The Monthly Dental
E-Journal Vol - I I
Number- IV September 2007
Laughter - The best
Miswak beneficial for dental health,
Radiation and chemotherapy induced
mucositis- Part 1 - Dr.Ghazala Danish
Type Of Oral Cancer Linked To
Ethnicity: Are Cultural Habits To Blame?
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.
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
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.
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
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-
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
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
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
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
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
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