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Research

RESEARCH

1.            A study of microbes, antimicrobial.

2.            Comparison in vitro of peniciline…

3.            Sensitivities of colonies of Fusiformis.

4.            Oral bacteriological findings – testing and resistance of bacteria to antimicrobial agents in periodontal diseases.

5.            Clinical and bacteriological effects of Tindazole (Fasigyn) in gingival bleeding.

6.            Survey report hyperplasia of gums during pregnancy in sheeps.

7.            Survey report on the dental and periodontal condition of sheep and hyperplasia of gums.

8.            Periodontal disease in children in Pakistan.

9.            HIV infection and Role of Oral Health Physicians.

10.         Medical Educational facilities and social services.

11.         Dental caries – A challenge.

 


 

 

 

A STUDY OF MICROBES, ANTIMICROBIAL AGENTS SUSCEPTIBILITY AND RESISTANCE TESTING OF HUSBAND AND WIFE ORAL FLORA

 

PURPOSE:

 

The purpose of this study is to compare the composition of cultivable micro-flora in the oral cavity of husband and wife for application of anti-microbial agents for control of periodontal diseases and to find out bacteriological agent responsible for causation of this disease by disc-method at 37 C for 48 hours in incubation.

 

The presence of a bacterial flora in the oral cavity is considered of importance and therefore its composition has been observed in two different close contact mouths.  This information becomes interesting for detailed knowledge.  

INTRODUCTION:

 

While dealing with clinical diagnosis, management and investigations of various types of periodontal cases, laboratory aids were sought for broad-spectrum antibiotic coverage.  Reports from laboratory of direct smear examination and culture sensitivity test when received fro treatment in my private surgery at Lahore, is different from the other life partner who have go close contact.  Therefore, I decided to isolate such pairs for study.  However, the present data is of isolation of common bacteria of clinically suspected cases of periodontitis and such observations were evolved during routine treatment and surgery.

 

OCCURANCE:

 

Viability and identification of the oral microbial flora between the husband and wife was studied using aerobic techniques.  The 50 pairs were checked clinically for complaints of bleeding gums, watery mouth and shaky teeth.  Specimens of pus from the 50 pairs were taken.  All the parents were of average 40 years age. 

 

No growth occurred in 3 cases.  Growth of identical bacteria was observed in 21 pairs on culturing and direct bacteriological examination and 29 cases were found to have different flora in the husband and wife.  Similarly some pairs with identical flora had different sensitivity to antibiotics.

 

INDIRECT SMEAR EXAMINATION:

 

Microbial flora, observed was mixed i.e. G+ iv Cocci, Fusiformis and Vibrioes, and in culture was mainly of Staphylococcus pyogens, Streptococcus Pneumoniae and Actinomyces etc.  The composition of the flora in all such cases was similar to that which may be observed in dental plaque and that found in other studies.

 

 

MATERIAL AND METHODS:

 

            Subjects of Periodontal patients (Husband & Wife)

            Identification for Various microbes.

Tools:            a.         Bacteriology laboratory & Microbiologist.

b.            Peri apical Radiographs.

c.            Dental Unit, Chair & Examination Instruments like WHO Probe, Denture Mirror, and Tweezer.

SUBJECTS:

 

            Bleeding and inflamed gingivae, moderate and advanced periodontal cases are common clinical conditions, which come across in our domicillary as well as teaching clinical practice.  These alongwith many other clinical conditions are generally bacterial in origin and thus bacterial diagnosis becomes essential and these conditions need to be managed for antimicrobials.  Recognition of various pathogens becomes essential for antimicrobial therapy so sensitivity and resistance testing is being done by the standard disc diffusion method.

 

            The specimen samples were collected from 100 cases of (Husband and wife) clinically diagnosed advanced destructive periodontitis, moderate periodontitis and marginal gingivitis in our routine examination for planning the treatment of periodontal surgery.  These patients were referred to this surgery from different parts of city and the province both by medical and dental practitioners. However, the present data is for isolation of common bacteria of clinically suspected cases of periodontitis and such observations are evolved during routine treatment and surgery.

 

MATERIAL AND METHODS:

 

            Before examination of the oral cavity of each pair, a detailed record chart was filled, teeth were blasted with dry air and a sterile curette was used to take exudates from the sulcus of infected teeth.  It was transferred to cotton swabs on wooden sticks prepared and sterilized by autoclaving and the sticks are kept in autoclaved test tubes for this process.

 

            These swabs are then streaked all over the blood agar plate three times and are kept at room temperature after closing the upper lid for a few minutes and kept at 37 C for 24 hours and next day the colonies are isolated and bacteria’s are identified through type of colony and staining under microscope. 

 

            The antibiotic discs of various types are placed on the agar plate having a diameter of 9 – 10 cm. Each disc is pressed down gently to ensure even contact with medium to further 24 hours in incubation at 37 C and results are prepared.

 

RESULTS:

 

            Direct smear results in 100 cases (50 pairs)

·                     Gram + ve                                          65 cases

·                     Fusiformis bacilli                              19 cases

·                     Grame – ve                                        01 case

·                     Only pus cells & epethial cells      15 cases

 

Culture and sensitivity test – 100 cases ( 50 pairs)

                                                                                              Male             Female

·                     Staphylococcus Pyogenes                                    20                    30

·                     Non-Haemolytic streptococcus                 13                    09

·                     Haemolytic streptococcus                          03                    02

·                     Strepto pneumoniae                                               04                    04

·                     Micrococci                                                     04                    01

·                     Fusiformis bacilli                                          01                    01

·                     Haemolytic influenza                                              -                       -

·                     Escherichia Coli                                          01                    -

·                     Normal Flora                                                             04                    02

 

Types of microbes in 21 identical cases

 

·                     Staphylococcus pyogenes                                     14 cases

·                     Streptococcus pnemoniae                                     04 cases

·                     Staphylococcus aureus                              01 case

·                     Non-haemolytic streptococcus                  02 cases

           

Types of microbes in 29 non-identical cases

·                     Staphylococcus pyogene                           18 cases

·                     Non-Haemolytic streptococcus                 18 cases

·                     Escherichia  coli                                          04 cases

·                     Fusiformis bacilli                                          02 cases

·                     Pathogene micrococci                                05 cases

·                     Haemolytic influenza                                  01 case

·                     Normal flora                                                  03 cases

Types and No. of organisms in the two sexes.

                                                                                    Male               Female

·                     Staphylococcus Pyogene                          30                    20

·                     Non-Haemolytic streptococcus                 09                    13

·                     Haemolytic streptococcus                          02                    03

·                     Streptococcus pneumoniae                       04                    04

·                     Micrococci                                                     01                    04

·                     Fusiformis bacilli                                          01                    01

·                     Haemolytic influenza                                  01                    -

·                     Escherichia coli                                           -                       04

·                     Normal flora                                                  02                    01

50                    50

DISCUSSION:

 

            All the cases had the periodontitis, resulting in the destruction of periodontal fibers and alveolar – bone loss as confirmed by the radiographs.  The severity and rate of progression of disease varied not only from husband to wife but in certain cases from tooth to tooth in the same patient.  The younger pairs also had the progression of the lesion supported by microbial results of the laboratory and radiographs. We have observed that he periodontal lesions were mostly localized to the molars and incisors which were involved in more advance disease.  In certain cases the bone loss was accompanied by apical migration of the epithelial cells and then attachment in the anterior region.

 

            The results of the laboratory has adequately demonstrated that the micro-organism cultured out of these cases were the aetiological agents.  Certainly the dental plaque was the primary agent for implicating the periodontitis as observed (1), (2), (3), (4).

            The variation of the flora from mouth to mouth is different in our study and (5), (6) observed that the plaque flora varies from site to site within the same mouth as well as from individual to individual.  Therefore, in our study a finite number of same species of bacteria were present in both the sexes.  We found many gram + ve cocci in the direct smear and culture sensitivity examination in our study which confirms (1), (7), (8), (9), (3).  The same has been observed in experimental gingivitis, where the predominant organisms were mostly gram + ve, (1), (7), (10).  In our studies of most of the cases of long standing gingivitis and periodontitis, we have found gram –ve organisms in the sub-gingival sites taken out with the curette for testing. Similarly the studies of (8), (4), in which the longstanding gingivitis found with the microbial plaque having gram + ve approximately 25% of the organism were observed gram – ve, located primarily on the areas of the plaque in contrast with the tissues in the sub-gingival sites.

 

            In our examination of the sub-gingival exudates associated with the destructive and advanced periodontitis, we have found the organisms like anaerobic gram –ve as (11) observed. The objective of these tests was to find out a treatment planning of in order to control the infection and inflammatory conditions for advance treatment, because this therapy i.e. first to suppress or inhibit growth of bacteria and then interference with surgery proves most successful.  The potential pathogens on one hand are controlled due to proper concentrated use of anti-microbial agents against the specific organisms according to the lab: reports.  This provides the better and longstanding results and the disease have been successfully treated.  However, the disease has been first controlled by regular mechanical removal of supra-gingival and sub-gingival deposits though in certain cases this procedure becomes difficult and we do the ultra-sonic curettage.  Consequently, the disease is controlled and chronic infection is eradicated.

 

            Among such clinical cases of periodontism, samples and results show variation in the type of micro-organisms, inspite of the fact that husband and wife have close relations and transmission of the micro-organisms is very much possible. This demonstrates that the concept of droplet or cross infection is to be considered again.  The micro-organisms flourish according to the type of environment.  It depends upon the type of oral aptitude of the individual, which provides the substrate to the bacteria. Saliva and its consistency provides the chance for initiation for the plaque and calculus formation, and the fluids secreted in various of food, the plaque the supragingival calculus, provide the chance to bacteria for irritation to the local tissues for production of enzyme and pocket formation.  The plaque on tooth causes the gingival inflammation and stands for pocket formation and these pockets provide shelter to bacteria for advancing disease of periodontal domain.

 

CONCLUSION:

 

            After having study the culture sensitivity reports of 50 couples the following observation were made: -

a.            21 couples out of 50 were those suffering from periodontal disease caused by identical organisms.

b.            29 couples out of 50 were those suffering from periodontal diseases caused by non-identical organisms.

 

This indicates that Staphylococcus is the microbes which is most commonly and easily transmitted from one person suffering from the periodontal diseases to the direct contact and other who is the closest and in direct contract.

 

Among the 29 couples who were suffering from periodontal disease a variety of organisms were seen to be the causative organisms.

 

REFERENCE:

 

1.            Loe H. Theilade E. and Jensed. B (1965).  Experimental Gingivitis in man. J. Periodontal 36.177-187.

2.            Genco R. J. Evans R.T. and Ellison  S.A. (1969).  Dental Research in J.A.D.A. 78, 1016-1036.

3.            Socransky S. S. (1977), Microbiology of periodontal disease, present status and future consideration. J. Periodontal 48.

4.            Slots J. Mashimo P. Levine M. J. et al (1979) Periodontal Therapy in humans. Microbiological and clinical effects of a single course of periodontal scaling and root planning as an adjunct to tetracycline, J. Periodontal, 50, 495 – 509.

5.            Bowden G. H. Hardie J. M. and Slack G. L. (1975), Microbial variations in approximal dental plaque. Caries Res. 9,253 – 277.

6.            Moore W.E.C. Holdeman L. V. cato E. P. et al (1984) variation in periodontal floras.  Infect Immun. 46, 720 –726.

7.            Listagartem M. A. Mayo H. E. and Treamblay R. (1975)  Development of Dental plaque on epoxy resin crowns in man.  A light and electron-microscope study. J. Periodontal 46. 10-26.

8.            Listagartem M. A. (1976) Structure of the microbial flora associated with periodontal disease and health in man.  A  light electron-microscope study. J. Periodontal 47, 1-18.

9.            Slots J. (1977a).  The  microflora in the healthy gingival sulcus in man.  Scand J. Dent. Res. 85, 247 –254.

10.         Syed S. A. Loesche W. J. and Loe H. (1975), Bacteriology of Dental plaque in Experimental Gingivitis. II-Relationship between plaques score and flora. J. Dent. Rest. 54 –72 abstract – 109.

11.         Slots J. (1977b).  The predominant cultivable microflora of advanced periodontitis.  Scand. J. Dent. Res. 85, 114 –121.


 

COMPARISON IN VITRO, OF PENICILLIN, LEDERAMYCIN, CEPHALORIDIN, NEOMYCIN & FLAGYL ISOLATED COLONIES OF FUSIFORMIS BACILLI FROM ACUTE NECROTIZING ULCERATIVE GINGIVITIS CASES

 

INTRODUCTION:

 

            Acute Necrotizing Ulcerative Gingivitis has a long history in Pakistan.  In recent years, much attention has been focused on anaerobic bacteria, in particular Fusobacteria and baceriodes etc. as being, major causes of morbidity.  We observed this disease in acute form in children, and in convalescing mothers, who had poor oral hygiene. The cases of mild form, with persistent bleeding characters, have been noticed in younger population. The virulence of such organisms resulted into cancrum oris (Fig-I, Fig-II).  The recognition of the disease either in acute or mild form was easy, as the presence of punched out interdental papillae; and gray paseundomembranous slough on the gums was accompanied with bleeding. Painful gingivae were characterized observation as well.

 

            A direct microscopic smear examination revealed an abundance of motile spirochetes and fusiform bacilli associated with epithelial cells. There is a necessity for an effective therapy against the oral habitat anaerobic bacteria.

 

            Antibiotics are the bedrock of such condition but the efficacy and antimicrobicidal effects of different drugs were needed to evaluate for the choice of treatment. Hence, it was decided to try the above named four drugs in vitro against fusiforms bacilli with serial dilution method (M.I.C).

 

            Metronidazole has been included in this study for its bacteriocidal effect against obligate anaerobic organisms. There arises a need for further continuity of study for the properties of the family of metronidazole against the fusospirochetal and other hidden anaerobic bacteria in the oral cavity.

 

OBJECTIVES OF THE STUDY:

 

I)             To find out the excellent therapeutic agent, against the predominant oral pathogenic anaerobes, observed in acute and in chronic gingival infections.

II)            To know the advantage of one drug, over the other in vitro and to analyze degree of activity, sensitivity or resistance against Fusiformis bacilli.

III)           To recognize the bacterial strain for this disease involving gingivae of the population.

IV)          To provide chance for further discovery and other opening for family of Metronidazole.

 

MATERIAL AND METHODS:

 

            10 young sufferers of acute Necrotizing Ulcerative Gingivitis aged 20-25 years, of sound socio-economic background are included in this study, as they presented for treatment having complaints of soreness, painful gingivae, bleeding, fever etc. in acute state. The history and clinical examination confirmed their disease (ANUG). Prior to this visit they were not administered with any drug or did not undertake any therapy.

 

Clinical examination.  On examination, punched out interdental papillae and ulcerated gingival was observed.  Tenderness foul smelling, sloughy and bleeding gums were also seen and more salivation was noticed.

 

Laboratory examination.     A bacterial sample was taken from gum crevice of the clinically judged patients with sterilized platinum loop.  A smear, about 1 cm. In diameter, was prepared by spreading the sample in a drop of distilled water on a glass slide, and was covered by a glass slip. The smear was assessed for presence of increased number of spirochaetes and fusiformis bacilli under the microscope. The smear was typical of the Vincent disease. Accordingly, blood agar plates were inoculated with smear taken from the ulcer of the papilla and were kept in the incubator at 37 C both aerobically and anaerobically for twelve hours.  Next day, the colonies of fusiformis thus obtained, were isolated with a platinum loop under the dissecting microscope and were re-cultured on blood agar plates for confirmation. After the confirmation was made pure colonies of fusiformis were transferred to a liquid ‘Omata Medium’.

 

Serial dilution tube  technique.  The  experiment was performed in serial dilution test in 5/8 (1.6 cm) test tube, 15 cm long each containing 10 ml of medium omata and were placed in a stand. The serial dilution (ug/ml) of the respective medicine was made. The antimicrobial agents were weighed in an electric balance which were diluted with the help of a pippete accordingly. A dropper (test tube) was used for inauculating the organisms (fusiformis) from omata medium to the test tubes.  The inauculated test tubes were placed in an incubator at 37 C for 18-24 hours for examination of turbidity of the medium. The tube with highest dilution showed no visible turbidity of the medium and this was considered M.I.C. i.e. minimum inhibitory concentration.  To confirm this a sub-culture from such test tube was taken, in which there was no visible growth, and on the agar plates too, we could not find any microbial growth.  The medium, so prepared had a pH 7.4 which did not change throughout the experiment.

 

            Staphylococcus was kept as a control. Neomycin sulphate has got no effect against fusiformis but it acted against staphylococcus aureus.

 

RESULTS:

 

            The results obtained by various drugs according to the above procedure were as follows: -

 

Metronidazole.   In this experiment, staphylococcus control was not affected by this drug.  The growth started in three cases at 0.125 ug/ml (one with a +  result).  At 0.15 ug/ml there was no growth in 2 cases and in 3 cases growth was +  and 5 cases were with  +ve growth and at 0.007 ug/ml no growth was observed in 2 cases and 8 were with  + ve growth. Two cases were noted as negative/positive at concentration of 0.0035 ug/ml and after this the growth was observed positively at 0.0017 ug/ml.  The average inhibitory or turbidity was considered at 0.015 ug/ml concentration (Table No. I). 

 

Benzyl Pencillin.  Only one case was +ve at 0.125 and 0.06 ug/ml whereas at 0.03 ug/ml, three cases (with one + ) showed turbidity.  Four cases were positive growth at 0.15 ug/ml concentration (with one + ).  No growth was seen after 0.007 and 0.0035 ug/ml except for one case that was found negative.  The drug has shown the efficacy at 0.007 ug/ml concentration for fusiformis and efficacy for staphylococcus has been confirmed (Table No. 2).

 

Lederamycin (Demethyle  Oxytetracyclin).          Three cases of turbidity were observed at 0.03 ug/ml concentration. Five were observed with positive growth and 2 were observed with a negative/+ve growth.  Three cases were observed with negative growth at 0.0035 ug/ml concentration and even two cases growth at 0.0035 ug/ml concentration and even two cases were found negative at the last test tube i.e. 0.0017 and 0.0008 ug/ml of the concentration.  The Staphylococcus control was reported positive growth at concentration 0.0035 ug/ml.

 

Ceporan (Cephaloridin).   At 0.5, 0.125 and 0.25 ug/ml concentration, two cases were found with growth.  Four cases were positive at 0.006 ug/ml concentration (with 2 + cases).  All cases were observed positive at 0.015 ug/ml concentration except one case was found negative. Similarly Staphylococcus control was also found positive at 0.15 ug/ml. 

 

DISCUSSION:

 

            In this study the M.I.C. of metronidazole was observed effective at 0.15 ug/ml whereas lederamycin has shown more potency and efficacy both to the fusiformis and to the staphylococcus control trial, more than penicillin and cephaloridin. The metronidazole has no effect on staphylococcus control.  The penicillin is the second drug which has concentration than the cephaloridin and metronidazole. The Lederamycin however, has proved to be more effective as compared to the other broad spectrum antibiotics.  Metronidazole in case of fusiformis has shown reasonable efficacy for this bacteria.

 

            Discovery of metronidazole in (1957) and its efficacy in clinical trials by Davies et al (1964) and Shin et al (1965), Duck worth et al (1966) has invited our attention for involvement of this drug into this experiment.  Lefrock (1962) describes that metronidazole diffuses readily into both aerobic and unaerobic bacteria.  The sensitive organism contains low-redox-potential electron transport proteins capable for reducing the nitrogen group of the compound, and it generates toxic transitory compounds, which bind to D.N.A. and inhibit its synthesis, resulting in the cell death.

 

            For this reason the drug is being used as alternative clinical choice for the treatment of anerobic infection on the basis of this experiment.

 

            Soofi (1978) made a clinical trial on 126 cases for treating acute ulcerative gingivitis and bleeding gums with tinidazole, a member of the family of metronidazole compound.  He further made a confirmatory study on 312 cases with the same drug for the same complaint & achieved successful results.

 

            Soofi (1987) made a third study on 342 subjects of gingival bleeding with bacteriologically proven cases having fusiformis with a single dose of 4 tablets of 500 mg. tinidazole and found excellent cure rate.

 

CONCLUSION:

 

            A detailed study of oral fusobacteria was carried out and antimicrobial drugs were tested against fusiformis bacilli grown in a special ‘Omata’ medium.  Metronidazole has proved effective drug against fusiformis and tinidazole., has been administered successfully in 3 consecutive studies by the author. 

 

 

 

ACKNOWLEDGEMENTS:

 

            The guidance of Dr. G. C. Blake, Head of the Department of Bacteriology, Institute of Dental Surgery (Eastman Dental Clinic) University of London are gratefully acknowledged so as assistance of Mrs. Joan Vidic, Senior Technician of that Department. 

 

REFERENCES:

 

1.            Duckworth R. Waterhouse J.P., Britton D.E.R. Nuki K., Sheiham Al, Winter R., Blake G. C. (1966), British Dental Journal, Vol. 120, pp. 599-602, June, 21.

2.            Davies A. H. McFadzean, J.A. and Squires, S. (1964), Brit. Med. J, I., 1149.

3.            Lefrock Jack L. (1981) Metronidazole, Clinical Pharmacology, Vol. 24, Number 1.

4.            Omata R.R. Braunberg, R.C. Disraily M.N. (1956) “A Selective Medium for Oral Fusibacteria”, J. Bacterial, 72, 677.

5.            Shin D.L.S., Squires, S. S. and McFadzean, J.A. (1965) Dent Practit., 15, 275.

6.            Soofi, M.A. (1979) ‘Fasigyn in treatment of acute Ulcerative Gingivitis and bleeding gums, Doctor Fortnightly, Vol 7 No. 16, Karachi, Pakistan.  Read in 8th International Conference on Dental Hygiene, U.K. Brighton London.

7.            Soofi M. A. (1987), Clinical & Bacteriological effects of Tinidazole (Fasigyn) in Gingival Bleeding, unpublished read in 3rd International Conference of Dental Surgeons, Karachi, Pakistan.

           

           

 

            TABLE NO. 1

RESULTS OF SERIAL DILUTION OF ANTIBIOTIC (METRONIDAZOLE) IN ug/ml IN VITRO AGAINST FUSIFORMIS

 

S No.

Name of Patient

0.5

0.25

0.125

0.06

0.03

0.015

0.007

0.0035

0.0017

0.0008

1.         

Hankin

-

-

-

-

+

+

+

+

+

+

2.         

Pesticho

-

-

-

-

-

+

+

+

+

+

3.         

Kutner

-

-

+

+

+

+

+

+

+

+

4.         

Mecwem

-

-

-

-

-

+

+

+

+

+

5.         

Earl

-

-

-

-

-

+

+

+

+

+

6.         

Bone

-

-

+

+

+

+

+

+

+

+

7.         

Neat

-

-

-

-

-

-

-

+

+

+

8.         

Davis

-

-

-

-

-

-

-

+

+

+

9.         

Zimamin

-

-

+

+

+

+

+

+

+

+

10.      

Scenterby

-

-

-

-

+

+

+

+

+

+

Staph.Control:          No effect                              +                 +                +                +                +                 +                         +                +

 

 

 

           

 

TABLE NO. 2

RESULTS OF SERIAL DILUTION OF ANTIBIOTIC (PENICILLIN) IN ug/ml IN VITRO AGAINST FUSIFORMIS

 

S No.

Name of Patient

0.5

0.25

0.125

0.06

0.03

0.015

0.007

0.0035

0.0017

0.0008

11.      

Hankin

-

-

-

-

-

-

+

+

+

+

12.      

Pesticho

-

-

-

-

-

-

+

+

+

+

13.      

Kutner

-

-

-

-

-

-

+

+

+

+

14.      

Mecwem

-

-

-

-

-

-

-

-

+

+

15.      

Earl

-

-

-

-

-

+

+

+

+

+

16.      

Bone

-

-

-

-

-

-

+

+

+

+

17.      

Neat

-

-

-

-

+

+

+

+

+

+

18.      

Davis

-

-

-

-

+

+

+

+

+

+

19.      

Zimamin

-

-

+

+

+

+

+

+

+

+

20.      

Scenterby

-

-

-

-

-

-

+

+

+

+

Staph. Control:                   -                 -                 -                  -                 -                  -                +                 +                         +                 +

 

 

           

 

 

 

RESULTS OF SERIAL DILUTION OF ANTIBIOTIC (CEPHALORIDIN) IN ug/ml IN VITRO AGAINST FUSIFORMIS

 

S No.

Name of Patient

0.5

0.25

0.125

0.06

0.03

0.015

0.007

0.0035

0.0017

0.0008

1.             

Hankin

+

+

+

+

+

+

+

+

+

+

2.             

Pesticho

-

-

-

-

+

+

+

+

+

+

3.             

Kutner

-

-

-

-

+

+

+

+

+

+

4.             

Mecwem

-

-

-

-

-

+

+

+

+

+

5.             

Earl

-

-

-

-

-

+

+

+

+

+

6.             

Bone

+

+

+

+

+

+

+

+

+

+

7.             

Neat

-

-

-

+

+

+

+

+

+

+

8.             

Davis

-

-

-

-

-

+

+

+

+

+

9.             

Zimamin

-

-

-

-

-

-

+

+

+

+

10.          

Scenterby

-

-

-

+

+

+

+

+

+

+

Staph. Control:                   -                 -                 -                  -                 -                 +                +                 +                         +                 +

 

 


 


 

SENSITIVITIES OF COLONIES OF FUSIFORMIS TO PENICILLIN, LEDERMYCIN, METRONIDAZOLE, NEOMYCIN SULPHATE & CEPHALORIDIN IN ACUTE NECROTIZING ULCERATIVE GINGIVITIS (IN VITRO) SERIAL DILUTION TECHNIQUE

 

Introduction

 

            Acute necrotizing ulcerative gingivitis has long history, often occurs in an acute form, whereas mild form and most persistent condition is referred to a sub-acute state.  Characteristically the lesions of this disease are recognized as punched out inter-dental papilla and the surface is covered by a gray pseudomembranous slough demarcated from the remainder of the gingival mucosa by a pronounced linear erythema (clinical periodontology –Fermin A. Carranza (1978).  The disease needed the treatment; therefore, it was decided to try these five drugs in comparative study in a serial dilution method for their efficacy.

 

            There is probably no other area of medicine in which problem of bacterial infection is as serious as in patients of A. U. G. and other periodontal diseases.  Infection with A.U.G. can lead to disastrous consequences like cancrum oris or Ludwing’s Angina.  The patients of all ages especially children can be attacked of this infection, hence this has got accommodating effect of other micro organism – mixed pathogens (gram +iv gram –iv) and such patients do have the poor response and tolerance to antimicrobial therapy. 

 

            Antibiotic therapy is, therefore, bedrock in the case of the patient with A.U. G., and we evaluated the drug of choice – for better tolerance and largely for better antimicrobial effect through this experiment. 

 

            In this study we have evaluated the antibacterial effect of penicillin, ledermycin, metronidazole, neomycin sulphate and cephaloridin (in vitro) in serial dilution method for fusiformis and spirochete obtained from case of A. U. G.   The results of this study are based upon M.I.C.   These results may act as potential.  The experiment was unique and one year was spent in a reputed bacteriological laboratory for convert of the dosage and sensitivity.  It has provided us choice in the treatment and clinical response.

 

            The metronidazole discovery in 1957 for a efficacy for trichomon as vaginalis infection and later on 1980 the drug was approved by the F.D.A. for use in anaerobic infection.  Therefore, this drug was also included in our study.

 

            Penicillin is a drug available commonly used for treatment of vincents disease but the efficacy of the treatment with metronidazole and other drugs was not known.  Therefore, it was decided to compare the efficacy of five drugs in serial dilution method.

 

Material and Method

 

            Ten young patients with A.U.G. presented for treatment, were selected and they were not given any treatment before.  The criteria of the diagnosis was true history of the gingival pain, bleeding with examination, punched out inter-dental papilla and ulcerative gingival.  Tenderness, bad smell and sloughy gums were also considered.

 

            At the first visit of each patient, bacteriological assessment of severity of the disease was made with care and guidance, patients were cooperative.

 

            A bacterial sample was taken from gum crevice from the clinically judged patients with the sterialized platinum loop.  A smear, about 1 cm in diameter, was prepared by spreading the sample in a drop of D/water on a glass slide.  The smear was assessed for presence of increased number of spirochaetes and fusiformis bacilli under the electronic microscope.  The smear was typical and classified as the Vincent disease.  Accordingly, blood agar plates were inauculated with smear taken from the ulcer of the papilla and put in the incubator at 37 C both for aerobically and inaerobically for twelve hours.  Next day the colonies of fusiformis were isolated with platinum loop under the dissecting microscope and re-cultured on blood agar plates for confirmation for twenty four (24) hours.  After this confirmation the pure colonies of fusiformis were transferred to liquid omata medium.

Serial Dilution Tube Technique

 

            The experiment was performed in serial dilution test in 5/8 (1.6 cm) test tube, 15 cm long each containing of 10 ml of medium omata placed in a stand, the serial dilution ug/ml of the respective medicine in experiment.  The solution of antimicrobial agent prepared already was prepared under strict care of electric balance and dilution was made, which later on diluted with pippite accordingly.  A stopper test tube was used for inauculating the material from omata medium to the test tubes.  The inauculated test tubes were placed in incubator at 37 C for 18-24 hours for examination of turbidity.  The tube with highest dilution showed no visible turbidity of the medium and this was considered M.I.C. i.e. minimum inhibitory concentration (bacterio-static concentration).  To confirm this sub-culture from such tube was taken, in which there was no visible growth, and on the agar plates found no microbial growths.

 

            Staphylococcus was put as a control.  Neomycin sulphate has got no affect against fusiformis but it acted against staphylococcus aureus.

 

            The medium, when prepared was at pH 7.4 which did not change throughout the experiment.  Metronidazole was supplied by M&B Co. whereas other drugs were supplied by Bacteriological Department and patients were referred by the Periodontal Department and Children Dentistry, Eastman Dental Hospital, London University.  The experiment was conducted in Department of Bacteriology, Institute of Dentistry, and University of London. 

 

Results of the Experiment

 

            Here are the results of the method of assessing the antibiotic sensitivity to fusiformis bacilli in an inauculated method in serial dilution of the liquid media with turbidity of the results:

 

1.            Metronidazole:  In this experiment staphylococcus control was not affected by this drug. The growth started in three cases at 0.125 ug/ml and in three cases at 0.06 ug/ml and four cases at 0.03 ug/ml, but it has shown no growth at 0.007 ug/ml and in two cases at 0.15 ug/ml cases respectively.  Two cases were noted as negative/positive at concentration of 0.0035 ug/ml concentration and after this the growth was observed positively at 0.0017. The average inhibitory or turbidity was considered at 0.015 ug/ml concentration. 

 

2.         Benzyl Pencillin:   Only one each at 0.125  ug/ml turbidity whereas at 0.03 ug/ml has shown the turbidity in three cases.  Four cases were positive growth at 0.15 ug/ml concentration.  No growth was seen after 0.007 and 0.0035 ug/ml except one case was found negative.  Similary at 0.007 ug/ml growth was observed in Staph: Control.  The drug has shown the efficacy at 0.007 ug/ml concentration for fusiformis and efficacy for Staph: has been confirmed.

 

3.         Ledermycin (Demethyle tetracycline):   Three cases of turbidity were observed at 0.03 ug/ml concentration. Whereas at 0.15 ug/ml concentration four were observed positive growth and one was observed negative growth. Two cases were observed with negative growth at 0.0035 ug/ml concentration and even two cases were found negative at the last test tube i.e. 0.0017 and 0.0008 ug/ml of the concentration. The Staph.  Control was reported positive growth at concentration 0.0035 ug/ml.  The drug has shown  high efficacy and antimicrobial activity at the minimum concentration of the drug against fusiformis and Staph: Control. 

 

4.         Cephoron (Cephalaoridin):           At 0.5 ug/ml concentration, two in each was found with growth, so as at 0.125 ug/ml and four cases were noticed positive at 0.006 ug/ml concentration.  All cases were observed positive at 0.015 ug/ml concentration except case found negative.  Similarly Staph: Control was also found positive at 0.015 ug/ml.  The drug has shown less  efficacy in this experiment, both against the Staphylococcus and fusiformis concentration. 

 

 

 

 

Discussion

 

            The smears taken from the ulcers of these ten cases presented scattered bacteria of various types under microscope in direct smear examination.  Predominately, spirochetes, fusiformis bacilli and desquamated epithelial cells were found. Filamentous organisms like actinomycetes two were seen. Staphlococcus and E. Vibro found present.  Electron microscope was used for identification of the bacteria.  The morphologic groups of spirochetes, the diagnosis of such cases were made on the basis of clinical fusiformis findings, history and experience, the confirmation of clinical diagnosis was made of the bacteria was carried out. The A.U.G. cases were taken between the age of 20-25 with the good socio-economic group of an educated class.  The cases were not having the debilitating disease or psychosomatic factors and nutritional deficiency was also not noticed except the oral hygiene was neglected.

 

            In this study the M.I.C. of metronidazole was observed effective at 0.15 ug/ml, whereas ledermycin as expressed more potency and efficacy both to the fusiformis and to the staphylococcus control trial, more than penicillin and cephaloridin.  The metronidazole has no effect on staph, control.  The penicillin is the second drug which has efficacy over the cephaloridin and  metronidazole.  The ledermycin, however, has proved more qualities of antimicrobial sensitivity as compared to the other broad  spectrum antibiotics.  Metronidazole in cases of fusiformis has shown reasonable efficacy for this bacteria. 

 

            Discovery of metronidazole in (1957) and its efficacy in clinical trials by Davies et. Al. (64) and Shin et. Al. (65), Duckworth et. Al. (66) has invited our attention for involvement of this drug into this experiment.  Lefrock (1962) describes that metronidazole diffuses readily into both aerobic and inaerobic bacteria.  The sensitive organism contains low-redox-potential electron transport proteins capable of reducing the nitrogen  group of the compound, and it generates toxic transitory compounds which bind to D.N.A. and inhibit its synthesis, resulting the cell death. 

 

            On this reason the drug is being used as alternative clinical choice for the treatment of anerobic infection.

 

Summary

 

            Minimum inhibitory concentration of benzyne penicillin demethyl chlortetracycline – cephaloridin and metronidazole, neomycin sulphate were tested against the strain of fusiformis obtained from A.U.G. cases.  The resistance of the colonies to antibiotics has been noticed and found ledermycin possess the more potency against the fusiformis and staphylococcus bacteria.  Whereas the penicillin possesses this efficacy over the cephaloridin and the metronidazole.  However, the metronidazole has shown its efficacy nearer to the penicillin and prompt from cephalordin.  The neomycin sulphate has shown no affect on fusiformis except on the control. 

 

Conclusion

 

            The practical technique for diagnosis of A.U.G. is available.  The drugs of choice have been anlaysed for treatment.

 

Thanks

 

            The assistance of Miss Joan Shephered, Senior Technician in the Department of Bacteriology, Eastman Dental Hospital, and other laboratory staff during this investigation is gratefully acknowledged.  Dr. G. C. Blake, Head of the Department of Bacteriology was the pivit of guidance in this experiment.

 

References:

 

1.            Duckworth R. Waterhouse J.P., Britton D.E.R., Nuki K., Sheiham A., Winter R., Blake G. C. (1966), British Dental Journal, Vol. 120, pp. 599-602, June 21.

2.            Davies A.H. McFadzean, J.A. and Squires, S. (1961), Brit. Med. J. I. 1149.

3.            Lefrock Jack L. afp, Clinical Pharmacology, Vol. 24, Number 1, Shinn, D.L.S. (1962) Lancet, I. 1191.

4.            Omata R.R. Braunberg, R.C. (1960), “Biochemical Study of Oral Fusibacteria”, J.D. Research 39, 685.

5.            Omata R.R. Braunberg, R.C. Disraily M.N. (1956), “A Selective Medium for Oral Fusibacteria”, J. Bacterial, 72, 677.


 

 

ORAL BACTERIOLOGICAL FINDINGS – TESTING THE SENSITIVITY AND RESISTANCE OF BACTERIA TO ANTIMICROBIAL AGENTS IN PERIODENTAL DISEASES

 

(Read in First International Dental Conference of Pakistan at Karachi December 17-19, 1981) 

 

 

ABSTRACT

 

            Microbiological investigations were carried out on oral infective diseases, reporting to Department of Dental Public Health Research Unit, College of Community Medicine, Lahore. The study is based on total sample of 650 cases.  The mean range of the age was 20 to 40 years belonging to well-to-do socio-economic class, study included 344 male, 316 female, from period November 1974 to November 1979. 

 

            Bacteriologically positive cases of periodontal disease has the following distribution of the micro-organisms. Pus cells were found only in 95.38 % cases, Gram positive Cocci 44.61 %, Gram negative Cocci 2.61 %, Fusiform bacilli and Spirochaetes were detected in 30.30 % cases respectively. 

 

            Staphylococcus pyogenes 55.00%, Non-Haemolytic Streptococci 17.68 %, Haemolyticus Streptococci 7.38%, Alpha haemolyticus Streptococci 4.76%, Beta Haemolytic Streptococci 3.07 %, Streptococcus viridans 1.23%, Streptococcus pneumonia 0.30 %, Escherchia coil 9.69%, Pseudomonas aeruginosa 0.15 %, Klebsiella pneumonia 0.46 % proteus  vulgaris 0.61 % and Haemophilus influenza 0.61 %. 

 

            The sensitivity and resistance reports have shown very interesting results.  Pencillin is being observed as the most resistant drug to oral bacteria, whereas Chloramphenicol has proved to be excellent sensitive for positive cases.  The other antibiotics have also indicated their trend of resistance. The study has been further split up to each bacteria and its sensitivity and resistance to each antibiotic.  Similar resistance has been observed in Tetracycline group.

 

            The utility of this study is of great importance for those who seek help of anti-biotics in their practice.

 

INTRODUCTION

 

            Periodontal diseases continue to be universal in its distribution all over the world.  Even earliest man had experience of its suffering.  Carranza (1978) opined that periodontal disease does not lend itself easily to objective measurement, because the signs of periodontal pathology involves colour changes in the soft tissues, swelling, bleeding and bone changes, which are reflected in sulcus depth, changes or Pathologic pocket formation and loss tooth function is due to mobility. 

 

            In Pakistan, the incidence of periodontal disease is enormously high, according to studies carried out by Soofi et. al. at Quetta (1962) Punjab (1978) and in NWFP (1979) and study by Day et. al (1947), Ramfjord (1963) examined Indian School of Children at Bombay and found 100% periodontal disease.  Similar results are available by the studies carried out by WHO elsewhere and other workers in the world. So in this study we have limited ourselves to the infection of periodontal disease to evaluate the causation and sensitivity to broad-spectrum antibiotics.

 

OBJECTIVE

 

            The oral flora consist of a diverse collection of bacterial and protozoal species existing in different parts of mouth.  Among the organisms, we have limited our study, for those, which are associated with periodontal disease, in trying to determine the reason for delicate organism and to know their sensitivity and resistance to broad spectrum antibiotic.

 

 

 

 

MATERIAL AND METHODS

 

            All suspected cases (650) of periodontal disease reporting to the Department of Dental Public Health (Research Cell), College of Community  Medicine are included in this study.  The investigation started at the end of November 1974 to December 1979.   The selection was made according to the clinical judgement, patient’s history, present symptoms or history treatment carried before.  However, complete history of each case recorded on a prepared proforma. The cases were examined in a standard light of the dental unit and ina sitting position.  Pus exudates specimen of 650 cases was taken in a sterile test tube and sent over to the Medical Laboratory for direct examination, culture and drug sensitivity test.  In certain advanced cases the purulent exudates was expressed from periodontal pocket by digital pressure, mostly exudates was taken with the help of curett for transferring to the laboratory in test tube.

 

            Diffusion Tests with filter paper disks was used to determine the sensitivity to antibiotics, because of the simplicity and reliable technique for such heavy routine type of bacteriological work.  Impregnated small disks of standard filter paper with known amounts of antibiotic were placed on the plates of culture medium inoculated with oral organism.  After incubation at 37 C for over a night, degree of sensitivity was measured by visible area of inhibition of growth produced by diffusion of antibiotic from the disks into surrounding medium.  Commonly the disks are 6.25 m.m in diameter.  After over night incubation, the diameter  of zones of inhibition were measured and sensitivity was obtained for each antibiotic.  The areas of inhibition measured included that of disks or were as surrounding zone and blood agar plates, which are inoculated uniformly with both culture. Resistance was recognized as lack of an inhibition zone whereas the zone of inhibition in sensitive cultures were read as radius of inhibition expressed in m.ms.  The pus samples were cultured on Blood agar  plates aerobically for overnight.  Drug sensitivity test for antibiotics was performed by the Gould and Bowie (1952) disks method. 

 

            In this study the mean range of age was 20 to 40 years, belonging to well-to-do socio-economic class.  The study included 650 cases in which 344 were the males and 316 were the females.  Most of the cases had the chronic periodontal disease.  The study does not include typical cases of candidiasis lichen planuus, leukoplakia and acute cases of ulcerative gingivitis and no epidemiological findings are included here.  No histopathology examination of the periodontal pocket or disease was carried out.  The study is limited only to the bacteriological involvement of the areas. 

 

            The study (1974-79) has proved oral bacteria in Table No. 1 are causative factors for periodontal disease and there is trend of antibiotic getting ineffective.  Test of sensitivity for antibiotic may be administered unless a report from a reasonable competent laboratory is received and proper investigations are carried out to identify bacteria.

 

PROCEDURE OF INOCCULATION

 

            The swab stick was inoculated onto blood agar, heated blood agar (chocolate agar) and MacConkey medium.  A liquid broth specimen was also inoculated.  Smears were prepared.  These media were incubated at 37 C for 18 to 24 hours.  The nature of colonies was examined on the solid medium and sub cultures made from liquid medium on to solid media for further identification of bacteria.  The pathogens were selected for antibiotic sensitivity by disk diffusion method on blood agar. These were again incubated for 18 hours at 37 C and zones of inhibition measured and compared with control organism after which sensitivity or resistance of a pathogen to an antibiotic was reported.

 

            The smears were stained by Grams stain and examined for presence of pus cells, fusiform bacilli and Borellia vencentii. 

 


 

TABLE NO. 1

 

A STUDY REPORT OF ORAL BACTERIOLOGICAL SPECIMENS

(NOVEMBER 1974 – NOVEMBER 1979)

% DISTRIBUTION OUT OF 650 CASES

 

 

Direct Smears Results                    Total                           Sex                 Distribution

Gram Positive Cocci                        44.61 %                      23.84 %          20.77%

Gram Negative Cocci                       2.61 %                        1.69%            0.92%

Fusiformis Spirochaetes                30.30%                       13.84%           16.46%

and pus cells in                                95.38%

 

 

TABLE NO. 2

 

CULTURE REPORT

 

Staphylococcus pygenes               55.00%           Proteus vulgaris                   0.61%

Non Haemolyticus                                                    

Streptococcus                                   17.69%           Beta Haemolytic                   -

                                                                                    Streptococcus                       3.07%

Haemolytic Streptococcus               7.38%            Streptococcus Pneumonae 0.30%

Alpha Haemolytic                                                    Pseudomonas aeruginosa            0.15%

Streptococcus                                   4.76%                        

Streptococcus viridans                   1.23%                         Escherchia coli                    9.69%

Haemophilus influenza                  0.61%                         Klebsiella pneumonae       0.46%

 

 

 

 

 

TABLE NO. 3

SENSITIVITY AND RESISTANCE TO ANTIBIOTICS

 

Resistance               Sensitivity

1.         Albamycin                                         97.00%                         3.00%

2.         Penicillin                                           87.00%                       13.00%

3.         Tetracyclines                                    80.00%                       20.00%

4.         Treptomycin                                      75.00%                       25.00%

5.         Vibramycin                                        72.00%                       28.00%

6.         Ceporan                                            61.00%                       39.00%

7.         Pyopen                                              53.00%                       47.00%

8.         Ampicilin                                           52.00%                       48.00%

9.         Co-Trimoxazole                                38.00%                       62.00%

10.       Erythromycin                                    35.00%                       65.00%

11.       Lincocin                                             33.00%                       67.00%

12.       Cloxacillin                                         31.00%                       69.00%

13.       Kanamycin                                        20.00%                       80.00%

14.       Gentamycin                                      11.00%                       89.00%

15.       Chloramphenicol                               5.00%                       95.00%

 

 

DISCUSSION

 

            Kelstrup (1977), has observed that bacteria of the mouth are similar throughout the world.  The difference he found is mostly of a quantitative nature and this he relates to the different dietary patterns.  In our study the second group of organism was belonged to the genus streptococcus whereas staph:Pyogenes was pre-dominant in addition to other group of organisms.  Similar study was made by NIOM (1977) that bacteria was demonstrated in the vacities.  Glickman (1963) observed several bacteria are found in smears in acute necrotzing gingivitis cases and other workers like Miller (1944), Merrit (1933), Iapira (1943) Delay (1928), Coutely (1943), Appleton (1929), Bettman and Ratte (1930), co-related Borrelia vincenti, Bacillus fusiformis, Filamentour organism (Actinomycetes or Leptotrichia), Streptococcus, Vibrio, Treponema microdentium as the cause of disease.  In our study, we have found the relative proportion of all such organism in our sample because our patients were not in acute state, but they were of periodontal disease.  Therefore, we could only detect in our direct smears Gram Positive Cocci as in Table No. I & II.

 

            Glickman (1963) also has agreed that the chronic inflammation is the most common local condition responsible for bone loss and he is of the opinion that the toxic effect of bacteria and other toxins upon the osteocytes, is responsible for the bone loss.  Potential organisms isolated in periodontal lesion could not be demonstrated in other ways. 

 

            Various workers like Gibbons et. al. (1966) and (1968), Irving et.al. (1973), Gordan et. al. (1972), Kaslick et.al. (1975), Kelstrup et.al. (1970), Loesche et.al. (1975) and (1977), Socransky et.al. (1970), demonstrated that Gram positive organisms from human oral cavity can initate periodontal destruction in gnotobiotic rats.  Some of the strains they included were Streptococcus mutans, S. Salivarius, Actinomyces baselundii, A. viscosus, Bacillus species, and Nocardia.  More recently, certain gram-negative isolates have been shown to be periodontophatic as monocontaminanss in gnotobiotic rats.  Carranza stated (1978) that there is evidence for a primary bacterial etiology in periodontal disease.  Similar to our study, he has mentioned that no specific agents causing periodontal destruction has been isolated.

 

CONCLUSION

 

            Periodontal disease is being caused by bacteria Table No. 1 and II a few are known to us in our study (1974-79), but larger are more to be detected through other studies and systems of identification with special medium, particular environment of facilities of technique and technology of laboratory.  Let us stress ourselves to identify the cause and then prescribe the drug. By this consciousness of mind, response to my treatment and line of action remained ideal in recovery and confidence of patients and satisfaction to myself.

 

            The choice of a drug to be used for treatment may be asked on the results of the vitro sensitivity test for particular strain of bacteria in section.

 

            We have identified oral pathogens – affecting the periodontal apparatus and due to our bacteriological results and sensitivity and resistance reports, a headway has been made, how, when, where and which antibiotic may be used to each bacteria in terms of choice?

 

ACKNOWLEDGEMENT

 

            We owe a lot of thanks to Prof. Nasir Alam Naru, Principal, College of Community Medicine, who has encouraged us in preparation of this research task.  Prof. Dr. Shamim Raza Bokhari, Head of the Department of Bacteriology, has provided us her research talents and her valuable technical criticism molded this study to correct direction.  Medical Laboratory of Dr. Zeenat Hassan provided us constantly excellent reports and due to her result we are able to compile this data. Mr. Adil Hussain of Dental Public Health Department deserves special appreciation for his hard work in preparation of data nicely so as the other workers of the Dental Department helped us. Our thanks are also due to Mr. Muhammad Ashfaq Baig, who took a lot of pains in typing and setting the paper. 

 

REFERENCES

 

1.            Angel, J. Newman, M.G., and Carranza, F.A.Jr.: Unpublished Observations, 1978.

2.            Appleton, J.L.T.P: Microscopic Examination in Vincent’s Stomatitis.  Dent. Cosmos, 71: 5776, 1929.

3.            Bettman, M. and Ratte, G. : Vincent’s Infection J. Canadian D. Assan, 1:283, 1935.

4.            Carranza A. F. (1978): Glickman’s Clinical Periodontology, Fifth Edition Asian Edition, W. B. Saunders Company, Philedelphia London Toronto IGAKU Shoin LTD. Tokyo.

5.            Coutely, R. L. : Vincent’s Infection. Brit. Dent. J., 74:34, 1943.

6.            Daley, F.H. : Studies of Vincent’s Infection at the Clinic of Tufts College Dental School from Oct. 1926 to February 1928. J. D. Res. 8: 408, 1928.

7.            Day, C.D. Marshall and Shourie, K.L. (1974). Hypertrophic Gingivitis in Indian Children and Adolescents.

8.            Gibbons, R. J., Berman, K.S. Knoettner, P., and Kapsimalis, B.: Dental Carries and alveolar bone loss in gnotobiotic rats infected with capsule forming streptocci of human origin. Arch. Oral Biol., 11: 549, 1966.

9.            Glickman I.  (1963) Clinical Periodontology. 2nd Edition W. B. Sounders Company London.

10.         Gordon, H.V., Keyes, P.H. and Bellack, S.: Periodontal lesions in hamsters and gnotobiotic rats infected with Actinomyces of human origin.  Arch. Oral Biol., 17: 175, 1972.

11.         Gould, J.C. and Bowie, JH (1952) The Determination of bacterial Sensitivity to antibiotics, Edinb med J, 59. 178.

12.         Irving J.T., Socransky, S.S., and Heeley, J.D. : Histological changes in experimental periodontal disease in gnotobiotic rats and conventional hamsters.  J. Periodont. Res., 9:73, 1974.

13.         Ivar A. NOIM (1977): Forsknigsveien I, N-oslo 3, Norway.  Bacteria in Experimentally infected cavity preparations, Scand J Dent Res 85: 599-605, Nove.

14.         Kaslick, R.S. West, T. L., Chasens, A.I., Terasaki, P.I., Lazzara, R., and Weinberg, S.: Association between HL-A2antigen and various periodontal diseases in young adults. J. Dent Res. 54: 424, 1975. 


 

CLINICAL & BACTERIOLOGICAL EFFECTS OF TINIDAZOLE (FASIGYN) IN GINGIVAL BLEEDING

 

342 men and women, with bacteriologically proven cases of chronic periodontitis accompanied with gingival bleeding were managed with single dose 4 tablets of 500 mg Tinidazole. The cure rate observed is excellent i.e. 98%.  Clinical results evaluated in 61.70% males, 38.30% females are shown in the tables. Side effects with this drug were insignificant i.e. 2 % cases reported bitterness and nausea.  The drug shows improvement both clinically and bacteriologically and proved effective against bleeding gums.

Gingival bleeding is an important disease of gums in acute and chronic form. It is caused by wide variety of aerobic and anaerobic bacteria “bacterial plaque”. The fusiform bacilli and Spirochetes are the most important in vitro and clinical observation for causing bleeding gums, but our repeated studies in recent years, are changing the old hypothesis of fusiformis as causative agent to some hidden anaerobes which need further proper investigations.

The common complaints of the patient are pain, bleeding, purulent discharge, odour and malaise etc., the patients with acute and chronic inflammation were included in this study with proper clinical examination and culture test and radiographs.

 


 

GINGIVAL BLEEDING

INTRODUCTION

Gingival bleeding is a common complaint.  It varies in severity, without discrimination of sex or age.

The bleeding has been noticed in acute gingival infection (ANUG) and in chronic inflammation.  Bleeding is observed with tooth brushing, tooth pick or biting on solid foods like apples. More bleeding and bad taste is the an other complaint after getting out of bed, and therefore, its management has become a challenge to the profession.

BACK GROUND OF MANAGEMENT

To control any problem, it is pertinent to find out acute exciting causative agent of the disease and to have the knowledge of the host.

Soofi (1966) carried out a study n vitro, on a few acute ulcerative gingivitis cases by taking bacterial smears from lesions in Acute Nectrozing Ulcerative Gingivitis. These semears were directly studied under electronic microscope in which fusiform bacilli and spirochetes were predominantly seen alongwith some vibrio, streptococci and filamentous organisms. The fusiform bacilli were cultured in special media called “Omata medium” and fusiforms bacilli were tested for MIC (Minimum Inhibition Concentration) against met-ranidazole, benzyl penicillin, demethyl-oxytetracycline and cephaloridin. Meteronidazole was found equally effective, like 3 other antibiotics against fusiforms bacilli.

The discovery of  Met-ranidazole in 1957 and further clinical trials by Duckworth et al (1968) for A.U.G. have proved its efficiency in control of bleeding of gums.  Soofi (1978) made a study on 126 cases of Acute Ulcerative Gingivitis.  79.80% of these trials cases had fusiform and Spirochetes, and 1.18 % of gram –ve bacilli in direct smear examination.  The cases were manage with 4 tablets of Tinidazole and its use has 98% proved effective against bleeding gums. Soofi (1978) made a further confirmatory study on 312 cases of bleeding gums in which 157 cases were without fusiforms and spirochetes in direct smear, and again bleeding gums in these cases was managed by a single dose of 4 tablets of 500 mg of Tinidazole.

Soofi (1987) is making further this study in management of cases of chronic nature.  In this observation of the bacterial smears, he found more cases without predominance of spirochetes and fusiforms bacilli.  This proves that gingival bleeding is caused by some hidden bacteria or protozoa or any other bacilli.   Because bleeding of gums has been controlled sufficiently for about a week, with single dose therapy of 4 tablets of Tinidazole of 500 mg each.

In all such cases, where gingival bleeding is being controlled by this drug, it only reduces the inflamed condition and reduces the engorged blood vessels and hence spontaneous bleeding stopped etc.  It does not take away the management by the dental surgeons, i.e. removal of bacterial plague, calculus or the technique of curettage and root planning or gingival surgery.  The other antibiotics only help in reduction or resolution of chronic gingival inflammation.  The previous hypothesis of fusiforms against this disease is changing its course.

REVIEW MECHANISM OF BLEEDING

Carranza (1979) has observed that the gingival fluid which is formed in the sulci of normal gingival, if it increases it can form an inflammatory exudates, which causes increased permeability of capillaries and bleeding of gums.

It is observed that the amount of gingival fluid increases with inflammation.  Jacoby et al (1972) has observed gingival pocket exudates in normal and inflamed gingival, in quantitative measurement. Oliver et al (1969)  observed it microscopically and evaluated inflammation in the gingival as a correlation between clinical scoring of exudates measurements and gingivitis. Further more, the severity of the disease has been correlated with amount of gingival fluid.  Egelberg (1964) observed in the study gingival score exudates amount for individual with rising degree of gingival inflammation and concluded that the inflammatory changes of the gingival are related to gingival exudates.  Gingival vessels get increased in permeability and flow of gingival fluid. With progesterone and estrogen increase or imbalance in animal, Lindhe et al (1968) has observed more gingival exudates in dogs with chronic gingivitis due to sex hormones changes.

Soofi et al (1969) made a study of Hyperplasia of gums on sheep during pregnancy and found gingival inflammation and exudates as result of hormonal changes.

THE COMPOSITION OF GINGIVAL FLUID

As explained in Glickmans clinical periodontology (fifth edition) it is similar to that of blood serum except in the proportions of some of its components. There are electrolytes (K+, Na+ Ca++), amino acid plasma proteins, fibrolytic factors, gamma globulin, Gamma M. Globulin (Immuno Globulins) albumin and lysozyme, fibrinogen and a variety of enzymes of bacterial and lysosomal orgin. Brandzaeg (1964-65)  has made a study on immunochemical and comparison of proteins in human gingival pocket, serum, saliva or on the lysozyme activity of the human gingiva.

In inflamed gingival, the sodium content of gingival fluid equals the serum level and calcium and phosphorus are more than three times higher.  The potassium sodium ratio is elevated and the acid phosphate content is increased.

MATERIAL AND RESULTS

TABLE NO. 1-2

342 cases i.e. 211 males (61.70 %) and 131 females (38.30%) have been selected out of thousands of humans suffering from gingival bleeding.  This population has previously been treated with various methods by dental colleagues. Among the group of men 134 i.e. 63.05% individuals were detected without fusiform bacilli and spirochete in direct smear, whereas 77 men i.e. 36.4% were observed with fusiforms bacilli in varying degrees.  A similar observation has been experienced with 131 females in which, 84 females i.e. 64.12% were observed without fusiform bacilli, whereas 47 females i.e. 35.80% were detected with fusiform bacilli in direct smear test.

 

All these individuals had a complaint of gingival bleeding and clinically they were found to suffer from chronic periodontal disease with radiographic evidence. A single dose of Tinidazole to these patients has shown a major progress, because it succeeded in arresting the chronic bleeding within 24 hours of its administration.  All cases were from higher strata of the society, 61 % were user of tooth brush in morning, 21 % twice in a day and 16% thrice in a day – 2 % were casual.

TABLE NO. 3

In our investigation and statistical analysis on 134 males (63.5 %) of population, 59.7% had G+ve Cocci, 2.9% had G-ve Cocci, 7.4% had the diplococci, 86.5% were observed with pus cells and 8.9% were noticed with epithelial cells in the direct smear.

TABLE NO. 4

A different situation was observed in 77 males, under the direct examination.  Surprisingly, we could not find G+ve and G-ve Cocci, only 32.4 % were found with pus cells, whereas 20.7% were detected with epithelial cells.

TABLE NO. 5

The culture sensitivity report of male population i.e. 36.4 % reveals as follows: -

36.3% population was witnessed with growth of staphylococcus pyogenes, 7.7% Eschericia Coli (E. Coli), 1.2% Haemolytic streptococcus, 6.4% non-Haemolytic Streptococcus, 22.1 % streptococcus aureus, 12.9% Streptococci and 9.89% were found with normal flora.

TABLE NO. 6

In male group of 134 i.e. 63.5% population was observed without fusiforms in culture and sensitivity as follows: -

 

21.6% Staphylococcus Pyogenes, 5.2% E. Coli, 16.4% Strepto Pneumonae, 1.4% Haemolytic Streptococcus. 1.4% Haemophilus influenzae 46.2% streptococcus aureus, 2.2% non-Haemolytic Streptococcus, 2.2% were found with normal flora.

TABLE NO. 7

84 females individuals i.e. 64.12% in which 90.4% cases were observed with pus cells.  48.8% with G+ve Cocci, 21.4% with diplococci and 9.5% were observed with epithelial cells and this lot was noted without fusiform bacilli.

TABLE NO. 8

47 individual female i.e. 35.8% of the population with fusiforms bacilli in direct smear were tested 31.9% of cases were noted with pus cells, 4.2% with G+ve Cocci and 40.4% with epithelial cells.

TABLE NO. 9

In the culture and sensitivity report on 35.8% females 48.7% have shown the presence of Staphylococcus Pyogenes. 12.7% of E. Coli, 8.5% Streptococcus, 8.9% normal flora and 21.2% Staphylococcus aureus. No growth of positive, proteus, vulgaris, Pseudomonas, klebsiella, Haemophilus influenzae, Candida alicans and non-Haemoytic Streptococcus was observed.

TABLE NO. 10

Whereas in females without fusiforms, 21.4% population had the Staphylococcus Pyogenes, 2.3% E. Coli, 1.1% and Haemolytic, 29.7% Staph: aureus, 7.1% non-Haemolytic Streptococci, 22.6% Strepto pheumonae-Cocci, 1.1%Candida Albicans, 8.3% Streptococci and 5.9% with normal flora. No Klebsiella or Pheumonae are noted. Here again, is difference in the direct smear and culture sensitivity.  Hence this study invites the intention of future work for causative agent for gingival bleeding. 

 

 

RESULTS FOR REVIEW

This shows the difference, both in the direct smear and the culture and sensitivity report.  It is evident, that the cases, who were found with fusiforms bacilli and Spirochetes had negative results for G-ve Cocci, whereas 59.7% of cases without fusiforms were found with G+ve Cocci, 2.9% G-ve Cocci and 7.4% diplococci.  Similar situation was of the pus cells i.e. 86.5% of the cases were found to have pus cells but were without fusiforms under the microscope. Only 32.4% of the cases of fusiforms were with pus cells and 20.7% were with epithelial cells.

In culture and sensitivity test, significant were staphylococcus pyogenes, 36.3% Streptococcus aureus 22.1% were found in the cases with fusiforms.  A higher position of Staphylococcus Pyogenes were seen, E. coli were not different statistically. Only the non-Haemolytics, 6.4% Streptococci were observed in the fusiforms culture report. All this endeavour was the aerobic study. The anaerobic study and special tests for other organisms is essential for research, eventually to recognize the actual causative agent.

DISCUSSION ON PRESENT STUDY

From this study it is accepted fact that the micro-organism has got leading role int eh etiology of gingival bleeding and periodontal disease. In our direct smear study we have discovered spirochetal forms of bacteria alongwith fusiform bacillus and in culture study we have recognized the presence of streptococci, staphylococci and penumococci and others and various forms of colonies.

In early studies of Soofi (1978) 126 cases; in which 27 were foud without spirochetal and fusifrm bacilli in direct smear test and similarly in second phase of 312 cases 157 cases were found without these organisms whereas the patients visited with major complaint of gingival bleeding.  With the single systemic dose of Tinidazole (Fasigy) 4 tablets of 500 mg) the bleeding complaint both in chronic and acute cases has stopped. The bleeding, as the chief complaint of the patient is being subsided his confidence in rest of the regula treatment becomes handy and easy.  Since the drug is antiprotozoal in action, therefore, it is concided with Hartzell (1915) where he suggested the use of emetine in the treatment of periodontal disease, Noguchi (1912) has observed a Treponema mucosum, a mucous producing spirochete from pyorrhea alveolaris grown in pure culture. Barett, (1914) and Bass (1915) have worked on amoebic pyorrhea.

Therefore, I am convinced to accept the concept that in addition to Microorganisms mentioned above there is some hidden parasite, or protozoa causing the inflammatory processes in the gingival, and the introduction of this drug systemically has stopped the cause of the bleedings designated with fusiforms bacillus and spirochete. The drug in vitro in our study (1966) has got no effect against the staphylococci or streptococci, it has got only vitality against the combination of fusiform bacilli and spirilla. This explanation provide us the chance for further studies of the Microbiology and changes in the concept of etiology of the gingival bleeding.

The sample has been taken from  the gingival sulcus and cultivated on the blood agar plates and study and treatment planning was made accordingly.  We found that the gingival bleeding can be controlled by control of the specific causative agent. 1st through medicine and then through Curettage and Surgery.

EXAMPLES OF CASES

In this respect we have got many cases to quote, however we quote a few cases as under:

A young girl of 18 years notices bleeding from her gingival and blood staining in her saliva. She consulted a Dental Surgeon, who cleaned the teeth without checking the inflammatory condition.  Immediate after polishing, bleeding started from the upper Anterior area and thus patient was hospitalized. To stop this bleeding she was given penbritin Capsules, Erythromycin tablets, Styptobioun tablets, vitamin C, Calcium Gluconate and Electricautery was applied to stop this mishap, but this situation became worse and she was put on Griseofulvin tablets, hydrocortisone vioform, cortiso Inj: then Flagyl tablets, vibamycin, reptilase Inj: anaroxyl Inj: and later on blood transfusion and Auto haemo therapy, but nothing could stop the bleeding. Blood was tested many times and no abnormality in bleeding or coagulation time was found and no blood dyscrasia or any other infective disease was discovered.  The patient absolutely was normal. The patient was seen by the undersigned as a last hope. Her plaque and sub gingivally specimen was taken for culture test for specific antibiotic. This laboratory test solved the whole problem.  She was given single dose of Tinidazole and later on Lincocin capsules according to the reports of bacterial sensitivity, this method immediately stopped the bleeding and it has added to our concept of bacterial etiology for periodontal disease and gingival bleeding.

The other case of 45 years female with complaint of bleeding of gums for the last 8 months visited our surgery.  All blood tested were carried out by the previous physician and nothing could help with all the similar medicine and nothing could relief her and she became a psychological case and she thought that she had to give blood to stop the blood from her gingival, she had been to shrines and slaughtered many lambs and cows for this cause.

We tested her oral flora for direct smear and culture sensitivity and she was managed like any other case of bleeding of gums and we stood successful.

CONCLUSION

Gingival bleeding is initiated by Micro organisms and it can be recognized with proper investigation by applying perfect techniques for cultivation of Micro organisms and their existence in the Gingival Sulcus and the management of this bleeding is easy with the proper medicine initially and later on complete curettage and surgery of the gums.

THANKS

Thanks are to Prof. Dr. Shamim Raza Bohari, M.Sc. Prof. of Bacteriology and Principal, College of Community Medicine, Lahore for encouragements Dr. Mrs. Iqbal Soofi and Dr. Shahid Anwar for help and discussion Mr. Ghulam Qadir for fine type work and Agha Riaz Ahmed and Mr. Mazhar Ehsan Draftsman and Mr. Rashid Ahmed for help.

 


 

REFERENCES

1.            Brandtzaeg. P. Immunochemical comparison of protenins in human gingival pocket fluid, serum and saliva.  Arch. Oral Biol., 10: 795, 1965.

2.            Brandtzaeg. P. and Mann, W: A comparative study of Thelysozyme activity of human gingival pocket fluid.  Acta Odontol. Scand, 22: 441, 1964.

3.            Duckworth. R. Waterhouse, J.P. Britton, D.E.R, Nuki, K. Sheiham, A. Winter, R. Blake, G.C. (1966) British Dental Journal, Vol. 120 PP 599-602.

4.            Egelberg J: Gingival exudates measurements for evaluation of inflammatory changes of the gingivae, Odontol Revy. 15:381, 1964.

5.            Jacoby, R. and Ketterl, W: Qunatitative measurements of gingival pocket exudates in normal and inflamed gingival. Dtsch. Zahnaerztl Z. 27: 485, 1972.

6.            Lindhe, J. Atstrom R., and Bjorn A.L: Influence of sex hormones on gingival exudation in dogs with chronic gingivitis J. Periodont, Res 3,3.2279, 1968.

7.            Noghuchi, H: Treponema mucosum (new species) A mucous producing spirochete from pyocchea alveolaris, growth in pur culture J. Exp. Med., 16: 194, 1912.

8.            Oliver, R.C. Holm  Pedersen, P. and Loe, H. the correlatin between clinical scoring exudates measurements and microscopic evaluation of inflammation in the gingival J. Periodontal, 40:201, 1969.

9.            Soofi, M. A. & Soofi, Hyperplasia of gums during different phases of pregnancy, Pak: Dent Review Vol XII No. 4 (1962).

10.         Soofi, M. A.  Sensitivities of colonies of fusiform to Metronidazole and comparison study with other antibiotic for AUG (in vitro) Pakistan Dental Review, Vol XX No. 4 (1966) published in October, 1970.

11.         Soofi, M. a. Fasigyn in treatment of acute ulcerative gingivitis and bleeding gums, paper read in 8th International Conference held at U.K. 1979 published in 1985 Doctor, Vol. 7 No. 16, Karachi.


 

 

SURVEY REPORT HYPERPLASIA OF GUMS DURING PREGNANCY IN SHEEP

 

There is a wide divergence of opinion with regard to the effect of pregnancy on dental and periodontal health.  One cannot doubt about the increased physical stress, hormonal imbalance and nutritional disorder, particularly proteins and minerals under the influence of new metabolic demands which are increased during pregnancy.

 

Root and Boot (1933) confirmed increase of basal metabolic requirements of pregnant women from 23 to 25% whereas Harrop (1930) believes in higher percentage.  Marshall Day (1933) is definite about the physical stress during period of gestation and subsequent months during which child is directly dependent upon its mother for substance.

 

The study was made to observe the clinical changes in the gingival tissue of sheep after the onset of pregnancy.  The first survey report of 384 sheep of different breeds represents the conditions of the gums before service and 87.8% possesses the normal gums.  Insignificantly low proportion (only 12.2 %) exhibited Grade I hyperplasia as such some of the ewes were mated (0-15 days) before our visit to Livestock Experiment Station at Bahadurnagar, Okara, District Sahiwal 29.9.1968.  

 

The results of the 1st examination are given in Table No. 1 and 2.

 

CONDITION OF GUMS

TABLE  NO. 1

Sr No

Breed of Sheep

No. of ewes observed

Percentage distribution

Normal Gums

Hyperplasia (Gr.I)

Hyperplasia (Gr.II)

Hyperplasia (Gr.III)

1.     

Lohi (L)

164

86.0

14.0

-

-

2.     

Kachhi (K)

52

77.8

22.2

-

-

3.     

Awassi (A)

85

92.9

7.1

-

-

4.     

Lxa (X-1)

28

82.1

17.9

-

-

5.     

Kxa (X-2)

7

100.1

-

-

-

6.     

Kxa (X-1)

55

90.0

9.1

-

-

7.     

Total Av.

384

87.2

12.8

-

-

 

CONDITION OF TEETH

Abnormal teeth (Nos.)

 

TABLE NO. 2

 

Normal Teeth

Fused

Missing

Misplaced

Fractured

Caries

157 (L)

1

2

3

4

-

50 (K)

1

-

-

-

-

77 (A)

-

2

2

1

1

28 (K-I)

-

-

-

-

-

7 (X-1)

-

-

-

-

-

55

-

-

-

-

-

374

2

7

5

5

1

 

On 12th January, 1969  (after some 3 ½ months of pregnancy) some flock of 361 sheep out of a total of 384 was studied23 being dead/culled.  (See Appendix).

 

Results and finding

 

 On 2nd examination (some  3 ½ months after pregnancy) 361 ewes of the same herd were examined for clinical examination to see the effect of pregnancy on gingival tissue.  Some of the ewes had already lambed.  The observations were classified and a comparative study of 1st visit (on 29.9.68 almost prior to mating) and 2nd examination was taken. 

 

Out of the lot, 95% of pregnant sheep were found with gingival hyperplasia and four sheep with pregnancy epulis.  Only 5% showed no change in the gums, whereas 28.2% had grade I, 56% grade II and 10.8 % grade III hyperplasia.

 

 

From the results of clinical examination of sheep before and after service, the study shows that pregnancy affects the gingival condition, both in human (Soofi and Soofi  1962) and in animals.   The possible cause of change in the gingival condition of the animal and the social animals is due to hormonal imbalance during such periods.  One cannot blame merely the nutritional disorder especially in case of sheep which are under the care  of technical personnel before, during and after pregnancy, in an experimental station.  The feed is controlled and all the other possible measures are taken.   

 

Four cases of pregnancy TUMOUR  were recorded.  5% of the pregnant sheep possessed normal gums whereas among the rest, 28.2% had hyperplasia of Grade I, 56% Grade II and 10.2 % Grade III.  These results were identical with the previous work of Soofi and Soofi (1962) on 42 women, where hyperplasia of gums was observed in pregnant mothers.

 

Result is reproduced below in Table 4

 

No. of cases examined

Total No. of pregnancies

Hyperplasia

Free

6

3

4

2

9

4

7

2

3

5

3

-

3

6

3

-

9

7

7

2

12

8

9

3

42

-

33

9

Total % 100

-

78.57

21.43

 

 

Discussion

 

Rogers and Keen (1954) observed that increase in estrogen during pregnancy activates the epithelial structure and inhibits the Mesenchyma, Loe (1965) made a study on 121 pregnant mothers to compare with that of 61 women after labour.   The quality and behaviour of the oral debris was the same in the two different groups.  Oral hygiene and gums inflammation was closer after parturition than during pregnancy.   Study suggests for some other factor for accentuating the inflammatory changes.  Loe (1965) believes in a strong relationship with sharp rise in sex hormone blood levels particularly oesterogens.

 

Rehstenier (1963)  suggests Schiller’s Iodine test for detection of Glycogen.  In healthy gums the Iodine test is negative.  In the enlargement of the gums during to pregnancy, the iodine test is positive because of glycogen content.  Wade (1965)  described a change from simple pseudo clefts to generalized enlargement with pseudo papillae, or occasionally localized pregnancy tumour.

 

Ziskin and Hotelling (1937) studied incidence of caries in women and found contradictory findings.

 

Rogers and Keen (1954) believe in demineralization of the alveolar process during pregnancy condition due to the insufficient calcium and phosphorus or vitamin ‘D; to expectant mothers.  They regard “Pregnancy Epulis”, super imposition of effects of pregnancy on a previously established gingival hyperplasia. These two workers advised for supply of all nutrients during pregnancy and lactation and extra intake of calcium until the 3rd trismister, vitamin ‘D’ and iron.

 

Wickham (1952) maintains that there is loss of calcium content of supporting bone, during pregnancy.  He does not believe in any change of gingiva during pregnancy if the periodontal tissue is healthy before onset of pregnancy and defines no particular relation to periodental apparatus.

 

Although he believes in two states of endocrine imbalance commonly seen in women, which effect the resistance of periodontal tissue and they are steroid group of hormone –one during pregnancy and other puberty during later’s manifestation gingiva remain upset – red, swollen and tender.

Shukers et al (1933) studied metabolism of pregnant and lactating mothers.  They found daily caloric intake  of three pregnant mothers was 2,200, 2,900 and 2,600 whereas in lactating mothers it increased to 4200, 4500 and 3800 respectively of three mothers under their observation.

 

Engel (1952) is of the opinion that gingival tissues undergo changes in association with various constitutional states, and the relation between the endocrine and the gingival disease is of great consideration.  Papamicolaou (1933) has found the positive results of the sex hormones on vaginal epithelium.

 

From the animal experiments and human patients, we have come to this point that the hormones, exerted during pregnancy exert and influence the state of gingival tissue, as such physiologically estrogens tend to augment the deposition of glycogen in susceptible epithelia.

 

Ziskin (1936) has shown the possibility, at least for clinical improvement with gonadotrophins in desquamative gingivitis.  They also found promising results with estrogens in atrophic gingivitis.  This endocrine activity represents a physiological alteration.  During the period of pregnancy there are transient symptoms in the target tissues and patient complain of enlargement of the gums, pain, oozing of the blood from the gums.

 

It is believed that there are abnormal amounts of water soluble, alcohol, insoluble glycoprotein present in the tissue, which disturbed the synthesis of ground substance and increased activity of nepolymerizing enzymes, or both.  Change in the water and electrolyte metabolism implicit the changes in the ground substances.

 

Doubthwaite (1963), defines estrogens are proliferative hormones concerned especially with the growth and proliferation of the structure of female reproductive tract.  They cause hypertrophy of the urine muscle, during pregnancy.  The metabolic effects of estrogens are to cause retention of water and salt in the tissues.  The corpus lutetium of pregnancy secretes estrogens and progesterone.  

 

Mechanism of Enlargement of Gingiva  

 

Gingival connective tissue consists of cells and components of extra-cellular substance (fibres, tissue fluid and ground substance).  The ground substance is largely of glycoprotein (carbohydrate protein)  and is believed to be a yolymar by its organization at subicroscopic level. 

 

Gresh and Catcepole (1949) proposed that residues arose from enzymatic depolymerization  of highly polymerized glycoprotein of ground substance and obvioously these enzymes were liberted by the cells of the connective tissue and is possible that this water soluble material  represents an altered Secretary activity of connective tissue.  It is believed that the changes in connective tissue are due to hormonal influence.

 

Peral et al (1950) and worked on guinea pigs and monkeys for physio-chemical methods and concluded that the connective tissue behave in such a manner as to indicate presence of negatively charged immobile macro-molecules.  Similar response was observed in sex skin of Monkey under influence of gonadotrophic hormones.  His study in gingivae showed the same results.

 

Administration of sex hormones (estradiol and gonadotrophin) increase in the amount of alcohol insoluble, water soluble carbohydrates.  The basement membrane is attenuated and ground substance is reduced.

 

During hyperplastic states the gingiva contain large amount of water soluble macroprotein carbohydrate which represent water – rich celloidpoor base.  In normal gingival 250 mg. on an average carbohydrate per 100 mg. of dry tissue is available and in inflamed gums its amount exceeds 400 mg . per 100 G. M. of weight. 

 

The electrochemical studies also reveal a difference of the interaction of ground substance colloid with potassium and sodiumations potassium mobility is greater than sodium in water.  The situation is highly polymerized and ground substance tends to  become reversed.  Potassium Ion bears an inverse reaction to the degree of aggravalim of ground substance.  Thus selective reaction with cautions implicate the connection tissue in a fundamental role of electroyte and water metabolism.  

 

Summary

 

Out of a total of 361 sheep, 95% showed hyperplasia of gums during pregnancy as result of changes in estrogen, 4 cases of pregnancy tumour were also observed.

 Thanks

Thanks to Mr. S. M. Ishaque, T. Q. A. , Director, Livestock Farms and to the other members of the staff for extending the help, cooperation and technical guidance in preparation of this manuscript.

 

References

 

1.            Lea, H (1965) J. P. 36: 209

2.            KehsIeiner (1963), Gynaecoltgia (Basel) 155, 55.

3.            Wade, A. B. (1965), Basic Periodontology, 2nd Ed. Wright Bristel.

4.            Ziskin, D. E. & Hotelling, H. (1937) J.D.R. 16, 507.

5.            Rogers, B. C. & Kean. M. R. (1954).  Pregnancy in relation to dental health, Dental Journal, New Zealand, Vol. 5: 242.

6.            Wickham, E. N. (1952).  The development and maintenance of sound periodontal structures, The  New Zealand D. J. 48: 234.

7.            Root, H. P. And H. K. Root (1923) , Arch. Int. Med. 32, Sept. P. 411.

8.            Harrop. George (1930) A diet in disease  19: Chapt. XXIII, P. 366.

9.            Douthwaite, A. H. (1963), Hall White Materia.  Medica, Pharmacology and Therapeutics J & A Churchil Ltd. Lond.

10.         Ganoug, W. F. (1965) A. Review of Med. Physiology, 2nd Ed. Langg Maruza.

11.         Marshall Day, CD (1933), Dental Cosmos, Vol. LXXV- No. 5, May

12.         William, F. Ganoug (1955), A review of Med. Physiology 2nd Ed. Lange Maruza.

13.         Engel, B. M. (1952) Hormonal gingivbities, J. A. D. A. Vol. 144, No. 6.

14.         Papanicoleoy, G. N. (1933) Sexual cycle in the human female as revealed by vaginal smear.  Am. J. Anst. 52-519, May.

15.         Gresh, I., and Catcphpole, H.R. (1949).  The organization of ground substance and basement membrane and its significance in issue injury, disease and growth. A. M. J. Anat. 85: 457.

16.         Perl. E. and Catchpole; H. R. (1950) Changes induced in tee connective tissue of the public symphysis of the quinea pig with estrogen and relaxin. Arch. Path. 50: 233, August.

17.         Jeseph, N. R. Engel, M. B. And Catchpole, H. R. (1950), Interaction of ions and connective tissue.  Bie-chimicaet Biephysica Acta- In press.

18.         Monach. S. (1926) Proliferative gingivitis of pregnancy, D. items Interest 48: 500 July.

19.         Riskin, D. No. & Nesse, G. J. (1946), Pregnancy gingivitis, history, classification, etiology, AM J. Orthodont. And Oral Surg. (Oral Surg. Sect), 32: 309.

20.         Zisking, D. E. Blackberg, S. No. and Slanetz, C. a. (1936), Effects of subcutaneous injections of estrogenic and gonadotrophic hormones on gums and oral mucous membranes of normal and castrated rheans monkeys, J. D. Res. 15:407, Dec.

21.         Ziskin, D. E. (1938), Effects of certain hormones on gingival and oral mucous membranes, JADA 25: 422, March.

22.         Engel M.B., Ray, H. G, and Orban, B. (1950) the pathogenesis of desquamative gingivitis, J. D. Res. 29: 410 August.

23.         Ziskin, D.E. & Zegarelli, E. (1942) Clinical and histopathologic study of chronic desquamative gingivitis and its treatment  with the sex hormones (Abst) J. D. Res. 21: 341 June.

24.         Snedecor, G. W. Statistical methods.

25.         Soofi & Soofi (1962), Hyperplasia of gums during pregnancy, Pakistan Dental Review, Vol. XII, No. 4, October.

 


 

APPENDIX

Study of Hyperplasia of Gums in Sheep comparison of the 1st & 2nd Examination (%)

 

 

Breeds

No. of Ewes

Normal Gums

HYPERPLASIA OF GUMS %

Grade I                                     

Grade II  

                Grade III                            

Overall

Observed

1st Visit

2nd Visit

1st Visit

2nd Visit

1st Visit

2nd Visit

1st Visit

2nd Visit

1st Visit

2nd Visit

Lohi

142

87.3

4.9

12.7

28.2

-

57.0

-

9.9

12.7

95.1

Kachhi

45

77.8

11.1

22.2

35.6

-

42.2

-

11.1

22.2

88.9

Awassi

84

92.8

1.2

7.2

17.9

-

65.5

-

15.4

7.1

98.8

L x A I

21

82.8

-

17.8

21.5

-

71.4

-

7.1

17.9

100.0

K x A

55

90.9

5.4

9.1

40.0

-

45.5

-

9.1

9.1

94.5

L x A II

7

100.0

28.6

-

42.8

-

28.6

-

-

-

71.4

Overall

361

87.8

5.0

12.2

28.2

-

56.0

-

10.8

12.2

95.0

 

 


 

SURVEY REPORT ON THE DENTAL AND PERIODONTAL CONDITION OF SHEEP AND HYPERPLASIA OF GUMS

 

Reprinted from Pakistan Journal of Science, Vol. 21, No. 5 and 6, Sept. – Nov. 1969

 

Prof. M. A. Soofi

de’Montmorency College of Dentistry, Lahore

 

M. R. Qureshi, M. Anwar Khan,

Directorate of Livestock Farms, Lahore

 

PURPOSE OF STUDY

 

Soofi and Soofi (1962) made a study on 42 female pregnant cases for huyperplasia of gums during different phases of pregnancy.  The study was carried out to find out any identical changes with the human folk regarding gums during pregnancy.  Ziskin et al (1933) and (1937) had investigated and suggested hormonal therapy for hyperplasia of gums as result of estrogens imbalance during pregnancy.

 

PLACE OF STUDY

 

The place of survey is “Bahadurnagar Livestock Experiment Farm” an experiment Station sponsored by the Government of West Pakistan, Department of Agriculture.  The Farm is situated at a distance of 102 miles from Lahore (11 miles from Okara) and is spread over canal irrigated land of 3050 acres.

 

The Farm stands for good type of breed of animals and research work is carried out in the field of Livestock Production for enhancing the productivity of Livestock at the village level by provision of better sires.  The Farm workers are engaged mainly in the breeding and evaluation of improved strains of "Sahiwal" cattle and indigenous sheep by scientific method of management.

 

Some 1,000 head of sheep of different breeds –‘Lohi’, ‘Kachhi’, and ‘Awassi’ and their cross-breeds are being maintained at this station for experimental purposes. Cross-breeding is proceeding satisfactorily for evaluation of new breeds having better milk and wool than the indigenous sheep.  The herds go  out for grazing at early morning and come back to their pens at evening.  If the grazing, however, is not sufficient to fulfil their daily requirements, cut-green fodder is supplemented with.  Six weeks prior to start of breeding i.e., first of August, the breeding folk is given ½-1 lb. of concentrate ration comprising of equal parts of cotton-seeds (Pawa) and Chokar or rice brain etc.   The concentrate ½-1 lb. daily / Ewe is continued titled the weaning age (average 120 days).

 

BREEDING BEHAVIOUR

 

Indigenous breeds of sheep show oestrus during autumn and  spring season, while the Awassi (imported) is strictly seasonal and come in heat (desires male) during autumn i.e., September to October.   The ewes in heat are detected by vesectomized rams and then inseminated artificially with the semen of appropriate ram. (Normally from 15th September to 31st October). 

 

METHOD OF EXAMINATION

 

The sheep were brought in line to a place of examination in day sunlight. The attendants read ear tag number of the sheep.  The condition of the teeth, gums and other abnormalities therein were detected and the raw data, thus collected, was classified, tabulated and presented in the tabular form.

 

EXAMINATION OF TEETH

 

Dentition in Sheep.  Like human dentition, a sheep has got two sets of dentition i.e.(a) milk teeth and (b) permanent teeth.  Milk teeth are 20 in number, and the permanent teeth are 32 in number exactly like human race.  Milk teeth are 8 nippers in lower jaw and none in the upper anterior jaw, except a pad, while 3 grinders or molars in each jaw on each side are present.  In permanent dentition, 8 nippers in lower jaw and 24 molars i.e. 6 in each jaw are present,.  The examination was looked for abnormality of teeth and condition of the gums, especially hyperplasia.  The survey was carried out on 384 sheep  on 19-8-1968 at Bahadurnagar, Livestock Farm in a broad daylight.

 

SCORING

 

The pattern of scoring is self evolved according to the condition prevailing in the animals.   The new criteria of scoring is not exactly like Russul’s (1956) i.e, method of classification and scoring for prevalence of periodontal diseases in human race, but it more or less follows the same pattern as such: -

 

Normal Grade           0-   No inflammation –no loss of function – no hyperplasia of gums.

Grade                         1-   Mild hyperplasia along the margin of teeth.  No change in                             colour of gums.

Grade                         2-  Inflammation – or hyperplasia of moderate nature, moderate                          glazing – oedema.

Grade                         3-   Hyperplasia of such nature, Circumscribing margin of teeth.

 

RESULTS AND COMMENTS

 

No pus pocket or loss of bone was detected due to non-availability of X-Rays.  With such number and behaviour of animals, even use of probe was impossible, nor disclosing agent as per advice of Sumter and Arnim (1965) could be used.  Green and Vermillion (1960) OHI could not be practised for lack of numerical.  Wades (1956) validity of anterior segment in gingival scores had a chance  to be practised but to hold an animal for such long for real reading difficult task.   In our study the availability of upper anterior segment is nil.  There is only lower anterior segment of which nippers and surrounding gums are studied and such that fresh method of scoring in the animals, having identical teeth’s structure like human folk, has to be evolved.

 

Ramfjerd (1959) had not agreed with suggestion of previous workers taking into consideration to  labial side of anterior segment.  Russul (1959), however, could not elaborate his difference with previous findings.

 

Plaques’s adherence  was also under close observation.  All such changes were limited to the anterior 8 nippers.  Nothing could be done about the posterior segment, so adding of the score was not needed.

 

GUMS

 

A total of 384 sheep (Ewes) of different breeds were examined.  A significantly low proportion (12.8%) possess grade-I hyperplasia and it may be due to the reason that mating had started about two weeks before the visit (0-15 days Post-Oestrous) and a few ewes might have been conceived. 

 

Among the different breeds presented in the table, 86% of Lohi, 77.8% of Kachhi,  92.9% of Awassi, 82.1% of LXA (X-1), 100 of LXA (X-2) and 90.9% of KXA (X-1) had normal gums.  14% of Lohi, 22.2% of Kachhi, 7.1% of Awassi, 17.9% of LXA (X-1) and 9.1%  of KXA (X-1) had a grade 1 hyperplasia of gums.

 

No pus pocket was found.  Gums were normal with proper texture and tone.  In cases of hyperplasitc condition, it was smooth, homogeneous and limited to lower anterior region mostly.  Kachhi and Awassi’s gums were with melanin.

 

TEETH

 

Condition of teeth was satisfactory.  Out of 384 sheep, only one sheep had one tooth carious.  Five sheep had traumatic fracture of nipper region.  Five had misplaced teeth and two sheep had fused nippers and 7 sheep with missing nipper only.

 

TABLE –1                 CONDITION OF GUMS

 

Breed of Sheep

No. of ewes observed

Normal Gums

Mild Hyperplasia Grade I

Moderate Hyperplasia Grade II

Severe Hyperplasia Grade III

LOHI (L)

164

86.0

14.0

-

-

KACHHI (K)

52

77.8

22.2

-

-

AWASSI (A)

85

92.9

7.1

-

-

 

TABLE-2—CONDITION OF TEETH

 

Normal Teeth

Abnormal Teeth

Fused

Missing

Misplaced

Fractured

Caries

157 (L)

1

2

3

4

-

50 (K)

1

1

-

-

-

77 (A)

-

4

2

1

1

28 (X-1)

-

-

-

-

-

7 (X-1)

-

-

-

-

-

55

-

-

-

-

-

374

2

7

5

5

1

 

 

DISCUSSION

 

Kammlade and Kammdade (1955) had described malformation of jaw of sheep and this study does not show any jaw abnormality.  Edger (1935) claims that leaves of Barley and other plants may injure the gums of teething lambs and produce possible phenomena during grazing.  One case has had abscess as a result of such injury while grazing the harder herbs or stone, which struck the alveolus tissue.  Such phenomena can injure the gums and harm the teeth.

 

Salisbury et al. (1958) reported gingivitis in sheep similar to trench mouth- the lesion was ulcerative and teeth were loosened.  “Sherophopus Necraorus”  was isolated in culture and cases were treated with Penicillin.   This study, however, does not reveal any such condition of the gums.

 

Feldman (1931) classified 40 tumours from sheep.  Feldman (1932) Tamaschke (1952)  and Pamukeu (1956), reported that sheep are less acceptable to neoplastic growth.  Where as Moulux et al (1956)  described 66, Jackson (1936)  had classified 39 tumours from South African collection of sheep.  No growth of any nature had been observed over here.

 

Davis and Shorten (1952), reported six cases of epidermoid carcinoma of eye, similar to cases of eye in cattle.  No such case is noted with this study.

 

Dollar’s Veterinary Surgery (1956)  reported by O’Conner states:

 

Neoplasms of jaw are fairly met with horse and dog but no case of any nature of neoplastic activity of cancer, sarcoma of oral cavity was observed.

 

No supplementary incisor or molar was observed.   No dental tartar or a case of alveolar perioestitis was seen. 

 

All the sheep were healthy and well-fed and looked after satisfactorily in this experimental farm. 

 

 

SUMMARY

 

Survey reveals hyperplasia manifestation of gums in pregnant sheep.  Rest of the sheep revealed normal gums.  Incidence of dental decay or orthodontic conditions are not significant.  No abnormality of gums other than hyperplasia had been seen, which, too, is not statistically significant at P <  05.

 

THANKS

 

Dr. S. M. Ishaq, T.Q.A, Director, Livestock Farm, West Pakistan, and Malik Zawar Hussain, Superintendent of Livestock Farm needs to be mentioned for their cooperation and help in this work. 

 


 

 

PERIODONTAL DISEASE IN CHILDREN IN PAKISTAN

 

 

National Conference on Health Care & The Child at Jinnah Hall, Lahore on 5th Feb. 1981.

 

Summary

 

Children of Pakistan, according to various studies are suffering from Periodontal Disease and that needs prevention, through Public Health Practice, an introduction of Postgraduate Diploma Courses in Preventive Dentistry and Dental Hygienist are key to built Dental Public Health team for combating the Dental Disease from our Community.  Periodontal Disease is an inflammatory condition of periodontal apparatus.

 

ANATOMICAL REVIEW

The periodontal apparatus is as follows: -

1.         Gingivae.

            Gingivae a part of oral mucosa membrane that covers the alveolar process of in jaws and surrounds the neck of teeth.  It is pink in colour, it is divided as :

 

a.            Marginal or unattached gingivae.  This is a free margin of gingivae that surrounds the teeth, in a collar like fashion.

b.            Attached gingivae.  It extends from marginal gingivae to the alveolar mucosa.

c.            Inter-Dental Papilla.  It extends inter proximally. 

 

2.         Periodontal Membrane

 

            It is component of periodontal apparatus.  It is made of connective tissue-which surrounds the root of tooth and connects it with the bone.  It  continue with connective tissue of gingivae and communicates with narrow spaces through the vessal channel with the bone.

 

Normal Structural Characteristics

 

That periodontal membrance includes bundles of connective tissue fibers,  connective tissue cells, strands of epithetiun blood vessels lymphatics and nerves.  Principal fibres or collagenous fibres are most important element, for a part of it inserted into cementum.  The principal fibres are arranged in groups some may ramify the gingivae and few extend between the approximatic teeth.

 

 

A.           Transplant Fibers. 

Extend introproximally over the alveolar crest and are emted in the cementum of adjacent teeth.

B.        Alveolar Fibres.

            Extend obliquely from cementum to alveolar crest, just beneath the epithelial attachment.  It counter balances the coronal thrust of more apical fibres and helps the teeth to be in socket.

            Horizontal Group

            It extends at right angles to the long of the tooth from cementum to the alveolar bone. 

3.         Oblique Group

            Extends from the cementum in a eoronal direction obliquely to the bone. This is largest group of fibres and bears the vertical stresses transforming them into tension on the alveolar bone.

4.         Apical Group

            Radiates from the cementum of the tooth at the fundus of the socket to the bone.

C.         Cementum  

Cementum is classified mesenchmal tissue which form the outer covering of anatomical root.

D.         The Alveolar Bone

The portion of jaws which forms socket of the teeth is called alveolar process.  It is made of osteceytes embedded in a calcified intra cellular matrix.

 

TYPES OF PERIODONTAL DISEASE AVAILABLE AMONG THE CHILDREN

Gingivitis – Inflamation of Gingivae as : -

a.            Acute necrotizing gingivitis

b.            Chronic desquamatic gingivitis

c.            Puberty gingivitis

d.            Perieoronitis- crupting gingivitis.

 

In all such conditions inflamation is common feature. Bacterial plaque is known source of aetiology.  Materia alba, calculus are additional source of irritation and casaction.

 

Disease is distributed to single tooth or group teeth or may be generalized throughout the mouth.  On the basis  of location the disease is termed as : -

 

a.            Marginai

b.            Rapillary

c.            Attached

 

So reviewing the anatomical explanation we now discuss the distribution and epidemiological study of the periodontal disease carried out here and elsewhere.

 

The Epidemiology of  Periodontal  Disease

 

Epidemiological investigations have been carried out in many parts of the world, starting from 1912 till today; still the epidemiology of periodontal disease is one of the important challenges before the dental profession in general and to preventive dentistry in particular at the moment.   There are, of course, retarding factors, e.g. Degree of accurate diagnosis, system of examination, expense and physical difficulty of X-Rays and absence of uniform method of assessment with the result that comparison has become difficult.  Before the advent of indices, various subjective studies show vast variation even when carried out in the same place.  King (1940) observed 90% result where Campbell and Cook (1942) noticed 22% gingivitis in Dundee (U.K) McCall (1926) observed 98% gingivitis in USA and Brucker (1943) noticed 8.3% in the same country.

 

There is a need of standardized study in order to compare the results of one place with another. The quantitative indices do exist and are of recent origin.  Still the task of comparison is to be considered with some problems of invariability of examiners, etc. etc.

 

Similarly, factors of age, sex, intraoral distribution, local agents and other environment need to be considered for evaluating the periodontal disease in a community.

 

Prevalence and Severity of Periodontal Disease in Pakistan Early Study

 

There have been few epidemiological studies of periodontal disease in Pakistan.  This is surprising in view of the widespread belief that there is a particularly high prevalence of certain types of periodontal disease in Pakistan an India.  The earliest study was by Day & Shourie (1947) who studied children and adolescents of Lahore from Islamia High School and Queen Mary College, Lahore.  Age range was 6 to 20 years.  There were 1054 boys from a middle class School from 9-17 years and from Queen Mary College there were two groups-girls & boys of lower age.   Total subjects were 1377 a typical cross section of Lahore population.  The criteria for assessment of gingival disease was followed according to King (1945).

 

Hypertrophic types of the gingival disease were observed and gingival disease was found highest so far reported elsewhere.  Among 1054  subjects from Islamia High School, only six were free of gingival disease.  Four age groups showed the disease about 100% and at all the age groups it was over 99% and average incidence was 99.43%.  73.62% showed either severe or very severe, whereas 25.8% slight to moderate gum disease.

 

In the case of girls the incidence is significantly less, % age of incidence of disease was 73.74%  for 176 girls in comparison with boys 99.43 %  of the same age group. This group comes from higher socio-economic division.  A small group of boys 62 from 5-11 years attending the Queen Mary College was examined.

 

On comparing 58 boys to 106 girls of the same age group it was found that incidence of disease is more with boys than with girls.

 

It was found subjects with calculus had severity of disease and it was more common with school boys than girls.  No relations could be made of ascorbic acid and gingival disease except vitamin –a deficiency might be the cause for hypertrophic exagition Gums.

 

Day and Tandan (1940) studied 756 children of School at Lahore and found 68% had gingivitis.  Deposition of calculus and poor oral hygiene was observed.  This study was carried out for incidence of dental caries and gingivitis was also included. Marshall Day was a Dean at de’Montomorency College of Dentistry, Lahore, emphasised the need of dental health education. 

 

SCHOOL STUDY DENTAL HEALTH SURVEY IN QUETTA DIVISION AND INFLUENCE OF THE DIETARY HABITS

 

Quetta  is an attractive district in West Pakistan.  There is the Historical Bolan Pass, its border meets with Iran and Kabul.  Area is 5310 Sq miles.  There are various tribes and clans.  Mountains add to the charm.   Snowfall irrigates the land in winter.  Springs water is thenormal source of drinking water except intown.  The Government is spending a lot to improve the education, and irrigation and roads. The local people are general tall and healthy.  However, negligence of health, illiteracy and poverty result in a number of ailments.

 

Soofi (1962) carried out an epidemiological study on school children and teachers in Quetta where he had an opportunity of serving this area for more than six years as a dental surgeon and a teacher in Aminud Din Medical School, Two types of schools were selected for comparison of dental condition habits of cleanliness, effect of dietary pattern and the general health. 

 

Islamia High School is a thickly populated school on Eastern pattern, the majority of students are of poor and lower middle class and of local origin.

 

St. Francis and Convents are Western styled schools, population is of high class and few students are from local population.

Age Grouping

The complement of schoolchildren was divided into the following age groups: -

 

1.         5          -           9 years

2.         10        -           14 years

3.         15        -           19 years

4.         20        -           34 years

 

The records of age, sources of income and the family history were recorded with the help of teachers in the proforma designed for the study.  The children were brought in batches in the sunlight and were seated in a chair in turn.  Dental examination was carried out with the help of mouth mirror and probe and data was recorded on the proforma.

 

The oral Hygiene Index of Green and Vormillion (1960) was utilized as an objective method of assessment. In younger children corresponding deciduous teeth were used and gingival conditions were assessed with Russell’s P.I. Index (1956)

 

Results

1507 school children and teachers of both the sexes have been examined for dental and general health. 

 

Mean Debris Scores (D.I.)

In the poor and lower middle class, the index for females is at a higher level as compared to males except in 15-19 years age group where females of rich and upper middle class remain at a lower level except for the age group 20-34 years.  Whereas the index level of females is higher in the first age group (5-9)  otherwise for the other age groups there is exact agreement for the two indices.

 

Calculus Index

Males of poor and lower middle class show a high level of index except at 10-14 years of age.  Index of the males of 5-9 years of age is at a higher level in rich and upper middle class and then there is an overlapping of the two indices for both the sexes.   Comparing the two classes, there is exact correspondence of the male indices except in the age group of 20-34 years where poor and lower middle class index is a higher level.  In the case of the female index for poor and lower middle classes it is at a higher level in the first two age groups and afterwards the indices of both the classes shadow each other.

 

Looking at detail in the group of poor and lower middle class calculus index stand one in male of 5-9 years 10-14 years and 2.5 in group of 20-34 years.  Similarly female from 5-9 years has 5 index, 10-14 years but 15-19 years have 1.5 and 20-34 years stands for 2.

Oral Hygiene Index (O.H.I.)

 

Index for males of the first group shows a rising trend being high at the start, low at 10-14 years of age and against at a higher level until it attains the same standard as that of females at 20-34 years.  Male index of group No. 2 remains at a higher level throughout except the age 20-34 years.

 

As compared to group No. 2 index of the males of group No. 1 is at a lower level through except at 20-34 years of age, whereas index of the fair sex remains at a higher level up to 14-15 years of age and then there is exact correspondence of both the indices.

 

Periodontal Index (P. I.)

 

The periodontal Index is higher among the 10-14 years of age group of rich and upper middle class and the last class of 20-34 years among the females.  The rest of the classes are identical in this index. 

 

Summary

 

A self sponsored clinical dental survey of 1507 children and young adults of Eastern and European styled educational institutions in the Quetta, West Pakistan, is reported.  The results show the prevalence of periodontal disease and give information on oral hygiene standards.   A comparative study of two different patterns of schools and the dietary habits is carried out.  The hard and fibrous diet is reported to produce better dental health.   The prevalence of periodontal disease is over 99% among the population examined.  

 

Dental fluorosis is widespread in inhabitants of Quetta.  However, dental decay was noted in cases having fluorosis.   No clinical signs of skeletal fluorosis were seen.  No case of ulcoratove gingivitis or congenital deformity or benign or malignant growth have been seen; although such ailments have been seen in a dental decay in the local population i.e. poor and lower middle class as compared to high and upper middle has been observed.

 

About 78%  of the poor and lower middle class had natural feeding against 65% of the rich and upper middle class.  The lower middle class enjoys good (general) health as compared to the higher group. 

 

Rich & upper middle class has used the toothbrush male 69.65% and female 91.0% whereas poor and lower middle class male 33.07 % and female 31.94 % has used the tooth brush still the IMF is significantly higher in the rich and upper middle class despite the fact that 20% of the poor lower middle class has not used anything.

 

Similarly, O.H.I is higher in the rich and upper middle class in the various age groups as compared to the poor and lower middle class.  However, there is no marked difference in the calculus index of both the classes but the debris index is higher in the rich and upper middle class.

 

The periodontal index also  represents the higher score in higher and upper middle class in the male group from 10-14 and in the female group from 20-34 years of age group.  The other ago group does not represent any other significant differences. 

 

Pattern of the prevalence of the disease in Pakistan is similar to that of other studies.  Day (1947) 99.4%, Ramfjord (1960) 100% in India, King (1940) 99%  in the Isle of Lowis, (1945)  99% in Dundee liassler et al. (1949) 80% U.S.A, McHugh et al (1964)  98% in Dundee, Scotland.  It appeared that the disease is more common and is affecting the majority of the population.  Prevalence of the disease in this particular study is different due to diet factor such as cheap diet and fruit are not available elsewhere.  It appeared the disease would be more in areas where there is less abundance of hard diet is utilized.

 

Soofi et al (1979)  examined 89 school children Girls High School, Nathiagali, NWFP for general and dental health, population was examined classwise, age group 10-15 years, he observed  46%  population had orthodontics problems and 43% had dental caries  whereas periodontal disease was prevalence  97% of the population.

 

Soofi (1975) examined 118 students of village Ferozewala, having 11 girls and 8 boys.  There was 100% prevalence of periodontal disease and in case of village Gujumata 960 children were examined 92% prevalence of periodontal disease was observed.

 

Soofi (1977) examined school children Punjab and found the following %age of periodontal disease.  In Threh 95% was noticed as prevalence of periodontal disease. Gujar Khan 100% in Sharqpur 95% in Burki 95% and Haripur Hazara 95%.

 

Soofi (1981) Unpublished examined Lahore school children and found 97% prevalence of disease.

 

References:

 

1.            Soofi, M.A. (1969) School Dental Health Survey in Quetta Division and influence of diet, Pak. Dental Review Vol. XIX No. 1 January.

2.            Soofi, M. A. (1978) An epidemiological study of periodontal disease in children, Med. : News, Fortnightly Karachi-April, 1.

3.            Soofi, M. A. (1979) A survey report on general and dental health of Nathiagali school children. Med: News fortnightly Sept. 1.

4.            Soofi, M. A. (1975) Baseline survey of Ferozewala & Gajumata (Punjab) dental and general health, Planning Commission Government of Pakistan, Islamabad.

5.            Soofi, M. A. (1968) The tooth and the eye, Pak: Dent. Review, 18.73.

6.            Soofi, M. A. (1968)  Dental health in Pakistan Dent. Abstracts, Vol: 13 No. 9. 53.

7.            King J. D. & Glover, R. E. (1945).  The relative  effect dietary constituents and other factors upon calculus formation Periodontal disease, caries in syrian hanstor. J. Dent. Res. 25 : 166.

8.            King. J. D. (1945). Gingival  disease in Dundee.  Dr. Record 65: 9 (Jan), 32 (Feb), 55 (March).

9.            King. J. D. & Franklyn. A. B. & Allen, I. (1944).  The gingival disease in Gibraltar ovacuoo children.  Lancot 1 : 495.

10.         Campbeoll, T. D. (1939).  Food, Food values & food habits of Australian Aborigines in relation to their dental condition.  Aust. J. Dent. 43: 1.

11.         McCall, J. O. (1937).  Tae periodontitis, looks at children dentistry, J. A. D. A. 20 : 1518.

12.         Bruckor, M. (1943).  Studies of the incidence and cause of dental defects in children. J. Dent. Ros. 22: 309-314.

13.         Day, G. D. Marshall, (1947), Hypertrophic gingivitis in Indian children and adolescents.  Ind. J. Med. Ras. 35 : 4.

14.         Day, C. D. et al. (1954) Periodontal disease.  Prevalence and incidence.  J. Periodent. 26. 185-303.

15.         Day, C. D. Marshall (1952).  The epidemiology of periodontal disease.  J. Periodent. 22: 13.

16.         Day, C. D. & Shourie, K. L. (1944) incidence of periodontal disease in the Punjab. Ind. J. Med. Res. 32, 47-51.

17.         Day, C. D. & Shourie, K. L. (1950) Gingival disease in the virgin Islands J. Amer, Dent. Ass. 40, 175-185

 

HIV INFECTION AND ROLE OF ORAL HEALTH PHYSICIAN

INTRODUCTION


            HIV infection has become a global problem, perhaps three quarters of the world’s countries are becoming victims of HIV and AIDS.  Increasing number of countries have reported this matter to the WHO and thus there is increased awareness of the HIV infection as a global problem.  The WHO has activated its activities “GLOBAL PROGRAMME ON ACQUIRED IMMUNODEFICIENCY SYNDROME AND ORAL HEALTH PROGRAMME”  in order to provide consultation and ot promote the information exchange concerning the infections diseases in the delivery of oral health care in Sept., 1987.  Nearly 57000 cases of AIDS have been reported uptil the end of August 1987 and the number is on the increase. The disease is more in the Caribbean, South America, Africa, Europe and North America.  However, the virus is found all over the world.

 

            The United States in 1989 was concerned about the worldwide epidemic of Acquired Immune Deficiency Syndrome.   The Surgeon General reported that 90% of those infected by this virus 5 years ago are now dead, and the disease/virus has been labeled as “one of the most lethal of mankind’s infections”. And thus the USA Government has committed to spend more than two billion dollars to the fight against AIDS including 600 million dollars for research.

 

Role of Oral Health Personnel in Prevention of HIV

 

·                     Oral Health personnel have a vital role in prevention of transmission of human immunodeficiency virus infection.  Because due to their position they can provide guidelines to industries for designing safer oral health facilities and equipment.

·                     They can disseminate knowledge and can educate patients, health workers and colleagues about the disease.

·                     They can prevent the transmission by oral care instruments by proper sterilization and instruction.

·                     They can provide care to patients infected with the virus responsible for AIDS.

·                     They can advise regarding vaccination  (Hepatitis-B) immunization.

 

The education efforts concerning the HIV infection by oral health physician is becoming a mechanism for community message for AIDS to the public and therefore education of oral health physician must be conducted rapidly and in coordination with other health care disciplines. Because they are to diagnose, refer and provide cure  services in conjunction with other health disciplines in any center, clinic or hospital. 

 

            Besides the educational therapy the hospital staff who are exposed to such patients should be vaccinated by a vaccine (B-Hepatitis).  A course of this vaccine provides perhaps 100% protection against the infection. 

 

Mode of Infection

 

            There are three main routes of transmission. 

1.            Penetrative:  Sexual intercourse (Homosexual) or  Heterosexual).

2.            Blood and blood contact (including transmission and blood products).

3.            Perinatally:  from infected mother to child.

 

Blood Donors

 

            In developing world especially in our country there are professional blood donors waiting at the various blood banks, mostly they are addicts or homosexual.  They are not screened for HIV.  Similarly skin-piercing instruments, needles and scalpels are not sterilized and they can contribute to HIV transmission. 

 

            The counseling of oral health physician, his knowledge, his personality and his sense of prevention can ultimately become successful in control of this disease.

 

            Such patients can be counseled to reduce the risk of acquiring infectious diseases and oral health physician, through his experience and skill can recognize oral signs and symptoms of infectious diseases and can refer to proper quarters for diagnostic evaluation appropriate treatment and prevention of spread to non-infected persons. 

 

            It is must for the oral health physician to have current knowledge of epidemioloogy and modes of transmission of infectious disease because: -

 

1.            He is to be confronted with these issues in his practice.

2.            Through the recommended strategy for infection control by the WHO: he can prevent cross infection among the patients of hepatitis, herpes, and HIV.

3.            He is to prepare the public for reducing risk behaviour for accurate information and for motivational behaviour.

 

Recognition of Infectious Agents

 

1.            The scientifically documented risks for transmission of infectious agents in oral-care settings should be identified and distinguished from perceived risks.

2.            Risk of infectious disease transmission from oral health physician to patients is very low.

3.            Risk of disease transmission to oral health physician is notably grater.

4.            Hepatitis-B virus (HIV) represents a “worst case scenario” relative to transmission of infectious diseases.

5.            HIV can be transmitted by small amounts of contaminated blood or other body fluids in the daily environment.

6.            Study documents are available showing the increased risk of oral health physician to hepatitis-B virus compared to the general population because 1ml of infected blood of a hepatitis-B carrier can have upto 10 billion infective viral particles.  It is estimated that every year about 50, 000,000 new cases are being reported.  And more than 2 billion die as a result of hepatitis-B. 1 in 5 carriers may die prematurely as a result of liver cirrhosis.  1 in 20 carriers will die prematurely from liver cancer.  Because of the nature of work of health worker his risk of catching infection becomes 10 times higher than the normal population. 

 

The Risk of Transmission to Health Personnel

 

            If there is parenteral or  mucous membrance exposure to blood or body fluids of patients infected with HIV i.e. by injury from contaminated instruments, onset of disease is rapid.

 

Therefore there is a need:

 

a.            To develop oral care strategies for HIV infected patients.

b.            Disseminate information on early detection & oral manifestations of HIV to oral health physician and :

c.            Extend the Global oral data bank to include oral manifestation of HIV infections.

d.            Develop information, training packages and curricula for oral health physician.

 

Infection Control

 

            Our equipment is of two types:

 

a.            Critical.

b.            Non-critical.

 

Critical

 

            Needles, Burs, Suction tips, hanpieces, and impression trays.  They can penetrate in the tissues and in close intact.

Non-Critical

 

            Items that come in contact with intact skin and clothes like, chair, unit, lamps etc.  The critical items are to be sterilized or disinfected thoroughly to reduce the transmission of infectious agents between patients and oral health personnel.  And thus there is need for proper sterilization to destroy the pathogenic organisms, such as HVI & HIV.

           

Sterilization through steam autoclave at 121 C for 20 minutes or dry heat at 170 to 180 C for 2 hours are usually employed.  Other choices like boiling for 20 minutes or chemicals disinfectants like sodium hypochlorite 0.1 to 0.5%. Hydrogen peroxide 6% may be used after cleaning /rinising the instruments in cold water.  For non-critical items disinfection by whipping with chemicals is acceptable e.g. by sodium hypochlorite.  It can decrease the risk of spread of infections. 

 

Prevention of Transmission of Hepatitis-B & Herpes in Dentistry

 

            At the primary oral health care level it includes:

 

a.            Oral examination of the patient.

b.            Health education to the family, and to the community workers. 

c.            Referral to the health authorities.

d.            Emergency care.

e.            Surface care.

 

In such primary settings a pressure cooker may be used to replace steam autoclaves.  Special care may be taken not to be pricked with needle during extraction of the teeth.  Similarly in oral epidemiological survey and emergency care the instruments should be steam autoclaved or boiled, or chemical disinfectants may be used:

 

-                      Double ended instruments may be avoided because they are more dangerous.

-                      Needles and syringes should be disposable and should be placed carefully, not to be pricked.

-                      Instruments like knifes and ultrasonic blades may be kept away after use, and similarly method of disposal of such needles and other sharp instruments should be done by a safer way.

Conclusion

 

            Risk of transmission of infectious diseases can be managed with information; technology and routine implementation of asepsis provided the oral health personnel have got commitment to the cause of humanity.  The HIV positive individual can be treated preferably in the oral medicine department of the hospitals.  There is human as well as professional obligation to treat and care for the HIV infected persons.

 

REFERENCES:

 

1.            Surgeon Generals Report (1989). “AIDS a Battle the World Must Wing” Voice of America. Vol. No. 32.

2.            Hilleman MR (1985), Journal of Infect Diseases, 151, 407, 419.

3.            Polakoff S (1986) Br. Med. J., 293, 37-8.

4.            Proceedings of an International Symposium Prospects for the Control of hepatitis-B, Berlin 26-27, Sept. 1986.  Postgraduate Med. J (1987) 63, Suppl. 2)

5.            Immunisation against Hepatitis-B, report of the Board of Science & Education. British Medical Association, March, 1987.

6.            WHO/ORH/INFECT. CTR/87 (1987) Infection Control & Hygiene in Oral Care Settings, Geneva, 2-3 Sept. 1987.

7.            Voice October (1987), Editorial, Russ Woodgates by Stephen Sinclair. 

 


 

MEDICAL, EDUCATIONAL FACILITIES AND SOCIAL SERVICES

FOR THE COMMON MAN

 

 

The Government of Pakistan  is providing medical facilities and preventive measures to the people of Pakistan little better than in the past.   Pakistan is one of the poor country in health, our mortality rate is 86 per 1000 birth due to lack of EPI that much of children are suffering by EPI diseases (Polio, Diphtheria, Tetanus, Tuberculosis, Pertussis, Measles & Hepatitis) and adult population is victim of many diseases.  Recent data give by World Health Organization on WHO day referred in daily DAWN 7th April 2007:

 

Approximately 7.27 million people are inferred to be diabetic in Pakistan.  Out of which 2 percent suffer from Type 1 remaining 98 percent with type 2 diabetes mellitus.  Type 1 diabetes mellitus was previously called insulin-dependent diabetes mellitus or early-onset diabetes. Type 1 always requires insulin therapy.  Type 2 diabetes mellitus was previously called non-insulin-dependent diabetes mellitus or adult-onset diabetes.  According to another statement of WHO our country Pakistan has been given number 8 in the world. And is predicted to be number 4 by the year 2025 with 14.5 million diabetics, if the situation remains the same.

 

AIDS and HIV is spreading in general population. The objective of AIDS control programme is “To Prevent HIV/AIDS from becoming established in vulnerable population and spreading to the general adult population while avoiding stigmatization of the vulnerable groups”. 

 

Existing position: Presently there are 490 recoded cases in NWFP and 3591 at the national level, however, according to an estimate by WHO and other UN agencies the number of positive cases  could range from 70000 to 120000.

 

The increasing level of HiV among high risk vulnerable groups indicates that the epidemics in the country has shifted from low level to “concentrated” epidemic among Intravenous Drug users especially in the provinces of Sindh and Punjab. It has raised significant conceptual, ethical and programmatic issues.  A few cases are also reported among high risk male & female  population at various sites. However in NWFP it has been found in the migrant workers mostly affecting the southern part of the province. In the last two years the reported new infections have risened by over 100 percent (more than doubled). 

 

Lacking in Medical Doctor in relation to Population 

 

Public health sector in Pakistan suffers from considerable inadequacies with only one doctor available for 1359 patients, one dentist for every 25, 107 persons and one nurse for every 3,175 people, according to the Economic Survey 2004-05.  Still the statistics for the current year represent a slight population to health ratio improvement as compared to 2003-04 when  1404 patients had only one doctor, 27,414 persons one dentist and 3, 296 persons one nurse.  There are 113, 206 doctors, 6,127 dentists and 48,446 trained nurses in the public health sector, according to the economic survey.  However,  their true numbers would be higher as many bona fide health professionals and paramedics are not registered with Pakistan Medical and Dental Council  PM&DC and yet practicing in hospitals and clinics, the survey said. 

 

In all the country’s public health sector consists of 916 hospitals, 552 rural health centers, 5, 301 basic health units and 4,582 dispensaries.   Expenditure in health sector in Pakistan, 0.7 percent of GNP, was low compared to other countries of the region, the survey said.  The World Health Organization WHO recommends $ 34 per capita as the required package for essential health services.

 

During 2003 life expectancy in Pakistan remained at 64 year, while infant mortality rate per 1000 was 74, mortality rate under five per 1000 was 98 and population average annual growth was 1.9 percent. (Referred in DAWN June 5, 2005).

 

60 pc Medical Institutions lack Medical Teachers 

 

Almost 60 % seats of medical teachers are lying vacant in the province causing deterioration in the standard of medical education and that  of the healthcare system.  However, it is learnt, the health department is in the process of introducing an amendment to the Punjab Medical and Health Institutions Act 2003 to provide for regular recruitment in the teaching cadre, which was suspended in 1996.   According to statistics made available to DAWN, only 696 regular and 204 contract teachers are running the Punjab’s entire medical education system.  Contract teachers are not satisfied by their appointment.  (Referred in DAWN April 26, 2006).

 

Lacking basic Health Facilities 

 

Access to essential health care is a basic human need and a fundamental human right of every Pakistani. The Constitution of Pakistan ensures the provision of basic necessities of life including health and medical relief for all citizens, irrespective of sex, caste, creed or race which so far is not being practiced by the successive Government. 

 

However, a considerable improvement in health sector facilities over the past year is reflected in the existing vast network of health care facilities which consist of 4712 dispensaries, 5, 336 basic health units/sub health centers, 560 rural health centers, 924 hospitals, 906 maternal and child health centers and 288 TB centers.  Available Human resource for the fiscal year 2006-07  turns out to be  122798 doctors, 7388 dentist and 57646  nurses which make the ratio of population per doctor as 1254, population per dentist as 20839 and population per nurse as 2671.    The new health facilities added to overall health services include construction of 87 new facilites, upgrading of 65 existing  facilites and addition of 5000 new doctors, 2300 nurses and 14000 lady health workers.  The total outlay on health sector is budgeted at Rs. 50 billion.  (Economic survey 2006-07).

 

Preventive Measures are Essential

 

We are lacking Medical institutions, staff and resources.  There is only way to help the population by prevention and prevention means effective health promotion and disease prevention services to give a chance to people for healthy life.  It is only way to reduce risk of health and should be responsibility of government to provide the preventive measures in full strength and length.  There is lot of negligence to our part and many diseases which are becoming enormous like heart disease. According to cardiologists, nearly 10 percent of the adult population in Pakistan and 50 percent of those above 50 year suffer from hypertension.  Nearly 12 million adult Pakistanis are diabetic or have impaired glucose tolerance.  Twenty million suffer from one renal disease or the other with 10,000 dying every year because of end-stage renal failure.  Tuberculosis kills 60,000 people every year.

 

For instance, it has been proved that diet and exercise have a direct impact on the prevalence of many diseases such as diabetes and cardiovascular disorders.  The quality of drinking water and cigarette consumption are related to kidney problems, diarrhoeal diseases and many types of cancers.

 

Behavioural Changes

 

Behavioural changes in people can be brought about basically through education.  Although health education is imparted primarily by the health profession.  After all, preventive measures are cheaper than the cost of treating patients suffering from cancer, tuberculosis, renal failure, etc.   According to the Human Development Report 2003, the Pakistan government spends 0.9 percent of its GDP on health while the private expenditure on health care amounts to 3.2 percent of GDP.  What is more, the government’s health expenditure has not registed a substantial increase over the years in terms of percentage of GDP.  Hence the growing burden of illhealth has to be borne by the people.  In the absence of any feasible and widely acedepted health insurance plan, in a preponderance of cases it is the patient who pays for his own treatment.

 

There is need that physicians, doctors should do preventive work and Government should monitor the preventive work.  Cigarette smoking is going to high there should be controlled on the publicity of cigarette on print media and electronic media.  There should be need  for encouraging the breast feeding.  Cigarette   smoking is being popular among school and college students.

 

Environmental Pollution

 

The environmental pollution caused by traffic and industries may also be controlled so that the people should be save from the hazard of oxygen.  Environmental pollution is very common in the city of Lahore.  Auto Rikshawas and motor vehicles omit a lot of smoke and it is very harmful for the police man and to the population.  Another problem is that we have no precedent of successful litigation by people for compensation when they have suffered because of the negligence of the authorities or any party responsible for causing pollution or creating a public health hazard.  The need of the hour is for greater emphasis  on prevention than on cure as is at present the trend.   Pakistan is spending 0.5 of GDP is a very less.  People of Pakistan however, are not getting medical aids as our standard.  Number of patients is much more, health centers, doctors and facilities of laboratory are less, therefore, common people are suffering.  If the medical aid means all the people are treated equally with same standard, it  should be meaningful services programme supported by the government.  Health centers should trustworthy as  treatmentis given  to VIP.  Our VIPs  for  minor ailment do not visit the government hospitals but they get treatment from private health centers.   It means standard of medical services of our hospitals is not upto the standard of our members of Assembly or VIPs.  Private Medical Institutions are helping to medical profession that they are getting the huge money and they are attempting to fulfill the facilities of imparting training and education to the students.  Many of the private institutions have not been approved by the Pakistan Medical & Dental Council and lot of medical institutions having lot of deficiencies in the clinical side. 

 

Established medical institutions and dental institutions are all inspected by the Pakistan Medical & Dental Council time to time to determine the sufficient facilities to impart proper training to the students of MBBS and BDS. 

 

The think tank and policy makers of Pakistan and Provincial Government should consider seriously importance of student training and matter of treated patients.  Matter of appointment of teachers with their status and government should also give attention to the status of medical education.  A regulation should be adopted and VIPs should visit the government hospitals and clinics, it shall certainly make difference for private medical center.  There is need of the day that medical insurance policy should be adopted.  Government claims lot, however, efforts should be made more effectively.  Postgraduate education is very important.  There is lot to be done by providing medical services in the better way to the common people. 

 

Out major problem is the population expansion.  If we look the population at the time of creation of Pakistan 1947, there were 32.5 million people live in Pakistan. With East Pakistan population was about 7 crore and Pakistan was largest Muslim Country on the globe.  If we review our population 2006-07, it is estimated now 156.77 million.  This is roughly three generation that Pakistan has increased 124.27 million of population or growth rate stands at an average rate of 26 % per annum.  This population needs more hospitals, hospital beds, more doctors and nurses facilities etc. etc. which the government cannot cope with high population.  So there is need we should control the population growth and there should be a gape between the children so that mother and child should become healthy.  So this high population of Pakistan  each year atleast 25000 women die due to complication of pregnancy or about 300000 infants including 160000 neonate die in their first year of life.  This is great burden on the family after the death of children and mother due to lack of proper facility at the primary health care. So there is need to prevent the deaths among the women and children and prevention of communicable diseases, this could be done only with sustainable economic growth, provision of medical facilities etc to the health caring centers.  

 

Sexual transmitted infections

 

AIDS and HIV is spreading in Pakistan in almost all the provinces and this infection transmission could be controlled by health education by involving Ulemas, teachers and parents and at government level, it should propagate about unsafe sex, unscreened blood and the syringes should not be used and instruments should be used after proper sterilization at the Hospitals, MCH centers and basic health units and private medical and dental clinics.

 

Pakistan is one of the most favourable land which provides the quacks of every type to practice.  Quacks or unqualified physician give advertisement in the newspaper and electronic media. By this advertisement so many innocent people become prey to unqualified health care and more disease evolves.  The government should organize programme or introduce regulation that the treatment should be given to each individual by the qualified persons trained in recognized medical institution approved by PMDC.  The unqualified practice of medical and dental field should be restricted and this concession to practice the medicine by unqualified personnel should be banned for the welfare of the population. 

 

The government hospitals doctors should be provided surety and security so that they provide better treatment and education to the public.

 

Net result is that the medical care is not sufficiently available to each Pakistani at the government institutions; therefore, we should not hope that our generation will be healthy and we shall work for the prosperity of Pakistan.  If the nation is not healthy and our children future of Pakistan are dying before reaching age of 5 our mothers are dying so how we shall become a great nation.  The government should enhance the legislation for control of spread of diseases by the illegal practice.  Government should also provide and develop playing grounds for the population so that the younger people should involve themselves in healthy atmosphere and this shall prevent them in indulging the bad company.  Government should also provide pure food and drinking water and should control the environmental pollution. This shall be good step towards the saving life of people of Pakistan. 

 


 

DENTAL  CARIES – A CHALLENGE

 

Dental caries is an ancient disease.  In ancient times it was very rare.  The industrial development of society has brought a rapid increase in it.  At present 100 percent of adults and 90 percent of the school age children suffer from dental caries.  However, over the past two decades the disease has decreased in industrial countries due to preventive programmes, whereas the third world is facing this disease because of the refined foods in the society.  The WHO presented a report that there is a threat in the third world of soaring caries’ as more and more people leave rural areas and move to the cities and begin consuming “modern junk food” and refined sugar which is considered a main cause of caries, and as a consequence of tooth ache.

 

State of the Dental Caries is mainly judged by DMF-T index, that is a count of “decayed”, ‘missing’ and filled’ teeth in 12 year old children.

 

An index of upto 1.1. is rated very low’ in caries; from 1.2 to 2.6 “low”, from 2.7 to 4.4 “moderate”, from 4.5 to 6.5 ‘high’, and above 6.6 “very high”. 

 

Round about the early 1960s the DMF-F index was less than 1 for developing countries, while for developed countries the ‘figures were reported as high as 10 to 12 for children leaving primary school at ages 12 to 14, the report notes.

 

That has changed today: the DMF-T index has declined in the industrialized world but has increased to levels around 4.5 in some third world countries and even higher in their urban areas.  The sharp reversal in trends is attributed to preventive programmes, carried out in developed countries, against both dental caries and periodontal diseases based on the use of fluorides in water and salt on tooth brushes, tooth pastes and gels, and on mouth rinses.

 

 

 

 

DENTAL ENAMEL

 

Dental enamel is a unique tissue; it is the most highly calcified component of the mammalian skeleton.  It comprises 80-90%  by volume of calcium phosphate in the form of large and well formed crystals of hydroxyapatite and about 1-2%  of organic matrix, observed by (J. Kirkham –1986).

 

Once erupted into the oral cavity enamel is subjected to assault mainly by organic acids derived from fermentation processes in oral bacteria.  If unchecked this can lead to gross destruction of enamel and dentine and ultimately tooth loss.  This is a costly disease process, which affects almost the entire population and because of this much effort has been expended in studying the tooth and enamel in particular.  This presentation attempts to outline the process of enamel formation describes the resulting tissue and how this is destroyed by carious attack in the oral environment.

 

FACTORS  WHICH INFLUENCE THE CARIES

 

Gustafsson et at, 1954: namely Vipeholam dental caries study has proved the effect of different level of carbohydrate intake on caries activity observed for 5 years and found that sugar is available to plaque bacteria with this frequency sugar – containing foods are ingested and length of time that sugar remains in mouth it causes caries.  Similar observation were made by Stephan, R.M (1966) and Konig, K. G. et al 1968 and it has been further confirmed by Lundcuist, 1952  and Weiss et at, 1960 that  sugar-containing foods are cariogenic.  Furthermore Stephan and Winter et al, 1960, observed that sugar in solution will also be cariogenic if consumed frequently during the day.

 

Fostwill 1967 and Scheinin 1975: that sucrose is more cariogenic than the other sugars.  Historically Greek philosophers has suspected that diet is involved in the process of caries.  Positive proof of the role diet in dental caries has, however, been difficult to establish.  Evidence particularly of the role of sucrose has been gathered from historical epidemiological and experimental sources.  (Hardwick 1960) observed that there is evidence of strong association between sucrose and dental caries through historical studies of early man who consumed a diet low in sucrose have demonstrated that although there was some evidence of dental caries the prevalence was low and was mainly of root lesions rather than caries in pits and fissures or on smooth surfaces of enamel.

 

Recent research adding to our knowledge of the caries process has helped in our understanding of just how some of the risk factors operate. The finding that dental caries is not simply a process of demineralization but an alternating process of de and re-mineralization  (Silver stone 1977). 

 

HOST FACTORS

 

Group of factors that can influence the carious process are those concerning the host.  This is a large group of factors that can be further subdivided to local risk factors those that operate within the mouth, and general risk factors that extend from the host of include the whole social and cultural environment of the community.