Sunday, March 1, 2020

Lupine Publishers | Oral Hygiene Habits and Dental Treatment Needs of Children with Dental Fluorosis and Those Without Dental Fluorosis Aged 12-15 Years In in a High Fluoride Area in North Kajiado Kenya

Lupine Publishers | Journal of Oral Healthcare


Background: The dental disease identified as dental caries, periodontal, gingival lesions and dental fluorosis when diagnosed early and the treatment needs assessment with patients’ perception ensures the proper use of the physical facilitates, It also enhances planning for rational health resource allocation, utilization and personnel distribution so as to tackle the health problems in a holistic way.
Objective: The objective of the study was to determine the dental treatment needs among children aged 13-17 years affected by dental fluorosis and those not affected by dental fluorosis in Kajiado North District of Kenya
Materials and Methods: Study design this was a cross sectional comparative study of the dental treatment needs among two age matched population groups in primary school children. Sampling and Sample size. Stratified random sampling was used to select four primary schools out of the primary schools in North Kajiado. All children in the school with a full permanent dentin and whose parents had signed the consent form were recruited into the study. The study involved 248 children, 98(40%) males and 150(60%) females aged between 13 -17 years (mean age = 14.75±1.45) selected by simple random sampling from 9 schools in Kajiado North District which was purposively selected. They were all clinically examined under natural light for plaque and gingival scores using the Silness and Loe 1, Loe and Silness, dental caries was recrded using the decayed Missing Filedl teeth (DMFT), while gingivitis, periodontal disease and fluorosis using indices:- Silness and Loe 1, Loe and Silness, DMFT,CPITN and TFI.
Results: The treatment needs for gingivitis were similar, majority 218 (88%) children with fluorosis and 213 (86%) without required oral hygiene instructions and prophylaxis. There were 3(1.2%) children who had periodontitis in the group with dental fluorosis and required scaling and root planning. There were 50% children with caries in the fluorosis group who required one surface and 24.2% for two surface amalgam/composite restorations and for those without fluorosis, 76% required one surface and 15.2% two surface amalgam/composite restorations. There were 321(60.8%) teeth surfaces which required bleaching and microabrasion or composite masking and another 207(39.2%) for direct composite / porcelain veneers or crowns.
Conclusion: Children with dental fluorosis were burdened more by dental disease and had more treatment needs (dental caries, fluorosis, periodontal disease and gingivitis) when compared to those without dental fluorosis.


Dental conditions like fluorosis, caries, gingival and periodontal diseases require varied treatment approaches to manage them depending on the severity hence the need to establish the levels of disease burden and treatment needs for proper planning of dental services. Well assessed dental treatment needs go a long way in the estimation of resources, rational fund allocation and efficient utilization of dental materials. Dental treatment needs should be assessed objectively and subjectively based not only on normative assessment but also on perceived needs and impact so as to obtain the best outcomes. The incorporation of both the clinician’s objective assessment and the client’s felt needs is essential in ensuring that they participate in the general management of their condition. In common practice today Bradshaw (1978) in a study on the problems and progress in medical care said that the treatment needs of most dental conditions are based on the clinician’s judgement using the recommended dental indices1. The age between 13-17 years forms the transition period between childhood and adulthood. The growth changes seen during this stage of life warrants a clear understanding of the health needs in general and support for optimal psychosocial and emotional development. Welbury pointed out that children affected by fluorosis suffer from low self - esteem, social stigma and poor performance in school.
Facial image is an important aspect with regard to an individual’s presentation and self-esteem in communication. This is greatly affected by the presence of dental fluorosis among other things like mal-aligned teeth, missing anterior teeth or even congenital malformations of the oral cavity. Globally there is often a permanent stigma associated with dental fluorosis among children or adults. A study conducted in Brazil by Rodriques showed esthetic changes in the permanent dentition are the greatest concern in dental fluorosis. Studies by Welbury and Glasser have observed that if left untreated, dental fluorosis causes embarrassment, psychosocial distress, difficulties in societal adjustment, damage to self-esteem and poor performance for the school-going children. Another study in Kenya by Mwaniki showed that between 60.4% and 84.3% of the respondents viewed dental fluorosis as a problem because of its unfavourable effects on an individual’s personality. It is important to note that dental fluorosis leads to shyness in expression thereby masking the true personality of an individual. It is further evidenced by a South African study by Mothusi that showed the trauma suffered by young people with dental fluorosis to be depressing such that they requested to have the teeth extracted and replaced with dentures.
Generally, the quality of life is greatly affected by oral diseases, dental fluorosis not being an exception, with a significant impact on the 13-17- year- olds due to their delicate stage of growth and development. Children experience appreciable impacts on oral health related quality of life with the greatest burden being associated with dental caries and to a lesser extent, fluorosis according to a study in Uganda by Robinson. The aspects considered when determining the quality of life with regard to oral diseases using the oral impact of daily performance (OIDP index) include eating, speaking and pronouncing clearly, cleaning teeth, sleeping and relaxing, smiling without embarrassment, maintaining emotional state and enjoying contact with others. A study in Tanzania by Roman on the impact and treatment needs of dental fluorosis where a total of 269 students with dental fluorosis aged 15-18 years (mean age 17.3) were involved, showed that a majority (65.4)% had severe dental fluorosis (TFI 6-9) while 29.4% had TFI 4-5 and 5.2% had TFI 1-3. Most of the students in this study (92.6%) perceived at least one (OIDP) with the most affected being smiling at 88.1%, emotional stability 81.4%, and having contact with others 75.5%. Studies by Locker and Leake indicated that the oral health status of at risk children and adolescents appeared to have been poor resulting in the need for several treatments including urgent, restorative, periodontal and preventive care Table 1.
Table 1: Distribution of study participants according to age and gender.

Materials and Methods

Study Population

The study population comprised of 13 -17- years who were born and brought up in Kajiado North District in the first 7 years of life. The target population involved 34,122 children aged 13- 17 years according to the Kenyan population and housing census 2009 for Kajiado North District. The public primary and secondary school enrolment was approximately 19,065 for the ages 13-17 years in the year 2011 in the study involved 248 children, 98(40%) males and 150(60%) females aged between 13 -17 years (mean age = 14.75 ±1.45) selected by simple random sampling from 9 schools in Kajiado North District which was purposively selected. They were all clinically examined under natural light for plaque and gingival scores, dental caries, gingivitis, periodontal disease and fluorosis using indices:- Silness and Loe 1963, Loe and Silness 1964, DMFT,CPITN and TFI. Information on biodata, consumption of sugary snacks, brushing was collected using an interviewer administered questionnaire. Water samples were collected for testing for fluoride levels at the government chemist laboratories.

Data analysis

The clinical examination forms were pre-coded. The quality of data was ensured during the entire study process especially at the data collection point to include completeness of questionnaires, and validity of responses. Data was de - indentified and stored in a password protected data base with access being granted to the statistician. Quality control through data cleaning and validation was censured by counter checking frequencies in the computer and any missing data was re - entered. The findings from the study were organized in the form of frequency tables and figures. Computations to calculate disease burden (caries experience, prevalence of gingivitis and periodontitis, treatment needs and the cost of treatment) were done. The independent variable for this analysis was presence/absence of fluorosis while the dependent variables were age, gender, gingivitis, periodontitis, caries experience and cost of treatment. The confounding factors were snacking and oral hygiene practices. For categorical variables association between dependent variables and fluorosis was tested using a Pearson Chi-square test while a student t-test was used for continuous variables and the conventional P value of cut-off of < 0.05 was used to establish a significant association. To calculate the total DMFT, the total number of teeth per child with caries, filled due to caries, missing due to caries was summed up. For the mean gingival and plaque scores, the total score per child was calculated by summing the individual tooth scores, divided by 6 and the total for the index teeth added and divided by 6. To determine the agreement rates between assessors, a Cohen kappa score (agreement rate) was calculated for each assessment (tooth and surface) for all children assessed. A median agreement rate was then computed from all individual scores calculated. Data collected was analyzed using statistical package for social sciences (SPSS version 17.0) Table 2.
Table 2: Sources of drinking water.


Socio demographic characteristics

This study involved 248 children aged between 13-17 years with a mean age of 14.75 years (±1.45 SD) who were all matched for age and gender. The ratio of children with dental fluorosis and those without was 1:1 and the male to female ratio was 2:3 and was not statistically significant [p= 0.104 (p ≤0.05)] as shown in Table 1. There were 241 (97%) participants born and raised in Kajiado North while 7(3%) moved to the district before 7 years of age.

Source of water and analysis

There was a similar pattern on the water sources which was not statistically significant [p=0.239 (p≤0.05)] for children with fluorosis and those without fluorosis. Most of the study participants consumed borehole water and most of tap water was also from boreholes. Dams and river sources were for a minority group as shown in Table 3.
Table 3:
Gishagi borehole which is in a raised ground recorded low fluoride levels of 0.1 ppm as well as Kerarapon springs 0.44 and Lemelepo borehole 0.5, Ngong main borehole had the recommended levels by WHO of 1ppm. Embulbul roadside and Embulbul community water supplies had very high levels of fluoride at 8.3 and 15ppm (Table 4).
Table 4:

Tooth brushing habits

Majority of the children 122(98%) from each group brushed their teeth, the frequency of brushing was similar where by 113(93%) with fluorosis and 105(88%) without used a toothbrush while a chewing stick was used by a few (Table 5). The type of tooth brushing aid used was not statistically significant p=0.120(p≤ 0.05). Majority brushed once a day either in the morning after breakfast 61(50%) and 59(48%) or in the evening after meals 49(40%) and 51(42% for the children with fluorosis and those without fluorosis respectively. Only a small percentage brushed their teeth twice a day. There was no statistical significant difference on the timing of brushing between the groups [p=0.180(p≤ 0.05].
Table 5:

Relationship between brushing habits and plaque scores

Generally, children who brushed once after breakfast in both groups had PSs which were statistically significant p=0.003(p≤0.05) and the children with fluorosis had the lowest PSs of 0.85(0.5). The other brushing timings were not statistically significant p=1.02(p≤0.05) for at night and p= 0.664(p≤0.05) for twice a day as depicted in.


Both groups had a similar pattern of treatment needs. There were 109(88%) for OHI, 12(10%) OHI and oral prophylaxis, 3(2%) OHI and scaling for children with fluorosis. Those without fluorosis, 107(86%) OHI, 15(12%) OHI and oral prophylaxis, 2(2%) OHI and scaling.


Of the 3(2.4%) children with fluorosis who had periodontitis they all required scaling and root planing.

Dental caries

In both groups, dental restorations in form of one surface fillings were mostly indicated as 35(50%)/ 35(76%) for the children with fluorosis/those without. Two surface restorations 5(7.1%) for fluorosis and 7(15%) those without fluorosis. Extraction and partial dentures 9(12%) for fluorosis and 2(4.3%) those without fluorosis. Three surface composite restorations among children with fluorosis were 4(5.7%).

Caries experience in relation to consumption of sugary snacks

In the group with fluorosis the children who consumed sugary snacks twice had a higher DMFT of 0.71(1.4) while children without dental fluorosis and consumed four times scored highest DMFT of 0.83(0.9). On the weekly snack consumption, those who sacked once had no caries in both groups p=0;000(p≤0.05) which was statistically significant while the highest DMFT was recorded in those who snacked twice/four times for the fluorosis group at 0.64/0.6 while in the group without fluorosis the scores ranged between 0.17-0.25 despite different weekly snacking times.
None of the children who brushed twice had dental caries experience in the fluorosis group for once a day (after breakfast or at night) had a DMFT of 0.5(1)/ 0.73(1.6). For the group without fluorosis, there was some caries experience despite the timings for brushing. Generally there was no statistical significant difference on the brushing timing for both groups. The children who brushed after breakfast had a p=0.850(p≤0.05), at night only p=0.073(p≤0.05) and twice a day p=0.217(p≤0.05) therefore, brushing did not have any influence on the caries experience.

Cumulative TFI frequencies

In both jaws TFI 4-5 was the most frequent at 2301(52.3%) on the labial and lingual surfaces of the anterior teeth in both the maxilla and of the mandibular anterior teeth 2240(51.8%). There were 321(60.8%) surfaces which required bleaching and/or micro abrasion or composite masking while 207(39.2%) surfaces required porcelain veneers or crowns Table 6.
Table 6:


The current study did not find much difference in the treatment needs for gingivitis between the two groups as majority 88% with fluorosis and 86% without fluorosis required oral hygiene instructions and oral prophylaxis and in periodontitis the 1.2% affected required scaling and root planing. Most of the subjects with dental caries required some form of restorations either one, two or three surface amalgam/ composite restorations. A smaller number required extractions and partial dentures. Since radiographs were not taken for this study, it was difficult to ascertain the teeth which were indicated for pulp therapy. Studies done in Trinidad and Tobago by Naidu and Uganda by Nalweyiso clearly indicated that the treatment burden of dental caries is mainly centered on fillings, fissure sealants, pulp therapy and extractions. This study considered treatment needs for dental fluorosis in terms of labial surfaces from canine to canine in the maxillary teeth only. It was established that 48% of the teeth surfaces required bleaching / micro abrasion, composite masking and 52% for direct/indirect composite veneers/crowns. In Kenya Mwaniki found that 60.4 - 84.3% of the respondents viewed dental fluorosis as a problem although the study design was different from the current study.


Children with dental fluorosis were burdened more by dental disease and had more treatment needs (dental caries, fluorosis, periodontal disease and gingivitis) when compared to those without dental fluorosis.

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Thursday, February 27, 2020

Lupine Publishers | Bioactivity, Biocompatibility and Biomimetic Properties for Dental Materials: Clarifying the Confusion?

Lupine Publishers | Journal of Oral Healthcare


Often in the profession of dentistry, a new or novel instrument, material, technique, and/or “system” is introduced which can incur a “state-of-the-art” status without necessarily being subjected to the rigors of clinical testing or longitudinal patient-based studies prior to receiving the stamp of approval or the moniker of “standard of care”. Recently, provocative terminology surrounding the field of dental materials has been publicized through the literature, promoting exciting claims and possible long-term advancements for patient care. In this “new era” of evidence-based restorative dentistry; conservative interdiction, i.e. “informed” removal of diseased tissue with concurrent substitution considering form and function, esthetics, and the interaction of the physical and mechanical properties of the replacement materials with living, dynamic structures found in the human tooth, has been of paramount importance.
Abbrevations: ACP: Amorphous Calcium Phosphates, MTA: Mineral Trioxide Aggregate, PVPA: Poly Vinyl Phosponic Acid, PAA: Polyacrylic Acids


The progression or evolution of dentistry has occurred, to a great degree, in concert, with the development of material technology [1]. During the last two decades, the categorization of dental materials, specifically, adhesive systems and composite resins have included the term “nanotechnology” into the lexicon of scientific literature [2]. Nanotechnology involves the science and engineering of functional molecules at the nanoscale (onebillionth of a meter) level [2]. As applied to dentistry, this innovative approach promotes the incorporation or interaction of nanostructured materials together with the complex arrangement of organic/inorganic molecular-level constituents comprising living tooth structure, allowing for a myriad of possible preventive and therapeutic applications [2]. Owing to this progression of material development, the assignments of additional revolutionary dimensions have included the origination of the concepts of biocompatibility or bioactivity into dental science.
As a possible expansion of nanotechnology applied to dental materials: the terms biocompatible, bioactive, bioinduction, and biomimetics can be defined independently; however, have often been characterized synonymously [3]. Biocompatible is simply a term to describe a substance or material that will do no harm to existing living structures, that is non-mutagenic and noncytotoxic. The term “bioactivity” was first described in 1969 by Hench, whereby a “bioactive material is one that elicits a specific biological response at the interface of the material which results in the formation of a bond between the tissues and the material” [4]. Furthermore, the definition was refined and updated to include two categories based upon intent and procedure, originally pertaining, specifically, to bone tissue:
a) Class A: A material that elicits an intracellular and extracellular response (osteoproductive);
b) Class B: Materials eliciting an extracellular response only (osteocontuctive) [5].

Accordingly, a bioactive material can have “the effect on, or eliciting a response from living tissue, organisms, or cells”, thus contributing to the formation of a new substance or creation of a living, compatible system [3]. A bioinductive property is defined as “the capability of a material for inducing a response in a biologic system”[3]. Biomimetics is the “study of formation, structure, or function of biologically produced substances and materials and biological mechanisms and processes for the purpose of synthesizing similar products by artificial mechanisms that mimic natural substances”[3,6]. So, although these terms seem to imply different connotations, what can a dental practitioner conclude, deduce, and/or apply for everyday use? Any substance, arrived from by any process (bioactive, bioinduction, biomimetic) should exhibit attributes of being biocompatible. It appears that both a bioactive and biomimetic substance can include the process of bioinduction and that a biomimetic substance could possibly be produced through bioactive activities.

Bioactive materials and processes are probably the most applicable for endodontics and restorative dentistry based upon current uses: luting cements, pulp capping agents, root repair materials, permanent restorations, hard tissue remineralization (fluoride, calcium, and phosphate ions) and bone regeneration properties, and treatment of dentinal hypersensitivity[1,3,7-13]. In order for these materials to become biocompatibily active or retain characteristics of bioactivity; bactericidal and bacteriostatic (inhibits bacterial growth and biofilm formation) properties for the stimulation of reparative dentin formation and maintenance of pulpal vitality must be achieved and maintained [3]. Examples include fluorides for remineralization, antibacterial resins and cements (Reactimer bond™ Shofu Dental Corp., Kyoto, Japan; ABF™ Kuraray, Kurasiki, Japan), restoratives (Active™ BioACTIVE, PULPDENT Corp., Watertown, MA, USA) releasing fluorides and containing amorphous calcium phosphates [ACP], medicaments (mineral trioxide aggregate [MTA] and bioaggregate; Biodentine™, Septodont, Lancaster, PA, USA; TheraCal™, Bisco Dental Products, Schaumburg, ILL, USA; and Endosequence root repair [RRM]™, Brasseler USA, Savannah, GA), and luting cements (Ceramir Crown & Bridge, Doxa Dental Inc., Chicago, ILL, USA) that induce healing and/or for creation of new tooth structures[1,3,7,8,10-14]. Biomimetic substances include the usage of polyvinylphosponic acid (PVPA) polyacrylic acids (PAA) as calcium phosphate matrix protein analogues for remineralization purposes [7,15].


Although these materials are in their infancy, with long-term efficacy based on improvements of mechanical and physical properties pending, future materials will hopefully create circumstances for increased tooth-like attributes due to properties of adhesion, remineralization, and integration [1,3,7].

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Monday, February 24, 2020

Lupine Publishers: Lupine Publishers | We Hear With our Brain as the ...

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Lupine Publishers | Down’s Syndrome- A Disease Caused By Genetic Alteration

Lupine Publishers | Dentistry Open Access Journal


Down’s syndrome is the most common syndrome, medical professional encounters in day to day practice. It is a genetic disorder with a typical face profile and few classical intraoral features. Herein we report case and review on Down’s syndrome with facial features.
Keywords: Down’s Syndrome; Trisomy; Chromosome; Oral Manifestation


Down syndrome is one of the commonest disorders with huge medical and social cost. DS is associated with number of phenotypes including congenital heart defects, leukemia, Alzheimer’s disease, Hirsch sprung disease etc. [1]. Down syndrome is a prevalent genetic disorder in intellectual disability in India. Its prevalence in tribal population is not known [2]. Down syndrome is one of the leading genetic causes of intellectual disability in the world. DS alone accounts 15-20% of ID population across the world [3,4].

Case Report

An 8 year old male patient came to the department of oral medicine and radiology for routine dental check-up. Extra oral examination revealed characteristic facial profile with increased inter canthal distance (Figure 1). Intraoral examination revealed Gingiva was soft with deposits on the teeth, High arched palate, with depressed nasal bridge was seen (Figure 2). Macro glossia was also seen .Correlating the intraoral and extra oral findings a Provisional diagnosis of Down’s syndrome/ Trisomy 21 was given. Patient was referred to the respective departments of pedodontics for restoration of decayed teeth.]
Figure 1: Extra oral features showing increased inter canthal distance and depressed nasal bridge.
Figure 2: Intraoral features showing high arched palate.


Down syndrome is one of the most leading causes of intellectual disability and millions of these patients face various health issues including learning and memory, congenital heart diseases, Alzheimer’s diseases, leukemia, cancers and Hirsch rung disease. The incidence of trisomy is influenced by maternal age and differs in population [5,6]. Facial findings in the patients can be characterised into extra oral and intraoral features (Table 1) [7]. Parents of children with Down’s syndrome should be aware of these possible conditions so they can be diagnosed and treated quickly and appropriately. According to Asim A et al. A Down’s syndrome child should have regular check-up from various consultants. These include:
a) Clinical geneticist - Referral to a genetic counselling program is highly desirable.
b) Developmental paediatrician.
c) Cardiologist - Early cardiologic evaluation is crucial for diagnosing and treating congenital heart defects, which occur in as many as 60% of these patients.
d) Paediatric pneumonologist -Recurrent respiratory tract infections are common in patients with DS.
e) Ophthalmologist.
f) Neurologist/Neurosurgeon - As many as 10% of patients with DS have epilepsy; therefore, neurologic evaluation may be needed.
g) Orthopaedic specialist.
h) Child psychiatrist - A child psychiatrist should lead liaison interventions, family therapies, and psychometric evaluations.
i) Physical and occupational therapist.
j) Speech-language pathologist.
k) Audiologist.
l) Paediatric dentist.
Hackshaw AK et al in their study, proposed a new screening method in which measurements obtained during 1st and 2nd trimester are integrated to provide the risk status of having pregnancy with DS. Moderate to severe intellectual disability occur as a constant feature, with IQ’s ranging from 20 to 85 [8]. Kennard in his review stated that there are a number of ultrasound markers in Down’s syndrome which includes nuchal fold thickness, cardiac abnormalities, duodenal atresia, femur length & pyelectasis [9]. The signs and symptoms of Down’s syndrome are characterised by neotenization of brain and bodies. Management strategies such as early childhood intervention, screening from common problems, medical treatment when indicated, a conductive family environment and vocational training can improve the overall development of children with Down’s syndrome [10].
Table 1:


Genetics have always have played a major role in physical and mental being of an individual. Downs patients being mentally and medically weak, best care needs to be taken with adequate precautions.

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