D e n t a l    F o l l i c l e               

             The        Monthly   Dental   E-Journal                 Vol - I I      Number-  IV      September  2007

In this Issue:

  • Editorial

  • News

  • Laughter - The best Medicine

  • Miswak beneficial for dental health, study finds

  • Radiation and chemotherapy induced mucositis- Part 1 - Dr.Ghazala Danish

  • Type Of Oral Cancer Linked To Ethnicity: Are Cultural Habits To Blame?


Editorial :

                      Dental education in India has shown an exponential growth in the last two decades, with the number of dental institutions growing 10 times and over 23,000 dentists graduating every year. With this increase in the output of Dentists the private practice sector is becoming more competitive. Keeping update of the developments in technology and treatment aspects has become vital. Keeping you updated with the latest developments we bring you this edition of Dental Follicle. With this Issue we also announce the beginning of skill enhancement program organized by Dental Follicle team at Mysore , India. We will be starting with a workshop on Full mouth rehabilitation. With a organized program and experienced faculty we hope the participants  will go back to work more confidently. For details mail with subject : workshop details .

                   I am also happy to inform you the is now on number 19 (among 28,000,000+ websites) on google search for the key word "dentistry" . Click here to see . I thank all of you for your support.



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Yours truly

Dr. Syed Nabeel

Editor of Dental Follicle & WebMaster

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News :



Laughter - The Best Medicine :

Patient to Dentist: "How much to get my teeth straightened?"
"Twenty thousand bucks" Patient heads for the door.

Dentist to patient: "Where are you going?"
"To a plastic surgeon to get my mouth ben



Miswak beneficial for dental health, study finds



A group of dentists at King Saud University in the Saudi Arabia have studied the medicinal properties of the miswak.The study was led by Dr. Khalid al-Mas, an assistant professor in the Division of Periodontics in the Department of Preventive Dental Sciences at the King Saud University College of Dentistry in Riyadh.

The research identified a total of 19 natural substances found within the miswak that benefit dental health. It contains a number of natural antiseptics that kill harmful microorganisms in the mouth; tannic acids that protect the gums from disease; and aromatic oils that increase salivation. Because of its built-in antiseptics, the miswak needs no cleaning, and because its bristles are parallel to the handle rather than perpendicular, it can reach more easily between the teeth, where a conventional toothbrush often misses.

According to the study, “the miswak has many medicinal properties and can fight plaque, gum line recession, tooth wear, gingivitis, and periodontal pocket depths.” The study also concluded that repeated use of one miswak releases fresh sap and silica, a hard glossy mineral that acts as an abrasive material for the removal stains and buildup.It releases a substance that soothes toothaches. “It is also used to prevent smoking in adults and thumb sucking in children,” and “it may also improve the appetite and regulate peristaltic movements of the gastro-intestinal tract,” said the study.

Muslims use the miswak on the recommendation of the Prophet Mohammed(peace be upon Him), who said, “Siwak cleanses the mouth and pleases the Lord”, and “if I had not found it hard for my followers or the people, I would have ordered them to clean their teeth with siwak for every prayer.” 



Radiation and chemotherapy induced mucositis- Part 1

Dr.Ghazala Danish


The oral cavity is a frequent site of the side effects of aggressive chemotherapy. Acute and chronic oral complications develop in 40 to 75% of patients. Risk factors include type of malignancy, chemotherapeutic agent used, cumulative dose, method of delivery and degree and duration of myelosuppression. Poor oral health and poorly maintained oral hygiene increase the severity of complications.
All chemotherapeutic agents damage rapidly proliferating cells. The mucous membrane of the oral cavity has a rapid epithelial turnover, rendering them vulnerable to the effect of cytotoxic agents. Direct cytotoxicity results in interruption of the integrity of the mucosa and in an increased risk for local or systemic infection in the immunosuppressed patient.
Oral complications significantly affect morbidity, the patient’s ability to tolerate treatment and the overall quality of life.
Direct stomatotoxicity or mucositis, a result of cytotoxic effect on the cells is the most common acute oral complication of chemotherapy. It may be seen as early as 3 days or more commonly 5-7 days after the start of treatment. Commonly seen with use of cyclophosphamide, bleomycin, cytarabine, doxorubicin, daunorubicin, etoposide, 5-fluorouracil, methotrexate, mitomycin, mercaptopurine, vinblastin, vincristin and floxuridine. Continuous infusion or frequent repetitive schedules are more likely to cause mucositis than equivalent doses of similar drugs given in a single bolus.
Chemotherapy causes a decrease in the renewal rate of basal epithelium, resulting in atrophy and thinning of the mucosa, development of edema and erythematous burn like lesions. These areas quickly ulcerate and coalesce to form large areas of mucosal denudation covered with a whitish gray membrane. Areas of deeper ulceration with erythematous halos and necrotic centers may develop on the lips, ventral surface of tongue, floor of the mouth, buccal mucosa and soft palate. Severe pain causes dysphagia, often resulting in decreased nutritional intake and dehydration. Patient’s who develop mucositis during their initial cycle of chemotherapy usually continue to develop increasingly severe mucositis during subsequent cycles. Mucositis often becomes cumulative and is the factor that limits the amount of chemotherapy that can be given, compromising treatment outcomes.
Indirect stomatotoxicity or stomatitis refers to injury of the mucosal tissues by trauma- biting, irritation from dental prostheses or orthodontic appliances or infections. Although mucositis and stomatitis are interchangeably used, stomatitis has a specific cause and treatment is aimed at identifying and eliminating the precipitating factor, whereas mucositis results from the direct effect of chemotherapy on cells. Factors that can initiate stomatitis include the presence of microorganisms, local mucosal health and the balance between the patient’s overall physical health and suppressive action of the therapy. Edema of the buccal mucosa and tongue can lead to serration by teeth. Dentures can produce traumatic wounds while harboring microorganisms that can cause secondary infections. Reactivation of the herpes simplex virus can also cause mucosal ulceration early in the chemotherapy cycle.
Infectious stomatitis can occur indirectly from myelosuppression caused by chemotherapy. It usually occurs 7-12 days after administration of an agent corresponding to the WBC count in the patient with neutropenia. Periodontal pockets and or periapical pathosis may provide a reservoir of pathogenic and opportunistic organisms that cause local or systemic infections during periods f myelosuppression. Marginal and papillary gingival inflammation can lead to breakdown of gingival, followed by ulcerative lesions that can extend to any region of the mucosa.

Radiation induced mucositis
The reaction of the tissues of the head and neck both perioral and oral varies with the type of radiation used, area of exposure, dose given
The onset, intensity, the duration of mucositis depends on the administered dose, dose fraction, type of ionizing radiation used, total dose given, the volume of tissue within the radiation portals and continued use of tobacco and alcohol products. Mucositis usually appears around 1,000 cGy at the beginning of the second week of treatment. It intensifies as treatment continues and resolves 2 or 3 weeks after completion of therapy. The nonkeratinized tissues in the path of radiation (soft palate, pharynx, floor of the mouth, buccal mucosa, and base of tongue) are affected primarily and become erythematous and hyperemic. As the mucosa thins and atrophies due to decreased epithelial proliferation, small areas of denudation and ulceration covered with a white, fibrinous exudates occur. These areas may be focal at first, but can quickly become diffuse. Generalized sloughing can occur where the mucosal surfaces rub against each other, such as the lateral and ventral borders of the tongue or buccal mucosa. Mucositis can be aggravated by mechanical irritation caused by faulty restorations, broken teeth, or ill-fitting prostheses. Patients with poor oral hygiene have an increased breakdown of inflamed marginal and interdental gingival. Patients receiving dose-intensive treatment, Such as a concomitant boost or implant, can have delayed healing.
Patients often experience pain and burning (even at rest) that is intensified by contact with coarse or spicy foods. They can also have difficulty in swallowing or speaking. When symptoms are severe, treatment may be discontinued until the acute reactions subside.

Treatment of complications
Basic oral care
Since there are currently no good preventive approaches available, management of mucositis is primarily palliative. Patients should be advised to eat a soft, bland diet and to avoid hard, abrasive foods that can mechanically traumatize the tissues. The oral mucosa should be cleaned as atraumatically as possible with an ultrasoft toothbrush or wet guaze. Sodium bicarbonate rinses used frequently clean and lubricate tissues, prevent crusting, and soothe sore tissues. Treatment of mucositis is mainly palliative, aimed at limiting tissue irritation, improving patient comfort, and controlling superinfection. A baking soda and salt water rinse (10ml baking soda and 2.5ml salt added to 0.95 L water) used four to six times a day facilitates pain relief, keeps oral tissues moist, and reduces oral debris. Good daily oral hygiene must be maintained with a soft brush and a bland tasting dentifrice. This helps decrease the oral microflora and prevents infection.

Topical antiseptic and antimicrobial agents
In mild cases, dilute chlorhexidine rinses can be used to decrease oral microflora. For increased penetration of topical medication, tissues must be cleaned of mucus and debris prior to application. Following emesis patients should rinse their mouth with sodium bicarbonate solution and swallow some water to clear the throat of acidic secretions. These secretions can cause increased irritations and ulceration of the mucosa.
Suspensions of topical anesthetics can be used to alleviate discomfort. Topical anesthetics, such as dyclonine hydrochloride (0.5%)and viscous lidocaine hydrochloride (2%) solution, can be effective in relieving discomfort but also can be chemically irritating. Care must be taken not to mechanically traumatize anesthetized tissues. A 1:2 dilution with water decreases the profound numbing effect and can still provide relief.
Topical anesthetics can be combined with coating agents like magnesium hydroxide (milk of magnesia, Maalox) or kaolin-pectin (kaopectate) and diphenhydramine hydrochloride (benadryl elixir) elixir in a 1:4:4 mixture to produce a swish and expectorate or swallow rinse. A cool solution can increase relief; thus, refrigerating or freezing the solution into ice cubes to dissolve in the mouth is recommended.
Kamillosan Liquidim (from the flower of the chamomile plant) rinse (10to 15 drops dissolved in 120 ml of warm water) can be used three times a day. Its main ingredients (chamazulene, levomenol, polyins, and flavonoids) are thought to have anti- inflammatory, spasmolytic, and antibacterial action and help promote granulation and re-epithelization of ulcerated tissues.
Chamomile mouthwashes- improves mucosal healing. 15 drops in 10 ml of warm water, three times a day reduces the intensity and severity of mucositis in cancer patients. It has anti-inflammatory and healing effects.
Allopurinol rinses have been shown to be effective in protecting against methotrexate induced mucositis.
Studies conducted at several cancer centers showed that lozenges containing 2g of polymyxin E, 1.8 mg of tobramycin, and 10 mg of amphotericin B may selectively eliminate gram –negative bacilli and yeast and prevent more severe mucositis.



Type Of Oral Cancer Linked To Ethnicity: Are Cultural Habits To Blame?

Dr. Satish Kumar and Dr.Parish Sedghizadeh, clinical professors in the school's Division of Diagnostic Sciences , USC School of Dentistry unravel connection between the incidence of oral cancer and race and ethnicity.The professors in the school's Division of Diagnostic Sciences, gleaned through 20 years of records from the California Cancer Registry (CCR)--the state's cancer surveillance database--for the incidence rates of invasive squamous cell carcinoma, the most common form of oral cancer.The research team theorized that cultural habits are to blame. From what we know of how the cancer develops, we can extrapolate that cultural habits and lifestyle choices are directly linked to the prevalence of oral cancer in certain groups,".

For example, African American and Caucasian men, with the highest rates of cancer of the tongue, also have the highest rates of cigarette smoking in the state. In Asian groups, Koreans have the highest cigarette smoking rates. The practice of chewing tobacco, or areca nut, most common in South Asian cultures like India , may account for that group's likelihood of developing the disease in the inner cheek.