Clinical Manual For PubliC HealtH Dentistry and PraCtiCal reCorD Book PDF

Clinical Manual for
Public Health Dentistry

and Practical Record Book
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Clinical Manual for
and Practical Record Book
DP Narayan MDS
Principal, Professor and Head
Vydehi Institute of Dental Sciences
Bengaluru, Karnataka, India
Foreword
S Kantha
The Health Sciences Publisher

New Delhi | London | Philadelphia | Panama
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Clinical Manual for Public Health Dentistry and Practical Record Book
First Edition: 2015
ISBN: 978-93-5152-089-4
Printed at
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Dedicated to
“My mother”
Who inspired me throughout my life to become whatever I am today
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Contributors
Mayur Nath T Reddy

Reader
Department of Public Health Dentistry
Vydehi Institute of Dental Sciences and Research Centre
Deepti Vadavi
Senior Lecturer
RV Dental College, Bengaluru, Karnataka, India
Ajitha Kanduluru
Senior Lecturer
Mahesh BS
Senior Lecturer
Department of Oral Medicine and Radiology
Sujatha BK
Senior Lecturer
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Foreword
The study of medical and dental courses involves two aspects,

the theoretical aspect and practical/clinical aspect. To understand
the theoretical aspect, practical/clinical observations are more
important than theoretical learning. Keeping this in view, I
appreciate the author Dr DP Narayan who has made an effort to
write a clinical manual along with a Clinical Record Book of Public
Health Dentistry for undergraduate dental students. This clinical
manual gives a total and comprehensive description of the practical/
clinical exercises. The author has made an exemplary attempt to
infuse the understanding of the description of criteria, methods and
procedures for dental indices needed for epidemiological surveys.
The detailed description of each and every exercise has been presented very kindly and
coherently and in a language that is quite clear to understand and which can be easily
practiced and perfected by the students during their training period. Most of the text is
self-explanatory and comprehensive with well-complied topics which are formatted in an
easy-to-follow manner.
This Clinical Manual of Public Health Dentistry is a commendable work since it consists
of the important yet often overlooked topics such as clinical management of medically
compromised patients and management of medical emergencies in dental practice. Another
aspect I admire is the exemplary attempt to include the World Health Organization, Oral
Health Surveys: Basic Methods, Geneva, 1997.
This is a much needed Clinical Manual of Public Health Dentistry to provide a simplified
approach to Dental Public Health teaching and practice in all the dental institutions in our
country. The author has covered all the topics in accordance with the Practical/Clinical/
Field Work Syllabus for Public Health Dentistry prescribed by Rajiv Gandhi University of
Health Sciences and Dental Council of India (RGUHS and DCI). This manual is ideal for
all undergraduates and postgraduates, who would like to have a strong foundation in the
subject of Public Health Dentistry. Dr DP Narayan is a man with vision and mission.
S Kantha
First Vice-Chancellor
Rajiv Gandhi University of Health Sciences
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Preface
Public Health Dentistry in India is an upcoming specialty in dentistry from its infancy stage.
Very few health universities and dental colleges in India had this specialty entity. Now the
idea of Dental Council of India of improving the academic standards of dentistry in India
by making it mandatory to have this specialty as a separate entity and separate dental
department for training undergraduate and postgraduate students is highly appreciated.
Though there is a separate department of Preventive and Community Dentistry in many
dental colleges, it is yet to get momentum.
The main aim of this specialty is to prevent and control oral diseases at individual,
family and community levels. Prevention is the backbone of control of any disease. If we
look at the data of the developed countries, most of them have achieved their oral health
goals through primary prevention such as use of fluorides, pit and fissure sealants and oral
health education, plaque control technique, etc.
To understand this subject, practical observation is more important than theoretical
learning. Hence, an attempt is made to bring out a Clinical Manual for Public Health Dentistry
and Clinical Record Book which would help the undergraduate and postgraduate students to
assess and understand a simplified approach to Dental Public Health practice an elementary
knowledge of those public health that will help them design and operate their own programs.
This Clinical Manual and Record Book presents a description of the criteria, methods,
procedures and operational requirements needed for epidemiological surveys, School and
Community, Oral Health Programs. It is designed as a teaching aid to be used by the dentist,
who wishes to teach another dentist to perform the examination and preventive procedures.
It is also designed to be used as a reference manual by the dentist who is responsible for
planning, organizing and conducting and participating in Dental Health Programs. Hope
this Clinical Manual for Public Health Dentistry and Clinical Record Book fulfill the words “a
good book, which is opened with expectation and closed with delight and profit” as said
by Amos Bronson Alcott.
DP Narayan
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Acknowledgments
To God the father of all, I am thankful for the strength that keeps me standing and for the
hope that keeps me believing that this affiliation would be possible and more interesting.
No one walks alone on the journey of life; just where you start to thank those who
joined you, walked beside you, and helped you along the way continuously urged me to
write a clinical manual, to put my thoughts down on paper. Over the years, those that I
have met and worked with this manual, and to share my insights together with the secrets
to my continual, positive approach to life and all that life throws at us. So at last, here it is.
Perhaps this clinical manual and its pages will be seen as “thanks” to the tens of thousands
of you who have helped make my life what is today.
I offer my sincere and heartfelt gratitude to our beloved Chairman, Late Shri Dr DK
Adikesavalu for his divine blessings leading to successful completion of this clinical manual.
This clinical manual would have not seen the light of day without the constant support
of our ever-encouraging dynamic Director, Mrs Kalpaja DA to whom I am deeply indebted.
I am also grateful to Dr Mrs S Kantha, our beloved Advisor, Vydehi Institute of Medical
Sciences and Research Centre, Bengaluru, Karnataka, India, for her guidance and nurturing
of this clinical manual.
Apart from the efforts of myself, the success of this clinical manual for depends largely
on the encouragement and guidelines of my peers Dr Mayur Nath T Reddy, Dr Deepti
Vadavi, Dr Ajitha K, Dr Manasa S, Dr Sujatha BK, Dr Shweta HL, Dr Mahesh BS. I take
this opportunity to express my gratitude to the people who have been instrumental in the
successful completion of this clinical manual showing my greatest appreciation.
I would like to specially thank the Staff and Management of Jaypee Brothers Medical
Publishers (P) Ltd at New Delhi and Bengaluru for taking up this publication and helping
me to endeavor this book.
Much of what I have learned over the years came as the result of being a husband to
Mrs Thejaswini, father to 2 wonderful and delightful children, DN Nitin, DN Alok and
my most loyal companion Brandi, my pet dog all of whom, in their own ways inspired me
and, subconsciously contributed a tremendous amount to the content of this book. A little
bit of each of them will be found here weaving in and out of the pages.
Last and not least: I beg forgiveness of all those who have been with me over the past
years and whose names I have failed to mention.
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Contents
Section 1: Clinical Manual for Public Health Dentistry

Chapter 1. Introduction 3
• Public Health Dentistry 4
• Community Dentistry 6
• Preventive Dentistry 8
Chapter 2. Comprehensive Oral Health Care Planning 10

• Comprehensive Oral Health Care 10
• Process of Comprehensive Oral Health Care 13
Chapter 3. Evaluation of the Patient for Comprehensive Oral Health Care 16

• Case History 16
• Demographic Data 16
• Chief Complaint 18
• Significance 19
• Complete Patient History 22
• Cardiovascular Diseases 24
• Liver 25
• Kidney 26
• Respiration and Lung Diseases 26
• Diabetes or Hormonal Problems 26
• Cancer Radiation and Cancer Chemotherapy 27
• Blood Disorder 27
• Bleeding Disorder 27
• Infectious Diseases 28
• Hepatitis B 28
• Tuberculosis 28
• Sexually Transmitted Infections 28
• Herpes 29
• Hiv Infection Aids 29
• Arthritis 29
• Mental and Psychiatric 29
• Physical Disabilities 29
• Epilepsy 30
• Gastrointestinal 30
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xvi Clinical Manual for Public Health Dentistry and Practical Record Book
• Family History 30
• Personal History 31
• Social History 31
• Diet and Dietary Analysis 31
• Food Diary 33
• Diet Counseling 35
• General Examination 37
• Vital Signs 37
• Body Temperature 37
• Pulse 39
• Blood Pressure 40
• Local Examination 40
• Extraoral and Intraoral Examinations 43
• Basic Terminology in Tooth Numbering System 48
• Universal or Continuous System Number 1 Through 32 System 50
• Palmer or Quadrant or Chevron Numbering 1 Through 8 System 51
• The European Tooth Numbering System 51
• Examination of Teeth 52
• Provisional Diagnosis 54
• Investigations 55
• Radiographs 55
• Treatment Plan 56
• Levels of Prevention 56
Chapter 4. Assessment of Oral Health Status Using Dental Indices 57

• Dental Index 57
• Armamentarium Used in Examination of Patient to Record Dental Indices 60
• Oral Hygiene Index 65
• Oral Hygiene Index-Simplified (Ohi-S)(Greene and Vermillion 1964) 69
• Assessment of Periodontal Diseases 74
• Russell’s Periodontal Index 75
• Community Periodontal Index of Treatment Needs (Cpitn) 78
• Community Periodontal Index (Cpi) 82
• Decayed Missing Filled (Dmf) Index 85
• Calculations for Dmf Index 95
• Dean’s Fluorosis Index (1942) 98
Chapter 5. Assessment of Oral Health Status Using WHO

Assessment Form 100
• General 100
• Standard Codes 100
• Oral Health Assessment Form 100
• Identification and General Information Sections of the Form 101
• Clinical Assessment 103
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Contents xvii
Chapter 6. Preventive Dentistry 116
• Professional Topical Application of Fluoride 116
• Knutson Technique: Sodium Fluoride 2% 120
• Stannous Fluoride 8% (Muhler’s Technique) 121
• Acidulated Phosphate Fluoride (Apf): Brudevold’s Technique 123
• Fluoride Varnishes 127
• Toxicity of Fluoride 129
• Pit and Fissure Sealants (The Acid Etch Technique in Caries Prevention Sealants) 130
• Atraumatic Restorative Treatment 143
• Biofilm Control 172
• Oral Health Education to Control Biofilm Using Php Index 174
• Plaque Control 175
Chapter 7. Diet Counseling 180

• Dietary Counseling 180
Chapter 8. Management of Physically and Mentally Challenged Children 184

• Definition 184
• Classification 184
• Preventive Measures 185
• Mental Retardation 185
• Learning Disability 186
• Epilepsy 186
• Deafness 187
• Blindness 187
Chapter 9. Management of Medically Compromised Patients 188

• Ischemic Heart Diseases 189
• Disorders of Blood 192
• Hemophilia 192
• Hemophilia B—Christmas Disease 193
• Von Willebrand Disease 193
• Thrombocytopenia 193
• Anemia 194
• Respiratory Disorders 194
• Renal Disorders 195
• Metabolic and Endocrine Disorders 195
• Hypoglycemia 196
• Infections 196
Chapter 10. Preparation of Oral Health Education Material 197

• Oral Health Education Materials 197
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xviii Clinical Manual for Public Health Dentistry and Practical Record Book
• Dental Poster or Chart 197

• Gunning Fog Index 205
Chapter 11. Field Program—A Visit to School 208

• A Visit to School 208
• Classroom Based Fluoride Programs 213
• Field Program After Field Program 214
Chapter 12. Early Detection of Oral Cancer 217

• Primary Prevention 217
• Secondary Prevention 217
• Tertiary Prevention 217
• Diagnostic Protocol for Oral Cancer 219
Chapter 13. Early Detection of Dental Caries 221

• Concepts of Risk Factor, Risk Indicator, Risk Prediction and Risk Assessment 221
• Risk Factors to Dental Caries 221
• Risk Groups 222
Chapter 14. Setting up of a Private Dental Clinic 227

• Financial Resources 228
• Designing of the Dental Office 228
• Designing of the Work Area 228
• Selection of the Equipments and Instruments 228
• Patients in Practice 229
Chapter 15. Consent Letter 233
Chapter 16. Public Health Laboratory 235

• Public Health Laboratories 235
Section 2: Practical Record Book
Chapter 17. List of Armamentarium Required in Department of

Public Health Dentistry 239
Chapter 18. Assessment of Oral Health Status Using Dental Indices 240
Indices Used to Assess Oral Hygiene 240
• Oral Hygiene Index (Greene and Vermillion, 1960) 240
• Oral Hygiene Index—Simplified (Greene and Vermillion, 1964) 240
• Patient Hygiene Performance Index 243
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Contents xix
Indices Used to Assess Dental Caries Status 244
• Dmf Index (Klein, Palmer and Knutson 1938) 244
• Dmfs Index 245
• Mixed Dentition 246
• Modification of Def Index 246
• Rationale for the Dmft Classification 247
• Examination Criteria and Rule for Coding 248
• Exclusions 249
• Permanent Tooth Present 249
• Primary Tooth Present 250
• Primary or Permanent Tooth Absent 250
• Extracted Permanent Tooth 250
• The Dmft Examination Procedure 250
• Do’s and Dont’s for the Examiner 251
Indices Used To Assess Periodontal Status 251

• Russel’s Periodontal Index 251
• Community Periodontal Index of Treatment Needs (Cpitn) 252
• Community Periodontal Index (Cpi) 257
Indices Used for Dental Fluorosis 259

• Dean’s Fluorosis Index 1942 259
Chapter 19. Assessment of Oral Health Status Using

Who Basic Oral Health Survey Form 260
• Survey Form 260
Chapter 20. Comprehensive Oral Health Care Planning 261

• Comprehensive Oral Health Care 261
• Evaluation of Dental Patient 261
Chapter 21. Preventive Dentistry 265

Topical Fluoride Application by Professionals 265
• Knutson’s Technique: Sodium Fluoride 2% 265
• Muhler’s Technique: Stannous Fluoride 8% 266
• Brudevold’s Technique: Acidulated Phosphate Fluoride (Apf) 266
Application of Pit and Fissure Sealants 268

• Procedure 268
• Pit and Fissure Sealants 268
Atraumatic Restorative Technique (Art) 269

• Steps in Preparing the Cavity for Art 269
• Atraumatic Restorative Technique 269
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xx Clinical Manual for Public Health Dentistry and Practical Record Book
Chapter 22. Oral Health Education Materials 270

• Description of Oral Health Talk and Presentation of
Oral Health Education Material 270
Chapter 23. Field Programs (Submission of Reports) 273

• A Visit to School 273
• Visit to Primary Health Center 274
• Visit to Water Purification Plant 275
• Visit to Sewage Treatment Plant 276
• Visit to Milk Dairy 277
• Visit to Pharmaceutical Company 278
• Visit to Institution for Handicapped People 279
• Caries Detection Program 280
• Cancer Detection Program 281
Chapter 24. Comprehensive Report on Setting up a Private Dental Clinic 282

• Comprehensive Report on Clinical Practice 282
Chapter 25. Proforma for Indices 285

• Proforma for Russel’s Periodontal Index 285
• Proforma for Community Periodontal Index of Treatment Needs 286
• Proforma for Community Periodontal Index 287
• Proforma for Caries Indices (Dmft, Dmfs, Dft, Dfs) 288
• Proforma for Oral Hygiene Index 289
• Proforma for Oral Hygiene Index-Simplified 290
• Proforma for Dean’s Fluorosis Index 291
References 293
Index 295
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SECTION 1
Clinical Manual for Public
Health Dentistry
Chapter 1. Introduction
Chapter 2. Comprehensive Oral Health Care Planning
Chapter 3. Evaluation of the Patient for Comprehensive Oral Health Care
Chapter 4. Assessment of Oral Health Status Using Dental Indices
Chapter 5. Assessment of Oral Health Status Using WHO Assessment Form
Chapter 6. Preventive Dentistry
Chapter 7. Diet Counseling
Chapter 8. Management of Physically and Mentally Challenged Children
Chapter 9. Management of Medically Compromised Patients
Chapter 10. Preparation of Oral Health Education Material
Chapter 11. Field Program—A Visit to School
Chapter 12. Early Detection of Oral Cancer
Chapter 13. Early Detection of Dental Caries
Chapter 14. Setting up of a Private Dental Clinic
Chapter 15. Consent Letter
Chapter 16. Public Health Laboratory
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Chapter
1 Introduction
We are all living in this wonderful world, main diseases responsible for premature loss
which is changing everyday. The pattern of of teeth and consequent crippling of the oral
life of people is changing in this changing cavity, thus causing oral and general health
society. The overall population is increasing problems are:
and within the population the relative age i. Dental caries or decay, affecting teeth and
structure of the society is changing. The ii. Periodontal or advanced gum diseases
life expectancy of man is rising because affecting gums and supporting jaw
of increased health care, better nutrition, bones. Both of these dental diseases are
sanitation and relief from communicative due to the presence of dental plaque.
diseases. Thus, due to many other reasons, Dental services which give priority to the
the relative improvement of general health treatment of oral diseases often do not reduce
shows a glaring contrast to the deteriorating their prevalence. Program for oral health care
situation in the field of oral health. This must recognize the paramount importance
glaring contrast between general and oral of prevention, if they are to be effective and
health is very wide in developing countries. economical. Can traditional dental care, still
In developing countries, the Public be recognized as proper treatment? The facts
Health Dentistry should have been given seems to indicate that symptomatic dental
due recognition and its rightful place. treatment is a highly ineffective means of
Unfortunately, the dental/oral health of curing caries and periodontal diseases. Only
people is not very good as is considered people who live in major cities can get rea-
and it has not received due recognition and sonable treatment for oral problems. Most
importance. An ordinary citizen knows rural and many poor urban communities
very little about the oral health. The rural have almost no access to even emergency
populations which constitute majority of our care and relief of pain. For too many people
populations are socially and economically dentistry is still “pain and pay”.
backward and quite ignorant about the In order to bring down the disease
benefits of good oral health. It is felt that very prevalence and severity, it is important to
little efforts have been made to motivate and implement organized oral health preventive
educate, the public about the oral health, to programs at community level, as has been
prevent the oral diseases in their early stages demonstrated in a number of Western
and to provide oral health services to public countries, where the increasing trend in
especially rural population. dental caries has been totally reversed.
Thus, the oral health of masses appears What is the explanation for the spectacular
to be deteriorating in our country. The two drop in caries prevalence in these countries?
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4 Clinical Manual for Public Health Dentistry and Practical Record Book
How can it be prevented from rising again? USA, gave the oft-quoted definition of
How can the worsening of the situation public health. The WHO Expert Committee
in other countries be halted? The reply to on Public Health Administration adapting
these questions is one and the same: Winslow’s earlier definition, has defined
Prevention, more prevention and still more it as: “The science and art of preventing
prevention. disease, prolonging life, and promoting
The proverb that “Prevention is better health and efficiency through organized
than cure” should be changed to “Prevention community efforts for the sanitation of the
is the only cure”. environment, the control of communicable
Each student should understand that infections, the education of the individual in
wisdom implies a mature integration of personal hygiene, the organization of medical
appropriate knowledge and seasoned ability and nursing services for early diagnosis and
to filter the inessential from the essential. preventive treatment of disease, and the
True knowledge exists in knowing that you development of social machinery to ensure
know nothing. The scientist visualizes the for every individual a standard of living
world from this view point. His wisdom lies adequate for the maintenance of health, so
in his vision. His descriptive language has organizing these benefits as to enable every
some unconventional words, which share citizen to realize his birth-right of health and
some special thoughts and suggestions. longevity”.
If these atypical words, are not rightly
understood by the teachers and taught, Dental Public Health
transfer of knowledge would be impossible. The American Board of Dental Public
Therefore, in every textbook of science the Health modified the Winslow’s definition
first few chapters describe the categories to of public health and defined dental public
understand it better. No scientific textbook health as:
can be prescribed to the student without an “The science and art of preventing and
initial chapter giving the description of terms controlling dental diseases and promoting
and terminologies that have been used in the dental health through organized community
body of the book. efforts. It is that form of dental practice,
which serves the community as a patient
rather than the individual. It is concerned
PUBLIC HEALTH DENTISTRY
with dental health education of the public
Definitions with research and the application of the
Health findings of research, with the administration
According to WHO, health is defined as “The of programs of dental care for groups and
state of complete physical, mental and social with the prevention and control of dental
well-being, and not merely the absence off disease through a community approach”.
disease or infirmity”. Science of Dental Public Health
It is the concept that oral health services
Public Health should be aimed at the community level
In 1920, Charles Edward A Winslow, a former rather than the individual patient. It involves
professor of public health at Yale University, the application of;
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Introduction 5
1. Principles of epidemiology 1. A condition or situation or disease that
2. Principles of administration is a widespread and majority of people
3. Social science health education are affected and is an actual or potential
4. Biostatistics cause of morbidity or mortality.
5. Preventive dentistry. 2. An existing perception that the condition
After applying theses services scien- is a public health problem on the part of
tifically community diagnosis is made and the public, government, or public health
appropriate community treatment rendered. authorities.
3. Certain preventive and control meas-
Art of Dental Public Health ures are known or exist but these
Just applying scientific principles and measures are not being implemented.
arriving at community diagnosis does
not suffice. For successful community Objectives/Functions of
treatment, art of dental public health has to Public Health Dentistry
be developed. Essential features in acquiring The following are the major activities of
this art are: public health dentistry:
1. To see that the ‘felt needs’ are given a 1. Health promotion for the entire
priority population
2. To see that there is a wide co-operation 2. Dental public health education
between the oral health care beneficiar- 3. Conducting periodic dental and oral
ies and providers to utilize existing epidemiological surveys:
resources with maximum efficiency i. To detect and eradicate or control
3. To see that the services are easily accessible those factors operating in the com-
4. To give a priority to high risk and munity, which are inimical to oral
vulnerable sections health, general health and well-
5. To make services available to all being
regardless of their ability to pay ii. To assess the needs for dental care of
6. To see that dental health education the community
imparted is easily comprehensible. iii. To determine the priorities and
Application of the knowledge of statement of objectives
behavioral sciences enables the practice of iv. To determine the available resources
art of dental public health. for program implementation.
A suggested modification of Knutson’s 4. The improvement of community oral
definition is “dental public health is a con- health by;
cern for and activity directed toward the i. Implementing effective preventive
improvement and promotion of the dental and therapeutic measures
health to the population as a whole as well ii. Deploying the available resources
as of individuals within that population”. to meet the needs on the basis of
priority
Determining a Public Health Problem iii. The measurement of the effective-
Today, we can define a public health problem ness of present services and the
as an issue that meets the following criteria: planning of new services
Chapter 1.indd 5 11/5/2014 6:09:11 PM

iv. The co-ordination and integration of 4. What is the prevailing philosophy of the
dental services and health services. people regarding the extent of health care,
To fulfill the above mentioned objectives, they expect to receive and the manner in
we should arrange dental care programs which they are willing to receive?
such as— 5. To what extent will prevention of disease
1. School dental health program obviate the need for treatment? If in fact
2. Community dental health program preventive measures could accomplish
3. Fluoridation of drinking water like this, would they be acceptable for a
school water fluoridation and commu- particular society or segment of society?
nity water fluoridation 6. What scope of service will be offered
4. Topical application of fluorides in a public health program, who will
5. Fluoride mouth rinsing programs receive the service, and in what manner
6. Early detection of oral cancer program will the service be delivered?
7. Monitoring and evaluation of pro- 7. How can the service be adjusted to
grams reach more of the population?
8. Providing treatment services to persons
who do not have easy access to general COMMUNITY DENTISTRY
dental practitioners or hospitals, dental
and oral health care for handicapped, What is Community?
physically, mentally and medically The word “community” has a variety of
compromised patients meaning as follows:
9. Establish and maintain a community 1. The term ordinarily refers to “the
laboratory setting in which the dentist lives and
10. Co-ordinate and participate in the practices his profession”.—Young and
teaching of dental public health and Stiffler.
preventive practices to students, teach- 2. “ A c o m m u n i t y a s t h e e c o l o g i s t
ers, health visitors, health educators, would call it, biotic community is a
dieticians, nurses and doctors. more complex affair, embracing all
population in a rather small geographic
Dental Public Health Programs area, both plant and animal, including
man”.—James Morse Dunning.
James Morse Dunning has raised a number of
3. “A body of people having com-
important questions that must be addressed
mon organiz ation or living in the
if a program is to be planned effectively, they
same place under the same laws and
are as follows;
regulations.”This definition encom-
1. What are the dental needs of the com-
passes not only a city, but also would
munity or population?
apply to a state, a region or the active
2. What dental personnel are available to
nation”.—Webster’s Third New Inter-
serve the population, and what is the
national Dictionary.
political climate in regard to the type of
staffing that can be used?
3. How extensive is the demand for dental What is Dentistry?
treatment in the population? According to Indian Dentist Act, 1948:
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Introduction 7
1. The performance of any operation and diagnosis, planning and implementation of
the treatment of any disease, deficiency measures for the benefit of the community”.
or lesion of human teeth or jaws, and (Ref: Lars Granath and William, ‘Systema-
the performance of radiographic work tized Prevention of Oral Disease’: Theory
in connection with human teeth or jaws, and Practice - 1986. Page - 224).
or the oral cavity. Community dentistry has an important
2. The use of any anesthesia in connection role in dissemination and implementing
with any such operation or treatment. knowledge obtained from the natural
3. The mechanical construction or the sciences as well as the social sciences.
renewal of artificial dentures or restora- Epidemiology, particularly analytical
tive dental appliances. epidemiology, is the instrument through
4. The performance of any operation on which much of this information can be
or the giving of any treatment advice or brought together, evaluated and systema-
attendance to, any person preparatory tized for the benefit of both individuals and
to or for the purpose of or in connec- the community at large.
tion with, the filling, inserting, fixing,
constructing, repairing, or renewing of Simple Definition of Community Dentistry
artificial dentures or restorative dental “It is the field concerned with the study of
appliances, and the performance of any dental and oral health and disease in the
such operation and the giving of any population of a defined community”. Its
such treatment, advice or attendance, as goal is to—
is usually performed or given by dentists. a. Identify the dental and oral health prob-
(DENTIST: Means a person who practices lems and needs of defined population,
dentistry). i.e. community diagnosis.
b. To plan, implement and evaluate the
Community Oral Health extent to which dental and oral health
Is the organization of an array (regular measure effectively meet these needs,
arrangement) and range of promotive, pre- i.e. community treatment.
ventive and curative oral health services
required at individual and community level What is Community Diagnosis?
for the people living in a community. It is systematic investigation of community
dental and oral health status and problems,
What is Community Dentistry? through epidemiological surveys. Important
Community dentistry is mainly concerned data collected are;
with health promotion in the community 1. Demographic pattern of the community
and should be defined as: “That branch of 2. Socioeconomic condition of the people
dentistry, which is practiced in relation to 3. Incidence and prevalence rates of dental
population and groups; which derives from and oral health status and diseases
social sciences and epidemiology an aware- 4. Identification of dental and oral health
ness of the strategies and tactics required problems and needs of population
and which including the development of 5. Identification of high-risk and vulner-
the techniques necessary for population able sections
Chapter 1.indd 7 11/5/2014 6:09:11 PM

6. Resources of community, i.e. manpower, What is “Prevention”?

finance, time, place, material, etc. It is the process of interception or intervention
to halt or prevent the onset of disease and
What is Community Treatment? treating the disease if occurs in early stages
It aims at working out plans, oral health to prevent the complications.
programs and schemes for carrying out oral
health and other services required to solve Why should we Prevent Dental and
the community oral health problems. Oral Diseases?
Community treatment should stress on The following 3 main points gives justifica-
utilization of already existing resources of tion to the prevention of dental diseases.
the community. Priority is to be given to the 1. Avoidance of pain
“felt needs of the people”. 2. Justification for oral and general health
Action in community treatment is aimed 3. Economy of dental treatment.
at 3 levels:
1. Individual level Avoidance of Pain
2. Family level The pain due to dental diseases is excruciating,
3. Community level. very severe and unbearable and because of
it there will be loss of attendance in school,
loss of work, loss of income, loss of sleep,
PREVENTIVE DENTISTRY discomfort, etc.
What is Preventive Dentistry? Justification for Oral and General Health
Preventive dentistry can be defined as “The
Because of the following reasons:
science and art of promotion and application a. Mouth acts as doorway for food
of measures to prevent the onset of oral and b. Mastication of food
dental diseases and to treat these diseases c. Phonation (speech)
in their early stages and prolonging life by d. Deglutition
promoting dental health as well as physical e. Oral cavity acts as foci of infections—
and mental health and efficiency for the dental and oral diseases act as foci of in-
individuals and families as well as groups fections, which lead to septicemia, bacte-
and community”. remia, bacterial endocarditis, cavernous
Preventive dentistry is defined as “The sinus infection and oral infections, also
efforts which are made to maintain normal spreads to other parts of the body.
development, physiologic function and to
prevent diseases of the mouth and adjacent Economy of Dental Treatment
parts”.—Blackerby. Dental treatment techniques are more
Brauer stated that “Prevention as it expensive than preventive techniques.
applies to dentistry refers to the treatment or
mechanisms which are employed to avert or Principles of Prevention of Disease
intercept dental or systemic diseases which Most of the dental and oral diseases are
tend to destroy or make less oral tissues preventable. Successful prevention depends
function”. upon;
Chapter 1.indd 8 11/5/2014 6:09:11 PM

Introduction 9
1. A knowledge of causation 6. Continuous evaluation and develop-
2. Dynamics of disease transmission ment of procedures to be applied.
3. Identification of risk factors and risk Before planning for any preventive proce-
groups dure, we should consider the following 3
4. Availability of prophylactic or early principles:
detection, preventive and treatment 1. Natural history of disease
measures 2. Levels of prevention
5. Organization for applying these meas- 3. Awareness and use of appropriate pre-
ures to appropriate persons or groups ventive techniques or measures.
Chapter 1.indd 9 11/5/2014 6:09:11 PM

t
Chapter
2 Comprehensive Oral
Health Care Planning
The dentist is a licensed primary oral health- Definition: It is a co-ordinated inter-discipli-

care personnel, oral healthcare educator and nary approach of providing preventive and
clinician who provides preventive, educa- therapeutic care followed by maintenance
tional and therapeutic services supporting care according to individual physical, men-
total health for the control of oral diseases tal and socioeconomical status.
and the promotion of oral health. Dental The candidate should be able to plan
services available for general population comprehensive treatment for the individual
includes programs for research, professional or for a group.
education, community health and hospital Under the guidance of teachers, the
and institutional care of disabled persons, students must use the specific proforma
as well as for federal programs, the armed and should be able to express his/her views
services and dental product promotion in about positive upgrading of oral health
corporate industry. status.
The term dental care is used to denote all 1. The demographic details are collected.
integrated preventive and treatment services The chief complaint is noted.
administered to a patient by a dentist. 2. The patient is examined for general and
It can be provided in two ways, educa- oral health status. Clinical findings are
tional and clinical services. noted down.
3. Investigation: Required investigations
Educational services: By providing informa-
should be carried out to confirm the
tion about the importance of oral health, its
provisional diagnosis. For example,
maintenance and relationship with general
deep dental caries involving pulp or
health. not can be confirmed by intra-oral
periapical (IOPA) radiographs.
Clinical Services: By providing treatment for
the already existing disease or condition. 4. The treatment priorities are to be listed
Both are mutual inseparable components of out and the levels of prevention for each
comprehensive oral health care in provid- treatment are to be noted.
ing total dental care to the patient. 5. Lastly the goal of achievements, which
the doctor wants to aim at is mentioned.
For example, improvement of mastica-
COMPREHENSIVE ORAL HEALTH CARE
tory efficiency, phonetics, esthetics, etc.
“It is the complete oral health treatment, social acceptance, social utility of the
planning for an individual or for a group so individual, psychosocial adjustment of
that the goal of total oral health is achieved.” the patient, etc.
Chapter 2.indd 10 11/5/2014 6:03:55 PM

Comprehensive Oral Health Care Planning 11
The comprehensive oral health care There are two modes of intervention:
responsibilities of the dentists are divided 1. Health promotion
into preventive, educational and therapeutic 2. Specific protection.
services. The activities of these services are
inseparable and overlap as patient’s care is Health promotion: It is the process of enabling
planned and accomplished. people to increase control over and to
improve health. It is not directed against any
particular disease and aimed at strengthening
Preventive Services
the host by improving the general health and
Preventive services are the methods quality of life of individuals. Examples are:
employed by the clinician and/or patient
• Health education to maintain in oral
to promote and maintain oral health.
hygiene
Preventive services fall into 5 categories:
• Improving good standard of nutrition
Primordial, primary, secondary and tertiary
• Diet planning
and quaternary services.
• Periodic screening and inspection.
Primordial services: It is the primary pre-
Specific protection: It refers to the specific
vention in its purest sense. It prevents the
procedures that remove the possibility of a
emergence or development of risk factors in
occurrence. Examples are:
population or country in which they have
not yet occurred. • Good oral hygiene maintenance
For example; discouraging children from • Fluoridation of public water supply to
adopting harmful lifestyles like smoking prevent dental caries
which can lead to oral cancer and periodontal • Topical fluoride application to prevent
problems in the future. dental caries
The mode of intervention in primordial • Avoidance of soft sticky food, between
prevention is through individual and mass meals
education. • Tooth brushing after eating
• Dental prophylaxis
Primary Prevention • Treatment of highly susceptible but un-
Refers to measures carried out so that disease involved areas of tooth in population at
does not occur and is truly prevented. high risk (prophylactic odontotomy)
• Preventive orthodontics.
Definition: Primary prevention can be de-
fined as “action taken prior to the onset of Secondary Prevention
a disease, which removes the possibilities Involves the treatment of early disease to
that a disease will ever occur”. It signifies prevent further progress of potentially irre-
intervention in the pre-pathogenesis phase versible conditions that, if not arrested, can
of a disease. lead eventually to extensive rehabilitative
Intervention can be defined as any treatment or even loss of teeth.
attempt to intervene or interrupt the usual
sequence in the development of disease in Definition: Secondary prevention can be
man. defined as “action which halts the progress
Chapter 2.indd 11 11/5/2014 6:03:55 PM

of a disease at its incipient stage and prevent Disability limitation: It aims at halting the
complications”. disease process by instituting appropriate
It is like stamping out the “spark” rather treatment and thus limiting the disability,
than calling the fire brigade to put out the preventing further complications and
fire. A WHO expert committee defined early preventing/postponing death. The objective
detection and health impairment as “the of this intervention is to prevent or halt
detection of disturbances of homeostatic the transition of the disease process from
and compensatory mechanism while impairment to handicap. Examples are:
biochemical, morphological and functional • Treatment of well developed lesions
changes are still reversible”. Examples are: • Pulp capping
• Periodic detailed oral examination with
• Root canal therapy
X-rays
• Extractions
• Prompt treatment of incipient lesions
• Orthodontic treatment.
• Extension of therapy into vicinity of
lesions for prevention of secondary Rehabilitation: It is the replacement of lost
lesions or missing tooth structures by appropriate
• Attention to development of defects appliances using a fixed partial dentures
related to oral cavity (bridges), complete dentures, or implants and
• Compulsory examination of school thereby restoring the harmony and function
children on regular basis of oral cavity.
• Removal of calculus and dental plaque
while debriding a root surface in a rela- For example: The replacement of a missing
tively shallow periodontal pocket is an tooth by using fixed partial denture or im-
example of secondary prevention treat- plant leads to restoration of the function of
ment that contributes to the prevention missing tooth.
of continued tooth attachment loss and
formation of deep periodontal pocket.
Educational Services
Tertiary Prevention This involves a comprehensive approach
Uses methods to replace lost tissues and to that requires changes in lifestyle as well as
rehabilitate the oral cavity to a level where in human behaviors.
function is as near normal as possible after • Educational strategies developed for an
secondary prevention failure. individual or a group of people to elicit
their behaviors, attitude towards oral
Definition: Tertiary prevention can be de- health and teach them healthy lifestyle
fined as “all measures available to remove factors which have positive influence on
or limit impairments and disabilities, mini- oral health.
mize suffering caused by existing departure • Educational aspects of dental service
from good health and to promote the patient permeate the entire patients care system.
adjustment to irremediable conditions”. • The preparation for clinical treatment,
There are two modes of intervention: the outcome of treatment, and the long-
1. Disability limitation term success of both preventive and
2. Rehabilitation therapeutic services depend on patients
Chapter 2.indd 12 11/5/2014 6:03:55 PM

understanding of each procedure and • Documentation of data in patient’s
on personal care of the oral cavity. record.
The subjective data are:
Therapeutic Services • Obtained by observation and interaction
• Therapeutic services are clinical treat- with patient
ment designed to arrest or control • Includes chief complaint, perception
disease and maintain oral tissues in of oral health need and the important
health. given to oral health
• Comprehensive oral health care services • Includes medical history, dental history,
are an integral part of the total treatment family history, personal history.
procedures designed in response to the The objective data are:
financial position and paying capacity • Includes general physical and oral
of patient towards their therapeutic health assessment—general physical
services. examination and extra-oral and intra-
oral examination.
• Records clinical and radiographic find-
PROCESS OF COMPREHENSIVE ings to show evidence of disease in teeth
ORAL HEALTH CARE and periodontal tissues, like dental car-
The process of comprehensive oral health ies, periodontal disease, malocclusion,
care includes assessment, dental diagnosis dental trauma. All these conditions are
or oral disease, planning, implementation recorded by using appropriate indices.
and evaluation. As a process, the procedures
performed are continued in nature and may Dental Diagnosis
overlap or occur simultaneously. The dental diagnosis identifies the health
The objectives of the process of compre- behaviors of individuals as well as the actual
hensive oral health care are: or potential oral health problems which
• To provide framework within which can be treated by well trained and licensed
felt or customized needs of the patient dentist. The diagnosis provides the basis
can be met. on which the dental care plan is designed,
• To identify causative or risk factor of a implemented and evaluated.
condition/disease that can be prevented, For preparations of dental diagnosis, the
reduced, eliminated by the dentist. data from the assessment phase are critically
analyzed and interpreted.
Assessment Justify the treatment proposal to the
The assessment phase is the first component patient and challenge the dentist to assume
of the comprehensive oral health care responsibility for patient care and move
process. This phase provides a foundation beyond a rote system of clinical practice.
for patient care by collecting both subjective
and objective data. Data Processing
The objectives of assessment are: Use critical thinking skills to collect and
• Systematic collection of comprehensive interpret information. Include classification,
data relative to oral health status of the interpretation and validation of information
individual patient. collected during the assessment phase.
Chapter 2.indd 13 11/5/2014 6:03:55 PM

Classification • Incorporate priorities, goals, interven-

Classification of data involves the sorting of tions, expect outcomes.
information into specific categories such as
general (systemic), oral hygiene, periodontal, Mechanism of Planning
dental caries. As information is organized,
Establishing Priorities
pertinent data are interpreted according to
the patient’s need. • Priorities are determined by the imme-
diacy of the condition, the severity of
Interpretation the oral health problems, and available
Data interpretation relies upon critical think- resources.
ing to identify significance. The cognitive • Patients are active participants in the
process of analysis, synthesis, inductive identification of priorities.
reasoning and deductive reasoning are the
basis for determining a diagnosis. Setting Goals
• Compare findings with standards or • Each problem is accompanied by a goal.
norms • A goal is directly related to the problems
• Recognize deviations or abnormalities and represents the anticipated level of
• Analyze abnormalities with respect to achievement.
significance.
Determining Interventions
Validation • Interventions are dental therapies or pa-
Validation is an attempt to verify the tient educational activities that reduce,
accuracy of data interpretation. Validation eliminate or prevent the course of the
can assist in recognizing errors, isolating problem. For example: For prevention
discrepancies, and identify the need for of halitosis one of the interventions may
additional information. include tongue cleaning that prevents
• Direct interaction with the patient collection of dental plaque on dorsal
• Consultation with other health-care surface of the tongue.
professionals.
• Comparison of data with an authenti- Identify Expected Outcome
cated reference.
• Expected outcome represents measur-
able criteria for each intervention.
Dental Care Planning
• It is selected according to the antici-
Dental care planning is the selection of pated effectiveness of the interventions.
interventions to be performed by the patient,
• It provides a way to evaluate the results
dentist, or others to meet the needs of the
of the intervention.
patient in attaining oral health.
For example: An expected outcome follow-
Objectives ing a patient education intervention about
• Develop strategies to meet the individual tongue anatomy might be that the patient
needs of the patient as identified by the is now able to perform a self-evaluation of
dental diagnosis tongue cleanliness.
Chapter 2.indd 14 11/5/2014 6:03:55 PM

Presenting the Dental Care Evaluation Phase
Plan to the Patient At this point, the process of care becomes
This helps in complete understanding full circle. The evaluation phase is used to
of the interventions needed and the ap- determine if the patient needs to be retreated,
pointment requirements, thus facilitating referred, or placed on maintenance.
integration with the comprehensive oral
health plan. Objectives
• Compare current oral health status with
Obtaining Informed Consent baseline data
• Demonstrates that the case plan has • Assess progress or lack toward the
been thoroughly explained to the stated good
• Determined change or modification of
patient.
the care plan
• Determines the willingness of the
• Determine maintenance interval accord-
patient to participate. ing to the patient’s health status and adher-
ence to personal oral hygiene protocols.
Implementation Phase
The implementation phase is the activation Maintenance Phase
of the dental care plan. It is the phase where The maintenance phase of care has also been
the dental care services are performed along termed as “continuing care” or “supportive
with oral care instructions. therapy” and may be scheduled at intervals
of 3, 4 or 6 months depending on the patient’s
Objectives health status and adherence to personal oral
• Dental care plan is brought into action. hygiene care.
• Perform identified activities. There All patients need to be placed on a main-
activities may be performed by the tenance program to prevent progression or
patient, dentist or others depending on recurrence of disease and to maintain their
patient needs. current level of oral health.
Chapter 2.indd 15 11/5/2014 6:03:55 PM

Chapter
3 Evaluation of the Patient for

Comprehensive Oral Health Care
In this changing world, the oral health status 5. Establishing diagnosis

of people is also undergoing changes. Due to 6. Formulating a plan of action includes
increase in the utilization of dental services comprehensive oral health planning
more people are going to retain their denti- and necessary medical references.
tion. So, the need for preventive dental care
is predicted to increase while the need for
CASE HISTORY
among the younger population. Furthermore,
recent information suggests that there is Definition (WHO)
more intimate relationship between oral and It can be considered as a planned professional
systemic health. Thus, the challenge facing conversation that enables the patient to
dentists in twenty-first century is rapidly communicate their symptoms, feelings and
growing population of patients who have fears to the clinician, so that the nature of
chronic systemic disease, use of multiple the patient’s real and suspected illness and
medications which have influence on oral mental attitudes may be determined.
health, yet require routine, safe, and appro-
priate comprehensive oral health care. This
section or chapter of this manual address the
DEMOGRAPHIC DATA
rationale and method for gathering relevant, Hospital Registration Number
personal, medical and dental information It is recorded for the purpose of:
(including the examination of the patient) and • Record maintenance file keeping
the use of this information for comprehensive • Billing
oral health care planning. This process can be • Legal purposes—medico-legal cases
divided into the following parts: • Retrospective—survey and studies.
1. Demographic data
2. Chief complaint and history of the
Date
present illness
3. Complete patient history: Records patient’s first dental visit which can
i. Past dental history be referred back.
ii. Medical history
iii. Family history Name
iv. Personal history. Purpose of recording the patients name is for
4. Examination of patient and performing • Aids in good rapport with patients
laboratory study • Identification of the patient
Chapter 3.indd 16 11/5/2014 6:04:52 PM

Evaluation of the Patient for Comprehensive Oral Health Care 17
• To maintain record planning. Growth modifications by
• To communicate with the patient has means of functional an orthodontic
psychological benefit. appliances elicit better response during
Patients particularly children are at ease the period of growth spurts.
when they are referred by the same names as
they are referred at home. Hence, recording Gender–Sex
nick names are useful in pediatric practice. • Certain diseases are specific to the
sexes, such as hemophilia is common
Date of Birth in male and juvenile periodontitis in
Chronological age—it is the age of the child females.
calculated from his/her birthday. Some of the • Timing of eruption sequence of teeth
reasons why recording age is important are: also varies between males and females.
• Know whether he/she is a minor or not Eruption of teeth is slightly earlier in
• Dental appointment time and duration females. Hence, DMFT and def indices
is different for different age groups. scores in girls are more than boys.
• Method of oral health education is • Likes and dislikes of child in behavior
different for different age groups. management technique may vary
• Treatment option varies according to depending on sex of the child. Boys like
age of the patient. toys such as cars and airplanes while
• Certain diseases occur in certain age girls like dolls. One can please a girl
groups and it aids to diagnose a disease child by praising her dress or looks. A
based on age factor boy child would be paired with regards
• Approach to patient instruction to his activities than dress.
depends on age of patient. • Variation in timing of growth spurts is
seen between girls and boys.
In Child Patient • Male preponderance—coronary heart
diseases, lung cancer.
• Informed consent of parent or guardian
• Female preponderance—hyperthyroid-
is necessary in case of minor, signature
must be obtained. ism, diabetes, obesity.
• Behavior management techniques that • More severe in males—syphilis.
• Drugs—during pregnancy, lactation—
have to be chosen are definitely age
indicated/contraindicated.
dependent.
• To relate the eruption and exfoliation
sequence of teeth. It helps to compare Occupations
the dental age of the patient with • May be a factor in etiology of certain
chronological age and if needed to diseases, dental stains, and occlusal wear.
initiate any preventive method of • Instructions applied to specific needs.
treatment. • Dexterity in use of self-care devices
• Also to compare the chronological age related to dexterity gained from
with the skeletal and mental age. occupation.
• Understanding the period of growth • Influence on oral health care of the
spurts is important for treatment entire family.
Chapter 3.indd 17 11/5/2014 6:04:52 PM

• Undemanding jobs may attract people Acne vulgaris is uncommon in Negroes

in poor health and demanding jobs and Japanese.
selectively include only those in good
health Physician
• Understanding the socioeconomic Name, address and telephone numbers for
status communication, consultation if needed—
• Occupational hazards—like attrition, • When disease symptoms are suspected
abrasion, erosion, hepatitis B and but patient does not state
radiation hazards. • In any emergency
• Medication/premedication.
For Child
• Parent’s occupation and parent’s name.
CHIEF COMPLAINT
• May affect diet, oral habits, and general
health. • Chief complaint is the reason which
• Parent’s supervision and assistance to prompted the patient to seek dental
child in oral care. treatment.
• Thus, the chief complaint is established
Martial Status by asking the patient, the reason for
seeking treatment.
• Cancer of cervix: Common in married
• Common reason for seeking treatment
women, rare in nuns.
includes pain, swelling and to improve
• Breast cancer common in unmarried
esthetics or may be referred from other
women.
practitioner or it may be any other
reason pertaining to oral health.
Address, Telephone Numbers, Place of • The chief complaint is recorded in
Birth and Residence in Early Years the patient’s own words as much as
• Communication—for future communi- possible and should not be documented
cation and correspondence. in technical (i.e. formal diagnostic)
• Presence of fluoride in drinking water language unless reported in that fashion
has effect on fluorosis of teeth. by the patient, this may give the dentist
• Conditions endemic to certain areas some sight into the patients ‘dental
show certain diseases or conditions. intelligence quotient’.
• For example—if the patient is residing • While recording the chief complaint
in the areas with high water fluoride it must be made in the chronological
content, there is increased chance that order, that is what appeared first should
he may develop dental or skeletal be mentioned first.
fluorosis. • Example—if the patient complaints
• Communicable diseases—HIV, hepati- of fever from yesterday, pain since 4
tis, herpes, etc. days and swelling began 2 days back. It
should be recorded are as follows:
Race – Pain from 4 days duration
Patients having higher incidence of G6PD – Swelling of 2 days duration
deficiency. – Fever of 1 day duration.
Chapter 3.indd 18 11/5/2014 6:04:52 PM

For safe, scientific comprehensive oral • Permit appraisal of general health
health care, a meaningful complete patient and nutritional status, which in turn
history is an essential part of the complete contributes to the prognosis of success
assessment. in patient care and instructions.
• Gives insight into emotional and
psychological factors, attributes and
Significance
prejudices that may affect present ap-
The significance of taking a complete pointments as well as continuing care.
and accurate patient history cannot be • Document records for references and
overestimated because: comparisons over a series of appoint-
• Oral conditions reflects the general ments for periodic following.
health of the patient, dental procedures • Furnish evidence in legal matters of
may complicate or be complicated question raises.
by existing pathologic or physiologic • Identify cultural benefits and practices
conditions elsewhere in the body. that affect risk for oral diseases.
• General health factors influence • Determine ethnic/racial influences on
response to treatment such as tissue risk factors for oral diseases.
healing and thereby influence the
outcomes that may be expected from History Preparations
oral care. The patient history can be of:
• The state of patient’s health is con- • Brief history
stantly changing. Therefore, the history • Complete history.
represents only the period in the pa-
tients life during which the history was Brief History
made. • A brief history of vital systems are
obtained during the initial emergency
Purpose of the History visit; a more complete history is
Carefully prepared personal, medical and obtained at a succeeding appointment.
dental histories are used in comprehensive • Purpose of brief history is to prepare
oral health care. for emergency care and to learn of
• Provide information pertinent to the any condition that may contraindicate
etiology and diagnosis of oral conditions instrumentation.
and the total patient care plan. • A brief history may be in the form
• Reveal conditions that necessitate pre- of questionnaire, as an interview for
cautions, modifications or adaptations follow-up provides opportunity for
during appointments to ensure that individual evaluation.
dental care procedures will not harm
the patient and the emergency situa- Complete History
tions will be prevented. • A complete history is made at the initial
• Aid in identification of possible visit and is a combination of interview
unrecognized conditions for which and questionnaire.
the patient will be referred for further • At successive appointments, the
diagnosis and treatment. complete history is reviewed with the
Chapter 3.indd 19 11/5/2014 6:04:52 PM

patient and changes are considered • Are you thirsty much of the time?
when planning patient care. • Does your mouth frequently become
dry?
The Questionnaire • Do you have to urinate more than six
times a day?
During patient history preparation, positive
• Positive answers could lead to tests for
findings depends upon the positive answer
diabetes detection.
from the patient during personal interview.
Therefore, it involves different types of Culture oriented: Questions related to the
questions. patient’s culture background can help to—
• Identify ethnic or gender related
Types of Questions
increase in risk for a systemic or oral
System oriented disease.
• Direct questions or topics that check • Determine traditional culturally related
whether the patient had a disease, health/illness behaviors that may
for example the digestive system, influence dental care intervention or
respiratory system or urinary system recommendations.
may be used. • Identify herbal preparations or other
• The questions may contain references to traditional medications used by the
body parts, for example, the stomach, patient that may affect oral care or risk
lungs and kidneys. for disease.
• Questions can then be directed to the
specific disease state and the dates, History of Present Illness
duration.
1. It is elaboration of chief complaint.
Disease oriented 2. Patient may or may not volunteer a
• A typical set of questions for the patient detailed history of the problem for
to check may start with ‘Do you have which they are seeking treatment.
or have you had any of the following 3. Hence, additional information usually
diseases or problems?’. needs to be elicited by the examiner in
• A listing under those questions contains the form of ‘history of present illness’.
such items as; diabetes, asthma, a 4. The history of present illness in the
rheumatic fever arranged alphabetically course of the patients chief complaint:
or grouped by systems or body organs. i. When and how it began
• Follow-up questions can determine ii. W h a t e x a c e r b a t e s a n d w h a t
dates of illness, severity and outcome. ameliorates the complaint (when
applicable)
System oriented: In the absence or previous iii. If and how the complaint has been
or current disease state questions may lead treated and what was the result of
to a suspicion of a condition, which in turn any such treatment
can provide an opportunity to recommend- iv. What diagnostic tests have been
ed and encourage the patient to schedule performed?
an examination by a physician. Examples of Thus, HPI includes of asking more direct
the symptoms oriented questions are: and specific questions to patient to elicit more
Chapter 3.indd 20 11/5/2014 6:04:52 PM

information regarding the chief complaint • Spontaneous pain without any provok-
that will be helpful in treatment planning. ing factors indicates wide involvement
This information should be recorded in the of pulp and requires radical therapy
patient record in narrative form as follows: such as pulpectomy.
1. When did the problem start?
2. What did you notice first? Attenuating Factors or Relieving Factors
3. Did you have any problem or symptoms Understanding factors that reduce or stops
related to this? the pain is also important. Pain that is
4. What makes the problem worse or relieved by removal of the stimuli indicates
better? reversible pulpitis.
5. Have the symptoms gotten better of
worse at any time? Duration
6. Have any test been performed to Pain following a stimulus for a short period
diagnose this complaint? or is transient in nature, indicates reversible
7. Have you consulted other dentists, pulpitis. Pain that begins on provocation and
physicians or anyone else related to this lingers on even after removal of stimulus
problem? indicates an irreversible pulpitis.
8. What have you done to treat these
symptoms? Intensity and Quality
For example, If the complaint is pain, the Sharp, lancinating pain indicates acute
history to be obtained is as follows: conditions and chronic conditions associated
with dull, gnawing type of pain.
Location of Pain
It is required to identify the offending tooth Radiation
or teeth. Pain can be radiated to other teeth or tissues.
This makes it difficult to identify the diseased
Inception
tooth or teeth. A tooth associated with
When did it start? chronic pain, most of the time radiates to the
• Pain that started few hours days tooth in the opposite arch or the patient just
indicates that it is an acute condition. cannot pin point the involved teeth. Pain due
• Similarly pain that is present for many to only pulpal origin is also difficult to point.
days or months is related to chronic
Note:
condition most of the time.
1. Type of pains can be sharp, dull, con-
tinuous, intermittent, mild, severe, etc.
Provoking Factors or Aggravating Factors 2. Pain in the pulp is difficult to localize,
There may be some factors that initiates or as the pulp does not contain proprio-
increases the pain. Examples are: ceptive fibers unlike the pain of the
• The pain that increases while lying down periodontium.
is usually due to pulpal hyperemia or 3. Pain which increases by lying down
pain present only while eating may be is due to increase in blood pressure to
due to deep caries (pressure through thin head, which increases the pressure on
dentin or pulp) or reversible pulpitis. the confined pulp.
Chapter 3.indd 21 11/5/2014 6:04:52 PM

COMPLETE PATIENT HISTORY - Any implants

- Anesthetic used—local, general
Past Dental History and adverse reactions.
It is one of the most important components – Previous dental appointment: This
of the patient history? Significant items reveals patient knowledge concerning
that should be recorded routinely are the regular dental care and co-operation
frequency of past dental visits and previous anticipated. Record notes about—
treatment. - Date of last treatment
• Type of treatment, frequency of mainte- - Services performed
- Regularity.
nance of appointment
– Radiation history: Record notes
• Whether referred to specialist
regarding—
• Past dental history reveals patient - Type, number, dates of dental
attitude towards specialized care and and medical radiographs
previous familiarity with role of dentist - Therapeutic radiation
• Past dental history gives information - Availability of dental radiographs
about attitude towards self-care and form previous dentist
disease control - Amount of exposure considered
• Previous treatment experiences like with exposure for medical pur-
pleasant/uneventful/good/bad poses.
• Patient awareness and motivation This information of amount of ex-
regarding specialties posures gives information to dentist
• Frequency of dental check-ups. about limitations patients’ apprecia-
– Periodontitis: Record notes of— tion for need and use of radiographs.
- History of acute infections (necro- – Fluoride history, including supple-
tizing ulcerative gingivitis) ments:
- Surgery, post treatment healing. - Use of well water
– Endodontics: Dates, etiology— - Systemic, topical, dates residue
during tooth development years.
periodic checks
- Amount of fluoride in drinking
– Orthodontics: Record notes about—
water.
- Age during treatment
This information gives ideas for
- Completion dates and previous
considerations regarding current
problem.
preventive procedures and need for
– Prosthodontics and previous resto-
re-evaluation.
rations: Record notes of—
– Dental allergies:
- Type of prosthesis
- Dental ointments
- Extent of restoration
- About care of prosthesis and - Toothpastes
abutment teeth - Mouthwash
- Understanding prevention. - Local anesthesia
– Oral surgical treatment: Record - Latex allergy
notes of— - Medications.
- Reason for tooth loss – Dentist and physician (also demo-
- Untoward complications of dental graphic data): The names, addresses
treatment and telephone numbers of dentist
Chapter 3.indd 22 11/5/2014 6:04:52 PM

and physicians involved and the Dentist should observe the general appear-
facility (hospital or clinic) where the ance of patient and record notes about dis-
treatment was given. coloration, overall impression of well-being
– Dental complications: Clear details and patients appraisal of own health. The
of any previous untoward compli- patient is asked again ‘Has there been any
cations of dental treatment must be change in your general health within past
recorded. years’. If yes, then record the following
items?:
Past Medical History
Medical examination: Collect data regarding—
Objectives
• Date of most recent examination
An appropriate interpretation of the infor- • Reason for the examination
mation collected through a medical history • Tests performed, results
archives. Three important objectives are: • What condition is being treated
1. It enables the monitoring of medical • Anticipated surgery
conditions and the evaluation of • New prescriptions received
underlying systemic conditions of
• Previous prescriptions continued.
which the patient may or may not be
The recording of these two items gives
aware.
clues of considerations for dental treatment
2. It provides basis for determining
procedure, like—
whether dental treatment might affect
• Response, co-operation and attitude to
systemic health of the patient.
expect during appointment
3. It provides an initial starting point
• Verification with physician for added
for assessing the possible influence of
information about patient.
patient’s systemic health on the patient’s
In the dental context, specific questions
oral health and dental treatment.
are asked about major illness, about any
i. Serious or significant illness
history:
ii. Hospitalization—recent hospitali-
• Cardiovascular diseases
zation
• Liver
iii. Transfusions
• Kidney
iv. Allergies—like penicillin
• Respiration and lung diseases
v. Medications
• Infectious diseases
vi. Pregnancy/lactation
• Diabetes or hormonal problems
vii. Fever.
• Cancer radiation or cancer chemother-
apy
Serious or Significant Illness
• Blood disorders
In this subdivision of past medical history, • Bleeding disorders
the following items should be recorded in • Arthritis
medical history.
• Gastrointestinal
General health and appearance: The patient is • Mental and psychiatric
asked to enumerate about general health by • Physical disabilities
asking question ‘Are you in good health?’. • Epilepsy.
Chapter 3.indd 23 11/5/2014 6:04:52 PM

The questions asked about the above Considerations for Dental Appointment
mentioned major illness also serve to remind Procedures
the patient about medical problems that can Antibiotic premedication may be required.
be concern to the dentist in considerations
for dental appointment procedures and Hypertension
management of medically compromised
Record Notes
patient in a dental hospital or dental clinic
to prevent future consequences and are • Symptoms of other diseased state
therefore worthy of reporting as follows. • Monitoring blood pressure for each
appointment
• Anesthesia—limit epinephrine or omit
CARDIOVASCULAR DISEASES as recommended as physician.
Record Notes
Medications and Treatment Modalities
• Consultation with physician
• Diuretics
• Refer for examination when patient
• Antiadrenergic drugs
seems unsure of problem.
• Vasodilators
• Angiotensin converting enzyme inhibi-
Cardiac Medications and Treatment Modalities
tors
• Glycosides • Calcium channel blockers.
• Antiarrhythmics
• Antianginals Considerations for Dental Appointment
• Antihypertensives Procedures
• Anticoagulants. • Postural hypotension (raise dental chair
slowly)
Considerations for Dental Appointment • Xerostomia, saliva substitute and
Procedures fluoride rinse may be needed
• Minimize stress • Gingival enlargement (drug side effect).
• Premedication for stress
• Ascertain that medications have been Angina Pectoris
taken
Record Notes
• Monitor vital signs.
Prepare for symptoms, have ready amyl
nitrate inhalant or nitroglycerin tablets or
Congenital and Rheumatic
spray.
Heart Diseases
Record Notes Medications and Treatment Modalities
• Susceptible to infective endocarditis Amyl nitrate, nitroglycerin or other anti-
• Type of problem anginal drugs.
• Type of rheumatic fever.
Considerations for Dental Appointment
Medications and Treatment Modalities Procedures
Antibiotics (prevent recurrence of rheu- • Allay fears and prevent stress
matic fever). • Morning appointments.
Chapter 3.indd 24 11/5/2014 6:04:52 PM

Heart Diseases Considerations for Dental Appointment
Record Notes Procedures
• History of disease symptoms of fatigue, • Antibiotic premedication vital for
shortness of breath or cough synthetic valves or other replacements,
• Consult with physician. indefinitely
• Gingival bleeding can be expected
Medications and Treatment Modalities • Gingival enlargement.
• Glycosides (digitalis)
• Anticoagulants Cerebrovascular Accident (Stroke)
• Antiarrhythmic drugs Record Notes
• Pacemaker.
• Date of onset, residual disabilities
Considerations for Dental Appointment • Speech, vision, mental function.
Procedures
• Monitor vital signs
• Short, more frequent appointments • No tobacco use
• Patient with breathing problem (sleeps • Anticoagulants
with two or more pillows) may be need • Antihypertensives
semi-upright position • Vasodilators
• Bleeding tendency associated with anti- • Steroid
coagulants • Anticonvulsant.
• Check use of ultrasonic pacemaker.
Surgically Corrected Cardiovascular Procedures
Lesions • Gingival bleeding likely when antico-
Record Notes agulants are used
• Type, date of surgery • Adapt procedures for physical disabili-
• Consultation with physician ties.
• Before surgical procedure when pos-
sible, the patient needs complete oral LIVER
evaluation and corrective dental work
Record Notes
done, with motivation to high level of
oral personal care daily. • History of jaundice, hepatitis
• Impaired drug metabolism
Medications and Treatment Modalities • Cirrhosis, history of alcoholism.
• No tobacco use
• Anticoagulants Medications and Treatment Modalities
• Cyclosporine • Nutritional emphasis
• Nifedipine. • Abstinence from alcohol.
Chapter 3.indd 25 11/5/2014 6:04:52 PM

Considerations for Dental Appointment Considerations for Dental Appointment

Procedures Procedures
• Laboratory tests for hepatitis • Dental chair position
• Bleeding problems. • Ultrasonic and air-powder polishing
contraindicated
KIDNEY • Anesthesia choice—nitrous oxide
contra-indicated
Record Notes • No aerosol agents.
• Renal disease, kidney stones
• Hemodialysis, hypertension
DIABETES OR HORMONAL PROBLEMS
• Anemia, hepatitis, cancer.
Diabetes Mellitus
Record Notes
• Salt restriction.
• Uncontrolled requires antibiotics pre-
• Many drugs are nephrotoxic
medication
• Immunosuppressive drugs (cyclo-
• Undiagnosed—Excess thirst, appetite
sporine).
and urination (more than 6 times a day)
Considerations for Dental Appointment • Family incidence—Helps in finding
Procedures susceptibility undiagnosed
• Severe advanced diabetes—Complica-
• Monitor blood pressure
tions like vision, kidney, cardiovascular,
• Bleeding tendencies
nervous systems.
• Poor healing.
RESPIRATION AND LUNG DISEASES • Insulin
Record Notes • Diet control
• Breathing problems • Hypoglycemic.
• Persistent cough
• Coughs up blood (hemoptysis) Considerations for Dental Appointment
Procedures
• Chest pain
• Precipitation of asthmatic attack. • Prepare for emergency, insulin, apple
juice, frosting sugar
Medications and Treatment Modalities • Appointment time related to insulin
• Codeine cough syrup therapy and meal time
• Antihistamine • Need frequent maintenance appoint-
• Bronchial dilators ment
• Expectorant • Periodontal disease accelerated
• Decongestant • Referral for tests for suspected undiag-
• Steroid. nosed and uncontrolled.
Chapter 3.indd 26 11/5/2014 6:04:52 PM

Endocrinal or Hormonal Problems Considerations for Dental Appointment
Record Notes Procedures
• Age–group relations to certain conditions • Bleeding
• Growth, development • Infections
• Menstruation, menopause. • Poor healing response
• Avoid trauma to tissues
Medications and Treatment Modalities • Effect on oral radiographic survey,
prevention of overexposure
• Thyroid hormone supplement
• Dental caries, preventive measures
• Antithyroid
• Xerostomia, saliva substitute.
• Estrogen/progesterone
• Oral contraceptives
• Corticosteroids. BLOOD DISORDER
Record Notes
• Type and duration of disease
Procedures
• Leukemia, remission, thrombocytope-
• Emphasis on high level of biofilm nia.
control
• Any patient taking steroids may need Medications and Treatment Modalities
antibiotic premedication for appoint- • Vitamins
ments • Minerals, iron (iron deficiency anemia)
• Monitor blood pressure. • Folic acid supplement (sickle cell anemia)
• Antineoplastic drugs.
CANCER RADIATION AND CANCER
CHEMOTHERAPY Considerations for Dental Appointment
Procedures
Record Notes
• Consultation with physician
• Head and neck radiation affect oral • Need for high level of oral health
cavity, salivary glands • Antibiotic premedication
• Dental and dental hygiene therapy • Immunosuppression
updated before start of surgery, radiation • Increases bleeding
therapy, or immune suppression • Oral lesions.
• Blood count prior to dental and dental
hygiene therapy.
BLEEDING Disorder
Medications and Treatment Modalities Record Notes
• Radiation therapy • Bleeding associated with previous
• Fluoride therapy, daily topical applica- dental appointments
tion • History of disorder with coagulation
• Antineoplastic drugs, alkylating agents problem
• Antimetabolites, antibiotics, plant • History of transfusion of other blood
alkaloids, steroids. products
Chapter 3.indd 27 11/5/2014 6:04:52 PM

• Check use of aspirin (relation to bleeding Medications and Treatment Modalities

tendencies) Vaccination for HBV.
• Laboratory tests for bleeding time,
coagulation may be needed. Considerations for Dental Appointment
Procedures
Medications and Treatment Modalities Precautions against percutaneous injury.
• Anticoagulant medication
• Hemophilia factor replacement. TUBERCULOSIS
Considerations for Dental Appointment Record Notes
Procedures • Active or passive
• Emergency prevention through pre- • Cough
appointment precautions • Duration of disease.
• May need to apply direct pressure or
hemostatic agent after scaling
• Special measures for hemophiliacs. • Isoniazid
• Rifampicin
• Pyrazinamide.
INFECTIOUS DISEASES
Communicable Diseases Considerations for Dental Appointment
Procedures
Record Notes
Length of the treatment, infectivity dimin-
• History of disease, immunizations
ished after few months of treatment.
• Prevent disease, communicability
• Residue or extended trips in countries
with high endemic incidence of certain SEXUALLY TRANSMITTED
diseases INFECTIONS
• Risk factor. Record Notes
• May not obtain history of sexually
transmitted infections (STIs)
• Immunizations • Oral and pharyngeal lesions may be
• Drug therapy for current infections. indicator of disease.
Considerations for Dental Appointment Medications and Treatment Modalities

Procedures
Antibiotics.
Appointment postponement.
Procedures
HEPATITIS B
• Infectiousness diminishes with antibi-
Record Notes otic therapy for gonorrhea and syphilis
• Jaundice history • Refer to physician and postpone treat-
• Clarification of type of hepatitis ment when lesions or other signs
• Laboratory clearance. suggest infection.
Chapter 3.indd 28 11/5/2014 6:04:52 PM

• Caution for risk from previously treated Medications and Treatment Modalities
diseases. • Aspirin
• Non steroidal anti-inflammatory drugs
HERPES • Corticosteroids
• Total joint replacement.
Record Notes
Lesions can be transmitted readily. Considerations for Dental Appointment
Procedures
• Antibiotic premedication, consult phy-
• Non definitive, symptomatic and sician if treated with chemotherapeutic
palliative treatment agent.
• Acyclovir. • Dental chair alignment.

Procedures MENTAL and PSYCHIATRIC
Postpone routine care when oral lesions are Record Notes
present. Emotional problems hinder oral care.
HIV INFECTION AIDS Medications and Treatment Modalities

• Antipsychotic drugs
Record Notes
• Anti-anxiety drugs
• Risk group identification • Tranquilizers
• Oral manifestations. • Antidepressants
• Anti-Parkinsons’s medication.
Wide variety of opportunistic infections and Considerations for Dental Appointment
complications require variety of drugs. Procedures
• Limited stress tolerance
Considerations for Dental Appointment • Xerostomia (side effect)
Procedures
• Avoid mouth rinse containing alcohol.
• Oral lesions
• Complete sterilization and barrier
Physical Disabilities
procedures as for all patients.
Record Notes
ARTHRITIS • Oral health consciousness
• Extent, course, duration
Record Notes
• Type of treatment related to individual
• Joint pain conditions
• Immobility • Consultation with physician or medical
• Temporomandibular joint involvement. specialist.
Chapter 3.indd 29 11/5/2014 6:04:52 PM

Medications and Treatment Modalities Medications and Treatment Modalities

• Good health habits • Antacids
• Regular exercise • Antidiarrheal
• Pain reliever • Laxatives
• Muscle relaxant • Antispasmodics.
• Anticonvulsant
Considerations for Dental Appointment Procedures
Procedures • Patient follow instruction accordingly
• Contribute to co-operative attribute in with prescribed diet and medication
maintaining oral health • Xerostomia.
• Adjustment of physical arrangements
• Wheelchair accessibility and transfer FAMILY HISTORY
• Adaptations of techniques and instruc-
tions This gives an idea of:
• Consult for antibiotic premedication for • Size of the family and socioeconomic
status
certain conditions, e.g. prosthetic joint
• Whether patient can afford for the time
replacement.
and the treatment
• To know the child psychology which
EPILEPSY has the effect on their behavior (chil-
Record Notes dren from larger families are more
adjustable, co-operative, willingness to
• Type, frequency of seizures
face the challenges on their own)
• Precipitating factors.
• To study the peer influence in relation
to dietary and oral health practice
• In case of joint family the younger
• Anticonvulsant children get information from the older
• Sedative. children, knowledge and follow them
in all aspects, but in case of single child
Considerations for Dental Appointment more care rendered by the parents and
Procedures
direct information can be received
• Minimize stress • In joint families, parents may be knowl-
• Medication make patient drowsy or less edgeable and aware but due to lack of
alert time and finance problem there is lack
• Valproic acid requires bleeding time of motivation
before treatment. • Should record number of siblings,
number of brothers, sisters, year or age,
GASTROINTESTINAL class of study
• If the patient is a married woman;
Record Notes – Number of children
• Nature and treatment of disease – D e l i v e r y c o m p l i c a t i o n ( m o r e
• Diet restriction prescribed by physician. number leads to anemia)
Chapter 3.indd 30 11/5/2014 6:04:52 PM

• Pedigree—inherited disorders like • Home surroundings
diabetes, hypertension • Travel abroad—H1H1, malaria.
• Consignors marriage
• Recent death in family with cause. DIET AND DIETARY ANALYSIS
Nutrition is an integral part of an individuals
PERSONAL HISTORY
overall health as well as the health status of
• Toothbrush/paste—anyother-finger, the oral cavity. The health of oral tissues can
neem stick, brick powder, ash powder be affected by nutrition, diet and food habits.
• Tooth brushing technique—fones The interrelationship between nutritional
method/bass method/modified status, systemic diseases and oral conditions
Stillman’s method supports the need for timely and effective
• Oral hygiene measures—dental floss/ diet intervention. With the scope of practice,
mouthwash/interproximal aids the dentist has a responsibility to assess,
• D i e t — V e g e t a r i a n / m i x e d — screen and deliver nutritional information
carbohydrates—caries prone, and instruction as part of comprehensive
phosphate—less prone to caries, education in health promotion and disease
vitamins—enamel hypoplasia prevention and intervention. Dietary and
• Habits—thumb sucking/tongue thrust- nutritional counseling as part of a dental
ing/mouth breathing/bruxism/pencil caries control program and periodontal
and nail biting/masochistic habits maintenance is an essential part of the
• Addiction—number of time, quantity comprehensive oral health care plan.
per day
– Tobacco—pan/snuff/zarda/khaini Dietary Assessment
– Smoking—cigarette/bidi/cigars/
chutta The dietary assessment is an integral part of
– Drugs—charas/ganja/marijuana disease, prevention and health promotion in
– Alcohol—name/amount/per day/ the scope of oral health care. The patient and
years dentist have the opportunity to collaborate in
• Sleep habits—bruxism, thumb sucking. the evaluation of diet adequacy and in diet
intervention.
SOCIAL HISTORY Purposes of Dietary Assessment

• Marital status—married/divorcee/single • Identify the patient who may be at
• Number of children—one/two/many nutritional and oral health risk
• Education—treatment necessity/cost • Obtain an overall picture of the types
• Job related information—sports person, of food in the patients diet, food
modeling, software, any other job preferences and quantity of food eaten
requirements • Study the food habits and snacking
• High social status—caries/heart diseases patterns
• Low social-economic status—periodon- • Record frequency of use and when the
titis cariogenic food is consumed
Chapter 3.indd 31 11/5/2014 6:04:52 PM

• Determine the overall consistency of the • Patient completes food diary for 3, 5, or
diet: 7 days, inclusive of one weekend day
– Identify fibrous food regularly • Affords the patient a more active role in
consumed the dietary assessment and a chance to
– Identify soft sticky foods regularly observe areas that require modification
consumed. • Provide patient with 3 to 7 copies of the
• Identify the nutritional status of an food diary request patient to return the
individual with regard to overall re- form at follow-up visit
quirements and the collaborate with • At follow-up visit the patients diary is
the patient to make suggestions for evaluated for
modification in nutritional adequacy of – Eating patterns
the diet in health promotion – Consumption and frequency of
• Plan with the patient for necessary fermentable carbohydrates
changes to improve the health of the
– Nutritional adequacy.
oral mucosa and periodontium and
prevent dental caries Presentation of Food Diary
• Provide an opportunity for a patient to form to the Patient
study personal dietary habits objectively
• Explain the purpose—
• Refer to a registered dietician when
intervention beyond the scope of dental – Briefly explain how diet relates to
practice is indicated. the dental and oral health
– Provide a foundation for the
Forms used for Assessment education to follow
Food diary – Avoid mention of specific foods not
• A diary of the patients dietary intake to bias patient.
over the previous 24 hours • Explain the form—
• Obtained by interview with patient – Provide written and oral instruction
• It is quick and easy to administer and for use of the food diary
can be done chair side in one visit – Provide suggestions for listing
• Assesses nutrients, food groups, diet various food and use of household
adequacy, forms and frequency of measurements for indicating
the carbohydrate intake and snacking quantity
patterns – Instruction for completing the food
• Reposts are reviewed and appropriate diary encourages the patient to
instructions given at appointment of a provide a more accurate portrayal
follow-up appointment of eating behaviors.
• Drawback: limited to one day’s
intake, therefore it is not necessarily Food Diary Instructions
representative of a patients normal diet.
• Write down everything eaten in the
Dietary analysis recording form 3–7 days food provided on diary form
• An accurate account of a patient’s • Record each meal as soon after eating as
intake possible to avoid forgetting
Chapter 3.indd 32 11/5/2014 6:04:53 PM

• Do not choose days when dieting, • Assist patient while deficiencies are
fasting, or ill identified.
• Be accurate in determining the amount
eaten using household measurements Analysis of Cariogenic Foods
(e.g. half cereal, 1 tip margarine, and Cariogenic food are listed and categorized as
3 oz fish). liquid, solid and sticky or slowly dissolving
Ounce serving size can be com- as shown in (Table 3.1).
pound to the size of a deck of cards
• Use brand names whenever possible Identify Physical form of Carbohydrate
• Record added spices, gravies, condi- • Liquids, sweetened or unsweetened soft
ments and extras (e.g. sugar or cream drinks, fruit juice with added sugars.
in coffee, sanguinarine, chewing gum, • S o f t s o l d / s t i c k y a n d r e t e n t i v e ,
cough drops) retentive cakes, cookies, chips, pretzels,
• Record food preparation methods (e.g. jellybeans, and chewy/sticky candies.
baked, fried, boiled, grilled) • Hard solid/slowly dissolving hard
• Record nutritional supplements and candies, mints, and cough drops.
all fluids: Include water and alcoholic
beverages Nutritional Analysis for Adequacy of
• Record in detail the component parts of a 24 Hour Recall Intake
combination dish such as a sandwich— • When tissue is a factor a 24 hour
– 2 slices of whole wheat bread analysis is appropriate
– 4 oz of chicken • Compare food group represented in the
– 1 tablespoon of mustard or light patients 24 hour food dairy with that of
– 2 slices tomato with lettuce the pyramid
– 1 slice of cheese. • Determine nutritional adequacy
• Calculate the patients sweet score as
FOOD DIARY outlined in the (Table 3.2) of scoring the
sweets
Analysis of Dietary Intake • Cariogenic foods are listed and
Three principal parts of food diary to analyze categorized as liquid, solid and sticky
are: or slowly dissolving as shown in
• The number of servings in each food (Table 3.2) of scoring the sweets
groups • Total for the one day are multiplied
• The frequency of cariogenic food by respective tissue factors and a score
• The consistency of the diet. determines patients caries risk.
Comparison of patients food diary with the
provided pyramid food guidance system: Nutritional Analysis for Adequacy of
• Total for the week are added and the Food Intake from the Food Diary
average per day calculated • Use the dietary analysis recording
• The average is compared to the recom- form to summarize adequacy of daily
mended servings for each food group portions of each food group
Chapter 3.indd 33 11/5/2014 6:04:53 PM

Table 3.1: Food diary. Sample of a form for patients to use to record the daily intake of food. Can be used for
the 24 hour recall or multiple forms used in the 3–7 day food diary
Food Diary
Name_________________________Tel___________________________
Age___________Sex______Height________Weight________BMI______
Types of foods/beverages Quantity eaten Preparation method

(cup, oz, tbsp, tsp, etc.)
Breakfast
7:30 AM: Orange juice ½ cup Bagel Shop
Bagel Whole
Cream cheese 2 tablespoons
Coffee 2 cups
Milk and sugar ½ cup, 2 packets
Snacks
10:00 AM Chocolate cookies 2
Orange soda 12 oz can
Lunch
1:00 PM Mushroom Pizza 2 slices School Cafeteria
Orange soda 12 oz can
Cheesecake 1 slice
Snacks
4:00 PM Whole wheat pretzels 1 bag Vending machine
Dinner
7:00 PM Turkey 6 oz Roasted
Potato 1 medium Baked
Sour Cream 2 tablespoons
Broccoli 1 cup Sauteed
Oil 2 tablespoons
Gravy ½ cup Canned
Snacks
9:30 PM Popcorn 3 cups Microwave
• Each food eaten is entered into a food – High frequency of eating events
group with number of servings decrease ability of calcium and
• Identify frequency of meals and snacks: phosphate to remineralize teeth
between episodes.
– When snacks are consumed
– Number of between meal snacks Analysis of Diet Consistency
consumed daily
• Help patient to identify the type of firm
– Circle in red and tally the number of and fibrous foods from the food diary
cariogenic foods, both solid and liquid such as:
– Frequency more relevant than – Uncoated fruits and vegetables
quantity in caries incidence – Cooked crisp vegetables.
Chapter 3.indd 34 11/5/2014 6:04:53 PM

Table 3.2: Scoring the sweets. Form to be used to determine the patient’s caries risk when
doing a 24 hour recall at chair side
SCORING THE SWEETS

(Caries-Promoting Potential)
Food items Reference foods considered cariogenic Frequency Weighted Total points
(from patients (Place a check for score each category
24 hour recall) each exposure to
cariogenic food)
1. Liquid — X1
2. Soft drinks, fruit drinks, cocoa, sugar and honey —
3. in beverages, nondairy creamers, ice cream, —
4. sherbat, flavored or frozen yogurt, pudding, —
custard, jello
1. Solid and Sticky — X2
2. Cakes, cupcakes, doughnuts, sweet rolls, potato —
3. chips, pretzels, pastry, canned fruit in syrup, —
4. bananas, cookies, chocolate candy, caramel, —
5. toffee, jelly beans, other chewy candy, chewing
6. gum, dried fruit, marshmallows, jelly, jam
1. Slowly Dissolving — X3
2. Hard candies, breath mints, antacid tablets, —
3. cough drops —
Total Score
Using the 24 hour recall diary:
• Classify each sweet into liquid, solid and sticky, or slowly dissolving. (Use reference food list)
• For each time a sweet was eaten, either at a meal or between meals (at least 20 minutes apart) place a check in the
frequency column
• In each category tally the number of sweets eaten and multiply by the weighted score. Record the category points in the
respective column
• Tally all the category points to determine the total score
Sweet score: How to lower your risk for caries:
(Risk for dental caries)
0-1 Low risk 1. Cut down on the frequency of sweets between meals
2-4 2. Do not sip constantly on sweetened beverage
5-7 moderate risk 3. Avoid using slowly dissolving items like hard candy, cough drops, etc.
8-9 4. Eat more non-decay promoting foods such as (low fat cheese, raw
>10 High risk vegetables, crunchy fruits, nuts, popcorn)
Benefits of Food Dairy Diet counseling

Analysis
Objectives
• Patient can identify appropriate and • To help patient understand the indi-
inappropriate practices for dental caries vidual oral problems and appreciate the
control need for changing habits
• Collaborate findings with clinical find- • To explain specific alterations in diet
ings and patient oral health problems in necessary for improved general and
preparation for counseling session. oral health for dental caries control
Chapter 3.indd 35 11/5/2014 6:04:53 PM

• To promote the minimal consumption of Teaching Materials

cariogenic foods, particularly between Appropriate teaching materials should be
meals used in diet counseling.
• To substitute non cariogenic foods in diet.
Diet Counseling Procedures
Planning
Diet counseling procedures starts with
During counseling appointment show the setting up of an ideal environment for den-
patient how to; tists and patients, parents of child patient;
• Select and circle in red the cariogenic presentation of topics should be done in a
foods on the scoring the sweets from systematic way stressing the points on main
(Table 3.3) selected topics only
• Select liquid, soft solid, hard solid, and a. Setting for meeting
time of eating b. Points for success of a meeting
• Total the number of sweets for liquids c. Presentation
and solids and multiply total by 20 min- i. Purpose of meeting
utes (liquids) and 40 minutes (solids) ii. Classification of cariogenic foods
• Divide by number of days (3, 5 or 7 days iii. Review of dental caries initiation
diary) iv. Frequency time of exposure of tooth
Help patient to identify the frequency and use; surface to sucrose
• Daily or occasionally v. Retention of cariogenic food.
• During meal, end of meal or between d. Specific dietary recommendation: After
meals. presentation the dentist should make
Add the liquid and solid score for total recommendations of good food habits
minutes teeth are exposed to sweets and acid that can be adopted to the patient’s
attack before planning for diet counseling pattern of living by making necessary
to the patient or parents of child patient we dietary changes
should know the attitude of patient and what • Guide the patient to study his food
are the possible barriers come across: diary.
• Patient attitude • Principles of patients dietary changes.
• Possible barriers. e. Evaluation of diet counseling.
Table 3.3: Calculation of sweet score
Sweets Total
Liquid With Meal Total all liquid exposures and multiply by 20 minutes and divide by total
End of Meal number of days to equal daily acid attack from liquids
Between Meal Total Liquid Minutes_____________
Soft/Solid With Meal Total all soft and hard solid exposures and multiply by 40 minutes and
Sticky/Retentive End of Meal divide by total number of days to equal daily acid attack from solids
Between Meal Total Solid Minutes_____________
Hard/Solid With Meal Add both liquid and solid totals to determine number of minutes per day
Slowly End of Meal teeth are under acid attack
Dissolving Between Meal Total Daily Minutes of Acid Attack______
Chapter 3.indd 36 11/5/2014 6:04:53 PM

GENERAL EXAMINATION Vital Signs
• Gait—hemiplegic/ataxic/parkinso- Name: ------------------------------------ Date: -----------

nian/scissor/foot drop/equine Blood pressure: ------------------------
• Built and nourishment Pulse: -------------------------------------
• Pallor—anemia/massive hemorrhagic Respiratory rate: -----------------------
shock/shock Temperature: ---------------------------
• Icterus—jaundice Smoking status: Current Former Never
• Clubbing—pulmonary/cardiac/endo- Adopted from Fiore, MC: The new vital sign assessment and
documentary smoking status, JAMA, 266, 3138, December 11, 1991
crine
• Cyanosis Figure 3.1: Vital signs stamp for a patient record
• Lymphadenopathy
• Definition—as enlargement or swelling New Vital Signs
of lymph nodes. Seen in face, neck
Adding a fifth new vital sign ‘smoking
and back of the neck. Other areas like
status’ gives the opportunity to introduce
underarms, abdomen.
early in the encounter with the patient the
• Cervical lymph nodes most commonly
significance of smoking to general and oral
affected
health. The fact that smoking is number one
• Generalized lymphadenopathy—
presentable cause of illness and death more
lympho-mas (Hodgkins, non-
than justifies including smoking status as a
Hodgkins) leukemia, tuberculosis, HIV
vital sign.
infection, secondary syphilis, infections,
For comprehensive oral health care planning:
sore throat, lymphosarcoma.
1. Recording vital signs contributes to
the proper systematic evaluation of a
VITAL SIGNS patient in conjugation with the complete
medical history
Determination of four vital signs (Figure 3.1):
2. Dental care planning and appointment
i. Body temperature
sequencing are directly influenced by
ii. Pulse rate
the findings
iii. Respiratory rate
3. When vital signs are not within normal,
iv. Blood pressure is considered standard
advice the patient to check with the
procedure in patient care.
physician
4. Refer for medical evaluation and
Instructions for Patient treatment is indicated.
1. Explain the vital signs and obtain consent
2. Explain how vital signs can affect oral
BODY TEMPeRATURE
health and dental treatment
3. Teach the patient to refrain from eating, While preparing the patient history, and
drinking or smoking before vital signs smoking the extra oral and intraoral ex-
are taken aminations, the need for taking the body
4. During the process, explain each step as temperature may become apparent in con-
recorded by the individual patient. jugation with current renal diseases.
Chapter 3.indd 37 11/5/2014 6:04:53 PM

Indications 2. Temperature increases: Exercise, hot

1. For complete examinations during a drinks, smoking or application to exter-
maintenance appointment nal heat.
2. When oral infection known to be present 3. Pathologic state: Infections, dehydra-
3. Necrotizing ulcerative gingivitis or tion, hyperthyroidism, myocardial
periodontitis infarction, tissue injury from trauma.
4. Apical or periodontal abscess 4. Temperature decreases: Starvation,
5. Acute pericoronitis hemorrhage, or physiologic shock.
6. With the vital signs prior to administra-
tion to local anesthetics Methods to Determining
7. At any appointment when the patient Temperature
reports illness or there is a suspected Location for Measurement
infection. Special significance during • Oral—must not have sore mouth, very
epidemics when community exposures dry mouth or recent oral surgery
are at risk. • Forehead—for disposable thermometers
• Ear—with a tympanic device
Maintenance of Body Temperature • Medical/hospital applications—also
1. Adults use axilla or rectum places are used for
– Normal average temperature is assessment.
37.0°C (98.6ºF)
– Normal range is from 35.5°C to Types of Thermometers
37.5°C (96.0° to 99.5°F) • Electronic with digital readout
Older adults: Above 70 years of age, • Tympanic—insert gently into ear canal,
average normal temperature is slightly short exposure for 2 to 5 seconds
lower – 36.0°C (96.8°F) • Mercury in glass
2. Children: There is no appreciable • Disposable single use chemical strips.
differences between boys and girls. Care of patient with temperature differences:
Average temperatures are: 1. Temperature over 41.0°C (105.8°F)
– 1st year: 37.7°C (99.1°F) i. Treat as a medical emergency
– 4th year: 37.5°C (99.4°F) ii. Transport to a hospital for medical care.
– 6th year: 37.0°C (98.6°F) 2. Temperature between 37.6°C to 41.0°C
– 12th year: 36.7°C (98.0°F) (99.6°F to 105.8°F)
i. Check possible temporary or facti-
Body Temperature Variations tious course, such as hot beverages
1. Fever (pyrexia) values are 37.5°C (99.5°F) or smoking land observe patient
2. Hyperthermia values are 41.0°C (105.8°F) while repeating the determination
3. Hypothermia values are 35.5°C (96.0°F) ii. Review the dental and medical history
Factors that alter body temperature: iii. Postpone elective oral care when
1. Time of day: Highest in late afternoon there are signs of respiratory infec-
and early evening, lowest during sleep tions or other possible communica-
and early morning. ble diseases.
Chapter 3.indd 38 11/5/2014 6:04:53 PM

PULSE 3. Emergency situations: If problems
with breathing, unconsciousness, ana-
1. The pulse in the intermittent throbbing
phylaxis, bleeding, poisoning, chest
sensation felt when the fingers are
pain, respiratory failure, mild airway
pressed against an artery.
obstruction, heart failure, cardiac arrest,
2. It is the result of the alternate expansion
asthma attack, syncope, shock, stroke,
and contraction of an artery as a wave of
cardiovascular diseases, myocardial
blood is forced out from the heart.
infarction, insulin reaction (hyperinsu-
3. The pulse rate or heart rate is the count
linism, hypoglycemia), allergic reactions,
of heart beats.
local anesthetic reactions (psychogenic,
4. Irregularities of strength, rhythm, and
allergic-very rare, toxic overdose),
quality of the pulse should be noted
hemorrhage, burns, internal poisoning,
while counting the pulse rate.
discoloration of jaws, facial fracture, etc.
Maintenance of Normal Pulse

Procedure for Determining Pulse Rate
Normal Pulse Rate
1. Sequence: The pulse rate is obtained
1. Adults following the body temperature. The
i. There is no absolute normal pulse can be counted while the ther-
ii. The range is 60 to 100 beats per mometer is in the mouth.
minute 2. Sites: The pulse may be felt at several
iii. Higher for women than men. points over body:
2. Children: The pulse rate or heart rate i. Radial pulse—at wrist
falls steadily during childhood: ii. Temporal artery on the side of head
i. In utero: 150 bpm in front of ear
ii. At birth: 130 bpm iii. Facial artery at the borders of man-
iii. 2nd year: 105 bpm dible
iv. 4th year: 90 bpm iv. Carotid artery used during cardio-
v. 10th year: 70 bpm pulmonary resuscitation for an adult
v. Brachial pulse used for infant.
3. Recording of pulse rate:
Factors that Influence Pulse Rate
i. Tell the patient what is to be done
An unusual fast heart rate over 100 bpm in ii. Have the patient in a comfortable
an adult is called tachycardia. position with arm and hand
Unusual slow heart rate below 50 bpm supported, palm down
is called as bradycardia. iii. Locate the radial artery on the
1. Increased pulse: Caused by exercise, thumb side of the wrist with the tips
stimulants, eating, strong emotions, of the first three fingers.
extremes of heat and cold and some Note:
forms of heart disease. 1. Does not use the thumb because it
2. Decreased pulse: Caused by sleep, contains a pulse that may be confused
depressants, fasting, quieting emotions, with the patient pulse, when the pulse
and low vitality form prolonged illness. is felt, exert light pressure and count for
Chapter 3.indd 39 11/5/2014 6:04:53 PM

1 clocked minute, check with a repeat Factors that Increase

count. Blood Pressure
2. While taking the pulse, observe the • Exercise, eating, stimulants and emo-
following: tional disturbance
i. Rhythm: Regular, regularly irregular, • Use of oral contraceptive.
irregularly irregular
ii. Volume and strength: Full, strong,
Factors that Decrease
poor, weak, thread.
Blood Pressure
3. A pulse rate over 100 bpm is considered
abnormal for an adult. • Fasting, rest, depressants and quite
emotions
• Fainting, blood loss, shock.
BLOOD PRESSURE
• Information about the patient’s LOCAL EXAMINATION
blood pressure is essential during
dental appointments because special A careful overall observation of each patient
adaptation may be needed and a thorough examination of the oral
• Readings taken at the start of an cavity and adjacent structures are essential to
appointment can be significantly higher total assessment prior to comprehensive oral
than at the end of treatment health planning. A variety of lesions may be
• Screening for blood pressure in dental observed for which the patient may or may
offices has been shown to be an effective not report subjective symptoms. Despite the
health service for all ages since many occurrence of many seemingly minor lesions,
patients are unaware that they have the danger of oral malignancies remains a
hypertension. definitive possibility. Every effort must be
made to detect potentially cancerous lesions
early.
Components of Blood Pressure
• Each area of the mucous membrane
• Systolic pressure: Normal systolic must be examined and minor deviations
pressure is less than 120 mm Hg. from the normal must be given prompt
• Diastolic pressure: Normal diastolic attention.
pressure is less than 80 mm Hg.
• The oral tissues are sensitive indicators
• Pulse pressure: It is the difference
of the general health of the individual
between systolic and diastolic pressure
changes in these structures may be the
normal = < 40 mm Hg.
first indication of subclinical disease
processes in other parts of the body.
Factors that Influence Blood Pressure • Prerequisite to the recognition of devia-
Maintenance of Blood Pressure tions from the normal appearances of
• Force of heart beat the oral cavity in knowledge and un-
• Peripheral resistance, condition of derstanding of the normal morphology,
arteries, change in elasticity of vessels anatomy and physiology of the oral cav-
• Volume of blood. ity and the surrounding area.
Chapter 3.indd 40 11/5/2014 6:04:53 PM

Objectives Type I: Complete Examination
A thorough examination is essential to the A complete examination means that a
total care of the patient. The dentist will— thorough comprehensive study is made with
1. Observe the patient overall, as well as all the assessment parts.
in all areas in and about the oral cavity A complete examination comprises the
and record those areas that appear to use of mouth mirror, explorer, compressed
deviate from normal and that may be air, adequate standardized illumination,
evidence of disease. transillumination, thorough radiographic
2. Screen each patient at each appointment survey and if indicated percussion, pulp
to detect lesions that may be pathologic, vitality tests and laboratory tests.
particularly those that may be cancerous. For example: This type of examination
3. Recognize a need for postponement should be the standard for diagnostic proce-
of the current appointment because dures used in clinical caries trials in order to
of evidence of communicable disease make an accurate and consistent, determina-
or in difference to the need for urgent tion of the identity, state of health, pathology
medical consultation and or treatment. and post treatment of each tooth present.
4. Prevent the development of advanced,
irreversible or untreatable oral disease Type II: Limited Examination
by early recognition of initial lesions. A limited examination is made for an emer-
5. Identify suspected conditions that gency. It may be used in the management
require additional testing and refer for of acute conditions. A limited examination
medical evaluation. comprises the use of mouth mirror and ex-
6. Identify extraoral and intraoral plorer, adequate standardized illumination
deviations from a normal for which and transillumination, posterior bitewing
dental care and instruction may need radiographs are sometimes made for the
special adaptations. detection of proximal caries of molars and
premolars.
7. Provide a means of comparison of
individual oral examinations over a Type III: Inspection
series of maintenance appointments
For an inspection, a mouth mirror and
and thus, determine the effects of
explorer and the best available illumination
dental care and the success of patient
are used. An inspection is the standard
instructions.
diagnostic procedure for estimating
8. Provide information for containing
caries prevalence in large samples or total
records of the patient’s diagnosis and
population. In this type of examination, a
treatment plan for legal purposes.
minimum of equipments is used and only
a few variables should be assessed, such as
Types of Dental Examinations status of oral hygiene, presence or absence of
According to the American Dental caries and filling, types of treatment required
Association: or number of missing teeth.
Chapter 3.indd 41 11/5/2014 6:04:53 PM

Type IV: Screening Examination Methods

Screening implies a brief examination. It A patient is examined by;
may be used for initial patient assessment 1. Visual examination:
and trial to determine priority for treatment. i. Direct observation: Visual examina-
Community screening is an initial survey tion is made in a systemic order to
of a group of individuals made to identify note surface appearance (color, con-
the prevalence of a particular disease or tour, size) and to observe movement
condition within population. and other evidence of function.
For screening, one uses only a tongue ii. Radiographic examinations: The use of
depressor and the best available illumination. radiographs can reveal deviations
A screening is a crude method for obtaining from normal and noticeable by
simple epidemiological data such as tooth direct observations.
mortality rate or the percentage of persons iii. Transillumination: A strong light
with one or more DMF teeth. directed through a soft tissue or
a tooth to enhance examination
Serial Examinations is especially useful for detecting
Serial examinations are periodic re-exami- irregularities of the teeth and
nation of the same individual at determined locating calculus.
intervals using the same standard each time. 2. Palpation: Palpation is an examination
It is a follow-up examination, a type of lim- using the sense of touch through
ited examination. It is used to observe the tissue manipulation or presence on
effects of treatment after a period of time an area with the fingers of hand. The
during which the tissue or lesion can recover method used depends on the area to be
and heal. Indications of the need for addi- investigated.
tional or alternate treatment are apparent at Types of palpation include the following:
a follow-up examination. i. Digital: Use of a single finger.
For example: Index finger applied
Periodic Examinations to inner border of the mandible
Periodic examinations of different samples beneath the canine-premolar area
from the same population using the same, to determine the presence of a torus
clearly defined sampling methods and mandibularis.
criteria each time. ii. Bi-digital: Use of finger or finger
and thumb from each hand applied
Maintenance/Re-evaluation simultaneously in co-ordination.
An examination is made after a specified For example: Index finger of one
period of time following the completion of hand palpates on the floor of the
treatment and the restoration of health. A mouth inside, while a finger or
maintenance or re-evaluation examination is fingers from the other hand press on
a complete re-assessment from which a new the same area from under the chin
care plan is derived. externally.
Chapter 3.indd 42 11/5/2014 6:04:53 PM

iii. Bilateral: The two hands are used procedure successfully, the examiner needs
at the same time to examine the following:
corresponding structures on 1. Adequate knowledge of the anatomy
opposite sides of the comparison of the region to be able to recognize
may be made. normal structures and their common
For example: Fingers placed beneath variations.
the chin to palpate the submandibu- 2. Knowledge of the variety of disease
lar lymph nodes. processes that can affect the superficial
3. Instrumentation: Examination instru- structures of the head, neck and oral
ments, such as the explorer and probe cavity.
are used for specific examination of the 3. The ability to succinctly (in writing)
teeth and periodontal tissues. both normal and abnormal findings
4. Percussion: Percussion is the act of noted during the examination.
tapping a surface or tooth with the An established and reproducible rou-
fingers or an instrument. tine order for examination is desirable
i. Information about the status of become:
health of the past is determined • Minimal possibility of over looking an
either by the response of the patient area and missing details of importance.
or by the sound. • Increase efficiency and conservation of
Example: A metal mirror handle time
may be used to tap each tooth • Maintenance of professional atmosphere
successively. which inspire the patients’ confidence.
ii. When a tooth is known to be painful The examination routine encompasses
to movement, percussion should be the following order:
avoided.
5. Electrical test: An electrical pulp vitality Overall Appraisal of Patient
test is used to detect the presence or To Observe
absence of vital pulp tissue. Posture, gait, general health status, hair,
6. Auscultation: Auscultation is the use scalp, breathing, state of fatigue, voice,
of sound. An example is the sound of cough, hoarseness.
clicking of the TMJ when the jaw is • Posture: Erect/slumping posture
moved. • Skin: Color/texture/pigmentations.
EXTRAORAL AND INTRAORAL Indication and Influence on Appointment

EXAMINATIONs Response, cooperation, attitude towards
treatment length of appointment.
The ability to perform a through physical
examination of the superficial structure of
the head, neck and oral cavity is essential in Head
diagnosing and comprehensive oral health Mesocephalic/brachycephalic/dolichoce-
care plan. To perform this examination phalic.
Chapter 3.indd 43 11/5/2014 6:04:53 PM

Hydrocephalic Indications and Influences on Dental

When rate of growth of head is greater than Appointments
normal for sex, age and size of the patient. • Dilated pupils or pinpoint may result
from drugs, emergency state
Face • Change of color of sclera indicates
To Observe further investigation and referral to
physician—postpone the treatment
Expression: Evidence of fear or apprehension.
• Hyperthyroidism
Shape: Twitching, paralysis. • Inflammation associated with maxillary
Jaw movement during speech, injuries: signs teeth may extend to the orbital region
of abuse. causing swelling of the eyelids and
conjunctivitis. Eyes also serve as
Indication and Influence of Appointment indicators for anemia, jaundice, etc.
• Need for alleviation of fears
• Evidence of upper respiratory or other Nose
infections To Observe
• Enlarged masseter muscle (related to • Contour (nasal bridge) can be—straight,
Bruxism) convex, crooked.
• Face form—mesoprosopic/leptopros- • Size—height should be about 1/3rd of
opic/euryprosopic the total facial height. Microrhinic is
• Facial profile—concave/convex/straight associated with high root of the nose,
• Facial symmetry—asymmetry/symmetry. short nasal bridge and an elevated lip.
• Ratio between the horizontal length
Skin with the height of the nose is 2:1.
To Observe • Nostrils—width is approximately 70%
Color, texture, blemishes, traumatic lesions, of the length of the nose.
eruptions, swellings, growths. • Certain infectious diseases leave their
marks on nose. For example: saddle
Indications and Influences on Appointment nose is congenital syphilis.
• Relation to possible systemic conditions • Identify deviated nasal septum is
• Need for supplementary history important in mouth breathers.
• Biopsy and other treatment
• Influences on instruction in diet. Lymph Nodes—Palpate
• Pre and post auricular
Eyes • Occipital
To Observe • Submental
Size of pupils, color of sclera, eye glasses • Submandibular
(corrective), protruding eyeballs, swelling • Cervical chain
of eyelids. • Subclavicular.
Chapter 3.indd 44 11/5/2014 6:04:53 PM

To Observe Examination of Temporomandibular Joint
Palpate for adenopathy, lymph adenopathy. Temporomandibular joint (TMJ) is palpated
The superficial and the deep lymph nodes by standing in front of the patient. This helps
of the neck are best examined from behind to visualize the movement of the mandible
the patient, with the patients head inclined during the opening and closure of the jaw
forward sufficiently to relax the tissues and thus note any discrepancies. The head
overlying the lymph nodes. of the each mandibular condyle can be
palpated by placing the index finger in front
Indication and Influences on Dental of the tragus and the posterior border of the
Appointments
condyle can be palpated by placing the index
• Need for referral finger in the external acoustic meatus.
• Medical consultation • It reveals pain on pressure and
• Coordinate with intraoral examination. synchrony of action of left and right
condyle.
Temporomandibular Joint (Palpate)
• Discrepancies of TMJ such as muscular
To Observe imbalances, anatomic deviations,
• Observe limitations or deviations of swellings or redness over joint region,
movement in the path of the mandible trismus and spasm of muscles can be
during opening and closing, as well as noted.
range of vertical and lateral movement. • Lateral pterygoid and masseter pain is
• Palpate the joints, and listen for click- also encountered associated with TMJ
ing and crepitus during opening and problems.
closing of the jaw: use a stethoscope to Clicking may be:
characterize and locate these sounds
– Initial clicking: Sign of reduced
accurately. Noises: Clicking, palpating,
condyle in relation to disk.
grating.
– Intermediate clicking: Unevenness of
• Note any tenderness over the joint
condyle surfaces and the articular
or masticatory muscles (temporalis,
disk which rides over one another
masseter) while palpating externally
during the movements.
and over the lateral pterygoid and
buccinator muscles (distal and lateral – Terminal clicking: Most common and
to upper molar teeth) and the medial is due to the condyle being moved
pterygoid muscle (pterygomandibular too far anteriorly in relation to the
ligament and medial aspect of anterior disk on maximum jaw opening.
faucial pillar) with patients mouth – Reciprocal clicking: Occurs during
open. opening and closing and expresses
• Explore the anterior wall of the external an uncoordination between
auditory meatus for tenderness and displacement of the condyle and
pain that are usually associated with disk. Clicking of the joint is rare in
capsulitis. children.
Chapter 3.indd 45 11/5/2014 6:04:53 PM

Indication and Influences on Dental 1. Positive lip step—protruded lower

Appointments lip associated with class 3 relation.
• Disorder joints, limitation of opening 2. Normal lip relation has a mild
• Discomfort during appointment and negative lip, with upper lip mildly
during personal biofilm control. protruded compared to the lower
lip.
Lips 3. Marked negative lip step—protrud-
ed upper lip, class 3 relation.
• Observe closed; then open
• Palpate. Indication and Influences on Dental
Appointments
To Observe
• Need further examination; referred
• Lip color, texture, size, any abnor- • Immediate need for postponement of
malities, angular or vertical fissures appointment when a lesion may be
(cracks, angular chelosis) lip pits, communicable or could interfere with
blisters, ulcers, scabs, nodules, keratotic procedures
plaques and scars. • Care during relation
• Traumatic lesions, irritation from lip- • Accessibility during intraoral proce-
biting. dures.
• Limitation of opening, muscle elasticity, • Patient instruction: Dietary, special
muscle tone. biofilm control for mouth breather.
Evidence of mouth breathing in duration
thickening or swelling. Note orifices of minor
Labial and Buccal Mucosa: Left and Right
salivary glands and presence of Fordyce’s
Examined Systematically
granules.
• Normally competent: Touch each other • Vestibule
lightly or with 0.1 mm of gap. When the • Mucobuccal folds
lips do not approximate each other at • Frenum
rest they are termed as incompetent. • Opening of stensons duct
• Length: Upper lip covers the entire • Palpate cheeks.
labial surface of upper anterior teeth
except the incisal third or incisal 2–3 To Observe
mm. • Color, size, texture, contour—note any
• Tonicity and color: Normal is pink and changes in pigmentation and mobility
firm, hypoactive lip is lighter in color of the mucosa
and is faccid. • Abrasions, traumatic lesions
• Hypotonic lip is flaccid. • Effect of tobacco use—leukoplakia,
• Lip protrusion is influenced by the hyperkeratotic patches
thickness of the soft tissue, tone of • Ulcers, growths, nodules, scars, other
the muscles, position of anterior teeth red and white patches and Fordyce’s
and configuration of underlying bony granules
structures. • Moistness of surfaces—observe opening
• Lip step (profile) according to Korkhaus of Stenson’s ducts and establish their
are of three types. potency by first drying the extent of
Chapter 3.indd 46 11/5/2014 6:04:53 PM

salivary flow from duct openings, with • Mucosa, frena
and without milking the gland. • Tongue action.
• Palpate muscles of mastication
• Relation of frena to free gingiva To Observe
• Induration • Varicosities
• Lesions: Elevated, flat, depressed,
Indication and Influences on Dental traumatic induration
Appointments • Limitation or freedom of movement of
• Need for referral, biopsy, cytology tongue
• Frena and other anatomic parts that • Frena: Tongue–tie.
need special adaptation for radiography
or impression tray. Indication and Influences on Dental
• Avoid sensitive areas during retraction. Appointments
Large muscular tongue influences retraction,
Tongue gag reflex, accessibility for instrumentation.
Film placement problems.
• Vestibule
• Lateral borders
• Base of the tongue (retract) Breath Odor—Halitosis
• Deviation on extension. To Observe
Severity: Relation to oral hygiene, gingival
To Observe health. May be due to blood in mouth, de-
• Dorsum of the tongue for any swelling, hydration, sinusitis, infection of adenoid
ulcers, coating or variation in size, tissue, disturbances of alimentary tract, etc.
color, texture, consistency, fissure,
papillae Indication and Influences on Dental
• Lesions, elevated, depressed, flat, Appointments
induration. • Possible relation to systemic condition
• Margin of the tongue—note the distribu- • Alcohol use history; special needs.
tion of filiform and fungiform papillae,
crenations and fasciculations, depapil- Saliva
lated areas, fissure and keratotic areas. To Observe
• Note frenal attachment any deviations.
• Quantity, quality (thick, ropy)
• Evidence of dry mouth; lip wetting
Indication and Influences on Dental
• Tongue coating.
Appointments
• Need for referral, biopsy, cytology Indication and Influences on Dental
• Need for instruction in tongue cleaning. Appointments
• Reduced in certain diseases, by certain
Floor of the Mouth drugs
• Ventral surface of the tongue • Special dental caries control program
• Palpate • Influence on instrumentation
• Whartons duct opening • Need for saliva substitute.
Chapter 3.indd 47 11/5/2014 6:04:53 PM

Hard Palate Indication and Influences on Dental

To Observe Appointments
• Height, contour, color • Referral, biopsy, cytology
• Appearance of rugae • Enlarged tonsils encourage gag reflex
• Tori, growths, ulcers, recent burns, • Throat infection, a sign for appointment
leukoplakia. postponement.
Indication and Influences on Dental BASIC TERMINOLOGY IN TOOTH

Appointments NUMBERING SYSTEM
• Need for referral, biopsy, cytology
Different tooth numbering systems are
• Signs of tongue thrust, deviate swallow
used in different dental offices and clinics.
• Influence on radiographic film placement.
The different tooth designation systems in
general use are:
Soft Palate, Uvula 1. FDI system—two digit system.
To Observe 2. Universal or continuous tooth number-
Color, size, shape, petechiae, ulcers, growths. ing system
3. Palmer or chevron or quadrant tooth
Indication and Influences on Dental numbers 1 through 8 systems
Appointments 4. The European tooth numbering system.
• Referral, biopsy, cytology
• Large uvula influences gag reflex. The FDI—Two Digit Tooth
Numbering System
Tonsillar Region and Oropharynx The FDI system is also called the International.
Gingiva This system was introduced in the early
Gingival should be examined for the features 1970’s and was subsequently accepted by
as mention in Table 3.4. the Federation Dentaire Internationale.
• Note color, size and any surface abnor- It was developed to make possible the
malities of tonsils and ulcers, tonsillitis computerization of dental research data. It
and secretion in tonsillar crypts. had been cumbersome or impossible to enter
• Palpate the tonsils for discharge or data into computers using tooth numbering
tenderness, and note restriction of the system common before 1970.
oropharyngeal airway. The two digit systems, the first digit
• Examine the faucial pillars for bilateral specifies the quadrant of the mouth and the
symmetry, nodules, red and white patch- second the actual tooth as follows:
es, lymphoid aggregates and deformities.
• Examine the postpharyngeal wall for Permanent Teeth
swellings, nodular, lymphoid hyperpla- Each tooth is numbered by the quadrant 1
sia, hyperplastic adenoids, post nasal to 4 and by the tooth within the quadrant
discharge and heavy mucous secretions. 1 to 8.
Chapter 3.indd 48 11/5/2014 6:04:54 PM

Table 3.4: Examination of the gingival clinical markers
Appearance in health Changes in disease and clinical appearance
Color Uniform pale pink or coral pink Acute: Bright red

Variation in pigmentation related to complexion, Chronic: Bluish pink, bluish red
race Attached gingiva: Color changes may extend to
the mucogingival line
Size Not enlarged Enlarged

Fits snugly around the tooth
Shape Marginal gingiva: Knife edged, flat, follows a Marginal gingiva: Rounded rolled
curved line about the tooth Papillae:
Papillae: Bulbous
Normal contact: Papilla is pointed and Flattened
pyramidal; fills the interproximal area Space Blunted
(diastema) between teeth; gingiva is flat or Cratered
saddle shaped
Consistency Firm Soft spongy: Dents readily when pressed with

Attached gingiva firmly bound down a probe
Associated with red color, smooth shiny
surface, loss of stippling, bleeding on probing
Firm, hard: Resists probe pressure
Associated with pink color, stippling, bleeding
only in depth of pocket
Surface texture Free gingiva: Smooth Acute condition: Smooth shiny gingiva
Attached gingiva: Stippling Chronic: hard, firm with stippling, sometimes
heavier than normal
Position of gingival Fully erupted tooth: margin is 1–2 mm above Enlarged gingiva: Margin is higher on the tooth,
margin CEJ, above normal, pocket deepened
or slightly below the enamel contour Recession: Margin is more apical, root surface
is exposed
Position of junctional During eruption along the surface Position determined by use of probe, is on the
epithelium Fully erupted tooth: Junctional epithelium is root surface
at CEJ
Mucogingival junction Make clear demarcation between the pink, No attached gingiva:
stippled attached gingiva and the darker Color changes may extend full height of the
alveolar mucosa with smooth shiny surface gingiva, mucogignival line obliterated
Probing reveals that the bottom of the pocket
extends into the alveolar mucosa
Frenal pull may displace the gingival margin
from the tooth
Bleeding No spontaneous bleeding or upon probing Spontaneous bleeding

Bleeding on probing: Bleeding near margin
in acute condition, bleeding deep in pocket in
chronic condition
Exudates No exudates expressed on pressure White fluid, pus, visible on digital pressure
Amount not related to pocket depth
Chapter 3.indd 49 11/5/2014 6:04:54 PM

Quadrant numbers
1 = maxillary right
2 = maxillary left
3 = mandibular left
4 = mandibular right.
Tooth number within each quadrant: Start with

number 1 at the midline, i.e. central incisor
to number 8, third molar as shown in the
Figure 3.2: Federation dentaire internationale two-
(Figure 3.2). digit tooth numbering system
Designation: The digits are pronounced sep- UNIVERSAL OR Continuous SYSTEM

arately. In designating a tooth, it is recom- NUMBER 1 THrOUGH 32 System
mended to calculate the quadrant number,
then the tooth number. For example, the up- This system is adopted by the American
per right second incisor, 12 = ‘one-two’ rath- Dental Association. This tooth numbering
er than ‘twelve’, the lower left third molar, method is referred to as the universal or ADA
38 = ‘three-eight’, rather than ‘thirty-eight’. system. In (Figure 3.3) shows the crowns of
the teeth with the corresponding numbers.
Primary Teeth This is the system which is still used to
a large extent in the United States today. It
Each tooth is numbered by quadrant, 5 to
is sequential numbering system.
8 to continue with the permanent quadrant
numbers. The teeth are numbered within
each quadrant 1 to 5. Permanent Teeth
1. Start with the right maxillary third
Quadrant number molar (number 1)
5 = maxillary right 2. Follow around the arch to the left
6 = maxillary left maxillary third molar (number 16)
7 = mandibular left 3. Descend to the left mandibular third
8 = mandibular right. molar (number 17)
4. Follow around to the right mandibular
Tooth numbering with each quadrant: Number third molar (number 32).
1 is the central incisor, and number 5 is the
primary second molar.
Primary Tooth
Designation: The digits are pronounced sep- 1. Use continuous upper case letter (A)
arately. For example, the mandibular right through (T) in the same order as de-
primary canine, 83 = ‘eight-three’ rather scribed for the permanent teeth.
than ‘eighty-three’. The maxillary left sec- 2. Right maxillary primary second molar
ond primary molar, 65 = ‘six-five’ rather (A) around to left maxillary primary
than ‘sixty-five’. second molar (J).
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Figure 3.3: Universal tooth numbering system
Figure 3.4: Palmer or quadrant or chevron numbering 1 through 8 system
3. Descend to left mandibular second vertical and horizontal lines as shown in

primary molar (K) and around to the right (Figure 3.4).
primary mandibular second molar (T).
Primary Teeth
PALMER OR QUADRANT OR CHEVRON 1. Upper case letters (A) through (E) are
NUMBERING 1 THROUGH 8 SYSTEM used instead of the numbers.
Names to identify this method are the palmer
system or set-square. THE EUROPEAN TOOTH
NUMBERING SYSTEM
Permanent Teeth Permanent Teeth
1. Each tooth is designated using the 1. Each tooth is designated using the
numbers 1 (central incisor) through 8 numbers 1 (central incisor) through 8
(third molar) (third molars).
2. The appropriate quadrant for each tooth 2. The appropriate quadrant for each
is designated using a specific pattern of tooth is designated using a ‘+’ mark
Chapter 3.indd 51 11/5/2014 6:04:54 PM

to left side of right upper teeth and ‘+’ Eruption

mark to right side of left upper teeth as To Observe
shown in (Figure 3.5).
• Sequence of eruption: Normal, irregular
• Unerupted teeth observed in radio-
Primary Teeth graphs.
01, 02, etc. or I, II, etc.
Dental Care Implications
8+7+6+5+4+3+2+1+|
• Care in using floss in the col area where
________________________________
+1+2+3+4+5+6+7+8
the epithelium is usually less mature in
8–7–6–5–4–3–2 –1–| young children
–1–2–3–4–5 –6–7–8 • Orthodontic needs
Figure 3.5: European tooth numbering system • Procedure for preservation of primary
teeth.
EXAMINATION OF TEETH
Deposits
Morphology Food debri, biofilm, calculus—supragingival
To Observe and subgingival.
• Number of teeth (missing teeth veri-
fied by radiographic examination), size, To Observe
shape, arch form, position of individual • Overall evaluation of self care and
tooth. biofilm control measures
• Injuries: Fractures of the crown (root • Relation of appearance of teeth to
fractures observed in radiographs). gingival health
• Extent and location of biofilm, debris
Dental Care Implications and calculus
• Selection and adaptation of instruments. • Calculus and the tooth surface pocket
• Areas prone to dental caries initiation, wall.
particularly difficult to reach areas
during biofilm control. Dental Care Implications
• Pulp test for vitality may be indicated. • Need for interaction and guidance
• Frequency of follow-up and mainte-
Development nance appointments.
To Observe
• Anomalies and developmental defects Stains
• Pits and white spots. Extrinsic and intrinsic.
Dental Care Implications To Observe

• Distinguish hypoplasia and dental • Extrinsic: Colors relate to cause
fluorosis from demineralization. • Intrinsic: Dark, grayish
• Identify deep pits and fissures for sealants. • Tobacco stain.
Chapter 3.indd 52 11/5/2014 6:04:54 PM

Dental Care Implications Dental Caries
• Need for test for pulp vitality To Observe
• Stain removal procedures: Selection of • Areas of demineralization
polishing agent • Stages of carious lesions
• Dentifrice recommendation • Proximal lesions observed in radio-
• Provide information concerning the graphs
oral effects of tobacco use • Arrested caries
• Tobacco cessation programs. • Root caries.
Regressive Changes Dental Care Implications

To Observe • Charting
• Treatment plan
• Attrition: Primary and permanent
• Cavitated vs non-cavitated
• Abrasion: Physical agents that may be a
• Preventive program for caries control,
cause
fluoride, diet factors
• Erosion.
• Follow-up and frequency of mainte-
Dental Care Implications nance.
• Evaluate causes and treat or counsel for
Restorations
prevention
• Dietary analysis: For finding foods that To Observe
may be related • Contour of restorations, overhangs
• Selection of non abrasive dentifrices • Proximal contact (see separate headings in
• Habitat evaluation. this section)
• Surface smoothness
Exposed Cementum • Staining.
To Observe
Factors Related to Occlusion
• Relation to gingival recession, pocket
To Observe
formation areas of narrow attached
gingiva • Health of supporting structures,
• Hypersensitivity. observation of radiographs for signs of
trauma from occlusion.
• Special care areas where only slight
Need for study of bruxism and other
attached gingiva remains
parafunctional habits.
• Non abrasive dentifrices advised
• Measures to prevent root surface caries
• Care during instrumentation
Tooth Wear
• Indication for application of desensitiz- To Observe
ing agent. Facets, worn—down cusp tips.
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Dental Care Implications Edentulous Areas

Chart inadequate contacts for corrective To Observe
measures. Radiographic evaluation for impacted
unerupted teeth, retained root tips other
Proximal Contacts deviations from normal.
To Observe
• Use of floss to find open contact areas
• Areas of food retention. • Supplemental fulcrum selection during
instrumentation.
Dental Care Implications • Applied biofilm control procedures for
Use of floss by patient. abutment teeth.
MOBILITY Replacement for Missing Teeth

To Observe To Observe
• Degree, comparison of chartings Teeth and tissue that support a prosthesis.

• Possible causes.
Dental Care Implications Preventive measures for harm to supporting
• Need for reduction of inflammatory teeth and soft tissues.
factors that may be related
• Dentist will identify and treat factors Dentures
related to trauma from occlusion. Partial dentures and implants.
Classification To Observe
To Observe • Cleanliness of a prosthesis
• Positions of teeth • Factors that contribute to food and
• Angle’s classification. debri retention.
Dental Care Implications Dental Care Implication

Relationship to orthodontic treatment • Instrumentation in personal care of
needs. fixed and removable dentures
• Use of floss under fixed partial dentures
Habits • Other appropriate care.
To Observe
• Nail or object biting, lip or cheek biting PROVISIONAL DIAGNOSIS
• Observe effects on lip, cheek, teeth • All records and clinical findings clubbed
• Tongue thrust, reverse swallow. together the clinician should be able to
frame a provisional diagonsis.
Dental Care Implications • Clinician should keep in mind the
Guidance for habit correction when indicated. differential diagnosis.
Chapter 3.indd 54 11/5/2014 6:04:54 PM

Differential Diagnosis • Biopsy.
• Differential diagnosis is the determina-
tion of which of two or more diseases Chairside Investigations
with similar signs and symptoms is the • Vital staining—Toluidine blue staining
one from which the patient is suffering. and Lugol’s iodine
• In this, clinician needs to access like- • Vizilite
lyhood of diagnosis, taking into • Caries detection—
consideration age, sex, race and patients – Transillumination test for caries
sign, symptoms and other information. detection
– Infrared laser fluorescence
Diagnosis of A Specific Problem – Digital imaging fiber optic transil-
• Soap evaluation is an effective meth- lumination (DIFOTI)
od—if the available diagnostic database • Identifying cracked tooth
is current and accurate. But if diagnostic • Pulp vitality test
database is unavailable, then significant • Salivary flow estimation—Schirmer’s
portions of patients history and exami- test.
nation be performed.
• Format of soap evaluation: Identifying Cracked Tooth
– Reason for evaluation is briefly • Rubber polishing wheels/orange wood
stated. sticks/tongue blades
– “ s ” e n t r y — i s t h e s u b j e c t i v e • Patient is asked to bite—reproduces the
information (or) symptoms of the pain of the cracked tooth syndrome
condition supplied by the patient. • Further light can be reflected from
– “o” entry—includes objective various direction to confirm the cracked
(sign) or the physical findings of the tooth.
clinician.
– “a” entry—analysis or the clinical
impression of the condition by the RADIOGRAPHS
clinician. Extra Oral Views
– “p” entry—plan or recommended • Panoramic
management for problem. • Lateral jaw
• Tmj—tomography magnetic resonance
INVESTIGATIONs • Cephalometric
• Chairside investigations • Water’s view
• Radiological investigations • Submentovertex view.
• Specialized radiographs
• Hematological investigations Periapical Radiography
• Serum chemistry/serology • Detection of apical infection/inflamma-
• Urine analysis tion—abscess, cyst granulomas, lesions
• Stool examination of alveolar bone
• Liver function test • Periodontal status
Chapter 3.indd 55 11/5/2014 6:04:54 PM

• Trauma to teeth and associated alveolar • Assessment and displacement of

bone fractures of teeth and alveolar bone.
• Assessment of presence and position of • Detection of presence and position of
unerupted teeth radiopaque calculi in submandibular
• Assessment of root morphology— duct.
before extraction
• During any endodontic procedure TREATMENT PLAN
• Preoperative and postoperative assess-
ment—apical surgery • Emergency phase
• Evaluation of implants. • Immediate treatment—abscess drain-
age/access opening/medication
Bitewing Radiographs • Patient education and motivation and
oral prophylaxis
• Detection of dental caries—proximal
• Preventive treatment
caries, root caries
• Restorative treatment
• Progression of dental caries
• Surgical treatment
• Assessment of existing restoration
• Prosthetic treatment
• Assessment of periodontal/interdental
• Orthodontic treatment
area.
• Maintenance phase—recall visits and
maintenance.
Occlusal Radiography
• Periapical assessment of teeth especially
in children/adults unable to tolerate LEVELS OF PREVENTION
periapical films. Primary Prevention
• Assessment of fractures of teeth and • Health promotion
alveolar bone especially in children, • Specific protection.
post trauma cases.
• Detect the presence of unerupted canines,
Secondary Prevention
odontomes, supernumeraries, cysts.
• Determine buccal/palatal/lingual view of Early diagnosis and prompt treatment.
the unerupted canines, periapical swelling.
• Evaluate size, extent of lesions—such as Tertiary Prevention
cyst, tumors, etc. Disability limitation/rehabilitation.
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Chapter
4 Assessment of Oral Health

Status Using Dental Indices
DENTAL INDEX Validity

This chapter provides an introduction to The index must measure what it is intended
scoring methods for a few indices used to measure, so it should correspond with the
by clinicians, researchers and community clinical stages of the disease under study at
practitioners to evaluate indicators for oral each point.
health status. It is not possible to explain all
of the many dental indices that have been Reliability
used in a variety of settings, but several well The index should be able to measure
known dental indices that are widely used consistently at different times a variety
in epidemiological survey procedures are of conditions. The term reliability is
described in this chapter. virtually synonymous with reproducibility,
repeatability and consistency, measuring the
What is Dental Index? ability of the same or different examiners
An index has been defined by Russell as to interpret and use the index in the same
“a numerical value describing the relative way.
status of a population on a graduated scale
with definite upper and lower limits which is Quantifiability
designed to permit and facilitate comparison The index should be amenable to statistical
with other population classified by the same analysis, means easy to persuade so that
criteria and methods”. the status of a group can be expressed
An index is an expression of clinical by a distribution, mean, median or other
observations in numerical values. statistical measure.
Ideal Requirements of a Dental Index Sensitivity

Clarity, Simplicity and Objectivity The index should be able to detect clinically
• The examiner should be able to carry relevant but reasonable small shifts, in either
out the rules of the index in his mind. direction in the group condition.
• The index should be reasonably easy to
apply so that there is no undue loss of Acceptability
time during field examinations. • An index should be universally
• The criteria for the index should be acceptable.
clear and unambiguous, with mutually • The cost and material: Required minimal
exclusive categories. equipment and expense.
Comfort IV. Evaluates the success on individual and

The use of the index should not be unneces- professional treatment over a period of
sarily painful or demeaning to the subject. time by comparing index scores.
Probably no index used in oral V. Provide a mean for personal assessment
epidemiology completely meets all of these by the dental hygienist of abilities
conditions, but choice of an index in any to educate and motivate individual
given situation should be made on the basis patient.
of how closely the index approximates them Clinical Trial in Research
and by the requirements of the study in
Purpose: A clinical trial is planned for the
which the index is being used.
determination of the effect of an agent or
procedure on the progression, control or
Uses of Dental Index in Dental Practice prevention of a disease. The trial is conduct-
To understand the purposes and uses of a ed by comparing an experimental group
“Dental Index”, a distinction must be made with a control group that is similar to the
between: experimental group in every way except for
1. Individual oral health assessment score the variable being studied.
2. Clinical trial in research Examples of indices used for clinical
3. Community health epidemiologic survey. trials are the Plaque Index (PI) of Silness and
Loe and Patient Hygiene Performance Index
Individual Oral Health Assessment Score (PHP) of Pods Hadley and Haley.
Purpose: In clinical practice, an index, plaque Uses
record or scoring system for an individual I. Determines baseline data before
patient can be used for education, motiva- experimental factors are introduced.
tion and evaluation. The effects of personal II. Measures the effectiveness of specific
disease control efforts, the progress of heal- agents for the prevention, control,
ing during professional treatments and the treatment or oral conditions.
maintenance of health over time can be III. Measures the effectiveness of mechanical
monitored. An example is the “plaque free devices for personal care, such as
score”, in which the patient is able to meas- toothbrushes, interdental cleaning
ure the effects of personal daily care efforts devices or water irrigators.
by the changes in the scores.
Community Health Epidemiologic Survey
Uses Purpose: The word epidemiology denotes
I. Provides an individual assessment the study of disease and characteristics of
to help a patient recognize his oral populations. An example of an index de-
problem. signed for a survey of population groups is
II. Reveals the degree of effectiveness of the DMF index. It has been used with popu-
present oral hygiene practice. lations around the world to determine the
III. Motivates the person in preventive and extent of dental caries. Such a survey was
professional care for the elimination not designed for evaluation of an individ-
and control of oral disease. ual patient.
Assessment of Oral Health Status Using Dental Indices 59
Uses Reversible index: Indices are used to meas-

I. Shows the prevalence and incidence of ure, changing conditions that may heal or
a particular condition occurring within progress with time. Reversible index scores
a given population. can increase or decrease on subsequent ex-
II. Provides baseline data to show existing amination, e.g. indices that measure peri-
dental health practices. Comparisons odontal conditions like, gingivitis, bacterial
between populations are facilitated. plaque, OHI-S index, plaque index, gingival
III. Assesses the needs of a community. index, patient hygiene performance index,
IV. Compares the effects of a community papillary marginal attached gingival index,
program and evaluates the results. gingival bleeding index, etc.
V. In community health programs the
dental index is employed to provide Irreversible index: Index that measures condi-
proof of legitimacy and effectiveness, tions that will not change. Irreversible index
and to provide data to support scores, once established cannot decrease in
recommendations for public health value on subsequent examinations. These
interventions to improve the health indices are used to measure cumulative
status of populations. conditions. They are extremely valuable in
VI. Serve as an evaluation mechanism for longitudinal studies to determine changes
the profession and public in estimating over a specific time span, e.g. an index that
future needs and evaluating treatment measures dental caries.
and preventive procedures.
Reversible and irreversible index: Indices are
used to measure both reversible and irre-
Classification of Dental Indices versible conditions of a disease, e.g. Russell’s
General Categories periodontal index, CPITN-Index, etc.
1. Simple index Depending upon the extent to which
2. Cumulative index. areas of oral cavity are measured. Indices
are classified into:
Simple index: One that measures the presence 1. Full mouth
or absence of the condition. An example is 2. Simplified.
an index that measures the presence of bac-
terial plaque without evaluating its effect Full mouth indices: These indices measure the
on the gingiva. patient’s entire periodontium or dentition,
e.g. Russell’s periodontal index (PI).
Cumulative index: One that measures all the
evidence of a condition, which is past and Simplified indices
present. An example is the DMF index for • These indices measure only a repre-
dental caries. sentative sample of the dental appara-
Depending upon the reversible change of tus, e.g. Greene and Vermillion’s oral
disease conditions the simple and cumulative hygiene index-simplified (OHI-S).
indices are classified into: • Indices may be classified in certain
a. Reversible index general categories according to the
b. Irreversible index entity which they measure like.
c. Reversible and irreversible index. – Disease index
– Symptom index 5. When evaluating the individual patient

– Treatment index. or when conducting studies with small
• The ‘D’ (decay) portion of the DMF samples, it is best to use a full mouth in-
index best exemplifies a disease index. dex. Simplified indices are most useful
• The indices measuring gingival/sulcu- in epidemiologic surveys and clinical
lar bleeding are essentially symptom trials in which sample sizes are large.
indices. 6. Examiners should establish their reliabil-
• The ‘F’ (filled) portion of the DMF index ity with an index prior to using it in any
best exemplifies a treatment index. research project. Additionally, through-
out the course of an investigation both
Selection of a Dental Index inter examiner and intraexaminer reli-
ability must be re-evaluated repeatedly.
The selection of a dental index depends upon
the following factors:
1. Type of conditions to be assessed ARMAMENTARIUM USED IN
2. Age of the population to be studied EXAMINATION OF PATIENT TO
3. Purpose of the research. RECORD DENTAL INDICES
Before using the dental indices in any
Instrumentation begins with the identification
epidemiological survey or study to be
of the various types of instruments for
conducted, the following points should be
specific intraoral examination of patient and
considered for better results:
to perform and record the dental indices
1. Studies conducted with different
during surgery procedures.
indices should be compared for general
A high degree of skill in the care and
findings rather than specific details.
use of fine instruments are required. Skill
2. Dental indices should be selected
depends on knowledge and understanding
according to their potential to best
of the goal of the dental reviewer and
evaluate the variable or condition being
how the goal can be reached through
assessed, e.g. It is difficult to accurately
application of the fundamental principles of
determine plaque severity scores on
instrumentation.
proximal tooth surfaces. On these
The instruments are classified by
surfaces, scoring on presence or absence
purpose and use as:
of plaque is probably more precise.
1. Examination instruments: Probe, mouth
3. In general, indices should be used
mirror, explorer
without modification of methodology
2. Treatment instruments: Scaling instru-
or criteria. In those rare instances, where
ments, filling instruments, surgical
the criteria are modified, interpretation
instruments.
of the results should be modified in a
like manner.
4. While indices measuring severity are Examination Instruments and Procedures
extremely useful in conducting epidemi- Parts of the gingival and dental examinations
ologic survey and clinical trials, indices are made by direct visual observation, whereas
measuring only the presence or absence other parts require tactile examination using
of an entity are probably more amenable a probe and/or an explorer. These two types
to patient’s motivation efforts. of instruments, assisted by a mouth mirror
are key instruments in patient examination by the clinician to any area of the oral cavity
and assessment. Considerable skill is can be accomplished by adapting the mirror.
required for accurate and efficient probing
and exploring. Transillumination
• Transillumination refers to reflection of
Precautions light through the teeth.
• A probe or an explorer is not applied • Mirror is held to reflect light from
to the teeth and gingiva until an initial lingual aspect while the teeth are
review of information from the patient examined from facial.
history has been made. • Mirror is held for indirect vision on the
• Particular significance is knowledge of a lingual while light from the overhead
particular susceptibility to bacteremia. dental light passes through the teeth.
• Patient at risk must receive prophylactic Translucency of enamel can be seen
antibiotic premedication before instru- clearly, whereas dental caries or calculus
mentation. deposits appear opaque.
Retraction: The mirror is used to protect or

The Mouth Mirror prevent interference by the cheeks, tongue
Types of Mouth Mirror Surfaces or lips.
• Plane (Flat): May produce a double
image Probe
• Concave: Magnifying A probe is a slender instrument with smooth,
• Front surface: The reflecting surface is rounded tip designed for examination of the
in the front of the lens rather than on depth and topography of a gingival sulcus
the back as with plane or magnifying or periodontal pocket.
mirrors. The front surface eliminates
“ghost images”. Types of Probes
• Two general types of probes available
Purpose and Uses
are the traditional or standard manual
A mouth mirror is used to provide— probes and the controlled probes or
• Indirect vision automated probes.
• Indirect illumination • Automated probes were developed and
• Transillumination researched in an attempt to overcome
• Retraction. the problems in obtaining convenient
Indirect vision: Needed for all surfaces where readings with traditional probes.
direct vision is not possible when the clini-
Purpose and Uses
cian is in neutral seated posture. Examples:
distal surfaces of posterior teeth, lingual A probe is used to:
surfaces of anterior teeth. 1. Assess the periodontal status for
preparation of a treatment plan
Indirect illumination: Reflection of light from 2. Make a sulcus and pocket survey
the dental overhead light or headlight worn 3. Determine clinical attachment level
4. Make a mucogingival examination 3. Hold side of instrument tip flat against

5. Make other gingival determinations the tooth near the gingival margin.
6. Evaluate gingival bleeding on probing 4. Gently slide the tip under the gingival
7. Determine consistency of gingival tissue margin.
8. Guide treatment a. Healthy or firm fibrotic tissue:
9. Summarize gingival characteristics Insertion of probe is more difficult
10. Detect pocket depth because of the close adaptation
11. Detect anatomic configuration of roots, of the tissue to the tooth surface;
subgingival deposits and root irregu- underlying gingival fibers are
larities strong and tight.
12. Evaluate success and completeness of b. Spongy, soft tissue: Gingival margin
the treatment is loose and flabby because of
13. Evaluation at maintenance appointments. destruction of underlying gingival
A probe may be of: fibers. Probe inserts readily and
bleeding can be expected on gentle
Straight working end probing.
• Tapered, round, flat or rectangular in
cross section with a smooth rounded end. Advance Probe to Base of Pocket
• Calibrated in millimeters at intervals • Hold side of probe tip flat against the
specific for each kind of probe; some tooth surface; probe in parallel with
have color coding. long axis of tooth for vertical insertion.
Examples of probes are: • Slide the probe along the tooth surface
• Williams (1-1-1-2-2-1-1-1) vertically down to the sulcus or pocket.
• Williams color coded – Maintain contact of the side of the
• Goldman-FOX (1-1-1-2-2-1-1-1) tip of the probe with the tooth:
• Michigan O (3-3-2) - Gingival pocket—side of the
• Hu-Friedy or Marquis color coded (3-3- probe is on enamel
3-3 or 3-3-2-3) - Periodontal pocket—side of the
• H u - F r e i d y P C P - U N C 1 5 ( e a c h probe is on the cementum or
millimeter to 15) color coded at 5-10-15. dentinal surface when inserted
to a level below the cementoe-
Curved working end: Paired furcation probes namel junction.
have a smooth, rounded end. For investiga- – As the probe is passed down the
tion of the topography anatomy around the side of the tooth, roughness may be
roots in a furcation. Examples: The Nabers felt. Evaluation of the topography
1N and 2N probes. and nature of the tooth surface is
essential to instrumentation.
Probing Procedures – When obstruction by a hard bulky
calculus deposit is encountered, lift
Probe Insertion
the probe away from the tooth and
1. Grasp probe with modified pen grasp. follow over the edge of the calculus
2. Establish finger rest on a neighboring until the probe can move vertically
tooth, preferable in the same dental arch. into the pocket again.
– The base of the pocket or sulcus

feels soft and elastic (compared
with hard tooth surface and calculus
deposits) and with slight pressure at
the base of the pocket can be felt.
• Use only the pressure needed to detect
by tactile means the level of the attached
tissue, whether junctional epithelium
or deep connective tissue fibers. A light
pressure of 20 gm to 25 gm is enough.
• Position the probe for reading: Bring the
probe to position as nearly parallel with
the long axis of the tooth as possible for
reading the depth.
Read the Probe

1. Measurement for a probing depth is
made from the gingival margin to the Figure 4.1: Probe walking stroke. The side of the tip
of the probe is held in contact with the tooth. From the
attached periodontal tissue. base of the pocket, the probe is moved up and down
2. Count the millimeters that show on in 1–2 mm strokes as it is advised in 1-mm steps. The
the probe above the gingival margin attached periodontal tissue at the base of the pocket
and subtract the number from the total is contacted on each down stroke to identify probing
number of millimeters marked on the depth in each area
particular probe being used.
Circumferential Probing in a “touch”…”touch”…… touch

rhythm (Figure 4.1).
• Probe stroke: Maintain the probe in the
– Obscure probe measurement at the
sulcus or pocket of each tooth as the
gingival margin at each touch.
probe is moved in a walking stroke (see
– Advance millimeter to millimeter
Figure 4.1)
along the facial and lingual surfaces
– It is not necessary to remove the
into the proximal areas.
probe and reinsert it to make individ-
ual reading. Time would be saved.
– Repeated withdrawal and reexami- Explorers
nation cause unnecessary trauma An explorer is a slender, wire-like metal tip
to the gingival margin and hence, that is circular in micron section tapers to a
increase post treatment discomfort. fine sharp point (Figure 4.2).
• Walking stroke:
– Hold the side of the tip against the General Purposes and Uses
tooth at the base of the pocket. An explorer is used to:
– Slide the probe up (coronally) about • Detect by tactile sense, the texture and
1–2 mm and back to the attachment character of tooth surfaces.
Basic Procedures for use of Explorers

• Development of ability to use an
explorer and a probe is achieved first
by learning the anatomic features
of each tooth surface and the types
of irregularities that they may be
encountered on the surface.
• The second step is repeated practice of
careful and deliberate techniques for
application of the instruments.
• The objective is to adapt the instru-
Figure 4.2: Explorer ments in a routine manner that relays
consistent comparative information
about the nature of tooth surface.
• Examine the supragingival tooth
• Concentration, patience, attention to
surfaces
detail and alertness to each irregularity
– For calculus, demineralized and
however small it may seem are necessary.
carious lesions, defects or irregulari-
ties in the surfaces and margins of Use of Sensory Stimuli
restorations and other irregularities
1. Both the explorer and probes can
that are not apparent to direct obser-
transmit tactile stimuli from tooth
vation.
surfaces to the fingers.
– An explorer is used to confirm direct
2. A fine explorer usually gives a more acute
observation.
sense of tactile discrimination to small
• Examine subgingival tooth surface
irregularities than that does a thicker
– For calculus, demineralized and
explorer.
carious lesions, diseased altered
3. Probes vary in diameter; the narrow
cementum and other cementum
types may provide greater sensitivity.
and other cemental changes that
can result from periodontal pocket Tooth Surface Irregularities
formation.
Two basic tactile sensations can be distin-
• Define the extent of instrumentation
guished when probing or exposing.
needed and guide techniques
• They may be grouped as
– For scaling and root planning
• Normal tooth surface
– Removing overhanging fillings.
– Irregularities created by excess or
• Evaluating the completeness of treat-
elevations in the surface
ment
– Irregularities caused by depressions
– For periodontal non surgical treat-
in the tooth surface.
ment as shown by the smooth tooth
Examples of these are listed below:
surface.
– For removal of an overhanging Normal tooth surface
filling by the smooth margins of the Tooth surface: The smooth surface of enamel
restoration. and root surface that has been planed;
anatomic configurations, such as lingual irregular tooth surface or restoration a

furcations. particular surface texture is apparent.
Restored surfaces: Smooth surfaces of metal With each contact, sound may be created.
(gold, amalgam) and the softer filling of • The clean smooth enamel is quite;
plastic, smooth margin of a restoration. the rough calculus on cementum is
scratchy or noisy. Sometimes a metal-
Irregularities: Increases or elevation in tooth lic restoration may “squeak” or have a
surface metallic “ring”. With experience dif-
Deposits: Calculus ferentiation can be made.
Anomalies: Enamel pearl
Restorations: Over contoured, irregular mar- ORAL HYGIENE INDEX
gins (overhang) Introduction
Irregularities: Depressions, grooves The relationship between periodontal
disease and the status of the oral hygiene
Tooth surface: Demineralized/carious
is so well established that the assessment
lesions, abrasions, erosions, pits such as
of calculus and oral debris must be made
those caused by enamel hypoplasia areas
before other factors are considered because
of cemental resorption on the root surface.
of this association. It is difficult to properly
Restorations: Deficient margin, rough surface. evaluate the influence of other factors
causing periodontal disease without due
Types of Stimuli
consideration of the amount of oral debris
During exploring and probing of irregularities and calculus present in the mouth.
can be made through tactile and auditory It is not sufficient to say that calculus
means. and debris are present or to categorize
Tactile individuals as ‘good’, ’fair’, or ‘poor’ as to
• Tactile sensations pass through the oral cleanliness. A system that allows for
instrument to the figures and hand and quantification of different levels of oral
to the brain for registration and action. cleanliness and that sets for the specific
• Tactile sensations, e.g. may be the result criteria for assigning scores is a must if it
of: is to be used as a population index. The
– Catching on over contoured restora- OHI-S fulfills these requirements and has
tion been utilized by numerous investigators
– Dropping into a carious lesion throughout the world.
– Hooking the edge of a restoration or The oral hygiene index, developed by
lesion John C Greene and Jack R Vermillion and
– Encounter in an elevated deposit referred to as OHI, was published in 1960
– Simply passing over a rough surface. and was later simplified in 1964. The OHI-S
was developed primarily for use as an
Auditory epidemiological tool and has been described
• As an explorer or probe moves over the as a reasonably sensitive method for assessing
surface of enamel, cementum, a metallic oral hygiene in population groups. Although
restoration, a plastic restoration or any the OHI-S does not possess as great degree of
sensitivity as original index, it offers a great Rules for Oral Hygiene Index
rapid method for evaluating oral cleanliness The rules for recording OHI are mentioned
of population groups. under the general rules for OHI-S.
It differs from the original index in:
• The number of tooth surfaces scored Criteria and Scoring for DI and CI in OHI
• The method of selecting surfaces to be The criteria and scoring for DI and CI is the
scores which can be obtained. same as that for DI-S and CI-S in OHI-S.
For OHI-S only six surfaces (4 posterior
and 2 anterior teeth) are examined for debris Calculation
and calculus, whereas the original method
1. Average debris score for the individual:
OHI required the examination of all the
i. Add together the debris score for
teeth in the mouth although 12 surfaces were
each tooth.
scored.
ii. Divide by the number of segments
scored.
Oral Hygiene Index (John C Greene and Debris score = total score/number of
Jack R Vermillion 1960) segments scored.
Purpose 2. Average calculus score for the indi-
To assess oral cleanliness by estimating the vidual:
tooth surfaces covered with debris and or i. Add together the calculus score for
calculus thus to know the oral hygiene status. each tooth.
ii. Divide by the number of segments
Examination Method scored.
Oral hygiene index (OHI) is composed of Calculus score = total score/number of
debri index and calculus index, representing segments scored.
the amount of debris or calculus found on 3. Average OHI score for the individual:
the buccal and lingual surfaces of each of the OHI = DI score + CI score.
three segments of each dental arch, namely:
• Upper right posterior segment Advantages
• Upper anterior segment 1. The OHI is sensitive enough to reflect the
• Upper left posterior segment cleaning efficiency of the tooth brushing
• Lower left posterior segment and the expected relationships between
• Lower anterior segment oral cleanliness and periodontal disease.
• Lower right posterior segment. 2. The OHI is simple, useful method for
The scoring for the buccal/labial and assessing a group of individuals oral
lingual surfaces is based on the tooth in the hygiene status quantitatively.
designated segment that has the greatest 3. Useful tool in program evaluation
surface area for the DI or supragingival and monitoring oral hygiene maintenance
subgingival calculus for CI. Therefore, the programs.
buccal/labial score and lingual score for a 4. The OHI assesses individual’s attitude
segment need not be taken from the same and effectiveness of tooth brushing in
tooth. oral hygiene practices.
Limitations to determine oral cleanliness of a person

1. In OHI, examination of all surfaces of all because;
teeth present in the mouth though only • The length of time required to evaluate
12 surfaces are scored hence, requires debris and calculus
more time. • As well as make subjective decisions on
2. Since it is time consuming, it cannot be tooth selection.
In OHI, the examination has to select the
used in epidemiological surveys.
tooth surface with most debris or calculus in
3. Cannot be used for mixed dentition.
each sextant, the OHI procedure is:
4. Inter and intraexaminer differences are
• Very tedious, tiring and time consuming
more.
• This will cause loss of interest of
examiner
Why Original Oral Hygiene Index is Simplified • This leads to inter and intraexaminer
The original oral hygiene index (OHI) was errors or variability
depicted as a ‘sensitive, simple method of • Therefore not suitable for epidemiologi-
assessing group or individual oral hygiene cal surveys
quantitatively’. Used by many investigators Considering all the drawbacks, an effort
since its introduction, the index has proved was made by some authors to develop
to be a useful tool in dental epidemiology OHI-S.
and program evaluation. • It is more or less equal sensitive index
Though sensitive, simple and useful, • It is an epidemiological tool.
OHI nevertheless requires the user to make When more detail about oral cleanliness
more decisions and to spend more time in is required that can be provided by OHI-S,
arriving at his evaluation of an individual’s either the original index or all surfaces
oral cleanliness than is always warranted. method can be used.
Greene and Vermillion have demonstrated
that relatively little information was lost by Differences Between OHI and OHI-S
an examination of only six representative
tooth surfaces rather than all. The OHI-S differs from the original OHI in
Thus the original oral hygiene index required: the number of tooth surfaces scored (6 rather
• The examination of all teeth in the than 12), the method of selecting the surfaces
mouth. to be scored, and the scores which can be
• Only 12 surfaces were scored. obtained. The criteria used for assessing
Later on, realizing that it was neither scores to the tooth surfaces are the same as
practicable not necessary to assess all teeth those used for the OHI (Table 4.1).
Table 4.1: Difference between OHI and OHI-S
OHI OHI-S
1. Tooth selection The examiner has to examine all the teeth to The examiner has to assess only 6 index
select the teeth with in the most debris or teeth. One is each sextant
calculus in each sextant 16 11 26
46 31 36
2. No. of surfaces evaluated 12 surfaces are evaluated Only 6 surfaces are evaluated
3. Scoring The OHI score ranges from 0 to 12 The OHI-S score ranges from 0–6
Uses, Advantages and Drawbacks of OHI-S habits while compared to original oral
Uses hygiene index.
3. Underestimation or overestimation of
1. The simplified oral hygiene index is
debris and calculus may occur.
useful.
2. In epidemiological studies of periodon- OHI-S scores are reversible and changes
tal disease and calculus. for the better following a prophylaxis or an
3. In determining the status of oral improvement in oral hygiene practices will
cleanliness. be reflected by improved scores.
4. It is also useful in evaluating the
effectiveness of tooth brushing and Definitions for Oral Hygiene Index
other oral hygiene practices in a group. The investigators should know the definitions
5. In evaluation of the effectiveness of of different oral hygiene conditions that are
dental health education procedures.
prevailing in oral cavity and going to assess
6. OHI-S index permits the comparison of
the presence of absence of the conditions for
data with similar data gathered from
oral hygiene index.
examinations of population groups in
1. Oral debris: Oral debris is the soft
all parts of the world.
foreign matter loosely attached to the
Advantages teeth. It consists of mucin, bacteria and
food and varies in color from grayish
1. It is easy to use.
white to green to orange.
2. Requires less time and hence can be
i. Mucin: It is the secretion of the
used in field studies, sometimes in
mucus or goblet cells, a polysaccha-
selected clinical trials and program
ride protein which combined with
evaluation.
water, forms a lubricator solution
3. It may be used as an adjuvant in
called mucus contained in saliva.
epidemiological studies of periodontal
ii. Bacterial plaque: It is a dense non-
disease.
mineralized, complex mass of
4. It determines the status of oral hygiene
cleanliness in groups. bacterial colonies in a gel-like
5. Useful in evaluation of dental health intermicrobial matrix. It adheres
education procedures (immediate and firmly to the acquired pellicle and
long term effects). hence to the teeth, calculus and
6. Inter and intra examiner errors are less. fixed, removable restorations.
2. Dental plaque: It is the non-miner-
Drawbacks alized microbial accumulation that
1. The OHI-S index lacks sufficient adhere tenaciously to tooth surfaces,
sensitivity for certain types of clinical restorations and prosthetic appliances
studies including detailed investigations and shows structural organization with
of plaque, debris or calculus formation. predominance of filamentous forms
2. In addition, the OHI-S index is not and is exposed of organic matrix de-
appropriate for the evaluation of an rived from salivary glycoproteins and
individual’s oral hygiene status of extracellular microbial products which
cannot be removed by rinsing or water debris and or calculus thus to know the oral
spray (Mosby 1973). hygiene status of individual or population.
Dental plaque is highly variable
specific entity resulting form the coloni- Examination Criteria and Rules for Coding
zation and growth of micro-organisms Selection for Teeth and Surfaces
on the tooth surfaces, restorations, soft
1. Sextants: Divide the dentition into six
tissue and oral appliances. It exhibits
sextant as:
sufficient structural and morphological
i. Two anterior sextants—from canine
characteristics. (Schluger, et al. 1977).
to canine in upper and lower jaws.
– Materia alba: It is loosely adherent
ii. Four posterior sextants—begin
mass of bacteria and cellular debris
that frequently occurs on top of distal to canine in upper and lower
bacterial plaque. jaws.
– Food debris: Loose food particles 2. Index teeth and teeth surfaces
collect about the cervical third and i. Index teeth to be examined: Score only
proximal embrasures of the teeth. first fully erupted permanent teeth
3. Extrinsic stains: It is a thin layer distal to the second premolars in
of foreign matter firmly attached to each quadrant, i.e. first permanent
the surface of the tooth, but may be molars and maxillary right and
removed by scraping with the tip of an mandibular left central incisors are
explorer. Color ranges from black to assessed separately for debris and
dark brown, green and reddish orange. calculus.
4. Oral calculus: It is a hard deposit of 16 11 26
inorganic salts compared primarily of 46 31 36
calcium carbonate and phosphate mixed ii. Tooth surfaces to be examined.
with food debris and desquamated iii. 46, 36 = lingual surfaces
epithelial cells. iv. 16, 26 = buccal surfaces
5. Supragingival calculus: Is usually v. 11, 31 = labial surfaces
white to yellowish brown in color and is
Exclusions
deposited occlusally to the free gingival
margin. The index tooth is excluded, if a designed
6. Subgingival calculus: Is usually light tooth:
brown to black in color because of • Is not a fully erupted permanent teeth
inclusion of blood pigments and is • If it has a full crown restoration
deposited apical to the free gingival • If it surfaces reduced in height by caries
margin on the cervical portion of the or trauma or attrition.
tooth.
Substitutions
If any of the index teeth are missing, or have
ORAL HYGIENE INDEX-SIMPLIFIED (OHI-S)
full crown restorations or surfaces reduced
(Greene and Vermillion 1964)
in height by caries or trauma, an alternate
Purpose: To assess oral cleanliness by teeth is selected if available according to the
estimating the tooth surfaces covered with following.
For index teeth 4. Calculus is not considered to be sub-

16 26 gingival unless it lies within the gingival
46 36 sulcus.
Select the first distal teeth to index teeth, 5. No score is assigned unless at least two
i.e. of the six possible surfaces have been
17 27 examined.
47 37 6. Evaluate each sextant to record first the
debris and then the calculus to avoid
Or 18 28 accidental removal of debris from the
48 38 tooth surface.
If they are fully erupted and functional.
If no distal tooth to index teeth is present
Components of OHI-S
or the only distal tooth has full crown or
surfaces reduced in height by caries, no other The simplified oral hygiene index has two
tooth is substituted. components (Figure 4.3):
For index teeth: substitute
11 21
31 41
If either 12 41
Is missing, have a full crown or surfaces
reduced in height by caries, trauma or
attrition, no other tooth is substituted. If a
tooth designated for substitution is absent
or cannot be used.
Code a check in the chart box to indicate
no substitution is possible and no other tooth
substituted.
General Rules
1. Only fully erupted permanent teeth
are scored. A tooth is considered to be
fully erupted and therefore available for
scoring when the occlusal and incisal
guidance has reached the occlusal plane.
2. A surface is defined as encompassing
half the circumference of the tooth. It
includes the entire area between the
incisal or occlusal, i.e. one half of the Figure 4.3: Oral hygiene index-simplified (OHI-S). Six
adjacent mesial, distal surfaces and the tooth surfaces are scored as follows: Facial surfaces
of maxillary molars and of the maxillary right and
crest of the gingiva.
mandibular left central incisors, and the lingual
3. Oral debris is detected by running surfaces of mandibular molars. Teeth are numbered
the side of a sickle explorer along the by the ADA system on the lingual surface and by the
surface to be examined. FDI system on the facial surface
a. Simplified debris index—DI-S (Figure Table 4.2: Simplified debris index (Di-S) criteria for coding
4.4 and Table 4.2)
Code Criteria
b. Simplified calculus index—CI-S (Figure
4.5 and Table 4.3) 0 No debris or intrinsic stains present on the
surface
The scores of two components may be
1 Soft debris is present but not covering more than
used separately or may be considered for one third of the tooth surface being examined
OHI-S. and/or
No debris is present but the presence of extrinsic
stains without debris regardless of the surface
Examination Procedure area covered
1. The surface area covered by debris 2 Soft debris is present and it covers more than
one-third soft the exposed surface; extrinsic
and calculus is estimated by running
stains may or may not be present
the side of no. 5 explorer (Shepherd’s 3 Soft debris is present and it covers more than
crook # 23) along the tooth surface two-third soft the exposed surface; extrinsic
being examined with the help of mouth stains may or may not be present
mirror.
2. The sequence of examination of ‘index Table 4.3: Simplified calculus index (CI-S)
teeth’ proceeds in a routine following
Code Criteria
tooth order tooth 16, 11, 26, 36, 31 and 46.
0 No supragingival and subgingival calculus
3. If any of the above ‘index teeth’ are
present
missing or have a full crown restorations 1 Only supragingival calculus is present and it
or surfaces reduced in height by caries covers not more than one third of the exposed
or trauma or attrition, an alternative tooth surface being examined
substitute tooth is selected if available for 2 Supragingival calculus is present and it covers
more than one third but not more than two-third
examination according to the following: of the exposed tooth surface
i. For tooth 16, 26, 36, 46 select the And/or
first tooth distal (i.e. 2nd and 3rd The presence of individual flecks of subgingival
calculus around the cervical portions of the tooth
molars), if no tooth is distal or the
3 Supragingival calculus is present and it covers
only distal tooth has a full crown or more than two-thirds of the exposed tooth
surface reduced in height by caries, surface
no other tooth is substituted. And/or
A definite continuous heavy band of subgingival
ii. For tooth 11 substitute 12 and for
calculus is present around the cervical portion of
tooth 31 substitute 41, if either 31 and the tooth
41 are missing, have a full crown or
surfaces reduced in height by caries, i. Tooth 16 and 26—upper molars,
no other tooth is substituted. buccal surface
4. The examination is made on the ii. Tooth 36 and 46—lower molars,
designated surface area for each tooth lingual surface
or substituted tooth. The buccal or iii. Tooth 11 and 31—anterior teeth,
lingual surfaces designed include one- labial surface.
half of the adjacent mesial and distal 5. The evaluation of each sextant to
surfaces, i.e. encompass one-half of the examine the ‘index teeth’ to record first
circumference of the tooth. the debris and then the calculus, to
stain is extrinsic when it can be

removed by scraping with the tip of
the explorer.
ii. The examination for calculus is
made by using the explorer to
Figure 4.4: Simplified oral hygiene index. For the
Debris Index, 6 teeth are scored. Scoring of 0 to 3 is identify the extent of the calculus
based on tooth surfaces covered by debris as shown so that the surface area covered
can be estimated, or to probe the
subgingival calculus.
iii. Note: Calculus is not considered to
be subgingival unless it lies within
the gingival area.
6. If a substitute tooth is examined,
the number of the tooth should be
called first, followed by the debris
score number, then the calculus score
number.
7. Before releasing the patient, give the
recorder, a chance to ask for a repeat
Figure 4.5: Simplified oral hygiene index. For the score, if necessary.
calculus Index, 6 teeth are scored. Scoring of 0 to 3 is
based on location and tooth surface area with calculus
as shown. Note slight subgingival calculus recorded as ORAL HYGIENE INDEX-SIMPLIFIED (OHI-S)
2 and more extensive subgingival calculus as 3 (Greene and Vermillion 1964)
avoid accidental removal of debris from Debris Index-Simplified (DI-S)
the tooth surface. 16 11 26
i. The examination for debris is
accomp-lished by running the side
of the explorer along and across the
tooth surface form incisal or occlusal 46 31 36
third to cervical third to assist in
Debris index-simplified (DI-S)
estimating the proportion of the

surface area covered by debris at Total debris score
= ––––––––––––––––––––––
incisal or occlusal third first, then
Number of teeth scored
middle third and then cervical
third to avoid drawing debris form Calculus Index-simplified (CI-S)
cervical third to occlusal third or
16 11 26
incisal third (if explorer is passed
from cervical third to occlusal third
or incisal third). If no debris is
present, and stain is present. The 46 31 36
Calculus index-simplified (CI-S) 2. In computing the average debris,

calculus or OHI-S scores for an
Total calculus score
= –––––––––––––––––––––– individual, round off the average to
Number of teeth scored one decimal place.
Oral hygiene index-simplified 3. In computing the average debris,
= Debris index-simplified + calculus or OHI-S score for a group of
Calculus index-simplified individuals, two decimal places may be
OHI-S = DI-S + CI-S used if there are 100 or more individuals
in the group.
Scoring: OHI-S for an Individual
Average debris score for the individual
1. Determine debris index-simplified 1. Add together the debris score for each
(DI-S) + calculus index-simplified (CI-S) tooth
i. Divide each total score by number of 2. Divide by the number of teeth scored
teeth scored Round off one place beyond the
ii. DI-S and CI-S values range from individual point.
0 to 3 Debris index score
2. Oral hygiene index- simplified (OHI-S)
i. Combine the DI-S and CI-S Total score
= ––––––––––––––––––––
ii. OHI-S value ranges from 0 to 6. No. of teeth examined

Suggested Range of Scores for Evaluation Average calculus score for the individual
1. Add together the calculus score for each
Debris index simplified (DI-S) and calculus
tooth
index simplified (CI-S):
2. Divide by the number of teeth scored.
Rating Scores Round off one place beyond the
Excellent 0 individual point.
Good 0.1–0.6
Calculus index score
Fair 0.7–1.8

Poor 1.9–3.0 Total score
= ––––––––––––––––––––
Oral hygiene index-simplified (OHI-S): No. of teeth examined
Rating Scores
Excellent 0 Average OHI-S score for the individual (Table 4.4)
Good 0.1–0.2 Add together the average debris score and
Fair 0.3–3.0 the average calculus score.
Poor 3.1–6.0 OHI-S = DI score + CI score = Number
and percentage of patients by debris, calculus
Computing Instructions for Selected Statistics or OHI-S score (groups).
General rules Count the patient with debris, calculus,
1. At least two tooth surfaces must be or OHI-S scores in each of the score groups (as
examined and scored in an individual mentioned in suggested nominal scale), enter
is to be included. in the table and compute the percentage.
Table 4.4: OHI-S examination for 50 patients Table 4.6: Statistical table for mean debris calculus
and OHI-S
Score Number of patients Percentage
Age groups Number Debris Calculus OHI-S
Excellent: 0 10 20
of persons index index
Good: 0.1 to 1.2 15 30 examined
Fair: 1.3 to 3.0 12 24
All ages 5685
Poor: 3.1 to 6.0 13 26
Total 5 to 9 years 1,072 1.64 0.12 1.76
10 to 14 1,247 1.68 0.42 2.10
Example: If 50 patients examined for OHI-S: 15 to 19 673 1.44 0.86 2.30
20 to 29 1,559 1.35 1.08 2.42
Average debris score for a group
30 to 39 648 1.61 1.53 3.14
• Add together the average debris score
40 to 49 251 1.80 1.90 3.70
for each patient
• Divide by the total number of patients. 50 and over 235 2.07 2.22 4.29
Average calculus score for a group group for all persons examined in Montana
• Add together the average calculus score and Ecuador (Table 4.6).
for each patient
• Divide by the total number of patients.
ASSESSMENT OF PERIODONTAL
Average OHI-S score for a group DISEASES
• Add together the average OHI-S score Introduction
for each patient
The problem of standardization of methods for
• Divide by the total number of patients.
recording and reporting periodontal disease
Mean debris, calculus and OHI-S has been considered by four committees
scores by the age groups (Table 4.5) of the WHO. In 1961, an expert committee
Complete the average debris, calculus and on periodontal disease recommended the
OHI-S score for each age group and enter in ‘Periodontal Index of Russell’ is the basic
table and compute the percentage. measurement in epidemiological studies. In
Examples of statistical table for mean 1962, another expert committee suggested
debris, calculus and OHI-S scores by age that in dental health surveys, prevalence
should be expressed as the age specific
percentages of persons with one or more
Table 4.5: Mean debris calculus and OHI-S score
signs of gingivitis, one or more periodontal
Age Num- Debris Calculus OHI-S
pockets or one or more signs of gingivitis
groups ber of index index and pocket formation.
persons In public health survey, the first and
examined
most obvious objective of a prevalence study
All ages is to assess the extent to which periodontal
5 to 9 1,072 0.15% 0.011% 0.164% disease is a public health problem. In this
years case the major requirement is to determine
10 to 14 1,247 0.13% 0.033% 0.168% what proportions of the population need
years
periodontal treatment. The WHO expert
committee on standardization of reporting epidemiologic index with a true biological

of dental diseases and conditions in 1962, gradient because the periodontal index
recommended that an index for measuring measures both reversible and irreversible
the prevalence of periodontal disease should aspects of the periodontal disease. The
be based on the clinical signs of inflammation significant feature of periodontal index
and periodontal pocket formation. lies in the fact that more data have been
Under this system the appropriate assembled using it than any other index of
indices are: periodontal index. Thus with care it may
a. The percentage of persons with one be used in clinical trials also. The criteria
or more signs of inflammation of the in periodontal index were based upon the
gingiva science of periodontitis and the sequence in
b. The percentage of persons with one or which they usually appear, i.e. inflammation,
more periodontal pockets pocket formation, and loss of function. The
c. The percentage of persons with evidence periodontal index has the advantage that it
of both gingival and periodontal can be readily applied under field conditions.
pockets. It has also been used in many countries, so
The criteria which were recommended there is large body of data with which future
are as follows: surveys can be compared.
Inflammation is recorded when there is
evidence of anyone or more of the following Purpose
signs around one or more teeth: redness, To assess and estimate periodontal
swelling, ulceration and bleeding. disease status of individual or population
A periodontal pocket is recorded if it by measuring the presence or absence
is more than 3 mm in depth. No specific of gingival inflammation, its severity
attempt is made to differentiate between true with pocket formation and masticatory
and false pockets. efficiency.
The second objective of a prevalence
study is to determine differences in preva-
Examination Procedure
lence between different ethnic or geographic
groups of people. In this case, the same • All the teeth are examined. Root stumps
indices are appropriate but additional valu- are excluded.
able information may be obtained by using • All of the tissue circumscribing a tooth
a more refined index which measures both is considered a scoring or gingival unit
prevalence and severity. and assessed for gingival inflammation
An appropriate index for this purpose is and periodontal involvement.
the Periodontal Index of Russell (1956). By using this periodontal index, the basic
questions which the examiner attempts to
answer as he examines each tooth and its
RUSSELL’S PERIODONTAL INDEX investing tissues are there:
Russell AL (1956) put forth the periodontal • Is gingivitis present?
index which is epidemiological tool to • Does gingivitis circumscribe the tooth?
measure periodontal disease in public • Has it progressed to periodontal pocket
health survey. Thus, periodontal index is an formation?
• Has the function of the affected tooth

been impaired?
The standard criteria on which these
decisions are based are shown in (Table 4.7)
“Classification and Criteria”.
Instrument Used
Each tooth is examined using a mouth mirror,
explorer and Williams periodontal probe
with adequate illumination (Figure 4.6). In
the original examination a Jacquette scaler
and chip blower were used to define the
presence of periodontal pockets. Figure 4.6: Williams periodontal probe
Rule: When in doubt assign lesser score.
Note: Gingivitis with pocket formation, there
is horizontal bone loss involving the entire is advanced bone loss involving more than
alveolar crest, up to half of the length of one half of the length of the tooth root, or
tooth root. a definite infrabony pocket with widening
In advanced destruction of periodontal of periodontal ligament. There may be root
tissue with loss of masticatory function, there resorption or rarefaction at apex.
Table 4.7: Criteria and scoring for the periodontal index
Score Classification and criteria Notes

0 Negative: There is neither overt inflammation in This result is recorded when at first glance there are no obvious
the investing tissues nor there is loss of function signs of change in color or form of the gingival tissues
due to destruction of supporting tissues
1 Mild gingivitis: There is an overt area of inflam- This includes both low grade chronic conditions and acute
mation in the free gingivae, but this area does not conditions. Gingivitis should receive the same rating in each
circumscribe the tooth person without regard to age, sex or ethnic groups
2 Gingivitis: Inflammation completely circumscribes
the tooth, but there is no apparent break in the
epithelial attachment
6 Gingivitis with pocket formation: The epithelial at-
The very deep crevice associated with an erupting tooth is
tachment has been broken and there is a pocketnot recorded as pocket. The usual signs of pocket are apical
(not merely a deepening of the gingival crevice
migration of the epithelial attachment, loss of tone and
due to swelling in the free gingivae). There is no
alteration in gingival form. A probe can be used to confirm a
interference with normal masticatory function, the
diagnosis but is not used in the absence of inflammation. A
tooth is firm in its socket and has not drifted
blast of air from a chip blower can be used to confirm obvious
pockets. Resorption and recession of gingiva with exposure of
cementum is not scored in the absence of inflammation
8 Advanced destruction with loss of masticatory Loss of function is usually determined by digital palpation;
function looseness by lateral finger pressure; dullness and depressibility
are used to differentiate periodontitis from periodontosis. All
the teeth expect for residual roots are scored
Russell’s Periodontal Index Table 4.8: Group periodontal index (PI) score and
clinical manifestations
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
Clinical condition Group PI Stage of
score disease
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38 Clinically normal 0 to 0.2
supportive tissue
Total score =
Simple gingivitis 0.3 to 0.9
Total number of teeth examined =
Beginning destructive 0.7 to 1.9 Reversible
Periodontal index score per person = periodontal disease
Established destructive 1.6 to 5.0 Irreversible
Total score periodontal disease
–––––––––––––––––––––––––
Total no. of teeth examined Terminal stage 3.8 to 8.0 Irreversible
PI score = Table 4.9: Individual periodontal index (PI) and

Periodontal health condition = clinical conditions
Calculation Clinical conditions Individual PI

scores
The patient’s periodontal index is calculated
Clinically normal supportive tissue 0 to 0.2
by adding the scores for each tooth and
dividing by the number of teeth examined. Beginning destructive periodontal disease 1.0 to 1.9
Each tooth is assigned a score from 0 (no Established destructive periodontal disease 2.0 to 4.9
disease) to 8 (severe disease with loss of Terminal stage 5.0 to 8.0
function) (Table 4.8).
For Individual (Table 4.9) epidemiological surveys because it is not

always possible to take radiographs.
Individual score
Since no radiographs is used when per-
Sum of individual tooth scores forming the periodontal index examination,
= ––––––––––––––––––––––––––––
the results tend to underestimate the true
Total no. of teeth examined
level of periodontal disease, especially early
Group score
loss of bone in a population. The number of

Sum of individual’s PI score periodontal pockets without obvious suprag-
= –––––––––––––––––––––––––––
Total no. of people examined ingival calculus is also underestimated in the

periodontal index.
Suggested Nominal Scale

Uses of Periodontal Index
Periodontal disease conditions can be inter-
1. Since, it is epidemiologic index, it is
preted by the periodontal score results as:
used in epidemiological surveys.
2. More data can be assembled using
Drawbacks of Periodontal Index periodontal index than any other index
Indices which are based upon measurement of periodontal disease. Most useful when
of resorption of alveolar bone have the it is necessary to distinguish between
advantage of greater objectivity but they are population with mild, moderate and
of limited practical usefulness in international advanced chronic destructive disease.
3. Periodontal index is used in clinical trials 6. No standardized probes are used.

with the assessment of the influence of a 7. It does not give past periodontal disease
specific form of therapy or treatment on experience.
the course of a clinical entity.
COMMUNITY PERIODONTAL INDEX OF
Advantages TREATMENT NEEDS (CPITN)
1. Easily and quickly learned and repro- The CPITN was developed in collaboration
ducible. between the Federation Dentaire
2. PI is simple enough to be practical Internationale (FDI) and the Oral Health
under a wide variety of field conditions. Unit of World Health Organization (WHO).
3. This index measures both reversible and A description of the methodology has
irreversible conditions of periodontal been published by Jukka Ainamo and his
disease. associates in 1982.
4. The application and uses of Russell’s PI The CPITN was developed primarily to
in the past have led to the development survey and evaluate periodontal treatment
of better understanding of periodontal needs rather than determining past and
health status including research in the present periodontal status like the recession
present area. of gingival margin, loss of alveolar bone,
5. Criteria are clear and most of the time mobility of tooth and loss of periodontal
in epidemiological studies, results attachment.
obtained are comparable.
Purpose
Limitations The purpose of CPITN is to screen and
1. Initially bone loss was recorded by monitor individual or group periodontal
radiographs. Grading can be given in treatment needs.
a sequence of radiographs are taken. The term “treatment need“ is intended
In field surveys carrying radiographs as a guide to the level or magnitude of need
facilities is impracticable and hence, for care using accepted periodontal criteria.
score 4 cannot be given. Thus, the CPITN records the common
2. Clinical signs and symptoms are taken treatable conditions, namely periodontal
from 0 to 8. It is difficult to differentiate pockets, gingival inflammation (identified
clinically from one stage to another and by bleeding on gentle probing) and dental
hence, let to the breakdown of scores. calculus and other plaque retentive factors.
3. Index move from 2 onwards jump to 4, • If no disease is observed, no treatment
6, and 8 only to signify the severity and need to be required.
nature of destruction of periodontium, • If gingivitis is present, but no evidence
which are not recordable and most of of calculus or pockets, then self care
them are irreversible. (plaque control) is recommended.
4. More time consuming. • If calculus or shallow pockets are
5. This index is not sensitive to minor present, its control would require
changes in periodontium. involvement of trained persons.
• If deep pocket is evident, its control • If no index teeth are present in a sextant
needs the services of specially trained qualifying for examination, all the
personnel. remaining teeth are examined.
Methodology Children and Adolescents: (Below 19 Years)
Sextants: The periodontal treatment needs are For many children and adolescents about
recorded for sextants, i.e. sixth of the dentition. 7 to 19 years of age, only 6 index teeth are
examined. The second molars are excluded
The dentition is divided into six sextants. The
as index teeth at these ages because of the
sextants contain the following teeth.
high frequency of false (non-inflammatory
17–14 13–23 24–27 association with tooth eruption) pockets. The
47–44 43–33 34–37 6 index teeth are:
• Third molars are not included, except 16 11 26
when they are functioning in the place 46 31 36
of second molars.
• When examining children and adoles-
• The treatment need in a sextant is re-
cents pockets are not recorded although
corded only when two or more teeth are
probing for bleeding and calculus are
present and not indicated for extraction.
carried out as a routine.
Note: The indication for extraction because • When the designated tooth is missing,
of periodontal involvement is that the tooth the sextant is recorded as missing and
has vertical mobility and causes discomfort marked as “X”.
to the patient.
If only one functioning teeth remains in a Procedure
sextant, it is included in the adjacent sextant. The WHO Periodontal Examination Probe
For simple recordings of the periodontal
Uses of Index Teeth treatment needs, the use of the WHO probe
Adults: (20 Years and above) is recommended. It is also called as CPITN
In epidemiological surveys assessing the probe (Figure 4.7).
periodontal treatment needs of a population The instrument was designed for two
the recordings per sextant are based on purposes namely;
findings from specified index teeth. The 1. Measurement of pocket depth
index teeth to be examined are: 2. Detection of subgingival calculus
17/16 11 26/27 The instrument has—

47/46 31 36/37 • Black mark from 3.5 mm to 5.5 mm.
• Ball tip of 0.5 mm in diameter.
• Although 10 index teeth are examined,
only 6 recordings, one relating to each The probe has a “ball tip” of 0.5 mm
sextant are made. that allows easy detection of subgingival
• When both or one of the designated calculus. The ball tip also facilitates the
molar teeth are present, the worst identification of the base of the pockets, thus,
finding from these tooth surfaces is decreasing the tendency for false reading by
recorded for sextant. over measurement.
assessment and recordings of deep pockets

for the purpose of preparing a treatment plan
for complex periodontal therapy.
The WHO CPITN-E probe is recom-
mended for epidemiological surveys for
screening and monitoring periodontal
treatment needs for groups of people in
community and individuals in clinics. Also,
it provides guidance on the planning and
monitoring of the effectiveness of periodon-
tal care programs and the dental personnel
required. A list of manufacturers of this
probe can be obtained from Oral Health,
WHO, 1211 Geneva 27, Switzerland.
Figure 4.7: Community periodontal index of The Probing Procedure

treatment needs (CPITN-C) Probe
Objectives
It is realized that the use of any pocket A tooth is probed to determine
probe does not provide the clinician with • Pocket depth
accurate measurements of pockets in millim- • Presence of calculus
eters which, even if feasible area of doubtful • Bleeding response.
value. Instead, the probe measures what is
‘normal’ and ‘abnormal’ with indications of Probing Force
treatment requirements being derived from The probing force can be divided into
‘abnormal’ scores. A force of no more than • A working component—to determine
20 to 25 gm is considered sufficient to reveal the pocket depth
pathology without causing pain to the subject. • A sensing component—to detect sub-
gingival calculus.
Types of CPITN Probe
This joint working committee of WHO/FDI Practical test for probing force: A practical
has advised the manufacturers of CPITN test for establishing the working force of
probes to identify the instruments: no more than 25 gm is to gently insert the
• CPITN-E: For the epidemiological probe point under the fingernail and press
probe with 3.5 mm markings. till blanching occurs without causing pain
• CPITN-C: For the clinical probe with and discomfort.
additional at 8.5 mm and 11.5 mm The recommended probing force corres-
markings. ponding to 20 to 25 gm should cause no pain
A variant of the WHO periodontal to the examine during probing procedure.
examination probe, i.e. CPITN-C probe has This practical test for establishing this force is
two additional lines at 8.5 mm and 11.5 mm to probe underneath the fingernail where the
from the working tip. The additional lines sensitivity approximately that of periodontal
may be of use when performing a detailed pocket.
Working component: When inserting the probe Table 4.10: Indications of periodontal status
into a periodontal pocket, the ballpoint
Indications Code
should follow the anatomic configurations
of the root surface. Pathologic pockets 6 mm or deeper 4
Pathologic pockets 4 to 5 mm deep 3
Sensing component: For sensing subgingival Supra or subgingival calculus, defective margins 2
calculus, the lightest possible force which of fillings or crowns
Gingival bleeding after gentle probing 1
will allow movement of the probe ballpoint
Healthy periodontium 0
along the tooth surface is used.
There is no rule specifying the number
of separate probings to be made. This will occurs after probing code 1 is given to
depend on the condition of the tissues the sextant examined.
surrounding the teeth. However, when only The gingivae of the designated tooth or
the index tooth or teeth are being examined teeth should be inspected for the presence
or when the recordings is based on the worst or absence of bleeding before the examinee
findings in all the teeth of the sextant, it would is allowed to swallow or close his mouth.
be rare to exceed four probing per sextant.
Whenever available, radiographs will Note: At times bleeding may be delayed for
greatly enhance identification of advanced 10 to 30 seconds after probing. If the sextant
periodontal lesions. is found healthy, code 0 (zero) is given to the
examined sextant.
Recording of Findings
Indications: In assessing treatment needs, the Classification of Treatment Needs
presence of the following indicators of peri- A subject or a sextant is classified into
odontal status is used for each sextant in the the different treatments need categories
sequence given in (Table 4.10). according to the highest score recorded
• Whenever a 6 mm or deeper pocket is during the examination. In epidemiological
found at any designated tooth or teeth surveys this classification will be made
in the sextant being examined, a code of automatically by the computer program,
‘4’ is given to the sextant. Recordings of according to the following rules under four
code 4 make further examination of that classes or scales (Table 4.11).
sextant unnecessary. • Obviously, a recording of code 0 (zero)
• If deepest pocket found at the designated for all 6 sextants indicates that there is
tooth or teeth in a sextant is 4 to 5 mm, no need for treatment. The patient come
code of 3 is recorded. Again there is no under class-0 (zero).
further examination. • If code of 1 is the only ones identified, the
• If no pockets deeper than 3 mm are need for improvement in the personal
observed, the presence of supra or sub- oral hygiene of that individual is indi-
gingival calculus and/or overhanging cated. The patient come under class-I.
of fillings or crowns is indicated by the • A maximum code of 2 indicates the
recording of code 2 for the sextant. need for professional debridement
• If neither deep or moderate pockets of the teeth. As moderate pocketing
nor calculus are observed, but bleeding (4–5 mm, code-3) likewise be manage
Table 4.11: Classification of treatment needs Examples of CPITN Recordings: Treatment

Planning
Treatment needs (TN)
The time needed for the CPITN in recording
Class A recording of code 0 indicates no treatment
of codes for the six segments should not
TN-0
Class A code of 1 indicates a need for improving the
exceed 1 to 2 minutes. The information
TN-1 personal oral hygiene of that individual-I obtained is illustrated by the following
Class A code of 2 and 3 indicates need for professional examples:
TN-2 cleaning, root planning and removal of plaque
retentive factors. In addition patient obviously
requires oral hygiene instructions-II plus I
Case 1 4 2 3
Class Code of 4 requires complete treatment which 2 2 X
TN-3 involves deep scaling, root planning and more
There is at least one deep pocket in
complex surgical procedures-III plus II plus I
right posterior and one or more moderately
with a combination of professional deep pockets in the left posterior sextant of
and personal cleaning of the teeth, the the maxilla. Three sextants have no pocket
treatment need is the same for code 2 depths over 3 mm, but do require scaling.
and 3. Clearly the patient also requires Apparently the patient also needs oral
oral hygiene instructions. The subjects hygiene instruction. One sextant is missing.
(patients) come under class-II.
• A sextant scoring code 4 (6 mm or
deeper pockets) may or may not be COMMUNITY PERIODONTAL INDEX (CPI)
successful treated by means of deep Purpose
scaling and efficient personal oral To screen and monitor the periodontal status
hygiene measures. Code 4 therefore of populations.
assigned to ‘complex treatment’ which
may involve deep scaling and root
Indicators
planning under local anesthesia or
require surgical exploration of the Three indicators of periodontal status are
infected root surface in order to gain used for this assessment:
access needed to clean it (Figure 4.8 and 1. Gingival bleeding
Table 4.12). 2. Calculus
3. Periodontal pockets.
Selection of Teeth
The mouth is divided into 6 sextants defined
by tooth numbers:
18–14 13–23 24–28
48–44 43–33 34–38
A sextant should be examined only if

there are two or more teeth present which
Figure 4.8: Community periodontal index codes are not indicated for extraction. (Note: This
Table 4.12: Periodontal screening and recording (PSR)†
Clinical Findings Code Description Management Guidelines

Code 0 Code 0
• Colored area of probe is completely • Dental biofilm control
visible in the deepest probing depth of • Preventive care
the sextant
• No calculus, no defective margins, no
bleeding
Code 0
Code 1 Code 1
• Colored area of probe is completely • Dental biofilm control
visible in the deepest probing depth of • Preventive care
the sextant
• Smooth surfaces, no calculus, no
defective margins
• There is bleeding after gentle probing
Code 1
Code 2 Code 2
• Colored area of probe is completely • Dental biofilm control instruction
visible in the deepest probing depth • Complete preventive care
• Rough surface felt may be supragingival • Calculus removal
and/or subgingival calculus • Correction of irregular margins of
• Defective margins of restorations restorations
Code 2
Code 3 Code 3
• Colored area of probe is only partly • Comprehensive periodontal assessment
visible in the deepest probing depth is indicated‡
• Requirements for Codes 1 and 2 may be • Patient is counseled concerning
present appropriate treatment plan
Code 3
Code 4 Code 4
• Colored area of probe completely • Comprehensive periodontal assessment
disappears is indicated†
• Probing depth greater than 5.5 mm • Patient is counseled concerning
appropriate treatment plan
Code 4
Code* Code*
• Any notable feature such as furcation • Abnormality in Codes 0, 1, or 2: specific
involvement treatment is planned
• Mobility • In Codes 3 or 4: included in
• Mucogingival problem comprehensive assessment and
• Marked recession area treatment plan
†American Dental Association and American Academy of Periodontology, 1992.
‡Comprehensive periodontal assessment includes but is not limited to radiographic and clinical examination (complete soft tissue record,
identification of probing depths, mobility, gingival recession, mucogingival problems, and furcation involvements).
replaces the former instruction to include Table 4.13: Community periodontal index score
single remaining teeth in the adjacent
Score Criteria
sextant).
0 Healthy
Index Teeth 1 Bleeding observed, directly or by using a mouth
mirror after probing
Adult 20 Years and Older
2 Calculus detected during probing, but all of the
a. A sextant is examined only if there are black band on the probe visible
two or more teeth present that are not 3 Pocket 4 or 5 mm (gingival margin within the
indicated for extraction. black band on the probe)
b. 10 teeth are examined. Teeth to be 4 Pocket 6 mm or more (black band on the probe
not visible)
examined are:
X Excluded sextant (less than 2 teeth present)
17, 16 11 26, 27 9 Not recorded
47, 46 31 36, 37
c. The 1st and 2nd molars in each posterior

sextant are paired for recording and if Procedure
one is missing there is no replacement Instrument
and the score for the remaining molar A specially designed WHO probe is recom-
is recorded. mended. It is also called as CPITN probe.
d. If no index tooth or teeth are present in
a sextant qualifying for examination, Examination
all the remaining teeth in that sextant The index teeth or all remaining teeth in a
are examined and the highest score sextant where there is no index tooth should
recorded as the score for the sextant. be probed and the highest score recorded in
The distal surfaces of the third molars the appropriate box (Table 4.13).
should not be scored.
Loss of Attachment
Children and Adolescents
(Less than 20 Years) (Figure 4.9 and Table 4.14)
a. 6 index teeth are examined: • Information on loss of attachment
may be collected from index teeth
16 11 26 in order to obtain an estimate of the
46 31 36 lifetime accumulated destruction of the
This modification is made in order periodontal ligament.
to avoid scoring the deepened sulci • This permits comparisons between
associated with eruption as periodontal population groups but is not intended
pockets. to describe the full extent of loss of
b. For the same reason, when children attachment in an individual.
under the age of 15 years are examined, • The most reliable way of examining for
pockets should not be recorded, i.e. loss of attachment in each sextant is to
only bleeding and calculus should be record this immediately after recording
considered. CPI score for that particular sextant.
Table 4.14: Loss of attachment attachment for that sextant is estimated to be

less than 4 mm (loss of attachment score = 0)
Score Criteria
0 Loss of attachment 0-3 mm (CEJ not visible and
CPI score 0 to 3) DECAYED MISSING FILLED (DMF) INDEX
If the CEJ is not visible and the CPI score is 4 or
Introduction
if CEJ is visible
1 Loss of attachment 4 to 5 mm (CEJ within the Dental caries is one of the major diseases of
black band) mankind. By the age of 25-years-old 95% of
2 Loss of attachment 6 to 8 mm (CEJ between the the people in the most population groups
upper limit of the black band and the 8.5 mm ring)
will be affected by dental caries. The dental
3 Loss of attachment 9 to 11 mm (CEJ between 8.5
mm and 11.5 mm ring) caries is widespread. Adversely affects the
4 Loss of attachment 12 mm or more (CEJ beyond total health conditions of the individual
11.5 mm ring) and results is unnecessarily expense and
X Excluded sextant discomfort if left untreated. Dental caries
9 Not recorded (CEJ neither visible nor detectable) can be prevented and most dental public
health programs are concerned about it.
The dental health program administrator
needs to known the patterns of dental
caries occurrence in various communities
or in special groups under his jurisdiction in
order to plan, conduct and evaluate various
activities directed towards prevention and
control of dental caries.
In early twentieth century, measurement
of intensity of dental caries was done by the
proportion of first molars lost dues to dental
Figure 4.9: Loss of attachment codes caries, and percentage of permanent teeth
affected by dental caries have been used. But
The highest score for CPI and loss of both these methods provided little useful
attachment may not be necessarily be comparative information and not sensitive.
found on the same tooth in a sextant. As early as 1931 Bodeker CF and Bodeker
• Loss of attachment should not be re- HWC described a caries index “Bodeker’s
corded for children under the age of 15. Index”, which was found to be sensitive
Probing pocket depth gives some but for complex to use in epidemiological
indication of the extant of loss of attachment. surveys. Bodeker modified this caries
This measurement is unreliable when index later where in addition to counting
there is gingival recession, i.e. when the the surfaces for decayed, an extra count
cementoenamel junction (CEJ) is visible. was allotted for those surfaces that could
When the CEJ is not visible and the experience multiple caries attacks. But this
highest CPI score for a sextant is less than 4 also was not used in major epidemiological
(probing depth less than 6 mm) any loss of studies.
Concept of DMF Index A survey using “DMF Index” can also

The original concept of DMF index was provide data useful in assessing the value of
developed over 70 years age. The first various preventive activities, examples are.
systematic description of DMF index is • Fluoridation of public water supplies
attributed to Henry Klein, Carrolle. Palmer • Topical application of fluorides
and JW Knutson in their studies of dental • Plaque control programs and
caries in Hagerstown, Maryland in 1938. • Other preventive programs.
The first publication presenting DMF index The information can be useful to pro-
was an article in the public health bulletin fessional groups, the public and governing
in 1937, entitled “Dental caries in American bodies in assessing the need for additional
Indian children” by Henry Klein and Carroll resources and preventive measures needed
E Palmer. in the community.
Subsequent to the initial work, many
dental investigators have used the concept, What Does DMF Index Describe?
modified criteria and methods on occasions The DMF index has received practically
or otherwise changed the original classi- universal acceptance and probably the best
fication system. The experimentation and known in all dental indices. DMF index is
modification have made the comparison of the most universally employed index for
data from surveys by different investigators measuring dental caries. DMF index is based
difficult and the various modifications pose on the fact that the dental hard tissues are
a particular problem in the training of public not self healing; established caries leaves a
health dentists to perform a survey examina- scar of some sort. The tooth either remains
tion. decayed or if treated it is extracted or filled.
The approach to measuring caries The DMF index is therefore an irreversible
by counting the number of teeth in the index, used to measure past and present
mouth visibly affected by caries was used lifetime caries experience of a population
in a systematic manner by Dean HT and with permanent teeth.
colleagues in their historic studies of the
dental caries/fluoride relation. Definition
The characteristics of dental caries in The DMF index is defined as quantitative
children and young adults can be estimated expression of a person’s lifetime caries
from a survey using “DMF Index” such a experience in permanent teeth. It describes
survey can provide information on: numerically the results of dental caries
• The number of persons affected by attacks on permanent teeth of a population
dental caries group. An average DMF score expresses
• The number of teeth that need treatment the mean caries prevalence in a group of
for dental caries individuals. DMF can therefore be defined
• Proportion of teeth that have been as irreversible index on a ratio scale. The
treated and DMF score for any individual can range
• Other statistical data that are useful in from 0 to 32 in whole numbers. DMF value
evaluating and directing dental health for a group studies in an epidemiological
program efforts. survey constitute the total of the individual
values divided by the number of subjects The “DMFT” index is generally expressed
examined, so the DMF group score can have as “the average number of DMF teeth per
decimal values. person” in the population being studied. The
In permanent dentition, the upper average is usually computed separately for
case letters for permanent teeth are used to each ‘age’ and ‘sex’ grouping since there two
designate the DMF index. (The symbol “D” factors are important in correctly interpreting
refers to the number of teeth present with the data. As we know for example:
unrestored carious lesions). The symbol “M” 1. The girls acquire their permanent teeth
refers to the number of teeth that are missing at a slightly earlier age than boys.
(extracted) due to caries. The symbol “F” Therefore, we expect a slightly higher
refers to the number of teeth that have been DMF average for girls than boys when
attacked by caries but have been restored the age is same.
and are now free from caries. 2. We also know that the older the child,
Thus, the DMF index is the sum of the higher the DMF average. The older
decayed (D), missing (extracted) because child has more permanent teeth that
of caries (M) and filled because of caries (F) are subject to attack by caries and he
permanent teeth (T) or tooth surfaces (S). also has permanent teeth that have
Each tooth or tooth surface is counted only been vulnerable to a caries attack for
once, either under DM or F. Thus the DMF a longer period of time. In addition to
index is expressed as DMFT or DMFS. the “average number of DMF teeth”
The symbol “T” is used to indicate that it is possible to compute a number of
unit of count for the index is the number of other statistical measures from the
permanent teeth affected, rather than the information collected on a DMFT Index
number of affected surfaces on the tooth or surveys.
the number of carious lesions in the mouth.
The symbol “S” is used to indicate that Decayed missing filled-surfaces (DMFS) Index
unit of count for the index is the number The DMF index is employed to assess
of surfaces affected by carious lesions in individual surface of each tooth rather than
permanent teeth. the teeth as a whole, it is termed as “decayed,
Thus, the DMF index can be applied to missing filled-surfaces index. (DMFS index).
whole tooth or to surfaces of teeth. The “S” symbol is used to indicate that the
The DMF can also be used in a “half unit of count for the index is the number
mouth fashion” or “shorthand method” of of surfaces affected by caries in permanent
DMF examination as recommended by WHO teeth, rather than the number of affected
in which apposite diagonal quadrants of the permanent teeth.
mouth are examined. Here the objective is to In studies, in which DMF surfaces are
obtain assessments of caries prevalence in a ascertained, it is necessary to decide how
population which has not been previously many affected surfaces to assign to teeth that
surveyed. This technique means that half have been extracted because of caries.
the upper arch only is scored, then the In epidemiological studies or surveys
contralateral lower half arch and the results for DMFS, it is decided to assign the affected
doubled. This is quicker and easier than full surfaces, i.e. facial, lingual, mesial, distal and
mouth DMF index. occlusal to posterior permanent tooth and
facial, lingual, mesial and distal to anterior The equivalent index for measuring
permanent tooth, that has been extracted caries in the primary dentition is the “DEF-
because of caries, i.e. U component. In index” described by Gruebbel in 1944
root stumps the D component it is decided in his study. A measurement of dental
to assign 5 affected surfaces to posterior caries prevalence and treatment service for
permanent anterior tooth. deciduous teeth as defined by Gruebbel.
Total surfaces count for DMF(S) = D(S) “D” stands for decayed deciduous teeth.
+ M(S) + F(S) “E” stands for indicated for extraction of
Total surfaces count for DMF(S) index – deciduous teeth.
Total number of surfaces examined, if only “F” stands for filled deciduous teeth
28 teeth are examined (i.e. third molars are because of caries.
excluded). It should be noticed that in DEF index
16 posterior teeth (16 × 5) = 80 surfaces deciduous teeth missing due to caries are
12 anterior teeth (12 × 4) = 48 surfaces not recorded because of difficulty in many
Total number of surfaces examined children of distinguishing between extracted
= 128 surfaces and naturally exfoliated primary teeth. The
Calculation of DMFS index for an DEF index does not take into account teeth
individual: that have been extracted or exfoliated because
Total no. of decayed surfaces = D of past caries experience.
Total no. of missing surfaces = M
Total no. of filled surfaces = F What does “DEF-Index” describe?
Total DMFS of an individual score The DEF index is a variation of DMF index, is
= D(S) + M(S) + F(S) used to measure observable caries experience
In some studies, this number has in primary tooth.
been chosen arbitrarily, e.g. 3 surfaces for
Definition: DEF index is defined as “It is a
posterior teeth and 2 surfaces for anterior
qualitative expression of the observable
teeth. In clinical trials, it has been shown that
caries experience or caries prevalence in
it is best to use an arbitrary number for three
the primary dentition. It is the sum of
surfaces if a tooth is absent on the baseline
number of primary teeth or surfaces that
but, for teeth that are extracted during the
are decayed (D), decayed beyond repair,
course of the trial, one should use the number
i.e. those that need to be extracted (E) and
of affected surfaces determined at the most
filled (F)”. WHO, Oral Health Surveys,
recently completed examination.
Basic Methods, (1971) substitutes “i” for “e”
to designate teeth indicated for extraction.
Mixed Dentition
The DEF index differs from the DMF index
Assessment of Caries in Primary Teeth in that primary teeth missing at the time of
“DEF-Index”: When a survey is made of the examination are ignored in the former.
a population of children having a mixed Caries indices used for primary dentition
dentition, DEF index is used to describe the DEFT index and DEFS index equivalent to
caries experience of deciduous teeth (pri- DMFJ and DMFS indices used for permanent
mary dentition). dentition. The DMFT and DMFS indices as
applied to the permanent dentition is always DECAYED FILLED (DF) Index

designated or signified by upper case letter, Definition
i.e. capital letters. The equivalent index for The DF index is a quantitative expression
primary dentition is the DEFT and DEFS is of a person’s or groups number of decayed
always designated or signified by lower case and filled deciduous teeth or tooth surfaces.
letter, i.e. small letters. When a survey is made of a population
of children having a mixed dentition, “DF
Modification of DEF Index index” is also used to describe the caries
It should be noticed that in DEF index experience of deciduous teeth.
deciduous teeth missing due to caries are not The symbol (d) stands for the number of
recorded because of the difficulty in many deciduous teeth present that are caries and
children of distinguishing between extracted not restored. The symbol (f) stands for the
and naturally exfoliated primary teeth. By number of restored deciduous teeth because
giving due considerations to these two facts, of caries. The missing teeth are ignored. This
DEF is modified into: is the method of choice of the WHO, Oral
1. DMF index Health Surveys, Basic Methods.
2. DF index. The DF index can be applied to the whole
tooth as the decayed—filled-tooth-DFT
Decayed missing filled Index index or to the individuals surfaces as the
Definition: DMF index is a quantitative ex- decayed—filled-surfaces-DFS index.
pression of the caries experience or caries When a survey is made of the population
prevalence in the primary teeth. It is the of children between the age groups of 6 to 12
sum of decayed (d), missing due to caries years having a mixed dentition, a DMFT in-
(m) and filled (f) because of caries primary dex or DMFS index used for permanent teeth
tooth (t), It is DMFT or tooth surfaces (s), along with DFT index and DFS index to describe
it is DMFS. It is used in the same way as the caries experience of deciduous teeth.
DMF index. Only those teeth which should The average should be computed
be present according to the subject (patient) separately for each age and sex grouping
age at the time of examination are assessed for children under 12 years of age. The
in the missing component. For example, it DMFT index or DMFS index for permanent
may be decided to classify missing decidu- dentition and DFT index or DFS index for
ous canines and molars as missing (m) only deciduous dentition, the data should be
in children less than nine years of age, be- computed separately to describe caries
cause beyond that age it may be impossi- experience in permanent and deciduous
ble to determine whether a given missing teeth respectively.
tooth has been extracted or has exfoliated. Close observation shows that DF index
If all missing primary teeth not replaced by and DMF index should be numerically the
a permanent successor are considered as same: DEF index allow for two grades of
m-teeth regard less of age, an overestima- caries and neither count missing. Both DMF
tion of the DMFT index results. Therefore, index and DF index may therefore under
the DMFT is used for children before age state the true extent of the carious attack
of exfoliation and DMF applied only to the and thus lose validity. For comprehensive
primary molar teeth. purpose, however the greater variability
gained by ignoring missing tooth can make are counted as teeth absent because of
both indices more useful. caries. Professional opinions can very
widely in the determination of when a
The DMF Classification System tooth should be extracted, particularly
when a decision is based upon a rapid
When a survey is made to a population of
children by using DMF and DF indices to visual inspection using a mirror and an
describe the caries experience of permanent explorer. The numerical value of the
and deciduous teeth, the examination DMF number does not change when
criteria, coding and tabulating procedures the category is eliminated but the ‘M’
and methods presented in this clinical component may be less when compared
manual and record book may differ in one to data obtained by a different method.
or more features from WHO criteria for 3. The category, “indicated for extraction”
caries index (1986). However, the following is not used for deciduous teeth for the
considerations are called to the reader’s same reasons as described above. The
attention. numerical value of the “DF index”,
1. The examination is performed to is identical with the “DEF index”,
determine the classification of 28 teeth deciduous teeth affected by caries are
or tooth surfaces. The third molars classified into two categories rather
are excluded from the system for two than three.
reasons: 4. A separate category for a tooth that is
i. In surveys of children under 15 years both decayed and filled is not used. It
of age (the group most commonly has been customary. When a separate
surveyed) the recording of four “DF” or “df” category has been used,
additional decisions by the examiner to tabulate these teeth with the count of
constitutes little new information, the “D” or “d” teeth respectively. The
because the third molars erupt at the additional statistic describing carious
age of between 18 to 25 years. teeth that have been filled at some
ii. For surveys of young adults, 15 to in the post appeared to be of limited
35 years variations in the eruption usefulness in most DMF surveys.
pattern and the frequent removal 5. A separate category and a code designa-
of the third molars because of tion for teeth that should be excluded
impactions or for other reasons, not from consideration in a study of the
related to caries makes an accurate caries experience of a population group
classification of the reason for an has been included. In other systems of
absent tooth unlikely. Even careful classification, a special notation is made
questioning of the patient does not on the record from requiring additional
always provide a sound basis for the tabulation procedures.
dentist to reach a decision. 6. The classification system and code
2. This classification system does not use does not include a method of obtaining
a category. “Indicated for extraction” statistics on other oral condition that
for teeth that are present in the mouth may be observed during the DMFT
but are decayed to the extent that they examinations. If statistics on other
oral conditions are needed, a separate 2. A tooth is considered to be present even

classification and recording system through the crown has been destroyed
should be used. and only the roots are left.
7. The code designations used in this 3. Supernumerary teeth are not to be
classification are numerical designations classified, if a primary tooth is retained
selected, because: and its permanent successor is present,
i. They are easy to learn classify the permanent tooth.
ii. Resemble a word used in the criteria
Note: The following points should be noted
iii. Easy to tabulate manually or by
clearly for just to make the student to
punch card
understand the examination and coding
iv. They are also different in sound
when spoken verbally and therefore, criteria and to avoid any confusion and doubts
easier for the recorder to hear. to eliminate the errors in survey procedures.
Note: Other types of code designation have General Rules

been used or could be used.
The general rules for examination and coding
criteria are as follows:
Rational for the DMFT Classification
1. No tooth or tooth space or tooth surface
The examiner’s task, during the survey should be counted more than once. It
examination is to classify the condition may be either decayed, missing, filled
of each of the 28 tooth spaces for each or sound.
patient examined. To arrive at the proper 2. The decayed, missing and filled tooth
classification for each tooth space, the or tooth surface or tooth space should
examiner must make: be recorded separately since the compo-
• Four decisions if a tooth is present or nents of DMF index are great interest.
• Three decisions if a tooth is absent. 3. A tooth may have several restorations
The examiner’s final decision for each but it is counted as one filled tooth.
tooth or tooth space is expressed as a code. Note: In DMFS index if the tooth shows
The special rules to be followed in making fillings on different surfaces, i.e. mesial,
decisions and the definition for each category distal and occlusal, lingual (or palatal)
of the code are included in the next section. and buccal. The filled tooth surfaces
The decision process that forms the basis for should be counted separately in DMFS
the coding system is expressed schematically index.
(Figure 4.10). 4. The tooth treated with pit and fissure
sealant and shows carious lesion.
Examination Criteria and Rule for Coding 5. Third molars are not included in DMF
index.
Special Rules
6. Naturally exfoliated tooth should not be
1. A tooth is considered erupted when the taken into considerations.
occlusal surface or incisal edge is totally 7. Measurement of caries status for
exposed or can be exposed by gently deciduous and permanent teeth should
reflecting any overlying gingival tissue be recorded separately. The deciduous
with the mirror or explorer. teeth are not included in DMF count.
Figure 4.10: Schematic presentation of coding system for DMFT index
8. If anterior tooth is missing due to caries 3. The tooth has been fractured and the
four surfaces and posterior tooth five fractured portion is restored with a
surfaces should be counted. filling, jacket, or crown.
9. If both a filling and caries lesions are 4. The tooth has a root hand filling due to
present on the same surface that surface trauma.
is considered as only one surface that 5. The tooth has a jacket crown because it
too as carious. is a poorly formed tooth, e.g. Peg lateral.
10. If a tooth is filled shows secondary caries
6. The tooth has a restoration used as
count that tooth or surface is considered
abridge abutment.
as caries only in “D” category of DMF
7. A permanent tooth has been removed
index tooth.
for orthodontic, reasons or for any
11. If the restoration has displaced from the
reason other than caries.
cavity and the tooth with base cavity is
considered as decayed tooth. Permanent Tooth Present
Sound permanent tooth 1 : Code a tooth “1”
Exclusions E
if there is no indication of caries and no fill-
Excluded tooth or tooth space: Code a tooth ings, jackets, crowns or bridge abutment.
“E” when one of the following conditions Other defects such as hypoplasia, fluorosis,
is present. enamel defects may or may not be present.
1. The tooth has been fractured and dam- If some surfaces of an apparently sound
aged to the extent that dention is exposed. tooth are obscured by an orthodontic band
2. It may be sound, carious, or filled. assume that tooth is sound.
Filled permanent tooth 2 : Code “2” when a • Unerupted deciduous tooth

tooth has been filled either permanently or • Impacted or congenitally missing
temporarily regardless of the material used. permanent or primary tooth.
A tooth that is both filled and decayed is
classified as code “3” decayed. In any in- Extracted Permanent Tooth
stance where the filling has fallen out, code X Code a tooth space as “x”.
the tooth as “3”.
• If according to the age of the person,
Decayed tooth 3 : Code a tooth “3” when a permanent tooth should be present
there is the following evidence of caries but in all probability has been extracted
present. because of caries.
1. Visual evidence of undermined enamel; • Special precautions.
there must be a definite cavitation with When not sure, the person should be
either discoloration or opacity around questioned regarding extractions. The
the edges and in which the explorer can final decision should be based upon the
penetrate. examinations and the person’s response.
2. Pits and fissures in which the end of the Clinical judgment is given preference in the
explorer catches should be classified event that the response is not conclusive.
as carious only if one of the following
criteria is met: The DMFT Examination Procedure
i. Tactile evidence of soft carious In the examination process, the examiner
material at the base of the pit and visually inspects and explores when
fissure. necessary the facial, occlusal, lingual, and
ii. Opacity around the edges or an proximal surfaces of all the teeth present
underlying stain typical of caries. (expect third molars), identifies the tooth
number of all the teeth that are absent,
Primary Tooth Present
and determine the reason for absence. The
Use the same criteria as for the classification examination is made using a plane glass
of a permanent tooth present code as follows: mouth mirror and a sharp standard no. 23
E Excluded tooth or tooth spaces explorer. Compressed air (or a chip blower)
P1 Sound deciduous tooth is used to improve visibility when the tooth
P2 Filled deciduous tooth surfaces are obscured by saliva or debris.
The patient should be positioned so that
P3 Carious deciduous tooth
the examiner has optimum visibility of the
quadrant to be examined. The examination
Primary or Permanent Tooth Absent
should be conducted as follows:
O Missing tooth 1. Begin with the maxillary right quadrant
Code a tooth space as “0” when the with the central incisor or tooth space
absence of a tooth is due to one of the number 1, and proceed in sequence to the
following: second molar or tooth space number 7.
• Primary tooth missing for any reason 2. As the examination proceeds, the ex-
• Unerupted permanent tooth aminer calls the appropriate diagnostic
code for each tooth or tooth space. 5. Do; encourage the recorder to speak to
Since, the examination proceeds in ask for a repeat code or clarification when
sequence from anterior to posterior, the patient is not sure. The completeness
tooth number is not called routinely. and accuracy of the examination record
3. When the quadrant is completed, is the examiner’s responsibility. Check a
the examiner pauses briefly, and the new recorder frequently to be sure that
recorded calls “check” to indicate that patient is recording accurately.
she has accounted for every tooth space 6. Do; take advantage of the educational
in the quadrant. opportunity when the patient asks
4. The maxillary left quadrant is examined questions or expresses concern.
next, and proceeds in the same manner 7. Do; keep a steady, even pace in your
beginning with the central incisor or examination. Experienced examiners
tooth space number 1 and proceeding to will average 25 to 30 examinations per
the second molar or tooth space number hour. You and your recorder should
7 for that quadrant. take a rest break once or twice during
5. The examination then proceeds to the each morning and afternoon session.
mandibular left quadrant and then to
the mandibular right quadrant. The Selection and Arrangement of the
6. At the end of the examination, the Examination area
examiner should pause before releasing
The selection and arrangement of the
the patient in order to give the recorder
examination area is an important aspect
an opportunity to verify that she has
of the DMFT survey. The size of the area
recorded a code in every space on the
needed will be depend upon the number
form and to ask for a repeat code if this
of examiners to be used. Ideally, 80 to 100
is necessary.
square feet should be allowed for each
examiner. Two or more entrances to the
Do’s and Don’ts for the Examiner examination room are necessary for effective
1. Do’s; when all possible, keep your control of patients’ traffic. If the location is to
hands out of the patient’s mouth. This be used more than one day, the room should
minimizes contamination. have doors that lock in order to protect
2. Don’ts probe gross carious lesions with equipments and supplies. Patient waiting
the explorer and cause unnecessary areas outside the entrances are helpful in
discomfort to the patient. The explorer reducing noise and traffic congestion in the
should be used only on those areas where examination room. Other factors that should
doubt exists as to the presence or absence be considered in the selection of the room are:
of a carious lesions or restoration. availability of running water, adequacy of
3. Do; question the patient regarding rea- ventilation, cooling/heating of the room, the
sons for extraction, but if the response is number of electrical outlets, the adequacy of
not conclusive, rely on your judgment. artificial or natural lightening room, central
4. Do; speak distinctly to minimize recording location of the examination room.
errors. Be sure the recorder is located so The accompanying diagram illustrates a
that you speak directly to patient. satisfactory arrangement of an examination
area in a school where four examiners Teeth Surfaces

will be used. The room is large, easily Decayed teeth (D)
accommodating the four examination units. code “3” 2 3
A student waiting area is available outside Missing teeth of caries (M)
the examination room. The space is adequate code “X” 2 9
enough for one student to wait behind each Filled teeth (F) code “2” 1 3
examiner and be quickly seated upon the DMFT = 2 + 2 + 1 = 5
departure of the previous student. Two DMFS = 3 + 9 + 3 = 15
doors to the room permit a smooth one-
way flow way of traffic from the entrance, The Number of DF Teeth (DFT)
to the examination chair, and to the exit. • Total each code separately, i.e. P2 and P3
The arrangement of equipments, such as • Add together code P2 and P3 and
compressor and light minimizes the hazards record total.
in the traffic pattern. The tabulators are
located in one corner of the area to minimize The Number of DF Surfaces (DFS)
distraction from the noise. The sterilizers
• Total the number of surfaces involved
are located in another corner away from the
in each code separately, i.e. P2 and P3.
traffic pattern.
• Add together the surfaces involved in
P2 and P3 and record total.
CALCULATIONS FOR DMF INDEX
Example: A 2½-year-old child has 18 teeth.
Instructions for Data Summary Teeth A (55) and J (65) are unerupted.
(For each person examined) There is no sign of dental caries in the
teeth M (73), N (72), O (71), P (81), Q (82),
The Number of DMF Teeth (DMFT) and R (83).
• Total each code separately, i.e. 2, 3 and x. All other teeth have two caries surfaces,
• Add together code 2, 3, and x and except B (54), which is broken down to the
record total. gum line because of dental caries.
The Number of DMF Surfaces (DMFS) Summary

• Total the number of surfaces involved Total teeth = 18
in each code separately, i.e. 2, 3, and x. Caries free teeth = 6
• Add together the surfaces involved in 2, Decayed teeth (D) code P3 = 12
3, and x and record the total.
Filled teeth (F) code P2 = 0 = 0
Example: An individual presents with dental DFT = (D) + (F) = P3 + P2
caries on the mesial and occlusal surfaces of P3 + P2 = 12 + 0 = 12
a posterior tooth, caries on the mesial surface
of anterior teeth are messing because of Interpretation: 12 of 18 teeth with caries le-
caries, and there is an amalgam restoration sions indicate a serious need for dental
on the mesial-distal- occlusal surfaces of treatment and a prevention program for the
posterior teeth. child.
Example individual DFS: Using the same 2½ 3, 4, 9, 9, 9, 10, 10, 10, 11, 11, 12 and 16 equals
year-old-child to calculate DFS: a group of total DMF of 124.
DFS = (D) + (F) = P3 + P2 • Total the DMFS for each individual
examined.
Total number of carious surfaces
• Divide the total DMFS by the number of
= 11 × 2 = 22
individuals in the group.
Total B (54) = 1 × 5 = 5
– 124/20 = 6.2 = the average DMF for
Total DFS = 27
the group, the average number of
The Number of Decayed Permanent Teeth DMF teeth per person.
– The DMF average represents accu-
Add code “3” (D-compound) and record
mulated dental caries experience for
the total.
the group.
The Number of Permanent Teeth Missing – The difference in caries experience
Because of Caries between two groups of individuals
within this population is notable and
Add code “x” (m-component) and record
the total. influence interpretation of the results.
For the first 10 individuals, the
The Number of Sound Permanent group average DMF is 10/10 = 1.7
Teeth Present and for the second 10 individuals
Add code 1 and record the total. the average DMF is 107/10 = 10.7.
Scores for the two groups can be
The Number of Filled Permanent Teeth presented separately because of the
Add code “2” (‘F’-Component) and record wide difference.
the total. – Average DMF scores can also be
presented by age groups.
The Number of Permanent Teeth Present
Number and Percentage of
Add together code 1, 2, and 3 and record Persons by DMF Statistics
the total.
• Count the persons with number of DMF
Computing Instructions for teeth such as, 1 DMF tooth, 2, 3, and on.
Selected DMFT Statistics • Enter in table and compute percentage.
Group DMF: Add together the number DMF • Divide number of persons with number
teeth for each person in the group and di- of DMF separately.
vide by the total number of persons. Round Example: A population of 20 individuals with
off to one number beyond the decimal individual DMF scores of 0, 0, 0, 0, 2, 2, 3, 3,
point. 3, 4, 9, 9, 9, 10, 10, 10, 11, 11, 12 and 16. The
Example: A population of 20 individuals with number and percentage of individuals by
individual DMF scores of 0, 0, 0, 0, 2, 2, 3, 3, DMF statistics are as follows.
Example:
Number of Number of Percentages
D = 175, M = 55, F = 18
DMF teeth persons
Total DMFT = 248
0 4 0% D 175
2 2 100% –––––––––– = ––––
3 3 100% Total DMF 248
4 1 25% = 0.70 or 70% of teeth
9 3 33% needs restoration
10 3 30% • To calculate the percentage of all teeth
11 2 18.18% that are missing:
12 1 8.33%
Example: 20 individuals have 28 × 20 = 560
16 1 6.25%
permanent teeth.
Total

M 55
Example: 20 individuals have 28 × 20 = 560 ––––––––––––––––––– = –––– = 0.09 or 9%
permanent teeth. Total teeth examined 560
Teeth lost because of dental caries.
D 175
–––––––––––––––––––– = –––––– = 31.25%. Percentage of Permanent Teeth Decayed
Total number present 560
Divide the total number of decayed teeth
Percentage of permanent teeth that are sound (code 3) by the total number of permanent
(Not affected by caries): Divide the total num- teeth present (code 1, 2 and 3).
ber of sound teeth (code 1) by the total
Percentage of Persons Needing Care for
number of permanent teeth present (code 1,
Carious Permanent Teeth
2 and 3). Round off percentage to one num-
ber beyond the decimal point. Count the number of persons with 1 or more
teeth coded “3” (i.e. decayed) divided by the
Example: 20 individuals have 28 × 20 = 560 total number of persons in the groups. Round
permanent teeth. off the percentage to one number beyond the
D + M + F = DMF decimal point.
= 175 + 55 + 18
Example: A population of 20 individuals, 10
= 248.
individuals with one or more permanent teeth.
Sound permanent teeth = Total number

of permanent teeth – Total DMFT. 10
–––– = 50%.
560 – 248 = 312. 20

Sound permanent teeth 312 Percentage of permanent teeth that are
––––––––––––––––––––––––– = ––– = 55.71%
filled:
Total no. of permanent teeth 560
Divide the total number of filled teeth
Specific Treatment Need of a Group (code 2) by the total number of permanent
teeth present (code 1, 2 and 3, 0)
To calculate the percentage of DMF teeth

that need to be restored, divide the total “D” F 18
––––––––––––––––––––––– = –––– = 36%
component by the total DMF.
Total no. of teeth present 50
Percentage of Persons with no 5. Root caries: DMF index cannot be used

Previous Caries Experience to assess root caries status.
Count the number of persons with all tooth 6. Even in extreme conditions by carious
spaces coded either 1, P1, or 0 and divide status the DMF scores are same.
by the total number of persons. Round off 7. The rates of caries progression cannot
percent to one place beyond decimal point. be assessed in terms of how fast caries
is progressing or how far caries has
Ratio of filled teeth to DMF teeth progressed.
Divide the total number of filled permanent 8. DMF index does not give the account
teeth (code 2) by the total number of DMF for treatment needs.
teeth (code 2, 3, and x). Express the ratio to 9. Radiographs: DMFT used in large sur-
two decimal places, e.g. 0.54. veys to have only quantitative measure
of caries experience without using
Example: radiographs. Radiographs are not rec-
ommended in surveys because of the
18
–––– = 7.25% impracticality of using the equipments
248
in all situations. It should be realized,
The Average Number of DF Teeth Per Child however, that without radiographic in-
Add together number of DF teeth for each formation the need for restorative care
child in the group and divide by the total will be underestimated.
number of children. Round off to one
number beyond the decimal point. DEAN’S FLUOROSIS INDEX (1942)
• Introduced in 1934 by Trendley
Limitations of DMF Index
H Dean as Dean’s classification system
DMF index has the following limitations. for dental fluorosis or Dean’s fluorosis
1. DMF index does not indicate the density index.
of dental caries attack. Therefore, its
• It was modified in 1939 and 1942. The
values are not related to the number of
1942 modification of Dean’s Fluorosis
teeth at risk.
index is the one still recommended by
2. In older adults the teeth can be lost
WHO in its basic survey manual (WHO,
for reasons other than caries. (e.g.
1997).
periodontal disease). Hence, the DMF
Endemic dental fluorosis is a specific
is invalid in older adults.
disturbance of tooth formation caused by
3. Orthodontic treatment: Children who
are undergoing orthodontic treatment, excessive intake of fluoride during the
DMF index can be misleading in formative period of dentition. Clinical
children whose teeth (premolars) have fluorosis is characterized by lusterless,
been lost due to orthodontic treatment. opaque white patches in the enamel, which
4. Preventive fillings: DMF index can may become striated, mottled and/or pitted
overestimate caries experience in teeth or may be stained yellow to dark brown
which “Preventive fillings“ have been the affected teeth may show a pronounced
placed. accentuation of the perikymata and in more
Table 4.15: Scores and criteria
Classification Criteria
NORMAL (0) The enamel represents the usual translucent semivitriform type of structure. The surface is smooth,
glossy and usually a pale-creamy-white color
QUESTIONABLE The enamel discloses slight aberrations from the translucency of normal enamel, ranging from a few
(0.5) white flecks to occasional white spots. This classification is used in those instances where a definite
diagnosis of the mildest form of fluorosis is not warranted and a classification of “normal” not justified
VERY MILD (1) Small, opaque, paperwhite areas scattered irregularly over the tooth, but not involving as much as
approximately 25% of tooth surface. Frequently included in this classifications are teeth showing no more
than about 1 to 2 mm of white opacity at the tip of the summit of the cusps of bicuspids or second molars
MILD (2) The white opaque areas in the enamel of teeth are more extensive, but do not involve as much as 50%
of the tooth
MODERATE (3) All enamel surfaces of the teeth are affected and surfaces subject to attrition show wear. Brown stain is
frequently a disfiguring feature
SEVERE (4) All enamel surfaces of the tooth are affected and hypoplasia is so marked that the general form of the
tooth may be affected. The major diagnostic sign of this classification is discrete or confluent pitting
Brown stains are widespread and teeth often present a corroded-like appearance
Figures 4.11A to F: (A) Normal; (B) Questionable; (C) Very mild; (D) Mild; (E) Moderate; (F) Severe
severe cases, discrete pits and larger areas of or category until he or she arrives at the
hypoplasia (confluent pitting) of the enamel present condition.
appear to such an extent that the morphology • If there is any doubt a lower score
of the tooth is lost. should be recorded.
• The recording is based on the two teeth
Procedures most affected.
• All the teeth are examined. • However, if the two teeth are not equally
• When the teeth are scored, the examiner affected, the score for the less affected
should start at the higher end of the tooth is recorded (Figures 4.11A to F
index (severe) and eliminate each score and Table 4.15).
Chapter
5 Assessment of Oral Health Status

Using WHO Assessment Form
GENERAL numerals should be written clearly in the

following manner:
A special format given by WHO which
1234567890
is used to record the oral health status is
When letters are used, as under dentition
explained/described in the present chapter.
status and treatment needs, they should be
Investigators should arrange to have copies
written in capitals as follows:
reproduced locally.
ABCDEFGPT
clear pronunciation is essential when calling
STANDARD CODES out scores by examiners in order to prevent
Standard codes must be used for all sections misrecording, e.g. 8 and A.
of the special format. If this requirement The two-digit numbers above or
is not observed, WHO will be unable to below some of the boxes indicate specific
process the data and summarize the results tooth, according to the system used by the
as the standard computer program will International Dental Federation (FDI). The
be unsuitable. If some of the oral health first digit specifies the quadrant of the mouth
assessments are not carried out or are not and the second specifies the actual tooth.
applicable to the age group being examined, In designating a tooth, the examiner
the unused sections of the form should should call the quadrant number, then the
be cancelled with a diagonal line, or by tooth number, e.g. the upper right second
using code 9 in the appropriate box (= not incisor, 12 = “one-two” rather than “twelve”;
recorded). the lower left third molar, 38 = “three-eight”
The special format are designed to rather than “thirty-eight”.
facilitate computer processing of the
results. Each box is given an identification ORAL HEALTH ASSESSMENT FORM
number (the small number in parentheses),
The standard form for oral health assessment
which represents a location in a computer
is designed for collection of all the information
file. Recording codes are shown near
needed for planning oral care services and
the appropriate boxes. To minimize the
thorough monitoring and replanning of
number of errors, all entries must be clear
existing care services. The form includes the
and unambiguous. Confusing similarities
following sections:
commonly occur in writing 1 and 7, 2 and 4,
• Survey identification information
6 and 0, and B and 8. To avoid confusion and • General information
the danger of computing inaccurate results, • Extraoral examination
Chapter 5.indd 100 11/5/2014 6:04:46 PM

Assessment of Oral Health Status Using WHO Assessment Form 101
• Temporomandibular joint assessment The appropriate code should then be recorded
• Oral mucosa in boxes 26 and 27 of each form during the
• Enamel opacities/hypoplasia survey. Similarly, a list of the examiners
• Dental fluorosis who will be involved in the study should
• CPI (Periodontal status, formerly called be made and a code assigned to each one. If
community periodontal index of treat- there is information about the ethnic groups
ment needs (CPITN) and occupations or if it is intended to record
• Loss of attachment other information such as fluoride content
• Dentition status and treatment need of the water or use of fluoride tablets, then
• Prosthetic status the codes for this information should also be
• Prosthetic need included in the coding list. This information
• Dentofacial anomalies should be entered in boxes 24, 25, 29 and
30. The coding list should be distributed to
• Need for immediate care and referral
all the examiners and recorders before the
• Notes.
examinations begin, this information should
This form is suitable for surveying
be recorded on the survey summary sheet.
children as well as adults. Where only
children are examined, it would not usually
be necessary to record the presence of oral Date of Examination (Boxes 5–10)
mucosal lesions, root caries, or prosthetic The year, month and day should be written
status or need. Similarly, if adults only on the form at the time of the examination.
are examined, it may be of little use to Only the year and month (recorded in boxes
record dentofacial anomalies. For certain 5–8) will be entered into the computer data
communities where extrinsic staining or file. Recording a day enables an investigator
other deposits obscure observation of tooth to refer back to any one day examinations
surfaces, it might also be impossible to score that may need to be reviewed or checked.
enamel opacities/hypoplasia or dental
fluorosis. Identification Number (Boxes 11–14)
Each subject examined should be given
IDENTIFICATION AND GENERAL an identification number. This number
INFORMATION SECTIONS OF THE FORM should always have the same number of
digits as the total number of subjects to be
The investigator should write the name of the examined. Thus, if it is intended to examine
country, in which the survey was conducted 1200 subjects, the first subject should be
in capital letters on the original assessment numbered 0001.
form before making additional copies. Boxes If possible, the identification numbers
1–4 on the forms are reserved for the WHO should be entered on the forms before the
code for the country in which the survey is day’s work starts. It is important to ensure
carried out and should not be filled by the that each identification number is used only
investigator. once. Cross-checking is necessary when more
During the planning of the survey, a than one examiner participates in a survey.
list of the examination sites should be made If a total of 1200 subjects are to be surveyed
and a two-digit code assigned to each one. by two examiners, examiner 1 should use
Chapter 5.indd 101 11/5/2014 6:04:46 PM

numbers 0001-0600, and examiner 2 should make an estimate on the basis of, for instance,
use numbers 0601-1200. stage of tooth eruption or, for adults, major
events in the community. Where age has
Examiner (Box 15) been estimated, the manner of estimation
If more than one examiner is participating should be reported.
in the survey, each examiner should be
assigned a specific code, which should be Sex (Box 23)
entered in box 15. Similarly, if a validating This information should be recorded at the
examiner is participating in the survey, he or time of examination because it is not always
she should also be assigned a specific code. possible to tell a person’s sex from name
alone. The appropriate code (1 = male, 2 =
Original/Duplicate Examinations (Box 16) female) should be entered in box 23.
If the subject is being re-examined to assess
reproducibility, then the first (original) Ethnic Group (Box 24)
examination is scored “1” and any subsequent In different countries, ethnic and other groups
duplication examinations are coded 2, 3, 4, are identified in different ways, e.g. by area
etc. in box 16. For all subjects for whom or country of origin, race, color, language,
duplicate examinations have been made, religion or tribal membership. Local health
data from the first examination only are and education authorities should be consulted
included in the survey analysis. before any decision is made as to which
ethnic groups should be recorded. When this
Name decision has been reached, a coding system
The name of the subject may be written should be made.
in block letters, beginning with the family Note: The codes 0–8 may be used to identify
name. It should be noted that, in some different subgroups. Since, it is often
countries, identification of survey subjects by not possible to identify a person’s ethnic
name is not permitted, in this case the space origin from name alone, ethnic group
should be left blank. information must be recorded at the time of
the examination and coded in box 24.
Date of Birth (Boxes 17–20)
Where possible, the year and month of
Occupation (Box 25)
birth should be entered for cross-checking A coding system should be devised according
purposes. to local usage for recording occupation
groups and the appropriate code entered
Age (Boxes 21 and 22) in box 25.
Note: The codes 0-8 may be used to identify
Age should be recorded as age at last
different occupations.
birthday (i.e. a child in the 13th year of life
is 12). If the age is less than 10 years, “0”
should be entered before specific age (i.e. Geographical Location (Boxes 26 and 27)
6 years = 06). In communities where age Boxes 26 and 27 should be used to record
is normally expressed in another way, a the site where the examination is conducted.
conversion must be made. If the age of the This allows up to 99 geographical locations
subject is not known, it may be necessary to (villages, schools, etc.) to be identified (00-
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98). A list relating each location to its code any part of the examination which might
number should be prepared. Usually, only a place subjects at risk or cause them discom-
few codes are needed. The code “99” should fort. Examiners should use their judgment
be entered if this information is not recorded. in this matter. The following codes are used:
0 – No contraindication
Location Type (Box 28) 1 – Contraindication
Box 28 is provided for recording information
about each survey site. The purpose of CLINICAL ASSESSMENT
including these data is to obtain general
In order to ensure that all conditions are
information about the availability of services
detected and diagnosed, it is recommended
at each survey site. Three codes are used:
that the clinical examination follows the
1. Urban site.
order of the assessment form.
2. Peri-urban area: This has been included
in order to indicate areas surrounding
Extraoral Examination (Box 32)
major towns, which may have charac-
teristics similar to those of rural areas, The extraoral examination should be
i.e. very few health facilities of any kind performed in the following sequence:
and usually no access to oral health care a. General overview of exposed skin areas
facilities. (head, neck, limbs)
3. Rural area or small village. b. Perioral skin areas (nose, cheeks, chin)
c. Lymph nodes (head, neck)
d. Cutaneous parts of upper and lower
Other Data (Boxes 29 and 30)
lips
Two boxes (29 and 30) have been provided e. Vermilion border and commissures
for recording other information about the f. Temporomandibular joint (TMJ) and
subjects examined or the survey location.
parotid gland region.
Information such as use of tobacco or a chew
The following codes and criteria are used:
stick, refugee status, or the level of fluoride
in the water can be recorded here; if sugar 0. Normal extraoral appearance
intake was of interest, a system could be 1. Ulceration, sores, erosions, fissures—
designed by the investigator whereby the head, neck, limbs
level and frequency of intake were given 2. Ulceration, sores, erosions, fissures—
suitable codes. It would then be possible nose, cheeks, chins
to summarize the results of the survey 3. Ulceration, sores, erosions, fissures—
according to the different codes placed in commissures
these boxes. 4. Ulceration, sores, erosions, fissures—
Note: The codes 0–8 may be used in these vermilion border
boxes. 5. Cancrum oris
6. Abnormalities of upper and lower lips
Contraindication to Examination (Box 31) (e.g. clefts)
Local practices must be taken into consid- 7. Enlarged lymph nodes—head, neck
eration when establishing the presence of 8. Other swellings of the face and jaws
conditions contraindicating the conduct of 9. Not recorded.
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Temporomandibular Joint Assessment c. Tongue (dorsal and ventral surfaces,

(Boxes 33–36) margins).
Symptoms (Box 33). The following codes and d. Floor of the mouth.
criteria are used: e. Hard and soft palate.
f. Alveolar ridges/gingiva (upper and
0. No symptoms
lower).
1. Occurrence of clicking, pain, or difficul-
Either two mouth mirrors or one
ties in opening or closing the jaw once
mirror and the handle of the periodontal
or more per week.
probe can be used to retract the tissues.
9. Not recorded.
Boxes 37–39 should be used to record the
Clicking (Box 34) of one or both temporo- absence, presence, or suspected presence,
mandibular joints: Clicking is evaluated of the conditions coded 1 to 7 for which
directly by an audible sharp sound or by examiners can make a tentative diagnosis
palpation of the temporomandibular joints. and to which they should be alert during
Tenderness (on palpation) (Box 35) of the clinical examinations. Code 8 should be
anterior temporalis and/or masseter muscles used to record a condition not mentioned
on one or both sides. in the precoded list, e.g. hairy leukoplakia
The tenderness should be evaluated by or Kaposi sarcoma. Whenever possible, the
unilateral palpation with the firm pressure tentative diagnosis should be specified in the
of two fingers, exerted twice on the most space provided.
voluminous part of the muscle. Tenderness is The codes and criteria are:
recorded only if the palpation spontaneously 0. No abnormal condition
provokes an avoidance reflex. 1. Malignant tumor (oral cancer)
2. Leukoplakia
Reduced jaw mobility—opening of mouth 3. Lichen planus
< 30 mm (Box 36): Taken as the distance 4. Ulceration (apthous, herpetic, traumatic)
between the incisal tips of the central 5. Acute necrotizing gingivitis
maxillary and mandibular incisors. As a 6. Candidiasis
general guide, in an adult jaw, mobility is 7. Abscess
considered to be reduced if the subject is 8. Other condition (specify if possible)
unable to open his or her jaw to the width 9. Not recorded.
of two fingers. The main location of the oral mucosal
lesion(s) should be recorded in boxes 40–42
Oral Mucosa (Boxes 37–42) as follows:
0. Vermilion border
An examination of the oral mucosa and soft
1. Commissures
tissues in and around the mouth should be 2. Lips
made on every subject. The examination 3. Sulci
should be thorough and systematic and be 4. Buccal mucosa
performed in the following sequence: 5. Floor of the mouth
a. Labial mucosa and labial sulci (upper 6. Tongue
and lower). 7. Hard and/or soft palate
b. Labial part of the commissures and 8. Alveolar ridges/gingiva
buccal mucosa (right and left). 9. Not recorded.
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Enamel Opacities/Hypoplasia 7. Diffuse opacity and hypoplasia.
(Boxes 43–52) 8. All three conditions.
The modified developmental defects of 9. Not recorded.
enamel (DDE) index are used. Enamel
Clinical Examination
abnormalities are classified into one of
three types on the basis of their appearance. Ten index teeth should be examined on the
They vary in their extent, position on the buccal surfaces only and coded in boxes
tooth surface, and distribution within the 43–52. If any index teeth are missing, the
dentition. relevant box(es) should be left blank.
The codes and criteria are as follows: Buccal surfaces, i.e. from the incisal
edges or cuspal points to the gingiva and
0. Normal.
from the mesial to the distal embrasure,
1. Demarcated opacity: In enamel of
should be inspected visually for defects
normal thickness and with an intact
and, if there is any doubt, areas such as
surface, there is an alteration in the
hypoplastic pits should be checked with the
translucency of the enamel, variable
periodontal probe to confirm the diagnosis.
in degree. It is demarcated from the Any gross plaque or food deposits should be
adjacent normal enamel with a distinct removed and the teeth should be examined
and clear boundary and can be white, in a wet condition.
cream, yellow or brown in color. Specific areas of concern in differentiating
2. Diffuse opacity: Also an abnormality in- between enamel opacities and other changes
volving an alteration in the translucency in dental enamel are: (a) white spot decay; and
of the enamel, variable in degree, and (b) white cuspal and marginal ridges on
white in color. There is no clear bound- premolar and molar teeth and, occasionally,
ary between the adjacent normal enamel on the lateral incisors.
If there is any doubt about the presence
and the opacity can be linear or patchy
of an abnormality, the tooth surface should
or have a confluent distribution.
be scored “normal” (code 0). Similarly a
3. Hypoplasia: A defect involving the surface tooth surface with a single abnormality less
of the enamel and associated with a than 1 mm in diameter should be scored
localized reduction in the thickness of “0”. Any abnormality that cannot be readily
the enamel. It can occur in the form of: classified into one of the three basic types
(a) pits—single or multiple, shallow or should be scored “other defects” (code 4). A
deep, scattered, or in rows arranged tooth should be regarded as present once any
horizontally across the tooth surface; (b) part of it has penetrated the mucosa and any
grooves—single or multiple, narrow or abnormality present on the erupted portion
should be recorded. If more than two-thirds
wide (maximum 2 mm); or (c) partial
of the tooth surface is heavily restored,
or complete absence of enamel over
badly decayed or fractured, it should not be
a considerable area of dentine. The examined (code 9).
affected enamel may be translucent or Note: It is strongly recommended that,
opaque. when examiners are trained and calibrated,
4. Other defects. subjects with a variety of enamel opacities/
5. Demarcated and diffuse opacities. hypoplasia should be included in the group
6. Demarcated opacity and hypoplasia. being examined.
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Dental Fluorosis (Box 53) 2, but covers less than 50% of the tooth
surface.
Fluorotic lesions are usually bilaterally
4. Moderate: The enamel surfaces of the
symmetrical and tend to show a horizontal
teeth show marked wear and brown stain
striated pattern across the tooth. The is frequently a disfiguring feature.
premolars and second molars are most 5. Severe: The enamel surfaces are badly
frequently affected, followed by the upper affected and hypoplasia is so marked
incisors. The mandibular incisors are least that the general form of the tooth may be
affected. affected. There are pitted or worn areas
The examiner should note the distribu- and brown stains are widespread; the
tion pattern of any defects and decide if teeth often have a corroded appearance.
they are typical of fluorosis. The defects in 8. Excluded (e.g. a crowded tooth).
the “questionable” to “mild” categories (the 9. Not recorded.
most likely to occur) may consist of fine
Community Periodontal Index (Cpi)
white lines or patches, usually near the in-
(Boxes 54–59)
cisal edges or cusp tips. They are paperwhite
Indicators
or frosted in appearance like a snowcapped
mountain and tend to fade into the surround- Three indicators of periodontal status are
ings enamel. used for this assessment: Gingival bleeding,
It is recommended that Dean’s index calculus and periodontal pockets.
criteria (3) should be used. The recording A specially designed lightweight CPI
is made on the basis of the two teeth that probe with a 0 to 5 mm ball tip is used, with
are most affected. If the two teeth are not a black band between 3.5 and 5.5 mm and
equally affected, the score for the less affected rings at 8.5 and 11.5 mm from the ball tip.
of the two should be recorded. When teeth
are scored, the examiner should start at the Sextants
higher end of the index, i.e. “severe”, and
eliminate each score until he or she arrives at The mouth is divided into sextants defined
the condition present. If there is any doubt, by tooth numbers: 18 to 14, 13 to 23, 24 to
the lower score should be given. 28, 38 to 34, 33 to 43 and 44 to 48. A sextant
The codes and criteria are as follows: should be examined only if there are two or
0. Normal: The enamel surface is smooth, more teeth present which are not indicated
glossy and usually a pale-creamy-white for extraction. (Note: this replaces the former
color. instruction to include single remaining teeth
1. Questionable: The enamel shows slight in the adjacent sextant).
aberrations from the translucency of
normal enamel, which may range from Index Teeth
a few white flecks to occasional spots.
2. Very mild: Small, opaque, paper-white For adults aged 20 years and over, the teeth
areas scattered irregularly over the tooth to be examined are: The two molars in each
but involving less than 25% of the labial posterior sextant are paired for recording
tooth surface. and, if one is missing, there is no replacement.
3. Mild: The white opacity of the enamel of If no index teeth or tooth is present in a
the teeth is more extensive than the code sextant qualifying for examination, all the
Chapter 5.indd 106 11/5/2014 6:04:46 PM

remaining teeth in that sextant are examined the second molar, and from the distobuccal
and the highest score is recorded as the score surface of the first molar towards the contact
for the sextant. In this case, distal surface of area with the premolar. A similar procedure
third molars should not be scored. is carried out for the lingual surfaces, starting
For subjects under the age of 20 years, distolingually to the second molar.
only six index teeth—16, 11, 26, 36, 31 and
46 are examined. This modification is made Examination and Recording
in order to avoid scoring the deepened sulci The index teeth or all remaining teeth in a
associated with eruption as periodontal sextant where there is no index tooth should
pockets. For the same reason, when children be probed and the highest score recorded in
under the age of 15 are examined, pockets the appropriate box. The codes are:
should not be recorded, i.e. only bleeding 0. Healthy.
and calculus should be considered. 1. Bleeding observed, directly or by using
a mouth mirror, after probing.
Sensing Gingival Pockets and Calculus 2. Calculus detected during probing, but
An index tooth should be probed, using the the entire black band on the probe vis-
probe as a “sensing” instrument to determine ible.
pocket depth and to detect subgingival 3. Pocket 4 to 5 mm (gingival margin within
calculus and bleeding response. The sensing the black band on the probe).
force used should be no more than 20 grams. 4. Pocket 6 mm or more (black band on the
A practical test for establishing this force is probe not visible).
to place the probe point under the thumb X. Excluded sextant (less than two teeth
nail and press until blanching occurs. For present).
sensing subgingival calculus, the lightest
9. Not recorded.
possible force that will allow movement of
the probe ball tip along the tooth surface
should be used.
Loss of Attachment (Boxes 60–65)
When the probe is inserted, the ball tip Information on loss of attachment may be
should follow the anatomical configuration collected from index teeth in order to obtain
of the surface of the tooth root. If the patient an estimate of the lifetime accumulated
feels pain during probing, this is indicative destruction of the periodontal attachment.
of the use of too much force. This permits comparisons between
The probe tip should be inserted gently population groups but is not intended to
into the gingival sulcus or pocket and the total describe the full extent of loss of attachment
extent of the sulcus or pocket explored. For in an individual.
example, the probe is placed in the pocket at The most reliable way of examining for
the distobuccal surface of the second molar, loss of attachment in each sextant is to record
as close as possible to the contact point with this immediately after recording the CPI
the third molar, keeping the probe parallel score for that particular sextant. The highest
to the long axis of the tooth. The probe is scores for CPI and loss of attachment may
then moved gently, with short upward and not necessarily be found on the same tooth
downward movements, along the buccal in a sextant. Loss of attachment should not
sulcus or pocket to the mesial surface of be recorded for children under the age of 15.
Chapter 5.indd 107 11/5/2014 6:04:46 PM

Probing pocket depth gives some frequent objections to exposure to radiation

indication of the extent of loss of attachment. outweigh the gains to be expected.
This measurement is unreliable when Examiners should adopt a systematic
there is gingival recession, i.e. when the approach to the assessment of dentition
cementoenamel junction (CEJ) is visible. status and treatment needs. The examination
When the CEJ is not visible and the highest should proceed in an orderly manner from
CPI score for a sextant is less than 4 (probing one tooth or tooth space to the adjacent tooth
depth less than 6 mm), any loss of attachment or tooth space. A tooth should be considered
for that sextant is estimated to be less than present in the mouth when any part of it is
4 mm (loss of attachment score = 0). The visible. If a permanent and primary tooth
extent of loss of attachment is recorded using occupy the same tooth space, the status of the
the following codes. permanent tooth only should be recorded.
0. Loss of attachment 0–3 mm (CEJ not vis-
Dentition Status
ible and CPI score 0–3). If the CEJ is not
visible and the CPI score is 4, or if the Both letters and numbers are used for
CEJ is visible. recording dentition status. Boxes 66–97 are
1. Loss of attachment 4–5 mm (CEJ within used for upper teeth and boxes 114–145
the black band). for lower teeth. The same boxes are used
2. Loss of attachment 6–8 mm (CEJ between for recording both primary teeth and their
the upper limit of the black band and the permanent successors. An entry must be
made in every box pertaining to coronal and
8.5 mm ring).
root status. In the case of surveys of children,
3. Loss of attachment 9–11 mm (CEJ be-
where the root status is not assessed, a code
tween the 8.5 and 11.5 mm rings).
“9” (not recorded) should be entered in the
4. Loss of attachment 12 mm or more (CEJ
box pertaining to root status.
beyond the 11.5 mm ring).
Note: Considerable care should be taken to
X. Excluded sextant (less than two teeth
diagnose tooth-colored fillings, which may
present).
be extremely difficult to detect.
9. Not recorded (CEJ neither visible nor
Codes for the dentition status of primary
detectable).
and permanent teeth (crowns and roots) are
given in the Figure 5.1.
Dentition Status and Treatment Need The criteria for diagnosis and coding
(Boxes 66–161) (primary tooth codes within parentheses) are:
The examination for dental caries should not 0 (A) Sound crown: A crown is recorded as
be conducted with a plane mouth mirror. sound if it shows no evidence of treated
Radiography for detection of approximal or untreated clinical caries. The stages of
caries is not recommended because of the caries that precede cavitation, as well as
impracticability of using the equipment other conditions similar to the early stages
in all situations. Likewise, the use of fiber of caries, are excluded because they can-
optics is not recommended. Although, it is not be reliably diagnosed. Thus, a crown
realized that both these diagnostic aids will with the following defects, in the absence
reduce the underestimation of the need for of other positive criteria, should be coded
restorative care, the extracomplication and as sound:
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Figure 5.1: Dentition status and treatment need
• White or chalky spots. only the root is left, the caries is judged to
• Discolored or rough spots that are not have originated on the crown and therefore
soft to touch with a metal CPI probe. scored as crown caries only. The CPI probe
• Stained pits or fissures in the enamel that should be used to confirm visual evidence
do not have visual signs of undermined of caries on the occlusal, buccal and lingual
enamel or softening of the floor or walls surfaces. Where any doubt exists, caries
detectable with a CPI probe. should not be recorded as present.
• Dark, shiny, hard, pitted areas of enam-
el in a tooth showing signs of moderate Decayed root: Caries is recorded as present
to severe fluorosis. when a lesion feels soft or leathery to probe
• Lesions that, on the basis of their with the CPI probe. If the root caries is dis-
distribution or history, or visual/ crete from the crown and will require a
tactile examination, appear to be due to separate treatment, it should be recorded as
abrasion. root caries. For single carious lesions affect-
ing both the crown and the root, the likely
Sound root: A root is recorded as sound
site of origin of the lesion should be record-
when it is exposed and shows no evidence
ed as decayed. When it is not possible to
of treated or untreated clinical caries. (Un-
judge the site of origin, both the crown and
exposed roots are coded 8).
the root should be recorded as decayed.
1 (B) Decayed crown: Caries is recorded as
present when a lesion in a pit or fissure, or 2 (C) Filled crown, with decay: A crown is con-
on a smooth tooth surface, has an unmistak- sidered filled, with decay, when it has one
able cavity, undermined enamel or a detect- or more permanent restorations and one or
ably softened floor or wall. A tooth with more areas that are decayed. No distinction
temporary filling, or one which is sealed is made between primary and secondary
(code 6 (f)) but also decayed, should also caries (i.e. the same code applies whether or
be included in this category. In cases where not the carious lesions are in physical asso-
the crown has been destroyed by caries and ciation with the restoration(s)).
Chapter 5.indd 109 11/5/2014 6:04:46 PM

Filled root, with decay: A root is considered used only if the subject is at an age when
filled, with decay, when it has one or more normal exfoliation would not be a sufficient
permanent restorations and one or more ar- explanation for absence.
eas that are decayed. No distinction is made Note: The root status of a tooth that has been
between primary and secondary caries. scored as missing because of caries should
In the case of fillings involving both the be coded “7” or “9”.
crown and the root, judgment of the site of In some age groups, it may be difficult
origin is more difficult. For any restoration to distinguish between unerupted teeth
involving both the crown and the root with (code 8) and missing teeth (codes 4 or 5).
secondary caries, the most likely site of Basic knowledge of tooth eruption patterns,
primary carious lesion is recorded as filled, the appearance of alveolar ridge in the
with decay. When it is not possible to judge area of the tooth space in question, and the
the site of origin of the primary carious caries status of other teeth in the mouth
lesion, both the crown and the root should may provide helpful clues in making a
be recorded as filled, with decay. differential diagnosis between unerupted
and extracted teeth. Code 4 should not be
3 (D) Filled crown, with no decay: A crown is used for teeth judged to be missing for any
considered filled, without decay, when one reason other than caries. For convenience, in
or more permanent restorations are pre- fully edentulous arches, a single “4” should
sent and there is no caries anywhere on the be placed in boxes 66 and 81 and/or 114 and
crown. A tooth that has been crowned be- 129, as appropriate, and the respective pairs
cause of previous decay is recorded in this of numbers linked with straight lines.
category. (A tooth that has been crowned
for readons other than decay, e.g. a bridge 5 (-) Permanent tooth missing, for any other rea-
abutment, is coded 7 (G)). son: This code is used for permanent teeth
judged to be absent congenitally, or ex-
Filled root, with no decay: A root is considered tracted for orthodontic reasons or because
filled, without decay, when one or more of periodontal disease, trauma, etc. As for
permanent restorations are present and code 4, two entries of code 5 can be linked
there is no caries anywhere on the root. by a line in cases of fully edentulous arches.
In the case of fillings involving both the Note: The root status of a tooth scored 5
crown and the root, judgment of the site of should be coded”7” or “9”.
origin is more difficult. For any restoration
involving both the crown and the root, the 6 (F) Fissure sealant: This code is used for
most likely site of primary carious lesion is teeth in which a fissure sealant has been
recorded as filled. When it is not possible to placed on the occlusal surface, or for teeth
judge the site of origin, both the crown and in which the occlusal fissure has been en-
the root should be recorded as filled. larged with a rounded or “flame-shaped”
bur, and a composite material placed. If a
4 (E) Missing tooth, as a result of caries: This tooth with sealant has decay, it should be
code is used for permanent or primary teeth coded as 1 or B.
that have been extracted because of caries
and is recorded under coronal status. For 7(G) Bridge abutment, special crown or veneer:
missing primary teeth, this score should be This code is used under coronal status to
Chapter 5.indd 110 11/5/2014 6:04:46 PM

indicate that a tooth forms part of a fixed Treatment Needs of Individual Teeth
bridge, i.e. is a bridge abutment. This code Countries vary greatly in the capacity of a
can also be used for crowns placed for rea- dental profession to meet demands for oral
sons other than caries and for veneers or health care and in professional attitudes and
laminates covering the labial surface of a treatment techniques. There may be wide
tooth on which there is no evidence of car- variations in the findings of examiners from
ies or a restoration. different areas, and even in the same area, on
Note: Missing teeth replaced by bridge treatment needs. Examiners are encouraged
pontics are coded 4 or 5 under coronal status, to use their own clinical judgment when
while root status is scored 9. making decisions on what type of treatment
would be most appropriate, based on what
Implant: This code is used under root status would be the probable treatment for the
to indicate that an implant has been placed average person in the community or country.
as an abutment. This could extend to scoring code “0” even
though the dentition status has been given
8 (-) Unerupted crown: This classification is re-
a different score.
stricted to permanent teeth and used only for
Data on treatment needs are of great
a tooth space with an unerupted permanent
value at local and national levels because,
tooth but without a primary tooth. Teeth they provide a basis for estimating personnel
scored as unerupted are excluded from all requirements and costs of an oral health
calculations concerning dental caries. This program under prevailing or anticipated
category does not include congenitally miss- local conditions, provided that demand
ing teeth, or teeth lost as a result of trauma, levels for those needs are taken into account.
etc. For differential diagnosis between miss- Treatment requirements should be
ing and unerupted teeth, see code 5. assessed for the whole tooth, including both
coronal and root caries. Immediately after
Unexposed root: This code indicates that the
the status of a tooth is recorded, and before
root surface is not exposed, i.e. there is no
proceeding to the next tooth or tooth space,
gingival recession beyond the CEJ.
the type of treatment required, if any, should
T (T) Trauma (fracture): A crown is scored as be recorded (boxes 98–113 and 146–161). If
fractured when some of its surface is miss- no treatment is required, code “0” should
ing as a result of trauma and there is no be placed in the appropriate treatment box.
evidence of caries. (If this is not done, it will be impossible to
determine later, when the data are processed,
9 (-) Not recorded: This code is used for any whether no treatment was necessary, or
erupted permanent tooth that cannot be whether the examiner or recorder omitted
examined for any reason (e.g. because of to make an appropriate entry).
orthodontic bands, severe hypoplasia, etc). The codes and criteria for treatment needs
This code is used under root status are:
to indicate either that the tooth has been 0. None (no treatment). This code is re-
extracted or that calculus is present to such corded if a crown and a root are both
an extent that a root examination is not sound, or if it is decided that a tooth
possible. should not receive any treatment.
Chapter 5.indd 111 11/5/2014 6:04:46 PM

P. Preventive, caries-arresting care. 3. Crown for any reason.

F. Fissure sealant. 4. Veneer or laminate (may be recommen-
1. One surface filling. ded for esthetic purposes).
2. Two or more surface fillings. 5. Pulp care and restoration. This code is
One of the codes P, F, 1 or 2 should be used to indicate that a tooth probably
used to indicate the treatment required needs pulp care prior to restoration
to: with a filling or crown because of deep
• Treat initial, primary or secondary and extensive caries, or because of tooth
caries. mutilation or trauma.
• Treat discoloration of a tooth, or a Note: A probe should never be inserted
developmental defect. into the depth of a cavity to confirm the
• Treat lesions due to trauma, presence of a suspected pulp exposure.
abrasion, erosion or attrition. 6. Extraction. A tooth is recorded as “indi-
• Replace unsatisfactory fillings or cated for extraction”, depending on the
sealants. treatment possibilities available, when:
A sealant is considered unsatis- • Caries has so destroyed the tooth
factory if partial loss has extended that it cannot be restored.
to exposure of a fissure, pit, or junc- • Periodontal disease has progressed
tion or surface of the dentine which, so far that the tooth is loose, painful
in the examiners opinion, requires or functionless and, in the clinical
resealing. judgment of the examiner, cannot be
A filling is considered unsatisfac- restored to a functional state.
tory if one or more of the following • A tooth needs to be extracted to
conditions exist: make way for a prosthesis.
• A deficient margin to an existing • Extraction is required for orthodon-
tic or cosmetic reasons, or because of
restoration that has leaked or is
impaction.
likely to permit leakage into the
7/8. Need for other care. The examiner
dentine. The decision as to whether
should specify the types of care for
a margin is deficient should be
which codes 7 and 8 are used. The use
based on the examiner’s clinical
of these two codes should be kept to a
judgment, on evidence gained from
minimum.
the insertion of a CPI probe at the
9. Not recorded.
margin, or on the presence of severe
staining of the tooth structure.
• An overhanging margin of an exist- Prosthetic Status (Boxes 162 And 163)
ing restoration that causes obvious The presence of prosthesis should be
local irritation to the gingivae and recorded for each jaw ( box 162, upper jaw;
cannot be removed by recontouring box 163, lower jaw). The following codes are
of the restoration. provided for this:
• A fracture of an existing restoration 0. No prosthesis.
that either causes it to be loose or 1. Bridge.
permits leakage into the dentine. 2. More than one bridge.
• Discoloration. 3. Partial denture.
Chapter 5.indd 112 11/5/2014 6:04:46 PM

4. Both bridge(s) and partial denture(s). reasons. Teeth should not be recorded as
5. Full removable denture. missing if spaces are closed, if a primary
9. Not recorded. tooth is still in position and its successor
has not yet erupted, or if a missing incisor,
Prosthetic Need (Boxes 164 And 165) canine or premolar teeth has been replaced
A recording should be made for each jaw on by a fixed prosthesis.
the perceived need for prosthesis (box 164, Crowding in the incisal segments (box
upper jaw; box 165, lower jaw), according to 168). Both the upper and lower incisal seg-
the following codes: ments should be examined for crowding.
0. No prosthesis needed. Crowding in the incisal segment is the con-
1. Need for one unit prosthesis (one tooth dition in which the available space between
replacement). the right and left canine teeth is insufficient
2. Need for multi-unit prosthesis (more to accommodate all four incisors in normal
than one tooth replacement). alignment. Teeth may be rotated or displaced
3. Need for a combination of one and/or out of alignment in the arch. Crowding in the
multi-unit prosthesis. incisal segments is recorded as follows:
4. Need for full prosthesis (replacement of 0. No crowding.
all teeth). 1. One segment crowded.
9. Not recorded. 2. Two segments crowded.
If there is any doubt, the lower scores
Dentofacial Anomalies (Boxes 166–176) should be assigned. Crowding should not
Dental aesthetic index (DAI) criteria (4) are be recorded if the four incisors are in proper
used. It is recommended that this index be alignment but either or both canines are
used for age groups in which there are no displaced.
longer primary teeth, usually from 12 years: Spacing in the incisal segments (box 169).
Missing incisor, canine and premolar Both the upper and lower incisal segments
teeth (boxes 166 and 167). The number of should be examined for spacing. When
missing permanent incisor, canine and measured in the incisal segment, spacing is
premolar teeth in the upper and lower arches the condition in which the amount of space
should be counted. This should be done by available between the right and left canine
counting the teeth present, starting at the teeth exceeds that required to accommodate
right second premolar and moving forward all four incisors in normal alignment. If one
to the left second premolar. There should or more incisor teeth have proximal surfaces
be 10 teeth present in each arch. If there are without any interdental contact, the segment
less than 10, the difference is the number is recorded as having space. The space from a
missing. The number of missing teeth in the recently exfoliated primary tooth should not
upper and lower arches should be recorded be recorded if it appears that the permanent
in (boxes 166 and 167) of the assessment replacement will soon erupt. Spacing in the
form (box 166, upper arch; box 167, lower incisal segments is recorded as follows:
arch). A history of all missing anterior teeth 0. No spacing.
should be obtained to determine whether 1. One segment spaced.
extractions were performed for aesthetic 2. Two segments spaced.
Chapter 5.indd 113 11/5/2014 6:04:46 PM

If there is any doubt the lower score arch is located and measured as described
should be assigned. before.
Diastema (Box 170): A midline diastema is Anterior maxillary overjet (Box 173): Meas-
defined as the space, in millimeters, be- urement of the horizontal relation of the
tween the two permanent maxillary inci- incisors is made with the teeth in centric oc-
sors at the normal position of the contact clusion. The distance from the labial-incisal
points. This measurement can be made at edge of the most prominent upper incisor to
any level between the mesial surfaces of the the labial surface of the corresponding sur-
central incisors and should be recorded to face of the corresponding lower incisor is
the nearest whole millimeter. measured with the CPI probe parallel to the
occlusal plane. The largest maxillary overjet
Largest anterior maxillary irregularity (Box 171):
is recorded to the nearest whole millimeter.
Irregularities may be either rotations out
Maxillary overjet should not be recorded if
of, or displacements from, normal align-
all the upper incisors are missing or in lin-
ment. The four incisors in the upper (maxil-
gual crossbite. If the incisors occlude edge
lary) arch should be examined to locate the
to edge, the score is zero.
greatest irregularity. The site of the great-
est irregularity between adjacent teeth is Anterior mandibular overjet (Box 174): Man-
measured using the CPI probe. The tip of dibular overjet is recorded when any
the probe is placed in contact with the la- lower incisors protruded anteriorly or lia-
bial surface of the most lingually displaced bally to the opposing upper incisor, i.e. is
or rotated incisor while the probe is held in crossbite. The largest mandibular over-
parallel to the occlusal plane and at right jet (mandibular protusion), or crossbite, is
angles to the normal line of the arch. The recorded to the nearest whole millimeter.
irregularity in millimeters can be estimated The measurement is the same as for ante-
from the markings on the probe. It should rior maxillary overjet. Mandibular overjet
be recorded to the nearest whole millimeter. should not be recorded is a lower incisor is
Irregularities may occur with or without rotated so that one part of the incisal edge
crowing. If there is sufficient space for is in crossbite (i.e. is labial to the upper inci-
all four incisors in normal alignment but sor) but another of the incisal edge is not.
some are rotated or displaced, the largest
irregularity is recorded as described before. Vertical anterior openbite (Box 175): If the
The segment should not be recorded is a lack of vertical overlap between any
as crowded. Irregularities on the distal of the opposing pairs of incisors (openbite),
surface of the lateral incisors should also be the amount of openbite is estimated using
considered, if present. the CPI probe. The largest openbite is re-
corded to the nearest whole millimeter.
Largest anterior mandibular irregularity (Box
172): The measurement is the same as on Anteroposterior molar relation (Box 176): This
the upper arch except that it is made on the assessment is most often based on the rela-
lower (mandibular) arch. The greatest irreg- tion of the permanent upper and lower first
ularity between adjacent teeth on the lower molars. If the assessment cannot be based
Chapter 5.indd 114 11/5/2014 6:04:46 PM

on the first molars because one or both are may vary from a few days to a month,
absent, not fully erupted, or misshapen be- depending on the availability of oral health
cause of the extensive decay or fillings, the services. Examples of conditions that require
relations of the permanent canines and pre- immediate attention include peripheral
molars are assessed. The right and left sides abscess and acute necrotizing ulcerative
are assessed with the teeth in occlusion and gingivitis. Gross caries and chronic alveolar
only the largest deviation from the normal abscesses may also be recorded.
molar relation is recorded. The following Three boxes are provided for the re-
codes are used: cording of the presence of the following
0. Normal. conditions:
1. Half cusp. The lower first molar is half a • A life threatening condition (oral cancer
cusp messial or distal to its normal rela- or precancerous lesions) or other severe
tion. condition with clear oral manifestation.
2. Full cusp. The lower first molar is on • Pain or infection that needs immediate
cusp or more mesial or distal to its nor- relief.
mal relation. • Other conditions, specify (box 179).
If the subject is referred for care, a “1”
should be recorded in box 180. The items
Need For Immediate Care and Referral coded in boxes 177–180 are not mutually
(Boxes 177–180) exclusive; several recordings may be made
It is the responsibility of the examiner or when more than one condition requiring
team leader to ensure that referral to an immediate attention is present.
appropriate care facility is made, if needed. Space is provided at the bottom of the
There is a need for immediate care if assessment form for the examiner/recorder
pain, infection or serious illness will result to note, for his or her own reference,
unless treatment is provided within a any additional information that might be
certain period of time. This period of time pertinent to the subject being examined.
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Chapter
6 Preventive Dentistry
PROFESSIONAL TOPICAL the first clinical study of NaF was carried

APPLICATION OF FLUORIDE out by Dr Basil G Bibby using Brockton,
Massachusetts, school children. Topically
Fluoridation of drinking water with one
applied fluorides are deposited on to the
part per million of fluoride has shown
surface of the tooth and they tend to provide
clearly impressive dental benefits. Water
local protection at or near the tooth surface.
fluoridation is probably accountable for more
At the time of tooth eruption, the
confrontation than any other public health
enamel is not yet completely calcified.
measures being used because; it clearly
After eruption of tooth, the calcification of
represents the most effective, efficient and
enamel continues in the post eruptive period,
economical of all known measures for the
approximately two years in length and the
prevention of dental caries. Unfortunately,
process is known as post eruptive enamel
no fluoridated water is available to the
maturation. During this period, there is a
population in our country wherever public continuous accumulation of fluoride as well
water system is present. Hence, it is obvious as other elements in the more superficial
that one of the additional measures like portions of enamel. This fluoride is derived
topical application of fluoride is needed from the saliva, dental plaque. Oral mucosa
for the dental profession to provide greater also serves as a reservoir for fluoride ions.
protection against caries to young children. During a cariogenic challenge, fluoride
The term topical fluoride therapy refers from these sources is mobilized to assist
to the use of systems containing relatively remineralization. Fluoride is also derived
large concentration of fluoride that are from the exposure of the teeth to fluoride
applied locally, topically to erupted tooth containing water and food.
surface to prevent the formation of dental
caries. Thus, this term encompasses the use How does the Topical Fluoride Act?
of— Most of the fluoride incorporated into
• Fluoride solution/thixotropic gel/foam enamel formation (i.e. systemic fluoride)
• Fluoride dentifrices and the posteruptive period of enamel
• Fluoride rinses maturation (i.e. topical fluoride). The
• Fluoride varnish continued deposition of fluoride into enamel
• Slow release system of fluoride. during the later stages of enamel formation
Efficient methods of fluoride therapy at and especially during the period of enamel
the individual level surfaced in 1941, when maturation, results in concentration gradient
Preventive Dentistry 117
of fluoride in enamel. In variably the highest can be markedly influence by a number of
accumulation of fluoride occurs at the very factors that include:
outer most portion of enamel surface with • Fluoride concentration
the fluoride content decreasing as one • pH of the solution
progresses inward into the dentin. • Length of exposure.
The presence of elevated concentration
For example: The use of acidic fluoride solu-
of fluoride in surface enamel serves to
tions greatly favor by the formation of CaF.
make the tooth surface more resistant to the
Neutral NaF solutions with fluoride
development of dental caries. Fluoride ions
concentrations of 100 ppm or less resulted
when substituted into the hydroxyapatite
primarily in the formation of fluorapatite,
crystals fit more perfectly into the crystal
while higher fluoride concentration
than do hydroxyl ions. This fact coupled
resulted in the formation of CaF. Since
with the greater bonding potential of fluoride
topical applications of NaF involve the
serves to make the apatite crystals more
use of 2% solution (slightly over 9000
compact and more stable. Such crystals are
ppm). Such solutions involved formation
there by more resistant to the acid dissolution
of CaF.
that occurs during caries initiation. This
effect is even more apparent as the pH of SnF2: The second fluoride compound
the enamel environment decreases due to developed for topical use during the 1950’s
momentary was of minute quantities of was stannous fluoride compared to that of
fluoride from the dissolving enamel and sodium fluoride, the reaction of stannous
its nearly simultaneous reprecipitation as a fluoride with enamel is unique in that both
fluorhydroxyapatite. the cation (stannous) and the anion (fluoride)
react chemically with enamel components.
NaF: It was initially postulated that the
The reaction is commonly depicted as
effectiveness of topically applied NaF was
follows:
due to the formation of fluorhydroxyapatite,
Ca10(PO4)6(OH)2+19SnF2 Þ 10CaF2 + 6Sn3F3PO4 + SnOH2O
subsequent investigations indicated that the
Hydro- Stan- Calcium Stannous Hydrated
primary reactions product involved in the xyapatite nous fluoride fluoro- tin
transformation of surface hydroxyapatite to fluoride phosphates oxide
CaF. Note from the equation that the formation
Ca10 (PO4)6 (OH)2 + 2 OF– Þ 10 CaF2 + 6 HPO4 + 2(OH)– of stannous fluorapatite prevents at least
Hydroxyapatite Calcium fluoride temporarily, the phosphate loss typical of
sodium fluoride applications. Incidentally
It can be noted from the preceding
the exact nature of the tin—containing
equation that the reaction involved the
reaction products is variable and depends
breakdown of the apatite crystals into its
upon reaction conditions including pH,
components followed by the reactions of
concentration and length of exposure (or
fluoride and Ca ions to form Ca fluoride with
reaction time).
a net loss of phosphate ions from treated
enamel. Newer fluoride systems incorporate APF: A third topical fluoride system was
a means to prevent such phosphate ion loss. developed during the 1960’s and is widely
The reaction of soluble fluoride and enamel known as APF (Acidulated Phosphate
Fluoride). This system was developed by 2. While the remainder is lost from the
Brudevold and co-workers in an effort to enamel surface to the dental plaque and
achieve: saliva.
• Greater amounts of fluorhydroxyapatite It is also recognized that the formation
• Lesser amounts of calcium fluoride of fluorhydroxyapatite in this manner is a
formation. relatively slow and inefficient process. Thus,
These workers reviewed the various the dissolution of calcium fluoride deposited
chemical reactions of fluoride with enamel on the enamel surface provides additional
(hydroxyapatite) and concluded that— fluoride ions, which becomes incorporated
• If the pH of the fluoride system were in maturing enamel.
made acidic to enhance the rate of
reaction of fluoride with hydroxyapatite. Repeated Series of
• If phosphoric acid were used as Four Fluoride Treatment
acidulated to increase the concentration
Repeating the fluoride treatment provided
of phosphate present at the reaction site.
It would be possible to obtain: essentially the same amount of fluoride
1. Greater amounts of fluoride deposited uptake, followed by a comparable fluoride
surface enamel as fluorhydroxyapatite. treatment. At the conclusion of fluoride
2. With minimum formation of calcium leaching period, an additional increase in
fluoride. the permanent fluoride content of the enamel
3. Minimal loss of enamel phosphate. surface was observed. Repeating this process
On the basis of this chemical reasoning, through a series of four fluoridated treatment
APF systems were developed and shown to resulted in an increase in the “permanent”
be more effective for caries prevention. The fluoride content of the enamel surface of
chemical reaction of APF with enamel may about 1300 ppm.
be written as follows: The cariostatic influence of topical fluo-
ride application may be due to that portion
Ca10 (PO4)6 (OH)2 + F– Þ 10CaF2 + Ca10 (PO4)6 (OH)2 F
of fluoride that is more or less permanently
Hydroxyapatite Calcium Fluorhydro-
fluoride xyapatite retained, rather than the transient surface
It is obvious from the preceding accumulation of calcium fluoride. It is also
discussion that the primary reaction product apparent that topical fluoride applications
with all three types of topical fluoride are relatively inefficient in that each treat-
systems (i.e. NaF, SnF2, APF) in the formation ment results in a rather small increase in
of calcium fluoride on the enamel surface. the amount of fluorhydroxyapatite in the
It has been suggested that the calcium superficial portion of enamel surface. Thus,
fluoride thus formed on the enamel surface it follows that maximal patient benefits can
following a topical fluoride application has only be derived from a repeated series of
two possible fates: applications. The original sodium fluoride
1. A portion of the initiated reaction prod- topical application procedure developed by
uct undergoes further reaction, resulting Knutson specified a series of four treatments
in the formation of fluorhydroxyapatite. during a 2-week period.
Topical Fluoride Therapy on 1. The ability of fluoride to inhibit
Incipient Caries Lesion glycolysis by interfering with the
The caries process begins with a demine- enzyme enolase has long been known
ralization of the apatite adjacent to the as concentration of fluoride as low as 50
crystal sheaths. This permits the diffusion ppm have been shown to interfere with
of weak acids into the subsurface enamel bacterial metabolism.
and since the surface enamel is less resistant 2. Moreover, fluoride may accumulate
to acid demineralization, it is preferentially in dental plaque in concentration
dissolved, forming an incipient subsurface above 100 ppm. Although the fluoride
lesion. As the process continues it becomes normally present in the plaque is
clinically apparent as a so called ‘white largely bound (and thus unavailable for
spot’ that in reality is a rather extensive antibacterial action), it will dissociate
subsurface lesion covered by a relatively to ionic fluoride when the pH of the
intact enamel surface. Thus enamel surface plaque decreases (i.e. when acids are
that clinically appear to be sound or free of formed). Thus, when caries process
demineralization frequently have areas that starts and acids are formed, plaque
have been slightly decalcified with minute fluoride in ionic form may serve to
subsurface lesions that are not yet detectable interfere with further acid production
clinically. This situation is particularly likely by plaque micro-organisms.
to exist in patients with clinical evidence of
3. In addition, it may react with the
caries activity on other teeth.
underlying layer of dissolving enamel,
It now appears that the predominant
promoting its remineralization as
mechanism of action of fluoride involves
fluorhydroxyapatite. The end result
its ability to facilitate the remineralization
of the process would be a physiologic
of these demineralized areas. Topically
restoration of the initial lesion (by
applied fluoride clearly diffuses into these
remineralization of enamel) and the
demineralized areas and reacts with calcium
and phosphates to form fluorhydroxyapatite formation of a more resistant enamel
in the remineralization process. It is also surface.
worthy to note that such remineralized 4. In addition to these possible effects
enamel is more resistant to subsequent of fluorides, several investigators
demineralization than was the original have reported that the presence of tin,
enamel. This process has been shown to especially as provided by stannous
occur with all forms and concentrations of fluoride is associated with significant
fluoride, including concentrations as low antibacterial activity that has been
as 1 ppm such as is found in optimally reported to decrease both the amount
fluoridated drinking water. of dental plaque and gingivitis.
In essence there are two procedures for
Topical Fluoride Therapy upon administering topical fluoride treatments.
Plaque and Bacterial Metabolism • One procedure: In brief involves the
The caries preventive action of fluoride may isolation of teeth and continuously
include an inhibitory effect upon the oral painting the solution onto the tooth
flora involved in the initiation of caries. surfaces.
• Second procedure: Currently more popu- Method of Application

lar, procedure involves the use of Essential armamentarium for application of
fluoride gels applied with a disposable fluoride solution consists of—
tray. • Cut cotton rolls
• Suitable cotton roll holders
KNUTSON TECHNIQUE: SODIUM • Cotton applicators
FLUORIDE 2% • Treatment solutions in plastic dispens-
ers.
1. Available in both powder and liquid
A thorough dental prophylaxis is done
form.
only in first visit and visit prior to the four
2. The compound is recommended for use topical application of fluoride. The presence
in a 2% concentration. of the pellicle and oral debris would reduce
3. Ready to use 2% solutions of sodium or interfere with the reaction of the fluoride
fluoride are commercially available. underlying enamel.
4. Sodium fluoride solutions are stable if
stored in plastic containers.
Isolation
5. Available fluoride is 9,200 ppm.
If a dental prophylaxis is performed, the
6. 29% effective in caries reduction.
patient is allowed to rinse thoroughly and
7. Milestone studies were done by Bobby
the cotton rolls and holders are positioned
and Dr John W Knutson in 1941, 1942,
so as to isolate the area to be treated. It is
1947, 1948 using various fluoride con-
a common practice when using fluoride
centrations and number of applications
solutions at one time so as to be able to treat
per year.
one half of the mouth simultaneously. The
8. The present preparation of sodium fluo-
isolated teeth are then dried with compressed
ride is developed by Knutson, which is
air, and the fluoride solution is applied using
referred to as Knutson’s technique. The
cotton applicators.
four applications are recommended
with weekly intervals. Application of Fluoride Solution
• The 2% NaF solution is applied using
Preparation of 2% NaF cotton applicator, care should be taken
• 20 gm of sodium fluoride dissolved in 1 to be certain that all the tooth surfaces
liter of distilled water to prepare 1 liter are treated. The application is per-
of neutral NaF. formed by nearly swabbing or painting
• It should be stored in plastic bottles the various tooth surfaces with cotton
because if stored in glass container, the applicator thoroughly moistened with
fluoride ions of solution react with silica fluoride solution. Once applied the
of glass forming SiF2, thus reducing the solution is kept wet and allowed to dry
availability of free active fluoride for on the tooth without reapplication for 4
anticaries action. minutes.
• At the conclusion of this period the CaF2 Þ Ca++ + F–
cotton rolls, holders are removed and Thus, calcium fluoride acts as a reservoir
the patient is allowed to expectorate for fluoride release. This fluoride is highly
and the process is repeated for the reactive and reacts with hydroxyapatite to
remaining quadrants. form fluoridated hydroxyapatite.
Advice to the Patient Disadvantages of Knutson Technique

• After the topical application has been 1. The patient has to make 4 visits to the
completed, the patient is advised not dentist within a short time (weekly
to rinse, drink, or eat for a period intervals for 4 weeks).
of 30 minutes so as to prolong the 2. The interval of up to 4 years between
availability of fluoride ion to react with series may be too long for maximal
tooth surface and significantly greater cariostatic protection.
fluoride deposition occurs. 3. The expected caries reduction is not
• Second, third and fourth applications satisfactory (20–25%).
are given at weekly intervals.
• A full series of four treatments is
STANNOUS FLUORIDE 8%
recommended at the age of 3, 7, 11, 13
(MUHLER’S TECHNIQUE)
years. These age groups were selected
depending on the eruption of deciduous • Available in powder form either in bulk
dentition, 1st permanent incisors and containers or preweighed capsules, also
molars, premolars and canines and 2nd available in gel and solution forms.
permanent molars respectively. • Stannous fluoride solutions are quite
acidic, with a pH of about 2.4 to 2.8.
Mechanism of Action • 19,500 ppm of available fluoride.
CaF10 (PO4)6 (OH)2 + 2NaF Þ 10CaF2 + 6HPO4 + 2OH • 32% effective in caries prevention.
Hydroxyapatite Calcium fluoride • Annual or biannual application.
When sodium fluoride is applied on the • Stannous fluoride solutions have a bitter
tooth surface there is rapid influx of fluoride metallic taste. To eliminate the need to
leading to the formations of calcium fluoride. prepare this solution from powder and
This is due to high concentration of fluoride to improve patient acceptance, a stable
(9200 ppm) in 2% NaF. The calcium fluoride flavored solution can be prepared
forms a thick layer on the tooth surface with glycerin and sorbitol to retard
blocking for the entry of fluoride ions. This hydrolysis of stannous fluoride and
phenomenon of sudden stoppage of the with any of a variety of compatible
entry of fluoride is termed as “choking of flavoring agents.
effect”. This is the reason why NaF once • Stannous fluoride is a compound
applied on tooth surface is left untouched to developed by Muhler (1947, 1950).
drive for 4 minutes. Later calcium fluoride • Dudding and Muhler in 1962 described
dissolves slowly in oral fluids and breaks the use of stannous fluoride and 8–10%
down into calcium and fluoride ions. This was tested and found to be effective,
leached out fluoride is free ionic form. which is reported as Muhler’s technique.
Method of Preparation Mechanism of Action

It has to be freshly prepared before use Muhler reported thus when SnF2 react with
each time as it has a short shelf life and also hydroxyapatite in addition to fluoride,
it is chemically highly unstable. Aqueous tin of SnF 2 also reacts with enamel and
solutions of stannous fluoride are not a new crystalline product gets formed
stable due to the formation of stannous which is different from fluorapatite and
hydroxide and subsequent stannic oxide, this new compound which is stannous
which is visible as a white precipitate and trifluorophosphate makes the tooth structure
not effective. stable and less susceptible to acid dissolution
It is convenient to prepare gelatin cap- and is more resistant to decay than enamel.
sules filled with 0.8 gm or 1gm of powdered It is due to this reason that always a
stannous fluoride and are stored in air tight freshly prepared SnF2 solution should be
plastic containers just before application. The used and the capsules of SnF2 should be
content of the capsule is dissolved in 10 mL of kept away in air tight containers, otherwise
distilled water in a plastic container to get 8 the stannous form of tin gets oxidized to
to 10% SnF2 respectively. The solution is thus stannic form, thus making the SnF2 inactive
prepared is shaken briskly. The solution is for anticaries action.
then applied immediately to the teeth. The The infrared absorption and X-ray
10 mL solution should be sufficient to treat diffraction analysis of the reaction of both
the whole mouth of a single patient. If any of the cations (stannous) and anions (fluoride)
SnF2 solution remains, it should be discarded of SnF2 with hydroxyapatite crystals shows
and not used again. that mainly 4 end products get formed as
follows.
Method of Application a. Low concentrations of SnF2 when reacts
with hydroxyapatite crystals form
• Perform thorough oral prophylaxis and
stannous hydroxyphosphate Sn2(OH)
isolation is followed by quadrant wise
PO4.
application using cotton rolls.
Ca 5 (PO 4) 3 OH + 2 SnF 2 Þ 2CaF 2 + Sn 2 (OH)
• Dry the teeth and keep the quadrant
PO4+Ca3 (POH)2
free from saliva by use of saliva ejector.
• Apply SnF2 solution continuously for b. High concentrations of SnF2 when re-
4 minutes. The SnF2 solution should acts with hydroxyapatite crystals form
be applied repeatedly so that the teeth calcium triphosphate along with stan-
are kept moist by reapplication with nous trifluorophosphate (main product).
solution for every 15 to 30 seconds for 4 Ca5 (PO4)3 OH + 2SnF2 Þ 2CaF2 + 2Sn3 F3 PO4 +
minutes. Sn2 (OH) PO4 + 4 CaF2 (SnF3)
• Tell the patient to expectorate the Note:
residual fluoride and instructed not to 1. Formation of stannous fluorophos-
eat, drink or rinse for 30 minutes. phates, prevents at least temporarily the
• It is found that significantly greater phosphate loss which is typical of NaF
fluoride deposition occurred when the application.
patients were not permitted to rinse, eat 2. CaF2 in low quantity is the end product
or drink following fluoride treatment. both in low and high concentrations
and when formed further reacts with concentration of tin complexes and
hydroxyapatite and forms fluoridated appear to be more calcified following the
hydroxyapatite. application of stannous fluoride. This
3. Stannous hydroxyapatite formed pigmentation has thus been suggested
gets dissolved in oral fluids and is as being indicative of the arrestment of
responsible for the metallic taste. incipient carious lesion and in typically
retained for 6 to 12 months or longer.
Advantages 4. Children do not like the taste because
1. Since, it is applied annually or biannually, of SnF2 has a metallic taste (astringent
avoids frequent visits to dentists. taste).
2. It is very potent and effective topical 5. SnF 2 when comes in contact with
fluoride application. gingival causes blanching and burning
3. It is very useful for spot application sensation due to astringent property
among patients with nursing bottle (gingival tissue irritation).
caries and rampant caries. 6. Not economical.
4. Stable stannous fluoride gel is recom-
mended in cases of radiation caries ACIDULATED PHOSPHATE FLUORIDE
(cervical) among patients under radia- (APF): BRUDEVOLD’S TECHNIQUE
tion therapy for consensus of hand and • 1.23% is used
neck. • 12,300 ppm of available fluoride
5. SnF2 reduces caries by 25 to 30%. • 3.0 pH
• 30–40% effective in caries reduction.
Disadvantages
1. SnF2 undergoes rapid oxidation, hence Critical Appraisal of APF as a
chemically unstable and difficult to Cariostatic Agent
store. The idea of acidulated phosphate fluoride
2. It makes more chair side time, because as a topical agent in the prevention of dental
it is unstable, it requires instant caries emerged with the in vitro investigation
preparation just prior to the application. of Bibby, who reported that as the pH of
3. Pigmentation of teeth after application the NaF solution was lowered, the fluoride
of SnF2 and brown discoloration can was absorbed into enamel more effectively.
occur on demineralized enamel and This statement of Bibby, had its inherent
anterior restoration, due to the greatest limitations as indiscriminate lowering of pH
accumulation of stannous complexes of NaF solution will cause decalcification
occurs in circumscribed areas of and demineralization of the enamel thus
enamel defects; typically such areas are obviating the fluoride effect.
hypomineralized and are frequently Brudevold and his co-workers did
the result of decalcification associated systemic investigations in 1963 to find out
with the initiation of caries process. an optimum acid concentration to provide
Clinically these areas of enamel defects maximal fluoride deposition while causing
which have been described as incipient minimal enamel demineralization and
carious areas become pigmented also found adding phosphate provided
presumably due to the presence of high maximum benefit.
Thus, the APF solution was developed • Another form of APF for topical
in an effort to achieve greater amounts of application namely thixotropic gels has
fluoridated hydroxyapatite (FHA) and lesser recently become available.
amounts of calcium fluoride (CaF2) formation.
It was acidulated with orthophosphoric acid Thixotropic Gels
and buffered to a pH of approximately 3. The term thixotropic denotes a solution
that sets in a gel like state but is not a true
Brudevold’s APF Solution Composition
gel. Upon the application of pressure, the
The APF solution usually contains of 1.23% thixotropic gels behave like solutions, it has
NaF2 in 0.1 M phosphoric acid at pH of 3.0. been suggested that these preparations are
It is stable with long shelf life when stored more easily forced into the interproximal
in opaque plastic bottles. spaces without dripping compared to
conventional gels. The active fluoride system
Practical Difficulties in Topical
in thixotropic gels is identical to conventional
Application of APF Solution
APF solutions. These preparations have been
1. Teeth must be kept wet with APF approved by the American Dental Association.
solution for 4 minutes.
2. Since APF solution is acidic and sour, Method of Preparation
bitter in taste so repeated application
Acidulated phosphate fluoride contains
necessitates the use of suction thereby
1.23% of NaF in 0.1 M phosphoric acid at pH
minimizing its use in field programs.
of 3.0 It is prepared by dissolving 20 gm of
3. This also made multiple chair programs
NaF in 1 liter of 0.1 M phosphoric acid and to
by one dentist or auxiliary difficult
this add 50% hydrofluoric acid to adjust the
thereby increasing the chair side
pH at 3.0 and fluoride concentration at 1.23%.
time and making this APF solution
Depending upon the requirement, APF
application program more expensive.
solution is also prepared by dissolving 2 gm
To overcome these practical difficulties
of NaF in 10 mL of 0.1 M phosphoric acid. To
and problems of APF solutions, APF gels
this 50% hydrofluoric acid is added to adjust
were introduced.
the pH at 3.0 and fluoride concentration at
Acidulated phosphate fluoride (APF) Gels/ 1.23%.
Foam For the preparation of APF gels, gelling
agent methylcellulose or hydroxyethyl
• Easier to work with—
cellulose is to be added to the solution and
• Since the gel fluoride comes in constant
the pH is to be adjusted between 4 to 5.
contact with teeth, reapplication is not
required.
• Permits application in trays—entire Method of Application
dentition can be treated at one time. • Oral prophylaxis and isolation is done
• As it is possible to do self application, first.
the cost of application also gets reduced. • APF solution is applied continuously
• APF gels contain cellulose compound with the cotton applicator on the teeth
for viscosity, e.g. methylcellulose or and the teeth are kept moist for 4
hydroxy-ethylcellulose. minutes.
• T h e A P F s o l u t i o n s a r e a p p l i e d Measured gel in tray: Not more than 2 mL of
semiannually or biannually. gel is placed in each tray for small children,
and no more than 5 mL is placed in each tray
Acidulated Phosphate Fluoride: Fluoride for adults (Figure 6.2).
Gel Application Note: A medicine cup can be used to measure
the amount of once so that the correct
In case of gel application, disposable trays of
level of gel in the tray can be determined.
various sizes are used. The use of plastic trays
A minimum amount of gel is indicated to
has been suggested as a more convenient
prevent ingestion by the patient.
procedure. Many different types of trays
If medicine cup is not available, trays
are available in the market. Selection of
are filled to 1/3 rd to 1/4 th its height. The tray
tray adequate for the individual patient is
is then placed in the mouth and the flanges
an important part of the technique. Most
are pressed against the tooth surface.
brands of trays offer different sizes so as to
1. Excess fluoride is removed with saliva
fit patients of different ages. An adequate
ejector.
tray should cover all the patients’ dentition, 2. Lower arch is done first followed by
it should also have enough depth to reach the upper arch. It is then removed and
beyond the neck of the teeth and contact discarded. Fluoride on the tooth surface
the alveolar mucosa to prevent saliva from is removed by saliva ejector or asking
diluting the fluoride gel. the patient to spit the excess.
At present disposable soft styrofoam 3. Patient is not allowed to wash his
trays are available and seem to be adequate. mouth. Rubbing with cotton is avoided
These trays can be bent to insert in the for removal of excess fluoride from the
mouth and are soft enough to produce no surface.
discomfort when they reach the soft tissues. 4. Instructions are given to the patient
With these trays, as well as with some of the which includes:
previous types of trays, it is possible to treat i. Not to drink any liquid food for at
both arches simultaneously (Figure 6.1). least 30 minutes.
Some of the early trays contained a ii. Not to eat any solid food for one
sponge like material that squeezed the gel hour.
against the teeth when the patient was asked iii. To report immediately if any symp-
to bite lightly or simulate a chewing motion toms of acute toxicity is noticed.
after trays were inserted.
Mechanism of Action of Acidulated
Tray Application Technique: Professional Phosphate Fluoride
Application of APF Gel Brudevold and his co-workers reported
1. Patient and the parents should be that the enamel acquired larger amounts of
explained regarding the benefits and fluoride with deeper penetration when pre-
risks of topical fluorides. treated with dilute phosphoric acid before
2. Patient is made to sit upright on the being exposed to fluoride solution.
dental chair so that the saliva and excess The further reported that when APF
fluoride is not accidentally swallowed. solution is applied to teeth, initially it leads
3. Saliva ejector is held in place to remove to dehydration and shrinkage in the volume
excess fluoride and saliva (Figure 6.1). of hydroxyapatite crystals which further on
A B
C D
E
Figures 6.1A to E: Tray selection
hydrolysis forms an intermediate product

called Dicalcium phosphate dihydrate
(DCPD). The DCPD is highly reactive with
fluoride, penetrate into the crystals more
deeply through the opening produced
by shrinkage and leads to formation of
fluorapatite (FAP).
Ca10 (PO4)6 + NaF Þ CaHPO4⋅2H2O
CaHPO4⋅2H2O + F Þ Ca5 (PO4)3 F + HPO4
The amount and depth of fluoride

deposited as fluorapatite (FAP) depends on
the amount and depth at which DCPD gets
formed into FAP. Since for the conversion of
whole of DCPD formed into FAP, continuous
supply of fluoride is required, hence APF
solution has to be applied every 30 seconds
and the teeth are kept wet for 4 minutes.
Figure 6.2: Measured gel in tray. No more than 2 mL Advantages

of gel is placed in each tray for small children and no
more than 5 mL for adults. A medicine cup can be used 1. Tissue compatibility.
to measure the correct amount 2. Semiannual or annual application.
3. Chemically stable and can be stored for Indication for Professional Topical
ready use. Fluoride Application (Patient at Risk of
4. Does not produce staining of enamel. Dental Caries)
5. They are available in different flavoring 1. Primary teeth (varnish only)
agents with acceptable taste. Infant/child—prevention of early
6. Expected caries reduction is about 30 to childhood caries, lack of parental oral
40% (better than NaF and SnF2). care; parental caries pattern.
7. APF gels can be recommended for tray
2. Post eruptive period
technique self home application.
Rapid uptake of fluoride important for
newly exposed enamel.
Disadvantages 3. Active caries (new carious lesions at
1. Acidic regular intervals).
2. When stored in glass container, etches 4. Secondary/recurrent caries adjacent to
the glass previous restorations.
3. Prolonged exposure to composite or 5. Wearing orthodontic appliances bands
porcelain results in loss of surface bonded brackets.
material and unaesthetic appearance 6. Compromised salivary flow.
The hydrofluoride component of APF Radiation therapy to head and neck,
dissolves the filler particles of the Sjogrens’ syndrome or other conditions
composite resin restorations that limit salivary secretion by the
4. Macroinorganic filler particles to glands medication with side effect of
composite materials demonstrate xerostomia.
noticeable etched patterns generated 7. Natural teeth supporting an overden-
by APF, where more recent microfilled ture.
particles are not sensitive to APF agent. 8. Exposed root surfaces following peri-
odontal recession.
Precautions for Professional Topical 9. Lack of compliance and conscientious
Application of Fluorides efforts for daily dental biofilm removal.
Precautions that should be undertaken 10. Low or no fluoride in drinking water.
by dental professional during topical 11. Early carious lesion.
application of fluoride include: 12. Pit and fissure restored with sealant
1. The use of only required amount of require topical fluoride for all other
fluoride solution or gel to adequately proximal surfaces.
perform the treatment.
2. Positioning the patient in an upright
FLUORIDE VARNISHES
position.
3. Using effective saliva aspirators or • First developed in Europe (1964) by
suctioning apparatus. Schmidt (Figure 6.3).
4. Requiring the patient to expectorate • Main advantage of varnish is that it
thoroughly upon completion of the increases the time the fluoride is in
fluoride application. contact with the tooth.
Indications Note: Fluorprotector contains low fluoride,

• Handicapped children. but the fluoride deposited in enamel is twice
• Incipient caries lesion. more than the duraphat but has low caries
• After restorative treatment is complete inhibition. This is due to: silane fluoride
under general anesthesia. + water = hydrofluoric acid = fluoride
• Very young children who cannot expec- penetrates readily and forms tags 0.5–1.0/
mm long, leading to increased fluoride
torate the gel or foam.
concentration. But this prevents further
Commonly used fluoride varnishes are:
fluoride penetration thus reducing anticaries
1. Duraphat
effect.
2. Fluorprotector
3. Carex.
Steps Involved in the Application of Varnish
Duraphat 1. Prophylaxis.
2. Isolation required is very minimum. It is
• 2.26% NaF in organic lacquer
sufficient to just remove the thick mucus
• 22,600 ppm fluoride
coat on the tooth surface. Isolation is not
• Hardens into a yellowish brown coating
done with cotton as it tends to stick
in the presence of saliva.
to the varnish and presence of mild
moisture tends to hasten the setting of
Fluorprotector
the varnish.
• 0.7% difluorosilane in polyurethane 3. Varnish is applied with single tufted
lacquer small brush (Figure 6.4).
• 7,000 ppm of fluoride. 4. Application done first on lower arch.
5. After application, the patient is asked
Carex to keep the mouth open till the varnish
Contains lower fluoride concentration than dries.
duraphat (1.8%) but anticaries effect is 6. Patient is instructed not to rinse or drink
equivalent to duraphat. for 1 hour.
Figure 6.3: Fluoride varnish Figure 6.4: Application of varnish

Topical fluoride can be used routinely for i. Nausea, vomiting, diarrhea
any child but some definite indications are: ii. Abdominal pain
• Caries active individuals iii. Increased salivation, thirst.
• Children shortly after periods of tooth 2. Systemic Involvements:
eruption i. Blood: Calcium may be bound by the
• Individuals who are on salivary flow circulating fluoride, thus causing
reducing medications symptoms of hypocalcemia.
• Individuals with disease that decrease ii. Central nervous system: Hyperreflexia,
salivary flow convulsions, paresthesias.
• Patients after periodontal surgery, iii. Cardiovascular and respiratory
when roots are exposed depression: If not treated, may lead
• Individuals with eating disorder to death in a few hours from cardiac
• Mentally and physically challenged failure or respiratory paralysis.
individuals.
Emergency Treatment
TOXICITY OF FLUORIDE 1. Induce vomiting
i. Mechanical: Digital stimulation at
Acute toxicity of fluoride refers to rapid intake back of tongue or in throat
of an excess dose over a short time. ii. Drug: Ipecac syrup
Chronic toxicity applies to long term 2. Call emergency service, transport to
ingestion of fluoride in amounts that exceed hospital
the approved therapeutic levels. 3. Administer fluoride binding liquid
Accidental ingestion of a concentrated when patient is not vomiting:
fluoride preparation can lead to toxic i. Milk
reaction. ii. Milk of magnesia
Acute fluoride poisoning is rare. iii. Lime water.
Certainly lethal dose (CLD): A lethal dose 4. Support respiration and circulation
is the amount of a drug likely to cause death 5. Additional therapy indicated at emer-
if not intercepted by antidotal therapy. gency room
CLD = adult: 5–10g NaF or i. Calcium gluconate for muscle
child 32–64 mg F/kg tremors or tetany
Safely tolerated dose (STD) = ¼ th of CLD; ii. Gastric lavage
adult: 1.25–2.5g NaF or 8–16 mg child. iii. Cardiac monitoring
iv. Endotracheal intubation
Signs and Symptoms of Acute Toxic Dose v. Blood monitoring
Symptoms begin within 30 minutes of vi. Intravenous feeding to restore blood
ingestion and may persist for as long as 24 volume, calcium.
hours.
1. Gastrointestinal tract: Fluoride in stomach Chronic Toxicity
is acted on by the hydrochloric acid to 1. Skeletal fluorosis: Instances of osteoscle-
form hydrofluoric acid, an irritant to the rosis result from chronic toxicity after
stomach lining. Symptoms include: long-term (20 or more years) use of
fluoridated water with 10–25 ppm or In addition, the dentist is provided

from industrial exposure. an opportunity to educate both parents
2. Dental fluorosis: Naturally occurring and children about the preventive
excess fluoride in drinking water can practices applicable to minimize the
produce visible fluorosis only when caries experience for the child and
used during the years of development adolescent.
of crowns of teeth namely, from birth 3. In developed countries, the group
until age 12 or 16 years or when the dental insurance programs that include
crowns of the third permanent molars expanded preventive and restorative
are completed. dental care for young children are now
common.
The availability of such programs has
PIT AND FISSURE SEALANTS removed some of the financial burden
(The Acid Etch Technique in Caries for children dental care in both urban
Prevention Sealants) and rural communities.
Introduction 4. The increase in dental man power and
As part of a complete preventive program, availability has allowed easy access
pit and fissure sealants are indicated for to state-of-the-art dental care in both
related patients. The prime area of concern urban and rural communities.
has been related to reducing the incidence 5. The interest of the dental profession in
preventive dentistry has increased as the
and prevalence of caries occurring on
beneficial effects of preventive regimens
smooth surfaces, because fluorides are highly
on dental disease have become evident
effective in reducing the number of carious
and scientific and clinical bases of thee
lesions occurring on smooth surfaces of
regimens have been demonstrated.
enamel and cementum.
A method to reduce the incidence of
The number of surveys and studies has
occlusal caries is needed. Unfortunately
shown dramatic reduction in dental caries
fluorides are not equally effective in
incidence and prevalence in pediatric and
protecting the occlusal pits and fissures,
adolescents groups with respect to smooth
where two thirds of all carious lesions occur.
surfaces. This significant change in the caries
The pit and fissures are approximately
status of children and adolescents are due to
eight times as vulnerable as the smooth
many factors:
surfaces. The incidence of new pit and fissure
1. This generation of children may have
caries can be lowered significantly by the
beneficial from the optimal use of both
application of adhesive sealants. Sealants
systemic and topical fluorides.
application is a part of a complete preventive
2. Parents have become increasingly
program, not an isolated procedure.
aware of the importance and need for
both preventive and restorative routine
dental care for their young children. Why Pit and Fissure are
Thus, parents bring their children More Susceptible to Caries?
to the dentist at an earlier age when The susceptibility to caries on tooth surfaces
perhaps only preventive measures or containing pits and fissures is related to the
minimal restorative procedures are form and depth of these pits and fissures, i.e.
indicated. pit and fissure anatomy.
Pit and Fissure Anatomy in general, the “typical” premolar has a
A review of the anatomy of pits and fissures prominent primary fissure with usually three
any be helpful in understanding the unique to four pits.
process of caries formation in pits and
fissure and also the effects of sealants in the A Unique Process of Caries Formation in
prevention of dental caries. The shape and Pits and Fissures
depth of pits and fissures vary considerably At one time, caries formation in fissures
even within one tooth. was thought to begin at the base of the
Because of the interest in caries formation fissure, involving the deeper aspect of the
in these pits and fissures, two main types of underlying tooth structure before the walls
pits and fissures are usually described. and cuspal inclines of the fissure become
1. Shallow, wide V-shaped or narrow involved by the caries process.
V-shaped fissures that tend to be self This process was expected because the
cleansing and caries resistant areas. fissure extended into the tooth surface for a
2. Deep, narrow I-shaped fissures, it is of considerable depth.
two types: However such is not the case.
i. Long narrow quite constricted pits • Rather the inclines forming the walls
and grooves reach to or nearly to the of the fissures are affected first by the
dentinoenamel junction. caries process.
ii. Long constricted form with a • The histological evidence of lesion
bulbous terminal portion, may formation occurs at the orifice of the
resemble a bottle-neck in that the fissure and is usually represented by
fissure may have an extremely two independent bilateral lesions in the
narrow slit-like opening with longer enamel composing the opposing cuspal
bone as it extends towards the inclines.
dentinoenamel junction. • As the lesion progresses, the depth of
These caries susceptible, I-shaped the fissure walls become involved and
fissures may also have a number of different coalescence of the two independent
branches. The typical fissure usually contains lesions into a single contiguous lesion
an organic plug composed of reduced occurs at the base of the fissure.
enamel epithelium, micro organisms forming • The enamel at the base of the fissure is
a dental plaque and oral debris. affected to a greater degree than that
The fissure provides a protected niche of the cuspal inclines and the lesion
for plaque accumulation. The rapidity with spreads laterally along the enamel
which dental caries occur in pits and fissures adjacent to the depth of the fissure and
is most likely related to the fact that the depth readily towards the dentinoenamel
of the fissures are in close proximity to the junction.
dentinoenamel junction and the underlying • Once the caries process involves the
dentin, which is highly susceptible to caries. dentin, the progress of the lesion is
The morphology of occlusal surfaces enhanced because caries susceptibility
varies from one tooth to the next and of dentin is increased compared with
from individual to individual. However, enamel.
• Eventually, cavitation of the fissure required for dentinal involvement to

occurs owing to loss of mineral and occur.
structural support from the adjacent • During this time period, remin-
enamel and dentin, resulting in a eralization of the smooth surface lesion
clinically detectable lesion. following exposure to fluoride agents
• The unique process of caries formation may occur, resulting in the arrest or
in pits and fissures is due to the presence reversal of the lesion.
of an organic plug in the fissure, this • When pits and fissures are present
organic plug acts as a buffer against on smooth surfaces, the pattern of
the acid by-products of plaque and involvement is identical to that seen
provides lessened acid attack at the on occlusal surfaces, and progression of
fissural base during the initial phase of the lesion to a clinically detectable level
caries formation. appears to be related to the lessened
thickness of the enamel present and
Why Fluoride is Less Efective in the morphologic form of the pit and
Preventing Caries in Pits and Fissures? fissures.
Although systemic and topical fluoride use
has been shown to be highly effective in Historical Perspective
prevention of caries on smooth surfaces, The placement of cement in pits and fissures
enamel surfaces with pits and fissures to prevent caries was reported by Wilson
receive minimal caries protection from either in 1895. During the 1920’s two different
systemic or topical fluoride agents. clinical techniques were introduces in an
• The reason why fluoride is less effective attempt to reduce the extent and severity of
in preventing caries in fissured surfaces, pit and fissure caries in occlusal and smooth
may be related to the total depth of surfaces.
enamel on smooth surfaces compared • In 1924, Thaddeus Hyatt advocated
with that underlying the fissures. prophylactic restorations. This
• On smooth surfaces, at least 1 mm procedure consisted of preparing a
of enamel is found superficial to the conservative class I cavity that included
dentinoenamel junction. all pits and fissures at risk for caries
• In contrast, the base of a fissure or pit development and then placing an
may be relatively close to or lie within amalgam restoration, the rationale for
the dentin. prophylactic restoration of an otherwise
• When caries develop in a fissure, the caries free surface was that—
underlying dentin becomes involved – The procedure prevented further
rapidly, resulting in a frank clinically insult to the pulp from caries.
detectable lesion. – Decreased loss of tooth structure.
• When caries formation occurs in enamel – Required less time for restoration
on a smooth surface, a considerable when the tooth eventually suc-
amount of enamel must become cumbed to caries.
involved before the dentin is involved; • In 1929, Bodecker presented a more
it is thought that 3 or 4 years may be conservative approach to prevention
of pit and fissure lesion. Initially, he the retention of restorative materials and
educated cleaning the fissure with improves marginal intergrity considerably.
an explorer and flowing a thin mix The initial studies evaluating the effects of
of oxyphosphate cement into the acid-etching on enamel were performed by
fissure-essentially an attempt to “seal” Buonocore in 1955. The sealants materials
the fissure. Later, he introduced an that utilized the acid-etch technique
alternative method for caries prevention. was introduced in mid 1960 and was a
The “prophylactic odontotomy” which cyanoacrylate substance; cyanoacrylates
involved mechanical eradication of were not suitable as sealants materials owing
fissure in order to transform deep, to bacterial degradation of the material in the
retentive fissures into cleansable ones. oral cavity over time. The cyanoacrylates not
• Three different kinds of plastic have recommended for routine use in dentistry
been used as occlusal sealants: because formaldehyde was formed as a part
– Polyurethanes of their biodegradation in the oral fluids.
– Cyanoacrylates
– Bisphenol A-glycidyl methacrylate
(BIS-GMA).
Bisphenol A-Glycidyl
Methacrylate (BIS-GMA)
Polyurethanes By the late 1960 a number of different resin
– They were among the first to appear on materials had been tested and a viscous
the commercial market. resin was forms to resistant to degradation
– They provided to be too soft and totally and produced a tenacious bond with etched
disinter prated in the mouth after 2–3 enamel. This resin was formed by reacting
months. bisphenol a with glycidlyl methylacrylate
– Despite this problem, their use was and this class of dimethacrylate resins has
continued for a period of time; not as a become known as BIS-GMA. It is now the
sealant but as a vehicle with which to sealant of choice. It is a mixture of BIS-GMA
apply fluoride to the teeth. and methyl methacrylate.
– The fluoride was mixed with the poly- BIS-GMA is a relatively large epoxy resin
urethane and then painted over all like hybrid monomer in which epoxy groups
surfaces of the teeth; the plastic adhered are replaced by methacrylate groups. BIS-
to the tooth, fluoride continuously GMA incorporates the rapid polymerization
leached out to increase the concentration characteristic of methyl methacrylate with
of fluoride in the enamel. the minimal polymerization shrinkage
– This technique has been superceded property of epoxy resins.
by use of fluoride varnishes, which are The vast majority of restorative resins
easier to apply. are based on the BIS-GMA formulation.
They differ from sealants in that restorative
Cyanoacrylates resin materials include filler particles such
The developmental of pit and fissure sealants as quartz, glass and porcelain to improve
was based on the discovery that etching their strength, where as the majority of
enamel with phosphoric aid increased sealants either are unfilled BIS-GMA or have
relatively few filler particles contain up to • The potential for retained damage with
50% filler particles in an attempt to improve long term exposure to ultraviolet light,
wear resistance. this method of curing sealants was
abandoned.
Polymineralization of the Sealants In its place, photoactivation of seal-
ant material with a visible light was
The liquid plastic is called the monomer.
introduced.
When the monomer is acted upon by the
In the manufacture of the current photo-
catalyst, repenting chemical bonds, begin
activated or visible blue sealant–activated
to form, increasing number and complexity
resins use a catalyst a diketone initiator that
as the hardening process (polymerization)
is sensitive to these light frequencies, such as
proceeds, finally, the resultant hard product
camphorquinones is places in the monomer
is known as a polymer.
at the time of manufacture and a reducing
BIS-GMA sealants differ in the ways
agent such as a tertiary amine to initiate
in which the material as polymerized. Two
polymerization. This photoinitiator system
methods have been employed to catalyze
is quite sensitive to light in the blue region
polymerization:
of the centered around 480 nm.
1. Autopolymerization (chemically cured)
Note: Use of visible light sources requires
systems involving mixing two liquids, a
eye protection due to the intensity of the
base resin (monomer) and catalyst res-
light created.
ins. The material sets by an exothermic
reaction, usually within 1–2 minutes. Important: With the auto polymerizing
Synonyms: Cold cure, self curing, sealants, the catalyst is incorporated with the
chemical activation. monomer; in addition, another bottle contains
2. Photoactivated (visible light cured) an initiator– usually benzyl peroxide. When
polymerization is currently the most the monomer and the initiator are mixed,
popular method used for curing sealants. polymerization begins.
Why Ultraviolet Light Curing Sealants Benefits of Light Cured

Abandoned? Chemical Cured
The two original caulk products, Nuva- • The sealant material sets in 10 to 20
seal and Niva-cote, were the only sealants seconds. Thus, polymerization time is
in the United States requiring ultraviolet shorter with the photocured sealants
for activation. They have been replaces by than with the self cured sealants.
other light cured sealants that require visible • No mixing of resins is required, elimi-
blue light. nating the incorporation of air bubbles
During the 1970’s and early 1980’s that may occur with chemical cured
ultraviolet light with a wavelength of 365 materials.
nm was used to initiate setting reaction. • The viscosity of the sealant remains
however, due to— constant during infiltration of the
• The inconsistency of the wavelength etched enamel pores and the sealant
from the ultraviolet light sources. does not set until it is light-activated.
• The main advantage of the photo cured • In particular, the argon laser produces
sealant is that the operator can initiate a visible blue green light beam with a
polymerization at any suitable time. monochromatic wavelength similar to
• The light cured sealants require the that used with visible light sources.
purchase of a light source, which adds • The laser light beam also exhibits
the cost of the visible light unit. coherence and may be collimated and
• When using a photocured sealant in focused to a small spot size.
the office, it is prudent to shield it
from bright office lighting, which can Advantages
sometimes initiate polymerization. i. A further reduction in the setting time.
• Conversely, the self-cured resins do ii. Control over specific radiation energy,
not require an expensive light source, wavelength and area of exposure.
however, they do not have the great iii. A decrease in the percentage of unpo-
disadvantage that once mixing has lymerized resin composed with conven-
commenced, the operator must either tional visible light curing.
continue under adverse conditioned iv. Resin materials exposed to the laser have
or stop and make a new mix if some increased tensile and bond strengths.
minor problems is experienced in the v. Based enamel has increased resistance
operating filed. to cariogenic challenger.
• For the autopolymerizing resins, the
time allows for sealant manipulation Disadvantages
and placement must not be exceeded,
i. Using of a laser for curing resin, materi-
even though the material might still
als are the cost of the instruments itself.
appear liquid.
ii. Need for adequate training in lower
• Once the hardening begins, it occurs
operation and safety techniques.
very rapidly and any manipulation of
the material during this critical time How Sealants Work?
jeopardizes retention.
• The light sealants have a higher Definition: A pit and fissure sealant in an
compressive strength and a smoother organic polymer (resin) that flows into the
surface, this is probably due to the face pits or fissure and bonds to the enamel sur-
that air is introduced into the self cure face mainly by mechanical retention when
resins during mixing, despite the above the acid etch process preceeds the applica-
differences, both the photocured and tion of the sealant material.
the autopolymerizing giving products
Action
appear to be equal in retention.
1. Purpose of the sealant
i. To provide a physical barrier to
Laser-Curing of Visible Light-Activated “seal off” the pit and fissure.
Sealant Resin Materials ii. To prevent oral bacteria and their
• Laser-curing of visible light-activated nutrients from collecting within
sealant and resin materials has been the pit or fissure to create the acid
advocated by Blan Kenan and Waterman environment necessary for the
in 1991. Kelrey and Powell in 1989. initiation of dental caries.
iii. To fill the pit and fissure as deep as etching time for either primary or
possible and provide tight smooth permanent teeth.
margins at the junction with enamel
surfaces. Microporosity
iv. When sealant material is worn or • Acid etching of surface enamel has been
cracked away on the surface around shown to produce a certain degree of
the pit and fissure the sealant in the porosity.
depth of the micropore can remain • Infact, sound enamel etched with
and provide continued protection phosphoric acid is affected at three
while sealant material is added for levels microscopically.
repair and to reseal the enamel/
First Level: A Narrow Zone of Enamel is
sealant junction.
Removed by Etching
2. Purpose of acid Etch
i. T o p r o d u c e i r r e g u l a r i t i e s o r • In this manner plaque, surface and sub-
micropore in the enamel surface organic pellicles are effectively
ii. To allow the liquid resin to penetrate dissolved.
into the micropores and create a • Fully reacted, inert, mineral crystals in
bond or mechanical locking. the surface enamel are also removed
resulting in—
The Acid Etch Technique—“Scientific Basis” – A more reactive surface
“Phosphoric Acid” – An increase in surface area
1. The initial studies of acid etching of – A reduced surface tension that
surface enamel used a solution of 85% allows resin to wet the etched
phosphoric acid. enamel more readily.
2. Since 1950’s a considerable number of The etched zone is approximately 10 µm
laboratory and clinical studies have in depth.
been performed to determine:
Second Level: The Qualitative Porous Zone
i. The appropriate acid type
ii. Acid concentration • The second zone in the qualitative
iii. Etching time porous zone, which is 20 µm in depth.
That would yield optimal bonding • Due to relatively large porosities created
characteristics with minimal loss of surface by the etching process, this zone may
enamel. be distinguished qualitatively from
• Phosphoric acid in the range of 35–40% adjacent sound enamel using polarized
with an application time of 15–60 sec- light microscopy.
onds for permanent and primary teeth
has been shown to produce adequate Third Level: The Quantitative Process
resin bonding while minimizing the • As its name implies, it has relatively
loss of surface enamel. small porosities, created by the etching
• No significant differences in sealant process that may be identified only by
retention rate or caries incidence have quantitative methods using polarized
been found with variations in the acid light microscopy.
• This zone extends into the enamel for an placement because they are basic requisites
additional 20 µm. for sealant retention and they cannot be
Following acid etching and creation isolated. They are:
of the three various zones, sealant 1. The maximum surface area
material is applied to the etched enamel 2. Pit and fissure anatomy have deep
and the resin material penetrates into irregular pits and fissure
the porosities created. This provides 3. Surface cleanliness
mechanical bond between the etched 4. Be absolutely dry
enamel and the resin material that
may extend 40 µm or more into the Maximum Surface Area or Increasing
underlying tooth structure. the Surface Area
• Sealants do not bond directly to the
Etching pattern: Three characteristic etching tooth. Instead they are retained mainly
patterns occur following exposure of sound by adhesive forces.
enamel to phosphoric acid. • To increase the surface area which in
Type I: The etching pattern has lost the prism turn increases the adhesive potential,
cores, but the prism peripheries remain. “tooth conditioner” also called etchants,
that are composed of 30% to 50%
Type II: In the etching pattern, the prism concentration of phosphoric acid are
peripheries are lost and the prism core placed on the occlusal surface prior to
appear to be relatively intact. the placement of sealant.
Type III: Some region of etched enamel • The etchant may be either in liquid or
show a generalized surface roughening and gel form. The former is carrier to apply
porosity with no exposure of prism cores and easier to remove. Both are equal in
or peripheries. This surface morphology is abetting retention.
characteristic of the Type III etching pattern. Note: If there are any etched areas on the
• No specific etching pattern is preferably tooth surface not covered by the sealant
created during the etching procedure or if the sealant is not retained, the normal
and the three types of etching patterns appearance returns to the tooth within one
are often found adjacent to one another. hour to a few weeks due to remineralization
• The type of etching pattern has not from constituents (calcium phosphates and
found to be related to increased or fluorides to certain extent) in the saliva.
decreased sealant retention rates or
caries incidence. Pit and Fissure Anatomy
Penetration of the sealant: The penetration of
Requisites for Sealant Retention the sealants depends on:
Four commandments for successful sealant • The configuration of pit and fissure.
placement: • The presence of deposits and debris
Before the sealant application and within the pit or fissure.
preventive resin restoration placement, • The properties of the sealant itself.
the operator should bear in mind the “four A review of the anatomy of pits and
commandments” for successful sealant fissures may be helpful in understanding
the effects of sealants in the prevention of • Retained cleaning material can block
dental caries. The shape and depth of pits the sealant from filling the fissure and
and fissures very considerably even within can also become mixed with the sealant.
one tooth. • Removal of pumice used for cleaning
Occlusal fissures vary in shape and depth as: and thorough working are necessary for
• Wide V-shaped or narrow V-shaped. the success of the sealant.
• Long narrow pits and grooves reach to • Removal of biofilm, debris and stain
or nearly to the dentinoenamel junction. is accomplished as part of a routine
• Long constricted form with a bulbous prophylaxis in a preventive dentistry
terminal portion. program.
The pit and fissure may take a wavy • The slurry must be a non fluoride oil
course, it may not lead directly from the free mixture to avoid contamination of
outer surface to the dentinoenamel junction. the tooth surface.
• Deeper, irregular pits and fissures offer • The use of an air-polisher is another
a much more favorable surface contour cleaning option.
for sealant retention compared to broad • Hydrogen peroxide has also been tried
shallow fissures. as cleaning agent but the disadvantage
• The deeper fissures protect the plastic that it produces a precipitate on the
sealant from the shear forces occurring enamel surface.
as a result of masticatory movements.
• Parallel interest is the fact that the possi- Dryness
bility of caries development increases as • The teeth must be dry at the time of
the slope of the inclined plane increases. sealant placement, since the present
• Thus as the potential for caries in- sealants are hydrophobic.
creases, so does the potential for sealant • The presence of saliva on the tooth is
retention. even more detrimental than water, since
its organic components interpose a
Surface Cleanliness barrier between the tooth and sealants.
As mentioned earlier the penetration of a • Whenever the teeth are dried with an
sealant depends on the pressure of deposits air syringe the air stream should be
and debris within the pit or fissure. A pit or checked to ensure that it is not moisture
fissure contains: laden. Otherwise sufficient moisture
• Dental biofilm, pellicle, debris can be sprayed on the tooth that will
• Rarely but possibly intact remnants of prevent adhesion of the sealant to the
tooth development. enamel.
Note: The need and method for cleaning Note: A check for moisture can be
the tooth surface prior to sealant placement accomplished by directing the air stream
are controversial. Usually the acid etching is onto a cool mouth mirror; any fogging
alone is sufficient for surface cleaning. indicates the presence of moisture.
Effect of cleaning Amount of penetration

• The narrow long fissures are difficult to • Wide V-shaped and shallow fissures are
learn completely. more apt to be filled by sealant.
• Although ideally the sealant penetrates Clinical Procedures (Figure 6.5)
to the bottom of a pit and fissure such Step 1: Isolation
penetration in frequently impossible.
Purpose: Keep the tooth clean and dry for
• Microscopic examination of pits and
optimal action and bonding of the sealant.
fissures after sealant application has
• Eliminate possible contamination by
shown that the sealant does not penetrate
saliva and moisture from the breath.
to the bottom because residual debris,
• Keep the materials from contacting the
cleaning agents and trapped air prevent oral tissues being swallowed acciden-
passage of material. tally or being unpleasant to the patient
• Incipient dental caries at the base of a because of flavor.
well sealed pit or fissure has no access • A dry field can be maintained in several
to nutrients required for survival. ways the tooth from salivary contami-
nation.
Clinical Technique • Isolation should be carried out ideally
Sealant Application by using rubber dam isolation. Cotton
General rules roll isolation with adequate suctioning
• Treat each quadrant separately. to remove saliva from the operating
• Use four handed method with assistant. field is also acceptable and is the pre-
1. To ensure moisture control ferred method of isolation for many
2. To work efficiently and save time. practitioners.
• Follow manufacturers direction for • The placement of bibulous pads over
each product. opening of the parotid duct can also be
used.
• Success of treatment (retention) de-
• Bibulous pad—in a triangular saliva
pends on the precision in each step of
disorder and applied over the opening
the application.
of the parotid duct in the cheek.
• Retention of sealant depends on main-
• For the maxilla there should be little
taining a dry field during etching and
problems with the placement of cotton
sealant placement.
rolls in the buccal vestibule and if
• Follow the steps in clinical procedures
desirable the placement of a bibulous
as below.
pad over parotid duct can be done.
Patient Preparation Rubber dam
1. Instruct the patient to thoroughly brush • Rubber dam application is the method
the teeth just before the sealant place- of choice because the most complete
ment. Request patient to brush and ap- isolation is obtained. This method is
ply filaments straight into occlusal pits especially helpful when more then
and fissure. one tooth in the same quadrant is to be
2. Explain the procedure and steps to be sealed.
performed. • Rubber dam is essential when profuse
3. The patient must wear safely eyewear saliva flow and overactive tongue
for both protection from the chemicals and oral muscles make retraction and
of etching and sealant and also from the consistent maintenance of a dry, clean
light of the curing lamp. field impossible.
Figure 6.5: Clinical procedure
• Combined treatment is planned. When Cotton roll isolation: Under most operating
a quadrant has a rubber dam and conditions, however it is not feasible to
anesthesia for restoration of other teeth, apply the rubber dam to the different quad-
indicated for sealant can be treated. rants of the mouth instead it is necessary to
• Use anesthesia when application of employ cotton rolls combined with the use
the clamp cannot be tolerated by the of an effective high volume, low vaccum as-
patient. pirator.
• Rubber dam may not be possible when Under such routine operating conditions,
a tooth that is essential for holding the cotton rolls with and without the use of
clamp is not fully operated. bibulous pads can usually be employed as
effectively as the dam for the relatively short brush with low speed handpiece in a
time needed for the procedure. prophy angle.
• Patient position: Tilt the head to allow • Disadvantage: Pumice particles become
saliva to pool on the opposite side of the lodged in the pits and not rinsed out.
mouth. • Alternative: Use bristle brush with clear
• Position cotton roll holder garmer water.
holder. • An other alternative method is to clean
• Place saliva ejector. the surface with an air polishing device
• Apply triangular saliva absorber over using an air powder abrasive (sodium
the opening of the parotid duct in the bicarbonate slurry) system.
cheek (bibulous pad). • Rinse the tooth surface thoroughly to
• Take greater care to prevent contamina- remove the prophylactic paste or slurry
tion from entering the area to be etched. and oral debris.
• Trace the pits and fissures with a sharp,
Step 2: Cleanse the Tooth Surface fine pointed explorer to remove any
Purpose: cleaning material lodged within the pits
• Remove deposits and debris. and fissures.
• Permit maximum contact of the etchant • If a sodium bicarbonate slurry has been
and the sealant with the enamel surface. used, it is necessary to neutralize the
• Encourage sealant penetration into pit retained slurry with phosphoric acid for
or fissure. 5–10 seconds.
Note: Some practitioners recommended
Patient with no stain or calculus cleaning the surface with hydrogen peroxide
• Request patient to brush, apply after using a prophylactic paste to remove
filaments straight into occlusal pits and additional debris from the fissure.
fissures. Once the tooth surface has been thor-
• Suction the pits and fissures with high oughly cleaned, rinse and air dry the surface.
velocity evacuator.
• Use explorer tips to dig out debri and Step 3: Acid Etching Tooth Surface
bacteria from the pit or fissure. Action
• Suction again to remove loosened • Create micropores to increase the sur-
material. face area and provide retention for the
• Evaluate for additional cleaning; the sealant.
brushing may be sufficient. • Remove contamination from enamel
surface.
Patient with stain or calculus:
• Provide antibacterial action.
• Cleaning procedure choices.
• Examine the surfaces—remove calculus Etch forms
and stains. • Phosphoric acid: Depends on product
• Prophylaxis of the tooth surface to be and manufacturer.
sealed should be carried out, using a • Liquid: Low viscosity allows good flow
fluoride free pumice slurry applied into pit or fissure but may be difficult to
with a rubber cup or pointed bristle control.
• Gel: Tinted gel with thick consistency • If salivary contamination does occur at
allows increased visibility and increased this stage, reisolate the tooth, rinse the
control over the areas to be etched and entire tooth surface, dry thoroughly and
a decreased likelihood of spillage onto repeat the etching process. Avoid contact
the interproximal surfaces but may be with the dry, etched enamel surface.
difficult to rinse off the tooth surface.
• Semi-gel: Tinted, with viscosity between Step 5: Apply Sealant to the Etched Tooth Surface
the gel form and the liquid allows good • Apply the sealant material to the etched
visibility, control and rinsing care. tooth surface and allow the material to
flow into the pits and fissures.
Etch timing • With mandibular teeth apply the seal-
• Exposure time varies from 15 to 16 sec- ant at the distal aspect and allow it to
onds for both permanent and primary flow mesially.
teeth. • For maxillary teeth apply the sealant at
• Follow manufacturers instructions for the mesial aspect and allow it to flow
each product. distally.
Etch delivery • Using a fine brush or mini sponge or
• Liquid etch: Use a small brush, sponge or applicator provided by the manufacturer
cotton pellet. carry a thin layer of sealant up the
• Apply continuously throughout the cuspal inclines to seal secondary and
etch time to keep the surface moist, then supplemental fissures and flow the
pat (do not rub). sealant material into buccal and lingual
• Periodically add fresh etching agent to pits and grooves.
the tooth surface. • Cure the sealant according to manufac-
Note: Care should be taken to avoid spillage turers instructions.
of the etchant onto interproximal surfaces.
Step 6: Explore the Sealed Tooth Surface
Interproximal etching may lead to gingival
irritation or seeding of adjacent interproximal • Explore the entire tooth surface for pits
surfaces together. and fissures that may not have been
sealed and for voids in the material.
Gel and semi-gel: Use a syringe, brush or • If deficiencies are present apply addi-
manufacturer supplied single use cannula. tional material.
Step 4: Completion of Etching Rinse and Step 7: Evaluate the Occlusion of the
Dry Etched Tooth Surface Sealed Tooth Surface
• Rinse thoroughly the etched tooth • Evaluate the occlusion of the sealed
surface with an air water spray for tooth surface to determine whether
10–20 seconds. This will remove the excessive sealant material is present and
etching agent and reaction products needs to be removed.
from the etched enamel surface. • Evaluate the interproximal regions
• The dried etched enamel should have a for inadvertent sealant placement by
frosted white appearance. If the enamel performing tactile examination with
does not have this appearance, repeat an explorer and passing dental floss
the etching step. between contact regions.
Step 8: Periodically Reevaluate and Reapply restorative procedures are accomplished
Sealant as Necessary using hand instrumentation only.
• During routine recall examinations it is • ART is also found to be useful in
necessary to reevaluate the sealed tooth treating patients with mentally retarded
surface for loss of material, exposure children and other patients with other
of voids in the material and caries medical and physical disabilities.
development. • The ART procedure may be easily
carried out in the patient’s home or in
ATRAUMATIC RESTORATIVE the hospital.
TREATMENT • Use of ART technique is also useful
in introducing children to dental care
The occasion that marked the beginning and helps to overcome any fears of
of the year of oral health, WHO presented traditional dental treatment.
atraumatic restorative treatment (ART) on
• A patient with multiple carious lesions
world health day on 7th April 1994. Later
is treated with this technique and the
in recognition of the huge potential that the
carious process is stabilized before a
ART approach offers to the management
more definite restorative treatment.
of dental caries, WHO has launched on
invitation for the global promotion of ART. History
• Atraumatic restorative treatment was
What is ART?
pioneered in the mid 1980’s in Tanzania.
The atraumatic restorative technique (ART) • In 1991, a community field trial started
is a procedure based on removing carious in Thailand comparing ART with
tooth structure using hand instruments traditional treatment using dental
alone and restoring the cavity with an filling equipment and amalgam.
adhesive restorative material. At present
• Another community field trial was set
the restorative material of choice is glass
up in Zimbabwe in 1993.
ionomer cement.
• The results of the study has shown that
By removing carious tooth tissue with
through the careful application of ART,
hand instruments alone and restoring the
about 85% of one surface restorations
cavity with glass ionomer will conserve
in the permanent dentition will be in
as much tooth structure as possible and
prevents further decay. a good to acceptable condition upto
The ART approach is ideal for school and about 3 years.
community dental health program because it • The studies in Thailand and Zimbabwe,
enables treatment of cavity in teeth of people and also another community field
residing in areas where electricity is not trail, which started in 1995 in Pakistan,
available and where the community cannot have clearly shown that pain is rarely
afford expensive dental equipments. experienced with this approach. Infact,
if applied correctly ART is well received
Specific uses of ART by the vast majority of patients.
• ART technique is useful for nervous • In conclusion, ART is a quality treatment
patients who are afraid of drilling and applicable to all communities.
Advantages 2. Restoring the cavity with a restorative

• ART provides care for decayed teeth, material that adheres to the tooth
which is non-threatening, low cost and surface (glass ionomer).
can prevent extractions in most cases.
• ART is based on modern knowledge Purpose of Hand Instruments Only in ART
about minimal intervention techniques • The present concept of conservative
thereby requires tooth removal. dentistry is to conserve sound tooth
• Because it is a noninvasive procedure, tissues as much as possible. The use of
there are great potentials for its use in a biological approach, which requires
children as well as in fearful adults. minimal cavity preparation that con-
• It also provides a restorative option serves sound tooth tissues and lower
for special groups in the community, trauma to the teeth.
such as the physically or mentally • The low cost of hand instruments
handicapped people living in nursing when compared to power electricity
homes and home- bound elderly. driven sophisticated and costly dental
equipments.
Indications • The limitation of pain by using hand
• Done where there is no power supply instruments that reduces the need
to run the motors required for cavity for local anesthesia to a minimum
preparation such as in very remote and reduces psychological trauma to
villages. patients.
• ART technique makes restorative more
• When many people have to be treated
accessible to all population groups.
such as in refugee camps.
• Simplified infection control, compared
• Areas where it is difficult to take heavy
to rotary instruments, easily cleaned
equipments due to natural constraints
and sterilized after every patient.
the equipments required for ART are
few.
Steps in Preparing the Cavity for ART
Contraindications • Cotton rolls are placed alongside the
tooth to be treated. This will absorb
• Presence of abscess or fistula associated
saliva and keep the tooth dry.
with the tooth to be restored.
• Plaque and other deposits are removed
• Presence of clinical pulp exposure. from tooth surface with a wet cotton
• Teeth that have been painful for a pellet, and then the surface is dried with
long time and may be associated with a dry cotton pellet.
chronic inflammation of the pulp. • The extent of the carried is judged.
• There is an obvious carious cavity but is • The access to the caries is widened
not inaccessible to hand instruments. by placing the blade of the dental
Hatchet into the cavity and turning the
Principles of ART instrument forward and backward like
The two main principles of ART are: returning a key in a lock. This move-
1. Removing carious tooth material using ment chips off small pieces of carious
hand instruments only. enamel.
• Carious dentin is then removed with • Have a basic understanding of the
the excavators by making circular caries process in the contrast of its man-
scooping movements around the long agement through minimal intervention
axis of the instrument. approaches.
• The unsupported enamel that may be • Understand the reasons for the selection
present is very weak and is removed and use of specific adhesive materials
with the blade of the Hatchet. for minimal intervention approaches.
• Restoring the cavity with glass ionomer • Understand the rationale for ART.
cement using finger press technique. • Be capable of preparing for ART
restorations and be able to place and
ART Training finish appropriate adhesive materials.
Introduction • Know how to maintain ART instruments.
• Know how to manage failure of ART
The occasion which marked the beginning
restorations when they occur.
of the year of oral health, WHO introduced
• Understand the applications of the
ART on World Health Day 7th April 1994.
ART approach within comprehensive
Later after understanding the beneficial
package of oral health care and know
effect of ART on dental caries and its
its limitations.
tremendous use in management of dental
caries, WHO launched an institute for the
Rationale for Application of ART
global promotion of ART.
The ART approach to the management Atraumatic restorative treatment can cer-
of caries has been validated in studies from tainly be used with confidence in one surface
a number of countries around the world. cavity particularly in permanent teeth. It is
A common finding, however that is the expected that ART will also perform equally
treatment outcomes from inexperienced or well in one surface cavities in deciduous
inadequately trained operators are poorer teeth of young children.
than for those who have received proper The maximum duration of restoration
training in the ART approach. can remain in a primary tooth is about 6–7
This shows that ART training of the years. ART restorations help to maintain
dental students during BDS course in the a natural teeth eruption pattern and avoid
department of public health dentistry disturbances in the positions of permanent
required to achieve optimal treatment using successor teeth.
this approach. Success of ART in multiple-surface cavities
However, the material contained in very much depends on the size of the cavity
third normal forms the basic knowledge and the restorative material used. Small to
that is considered to be necessary for dental medium size multiple-surface cavities can
students to achieve consistent and reliable be treated more successfully with ART than
outcomes from the application of the ART the large cavities.
approach.
Structure for a Basic ART Training
Educational Approach of ART Training The ART training is divided into a number
At the end of an ART training the dental of modules some being didactic with others
students should. being practical and clinical in nature. The
sequence of the training has been so arranged gradual loss of the minerals that make up
that knowledge gained from one module the tooth structures”
forms the basis for subsequent modules. This applies to both enamel and dentin
The first 6 modules are didactic in nature caries.
and comprise:
Module 1: Dentin caries, its progression Structure of Dentin
and how to stop it. Important points to be note:
Module 2: Adhesive restorative materials • Dentin tubules are surrounded by
for minimal cavity preparations. peritubular dentin.
Module 3: Equipments and materials • Intertubular dentin connects peritubu-
required for the ART approach. lar dentin.
Module 4: Selection of cases for ART and • Apatite crystals are embedded in a
a step-by-step guide to the ART approach. dentin matrix which contains collagen
Module 5: Survival of ART restorations fibers.
and sealants placed as part of the ART • These collagen fibers are connected
approach. to each other through inter molecular
Module 6: Failed ART restorations, their cross – linking.
cause and management.
The following modules are practical and Progression of Dentin Caries Bacterial
clinical in nature and comprise: Invasion
Module 7: Practical experience in the • Bacteria need to have a source of nutri-
handling and mixing of adhesive materials ents, i.e. from oral environment.
for ART approach, e.g. hand-mixing glass • Bacteria are found mostly in the biomass
ionomer. with few being found in the dentin
Module 8: Demonstration and practice tubules.
of cavity cleaning and restoration placement This follows a sequence.
using the ART approach on extracted teeth. • Acid from fermentation process pen-
Module 9: Demonstration and practice etrates the dentin tubules ahead of bac-
of isolation, cavity cleaning and restoration terial invasion.
placement using ART approach on patients.
• This softens the dentin matrix.
The final two modules are free format
• The collagen fibers are reversibly dam-
discussion sessions:
aged in the dissolution process.
Module 10: ART within the context of a
• Continuation of acid production dis-
comprehensive package oral health care.
solves crystals in the peritubular and
Module 11: Training evaluation.
intertubular dentin.
• Further continuation of acid production
Module 1: Dentin Caries: breaks the intermolecular crosslinks of
(Its Progression and how Best to Stop it) collagen fibers irreversibly.
Caries is a dynamic process (remineralization/
demineralization) and has been defined in Defence Reaction in Dentin
many ways. Ultimately, it can be considered • A defence reaction takes place in the
to be: “A bacterial process that results in dentin.
• Dissolution alters the hydroxyapatite • Reaction in enamel to caries—stimulat-
crystals. ing factors in plaque.
• Crystals with a lower hardness and a • Further demineralization follows the
lower calcium density (= whitlockite) enamel rods creating a reaction in the
remain. dentin directly underneath these lesions.
• The dentin tubules are blocked by • After caries has reached the EDJ, it
precipitated intratubular whitlockite first follows the direction of the dentin
crystals. tubules.
• These crystals originate from the • Lateral spread of dentin caries occurs
peritubular and intertubular dentin. mainly in cavitated lesions.
• This process is known as Tubular
Sclerosis. Stages of Dentin Lesion Formation and
• It is seen clinically as yellow-brownish Progression in an Occlusal Fossa
discoloration of the dentin. • Stimulating factors in dental plaque
Two Layers of Carious Dentin triggers enamel to react for initiation of
dental caries lesion.
Outer (infected) Inner (affected)
• Enamel demineralization follows the
• Bacterial invasion • Mineral
rods.
invasion bacterial
• Initial dentin demineralization does not
• Unremineralizable • Remineralizable
spread along the enamel dentin junction
• Dead • Alive
(EDJ) beyond the periphery of the lesion
• Without sensation • Sensitive
in the enamel.
Remineralization of Inner Carious Dentin • This leads to a cone shape lesion with
Two requisites are needed for physiological the base at the EDJ.
remineralization: • In any pit and fissure system there can
1. Presence of collagen fibers with an be multiple lesions in different stages of
intact structure for re-attachment of progression. (Stages A, B, and C.)
crystals. • Only when there is frank cavitation and
2. Presence of living odontoblastic pro- a cariogenic environment, will dentin
cesses—for supply of calcium phos- demineralization spread in lateral
phate from the vital pulp. direction (Stage D).
Both situations occur in the inner carious
dentine. Characteristics of Progression of
Approximal Caries
External Souces for Remineralization • Progression of approximal caries fol-
• Exposure to saliva lows the same principles as for occlusal
• Exposure to bio-active agents. caries.
• It follows the enamel rods, but because
Characteristics of Occlusal and of the curved shape of the approximal
Approximal Caries tooth surface, the lesion does not lead
Progressive stages of dentin lesion formation to a cone shape at the EDJ as present in
in an occlusal fossa. an occlusal fossa.
Traditional Concepts of Cavity Design • The teeth inevitably become weaker,

• Greene Vardiman Black’s cavity thereby reducing their prognosis.
preparations followed designs that • The complexity of the restorations
were largely dictated by the physical increases or tooth needs to be extracted.
properties of the filling materials used
Outcomes of Traditional
that time, e.g. amalgam and silicate
Treatment Approach
cement.
• These materials needed mechanical Summary
retention. Hence cavity preparations • Much sound tooth tissue needs to be
had: removed.
– Flat floors • Applied in the dental practice, the tradi-
– Vertical walls tionally placed restorations on average,
– Triangular retention niches do not last long.
– Undercut areas. • The replacement restorations, in many
A review of survival studies shows: cases, prepared using the same absolute
• Amalgam and composite resin restora- principles of cavity design and last for
tions survive on average between 6 and less time.
10 years. (Downer, et al. 1999). • The end result is a tooth that became
weaker and weaker each time a replace-
Reasons for Failure ment was made.
• Secondary caries (predominantly) • The weaker the tooth becomes, the
• Marginal breakdown more likely the restoration will fall,
Thus, Black’s principles could be con- resulting in a vicious cycle and termed
sidered as: “the application of a mechanical the “repeat restoration cycle”.
design to a biological process”.
• Except with respect to overt carious Biological Principles of Cavity Preparation
lesions, caries ‘diagnoses’ are uncertain, • This should be restricted to cavity
with considerable variation occurring cleaning
between dentists. Furthermore, in • It only involves:
general, dentists have an urge to place – Obtaining adequate access and
restorations to do something. – Remove dead, non-mineralizable
• Extensive cavity preparations (Black) in dentin and enamel.
the name of outline form and extension Thus, the shape of the cavity is deter-
for prevention result in restorations mined by “the anatomy of the carious lesion
with weak margins, leading to marginal as it presents at the time of cavity prepara-
breakdown and ‘ditching’. tion”.
• Dentists have an urge to replace resto- Therefore, there is no preconceived
rations as if this were panacea solution cavity design. Thus, Black’s principles of
to overcome whatever ‘problems’ may cavity design are redundant.
exist. Reasons why restorations fail are
not usually identified correctly. What Kind of Instrumentation is Required to
Remove Demineralized Tooth Tissues?
The cavities increase in size because there
is a perceived (but erroneous) requirement to • GV Black initially hand instruments but
‘freshen up’ the cavity walls and margins. did not provide sufficient retention for
the filling materials in use at that time; • Therefore, does not promote caries
the filling fell out. development
• Later, Black proposed the use of rotary • Chemomechanical gel
hand piece. This was done because of • To chemically disturb denatured col-
the need to cut hard sound tooth tissue lagen in partially demineralized dentin
to produce a mechanically retentive and remove the unsupported minerals
shape. by gently scraping
Nowadays adhesive restorative This approach is currently under inves-
filling material exists. tigation.
• There is little or no need for mechanical • Rotary instruments—These might be
retention as the filling materials bond to considered under certain circumstances.
tooth tissues. • Slow speed drill.
– With straight bur for further opening
Most Appropriate Instrument of dentinal lesions that have a very
This raises a question: small entrance.
“If mechanical retention is no longer – With round bur for gentle removal
needed, there is a need to use a rotary of dead tissue.
instrument for removing soft, demineralized • High speed drill.
tooth tissues” • Only for opening cavities that are
In other words, “can the soft, demineral- inaccessible.
ized tissues be removed in a different way?” • Removal of failed restorations.
The answer is “YES”.
If the shape of the cavity is determined Why Does the Cleaned Cavity
by the anatomy of the lesion surely, a rotary Need to be Restored?
instrument is not the best instrument for: • To stop the cavity process
• Removing only soft, completely • To facilitate easy plaque removal
demineralized tooth tissue and • To encourage remineralization of inner
• Preserving as much remineralized carious dentin
enamel and dentine as possible • To restore function
The best instrument for cleaning the cavity is: • To restore a esthetics.
• Hand instrument:
– Dental Hatchet or similar instrument How is this Best Achieved?
to gain access and Application of a material that:
– Excavators for the removal of dead • Produces a seal against bacterial inva-
tissues. sion
• Encourages remineralization
Why Hand Instruments? • Is sufficiently durable
• Creates the most ideal (conservative) • Maintains functions.
cavity shape
• Gives the operator improved tactile sense Which Material Best Offer for this?
• Does not damage surfaces adjacent to • Adhesive restorative material
the lesion. In the case of approximal – Resin and polyacid-modified com-
lesions posite resin (compomers)
– Composite glass-ionomer and resin ized tooth tissue. This is best achieved
modified glass-ionomer. through using hand instruments and/
• Nonadhesive restorative material or a slow rotating drill rather than a
– Amalgam. high-speed drill. In doing so, less sound
tooth tissues are removed to surfaces
Tooth Preservation Versus Cavity Preparation of other teeth is minimized. The use of
Preservation not only refers to restoration, it a gel for chemically and mechanically
also refers to prevention. removal of demineralized tooth tissue
For a dentin lesion in an occlusal surface, is under investigation.
preservation includes: • Since only soft, completely demineral-
• Restoring the cavity ized tissue is removed there can be no
• Sealing the adjacent pits and fissures, preconceived cavity design. The anato-
this is called a “sealant restoration”. my of the carious lesion dictate the size
For carious lesions in occlusal, buccal and shape of the cavity preparation.
• Treatment is completed by placing
and lingual surfaces of posterior teeth:
an adhesive filling material into the
• Preventive resin restoration
cleaned cavity preparation, over its
• Preventive glass ionomer restoration
margin and over the adjacent pits and
• Atraumatic restorative treatment (ART).
fissures. This sealant restoration will
For carious lesions in approximal arrest caries cavity that is present in
surfaces of posterior teeth: dentin and enamel, provided that the
• Box-type restorations bonding of the material to these tooth
• Tunnel preparation tissues is adequately established.
• Atraumatic restorative treatment. • This treatment modality has the
potential to:
Effect of Sealed Versus Non-sealed – Control dentin caries
Restorations – Increase survival of the restoration
Clinical trials in the USA: After 10 years, – Save tooth tissues and thus
the study revealed that, in comparison to – Increase tooth life expectancy.
conventional restoration, silent restorations
resulted in: Module 2: Adhesive Restorative Materials
• More sound tooth structure was for Minimal Intervantion Apporaches for
conserved Caries Management
• Restoration margins were better This module describes the adhesive restora-
protected tive materials that are used in connection
• Recurrent caries was less frequent with minimal intervention approach for car-
• Clinical survival of restorations was ies management. To date the ART approach
prolonged. has mainly used glass ionomers. This material
is most likely to be the material of choice
Summary in out reach situations. For these reasons,
• The biological principle to the man- glass ionomers have been explained in much
agement of a dentin lesion is to only more detail than other adhesive restorative
remove soft, completely demineral- materials.
Table 6.1: Historical development of adhesive restorative materials
Resins Macrofilled Microfilled Fine particle/

composites composites hybrid composites
Compomers
Resin—modified glass ionomers
Glass Conventional Metal containing GI’S High viscous GI’S
ionomers GI’S
1955 1970 1980 1990 2000
Adhesive Material for Minimal Cavity Liquid

Preparations • The liquid is usually a water soluble
• The arrival of adhesive restorative ma- organic polyalkenoic acid, mostly
terials meant that mechanical revolu- polyacrylic acid.
tion was no longer necessary. Thus, it • Some glass ionomers are supplied with
was possible to develop intervention the acid component and to the powder
techniques for caries management that in freeze-dried form. In this case, the
were more conservative of tooth tissue. liquid comprises deionized water.
• The historical development of adhesive How Does Glass Ionomer Harden?
restorative materials is presented in
The setting reaction
(Table 6.1).
• The acidic liquid decomposes the outer
Glass Ionomer (Self Cure) layer of the ionomer glass particle.
A dental glass ionomer is supplied as • Ions, such as calcium and aluminium
(Figure 6.6): are forced to react with polyacrylic mol-
• A powder and liquid in separate bottles ecule.
(hand mix version) or • Chains of calcium-polyacrylate and
• In an encapsulated form. alumininum-polyacrylate are formed.
• Other freed ions attach to this network
Powder: The powder comprises a fluoride of metal-polyacrylate chain.
glass that is made up of a number of ma- • This mixture hardens.
terials, the most important being SiO2 and • The initial setting taken place within 5
Al2O3. minutes.
What are the Main Characteristics of

Glass Ionomer?
• Glass ionomers bound to enamel and
dentin without acid etching.
• Leach fluoride into the tooth tissue and
oral environment are pulp-friendly.
How does Glass Ionomer Bound to

Tooth Tissue?
Adhesion between glass ionomer and tooth
Figure 6.6: Glass Ionomer restorative material structures:
• Adhesion occurs chemically through • Removal of outer carious dentin with

ion exchange. either, usually a instrument or a drill
• The polyacrylic acid attack the dentin result in production of a smear layer.
and the enamel and displace phosphate. • This smear layer prevents adequate
• Adhesion of glass ionomer to enamel is bonding of glass ionomer to the tooth
stronger than to dentin. tissue and should therefore be removed.
• In order to achieve this, a surface
What about Microleakage of Glass Ionomer? conditioner must be used.
• Usually less after seen with glass
ionomer than for composite resin Bond Strength of Glass Ionomer to Enamel and
restorations, particularly at dentin Dentin with or without Dentin Conditioners
margins. • Surface conditioning doubles the bond
• Polymerization shrinkage and shrinkage strength.
stress are low for glass ionomers. • A surface conditioner differs from a
• High adhesion values, necessary for liquid used for acid etchant of tooth
resin containing material are therefore tissue and they are not interchangeable.
not so relevant. • Acid etching is restricted for use with
resin based materials.
What does the Tooth Tissue—Glass Ionomer
Interface Look Like? What is the Role of Water in Glass Ionomer?
• A distinct zone exist’s at the interface of • Glass ionomers are water based
glass ionomer and tooth tissues. materials.
• This zone is more resistant to acid attack • Water is the reaction medium into
then the surrounding glass ionomer which the glass ionomer forming metal
material and tooth tissues. ions leach at the beginning of the setting
• This is an indication of higher minerali- reaction.
zation of interface. • This setting process is very fast during
the first 5 minutes or so. It continues
What if Glass Ionomer Fracture? over tissue and it may take a year before
• Fracture occur within the material the glass ionomer is completely mature.
(cohesively). • Both during the initial set and during
• Glass ionomer, therefore remains in this so-called ‘slow maturation phase‘,
contact with both dentin and enamel at the material is vulnerable to water
the interface. uptake and water loss.
When used as sealant, and if the sealant • Therefore, it is recommended that the
is eventually lost, the glass ionomer surface of the restoration or sealant
that is left behind in the deeper parts should be protected during the initial
of pits and fissures may act as a carries set by application of an impermeable
inhibiting agent. layer of varnish, petroleum jelly or
unfilled resin.
What is the Function of a Surface Conditioner? • Desiccation of the cavity preparation
• A surface conditioner is a weak organic prior to placing glass ionomer material
acid, usually a polyacrylic acid. leads to poor adhesion and to glass
between restoration material and tooth Fluoride concentration and its penetra-
tissue. This should thus be avoided. tion depth into enamel increases with the
time that glass ionomer are in contact with
What does Fluoride do in Glass Ionomer? it.
• Fluoride originates from the aluminium
What is Known About Fluoride in Plaque?
silicate glasses that can contain 28%
fluoride. • Fluoride leaches in plaque grown on
• Glass ionomer restoration and sealant glass ionomer restorations are much
can take up fluoride (e.g. from tropical higher than in plaque grown in compos-
fluoride application) and subsequently ite resin restoration.
release it. • The metabolic activity of the resident
• Leaching of fluoride does not affect the micro flora is reduced.
properties of glass ionomer because it • A low number of Streptococcus mutans
does not contribute to its matrix. is found in plaque samples from
• Fluoride continues to be released from margins of glass ionomer restoration
glass ionomer for a long period, upto 8 in permanent dentitions after 4 weeks.
years in-vitro. Those numbers are much lower than
those from comparable amalgam and
Pattern of Fluoride Release from Glass composite resin restoration.
Ionomer • The same trend has been observed in
the primary dentition.
• The pattern of fluoride release is char-
acterized by an initial burst of fluoride Has Glass Ionomer the Potential to
upto a week. This is followed by grad- Remineralize Carious Lesions in Adjacent
ual decrease that level off after some Tooth Surfaces?
months.
From the biological point of view, the
• The amount of fluoride increase with fact that a restorative material may have
increase of number of restoration remineralizing potential, is most appealing.
placed. • In-vitro, in-situ and in-vivo studies have
• As an indication, two restorations been carried out in which glass ionomer
surfaces provide 0.4 ppm fluoride in restorations have been compared to
saliva after 10 weeks. amalgam, composite resin and fluoride
containing composite resin restoration.
What happens to the Fluoride that is Released • The conclusion is that there is a reduction
from Glass Ionomer?
in proportion of the carious lesion in
• Cumulative release of fluoride, sodium dentin and enamel surfaces that are in
and SiO2 from glass ionomer by time. contact with glass ionomer restorations
• Release of fluoride takes place in two compared to carious lesion that were in
directions into: contact with other restorative materials.
– Surrounding enamel, dentin and • Reduction in progression of carious
cementum. lesion, one study measured as 20% in
– Saliva and plaque. enamel and 24% in dentin lesion depth.
Overview of Carious Inhibition Zone Adjacent improvements is related to water

to Resin Modified Glass Ionomer and resistance.
Composite Resin Restoration • Recent in-vitro studies have shown that
Higher mineralization of carious lesions wear of glass ionomer decreases as the
adjacent glassionomer compared to amalgam material matures, wear was greater
restorations in-situ. when the pH was low such as after
• The study reported that the carious like consuming acid beverages and during
lesions in tooth surfaces adjacent to glass application of APF gel.
ionomer became higher mineralized. • Long-term wear (one year) of the newer
• Further demineralization occurred in glass ionomer approached that of early
carious like lesions adjacent to both wear of composite resin materials. This
composite resin and amalgam restora- result is obviously related to the process
tions. of maturation of glass ionomer.
How Pulpal-friendly is Glass Ionomer? Pattern of Wear In-vitro

• Acid released from glass ionomer has • Early wear of conventional glass
been identified as a possible factor ionomer is high.
contributing to pulpal irritation. • Long term wear of some glass ionomers
• A thin mixture of glass ionomer may compare favorably with the composite
contain more unreacted acid. Thus resin material tested.
makes the powder/liquid ratio impor- • Resistance to wear is still less than
tant. composite or amalgam.
• Glass ionomers are the most pulpal • The compressive strength of matured
friendly restorative material but there glass ionomer is higher than that of
exists variation in the biocompatibility newly set glass ionomer.
of the various makers of glass ionomers. • The human factor for achieving good
• In case of pulpal exposure, the placement physical characteristics is important. A
of hard setting calcium hydroxide study showed that chair side variants
routinely used a lower powder to liquid
material over the area of the exposure
ratio than recommended. This resulted
is sometimes recommended.
in a mixture that had half the normal
• This leaves sufficient dentin on the floor
compressive strength.
of the cavity available for adhesion
• Other characteristics that need im-
and subsequently, for prevention of
provements are fracture toughness,
bacterial invasion.
flexure strength and tensile strength.
What can be said About the Physical • The physical characteristics of glass
Characteristics of Glass Ionomer? ionomers restrict its use to certain ap-
plications in preventive oral health care.
• Early glass ionomer were difficult to
handle and were very water sensitive.
Much has changed since then and Conclusions
improved glass ionomer has been • Glass ionomer adhere chemically to
marketed in recent years. One of the enamel and dentin but need a dentin
conditioner to remove the smear layer • Pattern of fluoride release
and improve adhesion. • Antibacterial effect
• It is very important to reduce exposure • Susceptibility to dehydration.
of a freshly placed glass ionomer The difference between the two materials
restoration or sealant to saliva and water includes:
for at least one hour. This achieved • The mechanism of adhesion that is
placing a varnish, unfilled resin or both mechanical and chemical for resin
petroleum jelly over the restoration or modified glass ionomers. Bonding to
sealant. enamel and dentin requires mostly acid
• Fluoride is released from the material conditioning. Setting is activated by
into the tooth tissues and into plaque light curing.
and saliva. • Greater mechanical strength for resin
• There growing evidence that the pro- modified glass ionomer which is
gression of carious lesions is reduced attributed to the polymerization setting
in tooth surfaces adjacent to glass reaction of the resin component.
ionomers. • However, resin modified glass ionomer
• The compressive strength and wear seem to wear more than conventional
resistance of glass ionomer restorative glass ionomers, particularly under
material are substantial but fracture acidic conditioners.
toughness and flexural strength need
further improvement. Composite Resin
• The optimal mechanical characteristics This adhesive restorative material exists in
are achieved if the specified powder/ many forms. Without an adhesive technique
liquid ratio is closely followed. A and chemicals, such as bonding and primer
thinner mixture may also irritate the materials, a composite resin does not bond
pulp during the early setting phase. to tooth.
• The use of glass ionomer in preventive • The material is available in two systems:
oral health have is restricted to certain – A t w o - c o m p o n e n t t h a t c u r e s
applications. chemically and
– A one component that requires light
Resin Modified Glass Ionomer curing.
This type of adhesive restorative material • For restorative purpose, a higher filler
was developed to improve the mechanical load and small particle size material is
properties of conventional glass ionomer. required.
• It is a combination of a glass ionomer and • In an attempt to match the carrier
a resin in the ratio of about 80 to 90%. reduced effect of glass ionomers, caries
• Resin modified glass ionomer sets by inhibiting agents such as fluoride have
an acid base and a polymerization been incorporated in composite resin.
reaction. • Studies have shown that caries is not
Because of the high proportion of acid based reduced the presence of composite resin
reaction, resin modified glass ionomer closely material. On the contrary, caries pro-
resemble the behavioral characteristics of gresses in dentin alongside composite
conventional glass ionomer with respect to the: resin material under circumstances of
continuous cariogenic etiology without Polyacid Modified Composite Resin

plaque removal. (Compomers)
• The biocompatibility of composite A compomer is a composite resin as a resin
resins in lower than that of conventional modified glass ionomer in to glass ionomer.
and resin modified glass ionomers. • The main difference between a com-
• In general, the physical properties of pomer and a resin modified glass
composite resin materials are the best ionomer is the ratio of resin to glass
of the adhesive restorative materials. ionomer filler which is in the order of
• Despite the high values for adhesion to 80% to 20% respectively.
enamel, polymerization shrinkage and • Therefore, the behavior of compomers
shrinkage stress remains a problem. is essentially that of composite resin
• This results in microleakage at the tooth materials.
filling interface and cracks in enamel. • As compomers do not contain water,
• The level of microleakage is dependent the acid based setting reaction that
on the technique used to insert the characterizes glass ionomers, does not
material, quality of light curing surface take place.
and skill of the operator. • The setting is completed after the light
Strengths and weakness of four adhesive curing the material.
dental restorative materials according to • The physical properties are somewhat
requirements summary is given in Table 6.2. lower than for normal composite
Table 6.2: Strengths and weakness of four adhesive dental restorative materials according to requirements
Requirements Glass Ionomer Resin modified glass Polyacid modified composite Composite
Ionomer resins (Compomers) resins
Biological
• Biocompatible +++ ++ ++ ++
• Encourage +++ +++ + –
remineralization +++ +++ + –
• Reduces demineralization
Physical
• Adhesion to enamel ++ ++ +++ +++
• Adhesion to dentin ++ ++ + +
• Microleakage ++ ++ ++ ++
• Occlusal wear + - ++ +++
• Fracture resistance + ++ +++ +++
• Thermal expansion +++ ++ + +
• Esthetic + + ++ +++
• Moisture tolerant +++ ++ – –
General
• Hand mix +++ n/a n/a +
• Self curing +++ n/a n/a +
• User tolerant ++ ++ + +
• Shelf life ++ ++ ++ ++
+++ very good ++ satisfactory + could be better – poor n/a not available
resin but are generally higher than – Patients oral health promoting or
for resin modified glass ionomer and harmful behavior
conventional glass ionomer. – K n o w l e d g e a n d s k i l l s o f t h e
• Despite the presence of fluoride con- operator.
taining glass particles, compomers do
not leach enough fluoride to reduce Module 3: Equipments and Materials
caries progression. Required for the ART Approach
• As with normal composite resin, polymeri-
General Introductory Statement to the Module
zation and shrinkage stress are a problem.
Point out that before applying the ART
Comment approach it will be necessary to assemble
all the equipment and material required
• Conventional and resin modified glass
includes:
ionomer are high on the biological but
1. Appropriate support for the patient and
lower on the physical requirements.
for the operator
• The opposite is applicable for composite
2. Dental instrument
resin and polyacid modified resins
3. Restorative material
(compomers) materials. They score low
4. Miscellaneous consumable materials
on the biological and are high on the
5. A light source.
physical requirements.
• Conventional glass ionomer and The relation of these depends upon the
chemically cured composite resins working environment where ART is to be
are available in hand mix form and applied. These can loosely be divided into:
therefore be used without electricity. • The use of ART in the well equipped
• The cost and availability of materials dental clinic environment
vary according to country. • ART placed in outreach situations, e.g.
where conventional dental equipment
Summary is not available such as in schools and
homes.
• Glass ionomer have been explained in
more details than the other adhesive
Appropriate Support for the
restorative material for that this material Patient and the Operator
has been used in the ART studies.
Well-equiped dental clinic
• Each material has its strengths and
Points to be noted:
weaknesses.
• An ideal biological restorative material • Both the operator and the patient
has not been manufactured. should be comfortable.
• The selection of material for caries pre- • Because the operator is likely to be
ventive and tooth restorative purposes working for extended periods at anyone
is dependent on the number of factors time, it is best for him/her to be seated.
such as: • The patient should be in supine position
– The size of caries lesion so that the operator can achieve
– Its site in the mouth maximum visibility of the oral cavity.
• With the patient so positioned there is the procedure safely and effectively
not need for the operator to bend or (Figure 6.7).
twist from and upright seated position • This reduce the cost and effort required
since the correct positioning of the for maintenance and sterilization.
patient’s head enables all parts of the • The instruments are based on the stages
oral cavity to be seen. involved in placing an ART restoration
• In this position saliva collects at the back and are almost all commonly found in
of the oral cavity there by facilitating dental surgeries.
saliva control.
Mouth mirror
Outreach situation
Point to be noted:
Points to be noted:
• The mouth mirror is used for viewing
• The patient can be positioned on a
tooth surfaces indirectly, for reflecting
portable dental ‘bed’ which are available
light into the field of operation and
commercially or been locally made.
retracting the soft tissues of the mouth,
• A suitably sized table can be adapted
e.g. tongue and cheek.
by the use of cushioning from rubber,
e.g. the addition of a support for patient Explorer (Probe)
head made of fur foam or a rubber Points to be noted:
ring with a cover stabilizes the patient
• The explorer is used to determine the
head in desired position for maximum
softness of dentin caries prior and
visibility by the operator and improve
during cavity preparation.
the comfort of the patient.
• Whatever support is used it must be • It is also used for scraping plaque
stable and secure to assume the safety from fissures prior to conditioning for
of the patient. restorations or sealant.
• The probe must be “Not be used” for
Dental Instruments Required for ART probing into small carious lesion there
Basic ART instruments overview after have the ability to remineralize.
Points to be noted: • In addition, the probe must not be used
• The number of instruments is kept to on the floor of deep cavitation where
the minimum required to undertake there is a danger of exposing pulp.
A B
Figures 6.7A and B: Armamentarium for ART
Tweezers be approximately 2 mm across (an
Points to be noted: example is the 127–128).
• Used for placing and removing the
cotton wool rolls used for isolation of Dental Hatchet
the tooth being restored. Points to be noted:
• They are also used to hold cotton wool • This double ended instrument has a
pellets used for cleaning, conditioning chisel like working-end.
and drying the tooth surface and for • The Hatchet is used when there is need to
articulating paper used to check the open the entrance into a cavity or to break
occlusion after placement of restoration off very weak unsupported enamel.
or sealant. • In order to permit access to cavities with
the smallest excavator the width of the
Excavators blade should be minimum of 1 mm in
Points to be noted: width.
• The spoon shaped excavators have
been found to be the most useful for Applier/Carver
ART restorations. They are used for Points to be noted:
removing soft carious dentin. A set of • This is a double ended instrument that
two or three double ended excavators fulfills two functions.
is recommended. • The round end is principally used for
• A small excavator is used for excavating placing the filling material into the
small cavities and for removing carries cavity and fissures.
under the enamel dentin junction. • The square end which has sharp edge
The diameter of the spoon should be is used for removing excess restorative
approximately 1 mm across. This is a material and shaping the restoration.
delicate instrument and must not be Mixing spatula and pad
used with excess force (an example in Points to be noted:
the 153–154). If hand mixing restorative material is
• A medium sized excavator is used for used, then a mixing spatula and a pad are
removal of carries from larger cavities required. Many materials designed for ART
and at the pulpal floor of the cavities. are supplied with a plastic spatula and
The convex surface of the head of disposable paper mixing pad. The latter
the instrument can be used to place saves time, since there is no need to clean
filling material into small cavities. the pad between fillings and also helps with
The diameter of the spoon should be respect to infection control.
approximately 1.5 across (an example
is the 131–132). Plastic strip
• A large size excavator is used for Points to be noted:
carries removal in large cavities and at For multiple surface a matrix band
the pulpal floor cavities. It can also be necessitating a holder or a plastic strip is
used for the removal of excess filling required. This prevents the formation of
material from the restoration material. overhangs and prevents the restoration from
The diameter of the spoon should bonding to the adjacent tooth.
Tumbler/Cup ART restorations are going to be placed,

Points to be noted: the availability and cost of materials.
This should either be disposable, • For practical reasons, in outreach situ-
e.g. plastic, or stainless steel to permit ations (schools, villages) a hand mix,
sterilization. The tumbler is used to hold self curing material is advisable. In a
water used for rinsing the operating side. well equipped dental clinic where light
curing material and efficient aspiration
Miscellaneous equipment 1 is available, other materials might be
(Rotoary instrument) considered.
Points to be noted: • To date, almost all studies evaluating
• When ART restorations and sealant are the ART approach have used glass
being placed in a well equipped dental ionomer restorative material. Materials
surgery, some minor modifications to shown are GC, Fuji IX, ESPE, Ketac-
the basic approach are possible. molar, Dentsply Chemflex.
• In some situations, where there might
be difficulty in obtaining access to Miscellaneous Consumable Materials
underlying carious dentin, the careful Required for ART
use of a slowly rotating bur in a hand Points to be noted:
piece might be considered. This is only • Cotton wool rolls are used for moisture
to achieve access since once gained, control so that the operating site is
the remaining excavation of caries kept dry. This is not only important
should be undertaken with hand for visibility but also to ensure that the
excavators. This will ensure that only optimal properties of the restorative
soft carious dentin is removed with materials are achieved. The cotton wool
retaining amount sound tooth tissue. roll used is dependent upon the size of
the mouth of the patient. A large cotton
Miscellaneous equipment 2 wool roll in a child will hinder visibility
(Light cure machine) and access. A small cotton wool roll
Point to be noted: in an adult will be less effective in
• Light curing unit permit the option of moisture control.
using light cured restorative materials. • Cotton wool pellets are used for cleaning
• While there is currently no data on and drying cavities as well as for
how materials such as light cured glass applying conditioner and varnish if a
ionomers, compomers or composites glass ionomer is used as the restorative
perform in the context of ART, it is material. They are available in a number
likely that they will perform in similar of sizes with size 4 being the smallest.
manner to the self curing glass ionomers Even this is often too large for the
currently used. smaller cavities produced by the ART
approach and therefore they need to be
Restorative Materials Required for ART cut in half with scissor.
Points to be noted: • Petroleum jelly is used both as a lubricant
• The restorative material used is to prevent gloves from sticking to
dependent upon many factors. This the restorative material and later for
includes the conditions under which the protecting the surface of the restorative
material if self curing glass ionomer is • The wearing of heavy duty rubber
used. gloves is recommended to protect the
• Wooden wedges are used both to hold hands.
matrix bands and strip in place when
placing approximal restoration and to Use of an autoclave to sterilize
prevent overhanging margins at the ART instruments
portion of the restoration closest to the Points to be noted:
gingival margin. • In outreach situations it is usually
possible to carry sufficient instruments
Operating Light for a day’s work.
Portable light source in field setting (head • The instruments are than returned to
lamp). a facility where they can be properly
Points to be noted: sterilized before the next treatment
• Good illumination of the operating site session.
is essential for the good vision.
Use of pressure cooker to sterilize
• In the dental clinic situation operating
ART instruments
lights are always available.
Points to be noted:
• In outreach (field, community) situa-
• In outreach situations, a pressure
tions the light source can be the sun
cooker can be used for sterilization.
(natural or artificial).
• The clean instruments are placed in
• Artificial lights are more reliable and
a pressure cooker and clean water is
constant than a natural light and can
added to a depth of 2 to 3 cm from the
also be focused on a particular spot.
bottom. The instruments should be
• In a field setting a portable light source
is recommended. evenly distributed around the cooker
• This can take the form of head lamp, (read instructions supplied with the
glasses with a light source attached. pressure cooker).
• It can also be a light attached to the • The pressure cooker is placed on the
mouth mirror or a light on a portable stove and brought to a boil. When
stand. the steam comes out from the vent
• Electric power can either be provided the weight should be put in place. If
by main electricity or by a rechargeable available a timer should be set for 15
portable battery. minutes.
• The pressure cooker is heated continu-
Sterilization of Instruments ously on the low heat for minimum of
Sterilization of hand instrument is a straight 15 minutes. The steam must continue
forward procedure. It is essential that cross to be released from the pressure cooker
infection be prevented. during this time if this stops there may
be no water left in the pressure cooker.
Washing of instruments prior to sterilization • If this happens, the pressure cooker
Points to be noted: must be removed from the heat, allowed
• After use the instrument should be to cool, and the cycle repeated (read the
washed in soapy water to remove all instruction supplied with the pressure
debris. cooker).
• Care must be taken when opening the Sharpening the dental Hatchet and carver
pressure cooker. The pressure must be Points to be noted:
released first. • A flat sharpening stone with a fine grain
• The pressure cooker is removed from the is used such as ‘Arkansas’ stone. Coarse
stove after 15 minutes, and left to cool. grained sharpening stone should be
• The instruments are taken out of avoided their use results in rapid wear
the pressure cooker with instrument of instrument.
forceps and dried with clean towel. • The approach adapted in sharpening
• They are then stored in a covered, the instrument varies with the design of
preferably metal box. instrument but the objective should be
to produce a sharp cutting edge while
Sharpening of ART Instruments maintaining the original shape of the
Note: Sharpening is an essential component instrument.
in the maintenance of ART instruments • The Hatchet and the carver are
the instrument that will need sharpening sharpened in a similar manner since
are those used for cavity preparation, i.e. they both have a bevel that forms a
the Hatchet and excavators, and the carver straight cutting edge.
used for the finishing of the restoration. • The sharpening stone is sterilized on a
They should be kept sharp to be effective flat surface such as table. A drop of oil
since when blunt they will require excessive is placed on the stone (this prevents the
force to function. This is not only tiring for fine stone from clogging). This stone
the operator but can be hazardous since is held firmly with one hand and the
the instrument can easily slip and damage middle finger of the other hand is rested
adjacent tissues. In addition, the tissue on the stone as a guide. The beveled
required to prepare a cavity might take surface of the instrument is placed flat
longer with blunt instruments. on the stone. Particular attention is
During use an experienced operator taken to ensure the bevel is parallel to
will be able to detect when the cutting edge the surface of the stone.
of an instrument has become blunt since its • The instrument is slide back and forth
effectiveness is reduced. over the oil covered stone several times
for maximum sharpness.
Testing the sharpness of the • Care must be taken to ensure the surface
instrument on the thumb nail to be sharpened stays parallel to the stone
Points to be noted: surface.
• If the cutting edge digs in during an • The instruments are re-sterilized after
attempt to slide the instrument over the they have been sharpened.
thumb nail, the instrument is sharp. If it
slides, the instrument is blunt. Sharpening the spoon excavator
• Only light pressure is exerted in testing Points to be noted:
for sharpness. • To sharp, the sharpening stone is
• The instrument should be sterilized stabilized on a flat surface such as table.
afterwards. • A drop of oil is placed on stone.
• The stone is held firmly with in hand.
The round surface of the excavator is
placed in the oil and small strokes are
made from the center of the round
surface to the edge of the spoon.
• This is done in all direction so that the
entire cutting edge is sharpened.
Module 4
Selection of Cases for ART
In general, ART can be applied when:
• There is a cavity involving the dentin,
and
• That cavity is accessible to hand instru-
ments.
There are no other special limitations
to the use of the ART approach in the Figure 6.8: Isolation of teeth with cotton roll
management of dental caries other than
applicable to conventional treatment
concepts such as pulp exposure. to the tooth surface and prevent the
glass ionomer from setting optimally.
Step-by-Step Guide to the ART Approach
• Cotton wool rolls must be changed
Preparation of the ART instruments and regularly as soon as they are saturated
materials with saliva.
• All the instruments and materials that • For lower teeth cotton wool rolls are
are likely to be required for an ART placed at either side of the tooth to be
restorations are laid out in a logical and restored.
ordered manner in the sequence that
they will be used. Examining the cavitated tooth
• This simple step will save time and • Once isolated, the tooth and the extent
mean that the operator can concentrate of caries can be examined more easily
on the preparation and restoration (Figure 6.9).
of the cavity instead of searching for • Any plaque or food debris is removed
instruments or materials. from the pits and fissures with a caries
probe.
Isolation of the operating site • Clean the tooth surface by rubbing with
• Isolation of the operating site is an a wet cotton wool pellet. This is then
essential component in the placement followed by drying the surface with a
of ART restorations for reasons of saliva dry pellet.
must be controlled (Figure 6.8).
• Failure to control saliva adequately will Gaining access to the carious lesion
compromise visibility of the operating • Important: A local anesthetic is usually
site, effect bonding of the glass ionomer not required since only dead tooth
Figure 6.9: Tooth with carious lesion for Figure 6.10: Widening cavity for removal of caries
ART procedure using enamel Hatchet
tissue is being removed during cavity developed for this purpose or the liquid
preparation. component of the glass ionomer itself.
• In small carious lesions where the opening • The latter usually contain a solution of
to the cavity is small, it is necessary to between 25 to 40% polyacrylic, tartaric
widen the entrance for access using a and/or maleic acid.
dental Hatchet (Figure 6.10). • The glass ionomer liquid for condition-
• The corner of the Hatchet is placed in ing can only be used if it contains the
the opening that is usually the deepest acid component of the glass ionomer.
part of the pit or fissure. • The liquid component of some brands
• The Hatchet is rotated backwards and of glass ionomer contains only demin-
forwards whilst maintaining slight eralized water, the acid being in freeze
pressure. dried form in the powder. This cannot
• This breaks off unsupported and dem- be used for conditioning.
ineralized enamel.
• Whenever in any doubt, follow the
• The cavity entrance is thereby increased
manufacturer’s instructions.
to at least 1 mm which permits access
for the smallest excavator. Removal of soft, completely
Conditioning the cavity demineralized dentin
• The use of hand-instruments on the • Soft dentin is removed with excavators
dentin surface results in a smear layer. (Figure 6.11).
• In order to improve the chemical • This is achieved by making circular
bonding of the glass ionomer to the scooping movements around the axis of
tooth tissues this smear layer must be the instrument.
removed by the use of a conditioner. • It is important that the soft dentin from
• This can be achieved either by the the enamel-dentin junction is removed
use of a dentin conditioner specially first by use of a small excavator.
• Without releasing the pressure, the
bottle is moved vertically towards the
center of pad or slab.
• A second drop of liquid is dropped on
the pad. That is usually bubble-free.
• Drops with bubbles must not be used
for mixing the glass ionomer since it will
result in a mix being over-dried thereby
compromising chemical bonding.
• The top of the liquid bottle is replaced.
Conditioning the cavity

• The conditioner is applied to the cavity,
pits and fissures using a cotton wool
Figure 6.11: Carious removal using small excavator
pellet for a minimum 15 seconds or
for the period of time specified by the
Removal of thin, Overhanging enamel manufactures.
• The removal of soft dentin from the
• The cavity, pits and fissures are then
enamel-dentin junction often results in
washed with pellets dipped in clean
thin overhanging enamel. When thin, it
water and then carefully dried.
is best removed. Its removal improves
• Compressed air should not be used if
visibility and access to the deeper parts
glass ionomer is the restorative material
of the cavity.
since this can over-dry the tooth and
• The Hatchet is placed at the edge of the
reduce the chemical bonding of the
enamel and slight pressure applied. The
glass ionomer
thin enamel should break off.
• At this stage proper isolation is essential.
• Important: It is not always necessary
Contamination of the conditioned tooth
or possible to remove all overhanging
surface with saliva or blood will have a
enamel. Only that enamel which is
severe effect on the chemical bonding
weak and thin or that hinders access
of the glass ionomer. Therefore, if the
for removal of soft dentin should be
conditioned tooth surface becomes
removed.
contaminated then it is essential to wash,
Dispensing the glass ionomer clean and condition it again.
liquid and powder
• The liquid bottle is carefully tipped Mixing the glass ionomer
upside down to avoid the formation of • The powder bottle is shaken to ensure
air bubbles. an even powder consistency.
• One drop of the liquid is allowed to • The measuring scoop provided by
drop at one corner of the mixing pad or the manufacture is used to take a full
slab. scoop of the powder. Excess powder is
• This drop usually contains air bubbles removed from the scoop by scraping the
and is used for conditioning. top surface against the lip of the bottle.
• The measured powder is then checked • The ball of the index finger is rolled
for any voids that would result in too slightly bucco-lingually and then
little powder being used. mesio-distally so that material is spread
• The powder is placed on the mixing pad over the whole occlusal surface. This is
or slab to one side of the center. called “the press-finger technique”.
• The top of the powder bottle is • After a few seconds, the index finger
immediately replaced to prevent the is moved sideways to prevent the
powder from taking up water from the restorative material from lifting out of
atmosphere. the cavity or pits and fissures.
• The powder and liquid are spatulated • This excess should be quickly removed
until a consistent mix has been with either the carver instrument or
achieved. This must be completed the large excavator. Make sure that
within the mixing time advised by the the ART restoration is not dislodged
manufacturer. (Figure 6.12).
• The working time of glass ionomers is
temperature dependent. It sets more Adjusting the bite
slowly in cold temperatures and faster • When the glass ionomer has semi-
in high temperatures. hardened it is important to check the
• Overly dry or thin mixes should not be bite.
used since they will compromise the • The bite is checked by asking the patient
success of the restoration. to bite from side to side on articulating
paper placed on the surface of the
Restoring the cavity and filling the restoration.
pits and fissures • Any part of the restoration that are too
• The mixed glass ionomer must be high are identified by colored marks on
used promptly, since any delay will the restoration.
compromise chemical bonding to the
• These areas are then be adjusted using
tooth surface.
the carver instrument and the bite is
• The glass ionomer is inserted into cavity
then rechecked and further adjusted as
in small increments using the rounded
necessary.
end of the applier/carver instrument.
• The restoration is then painted with
• Where possible, the glass ionomer
varnish or with petroleum jelly.
should be packed around the margins
• The cotton wool rolls are removed
of the cavity particularly under any
(Figure 6.13).
overhanging enamel before filling
the central portion of the cavity. This
Restoring Multiple-surface Cavities
helps to prevent air bubbles from being
incorporated into the restoration. The approach to prepare multiple-surface
• A small amount of petroleum jelly is ART restorations closely follows that for
rubbed onto the gloved index finger. single-surface. Restorations such as the use
• The gloved index finger is then used to of a dental Hatchet to open the cavity.
press the glass ionomer firmly into the Specific points to be observed are as
cavity, pit and fissures. follows:
Figure 6.12: Restoration of tooth with glass Ionomer cement
Figure 6.13: Checking for high-points by biting the teeth and removal of
excess restorative material
Removal of carious tissue with excavators: patient is asked to refrain from eating for at
Follow the same principles as that for one least one hour.
surface restorations.
Caution in restoring the cavity: Placing large
Use of a matrix band: Where a multiple-sur- parts of glass ionomer material into the
face restoration is adjacent to another tooth, cavity and or insufficient condensing may
such as one involving a proximal surface in cause voids in the restoration.
posterior teeth, a matrix band held in place Insufficient care in placing glass ionomer
with a wedge should be used interproxi- under overhangs may cause voids at the
mally. dentin—glass ionomer interface. There will
This prevents the adhesive restorative be no adhesion at that spot.
material from adhering to the adjacent tooth,
it gives the restoration shape and avoids the Properly restored cavity using ART
production of an overhang. • Good adaptation of glass ionomer to the
cavity walls.
Restorative procedure is completed: The resto- • Good packing of glass ionomer in the
ration procedure is now finished and the cavity.
Note: Multiple-surface restorations often population (41% and a mean DMFT

require more restorative material than single score of 1.1).
surface restoration. • Syria; the total number of carious
A careful assessment of the amount surfaces in deciduous dentitions of
required should be made before mixing up 6 to 7 year old that were in need of a
the restorative material. restoration, 90% were diagnosed as
In the event of the underestimation of being treatable through ART. In 50% of
the material required, the existing material carious surface diagnosed as requiring
should be pressed into the proximal part of a restoration in permanent dentition
the cavity as much as possible. A second mix of these children, the examiners had
of glass ionomer is then made to complete indicated that ART could be applied.
the restoration. It is important to avoid
contaminating the first mix while the second How Well are Hand Instrument Accepted by
mixes being prepared since this will prevent Care Receivers?
adhesion between the mixes. Pakistan; hand-instrument used in ART with
glass ionomer were better accepted than
Adjusting the marginal ridge: If glass ionomer
rotary instrument and amalgam.
is being used as the restorative material, it is
advisable to avoid excessive occlusal load- What can be Said About Discomfort Felt During
ing of the restoration in the region of the Treatment with ART?
margin ridge.
Pakistan; restoration placed using ART were
This area is to be carved so as to be just
compared to those placed using conventional
out of contact with the opposing tooth.
procedure.
Module 5 Have Changes in Treatment Pattern Occurred
Survival of Single Surface ART Restoration due to the Introduction of ART?
Detect potential weaknesses in approach. South Africa: Another advantage was the
Be pragmatic, easy to use and reproducible. simplified infection control, very relevant
Identify problems associated with glass in an area with a high prevalence of HIV
ionomers used. and hepatitis.
Appicability of ART How do ART restorations compare to conventional
How effective are existing hand instruments? restorations in permanent dentition?: As discussed
Dental Hatchet to wide the opening of dentin the quality of a restoration is dependent on
lesion. number of factors that are material, operator
• Zimbabwe; it was possible to treat 84% and patient related (Table 6.3).
of the dentin lesion that were judged to Longevity of amalgam and composite
be needed of treatment resins restorations varies tremendously and
• Access was difficult to dentin lesion ranges from 3 to more than 20 year.
that were present in approximal surface In general dental practice, amalgam and
of the anterior teeth. This study was composite restoration survive on an average
carried out in a low-caries prevalence between 6 to 10 years.
Table 6.3: Mean survival of amalgam and composite Principles of doing Replacements
restoration in general practice
If the failure is due to ART approach being
Average life of In years used in a situation where it is inappropriate
restoration MJOR then an alternative more appropriate
MJOR 1992 et al, 1997 approach should be considered. This of
Amalgam course depends on local circumstances.
• Single suface 10 8
• Multiple surface 8 6 Module 7: Practical Experience in the
Composite resin Handling and Mixing of Adhesive Materials
• Single surface 7 6 for use in the ART Approach
• Multiple surface 4 3
Module Objectives
This module comprises of some guidelines
The ART approach caused less discomfort on how best to train participants in mixing
than the conventional approach. and handling adhesive restorative materials.
This module is practical in nature.
Module 6
What are the Perceived Reason for the General Introductory
Failure of ART Restorations? Statements to the Module
Most of this module is devoted to mastering
Material related reasons: The mechanical
the technique of hand-mixing glass ionomers.
strength of the glass ionomers that frac-
This is because glass ionomers have been
tured. Excessive wear of the glass iono-
used in most of the studies on ART and as the
mer resulting in exposure of the enamel of
hand-mix version of this material is suitable
greater than 0.5 mm at the margin.
for use in outreach situations. If capsulated
glass ionomers and resin containing adhesive
What are the Reasons for Replacement of
Amalgam and Composite Resin Restoration materials will be used, the handling of these
in General Practice? materials should be demonstrated, if needed,
glass ionomers, powder and liquid.
A large proportion of restoration placed by
the oral care workers comprise replacement Requirements: Set of powder, corresponding
of existing restorations. the measuring scoop, liquid, spatula and
mixing pad.
Conclusions about Restoration Failure Make sure that sufficient sets are
Concerning restorations in general dental available, e.g. one set for 2 to 3 participants.
practice: Start with demonstrating the proper manner
A large proportion of rest approach of laying out of the powder and liquid for
being used in general dental practice mixing as explained in module 4. Use the
comprises of replacement restorations. manufacturer instruction to mix the powder
Secondary caries is the main reason for and liquid. Some manufacturers have
amalgam and composite resin restorations to produced a video film showing the mixing
fail. technique.
Salient Points to Note Glass ionomer in capsules usually

Most participants have difficulties in does not pose any difficulty in producing
producing a good mixture of glass ionomer a standard mixture. While the price of the
in the first time. They should be warned material is usually higher, its application is
beforehand that, this might take some usually easier than for the hand mix form.
practice. Mixing glass ionomers is quite Follow the manufacturer’s instruction
different from mixing ZnO -eugenol cement, when demonstrating the use of the capsulated
which most participants master, in mixing glass ionomer.
glass ionomers, one should strictly adhere Resin-modified glass ionomer are
two types: Light and auto-cured. The
to the measured powder to liquid ratio.
requirements for showing the handling
We have noticed from previous classes
of these materials include:
that participants usually have difficulty
initially in incorporating all the powder Light-cured
into the liquid. Obviously, this will lead to • Powder, corresponding measuring
a runny mixture that is not acceptable. Also scoop, liquid, spatula and mixing pad
in the beginning, participants often spend • Light-curing device.
longer than the allotted time for mixing.
Auto-cured
They may go on and on, as they are used
• Powder, corresponding measuring
to when mixing ZnO-eugenol cement. For
scoop, liquid, spatula and mixing pad.
participants who work with a chair side
The auto-cured resin-modified glass
assistant, mixing powder and liquid maybe
ionomer cannot usually be used in outreach
something of the past.
situations where lack of electricity might
• As a trainer, do not accept mixtures
pose a problem. Furthermore, experiences
that are too dry or too wet. Give proper
in using this material as a part of the ART
advice to the participants so that they
approach is limited. Therefore, follow the
can improve. Have the participants
manufacturer instruction carefully when
mix until they have shown the ability
demonstrating how to mix these adhesive
to produce a good mixture a number of
materials.
times. This may take several attempts.
• Compomers and composite resins.
• Mixing glass ionomers in hot and
humid climates is more demanding Requirements
than in temperate climates. The setting • Compomer or composite resin material,
reaction is much faster. Make sure that capsules or tubes
mixing does not take too long. • Primer and bonding material
• Glass-ionomers, capsulated • Application sticks
• Light-curing device
Requirements • Water-air spray system.
• Capsules of powder and liquid The use of resin containing adhesive ma-
• Capsule pistol/gun terials will usually be restricted to the dental
• Mixing machine. surgery.
Module 8: Practice of Cavity Cleaning and • If sufficient teeth with non-cavitated
Restoration Placement using the ART occlusal surface are available, then
Approach on Extracted Teeth participants should also place a glass
ART Restorations on Extracted Teeth ionomer sealant.
Requirements
Sharpening Hand Instruments
• Extracted teeth with cavities. These
cavities should not be too big, which Requirements
unfortunately is not always possible, if • Dental Hatchet and excavator
possible, mounted these teeth before- • Flat surfaced ‘Arkansas’ stone
hand in plaster of Paris • Oil.
• Set of hand instruments
• Materials needed for cavity cleaning Salient points to the note
such as cotton wool pellets and water • Stress the utmost importance of working
• Restorative material with sharp instruments.
• Paper towels and petroleum jelly. • Utmost care must be taken when
sharpening. Instruments should not be
Salient points to note damaged by faulty positioning of the
• Have the instruments and materials instrument.
nicely arranged placed on a paper
towel. Module 9: Practice of the ART
• Start with a demonstration on a cavity Approach on Patients
that is not too big. This will allow you to
Requirements
demonstrate the use of the Hatchet.
• Pre-selected patients—preferably not
• Stress the need to clean the dentin-
young children.
enamel junction.
• A treatment room can be a university
• Make sure that very thin enamel is
clinic or classroom in a school.
removed.
• Pay special attention to cleaning the pits • Sufficient sets of instruments and
and fissures adjacent to the cavity. materials, including local anesthesia.
• Do not accept mixtures that have an • Water, soap and towels.
inadequate consistency.
Salient features to note
• The ‘press-finger’ technique is difficult
to perform on a multiple-surface cavity • Ask the participants to pair up to form a
in an extracted tooth. It is only possible unit of operator and assistant. Each will
when a matrix holder is in place. do an ART restoration in turn.
• Explain the procedures while demon- • For adequate supervision and good
strating the various stages. Show the guidance, a trainer/instructor should
participants certain stages. Emphasis be responsible for not more than 6 units.
the need for a very good finger rest • Have the operator inform the patient
while using hand-instruments. what is going to happen.
• The participants should place at least • Make notes of clinical situations that
two restorations. need discussion at the end of the day.
Module 10: Free Format Discussion immediately separated from the surface, they
Requirements can anchor themselves more permanently
• Flip-over sheets or overhead transpar- using cell adhesion molecules such as pili.
encies. Dental plaque is an example of biofilm,
• Color markers. it has a diverse microbial composition.
There is a dynamic relationship between
Salient points to note the environment and the diversity and
Outreach situations: Try to arrange the groups abundance of species. A change in a
such as from the same area or the same key environmental factor can alter the
country are together. They then can discuss competitiveness of individual species. This
the benefits of ART. can result in the enrichment of a previously
minor component of the community or a loss
Private Practice of a dominant organism. This relationship
• Have participants come up with case may be fundamental to explaining how
stories in which they think the ART plaque-related dental diseases arise. For
approach is particularly helpful. example, Mutans streptococci would be
• Point to the fee structure and the favored by the low pH conditions from
changes for an ART restoration. eating sugary food, thus the presence of
various specific microorganisms in the
Module 11: Course Evaluation plaque (including mutans streptococci) and
the sugar consumption will attack the tooth
This is done through an open questionnaire.
and cause cavities).
Bacterial cells exhibit several density-
BIOFILM CONTROL dependent phenotypes. Such a biological
Plaque as Biofilm phenomenon is referred to as quorum-sens-
ing. Quorum-sensing is achieved through
Dental plaque is defined clinically as
the production of an autoinducer by the
a structured, resilient, yellow-grayish
organism, which upon acquiring a threshold
substance that adheres tenaciously to
concentration, a direct reflection of popula-
the intraoral hard surfaces that adheres
tion density, is able to activate the genes,
tenaciously to the intraoral hard surfaces,
bringing into effect the concerned pheno-
including removable and fixed restorations.
types. While this cell-to-cell communication
A biofilm is a complex aggregation
has played an important role in many diverse
of microorganisms growing on a solid
community-based functions, it also helps the
substrate. Biofilms are characterized by
establishment of a population in changing
structural heterogeneity, genetic diversity,
environment according to the requirement.
complex community interactions, and an
extracellular matrix of polymeric substances.
Formation of a biofilm begins with the Plaque Metabolism
attachment of free-floating microorganisms The metabolic processes of plaque are very
to a surface. These first colonists adhere to complex. Fermentation, alkalinization,
the surface initially through weak, reversible synthesis of carbohydrate polymers and
van der Waals forces. If the colonists are not the elaboration of inflammation-producing
(phylogenetic substances) are functions which Phlogogenic Substances
have been extensively researched. These will In dental caries: Enamel is a highly mineralized
be described. acellular tissue, and caries act upon it
through a chemical process brought on by
Plaque Acidification due to
the acidic environment produced by bacteria.
Fermentation or Glycolysis
As the bacteria consume the sugar and use
Plaque may become acidic when fermentable it for their own energy, they produce lactic
substrate in the food we eat is metabolized acid. The effects of this process include
by acidogenic bacteria within the dental the demineralization of crystals in the
plaque. Lactic acid produced in this manner enamel, caused by acids, over time until
causes enamel demineralization and carious the bacteria physically penetrate the dentin.
lesions. The decrease in pH is known as the Enamel rods, which are the basic unit of
“Stephan Curve”. the enamel structure, run perpendicularly
from the surface of the tooth to the dentin.
Plaque Alkalinization by Ammonia Production
Since demineralization of enamel by caries
Some microorganisms have the ability to generally follows the direction of the enamel
metabolize urea from the crevicular fluid rods, the different triangular patterns
and from the oral fluid, and this results in between pit and fissure and smooth-surface
alkalinization of the dental plaque. Ureases caries develop in the enamel because the
within bacterial plaque split urea into orientation of enamel rods are different in
ammonia and carbonic acid. Alkalinity the two areas of the tooth.
creates more ideal conditions for plaque As the enamel loses minerals, and dental
mineralization, i.e. the formation of dental caries progresses, they enamel develop
calculus. several distinct zones, visible under a light
microscope. From the deepest layer of the
Synthesis of Polysaccharides (Polymers) enamel to the enamel surface, the identified
Certain microorganisms polymerize sucrose areas are the: Translucent zone, dark zones,
to extracellular glucans (dextran, mutans) body of the lesion, and surface zone. The
and fructans (levans). Many microbes translucent zone is the first visible sign of
metabolize sucrose and other mono and caries and coincides with a one to two percent
disaccharides to intracellular glucans. loss of minerals. A slight remineralization of
Intracellular polymers serve as energy enamel occurs in the dark zone, which serves
reserves for plaque bacteria. Extracellular as an example of how the development
polymer forms the cementing substance of dental caries is an active process with
which binds plaque to the tooth surface and alternating changes. The area of greatest
which binds the bacteria within plaque to demineralization and destruction is in the
one another. The extra cellular polymers body of the lesion itself. The surface zone
also have roles to play in determining the remains relatively mineralized and is present
permeability or semi permeability of dental until the loss of tooth structure results in a
plaque; in addition they may serve as cavitation.
carbohydrate reserves, thus aiding in acid In periodontal disease: Plaque allowed to
production. accumulate upon a perfectly cleaned tooth
surface, in immediate contact with healthy Table 6.4: Selection of teeth and surfaces
gingival margin, can cause inflammatory
Tooth Surfaces
alterations after only a few days.
The inflammation is the result of this 16 Buccal
marginal chronic infection. It does not 11 Labial
26 Buccal
occur as result of bacterial invasion. The
36 Lingual
plaque produces substances which loosen
31 Labial
the cementing substance of the cells of the
46 Lingual
junctional epithelium (bacterial enzymes
such as glucuronidase and hyaluronidase). Substitutions for Missing Teeth
Because of this increased permeability,
• When a first molar is missing, less than
high molecular weight plaque substances
¾ erupted, has a full crown or is broken
(e.g. antigens, endotoxins from bacterial
down, the second molar is used or the
membrane lipopolysaccharides) can also
third molar when the second molar is
migrate through the epithelial attachment.
missing.
Chemotactic substances, stemming either
• When a central incisor is missing, the
directly from the plaque or produced
adjacent incisor of the opposite side is
secondarily in subepithelial connective
used.
tissue (complement activation), attract
inflammatory cells to the site. These cells
Procedures
have in their lysosomes numerous tissue-
digesting substances which can weaken 1. Apply disclosing agent before scoring.
the marginal connective tissue apparatus, 2. Instruct the patient to swish for 30
and lead eventually to irreversible damage. seconds and expectorate but not rinse.
In the realm of cellular immune reaction, 3. Examination is made using a mouth
substances are perhaps released which play mirror.
a toxic role. 4. Each tooth surface to be evaluated is
If the plaque is removed, the gingiva subdivided into 5 sections:
returns to normal in a few days. The greater i. Vertically: 3 divisons—mesial,
the marginal accumulation of plaque, the middle and distal.
longer and more intense is the marginal ii. Horizontally: Middle third is sub-
inflammatory reaction. Gingivitis permitted divided into gingival, middle and
to persist for years usually progresses to occlusal or incisal thirds.
marginal periodontitis. 5. Each of the subdivisions are scored for
the presence of stained debri as follows:
ORAL HEALTH EDUCATION TO PHP score Criteria

CONTROL BIOFILM USING PHP INDEX 0 No debri (or questionable)
1 Debri definitely present
Purpose M When all three molars or both incisors
To assess the extent of biofilm and debri over are missing
a tooth surface (Table 6.4). S When a substitute tooth is used
Scoring – Flosses and tapes
Debri Score for Individual Tooth Professionally – Rotating cups, brushes
administered and flexible tips
Add the scores for each of the 5 subdivisons.
– Tapes and flosses
The scores range from 0 to 5.
– Ultrasonic instruments
PHP Index Value for the Individual – Air abrasives
Total the scores for the individual teeth and Chemical
divide by the number of teeth examined. The Self administered – Dentifrices
PHP value ranges from 0 to 5. – Mouth rinses
– Chewing gums
PHP Index Value for a Group – Lozenges
Total the individual scores and divide by the – Pulsed irrigation
number of people examined. Professionally – Syringing
applied – Pulsed irrigation
Nominal Scale for Evaluation of Scores – Slow release devices
– Gel application
Rating Scores
– Varnishes containing
Excellent 0 (No debris) active agents.
Good 0.1–1.7
Fair 1.8–3.4
Mechanical Methods for the
Poor 3.5–5.0
Control of Plaque
Traditional Tooth Sticks
PLAQUE CONTROL
• Ancient people chanced twigs of plants
Plaque control is the removal of dental with high aromatic properties.
plaque on a regular basis and the prevention • They also contained antibacterial oils
of its accumulation on the teeth and adjacent and tannin which help remove plaque.
gingival surfaces. • Arabs before Islam used a piece of the
The plaque control is an effective way of roof from the Arrak tree, since its fibers
treating and preventing gingivitis and is a stood out like bristles. This device is
critical part of all the procedures involved in called as ‘Siwak’.
the treatment and prevention of periodontal
diseases. Toothbrushes
• The Chinese are given credit for inventing
Procedures for the Control of toothbrush during Tang Dynasty (618–907
Plaque and Calculus AD)
Mechanical • In 1780, William Addis in England
Self administered – Finger application (char- manufactured ‘the first effective brush’.
coal)
– Traditional tooth sticks Toothbrush Design
(Miswak, Siwak) 1. Made up of a handle a head and bristles.
– Brushes 2. Constriction between handle and head
– Wood sticks is called shank.
3. Toothbrush has three parts: • Three basic patterns:

i. Head – Reciprocating: Back and forth move-
ii. Shank ment.
iii. Handle – Arcuate: Up and down movement.
4. Toothbrush can be of three sizes: – Elliptical: A combination before.
i. Large • Has alternate tuffs of 2 different lengths
and each of the 10 tuffs is independently
ii. Medium
driven and rotates at approximately
iii. Small
4200 rpm. Individual tufts rotate 1½
5. The stiffness of the toothbrush bristles
revolution in one direction then ½
can be:
revolutions in opposite direction.
i. Hard
ii. Medium Special Uses
iii. Soft 1. Parental brushing of child’s teeth.
2. Physically handicapped, mentally
ADA Specification for Toothbrushes retarded, aged, arthritic or otherwise
A brushing surface 1–1.25 inches long (25.4– with poor dexterity.
31.8 mm) and 5/16 to 3/8 inch (7.9–9.5 mm) wide, 3. Poorly motivated.
2–4 rows of bristles, and 5–12 tufts per row.
A toothbrush should be able to reach and Toothbrushing Methods
efficiently clean most areas of the teeth. 1. Horizontal: Most used method
i. Bristles placed perpendicular to the
Bristle Shape crown.
1. Nylon bristles have a uniform diameter ii. Brush moved back and forth in hori-
and a wide range of predictable zontal strokes.
firmness. iii. Over prolonged use, may result in
2. Rounded, tapered, or smooth bristle gingival recession and abrasion.
tips were less abrasive. 2. Fones: Similar to horizontal scrub
3. Bristle firmness depends on technique
i. Rotary strokes are used.
i. Material
ii. Fones cautioned about possible
ii. Diameter
damage of gingiva but encouraged
iii. Length
stimulating the gingiva.
10–12 mm long 0.007–0.009 (soft) iii. Fones advocated month brushing
0.007–0.015 in which included teeth, gingivae and
diameter (adult) 0.010–0.012 (medium) tongue.
0.005 (children) 0.012–0.015 (hard) 3. Stillman: Originally developed to
provide gingival stimulation. The
Electric Toothbrush toothbrush is positioned with the
• The head of the electric toothbrush B is bristles inclined at a 45°C angle to
smaller and is removable. the apex of the tooth, which part of the
• The head approximately ¾ in long and brush resting on gingiva and a part on
¼–½ in wide. tooth. A vibratory motion is used with
a slight pressure on gingiva. Bristles are 6. The rolling stroke (Press roll)
mainly pulsed. i. Involves the general cleaning of
4. Charters: Advocated a pressure vibratory the gingiva and the teeth without
technique to clean the interproximal emphasis on the sulcus.
areas. ii. Offers preparatory instruction for
i. To reduce interproximal caries. the modified Stillman, Charter’s and
ii. Bristles are placed on gingiva at Bass’s techniques.
a 90° angle to the facial surfaces iii. Toothbrush bristles are positioned
greatly gently manipulated into the
parallel to and against the attached
interproximal areas.
gingiva, with the toothbrush head
iii. Vibratory action is given.
level with the occlusal plane. The
iv. Indicated: Cleaning the abutting
wrist is then turned to flex the
surfaces of fixed bridges, around
toothbrush bristles first against the
fixed orthodontic appliances and
when interproximal tissues are gingiva and then the facial surface.
missing. An arcuate sweeping motion is
5. Bass method: First technique to focus continued until the occlusal or
on the remove of dental plaque and incisal surface is reached. The
debris from the gingival sulcus. Dr CC toothbrush bristles are at right
Bass, physician and former dean at angles to the tooth surface as the
the Tulane Medical School published brush passes over the crown.
his initial paper in the journal of the iv. Repeated at least 5 times.
Louisiana Medical Society. 7. Modified Bass techniques: Sulcular
i. Tooth brush recommended by Dr brushing is done either before or after
CC Bass the use of the rolling method. The
ii. 3 rows of nylon bristle Bass sulcular brushing and the rolling
iii. 6 tufts per row stroke should not be combined into
iv. 80 filaments per tuff one continuous movement, since this
v. With rounded and polished equal may result in an inadequate amount
length bristles of pulsing or the brush not being
vi. Individualized toothbrush size positioning correctly in sulci.
vii. Easily and effectively manipulated
I n t h e m o d i f i e d S t i l l m a n a n d
viii. Readily cleaned and aerated
Charter’s methods the toothbrush
ix. Impervious to moisture
bristles are placed in approximately
x Durable
the same position as advocated in the
xi Inexpensive
original method and a pulsing action
xii Toothbrush is positioned in the
gingival sulcus at a 45° angle to is started. Then the toothbrush is press
the tooth apex. The bristles are rolled coronally. A continued vibratory
then gently pressed to enter the motion is used during this rolling
sulcus. A vibratory action, (back stroke.
and forth horizontal jiggle) causes 8. Leonard’s method:
a pulsing of the bristles to clean i. Advocated a vertical stroke in
the sulci. Ten strokes are advised which maxillary and mandibular
for each area. teeth were brushed separately.
ii. With the teeth edge to edge, place Supplemental Oral Hygiene Care
the brush with the filaments against Dental floss
the teeth at straight angles to the 1. Removes plaque and debris that are
long axes of the teeth. adherest to the teeth, restorations, or-
iii. Brush vigorously with great pres- thodontic appliances, fixed prostheses
sure, with a stroke that is mostly and gingiva in the interproximal embra-
up and down on the tooth surfaces, sures and under pontics.
with just a slight rotation or circular 2. Polishes the surfaces.
movement after striking the gingi- 3. Massages the interproximal papilla.
val margin with force. 4. To identify the presence of subgingival
9. Smith’s physiologic method: calculus deposits, over hanging restora-
i. Described by Smith and advocated tion and interproximal carious lesions.
later by Bell. 5. Reduces gingival bleeding.
ii. It was based on the principle that 6. Contributes to general oral sanitation,
the toothbrush should follow the and the control of halitosis.
same physiologic pathway that food
follows when it traverses over the Knitting yarn: In areas where the IDP have
tissues in a natural masticating act. receded and the interdental embrasure is
iii. A soft brush with “small tuffs of fine wide open for proximal cleaning.
bristles arranged in 4 parallel rows
and trimmed to an even length was Pipe cleaner
used in a brushing stroke directed Used in:
down over the lower teeth onto the 1. Exposed proximal surfaces.
gingival and upward over the teeth 2. Open furcation areas.
for the maxillary. 3. Malposed or separated teeth.
iv. Smith also suggested a few gentle Gauze strip
horizontal strokes to clean the 1. Proximal surfaces adjacent to edentulous
portion of sulci directly over the areas, teeth that are widely spread and
bifurcations of the roots. implant abutments.
10. Scrub brush: 2. A facial-lingual ‘shoeshine’ stroke is
i. Vigorously combined horizontal, used to loosen plaque and debris.
vertical and circular strokes, with
some vibratory motions for certain Interdental tip stimulator
areas. • Consists of a conical, flexible, rubber or
plastic tip attached to a handle or to the
Supplemental Brushing end of the toothbrush.
Tongue brushing: The papillae on the tongue – To remove interdental plaque from
provide an area especially conducive to open embrasures.
bacteria and debris retention. Placing the – Recontour the gingiva following
brush in the center of the tongue, it is swept periosurgery.
forward repeating 6 to 8 times in each area. – Massage the IDP.
A palate should also the cleansed with a – Increased epithelial keratinization.
sweeping motion. – In inaccessible areas.
Wedge stimulator Foaming agent
1. Made of wood/plastic. (soup/detergent) – 1–2%
2. Triangular in shape. Binding agent – Up to 2%
3. Used for ID areas where there are Flavoring agent – Up to 2%
exposed tooth surfaces and missing Sweetening agent – Up to 2%
inter dental papilla. Therapeutic agent – Up to 2%
4. To massage the IDP. Coloring/preservative – Up to 1%
5. They do not completely remove plaque.
Mouth rinses: Can be classified by cosmetic
6. Recent studies suggests use of the
and therapeutic.
wooden wedge to determine presence/
absence of gingival bleeding as an
Purposes
indicator/gingival health status.
In dental office:
Tooth picks 1. Preoperative rinse
1. Made of metal, ivory and carved wood. 2. Postoperative rinse
2. In open embrasures. 3. To facilitate important procedures
4. During film placement for radiography.
Interdental brush and swab
1. Is a small, spiral, bristle brush, cotton
swab or single tuft of bristles attached Classification of Chemical
to a handle. Plaque Control Agents
2. Interdental is used: First Generation Antiplaque Agents
i. Clean interdental spaces and around • They are capable of reducing plaque
fractions, ortho bands and fixed scores by about 20 to 50%.
prosthodontic appliances. • They exhibit poor retention within the
ii. To stimulate gingival tissues. mouth.
iii. To apply chemotherapeutic agents. • For example antibiotics, phenols, qua-
3. Swab tips are used for plaque removal ternary compounds and sanguinarine.
from root concavities, craters, furcations
and periodontal pockets and around Second Generation Antiplaque Agents
ortho appliances. They produce an overall plaque reduction
Dentifrices of around 70 to 90% and are better retained
1. According to ‘Webster’ the term denti- by the oral tissues and exhibit slow release
frice is derived from dens (tooth) and properties.
fricare (to rub). For example, Bisbiguanides (chlorhex-
2. Marketed as tooth powders, tooth pastes, idine).
liquids and gels. All are sold as being either
cosmetic (clean and polish) or therapeutic Third Generation Antiplaque Agents
(reduce some disease process). • They block binding of microorganisms
Ingredients to the tooth or to each others.
Abrasives – 20–40% • As compared to chlorhexidine, they do
Water – 20–40% not exhibit good retentive properties.
Humectants – 20–40% For example delmopinol.
Chapter
7 Diet Counseling
INTRODUCTION Dietary Counseling

Dentists sometimes see highly caries prone Requirements for Dietary Counseling
patients whose teeth surfaces are partly • Active patient involvement in planning,
covered with dental plaque bacteria. These implementing and evaluating the diet
bacteria degrade the ingested carbohydrate before and after counseling.
rich foods that adhere to the tooth enamel • Insisting on a series of follow-up visits
and produce organic acids which causes to tailor, the diet to the patient’s need
demineralization of tooth surface leading and likes, and if possible without jeop-
to dental caries. In these instances dietary ardizing the dental oral health status.
counseling to inhibit the caries process
rather than systemic nutritional counseling Communication
for developing a caries resistant tooth is 3 Rules for Effective Communication
appropriate.
1. Face to face interview, eye contact.
Dietary guidelines have 2 primary aims:
2. Verbal and nonverbal communication.
1. To provide a diet that meets the 3. Message must be adapted to the patient’s
requirement for all nutrients. needs and level of understanding.
2. To avoid diet related diseases. To communicate with the patient a
Dietary guidelines are designed to combination of interviewing, counseling
maintain an adequate intake of nutrients and teaching and motivation are used.
to protect against diet related disease.
Interviewing
DIETARY COUNSELING Purpose
Points to be considered while giving dietary To obtain information about diet and provide
advice: required guidance to maintain healthy diet.
• It cannot be considered a one-off event.
• It usually involves challenging the be- Goals
liefs of the entire family and modifying • To understand the problem.
certain aspects of lifestyle. • To understand the factors that contribute
• Changes in diet related behavior should to it.
be paralleled with changes in other • To understand the lifestyle related
aspects of healthier related behavior, in behavior of the patient.
order to become healthier person. • It serves as a diagnostic aid.
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Diet Counseling 181
• Knowledge of a person’s routine diet is • Nondirective—In nondirective coun-

important for adapting the caries pre- seling the counselor’s role is merely to
ventive diet to an individual’s lifestyle. aid the patient in clarifying and under-
standing his or her own situation and to
How to Interview a Patient? provide guidance so that the patient can
• Make the patient relaxed and comfort- make his or her own final decision as to
able. the type of action that should be taken.
• Start with a brief introduction of the Note: Nondirective counseling approach
purpose of the interview. is recommended.
• Ask questions that will encourage
patient’s expression. Guidelines for Counseling
• Listen before speaking. • Gather information
• Interviewer should unobtrusively • Evaluate and interpret information
direct the interview. • Develop and implement a plan of action
• Do not make decisions for the patient. • Seek active participation of the patient’s
• Recapitulate what the patient has family
learned and future action you have • Follow-up to assess the progress made.
agreed on before closing the interview.
• A new appointment for reinforcement, Principles of Diet Management
answering questions and taking further Fundamental principle are simply slight
action should be made. modifications of a normal or adequate diet.
• Various teaching aids can be used. 4 rules while making dietary modifications:
• Visual aids like ivorine teeth models • Maintain overall nutritional adequacy.
and plastic or rubber like food models— • Prescribed diet should vary as little as
to visualize what you are teaching. possible from the normal diet pattern.
• Best teaching aids—black board and • Principles of diet management.
chalk or paper and pencil. • Diet should meet body’s requirements
• Always present information in small for essential nutrients.
increments. • Diet should take into consideration
• Do not move to next level till first level and accommodate patient’s likes
is completely understood. and dislikes, food habits and other
• Use analogies with everyday experi- environmental factors.
ences to explain.
• Involve the patient in educational process. Application to Caries Prevention
Step by Step Dietary Counseling for
Counseling Caries Prevention
Counseling can be of 2 types: 1. Initial examination including dental
• Directive—In directive counseling, the and medical history.
role of the patient is passive and the 2. Formulation of overall treatment plan
decisions are made by the counselor for incorporating restorative and preven-
the patient. tive procedures.
Chapter 7.indd 181 11/5/2014 6:04:08 PM

3. Evaluation of related circumstances and • Liberal use of firm detergent foods, i.e.
problems like attitudes and beliefs and raw foods and vegetables.
socioeconomic history, etc. should be • Recommend drinking and cooking
taken into account. with fluoridated water or ingestion of
4. Determination of entry knowledge of fluoride supplements.
the patient on the role of carbohydrates, • Also recommend use of fluoridated
sugars, non milk extrinsic sugars in the dentifrice or mouth rinse.
process of caries formation.
5. Diet history and evaluation. How to Assist the Patient to Select an
Adequate Noncariogenic Diet?
Diet diary can be maintained for:
i. 24 hour recall Acceptable snacks from the four food groups
ii. 3 day diet diary • Milk group: Milk, cheese, hard or soft
iii. 7 day diet diary varieties.
iv. 21 day diet diary • Meat group: Turkey, chicken, nuts of all
Instructions for keeping a food diary: kinds.
• Fruit and vegetable group: Raw fruits
i. An accurate complete record of food
like oranges, grapes, grapefruit, peach-
intake.
es, pears. Raw vegetables like carrots,
ii. Description of what was consumed
celery, cucumbers, lettuce, salad greens
in detail (Should give brand names,
and tomatoes, unsweetened fruit juices,
comment upon recipes used). tomato or vegetable juices.
iii. Time of consumption. • Bread and cereal group: Crackers, toast,
iv. Recording the circumstances of pretzels.
consumption.
Diet diary is analyzed for: Dietary Advice for Particular Groups
i. Adequacy of intake of foods from
Preschool children
food groups.
• Future dietary habits formed during
ii. Amount and type of foods sweetened
early years.
with sugar and frequency of eating
• Advice and instructions should include
them. reference to anyone who cares for the
child.
General Principles to be Applied for
• Sugar should not be added to bottle
Prevention of Dental Caries
feeds, sugared drinks should not be
• Limit the number of eating periods to given to feeders which may enable liquid
4 regular meals/day, avoid in between to be in prolonged contact with teeth.
meal snacks. • Diets composed of low fat and high
• Increase the intake of protective foods. fiber foods are recommended.
• Decrease the total amount of carbohy-
drates (should provide no more than Pre-adolescent school children
50% and no less than 30% calories) • Young children are usually more enthu-
• Wean the patient from sweet taste siastic for change than their parents.
restrict the consumption of sugar con- • Child should be addressed directly and
taining foods to meals. included in discussions.
Chapter 7.indd 182 11/5/2014 6:04:08 PM

Diet Counseling 183
• Problem to convince children that what • Dietary advice should be especially

they do now is important to them. guarded.
• Children may ask questions on habits • Craving for sweets are relatively com-
and answers should be readily available mon and hence, importance of oral
in a language they can understand. hygiene should be stressed.
• Prolonged breast or bottle feeding is
Teenagers avoided during night time in order to
• Do not alienate the child and ensure prevent early childhood caries without
that contact is maintained. adequate oral hygiene and protection
• Enforcement of desirable behavior. from fluoride has been associated to
• Adolescents can show bizarre eating cause rampant dental caries.
patterns. • Breast milk does have high lactose
Young adults and adults content but several studies have shown
• Early adulthood is a period of irregular it to be protective against dental caries
habits in general and eating habits in and variety of infections and possibly
particular. even problems such as development of
• Period when new habits are formed CHD in later life. Breastfeeding should
with responsibility for health. therefore be encouraged.
• Adults are more likely to take care of
Elderly
their health but some are mistaken that
• Elderly people with teeth are still prone
it is too late for them to influence their
to dental caries.
health with regard to dental caries.
• Exposure of roots, declining salivary
Pregnancy and lactation flow and other factors like, ill health,
• Receptive time for advice. poor financial situation, deterioration in
• Messages given and targets set now mental health and eating habits.
are more likely to be met and influence • Sympathetic approach with realistic
change in behavior. targets.
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Chapter
8 Management of Physically and

Mentally Challenged Children
Dental care for special children is often 6. Systemic disorder

neglected by parents and dentists, a sad 7. Metabolic disorder
but true fact. The terms “special child“ or 8. Osseous disorder
“disabled child” are often reserved for those 9. Malignant disorder.
who are having impairment that restricts
or limits daily activities in some manner. Treatment Factors to be Considered
There by these handicapped children can be 1. Understanding the condition: Before
broadly divided into medically compromised planning any treatment, the dentist
children and developmentally disabled must carefully assess and evaluate the
children. These children need dentist’s/ handicap patient’s dental needs and
parent’s/guardian’s attention more so his/her ability and willingness to co-
because of facts that they are unable to take operate during treatment. Assessment
care of their basic oral health care needs. should be achieved via a history and
clinical examination. The level of
communication and intelligence of
DEFINITION
the child should be elicited along with
The WHO has defined a handicapped the relevant past medical and dental
person as “one who over an appreciable history. During clinical examination, an
period of time, is prevented by physical or assessment of ease of operation can be
mental conditions from full participation made.
in the normal activities of their age groups 2. Attitude of the parents towards
including those of a social, recreational, particular problems: The family has
been emotionally, physically and
educational and vocational nature”.
financially tied up with the patient’s
medical conditions, which makes them
CLASSIFICATION difficult to get interested in dental
needs of the child. Informed consent
Nowak (1976) has classified handicapping
must be taken prior to starting any
conditions into nine categories as follows: treatment which may also include
1. Physically handicapped general anesthesia or even the use of
2. Mentally handicapped physical restraints.
3. Congenital defects 3. Attitude of the society: These children
4. Convulsive disorder are sometimes not well accepted
5. Communication disorder by the society and this may have a
Chapter 8.indd 184 11/5/2014 6:03:13 PM

Management of Physically and Mentally Challenged Children 185
psychological impact on the child’s Where the level is suboptimal, fluoride

mind. This fact should be taken into supplementation is required. Regularly,
consideration during treatment. scheduled professional application of topical
4. Attitude of the patient: The dental fluoride should be carried out both in the
management techniques must be carried fluoridated and non-fluoridated areas based
out carefully. These children have on the concentration of fluoride in central
indifferent attitude towards everything water supply.
including dental care. Special efforts and
care should be taken to desensitize them
towards dental treatment. Preventive Restorations
5. Attitude of the dentist towards the partic- These include application of the pit and
ular condition should always be positive. fissure sealants, preventive resin restorations
and even stainless steel crowns.
PREVENTIVE MEASURES
Plaque Control MENTAL RETARDATION
Handicapped patients have poor standard Mental retardation is defined by the
of oral hygiene along with higher prevalence American academy on mental deficiency
of periodontal disease. Prevention centers on as significantly subaverage intellectual
systemic removal of bacterial plaque. Tooth functioning, existing concurrently with
brushing and dental flossing, are the most deficit in adaptive behavior and manifested
effective plaque controlling methods require during the developmental period.
practice, skill and effort. The brushing
technique for these children should be
Dental Problems
carried out by the parents/guardians.
An often recommended technique is the Patients with mental retardation present
horizontal scrub method due to its ease of with multiple anomalies of facial structures,
performance. Modifications of toothbrushes eruption time, sequence and number,
can be made, i.e. the grips can be modified presence of malocclusion, enamel hypoplasia,
using the patients hand to custom design the etc. They may also show higher prevalence
handle, bicycle handles can be fitted over the of dental caries and periodontal disease,
brush handle to give a better grip. Electric because of poor oral hygiene and cariogenic
toothbrushes can also be used. diet patterns.
Diet Treatment Considerations

A balanced diet is essential for proper The dentist must first asses the child’s mental
nutrition and as a part of preventive program level so as to gauge the level of co-operation
for the handicapped children. to be expected and make adjustments
accordingly:
Fluorides 1. Short attention span, restlessness,
Systemic fluoride through the ingestion hyperactivity and erratic emotional
of optimally fluoridated water should behavior characterize MR patients
be advocated to handicapped children. under going dental treatment.
Chapter 8.indd 185 11/5/2014 6:03:14 PM

2. Familiarize the patient to the dental changes in neurological functions caused

office, dental personnel to reduce his or by abnormalities in the electrical activity of
her fear of unknown before undertaking the brain.
any treatment.
3. Speech must be slow and simple. Oral Manifestations of Epilepsy
4. Only one instruction should be given at Injuries caused by the epilepsy are:
a time. • Soft tissue lacerations on tongue or
5. Carefully listen to the patients, as these buccal mucosa.
children often have problem in commu- • Facial fractures.
nication. • Trauma to teeth-avulsion, luxation,
6. Appointments should be short and fractures.
scheduled during the early part of the • Subluxation of the TMJ.
day. Injuries due to drug therapy:
7. General anesthesia may be indicated
• Gingival hyperplasia
in cases where adequate level of coop-
• Recurrent aphthous ulceration
eration cannot be achieved or where
• Developmental dental anomalies like
extensive rehabilitation is required.
small teeth, delayed eruption
8. Permanent restoration and preventive
• Cervical lymphadenopathy
procedures are advised along with
• Secondary infection of this fibrous
regular dental check up.
overgrowth when oral hygiene practices
are neglected resulting in friable and
LEARNING DISABILITY hemorrhagic tissues.
This term is applied to children to exhibit
a disorder in one or more of the basic Dental Management
psychological processes, involved in Prevention of seizures in the dental office can
understanding or using spoken or written be best managed by:
language. • Complete medical history should
be acquired regarding the type and
Dental Treatment Considerations frequency of seizure episodes prior to
• Most of them accept dental care treatment.
willingly, do not cause any unusual • Reduce stress on the patients with psy-
management problems. chobehavioral preparations, sedation,
• For patients who are unwilling to etc. Diazepam is the drug of choice be-
undergo dental treatment analgesia, cause it has anticonvulsant properties.
sedation or general anesthesia may be • Use of dental chair light is avoided.
used. • Avoid seizure promoting drugs such as
phenothiazines.
• Appropriate drug therapy for seizures.
EPILEPSY
• Due to the use of antiepileptic medica-
Epilepsies are a group of disorders charac- tion, typical fibrous gingival hyperplasia
terized by chronic, recurrent, paroxysmal may occur.
Chapter 8.indd 186 11/5/2014 6:03:14 PM

Management of Physically and Mentally Challenged Children 187
DEAFNESS if the visual acuity does not exceed 20/200

in the better eye with corrective lenses or if
This includes individuals who have total
the visual acuity is greater than 20/200 but
deafness as well as hearing impaired making
accompanied by a visual field of no greater
them suffer from varying degrees of deafness.
Inevitably their speech is affected as sounds than 20 degrees.
have to be heard to be imitated. This reduced
ability to communicate through speech Dental Problems and Treatments
influences adversely the psychological • Complete medical history along with
development and social integration of the the degree of visual impairment is
deaf children. ascertained prior to treatment.
• Describe in detail the office settings,
Dental Problems and Treatments office personnel and treatment proce-
• Poor oral hygiene related to learning dures before starting anything.
disability and hypoplastic teeth can • Make physical contact reassuringly and
occur in hearing impaired children. do not suddenly grab or move patient
• During the pre appointment interview without prior notice.
the manager of the communication
• The dentist can make use of touch, taste
should be elicited along with a detailed
and smell rather than the TSD method.
medical history.
• If the parent is allowed to remain in • Prolonged immature swallowing
the operatory, then he/she should be pattern due to a reluctance to consume
seated such that the child can see them. solid foods, poor oral hygiene related
• Proceed slowly in a warm and reassuring to learning disabilities as well as
manner using facial expressions, smiles, hypoplastic teeth have been identified as
gestures, physical contact and praise. possible oral manifestations in visually
• Speak directly facing the patient in a impaired children.
normal tone, without using slang. • Frequency of trauma to anterior teeth
• Adjust the hearing aid while using is higher in physically and mentally
a handpiece as all sounds may be challenged population when compared
amplified. to normal population.
• Use tell show do, positive reinforcement • Increased gingival inflammation due
and modeling desensitization behavior to inability to visualize and remove
modeling techniques.
dental.
• Pretreatment sedation or even general
• Avoid using any signs, expressions of
anesthesia may be required for more
pity and references to blindness as an
serious behavioral management prob-
lems. affliction.
• Oral hygiene should be explained
and the child guided through the
BLINDNESS
procedures by the dentist along with
It is an all or none phenomenon and a the use of audio cassettes and Braille
person is considered affected by blindness pamphlets.
Chapter 8.indd 187 11/5/2014 6:03:14 PM

Chapter
9 Management of Medically
Compromised Patients
There are three basic problems regarding the • Avoid NSAIDs in renal patients which
dental treatment of patients with significant may increase the risk of renal damage.
systemic disease:
• First is to detect such patients. Drugs which may Complicate
• Secondly if the patient is found to have Treatment Include
a systemic disease, it becomes necessary • Digitalis—vomiting
to determine what implications the • Acetazolamide—facial paresthesia
disease or their treatments have for • Procainamide—leukopenia
dental management.
• Finally it remains necessary to discover Hypertension
how best to deal with the problem. • Defined as a systolic BP of >140 mm
Hg or diastolic >90 mm Hg (based on a
Cardiovascular Disorders average of 3 values)
Common Symptoms and Signs • Age of the patient must be taken into
• Breathlessness (dyspnea)—typical of consideration as BP increases with age.
left sided heart failure. • Classified as primary (essential) and
• Chest pain—ischemic heart disease. secondary:
• Palpitations—maybe sign of dysrhyth- – Primary—no underlying pathology
mia. to explain the disease constitutes
• Sudden loss of consciousness—defect in 95% of the patients.
conduction (heart block). – Secondary—causes include renal,
• Central cyanosis—cardiac failure or cor endocrine, neurogenic.
pulmonale.
Medical Management Includes Classification Systolic Diastolic Dental treatment

Diuretics, digitalis, other vasodilators. Normal <120 <80 no changes
Pre- 120–139 80–89 no changes
Dental Aspects hypertension
• In controlled patient treatment under Stage 1: 140–159 90–99 routine medical
local anesthesia can be carried out. Hypertension consultations
• Placing the patient supine may increase Stage 2: systolic diastolic no changes in
Hypertension ≥ 160 ≥ 100 dental treatment
dyspnea, to be avoided.
Chapter 9.indd 188 11/5/2014 6:04:02 PM

Management of Medically Compromised Patients 189
• Afternoon appointments are preferred • 40% of the hypertensive have increased

as BP is higher in the mornings. catecholamine which may lead to
increased sympathetic activity. Hence,
Treatment Considerations all care must be taken to avoid acute
• Medical consultations, monitor BP at emotional reaction (like anger).
each appointment. • NSAIDs can alter BP in toxic doses but
• If systolic BP is <180, diastolic <110 have no action on vasomotor center
then selective treatment (examination, therapeutic doses.
prophylaxis, restorative non surgical • b-blockers—dry mouth, lichenoid
endodontic and periodontic); minimize reactions, paraesthesia with labetelol.
• ACE—inhibitors enalapril—loss of
stress.
taste, captopril—burning sensation,
• If systolic ≥180 or diastolic ≥100 then
ulceration.
immediate medical consultation and
• CCBs—Gingival hyperplasia, saliva-
emergency dental care (pain alleviation,
tion—nicardipine.
bleeding, infection control), stress
• LA contains <1:100,000 epinephrine is General Anxiety Reduction Protocol (ARP)
preferred
Before appointment
• Maximum cardiac dose of epinephrine
• Hypnotic agent previous night or on the
in cardiac patients is 0.04 mg/kg morning of surgery.
• 1 ml LA contains 0:01 mg of epinephrine, • Scheduling of appointment with mini-
and the ratio of LA and epinephrine is mum waiting time.
1:100,000.
• Hence a cardiac patient can receive up During appointment
to 4 ml of LA safely • Non pharmacological methods include
• Intraligamentary injections are contra- constant verbal communication and
indicated as the hemodynamic changes assurance, distracting conversations,
are similar to IV injections. avoiding unnecessary sounds, instru-
ments out of sight, relaxing background
Pain Control music, etc.
• Pharmacologic means include using
Pain control → profound anesthesia and
profound analgesia, nitrous oxide, an-
analgesia → ↓ stress → ↓ endogenous
xiolytics, etc.
epinephrine → control of hypertension.
The benefits of small doses of epinephrine After appointment
used in dentistry far outweigh the potential • Sufficient post operative care and in-
for hemodynamic compromise. structions.
• Effective analgesics, reassurance.
Side Effects of Antihypertensive Drugs
• Postural hypotension—hence change ISCHEMIC HEART DISEASES
the position of the patient from supine
to upright in a gradual manner. Angina Pectoris and Mi
• Bronchospasm—b-blockers in patients • Angina pectoris occurs when myocar-
with history of obstructive lung disorders. dial oxygen demand exceeds supply
Chapter 9.indd 189 11/5/2014 6:04:02 PM

resulting in temporary myocardial is- • If signs and symptoms ease in 3 minutes

chemia which usually lasts for 10 to 15 complete the procedure
minutes. • Repeat GTN if no relief is obtained yet
• Failure to resolve in this period may • No relief after 6 minutes—suspect MI.
indicate permanent damage from administer morphine and transfer the
myocardial infarction. patient to the hospital.
Symptoms
Cardiac Pacemakers
Crushing pain which radiates across the
• Consult the physician
chest in to the arms, neck and upto the jaw.
• Older unipolar pacemakers were
Underlying Pathology affected by dental equipments
• Newer ones (bipolar) are generally not
Hypercholesterolemia → reduced lumina
affected
of arteries → deprivation of oxygen to the
• Newer pacemakers activate auto-
myocardium.
matically and this may cause sudden
Drug of Choice movement of the patient
Glyceryl trinitrate (GTN) spray buccally • Care should be taken to stabilize the
of placed sublingually Ca++ channel operating field with bite blocks.
antagonists, b-blockers used for prophylaxis. Infective endocarditis is an inflammation
of the endothelial lining of the heart and
Unstable Angina may be infected to bacterial, fungal, or rarely
Only emergency treatment. Rickettsia infection.
The organisms tend to settle down
Stable Angina on damaged endothelial surfaces, but
• ARP predominantly on valves which are
• Profound LA+ supplemental oxygen if congenitally deformed or damaged by
necessary/possible previous disease.
• 3% mepivacaine is preferred in patients Although it is not proven that antibiotics
on non selective b-blockers prevent infective endocarditic it is generally
• MI accepted that prophylactic antibiotics should
• Dental treatment deferred for 6 months be given during extractions, scaling, other
• Prophylactic antibiotics are not invasive procedures which may cause
necessary bacteremia.
• Use aspirating syringe.
Common Causative Organism
Angina attack on the chair Streptococcus viridans….. is an alpha hemolytic
• Discontinue all treatment streptococci
• One tablet of GTN (0.3–0.6 mg) given Nonstreptococcal organisms increasingly
sublingual impl icat ed ar e E i k enel l a co rr o de ns,
• Reassure the patient, loosen garments Capnocytophaga and, Lactobacillus species.
• Administer O2 It is of 2 types:
Chapter 9.indd 190 11/5/2014 6:04:02 PM

Acute: Virulent organisms, generally non- Standard regimen Amoxicillin 2.0 g, 1 hr

hemolytic strains of staph and strep → Allergic to Clindamycin
invade cardiac tissue → septic emboli → fa- penicillin or
tal course. Azithromycin/ 500 mg, 1 hr
clarithromycin
Subacute: Result from colony formation on or
Cephalexin 2.0 g, 1 hr
damaged endocardium or heart valves by
Parenteral Ampicillin 2.0 g, IV/IM, 1 hr
low-grade pathogenic organisms → rheu-
matic fever. Parenteral allergic Clindamycin 600 mg IV, 30 min
to penicillin 1.0 g, IV/IM, 30 min
Antibiotic regimen for medically Cefazolin
compromised patients before dental

procedures (Table 9.1)
Risk Group Table 9.1: Antibiotic prophylaxis

High Risk Standard Amoxicillin Adults: 2 g
• Previous history of IE (infective endo- general Children: 50 mg/kg
prophylaxis Taken orally one hour
carditis)
before the procedure
• Prosthetic heart valves
Patient is Ampicillin Adults: 2 g
• Major congenital heart diseases: unable to Children: 50 mg/kg
– Tetralogy of Fallot (TOF) take oral Given IM/IV within 30
– Transposition of the great arteries medications minutes before the
– Single ventricle states procedure
– Shunts. Patient is Clindamycin Adults: 600 mg

allergic to Children: 20 mg/kg
Moderate Risk penicillin Taken orally one hour
• Acquired valvular dysfunction
Cefadroxil or Adults: 2 g
• Rheumatic heart disease cephalexin Children: 50 mg/kg
• Other congenital heart malformations Taken orally one hour
• Mitral valve prolapse. before the procedure
Azithromycin Adults: 500 mg
Signs and Symptoms or Children: 15 mg/kg
• Hematuria clarithromycin Taken orally one hour
• Enlargement of spleen
Patient is Clindamycin Adults: 600 mg
• Splinter hemorraghes
allergic to Children: 20 mg/kg
• Medical management penicillin and IV within 30 minutes
• Early active treatment with antibiotics unable to take before procedure
• Heart valve replacement if necessary. oral medication
Cefazolin Adults: 1 g
Children: 25 mg/kg
Dental Aspects
IM/IV within 30
Aim minutes before
To prevent the dental diseases and treatment. procedure
Chapter 9.indd 191 11/5/2014 6:04:02 PM

Preventions the URTI and involves the joints and the

• Define susceptible patient heart. Sore throat → immune complex
mediated reaction between strep Ag
• Oral hygiene measures
– Ab → soluble Ag + Ab complexes
• Significant inflammation—gentle proce-
deposited in small blood vessels of
dures like oral rinse tooth brushing
the heart and joints → complement
• Better gingival health—more aggressive
activation → tissue damage.
measures
• Reduce/eliminate the infection Signs and Symptoms
• Extract teeth with poor prognosis
• Pyrexia
• Pretreatment CHX rinse
• Arthralgia
• Minimum number of appointments
• Arthritis
• Allow atleast 7 days between appoint-
• Swollen heart valves nodules along
ments
lines of valve closure on ECG.
• Prophylactic regimen before flap sur-
geries as usual antibiotic regimens are Medical Management
insufficient
• Bed rest during acute phase
• Sutures that resorb fast-absorbing
• Antibiotics and antipyretics
chromic catgut
• Steroids to relieve exudates.
• Regular recall and maintenance pro-
gram.
Dental Aspect
Objective of Antibiotic Prophylaxis Antibiotic prophylaxis.
• Good oral health to reduce potential
sources of bacterial seeding DISORDERS OF BLOOD
• To reduce microbial population and
Clinical Signs and Symptoms
minimize soft tissue inflammation and
bacteremia • Jaundice, ecchymosis, telangiectasia,
• In patients on penicillin—change the spontaneous gingival bleeding, and
drug after any regenerative procedure gingival hyperplasia.
(azithromycin).
• Patients with aggressive periodontitis Laboratory Tests
with high levels of actinomycete comi- • Clotting time (CT), bleeding time
tans, tetracycline 250 mg/qid/14 days (BT), activated partial thromboplastin
followed by conventional antibiotic time (APTT), prothrombin time (PT),
prophylaxis. complete blood count (CBC)
• If full mouth/extensive probing is
required antibiotic prophylaxis is a
must not required for suture removal. Hemophilia
• X-linked recessive factor, rarely affects
Rheumatic Fever females
• It is a systemic disease following a • Deficiency of factor VIII—globulin,
lancefield group 'A' strep infection of AHG.
Chapter 9.indd 192 11/5/2014 6:04:02 PM

Hemophilia A INR—Prothrombin Time

• >25% factor VIII may lead a normal life • INR < 3.0 infiltration anesthesia—
except during major trauma scaling, root planing
• 6–25% mildly affected • INR < 2.0 block anesthesia—minor
• 1–5% severely affected periodontal surgery, simple extractions
• Hemarthrosis. • INR < 1.5 complex surgery, multiple
extractions
Medical Management • In simple terms—Platelets count:
• Avoid trauma – <30,000 regional blocks are contra-
• Factor VIII concentrates indicated
• DDAVP—1-deamino-8–D–arginine – >50,000 hemostasis is achieved after
vasopressin, desmopressin acetate minor surgery.
• Tranexamic acid
• EACA—Epsilon aminocaproic acid
HEMOPHILIA B—CHRISTMAS DISEASE
• Fresh frozen plasma
• Fresh whole blood. • Factor IX deficiency, female carriers also
have a tendency to bleed
Dental Aspects • Surgical therapy requires a 30 to 50%
• Periodontal treatment can be performed factor IX level.
provided sufficient precautions are
taken
von WILLEBRAND DISEASE
• Probing, scaling, prophylaxis can be
done without medication The most common inherited bleeding
• B l o c k a n e s t h e s i a , r o o t p l a n i n g , disorder, affects both males and females,
surgery—physician’s approval deficiency in platelet adhesion, management
• Ensure clot stability similar to hemophilia A.
• Ensure primary wound closure
• Antifibrinolytics, tranexamic acid, THROMBOCYTOPENIA
EACA
• Avoid aspirin • Reduction in the number of platelets
• Avoid nerve blocks especially inferior <100000 cells/cu mm
alveolar, bleeding in the pterygoman- • Acute immune
dibular region can cause asphyxia • Leukemic infiltration of the marrow
• Paracetamol can be used safely • Drug induced
• Almost all the other NSAIDs are contra- • Infection
indicated • Platelet count of <60,000 scaling root
• Extract previous dental/medical history planing >80,000 for surgical purposes
before starting the procedure • Leukemia
• Prevention by regular monitoring and • Malignant disease with widespread
recall proliferation of immature WBCs
• Physician’s approval must before • Cause is unknown, increased incidence
invasive procedures. seen in patients
Chapter 9.indd 193 11/5/2014 6:04:02 PM

• Suffering from Down’s syndrome Medical Management

• Radiation exposure • None is necessary except during crisis
• Certain chemicals • Avoid—cold, dehydration, acidosis
• Genetic disposition. • Codeine for pain control.
Dental Aspects Dental Aspects

• Medical evaluation, antibiotic prophy- Check Hb levels before treatment, antibiotics,
laxis LA.
• Extract all hopeless teeth at least 10 days
before chemotherapy
• Perform SRP RESPIRATORY DISORDERS
• 0.12% CHX rinse daily Common Signs and Symptoms
• Emergency periodontal care during Increased respiratory rate, cyanosis, club-
acute phase bing, chronic cough, chest pain, wheezing,
• All surgical treatment must wait till Hemoptysis, dyspnea.
remission phase of treatment
• Nerve blocks are contraindicated
Asthma—Panting/Gasping in Greek
• Nausea due to high dose of drugs to
Symptoms
bring the patient to remission phase
• Check platelet count before extraction • Wheeze, breathlessness, tightening of
or extensive scaling the bronchial smooth muscles → edema
• Viral infections of tissues lining the bronchi → increase
• Candida infections—treat symptomati- in mucus secretions → decrease in air-
cally. way diameter → wheezing.
• Dry non productive cough
• Bronchiectasis—halitosis.
ANEMIA
A reduction of the red cell volume or Hb Cystic Fibrosis
concentration below the range of values • Autosomal recessive disorder causing
occurring in healthy individuals. Its a fibrosis of many organs including the
manifestation of underlying pathology. lungs.
• Cirrhosis of the liver occurs frequently—
Signs and Symptoms
increased bleeding.
Pallor, tiredness, fatigue, breathlessness as • Common medications include steroids.
a result of tissue hypoxia, angina pectoris in
older individuals. Dental Aspects
• Afternoon appointments
Types
• Several hours of sleep gives the patient
• Acute posthemorraghic adequate airway clearance
• Deficiencies of nutrients • Avoid medications causing respiratory
• Hemolytic depression
• Sickle cell. • Sedatives, GA
Chapter 9.indd 194 11/5/2014 6:04:02 PM

• Avoid bilateral mandibular nerve Immunosuppression

block, airway obstruction Dental Aspects
• Take care not to physically obstruct the
• Patients awaiting transplants are made
airway
dentally fit, any teeth with questionable
• Avoid excess pack
prognosis are removed.
• Evaluate for acute respiratory infection
• Nystatin mouthwash, gingival hyper-
• Keep an inhaler handy.
plasia due to cyclosporin, maintenance
of oral hygiene
RENAL DISORDERS • Main complication is infection—Ex-
• Results—Electrolyte imbalances, pro- cessive bleeding due to drug induced
longed bleeding, cardiac arrhythmias, thrombocytopenia, anticoagulant ther-
CHF. apy, teeth with severe bone loss, furca-
• Check laboratory values of PTT, PT, BT, tion involvement, periodontal abscess,
blood urea nitrogen (BUN)—Do not extensive surgical requirements.
treat if less than 60 mg/dL.
• Serum creatinine—Do not treat if less METABOLIC AND ENDOCRINE DISORDERS
than 1.5 mg/dL.
Diabetes Mellitus
Nephrotic Syndrome It is an endocrine disorder resulting in hyper-
• >3.0 g of proteinuria/day, edema espe- glycemia. There may be absolute or relative
cially in the face, eyelids, lower extremi- lack of insulin or presence of factors that
ties oppose the action of insulin.
• Increased susceptibility to infection.
Type I—IDDM
Dental Aspect Insulin dependent, juvenile, damage and
Antibiotic cover prior to invasive procedures, eventual loss of b-cells of islets of langerhans.
patient on steroids.
Type II—NIDDM
Chronic Renal Failure Non insulin dependent, over weight
individuals.
• Oral ulceration, candidiasis
• Fracture of mandible is possible during
Common Symptoms and Signs
extraction due to renal osteodystrophy
• Dialysis—Requires special precautions. Polyuria, polydipsia and polyphagia.
Dental Aspects Common Medications

Increased risk of staphylococcal infection, • Insulin
anemia may be present, increased bleeding, • Oral hypoglycemic agents are sulfony-
anti coagulant therapy, deficiency of proteins. lureas, meglitinides, phenylalanine de-
Transplantation—most common transpla- rivatives, biguanides, thiazolidinediones,
ntation done is the kidney. a-glucosidase inhibitors.
Chapter 9.indd 195 11/5/2014 6:04:02 PM

Symptoms of Diabetes Management

• Random plasma glucose ≥ 200 mg/dL • 15 g of oral carbohydrate
(approximately 6 mmol/L) • 25 ml of 50% dextrose IV
• Fasting blood sugar (no caloric intake for • 1 mg glucagon IV.
8 hrs) >126 mg/dL
• Normal range is 70–100 mg/dL INFECTIONS
• 2-hour postprandial glucose >200 mg/
dL during an OGTT HIV, AIDS, HTLV III
• Glycated Hb assay ( HbA1c) • Profound impairment of the immune
– 4–6%—normal system
– < 7%—good diabetes control • Helper T-cells are most affected
– 7–8%—moderate diabetes control • Monocytes, macrophages, langerhans
– >8%—action suggested to improve cells, neuronal and glial cells.
diabetes control. Lesions of the oral cavity includes: Oral hairy
It reflects blood glucose concentra- leukoplakia, candidiasis, KAPOSI’s sarcoma,
tions over the preceding 6 to 8 weeks bacillary angiomatosis, hyperpigmentation,
and may provide a potential response atypical ulcers, delayed healing, necrotising
to periodontal therapy. gingivitis and periodontitis.
• Periodontal infection may worsen
diabetic status, oral hygiene instructions, Goals of Treatment
mechanical debridement • Restoration and maintenance of oral
• Regular maintenance and recall. Morn- health, function and comfort, control of
ing appointments, HbA1c ideally 10% candidiasis, conservative nonsurgical
prior to therapy, systemic antibiotics are therapy, local debridement, scaling, root
not needed routinely. Only in patients planing, mouthwash, patient motivation.
with poor glycemic control, tetracy- • Implant placement is not contraindi-
clines have been shown to be beneficial cated.
along with SRP, HTLV I.
Precautions
Hypoglycemia • Needle prick injury—Aerosol genera-
tion, Airotors, ultrasonic instruments, air
Common in patients on insulin therapy. syringes
• Protective eyewear
Signs and Symptoms • Rubber gloves and mask
• Tremors, confusion, agitation, anxiety, • Suspected screen for HIV infected
sweating, tachycardia, dizziness, un- individuals.
consciousness, seizures.
Chapter 9.indd 196 11/5/2014 6:04:02 PM

Chapter
10 Preparation of Oral Health

Education Material
ORAL HEALTH EDUCATION MATERIALS guide the dental students to prepare good
standard and universally acceptable dental
Each dental institute should have a separate
health education materials.
place for dental health museum to be
organized to set up different types of dental
charts and models, etc. pamphlets, folders DENTAL POSTER OR CHART
and booklets on dental health are to be Effective Poster Design
prepared by the students to be distributed
• A poster is an abstract
free of cost to patients who visits dental
• The mistake most frequently made is
college hospital for dental treatments and
to put too much information on your
to school children and community people
poster.
whenever the students conduct school dental
• Your poster should be:
health program or community dental health
– An eye-catcher
camps.
– Containing a brief message
Preparation of the dental health
– Understood at a glance.
education material should be of academic
• It is claimed that you have about three
oriented topics like normal structure of
seconds to catch the audience attention.
dental and oral tissues, pathology of these
• To achieve this “three second hint”.
tissues due to dental and oral diseases,
there are some aspects that you can take
etiological factors, different modalities of
into account when you setout to design
preventive and therapeutic effects, etc.
a poster.
patients after visiting the department of oral
• This clinical/field program manual
medicine should be directed to go to the
address the issues that help you create
dental health education museum for health
an attractive and effective poster.
education. Preparation of scripts on skits,
folk songs and dances, etc. on oral health
should be encouraged and to perform in the Steps in Poster Design
mass of dental camps. • What is the “overall message” you
Audio cassettes and video films on intend to present?
dental health education are played in the • Define your audience:
dental museum in dental institutions and at – Whom do you want to reach?
the sites of these dental camps. – How expert are they?
The faculty members in the department – What can you assume to be common
of public health dentists should monitor and knowledge?
Chapter 10.indd 197 11/5/2014 6:04:23 PM

• What should the audience remember? Color

• Gather content: Before editing, write • Use color for a logo or a picture
down all aspects of your message that • Avoid colored background
you can think of: • In the body of the poster, only use a
– The effective issues support color to group information that
– Arguments belongs together
– Items of evidence • Remember that 8% of the male popula-
– Explanations tion has impaired color vision.
– Conclusions.
• Think of a sequence that will hold the Text size
audiences attention and lead the eyes • If readable on an A4 or legal sized
and mind to follow your argument from sheet, the enlargement to a poster has
its start to its conclusion. adequate text size.
• Create sections: Classify the information
that you have gathered Style and Type
• Make a heading for each section:
• Use one or at most two fonts, preferably
– To stimulate the interest of the
Arial or Times roman.
audience and
• Only use bold, CAPITALS or italic
– Introduce the following text.
when it absolutely cannot be avoided.
• Make a statement for the information in
each section: Paragraph Formatting
– Limit the information in each
Justification in generally the optional reading
section to a caption and a statement
comfort, but avoid too long spaces between
– Not exceeding five points.
words.
• Find a focus, eliminate noise (edit, edit,
edit!):
Visuals
– Try to explain your message to an
11-year-old. • Only use pictures or other illustrations
• Put it together: Only after all these as an eye-catcher or when necessary to
steps have been taken you can make the understand your message.
poster. • Avoid unnecessary details on the
• If your message can be read when you picture.
sketch it on one sheet of A4 (21 × 30 cm)
Space
or legal sized (8.5 × 14 inch) paper, then
the proportion is probably good. • Leave about 50% of the surface of your
poster as white space.
Design of the Poster
Layout Criteria of a Good Poster
• Title and key message should catch the eye. Clarity
• If you design your poster on an A4 • Is the poster is key message immediately
or legal-sized sheet, it can easily be clear to the reader?
enlarged to the optimal size (8 × original) • Usually, people can remember a mean
without altering the proportions. of seven items, plus or minus two.
Chapter 10.indd 198 11/5/2014 6:04:24 PM

Preparation of Oral Health Education Material 199
• Be on the safe side, and list no more help in the preparation of health educational
than five items. materials suitable for the target group.
• If you must address more than five
items, group and categorize these into How to Write Easy to Read Health
a tree structure with headings and sub- Materials?
headings. Medical and dental concepts and language
are very complex. People need easily under-
Relevance
standable health information regardless of
• Every word on the poster should be age, background or reading level. Here are
relevant to the poster. guidelines to help you create “Easy-to-Read”
• Omit gridlines, a poster is an abstract. health materials.
Concussion
What are Easy-to-Read (Etr) Materials?
• Every word on the poster should be
It is also called ease of reading (ERI). ETR or
necessary to understand the posters
ERI materials are written for audiences who
message.
have difficulty reading or understanding
• This information should be limited as
health information.
much as possible.
Appeal How can you Create Easy-to-Read

Health Materials?
• The poster should look nice and inviting.
• It must attract attention and its ap- Writing ETR materials is a process involving
pearance must not distract from the several important steps:
message. • Step 1: Plan and research
• Simplicity is usually the best. • Step 2: Organize and write
• Step 3: Evaluate and improve
Readability • Step 4: Readability
• Step 5: Inform and stay informed.
• The lettering should be large enough,
also for older viewers standing at a
distance of 1–2 meters. Step 1: Plan and Research
• It is tempting to reduce the font size to Know your Target Audience
allow for more information on the poster, • Consider reading level
but this will discourage passers by. • Cultural backgrounds and attitudes
People do not show interest to follow • Age groups
professional advice given in the form of • English language proficiency (ELP)
posters, charts and pamphlets unless that • Local language proficiency (LLP).
the suitability of educative material for a
particular target group has not been carefully Include your Target Audience
considered during the planning phase. • Bring members of the audience into
Before dispensing any health education early planning stages, if at all possible.
material it should be assessed in terms of the • This is especially important in cross-
“Easy-to-Read” health materials which will cultural communication.
Chapter 10.indd 199 11/5/2014 6:04:24 PM

Research your Target Audience in such a way to stimulate the interest

• Use tools such as surveys and interviews of target groups to accept the dental
to learn about the need of the target messages as personally relevant.
group. • Examples and stories may help engage
• If extensive research is not feasible due readers.
to time or budget constraints, contact • Use the “you” attitude. Personalization
other organizations who communicate helps the reader understand what he or
regularly with similar target audience. she is supposed to do.
• Structure the material logically. Some
Determine Objective and Outcomes users prefer step-by-step instructions.
• What do you want your target audience Others may find concepts arranged
to learn? from the general to the specific easier to
• For example, if your objective is to show understand.
the proper use of brushing technique of • Emphasize benefits of adopting the
teeth, emphasize the outcome of their desired behavior for example, “follow-
proper use. A sample sentence might ing these directions will help you to
be “following the directions for your improve your oral and general health”.
proper brushing technique of teeth may • Do not make assumptions about people
help you to prevent dental decay and who read at a low-level. Maintain an
gum diseases”. adult perspective.
• Many who are challenged by English
Step 2: Organize and Write are extremely fluent in different first
General Points language. Is your school hindi or kan-
• Keep within a range of about 4th to 6th nada or other regional language good
grade reading level. enough to read medical instructions?
• Focus on few key concepts.
Language and Writing Style
• The range of topics covered in a
pamphlet, poster or film is important • Find alternative for complex words,
as new information is prone to the medical jargon, abbreviations and
problem of interference. It is best to deal acronyms. When no alternatives are
with one topic at a time. available, spell complex terms and
• Use a clear topic sentence at the begin- abbreviations phonetically and give
ning of each paragraph. Follow the topic clear definitions.
sentence with details and examples. For • Jargon forms on integral part of the dental
example, proper use of brushing tech- vocabulary. Unfortunately many of the
nique of teeth helps you prevent dental words used may be incomprehensible
decay and gum diseases. Here are rea- to the layman, so great care should be
sons “why” then give reasons. taken to substitute, commonly used
• The health educators should remember words for dental terminology.
that their programs have to compete • Keep most sentences short. Use varied
with many other media presentations, sentence length to make them interest-
therefore the subject must be presented ing, but keep sentences simple.
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• Use the active voice and vivid verbs. • When possible use graphics or spell out
Here is an example. fractions and percentages.
Active: Ananda used her dental floss
today. Step 3: Evaluate and Improve
Passive: The dental floss was used by Always test your materials on a sample group
Ananda today. from target audience. Evaluate the feedback
• Be consistent with terms. For example, and revise your material if necessary. Testing
do not use “drugs” and “medications” during the writing process can help ensure
interchangeably in a same document. your audience in getting the message.
• When possible, say things positively, not
negatively. For example, “eat less sweets”
Step 4: Readability
instead “do not eat lots of sweets”.
What is Readability?
Visual Presentations and Representations Readability may be defined as the interest
Layout of written material can also have a or ease with which a document or an article
dramatic effect on readability: can be read. Webster defines “readable” as:
• Too many changes of type size. • Fit to be read
• Frequent use of statistics and avoid • Interesting
italics • Agreeable and attractive in style; and
• Thin print and diagrams dotted about • Enjoyable
in random fashion will confuse the Readability tests which are mathematical
reader. formulas were designed to assess the
• Use colors that are appealing to your suitability of a text for people at particular
target audience. Be aware, however, grade levels or ages. Obviously readability
that some people can not tell red from formulas can not measure features like
green. interest and enjoyment. Also, when we ask
• Use pictures and photos with concise cap- whether text is understood by its reader we
tions. Keep captions close to graphics. are questioning its “comprehensibility”.
• Avoid graphs and charts unless they Readability formulas can not measure how
actually help understanding. comprehensible a text is, and they can not
• Balance the use of text, graphics, and measure whether a text is suitable for reader
clear or “white” space. needs.
Note: There is usually a considerable disparity
in dental scientific knowledge between the A Brief Historical Overview
illustrator and the target group: For example The first formula: Readability formulas were
it is totally unrealistic to assume that people first developed in the 1920s in the United
will be able to interpret complex anatomical States. From the earliest records to today
diagrams. readability test have been designed as
• Avoid words or sentences in all capital mathematical equations which correlate
letters. measurable elements of writing such as:
• Use bolded subheadings to separate • The number of personal pronouns in
and highlight document sections. the text.
Chapter 10.indd 201 11/5/2014 6:04:24 PM

• The average number of syllables in the lists and reading lessons were adapted to
words. measure word difficulty. It was assumed
• Number of words in sentences in the that words that were encountered frequently
text. by readers were less difficult to understand
Factors like these are usually described than words that appeared rarely. Familiarity
as “semantic” if they concern the word used breeds understanding. There is some
and “syntactic” if they concern the length or soundness to this, today more than 4,90,000
structure of sentences. Both semantic and words in the English language and another
syntactic elements are surface level features 3,00,000 technical terms. It is unlikely that
of the text and do not take into account any and individual will use more than 60,000
of the nature the topic on characteristics of words and the average person probably
the readers. encounters between 5,000 and 10,000 words
• Semantic: are relating to meaning. in a life time.
• Serrantics: The study of meaning in
language Readability Formulas Today
connotative meaning. How do they work? Readability formulas
• Syntactic: The way in which words are measure certain features of text which can
put together to form phrases, clauses or be subjective to mathematical calculations.
sentences. Not all features that promote readabil-
Other factors in easy readability formula were: ity can be measured mathematically. And
• Average number of words in sentences these mathematical equations cannot meas-
• Percentage of different words ure comprehension directly. Readers can be
• Number of prepositional phrases. questioned or tested on material they have
read and the material can be tested with for-
How and Why were they Developed? mulas. The reader’s success in understand-
The very first readability study was a ing the material as measured on an exam
response to demands by Junior High School can be correlated to the readability score of
teachers to provide them with books which the text itself. This is one method to validate
led them teach scientific facts and methods the formulas.
rather than get bogged down in teaching the Other features of a document or article
science vocabulary necessary to understand just as important as word length and
the text. The earliest investigations of sentences to determining reading ease.
readability were conducted by asking Other aspect of language, sentence
students, librarians and teachers what structure and organizations of ideas are
seemed to make text readable. significant to comprehension. Also physical
The publication in 1921 of “The Teachers aspects of the document are important.
Word Book” by Thorndike provided a These are type styles, layout, design, use of
means for measuring the difficulty of graphics and so on.
words and permitted the development of Other features of clear writing are:
mathematical formula. Thorndike tabulated • Use of language that is simple, direct,
words according to the frequency of their economic and familiar
use in general literature. Later other word • Omission of needless words
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• Use of sentence structures that are tion (paragraphs) or actual content (the
evident and unambiguous. words from a specific domain?)
• Organization and structure of material Having said that we can move on to
in and orderly and logical way testing our content.
So readability formulas are considered
to be predictions of reading ease but not the Readability Tests
only method for determining readability and Gunning Fog, Fry Readability Graph,
they do not help us to evaluate how well the SMOG, SAM (Suitability Assessment of
reader will understand the ideas in the text. Materials), Flesch Reading Ease, Flesch-
Kincaid Grade Level or Reading Level
What Factors do they Measure? Algorithms. (A procedure for solving a
Today readability formulas are usually based problem as in mathematics.) that can be
on one semantic factor “the difficulty of helpful in determining how readable your
words” and one syntactic factor (difficulty content is.
of sentence). Studies have confirmed that Reading level algorithms only provide
the inclusion of other factors in the formula a rough guide as they tend to reward short
contributes more words than it includes the sentences made up of short words. While
results. Put another way, counting more they are rough guides they can give a useful
things does not make the formula any more indication as to whether you have pitched
predictive of reading ease but takes a lot your content at the right level for your
more effort. intended audience.
Measuring a Readability of a Text Reading Level Algorithms

There are number of methods to measure Readability is the measure of how easy it is
the readability of text. Most of them are to read and comprehend a document. Being
based on multiple correlation analysis where mathematically based, readability tests are
researchers have related a number of text unable to determine the likely hood that the
properties (such as words per sentence, document is comprehensible, interesting, or
average number of syllables per word, enjoyable.
etc.) and then asked test subjects to grade It is possible to obtain good readability
readability of various text on a scale by scores with gobbledygook (generally
looking at the text properties it is possible jargon), providing the content contains short
to correlate how much “words per sentence” sentences made up of monosyllabic (a word
influence readability. of one syllable) words.
Some important facts about readability Layout and design are also important
measurement methods: factors top the readability of a document that
• Readability index formulas only work cannot be determined using readability tests.
for a specific language. Documents aimed at higher level may
• Readability does not equal understand- require background knowledge, which
ability. cannot be determined by the tests.
• A readability index score is not an exact For a document to be easily understood,
signs, e.g. it does not consider disposi- the writing style should be clear and simple.
Chapter 10.indd 203 11/5/2014 6:04:24 PM

This involves a writing style that is direct, Yet, it can be argued that long sentences
and familiar to the intended reader. The and difficult words are merely signals that the
structure of the document should be logical, text is not written for ease of understanding.
unambiguous and avoid redundant (using Some say difficult text often contains difficult
more words than necessary) words. words because it discusses abstract ideas
Many of these factors can not be while easy text uses common words because
measured using readability tests. Instead, it discusses concrete experiences. Choosing
readability tests provide a prediction of the smaller words and shorter sentences may
reading ease for a document. Sentence length not be as much help as reconstructing the
and polysyllable words do have a direct sentences and using familiar vocabulary.
impact on the readability of documents, In recent years, researchers have empha-
albeit a surface measure of the characteristics sized that readability tests can only measure
of the tests. They provide an indication the surface characteristics of text. Quality
that the content may be too tough with a factors such as:
quantifiable measure. The results should be • Vocabulary difficulty
used in conjunction with good writing style • Composition
guidelines. • Sentence structure
• Concreteness and abstractness
What you can do to Improve Readability?
• Obscurity and incoherence.
The policy code includes the following Cannot be measured mathematically.
guidelines: They have pointed out that material which
1. Explain abbreviations and acronyms receives a low grade level score may be
the first time they are used. incomprehensible to the target audience. As
2. Provide a subset of your content in in example they suggest that you consider
basic English or the corresponding basic what happens if you scramble the words
version of your language. in a sentence or on a larger scale, randomly
3. Try to keep sentences short. rearrange the sentences in a whole text.
4. Avoid symbolic language (metaphors)— The readability score could be low, but
a figure of speech to which a word de- comprehension would be lacking.
noting one subject or idea is used in
place of another to suggest likeliness Things they can do
between them.
5. Avoid complicated words. Make sure 1. Their primary advantage is they can
you are writing from your users point serve as an early warning system to let
of view. Use their terminology instead the writer know that the writing is too
of your own. dense. They can give a quit on the spot
assessment. They have been described
Should you use Readability Formula? as “screening devices” to eliminate
Some say that readability formula measure dense traps and give rise to revisions or
word length or frequency and sentence substitutions.
length. In using the formulas we accept 2. In some organizational settings, read-
that these features affect readability in a ability tests are considered useful to
significant way.
Chapter 10.indd 204 11/5/2014 6:04:24 PM

show measurable improvement in writ- • The layout and design of the text
ten documents. They provide a quantifi- • The topography (use of highlighting
able measure to improve or simplifica- and italics, etc.)
tion. • The use of signal words (now, then, but,
later and so on)
Things they cannot Tell you why? Readability tests cannot tell you whether
• How complex the ideas are the information in the text is written in
• Whether or not the content is a logical a way to interest the reader nor can they
order tell you whether reader has sufficient
• Whether the vocabulary is appropriate background information to appreciate the
new information provided in the text.
for the audience
• Whether there is a gender, class or
cultural bias GUNNING FOG INDEX
• Whether the design is attractive and
The test was developed by Robert Gunning,
helps or hinders the reader.
an American businessman in 1952. In
• Whether the material appears in a form linguistics the Gunning Fog Index is a test
and type style that is easy or hard to designed to measure the readability of a
read. sample of English writing. The resulting
Because the readability formula are number is a rough estimate of the number
based on measuring words and sentences of years of formal education that a person
they cannot take into account the variety requires in order to understand the text on
of resources available to different readers. a first reading that is, if a passage has a Fog
Reader resources are: index of 12, it has the reading level of a US
• Word recognition skills high school senior.
• Interest in the subject The Fog index is generally used by
• Prior knowledge of the topic people who want their writing to be read
The formula can not measure the easily by a large segment of the population.
circumstances in which the reader will be Texts that are designed for a wide audience
using the text or form—both the psychological generally require a Fog index of less than
and physical situations. The formula can not 12. Texts that require a close to universal
adjust for the needs of people for whom understanding generally require an index
the text is written in a second or additional of less than 8.
language.
Studies have shown that readability, Calculating the Gunning Fog Index
interest and prior knowledge in the reader are The following is the algorithm to determine
equally important factors incomprehension the gunning fog index:
and retention of information. The ease of 1. Calculate the average number of words
reading that the reader experiences is also you use per sentence.
directly influenced by the writer views of Take a full passage that is around 100
physical, syntactic, symantic and contextual words (do not omit any sentence).
clues which cannot be measured by these 2. Determine the average sentence length:
tests. Such clues include: divide the number of words by the
• The use of personal pronouns number of sentences.
Chapter 10.indd 205 11/5/2014 6:04:24 PM

The total number of words is divided Examples

by the total number of sentences to 1. Passage from the nursery rhyme—
equal the average number of words per Rock-a-bye Baby:
sentence. The following paragraph has a Gunning
3. Determine the percentage of hard Fog index of 3.1.
words (complex words) by counting the Rock-a-bye Baby on the treetop
number of words of 3 or more syllables. When the wind blows the cradle will
i. Count words with 3 or more sylla- rock
bles (complex words), not including When the bow breaks the cradle will fall
proper nouns (for example, Dji- Down will come baby cradle and all.
bouti), familiar jargon or compound Analysis
words or common suffixes such as – There are 31 words in 4 sentences.
-es, -ed, or-, -ing as a syllable. – There are no complex words.
ii. Calculate the percentage of difficult – 0.4 [(31/4) + 100 (0/31)]
words in the sample. – 0.4 (7.75 + 0)
iii. The number of words with more – Fog index is 3.1.
than 3 syllables is divided by the 2. Passage from the Wikipedia article on
number of words to equal the “logorrhea”
percentage of difficult words. The following paragraph has a Gunning
4. Obtain the Fog index by totaling these Fog index 16.6.
two factors and multiply by 0.4. The word logorrhea is often used pejo-
i. Add the average sentence length ratively to describe prose that is highly
abstract and contains little concrete
and the percentage of complex
language. Since abstract writing is hard
words
to visualize, it often seems as though it
ii. Multiply the result by 0.4
makes no sense and all the words are
iii. Total these two figures (2 and 3) excessive. Writers in academic fields that
and multiply that total by 0.4. This concern themselves mostly with ab-
figure in the Fog index in years of stract, such as philosophy and especially
education postmodernism, often fail to include ex-
iv. The complete formula is as follows: tensive concrete examples of their ideas
0.4 [(words/sentence + 100 (complex and so a superficial examination of their
words/words)] work might lead one to believe that is
The result is your Gunning Fog index, nonsense.
which is a rough measure of how
Analysis
many years of schooling it would take
– There are 86 words in three sen-
someone to understand the content.
tences.
The lower the number, the more
– The ten italic words (outlined
understandable the content will be words) are considered complex.
to your visitors. Results over 17 are – 0.4 [(86/3) + 100 (10/80)]
reported as 17, where 17 is considered – 0.4 (28.67 + 11.7)
postgraduate level. – Fog index = 16.6
Chapter 10.indd 206 11/5/2014 6:04:24 PM

3. Passage from the Wikipedia article on iii. 0.4 [(79/7) + 100 (5/79)]
“The English language”: iv. 0.4 (11.28 + 6.3)
The following paragraph has a Gunning v. Fog index = 7.07
Fog index 24.4.
As a result of the military, economic, sci- Smog Index
entific, political and cultural influence of SMOG (Simple Measure of Gobbledygook)
the United Kingdom from the 18th cen- is a readability formula that estimates the
tury and the United States since the mid year of education needed to completely
20th century, it has become the lingua understand a piece of writing. SMOG is
franca in many parts of the world, and widely used particularly for checking health
the most prominent language in interna- messages.
tional business and science. It is used ex- SMOG was published by G Harry Mc
tensively as a second language and as on Laughlin in 1969 as a more accurate and
official language in the European Union more easily calculated substitute for the
and many commonwealth countries, as Gunning Fog index.
well as many international organizations.
Analysis Fry Readability Formula
i. There are 79 words in two sentences. The Fry Readability formula or (Fry
ii. The 17 italic (underlined words) are Readability graph) is readability metric for
considered complex. English texts, developed by Edward Fry.
iii. 0.4 [(79/2) + 100 (17/79)]
iv. 0.4 (39.5 + 21.5)
Coleman Lian Index
v. Fog index = 24.4
The same passage simplified: Under Coleman Lian index is a readability test
following paragraph have a Gunning designed by Merry Coleman and TL Lian to
Fog index 7.07. gauge the understandability of a text. Like
English have become the standard the Flesch-Kincaid grade level, Gunning
language around the world. This was Fog index, SMOG index and Automated
the result of much practice. In the readability index, its output approximates
1700s, the British affected English with the US grade level thought necessary to
the army, economy, science, politics and comprehend the text.
culture. In the mid 1900s, the United
States caused change. It is the most used Sam Index
language in world business and science. SAM (Suitability Assessment Materials) a
It is the famous 2nd language and an tool created by Cecilia and Leonard Doak.
official language in most of Europe and SAM assesses not only readability, but also
in commonwealth countries. It is also usability and suitability elements.
the case in groups around the world.
Analysis Flesch Reading Ease/Flesch-Kincaid
i. There are 79 words in 7 sentences. Grade Level
ii. The 5 italic (underlined ones) words Used in the Microsoft word grammar
are considered complex. checker.
Chapter 10.indd 207 11/5/2014 6:04:24 PM

Chapter
11 Field Program—A Visit to School
A VISIT TO SCHOOL 7. To stimulate dentists to perform

adequate health services for children.
School provides an ideal setting for promot-
Well planned and executed school
ing oral health by preventive and therapeutic
dental services, starting at the easiest school
services at an early age of a child. School den-
grades, could greatly accelerate the decline
tal health is an important branch of dental
of dental diseases especially dental caries
public health. School dental health service is
among school children. Treatment is not
an economical and powerful means of raising
the answer to solve children oral health;
community dental health and more impor-
instead, prevention is the key to good dental
tant in future generation. The main aim of a
health. To achieve successfully the objectives
visit to school should be to provide school
of school dental services, it is very much
dental health services to the school children.
essential to set up “school-based dental
health programs”.
Objectives of School Dental Services
American dental association has mentioned School Based Dental Health Program
the following objectives of school dental
Elements of School—Based Dental
services: Health Program
1. To help every school child appreciate
• Improving school—community relations
the importance of a healthy mouth.
2. To help every school child appreciate • Conducting dental inspections
the relationship of dental health to • Conducting dental health education
general health and appearance. • Performing specific programs:
3. To encourage the observance of dental – Toothbrushing program
health practice, including personal care, – Classroom-based fluoride program
professional care, proper diet and oral - Fluoride mouth rinse program
habits. - Fluoride tablet program
4. To enlist the aid of all groups and – School water fluoridation program
agencies interested in the promotion of – Nutrition as a part of preventive
school health. dentistry program
5. To correlate dental health activities with – Topical fluoride application pro-
the total school health activities. grams
6. To stimulate the development of – School based sealant programs.
resources to make dental care available • Referral to dental care
to all children. • Follow-up of dental inspections.
Chapter 11.indd 208 11/5/2014 6:04:30 PM

Field Programme—A Visit to School 209
Advantages (1997) may be used for this purpose. Before
1. The children of different age groups are implementing the survey in the school:
available for preventive or treatment 1. Contact with persons in authority:
procedures, because schooling years i. The organization of a survey should
cover a period that runs from childhood commence well before the date on
to adolescence. which it is intended to start exami-
2. Children are particularly receptive nations.
during this period and earlier the habits ii. The school, authorization should be
are established, the longer the lasting approached and the purpose of the
impact bad message can be reinforced visit and survey explained to them.
regularly throughout the school years. iii. Their approval of the school visit
3. School atmosphere is less threatening program should be obtained to
than private offices. ensure full cooperation.
4. Schools can provide a supportive iv. The principal should be contacted
environment for promoting oral health, for information.
for example, provision of safe water and - When the school is in session
sanitation for toothbrushing program. - When the children will be avail-
able for examination.
5. Collective education can also be pro-
- Whether there is a suitable area
vided along with individual treatment.
or room that could be used for the
6. With adequate training, school teachers examination.
can play an important role in oral health - Maintain a logbook in which are
activities. recorded the name of the school,
7. The dental service supplements the locality, each day examinations,
nursing services by helping to provide the number of school children
total health care for school children. examined and any information
about the school.
Disadvantages 2. Preliminary exercise: The reliability of
1. Performing dental treatment in a school data depends upon the calibration
is difficult due to certain limitations examination and training of the records
such as insufficient dental equipments, can be performed in advance. To achieve
chairs, infrastructure, etc. this objective the dental students should
2. Short school hours and long vacations be thoroughly trained in the department
may hinder the program. clinics in dental colleges.
“Calibrating examiners” although
Assessment of Oral Health Status of the dental students as examiners
School Children may differ in their assessments of the
A basic oral health survey is conducted oral health status of school children,
to assess the oral health status of school they should be in close agreement in
children. The objective of such survey is assessing the status of school children.
initially to provide a full picture of the oral When such survey is undertaken by a
health status and need of school children. team of dental students, it is essential
The WHO oral health assessment form that the participating dental students,
Chapter 11.indd 209 11/5/2014 6:04:30 PM

as examiners be trained thoroughly A Group of Examiners

in the department clinics in dental When the survey is to be conducted by a
institutions during clinical postings, to group of examiners, it is necessary to assess
make consistent clinical judgments. the consistency of each examiner and also
The objectives of standardization and the variations between examiners. This can
calibration are: be done by asking each examiner to examine
– To ensure uniform interpretation, the same group of 20 or more school children
under-standing and application of and comparing the findings. When findings
the criteria for the various diseases contain major discrepencies, subjects should
and conditions to be observed and be recalled in order that differences in
recorded diagnosis can be reviewed by the examiners
– To ensure that each examiner can and resolved by group discussion. It is
examine to a “uniform” standard; and essential that a group of examiners should be
– To minimize variations between able to examine with reasonable consistency,
different examiners. using a common standard.
To achieve the first objective, define
the criteria clearly and precisely in Scheduling personnel and organization: When
terms. The second and third objectives batches of dental students make a visit to
can be achieved by conducting “trial for a school for assessment of oral health sta-
calibrating examiner”. tus of school children, one of the most
important aspects of survey planning is the
Trial for Calibrating Examiners preparation of an orderly schedule for data
Single Examiner collection. If this is not done, examining
personnel may waste valuable time waiting
When only one examiner is involved he/
for subjects to arrive or will be otherwise
she should determine how consistently
unnecessarily delayed.
he/she apply the diagnostic criteria by
The survey planning should be done in
examining a group of about 20 school
such a way:
children twice, on successive days. These
school children should be pre- selected so • How much time, on average, each ex-
that they poses, collectively, the full range amination will take
of condition expected to be assessed in the • Daily schedule can then be prepared.
main survey. By comparing the results of the Reliable observations and consistent
2 examinations, the examiner will be able to judgments are important in such surveys.
obtain an estimate of the extent and nature Since fatigue contributes significantly to
of the diagnostic errors. If the number of inaccuracy and inconsistency, it is unwise
error is large, the examiner should review to make the schedule too demanding. To
the interpretation of the criteria and conduct overcome this problem, it is advisable to
additional calibration examinations until he/ divide the batch of dental students into
she can achieve acceptable consistency in different groups as:
his/her assessments. In general, agreement 1. A group of examiners—who examine the
for most assessments should be in the range school children to assess their oral health
of 85–90%. status
Chapter 11.indd 210 11/5/2014 6:04:30 PM

2. A group recording clerks • This person should be responsible for
3. A group of organizing clerks ensuring that the examiners have an
Those three groups of dental students adequate supply of sterile instruments.
in a batch should be thoroughly trained
in all aspects so that they can be timely Instruments and Supplies
interchangeable for orderly schedule for data The quantity and weight of instruments and
collection. supplies used in the survey should be kept
to a minimum. The following instruments
Recording Clerk and supplies are required for each examiner:
Each examiner should be assisted by a well • Caries explorers
trained, alert and cooperative recording clerk • Plane mouth mirrors
who is able to follow instructions exactly • Periodontal probes designed according
and to enter the numbers and letters clearly to approved specifications (addresses
in the boxes provided in WHO oral health of companies manufacturing this probe
assessment forms. Before the survey begins, may be obtained from the oral health
the students who are designated as recording unit of who)
clerks should be given: • Pans for sterilizing instruments, con-
• Clear instructions about recording data centrated sterilizing solution
on the survey form. • Washbasins (one for plain water and
• The clerk should be told of the terms one for water with soap)
that will be used. • Cloth or paper hand towels and soap
• The clerk should practice by recording • Gauze pads for removing debris from
findings from a few preliminary exami- the teeth.
nations.
• Special instructions and additional Examination Area
practice must be given if the clerk is The area for conducting examinations should
not familiar with the alphabetical or be planned and arranged for maximum
numerical symbols used on the survey efficiency and ease of operation. The exact
form. arrangement will be determined by the
physical condition of the site, but certain
Organizing Clerk
controllable features should be kept in mind.
It is also desirable to have an organizing clerk
at each examination site: Light source: Artificial light source—posi-
• To maintain a constant flow of subjects tioning of chair affected by location of elec-
to the examiner or examiners. trical supply.
• To enter general descriptive information Artificial + natural light source—
on the record forms. examining chair should face away from
• Also scan the finished records for accu- natural light source to avoid variation in
racy and completeness, so that missing illumination.
information may be obtained before the Natural light only—subject seated in
survey team moves to another location. apposition to receive maximum illumination.
Chapter 11.indd 211 11/5/2014 6:04:30 PM

Table or platform usually delivered personally, on the spot. A

• Needed to hold dental instruments and full technical report will require more time
basins. to prepare and will have to be sent later.
• Should be within easy reach of examiner. Occasionally, both types of report will be
necessary.
Seating of recording clerk: Should face the
examiner so that he/she can easily hear in-
structions and codes and the examiner can
School Based Preventive Dental
see that findings are being recorded prop-
Health Programs
erly. Classroom Based Tooth
Brushing Programs
Supply of survey forms: A generous supply of
There is overwhelming evidence that
forms, carbon paper, hardboard bases and
tooth brushing with a fluoride dentifrice
clips, sharpened pencils, erasers and a copy
is beneficial in preventing dental caries
of the recording instructions and measure-
although it is known that plaque control
ment criteria should be readily available.
through tooth brushing can be effective in
Traffic arrangements: If possible, examination controlling gingivitis. The educator should
area should be partitioned or arranged in endeavor to habituate daily plaque control
such a way that subjects enter at one point and fluoride dentifrice use as the objective
and leave at another. and not daily tooth brushing as an exercise.
Reinforcement is continually needed, since
Avoidance of crowding: Subjects should not be even in well directed programs where
permitted to crowd around the examiner or improvement is noted, a relapse can be
recorder but should approach the examina- expected after summer vacations.
tion chair one at a time.
Limitations
Emergency Care • The daily brushing of teeth in the class-
All survey teams should be equipped for room may be an ideal objective but at
ready to provide, emergency care if required. times is an impractical reality.
This service is especially important in remote • The daily storage and continual
areas where there are no regular oral health replacement of worn out and lost
services. However, permission should be brushes poses major problems.
obtained from the competent authorities • Unless tooth brushes are continually
for members of the survey team to give made available to the children without
emergency care where necessary. cost, there is reluctance to schedule
classroom time for activities in which
Courtesy Reporting several students do not benefit due to
It is appropriate and often essential, to report economic or other factors.
the survey findings to local authorities. • Most classrooms do not have the water
The report may be a simple summary of supply and the sinks necessary for
the number of subjects examined and the conveniently scheduling brushing as a
observations of the examiner. This can be classroom activity.
Chapter 11.indd 212 11/5/2014 6:04:30 PM

• Many teachers prefer to leave such • During the entire process appropriate
activities to dental health professionals. corrections and reinforcement of brush-
Yet, despite these problems many ing techniques should be emphasized.
classroom brushing programs have been a
success if we overcome these limitations. CLASSROOM BASED FLUORIDE
• In teaching tooth brushing in the
PROGRAMS
classroom 6 to 8 children can be taught
as a group. Each is given a cup, a napkin, Two feasible and highly effective fluoride
and a kit containing a disclosing tablet, programs can be performed in the classroom.
a toothbrush and a tube of fluoride These are two program:
dentifrice. • Fluoride mouth rinse program
• School children should be taught how • Fluoride tablet program
much paste should be dispensed on the Once-a-week mouth rinse can be
bristles of the brush. expected to result in an approximate 20–40%
• How the dentifrice is dispensed by reduction in dental caries.
pushing the dentifrice between the bris- Children in the various schools in
tles of the brush for uniform application the age group of 5–18 years would do
on tooth surface and to avoid escape of weekly/fortnightly mouth rinse using 0.2%
dentifrice from the bristle to sinks. NaF solution.
• Demonstrate the Bass technique of Every school can be provided with a
tooth brushing. plastic measure which when filled would
• Emphasis should be placed on the need contain 2 gm of sodium fluoride powder. A
to follow a definite sequence to ensure plastic semitransparent jug with a capacity
that all teeth surfaces are brushed. of over 1 liter should be procured by each
• Next the children are asked to chew a school. The jug should be marked to indicate
disclosing tablet and to swish it around 1,000 mL level and 100 mL level. School
the mouth for 30 seconds. The excess should also buy NaF powder 500 gm packs
saliva is expectorated into a cup. available at chemical and scientific stores
• The children are then encouraged to look (the cost of anhydrous NaF powder is
at each others teeth with appropriate approximately Rs 250 to Rs 350) the yearly
emphasis on the fact that the red stain cost of weekly rinse program in a school of
colors the plaque in which bacteria live. 1000 children would be approximately Rs
• Next a magnifying mirror is passed 300. If the school authority fails to purchase
around so that the participants can note these items, the concerned dental institution
that their teeth are so different from should provide the necessary items for
those of their neighbors—that all people classroom mouth rinse programs whenever
have plaque. the dental students make a visit to the school
• Guided brushing can then begin, with to conduct school based oral health program.
the instructor establishing the sequence
of teeth to be brushed.
• At the end the mirror is again passed Method of Preparation and Dispensing
around to show that progress has been School teachers shall dissolve 2 gm of NaF
made. from plastic measures in 1,000 mL of cold
Chapter 11.indd 213 11/5/2014 6:04:30 PM

water in the polythene bottles provided placement procedure for the sealants is rapid
there. They shall prepare a fluoride solution and painless; once placed, they are highly
of 0.2% for mouth rinsing and the rinse effective in protecting the occlusal pits and
be non sweetened and non flavored to fissures where over 66% of all the carious
discourage swallowing. lesions occur.
The first, second, sixth and seventh
Method of Use grades would be desirable grade levels to
selectively intervene to prevent pit and
To conduct the mouth rinse exercise, four
fissure lesions.
students are selected from the classroom
Sealant placement when coupled with a
one to dispense NaF solution into the cups,
follow-up application of fluoride (in addition
other the “cup-passer outer” and another he
to the classroom fluoride mouth rinse or
“host/hostess” who distributes the napkins.
fluoride tablet program) helps provide a
The last child is the “trash person”.
continuous protection of the whole tooth.
After all children have received a cup
and napkin they pass to the first child who
dispenses 5-6 mL of rinse into the cup. When Field Program After
all the children have retired to their seats they Field Program
are instructed to rinse the solution around
Field Visits
the mouth for a period of 2 minutes, after
that they can expectorate carefully into the The following field visits are undertaken by
cup. The rinsing starts when the second’s the undergraduate and postgraduate students
hand of the clock gets to a pre announced as a part of their academic curriculum. After
number. To maintain class interest during obtaining required permission from the
the swishing period the teacher must keep up concerned authorities the students will visit
an active chatter. “The girls are doing better the places, collect information on its purpose,
than the boys. They are a good swisher”etc. working method for better understanding of
The napkin is used to wipe the mouth after the pertaining topic. Lastly submit the details
which it is forced into the bottom of the cup in the form of report.
to absorb all fluid. The trash person then Different field visits are as follows:
collects the cups. After the first introductory
session, approximately 5 minutes are needed Anti-Tobacco Cell
to complete a classroom mouth rinse. Anti-tobacco cell has been established by the
Fluoride mouth rinsing program received Directorate of Health and Family Welfare
official recognition of safety from the food services. The anti-tobacco cell is responsible
and drug administration (FDA) in 1974 and for overall planning, implementation,
by the Council of Dental Therapeutics of the monitoring and evaluation of the different
ADA in 1975. activities, and achievement of targets
planned under the National Tobacco Control
School Based Pit and Fissure Program in the State.
Sealant Program The anti-tobacco cell is headed by
The placement of pit and fissure sealants Secretary, Health and Family Welfare
is ideally suited for a school program. The Services and is functioning under the
Chapter 11.indd 214 11/5/2014 6:04:30 PM

guidance of Joint Director (Medical) who is universally accessible to all in the community
the State Nodal Officer for Tobacco Control. through their full participation; at an
The cell primarily focuses on planning, affordable cost; and geared toward self-
monitoring, implementation, Information, reliance and self-determination (WHO and
Education and Communication (IEC) UNICEF, 1978).” Primary health care shifts
activities in the light of COTPA (Cigarette the emphasis of health care to the people
and Other Tobacco Product Act-2003) themselves and their needs, reinforcing and
and FCTC (Framework Convention on strengthening their own capacity to shape
Tobacco Control) provisions. Students their lives. Primary health care is provided
visit the anti-tobacco cell to understand its by primary health center. The primary
purpose, functions, ongoing programs and health centre (PHC) is the basic structural
future plans to curb systemic as well as oral and functional unit of the public health
diseases. services in developing countries. PHCs were
established to provide accessible, affordable
Milk Dairy and available primary health care to people,
Milk may be defined as the whole, fresh, in accordance with the Alma Ata Declaration
clean, lacteal secretion obtained by complete of 1978 by the member nations of the World
milking of one or more healthy milk animals, Health Organization. Students should visit
excluding that obtained within 15 days the PHC to understand its purpose, staffing
before or 5 days after calving or such periods pattern, its function, programs in progress,
as may be necessary to render the milk facilities available as it is the first level of
practically colostrum-free and containing contact of people with the national health
the minimum prescribed percentages of milk system.
fat and milk-solids-not-fat. In India, the term
‘milk’, when unqualified, refers to cow or Public Health Institute
buffalo milk, or a combination thereof. Public health institute is a science-based
A dairy is a business enterprise governmental organization that serves as
established for the harvesting of animal a focal point for a country’s public health
milk—mostly from cows and buffalos for efforts, as well as a critical component of
human consumption. A dairy farm produces global disease prevention and response
milk and a dairy factory processes it into systems. It is mainly involved in health
a variety of dairy products (like butter, systems research and is committed to
cheese and yogurt). These establishments improving service delivery in the government
constitute the dairy industry, a component of health services with the aim of improving
the food industry. Students visit milk dairy, health care for the community. In Bangalore
understand its working, as milk is one of the Public Health Institute was started in the year
complete nutrient diets required for all the 1908. Students visit public health institute to
human beings. understand its structure and function.
Primary Health Center Sewage Treatment Plant

Primary health care is “essential health care; Sewage treatment is the process of removing
based on practical, scientifically sound, and contaminants from wastewater and
socially acceptable method and technology; household sewage, domestic, commercial
Chapter 11.indd 215 11/5/2014 6:04:30 PM

and institutional. It includes physical, countries they exhibit high rates of disease
chemical and biological processes to due to unsanitary conditions, malnutrition,
remove physical, chemical and biological and lack of basic health care. The students
contaminants. Its objective is to produce should visit slums, collect information about
an environmentally safe fluid waste stream their demographic details, living conditions,
(or treated effluent) and a solid waste factors which influence their health as well as
(or treated sludge) suitable for disposal oral health inorder to educate and motivate
or reuse (usually as farm fertilizer). The people towards health and healthy practices.
objective of sewage treatment is to produce a
disposable effluent without causing harm to Water treatment Plant
the surrounding environment, and prevent Water is the fundamental part of our
pollution. Being students of Public Health lives. After sufficient food, a clean water
Dentistry, students should have knowledge supply and adequate sanitation system are
about the sewage treatment as it is one of the considered to be the most important factors
major environmental factors which influence in ensuring good health in a community.
health as well as oral health. Improved water supply and a sanitation
system were major elements of public
Slum Survey health measures that drastically cut death
A slum, as defined by the United Nations rates and improved health levels in the
agency UN-HABITAT, “is a run-down industrialized countries. Though it is not
area of a city characterized by substandard generally appreciated, these measures have
housing, squalor, and lacking in tenure been considerably more important than
security.” According to 2012 report curative medicine in contributing to good
submitted to the World Bank by Karnataka health, long life expectancy and low infant
Slum Clearance Board, Bangalore has 862 mortality. The students should gain required
slums from total of around 2000 slums in knowledge about water, its importance and
Karnataka. It is estimated that about 20% the steps involved in purifying it. Steps
of Bangalore population reside in Urban involved are
slums. Slums are usually characterized • Aeration
by Urban decay, high rates of poverty, • Chemical housing
illiteracy and unemployment or lack of • Clari flocculation and sedimentation
personal/community land ownership. • Filtration
They are commonly seen as “breeding • Post chlorination
grounds” for social problems such as crime, • Storage
drug addiction, alcoholism, high rates of • Water quality
mental illness, and suicide. In many poor • Record keeping
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Chapter
12 Early Detection of
Oral Cancer
Primary Prevention • The prevention approach is therefore

clear and all health care professionals
Primary prevention is the approach which
have an obligation and excellent
concentrates on removing risk factors
opportunities to contribute.
from the community with the intention
• So disease prevention or health promo-
of minimizing the number of cases of the
tion messages can be directed at whole
disease which arise in that community
communities, targeted at sectors of the
namely reducing the incidence of disease.
population.
Secondary Prevention Risk Factors

Secondary prevention refers to the detection Tobacco products
of cases of the disease in question at an • Smoking tobacco
early stage in its natural history at which • Cigarettes
intervention is likely to lead to cure, or to • Cigars
minimize morbidity and reduce eventual • Pipes
mortality. If effective at an affordable cost, • Chewing tobacco
this is clearly the best approach in terms of • Snuff
both public and personal health gain. • Ethanol products.
Chemicals
Tertiary Prevention • Asbestos
• Chromium
• Tertiary prevention refers to interven- • Nickel
tions designed to reduce recurrence of • Arsenic
disease after treatment or to minimize • Formaldehyde.
the morbidity arising from treatment.
Other factors
Primary Prevention of Oral Cancer • Ionizing radiation
• Plummer-Vinson syndrome
• The major risk factors for oral cancer are
• Epstein-Barr virus
exhaustively studied.
• Human papilloma virus.
• Taken together, the effects of tobacco
use, heavy alcohol consumption and Occupational risks
poor diet probably explain over 90% of • Woodworking
cases. • Leather manufacturing
Chapter 12.indd 217 11/5/2014 6:04:40 PM

• Nickel refining • Soft palate complex

• Textile industry • Soft palate
• Radium dial painting. • Anterior tonsillar pillar
• Lingual side of the retromolar trigone.
Prevention and Early Detection
Screening: Screening for cancer is examina- Factors Delaying the Diagnosis
tion (or testing) of people for early stages • Patient procrastination in seeking
in the development of cancer even though medical attention
they have no symptoms. Not all screening • Physician delay in diagnosis
tests are helpful, and most have risks such • Patient remains asymptomatic for a
as bleeding or infection due to a biopsy for prolonged period.
an abnormal screening test. For this reason,
scientists at the National Cancer Institute Screening Exam Requires
are studying many screening tests to find • Good light
out how useful they are and to determine • Use of a dental or laryngeal mirror
the relative benefits and harms. • Inspection of high-risk areas
• Palpation
Objectives There are several clinical procedures that the
• Recognize the difference and significance dentist may employ for early detection and
of leukoplakia and erythroplasia. prevention of oral cancer.
• Recognize early signs and symptoms.
• Understand the importance and tech- Listen: Dentist should conduct an interview
niques of a thorough examination. with the patient in such a manner that the
• Counsel patients regarding the impor- following information may be learned: a
tance of avoiding tobacco and ethanol complete history of a present complaint,
products. previous dental complaint, previous dental
and medical history and therapy, lifestyle
Warning signs of oral cancer and personal habits, oral habits, medical
• Hoarseness and dental phobia and fears, nutritional
• Erythroplasia and religious backgrounds, family history,
• Referred otalgia socioeconomic status, family size and
• Persistent sore throat occupational pursuits.
• Epistaxis
• Nasal obstruction Look: Look for edematous ankles height-
• Neck mass ened respiration, the pallor to the nail bed,
• Non-healing ulcer vitiliginous or hyperpigmented zones, fa-
• Dysphagia cial asymmetry, open bite, cervical lym-
• Submucosal mass. phadenopathy, keratotic zones, or butterfly
lesions. These signs may be the first evi-
Common sites of oral cancer dence of abnormality.
(Excluding lip cancer)
• Floor of mouth Examine: The tissues should be examined so
• Ventrolateral tongue as to locate and to describe deviations from
Chapter 12.indd 218 11/5/2014 6:04:40 PM

Early Detection of Oral Cancer 219
the normal. When examining the external 4. Apply 1% toluidine blue to lesions.
face and the oral cavity, one should look for 5. Rinse mouth with 100 mL of 1% acetic
changes in color and take particular notice acid for 1 minute.
of white, red, and black. Four other feature 6. Rinse with water.
need to be evaluated. Physicians, dentists, and other providers
• Consistency: Is the tissue flaccid, have a unique opportunity to detect
fluctuant, hard, firm or modular? malignant oral neoplasias while they are
• Contour: Is the surface rough, asym- asymptomatic.
metric, ulcerated or pitted is a sinus of
fistula present? Scrape: Surface biopsy or surface scraping
• Temperature: Is the tissue cold, flushed, may be collected by using a moist wooden
hot, dry or moist? tongue blade. This usually produces sheets
• Function: Can the patient open his of cell in various stages of maturation. The
mouth fully? Can he eat, talk and collected tissue can be sent to the laboratory
breath, normally? for diagnosis.
X-ray: The X-ray is a fairly reliable tool for

DIAGNOSTIC PROTOCOL FOR
the detection of changes in bone contour,
ORAL CANCER
bone profile and patterns of bone growth.
1. Complete patient history and head and
Supravital Staining with Toluidine neck examination.
Blue for Oral Cancer (Figure 12.1) 2. Remove possible sources of irritation.
Steps: 3. Re-examine after 10 to 14 days.
1. Rinse mouth with water twice. 4. Consider persistent lesions malignant.
2. Rinse mouth with 100 mL of 1% acetic 5. Consider toluidine blue rinse.
acid for 20 seconds. 6. Biopsy lesions that stain positive are
3. Gently dry areas with gauze. suspicious.
Figure 12.1: Detection of oral cancer using Toluidine blue staining method
Chapter 12.indd 219 11/5/2014 6:04:41 PM

CONCLUSION modalities for oral cancer, scant atten-

• In summary, oral cancer is a disease that tion has been paid to its prevention,
frequently has been given low priority by early detection, and control.
both health care providers and the public. • Although there are numerous barriers
• Furthermore, although there is current- to prevention and early detection of oral
ly great interest in exploring therapeutic cancers, none is insurmountable.
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Chapter
13 Early Detection of
Dental Caries
Dental caries is a multifactorial microbial When applied on populations, the

disease of the calcified tissues of the teeth, caries risk procedure is termed “caries
characterized by demineralization of the prediction”. Before that, we believe it
inorganic portion and destruction of the is important to analyze the difference
organic substance of the tooth. between a ‘risk model’ and a ‘prediction
model’, and we base the description on
Beck’s proposals.
Concepts of Risk Factor,
Risk Indicator, Risk Prediction and
Purpose of Risk Prediction
Risk Assessment
• To identify those persons who will
Risk is the probability that an event will occur. most likely develop caries.
• To provide these individuals proper
Risk Factor preventive and treatment measures to
An environmental, behavioral, or biologic stop the disease.
factor confirmed by temporal sequence,
usually in longitudinal studies, which if
Risk Factors to Dental Caries
present directly increases the probability of
a disease occurring, and if absent or removed According to Axelsson, risk factors for dental
reduces the probability. caries can be classified as:
Risk Indicator Etiologic Factors

An exposure that is associated with an • Streptococcus mutans
outcome only in cross-sectional data is called • Salivary lactobacilli
a risk indicator. A risk indicator may be a • Plaque formation rate.
probable risk factor, but caution is needed
because cross-sectional relationships can be External Modifying Risk Indicators, Risk
deceptive. Factors, and Prognostic Risk Factors
• Very high frequency of intake of
Risk Assessment vs Prediction sugar-containing products (extremely
A caries risk assessment is a procedure to prolonged sugar clearance time).
predict future caries development before the • Low or very low socioeconomic back-
clinical onset of the disease. ground.
Chapter 13.indd 221 11/5/2014 6:11:01 PM

Internal Modifying Risk Indicators, Risk 4. Key-risk age groups in young adults
factors, and Prognostic Risk Factors and adults secondary maturation.
• Very low salivary buffering effect
• Reduced immune response. Other Risk Groups
1. Persons who work in occupations where
Preventive Factors frequent food sampling is required
• Very low standard of oral hygiene, 2. Persons who are obese because of
without assistance by the parents for frequent eating
children. 3. Persons who abuse recreational drugs
• Irregular or no use of fluoride toothpaste. 4. Persons who have systemic diseases
and are taking regular medication
• Very poor dietary habits.
5. Women who are pregnant
• No preventive dental care and irregular
6. Persons who have psychiatric disorders
dental care.
7. Persons who have impaired salivary
Three main factors for risk assessment, which
function or immune response
are based on:
8. Persons who are poorly educated
1. Past caries experience
9. Persons who have poor dental care habits.
2. Socioeconomic factors and
3. Biological factors. Individual Risk
By combining etiologic factors, caries
Approaches to Risk Prediction prevalence (experience), caries incidence
Risk assessment strategies can be applied on (increment), external and internal modifying
three different levels: risk indicators, risk factors, and prognostic
1. For populations risk factors, as well as preventive factors,
2. For groups caries risk may be evaluated at the individual
3. For an individual. level, as no risk (CO), low risk (C1), risk (C2),
and high risk (C3) (Tables 13.1 to 13.3.)
Risk Groups
Key-Risk Teeth and Surfaces
Risk Age Groups The pattern of dental caries in the dentition,
Recent studies have shown that carious reflected in decayed, missing, and filled sur-
lesions are initiated more frequently at faces, is generally as unevenly distributed as
specific ages. This applies particularly to caries prevalence among individuals. There
children but also to adults. In children, the fore, needs related preventive programs
key-risk periods for initiation of caries seem not only should be tailored to predicted
to be during eruption of the permanent individual risk, but also should focus on the
molars and the period during which the key-risk teeth and surfaces in the dentition.
enamel is undergoing. The molars are clearly the key-risk teeth.
1. Key-risk age group 1: Ages 1 to 2 years In a tooth brushing population, the key-
2. Key-risk age group 2: Ages 5 to 7 years risk surfaces are the fissures of the molars
(eruption of first molars) and the approximal surfaces, from the mesial
3. Key-risk age group 3: Ages 11 to 14 aspect of the second molars to the distal
years (eruption of second molars) aspect of the first premolars.
Chapter 13.indd 222 11/5/2014 6:11:01 PM

Early Detection of Dental Caries 223
Table 13.1: Prediction of caries risk in preschool children (6–19 years of age)
No caries risk [C0 (green)] Caries risk [C2 (yellow)]
• Etiologic factors: • Etiologic factors:
– Streptococcus mutans negative – Streptococcus mutans positive (>100,000 CFU/mL)
– Low levels of salivary lactobaccilli (<10,000 CFU/mL) – High levels of salivary lactobacilli (100,000 CFU/mL)
– Very low or low plaque formation rate (PFRI 1 or 2) – Moderate or high plaque formation rate (PFRI 3 or 4)
• Caries prevalence: Caries free • Caries prevalence: High (approximal carious lesions in
dentin or restored surfaces on the primary molars)
• Caries incidence: No incidence • Caries incidence: High (more than one new carious lesion
in dentin per year)
• External modifying risk indicators and risk factors: None • External modifying risk indicators, risk factors, and
prognostic risk factors:
– High frequency of intake of sugar-containing products
(prolonged sugar clearance time)
– Low socioeconomic background
• Internal modifying risk indicators and risk factors: None • Internal modifying risk indicators, risk factors, and
– Low salivary buffering effect
– Reduced immune response
• Preventive factors: • Preventive factors:
– Excellent standard of oral hygiene: Well-motivated and – Poor standard of oral hygiene
well-educated parents – Irregular use of fluoride toothpaste
– Regular use of fluoride toothpaste – Poor dietary habits
– Excellent dietary habits – Irregular preventive dental care habits
– Regular preventive dental care habits
Low caries risk [C1 (blue)] High caries risk [C3 (red)]
– Streptococcus mutans positive (<100,000 CFU/mL) – Streptococcus mutans positive (>1 million CFU/mL)
– Low levels of salivary lactobacilli (<10,000 CFU/mL) – Very high levels of salivary lactobocilli (>100,000 CFU/mL)
– Very low or low plaque formation rate (PFRI 1 or 2) – High or very high plaque formation rate (PFRI 4 or 5)
• Caries prevalence: Caries free (no carious lesions in • Caries prevalence: Very high (carious lesions in dentin or
dentin) restorations on most approximal surfaces and fissures
and some active carious lesions in enamel on the buccal
surfaces)
• Caries incidence: No new carious lesions in dentin • Caries incidence: Very high (more than two new carious
lesions in dentin per year)
• External modifying risk indicators and risk factors: None • External modifying risk indicators, risk factors, and
– Very high frequency of intake of sugar-containing
products (extremely prolonged sugar clearance time)
– Low or very low socioeconomic background
• Internal modifying risk indicators and risk factors: None • Inernal modifying risk indicators, risk factors, and
– Very low salivary buffering effect
– Fairly good standard of oral hygiene: Regular cleaning – Very low standard of oral hygiene, without assistance
by well-motivated parents by the parents
– Regular use of fluoride toothpaste – Irregular or no use of fluoride toothpaste
– Fairly good dietary habits – Very poor dietary habits
– Regular preventive dental care habits – No preventive dental care and irregular dental care
Chapter 13.indd 223 11/5/2014 6:11:02 PM

Table 13.2: Prediction of caries risk in children

No Caries risk [C0 (green)] Caries risk [C2 (yellow)]
– Low levels of salivary lactobacilli (<10,000 CFU/mL) – High levels of salivary lactobacilli (100,000 CFU/mL)
• Caries prevalence: Caries free • Caries prevalence: High
– In 6 to 11 year olds: Fissure caries in permanent first
molars and approximal carious lesions in dentin or
restorations in primary molars
– In 12 to 19 year olds: Fissure caries in most molars,
carious lesions in enamel, and a few carious lesions
in dentin on the approximal surfaces of some molars
and premolars
• Caries incidence: No incidence • Caries incidence: High (more than one new carious
lesion in dentin or some new carious lesions per year)
• External modifying risk indicators and risk factors: • External modifying risk indicators, risk factors, and
None prognostic risk factors:
– High frequency of intake of sugar-containing
products (prolonged sugar clearance time)
– Low socio-economic background
• Internal modifying risk indicators and risk factors: None • Internal modifying risk indicators, risk factors, and prog-
nostic risk factors:
– Reduced stimulated salivary secretion rate (< 0.7 mL/
min)
– Excellent standard of oral hygiene – Poor standard of oral hygiene
– Regular use of fluoride toothpaste – Irregular use of fluoride toothpaste
– Excellent dietary habits – Poor dietary habits
– Regular preventive dental care habits – Irregular preventive dental care habits
Low Caries risk [C1 (blue)] High caries risk [C3 (red)]
– Streptococcus mutans positive (<100,000 CFU/mL) – Streptococcus mutans positive (>1 million CFU/mL)
– Low levels of salivary lactobacilli (<10,000 CFU/mL) – Very high levels of salivary lactobacilli (>100,000
– Very low or low plaque formation rate (PFRI 1 or 2) CFU/mL)
– High or very high plaque formation rate (PFRI 4 or 5)
• Caries prevalence: No carious lesions in dentin or • Caries prevalence: Very high
restored surfaces – In 6 to 11 year olds: Occlusal and mesial surfaces of the
permanent first molars are carious (active enamel or
dentin caries) or restored; most primary molars are re-
stored or lost; and same active carious lesions in enamel
may be present on surfaces of the permanent incisors
– In 12 to 19 year olds: Occlusal surfaces of the per-
manent molars are restored; active carious lesions in
enamel or dentin or restorations are present on most
of the approximal surfaces of the molars and premo-
lars and some incisors; and same active carious le-
sions in enamel are present on the buccal surfaces
of the posterior teeth and the lingual surfaces of the
mandibular molars
Contd...
Chapter 13.indd 224 11/5/2014 6:11:02 PM

Early Detection of Dental Caries 225
Contd...
Low Caries risk [C1 (blue)] High caries risk [C3 (red)]
• Caries incidence: No new carious lesions in dentin • Caries incidence: Very high (more than two new carious
lesions in dentin and several new carious lesions in
enamel per year)
• External modifying risk indicators and risk factors: • External modifying risk indicators, risk factors, and
None prognostic risk factors:
– Very high frequency intake of sugar-containing
products (extremely prolonged sugar clearance time)
– Low or very low socio-economic background
• Internal modifying risk indicators and risk factors: None • Internal modifying risk indicators, risk factors, and
– Reduced stimulated salivary sectetion rate (< 0.7 mL/
min)
– Very low salivary buffering effect
– Severely compromised immune response

– Good standard of oral hygiene – Very low standard of oral hygiene
– Regular use of fluoride toothpaste – Irregular or no use of fluoride toothpaste
– Good dietary habits – Very poor dietary habits
– Regular preventive dental care habits – No preventive dental care and irregular dental care
Table 13.3: Prediction of caries risk in adults

– Low levels of salivary lactobacilli (<10,000 CFU/mL) – High levels of salivary lactobacilli (100,000 CFU/mL)
• Caries prevalence: Caries free or only occlusal carious • Caries prevalence: High
or restored surfaces in the molars – In 20 to 35 year olds: Carious lesions or restorations on
most occlusal and some posterior approximal surfaces
– In 36 to 50 year olds: More than one tooth last directly
or indirectly to caries; carious lesions or restorations
on most occlusal and posterior approximal surfaces
– In 51 to 65 year olds: More than two teeth lost directly
or indirectly to caries; carious lesions or restorations
on most occlusal and approximal surfaces (also in the
maxillary incisors) as well as some buccal surfaces
(in industriolized countries, most carious lesions are
recurrent caries)
• Caries incidence: No incidence • Caries incidence: High
– In 20 to 50 year olds: More than one new carious
surface per year
– In 51 to 65 year olds: More than two new carious
surfaces per year (more than 75% recurrent caries)
Contd...
Chapter 13.indd 225 11/5/2014 6:11:02 PM

Contd...

• External modifying risk indicators, risk factors, and • External modifying risk indicators, risk factors, and
prognostic risk factors: None prognostic risk factors:
– High frequency of intake of sugar-containing
products (prolonged sugar clearance time)
– Low socio-economic level (particularly low educational
level)
• Internal modifying risk indicators, risk factors, and • Internal modifying risk indicators, risk factors, and
prognostic risk factors: None prognostic risk factors:
– Reduced stimulated salivary secretion rate (< 0.7
mL/min)
– Excellent standard of oral hygiene – Poor standard of oral hygiene
– Regular use of fluoride toothpaste – Irregular use of fluoride toothpaste
– Excellent dietary habits – Poor dietary habits
– Regular preventive dental care habits – Irregular preventive dental care habits
Low caries risk [C1 (blue)]
• Etiologic factors: • Caries prevalence:
– Streptococcus mutans positive (<100,000 CFU/mL) – In 20 to 35 year olds: A few occlusal carious or
– Low levels of salivary lactobacilli (<10,000 CFU/mL) restored surfaces in the molars
– Very low or low plaque formation rate (PFRI 1 or 2) – In 36 to 50 year olds: Only occlusal carious or
restored surfaces
– In 51 to 65 year olds: Occlusal carious or restored
surfaces and fewer than four approximal carious or
restored surfaces
• Caries incidence: Fewer than one new carious surface • Internal modifying risk indicators, risk factors, and
every 5 years prognostic risk factors: Few or none
• External modifying risk indicators, risk factors, and • Preventive factors:
prognostic risk factors: Few or none – Good standard of oral hygiene
– Regular use of fluoride toothpaste
– Good dietary habits
– Regular preventive dental care habits
Chapter 13.indd 226 11/5/2014 6:11:02 PM

Chapter
14 Setting up of a Private
Dental Clinic
Dentistry is a healthcare profession that has and the patient who seek the professional
a two fold roles. First to provide healthcare care from them within the walls of the office.
service and second to make a profit as a small
business. Private Practice
As a health care, dentistry embraces the Advantages
following objectives:
• Flexibility of provider and patient in
• Provide relief of pain from dental origin.
terms of duration of work, fees and soon.
• Help oral health promotion by practicing
• Provides free choice for the practitioner
preventive dentistry, maintain patients’
as well as for the patient.
personal appearance, masticate their
food throughout their lifetimes. Types
• Assist in view of maintaining oral
1. Solo
health in relation to general health.
2. Group
i. General group practice
Practice
ii. Single specialty group
The term “practice” means arrangement or iii. Multiple specialty groups
an agreement to provide certain services 3. Solo with visiting specialties.
under a roof by an authorized person.
Establishment of Practice
Management • Selection of the place/location
“The act or art of leading a team to accomplish • Financial resources
goals and objectives while using skill, care • Equipments and materials
and tactful behavior.” • Designing of the dental office.
Structure of Oral Health Care Selection of The Place/Location

The delivery system of oral health care can The place selection should follow a thoughtful
be through: decision which depends upon many factors:
1. Private practice • Personal and family choice of the
2. Salaried practice dentist
3. Hospital dentistry • His/her liking for a place. (e.g. native
4. Public programs place)
The practice of dentistry involves a • Number of dentists practicing in that
personal relationship between the assistants area
Chapter 14.indd 227 11/5/2014 6:04:17 PM

• Dentists’ interest in different hobbies fixtures and fittings designed differently in

• The area’s social and economic status each dental office.
• Transportation While designing the dental office one
• Easy access to schools and residential should consider the functional, esthetic
areas and utility value of the available space. A
• Weather spacious waiting area, work area with dental
• Job of spouse chair and unit, X-ray room, laboratory,
• Local language resting place, toilet, proper concealed
• Where dental colleges are present electrical connections, proper designing of
But not always the personal desires plumbing work, etc. should be incorporated
decide the place. The commitment and in the design.
conscience overrules the personal desires.
DESIGNING OF THE WORK AREA
FINANCIAL RESOURCES
Enough space for dental chair in the supine
Over the years many changes have taken position, space for the movements of the
place in the banking system in our country. assistant around the dental chair and
About three decades ago it was very operating stool should be present. A separate
difficult to get financial assistance from X-ray room with the wall enclosed with
the bank unless one had enough assets for lead barrier will help to minimize the X-ray
hypothecation. In recent years, sources are hazards. Autoclaving and sterilization can
banks, both nationalized and private, state be done in a separate chamber near the work
financial corporations, private financiers or area so that it is easy to carry the instruments
corporate houses which render their help to from there.
establish a new graduate. The compressor and the generators
Applicant who is of good standing, should be kept as much as possible away from
having all documentation, and having a the dental office. It is better to keep them in
guarantee should be able to avail the grants the basement area, if available to reduce
or loans from such institutions. Care should noise level.
be taken to be familiar with the rules, terms
and conditions before availing financial SELECTION OF THE EQUIPMENTS AND
assistance from sources. The interest rates,
INSTRUMENTS
mode of repayment, facilities available, etc.
differ in these different financing bodies, Success depends on the right selection of
from time to time. equipments and instruments.
How should one select the dental equipments?

DESIGNING OF THE DENTAL OFFICE • Basic equipments and instruments in-
For the construction of house, we take help clude the dental chair, dental unit, light
from the architects, and for the dental office cure unit, ultrasonic scalers with tips,
we join our hands with architect. Since there X-ray unit, X-ray developer, autoclave,
is no ideal design, you can do it to your amalgamator, instruments cleaning
requirements for common defined areas, gadget, etc. to run the dental office.
Chapter 14.indd 228 11/5/2014 6:04:17 PM

Setting up of a Private Dental Clinic 229
• He/she can keep on adding the addi- Dental emergencies need to be ad-
tional instruments and gadgets as per dressed, immediately as sympathetically.
the professional and financial capabili- Satisfied patients are one good source of
ties and the requirements of the clinics. advertisement for the dentist. Through
• The selection of the equipments defi- practice dentist comes across a vast section
nitely depends on the availability of of the public and hence it is more important
finance. that he/she maintains a very high standard
• Prime importance—reputation of the of honesty, work ethics and principles while
company and service provided by the he/she is discharging his/her duties.
company.
• One should thoroughly go through the Factors Responsible for a Successful
literature provided by these companies. Dental Practice
• It is always better to have autoclavable
• Relationship with other professionals
instruments especially the hand piece,
• Updating knowledge and skills
scaler handle and tips.
• Disposable items are always preferred. • Personal qualities related to dentist.
• Sterilized or pre-autoclaved materials
Relationship with Other Professionals
should be preferred when one buys
consumable materials like blades, suture It is an ethical value. A dentist should al-
materials, gloves, syringes, needles, etc. ways maintain a good relationship with
• Importance is given to quality and fellow dentists and other professionals. This
warranty period. Interchangeable becomes even more important in a group
spares also should be considered. practice. Conflicts lead to loss and a bad im-
Before starting a dental clinic all the age among patients.
required statutory licenses should be
Updating Knowledge and Skills
attained. It is always better to have insurance
coverage. The modern world of today is facing new
diseases which need new treatments. Also
the improvement in standard of living of
PATIENTS IN PRACTICE
people has made patients demand for the
Patients attending the dental office in private best and latest modality of treatment.
set up irrespective of the city or town or rural The dentist should be competent enough
areas differ from their race, culture, religion, to provide a satisfactory treatment to all
occupation, socio-economic status, literacy sections of people with differing needs. This
levels, behaviors and personalities. The requires updating his knowledge and skills
dentist should be discrete and polite while to be on par with his contemporary.
offering services to the patients. All patients
pay for services, either in cash or in kind as Personal Qualities Related to Dentist
in case of a rural practice. Preference is to The important personal qualities required
be given to those who value the treatment by the dentist in order to be successful are:
offered while being strict with “window • Human attitude
shoppers”. • Confidence
Chapter 14.indd 229 11/5/2014 6:04:17 PM

• Salesmanship Children’s corner: Children special needs

• Punctuality should be considered. Because children are
• Perseverance more apprehensive than adults and they
• Personality get bored easily. They needs chair and ta-
• Politeness ble with children books, comics, building
• Patience blocks, toys, posters, cartoons, etc.
• Good health
Time Management
Tips and Guidelines for Proper Appointments
Management of Dental Office
Correct appointment scheduling is the very
Practice Image
basic of practice efficiency.
External décor: Good practice image starts at A good appointment system will be:
the entrance to the premises, so attention • Maximize productivity
must be paid to the outside appearance. The • Minimize wastage of time
external appearance of the building must be • Reduce tension
clean, tidy, attractive and welcoming.
• Helps patient without causing the
Internal décor: Internal décor can be broadly dentist to work inefficiently
grouped into following categories: • Maintain concern for the patients needs.
• Textures Recall Systems
• Colors
• To maintain an adequate patient flow
• Lighting
throughout the year.
• Windows
• To ensure a sound patient basis for
• Visual foci
future years.
• Music
• Air conditioner Methods of recall
• Reception and waiting areas • Advance appointments
• Uniform • Telephoned reminder
Reception areas: It gives image of warmth, • Mailed reminder/appointment
care, quality. The reception desk with a
sliding glass panel should be avoided Patient Management
completely since it gives the patient an im- Patients are part of dental practice. Private
pression of detachment and lack of personal practice receives all kinds of patients
contact. A smiling receptionist should be the belonging to different caste, creed, race,
first sight to greet patients when they enter. socio-economic status, literacy levels,
rural areas, children and adults, normal
Waiting areas: Waiting time should be turned and the handicapped. Dentist should not
to advantageous and opportunity to use discriminate among his patients and treat
this time for positive dental education. them and be polite while offering services to
Video playing is the excellent method of the patients. Satisfied patients are one good
education. source of advertisement for the dentist.
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Setting up of a Private Dental Clinic 231
Patient Communication Stock Control Materials
Improving Verbal Images The staff working in the clinic should know
A health professional has an obligation to the amount of each material required for
allay fears and comfort patients. The most a particular period, amount of material in
obvious way of accomplishing these tasks the stock, quantity to order, from where to
is to create a good image in the patient’s purchase, the mode of payment, etc. Care
mind. In a dental office you need to eliminate should be taken to have sufficient amount
the use of words or phrases that conjure a in the stock, so that the routine work does
negative thought. not get disturbed.
Managing the Patients Special Needs Records and Accounting

Many of them come for treatment. A patient Maintenance of clinical records of patients,
who is physically, psychologically chal- consent papers, radiographs, casts, photo-
lenged, an older adult, child, single parent, graphs, hematological reports and other
homeless person. In such situations its investigations carried out during the course
necessary for you to make special efforts in of the treatment is a must, and they should
communication. be kept confidential. These records not only
For example: Hearing problem—need to serve as the basis for future treatment, but
stand in front of them. So that with your lip also as evidence in case of legal claims or
moment they understand. when summoned by law.
Accounting gives the dentist the
Waiting Patients
figurative information on the performance of
Its a responsibility of receptionist to inform a practice. The accounting includes: income
about delays, emergencies, the length of generated, expenses met, tax paid, interest
time the patient will have to wait should be on loans, professional indemnity, and
explained honestly. membership fee for associations, etc. Proper
Forms to be used in Dental Practice accounting gives insight to the direction
of the practice and also to plan for future
• Health history
additions. The dentist or his/her assistant
• Telephone call slip
can do accounting, but by preference, should
• Consent form
be done by a qualified auditor.
Finance Control Insurance

Payment It is always good that the dentist in private
Methods of payment practice has indemnity insurance. This helps
• Conventional the dentist in facing any case filed against
• Cash discount him by the patients at the consumer court.
• Extended payment This prevents additional expenditure which
• Credit card could be a large sum and paying at a time
• Banker order may be difficult.
Chapter 14.indd 231 11/5/2014 6:04:18 PM

Administrative Applications of Computers Universal precautions, 1980 OSHA

• Patient appointments and recall Occupational Safety and Health Adminis-
• Payment information and billing tration have been shown to be effective in
• Accounting preventing transmission of infectious dis-
• Correspondence eases from dentist to patient, and vice-versa.
• Inventory controls and supply orders
Guidelines for Control
• Dental insurance claims
• Document preparation and word pro- • Medical history
cessing • Personal protection
• Referral information – Immunization
• Missed appointments follow-up – Hygiene
– Personal protective equipment
Dental Assistants (PPE)/Barrier techniques
– Sterilization and disinfection
It is advisable to have at least one hygienist
– Proper disposal of the waste
and one assistant to receive patients, wash
– Recommendations for dental office
instruments, etc. The practice will be more
water line quality
organized with an assistant as he/she can
– Environmental surfaces
take some responsibility and the dentist
can concentrate more on treatment aspects.
Space out Professional Work
Assistant should open at least 30 minutes
before first appointment and should keep When the hands and the mind work
working area and all necessary equipments together— effective and efficient dental
ready for the work after each case, which can office management occurs. For this good
save a lot of time by maintaining continuity coordination of hands and mind, all the
in the treatment work. The front office staff professionals need, occasional rests from
plays a very vital role in the success of the the work. A dental practitioner must take
practice. Because they are the first contact one-day-off every week, should have at least
person to patient. two vacations every year to spend his time
with his family.
Infection Control
Dental practice has been an identifiable CONCLUSION
source of cross infections. Dental patients In this noble profession of dentistry, one can
and dental health care personnel are from render quality services to the people and take
bloodborne viral pathogens, saliva-droplet care of their oral health. Private practice is
route, and water-droplet route and by direct definitely one of the best modes of delivering
contact with contaminated surfaces which oral health care to the public where you are
cause life threatening diseases. your own boss and sky is the limit for you.
Chapter 14.indd 232 11/5/2014 6:04:18 PM

Chapter
15 Consent Letter
Consent Form (English)

Study Title ______________________________________________________________________________________
Study Number __________________________________________________________________________________
Subject’s Full Name _____________________________________________________________________________
Date of Birth/Age ______________________________________________________________________________
Address of Subject
________________________________________________________________________________________________
_______________________________________________________________________________
___________________________________
Qualification _________________________________
Occupation: Student/self-employed/service/housewife/other (please tick as appropriate)
Annual income of subjects ____________________________________________
Name and address of nominee(s) and his relation to
Subject ________________________________________________________________________
_________________________________________________________________
1. I confirm that I have read and understood the information document dated
__________________ for the above study and have had the opportunity to ask questions.
OR I have been explained the nature of the study by the investigator and had the
opportunity to ask questions.
2. I understand that my participation in the study is voluntary and that I am free to
withdraw at any time, without giving any reason and without my medical care or legal
rights being affected.
3. I understand that the sponsor of the clinical trial/project, others working on the
Sponsor’s behalf, the Ethics Committee and the regulatory authorities will not need my
permission to look at my health records both in respect of the current study and any
further research that may be conducted in relation to it, even if I withdraw from the
trial. However, I understand that my identity will not be revealed in any information
released to third parties or published.
4. I agree not to restrict the use of any data or results that arise from this study provided
such a use is only for scientific purpose(s).
Chapter 15.indd 233 11/5/2014 6:11:24 PM

5. I permit the use of stored sample (tissue/blood) for future research. Yes [ ] No [ ]
6. I agree to take part in the above study.
Signature (or Thumb impression) of the Subject/Legally Acceptable
Representative: ___________________________
Signatory’s
Name ____________________ Date ____________________ Signature of the
Investigator____________________
Date ____________________
Study Investigator’s Name ____________________
Signature of the Witness ____________________ Date ____________________

Name of the Witness____________________
Received a signed copy of Participant Information Document and Consent Form.
Signature (or Thumb impression) of the Subject/Legally Acceptable
Representative: ____________________ Date____________________
Chapter 15.indd 234 11/5/2014 6:11:24 PM

Chapter
16 Public Health Laboratory
PUBLIC HEALTH LABORATORIES • Environmental health and protection.

• Food safety.
Public health laboratories operate as a first
• To examine samples of food, stool and
line of defense to protect the public against
vomit for isolation of enteric pathogens.
diseases and other health hazards. Working
• Food adulteration.
in collaboration with other arms of the
• Infestation of food poisoning cases.
nation’s public health system, public health
laboratories provide diagnostic testings,
Role as Central Food Laboratory
disease surveillance, applied research,
laboratory training and other essential • To examine statutory sample of food
services to the communities they serve. received from various courts and port
Public health laboratory scientists are highly health officers.
educated specialists with knowledge of one • To analyze samples of food sent by
or more scientific disciplines, advanced skills any officer or authority, authorized by
in laboratory practice and the ability to apply central government.
• To do investigations for purpose of
this expertise to the solution of complex
fixation of standards of any article of
problems affecting human health.
food.
• To participate in various investigations
Core Functions of Public Health and collaborative work with other
Laboratories institutions.
• Disease prevention, control and • To take active participation in various
surveillance control and prevention of subcommittee of central committee of
epidemic due to water borne diseases. food standards.
• Integrated data management. • Laboratory improvement and regula-
• Reference and specialized testing. tion.
• To examine water samples chemically • Emergency response.
and bacteriologically for portability. • Public health related research.
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Chapter 16.indd 236 11/5/2014 6:08:08 PM
SECTION 2
Practical Record Book
Chapter 17. List of Armamentarium Required in Department of Public Health

Dentistry
Chapter 18. Assessment of Oral Health Status Using Dental Indices
Chapter 19. Assessment of Oral Health Status Using Who Basic Oral Health
Survey Form
Chapter 20. Comprehensive Oral Health Care Planning
Chapter 21. Preventive Dentistry
Chapter 22. Oral Health Education Materials
Chapter 23. Field Programs (Submission of Reports)
Chapter 24. Comprehensive Report on Setting up a Private Dental Clinic
Chapter 25. Proforma for Indices
Chapter 17.indd 237 11/5/2014 6:12:18 PM

Chapter 17.indd 238 11/5/2014 6:12:18 PM
Chapter
List of Armamentarium
17 Required in Department of
Sl. No. Items Nos.

1. Instrument tray(steel) 1
2. Kidney tray 2
3. Drapes 2
4. Face mask 2
5. HU-FriedyU-15/30 2
6. Supragingival scalers(API) 2 sets
7. Diagnostic instruments 2 sets
(Mouth mirror, explorer, Williams periodontal probe)
8. Cotton holder 1 set
9. Dappen dish 2
10. Upper and Lower study casts 1 Pair
11. Tooth brush 1
12. Interdental brush 1
13. Disclosing agent a-2 tone 1 bottle
14. Sterilization pouches 2/day
Chapter 17.indd 239 11/5/2014 6:12:18 PM

Chapter
18 Assessment of Oral Health

Status Using Dental Indices
INDICES USED TO ASSESS ORAL HYGIENE Criteria and Scoring for Di and Ci in Ohi
The criteria and scoring for DI and CI is the
Oral Hygiene Index
same as that for DI-S and CI-S in OHI-S.
(Greene and vermillion, 1960)
Purpose Calculation
To assess oral cleanliness by estimating the 1. Average debri score for the individual:
tooth surfaces covered with debris and/or a. Add together the debri score for
calculus thus to know the oral hygiene status. each tooth.
b. Divide by the number of segments
Examination Method scored.
Debri score = total score/number of
OHI is composed of Debri index and segments scored
Calculus index, representing the amount of 2. Average calculus score for the individual:
debri or calculus found on the buccal and a. Add together the calculus score for
lingual surfaces of each of the three segments each tooth.
of each dental arch, namely- b. Divide by the number of segments
• Upper right posterior segment scored.
• Upper anterior segment Calculus score = total score/number
• Upper left posterior segment of segments scored
• Lower left posterior segment 3. Average OHI score for the individual:
• Lower anterior segment OHI = DI score + CI score
• Lower right posterior segment
The scoring for the buccal/labial and Oral Hygiene Index – Simplified
lingual surfaces is based on the tooth in the (Greene and Vermillion, 1964)
designated segment that has the greatest
surface area for the DI or supragingival and Purpose
sub-gingival calculus for CI. Therefore the To assess oral cleanliness by estimating the
buccal/labial score and lingual score for a tooth surfaces covered with debris and or
segment need not be taken from the same calculus thus to know the oral hygiene status
tooth. of individual or population.
Rules for Oral Hygiene Index General Rules

The rules for recording OHI are mentioned 1. Only fully erupted permanent teeth
under the general rules for OHI – S. are scored. A tooth is considered to be
Chapter 18.indd 240 11/5/2014 6:07:12 PM

fully erupted and therefore available – For tooth 16,26,36,46 select the first
for scoring when the occlusal or incisal tooth distal (i.e. 2nd and 3rd molars).
guidance has reached the occlusal if no tooth is distal or the only distal
plane. tooth has a full crown or surface
2. A surface is defined as encompassing reduced in height by caries, no other
half the circumference of the tooth. It tooth is substituted.
includes the entire area between the – For tooth 11 substitute 12 and for
incisal or occlusal, i.e. one half of the tooth 31 substitute 41. if either 31 and
adjacent mesial, distal surfaces and the 41 are missing, have a full crown or
crest of the gingiva. surfaces reduced in height by caries,
3. Oral debris is detected by running the no other tooth is substituted.
side of a sickle of an explorer along the 4. The examination is made on the
surface to be examined. designated surface area for each tooth
4. Calculus is not considered to be sub- or substituted tooth. The Buccal or
gingival unless it lies within the gingival lingual surfaces designed include one-
sulcus. half of the adjacent mesial and a distal
5. No score is assigned unless at least two surface i.e. encompasses one – half of
of the six possible surfaces have been the circumference of the tooth.
examined. – Tooth 16 and 26 – upper molars,
6. Evaluate each sextant to record first the buccal surface
debris and then the calculus to avoid – Tooth 36 and 46 – lower molars,
accidental removal of debris from the lingual surface
tooth surface. – Tooth 11 and 31 – anterior teeth,
labial surface.
Examination Procedure 5. The evaluation of each sextant to
1. The surface area covered by debris examine the ‘index teeth’ to record first
the debris and then the calculus, to
and calculus is estimated by running
avoid accidental removal of debris from
the side of no.5 explorer (shepherd’s
the tooth surface.
crook # 23) along the tooth surface
– The examination for debris is
being examined with the help of mouth
accomplished by running the side
mirror.
of the explorer along and across
2. The sequence of examination of ‘index
the tooth surface from incisor or
teeth’ proceeds in a routine following
occlusal third to cervical third to
tooth order tooth 16, 11, 26, 36, 31 and
assist in estimating the proportion
46.
of the surface area covered by debris
3. If any of the above ‘index teeth’ are
at incisal or occlusal third first,
missing or have a full crown restorations
then middle third and then cervical
or surfaces reduced in height by caries
third to avoid drawing debris from
or trauma or attrition, an alternative
cervical third to occlusal third or
substitute tooth is selected if available
incisal third (if explorer is passed
for examination according to the
from cervical third to occlusal third
following.
or incisal third). if no debris is
Chapter 18.indd 241 11/5/2014 6:07:12 PM

present, and stain is present. The Simplified Calculus Index (CI-S)

stain is extrinsic when it can be
Code Criteria
removed by scraping with the tip of
0 No supragingival and subgingival calculus
the explorer.
present.
– The examination for calculus is
1 Only supragingival calculus is present and it
made by using the explorer to covers not more than one third of the exposed
identify the extent of the calculus tooth surface being examined.
so that the surface area covered 2 Supragingival calculus is present and it covers
can be estimated, or to probe the more than one-third but not more than two-third
subgingival calculus. of the exposed tooth surface.
And/or
– Note: Calculus is not considered to
The presence of individual flecks of subgingival
be subgingival unless it lies within calculus around the cervical portions of the tooth.
the gingival area. 3 Supragingival calculus is present and it covers
6. If a substitute tooth is examined, more than two - thirds of the exposed tooth
the number of the tooth should be surface.
called first, followed by the debris And/or
A definite continuous heavy band of subgingival
score number, then the calculus score
calculus is present around the cervical portion of
number. the tooth.
7. Before releasing the patient, give the
recorder a chance to ask for a repeat
score, if necessary.
Criteria for Coding

Simplified Debri Index (DI-S)
Code Criteria
0 No debris or intrinsic stains present on the surface.
1 Soft debris is present but not covering more than
one-third of the tooth surface being examined.
And/or
No debris is present but the presence of extrinsic
stains without debris regardless of the surface area
covered. Scoring
2 Soft debris is present and it covers more than one- OHI-S for an individual
third of the exposed surface; extrinsic stains may
or may not be present. 1. Debris index-simplified (DI-S) +
3 Soft debris is present and it covers more than two- calculus index - simplified (CI-S)
third of the exposed surface; extrinsic stains may – Simplified (CI-S)
or may not be present.
– Divide each total score by number of
teeth scored
– DI-S and CI-S values range from 0–3
2. Oral hygiene index – simplified (OHI-S)
– Combine the DI-S and CI-S
– OHI-S value ranges from 0–6
Chapter 18.indd 242 11/5/2014 6:07:12 PM

Suggested Range of Scores for Evaluation b. When a central incisor is missing, the
Debris index simplified (DI-S) and adjacent incisor of the opposite side is
calculus index simplified (CI-S) used.
Rating Scores
Excellent 0 Procedure
Good 0.1–0.6 1. Apply disclosing agent before scoring.
Fair 0.7–1.8 2. Instruct the patient to swish for 30
Poor 1.9–3.0 seconds and expectorate but not rinse.
3. Examination is made using a mouth
Oral hygiene index – simplified (ohi-s) mirror.
Rating Scores 4. Each tooth surface to be evaluated is
subdivided into 5 sections –
Excellent 0
a. Vertically – 3 divisons – mesial,
Good 0.0–1.2
middle and distal
Fair 1.3–3.0 b. Horizontally – middle third is
Poor 3.1–6.0 subdivided into gingival, middle
and occlusal or incisal thirds.
5. Each of the subdivisions are scored for
Patient Hygiene Performance Index
the presence of stained debri as follows:
Purpose
PHP score Criteria
To assess the extent of biofilm and debri over
a tooth surface. 0 No debri (or questionable)
1 Debri definitely present
Selection of Teeth and Surfaces M When all three molars or both
incisors are missing
Tooth Surfaces
S When a substitute tooth is
16 Buccal
used.
11 Labial
26 Buccal
36 Lingual
31 Labial
46 Lingual
Substitutions for Missing Teeth

a. When a first molar is missing, less than
Scoring
¾ erupted, has a full crown or is broken Debri Score for Individual Tooth
down, the second molar is used or the 1. Add the scores for each of the 5
third molar when the second molar is subdivisons. The scores range from
missing. 0–5.
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Php Index Value for The Indivual experience in permanent teeth. It describes
1. Total the scores for the individual teeth numerically the results of dental caries
and divide by the number of teeth attacks on permanent teeth of a population
examined. The PHP value ranges from group. An average DMF score expresses
0–5. the mean caries prevalence in a group of
individuals.DMF can, therefore, be defined
Php Index Value for a Group as irreversible index on a ratio scale. The
1. Total the individual scores and divide DMF score for any individual can range
by the number of people examined. from 0–32 in whole numbers. DMF value
for a group studies in an epidemiological
Nominal Scale for Evaluation of Scores survey constitute the total of the individual
values divided by the number of subjects
Rating Scores
examined, so the DMF group score can have
Excellent 0 (No debris) decimal values.
Good 0.1 – 1.7 In permanent dentition, the upper
Fair 1.8 – 3.4 case letters for permanent teeth are used to
Poor 3.5 – 5 designate the DMF index. (The symbol “D”
refers to the number of teeth present with
unrestored carious lesions).
INDICES USED TO ASSESS DENTAL The symbol M refers to the number of
CARIES STATUS teeth that are missing (extracted) due to
DMF INDEX (Klein, palmer and caries.
Knutson 1938) The symbol “F” refers to the number of
teeth that have been attacked by caries but
What does Dmf Index Describe?
have been restored and are now free from
DMF Index has received practically universal caries.
acceptance and is probably the best known Thus the DMF index is the sum of
of all dental indices. DMF index is the most decayed(D),missing(extracted) because of
universally employed index for measuring caries(M) and filled because of caries (F)
dental caries. DMF index is based on the permanent teeth (T) or tooth surfaces(S).Each
fact that the dental hard tissues are not self tooth or tooth surface is counted only once,
healing; established caries leaves a scar of either under D,M or F. Thus the DMF index
some sort. The tooth either remains decayed is expressed as DMFT or DMFs.
or if treated it is extracted or filled. The DMF The symbol “T” is used to indicate that
index is therefore an irreversible index, used unit of count for the index is the number of
to measure past and present lifetime caries permanent teeth affected, rather than the
experience of a population with permanent number of affected surfaces on the tooth or
teeth. the number of carious lesions in the mouth.
The symbol “S” is used to indicate that
Definition unit of count for the index is the number
DMF index is defined as quantitative of surfaces affected by carious lesions in
expression of a person’s lifetime caries permanent teeth.
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Thus the DMF index can be applied to the teeth as a whole, it is termed as “Decayed,
whole tooth or to surfaces of teeth. missing – filled surfaces index. “DMFs”
DMF can also be used in a “half – mouth index. The “S” symbol is used to indicate that
fashion” or “Short hand method” of DMF the unit of count for the index is the number
examination as recommended by WHO in of surfaces affected by caries in permanent
which apposite diagonal quadrants of the teeth, rather than the number of affected
mouth are examined. Here the objective is permanent teeth.
to obtain assessments of caries prevalence in In studies in which DMF surfaces are
a population which has not been previously ascertained, it is necessary to decide how
surveyed. This technique means that half many affected surfaces to assign to teeth that
the upper arch only is scored, then the have been extracted because of caries.
contralateral lower half arch and the results In epidemiological studies or surveys
doubled. This is quicker and easier than full for DMFs it is decided to assign the affected
mouth DMF index. surfaces, i.e. facial, lingual, mesial, distal and
The “DMFT” index is generally expressed occlusal to posterior permanent tooth and
as “the average number of DMF teeth per facial, lingual, mesial and distal to anterior
person” in the population being studied. The permanent tooth, that has been extracted
average is usually computed separately for because of caries, i.e. U component. In
each ‘age’ and ‘sex’ grouping since there two root stumps the D component it is decided
factors are important in correctly interpreting to assign 5 affected surfaces to posterior
the data. As we know for example. permanent anterior tooth.
1. The girls acquire their permanent teeth Total surfaces count for DMF(S) – D(S) +
at a slightly earlier age than boys. M(S) + F(S)
Therefore, we expect a slightly higher Total surfaces count for DMF(S) Index –
DMF average for girls than boys when Total number of surfaces examined, if only
the age is same. 28 teeth are examined (i.e., third molars are
2. We also know that the older the child, excluded).
the higher the DMF average. The older 16 posterior teeth (16 × 5) = 80 surfaces
child has more permanent teeth that 12 anterior teeth (12 × 4) = 48 surfaces
are subject to attack by caries and he Total number of surfaces examined = 128
also has permanent teeth that have surfaces.
been vulnerable to a caries attack for Calculation of DMFs index for an
a longer period of time. In addition to individual:
the “average number of DMF teeth” Total no. of decayed surfaces = D
it is possible to compute a number of Total no. of missing surfaces = M
other statistical measures from the Total no. of filled surfaces = F
information collected on a DMFT Index Total DMFs of an individual score - D(S)
surveys. + M(S) + F(S)
In some studies, this number has
been chosen arbitrarily, e.g., 3 surfaces for
DMFS Index
posterior teeth and 2 surfaces for anterior
The “DMF” index is employed to assess teeth. In clinical trials, it has been shown that
individual surface of each tooth rather than it is best to use an arbitrary number for three
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surfaces if a tooth is absent on the baseline It is the sum of no of primary teeth or surfaces
but, for teeth that are extracted during the that are decayed (d), decayed beyond repair
course of the trial, one should use the number i.e., those that need to be extracted (e) and
of affected surfaces determined at the most filled (f). WHO’s oral health surveys – Basic
recently completed examination. methods (1971) substitutes “i” for “e” to
designate teeth indicated for extraction.
The def-index differs from the dmf index
MIXED DENTITION
in that primary teeth missing at the time of
Assessment of Caries in Primary Teeth the examination are ignored in the former.
“def-index” Caries indices used for primary dentition
When a survey is made of a population of deft index and defs index equivalent to
children having a mixed dentition, def index DMFT and DMFs indices used for permanent
is used to describe the caries experience of dentition. The DMFT and DMFs indices as
deciduous teeth (primary dentition). applied to the permanent dentition is always
The equivalent index for measuring designated or signified by upper case letter
caries in the primary dentition is the “def- i.e., capital letters. The equivalent index for
index” described by Gruebbel in 1944 primary dentition is the deft and defs is
in his study “A measurement of dental always designated or signified by lower case
caries prevalence and treatment service for letter i.e. small letters
deciduous teeth as defined by Gruebbel”
“d” stands for decayed deciduous teeth. MODIFICATION OF DEF INDEX
“e” stands for indicated for extraction of
deciduous teeth. It should be noticed that in def index
“f” stands for filled deciduous teeth deciduous teeth missing due to caries are not
because of caries. recorded because of the difficulty in many
It should be noticed that in def index children of distinguishing between extracted
deciduous teeth missing due to caries are and naturally exfoliated primary teeth. By
not recorded because of difficulty in many giving due considerations to these two facts,
children of distinguishing between extracted def is modified into
and naturally exfoliated primary teeth. The 1. dmf index
def does not take into account teeth that have 2. df index
been extracted or exfoliated because of past
caries experience. dmf Index
What does “def–index” Describe? Definition
The def index is a variation of DMF dMf index is a quantitative expression of
Index, is used to measure observable caries the caries experience or caries prevalence in
experience in primary tooth. the primary teeth. It is the sum of decayed
(d), missing due to caries (m) and filled (f)
Definition because of caries primary tooth (t) – it is
def-index is defined as “It is a qualitative dmft or tooth surfaces (s) – it is dmfs.
expression of the observable caries experience It is used in the same way as DMF index.
or caries prevalence in the primary dentition. Only those teeth which should be present
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according to the subject (patient) age at teeth along with dft index and dfs index to
the time of examination are assessed in the describe the caries experience of deciduous
missing component. For example, it may teeth.
be decided to classify missing deciduous The average should be computed
canines and molars as missing (m) only in separately for each age and sex grouping
children less than nine years of age, because for children under 12 years of age. The
beyond that age it may be impossible to DMFT index or DMFs index for permanent
determine whether a given missing tooth dentition and dft index or dfs index for
has been extracted or has exfoliated. If all deciduous dentition, the data should be
missing primary teeth not replaced by a computed separately to describe caries
permanent successor are considered as experience in permanent and deciduous
m-teeth regardless of age, an overestimation teeth respectively.
of the dmft index results. Therefore, the Close observation shows that df index
dmft is used for children before age of and def index should be numerically the
exfoliation and dmf applied only to the same: def index allow for two grades of caries
primary molar teeth. and neither count missing. Both def index
and df index may therefore under state the
df Index true extent of the carious attack and thus
lose validity. For comprehensive purpose,
Definition
however the greater variability gained by
df index is a quantitative expression of a ignoring missing tooth can make both indices
person’s or groups number of decayed and more useful.
filled deciduous teeth or tooth surfaces.
When a survey is made of a population
of children having a mixed dentition, a “df Rationale for the DMFT
index” is also used to describe the caries classification
experience of deciduous teeth. The examiner’s task, during the survey
The symbol‘d’ stands for the number of examination, is to classify the condition
deciduous teeth present that are caries and of each of the 28 tooth spaces for each
not restored. The symbol ‘f’ stands for the patient examined. To arrive at the proper
number of restored deciduous teeth because classification for each tooth space, the
of caries. The missing teeth are ignored. This examiner must make:
is the method of choice of the WHO’s oral • Four decisions if a tooth is present or
health surveys – Basic methods. • Three decisions if a tooth is absent
The df index can be applied to the whole The examiner’s final decision for each
tooth as the decayed-filled-tooth—dft index tooth or tooth space is expressed as a code.
or to the individual’s surfaces as the decayed- The special rules to be followed in making
filled-surfaces—dfs index. decisions and the definition for each category
When a survey is made of the population of the code are included in the next section.
of children between the age groups of 6 to The decision process that forms the basis for
12 years having a mixed dentition, a DMFT the coding system is expressed schematically
index or DMFs index used for permanent below:
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For Each of the 28 Tooth Spaces
EXAMINATION CRITERIA AND and coding criteria and to avoid any

RULE FOR CODING confusion and doubts to eliminate the
errors in survey procedures.
Rules
Speicial Rules General Rules
1. A tooth is considered erupted when the The general rules for examination and coding
occlusal surface or incisal edge is totally criteria are as follows:
exposed or can be exposed by gently 1. No tooth or tooth space or tooth surface
reflecting any overlying gingival tissue should be counted more than once. It
with the mirror or explorer. may be either decayed, missing, filled
2. A tooth is considered to be present even or sound.
through the crown has been destroyed 2. The decayed, missing and filled tooth
and only the roots are left. or tooth surface or tooth space should
3. Supernumerary teeth are not to be be recorded separately since the
classified. components of DMF index are great
4. If a primary tooth is retained and its interest.
permanent successor is present, classify 3. A tooth may have several restorations
the permanent tooth. but it is counted as one filled tooth.
Note: The following points should Note: In DMFs index if the tooth shows
be noted clearly for just to make the fillings on different surfaces i.e., mesial,
student to understand the examination distal and occlusal, lingual (or palatal) and
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buccal. The filled tooth surfaces should be 6. The tooth has a restoration used as a
counted separately in DMFs index. abridge abutment
4. The tooth treated with pit and fissure 7. A permanent tooth has been removed
sealant and shows carious lesion. for orthodontic, reasons or for any
5. Third molars are not included in DMF reason other than caries.
index.
6. Naturally exfoliated tooth should not be PERMANENT TOOTH PRESENT
taken into considerations.
7. Measurement of caries status for Sound Permanent Tooth 1
deciduous and permanent teeth should Code a tooth “1” if there is no indication of
be recorded separately. The deciduous caries and no fillings, jackets, crowns or bridge
teeth are not included in DMF count. abutment. Other defects such as hypoplasia,
8. If anterior tooth is missing due to caries fluorosis, and enamel defects may or may not
four surfaces and posterior tooth five be present. If some surfaces of an apparently
surfaces should be counted. sound tooth are obscured by an orthodontic
9. If both a filling and caries lesions are band assume that tooth is sound.
present on the same surface that surface
is considered as only one surface that Filled Permanent Tooth 2
too as carious.
Code a tooth “2” when a tooth has been filled
10. If a tooth is filled shows secondary caries
either permanently or temporarily regardless
count that tooth or surface is considered
of the material used. A tooth that is both
as caries only in “D” category of DMF
filled and decayed is classified as code “3”
index tooth with.
decayed. In any instance where the filling has
11. If the restoration has displaced from the
fallen out, code the tooth as “3”.
cavity and the tooth with base cavity is
considered as decayed tooth.
Decayed Tooth 3
EXCLUSIONS E Code a tooth “3” when there is the following
evidence of caries present.
Excluded Tooth or Tooth Space • Visual evidence of undermined enamel;
Code a tooth “E” when one of the following there must be a definite cavitation with
conditions is present. either discoloration or opacity around
1. The tooth has been fractured and is the edges and in which the explorer can
damaged to the extent that dentin is penetrate.
exposed. • Pits and fissures in which the end of the
2. It may be either sound, carious, or filled. explorer catches should be classified
3. The tooth has been fractured and the as carious only if one of the following
fractured portion is restored with a criteria is met:
filling, jacket, or crown. i. Tactile evidence of soft carious
4. The tooth has a root hand filling due to material at the base of the pit and
trauma. fissure
5. The tooth has a jacket crown because it ii. Opacity around the edges or an
is a poorly formed tooth, e.g. peg lateral. underlying stain typical of caries.
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PRIMARY TOOTH PRESENT necessary the facial, occlusal, lingual, and

proximal surfaces of all the teeth present
Use the same criteria as for the classification
(expect 3 rd molars), identifies the tooth
of a permanent tooth present code as follows
number of all the teeth that are absent,
E Excluded tooth or tooth spaces and determine the reason for absence. The
examination is made using a plane glass
P1 Sound deciduous tooth mouth mirror and a sharp standard No. 23
explorer. Compressed air (or a chip blower)
P2 Filled deciduous tooth
is used to improve visibility when the tooth
P3 Carious deciduous tooth surfaces are obscured by saliva or debris.
The patient should be positioned so that
the examiner has optimum visibility of the
PRIMARY OR PERMANENT TOOTH ABSENT quadrant to be examined. The examination
should be conducted as follows:
O Missing Tooth
1. Begin with the maxillary right quadrant
Code a tooth space as “0” when the absence with the central incisor or tooth space
of a tooth is due to one of the following: number 1, and proceed in sequence
• Primary tooth missing for any reason to the second molar or tooth space
• Un-erupted permanent tooth number 7.
• Un-erupted deciduous tooth 2. As the examination proceeds, the
• Impacted or congenitally missing examiner calls the appropriate
permanent or primary tooth. diagnostic code for each tooth or tooth
space. Since the examination proceeds
EXTRACTED PERMANENT TOOTH in sequence from anterior to posterior,
the tooth number is not called routinely.
X Code a tooth space as “x” 3. When the quadrant is completed,
• If according to the age of the person, the examiner pauses briefly, and the
a permanent tooth should be present recorded calls “check” to indicate that
but in all probability has been extracted she has accounted for every tooth space
because of caries. in the quadrant.
• Special Precautions. 4. The maxillary left quadrant is examined
When not sure, the person should be next, and proceeds in the same manner
questioned regarding extractions. The beginning with the central incisor or
final decision should be based upon the tooth space number 1 and proceeding to
examinations and the person’s response. the second molar or tooth space number
Clinical judgment is given preference in the 7 for that quadrant.
event that the response is not conclusive. 5. The examination then proceeds to the
mandibular left quadrant and then to
the mandibular right quadrant.
THE DMFT EXAMINATION PROCEDURE 6. At the end of the examination the
In the examination process, the examiner examiner should pause before releasing
visually inspects and explores when the patient in order to give the recorder
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an opportunity to verify that he/she has measuring the presence or absence of
recorded a code in every space on the gingival inflammation, its severity with
form and to ask for a repeat code if this pocket formation and masticatory efficiency.
is necessary.
Examination Procedure
DO’S AND DONT’S FOR THE EXAMINER • All the teeth are examined. Root stumps
are excluded.
1. Do, when at all possible, keep your
• All of the tissue circumscribing a tooth
hands out of the patient’s mouth. This
is considered a scoring or gingival unit
minimizes contamination.
and assessed for gingival inflammation
2. Don’t probe gross carious lesions with
and periodontal involvement.
the explorer and cause unnecessary
discomfort to the patient. The explorer
should be used only on those areas Instruments Used
where doubt exists as to the presence • Each tooth is examined using a
or absence of a carious lesions or mouth mirror, explorer and Williams
restoration. periodontal probe with adequate
3. Do, question the patient regarding rea- illumination. In the original examination
sons for extraction, but if the response is a Jacquette scaler and chip blower
not conclusive, rely on your judgment. were used to define the presence of
4. Do take advantage of the educational periodontal pockets.
opportunity when the patient asks
questions or expresses concern. Rule
5. Do keep a steady, even pace in your ex- When in doubt assign lesser score.
amination. Experienced examiners will Note:
carry out average 25-30 examinations • Gingivitis with pocket formation, there is
per hour. You and your recorder can horizontal bone loss involving the entire
take a break once or twice during each alveolar crest, upto half of the length of
morning and afternoon session. tooth root.
• In advanced destruction of periodontal
INDICES USED TO ASSESS PERIODONTAL tissue with loss of masticatory function,
STATUS there is advanced bone loss involving
more than one half of the length of
RUSSEL’S PERIODONTAL INDEX the tooth root, or a definite infrabony
Purpose pocket with widening of periodontal
To assess and estimate periodontal disease ligament. There may be root resoprtion
status of individual or population by or rarefaction at apex.
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Criteria and Scoring for the Periodontal Index

Score Criteria Notes
0 Negative: there is neither overt inflammation in the This result is recorded when at first glance there are no
investing tissues nor there is loss of function due to obvious signs of change in color or form of the gingival
destruction of supporting tissues. tissues.
1 Mild gingivitis: there is an overt area of inflammation in This includes both low grade chronic conditions and
the free gingivae, but this area does not circumscribe acute conditions. Gingivitis should receive the same
the tooth. rating in each person without regard to age, sex or
ethnic groups.
2 Gingivitis: Inflammation completely circumscribes the
tooth, but there is no apparent break in the epithelial
attachment.
4 Used only when radiographs are available. There is an early notch like resorption of alveolar crest.
6 Gingivitis with Pocket Formation: The epithelial The very deep crevice associated with an erupting
attachment has been broken and there is a pocket tooth is not recorded as pocket. The usual signs of
(not merely a deepening of the gingival crevice due to pocket are apical migration of the epithelial attachment,
swelling in the free gingivae). There is no interference loss of tone and alteration in gingival form. A probe
with normal masticatory function, the tooth is firm in its can be used to confirm a diagnosis but is not used in
socket and has not drifted. the absence of inflammation. A blast of air from an
chip blower can be used to confirm obvious pockets.
Resorption and recession of gingiva with exposure of
cementum is not scored in the absence of inflammation.
8 Advanced destruction with loss of masticatory function. Loss of function is usually determined by digital
palpation; looseness by lateral finger pressure; dullness
and depressibility are used to differentiate periodontitis
from periodontosis. All the teeth expect for residual
roots are scored.
Suggested Nominal Scale Individual Periodontal Index (Pi) and Clinical

• Periodontal disease conditions can be Conditions
interpreted by the periodontal score and Clinical conditions Individual PI scores
results as: Clinically normal supportive tissue 0 to 0.2
Group Periodontal Index (Pi) Score and Beginning destructive periodontal 1.0 to 1.9
Clinical Manifestations disease
Established destructive periodontal 2.0 to 4.9
Clinical condition Group PI score Stage of disease
disease
Clinically normal 0 to 0.2 Terminal stage 5.0 to 8.0
supportive tissue
Beginning 0.7 to 1.9 Reversible COMMUNITY PERIODONTAL INDEX OF
destructive TREATMENT NEEDS (CPITN)
periodontal disease
Established 1.6 to 5.0 Irreversible The Community Periodontal Index of Treat-
destructive ment Need was developed in collaboration
periodontal disease
between the Federation Dentaire Inter-
Terminal stage 3.8 to 8.0 Irreversible
nationale (FDI) and the Oral Health Unit
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of World Health Organization (WHO). A The dentition is divided into six sextants.
description of the methodology has been The sextants contain the following teeth.
published by Jukka Ainamo and his asso-
17 – 14 13 – 23 24 – 27
ciates in 1982.
The CPITN was developed primarily to 47 – 44 43 – 33 34 – 37
survey and evaluate periodontal treatment
needs rather than determining past and • Third molars are not included, except
present periodontal status like the recession when they are functioning in the place
of gingival margin, loss of alveolar bone, of second molars.
mobility of tooth and loss of periodontal • The treatment need in a sextant is
attachment. recorded only when 2 or more teeth are
present and not indicated for extraction.
Purpose NOTE: The indication for extraction
The purpose of CPITN is to screen and because of periodontal involvement is
monitor individual or group periodontal that the tooth has vertical mobility and
treatment needs. causes discomfort to the patient.
The “Treatment need” is intended as If only one functioning teeth remains in a
a guide to the level or magnitude of need sextant, it is included in the adjacent sextant.
for care using accepted periodontal criteria.
Thus the CPITN records the common Uses of Index Teeth
treatable conditions, namely periodontal A. Adults (20 Years and Above)
pockets, gingival inflammation (identified In epidemiological surveys assessing
by bleeding on gentle probing) and dental the periodontal treatment needs of an
calculus and other plaque retentive factors. population, the recordings per sextant are
• If no disease is observed, no treatment based on findings from specified index teeth.
need is required.
• If gingivitis is present, but no evidence The index teeth to be examined are:
of calculus or pockets, then self care 17,16 11 26, 27
(plaque control) is recommended.
47, 46 31 36, 37
• If calculus or shallow pockets are
present, its control would require
• Although 10 index teeth are examined,
involvement of trained persons.
only 6 recordings, one relating to each
• If deep pocket is evident, its control
sextant are made.
needs the services of specially trained
• When tooth or one of the designated
personnel.
molar teeth are present, the worst
findings from these tooth surfaces is
Methodology recorded for sextant.
Sextants • If no index teeth are present in a sextant
The periodontal treatment needs are re- qualifying for examination, all the
corded for sextants, i.e. 6th’s of the dentition. remaining teeth are examined.
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B. Children and Adolescents (Below 19 Years) It is realized that the use of any pocket
For many children and adolescents about probe does not provide the clinician with
7 to 19 years of age, only 6 index teeth are accurate measurements of pockets in
examined. The second molars are excluded millimeters which, even if feasible are of
as index teeth at these ages because of the doubtful value. Instead, the probe measures
high frequency of false (non-inflammatory what is ‘normal’ and ‘abnormal’ with
association with tooth eruption) pockets. The indications of treatment requirements being
6 index teeth are: derived from ‘abnormal’ scores. A force of no
more than 20 to 25 g is considered sufficient
16 11 26 to reveal pathology without causing pain to
the subject.
46 31 36
• W h e n e x a m i n i n g c h i l d r e n a n d Types of CPITN Probes

adolescents pockets are not recorded This joint working committee of WHO/FDI
although probing for bleeding and has advised the manufacturers of CPITN
calculus are carried out as a routine. probes to identify the instruments as either
• When the designated tooth is missing, CPITN–E: for the epidemiological probe
the sextant is recorded as missing and with 3.5 mm markings
marked as “X”.
CPITN–C: for the clinical probe with
Procedure additional at 8.5 mm and 11.5 mm markings.
The WHO Periodontal Examination Probe A variant of the WHO periodontal
For simple recordings of the periodontal examination probe, i.e. CPITN–C probe has
treatment needs, the use of the WHO probe two additional lines at 8.5 mm and 11.5 mm
is recommended. It is also called as CPITN form the working tip. The additional lines
Probe. may be of use when performing a detailed
The instrument was designed for two assessment and recordings of deep pockets
purposes namely, for the purpose of preparing a treatment plan
1. Measurement of pocket depth for complex periodontal therapy.
2. Detection of sub gingival calculus The WHO CPITN–E probe is
recommended for epidemiological surveys
The instrument has for screening and monitoring periodontal
• Black mark from 3.5 mm to 5.5 mm. treatment needs for groups of people in
• Ball tip of 0.5 mm in diameter. community and individuals in clinics.
The probe has a “ball tip” of 0.5 mm Also, it provides guidance on the planning
that allows easy detection of sub-gingival and monitoring of the effectiveness of
calculus. The ball tip also facilitates the periodontal care programs and the dental
identification of the base of the pockets, thus personnel required. A list of manufacturers
decreasing the tendency for false reading by of this probe can be obtained form Oral
over measurement. Health, WHO, 1211 Geneva 27, Switzerland.
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underneath the fingernail where the
sensitivity approximates that of periodontal
pocket.
Working component
When inserting the probe into a periodontal
pocket, the ball point should follow the
anatomic configurations of the root surface.
Sensing component
For sensing sub-gingival calculus, the lightest
possible force which allows movement of the
probe ball point along the tooth surface is
used.
There is no rule specifying the number
of separate probing to be made. This will
depend on the condition of the tissues
The Probing Procedure surrounding the teeth. However, when, only
Objective the index tooth or teeth are being examined
A tooth is probed to determine: or when the recording is based on the worst
• Pocket depth findings in all the teeth of the sextant, it would
• Presence of calculus be rare to exceed four probing per sextant.
Whenever available, radiographs will
• Bleeding response
greatly enhance identification of advanced
Probing Force periodontal lesions.
The probing force can be divided into:
Recording of Findings
• A working component—to determine
the pocket depth Indications
• A sensing component—to detect sub- In assessing treatment needs, the presence
gingival calculus of the following indicators of periodontal
status is used for each sextant in the sequence
A Practical Test for Probing Force given below.
A practical test for establishing the working
force of no more than 25 g is to gently insert Indications Code
the probe point under the fingernail and Pathologic pockets 6 mm or deeper 4
press till blanching occurs without causing Pathologic pockets 4 to 5 mm deep 3
pain and discomfort. The recommended
Supra or sub-gingival calculus, defective margins 2
probing force corresponding to 20 to 25 of fillings or crowns
g should cause no pain to the examinee
Gingival bleeding after gentle probing 1
during probing procedure. This practical
Healthy periodontium 0
test for establishing this force is to probe
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• Whenever a 6 mm or deeper pocket is Treatment Needs (Tn)

found at any designated tooth or teeth TN-0 A recording of code 0 indicates no treatment
in the sextant being examined, a code of
TN-1 A code of 1 indicates a need for improving the
‘4’ is given to the sextant. Recordings of personal oral hygiene of that individual-I
code 4 make further examination of that TN-2 A code of 2 and 3 indicates need for professional
sextant unnecessary. cleaning, root planning and removal of plaque
retentive factors. In addition patient obviously
• If deepest pocket found at the designated
requires oral hygiene instructions-II plus I
tooth or teeth in a sextant is 4–5 mm,
TN-3 Code of 4 requires complete treatment which
code of 3 is recorded. Again there is no involves deep scaling, root planning and more
further examination. complex surgical procedures - III plus II plus I
• If no pockets deeper than 3 mm are
observed, the presence of supra or sub- • Obviously, a recording of code 0 (zero)
for all 6 sextants indicates that there is
gingival calculus and/or overhanging
no need for treatment. The patient come
of fillings or crowns is indicated by the
under class–0 (zero)
recording of code 2 for the sextant.
• If code of 1 is the only ones identified,
• If neither deep or moderate pockets
the need for improvement in the
nor calculus are observed, but bleeding personal oral hygiene of that individual
occurs after probing code 1 is given to is indicated. The patient come under
the sextant examined. class–I.
• The gingivae of the designated tooth • A maximum code of 2 indicates the
or teeth should be inspected for the need for professional debridement
presence or absence of bleeding before of the teeth. As moderate pocketing
the examinee is allowed to swallow or (4–5 mm, code–3 ) likewise be manage
close his mouth. with a combination of professional
Note: At times bleeding may be delayed and personal cleaning of the teeth, the
for 10 to 30 seconds after probing. treatment need is the same for code 2
• If the sextant is found healthy, code 0 and 3. Clearly the patient also requires
(zero) is given to the examined sextant. oral hygiene instructions. The subjects
(patients) come under class II.
• A sextant scoring code 4 (6 mm or deeper
Classification of Treatment Needs
pockets) may or may not be successful
A subject or a sextant is classified into treated by means of deep scaling and
the different treatment need categories efficient personal oral hygiene measures.
according to the highest score recorded Code 4 therefore assigned to ‘complex
during the examination. In epidemiological treatment’ which may involve deep
surveys this classification will be made scaling and root planning under local
automatically by the computer program, anesthesia or require surgical exploration
according to the following rules under four of the infected root surface in order to
classes or scales. gain access needed to clean it.
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COMMUNITY PERIODONTAL INDEX (CPI) one is missing there is no replacement
and the score for the remaining molar
Purpose
is recorded.
To screen and monitor the periodontal status d. If no index tooth or teeth are present in
of populations.
a sextant qualifying for examination,
all the remaining teeth in that sextant
Indicators are examined and the highest score is
Three indicators of periodontal status are recorded as the score for the sextant.
used for this assessment. The distal surfaces of the third molars
1. Gingival bleeding should not be scored.
2. Calculus
3. Periodontal pockets Children and Adolescents
(Less than 20 Years)
Selection of Teeth a. Six index teeth are examined
The mouth is divided into 6 sextants defined
by tooth numbers. 16 11 26
46 31 36
18–14 13–23 24–28
48–44 43–33 34–38 This modification is made in order
to avoid scoring the deepened sulci
A sextant should be examined only if there associated with eruption, as periodontal
are two or more teeth present which are not pockets.
indicated for extraction. (Note: this replaces b. For the same reason, when children
the former instruction to include single under the age of 15 years are examined,
remaining teeth in the adjacent sextant.) pockets should not be recorded, i.e.
only bleeding and calculus should be
Index Teeth considered.
Adult 20 Years and Older
a. A sextant is examined only if there are Procedure
two or more teeth present that are not Instrument
indicated for extraction. A specially designed WHO probe is
b. Ten teeth are examined. Teeth to be recommended. It is also called as CPITN
examined are – probe.
17,16 11 26, 27 Examination
47, 46 31 36, 37 The index teeth or all remaining teeth in a

sextant where there is no index tooth should
c. The 1st and 2nd molars in each posterior be probed and the highest score recorded in
sextant are paired for recording and if the appropriate box.
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Criteria: Cpi Score • Loss of attachment should not be re-

corded for children under the age of 15.
Score Criteria
Probing pocket depth gives some
0 Healthy
indication of the extant of loss of attachment.
1 Bleeding observed, directly or by using a mouth
This measurement is unreliable when
mirror after probing
there is gingival recession, i.e. when the
2 Calculus detected during probing, but all of the
black band on the probe visible cementoenamel junction (CEJ) is visible.
When the CEJ is not visible and the
3 Pocket 4–5 mm (gingival margin within the black
band on the probe) highest CPI score for a sextant is less than 4
4 Pocket 6 mm or more (black band on the probe (probing depth less than 6 mm) any loss of
not visible) attachment for that sextant is estimated to be
X Excluded sextant (less than 2 teeth present) less than 4 mm (loss of attachment score =0)
9 Not recorded
Criteria: Loss of Attachment
Score Criteria
0 Loss of attachment 0-3 mm (CEJ not visible
and CPI score 0-3)
If the CEJ is not visible and the CPI score is 4 or if CEJ
is visible.
1 Loss of attachment 4-5 mm (CEJ within the
black band)
2 Loss of attachment 6-8 mm (CEJ between the
upper limit of the black band and the 8.5 mm
ring)
Loss of Attachment
3 Loss of attachment 9-11 mm (CEJ between 8.5
• Information on loss of attachment mm and 11.5 mm ring)
may be collected from index teeth 4 Loss of attachment 12 mm or more (CEJ
in order to obtain an estimate of the beyond 11.5 mm ring)
lifetime accumulated destruction of the X Excluded sextant
periodontal ligament. 9 Not recorded (CEJ neither visible nor
• This permits comparisons between detectable)
population groups but is not intended
to describe the full extent of loss of
attachment in an individual.
• The most reliable way of examining for
loss of attachment in each sextant is to
record this immediately after recording
CPI score for that particular sextant.
The highest score for CPI and loss of
attachment may not be necessarily be
found on the same tooth in a sextant.
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INDICES USED FOR DENTAL FLUOROSIS Scores and Criteria
DEAN’S FLUOROSIS INDEX 1942 Classification Criteria
Normal (0) The enamel represents the usual
• Introduced in 1934 by Trendly H Dean as translucent semivitriform type of
“Dean’s classification system for dental structure. The surface is smooth, glossy
and usually a pale, creamy white color.
fluorosis” or “Dean’s fluorosis index.”
Questionable The enamel discloses slight aberrations
• It was modified in 1939 and 1942. The
(0.5) from the translucency of normal enamel,
1942 modification of Dean’s fluorosis ranging from a few white flecks to
index is the one still recommended by occasional white spots. This classification
WHO in its basic survey manual (WHO is used in those instances where a definite
diagnosis of the mildest form of fluorosis
1997). is not warranted and a classification of
“normal” not justified.
Endemic dental fluorosis is a specific
Very mild (1) Small, opaque, paper white areas
disturbance of tooth formation caused by scattered irregularly over the tooth, but
excessive intake of fluoride during the not involving as much as approximately
formative period of dentition. 25% of tooth surface. Frequently included
in this classification are teeth showing no
more than about 1–2 mm of white opacity
Procedure at the tip of the summit of the cusps of
bicuspids or second molars.
• All the teeth are examined.
Mild (2) The white opaque areas in the enamel
• When the teeth are scored, the examiner of teeth are more extensive, but do not
should start at the higher end of the involve as much as 50% of the tooth.
index (severe) and eliminate each score Moderate (3) All enamel surfaces of the teeth are
or category until he or she arrives at the affected and surfaces subject to attrition
show wear. Brown stain is frequently a
present condition.
disfiguring feature.
• If there is any doubt a lower score should
Severe (4) All enamel surfaces of the tooth are
be recorded. affected and hypoplasia is so marked
• The recording is based on the two teeth that the general form of the tooth may
most affected. be affected. The major diagnostic sign of
this classification is discrete or confluent
• However, if the two teeth are not equally pitting. Brown stains are widespread
affected, the score for the less affected and teeth often present a corroded-like
tooth is recorded. appearance.
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Chapter
Assessment of Oral Health Status
19 Using Who Basic Oral Health
Survey Form
Survey form Tissues/Areas Examined

The standard form for oral health assessment
Purpose is designed for collection of all the information
To collect comprehensive data on oral health needed for planning oral care services and
status and treatment needs of both adults thorough monitoring and replanning of
and children in a community. existing care services. The survey categories
of form include:
Standard Codes • Survey identification information
• Standard codes must be used for all • General information
sections of the form. This facilitates to • Extraoral examination
prices and summarizes the data to feed • Temporomandibular joint assessment
for standard computer program • Oral mucosa
• If some of the oral health assessments • Enamel opacities/hypoplasia
are not carried out, or are not applicable • Dental fluorosis
• CPI (periodontal status, formerly
to the age group being examined. The
called community periodontal index of
unused sections of the form should be
treatment needs or CPITN)
cancelled with a diagonal line or by
• Loss of attachment
using code 9 in the appropriate box
• Dentition status ad treatment needs
(= not recorded) • Prosthetic status
• The forms are designed to facilitate • Prosthetic needs
computer processing of the results • Dentofacial anomalies
• Each box is given an identification • Need for immediate care and referral
number (the small number in paren- • Notes.
thesis) which represents a location in a
computer file Procedures
• Recording codes are shown near the • Standardized assessment form with
appropriate boxes boxes for data entry identifies the codes
• To minimize the number of errors, all and descriptive criteria for each data
entries must be clear and unambiguous collection category as described in the
• Numerals should be written clearly clinical field program manual.
to avoid confusion and the danger of
computing inaccurate results Scoring
• When letters are used as under dentition • Data can be analyzed by survey team or
status and treatment needs they should arrangements can be made for data entry
be written in capitals, i.e. upper case from to be analyzed by the world health
letters. organization.
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Chapter
20 Comprehensive
Oral Health Care Planning
COMPREHENSIVE ORAL HEALTH CARE EVALUATION OF DENTAL PATIENT

It is the complete oral health treatment, Date: OP No:
planning for an individual or for a group, so Patient’s name: Students name:
that the goal of total oral health is achieved.
Age/Sex: Marital status:
Date and place of
Definition
birth:
It is a coordinated inter-disciplinary
Address and
approach of providing preventive and
telephone number:
therapeutic care followed by maintenance
care according to individual physical, mental Religion: Education:
and socioeconomic status. Occupation: Income:
The candidate should be able to plan
comprehensive treatment for the individual Chief Complaint
or for a group.
Under the guidance of teachers the
students must use the specific proforma and
should be able to express his views about
positive upgrading of oral health status.
1. The personal history details are taken.
The chief complaint is noted. History of Present Illness
2. The patient is examined for general and
oral health status. Clinical findings are
noted down.
3. The treatment priorities are to be listed
out and the levels of prevention for each
treatment are to be noted.
Lastly, the goal of achievements which Past Dental History
the doctor wants to attain at is mentioned.
For example, improvement of masticatory
efficiency, phonetics, esthetics social
acceptance, social utility of the individual,
psychosocial adjustment of the patient, etc.
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Medical History c. Material used: tooth paste/tooth

powder/charcoal/sand/brick/any
other material
d. Frequency of cleaning/brushing:
once/twice/thrice
e. Time of brushing: before meal/
after meal and morning/night/both
Family History times
f. Duration of brushing: how long
g. F r e q u e n c y o f c h a n g i n g t h e
toothbrush: once in 3 months/6
months/1 year
h. Any other oral hygiene aids used:
flossing/interdental brushing/oral
mouth rinses (specify) and other:
Personal History
Dental floss
1. Number and age of siblings: Tooth picks
2. Personal habits: Mouth washes
a. S m o k i n g : t y p e / n u m b e r / Any others:
frequency/duration 5. Nutritional status
b. Pan chewing: number/frequency/ a. Dietary habits: veg/non-veg/mixed
duration b. Source of water
c. Pan chewing with tobacco: type/ c. Sugar consumption(per day)
number/frequency/duration – Type
d. Only tobacco chewing: type/ – Frequency — number of times
number/frequency/duration – Time of intake — with meal/in-
e. P a n m a s a l a / a r e c a n u t : t y p e / between meal/with snacks
number/frequency/duration – Form and consistency — solid/
f. A l c o h o l c o n s u m p t i o n : t y p e / liquid/sticky/non-sticky
frequency/duration 6. Diet assessment and analyzing:
3. Habits related to oral cavity: In this method, the accounts of food
a. Mouth breathing consumed are recorded. Diet chart —
b. Thumb sucking sample of one day or over a certain
c. Tongue thrusting period of time (3–7 days) including
d. Bruxism weekends can be recorded. It can be
e. Lip biting/nail biting/pencil biting used by a group of people living in
4. Oral hygiene practice: institutions, families or on individual
Tooth brushing basis.
a. Type of cleaning of teeth: brush/
finger/stick/any other method General Physical Examination
b. Method of cleaning: vertical/ 1. Height
horizontal/circular 2. Weight
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3. Gait d. Palate:
4. Built e. Frenum:
5. Posture f. Salivary gland opening:
6. Hands g. Vestibule:
h. Tonsils and uvula:
Vital Signs i. Gingiva:
– Color
1. Blood pressure:
– Shape
2. Pulse rate: – Size
3. Respiratory rate: – Consistency
4. Temperature: – Position
j. Saliva:
Local Examination 3.
Hard tissue examination
1. Extraoral Examination a. Type of dentition:
I. Face: b. Number of teeth present:
a. S y m m e t r y : s y m m e t r i c a l / c. Teeth absent and reason for loss:
asymmetrical d. Dental caries:
b. Profile: convex/concave/straight e. Filled teeth:
c. Lymph nodes: f. Any prosthesis: crown/bridge/
d. TMJ jacket crown/RPD
– Tenderness g. W a s t i n g d i s e a s e s : a t t r i t i o n /
– Clicking abrasion/erosion
– Jaw deviations h. Enamel hypoplasia:
e. Skin: i. Supernumerary teeth:
f. Nose: j. Occlusion:
g. Eyes: – Occlusal analysis
h. Lips: competent/incompetent – Angles classification
i. Ears: – Over-bite and over jet
– Open bite
j. Lymph nodes:
– Premature contact
– Submental
– Cross-bite:
– Submandibular
– Trauma from occlusion
– Cervical
– Plunger cusps
II. Skull:
– Edge to edge bite
a. Scalp: – Prematurities
b. Hair: – Pathological tooth migration
c. Shape of head: k. Fractured/non-vital teeth
l. Periodontal health:
2. Intraoral Examination – Periodontal pockets: localized/
1. Breath: generalized
2. Soft tissue examination: – Loss of attachment:
a. Buccal and labial mucosa: – Mobility of teeth:
b. Tongue: m. Dental deposits:
c. Floor of the mouth: n. Dental stains: extrinsic/intrinsic
stains
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Indices Restorative Treatment
Surgical Treatment
Prosthetic Treatment
Maintenance Phase
Provisional Diagnosis
Levels of Prevention
Primary Prevention
Recommended Investigations Health Promotion
a. Radiographs:
b. Laboratory investigation: Specific Protection
Diagnosis Secondary Prevention

Early diagnosis
Prompt treatment
Comprehensive Treatment Plan

Emergency Treatment Tertiary Prevention
Disability limitation
Patient Education and Motivation and Oral
Prophylaxis Rehabilitation
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Chapter
21 Preventive Dentistry
the cotton rolls and holders are positioned,

Topical Fluoride application by
so as to isolate the area to be treated. It is
professionals
a common practice when using fluoride
KNUTSON’s TECHNIQUE: SODIUM solutions at one time, so as to be able to
FLUORIDE 2% treat one half of the mouth simultaneously.
Preparation of 2% Naf The isolated teeth are then dried with
compressed air, and the fluoride solution is
• 20 g of sodium fluoride dissolved in 1
applied using cotton applicator.
liter of distilled water to prepare 1 liter
of neutral NaF.
• It should be stored in plastic bottles
Application of Fluoride Solution
because if stored in glass container, the • The 2% NaF solution is applied using
F ions of solution react with silica of cotton applicator, care should be taken to
glass forming SiF2, thus reducing the be certain that all the tooth surfaces are
availability of free active fluoride for treated. The application is performed by
anticaries action. nearly swabbing or painting the various
tooth surfaces with cotton applicator
Method of Application thoroughly moistened with fluoride
solution. Once applied the solution is
Essential armamentarium for application of
kept wet and allowed to dry on the tooth
fluoride solution, consists of
with out reapplication for 4 minutes.
• Cut cotton rolls
• At the conclusion of this period the
• Suitable cotton roll holders
cotton rolls, holders are removed and
• Cotton applicators
the patient is allowed to expectorate and
• Treatment solutions in plastic dispensers.
the process is repeated for the remaining
A thorough dental prophylaxis is done quadrants.
only in first visit and visit prior to the four
topical application of fluoride. The presence Advice to the Patient
of the pellicle and oral debris would reduce • After the topical application has been
or interfere with the reaction of the fluoride completed, the patient is advised not
underlying enamel. to rinse, drink, or eat for a period of 30
minutes so as to prolong the availability
Isolation of fluoride ion to react with tooth
If a dental prophylaxis is performed, the surface and significantly greater fluoride
patient is allowed to rinse thoroughly and deposition occurs.
Chapter 21.indd 265 11/5/2014 6:07:34 PM

• Second, third and fourth applications are • Apply SnF2 solution continuously for 4
given at weekly intervals. minutes. The SnF2 solution should be
• A full series of four treatments is applied repeatedly, so that the teeth
recommended at the age of 3, 7, 11, 13 are kept moist by reapplication with
years. These age groups were selected solution for every 15–30 seconds for 4
depending on the eruption of deciduous minutes.
dentition, 1st permanent incisors and • Tell the patient to expectorate the
molars, premolars and canines and 2nd residual fluoride and instructed not to
permanent molars respectively. eat, drink or rinse for 30 minutes.
• It is found that significantly greater
MUHLER’s TECHNIQUE: fluoride deposition occurred when the
STANNOUS FLUORIDE 8% patients were not permitted to rinse, eat
Method of Preparation or drink following fluoride treatment.
It has to be freshly prepared before use to

each time as it has a short shelf life and also BRUDEVOLD’S TECHNIQUE: ACIDULATED
it is highly unstable. Aqueous solutions PHOSPHATE FLUORIDE (APF)
of stannous fluoride are not stable due to Method of Preparation
the formation of stannous hydroxide and Acidulated phosphate fluoride contains
subsequent stannic oxide, which is visible as 1.23% of NaF in 0.1 M phosphoric acid at pH
a white precipitate and not effective. of 3. It is prepared by dissolving 20 g of NaF
It is convenient to prepare gelatin in 1 liter of 0.1 M phosphoric acid and to this
capsules filled with 0.8 g or 1 g of powdered adds 50% hydrofluoric acid to adjust the pH
stannous fluoride and are stored in air tight at 3 and F concentration at 1.23%.
plastic containers just before application. The Depending upon the requirement, APF
content of the capsule is dissolved in 10 ml of solution is also prepared by dissolving 2 g
distilled water in a plastic container to get 8 of NaF in 10 mL of 0.1 M phosphoric acid.
to 10% SnF2 respectively. The solution is thus To this 50% hydrofluoric acid is added to
prepared is shaken briskly. The solution is adjust the pH at 3 and fluoride concentration
then applied immediately to the teeth. The at 1.23%.
10 mL solution should be sufficient to treat For the preparation of APF gels, gelling
the whole mouth of a single patient. If any of agent methylcellulose or hydroxyethyl
SnF2 solution remains, it should be discarded cellulose are added to the solution and the
and not used again. pH is to be adjusted at 4 to 5.
Method of Application Tray Application Technique:

• Perform thorough oral prophylaxis. Professional Application of Apf Gel
Isolation is done by using cotton rolls. 1. Patient and the parents should be
• Dry the teeth and keep the quadrant free explained regarding the benefits and
from saliva by use of saliva ejector. risks of topical fluorides.
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2. Patient is made to sit upright on the Precautions for Professional Topical
dental chair, so that the saliva and Application of Fluorides
excess fluoride is not accidentally Precautions to be taken by dental professional
swallowed. during topical application of fluoride
3. Saliva ejector is held in place to remove include:
excess fluoride and saliva. 1. The use of only required amount of
Measured gel in tray: not more than fluoride solution or gel to adequately
2 mL of gel is placed in each tray for perform the treatment.
small children, and no more than 2. Patient should be placed in an upright
5 mL is placed in each tray for adults. position.
Note: A medicine cup can be used to 3. Using effective saliva aspirators or
measure the amount once, so that the suctioning apparatus.
correct level of gel in the tray can be 4. Requiring the patient to expectorate
determined. A minimum amount of gel thoroughly upon completion of the
is indicated to prevent ingestion by the fluoride application.
patient.
If medicine cup is not available, trays Fluoride Varnishes
are filled to 1/3rd to 1/4th its height. • First developed in Europe (1964) by
The tray is then placed in the mouth and Schmidt.
the flanges are pressed against the tooth • Main advantage of varnish is that it
surface. increases the time the fluoride is in
4. Excess fluoride is removed with saliva contact with the tooth.
ejector.
5. Lower arch is done first followed by Steps Involved in The Application of
the upper arch. It is then removed and Varnish
discarded. Fluoride on the tooth surface
1. Oral prophylaxis
is removed by saliva ejector or asking 2. Minimal isolation is required. It is
the patient to spit the excess. sufficient to just remove the thick
6. Patient is not allowed to wash his mucous coat on the tooth surface.
mouth. Rubbing with cotton is avoided Isolation is not done with cotton as
for removal of excess fluoride from the it tends to stick to the varnish and
surface. presence of mild moisture tends to
7. Instructions are given to the patient hasten the setting of the varnish
which includes 3. Varnish is applied with single tufted
– Not to drink any liquid food for at small brush.
least 30 minutes 4. Application done first on lower arch
– Not to eat any solid food for one 5. After application, the patient is asked
hour to keep the mouth open till the varnish
– To report immediately, if any dries.
symptoms of acute toxicity is 6. Patient is instructed not to rinse or drink
noticed. for 1 hour.
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Topical Fluoride Application Exercise

Sl. No. Name of the patient Age Sex Name of the F applied Time applied Signature of the staff
APPLICATION of PIT AND FISSURE SEALANTS

Procedure 5. Isolate and dry the tooth
6. Sealant application
1. Polish the tooth surface.
7. Evaluate the sealant
2. Isolate and dry the tooth surface
8. Check occlusion
3. Acid etching
9. Retention and periodic maintenance
4. Rinse the tooth
PIT AND FISSURE SEALANTS

Sl. No. Name of the patient Age Sex Sealant used Signature of the staff
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ATRAUMATIC RESTORATIVE pellet, and then the surface is dried with

Technique (ART) a dry cotton pellet.
3. The extent of the caries is judged.
The Atraumatic Restorative Technique (ART) 4. The access to the caries is widened
is a procedure based on removing carious by placing the blade of the dental
tooth structure using hand instruments hatchet into the cavity and turning the
alone and restoring the cavity with an instrument forward and backward like
adhesive restorative material. At present turning a key in a lock. This movement
the restorative material of choice is glass chips off small pieces of carious enamel.
ionomer cement. 5. Carious dentin is then removed with
the excavators by making circular
STEPS IN PREPARING THE CAVITY scooping movements around the long
FOR ART axis of the instrument.
1. Cotton rolls are placed alongside the 6. The unsupported enamel that may be
tooth to be treated. This will absorb present is very weak and is removed
saliva and keep the tooth dry. with the hatchet.
2. Plaque and other deposits are removed 7. Restoring the cavity with glass ionomer
from tooth surface with a wet cotton cement using finger press technique.
ATRAUMATIC RESTORATIVE Technique

Sl. No. Name of the patient Age Sex Teeth treated Signature of the staff
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Chapter
22 Oral Health
Education Materials
DESCRIPTION OF ORAL HEALTH TALK AND PRESENTATION OF ORAL HEALTH

EDUCATION MATERIAL
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Oral Health Education Materials 271
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Chapter
23 Field Programs
(Submission of Reports)
A VISIT TO SCHOOL
Place of Visit ______________________________________________________________
Date of Visit _______________________________________________________________
Detailed Report of the Visit

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VISIT TO PRIMARY HEALTH CENTer
Place of Visit ______________________________________________________________
Date of Visit _______________________________________________________________

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Field Programs (Submission of Reports) 275
Visit To Water Purification Plant
Place of Visit ______________________________________________________________
Date of Visit _______________________________________________________________

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VISIT TO SEWAGE TREATMENT PLANT
Place of Visit ______________________________________________________________
Date of Visit _______________________________________________________________

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VISIT TO milk dairy
Place of Visit ______________________________________________________________
Date of Visit _______________________________________________________________

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VISIT TO pharmaceutical company
Place of Visit ___________________________________________________________
Date of Visit ___________________________________________________________

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VISIT TO INSTITUTION FOR HANDICAPPED PEOPLE
Place of Visit ___________________________________________________________
Date of Visit ___________________________________________________________

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CARIES DETECTION PROGRAM
Detailed Report
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CANCER DETECTION PROGRAM
Detailed Report
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Chapter
24 Comprehensive Report on
Setting up a Private Dental Clinic
COMPREHENSIVE REPORT ON CLINICAL PRACTICE

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Comprehensive Report on Setting up a Private Dental Clinic 283
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Chapter
25 Proforma for Indices
Proforma for Russel’s Periodontal Index

NAME: ____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ___________________________
ORAL HYGIENE HABITS: _____________________________________________________
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
CALCULATION:
SUM OF INDIVIDUAL SCORES
PI SCORE =
NUMBER OF TEETH PRESENT
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PROFORMA FOR COMMUNITY PERIODONTAL INDEX OF TREATMENT NEEDS
NAME: _____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ____________________________
CPI SCORES:
16/17 11 26/27
46/47 31 36/37
TREATMENT NEEDS:
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Proforma for Indices 287
PROFORMA FOR COMMUNITY PERIODONTAL INDEX
NAME: _____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ____________________________
CPI SCORES:
16/17 11 26/27
46/47 31 36/37
LOSS OF ATTACHMENT:
16/17 11 26/27
46/47 31 36/37
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PROFORMA FOR CARIES INDICES (DMFT, DMFS, dft, dfs)
NAME: _____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ____________________________
DIET:
55 54 53 52 51 61 62 63 64 65
18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
85 84 83 82 81 71 72 73 74 75
Color Coding:
DECAYED
MISSING
FILLED
EXCLUDED
DMFT DMFS dft dfs

D= D= d= d=
M= M= f= f=
F= F= dft= dfs=
DMFT= DMFS=
The caries experience of patient is _____________.
Chapter 25.indd 288 11/5/2014 6:08:03 PM

PROFORMA FOR ORAL HYGIENE INDEX
NAME: _____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ____________________________
DEBRI INDEX CALCULUS INDEX

17–14 13–23 24–27 17–14 13–23 24–27
47–44 43–33 34–37 47–44 43–33 34–37
ORAL HYGIENE INDEX = DEBRI INDEX + CALCULUS INDEX

=
The oral hygiene status of the patient is ___________.
Chapter 25.indd 289 11/5/2014 6:08:03 PM

PROFORMA FOR ORAL HYGIENE INDEX-SIMPLIFIED
NAME: _____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ____________________________
DEBRI INDEX-SIMPLIFIED CALCULUS INDEX-SIMPLIFIED

16 11 26 16 11 26
46 31 36 46 31 36
Oral Hygiene Index-Simplified = Debri Index – Simplified + Calculus Index-Simplified

=
The oral hygiene status of the patient is ___________.
Chapter 25.indd 290 11/5/2014 6:08:03 PM

PROFORMA FOR DEAN’S FLUOROSIS INDEX
NAME: _____________________________________________________________________
OP NO.: ____________________________________________________________________
AGE: ____________ SEX: _______________ DATE: ____________________________
SOURCE OF WATER:

Deans fluorosis score =
Chapter 25.indd 291 11/5/2014 6:08:03 PM

Chapter 25.indd 292 11/5/2014 6:08:03 PM
References
1. National oral health policy for India. Journal 19. Gibbons RJ, Socransky SS. Intracellular
of Indian dent Asso: 58,378-401,1986. polysaccharide storage by organisms in
2. Harris NO, Christen AG. Primary dental plaque; Arch Oral Biol: 7, 73:1962.
preventive dentistry 3rd edition, 1990. 20. Guggenheim B. Extra cellular
3. WHO-Oral Health Surveys, Basic Methods polysaccharides and microbial plaque; Int
4th edition; AITBS Indian Edition, 2004. Dent J; 20,657:1970.
4. Park K. Park’s Textbook of Preventive and 21. Rajiv Gandhi University of Health Sciences,
Social Medicine, 18th edition; 2005. Karnataka. Revised Ordinance Governing
5. Slack; Textbook of Dental Public Health. Bachelor of Dental Surgery (BDS) Degree
6. Greenberg MS, Glick M. Textbook of course-2008, Ist edition, 2008.
Burkett’s Oral Medicine; Diagnosis and 22. BDS course regulation, Dental Council of
Treatment; 10th edition; 2003. India.
7. Hiremath SS. Textbook of Preventive and 23. http://www.standards-schmandards.
Community Dentistry; 2007. com/2005/measuring-text-readability
8. Davies GN. The different requirements of 24. http://www.nlm.nih.gov/medlineplus/
periodontal indices for prevalence studies
etr.html
and clinical trials; Int dent J, 18:560-69, 1968.
25. http://en.wikipedia.org/wiki/public_
9. Wilkins; Textbook of Clinical Dentistry for
health_laboratory
Hygienists.
26. American Dental Association: System of
10. Morse D. Principles of Dental Public Health.
tooth numbering and radiograph mounting,
11. Rao A. Principles and Practice of
Approved by the American Dental
Pedodontics, 2nd edition; 2008.
Association, House of Delegates, 1968.
12. Tandon S. Textbook of Pedodontics.
13. Peter S. Essentials of Preventive Community 27. Federation Dentaire Internationale: Two
Dentistry. digits system of designing teeth, Int Dent J,
14. Education for Health, Volume 15, no. 1: 2002, 21, 104, 1971.
79-83. 28. Palmer C: Palmers Dental Notation, Dent
15. Journal of the Dental Association, 58;378– Cosmos 33,194,182.
401. 29. American Dental Association: Proceedings
16. OHI-S Manual, US Public Health Service, of Dental Societies, Dent. Cosmos, 12,522,
Division of Dental Health, Dental Health October 1870.
Center, March 1st 1967. 30. Greene JC, Vermillion JR. The Simplified
17. Training aid—US Public Health Service, Oral Hygiene Index, J Am Dent Assoc; 68:7,
Division of Dental Health, Dental Health 1964.
Center, Research and Data Service, Draft, 31. Greene JC. The Oral Hygiene Index—
2-5-65. Development and Uses, J Periodontol.
18. Kleinberg I: Regulation of the acid base 38:625; Nov-Dec. 1967.
metabolism of the dento-gingival plaque 32. Podshadley AG, Haley JV. A method for
and its relation to dental caries and Evaluating Oral Hygiene Performance,
periodontal disease Int. Dent J 20,45;1670. Public Health Rep:83;259, March 1968.
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33. WHO, Oral health surveys: Basic Methods, 36. Gruebhal AO. A Measurement of Dental
Geneva, WHO, 1997. Caries Prevalence and Treatment Service
34. United States Department of Health for Deciduous Teeth, J Dent Res, 23, 163,
and Human Services. Public Health June, 1944.
Service, National Institute of Health: Oral 37. Classification of Epidemiologic Studies of
health surveys of the National Institute Dental Caries and Definition of Related
of dental research, Diagnostic criteria Terms: Compiled by the Commission
and procedures. NIH Publication No. on Classification and Statistics for Oral
91-2870. Bethesda, MD, National Institute of Conditions, FDI Int Dent J, 1975; 25:79-87.
Dental Research, 1991. 38. Cawson and Scully-Medical Problems In
35. Klein H, Palmer CE, Knutson JW. Studies Dentistry 4th Edition.
on dental caries, Dental status and dental 39. Grundy, Shaw, Hamilton. Dental Care for
needs of elementary school children, public the Medically Compromised Patient.
health rep: 53;751, May 13, 1938. 40. Tandon S. Textbook of Pedodontics.
References.indd 294 11/5/2014 6:07:57 PM

Index
Page numbers followed by f refer to figure and t refer to table.
A second generation 179 specific uses of 143

third generation 179 training 145
Acetazolamide 188 educational approach of
Anxiety reduction protocol
Acidulated phosphate fluoride 145
(ARP) 189
(APF) 123, 125, 266 structure for basic 145
Arthralgia 192
gels/foam 124
Arthritis 29, 192
Adhesive material for minimal
for dental appointment B
cavity preparations 151
procedures 29
Adhesive restorative materials Biofilm control, average 172
medications 29
development of 151f Bisphenol a-glycidyl
treatment modalities 29
for minimal intervantion for methacrylate (bis-gma)
Asthma 194
caries management 150 133
symptoms 194
AIDS 196 Bleeding disorder 27
Anemia 194 Atraumatic restorative
considerations for dental
acute posthemorraghic 194 technique (ART) 143, 269
appointment procedures
attack on chair 190 Atraumatic restorative 28
deficiencies of nutrients 194 treatment medications 28
hemolytic 194 advantages 144 treatment modalities 28
pectoris 24 armamentarium for 158f Blindness 187
sickle cell 194 cavity for 144 dental problems 187
signs 194 dental instruments required treatments 187
symptoms 194 for 158 Blood disorder 27
types 194 hand instruments in 144 considerations for dental
dental aspects 194 history 143 appointment procedures
Angina pectoris indications 144 27
considerations for dental instruments medications 27
appointment procedures sharpening of 162 treatment modalities 27
24 use of autoclave to Blood pressure 40
drug of choice 190 sterilize 161 components of 40
medications 24 use of pressure cooker to decrease blood pressure 40
stable 190 sterilize 161 examination methods 42
symptoms 190 miscellaneous consumable factors that influence 40
treatment modalities 24 materials required for increase blood pressure 40
underlying pathology 190 160 maintenance of 40
unstable 190 principles of 144 Blood signs, disorders of 192
Antibiotic prophylaxis 191t rationale for application of Blood symptoms, disorders
Antihypertensive drugs, side 145 of 192
effects of 189 restorative materials Blood, disorders of 192
Antiplaque agents required for 160 Body temperature 37
first generation 179 selection of cases for 163 indications 38
Index.indd 295 11/5/2014 6:06:10 PM

maintenance of 38 signs 188 diagnosis 7

methods to determining 38 symptoms 188 oral health 7
variations 38 Cardiovascular lesions, periodontal index (CPI) 82,
Breath odor surgically corrected 25 106, 257
halitosis 47 medications 25 classification of treatment
indication on dental treatment modalities 25 needs 81
appointments 47 Caries codes 82f
severity 47 enamel hatchet, widening indicators 82, 106, 257
Breathlessness 194 cavity for removal of instrument 257
Brudevold’s APF solution 164f of treatment needs
composition 124 in primary teeth, assessment (CPITN) 78, 252
Brudevold’s technique 123, of 88, 246 probe 80f
266 indices, proforma for 288 proforma for 286
method of preparation 266 prediction of procedure 79, 257
Brush, interdental 179 adults 225t proforma for 287
Brushing, supplemental 178 children 224t purpose 82, 257
Buccal mucosa preschool children 223t score 84t
left examined systematically prevention sealants selection of teeth 82
46 acid etch technique in 130 sextants 106
right examined introduction 130 teeth 106, 257
systematically 46 prevention, application to adolescents 257 257
181 adult 257
C Cariogenic foods, analysis children 257
selection of 257
Calculus index simplified of 33
treatment 8
(CI-S) 72, 71t, 243 Carious dentin,
Congenital heart diseases 24
Calculus, procedures for remineralization of inner
Consent letter 233
control of 175 147
Cpitn probes, types of 80, 254
Cancer chemotherapy See Carious removal small
Cyanoacrylates 133
cancer radiation excavator 165f
Cystic fibrosis 194
Cancer radiation 27 Cavity for ART, steps in
dental aspects 194
for dental appointment preparing 269
procedures 27 Cerebrovascular accident
(stroke) 25
D
medications 27
treatment modalities 27 for dental appointment Deafness 187
Carbohydrate, physical form procedures 25 dental problems 187
of 33 medications 25 treatments 187
Cardiac medications 24 treatment modalities 25 Dean’s fluorosis index 1942
Cardiac pacemakers common Chemical cured, benefits of 98, 259
causative organism 190 134 proforma for 291
acute 191 Christmas disease 193 Debri score for individual
subacute 191 Coleman Lian index 207 tooth 243
Cardiac treatment modalities Communicable diseases Debris index (DI-S)
24 considerations for dental criteria for coding,
Cardiovascular diseases 24 appointment procedures simplified 71t
Cardiovascular disorders 188 28 simplified (DI-S) 72, 243
breathlessness 188 medications 28 Decayed filled (DF) index 89,
central cyanosis 188 treatment modalities 28 247
chest pain 188 Community definition 89, 247
ischemic heart disease 188 dentistry 6, 7 Decayed filled surfaces,
palpitations 188 definition of 7 number of 95
Index.indd 296 11/5/2014 6:06:10 PM

Index 297
Decayed filled teeth type III inspection 41 Dental treatment, economy
number of 95 type IV screening 42 of 8
per child, average number types of 41 Dentifrices 179
of 98 Dental fluorosis 106 Dentin caries 146
Decayed missing Dental index 57 bacterial invasion ,
filled (DMF) advance probe to base of progression of 146
classification system 90 pocket 62 Dentin
index 85, 89, 244, 246 armamentarium used in defence reaction in 146
calculations for 95 examination of patient to lesion formation, stages of
concept of 86 record 60 147
definition 89, 246 circumferential 63 structure of 146
describe 86 clarity 57 two layers of carious 147
introduction 85 classification of 59 Dentistry 6
limitations of 98 general categories 59 prevention 8
surfaces (DMFS) index 87, cumulative index 59 preventive 265
245 full mouth indices 59 preventive 8, 117
surfaces, number of 95 irreversible index 59 Dentition status 108
teeth, number of 95 reversible 59 decayed crown 109
Decayed tooth 93 and irreversible index 59 decayed root 109
Dental appointment simple index 59 filled crown, with
indication and influences on ideal requirements of 57 decay 109
46 in dental practice, uses of 58 no decay 110
procedures, considerations mouth mirror 61 filled root, with
for 24 surfaces types of 61 decay 110
procedures, physical objectivity 57 no decay 110
disabilities for 30 probe 61 missing tooth 110
Dental aspects 188 insertion 62 sound
Dental assistants 232 procedures 62 crown 108
Dental care purpose 61 root 109
implications 54 types of 61 Dentition treatment 108
plan to patient 15 uses 61 Dentition, mixed 88
Dental caries purpose 61 Dentofacial anomalies 113
early detection of 221 quantifiability 57 anterior
prevention of 182 reliability 57 mandibular overjet 114
risk factors to 221 selection of 60 maxillary overjet 114
Dental clinic, setting up of sensitivity 57 anteroposterior molar
private 227 simplicity 57 relation 114
Dental disease uses 61 diastema 114
prevention of 8 indirect illumination 61 largest anterior
principles of 8 indirect vision 61 mandibular irregularity
Dental effective poster retraction 61 114
design 197 transillumination 61 maxillary irregularity 114
Dental examinations validity 57 vertical anterior openbite 114
maintenance 42 Dental office Dentures 54
periodic examinations 42 designing of 228 Diabetes 26
re-evaluation 42 management of 230 mellitus 26
serial examinations 42 Dental patient, evaluation of for dental appointment
type I complete examination 261 procedures 26
41 Dental poster medications 26
type II limited examination design, steps in 197 treatment modalities 26
41 or chart 197 symptoms of 196
Index.indd 297 11/5/2014 6:06:11 PM

Diet 185 Endocrine disorder 195 meat group 182

analysis 31 diabetes mellitus 195 milk group 182
consistency, analysis of 34 symptoms 195 vegetable group 182
counseling 35, 180 Epilepsy 30, 186 Food laboratory, role as central
objectives 35 dental management 186 235
planning 36 for dental appointment Fry readability formula 207
procedures 36 procedures 30
teaching materials 36 medications 30 G
management, principles of oral manifestations of 186
treatment modalities 30 Gastrointestinal 30
181 for dental appointment
Etched tooth surface 142
Dietary analysis See diet procedures 30
Etching
analysis medications 30
pattern 137
Dietary analysis recording 32 treatment modalities 30
rinse 142
Dietary assessment 31 Gauze strip 178
Eyes 44
food diary 32 Gingival clinical markers,
purposes of 31 F examination of the 49
Dietary counseling 180 Gingival hyperplasia 192
communication 180 Face 44 Glass ionomer (self cure) 151
3 rules for effective 180 Facial paresthesia 188 bound to tooth tissue 151
counseling guidelines for Financial resources 228 fluoride in 153
181 Fissure anatomy of 131, 137 fracture 152
for caries prevention 181 Fissure sealant 110, 130, 268 harden 151
requirements for 180 Fissures, unique process of interface 152
Dietary for particular groups caries formation in 131 liquid and powder,
182 Fluoride 185 dispensing 165
Dietary intake, analysis of 33 application 116 main characteristics of 151
Digitalis 188 exercise 268 microleakage of 152
gel 125 mixing 165
Disabilities, physical 29
release from glass ionomer, physical characteristics of
DMFT
pattern of 153 154
classification, rationale for
solution , application of 120, pulpal-friendly 154
91, 247
265 resin modified 155
examination procedure 93
treatment, repeated series of restorative material 151f
index, coding system for 92f
four 118 role of water in 152
Dry etched tooth surface,
varnishes 127, 128f, 267 to enamel 152
completion of 142
carex 128 Gunning fog index 205
Dyspnea 188 duraphat 128 calculating 205
fluorprotector 128
E indications 128
H
Ecchymosis 192 Food diary 33, 34t
Enamel analysis, benefits of 35 Head 43
opacities/hypoplasia 105 form to patient, presentation hydrocephalic 44
removal of thin, of 32 Health 4
overhanging 165 instructions 32 Health care, comprehensive
Endocrinal problem 27 Food groups, snacks oral 10
for dental appointment from 182 definition 10
procedures 27 bread and cereal educational services 12
medications 27 group 182 preventive services 11
treatment modalities 27 fruit 182 primary prevention 11
Index.indd 298 11/5/2014 6:06:11 PM

Index 299
definition 11 Hormonal problems See Knutson’s technique
health promotion 11 diabetes disadvantages of 121
secondary prevention 11 Hygiene performance index sodium fluoride 2% 120, 265
definition 11 243
tertiary prevention 12 Hypertension 24, 188 L
definition 12 for dental appointment
disability limitation 12 procedures 24 Labial mucosa
rehabilitation 12 medications 24 left examined systematically
therapeutic services 13 pain control 189 46
Health care, process of treatment right examined
comprehensive oral 13 considerations 189 systematically 46
assessment 13 modalities 24 Laser-curing of visible light-
dental care planning 14 Hypoglycemia 196 activated sealant resin
dental diagnosis 13 management 196 materials 135
classification 14 signs 196 advantages 135
data processing 13 symptoms 196 disadvantages 135
interpretation 14 Light cured, benefits of 134
validation 14 Lips 46
I
mechanism of planning 14 Liver 25
Health materials 199 Immunosuppression 195 for dental appointment
Health, justification for dental aspects 195 procedures 26
general 8 Implant 111 medications 25
oral 8 Index teeth, uses of 253 treatment modalities 25
Heart diseases 25 adolescents 254 Lung diseases See respiration
for dental appointment adults 253 Lymph nodes, palpate 44
procedures 25 children 254
medications 25 Infections 196 M
treatment modalities 25 Infectious communicable Medically compromised
Hematuria 191 diseases 28 patients, management
Hemophilia 192 Infectious diseases 28 of 188
A 193 Instruments , sterilization of Mental 29
dental aspects 193 161 for dental appointment
medical management 193 Ischemic heart diseases 189 procedures 29
B 193 angina pectoris 189 medications 29
Hemorraghes, splinter 191 cardiac pacemakers 190 retardation 185
Hepatitis B 28 dental aspects 191 dental problems 185
for dental appointment rheumatic fever 192 treatment 185
procedures 28 dental aspect 192 dental 186
medications 28 signs 192 treatment modalities 29
treatment modalities 28 symptoms 192 Mentally challenged children,
Herpes 29 management of
for dental appointment J physically 184
procedures 29 Jaundice 192 Metabolic disorder 195
medications 29 diabetes mellitus 195
treatment modalities 29 K signs 195
HIV 196 symptoms 195
infection AIDS 29 Kidney 26 Mouth rinses 179
for dental appointment for dental appointment Mouth, floor of 47
procedures 29 procedures 26 Muhler’s technique 121, 266
medications 29 medications 26 advantages 123
treatment modalities 29 treatment modalities 26 disadvantages 123
Index.indd 299 11/5/2014 6:06:11 PM

mechanism of action 122 serious illness 23 examination criteria 69

method of application 122 significant 23 examination procedure
method of preparation 122 instructions for patient 37 71
martial status 18 proforma for 290
N new vital signs 37 rules for coding 69
occupations 17 selection for teeth 69
Nephrotic syndrome 195 for child 18 surfaces 69
dental aspect 195 of present illness complete Oral mucosa 104
Nose 44 patient history 22 Oral tooth care mobility 54
Nutritional analysis for personal history 31 classification 54
adequacy 33 planning 11 dental care implications 54
of food diary 33 comprehensive 261 edentulous areas 54
significance 19 habits 54
O social history 31 Oropharynx See tonsillar
OHI and Ohi-S, differences structure of 227 region
between 67 types 227
OHI-S examination for 50 vital signs 37 P
patients 74t Oral health education material
197, 271 Pain, avoidance of 8
OHI-S for individual 73
preparation of 197 Palate, hard 48
OHI-S score
Oral health education to Palate, soft uvula 48
for individual, average 73
control biofilm PHP Periodontal diseases
mean debris calculus and
assessment of 74
74t index 174
introduction of 74
OHI-S, advantages of 68 procedures 174
Periodontal index
OHI-S, drawbacks of 68 Oral health status
criteria for 76t
OHI-S, uses of 68 dental indices, assessment of
scoring for 76t
Oral cancer 241, 57
uses of 77
diagnostic protocol for 219 WHO basic oral health
Periodontal status, indications
early detection of 217 survey form, assessment
of 81t
toluidine blue staining of 260
Permanent teeth
method, detection of WHO form, assessment of
extracted 93, 250
219f 101 filled 249
Oral disease, prevention of 8 Oral hygiene care, missing 110
Oral health assessment form supplemental 178 caries, number of 96
of 100 dental floss 178 number of
Oral health care 16 knitting yarn 178 decayed 96
advantages 227 Oral hygiene index (OHI) 65, filled 96
chief complaint 18 66, 240 present 249
comprehensive 16, 261 advantages 66 present, number of 96
definition 16, 261 calculation 66 sound 96
demographic data 16 criteria 66 sound 249
family history 30 definitions for 68 Phlogogenic substances 173
gender–sex 17 examination method 66 PHP index value for
general examination 37 introduction 65 group 175, 244
history of present illness 20 proforma for 289 individual 175, 244
inception 21 purpose 66 Pipe cleaner 178
location of pain 21 rules for 66, 240 PIT anatomy of 131, 137
medical examination 23 simplified 69, 70f, 72, 72t, PIT sealant 130, 268
past dental history 22 240, 243 Plaque acidification to
past medical history 23 components of 70 fermentation 173
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Index 301
Plaque acidification to medications 26 Stimuli, types of 65
glycolysis 173 treatment modalities 26 auditory 65
Plaque alkalinization by Respiratory disorders 194 tactile 65
ammonia production signs 194 Sweet score, calculation of 36
173 symptoms 194 Sweets, scoring 35
Plaque biofilm 172 Restoration in general practice, Synthesis of polysaccharides
Plaque control 175, 185 mean survival of (polymers) 173
agents, classification of amalgam 169t
chemical 179 composite 169t T
Plaque metabolism 172 Rheumatic heart diseases 24
Plaque, mechanical methods dental appointment Teeth and
for control of 175 procedures, removal of excess restorative
Plaque, procedures for control considerations for 24 material, biting the 167
of 175 medications 24 surfaces, selection of 174t
Polyacid modified composite treatment modalities 24 Teeth with cotton roll,
resin (compomers) 156 Russel’s periodontal index 75, isolation of 163f
Polyurethanes 133 77, 251 Teeth, examination of 52
Probe walking stroke 63f advantages 78 dental care implications 52
Procainamide, leukopenia 188 calculation 77 deposits 52
Prosthetic status 112 limitations 78 dental care implications
Psychiatric See mental proforma for 285 52
Public health 4 stains 52
ART of dental 5 dental care implications
S
dental 4 53
dentistry 4 Saliva 47 dental caries 53
definitions 4 Sam index 207 exposed cementum 53
department of 239 Sealant application 139 proximal contacts 54
functions of 5 general rules 139 restorations 53
objectives of 5 Sealant retention, requisites tooth wear 53
laboratories 235 for 137 eruption 52
core functions of 235 Sealant, penetration of 137 morphology 52
problem, determining a 5 Sealants, polymineralization Teeth, index 84
programs, dental 6 of 134 Teeth, permanent 48, 50, 51
science of dental 4 Sealed versus non-sealed Teeth, primary 50, 51
Pulse 39 restorations, effect of 150 quadrant number 50
maintenance of normal 39 Sexually transmitted infections Teeth, replacement for
rate 28 missing 54
factors influence 39 for dental appointment Teeth, substitutions for
normal 39 procedures 28 missing 174
procedure for determining medications 28 Teeth, treatment needs of
39 treatment modalities 28 individual 111
Pyrexia 192 Skin 44 Teeth, uses of index 79
Smog index 207 adolescents 79
Spleen, enlargement of 191 adults 79
R
Spontaneous gingival bleeding children 79
Renal disorders 195 192 Telangiectasia 192
Renal failure, chronic 195 Stannous fluoride 8% 121, Temporomandibular joint
dental aspects 195 266 assessment of 104
Respiration 26 Stannous fluoride method of examination of 45
for dental appointment application 266 palpate of 45
procedures 26 preparation 266 Thermometers, types of 38
Index.indd 301 11/5/2014 6:06:11 PM

Thixotropic gels 124 Tooth sticks, traditional 175 upon plaque and bacterial
Thrombocytopenia 193 Tooth surface 141 metabolism 119
dental aspects 194 acid etching 141 Toxic dose, acute
Tobacco products 217 action, acid etching 141 signs of 129
Toluidine blue for oral cancer, etch delivery, acid etching symptoms of 129
supravital staining with 142 Toxicity of fluoride 129
219 etch forms, acid etching 141 chronic toxicity 129
Tongue 47 etch timing, acid etching emergency treatment 129
Tonsillar region 48 142 Tray selection 126f
gingiva 48 explore sealed 142 Tuberculosis 28
indication 48 patient with considerations for dental
influences on dental no stain or calculus 141 appointment procedures
appointments 48 stain or calculus: 141 28
Tooth absent Tooth with carious lesion for medications 28
permanent 93, 250 art procedure 164f treatment modalities 28
primary 93, 250 Tooth with glass ionomer
Tooth number within each cement, restoration of U
quadrant 50 167f
Tooth numbering system 50f Tooth Ultraviolet light curing
basic terminology in 48 debri score for individual sealants abandoned 134
european 51, 52f 175 Unerupted crown 111
European permanent teeth decayed 249
51 filled permanent 93 V
European primary teeth 52 identifying cracked 55 Varnish, application of 128,
two digit 48 primary 50 267
universal 51f sound permanent 92 von Willebrand disease 193
Tooth numbering with each Toothbrush 175
quadrant 50 design 175 W
Tooth or tooth space, excluded ADA specification for 176
92 electric 176 Washing of instruments
Tooth picks 179 Toothbrushing methods 176 prior to sterilization
Tooth present, permanent 92 Topical fluoride act 116 161
Tooth present, primary 93, 250 Topical fluoride therapy Wheeze 194
Tooth preservation versus on incipient caries lesion Williams periodontal probe
cavity preparation 150 119 76f
Index.indd 302 11/5/2014 6:06:11 PM

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Clinical Manual for

Public Health Dentistry

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The Health Sciences Publisher

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Jaypee Medical Inc. Jaypee Brothers Medical Publishers (P) Ltd

Jaypee Brothers Medical Publishers (P) Ltd

© 2015, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: [email protected]

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Mayur Nath T Reddy

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The study of medical and dental courses involves two aspects,

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Section 1: Clinical Manual for Public Health Dentistry

Chapter 2. Comprehensive Oral Health Care Planning 10

Chapter 3. Evaluation of the Patient for Comprehensive Oral Health Care 16

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Chapter 4. Assessment of Oral Health Status Using Dental Indices 57

Chapter 5. Assessment of Oral Health Status Using WHO

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Chapter 7. Diet Counseling 180

Chapter 8. Management of Physically and Mentally Challenged Children 184

Chapter 9. Management of Medically Compromised Patients 188

Chapter 10. Preparation of Oral Health Education Material 197

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• Dental Poster or Chart 197

Chapter 11. Field Program—A Visit to School 208

Chapter 12. Early Detection of Oral Cancer 217

Chapter 13. Early Detection of Dental Caries 221

Chapter 14. Setting up of a Private Dental Clinic 227

Chapter 15. Consent Letter 233

Chapter 16. Public Health Laboratory 235

Section 2: Practical Record Book

Chapter 17. List of Armamentarium Required in Department of

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Indices Used To Assess Periodontal Status 251

Indices Used for Dental Fluorosis 259

Chapter 19. Assessment of Oral Health Status Using

Chapter 20. Comprehensive Oral Health Care Planning 261

Chapter 21. Preventive Dentistry 265

Application of Pit and Fissure Sealants 268

Atraumatic Restorative Technique (Art) 269

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Chapter 22. Oral Health Education Materials 270

Chapter 23. Field Programs (Submission of Reports) 273

Chapter 24. Comprehensive Report on Setting up a Private Dental Clinic 282

Chapter 25. Proforma for Indices 285

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