Capillary Haemangioma of Gingiva - A Rare Lesion

Capillary Haemangioma is a benign vascular tumour characterized by proliferation of blood vessels with a very striking similarity to pyogenic granuloma with a predilection to occur on the gingiva. Though the head and neck are the most common region of occurrence, but is considered to be rare occurring on the gingiva, intra-orally. The lesion clinically mimicked pyogenic granuloma but was histopathologically diagnosed as capillary haemangioma. It was surgically excised and followed up for 6 months without any recurrence.

Sagittal Root Position of Maxillary Anterior Teeth in Nepalese Population Using Cone Beam Computed Tomography

Background There are no radiographic studies in Nepalese population for determination of sagittal root positioning in maxillary anterior teeth. The sagittal root positioning and root angulation plays a vital role for case selection in immediate implant placement. Objective To evaluate, classify and compare sagittal root position between different maxillary anterior teeth. Method A 2-year retrospective study was conducted on 100 patients (53 males and 47 females) who fulfilled the inclusion criteria using cone beam computed tomographic images. The relationship of root of tooth to its alveolar housing were recorded as Class I to IV. In addition, the root angulation relative to the alveolar process was also measured. Result The sagittal root position (SRP) calculated on six maxillary anterior teeth on average was found to be 87.83% for Class I, 6.67% for Class II, 0.67% for Class III and 5.17% for Class IV respectively. The mean root angulation was found to be higher with canines on both side whereas lateral incisors had lesser mean root angulation. Root angulation of maximum teeth were between 10-20 degrees where immediate implant placement is possible. Conclusion Within the limitations of this study, the sagittal root positioning and root angulation in Nepalese population showed a favorable result for immediate implant placement. Maximum teeth were found to be close to the alveolar process with the exception of few teeth.

Crown Lengthening Surgery for Enhancing Restorative Treatment in Esthetic Zone

For obtaining adequate retention for restoring cases like subgingival caries or extensive caries that shortens the tooth, short clinical crown, and fractures, it is usually necessary to disclose more tooth structure. Crown lengthening procedure is done to increase the clinical crown length for restorative or esthetic reasons without breaching the biologic width. These procedures are also utilized to improve the appearance and retention of restorations placed within the esthetic zone. We report a case of crown lengthening surgery with an internal bevel gingivectomy which was done in our department without compromising tooth support and esthetics.

Self-confidence Level among Intern Dentists in Performing Endodontic Treatment Procedures in Nepal

Background Endodontics is considered as one of the most difficult and stressful disciplines in dentistry. This might be due to the complex anatomical variations, recent advances in equipment, technology, materials and lack of self-confidence. Objective To determine the self-confidence level among the intern dentists in performing endodontic procedures from six different colleges of Kathmandu University, Nepal. Method A descriptive cross-sectional study was conducted among 145 intern dentists. The online questionnaire regarding confidence level (5 point Likert scale) in different endodontic procedures and difficulty level (easy, ok and difficult) with respect to teeth was distributed. For descriptive purpose, frequency and percentage for each response were calculated. Result Dental interns were confident in performing majority of the normal endodontic procedures, however, they showed less confidence in performing difficult steps like rubber dam application for anterior (74, 51%) and posterior tooth (91, 62.7%), use of electronic apex locator (89, 61.4%), using rotary files (114, 78.6%), management of flare-ups (86, 59.4%), assessment of quality of post-endodontic treatment (85, 58.5%), recall periods (75, 51.6%) and performing post and core (82, 56.6%). Likewise, upper first molars (84, 57.9%) and second molars (104, 71.7%) were found to be the most difficult teeth to treat. Conclusion It can be concluded that majority of the dental interns were confident in performing basic endodontic procedures, however, they were found to have low confidence in performing difficult steps. Further training and exposure should be incorporated to increase their confidence level.

Dental Negligence: Accidental Administration of Formalin Instead of Local Anesthetic

A solution like formalin used as a fixative has to be handled with lot of care and needs to be stored with utmost care. Negligence on part of the dental professional by accidentally injecting formalin instead of the local anesthetic can lead to permanent tissue damage and also may induce a life threatening situation. The operating dentist injected formalin accidentally instead of the local anesthetic and the patient experienced severe pain and burning sensation. The general practice of formalin being stored in the local anesthetic bottles and being assisted by untrained assistant is the most common reason for mishaps to happen. The dentist operating should be careful and aware of the drugs and chemicals being available in the operatory and re-check the solution being injected in the patient as to not land up in complications because of the negligence.

Necrotizing Stomatitis in Varicella Zoster Infection

Necrotizing periodontal disease are acute periodontal conditions which can present with simple gingivitis to more complex life threatening condition where it can perforate the skin of cheek. They are found in patients with severe illness, stress and reduced immunity. The prevalence of this whole group of disease is usually very low and is stated frequently as the first manifestation in HIV infection. Herpes zoster, a common dermatological condition is a secondary infection due to re-activation of Varicella zoster virus in a person previously acquiring a chicken pox in his/her lifetime. There are limited scientific literatures citing the occurrence of necrotizing stomatitis in varicella zoster infection. Thus, here we present a detail about a case and management of 46 years old female who had a hospital stay of over 5 days for treatment of Herpes zoster infection of mandibular nerve presented with necrotizing stomatitis lesion within oral cavity.

Tooth -A Potential Graft Material for Periodontal Regeneration ?

Use of tooth as a promising replacement substitute has been validated by various animal as well as human studies. Though widely used in GBR and Sinus grafting techniques, its use in periodontal intrabony defect is not documented. In the present case report, the tooth graft has been placed in periodontal intrabony defect. Postoperative CBCT after 26 weeks revealed homogeneous incorporation of tooth graft. Clinical parameters show bone fill. However; results with larger sample size could further validate the use of tooth graft in periodontal regeneration.

Clinicopathological Analysis of Oral Lesions - A hospital based retrospective study

Background Proper diagnosis plays a key role that determines treatment and prognosis of the disease. To give appropriate clinical diagnosis, clinicians must be well aware of the presentation and demographic information of the lesion including the rare ones. Histopathology is still considered as gold standard in diagnostic pathology but final diagnosis becomes difficult unless detailed clinical and radiological descriptions are given. Hence an interdisciplinary approach is needed which requires correlation between both clinical and pathological details. Objective To analyze the clinicopathological details of all the oral lesions diagnosed in Dhulikhel hospital within the period of two years and to assess the concordance between clinical and histopathological diagnosis of these lesions. Method Laboratory record file of all the oral lesions diagnosed between January 2016 to December 2017 were retrieved from the department archives and the data were collected. The extracted data were analyzed using SPSS version 23.0. Result A total of 237 cases were analysed in the present study. Odontogenic cysts were the most common category followed by benign lesions. However considering the individual lesion, mucocele was the commonest lesion followed by squamous cell carcinoma. Total concordance between clinical and histopathologic diagnosis was found in 56.5% cases. The most clinicopathological agreement was seen for benign lesions followed by malignant lesions. Conclusion Mucocele and oral squamous cell carcinoma are the two most common lesions found among the patients visiting our hospital. The cases of oral squamous cell carcinoma are on a rise with each subsequent year. At present, though it is the second most common entity, it can be hypothesized that it may be higher up on the list. Therefore, oral healthcare awareness is paramount and this may be one of the best ways to reduce the oral cancer incidence rates and lowering the healthcare management burden.

Assessment of Periodontal Status of the People in Chepang Hill Tract of Nepal: A Cross Sectional Study

Background Periodontal disease is one of the common oral and dental disease globally. The main etiology of periodontal disease is microbial plaque. However, it shares many common etiological factors with other chronic diseases. The Chepang are an indigenous TibetoBurman people group numbering around fifty-two thousand mainly inhabiting the rugged ridges of the Mahabharat mountain range of central Nepal. They are the tribes with different food habit, religion and culture. Till date no studies has been conducted about the periodontal and oral health status of the Chepang people. Objective To determine the prevalence of periodontitis in adult Chepang population so that knowing about its prevalence and distribution, besides serving as a demographic tool, will also help in having overview about the need for providing proper oral health care and awareness programs and initiatives aimed at reducing the disease prevalence in this indigenous group. Method The study was conducted among the adult (21 to 70 years) Chepang of Chitwan district. It was the cross sectional study with the random sampling technique. Modified Community Periodontal Index (CPI) and loss of attachment were used to record the periodontal status of all 308 sampled population. Result Out of 308 sampled participants 179 were male and 129 were female. The highest number of participants were from 41 to 50 years old (38.31%). 57.14% adult Chepang brushes their teeth once daily and 31.49% brushes twice daily and 1.30% of them had never brushes their teeth. 36.36% had loss of attachment of 4-5 mm without any significant gender difference. 6.17% of the study population had severe form of periodontitis with ≥ 12 mm of attachment loss. Calculus deposit was abundant in 57.79% of the study sample, and 25.64% shows pocket depth of 4 to 5 mm. Loss of attachment and CPI score is found to be increased with increasing age. Conclusion Result of this study reveals the presence of periodontal problems in adult Chepang population. Higher calculus with attachment loss and pocket depth were the major problems seen in this community. This highlights the necessity of implementation of more preventive program in this specific targeted population.

Self-Perception of Halitosis among Undergraduate Students of Kathmandu University School of Medical Sciences - A Questionnaire Based Study

Background Halitosis is a frequently reported oral health problem worldwide with a prevalence rate of 10-30% in the general population. It is defined as the disagreeable or foul smelling breath originating consistently from a person's oral cavity. It not only effects the normal daily life activities of the patient but also bring humiliation, reduced self- esteem, ultimately resulting into decreased quality of life. Objective To determine the self-perception of halitosis among undergraduate students of different medical branches of Kathmandu University School of Medical Sciences (KUSMS); Kavre, Nepal. Method A descriptive cross-sectional epidemiological survey was conducted among undergraduate students of Physiotherapy, B.Sc Nursing, Bachelor of Nursing Sciences (BNS), MBBS and BDS program of Kathmandu University School of Medical Sciences, Dhulikhel. A self-administered questionnaire was developed and were distributed among 500 undergraduate students. Result Out of total 500 distributed questionnaires, 406 were completely filled and returned giving an overall response of 81.2%, in which 70 (89.7%) male and 280 (85.4%) female students from different medical branches were aware of the term halitosis. Among them 29 (7.14%) of students think that they suffer from halitosis. Similarly 178 (43.84%) students had severe impact of halitosis on their social life while 153 (37.68%) and 62 (15.27%) students had moderate and mild impact respectively. Conclusion Due to the multifactorial complexity of halitosis, further longitudinal studies including objective assessment of malodor are required to determine its prevalence and to further investigate the association of this problem with other etiological factors in the context of Nepal. Also, curriculum of different fields should be modified to include this simple but very necessary topic.

Nepalese Esthetic Dental (NED) Proportion in Nepalese Population

Background Lots of studies on maxillary anterior teeth proportions have been studied in different populations in various countries, but no studies have been conducted in Nepal on the esthetic maxillary anterior teeth proportions. Objective The study was done to investigate the maxillary anterior teeth proportions in a Nepalese population. Teeth proportions in the total population were compared with golden proportion (GP) and golden standard (GS). Method A total of 150 Nepalese subjects were divided in three facial types; broad, average and narrow group. Maxillary anterior teeth were measured from dental casts using digital calipers. The perceived width ratios of lateral to central incisor (LI/CI) and canine to lateral incisor (CN/LI), ratios of mean central incisor length to 2 central incisor widths (CIL/2CIW), and actual width to length ratios (WLRs) (%) were calculated in each facial type and compared. Mean LI/CI, CN/LI and CIL/2CIW in total population were calculated and compared with GP (0.618), and mean WLRs in the total population were compared with GS (80%). All teeth proportions were compared among three facial types. One-sample t-test and one-way ANOVA were performed to analyze the data (α = 0.05). Result The LI/CI, CN/LI, CIL/2CIW and WLRs in three facial types showed no significant difference. The LI/CI, CN/LI and CIL/2CIW in the total population were 66%, 70% and 55% respectively, and were significantly different from GP. The WLRs for CI, LI and CN in the total population were 90%, 86% and 89% respectively and significantly differed from GS. These values were considered to constitute the Nepalese Esthetic Dental (NED) proportion. Conclusion No significant difference of maxillary anterior teeth proportions were observed among three facial types. Teeth proportions in the total population significantly differed from GP and GS. We propose the NED proportion as a guideline for dental treatment in the maxillary anterior region in Nepalese populations.

Peripheral Cemento-Ossifying Fibroma

Peripheral cemento-ossifying fibroma (PCOF), a relatively uncommon lesion, reactive in nature is seen as an overgrowth of the gingival tissues often leading to periodontal problems. It is a benign tumor with slow-growing potential commonly affecting the anterior maxilla whose pathogenesis till date is uncertain. It is usually challenging to diagnose peripheral cemento-ossifying fibroma based on clinical observation and examination, hence histopathological examination is mandatory to arrive at an accurate diagnosis. Recurrence of the lesion is common unless and until it is completely excised. We present the report of two cases of peripheral cemento-ossifying fibroma of our department, complaining of a mass in the gingiva of posterior maxilla and mandible.

A Survey on Oral Health and Practice of Nepalese in Areas Affected by Earthquake in 2015

Background Understanding post-earthquake oral health indicators is essential for developing oral health interventions of the victims. Presumably, due to a geographic difficulty, there has been no investigation to reveal the oral health status of individuals after the Gorkha earthquake in Nepal. Objective The main objective was to determine the oral health and practice of Nepalese affected by earthquake in April-May, 2015. Method The epidemiological cross sectional study was done at 5 different districts (Sindhupalchok, Dadhing, Bhaktapur, Kathmandu and Kavre) of Nepal from September till November, 2015. Altogether 500 subjects aged form 16 to 80 years of age living in the transitional shelters community were included in earthquake-affected areas. Different parameters were studied from past and present medical and dental problems, habits, oral hygiene habits. DMFT, gingival index, periodontal index were studied and correlation was studied among them. Result It shows that 98% of the participants had plaque and 96.4% of the participants had calculus. Mean decayed was 9, mean missing was 4 and mean filling was 1. 22.60% of the participants had score 0, 34.8% had score 1, 34% had score 2 and 8.60% had score 3 of mean gingivitis index. 10% of the participants showed score 0, 36% showed score 1, 35% showed score 2, 10.2% showed score 3 and 8.2% showed score 4 of mean periodontal index. Moreover, significant correlation was observed among DMFT index, gingival index and periodontal index (p<0.001). Conclusion The oral health care practice, oral hygiene habits, nutritional intake of the people have been affected in the earthquake affected areas. It showed high caries index, gingival index and periodontal index in earthquake affected people suggesting further efforts are needed for an oral health improvement. Data from this study may be used as basic information for oral health planning and future steps in oral health care preventive and therapeutic programs.

Gender Based Comparison of Gingival Zenith Esthetics

Background The size, proportion and gingival zenith position of maxillary anterior teeth plays in the anterior teeth esthetics. Objective To compare the gingival zenith positions and levels between male and female in right and left side as an esthetic parameter. Method Impression of the maxillary arch was made in each participant with irreversible hydrocolloid, and dental cast was made with dental stone type IV. Two clinical parameters were evaluated: (1) the gingival zenith position (GZP) from the vertical bisected midline along the long axis of each individual maxillary anterior tooth; and (2) the gingival zenith level (GZL) of the lateral incisors in an apical-coronal direction relative to the gingival line joining the tangents of the GZP of the adjacent central incisor and canine teeth under healthy conditions. Statistical analyses were conducted using SPSS with the level of significance (α) = 0.05. Descriptive statistics was done and Independent t-test was used to compare the GZP and GZL between male and female. Result In male, the gingival zenith position for right side central, lateral and canine were 1.05 mm, 0.57 mm and 0.14 mm, and in left side were 1.02 mm, 0.53 mm, 0.15 mm. In female, the gingival zenith position for right side central, lateral and canine were 0.99 mm, 0.48 mm and 0.15 mm, and in left side were 0.94 mm, 0.44 mm and 0.14 mm. The gingival zenith position was significantly different between male and female for both lateral incisors. In addition, significantly different was found for the lateral incisor between right and left side. In male, the gingival zenith level of right and left lateral incisors 0.74 mm and 0.71 mm. In female, the gingival zenith level of right and left lateral incisors 0.76 mm and 0.72 mm. No significant difference was found between male and female for the gingival zenith level of right and left lateral incisors. Conclusion The GZP and GZL obtained from this study can be clinically applied to reestablish the GZP of the maxillary anterior teeth during periodontal surgery; crown lengthening or root coverage procedures.

Clinico-histopathological Survey of Head and Neck Cancer at Tertiary Health Care Centre -Dhulikhel Hospital

Background Head and neck is one of the most prevalent site for cancers along with lungs, cervix, breast and stomach. Hospital based cancer registries required for effective evaluation of diagnosis and management of cancer is inadequate in Nepal. Cancer registry system established by WHO is acquired by seven major hospitals in our country. However, data from tertiary health care centres like ours remain undocumented. Objective The objective of this study is to perform retrospective analysis of clinicohistopathological types of head and neck lesions which were eventually diagnosed as cancer in Dhulikel Hospital, a tertiary health care centre of Central East Nepal. Method Data regarding head and neck lesions diagnosed as cancer (January 2001- December 2014) were extracted from the archives of Department of General Pathology. These cases were categorised according to demographic profile, site of cancer and histological diagnosis. Result A total of 240 cases matched the inclusion criteria and were selected for this study. Male: Female ratio of 1.3:1 with a mean age of 52 years (52.82±1.8) was found. Two hundred and two (84.16%) patients were diagnosed with carcinoma, 31 (15%) with lymphoma, 3 (1.25%) with melanoma, 2(0.83%) with small round cell tumor and 2 (0.83%) with sarcoma. The most common histological types of carcinoma seen were Squamous cell carcinoma (138 cases; 57.5%) followed by papillary carcinoma (26 cases; 10.8%). Among the lymphomas Non-Hodgkin's lymphoma (21 cases; 8.75%) was the most predominant type. The most common site of presentation was oral cavity (60 cases; 25%) followed by skin (36 cases; 15%), thyroid (32 cases; 13.33%) and oesophagus (27 cases; 11.25%). Metastasis to cervical lymph node was found in 39 cases (16.25%). Conclusion Based on these finding, it was observed that Squamous cell carcinoma was the most common type followed by different epithelial and mesenchymal malignancies in head and neck region. The results revealed by this study will provide useful information for planning the health care policies about cancer in Nepal and will be more effective and helpful to the patients of remote areas.

Prevalence of palate-gingival groove in patients of Dhulikhel Hospital

Background: Palato-gingival groove is a rare developmental anomaly leading to pulpal and periodontal diseases. Radicular extensions of these grooves are areas for plaque accumulation which are difficult to clean. Its clinical and radiographic findings mimic endo-perio lesions leading to diagnostic dilemma, ineffective treatment attempts and treatment failures. Objectives: To investigate the prevalence of coronal and radicular palato-gingival groove in dental patients visiting Dhulikhel Hospital and its association with gingival disease. Methods: Patients (N=231) visiting dental out-patient department of Dhulikhel Hospital, were examined for the presence or absence of palato-gingival groove in maxillary anteriors. Loe and Silness Gingival index was also recorded for all the patients using University of North Caroline-15 periodontal probe. Chisquare test was used to test the association of the presence of palato-gingival groove and gingival disease. P value of <0.05 was considered to be significant. Results: A total of 1362 maxillary anterior teeth were included in the study. The prevalence of coronal palatogingival groove among 1362 teeth was 6.6%. Coronal palato-gingival grooves were more common in females (56.6%) than in male (43.3%) patients. Prevalence of radicular groove was only 0.88% for lateral incisors and 0.2% for canines. There was no significant association between palate-gingival groove and gingival disease (P=0.91). Conclusion: The prevalence of palato-gingival groove is common in dental patients visiting Dhulikhel Hospital. Gingival disease is not significantly associated with palate-gingival groove. DOI: http://dx.doi.org/10.3126/jcmsn.v10i1.12765 Journal of College of Medical Sciences-Nepal, 2014, Vol.10(1); 32-36

Adjunctive orthodontic treatment with lingual orthodontic system

The lingual orthodontic therapy though started in 1972, could not be popular till the beginning of 1990. In Nepal it does not have a history of more than a year. It is started in Dhulikhel Hospital for the first time in Nepal. Usually orthodontic therapy is meant for putting braces on the labial surface of the teeth which is called labial orthodontic system. Lingual orthodontic system is a purely invisible kind of orthodontic therapy in which braces are placed behind the teeth. The advantages of lingual orthodontic therapy are: invisibility, better biomechanics and improved patient compliance. On the other hand it is difficult to master and costlier than labial orthodontics. We have presented six adjunctive orthodontic cases treated by lingual system with the same end result comparable to labial orthodontic system.

Periodontal infections and cardiovascular disease: is it a mere association?

The oral cavity is a major site of chronic infection and inflammation, particularly periodontal or chronic gum diseases. In recent years there has been increasing interest in the "periodontal systemic connection" between periodontal health parameters and risks of cardiovascular disease. Given that poor oral health and cardiovascular disease are major worldwide health problems, their association are potentially important. The article summarizes the evidences from epidemiologic studies and studies that focused on potential contributing mechanisms to provide an insight of this association.

The pattern of tooth loss due to dental caries and periodontal disease among patients attending dental department (OPD), Dhulikhel Hospital, Kathmandu University Teaching Hospital (KUTH), Nepal

Aims and objectives: The aim of this study was to investigate the type of tooth usually associated with extraction due to caries or periodontal disease and its relation to age at which these were lost, among patients attending dental surgery outpatient clinic, Dhulikhel Hospital, Kathmandu University Teaching Hospital (KUTH). Materials and methods: A total no of 626 patients (male-299 and female-327) attending at outpatient clinic, in the department of Dentistry, Dhulikhel Hospital were taken in over a period of six months. The details about the permanent teeth to be extracted regarding each tooth type, including age and sex of the patient, type of tooth extracted, cause of extraction were collected, causes other than dental caries and periodontal disease were excluded. Results: The highest proportion of extraction due to caries occurred between 21-30 years of age, while that of periodontal disease was between 51-60 years of age. More than 80% of teeth lost were from below 40 years of age group. Mandibular first molar was by far the most frequently extracted tooth due to dental caries followed by maxillary first molar. Maxillary teeth were lost more than mandibular teeth due to periodontal disease. Conclusion: Dental caries and periodontal disease are the two most important factors for extraction or removal of tooth. In this study dental caries is the major cause for loosing tooth among young group of people. Key words: dental caries, periodontal disease, extraction    doi: 10.3126/kumj.v7i1.1767       Kathmandu University Medical Journal (2009), Vol. 7, No. 1, Issue 25, 59-62