7 Ways Dentists Can Address Patient Expectations

Patient satisfaction is key for a successful dental practice. There are many varieties of treatments available in dentistry from preventive to restorative to replacement. For each of these treatments and conditions, patient expectations vary from person to person. While addressing patients, dentists needs to keep details of all the patient’s expectations. Some patients are highly demanding and some are happy with average treatment results.

Restoring single decayed tooth is different from doing the full mouth rehabilitation. In daily general dental practice the challenges are many and diverse; often the patient wants one thing corrected. They assume it is just a simple fix, “I just want all my teeth to have the same colour, and beautiful smile.”.

Depending upon the initial situation, the amount of dentistry work required to provide a healthy, beautiful and dazzling smile can vary enormously. Patient’s medical and dental conditions makes treatment plans complicated and may hamper the final outcome.

7 Essential steps while addressing patient treatment

Careful evaluation of patient’s dental and medical condition

This is the main step after understanding the patient’s chief complaint. Careful evaluation of dental and medical conditions helps to formulate and make decisions about available treatment options. Ask patients about any bleeding disorders, previous history of diseases and medications.

Understand patient’s requirements and expectations

This is the key to make the patient happy about the final treatment results. Some patients have a very clear and detailed outcome picture in their mind. Sometimes that may be realistic and sometimes they may be vague.  The purpose of managing patient’s expectations in dental practice is to minimise the discrepancies between expectations and their actual experiences.

Whenever patient’s expectations are high, make him aware about his current situation and available treatment options and challenges while treating him. Unless and until dentists don’t do this, patients will continue to be highly demanding. For example, sometimes  a case of generalised periodontitis comes to the clinic and demands teeth whitening treatment. Likewise, some patients demand implants but there is an occlusal discrepancy or no space in bite. Some complete denture patients harbour expectations to chew nuts with dentures. We need to educate and motivate them to consider the prior procedures and corrections which may be required to reach their goals. Sometimes this may be just too expensive, not only in terms of money but also in terms of time.

No one wants time consuming dentistry, everyone wants instant end results, and we as dentists are often under pressure to provide that quick, inexpensive service without the time to consider all options. By structuring proper protocols and time to consider available options, we can reduce errors and one can easily deliver the smile that fulfills the patient’s expectations.

Use proper diagnostic measures

Diagnostic measures may include IOPA, OPG, CBCT, lab tests, plaster study models, diagnostic wax ups, intra and extra oral photographs etc. This helps to educate the patient about his current situation as well as formulating a treatment plan. Digital smile designing is a recent concept that plays an important role in patient education and treatment formulation.

Educate patients about their treatment plan

Study models and diagnostic wax ups can be used for patient education; this helps patients imagine final outputs and the results of the treatment. Along with this, digital software which can simulate the final results on patients photographs can be really helpful.

This can give an idea to the patient about the final result in their own mouth. Digital photographs helps in diagnosis by placing lines and essential measurements  that can be calibrated. Show patients previously treated cases; carefully teach them before and after treatment results. That gives patient a gross idea about the final outcomes. Patient can be assured about the treatment and the results.


Consent discussion is an important opportunity to detect unrealistic patient’s expectations. Information about the risks of treatment or complications which may occur should be told and explained to the patient. Ensure patient is actively authorising and not passively agreeing to the treatment plan.

Consent documentation and their storage should be done for medico legal issues. The patient who has accepted all the risks and problems for the treatment decision is less likely to blame us, when the outcome is less inferior to the actual expectations. Many a time patients are taken by surprise by results and hence clinical malpractice claims have arisen.


After educating about the treatment plan, definitive treatment should be initiated. Whenever required, give temporary crowns and bridges instead of giving final crowns and bridges, that helps to understand errors and corrections can be done. A good dental lab is important while managing patient’s expectations.

Follow up and feedback

After delivering the wonderful smile, patients should be recalled time to time to monitor the prosthesis and any other dental problem. Don’t forget to take feedback from patients about the treatment experience and about their happiness. That is the only reward for any dentist and also helps to assure other patients by showing it.


Comprehensive treatment planning in dentistry including aesthetic dentistry, implant dentistry and full mouth rehabilitation can be complex. While treating such complex cases – aesthetics, biology and function all need to be considered.

Time spent in this preparation using digital technology and visual communication is a very important factor. Time should be spent for understanding the psychology of how patients will take decisions and how we should communicate with them to guide them in their decision making process and make sure they are fully informed.

How can we manage patient expectations and ensure optimum results? A thorough preparation, visual communication, patient motivation and education is always recommended.

World No Tobacco Day 2019

World No Tobacco Day
World Health Organization (WHO) and global partners recognises 31 May as World No Tobacco Day every year.
The objective is to spread awareness of deadly and harmful effects of tobacco smoking and second-hand smoke exposure; along with this, to discourage tobacco consumption in any form.
WHO focuses on ‘Tobacco and Lung Health’ on this day and this campaign spreads awareness:
  • Tobacco’s negative impact on people’s lungs, from causing oral cancer to chronic respiratory diseases
  • Disseminate awareness for reducing tobacco consumption
  • Engage stakeholders across multiple sectors for an anti-tobacco campaign
Goals of World No Tobacco Day campaign
  • Highlight risks due to tobacco smoking and exposure to second hand smoke
  • Reduce the magnitude of death and illness of lung diseases caused by tobacco smoking globally
  • Create awareness of emerging evidence of the link between tobacco smoking and tuberculosis deaths
  • Illustrate feasible actions and measures to reduce the risks to lung health posed by tobacco through public and government information programs

Save Live: Clean Your Hands – World Hand Hygiene Day 2019

Hand Hygiene Day is celebrated on 5th May every year. World Health Organization (WHO) conducts various activities to spread the importance of clean hands. The basic aim of this day is infection prevention and control. Meanwhile, Clean Your Hands is the main tagline for this campaign. WHO has taken the initiative to ask healthcare providers especially and general public to keep their hands clean.

WHO aims to achieve better health and well-being of all aged people through effective and affordable medicines and vaccines.

Infection Control and Prevention, including hand hygiene, is critical to achieve universal health coverage goals as it is a most practical and evidence-based approach with demonstrated impact on quality of care and patient safety across all levels of the health system.

Many diseases are transmitted from individual to individual by contaminated hands while consuming food. Maintaining hand hygiene is crucial for infection prevention and control program.

Various posters are available on the WHO site; one can download them and help WHO achieve these goals by spreading the message in the public interest. WHO is conducting surveys on infection prevention and control program. Detailed information is available on their website only.


April 2019 – Oral Cancer Awareness Month

April is oral cancer awareness month worldwide. To highlight this, here are some oral cancer knowledge updates. Dentists are the only medical faculty to diagnose oral cancers initially than others during routine mouth check-up. That’s why visiting a dentist is mandatory.

Why is oral cancer awareness an important public service message?

Many oral cancers can be prevented in their initial stages, before getting worse. Diagnosing malignant lesions and oral cancers during mouth check-ups is dentist’s responsibility. Make patients aware of their oral health. Oral cancer awareness is the basic aim of this article. Statistics are provided in this article are from various sources.

In India, death due to tobacco is estimated at 3,500 people per day approximately. According to the latest data, smoking caused 3, 17,928 deaths among men and women approximately.

Over 25% of male cancer deaths are due to Oral and Lung cancers. cancer of breast and oral cavity account for 25% of deaths in women. One-third of oral cancer cases are from India in the world. Oral cancer accounts for 30% of all cancers in India.

According to Globocan, around 1, 19,992 new cases of oral cancers diagnosed every year and deaths 72,616 worldwide. Out of the newly diagnosed cases, about 60% won’t live longer than 5 years. Many who survive after the treatments suffer from severe facial disfigurement or difficulties in eating and speaking. The death rate from oral cancer is high due to routinely late discovered. Generally, men suffer and die more than women from oral cancer.

Causes for Oral Cancer

Oral cancer is any neoplasm found on the lip, floor of the mouth, cheek lining, gingiva, palate or in the tongue. Oral cancer is among top three types of Cancer observed in India. Common risk factors are severe alcoholism, use of tobacco like cigarettes, smokeless tobacco, betel nut chewing and human papillomavirus (HPV).

It may also occur due to poor dental care and poor diet. The incidence of oral cancer is higher in India, South and Southeast Asian countries. Around 90 -95% of the oral cancers are squamous cell carcinomas in India.

According to the international agency for cancer research, India’s incidence has increased from 1 million in 2012 and would increase more than 1.7 million by 2035. This indicates that the cancer death rate would also increase from 680,000 to 1- 2 million at the same time.

In India, oral cancer is interrelated to low income. Low social-economic class is often associated with factors like lack of nutrition, health care, squalid living conditions and risk behaviours, contributing to oral cancer development.

Most of the population lacks access to a well organised and well regulated cancer care system in low and middle-income countries; they don’t have personal health insurances.

A cancer diagnosis often burdens high health expenditures. Such expenditures impoverish homes and push entire families below the poverty line, bringing about social instability. There are no significant advancements in the treatment so far.

Although, present treatments improve the life of oral cancer patients but for public point of view,  these treatment results have failed to improve overall survival rates of 5 years in the past decades.

Incidence of oral cancer in India

Incidence of oral cancer is 53,842 in males and 23,161 in females seven years ago. Oral cancer is considered to be a disease which occurs in elderly people. Most of the oral cancer cases occur between 50 to 70 years but may occur in 10 years old children. Incidences of oral cancer increase with age.

Fifth decade of life is common for cancer development. In India, men are two to four times more affected than women due to changes in the behavioural and lifestyle patterns, but high incidence rates are seen amongst South Indian women due to tobacco chewing. Tongue Cancer is the most common type of cancer and common sites are buccal mucosa and gingiva.

Chances of developing oral cancer in addicted patients are 8.4 times higher than that non-addictive patients. Use of tobacco in the form of smoking has 5.19 times higher risk or chances of having pre-cancerous lesions on palate when compared to that of tobacco chewing. Most of the oral cancer patients are found in Uttar Pradesh, Jharkhand and Bihar.

Burden of Oral cancer in India

20 per 100,000 people are affected by oral cancer which is about 30% of all types of cancer. More than 5 people in India die every hour because of oral cancer and the same for cancer of oropharynx and hypo pharynx.

Cancer registration is not compulsory in the country; so actual incidence and mortality are not predicted. Many cases are unrecorded and lose to follow up during treatment. There is no national registry that monitors cancer incidences, that’s why actual cases are based on various surveys.

The National Cancer Registry Program collects numbers that are population-based data from a selected network of 28 cancer registration centres located in different parts of the country. Various studies use data from urban and rural cancer registries established at national and regional level.

Urban registries are at Delhi, Mumbai and Chennai, and rural registries are at Barshi, Dindigul, Manipuri, Karunaga-pally, Ernakulum, Srikakulam and Bhavnagar.

There is still need for providing cancer detecting, treatment centres.  Many people can’t afford high treatment cost. Negligence in the initial stages makes the situation worse for the advanced ones.

This burden of detecting oral cancer at initial stages can be reduced by implementing dentist in this program as they are the first one to diagnose oral cancers during routine dental checkups.


Visit your dentist for dental checkups regularly as they are the only medical faculty to diagnose precancerous lesions and cancers at initial stages. Governments should enrol more dentists in oral cancer screening programs across India to reduce the burden. Spread awareness to the general public about oral cancer in various campaigns and social activities, etc.

    1. http://cancerindia.org.in/cancer-statistics/
    2. http://cancerindia.org.in/oral-cancer/
    3. https://www.timesnownews.com/health/article/oral-cancer-cases-increase-by-114-per-cent-in-india-in-6-years-risk-factors-and-prevention-tips/315143

Connective Tissue Graft in Treatment of Recession

Normally, gingival margin is located at or coronal to cementoenamel junction (CEJ). When gingival margin migrates apical to CEJ, it is called a gingival recession. Gingival recession may occur due to excessive tooth brushing trauma. Localised plaque induced inflammatory process, malocclusion, and orthodontic tooth movement, as a part of generalised chronic periodontitis.


For treating gingival recession it is important to diagnose the cause of recession. Elimination of causative factors is the most important step in treating recessions. This may include oral hygiene technique modifications, treating periodontitis, elimination of plaque retentive structures, tooth repositioning, etc.

After this, surgical intervention can be considered if the goal is to correct the defect and possible root coverage by regenerated gingiva.

Indications for Root Coverage
  • Highly esthetic demands
  • Lack of keratinised gingiva
  • Continuous recession even after eliminating causative factors
  • Root hypersensitivity
Connective Tissue Graft (CTG)

This technique utilises subepithelial CTG from the palate. Palate has keratinised tissue with dense lamina propria. The connective tissue grafting along with the various flap techniques can be used to treat recessions. The coronally advanced flap plus connective tissue grafting is still the gold standard in treating recessions.

Indications for CTG
  • Inadequate tissue around recession defect
  • Wide gingival recession defect
  • Multiple gingival recessions
  • It has high predictability
  • Graft receives abundant blood supply from the inside of the flap as well the periosteum- connective tissue
  • Wound can be sutured at palatal donor site after harvesting of connective tissue graft. Which make hemostasis easy and healing rapidly.
  • Less discomfort and pain during healing
  • Better aesthetic results
  • Multiple gingival recession defects can be treated.
  • Technically demanding
  • As the graft is thick, the grafted tissue is thick. Gingivoplasty may require sometimes to obtain better morphology

If the thickness of donor tissue is less. The thickness of the connective tissue graft for root coverage should be 1.5-2.0 mm, and the thickness of the palatal flap should be 1.5-2.0 mm after graft harvesting, to prevent further necrosis. As a result, at least 3-mm thickness is required at the donor site of palatal soft tissue.

CTG Technique
  • Local anaesthesia application
  • Preparation of  exposed root surface
  • Recipient bed preparation
  • CTG harvesting
  • Suturing and stabilizing the graft at the recipient site
  • Management of donor site
Preparation of the Exposed Root Surface

Scaling and root planning of the exposed root surface. If the goal is to obtain root coverage over existing caries or class V restoration, caries and restoration must be completely removed. Recent studies have shown root coverage over restored root surfaces too. Convexity of the root should be eliminated with diamond burs. Chemical root surface modifiers such as citric acid, tetracycline, EDTA is used to demineralise and decontaminate the root surface and to expose the collagen fibres. This is to facilitate attachment of fibres to the root surface. Evidence recently demonstrated that the use of such chemical modifiers provides no additional benefit of clinical significance. (Mariotti et al 2003).

Preparation of the recipient bed

The recipient bed is prepared for the connective tissue graft by a split thickness flap which is performed so as the periosteum remains attached to the underlying osseous structure. The split thickness flap is prepared by sharp dissection using 15 c blade. Presence of any muscle fibres or attachment is also eliminated so that flap is mobile and can be coronally repositioned without any tension.

Harvesting CTG from the Palate

The CTG is harvested from the hard palate area. The ideal location for harvesting the graft is 5-6 mm apical to the gingival margin of the palatal aspects of the maxillary premolars and the mesial half of the maxillary first molar. Incisions are made to gain access to the connective tissue. The incisions create a trap door effect where a flap is raised toward the palate, and then the connective tissue is harvested. There is different incision technique’s single incision, double incision, L- shaped incision. The ideal thickness of the graft is 1-1.5 mm thick. During harvesting, the connective tissue extra precautions should be taken to avoid injury to the vital structures like the greater palatine artery. Depending on the depth of the palatal vault, generally, the artery is about 12 mm apical to the gingival margin. Reiser et al 1996, Monnet-Corti et al 2006.

Placement of the Graft

The harvested connective tissue graft is immediately placed in the recipient site and secured into position with sutures. The 5-0 silk or 6-0 absorbable sutures can be used. Optimised healing requires the graft to be in intimate contact with the recipient bed with the absence of any dead space. Suturing techniques play an important role in the success of any periodontal plastic surgery.

Management of the Donor Site

For better healing, positive hemostasis is required at the donor site and can be achieved by application of pressure. Hemostatic agents like collagen sponges may be used to aid with hemostasis. Ligation of the greater palatine artery with a suture in case of injury to the artery. For patient comfort, dressing in the form of tinfoil may be placed or palatal stent that should be pre-surgically fabricated may be inserted.

Post-Operative Maintenance

Patient should be recalled for reassessment in between 2 weeks following surgery for a post-operative visit and suture removal better to use absorbable sutures. Patient should be instructed to avoid tooth brushing and flossing around the surgical site for first 2 weeks. Gentle rinsing with chlorhexidine gluconate 0.12% or 0.2 % should be advised.

Causes of CTG Failure
  • Insufficient interdental bone and soft tissue heights
  • If horizontal incision placed apical to the CEJ
  • Reflection of interdental papilla
  • Flap tearing
  • Inadequate or improper root planing
  • Failure to provide sufficient blood supply from surrounding tissue due to inadequate recipient site preparation is the main cause for failure
  • CTG too small
  • Graft too thick
  • Failure to cover graft coronally by the flap

Management of gingival recession requires the identification and elimination of the etiology. Many recessions do not require treatment. In some cases, the decision may be to treat the recession with a root coverage procedure. One of the most predictable techniques is CTG.

Connective tissue grafting
  1. Preoperative


2. Incision and recipient bed preparation

3.CTG Graftt

4.Donor site suturing

5. Graft stabilization

6. Flap suturing

7. Results after 3 weeks

Are dentists trapped between patient satisfaction and unnecessary prescriptions?

If you chase perfection, you often catch excellence.

William Fowble

Medical health care services are revamping rapidly with the latest scientific research and technology advancements. Patients are getting aware of dental treatments due to educational programs and are becoming more demanding. Some patients are coming to doctors by Google diagnosis and demand for various available treatments on Google. Antibiotics are common treatment in dentistry.

Antibiotic resistance complication is commonly seen and heard in dentistry during this era. There is ample evidence showing significant relationship between increases in antimicrobial resistance to bacteria isolated from areas with higher antibiotic utilisation compared with lower antibiotic utilisation areas.

Proper knowledge about dosage, indications and their side effects should be known before prescribing it to patients.

Every dentist dreams to make perfect anatomically correct restorations. Patients don’t always accept and appreciate dentist’s effort. Some patients even accept poorly done restorations, as long as they don’t affect them adversely.

That’s why patient’s satisfaction in dentistry is of utmost importance after every treatment. In a true sense, dentists are trapped between perfection and patient satisfaction.

Treatment success depends on dentist’s skills, patient cooperation and the adeptness of the dental technician or ceramist. A drawn balance between all these factors can provide amazing results; a missing component will offer limited outcome.

Not always will we get a cooperative appreciating patient and doing a job for an uncooperative customer can be a difficult and thankless task. In such situations, dentists apply all their knowledge, clinical skills as well as patient communication and management skills for an ideal result.

Every dentist is skilful after the precious time spent in dental school, careful patient handling and management is the key to success in situations like these.

Sometimes dentists have to perform out of box treatments at patient’s demands and satisfaction as in case of a decayed tooth which needs root canal treatment, patients do not wish to undergo root canal treatment instead demands a cement filling.

After explaining all the possibilities without root canal treatment, patient stick to their wish and dentists performs fillings to appease the patient. Care must be taken during such treatments, and doctors must ensure the patient fills a consent form before undergoing the procedure to avoid later any backlash from the patients.

Are dentists prescribing unnecessary prescriptions? Well, this is an individual centric problem. I don’t think that dentists are prescribing unnecessary prescriptions some might be but not all.

Some patients demand prescriptions to alleviate pain instead of treatment or addressing the root cause. Dental diseases are chiefly caused by microorganisms. Antibiotics are often used in endodontic cases; however, successful treatment can predominantly be achieved by mechanical and chemical cleaning of the canal.

Dentist is the most antibiotic prescribing medical practitioners. In dentistry, antibiotics are prescribed after tooth extractions, root canal treatments and while treating Periodontitis. Whether to prescribe routine antibiotics during root canal or not, is a debatable question. But what we are following is what we were taught in dental school, recent updates in dentistry, dental journals and articles.

Prescription of antibiotics during routine root canal treatment is unnecessary and doing this unnecessarily increases antibiotics resistance. One day, no antibiotic will work because of the resistance. Dental infections are due to most complex anaerobic bacteria to suppress their activity one has to prescribe antibiotics.

Antibiotic prescription is blind in dentistry because dental practitioners do not know which microorganisms are responsible for the infection, as samples from the root canal or periapical region are not routinely taken and analysed, also not economic for each and every case.

Based on clinical and bacterial epidemiological data, the microorganisms responsible for the infections are being suspected, and treatment is decided on a presumptive basis with broad‐spectrum antibiotics (Poveda Roda et al. 2007). There is clear guideline to prescribe antibiotics in dental conditions as given in the chart.

Pulp/Periapical condition Clinical and radiographic data Antibiotics as adjunct
Symptomatic irreversible pulpitis
  • Pain
  • No others symptoms and signs of infection
Pulp necrosis
  • Nonvital teeth
  • Widening of periodontal space
Acute apical periodontitis
  • Pain
  • Pain to percussion and biting
  • Widening of periodontal space
Chronic apical abscess
  • Teeth with sinus tract
  • Periapical radiolucency
Acute apical abscess with no systemic involvement
  • Localized fluctuant swellings
Acute apical abscess in medically compromised patients
  • Localized fluctuant swellings
  • Patient with systemic disease causing impaired immunologic function
Acute apical abscess with systemic involvement
  • Localized fluctuant swellings
  • Elevated body temperature (>38 °C)
  • Malaise
  • Lymphadenopathy
  • Trismus
Progressive infections
  • Rapid onset of severe infection (less than 24 h)
  • Cellulitis or a spreading infection
  • Osteomyelitis
Persistent infections
  • Chronic exudation, which is not resolved by regular intracanal procedures and medications




  1. https://onlinelibrary.wiley.com/doi/full/10.1111/iej.12741
  2. Nabavizadeh MR, Sahebi S, Nadian I. Antibiotic Prescription for Endodontic Treatment: General Dentist Knowledge + Practice in Shiraz, Iran Endod J. 2011;6(2):54-9.
  3. https://www.aae.org/specialty/2016/08/19/antibiotics-a-risky-prescription/

Probiotics in Periodontics

Bacterial colonisation in the oral cavity starts few hours after a baby is born. As soon as teeth start erupting, the oral microflora starts changing. The oral cavity in adults contains more than 500 species of bacteria. Out of these, some are healthy and some are disease producing species. According to the ecological theory of plaque hypothesis, balance between the healthy and disease-producing bacteria collapse, and the disease starts developing.

With the growing number of bacteria-resistant diseases and the length of time it takes to develop new antibiotics, it might be time to consider another alternative, ‘Probiotics’, in the treatment of periodontal disease. Antibiotics indiscriminately kill harmful bacteria that cause infection and also kill good bacteria which help fight infection. Whereas probiotics increase the population of the beneficial bacteria which kill pathogenic bacteria and fight against infection. Oral administration of probiotics may also benefit oral health by preventing the growth of harmful microbiota or by modulating mucosal immunity in the oral cavity.

Probiotics are live microorganisms, when administered in adequate amounts have beneficial health effects on the host. Probiotics act as nano soldiers, referring to genera of organisms, which halt, alter or delay periodontal diseases. It poses a great potential in the arena of periodontics in terms of plaque modification, halitosis management, altering anaerobic bacteria colonisation, improvement of pocket depth and clinical attachment loss.

Probiotics can help prevent and treat disease via several mechanisms.
Direct interaction

Probiotics interact directly with the disease-causing microbes, making it harder for them to promote infection or disease. Production of antimicrobial substances against periodontal pathogens.

Competitive exclusion

Beneficial microbes directly compete with the disease, developing microbes for nutrition or enterocyte adhesion sites.

Host modulation

Probiotics improve the immune system and help prevent disease. It causes innate and acquired immune system modulation.

Probiotic bacteria or their products can modulate the immune system. Regulatory T cells are known to be very important in reducing inflammation in response to non-pathogenic antigens. It has been suggested by recent studies that toll-like receptors may mediate interaction between T lymphocytes, dendritic cells and mast cells. These interactions help in modulating response. This mechanism of action is similar to what is observed in the gastrointestinal tract. Probiotic bacteria also produce various metabolites like bacteriocin, free fatty acids, bacteriocin and bacteriocin like substance which inhibit the growth of another pathogenic organism thus enabling them to colonise the oral cavity.

One of the essential characteristics of a probiotic to exert oral effects is by far the property of colonisation in order to integrate into the oral microbiome and maintain balance. This is a direct mechanism of action to inhibit the periodontal pathogens. Whereas indirect mechanism would include competitive exclusion by means of competing for nutrients and growth factors thereby passively creating niches for colonisation and actively reducing the adhesion capacity of pathogen in the oral cavity.

Probiotics compete for adhesion sites, aggregate, compete for nutrients and growth factors, produce antimicrobials, enhance the host immune responses, inhibit pathogen induced production of pro-inflammatory cytokines, decrease MMP production leading to inhibition of pathogen adhesion by antagonism and reduction of tissue destruction. According to the ecological plaque hypothesis, selective pressure in environmental conditions can change the balance between oral health and disease.

Since bacteria are capable of influence the environment by both synergistic and antagonistic interactions, the environmental pressure in the ecological plaque hypothesis is partly introduced by them. It is well known that normal microbiota protects the oral cavity from infections; similar to species associated with oral diseases, there seem to be species associated with oral health.

Bacteria used as a probiotics

  1. Streptococcus salivarius
  2. Lactobacillus salivarius
  3. Lactobacillus reuteri
  4. Lactobacillus acidophilus
  5. Lactobacillus rhamnosus
  6. Lactobacillus plantarum
  7. Lactobacillus paracasei

Delivery of the probiotics

In the forms of tablets, powder, mouthwash and chewing gums probiotics can be easily delivered to the oral cavity.

1. For treatment of gingivitis and periodontitis

Various periodontal diseases, gingivitis, periodontitis and pregnancy gingivitis were locally treated with a culture supernatant of aL.acidophilus strain. Using probiotics in treatment of periodontal diseases improve gingival health, as measured by decreased gum bleeding.

Use of tablets containing L. Salivarius WB21 has shown decrease in gingival pocket depth, in heavy smoker groups. It also affects the number of pathogens in plaque. Mouthwash containing strains of L.reuterri or tablets containing 6.7 x 108 colony forming units of L. salivarius and Xylitol [280 mg/tablet] has shown decrease in gingivitis and plaque formation. Also 14 days intake of L. reuteri led to the establishment of the strain in the oral cavity and significant reduction of gingivitis and plaque in patients with moderate to severe gingivitis.

2. Halitosis

Halitosis is not s disease but a discomfort, although some oral diseases including periodontitis may be the underlying cause; however, in approximately 90% of cases, the origin can be found in the oral cavity and probiotics are marketed for the treatment of both mouth and gut-associated halitosis.Streptococcus salivarius K12, a pioneer colonizer of oral surface and predominant non-disease-associated member of the oral microbiota of healthy humans, have been effectively used as a probiotic to replace bacteria implicated in halitosis.


The micro bacteria, although invisible to the naked eye, should not be underestimated as a key determinant of health and disease. The oral microbial ecosystem is essential in maintaining both oral and overall health in the body. The microbial equilibrium is maintained within the oral cavity by the salivary flow and biofilms on the teeth and soft tissue. Pathogen activity initiation can lead to oral diseases if the homeostasis of the oral cavity is disturbed. Since the oral cavity is a primary gateway to the body, severe cases of oral diseases may result in the spread of infection to other body sites, producing systemic diseases or aggravating an already compromised immune system. Practicing good oral hygiene and maintaining stable oral biofilms is indispensable to keeping body healthy and also preventing rapid spread of disease to other individuals. Probiotics offer a natural and promising option to establish this.


  1. Teughels W, E V Mark, Slipen I and Quirynen M. Probiotics and oral healthcare. Periodontology 2000, Vol. 48, 2008, 111–147.
  2. Krasse P, Carlsson B, Dahl C, Paulsson A, Nilsson A, Sinkiewicz G. Decreased gum bleeding and reduced gingivitis by the probiotc Lactobacillus reuteri. Swed Dent J 2006; 30:55-60.


Magical Innovation- Laser Applications in Periodontics

Latest innovations in technology, science and health care are happening since the early days of mankind on this planet. Recently, the most popular innovation in periodontics is Laser. Light Amplification by Stimulated Emission of Radiation is the full form of Laser. Laser is a device, widely used in the field of periodontics both for non-surgical treatment and surgical treatment. Most of the patients have fear of scalpel, noise and vibration produced by the mechanical action of the air turbine or ultrasonic scalers. Laser is always helpful to treat such kind of patients.

Latest innovations in technology, science and health care are happening since the early days of mankind on this planet. Recently, the most popular innovation in periodontics is Laser. Light Amplification by Stimulated Emission of Radiation is the full form of Laser. Laser is a device, widely used in the field of periodontics both for non-surgical treatment and surgical treatment. Most of the patients have fear of scalpel, noise and vibration produced by the mechanical action of the air turbine or ultrasonic scalers. Laser is always helpful to treat such kind of patients.

Numerous varieties of lasers available in the dental market

Type of laser Wavelength           Color
Excimer lasers Argon Fluoride (ArF) 193 nm Ultraviolet
Xenon Chloride (XeCl) 308 nm Ultraviolet
Gas lasers Argon 488 nm Blue
514 nm Blue-green
Helium Neon (HeNe) 637 nm Red
Carbon Dioxide (CO2) 10,600 nm Infrared
Diode lasers Indium Gallium Arsenide Phosphorus (InGaAsP) 655 nm Red
Gallium Aluminum Arsenide (GaAlAs) 670–830 nm Red
Gallium Arsenide (GaAs) 840 nm Red-infrared
Indium Gallium Arsenide (InGaAs) 980 nm Infrared
Solid state lasers Frequency-doubled Alexandrite 337 nm Ultraviolet
Potassium Titanyl Phosphate (KTP) 532 nm Green
Neodymium:YAG (Nd:YAG) 1,064 nm Infrared
Holmium:YAG (Ho:YAG) 2,100 nm Infrared
Erbium, chromium:YSGG (Er,Cr:YSGG) 2,780 nm Infrared
Erbium:YSGG (Er:YSGG) 2,790 nm Infrared
Erbium:YAG (Er:YAG) 2,940 nm Infrared


Applications of lasers in periodontics

  • Gingivectomy
  • Esthetic Crown Lengthening
  • Frenectomy
  • Depigmentation of gingiva
  • Treatment of hypersensitivity.
  • Subgingival calculus detection

Non-surgical periodontal therapies

  • Root debridement, subgingival calculus removal, root conditioning, periodontal pockets have a complex anatomy with a complex environment which is favorable for growth of number of bacterial species. Conventional mechanical debridement cannot completely eliminate bacteria and their toxins from the complex periodontal pockets. Furcations and grooves hamper complete debridement and elimination of bacteria. Furthermore, conventional mechanical debridement using curettes is still a gold standard, and power scalers sometimes cause discomfort and stress in patients. Lasers have benefits like ablation, bactericidal and detoxification effects, as well as photo-bio modification. These can be used for periodontal pocket treatment. Lasers can be used for an adjunctive or alternative tool to conventional periodontal mechanical therapy. Er: YAG laser is most commonly used by dentists.
  • Pocket lining epithelium removal for Laser-assisted new attachment procedure (LANAP). Elimination pocket lining by using Nd: YAG laser results in LANAP. It is associated with cementum-mediated new connective tissue attachment and apparent periodontal regeneration of diseased root surface in humans.
  • Low-level laser therapy after periodontal surgeries to promote wound healing. Low laser irradiation along with conventional scaling and root planing can proliferate gingival fibroblast, periodontal cells and release growth factors. This results in early wound healing.
  • Photodynamic Therapy (PDT): Routinely we prescribe antimicrobial drugs to beat microbial infection in pockets along with scaling and root planing. Continuous uses of antimicrobials for any infection in patients may result in resistance to drugs. Instead of these antimicrobial drugs, we can use photodynamic therapy in deep pockets. PDT involves three components including Light, photosensitizer, and oxygen. The photosensitizer is administered to the periodontal pocket, and upon irradiation with a specific wavelength laser, the photosensitizer undergoes transition from a low energy ground state to an excited singlet state. In the end, the photosensitizer decays back to its ground state with the emission of fluorescence or undergoes a transition to a higher energy triplet state. This singlet oxygen acts as a bactericidal. Therefore photodynamic therapy is important antimicrobial therapy adjunct to mechanical therapy.

Surgical Pocket therapies and osseous surgeries

  • Previously soft tissue laser was only available but recently hard tissue lasers are also accessible with bone cutting efficiency. Hard tissue lasers for osteoplasty or ostectomy is costlier. Soft tissue lasers are effective in debridement of intrabony defects. Ex: Er: YAG lasers, Nd: YAG lasers.

Treatment of peri-implantitis

  • Combination of above discussed methods is used. Classical curettes may result in roughening of titanium implant surface and it promotes bacterial adhesion. Laser irradiation not only eliminates bacteria but also removes granulation tissues. Therefore laser irradiation in peri-implantitis is really helpful and innovative application.

Effects of Lasers on Periodontal Therapy

  • Pain relief
  • Inflammation reduction
  • Accelerated tissue repair and cell growth
  • Wound healing
  • Reduced formation of scar tissue
  • It is bactericidal

Advantages of Laser

  • Relatively bloodless surgical and post-surgical course.
  • Ability to coagulate, vaporize, or cut tissue.
  • Sterilization of wound tissue.
  • Minimal swelling and scarring.
  • No requirement of sutures as many patients fear if we tell about sutures.
  • Little mechanical trauma.
  • Reduced surgical time.
  • Decreased post-surgical pain.
  • High patient acceptance.

Disadvantages of Laser

  • Caution before and during irradiation
  • Use glasses for eye protection for patient, operator as well as assistants.
  • Inadvertent irradiation (action in noncontact mode).
  • Protect patient’s eyes, throat, and oral tissues outside the target site.
  • It reflects from shiny metal surfaces, therefore, it is important to understand laser physics before using it.
  • High-speed evacuation requires to capture the laser plumes.
  • Direct ablation may cause excessive tissue destruction and thermal side-effects

Destruction attach attached tissues at the bottom of pockets

Excess tissue ablation of root surface and gingival tissue within periodontal pockets

Thermal injuries to the root surface, gingival tissue, pulp and bone tissue.

  • Problems of laser systems

Further development of a new laser system as well as improvement of currently available laser systems

Development and improvement of contact probes suitable for periodontal treatment

High Cost of the laser system is the major dilemma for its use in clinical practice.

Laser functioning depends on wavelength with each different wavelength function get changed. Therefore proper knowledge of laser physics is needed to use lasers confidently. Very few universities provide proper knowledge about lasers and because of this, it is difficult for the users to learn all aspects of the techniques and precautions required for the newer technologies.


Proper knowledge about laser physics, diagnosis of the case and laser applications in periodontics essential before using it. If we follow all the guide lines, lasers use is really an innovative and magical experience. Laser is just a one weapon with multipurpose uses.


  1. Ishikawa I, Aoki A, Takasaki A, Mizutani K, Sasaki K & Izumi Y. Application of lasers in periodontics: true innovation or myth? Periodontology 2000, Vol. 50, 2009, 90–126.
  2. Aoki A, Sasaki K, Watanabe H & Ishikawa. Lasers in nonsurgical periodontal therapy. Periodontology 2000, Vol. 36, 2004, 59–97.
  3. Rakhewar P S, Patil HP, Thorat M. Diode laser treatment of an oral squamous papilloma of soft palate. J Dent Lasers 2015; 9:114-7.

National Dentist Day: 24th December, 2018

Indian Dental Council (IDA) had declared 24 December as a National Dentist Day in its Central Council Meeting held on January 17th, 2016 at Jaipur to coincide with the birth anniversary of Padmabhushan Dr Rafiuddin Ahmed who is known as Father of Modern Dentistry, India. On this day IDA creates awareness on oral health among the public, educates them about the importance of the oral health and role of a dentist to keep their oral health well. For this awareness campaign IDA use tagline as, “This National Dentist Day Thank Your Dentist for Your Sparkling Smile

Dr Rafiuddin Ahmed was born on 24th December 1890 to Maulavi Safiuddin Ahmed a deputy collector and Faizunnesha at Bardhanpara, East Bengal, India. Dr Ahmed graduated in 1915 as Doctor of Dental Surgery from Iowa University, United States. In 1919 he returned to India to start dental practice at Kolkata. In 1920, he started the first Indian Dental College at Kolkata financed by New York Soda Fountain. Dr Ahmed followed his philosophy, ‘‘Education is the responsibility of the State; but if no one is willing to carry the cross, I will, for as long as I can.’’ In 1925 he started Indian Dental Journal and served as the editor until 1946. In 1928 he published 1st Student Handbook on Operative Dentistry. He was councillor and alderman of Culcutta Corporation from 1932 to 1944. In 1949 he donated his college to West Bengal Government and named it as Culcutta Dental College. Later it was renamed as Dr R Ahmed Dental College and Hospital by the government. Now it is affiliated to the West Bengal University of Health Sciences and is recognised by Dental Council of India. It offers Bachelor of Dental Surgery (BDS) courses and Master of Dental Surgery (MDS) courses in various specialties. He served as the principal of the college from 1920 to 1950. In 1946 he established Bengal Dental Association which was later renamed as Indian Dental Association. He served as a President of IDA for three terms. He played a major role in establishing Bengal Dentist Act in 1939 which was the first dental act by Indian Government and stood as a model for Indian Dental Act 1948.

He was awarded with various fellowships like the Fellowship from International College of Dentist in 1947, Fellowship from Royal College of Surgeons and a fellowship from the Pierre Fouchard Academy in 1949. In 1950, Dr Ahmed became a minister in the West Bengal government. He was supervisor for the Departments of Agriculture, Community Development, Co-operation, Relief, and Rehabilitation until 1962. In 1964 he was awarded the Padma Bhushan by the Indian Government.

Inscription on the ICD Memorial Roll in 1965 was a special tribute for Dr Ahmed, he earned many honours and memorial tributes. Dr Ahmed died on January 18th 1965, the IDA recognised his many contributions to Indian dentistry by establishing the Dr R Ahmed Memorial Oration at the 1977 Annual Indian Dental Conference and declared his birth anniversary 24th December as a National Dentist Day in 2016. The Pierre Fauchard Academy dedicated its quarterly PFA Journal in Dr Ahmed’s memory in 1987. The University of Iowa School of Dentistry Alumni Association presented him with their First Distinguished International Alumnus Award in 1989.

No person was ever honoured for what he received. Honour has been the reward for what he gave.”

-Calvin Coolidge.

Let’s spread oral health awareness among the public and give tribute to Dr Ahmed by celebrating his birth anniversary as National Dentist Day.


  1. http://activities.ida.org.in/program.htm#/ProgramBody?PID=21
  2. https://www.ida.org.in/AboutUs/Details/Founder-Father-of-IDA
  3. https://en.wikipedia.org/wiki/Rafiuddin_Ahmed_(dentist)
  4. https://en.wikipedia.org/wiki/Dr._R._Ahmed_Dental_College_and_Hospital
  5. https://youtu.be/P-j_WpVafHs

Platelet concentrate in periodontal regeneration

Nov 30, 2018
Platelet concentrate in periodontal regenerationPlatelet concentrate in periodontal regeneration

Platelet concentrate is nothing but a centrifuged blood with only platelets and fibrin in maximum amount and less or very few leucocytes at the bottom. Other components get separated from the platelet concentrates in the upper layer. Several techniques for platelet concentrates are available. This is because of the commercialization and also their applications have been confusing, each method leads to a different product with different biology and potential uses. Development of bioactive surgical additives regulating inflammation with increasing healing is a great challenge and even after each intervention, surgeons face complex tissue remodeling phenomena affecting healing and tissue survival. To limit such consequences autologous grafting and regeneration have been researched.

Platelet concentrates are classified on their leucocyte, fibrin content and method of preparation.

  1. Pure Platelet-Rich Plasma (P-PRP), such as cell separator PKP, vivostat PRF or Anitua’s PRGF.
  2. Leucocyte-and Platelet-Rich Plasma (L-PRP), such as Curasan, Kegen, Plateltex, Smart PReP, PCCS, Magellan or GPS PRP.
  3. Pure Platelet Rich Fibrin (PRGF), such as Fibrinet and Leucocyte.
  4. Platelet-Rich Fibrin (L-PRF), such as Choukroun’s PRF, T-PRF (Titanium PRF), I-PRF (Injectable PRF), A-PRF (Advance PRF) all these variants are due to either differences between centrifuge speed or use of titanium as a collection tube instead of normal glass tubes or vacuum blood collection tubes.
  5. Concentrated Growth Factors (CGF).

Why platelets concentrate is so popular?

Platelets concentrate is popular because they contain growth factors essential for regeneration and early wound healing.

Growth factors present in platelets

Growth Factors Primary functions
Epidermal growth factors (EGP) Regulation of cell proliferation, differentiation, and survival.
Insulin like growth factors IGF Key regulators of cell metabolism and growth

Stimulates proliferation and differentiation functions in osteoblast

Platelet derived growth factor Mitogen for connective tissue cells and other cell types. Enhance the synthesis of collagen and structural proteins
Transforming growth factors alpha beta Regulation of cell proliferation, differentiation and apoptosis

Induction of intimal thickening

Vascular endothelial growth factor Regulation of angiogenesis


  1. Epidermal Growth factors (EGP)
  2. Regulation of cell proliferation, differentiation and survival.
  3. Insulin like growth factors IGF

Key regulators of cell metabolism and growth

Stimulates proliferation and differentiation functions in osteoblast. Mitogen for connective tissue cells and other cell types enhance the synthesis of collagen and structural proteins.

Regulation of angiogenesis and method of preparation of PRP:

  • Venous blood is drawn and mixed with anticoagulant to avoid platelet activation and degranulation.
  • The first soft spin centrifugation separates blood in 3 distinct layers:
  1. The red blood corpuscles constitute 55% of total volume form the bottom layer of the tube.
  2. The acellular plasma layer is mainly made up of fibrinogen and low in platelets called as Platelet-Poor Plasma (PPP) and constitutes 40% of total volume forms a top layer of the tube.
  3. Between the 2, an intermediate layer is where platelets concentrations are largely increased. It constitutes only 5% of total volume called as buffy coat. It will compose the major part of the future PRP, but at this stage, it is non separable completely.
  4. A sterile syringe is used to aspirate PPP, PRP and some red blood corpuscles, the remaining content is transferred to another tube which is anticoagulant less.
  5. This second tube will then undergo another centrifugation, purported to be longer and faster than the first (‘‘hard spin’’). This makes it possible to concentrate platelets at the bottom of the tube and subsequently to obtain once again 3 distinct layers some residual red blood corpuscles trapped at the bottom of the tube and at the top acellular plasma (PPP) consists of 80% of total volume and between these two a buffy layer called PRP.
  6. It becomes easy to collect the PRP at this stage. Major part of the PPP is discarded by using a syringe, just leaving some serum to place the platelet concentrate in suspension. The unit is then gently shaken to obtain a ready-to-use PRP. Note that the red blood corpuscles trapped at the bottom of the tube are also suspended by this last operation, which explains the rosy aspect of the final PRP.
  7. PRP is then mixed with bovine thrombin and calcium chloride at the time of application, with the help of a mixing syringe. Gelling of platelet concentrate will then quickly occur: Fibrinogen is also concentrated during the PRP preparation and its polymerisation will constitute a fibrin matrix with particularly interesting homeostatic and adhesive properties.


PRF preparation

PRF protocol is very simple compared to PRP. Venous blood is drawn without anticoagulant in 10 ml tubes which centrifuged immediately at 3000 rpm (approximately 400 g) for 10 minutes. Care in handling of blood and quick action is required.


Properties of PRF

  1. Contains intimate assembly of cytokines, glycanic chains, structural glycoproteins enmeshed between slowly polymerized fibrin network
  2. Considered as an immune node which stimulates defense mechanism
  3. Significant inflammatory response at surgical site after PRF placement due to cytokines enmeshed within the matrix

Application in Periodontics

  1. Treatment of Intrabony Defects – PRP alone or in combination with bone grafts, PRF alone or in combination with bone grafts have shown adequate regeneration than only open flap debridement
  2. Treatment of furcations involvement – PRP alone or in combination with bone grafts, PRF alone or in combination with bone grafts have shown bone regeneration in class 2 class 3 furcation cases
  3. Ridge augmentations
  4. Sinus perforation repair by using PRF membrane
  5. Gingival recession treatments
  6. Papilla reconstruction using PRF
  7. Socket preservation after extraction
  8. Enhance the healing at palatal wound after Free Gingival Graft.

Advantages of PRF over PRP

  1. No bovine thrombin or anticoagulant is used
  2. Single centrifuge cycle requires
  3. Easy handling
  4. Even act as a vehicle for tissue engineering


PRPs are often considered as improved fibrin glues without consistency, however PRFs can be regarded as dense fibrin biomaterial with biomechanical properties. A dese fibrin clot can serve as a biological healing matrix. It supports cell migration and cytokine release. Expensive and complex procedures cannot always used in daily practice and many will disappear with time. Simple and free systems such as Choukroun’s PRF were developed by clinicians for clinicians and are anticipated to be major methods in the coming years. PRF have many advantages and prepared by chair side with less time, no complicated method of preparation, simple handling makes it a better choice in periodontal procedures.


  1. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): A second-generation platelet concen-trate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006; 101:e37-e44.
  2. Dohan DM , Rasmusson L and Albrektsson T Classification of platelet concentrates: from pure platelet-rich plasma (P-PRP) to leucocyte and platelet-rich fibrin(L-PRF). Trends in Biotechnology Vol.27 No.3

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DISCLAIMER : “Views expressed above are the author’s own.”

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