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

Experiencing the White Coat

Compassion of the White Coat

The word is simple but the experience is difficult to understand. Wearing a white coat is privilege for medical professionals. It is a provision of keeping surroundings safe and secure. The White Coat is an award for itself; it beholds the nature of work. When wearing The White Coat, the experience is beyond one’s imagination. The White Coat provides a designation to perform for the wellness of people; also becomes hard to ignore when living every moment in The White Coat.

The White Coat represents a great amount of knowledge, status and sense of comfort for medical practitioners. There are multiple reasons to wear the coat with pride. Doctors wearing the white coat may be of senior consultants, surgeons, physicists and pathologists; they preserve the same culture of treating ill or infirm patients.

The White Coat augments the pride in the profession by representing simplicity of the world and helping people in need. Patients rely more on doctors to wear the white coat, and it means a lot for them. Though, the quality of experience has come after several years of mutilating self into various forms of knowledge and practice.

Every doctor plays an important role in a patient’s life, irrespective of their cultural and economic backgrounds.

Why patients prefer The White Coat?

According to studies, the attire of doctors influences patients to confidently open up with their problems.

It is difficult to wear the coat all around the day, and juggling between the ramifications of caring, treating life with only a single intention and purpose. Wearing the same outfit in a practice zone full of infections is dangerous to patients and to self. For these reasons, some of the doctors prefer not to wear the coat; or wear it only during the first half of the day.

Why is The White Coat so meaningful? Because you have worked hard for your credentials; you have earned the right to wear The White Coat proudly. With a distinguished name on a broach on the first pocket, a doctor will certainly be more dignified. These little differences in The White Coat create a big significance in the minds of the patients and well-wishers. Any patient would wait to address the doctor with genuine respect to communicate their queries.

Confidence and Proficiency

The lab coat not only puts together the medical profession but also provides confidence. Patients value the opinion of a doctor rather than a random person. It also projects professionalism and aptitude, all while giving you an easy outfit choice every morning. Though there is a different form of lab coats, mainly suited to the new nature of attire.

The view of patients of doctors is beyond imagination. Every patient feels differently with doctors depending on their gender, male and female lab coats are designed to provide a sense of professionalism fitting the structure of one’s body though both provide the same responsibility and nature of work.

In the same way, patients interact differently with doctors with dark hair or grey hair. Wearing a White Coat changes the perspective of the patients seeking the notice and support of a doctor. In case of an emergency, every doctor prefers the same form of treatment irrespective of the gender or age.

For the record, a doctor working an average of 59.6 hours/week, can no longer differentiate with wearing a coat but gives satisfaction of attaining stability on the practice by the age of 30. The doctor-patient relationship built by the form of a doctor’s attire with The White Coat forms a major connection with healthcare and the practice of medicine. Therefore, the relationship can form on one of the foundations of the contemporary roles of a doctor; to help, support, protect and treat ones with ailments.

A doctor’s point of view

Medical practices handle a lot of sensitive patient information every day. The patient also trusts the practice of a doctor with their lives. This plays the hard role to keep The White Coat by saving lives by any means possible. With the Hippocratic Oath to The White Coat, a doctor is responsible to help any type of patient, irrespective of their nature of work, or a law-breaker, offender or felon of any kind. Similarly, that person will also respect The White Coat on the doctor and open up to medicines; a doctor uses for the treatments. For a respectful job, a respectful uniform is necessary.

In many cases, patient’s preferences are primarily shaped by cultural norms. The culture of medicine has been the same for many years; these little events make it very powerful and hard to break like the code of wearing The White Coat.

The White Coat is remarkably great in the eyes of many; but in the coming years, the pattern of practice will change. Along with it the form and attires will also no longer be relatable to only saving someone from danger. Wearing The White Coat is the closest thing to wear the certificate of the hardship of becoming a doctor. With a lack of management, time and safety, the feelings become more logical. The White Coat comes with a load of responsibility.

Management of Dental Anxiety in Paediatric Patients

Dental anxiety in children leads to uncooperative behaviour, posing challenges for dentists in a clinical setting. According to studies, girls generally exhibit more dental anxiety than boys. Other proposed etiologic factors include socioeconomic status, culture, parental anxiety, negative experiences from dental treatments, and temperament of the child. Clearly, dental F/A is a multidimensional construct influenced by biology and environment.

Behaviour management is fundamental in dealing with children’s F/A in a clinical setting. Nearly one in four children is seen by paediatric dentists present with management difficulties.

There are currently 14 behaviour management therapies described by American Academy of Paediatric Dentistry (AAPD).

Basic behaviour guidance techniques include positive pre-visit imagery, direct observation, tell-show-do (TSD), ask-tell-ask, voice control (VC), non-verbal communication (NC), positive reinforcement and descriptive praise (PR), distraction (Dis), memory restructuring, parental presence/absence (PP/A) and nitrous oxide/oxygen inhalation (NO). Advanced behaviour guidance techniques include protective stabilization (PS), sedation (Sed) and general anaesthesia (GA).

Dentists resort to more invasive techniques including hand-over mouth (HOM), VC, and active and passive stabilisation for unruly and defiant children to obtain their attention and gain cooperation for treatment 7. Pharmacologic BMTs may be considered222 when non-pharmacological techniques are ineffective or not accepted by parents.

Positive previsit imagery

The functional inquiry from a behavioural viewpoint should be conducted. During the inquiry, there are two primary goals:

  • Learning about the patient and parental concerns
  • Gathering information for cooperative ability of the child

Functional inquiries are conducted in two ways:

  • Paper and pencil questionnaire completed by the parent
  • Direct interview of child and parent

Pre-appointment behaviour modification can be performed with live patient models such as siblings, children and parents. Many pedodontists allow parents into their working place to see the experience of their small patients. A parent’s recall visit offers an excellent modeling opportunity by observing child at dental examination. After seeing their parents in the chamber the patient become cooperative and sits in the dental chair on his/her own. These previews should be selected carefully.

Tell Show Do (TSD)

Euphemisms or word substitutes are like second language for pediatric dentists. Examples of word substitutes for explaining procedures to children are rubber dam as rubber raincoat.

  • Sealant as tooth paint
  • Air syringe as wind gun
  • Water syringe as water gun
  • Suction as vacuum cleaner
Voice Control

Sudden and firm commands are used to get a child’s attention or to stop them from whatever they are doing. Slow and deliberate cadence function like music is another form of voice control. In both cases, what is heard is more important because the dentist is attempting to influence behaviour directly, not through understanding.

Non-verbal communication

Non-verbal messages can be sent to patients or received from them. Body contact can be another form of nonverbal communication. Dentist’s simple act of placing a hand on a child’s shoulder while sitting on a chair-side stool conveys a feeling of warmth and friendship. Greenbaum and colleagues found that this type of physical contact helped children relax, especially those between 7 to 10 years.

Positive Reinforcement

Giving gifts to children has become a fact of commercial life in North America. There is general agreement on the merit of this practice; gifts can be given to patients after successful treatment as a reward. It can be of dental use like toothbrush kit.

HOME (Hand Over Mouth Exercise)

This technique fits the rules of learning theory: maladaptive acts (screaming, kicking) are linked to restraint (hand over mouth) and cooperative behaviour is related to removal of the restriction and praising can be used as positive reinforcement. It is important to stress that aversive conditioning is not used routinely but as a last resort method, usually with children between 3 to 6 years who have appropriate communicative abilities.

Cultural factors also affect behavioural guidance, requiring the utmost attention in today’s increasingly diversified world. All practitioners encounter patients of a different culture daily and in certain instances, may experience difficulty or barriers in communicating treatment objectives and expectations.


  1. Hmud R, Walsh LJ. Dental anxiety: causes, complications and management approach. J Minim Interv Dent. 2009;2(1):67–78.
  2. Armfield JM, Heaton LJ. Management of fear and anxiety in the dental clinic: a review. Aust Dent J. 2013;58(4):390–407

Diabetes and the oral health – World Diabetes Day

Diabetes and the oral health - World Diabetes DayDiabetes and the oral health - World Diabetes Day

Diabetes is the most common disease in India and every year the number of people diagnosed with diabetes is ever increasing, current data shows more than 62 million people suffer with the disease. India tops the list for maximum individuals diagnosed with diabetes mellitus (31.7 million) followed by China (20.8 million) and United States (17.7 million) according to 2000 statistics. Diabetes mellitus is metabolic disorder characterized by high glucose level in blood. It a syndrome of abnormal carbohydrate, lipid and protein metabolism that results in acute and chronic complications due to the absolute or relative lack of insulin. There are three types of diabetes: Type 1, which results from an absolute insulin deficiency; Type 2, which is the result of insulin resistance and an insulin secretory defect; and gestational, a condition of abnormal glucose level during pregnancy. Keeping in mind the increasing prevalence of diabetes in the world’s population day by day International Diabetic Federation and WHO created World Diabetic Day (WDD) to spread diabetes awareness. WDD was decided as 14 November after the birthday of Sir Frederick Banting, the co-discoverer of insulin along with Charles Best in 1922. WDD has become the world’s largest diabetes awareness program which is reaching a global population in more than 160 countries. This campaign highlights the importance of awareness about diabetes in the global population.

The WDD campaign aims to

  1.  Be the platform to promote IDF advocacy efforts throughout the year.
  2.  Be the global driver to promote the importance of taking coordinated and concerted actions to confront diabetes as a critical global health issue.

Diabetes is a multifactorial disease. The causative factors  includes genetic factors coupled with environmental influences such as obesity associated with rising living standards, steady urban migration and lifestyle changes. Lack of exercise, no fixed timings for meals or skipped meals because of a busy lifestyle resulting in abnormal metabolism and some of the causative factor for developing diabetes mellitus. Diabetes mellitus impairs many other systems of the body and develops different diseases in the body and hence many diseases and symptoms are often correlated with the diabetes mellitus.  There is also a correlation between oral health and the diabetes.

Classification of diabetes

Type 1 diabetes (formerly insulin-dependent diabetes)

Type 2 diabetes (formerly non-insulin-dependent gestational diabetes, other types of diabetes)

  • Genetic defects in p cell function
  • Genetic defects in insulin action
  • Pancreatic diseases or injuries

Pancreatitis, neoplasia, cystic fibrosis, trauma, pancreatectomy

  • Infections

Cytomegalovirus, congenital rubella

  • Drug-induced or chemical-induced diabetes

Glucocorticoids, thyroid hormone

  • Endocrinopathies

Acromegaly, pheochromocytoma, glucagonoma, hyperthyroidism, Cushing’s syndrome

  • Other genetic syndromes with associated diabetes

Signs and symptoms of diabetes

Polyuria, polydipsia, polyphagia these are the classical triad associated with diabetes mellitus. Along with this, weight loss, irritability, fatigue and mental confusion also common findings. In long standing, poorly controlled hyperglycemia cases, microvascular and macrovascular conditions may develop that can produce retinopathy, cataracts, nephropathy, neuropathy and paresthesia and atherosclerosis as well as recurrent infections and impaired wound healing. Oral malodor like fruity breath presents with acute hyperglycemia cases.


Lab diagnosis

Random casual non fasting glucose level ≥ 200 mg/dl

Fasting plasma glucose level ≥ 126 mg/dl

Post prandial plasma glucose level ≥ 200 mg/dl

HbA1c test is used to measure effectivity of diabetic drugs.

Oral manifestations of the diabetes

  1. Burning mouth syndrome
  2. Candidiasis – a fungal infection
  3. Dental caries
  4. Gingivitis
  5. Glossodynia
  6. Lichen planus
  7. Neurosensory Dysesthesias
  8. Periodontitis
  9. Salivary dysfunction
  10.  Xerostomia

Gingivitis and periodontitis

There is also an association between periodontitis and diabetes mellitus and it is considered as two way mechanism that means diabetes can cause periodontitis as well as severe periodontitis can results in to diabetes mellitus.  In diabetic patients there is altered host defense, altered subgingival microflora, alter collagen synthesis and metabolism, defects in PMNs (polymorphonuclear leukocytes), Increased AGE (advanced glycosylation end products) formation. Multiple pathophysiological mechanisms (compromised neutrophil function, decreased phagocytosis and leukotaxis) also responsible for the increased alveolar bone loss in diabetic patients. Multiple periodontal abscesses is a common finding in  uncontrolled diabetic patients.


Dental caries

In diabetic patients there is abnormal salivary function leading to dry mouth, periodontal diseases and abnormal oral sensory functions which could increase their risk of developing new and recurrent dental caries.

Salivary dysfunction

People with diabetes often complain of dry mouth or xerostomia and experience salivary gland dysfunction.  Impaired salivary uptake and excretion is most common finding in diabetic patients. The cause is unknown, but polyuria or altered basement membranes of salivary glands were considered as the possible factors.

Oral mucosal disease

Diabetes mellitus generate chronic immunosuppression in body that may result in development of the oral mucosal diseases like lichen planus, recurrent apthous stomatitis. Coordination between physician and dentist required to treat oral mucosal diseases, which can improve the referral of patients to oral health practitioners.


Immunosuppressed condition can lead to development of opportunistic infections like candidiasis. Candidiasis is a fungal infections and most commonly associated with diabetes patients. It is also associated with smoking, using unclean dentures and uncontrolled diabetes.

Taste disturbances

In patients with diabetes taste disturbances are common, taste is considered as one of the important function of oral health. According to studies, more than one-third of adults with diabetes have diminished taste perception (hypogeusia), which could result in obesity. This sensory dysfunction leads to poor glycemic regulation and abnormal diet habits.


General physician and dentist coordination is required to treat diabetic patients with oral manifestations.

Studies have shown that treatment of periodontitis in a diabetic patients can help lower the glucose level for 3 months and doses of insulin required were reduced to half of the previous doses.

During any procedure that may require local anesthesia with epinephrine, doses of epinephrine need to be kept low as higher doses can interfere with insulin uptake and may result into hyperglycemia.

Even corticosteroids treatment can cause hyperglycemia condition and a slightly higher amount of insulin may require to control glucose level.

Presence of acute infection can also interfere with insulin uptake and that’s why slightly higher doses of medication require to control hyperglycemia during acute infections.


Diabetes is a non-curable disease, but with  medicines hyperglycemia can be controlled. In cases of periodontitis in diabetic patients, treatment of periodontitis can help to control glycaemia and reduce the doses of drugs required. Symptomatic treatment required in case of other oral manifestations. The goal of the therapy should be to maintain the oral health in a diabetic patients. Prevalence of diabetes is  increasing and awareness about oral manifestations among diabetics  is essential.


  1. Nishimura F, Iwamoto Y & Soga Y. The periodontal host response with diabetes. Periodontology 2000, Vol. 43, 2007, 245–253.
  2.  Mealey B & Ocampo G. Diabetes mellitus and periodontal disease. Periodontology 2000, Vol. 44, 2007, 127–153
  3. Ship J. Diabetes and oral health. An overview. JADA, Vol. 134, October 2003.

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

How to be a Good Dentist You’ll Smile About!

How to be a Good Dentist You’ll Smile About!How to be a Good Dentist You’ll Smile About!

A dentist from the common man’s point of view is, “A doctor who has specialized in oral healthcare. Or a person who has qualified to treat diseases pertaining to teeth and gums, replacement and repair or any kind of oral health-related issues where it’s beyond the limit of a common man to solve the problem.” But it also comes along with many other characterizations.

What exactly are the expectations of patients when they think of consulting a dentist?

  • Diagnosing dental ailments and conditions
  • Promoting oral hygiene and preventing dental diseases
  • Taking X rays and understanding them correctly
  • Safe administration of medicines
  • Proper anaesthetisation before any dental procedures
  • Treating various causes that lead to tooth loss
  • Provide best solutions for missing or decayed teeth
  • A doctor who upgrades and keeps abreast of the latest technology
  • Give patients confidence of a good smile and chewing efficiency

There is always a discrepancy between dentists’ thinking towards their profession and patients’ expectation from their dentist. Empathy and patience are the key to building a successful clientele and practice. Moreover, improvising on practice management can help dentists gain good patient leverage. Most of the time dentists focus on improving their skills to administer a certain treatment or to improve revenue per month.

Somethings dentists could focus to improve patient flow and win loyal public attention.

Good eye contact with your patients help them to build trust in you. Listening carefully and using correct body language and ease in delivering treatments. Showing empathy towards the patient during their dental check-up.

Explanation of X-rays and treatmentto the patients in simple lay man’s language to avoid any kind of confusion, misunderstanding and fear.

Value patients’ time and scheduling appointments in accordance to patient’s availability. Using special software or digital calendars to recall patients’ name helps a lot.

Issuing a complete treatment regime in a written format for every patient as a reminder of pending treatment. Give them have a registered op card and keep one for their record. Enter all findings so they can come back every three months to check on their dental problems which are yet to be treated.

Recall and remind patients in the form of an SMS or email and even better a direct phone to save time.

Have trained staff to record new patient calls and track good service at the reception when you’re not around to answer patient queries. Dentist can even sponsor a training program for the in-house staff.

Birthday perks go a long way to win patients’ loyalty in some practices. Like a free birthday dental check-up, complimentary family check-up, etc.

Patients are impressed and comforted with dentists using technology like intraoral camera, iopars, RVGs, Ortho pantamographs.

Easy payment methods and basic insurance tie-ups with the most commonly used insurance by patients, helps clientele get treatments done as soon as they want and without any payment hassles. Insurance companies are more than willing to have tie-ups with private practices to gain more customers; for instance, Bajaj Fiserv, Capital Float, etc.


The practice management: Peter F Drucker

Emotional Intelligence, why it can matter more than IQ: Daniel Goleman

Put your best foot forward by Mark Mazzarella

Digital marketing for dummies

Front office management and operations by Sudhir Andrews

The selection of essential drugs.Report of a WHO expert committee.Geneva world health organization; 1977

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

Shade-Matching Challenge: A Single Central Incisor

Shade-Matching Challenge: A Single Central IncisorShade-Matching Challenge: A Single Central Incisor

Patients today are more conscious than ever about the appearance of their teeth. As a result, have high expectations and are more insistent they receive high-quality aesthetically pleasing restorations. Aesthetic restorative dentistry presents multiple challenges for the restorative team. One of the most significant challenges is accurately achieving the unique characteristics of a single maxillary central incisor so that it is perceived as a natural tooth.

The loss or damage to a single central incisor is mainly attributed to trauma. A traumatically fractured or decayed single central incisor can be managed with a fiber post and core supported crown. In such cases, as well as in unilateral missing central incisor cases, all ceramic crowns offer better potential than metal-ceramic ones. Atraumatic incisal fractures of a single central incisor are mostly treated using composites. However, the composite restorations tend to discolor over time and also become less than ideal in contour and shape. Many patients have perfectly healthy teeth except for that one incisor that has been restored with either a composite restoration or a single crown that does not quite match. The plight of this category of patients is to such an extent that they avoid smiling altogether because of the perceived unpleasant appearance. Creating a single restoration, whether direct or indirect that blends imperceptibly in form, colour, contour, value, texture and translucency with adjacent dentition is a very challenging process.

Back in the day, dentists preferred restoring both the centrals rather than a single central incisor. However, modern technology with higher quality materials, digital photography and better shade options enable us to follow the concept of minimally invasive restorations, wherein a unilateral central incisor can be created to match the artistry of the natural dentition and the supporting tissues. Accurate shade selection and shade matching is a paramount step in order to achieve this natural blend of the restoration with the adjacent dentition. Conventional shade matching is a combination of art, science and experience of both the restorative dentist and the dental technician. Colour commonly referred to as the shade is divided into 3 components:

Hue which refers to the basic colour (e.g., red, blue, green); Chroma refers to the intensity of the colour (e.g., firetruck red versus pastel pink); Value refers to the brightness of the colour (e.g., the range of grey from black to white).

Comprehensive shade matching is a time consuming process. A single base shade can never offer a suitable aesthetic match. Different shades are required in the gingival, body and incisal thirds of the tooth. This must be further divided according to its mesial and distal characterisations. The standard shade tabs (Bioform, Vita classic, Vita pan, Vita 3-D, Ivoclar) that are available offer a place to start. However, the thickness of the shade tabs does not match that of the finished restorations. Hence, some colour difference must be anticipated when using these as well. Moreover, shade guides are not representative of the value of real teeth, which is another reason why relying on shade tab assessment alone can be problematic. It would be a great advantage to have special shade tabs for opalescence, fluorescence and translucency of natural teeth.

Numerous shade guides have been developed through the years in order to enhance shade selection but the degree of success is dependent not only on the illumination conditions and level of tooth characterisation but mostly on the subjective assessment and skill of the clinician. In order to overcome the subjective variable related to shade selection, several computerised shade selection devices have been developed which use either colourimeter or spectrophotometer technology. Even though scientific data on the ability of such devices to provide a consistent and predictable tooth shade, matchings are limited, studies have demonstrated that such devices can serve only as an aide to the traditional shade selection techniques.

Dentists and dental technicians have been using multiple methods including photos with shade guides, photos with customised shade tabs, computerised shade matching devices and visits of the patient to the technician’s office to facilitate shade communication and accurate reproduction of a restoration that mirrors the adjacent maxillary central incisor. In a normal scenario, the dental technician does not meet the patient in person, therefore photography must be used to supplement and enhance communication between the dentist and dental technician. Specifics such as colour, glaze, texture and luster are demonstrated remarkably by digital photographs. The shade is communicated with a conventional shade prescription and digital images taken under controlled lighting conditions. The teeth must be hydrated without plaque and debris. The most important colour component for matching dental restorations i.e. value can be selected with the aid of black and white digital images.

Fabrication of the single central incisor can be the most difficult tooth for a dental technician too. Apart from the selection of the material for the framework, several other factors need to be considered, including the design of the restoration, patient’s medical history, adverse habits and durability of the material. Once the correct material is selected, the communication between dentist and dental technician along with the dental technician’s talent and knowledge are of utmost importance in achieving an undetectable, natural looking restoration and a successful aesthetic result.

Apart from the shade selection process, the dentist should also look out for accuracy in the shape and surface characterisation, translucency and opacity, surface gloss, etc. Many variables, such as metamerism, variations in lighting and illumination, individual characterisations and shade evaluator variations, have all contributed to the reduced predictability of providing the desired shade and characterisations for the prospective maxillary central incisor crown. An assortment of new all-ceramic restorative materials are available with not just varying mechanical properties and technologies of fabrication, but also with different optical properties for both the core as well as the veneering porcelains. This possibly will contribute to the extent of challenge the restorative team has to face.

With regard to aesthetics, the single central incisor cases pose a great restorative challenge for the dental practitioner as well as the dental technician. To produce a lifelike restoration, it is important to develop skills at describing the features of a tooth to aid the dental technician in creating a faithful reproduction. A thorough analysis and treatment plan, along with clear communication between the clinician and laboratory technician, can result in an exceptional aesthetic outcome.


  1. Kahng LS. Material selection and shade matching for a single central incisor. The Journal of Cosmetic Dentistry 2006; 22(1): 78-84.
  2. Raigrodski AJ. Managing the challenge of crowning the single central maxillary incisor. Masters of Esthetic Dentistry, Wiley Periodicals 2008; 20 (5): 337-342.

Fondriest JF. Shade matching a single maxillary central incisor. QDT 200

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

A Novel Approach to Grafting Around Implants

A Novel Approach to Grafting Around ImplantsA Novel Approach to Grafting Around Implants

Tooth extractions and dental implants are sometimes part and parcel of the same process. Implant placement is a straightforward procedure, the size of the implant should be either equal to or greater than residual root socket. During the procedure, clinicians experience moderate to large gap between implant and walls of the socket mostly in the molars. However, the shape of the socket is not cylindrical. The larger gap in molar is defined as the jumping distance, exhibiting the periphery of the implant and surrounding bone. Both the vertical and horizontal components must be considered to get an aesthetic favourable outcome. Effect of vertical component is inclined towards initial stability at the time of implant and it is trouble free.

History of bone grafting

Bone grafting is a surgical procedure that took a bigger step with the invention of pre-prosthetic oral surgery in dental care segment. These materials along with ceramics helped in providing some bridging to patients who were experiencing severe jaw atrophy. When teeth are lost, jaws reach atrophy to a certain level. The entire process is termed as basal bone; with time, jaws strength decreases. Meanwhile, the treatment does not focus only at functional restoration but also aims to prevent jaw fractures. Tooth loss leaves behind narrow hoop in mandible bone and resembles as a flat pancake for maxillary bone. In earlier days, displacing dentures was the biggest challenge while eating or talking, it was prevented by musculature of the oral cavity. Sometimes a skin grafting was harvested from the patients’ thighs to apply it intra-orally. In recent dentistry, modern amenities are combined with a contemporary approach to prevent tooth loss.

Grafting for Dental Implants

The earliest traces of dentistry depicts bone grafting which included gathering of large quantities of patients’ bone. This horrendous process was known as autogenous graft. The impact of modern technology has changed the older method of grafting. Now, bones are harvested from animals and it is popularly known as Xenograft. Xenograft comprises natural bone mineral sterilized for several years. Guided tissue regeneration is a procedure through biochemical action, popularly termed as natural bone in grafting. Re absorption and replacement of patients’ bone occur with the progression of time.

Some common bone grafting involves

Socket graft or alveolar ridge preservation

Ridge graft is well-designed to fill the void and the empty space is filled with quality bone. It requires 3-6 months before implant treatment, depending on the size of the tooth. Xenograft is the material used for ridge preservation consisting of bovine bone. It is processed through a procedure of freeze-drying which contains only natural bone, mineral content and also renders as a sterile product. This product is applied after tooth extraction. Pledget collagen is used with one or two dissolvable sutures and it is retained to consolidate.

Block bone graft or autogenous ramus/chin graft

It is used in common etiologies such as

  • Bone loss due to dental trauma
  • When teeth are extracted without an immediate socket graft, implant/tooth re-implantation
  • The tooth is missing with extensive bone destruction due to cysts, tumours and or infections
  • Congenitally missing permanent teeth in the area of jaws due to supporting bone which failed to develop.

The autogenous graft is commonly used grafting procedure in the block form. In this procedure a small bone block approximately about 1 cm square is removed either from ramus or chin, then the bone is transferred to bone deficiency area, after that one or two tiny screws along with bovine bone particulate and membrane of collagen. Nearly 4 months is allowed for the graft to fuse to the jaw bone underlying before placing an implant. Once the mature graft is seen, an implant can be placed and it also acts as a support for the soft tissue which aesthetically resonates as well as maintaining hygiene is considered to be easy.

Sinus lift procedure or Subantral graft

It is performed to allow implants for replacement of maxillary molars and also in sinus a small window is performed above the maxillary teeth. The bovine bone is filled with a balloon-like space which is formed as a small cavity. Nearly 6-9 months is required for this bone to consolidate in order to replace a natural bone, forming a scaffold. There are 2 possibilities since this procedure relates to implant placement such as immediate placement of the implant with subantral grafting and delayed placement of the implant with primary subantral grafting.

Replacing missing teeth with dental implants involves grafting, which the dentist before performing the procedure must explain in detail. Any question asked from the patient regarding the experience of preoperative and postoperative procedures must be addressed in detail. The results are much effective and the outcome is best when the clinician has more knowledge about procedures of implant placement and also experience in placing it.

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

Dental Insurance in India: Tooth Matters

Dental Insurance in India: Tooth MattersDental Insurance in India: Tooth Matters

Oral health is probably still most neglected areas in Indian health. Cost of dental treatment is cited as one of the main reasons for its negligence and the expenses not being covered under most of the medical health insurances. There is just a lack of dental treatment insurance policies. However, there are some insurance companies who have started covering dental treatment expenses but to a limit. Dental insurance is insurance designed to pay the costs associated with dental care.

Dental and oral health in India

Fifty percent of school going children suffer from dental caries. Ninety percent of the adult population suffer from periodontitis and gingivitis. Tooth loss rate is greater due to periodontitis as compared to dental caries. Increased consumption of tobacco has increased prevalence of oral pre-cancer conditions and oral cancers. Oral cancer is a life-threatening condition and the available treatment modalities are expensive and are way beyond the reach of the common citizen. These can be prevented and controlled by public education and motivation to a significant level. Private fee for service is the only mechanism of payment for dental care in India and government hospitals and facilities providing treatment and care lack infrastructure, manpower, funds and hygiene. The major disadvantage of this type of payment structure is that many patients are unable to receive any care. Many NGO’s are also working but they also lack infrastructure, materials and funds. Government funds on medical healthcare in India is only 2% and out of this very few get for dental healthcare, as a result private dental care clinics are increasing.

Day by day dental graduates and specialists in India are increasing. Government has failed to provide job opportunities to them, resulting in private dental clinics mushrooming, and such facilities are beyond reach for a common man. To run a private practice also needs finance which cannot be maintained by keeping charges low; which means in India manpower is not less only cost of the treatment is the only issue regarding oral health care. Hence dental insurances can remove these barriers for oral health cares.

Why dental insurance is not common in India?

Our policy makers have given oral health last priority during National Oral Health Care Program. They are not aware of dental oral problems and its association with systemic health, that if not treated can be life threatening. Indian Dental Association (IDA) has failed to bring dental insurances policies in India, instead focussing on other off track work. Some private insurance companies have started covering dental expenses, but all these are not up to the mark and contain some serious shortcomings.

Also some private sector companies have started giving dental expenses to their employees with direct reimbursement plans. Under such schemes employees as a patient have the freedom to go any dentist they wish and present the bills of treatment done and employee will get some expenses reimbursed by the company. Companies are funding all these expenses because they know if small dental problems keep their employee home, companies lose their productivity. This however, is for a small percentage of the population. For the rest of the population, they still need proper planning and policies.

Types of dental insurances

In India

Stand-alone dental insurance plans

This type of plan covers the expenses related to general dental problems such as periodontitis and extraction of permanent teeth due caries. The amount of expense to be reimbursed as well as the period of such cover is fixed. Such insurances are provided by manufacturers like Pepsodent after buying their products.

Dental insurance cover as part of general health insurance plan

These are basically general medical insurances which cover some amount of dental expenses but not separate dental insurances. Some are shown in table with the types of coverage they provide.

In other countries

Indemnity plans

This type of dental plan pays the dental office on a traditional fee-for-service basis. A monthly premium is paid by the client and/or the employer to the insurance company, which then reimburses the dental office (dentist) for the services rendered. An insurance company usually pays from 50 to 80% of the dental office fees for a covered procedure; the remaining 20–50% is paid by the client.

Dental health maintenance organisations

They provide a comprehensive dental care to enrolled patients through their own fixed dentist. The dentist is paid on a per capita (per person) basis rather than for actual treatment provided.

Preferred provider organisations

If a patient takes a policy from a group of dentists, they get a discount as long as patient receives treatment from the particular group. If they wish to go out of the network dentists, they have to pay some extra fees.

Dental discount

The managing organizations negotiate with local dental offices to establish a set price for a particular dental procedure and offer deep discounts off the regular pricing code.

Benefits of dental insurances
  1. Oral health care can be available to every person from all socioeconomic levels and locations.
  2. Dental insurances can promote positive attitude in patients regarding oral health.
  3. Patients will visit their dentist regularly and preventive measures can be undertaken in the early stages. Patients will become aware of available treatment option to treat them. Ultimately dentistry is not expensive, neglect is.
  4. Basic preventive and few cosmetic treatments can be covered.
  5. Affordability and access will give everyone a good reason to smile.


There is great initiative still required from the government to initiate such policies. Private policy companies need to modify their schemes by thinking from a patient perspective and dentist perspective. They need to come up with separate dental insurances covering most of the expenses.

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

Obesity and Dental Caries in Children: Markers and indicators for Future Non-Communicable Diseases

Obesity and Dental Caries in Children: Markers and indicators for Future Non-Communicable DiseasesObesity and Dental Caries in Children: Markers and indicators for Future Non-Communicable Diseases

Globalization is bi-directional and has asymmetric manifestations in terms of health and wealth (Labonte and Schrecker, 2007). The health impacts of globalization include the rising levels of non-communicable diseases. (Huynen et al, 2005). The global epidemic of non-communicable diseases is responsible for significant mortality and morbidity; NCDs will be responsible to cause 73% of all deaths globally and 70% of all deaths in developing countries by 2020 (Gwatkin et al, 1999; Habib and Saha 2010). The major causes of deaths include ischaemic heart, cerebrovascular, respiratory, obstructive lung, cancer and diabetes diseases (Habib and Saha, 2010). The public health impact of NCDs is widespread and on the rise in developing countries. Majority of NCDs may start early in life, continue into adulthood and their consequences aggravate with ageing (Habib and Saha, 2010). ‘WHO Guideline for Sugars intake for adults and children’ reported that “Noncommunicable diseases (NCDs) are the leading causes of death and were responsible for 38 million (68%) of the world’s 56 million deaths in 2012. More than 40% of those deaths (16 million) were premature (i.e. under the age of 70 years). Almost three-quarters of all NCD deaths (28 million) and the majority of premature deaths (82%) occurred in low and middle-income countries. Modifiable risk factors such as poor diet and physical inactivity are some of the most common causes of NCDs; they are also risk factors for obesity – an independent risk factor for many NCDs – which is also rapidly increasing globally”. (2015)

Increasing prevalence of dental caries and other oral diseases parallels the trend of NCDs in developing countries. Inequalities in oral health continue to exist globally with rich countries witnessing a marked reduction in the experience of dental caries in children and young adults during 1970 and 2000 (Fejereskov and Kidd, 2008). However, in the developing countries, owing to the westernized diets, the consumption of sugar and as a result, dental caries increased during the same period (Watt, 2005). Oral health is affected by the same factors as those for general health (Hobdell et al, 2002). Oral health, similar to general health, depends on the conditions in which people live and the choices they make (Petersen, 2003). Oral diseases and other chronic diseases have “common risk factors” (Sheiham and Watt, 2000; Sheiham, 2005).

The rising levels of obesity and dental caries in children and the recent emphasis on life course perspective in the prevention of diseases underline the fact that comprehensive primordial prevention must begin in early childhood. Both obesity and dental caries are growing concerns in the developing world and can be regarded as markers for NCDs as they can manifest in early childhood (Hujoel, 2009). Furthermore, both fulfil the criteria stated for a condition to be identified as a public health concern (Daly et al, 2002).

Prevalence and severity of the condition

Both the conditions are widely prevalent. In India, one of every two 5 year old children (rural as well as urban) suffers from dental caries (National Oral Health Survey and Fluoride Mapping, 2004; Bagramian et al, 2009) and one out of ten children belonging to middle class parents (urban) is obese or overweight (Bhave et al, 2004). Dental caries may lead to severe pain and infections (Sheiham, 2005); whereas obesity may well be a determinant of life-threatening non-communicable diseases such as diabetes, CHD and a few cancers, which account for a majority of deaths (WHO, 2003).

Impact of the condition on Individual level

Dental caries in children affects children physically, socially and psychologically (Sheiham, 2006). Tooth decay also affects the quality of life: pain, impaired aesthetics, recurrent infections, eating and sleeping difficulties, emergency visits to dentists and hospitals, poor ability to learn, insufficient nutrition, and improper growth and development (Sheiham, 2005). Treating is expensive due to the direct and the indirect costs, e.g. time taken off by the parents (Sheiham, 2006).

The extreme levels of obesity may affect systemic functions and make an individual prone to a variety of health conditions apart from the psychosocial stigmatization the individual may face (Bhave et al, 2004).

Impact on wider society

The costs of treating non-communicable diseases including dental caries are enormous. Oral diseases are the commonest chronic diseases and are amongst the most expensive diseases to treat (Sheiham, 2005). Restoring decayed teeth remains well out of the reach of most countries due to the budgetary constraints; more than 90% of caries remains untreated (Petersen, 2005). Obesity and related NCDs burden economies, too. Diabetes alone may account for 2.5% and 15% of the total healthcare expenditure. For the age category 20–79, the global annual direct cost is likely to be over $153 billion and anticipated to double in 2025 (Habib and Saha, 2010).

Condition is preventable and effective treatments are available

Rich countries witnessed a marked reduction in caries in children during 1970-2000 (Fejerskov and Kidd, 2008); however, dental caries is increasing in developing countries due to increased sugar consumption and inadequate fluoride exposure (Petersen 2005).

Although there have been limited published reports of successful programmes pertaining to obesity prevention and management; obesity and related dietary causes have become a major focus of health policies in the Western World. Since 1998, the WHO has prioritized the prevention of NCDs and has developed strategies for monitoring, preventing and managing major NCDs with special emphasis on four major disease groups that share the same determinants and risk factors, such as the cardiovascular diseases, cancer, diabetes and chronic obstructive lung disease (Habib and Saha 2010).

Relationship between Obesity and Dental Caries in Children and Rationale for an Integrated Approach for Prevention

A systematic review of published literature between 1980 and 2010 addressing childhood obesity and dental caries with a random effects model meta-analysis reported a significant relationship between childhood obesity and dental caries (effect size = 0.104, P = 0.049) (Hayden et al, 2012). Another systematic review of published literature between 2005 and January 2012 did not find sufficient evidence regarding the association between obesity and dental caries; however, the review included studies on children as well as adults (Silva et al, 2013). Yet another recent systematic review of published literature between 2004 and 2011 pertaining to the body mass index and dental caries in children and adolescents reported that dental caries is associated with both high and low BMI; with socio-economic strata modifying the association. The authors advocated combined strategies to target both dental caries and obesity simultaneously (Hooley et al, 2012).

Evidence is emerging from the USA in terms of effective campaigns for wide-scale initiatives targeting environments in schools and beyond. Healthy study using a cluster design in 42 schools throughout the United States, School Nutrition Policy Initiative, a school-based obesity prevention program in Philadelphia, and Healthy Corner Store Initiative are a few examples (AHA, 2010). In the USA, the CATCH study (Child and adolescent trial for cardiovascular health) and the ‘Go Girls’ in African American girls have demonstrated that the eating behaviour of children can be influenced and they can be trained to be more physically active (Bhave et al, 2004). In Singapore; an 8-year school based initiative targeted at obese children was successful in reducing the prevalence of obesity (from a high of 16.6% in early 90s to less than 14.6%. In Brazil, a programme started in Sau Paulo, and because of its impact, now adopted throughout the country, ‘AgitaBrasil’, has demonstrated psychosocial, educational and physical benefits to children (Bhave et al, 2004).

It must be kept in mind that oral health is an integral aspect of systemic health and its isolation from the larger goal of achieving health can seldom meet success. Often oral health does not remain a priority of many health authorities, particularly of poor economies, as other health concerns need preferred attention (Yee and Sheiham, 2002). Furthermore, health messages in isolation may involve unnecessary duplication of efforts and may even create conflicts (Watt, 2005). The Common Risk Factor Approach identifies diet, alcohol, tobacco, physical activity, hygiene as the determinants of health; working on most of them is essential for oral health, too. Nevertheless, often the risk behaviours are clustered within the deprived communities and this could mean an opportunity to address various concerns together (Sheiham and Watt, 2000). This approach makes possible promotion of health with respect to those conditions that are perceived as higher threats (e.g. obesity, coronary heart diseases, cancer) while also covering the promotional aspects related to those oral conditions usually regarded as lesser threats (such as dental caries and periodontal diseases) by people.

So far, there has not been a national programme for the prevention and management of obesity in children. In different parts of the world, the concern is attracting recognition and a few public health campaigns have been run successfully.

Dietary Sugars and Body Weight: Systematic Review and Meta-Analyses of Randomised Controlled Trials and Cohort Studies reported that in adults, reduced intake of dietary sugars was associated with a decrease in body weight [0.80 kg, 95% (0.39 to 1.21); P<0.001]; increased sugars intake was associated with increased [0.75 kg, 0.30 to 1.19; P=0.001]; whereas in children, prospective studies on sugar-containing beverages, the odds ratio for being overweight was 1.55 (1.32 to 1.82) consuming higher quantities compared to those with the lowest. In a recent systematic review by Moynihan and Kelly (2014), Effect on Caries of Restricting Sugars Intake, 42 out of 50 studies on children and 5 out of 5 studies on adults demonstrated lower dental caries experience with free-sugars intake < 10% for energy (based on evidence of moderate quality), and significantly lower dental caries experience with free-sugar intake < 5% for energy (based on evidence of very low quality). An interventional study providing nutritional guidelines to preschools in Racife, Brazil reported that not adopting the guidelines on sugar-reduction was associated with a significantly high caries risk in children (OR: 3.6) compared to those in preschools adopting the guidelines (Rodrigues and Sheiham, 2000). Thus, there exists a potential for an integrated approach based on the provision of dietary guidelines to prevent obesity and dental caries in children. Reduced intake of dietary sugars was associated with a decrease in body weight [0.80 kg, 95% (0.39 to 1.21); P<0.001]; increased sugars intake was associated with increased [0.75 kg, 0.30 to 1.19; P=0.001]; whereas in children, prospective studies on sugar-containing beverages, the odds ratio for being overweight was 1.55 (1.32 to 1.82) consuming higher quantities compared to those with the lowest (Morenga et al, 2013).

Current Recommendations on Free Sugars and NCDs

The WHO, since 2002, recommended that sugars should make up less than 10% of total energy intake per day (WHO, 2003). In the “Sugar Guidelines” published in 2015, the WHO has proposed following recommendations:

“WHO recommends a reduced intake of free sugars throughout the life course (strong recommendation). • In both adults and children, WHO recommends reducing the intake of free sugars to less than 10% of total energy intake (strong recommendation). • WHO suggests a further reduction of the intake of free sugars to below 5% of total energy intake (conditional recommendation). • Free sugars include monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook or consumer, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates. • For countries with a low intake of free sugars, levels should not be increased. Higher intakes of free sugars threaten the nutrient quality of diets by providing significant energy without specific nutrients (3). • These recommendations were based on the totality of evidence reviewed regarding the relationship between free sugars intake and body weight (low and moderate quality evidence) and dental caries (very low and moderate-quality evidence). • Increasing or decreasing free sugars is associated with parallel changes in body weight, and the relationship is present regardless of the level of intake of free sugars. The excess body weight associated with free sugars intake results from excess energy intake. • The recommendation to limit free sugars intake to less than 10% of total energy intake is based on moderate quality evidence from observational studies of dental caries. • The recommendation to further limit free sugars intake to less than 5% of total energy intake is based on very low quality evidence from ecological studies in which a positive dose–response relationship between free sugars intake and dental caries was observed at free sugars intake of less than 5% of total energy intake. ”

The American Heart Association (2013) recommended “reductions in added sugars with an upper limit of half of the discretionary calorie allowance, which for most American women is no more than 100 calories per day and for most American men is no more than 150 calories per day from added sugars, or about 6 teaspoons of added sugars a day for women and 9 teaspoons a day for men. As a reference, one 12-ounce can of regular soda contains 140 calories (about 9 teaspoons) from added sugars, one 16-ounce bottle of sugar-sweetened iced tea contains 184 calories (about 11.5 teaspoons) from added sugars, and one regular-sized chocolate candy bar contains 120 calories (about 7.5 teaspoons) from added sugars”.

In a paper published in Nature: The Toxic Truth About Sugar, the authors Lustig et al (2012) claim that excessive sugar consumption results in all the diseases associated with metabolic syndrome; which include diabetes, hypertension, ageing, liver toxicity (similar to alcohol), etc. Following is quoted from the paper:

“A growing body of epidemiological and mechanistic evidence argues that excessive sugar consumption affects human health beyond simply adding calories. Importantly, sugar induces all of the diseases associated with metabolic syndrome. This includes: hypertension(fructose increases uric acid, which raises blood pressure); high triglycerides and insulin resistance through synthesis of fat in the liver; diabetes from increased liver glucose production combined with insulin resistance; and the ageing process, caused by damage to lipids, proteins and DNA through non-enzymatic binding of fructose to these molecules. It can also be argued that fructose exerts toxic effects on the liver that are similar to those of alcohol. This is no surprise because alcohol is derived from the fermentation of sugar. Some early studies have also linked sugar consumption to human cancer and cognitive decline. Sugar also has clear potential for abuse. Like tobacco and alcohol, it acts on the brain to encourage subsequent intake. There are now numerous studies examining the dependence-producing properties of sugar in humans. Specifically, sugar dampens the suppression of the hormone ghrelin, which signals hunger to the brain. It also interferes with the normal transport and signalling of the hormone leptin, which helps to produce the feeling of satiety. And it reduces dopamine signalling in the brain’s reward centre, thereby decreasing the pleasure derived from food and compelling the individual to consume more”.

The “Carbohydrate Hypothesis” has caught attention recently after the acclaimed publication: Good Calories, Bad Calories by Gary Taubes (2008). Two hypotheses “Carbohydrate Hypothesis” and “Lipid Hypothesis” were reported in 1970s explaining the causality of NCDs. The “Carbohydrate Hypothesis” proposed by Cleave and Yudkin, the fermentable carbohydrate intake was cited as the cause of coronary heart diseases and other NCDs. The dental diseases namely dental caries and periodontal diseases were considered to be related to the excessive fermentable carbohydrate consumption. In a contrary view, Keys postulated the “Lipid Hypothesis” stating that excessive dietary fat intake led to systemic diseases. The lipid hypothesis recommended a diet high in fermentable carbohydrate for overall good health, and dental diseases were considered as mere local side effects.

The lipid hypothesis attracted more popularity and the policy makers and the food industry responded positively to it. Several recommendations to regulate the intake of dietary fats over the last few decades of the 20th century, however, failed to make a significant impact in terms of reduction of NCDs (Hujoel, 2009).

The recent published work of Robert Lustig, Gary Taubes, Philip Hujoel and the revision in the dietary guidelines of WHO and AHA are the examples of increased acceptance to the “Carbohydrate Hypothesis”.


A bad diet for dental health is usually a bad diet for general health. Dental diseases can prove to be markers for unhealthy diets and NCDs that appear later in life (Hujoel, 2009). Thus, regulating the intake of free/ added sugars can be an integrated approach to improve health which may first manifest in reduction in dental diseases (particularly, dental caries) and obesity; and later the NCDs (Hujoel, 2009).


American Heart Association (2013) The American Heart Association’s Diet and Lifestyle Recommendations http://www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyEating/The-American-Heart-Associations-Diet-and-Lifestyle-Recommendations_UCM_305855_Article.jsp

Bagramian RA, Garcia-Godoy F and Volpe AR (2009) The global increase in dental caries: a pending public health crisis. American Journal of Dentistry 22:3-8.

Bhave S, Bavdekar A and Otiv M (2004) IAP National TaskForce for Prevention of Adult Diseases in Childhood: Obesity. Indian Pediatrics 41:559-575.

Daly B, Watt R, Batchelor P and Treasure E (2002) Essential Dental Public Health. Oxford University Press.

Fejerskov O and Kidd E (2008) Dental Caries- The Disease and Its Management. Blackwell Munksgaard Second Edition.

Gwatkin DR, Guillot M and Heuveline P (1999) The burden of disease among the global poor. Lancet 354: 586–89.

Habib, S H and Saha, S (2010) Burden of non-communicable disease: Global overview. Diabetes and Metabolic Syndrome: Clinical Research and Reviews 4: 41-47.

Hayden C, Bowler JO, Chambers S, Freeman R, Humphris G, Richards D and  Cecil JE (2012) Obesity and dental caries in children: a systematic review and meta-analysis. Community Dentistry and Oral Epidemiology 41 (4); 289-308. DOI: 10.1111/cdoe.12014

Hobdell, M H, Oliveira, E R, Bautista, R, Myburgh, N G, Lalloo, R, Narendran, S and Johnson, N W (2003). Oral diseases and socio-economic status (SES). British Dental Journal 194:91-96.

Hooley M, Skouteris H, Boganin C, Satur J and Kilpatrick N (2012) Body mass index and dental caries in children and adolescents: a systematic review of literature published 2004 to 2011: Systematic Reviews 1:57 http://www.systematicreviewsjournal.com/content/1/1/57

Hujoel P (2009) Dietary Carbohydrates and Dental-Systemic Diseases. Journal of Dental Research 2009 88: 490Hujoel P (2009) Dietary Carbohydrates and Dental-Systemic Diseases. Journal of Dental Research 2009 88: 490

Huynen, M T E, Martens, P and Hilderink, H B M (2005) The health impacts of globalisation: a conceptual framework. Globalization and Health 1(14): 1-12.

Labonte, R and Schrecker, T (2007) Globalization and social determinants of health: Introduction and methodological background (part 1 of 3).Globalization and Health 3(5): 1-10.

Ministry of Health and Family affairs, Government of India (2004). National oral Health survey and fluoride mapping (2002 -03).

Lustig R, Schmidt LA and Brindis CD (2012): The Toxic Truth about Sugar. Nature 482; 27-29.

Morenga LT, Mallard S, Mann J (2013) Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.e7492 (Published 15 January 2013)

Moynihan P and Kelly SAM (2014) Effect on Caries of Restricting Sugars Intake: Systematic Review to Inform WHO Guidelines J Dent Res 93(1):8-18.

Petersen, P E, Bourgeois, D, Ogawa, H, Estupinan-Day, S and Ndiaye, C (2005) The global burden of oral diseases and risks to oral health. Bulletin of World Health Organization 83(9): 661-669.

Rodrigues and Sheham A (2000) The relationships between dietary guidelines, sugar intake and caries in primary teeth in low income Brazilian 3-year-olds: a longitudinal study. International Journal of Paediatric Dentistry. 10 (1) 47–55.

Silva AER, Menezes AMB, Demarco FF, Vargas-Ferreira F and Peres MA (2013) Revista de SaúdePública 47(4) http://dx.doi.org/10.1590/S0034-8910.2013047004608

Sheiham A and Watt R G (2000) The common risk factor approach: a rational basis for promoting oral health. Community Dentistry and Oral Epidemiology 28:399-406.

Sheiham (2005) Oral health, general health and quality of life. Bulletin of the World Health Organization 83 (9): 644-645.

Sheiham A (2006) Dental caries affects body weight, growth and quality of life in pre-school children. British Dental Journal 201: 625-626.

Taubes G (2008) Good Calories, Bad Calories: Challenging the Conventional Wisdom on Diet, Weight Control, and Disease. Knopf. 2007.

Watt R (2005) Strategies and approaches in oral disease prevention and health promotion. Bulletin of the World Health Organization 2005;83:711-718.

World Health Organization (2015) Guideline for Sugars intake for adults and children.

World Health Organization (2003) World Health Organization Global Strategy on Diet, Physical Activity and Health- Obesity And Overweight

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

Alternatives to Rubber Dam Isolation technique

Alternatives to Rubber Dam Isolation techniqueAlternatives to Rubber Dam Isolation technique

Adhesive techniques are comparatively more sensitive than conventional ones. Here we will focus on atraumatic technique of restoring cervical abrasion-erosion and carious lesions. It is absolutely mandatory to isolate the operatory field to use an alternative placement of sequence in the dental rubber dam. The environment should be suitable enough to be visible, adequate space for instrumentation, easily accessible, moisture controllable for insertion as well as manipulation of dental restorative materials. It should be isolated from soft tissue and moisture including tongue, gingiva, lips and cheeks, blood, saliva and gingival crevicular fluid.

The aim of isolation

Control of moisture

During the operation, control of moisture is required to prevent debris restorative and hand piece spray from being aspirated by the patient. It refers in the operating field excluding saliva, gingival bleeding and sulcular fluid. The operative dentistry cannot be applied unless the moisture in the oral cavity is controlled properly for execution. Absorbents, suction devices and rubber dam help in controlling the moisture.

Access and retraction

This provides maximal exposure during the operation which includes maintaining an open mouth and retracting or depressing tongue, gingival tissue, cheeks and lips. Retraction cord, absorbents, rubber dam, mouth prop, high volume evacuator are useful for access and retraction. The restorative procedure cannot be managed with ease in case of improper access and retraction.

Prevention of harm

An important aspect to be considered is to prevent the patient from being harmed and members of health professions. The axiom taught is “DO NO HARM”, it is basically an awareness to prevent the patients from being protected from harm. The main aspect of prevention of harm along with retraction and moisture control are mouth props (occasional use), absorbents, suction devices and rubber dams.


Moisture isolation

Direct method

Rubber dam, cotton roll and holder, pieces of gauze, absorbent wafers, suction devices and gingival retraction devices.

Indirect method

Comfortable position and relaxed surrounding for the patient, local anaesthesia, muscle relaxants, antisialagogue and anti-anxiety medication.

Rubber dam

It has good visibility and adequate access to the operating field, patient protection and management.

History: On 15th March 1864, Dr Sanford Christine Barnum Connecticut valley, dental society.

Dr JF Hadson 1870, seven types of clamps, no forceps used.

Dr Tees 1870, festooned clamps

Dr Elliot 1878, designed clamp forceps

Ainsworth 1879, rubber dam punch

Dr Hickmans 1880, lipped clamps

In 1890, clamps with holes.

Rubber dam frame introduced a metal Fernald’s frame in early 20th century.


  • Access and visibility
  • Clean and dry operating field
  • Protects operator and patient
  • Psychologically more relaxing
  • Reduces risk of cross-contamination and objection by the patient


  • Minor changes in cervical cementum and marginal gingiva during clamp removal
  • Time consuming and patient willingness
  • Ceramic crowns may fracture in case of clamps, gripped to the margins
  • Metal crown margins show defects at a microscopic level following removal of the clamp


Bleaching, endodontic treatment and caustic chemicals.


In fixed orthodontic appliances, a newly erupted tooth has been found where the clamp does not retain due to physiological resistance and allergies.

Cotton rolls and holders

When rubber dam application is impractical, absorbent in case of moisture helps in minimally retracting soft tissues.

Manually rolled as well as prefabricated with smooth and woven maybe be employed.

Fluid absorbing materials:

Cotton rolls are used in association with anaesthesia will provide acceptable dryness for procedures such as examination, topical fluoride application, sealant placement, impression taking, cementation.

Cotton roll holders in which cotton rolls can be placed into position and with commercial devices stabilised withholding it.


Visibility and accessibility improvements in the working area and it provides more retraction.


It is time-consuming as it has to be constantly changed.

Techniques used for application

  • Maxillary anterior area isolation
  • Labial frenum on either side, a small sized roll is placed
  • Mandibular anterior area isolation
  • Mandibular labial frenum along with a lingual sulcus on either side small sized rolls

Absorbent Pads/Cellulose wafers

Dry aid/parotid shield

Silver dri aid: It reflects light for improved visibility in which laminated side prevents soak through it.

Gauze pieces

2” * 2” (5*5 cm)

The functionality is same as cotton rolls and also delicate tissue is better tolerated by it.

Evacuation system

There are two types of Evacuation system

  • High vacuum evacuation system
  • Low vacuum evacuation system

Debris and fluid evacuation equipment

High volume evacuation: Metallic autoclavable tips and disposable plastic.

Approximately 150 ml of water per second, it is also more efficient.


In the working site it removes shavings of the tooth and restorative material as well as other debris to remove the toxic material. Washing is avoided with intermittent rinsing and decreases the time of treatment.

Saliva Ejector

  • Metallic autoclavable tips
  • Disposable plastic


It is not directly in contact with tissues; saliva ejectors should be placed with their tips on the floor of the mouth.

Sweflex Saliva ejector

It is curved, flexible, efficient and comfortable as well as reduces aerosols with superior suction capability.

Indirect methods

Local anaesthesia reduces discomfort and makes the patient less anxious. It reduces sensitivity to stimuli and less salivary secretion is also observed.

Prescription Drugs

Though rarely indicated it, used for controlling bleeding of gingival with pain control medication.

Anti-anxiety drugs like valium – 5 to 10 mg, 30 min before.

Atropine (antisialogogues) – 5 mg, 30 min before procedure to reduce salivation.

Muscle relaxants.

Soft tissue isolation

  • Tongue retractors
  • Svedopter
  • Hygoformic saliva ejectors
  • Cheek and lip retractor

Lip retractor

  • Wire lip retractor
  • Oringer lip retractor
  • Simple lip retractor
  • Plastic lip retractor

Cheek and tongue retractor

Disposable spend ezz expanders: sizes small (green), medium (blue), large (red).

Dry field system: Red–pedo, white in colour adult, it is autoclavable at 280 degrees F, it is high heat plastic and silicone construction, it is for posterior restorations, sealants and ortho bandings.

Fast dam: It is used when applying sealants and 17 suction holes along the perimeter.

Mirror-vac saliva ejector mirrors: Ideal for sealants, bonding, air abrasion and other dry field procedures.

Mouth prop: It is used for relief of muscle pain, muscle fatigue and also for the relief of responsibility for adequate mouth opening. The prop ensures adequate constant opening of the mouth which permits multiple extended operations.

Gingival retraction aids: Retraction cords and gingival retractor collars.

Collars: Margins fully visible especially sub-gingivally, reduces chance of recession, better tissue control and helpful for physical retraction.

Gingiva retraction:

  • Physico-chemical means
  • Chemical-mechanical means
  • Electro-chemical means
  • Surgical means

Types of retraction cords:

  • Cotton, synthetic
  • Braided, twisted, woven
  • Coarse and fine
  • Impregnated and non-impregnated

Isolating materials are used for various reasons in the field of operative dentistry for better isolation during the treatment procedure. The rubber dam is one of the isolation techniques in endodontic cases, it is ideal for the treatment procedure of root canal system as well as restorative dentistry. It is considered as a boon and best isolating technique to use with comfort for all involved for better outcomes.


  1. Restorative techniques in paediatric dentistry – M.S Duggal
  2. Paediatric dental medicine – Donald Forrester
  3. Sturdevant’s art and science of operative dentistry – 7th edition
  4. Textbook of pedodontics – Shobha Tandon

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

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