Crohn’s disease is an inflammatory bowel disease of unknown aetiology. However, it shares many features with the autoinflammatory diseases,and some cases are known to be associated with mutations in the gene NOD2 that controls inflammatory responses to bacteria. Mutations cause failure of the formation of the mucin and antimicrobial barrier lining the bowel and may also inhibit degradation of bacteria. Changes in bowel flora are probably also important. Granulomatous inflammation affects the ileocaecal region, causing thickening and ulceration. Symptoms vary with the severity of the disease, but effects can include abdominal pain, variable constipation or diarrhoea and, sometimes, obstruction and malabsorption. Repeated bowel resections may ultimately be needed. Many other sites can be affected including any part of the bowel, joints and skin. Treatment controls symptoms but is not curative. Dietary adjustment, corticosteroids, antibiotics, sulfasalazine or mesalazine, immunosuppressants and tumour necrosis factor (TNF)-alpha blockers (e.g. infliximab) are used.
Oral effects 1)Most patients have no oral signs, although aphthous ulcers and candidosis may be associated with anaemia.
2)When the disease process itself affects the mouth, the signs and symptoms are the same as those in orofacial granulomatosis.
3)Non-caseating granulomas resembling those in the intestine develop in the oral mucosa. The common sites of involvement are lips and buccal mucosa. These show prominent oedema with folds tethered to the underlying deeper tissues, producing the characteristic cobblestone mucosa appearance.
4)Linear ulcers often run along the buccal sulci, particularly the lower sulci, and have hyperplastic folds of inflamed mucosa along their margins. The gingiva show an erythematous nodular gingivitis with hyperplastic tags.
5)The granulomas are typically small, loose and contain few multinucleate giant cells and are often sited deeply in underlying muscle. They may be few in number, and a biopsy needs to extend unusually deeply to increase the chance of finding them because only by identifying granulomas can the diagnosis be made. The granulomas are associated with vascular dilatation and tissue swelling in early disease. Later, there is dense fibrosis that fixes the tissues in their distorted shape.
These features can be the presenting features of Crohn’s disease, and occasionally oral lesions precede gastrointestinal symptoms by a long period. Oral disease is much more likely to progress to bowel disease in children than when diagnosed in an adult.
Typical orofacial features of Crohn’s disease: • Diffuse soft or tense swelling of the lips, or mucosal thickening • Cobblestone thickening of the buccal mucosa, with fissuring and hyperplastic folds • Gingivae may be erythematous and swollen • Sometimes, painful mucosal ulcers, linear in sulci or resembling aphthae • Mucosal tags in sulcuses • Glossitis due to iron, folate or vitamin B12 deficiency can result from malabsorption • Orofacial granulomatosis shares many features
Oral lesions may lessen in severity with treatment of systemic disease. Aggressive treatment is merited in the early stages to prevent fibrosis and permanent disfigurement. The same drugs as are used for bowel disease are required, together with steroid injections of swollen mucosa.
Dr. Iswarya V, BDS
REFERENCE: Cawson’s Essentials of Oral Pathology and Oral Medicine – E. W. Odell
The following fundamental rules apply to every surgical procedure, concerning the incision and flap:
1) The incision must be carried out with a firm, continuous stroke, not interrupted strokes. During the incision, the scalpel should be in constant contact with bone. Repeated strokes at the same place,many times, impair wound healing.
2) Flap design and incision should be carried out in such a way that injury of anatomic structures is avoided, such as: the mental neurovascular bundle, palatal vessels emerging from the greater palatine foramen and incisive foramen, infraorbital nerve, lingual nerve, submandibular duct, parotid duct, hypoglossal venous plexus, buccal artery (of concern when incision of an abscess of the pterygomandibular space is to be performed), facial nerve and facial artery and vein, which are of concern basically for the drainage of abscesses performed with extraoral incisions.
3)Vertical releasing incisions should begin approximately at the buccal vestibule and end at the interdental papillae of the gingiva.
4) Envelope incisions and semilunar incisions, which are used in apicoectomies and removal of root tips, must be at least 0.5 cm from the gingival sulcus.
5) The elliptic incision, which is used for the excision of various soft tissue lesions, comprises two convex incisions joined at an acute angle at each end, while the depth of the incision is such that there is no tension when the wound margins are sutured.
6) The width of the flap must be adequate, so that the operative field is easily accessible, without creating tension and trauma during manipulation.
7) The base of the flap must be broader than the free gingival margin, to ensure adequate blood supply and to promote healing.
8) The flap itself must be larger than the bone deficit so that the flap margins, when sutured, are resting on intact, healthy bone and not over missing or unhealthy bone, thus preventing flap dehiscence and tearing.
9) The mucosa and periosteum must be reflected together. This is achieved (after a deep incision)when the elevator is continuously kept and pressed firmly against the bone.
10) When the incision is not made along the gingival sulcus, for esthetic reasons, and especially in people with broad smiles, the scar that will result must be taken into consideration, particularly on the labial surface of the front teeth.
11) During the surgical procedure, excessive pulling and crushing or folding of the flap must be avoided, because the blood supply is compromised and healing is delayed.
Types of Flaps Various types of flaps have been described in oral surgery, whose name is based mainly upon shape. The basic flap types are: trapezoidal, triangular, envelope, semilunar, flaps created by and incisions, and pedicle flaps.
Trapezoidal Flap The trapezoidal flap is created after an incision, which is formed by a horizontal incision along the gingivae, and two oblique vertical releasing incisions extending to the buccal vestibule. The vertical releasing incisions always extend to the interdental papilla and never to the center of the labial or buccal surface of the tooth. This ensures the integrity of the gingiva proper, because if the incision were to begin at the center of the tooth, contraction after healing would leave the cervical area of the tooth exposed. A satisfactory surgical field is ensured when the incision extends at least one or two teeth on either side of the area of bone removal. The fact that the base of the resulting flap is broader than its free gingival margin ensures the necessary adequate blood supply for the healing process. The trapezoidal flap is suitable for extensive surgical procedures, especially when the triangular flap would not provide adequate access.
Advantages. Provides excellent access, allows surgery to be performed on more than one or two teeth, produces no tension in the tissues, allows easy reapproximation of the flap to its original position and hastens the healing process. Disadvantages. Produces a defect in the attached gingiva (recession of gingiva).
Triangular Flap This flap is the result of an L-shaped incision, with a horizontal incision made along the gingival sulcus and a vertical or oblique incision. The vertical incision begins approximately at the vestibular fold and extends to the interdental papilla of the gingiva. The triangular flap is performed labially or buccally on both jaws and is indicated in the surgical removal of root tips, small cysts, and apicoectomies.
Advantages. Ensures an adequate blood supply, satisfactory visualization, very good stability and reapproximation; it is easily modified with a small releasing incision, or an additional vertical incision, or even lengthening of the horizontal incision. Disadvantages. Limited access to long roots, tension is created when the flap is held with a retractor, and it causes a defect in the attached gingiva.
Envelope Flap This type of flap is the result of an extended horizontal incision along the cervical lines of the teeth. The incision is made in the gingival sulcus and extends along four or five teeth. The tissue connected to the cervical lines of these teeth and the interdental papillae is thus freed. The envelope flap is used for surgery of incisors, premolars and molars, on the labial or buccal and palatal or lingual surface, and is usually indicated when the surgical procedure involves the cervical lines of the teeth labially (or buccally) and palatally (or lingually), apicoectomy (palatal root), removal of impacted teeth, cysts, etc.
Advantages. Avoidance of vertical incision and easy reapproximation to original position. Disadvantages. Difficult reflection (mainly palatally), great tension with a risk of the ends tearing, limited visualization in apicoectomies, limited access, possibility of injury of palatal vessels and nerves, defect of attached gingiva.
Semilunar Flap This flap is the result of a curved incision, which begins just beneath the vestibular fold and has a bowshaped course with the convex part towards the attached gingiva. The lowest point of the incision must be at least 0.5cm from the gingival margin, so that the blood supply is not compromised. Each end of the incision must extend at least one tooth over on each side of the area of bone removal. The semilunar flap is used in apicoectomies and removal of small cysts and root tips.
Advantages. Small incision and easy reflection, no recession of gingivae around the prosthetic restoration, no intervention at the periodontium, easier oral hygiene compared to other types of flaps. Disadvantages. Possibility of the incision being performed right over the bone lesion due to miscalculation, scarring mainly in the anterior area, difficulty of reapproximation and suturing due to absence of specific reference points, limited access and visualization, tendency to tear.
Flap Resulting from Y-shaped Incision.An incision is made along the midline of the palate, as well as two anterolateral incisions, which are anterior to the canines. This type of flap is indicated in surgical procedures involving the removal of small exostoses.
Flap Resulting from X-shaped Incision. This type of flap is used in larger exostoses, and is basically an extension of the -shaped incision. The difference is that two more posterolateral incisions are made, which are necessary for adequate access to the surgical field. This flap is designed such that major branches of the greater palatine artery are not severed.
Pedicle Flaps The three main types of pedicle flaps used for closure of an oroantral communication are: buccal, palatal, and bridge flaps.
Buccal Flap. This is a typical trapezoidal flap created buccally, corresponding to the area which is to be covered, and is usually used on dentulous patients. It is the result of two oblique incisions that diverge upwards, and extend as far as the tooth socket. After creating the flap, the periosteum is incised transversally, making it more elastic so that it may cover the orifice that results from the tooth extraction. The oblique buccal flap is a variation of the buccal flap. It is the result of an anteroposterior incision, so that its base is perpendicular to the buccal area, posterior to the wound. The flap is rotated about 70°-80° and is placed over the socket. Both cases require that, before placing the flap, the wound margins must be debrided.
Palatal Flap. This type of flap is used in edentulous patients so that the vestibular depth is maintained. The resulting palatal mucoperiosteal flap is rotated posteriorly and buccally, always including the vessels that emerge from the corresponding greater palatine foramen. After rotation, the flap is placed over the orifice of the socket, the wound margins are debrided, and the flap is sutured with the buccal tissues. A gingival dressing is applied for a few days at the void created and healing is achieved by secondary intention.
Pedicle Bridge Flap. This flap is palatobuccal and is perpendicular to the alveolar ridge. After creation, the flap is rotated posteriorly or anteriorly, to cover the orifice of the oroantral communication, without compromising the vestibular fold. This type of flap is used only on edentulous parts of the alveolar ridge.
Dental caries is caused by bacteria, and as ozone will kill certain bacteria,many studies have investigated whether ozone is effective in arresting the progression of caries. No serious side effects to the treatment have been reported.
Advocates of this treatment modality recommend ozone as a disinfectant gas to eliminate bacteria from occlusal caries (up to 2mm in depth), root carious lesions, and pit and fissure lesions, often with the absence of further operative treatment. The carious lesion is encouraged to remineralize over 4 weeks using fluoride and mineral mouthwashes, toothpaste, and sprays.
Baysan and Lynch (2004) found that ozone application for 10–20s eliminated most of the microorganisms found in primary root caries lesions. Ozone can reduce the numbers of S. mutans and S. sobrinus on saliva-coated glass beads in vitro (Baysan et al. 2000). However, the role that this disinfection process can play in the long-term reversal of previously active carious lesions is controversial.
Rickard et al. (2004) analyzed the available published literature and concluded that “given the high risk of bias in the available studies and lack of consistency between different outcome measures, there is no reliable evidence that application of ozone gas to the surface of decayed teeth stops or reverses the decay process.” Further research is necessary
With the HealOzone system (KaVo Dental, Biberach, Germany), ozone gas is delivered via a special handpiece that fits over and bathes the tooth. HealOzone (KaVo Dental, Biberach, Germany) delivers ozone gas, which disinfects the tooth. The minimally carious lesion is encouraged to remineralize over a period of 4 weeks using fluoride and mineral mouthwashes, toothpaste and sprays.
Carisolv is a chemomechanical method of removing dental caries that is minimally invasive. First of all a fluid is mixed consisting of a cocktail of amino acids and 0.5% sodium hypochlorite, and is applied to the dentin. The amino acids and hypochlorite form high-pH chloramines (pH 12), which react with the denatured collagen in the carious dentin, allowing it to be removed more easily. The softened dentin is removed by scraping the surface with special hand instruments.
This technique requires longer clinic time than similar cavity preparation employing conventional bur removal. However, because only soft carious dentin is affected and not normal dentin, the need for anesthesia is reduced, which is a major advantage in dental-phobic patients, children, and special needs patients.
The technique is useful for the removal of root or coronal caries where access is easily obtained, but requires repeated application of the solution over the caries.
Use of Carisolv Gel may be an inefficient method of removing caries at the enamel-dentin junction. Carious dentin may go unnoticed beneath the overhanging enamel because ideal access may require extensive preparation with a rotary bur. However, in this region, conventional removal of caries with a bur can be demanding, even when using magnifying loops.
Kidd et al. (1989) showed that demineralized dentin remained at the enamel-dentin junction in 57% of cavities that had originally been assessed as caries-free using conventional visual and tactile means. Some bacteria will remain at the enamel-dentin junction whatever approach is adopted therefore stained, hard dentin should be left alone in this area and no attempt should be made to remove it.
Carisolv Gel removes the smear layer and has no adverse effect on the bond strength of adhesive materials to dentin. Should Carisolv come into contact with exposed pulp tissue, no toxic effect should be expected.
Young et al. (2001) found no adverse effects with Carisolv when it was left in contact with rat pulp tissue.
Bulut et al. (2004) exposed the pulp chambers of 40 human first premolars with class V cavities and applied either Carisolv or sterile saline solution for 10min. The cavities were restored with a compomer filling material and the teeth extracted after either 1 week or 1 month. No adverse histologic effects due to Carisolv were observed.
AMALGOMER Technology is the latest innovation in restorative dentistry. For the first time the strength of a classic amalgam restorative has been combined with the aesthetics and the many other advantages of Glass Ionomers.
In short AMALGOMER is the world’s first GIC to pass the ISO strength test requirements for amalgam (ISO1559:2001) as well as that of the GIC standard (ISO9917:1991).
Designed to match the strength and durability of amalgam
Superb aesthetics, Industry standard shading
Minimal cavity preparation
Natural adhesion to tooth structure, Good biocompatibility
Hard, snappy chemical set with good working time
Water mix and Powder/Liquid versions available
No shrinkage, corrosion, expansion or thermal conductivity problems associated with other filling material
Amalgomer CR High Strength Posterior GI
AMALGOMER CR High Strength Posterior GI Restorative offers a wide range of features:
1) Ceramic Reinforcement
2) Exceptionally low wear
3) High Radiopacity
4) Excellent for core build ups
5) High strength, exceeds 300MPa compressive strength
6) Universal tooth shade or white
7) Natural Adhesion to tooth structure
Amalgomer High Strength Anterior GI
AMALGOMER High Strength Anterior GI Restorative offers a wide range of features:
7 Vita® Shades A1, A2, A3, A3.5, B2, B4 and C3
High Strength, exceeds 300MPa compressive strength
Natural Adhesion to tooth structure
Amalgomer Light Cure Varnish
A light curable varnish for protection of AMALGOMER and AMALGOMER CR restorations. This protects the restoration against moisture. This can be used with any GI restorative.
Dentine conditioner for use prior to placing AMALGOMER and AMALGOMER CR restorations.
It is a natural Fibrin-based biomaterial prepared from autologous blood and is clinically used to deliver growth factors in high concentration to the site having a bone defect or requiring augmentation.
It is introduced by Dr. Choukroun. et. Al, 2000. It is a second generation platelet concentrate that contains platelets and growth factors, prepared from self blood devoid of anticoagulant or other artificial modifiers.
10ml of human blood is taken in a test-tube without any anticoagulant and is centrifuged in a tabletop centrifuge machine for 12 minutes at 2500RPM or 10 minutes at 3000RPM.
After centrifugation, the three components in the blood are localised in the test tube.
Red blood cells (at bottom)
A Fibrin clot (in middle)
Plasma (at top)
Fibrin clot is extracted from the test-tube with a pair of sterile forceps and PRF is obtained by removing the red clot from its lower end.
Have you ever dreamt of having wonderful lips as you see in ads?
Are you worried about how your lips do appear?
YES. Find out the route to ‘pretty lips’ – Lip Fillers
Lips and eyes make up the important parts of face and determine to an extent, the beauty of an individual. Lips form a major aspect of cosmetic treatment.
Factors to consider for lip augmentation :
Lips in relation to teeth
Lips should look gentle and natural
Ageing can lead to thinner lips
Injectable intradermal Fillers are commonly used for lip augmentation. These can be done fully in a single session. The procedure seem difficult and challenging but can be done in a safe, effective and as an in-office procedure by a skilled professional. It is advisable to consult a plastic surgeon before any cosmetic procedure.
There are many types of intradermal Fillers, the most common being products that contain substances similar to hyaluronic acid. Allergic reactions are unlikely as these are biocompatible.
A minimally invasive treatment with little chair time and minimal post operative effects.
Replenishes lost volume for a softer, younger look.
Hydrated lips give a more youthful looking appearance.
Results typically last for 9 – 12 months.
Points to ponder:
Care should be taken on dosage and area of injection. Symmetry of face should be balanced.
Ensure that the Fillers are branded and US FDA approved for safety.
Your consultant doctor should have adequate knowledge and training to do the procedure.
Inform your professional about any allergies you have prior to treatment.
Diagnosis • Demonstration of HAV antigen in feces. • Serology: detection oflgM anti-HAV.
Clinical features • The incubation period is 2-7 weeks.
Many infections are asymptomatic. Clinical disease is mild with few complications. There is no carrier state.
Prevention and Control
Good hygienic measures and sanitary disposal of excreta. Passive immunization gives immediate protection for 3-6 months. Active vaccination: the formalin-inactivated vaccine provides protection for up to 10 years. HAV is not a major cross-infection hazard in dentistry but is a hazard if traveling, especially to the tropics.
Hepatitis B virus (HBV)
This highly infectious blood-borne virus poses a major cross-infection hazard in surgery and dentistry: • It is a member of the hepadnavirus family. • The intact viral particle (Dane particle) has a double-shelled structure, with the outer hepatitis B surface antigen (HBsAg) coat surrounding the central hepatitis B core antigen (HBcAg), DNA, and DNA polymerase. • Peripheral blood of infected patients also contains non-infective spherical and filamentous particles of HBV
• HBV can be present in blood, saliva, cervical secretions, and semen.
• Spread is via the parenteral route, especially by intravenous drug use, but transmission by intimate contact and sexual activity also occur.
• Perinatal infection is important in certain parts of the world, for example east and southeast Asia.
• There is a large reservoir of unidentified carriers within the population.
• Infected patients may have up to 1010 Dane particles per ml of blood; as little as 0.0001 ml of blood may transmit the infection.
• HBV has been transmitted in dentistry, to patients and dental staff. Some have died from infection.
• Initial screening is for HBsAg; if present, it indicates infection with HBV.
• Screen then for HBeAg. If present, the person is at high risk for transmission.
• A minority who are HBeAg negative can also transmit infection. Hepatitis B carriers produce HBsAg and, in high-risk carriers, HBeAg for many years.
• Development of anti-HBs, anti-Hbe, and anti-HBc antibodies is associated with recovery. The incubation period is 2-3 months duration. There are a number of possible outcomes of exposure to HBV:
• Subclinical infection (65%).
• Acute hepatitis B with full recovery (30%).
• Chronic carriage (up to 9% of adults): this gives a long-term risk of cirrhosis, liver failure, and hepatocellular carcinoma. Carriers remain infectious to others.
• Fatal fulminant hepatitis (1 %).
Prevention and Control
• Modifications to behavior.
• Adequate infection control procedures in clinical practice.
• Passive immunization: hyperimmune hepatitis B immunoglobulin is used following a single acute exposure in an unprotected individual.
• Active immunization. Hepatitis B vaccine consisys of20 mg ofHBsAg given intramuscularly at 0, l, and 6 months. Boosters have been recommended at 5-year intervals. All vaccinees should have their serum antibody level assessed after vaccination. High-risk carriage of HBV should be excluded in non-responders who are health care workers.
• Interferon may be effective in the treatment of chronic HBV infection.
Hepatitis C virus (HCV)
This blood-borne virus, discovered in 1989, is responsible for most cases of what was previously known as parenterally transmitted non-A, non-B hepatitis(NANBH). Is an enveloped RNA virus. • Is related to animal pestiviruses and human flaviviruses. • Has multiple genotypes. • Cannot be grown in tissue culture.
Diagnosis • Serological. • Initial detection of HCV antibodies. • Confirmation by PCR for HCV RNA.
Transmission • The prevalence of HCV antibodies among UK blood donors is 0.1-0.3%. • In recipients of blood products and among intravenous drug users the seroprevalence is high(> 80%). • Parenteral transmission is the major route, especially in intravenous drug use. • Sexual transmission is inefficient. • Occupational transmission may be through needlestick injuries, though it is less infectious than HBV. • Undefined routes: in a significant number ofHCV-infected individuals, the route of infection is unknown.
Clinical features • The mean incubation period is 6-12 weeks. • Acute disease is mild and often subclinical. • Chronic disease is common (> 60%). These patients may develop longterm liver disease, including hepatocellular carcinoma. Some patients may develop oral disorders similar to Sjogren’s syndrome or lichen planus.
Prevention and Control • Changes in behavior, e.g. needle exchange schemes for intravenous drug users. • Screening of donated blood. • Effective universal infection control in health care settings. • No vaccine is available. • Treatment of chronic carriers with interferon and ribavirin is effective in about 40% of cases.
Hepatitis D virus (HDV)
• A defective, independently transmissible agent which requires hepatitis B virus for replication. • In developed countries it is mainly a problem among intravenous drug users. • The genome is single-stranded RNA. • Transmission is primarily parenteral, either at the time of first infection with HBV (co-infection) or during a subsequent exposure in a patient already infected with HBV (superinfection). • HDV increases the severity of HBV infection and fulminant hepatitis is common. • HDV has been transmitted in dentistry, to patients and dental staff. Dental patients have died from infection.
Hepatitis B vaccination is protective.
Hepatitis E virus
This recently discovered virus causes the disease described previously as enterically transmitted non-A, non-B hepatitis: • It is a spherical, non-enveloped, RNA virus. • Transmission is via fecal!y contaminated drinking water. • The incubation period is 2-9 weeks. • It mainly affects young adults. • Infection is usually self-limiting. • There are no chronic carriers. • Infection carries a high mortality (up to 20%) in pregnancy. • It is not a major cross-infection risk in surgery.
Hepatitis G virus
• Hepatitis G is a flavivirus, first isolated in 1995 from a patient with chronic hepatitis. • Seroprevalence studies show evidence of infection in 3% of blood donors in the United Kingdom, 18% of hemophiliacs, and 33% of intravenous drug users. • Hepatic damage appears mild or absent and the virus is not considered an important pathogen. • It is not a major cross-infection risk in surgery.
Crevicular fluid is a serum ultrafiltrate that accumulates in gingival connective tissue resulting from increased vascular permeability. When its production increases, it passes to the gingival crevice.
Gingival crevicular fluid contains products derived from microbial plaque, tissue breakdown, host cells, and host immunity that, in some instances, have been demonstrated to be related to the active phases of periodontal destruction.
Aspartate aminotransferase (AST) is an enzyme normally confined to cell cytoplasm, but is released to the extracellular environment upon damage. AST levels in serum and other body fluids ( cerebrospinal fluid, arthritic joint fluids) have been used for several decades as a laboratory diagnostic aid for assessing tissue destruction (i.e.MI, hepatitis). Furthermore, the amount of AST activity observed generally reflects the extent of cell death and, consequently, the magnitude of tissue destruction. AST activity greatly depends on cellular damage in periodontal tissues. Levels of various inflammatory cytokines can also be determined in GCF.
The periimplant gingival sulci has been shown to be similar to the periodontal crevice with respect to gingival fluid flow. In spite of this observation, to date relatively few studies have focused their attention on the investigation of the periimplant crevicular fluid (PCF) components and their relationship with the peri-implant condition.
Functions of GCF:
• Promotes adhesion of the gingival crevice epithelium to the enamel through the presence of salivary and plasma proteins. • Defense through the presence of inflammatory cells and molecules. • Elimination of micro-organisms and food debris through the washout effect of fluid formation.
Diet can affect teeth: • Pre-eruptively—fluoride is the most important. The effect of calcium,phosphate, vitamins, and sugar is unclear, but is unlikely to be great. • Post-eruptively—again, fluoride is important, as is sugar. Acidic foods or drinks can cause erosion.
Aim: To determine the time for which the teeth are at risk of demineralization and increase the potential remineralization period. Indications:
(i) high caries activity,
(ii) unusual caries pattern,
(iii) suspected dietary erosion.
Dietary advice should be tailored to the individual. This is most easily done after analysing the patient’s present eating pattern.
A consecutive 3- or 4-day analysis (including at least one weekend day) is the most widely used, with the patient recording the time, content, and quantity of food/drink consumed. In addition, toothbrushing and bed-time should be indicated. When the form is returned the entries should be checked with the patient.
Analysis: • Ring the main meals. If in any doubt,identify those snacks that contain complex carbohydrate. Assess nutritional value of meals. • Underline all sugar intakes in red. • Identify between-meal snacks and note any associations, e.g. following insubstantial meals or at school. • Decide on a maximum of three recommendations.
Dietary advice should include an explanation of the effect of between-meals eating and sugary drinks. It must also be personal, practical,and positive! The suggestion that a child should select crisps when friends are buying sweets is more likely to be followed than total abstinence.
Some helpful hints: • Save sweets to be eaten on a day, e.g. Saturday dinnertime, or to be eaten at the end of a meal. • All-in-one chocolate bars are preferable to packets of individual sweets. • Foods which increase salivary flow (e.g. cheese, sugar-free chewing gum) can help to reverse the pH drop due to sugar if eaten afterwards.
• Treacle, honey, and fruit (especially fruit juice) are cariogenic. • Artificial sweeteners should be avoided in pre-school children. • Fibrous foods, e.g. apples, are preferable to a sucrose snack, but they can still cause decay and there is no evidence that they can clean teeth. Where the nutritional content of meals is inadequate, considerable tact is necessary. It may be possible to suggest that larger meals would reduce the temptation to eat snacks. For children who are ‘picky’ eaters snacks and sweets saved until the end of a meal can act as an encouragement to consume more food at mealtimes.
Remember that while cheese, peanuts, and crisps may constitute a safe snack in dental terms, they are all high in fat, and peanuts can be inhaled by small children. Also, ‘diet’ cola drinks are sugar-free, but can still cause erosion if large quantities are drunk. Therefore, dental dietary advice should be given in the wider context of the general health of the individual, i.e. decrease consumption of sugars and fats, and increase consumption of fibre-rich starchy foods, fresh fruit, and vegetables. Meals provide a better nutritional balance than snacks. Hence good eating/drinking at mealtimes and avoiding between meals snacking is healthy.