Journal of Indian Society of Periodontology
Journal of Indian Society of Periodontology
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   2017| July-August  | Volume 21 | Issue 4  
    Online since January 29, 2018

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Comparative evaluation of the efficacy of a herbal mouthwash and chlorhexidine mouthwash on select periodontal pathogens: An in vitro and ex vivo study
Multazim Muradkhan Pathan, Kishore Gajanan Bhat, Vinayak Mahableshwar Joshi
July-August 2017, 21(4):270-275
DOI:10.4103/jisp.jisp_382_16  PMID:29456300
Background: Several herbal mouthwash and herbal extracts have been tested in vitro and in vivo in search of a suitable adjunct to mechanical therapy for long-term use. In this study, we aimed to look at the antimicrobial effect of the herbal mouthwash and chlorhexidine (CHX) mouthwash on select organisms in in vitro test and an ex vivo model. Materials and Methods: The antimicrobial effects were determined against standard strains of bacteria that are involved in different stages of periodontal diseases. The in vitro tests included determination of minimum inhibitory concentration (MIC) using broth dilution and agar diffusion. In the ex vivo part of the study supragingival dental plaque were obtained from 20 periodontally healthy adult volunteers. Descriptive analysis was done for the entire quantitative and qualitative variable recorded. Results: The MIC by broth dilution method found no statistically significant difference between the mouthwashes. The agar dilution method showed CHX was more effective as compared to the herbal mouthwash against standard strains of Streptococcus mutans, Streptococcus sanguinis, and Aggregatibacter actinomycetemcomitans. However, no difference was observed between the mouthwashes for Porphyromonas, Pseudomonas aeruginosa, and Fusobacterium nucleatum. The ex vivo results conclude that none of the selected mouthwashes were statistically significantly different from each other. Conclusion: In the present study, CHX showed higher levels of antimicrobial action than the herbal mouthwash against bacterial species. The results reinforce the earlier findings that the in vitro testing is sensitive to methods and due diligence is needed when extrapolating the data for further use. However, long-term use and in vivo effectiveness against the periopathogens need to be tested in well-planned clinical trials.
  2,799 307 -
Applications of a modified palatal roll flap in peri-implant soft-tissue augmentation – A case series
Mihir Raghavendra Kulkarni, Purva Vijay Bakshi, Abhishek Somanath Kavlekar, Srinath Lakshman Thakur
July-August 2017, 21(4):333-336
DOI:10.4103/jisp.jisp_87_17  PMID:29456310
Abrams's palatal roll technique has been used extensively to augment peri-implant soft tissues in the maxillary esthetic zone and has seen numerous modifications. An adaptation of the palatal roll technique is described here and its simplicity of application in three different scenarios is demonstrated. At second-stage implant surgery, a partial thickness initial incision followed by a palatal subepithelial dissection at the site of implant was done and a connective tissue graft with a buccal pedicle was obtained. The graft was rolled under the buccal flap and allowed to heal with the support of a healing abutment. The graft healed uneventfully and provided excellent contours of tissues around the implant. The procedure demonstrated good results for augmentation of a buccal ridge deficiency, for covering exposed and unsightly implant fixtures and was also done with a papilla preservation incision. In addition, a second surgical site to obtain the connective tissue graft was avoided.
  2,719 297 -
Management of fenestration using bone allograft in conjunction with platelet-rich fibrin
Anuradha Bhatsange, Alkesh Shende, Sabina Deshmukh, Sharanabasappa Japatti
July-August 2017, 21(4):337-340
DOI:10.4103/jisp.jisp_101_17  PMID:29456311
Fenestration and dehiscence are said to be anatomical variations of cortical bone and not true pathological entities. They represent window-like defects covered by periosteum and overlying gingiva with or without the intact marginal bone. The etiology of such defects is still unclear, though many hypotheses such as occlusal traumatism, trauma, and variation in root bone angulation have been put forward. Diagnosis of such defects is challenging clinically, and they cannot be appreciated in conventional radiographs. In many instances, they are accidentally discovered during periodontal and oral surgical procedures. These defects, if not treated, can affect prognosis and complicate healing of the affected teeth. Treatment of such cortical bony defects is challenging and involves the use of potential regenerative materials to aid in regeneration. This case report describes the successful management of such a defect, discovered through exploratory flap approach, using PRF in conjunction with bone allograft.
  1,854 207 -
A clinicoradiographic assessment of 1% metformin gel with platelet-rich fibrin in the treatment of mandibular grade II furcation defects
Parul Sharma, Harpreet Singh Grover, Sujata Surendra Masamatti, Neha Saksena
July-August 2017, 21(4):303-308
DOI:10.4103/jisp.jisp_292_17  PMID:29456305
Background: Management of furcation defects is challenging, and constantly newer therapeutic strategies are evolving. Platelet-rich fibrin (PRF) is successfully used alone and in combination with various agents in the furcation defects. Lately, metformin (MF), a second generation biguanide has gained popularity owing to its osteogenic potential. Aims and Objectives: The aim of the present study was to evaluate the clinical and radiographic effectiveness of open flap debridement (OFD) and PRF when compared to OFD + PRF + 1% MF gel in the management of mandibular Grade II furcation defects. Materials and Methods: Thirty mandibular grade II furcation defects were stratified into two groups; in one group OFD and PRF is used, and the other group had an additional MF gel with PRF in OFD. Clinical parameters such as plaque index, modified sulcus bleeding index, probing pocket depth (PD), relative vertical attachment level (RVAL), and relative horizontal attachment level (RHAL) were recorded at baseline and at 6 months. Radiovisiography and ImageJ software were used to evaluate the intrabony defect depth. Results: The OFD + PRF + MF group showed significantly higher probing PD reduction, RVAL and RHAL gain than the OFD + PRF group. Conclusions: PRF when combined with a potential osteogenic agent like MF can provide a better therapeutic benefit to a furcation involved tooth.
  1,791 231 -
Atomic force microscopy: A three-dimensional reconstructive tool of oral microbiota in gingivitis and periodontitis
Shyam Sunder Salavadhi, Srikanth Chintalapani, Radhika Ramachandran, Kirankumar Nagubandi, Arpita Ramisetti, Ramanarayana Boyapati
July-August 2017, 21(4):264-269
DOI:10.4103/jisp.jisp_209_17  PMID:29456299
Aim: This study aims to ascertain the advantages of Atomic Force Microscopy (AFM) in the morphologic study of microorganisms and their interactions within the subgingival biofilm in patients with gingivitis and periodontitis. Settings and Design: Conducted a study on twenty patients, ten patients with severe periodontitis with probing the pocket depth of ≥8 mm, with a clinical attachment loss (CAL) of ≥6 mm CAL and ten patients with gingivitis: ≥5 mm pocket depth, and no attachment loss, was selected for the study. Materials and Methods: Bacterial biofilms were collected and slide preparation done. Morphological study was done using AFM. AFM consists of a cantilever-mounted tip, a piezoelectric scanner, a photodetector diode, a laser diode, and a feedback control. The laser beam is reflected from back of the cantilever into the quadrant of the photodetector. AFM works on the principle of interaction between the tip and the sample which causes the cantilever to deflect, thereby changing the position of laser onto the photodetector. Methodology used for studying the bacteria through AFM includes the following: (1) Probe type: Platinum coated silicon nitrate tip. (2) Probe force: 0.11 N/m. (3) Probe geometry: Triangular shaped tip. (4) Probe frequency: 22 KHz. (5) Probe immobilization: Used in Contact mode. AFM Solver Pro-M (NT-MDT) equipped with ETALON probe was used to take images in Nova software. Results: The investigation showed various morphological features, such as shape, size, and secretory product-like vesicles of the bacterial species involved in gingivitis and periodontitis. More bacterial surface details were studied by reproducing a three-dimensional reconstruction using AFM. Conclusions: The morphological variations of bacteria of different sizes, and shapes, cell wall structures, secretory product-like vesicles flagellated and filamentous microorganisms, polymorphonuclear leukocytes, and bacterial coaggregation analysis were done by AFM. Results of the present study conclude that AFM is a quite a reliable method for studying morphology of bacterial species involving periodontal diseases and is also used to study microbial interactions in biofilm.
  1,537 135 -
Awareness, knowledge, and attitude of patients toward dental implants – A questionnaire-based prospective study
Rajesh Hosadurga, Tenneti Shanti, Shashikanth Hegde, Rajesh Shankar Kashyap, Suryanarayan Maiya Arunkumar
July-August 2017, 21(4):315-325
DOI:10.4103/jisp.jisp_139_17  PMID:29456307
Background: In developing nations like India awareness and education about dental implants as a treatment modality is still scanty. Aim: The study was conducted to determine the awareness, knowledge, and attitude of patients toward dental implants as a treatment modality among the general population and to assess the influence of personality characteristics on accepting dental implants as a treatment modality in general and as well as treatment group. Materials and Methods: A structured questionnaire-based survey was conducted on 500 randomly selected participants attending the outpatient department. The study was conducted in 2 parts. In the first part of the study, level of awareness, knowledge, and attitude was assessed. In the second part of the study, interactive educational sessions using audiovisual aids were conducted following which a retest was conducted. The participants who agreed to undergo implant treatment were followed up to assess their change in attitude towards dental implants posttreatment. Thus pain, anxiety, functional, and esthetic benefits were measured using visual analog scale. They were further followed up for 1 year to reassess awareness, knowledge, and attitude towards dental implants. Results: A total of 450 individuals completed the questionnaires. Only 106 individuals agreed to participate in the educational sessions and 83 individuals took the retest. Out of these, only 39 individuals chose implants as a treatment option. A significant improvement in the level of information, subjective and objective need for information, was noted after 1 year. Conclusion: In this study, a severe deficit in level of information, subjective and objective need for information towards, dental implants as a treatment modality was noted. In the treatment group, a significant improvement in perception of dental implant as a treatment modality suggests that professionally imparted knowledge can bring about a change in the attitude.
  1,475 171 -
Effect of supragingival oral irrigation as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients
Manish Khatri, Aamir Shams Malik, Mansi Bansal, Komal Puri, Geeti Gupta, Ashish Kumar
July-August 2017, 21(4):296-302
DOI:10.4103/jisp.jisp_393_15  PMID:29456304
Aim: The aim of this study was to evaluate the efficacy of supragingival oral irrigation either with water or different concentrations of chlorhexidine (CHX) digluconate as an adjunct to toothbrushing on plaque accumulation in chronic generalized gingivitis patients. Materials and Methods: Fifty patients were randomly allocated into five groups. Group 1: toothbrushing alone, Group 2: toothbrushing with mouthwash, Group 3: toothbrushing with water irrigation, Group 4: toothbrushing with 0.0075% CHX digluconate (36 mg) supragingival irrigation, and Group 5: toothbrushing with 0.02% CHX digluconate (96 mg) supragingival irrigation. The collected data were subjected to statistical analysis. Statistical Analysis: Descriptive data were obtained for all outcome variables and reported as mean ± standard deviation. The Student's t-test, Chi-square test, and one-way analysis of variance (ANOVA) were applied for the statistical evaluation of means and comparisons of proportions, and post hoc Bonferroni test was used for multiple comparisons after the application of the ANOVA test for comparison within the groups. Results: When intergroup difference of the mean differences was compared for individuals using toothbrushing along with 0.0075% CHX digluconate irrigation and those using toothbrushing along with 0.02% CHX digluconate irrigation from BL-14, BL-28, and between 14 and 28 days, it was found to be statistically nonsignificant. Conclusions: In our study, the CHX digluconate concentration for mouthwash and oral irrigation in addition with toothbrushing was found to be same, i.e., <50 mg for improving the gingival health by reducing gingival inflammation.
  1,479 165 -
Impact of mandibular third molar extraction in the second molar periodontal status: A prospective study
Paulo Eduardo Melo Stella, Saulo Gabriel Moreira Falci, Lorrayne Estéfane Oliveira de Medeiros, Dhelfeson Willya Douglas-de-Oliveira, Patricia Furtado Gonçalves, Olga Dumont Flecha, Cássio Roberto Rocha Dos Santos
July-August 2017, 21(4):285-290
DOI:10.4103/jisp.jisp_79_17  PMID:29456302
Aim: The aim of the present study was to assess the periodontal condition and sensitivity of second mandibular molars after the extraction of the adjacent third molar, while also assessing the quality of life of the patients. Materials and Methods: Twenty-three healthy patients were assessed in terms of probing depth, gingival height, gingival thickness, dental sensitivity, plaque index and bleeding on probing (adjacent second mandibular molar), before the surgical procedure, as well as 60 and 180 days after the surgery. The following data were also recorded and measured: the position and size of the impacted teeth; the size of the alveoli after surgery and the quality of life of the patient. Results: Significant differences were found for probing depth and gingival height before and after 180 days. The plaque index increased significantly after surgery (P = 0.004), as did bleeding on probing. No significant difference was found for the quality of life. The size of the third molar extracted was correlated with bleeding on probing 180 days after the surgery. Conclusion: An improvement was noted in the periodontal condition of the second mandibular molars after the extraction, based on the assessments of probing depth and gingival height. The position of the third molar affected the periodontal condition of the second mandibular molar. No alterations were recorded for dental sensitivity or the quality of life after the extraction.
  1,453 159 -
Chronic periodontitis among diabetics and nondiabetics aged 35–65 years, in a rural block in Vellore, Tamil Nadu: A cross-sectional study
Khushboo Yamima Nand, Anu Mary Oommen, Rabin Kurudamannil Chacko, Vinod Joseph Abraham
July-August 2017, 21(4):309-314
DOI:10.4103/jisp.jisp_217_17  PMID:29456306
Background: Chronic periodontitis is a common cause of poor oral health globally. Those at higher risk of this preventable and easily treatable condition need to be identified so that efforts can be taken to decrease disease burden and subsequent consequences. Aims: The aims of the study were (1) To compare the prevalence of chronic periodontitis among individuals with and without type 2 diabetes, aged 35–65 years from a rural block in Vellore, Tamil Nadu and (2) to assess risk factors for chronic periodontitis among individuals with diabetes. Settings and Design: A cross-sectional study was done in nine villages of Kaniyambadi block, Vellore, between October 2015 and July 2016 among participants aged 35–65 years of a previous cross-sectional survey which had identified individuals with and without type 2 diabetes. Materials and Methods: Chronic periodontitis was assessed using the Community Periodontal Index and Treatment Needs index. Oral hygiene was assessed clinically using the Simplified Oral Hygiene Index. Diabetes was defined as on medication for type 2 diabetes or detected to have fasting blood glucose ≥126 mg/dl (in a previous survey). Statistical Analysis: Chi-square test and odds ratios (adjusted using logistic regression) were used to study risk factors for periodontitis among those with diabetes. Results: Prevalence of chronic periodontitis was 45.9% (95% confidence interval [CI]: 40.88%–50.9%) among 98 individuals with diabetes and 35.6% (95% CI: 30.91–40.29%) among 104 individuals without diabetes. Poor oral hygiene (odds ratio: 8.33, 95% CI: 3.33–25.00), low socioeconomic status (odds ratio: 3.19, 95% CI: 1.00–10.12), and smoking (odds ratio: 3.51, 95% CI: 1.17–10.51) were associated with periodontitis among diabetics. Conclusions: Individuals with type 2 diabetes have a higher prevalence of periodontitis. As poor oral hygiene is a strong risk factor for periodontitis, there is a need for targeted education regarding dental hygiene to reduce this preventable condition.
  1,449 127 -
Reactive lesions of oral cavity: A retrospective study of 659 cases
Biji Babu, Kaveri Hallikeri
July-August 2017, 21(4):258-263
DOI:10.4103/jisp.jisp_103_17  PMID:29456298
Objective: This study reviews, analyzes, and compares the demographic data, histopathological features and discusses the treatment and prognosis of reactive lesions (RLs). Materials and Methods: Retrospective study was performed on the departmental archives from July 2006 to July 2016 (total 5000 cases) comprising of 659 cases of RLs of the oral cavity. The recorded data included age, gender, size, site, duration, habits, etiology, histopathological diagnosis, treatment, and prognosis. Results: The most common lesion was found to be inflammatory fibrous hyperplasia (47%) followed by pyogenic granuloma (PG) (27.16%) and the least cases were of peripheral giant cell granuloma (1.6%). The mean age for the occurrence was 4th–5th decade in all the RL's exceptperipheral ossifying fibroma (POF) which presented in the third decade. Female predominance was noted in all lesions except irritational FIB. The sizes of majority of the lesions were approximately 0.5–1 cm. The common sites were anterior maxilla followed by posterior mandible and least in tongue with no associated habits (82.2%). The duration of all the lesions was seen to be <1 year. Majority of them presented with poor oral hygiene status (87.2%). Recurrences were present in 13.5% of surgically excised lesions. Conclusion: The RLs present commonly in oral cavity secondary to injury and local factors which can mimic benign to rarely malignant lesions. The clinical and histopathological examination helps to categorize the type of lesions. The complete removal of local irritants with follow-up and maintenance of oral hygiene helps to prevent the recurrences of such lesions.
  1,333 231 -
Long-term effect of Lactobacillus brevis CD2 (Inersan®) and/or doxycycline in aggressive periodontitis
Mishal Piyush Shah, Sheela Kumar Gujjari, Veerendrakumar Siddhpur Chandrasekhar
July-August 2017, 21(4):341-343
DOI:10.4103/jisp.jisp_215_17  PMID:29456312
Context: The over usage and broad use of antibiotics resulted in the emergence of resistant microorganisms to the drugs which also disturb the indigenous microflora, which include the Lactobacillus in the oral cavity. Hence, it is preferred to avoid the use of antibiotics. Aims: The hypothesis tested in this study was that 14 days of treatment with Lactobacillus brevis CD2 lozenges, L. brevis CD2 with oral doxycycline, or doxycycline alone would have a beneficial effect on periodontal health after 5 months. Settings and Design: It was a randomized clinical trial. Materials and Methods: Eighteen nonsmoking patients aged 14–35 years, with aggressive periodontitis, were randomized to receive 14 days of treatment with L. brevis CD2 lozenges (two lozenges daily), L. brevis CD2 lozenges with oral doxycycline (100 mg tablet once daily), or doxycycline alone. Saliva samples were taken on day 0, 2 weeks, 2 months, and 5 months. Clinical parameters (plaque index, gingival index, probing pocket depth, and clinical attachment level) and microbiological parameters (lactobacilli and Aggregatibacter actinomycetemcomitans) were evaluated. Statistical Analysis Used: Changes between groups were evaluated using repeated measure analysis of variance. Results: All clinical parameters shown to be numerically improved at 5 months when compared with baseline in all the three groups. The improvement (P < 0.01) in gingival index was statistically significant, and the intergroup results were also statistically significant (P < 0.01). Conclusions: Fourteen days of treatment with lozenges having L. brevis CD2 have a lasting effect on clinical measures of aggressive periodontitis, particularly gingival index. This effect appears to be equivalent to that produced by doxycycline.
  1,435 121 -
Impact of nonsurgical periodontal therapy on total antioxidant capacity in chronic periodontitis patients
Neha Bansal, Narender Dev Gupta, Afshan Bey, Vivek Kumar Sharma, Namita Gupta, Himanshu Trivedi
July-August 2017, 21(4):291-295
DOI:10.4103/jisp.jisp_281_15  PMID:29456303
Aim: The aim of this study was to determine the utility of plasma total antioxidant capacity (TAC) as marker of periodontal disease by estimating TAC of periodontally healthy and chronic periodontitis patients and the impact of scaling and root planning on total antioxidant status of periodontitis patients. Materials and Methods: Blood plasma samples were collected from randomly selected eighty individuals (40 periodontally healthy controls and 40 chronic periodontitis patients), with an age range of 20–45 years and were analyzed for TAC by ferric reducing antioxidant power assay. Scaling and root planing was performed in periodontitis patients, and TAC level was measured again after 3 weeks. Data were analyzed with t-test, using SPSS software (PSAW, Windows version 18.0). Results: The mean plasma TAC was significantly lower (792.33 ± 124.33 μmol/L, P < 0.001) in chronic periodontitis patients compared to healthy control (1076.08 ± 193.82 μmol/L). Plasma TAC level increased significantly (989.75 ± 96.80, P < 0.001) after scaling and root planing. Conclusions: An inverse relationship exists between plasma TAC and severity of chronic periodontitis suggesting disturbed oxidant-antioxidant balance in chronic periodontitis. Scaling and root planing resulted in the restoration of TAC to normal levels. These results are important from the perspective of including antioxidants in periodontal therapy regime to boost up body's antioxidant defense system and to reduce oxidative stress-mediated periodontal tissue damage. We concluded that TAC can be used as a biomarker to evaluate the health of periodontium.
  1,336 161 -
Gingival enlargement unveiling crohn's disease – A report of a rarefied case
Krishnamurthi Malathi, Arunachalam Muthukumaraswamy, MariaAntony PremBlaisie Rajula, Singh Arjun
July-August 2017, 21(4):326-328
DOI:10.4103/jisp.jisp_417_14  PMID:29456308
This article highlights a peculiar case of Crohn's disease (CD) with the primary presenting symptom as localized gingival overgrowth in the anterior region of maxilla. The patient underwent surgical treatment with external bevel gingivectomy procedure. Follow-up after 6 months revealed no recurrence. A final diagnosis of CD was made, after following histopathological evaluation of the gingival biopsy and other special investigations. It is thus crucial to associate the localized granulomatous gingival overgrowth to systemic signs of CD. Intraoral occurrence preceding intestinal involvement is very rare in CD with an incidence of about 8%–9% of patients. Therefore, precise diagnosis, treatment planning, and timely management are vital to the overall health and welfare of patients.
  1,322 107 -
Idiopathic peripheral ossifying fibroma in a young adolescent girl: A very rare clinical presentation
Shaik Hasanuddin, Yempati Malleshwar
July-August 2017, 21(4):329-332
DOI:10.4103/jisp.jisp_125_17  PMID:29456309
The use of the term “fibroma” for any soft-tissue lesion or gingival lesion by general practitioners has led to inadequate diagnosis of quite a few rare entities. The occurrence of gingival lesions in adolescent female patients is a routine clinical finding. The site of occurrence of such a lesion is of prime significance, as the rarity of these lesions is determined by the site and size of the lesion. On the other hand, the dilemma over the diagnosis of peripheral ossifying fibroma (POF) versus peripheral odontogenic fibroma still continues. Commonly used synonyms for POF include calcifying fibroblastic granuloma, peripheral fibroma with calcification, peripheral cementifying fibroma, and calcifying or ossifying fibrous epulis. The present case report deals with the management of a unique case of POF between two maxillary central incisors in an adolescent female child patient, followed up to 2-year postsurgical excision.
  1,282 129 -
Correlative analysis of plasma and urine neopterin levels in the pre- and post-menopausal women with periodontitis, following nonsurgical periodontal therapy
Jammula Surya Prasanna, Chinta Sumadhura, Parupalli Karunakar, Koduganti Rekharani, Gireddy Himabindu, Ambati Manasa
July-August 2017, 21(4):276-284
DOI:10.4103/jisp.jisp_278_17  PMID:29456301
Context: Periodontitis is an inflammatory condition which is distinguished by the devastation of the supported tooth structures. In such inflammatory conditions, some biomarkers such as neopterin will be secreted and elevated in the body fluids, which can be used as a diagnostic marker for the present and future disease activity. Aims: Assessment of the neopterin as a biomarker in inflammatory conditions such as menopause and periodontitis. Settings and Design: A cross-sectional interventional study. Materials and Methods: Sixty female individuals with a mean age of 40–60 years with chronic periodontitis were included in this study. All were categorized into two groups of thirty each, depending on their menstrual history: Group I – thirty premenopausal women and Group II – thirty postmenopausal women. Urine and plasma were collected from both groups to estimate neopterin levels. ELISA kit was used to assess the neopterin levels at baseline and after 3 months of nonsurgical periodontal therapy (NSPT). Statistical Analysis Used: IBM SPSS version 21 software. Results: A significant depreciation in the mean values of all the parameters from baseline to 3 months (P < 0.001), in the intragroup analysis, was observed. Plasma (0.006) and urine (0.004) reduction was seen. Conclusions: In both the groups, in 3 months after NSPT, decreased neopterin levels were found, suggesting that the NSPT is the definitive therapy. Further, suggesting that, neopterin levels in the plasma and urine can be used as an index to identify the periodontal inflammation and destruction.
  1,163 88 -
Back to basics…
Ashish Kumar
July-August 2017, 21(4):253-254
DOI:10.4103/jisp.jisp_42_18  PMID:29456296
  627 59 -
You are always a student, never a master: Keep moving forward
Avani Raju Pradeep
July-August 2017, 21(4):255-255
  526 58 -
Double pronged strategy with incremental efforts in generating awareness on oral hygiene day
Abhay Kolte
July-August 2017, 21(4):256-257
DOI:10.4103/jisp.jisp_31_18  PMID:29456297
  537 40 -