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Reference Mannualon
Oral Healthfor
Allopathic and AYUSH Practitioners
Developed underGOI-WHO Collaborative Programme
(Biennium 10-11)
CENTRE FOR DENTAL EDUCATION & RESEARCHAll India Institute of Medical Sciences, New Delhi
Reference Mannualon
Oral Healthfor
Allopathic and AYUSH Practitioners
Developed underGOI-WHO Collaborative Programme
(Biennium 10-11)
CENTRE FOR DENTAL EDUCATION & RESEARCHAll India Institute of Medical Sciences, New Delhi
Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
CENTRE FOR DENTAL EDUCATION & RESEARCHAll India Institute of Medical Sciences, New Delhi
Research Team
Principal Investigator : Prof. Naseem ShahChiefProfessor & HeadConservative Dentistry & Endodontics
Co-Investigators : Dr. Vijay Prakash MathurAssociate ProfessorPedodontics & Preventive DentistryDr. Ajay LoganiAssociate ProfessorConservative Dentistry & Endodontics
Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
CONTENTS
?Preface 1
?Introduction 3
?Why Oral Health is Important? 5
?General Anatomy & Functions of Teeth 6
?Dental Caries 8
?Periodontal Diseases 17
?Dentofacial Anomalies and Malocclusion 19
?Oral Cancer 21
?Dental Fluorosis 26
?Dental Trauma 29
?Other Dental Conditions 32
?Some Important Facts 34
Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
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Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
P.K. PRADHANSecretaryDepartment of Health & FWTel.: 23061863 Fax: 23061252e-mail : [email protected]
Message
It gives me great pleasure that the Reference Manual on Oral Health prepared by the
Centre for Dental Education and Research, A"India Institute of Medical Sciences
supported by Ministry of Health and Family Welfare, DGHS and WHO.
Oral health is an integral part of general health. Oral diseases are universal and widely
prevalent. Recognizing the nature and burden of oral diseases, WHO in 2005 included
Oral Health into Non-Communicable Disease (NCD) programme for its effective
monitoring, prevention and health promotion activities. Oral and Dental diseases are
also, like other NCDs, is life style related diseases and has common risk factors with
other NCDs. Therefore, if Oral Health education and promotion is incorporated with
NCDs and if a" health care professionals are involved in their prevention; oral diseases
can be curtailed to a great extent.
I find that this reference manual is written in simple language with liberal pictorial
presentation, making it very easy to understand. I hope it will be used by a" the health
care professionals and they will be able to integrate this knowledge in their day to day
clinical practice. I compliment the entire project team for this effort.
(P. K. PRADHAN)
GOVERNMENT OF INDIAMINISTRY OF HEALTH & FAMILY WELFARE
NIRMAN BHAWAN, NEW DELHI-110011
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Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
vfuy dqekjANIL KUMAR
Message
Oral health is very important for the general health of a person. Often, this oral examination is useful in diagnosing a systemic disease. AYUSH systems have given immense importance to oral examination in general clinical methods. The father of surgery 'Sushrut', and many others have given elaborate descriptions of various oral disease conditions including those of the teeth e.g. caries, dental plaques etc. Oral care with gargling of hot perfusion of medicinal herbs, and brushing with medicinal herbs e.g. Neem, Arjun etc., has been practiced as part of ' Swasthavritta'
Despite the elaborate description in ancient AYUSH texts, oral health however is neglected in society. In this background, I am very happy that the Centre for Dental Education and Research at the All India Institute of Medical Sciences has brought out this concise reference manual on oral health for both Allopathic and AYUSH practitioners.
The Deptt. of AYUSH, Ministry of Health and Family Welfare finds this reference manual very comprehensive, and also lucidly written, to give information on major dental and oral diseases. It is expected that this will facilitate the diagnosis of such diseases by AYUSH and Allopathic practitioners, and more importantly, enable them to take appropriate and timely action for the treatment of the diseases.
(Anil Kumar
New Delhi,January 24, 2012
SECRETARYGOVERNMENT OF INDIA
DEPARTMENT OF AYURVEDA, YOGA & NATUROPATHYUNANI, SIDDHA AND HOMOEOPATHY (AYUSH)
MINISTRY OF HEALTH & FAMILY WELFARERED CROSS BUILDING, NEW DELHI-110001
Tel. : 011-23715564, Telefax :011-23327660e-mail : [email protected]
Mailing No. 110 108
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Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Dr. Jagdish PrasadM.S. M.Ch., FIACS
Director General of Health Services
Message
I am very happy that the Centre for Dental Education & Research (CDER), All India Institute
of Medical Sciences has prepared a Reference manual on Oral Health for the Allopathic and
AYUSH practitioners as part of a projected supported by Ministry of Health and Family
Welfare, DGHS and WHO.
Oral disease burden in India is known to be very high; 45-50% of the population suffers from
Dental caries, 90% from periodontal diseases, and 30% from malocclusion, in addition to a
huge burden of Oral Cancer in our country; 14-16% of total body cancers are Oral cancers.
Therefore it is essential that all health care professionals actively engage in curtailing oral
diseases which are a huge burden on National economy and affect the quality of life of
individuals and the society.
Oral diseases, as other Non-communicable diseases, are life-style related diseases and hence
preventable to a great extent. For this, it is essential that information about various oral
diseases, in terms of their causative factors, clinical presentation for early identification and
prompt intervention to prevent complications be known, especially to practitioners of all
streams of medicine and AYUSH. Towards this goal, I feel that the Reference Manual will
serve a very useful purpose. I compliment the team at CDER for bringing out this useful
manual.
Best wishes,
(DR. JAGDISH PRASAD)
GOVERNMENT OF INDIAMINISTRY OF HEALTH & FAMILY WELFARE
DIRECTORATE GENERAL OF HEALTH SERVICESNIRMAN BHAWAN, NEW DELHI-110001
Tel. 23061063, 23061438 (0), 23061924 (F)Ernail : [email protected]
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LokLF; lsok egkfuns'kky;fuekZ.k Hkou] ubZ fnYyh & 110011
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Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
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Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
PREFACE
Oral health is an integral part of general health. Association of various chronic diseases
such as CVD, diabetes, stroke, low-birth weight babies and preterm labour etc. have
been shown to be linked with poor oral hygiene and periodontal infection.
The magnitude of oral health problems in India is very high, placing a huge burden on
the economy. Prevalence of dental caries is approx 45-50%, periodontal diseases 90%,
malocclusion 30 %, dental fluorosis 6% and oral cancer 14-16% of total body cancers.
There is a significant rise in oral trauma cases due to road traffic accidents, contact
sports, conflict and fights, domestic violence etc. Oral cancer incidence in India is the
highest in the world, due to various tobacco habits and poor oral hygiene and
nutritional status. Besides the high incidence, oral cancer in our country are diagnosed
at very late stage, generally in stage III or IV increasing the morbidity and mortality due
to ignorance and low level of awareness of the masses. Combined together, oral
diseases, though not life threatening, puts a huge burden on health infrastructure and
national economy. Therefore, it is very important to create a large body of health
professionals, besides dental workforce, who can impart oral health promotion &
prevention, identify early signs of oral diseases and provide emergency care and referral,
when needed, to curtail the oral health related problems.
Medical Officers and various Ayurveda, Yoga, Unani, Siddha and Homoeopathy
(AYUSH) doctors posted at various levels can prove to be a useful resource to provide
oral health promotion and prevention, if properly motivated and trained. Moreover,
they are very well trained in control and management of several Non-Communicable
Diseases (NCD), which share common risk factors with oral and dental diseases.
Therefore, they can incorporate oral health messages in their other NCD control
programmes easily, without any additional cost, in terms of time and resources. As a
part of National Rural Health Mission and other programmes, there has been a radical
shift in utilization of manpower trained in other systems of medicine (AYUSH) in the
health care system. They share the responsibility of health care in conjunction with
remaining members of health care teams.
Hence, it was proposed to develop a training module, based on their need assessment
1Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
and pre-testing it in an appropriate setting. For this purpose, a brain-storming meeting
of all stake holders; Representatives of Director General of Health Services, National
Institute of Health & Family Welfare, Public Health Dentists, doctors from all the
streams of AYUSH, and allopathic practitioners was conducted on 18th January, 2011.
Also, a quick survey of baseline knowledge and need assessment was undertaken. Based
on these inputs, this training manual has been developed and also pre-tested. It is hoped
that it will provide a ready reference to all AYUSH and allopathic practitioners and
sensitize them regarding importance of Oral Health as an integral part of General
Health. It will also motivate and encourage them to actively undertake Oral Health
Promotion and prevention along with their routine clinical practice. To conclude, it is
hoped that this training manual will enable them for the following:
1. To promote oral health by providing oral health education and relevant health
information during their day to day practice.
2. Integration oral health into various other NCD control programmes, since they
share common risk factors such as diet, hygiene and abstinence from harmful
habits such as tobacco and alcohol use etc.
3. Identify and provide primary treatment for oro-dental problems and timely
referral, where dental officers are not available.
Oral cavity is the gateway to the body and closely linked to general health. Oral diseases
are wide spread, very painful resulting in loss of precious man-days, affect the
personality and quality of life of individuals. These are also very expensive to treat and
comparatively easy to prevent. Only by active participation of all Health care
professionals, we can hope to curtail the burden of oral diseases in our country.
Towards that goal, this manual is a small step, which by active involvement of all health
care professionals, can become a movement!!
Naseem Shah
Vijay Prakash Mathur
Ajay Logani
2Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
INTRODUCTION
About Dentistry
Conservative Dentistry and Endodontics:
Orthodontics and Dentofacial Orthopedics:
Oral and Maxillofacial Surgery:
Oral Medicine and Radiology:
Oral Pathology and Microbiology:
Pedodontics and Preventive Dentistry –
Periodontics –
Prosthodontics -
The science of dental surgery has evolved to a great extent over the past 5 decades.
Today, in India, there are more than 290 Dental colleges. There are 9 disciplines of
dentistry in which 3-years postgraduate Masters programme is available in over 150
Dental colleges as given below:
? It deals with restoration of tooth
defects caused by dental caries, trauma, attrition, abrasion, erosion etc to optimum
level of function and aesthetics.
? It deals with the correction of mal-
aligned teeth and jaw bones to achieve an adequate aesthetics and function and
control and modification of facial growth.
? It deals with correction of a wide spectrum of
diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues
of the oral and maxillofacial region.
? It deals with the diagnosis of various oral diseases,
inter-relationship of oral and general diseases by various diagnostic tools including
radiographs, and provide medical management for the oral diseases.
? It is the study of various oral pathologies and
microbiology as related to oral diseases, disorders and infections.
? It deals with prevention and
management of dental and oral diseases in children from birth through adolescence
and special need patients.
? It deals with study of supporting structures of teeth i. e. gingiva
(gums), alveolar bone, cementum, and the periodontal ligament and the diseases and
conditions that affect them and their management.
? It deals with diagnosis, treatment planning and rehabilitation of
oral function, comfort, appearance and health of patients with missing teeth and/or
oral and maxillofacial tissues using biocompatible substitutes.
3Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
? It involves the assessment of dental health needs and
improving the dental health of populations rather than individuals.
Apart from these, newer disciplines or sub specialties are emerging such as:
? It deals with placing a metallic implant usually made of
Titanium in the bone to support replacement of lost tooth/ teeth or other facial
structures.
? It refers to any dental work that improves the aesthetics of a
person’s teeth, gums and/or bite.
? It is the delivery of dental care to older adults involving the
diagnosis, prevention, and treatment of problems associated with normal aging and
age-related diseases as part of an interdisciplinary team with other health care
professionals.
Public Health Dentistry-
Implant Dentistry-
Aesthetic Dentistry –
Geriatric Dentistry-
4Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
WHY ORAL HEALTH IS IMPORTANT?
Oral health is an integral part of general health. Teeth serve the function of
mastication, speech and aid in the growth of alveolar processes and jaws as well
as psycho-social wellbeing of an individual. Loss of tooth/ teeth not only
hampers the function of mastication but also grossly and adversely affects the
personality of a person by disturbing his/ her psychological wellbeing and
quality of life (QOL). As the number of teeth decline, due to various oral
diseases, mastication is affected and the person tends to avoid roughage in the
diet. There occurs a shift from fibrous, natural diet to soft sweet diet, resulting
in micro-nutrient deficiencies. It has also been reported that in very old age,
patient's inability to chew well due to multiple missing teeth leads to chocking
on the food bolus, sometimes resulting in death.
Recent evidence has shown that poor periodontal health is closely associated
with cardio-vascular and pulmonary diseases, atherosclerosis, stroke as well as
poor glycaemic control in diabetic patients. In pregnant women, severe
periodontal infection has been linked to premature labour and low-birth weight
babies.
Tobacco usage is known to be associated with several chronic systemic diseases
and cancers of various organs in the body. Tobacco-related most common
cancer is the Oral cancer. In India it is the most common cancer in men and 3rd
most common cancer in women. Awareness regarding health effects of
smoking and chewing tobacco in various forms and oral pre-malignant lesions
among health professionals can help to reduce the incidence and facilitate early
diagnosis of oral and other body cancers as well as can reduce the morbidity and
mortality.
Gross neglect of oral healthHealthy teeth and gums
5Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
GENERAL ANATOMY AND FUNCTIONS OF TEETH
A tooth has the following parts:
That parts of the tooth which is visible in the mouth.
That part of the tooth that is anchored within the bone and is generally not
visible in the mouth.
Humans have two sets of teeth:
Crown:
Root:
Upper Central Incisor
Upper Lateral Incisor
Canine
First Premolar
Second Premolar
First Molar
Second Molar
Third Molar
Second Molar
First Molar
Second Premolar
First Premolar
Canine
Lower Lateral Incisor
Lower Central Incisor
Upper Central Incisor
Upper Lateral Incisor
Canine
First Molar
Second Molar
First Molar
Canine
Lower Lateral IncisorLower Central Incisor
Incisor Canine Premolar Molar
CrownCrown
RootRoot
6Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Primary Dentition
Permanent Dentition
There are 20 primary/ deciduous/ milk teeth; ten in the upper jaw and ten in the lower
jaw. These erupt in the mouth from 6-months to 2 ½ years of age.
There are 32 adult teeth; 16 in the upper jaw and 16 in the lower jaw. These erupt from
6 -18 years of age.
Their primary function is mastication of food and preparation of bolus for easy
digestion. Chewing the food also contributes towards development of alveolar
processes and jaw bones. In conditions where multiple teeth fail to develop or erupt,
severe deficiency in jaw size is seen. Teeth also help in speech and are primarily
responsible for facial aesthetics. In addition, primary teeth also serve as space
maintainers for succedanous permanent teeth and proper development of speech in
children during formative years.
Primary Dentition
Permanent dentition
Functions of teeth
7Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
DENTAL CARIES
Dental caries is an infectious microbiological disease of the teeth that results in localized
dissolution and destruction of the calcified tissues. It is the second most common cause
of tooth loss and is found universally, irrespective of age, sex, caste, creed or geographic
location. It is considered to be a disease of civilized society, related to lifestyle factors,
but heredity also plays a role. In the late stages, it causes severe pain, is expensive to treat
and leads to loss of precious man-hours. However, it is preventable to a certain extent.
The prevalence of dental caries in India is 50%–60%.
Interplay of three principal factors is responsible for this multi-factorial disease.
Host - Teeth and Saliva
Agent - Microorganisms in the form of dental plaque
Substrate - Diet
Thus, caries requires a susceptible host, cariogenic oral flora and a suitable substrate,
which must be present for a sufficient length of time.
1. Teeth:
a) Composition - Deficiency of certain trace elements in diet such as fluorine,
Etiology
Host factors
4
Saliva
Tooth
Bacteria
CARIES
Carbohydrate
Dental caries etiology
8Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
zinc, lead and iron during tooth development results in enamel which is more
susceptible to dental caries.
b) Morphological characteristics - Deep, narrow occlusal fissures, and lingual
and buccal pits tend to trap food debris and bacteria, which can cause caries.
As teeth get worn during mastication (attrition), incidence of caries declines.
c) Position - The inter-dental areas are more susceptible to dental caries.
Crowding of teeth or abnormal spacing between the teeth can increase the
susceptibility to caries.
2. Saliva: Saliva has a cleansing effect on the teeth. Normally, 700–800 ml of saliva is
secreted per day. Caries activity increases as the viscosity of the saliva increases.
Eating fibrous food and chewing vigorously increases salivation, which helps in
digestion as well as improves the cleansing effect on the teeth. The quantity
9Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
(Reduced salivary secretion as found in xerostomia and salivary gland aplasia
gives rise to increased caries activity) as well as composition, pH, viscosity and
buffering capacity of the saliva plays a significant role in dental caries.
Dental plaque: It is a thin, tenacious microbial film that forms on the tooth surfaces.
Microorganisms in the dental plaque ferment carbohydrate foodstuffs, especially the
disaccharides like sucrose, to produce acids that cause demineralization of inorganic
substances and furnish various proteolytic enzymes to cause disintegration of the
organic substances of the teeth, the processes involved in the initiation and progression
of dental caries. The dental plaque holds the acids produced in close contact with the
tooth surfaces and prevents them from cleansing action of saliva.
Salivary protiens form a thin film called pellicle on tooth surfaces
â in 2 hrs.
Bacterial colonization, desquamated epithelial cells & food debris
â in 24 hrs.
Plaque microorganisms predominantly streptococci
â Mature Plaque
Mixed flora of cocci, bacilli, spirochetes & filamentous organisms
Fermentable carbohydrates
The role of refined carbohydrates, especially the disaccharide sucrose, in the Etiology of
dental caries is well established. The total amount consumed as well as the physical
form, its oral clearance rate and frequency of consumption are important factors in the
Etiology.
The disacchride, sucrose and lactose, is fermented by plaque bacteria and produce acids
which demineralize the enamel. The pH of resting saliva is 6.2. After taking sugar
solution, within 10 minutes, the pH of saliva drops to 2, which then gradually returns
to baseline level over 30-60 minutes depending on type of sweet food consumed. Sticky
food takes longer than other solid foods to get cleared from mouth and liquid is cleared
Agent : Microorganisms
Formation of Dental Plaque
Substrate:
10Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
the fastest. Saliva helps to wash away the acids produced. Therefore, decreased
salivation due to any reason,like Sjogren's syndrome, medication or radiation etc.
increases the caries incidence.
Plaque disruption by frequent brushing (at least every 12 hrs.) and rinsing the mouth
provides protection against dental caries.
Vitamins A, D, K, B complex (B6), calcium, phosphorus, fluorine, amino acids such as
lysine and fats have an inhibitory effect on dental caries.
Dental caries can be classified as:
(In the crown of tooth)
i) Pits and fissures caries – affects pits and fissures on occlusal, buccal or lingual surfaces
ii) Smooth surface caries - affects inter-proximal surfaces, just under the contact areas of
teeth or in the cervical third of the crown on labial/ buccal or facial and lingual
surfaces.
It is generally found in older adults. When due to
gingival recession the root surfaces get exposed to oral
environment, the cementum covering is quickly lost
due to abrasive action of tooth brushing/ tooth
Classification of Dental caries:
Coronal and root caries-
Coronal caries:
Root caries
Pits & fissure caries Smooth surface caries
Root caries
11Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
powder etc. and dentin gets exposed. The irregular, rough surface attracts plaque
deposition and initiation of caries.
Dental caries is further classified as :
Which is rapidly progressing caries leading to faster involvement of pulp.
which is slowly progressing and takes months or sometimes years to progress and
involve the pulp.
This condition is the result of prolonged feeding with the bottle, specially at night time. It
can also be the result of demand breast feeding at night and not rinsing the baby's mouth
afterwards. In this case, most of the erupted milk teeth develop caries. Only the
mandibular anterior teeth are spared from caries attack as the suckling position protects
the lower teeth, flooding the rest of the oral cavity with milk.
It affects few individuals where caries involve multiple teeth and even the tooth surfaces
generally considered immune to caries attack such as mandibular anterior teeth or
involving labial surface of upper anterior teeth or at the cusp tips. The caries progress is
generally very rapid in this condition and therefore requires prompt intervention to
arrest the progression of caries.
Acute caries
Chronic caries
Nursing bottle caries
Rampant caries
Nursing bottle caries Rampant caries
12Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Arrested caries
Strategies for Prevention and Control of Dental Caries
1. Increase the resistance of the teeth:
2. Combat the microbial plaque by physical and chemical methods.
On few occasions, an active carious lesion gets arrested when the area involved becomes
self-cleansing. For example when an adjoining tooth is lost, the smooth surface caries
gets arrested or when the tooth margin gets chipped off, the occlusal carious lesion
becomes saucer shaped and no longer traps food debris or plaque and hence gets
arrested.
Systemic use of fluoride: (i) Fluoridation of water, milk and salt;
(ii) Fluoride supplements in the form of tablets, drops and
lozenges.
Though the beneficial effect of Fluoride is well established in caries prevention and
control, in India, use of fluoride, specially the systemic use in caries prevention has
remained controversial. There are endemic zones of high Fluoride in India causing very
unsightly Dental Fluorosis and crippling Skeletal Fluorosis (which is dealt with in a
separate chapter), Over 85% of the country's population does not get optimum fluoride
concentration in drinking water. Though Indian spices, tea drinking and fish in diet
compensate to some extent the deficient fluoride level in water, additional topical
application to replenish lost fluoride from surface enamel (due to wear ) is highly
desirable.
(i) Use of fluoridated toothpaste and mouthwash; (ii) Use of fluoride varnishes (in-
office application, longer duration of action, high fluoride content);
(iii) Use of casein phosphopeptide–amorphous calcium phosphate (CPP–ACP),
which is available as tooth mousse, helps to remineralize the soft initial carious,
demineralised areas of the teeth.
(i) Physical methods: The correct method and frequency of brushing should be
followed - in the morning and before going to bed and preferably after every major
meal. Tongue cleaning and the use of indigenous agents such as the bark of neem or
mango (where toothbrush and paste are unaffordable) should be encouraged. The use of
coarse toothpowder and tobacco-containing dentifrices should be avoided.
13Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Correct method of brushing
3. Modify the diet.
Teeth should be brushed with a medium brush at least two times in a day. Upper teeth
should be brushed downwards and lower teeth upwards, starting from gum margins
both on outer and inner side.
The chewing surfaces of posterior teeth should be brushed by to and fro and rotational
movements.
Tongue should also be cleaned by gentle scripping motion of the tooth brush.
While rinsing the mouth the gums should also be massaged with the index finger.
The use of various inter-dental cleaning aids such as dental floss, inter-dental brushes,
water pik, etc. should be recommended as supplements where required such as in cases
of crowding/ spacing between teeth, during orthodontic treatment, in cases of hypo-
salivation after chemo or radio-therapy for Head & Neck cancers etc. Use of an
electronic toothbrush in children and persons with decreased manual dexterity is
recommended.
(ii) Chemical methods: These include the use of fluoride-containing toothpaste, mouth
rinses and 0.2% chlorhexidine and povidine–iodine mouthwash. These should be used
on prescription of a dental surgeon.
?Reduce the intake and frequency of refined carbohydrates.
?Avoid sticky foods and replace refined sugar with un refined, natural food.
The correct brushing technique
14Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
?Increase the intake of fibrous food to stimulate salivary flow, which is protective
against caries.
?Consume caries-protective foods such as cheese, all types of nuts, raw vegetables,
fruits, etc.
?Stimulate salivary flow with sugar free chewing gum.
Xylitol (a sugar substitute)-containing chewing gum, if chewed between meals,
produces an anti-caries effect by stimulating salivary flow.
Certain early interventions can help to prevent dental
caries to a large extent. These are
1. Use of pit and fissure sealants – The susceptible pits and fissure on occlusal
surfaces of newly erupted posterior teeth are sealed with a fluoride releasing glass
ionomer cement or composite resin.
2. Application of fluoride varnish – It decreases the attachment of plaque on surface
enamel and increases the abilty to resist demineralization due to acids produced
by fermentation of carbohydrates and helps in remineralization by sustained
release of fluoride.
Preventive interventions:
Pit & fissure sealants
15Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Other preventive measures
Treatment of dental caries
?To maintain ideal contacts between teeth
-Prevention of malocclusion (especially crowding of the teeth)
-Prevention of premature loss of deciduous teeth
-Restoration of missing permanent teeth by prosthesis (dentures)
?Making sugar-free chewing gum freely available and affordable in the country
?Using sugar substitutes such as saccharine, xylitol, mannitol, aspartame, etc.
in paediatric medicinal syrups, bakery products, jams, marmalade, etc.
?Making toothbrushes and fluoridated toothpaste available to the masses at
low cost. Regular use of fluoridated toothpaste is proven to reduce the
incidence of dental caries by 30%.
Treatment comprises removal of decay by operative procedures and restoration with
appropriate materials such as silver fillings, gold inlays, composite resin, glass ionomer
cement, full metal or porcelain crowns, etc. In advanced cases, where the pulp of the
tooth is involved, endodontic treatment (root canal treatment) may be required. Where
there is extensive destruction of the tooth structure or when endodontic treatment is
not feasible, extraction of the tooth and replacement by an artificial prosthesis may be
required.
16Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
PERIODONTAL DISEASES
Periodontal diseases which includes gingivitis and periodontitis. This disease affects the
supporting structures of teeth, i.e. the gingiva (gums), periodontal ligament, alveolar
bone and cementum (covering the roots of the teeth) and is the most common cause of
tooth loss in India. It is a slow progressing, relatively painless bacterial infection of the
gums and bones surrounding the teeth. If not checked in time, it leads to progressive
loss of bone support to the tooth resulting in mobility and finally loss of the tooth. It
affects over 90% of the Indian population in the form of at least mild gingivitis and
bleeding from the gums, which is reversible with proper oral hygiene. More severe and
advanced disease, threatening tooth loss, affects 40-45% of the affected population.
Dental Plaque, a thin, adherent microbial film on the tooth surfaces, is the main
pathological cause of gingival and periodontal inflammation. Plaque is the causative
agent for both dental caries and periodontal diseases. If plaque is not removed from the
teeth by regular brushing twice a day, it thickens and gets mineralized and presents as a
hard greenish-yellow deposit called calculus.
Occlusal trauma due to defective occlusal relationship of upper and lower teeth is also
Etiology of Periodontal diseases
17Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
one of the causative factor for periodontal diseases.
Plaque deposition leads to gingival inflamation which manifest as red, inflammed
gingival margins and interdental papilla. Gingiva appear swollen and hence the patient
avoids brushing which further aggravate plaque deposition and gingival inflammation.
Gradually, the infection & inflammation spreads deeper into the bone, leading to bone
resorption & mobility of teeth.
Plaque control methods are the same as for dental caries prevention:
?Correct method and frequency of brushing, rinsing, gum massage and tongue
cleaning etc. needs to be stressed. In addition, dental floss, inter-dental brushes,
electronic brushes and water pik etc. are useful adjuncts in oral hygiene
maintenance.
?The use of chemical mouthwashes should only be by prescription for specific time
period.
?Removal or treatment of contributing factors
?Improved nutrition
?Oral prophylaxis (scaling and root planing)
?Emphasis on home care-proper brushing technique and frequency (shown on page
10) and use of other oral hygiene aids.
Prevention and Treatment
Treatment methods for periodontal disease:
Initial stage of periodontal disease showing red swollen
and inflamed gums
Advanced stage of periodontitis showing increased spacing between the teeth due to destructionof supporting structures and root exposure
18Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
DENTOFACIAL ANOMALIES AND MALOCCLUSION
Irregularrities in the alignment of teeth and disproportionate jaw relations is termed as
malocclusion. It may present as crowding, spacing, proclination or retrortination of
teeth. The prevalence of malocclusion in India is estimated to be 30% in school-age
children. Malocclusion may vary from mild to severe, causing aesthetic and functional
problems, and may also predispose to dental caries, periodontal diseases as well as
increased susceptibility to trauma, especially to excessively proclined teeth. The major
dento-facial deformity is cleft lip and palate, which is seen in 1.7/1000 live-births.
Hereditary factors play an important role in conditions such as cleft lip and
palate, facial asymmetries, variations in tooth shape and size, deep bites, discrepancies
in jaw size.
These include cleft lip and palate, and syndromes associated with
anomalies of craniofacial structures, cerebral palsy, torticollis, cleidocranial dysostosis,
congenital syphilis, etc.
These include abnormal suckling, thumb and finger sucking, tongue thrusting and
sucking, lip and nail biting, mouth breathing, enlarged tonsils and adenoids, trauma and
accidents.
These include abnormalities of number such as supernumerary and
Etiology
Heredity:
Congenital:
Abnormal pressure habits and functional aberrations:
Local factors:
Malocclusion
19Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
missing teeth, abnormalities of tooth size and shape, abnormal labial frenum causing
spacing between the upper anterior teeth, premature tooth loss with drifting of the
adjoining and opposing teeth, prolonged retention of the milk teeth, delayed eruption
of the permanent teeth, abnormal eruptive path, dental caries, and improper dental
restorations.
This includes
?Control of harmful oral habits (Habit-breaking appliances can be used).
?Preservation and restoration of primary and permanent dentition.
?Serial planned extractions, space maintainers/ regainers, and functional appliances
to correct jaw relations are other modalities.
?Frenectomies (excision of high frenum attachment) and simple appliances can be
Prevention and Treatment of Malocclusion
20Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
ORAL CANCER
India has the highest prevalence of oral cancer in the world (19/100, 000 population). It
is the most common cancer in men and the third most common cancer in women, and
constitutes 13%–16% of all cancers. Of all the oral cancers, 95% are related to the use of
tobacco.
Oral cancer has a high morbidity and mortality. The 5-year survival rate is 75% for local
lesions but only 17% for those with distant metastasis. Therefore, early diagnosis of oral
cancer is important. Since the oral cavity is easily accessible for examination and the
cancer is generally preceded by some pre-cancerous lesion or condition such as a white
or red patch, a non-healing ulcer or restricted mouth opening. It is preventable to a great
extent. Unfortunately, in India, most cancers are diagnosed at a very late stage, when
treatment not only becomes more expensive, but the morbidity and mortality also
increases.
95% of all oral cancers are associated with tobacco use in some form or the
other. It is used in many forms in India like;
?smoking (78%);
?chewing of betel quid, paan masala, gutka, etc. (19%);
?inhalation of snuff (2%); and
?dentifrices (>1%).
It produces synergistic effect with tobacco chewing or smoking as it
increases the permeability of oral mucous membrane and increases the absorption of
toxic products of tobacco.
Etiology
1. Tobacco:
2. Alcohol:
Oral Cancer
21Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
3. Oral Infections:
4. Chronic irritation
5. Radiation exposure
6. Nutritional deficiencies:
7. Industrial pollution
Bacterial infections such as syphilis, fungal infection such as
candidiasis and viral infection such as HPV, HSV, AIDS are associated with increased
risk for oral cancer.
in any form - Sharp edges of teeth and faulty prosthesis
Vitamin A, Iron and B-complex deficiency can produce
metaplasia of epithelial structures, increasing its susceptibility to malignant conversion.
due to asbestos, lead etc.
Oral cancer is generally preceded by some precancerous condition like leukoplakia,
erythroplakia, non-healing ulcer of > 15 days' duration, oral submucous fibrosis and
erosive lichen planus (Occasionally).
Leukoplakia
22Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Leukoplakia
Erythroplakia
Lichen Planus
Oral sub-mucous fibrosis
It is a raised white patch which cannot be scraped off appearing anywhere on the oral
mucosa, varying from small circumscribed area to an extensive lesion involving a large
part of oral mucosa. The surface may be smooth or wrinkled. Sometimes smooth surface
may be traversed by small cracks or fissures. The lesion may be nodular or may get
ulcerated.
When white lesion is interspersed with red lesion it is called speckled leukoplakia.
Prevalence of leukoplakia is reported to be 0.2-11.7% and its malignant
transformation rate (MTR) reported is 3 - 6 % over 10 years period.
– It presents as bright or fiery red, velvety plaque or patch which may be
raised or depressed. Its prevalence is 0.02 - 0.1%. As compared to leukoplakia, its
incidence is lower but its malignant potential is very high. It actually represents either
an early sign of asymptomatic cancer (carcinoma in situ) or sometimes as inrasive
carcinoma.
– It is a muco-cutaneous disease which usually present as whitish,
bilateral lesions anywhere on oral mucosa. It may present in different clinical form such
as reticular, annular, erosive, ulcerative or atrophic type. 25-35 % of patients may have
accompanying skin lesions in the form of large, flat purple plaques or nodules on skin. It
has low malignant potential. Only the ulcerative, erosive or atrophic type of lichen
planus of long duration may have some malignant potential.
– It is designated as a pre-malignant condition (And not a
premalignant lesion) as the entire oral mucous membrane is conditioned to transform
into malignancy. In this condition the oral mucous membrane becomes pale pink to
whitish in colour. The epithelium becomes atrophic and patient complains of severe
burning sensation. The excessive and abnormal collagen fibrous deposition in the
submucosa gradually leads to loss of elasticity of mucous membrane and becomes stiff
and board like, restricting the mouth opening. It is associated with betel nuts, quid, pan
masala and gutka chewing. Its malignant potential rate is 7.6 % over a 7- 10 year period.
Its prevalence has increased very significantly and dangerously in the past few decades as
more and more young and adolescent population has taken to habits of chewing pan
23Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
masala and gutka increasing the incidence of oral cancer in the country. Moreover, it
can cause multi-site cancer in the oral cavity and at a comparatively younger age.
- By itself, it is not considered a premalignant lesion but if it is super
imposed on any of the other premalignant lesion, the probability of it turning malignant
is increased. The patient may give a history of prolonged course of broad spectrum
antibiotics, which might have suppressed the normal bacterial flora. It is a fungal
infection found either in the very young or very old.
?It appears like fine white deposits on erythematous patch of mucosa or as more
highly developed small, soft, white, slightly elevated plaques bearing a remarkable
resemblance to milk curd.
?If the white pseudo membranes are wiped away with a gauze swab a raw bleeding
area is left behind.
?The patient may complain of a burning sensation in the mouth but pain is not a
common feature of this disease.
?The disease may range in severity from a solitary region to diffuse whitish
involvement of all the surface especially the tongue.
?Prevent initiation of tobacco and alcohol habits
?Take nutritious, balanced diet to prevent nutritional deficiencies and to maintain
optimum immune status
Oral Candidiasis
Strategies for prevention and treatment of oral cancer
Primordial Prevention & Health Promotion
Oral submucous fibrosisshowing whitish bands
in cheek mucosa
Advanced case of submucousfibrosis showing severe
restrictions in mouth opening
Multiple cancerous lesionsin a case of oral submucous
fibrosis
24Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Primary Prevention
Secondary Prevention
Tertiary Prevention
Treatment of Oral Cancer
Rehabilitation
?STOP all harmful oral habits such as tobacco smoking, chewing, pan masala and
gutka chewing, alcohol drinking etc.
?Maintain proper oral hygiene
?Regular visit to a Dentist for dental and oral check-ups
?Biopsy of suspicious lesions like leukoplakia, erythroplakia, submucous fibrosis,
erosive lichen planus or non-healing ulcers of > 2 weeks' duration etc.
?
exten possible
?Maximise rehabilitation of the patient by restoring function, aesthetics and psycho-
social support
?Surgery
?Radiotherapy
?Chemotherapy
?Combination of above
Loss of aesthetics and compromised function of mastication, deglutition, speech and
psychological trauma affect the quality of life (QOL) of Oral Cancer patient to a great
extent.
Surgery and grafts to replace the loss structures is the prime strategy. However, in cases
where it is not possible, restoration of surgical defects can be done with maxillo-facial
prosthesis by a trained Prosthodontist. Psycho-social support is of immense value in
restoring the confidence following oral cancer treatment.
Severe dryness of the mouth and severe mucositis following radiation and
chemotherapy can be helped by prescribing medication and artificial saliva. Increased
susceptibility to dental caries (due to lack of saliva) can be countered by use of Fluoride
and Chlorhexidine mouth washes, other caries control measures such as Tooth mousse
containing ACP-CPP, Fluoride varnishes etc.
To minimize morbidity and disability due to disease itself or its treatment to the
25Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
DENTAL FLUOROSIS
Fluoride is an essential element for human health and plays a critical role in the
calcification of bones and teeth. Its deficiency causes increased susceptibility to dental
caries and its excessive exposure leads to dental and skeletal fluorosis.
In India, 17 states & union territories have endemic zones of high fluoride in drinking
water, affecting 6.6% of population in the endemic zones. Dental fluorosis is found in
58% and skeletal fluorosis in 4.3% of exposed population.
The main dietary source of fluoride is drinking water and vegetables grown in fluoride
rich soil, tea, turmeric and other Indian spices. The fluoride ion in very low
concentration of about 1 part/ million (ppm) or 1 mg/ litre gives protection to dental
enamel from dissolution and subsequently prevents dental caries. The optimal caries-
protective fluoride content in drinking water is approximately 1mg/L in temperate
climates. In tropical countries, where people drink more water due to hot climatic
conditions, the desirable fluoride content is approximately 0.5mg/L.
?When Fluoride concentration increases to > 2 ppm, dental fluorosis manifests in
the form of Chalky white (Snow capped mountain appearance) to light and the
heavy brown discoloration and in severe cases, structural defects in the form of
pitting of surface to flaky enamel which chips off easily.
At still higher concentration of > 4ppm, it leads to skeletal fluorosis with all its
accompanied systemic problems such as increased density of bone specially vertebra,
ribs and pelvic girdle causing stiffness of vertebral column and severe pain due to
excessive pressure on spinal nerves and increased susceptibility to fractures ; impaired
Moderate dental fluorosis Severe fluorosis
26Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
joint mobility, bowed legs and restricted mobility, impairment of thyroid function and
resultant Hyperparathyroidism resulting in excess calcium in blood anaemia, nausea,
vomiting etc.
Severity of fluoride toxicity depends on
?The total amount of fluoride ingested per day
?The duration of exposure
?The nutritional status.
Dietary deficiencies and mal-nutrition has been shown to be associated with
fluoride toxicity. Diet rich in Vitamin D, Calcium and Phosphorous can exert a
protective effect against toxic effects of fluoride.
On the other hand, increased density and thickened cortical bone and periosteum due
to high fluoride level has been found to be beneficial in countering the osteoporotic
changes associated with ageing process.
There are endemic zones of high fluoride level in India affecting 17 states and
approximately 666 lakh people for which effective de-fluoridation methods need to be
devised and implemented.
But for caries prevention which affects 45-50% of the population, topical fluorides are
highly desirable. Dental caries by its sheer magnitude, is impossible to treat in all
affected individuals besides being expensive to treat. Its progress leads to immense pain
27Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
and suffering and needs advanced procedures like root canal treatment to save teeth. It is
also the second most common cause for tooth loss. Therefore, topical application of
fluoride in the form of toothpaste, mouth rinse gels and varnishes etc. are
recommended for use. Fluoride in the surface layers of enamel resists demineralization
and also helps to reverse the incipient carious, demineralised areas. Fluoridated
toothpaste is the most practical and effective way of providing topical fluoride to the
masses. It replenishes the lost fluoride from surface layers of enamel and does not have
undesirable systemic effects of fluoride. To safeguard against systemic effects, fluoride
toothpaste is not recommended in children below 4 years of age and supervised use till 6
years of age till swallowing reflex is fully established.
28Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
DENTAL TRAUMA
Traumatic injuries to face and jaws often results due to road traffic accidents, fall,
domestic violence, sports injuries, conflicts etc. Any injury to the head and face region
can cause from minor to very major, grevious injuries to teeth, its supporting structures
and basal bone.
The types of dento-alveolar injuries can broadly be classified as:
– Fracture of enamel, dentin with or without involving the pulp
– In addition to the crown of the tooth, root can get fractured at
any level in the bone.
– The tooth can be displaced in either bucco-lingual (causing
mobility) or inciso-gingival direction (causing extrusion or intrusion of a tooth in the
socket).
– The tooth or teeth may get dislodged and fall
out at the site of accident/ injury.
Tooth fracture
Crown-root fracture
Luxation injuries
Complete avulsion or ex-articulation
Tooth Fracture Crown root fracture
Luxation injuries
Teeth stabilized with awire and composite resin splint
Extrusive luxation
29Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Dento-alveolar injuries
Basal bone fracture
– Along with the tooth the alveolar bone may also fracture, in
which, excessive mobility of the fragment is noticed.
– Either mandible or maxilla or both along with other facial bones
may get fractured.
These types of injury require very prompt attention as the patient may have excessive
bleeding, ecchymosis, large swelling on face, and respiratory distress in some cases or
may also present with signs of shock and hence require prompt emergency
management.
All traumatic injury cases with open bleeding wounds require tetanus and antibiotic
prophylaxis, bleeding control, care of the open wound and prompt referral. The
physician attending first to the injured patient must know the following about
management of dento-alveolar injuries:
Tooth avulsion(Ex-articulation)
The avulsed tooth Tooth splinted in position
Tooth discolourationfollowing trauma
30Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
?Loose teeth and alveolar process can be repositioned and splinted together. There is
no need for removal of a loose tooth most of the time.
?The delayed complication of trauma may result in crown discolouration.
?Following trauma, a tooth may get completely dislodged from its socket, known as
avulsion.
The dislodged tooth can be replanted back into its socket. The procedure is as
follows;
The tooth should be picked up and washed under running water and placed back
into the socket without wasting any time and referred to a dentist as soon as
possible.
If it fails to seat properly in the socket, the patient may be asked to hold the tooth
in the upper or lower vestibule (the place between the lip/ cheek and the jaw) and
report to the dentist immediately.
If the patient is young and cannot hold the tooth as described above, The tooth should
be put in a transport medium such as Viaspan (Medium used in organ transplants,
contact lens storage liquid or milk and if nothing is available, in water. At no time the
tooth should be allowed to dry as it adversely affects the viability of periodontal
ligament cells and lowers the prognosis for re-attachment. Extra-articular time if less
than 30 minutes gives the best result. As the time span increases, the prognosis become
more unfavourable.
Saving a dislodged tooth
31Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
OTHER DENTAL CONDITIONS
Edentulism/ Edentulousness – It is a myth that tooth loss is inevitable with advancing
age. Like other NCDs, oral and dental diseases are also life-style related diseases and are
preventable to a great extent. It require healthy life-style, proper dietary and oral
hygiene practices and avoidance of harmful habits like tobacco and alcohol use.
Periodontal diseases, dental caries and trauma are the main causes for tooth loss. Loss of
anterior tooth/ teeth affects the personality and speech of an individual. Loss of
posterior teeth compromises chewing ability and food choices. Loss of teeth also affects
the psycho-social wellbeing and ultimately quality of life (QOL) of an individual.
Therefore replacement of missing tooth/ teeth is very important.
The options for replacement of few missing teeth are
?Removable partial denture.
?Fixed partial denture.
A case with missing lower and upper anterior teeth, rehabilitated with partial dentures
A case of complete edentulism rehabilitation with upper and lower complete dentures
32Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
?Implants/ implant supported denture.
? (When all the teeth are lost)
Teeth wear away due to masticatory forces over the years, which is normal and
physiological.
But several other causes also cause tooth wear. Tooth wear is classified as
It is due to functional contacts of teeth during mastication. It is generally
observed on chewing surfaces (occlusal) of teeth and contact surfaces (proximal) of
teeth.
Some persons have the habit of clenching and grinding of teeth, a condition called
bruxism. In this condition, excessive attrition of teeth occurs.
It is due to use of heavy brushing forces, faulty brushing technique or use of
excessively coarse, gritty tooth powder. Generally labial and buccal surfaces (outer) of
teeth get abraded.
This is caused by chemical dissolution of tooth substance caused by excessive
consumption of aerated drinks, fruit drinks and tobacco containing dentifrices and in
cases where the patient has excessive regurgitation. Generally abrasion and erosion are
combined together.
This condition causes v-shaped defects at the neck of tooth (junction
between crown and root of a tooth). It is due to masticatory stresses concentrating at
that point, causing micro-enamel fracture and then development of gross defect. It is
generally observed in canine and premolar region of both the arches.
Complete dentures
Tooth Substance Loss
Attrition:
Abrasion:
Erosion:
Abfraction:
Chemical erosion of teeth
33Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
SOME IMPORTANT FACTS
Certain oral conditions which may mimic diseases of other body systems.
1. Partial or complete trismus
2. Extra oral discharging sinus on the face
Consequences of loss of a tooth
– In this condition, patient has difficulty in
opening the jaw due to fibrosis of muscles and tissues in the region which is
similar to lock jaw like in tetanus. This condition can arise due to a condition
called Oral Sub-mucous Fibrosis, which is a pre malignant condition of oral
mucosa.(Discussed under Oral pre-malignant lesions and conditions)
It can also be mistaken as a Temporo-mandibular Joint (TMJ) problem and the
patient may be subjected to unnecessary investigations like X-ray, MRI etc.
Restrictited mouth opening can also result due to sub condylar fracture with
resultant fibrosis and ossification of the joint capsule resulting in trismus. In
growing children this can also lead to arrest in the growth and development of
the mandible resulting in micrognathia.
-This condition can be mistaken
for a skin lesion but could be due to infection from an infected tooth tracking
down the bone and soft tissues, to form a sinus on the skin.
- Maintaining the integrity of the dental arch is
very important to maintain the balance of occlusion and harmony of dental
arches and oral hard and soft tissues. Loss of one single tooth from the arch can
lead to the following consequences:
Draining sinus on cheekdue to infected upper molar
34Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
1. Drifting of adjoining teeth towards the edentulous space
2. Extrusion/ over eruption of the tooth in the opposing arch
As a result of 1 & 2, disturbed contacts between teeth in both the arches leads to food
impaction between teeth. This increases the risk of dental caries and periodontal
diseases. Besides, food impaction is a painful condition making mastication on the
affected side difficult. Thus the person tends to avoid chewing on that side and
unilateral mastication pattern develops. Lack of cleansing effect (by friction) of food
causes heavy deposits of calculus on teeth on the unused site (similar to disuse atrophy).
As explained above, a missing tooth/ teeth in the arch can aggravate the dental
problems; therefore replacing a missing tooth or teeth is essential and highly desirable.
Many patients are unaware that few missing teeth can be replaced and they wait for all
the teeth to be lost to get complete dentures made. But it is a misconception. Few
missing teeth or even one single tooth can be replaced by artificial teeth. The option for
replacement of lost teeth is by either removable or fixed partial dentures or by implant
supported prosthesis.
Tobacco is the major killer all over the world; about 7 million deaths/ annum.
In India tobacco use is widely prevalent in various forms as given under Oral Cancer.
Therefore, it is very essential that all health care professionals join hands to curtail its
use by taking every opportunity to counsel the patients against its use.
Since oral cavity is easily accessible for examination and diagnosis of tobacco use (by
tobacco smell, teeth discoloration, mucosal ulceration or inflammation and/ or
presence of early dysplastic changes or premalignant lesion), all patients attending any
of the health care settings should get oral examination and also be asked about tobacco
habits. If positive, “National Guidelines for smokeless tobacco cessation” published by
Ministry of Health & Family Welfare, Govt. of India, 2011 must be followed to give
counseling and treatment as prescribed in different streams of Medicine and AYUSH.
it is generally caused due to dental caries involving the pulp. The pulp
Missing tooth /teeth should be replaced
Tobacco Cessation counselling and treatment
Dental Emergencies and their management in Health Care Set-up
1) Toothache :
35Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
inflammation is responsible for severe toothache, as it is enclosed in hard tissues all
around with the no scope for inflammatory exudates to escape, thus causing pressure on
the nerve endings in the pulp. Other causes for severe toothache are acute apical
periodontitis and apical abscess. These conditions cause unbearable acute, sharp
shooting or throbbing pain to the patient.
In the health set-up, a carious tooth can be cleaned and a plug of clove oil, squeeze-dried
can be placed in the open cavity. In case the pain is very severe, a long acting local
anesthetic injection may be given in the vicinity of the tooth. For systemic control of
pain, intra muscular injection of Diclofenac Sodium or any other appropriate pain
reliever may be prescribed. Generally this kind of pain occurs at night and in these
cases, a sedative / tranquilizer may help the patient to sleep.
Sometimes a patient may present with excessive bleeding
from the freshly extracted tooth socket. In this condition, after proper history taking
and clinical evaluation, the local site can be cleaned with the gauge and a pressure pack
of sterile cotton / gauge may be given and patient may be asked to bite on it for at least
30minutes. In case on examination, excessive laceration or detached soft tissue flap is
seen, suturing of the soft tissue may be required.
In case there is history any blood disorder or patient taking anti-coagulants, appropriate
management for this condition is required by the experts.
A patient may sometimes present with the loosely
hanging anterior teeth and bleeding from soft tissues in the mouth following fall or
sports injuries. Generally these are young children or adolescents. In these cases, after
thorough examination and evaluation, the bleeding area may be gently cleaned and
with the simple manual pressure, the teeth should be repositioned. A Tetanus toxoid
injection and antibiotic cover may be given. The case should be promptly refered to a
dentist for further management.
1. Shah N. Oral and Dental Diseases: Causes, prevention and treatment strategies. In
Burden of Disease in India. National Commission on Macroeconomics and Health,
Ministry of Health & Family Welfare & Ministry of Finance, Government of India, 2005
2. “National Guidelines for smokeless tobacco cessation” published by Min H & FW,
2) Post-extraction bleeding:
3) Accidental fall or trauma:
Sources Used and for Further Reading
36Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners
Important tips for Good Oral Health
1. Maternal health and diet during pregnancy is important for proper development
of teeth
2. Care of Milk teeth is very important. They serve as space maintainers for
permanent teeth, help in development of jaws, speech, mastication and esthetics.
3. Diet rich in Vit A, C and D, Ca, P and traces of fluoride helps to form strong,
caries resistant teeth. Eating raw vegetables and fruits and food which require
rigorous chewing promotes oral health.
4. Refined carbohydrate, specially the solid and sticky type, consumed frequently
between meals, increases caries prevalence. Eating brown bread instead of white,
using jaggery in place of refined sugar crystals in sweet preparation are some of
the examples of dietary modifications, that can help to reduce caries incidence.
5. Healthy snacks for in-between meals include; cheese, cottage cheese, all kinds of
nuts, fruits and vegetables.
6. Natural and fibrous food which require rigorous chewing stimulate salivary
flow and provide protection against dental diseases.
7. Oral hygiene maintenance by brushing twice a day using correct technique, (as
described in the text on page …) cleaning and gum massage helps to maintain
optimum oral health. In addition, brushing after every major meals (even
without toothpaste with a wet brush) removes the food particles sticking on to
teeth and reduces the caries incidence.
9. Get oral check up done every 6-month by a dentist.
8. Avoid use of alcohol and tobacco in any form.