DT Pakistan No. 3, 2014

News / Interview: “Aesthetic dentistry in itself means nothing” / CBCT in endodontic treatment of fused second & third mandibular molars / Stem Cells in Implant Dentistry / Treatment of aphthous stomatitis using low-level laser therapy

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PUBLISHED IN PAKISTAN

Dental curriculum - time
for change?
By Kashif Arif

www.dental-tribune.com.pk

“Aesthetic dentistry
in itself means nothing”
An interview with
>>>Page 2

Dr. Pascal Magne, USA

>>>Page 4

MAY, 2014 - Vol. 03 No.1

Treatment of aphthous
stomatitis using
low-level laser
therapy

>>>Page 8

No revolutionary change Take drops or Travel stops
in new Health Budget
By Hashim Hasan

Government allocates Rs. 26.80 Billion
for Health Budget in 2014-2015
By Kashif Arif
Another year has passed by
and the ruling elite &
2014-2015
legislators of Pakistan have,
Rs. in Billion
once again failed to respond
4,000
228
162
generously to the health
Other
Bank Borrowing
3,500
Dev. Expenditure
miseries and medical needs
of the common man in this
3,000
289
120
Estimated
Net Lending
Provincial Surplus
poor country.
2,500
525
The National Budget 2014508
Federal PSDP
2,000
External
Receipts
(Net)
2015 was announced, among
3,130
1,500
great expectations, but the
686
Current
Net Capital Receipts
poor masses were once again
Breakup
1,000
disappointed to see that;
of Current Expenditure
2,225 500
Net Revenue Receipt
among the massive
Interest payment
1325
0
allocations made for the non- Breakup
Pension
215
Resources Expenditure Denfence
700
developmental expenditure Net Revenue Receipts
Grants & transfer
3129
371
& luxuries of the rulers, the Tax revenue
Subsidies
Non-tax
revenue
816
203
Healthcare budget will be an
Running of Civil Govt. 291
Gross revenue receipts 3946
insufficient fund of 26.80 Provincial share
Provision for pay & pension 25
1720
billion Rupees. It surely
cannot suffice for providing
several national health-related programmes,
quality health services to more than 180 including the Expanded Programme on
million people living in Pakistan today. Immunisation, (EPI), Control of Diarrhoeal
Another meager amount of Rs. 31 million has disease and National Institute of Health (NIH).
been allocated as the additional fund to run The Prime Minister has also announced the
the Prime Minister’s Dengue and Pollen intention of launching a health insurance
Allergy Programme over the next year. scheme with Rs. One Billion to help the
Following the 18th constitutional amendment, poorest of segments.The size of PSDP
health has become a provincial subject. (Public Sector Development Programme) for
However, the federal government still runs
Continued on page 11

Budget at a glance

Pakistani Dental
students win
accolades in Dubai
DT Pakistan Report
LAHORE- The University of
Health Sciences (UHS) had
recently sent a six-member
delegation to Dubai - UAE for
attending the 2nd International
Conference and Exhibition on
Dental and Oral Health, where
these young Pakistani students
won several rewards for
exceptional performance and
competitiveness.The OMICS
Group conducted this
international conference, from
21st April to 23rd April. It
brought together more than 1,000
faculty members, post-doctorate
candidates, graduate students,
and undergraduates from
medical institutions from all over;
Continued on page 11

ISLAMABAD- The WHO has placed International travel restrictions
on Pakistan, due to the country's failure in controlling the spread of
wild polio virus, whereby 56 cases of polio were detected
from different parts of the country. Most of these
cases have primarily emerged from the Federally
Administered Tribal Areas (FATA).
An independent International Health
Regulations Emergency Committee
comprising of 21 members, was formed
as per the recommendations of the World
Health Organization (WHO). This
committee discussed and reviewed
the status of polio-affected countries.
The committee has made recommendations to Director General
of WHO - Dr. Margaret Chan. It stated that; Over the past few
months, serious concerns.
Pakistan government's ineffective efforts to control the disease.
Pakistanis might soon be subjected to immense difficulties in visiting
other countries, especially those that are polio-free.
Pakistani's may need to provide medical certificates from authentic
medical laboratories before traveling abroad and they might have
to go through a medical check-up and tests at the destination airports.
Such restrictions can be very detrimental for the country’s economy
and business community, which is already facing travel restrictions
internationally, due to security reasons. The restrictions will
further spoil the country's image. Ten nations were critically
scrutinized due to active transmission of poliovirus over
the recent six months; three of these countries are still endemic
for the disease and seven have been re-infected.
Is WHO satisfied?
The World Health Organization (WHO) has expressed it's satisfaction
with the initial steps taken by the government of Pakistan in an
immediate response to the international travel restrictions. This will
help in stopping the spread of wild poliovirus outside Pakistan's
borders. This was stated in the UK by WHO's Polio Chief - Dr. Elias
Continued on page 11

President Mamnoon Hussain
visits Dow University

DT Pakistan Report
KARACHI- As a token of appreciation for the outstanding services
of Dow University of Medical Sciences in the educational and
healthcare sector, the President of Pakistan Mr. Mamnoon Hussain
recently paid a visit to the Dow University Ojha Campus in Karachi.
The President was accompanied by the Governor of Sindh - Dr.
Ishrat ul Ebad Khan and the provincial minister of Health – Dr.

Sagheer Ahmed along with the
Secretary Health – Mr. Iqbal Durrani.
On this occasion, the Vice Chancellor
of Dow University – Prof. Masood
Hameed Khan, Pro-Vice Chancellor
Prof. Umar Farooq welcomed the
dignitaries at the Ojha campus. Prof.
Masood Hameed Khan briefed the
President about the numerous
medical, academic and research
activities carried out by the
University, besides elevating the
public health standards and facilities
in the country. He also highlighted
the future projects being initiated by
the Dow University, and several
healthcare institutions, established
and operated by the university, during
recent years.The President of
Pakistan paid tribute to the relentless efforts and progress made by
the university under the able guidance of Prof. Masood Hameed
Khan. He expressed hope that the Dow University will continue
with its efforts and formulate new endeavors to strengthen medical
education and provide healthcare services in Pakistan. At the end
of the ceremony, Prof. Masood Hameed presented a Memento
Shield of the University to President Mamnoon Hussain.

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2 DENTAL TRIBUNE Pakistan Edition May 2014

Dental curriculum - time for change?
By Kashif Arif
We need to completely realign our curriculum
after identifying the various social demographics
and the diverse needs of each segment
of our society – said Prof. Dr. Ayyaz Ali Khan
(PhD – Community Dentistry)
The Medical and Dental Council of Bangladesh
has recently approved a new curriculum for the
Bachelor of Dental Surgery (BDS) programme,
by extending their four-year programme to a
duration of five years. The decision was taken
in Dhaka to improve the knowledge-base, skillset and global accreditation of Dental graduates
in Bangladesh.
In Pakistan too, over the past several years, the
medical and dental sector stakeholders and
academicians have been repeatedly engaged in
a similar debate over the appropriateness of our
current health sciences curriculum, which was
inherited way-back from the Britain Raj in the
Subcontinent. Numerous debates were aimed to
make the Pakistani graduates competent enough
to cure the patients, using the latest advancements
in medical sciences & techniques, while becoming
more competitive on a global scale.
Prof. Dr. Ayyaz Ali Khan (PhD) – the leading
dentist and researcher of Pakistan, in a statement
given to Dental News recently said that; There
is a need for total revamping of the failed to meet
the needs of our society.
The current curriculum debate in Pakistan is
mostly revolving around arguments on shuffling
various topics from one subject to another. It
totally ignores the importance of our social
demographics. We do teach Implants to our undergraduates, but we forget that Implants is only 3%
of the market needs.
Prof. Dr. Ayyaz Ali Khan further stated that; our
grads are virtually ignorant of Paediatrics,
although more than 25% of our society comprises
of young citizens. We ignore the subject of

Geriatrics, although 22% our society comprises
of elderly people. The fresh dental graduate knows
little about treatment considerations for Medicallycompromised patients, despite the extremely high
incidence of Diabetes and Hepatitis. We need to
completely realign our syllabus after identifying
the demographics and the diverse needs of each
segment of our society. In order to create
comprehensively trained dental surgeons, our
BDS programmes might as well be extended to
a duration of 6 years.
Another pioneering Dental Surgeon, seasoned
academician and Editor of JPDA – Dr. Inayat
ullah Padhiar commented on the curriculum,
saying; There is a lack of research-orientation in
our BDS programme curriculum, whereby our
graduates donot gain sufficient skills or inspiration
towards research or segmentation of their patients,
which can lead them to qualify in the more
demanded specializations. The society's
demographics and disease-burden needs to be
categorized according to the different regions in
the country. Dr. Inayat feels that the regulatory
guidelines provided by PMDC are similar to the
globally accepted rules, however, as a nation we
lack the will to implement the rules, strictly &
prudently, in every aspect of our social and
professional lives. Thus, more prudent behaviors
are desirable in the field of dental education too.
“Our colleges are also accused of producing elitist
doctors, who are best suited to practice in urban
centers rather than in the less privileged rural
communities. Our community based dental
awareness programs are still in an infancy stage
and are suffering from the neglect of higher
decision making bodies and even of the dental
professional organizations. We need to re-define
the characteristics of our doctors to enable them
to meet the specific needs of our health-deprived
Continued on page 11

Publisher/CEO
Syed Hashim A. Hasan
hashim.hasan@dental-tribune.com.pk
Editor Clinical Research:
Dr. Inayatullah Padhiar
Editors Research & Public Health
Prof. Dr. Ayyaz Ali Khan
Editorial Assistance
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Editor - Online
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Free Health Insurance for poorest Pakistanis
By Kashif Arif
The Government of Pakistan has recently
announced the National budget for the fiscal year
2014-2015, in which one big relief promised for
the poorest segments of the society, is a Free Health
Insurance Scheme being launched through a special
financial allocation of One Billion Rupees.
According to the plan of this pioneering effort, the
allocated fund of One Billion Rupees should be
enough to extend health insurance facilities to
nearly 100 million common people. The
implementation of this Pilot project has been
spread over several phases. Each beneficiary of
the Scheme will enjoy health coverage against
tertiary diseases and special ailments.
The scheme has recently recieved the approval
from the prime minister, in the presence of the
Youth Programme's Chairperson - Maryam Nawaz
Sharif, Finance Minister, Health Minister, and top
officials of these ministries.
The scheme will operate through the Health
Ministry, and deliver the benefits through the joint
efforts of authorized institutions including; Benazir
Income Support Program (BISP) and National
Database & Registration Authority (NADRA),
who will also be responsible for systematic
identification and selection of the most deserving
beneficiaries.
It has been suggested that, each beneficiary may
be issued a Health Insurance Card, which will be
digitally identified at numerous designated medical
institutions, for “Cash-Free” payment of healthcare
expenditure. This scheme will also foster productive
competition between public and private institutions.
The scheme will begin specific districts, which are

commonly known to be totally deprived of
healthcare facilities since decades. In the next
phase, it will be strategically expanded throughout
the country. Slum dwellers and the most underprivileged segments of the population have been
targeted as the primary beneficiaries.
During the formulation of this scheme, the planners
took some concepts from highly successful systems
of “Social Security” and “Grievance Redressal”
for the lowest income segment, adopted in the
USA and other European Union States. Even the
Indian method was studied, as it presents similar
social and economic circumstances.
Prime Minister – Nawaz Sharif has expressed hope
that; “the scheme will also enhance public-private
partnership in Pakistan and will open up further
avenues for investment”. Maryam Nawaz Sharif
has commented that; The scheme is designed on
simple lines to ensure cost efficiency, and will be
devoid of any political influence. It will provide
a blanket cover for cash-free treatment to poor
people for major diseases including; Cardiovascular,
Diabetes Mellitus, life and limb saving treatment,
implants, prosthesis, end-stage renal diseases and
dialysis, chronic infections (hepatitis), organ failure
(hepatic, renal, cardio-pulmonary) and cancer
treatment (chemotherapy, radiation & surgery).
The high-level participants of the meeting have
also agreed upon the establishment of a pioneering,
cutting-edge organ transplant centre in Islamabad.
The relevant ministries have been instructed by
the Prime Minister, to finalize all the technical
modalities and collaborate swiftly, to provide the
earliest possible relief to the suffering humanity.

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[3] =>

[4] =>

Interview

4 DENTAL TRIBUNE Pakistan Edition May 2014

“Aesthetic
dentistry in
itself means
nothing”
An interview with Dr. Pascal Magne, USA

Dr. Pascal Magne

Success in aesthetic dentistry
depends on biology, function and
mechanics; aesthetic dentistry
cannot exist independently.
cosmetic dentistry had the
opportunity to speak with Dr.
Pascal Magne, a specialist in
aesthetic dentistry, lecturer,
author of many clinical and
research articles and the wellknown book Bonded Porcelain
Restorations, and associate
professor at the University of
Southern California in Los
Angeles, where he holds the Don
and Sybil Harrington Foundation
Chair in Esthetic Dentistry, about
the latest trends in modern
restorative dentistry at the 12th
Annual Scientific Conference of
the Polish Academy of Esthetic
Dentistry and Art Oral, which
was held in June 2013 in Sopot,
Poland.
cosmetic dentistry: Dr. Magne,
you created an impressive
training programme on aesthetic
restorative dentistry and have
become one of the most reputable
lecturers on this topic. What is
the philosophy underlying your
success?
Dr. Pascal Magne: I believe that
success needs to be defined first.
Success at work, success in life,
personal success? Often,
professional success has been
obtained by sacrifice of a
personal nature. Can it then still
be considered success?
I strongly believe in what I call
“balanced success”, meaning that
the most important values, such
as spirituality and family, are
preserved. I also believe in
mentorship.
My advice to young colleagues
is to choose one mentor (or
several), a kind of dental parent.
I know it is not easy to find such
a person but it is worth the
search. I have been blessed in
my career to have three mentors,
my clinical mentor, Prof. Urs
Belser (University of Geneva);
my research mentor, Prof.
William Douglas (University of

Minnesota); and my dental
technique mentor, my brother
Michel (university of „life“).
Of course, none of this would
have been possible without my
mentor above all, my Lord Jesus,
and I pray to receive his
inspiration every day. One of my
favourite quotes is Proverbs 16:9:
“In his heart a man plans his
course, but the Lord determines
his steps.”
What are current concepts in
aesthetic restorative dentistry?
In which direction is aesthetic
dentistry developing?

Fig. 1 Partial bonded restorations teeth
13 to 23 (porcelain by Michel Magne,
Oral Design Beverly Hills, on teeth
12–22). (Image courtesy of European
Journal of Esthetic Dentistry)

Fig. 2 Partial bonded restorations teeth
13 to 23 (porcelain by Michel Magne,
Oral Design Beverly Hills, on teeth 1222) in black and white. (Image courtesy
of European Journal of Esthetic
Dentistry)

Aesthetic dentistry in itself
means nothing; it is contingent
on biology, function and
mechanics. Aesthetic dentistry
is the cherry on the cake for those
who follow sound biomimetic
concepts in restorative dentistry.
Above all, as described by Rev.
W. John Murray in his book The
Realm of Reality, “the aesthetic
is itself nothing more than a
beautiful symbol of the spiritual,
without which spiritual, the
aesthetic is a shadow without
substance”.1
I like to remind my patients that
they can always have internal
beauty, the beauty of the heart,
which surpasses physical
aesthetics. That said, if we look
at your question from a more
technical perspective, the answer
lies in the biomimetic approach
to restorative sciences,which in
turn is dependent on adhesive
dentistry and minimally invasive

approaches - no post, no crown
dentistry.
Restorative dentistry is likely to
evolve in a manner similar to
technological advancements in
general. If you have a
smartphone, you know what I
mean. CAD/CAM and
technology will be used
increasingly, and I hope for the
best, meaning just as an
additional tool in our
armamentarium and not as an
excuse to treat more patients.
I believe we will stop using posts,
crowns and metal alloys, and
stop performing intentional
endodontics eventually—this has
already happened for many of us
who believe in the biomimetic
approach.
My hope is that technology will
make better treatment accessible
to more patients, with a reduced
need for root-canal treatment and
crown lengthening. I see an
increase in the diagnosis of dietrelated problems and improved
differential diagnosis between
wear- and erosion-related lesions.
Such cases will force us to strive
for the solution that will preserve
as much of the tooth as possible
(keep the pulp alive using nonre - tentive preparation) that is
no-post no-crown restorative
dentistry. In summary I would
say for the future less is more
(minimally invasive). We will
learn to think differently, think
biomimetically, think bonding.
Technically, good bonding
implies some cardinal rules: good
isolation (very important; ideally
a rubber dam) and knowledge of
your materials, products, and
procedures. A checklist is the
best aid—this is similar to pilots
going through a checklist before
flying an airplane!
Dentists need to have a look at
sound, un - biased literature
before choosing products. Manu
facturers do not always sell the
best product but rather the most
convenient one. Many new
products today have been
developed in response to the
pressure of the market; for
example, one company starts a
new trend and then all the other
companies follow with
competing products even if this
trend does not yield the best per
- formance. It is business driven.
It happens a lot.
I would say that dentists need to
undergo training and gain as
much experience as possible
because we know that the
operator factor is even more
critical than the choice of product
and technique. This is why as an
academic I want my students to
have as much experience as
possible with the materials and
techniques that are going to
represent their daily bread when
they start their practice. Today,
we can no longer ignore that
adhesive dentistry is this daily
bread.
Is it possible to reproduce the
original stiffness of a tooth?
How can this be achieved?
Absolutely! Much research,

starting in the early 1980s, has
demonstrated that adhesive
forces obtained solely on enamel
can restore the original stiffness
of a tooth. Various degrees of
stiffness are obtained with a
combi - nation of dental
adhesives, composite resins and
ceramics that simulate dentine
and enamel, respectively.
One of the objectives of your
courses is to explain a new
biomimetic approach to
restorative dentistry. What is
this concept about?
I can respond in two words:
mimicking nature. As said earlier,
it implies first respecting
biological parameters, such as
pulp vitality— once lost, the pulp
will not come back and we know
that a non-vital tooth has a poor
prog nosis—then emulating
mechanical function as intended
by nature. This will ultimately
form an aesthetic and pleasing
whole with the tooth because
dental materials that are able to
simulate the mechanical
properties of dentine and enamel
are also available in tooth
colours.
This is the fundamental
difference between a filling (old
alloy restorations) that only fills
a cavity like an obturator and
one that rehabilitates the
biomechanics of the tooth.
Biomimetic research is changing
dentistry using apparently weak
materials synergistically to
simulate enamel and dentine.
After all, enamel is extremely
brittle (more brittle than glass)
and dentine absolutely not wear
resistant; yet, together (bonded)
they can make a tooth that can
withstand stress and function for
a lifetime. How do you explain
that? That is synergy! What I call
the “dental trinity” (enamel,
dentine and dentino-enamel
junction) should be the model
and we can realistically approach
this model today with the
structured
use
of
porcelain/ceramics, composite
resin, and enamel and dentine
bonding agents. Adhesive
dentistry is the cornerstone
of this process. Even
endodontically treated teeth can
benefit from this approach
because the remaining enamel
and dentine can be preserved.
Adhesive dentistry today is
capable of producing continuity
between the ceramic/polymer
and the tooth, and above all
allows us to save a great deal of
intact tooth structure (adhesion
replacing retention and resistance
form). It would be foolish to
ignore bonding techniques today
and remove precious enamel and
dentine instead. In summary, it
is not about aesthetics but about
tooth-conserving dentistry.
I believe biomimetic research
will allow us to develop better
solutions for tooth replacement.
Currently, dental implants are
not biomimetic per se because
of the lack of periodontal
ligament, extreme stiffness, etc.
(they are only indirectly

biomimetic because they do not
require the neighbouring teeth to
be altered). We are looking at
ways to make them more
biomimetic through the use of
materials that are more
compliant2 and even adhesive
techniques - bonding to implant
abutments can be very useful.3
What is your view of the role of
CAD/CAM techniques in
modern aesthetic restorative
dentistry? Is this the future or
just a temporary trend?
It is a growing trend, and it will
grow not only as a restorative
tool but also as a diagnostic tool
through the inclusion of various
modules, such as wear/erosion
monitoring, caries detection, etc.
I strongly believe in CAD/CAM
but only as a tool, not a
philosophy of work. That means
that the operator still needs to
have his or her own core values,
treatment planning strategies, etc.
that are totally independent of
the tools that are used to reach
the treatment objective.
You have lectured all over the
world. What do you think dental
education today should entail?
What should its main objective
be?
I believe that an effective
educator should be imbued with
passion and knowledge, and must
infect others with this passion
and knowledge.
His or her teaching must be based
not only on science, but also on
common sense and experience.
The educator must not hide
anything, especially not his or
her failures.
When listening to such a teacher,
dentists taking the course should
feel empowered with new
abilities to provide their patients
with durable treatments that are
better adapted and more
conservative.
Ideally, this kind of teacher
should be a model in his or her
personal life too. This is the
difference between just having
success and being a successful
human being. I am not saying
that I am a successful human
being but I strive to be. Albert
Einstein once said, “I want to
know God’s thoughts; the rest
are details.”
The main objective of dental
education should be to establish
very strong core values; values
that will not age, that will be
timeless. We know that ten years
from now, most of the materials
and tools that we use today will
have been supplanted by new
ones.
So I always ask my colleagues,
“What is it that you would like to
be remembered for when you
retire?”. This question usually
calls for a deep reflection about
one’s values.
Deep respect for God’s creation,
including teeth, and trying to
emulate it - this is the kind of
value that I want to pursue.
Thank you very much for the
interview; it was very inspiring.
Editorial note: A complete list of references
is available from the publisher.

[5] =>

Dental Practice

May 2014 Pakistan Edition DENTAL TRIBUNE 5

CBCT in endodontic treatment
of fused second & third
mandibular molars
Authors Dr. Andreas Krokidis, Greece, & Dr. Riccardo Tonini, Italy
Abstract
The aim of this article is to report a rare
anatomic case and the contribution of new
technologies in best resolving it. Fusion
is defined as the union of two separate
tooth germs at any stage of tooth
development. Planning treatment for this
condition can be difficult and requires all
diagnostic means available. A 45-year-old
female patient presenting with a fused
second and third molar underwent
endodontic treatment and direct restoration
after CBCT imaging revealed a direct
relationship between the two germs. The
treatment was successful once the correct
diagnosis had been made.
Introduction
Fusion is defined as the union of two
separate tooth germs at any stage of tooth
development. Fused elements may be
attached at the dentine or enamel. This
process involves the epithelial and
mesenchymal germ layers, and results in
irregular tooth morphology.1 Depending
on the stage of development in which the
fusion occurs, pulp chambers and canals
may be linked or separated.
The reason for this phenomenon is
unknown, but genetic factors, physical
forces, pressure, and trauma may be
influencing factors.2 The prevalence of
dental fusion is higher in primary dentition
(0.5–2.5%) than in permanent dentition
(0.1%); in both cases, the anterior region
has the highest prevalence.3 The incidence
is the same between males and females.
Cases of affected posterior teeth are rare
in the literature. Most posterior teeth are
fused with fourth molars (supernumerary).
Fusion between premolars and molars or
second and third molars has also been
reported, but is less common. In some
reported cases, teeth are bilaterally fused
with supernumerary molars.4–9 In these
cases, the number of teeth in the dental
arch is also normal and differentiation
from gemination is clinically difficult or
impossible. A diagnostic consideration,
but not a set rule, is that supernumerary
teeth are often slightly aberrant and have
a cone-shaped clinical appearance. Thus,
fusion between a supernumerary and a
normal tooth will generally involve
differences in the two halves of the joined
crown. However, in gemination cases, the
two halves of the joined crown are
commonly mirror images.9
Periodontic problems occur as a part of
the pathology in these cases.5–8 A high
prevalence of caries also occurs due to
anatomically abnormal plaque retention.
In the anterior region, an anti-aesthetic
effect occurs owing to the abnormal
anatomy. In contrast, crowding and
occlusal dysfunction may occur in the
posterior region, especially in cases with
supernumerary teeth, which often leads to
tooth extraction.5,10,11
Fused teeth are usually asymptomatic. The
collaboration of practitioners with expertise
in multiple areas of dentistry is important
to create or achieve functional and aesthetic
success in these cases. Several treatment
methods have been described in the
literature with respect to the different types
and morphological variations of fused
teeth, including endodontic, restorative,
surgical, periodontal, and orthodontic
treatment.3–6,10–12
In cases in which endodontic therapy is
indicated, clinicians must be very careful

during access because anatomy is not
predetermined and canals may be displaced
from their normal position, depending on
the position of the two germs and whether
the teeth involved are part of the normal
dentition or supernumerary. For this reason,
clinicians should examine the element
meticulously, both clinically and
radiographically. This case report
demonstrates the usefulness of a CBCT
scan in addition to conventional intra-oral
X-rays from different projections in
diagnosing and designing appropriate
treatment for this rare case.13,14
Case presentation
A 45-year-old woman was referred by an
oral surgeon who had proposed an
extraction of the last mandibular molar
because of pain and abnormal anatomy.
The patient complained of pulsing pain in
the right side of the oral cavity, which
extended to the ear region and worsened
at night.
After a comprehensive extra-oral and intraoral examination, the pain was found to
be localised to the region of teeth 47 and
48 (Fig. 1). Both cold and hot stimuli
consistently caused pain in those teeth. An
obvious anatomic abnormality noted during
the clinical examination was confirmed
with intra-oral X-rays using a parallelcone technique and various projections.The
X-ray (Fig. 2) also revealed a deep
amalgam restoration extending into the
pulp chamber, which had been infiltrated,
and distal caries in the fused tooth. A deep
carious lesion was also observed on tooth
46, but a simple filling was scheduled
because the tooth responded normally to
cold and hot stimuli.
In this case, the treatment plan was
determined to be root-canal therapy for
the pulpitis in the fused tooth and a direct
restoration for the same tooth. In addition,
dental hygiene sessions were scheduled
for the patient because of generalised
plaque and to avoid worsening of
periodontal conditions in the area of the
fused tooth. Direct restorations were also
arranged with the general practitioner to
avoid any other pulp implications in other
teeth with marked infiltrated restorations.
Initially, the treatment plan was targeted
at the root-canal therapy of the fused tooth,
which was urgent. In order to clarify the
anatomy of this element, a CBCT
examination was also performed; it
revealed two independent mesial roots
(lingual and buccal) and a single distal
root. The fused root in the middle involved
two independent canals ending in the same
area (Figs. 3 & 4).
After anaesthetic with 1:100,000 lidocaine
had been administered, the tooth was
isolated with a rubber dam (KKD,
Sympatic Dam). Because of the abnormal
a n a t o m y, t h e u s e o f a l i q u i d
photopolymerising dam (DAM COOL,
Danville Materials) was necessary to seal
gaps completely and to avoid leakage of
saliva into the treated tooth and sodium
hypochlorite into the patient’s mouth. An
extended access cavity using a 1.2 mm
cylindrical bur and a #2 Start-X ultrasonic
tip (DENTSPLY Maillefer) was created
to visualize all five orifices (Fig. 5).
Once the surface was clean and canals
were visible, negotiation with hand files
(K-files) and Path Files (DENTSPLY
Maillefer) was performed to ensurepatency
of the canals. First #10 and #08 K-files (if

Fig.1

Fig.2

Fig.3

Fig. 1 Initial clinical situation. Observe the plaque in the lingual side in the fusion
area and discoloration due to caries. Fig. 2 Initial X-ray situation.
Fig. 3 Reconstruction.

Fig.5

Fig.4

Fig.6

Fig. 4 Axial images where fusion is obvious. Fig. 5 Access cavity. Non-conventional
shape due to abnormal anatomy. Fig. 6 Working length X-ray.

Fig.7

Fig.8

Fig.9

Fig. 7 Finished case. Fig. 8 X-rays of the finished case.
Fig. 9 After restoration.

Fig.10

Fig.11

Fig.12

Fig. 10 After restoration. Fig. 11 One-year recall X-ray.
Fig. 12 One-year recall.
needed) were alternated along the canals
with copious irrigation with sodium
hypochlorite and using 17% EDTA gel
(B&L Biotech) until the #10 file was at
the apex. Working length was measured
with an apex locator (Root ZX, Morita).
Afterwards #1–3 PathFiles were used until
the #3 file reached working length in all
five canals. Once patency had been
confirmed, working length was also
confirmed radiographically (Fig. 6).
The next step was to shape the canals using
reciprocating files (WaveOne, DENTSPLY
Tulsa Dental Specialties) with a singlefile reciprocating technique. Since the
anatomy was slightly different, the shaping
technique was changed. After the primary
file (25.08, red code), apical gauging was
performed with manual NiTi K-files (ISO)
to measure the apical restriction diameter.
For the distal canal, the large file was also
needed. Throughout the procedure,
irrigation with preheated 5.25% sodium
hypochlorite was performed with 30g
irrigating needles (NaviTip, Ultradent) and
the irrigant was activated with IrriSafe
files (ACTEON).15–17 Once the shaping
had been completed, apical diameter was
confirmed through apical gauging, and
cones were fitted. Irrigation with preheated
and activated 17% EDTA solution (Vista
Dental Products) was used to remove
inorganic debris from the canals. Canals
were then dried with paper cones and the
roots were sealed with vertical
condensation of hot gutta-percha (Endo2 B&L Biotech) with standardised guttapercha cones and Pulp Canal Sealer. Backfilling was performed with warm liquid
gutta-percha (SuperEndo-B&L Biotech;
Figs. 7 & 8). The treatment was completed
with a direct composite restoration (Figs.
9 & 10). All treatment was performed
under clinical microscope (OMNI pico,
Zeiss).
The patient kept to her treatment plan and
attended several recall appointments after
the rootcanal therapy. She also attended
six-monthly oral hygiene appointments

with the dental hygienist (Figs. 11–13).
Discussion
Treatment planning for rare conditions
such as fused teeth is fundamental to the
success of each case. For this reason,
clinicians must consider every parameter
before starting treatment. In this case, a
tooth extraction would have been the likely
outcome without a CBCT examination.
Because the fused teeth complex did not
involve any occlusal or periodontal
problems, the extraction would have caused
significant biological damage and held
significant financial implications.
Once a treatment plan was in place, a
CBCT scan was very helpful in
determining the exact position of the canals
and in designing the access cavity
according to the exact anatomy, which was
different from that of a normal single tooth.
The single-file reciprocating technique
chosen for this case was adapted to the
need of the tooth. Since the anatomy was
complex, the direct use of a large file in
the distal root might have failed. Had
different diameters been established during
apical gauging, the shaping technique
would have been changed and more files
would have been introduced. For this
reason the shaping technique was modified
using more files for this particular root.
Conclusion
In conclusion, this case demonstrates the
importance of treatment planning. In
designing a treatment plan, all diagnostic
methods should be considered. In this case,
a CBCT examination resulted in a
successful and predictable treatment.
Editorial note: A complete list of references is available
from the publisher.

contact

roots

Andreas Krokidis, DDS, MSc, is a
research associate at the National and
Kapodistrian University of Athens in
Greece. He can be contacted at
andreaskrokidis@hotmail.com
Riccardo Tonini, DDS, MSc, is in private
practice in Brescia in Italy.

[6] =>

Implant Dentistry

6 DENTAL TRIBUNE Pakistan Edition May 2014

Stem Cells

in Implant Dentistry
Fig.3

Fig.2

Fig.4a

Fig.1
Fig.5d

Fig.5b

Fig.5a

Fig.5c

Fig.5e
Fig.8b

Fig.8a

Fig.6

Fig.4b

Fig.7

Fig.9
Fig.11d

Fig.10b
Fig.10a

Fig.11a

Fig.11c

Fig.11b
Fig.11g

Fig.11f

Fig.11h

beyond the conventional mesodermal
lineage to include differentiation into
liver, kidney, muscle, skin, cardiac, and
nerve cells (Fig. 2).
The recognition of stem cell potential
unearthed a new age in medicine: the
age of regenerative medicine. It has made
it possible to consider the regeneration
of damaged tissue or an organ that would
otherwise be lost. Because the use of
embryo stem cells raises ethical issues
for obvious reasons, most scientific
studies focus on the applications of adult
stem cells. Adult stem cells are not
considered as versatile as embryo stem
cells because they are widely regarded
as multipotent, that is, capable of giving
rise to certain types of specific
cells/tissues only, whereas the embryo
stem cells can differentiate into any types
of cells/tissues. Advances in scientific
research have determined that some
tissues have greater diffi culty
regenerating, such as the nervous tissue,
whereas bone and blood, for instance,
are considered more suitable for stem
cell therapy. In dentistry, pulp from
primary teeth has been thoroughly
investigated as a potential source of stem
cells with promising results. However,
the regeneration of an entire tooth,
known as third dentition, is a highly
complex process, which despite some
promising results with animals remains
very far from clinical applicability. The
opposite has been observed in the area
of jawbone regeneration, where there is
a higher level of scientific evidence
for its clinical applications. Currently,
adult stem cells have been harvested
from bone marrow and fat, among
other tissues.

Bone marrow is haematopoietic, that is,
capable of producing all the blood cells.
Since the 1950s, when Nobel Prize
winner Dr. E. Donnall Thomas
demonstrated the viability of bone
marrow transplants in patients with
leukaemia, many lives have been saved
using this approach for a variety of
immunological and haematopoietic
illnesses. However, the bone marrow
contains more than just haematopoietic
stem cells (which give rise to red and
white blood cells, as well as platelets,
for example); it is also home to
mesenchymal stem cells (which will
become bone, muscle and fat tissues, for
instance; Fig. 3).
Bone marrow harvesting is carried out
under local anaesthesia using an
aspiration needle through the iliac
(pelvic) bone. Other than requiring a
competent doctor to perform such a task,
it is not regarded as an excessively
invasive or complex procedure. It is also
not associated with high levels of
discomfort either intra or postoperatively (Figs. 4a & b). Bone
reconstruction is a challenge in dentistry
(also in orthopaedics and oncology)
because rebuilding bony defects caused
by trauma, infections, tumours or dental
extractions requires bone grafting. The
lack of bone in the jaws may impede the
placement of dental implants, thus
adversely affecting patients’ quality of
life. In order to remedy bone scarcity, a
bone graft is conventionally harvested
from the chin region or the angle of the
mandible. If the amount required is too
large, bone from the skull, legs or pelvis
may be used. Unlike the process for
harvesting bone marrow, the process

Fig.11e
Author: Dr. André Antonio Pelegrine, Brazil
The human body contains over 200
different types of cells, which are
organised into tissues and organs that
perform all the tasks required to maintain
the viability of the system, including
reproduction. In healthy adult tissues,
the cell population size is the result of
a fine balance between cell proliferation,
differentiation, and death. Following
tissue injury, cell proliferation begins to
repair the damage. In order to achieve
this, quiescent cells (dormant cells) in
the tissue become proliferative, or stem
cells are activated and differentiate into
the appropriate cell type needed to repair
the damaged tissue. Research into stem
cells seeks to understand tissue
maintenance and repair in adulthood and
the derivation of the significant number
of cell types from human embryos.
It has long been observed that tissues
can differentiate into a wide variety of
cells, and in the case of blood, skin and
the gastric lining the differentiated cells
possess a short half-life and are incapable
of renewing themselves. This has led to
the idea that some tissues may be
maintained by stem cells, which are
defined as cells with enormous renewal
capacity (self-replication) and the ability
to generate daughter cells with the
capacity of differentiation. Such cells,
also known as adult stem cells, will only
produce the appropriate cell lines for the
tissues in which they reside (Fig. 1).
Not only can stem cells be isolated from
both adult and embryo tissues; they can
also be kept in cultures as
undifferentiated cells. Embryo stem cells
have the ability to produce all the
differentiated cells of an adult. Their
potential can therefore be extended

Fig. 1 A stem cell following either selfreplication or a differentiation pathway.
Fig. 2 Different tissues originated from
mesenchymal stem cells.
Fig. 3 The diversity of cell types present
in the bone marrow.
Fig. 4a Point of needle puncture for access
to the bone marrow space in the iliac bone.
Fig. 4b The needle inside the bone marrow.
Fig. 5a A bone graft being harvested from
the chin (mentum).
Fig. 5b A bone graft being harvested from
the angle of the mandible (ramus).
Fig. 5c A bone graft being harvested from
the angle of the skull (calvaria).
Fig. 5d A bone graft being harvested from
the angle of the leg (tibia or fibula).
Fig.5e A bone graft from the pelvic bone
(iliac).
Fig. 6 A critical bony defect created in the
skull (calvaria) of a rabbit.
Fig. 7 A primary culture of adult
mesenchymal stem cells from the bone
marrow after 21 days of culture.
Fig. 8a A CT image of a rabbit’s skull
after bone-sparing grafting without stem
cells (blue arrow). Note that the bony
defect remains.
Fig. 8b A CT image of a rabbit’s skull
after bone-sparing grafting with stem cells.
Note that the bony defect has almost been
resolved.
Fig. 9 A bone block from a musculoskeletal
tissue bank combined with a bone marrow
concentrate.
Fig. 10a A histological image of the site
grafted with bank bone combined with
bone marrow.
Note the presence of considerable amounts
of mineralised tissue.
Fig. 10b A histological image of the site
grafted with bank bone not combined with
bone marrow.
Note the presence of low amounts of
mineralised tissue.
Fig. 11a Bone marrow.
Fig. 11b Bone marrow transfer into a conic
tube in a sterile environment (laminar
flow).
Fig. 11c Bone marrow homogenisation in
a buffer solution (laminar flow).
Fig. 11d Bone marrow combined with
Ficoll (to aid cell separation).
Fig. 11e Pipette collection of the interface
containing the mononuclear cells (where
the stem cells are present).
Fig. 11f Second centrifuge spin.
Fig. 11g The pellet containing the bone
marrow mononuclear cells after the second
centrifuge spin.
Fig. 11h A bovine bone graft combined
with a bone marrow stem cell concentrate.
All images courtesy of Células Tronco em
Implantodontia.2

involved in obtaining larger bone grafts
is often associated with high levels of
discomfort and, occasionally, inevitable
post-operative sequelae
(Figs. 5a–e).
The problems related to bone grafting
have encouraged the use of bone
substitutes (synthetic materials and bone
from human or bovine donors, for
example). However, such materials show
inferior results compared with autologous
bone grafts (from the patient
himself/herself), since they lack
autologous proteins. Therefore, in critical
bony defects, that is, those requiring
specific therapy to recover their original
contour, a novel concept to avoid
autologous grafting, involving the use
of bone-sparing material combined with
stem cells from the same patient, has
been gaining ground as a more modern
philosophy of treatment. Consequently,
to the detriment of traditional bone
grafting (with all its inherent problems),
this novel method of combining stem
cells with mineralized materials uses a
viable graft with cells from the patient
himself/herself without the need for
Continued on page 11

[7] =>

[8] =>

Clinical Study

8 DENTAL TRIBUNE Pakistan Edition May 2014

Treatment of aphthous
stomatitis using low-level
laser therapy
Authors Pedro J.J. Muñoz
Authors_Pedro
Muñoz Sánchez,
Sánchez, Cuba,
Cuba, José
José Luis
Luis Capote Femenias, Cuba & Jan
Tunér,
Sweden
&
Jan Tunér,
Sweden

[PICTURE:
[PICTURE:©MATHAGRAPHICS]
©MATHAGRAPHICS]

Introduction
Aphthous stomatitis has been investigated to a great
extent; however, the aetiology of these lesions is still
to be identified accurately. Recurrent aphthous
stomatitis is considered a chronic illness accompanied
by painful oral ulcers that reappear with irregular
frequency.
The following categories have been described:
smaller aphthous ulcers (80–85% of cases; of a
diameter of 1–10mm; healing spontaneously in seven
to ten days);larger aphthous ulcers (Sutton’s disease;
10–15% of cases; of a diameter larger than 10mm;
healing spontaneously within ten to 30 days or more;
may leave a scar); and herpetiform ulcers (5–10% of
cases; multiple clusters of lesions of a diameter of
1–3mm, which can coalesce into larger erosions;
healing in seven to ten days).1
The predisposing factors of recurrent aphthous ulcers
are speculative; among them are trauma, emotional
stress, coeliac disease, hormonal changes,
hypersensitivity to certain foods, allergic reactions
and intoxications. 1 It is believed that aphthous
stomatitis affects 20 % of the US population and
studies have demonstrated a worldwide prevalence of
31–66%.2 It is important to highlight that the diagnosis
of aphthous stomatitis is primarily clinical and should
be differentiated from systemic conditions, such as
coeliac disease, Crohn’s disease, herpes simplex virus
Type I, Reiter’s syndrome, syphilis, systemic lupus
erythematosus, T cell disorders, chicken pox and B6
deficiency.3–7
The benefits of local therapies have been demonstrated
with anaesthetics and cortico steroids, applied in
prodromal stages or in early stages of the lesions.
When treating with systemic steroids, it is important
to consider the course of the ulcer.8–21 According to
reports from Cuba, treatment with lowlevel laser
therapy (LLLT) is effective, achieving rapid relief of
pain, quicker wound healing and lower frequency of
recurrence. 22–24 The aim of the present clinical
unblinded study was to evaluate the prevalence of
aphthous stomatitis in various age groups, as well as
the effect of LLLT in the treatment of aphthous
stomatitis.
Material and methods
An experimental study was carried out in patients
with a clinical diagnosis of aphthous stomatitis
attending the Leonardo Fernández Sánchez dental
clinic in Cienfuegos in Cuba between September 2010
and March 2011. Among the 252 patients registered,
208 attended the clinic until the lesions had healed
completely. The study was approved by the Scientific
Council of the University of Medical Sciences,
Cienfuegos. All of the patients were informed about
the parameters of the study and gave their informed
consent. LLLT was administered to 104 patients (study
group) and the remaining 104 (control group) received
conventional treatment, such as topical anaesthetics

(2% lidocaine), dietary advice
and oral painkillers. Every
second patient with the same
type of ulcer was allocated to
either the study or the control
group. The two groups
consisted of 56 males and 148 females, with a great
variation in age distribution (Table 1).
All of the patients were seen daily and the patients in
the study group received LLLT every second day

unless their ulcer had already healed. The patients
were categorised with regard to age and ulcer type
(Tables 1 & 2). Special diagnostic procedures were
performed in patients with large ulcers to confirm a
safe differential diagnosis. Pain was evaluated, but

since pain is subjective, it was decided only to register
the time until wound closure (Fig. 1), which can be
registered objectively. No patient in the study group
reported any negative effects of the laser irradiation.
The laser used was the Lasermed 670DL (Cuban
manufactured), 670nm, 40mW. Each ulcer underwent
40 seconds of irradiation at 1.6 J, 2.04J/cm 2 and
51mW/cm 2 from a distance of about 0.5cm. The
parameters used were based upon the successful
application of these in a previous study on herpes
simplex virus Type I blisters.32
The study was unblinded. A 660 nm laser emits clear

red light and, although a patient-blinded design is
possible, it is not possible to mask a placebo laser for
the therapist.
The distribution of the age of the patients, of the types
of ulcer according to age, and of the types of ulcer in
the study and control groups is shown in Tables 1–3.
This data corresponds with the literature, where smaller
aphthous ulcers represent 80–85% of cases, larger
ulcers 10–15% and herpetiform ulcers 5–10%. 1
Results
The main results of the study are presented in Figure
1. The results shown are for small ulcers, which were
the dominant type of ulcers treated. As for the large
ulcers in the study group, four scarred between two
and four days, and another four scarred between five
and seven days. In the control group, eight large ulcers
scarred within seven days. For ethical reasons, and
because of the small number of cases, the four
herpetiform ulcers were all treated with laser. They
healed between two and four days. According to the
literature, the normal healing time with no treatment
is seven to ten daysfor small aphthous ulcers, ten to
30 days for large aphthous ulcers, and seven to 14
days for herpetiform ulcers.1, 3
Discussion
The use of LLLT to treat aphthous stomatitis was
suggested in 1986 already by Quang-Hua 25 using a
helium–neon laser and in 1987 by Von Alften26 using
a gallium arsenide laser. Recent studies, such as the
one by De Souza et al.27 have used a laser similar to
ours, 670nm, 50mW, 3J/cm2. It therefore appears that
the wavelength itself is not decisive. Indeed, Zand et
al.28 report good results using a carbon dioxide laser
at non-thermal levels in combination with a transparent
gel to reduce beam absorption. Surgical lasers have
also been reported to be effective, but the mechanism
here ought to be different, since it entails superficial
tissue evaporation. Tezel et al. 29 report fair results
using an Nd:YAG laser, while the erbium laser in
addition can be used for surface modification of the
lesion and pain relief.30
The biological mechanism behind the effect of the
various lasers is still unknown. The power setting
used in our study was rather low and the effect of
higher power settings needs to be investigated. Another
aspect is the number of sessions. In our study, the
patients were treated every second day until wound
closure had been achieved. In the De Souza study,27
patients were treated daily until an obvious result was
observed. Only four patients with a herpetiform ulcer
took part in the current study. Although these ulcers
responded well to LLLT, no definite conclusions can
be drawn, since all four were included in the study
group.
Patients typically have an occasional aphthous ulcer.
The problem arises in patients with recurrent aphthous
ulcers. The frequency of recurrence was not
investigated in our study, but no presently available
treatment has been able to reduce recurrence. 31
However, such a possibility is suggested in some
sources.22–24 In a recently published study,32 our clinic
found that LLLT reduced the recurrence frequency in
herpes simplex virus Type I patients. Although
aphthous ulcers are different to herpes simplex virus
Type I blisters, LLLT might reduce their frequency
of recurrence too.
Conclusion
LLLT appears to be a safe and effective option for
treating aphthous stomatitis. The distribution of
aphthous stomatitis in the various age groups was
found to be in accordance with previous reports. 33
Further studies are warranted to investigate the optimal
laser parameters and frequency of irradiation.
Statement
The present study was financed by the authors and
their clinics. Pedro J. Muñoz Sánchez and José Luis
Capote performed the clinical part. Jan Tunér served
as scientific advisor and authored the manuscript.
Editorial note: A list of references is available from the publisher.

contact

roots

Jan Tunér Spjutvagen 11 772 32 Grängesberg Sweden
jan.tuner@swipnet.se

[9] =>

[10] =>

[11] =>

May 2014 Pakistan Edition DENTAL TRIBUNE 11

Health Budget 2014-15

Dental curriculum - time for change?

Continued from front page

Continued from page 2
society, with a more humane approach. But we
can only do this successfully, if we provide the
rural dental clinician with decent amenities of
life. There is also a need to focus on diseaseprevention, rather than disease-treatment”
Dr. Inayat added.
Pakistan needs a paradigm shift towards research
oriented and clinical based scientific
methodologies with emphasized training on
medical jurisprudence and human consumer rights
as well. In Pakistan, there is no dearth of
experienced professionals and academicians, who
have the global exposure to upgrade our
curriculum and enable faster access to
global developments.
Pakistan Medical and Dental Council (PMDC)
has the authority and responsibility to lead and
guide all the medical and dental education
institutions, with a regulated curriculum, to ensure
uniformity of syllabus and train all the Graduates
in important subjects, surgical skill and
relevant sciences.
There have been numerous debates, where dental
and oro-facial educators were collectively
deliberating to enhance the knowledge and skills
of our students and graduates. The new scientific
revolutionary era of molecular biology, genetic
tissue engineering, bio-informatics and nanotechnology appear to reshape the current trends
and practices in dental care education, services
and curriculum designing.
Internationally, there is a transformation towards
new research-based, objectively structured and
clinically oriented curriculum, which should not
only be able to produce health care professionals
with a broad knowledge and expertise of existing

National Health Services, Regulations & Coordination Division
shows a minor increase from Rs. 26,802 million during the previous
year to Rs. 27,015 millon in the new budget for 2014-2015.
However, the government has shown some generosity for health
sector, by waiving off the import duties applicable on Modern
Medical Equipment and healthcare technology. Another generous
allocation of Rs. 63 billion has been made for promotion of higher
education, which will be helpful to many of the medical
professionals who desire to improve their qualifications for serving
their nation better.
Under the head of Health Affairs and Services, a total allocation
of Rs 10,017 million has been made, which is higher by 1.6% and
6.2% respectively when compared with budget and revised
estimates 2013-14. The allocation for Hospital Services forms the
major component under this classification.
Considering the high costs of medical facilities and the large
segments of poor Pakistanis, the government should have made
a sizeable increase in the Health budget to ensure relief for the
deprived segments of our society.

Take drops or Travel stops
Continued from front page

Durry. "We know that Pakistan was doing a lot to prevent the export
of polio". Durry added. According to news reports; Dr. Durry also
stated that; “Pakistan should continue to take steps to ensure that
the international community is not affected by the poliovirus.”
WHO Pakistan Country Director - Dr. Nima Saeed Abid was also
hopeful. “We are taking concrete measures with regard to Polio
vaccination. The WHO is committed to facilitating the government
of Pakistan and will continue supporting all the steps taken to
implement WHO recommendations to protect the world from polio,”
Earlier, Pakistan had pointed out the difficulties faced with regard
to the unstable security situation in certain areas, the threat of
terrorism and attacks on polio workers among other factors. To
compound the problem, a vaccination campaign had been used as
a cover to launch a military operation on Pakistani soil. It was also
reported that; Numerous counters issuing polio vaccination
certificates have become operational at a number of institutions,
airports and important locations to facilitate the international
travelers.Health officials should ensure that all the confusions
regarding the authorized certification are removed quickly. The
certificates should be issued international travelers free of cost and
the vaccination counters should be operative throughout the week.

Pakistani Dental students ....
Continued from front page

UHS Asia, Africa, America and Europe.The Pakistani delegation
from comprised of MPhil students of Oral Pathology Department
and was led by Assistant Professor Dr. Nadia Naseem.
In the poster competition, Dr. Sunnaeyah Waris bagged the Third
prize for her poster titled: Histopathological Changes
in Gingival Tissues of Patients having Pulmonary Tuberculosis
in Pakistan".
Dr. Samia Qadir received an overwhelming response on her
presentation on; "The Oral Mucosal Changes in Patients of
HIV/AIDS taking Anti-Retroviral Therapy (ART) in Pakistan".
Dr. Qadir’s study highlighted the preventive aspects required to
improve oral health which could enhance the quality of life and
compliance to drug therapy for HIV patients.
Dr. Rabia Anjum displayed her poster on:
"The Clinico-pathological characteristics and Expression of
CD10 in Soft Tissue Lesions Associated with Impacted Third
Molar."Dr. Abdul Khaliq displayed his poster titled; "
Morphological Changes in Oral Mucosa of Rabbit, Induced by
Light Emitting Diode (LED) used as Dental Curing Light".
Dr. Mohayman Sarfaraz presented a paper on; "Oral
Cytopatological Changes in Habitual Wet Snuff Dippers in
Pakistan".
The Head of UHS Pathology Department - Dr. AH Nagi said,
“The recognition we have recieved is particularly exciting for
students, because they were competing with students not only
from the local institutions, but also from among the leading
research universities of the world.”

dental scientific concepts, but also with a global
vision to develop new strategies in prevention
and management of human diseases with a major
emphasis on evidence based clinical practices.
However, the health education systems in
Pakistan and many other developing countries,
have not evolved sufficiently to match this
revolutionary era of scientific development.
Presently followed and practiced clinical dentistry
concepts and techniques are perhaps rather old
and mainly focus on the symptomatic relief of
oral health related issues and rehabilitation or
repair of damaged or lost natural body parts. The
very important components like oral healthcare
education and prevention of these disease
conditions are greatly neglected in the presently
working system of dental health education. The
supportive utilization of our robust print and
electronic media has not been optimized for this
purpose. The assimilation and incorporation of
recent advancements & technologies is also quite
slow.
The establishment of a National Dental Council
(exclusive of PMDC), has also been
recommended to carry out evaluation, recognition
and structuring of dental profession on an
independent basis. Several gurus of dental
education in Pakistan also recommend that the
BDS programmes in Pakistan should be extended
to a 5 years duration, to make it more
comprehensive and gain global acceptance. All
the stakeholders must work together with the
universities and PMDC to reach the right
conclusions, solid decisions and a comprehensive
road-map for resolving this crucial issue of
upgrading the curriculum. We need a stronger
academic visionary leadership and collaboration.

Stem Cells in Implant Dentistry
Continued from page 6
surgical bone harvesting.
Until recently, no studies had compared the
different methods available for using bone
marrow stem cells for bone reconstruction. In
the fol lowing paragraphs, I shall summaries
a study conducted by our research team, which
entailed the creation of critical bony defects
in rabbits and subsequently applying each of
the four main stem cell methods used globally
in order to compare their effectiveness in terms
of bone healing:1
fresh bone marrow (without any kind of
processing);
a bone marrow stem cell concentrate;
a bone marrow stem cell culture; and
a fat stem cell culture (Figs. 6 & 7).
In a fifth group of animals, no cell therapy
method (control group) was used. The best
bone regeneration results were found in the
groups in which a bone marrow stem cell
concentrate and a bone marrow stem cell culture
were used, and the control group showed the
worst results. Consequently, it was suggested
that stem cells from bone marrow would be
more suitable than those from fat tissue for
bone reconstruction and that a simple stem cell
concentrate method (which takes a few hours)
would achieve similar results to those
obtained using complex cell culture procedures
(which take on average three to four weeks;
Figs. 8a & b).
Similar studies performed in humans have
corroborated the finding that bone marrow
stem cells improve the repair of bony defects
caused by trauma, dental extractions or
tumours. The histological images below
illustrate the potential of bone-sparing materials
combined with stem cells for bone
reconstruction (Fig. 9).

It is clear that the level of mineralized
tissue is significantly higher in those areas
where stem cells were applied (Figs. 10a & b).
Evidently, although bone marrow stem cell
techniques for bone reconstruction are very
close to routine clinical use, much caution must
be exercised before indicating such a procedure.
This procedure requires an appropriately trained
surgical and laboratory team, as well as the
availability of the necessary resources (Figs.
11a–h, taken during laboratory manipulation
of marrow stem cells at São Leopoldo Mandic
dental school in Brazil).
1
André Antonio Pelegrine, Antonio Carlos
Aloise, Allan Zimmermann et al., Repair of
critical-size bone defects using bone marrow
stromal cells: A histomorphometric study in
rabbit calvaria. Part I: Use of fresh bone marrow
or bone marrow mononuclear fraction, Clinical
Oral Implants Research, 00 (2013): 1–6.
2
André Antonio Pelegrine, Antonio Carlos
Aloise & Carlos Eduardo Sorgi da Costa,
Células Tronco em Implantodontia (São Paulo:
Napoleão, 2013)

contact

roots

Dr. André Antonio Pelegrine is a specialist
dental surgeon in periodontology and implant
dentistry (CFO) with an MSc in Implant
Dentistry (UNISA), and a PhD in clinical
medicine (University of Campinas). He
completed postdoctoral research in transplant
surgery (Federal University of São Paulo). He
is an associate lecturer in implant dentistry at
São Leopoldo Mandic dental school and
coordinator of the perio-prosthodontic-implant
dentistry team at the University of Campinas
in Brazil. He can be contacted at
pelegrineandre@gmail.com.

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[cover] => DT Pakistan No. 3, 2014

[toc] => Array ( [0] => Array ( [title] => News [page] => 01 ) [1] => Array ( [title] => Interview: “Aesthetic dentistry in itself means nothing” [page] => 04 ) [2] => Array ( [title] => CBCT in endodontic treatment of fused second & third mandibular molars [page] => 05 ) [3] => Array ( [title] => Stem Cells in Implant Dentistry [page] => 06 ) [4] => Array ( [title] => Treatment of aphthous stomatitis using low-level laser therapy [page] => 08 ) ) [toc_html] =>

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