Dr.

Ebtisam ElHamalawy
MFDS RSC (Edh.), MJDF RSC (Lon.), BDS (Misr
International University)
 Advantages:
 Pre-eruptive effects:

1. improve crystallinity / increase the crystal

size
2. decrease the acid solubility
3. Roundation of the cusps and fissures
Post eruptive effects:
inhibit demineralization and promotes
remineralisation
Prenatal fluoride is ineffective
 Topical:
Types of fluoride varnish Concentration of
fluoride
 Fluor protector 8,000 ppm 0.8% F
 Lawefluor 22,600 ppm 2.2% F
 Duraphat 22,600 ppm 2.2% F
 Bifluorid 56,300 ppm 5.6% F
 Prescribing high concentration fluoride toothpaste
 Sodium fluoride 2,800 ppm toothpaste Indications:
high caries risk patients aged 10 years and over.
 Sodium fluoride toothpaste 0.619% DPF
 Specimen
 Sodium fluoride 5,000 ppm toothpaste Indications:
patients aged 16 years and over with high caries
risk, present or potential for root caries, dry
mouth, orthodontic appliances, overdentures,
those with highly cariogenic diet or medication.
 Fluoride rinses
 These can be prescribed for patients aged 8 years and
above, for daily or weekly use, in addition to twice
daily brushing with toothpaste containing at least 1,350
ppm fluoride. Rinses require patient compliance and
should be used at a different time to toothbrushing to
maximise the topical effect, which relates to frequency
of availability.
 Sodium fluoride mouthwash 0.2% Rinse for 1
minute and spit out, use weekly
 Sodium fluoride mouthwash 0.05 % Rinse for
1 minute and spit out, use daily
 Use of fluoride supplements : It is recognised
that the use of fluoride tablets requires
compliance by families and this may include
under and over-use.
 There is a risk of fluorosis if children aged
under 6 years take over the advised dose.
 Tablets are available in 500 µg and 1 mg fluoride levels.
 Tablets should be given at a different time to tooth
brushing and allowed to dissolve slowly in the mouth
to maximise their topical effect.

Age of child < 0.3 ppm 0.3–0.7 ppm > 0.7 ppm
6 months – birthday Not advised Not advised
250 µg daily
3rd birthday (need to halve
500 µg tablet )

3–6th 500 µg daily 250 µg daily Not advised

birthday (need to
halve 500 µg
tablet )
6 and over 1 mg daily 500 µg daily
 Sodium fluoride tablets 1.1 mg (F– 500 µg) One
tablet to be sucked or chewed daily
 tablets 1.1 mg (F– 500 µg) One tablet to be
sucked or chewed daily
 Sodium fluoride tablets 2.2 mg (F-1mg) One
tablet to be sucked or chewed daily
Breast feeding provides the best nutrition for babies

From six months of age infants should be introduced to drinking from a cup,
and from age one year feeding from a bottle should be discouraged

Sugar should not be added to weaning foods

Parents should brush or supervise toothbrushing

Use only a smear of toothpaste containing no less than 1,000 ppm fluoride
As soon as teeth erupt in the mouth brush them twice daily

The frequency and amount of sugary food and drinks should be reduced
and, when consumed, limited to mealtimes. Sugars should not be consumed
more than four times per day
Sugar-free medicines should be recommended
Brush last thing at night and on one other occasion
Brushing should be supervised by an adult

Use a pea-sized amount of toothpaste containing 1,350–

1,500 ppm fluoride
Spit out after brushing and do not rinse

The frequency and amount of sugary food and drinks

should be reduced and, when consumed, limited to
mealtimes. Sugars should not be consumed more than
four times per day
Sugar-free medicines should be recommended

 Apply fluoride varnish to teeth twice yearly (2.2% F–)

 All advice as above, plus:
 Use a smear or pea-sized amount of toothpaste
containing 1,350–1,500 ppm fluoride
 Ensure medication is sugar free
 Give dietary supplements containing sugar and
glucose polymers at mealtimes when possible (unless
clinically directed otherwise) and not last thing at
night. Parents should be made aware of the
cariogenicity of supplements and ways of minimising
risk
Apply fluoride varnish to teeth 3–4 times yearly (2.2% F–)

Prescribe fluoride supplement and advise re maximising

benefit

Reduce recall interval

Investigate diet and assist to adopt good dietary practice

Ensure medication is sugar free or given to minimise

cariogenic effect
 Brush twice daily
 Brush last thing at night and on one other occasion •
Use fluoridated toothpaste (1,350 ppm fluoride or
above)
 Spit out after brushing and do not rinse
 The frequency and amount of sugary food and drinks
should be reduced and, when consumed, limited to
mealtimes. Sugars should not be consumed more than
four times per day
 Fissure seal permanent molars with resin sealant

 Apply fluoride varnish to teeth 3–4 times yearly (2.2% F–)

 For those 8+ years with active caries prescribe daily fluoride

rinse

 For those 10+ years with active caries prescribe 2,800 ppm
toothpaste

 For those 16+ years with active disease consider prescription

of 5,000 ppm toothpaste

 Investigate diet and assist adoption of good dietary practice

 The recommended limits are:
1. up to 2 to 3 units a day for a woman
2. up to 3 to 4 units a day for a man
3. 2 days free from alcohol for everyone.

One unit of alcohol is 10 ml (1 cl) by volume, or 8 g by weight, of pure

alcohol.
For example, one unit of alcohol is about equal to:
•half a pint of ordinary strength beer, lager, or cider (3–4% alcohol by
volume),
a small pub measure (25 ml) of spirits (40% alcohol by volume), or •a
standard pub measure (50 ml) of fortified wine such as sherry or port
(20% alcohol by volume).
there are one and a half units of alcohol in: –
a small glass (125 ml) of ordinary strength wine (12% alcohol by volume),
a standard pub measure (35 ml) of spirits (40% alcohol by volume).
 People who smoke two or more packets of
cigarettes and drink four or more units of
alcohol a day have a 35 times increased risk of
developing oral cancer compared with those
who neither smoke nor drink more than two
units of alcohol a day.
 Within this, 32% of men and 15% of women are
hazardous or harmful alcohol users (23%
overall), which is equivalent to 7.1 million
people in England.
Laboratory studies have shown that the following
types of drinks, foods and medication have
erosive potential:
{ drinks containing citric acid – eg orange,
grapefruit, lemon, blackcurrant / carbonated
drinks; • alcopops and designer drinks/
cider;/ white wine/ some sports drinks which
contain acid/ acidic fresh fruit – lemons, oranges,
grapefruit – that are consumed with high
frequency/ pickles/ chewable vitamin C tablets,
aspirin, some iron preparations.
 Advice that may be given to prevent erosion
progressing:
1.Use toothpaste containing 1,450 ppm fluoride
twice daily.
2. Avoid frequent intake of acidic foods or drinks
– keep them to mealtimes.
3. Do not brush immediately after eating or
drinking acidic food or drinks.
4. Do not brush immediately after vomiting.
 Sugars (excluding those naturally present in
whole fruit) should provide less than 10% of total
energy in the diet or less than 60 g per person per
day. Note that for young children this will be
around 33 g per day.
 Key message 5 – Eat less salt – no more than 6 g a
day
 Key message 6 – Drink plenty of water
 We should be drinking about six to eight glasses
(1.2 litres) of water, or other fluids, every day to
stop us getting dehydrated.
 DIET CHART
 10 % OF THE WATER IN THE UNITED
KINGDOM IS FLOURIDATED
 City to be flouridated in 2011 is Southampton
 Planned flouridation – Parts of the county of
Hampshire.
 INDICATIONS FOR FLOURIDES

- HIGH CARIES RATE/RISK IN INDIVIDUALS

- MENTAL INCAPACITATED PATIENTS
WHO CANNOT MANAGE THEIR ORAL
HYGIENE
- PTS WITH A DRY MOUTH
- POST RADIATION
 ULCERATIVE GINGIVITIS
 GENERALISED STOMATITIS
 Band 1
Diagnosis, treatment planning and
maintenance
Examination, x-rays, scale and polish,
preventative work, for example an assessment
of a patient’s oral health, minor changes to
dentures.
 Band 2
Treatment
Simple treatment, for example fillings
(including root canal treatment), extractions
and periodontal (gum) treatment.
 Band 3
Complex treatment that includes a lab element, for example
bridges, crowns and dentures (excludes mouth guards).
 Urgent treatment
Examination, x-rays, dressings. Re-cementing crowns which
have become loose, up to two extractions and one filling.
 A UDA is variable, one UDA might be worth anywhere
between £15 and £25, but can be more than this or less. The
actual UDA varies according to where in the country a
dentist is located (although it might vary street to street) and
the amount of work previously carried out by the dentist
before the new contract. It is thought that the more
desperate a PCT is for NHS dentists, the more a UDA might
be worth.
This determines what patients pay and the amount of
UDAs a dentist gets.
• Band 1 excluding urgent treatment – 1 UDA

• Band 1 urgent treatment only – 1.2 UDAs

• Band 2 – 3 UDAs
• Band 3 – 12 UDAs
• Issue of prescription – 0.75 UDA
• Repair of dental appliance (denture) – 1 UDA
• Repair of dental appliance (bridge) – 1.2 UDAs
• Removal of stitches – 1 UDA
• Stopping bleeding – 1.2 UDAs
1. Intact dentition and xerostomia after
radiotherapy – OHI and dietary advice??
2. High caries risk and teenager 17 – OHI and
fluoride mouthwash??
3.  Erosion (4 cans Coca-cola per day) – Dietary
advice and fluoride mouthwash??
4. Gingivitis but not other problems – OHI?
5.Maximum recommended alcohol units for
men ??
6.Max. Rec. alcohol units for women ??
 Broader contacts
 Thinner enamel
 M-D width of canines and incisors is lesser
 M-D width of decd. molars is more than
permanent premolars
(Leeway space – upper arch – approx. 1.8mm
lower arch – approx 3.4mm)
 Increased wear and tear
 TELL –SHOW-DO:{ EXPLAINATION OF THE PROCEDURE/
DEMONSTRATION/ DO IS INTIATED WITH MINMAL DELAY}

 Enhancing control: stop signal

 Modelling: watching other pts, dvd
 Behaviour shaping and positive reinforcement
 Distraction: raising their legs as imp is taken
 Desensitization: patients are taught to relax and are
exposed to the stimulus in a hierarchy in turn.
 A stained fissure is taken to mean a fissure which is discoloured, brown
or black.
Also included are fissures where there is an area of white or opaque
enamel, i.e. its normal translucency is lost but which has no evidence
of surface breakdown (cavitation)
cavitation
For carious occlusal pits and fissures on first and second permanent
molars
If fissure caries is suspected, only restore if there is either:
• microcavitation
or
• shadowing visible under the enamel adjacent to the fissure after
cleaning and drying the tooth
or
• dentinal caries clearly visible on a bitewing radiograph
In any of these cases, remove caries, place a restoration, and seal the
remaining fissures. Otherwise place a fissure sealant alone, and
review the tooth at every recall visit.
 Make it a priority to identify and arrest early
enamel-only lesions on the mesial surface of 6s by:
 • applying fluoride varnish, and monitoring for
progression with bitewing radiographs;
 • ensuring parent/carers are aware of the
potential impact on their child’s oral health, and
encouraging them to floss or use floss wands on
the 6/E contact 2–3 times a week;
 • if the distal of the E is carious, considering
managing the E with either a restoration, a Hall
crown or slice preparation (taking care to avoid
iatrogenic damage to the 6), or even extraction of
the E.
 At around the age of 9 years, make an
assessment of the likely prognosis of any 6s
affected by caries. If prognosis is poor, consider
planned loss.
 Manage a primary tooth that is associated with
sepsis (signs or symptoms of abscess, sinus,
inter-radicular radiolucency, non-physiological
mobility) with either a pulp therapy or an
extraction; do not leave sepsis untreated.
 Closely monitor lesions managed with
prevention only. Do not leave active caries in
primary teeth unmanaged.
 Anatomical form makes them plaque retentive
 During eruption tooth is below line of arch and
is missed by the toothbrush
 Molars are not readily accessible being at the
back of the mouth, difficult to brush
 Children may not be adept or motivated to
brush and maintain oral hygiene
 Visual (dry tooth)
 Probe/explorer
 Radiographs
 Fibre Optic Transillumination (FOTI)
 Continuous luminescence (Diagnodent)
 Bright light
 Remove all plaque
 Dry tooth
 Blunt probe
 Brown shiny areas – arrested lesions
 White matt lesions – active caries
 Enameloplasty
 Air abrasion
 Pit and Fissure sealants
 Resin modified Glass Ionomers
 Composite resins
 Silver Amalgam
 Fissure morphology
 Diet
 Level of oral hygiene
 Plaque control
 Mentally or physically disabled
 Medical conditions (cardiac problems,
immunocompromised, blood dyscrasias,
endocrine problems)
 Actual carious involvement of the pit and fissure
 CLEAR, COLOURED OR OPAQUE

 FILLED OR UNFILLED
 Unfilled resins have low wear
resistance
 Marginal leakage
 Clear resins – difficult visual
examination and long term
supervision
 Opaque resins, recommended easily
identifiable
 Composites better than pit and fissure
sealants?
 Composites have better wear resistance,
compressive strength
 Less maintenance
 Wear of opposing tooth an issue with
composites
 Check occlusion
 LA and isolation
 Cleaning (pumice, air polishing or air abrasion
using sod. Bicarbonate or aluminium oxide
powder)
 Etching (whole occlusal surface extending
palatal or buccal as required)
 Washing for approx. 20-30 secs
 Dry tooth surface (hydrophobic sealant - 15-20
secs)
 Apply sealant and cure
 Apply fluoride-containing varnish
 Check occlusion
Pit and fissure decay confined to one area of the
fissure system. The localized decay is present
either in the enamel or involving the dentin.
(natural extension of the pit and fissure sealant
technique)
technique
 Check occlusion
 LA and isolation
 Tooth surface cleaning
 Use of high and low-speed hand with TC 330
bur and small round steel burs respectively
 Cavity kept as small as possible
 Deep dentin – Calcium hydroxide liner
 Dentin replacement –
Resin Modified GIC,
GIC apply polyacrylic acid
conditioner for 10 secs and then wash. Apply
RMGIC and proceed
OR
All-etch technique – composite directly bonded
to etched and bonded enamel and dentin

 After RMGIC used - Etch walls of cavity and

occlusal surface for 20 secs and wash for 20-30
secs
 Dry tooth surface
 Apply bond to enamel walls and occlusal
surface, air dry and cure
 Incremental technique for layering composite
 Remaining pit and fissures are then sealed with
pit and fissure sealant or the composite resin
itself
 Check and adjust occlusion
 CARIES LOW MEDIUM HIGH
RISK
CHILD 3 month 6 month 12 month
ADULT 3 month 6 month 12 month

INTERVAL BETWEEN BITEWING EXAMINATION

CARIES RISK LOW MDERATE HIGH

CHILD 12-18 12 6
ADULT 24 12 6
 Boys affected twice as often as girls
 Anterior teeth more often involved
 Maxillary centrals more common
 Maxillary laterals and mandibular centrals less
commonly involved
 Concussion, subluxation and luxation common
in deciduous dentition
 Permanent teeth uncomplicated fractures
 2-4 yrs most accident prone in prim dent.
 7-10 yrs most accident prone in perm dent
 Child physical abuse or Non-accidental injury,
upto 50 % have facial injuries
 Dental history
when, why, how, where, lost teeth fragments,
vomiting, headache, amnesia,
previous history of trauma
- timing since injury imp for prognosis
- suspicion of NAI
- tetanus prophylaxis
 Medical history
- congenital heart problems
- rheumatic heart fever
- juvenile diabetes
- bleeding disorders
- allergies
- tetanus immunization
 Extra-oral examination
- lacerations, avulsions, contusions
- facial redness, swelling, bruising,
- general body exam
- TMJ
- head and scalp
- signs of shock
- signs of head injury
 Intra-oral examination
- soft tissue examination
- hard tissue exam
. Occlusion
. Mobility
. Tenderness to percussion
. Colour of tooth
. Reaction to sensitivity tests
 Radiographic examination
- PA’s, occlusal views, OPG’s, other extra-oral
views
 Photographic examination

- medico-legal purposes
 2 – 4 yrs most prone to injury
 Extraction vs Maintenance
 If development of permanent tooth bud
jeopardized, primary incisor extracted
 Review every 3-4 months and then annually
 Uncomplicated crown fracture
smooth sharp edges and restore
 Complicated crown fracture

extraction or endo with ZOE cement followed

by restoration
 Crown-root fracture

extraction
 Root fracture
- minimal displacement and mobility, keep
under observation
- If coronal fragment becomes non-vital remove
tooth coronal fragment
- Root fragment remains vital undergoes
resorption
 Concussion , subluxation and luxation
- Concussion
.dentist sees the pt when tooth discolours
- Subluxation
.slight mobility, soft diet
.marked mobility, extraction
- Extrusive luxation
.marked mobility, extraction
- Lateral luxation
.Crown displaced buccally, apex moves
palatally- EXTRACTION
.Crown displaced palatally, apex move buccally
– CONSERVATIVE TREATMENT
- Intrusive luxation
. Displaced palatally – extraction
. Displaced buccally – wait and watch

Review weekly for one month, then monthly for

6 months.
re-eruption between 1-6 months, if no signs
(ankylosis) then EXTRACT
- Exarticulation (Avulsion)
. Replantation not necessary
. Space maintenance not required
. Perm tooth eruption delayed by a month
 PULPAL NECROSIS

 PULP OBLITERATION

 ROOT RESORPTION
 Primary teeth trauma, 12-68 % instances there
are injuries to permanent teeth
 Intrusive luxation most injuries
 Most damage to perm tooth bud under 3 yrs of
age
 Most changes are in morphology and
mineralization of permanent crowns
 White or yellow brown discoloration of enamel – injury
at 2-7 yrs
 Above with circular enamel hypoplasia – injury at 2-7
yrs
 Crown dilaceration – injury at 2 yrs
 Odontoma-like malformation – under 1-3 yrs
 Root duplication – 2-5 yrs
 Vestibular or lateral root angulation and dilaceration –
2-5yrs
 Partial or complete arrest of root formation
 Sequestration of perm tooth buds
 Disturbance in eruption
 Yellow-brown discoloration of enamel with or
without hypoplasia
- Microabrasion
- Composite resin
- Porcelain
 Crown dilaceration
- Surgical exposure with ortho
- Remove dilacerated part of crown
- Temp crown till root formation complete
- Semi or permanent restoration
 Vestibular root angulation
- combined surgical and orthodontic alignment
 Disturbance in eruption

- surgical exposure with ortho alignment

 Enamel infraction
incomplete fracture without loss of tooth
substance – periodic recalls
 Enamel fracture

smooth and splint if necessary

 Enamel-dentin fracture

. Emergency protection
- protect dentin with Calcium hydroxide and
restore with composite
- Calcium hydroxide with glass ionomer with
ortho band or stainless steel crown
. Intermediate restoration
- composite resin, free hand or using a celluloid
crown
- reattachment of crown fragment
 Complicated crown fracture

. Partial pulpotomy or pulpotomy

 Uncomplicated crown-root fracture

. Fracture subgingival
. Gingivoplasty or ortho extrusion and then
restore tooth
 Complicated crown-root fracture
. As above with endo requirements but final
root length should not be shorter than crown
height
 80 % root fractures pulp remains viable and
three categories of repair seen:
1. Repair with calcified tissue
2. Repair with connective tissue
3. Repair with bone and connective tissue

 Fractures occurring in the middle and apical

3rd , reposition luxated crown, sometimes
splinting required
 Root fractures at the cervical third heal as well
except when in communication with gingival
sulcus and if so :
1. Extract coronal fragment retain root
2. Extract two fragments
3. Internally splint root fracture
 Advice on phone
1. Don’t touch root- hold by crown
2. Wash gently under running tap water
3. Replace into socket, sulcus, saline or milk
4. If replaced bite on handkerchief
 Immediate surgery treatment
1. don’t handle root, if replanted remove tooth
2. Rinse tooth with normal saline
3. Give LA
4. Irrigate socket with saline, remove clot, and
foreign material
5. Place tooth into socket
6. Splint for 7-10 days
7. Check occlusion
8. Anti-biotics, mouthwash, soft diet
9. Check tetanus immunization
 Review
1. Radiograph prior to splint removal after 7-10
days
2. Remove splint
3. endodontics
 Primary and young perm. teeth with open
apices have very rich blood supply
 A-delta fibres scanty and sparse in pulp, C
fibres predominate
 Newly erupted teeth have short roots and
blunderbuss apices – unfavourable crown-root
ratio
 Walls are thin but dentin will continue to be
deposited even after eruption – initially
vulnerable to fracture
 Impervious enamel shell breakdown by caries,
trauma, erosion, abrasion etc
 Caries spread very rapid
 Dentinal sclerosis and secondary dentin
deposition inadequte
 Even after .5mm invasion of pulp tooth still
gives reversible pulpitis response
 Radicular pulp great capacity to function if
infected coronal pulp removed
 PERM TOOTH GERM PRESERVATION
 ALVEOLAR HEIGHT AND WIDTH
MAINTENANCE
 Avoid physical and psychological trauma of
extraction
 Medical condition {hemo.}
 Unrestorable tooth

 Uncooperative child

 Medical considerations { congenital/acquired

heart disease}

 Orthodontic considerations
 Mobility
A pulp cap is a layer of lining or cement
material placed onto a thin layer of dentin
overlying a macroscopically unexposed pulp
(indirect pulp cap) or directly on to exposed
pulp tissue (direct pulp cap) with the intention
of preserving the pulp vitality
 Indirect pulp capping

 Direct pulp capping

- primary teeth – contraindicated
Pulp amputation or pulpotomy is a procedure
in which a portion of exposed vital pulp is
removed, usually as a means of preserving the
vitality and function of the remaining portion
 formaldhyde
 Mutagenecity and carcinogenecity

 Absorbed fast in systemic circulation

 Bind with cells in kidneys, lungs and liver

 Pulpotomy:
A. Pulpotomy: 15% Ferric sulphate

b. Two staged pulpotomy:

Ledermix {steroida antibiotic}
a. Bleeding

b. Inadequate LA
 pulpectomy
 Portion of infected irreversibly inflamed
coronal pulp removed
 Vitality and function of radicular pulp
maintained
 Completion of apexogenesis
 General thickening of dentinal walls allowed to
proceed
 Material used for non-vital pulpotomy
 Material used for primary teeth pulpectomy
 Indication of Apexogensis
 Indication of Apexification
 what is cevk pulpotomy
 What is the dental recall interval / x-ray interval
for a child with a high caries risk
 Recall for an adult with low caries index
 What is the Percentage of water fluoridation in UK
 A PATIENT WITH RHEUMATIC FEVER , WILL
U PRESCRIBE AB?