Reducing Risks of Bacterial Endocarditis from Dental Procedures with Oral Time Released Xylitol

Jan 30, 2019

Infective Endocarditis (IE) is a cardio vascular disease which occurs due to microbial infection and it has been one of the major concerns in patients with pre-existing endocardial damage or sometimes even in normal healthy individuals. According to research papers,  varieties of pathophysiologies leading to IE carried out globally.

As per the revised guidelines for prevention of IE by ADA and its council of scientific affairs, the classes of patients indicated for antibiotic prophylaxis have reduced considering the risk of morbidity resulting from antibiotic usage overshadowing its probable benefits.

Therefore highlighting the issue, controlling oral bacteria prior to dental procedures and overall oral care might be a more beneficial preventive modality specially for individuals at high risk for IE. Oral time released Xylitol has come up with such preventive option for Bacterial Endocarditis. It promises a good and successful preventive outcome and which can incorporated into a time release vehicle adhering to gingiva or teeth.

Various methods of reducing the oral bacterial
  • Maintenance of good oral hygiene
  • Supra and subgingival calculus and plaque clearance
  • Caries control and management
  • Management of periodontal health
  • Restricted deleterious habits
  • Usage of sugar substitutes
Xylitol as an option

Xylitol is the most commonly used sugar substitute usually in chewing gum, lozenges and syrups. According to the dental researches, usage of Xylitol four to five times a day reduces numerous pathogenic oral microbes like  S mutans, Streptococcus salivarius, Streptococcus sobrinus, Lactobacillus rhamnosus, Actinomyces viscosus, Porphyromonas gingivalis, and Fusobacterium nucleatum, Streptococcus sanguis etc. Therefore, it targets various disease mechanisms in head and neck region like periodontal infections, maxillary sinus infections and otitis media. Its regular consumption by mothers also reduces mother-child transmission.

Xylitol has also been incorporated into a time-release adhering disc called XyliMelts that can be adhered to the teeth or adjoining gingiva. Xylitol delivered in this manner is likely to be present in the mouth for longer periods of time between 30 to 120 minutes.

XyliMelts can also be used while sleeping, when saliva flow is low, potentially increasing the effectiveness of overall antibacterial action. A similar oral adhering disc called Oramoist (Quantum) designed to adhere to the roof of the mouth and release flavour to stimulate saliva containing Xylitol. Various studies have demonstrated the action of Xylitol on various microbes.

Delivery of this kind of Xylitol can be in a dissolving disc adhered to molar or gingiva. In buccal vestibule, it would easily accomplish the goal and make the process more palatably. According to the suggestion, time release disc containing one-half grams of Xylitol should be used at bedtime and after every meal. At least 4 discs per day, for a minimum of 2 grams per day can be used.

Studies are still in progress however in this regard, in order to successfully document its mechanism of action based on the above-mentioned dosage. As previously noted, this approach to the delivery of Xylitol prior to dental procedures would likely be particularly worthwhile in those with physical or mental disabilities and in frail older people where maintenance of good oral health is often problematic and where bacterial endocarditis can be a significant problem.

Concept of time released drug delivery

The goal of sustained or time released drug delivery can be achieved with the use of matrix tablets, the mechanism of action and usage of which is demonstrated with the help of following schematic representations.

The advantage of these matrix tables over the conventional counterpart lies in the fact that they offer enhanced patient compliance, minimize toxicity and maintain equilibrium of constant plasma drug concentration level. It is also a cost-effective approach which promises to maintain drug concentration within a therapeutic range, minimises the irrational use of drugs, especially antibiotics.

  • Reduced see-saw fluctuation
  • Increased safety of drugs
  • Reduced total drug dosage
  • Dose dumping
  • Difficulty in retrieving the dosage
  • Expensive formulation
  • Low patient awareness
  • Reduced potential for accurate adjustment of the case (as demonstrated by the graph below).

Oral sustained release tablets provide the drug release in a modified form which is more effective than their conventional counterparts in achieving the therapeutic goals. These products might also be recommended by health care providers other than dentists for varying reasons. Due to its key benefits and better patient compliance it will be readily accepted by the patients eventually replacing its counterparts.

  1. Soderling E, Isokangas P, et al: Influence of maternal xylitol consumption of acquisition of mutans streptococci by infants. J Dent Res 79(3):882-887, 2000.
  2. Soderling E, Isokangas P, et al: Influence of maternal xylitol consumption on mother-child transmission of mutans streptococci: 6-year follow up. Caries Res. 35(3):173-177, 2001.
  3. Badet M-C. Effect of xylitol on a model of oral biofilm. IADR abstract, 2007.
  4. Brown CL, Graham SM, et al: Xylitol enhances bacterial killing in the rabbit maxillary sinus. Laryngoscope. 114(11):2021-2024, 2004.
  5. Tapiainen T, Sormunen R, et al: Ultrastructure of streptococcus pheumoniae after exposure to xylitol. J Antimicrob Chemother. 54(1):225-228, 2004.
  6. Wilson W, Taubert KA, et al: Prevention of Infective Endocarditis, Guidelines from the American Heart Association. A Guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasake Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc. 138(6):739-745, 747-760 2007.
  7. Bashore TM, Cabell C, Fowler V Jr. Update on infective endocarditis. Curr Probl Cardiol. 31(4):274-352, 2006.
  8. Martin MV, Longman LP, et al: Infective endocarditis and dentistry: the legal basis for an association. Br Dent J. Feb 2; E15 [Epub ahead of print], 2007.
  9. Savarrio L, Mackenzie D, et al: Detection of bacteraemias during non-surgicalroot canal treatment. J Dent 33: 293-303, 2005
  10. Heimdahl A, Hall G, et al: Detection and quantitation by lysis-filtration of bacteremia after different oral surgical procedures. J Clin Microbiol 28: 2205-2209, 1990
  1. Ruba      N Khader, Morton Rosenberg, the 2007 American Heart Association Guidelines      for the Prescription of Antibiotic Prophylaxis. Journal of the      Massachusetts Dental Society,      accessed 12/14/07

Fragment reattachment / Biological restoration


Patient came with c/c of Ellis class III i.r.t 11

Coronal fractures are the most frequent traumatic injuries that affect permanent teeth. Majority of dental injuries involve the anterior teeth, especially maxillary incisors whereas the mandibular central incisors and maxillary lateral incisors are less frequently involved.

Reattachment of original tooth fragment has some advantages like natural tooth contours, texture, colour, translucency with better esthetic. Even, it enhances the durability because of natural incisal wear resistance of a sound dental tissue.


  • Offering easy reproduction of shape, contour, and texture of the natural tooth.
  • Provides unchanged colour and optical characteristics.


  • Colour change due to inadequate rehydration of the fragment.
  • Carries the possibility of detachment of the fragment.

Case Report

A 9-year-old girl reported to our clinic with a traumatic injury while playing. On clinical examination, Ellis class III fracture was present i.r.t. 11. A pinpoint exposure was seen i.r.t. 11. No symptoms of pain or swelling reported. So, Cvek’s pulpotomy using MTA was planned w.r.t. same followed by composite build up.

While doing the parental counselling on treatment, parents were explained to on the benefits of fractured tooth fragment and its consequences in the future. Parents went back to school at the injury site and found out the tooth fragment. As discussed, they immediately put the fragment in cold milk and came back.

Extremely happy to see the results of positive counselling, changed the treatment plan to Cvek’s pulpotomy using MTA followed by fragment reattachment using flowable composite resin.

cvek’s pulpotomy was done using GIC and MTA

After cvek’s pulpotomy

Tooth fragment

Etching the fragment with 37% phosphoric acid for 15 seconds.

Application of 3M ESPE (Single bond 2) bonding agent.

Light curing for 15 seconds.

Before starting full-mouth scaling was done.

Etching with 37% phosphoric acid (Sorry did’nt have teflon sheet).

Fragment reattachment using flowable composite resin.

Post operative.

No high points.

Post operative radiograph i.r.t. 11

After 6 months follow-up


It can be concluded from the case report that fracture reattachment is viable, conservative and aesthetic alternative for treatment of crown fractures. The long term prognosis is still obscure, but it is an immediate technique of aesthetic rehabilitation in the management of traumatized tooth.

Bearing in mind that it is a simple, fast, affordable, and aesthetically predictable technique. Tooth fragment reattachment should always be the treatment method of choice when the fragment is present and in good condition. Even, if a perfect adaptation is not observable.

Probiotics in Periodontics

Bacterial colonisation in the oral cavity starts few hours after a baby is born. As soon as teeth start erupting, the oral microflora starts changing. The oral cavity in adults contains more than 500 species of bacteria. Out of these, some are healthy and some are disease producing species. According to the ecological theory of plaque hypothesis, balance between the healthy and disease-producing bacteria collapse, and the disease starts developing.

With the growing number of bacteria-resistant diseases and the length of time it takes to develop new antibiotics, it might be time to consider another alternative, ‘Probiotics’, in the treatment of periodontal disease. Antibiotics indiscriminately kill harmful bacteria that cause infection and also kill good bacteria which help fight infection. Whereas probiotics increase the population of the beneficial bacteria which kill pathogenic bacteria and fight against infection. Oral administration of probiotics may also benefit oral health by preventing the growth of harmful microbiota or by modulating mucosal immunity in the oral cavity.

Probiotics are live microorganisms, when administered in adequate amounts have beneficial health effects on the host. Probiotics act as nano soldiers, referring to genera of organisms, which halt, alter or delay periodontal diseases. It poses a great potential in the arena of periodontics in terms of plaque modification, halitosis management, altering anaerobic bacteria colonisation, improvement of pocket depth and clinical attachment loss.

Probiotics can help prevent and treat disease via several mechanisms.
Direct interaction

Probiotics interact directly with the disease-causing microbes, making it harder for them to promote infection or disease. Production of antimicrobial substances against periodontal pathogens.

Competitive exclusion

Beneficial microbes directly compete with the disease, developing microbes for nutrition or enterocyte adhesion sites.

Host modulation

Probiotics improve the immune system and help prevent disease. It causes innate and acquired immune system modulation.

Probiotic bacteria or their products can modulate the immune system. Regulatory T cells are known to be very important in reducing inflammation in response to non-pathogenic antigens. It has been suggested by recent studies that toll-like receptors may mediate interaction between T lymphocytes, dendritic cells and mast cells. These interactions help in modulating response. This mechanism of action is similar to what is observed in the gastrointestinal tract. Probiotic bacteria also produce various metabolites like bacteriocin, free fatty acids, bacteriocin and bacteriocin like substance which inhibit the growth of another pathogenic organism thus enabling them to colonise the oral cavity.

One of the essential characteristics of a probiotic to exert oral effects is by far the property of colonisation in order to integrate into the oral microbiome and maintain balance. This is a direct mechanism of action to inhibit the periodontal pathogens. Whereas indirect mechanism would include competitive exclusion by means of competing for nutrients and growth factors thereby passively creating niches for colonisation and actively reducing the adhesion capacity of pathogen in the oral cavity.

Probiotics compete for adhesion sites, aggregate, compete for nutrients and growth factors, produce antimicrobials, enhance the host immune responses, inhibit pathogen induced production of pro-inflammatory cytokines, decrease MMP production leading to inhibition of pathogen adhesion by antagonism and reduction of tissue destruction. According to the ecological plaque hypothesis, selective pressure in environmental conditions can change the balance between oral health and disease.

Since bacteria are capable of influence the environment by both synergistic and antagonistic interactions, the environmental pressure in the ecological plaque hypothesis is partly introduced by them. It is well known that normal microbiota protects the oral cavity from infections; similar to species associated with oral diseases, there seem to be species associated with oral health.

Bacteria used as a probiotics

  1. Streptococcus salivarius
  2. Lactobacillus salivarius
  3. Lactobacillus reuteri
  4. Lactobacillus acidophilus
  5. Lactobacillus rhamnosus
  6. Lactobacillus plantarum
  7. Lactobacillus paracasei

Delivery of the probiotics

In the forms of tablets, powder, mouthwash and chewing gums probiotics can be easily delivered to the oral cavity.

1. For treatment of gingivitis and periodontitis

Various periodontal diseases, gingivitis, periodontitis and pregnancy gingivitis were locally treated with a culture supernatant of aL.acidophilus strain. Using probiotics in treatment of periodontal diseases improve gingival health, as measured by decreased gum bleeding.

Use of tablets containing L. Salivarius WB21 has shown decrease in gingival pocket depth, in heavy smoker groups. It also affects the number of pathogens in plaque. Mouthwash containing strains of L.reuterri or tablets containing 6.7 x 108 colony forming units of L. salivarius and Xylitol [280 mg/tablet] has shown decrease in gingivitis and plaque formation. Also 14 days intake of L. reuteri led to the establishment of the strain in the oral cavity and significant reduction of gingivitis and plaque in patients with moderate to severe gingivitis.

2. Halitosis

Halitosis is not s disease but a discomfort, although some oral diseases including periodontitis may be the underlying cause; however, in approximately 90% of cases, the origin can be found in the oral cavity and probiotics are marketed for the treatment of both mouth and gut-associated halitosis.Streptococcus salivarius K12, a pioneer colonizer of oral surface and predominant non-disease-associated member of the oral microbiota of healthy humans, have been effectively used as a probiotic to replace bacteria implicated in halitosis.


The micro bacteria, although invisible to the naked eye, should not be underestimated as a key determinant of health and disease. The oral microbial ecosystem is essential in maintaining both oral and overall health in the body. The microbial equilibrium is maintained within the oral cavity by the salivary flow and biofilms on the teeth and soft tissue. Pathogen activity initiation can lead to oral diseases if the homeostasis of the oral cavity is disturbed. Since the oral cavity is a primary gateway to the body, severe cases of oral diseases may result in the spread of infection to other body sites, producing systemic diseases or aggravating an already compromised immune system. Practicing good oral hygiene and maintaining stable oral biofilms is indispensable to keeping body healthy and also preventing rapid spread of disease to other individuals. Probiotics offer a natural and promising option to establish this.


  1. Teughels W, E V Mark, Slipen I and Quirynen M. Probiotics and oral healthcare. Periodontology 2000, Vol. 48, 2008, 111–147.
  2. Krasse P, Carlsson B, Dahl C, Paulsson A, Nilsson A, Sinkiewicz G. Decreased gum bleeding and reduced gingivitis by the probiotc Lactobacillus reuteri. Swed Dent J 2006; 30:55-60.


The Secret to success in Dentistry

The Secret to success in DentistryThe Secret to success in Dentistry

A successful dentist is one who seamlessly manages his work and daily chores hassle-free. In dentistry, success depends on myriad aspects. Managing a clinic and life outside of work are their key priorities to accomplishing both at the same pace can be arduous task. Most dentists who are working as entrepreneurs make mistake of focussing only on one aspect, whilst ignoring the other.

Dental professionals lean toward pursuing specialised training to enhance their technical skills for career growth. Training helps them to easily perform critical dental cases with skill and dexterity. During their training, dentists learn to develop their leadership traits and motivate patients to give more priority to their health and wellness. These training sessions aid them to monitor some prime roles that can exhibit in their staff management. All these aspects help render a successful business, but it doesn’t help from the clinical aspect.

Specialised trainings not only helps them perform well in their professional field but also teaches them to interact with their patients. Dentists learn how to encourage their patients to take care of their health, as their mouth is the window of overall well being. A self-contemplation mindset helps dentists flourish in their career after identifying their strengths and weaknesses.

Investing in dental equipment and aids helps accomplish their goals better, faster and with ease. Modern amenities provide dentists and patients reliable and immediate information. It surges the number of new patients and helps alleviate in lull business environment.

Success ideas

  • Have a clear business vision: Vision without action is merely a dream, but vision with action can change the world. So, having a clear vision would help in business growth.
  • Create an open culture atmosphere: Working in a right and healthy environment helps everyone to grow in their professional sphere. Assigning specific goals and attainable staff goals.
  1. Greet patients by name
  2. Making them feel relaxed and comfortable
  3. Maintain eye contact with patients
  4. Introduce yourself with a smile and handshake
  5. Explaining the procedure cost, duration and services offered
  6. Gain their trust
  • Invest in upgrading skills and training for staff: Training in quantitative methods will boost dental services and help to build a strong team. So, investing and training for staff are important for better results.
  • Always have a goal and know what you do before proceeding: Detailed study of patients and clarity in their symptoms and diagnosis helps bring about a positive outcome.
  • Love what you do and offer quality advice: Quality over quantity in the dental care segment is driven by sheer passion. Quality work burgeons the number of patients.
  • Make a good impression in the first visit of the patient: It is highly important to create the best impression at the first meet. First impression is the last impression; so positive greeting, attitude and answering the patients with lot of patience and compassion helps to build a dentist-patient relationship and thereby a good dental practice.
  • Understand patient needs and wants to be served: Dental professionals should give more importance to patients need and wants. Taking care of patients help to build a good business.
  • Develop an immense patience attitude: Dental staffs should inculcate patience for their clients; they should devote a prerequisite time to each patient.
  • Develop a positive attitude towards your work: A positive attitude will help to develop a cycle of success and boost the confidence level of patience, staff, colleagues, etc. It helps to perform the task in a great way.

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DISCLAIMER : “Views expressed above are the author’s own.”

Evidence based Dentistry – Need of the hour

Oct 25, 2018
Evidence based Dentistry - Need of the hourEvidence based Dentistry - Need of the hour

“Continuous learning is a minimum requirement for success in any field”

Brian Tracy

A dentist will come across innumerable clinical scenarios during their practice. While working in a chain of dental clinics, I came across a case of Squamous Cell Carcinoma in a middle aged woman. While discussing about the possible treatment options, we all focused on surgical excision and chemotherapy. We had recruited a dentist, who was a fresher, he told us about an alternative option called chemoradiation using Cisplatin. This made realise the importance of evidence based dentistry and continuous dental education.

Fresh graduates from dental schools are more likely to be up-to-speed with recent advances in technology, science, therapy, treatment in current dentistry. Some of this knowledge gradually becomes obsolete as new information and research appears. It is important especially with regards to patient safety, for dentists to keep in the know with development in diagnosis, prevention and treatment of oral diseases along with newly discovered causes of the diseases.

What is evidence based dentistry?

The concept of evidence based dentistry was introduced in 19th century and referred to as conscientious, explicit and judicious use of best current practise in making knowledge based decision in the care of an individual patient.

As accepted by the FDI, evidence based dentistry is an approach to oral healthcare that requires a judicious integration of:

  • Systemic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with
  • the dentist’s clinical expertise, and
  • the patient’s treatment needs and preferences.

Evidence based dentistry is an inter-disciplinary approach that emphasises on utilisation of evidence and conducted researches to optimise decision making and improve treatment outcomes. It is like climbing a mountain to get a better view.

Attitudes have dramatically changed thanks to the internet over the past few years. Patients want to know about the treatment they are undergoing, the outcomes of the treatment and the options available to them. On the flip side, dentists encounter different drug companies advertising new drug formulations. How does one decide whether to go for a particular drug or not? The answer to the question is evidence based dentistry. Throughout their career, a dentist needs to know from where to obtain information and more importantly how to interpret that information correctly. Evidence based dentistry simply put is nothing but combining correctly interpreted information with the clinical knowledge to make judicious decisions.

Why do we need evidence based dentistry?

Patients respond differently to exposure or treatment. To understand this better consider the following two examples.

Given these two examples how can we say that smoking is the cause of periodontitis?

Acute Ulcerative Gingivitis can be treated with the antibiotic metronidazole.

Why is that not every patient given metronidazole recovers from the disease?

Given this how can we say that metronidazole is an effective?

We cannot always afford more than a few minutes per patient for finding and assimilating evidence regarding people responding differently to same exposure or same treatment. This is where evidence based dentistry comes into play. Clinical research allows us to make decisions about causes of and possible treatments for the disease.

Evidence based dentistry is founded on clinical research.

Where to search for reliable information?

  • Journals
  1. Evidence based dentistry
  2. Journal of evidence based dental practise
  3. Dental research papers are often published in journals such as  British Dental Journal, American Journal of Dentistry, Community Dentistry and Oral Epidemiology, Journal of Clinical Periodontology and Journal of Paediatric Dentistry.
  • Electronic Databases
  1. Medline
  2. Pubmed
  3. Embase
  • Academic Databases of Systematic Reviews
  1. The Centre for Evidence Based Dentistry
  2. The Cochrane Library
  3. Cochrane Collaboration
  4. The Cochrane Oral Health Group
  5. The Centre For Review and Dissemination
  • Applying obtained information in the clinical practise

It is important to ascertain that the available evidence is reliable before applying it to a patient in terms of diagnostic tests or therapies. One must consider research with strong supporting evidence, it should be backed up by at least one systematic review of multiple well designed randomized clinical trails.

  • Limitations

Even though evidence based dentistry helps dentists in clinical decision making the overload of information available nowadays which is growing at an exponential rate is sometimes confusing for the dentist.

There is concern regarding quality of studies on which evidence is based. Studies may have excluded the type of patient for whom we are studying the evidence. Therefore it is important to strengthen the evidence base before disseminating it.

  • Conclusion

For an effective future dental workforce, it is important to be able to assess and synthesize the dental literature in order to cope with the ever growing research and new developments going on in the field of dentistry. It will improve the clinical outcomes of therapy and improve cost effectiveness thereby reducing the economic burden on the patient.

Never become so much of an expert that you stop gaining expertise. View life as a continuous learning process.”

Dennis Waitley

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DISCLAIMER : “Views expressed above are the author’s own.”

Women, Well-being and Oral Care

Women, Well-being and Oral CareWomen, Well-being and Oral Care

It is rightly said The mouth is a window of overall health.” It can reveal a number of symptoms, conditions, diseases in our body. Women go through various hormonal changes during different phases of her life which may influence her periodontal health to a great extent and periodontal diseases in turn have an influence on her overall well-being.

Gingival alterations during puberty, pregnancy, and menopause are associated with physiologic hormonal changes in a woman’s life stages. These can be seen as follows:

During puberty there is often an exaggerated response of the gingiva to plaque. Pronounced inflammation, edema, and gingival enlargement accompanied by bleeding resulting from local factors. This can be prevented with good oral hygiene.

During menstrual cycles, bleeding or bloated, tense feeling in the gums is often experienced. Preexisting gingivitis often gets aggrevated during this time.

Hormonal changes during pregnancy accentuate the gingival response to plaque and modify the resultant clinical picture. Tooth mobility, pocket depth, and gingival fluid are also increased during pregnancy.

The greatest severity is experienced between the second and third trimesters. Pronounced ease of bleeding is the most striking clinical feature. The gingiva is inflamed and varies in colour from bright red to bluish red. The marginal and interdental gingivae are edematous. They pit on pressure, appear smooth and shiny, are soft and pliable, and sometimes have a raspberry-like appearance. In some cases, the inflamed gingiva forms discrete “tumour like” masses, which are referred to as pregnancy tumours.

Hormonal Contraceptives aggravate gingival response to local factors in a manner similar to that seen during pregnancy. This invariably increases periodontal destruction.

During menopause, the usual rhythmic hormonal fluctuations in the woman’s cycle end as estradiol ceases to be the major circulating oestrogen, as a result, women tend to develop a gingivostomatitis. The gingiva and the remaining oral mucosa are dry and shiny, colour varies from pale pink to red, and bleed easily. Patients complain of a dry, burning sensation throughout the oral cavity that is associated with extreme sensitivity to thermal changes; abnormal taste sensations described as “salty,” “peppery,” or “sour.”

Problem of low birthweight (including preterm birth) Worldwide, in all population groups, birth weight is the most important determinant of the chances of a new born infant to survive, grow and develop healthily. It is important to state that birthweight is an unrefined measure of fetal growth; associated with increased risks of adult conditions such as cardiovascular disease, diabetes and obstructive lung disease.

The international definition of low birth weight adopted by the Twenty-ninth World Health Assembly in 1976 is a birthweight of ‘‘less than 2500 g’’. Low birth weight can be as a result of both a short gestational period and retarded intrauterine growth.

Multifactorial nature of risk factors for preterm rupture of the membranes and premature labour.

By definition preterm low-birth-weight infants result from a shortened gestational period. Poor socioeconomic conditions, stress and anxiety, high maternal physical workload and maternal education have been shown to be related to increased rates of preterm birth.

Simplified scheme of some of the putative mechanisms involved in preterm labour and premature rupture of the membranes.


It is suggested that prostaglandins and proinflammatory cytokines play a pivotal role in the labour initiation process. Given the close relationship between inflammation and infection, it seems likely that alterations to the levels of these inflammatory mediators resulting from the normal host response to an infectious agent may represent the key mechanism through which infection is linked to preterm low birth weight. Tumour necrosis factor alpha and interleukin – 6 have been shown to cross human fetal membranes in an in vitro culture study. The possibility that periodontal gram-negative infections may be important with respect to preterm birth has come from an Offenbacher S, 1995 in which periodontal disease was shown to be a significant risk for preterm birth. The infected periodontium can also be regarded as a reservoir for both microbial products and inflammatory mediators. Local prostaglandin E2 and both local and systemic tumor necrosis factor alpha levels have been shown to be increased in periodontitis. Findings suggest that infection with P. gingivalis may affect human pregnancy outcome.


Periodontal diseases share many common risk factors with preterm low birth weight. The inflammatory mediators that occur in the periodontal diseases play an important part in the initiation of labour, there are plausible biological mechanisms that could link the two conditions which leads to preterm low birth weight infants many of which fight for survival.

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DISCLAIMER : “Views expressed above are the author’s own.”

Vital Pulp therapy in primary teeth: An update

Sep 27, 2018
Vital Pulp therapy in primary teeth: An updateVital Pulp therapy in primary teeth: An update

Growing up our parents had interesting elucidations to advocate our shedding of teeth: the famous story of tooth fairies, but how well is it known that tooth fairies do not only replace the milk teeth but also can save them in case of germ attacks? We dentists, are nothing but the real-world version of tooth fairies who have established advanced supremacies and technologies to save the deciduous dentition from intentional extractions and early exfoliations. With increasing carbohydrate diet in children like excessive consumption of sugar-coated chocolates or milk through bottle overnight, the early childhood caries and rampant caries have been trending diagnosis before clinicians, and therefore in the era of aesthetic and conservative dentistry, the preferment of conservation and minimal intervention in dentistry has taken a flight toward the horizon. Saving deciduous teeth is necessary before its natural exfoliation and this can be achieved beautifully in technological dentistry termed as Pulp Therapy’.  Pulp Therapy or Vital Pulp Therapy is a technique which is supported through combination factors out of which the first main factor being the early diagnosis and treatment planning. It not only helps in preserving the arch integrity by sidestepping malocclusion but also upholds the confidence of patients and preserves their smile without hampering their daily chores. Other factors include peri-radicular area disinfection, homeostasis, blood supply to the teeth and severity of inflammation.

Vital pulp therapy has two different but significant approaches which can be broadly classified as indirect pulp capping and direct pulp capping. To understand the concept, a need for early diagnosis is necessary; early diagnosis as in, if a tooth has no signs and symptoms of pulp involvement with minimal or no inflammation, then condition of reversible pulpitis can be treated by the technique indirect pulp capping, whereas in case the injury has reached the pulp but vitality and integrity is still preserved, treatment regime follows direct pulp capping route, both being the treatment of choice in case of a vital tooth. When we discuss vital pulp therapy via its treatment regimes, indirect pulp therapy includes restoration of deep dental caries along with use of biomaterials like mineral trioxide aggregate and bio dentin, these help in regeneration of tooth structure such as dentin lost by destructive demineralising activities of caries. Indirect pulp capping can be defined theoretically as “a procedure on which a material is placed on a thin partition of remaining carious dentin that, if removed, might expose the pulp in immature permanent teeth. This technique shows some success in teeth with the absence of symptomatology and with no radiographic evidence of pathosis” By these procedures we not only achieve the goals of minimal intervention dentistry but also, we move from extension for prevention to prevention of extension, and as an end consequence we have a vital tooth with its complete functionality achieved. Direct pulp capping, on the other hand, is a small exposure to a pulp with an intent to conserve the vitality of the tooth. The main component of direct pulp capping refrains itself to pulpotomy procedures.

Pulpotomy is defined theoretically as “surgical removal of entire clinical pulp, leaving intact vital tissues in the canal, followed by placement of a medicament or dressing over the remaining pulp stump in an attempt to promote healing and retention of this vital tissue.” In a concept of clinical dentistry, a pulpotomy is a procedure which refers to removal of the effected or infected pulp horns, it is classified into two broad types as partial and total pulpotomy. Apart from these broad types, it can also be classified as devitalisation, preservation and regeneration practices. A partial pulpotomy is precise removal of a small portion or single vital coronal pulp horn and preservation of the remaining coronal and radicular pulp, usually done in posteriors which have multiple pulp horns and in case teeth are subjected to trauma, a modification is suggested termed generally as Cvek Pulpotomy. It involves removal of 2mm of inflamed coronal pulp with a sterile bur with a high-speed handpiece cooled with a sterile solution. Another pulpotomy method which has been advocated studied and modified by famous dental practitioners like Sweet, Doyle, Garcia and Godoy is clinically termed as Formocresol Pulpotomy or 5-minute pulpotomy. The exact magic of formocresol pulpotomy is through the agent called Buckley`s solution, which is nothing but 20% formocresol in 1:5 dilution. Formocresol binds and renders tissue incapable of autolysis, but capable of replacement by granulation tissue. It would not be incorrect to address formocresol pulpotomy as total pulpotomy where involvement of all the coronal pulp horns in posteriors and complete coronal pulp in anterior teeth takes place, gradually following the principles of devitalisation technique of pulpotomy. The other devitalisation techniques include electrocautery and lasers whereas in preservation pulpotomy agents like glutaraldehyde and ferrous sulphate are used in regeneration technique, it is inductive that there is the formation of calcific barrier or introduction of reparative dentin through agents like calcium hydroxide and bone morphogenic proteins.

Clinically, when the infection is extending beyond the coronal pulp and the periapical region is involved, as seen in the majority of the cases, the clinicians prefer to go with the procedure of pulpectomyPulpectomy is again theoretically defined as “removal of entire pulp and subsequent filling of the canals of the primary teeth with a certain resorbable material.” This procedure can be broadly classified based on the complexity of the case, as in single visit pulpectomy and multi visit pulpectomy.

The materials used in vital pulp therapy procedures are a matter of importance for any general practitioners, after all, it decides the fate of the teeth which is of key importance as discussed earlier in pulpotomy procedures, formocresol in the form of Buckley`s solution is a key important material. Formocresol has been debatable due to its three main harmful effects were seen almost in 10-15% of cases and local toxicity is a predominant adverse effect where actual healing of the pulp is never seen but a vital pulp starts progressing towards devitalisation. In certain cases, systemic toxicity is also observed with formocresol which is playing a key role in tampering with the DNA and RNA functionality and metabolism periods. The effect of formocresol on succedaneum tooth formation is also a key concern for practitioners. In pulpectomy procedures, the focus of practitioners has always been obturation of the canals with deciduous teeth were subjected to root resorption. Gutta Percha has always been out of the question but instead of that various materials like Zinc Oxide Eugenol, Iodoform paste, Calcium Hydroxide and Mineral Trioxide Aggregate are used. The trending material advocated widely by practitioners in India as well as abroad is Mineral Trioxide Aggregate which is a most biocompatible pulp-capping agent as of now with a compressive strength of 40 Mpa rising towards 60 Mpa roughly for a period of one month. The solubility rate is very low but it is commercially expensive. This material is an update which is preferred widely due to its capability of tissue regeneration, mutagenicity and reactivation of cementogenesis and dentinogenesis along with regeneration of periodontal ligament.

Vital pulp therapy in primary teeth is a necessity in current generation when dentistry is reaching heights of preservation of natural teeth. Early loss of deciduous teeth is not a good indication as the occlusion of succeeding permanent teeth depends on the existence of these teeth. These procedures not only help to maintain the occlusal integrity of the arch but also help in providing dentistry with a new standard in conservative medical science. The trending research on these procedures further includes achieving atraumatic and more biocompatibility procedures for patient co-operation and comfort and also understanding the commercial availability of dental materials for ease of cost reduction and longevity of the treatment.


¹page 278; Pulp therapy; Principles and practice of Pedodontics by Arathi Rao, third edition:2012, ISBN: 978-93-5025-891-0

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DISCLAIMER : “Views expressed above are the author’s own.”

What is Bioactive Dentistry? A Review

What is Bioactive Dentistry? A ReviewWhat is Bioactive Dentistry? A Review

As we all know, the traditional materials commonly used in dentistry are passive and inert, i.e. they exhibit little or no interaction with body tissues and fluids. In the past, materials were thought to be ideal and biocompatible based on their ability to sustain without interacting with the oral environment. However, the current trends are changing due to the advancements in material science. Many of the advanced materials are required to be functionally beneficial, playing an active part, thereby working with dental tissues to remineralize and heal them.

Materials used in dentistry can be classified as bioinert (passive), bioactive, and bioresponsive or smart materials based on their interactions with the environment. As the name suggests, a bioactive substance is one that has an effect on a living organism, tissue or cell. The concept of bioactivity was first introduced in 1969 and later defined by Cao and Hench in 1996. In general, it refers to a specific property of a material that has an effect on or will elicit a response from a living tissue or cell, such as induc­ing the formation of hydroxyapatite. Perhaps the benefits of fluoride release from materials attracted the use of active materials rather than passive ones in dentistry. However, bioactivity is not just limited to fluoride release and the conversion of hydroxyapatite to its stronger form of fluorapatite anymore! The definition of bioactivity in dentistry is expanding by leaps and bounds due to the emergence of bioactive dental materials in the market.

Some of the bioactive materials available are calcium hydroxide, mineral trioxide aggregate (MTA), calcium enriched mixture (CEM), Biodentine, Doxadent, Ceramir, Bioaggregate, Activa BioACTIVE restorative material, MTYA1-Ca filler, tetracalcium phosphate (TTCP), Theracal, sol-gel-derived bioactive glass (BAG) ceramic containing silver ions (Ag-Bg), calcium phosphate, fluoro calcium phosphosilicate, novel endodontic cement (NEC), endo sequence root repair material.

The ideal properties of bioactive materials are: bactericidal or bacteriostatic, sterile, stimulate reparative dentine formation and maintain pulp vitality. The bioactive materials have been put to various uses in dentistry such as pulp capping material, permanent restorations, root canal therapy, dentinal tubule occlusion in dentinal hypersensitivity cases, to act as scaffold to help in the regeneration of bone tissue, for tooth repair & regeneration, periodontal regeneration, to promote tooth remineralization, bone grafts, implant coating etc.

Bioactive materials are currently a significant topic of interest in restorative dentistry for regeneration, repair and reconstruction. This is evidenced by the change in the com­positions of restorative materials away from inert “fillers” and more toward being biologically adaptive materials. A bioactive dental restorative material is one that forms a layer of hydroxyapatite when immersed in a simulated body fluid or a solution containing inorganic phosphate. This is possible by induction of various growth factors to stimulate nat­ural mineralization. Imagine being able to re-calcify a carious tooth?? Sounds amazing! Isn’t it?? It’s no longer an imagination! The advent of bioactive dental materials has made it a possible reality.

The luting and restorative materials that have been used in the past merely restore the form and function of the tooth, but are not influential on the activity of the oral environment. They do not provide a continuous seal, resulting in micro-leakage and marginal failure of crowns, inlays, and veneers. Furthermore, these materials typically function at a continuous and constant pH, which causes the materials to fail, creating crevices where plaque can build up and secondary caries even before the restoration fails. On the other hand, bioactive restor­ative materials, such as bioglass, glass-ceramic, calcium phos­phate ceramic, composites, and coatings, are able to stimulate the biological tissue of the tooth and/or bond to living tissues. Therefore, the hope for bioactive materials is that they will prevent micro-leakage by forming apa­tite, which will provide a continuous seal to the margins between the restoration and tooth thereby extending the life of the restoration. Moreover, bioactive materials may also help to re-establish minerals lost to caries.

Apart from that, bioactive materials are considerably less harmful to local and generalized tissues. Additionally, these materials have been shown to considerably enhance the aesthetic outcome of restor­ative dental procedures. This evolution of materials and compo­sitions that display greater interactions with tooth structure is the drive for the future, as seen by the following trend of bioac­tive material compositions from zinc phosphate to polycarboxylate to glass ionomer cements.

ACTIVA BioACTIVE-RESTORATIVE (Pulpdent) is a composite resin that is more bioactive and releases more fluoride than glass ionomer cement, which is particularly useful for patients with high caries indices. There are a composite material, Beautiful II and Beautiful Flow Plus (Shofu Dental) with a Giomer glass filler. While Giomers do not release calcium and phosphate ions, they do release many other basic ions that can help buffer the effects of the acid environment in the oral cavity helping to inhibit plaque accumulation on restorations and at the margins. Examples of luting agents currently available in the market which have been shown to have bioactivity are ACTIVA BioACTIVE-CEMENT (Pulpdent), Ceramic Crown and Bridge (Doxa), and biochem Universal BioActive (NuSmile).

Experiences with calcium hydroxide as a lining material for resto­rations located close to the pulp has greatly influenced the initia­tive to develop bioactive lining materials rather than just biocompatible ones. Placement of a bioactive liner in deeply carious teeth can help remineralize and rebuild the remaining affected dentin after infected dentin removal, returning to healthy dentin. Examples of bioactive cavity liners available in market include ACTIVA BioACTIVE-BASE/LINER (Pulpdent) and TheraCal LC (BISCO Dental Products), and both have been shown to exhibit bioactive properties based on the mentioned definition of bioactivity. The calcium silicate chemistry of TheraCal LC enables this material to be used on pulp exposures. Biodentine (Septodont) is a tricalcium silicate material, which can be used as a bioactive build-up material where large areas of tooth structure are missing, and when a pulp exposure or root perforation may exist. While some of the more heroic cases may eventually still require endodontic therapy, there will be many cases that will respond favorably thus avoiding an additional procedure and preserving the vitality of the tooth.

Dentinal hypersensitivity is traditionally treated by occluding the dentinal tubules. The conventional toothpaste or professional prophylaxis materials use a soluble source of fluorides such as sodium fluoride and sodium monofluorophosphate which are washed away and lose their effect more quickly. Nowadays toothpaste incorporating bioactive glass has the additional benefit of remineralization, thereby significantly reducing dental decay apart from their ability to solve tooth sensitivity. They adhere to tooth structure through a special polymer, from where it slowly dissolves ions that form Fluorapatite, over an 8–12 hour period to make teeth more resistant to acids from food. One such example is the Elsenz toothpaste (Group Pharmaceuticals Limited) which releases the controlled level of fluoride for up to 12 hours.

The area of regenerative dentistry has been affected more by the use of bioactive materials than by biocompatible materials. Dentin extracellular matrix proteins contain growth factors to promote tooth healing and pulp regeneration via stimulation of pulp stem cells. Denton can stimulate reparative mineralization of the coronal pulp and occlusion of the lumen of the root canal. Biomaterials such as Emdogain contain porcine proteins that help in periodontal regeneration following gum disease or injury. N-Butyl-2-cyanoacrylate is widely used for filling and repair of bone defects. Implants coated with hydroxyapatite are available to promote osteogenesis and bone healing.

The emergence of bioactive materials is a boon for dentistry and a promising alternative to their inert counterparts. Restorations and adjunctive materials will no longer just occupy the space between themselves and the surrounding tooth, but will help repair and sustain healthy tooth structure allowing our patients to have a better chance to enjoy a healthy dentition throughout their lifetime! However, there is scope of improvement and further development of bioactive materials used in dentistry. We are yet to reach a stage where materials can completely emulate biological systems.


  2. Badami V, Ahuja B. Biosmart Materials: Breaking New Ground in Dentistry. The Scientific World Journal 2014; 2014.
  3. Asthana G, Bhargava S. Bioactive Materials: A Comprehensive Review. Sch J App Med Sci 2014; 2 (6E): 3231-3237.
  4. Bhushan M, Tyagi S, Nigam M, Choudhary A, Khurana N, Dwivedi V. Bioactive Materials: A Short Review. J Orofac Res 2015; 5(4):138-141.
  5. Abbasi Z, Bahrololoom ME, Shariat MH, Bagheri R. Bioactive Glasses in Dentistry: A Review. J Dent Biomater 2015; 2(1):1-9.
  6. Sonarkar S, Purba R. Bioactive materials in conservative dentistry. Int J Contemp Dent Med Rev 2015.

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DISCLAIMER : “Views expressed above are the author’s own.”

Technology expands the scope of general practice

Technology expands the scope of general practiceTechnology expands the scope of general practice

The future prospects of dental profession lie in modern technology. Latest dental technology plays a crucial role in empowering general dentistry and provides the best treatment to its patientDental field has dynamically evolved in scientific understanding and technology. This has offered better dental solutions and broadened the horizons which enable dentists to improve the quality of treatment being provided to patient.

In what ways can technology improve our dental practice? Well, it has facilitated simplification of complex procedures that dentists once dreaded to take up. This has helped in providing superior and comfortable patient experiences for them. A host of innovations in dental care have created avenues for easy access and lower costs of dentistry. Newer technologies enable patient to be treated with less-invasive methods and better care. In a short span of time, dentists are providing the high standard treatment to its patient. Technological developments have transformed modern-day dental practice significantly beginning from diagnostics to high-end surgical procedures.

Intraoral Camera

Any patient walking into a dental clinic will be intraorally examined first. Intraoral camera is a lightweight tool to produce accurate images of teeth and oral cavities. This camera is available in most of the dental clinics to visualize dental problems. They serve as an excellent patient education tool with higher case acceptance rate and improved patient communication.

Digital Radiography and Teleradiology

Radiovisiography (RVG) has digitalized diagnostic dentistry which eliminated the requirement of dark rooms and processing. In a few seconds, the radiographs can be viewed on the monitor. They offer image enhancement which provides precision in the analysis of minute features such as cracks and caries that cannot be sensed using traditional film-based radiographs. Teleradiology has made it possible to take the opinion of radiologists and other dentists staying far off places.

Cone Beam Computed Tomography (CBCT)

Cone beam computed tomography (CBCT) has gained widespread popularity in recent times with vast areas of applications in dentistry. It has revolutionized implant planning enabling precise implant placement, viewing root canal anatomy and missed canals in endodontically treated teeth, the location of impacted teeth, dental traumatic injury detection, vertical root fracture detection, tumours and cysts. The 3D reconstructed images can serve as an excellent patient education tool.

Caries Diagnostics

Dental caries has been traditionally detected at the cavitation stage. Caries diagnostics classically meant examining the tooth and its softness at the base of the cavity resulting in operative management. The advent of non-invasive techniques including DIAGNOdent, Quantitative Light-induced Fluorescence (QLF), fibre-optic transillumination (FOTI), optical coherence tomography (OCT) and electronic caries monitor (ECM). These have created awareness among dentists regarding the importance of detecting non-cavitated lesions. Early detection will help in preservation of the tooth structure and its preventive management techniques.

Bioactive Dentistry

The introduction of smart materials has enhanced the restorative dentistry arena making remineralization a reality. Success with biomimetic materials and progress in tissue reconstruction with stem cells has opened new doors to restoration, replacement and repair of tooth loss structure. This will enable patients to sustain a healthy dentition throughout their lives.


In spite of undergoing for preventive and restorative measures, there will a tooth that needs to be replaced with a crown or bridge. Currently, computer-assisted design/ computer assisted manufacture (CAD/CAM) is employed to mill a tooth from a 3-D scan.

3-D Printing

3-D printing is the next big thing and it is being employed in dentistry to replace crowns, bridges and dental veneers. It is even possible to incorporate tooth decay-fighting chemicals into 3-D printed teeth. Other forms of bio-printing include building a jawbone lost due to periodontal disease and tumours.

Conscious Sedation

Anxiety control is an integral part of dentistry. Due to safety factor and effectiveness, conscious sedation using nitrous oxide is being utilized by more dentists. The patient remains conscious and is able to respond to verbal commands. So, needles are not required to calm down anxious and pediatric patients.

Dental Loupes

The magnification provided by dental loupes has made it possible to work with high visual performance.

Single Visit Root Canal Treatment

Endomotors, electronic apex locators and rotary endodontic files have made single sitting root canal treatments which are easily available to patients, eliminate their long and repeated appointments.

Laser Dentistry

The advent of lasers into dentistry has provided bloodless surgical procedures with minimized post-operative inflammation and almost painless healing period. Currently, lasers are replacing conventional, high-speed drills to treat tooth decay painlessly, gingival and periodontal disease, teeth whitening and surgical biopsies.


Invisalign consists of a series of clear, practically invisible customized removable aligners that gently straighten the misaligned teeth without undergoing the discomfort of wearing heavy metal braces. Patients will no longer have a metallic smile with diet restrictions.

Implants & Osseointegration Monitor

Implants are screw retained prosthetic replacements for missing teeth with the strength and feel of a natural tooth. Advancements in implant technology have led to improved treatment outcomes in recent times. Nowadays devices are available to precisely monitor osseointegration which makes it possible to view and store the measurements.

ZOOM! Whitening

Zoom! Whitening is a new state of the art whitening treatment that gives fast and easy results in one appointment. The latest treatment will make your teeth up to eight shades whiter.


Nanotechnology is yet another highly researched area which can haul oral health care to unprecedented heights. Nanoparticles can be utilized for tissue engineering, local drug delivery systems, prosthesis, implants, restorative dentistry, dental nanorobots for local anaesthesia. Oral fluid nanosensor test (OFNASET) and oral cancer diagnostics are few of the applications.

Oral Cancer Screening

The major goal of oral cancer screening is early detection to provide a greater chance of cure. Early detection of malignant disorders is made possible by recent advancements in screening of oral premalignant lesions that too, at the molecular level. VELscope is a simple process for the enhanced visualization of oral mucosal abnormalities including potentially malignant disorders and cancer. ViziLite is a painless screening tool for detection of small changes in oral mucosa and monitors abnormalities in patients at an increased risk for oral cancer. Other methods include spectroscopy, optical coherence tomography, immunohistochemistry etc.

A Peek into the Future?

It may not be wrong to anticipate technological advances that will allow patients to scan their own teeth in the comfort zone of their homes using their smart phones. This data can be analyzed and shared with the dentist to schedule an appointment for the appropriate procedure. It’s just a matter of time when all this will be possible.

The constant demand for new innovative solutions to dental care has helped in the advancement and evolution of dental research to best suit patient needs. The future of dentistry looks very different than present practice: no noisy drills, no painful injections, self-healing teeth, easier access and shorter treatment appointments. There will be greater emphasis on prevention leading to fewer diseased states. On an endnote, technological improvement has simplified dental practice with less invasive treatment options for patients. It is definitely transforming dentistry for the better.


  1. Drake D. Technology Expands the Scope of the General Practice. Dent Today 2017 Mar; 36(3):58, 60-1.
  2. Porter Y. Technology in practice: Its impact on Practitioners, Patients, and Dental Hygiene Education. The Healthcare guys 2018 Jan.
  3. Gomez J. Detectin and diagnosis of the early caries lesion. BMC Oral Health 2015; 15 (1): S3.
  4. Gupta S, Rakesh K, Gupta OP, Khanna S, Purwar A, Verma Y. Role of Nanotechnology and nanoparticles in dentistry: A review. IJRD 2013; 3: 95-102.
  6. Guynup S. How Technology is changing dentistry. Scientific American 2016 Oct.

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DISCLAIMER : “Views expressed above are the author’s own.”

Trauma and nerve damage to teeth (Part II)

Trauma and nerve damage to teeth (part 2)Trauma and nerve damage to teeth (part 2)



  • Concussion refers to vascular structures at the tooth apex and periodontal ligament resulting in inflammatory edema
  • No displacement, only minimal loosening of tooth occurs
  • May result in mild avulsion of the tooth from its socket causing occlusal surface to make premature contact with an opposing tooth

Clinical features

  • Tenderness on gentle horizontal or vertical percussion
  • Tooth sensitive to biting forces
  • Patients usually try to modify occlusion to avoid traumatized tooth


  • Soft diet
  • Relief of occlusal interferences
  • Flexible splinting
  • Periodic monitoring with repeated vitality testing and radiographs


  • Pulp necrosis
  • Root resorption is very rare


  • Dislocation of the tooth from its socket after severing of the periodontal attachment
  • Usually two or more teeth involved
  • Teeth mostly affected: deciduous and permanent maxillary incisors
  • Mandibular teeth seldom affected
  • Vitality testing: temporarily decreased or undetectable
  • Vitality may return after weeks or several months
  • Depending on magnitude and direction of traumatic force
  • Subluxation
  • Extrusive luxation
  • Lateral luxation
  • Intrusive luxation


Subluxation denotes an injury to supporting structures of the tooth that results in abnormal loosening of the tooth without frank dislocation.

Clinical features

  • Teeth are in normal location or limited elevation of tooth from its socket
  • Abnormally mobile
  • Extravasated blood emanating from gingival crevice depicts PDL damage
  • Tenderness to percussion and masticatory forces


  • Partial displacement of a tooth out of its socket
  • Often found in deciduous teeth

Clinical features:

  • Tooth appears elongated
  • Usually displaced palatally
  • Bleeding from gingival sulcus
  • Mobile


Movement of tooth in a direction other than intrusive or extrusive displacement

Clinical features

  • Comminution or crushing of alveolar process accompany tooth dislocation
  • Movement direction depends on:
  • Orientation and magnitude of the force
  • Root shape
  • Tooth may be pushed through buccal or less commonly lingual cortical plate
  • Root apex palpable insulcus area

Management (Subluxation, Extrusion, Lateral luxation)

  • Restoring teeth to normal position by digital pressure under LA
  • Comminuted pieces of alveolar bone to be repositioned by digital pressure
  • Removal of occlusal interferences if necessary
  • Immobilization for 2-3 weeks using flexible splints
  • Root canal therapy prior to splint removal
  • Extraction of the traumatized teeth should be the last resort
  • Periodic follow up clinically and radiographically


  • Pulp necrosis: Open apex -9%, Closed apex -55%
  • Chances of surface resorption
  • Inflammatory resorption can be seen in association with pulp necrosis
  • Due to compression to the PDL, both inflammatory and replacement resorption may occur


  • Displacement of tooth into alveolar process
  • Comminution or crushing of alveolar process accompany tooth dislocation
  • Often seen with deciduous dentition, less in permanent dentition

Clinical features

  • Reduced height of clinical crown
  • Gingival bleeding evident
  • High metallic sound on percussion
  • Maxillary incisors may be intruded into the alveolar process
  • Damage to adjacent teeth especially underlying permanent teeth

Management for intrusion:

Depends entirely upon the stage of root development

Immature root formation

  • Spontaneous eruption can be anticipated
  • Luxation of tooth slightly with the forceps done if no signs of re-eruption after 10 days
  • Pulpal healing is monitored during the period of re-eruption at 3, 4, 6 weeks after injury
  • In case of negative response of the pulp or periapical radiolucency
  • Endodontic therapy with calcium hydroxide dressing is done

Completed root development

  • Spontaneous re-eruption is unpredictable
  • Orthodontic extrusion is indicated over a period of 2-3 weeks
  • Prophylactic endodontic therapy is indicated as frequency of pulp necrosis


  • Pulpal necrosis-Open apex-63%, Closed apex –100%
  • External surface, inflammatory and replacement resorption are very frequent findings, especially in teeth with complete root development
  • Severe complication can be seen as late as 5-10 years after trauma


  • Complete displacement of a tooth from the alveolar process
  • Can occur due to direct or indirect trauma 

Clinical features

  • Seen in relatively younger age group
  • Maxillary central incisors-most commonly avulsed teeth in both dentitions
  • Affects single tooth mostly
  • Socket is found empty or filled with coagulum
  • Lip laceration
  • Fracture of alveolar process may occur 


  • If avulsed tooth is not found clinically or radiologically, chest or abdominal radiograph to locate it
  • Reimplantation of permanent teeth. The prognosis depends on:
  • Condition of tooth
  • Time out of socket
  • Viability of residual PDL fibres
  • Splinting
  • Endodontic therapy after reimplantation
  • Follow up

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