeth?

103 (47) 127 (57.2) 230 (52.2) 4.574, 1, 0.032

Do you think malaligned teeth can affect appearance? 94(42.9) 129(58.4) 223 (50.7) 10.503, 1, 0.001Do you think malaligned teeth can affect chewing ability? 111 (50.7) 146 (65.8) 257 (58.3) 10.312, 1, 0.001Do you think malaligned teeth can affect speech? 92(42) 146 (65.8) 238 (54) 25.046, 1, <0.001Do you think malaligned teeth can affect oral hygiene? 88 (40.2) 132(59.5) 220(49.9) 16.387, 1, <0.001Do you think dental checkup and treatment of malalignment is essential in early childhood and adolescent?

115 (52.5) 141 (63.5) 256 (58) 5.480,1,0.019


61(27.9) 117 (52.7) 178 (40.4) 28.279,1,<0.001


49(22.4) 104 (46.8) 153 (34.7) 29.141,1,<0.001


80 (36.5) 110(49.5) 190(43.1) 7.621, 1, 0.006


79(36.1) 108 (48.6) 187 (42.4) 7.139,1,0.008

Have you undergone any treatment for malalignment teeth in the past? 10 (4.6) 61 (27.5) 71 (16.1) 42.842, 1, <0.001If yes

Was the treatment complete as planned? 8 (100) 27 (55.1) 35 (61.4) 5.850, 1, 0.016Didyouweartheremovableretentionplatefortheentiredurationspecifiedby your doctor?

2 (25.0) 30 (61.2) 32 (56.1) 3.665, 1, 0.056

Did you consult your doctor for any suggestion after completion of treatment? 2 (25) 32 (65.3) 34(59.6) 4.642, 1, 0.031



Case Rep 2015;5:18‑24.11. Chand S, Arfan HM. Oral health‑related knowledge, attitude, and

practice among school children from Rural and Urban areas of district Sheikhupura,Pakistan.PakOralDentJ2014;34:109‑12.

12. Kreit LH, Burstone C, Delman L. Patient cooperation in orthodontic treatment.JAmCollDent1968;35:327‑32.

13. Gravely JF. A study of need and demand for orthodontic treatment in two contrasting National Health Service regions. Br J Orthod 1990;17:287‑92.

14. Gray M, Anderson R. A study of young people’s perceptions of their

orthodontic need and their experience of orthodontic services. Prim DentCare1998;5:87‑93.

15. StarnbachHK,KaplanA. Profile of an excellent orthodontic patient.AngleOrthod1975;45:141‑5.

16. Rafighi A, Foroughi Moghaddam S, Alizadeh M, Sharifzadeh H.Awareness of orthodontic treatments among school teachers of two cities in Iran. J Dent Res Dent Clin Dent Prospects 2012;6:25‑8.

17. Wedrychowska‑Szulc B, Syrynska M. Patient and parent motivation for orthodontic treatment – A questionnaire study. Eur J Orthod 2010;32:447‑52.

annexure

Annexure 1: Questionnaire

Participant Name: Age in years: Gender: Male/Female

Education: College: Government/Private

Area: Rural/Urban Date:

Please tick your option to the following questions

Serial number Item Yes No Don’t know κ1 Have you heard of the term malalignment of teeth? 0.922 Doyouthinkhereditycaninfluencetheoccurrenceofmalalignmentofteeth? 0.893 Do you think habits such as thumb sucking, tongue thrusting, and mouth breathing can cause

malalignment of teeth?0.89

4 Do you think malaligned teeth can affect appearance? 0.895 Do you think malaligned teeth can affect chewing ability? 0.906 Do you think malaligned teeth can affect speech? 0.917 Do you think malaligned teeth can affect oral hygiene? 0.898 Do you think dental checkup and treatment of malalignment is essential in early childhood

and adolescent?0.89

9 If the correction of malalignment extends for duration of around 1‑2 years, would you like to undergo treatment?

0.92

10 If some teeth have to be removed in the course of your treatment of malalignment teeth, will you agree for the removal of healthy teeth?

0.89

11 If the doctor instructs you to wear an appliance for additional 6 months to 1 year even after the completion of your treatment, will you wear that appliance?

0.91

12 If you experience slight pain, ulcerations, or some discomfort during the treatment for malalignment, will you still continue with the treatment?

0.92

13 Have you undergone any treatment for malalignment teeth in the past? 0.91If yes

14 Was the treatment complete as planned? 0.9115 Didyouweartheremovableretentionplatefortheentiredurationspecifiedbyyourdoctor? 0.8916 Did you consult your doctor for any suggestion after completion of treatment? 0.90Kappacoefficientrangedfrom0.89to0.92


Original Article

IntroductIon

Periodontal diseases are among the most common infectious diseases disturbing human kind and can lead to the demolition of the periodontal ligament, cementum, gingiva, and alveolar bone. Plaque is the primary etiological factor in gingival inflammation.[1] Thus, control of dental plaque holds the key to bring to a standstill the progression of periodontal disease. Since a majority of the population is not able to execute plaque control effectively, the onus lies on the dental health‑care provider to impart the correct knowledge about the oral hygiene aids and adjunctive use of various chemical plaque control agents. Chemotherapeutic mouthrinses endow with chemically significantbenefitinthereductionofplaque‑inducedgingivitis.Mouthrinses encompass the ability to deliver therapeutic ingredientsandbenefitstoallaccessiblesurfacesinthemouthincluding interproximal surfaces. They also remain effective for unmitigated period of time depending on their substantivity.

Chlorhexidine has been prescribed by dentists for decades and accepted as the gold standard in reducing dental plaque asithasreflectiveanti‑plaqueandantibacterialproperties.[2‑5] However, it has few detrimental side effects primarily brown staining of the teeth[6] and transient impairment of taste sensation. Recently, numerous studies have been conducted to verify the enormous wealth of medicinal plants. These herbal mouthwashes are gaining popularity as they contain naturally occurring ingredients called as phytochemicals thatachievethedesiredantimicrobialandanti‑inflammatoryeffects. Herbal formulations may be more appealing because

Assessment of the Efficacy of Licorice Versus 0.2% Chlorhexidine Oral Rinse on Plaque‑induced Gingivitis:

A Randomized Clinical TrialPrateek Jain, Priyanka Sontakke, Satinder Walia, Pramod Yadav, Gautam Biswas, Diljot Kaur

Department of Public Health Dentistry, Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh, India

Background:Supragingivalplaquecontroliselementarytothepreventionandmanagementofperiodontaldiseases.Conversely,significantproportions of all individuals fail to practice a high standard of plaque removal. The adjunctive use of chemicals would therefore appear a wayofovercomingdeficienciesinmechanicaltoothcleaninghabits.Thisprospective,randomizedpositivelycontrolledclinicaltrialwasaimedtoevaluatetheshort‑termclinicaleffectsofalicoriceoralrinseinthereductionofplaqueandgingivalinflammationinindividualswith gingivitis. Materials and Methods: A total of 104 individuals, 12–15 years of age diagnosed with chronic generalized gingivitis, were selected and randomly divided into two groups: Group 1: chlorhexidine mouthwash and Group 2: licorice mouthwash. Clinical evaluation was undertaken using the gingival index, the plaque index, and bleeding on probing at baseline, 1st, 2nd, and 4th week. Results: Both chlorhexidine andlicoricemouthwashshowedasignificantreductioninplaqueandgingivalindexscoresfrombaselineto1st, 2nd, and at 4th week. However, the improvement in plaque and gingival index scores were better in chlorhexidine group than herbal mouthwash. Both mouthwashes were found to be equally effective in reducing bleeding on probing. Conclusion: Unlike chlorhexidine mouthwash, licorice mouthwash was not associatedwithanydiscolorationofteethorunpleasanttasteandwaseffectiveinreducingplaqueaccumulationandgingivalinflammation.However, chlorhexidine still remains a gold standard in reducing plaque, gingivitis, and bleeding on probing.

Keywords: Chlorhexidine, gingivitis, licorice, plaque




Address for correspondence: Dr. Prateek Jain, Senior Lecturer, Department of Public Health Dentistry,

Maharana Pratap College of Dentistry and Research Centre, Putlighar Road, Gwalior ‑ 474 001, Madhya Pradesh, India.




How to cite this article: Jain P, Sontakke P, Walia S, Yadav P, Biswas G, KaurD.Assessmentoftheefficacyoflicoriceversus0.2%chlorhexidineoral rinse on plaque‑induced gingivitis: A randomized clinical trial. Indian J Oral Health Res 2017;3:XX‑XX.

Abstract

Jain, et al.: Licorice versus chlorhexidine: A randomized clinical trial


theyworkwithout alcohol, artificial preservatives, flavors,or colors. One other mouthwash is licorice (manufactured privately).Thismouthrinsecontainslicoricewithsignificantantiinflammatory properties. The principal ingredient isGlycyrrhiza Glabra (Licorice); the key therapeutic compound in licorice is glycyrrhizin. It prevents the breakdown of adrenal hormonessuchascortisol(thebody’sprimarystress‑fightingadrenal hormone), making these hormones more available to the body, hence acting as immunostimulant. Licorice flavonoidconstituentsmainlyincludeflavones, isoflavones,andchalconeswhichshowantioxidant,antiinflammatory,andantibacterial properties.[6]

Thus, the present study was undertaken to compare the clinical efficacyof0.2%chlorhexidinewithlicoricemouthwashongingival health status over a period of 4 weeks.


This study was designed and conducted in a private school, Jaipur, India. One hundred and four children with clinical signs and symptoms of chronic plaque‑induced gingivitis were selected from the various classes. All patients were systemically healthy and between 12 and 15 years of age. Approval from the Institutional Ethics Committee of Dental College, Jaipur, was obtained before initiating the study. An informed consent was obtained from all the parents of participants. The individuals were randomly assigned to one of the 2 treatment groups, i.e., 0.2% chlorhexidine (HEXIDINE by ICPA Health products Ltd.) and licorice mouthwash (a Private company manufactured, Jaipur, Rajasthan, India) and were followed for 4 weeks.

In the majority of cases, participants were examined at the same time of day to reduce extraneous variables in plaque accumulation, such as the length of time between home care and data collection. Fifty‑two individuals (27 males and 25 females) were instructed to use 10 ml of 0.2% chlorhexidine mouthwash twice daily and 52individuals(19malesand33females)wereinstructedto use 10 ml of licorice mouthwash twice daily. Individuals were given the same type of toothbrush (by Oral B) and toothpaste (Pepsodent) and were also given appropriate oral hygiene instructions.

Data were collected at baseline, 1st, 2nd, and 4th week utilizing the following:a. Plaque index[7]

b. Gingival index[8]

c. Bleeding on probing (percentage of bleeding sites).

Statistical analysisStatistical analysiswas carried out bymeans of SPSS21.Pairedcomparisontestswereusedtoconfirmtheresultswith P < 0.05. Mean and standard deviation was calculated using the paired t‑test and mean difference was calculated at each weektoyieldsignificantresults.

results

One hundred and four participants (58 females and 46 males) participated in the study, and the response rate to the study was 100%.

Gingival healthAnalysis of plaque indices showed that both chlorhexidine and licorice mouthwash were helpful in reducing mean plaque accumulation from baseline to 4 weeks. The mean plaque index scoresreducedfrom3.8±0.7to1.24±0.92inchlorhexidinegroupandfrom3.88±0.83to2.28±0.93inthelicoricegroup[Figure 1].

Analysis of gingival scores indicated that chlorhexidine and licorice mouthwash independently showed a statistically significant improvement from baseline to 1st week with further improvement at 2nd and 4th week. The reduction in gingival index scores in chlorhexidine and licorice mouthwash groupwas2.0±0.00–0.28±0.45and1.96±0.20–0.6±0.5(from baseline to 4 weeks), respectively [Figure 2].

Intergroup comparisons depicted that chlorhexidine was significantly more persuasive in reduction of plaque accumulation and gingivitis as compared to licorice mouthwash, signifying that chlorhexidine still remains a gold standard.

Bleeding on probingAlthoughresultsdonotreachtolevelofsignificancewhenintergroup comparisons were made, individually both chlorhexidine and licorice mouthwash were effective in reducing bleeding sites. The mean percentage of bleeding sites reduced from 84.0% ± 37.2%–44.2% ± 50.3% in chlorhexidine group and 87.4% ± 48.23%–56.1 ± 33.5% in licorice mouthwash group at 4 weeks. Licorice mouthwash contains certain ingredients with astringent property, so a steady fall in bleeding sites was noticed as compared to chlorhexidine [Figure 3].

dIscussIon

Thestudywasconductedtoauthenticatetheefficacyoflicoricemouthwash versus chlorhexidine mouthwash on gingival status and plaque biofilm accumulations over a period of

0

20

40

60

80

100

Baseline 1 week 2 week 4 week

Cholorhexidine

Herbal MouthWash

Figure 1: Reduction in plaque index with chlorhexidine and licorice mouthwash from baseline to 4 weeks



4 weeks. Chlorhexidine remains the gold standard anti‑plaque andantigingivitisagents.Itsefficiencycanbeendorsedtoitsbactericidal and bacteriostatic effects and its substantivity within the oral cavity. Licorice has shown promising results with minimal side effects. Furthermore, their additional effect on inflammatory pathways and antioxidant potentialmakethem eligible to be used as effective antigingivitis agents. The licorice ingredients are abundantly available, easily accessible, economically feasible, and culturally acceptable. They possess minimal side effects and hence can be recommended for long‑term use. Although around 6000 plants in India are used as herbal medicine, little research has been conducted to evaluate theefficacy,safety,andpropertiesofherbalproducts.Hence,more clinical trials are required to know the effectiveness of natural products and their advantage over the prototype chemical plaque control agents.

Numerousstudieshavereportedtheefficacyofchlorhexidineinreducingplaqueaccumulationandgingivalinflammation.[9,10]

Azadirachta indicahasbeenshowntobeefficientinreducingthe plaque index and bacterial count.[11] In a comparative study between A. indica and chlorhexidine, it was established that A. indica‑basedmouthrinsewashighlyefficaciousinreducingplaque index, gingival index, and gingival bleeding index and that it may be used as an alternative therapy in the treatment of periodontal disease.[12] Neem extract has also revealed to effectively reduce interleukin‑2 and interferon‑gamma levels in gingival tissue of patients with chronic gingivitis.[13]

Methanolic extract of Quercus has shown to have a considerable antibacterial activity against Streptococcus mutans, Streptococcus salivarius, and Lactobacillus which play a major role in plaque development and its activity against caries and gingivitis.[14] Bajajet al. stated that 0.6% triphala has an inhibitory effect on plaque, gingivitis, and growth of S. mutans and Lactobacillus and was found to be equally effective as 0.1% chlorhexidine.[15] Similar results were reported by Gupta et al. wherein 0.6% triphala was found to be highly effective in preventing plaque accumulation and gingivitis.[16]

Tulsi extract has also shown to demonstrate a significantantimicrobial potential against S. mutans.[17] Goultschin et al.

tested the effect of glycyrrhizin, the main saponin of licorice on gingival health as a supplemental agent in toothpaste. The toothpaste,however,failedtoshowanysignificantreductionin plaque, gingival, and bleeding indices.[18] A study by Jayashankar et al. also demonstrated that a herbal toothpaste containing Mimusops elengi, Syzygium aromaticum, and Quercus infectoria significantly reduced plaque index andbleeding on probing.[19]

A study by Pistorius et al. showed that subgingival irrigation with an herbal‑based mouthrinse (containing salvia officinalis, methapiperita,menthol,Matricaria chamomilla, Commiphora myrrha, Carum carvi, Eugenia caryophyllus, and Echinacea purpurea) proved to be fruitful in reducing gingival inflammation as it leads to significant reductionin both bleeding and gingival score.[20] In the present study, analysis of plaque index suggests that both the mouthwashes were helpful in reducing plaque, but chlorhexidine reduced plaque scores to greater extent as compared to licorice mouthwash group.These findings are similar to previousstudies.[21,22] The reduction in plaque score in chlorhexidine group was due to antibacterial action. In a microbiological study, it was reported that herbal mouthwash had less potent antibacterial action than chlorhexidine. Chlorhexidine has antibacterial activity against actinomyces species, periodontal pathogens Eubacterium nodatum, Tannerella forsythia, and Prevotella species, as well as the cariogenic pathogen S. mutans. However, variations in the plaque accumulation mayalsohavebeeninfluencedbytheHawthorneeffectorthetendency of participants to improve behavior because of the expectation created by the situation.

Chlorhexidinewasalsomoreefficientinimprovinggingivalinflammation.Both chlorhexidine and licoricemouthwashwere found to be helpful in reducing bleeding score, but results werenot significant statistically.This substantial reductionin bleeding score in herbal group might be because of its ingredients M. elengi, Acacia catechu, and Mentha spicata which reduce bleeding because of their astringent action. These results are consistentwithotherfindingsbySchereret al.1998whodemonstratedthatherbalmouthwashreducesgingival bleeding over a period of time.[23]

0

20

40

60

80

100


Cholorhexidine

Herbal MouthWash

Figure 2: Reduction in gingival index with chlorhexidine and licorice mouthwash from baseline to 4 weeks

0

20

40

60

80

100


Cholorhexidine

Herbal Mouth Wash

Figure 3: Reduction in percentage of bleeding sites with chlorhexidine and licorice mouthwash from baseline to 4 weeks



conclusIon

The results of the present study indicate that both mouthwashes were effective in improvement of plaque and gingivitis scores, though chlorhexidine showed better clinical improvement. Licorice mouthwash was found to be comparable to chlorhexidine in reducing bleeding on probing.

Thus, licorice mouthwash can be effectively used as an alternative to chlorhexidine and can be prescribed for longer duration without any side effects for the management of periodontal diseases.

AcknowledgmentI want to acknowledge all the participants of the study who voluntarily participated in our study group. I want to thank our institution for constant support.



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9. Becerik S, Türkoglu O, Emingil G, Vural C, Ozdemir G,Atilla G.Antimicrobial effect of adjunctive use of chlorhexidine mouthrinse in untreated gingivitis: A randomized, placebo‑controlled study. APMIS 2011;119:364‑72.

10. Corbet EF, Tam JO, Zee KY, Wong MC, Lo EC, Mombelli AW, et al. Therapeutic effects of supervised chlorhexidine mouthrinses on untreatedgingivitis.OralDis1997;3:9‑18.

11. Pai MR, Acharya LD, Udupa N. Evaluation of antiplaque activity of Azadirachta indica leaf extract gel – A 6‑week clinical study. JEthnopharmacol2004;90:99‑103.

12. Botelho MA, Santos RA, Martins JG, Carvalho CO, Paz MC, Azenha C, et al.Efficacyofamouthrinsebasedonleavesoftheneemtree (Azadirachta indica) in the treatment of patients with chronic gingivitis: A double‑blind, randomized, controlled trial. J Med Plants Res 2008;2:341‑6.

13. Sharma S, Saimbi CS, Koirala B, Shukla R. Effect of various mouthwashes on the levels of interleukin‑2 and interferon‑gamma in chronic gingivitis. J Clin Pediatr Dent 2008;32:111‑4.

14. Vermani A; Navneet; Prabhat. Screening of Quercus infectoria gall extracts as anti‑bacterial agents against dental pathogens. Indian J Dent Res2009;20:337‑9.

15. Bajaj N, Tandon S. The effect of triphala and chlorhexidine mouthwash on dental plaque, gingival inflammation, andmicrobial growth. Int JAyurvedaRes2011;2:29‑36.

16. Gupta K, Tandon S, Rao S, Malagi KJ. Effects of triphala mouthwash on the oral health status. Malays Dent J 2004;25:27‑46.

17. Agarwal P, Nagesh L; Murlikrishnan. Evaluation of the antimicrobial activity of various concentrations of Tulsi (Ocimum sanctum) extract against Streptococcus mutans: An in vitro study. Indian J Dent Res 2010;21:357‑9.

18. Goultschin J, Palmon S, Shapira L, Brayer L, Gedalia I. Effect of glycyrrhizin‑containing toothpaste on dental plaque reduction and gingival healthinhumans.Apilotstudy.JClinPeriodontol1991;18:210‑2.

19. JayashankarS,PanagodaGJ,AmaratungaEA,PereraK,RajapaksePS.A randomised double‑blind placebo‑controlled study on the effects of a herbal toothpaste on gingival bleeding, oral hygiene and microbial variables.CeylonMedJ2011;56:5‑9.

20. PistoriusA,WillershausenB,SteinmeierEM,KreislertM.Efficacyofsubgingival irrigationusingherbal extractsongingival inflammation.J Periodontol 2003;74:616‑22.

21. Overholser CD, Meiller TF, DePaola LG, Minah GE, Niehaus C. Comparative effects of 2 chemotherapeutic mouthrinses on the development of supragingival dental plaque and gingivitis. J Clin Periodontol1990;17:575‑9.

22. Haffajee AD, Yaskell T, Socransky SS. Antimicrobial effectiveness of an herbal mouthrinse compared with an essential oil and a chlorhexidine mouthrinse.JAmDentAssoc2008;139:606‑11.

23. Scherer W, Gultz J, Lee SS, Kaim J. The ability of an herbal mouthrinse toreducegingivalbleeding.JClinDent1998;9:97‑100.


Original Article

IntroductIon

Increasing prevalence of childhood obesity is seen globally. In India, 22.0% children are suffering from childhood obesity.[1] One of the major causes for this high prevalence is the change in lifestyle and dietary patterns.[2] Some dietary patterns appear quite common among children and adolescents such as snacking, usually on energy‑dense foods; meal skipping, particularly breakfast or irregular meals; wide use of fast food; and low consumption of fruits and vegetables.[3,4] Various studies on diet and nutrition intake of adolescents and young adults in the developed world have shown that their diets are oftenhighinfatsandrefinedcarbohydrate.[5] A study by Punjab Agricultural University, Ludhiana, on consumption pattern of fast foods among teenagers found that fast foods are most commonly consumed between regular meals.[6] Consumption of diet which is rich in sugar, saturated fat, salt and calorie content in children can lead to early development of obesity, hypertension, dyslipidemia, and impaired glucose tolerance.[7]

Starchy foods such as crispy snacks, due to their high fermentability and their tendency to be retained in the mouth

for a long period probably have a moderate to high cariogenic potential if consumed frequently.[8] One approach to estimate the cariogenic potential of food involves evaluation of magnitude of pH response of the dental plaque obtained following ingestion.[8]

Dental plaque is an adherent deposit of bacteria and their products, which forms on all tooth surfaces and is the cause of caries.[9] Fermentable carbohydrates provide plaque bacteria with substrate for acid production and the synthesis of extracellular polysaccharides. The plaque remains acidic for some time, taking 30–60 min to return to its normal pH.[9] The gradual return of pH to baseline values is a result of acids diffusing out of the plaque and buffers in the plaque andsalivaryfilmoverlyingit,exertinganeutralizingeffect.

The Acidogenicity of Crispy Snacks Available in Indian Market: A Comparative Study

Ashveeta J. Shetty, Farhin Katge, Debapriya Pradhan, Mayur Wakpanjar

Department of Paedodontics and Preventive Dentistry, TPCT’s Terna Dental College and Hospital, Navi Mumbai, Maharashtra, India

Background: Sucrose and starches are the predominant dietary carbohydrates in modern societies. This study has been conducted to determine whether a relationship exists between dental caries and commonly consumed crispy snacks which are processed starches. One approach to estimate the cariogenic potential of a food involves evaluation of the magnitude of the pH response obtained following ingestion. Aim: The aim of the study is to compare the dental plaque pH changes after consumption of four commercially available crispy snacks in the Indian market. The pH was measured using the plaque sampling method in 40 subjects. Statistical analysis was done using the SPSS version 17 software (SPSS Inc., Chicago, IL, USA). One‑way ANOVA test with Bonferroni post hoc test was used for statistical evaluation. P value was set to 0.05. Results:IntragroupcomparisonshowedadropinpHwhichwasstatisticallysignificantineachgroupimmediatelyaftertheconsumption of the crispy snacks and the pH returned to baseline values by 30 min. The pH response comparison between the different groups ofcrispysnackswasnotstatisticallysignificantfrombaselinetoimmediatelyafterconsumptionofthecrispysnacks(P = 0.241) and at 30 min interval (P = 0.580). Conclusion: Frequent consumption of crispy snacks may have a cariogenic potential due to high fermentability in dental plaque of these processed starch products.

Keywords: Crispy snacks, digital pH meter, plaque pH, processed starches




Abstract

Address for correspondence: Dr. Ashveeta J. Shetty, Department of Paedodontics and Preventive Dentistry, TPCT’s Terna Dental

College and Hospital, Nerul, Navi Mumbai ‑ 400 706, Maharashtra, India. E‑mail: [email protected]

How to cite this article: Shetty AJ, Katge F, Pradhan D, Wakpanjar M. The acidogenicity of crispy snacks available in Indian market: A comparative study. Indian J Oral Health Res 2017;3:XX‑XX.



Shetty, et al.: Acidogenicity of crispy snacks


Repeated and frequent consumption of such fermentable carbohydrates will keep plaque pH depressed and cause demineralization of the teeth.[9]

The aim of the present study is 1. To check the pH response of human dental plaque

immediately after consumption of crispy snacks and at 30 min intervals

2. To compare the pH response between four different types of commonly consumed crispy snacks available in the Indian market.


Ethical clearance was obtained from the Institutional Review Board.

Subject selection: Subjects were screened and forty subjects in the age group of 7 to14 years with plaque score >2 according toplaqueindexbySilnessandLoe(1967)wereincludedinthestudysothatsufficientamountofplaquewasavailableforsample collection.[10] Parent consent and patient assent were obtained. Medically compromised subjects were excluded from the study. The subjects were refrained from eating or drinking anything except water 2.5 h before collection of the baseline plaque samples.[11]

Test groups: Subjects were randomly assigned to the four groups of crispy snacks to be tested in the study: Group A (Lays Classic Salted, Pepsico India), Group B (Cheetos Cheeez Puffs, Pepsico India), Group C (Kurkure Masala Munch, Pepsico India), and Group D (Peppy, SM Foods India).

Plaque sampling technique and pH measurementsA pocket type digital pH meter (HMDPHM80 Digital pH/Temperature Meter, HM Digital, India) was used to measure the plaque pH. The electrode was calibrated against standard pH buffers before each test session [Figure 1]. Plaque sample was collected from the buccal surfaces of posterior teeth using a sterile blunt explorer.[11] Each plaque sample was thoroughly mixed with 15 ml of distilled water, measured by a pipette into a beaker.[12] The recording of pH reading was done chairside. The electrode of the digital pH meter was dipped into the diluted sample. The reading on the pH meter was recorded, and thereafter, the electrode was cleaned with a stream of distilled water and dried.

A plaque sample taken before the test product was consumed and a baseline plaque pH was recorded. The subjects were then given 30 g of the crispy snacks to eat. Plaque samples were again taken immediately after consumption of the crispy snack and at 30 min interval from the time of consumption of the snack. The pH of these samples was measured and recorded using the digital pH meter.

Statistical analysis was done using the SPSS version 17 software (SPSS Inc., Chicago, IL, USA). One‑way ANOVA test with Bonferroni post hoc test was used for statistical evaluation. P value was set to 0.05.

results

Maximumsubjects (52.5%)were in the9years agegroup[Figure 2]. 62% were male and 38% were female [Figure 3]. Figure 4a‑d show the pH changes within the four groups of crispy snacks from baseline to immediately after consumption of the crispy snacks and at 30 min interval. A drop in the pH was observed from the baseline to immediately after consumption of the crispy snack in Group A, B, C, and D. This drop in pH was statistically significant for all four groups from baseline to immediately after consumption of the snack (Group A, P < 0.05; Group B, P < 0.05; Group C, P < 0.05; Group D, P < 0.05). The difference in pH was also statistically significant after snack consumption to the30 min interval. A recovery in the pH values was obtained at the 30 min interval in all four groups (Group A, P < 0.05; Group B, P < 0.05; Group C, P < 0.05; Group D, P < 0.05). Intergroup comparison showed that pH changes from baseline to immediately after consumption of the snacks were not statisticallysignificant (P > 0.05). A rise in pH values was observed at 30 min following consumption of the snacks. pH difference between the four groups at 30 min interval was not statisticallysignificant(P > 0.05). Figure 5 shows intergroup comparison of the pH changes.

dIscussIon

Changes in human dental plaque pH can be used to estimate of the acidogenic potential of ingested foods.[8] Modern diets of

Figure 1: Pocket type digital pH meter (HM DPHM80 Digital pH/Temperature Meter, HM digital, India) calibration before measuring plaque pH



urbanpopulationscontainawiderangeprocessedfoods,refinedflours,foodsconsistingofmixturesofstarchandsugarsandfoods with a soft consistency. The cariogenic potential of starch andstarchcontainingfoodproductsseemstobeinfluencedby a large number of factors such as the processes used for manufacturing these products, the frequency of consumption, different tendencies for retention on the dentition, presence of caries‑promoting or inhibitory ingredients, and the interactions with salivary amylase in vivo.[13] Studies suggest that the pH response to a single substrate varies with factors endogenous to individual subjects but that in response to differing foods, acid production becomes the dominant factor in determining the plaque pH.[14] In the present study, the plaque sampling method was used to determine the plaque pH. A pocket type digital pH meter was used to measure the plaque pH. The advantages of using this method are that it does not require sophisticated equipment, can be efficiently used on a large number ofsubjects, can be used chairside.[8]

Age and gender have been mentioned to show demographic distribution of subjects, random allocation of subjects, and similar eating habits in common age group children.

The present study shows that intragroup comparison showed a significant drop in pH in each group immediately afterconsumption of the crispy snacks and the pH returned to normal by 30 min. Intergroup comparison was not statistically significantbetweenthedifferentgroupsofcrispysnacks.

The fact that a processed starch product, such as potato chips, causes low pH values in dental plaque is in agreement withearlierreports(Lingstrom,1993).[8]Starchmodifiedbydifferent processes shows an increasing susceptibility to hydrolysis by alpha‑amylase and correspondingly produces an increased pH drop in dental plaque compared with raw starch.[8]

The products used in the present study contain starches modifiedbyvariousprocesses.Processedpurewheat,corn,rice,rye,andpotatostarchcanallcauseasignificantplaquepH drop (Lingstrom et al.,1989,1993).[8] In addition to these, there is added sugar present in each of the products tested in the present study. Sugars, even in low concentration, can significantlyaffectplaquepH.[15]Anotherimportantfindingisthat though certain crispy snacks contain cheese, the quantity of cheese powder is very less and has no protective effect against caries.

The aim of this study was to evaluate the drop in pH of the samplesasawholeandnotofindividualcomponents.Influence

Figure 3: Gender distribution of the subjects

Figure 2: Age distribution of the subjects

Figure 5: Intergroup comparison between four study groups. Mean pH immediately after consumption of the snack and at 30 min interval

Figure 4: (a‑d) pH changes immediately after the consumption of crispy snacks and at 30 min interval

dc

ba



of pH of individual components was beyond the scope of this study. Further research can be undertaken to analyze the effect of individual components of such crispy snacks.

Junk foods are preferred by children as well as parents due to their easy availability and attractive packaging. These products are usually inexpensive and hence, a preferred snack especially by school children during breaks. It is important for dental professionals to guide parents regarding the effects of these foodstuffs on the oral health of their children. Guidelines regarding caries risk for sugary foods should be further supplemented by similar guidelines for crispy snacks consisting of starch‑sugar mixtures.

conclusIon

It is believed that most processed starch products have a cariogenic potential due to high fermentability in dental plaque of the crispy snacks included in the present study and the probability of frequent consumption in conjunction with other cariogenic foodstuffs. Counseling should be done to guide parents regarding the right choices of foodstuffs that affect the teeth as well as overall well‑being of their children.

AcknowledgementWe thank the Department of Public Health Dentistry, Terna Dental College, for their support in statistical analysis of data.



references1. Gupta N, Goel K, Shah P, Misra A. Childhood obesity in developing

countries: Epidemiology, determinants, and prevention. Endocr Rev 2012;33:48‑70.

2. Tong HJ, Rudolf MC, Muyombwe T, Duggal MS, Balmer R. An investigation into the dental health of children with obesity: An analysis of dental erosion and caries status. Eur Arch Paediatr Dent 2014;15:203‑10.

3. Cavadini C, Decarli B, Dirren H, Cauderay M, Narring F, Michaud P. Assessment of adolescent food habits in Switzerland. Appetite 1999;32:97‑106.

4. Dausch JG, Story M, Dresser C, Gilbert GG, Portnoy B, Kahle LL. Correlates of high‑fat/low‑nutrient‑dense snack consumption among adolescents: Results from two national health surveys. Am J Health Promot1995;10:85‑8.

5. Bull NL. Studies of the dietary habits, food consumption and nutrient intakes of adolescents and young adults. World Rev Nutr Diet 1988;57:24‑74.

6. Sadana B, Khanna M, Mann SK. Consumption pattern of fast foods amongteenagers.ApplNutr1997;22:41‑5.

7. Seethalakshmi SS. Indian Food Worse Than Western Junk. Times of India; 13March, 2007.Available from:http://timesofindia.indiatimes.com/india/Indian‑food‑worse‑than‑Western‑junk/articleshow/1755418.cms. [Last accessed on 2017 May 15].

8. Lingström P, Imfeld T, Birkhed D. Comparison of three different methods for measurement of plaque‑pH in humans after consumption of softbreadandpotatochips.JDentRes1993;72:865‑70.

9. KiddEA,editor.Dentalplaque.In:EssentialsofDentalCaries.3rd ed. NewYork:OxfordUniversityPress;2005.p.2‑19.

10. Peter S, editor. Indices in dental epidemiology. In: Essentials of Preventive and Community Dentistry. 4th ed. New Delhi: Arya PublishingHouse;2006.p.312‑59.

11. Verakaki E, Duggal MS. A comparison of different kinds of European chocolates on human plaque pH. Eur J Paediatr Dent 2003;4:203‑10.

12. Hegde AM, Shetty R, Sequeira AR. The acidogenicity of various chocolates available in Indian market: A comparative study. Int J Clin PediatrDent2009;2:20‑4.

13. Lingström P, Holm J, Birkhed D, Björck I. Effects of variously processed starch on pH of human dental plaque. Scand J Dent Res 1989;97:392‑400.

14. Dodds MW, Edgar WM. The relationship between plaque pH, plaque acid anion profiles, and oral carbohydrate retention afteringestion of several ‘reference foods’ by human subjects. J Dent Res 1988;67:861‑5.

15. Kleinberg I. Studies on dental plaque. The effect of different concentrations of glucose on the pH of dental plaque in vivo. J Dent Res 1961;40:1087‑111.


Original Article

IntroductIon

In pediatric dentistry, the premature loss of deciduous posterior teeth can lead to difficulty inmastication and space loss.Hence, preservation of the carious deciduous teeth with pulpal involvement by endodontic therapy is a wise option compared to extraction. Endodontics has evolved with the introduction of many new instruments, materials, and techniques. Hence, upgradation of knowledge of the clinicians is essential to provide patients with most recent and predictable treatment planning.[1] Traditionally, hand instruments made up of stainless steel were used for cleaning and shaping of the root canal in primary teeth. However, the concerns of its useinprimaryteethwerealackofflexibilityandincreasedpreparation time. Especially, in young children with limited cooperation, procedural errors and inconsistency of quality tapered preparation compromised the clinical prognosis. To overcome some of these issues, nickel–titanium alloy

was introduced in endodontics by Walia et al.(1988)whichfulfilledtheobjectivesofsimplicity,speed,safety,andstressreduction for both the clinician and the patient. The use of rotary systems demands a thorough knowledge and previous training regarding their use. Moreover, root canals of primary teetharecomplex,flattened,narrow,curved,andribbon‑shapedwitha lotofvariabilitywhichmakes itdifficult topreparethem. Research data on knowledge, attitude, and practice regarding the use of rotary instruments in cleaning and shaping by pediatric dentists are rare,[1] and hence this study will help to generate data for the same.

Knowledge, Attitude, and Practice among Pediatric Dentists Regarding the Use of Rotary Endodontic Instruments for

Endodontic Treatment in IndiaDevanshi Nareshkumar Mehta, Bhavna Haresh Dave, Seema S. Bargale, K. S. Poonacha, Vinay Mulchandani, Princy S. Thomas

Department of Paedodontics and Preventive Dentistry, K M Shah Dental College and Hospital, Vadodara, Gujarat, India




Background: In pediatric dentistry, loss of deciduous molars due to carious involvement is a major concern. Hence, endodontic therapy for primary teeth should be considered as a treatment of choice wherever required. Traditionally, used hand instruments were replaced by nickel–titanium alloy instruments to overcome disadvantages. Students’ perceptions of these instruments and techniques used for endodontic treatment must be collected for knowledge, quality of endodontic education, and the level of practice among the students in the branch of pediatric dentistry. Aim: To evaluate the view of pediatric dentists on the use of rotary endodontic instruments for cleaning and shaping of canal in primary teeth in India. Materials and Methods: A totalof596pediatricdentistsregisteredwiththeIndianSocietyofPaedodonticsand Preventive Dentistry were included in the study using an online questionnaire sent to the student members through the source of e‑mail twice. Results: According to this study, from 365 participants, 85% of the participants were in favor of using rotary instruments for cleaning and shaping during endodontic treatment in pediatric practice and 38.1% of the participants were using rotary endodontic instruments in pediatric practice. Nearly 86.6% of the participants were in favor of the absolute need for an exclusive pediatric rotary endodontic system. Conclusion:Theresponseofthestudywasasmuchas60.83%.Theresultsofthestudyreflectthatthepostgraduatestudentsarekeenontheusage of rotary instruments for cleaning and shaping of canal in endodontic treatment in primary teeth in pediatric practice.

Keywords: Cleaning and shaping, endodontic instruments, primary teeth, rotary instruments

Abstract

Address for correspondence: Dr. Devanshi Nareshkumar Mehta, 10/56, Ellora Park, Nr. Race Course Circle, Subhanpura,

Vadodara ‑ 390 023, Gujarat, India. E‑mail: [email protected]

How to cite this article: Mehta DN, Dave BH, Bargale SS, Poonacha KS, Mulchandani V, Thomas PS. Knowledge, attitude, and practice among pediatric dentists regarding the use of rotary endodontic instruments for endodontic treatment in India. Indian J Oral Health Res 2017;3:XX‑XX.



Mehta, et al.: Knowledge, attitude, and practice among pediatric dentists regarding the use of rotary endodontic instruments

Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January-June 201724

The questionnaire‑based study aimed at identifying issues thatinfluencetreatmentdecisionsfromtheoperatorpointofview, by exploring pedodontists’ perspectives on treatment approaches.


The present cross‑sectional study was carried out among the students in pediatric dentists in different parts of India. A list of student members registered with the Indian Society of Paedodontics and Preventive Dentistry was obtained from theOfficeofIndianSocietyofPaedodonticsandPreventiveDentistry.Atotalsampleof596washencetaken.Thesurveywas conducted online using a questionnaire.

The questionnaire was self‑prepared, validated, and reliable using Chi‑square test. The questionnaire comprised a set of 12 validated questions. The validation of the questionnaire was done by the principal investigator himself/herself along with the professors, readers, and senior lecturers of the Department of Paedodontics and Preventive Dentistry of the same institute. Ethical clearance was obtained from the Institutional Ethical Committee Review Board.

A questionnaire was sent to the student members through the source of e‑mail. Each student was sent the questionnaire twice. A response was awaited for a period of 3 months. Sixty percent of response rate was considered in the study as stated as a requirement by the American Association for Public Opinion Research.[2,3]

results

According to this study, the observations were obtained from 365 participants from the total 600 participants who were sent the questionnaire through e‑mail. That makes up to 60.83% response rate.

The question‑wise result was obtained which is as under.

Out of the total participants, 85% of the participants favored the use of rotary instruments for cleaning and shaping during endodontic treatment in pediatric practice [Graph 1].

Nearly 55% of the total participants had attended a Continuing Dental Education (CDE) or Workshop regarding rotary instruments while 45% had not. Almost 67.2% of the participants were aware of the different generations and types of rotary endodontic instruments in pediatric practice from various sources. Only 43.2% were aware of minimally invasivefiles and itsuse in rotary endodontics inpediatricpractice [Graph 2].

Only 38.1% of the participants were using rotary endodontic instruments for cleaning and shaping of canal during endodontic treatment in pediatric practice. Out of ten cases, 49.3%neverused,11.9%usedinhalfofthecases,and7.5%used in two cases out of ten for cleaning and shaping [Graph 3].

Almost 59.3% of the participants used rotary endodonticinstrumentsinpermanentteethonly,9%participantsusedfor

primary teeth, and 41.8% used for both primary and permanent teeth. For 38.8% of the participants, use of both hand and rotary instruments was feasible [Graph 4].

Graph 1: Participants in favor of using rotary instruments for cleaning and shaping during endodontic treatment in pediatric practice

Graph 2: Knowledge among the pediatric dentists regarding the use of rotary endodontic instruments for endodontic treatment in primary teeth

Graph 3: How often did they use rotary endodontic instruments for endodontic treatment in pediatric practice (out of ten cases)


Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January-June 2017 25

use of rotary instruments is mandatory to avoid the procedural errors and patient discomfort. Even the general practitioners and the endodontists are not well versed with the actual use of the rotary instruments to an extent.[7] Therefore, it becomes more of concern about the knowledge among the pedodontists because of the age group they deal with. The awareness was found to be quite high in the participants of this but still was deficit.Themodes of creating the awareness can bethrough lectures, CDE programs, web, etc. Reaching to the postgraduate students is the best way to spread the awareness as they are budding practitioners.

The minimally invasive dentistry is gaining popularity due to its advantages over the conventional. Minimal invasive dentistry in endodontic treatment is the use of the self‑adjusting files.Thesefileshaveanadvantageoflesscutting,saferuse,andmoreflexibility. Its successwith the curved canals inpermanent teeth is well established.[8,9] Hence, its knowledge which is limited among the pedodontists (43%) should be enhanced to gain out of the advantages in the permanent teeth and primary teeth.

The use of rotary instruments in primary teeth is less prevalent and practiced due to many possible reasons. Some of the known issues are the increased cost of the armamentarium involved, cyclic fatigue of endodontic instruments, proneness to fracture, and insufficient knowledge aboutthe technique.[10,11] The ratio of the participants using rotary instruments to the participants not using was very high in this study. The participants favored the use of rotary instruments in permanent teeth more compared to primary teeth. They had comfort in using both hand and rotary instruments in combination. The ease of working was more in the mandibular arch due to greater accessibility and higher visibility. This was similar to other studies.

The participants included in this study also voted for the introduction of an exclusive rotary system for primary teeth in pediatric practice. This will eliminate the fear from the

Fromtheresultsobtainedfromthestudy,59.7%oftheparticipantshad the ease of working using rotary endodontic instruments in mandibulararch,5.7%inmaxillaryarch;for26.9%participants;it was same in both the arch while 7.7% participants found no difference.Nearly79.1%oftheparticipantsfoundtheuseofhandinstrumentsmoretimeconsumingandonly4.9%foundrotary instruments time consuming. When asked about the reasons for not using rotary endodontic instruments in some cases, the participants were found to be concerned regarding the cost‑effectiveness of the rotary instruments (36.4%), 33.2% hadthefearofthecurvedcanalswhile14.9%hadaconcernregarding the patient cooperation [Graph 5].

In addition, 86.6% of the participants were in favor of the absolute need for an exclusive pediatric rotary endodontic system for cleaning and shaping during endodontic procedure.

dIscussIon

The introduction of these new technologies made endodontic treatment easier, faster, and better.[4] In a postgraduate program, acquiring the knowledge of new instruments and techniques is very essential.

Various aspects regarding the knowledge, attitude, and practice of the postgraduate students were evaluated. According to this study, the maximum participants were in favor of rotary instruments for cleaning and shaping during endodontic treatment in pediatric practice [Graph 1]. The reason being cleaning and shaping could be done more effectively and efficientlyusingrotaryinstruments.Theuseofrotaryfilesinprimary teeth has several advantages when compared with manualfilesincludingtheefficiencyinboth,preparationtimeand root canal shape as a decreased working time, increased patient cooperation by diminishing the potential for tiredness, favoringahigherqualityoftherootcanalfilling,andincreasingclinical success.[5,6]

The adequate and quality knowledge regarding any instruments before its use is of utmost importance. The knowledge of the

Graph 4: Feasibility of instruments for cleaning and shaping of canal during endodontic procedure in pediatric practice

Graph 5: Reasons for not using rotary endodontic instruments for cleaning and shaping of canal during endodontic treatment in some cases



practitioner’s mind, encouraging more use, and thus demystify the suspense cloud.

conclusIon

The response of the study was as much as 60.83%. The results ofthesurveyreflectthatthepostgraduatestudentsarekeenon the usage of rotary instruments for cleaning and shaping of canal in primary teeth in pediatric practice. The survey helps us to know that the participants have a positive attitude regarding the same. The advantages of the rotary instruments such as effectiveness for debridement of the uneven walls of primary teeth,timeefficient,andcost‑effectivenesshaveinclinedthepractitioners to use them. Moreover, preparation of root canal ofprimaryteethusingrotaryinstrumentsgivesabetterfill[12] which increases the longevity. However, a proper training and knowledge regarding the use is mandatory to procure good results of the procedure. Hence, more training workshops should be held, and inclusion of the same in the curriculum should be done to the enhance the knowledge, ensure the proper use of rotary instruments, and to reduce errors as it is a technique‑sensitive step in the procedure of pulpectomy.

AcknowledgmentSpecial thanks to my university, Sumandeep Vidyapeeth for the support and provision of the background and needful resources.



references1. Gupta R, Rai R. The adoption of new endodontic technology by

Indian dental practitioners: A questionnaire survey. J Clin Diagn Res 2013;7:2610‑4.

2. Fincham JE. Response rates and responsiveness for surveys, standards, and the Journal. Am J Pharm Educ 2008;72:43.

3. The American Association for Public Opinion Research. Standard definitionsfinaldispositionsofcasecodesandoutcomeratesforsurveysrevised. ESOMAR: The American Association for Public Opinion Research; 2008. p. 1‑50.

4. Kathariya MD, Patil S, Patil A, Jadav RH, Mandlik J, Sharma AS. Evaluate the usage of different advanced endodontic instruments and techniques in pediatric dentistry. J Contemp Dent Pract 2013;14:61‑4.

5. Crespo S, Cortes O, Garcia C, Perez L. Comparison between rotary and manual instrumentation in primary teeth. J Clin Pediatr Dent 2008;32:295‑8.

6. Vieyra JP,EnriquezFJ. Instrumentation timeefficiencyof rotary andhand instrumentation performed on vital and necrotic human primary teeth: A randomized clinical trial. Dentistry 2014;4:1‑5.

7. Mozayeni MA, Golshah A, Nik Kerdar N. A survey on NiTi rotary instruments usage by endodontists and general dentist in Tehran. Iran Endod J 2011;6:168‑75.

8. Metzger Z. The self‑adjusting file (SAF) system:An evidence‑basedupdate.JConservDent2014;17:401‑19.

9. Pawar AM, Pawar MG, Kokate SR. Meant to make a difference,the clinical experience of minimally invasive endodontics with theself‑adjustingfilesysteminIndia.IndianJDentRes2014;25:509‑12.

10. BarrES,KleierDJ,BarrNV.Useofnickel‑titaniumrotaryfilesforrootcanal preparation in primary teeth. Pediatr Dent 2000;22:77‑8.

11. Katge F, Patil D, Pimpale J, Wakpanjar M, Shivsharan P, Dalvi S. Application of rotary instrumentation in paediatric endodontics – A review. Int J Prev Clin Dent Res 2014;1:48‑52.

12. Poornima P, Disha P, Nagaveni NB, Roopa KB, Bharath KP, Neena IE. ‘Volumetric analysis of hand and rotary root canal instrumentation and filling in primary teeth using SpiralComputed Tomography’ – An in vitro study. Int J Paediatr Dent 2016;26:193‑8.


Case Report

IntroductIon

Gingival enlargements are frequently encountered in the oral cavity. These enlargements may be inflammatory, noninflammatory,oracombinationofthetwotype.[1] Gingival enlargement may be esthetically displeasing, cause speech disturbances, masticatory disturbance, and impede effective tooth cleaning. It may also cause abnormal tooth movement or force the teeth out of alignment.

Some of these enlargements are localized reactive lesions whichincludefocalfibroushyperplasia,pyogenicgranuloma,peripheral giant cell granuloma, and peripheral ossifying fibroma(POF).[2‑4] The lesions are considered reactive because they are nonneoplastic in nature and not implicated with drug involvement. The duration of the lesion is often weeks to months due to the slow growth with mild symptoms, rarely painful but often interfere with adequate plaque control. Since their duration is long, it is not uncommon to see ulceration to the epithelial surface from trauma.[5]

These lesions may arise as a result of such irritants as microorganisms in plaque or from trauma, defective restorations, dental calculus, and iatrogenic factors.[4,5] They are not considered neoplasms and have distinctive histopathology foridentification.Althoughbenigninnature,theydohavea

tendency toward recurrence with incomplete removal of the lesion or the local irritants involved at the site.[5] The ability of the clinician to obtain a good outcome involves proper planning with complete removal of the lesion and one of the treatment option is surgical excision.[5]

POF is a focal, reactive, nonneoplastic tumor‑like growth of the soft tissue that often arises from the interdental papilla.[6] Literature reveals that various terminologies have been used to namePOF, namely, peripheral fibroma, fibrous epulis,ossified fibrous epulis, peripheral cementifying fibroma, calcifying fibroblastic granuloma, or peripheral fibroma withcalcification.[7]Ossifyingfibromasoforalcavitycanbedivided into central type which arises from the endosteum or periodontal ligament and peripheral type which arises from the soft tissue.[7] About 60% of these gingival growth occur in the maxilla and more than 50% of all cases of maxillary POFs are found in the incisors and canine areas.[8] POF is an occasional growth of the anterior region of mandible and accounts for

Esthetically Displeasing and Recurrent Gingival Enlargement: A Report of Two Cases

Clement Chinedu Azodo, Ifeyinwa E. Uche1, Patrick I. Ojehanon, Adebola O. Ehizele, Osawe F. Omoregie2

Departments of Periodontics and 2Oral Surgery and Oral Pathology, University of Benin, 1Department of Periodontics, University of Benin Teaching Hospital, Benin City, Nigeria

Two cases of esthetically displeasing and recurrent gingival enlargement were reported. A case of 26‑year‑old female with gingival enlargement in the maxillary anterior region which has been excised twice by General Dental Practitioners and another case of 42‑year‑old female with gingival enlargement in the maxillary anterior region that caused displacement and mobility of associated tooth. Both cases had radiologic evidenceofboneloss.Excisionalbiopsywascarriedoutandthehistologicdiagnosiswasperipheralossifyingfibroma(POF).Healingofthesurgical site was uneventful. POF should be considered as the diagnosis in cases of esthetically displeasing and recurrent maxillary anterior region gingival enlargement.

Keywords: Gingival enlargement, periodontal care, recurrent




Address for correspondence: Dr. Clement Chinedu Azodo, Room 21, 2nd Floor, Department of Periodontics, Prof. Ejide Dental

Complex, University of Benin Teaching Hospital, P.M.B. 1111, Ugbowo, Benin City, Edo State, Nigeria.




How to cite this article: Azodo CC, Uche IE, Ojehanon PI, Ehizele AO, Omoregie OF. Esthetically displeasing and recurrent gingival enlargement: A report of two cases. Indian J Oral Health Res 2017;3:XX‑XX.

Abstract

Azodo, et al.: Esthetically displeasing and recurrent gingival enlargement


3.1%ofalltumorsand9.6%ofthegingivallesions.[9] Due to their histopathological as well as clinical resemblance, POFs are thought to arise as pyogenic granuloma which undergoes fibrousmaturationandsubsequentcalcification.[10] It affects both gender, but female predilection is more than male.[10] Racial predominance is 71% in white in contrast to 36% in black. The peak incidence occurs in the second and third decade of life.[11]

The clinical presentation of POF is sometimes confused with pyogenic granuloma, but it can be very well differentiated from otherfibrousproliferativelesionsbythepresenceofdifferenttypesofcalcificationssuchasmaturelamellarbone,immaturebone,anddystrophiccalcificationwhicharemorecommonin initial lesions and even lamellar bone may be present in older lesions.[12]

case rePorts

Case 1A 26‑year‑old female seamstress presented to the Periodontology Clinic of University of Benin Teaching Hospital, Benin City, Edo State, Nigeria, with a slow growing, painless gingiva growth that was present in her left maxillary anterior region. The lesion started as a small nodule 2 years earlier and gradually increased in size with a history of slight bleeding on brushing. The patient did not give a history of trauma, injury, or food impaction. Patient history revealed that excision had beendonetwicebeforepresentation.Thefirstexcisionwasa year after the onset of growth and the second excision was 6 months before presentation. Both excisions were done in different clinics by General Dental Practitioners in same location, but no histology report was requested of the excised lesion. The growth reoccurred in same area after the excisions. The patient also gave a history of use of oral contraceptives and been pregnant 6 months before presentation and had an evacuation done due to health reasons.

An intraoral examination revealed a nodular growth, pinkish red,nontender,firm inconsistency, sessile innature, arisingon the labial gingiva of the interdental papilla of 21 and 22, measuring 1 cm by 1.5 cm [Figure 1]. The growth caused

spacing between 21 and 22 and associated bleeding on probing. Radiography showed horizontal bone loss between the 21 and 22 and slight widening of periodontal space of 21 [Figure 1]. Based on the clinical and radiographic features, a provisional diagnosis of pyogenic granuloma was made. Differential diagnosis of peripheral giant cell granuloma and POF was considered. After performing oral prophylaxis, consent for the surgical procedure was obtained from the patient after proper counseling was done. Under local anesthesia, the lesion was completely excised, underlying surface was thoroughly curetted up to deepest possible tissue. Hemostasis was achieved and a periodontal dressing was placed. Medications prescribed included diclofenac 50 mg BD X 3/7, amoxicillin 500 mg TDS X 5/7, and metronidazole 400 mg TDS X 5/7. Postoperative instruction was given to the patient. The excised tissue was submitted to the Oral Pathology Department for histologic diagnosis. The patient was recalled after 1 week for the removal of the periodontal dressing and site showed uneventful healing.

Histology section showed a reactive lesion with a covering of parakeratinized stratified squamousepitheliumwith fociofepithelial hyperplasia. There was underlying proliferation of fibrocollagenousconnectivetissuewithinfiltratesofchronicinflammatorycellsandfocalaggregatesofbasophiliccalcificislands surrounded by cellular fibrous connective tissue [Figure 2]. A histologic diagnosis of POF was made. Periodic review was done at 1 week, 2 weeks, 1 month, 3 months, 6 months, 12 months, and 24 months [Figure 3] after treatment and revealed no recurrence of the lesion.

Case 2A 42‑year‑old female teacher presented in the Periodontology Clinic with a slow‑growing gingival enlargement present in her left maxillary anterior region. The lesion started as a small nodule 4 years earlier and gradually increased in size, with no pain initially but with associated pain on presentation. The patient did not give a history of trauma, injury, or food impaction.Thepatientmedicalhistorywasinsignificant.

An intraoral examination revealed a nodular growth which was interfering with upper and lower lip seal and displacing 21 and22, pinkish red,well demarcated, tenderwithfirm

Figure 1: Preoperative buccal, palatal, and radiographic view



pressure, firm in consistency, sessile in nature arising onthe labial gingival of the interdental papilla of 11, 21, and 22 [Figure 4]. Measuring 2 cm× 2 cm,with associatedmobility of 21 (Grade 1). Radiography showed horizontal bone loss of 11, 21, and 22 and associated widening of periodontal ligament space of 21 and 22 [Figure 4]. After performing oral propylaxis, consent for the surgical procedure was obtained from the patient after proper counseling was done. Under local anesthesia, the lesion was completely excised, intraoperatively revealed bony involvement, and 21 was extracted. Hemostasis was achieved and a periodontal dressing was placed. The excised tissue was submitted to the Oral Pathology Department for histologic diagnosis. Medications were analgesic: tablet diclofenac 50 mg BD X 3/7; antibiotics: capsule amoxicillin 500 mg TDS X 5/7 and tablet metronidazole 400 mg TDS X 5/7. Postoperative instruction was given to the patient. The patient was recalled after 1 week for the removal of the periodontal dressing and site showed uneventful healing. Histologic examination revealed a benign lesion composed of

acoveringparakeratinizedstratifiedsquamousepitheliumandunderlyingdensefibrocollagenousconnectivetissuewithinwhich were trabeculae of bone. There was peripheral residual bone.Therewere areaswith dense chronic inflammatoryinfiltrate[Figure 5]. A diagnosis of POF was made. Follow‑up visits were arranged after 1 week, 1 month, 2 months, 3 months, 6 months, 12 months, and 24 months [Figure 6] to rule out recurrence. Removable denture was fabricated to replace the missing teeth [Figure 6].

dIscussIon

Localized gingival enlargements represent a group of lesions with distinctive clinical manifestations. They are reactive lesionsemanatingfromthesuperficialfibersofperiodontalligaments. Different lesions with similar clinical presentations make it difficult to arrive at a correct diagnosis. POF is anonneoplastic enlargement of the gingiva that is thought to be reactive in nature.[2,4] Local irritants such as dental plaque, calculus,masticatory forces, ill‑fitting dentures, and poorquality restorations have been implicated in the etiology of POF.[13]

Therearetwotypesofossifyingfibromas:thecentraltypeandthe peripheral type. The central type arises from the endosteum or the periodontal ligament adjacent to the root apex and causes the expansion of the medullary cavity. The peripheral type occurs solely on the soft tissues covering the tooth‑bearing areas of the jaws.[14] Pathogenesis of POF is uncertain, they are thought to arise from periosteal and periodontal membrane.[15,16] There are two school of thoughts regarding the histogenesis of

Figure 3: One week 6 months and 24 months postoperative view

Figure 4: Preoperative extraoral, intraoral, and radiographic views

Figure 2: Histology slide low and high magnification



POF.ThefirstoneexplainsthatPOFdevelopsfromthecellsof periodontal ligament or periosteum. Chronic irritation of the periosteal and periodontal membrane causes metaplasia of the connective tissue and results in the initiation of formation ofboneordystrophiccalcification.Accordingtothesecondschool of thought, POF lesions were simply a more mature variant of pyogenic granuloma.[17]

POF most often occurs in the second decade of life with a female predilection, with peak occurrence in the second and third decade of life,[18] and this occurrence suggests hormonal influences.[19] The female to male ratio described in the literature varies from 1.22:1 to 4.3:1.[6] In this case report, case #1 was 26 years which was within the prevalent age group and case #2 was 42 years and both cases were females.

Approximately, 60% of POF occurs in the maxilla where >50% occurs in the anterior region[8,19] and this was seen in both case #1 and case #2 occurring in the anterior maxilla region [Figures 1 and 4]. POF exclusively occurs on the gingiva.[20] Most of the time, the underlying bone will not be affected. Several cases of tooth migration and bone destruction have been reported.[21] This was seen in our report in case #1 showing bone destruction [Figure 1] and case #2 showing tooth migration and bone destruction [Figure 4].

Clinically, the lesion appears as a nodular mass which may be pedunculated or sessile, pink to red and surface is usually but not always ulcerated. In the both cases reported, the lesion occurred in female patients, in anterior maxilla region, and appeared as a nodular pink to red growth without ulceration.

Radiographically, the features of POF tend to vary. Foci of calcificationshavebeenreportedtobescatteredinthecentralarea of the lesion but not in all lesions. Underlying bone

involvement is usually not visible on a radiograph; however, inrareinstances,superficialerosionofbonecanbeseen.[22]

Periodontal care of gingival enlargement entails a thorough history and examination, and it is important to establish a differentialdiagnosis. Incase#1,adifferentialdiagnosisofpyogenic granuloma, peripheral giant cell granuloma, and POF was performed, while in case #2, a differential diagnosis ofPOFandperipheralcementifyingfibromawasperformed.Because the clinical appearance of these various lesions can beremarkablysimilar,classificationisbasedontheirdistincthistologic differences.

POF is definitively diagnosed through a histopathologicalexamination. The histopathological examination usually showsthefollowingfeatures:benignfibrousconnectivetissuewithvaryingfibroblast,myofibroblastandcollagencontent,sparse to profuse endothelial proliferation, and mineralized material that may represent mature, lamellar or woven osteoid, cementum‑likematerial, or dystrophic calcifications.Acuteorchronicinflammatorycellinfiltrationcanalsobeobservedin these lesions.[23] In our report, histopathological result showedparakeratinizedstratifiedsquamousepitheliumwithfibrocollagenousconnectivetissuewithchronicinflammatoryinfiltratewhichconfirmthediagnosisoflesionasPOFinbothcase #1 [Figure 2] and case #2 [Figure 5].

Some authors believe that POF initially develops as pyogenic granuloma,which undergoes fibrousmaturation and thencalcification.[17] Treatment consists of the removal of the local irritants by way of scaling and root planing and surgical intervention that ensures thorough excision of the lesion including the involved periosteum and the periodontal ligament.Earlyrecognitionanddefinitivesurgicalinterventionresult in less risk of tooth and bone loss.[19] In case #2, the lesion was excised with extraction of involved tooth [Figure 6]. It is important to obtain complete removal of gingival lesions down to normal underlying tissue to reduce recurrence as well as thorough debridement of stem cells in the periodontal ligament space and periosteum to reduce recurrence rate.[5]

After the removal of these gingival enlargements, a follow‑up is required to ensure the early diagnosis of any recurrence.[24] POF has a very high rate of recurrence ranging from 8% to 20% and repeated recurrences are not uncommon, with studies reporting 16%–20% recurrence.[25] Due to the high rate of Figure 5: Histology slide low and high magnification

Figure 6: Two months and 24 months postoperative view and removable denture in situ



recurrence, close postoperative monitoring is required in all cases of POF.[6] POF recurs due to (1) the incomplete removal of the lesion as seen in case #1; (2) the failure to eliminate localirritants;and(3)difficultyinaccessingthelesionduringsurgical manipulation as a result of the intricate location of the lesion, usually an interdental area.[26] Both cases did not show clinical signs of recurrence after nearly 2 years of follow‑up.

conclusIon

Apart from gingival enlargement being esthetically displeasing, causing pathological migration of teeth and hindering ability to maintain a good oral hygiene, a higher chance of recurrence mandates histopathologic examination and frequent recall visits. POF should be considered as one of the diagnoses in cases of esthetically displeasing and recurrent maxillary anterior region gingival enlargement. This report reinforces theimportanceofarrivingatdefinitivediagnosistoprovideproper treatment and for adequate monitoring protocols.



references1. Rajendran R, Shivpathasundharam B. Shafer’s Textbook of Oral

Pathology. 5th ed. New Delhi, India: Elsevier; 2007. p. 543‑8.2. BhaskarSN,JacowayJR.Peripheralfibromaandperipheralfibromawith

calcification:Reportof376cases.JAmDentAssoc1966;73:1312‑20.3. Eversole LR, Rovin S. Reactive lesions of the gingiva. J Oral Pathol

1972;1:30‑8.4. Gardner DG. The peripheral odontogenic fibroma: An attempt at

clarification.OralSurgOralMedOralPathol1982;54:40‑8.5. Rossman JA. Reactive lesions of the gingiva: Diagnosis and treatment

options. Open Pathol J 2011;5:23‑32.6. Farquhar T, Maclellan J, Dyment H, Anderson RD. Peripheral ossifying

fibroma:Acasereport.JCanDentAssoc2008;74:809‑12.

7. Saravanan SP, Shreehari AK, Singh S, Sethurathinam DK. Peripheral ossifyingfibromaofmaxillarygingiva:Acasereport.IntJDentSciRes2014;2:10‑3.

8. Neville BW, Damm DD, Allen CM. Text Book of Oral Maxillofacial Pathology. 2nd ed. Philadelphia: W.B. Saunders; 2004. p. 452.

9. KeluskarV,ByakodiR,ShanN.Peripheralossifyingfibroma.JIndianAcad Oral Med Radiol 2008;20:54‑6.

10. Batra J, Kumar P, Chatar M, Attresh G, Berwal V. Managemnet of massive peripheral ossifyingfibroma in the right lingual vestibule ofmandible. J Dent Appl 2015;2:243‑5.

11. Buchner A, Hansen LS. The histomorphologic spectrum of peripheral ossifyingfibroma.OralSurgOralMedOralPathol1987;63:452‑61.

12. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology.Philadelphia:W.B.SaundersCompany;1995.p.374‑6.

13. Miller CS, Henry RG, Damm DD. Proliferative mass found in the gingiva.JAmDentAssoc1990;121:559‑60.

14. SpeightPM,CarlosR.Maxillofacailfibro‑osseouslesions.CurrDiagnPathol 2006;12:1‑10.

15. Mesquita RA, Orsini SC, Sousa M, de Araújo NS. Proliferative activity in peripheral ossifying fibroma and ossifying fibroma. J Oral PatholMed1998;27:64‑7.

16. KendrickF,WaggonerWF.Managingaperipheralossifyingfibroma.ASDCJDentChild1996;63:135‑8.

17. DahiyaP,KamalR,SainiG,AgarwalS.Peripheralossifyingfibroma.JNatSciBiolMed2012;3:94‑6.

18. BodnerL,DayanD.Growthpotentialofperipheralossifyingfibroma.JClinPeriodontol1987;14:551‑4.

19. Kenney JN, Kaugars GE, Abbey LM. Comparison between theperipheralossifyingfibromaandperipheralodontogenicfibroma.JOralMaxillofacSurg1989;47:378‑82.

20. VijayanV,PaulKA,ManojM,BabuSK.Peripheralossifyingfibroma.UnivResJDent2015;5:99‑102.

21. PoonCK,KwanPC,ChaoSY.Giantperipheralossifyingfibromaofthemaxilla:Reportofacase.JOralMaxillofacSurg1995;53:695‑8.

22. SatishBN,KumarP.Peripheralossifyingfibromaofhardpalate:Acasereport. Int J Dent Clin 2010;2:30‑4.

23. Kumar SK, Ram S, Jorgensen MG, Shuler CF, Sedghizadeh PP. Multicentricperipheralossifyingfibroma.JOralSci2006;48:239‑43.

24. Savage NW, Daly CG. Gingival enlargements and localized gingival overgrowths. Aust Dent J 2010;55 Suppl 1:55‑60.

25. DasUM,AzherU.Peripheral ossifyingfibroma. J IndianSocPedodPrevDent2009;27:49‑51.

26. Shetty DC, Urs AB, Ahuja P, Sahu A, Manchanda A, Sirohi Y. Mineralized components and their interpretation in the histogenesis of peripheralossifyingfibroma.IndianJDentRes2011;22:56‑61.

© 2017 Indian Journal of Oral Health and Research | Published by Wolters Kluwer - Medknow32

Case Report

IntroductIon

The parasitic infestation by the pork tapeworm larval stage, the cysticercus cellulosae, is called cysticercosis, and results from the ingestion of tapeworm eggs through contaminated food and water or dirty hands.

Platyhelminthes have a life cycle characterized by two stages; firstasalarva,andthenasanadultworm,besidesaneggphase.Each of these phases requires a different host.

The adult Taenia solium, or pork tapeworm, lives in the small intestineofman,itsdefinitivehost.InfestationbyT. solium is common in areas where pig breeding is not controlled and sanitation is inadequate.[1] The eggs develop into the oncospheres and penetrate the gut wall to enter the systemic circulation.Thereafter, these are filtered from circulationinto the muscular tissue.[2] Oral cysticercosis is common in tongue followed by lower lip, oral mucosa, submandibular and submental region.[3] Highest incidence countries are Brazil, Chile, Ecuador, Mexico, South Africa, East Africa, and India.[1]

case rePort

A 12‑year‑old female presented with the complaint of swelling in the right back cheek region for 1 year. Patient gave the history of painless swelling which was insidious in onset and

progressed in size for 2 months and became static. Medical and dental history were noncontributory. On examination, a solitary diffuse swelling of size 3 cm in diameter was seen extending over 47–48 region. On palpation the swelling was softtofirminconsistency,nontender,andmobile.Theoverlyingmucosawasthinandbluish.Basedonthesefindings,the clinical diagnosis of mucocele was made and differential diagnosisofminorsalivaryglandtumorandfibromawasgiven.Excisional biopsy of the lesion was performed.

Gross specimen measuring approximately 1 cm in diameter, was soft in consistency and globular. On dividing the specimen longitudinally, a cystic cavity containing whitish material was seen which appeared caseated [Figure 1].

Sections were taken after processing the specimen and hematoxylin and eosin staining was performed. Histopathological examination revealed a cystic cavity containing a distinct component of tissue which showed papillary projections lined by amorphous eosinophilic lining. Connectivetissuecomponenthadmacrophages,inflammatorycells, and degenerating empty appearing cells. Host connective tissuewasfibrocellularwithbloodvesselsandinflammatory

Oral Cysticercosis: Mimicking Mucocele of the CheekSimrata Ajrawat, Jatin Kharbanda1, Susmita Saxena1

Department of Oral Pathology and Microbiology, M.A. Rangoonwala College of Dental Sciences and Research Centre, Pune, Maharashtra, 1Department of Oral Pathology and Microbiology, ESIC Dental College, New Delhi, India

Cysticercosis is a parasitic infection caused by “cysticercus.” Cysticercosis is a larval form of certain Taenia species of which cysticercus cellulosae, a larvae form of Taenia solium is the one which infects humans. The larvae form of T. solium, that is, cysticercus cellulosae resides in the muscles and other tissue in pigs that serves as intermediate host. The most frequent sites of cysticercosis are subcutaneous layers, brain, muscles, heart, liver, lungs, and peritoneum. Oral cysticercosis is rare and when it affects the mouth, it commonly occurs in the tongue, labial, orbuccalmucosa,andsometimesfloorofthemouth.Here,wepresentacaseof12‑year‑oldfemalewithswellingintherightcheekregionas an asymptomatic nodule which clinically looked like a mucocele.

Keywords: Cysticercus cellulosae, oral cysticercosis, Taenia solium




Abstract

Address for correspondence: Dr. Simrata Ajrawat, A3/2, Paschim Vihar, New Delhi ‑ 110 063, India.


How to cite this article: Ajrawat S, Kharbanda J, Saxena S. Oral cysticercosis: Mimicking mucocele of the cheek. Indian J Oral Health Res 2017;3:XX‑XX.



Ajrawat, et al.: Oral cysticercosis


infiltrate.Basedonthesefindings,thediagnosisof“CysticercusCellulosae” was given [Figures 2‑5].

dIscussIon

AristophanesandAristotlefirstdescribedcysticercosisinthe3rd century BC in pigs. In 1550, it was observed in humans by Parunoli.[4] T. solium (tape worm) infection is endemic in many parts of the world including Latin America, India, Eastern Europe, Asia, Africa, Russia, Indonesia, Philippines, and Mexico.[5]

The tape worm is composed of scolex (head) and proglottids (caudal end). Every proglottid contains 40,000 to 60,000 eggs and are released with the feces. Pigs being the intermediate host, are infected with it following ingestion of eggs from the ground contaminated with human feces, when it develops into the larval form. The eggs develop into the oncospheres and penetrate the gut wall to enter the systemic circulation [Figure6].Thereafter,thesearefilteredfromcirculationintothe muscular tissue. Humans are infected with the consumption

of raw or undercooked pork.[2] T. solium eggs could be ingested through consumption of contaminated water and vegetables by humans and autoinfection due to improper hygiene may also be a cause.[2]

In the present case, no proper history could be elicited from the patient or her guardian and it may be assumed that compromised hygiene or contaminated consumption of food or water may be the sourceof such infection.Humansbeingadefinitivehost for cysticercosis, it can manifest in various tissues and organs of the individual. The symptomatic presentation of cysticercosis is seen only in case of involvement of central nervous system (CNS) and ocular system.[6]

Generalized symptoms include headache, fever, and myalgia. Involvement of CNS may result in episodes of seizures, increased intracranial pressure, meningitis, and mental disorders.[7,8] Other commonly affected sites in the body include heart, liver, lung, and peritoneum.[5]

Oral and maxillofacial region has abundance of musculature in spite of which the incidence of oral cysticercosis is rare.

Figure 1: Grossing of the specimen showing a cystic cavity containing whitish material Figure 2: Cystic cavity with papillary projections into the cavity

Figure 3: Papillary projections lined by amorphous eosinophilic lining; indicating the scolex (S)

Figure 4: Connective tissue component showing degenerating empty appearing cells



cerebral cysticercosis.[11] Serological investigations, such as enzyme‑linked immunosorbent assay or enzyme‑linked immunoelectrotransfer blot, used for detecting antibodies to T. soliumintheserumandcerebrospinalfluidcanconfirmthediagnosis, although they are not 100% sensitive.[12]

The treatment for oral cysticercosis is surgical enucleation. Drugs such as praziquantel and albendazole are potent anthelminthic used in the treatment of cysticercosis, replacing niclosamide, which was the drug of choice for the treatment of the disease for a long time. Drugs should be used, especially in symptomatic patients, disseminated cysticercosis, and cases where surgical treatment is risky or not possible, as in neurocysticercosis.[13]

Because the patient in the present case had no other manifestation of cysticercosis and did not have any other symptoms, no additional treatment was prescribed other than excisional biopsy and a course of anthelminthic. Periodic follow‑ups did not reveal any kind of recurrence or untoward symptoms.

conclusIon

It is of utmost importance to submit all lesions for histopathological diagnosis irrespective of its innocuous andblandclinicalappearance.Thefindingsofcysticercosiscellulosae in the oral tissues are quite often a histopathological revelation and unexpected diagnosis for the clinician. However, timely treatment and intervention will save the patient from serious systemic and CNS manifestations caused by this parasitic infection.



The most frequently involved site of the oral cavity are the tongue (42.15%) followed by lips (26.15%) with the lower lipbeingaffectedin64.71%andbuccalmucosa(18.9%).[2]

Patients infected with cysticercosis usually present with the chief complaint of swelling rather than pain unless secondarily infected.[2] In the present case also the patient complained of an asymptomatic swelling which was progressive in size.

According to Delgado‑Azañero et al., oral cysticercosis presentsasfirmnodulesonpalpationbecauseof theirhighintraluminal pressure.[9]

According to Lee et al., two similar cases were reported in which the most common complaint by patients was swelling. Pain is not a frequent feature unless secondarily infected. Lesions on the tongue interfered with the movement, causing discomfort during speaking and eating. According to him, most oral presentations are in the form of painless, well‑circumscribed,softswellingsthatmaymimicfluctuantlesions like mucocele.[10]

In the present case, the presentation was similar to mucocele of the buccal mucosa and clinicians did not consider any other pathology in their differential diagnosis and cysticercosis was a histologic revelation.

Histopathological examination helps in the diagnosis of cysticercosis by the detection of a cystic space containing the cysticercus cellulosae. The scolex has four suckers and a double crown of rostellar hooklets. A duct‑like invaginated segment, lined by a homogeneous anhistic membrane, composes the caudal end. The eosinophilic membrane that lines the capsule is double‑layered, consisting of an outer acellular and an inner sparsely cellular layer. After 3–5 years, the larva dies and the cystundergoescalcification.[2]

Although an excisional biopsy is usually considered the only definitive diagnostic procedure, there are someotherdiagnostic tools that may be used. Computerized tomography or magnetic resonance imaging is valuable for diag‑nosing

Figure 5: Connective tissue component showing macrophages and inflammatory cells

Figure 6: Life cycle of Taenia solium [4]



references1. Prabhu SR. Oral Diseases in the Tropics. Oxford: Oxford University

Press;1992.p.126‑9.2. Ribeiro AC, Luvizotto MC, Soubhia AM, de Castro AL. Oral

cysticercosis: Case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e56‑8.

3. Nigam S, Singh T, Mishra A, Chaturvedi KU. Oral cysticercosis – Report ofsixcases.HeadNeck2001;23:497‑9.

4. Kulkarni PG, Palakurthy P, Muddana K, Nandan RK. Oral cysticercosis–Adiagnosticdilemma.JClinDiagnRes2015;9:ZD01‑2.

5. Elias FM, Martins MT, Foronda R, Jorge WA, Araújo NS. Oral cysticercosis: Case report and review of the literature. Rev Inst Med TropSaoPaulo2005;47:95‑8.

6. Flisser A, Plancarte A, Correa D, Rodriguez‑Del‑Rosal E, Feldman M, Sandoval M, et al. New approaches in the diagnosis of Taenia solium cysticercosis and taeniasis. Ann Parasitol Hum Comp 1990;65Suppl1:95‑8.

7. Lustmann J, Copelyn M. Oral cysticercosis. Review of the literature and reportof2cases.IntJOralSurg1981;10:371‑5.

8. Webb DJ, Seidel J, Correll RW. Multiple nodules on the tongue of a patientwithseizures.JAmDentAssoc1986;112:701‑2.

9. Delgado‑Azañero WA, Mosqueda‑Taylor A, Carlos‑Bregni R,Del Muro‑Delgado R, Díaz‑Franco MA, Contreras‑Vidaurre E. Oral cysticercosis: A collaborative study of 16 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:528‑33.

10. Lee KH, Cepeda L, Miller M, Siegel DM. Mucoceles not – Oral cysticercosis and minor salivary gland adenocarcinoma: Two case reports.DermatolOnlineJ2009;15:8.

11. Rajshekhar V. Etiology and management of single small CT lesions in patients with seizures: Understanding a controversy. Acta Neurol Scand 1991;84:465‑70.

12. Diaz JF, Verastegui M, Gilman RH, Tsang VC, Pilcher JB, Gallo C, et al. Immunodiagnosis of human cysticercosis (Taenia solium): A field comparison of an antibody‑enzyme‑linked immunosorbentassay (ELISA), an antigen‑ELISA, and an enzyme‑linked immunoelectrotransfer blot (EITB) assay in Peru. The Cysticercosis WorkingGroupinPeru(CWG).AmJTropMedHyg1992;46:610‑5.

13. Jay A, Dhanda J, Chiodini PL, Woodrow CJ, Farthing PM, Evans J, et al. Oral cysticercosis. Br J Oral Maxillofac Surg 2007;45:331‑4.


Case Report

IntroductIon

Adenoid cystic carcinoma (ACC)wasfirstlydeterminedbyRobin, Lorian and Laboulbene in their articles published in 1853 and 1854, in these articles the cylindrical appearance of the tumor wasmentioned.Billrothin1859definedthetumorascylindromaandreportedgreatrecurrencerateofthistumor.Spiesin1930termed as “adenoid cystic carcinoma” in his report of cutaneous and noncutaneous tumors of the basal cell type.[1]

ACC is an uncommon epithelial tumor of the salivary glands. It accounts for about 5%–10% of all salivary gland neoplasms with 2%–4% of malignant occurrences of the head and neck region. About the 31% of lesions are seen in minor salivary glands, especially the palate, but besides that they may also be seen in the submandibular and parotid glands.[2]

ACC has a widespread age distribution but is observed predominantlyinwomen,betweenthefifthandsixthdecadesof life.[3]Typical clinicalfindings contain local recurrence,slow growth, perineural invasion, and distant metastasis.[4]

We present ACC of the base of tongue and a brief literature review on the report.

case rePort

A 65‑year‑old female patient had complained of a swelling in the median part of the tongue and pain in tongue for

10 months, which had started spontaneously and then showedanincreaseinsize.Shehaddifficultywithspeechand swallowing. The patient reported an insignificant medical and family history except she had hypertension as systemic disease. Extraoral examination and palpation revealed cervical lymph node chain with normal size. On intraoralclinicalexamination,afirmsessilenoduleofabout2cm×1cmindiameterwithasimilarcolorationtothatof the buccal mucosa was observed [Figure 1]. There was pain in palpation. Based on patient’s history and clinical examinations, associated with suspicious appearance of observed lesion with irregular form, malignant neoplasm was thought as early diagnosis.

Magnetic resonance imaging (MRI) revealed an ill‑defined,hypointense lesion on T1‑ and T2‑weighted images [Figure 2a and b]. The lesion enhanced markedly on postcontrast T1 with fat suppression [Figure 3a and b]. Lesion was seen in left lateral and posterior aspect of the base of tongue extending up to lingual septum and crossing the midline. The lesion was involved the genioglossus and intrinsic muscles of thetonguebaseandinfiltratedtoposteriorofleftsublingual

Adenoid Cystic Carcinoma of the Base of the Tongue: Case Report and Literature Review

Gozde Serindere, Gul Soylu Ozler1, Sibel Hakverdi2, Mehmet Serindere3

Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Mustafa Kemal University, Departments of 1Otorhinolaryngology and 2Pathology, Faculty of Medicine, Mustafa Kemal University, Hatay, 3Department of Radiology, Gulhane Education and Research Hospital, Ankara, Turkey

Adenoid cystic carcinoma (ACC) is a rare malignant tumor arising from salivary glands. ACC of the head and neck has some features such as slow growth, high recurrence percentages, distant metastasis, and a tendency for perineural invasion. It comprises almost 2%–4% of head and neck area tumors. In minor salivary glands, it is generally observed in the palate. We report such a rare case that affected the base of the tongue in a 65‑year‑old‑female patient and also carried out a brief literature review on the subject.

Keywords: Adenoid cystic carcinoma, base of tongue, head and neck cancer, minor salivary gland

Address for correspondence: Dr. Gozde Serindere, Department of Dentomaxillofacial Radiology, Faculty of Dentistry, Mustafa

Kemal University, Hatay, Turkey. E‑mail: [email protected]






How to cite this article: Serindere G, Ozler GS, Hakverdi S, Serindere M. Adenoid cystic carcinoma of the base of the tongue: Case report and literature review. Indian J Oral Health Res 2017;3:XX‑XX.

Abstract

Serindere, et al.: Adenoid cystic carcinoma of base of tongue


space. There was the indistinct border between the lesion and left lingual tonsil. There was oval shaped lymph node measured 10mm×5mminthecervicallevel2b[Figure 4].

Due to hypointense lesion on T2, squamous cell carcinoma was eliminated, and we thought ACC and tongue of lymphoma as a differential diagnosis.

Soon after, the patient was referred to surgery, and the biopsy was performed, and specimen was sent for histopathologic

study. Figure 5a shows the formation of tubular pattern that is characterized by eosinophilic content, infiltrating well‑hyalinizedbackground.Therewasperineuralinfiltrationon serial sections [Figure 5b]. The immunohistochemical results revealed epithelial membrane antigen and Pan‑CK in positive in tumor cells [Figure 6].

Figure 1: Intraoral photograph showing a swelling on the base of the tongue

Figure 4: Coronal scan showing the dimension of observed lymph node in the cervical level 2b

Figure 6: The tumor cells are positive with this stain (PAN‑CK ‑ IHC, ×200)

Figure 3: Postcontrast T1‑weighted axial (a) and sagittal (b) images showing ill‑defined heterogeneous signal intensity nodular mass lesion involving left lateral aspect of the tongue and extending up to lingual septum and crossing midline

a b

Figure 5: (a) Formation of tubular pattern is characterized by eosinophilic content, infiltrating well‑hyalinized background (H and E, ×200). (b) Adenoid cystic carcinoma cells infiltrated along nerve sheath (H and E, ×200)

a b

Figure 2: (a) T1‑weighted and (b) T2‑weighted axial scans showing an ill‑defined, hypointense lesion

a b



from minor salivary glands in rest of them, and 5 ACC cases in tongue of 68 cases.

MRI has higher accuracy in describing the soft tissue lesion.[18] For this reason, in our case, MRI was used as an imaging modality.

Histologically, ACC has three different types as cribriform, tubular, and solid. Worst prognosis was based on the presence ofincreasedmitoticfigures.Italsohasastrongneurotrophismincluding the nerves neighboring on the lesion.[19] Soares et al.[19] and Batsakis et al.[20] reported that survival rate was less in the solid pattern than the cribriform and tubular patterns in their studies about the relationship between the histological pattern and the prognosis.

Surgical excision of the tumor with adjuvant radiotherapy in patients with advanced T stage and/or positive surgical margins is the treatment choice.[21]Thedeficiencyofsurvivaladvantagefor patients treated with combination surgery and radiotherapy is presumed to be because of the high rate of distant metastases and the relatively high possibility of long‑term survivability after salvage therapy for patients who experienced locoregional recurrence.[22] Nascimento et al.[15] reported that local recurrence wasidentifiedin17(37%)ofthe46patients.

PatientswhohaveACCinthetonguecomplaininsufficientfunction. Thereby improvement the speech and swallowing of the patient must be the purpose of the treatment. As a result, the quality of life for the patient will increase.

conclusIon

ACC of the tongue is a very rare neoplasm and early diagnosis and suitable treatment are important and remarkable factors. TonguelesionsinvolvingACCisdifficultfordiagnosisandsurgical treatment because of their anatomical location and the adjacency with blood vessels and nerves. In the literature, tongue has the low percentage as the sites of ACC to make this case a rare one. The histopathological study and the presence or absenceofdistantmetastases are important tofindfinaldiagnose and describe the survival of the patient.



references1. Shankar NV, Prakash SM, Sumalatha MN, Shankar A. Adenoid cystic

carcinoma of the tongue. Int J Acad Res 2011;3:580‑3.2. Triantafillidou K, Dimitrakopoulos J, Iordanidis F, Koufogiannis D.

Management of adenoid cystic carcinoma of minor salivary glands. J Oral Maxillofac Surg 2006;64:1114‑20.

3. Waldron CA, el‑Mofty SK, Gnepp DR. Tumors of the intraoral minor salivary glands: A demographic and histologic study of 426 cases. Oral SurgOralMedOralPathol1988;66:323‑33.

4. HuangM,Ma D, Sun K,Yu G, Guo C, Gao F. Factors influencingsurvival rate in adenoid cystic carcinoma of the salivary glands. Int J OralMaxillofacSurg1997;26:435‑9.

Basedontheclinical,MRI,andhistopathologicalfindings,afinaldiagnosiswasmadeasACCoftonguebase.

dIscussIon

Neoplasms of accessory salivary gland origin occur less commonly than major salivary glands. The tongue is a slightly uncommon region for salivary gland neoplasms.[5]

ACC derives from both the minor and the major salivary glands. It is an uncommon lesion and constitutes about 1%–2% of all malignant neoplasms of the head and neck, and up to 10%–15% of all malignant salivary gland neoplasms. The most frequently seen intraoral region for minor salivary gland tumors isthehardpalate,secondlythebaseofthetongue,upto96%of all tumors are malignant, when the neoplasm is observed in tongue associatively and ACC comprises 30% of them.[6] Similarly, in the study of Moran et al.,[7] the hard palate is the mostcommonregionofthistumor,theyreportedthat9of38cases of ACC in this area.

Eveson and Cawson[8] reported a discreet predominance of ACC cases in women (female:male 1.2:1) with ages varying from 24 to 78 years. Similarly, our patient was female and 65 years old.

In the clinical examination, ACC of the tongue is painless, slow submucosal growth which blocks the early diagnosis of ACC. Previous studies reported that the elapse time from thefirstclinicalappearancetotheentityofsymptomsrangesfrom 2.5 to 7 years,[9] with one case reported by Luna‑Ortiz et al. that had a duration of 10 months.[10] Similarly, in our case, the patient had pain and swelling within the duration of 10 months.

Table 1 shows case series of ACC in tongue. In the study of Spiro et al.[12] lesions involving accessory glands were observed in 171 patients of 242 salivary gland ACC cases while the palate was observed as the affected site in 64 patients (26%) and the tongue was reported as the second most affected area. Isacsson and Shear[13] reported neoplasm occurrences in the palate, floor of themouth, tongue, andgingiva, respectively. Khan et al.[16] reported that ACC originates from major salivary glands in 26 of 68 cases and

Table 1: Case series of adenoid cystic carcinoma in tongue

Author Year Adenoid cystic carcinoma

Tongue Percentage

Moran et al.[7] 1961 38 1 2.6Leafstedt et al.[11] 1971 56 11 19.6Spiro et al.[12] 1974 171 26 15.2Isacsson and Shear[13] 1983 21 2 1Maso et al.[14] 1985 37 2 5.4Eveson and Cawson[8] 1985 44 3 0.9Nascimento et al.[15] 1986 59 8 13.5Huang et al.[4] 1997 48 10 20.8Khan et al.[16] 2001 68 5 7.3Perez et al.[17] 2006 129 10 7.7Luna‑Ortiz et al.[6] 2009 68 8 11.7



5. Goldblatt LI, Ellis GL. Salivary gland tumors of the tongue. Analysis of 55newcasesandreviewoftheliterature.Cancer1987;60:74‑81.

6. Luna‑Ortiz K, Carmona‑Luna T, Cano‑Valdez AM, Mosqueda‑Taylor A, Herrera‑Gómez A, Villavicencio‑Valencia VV. Adenoid cystic carcinoma of the tongue clinicopathologic study and survival analysis. HeadNeckOncol2009;1:15.

7. Moran JJ, Becker SM, Brady LW, Rambo VB. Adenoid cystic carcinoma. Aclinicopathologicalstudy.Cancer1961;14:1235‑50.

8. Eveson JW, Cawson RA. Tumours of the minor (oropharyngeal) salivary glands:Ademographicstudyof336cases.JOralPathol1985;14:500‑9.

9. CarrascoOrtizD,AldapeBarriosB.Adenoidcysticcarcinomaof thedorsum of the tongue: Presentation of a case. Med Oral Patol Oral Cir Bucal 2006;11:E417‑20.

10. Luna Ortiz K, Carmona Luna T, Herrera Gómez A, Cano Valdez AM. Macroglossia caused by adenoid cystic carcinoma. Case report. Med OralPatolOralCirBucal2008;13:E395‑7.

11. Leafstedt SW, Gaeta JF, Sako K, Marchetta FC, Shedd DP. Adenoid cystic carcinoma of major and minor salivary glands. Am J Surg 1971;122:756‑62.

12. Spiro RH, Huvos AG, Strong EW. Adenoid cystic carcinoma of salivary origin. A clinicopathologic study of 242 cases. Am J Surg 1974;128:512‑20.

13. Isacsson G, Shear M. Intraoral salivary gland tumors: A retrospective studyof201cases.JOralPathol1983;12:57‑62.

14. Dal Maso M, Lippi L. Adenoid cystic carcinoma of the head and neck:

Aclinicalstudyof37cases.Laryngoscope1985;95:177‑81.15. Nascimento AG, Amaral AL, Prado LA, Kligerman J, Silveira TR.

Adenoid cystic carcinoma of salivary glands. A study of 61 cases with clinicopathologiccorrelation.Cancer1986;57:312‑9.

16. Khan AJ, DiGiovanna MP, Ross DA, Sasaki CT, Carter D, Son YH, et al. Adenoid cystic carcinoma: A retrospective clinical review. Int J Cancer2001;96:149‑58.

17. da Cruz Perez DE, de Abreu Alves F, Nobuko Nishimoto I, de Almeida OP, Kowalski LP. Prognostic factors in head and neck adenoidcysticcarcinoma.OralOncol2006;42:139‑46.

18. Baskaran P, Mithra R, Sathyakumar M, Misra S. Adenoid cystic carcinoma of the mobile tongue: A rare case. Dent Res J (Isfahan) 2012;9Suppl1:S115‑8.

19. SoaresEC,CarreiroFilhoFP,CostaFW,VieiraAC,AlvesAP.Adenoidcystic carcinoma of the tongue: Case report and literature review. Med Oral Patol Oral Cir Bucal 2008;13:E475‑8.

20. Batsakis JG, Luna MA, el‑Naggar A. Histopathologic grading of salivary gland neoplasms: III. Adenoid cystic carcinomas. Ann Otol RhinolLaryngol1990;99:1007‑9.

21. Silverman DA, Carlson TP, Khuntia D, Bergstrom RT, Saxton J, Esclamado RM. Role for postoperative radiation therapy in adenoid cysticcarcinomaoftheheadandneck.Laryngoscope2004;114:1194‑9.

22. Mendenhall WM, Morris CG, Amdur RJ, Werning JW, Hinerman RW, Villaret DB. Radiotherapy alone or combined with surgery for adenoid cystic carcinoma of the head and neck. Head Neck 2004;26:154‑62.


Case Report

IntroductIon

Glandular odontogenic cyst (GOC) is a rare odontogenic cyst of the jaw bones, accounting for 0.012%–0.3% of all odontogenic cysts.[1] It usually presents as a slow‑growing, asymptomatic swelling generally affecting the anterior parts of jaws, particularly the mandible. Radiographically, GOC is localized intraosseously and may appear as a multilocular or unilocular radiolucent lesionwithwell‑definedborders.Although the histopathological features are unique, situations may arise wherein similar features may be seen in other cysts or even tumors, thus posing a challenge in making the diagnosis.[2‑4] GOC has an aggressive potential with a relatively high rate of recurrence.[5] Therefore, the correct diagnosis is a major challenge and is of extreme clinical importance.Thisstudyforthefirsttimeemphasizesonthecorrelation of histopathological criteria given by two different authors, which has to be followed while diagnosing the cases of GOC.

The aim of the present study is to discuss the histopathological featuresandthedifferentialdiagnosisoffivecasesofGOCreported in our institution.

rePort of fIve cases

FivecasesofGOCwerediagnosedover7years(2009–2015)in the Department of Oral and Maxillofacial Pathology, DA Pandu Memorial RV Dental College, Bengaluru, Karnataka. Details of clinical data, radiographic features, and provisional diagnosis are shown in Table 1.

Clinical and radiographic dataThe age of the patients ranged from 13 to 60 years with a mean of 41.5 years. Three females and 2 males were affected. The most common site was the mandibular posterior region (three cases) with the remaining two cases occurring in the maxillary anterior region. Only one case was symptomatic. Radiographically, all patients presented with a unilocular radiolucency [Figures 1 and 2].

Glandular Odontogenic Cyst: Analysis of Clinicopathological Features of Five Cases

Sarita Yanduri, K. K. Deepa, B. Veerendra Kumar, S. Suma, M. G. Madhura, Chinmay Dilip Vakade1

Departments of Oral and Maxillofacial Pathology and 1Oral and Maxillofacial Surgery, D.A. Pandu Memorial R. V. Dental College and Hospital, Bengaluru, Karnataka, India

Glandular odontogenic cyst (GOC) is a rare developmental cystic lesion of the jaws accounting for 0.012%–0.3% of all the odontogenic cysts. It occurs most commonly in middle‑aged men, especially in the anterior mandible. It clinically presents as a slow‑growing intraosseous lesion. Small cysts may be asymptomatic while larger ones may cause expansion with pain or paresthesia. Radiographically, it frequently presents as a multilocular radiolucency. Microscopic features are characterized by nonkeratinized stratified squamous epithelium of variable thickness with many microcystic or pseudoglandular spaces and plaque‑like extensions. Although its microscopic features are characteristic, few situations may arise where this entity may be confused with dentigerous, botryoid odontogenic, radicular cyst, and central mucoepidermoid carcinoma. The importance of GOC relates to its high rate of recurrence making its diagnosis important. The purpose of this study is to present the clinicopathological features of five cases of GOC which have been reported in our institution.

Keywords: Glandular odontogenic cyst, microcysts, odontogenic cyst

Address for correspondence: Dr. K. K. Deepa, Department of Oral and Maxillofacial Pathology, D.A. Pandu Memorial

R. V. Dental College and Hospital, Bengaluru, Karnataka, India. E‑mail: [email protected]






How to cite this article: Yanduri S, Deepa KK, Kumar BV, Suma S, Madhura MG, Vakade CD. Glandular odontogenic cyst: Analysis of clinicopathological features of five cases. Indian J Oral Health Res 2017;3:XX‑XX.

Abstract

Yanduri, et al.: GOC‑5 cases


Histopathological dataHistopathological data were analyzed by using two methodologies: One was with the criteria given by Kaplan et al. [Table 2], and the second by Fowler et al. [Table 3].[6,7]

Kaplan et al. divided the histopathological features diagnostic of GOC into major and minor criteria. Compatibility with all major criteria was required for a diagnosis while the minor criteria played a supportive role.[6]All thefivecases in thecaseseriesfulfilledthemajorcriteria.

Fowler et al. combined all the histopathological features into ten parameters and suggested that seven or more parameters need to be met for a diagnosis of GOC.[7] In the present case series, four cases met more than seven criteria while one case fulfilledsixcriteria.

The important histopathological features of all the 5 cases are illustratedinFigures3‑10.Otherfeaturessuchasinflammation(twocases),cholesterolclefts(twocases),calcifications(twocases),and epithelial rests (one case) were also seen.

dIscussIon

GOCwasfirst documented as a sialo‑odontogenic cyst byPadayacheeandVanWykin1988.[8] Gardner et al.in1988

characterized the histopathological features of this entity and proposed the term GOC.[9] In1992, theWHOaccepted theterm GOC and categorized it under the group of developmental odontogenic cysts.[10]

GOC has been reported to occur in patients older than 30 years of age with a male predilection. In the present case series, three patients were female and two were male. The prominent location of GOC in this study was in the mandibular region which correlates with that of literature.

GOC is a cyst of multiple histopathological features; however, often all the features are seen only at focal areas or not all the features are seen in the cyst. In addition, few of these features are known to occur in other lesions such as botryoid odontogenic cyst, radicular cyst (RC), dentigerous cyst, and low‑grade mucoepidermoid carcinoma. Therefore, this may makearrivingatadiagnosisdifficult.[11]

To address this problem, Kaplan et al. put forward a set of criteria for histological diagnosis wherein all the histological features were divided into major and minor criteria. They suggested that focal presence of all major criteria needs to be met, while the minor ones support the diagnosis.[6] In the presentstudy,allthefivecasesmetallthemajorcriteriaandafewoftheminorcriteria,thereforeconfirmingthediagnosisof GOC.

However, Fowler et al. believed that the presence of all of the major criteria does not need to be met for a diagnosis. They proposedacombinationoftenspecificmicroscopicfeatures

Table 1: Clinical data, radiographic features, and provisional diagnosis of five cases

Case number Age (years) Sex Site Lesion presented as Tenderness Radiographic findings Provisional diagnosis1 13 Female Mandibular

premolar regionSwelling Nontender Unilocular radiolucency Radicular cyst

2 22 Male Maxillary anterior region

Swelling Nontender Unilocular radiolucency Radicular cyst

3 54 Female Maxillary anterior region

Swelling Tender Unilocular radiolucency Odontogenic keratocyst

4 60 Female Mandibular anterior region

Swelling Nontender Unilocular radiolucency Dentigerous cyst

5 60 Male Mandibular posterior region

Swelling Nontender Unilocular radiolucency Dentigerous cyst

Figure 1: Case 3: Unilocular radiolucency (arrow) in the anterior region of the maxilla with expansion and destruction of cortical plates (cone‑beam computed tomography)

Figure 2: Case 5: Unilocular radiolucency (arrow) seen on the posterior part of the right mandible associated with an impacted tooth



and said that the presence of seven or more microscopic findingswashighlypredictiveofadiagnosisofGOC.Theysuggested thatwhenfiveor less parametersweremet, thediagnosis may be that of non‑GOC or what they called as a “GOC mimicker.”[7] In the present study, four cases met

with more than seven criteria, with only one case meeting six criteria. As a result of this, all can be considered as GOCs.

In the present case series, two cases were given a provisional diagnosis of dentigerous cyst because of the presence of a pericoronal radiolucency. Often, metaplastic changes in the

Figure 3: Squamous epithelium lining of variable thickness (blue arrow) with a flat interface with the connective tissue wall (orange arrow) (H and E, ×40)

Figure 4: Cuboidal eosinophilic cells or hobnail cells (arrow) (H and E, ×200)

Table 2: Correlation of histopathological features of the five reported cases with the major and minor criteria given by Kaplan et al.

Case 1 Case 2 Case 3 Case 4 Case 5Major criteriaSquamousepitheliallining,withaflatinterfacewiththeconnectivetissue wall, lacking basal palisading

Present Present Present Present Present

Epithelium exhibiting variations in thickness along the cystic lining with or without epithelial spheres or whorls or focal luminal proliferation


Cuboidal eosinophilic cells or hobnail cells Present Present Present Present PresentMucous (goblet) cells with intraepithelial mucous pools, with or without crypts lined by mucous producing cells


Intraepithelial glandular, microcystic, or duct‑like structures Present Present Present Present PresentMinor criteria

Papillary projections of the lining epithelium Present Absent Absent Present AbsentCiliated cells Present Present Present Present PresentMulticystic or multiluminal architecture Present Absent Absent Absent AbsentClear or vacuolated cells in the basal or spinous layers Present Present Present Present Present

Table 3: Correlation of histopathological features of the 5 reported cases with the parameters given by Fowler et al.

Serial number Parameters Case 1 Case 2 Case 3 Case 4 Case 51 Surface eosinophilic cuboidal cells, also called “hobnail cells” Present Present Present Present Present2 Intraepithelial microcysts or duct‑like spaces Present Present Present Present Present3 Apocrine snouting of hobnail cells Absent Present Absent Absent Present4 Clear or vacuolated cells Present Present Present Present Present5 Variable thickness of the cyst lining Present Present Present Present Present6 Papillary projections or “tufting” into the cyst lumen Present Absent Absent Present Present7 Mucous goblet cells Present Present Present Present Present8 Epithelial spheres or plaque‑like thickenings Present Present Present Present Present9 Cilia on the surface of eosinophilic cuboidal cells Present Present Absent Present Present10 Multiple compartments Absent Absent Absent Absent Present



epithelial lining of dentigerous cysts such as the presence of ciliated cells, mucous cells, and eosinophilic cuboidal cells may mimic a GOC.[12‑14] Similar histopathological changes may also

be seen in RCs, especially ciliated cells which are evident in cases of RCs of the maxilla.[12‑14] In one of the present cases, the cyst was associated with a nonvital tooth as well as showed

Figure 5: Mucous (arrow) cells seen within the cyst lining (periodic acid‑Schiff, ×40)

Figure 10: Clear cells (arrow) in the spinous layer of the epithelium (H and E, ×40)

Figure 6: Intraepithelial pseudoglandular, microcystic spaces (arrow) lined by cuboidal cells (H and E, ×40)

Figure 7: Papillary projection of the epithelium (arrow) (H and E, ×40) Figure 8: Ciliated cells (arrow) seen in the epithelial lining (H and E, ×40)

Figure 9: Multicystic or multiluminal compar tments (arrow) (H and E, ×40)



areasof intense inflammatory infiltratewith theepitheliumexhibiting an arcading pattern simulating an RC. In addition, cholesterol clefts were also seen. In addition, one case had multicystic compartments which may be confused with that of a botryoid odontogenic cyst.

Another important differential diagnosis is that of a low‑grade mucoepidermoid carcinoma (MEPCa) due to the presence of multiple cyst‑like structures lined by mucus‑producing cells, clear cells, and epidermoid component which are typically found.[15‑16]

However, the fact that all these cysts in the present case series had the additional features of a variable thickness of the epithelial lining, epithelial spheres, microcysts with periodic acid–Schiff‑positive material, crypt formation, and clear cells helped us arrive at a diagnosis of GOC. According to Fowler et al., the above‑mentioned set of factors are supposed to be most helpful in distinguishing GOCs from GOC mimickers.[7] The problemmaybe furthermagnified in caseswhere anincisional biopsy is received and the characteristic features are seen only at focal areas. In such situations, it is recommended that the report contains a mention of the fact that GOC‑like features are seen so that the surgeon can accordingly plan the treatment.

Kaplan et al. investigated the use of p53, Ki67, and PCNA as an aid in the diagnosis of GOC.[6] Mean p53 labeling index (LI) was higher in GOC and MEPCa than in RC with mucous metaplasia (RCM) which showed a very minimal expression. They suggested that the expression of p53 in GOC though higher than RC is not as high as that of squamous cell carcinoma. Ki67 LI was higher in GOC and RCM than in low‑grade MEPCa, thus indicating the indolent behavior of this salivary gland tumor. These molecular markers can help in diagnosing GOC in situations of overlapping histopathology.[6]

There was a time in literature when this cyst was speculated to be of salivary gland origin due to the presence of numerousmucous‑producingcells.Infact,Sadeghiin1991termed this cyst as a mucoepidermoid odontogenic cyst or mucous‑producing cyst.[17] Although studies on the cytokeratin profile failed to support either an odontogenic origin or asialogenic origin, there is ample evidence to favor the former.[18] Histologically, the presence of odontogenic epithelial plaques and whorls which are also seen in other odontogenic cysts and the fact that this cyst has been reported to occur along with other odontogenic tumors such as ameloblastoma and keratocystic odontogenic tumor have confirmed its odontogenic nature. The minimal expression of mammary serine protease inhibitor and epithelial membrane antigen inGOCasopposedtothesignificantlyhigherexpressioninMEPCa is an additional indication against a true glandular origin, in spite of the morphologic resemblance.[19] In our study, we also found that one particular case showed evidence of epithelial rests in the connective tissue capsule which further confirmsitsodontogenicorigin.

Treating GOC ranges from enucleation for small unilocular lesions to marginal resection and en bloc excision for large lesions. The choice of treatment thus depends on the size of the lesion, integrity of the jaw borders, and proximity of the lesion to vital structures.[5] A global recurrence rate of 18% has been reported with the risk of recurrence depending on the size, presence of multilocularity, and choice of treatment.[20] The follow‑up period for patients has been recommended to be a minimum of 3 years and preferably up to 7 years.

conclusIon

GOC is a rare lesion with unique microscopic features. If all the histopathological features are evident, then the diagnosis is straightforward. The problem arises with GOC mimickers in which situations it is recommended to use criteria suggested by either Kaplan et al. or Fowler et al. to arrive at a diagnosis.



references1. Manzini M, Deon C, Corte LD, José Bertotto C, de Abreu LB. Glandular

odontogenic cyst: An uncommon entity. Rev Bras Otorrinolaringol 2009;75:320.

2. Shah M, Kale H, Ranginwala A, Patel G. Glandular odontogenic cyst: A rareentity.JOralMaxillofacPathol2014;18:89‑92.

3. Mittal A, Narang V, Kaur G, Sood N. Glandular Odontogenic Cyst of Mandible:ARareEntity2015;9:ED09‑10.

4. Krishnamurthy A, Sherlin HJ, Ramalingam K, Natesan A, Premkumar P, Ramani P, et al. Glandular odontogenic cyst: Report of two cases and reviewofliterature.HeadNeckPathol2009;3:153‑8.

5. Kaplan I, Gal G, Anavi Y, Manor R, Calderon S. Glandular odontogenic cyst: Treatment and recurrence. J Oral Maxillofac Surg 2005;63:435‑41.

6. Kaplan I, Anavi Y, Manor R, Sulkes J, Calderon S. The use of molecular markers as an aid in the diagnosis of glandular odontogenic cyst. Oral Oncol2005;41:895‑902.

7. Fowler CB, Brannon RB, Kessler HP, Castle JT, Kahn MA. Glandular odontogenic cyst: Analysis of 46 cases with special emphasis on microscopic criteria for diagnosis. Head Neck Pathol 2011;5:364‑75.

8. Padayachee A, Van Wyk CW. Two cystic lesions with features of both the botryoid odontogenic cyst and the central mucoepidermoid tumour: Sialo‑odontogeniccyst?JOralPathol1987;16:499‑504.

9. Gardner DG, Kessler HP, Morency R, Schaffner DL. The glandularodontogeniccyst:Anapparententity.JOralPathol1988;17:359‑66.

10. Kramer IR, Pindborg JJ, Shear M. The WHO histological typing of odontogenic tumours: A commentary on the second edition. Cancer 1992;70:2988‑94.

11. Shah AA, Sangle A, Bussari S, Koshy AV. Glandular odontogenic cyst: A diagnostic dilemma. Indian J Dent 2016;7:38‑43.

12. Azmi KE, Patel S, Pathak J, Swain N. Glandular odontogenic cyst mimicker: A novel entity. J Contemp Dent 2016;6:145‑8.

13. Takeda Y, Oikawa Y, Furuya I, Satoh M, Yamamoto H. Mucous and ciliatedcellmetaplasiainepithelialliningsofodontogenicinflammatoryand developmental cysts. J Oral Sci 2005;47:77‑81.

14. Kaplan I, Shuster A, Reiser V, Shlomi B. Histologic look‑a likes: Glandular odontogenic cyst and odontogenic cysts with mucous metaplasia. JSM Dent Surg 2016;1:1005.

15. Prabhu S, Rekha K, Kumar G. Glandular odontogenic cyst mimicking central mucoepidermoid carcinoma. J Oral Maxillofac Pathol 2010;14:12‑15.



16. Pires FR, Chen SY, da Cruz Perez DE, de Almeida OP, Kowalski LP. Cytokeratin expression in central mucoepidermoid carcinoma and glandular odontogenic cyst. Oral Oncol 2004;40:545‑51.

17. Sadeghi EM, Weldon LL, Kwon PH, Sampson E. Mucoepidermoid odontogeniccyst.IntJOralMaxillofacSurg1991;20:142‑3.

18. Purohit S, Shah V, Bhakhar V, Harsh A. Glandular odontogenic cyst in

maxilla: A case report and literature review. J Oral Maxillofac Pathol 2014;18:320‑3.

19. Kaplan I, Anavi Y, Hirshberg A. Glandular odontogenic cyst: Achallenge in diagnosis and treatment. Oral Dis2008;14:575‑81.

20. Macdonald‑Jankowski DS. Glandular odontogenic cyst: Systematic review.DentomaxillofacRadiol2010;39:127‑39.

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Print ISSN 2393-8692 Indian Journal of Oral Health and Research · 2017-08-10 · Indian Journal of Oral Health and Research ¦ Volume 3 ¦ Issue 1 ¦ January‑June 2017 I Editorial