SMILE-Journal of IDA Central Kerala Kottayam Branch

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					SMILE - Vol. 12, Issue 1, Jan. - March 2012   1
SMILE - Vol. 12, Issue 1, Jan. - March 2012   2
                                                                                        Smile Kottayam Dental Journal
                                                                                        Vol. 12 | Issue 1 | Jan. - March. 2012
                                  Dr.ANIL KURIAN

                                  Representatives to State
                                  Dr. ANTONY P.G.
                                  Dr. CHERIN JOHN
                                  Dr. ROBIN THERUVIL
                                  Dr. PRAVEEN THAYIL

                                  Exe. Committee Members
                                  Dr. AUGUSTINE J.C.
                                  Dr. LINU M. NINAN
                                  Dr. GEORGE ANTONY
                                  Dr. GEORGE CHERIAN
                                  Dr. ITTYVIRAH BABU

                                  Members Welfare Fund
                                  Dr. RAJAN JOHN

                                  Dr. CHERIN JOHN

     OFFICE BEARERS OF                                                                EDITORIAL BOARD
                                  Family Meet
                                  Dr. MATHEW V JOSEPH
                  President                                                                    Dr Anil Kurian
             Dr. ABY JOSE         Image
                                  Dr. RAJESH KRISHNAN NAIR                                    ADVISORS
               Hon.Secretary                                                             Dr Mathew Joseph Vayalil
        Dr. JOHN REJU PHILIP      Membership                                               Dr George Varghese
                                  Dr.NITHIN JOSEPH                                          Dr Baby K Antony
            President Elect
                                                                                             Dr Rajan John
                                  Sports & Cultural
                                  Dr. TIMMY GEORGE
                       I.P.P                                              ORAL & Maxillofacial            Prosthodontics
             Dr. ANTONY P.G.                                                           Surgery            Dr Abraham Scaria
                                  Web-Site & Promotions
                                                                                 Dr PG Antony             Dr Anil Kumar
         1st Vice President       Dr. VISHY TOM                               Dr Eapen Thomas
                                  PRO & Communications                                Periodontics        Community Dentistry
          2nd Vice President      Dr. NIDHISH MOULANA                              Dr Jose Richard        Dr Praveen Thayil
          Dr. GEOGI CHERIAN
                                                                                  Dr Jacob George
                                  IDA Women’s Wing
              Dr. ANUKESH P
                                  Dr. SHINY ANTONY RAUF                               Orthodontics        Oral Medicine
                                                                                       Dr Aby Jose        Dr Sreela
              Joint Secretary                                                             Dr Tony
              Dr.RENJU TITUS
                                                                                     Endodontics          Legal affairs
                                  Editor for Contact:-                          Dr Robin Theruvil         Dr Cherin John
              Asst. Secretary
                                  Dept. of Oral Pathology
        Dr. RENJITH GEORGE                                                         Dr Baby James
                                  Pushpagiri College of Dental
              CDH Convenor        Medicity, Perumthuruthy P.O.
                                                                                      Pedodontics         General affairs
             Dr. JINU MOHAN       Thiruvalla                                        Dr Raju Sunny         Dr Augustine Cherukara
                                  Mob : 9495220216                                                        Dr John Reju Philip
             CDE Convenor         Email :               Oral Pathology          Dr Rajesh Krishna
            Dr. RAJU SUNNY                     Dr Alex K Varghese

    Edited by: Dr. Anil Kurian, Editor | Published by : Dr. John Reju Philip, Hon. Secretary | For IDA Centre Kerala Kottayam Branch
                                                  Production :
                            GUIDELINES FOR AUTHORS
1.   SMILE is the quarterly journal of IDA Central Kerala        11. References: should be in Vancouver style.
     Kottayam Branch.
                                                                 12. Submission –
2.   All manuscripts that are sent to SMILE for                      a. First page file – should contain covering letter,
     consideration are to be prepared in accordance with                title page, and acknowledgement (if any).
     “Uniform Requirements for Manuscripts Submitted
                                                                      b. Article file – should contain abstract, key words,
     to Biomedical Journal” developed by International
                                                                         main text, and references.
     Committee of Medical Journal Editors, updated April
     2010 (Ref:                  c.    Images and tables – good qualities images (jpeg,
     These requirements and specific requirements are                       tiff, gif formats) with their legends and tables are
     summarised below.                                                      to be send separately.
3.   Article/ manuscripts – the article/ manuscripts can         13. All clinical trials should have clearance from Ethical
     be of any aspect related to dental sciences in the              Committees and/ or institutional review boards (IRB).
     form of original research, case reports, review             14. Photographs of patients should have prior written
     articles etc. Authors have to specify the category of           permission and masking of eyes is to be done wherever
     their article.                                                  necessary. Colour photographs will be published as
4.   Author(s) – person(s) who have made substantive                 per availability of funds or at the expense of the
     intellectual contributions to a published study and             authors (authors may have to bear the printing costs
     biomedical authorship continues to have important               for colour photographs) and is under the discretion
     academic, social, and financial implications.                   of the editorial board.
5.   Corresponding author – one of the authors is to be          15. Conflict-of-interest - It is the responsibility of the
     assigned as corresponding author and all                        authors to disclose any financial and personal
     correspondence from SMILE will be sent to the                   relationship that may bias their work. They have to
     address/email id/phone number/fax number                        state explicitly whether a conflict-of-interest do or
     provided by him for the purpose.                                do not exist.
6.   Submission of the article – the articles can be typed       16. Copy Rights – Submission of manuscripts implied that
     in Microsoft word 2003/2007 or Adobe PageMaker 7                the work described has not been published before
     (PDF files not accepted, original source files are              (except in the form of an abstract or as a part of
     required) and can be emailed as attachment to                   published lecturers, review, or thesis) and is not as follows......                      under the consideration for publication elsewhere
                                                                     and if accepted for publication in SMILE, the same
7.   Title page – it should include the running title, name,
                                                                     article should not be reproduced elsewhere without
     address, designation, degrees and the contributions
                                                                     the permission of the copy right holders.
     of each authors and complete mailing address, email
     id, telephone and fax number of the corresponding           17. Disclaimer – The views/opinions expressed by the
     author.                                                         authors are their own. The editors and publisher can
                                                                     accept no responsibility for any errors, omissions,
8.   Abstract - Abstract should not be more than 150
                                                                     or opinions expressed by the authors. The journal is
     words, concise and clear and can be structured in to
                                                                     edited and published under the directions of the
     following headings as: Objective(s), Study Design,
                                                                     editorial board that reserves rights to reject any
     Results, and Conclusion.
                                                                     material without giving explanations. No
9.    Key Words : should be representative of the entire             responsibility will be taken for undelivered issues
     article and to be included under the abstract                   due to circumstances beyond the control of the
                                                                     publishers. All legal responsibilities of the published
10. Text: text of articles should be in IMRAD format
                                                                     articles rest with the respective authors themselves.
    (Introduction, Materials& Methods, Results, and
    Discussion). Authors can use a different format if it
    is essential in that particular case.

                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                                         4
Smile Kottayam Dental Journal

Vol. 12 | Issue 1 | Jan. - March 2012

Dr. Anil Kurian .................................................................................................................................................................... 6

Dr. M. Raveendranath ..................................................................................................................................................... 7

President’s Message
Dr. Aby Jose ..................................................................................................................................................................... 8

Dr. Sudheesh M | Dr. Bobby John | Dr. Antony PG | Dr. Lekshmi M ............................................................................ 9

Dr. Shalini Nair | Dr. Anuja Mathews | Dr Alex K Varghese .......................................................................................... 14

ASK THE SPECIALIST .......................................................................................................................................................... 16

Dr. Ankit Sharma | Dr. Yogesh Mittal | Dr. Shashank Uniyal | Dr. Lylajam S. .............................................................. 17

Dr. Shashank Uniyal | Dr Ankit Sharma | Dr. Lylajam S. ............................................................................................. 19

TRUE AND SCARY INCIDENCES IN DENTAL PRACTICES ...................................................................................................... 23

Dr Eapen Cherian, MDS | Jose Kurian ......................................................................................................................... 24

BOOK REVIEW ................................................................................................................................................................. 28

Dr. J. Vengatesh Kumar | Dr. S. Anil Kumar | Dr. Antony PG ........................................................................................ 29

Dr Anil Kurian | Dr Anuja Mathews | Reeja Susan Thomas | Remya M .................................................................... 32

                                                               SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                                           5

History Sustained !!!!!!. Another exhilarating IDA year ends, with full of national and
state awards.

Despite his busy schedules and commitments the ever enthusiastic Dr Antony PG along
with equally energetic Secretary, Dr Reju Philip, bagged every awards they can get. He
took the pride of IDA CKK to heights beyond and now, passing a huge responsibility to Dr
Aby Jose. But Dr Aby have proved himself, as an award winning secretary before. We are
looking forward to another exuberant IDA year with lot of fun and action.

SMILE kept its smile once again – National level best local branch journal for seventh
time and runner up state award. Kudos!!! to Dr Raju Sunny and his team.

I have a couple of announcements to be made.

SMILE has obtained ISSN number (2250-3315), and it will be displayed on the top right
hand side of the cover page.

Now SMILE is available internationally!!!      The online version is available at http://

The journal has kept its high quality since its first issue onwards. Now being international
and looking forward for indexing, we cannot compromise on quality. All the articles sent
to SMILE will be peer reviewed by the specialists in the respective field before coming to
print. An advanced apology for the authors whose articles are rejected by the editorial
board. I humbly request you to take rejection as an opportunity to improve and pray that
it should not deter you from sending further articles to SMILE.

Finally a note of thanks to Dr Augustine Cherukara and Dr Antony PG who helped a lot to
find funds for this release.

Please keep on writing to us. Keep on sharing your knowledge, experience, opinions,
views etc with your fellow beings, through this platform – SMILE.

With prayers to God Almighty,

                                                               Dr Anil Kurian
                                                           Mob: 919495220216

                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                  6
State President’s Desk

             State President’s Desk

             I am happy to learn that IDA Central Kerala Kottayam Branch is bringing out the first
             issue of its journal SMILE in the first month of the IDA Year itself. Central Kerala
             Kottayam Branch is the leader in IDA Activities for the last many years and is recognized
             well by the State and National IDA. The swiftness in action shows the dedication of the
             organizers and keenness of its members. I would like to remind all the members that
             a powerful IDA is the need of the hour to combat the challenges to our profession and
             hope the journal SMILE will do its share to achieve the objectives.

             Wish you all the best and a perfect IDA Year ahead

                                                           Thanking You,

                                                                   President-IDA Kerala

                     SMILE - Vol. 12, Issue 1, Jan. - March 2012                                    7
                                                                                        President’s Desk

Dear colleagues

                                   Warm greetings

Writing is one of the distinctive features of human civilization like speech. Akin to
others who write, we dentists involved in clinical practice or research need to write in
order to document our observations and accomplishments. Dentists in general may
not be members of an elite literati but it is a great advantage to be able to write
clearly, succinctly and effectively. Research and clinical studies even if outstanding,
are incomplete, until they have been published. The published work paves the way for
additional opinons, criticisms, refutations and discussion from professional
colleagues. Dental practice is after all a knowledge based profession. The temperament
to document, contribute, read and analyze an article in a journal will make us better
dentist. I salute the past editors for their dedication and effort they have put in
publishing our journal.

These are changing times for our profession, changing values and ethical standards
in our practice, entry of corporate into dental practice threatening our very livelihood.
Dear colleagues let us stand together and take our beloved profession to greater

                                              Yours in IDA,
                                                            Dr Aby Jose
                                                    IDA Central Kerala Kottayam

                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                  8
Case Report
Mandibular reconstruction with fibula free flap

Dr. Sudheesh M                                Dr. Bobby John                             Dr. Antony PG                               Dr. Lekshmi M
Final year P.G student, Dept. of          Assistant professor, Dept. of           Assistant Professor Department of    Assistant Professor, Dept. of Plasic
Oral and Maxillofacial Surgery,        Oral and Maxillofacial Surgery, Govt.       Oral & Maxillofacial Surgery GDC,       Surgery, Govt. Medical College,
Govt. Dental College, Kottayam               Dental College, Kottayam                      Kottayam, Kerala                                     Kottayam

                                   A dramatic improvement in aesthetics and neurological function has been
                                   obtained in patients with acquired skull defects after cranioplasty using
                                   titanium plates. Cranioplasty is surgical repair of a defect or deformity of
                                   a skull. It can be described as a procedure not only for anatomical
                                   reconstruction and aesthetic purposes but also for neurological improvement.
                                   In the following case reports two cases of Neuro-prosthetic rehabilitation of
                                   acquired skull defects following pathology of skull bones which were removed
                                   surgically and the resulted skull defects were recorded through conventional
                                   impression technique and reconstructed using Titanium plates.

                                   Key Words
                                   skull defects, conventional technique, Titanium plate

INTRODUCTION                                                                       We report a case of mandibular reconstruction using
    Reconstruction of the mandible has been a surgical                         fibula free flap in a 35 year old lady following segmental
challenge due to the significant complexity of function                        resection for ameloblastoma of mandible.
and esthetics. The advent of microvascular surgery has
catapulted the reconstruction of complex head and neck                         CASE REPORT
defects to a single stage reconstruction. This technique                           A 34 year old lady reported with a hard, non tender
allows for larger resections and reconstruction, which                         diffuse swelling of size 3x2 cm size approximately over
allows patients to return to normal function in a much                         the right body of mandible of six months duration (Fig.
shorter period when compared with multistage local,                            1a). There was no invasion into the skin or overlying
regional pedicled flaps and nonvascularized free bone                          mucosa. Panoramic radiograph showed a multilocular
grafts. Multiple studies have shown the clear                                  radiolucent lesion over the right body of mandible,
superiority of microvascular reconstruction of the                             extending up to the angle of mandible (Fig. 1b). CT scan
mandible when compared with ‘‘traditional’’ methods.                           revealed no evidence of any periosteal breach.
The options for bony free-tissue transfer for mandibular                       Histopathologic report was compatible with follicular
reconstruction primary rest on the fibula, iliac, scapula,                     ameloblastoma.
and to a much lesser degree, the radius bone1, 2,3.
                                                                                  Considering the aggressive behavior of the lesion,
    The fibula free flap continues to be the gold standard                     treatment with segmental resection of the involved
and the workhorse flap in the reconstruction of                                mandible and primary bony reconstruction with fibula
mandibular defects2. The advantages of the fibula free                         free flap was elected. Evaluation of the vasculature of
flap over other microvascular free tissue flaps include                        lower extremities with color Doppler was done.
its consistency and uniformity in width and length, its
pedicle length and vessel diameter, and the ability to                             The patient was placed under general anesthesia. A
incorporate a skin or muscle component with the flap1,2.                       transcervical approach to the left mandible was
The location of the fibula away from the head and neck                         accomplished with a submandibular incision. The inferior
also allows for a simultaneous two-team approach,                              lateral mandible with intact cortex was exposed in a
which shortens the operative time.                                             subperiosteal plane. The osteotomy was then completed

                                                        SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                      9
                                        MANDIBULAR RECONSTRUCTION WITH FIBULA FREE FLAP

and the mandible resected with care taken to preserve                  for bone viability
periosteum and soft tissue coverage over the lesion in the       •     The vascular pedicle has sufficient length and is of
regions with extrabony extension (Fig. 2a).                            large diameter
                                                                 •     The flexor hallucis longus muscle is conveniently
    The left lower extremity was selected for harvest of               located along the posterior border of the bone. This
the fibula flap. Under tourniquet control, the lateral                 muscle is ideal for filling in adjacent soft-tissue
approach was used to harvest the osseous flap based                    defects in the submandibular portion of the upper
on the peroneal vessels. The mandibular defect was                     neck
reconstructed with the flap. Fixation was done with              •     The skin island available with the fibula is reliable in
titanium miniplates and screws. The vascular pedicle                   approximately 91% of patient
was positioned on the medial aspect of the flap with             •     Of all potential donor sites, the fibula is the most
the vessels exiting the anterior portion of the flap (Fig.             convenient because it is located farthest from the head
2b,c,d).                                                               and neck area

   The length of the vessels was adjusted to allow a                 Surgical anatomy: The fibula is the only long and
favorable geometry and the microvascular anastomosis             straight bone that is not indesensible. It has a slender
was then completed with end-to-end anastomosis of                shaft with a thick cortex. The fibular head articulates with
the peroneal artery to the facial artery and the peroneal        the tibia 2 cmm below the knee joint. The common peroneal
vein to the common facial vein (Fig. 2e,f).                      nerve runs around the fibular head. Damage to the nerve
                                                                 and the knee joint can be avoided by leaving 8 cm of the
   In the postoperative period the flap was observed             proximal fibular end in the leg. Also distally, 8 cm are left
with doppler monitoring of the arterial pedicle. No              in order to retain the ankle joint fork. A fibula 40 cm long
vascular compromise was observed. The patient was                can provide up to 26 cm for transplantation. This makes
discharged after one week. Intermaxillary elastic was            the fibula the longest transplantable bone segment found
given to guide the occlusion for one week in the                 in the body.
postoperative period; the patient maintained his
premorbid occlusion, has excellent joint mobility and                If we view the fibula in a cross section, we can identify
good esthetics (Fig. 3a,b). Implant restoration of his           a triangular shape established by three borders. The
dentition is planned in the near future.                         anterior border is the area of attachment of the anterior
                                                                 intermuscular septum, and the interosseous or medial
DISCUSSION                                                       border is the point of attachment of the interosseous
    The goals of mandibular reconstruction are not only          membrane that binds the fibula to the tibia. The posterior
to re-establish the continuity of the mandible but also          intermuscular septum attaches to the posterior border.
to restore function. The return of function entails speech,
swallowing, and chewing. To that end, the fibula provides            In the proximal aspect the fibula articulates with the
the bony platform for eventual prosthetic rehabilitation         tibia and the knee joint, whereas in the distal aspect it
of the patient, whether that involves the placement of           articulates with the tibia and the talus. Above the knee the
intraosseous dental implants or conventional                     popliteal artery divides into the anterior and posterior
dentures4,7.                                                     tibial arteries. Distal to the knee the posterior tibial artery
                                                                 has a collateral branch, the peroneal artery. The blood
   The fibular graft was discovered to be suitable               supply to the fibula is delivered through perforators
transplant material for microsurgical transplantation            originating in the peroneal artery which is usually between
independently by Ueba and Fujikawa8 in Japan. They               2 and 4 mm in diameter. The venae comitantes provide the
recognized that in isolation the fibula is nourished             venous drainage; these are paired vessels that run along
adequately via the peroneal vessels and its lateral              the artery.
branches. Hidalgo 10 was the first to describe fibular
transplant for reconstruction of mandible.

The advantages of fibula in mandibular reconstruction
• The bone is available with enough length to
    reconstruct any mandible defect.
• The straight quality of the bone with adequate height
    and thickness constitutes the ideal bone stock for
    precisely shaping a mandible graft
• Osteotomies can be planned wherever necessary and                  Fig 4a: Cross-sectional view of the tibia and fibula with
    can be placed as close as 1 cm apart without concern                       the surrounding anatomic structures.

                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                                        10
                                        MANDIBULAR RECONSTRUCTION WITH FIBULA FREE FLAP

                                                                     The dissection is carried down to the crural fascia
                                                                 that is incised. The dissection continues through the
                                                                 anterior border of the peroneal muscles while
                                                                 maintaining a cuff of 2 to 3 mm of muscle surrounding
                                                                 the bone. The extensor digitorum longus and the
                                                                 extensor hallucis longus are elevated anteriorly,
                                                                 exposing the interosseous septum that connects between
                                                                 the fibula and the tibia. The peroneal vessels and the
                                                                 anterior tibial vessels are located posterior to the
                                                                 interosseous septum; therefore, careful dissection with
                                                                 fine dissecting scissors should be performed in order
                                                                 to avoid damage to the vascular structures or to the
                                                                 deep peroneal nerve. At this stage, two horizontal
                                                                 incisions are performed in the proximal and distal
                                                                 aspects of the fibula where the osteotomy is being
                                                                 planned. The bony cuts are performed with a Gigli, a
                                                                 reciprocating, or an oscillating saw while the medial
                                                                 aspect is protected with a malleable retractor. The
          Fig 4b: Vascular anatomy of the fibula                 peroneal vessels are ligated in their distal aspect and
                                                                 the vascular pedicle is carefully dissected superiorly
    Preoperative evaluation: The suitability of the fibula       until the branching of the peroneal artery from the
is based on the perfusion status of the lower extremity          posterior tibial is identified.
and the foot. The clinician should look for signs of
previous surgery or trauma and assess the skin                        Osteotomy of fibula: It is recommended to perform
temperature, hair growth, and thickening of the nail beds        the osteotomies to shape the fibula while pedicled to
for any evidence of peripheral vascular disease. The             the proximal vessels in order to minimize the ischemia
evaluation of the lower extremity vasculature has evolved        time as well as preparation of the vessels in the recipient
from the use of angiography to less invasive studies, such       site before ligation of the proximal aspect of the
as color Doppler examination, CT angiography, and MRI.           peroneal artery. Once the fibula is harvested, the flap
This is important not only to confirm adequate perfusion         is transferred to the head and neck, where the recipient
of the lower extremity but also to confirm the presence of       site had been prepared. In cases in which only a straight
the peroneal artery and rule out the presence of peroneal        segment is needed, the preparation is straightforward.
arterial magna, in which the peroneal artery is the main         Graft shaping can be done while ablation is in progress
blood supply to the foot2. This variation has been reported      with the aid of the templates designed preoperatively.
to range from 0.2% to 7%.                                        The surgical specimen is also a valuable visual aid.
                                                                 Measurements of total graft length as well as
   An evaluation of the anticipated mandibular defect            measurements to identify osteotomy sites are best made
should be undertaken. This study is commonly done with           to duplicate mandible shape. Lateral defects differ from
the aid of a panoramic radiograph and CT of the                  anterior defects in terms of the approach to shaping
mandible. Evaluation of the recipient vessels in the head        the graft. Angle of the mandible is generally planned
and neck is important. The recipient vessels most                where the vascular pedicle enters the bone (Fig. 4c).
commonly used when reconstructing the mandible are               This provides maximum pedicle length to reach the
the facial artery and vein. Alternatively, the superior          recipient vessels in the neck. This is where the first
thyroid artery, the external jugular vein, and the internal      osteotomy is made in the bone. Second osteotomy made
jugular vein may be used as the recipient vessels. The           to form the curve in the midbody. The ramus height is
decision as to which vessel to use depends on the most           determined by measurements taken from the specimen.
ideal geometry and the best match of the vessel

    Flap technique: The patient is placed in the supine
position, the hip and the knee are slightly flexed, and a
pneumatic tourniquet is placed in the proximal aspect
of the leg. A line is drawn from the lateral malleolus to
the fibular head. If a skin paddle is included, it should
be centered more posteriorly than the axis of the fibula
in order to include both the septocutaneous and the                Fig 4c: Demonstration of osteotomy fo fibula. Note the
musculocutaneous perforators.                                         angle of mandible at the level of vascular pedicle

                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                                       11
                                        MANDIBULAR RECONSTRUCTION WITH FIBULA FREE FLAP

Morbidity following Free Fibula Flaps                            6. Strackee SD, Kroon FH, Jaspers JE; Modelling a fibula
    A retrospective analysis of donor site morbidity was            transplant in mandibular reconstruction: evaluation
performed by Shindo and colleagues on 53 consecutive                of the effects of a minimal number of osteotomies
patients who underwent fibula osteocutaneous free                   on the contour of the jaw; Plast Reconstr Surg. 2001;
tissue transfer 16 . Donor site wound complications                 108: 1915-1921
occurred in 15 patients, 4 of whom (8%) had extensive
                                                                 7. Peled M, El-Naaj IA, Lipin Y et al; the use of free
wound breakdown, muscle necrosis, and/or exposure
                                                                    fibular flap for functional mandibular
of tendon and/or bone, whereas the other 11 patients
                                                                    reconstruction; J Oral Maxillofac Surg. 2005: 63:
(21%) had only minor wound complications limited to
superficial skin slough.
                                                                 8. Ueba Y, Fujikawa S; nine years follow up of a free
    Shindo and colleagues recommended avoiding skin                 vascularized fibular graft in neurofibromatosis; a
closure under tension since the group with the higher               case report and literature review; Jpn J Orthop
complication rate had primary closure of the donor                  Trauma Surg; 1983; 26: 595-600
site.91 Other reported complications have included               9. O’Brien BM, Morrison WA; reconstructive
weakness of great toe dorsiflexion, reduced spring                  microsurgery; 1987: Churchil Livingstone
action of the donor leg, ankle stiffness, and in a few
cases, ankle instability. Despite the mentioned deficits,        10. Hidalgo DA; Fibula free flap; A new method of
all patients were able to resume daily and recreational              mandible reconstruction; Plast Reconstr Surg. 1989;
activities 11 .                                                      84: 71-79
                                                                 11. Anthony JP, Rawnsley JD, Benhaim P, et al. Donor leg
CONCLUSION                                                           morbidity and function after fibula free flap
    The goals of mandibular reconstruction are not only              mandible reconstruction. Plast Reconstr Surg
to re-establish the continuity of the mandible but also              1995;96:146–52.
to restore function. The return of function entails speech,
swallowing, and chewing. To that end, the fibula provides        12. Bodde EW, de Visser E, Duysens JE, et al. Donor site
the bony platform for eventual prosthetic rehabilitation             morbidity after free vascularized autogenous
of the patient, whether that involves the placement of               fibular transfer: subjective and quantitative
intraosseous dental implants or conventional dentures.               analyses. Plast Reconstr Surg 2003;111:2237–42.
                                                                 13. Chang YM, Santamaria E, Wei FC, et al. Primary
REFERENCES:                                                          insertion of osseointegrated dental implants into
1. Michael Miloro, G. E. Ghali, Peter E. Larsen, Peter D.            fibula osteoseptocutaneous free flap for mandible
    Waite; Peterson’s Principles Of Oral And                         reconstruction. Plast Reconstr Surg 1998;102:680–8.
    Maxillofacial Surgery 2e; 2004; Bc Decker Inc
                                                                 14. Chen HC, Demirkan F, Wei FC, et al. Free fibula
2. Rui Fernandes; Fibula Free Flap in Mandibular                     osteoseptocutaneous-pedicle pectoralis major
   Reconstruction; Atlas Oral Maxillofacial Surg Clin                myocutaneous flap combination in reconstruction
   N Am 14 (2006) 143–150                                            of extensive composite mandibular defects. Plast
3. Wolfgang Zemann, Matthias Feichtinger, Eberhard                   Reconstruct Surg 1999;103:839–45.
   Kowatsch, Hans Kärcher; Extensive ameloblastoma               15. Cordeiro PG, Disa JJ, Hidalgo DA, et al.
   of the jaws: surgical management and immediate                    Reconstruction of the mandible with osseous free
   reconstruction using microvascular flaps; Oral Surg               flaps: a 10-year experience with 150 consecutive
   Oral Med Oral Pathol Oral Radiol Endod                            patients. Plast Reconstr Surg 1999;104:1314–20.
                                                                 16. Shindo M, Fong B, Fung G, et al. The fibula
4. Peter Ward Booth, S. A. Schendel, J.E. Hausamen;                  osteocutaneous flap in head and neck
   Maxillofacial Surgery; 2e. 2007; Churchil                         reconstruction: a critical evaluation of donor site
   Livingstone                                                       morbidity. Arch Otolaryngol Head Neck Surg
5. Stephen L. Engroff; Fibula flap reconstruction of the             2000;126:1467–72.
   condyle in disarticulation resections of the
   mandible: A case report and review of the technique;          FIGURES:
   Oral Surg Oral Med Oral Pathol Oral Radiol Endod              Fig. 1a: pre op photo
   2005;100:661-5                                                Fig. 1b: Panoramic view of the lesion
                                                                 Fig. 2a: After segmental resection of the mandible.
                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                                  12
                                       MANDIBULAR RECONSTRUCTION WITH FIBULA FREE FLAP

Fig. 2b: marking of the incision on the left leg. Note the
marking of the peroneal nerve near the knee joint
Fig. 2c: Harvesting the flap. Note the peroneal artery
Fig. 2d: Harvested flap
Fig. 2e: Fixation of the flap
Fig. 2f: Anastomosis of the vessels

                                                                                    Fig. 3b: Post op occlusion

                 Fig. 3a: post op photo

                                                                                   Fig. 3c: post op radiograph

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                                          SMILE - Vol. 12, Issue 1, Jan. - March 2012                               13
Case Report

Dr. Shalini Nair                                                   Dr. Anuja Mathews                                             Dr Alex K Varghese
Sr Lecturer                                                                  Lecturer                                                             Prof&HOD
Dept of Oral Pathology                                              Dept of Oral Pathology                                            Dept of Oral Pathology
Pushpagiri College of Dental Sciences,                        Pushpagiri College of Dental Sciences,                   Pushpagiri College of Dental Sciences,
Tiruvalla                                                                    Tiruvalla                                                               Tiruvalla

                                     Pleomorphic adenoma is a benign salivary gland tumour that exhibits wide
                                     cytomorphologic and architectural diversity. A case of palatal pleomorphic
                                     adenoma in a 49-year old male patient is reported here. The differential
                                     diagnoses, clinical, radiological and histopathological features as well as the
                                     surgical management and prognosis of the lesion is discussed. It is significant
                                     for the clinicians to be familiar with the clinical presentations of minor salivary
                                     gland tumours to be able to diagnose and manage the case appropriately.

Introduction                                                                      aspect of the hard palate in the midline and extending to
    Tumours of the salivary gland are rare and account for                        the soft palate. The mucosa over the lesion was normal
less than 3% of the head and neck tumours (1). The tumours                        except at two points on the middle and left side where
maybe derived from the salivary epithelium or the                                 small pointed abscess-like formations were present (Fig.
supportive stroma. Among the benign tumours,                                      1). There was no tenderness on palpation. Computed
pleomorphic adenoma is the most common, accounting                                tomography scan revealed an oval shaped mass with soft
for approximately 60% of all salivary gland neoplasms(2).                         tissue density in the hard palate region and extending to
Fifty percentof all oral minor salivary gland tumours are                         the soft palate with no bone destruction or invasion into
pleomorphic adenoma of which 55% arise in the palate,                             the adjacent structures (Fig. 2). A provisional diagnosis
25% in the lip, 10% in buccal mucosa, and 10% other sites                         of salivary gland tumour was made and an incision biopsy
in the oropharynx. (3) The tumour cells show a wide                               performed on the patient.
spectrum of epithelial and mesenchymal differentiation
and thus the name pleomorphic adenoma or benign mixed                                 Haematoxylin and eosin section of the tissue revealed a
tumour. The origin of the cellular elements is from the                           well encapsulated lesion composed of connective tissue
epithelial cell, myoepithelial cell, or both. Regardless of                       stroma with numerous duct-like spaces lined by cuboidal
thegreat variety of histopathological aspect the main                             cells. The ductal cells were surrounded by spindle-shaped
diagnostic feature is the presence of both epithelial and                         myoepithelial cells. Some of the spaces contained amorphous
mesenchyme-like tissues.                                                          eosinophilic material (Fig. 3).Some areas showed tumour
                                                                                  cells arranged in interlacing cords. In other areas the stroma
Case report                                                                       was myxoid and adipose cells were noticed. The periphery of
   A 49-year-old male patient presented at the clinic with                        the lesion had an intact fibrous capsule. A histopathological
chief complaint of a swelling on the palate of 3 years                            diagnosis of pleomorphic adenoma was made.
duration. He gave the history that the swelling had been
noticed as a small, painless nodule and it had gradually                              The lesion was treated with wide local excision. At
grown to the present size. There was no history of local                          surgery, the solid mass was encapsulated, well
surgery, trauma, or infection. His medical history was non-                       circumscribed and not adhered to the surrounding tissues.
contributory. Intra oral examination revealed a                                   The patient’s post-operative course was uneventful and no
5x4cm,sessile, soft to slightly firm mass on the posterior                        recurrence was observed after a five- year follow-up period.
                                                        SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                        14

Discussion                                                             pleomorphic adenoma and the frequency of this
    Pleomorphic adenoma is a slow-growing benign                       transformation increases as a result of the tumour
salivary gland tumour, most commonly arising in the                    persisting without being treated (8). A close follow-up is
parotid gland.Studies have shown that females are                      necessary postoperatively.
affected more than males and the peak incidence occurs
in the fourth and fifth decades (4).
                                                                           A patient presenting with a palatal swelling needs to
     The differential diagnoses for this case included                 be evaluated with a thorough history and comprehensive
dentoalveolar abscess, odontogenic and non- odontogenic                clinical,    radiological,    and     histopathological
cysts, soft tissue mesenchymal and odontogenic tumours,                examination. Generally, slow growing, sessile-based, firm,
and salivary gland tumours. Dentoalveolar abscess was                  painless mass, which occasionally has an ulcerated
initially suspected due to the presence of two areas which             surface, if not inflammatory in nature, are probably of
looked like pointing abscesses. But it was ruled out since a           salivary gland origin.
focus of infection in the close vicinity could not be detected
by clinical and radiographic examination. In addition, the
patient showed no signs of inflammation. Inflammatory
cysts were also ruled for the same reason. Both odontogenic
and non-odontogenic cysts were excluded at the time of
exploration into the mass since it did not demonstrate
cystic nature. Soft tissue tumours such as fibroma, lipoma,
neurofibroma, neurilemmoma as well as salivary gland
tumours were also considered in the differential diagnoses
for this case as the palate harbours all these kinds of
tissues. Rarely, extra- nodal lymphomacan also present
with palatal swelling. Since the radiographic and clinical
examination of this patient did not reveal signs and                     Fig. 1: Clinical photograph showing palatal swelling.
symptom associated with malignant tumour such as ulcer,
pain, paraesthesia or invasion into adjacent structures
and also the fact that the lesion had a rather slow
development over three years made the differential
diagnosis of lymphoma unlikely.
     Pleomorphic adenomas have been classified as
myxoid or stroma- rich, cellular or cell rich, and classic
based upon the histologic characteristic of the stroma
(5). According to the morphologic characteristics, they
have been classified as trabecular, ductal, cystic, and
solid. And also taking into consideration the epithelial
components, they can be plasmacytoid, spindle, clear,
squamous, basaloid, cubic, oncocytoid, and mucous
types (4). The histopathology of the presented case was
cellular with ductal morphology predominantly and with
                                                                          Fig 2: CT scan showing the palatal soft tissue mass
spindle and plasmacytoid epithelial components. This
classification however, does not have therapeutic or
prognostic significance (2).
    The treatment of choice for pleomorphic adenoma in
minor salivary gland is wide local excision with removal
of periosteum or bone if they are involved. Simple
enucleation might not suffice and can also lead to high
local recurrence rate. Removal of the tumour en mass is
also important as rupture of the capsule or tumour spillage
also may increase the risk of recurrence. Recurrence rate
of pleomorphic adenoma following adequate surgical                     Fig 3:Photomicrograph showing duct-like structures lined
excision has been shown to be generally nil or rare (7).               byan inner cuboidal epithelial cell layer and an outer
Pleomorphic adenoma presents a risk of malignant                       myoepithelial layer oftumour cells in a hyalinised stroma.
transformation, usually giving rise to a carcinoma ex                  (H & E section, 10x)

                                               SMILE - Vol. 12, Issue 1, Jan. - March 2012                                      15

References                                                            5.    Seifert G, Langrock I, Donath K. A pathological
1. Van der Wal JE, Leverstein H, Snow GB, Kraaijenhagen                     classification ofpleomorphic adenoma of the
    HA,Van der Waal I. Parotid gland tumors: histologic                     salivary glands (author’s transl). HNO.1976;24:415-
    revaluation andreclassification of 478 cases. Head                      26.
    Neck. 1998;20:204-7.
                                                                      6.    Ogata H, Ebihara S, Mukai K. Salivary gland
2.   Ellis GL, Auclair PL. Tumors of the Salivary Glands                    neoplasms in children.Jpn J ClinOncol. 1994;24:88-
     (Atlas ofTumor Pathology). 3rd series. Fascicle 17.                    93.
     Washington, DC: ArmedForces of Institute of
                                                                      7.    Shaaban H, Bruce J, Davenport PJ. Recurrent
     Pathology; 1996.
                                                                            pleomorphic adenomaof the palate in a child. Br J
3.   Takahama A Jr, Da Cruz Perez DE, Magrin J, De Almeida                  Plast Surg. 2001;54:245-7.
     OP,Kowalski LP. Giant pleomorphic adenoma of the
                                                                      8.    Rodríguez-Fernández J, Mateos-Micas M, Martínez-
     parotid gland.Med Oral Patol Oral Cir Bucal. 2008
                                                                            Tello FJ, Berjón J, Montalvo JJ, Forteza-Gonzalez G, et
                                                                            al. Metastatic benign pleomorphic adenoma. Report
4.   Ito FA, Jorge J, Vargas PA, Lopes MA. Histopathological                of a case and review of the literature. Med Oral Patol
     findings ofpleomorphic adenomas of the salivary                        Oral Cir Bucal. 2008;13:E193-6
     glands. Med Oral Patol Oral CirBucal. 2009 Jan 1;14

 Ask the Specialist
QUESTION:                                                             REPLAY:

Dear Doctor,                                                          Dear Doctor
I am sending I/O photographs of a 28 year old male patient,           The photographs and the clinical history give a picture of
came to me with a complaint of pain and tenderness of                 Fordyce granules itself. The pain and erythema may be
buccal mucosa. He had pain for six months and when he
                                                                      due to the constant palpation by the patient. No aggressive
touches the mucosa with his hand there is peeling of
mucosa and some yellow spots are seen at the site. He                 treatment is needed now. We can wait and watch for the
consulted a dermatologist who said there is nothing to be             time being. Do a regular follow up once in two weeks and
worried about it and gave some anaesthetic cream for                  in the mean time prescribe some anaesthetic cream for
local application. Pain recurs when he stops applying local           local application. Assure the patient that there is nothing
anaesthetic. The patient has no other relevant medical                to worry. I think that is all needed for the time being.
history and otherwise normal. O/E multiple yellowish
patches are seen on right and left buccal mucosa and lips
along with erythematous areas. There is tenderness on                                                            Dr Alex K Varghese
the right buccal mucosa.                                                                                          Professor & HOD
                                                                                                    Department of Oral Pathology
 My diagnosis is that it is Fordyce granules but I cannot
                                                                                              Pushpagiri College of Dental Sciences
account for the continuous pain. Patient’s nourishment is
affected due to the pain. I request you to kindly give your                                                              Thiruvalla
valuable opinion regarding it as well as the treatment

                                           Dr Rajesh Krishnan
                                        Rajesh’s Dental Clinic
                                               SMILE - Vol. 12, Issue 1, Jan. - March 2012                                       16
Case Report

Dr. Ankit Sharma                            Dr. Yogesh Mittal                       Dr. Shashank Uniyal                                Dr. Lylajam S.
PG Student, Govt. Dental College,       PG Student, Govt. Dental College,        PG Student, Govt. Dental College,           Prof & HOD, Department of
Kottayam, Kerala                               Kottayam, Kerala                         Kottayam, Kerala             Prosthodontics, Govt. Dental College,
                                                                                                                                         Kottayam, Kerala
                      Congenital absence of the vagina, a rare anomaly, is an aplasia or dysplasia of the Müllerian
                      (paramesonephric) ducts. It is usually associated with Mayer–Rokitansky–Kuster–Hauser (MRKH)
                      Syndrome1 . The correction of vaginal agenesis requires the creation of a neovaginal cavity that is
                      dissected between the bladder and the rectum. 2 In order to prevent a possible contraction of the
                      reconstructed vagina, a long-term vaginal stent use is required to maintain vaginal width and depth.
                      This article describes a case report of a 25 year old female, diagnosed with vaginal agenesis and
                      managed by vaginoplasty, followed by placement of a vaginal stent for postoperative maintenance.

                      Vaginal agenesis, Vaginoplasty, Vaginal stent, Neovagina, MRKH syndrome.

Introduction                                                                   The stent was slightly tapered anteriorly to achieve a
    Vaginal agenesis is a congenital anomaly of the female                  blunt rounded end for easy insertion and to prevent any
genitourinary tract. The management of vaginal agenesis                     undue pressure on urinary bladder, urethra and rectum to
includes the surgical creation of a neovagina by                            avoid pressure necrosis (Figure 2).
vaginoplasty followed by postoperative maintenance of
the neovaginal cavity using a vaginal stent. The following
case report describes the prosthodontic aid in the
management of vaginal agenesis.
Case report
   A 25 year old female was referred to the Department of
Prosthodontics, Govt. Dental College, Kottayam from the
Department of Plastic Surgery, Govt. Medical College,
Kottayam for the purpose of fabrication of a vaginal stent.
The patient gave a history of congenital vaginal agenesis
which was surgically managed by vaginoplasty a week
ago. The patient was referred to the Department of                               Figure 2: Rounded blunt end of the vaginal stent
Prosthodontics for the purpose of fabrication of a vaginal
                                                                                The posterior end was designed in the form of a handle
stent to prevent contraction of the reconstructed vagina.
                                                                            to hold the vaginal stent for the ease of placement and
   After discussing with the Plastic Surgeons, a wax                        removal. The wax pattern was acrylized into heat cured
pattern of the vaginal stent of a desired form and length                   acrylic resin using conventional method. The acrylized
was designed (Figure 1). It was 2 cm in diameter and 10                     vaginal stent was then finished and polished. A groove
cm in length.                                                               was made just before the posterior end which will grip the
                                                                            condom with the elastics. Four diagonally placed holes
                                                                            were drilled on the handle at the posterior end of the stent
                                                                            to aid in the stabilization of the position of the stent in
                                                                            situ under patient’s clothing using threads passing through
                                                                            these holes and tied around the patient’s waist (Figure 3).
                                                                            Currently, the patient is under review and has been
          Figure 1: Wax pattern of the vaginal stent                        asymptomatic since 2 months.

                                                     SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                       17

                                                                  prevent the contracture of the opening. The patient was
                                                                  then referred to the Department of Prosthodontics after 1
                                                                  week of surgery for the purpose of fabrication of a more
                                                                  hygienic, rigid and a definitive vaginal stent that will stay
                                                                  in situ for another 6 months except during urination,
                                                                  defecation, and routine cleaning.
                                                                       Though the fabrication of the vaginal stent is a simple
                                                                  procedure, it involves a special care in the design, usage
                                                                  and the postoperative care of the prosthesis. The design
 Figure 3: Vaginal stent in heat cured acrylic resin with         of the stent should be well discussed with the concerned
             the desired grooves and holes                        Gynecologist or the Plastic Surgeon. In the case reported,
                                                                  the patient was asked to keep the vaginal stent in position
Discussion                                                        for 24 hours a day for a period of minimum six months.
   Mullerian agenesis, a congenital malformation of the           The sexual attempt may be attempted only after 3 months.
genital tract, is a common cause of primary amenorrhea,           The vaginal stent should be covered with a sterile condom
second only to gonadal dysgenesis 3 . It is usually               whenever in use, which should be replaced every day. The
associated with Mayer–Rokitansky–Kuester–Hauser                   condom will smoothen the surface of the stent for its easy
(MRKH) syndrome which is regarded as an inhibitory                insertion, prevent the direct contact of the vaginal mucosa
malformation of the Müllerian (paramesonephric) ducts.4           with the acrylic resin and also maintain a good hygiene of
The woman with mullerian agenesis has normal external             the stent. The vaginal stent should be washed with mild
genitalia and normal functioning ovaries. The phenotype,          soap and water every day. Care should be given to rinse
therefore, is normal with normal secondary sexual                 all the soap off so that no film is left to irritate the vagina
characteristics. The vagina may be totally absent, or             in the next use. A routine review should be carried out for
represented by a rudimentary pouch of up to one half to           better results.
three quarters of an inch deep. There are associated renal
and vertebral anomalies (e.g., fused or solitary pelvic           Conclusion
kidney, spina bifida). The usual lesion consists                      The ideal treatment of the MRKHS is a combination of
of absence of the middle and upper vagina,                        surgical and non surgical procedures. A valid treatment
total absence or a rudiment in the location of the uterus,        for vaginal agenesis is the creation of the neovagina by
and an absence or vestige in place of one or both Fallopian       Abbe–McIndoe vaginoplasty. This consists in the creation
tubes.                                                            of a vaginal canal created by dissecting the potential
                                                                  neovaginal space, which is then subsequently covered by
    Treatment is usually delayed until the patient is ready       a skin graft. To prevent contraction of the reconstructed
to start sexual activity, even when the diagnosis is made         vagina, a vaginal stent is required to be used not only at
during adolescence.5 In the present case, the patient             peroperative period after sterilization, but also for the
reported to the Department of Plastic Surgery with the chief      postoperative period for stenting. The above mentioned
complaint of primary amenorrhea and inability to have             case report describes this valuable prosthodontic aid in
her normal sexual activity because of vaginal agenesis.           the management of vaginal agenesis associated with MRKH
The patient reported to be diagnosed with MRKH syndrome           syndrome.
at the onset of her puberty but the treatment was delayed
until her marriage.
   The treatment of Mullerian agenesis may be either              References
surgical or nonsurgical, but the chosen method needs to           1.   M. Folch, I. Pigem and J.C. Konje. Mullerian Agenesis: Etiology,
be individualized depending on the patient’s needs,                    Diagnosis and management. Obsterical and Gynecological
                                                                       Survey. Volume 55, Number 10
motivation, and the options available. The most commonly
                                                                  2.   McIndoe A: Treatment of congenital absence and obliterative
used surgical method to correct the inadequate vagina is               conditions of the vagina. Br J Plast Surg 1950, 2:224-67.
the Abbe-McIndoe technique, described by McIndoe in the
                                                                  3.   Varner RE, Younger JB, Blackwell RE. Mullerian dysgenesis. J
1950s.6 The vaginoplasty is followed by placement of a                 Reprod Med 1985;30:443–450.
vaginal stent into the neovaginal cavity to prevent a
                                                                  4.   Clinical aspects of Mayer–Rokitansky–Kuester–Hauser
possible contraction of the reconstructed vagina and to                syndrome: recommendations for clinical diagnosis and
maintain the vaginal width and depth. The vaginal stent                staging. Human Reproduction Vol.21, No.3 pp. 792–797, 2006
should be placed immediately after the surgery and should         5.   Lindenman E, Shepard MK, Pescovitz OH. Mullerian agenesis:
be continued for a period of six to nine months.7                      An update. Obstet Gynecol 1997;90:307–311.
   In the case reported, the patient underwent McIndoe            6.   Linde T. Surgery for anomalies of the mu ¨ llerian ducts.
vaginoplasty and since then during the healing phase, the              In:Thompson J, Rock J, eds. Operative Gynecology, 7th
                                                                       ed.Philadelphia: JB Lippincott, 1992, pp 614–619.
continuous prolonged dilatation of the vaginal cavity was
done by a soft vaginal stent of desired length made by            7.   J.B. Costello and E.J. Badre. Construction of an Artificial Vagina.
                                                                       Canadian Medical Association Journal. Sept. 17,1966, vol. 95
using sponge in a rolled form and covered by a condom to

                                           SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                 18
Case Report

Dr. Shashank Uniyal                                           Dr Ankit Sharma                                                       Dr. Lylajam S.
P.G Student, Dept. Of                                          P.G student, Dept. Of                                      Prof & HOD, Department of
Prosthodontics,Govt. Dental                                 Prosthodontics,Govt. Dental                           Prosthodontics, Govt. Dental College,
College,Kottayam                                                 College,Kottayam                                                     Kottayam, Kerala

                              Proper nutrition of elderly persons is essential both for general and oral health.
                              Adequate nutrition plays a part in the health of aging oral tissues which in turn
                              influences the prognosis of any prosthetic treatment. The long term
                              relationship dentists establish with their patients creates an ideal situation
                              for the identification of older patients at nutritional risk. This article highlights
                              the nutritional aspects of elderly people and role prosthodontist plays to help
                              elderly patient to achieve optimum health.

                              Key words
                              Nutrition, Dietary counselling, Geriatrics,Gerodontic.

INTRODUCTION                                                              AGING FACTORS THAT AFFECT NUTRITIONAL STATUS
   The elderly are not just “old” people; they are                        1.PHYSIOLOGIC FACTORS
structurally, functionally, and mentally different from                      Declines in physical and cognitive status often increase
what they were in the days of their youth and early maturity.             with age. Six essential nutrients are required to meet the
There is no separation of good physical health and good                   physiologic needs of body. They are carbohydrates, fats,
dental health. A diseased body contributes to a diseased                  proteins, minerals, vitamins, and water. Single nutrient
dental state, and conversely, a diseased dental state often               deficiencies are very rare. Usually it is a general decline
leads to a diseased or malnourished body. Geriatric                       in food intake that leads to multideficiencies.The
medicine and dentistry have the responsibility of enabling                importance of each nutrient is discussed below.
the older patient recognise his problem and providing
adequate treatment. Specifically, it is prosthodontist who                PROTEINS: The protein requirements of a person increases
plays the important role for dentistry in the rehabilitation              with age. Disturbances due to protein deficiency are
of aging individual.                                                      evident in one day and become severe within a few
                                                                          days 1.Protein deficiency results in lower antibody
    Nutrition is more than just diet. Nutrition includes not              production, reduced resistance to infection, anemia, and
only the ingestion of an adequate and balanced diet, but                  a decrease in muscle volume. For optimum nutrition, 1.4
also the digestion, absorption, and transportation to the                 gm. of protein per kilogram of body weight is necessary2.
tissues of essential food elements, and utilization of these              Doubling the protein intake results in a threefold increase
elements by the body cells. Good nutrition enhances                       in calcium utilization1.
quality of life by preventing malnutrition and promoting
optimal functioning. Nutritional problems may result from                 VITAMINS: An increased vitamin intake for geriatric
changes associated with the aging process itself, from                    patients is important. Vitamins contribute to nervous
disease or other medical conditions, from interactions                    stability and effective resistance to bacterial infection by
with medications, or from all of these. Malnutrition is                   promoting the growth of healthy tissue. The intake of all
common in elderly populations throughout the world.                       vitamins should be increased in aged persons, especially

                                                 SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                        19

vitamins A, B complex, C, and D. Elderly person feel better             The elderly patient who appears clinically dehydrated,
and are able to do more work when vitamin C is added to             especially in terms of xerostomia, requires treatment to
their diet. Vitamin C is nontoxic even in massive doses.            restore the health of the oral tissues as well as general
Vitamin A is necessary for maintaining the integrity of the         health before a satisfactory prosthesis can be expected.
mucous membranes and the epithelial structures. The                 Elders should be encouraged to have six to eight 8 oz
major dietary sources of vitamin A are the fats of dairy            glasses of fluid daily 3. Soups are probably the most
products and eggs.                                                  efficient food for providing water and nutrients to the
                                                                    dehydrated tissues and cells of the elderly. The elderly
    Vitamin D deficiency is also common in the elderly for          patient is well advised to have soup once each day.
several reasons like insufficient sun exposure and                  Vegetable fibers are strongly hydrophilic and bind the
impaired kidney or liver function needed to activate                water until it reaches the large intestine. Vegetable soup
vitamin D. Vitamin D synthesis at age of 80 years is half           can be enriched by adding meat (or fish) and bon e (for
as that at 20 years3. It enhances the absorption of calcium         calcium).
and is necessary for proper calcium-phosphorus
metabolism.                                                         CARBOHYDRATE TENDENCY AND OBESITY: Due to reduced
                                                                    muscular activity and metabolic rate, geriatric patients
    Declines in gastric acidity results from atrophic gastritis     require fewer calories. A soft diet that is high in
and cause malabsorption of food-bound vitamin B12.Vitamin           carbohydrates and low in protein, fibre and nutrient
B12 deficiency, in turn, can result in neuropathy, megaloblastic    density is usually common in old age. This high calorie
anemia, gastrointestinal symptoms, and cognitive                    value produces obesity. A change from a carbohydrate to
impairment. Neurologic complications are seen in 75% to             a protein diet does not initially satisfy demands of hunger
90% of individuals with vitamin B12 deficiency4.Milk and milk       since carbohydrates occupy more space and distend the
products are good source of vitamin B12.                            stomach more than similar amounts of protein.

     It is duty of dentist to prescribe vitamins for elderly        COGNITIVE INFLUENCES: Cognitive function decline with
denture patients like paediatricians and physicians                 advancing age and range from simple memory deficit to
prescribe vitamins for babies and children to keep them             profound dementia. Overt deficiency of several vitamins
healthy. The cost of vitamin supplements, although great,           is associated with neurologic and/or behavioural
is less than a package of cigarettes per day.                       impairment (B1,B2,niacin,B6,B12, folate, pantothenic acid,
                                                                    vitamin C, and vitamin E). Mild or subclinical vitamin
MINERALS: The minerals are of particular importance to              deficiencies may also play an important role in the
aged persons. Elderly persons often experience calcium              declining neurocognitive function in aging 6. Oxidative
deficiency which is manifested as bone fragility and a              stress in the body is also thought to be important in the
rapid and excessive ridge resorption under complete                 pathogenesis of cognitive decline. The dietary antioxidants
dentures which may be related to a negative balance of              like Vitamins E, A, and C, zinc, and selenium may help to
calcium. The calcium level may be improved by increasing            counteract these oxidative stress7.
the intake of milk and milk products plus a vitamin D
supplement of 400 to 1,000 units a day. Acidulated milk             2.PSYCHOSOCIAL FACTORS
with a soft curd is especially valuable.                                 Psychosocial factors may play even greater roles than
                                                                    physical, medical, and dental issues in determining the
   Zinc deficiency results in decreased immune response.            health and well-being of elders. Elders particularly at risk
Indeed, the immune response in older adults is more                 include those living alone, the physically handicapped
sensitive to nutritional status than in younger adults5.            and isolated persons. Depression, anxiety, and loneliness
                                                                    all can undermine the desire to prepare and eat food and
WATER: Water is probably the most important and                     have been associated with anorexia, weight loss, and
essential nutrient in the diet of man. Water is essential to        increased morbidity and mortality in older people.
all body functions: cell activity, all secretions , absorption
of foods, and elimination of catabolites. There is a theory         3.FUNCTIONAL FACTORS
that suggests that tissue dehydration influences the rate               Functional disabilities such as arthritis, stroke, or
of aging. Alcohol is a prime factor in kidney damage.               vision or hearing impairment can affect nutritional status
“One drink per day knocks out one kidney cell and one               indirectly. The older person may have difficulty getting to
brain cell.” as a result, the dehydrated elderly patient is         and from grocery stores, carrying groceries, and preparing
tired and listless; the skin, the eyes, and the oral mucosa         meals in general. Inability to handle eating utensils, see
are dry and easily irritated.                                       food clearly, or hear others’ conversation may all lead to
                                             SMILE - Vol. 12, Issue 1, Jan. - March 2012                                      20

social isolation, poor eating habits, and subsequent              of estrogen. The taste for salt disappears early in life, and
malnutrition.                                                     the taste for sweet foods goes soon after. This leaves only
                                                                  the bitter taste receptors in the circumvallate papillae at
4.PHARMACOLOGIC FACTORS                                           the base of the tongue to survive the aging process14.
   The elderly are major users of prescription
medications, a number of which can cause malabsorption                Perception of taste for geriatric patient can be
of nutrients, gastrointestinal symptoms, and loss of              improved by encouraging them to chew patiently in small
appetite. For example, digoxin and some forms of                  pieces. Chewing increases salivation, salivation increase
chemotherapy can cause nausea, vomiting, and loss of              taste, and taste increase appetite. Patient can be advised
appetite8. Penicillamine induces zinc depletion, which can        to add flavouring agents to food to increase palatability.
lead to loss of taste acuity and decreased food intake8.          A dirty mouth cannot taste the subtle flavours in a good
High doses of aluminum or magnesium hydroxide antacids            food so tongue brushing and cleansing of denture with
deplete phosphate and potassium stores, which can lead            flavoured dentifrice is important in elderly. Smoking
to muscle weakness and anorexia10.                                should be avoided since it diminishes the taste for food
                                                                  and it makes even flavourful foods taste flat and
   Alcohol provides calories but is of little nutritional         unappetizing. Henkin15 found that acid and bitter tastes
value and can undermine nutritional status by decreasing          could be detected on the hard palate, especially at the
appetite and by substituting for more nutritious foods in         junction of the hard and soft palate. He speculates that
the diet. A small alcoholic beverage before meals may             upper dentures might diminish bitter taste in some
enhance appetite, but greater amounts suppress it.                patients.

5.ORAL FACTORS                                                    DIETARY COUNSELLING FOR DENTURE WEARERS16
XEROSTOMIA: Xerostomia (dry mouth or hyposalivation)                  Patients must be informed that they can be well
affects almost one in five older adults9. When salivary           nourished without natural teeth and semisolid or even
levels decline, teeth become more susceptible to dental           liquid foods can supply all the essential elements
caries and oral mucous membranes become hot, dry, and             necessary for good nutrition. Although the sequence of
fragile. Dentures cannot be tolerated by the dry and fragile      eating food is incising, then chewing, and finally
mucosa. Xerostomia can also impair complete denture               swallowing, it is much easier for denture patients to learn
retention and is associated with increased periodontal            eating procedures in the opposite order, namely,
disease, and difficulties in chewing and swallowing—all           swallowing, chewing, and incising. So foods of the proper
of which can adversely affect food selection and contribute       consistency must be chosen so that these functions can
to poor nutritional status9. Xerostomia is not an inevitable      he learned in this order. For the first day, liquid foods
consequence of aging, it is now known that saliva levels          which require only swallowing should be selected. Second
are normal in healthy elders10 and xerostomia is a side           and third day should include food that require minimum
effect of diseases or their treatment. Indeed, the use of         of chewing. Diet for the fourth and subsequent days can
medications is the most common cause of xerostomia.               be expanded to semi solids. After several weeks, solid food
More than 400 medications commonly used by elders have            requiring incising may be consumed. Patients should
xerostomia as a side effect11. Food must be prepared in           adapt to their new dentures by cutting foods into small
liquid or semiliquid form so that it may be swallowed.In          pieces and chewing them with the molars. Later on
severe condition food must be lubricated with artificial          progressing to biting and incising food. New denture
saliva12 or sialogogues (drugs stimulating salivary flow)         wearers need to chew longer, eat slowly, and cut fibrous
may be prescribed.                                                foods into bite-sized pieces.In the aged, the tendency to a
                                                                  higher carbohydrate and lesser protein intake must be
SENSE OF TASTE AND SMELL: Age-related changes in taste            reversed in order to meet the nutritional demands of old
and smell alter food choice and decrease diet quality in          age. Cheraskin has stated that all nutrition supplements
some people. Factors contributing decreased function may          are more effectively utilized when taken with meals and in
include health disorders, medications, oral hygiene,              divided doses1. He also recommends a protein supplement
denture use, and smoking. This loss results from the              1 week before denture delivery1.
decline in the peripheral sensory receptors caused by
degeneration of the taste buds in the tongue and the smell        ROLE OF PROSTHODONTIST
receptors in the roof of the nose. In early and middle years,        The highly specialized tissues of oral cavity are often
taste buds are renewed approximately every 10 days13.             the first to be affected by nutritional disturbances.
Renewal is slow in the elderly, especially in the                 Prosthodontist see elderly patients frequently especially
postmenopausal woman suffering from severe depletion              those with oral complaints under artificial dentures. It is
                                           SMILE - Vol. 12, Issue 1, Jan. - March 2012                                      21

self-evident that prosthodontists are in a strategic position      his patient. The food intake that is best for dental health
to intercept early evidence of disturbances and educate            also satisfies the needs of all the body tissues and there
the geriatric patient toward good nutrition. The                   can be no diet for dental health that is not a diet for total
prosthodontist must be aware of the oral problems                  health.
peculiar to process of aging, along with the nutritional
and dietary requirements, food habits, and tissue                  REFERENCES
deficiencies of the aged. It is a common tendency to become        1. James V. Barone:Nutrition-Phase one of the edentulous
so engrossed with the technical details of denture                     patient. J.Pros. Dent.40:122-126,1978
construction that we lose sight of the patient as a whole.         2. James V. Barone:Nutrition of edentulous patients, J.
However, even with new conventional dentures, which                    Pros. Dent.15:804-809,1965
improve ease of chewing, dietary intake often remains              3. C.A. Palmer / Dent Clin N Am 47 (2003) 355–371
unchanged17. Numerous studies over the past 2 decades              4. Baik H, Russell RM. Vitamin B-12 deficiency in the
have shown that implant-retained overdentures                          elderly. Annu Rev Nutr 1999;19:357–377.
significantly improve ease of chewing18, and investigators         5. Russell R. Gastric hypochlorhydria and achlorhydria
are now measuring the effect of implant therapy on                     in older adults [letter]. JAMA 1997;278:1659–60.
nutrition. Mental and physical health in patients of any           6. Rosenberg IH, Miller JW. Nutritional factors in
age are factors exerting great influence on the successful             physical and cognitive functions of elderly people.
use of dentures. Patients with extremely poor nutritional              Am J Clin Nutr 1992;55(Suppl):1237–43.
intakes and complex dietary problems should be referred            7. Christen Y. Oxidative stress and Alzheimer’s disease.
to a nutritionist for complete dietary counselling. Although           Am J Clin Nutr 2000;71(Suppl):621–9.
we must look to the physician for help in treating chronic         8. Thomas JA, Burns RA. Important drug-nutrient
glandular dysfunctions, circulatory disturbances, and                  interactions in the elderly.Drugs Aging 1998;13:199
bone and tissue pathologies, but we can and should                 9. Rhodus NL, Brown J. The association of xerostomia
concern ourselves with the factor of nutrition in relation             and inadequate intake in older adults.J Am Diet Assoc
to dental dysfunction among older age groups. The                      1990;90:1688–92.
prosthodontist who gives some thought to the importance            10. Baum B. Salivary gland fluid secretion during aging. J
of nutrition can help the older patient make the most of               Am Geriatr Soc 1989;37:453–8.
his limited functional resources, and can spare the patient        11. Arky R. Medical Consultant, 1998. Physician’s Desk
from many of the consequences of nutritive and                         Reference, vol. 51. Montvale (NJ):Medical Economics
masticatory deficiencies.                                              Company; 1997.
                                                                   12. Muray Massler:Geriatric nutrition II:Dehydration in
   Since patience and kindness are often the secrets of                elderly,J Pros. Dent.42:489-491,1979
success with the geriatric denture patient so the                  13. Jenkins, G.: The Physiology and Biochemistry of the
prosthodontist needs to be a gerontophile, one who has a               Mouth,ed 4. London, 1978, Blackwell Scientific
special fondness for old people.                                       Publications, pp506, 542-558.
                                                                   14. Maury Massler:Geriatric nutrition:The role of taste
SUMMARY AND CONCLUSION                                                 and smell in appetite, J Pros. Dent.43:247-250,1980
    Its well said by Brillat Savarin that “Tell me what you        15. Kaplan, A. R., Glanville, E. V., and Fischer R.: Cumulative
eat and i will tell you what you are”. Estimates indicate that         effect of age and smoking on taste sensitieity in males
one third to one half of health problems in elderly                    and females. J Gerontol 20:334, 1965.
individuals are a direct or indirect consequence of                16. Henkin, R. 1.: Taste localization in man. In Bosma, J.
nutritional deficiency The diet of the patient is one of the           F.,editor: Second Symposium on Oral Sensation and
most valuable implements that he has for combating                     Perception.
infections, hastening the healing process, and building            17. Gunne HS, Wall AK. The effect of new complete
the necessary healthy structures for the acceptance of                 dentures on mastication and dietary intake. Acta
prosthetic restorations. Infact prosthetic failures are often          Odontol Scand 1985; 43(5):257-68.
the result of tissue deficiencies than technical                   18. Allen PF, McMillan AS, Walshaw D. A patient-based
deficiencies19.So nutrition is one of the most important               assessment of implant-stabilized and conventional
factor which determine success or failure of prosthetic                complete dentures. J Prosthet Dent 2001; 85(2):141-7.
appliances in the mouth of aging people. Whether or not            19. Massler, M.: Geriatrics and Gerodontics, New York J.
poor nutrition is the cause of denture trouble, the results            Den. 26:54-63, 1956.
are the same-poor health and an unhappy patient. The
true specialist in any field of dentistry, including
prosthodontics, never loses the concept of total health of
                                            SMILE - Vol. 12, Issue 1, Jan. - March 2012                                        22
            True and scary incidences in dental practices

       These incidences are true as far as our information is       breathing heavily and breathing difficult increases when
concerned. Names of persons, places, and clinics involved           she sits or lie down. Seeing the seriousness the dental
cannot be published for obvious reasons. These incidences           surgeon shifted the patient to the nearby hospital and
may be known to some of you. You are warned against                 admitted to the causality.
divulging any information that leads to the identification
of person(s), place, or clinic involved. The person(s) doing              The physician of the hospital identified her as one
so will solely be held responsible for the act and the journal,     of his own patient who has unstable angina who is under
IDA CKK, and the editor will not hold any responsibility for        irregular treatment. This lady is irregular in seeking
the same. We do not claim any accuracy or authenticity to           medical help. She used to carry a few tablets of
these narrations, despite the efforts made by us to make it         Nitroglycerin, which would be place under her tongue
same. Authors are warned against cooking up stories from            when she feels chest pain. This condition is known to no
their imagination – only true incidences will be published.         one except the patient and the physician himself. The
These incidences are published not to scare you, but to make        bystander who came along with her is only a recently
you more cautious in your daily practice as these things can        recruited servant who is also unaware of the lady’s medical
happen to any one of us.                                            condition. When the physician contacted the lady’s sons,
                                                                    they also claims that they know she had diabetics but
      One day a 64 year old lady came to a dental clinic            unaware about her cardiac conditions.
accompanied by a girl whom could be taken as her
daughter or daughter-in-law. The old lady was palpating                   Despite the cumbersome efforts taken by the
and complained about the steepness of the stairs to the             physician and the other staff in the hospital, she passed
dental clinic. The old lady has a root stump of lower left          away after an hour. The situation was explained to the
first molar and wants extraction. The dental surgeon                aggrieved family and they were able to understand the
prepared for extraction. Meanwhile he enquired the lady             situation. This saved the dental surgeon from further
about her medical history. She said she has diabetics, but          complications.
under control. The previous day she had checked it and
found it within normal limits. She said she have no other           NB: This is a true story as far as my knowledge is concerned.
medical problems and had extractions few months back                Those who have good suggestions regarding how to prevent
without any complications.                                          such incidences occurring again or how to foresee such
                                                                    things, please make yourself free to write to us through the
      Her narration of the medical history was so clear             email : or
that the dental surgeon confidently gave nerve block and            Those suggestions that are worth publishing will be
extracted the teeth. Then she was sent to the waiting area          published in the next issue of SMILE in the Letters to Editor
for a short rest before going out. After a few minutes the          column.
bystander rushed in to the clinic telling that the patient is
not feeling well. The patient was called inside. She is

                                             SMILE - Vol. 12, Issue 1, Jan. - March 2012                                      23
Review Article

Dr Eapen Cherian, MDS                                                                                                                    Jose Kurian
Reader                                                                                                                                  Final Year Student
Department of Oral Pathology Sciences                                                                               Pushpagiri College of Dental Sciences
Pushpagiri College of Dental Sciences                                                                                                             Tiruvalla

                                  A diagnosis of epithelial dysplasia is based on a static snapshot. In spite of
                                  this, this histologic diagnosis implies the possibility of a dynamic process, i.e.,
                                  subsequent malignant transformation. A better understanding of the
                                  fundamental molecular biology of the process of cancer development in the
                                  oral cavity through stages, conventionally defined as epithelial dysplasia/
                                  carcinoma in situ, may be the only way to improve our possibilities for
                                  predicting malignant development from precursor lesions. There are numerous
                                  reports on the application of molecular biological markers for the assessment
                                  of cancer risk, and recent reviews are available. This a review of the literature
                                  available regarding the molecular aspect of leukoplakia.

 INTRODUCTION                                                                    Reference has earlier been made to the fact that
    When evaluating molecular changes in oral pre-                           reactive lesions and benign tumors sometimes display
malignancy and oral cancer, one should note that there                       features of epithelial dysplasia.1 The reaction patterns of
are differences in the ethnic and etiologic characteristics                  molecular markers in such lesions are largely unknown;
in different parts of the world.11 Two approaches have been                  however, a few studies have shown that benign lesions in
used for the study of markers of malignant development.                      some cases reveal a reaction pattern similar to that seen
In some studies, epithelial dysplasias on the one hand                       in epithelial dysplasias and cancer. One study showed
and oral cancers on the other are characterized with                         that hyperplastic oral epithelium in inflamed specimens
respect to the presence/absence or the pattern of                            (inflammatory papillary hyperplasia of the palate), which
distribution of the marker in question, and generally, the                   are rarely if ever associated with malignant development,
marker is characterized as a promising tool if the reaction                  exhibited a significant increase in positively stained cells
pattern in epithelial dysplasias is similar to that in                       for p53 and a proliferation marker (proliferating cell
carcinomas and/or if the aberrant reaction pattern is                        nuclear antigen [PCNA]) compared with normal palatal
positively related to the grade of epithelial dysplasia. In                  epithelium.6 and another study revealed a similar increase
light of the subjectivity that exists in the diagnosis and                   in cells stained positive for markers of cell cycle regulation
grading of epithelial dysplasia, this approach is probably                   (PCNA, Ki-67, AgNORs) in inflamed compared with non-
useful as a preliminary approach in the planning of further                  inflamed keratocysts .7 Furthermore, it has been shown
studies. Studies of markers thought to be directly related                   that inflamed gingival epithelia exhibit a staining pattern
to malignant development, such as the expression of                          for keratin 19.12 that has been described as characteristic
oncogenes or the loss of tumor suppressor genes, however,                    of dysplastic epithelium.13
are of interest, although the outcome of the lesions                             Similar staining patterns for low-molecular-weight
examined is unknown. Other studies, mostly retrospective,                    keratins have been reported in the reticular epithelium of
compare the reaction pattern in pre-malignant lesions with                   the palatine tonsils in which a close relationship exists
the outcome (cancer or non-cancer) after a follow-up                         between epithelium and immunocompetent cells.6 A recent
period. Despite the problems related to the retrospective                    study concluded that the pattern of keratin gene expression
nature of such studies and problems in gathering a                           may be altered in response to frictional/smoking stimuli
substantial number of pre-malignant lesions, such studies                    or immune-mediated mechanisms.8 Expression of keratins
should be encouraged.                                                        8 and 18 was reported to be amplified in gingival epithelia
                                                     SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                        24

in the presence of inflammation1, and discontinuities or           LOSS OF HETEROZYGOSITY
disruptions in the staining patterns for type IV collagen              Loss of genomic material in one of a pair of
and lamina in the basement membrane similar to those               chromosomes is designated loss of heterozygosity (LOH).
seen in epithelial dysplasia and cancer ) have been                LOH at chromosomal regions supposed to contain tumor
reported.11 The aforementioned changes have been shown             suppressor genes might be related to the process of
to parallel the progression of oral epithelial neoplasia.11        malignant development, although it is recognized that the
Thus, it is important to evaluate descriptive studies with         development of malignancies, in general, requires multiple
caution; they do not necessarily reflect the biological            genetic alterations.8 LOH in oral pre-malignant lesions
significance of these molecular markers. 12 Therefore,             and its possible predictive value were recently reviewed.5
studies on molecular markers in epithelial dysplasias              LOH, in particular at chromosome arms 3p and 9p, was
should include controls such as the normal counterparts            shown to be associated with a greater possibility of
of the dysplastic tissue, and inflamed tissues in which the        malignant development of premalignant lesions 1,3,5,8
inflammatory process seems to induce proliferative and             although with longer follow-up the association weakened
differentiation- related changes mimicking those seen in           somewhat.2 Other chromosomal losses in addition to 3p
pre-malignancy. The use of antigen retrieval methods that          and 9p increased the possibility of malignant
sometimes bring out false-positive reactions will possibly         development. Thus, those lesions with LOH limited to 3p
enhance the need for appropriate controls.10 The best-             and/or 9p had a 3.8-fold increased risk, whereas those
characterized markers for determining future cancer                with loss at any of the chromosomes 4q, 8p, 11q, 13q, and
development in oral pre-malignant lesions can be divided           17p in addition to LOH at 3p and/or 9p had a 33-fold
into: (1) genomic markers, including DNA content (ploidy),         increased risk for progression to cancer compared with
chromosome aberrations (allelic loss or gain), and                 lesions that retained these arms. It has been shown, in the
changes in the expression of oncogenes and tumor                   aerodigestive tract, that LOH at an increasing number of
suppressor genes (p53); (2) proliferation markers; and (3)         loci correlates with histopathological progression from
differentiation markers, including keratins and                    benign squamous hyperplasia via dysplasia and
carbohydrate antigens. The rationale for studying these            carcinoma in situ to invasive carcinoma.10
markers in cancer development seems obvious. It is not                 An increase in LOH in oral leukoplakia with foci of
within the scope of this review to describe the biological         early cancerization (foci with superficial invasive growth)
aspects of cancer development in any detail. However,              has been reported in these foci. Furthermore, it appeared
examples of markers (genomic and differentiation) with a           that, apart from the additional LOH, the chromosome arms
potential for predicting malignant transformation in oral          lost in 11 of 13 cases in the non-invasive parts of the
premalignant lesions will be discussed. Admittedly, this           leukoplakias were also lost in the foci of early
field of research is rapidly evolving, and new potential           cancerization, thereby suggesting the concept of a single
predictive markers are probably on the horizon.                    clone in the leukoplakia and invasive areas. Reference
DNA ANEUPLOIDY                                                     was made earlier to a study on LOH in high-risk sites of
    The DNA content (DNA ploidy) of a cell gives a rough           oral leukoplakia12 in which dysplasias at high-risk sites
measurement of genetic instability and DNA aberration. In          harbored significantly higher LOH frequencies than those
cancers, genetically stable diploid cells are replaced by          at low-risk sites. This finding was applied in a comparison
genetically unstable aneuploid cells. In oral squamous cell        of lesions with mild and moderate epithelial dysplasia in
carcinomas, DNA aneuploidy has been studied by flow and            high- and low-risk areas, respectively. However, there were
image cytometry, and the findings reveal that aneuploid            no differences when severe dysplasias/carcinomas in situ
tumor populations exist in a high number of cases and that         at the two types of sites were compared. This suggests
the ploidy status is an important prognostic factor.8 Other        that when a stage of severe dysplasia/carcinoma in situ
studies, however, did not find DNA ploidy status to have           has been reached, the genetic disturbances are of such
any prognostic value.5 In oral leukoplakias, aneuploid             magnitude that they mask the influences of other possible
populations have also been reported with or without                risk factors. LOH analysis has recently been suggested to
correlation to the grade of dysplasia. A recent impressive         be of value in differentiating verrucous hyperplasia/
series of studies has focused on DNA ploidy measurements           verrucous carcinoma from reactive lesions.5
in patients with oral epithelial dysplasias during a rather        P53
long follow-up period.6 DNA aneuploidy was a powerful                  Mutation of the p53 tumor suppressor gene may
predictor of malignant development in oral leukoplakias            represent the most common genetic change in human
and erythroplakias, whereas normal DNA content indicated           cancer.1 The physiologic function of the p53 protein is
a low risk. The results are indeed promising; however,             that of preventing accumulation of genetic damage in cells
although the sample analyzed was comparatively large,              either by allowing for repair of the damage before cell
the clinical value of this marker must be evaluated in large-      division or by causing death of the cell. The normal p53
scale prospective trials. Furthermore, there is a need for         protein has a very short half-life; the quantity in normal
the development of simple methods for DNA measurements             cells is extremely small. Therefore, it is usually not
for routine diagnostic work.
                                            SMILE - Vol. 12, Issue 1, Jan. - March 2012                                     25

detectable by immunohistochemistry. Mutant p53 protein             DIFFERENTIATION MARKERS
has a prolonged half-life and can accumulate in cells to               Cell-surface carbohydrates Cell-surface carbohydrates
levels that are detectable. This mutant protein is normally        with blood group antigen activity are widely distributed
not active, thus leading to the loss of the tumor                  in human tissues .5,7 The term ‘histo-blood group antigens’
suppressor function of the protein. More than 50% of               has been suggested for blood group antigens located on
oral squamous cell carcinomas are positive for p53                 cells other than erythrocyt.3,8 Histo-blood group antigens
protein, and mutations of the p53 gene have been                   of the ABH, Lewis, and T/Tn systems are seen at the surfaces
documented.6Furthermore, in oral epithelial dysplasias             of epithelial cells in oral squamous epithelium. During
adjacent to oral carcinomas and in epithelial dysplasias           cellular differentiation in stratified squamous epithelium,
not associated with oral carcinomas, overexpression of             there is a sequential elongation of the terminal
p53 protein and gene mutations have been detected as               carbohydrate chain of precursors of histo-blood group
well.5 ,7, 9, 10 Several studies have compared p53 staining        antigens by the action of gene-encoded
in pre-malignant lesions with subsequent malignant                 glycosyltransferases.11,14 During malignant development,
development.2,9,11,12,13,14 Various results were obtained,         the synthesis of histoblood group antigens is disturbed4,
none of which points toward an established relationship            possibly due to aberrant expression of the
between p53 over expression in pre-malignant lesions               glycosyltransferases.5 Almost 30 years ago, Dabelsteen
and subsequent malignant development. Small samples                and Pindborg (1973) showed that histo-blood group
make firm conclusions difficult, and a recent meta-                antigen A was lost in oral carcinomas. Further, in oral
analysis of published results from seven studies showed            epithelial dysplasias, there was a loss of the normally
that 47% of oral pre-cancers had p53 over expression3 -            expressed histo-blood group antigens (A or B) in the
a much higher percentage than the percentage of                    spinous cell layer, and an increased number of epithelial
malignant transformation of pre-malignant lesions.                 cell layers stained for the precursor molecule (H-antigen),
Interestingly, a recent study, taking into account the             which is normally expressed only in the parabasal
expression pattern of p53 within the epithelium,                   cells.12,13 In normal epithelium, histo-blood group antigen
suggested that clear expression of p53 above the basal             Ley is present on parabasal cells, whereas in epithelial
cell layer is an indicator of a developing carcinoma, even         dysplasias the expression of Ley is seen in cell surfaces of
in the absence of obvious dysplasia. 1 However, it was             the superficial spinous cells, possibly reflecting a lack of
strongly recommended that conventional histological                normal epithelial differentiation.13,14 A similar pattern of
parameters should also be taken into account, since p53            expression of simple Mucin type carbohydrate antigens
positivity is not always seen in lesions that undergo              (T/Tn) has been reported in oral leukoplakias and
malignant transformation. In yet another study 6, para             erythroplakia.13 Interestingly, mice genetically deficient
basal p53-positivity was also associated with a higher             in Muc2, a gastrointestinal mucin with a glycosylation
cancer risk, even more so when combined with two other             pattern related to the T/Tn antigens, developed adenomas
markers (chromosomal polysomy and loss of                          in the small intestine that progressed to adenocarcinomas,
heterozygosity at chromosome 3p or 9p). This study,                suggesting a role for this mucin in the suppression of
however, was performed on ‘advanced’ pre-malignant                 cancer development . 2 Changes in histo-blood group
lesions and included patients with a previous oral cancer          antigen expression, similar to those in oral epithelial
history. At present, it is not possible to detect p53 protein      dysplasia, have been demonstrated in cancer development
selectively by immunohistochemistry. Thus, what is                 in the bladder.6 Some of the aberrant expression patterns
detected by immunohistochemistry may not be p53 gene               referred to above were seen in pre-malignant lesions
mutation 5,6 but rather the stabilized normal protein. In          without epithelial dysplasia,1,3 suggesting that histoblood
other words, the correlation between cells that are                group antigen changes appear early in the development
positive for p53 and mutations of the genes in the same            of malignancy. However, only in a very limited number of
cells is still controversial. Immunohistochemical                  cases have the histo-blood group antigen changes been
detection of p53 in pre-malignant lesions, therefore, is           related directly to the ultimate fate of the lesions (cancer/
unlikely to be a reliable predictor—at least when used             non-cancer).5,6 These studies showed that pre-malignant
as a single marker .                                               lesions that later developed into cancer exhibited a loss
   A recent immunohistochemical study of p53 and p21,              of histo-blood group antigen A years before malignant
one of the downstream target genes activated by p53, in            transformation. Preliminary studies indicate that this loss
53 oral verrucous leukoplakias reported that aberrant              is due to allelic loss of the ABO glycosyltransferase-
immunoreactivity of p53 and p21 was closely associated             encoding genes, although post-transcriptional down-
with malignant transformation.2,3 It has been reported             regulation of the gene transcript may also be involved.14
earlier that, in most oral squamous cell carcinomas, p21           Some of the changes seen in pre-malignant and malignant
expression does not depend on p53 status,1,4 whereas in            lesions are also seen in non-malignant circumstances
another study, the p21 expression seemed to correlate with         such as wound healing.7,8 Thus, the prognostic value of
p53 status .                                                       aberrant histo-blood group antigen expression in oral pre-
                                                                   malignant lesions is largely unknown. It should be

                                            SMILE - Vol. 12, Issue 1, Jan. - March 2012                                      26

mentioned, however, that, in experimental carcinogenesis           samples. 13,14 In moderate to severe dysplasia and
in rat oral mucosa, changes in cell-surface carbohydrates          carcinoma in situ, whether hyperkeratinized or not, strong
were always seen in non-invasive lesions. 6,7 This is of           staining for K19 was found in basal and suprabasal layers.
interest, because all rats in this model were known to             Similar results were obtained in another study, although
develop cancer if they were not killed. Furthermore, in            the staining for K19 was more heterogeneous in and
this rat model, lesions classified as questionable epithelial      between samples 8. In this study, K19 mRNA expression
dysplasia also revealed marked changes in the expression           was present in cornified and non-cornified normal
of histo-blood group antigens. 9 The histo-blood group             epithelia but with a higher density of labeling in
antigen expression in this model paralleled morphological          suprabasal cells of dysplastic epithelia. It is noteworthy
changes in malignant development. Furthermore, in                  that inflamed gingival epithelium exhibits diffuse staining
cervical,8 head and neck , 9 and oral carcinomas,10 the            for K19.11 Hence, it is difficult to evaluate the significance
expression of histo-blood group antigens has been shown            of K19-staining in epithelial dysplasias. Loss of
to be related to prognosis. Several studies have shown             differentiation-related keratins in dysplastic lesions may
that loss of A or B histo-blood group antigen expression is        be the most promising keratin-related marker of dysplasia
associated with increased motility of tumor cells, invasion        and malignant development. Large-scale studies relating
in matrigel, and tumorigenicity in syngeneic animals.3             the changes in keratin expression to subsequent malignant
Thus, the prognostic value of the histo-blood group                development, however, are lacking
antigens as markers of malignant development in oral                   This has led to such confusion that many clinicians
pre-malignant lesions in well-controlled follow-up studies         refuse to use any term beyond a simple “white patch”, and
is warranted. Keratins Keratins are proteins that constitute       the term is no longer used to describe similar lesions of
the intermediate filament cytoskeleton of epithelial cells.        the urogenital tract. Nevertheless, the name is a good one,
About 20 keratins are known, and they have been numbered           as was recognized by the World Health Organization when
1-20. In the oral squamous epithelium, a certain set of            it provided the clinical definition which is now generally
keratins is present under normal circumstances; however,           accepted for oral leukoplakia: A keratotic white plaque
during malignant development, changes in the type or               that cannot be scraped off and cannot be given another
distribution of keratins are seen. In all normal oral              specific diagnostic name. It is no longer acceptable to
epithelia, K5/K14 is present in the basal cell layer, whereas      presume that microscopic evidence of dysplasia is
K4/K13 and K1/K10 are present in the spinous cell layer            necessary for this diagnosis, and in retrospect it seems
in non-cornified and cornified epithelium, respectively.1          surprising that microscopy was ever considered essential
In general, the distribution of keratin mRNAs involves a           to the diagnosis of a lesion which is typically not biopsied.7
higher number of epithelial cell layers than the
corresponding proteins, indicating that these genes are            Leukoplakia, then, is a clinical diagnosis which has the
under post-transcriptional control.2                               unusual attribute of being dependent not so much on
                                                                   definable appearances as in the exclusion of other lesions
    The K5/K14 keratins that normally are present only in          which present as oral white plaques. Such lesions as
the basal cell layer are also expressed in the parabasal           lichen planus, chronic cheek bite, frictional keratosis,
and spinous cell layers in dysplastic epithelia, 3,5,6,8           tobacco pouch keratosis, nicotine palatinus, leukoedema,
probably reflecting the basal cell hyperplasia that is             white sponge nevus, etc. must be ruled out before a
frequently seen in dysplasias. Furthermore, the keratins           diagnosis of leukoplakia can be made. This concept
(K4/K13 or K1/K10) characteristically present in                   confuses many, but is not unparalleled in dentistry.
suprabasal cell layers show reduced expression or loss             Juvenile periodontitis also requires that all systemic
in epithelial dysplasias. 2,4,6,12 In one study,3 a relation       diseases capable of producing periodontal destruction
between the severity of dysplastic changes and altered             (e.g. neutropenia, juvenile diabetes, histiocytosis be ruled
keratin expression was demonstrated. Thus, in severe               out before the term can be used as a diagnosis
dysplasia, keratins (K4/K13 and K1/K10) associated with
normal epithelial differentiation were almost completely           Referances
lost. In normal oral epithelium, keratins 8 and 18,                1.   Sol Silverman Jr MA, DDS1, Meir Gorsky DMD2, Francina Lozada,
normally expressed in simple epithelia, are generally not               Dds, Ms ,Oral leukoplakia and malignant transformation. A
detected by immunohistochemistry, although their mRNAs                  follow-up study of 257 patients, Cancer,Volume 53, Issue 3,
                                                                        pages 563–568, 1 February 1984
are present in basal and lower spinous cells .8 However,
in oral epithelial dysplasias, these keratins were detected        2.   B.Mc. Cartan - Malignant transformation of leukoplakia.
by immunohistochemistry in more than half of the case                   McCartan B. Comment in: Oral Surg,
this protein expression is due to a release of a post-
transcriptional block or a suppression of their rapid              3.
degradation in normal epithelia is not known (Su et al.,           4.   Neville B, Damm D, Allen C, Bouquot J. Oral and maxillofacial
1994). Another simple epithelia-associated keratin, K19,                pathology. Philadelphia: W. B. Saunders, 1995: 280-292
was shown to be present in the basal cell layer in normal          5.   Fali S. Mehta, P. C. Gupta and J. J. Pindborg, Chewing and
non-cornified oral epithelia but not in cornified
                                            SMILE - Vol. 12, Issue 1, Jan. - March 2012                                           27

     smoking habits in relation to precancer and oral cancer                     reference to nodular leukoplakia. Cancer, 63: 2247–2252.
                                                                                 doi: 10.1002/1097-0142 (19890601)63:11<2247::AID-
6.   T. Saito1,*, C. Sugiura1, A. Hirai1, K. Notani1, Y. Totsuka2, M.
                                                                                 CNCR2820631132> 3.0.CO;2-D
     Shindoh3, T. Kohgo3, H. Fukuda, High malignant transformation
     rate of widespread multiple oral leukoplakias,Volume 5, Issue          11. Daftary DK, Murti PR, Bhonsle RB, et al. Oral precancerous
     1, pages 15–19, January 1999                                               lesions and conditions of tropical interest. In: Prabhu SR, Wilson
7.   Shafer WG, Waldron CA. Erythroplakia of the oral cavity. Cancer            DF, Daftary DK, Johnson NW (eds). Oral diseases in the tropics.
     1975; 36:1021-1024                                                         Oxford: Oxford University Press, 1993:402-424.
                                                                            12. Axell T, Pindborg JJ, Smith CJ, et al. Oral white lesions with
8.   Xiaolin Zhang, Chengjie Li, Yi Song and Peter A. Reichart, Oral
                                                                                special reference to precancers and tobacco-related lesions:
     and Maxillofacial Surgery ,Volume 14, Number 4, 195-202, DOI:
                                                                                conclusions of an international symposium held in Uppsala,
                                                                                Sweden, May 18-21, 1994. J Oral Pathol Med 1996; 25:49-54
9.   Bouquot JE, Gnepp DR. Laryngeal precancer—a review of the
     literature, commentary and comparison with oral leukoplakia.           13. Miller. Ein Beitrag zur Aetiologie der Leukoplakia oris. D. M fur
     Head Neck 1991; 13: 488-497                                                Z. 1892; 12(H):515
                                                                            14. Kramer IRH, Lucas RB, El-Labban N, et al. A computer-aided
10. Gupta, P. C., Bhonsle, R. B., Murti, P. R., Daftary, D. K., Mehta, F.
                                                                                study on the tissue changes in oral keratoses and lichen planus,
    S. and Pindborg, J. J. (1989), An epidemiologic assessment of
                                                                                and an analysis of case groupings by subjective and objective
    cancer risk in oral precancerous lesions in India with special
                                                                                criteria. Br J Cancer 1970; 29:408-426.

 Book Review

                                                                                                                       Published by
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                                                                                 4838/24, Ansari Road, Daryanganj, NewDelhi 110 002
                                                                                    Phone: +91-11-43574357, Fax: +91-11-43574314
Dr Eapen Cherian
                                                           Stem cells are biological cells found in all multi cellular organisms
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                                                      every day. Medical scientists are fascinated by the potentials of stem cells
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                                                      This book gives a complete and comprehensive knowledge about stem cells,
                                                      its properties, its potential uses in human beings, stem cells in tissue
                                                      engineering, cancer, gene therapy and stem cells in dental tissue. This book
                                                      is helpful guide for stem cell researchers, medical, dental and biological
                                                      students and the general public as well.

                                                            About the author: Dr Eapen Cherian is the Faculty of Dentistry, Oral
                                                      and Maxillofacial Pathology, Microbiology and Forensic Odontology. He
                                                      completed his MDS from SRM College of Dental Sciences, Chennai, Tamil
                                                      Nadu and now working as a Reader in Pushpagiri College of Dental Sciences,
                                                      Thiruvalla, and Kerala. He has managed to learn by teaching and tries to
                                                      modify and adapt innovation in the field of stem cells. He is also one of the
                                                      first forensic odontologists in Kerala. He has over 15 publications in
                                                      international and national journals to his credit and also done several
                                                      paper presentations at national and international conferences.

                                                    SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                28
Case Report

Dr. J. Vengatesh Kumar                                          Dr. S. Anil Kumar                                              Dr. Antony PG
MDS 2nd Year Student Department of                            Prof & HOD, Department of                      Assistant Professor Department of Oral
Prosthodontics, GDC, Kottayam, Kerala                    Prosthodontics, GDC, Kottayam, Kerala               & Maxillofacial Surgery GDC, Kottayam,

                                  A dramatic improvement in aesthetics and neurological function has been
                                  obtained in patients with acquired skull defects after cranioplasty using
                                  titanium plates. Cranioplasty is surgical repair of a defect or deformity of
                                  a skull. It can be described as a procedure not only for anatomical
                                  reconstruction and aesthetic purposes but also for neurological improvement.
                                  In the following case reports two cases of Neuro-prosthetic rehabilitation of
                                  acquired skull defects following pathology of skull bones which were removed
                                  surgically and the resulted skull defects were recorded through conventional
                                  impression technique and reconstructed using Titanium plates.

                                  Key Words
                                  skull defects, conventional technique, Titanium plate

INTRODUCTION:                                                                cranial prosthesis for the purpose of cranioplasty.Both
Cranial vault defects may results from trauma, infection,                    the patients had history of fibrous dysplasia of skull bones
tumour ablation or cerebral decompression                                    and undergone craniectomy to remove the infected bones.
procedures.Cranial defects determine not only aesthetics                     Skull defects were resulted after craniectomy which
but also functional alterations2. Thus,the main purpose                      psychologically affected the patients regarding their
of a cranioplasty is not only cosmetic repair but also                       appearance and left the brain uncovered. History of head
improving the neurological status2. Various techniques                       ache and seizures post-operatively. As,the patient is from
for recording the defects and materials have been used to                    poor economical background,the decision was made to
fill defects in the cranial vault, such as metal, xenografts,                record the skull defects by conventional impression
autografts, and allografts are available. The material used                  methods and later fabrication of titanium plate for the
should be inert in the tissues, radiolucent, easily and                      purpose of cranioplasty Fig(1)
accurately shaped, capable of being adjusted at the time
of insertion, and it should have sufficient mechanical
strength to resist fracture or deformation under severe
impact loading1. In the following case report, two patients
with acquired skull defects which were successfully treated
using conventional impression procedures and titanium
cranioplasty is reported here.

Two patients with acquired skull defects reported to
department of Prosthodontics, govt dental college,
Kottayam referred from department of neurosurgery
government medical college, kottayam for fabrication of                             Figure 1: Preoperative view with skull defects
                                                    SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                  29

MATERIALS AND METHODS                                                   inert1. The plate is tried in patient and checked for its
    The cleanly shaved skull defect of the patients is gently           contour and fit,fig(2.7)
palpated to identify the periphery of the cranial defect
and carefully demarcated using indelible pencil3, fig (2.1).
A wide band of modeling wax is trimmed to conform to the
periphery of the skull defect and stabilized over skull to
demarcate the extension of flow of the alginate impression
material. A thin mix of alginate impression material is
poured onto the skull defect bounded by the band of wax
sheet. A layer of cotton fibers were placed over the alginate
just at the time it is about to set, in order to act as a
binding unit between the alginate and the cast formed by                           2.5 Cast of Defect                  2.6 Wax try-in
pouring lightly mixed plaster of Paris over the cotton, fig
(2.2&2.3) The plaster of Paris cast is to provide a rigid
support for the alginate impression and also to prevent
dimensional distortion during the removal of the set
alginate material from the patient’s head3. Dental stone is
mixed and poured onto the alginate impression, fig
(2.4&2.5).The indelible pencil mark shown on the alginate
impression is intensified so that it will show on the final
cast. After setting, the cast is detached from the alginate
                                                                                               2.7 Titanium plate try-in
impression. A wax pattern is then made to the exact
dimension and contour of the skull defect derived from
the stone cast. Wax try-in was done and pattern is                      SURGICAL PLACEMENT OF PROSTHESIS:
examined from all aspects to check the extension                            The surgical placement of prosthesis was done by
&contours and necessary corrections were made, fig (2.6)                neurosurgeons.The choice of incision will often be dictated
                                                                        by the size and position of the scar from the original
Figure 2:                                                               wound1. In this case bicoronal incision was made and
                                                                        flap was raised and the titanium plate is placed over the
                                                                        defect and checked for its adaptation. After necessary
                                                                        corrections the titanium plate is sutured with the
                                                                        periosteum through the holes in the periphery of the plate.
                                                                        A vacuum drain was placed and flap was repositioned
                                                                        and stapled1 Fig (3).

     2.1 Margins of Defect         2.2 Alginate impression

                                                                                 Figure 3 : Surgical Placement of Prosthesis

                                                                           At present various advanced techniques for recording
            2.3 Plaster backu            2.4 Final Impression
                                                                        the skull defects and various materials for fabrication of
                                                                        the prosthesis were available, the selection of technique
                                                                        was determined by availability of the technique and
    Surface of the wax up is scanned.A titanium plate is
                                                                        patient’s affordability. The conventional impression
casted according to the data collected through scanning.
                                                                        technique with alginate was used, as the patient can’t
2mm holes were drilled in the plate. These holes helps for
                                                                        afford for advanced techniques. The prosthesis is
fixation of prosthesis and to prevent development of an
                                                                        fabricated in titanium as titanium has good
epidural haematoma and also to permit escape of
                                                                        biocompatibility, good tissue acceptance, low density,
underlying fluid1. Titanium plate is anodized to make it
                                                 SMILE - Vol. 12, Issue 1, Jan. - March 2012                                            30

radiolucent and easily secured with periosteum by                       pattern and subsequent fabrication of titanium plate &
sutures1. Although the conventional technique has certain               proper surgical placement, the contour of lost skull bone
disadvantages like difficult to locate exact margins of the             can be restored. The neurological status also improved
defect due to muscle & skin thickness, individual                       considerably. The impression technique is simple and
variations and dimensional changes of impression                        economical without causing much burden to the patients.
materials & dental stone,multidisciplinary approach with
patience and coordination can achieve very satisfactory                 REFERENCES:
results as reported Fig(5).                                             1. Titanium cranioplasty; Gordon & Blair ; British
                                                                            Medical Journal, 1974, 2, 478-481 Beumer J. Firtell
                                                                            DN, Curtis TA. Current concepts in cranioplasty. J
                                                                            Prosthet Dent 1979:42;67-77
                                                                        2. Reconstructionof the calvarial defects using custom-
                                                                            made cranioplasty plates Horatiu Rotaru, Horatiu
                                                                            Stan, Horea Chezan, Doru Munteanu, Seong-Gon Kim,
                                                                            Alexandru Rotaru1, Grigore Baciut, Petru
                                                                            Berce,Cristian Dinu, Simion Bran, TMJ 2007, Vol. 57,
                                                                            No. 1
                                                                        3. Cranioplasty using polymethyl methacrylate im-plant
              Figure 5: Post operative view                                 constructed from an alginate impression and wax
                                                                            elimination technique, a.e. abdulai, m.i. iddrissu and
CONCLUSION                                                                  t.k. dakurah Ghana medical journal, march 2006
   The esthetics resulted after cranioplasty has enabled                    volume 40, number 1
patient to smile again with confidence to see the world                 4. Textbook of Calvarial and Dural reconstruction; Setti
with their normal face. Eventhough the conventional                         S. Rengachary & Benzel
technique has certain disadvantages, correct procedures                 5. Textbook of Plastic and reconstructive surgery; Maria
with accurate impressions & ideal contouring of wax                         Siemionow

                            UP COMING EVENTS AND REMINDERS
         9th -12th FEBRUARY 2012             –      65 TH Indian Dental Conference 2012, MMRDA Ground,
                                                    Bandra Kurla Complex, Mumbai

         25th &26th FEBRUARY 2012            –      President Secretary Meet and 2 ND State Executive Meeting

         19th FEBRUARY 2012                  –      CDE on Rotary Endodontics with hands on course by
                                                    Dr. Jayasree HOD. Dept of Conservative Dentistry and Endodontics
                                                    Oxford Dental College, Bangalore – Full day Programme

         18th MARCH 2012                     -      CDE on Restorative Dentistry

         27th - 30th APRIL 2012              -      Family Tour to Ootty – contact – Dr. Mathew V. Joseph - 9447504998

         Renew your HOPE before 31 March 2012 – contact Dr Cherin John for                     details - 9447057199

         Renew your Municipality/Panchayath Registration before 31 March 2012

                                                 SMILE - Vol. 12, Issue 1, Jan. - March 2012                                      31
Review Article

Dr Anil Kurian, BDS                 Dr Anuja Mathews, BDS                        Reeja Susan Thomas                                  Remya M
Lecturer                                          Lecturer                            Final Year Student                        Final Year Student
Department of Oral Pathology          Department of Oral Pathology           Pushpagiri College of Dental sciences,   Pushpagiri College of Dental
Pushpagiri College of Dental       Pushpagiri College of Dental Sciences,                   Tiruvalla                           sciences, Tiruvalla
Sciences, Tiruvalla                               Tiruvalla

                               Background: It is a common practice by the dental professionals to advice
                               patients to discontinue antiplatelet therapy before performing extractions
                               and other minor oral surgical procedures. This is in fear of uncontrollable
                               bleeding that is anticipated in patients taking antiplatelet medications.
                               However several authorities have questioned this in view of increased risk of
                               cardiovascular complications the patient may be placed in by discontinuation
                               of such drugs. Conclusion: Though there are several case reports of excessive
                               bleeding on patients taking antiplatelet drugs, all studies done on antiplatelet
                               therapy concluded that antiplatelet therapy need not be discontinued for minor
                               oral surgical procedures if the clotting and bleeding time of the patient remains
                               within the normal limits.

                               Key words:
                               Antiplatelet therapy, Aspirin, Postoperative bleeding

Introduction                                                                Dental Implications
    Platelets provide the initial haemostatic plug at the                       There are certain case reports describing the bleeding
site of vascular injury. They also participate in peripheral                complications associated with extractions and gingival
vascular thrombosis. Introduction of antiplatelet therapy                   surgery in patients taking low-dose aspirin. In a study
revolutionised the preventive care rendered to patients                     conducted on bleeding on probing(BOP) in patients with
who are at risk of major vascular events (Myocardial                        gingivitis, it was concluded that there is significant rise
Infarction, stroke and vascular death).[5] The antiplatelet                 in BOP in patients taking low-dose aspirin.[8] In another
drugs block Thromboxane A2 which is a liable inducer of                     study to evaluate the effect of aspirin on periodontal
platelet aggregation and a potent vasoconstrictor.[6] Thus                  parameters it was concluded that aspirin intake of 325mg
platelet aggregation that may lead to thrombus formation                    daily for 7 days moderately increases the appearance of
is prevented. Most commonly used antiplatelet drug is                       BOP in patients having 20% or more BOP sites.[9] But in all
aspirin in low doses (40 – 320 mg daily).[7] Several studies                the above cases it is unclear whether the bleeding episodes
suggest that this low-dose aspirin is optimal for the long                  are directly related to aspirin intake or due to any other
term prevention of serious vascular event in high risk                      factors. Some randomized clinical studies conducted
patients.[7] But there are concerns regarding the risk of                   recently failed to demonstrate any association between
uncontrolled bleeding that may occur due to an injury as                    aspirin use and post operative bleeding episodes. [7] A
the primary mechanism of haemostasis is impaired by                         randomized study on 36 patients where 325 mg of aspirin
the drug. Studies show that the risk of gastrointestinal                    or placebo were given 2 days before and 2 days after a
bleeding doubles and there is 1 to 2 hemorrhagic strokes                    single tooth extraction failed to demonstrate any
per 10,0000 patients on antiplatelet therapy.[7]                            association between aspirin use and post extraction

                                                    SMILE - Vol. 12, Issue 1, Jan. - March 2012                                                 32

bleeding episode.[7] In a second study, where 39 patients             investigations for bleeding prior to all procedures, where
are randomised to 100 mg of aspirin or no aspirin before              bleeding is anticipated. [7]
single or multiple extractions no episodes of excessive
intraoperative or post operative bleeding was reported.[7]            Antiplatelet therapy and invasive dental procedure
There are a number of similar studies on almost all                       Data from several studies indicates that the amount of
invasive dental procedures and all of these have shown                bleeding from oral surgical procedures are controllable
similar results. [2,3,4,7,8,9]                                        by local haemostatic measures like suturing, pressure
                                                                      packing with gauze, placement of resorbable gelatine
Consequences of aspirin discontinuation                               sponge, oxidized cellulose or microfibrillar
    A science advisory from the American Heart                        collagen.[1,2,3,4,7,] In extensive surgeries like impactions,
Association, American College of Cardiology, Society for              implant placement, osteotomies etc a consultation with
Cardiovascular Angiography and Interventions, American                the patient’s cardiologist is recommended prior to the
College of Surgeons, and American Dental Association,                 procedures. The risk of bleeding as well as the potential
with representation from the American College of                      cardiac risk in case of discontinuation of antiplatelet
Physicians is advising the continuation of antiplatelet               therapy is to be weighed carefully before undertaking any
therapy during the perioperative period for high risk                 extensive invasive procedures. An important point to be
patients. [10] This is in view of several case reports which          noted is that experts in Canada, Great Britain, Netherlands,
concluded that premature discontinuation of antiplatelet              and US are now not recommending discontinuation of
therapy resulted in markedly increased risk of stent                  aspirin for vascular and orthopaedic surgeries. [7]
thrombosis that frequently leads to MI and/or death.[1,10,11]
In a large observational cohort study who discontinued                   However in patient taking high doses of aspirin for its
antiplatelet therapy, it was found that stent thrombosis              analgesic and/or anti-inflammatory properties,
occurred in 29% of the patients. [1] In an analysis                   discontinuation is recommended before invasive
conducted by Spertus et al in 500 patients, they found                procedures as here, the antithrombotic effect is of no
that the mortality rate of patients who stopped antiplatelet          concern.[7]
therapy was 7.5% compared with 0.7 % in those who had
not done so.[1]                                                       Conclusion
                                                                         Reviewing the available studies, expert opinions, and
Hematologic findings and bleeding                                     recommendations by the advisory group of American
    There are a number of hematologic tests to assess the             Dental Association we can conclude that
coagulation status of a patient. Cutaneous bleeding time
results have been used over the years to assess the bleeding          1. Patient who are to undergo minor oral surgeries and
status of patients. But it is very technique sensitive and a             extractions need not discontinue antiplatelet therapy
lot of studies give evidence that cutaneous bleeding tests               if there is no previous history of excessive bleeding
are not very efficient in predicting increased blood loss                from trauma or surgeries and their laboratory tests
from dental or even orthopaedic surgeries. [7] Currently,                for bleeding and platelet functions are within the
there are numerous tests available to measure the                        normal limits.
alterations in platelet function on aspirin therapy. Among            2. For extensive surgeries a consultation with patient’s
them platelet aggregation (impedance) test is said to be                 cardiologist is to be done and the potential risks of
more accurate than cutaneous bleeding test in determining                bleeding as well as the cardiac complications involved
the adequacy of platelet functions. As little as 81 mg of                in discontinuation are to be weighed thoroughly.
aspirin will impede aggregation by this test.[7] Although             3. Elective procedures for which there is significant risk
these tests are sensitive to the effects of aspirin in platelet          of perioperative or postoperative bleeding should be
aggregation, only limited literature is available on the                 deferred until patients have completed an appropriate
effectiveness of these tests to predict the bleeding during              course of antiplatelet therapy
and after dental surgical procedures. [7]                             4. In case discontinuation of therapy is needed, it should
                                                                         be limited to a maximum of 3 days as the risks of
    In essence, at present there are no tests available that             thrombotic events increases when discontinuation is
can predict the possibility of bleeding during surgery and               between 4 – 30 days.[7]
extractions. Experts recommend a through medical history
including previous bleeding associated with trauma or                 Reference
surgery and medications that can influence bleeding to                1. Cindy L, Robert O. Bonow, Donald E. Casey, Timothy J,
be considered with platelet count and other laboratory                   Gardner, Peter B, David J. Moliterno, Patrick O’Gara

                                              SMILE - Vol. 12, Issue 1, Jan. - March 2012                                       33

     and Patrick Whitlow. Prevention of premature                          therapeutics. 11th ed , 1481-1482
     discontinuation of dual antiplatelet therapy in                   7. Michael T. Brennan, Richard L. Wynn, Craig S. Miller,
     patients with coronary artery stents. J Am Dent Assoc,                Charlotte, Baltimore and Laxington. Aspirin and
     Vol 138, No 5, 652-655. © 2007                                        bleeding in dentistry: an update and recommendations.
2.   Leon Ardekian, Ronen Gaspar, Micha Peled, Benjamin                    Oral surgery, oral medicine, oral pathology,oral
     Brener and Dov Laufer. Does low-dose aspirin therapy                  radiology and endodontology September 2007;104;
     complicate oral surgical procedures? J Am Dent Assoc                  316-321
     2000;131-335                                                      8. Royzman D, REcio L, Badovinac RL, Fiorellini J, Goodson
3.   Joel J. Napenas, Catherine H.l. Hong, Michael T. Brenan,              M, Howell H, et al. The effect of aspirin intake on
     Scott L. Furney, Philip C. Fox and Peter B.Lockhart. The              bleeding on probing in patients with gingivitis. J
     frequency of bleeding complications after invasive                    Periodontol 2004;75; 679-84.
     dental treatment in patients receiving single and dual            9. Schrodi J, Recio L, Fiorellini J, howell H, Goodson M,
     antiplatelet therapy. J Am Dent Assoc 2009; 140;690-                  Karimbux N. The effect of aspirin on the periodontal
     695                                                                   parameter bleeding on probing. J Periodontol 2002;
4.   Gautam A. Madan, Sonal G. Madan, Gauri Madan and                      73; 871-6.
     A.D. Madan. Minor oral surgery without stopping daily             10. Abualsaud AO, Eisenberg MJ. Perioperative
     low-dose aspirin therapy : a study of 51 patients. J                  management of patients with drug-eluting stents. JACC
     oral and maxillofacial surgery, Sept 2005,Volume 63,                  Cardiovasc Interv. 2010 Feb;3(2):131-42.
     Issue 9, Pages 1262-1265                                          11. Moussa ID, Colombo A. Antiplatelet therapy
5.   J. Lam, J. Bormanis, J. Cusson, A. Roussin. Clinical guide-           discontinuation following drug-eluting stent
     Antiplatelet therapy( November 2004). The thrombosis                  placement: dangers, reasons, and management
     interest group of Canada.                                    recommendations. Catheter Cardiovasc Interv. 2009
6.   Goodman & Golman’s , The pharmacological basis of                     Dec 1;74(7):1047-54.

                                               SMILE - Vol. 12, Issue 1, Jan. - March 2012                                     34
SMILE - Vol. 12, Issue 1, Jan. - March 2012   35
SMILE - Vol. 12, Issue 1, Jan. - March 2012   36

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Description: Journal of IDA Central Kerala Kottayam Branch