Sialolith- The Story of A Stone : A Case Report
Dr. Muralee Mohan
Professor
Department of Oral and Maxillofacial Surgery, A.B. Shetty Memorial Institute of Dental Sciences, Mangalore (Karnataka)
Introduction
S ialolithiasis is the most common
cause of salivary gland
obstruction. Obstruction can be
complete or partial and may cause recurrent
symptoms. The retained saliva exerts
retrograde pressure on the salivary gland, and
may cause transient or total damage to the
parenchyma and the ductal system.1
Sialolith is one of the most common
forms of pathologic conditions found in the
salivary glands. Sialoliths frequently occur in
the submandibular gland (80% to 90%),
whereas 5% to 20% are located in the parotid
gland. 2 Although large sialoliths have
occasionally been reported in the salivary
gland, they have rarely been reported in the
salivary ducts.
Case Report
The patient, a 54 year old man, appeared
for evaluation and treatment of intermittent,
dull, aching pain and swelling in his left
submandibular area. The symptoms had been
present for 2 to 3 months. This phenomenon
occurred 2 to 3 times per day, during meals.
Lime test was performed, and was found to be
positive. The patient noted that sour food was
more likely to produce symptoms than were
other types of food. His health history was
unremarkable, and there was no history of
any systemic illnesses or of previous
hospitalization.
On examination, he was found to have a
firm mass 1 cm in diameter on the floor of his
mouth, along the course of the left
submandibular duct. The mass was slightly
tender. It was bimanually palpable. Saliva
was noted to flow from the orifices of the
submandibular ducts on both sides when the
glands were massaged. The left
submandibular gland measured 1 cm by 2 cm;
the right submandibular gland measured 0.8
cm by 1 cm. Both submandibular glands were
nontender. The patient was afebrile, and his
vital signs were normal. The rest of the
findings of the physical examination were
unremarkable. On the basis of the history and
physical findings, a clinical diagnosis of right
32
Dr. Smitha Bhat Dr. Arvind Karikal
Asst. Professor Asst Professor
Submandibular Sialolithiasis was made.
A plain radiograph of the left half of the
mandible and floor of the mouth showed a
large radiopaque calculus in the floor of the
mouth. A left submandibular sialograph
showed complete obstruction of the left
submandibular duct by a radiopaque calculus
2 cm from the orifice of the duct.
After induction of local anesthesia, the
left submandibular duct was sutured along
with the mucosa distal to the location of the
sialolith.
The duct orifice was traced with a
lacrimal probe, and an incision was made
through the oral mucosa and the duct along
the course of the left submandibular duct. The
duct was dissected to expose the large
calculus. The calculus was freed with
difficulty by blunt dissection and removed
from the left submandibular duct. A cannula
was inserted into the duct and sutures were
placed using 3-0 bbs only on the mucosa
sparing the duct. The purpose of placing the
cannula was to maintain patency of the duct
and to prevent fibrosis, The cannula would be
removed after 7 days.
The calculus was yellow in color. It
measured 15 6 mm and weighed 0.54 g.
Minute cracks were seen on the surface of this
calculus. Chemical analysis showed it to be
an admixed mass of microcrystalline
hydroxyl and carbonate apatites, protein, and
cryptocrystalline tricalcium phosphate.
Discussion
Obstructive salivary gland disease is one
of the most common problems that afflict
salivary glands and is a major cause of
salivary gland dysfunction and
sialoadenectomy.
Sialoliths located in Wharton's duct or in
Stensen's duct are the most frequent cause of
obstruction and consequent acute or chronic
infection.3
Salivary calculi are usually unilateral in
occurrence and round to oblong, have an
irregular (majority) or smooth surface, vary
in size from a small grain to the size of a fruit
seed, and are usually yellow. The stones may
Dr. Shyam S Bhat
P.G. Student
occur in the duct or gland, with multiple
stones not uncommon. They are found more
often in adults, although they also occur in
children. The classic symptoms are that of
obstruction manifested by pain and swelling
of the involved gland during eating. Since
obstruction is rarely complete, the gland
swelling will subside to some degree during
rest periods.
Stones apparently develop as a result of
an initial organic nidus followed by the
deposition of inorganic material, both of
which are derived from the salivary fluid. The
filamentous stroma or nidus is not bacterial in
nature but rather precipitated mucoids and
possibly salivary proteins.4
Submandibular sialoliths are more
common than those of the parotid for a
number of reasons. Anatomically, the
submandibular duct is longer than the parotid,
traversing upward and forward from the
gland to the oral floor, whereas Stensen's duct
moves in a horizontal direction. In addition,
there is diminution in the calibre of Wharton's
duct with a corresponding decrease in wall
thickness compared with the parotid. Salivary
stasis is also facilitated by the fact that the
orifice of Wharton's duct is much narrower
than that of Stensen's duct. There is one other
region in the submandibular duct that is
conducive to salivary stasis, and the comma
area, where the duct takes a radical turn
inferiorly behind the posterior border of the
mylohyoid muscle as it approaches the hilus
of the gland. Regarding salivary viscosity,
submandibular saliva is more than twice that
of the parotid because of its mucus content.4
A small sialolith that enables saliva to
flow through Wharton's duct may cause no
symptoms, while a temporary occlusion of
the duct by a larger stone may initiate
intermittent pain and swelling in the
submandibular region. When the sialolith
reaches a size to obstruct the passage
completely, the secretion in the gland is
hampered because of pressure. This condition
leads to destruction of the gland.2
Sialoliths are composed of a variety of
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 Mohan, et al. : Sialolith- The Story of A Stone : A Case Report
organic and inorganic substances. The
organic substances are glycoproteins,
mucopolysaccharides, and cellular debris,
while the inorganic substances are mainly
calcium carbonates and calcium phosphates.
There are several hypotheses regarding the
pathogenesis of sialolithiasis. The first theory
is based on the existence of intracellular
microcalculi, which when excreted in the
canal become a nidus for further calcification.
The second theory is based on the existence of
mucous plugs, which are present in the ductal
system and represent the nidus. There is an
initial organic nidus that progressively grows
by the deposition of layers of inorganic and
organic substances. Another possibility is that
aliments, substances, or bacteria within the
oral cavity migrate in the salivary ducts and
become the nidus for further calcification.5
Fig. 1
Fig. 5
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Giant salivary calculi (>15 mm) are rare. 3. Yu-xiong Su, Kai Zhang. Increased calcium and
decreased magnesium and citrate concentrations of
Although large sialoliths have been described submandibular/sublingual saliva in sialolithiasis.
in the body of salivary glands, they are rarely Archives of Oral Biology 55 (2010) 15-20
found in the salivary ducts, particularly when 4. Harold D. Baurmash. Submandibular Salivary
the patients have no painful symptoms. Stones: Current Management Modalities. J Oral
Maxillofac Surg 62:369-378, 2004
For intraductal stones, a transoral 5. Kiminori Sato. Fish bone-induced sialolith.
approach is adequate, whereas for Otolaryngology- Head and Neck Surgery (2009) 141,
intraglandular stones, an extraoral 539-540
6. Eduardo Costa Studart Soares. Giant salivary
submandibular gland excision is indicated. calculus of the submandibular gland.
Intraoral sialolithotomy carries fewer risks Otolaryngology- Head and Neck Surgery (2009) 140,
than surgical glands removal, such as the risks 128-129
of a surgical scar, facial nerve damage, and Legends
Frey's syndrome.6 Fig. 1 Extraoral appearance
Fig. 2 Lime test
References Fig.3 Sublingual swelling
1. Badri Aziz, Eran Regev. Sialolithectomy done with a Fig. 4 Occlusal view
CO2 Laser. J Oral Maxillofac Surg 54:685-688, 1996 Fig. 5 Tracing Wharton's Duct
2. Oguzcan Kasaboglu. Micromorphology of Sialoliths Fig. 6 Milking the duct
in Submandibular Salivary Gland: A Scanning Fig. 7 Sialolith exposed
Electron Microscope and X-Ray Diffraction Fig. 8 Measurements
Analysis. 10.1016/I.IOMS.2003.11.018
Fig. 2 Fig.3 Fig. 4
Fig. 6 Fig. 7 Fig. 8
33
Opportunities for Oral Healthcare Professionals in Tobacco
Cessation in Adolescents
Dr. Shilpa Khullar Dr. S. Sood
Professor, Dept. of Prosthodontics, Post-graduate Student,
Inderprastha Dental College & Dept. of Public Health Dentistry
Hospital, Sahibabad, Ghaziabad, UP. ITS-CDSR, Muradnagar,
Ghaziabad UP.
Abstract
T obacco use is one of the leading
preventable causes of morbidity
and mortality. The most powerful
predictor of adult tobacco use is its initiation
during adolescence, the most susceptible time
for onset of this habit. Initiation of tobacco
use is associated with peer pressure, parental
use, school factors, cultural norms, lower self
esteem, accessibility, moderate pricing,
desire for experimentation and aggressive
marketing by tobacco companies.
While dentists have a positive attitude
regarding their role in tobacco cessation, the
same is not extrapolated into practice. Several
barriers to counseling in the dental clinic have
been identified. Dental professionals can
render tobacco cessation services to the
youth. Brief interventions, self-help
materials, and nicotine replacement therapy
for established nicotine dependence form the
mainstay of therapy. The purpose of this
paper is to identify the several factors leading
to tobacco initiation in adolescent and discuss
the role of dentist in tobacco cessation
programs.
Key Words: Adolescents, tobacco,
initiation, cessation, oral health, dentist
Introduction
Tobacco is considered to be the single
most important cause of preventable deaths in
the world. Preventing and treating diseases
caused by tobacco usage is one of the major
challenges of public health today. Despite the
current knowledge of the harm caused by
tobacco, its consumption continues to
increase. The tobacco epidemic is shifting
from industrialized to developing countries,
due to steady population growth coupled with
tobacco industry ensuring that millions of
people become fatally addicted each year.
Nearly 5 million people die due to tobacco
use every year and this figure will increase to
10 million tobacco attributable deaths per
year by 2020. Of these, 7 million deaths will
occur in the developing countries, mainly
China and India.1
Tobacco And Youth
There is a need to identify high-risk
segments of the population such as youth as
an entry point to tobacco use as targeted by
industry promotion. Most tobacco users start
using it before the age of 18 years, while some
start as young as 10 years2, the time for
discovery, challenge and experimen-tation,
when they are far too young to understand or
resist social expectations. The early age of
initiation underscores the urgent need to
intervene and protect this vulnerable group
from falling prey to this addiction. The risks
of tobacco use are highest among those who
start early and continue its use for a long
period. In order to reduce the long-term
burden of tobacco related diseases, adoption
of successful prevention and cessation
34
Dr. A. Mittal Dr. K. Bhargave
Professor & H.O.D. Professor & H.O.D.
Dept. of Conservative Dept. of Oral Pathaology Deptt. of Prosthodontics
Dentistry & Microbiology
Inderprastha Dental College & Hospital, Sahibabad, Ghaziabad UP.
strategies is the only feasible solution in less-
resourceful countries.
It is important for Oral health
professionals to understand the factors which
lead to tobacco abuse in youth, to counter this
public health threat by their intervention.
Determinants of Tobacco Use in Youth
Tobacco use in adults is primarily due to
nicotine dependence whereas in adolescents
there are unique social and behavioral factors
associated with tobacco use.3
Socio-environmental factors such as
advertisements by tobacco companies and
effect of role models in movies who are
smokers and portrayed as smart, successful
and courageous considerably increases the
chances of smoking initiation among teens.4
E n h a n c e m e n t o f a t h l e t i c a b i l i t y,
concentration powers and being 'cool' have
been wrongly associated with tobacco use.
Moderate pricing and easy availability of
tobacco products to even the small kids
despite the ban by the governments has led to
sharp rise in its use. Children may also start
using tobacco for psycho-social reasons like
peer influences, curiosity, desire for
experimentation or as a remedy for stress.5
Personal characteristics of adolescent
tobacco users include low self-esteem, low
aspirations, depre-ssion/anxiety and risk
taking. These personal traits are associated
with certain behavior patterns such as poor
school performance, violence, gang
membership, and alcohol and drug abuse.4
Nicotine gives these users excitement and
relief from the all pervasive gloom of life.5
Development of Dependence
For the past two decades, the onset of
dependence has been conceptualized by the
Stage theory as a slow and sequential process,
with the daily use of tobacco over an extended
period of time as a prerequisite for nicotine
dependence.6 Contradicting this theory,
preliminary results from the DANDY
(Development and Assessment of Nicotine
Dependence in Youth) study suggested that
the first symptoms of nicotine dependence
can appear within a matter of days or weeks of
the onset of intermittent tobacco use.6, 7
Once adolescents have experi-mented
with tobacco, approximately 50% continue
its use and become addicted. Preventing this
use requires intervention in the early
adolescence prior to the time when these
behaviors have already become ingrained.8
Ill. Effects of Tobacco on General Health
Tobacco use is a common risk factor to
several systemic and oral diseases. Second
hand smoke from parents puts the children at
an increased risk of developing lung cancer,
respiratory and cardiovascular diseases,
middle-ear infections and delayed
development of permanent teeth by as many
as 4 months.9
Smoking during pregnancy increases the
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Dr. Pankaj Datta Dr. S. Sharma
Principal & H.O.D. Deptt. of Pedodontics,
chance of a low-birth-weight baby, premature
birth, stillbirth, sudden infant death syndrome
and six times greater chance of cleft palate
formation.10
Although the most serious health
outcomes associated with smoking typically
emerge later in life, adolescent smokers show
evidence of airway obstruction, slowed
growth in lung function and other respiratory
symptoms, compared with non-smokers. In
addition, the earlier individuals begin to
smoke, the higher their risk for heart disease,
stroke, and chronic obstructive lung disease,
risk of developing anxiety disorders/
depression and nicotine addiction.11
Ill Effects of Tobacco on Oral Health
Tobacco-induced oral diseases contribute
significantly to the global oral disease
burden12,13. A clear association between
tobacco use and the prevalence and severity
of periodontal diseases exists.14. Tobacco use
is responsible for up to half of all periodontitis
cases among adults13. Moreover, tobacco use
impedes the effectiveness of periodontal
therapy and wound healing.15 Smoking has
been shown to affect both taste and smell
acuity. Tobacco, whether chewed or smoked,
causes halitosis and staining of teeth16.
Smoking a pack of cigarettes a day or
using smokeless tobacco quadruples the risk
of developing oral cavity or oro-pharyngeal
cancer, which kills about 50% of its victims
within 5 years of diagnosis. Vast majority of
oral cancers are preceded by precancerous
lesions and conditions caused by the use of
tobacco in some form.17 Such lesions can be
easily seen due to their peculiar oral location,
making oral cancers particularly amenable to
prevention.
The clear link between oral diseases and
tobacco use provides an ideal opportunity for
oral health professionals to take part in
tobacco control and cessation programs.
Role of Dentist in Tobacco Control
Measures
Dentists can play a major role to control
tobacco menace by Public Health Education
at community level and counseling and use of
Nicotine Replacement Therapy for tobacco
cessation in the clinics.
Health Education and Information
Prevention against the diseases that come
with tobacco usage is based primarily on
public and individual education to drop the
habit or preferably not to begin in the first
place.
Pediatric dentist can take initiative to
conduct school-based tobacco prevention
programs to educate the adolescents about the
health risk of tobacco consumption, risk of
addiction and benefits of tobacco cessation.
Such programs identify the social influences
which promote tobacco use among the youth
and teach skills to resist such influences
which can produce a long term relative
 Khullar, et al. : Opportunities for Oral Healthcare Professionals in Tobacco Cessation in Adolescents
improvement of 25-30% in quit rates,18 or
delay adolescent tobacco use, especially if
strengthened by booster session and
community programs involving parents and
community participation.
Public health Dentist can write articles
about benefits of tobacco control, participate
in talk shows, demonstrations, discussions
and link with NGO's to involve youth in anti-
tobacco advocacy. The focus should not be
only on primary prevention, that is not only
on discouraging young people from taking up
the habit but also on providing help and
support for those who wish to quit tobacco
usage.
Tobacco Cessation for Youth in Dental
Clinics
The scope of preventive dentistry is
constantly expanding and can be as far
reaching as a professional's imagination,
sense of responsibility and efforts. Dentists
have been recognized as "ideally positioned
to counsel against the use of tobacco
products." They can relay specific
information concerning the oral ill effects of
tobacco use. The dental encounter probably
constitutes a "teachable moment" when the
patient is receptive to counseling about life-
style issues. Oral health professionals should
integrate tobacco use, prevention and
cessation services into their routine and daily
practice19 for the following reasons.
1. They are especially concerned about
the adverse effects of tobacco practices in the
oro-pharyngeal region of the body.
2. They have easy access to children,
youths and their caregivers, thus providing
opportunities to influence individuals to
avoid all together, postpone initiation or quit
using tobacco before they become dependent.
3. They often have more time with
patients than many other clinicians, providing
opportunities to integrate education and
intervention methods into practice.
4. T h e y o f t e n t r e a t w o m e n o f
childbearing age, thus are able to inform such
patients about the potential harm to their
babies from tobacco use.
5. They can build their patient's interest
in discontinuing tobacco use by showing
actual tobacco effects in the mouth.
Dentists in many parts of the world have a
positive attitude about intervening for their
adolescent patients. The majority of dentists
consider smoking cessation and prevention
for adolescents and children as part of their
responsibility20. Pediatric dentists should
encourage, advice and assist tobacco users to
quit21.
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Most dentists and hygienists don't
counsel children to prevent tobacco use due to
lack of confidence and doubt about the
effectiveness of their intervention efforts.20,22
Barriers Mitigating Provision of Tobacco
Cessation Counseling
Numerous barriers have been identified
for the limited involvement of dental
professionals in tobacco cessation programs
for youth.20,21,22,23,24 Some of the consistently
reported barriers are lack of time, lack of
reimbursement or incentives, resistance from
the patients or parents, lack of skills or formal
training translating into lack of confidence,
lack of readily accessible patient education
materials, perception of poor effectiveness
and fear that giving unwanted tobacco
cessation counseling may upset the dentist-
patient relationship. Children and adolescents
also under- report tobacco use on health
history forms that ask them to specify
whether they use tobacco products25 making it
difficult to identify them in the first place.
Globally about 70% of 13-15 year olds
who currently smoke have a desire to quit.
Though a high number of tobacco users want
to quit, few make a dedicated quit attempt
(around 40%) and a negligible proportion of
these (around 3%) are successful in achieving
long term abstinence18. Parents are more
likely to approve than disapprove of the
dentist counseling the child and the parent.26.
The lack of training at the graduate level
is also an important barrier that hinders large-
scale involvement of dentists. The
professional skills required by the dentists to
provide tobacco cessation counseling to their
patients ideally should be learnt during the
dental curriculum and reinforced within
continuing education. Dental colleges need to
incorporate into their curricula not just
didactic instruction on the oral health impact
of tobacco use, but relevant counseling
techniques and training in nicotine
replacement therapy.
ideally should be learnt during the dental
curriculum and reinforced within continuing
education. Dental colleges need to
incorporate into their curricula not just
didactic instruction on the oral health impact
of tobacco use, but relevant counseling
techniques and training in nicotine
replacement therapy.
Brief Interventions
Dentists can help youth by providing
advice on when to quit, help the patient to
identify problems and strategies to deal with
problems.
Behavioral interventions for tobacco use
conducted by oral health professionals in the
dental clinic and community setting may
increase tobacco abstinence rates among
smokeless tobacco users27 Dental treatment
often necessitates frequent contact with
patients over an extended period of time,
providing a mechanism for long-term contact
and reinforcement, coupled with visible
changes in the oral cavity in response to
counseling28.
Brief interventions typically involve an
assessment of tobacco use, dependence, and
motivation to quit; advice on the benefits and
methods of quitting; and assistance with
quitting, including referrals to other treatment
modalities.
Motivating Factors for Tobacco Cessation
1. It is important to note that adolescents
consistently rank physical attractiveness,
dental concerns, and oral health as greatly
important.
29
2. Relating tobacco to short-term
adverse effects such as staining of teeth,
halitosis, loss of taste may be more relevant
and meaningful to an adolescent than long-
term health effects such as cardiovascular or
lung diseases30
3. Highlighting role models abstaining
from tobacco use and making the dental clinic
adopt a no tobacco policy can also be used.
However, it is important to realize that
tobacco cessation is a process and a number
of stages are encountered in the process.
Some of the attributes required for the
clinician are to be persistent, supportive and
not to give up.31
The 5 A's (ask, advice, access, assist and
arrange) is a brief intervention method, used
to guide the dentist in tobacco cessation
counseling. It is important to include some
sort of intervention to bring behavior change,
in cases where the adolescent wishes to quit
tobacco.32
Initial question about tobacco use
Whether the person uses tobacco currently (type and quantity)
ASK & if so whether the Individual is interested at present in stopping
To quit tobacco
ADVICE
Determine stage of readiness to change,
commitments and barriers
ACCESS
Firm commitment to change; user to
ASSIST change by action and maintenance
Follow-up to monitor progress
ARRANGE
35
 Khullar, et al. : Opportunities for Oral Healthcare Professionals in Tobacco Cessation in Adolescents
Ask every adolescent a simple question
about current tobacco use and use record
system in the clinic to document his/ her
tobacco use status during every visit. Once a
tobacco user is identified, assess willingness
to make a quit attempt, the dentist should urge
him or her, in a clear, strong and
personalized manner, to quit. The dentist can
assist tobacco users by helping them set a quit
date; referring them to a telephone counseling
service, cessation group or intensive
cessation program; prescribing pharmaco-
therapy; and providing educational materials
about tobacco cessation. Follow-up contact to
support and guide a patient's quit attempt
should be arranged otherwise, users may slip
back to earlier stages of change.
Users unwilling to make a quit may
respond to a motivational intervention that
provides the clinician an opportunity to
educate, reassure, and motivate. Motivational
intervention is built around the '5 R's':
Relevance, Risks, Rewards, Roadblocks and
Repetition.Such counseling involves talking
about tobacco and quitting and then
reinforcing the points most likely to motivate
adolescents to quit. Information should be of
their relevance, such as health concerns,
rewards or specific barriers to quitting. A
discussion of the health effects of tobacco and
the benefits of quitting (such as immediate
improved oral health and financial savings)
may allow the dentist to identify and highlight
risks and rewards that seem most relevant to
the user. Identifying the patient's perceptions
of roadblocks to quitting, such as fear of
withdrawal symptoms or weight gain and
address those barriers. The motivational
intervention should be repeated during every
clinic visit by a user, who is unwilling to quit.
Nicotine replacement therapy (NRT)
The pharmacological means include NRT
and antidepressants like bupropion. While
intensive therapy is not in the realm of
dentists providing brief interventions but
NRT holds plenty of promise. Even though
these methods may seem exclusive of each
other, the existing data suggest that a
combination of the two is often essential to
achieve good success rates.33 Normally these
services will lie outside the dental practice
although some trained dental teams will be
able to provide these services.
Adolescent tobacco users are different
from older tobacco users in that their
motivation to stop smoking tends to be more
unstable. It is sensible, therefore, to check
that they are fully committed to trying to stop
smoking permanently before offering them
NRT and to attempt to establish that they are
dependent34
Self-help
The self-help, non-interactive approach
includes minimal interventions that do not
require responses from the adolescent and are
delivered through written or audio-visual
materials or on a computer; to motivate the
patient to quit the habit.
Challenges to Youth Tobacco Cessation
Programs
1. Tobacco cessation programs especially
for youth are a resource-intensive
intervention.
2. Negligible cessation clinics are available
for adolescents or implemented in the
36
developing countries.
3. Cessation programs implemented in
isolation with lack of supportive
environment and government policies for
tobacco control.
4. Low importance placed by oral health
professional on tobacco cessation.
Conclusion
Though we do not fully understand all the
factors that contribute to onset of tobacco use,
which leads to addiction and eventual adverse
health outcomes; we do need to understand
better the patterns of use and how the
determinants of initiation interact.
As oral health care providers, dentists
must take the responsibility of providing
tobacco cessation services and encourage
non-users to be tobacco free, though few
translate this into practice. Admittedly, there
are several barriers in this process, both real
and perceived, which should be addressed
with further research. Screening for tobacco
use, interventions, referring adolescents to
additional resources for cessation, and
establishing a follow-up system that will
track each adolescent's progress should be
made mandatory. Brief advice from a dentist
for adolescents is cost-effective and has a
potentially large reach.
Success in relation to cessation does not
only mean that more number of patients has
quit, but it also includes educating the masses,
so that the number of individuals taking to
this habit afresh will also reduce. Today, we
the members of the oral health profession
along with policy makers should help in
achievement of a tobacco-free society so that
we can protect the health of the coming
generations.
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14. Bergstrom, J., Eliasson, S., Dock, J. 10-year
prospective study of tobacco smoking and
periodontal health. Journal of Periodontology 2000;
71, 1338-47.
15. Davis JM. Tobacco Cessation for the Dental Team: A
Practical Guide Part: I background and overview. J
Contemp Dent Pract 2005;3:158-66.
16. Allard, R., Johnson, N., Sardella A et al.Tobacco and
Oral Diseases: Report of EU Working Group. Journal
of Irish Dental Association 1999; 46, 12-23.
17. WHO: Tobacco-related Oral Mucosal Lesions and
D e n t a l D i s e a s e s 4 . 7 . Av a i l a b l e f r o m :
http://www.whoindia.org/ SCN/ Tobacco/
Report/03-Chapter-04.7.pdf
18. Global youth meet on tobacco control (GYM 2009).
Youth advocacy for global tobacco control: insight,
issues and incentives. HRIDAY
19. Petersen PE.The World Oral Health Report 2003.
Continuous improvement of oral health in the 21st
century and the approach of the World Health
Organization Global Oral Health Programme.
Geneva,World Health Organization, 2003
20. Wyne AH, Chohan AN, Al-Moneef MM, Al-Saad AS.
Attitudes of General Dentists about Smoking
Cessation and Prevention in Child and Adolescent
Patients in Riyadh, Saudi Arabia. J Contemp Dent
Pract 2006;1:35-43.
21. Gansky SA, Ryan JL, Ellison JA, Isong U, Miller AJ,
Walsh MM. Patterns and correlates of tobacco control
behavior among American Association of Pediatric
Dentistry members: a cross-sectional national study.
BMC Oral Health 2007;7:13.
22. Kast KR, Berg R, Deas A, Lezotte D, Crane LA.
Colorado Dental Practitioners Attitudes and
Practices Regarding Tobacco-Use Prevention
Activities for 8- Through 12-Year-Old Patients. J Am
Dent Assoc 2008:139:467-75.
23. Goodman H S., Vargas C M. et al. Maryland. General
and pediatric dentists attitudes regarding tobacco use
prevention and cessation in their child and adolescent
patients. Public health and the environment. APHA
2004. p. 6-10.
24. Beaglehole, R.H.The role of oral health professionals
in tobacco control in OECD countries: policies and
initiatives. Master's Thesis. University College
London, 2003.
25. Hennrikus D, Rindal DB, Boyle RG, Stafne E,
Lazovich D, Lando H. How well does the health
history form identify adolescent smokers? J Am Dent
Assoc 2005;136:1113-20.
26. Vergotine R J, Koerber A, Shires D. Pediatric
Dentists role in Tobacco Counseling for Children:
Parental Attitudes. IADR 86th General session and
Exhibition.
27. Carr A, Ebbert J. Interventions for tobacco cessation
in the dental setting. Cochrane Database of
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CD005084. DOI: 10.1002/ 14651858. CD005084.
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28. Albert DA, Severson HH, Andrews JA. Tobacco use
by adolescents: the role of the oral health professional
in evidence-based cessation programs. Pediatr Dent
2006;28:177-87.
29. Johnson JG, Cohen P, Pine DS, Klein DF, Kasen S,
Brook JS. Association between cigarette smoking and
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Walsh MM. Patterns and correlates of tobacco control
behavior among American Association of Pediatric
Dentistry members: a cross-sectional national study.
BMC Oral Health 2007;7:13.
31. Albert DA, Severson HH, Andrews JA. Tobacco use
by adolescents: the role of the oral health professional
in evidence-based cessation programs. Pediatr Dent
2006;28:177-87.
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guidance_uk_1205.
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Early Childhood Caries & Feeding Practices in Children aged
3 Yrs. Attending Anganwadi Centers of Bangalore South
Dr. Ramakrishna T.
Professor
Oral & Maxillofacial Surgery
The Oxford Dental College, Hospital and Research Center,, 10th mile stone, Bommanahalli, Hosur Road, Bangalore-560078
Abstract
B ackground and Objectives:
Preschool oral health is an
overlooked aspect of childhood
health and well being, especially Early
Childhood Caries. It is an infectious and
multifactorial disease of the Childhood.
Several factors play a role in the etiology of
disease. The objectives of the present study
was to
1) To determine prevalence of Early
Childhood Caries in children aged 3 years
attending the Anganwadi Centers of
Bangalore South
2) To correlate the Early Childhood
Caries in children aged 3 years with feeding
practices.
Methodology: A Cross-sectional study
was conducted in children aged 3years
attending Anganwadi centres of Bangalore
South. Required and relevant information
regarding feeding practices were obtained
from parents. Dentition Status and Treatment
Need (WHO 1997) was used to record caries.
ANOVA and f-test was used for statistical
analysis.
Results: The prevalence of ECC was
31.4% with mean dmft of study population is
1.152.28 with the males having an average
dmft of 1.312.48 and females having an
average dmft of 1.012.07. The risk factors
for caries in this study population were found
to be the habit of bottle feeding in the night
with a p value of <0.001, children who
consumed more in between meal snacks had a
higher ECC prevalence with a p value of
<0.001.
Conclusions: The present study provides
an insight regarding the caries prevalence in
children aged 3 years. This study indicates
high caries levels in children with bottle
feeding at night and snacking frequency of
more than 3 times in a day.
Key Words: Early Childhood Caries,
Bottle feeding, Snacking frequency
Introduction
Despite great achievements in oral
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Dr. Shilpashree K.B.
Senior Lecturer
Dept. Preventive& Public Health Dentist
health, even with dramatic advances in the
armamentarium for fighting oral diseases,
such as dental caries and periodontal disease,
these conditions remain prevalent in many
parts of the world without regard for
geopolitical boundaries. Early Childhood
Caries (ECC), also known as early childhood
tooth decay is particularly destructive form of
tooth decay that afflicts young children. It is
the most common disease of the childhood
although it is not life threatening, it may
contribute to suboptimal health and failure to
thrive1. It is a unique form of rampant caries
that develops in the primary dentition at a
very young age2. ECC can manifest itself in
severe pain, infection, abscesses, chewing
difficulty, malnutrition, and gastro intestinal
disorders. Further decay of primary teeth can
affect child's growth, leading to malocclusion
by adversely affecting the eruption of the
permanent dentition, and cause poor speech
articulation and low self esteem3.
The older terms nursing caries, baby
bottle tooth decay, nursing bottle syndrome,
maxillary anterior caries lesions, rampant
caries lesions and most recently has been
largely replaced with the broader and
umbrella term ECC. This change in
terminology has helped to focus attention on
risk factors other than prolonged breast
feeding and bottle feeding1,3,4. It is a serious
socio-behavioural and dental problem that
afflicts infants and toddlers. American
Academy of Pediatric Dentistry (AAPD) in
2003 defined ECC as the presence of one or
more decayed, missing (due to caries), or
filled tooth surfaces in any primary tooth in a
child 6 years of age or younger1,4,5,6. Bangalore
being a metropolitan city has children from
different socio-economic and cultural
backgrounds. Despite the seriousness of
Early Childhood Caries problems, there has
been a paucity of prevalence studies in
Bangalore, which may be due to the difficulty
of access to this age group. Hence an attempt
is made to assess the prevalence of Early
Childhood Caries and its association with
Dr. Shabana A G
Senior Lecturer
Dept. of Public Health Dentistry
feeding practices in children attending
Anganwadi centres of Bangalore South.
Materials And Methods
A prevalence study was conducted to
assess Early Childhood Caries in children
aged 3 years attending Anganwadi Centers of
Bangalore South and to associate the
presence of ECC with feeding practices. The
Bangalore South zone consists of 109
Anganwadi Centers in the rural areas with a
population of around 1897 children who
formed the study population.
Permission, required and relevant
information regarding the study centres was
obtained from the Child Development Project
Officer. A survey was systema - tically
scheduled to spread over a period of 3
months. Examination criteria employed was
Dentition status and Treatment needs
proposed by WHO (1997) in Basic Oral
Health Survey Methods, 4th edition. Before
the start of the survey, the investigator was
calibrated at Department of Community
Dentistry, The Oxford Dental College and
Hospital under the guidance of the Professor
in order to limit the examiner variability. The
Kappa co-efficient value for intra-examiner
reliability with respect to Dentition status and
Treatment needs was 0.8. A specially
designed and pretested proforma was used for
recording the data which included questions
regarding child's feeding habits. A recording
assistant who was trained to assist the
recording procedure helped the investigator
in recording the findings. A pilot study was
carried out on 10% (190) of the study
population to check the feasibility and to have
prior idea regarding the estimate of the time
taken to examine each patient and the survey
was planned accordingly. Voluntary written
informed consent was obtained from parents
of the children participating in the study
before the clinical examination.
Questionnaires were distributed to the
parents and were explained to the parents in
case they do not understand, the same was
recorded by the examiner or the care takers.
37
 Ramakrishna, et al. : Early Childhood Caries & Feeding Practices in Children Aged 3 Yrs. Attending Anganwadi Centers of Bangalore South
Examination was carried out by making the
child sit on ordinary chair with back rest, with
the examiner standing behind the chair.
Survey findings were reported to the
concerned care takers of these centres and
were referred to The Oxford Dental College
and Hospital for further treatment. The data
obtained was compiled systematically and
statistical analysis has been carried out.
Results
The study population comprised of 1897
children, out of whom 901 (47%) were males
and 996 (53%) were females (Table 1).
Among the study population 33.8% of the
males and 29.1% of the females had caries
with mandibular first molars being most
affected (10.7%), followed by maxillary
central incisors (7.79%) and least affected
were mandibular lateral incisors (0.06%).
Caries was significantly seen in children who
were bottle fed only (0.96) than children who
were breast fed only (0.88). Children who
were bottle fed at night had higher caries
prevalence with mean dmft of 1.00 compared
to the children who were not bottle fed at
night with a mean dmft of 0.88. Children who
consumed snacks and sticky type of food had
higher caries prevalence with a mean dmft of
1.39. Children who frequently (more than
once) consumed snacks in between meals
reported a mean dmft of 0.91.
The results after considering independent
variables simultaneously, the risk factors for
caries in children was the habit of bottle
feeding in the night and children who
consumed snacks in between meals had a
higher ECC prevalence with a p value of
<0.001.
Discussion
This investigation considered the
prevalence of caries in 1897, 3 year children
attending Anganwadi centres of Bangalore
South.
Prevalence of Early Childhood Caries
(n=1897)
This study documents the prevalence rate
of 31.4%. The finding was similar in studies
by Bian and champion of china who reported
a ECC prevalence of 36% and Gomez et al
30.5%9. Caries prevalence (31.4%) was
slightly lower in this population with a mean
dmft of 1.152.28. It was slightly lower
compared to the studies by Dr Rajath
Bhargave who reported a ECC prevalence of
58%, Horowitz et al who reported a
prevalence of 56.5% with a mean dmft of
1.93. Brothwell et al reported a prevalence of
40.7% with a mean dmft of 2.03.3. The
caries prevalence rate in this study among the
3 year old children was 28.1% is lesser than
that report from Northern Philippines 85%;
Japan 60%; and Thailand was 62%.
The prevalence of caries and the mean
dmft was slightly high among boys compared
to the girls with a mean dmft of 1.312.48 and
1.012.07 respectively. This was similar in
the study by Anegundi R and Carino KMG,
Shinada K and Kawaguchi Y10. This may be
due to apparent sex difference in eruption
38
times of teeth and to the length of exposure of
the teeth to the oral environment11.
Child rearing practices and ECC
The influence of infant feeding per se on
ECC remains a complex and some what a
controversial issue. Under the normal
conditions, milk is not considered to be a
cariogenic agent, but repeated and prolonged
exposure leads to larger decrease in plaque
PH14. The lactose content of both human and
bovine milk can be cariogenic if the milk is
allowed to stagnate on the teeth. In this study,
majority of the children had been exclusively
breast fed for more than a year. Data from the
developing countries also suggest that breast
feeding is protective of caries development
till 12 months. Breast feeding duration
beyond 12 months has been implicated in
ECC development and this effect could be
due to gradual depletion of the protective
elements in human breast milk after
prolonged lactation. In this study the
association between children who were bottle
fed at night and the prevalence of dental
caries was statistically significant (p<0.001).
This was similar to the results quoted by
Hallet and Rourke 5,15, Dini et al and Weinstein
and Foeres15 who said bottle feeding
increased the risk of ECC development. In
this study children who were bottle fed only
had more caries than children who were
breast fed only. This was similar to the results
by Bian and Champion of china, Oulis et al16,
winstein et al, winter et al17, Grandefjord et al,
creedon and Mullane (2001), Holland et
al(1988) Tee17 , Horowitz et al who observed
that children who fall asleep with the nursing
bottle have a significantly greater chance of
developing caries than children discarding
the bottle, before they fall asleep. However
any relationship between breast feeding and
dental caries is very difficult to establish
conclusively since it may be masked by the
influence of other factors such as
socioeconomic status of the family and
parental education, or factors like enamel
hypoplasia, streptococcus mutans infection,
diet, medical conditions in infancy. The
average age at which the children started solid
food consumption was 1.33 years. Children
who started having semisolid food at an age 1
year or lesser and 1+ years reported caries in Table 3: Distribution of The Study
30.1% and 35.4% respectively. This was
similarly reported by Hallet and Rourke15.
Children who started drinking with cup 1 year
or lesser and 1+ years reported caries with
39.2% and 41.3% respectively. This was
similarly reported by Hallet and Rourke14. < 6 months
Early introduction of solids may help to
encourage more even mixing of saliva with
food, prevent stasis of cariogenic liquids
around the teeth and reduce caries risk.
Child Dietary Habits and ECC
In the present study, most of the children
had the habit of sticky food consumption. In Bottle feed
this study children with a frequency of Milk
snacking between meals more than twice or
more had a higher caries prevalence with a
Heal Talk | July-August 2012 | Volume 04 | Issue 06
mean dmft of 0.8 than children who did not
have a habit of snacking in between meals
which is supported by a study in Washington
state by Tsuobochi J et al, Creedon and
Mullane who reported a mean dmft of 3.117.
The children who had a habit of snacking in
between meals for more than 3 times a day
than children who snacked once a day or
lesser suggests a positive association between
the occurrence of caries and frequency of
snacking between meals. This was also
supported by study done by Sillanpaa et al,
Babu Jose of Kerala, Steel et al and Horowitz
et al who reported caries in 87.9% of the
children who consumed in between meal
snacks15. The relationship between meal
snacking and caries status in this study
showed statistically significant association
(p<0.001). This was supported by Hyoung B
et al , Rugg Gunn 1983, Bowly and Birkhe,
1986. The frequency with which sugary foods
are consumed is usually considered of greater
etiological importance than the total amount
of sugar. Several studies in children have
found a relationship with a reported
frequency of eating sugary foods. These
findings do substantiate often considered a
single factor which had profound influence
on the occurrence of caries.
Recommendations
1. Mother should be encouraged to breast
feed the baby for the first year and then to
go directly to cup or spoon feeding rather
than starting bottle habits.
2. After the eruption of the first tooth the
baby should not be fed while sleeping.
3. After every feed the child should be given
a sip of water to clear residual milk from
the mouth and hold the child upright
thereafter for five to ten minutes.
Table 1: Distribution of The Study
Population Based on Age And Gender of The
Children.
Total Male Female
1897 901 (47%) 996 (53%)
Table 2: Distribution of The Study
Population Based on Type of Feeding.
(n=1897)
Type of Feeding Number %age
Breast Fed only 1504 79.2%
Bottle Fed onmly 37 2.0%
Population Based on The Duration And
Frequency Of Breast Feeding.
Duration of Number %age
Breast Feeding (1860)
Not breast fed 37 1.98%
52 2.8%
6 months-1 yr. 523 28.1%
> 1 yr. 1248 67.12%
Table 4: Distribution of The Study
Population Based on the Content of Bottle
Feed
Content of Number %age
(393)
256 65.1%
Milk powder & milk 112 28.4%
Others 18 6.5%
 Ramakrishna, et al. : Early Childhood Caries & Feeding Practices in Children Aged 3 Yrs. Attending Anganwadi Centers of Bangalore South

Table 5: Distribution of The Study status of preschool children in Hong Kong. British 8. How long was the child bottle fed?
Dental Journal 1999; 187: December 11: 616-20.
Population Based on the Bottle Feeding at 9. National Oral Health Survey and Fluoride Mapping
Never [ ]
Bed Time 2002-2003, Karnataka by Dr R.K.Bali, Dr S.S. Less than six months [ ]
Bottle fed Number %age Hiremath and Dr Manjunath Puranik. Dental Council Six months to one year [ ]
at Night (393) of India, New Delhi
10. Carino KMG, Shinada K and Kawaguchi Y. Early
More than one year [ ]
Yes 97 75.4% childhood caries in Northern Philippines. 9. Time of bottle feeding in a day?
No 296 24.6% Community Dent Oral Epidemiol 2003; 31: 81-9. Never [ ]
Table 6: Mean dmft Score in Different Age 11. Shafer, Hine and Levy. A Textbook of Oral Pathology, Once a day [ ]
4th edition 2000
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Feeding Early Childhood caries. Community Dent Oral Thrice a day [ ]
Type of feeding dmft Prevalence Epidemiol 2006, 34: 25-35. More than thrice a day [ ]
Breast fed only 0.882.00 < 0.001** 13. Ferreira S.H, Beria J.U, Kramer P.F, Feldans E.G and
Feldens C.A. Dental caries in 0-5 year old Brazilian 10. Was the child bottle fed at night?
Bottle fed only 0.962.04 < 0.001** children: prevalence, severity, and associated Yes / No [ ]
Both 0.912.04 < 0.001** factors.International Journal of Pediatric Dentistry 11. If yes, Contents of feeding bottle
Duration of Breast Feeding 2007; 17:289-296.
14. Dileep C.L, Basavaraj P, Jayaprakash K and
Milk [ ]
Not breast fed 0.721.41 0.77 Bhargava R. Journal of Indian Association of Public Milk and Milk powder [ ]
Less than 6 months 1.603.83 - Health Dentistry 2007; 9: 60-62. Any other liquids _________
6 months-one year 0.920.011 0.011 15. Hallet K.B and Rourke P.K. Early Childhood Caries Was sugar added to the contents of
and infant feeding practice. Community Dental
> 1 year 0.962.04 < 0.001 Health 2002 19, 237-242. bottle? Yes / No [ ]
Bottle Feeding at Night 16. Bian M.D.Z, Guo L, Holt R, Champion J and Bedi R. 12. At what age did child start?
Yes 1.002.12 < 0.001* Caries patterns and their relationship to infant feeding A. drinking from a cup / glass_________
and socio-economic status in 2-4 year old Chinese
No 0.881.96 < 0.06 children. International Dental Journal 2000 B. Eating solid foods _______________
Table 7: Mean dmft Score in Different Age Dec;50(6):385-9. 13. Does your child have between meal
Groups According To Dietary Habits 17. Livny A, Assali R and Cohen H.D. Early Childhood snacks? Yes / No [ ]
Dietary Habits Caries among a Bedouin community residing in the
eastern outskirts of Jerusalem. BMC Public Health; If yes, what kind________ & how many
Snacks Preference 2007 Jul 24;7:167 times ________
Yes 1.052.21 < 0.064 Annexure
No 0.951.85 < 0.489 The Oxford Dental College, Hospital &
Frequency of Snack consumption Research Centre, Dept. of Preventive &
Once daily 0.882.00 < 0.05 Community Dentistry, Questionnaire For Coming soon...
Twice daily 0.62.04 < 0.064 Parents
Thrice daily 0.912.04 < 0.01 1. Name of child ___________________
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1. Schroth R.J. and Douglas J. Brothwell. Prevalence of Mother _________ Father _________
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jkstkuk

2feuV
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Heal Talk | July-August 2012 | Volume 04 | Issue 06 39

Prophylactic Extraction of Impacted Third Molars : A Review
Dr. Safeena
Reader, Dept. of Orthodontics
Al-Badar Dental College & Hospital, Gulbarga
Abstract
T hird molars often develop in
inappropriate positions, and they
may be unable to erupt properly.
Removal of third molars is the most
commonly performed oral surgical
procedure. It is not possible to predict reliably
whether impacted third molars will develop
pathological changes if they are not removed.
Surgical removal of third molars can only be
justified when clear long term benefit to the
patient is expected. This review scans the
literature for any evidence to justify the
prophylactic removal of asymptomatic third
molars which has been a long standing
controversy
Key Words: Third molar, Pathologic
changes, Prophylactic removal.
Introduction
Removal of third molars is the most
commonly performed oral surgery
procedure.1,2,3 It is justified to extract an
impacted third molar when they cause
pathological changes and/or severe
symptoms such as infection, non-restorable
carious lesions, cysts, tumours and
destruction of adjacent teeth and bone2.
However, the justification for prophylactic
removal of impacted third molars has been
debated for many years. The reason being that
many impacted or unerupted third molars
may eventually erupt normally and many
impacted third molars never cause clinically
important problems.
Several reasons are given for the early
removal of asymptomatic or pathology-free
impacted third molars, almost all of which are
not based on reliable evidence: They are as
follows
They have no useful role in the mouth;
They may increase the risk of
pathological changes and symptoms;
If they are removed only when
pathological changes occur, patients may
be older and the risk of serious
complications after surgery may be
greater.
Indications for prophylactic extraction of
third molar are:
Pericoronitis (inflammation of the
gingival surrounding the crown of a
tooth)
Cyst development
The risk of malignant neoplasms arising
Indicated for Prophylactic Extraction
Higher-level reasons associated with the patient's life situation.
If other measures are being conducted under anesthetic and further
anesthesia would be necessary for removal of a third molar.
Where prosthetic treatment is planned and secondary eruption due to further
atrophy of the alveolar ridge or to pressure of the removable prosthesis is
likely.
To facilitate orthodontic treatment such as tooth movement and/or retention.
40
in a dental follicle
Third molars causing dental caries of
second molars
Impacted third molar causing root
resorption of the adjacent second molar
To facilitate orthodontic treatment such
as tooth movement and/or retention
Symptoms such as pain, swelling, trismus
due to non availability of space in the
dental arch for eruption of third molar
To prevent any lower incisor crowding
due to impacted third molars
Pericoronitis is a condition where there is
inflammation of the gingival surrounding the
crown of a tooth. This is the most common
indication for third molar surgery4, and
mainly occurs in adolescents and young
adults. This condition is rarely seen in older
people5. A study reported that over 4 years of
follow up, 10% of lower third molars develop
pericoronitis6. Cyst development is very rare
and is not and indication for prophylactic
removal5. The risk of malignant neoplasms
arising in a dental follicle is negligible and is
not an indication for prophylactic removal.
Very few impacted third molars cause
dental caries (decay) of second molars5,
though estimates vary (1% to 4.5%). Fear of
second molar caries is not a justification for
prophylactic removal. There is a low
incidence (less than 1%) of root resorption of
second molars with impacted third molars6.
The association between lower incisor
crowding and impacted third molars is not
significant and does not warrant the removal
of third molars7.
To facilitate orthodontic treatment such
as tooth movement and/or retention. During
planning of orthodontic treatment, on routine
OPG examination, if the impacted third
molars have a mesioangular or a horizontal
impaction, the eruptive forces of these teeth
may be in the mesial direction, compromising
the extraction space for retraction of
proclined anteriors. In such situations, it is
indicated for prophylactic removal of
asymptomatic third molar.
Common complications following third
molar surgery include sensory nerve damage
(paraesthesia), dry socket, infection,
haemorrhage and pain. Rarer complications
include severe trismus, oro-antral fistula,
iatrogenic damage to the adjacent second
molar and iatrogenic mandibular fracture.
Table-1
Not Indicated for Prophylactic Extraction
Where spontaneous regular positioning of the third molars in the dental arch is likely.
If the extraction of other teeth and/or orthodontic treatment with correct positioning of the
tooth is appropriate.
Deeply impacted and malposed teeth without associated pathology, where a high risk of
surgical complications exists.
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Dr. Mohammed Najmuddin
Asst. Prof., Dept. of Oral Medicine and Radiology
AME's Dental College, Raichur.
The rate of sensory nerve damage after
third molar surgery has been shown to range
from 0.5% to 20%.9 The overall rate of dry
socket varies from 0% to 35% among
studies.9 The risk of dry socket increases with
lack of surgical experience and tobacco use,
though this does not justify prophylactic
removal5,8.
Discussion
A recent evaluation of published reviews9
has concluded that there is little reliable
evidence to support prophylactic removal of
impacted third molars. Two decision analyses
also concluded that, on average, patients
longer term well being is more likely to be
maximised if only those impacted third
molars with pathology are removed10.
Two reviews from North America also
confirm this conclusion. One acknowledged a
lack of reliable evidence to support the
prophylactic removal of impacted third
molars. The other concluded that 'routine
prophylactic third molar extraction is
unjustifiable5. It showed that impacted third
molars in adolescents are most likely to
develop pathological indications, while
impacted third molars in adults are unlikely to
undergo significant pathological changes.
This review also indicated that older patients,
for whom third molar extraction is necessary,
generally tolerate the procedure well
Proffit et al suggest that an asymptomatic
third molar does not always mean pathology
free. So, a radiographic assessment is
necessary to conclude the existence of
pathology and the decision to extract or not
should be left to the patient after educating the
patient about the problems associated11.
In a comparison of the risk of
pathological changes in retained third molars
and complications after third molar surgery,
the rate of complications after removing third
molars was 11.8% in youths (age range 12-
29) and 21.5% in older age (age range 25-81).
In addition, results from several studies
showed that the risk of pathological changes
in older adults ranges from zero to 12%.
Using these figures, it can be calculated that
there will be more complications after
prophylactic removal of pathology free third
molars than after removing only those third
molars with pathological changes (see
Table1).
 Safeena, et al. : Prophylactic Extraction of Impacted Third Molars : A Review
The fact that most third molars, impacted
or not, do not become diseased and that the
risk of iatrogenic injury from such surgery is
greater than the risk of leaving asymptomatic,
nonpathologic teeth alone does not override
the expert opinion of oral and maxillofacial
surgeon On the other hand, the probability of
impacted third molars causing pathological
changes in the future may have been
exaggerated.3,7 In addition, third molar
surgery is not risk free, the complications and
suffering following third molar surgery may
be considerable. Therefore, prophylactic
removal should only be carried out if there is
good evidence of patient benefit.
Conclusion
It is not possible to predict reliably
whether impacted third molars will develop
pathological changes if they are not removed.
Surgical removal of third molars can only be
justified when clear long term benefit to the
patient is expected. Based on evidence and
guidelines from the past ten years of
evidence, there is currently insufficient
Dear Doctor,
Healtalk (A Journal of Clinical
Dentistry) is bibliographic listed with
International Standard Series Number
0975-6329 and also with Index
Copernicus International-Poland,
European State, Ulrichs International
Periodical Directory U.S.A. &
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If you want to send some article
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send the matter at the editorial office.
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Heal Talk | July-August 2012 | Volume 04 | Issue 06
evidence supporting or refuting the practice
of prophylactic removal of asymptomatic
third molars. Regarding clinical practice, the
decision to remove asymptomatic wisdom
teeth appears to be best based on careful
consideration by practitioners of the potential
risks and benefits for individual patients,
explaining to the patient regarding the same
and decision be made by the consent of the
patient
References
1. NHS Centre for Reviews and Dissemination.
Prophylactic removal of impacted third molars: is it
justified? Effectiveness Matters [Internet]. 1998 Oct
[cited 2010 Jul 9];3(2):1-4. Available from:
http://www.york.ac.uk/inst/crd/EM/em32.pdf
2. Jasinevicius TR, Pyle MA, Kohrs KJ, Majors JD,
Wanosky LA. Prophylactic third molar extractions:
US dental school departments' recommendations
from 1998/99 to 2004/05. Quintessence Int. 2008
Feb;39(2):165-76.
3. Cabbar F, Guler N, Comunoglu N, Sencift K, Cologlu
S. Determination of potential cellular proliferation in
the odontogenic epithelia of the dental follicle of the
asymptomatic impacted third molars. J Oral
Maxillofac Surg. 2008 Oct;66(10):2004-11.
4. Worrall SF, Riden K, Haskell R, Corrigan AM.
UKNational Third Molar project: the initial report.
Author Guidelines
Please note that we prefer case studies
& case review type article. We reserve
the right to reject articles without
assigning any reason.
Selection of articles will be the sole
discretion of the editorial board.
Unselected articles will not be returned.
Please send your brief bio-data &
passport size photograph along with the
article. Ideally the articles should be
approximately of about 1400 or above
words. We would prefer the article in
word format only. Also send the images
in high resolution i.e. Minimum 300 dpi
in JPEG Format.
Authors from India are requested to
send article by upload your article
British Journal of Oral and Maxillofacial Surgery.
1998; 36(1):14-18.
5. Daley TD. Third molar prophylactic extraction: a
review and analysis of the literature. General
Dentistry 1996; 44(4): 310-320.
6. Von Wowern N, Nielsen HO. The fate of impacted
lower third molars after the age of 20. A four-year
clinical follow-up. International Journal of Oral and
Maxillofacial Surgery 1989; 18(5): 277-280.
7. Vasir NS, Robinson RJ. The mandibular third molar
and late crowding of the mandibular incisors a
review British Journal of Orthodontics 1991; 18: 59-
66.
8. Mercier P, Precious D. Risks and benefits of removal
of impacted third molars. International Journal of
Oral and Maxillofacial Surgery 1992; 21: 17-27.
9. Song F, Landes DP, Glenny AM, Sheldon TA.
Prophylactic removal of impacted third molars: an
assessment of published reviews. British Dental
Journal. 1997; 182(9): 339-346.
10. Carmichael FA, McGowan DA. Incidence of nerve
damage following third molar removal: a review..
British Journal of Oral and Maxillofacial Surgery
1992; 30(2):78-82.
11. Evaluation and management of asymptomatic third
molars: Lack of symptoms does not equate to lack of
pathology Raymond P. White, Jr and William R.
Proffit American Journal of Orthodontics and
Dentofacial Orthopedics July 2011 Vol 140 Issue 1
through our website :
www.healtalkht.com
And also authors from India are
requested to send article on a CD along
with two printout on the below address :
The authors photographs & a brief
bio-data must accompany all the
articles.
Afzal A.
Managing Editor
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Faridabad (Haryana)
+91-9027637477
info@healtalkht.com,
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www.healtalkht.com
41
 Endodontic Management of Maxillary First Molar with
Four Roots & Five canals with the Aid of Cone-Beam
Computed Tomography Scanning : A Clinical Report
Dr. Amit Jena
Reader
Dept. of Conservative Dentistry & Endodontics , Institute of Dental Sciences, Siksha 'O' Anusandhan University, Bhubaneswar, Orissa.
Abstract
A n accurate diagnosis of the
morphology of the root canal
system is a prerequisite for
successful root canal treatment. A review of
the literature reveals a low incidence of four
roots with five canals in maxillary first molar.
The diagnostic and therapeutic problems
concerning molars with unusual anatomy are
described on the basis of clinical examples.
Diagnostic means such as preoperative
radiographs, examination of the pulp
chamber floor and spiral CT aid the location
of additional root canals and anatomical
variations. This case report describes the
unusual variation in roots and canal
morphology of maxillary first molar and use
of advanced adjuncts cone beam CT (CBCT)
in successfully diagnosing and negotiating
them, this report also describes the
management of separated instrument during
root canal preparation procedure in an
unusual root.
Key words: Maxillary first molar, Four
Roots, five root canals, Cone-Beam
Computed Tomography Scan (CBCT),
Broken instrument, Mesiopalatal Root.
Introduction
The possibility of additional roots and
root canals should be considered even in teeth
with a low frequency of abnormal root canal
anatomy. Maxillary first molar usually
represents three roots and three canals, along
with greater incidence of second mesiobuccal
canal between 18% and 96.1% 1,2. Several
studies revealed that the majority of these
teeth had three roots (96.2% of 416 teeth)3.
Martnez-Bern and Ruz-Badanelli (1983)
reported three cases of maxillary first molar
with six canals: three mesio-buccal, two
disto-buccal and one palatal roots. Adanir N
(2007) reported a clinical case having four
roots (mesiobuccal, mesiopalatal,
distobuccal, and palatal) and six canals with
one mesiobuccal, two mesiopalatal, two
distobuccal, and one palatal. Whereas,
Barbizam JV et al (2004) reported a clinical
case of five roots (2 palatal, two mesiobuccal
and one distobuccal). Maggiore et al (2002)
reported the maxillary first molar having six
canals with two mesiobuccal, three palatal,
and one distobuccal. Barotto Filho et al4
reported a maxillary first molar with three
roots and seven root canals.
During biomechanical preparation in an
unusual canal configuration, the potential for
instrument breakage is always present. The
consequences of leaving, versus removing
42
broken instruments from the canal have been
discussed in the literature and a variety of
approaches for managing these obstructions
have been presented. The ability to
nonsurgically access and remove a broken
instrument will be influenced by the diameter,
length and position of the obstruction within a
canal and also it depends on the anatomy,
including the diameter, length, thickness of
dentin, the depth of external concavities and
curvature of the canal5. There are three
possible outcomes that may be encountered
when treating these cases: (i) Retrieval, (ii)
Bypass and sealing the fragment within the
root canal space, (iii) True blockage.
The present case report discusses the
successful endodontic management of a
maxillary first molar presenting with four
roots (mesiobuccal, mesiopalatal, palatal and
distobuccal) and five root canals (one
mesiobuccal canal, two mesiopalatal canal
with one apical foramen {weine's type II
canal configuration}, one palatal and one
distobuccal canal) and managing the broken
instrument in one of the root (mesiopalatal).
This unusual morphology was confirmed
with the help of cone beam computerized
tomography (CBCT).
Case report
A 21-Year-old male patient presented
with a chief complaint of intermittent pain in
the posterior left maxillary region for past 3
week. His past medical history was non-
contributory. Clinical examination revealed a
deep dental caries with pulpal cavity
exposure in relation to left maxillary first
molar, which was tender on percussion. The
clinical findings, radiographic findings and
vitality tests led to a diagnosis of chronic
apical periodontitis, necessitating endodontic
therapy.
Radiographic evaluation of the involved
tooth did not indicate any variation in the
canal anatomy (Fig. 1). The involved tooth
was anesthetized using local anesthesia of 2%
lidocaine with 1:100,000 epinephrine
(Xylocaine; AstraZeneca Pharma Ind Ltd,
Bangalore, India.) followed by rubber dam
isolation. An endodontic access cavity was
established. Clinical examination with a DG-
16 endodontic explorer (Hu-Friedy, Chicago,
IL) revealed one canal opening in each of the
distobuccal, mesiobuccal, and palatal root.
On further examination and exploring the
pulp chamber, two orifices (MP1& MP2)
were noticed between the mesiobuccal and
palatal orifices. Coronal enlargement of the
canals was done with a nickel-titanium
Dr. Shashirekha .G
Reader
ProTaper series orifice shaper (Dentsply
Maillefer, Ballaigues, Switzerland) to
improve the straight-line access. The working
length was determined with the help of an
apex locator (Root ZX; Morita, Tokyo, Japan)
and later confirmed using a radiograph.
Multiple working length radiographs were
taken at different angulations. During
removal of the No 20 K file from the
mesiopalatal canal (MP2), the instrument got
separated (appoximayely 4mm) due to
presence of severely curved root apically.
Radiograph revealed presence of broken file
in middle third of the mesiopalatal root canal
(Fig 2). The radiographs did not clearly reveal
the number and morphology of root canal
systems. As to confirm this unusual
morphology, it was decided to perform CBCT
imaging of the tooth.
Access cavity was sealed with IRM
cement (Dentsply De Trey GmbH, Konstanz,
Germany). An informed consent was
obtained from the patient, and a multislice
CBCT scan of the maxilla was performed
with a tube voltage of 100 KV and a tube
current of 8 mA. The involved tooth was
focused, and the morphology was obtained in
transverse, axial, and sagittal sections of 0.5-
mm thickness. CBCT scan slices revealed
five canals (one mesiobuccal, two
mesiopalatal, one palatal, and one
distobuccal) (Fig 3) in the left maxillary first
molar and 3D imaging revealed 4 roots
(Mesiobuccal, Mesiopalatal, Distobuccal,
Palatal).
At the second appointment, the patient
was asymptomatic. After administering 1.8
mL (36 mg) 2% lignocaine with 1:200,000
epinephrine (Xylocaine), cleaning and
shaping was performed under rubber dam
isolation using ProTaper nickel-titanium
rotary instruments (Dentsply Maillefer) with
a crowndown technique. Irrigation was
performed using normal saline, 2.5% sodium
hypochlorite solution, and 17% EDTA; 2%
chlorhexidine digluconate was used as the
final irrigant. Multiple instrument removal
methods like IRS and Masseran instrument
removal system was implemented but it was
unsuccessful, only bypassing the instrument
was successful due to severe curvature in
apical third. The canals were dried with
absorbent points (Dentsply Maillefer), and
obturated with 0.06 taper (ProTaper gutta-
percha Dentsply), single cone obturation
technique followed by warm vertical
compaction with hand pluggers in the coronal
third of each canal. Resin sealer (AH plus,
Heal Talk | July-August 2012 | Volume 04 | Issue 06
 Jena, et al. : Endodontic Management of Maxillary First Molar with Four Roots & Five canals with the Aid of
Cone-Beam Computed Tomography Scanning A Clinical Report
Maillefer, Dentsply, Ballaigues,Switzerland)
was used (Fig 4). After completion of root
canal treatment, the tooth was restored with a
posterior composite filling (Ceram X mono
Dentsply). Full-coverage porcelain crown
was done after a week. The patient was
asymptomatic clinically and radiograpically
after 7 months (Fig 5).
Discussion
For a successful Endodontic treatment
clinicians should have a sound knowledge of
root canal morphology, application of
modern diagnostic tools like digital
radiography, dental microscope, spiral CT,
micro CT, and cone beam CT.
In the present case, the presence of fourth
root (mesiopalatal root) in the pre-operative
radiograph was not noticed in the preliminary
investigation of endodontic treatment due to
2-dimentional image of radiograph which
was later found with 3D imaging CBCT. The
K-file got separated during negotiating the
apical curvature in the mesiopalatal root, this
procedural error could have been prevented if
various preliminary diagnostic methods have
been implemented. The technique of by-
passing the instrument was opted to prevent
the potential complication of excess removal
of root dentin at the expense of removing the
instrument from the curved canal. Success
rate can be quite variable because removal of
fractured instrument is difficult and time
consuming5
As to overcome the drawback of
conventional and digital radiograph, an
Fig. 1 Fig. 2
Heal Talk | July-August 2012 | Volume 04 | Issue 06
alternative new type of imaging apparatus
cone beam CT system can be utilized for the
examination of smaller parts of the
dentomaxillofacial area. Literature revealed
that CBCT technology aids in the diagnosis of
endodontic pathosis, assessing root and
alveolar fractures, analysis of resorptive
lesion, identification of pathosis of
nonendodontic origin and pre surgical
assessment before root end surgery. The
major advantage of CBCT scanning over the
conventional CT-Scan are X-ray beam
limitation, rapid scan time, effective dose
reduction and high resolution 3D images and
the disadvantages are scattered radiation and
poor soft tissue visualization. The radiation
dose (45Sv and 650Sv) is high in
comparison with conventional intraoral
radiographs. The approximate dose for a full
mouth intra oral X ray examination using 21
analogue films is 150Sv. whilst an analogue
panoramic examination results in an
exposure of about 54Sv.6,7,8,9
Conclusion
A thorough knowledge of root canal
anatomy, application of modern diagnostic
tools (CBCT) and proper modification of the
conventional access opening are essential for
recognition and treatment of teeth with
anatomical variations. Application of proven
concepts, integrating best strategies and
utilizing safe techniques during root canal
preparation procedures in an aberrant root
anatomy will virtually eliminate the broken
instrument procedural accident.
Fig. 3 Fig. 4
References
1. Kulild JC, Peters DD. Incidence and configuration of
canal systems in the mesiobuccal root of maxillary
first and second molars. J Endod 1990;16:3117.
2. Buhrley LJ, Barrows MJ, BeGole EA, et al. Effect of
magnification on locating the MB2 canal in maxillary
molars. J Endod 2002;28:3247.
3. Blaine M. Cleghorn, DMD, MS, William H. Christie,
DMD, MS, FRCD(C), and Cecilia C.S. Dong, DMD,
BSc (Dent), MS, FRCD(C) Root and Root Canal
Morphology of the Human Permanent Maxillary
First Molar: A Literature Review JOE Volume 32,
Number 9, September 2006 813-821.
4. Baratto Filho F, Zaitter S, Haragushiku GA, et al.
Analysis of the internal anatomy of maxillary first
molars by using different methods. J Endod
2009;35:33742.
5. Shen Y, Peng B, Cheung GS. Factors associated with
the removal of fractured NiTi instruments from root
canal systems. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2004; 98: 60510.
6. Araki K, Maki K, Seki K et al. Characteristics of a
newly developed dentomaxillofacial X-ray cone
beam CT scanner (CB MercuRay): system
configuration and physical properties. Dento Maxillo
Facial Radiology2004: 33:519.
7. Tyndall DA, Rathore S. Cone-beam CT diagnostic
applications: caries, periodontal bone assessment,
and endodontic applications. Dent Clin North Am
2008:52:82541.
8. Ludlow JB, Davies-Ludlow LE, Brooks SL, et al.
Dosimetry of 3 CBCT devices for oral and
maxillofacial radiology: CB Mercuray, NewTom 3G
and i-CAT. Dentomaxillofac Radiol 2006;35:21926.
9. Mah JK, Danforth RA, Bumann A, et al. Radiation
absorbed in maxillofacial imaging with a new dental
computed tomography device. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2003;96:50813.
Legends
Figure 1: Preoperative radiograph of 26
Figure 2: Working length radiograph of 26
Figure 3: CBCT Scanning axial Image 26
Figure 4: Post-obutration Radiograph of 26.
Figure 5: Radiograph after 7months of 26.
Fig. 5
43
 International Congress of Oral Implantology Organized
A Continuing Dental Education
n
re ope
o ns a
dmissi
A

I nternational congress of oral

Implantology organized a
continuing dental education
programme in Delhi from their Learn
from the Master Series on Current trends
in Implantology and Bone augmentation
on 12th August 2012 at NSCI Club Delhi,
conducted by North Delhi Academy of
Continuing Dental Education along with
Lifecare.
The programme was a preview lecture
on Basic and Advanced Implantology
course, which will be starting soon in
Delhi, and since the companies have no
influence on the contents of the programme
or the course, it remains an independent
and scientifically neutral programme.
The programme was mentored by Dr.
Dilip Deshpande, leading Prosthodontist
and Implantologist, practicing in Mumbai.
He talked about the scope of Implantology,
case assessments, and stressed on a proper
diagnosis and treatment planning of cases
and that can lead you to a successful
implant practice. He even showed various
methods of bone augmentation, and the
latest procedure of using PRF and an
overview on sinus lift procedures. The
lecture was followed by hands on practice
on models of implant placement and
indirect sinus lift procedure.
The programme was a attended by
leading practioners of Delhi NCR, H.O.Ds
from the Department of Periodontics,
Prosthodontics and Oral Surgery of various
colleges of Delhi NCR and also post
graduate students. It was well appreciated
by one and all.

North Delhi Dental Academy

For more information contact

ic Dr. Meenu Bhasin

Bas olgy
mp lant gins +91-9871044433
I e
urse b ...
Co soon Dr. Prashant Bhasin
+91-9971615587.

44 Heal Talk | July-August 2012 | Volume 04 | Issue 06

 The Phoenix Pontic : A Review Article
Dr. Rahul P. Ganani
P.G. Student (Prosthodontic)
M ere replacement of the tooth
does not serve the purpose of
high esthetic outcome.
Advances in the field of restorative materials
allow a lost tooth to be replaced by an
artificial tooth structure that is virtually
indiscernible from the original. However, in
fixed partial dentures, the standards for the
pontic area and the adjacent soft tissue have
increased in particular. One of the most
challenging issues in a dental treatment plan
is to preserve interproximal tissue after the
loss of tooth, which is most detrimental in the
esthetic outcome of the case. The loss of an
anterior tooth is a severe emotional trauma to
the patient and if the replacement does not
simulate the natural tooth, the effect is
multifold. The ovate pontic is a technique
used to create the illusion that the tooth is
growing out of the gum, it can also help to
create or maintain the presence of interdental
papilla, plus an ovate pontic contour has an
effective design for cleansibility. Unfortu-
nately, an ovate pontic design is not usually
utilized by clinicians, as it is a technique
sensitive. In this paper i am going to throw
light on various easy approaches for desirable
ovate pontic.
Pontics of fixed partial dentures (FPDs)
have to fulfill esthetic, mechanical,
functional, and hygienic demands in
restorative dentistry. For years, a controversy
exists regarding the pontic surface facing the
tissue. With use of the full ridge lap pontic,
alveolar ridge deficiencies were
accommodated, but oral hygiene was difficult
because of the concave pontic design. The
modified ridge lap pontic and the sanitary
pontic were introduced to minimize or even
avoid any contact between the pontic and the
mucosa. An ovate pontic was
recommended to fulfill esthetic and
functional requirements. The convex design
of this pontic was intended to form a concave
soft tissue outline in the site of the alveolar
ridge mucosa.
Term ovate pontic was first coined by
Dewey and Zugsmith in 1933, but only
recently considered a clinical alternative for
optimal esthetics, their studies were only
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Dr. Gaurang Mistry
Professor, Dept. of Prosthodontics
Dr. D.Y. Patil Dental College, Navi Mumbai
restricted to an extraction site and modified
by other investigators to include the other
edentulous ridge. Earlier in year 1928
Reichenbach contradicted the idea of
inserting porcelain pontics should not be
extended in post extractions sites. Later with
the help of histological section Dewey and
Zugsmith concluded that there is no reason
for rejection of this method which owing to
the absence of recession of gingival tissues
and bone resorption has special esthetics and
hygienic advantages.
Classification of Pontics
According to contact with mucosa
A. Mucosal Contact
1) Saddle
2) Ridge Lap
3) Modified Ridge Lap
4) Conical
5) Ovate
B. No Mucosal Contact
1) Sanitary (Hygienic or perel pontic)
2) Modified Sanitary (Hygienic)
C. According to Material Used
1. All metal
2. Metal Procelain
3. Metal Resin
4. All Resin
5. Facings
Different types of Anterior pontics
commonly used are :
Fig 1.1
a) Ridge lap
b) Modified ridge lap
c) Ovate pontic
Ovate pontic is defined as : A Pontic that
is shaped on its tissue surface like an egg in
two dimensions, typically partially
submerged in a surgically-prepared soft-
tissue depression to enhance the illusion that a
natural tooth is emerging from the gingival
tissues (GPT).
Dr. Omkar Shetty
HOD Prosthodontics
Ovate pontic Was developed by Abrams
in 1980. It has number of advantages compare
to pontics having concave tissue surface like
ridge lap and modified ridge lap. They carry
convex tissue surface, easier to clean and give
an emerging profile. In case of economical
consideration of patient, or when edentulous
site is not healthy enough to receive an
implant, ovate pontic is first choice of dentist.
The ovate pontic is the most esthetically
appealing pontic design. Its convex tissue
surface resides in a soft tissue depression or
hollow in the residual ridge, which makes it
appear that a tooth is literally emerging from
the gingival. Careful treatment planning is
necessary for successful results.With time
various modifications and changes in
preparation of recipient site are accepted by
dentist.
1. Socket Preservation Technique
In this technique , immediately after a
traumatic extraction, tooth preparation of
abutments is done and provisional's are given
extending 2 to 3 mm inside pontic site for 3 to
4 weeks which eventually replaced by
permanent restoration
Fig 2.1 Fig 2.2
Fig 2.3 Fig 2.4
2. S o f t T i s s u e R e s i d u a l R i d g e
Augmentation
This technique is usually followed when
pontic site is edentulous for longer time.
Gingivoplasty and alveoplasty is done using
long torpedo bur under anesthetia. Followed
by preparation of abutments then provi-
sionals are given extending 2 to 3 mm inside
pontic site n replaced by finals after 3 to 4
weeks.
45
46 Heal Talk | July-August 2012 | Volume 04 | Issue 06

Fig 3.1 Fig 3.2
Fig 3.3 Fig 3.4
Fig 3.5 Fig 3.6
3. Soft Tissue Residual Augmentation
using Laser
This technique is follows same principal
as above, except the armamentarium used ie.,
instead of rotary instruments , soft and hard
tissue lasers are used.
Fig 4.1 Fig 4.2
Fig 4.3 Fig 4.4
Disadvantages of Ovate Pontic
I. Cleaning the pontic is difficult
II. More of ridge augmentation required
III. Cannot be indicated in knife edge ridges
Modified Ovate Pontic
Modified pontic was coined by Liu in
2003 . The modified ovate pontic design was
developed to circumvent the problems
encountered with the ovate pontic. The
modification of the ovate pontic involves
moving the height of contour at the tissue
surface from the center of the base to a more
labial position. The modified ovate pontic
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Ganani, et al. : The Phoenix Pontic : A Review Article
examination of 35 patients to evaluate the securing ol'
with the replacement of porcelain roots. Dent Cosmos
i926.
10. Loos O, G1055 H. Dental oral treatment. D Zahnarzt!
Wchschr 1933; 36:3?l.
11. Certosimo F1, BK, Nelson RR, Wolfgang M. Would
healing and repair: a review of the acc and science.
Gen Dent i998:46:3629.
12. Dawson PE. Evaluation. diagnosis and treatment of
occlusal problems. 2nd ed. St Louis: CV Mosby;
1989. p.
Fig 5.1 Ovate pontic Fig 5.2 Modified
Ovate Pontic
does not require as much faciolingual
thickness to create an emergence profile. It is
much easier to clean compared with the ovate
pontic owing to the less convex design. Its
major advantage over the ovate type is that
often there is little or no need for surgical
augmentation of the ridge.
Advantages
I. Excellent esthetics because it produce
exact emergence profile
II. Fulfill functional requirement
III. Greater ease for cleaning
IV. Effective air seal
V. Appearance of free gingival margin
VI. Minimizes the black triangle in between
teeth Coming soon...in...Updent
VII. Little or no ridge augmentation
Conclusion
Within the limitations of this study, a
clinically healthy mucosa was maintained
with an ovate pontic designed restoration,
providing that the contact to the mucosa was
tight but noncompressive and the infrapontic
area was regularly cleaned
Reference
1. Miller MB. Aesthetic anterior reconstruction using a
combined periodontal approach.
2. Winter RR. Esthetic pontics.
3. Garber DA, Rosenberg ES. edentulous ridge 'in fixed
prosthodontics.
4. Johnson GKE Leary JM. Pomic design and localized
ridge augmentation in fixed partial denture design.
Dent Clin North Am 1992;36:59T-605.
5. Stein RS. Pomicresidual ridge relationship: a
research report.Dent 1966;'| 62251-85.
6. Dewey KW, Zugsmith R. An experimental study of
tissue reaclions about porcelain roots. I Dent Res
1933;l3:459-72.
7. Reichenbaach E. Examination of a suitable arranging
of bridge pontics.
8. Irving Aj. A consideration of modern methods for
supplying missing teeth with fixed bridgework. Dent
Cosmos 192B;70:191-B.
9. Brill E. The surgical securing of prosthesis. Dentist
47
 Conservative Management of Teeth with an Open Apex
Dr. Raghavendra Ainapur
Asst Professor
Dept. of Conservative
Dentistry & Endodontics
S.D.M. College of Dental Science
& Hospital, Dharwad-580009.
Abstract
A
veneering.
im: To present a case of
immature tooth which was
obturated with MTA and
discoloration treated by direct composite
Summary: A discolored upper left
central incisor was subjected to radiographic
examination revealing an open apex and a
periapicalradioluscency. The canal was
cleaned using K-files and 5.25% of NaOCl
irrigation. The canal was disinfected with
slurry of calcium hydroxide repeated two
times at the interval of 1 week. After two
weeks the canal was obturated with MTA and
remainder of canal was filled with glass-
ionomer cement. The discoloration was
treated with direct composite veneering. A
six-month follow up demonstrated clinically
asymptomatic and adequately functional
tooth, with radiographic signs of healing.
Keywords: Immature tooth, MTA,
Direct composite veneering.
Introduction
Conventional root canal filling
techniques rely on the presence of a
constriction at the apical level of the canal;
therefore, the absence of the apical
constriction because of incomplete root
development, aggressive apical resorption, or
i a t r o g e n i c e n l a rg e m e n t p r e s e n t s a
management challenge. Placement of the root
filling in a canal with an open apical foramen
carries the risk of root filling material
extrusion1, 2.
Of the options currently available for the
management of root canals with an open
apex, the use of calcium hydroxide dressing
to induce an apical hard tissue barrier
(apexification) has gained the widest
acceptance. This procedure normally requires
several visits to the dentist over a period of 5
to 20 months3. This approach requires
temporary restoration to be paced for long
period of time which may result in
microleakage and also long term Calcium
hydroxide may alter the mechanical
properties of dentin4, 5, 6.
A one step apexification procedure
eliminatesthese problems. It implies the non-
surgicalcompaction of a biocompatible
material into theapical end of the root canal,
thus, creating an apicalstop and enabling
immediate filling of the rootcanal7.
An alternative to apexification with
calcium hydroxide is to seal the open apical
foramen with a mineral trioxide aggregate
(MTA) apical plug8. This procedure can be
completed in oneor two treatment sessions,
making it possible to restore the tooth within a
Heal Talk | July-August 2012 | Volume 04 | Issue 06
Dr. Srinidhi .V.B Dr. Prashant Bhasin
Asst. Professor, Reader
Dept. of Conservative Dept. of Conservative
Dentistry & Endodontics Dentistry & Endodontics
St. Joseph Dental College Santosh Dental College
Eluru Ghaziabad
short timeframe while avoiding reliance on
patient compliance and prolonged exposure
of root dentin to calcium hydroxide9,
10
.Clinical studies have reported that 77% to
85% of teeth with open apices healed
completely 1 to 3 years after the placement of
MTA apical plugs.
MTA has been described as a good
materialfor this procedure owing to its good
canal sealingproperty, biocompatibility and
ability to promotedental pulp and
periradicular tissue regeneration11, 12, 13.
Recently, MTA has been used as an
obturating material in cases of apexification,
dens in dente, before surgery, and in internal
resorption cases14.
This report demonstrates a tooth with
open apex and discoloration which was
treated by MTA obturation and direct
composite veneering.
Case Report
A 32 year old female presented to the
department of conservative dentistry and
endodonticsin the St Joseph dental college,
Eluru, with discolored upper left central
incisor. The patient gave history of trauma
when she was 10 year old. The treatment was
not taken as the tooth was asymptomatic.
When patient was about 18 years old she
underwent orthodontic treatment for the
malocclusion. The tooth showed evidence of
color change during the course of treatment.
Once treatment was finished sinus opening
was noted with relation to upper left incisor.
She consulted dentist for which medication
was prescribed and patient didn't went for
further treatment as sinus opening resolved.
The episode of sinus opening and resolving
occurred for quite number of time. Then
finally she visited our college where detail
history was taken. Clinical and radiographic
examination revealed a discolored tooth 21,
sinus tract over the attached gingiva, wide
open apex and periapically radiolucent area
(Fig.1).
A diagnosisof immature nonvital tooth
with periapicalradioluscency was made. A
one step apexification preceded by
canaldisinfection for two weeks with calcium
hydroxide followed by composite veneering
was planned for this tooth.
After application of rubber dam and
accesscavity preparation, working length was
obtained.At this stage, the number 80 file was
found looseand easily passing beyond the
apical limit of thecanal. The working length
was determined by apex locator (Root ZX, J
Morita corporation, Kyoto, Japan) and
subsequently confirmed by radiograph. The
canal was thoroughly cleaned usingintracanal
Dr. Priya Horathi
Professor & HOD.
Dept. of General Dentistry
S.D.M. College of Dental
Science & Hospital
Dharwad-580009
instruments and 5.25% hypochlori-
teirrigation. To obtain canal disinfection prior
to MTAplacement, a slurry of calcium
hydroxide mixedwith Metrohexwas applied
twice within an interval of two weeks
andtemporized. After two weeks sinus tract
disappeared and placement of MTA was
decided.
The white MTA(ProRoot, Dentsply,
Tulsa, OK) was mixed to a pasteconsistency
with sterile water and delivered to thecanal
using an amalgam carrier in about
3mmthickness. Cotton was wrapped onto a
80 K-file, moistened and used as a plugger to
condense the MTA apically. MTA can also be
used as aobturating material. So it was
decided to fill the canal with MTA upto
middle third. A moist cotton pellet wassealed
inside forsetting of MTA. Patient was recalled
after two days and the hard set of MTA was
confirmed and remained of canal was filled
with glass ionomer cement followed by
composite resin to reinforce and to obtain
better seal.
Patient returned after 1 week requesting
treatment for the discolored tooth. Treatment
alternatives and cost was explained and
patient opted for composite veneering. Shade
selection was done taking left lateral incisor
as reference. A uniform reduction of 0.5 to 1
mm was done. The tooth was slightly placed
labially so reduction was done accordingly.
The preparation was etched with 37%
orthophosphoric acid for 15 seconds, and was
thoroughly rinsed with air and water leaving
moist for wetbonding adhesion. Bonding
agent was applied to the water-moistened
preparation.excess solvent was blowed off
with a one second blast of air. Light curing
was done for 10 seconds. Composite resin
was applied incrementally and cured for 20
seconds. Finishing and polishing was done to
provide contour and proper texture to the
restoration.
Discussion
There are many ways of treating a tooth
with an immature apex. These include
apexogenesis, apexification, apical plug,
conventional root canal treatment with tailor-
made gutta-percha, surgery15. Apexogenesis
can be followed only when the inflammation
is limited to coronal pulp and is carried out by
performing pulpotomy16.
Apexification with calcium hydroxide
has been the traditional method followed.
However, the technique has some
disadvantages. The primary disadvantage is
that it typically takes between 6 and 18
months for the body to form the hard tissue
barrier. The patient needs to reportevery 3
49
 Ainapur, et al. : Conservative Management of Teeth with an Open Apex
months to evaluate whether the calcium
hydroxide has washed out and/or thebarrier is
complete enough to provide a stop to a filling
material. This requires patientcompliance for
up to 6 visits before the procedure is
completed. It has also beenshown that the use
of calcium hydroxide weakens the resistance
of the dentin to fracture. Thus it is common
for the patient to sustain another injury and
also fracture theroot before the hard tissue
barrier is formed4. The barrier produced by
calcium hydroxide apexification has been
reported to beincomplete having swiss cheese
appearance, andcan allow apical
microleakage17. The use of calcium hydroxide
apical barriers has also been associated with
unpredictability of apical closure, risks of re-
infection resulting from the difficulty in
creating long term seals with provisional
restorations18.
Pulp revascularization remains a good
treatment option for such cases but the patient
was not agreeable to the time constraints. So,
one step apexification with MTA was decided
for this case.
Recenty MTA was used as an alternative
to gutta-percha14. The reported advantage of
using MTA as an obturating material include
superior sealabilityagainst bacterial
microleakage, demonstrates antibacterial and
bioinductive properties that can improve
treatment outcomes. Furthermore, the
material is sterile, radiopaque, resistant to
moisture, and nonshrinking and stimulates
mechanisms responsible for the
bioremineralization and resolution of
periapical disease. Hence it was thought to
obturate the root canal with MTA upto middle
third of the canal.
MTA consists of fine hydrophilic
particles that set in the presence of moisture in
approximately 4 hours19. In this case final
obturation was carried out at a subsequent
8.
visit to enable setting of MTA.A moist cotton
pellet was left over the MTA to facilitate
setting. 9.
Studies have shown that intracoronal
bonded restorations can internally strengthen
endodontically treated teeth and increase 10.
their resistance to fracture20, 21.Since the canal
was wide at the coronal and middle third, 11.
glass ionomer was placed with ease in
remainder of the canal.
12.
Among the different approaches for the
management of discolored teeth, composite
veneering was selected as a temporary mode 13.
of treatment since the patient was placed
under observation to evaluate the healing.
14.
Conclusion
MTA has numerous applications in
endodontic therapy that range from 15.
apexification to pulpotomy. The primary 16.
advantages of this material include 17.
development of proper apical seal and
excellent biocompatibility.The use of MTA as 18.
an obturating material along with composite
veneering showed a positive initial clinical 19.
outcome for the immature tooth. Long term
follow up is necessary to ensure success.
References 20.
1. Ritchie GM, Anderson DM, Sakumura JS. Apical
extrusion of thermoplasticized Gutta-percha used as a
root canal filling. J Endod 1988;14:12832. 21.
2. Sjogren U, Hagglund B, Sundqvist G, et al. Factors
affecting the long-term results of endodontic treatment. J
Endod 1990;16:498504.
3. Rafter M. Apexification: a review. Dent Traumatol
Legends
2005;21:18. Fig. 1
4. Andreasen JO, Farik B, Munksgaard EC. Long-term Fig. 2
calcium hydroxide as a rootcanal dressing may increase Fig. 3
risk of root fracture. Dent Traumatol 2002;18:1347.
5. Rosenberg B, Murray PE, Namerow K. The effect of Fig. 4
calcium hydroxide root filling ondentin fracture strength.
Dent Traumatol 2007;23:269. Fig. 5
6. Pace R, Giuliani V, Pini Prato L, Baccetti T, Pagavino G. Fig. 6
Apical plug technique using mineral trioxide aggregate:
results from a case series. IntEndod J 2007; 40:478 84. Fig. 7
7. Steinig TH, Regan JD, Gutmann JL. The use and
predictableplacement of Mineral Trioxide Aggregate in
one-visitapexificationcases.AustEndod J. 2003
Apr;29(1):34-42
Holden DT, Schwartz SA, Kirkpatrick TC, et al. Clinical
outcomes of artificial rootendbarriers with mineral
trioxide aggregate in teeth with immature apices. J
Endod2008;34:8127.
Sarris S, Tahmassebi JF, Duggal MS, et al. A clinical
evaluation of mineral trioxideaggregate for root-end
closure of non-vital immature permanent incisors in
children-a pilot study. Dent Traumatol 2008;24:7985.
Witherspoon DE, Small JC, Regan JD, et al.
Retrospective analysis of open apex teethobturated with
mineral trioxide aggregate. J Endod 2008;34:11716.
Torabinejad M, Watson TF, Pitt FTR . The sealing ability
of a mineral trioxide aggregate as a retrograde root filling
material J Endodon 1993 ; 19:591 5
Torabinejad M, ChivianN . Clinical applications of
mineral trioxide aggregate . J Endodon 1999 ; 25 : 197
205
Simon, F. Rilliard, A. Berdal& P. Machtou. (2007) The
use of mineral trioxide aggregate in one-visit
apexification treatment: a prospective study.
International Endodontic Journal 40:3, 186197
George Bogen, Sergio Kuttler. Mineral Trioxide
Aggregate Obturation: A Review and CaseSeries.
JEndodon, 2009; 35, 770-790.
K. J . Ramesh, Srinidhi, Ravi kumar, Ch. N. Murali
Krishna
Principles and practice of endodontics Torabinejad
Martin Trope. Treatment of theImmature Tooth witha
NonVital Pulp andApical Periodontitis. Dent Clin N Am
54 (2010) 313324.
El-Meligy OA, Avery DR. Comparison of apexification
with mineral trioxide aggregateand calcium hydroxide.
Pediatr Dent 2006;28:248 53
Torabinejad M, Pitt Ford TR, McKendry DJ, Abedi HR,
Miller DA, KariyawasamSP. Histologic assessment of
mineral trioxide aggregate as a rootendfilling in monkeys.
J Endod. 1997; 23(4): 2258.
Katebzadeh N, Dalton BC, Trope M. Strengthening
immature teeth during and after apexification. J Endod
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Goldberg F, Kaplan A, Roitman M, et al. Reinforcing
effect of a resin glassionomer in the restoration of
immature roots in vitro. Dent Traumatol 2002;18:70.
Pre-operative radiograph
Working length determination
Radiograph showing MTA obturation up to
middle third.
Backfilling the remainder of the canal with
glass-ionomer cements.
Discolored left central incisor
Tooth preparation for direct composite
veneering
After direct composite veneering

Fig. 1 Fig. 2 Fig. 3 Fig. 4

Fig. 5 Fig. 6 Fig. 7

50 Heal Talk | July-August 2012 | Volume 04 | Issue 06