Reference Mannual on Oral Health - Home | Ministry of ... · Oral Medicine and Radiology: Oral Pathology and Microbiology: Pedodontics and Preventive Dentistry? – Periodontics?

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)


Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners


Research Team

Principal Investigator : Prof. Naseem ShahChiefProfessor & HeadConservative Dentistry & Endodontics

Co-Investigators : Dr. Vijay Prakash MathurAssociate ProfessorPedodontics & Preventive DentistryDr. Ajay LoganiAssociate ProfessorConservative Dentistry & Endodontics


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


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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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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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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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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


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.


? 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-


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


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


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


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


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


(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:


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


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


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.


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


?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


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.


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


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


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


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


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


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


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


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


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


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


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


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.


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


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


?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


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


?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


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


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 :


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


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.

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