Bleeding and its Management in Dental Clinics – A Challenge

Jun 3, 2019

The human body is prone to various diseases and disorders. The relationship between our body and diseases goes hand in hand, having various processes and effects. Bleeding is actually a natural process to bring about efficient wound healing.

But, when this bleeding gets associated with any abnormality or becomes a part of manifestation of any disease, it becomes a disorder which needs to be carefully managed. The father of Indian surgery, Sushruta, in his compilation entitled ‘Susruta Samhita‘ which is many decades old, mentions about more than one hundred and fifty bleeding disorders of oral environment and about five hundred ways to manage them.

The various bleeding disorders where in dental management would be required, is totally a clinical perspective rather than being a theoretical one. This is because it’s a condition where a particular dentist needs to manage a particular patient on his/her dental chair at that very moment to prevent the worsening of the condition. Enumeration of such disorders includes

  • Vitamin K deficiency
  • Leukemias
  • Polytcythemia
  • Aplastic Anaemia
  • Purpura
  • Haemophilias
  • Hereditary Haemorrhagic Telangiectasia
  • Diabetes
  • Imbalance of sex hormones
  • Ulcerative colitis
  • Severe gum bleeding due to cardiovascular diseases
  • Haemangioma
  • Infections
  • Trauma and
  •  various malignancies

Taking the etiology into consideration, it basically revolves round the qualitative and quantitative defects in physiology of the three major components of homeostasis, viz, vascular, platelets and coagulation, i.e – Vessel Wall/Vascular Disorders and Platelet Disorders.

  1. Congenital
  2. Acquired
  • Coagulation Disorders
  1. Congenital coagulopathies {Haemophilia A and B, Von Willebrand’s Disease}
  2. Anticoagulant related coagulopathies {Heparin, Coumarin}
  3. Disease related coagulopathies {Liver Disease, Vitamin K deficiency}
  4. Fibrinolytic Disorders. These would have their own oral manifestations, few being Pathognomonic while others characteristic.

The common signs and symptoms include bleeding from superficial cuts and scratches, delayed bleeding time, spontaneous gingival bleeding, petachiae, ecchymoses, epistaxis, deep dissecting hematomas, hemarthroses etc. The Blood dyscrasias would show bleeding and necrosis of gingiva, hematoma and ulceration of mucosa, excessive bleeding upon trauma or extraction of teeth.

Most of the metabolic (Diabetes) and Endocrine (imbalance in hormones) disorders and disturbances too would present a similar picture. Certain Granulomatous diseases like ulcerative colitis would present with haemorrhagic ulcers. Some others severe conditions include Henoch Schonlein Purpura presenting with purpuric rashes and haemorrhage due to increased vascular permeability.

Genes and chromosomes too have a vital role to play when it comes to bleeding disorders. The X-linked recessive disorders –

Haemophilia A (deficiency of Antihaemophilic factor) and Haemophilia B (deficiency of Christmas factor) and Hereditary Haemorrhagic Telangiectasia (Rendu – Osler – Weber Syndrome) present with tendency of bleeding profusely due to thinness of capillaries and arterioles.

The severity of Haemophilia can be explained by a flash back of history where the very first descendent of the Royal family of Britain after Queen Victoria died on the dental chair after getting his tooth extracted due to profused unstoppable bleeding as there was deficiency of Christmas factor and lack of management measures.

Besides all these, the various Autoimmune  disorders causing severe and profused oral bleeding can’t go unnoticed, the examples being Thrombocytopenic Purpura where there is bleeding due to excessive reduction in the platelet count that prolongs the bleeding time. There are spontaneous haemorrhagic lesions intraorally and bruising tendency.

Oral bleeding may be as a result of various periodontal problems as well such as in Aggressive Periodontitis, Acute Necrotizing Ulcerative Periodontitis and Gingivitis. Various other conditions such as Agranulocytosis and Chediak Higashi Syndrome that have negative impact on gingiva and periodontium can lead to bleeding on the chair during treatment.

After an overall slideshow of the various bleeding disorders, their etiology, clinical features, signs and symptoms, the fresh page of its management or treatment now opens. With a bleeding patient on the dental chair, most of the dentists panic as there is no time to correlate the theoretical knowledge with the practical one. At that very moment, the sharp practical reaction is what a dentist should have toward the existing problem.

The Indian history enumerates a variety of procedures used to tackle bleeding problems, both oral and systemic. The flashback dates back to “Bhagvad Gita” where Neem and Tulsi, crushed and applied were the ways to control bleeding. The medical works of ancient India, ‘Manu Smriti’ and ‘Susruta Samhita’ mention about volatile oil, Tannins, Vitamin C, Neem, roots of marshmallow, Siwak/Miswak to be the materials of choice for an effective bleeding control.

In those days, although people were hardly concerned about their oral health, as dentistry was not that evolved compared to medicine, yet people cared about the bleeding in their oral cavity due to any reason (according to surveys). The Sumerians were the first one to carry out extraction procedures but could not control severe bleeding as they used crushed bone, crushed egg and oyster shells for the purpose.

The Unani System of medicine was the first one to carry out surgical procedures in oral cavity with effective bleeding management using saline water, decoction of mint water, herbal powder water, amla rinses and water boiled with basil leaves (tulsi) and mint (pudina). Some of the Ayurvedic systems in India also used Grapefruit, Alum powder, Turmeric root powder, Black pepper powder and tea tree oil to control bleeding in the oral cavity.

‘Necessity is the mother of Invention’ and this proverb has given dental sciences, numerous opportunities today, through inventions, discoveries and even serendipity to reach up to a level in management of bleeding that would surely relieve today’s dentists off the tension of panicking and thinking ‘What to do now?.’ Today’s scenario of dental management of bleeding has turned over a new leaf. Today’s arena of bleeding management is based on ‘prevention’ and ‘cure’ methods.

Prevention– A detailed Case history of the patient would enable a dentist to prevent any such havocs as one would be aware of patients systemic health conditions, his body parameters and the various drugs / medicines (if any) the patient is taking. In addition to this the patients’ physician’s consult and various laboratory test reports (specific and non specific) before any treatment is an important preventive measure.

The various such specific and non specific laboratory tests would encompass:

  • Platelet count
  • Bleeding time
  • Prothrombin time or international normalized ratio(INR)
  • Activated partial thromboplastin time (aPTT)
  • thrombin time
  • Fibrin degradation products
  • Fibrinogen assay
  • Von Willebrand’s antigen
  • Coagulation factor assays
  • Coagulation factor inhibitor assays units
  • Cogulation factor Inhibitor screening test (Blocking Antibodies)
  • Capillary fragility test
  • Tourniquest test, INR

Of all these tests, aPTT is a very sensitive test while INR (normal value:1) evaluates the extrinsic coagulation system, thus determining the presence or absence of clotting factors I (Fibrinogen), II (Prothrombin), V (Labile factors), VII (Proconvertin) and X (Stuart Prower factor). The labile factors include: Proaccelerin and Ac globulin. These methods work on the principle of “Prevention, being better than cure”.

Cure – There are various curative measures for management of bleeding in a dental office

  • local hemostatic measures
  • mechanical methods
  • thermal agents
  • chemical agents and
  •  various drugs

After dental extraction procedures, local agents which can be used are: Oxycellulose, Gelation pack, Gelatin resorcin formol, Glue, Cyanoacrylate, absorbable sutures, compressive splints and intermittent T.A.

Mechanical methods include  pressure application, sutures and ligation and embolisation of the vessels.

Thermal agents account to cautery, cryosurgery, electrosurgery and lasers.

Chemical agents include: Astringent agents and styptics, monsels (ferric subsulphate), tannic acid, Bone wax, thrombin, Gelfoam, Oxycelm Fibrin Glue, Adrenaline (1:1000 or with L.A. à 1:80,000 to 1: 2,00,000).

The various essential Drug Therapy encompasses EAEA (Epsilon Amino Caproic Acid) and Tranexamic acid which reduces post operative blood loss and transfusion requirements. Factor VIII concentrate raises plasma level by two per cent (Protocol by Haemophilia of Georgia). During major procedures, factor level needs to be raised to about eighty to hundred percent at the time of surgery.

Now, since all these facilities are available today as options in front of a dentist, it does not necessarily symbolise efficient treatment or management. Management ends up perfectly only if a dentist knows how to use them judiciously, keeping the indications and contraindications of each in mind so that one does not end up with further complications (local or systemic).

For example, in cases where EACA is contraindicated, Heparin or Aprotinin can be used as substitutes. Hence, dental management required for patients with bleeding would depend on: the type and involved dental procedure, plus type and severity of bleeding.

For example, in case of reversible coagulopathies, it may be best to remove the causative agent and treat the primary illness or defect. For irreversible coagulopathies, the missing or defective elements may need to be replaced.

For restorative and prosthodontic therapies, rubber dam isolation is advised, so as not to traumatise soft tissues. Severely inflamed and swollen tissues are best treated initially with antiseptic mouthrinses (like chlorhexidine) to allow gingival shrinkage prior to deep scaling.

Doctors are considered to be Gods on Earth; in order to be obliged to this prestige that we have been honoured with in our profession, it becomes mandatory on our part as health care professionals to tackle the problems on our dental chair with care.

In addition to having the knowledge of various treatment patterns that science has given us today, adequate command over the subject and its judicious use would definitely send the patient back with a Happy Dent, which at the end of the day should be our Goal as a Dentist!


Cone Beam Computed Tomography in Endodontics

Apr 8, 2019

Cone Beam Computed Tomography (CBCT) including endodontics has become widely available and utilised in all aspects of dentistry in recent years. It became an inevitable part of treatment planning for every dentist since the discovery of X-ray and its application. Though X-rays proved to be very useful in the success of treatments like root canal by determining the proper working length and ensuring an impervious seal, it has its limitations.

X-rays provide a two-dimensional image of a three-dimensional object and sometimes give a distorted view of overlapping anatomic structures (Anatomic noise).

With the advent of CBCT, one can get an undistorted, three-dimensional image of the area under examination in endodontics. A clearer image gives clearer idea of the endodontic anatomy and pathology which helps in better treatment plan and achieves a predictable outcome. Although, conventional radiography still remains the default diagnostic tool in endodontics. According to recent research, CBCT is an evolving trend, and its acceptance would dramatically increase in near future.


After a century of conventional radiography, a first clinically practical technology of three-dimensional imaging was introduced as maxillofacial CBCT in 1996.

CBCT is accomplished by using a rotating gantry fixing an X-ray source and detector. A divergent pyramidal or cone shaped source of ionizing radiation is directed through the middle of the area of interest onto an area X-ray detector on the opposite side of patient.

The X-ray source and detector rotate around a fixed fulcrum within the region of interest. During the exposure sequence hundreds of planar projection images are acquired from the field of view in an arc of at least 180 degrees. Thus, a 3D volume of data is acquired in a single sweep of scanner. The beam of X-ray used is coned shaped and hence is the name of the technique.

Applications of Cone Beam Computed Tomopraphy in Endodontics

Though CBCT cannot completely replace the use of conventional radiography in endodontics, it can be used as a complementary aid to assist in diagnosis, treatment planning and post operative assessment with the following important applications in the field:

  • Evaluation of complex tooth root morphologies

The two-dimensional images produced by conventional radiograph give idea of morphology in mesiodistal plane leaving behind the curvatures, extra roots and additional canals in the buccolingual planes.

CBCT is invaluable in assessing teeth with unusual anatomies such as extra roots, dilacerated tooth, dens invaginatus, C-shaped canals, and fused teeth. According to studies, CBCT is superior to conventional radiographs in detecting supplemental canals posing threat to the outcome of treatment if went undetected.

CBCT can more accurately assess canal curvatures, which may be helpful in preventing mishaps like ledge formation, transportation and perforations.

Apical periodontitis is caused by the resorption of bone that occurs as a result of response of host’s immune system to the bacteria that enters the root canal system. If the periapical radiolucency exceeds twice the normal width of periodontal ligament, it is classified as a periodontal lesion.

A conventional radiograph shows this apical radiolucency only after demineralisation progresses to the buccal and lingual plate as the superimposition of anatomical structures limits its usefulness in identifying the process occurring in cancellous bone, which is possible to visualise using a CBCT.

Studies show that the outcome of treatment is more favourable when the treatment is started before the lesion starts to show on periapical radiographs.

  • Assessment of potential surgical sites

While performing any surgical procedure a surgeon is always at risk of iatrogenic errors. Especially as a dental surgeon, we need to work in the vicinity of important structures like mental nerve, inferior dental nerve, maxillary sinus, etc. Three-dimensional imaging like CBCT allows the clinician to view anatomic structures and its various spatial relationships to the root apices in any desired plane, which cannot be viewed using a two-dimensional conventional method.

In addition to this, the thickness of cortical plate, the cancellous bone pattern, fenestrations and inclinations of roots under consideration can also be accurately analysed. The proximity of nerve bundle to the root which is to be operated can be assessed by reducing the chances of damage during surgeries to a greater extent.

  • Assessment of traumatic injuries

The diagnosis of traumatic injuries is often a difficult task, and the drawbacks of conventional radiography like anatomic noise and image compression add to the difficulty. Failure to identify the root fractures before undergoing treatment has been reason for failure of treatment and poor prognosis of a tooth which could have been saved by a proper diagnosis.

CBCT has proved to be far more sensitive than conventional radiography in assessment of fractures. Another advantage being that trauma patient often has difficulty in accommodating bulky film holders and image receptors for conventional photography owing to pain and injury to the dental tissue which is eliminated while using CBCT.

Studies show that external root resorption is a very common complication following dental luxation and avulsion injuries. It is so rapidly progressing that it can resorb the entire root within three months of injury if not diagnosed and treated on time. Conventional radiography cannot detect it unless it has caused greater destruction, unlike CBCT, which can detect it at its initial stage, which is critical to the survival of affected tooth.

Limitations of CBCT
  • The effective dose of CBCT is higher when compared to conventional radiographs.
  • Presence of high density objects like enamel or metallic restorations may produce artifacts like cupping artifacts or presence of streaks or dark bands which may negatively affect the quality of image produced.
  • The spatial resolution of CBCT is lower when compared to conventional radiography.
  • It has limited contrast resolution.

Although conventional radiography is a cost-effective and reliable diagnostic tool for a dentist, the usefulness of CBCT in preoperative as well as postoperative diagnosis should not be underestimated.


Patel S, Dawood A, Pitt Ford T, Whaites E. The Potential Applications of Cone Beam Computed Tomography in the Management of Endodontic  Problems. Int Endod J 2007;40:818-30.

Scarfe WC, Levin MD, Gane D, Farman AG.:Use of  Cone Beam  Computed Tomography in Endodontics. Int J Dent 2009:

Scarfe WC, Farman AG, Sukovic P. Clinical Applications of Cone Beam Computed Tomography in Dental Practice. J Canadian Dental Association 2006; 72:75-80.

  1. Patel, “New Dimensions in Endodontic Imaging: part 2. Cone Beam Computed Tomography”, International Endodontic Journal, Vol. 42.

April 2019 – Oral Cancer Awareness Month

April is oral cancer awareness month worldwide. To highlight this, here are some oral cancer knowledge updates. Dentists are the only medical faculty to diagnose oral cancers initially than others during routine mouth check-up. That’s why visiting a dentist is mandatory.

Why is oral cancer awareness an important public service message?

Many oral cancers can be prevented in their initial stages, before getting worse. Diagnosing malignant lesions and oral cancers during mouth check-ups is dentist’s responsibility. Make patients aware of their oral health. Oral cancer awareness is the basic aim of this article. Statistics are provided in this article are from various sources.

In India, death due to tobacco is estimated at 3,500 people per day approximately. According to the latest data, smoking caused 3, 17,928 deaths among men and women approximately.

Over 25% of male cancer deaths are due to Oral and Lung cancers. cancer of breast and oral cavity account for 25% of deaths in women. One-third of oral cancer cases are from India in the world. Oral cancer accounts for 30% of all cancers in India.

According to Globocan, around 1, 19,992 new cases of oral cancers diagnosed every year and deaths 72,616 worldwide. Out of the newly diagnosed cases, about 60% won’t live longer than 5 years. Many who survive after the treatments suffer from severe facial disfigurement or difficulties in eating and speaking. The death rate from oral cancer is high due to routinely late discovered. Generally, men suffer and die more than women from oral cancer.

Causes for Oral Cancer

Oral cancer is any neoplasm found on the lip, floor of the mouth, cheek lining, gingiva, palate or in the tongue. Oral cancer is among top three types of Cancer observed in India. Common risk factors are severe alcoholism, use of tobacco like cigarettes, smokeless tobacco, betel nut chewing and human papillomavirus (HPV).

It may also occur due to poor dental care and poor diet. The incidence of oral cancer is higher in India, South and Southeast Asian countries. Around 90 -95% of the oral cancers are squamous cell carcinomas in India.

According to the international agency for cancer research, India’s incidence has increased from 1 million in 2012 and would increase more than 1.7 million by 2035. This indicates that the cancer death rate would also increase from 680,000 to 1- 2 million at the same time.

In India, oral cancer is interrelated to low income. Low social-economic class is often associated with factors like lack of nutrition, health care, squalid living conditions and risk behaviours, contributing to oral cancer development.

Most of the population lacks access to a well organised and well regulated cancer care system in low and middle-income countries; they don’t have personal health insurances.

A cancer diagnosis often burdens high health expenditures. Such expenditures impoverish homes and push entire families below the poverty line, bringing about social instability. There are no significant advancements in the treatment so far.

Although, present treatments improve the life of oral cancer patients but for public point of view,  these treatment results have failed to improve overall survival rates of 5 years in the past decades.

Incidence of oral cancer in India

Incidence of oral cancer is 53,842 in males and 23,161 in females seven years ago. Oral cancer is considered to be a disease which occurs in elderly people. Most of the oral cancer cases occur between 50 to 70 years but may occur in 10 years old children. Incidences of oral cancer increase with age.

Fifth decade of life is common for cancer development. In India, men are two to four times more affected than women due to changes in the behavioural and lifestyle patterns, but high incidence rates are seen amongst South Indian women due to tobacco chewing. Tongue Cancer is the most common type of cancer and common sites are buccal mucosa and gingiva.

Chances of developing oral cancer in addicted patients are 8.4 times higher than that non-addictive patients. Use of tobacco in the form of smoking has 5.19 times higher risk or chances of having pre-cancerous lesions on palate when compared to that of tobacco chewing. Most of the oral cancer patients are found in Uttar Pradesh, Jharkhand and Bihar.

Burden of Oral cancer in India

20 per 100,000 people are affected by oral cancer which is about 30% of all types of cancer. More than 5 people in India die every hour because of oral cancer and the same for cancer of oropharynx and hypo pharynx.

Cancer registration is not compulsory in the country; so actual incidence and mortality are not predicted. Many cases are unrecorded and lose to follow up during treatment. There is no national registry that monitors cancer incidences, that’s why actual cases are based on various surveys.

The National Cancer Registry Program collects numbers that are population-based data from a selected network of 28 cancer registration centres located in different parts of the country. Various studies use data from urban and rural cancer registries established at national and regional level.

Urban registries are at Delhi, Mumbai and Chennai, and rural registries are at Barshi, Dindigul, Manipuri, Karunaga-pally, Ernakulum, Srikakulam and Bhavnagar.

There is still need for providing cancer detecting, treatment centres.  Many people can’t afford high treatment cost. Negligence in the initial stages makes the situation worse for the advanced ones.

This burden of detecting oral cancer at initial stages can be reduced by implementing dentist in this program as they are the first one to diagnose oral cancers during routine dental checkups.


Visit your dentist for dental checkups regularly as they are the only medical faculty to diagnose precancerous lesions and cancers at initial stages. Governments should enrol more dentists in oral cancer screening programs across India to reduce the burden. Spread awareness to the general public about oral cancer in various campaigns and social activities, etc.


Connective Tissue Graft in Treatment of Recession

Normally, gingival margin is located at or coronal to cementoenamel junction (CEJ). When gingival margin migrates apical to CEJ, it is called a gingival recession. Gingival recession may occur due to excessive tooth brushing trauma. Localised plaque induced inflammatory process, malocclusion, and orthodontic tooth movement, as a part of generalised chronic periodontitis.


For treating gingival recession it is important to diagnose the cause of recession. Elimination of causative factors is the most important step in treating recessions. This may include oral hygiene technique modifications, treating periodontitis, elimination of plaque retentive structures, tooth repositioning, etc.

After this, surgical intervention can be considered if the goal is to correct the defect and possible root coverage by regenerated gingiva.

Indications for Root Coverage
  • Highly esthetic demands
  • Lack of keratinised gingiva
  • Continuous recession even after eliminating causative factors
  • Root hypersensitivity
Connective Tissue Graft (CTG)

This technique utilises subepithelial CTG from the palate. Palate has keratinised tissue with dense lamina propria. The connective tissue grafting along with the various flap techniques can be used to treat recessions. The coronally advanced flap plus connective tissue grafting is still the gold standard in treating recessions.

Indications for CTG
  • Inadequate tissue around recession defect
  • Wide gingival recession defect
  • Multiple gingival recessions
  • It has high predictability
  • Graft receives abundant blood supply from the inside of the flap as well the periosteum- connective tissue
  • Wound can be sutured at palatal donor site after harvesting of connective tissue graft. Which make hemostasis easy and healing rapidly.
  • Less discomfort and pain during healing
  • Better aesthetic results
  • Multiple gingival recession defects can be treated.
  • Technically demanding
  • As the graft is thick, the grafted tissue is thick. Gingivoplasty may require sometimes to obtain better morphology

If the thickness of donor tissue is less. The thickness of the connective tissue graft for root coverage should be 1.5-2.0 mm, and the thickness of the palatal flap should be 1.5-2.0 mm after graft harvesting, to prevent further necrosis. As a result, at least 3-mm thickness is required at the donor site of palatal soft tissue.

CTG Technique
  • Local anaesthesia application
  • Preparation of  exposed root surface
  • Recipient bed preparation
  • CTG harvesting
  • Suturing and stabilizing the graft at the recipient site
  • Management of donor site
Preparation of the Exposed Root Surface

Scaling and root planning of the exposed root surface. If the goal is to obtain root coverage over existing caries or class V restoration, caries and restoration must be completely removed. Recent studies have shown root coverage over restored root surfaces too. Convexity of the root should be eliminated with diamond burs. Chemical root surface modifiers such as citric acid, tetracycline, EDTA is used to demineralise and decontaminate the root surface and to expose the collagen fibres. This is to facilitate attachment of fibres to the root surface. Evidence recently demonstrated that the use of such chemical modifiers provides no additional benefit of clinical significance. (Mariotti et al 2003).

Preparation of the recipient bed

The recipient bed is prepared for the connective tissue graft by a split thickness flap which is performed so as the periosteum remains attached to the underlying osseous structure. The split thickness flap is prepared by sharp dissection using 15 c blade. Presence of any muscle fibres or attachment is also eliminated so that flap is mobile and can be coronally repositioned without any tension.

Harvesting CTG from the Palate

The CTG is harvested from the hard palate area. The ideal location for harvesting the graft is 5-6 mm apical to the gingival margin of the palatal aspects of the maxillary premolars and the mesial half of the maxillary first molar. Incisions are made to gain access to the connective tissue. The incisions create a trap door effect where a flap is raised toward the palate, and then the connective tissue is harvested. There is different incision technique’s single incision, double incision, L- shaped incision. The ideal thickness of the graft is 1-1.5 mm thick. During harvesting, the connective tissue extra precautions should be taken to avoid injury to the vital structures like the greater palatine artery. Depending on the depth of the palatal vault, generally, the artery is about 12 mm apical to the gingival margin. Reiser et al 1996, Monnet-Corti et al 2006.

Placement of the Graft

The harvested connective tissue graft is immediately placed in the recipient site and secured into position with sutures. The 5-0 silk or 6-0 absorbable sutures can be used. Optimised healing requires the graft to be in intimate contact with the recipient bed with the absence of any dead space. Suturing techniques play an important role in the success of any periodontal plastic surgery.

Management of the Donor Site

For better healing, positive hemostasis is required at the donor site and can be achieved by application of pressure. Hemostatic agents like collagen sponges may be used to aid with hemostasis. Ligation of the greater palatine artery with a suture in case of injury to the artery. For patient comfort, dressing in the form of tinfoil may be placed or palatal stent that should be pre-surgically fabricated may be inserted.

Post-Operative Maintenance

Patient should be recalled for reassessment in between 2 weeks following surgery for a post-operative visit and suture removal better to use absorbable sutures. Patient should be instructed to avoid tooth brushing and flossing around the surgical site for first 2 weeks. Gentle rinsing with chlorhexidine gluconate 0.12% or 0.2 % should be advised.

Causes of CTG Failure
  • Insufficient interdental bone and soft tissue heights
  • If horizontal incision placed apical to the CEJ
  • Reflection of interdental papilla
  • Flap tearing
  • Inadequate or improper root planing
  • Failure to provide sufficient blood supply from surrounding tissue due to inadequate recipient site preparation is the main cause for failure
  • CTG too small
  • Graft too thick
  • Failure to cover graft coronally by the flap

Management of gingival recession requires the identification and elimination of the etiology. Many recessions do not require treatment. In some cases, the decision may be to treat the recession with a root coverage procedure. One of the most predictable techniques is CTG.

Connective tissue grafting
  1. Preoperative


2. Incision and recipient bed preparation

3.CTG Graftt

4.Donor site suturing

5. Graft stabilization

6. Flap suturing

7. Results after 3 weeks

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.

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  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.”

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