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Geriatric Dentistry

The mouth is often referred to as a mirror of one’s health, and it is substantiated that, oral health is an integral part of general health. The large increase in human life expectancy over the years has resulted not only in a very considerable increase in the number of older persons but in a major shift in the age groups of 80 and above. Indian demographic profile depicts that in the year’s 2000 to 2050 age group of 80 and above will grow fastest i.e 700 %. Oral health care in elderly is often neglected and is dependent on many factors such as systemic health, socioeconomic status and availability of dental health care.
Oral diseases have a negative effect on quality of life. Impaired oral health and loss of teeth directly affects the Diet, nutrition, sleep, psychological status, social interaction and restricts major oral functions.
These findings gives special emphasis to the field of geriatric dentistry or gerodontology, which is a specialized multidisciplinary branch of general dentistry designed to provide dental services to elderly patients.

Effect of aging on oral tissues:

1) Loss of teeth: loss of teeth occurs due to loss of supporting bone which is most often due to periodontitis( pyorrhoea). Local factors such as plaque (soft deposits) and calculus or tartar (hard deposits) along with certain systemic factors can cause periodontitis at early age or at later part of life. Many researchers had found predominance of teeth loss in geriatric patients. Loss of teeth leads to dramatic decrease in chewing capacity of regular food. This ultimately leads to swallowing of larger food particles and avoidance of hard textured fibrous food, which can result in the development of digestive disturbances particularly in elderly patients. It is known that intake of carbohydrate, various vitamins, dietary fibre, calcium and iron is lower in patients who lack adequate chewing teeth.

2) Root surface decay: Due to the loss of supporting bone and gums, root portion of teeth becomes exposed in the oral cavity which becomes prone to decay if oral hygiene is not maintained religiously. Root portion decay is commonly seen in geriatric patients.

3) Wear and tear of teeth: Structural wear and tear of teeth occurs due to several habits such as bettlenut chewing, excessive consumption of acidic drinks, bruxism (night grinding) and due to wrong brush or brushing medium and erroneous brushing technique. Gastric hyperacidity can also cause erosive teeth wear. These structural changes can result in sharp teeth which in turn can cause injury to tongue and cheek bite.

4) Pain at jaw joint: Pain and dysfunction of various body Joints predominantly knee joints are characteristically seen in elderly. Similar changes and discomfort are often seen at the jaw joint or Temporomandibular joint in elderly. Pain and dysfunction of jaw joint and adjoining muscles in elderly may be aggravated due to the overclosure of jaw which may be due to loss of primary supporting teeth such as molars and premolars.

5) Esthetical changes: Loss of teeth and supporting bone of both jaws causes reduction of support for facial muscles and facial height is also reduced. This eventually leads to increased prominences of facial wrinkles such as hollowness of cheek, prominence of chin bone, and drooping of lips.

Geriatric patients are often affected by several systemic diseases which directly or indirectly can cause many oral diseases.

Effect of systemic diseases and drugs on oral tissue in elderly:

1) Diabetes: The amount of loss of teeth is directly proportional to the duration of uncontrolled blood sugar level. In diabetic patients it is common to see Gingivitis, Periodontitis(pyorrhoea) and loss of teeth.

2) Cardiac diseases: Many antihypertensive drugs and antianginal drugs if taken for long duration can cause dry mouth (xerostomia), swelling of tongue (glossitis), altered taste sensation and gingival enlargement.

3) Due to reduced manual dexterity in patients with history of paralysis and arthritic changes of joints they are unable to maintain their oral hygiene appropriately which ultimately leads to Periodontitis and loss of teeth.

4) Dry mouth(xerostomia): Many geriatric patients complains of dry mouth due to atrophic changes in salivary glands and as side effects of several drugs. Due to reduced saliva, the natural defence mechanism of oral cavity against microorganisms is hampered and elderly are more prone for caries and periodontitis.

Preventive measures which can be taken at early age:

It has been rightly said that, “Prevention is always better than cure” most of the above discussed oral features of elderly can be prevented at an early age if diagnosed and treated at right stage and time.

  • Periodontitis and caries which are the major causes of teeth loss, if diagnosed at right stage, can be successfully treated.
  • Wear and tear of teeth can be prevented by avoiding vicious bettlenut chewing, diagnosing and treating bruxism, practising proper brushing technique and using nonabrasive brushing medium.
  • Erosive loss of teeth structure can be prevented by treating gastric hyperacidity and avoiding acidic drinks.
  • Negative effect of dry mouth (xerostomia), can be prevented by maintaining proper oral hygiene and hydration.

Treatment options:

There are many treatment options for treating geriatric patients which can range between the basic treatment modalities and complex interventions. The first and the foremost prerequisite for treating geriatric patients is there perception for oral health care. The majority of dentate and edentulous elderly consider they have no need for dental care until they develop pain or eating difficulties. There are many barriers for elderly people to demand and utilise dental treatment, such as, availability, accessibility and affordability of dental care.

Dentist’s attitudes toward the treatment of older patients can also create barriers. A dental professional having sufficient expertise and qualification for dealing with the elderly should be preferred.

Maintenance therapy:

Rather than restoring the lost teeth it is imperative to take efforts to safeguard healthy teeth. The main concern should be to completely clean away plaque on a daily basis.

  • Toothbrush with soft bristles should be used. This protects the enamel on the teeth from wearing away and the gums from being damaged while brushing. Brushing should be done using small circular movements and gently massaging the gums for approximately 2 minutes is sufficient.
  • Flossing cleans the plaque from between the teeth and under the gums. Regular flossing and interdental brushes can be used to remove plaque from between the teeth and under the gums where tooth brush cannot reach.
  • For dependent and bed ridden geriatric patients the caregivers had to be trained for oral hygiene maintenance procedure.

Replacement of missing teeth:

There are many treatment modalities for replacement of missing teeth depending upon the prognosis of present teeth and financial state of the patient. Dental implants are preferred to replace missing teeth if there are no systemic health and financial barriers. But other treatment options such as tooth supported partial and complete dentures and fixed crown and bridges can also be considered when indicated. These prosthetic replacement of missing teeth restores the masticatory function and also gives sufficient support to facial muscles to re-establish the facial appearance. For elderly patients with severe wear of all teeth, full mouth rehabilitation can also be done with restoration of normal structure of teeth and facial height.

At present times geriatric dental care is often the largely neglected subject, primarily due to the lack of perception of oral health care by elderly and financial constraints. Proper education and awareness is required among the elderly regarding effect of oral diseases on quality of life. The caregivers and kin should sympathetically understand the treatment need of elderly and should provide them with specialized dental care by geriatric oral health providers such as (gerodontologist).

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Preventive Dentistry

i) Pit and fissure sealents : New methods of caries prevention focus on pit and fissure caries because tooth surfaces with pits and fissures have always been the earliest and most prevalent of carious areas. The disproportion of caries on fissured surfaces continues to this day, with these surfaces accounting for over 80% of all caries in young permanent teeth. “Dental sealants are an important dental caries prevention technology, ideally used in combination with patient education, effective personal oral hygiene, fluorides and regular dental visits. Pit and Fissure sealants act by forming a mechanical barrier between the tooth and oral environment so as to prevent the food lodgement and thus the chances of having caries thereby. Along with this the sealant material releases fluoride adding up to caries prevention.
ii) Habit breaking appliances: Tongue thrusting and thumb sucking are the most commonly seen oral habits which act as the major etiological factors in the development of dental malocclusion. Tongue thrust (also called reverse swallow or immature swallow) is a human behavioural pattern in which the tongue protrudes through the anterior incisors during wallowing, speech, and while the tongue is at rest.

  • Causes: Factors that can contribute to tongue thrusting include macroglossia (enlarged tongue), thumb sucking, large tonsils, hereditary factors, ankyloglossia (tongue tie). In addition, allergies or nasal congestion can cause the tongue to lie low in the mouth because of breathing obstruction, contributing to tongue thrusting.
  • Effect: Tongue thrusting can adversely affect the teeth and mouth. A person swallows from 1,200 to 2,000 times every 24 hours with about four pounds (1.8 kg) of pressure each time. If a person suffers from tongue thrusting, this continuous pressure tends to force the teeth out of alignment. Many people who tongue thrust have open bites, the front lips do not close and the child often has his mouth open with the tongue protruding beyond the lips, Upper incisors are extremely protruded and the lower incisors are pulled in by the lower lip.
  • Treatment: There are two methods for treating tongue thrusting. The patient may place an appliance similar to a nightguard in the mouth at night, or may wear a more permanent device that can be removed and adjusted by a dentist. The other method requires oral habit training, an exercise technique that re-educates the muscles associated with swallowing by changing the swallowing pattern.

iii) Nightguard appliance:

  • Bruxism: The habitual, involuntary grinding or clenching of the teeth, usually during sleep, as from anger, tension, fear, or frustration. About 50-55% of the population are bruxers, half of whom become chronic enough to require treatment. Bruxism can occur at any time, but it’s most common at night while sleeping. Because it happens during sleep, most people don’t know they brux until their dentist tells them that they are showing signs of bruxing. Often a spouse or family member hears the grinding sound. When diagnosed early, teeth grinding can be treated before it causes permanent damage to the teeth. Severe bruxism if kept untreated can cause heavy wear and tear of teeth structure in early age.
  • How do I know if I grind my teeth? How do I know if I grind my teeth? There are several telltale signs. Sore or tender jaws, morning headaches, earaches and neck pain are common signs of moderate to severe bruxing. Others may notice their teeth have become more sensitive over time, or that their teeth look flat or worn. Other physical indications of chronic teeth grinding are chipped teeth; increased sensitivity to hot or cold foods and beverages; and loose or broken fillings. To be sure, it’s best to ask your dentist or hygienist. They can give you a definitive answer, and recommend the best treatment options.
  • Causes of teeth grinding. Most often, bruxism is related to stress. It may also be a response to pain elsewhere in the body, or the result of misaligned teeth. Alcohol, caffeine and other stimulants can aggravate the condition, causing more severe grinding or clenching.
  • What are treatment options? When bruxism is serious enough to cause pain and/or physical damage to your teeth, we will suggest you wear a night guard while sleeping. A night guard is a soft, removable tray made of a clear, tasteless polymer (plastic) material. It is custom-fit to either your upper or lower teeth and worn while sleeping to prevent grinding of your teeth. For severely degraded teeth Full mouth rehabilitation is advised
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Cosmetic Dentistry

i) Smile designing: Modern Cosmetic Dentistry and the advent of new materials and techniques have transformed the way people think about their smiles and each other. Smiles convey warmth, confidence, social status and career success. Best of all, smiles help you feel good about yourself. Nothing compares to a confident attractive smile. It’s there when you laugh, when you greet, say thank you, or express a happy thought. Your smile is your most important social bonding gesture, and your most important professional announcement - it tells others who you are. In short, your smile sells you! Give your smile that Picture Perfect look of confidence, beauty and health - because when you feel good about yourself, people are naturally attracted to that! A smile can be designed or perfected digitally or manually For digital smile designing dentist first shows what smile pattern can be achieved virtually and the patient has to select the most perfect option. To do it manually, dentist tries different smile patterns live on the patient and the perfect one is selected. For restoring smile perfectly, all ceramic laminates or jacket crowns are preferred which gives the greatest esthetic appearance. Form minor corrections in smile, tooth colour light cure composite resin material is used.
ii) Space closure(midline Diastema): In humans, the term is most commonly applied to an open space between the upper incisors (front teeth). It happens when there is an unequal relationship between the size of the teeth and the jaw. Diastema is sometimes caused or exacerbated by the action of a labial frenulum (the tissue connecting the lip to the gum) causing high mucosal attachment and less attached keratinized tissue which is more prone to recession or by tongue thrusting, which can push the teeth apart. Diastema is a correctable dental condition. It can be treated by traditional braces, Invisalign, dental bands or direct dental bonding to make the teeth wider and thus fill up the space.
iii) Bleaching: Dental bleaching, also known as tooth whitening, is a common procedure in general dentistry. According to the FDA, whitening restores natural tooth colour and leaching whitens beyond the natural colour. There are many methods available, such as brushing, bleaching strips and bleaching gel. Teeth whitening have become the most requested procedure in cosmetic dentistry today. Bleaching methods use carbamide peroxide which reacts with water to form hydrogen peroxide. Carbamide peroxide has about a third of the strength of hydrogen peroxide. This means that a 15% solution of carbamide peroxide is the rough equivalent of a 5% solution of hydrogen peroxide. The peroxide oxidizing agent penetrates the porosities in the rod-like crystal structure of enamel and breaks down stain deposits in the dentin. Power bleaching uses light to accelerate the process of bleaching in a dental office. Another bleaching agent is 6-phthalimido peroxy hexanoic acid (PAP).

Causes of tooth discoloration A child's deciduous teeth are generally whiter than the adult teeth that follow. As a person ages the adult teeth often become darker due to changes in the mineral structure of the tooth, as the enamel becomes less porous and phosphate-deficient. Teeth can become stained by bacterial pigments, food-goods and vegetables rich with carotenoids or xanthonoids. Certain antibacterial medications (like tetracycline) can cause teeth stains or a reduction in the brilliance of the enamel. [3] Ingesting colored liquids like coffee, tea, and red wine can discolour teeth.

Other causes:

  • Tetracyclines
  • Enamel hypoplasia
  • Fluorosis
  • Age of the tooth: the teeth become more yellow or opaque and generally have a darker hue, usually after 50.
  • Tea
  • Coffee
  • Tobacco ( tar )
  • Wine and cola drinks consumed in excess
  • Other foods and oral tobacco products with strong content of pigments
  • Chlorhexidine (chemical bactericidal and bacteriostatic used as antiseptic in mouthwashes and toothpastes for the treatment of gingivitis and halitosis ). Chlorhexidine does not stain the teeth; it destroys the bacteria in the plaque, allowing other staining agents to discolour the accumulation if the plaque is not removed.
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Prosthetic Dentistry

complete dentures
Tooth loss and dentures
Tooth loss can occur for many reasons (periodontal disease, decay or trauma). Dentures have been used to replace missing teeth for many years now. Alternative methods used to replace missing teeth include dental implants and fixed bridges. The loss of your teeth can have negative effects on your self- confidence, your ability to chew food and your bite. Since your teeth provide structure and support to your cheeks, tooth loss can result in the sagging of your cheeks and make you appear older than you are. It is essential that your missing teeth are replaced as soon as possible. Dentures, also known as false teeth, are prosthetic devices constructed to replace missing teeth; they are supported by the surrounding soft and hard tissues of the oral cavity. Conventional dentures are removable. However, there are many different denture designs, some which rely on bonding or clasping onto teeth or dental implants. There are two main categories of dentures, the distinction being whether they are used to replace missing teeth on the mandibular arch or on the maxillary arch. Causes of tooth loss
Patients can become entirely edentulous (without teeth) by many reasons, the most prevalent being removal because of dental disease typically relating to oral flora control, i.e., periodontal disease and tooth decay. Other reasons include tooth developmental defects caused by severe malnutrition, genetic defects such as dentinogenesis imperfecta, trauma, or drug use.

Advantages
Dentures can help patients through:

  • Mastication, as chewing ability is improved by replacing edentulous areas with denture teeth.
  • Aesthetics, because the presence of teeth gives a natural appearance to the face, and wearing a denture to replace missing teeth provides support for the lips and cheeks and corrects the collapsed appearance that results from the loss of teeth.
  • Pronunciation, because replacing missing teeth, especially the front teeth, enables patients to speak better. There is especially improvement in pronouncing words containing sibilants or fricatives.
  • Self-esteem, because improved looks and speech boost confidence in the ability to interact socially.

Fabrication of complete dentures
Modern dentures are most often fabricated in a commercial dental laboratory using a combination of tissue shaded powders Polymethylmethacrylate acrylic (PMMA). These acrylics are available as heat cured or cold cured types. Commercially produced acrylic teeth are widely available in hundreds of shapes and tooth colours.
Step1: The process of fabricating a denture usually begins with an initial dental impression of the maxillary and mandibular ridges. Standard impression materials are used during the process. The initial impression is used to create a simple stone model that represents the maxillary and mandibular arches of the patient's mouth. This is not a detailed impression at this stage. Once the initial impression is taken, the stone model is used to create a 'Custom Impression Tray' which is used to take a second and much more detailed and accurate impression of the patient's maxillary and mandibular ridges.
Step2: Polyvinylsiloxane impression material is one of several very accurate impression materials used when the final impression is taken of the maxillary and mandibular ridges.
Step3: A wax rim is fabricated to assist the dentist in establishing the vertical dimension of occlusion. After this, a bite registration is created to marry the position of one arch to the other. Once the relative position of each arch to the other is known, the wax rim can be used as a base to place the selected denture teeth in correct position.
Step 4: This arrangement of teeth is tested in the mouth so that adjustments can be made to the occlusion. After the occlusion has been verified by the dentist and the patient, and all phonetic requirements are met, the denture is processed. Processing a denture is usually performed using a lost-wax technique whereby the form of the final denture, including the acrylic denture teeth, is invested in stone. This investment is then heated, and when it melts the wax is removed through a spruing channel. The remaining cavity is then either filled by forced injection or pouring in the uncured denture acrylic, which is either a heat cured or cold-cured type. During the processing period, heat cured acrylics—also called permanent denture acrylics—go through a process called polymerization, causing the acrylic materials to bond very tightly and taking several hours to complete. After a curing period, the stone investment is removed, the acrylic is polished, and the denture is complete.
Step 5: The end result is a denture that looks much more natural, is much stronger and more durable than a cold cured temporary denture, resists stains and odours, and will last for many years. Cold cured or cold pour dentures, also known as temporary dentures, do not look very natural, are not very durable, tend to be highly porous and are only used as a temporary expedient until a more permanent solution is found. These types of dentures are inferior and tend to cost much less due to their quick production time (usually minutes) and low cost materials. It is not suggested that a patient wear a cold cured denture for a long period of time, for they are prone to cracks and can break rather easily.

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Implant Dentistry

implant supported single tooth replacement
If you are missing a single tooth, one implant and a crown can replace it. A dental implant replaces both the lost natural tooth and its root.
What are the advantages of a single-tooth implant over a bridge?
A dental implant provides several advantages over other tooth replacement options. In addition to looking and functioning like a natural tooth, a dental implant replaces a single tooth without sacrificing the health of neighbouring teeth. The other common treatment for the loss of a single tooth, a tooth-supported fixed bridge, requires that adjacent teeth be ground down to support the cemented bridge. Because a dental implant will replace your tooth root, the bone is better preserved. With a bridge, some of the bone that previously surrounded the tooth begins to resorb (deteriorate). Dental implants integrate with your jawbone, helping to keep the bone healthy and intact. In the long term, a single implant can be more esthetic and easier to keep clean than a bridge. Gums can recede around a bridge, leaving a visible defect when the metal base or collar of the bridge becomes exposed. Resorbed bone beneath the bridge can lead to an unattractive smile. And, the cement holding the bridge in place can wash out, allowing bacteria to decay the teeth that anchor the bridge.
How will the implant be placed?
First, the implant, which looks like a screw or cylinder, is placed into your jaw. Over the next two to six months, the implant and the bone are allowed to bond together to form an anchor for your artificial tooth. During this time, a temporary tooth replacement option can be worn over the implant site. Often, a second step of the procedure is necessary to uncover the implant and attach an extension. This temporary healing cap completes the foundation on which your new tooth will be placed. Your gums will be allowed to heal for a couple of weeks following this procedure. There are some implant systems (one-stage) that do not require this second step. These systems use an implant which already has the extension piece attached. Your implantologist will advise you on which system is best for you. Finally, a replacement tooth called a crown will be created for you by your dentist and attached to a small metal post, called an abutment. After a short time, you will experience restored confidence in your smile and your ability to chew and speak. Dental implants are so natural-looking and feeling, you may forget you ever lost a tooth. Every case is different, and some of these steps can be combined when conditions permit. Your dental professional will work with you to determine the best treatment plan.
Full Mouth Dental Implants
If you are missing all of your teeth, an implant-supported full bridge or full denture can replace them. Dental implants will replace both your lost natural teeth and some of the roots.
What are the advantages of implant-supported full bridges and implant-supported dentures over conventional dentures?
Dental implants provide several advantages over other teeth replacement options. In addition to looking and functioning like natural teeth, implant-supported full bridges or dentures are designed to be long lasting. Implant-supported full bridges and dentures also are more comfortable and stable than conventional dentures, allowing you to retain a more natural biting and chewing capacity. In addition, because implant-supported full bridges and dentures will replace some of your tooth roots, your bone is better preserved. With conventional dentures, the bone that previously surrounded the tooth roots begins to resorb (deteriorate). Dental implants integrate with your jawbone, helping to keep the bone healthy and intact. In the long term, implants can be more esthetic and easier to maintain than conventional dentures. The loss of bone that accompanies conventional dentures leads to recession of the jawbone and a collapsed, unattractive smile. Conventional dentures make it difficult to eat certain foods. How will the implants be placed? First, implants, which looks like screws or cylinders, are placed into your jaw. Then, over the next two to six months, the implants and the bone are allowed to bond together to form anchors for your artificial teeth. During this time, a temporary teeth replacement option can be worn over the implant sites. Often, a second step of the procedure is necessary to uncover the implants and attach extensions. These temporary healing caps, along with various connecting devices that allow multiple crowns to attach to the implants, complete the foundation on which your new teeth will be placed. Your gums will be allowed to heal for a couple of weeks following this procedure. There are some implant systems (one-stage) that do not require this second step. These systems use an implant which already has the extension piece attached. Your implantologist will advise you on which system is best for you. Depending upon the number of implants placed, the connecting device that will hold your new teeth can be tightened down on the implant, or it may be a clipped to a bar or a roundball anchor to which a denture snaps on and off. Finally, full bridges or full dentures will be created for you and attached to small metal posts, called abutments, or the connecting device. After a short time, you will experience restored confidence in your smile and your ability to chew and speak. Every case is different, and some of these steps can be combined when conditions permit. Your dental professional will work with you to determine the best treatment plan.

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Restorative Dentistry

Painless root canal treatment:
Endodontic therapy or root canal therapy is a sequence of treatment for the pulp of a tooth which results in the elimination of infection and the protection of the decontaminated tooth from future microbial invasion. Root canals and their associated pulp chamber are the physical hollows within a tooth that are naturally inhabited by nerve tissue, blood vessels and other cellular entities which together constitute the dental pulp. Endodontic therapy involves the removal of these structures, the subsequent shaping, cleaning, and decontamination of the hollows with small files and irrigating solutions, and the obturation (filling) of the decontaminated canals with an inert filling such as gutta-percha and typically a eugenol- based cement. Epoxy resin, which may or may not contain Bisphenol A is employed to bind gutta-percha in some root canal procedures.
Treatment Procedure:
In the situation that a tooth is considered so threatened (because of decay, cracking, etc.) that future infection is considered likely or inevitable, a pulpectomy, removal of the pulp tissue, is advisable to prevent such infection. Usually, some inflammation and/or infection is already present within or below the tooth. To cure the infection and save the tooth, the dentist drills into the pulp chamber and removes the infected pulp and then drills the nerve out of the root canal(s) with long needle-shaped hand instruments known as files. This process serves to remove debris and infected tissue and facilitates greater penetration of an irrigating solution. After this is done, the dentist fills each of the root canals and the chamber with an inert material and seals up the opening. This procedure is known as root canal therapy. With the removal of nerves and blood supply from the tooth, it is best that the tooth be fitted with a crown. The standard filling material is gutta-percha, a natural polymer prepared from latex from the percha ( Palaquium gutta ) tree. The standard endodontic technique involves inserting a gutta- percha cone (a "point") into the cleaned-out root canal along with a sealing cement. Gutta-percha is radiopaque, allowing verification afterwards that the root canal passages have been completely filled, without voids. For some patients, root canal therapy is one of the most feared dental procedures, perhaps because of a painful abscess that necessitated the root canal procedure. However, dental professionals assert that modern root canal treatment is relatively painless because the pain can be controlled with a local anaesthetic during the procedure and pain control medication can be used before and/or after treatment assuming that the dentist takes the time to administer one. However, in some cases it may be very difficult to achieve pain control before performing a root canal. For example, if a patient has an abscessed tooth, with a swollen area or "fluid-filled gum blister" next to the tooth, the pus in the abscess may contain acids that inactivate any anaesthetics injected around the tooth. In this case, the dentist may drain the abscess by cutting it to let the pus drain out. Releasing the pus releases pressure built up around the tooth; this pressure causes the pain. The dentist then prescribes a week of antibiotics such as penicillin, which will reduce the infection and pus, making it easier to anesthetize the tooth when the patient returns one week later. The dentist could also open up the tooth and let the pus drain through the tooth, and could leave the tooth open for a few days to help relieve pressure. A root treated tooth may be eased from the occlusion as a measure to prevent tooth fracture prior to the cementation of a crown or similar restoration. Sometimes the dentist performs preliminary treatment of the tooth by removing all of the infected pulp of the tooth and applying a dressing and temporary filling to the tooth. This is called a pulpectomy. The dentist may also remove just the coronal portion of the dental pulp, which contains 90% of the nerve tissue, and leave intact the pulp in the canals. This procedure, called a "pulpotomy", tends to essentially eliminate all the pain. A pulpotomy may be a relatively definitive treatment for infected primary teeth. The pulpectomy and pulpotomy procedures aim to eliminate pain until the follow-up visit for finishing the root canal. Further occurrences of pain could indicate the presence of continuing infection or retention of vital nerve tissue. After receiving a root canal, the tooth should be protected with a crown that covers the cusps of the tooth. Otherwise, over the years the tooth will almost certainly fracture, since root canals remove tooth structure from the tooth and undermine the tooth's structural integrity. Also, root canal teeth tend to be more brittle than teeth not treated with a root canal. This is commonly because the blood supply to the tooth, which hydrates and nourishes the tooth structure, is removed during the root canal procedure, leaving the tooth without a source of moisture replenishment. Placement of a crown is recommended also because these have the best ability to seal the root canaled tooth. If the tooth is not perfectly sealed, the root canal may leak, causing eventual failure of the root canal. Also, many people believe once a tooth has had a root canal treatment it cannot get decay. This is not true. A tooth with a root canal treatment still has the ability to decay, and without proper home care and an adequate fluoride source the tooth structure can become severely decayed (often without the patient's knowledge since the nerve has been removed, leaving the tooth without any pain perception). Thus, non-restorable carious destruction is the main reason for extraction of teeth after root canal therapy, with up to two-thirds of these extractions. [9] Therefore it is very important to have regular X-rays taken of the root canal to ensure that the tooth is not having any problems that the patient would not be aware of.

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Periodontal Therapy

Teeth scaling and polishing:
What are dental cleanings (scaling and polishing) and why have them?
Dental cleanings involve removing plaque (soft, sticky, bacteria infested film) and tartar (calculus) deposits that have built up on the teeth over time. Your teeth are continually bathed in saliva which contains calcium and other substances which help strengthen and protect the teeth. While this is a good thing, it also means that we tend to get a build-up of calcium deposits on the teeth. This chalky substance will eventually build up over time, like limescale in a pipe or kettle. Usually it is tooth coloured and can easily be mistaken as part of the teeth, but it also can vary from brown to black in colour. If the calculus (tartar, as dentists like to call it) is allowed to accumulate on the teeth it will unfortunately provide the right conditions for bacteria to thrive next to the gums. The purpose of the cleaning and polishing is basically to leave the surfaces of the teeth clean and smooth so that bacteria are unable to stick to them and you have a better chance of keeping the teeth clean during your regular home care. Also it leaves your teeth feeling lovely and smooth and clean, which is nice when you run your tongue around them. The professional cleaning of teeth is sometimes referred to as prophylaxis (or prophy for short). It’s a Greek word which means “to prevent beforehand” – in this case, it helps prevent gum disease.
How are dental cleanings done?
The dental hygienist or dentist uses specialized instruments to gently remove these without harming the teeth. The instruments which may be used during your cleaning, and what they feel like, are described below.
Ultrasonic instrument
Commonly used first is an ultrasonic instrument which uses tickling vibrations to knock larger pieces of tartar loose. It also sprays a cooling mist of water while it works to wash away debris and keep the area at a proper temperature. The device typically emits a humming or high pitched whistling sound. This may seem louder than it actually is because the sound may get amplified inside your head, just like when you put an electric toothbrush into your mouth. The ultrasonic instrument tips are curved and rounded and are always kept in motion around the teeth. They are by no means sharp since their purpose is to knock tartar loose and not to cut into the teeth. It is best to inform the operator if the sensations are too strong or ticklish so that they can adjust the setting appropriately on the device or modify the pressure applied. With larger deposits that have hardened on, it can take some time to remove these, just like trying to remove baked-on grime on a stove that has been left over a long time. So your cleaning may take longer than future cleanings. Imagine not cleaning a house for six months versus cleaning it every week. The six-month job is going to take longer than doing smaller weekly jobs.
Fine hand tools
Once the larger pieces of tartar are gone, the dental worker will switch to finer hand tools (called scalers and curettes in dental-speak) to remove smaller deposits and smoothen the tooth surfaces. These tools are curved and shaped to match the curves of the teeth. They allow smaller tartar deposits to be removed by carefully scraping them off with a gentle to moderate amount of pressure. Just like taking a scrubbing brush to a soiled pot, the dentist has to get the areas clean and smooth.
Polishing
Once all the surfaces are smooth, the dentist may polish your teeth. Polishing is done using a slow speed handpiece with a soft rubber cup that spins on the end. Prophylaxis (short for prophy) paste – a special gritty toothpaste-like material – is the cup and spun around on the teeth to make them shiny smooth.
Fluoride application:
Your dentist may also apply fluoride. Fluoride comes in many different flavours such as chocolate, mint, strawberry, cherry, watermelon, pina colada and can be mixed and matched just like ice cream at a parlour for a great taste sensation! Make no mistake though, this in- office fluoride treatment is meant for topical use only on the surfaces of the teeth and swallowing excessive amounts can give a person a tummy ache as it is not meant to be ingested. Fluoride foam or gel is then placed into small, flexible foam trays and placed over the teeth for 30 seconds. Afterwards the patient is directed to spit as much out as possible into a saliva ejector. The fluoride helps to strengthen the teeth since the acids from bacteria in dental tartar and plaque will have weakened the surfaces. It is best not to eat, drink or rinse for 30 minutes after the fluoride has been applied0.
Is it going to be painful?
Most people find that cleanings are painless, and find the sensations described above – tickling vibrations, the cooling mist of water, and the feeling of pressure during “scraping” – do not cause discomfort. A lot of people even report that they enjoy cleanings and the lovely smooth feel of their teeth afterwards! There may be odd zingy sensations, but many people don’t mind as they only last a nanosecond. Be sure to let your dentist/hygienist know if you find things are getting too uncomfortable for your liking. They can recommend various options to make the cleaning more enjoyable. Painful cleaning experiences can be caused by a number of things: a rough dentist or hygienist, exposed dentine (not dangerous, but can make cleanings unpleasant), or sore gum tissues. In case you may have had painful cleaning experiences in the past, switching to a gentle hygienist/dentist and perhaps a spot of nitrous oxide can often make all the difference. You could also choose to be numbed. If you find the scaling a bit uncomfortable because the gum tissues (rather than the teeth themselves) are sensitive, topical numbing gels can be used.

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Orthodontic Care

Ceramic Braces
There are now a number of options for consumers to straighten misaligned or wrongly angled teeth. You can have the traditional metallic braces which are proven to do the job but are plagued with a few unwanted disadvantages such as looking unsightly when smiling apart from clinically causing tooth decay and shortening of tooth roots.One of the better options out there is using ceramic braces made of composite materials. They come in varying levels of transparency so you have ceramic brace that can take on the natural colour of the teeth or are thoroughly translucent to be called clear ceramic braces and they do not stain. Most adults prefer ceramic braces because they blend in with the colour of the teeth and are cosmetically less noticeable than metal.
Clear Ceramics
Clear ceramic braces are made of ceramic alloys. Because of their transparency, they also have a great following, especially among adults who are to correct their buckteeth but without shouting to the world, they’re being corrected every time they smile. In addition to the clear ceramic brackets, there are two types of brace wires or ties that can make them more inconspicuous. The ties are made up of either clear elastic ties or white metal ties. The metal ties provide a stronger bind but tend to lose the white coating over time.
Advantages of Ceramic Braces
The main edge of ceramic braces is their aesthetic and cosmetic appeal. The ceramic brackets do not stain but the clear elastic wires or ties holding the brackets to your teeth stain, especially if you smoke, eat a lot of curry or drink loads of coffee. But these ties are changed every time an adjustment is made, usually, monthly.
Disadvantages of Ceramic Braces

  • Everyone knows that ceramic is used in dinnerware and resemble glass in both hardness and brittleness. Hence, they are less resilient or absorbent to shock abuse or force than metal braces. Whether clear or not, ceramic braces are more brittle and sensitive to shock so that they can break, chip or fracture easily. Most dentists would caution applying them in teeth that are often used for chewing food.
  • Orthodontists charge higher for using ceramic braces than they would for metal braces. Ceramic braces cost more for the orthodontist to procure and often take more visits and more time to install than metal braces.
  • Ceramic brackets generally present more friction when sliding the metal ties to adjust the brace which accounts from more effort and time in the process. But the latest generation of ceramic brackets with metal slots has made this a problem of the past.
  • Because ceramic is harder than enamel, teeth that bite or rub against the brackets can easily wear where the brackets contact the teeth. This is why ceramic braces don’t get recommended in certain teeth biting patterns or tooth anatomy such as those with long cusps on opposite teeth. /li>

Invisaline ( invisible braces):
Invisalign is a proprietary method of orthodontic treatment which uses a series of clear, removable teeth aligners used as an alternative to traditional metal dental braces.

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Maxillofacial Surgery

Maxillofacial prosthetics (Oral and Maxillofacial Prosthodontics) is a sub-specialty (or super-specialty) of Prosthodontics. It is the only recognized sub-specialty of all dental specialties by the American Dental Association. Maxillofacial prosthodontists treat patients who have acquired and congenital defects of the head and neck (maxillofacial) region due to cancer, surgery, trauma, and/or birth defects. Maxillary obturators, speech-aid prosthesis (formerly called as Pharyngeal/soft palate obturators) and mandibular-resection prostheses are the most common prostheses planned and fabricated by Maxillofacial prosthodontists. Other types of prostheses include artificial eyes, nose and other facial prostheses fabricated in conjunction with an anaplastologist. Treatment is multidisciplinary, involving oral and maxillofacial surgeons, plastic surgeons, head and neck surgeons, ENT doctors, oncologists, speech therapists, occupational therapists, physiotherapists, and other healthcare professionals. Due to their extensive training in prosthetic reconstruction, breadth of knowledge and capability of handling most types of complex cases, Maxillofacial prosthodontists have been referred to as "bullet-proof" dentists.
Removal of impacted teeth:
The oral cavity often harnesses teeth which, due to certain developmental difficulties, do not erupt in their right place. They often remain dormant inside the bone. However, when they pose a problem due to the forces they exert or when they become foci of infection, their removal is their only cure. The most common impactions are seen in cases of wisdom teeth (third molars). Sometimes, even canines or other teeth might be found impacted in one’s mouth. Each individual wisdom tooth is unique and depending on how it grows, it can have different impact on bones and/or tissues. Their varied developments may effect other teeth and cause troubles. If the impaction is between the third molar and part of the second molar, this kind is called bone impaction. It can subcategorized into vertical, horizontal, and angular depending on the way they are intersecting. If the wisdom tooth is directly breaking out of the tissue, it is known as tissue impaction.
The following four impactions are commonly found in patients :
Bone Impaction (Vertical) :
Impaction would cause pathosis inside the cheek bone or jaw bone.
Bone Impaction (Horizontal) :
Besides leading pathosis, horizontal placement would hurt the hard tissue of the second molar to cause toothache and cavities. Bone Impaction (Angular) :
Besides leading pathosis, angular placement would hurt the hard tissue of the second molar to cause toothache and cavities. Tissue Impaction :
The wisdom tooth almost erupts out of gum, or its half erupts out of gum to cause pseudo-pocket. Besides leading pathosis, it easily tracts food debris and causes gum irritation.

Vertical Horizontal Angular Tissue Disimpaction
facture management :
Mandibular fracture, also known as fractures of the jaw, are breaks through the mandibular bone. They usually occur due to trauma and are often associated with other facial trauma. The types of mandibular fractures include fractures at the symphyseal area, horizontal ramus, mandibular angle and condylar neck. Classification
There are various classification systems of mandibular fractures in use.
Location
Photo of the mandible demonstrating the frequency of mandibular fractures by location. This is the most useful classification, because both the signs and symptoms, and also the treatment are dependent upon the location of the fracture. The mandible is usually divided into the following zones for the purpose of describing the location of a fracture (see diagram): condylar, coronoid process, ramus, angle of mandible, body (molar and premolar areas), parasymphysis and symphysis.

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Paediatric Dentistry

Cavity filling:
we recommend composite resin or tooth color fillings. These fillings are generally strong and resistant to the daily pressures that a tooth may be subjected to, making it an ideal material for this purpose.
When are fillings necessary?
During the dental examination, your child’s dentist may identify cavities. The digital x-rays used in our office, along with tooth examination with a dental explorer can help uncover areas of decay. As long as the decay is not too large, in which case it would need a root canal, the tooth can be treated with a simple filling.
What are the different options for direct fillings?
For the most part, there are two types of direct dental fillings that are done. These are either composite (white fillings) or amalgam (silver fillings). While amalgam fillings are often stronger, composite fillings are more aesthetic.
Why choose tooth colour fillings?
Composite, or tooth colour fillings, match the colour and physical appearance of our natural teeth closely and is preferred by most paediatric dentists for restorations made in aesthetic areas. They are also used successfully on molars or other chewing surfaces, as long as the fillings are relatively small. For larger fillings, or those that go in between the teeth (interproximal decay), silver fillings may be recommended. However, for the most part, both types are filling material, be it composite or amalgam, can be used to restore teeth that have been affected by decay.
How are white fillings placed inside teeth?
Before placing any filling, children are made to feel comfortable in the dental setting. Sometimes this is achieved by using techniques in pediatric oral sedation or nitrous oxide. The tooth affected is made numb using local anesthesia, and the decay is removed. The preparation in the tooth is then exposed to acid etch and a resin bonding material before the composite is placed onto the tooth. Once the filling is in place, a blue light is placed on the filling, making it hard. Finally, adjustments are made so that the child is comfortable biting.
Does it hurt to get fillings?
After the initial process of making the child numb, the child no longer feels pain while getting a filling placed. Nevertheless, throughout the preparation process, the child may feel the cold water that is sprayed on the tooth and may also feel pressure. Overall, the process is completed fairly quickly and is mostly painless. After the filling is placed, it is common for some children to experience sensitivity on the tooth. This sensitivity could last up to two weeks, but it dies down with time.
How do you take care of composite, tooth colour fillings?
After having the fillings placed, it is very important for children to maintain good oral habits by brushing and flossing two times a day. This way they can prevent recurrent decay from happening and can keep their fillings strong.
Root canal treatment: When does a child need root canal therapy?
This treatment is often indicated if your child feels pain in a tooth, is sensitive to different temperatures, or if the tooth is chipped or cracked with the pulp already exposed. When this happens, the pulp becomes damaged beyond simple medication or surface repair. As a result, the infected pulp is removed and a crown is placed on the tooth, allowing it to be strong enough so the tooth can remain in the child’s mouth until the permanent tooth erupts.
How is root canal therapy on baby teeth different than that done on adult teeth?
For children, a pulpotomy is done, where only the infected pulp chamber is removed. For the most part, the dentist does not need to use special instruments to remove the pulp from roots of the tooth since only the surface nerve structure in the chamber is removed. This makes the procedure much faster and a lot more painless for children. Also, after the treatment is completed, a baby crown is placed on the tooth right away to protect the weakened tooth.
What will happen when the permanent tooth wants to come in if the baby tooth has a root canal and crown?
Since the material we use for the baby root canal is completely biocompatible, it will not negatively affect the incoming permanent tooth. Rather, the tooth will get loose in its own time and will fall out like all other baby teeth.
Will my child have pain after a baby root canal is performed?
Since the affected nerves of the tooth are removed, your child should have very minimal pain after the treatment. During the treatment itself, the tooth is completely numbed using local anaesthesia. However, it is common to have sensitivity to the crown or to any dental procedure for the first two weeks. During this time, it is important to continue brushing, particularly around the gums of the tooth, to keep them from becoming inflamed. If excessive pain or irritation is experienced, have the child brought to the dental office for a re-evaluation.