Oral Diseases Edited by Gokul Sridharan, Anil Sukumaran and Alaa Eddin Omar Al Ostwani Oral Diseases Edited by Gokul Sridharan, Anil Sukumaran and Alaa Eddin Omar Al Ostwani Published in London, United Kingdom Supporting open minds since 2005 Oral Diseases http://dx.doi.org/10.5772/intechopen.84931 Edited by Gokul Sridharan, Anil Sukumaran and Alaa Eddin Omar Al Ostwani Contributors Duy Quoc Ngo, Quang Le Van, Toan Tran Duc, Quy Ngo Xuan, Márcio Campos Oliveira, Igor Ferreira Borba De Almeida, Almira Oliveira Pereira, Maria Da Conceição Andrade, Viviane Ferreira Guimaraes Xavier, Luiz Moreira, Daniel Xavier, Juliana Xavier, Whyrllene Steine, Manoela Garcia Dias Da Conceição, Vera Lucia Luiza, Ana Cláudia Figueró, Randa Alfotawi, Alvaro Zubizarreta, Jesús Mena Álvarez, Reghunathan Preethanath, Wael Ibraheem, Aiswarya Anil, Andres Chala, Esra Guzeldemir-Akcakanat, Seham Alyafei, Sukumaran Anil, Elna Chalisserry, Anahita Punj, Manav Chaturvedi, Biagio Rapone, Elisabetta Ferrara, Daryl Anne Del Mundo, Alfredo Quintin Pontejos © The Editor(s) and the Author(s) 2020 The rights of the editor(s) and the author(s) have been asserted in accordance with the Copyright, Designs and Patents Act 1988. 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First published in London, United Kingdom, 2020 by IntechOpen IntechOpen is the global imprint of INTECHOPEN LIMITED, registered in England and Wales, registration number: 11086078, 7th floor, 10 Lower Thames Street, London, EC3R 6AF, United Kingdom Printed in Croatia British Library Cataloguing-in-Publication Data A catalogue record for this book is available from the British Library Additional hard and PDF copies can be obtained from orders@intechopen.com Oral Diseases Edited by Gokul Sridharan, Anil Sukumaran and Alaa Eddin Omar Al Ostwani p. cm. Print ISBN 978-1-83880-502-9 Online ISBN 978-1-83880-503-6 eBook (PDF) ISBN 978-1-83880-541-8 Selection of our books indexed in the Book Citation Index in Web of Science™ Core Collection (BKCI) Interested in publishing with us? Contact book.department@intechopen.com Numbers displayed above are based on latest data collected. For more information visit www.intechopen.com 4,800+ Open access books available 151 Countries delivered to 12.2% Contributors from top 500 universities Our authors are among the Top 1% most cited scientists 122,000+ International authors and editors 135M+ Downloads We are IntechOpen, the world’s leading publisher of Open Access books Built by scientists, for scientists BOOK CITATION INDEX C L A R I V A T E A N A L Y T I C S I N D E X E D Meet the editors Dr. Gokul Sridharan is currently working as an associate professor in the Department of Oral Pathology and Microbiology at YMT Dental College and Hospital, Navi Mumbai. He has obtained his Doctor of Philosophy (PhD) for the work titled “Salivary and serum metabolomics in oral leukoplakia and oral squamous cell carci- noma”. His field of interest includes oral pre-cancer, oral cancer, salivary diagnostics, oral and maxillofacial diseases, and advanced diagnostic aids with emphasis on bioinformatics and metabolomics. He has several scientific publications and actively contributes as a peer reviewer to numerous journals. He is an active member of the editorial board of several journals of repute. Dr. Gokul Sridharan has undergone training and is a qualified diploma holder in medial law and ethics and is also certified in tobacco cessation and control. Prof. Sukumaran Anil, BDS, MDS, PhD, FDS RCPS (Glas), FDS RCS (Edin) FICD, FPFA, is currently serving as the Director of the Oral Health Institute, Hamad Medical Corporation, Doha, Qatar. He is a Professor and Senior Consultant in periodontics and implant dentistry. He received his Doctoral Degree in Dentistry (PhD) from the University of Hong Kong in 2002. Further, he underwent one year of advanced training at the UK Center for Oral HIV Research, Guys’ and St. Thomas’s Hospital, London. Based on his contribution to the field, Prof. Sukumaran received honorary fellowship from the Royal College of Physicians and Sur- geons, Glasgow (FDS, RCPS), and Royal College of Surgeons Edinburgh (FDS RCS), International College of Dentist (FICD) and Pierre Fauchard Academy (FPFA). He has been the recipient of several awards for excellence in the field, Gold-medal winner (BDS-India), Ratan H. Doctor National Award (INDIA), Wang Gungwu Scholarship for Research Students (Hong Kong), and the Golden Quill award for research excel- lence from King Saud University, Riyadh. He has more than 35 years of undergraduate and postgraduate teaching experience and PhD supervision in various countries such as India, Hong Kong, Saudi Arabia, United Kingdom, The Netherlands, South Korea, and USA. Previously, he served as Full Professor at King Saud University, Riyadh for the past 12 years and worked as chairman and member of the National Accreditation (NCAAA), European and US accreditation for the courses at King Saud University. He plays a major role in developing a medical research facility (biomaterials and dental) for the medical division of the Ministry of Defense in Riyadh. He has published more than 350 research papers in high-impact journals, chapters, and books in the field. Dr. Al Ostwani Alaa Eddin Omar received a master’s degree in Den- tistry and a PhD in Pediatric Dentistry from Damascus University, Syria, in 2010 and 2014, respectively. He also received a fellowship diploma in Laser Dentistry and The Advanced Fellowship Post- graduate Diploma in Endodontics from the University of Genoa, Italy, in 2019 and 2020, respectively. Dr. Al Ostwani has been an assistant professor at the International University of Science and Technology (IUST) since 2014. During his academic experience he has received several awards, including the scientific research award from the Union of Arab Universities, the Syrian gold medal, and the international gold medal for invention and creativity. He has published eight articles in international and national academic journals, and is a member of the International Association of Dental Traumatology and Syrian Society for Research and Preventive Dentistry, the editorial board for the International Journal of Dental Medicine and the reviewer board for the Indian Journal of Conservative and Endodontics. Contents Preface X II I Section 1 Gingival and Periodontal Diseases 1 Chapter 1 3 Interdental Brushes in Maintaining Periodontal Health by Esra Guzeldemir-Akcakanat Chapter 2 11 Pathogenesis of Gingivitis by Reghunathan S. Preethanath, Wael I. Ibraheem and Aiswarya Anil Chapter 3 31 Diagnosis and Treatment Plan for Gingival Diseases and Conditions by Anahita Punj and Manav Chaturvedi Chapter 4 49 Host Modulation by Wael I. Ibraheem and Reghunathan S. Preethanath Chapter 5 55 Adverse Effects of Medications on Periodontal Tissues by Sukumaran Anil, Seham H.S.A. Alyafei, Annie Kitty George and Elna Paul Chalisserry Section 2 Oral Oncology 73 Chapter 6 75 Potentially Malignant Oral Disorders by Márcio Campos Oliveira, Igor Ferreira Borba de Almeida, Almira Oliveira Pereira and Maria da Conceição Andrade Chapter 7 89 Oral Cancer: The State of the Art of Modern-Day Diagnosis and Treatment by Quang Van Le, Duy Quoc Ngo, Toan Duc Tran and Quy Xuan Ngo X II Chapter 8 105 Non-Invasive Methods for Early Diagnosis of Oral Cancer by Manoela Garcia Dias da Conceição, Ana Cláudia Figueiró and Vera Lucia Luiza Chapter 9 121 Vascular Endothelial Growth Factor Expression in the Pathological Angiogenesis in Oral Squamous Cell Carcinoma by Biagio Rapone and Elisabetta Ferrara Chapter 10 133 The Role of Neck Dissection in Oral Cavity Carcinoma by Alfredo Quintin Y. Pontejos Jr. and Daryl Anne A. del Mundo Chapter 11 141 Modalities and State of Art in Oral Cancer Reconstruction by Andres Chala Section 3 Endodontics 161 Chapter 12 163 Applications of CBCT in Endodontics by Jesús Mena Álvarez and Álvaro Zubizarreta Macho Chapter 13 179 Bioceramic Cements in Endodontics by Viviane Ferreira Guimarães Xavier, Luiz Felipe Moreira, Daniel Guimarães Xavier, Juliana Guimarães Xavier and Whyrllene Steine Section 4 Oral Surgical Procedures 193 Chapter 14 195 Flap Techniques in Dentoalveolar Surgery by Randa Abdulmoein AlFotawi Preface The mouth is the mirror of the body’s health. Oral diseases are one of the most common disorders among the various communi- cable and non-communicable health diseases. They pose a major health burden for many countries and affect people throughout their lifetime causing pain, discom- fort, disfigurement, and even death. As per WHO, it is estimated that oral diseases affect nearly 3.5 billion people globally. In developing countries, the estimate could be even higher owing to the lack of awareness among the general public, the lack of adequate infrastructure, and less accessibility to oral health care providers, espe- cially amongst people of lower socio-economic status. The different diseases affecting the oral cavity include dental caries, gingival and periodontal diseases, microbial infections, oral cancer, autoimmune disor- ders, diseases of the salivary gland, cysts and tumors of odontogenic origin etc. Additionally, the oral cavity exhibits early manifestations of systemic diseases such as diabetes, HIV, as well as metastatic cancers from other sites. In such circum- stances, the role of the dental clinician assumes significance owing to their ability to diagnose the condition early and implement appropriate management strategies. Keeping this in mind, the aim of this book project is to provide an overview of various oral diseases with emphasis on the pathogenesis, investigation, and the management protocol of different oral and maxillofacial diseases. The book has been divided into sec - tions based on the categorisation of oral lesions into gingival and periodontal diseases, oral oncology, endodontics, and oral surgical procedures with the objective of providing a comprehensive outline of the different chapters for the readers and clinicians alike. D r. Gokul Sridharan MDS, PhD, PGD (Medical Law and Ethics) Associate Professor, Department of Oral Pathology and Microbiology, Dr. G. D. Pol Foundation YMT Dental College and Hospital, Kharghar, Navi Mumbai, India Dr. Anil Sukumaran BDS, MDS, PhD, FDS RCPS (Glas), FDS RCS (Ed), FICD, FPFA Professor, Senior Consultant, Hamad Medical Corporation, Doha, Qatar Dr. Alaa Eddin Omar Al Ostwani Assistant Professor of Pediatric Dentistry BDS, MSc, PhD, International University for Science and Technology, Syria 1 Section 1 Gingival and Periodontal Diseases 3 Chapter 1 Interdental Brushes in Maintaining Periodontal Health Esra Guzeldemir-Akcakanat Abstract According to the World Health Organization (WHO), oral diseases are accepted as the most prevalent noncommunicable diseases. Oral hygiene and cleanliness is vital and essential to preserve and maintain oral health. Although periodontal diseases are controllable and preventable diseases, periodontal diseases are the most common type of oral disease. Mechanical plaque control is the key factor for not only in prevention but also in the treatment of periodontal diseases and mainte- nance of health. The primary factor for the development of gingivitis is poor oral hygiene which is microbial plaque formation. Achieving ideal plaque control may be obtained by toothbrushing together with interdental cleaning such as dental floss, interdental brushes (IDB), wood sticks, and waterjet devices. Evidence suggests that the most effective method for interdental plaque removal is the use of inter- dental brushes. In this chapter, while the importance of interdental brushes in oral hygiene is explained in detail, the types and use of interdental brushes will also be mentioned. Keywords: dental hygiene, dental plaque, gingivitis, interdental brushes, interdental cleaning, oral hygiene 1. Introduction While oral diseases are the most prevalent noncommunicable diseases, severe periodontal disease was estimated to be the 11th most prevalent human disease globally (WHO) [1]. Generally, seven oral diseases are described as follows: dental caries, periodontal diseases, oral cancers, oral manifestations of HIV, oro-dental trauma, cleft lip and palate, and noma. The Global Burden of Disease Study reported that oral diseases affected at least 3.58 billion people worldwide, and the most prevalent oral condition was caries of the permanent teeth [1]. Microbial biofilm which is a surface-associated and structurally and function- ally organized multi-species biofilm [2] is the main reason of both dental caries and periodontal diseases. Microorganisms destroy not only tooth structures but also supporting structures of the tooth even though they have different microbial back- grounds. In both, the final result is losing the tooth, affecting dentition, function, esthetic, self-esteem, quality of life, and, moreover, pain, systemic infection and/or inflammation, and psychologic and physiologic discomfort. However, both diseases are preventable, and the main causes for both are poor oral hygiene and smoking which are modifiable risk factors. Oral Diseases 4 Oral cleanliness, hence periodontal health, is crucial not only for maintaining the dentition but also general health, quality of life, and well-being for whole individuals [3–5]. Periodontal diseases are multifactorial in nature. While the etiology of periodontal diseases is basically associated with microbial biofilm; genetic, environmental such as smoking, alcohol consumption, unhealthy diet, stress, and immunological factors and systemic health have effects on the disease progression [6]. Current understanding is that the periodontal tissue destruction is mediated by host inflammatory mediators. Transition from gingivitis to peri - odontitis is still not known. 2. Prevention Self-performed and professionally administered mechanical plaque control and removal is the pillar in prevention of dental and periodontal diseases and maintain- ing overall oral health. Keeping plaque accumulation around 20% would result in good periodontal health [7]. There are three stages of preventing and controlling the periodontal disease [6]. Primary prevention implies preclinical and pre-pathological stages. The aim is to prevent the onset of the disease to maintain health. Secondary prevention indicates prevention at the early stages of the disease and restoring health. The aim is to stop and reverse the progression of the disease. And tertiary prevention refers to disease conditions. The aims are to limit the sequels and regain function. In addition, supportive periodontal therapy and periodontal maintenance are crucial to maintain the oral health and prevent the recurrence, since the major risk factor for periodontal diseases is to have had the disease before. Prevention and control of the dental and periodontal diseases rely on high standards of oral hygiene [8, 9]. Higher standards in oral hygiene can be achieved by education, teaching, motivation, risk assessment, needs-related oral hygiene instructions, and improving the individuals’ skills and attitudes towards their oral health [10]. The patient has to understand the disease and its etiology. On the other side, the clinician has to be aware that every patient is unique, needing different approaches for education and clinical implementation. Moreover, there is no consensus or standard on what the proper oral cleaning or hygiene is and what the frequency and the extent of the oral hygiene are. In every situation, today, patients have an active role on their own health and responsibility, and compliance is crucial. 3. Self-administered oral care The first step of self-administered oral care is to provide professional oral hygiene instruction. There are mechanical and chemical methods to reduce gingi- val inflammation by controlling the plaque biofilm. The European Federation of Periodontology recommends that “all people should brush their teeth twice a day for at least 2 min. with fluoridated dentifrice, and, periodontitis patients have to use inter-dental cleaning devices” [11]. Mechanical plaque removal may include manual or powered toothbrushes as well as interdental devices. The most common mechanical method for plaque removal is still manual toothbrushes [12]. A single, self-administered brushing with a toothbrush leads to reduction in plaque scores around 42% compared to pre- brushing scores [11]. Powered toothbrushes may increase plaque removal efficacy by 7–17% compared to manual brushes [2]. Toothbrushes do not reach the interden- tal areas [13]. 5 Interdental Brushes in Maintaining Periodontal Health DOI: http://dx.doi.org/10.5772/intechopen.91392 3.1 Interdental cleaning Interdental cleaning is essential and achieved by interdental cleaning tools such as dental floss, toothpicks (wood sticks), rubber-tip simulators, interdental brushes (IDB), single-tufted brushes, and electrically powered cleaning devices such as waterjet devices. While the adjunctive use of wood sticks, dental floss, or irrigators showed weak evidence for removal of plaque, IDB were found to be more effective than other interdental cleaning tools especially when the interdental space is not filled with gingiva [14]. Dental flossing may be a better choice for sites with intact interdental gingiva and healthy periodontium; however, self-administered flossing was found not very effective in removing interdental plaque. 3.1.1 Interdental brushes IDB were launched in the 1960s as an alternative to wood sticks [15]. The term of IDB was used for “brushes with helical alignment of ligaments fixed to a twisted stainless steel central wire” [14]. The quality of IDB is backed by the ISO 16409 standard [16]. In ISO 16409, manual IDB is defined as “hand-powered device composed of filaments that is single strand, attached to the stem, emanating radi- ally from a stem which is a central support structure of the manual IDB, usually of twisted wire, which secures the filaments, intended for cleaning of interdental surfaces.” They may be conical or cylindrical in shape, and usually widths of IDB are ranging from 1.9 to 14 mm [4]. The ISO brush size is determined by passage hole diameter which is a minimum diameter in mm of a hole through which a manual IDB can pass without deformation of the stem. Usually, IDB tend to bend, buckle, and distort [17]. The lengths of filaments and texture of IDB vary, and they may be cylindrical, conical, or in other shapes or have hard and soft filaments and are usually available in a sealed package ( Figure 1 ). Due to various interdental spaces and shapes, it is clear that various IDB shapes, sizes, and different angulations (angled or straight) are required ( Figures 2 – 6 ). As examples: • Figure 2 shows an IDB with micro ultrasoft brush-top with 1.80 mm diameter of bristle and 0.35 mm diameter of stem for narrow interdental spaces (ISO 0). • Figure 3 shows an IDB with extra ultrasoft brush-top with 2.00 mm diameter of bristle and 0.40 mm diameter of stem (ISO 1). • Figure 4 shows an IDB with super ultrasoft brush-top with 2.20 mm diameter of bristle and 0.45 mm diameter of stem. (ISO 2). • Figure 5 shows an IDB with conical ultrasoft brush-top with 2.50–4.50 mm diameter of bristle and 0.50 mm diameter of stem (ISO 3). • Figure 6 shows an IDB with middle optimized brush-top with 3.50 mm diameter of bristle and 0.60 mm diameter of stem (ISO 4). There is a relationship between position of the tooth and interdental spaces [18]. It would be logical to use dental floss in the anterior region since the inter- dental spaces are narrow. However, at the premolar and molar sites, interdental spaces are larger, and IDB may even reach to dental grooves and fissures. While the clinician is searching for the most appropriate size and shape of IDB, contour and Oral Diseases 6 consistency of interdental tissue, and shape, alignment, and position of tooth, the size and form of embrasure have to be considered. The most appropriate interdental devices or IDB may differ between patients. In young individuals, dental floss is Figure 1. A sealed package of IDB. Figure 2. ISO 0 micro IDB.