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.”

Be A Super dentist: Understanding your patients

Be A Super dentist: Understanding your patientsBe A Super dentist: Understanding your patients

We live in an evolving world where life is all about change. This is no different for a dental practitioner. If practitioners run their practices in the same manner day after day, year after year; without inculcating a habit of constant up gradation, it’s going to take a toll on them in the long run. In this technological era, we need diverse set of skills to run a smooth practice.

A good dentist is well-versed, rather than well-trained to handle patients with zeal and passion. He works on intuition and looks at the practice in a new light each and every day.  In the 21st century, the dental practice is all about promotions, marketing, scoring high with patient conversions, swift ethical treatment along with fetching positive patient reviews. Besides expertise in dentistry one requires to have keen interest to analyze patient needs by stepping into their shoes.


To achieve this understanding one needs to have a growth mindset. When I say growth mindset it means ‘To be able to accept new ideas from people of the same domain and give out practical solutions to people who come to you for treatment, instead of following what you think is the safer conventional method’.

Our education system has a long way to go before we can analyze things in a broader light. Dealing with misunderstandings, delayed deliveries from dental labs, coordination with patients over the phone, scheduling appointments, creating scope for continuous professional development, how to build a good clientele. All these require an exceptional behavior and patience from the dentist.

When I started my practice in Mumbai eight years ago, I was an amateur and expected thing to work my way. But with time I realized the importance of working smart, rather than working hard. Maintaining a balance between my household responsibilities and the dental practice requires time management, support from family members and patients. But of all the skills that I had, I wish I had a good understanding about growth mindset.


During my struggling days, I met some great people on my way to self-improvement. I realized that I need to change my perception to ameliorate my career. Initially, I was struggling with life and working in a team was a giant task for me.

Our education system does not teach us the importance of teamwork and solely revolves around ‘me’ rather than ‘we’. The conventional education system did not teach us how to create a win win situation in our practices. However, these days we can see a change in pattern. The dental education system has started emphasizing on practice management as a serious subject of concern. With the use of smart technology, where students can discuss their ideas in the open forum the present generation are well equipped to market themselves well.

So what is growth mindset?


Enhancing your handskills skills regularly and working in a team are required to be a successful entrepreneur. To stay in your cocoon and never be a part of self-development is a fixed mindset. The transformation must happen from within. If we change this fixed to a growth mindset, the possibilities are endless that allow us to excel in our business.

There are many instances in practice where an open mindset or growth mindset can help you. The behavior of dentist with growth mindset is entirely different from that of a person with closed or fixed mindset. Attitude of a dentist with growth mindset is similar to fearless trader. These kinds of individuals can easily step into patient’s shoes and read their minds. Dentists with growth mindset are keen to learn, ready to evolve everyday and this makes a practitioner happier, interesting and appealing to the public. A dentist with a growth mindset can never settle with being a mediocre.

The aura, ambience, method of practice in a clinic solely depends on how happy you are and how confident you sound to your patients. If you encourage all your clinic staff to build a growth mindset it’s going to help everybody around you grow. To accept, adapt and evolve is what we call growth mindset.

Having a growth mindset is crucial to be a good marketer and helps you in marketing yourself well.

What is marketing? How is it useful for a dental practitioner in the 21st century?

Various actions taken to promote or sell products and services along with research and advertising is called Marketing.

Advantages of marketing for dentists:

  • Helps increase number of patients as you become more popular.
  • Improves your visibility among people with little knowledge on the subject.
  • Makes dentistry interesting and economically viable profession.
  • Gains are realized within a brief period of time.

There are four pivotal parameters we take in consideration when we talk about marketing. In short, we call them the marketing mix. This applies in dentistry to the core.

1. Product

Here dentist should clearly define the services available and his/her strengths to the patients(audience). This will help to gain clarity when they speak in public about their practice. Gives more confidence to the practitioners during consultations, dental camps, online marketing or webinars. Since they are sure about their  products and services.

2. Price

The price of treatment services should always be at par with market prices. For example, if a root canal in your vicinity costs about Rs 3500 for manual RCTs and Rs 5000 for rotary endodontics. However, you wish to charge Rs 5500 for manual RCTs and Rs 7000 for rotary endodontics as you claim your work is better than other dental practitioners; it will not help you gain popularity in patients. Prices should be more or less in par with the dental practices in your locality.

3. Place

Being at the right place at the right time to promote your practice is essential to grow your patient flow and the brand name of your practice. As a practitioner, I have recommended my boss to sponsor certain events at a very low budget in the area, to get noticed. The place where we market will solely determine the kind of patients we attract in the future.

4. Promotion

There are many ways we can come up with packages for various age groups to improve walk-ins. Tracking reward points in the software, giving out loyalty coupons, advertising group packages for treatment and giving offers all come under this marketing sector of dentistry. Use of banners, coupons, flex boards in various locations around your practice can help you sustain the competition.

What is Holistic Marketing?

The word holistic stands for ‘whole’. Though the responsibility of running a business comes under the hands of one proprietor the task of running the practice should be divided into various departments. It’s for this reason, using strategies from marketing gurus like Philip Kotler and Kevin Lane Keller is very important to become a super dentist in today’s world.

Holistic marketing constitutes of

  • Internal marketing
  • Relationship marketing
  • Integrated marketing
  • Performance marketing

What is internal marketing?


Internal marketing literally means training and development of your staff. Teaching them to effectively communicate with patients and making them familiar with the dental business. It involves training them to actively involve in your practice toward creating a brand image. Internal marketing is simple but vital for the sustenance of a dental practice.

Some examples of internal marketing in dental office are:

  • Training them to engage patients in conversations which helps them cooperate. Especially on days when you have bulk appointments placed for specialists.
  • Interacting with your staff in friendly manner create a feeling of self-belonging. Help them to improvise their work from time to time.
  • Provide some assistance in educating receptionist and other dental staffs.
  • Maintain a peaceful clinic ambience on a daily basis and never losing a patient..
  • Giving timely incentives and appraisals for their extra efforts.

There could be many ways you want to improvise your practice and all these methods are a part of internal marketing. If your own team is on your side, success is guaranteed.

2)  What is Relationship marketing?


Relationship marketing stands for creating a long-term relationship between the practitioner and patient in the dental practice.  It involves building mutual satisfaction with patients to get more leads or new patients. This helps in retaining the patients successfully.

Loyalty coupons, premium memberships and reward points can be given to existing patients to build long-term relationship.

3)  What is Integrated marketing?

The mode of developing new products and communication. Creating new channels to develop brand awareness in public is termed as integrated marketing. Making your clinic linked with the top brands in the country.

Example of integrated marketing would be to have a tie-up with businesses like insurance companies which provide the loan to patients to avail treatments. Example Bajaj Finserv, Capital Float and Religare.

There could also be tie-ups with oral healthcare care product manufacturers like Colgate, Oral B etc. Display products in clinics and sales promotion could attract a lot of patients to walk into your practice. This benefits the dentist too when we sell products for a good margin, as well as the companies benefit from the brand promotion. Creates a win win situation.

4)  Performance marketing

This is an extremely innovative method used by brand marketers to reach number of people who can be useful to dentists to advertise their practices and sell products. Gives one the ability to measure everything from brand reach to tracking conversion rate in a single advertisement. It’s easy to track with minimal risk when it comes to advertising via social media.

This also includes knowing your competitors in your area of practice. Tracking their success and information for survival in dental market.

I shall be discussing this in detail, in my upcoming articles for DentalReach.

Marketing opens means to generate more patients apart from mouth to mouth publicity which dentists have been relying on since ages.

Tips to improve your marketing skills as a practitioner:

1)  Gauge your market value in today’s competitive world:

google scholar

The new era is for multi-talent and there are always multiple ways to learn new skills in dentistry. For instance, if a general practitioner would like to learn about rotary files and use of endomotor in his practice, nothing should stop him.

There are many practitioners who are making good amount of revenue based on the maximum number of skills they can use in their day to day practice.

Unfortunately, when a dentist passes out of MDS from a reputed colleges they are fed with the fact that they can just handle a certain type of cases. The stereotypical nature of the college staff gets into their blood for years together. It takes a while for them to come to reality. For example, a surgical case is supposed to be handled only by an oral and maxilla facial surgeon. A root canal can be performed only by an endodontist.

This in turn, brings down your demand in the market of dentistry. Is this what you want to happen to you?

Jobs get scarce and you again need to plan to get another degree to specialize in each one of these skills. The cycle never ends. Unless you decide to take the risk and start learning new skills. Being an all-rounder is all that it takes to win a number of patients into your practice.

2)  Have a look at your career graph:

journal of dentistry

What you did yesterday, shouldn’t be what you are today? Improve in all aspects like the salary you draw, standard practice you work in, number of complicated cases you handle in your career, way you engage your dental supporting staff, all these enhance your career.

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The career graph can vary for every single individual. But the pointer should always move up with every year we approach in our practice. For instance, this year I have learnt to take in patients for flap surgery confidently and after six months I’m going to place implants myself.

I have a Facebook page for my clinic, coming years I need to have my own website. This kind of approach at a very early stage of establishing a practice can take you to heights very soon.


3)  Make sure your patients love your services:

dental treatment videos

This is crucial in the competitive world of dentistry. It’s also a part of internal marketing as I discussed earlier. In the current scenario, patients have wider options ahead of them at the click of a finger. But the dentists with the highest number of stars and honest reviews from patients get the benefit. When I say ‘love’ it literally means loving to come to you for every appointment. The goal of every dentist should be to be able to win the patients mind when it comes to comfort, approachability and enjoying the ambience of the clinic. A small investment on a music system, or a fish tank with multiple things in it, a good library in the reception area, having a well-trained staff can go a long way to help them engage themselves in your practice.

4)  Understanding patient psychology

This is a wide area of discussion and has many aspects to it. However, I can bring it down to one simple concept, that is a chart from Maslow’s hierarchy of needs which stands true for any business.

dental treatment videos

To convert your patients into a treatment in the first meeting, categorize the patients into the following sections. Psychological, Security, Social, Ego, Self-actualization. The fact that different people have diverse needs, and you realizing it before they even say it, this is what will help you escalate your practice to another level.

Now based on their needs they can be divided into 5 categories. Here I can take you through the lowest to the highest for dental patients.


They can nowhere afford a day’s meal or pay for their child’s school. Et they want help from you as a dentist as they are in pain. Here it makes no sense to explain all kinds of options of treatments and come out with your catalogue. However, if the patients are interested to know we should explain all the treatments with due respect.


These set of patients do have some means to fulfil their basic requirements and have planned ways to get treatments done through insurance or pension schemes. All options should be provided for such patients since they take time to decide what treatment can be done now and what can be planned for some months later. However, these set of individuals shouldn’t be over burdened with the heavy dental treatment. Instead, talking to them about the treatments one by one will benefit them a lot.


These set of patients have all the money and resources but are very cautious and knowledgeable people. They can ask you a multiple number of questions and will still never do the treatment. Yet they do return if they are fully gratified with your suggestions in comparison to the next dentist they just visited to cross check what you said stands true or not.


These set of patients come to you just because they were referred from other patients who had already taken treatment from you. They may just be convinced even before you try convincing them. But you need to make sure you charge uniformly for all these set of patients. Time is a big factor for these patients to be kept under consideration.


These set of patients according to me are the best suited to understand any kind of treatment planning and will go to any extent to know what problems they have. Finance should never be a problem for these set of patients. They are knowledgeable and undoubtedly the loyal kind of patients who will turn up for the treatment and yes, they need that VIP call for their appointment scheduling since they have many things on their priority list.

5. Prove your worth in the first meeting

The old saying ‘first impression is the best impression’ has a lot to do with building a good clientele. The body language of the dentist, the persona and the management skills go hand in hand to build a comforting feeling in the patients.

6. Respect one’s time

One should keep a watch on the time allocated for a treatment to get to the next patient who is equally important and needs attention in the peak hours. If in case there must be a delay, the dentist is always advised to take a quick walk around his reception to greet the patients in person and let them know you will be calling them in any minute. This reduces patient anxiety in the waiting area and patients respect it if you care for their time. Unlike, cardiac or general medicine, dentistry is a field that is taken for granted by people. Until the dentist starts the treatments on day 1 the patients are never inclined to the dentist.

Remember the saying from the great orator Shiv Khera-‘Winners don’t do different things, they do things differently’.

This is just what we need to understand in our practices worth crores of rupees today. These ideas and principles in my practice have always lead to success and I’m sure it will help you too.

Practice management is a major topic of discussion in many forums today and deserves your undivided attention. DentalReach is going to bring forth many such articles which will help you improvise your practices and help you enjoy being a dental practitioner for the next few decades.

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

Top 10 Dental Movies

Top 10 Dental MoviesTop 10 Dental Movies

Looking for binge-watching some great dental movies or movies with dentist characters? Allow me! Here is the list of the top 10 dental movies of all time.

1) The Great Moment, 1944

It is a biography of Dr William Thomas Green Morton, a 19th century Boston based dentist who tried to get accepted as a surgical anaesthetic. The movie shows fear of dental pain among public and the quest of Dr WTG Morton to provide painless dental extractions to his patients. On September 30 1846, Morton successfully performed a painless tooth extraction. This was followed by a demonstration of operating theatre at Massachusetts General Hospital on October 16, 1846. Dr John Collins Warren painlessly removed tumour from the neck of a patient. This movie will instil a sense of gratitude for the current era of painless surgeries effortlessly done by pioneer dentist like him.

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2) Eversmile, New Jersey, 1989

It depicts the story of a travelling dentist, Dr Fergus O’Connell who works for a foundation based in New Jersey. He offers his services free of charge to rural population of Patagonia, South America. The movie shows the ignorance towards dental health and its barriers faced by dentist to spread oral hygiene. Dr Fergus’s glowering expressions on seeing someone eat candy is certainly enough for him to quit candy forever. It was quite impressive that they managed to convert a bar into a dental clinic to perform an auto transplantation of a wisdom tooth into an edentulous space of recently extracted missing molar. The bike being repurposed into a makeshift dental chair setup reminded me of mobident that provides door to door dental services.

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3) The Dentist, 1932

This slapstick comedy movie deals with an unsociable and forgetful dentist, who deals with his patients unconventionally, runs his clinic in the house and share memories with his disobedient daughter. Various patients with unusual physical traits such as a tall “horse” faced woman, a tiny, heavily-bearded man arrive at the office and he attempts to use his dental drill on them without any apparent painkiller. With one of his patients, he engages in an intimate wrestling match. A lighthearted movie that will teach you the things NOT to do in your dental practice.

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4) Charlie and the Chocolate Factory, 2005

It is the second adaptation of Roald Dahl’s classic book. This movie is about Charlie Bucket, a poor boy who lives near Wonka Candy Company. While the movie is about Charlie, star of the movie is Johnny Depp’s supremely weird character Willy Wonka, the candy company’s owner. And the reason for his odd behaviour? You guessed it right, an overbearing dentist father, Dr Wilbur Wonka denying his young son candy because of the potential risk to his teeth. Don’t be harsh with your kids or they will run away and consider family a hindrance in pursuing their dreams. This is the message conveyed by the movie.

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5) The Hangover, 2009

When four friends travel to Las Vegas for a bachelor party of their friend Doug’s upcoming marriage, things quickly go out of control. Doug’s hilariously strange future brother-in-law, Alan played by Zach Galifianakis gave them drugs in hopes of a better night. Dr Stuart “Stu” Price, played by Ed Helms is a dentist, the normal one among his group of insane friends. Being a dentist does not ensure safety from dental injuries. Stu performs an extraction on himself to defend his honor as a dentist on being bet that he couldn’t perform an extraction.

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6) Horrible Bosses, 2011

This movie depicts the story of three friends and their delightfully nasty tale of resentment, desperation and amoral revenge against their “horrible bosses”. One of the titular bosses, Dr Julia Harris aka Man-eater played by Jennifer Aniston. She is a dentist and frequently assaults her dental assistant, Dale, played by Charlie Day. Dale and his two friend’s team up to murder their respective abusive bosses and things go horribly wrong. Homicide is probably the worst option to deal with a difficult boss.

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7) Thumbsucker, 2005

The movie focuses on teenager Justin Cobb as he copes with his thumb-sucking habit and low confidence. Justin’s orthodontist, a mystical-hippie person played by Keanu Reeves tries to help him overcome his adverse habit. During his final checkup, Dr Lyman reveals to Justin his discovery that thumb-sucking is not a medically debilitating problem but says that everyone has their own flaws and nobody has all the answers. Good one! Dr Lyman. Wonder if this answer will convince our examiners during viva!

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8) Rudolph the Red-Nosed Reindeer, 1964

It is a television Christmas special released on December 6, 1964 depicting the story of Rudolph, a reindeer who is bullied because of his red nose. Meanwhile, Hermey one of Santa’s elves dislikes making toys and wishes to be a dentist instead of a toy maker. This outrages the elf foreman and other elves chastise him for his interest in dentistry. Despite this Hermey continues his studies. This movie gives a rare glimpse of dentistry as a positive profession. As dentists, we acquire skills to pull out teeth, which can always be used to defeat the bad guys and save the day!

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9) Finding Nemo, 2003

A Sydney based dentist Dr Philip Sherman captures Nemo and adds him to the collection in his dental office fish tank. He is supposedly going to gift Nemo as a pet fish to his nasty niece who terrifies the fishes. Nemo along with the Tank Gang devise an escape plan. The dental expertise shown by the aquarium inhabitants while watching the dentist performing RCT is amazing! This movie shows another psychotically weird child related to a dentist, reinforcing the point that dentists apparently pass on cruelty to their progeny?? A food for thought…

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10) Talvar, 2015

The story revolves around the mysterious murder cases of a teenager and the domestic help, who worked at her place. The film is based on the real life 2008 Noida Double Murder Case, in which 14 year old Aarushi Talwar was found, murdered at her home. The family’s missing 45-year-old servant Hemraj was initially sought for the murder, until his dead body was discovered in another part of the building on the following day. The parents, a dentist couple were convicted for the crime. The film showcases three perspectives to the case which emerge as the investigation moves forward, portraying the parents as guilty or innocent. The movie depicts how office politics and grudges held by a dental assistant can prove to be dangerous. Beware! Treat them right.

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

Chemotherapy agents and dentistry

Chemotherapy agents and dentistryChemotherapy agents and dentistry

Chemotherapy is a type of treatment given to cancer patients who are under medication in order to overcome a particular ailment. This treatment involves chemical substances like cytotoxic and other drugs may be used. Chemotherapy is given to alleviate the symptoms and control cancer that has spread. Patients should be aware of the dental treatment after chemotherapy to avoid any major problems. Dentists should be careful about the dental treatment after chemotherapy for the cancer patient.


Chemotherapy agents are divided into many groups depending on several factors such as:

  • Mechanism of action
  • Cell-specific types
  • Formulation
  • Relationship to the different drug

Chemotherapeutic agents consist of five classes:

Mitotic Inhibitors: It is derived from compounds and plants in phase of cell cycle by stopping mitosis as it can damage cells for reproduction. Some of the mitotic inhibitors are vincristine, vinblastine (vinca alkaloids), taxotere, taxol (taxanes) and ixempra (epothilones).

Anti-tumour antibiotics: It is used to treat infections and cells of DNA. Group of anti-tumour antibiotics agents are daunorubicin, idarubicin, epirubicin, adriamycin. There are some other types of anti-tumour antibiotics drugs such as bleomycin, actinomycin- D, mitomycin, mitoxantrone.

Topoisomerase Inhibitors: Specific type of enzyme interfered by drugs known as topoisomerases. During S phase, it helps for strands of DNA to separate cancer cell propagation enzymes inhibitors which prevent DNA replication. Topoisomerase inhibitors consist of irinotecan, topotecan and topoisomerase ii inhibitors which consist of teniposide and etoposide. The risk of acute myelogenous leukaemia has topoisomerase ii inhibitors after 2 to 3 years.

Antimetabolite: The normal building blocks of DNA and RNA in which antimetabolites interfere. During S phase antimetabolite damage cells and use to treat ovary, breast and gastrointestinal tract cancer. Some antimetabolite are is hydroxyurea, methotrexate, floxuridine and fludarabine.

Alkylating agents: It is used to treat cancers like leukaemia, sarcoma, lung cancer, lymphoma, Hodgkin disease as it damages DNA directly and in all phases of cycle. Alkylating agents are triazines, nitrosoureas, nitrogen-mustard, ethylenimines and alkylating sulfonates.

There are other agents like cytokines, corticosteroids, monoclonal antibodies and biologic medications. Corticosteroids help to avoid hypersensitivity reactions, nausea and vomiting for treatment with radiation and chemotherapy. Biologic therapy involves some substance which is extracted from living organisms. It has developed for disease like cancer in order to target specific types of cells. Some vaccines or bacteria are used to trigger immune system, these are also known as biologic response modifier therapy. There are other therapies of biological type like genetic material DNA, RNA and antibodies.

Chemotherapy side effects

The side effects of chemotherapy are mucositis/stomatitis, mucosal ulcerations, xerostomia, fungal and bacterial infections. Patients who undergo chemotherapy may also suffer from oral complications from the ailment and the treatment. It mainly affects oral mucosa and bone marrow. It is used individually or with another aspect of antineoplastic treatment with palliative combination. The combination may arise with immunosuppressed state of patients and ulcers may occur in a span of 2 weeks after chemotherapy. Patients with advanced cancer are commonly used as the stimulant and it may help in relieving pain. Severity of mucositis is caused by alkylating agents and antimetabolites suffering from advanced stage of cancer.

During the treatment, dividing cells are affected and normal cells are also involved. (Technically not making sense) Chemotherapy depends on location, type and dosage of treatment which varies from person to person. These also include nausea, loss of appetite and hair, sexual dysfunction, diarrhoea, pain, fatigue and constipation. It affects both peripheral and central nervous system, which could linger and last for long durations. Sometimes these side effects could be permanent.

Healing of lesions takes nearly 2 to 4 weeks after the last chemotherapy dose. Status of oral mucosa and changing peripheral blood counts have a direct relation, as it appears to be affected by chemotherapy. Neutropenic ulcers are seen in the case of severe neutropenia. When there is a chemotherapy treatment undergoing by agents secondary to xerostomia, it leads to rampant decay and affects teeth cementoenamel junction (CEJ). Patients with low white blood cells are more prone to fungal and bacterial infections. There is strong relationship between oral cavity, sepsis and bacteremia for myelosuppressed patients.

Chemotherapy management: Patients with dental problems undergoing chemotherapy prerequisites (Unable to understand) a focus on medical history prior to treatment initiation. During treatment, patient’s age has a strong influence on overall health fighting against cancer. The psychological impact upon them has to be recognised in suffering patients as it relates to perception and attitude.

Acute infection must be first considered by dental practitioners. Patient who is under chemotherapy medication or about to begin must be addressed to practitioner since there are areas of potential spread of infection.

Maintenance therapy must be monitored by a dentist and recalled frequently not only to those who have better healthy dentition, and also for acute diseases. Oral prophylaxis and root planning must be taken, good initiative care in the maintenance therapy stage. Patients whose system are recovered from the effects of chemotherapy must delay undergoing elective and cosmetic services. Radiation therapy of head and neck for the patients suffer from cervical caries, so the use of customised fluoride trays helps reduce the degree of impact in the oral cavity.

The chemotherapy agents have a great influence and closely related to the field of dentistry. Every dental practitioner during the course practice will come across patients with one or more who are suffering from cancer. Chemotherapy is included in the combination of treatment presently available for the disease treatment in the course of a lifetime. These agents are complex and also targets with the sophisticated mechanism of action when they are directed. In the field of dentistry is advancing through research to render for better service by enhancing the knowledge with experience and skills by the dental practitioner.

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