**4.2 Corticosteroids**

Corticosteroids are widely used for the management of numerous oral inflammatory conditions due to their anti-inflammatory and immune modulatory effects. They could be delivered either intramucosally (within the lesion), topically, or systemically [20].

Intralesional (intradermal) corticosteroid injection is a favorite method in delivering the drug directly to the target site resulting in rapid action as well as less systemic complications. Injectable steroids are clear fluids; their color and dose depend on the formulation of steroids used. It is commonly used in managing the longstanding oral lichen planus lesions and oral submucous fibrosis, but it has a localized side effect such as mucosal atrophy [21, 22]. Hydrocortisone and triamcinolone are the commonest formulas used in local delivery with weekly injections reaching up to 11 injections [22, 23].

Although surgical excision is considered the gold standard technique for treating mucocele and orofacial granulomatosis, the use of intralesional corticosteroid injection was also reported. However, some investigators have suggested that the intralesional corticosteroid could be used as a new modality in the treatment, but cases of relapse with corticosteroid have been reported [24, 25]. Great differences were detected in the used doses and the number of sessions according to the severity, extension, and the systemic condition of the patient [22, 23, 26–28].

#### **4.3 Vitamins**

According to literature, vitamins were usually introduced either by intraligamentary or intraepidermic techniques. The intraepidermic technique was conducted in 2016 by Yussif et al. [29].

#### *4.3.1 Vitamin D*

Although vitamin D has a great role in maintaining the bone health and metabolism, it is just recently discovered that vitamin D deficiency has a great role in the occurrence and progression of various periodontal diseases. It is a steroid hormone that controls the bone metabolism and calcium homeostasis [30–32].

**73**

**Figure 3.**

*Vitamin D injection and periodontitis [37].*

*Oral Mesotherapy: Might Be Considered as An Adjunctive Technique for the Different Surgical…*

It was detected that the level of vitamin D reaches its lowest levels during periodontal disease especially aggressive periodontitis. The daily supplementation is

The introduction of locally delivered vitamin D injections provides short treatment visits, non-traumatic, less patient morbidity, non-stressful procedure with no post-operative side effects. The procedure is not painful. There is also no need for preoperative local anesthesia. It could be either delivered alone [34] or in combination with calcium [35]. The promising improvement of the regenerative power was attributed to minimal trauma and preserving the periosteum adapted over the alveolar bone. Great reduction of the clinical attachment loss and the absence of bleeding on probing were also detected indicating the absence of inflammation. On the radiographic examination, improvement of the alveolar bone density as well as

In orthodontic therapy, locally delivered vitamin D is commonly introduced in small doses using periodontal injection technique in order to accelerate the osteoclastic activity in the pressure site which in role accelerates the orthodontic movement. The dose and the number of the treatment sessions are determined according

Ascorbic acid is also an essential vitamin in the treatment of periodontal diseases. Its deficiency causes impaired wound healing with higher bleeding index. Lower levels of serum vitamin C were reported in periodontitis. The importance of vitamin C lies behind its powerful scavenging and antioxidant effect as it usually

*DOI: http://dx.doi.org/10.5772/intechopen.88355*

important to maintain the periodontal health [30–33].

accentuation of lamina dura was also reported [34, 35].

*4.3.2 Vitamin C*

to the distance that the tooth needed to travel [34, 36] (**Figure 3**).

*Oral Mesotherapy: Might Be Considered as An Adjunctive Technique for the Different Surgical… DOI: http://dx.doi.org/10.5772/intechopen.88355*

It was detected that the level of vitamin D reaches its lowest levels during periodontal disease especially aggressive periodontitis. The daily supplementation is important to maintain the periodontal health [30–33].

The introduction of locally delivered vitamin D injections provides short treatment visits, non-traumatic, less patient morbidity, non-stressful procedure with no post-operative side effects. The procedure is not painful. There is also no need for preoperative local anesthesia. It could be either delivered alone [34] or in combination with calcium [35]. The promising improvement of the regenerative power was attributed to minimal trauma and preserving the periosteum adapted over the alveolar bone. Great reduction of the clinical attachment loss and the absence of bleeding on probing were also detected indicating the absence of inflammation. On the radiographic examination, improvement of the alveolar bone density as well as accentuation of lamina dura was also reported [34, 35].

In orthodontic therapy, locally delivered vitamin D is commonly introduced in small doses using periodontal injection technique in order to accelerate the osteoclastic activity in the pressure site which in role accelerates the orthodontic movement. The dose and the number of the treatment sessions are determined according to the distance that the tooth needed to travel [34, 36] (**Figure 3**).

## *4.3.2 Vitamin C*

*Periodontal Disease - Diagnostic and Adjunctive Non-surgical Considerations*

Despite its rapid onset, effectiveness, and safeness, its action has shorter duration than other techniques [18]. Finally, the intraosseous technique provides rapid introduction, which is commonly used following failure of the field or nerve block technique. It depends on the direct introduction of the anesthetic agent to the interdental bone resulting in rapid delivery of the anesthetic agent to the blood circulation which should be avoided in cardiovascular patients [19] (**Figure 2**).

Corticosteroids are widely used for the management of numerous oral inflammatory conditions due to their anti-inflammatory and immune modulatory effects. They could be delivered either intramucosally (within the lesion), topically, or

Intralesional (intradermal) corticosteroid injection is a favorite method in delivering the drug directly to the target site resulting in rapid action as well as less systemic complications. Injectable steroids are clear fluids; their color and dose depend on the formulation of steroids used. It is commonly used in managing the longstanding oral lichen planus lesions and oral submucous fibrosis, but it has a localized side effect such as mucosal atrophy [21, 22]. Hydrocortisone and triamcinolone are the commonest formulas used in local delivery with weekly injections

Although surgical excision is considered the gold standard technique for treating mucocele and orofacial granulomatosis, the use of intralesional corticosteroid injection was also reported. However, some investigators have suggested that the intralesional corticosteroid could be used as a new modality in the treatment, but cases of relapse with corticosteroid have been reported [24, 25]. Great differences were detected in the used doses and the number of sessions according to the sever-

According to literature, vitamins were usually introduced either by intraligamentary or intraepidermic techniques. The intraepidermic technique was con-

Although vitamin D has a great role in maintaining the bone health and metabolism, it is just recently discovered that vitamin D deficiency has a great role in the occurrence and progression of various periodontal diseases. It is a steroid hormone

ity, extension, and the systemic condition of the patient [22, 23, 26–28].

that controls the bone metabolism and calcium homeostasis [30–32].

**72**

**4.2 Corticosteroids**

**Figure 2.**

systemically [20].

**4.3 Vitamins**

*4.3.1 Vitamin D*

reaching up to 11 injections [22, 23].

*Corticosteroids and chronic gingival inflammation.*

ducted in 2016 by Yussif et al. [29].

Ascorbic acid is also an essential vitamin in the treatment of periodontal diseases. Its deficiency causes impaired wound healing with higher bleeding index. Lower levels of serum vitamin C were reported in periodontitis. The importance of vitamin C lies behind its powerful scavenging and antioxidant effect as it usually

**Figure 3.** *Vitamin D injection and periodontitis [37].*

accumulates in the immune cells as PMNs and macrophages and significantly enhances chemotaxis, phagocytic, opsonization, degranulation, and killing functions of immune cells [33, 38]. It also has a great role in collagen biosynthesis [39]. It could be supplied orally, topically, or by intraepidermal injection [37, 40]. Vitamin C is widely used in dermal mesotherapy as it restores the tissue integrity and brightness by neutralizing the free radicals in the newly formed tissues, stimulates the collagen formation, and inhibits melanogenesis [10, 41].

Growing evidence has suggested the role of vitamin C in enhancing the quality and outcome of the orthodontic treatment. This is proven when tooth movement was enhanced following systemic administration of vitamin C for 17 days [42, 43]. It was also noticed that its deficiency is accompanied with limited tooth movement and arrested osteogenesis [44].

Vitamin C induces its action through modifying the osteoclastic activity, osteogenesis, tissue healing, and periodontal ligament organization. It increases the collagen I synthesis that represents the main component of bone matrix and periodontal ligament [45]. It also accelerates the bone mineralization, calcium absorption, formation of collagen type X, expression of alkaline phosphatase, and osteoblast growth and differentiation [46, 47] (**Figure 4**).

Furthermore, the depigmenting effect of vitamin C depends mainly on its antioxidant property. The efficiency of vitamin C in the treatment of physiologic or pathologic dermal problems such as hyperpigmentation, aging, and dryness was promising due to several factors that are not only related to its direct interaction with melanin and melanocytes but also due to the overall effect on the applied tissues. Once vitamin C is introduced to the target tissue, it binds efficiently to melanin because melanin is the main store of ROS, calcium, and copper content that causes intracellular deficiency of these items. Lower intracellular calcium level causes failure of melanocytes to perform cellular adhesion as calcium is essential to form cadherins [48, 49]. The contact to keratinocytes is important simulator to

**75**

**Figure 5.**

*hyperpigmentation [29].*

modality.

dose efficiently [54] (**Figure 7**).

ranging between 0.5 and 1 mm [29].

*Oral Mesotherapy: Might Be Considered as An Adjunctive Technique for the Different Surgical…*

melanocytes to produce melanin, formation of dendrites and transfer the produced melanin to neighboring cells [48, 50]. Also, shortage of the intercellular copper limits the formation of tyrosine, tyrosinase enzyme, and peroxidase enzyme which

Pain and itching were regarded as painful stimuli. Itching may transit to pain due to increased discharge frequency of nociceptors (intensity theory) [51] (**Figure 5**). In 2016, Yussif et al. used the intraepidermic injection technique (oral mesotherapy technique) in order to treat physiological hyperpigmentation. Vitamin C injection is a safe, minimally invasive nonsurgical depigmenting technique which also improves health of gingival tissues. They concluded that the direct effect of vitamin C could be due to the affinity of melanin to react with it, which in turn affects the cellular junctions (causing the immediate fainting) and forces such cells to spell out their contents of melanin leading to tissue darkening after a while. Further investigations and studies are recommended to detect its long-

During persistent gingival inflammation, Yussif et al. [45] have reported significant enhancement of the gingival health by the usage of the intraepidermic vitamin C injection as an adjunctive approach for the conventional nonsurgical treatment

During inflammation, it was found that the tissue antioxidant level (as vitamin C, vitamin E, etc.) decreases rapidly indicating the need of its supplementation. On the other hand, the free radical production increases at the site of inflammation [52, 53]. Extra doses of antioxidants especially vitamin C are essential. In localized inflammatory conditions, the administration of the needed higher doses via systemic route (higher than 500 mg) cannot be absorbed by the gastrointestinal tract, which is easily excreted through urine. Moreover, in order to reach this dose at the site of inflammation, it needs administration of very high systemic doses that could be harmful to the patient. The local injection provides the needed

In 2014, [55] reported that the switch of the gingival tissue to the thick biotype is important to gingival and periodontal health as well as esthetic outcome. Ascorbic acid enhances the periodontal ligament maturation and renewal by induction of the collagen formation especially collagen III (young collagen) and keeps the balance between collagen I (mature collagen) and III for tissue maturation. It also modifies the rate of fibroblast proliferation [56]. In 2016, Yussif et al. reported the improvement of the gingival biotype following the intraepidermic vitamin C injection

*Pre- and postoperative histopathological photos of local vitamin C injection in treatment of gingival* 

term effect on the melanocytes and keratinocytes [29] (**Figure 6**).

*DOI: http://dx.doi.org/10.5772/intechopen.88355*

in turn stops the melanin production [41].

**Figure 4.** *Pre- and postoperative local vitamin C injection in impacted canine traction [37].*

*Oral Mesotherapy: Might Be Considered as An Adjunctive Technique for the Different Surgical… DOI: http://dx.doi.org/10.5772/intechopen.88355*

melanocytes to produce melanin, formation of dendrites and transfer the produced melanin to neighboring cells [48, 50]. Also, shortage of the intercellular copper limits the formation of tyrosine, tyrosinase enzyme, and peroxidase enzyme which in turn stops the melanin production [41].

Pain and itching were regarded as painful stimuli. Itching may transit to pain due to increased discharge frequency of nociceptors (intensity theory) [51] (**Figure 5**).

In 2016, Yussif et al. used the intraepidermic injection technique (oral mesotherapy technique) in order to treat physiological hyperpigmentation. Vitamin C injection is a safe, minimally invasive nonsurgical depigmenting technique which also improves health of gingival tissues. They concluded that the direct effect of vitamin C could be due to the affinity of melanin to react with it, which in turn affects the cellular junctions (causing the immediate fainting) and forces such cells to spell out their contents of melanin leading to tissue darkening after a while. Further investigations and studies are recommended to detect its longterm effect on the melanocytes and keratinocytes [29] (**Figure 6**).

During persistent gingival inflammation, Yussif et al. [45] have reported significant enhancement of the gingival health by the usage of the intraepidermic vitamin C injection as an adjunctive approach for the conventional nonsurgical treatment modality.

During inflammation, it was found that the tissue antioxidant level (as vitamin C, vitamin E, etc.) decreases rapidly indicating the need of its supplementation. On the other hand, the free radical production increases at the site of inflammation [52, 53]. Extra doses of antioxidants especially vitamin C are essential. In localized inflammatory conditions, the administration of the needed higher doses via systemic route (higher than 500 mg) cannot be absorbed by the gastrointestinal tract, which is easily excreted through urine. Moreover, in order to reach this dose at the site of inflammation, it needs administration of very high systemic doses that could be harmful to the patient. The local injection provides the needed dose efficiently [54] (**Figure 7**).

In 2014, [55] reported that the switch of the gingival tissue to the thick biotype is important to gingival and periodontal health as well as esthetic outcome. Ascorbic acid enhances the periodontal ligament maturation and renewal by induction of the collagen formation especially collagen III (young collagen) and keeps the balance between collagen I (mature collagen) and III for tissue maturation. It also modifies the rate of fibroblast proliferation [56]. In 2016, Yussif et al. reported the improvement of the gingival biotype following the intraepidermic vitamin C injection ranging between 0.5 and 1 mm [29].

#### **Figure 5.**

*Pre- and postoperative histopathological photos of local vitamin C injection in treatment of gingival hyperpigmentation [29].*

*Periodontal Disease - Diagnostic and Adjunctive Non-surgical Considerations*

collagen formation, and inhibits melanogenesis [10, 41].

osteoblast growth and differentiation [46, 47] (**Figure 4**).

*Pre- and postoperative local vitamin C injection in impacted canine traction [37].*

and arrested osteogenesis [44].

accumulates in the immune cells as PMNs and macrophages and significantly enhances chemotaxis, phagocytic, opsonization, degranulation, and killing functions of immune cells [33, 38]. It also has a great role in collagen biosynthesis [39]. It could be supplied orally, topically, or by intraepidermal injection [37, 40]. Vitamin C is widely used in dermal mesotherapy as it restores the tissue integrity and brightness by neutralizing the free radicals in the newly formed tissues, stimulates the

Growing evidence has suggested the role of vitamin C in enhancing the quality and outcome of the orthodontic treatment. This is proven when tooth movement was enhanced following systemic administration of vitamin C for 17 days [42, 43]. It was also noticed that its deficiency is accompanied with limited tooth movement

Vitamin C induces its action through modifying the osteoclastic activity, osteogenesis, tissue healing, and periodontal ligament organization. It increases the collagen I synthesis that represents the main component of bone matrix and periodontal ligament [45]. It also accelerates the bone mineralization, calcium absorption, formation of collagen type X, expression of alkaline phosphatase, and

Furthermore, the depigmenting effect of vitamin C depends mainly on its antioxidant property. The efficiency of vitamin C in the treatment of physiologic or pathologic dermal problems such as hyperpigmentation, aging, and dryness was promising due to several factors that are not only related to its direct interaction with melanin and melanocytes but also due to the overall effect on the applied tissues. Once vitamin C is introduced to the target tissue, it binds efficiently to melanin because melanin is the main store of ROS, calcium, and copper content that causes intracellular deficiency of these items. Lower intracellular calcium level causes failure of melanocytes to perform cellular adhesion as calcium is essential to form cadherins [48, 49]. The contact to keratinocytes is important simulator to

**74**

**Figure 4.**

#### **Figure 6.**

*Pre- and postoperative local vitamin C injection in physiologic gingival hyperpigmentation [29].*

**Figure 7.** *Pre- and postoperative local vitamin C injection in gingival inflammation [45].*
