Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners

Developed under GOI-WHO Collaborative Programme (Biennium 10-11) CENTRE FOR DENTAL EDUCATION & RESEARCH All India Institute of Medical Sciences, New Delhi Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners

Developed under GOI-WHO Collaborative Programme (Biennium 10-11) CENTRE FOR DENTAL EDUCATION & RESEARCH All India Institute of Medical Sciences, New Delhi

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners Research Team Principal Investigator : Prof. Naseem Shah Chief Professor & Head Conservative & Endodontics Co-Investigators : Dr. Vijay Prakash Mathur Associate Professor Pedodontics & Preventive Dentistry Dr. Ajay Logani Associate Professor Conservative Dentistry & Endodontics

CENTRE FOR DENTAL EDUCATION & RESEARCH All India Institute of Medical Sciences, New Delhi

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 19

? 21

?Dental Fluorosis 26

? 29

?Other Dental Conditions 32

?Some Important Facts 34

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners Blank Page

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners P.K. PRADHAN Hkkjr ljdkj Secretary Department of Health & FW LokLF; ,oa ifjokj dY;k.k ea=kky; Tel.: 23061863 Fax: 23061252 fuekZ.k Hkou] ubZ fnYyh & 110011 e-mail : [email protected] GOVERNMENT OF INDIA lR;eso t;rs MINISTRY OF HEALTH & FAMILY WELFARE NIRMAN BHAWAN, NEW DELHI-110011

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)

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners lfpo Hkkjr ljdkj vk;qosZn] ;ksx o izkÑfrd fpfdRlk ;wukuh fl¼ ,oa gksE;ksiSFkh (vk;q"k) foHkkx lR;eso t;rs LokLF; ,oa ifjokj dY;k.k ea=kky; vfuy dqekj jsM Økl Hkou] ubZ fnYyh & 110001 ANIL KUMAR SECRETARY GOVERNMENT OF INDIA DEPARTMENT OF AYURVEDA, YOGA & NATUROPATHY UNANI, SIDDHA AND HOMOEOPATHY (AYUSH) MINISTRY OF HEALTH & FAMILY WELFARE RED CROSS BUILDING, NEW DELHI-110001 Tel. : 011-23715564, Telefax :011-23327660 e-mail : [email protected] Mailing No. 110 108

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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners Dr. Jagdish Prasad M.S. M.Ch., FIACS Hkkjr ljdkj Director General of Health Services LokLF; ,oa ifjokj dY;k.k ea=kky; LokLF; lsok egkfuns'kky; fuekZ.k Hkou] ubZ fnYyh & 110011 lR;eso t;rs GOVERNMENT OF INDIA MINISTRY OF HEALTH & FAMILY WELFARE DIRECTORATE GENERAL OF HEALTH SERVICES NIRMAN BHAWAN, NEW DELHI-110001 Tel. 23061063, 23061438 (0), 23061924 (F) Ernail : [email protected]

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)

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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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 1 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 2 INTRODUCTION

About Dentistry 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: ?Conservative Dentistry and Endodontics: It deals with restoration of tooth defects caused by dental caries, trauma, , , erosion etc to optimum level of function and aesthetics. ?Orthodontics and Dentofacial Orthopedics: 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. ?Oral and Maxillofacial Surgery: 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. ?Oral Medicine and Radiology: 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. ?Oral Pathology and Microbiology: It is the study of various oral pathologies and microbiology as related to oral diseases, disorders and infections. ?Pedodontics and Preventive Dentistry – It deals with prevention and management of dental and oral diseases in children from birth through adolescence and special need patients. ?Periodontics – It deals with study of supporting structures of teeth i. e. gingiva (), alveolar bone, , and the periodontal ligament and the diseases and conditions that affect them and their management. ?Prosthodontics - 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 3 ?Public Health Dentistry- 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: ?Implant Dentistry- 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. ?Aesthetic Dentistry – It refers to any dental work that improves the aesthetics of a person’s teeth, gums and/or bite. ?Geriatric Dentistry- 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 4 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.

Healthy teeth and gums Gross neglect of oral health

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 5 GENERAL ANATOMY AND FUNCTIONS OF TEETH

A tooth has the following parts: : That parts of the tooth which is visible in the mouth. Root: That part of the tooth that is anchored within the bone and is generally not

Root Root

Crown Crown

Incisor Canine Premolar Molar visible in the mouth. Humans have two sets of teeth:

Upper Central Incisor Upper Lateral Incisor Upper Central Incisor Canine Upper Lateral Incisor First Premolar Canine Second Premolar

First Molar First Molar

Second Molar

Second Molar Third Molar

Second Molar

First Molar First Molar

Canine Second Premolar Lower Lateral Incisor First Premolar Lower Central Incisor Canine Lower Lateral Incisor Lower Central Incisor

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 6 Primary Dentition Permanent Dentition Primary 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. Permanent dentition There are 32 adult teeth; 16 in the upper jaw and 16 in the lower jaw. These erupt from 6 -18 years of age. Functions of teeth 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 7 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 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%.

Tooth Carbohydrate

CARIES

Bacteria

Saliva Dental caries etiology

Etiology 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. Host factors 1. Teeth: a) Composition - Deficiency of certain trace elements in diet such as ,

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 4 8 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 9 (Reduced salivary secretion as found in xerostomia and 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. Agent : Microorganisms 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. Formation of Dental Plaque 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 Substrate: 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 10 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. Classification of Dental caries: Dental caries can be classified as: Coronal and root caries- Coronal caries: (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.

Pits & fissure caries Smooth surface caries

Root caries 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

Root caries

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 11 powder etc. and gets exposed. The irregular, rough surface attracts plaque deposition and initiation of caries. Dental caries is further classified as : Acute caries Which is rapidly progressing caries leading to faster involvement of pulp. Chronic caries which is slowly progressing and takes months or sometimes years to progress and involve the pulp. Nursing bottle caries 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. Rampant caries 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.

Nursing bottle caries Rampant caries

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 12 Arrested caries 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. Strategies for Prevention and Control of Dental Caries 1. Increase the resistance of the teeth: Systemic use of : (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 (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 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. 2. Combat the microbial plaque by physical and chemical methods. (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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 13 The correct brushing technique

Correct method of brushing 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.

3. Modify the diet. ?Reduce the intake and frequency of refined carbohydrates. ?Avoid sticky foods and replace refined sugar with un refined, natural food.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 14 Pit & fissure sealants

?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.

Preventive interventions: 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 – 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 15 Other preventive measures

?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 of dental caries 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 16 PERIODONTAL DISEASES

Periodontal diseases which includes 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. Etiology of Periodontal diseases 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. due to defective occlusal relationship of upper and lower teeth is also

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 17 Initial stage of periodontal Advanced stage of periodontitis showing increased disease showing red swollen spacing between the teeth due to destruction and inflamed gums of supporting structures and root exposure 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. Prevention and Treatment 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 Treatment methods for :

?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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 18 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 and , which is seen in 1.7/1000 live-births.

Malocclusion

Etiology Heredity: 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. Congenital: These include cleft lip and palate, and syndromes associated with anomalies of craniofacial structures, cerebral palsy, torticollis, cleidocranial dysostosis, congenital syphilis, etc. Abnormal pressure habits and functional aberrations: 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. Local factors: These include abnormalities of number such as supernumerary and

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 19 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. Prevention and Treatment of Malocclusion 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 20 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

Oral Cancer 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. Etiology 1. Tobacco: 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%). 2. Alcohol: 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 21 3. Oral Infections: 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. 4. Chronic irritation in any form - Sharp edges of teeth and faulty prosthesis 5. Radiation exposure 6. Nutritional deficiencies: Vitamin A, Iron and B-complex deficiency can produce metaplasia of epithelial structures, increasing its susceptibility to malignant conversion. 7. Industrial pollution due to asbestos, lead etc. Oral cancer is generally preceded by some precancerous condition like , , non-healing ulcer of > 15 days' duration, and erosive (Occasionally).

Leukoplakia

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 22 Leukoplakia It is a raised white patch which cannot be scraped off appearing anywhere on the , 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. Erythroplakia – 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. Lichen Planus – 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. Oral sub-mucous fibrosis – 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 23 Oral submucous fibrosis Advanced case of submucous Multiple cancerous lesions showing whitish bands fibrosis showing severe in a case of oral submucous in cheek mucosa restrictions in mouth opening fibrosis 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. Strategies for prevention and treatment of oral cancer Primordial Prevention & Health Promotion

?Prevent initiation of tobacco and alcohol habits

?Take nutritious, balanced diet to prevent nutritional deficiencies and to maintain optimum immune status

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 24 Primary Prevention ?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 Secondary Prevention ?Biopsy of suspicious lesions like leukoplakia, erythroplakia, submucous fibrosis, erosive lichen planus or non-healing ulcers of > 2 weeks' duration etc. Tertiary Prevention ?To minimize morbidity and disability due to disease itself or its treatment to the exten possible ?Maximise rehabilitation of the patient by restoring function, aesthetics and psycho- social support Treatment of Oral Cancer ?Surgery ?Radiotherapy ?Chemotherapy ?Combination of above Rehabilitation 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 25 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 26 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 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 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

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 27 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 28 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.

Tooth Fracture Crown root fracture

The types of dento-alveolar injuries can broadly be classified as: Tooth fracture – Fracture of enamel, dentin with or without involving the pulp Crown-root fracture – In addition to the crown of the tooth, root can get fractured at any level in the bone. Luxation injuries – 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). Complete avulsion or ex-articulation – The tooth or teeth may get dislodged and fall out at the site of accident/ injury.

Luxation injuries

Extrusive luxation Teeth stabilized with a wire and composite resin splint

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 29 Tooth discolouration following trauma

Dento-alveolar injuries – Along with the tooth the alveolar bone may also fracture, in which, excessive mobility of the fragment is noticed. Basal bone fracture – Either 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 The avulsed tooth Tooth splinted in position (Ex-articulation)

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 30 ?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.

Saving a dislodged tooth 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 31 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.

A case with missing lower and upper anterior teeth, rehabilitated with partial dentures

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 of complete edentulism rehabilitation with upper and lower complete dentures

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 32 ?Implants/ implant supported denture.

?Complete dentures (When all the teeth are lost) Tooth Substance Loss Teeth wear away due to masticatory forces over the years, which is normal and physiological. But several other causes also cause . Tooth wear is classified as Attrition: 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 . In this condition, excessive attrition of teeth occurs. Abrasion: 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. Erosion: 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.

Chemical erosion of teeth

Abfraction: 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.

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 33 SOME IMPORTANT FACTS

Certain oral conditions which may mimic diseases of other body systems. 1. Partial or complete – 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

Draining sinus on cheek due to infected upper molar

growing children this can also lead to arrest in the growth and development of the mandible resulting in micrognathia. 2. Extra oral discharging sinus on the face -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. Consequences of loss of a tooth - 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:

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 34 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). Missing tooth /teeth should be replaced 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 Cessation counselling and treatment 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. Dental Emergencies and their management in Health Care Set-up 1) Toothache : it is generally caused due to dental caries involving the pulp. The pulp

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 35 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. 2) Post-extraction bleeding: 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. 3) Accidental fall or trauma: 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.

Sources Used and for Further Reading 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,

Reference Mannual on Oral Health for Allopathic and AYUSH Practitioners 36 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. 8. Avoid use of alcohol and tobacco in any form. 9. Get oral check up done every 6-month by a dentist.