Dental Caries-Part 2: Treatment Planning

In this chapter, you will know about the treatment planning of dental caries. In previous chapter you studies the etio-pathogenesis and clinical characteristics of dental caries. If you have not gone through it, it is advised that you study the previous chapter before proceeding further.

Mechanism of Remineralisation of Enamel

When the oral environment of a person is favourable where the pH is above 5.5 and saliva contains enough calcium and phosphate ions, the remineralisation process of enamel occurs. The supersaturated saliva acts as driving force for remineralisation. In a non cavitated enamel caries lesion, the original crystalline structure of rods remains intact. When it is etched, it acts as nucleating agent for remineralisation. When trace amount of fluoride ions is added to the environment, it enhances the remineralisation process by enhancing the precipitation of calcium and phosphate. The inclusion of fluoride ions results in the formation of fluorapatite crystals in enamel rods which is more resistant to acid attack compared to calcium apatite of the natural enamel rods. Thus, the new enamel becomes resistant to caries process. 

Dental Caries-Part 1: Etio-pathogenesis and Clinical Features

This lesson presents basic definitions, terminologies, etiologies, demineralisation-remineralisation of enamel and clinical characteristics of the caries lesion in the context of clinical operative dentistry. 

Definitions of Dental Caries and Dental Plaque 

Dental caries is defined as a multifactorial, transmissible, infectious oral disease caused primarily by the complex interaction of cariogenic oral flora (biofilm) with fermentable dietary carbohydrates on the tooth surface over time.

Dental plaque is a gelatinous mass of bacteria adhering to the tooth surface. Carious lesions occur only under the plaque. The plaque bacteria metabolises the refined carbohydrate (sucrose mainly) for energy production and produces organic acids as a by product. These acids cause dissolution of crystalline structures of enamel that result in caries lesions of the tooth.  

Seven Ways to Prevent Dental Caries in Your Child

Dental caries is an endemic disease in children. It is caused by a bacterial infection. The causative bacteria are known as Streptococcus Mutans and Lactobacilli.

Although the dental caries is caused by bacteria, the initiation and progression of dental caries depend on several factors. The less the risk factors present, the less are the chances of dental caries development in your child’s tooth.

I shall discuss those factors for you so that you can understand the developmental process of dental caries and take appropriate measures to prevent developing it in your son’s or daughter’s mouth. Broadly, we can categorize a child belonging to either high risk or low risk category. The children of high-risk category have higher chances of developing dental caries compared to those of lower category.

The rampant caries develops rapidly in young children and involves all anterior teeth within a very short period. Early intervention may prevent its development. So, my advice to you, visit a dentist when you see his/her first tooth. 

Sign of rampant caries: Note caries in all teeth 

The factors that determine the risk category of a person are as follows: 

1. Social factors 
2. General Health Factors 
3. Dietary factors 
4. Preventive Factors 
5. Plaque factors 
6. Salivary factors 
7. Clinical factors 

  

1. 1. Social Factors 
   

   A socially deprived or isolated child with frequent snacking habit, irregular dental visits, siblings having dental caries, with parents having little knowledge of dental disease, will be at higher risk of developing dental caries compared to the child who is not having the above-mentioned factors. You should always try to remove and maintain these factors at low level to keep your child in low category. 

2. 2. General Health Factors 
   

   If your child is medically compromised, disabled, having xerostomia or on long term cariogenic medicine, s/he is at higher risk of developing caries. The lesser number of factors present with your child, the risk of developing dental caries is less. If your child is having any of these factors, help him/her to remain in the low-risk category by visiting a dentist. 

3. 3. Dietary Factors 
   

   The most important factor is frequent intake of sugars. As the frequency of sugar increases, the risk goes up. So, encourage your child to reduce the frequency of sugar intake. For example, you can give him/her two chocolates/candy instead of one and encourage him/her to eat them all together. Afterwards, you can clean his/her teeth off of sticky chocolates/candy. 

4. 4. Preventive Factors- Uses of Fluoride/CPP-ACP 
   

   If your child is living in a non-fluoridated area, with no fluoride supplementation and using non-fluoridated toothpaste, s/he is at high risk. Living in an area supplied by fluoridated water, or using fluoride supplement or using a toothpaste containing fluoride decreases the risk of caries development. 
   The newly developed protective material Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP), a milk derivative helps in remineralization of the carious lesion by replenishing lost minerals like calcium, phosphate ions into the tooth structure. Using a toothpaste containing CCP-ACP will remineralize the enamel of your child and make it more resistant to caries development. 

5. 5. Plaque Control Factors 
   

   If your child does infrequent or ineffective tooth brushing s/he is at higher risk. Teaching him or her regular and effective tooth brushing to remove plaque. This habit decreases the risk of developing tooth decay. If s/he cannot perform effective tooth brushing, help him/her. 

6. 6. Salivary Factors 
   

   Low flow of saliva, low buffering capacity of saliva and higher Streptococcus Mutans and Lactobacilli count in saliva put your child in a high-risk category. Removing these factors with the help of a dentist will shift your son/daughter into the low-risk category. 

7. 7. Clinical Factors 
   

   New carious lesions, premature extractions, caries or restorations (fillings) in anterior teeth, multiple restorations, history of repeated restorations, no fissure sealants, multi-band orthodontics and presence of partial dentures increase the risk of caries development and put the child in high risk. As these factors decrease, the child moves from high to low-risk category.

8. 
   

Conclusion 

So, now you know the causes that may put your child at high risk for developing dental caries. I advise you to understand these factors and take appropriate action. The first step you must take is to start using a toothpaste that contains either fluoride or CCA-ACP. Also, plan for and have your child get checked by a dentist. 

Oral Malodour / Foetor / Bad Breath / Halitosis

Halitosis is a common social condition that affects a considerable portion of the general population. The prevalence of halitosis is close to 50% in a few populations. Under few circumstances, this oral condition may cause embarrassment, depression and make relationships more difficult. Some studies have investigated whether the psychology of the patients might have some influence on the complaints about halitosis, or even on halitosis itself. In a study that included more than one thousand participants and self-reported halitosis, scientists have reported that poor oral hygiene and general anxiety are associated with halitosis.[1]

Halitosis is divided into intraoral, extraoral, pseudohalitosis and halitophobia. Intraoral halitosis, responsible for 85% of the cases of halitosis, is subdivided into physiologic (genuine) halitosis or pathologic halitosis. Extraoral halitosis occurs when malodor appears with no oral cause, as in the case of pulmonary causes. Both patients with pseudohalitosis and halitophobia present with complaints of halitosis, but without any diagnostic evidence of malodor.[1]

The most common cause of oral malodor is the poor oral hygiene. Due to poor oral hygiene, a large number of bacteria belonging to different species make their home in the mouth. They survive on the food particles entangled in between the teeth and as a by-product, produce different substances like Sulphides, Mercaptans and Amines in gas form. These gases are perceived as bad breath by other people.  

Basic Reason of Fear in a Four Years Old Child Who is Aggressive in Dental Office

The quality of dental treatment of a child depends on one's cooperation and repo with a dentist in the treatment room. How a dentist manages a child depending upon the understanding the child's behaviour pattern.  

There are certain guidelines that are useful in helping a child to show a positive & compliant behaviour while getting the dental treatment. These guidelines have been prepared from the findings and principles of behavioural dentistry, behavioural psychology, developmental psychology, and paediatric psychology. 

Can Alginate Be Used As Muco-Compressive Impression Material?

The alginate impression material cannot be used as muco-compressive material. This material does not have consistency enough to apply pressure on mucosa. Therefore, muco-compressive impressions cannot be taken by alginate.

The muco-compressive impression can only be taken by impression compound or heavy duty (putty) rubber base impression materials as they both have thick consistency.

What is best during placement of Crown?

A ceramic crown being placed over a tooth. The excess cement is protruding at margin [1].

The placement of crown is an important step in the longevity of the crown and the comfort of the patient. There are certain points that should be taken into consideration by a dentist during placement i.e. cementation.

The gingival margins should not be inflamed at the time of crown cementation. This may happen due to gingivoplasty or crown lengthening. For a common man, it means, the gum margins of the tooth receiving the artificial crown should not have redness, swelling or puffiness. If there is any, better to wait till it subsides.

The choice of cement/luting agent should be decided based on the type and material of the crown. The available materials are Zinc phosphate, Glass ionomer, Polycarbonate, Zinc silicophosphate, and resin luting agents. The anterior crowns need different cementing material than that of posterior crowns. The all ceramic crowns are best cemented by resin luting agents, but the use is limited to the cementation of anterior crowns. The reason is, after cementation, it becomes extremely difficult to remove set resin from the interproximal area of posterior teeth. Rest luting materials are brittle enough to break and remove, therefore, they can be used in all areas-anterior as well as posterior.

1. ADC Examination: Initial Assessment Process Explained

The ADC examination process along with initial assessment has been explained in this article. You can also watch the video for the same if you are unwilling to read the text.

The dentist who has got his or her bachelor dental degree from a non-Australian institution needs to pass the skill assessment test/examination conducted by the Australian Dental Council and register themselves in Dental Board of Australia to practice as a general dentist in Australia or to get a job in public or private sector.

The ADC test/examination is a screening examination to establish that dentists trained in dental schools which have not been formally reviewed and accredited by the ADC have the necessary knowledge and clinical competence to practice dentistry. 

Following are the steps, an overseas dentist needs to go through to qualify the ADC examination: 

Exopsure Time for Dental Radiography

The exposer time for dental radiography is dependent upon the speed of the film whether its ‘D’ or ‘E’. The exposer time for various areas is given in the table below.

For exact data, you can see the instructions written on the inner side of the carton of the film. The modern microprocessor controlled radiography machines are coming with software that takes care of everything. You need to place the film properly, choose whether the patient is an adult or child, choose the tooth/area desired and shoot the film. You must take care of yourself and your staff for radiation protection. For radiation protection, read the article given below:

Radiography: Radiation Safety

 

Ref:

1. Oral Radiology Principles and Interpretation 5th Ed

Overseas Registration Examination (ORE)

If you do not want to read the text, you can listen this presentation on YouTube at this link Overseas Registration Examination

What is the Overseas Registration Examination (ORE)?

ORE means Overseas Registration Examination. It is an exam that overseas qualified dentists have to pass because their dental bachelor degrees are not recognised by GDC. After passing ORE, a dentist can get registration in GDC and he or she will be allowed to practise dentistry unsupervised in the UK. The ORE tests the clinical skills and knowledge of overseas dentists who  are referred to as a candidate. Candidates are expected to be at equal or above the standard of a ‘just passed’ UK BDS graduate. A candidate should be able to show competence, knowledge and familiarity in the different aspects of dentistry in the exam. 

The ORE has two parts

The​ Part 1 is designed in such a way that it tests candidates’ application of knowledge to clinical practice. ORE part 1 consists of two computer-based exam papers:

Paper A covers clinically applied dental science and clinically applied human disease. Basically it will check your ability to apply your knowledge of non clinical subjects to understand its role in human diseases.

Paper B covers aspects of clinical dentistry, including law, ethics, health and safety. It means paper B will check your ability to treat patients taking care of existing laws of the UK, ethics, and safety. Each paper lasts three hours and is made up of multiple short answer questions. They will contain extended matching questions and single best answer questions. A candidate is expected to be able to show competence, knowledge and familiarity in the different aspects of dentistry.

You need to achieve a minimum 50% marks in each paper to pass the part 1 of ORE. There are a maximum of 200 places available at each examination period. You must pass both papers in order to progress to Part 2. 

Location and Cost of Overseas Registration Examination

The Part 1 exam is held at King’s College London and costs £806. There are currently no confirmed dates for 2021. Your exam results will be sent to you by email. Generally it is declared within 20 working days of the examination. You will be given a percentage mark out of 100 for paper 1 as well as paper 2. Also, you will get an overall pass or fail award. Approximately 40 working days after the examination, the Part 1 Supplier, King’s College London, will provide you with result feedback. Upon passing Part 1, your name will be added to the Part 2 candidate list. You will be allowed four attempts for Part 1. 

Part 2 of ORE 

Part 2 is designed for candidates to demonstrate practical clinical skills. For each examination period, a maximum of 144 candidates are able to undertake the Part 2 exam. The current cost of the examination is £2,929 per candidate, payable at the time of booking. 

Part 2 Examination Dates: 

There are currently no confirmed dates for 2021 part 2.

Four Components of Part 2 of the ORE:

1. DM,
2. OSCE,
3. DTP &
4. EM 

First component is An operative test on a dental manikin: Candidates are required to perform three procedures over a period of three hours. These procedures primarily involve the preparation and restoration of teeth, but may also include other procedures where appropriate simulation can allow assessment of operative skills. 

Second component is An objective structured clinical examination (OSCE).  This is where candidates visit a series of ‘stations’ which test their clinical skills. These may include history-taking and assessment, communication skills such as an explanation of problems and treatment plans, judgement and decision making, ethics and attitudes, and clinical examination. The series of stations will cover aspects of behavioural sciences, human disease, law, ethics, professionalism, clinical dentistry, restorative dentistry, paediatric dentistry, orthodontics, preventive dentistry, dental public health, comprehensive oral care, oral surgery, oral medicine, oral pathology, oral microbiology, dental radiology and imaging.

Third component is A diagnostic and treatment planning exercise (DTP):  This involves an actor who will provide an appropriate history. You will be provided relevant additional information such as photographs, radiographs, study models or results of other special tests. You will not examine the actor. The exercise may involve any of the above aspects of clinical dentistry I just mentioned.

Fourth component is a practical examination in medical emergencies (ME).  This assessment consists of two parts: First is a structured scenario-based oral and the second is a demonstration of single handed basic life support. This will include cardiopulmonary resuscitation using a resuscitation manikin. You will be allowed four attempts for Part 2. Your exam results will be sent to you by email. The result will be declared within 20 working days of the exam. If you only fail the medical emergencies exercise during the ORE Part 2 , you will be able to re-sit this component only at a future exam. Sitting the ME only exam costs £300. If you pass the ME component at this sitting, you will have passed Part 2 of the ORE. If you fail, you will need to retake the full ORE Part 2 exam, if you are eligible to do so. The ME only exam is held at the same time as the full Part 2 exam. Once you have passed Part 2, you will be able to apply for registration with the GDC.   

Books Recommended for ORE Preparation

• Oxford Handbook of Applied Dental Science
• Oxford Handbook of Clinical Dentistry 6
• Scully’s Medical Problems in Dentistry, 7 e
• Master Dentistry: Volume 1
• Master Dentistry: Volume 2
•  Essentials of Dental Radiography and Radiology-Eric Whaites
• Vanders Physiology
• BD Chaurasia for Anatomy