OHE
- Created by: brogan2001
- Created on: 25-02-23 19:50
erupting dates permanent dentition
6-7- lower and upper central incisors, first molars
7-8- upper and lower laterals
9-10- lower canines
10-11- first pre-molars
11-12- second pre molars and upper canines
12-13- second molars
17-24- wisdom teeth
erupting dates primary
6-12 months - A/B
12-24 months- D
14-20 months- C
18-30 months- E
functions of teeth
molars and pre-molars- chewing
incisors central and lateral- biting
canines tearimg
organic and inorganic
enamel - 96% inorganic / 4% organic
dentine- 70% inorganic / 30% organic
cementum- 45% inorganic / 55% organic
enamel
made up of prisms crystals of hydroxyapatite arranged vertically in wavy pattern. prisms supported by matrix of organic material including keratinised cells.
properties:
- hardest substance in body
- brittle # when dentine weakened by decay
- insensitive to stimuli
- darkens slightly with age, secondary dentine placed down, stains from proteins in diet, tannin-rich food and drinks and smoking
dentine
main bulk of tooth, consists of microscopic tubules running in curved pattern.
properties:
- softer than enamel but harder than cementum and bone
- light yellow
- sensitive to stimuli
lays down secondary dentine through life
cementum
covers surface of root and provides attachment for periodontal ligament
properties:
- similar hardness to bone
- thickens through life to counteract wear and tear caused by chewing and movement
pulp
soft living tissue within pulp chamber and root canal of tooth. consists of blood vessels, nerves, fibres and cells
properties:
- pulp chamber shrinks with age as more secondary dentine is laid down so tooth becomes less vulnerable to damage.
periodontium
supporting structures of the tooth
compromises:
- periodontal ligament
- cementum
- alveolar bone
- gingivae
periodontal ligament
connective tissue that holds the tooth in place in the alveolar bone
ligament between 0.1-0.3mm wide
contains - blood vessels, nerves,cells, and collagen fibres
collagen fibres attach tooth to alveolar bone and run in different directions proving strength and flexibility.
acts as a shock absorber, teeth need to move slightly in sockets to withstand pressures of mastication
alveolar bone
horseshoe-shaped projections of maxilla and mandible.
provide attachment for fibres of periodontal ligament, sockets for the teeth and support teeth by absorbing and distributing occlusal forces.
gingivae
consists of mucous membranes and underlying fibrous tissue, covering alveolar bone
- attached gingiva - firm, pale pink, stippled gum tightly attached to underlying bone. keratinsied to withstand chewing.
stippling comes from tightly packed bundles of collagen fibre that attach it to bone
- free gingiva - gum meets tooth. less tightly attached and not stippled. keratinised and contoured to form idp
indentation between attached and free ginigva is the free gingival groove
- gingival crest - edge of gum and idp bordering tooth. behind crest is sulcus(crevice)no more than 2mm in depth. base of crevice lined with cells called junctional epithelium (attechs gum to tooth) when breaks down in disease, perio ligament fibres exposed to bacteria enzymes/toxins. perio pocket is formed
- mucogingival junction- meeting point of keratinised attached gingiva and non-kertinised vestibular mucosa
tongue
Dorsal upper surface- covered by thick keratinised epithelium to withstand chewing, large projection of papillae. papillae contain taste buds.
dorsal divided into 2 sections - anterior and posterior
ventral - covered in thin mucous membrane. in middle of front section, mucosa divided by sharp fold (lingual frenulum) joins tip of tongue to floor of mouth
tip- pointed front, protruded or moved around the mouth by muscular action.
root- deep attachment of tongue, forms anterior surface of pharynx
functions of tongue
muscles
- intinsic - alter shape
- extrinsic - move tongue and helps alter shape
functions
- taste - covered with taste buds to distinguish between sweet, sour, salt, bitter, and savoury tastes.
- mastication- helps pass mass of chewed food along dorsal surface and presses against hard palate.
- deglutition - helps pass bolus towards entrance of oesophagus
- speech- movement plays part in production of different sounds
- natural cleansing- allow movement and tongue can help remove food particles from all areas of mouth
- protection- moves saliva (antibacterial property) around
salivary glands
parotid - in front of the ear. largest gland , produces 25%. serous saliva (watery) transported in mouth by parotid duct that opens adjacent to upper molars. swells during mumps
submandibular- beneath mylohyoid muscle towards base of mandible. produces serous and mucous salvia. produces 70% saliva. opens via submandibular duct on floor of mouth
sublingual gland - beneath anterior floor of mouth under front of tongue. produces 5% saliva. in form of mucous. drains through many small ducts on ridge of sublingual fold.
composition of salvia
made up of 99.5% water and 0.5% dissolved substances
disolved substances:
- mucins - glycoproteins that give saliva its viscosity (stickiness) lubricates oral tissues and are origin of salivary pellicle
- enzyme
- - salivary amylase (ptyalin) converts starch into maltose
- -lysozyme attacks the cell walls of bacteria, protect cavity from invading pathogens
- serum proteins - albumin and globulin (saliva formed from serum)
- waste products- urea and uric acid
- gases- oxygen, nitrogen and carbon dioxide in solution. latter vaporises when enters mouth and gives off a gas
- inorganic ions- sodium, sulphate, potassium, calcium, phosphate, and chloride. calcium and phosphate ions which are connected to remineralisation and development of calculus
- saliva- large amounts of microorganisms and remnants of food substances
functions of saliva
- aids mastication and deglutition.- mucous helps form food bolus
- OH- washing and antibacterial action helps control disease of the oral cavity. lysozyme controls bacterial growth
- speech- lubricant
- taste - saliva dissolves substances and allows taste buds to recognise taste
- helps maintain water balance. when water balance low saliva is reduced.
- excretion- trace amounts of urea and uric acid
- digestion - salivary amylase begins the breakdown of cooked starch
- buffering action- maintains neutral PH. Biocarbonante ion is vital to health of mouth as concerned with buffering action. Average PH is 6.7.
saliva facts
- more screted when required
- compsoition varies according to what is being eaten (more mucous with meat)
- average amount produced daily by adults is 0.5-1 L. certain medical conditions cause overproduction of saliva resulting in dribbling
- flow ceases during sleep
- saliva sterile until enters mouth
- saliva tests can solve crimes as contains DNA.
other additives in the mouth
- microorganism - bacteria, viruses and fungi
- leucocytes (white blood cells) which fight infection. not present in edentulous babies or from duct so comes from gingival crevice after teeth erupt
- dietary substances. (meal remains)
plaque
soft non-calcified adherent film that collects on the surfaces of teeth and compromises:
70% microorganisms = 30 % matrix
most common sites
- occlusal pits
- fissures
- cervical margins
- periodontal pockets
natural balance of bacteria but when antiobiotics /illness affect the balance or teeth not cleaned often/appropriately, plaque matures. waste products produce inflmmatory response in gingival tissues leadimg to gingivitis. sometimes can progress to perio.
bacteria
microorganism found in plaque biofilm.
aerobic bacteria - oxygen dependent, streptococci genus. can feed on sucrose from diet and produce sticky substances that enable other harmful organisms to attach causing plaque to dense and be harmful to tissues
- streptococcus sanguis
- streptococcus mutans
- streptococcus mitis
- streptococcus salivarius
anaerobic - more potentially pathogenic (disease causing). produce enzymes and toxins and do not need oxygen to survive. found in deeper layers of plaque and areas of mouth (perio pockets)
- fusiforms
- vibrios
- spirochaetes
microorganisms
bacteria - aerobic and anearobic. - streptococcus mutans
fungi- such as candida albicans. does not affect oral cavity unless bodys resistance is lowered and immune system is upset. can cause dental thrush or stomatitis
virus- herpes simplex virus which causes coldsores
the matrix
substances that make up matrix
- proteins and carbohydrates
- dead cells
- red blood cells
- white blood cells
- antigens
- enzymes and toxins
- lactic acid
- mineral salts
plaque formation
stage 1- within few mins of cleaning the tooth is covered in a sticky film made from salivary proteins called salivary pellicle. provides receptors for early bacterial colonisers to attach to . early aerobic bacteria are gram-positive and feed on sugars in diet.
stage 2- bacteria begins to produce substances that anchor them to the pellicle, increasing adhesive properties to plaque. matrix builds with some matrix components made by bacteria.
stage 3- bacteria produce carbon dioxide and excrete waste products. enviroment becomes more attracted to gram-negative species. plaque becomes thicker and denser as it matures, contains species that have potential to cause disease
stage 4- biofilms thicken, some bacteria start to die or break off to form new colonies. bacteria within the colony reproduce to replace those that have broken away or died
secondary factors in retention of plaque
- large or uneven restorations
- bridges
- crowns with poor margins
- implants
- dentures
- ortho appliances
- pockets
plaque control
physical - toothbrushing
chemical - chlorhexidine mouthwash, not needed by all patients
a low sucrose diet
calculus
mineralised hard deposit of calcium salts that form plaque. plays role in development of perio by attarcting more plaque.
calculus consists of:
- 70% inorganic salts
- 30% mircoorganisms and organic materials
types of calculus
supra gingival- above gingival margin. forms after 2-14 days of inadequate plaque removal, depending on pt cleaning ability and mineral content in saliva, most found on teeth adjacent to main salivary ducts. usually preceded by plaque accumlation that becomes hardened by mineral salts in saliva, some pt have more than others as:
- have more calcium and phosphate ions in saliva
- do not remove plaque effectively
- have highly alkaline saliva that favours production
subgingival- forms in periodontal pocket, below gum margin. often black, dark brown or green and formed when fluid in gingval crevice come in comtact with plaque . indicates periodontitis is present
staining, intrinsic
describes pigment deposit on teeth. can be instrinsic or extrinsic
intrinsic - staining within tooth structure during its development or before birth. cannot be removed, tooth whitening can conceal them.
causes:
- tetracycline - an antibiotic taken by baby, young child or pregnant mother (white, yellow, brown, and grey) not recomended for children under 12 or pregnant women.
- fluoride taken in excess- tablets, swallowing tp and naturaly occuring high levels in water. called fluorosis.
- systemic upset- premature birth, acute illness as baby, young child or pregnant mother can cause hypoplasia- underdevelopment of tooth
- rare inhertited imperfections in enamel or dentine - amelogenesis imperfecta, dentinogenesis imperfecta
- death of pulp
- age - teeth darken with age
extrinsic staining
extrinsic staining - occurs on enamel surfaces after tooth erupted, when pigments stain the salivary pellicle
causes:
- tannin (tea,coffee and red wine
- tobacco
- betel nut
- mouthwash - chlorhexidine or essential oils
- iron supplements
- foods - berries and trmeric
can be removed from scaling or air polish
oocasionally pt may deveop dark stain on lingual/palatal which is hard to remove called black stain. children can develop green stain when membrane covering erupting tooth remains and stained by bacteria. difficult to remove.
whitening
only registered professionals can provide tooth whitening and only undertaken through assesment of dentist. illegal for anyome else to provide it. products that contain or release less than 0.1% hydrogen peroxide can be legally sold.
advise that illegal txt and home whitening put oral health at risk and can cause sensitivity and blistering.
toothpaste products have insufficient whitening products to make difference and will only help remove stains.
whitening does not cause damage to teeth and can be used on pt above 18. changes colour of dentine . process uses gels of hydrogen peroxide, the higher the concentration the more sensitivity. takes 2-3 weeks process
will not change colour of restorations
whitening is not permanent and will last from a few months to 3 years
dental plaque induced gingivitis
inflammation of gums
primary cause- poor OH , the bacterial by-products produced by mature plaque have potential to directly damage the gingival tissue and intitiate inflammatory and immunological reactions.
secondary causes- can be local (increasing plaque retention in specific area) or systemic conditions that alters body response to inflammation
local factors:
- malpositioned teeth
- overhanging fillings
- ill-fitting crowns, bridges or dentures
- implants
- orthodontic appliances
- calculus
- lip apart posture - dryness of attached gingivae in those pt increases plaque retention
dental plaque induced gingivitis, systemic
systemic factors:
- hormone changes during
- pregnany (pregnancy gingivitis)
- puberty
- menopause
- drug induced:
- anticonvulsants (epilepsy)
- immunosuppresants (anti-rejection medication foir transplant)
- certain calcium channel blockers (high bp)
- deep overbite causing direct gingival trauma
inflammation
inflammation is the response of a tissue to injury, first process by which body defends itself against attack from:
- physical sources (blow to mouth or scratch from tb bristle)
- chemical sources (asprin burn)
- microorganisms (invasion by bacetria, virus or fungi)
stages of inflammation:
- redness (rubor) - due to increased blood flow
- swelling (tumor) - tissue fluid accumulates
- heat (calor) - tisue temp rises
- pain (dolor) - rare in gingivitis
signs and symptoms of gingivitis
signs
- loss of stippling - inflammatory process damages the bundles of collagen fibres
- rounding of ginigval margin
- false pocketing - swelling of marginal gingivae.
- loss of contour - ginigivae lose pointed shape due to swelling
- loss of consistency - gingivae lose firmness and become soft and spongy
symptoms
- red, swollen gums
- bleeding on brushing - may also mention gums bleed when eating crisp foods like apples or blood on pillow in morning
- halitosis - may be cause by bleeding nut more likely noticed in perio when debris on pockets
- itching or pain - usually from trauma from vigorous brushing with stiff brush or when another factor is present like hormonal changes during pregnancy
gingivitis treatment
treatment:
- OH instruction , encouragement and motivation
- removal/good care of potential plaque retentive sites
- fluoride - antibacterial effect and can be applied through tp or mw
- chemical (chlorhexidine mw)
- regular monitoring, including scaling, polishing and reinforcement of oral health instruction
periodontitis
describes inflammation and gradual destruction of the periodontium
primary causes:
sometimes a progression from gingivitis and primarily caused by enzymes and toxins of mature plaque anearobic bacteria which gradually break down the tissues of the periodontium in a suseptable host (poor oh)
secondary factors
- smoking - reduces blood flow and white blood cell mobility/function, impair healing and increase inflammatory substances (cytokines)
- poor oh - plaque accumilation
- age - older people more prone as exposed to plaque for longer period and dont heal as well
- plaque retention factors - poorly finished/worn fills, dentures, crowns, bridges, partially erupted/impacted teeth and sub/supragingival calc, carious cavities
- crowding/malocclusion - prevents effective tooth cleaning
- high fremulum attachment - so tight it restricts access or strips gingivaew back = recession
- systemic conditions- those who experience hormonal changes, immunological disorders
signs of perio
signs
- variable degree of gingivitis
- bop of deep probing
- subgingival calculus
- gingival recession
- bone loss
- advanced stages:
- periodontal abscess
- drifting / mobility of teeth due to loss of attachment. true pocketing which can be :
- -suprabony (horizontal) base of pocket above crest of alveolar bone
- -infrabony (vertical) base of pocket below crest of alveolar bone
symptoms of perio
symptoms
- recession- teeth may be sensitive to hot/cold
- halitosis- due to accumilation of bacteria in pockets and pus formation
more advanced stage:
- drifting/mobility
- pain
- pus oozing from pockets
treatment for perio
- encouragement and help stop smoking
- regular maintainance and monitoring by:
- dianosing and monitoring with pocket charting , bleeding indicies and removal of plaque retentive factors
- effective regular plaque removal using manual or powered tb and id brushes, plus chlorhexidine mw in severe cases
- tp and mw containing fluoride are antibacterials and interfere with bacterial metabolism, reducing muber of bacteria
- scaling, rsd with uss and handscalers
- airpolishing - remove subgingival bacteria and reduce colonisation
- laser treatment
- antibiotics- systemic or local
- chlorhexidine chip placed in pocket
- surgey- recontouring gingivae and removal of pockets
classification of periodontal disease
assessed by the british society of periodontology (BSP)
- extent - localised or generalised
- stage- ranging from stage 1 (early, mild) to stage IV(severe) using x-rays to measure the extent of interdental bone losson worst site
- grade A, B or C. dividing bone loss at worst site due to periodontitis by patients age to determine rate of progression of disease
- current status of disease - stabel, in remission, or unstable
- risk factors - smoking or medically compromised
ANUG
nectroising ulcerative gingivitis or acute nectroising ulcerative gingivitis, trench mouth or vincents angina. can make pt ill.
found in adults between 18-25 years and odten associated with students that have moved away from home.
predisposing factors include:
- poor OH
- poor diet
- smoking
- immune system deficiency
- stress/fatigue
features of ANUG
features
- sudden onset and rapid development
- painfully inflammed gingivae and ragged, sloughing ulcers as bacteria invade tissues
- acute inflammation and bleeding
- halitosis and complain of metalic taste
- swollen glands, temperature and general maliase
- destruction of tissues when no treatment available - people with repeated attacks often exhibit permanent loss of idp
anug treatment
treatment
- stop smokingand recreational drugs
- scaling
- hydrogen peroxide mw- mechanical cleaning properties and releasing oxygen into area killing anaerobic bacteria
- chlorhexidine mw- reduce plaque formation
- antibiotics- if shows ilness or fever
- emphasis on good oh
- reducing stress levels
- healthy well balanced diet
- regular dental appointments
peri-implant mucositis and peri-implantitis
per-implant mucositis - reversible inflammatory reaction causing redness and swelling localised to soft tissue around implants
dental implant - consists of titanium screw placed in bone of maxilla or mandible which is left 6 months to intergrate with bone before restoration attached.
depth of gingival sulcus- 3-4mm
peri-mucositis can progress to peri-implantitis which involves destruction of bone
caries
caries- progressive destrcution of enamel, dentine and cementum initiated by microbial activity at a susceptible tooth surface.
3 types- smooth surface, pit and fissure, root caries
development
- suseptible
- plaque
- bacertial substrate
- time
acid attack
during acid attack calcium hydoxyapatite in enamel disolves as calcium and phosphate ions leave tooth and pass in saliva. known as demineralisation.
saliva contains bicarbonate ions, which have a buffering effect and if no sugra consumed the calium and phosphate ions return to enamel and PH returns to normal.
takes 30- 60 mins for buffering to take effect and known as remierlisation.
ionic seesaw - changes in enamel surface duriong demineralisation and reminerlisation
when episode of demineralisation exceed episodes of reminerlisation dental caries occur.
stephans curve
shows developemnt of an acid attack, inillstrates how quickly PH falls and how long it takes to return to normal
role of bacterial plaque in development of caries
- maintains concentration pf acid at tooth surface
- resists salivary buffering
- provides carbohydrate substrate
stages of caries
1. small pit- initial break in the enamel extends to the enamel / dentine junction. can be detected by a probe
2. blue and white lesion- caries destroys dentine more rapidly than enamel because it is softer. decay shows through the translucent enamel as blue/white area
3, open cavity- unsupported enamel collapses
4. pulpitiis- pulp cavity reached pulp becomes inflammed and pain occurs
5. apical abscess - infection spreads through apical foramen into the periodontal ligament. pulp is now dead and tooth is non-vital. infection develops at the apex of the tooth, can result in swelling
carie sites
sites:
- occlusal surfaces, and buccal pits and fissures of newly erupted molars and pre-molars
- contact areas between adjacent teeth
- exposed root surfaces
- cervical surfaces at tooth/gingival junction
prevention:
- cut down on refined sugars
- restrict sugar to meal times
- brush twice daily with flouride tp and spit, no rinse
- clean daily interdentally before brushing
vipeholm study
swedish study of caries in patients in vipeholm hospital 1939. relationship between diet and caries to see what measures to reduce caries.
study concluded:
- sugar consumption increases caries activity
- risk of caries is greater if sugar in sticky form
- risk is greatest if sugar in sticky form taken between meals
- increase of caries under uniform conditions showed great individual variation (therefore other factors involved)
- increase in caries incidence disappears on withdrawal of sticky foods from diet.
hopewood study
1942 childrens home in Australia, hopewood house
diet exluded refined carbohydrates (OH previously poor) no fluroide in water supply
study conculded:
- 63-81 children were caries free
- no child had more than 6 lesions
- lesions were small
- rates of new lesions and progress of existing lesions less than general population
- difference between children and general population was absence of refined carbohydrate
- after leaving hopewood, children's caries rate rose to that of general population
other evidence based studies
show relationship between sugar consumption and caries
- toverund- Norwegian world war II study when sugar in short supply, drop in caries rate
- tristan da cunha- remote untouched island in south atlantic until 1940s when fish- canning factory was built. jams, cakes and sweets imported due to increased wealth. survery in 1962 showed caries rate tripled due to introduction of sugar.
- gntobiotic (germ free) rats - lab study- fed high levels of sugar but did not develop caries- proving bacteria needs to be present for caries
- sweetened medicines- various studies on children long term sugared medication shown to cause higher caries rate
tooth surface loss
describes loss of dental hard tissue when bacterial action (caries) is not a factor
3 main types
- erosion
- attrition
- abrasion
erosion
usually seen: occlusal, palatal, lingual surfaces and cervical margins
cause- chemical process caused by acid
- sources of acid
- diet
- regurgitation of stomach acids
- acid pollution in workplace
clincial features- surfaces smooth and polished, distinguishing factors lost and shallow depressions occur. raised surfaces of restorations
- commomly seen in patients:
- teenagers
- sports players
- anorexics, bulimics and alcoholics
- people who reguarly eat citrus fruits
- eldery /medically compromised (less saliva)
- pre-school children
erosion management
- modify diet to reduce acid intake
- limit fruit juices to meal times,
- eat cheese after meals,
- chew sugar-free gum after meals,
- gentle toothbrushing (1 hour after acid consumption)
- fluoride,
- desensitising agents,
- reconstruct teeth
erosion can be monitored by basic erosive wear examination, if affected teeth shows signs of staining then erosion is no longer happening as stains would be washed away from acid.
attrition
desctibes the wear seen on the crown of the tooth caused by friction from tooth to tooth contact.
found on: occlusal, incisal surfaces. common on children as deciduous dentition is soft
causes
- bruxism ,
- diet (abrasive wholefoods)
- occupational (dust)
features- matching wear on occlusal surfaces, shiny facets on amalgam contacts, enamel and dentine wear at same rate, frcature of cusps/restorations
commonly seen on patients:
- persistant grinders
- abrasive wholefood diet
management of attrition
- use of bite-raising splint at night
- modify diet to reduce acid intake
- linit fruit juices to meal times
- eat cheese after meals
- chew sugar free gum after meals
- gentle toothbrushing
- fluoride
- densensitising agents
- reconstruct teeth
abrasion
loss of hard tissue due to mechanical factors from a foreign object in the mouth (other than tooth to tooth)
- causes:
- destructive toothbrushing,
- pipe smoking,
- oral piercings,
- occupational (hairpins)
- saliva joined with abrasive dust
features- worn, shiny , often yellow/brown stained areas at crevical margins when aggresive toothbrushing is the cause or biting surfaces
- seen in patients:
- aggresive tooth brushers
- users of hard toothbrushes and abrasive tp
- pipe smokers
- piercings
- people that hold foreign objects in mouth
management of abrasion
- improve toothbrushing technique
- remove piercing or replace with plastic version
- modyify diet to reduce acid intake
- limit fruit juices to meal times
- eat cheese after meals
- chew sugar free gum
- gentle toothbrushing
- fluoride
- densensitising agents
- reconstruct teeth
dentine sensitivity
sensitivity- also known as dentine hypersensitivity (DH or DHS)
characterised- short, sharp pain arising from exposed dentine in response to external stimuli such as: cold air, cold foods, touch by metal, sweet foods and heat.
cause- exposure of dentinal tubules to external stimuli. amount of pain not related to amount of exposed dentinal tubules. gingival recession and tsl will expose tubules.
common sites: buccal and labial surfaces of crevical margins (canines and premolars)
commonly seen in patients:
- young adults
- females (brush harder)
- high acidic diets
- who vomit reguarly
- sever occlusal trauma
- orthodontic patients
treatment for dentine sensitivity
- toothpastes containing potassium salts (potassium chloride & potassium citrate)
- fluroide varnishes, mouthwash, topical cream
- siloxane esters
- potassium containing liquids/ mw
- glass ionomer cements / resins
- composite restorations
- extreme cases - removal of pulp
- tp wit higher fluoride content (2800ppm or 5000ppm)
- laser treatment
xerostomia and cause
xerostomia- excessive dryness of mouth due to insufficient saliva
cause:
- certain prescription drugs (rheumatoid arthritis and parkinsons disease)
- acute illness with diarrhoea and vomiting can cause dehydration
- mumps (cause parotid gland to swell)
- chronic illness (diabetes)
- patients that are on oxygen (emphysema or lung cancer pt)
- sjogrens syndrome (autoimmune condition) lubrication of mucous membranes is reduced
- mouth breathing (at night or associated with malocclusion or sinus conditions)
- radiotherapy (treatment to head or neck)
- anxiety (dry mouth prior to public speaking)
- age (old people tend to suffer more through reduced saliva, drugs)
effects of xerostomia
certain pt suffer permanently from effects that include:
- increased caries risk (tooth prone to demineralisation)
- gingivitis & peridontitis - as no saliva to remove food debris and help fight bacteria, so plaque increases
- fungal and yeast infections
- glossitis
- ulcers (especially radiotherapy pt)
- eating and speech difficulties
management of xerostomia
management depends upon cause of condition but includes:
- sometimes possible to remove cause
- good diet, fresh fruit and vegetables
- avoid smoking
- stop sugary snacks
- sucking small ice chips
- sugar free gum
- frequent sipping of drinks (unsweetened, non-alcoholic, non-acidic)
- maintain excellent oral health (including floss, high flouride toothpaste, mouthwash and tongue cleaning)
- toothpaste designed for xerostomia patients
- radiotherapy patients may need extra care
- saliva substitutes
radio/chemo therapy xerostomia managment
- frequent gentle cleaning procedures with specially designed soft swabs and sometimes diluted chlorhexidine gluconate mw
- prescription drugs that stimulate salivary glands
- artificial saliva
- using soft toothbrush/id brushes / sonic powered brush that does not cause trauma
periodontal abscess
localised collection of pus or also referred to as lateral periodontal abscess as occures on side of the root or in furcation.
cause: foreign body invades periodontal pocket (often results from periodontitis)
- features:
- swelling,
- redness,
- pain,
- pus,
- transparent on x-ray
treatment:
- salt water rinses,
- drainage (short term),
- deep scaling,
- extraction (long term)
mouth ulcers
mouth ulcers- painful open sore
cause- trauma, genetic, chemicals, vitamin deficiency, hormonal changes, stress, immunodeficiency, allergies
features: painful sores ranging from 2-8mm- 10mm +
treatment:
- avoid spicy, acidic, sharp foods
- good diet
- control stress
- avoid substances that cause allergic reaction
- pain relief
- chlorhexidine mw
cold sores
cold sore- painful exterior sore
cause- infection with herpes simplex virus - can reactiviate throughout life
triggers- fatigue, stress, physical injury, bright sunlight, hormonal changes
features:
- tingling
- raise blotch
- blister
- weeping
- scab
treatment: antiviral cream (at tingling stage), systemic antiviral drugs
acute herpetic gingivostomatitis
herpes simplex virus in babies and small children
cause- reaction when first infected with herpes simplex virus
features:
- blisters (oral cavity and throat)
- feeling unwell
- refusal to eat
- dribbling, fever
- swollen tongue
- bad breath
treatment: rest, frequent drinks, mild analgesics, gentle oral care, amtiviral drugs
oral thrush
candidiasis or candidosis, fungi. mostly caused by candida albicans
cause- candida albicans
features: thick white patches (when removed, red sore patches revealed)
treatment: anti-fungal drugs
denture stomatitis
cause- candida albicans
features: sore patches on cheeks, gums, tongue, floor of mouth and palate
treatment:
- wait for antibiotic course to finish
- use anti-fungal drugs
- gentle brushing
- remove dentures at night
- keep clean
angular cheilitis
cause-candida albicans
features-
- small, reddened cracks at angle of lips (continually moist) , often caused by ill fitting dentures.
- dry lips,
- burning sensation
treatment- changing dentures / or anti fungal cream
lichen planus
cause- unknown, can affect oral cavity or systemic (whole body)
features in oral cavity:
- white striped skin lesions (buccal mucosa)
- in some cases gingivae red and sore
treatment:
- carry on as normal with gentle OH,
- avoid irritants (spicy food)
- in severe cases steriod mw
white patches (leukoplakia)
causes:
- smokers keratosis
- trauma (cheek biting)
- asprin burn
features: white patch
treatment:
- sometimes malign
- other cases cancer
oral cancer
cause:
- smoking
- alcohol
- betel nut chewing
- poor diet
features: red patches, white patches, lumps, ulcers or sores (non-healing)
prevention: stop smoking, cut down excessive alcohol, healthy diet
treatment:
- surgery,
- radiotherapy,
- chemotherapy,
- gentle palliative care
systemic diseases
diabetes- caused by pancreas failing to produce sufficient insulin
- oral implications: periodontitis
crohns disease and colitis - sometimes oral manifestations (gingivitis and ulceration)
acquired immune deficiency syndrome (AIDS)
- cause - HIV
- features- gingivits, thrush, herpes simplex, swollen lymph nodes, kaposis sarcoma (rare, late stage)
- treatment- systemic drugs, palliative care, scaling, mouthwash, antibiotics
recreational drug users
prone to oral diseases associated with low immunity (anug and candidasis)
sugar
sugar- a specific group of carbohydrates including sucrose (sugar cane and sugar beet), glucose (fruit and veg), lactose and galactose (milk), maltose (barley), and fructose (fruit) - excessive consumption can affect oral and general health
hidden sugars- sugars added to processed food and drink not immediately obvious from their name
- SACN- scientific advisory commitee on nutrition, made up of independent scientifiic experts, 2000 to advise government on diet
- 2015 SACN published report recomendating how much sugar should be consumed and how its classified
classified sugars
SACN classified sugars
intrinsic - found in cell wall of whole fruits and veg. unprocessed foods and drinks (fructose, glucose and sucrose)
extrinsic - found outside of food cells and includes sugar added to foodsand drinks, split into 2 types
- milk sugars - lactose and galatose in milk and milk products - large amount of calcium in milk counteracts their cariogenicity
- free sugars - glucose, fructose, sucrose, maltose that are added to food and drink. also includes naturally occuring sugars in fruit juices and honey
cariogenicity- ability of sugar to induce caries. order of cariogenicity- sucrose, glucose, fructose and maltose. least cariogenic are milk sugars lactose and galatose.
sweetners
2 main types of sweetners in UK
- bullk sweetners - similar properties to sugar, replace sugar weight for weight, can be used in cooking or sweets. cannot easily be used by bacteria to make acid, so less cariogenic.
- include: sorbitol, mannitol, isomalt, malitol, lactitol, xylitol, hydrogenated glucose syrup.
- intense sweetners - no nutritional value, not readily used by bacteria to make acid and often used to sweeten tea and coffee and in soft drinks,
- include: acesulfame K, aspartame, saccharin, thaumatin.
OHE advice on sugar consumption
- avoid adding extra sugar to food and drinks
- free sugar consumption should not exceed more than 30g per day, 5% of total dietry intake
- reduce frequency of sugar intake and limit cariogenic food and drink to meal times- eg. dried fruits although nutrituional are sticky and can increase risk of caries
- consider using sugar substitutes (sweetners)
- find tooth-kind snack alternatives, eg. raw vegetables, fresh fruit, bread, cheese, water, milk and unsweetened tea and coffee
- monitor sugar intake by indentifying hidden sugars on food labels
fluoride
fluroide - naturally occuring compound found in rocks, soil, water, air, plants, animals and fish.
biggest single factor in preventing caries
optimum level in drinking water = 1ppm, optimum in tp 1500ppm
calcium fluoride occurs naturally in water, sodium fluoride is added artificially
history of fluoride
- 1892 UK- dentist Sir James Crichton Browne recognised connection with caries
- 1901- USA, DR F McKay observed mottled enamel
- 1930'a USA, McKay and black linked mottled effect and low caries rates with fluoride in drinking water
- 1930-1940 south dakota usa, DR H TRENDley-dean recomended optimum level of 1ppm in water to negate fluorosis
- 1945 USA Michigan, sodium fluoride added to drinking water= 50% caries reduction
- 1955 UK- 1ppm added to Kilmarnock, watfordm anglesey = 50% caries reduction
- 1964 - Birmingham and Newcastle fluoridated water. mightr be expected that whole of UK water supply would be fluoridated but opposition arrised based on fear that its harmful.
- 1978 UK- fluoridation of strathclyde water opposed to on the grounds that may cause cancer and ruled aginst by lord jauncy saying it was outside his power uktra vires
- 1985 - Strathclyde case led to the knox report that found no evidence that fluoride added to water causes cancer
- 2000 UK, york report concluded: fluoride reduces caries, reduces dental health inequality for 5-12 year olds across social classes. no association found between certain cancers/bone conditions. dentakl fluorosis increases with greater concentration.
fluoride protection
protects teeth from caries in 3 ways
- encourage reminerlisation of teeth, making teeth more resistant to acid attacks
- incorporates into developing teeth - calcium hydroxypatitie replaced by calcium fluroapatite (withstands lower PH 4.5 before starts to demineralise. teeth will also have shallower pits and fissures making them easier to keep clean
- inhibits the enzymes in bacteria that convert sugar into acid
fluoride applied
administered systemically or topically
topical- to surfaces of teeth
- toothpastes - not contain more than 1500ppm. tp with higher concentration available through nhs prescriptions for people with high carie rates, root caries, and fixed appliance therapy
- mouthwashes- daily 225ppm, weekly 900ppm. daily use more effective
- fluoride varnish - applied in surgery (duraphat) comtains 22.600ppm - to treat caries and hypersensitivity, recomended to elderly patients with xerostomia
Systemic - carried to teeth via blood, when ingested from water, food or supplements
- in europe fluoridated salt is used sodium fluoride no available in uk
- fluoridated milk, given to 40,00 UK school children, not recieved during holidays.
- tablets or drops - only recomended with children when medical histiry prevents dental treatment (cardiac, haemophilliac, sveerly physically/mentally disabled or those with family history of caries
- water fluoridation
fluoride supplements
recomended to:
- children in areas with low fluroide levels
- medically compromised children
- children with siblings with high caries rates
when considering suppliments, take into account:
- only considered when water supply known
- maximum benefit when administered between 6 months- 13 years old
- critical fluorosis between 15-30 months for permanent incisors
- not to be administered at same time as fluoride tp
- if one dose missed must not double next day
- dont use away from home- as may be fluoride in destinations water supply
fluorosis
occurs when too much systemic fluoride ingested
presents as opaque/white areas on emamel and can result in yellow/ brown pitted teeth when occurs in high natural concentrations
greater risk of fluorosis on incisors between 15-30months old
children should be supervised and those under 3 use smear of tp (1000ppm)
excessive fluoride consumption can be toxic
fluorosis
occurs when too much systemic fluoride ingested
presents as opaque/white areas on emamel and can result in yellow/ brown pitted teeth when occurs in high natural concentrations
greater risk of fluorosis on incisors between 15-30months old
children should be supervised and those under 3 use smear of tp (1000ppm)
excessive fluoride consumption can be toxic
arguments for fluoridation
for water fluoridation:
- improves dental health
- reduction in caries rates last throughout life
- economic- fluoridated water cheaper than fillings
- safest and most effective way of providing systemic fluroide
- provides children with high resistance to caries for life and provides adults with a constant supply of fluoride in their saliva
- at 1ppm significant decrease in caries rate with no significant increase in fluorosis risk
- knox report 1985 and york report 2000 found no link between fluoride and cancer
- york report no evidence to suggest it will cause cot deaths, mental or physical retardation or bone fractures and bone development problems
arguments against fluoridation
- removes peoples freedom of choice, their right to refuse water fluoridation
- unnecessary as there are other ways of providing systemic fluoride for those who want it
- systemic fluoride most beneficial to children, important benefits of fluoride for adults can be achieved with topical fluoride, therefore not needed.
- increases risk of fluorosis
- concerns might cause cancer, cot deaths, mental or physical retardation, bone development problems
fissure sealants
fissure sealant:
- plastic resin placed in fissures and pits of molar teeth, cingulums and palatal grooves of incisors.
- helps stop plaque build up in crevices and makes teeth easier to clean
- sealants work by leaching fluoride inot the tooth, curtting off food and oxygen suuply to bacteria already present
patients suitable:
- children (most common group as newly erupted teeth have soft enamel until mature) secondary premolars and molars
- patients with sticky fissures suceptable to attracting food debris
- patients suceptible to caries
- patients with medical conditions who need to avoid xla
- patients with reduced oral healthcare skills/attendence
fissure sealant protocol
- polish with oil free paste - wash away
- isolate tooth with cotton rolls or rubber dam and airdry tooth
- etch surface of tooth with solution containing phosphoric acid
- clean tooth surface avoiding contamination from saliva
- apply sealant in one direction across surface avoiding air bubbles
- polymerise using white light
- check bite and id with floss
- pt can eat and drink immediately
- check sealants reguarly to see if repairs needed
advised to prevent risk of caries by:
- diet
- encourage good oh
- floride use
smoking reasons
- makes them look grown up
- began smoking before dangers known
- relieves stress, boredom or anger
- keeps weight down
- social smokers
- addicted smokers
effects of tobacco, general
120,000 people die prematurely each year due to tobacco use
effects on general: health
- chronic bronchitis
- emphysema
- coronary disease
- peripheral vascular disease
- infertility
- strokes
- cancer (lung, pancreatic, bladder and cervical cancer)
effects of tobacco, oral
oral health effects of tobacco:
- stained teeth
- halitosis
- xerostomia
- hairy tongue
- loss of taste
- increased risk of periodontal disease
- slows down wound healing in mouth
- smokers keratosis (white patches)
- oral cancer
other risks with smoking
passive smoking by children increases risk of:
- sudden infant death
- respiratory infections
- asthma
- glue ear
during pregnancy:
- premature labour
- prenatal death
- low birth rate
- also higher risk of caries in children whose mothers smoked during pregnency
OHE support to quit smoking
- studying the theory behind changing behaviour- process of change
- advising on nicotine replacement therapy
- showing empathy, motivation, support and understanding
- giving accurate information and drawing advice from experts in smoking cessation
process of change
- describes stages people go through when quitting
- developed by prochaska and DiClemete (1986) - show that changing attitides and behaviours is a continuous cycle rather than a one off event
stages of cycle related to smoking
- 1- thinking about change, concerned smoker thinking about quiting
- 2- preparing to change - planning a quit date and preparing for that date
- 3- making a change - quit day
- 4- maintaining the change
- 5- relapse - gone back to smoking, temporary or long term. not the end but beginning of cycle again. not all patients relapse
OHE to recognise which stage a smoker is and help
NRT
increases chance of cessation, but remind pt NRT does not replace will power
NRT products are widely available from pharmacists and GPs may prescribe them
each product delivers nicotine in a different way and in different amounts. include:
- nasal spray - suitable for those with high addiction
- patches - available in low doses, the easiest and most discreet product to use
- inhalators - simulate cigarettes
- lozenges
- chewing gum
- microtabs
- pharmacotherapy products - bupropion and varenicline
Bupropion
- antidepressant that reduces severity of withdraw symptoms
- prescrived by gp or NHS stop smoking services
communication
- communication - is making sure that the message recieved is the same as the message that was sent
- vital part of OHE and is not the patients fault if message is not understood
- OHE should establish good relationships with all patients
3 main aspects of effectice communication:
- be genuine - warmth, interest and concern for patients shown through verbal and non-verbal bahaviour, including:
- active listening
- eye contact
- head-nodding
- facial expressions
- other non-verbal signs
- respect- understanding that others may have opinions different from your own
- empathy - seeing a situation from another's point of view
how we communicate
three rules:
- tell me - I forget
- show me - I remember
- Involve me- I learn
how we communicate . 3 main ways. the listener judges and takes on board most by non-verbal (55%)
- what you say, words used 7%
- how you say it, tone of voice , volume, speed 38%
- non-verbal, gestures, facial expressions, eye contact, body language 55%
active listening
- lets patient know you are listening, encouraging them to say more
- sit facing patient, same level
- avoid crossing arms or legs
- lean forward slightly, make eyecontact
- matching behaviour is a good sign communication is going well
communication barriers
social/ cultural barriers between OHE and patient due to
- ethnic background
- social class
- values
limited receptiveness of patient due to
- learning difficulties / confusion
- illness, tiredness or pain
- emotional stress/fear
- busy / distracted
- low-self esteem
communication barriers
negative attitude towards OHE due to:
- previous bad experience
- see you as a threat and think you will criticise them
- patients believe they know it all
- patient doesn't want to know
- OHE advice conflicts with patients experience
- not trusting authority
limited understanding due to:
- language barrier
- receieved little or no education
- OHE use jargon
- poor memory
communication barriers
insufficient emphasis on education by the OHE due to:
- lack of training
- low priority in practice
- lack of confidence
- hurried approach
contradictory messages due to conflicting advice from:
- dentists and other health professionals
- family and friends
- expert advice changes with new knowledge
information fade
information fade- patients only remember around 10% of information
it is therefore important to back up advice with printed information for the patient
different ways of communication
other professional and public communication through:
- TV shows and adverts which can influence patients and they may ask you about
- dental journals and publications
technology and resources
- exhibition displays
- laminated leaflets, posters
- digital photos
- DVD players
principles of education
principles of education- help you prepare and devliver an OHE session
three domains of learning, remember KAB
- knowledge - learning factual information and understanding ideas
- attitude - beliefs, values and opinions
- behaviour - skills and actions
structure of lesson- aim and objective, less plan and devise evaluation method
- aim- brief, clear, simple and comprehensive
- objective - SMART. take into account: age,sex, social class, existing knowledge/behaviour, resources, time and what patient can realistically achieve
- S- specific
- M-measurable
- A- agreed and attainable
- R- realistic
- T- time related
evaluation
will tell you whether your aim and objectives were achieved
5 types of evaluation:
- outcome - what is outcome of session
- process evaluation- how the session is going during it
- patient evaluation- verbal and non-verbal feedback
- peer evaluation- feedback from colleagues
- self-evaluation - look at own perfromance and asses it
Evaluation methods
- Q&A session with pt /group
- visual method - demonstration of new skill
- record behaviour change
- questionnaire
questionnaires
2 types of questions
- open question - qualitive data
- closed question - quantitive
- avoid questions that are irrelevant, offensive and ambiguous
- confidentiality - pt may wish to remain anonymous
- when designing a questionaire consider:
- If a pilot question will help
- how many questions- 10 or less
- write in easy to understand language
- relate questions to aims and objectives
- give clear instructions on how to answer
- leave good space for open questions
- plan how to hand them out and how will collect them
- consider costs
PDU
PDU- preventative dental unit.
self contained area where oral health educator can be given.
where you can motivate patients in a friendly informal way/setting
setting up PDU
- business plan
- purpose - what you will hope to achieve
- what resources you will need
- advantages - fiscal happier patients
- long term aims
- aspects that you are unsure on - risks, affect not setting one up would have
- marketing
- how to promote -posters, newletters, referrals, email
- identify target groups
- opening times
- budget
- inital start up cost
- ongoing budget for resources
- a suitable location preferably separate from surgery
- enthusiasm and support from employer/ colleagues
- well-trained staff
PDU design
2 aspects that impact work- location of practice and PDU within practice
good PDU design
- decor that takes into account different patient groups
- good lighting
- easy access
- hardwearing floor
- robust fittings
- worktops at suitable heights
- space for displays
- sink
- mirror
- motivational aids
PDU display and organising
display
- posters - simple, eyecatching and clear. make use of wall space and worktops
- books'
- toys/games
- mouth models
- leaflets
- oral hygiene aids- toothbrushes
organising
- pt referrals from dentist / hyg
- appointment system
- flexible opening times
- to keep to time
- evaluation process - monitor pt progress/ gain feedback
antiplaque agents
antiplaque agents - agents that work to reduce plaque levels in our mouths by inhibiting, controlling or killing micro-organisms that are associated with the formation of plaque
anti-plaque agents are delivered through toothpastes, gel, mouthwashes and chewing gum
toothpastes
advise pt on fluoride tp
consitutes and functions of toothpaste
- polshing agents - mild abrasives that physically remove plaque
- anti-plaque agent - reduces plaque or helps prevent the build-up of plaque eg. chlorhexidine or triclosan
- fluoride - strengthening against decay
- over the counter toothpaste contains 1500ppm fluoride for adults
- 1000ppm for children under 3
- foaming agents - mild detergent makes mouth feel clean (sodium lauryl) sulphate) and removes food debris
- flavouring - pepermint and spearmint
- potassium salts, potassium chloride and potassium citrate- desensitising
- whitening agents - remove extrinsic stains
mouthwash
- can be effective against gingivitis, periodontitis, pericoronitis, caries and sensitivity
different types include:
- chlorhexidine, gluconate, fluoride, hydrogen peroxide, sodium barbonate, benzydamine hydrochloride, sanguinaria, cetylpyridinium chloride (CPC)
chlorhexidine gluconate
- shown to reduce plaque by 55%, gingivitis 45%
- leave gap of 30 mins to 1 hour before brushing as reaction between chlorhexidine and leave sodium lauryl sulphate in toothpaste reduces benefits.
forms of chlorhexidine (including those other than mw.
- mouthwash (0.2% solution) rinse for 1 min every 12 hours
- gel (1% solution) applied topically
- spray (0.2% solution)
- chewing gum
- slow release chip (periochip)
chlorhexidine gluconate uses and side effects
uses
- where plaque control poor
- for chronic gingivitis and acute conditions when brushing may be painful
- adjunct to periodontal therapy
- in cases of recurrent ulceration
side effects
- staining of material left on teeth
- loss of taste
- increased calculus (long term use)
- parotid gland swelling (rare)
fluoride mouthwashes
- found in most mouthwashes
- anti-plaque properties of fluoride are that it can inhibit plaque bacteria enzymes, slowing bacteria growth and amount of acid they produce
- shown to reduce caries by between 25-50%
- used:once daily (225ppm or 0.05% sodium fluoride) once weekly (900ppm or 0.2% sodium fluoride)
good for:
- caries prevention in high-risk patients
- patients undergoing orthodontic therapy
- preventing root caries in older people
- patients with sensitive teeth
hydrogen peroxide mw
releases oxygen killing anaerobic bacteria
recomended for the intial treatment of ANUG and pericoronitis
used for no more than 7 days at a time
mouthwashes contain 1.5% hydrogen peroxide
other mouthwashes
sodium bicarbonate mouthwash-
- neutralizing effect on acids, therefore goods after vomiting
benzydamine hydrochloride (spray or mouthwash form)
- non-steroidal anti-inflammatory drug recomended for patients suffering from severe recurring ulcers
- 15ml rinsed every 1.5-3hours (not more than 7 days) for pain relief
sugar free chewing gum
increasing saliva flow to wash away food debris and dilute toxins made by bacteria
raising the PH of plaque
the sweetner xylitol has been shown to have several anti-plaque properties making chewing gum more effective at reducing caries
OHE in practical session
in practical session the OHE:
- cannot use instruments in patients mouth
- can use toothbrushes and interdental aids (if given written permission by dentist / patient)
- should motivate patients to improve plaque control
- explain and demonstrate disclosing
- advise on suitable toothbrushes and toothbrushing techniques
- discuss advantages and disadvantages of various toothpastes
- give practical instruction on interdental cleaning
motivation involves
- time to talk, relaxed and unhurried
- empathy
- regular appointments
- endless patience
advising on disclosing
suggest:
- regular use of disclosing tablets- once a week until plaque removing skills improve
- disclose after brushing and interdental cleaning to highlight where plaque remains
- at a suitable time of day
- apply patroleum jell (vasoline) to prevent lips staining
- two-tone tablets stain new and old plaque different colours
- involve parents or carers of children, if child will be disclosing as can get messy
advising on toothbrushes
toothbrushes, suggest:
- place little emphasis on brand, there are many good ones but there may be one who design particulary suits patient
- good quality, medium textured brush with head-size to fit patients mouth
- simple design
- remind to change brush when filaments wear out
- advise on rechargeable electric toothbrushes- head changed every2-3 months on average
when advising on toothbrushing take into account patients:
- needs - what is plaque control like, gingiviits or periodontitis
- time - will patient spend time on partticular technqiue
- manual dexterity - what can patient cope with?
toothbrush techniques
- bass technique - circulatr movements at 45 degree anle to gingiva crevice
- modified bass method - circular movement at 45 degree angle to gingiva crevice and followed by rolling the brush towards the occlusal surface of the teeth (flick at the end)
- roll - as with bass but without the filaments entering the crevice. the brush is then roolled over the tooth towards the occlusal surface several times on all facets of the tooth
- charters technique - important when interdental papilla lost to anug - filaments vibrated into interdental spaces
- scrub- surfaces are cleaned with short, scrubbing movements, relatively easy technique can be easy to miss areas and watch out for heavy handed patients
- fones (circular) technique good for kids. bite together, then large circular movements (brushing gums and teeth)also remind them to gently scrub lingual and occlusal surfaces
- vertical technqiue - moved up and down to prevent damage caused by horizontal brushing
- brushing with power brush - work each tooth in turn, holding brush so ginigval margins included
patients may use combination of tb techniques- if works don't change it.
brushing implants, crowns and bridges
crowns and bridges should be cleaned in same way as natural teeth
titanium implants are softer and must be cleaned with products that wont scratch them - for example id brushes coated in plastic
id aids
floss and tape
- encourage patients to see which ones suit them best
- demonstrate flossing on a model or show pictures, then encourage them to try
- take 20cm of floss and wind it around middle fingers of both hands, use thumb and index, floss goes under interdental papilla then remove
interdental / interspace brushes
- interdental brushes have multiple brushing fibres and particularly good for patients with bone loss, as result of periodontal disease
- interspace brushes have single tuft of bristles angled to make it easier to clean around gum margin. useful for cleaning implants, braces, crowns &bridges
- patients should be encouraged to use largest head possible
- take great care if demonstrating as can damage gums
id aids
woodsticks
- less efficient than floss but better for less motivated patients
- show pictures or demonstrate on mouth model
water irrigation units
- expensive, inefficient and not to be recomended
pregnant and nursing mothers
about them:
- good dental advice essential to avoid gum disease, caries and effects of smoking
- generally receptive to information
- have free NHS treatment, which can encourage attendence
pregnant women more suseptible to:
- caries
- ginigval problems
- periodontal infection
increased suseptability to caries due to:
- vommiting- morning sickness
- frequent snacking
- cravings - often sweet food
- nausea when toothbrushing
pregnant mothers and gum disease
increased risk of gingival problems due to:
- nausea (preventing effective oral hygiene)
- hormonal changes (causing exaggerated response to plaque toxins
pregnancy gingivitis
- symptoms
- bleeding on brushing
- spontaneous bleeding (on pillow or eating crisp foods)
- itchy gums
- halitosis
- signs
- gums bleed on gentle probing
- swollen, smooth, shiny blue/red gums
- epulis (swollen id papilla)
- often goes away following birth
periodontal infection pregnancy
can lead to:
- pre-term labour
- premature birth
- low birth weight
periodontal infection pregnancy
can lead to:
- pre-term labour
- premature birth
- low birth weight
smoking pregnant and nursing mothers
- smoking in pregnancy can lead to:
- stickier plaque and dries mouth
- miscarriage
- still birth
- premature membrane rupture and delivery
- placenta previa
- foetal growth restriction
- smoking postnatal period:
- sudden infant death syndrome (SIDS)
- increase in mothers blood pressure
- mental retardation, behavioural problems
- smoking by parents of small children:
- respiratory illness
- asthma
- middle ear infection (otitis media)
advice to pregnant women
- carry out oral care at time of day when sickness not present
- use fluoride toothpaste
- choose softer toothbrush if gums sore/bleeding and use gentle bass technique
- interdental care even more important
- use chlorhexidine gluconate mouthwash/gel (sparingly)
- keep up regular dental visits
- fluoride mouthwash may help against effects of frequent snacking and nausea
- stop smoking
- ensure your advice is consistent with other health professionals (such as pt midwife)
advice to parents of 0-2 year olds
- eruption dates
- effectice cleaning of teeth (including newly erupted) by:
- application of smear tp containing 1000ppm fluoride
- use cotton wool bud or soft childs brush
- rinse with water on brush
- encourage spitting out
- stress importance of preventing caries
- brush 2 x daily
- fluoride supplements- rarely used, responsibility of dentist
- comforters dipped in sweet substances to be avoided and not left alone with liquid in bottle as unsafe and can lead to caries. only milk or water in bottles
advice to parents of 0-2 year olds
- breast milk substitutes - sugar free options are available & formula milk given unil 1 year old ,thereafters cow's milk until age of 2
- weaning and diet - read food labels, suggest sugarfree foods & suggest grandparents &friends follow same advice. suggest investigating snacks at nursery/preschool
- drinking cups - sipping from feeder cups can be detrimental to erupting teeth. recomend using doidy cup, eays to use and no lid
- refusal of child cooperation, teeth/mouth clamp shut on tb. create diversions/charts/games/rewards for older siblings may help or make toothbrushing look fun
advice to parents of 2-5 year olds
- ideal time to begin dental visits
- still very dependent on parent/carer for oral health
- OHE should be able to discuss the following with parents:
- eruption dates
- size/type of toothbrush
- fluoride toothpaste (amount and strength) from 3 years adult strength
- fluoride supplements
- toothbrushing technique - fones circular technique effective, easiest to sit with childrens back towards parent and head tilted back
- diet &drinks - establish good habits at this stage & ground rules eg meal planning &semi-skimmed milk advised
advice to parents of 6-11 year olds
- supervising/helping with teeth cleaning until at least 7 years old
- involve parents and children in advice
- eruption dates - permanent teeth erupting
- suitable brushes, technique and toothpaste
- fluoride mouthwashes post 6 year olds, if required.
- diet and sugar intake- children becoming more receptive to advice on health snack and drinks
- using games to encourage children to read food labels and encourage parents to read labels
- use sugar free medicines
- preventing gum disease - surprising number children have gingiviits and may enjoy using disclosing tablets to highlight condition
- encourage one hour before bed rule- no snacks or drinks &tp should be last thing on teeth at night with exception of water
- what to do if childs tooth gets knocked out
- OHE can also build links with local schools, provide advice, carry out exhibitions and displays
adolescents 11-19 year olds when treating
when treating
- by mid-teens will have full dentition
- go through growth spurts and frequently hungry between meals
- tackle one problem at a time
- target the young person rather than the parent
- never patronise or talk down to patient - same language as would with adult
- motivate them according to interests (appearance of TV, sports stars)
- look out for signs of bulimia and anorexia
- peers influential - therefore talking to groups (e.g schools) can be helpful
adolescents 11-19 year olds advice
- oral-piercing including:
- intra-oral mouth piercing should be discouraged as can damage incisors, blood poisoning and toxic shock syndrome
- can result in cracked teeth, accidental inhalation and allergic reactions
- recomend using reputable piercing practcitioner (if pt wants to go ahead)
- brush and clean piercings reguarly
- care when eating
- seek help if infection occurs or tooth chipped by stud. consider replacing with plastic studs to prevent tooth damage
- promote sports guards
- anti-smoking- provide general advice if parent there, if not there you could question teenager more closely, yet diplomatically
- diet including:
- importance of balanced diet, low in non-milk extrinsic sugars &promote healthy snacks
- consequences of sipping fizzy, high glucose or isotonic sports drinks
- consequences of drinking diet fizzy drinks- acidic can cause erosion
- chewing sugar free gum between meals, when appropriate can be beneficial
adolescents 11-19 year olds advice
- effective cleaning including:
- toothbrushing techniques
- toothbruses - rechargeable & ordinary brushes
- toothpaste - amount and fluoride
- id cleaning- types (floss and id brushes) &why important
- mouthwashes - important if high decay rate
- stress importance of regular visits
orthodontics
- treatment of malalignment of teeth - for preventative, functional and cosmetic reasons
- many adolescents have ortho appliances
orthodontics consider these when determining treatment:
- skeletal pattern
- occlusion - including angles classifications - based on molar and incisal relationships, which define the terms:
- overbite - how the lower incisors bite into the uppers
- overjet- the horizontal relationship how teeth stick out
angles classifications
class I - normal - lower 6 cusp tip bites half a cusp width in front of the upper 6. The overjet & overbite are between 2-4mm
class II - lower 6 is less than half a cusp width in front of the upper 6 & so the upper centrals are infront of lowers. class broken down into 2 divisions:
class II div 1 - upper teeth proclining /protruding further than the lowers
class II div 2- upper incisors retroclined or leaning back
class III - lower teeth in front of uppers, wirth the lower 6 more than half a cusp tip width forward. the bite is either edge to edge or reverse overbite
advice for ortho patients, removeable
removable appliances
- should be worn at all times, except when directed otherwise
- brush their teeth 2 x daily, excellent oral health should be maintained
- cleaned 2 x daily with brush and soapy water
- rinse quickly after meals to remove food debris
- dislcose weekly
- avoid sticky foods
- broken or lost appliances should be replaced immediately
advice for ortho patients fixed
fixed appliances
- stress importance of removing all food debris
- use of special orthodontic brushes
- importance of fluoride toothpaste & mouthwashes
- interdental aids
- stress importance of diet (particularly avoiding sugars, sticky foods & chewing gum)
- retainers should be fitted after active treatment
older people
BDA categoerise people according to functionality regardless of age:
- entering old age - around retirement age, active, healthy & independent
- transitional phase - making transition from active life to frality
- frail older people - vulnerable & often dependent on care
life expectany & oral health means people keeping teeth for longer:
- 1988 UK survey 80% of over 75's had no natural teeth
- 1998 UK survey 58% over 75's had no teeth
- 2009 UK survey 30% over 75's had no teeth
older people barriers to good nutrition
barriers to good nurtition include:
- physical problems
- discomfort from ill-fitting dentures
- reduction in activity/physical disability
- failing health, illness, eyesight
- xerostomia
- deterioration of smell/taste
- living circumstances
- poverty
- access to shops
- dependent on carers of smell/taste
- bahavioural factors
- death of spouse
- deeply ingrained eating habits
older people diet
older people tend to eat smaller meals & snack often and important that they:
- cut down sugary snacks
- use sugar substitutes
- SACN recomends that free sugars should not exceed 5% of total dietary intake & that people over 65 who have natural teeth should reduce their frequency of sugra intake
have lower energy requirements, but still need balanced diet particularly:
- vitamins C &D
- fibres (for digestive systems)
- carbohydrates
older people good health
barriers to good oral health:
- difficulty in accessing care & cleaning teeth / dentures due to:
- medical conditions (heart problems, strokes, arthritis, cancer & parkinsons)
- manual dexterity problems, which leave them struggling to clean their teeth effectively
- poor parking/public transport/disbaled access
help older people maintain good oral health by:
- ensuring regular dental visits at convenient times
- allow longer visits at convenient times
- give written notes to take home
- being tactful & understanding. older people should always be treated with the same respect you give to younger patients. Age should not be a barrier to a healthy mouth.
older people oral problems
- xerostomia - saliva substitutes may help
- denture stomatitis caused by candida albicans due to poor plaque removal of dentures. responds to anti-fungal treatment & improved oral hygiene
- angular chelitis - caused by candida albicans due to ill-fitting dentures causing mouth to overclose. responds to anti-fungal treatment & better fitting dentures
- root caries - due to root becoming exposed. reduced risk by cutting down sugar intake & effective cleaning with fluoride products
- dentine hypersensitivity due to gum recession - recomend toothpastes with desensitising agents
- soft tissues, particularly oral mucosa, become more fragile & prone to damage from food & dentures and thermal trauma from hot drinks
- oral cancer- more prevalent in people over 50. red/white patches & ulcers whcich do not heal, should always be investigated
advice for full&partial dentures
- remove dentures and rinse after each meal
- clean with soap & soft toothbrush at night, then rinse
- leave dentures out at night - to help soft tissues recover (store in clean water or let dry to prevent fungal infection)
- soak in a weak hypochlorite solution to sterilize the dentures (30 minutes only) ensure rinsed thoroughly in clean, running water before replacing it in the mouth
- gently clean soft tissues with toothbrush
- clean remaining teeth for partial wearers with medium toothbrush and fluroide toothpaste
- regular dental visits
advice for carers
advice for carers of older people with teeth/dentures
- brush teeth with patient sitting in supported chair, stand behind or to the side
- gently draw back lip and use a small headed medium toothbrush
- take extra care near loose teeth or bleeding gums
- patients with dementia may be uncooperative/unpredicatble - use finger guards
- may be possible to brush one side of the mouth in the morning & other side in the evening if, for example patient tires easily
additional advice
- wear new gloves each time to prevent cross-infection
- patients should have their own toothpaste & brush
- record any changes in the patients mouth & seek help/advice when needed
at risk patients
have higher risk of developing dental disease & include:
- medically compromised
- physically impaired
- mentally impaired
- patients with low socioeconomic status
- severely compromised (special care) patients
medically impaired patients
- patients with diabetes
- more prone to periodontal disease and caries
- make sure you see them on time
- look for signs of low blood sugar (irritation and confusion)
- patients with haemophilla
- need to avoid procedures where blood loss is a risk, including dental treatment
- prevention is key, good oral health education from early age
- patients with epilepsy
- more prone to gingival enlargement due to anticonvulsant drugs
- empathetic, tactful approach as patient may be sensitive about the stigma that can be associated with this condition
- patients on continual medication
- may find oral hygiene difficult
- xerostomia is common side effect of many drugs (drugs for blood pressure & anti-depressants)
physically impaired patients
- mobility problems
- visual or hearing impairment
- limited manual dexterity
mentally impaired patients
often unable to follow oral health regime
- depression
- phobias
- autism
- dyslexia
- head injuries
- short attention span
- dementia
- down's syndrome
low socioeconomic status patients
- homeless people - often only seek emergency dental treatment - you should encourage them to revisit. offer free oral hygiene aids. remember some may not have access to running water. listen & adapt your advice
- drug users (often homeless) be aware of challenging behaviour, signs of abuse & side effects of drugs (methadone in syrup form can be cariogenic)
severe dental phobias
- more likely to be treated in hospital or community dentistry (referred to by dentist)
- adopt a gentle, understanding approach
- conduct session in non-dental setting, free from noises & smells of dental surgery
- consider wearing clothes other than your uniform (sometimes seen as a barrier)
- a number of visits may be needed before a positive result achieved
severely compromised patients
- have physical, mental or sensory impairments, including:
- paraplegics
- patients with motor-neurone disease
- patients with dementia
- patients needing palliative care
- these patients often live in residential homes/ or rely on home care
- are unable to take care of their personal oral hygiene
severely compromised patients
- have physical, mental or sensory impairments, including:
- paraplegics
- patients with motor-neurone disease
- patients with dementia
- patients needing palliative care
- these patients often live in residential homes/ or rely on home care
- are unable to take care of their personal oral hygiene
advice to special care patients
- reduce sugar (frequency and sugar free medicine
- brush with fluroide toothpaste 2 x daily (manageable technique & adapted handles where appropriate)
- fissure sealing
- regular dental visits
advice for carers
- positioning patient for effective & comfortable care
- safe. effective plaque control
- adapting oral aids
- preserve patients dignity & encourage them to do as much as possible
all patients to be treated with dignity, respect and as your equal.
include carers in conversation when patient agrees but always focus on patient
minority ethnic group key points
12.9% of UK population made up from black and minority ethnic groups and important that you:
- are aware of cultural & religious diversity
- can adapt your oral health advice to take any differences into account
- recognise that people from this group tend to visit teh dentist less reguarly (be careful not to overgeneralise- we are all indiviuals)
barriers of minority ethnic groups
- language & comunication
- culture (some only visit dentist when have problem)
- religion (some orthodox muslim women wear veils & only husbands may see them unveiled not other males
- may be unaware of dental services & facilities available to them
- concerned about cost of dental treatment
- n.b these are generlisations and dont assume that every person from a particular group thinks these ways
breaking down the barriers
- approach community leader
- attend a group with a translator
- be aware of religious festivals taht involve fasting
- get doctors, health visitors & teachers involved
- can be very cost-effective method of spreading your message
OHE messages to minority ethnic groups
- listen and learn about pateint and culture
- adapt your oral health messages to be compatible with their beliefs
- consider dfiferent diets that may need different dietry advice to suit
- diet can also influence oral products you advise (some saliva products contain proteins from pigs, some mouthwashes contain alcohol)
- diet can impact oral health (heavily spiced foods on a regular basis can lead to stained enamel
- betel nut chewing can stain teeth & gums red/black. it is addictive & along with tobacco can cause oral cancer. make users understand the potentially serious health implications but be sensitive.
producing promotion material for minority ethnic g
consider the following points
- individuals in an illustration should reflect ethnicity, customs and culture of group
- written in appropriate langauge (somoe languages have more than one alphabet & some read right to left
- food/drink should relate to diet & eating method
- certain symbols & icons can mean other things in different languages
- handouts & leaflets should be presented clearly & pilot material with a community leader first
- look out for dental leaflets translated in different languages
sociology
sociology is the study of the structure & functioning of human society and can:
- help us understand what influences individuals & groups within our society & what might deter or encourage them from taking up dental treatment
- reveals trends in low uptake of dental treatment & lack of oral health
- education in certain groups of society
socialisation is process by which infants & young children become aware of society & relationships with others
2 types of socialisation
- primary
- secondary
primary socialisation
refers to early stages of socialisation
- from birth to start of pre-school/ school
- very important as child learns acceptable behaviour, norms & values of family life which can form the foundation for their social behaviour in life
- some sociologists believe that attitudes learned in pre-school years are almost impossible to change in later life
- children are most receptive to learning during this time, so good time to teach them the importance of toothbrushing, good diet & generally looking after their oral health
secondary socialisation
refers to learning taht takes place outside of close family
- occurs when child gets older & is exposed to external influences from: carers, peers, teachers, TV & other media
- child learns rules of behaviour in wider society - the norms & values of society
values and norms
values are deeply held views that act as guiding principles for society:
- referred to as collected beliefs
- usually refers to ideals that society would like to maintain or achieve for exmaple 'society demands equality in healthcare for all individuals'
norms are the approved way of doing things:
- it is considered the norm for people to brush their teeth twice a day but not everyone conforms
values and norms
values are deeply held views that act as guiding principles for society:
- referred to as collected beliefs
- usually refers to ideals that society would like to maintain or achieve for exmaple 'society demands equality in healthcare for all individuals'
norms are the approved way of doing things:
- it is considered the norm for people to brush their teeth twice a day but not everyone conforms
individual uptake of health care
sociologists believe that individuals uptake of healthcare can be influenced by:
political decisions, for example
- changes in government funding to NHS dentistry in 1990 resulted in many dentists moving to the private sector & many people couldn't afford to attend dental visits regularly
cultural influences, for example
- immigrant comes from a country where it is not the norm to attend the dentist for checkups, but not only when they have a problem
- social class. different socio-economic groups hold different values & norms when it comes to health care
epidemiological surveys
show general values & norms with relation to healthcare
- in general, socio-economic classes 1-4 are more future orientated & more likely to take preventive action & visit dentist & have lowest refined carbohydrate intake
- classes 5-8 less future-orientated , have highest caries rate & visit dentist irregularly. teenagers from these groups also have the highest refined carbohydrate intake.
epidemiological surveys
show general values & norms with relation to healthcare
- in general, socio-economic classes 1-4 are more future orientated & more likely to take preventive action & visit dentist & have lowest refined carbohydrate intake
- classes 5-8 less future-orientated , have highest caries rate & visit dentist irregularly. teenagers from these groups also have the highest refined carbohydrate intake.
patients perception
patients perception of their health care needs can also affact their uptake of treatment:
- patients perception of what they need & their actual need as determined by a health care professional can differ greatly & is known as the iceburg effect
- the tip of the iceburg (one-fifh) represents the patients knowledge of what treatment they need
- the submerged four-fifhsof the iceburg represnets the healthcare professionals kmowledge of treatment needed -known as the performance gap
- performance gap caused by:
- poor communication by dental professional
- socio-economic class, eg professional may not be aware that patient cannot afford recomended products & patient too embarrassed to say & therefore does nothing.
- OHEs can lessen the performance gap by recognising not everyone can afford the best products & offer cheper alternatives
- victim blaming- occurs when what patient sees as a responsible action is viewed by the professional as irresponsible
epidemiology
epidemiology is the study of the pressence & distribution of diease within a population group & can ascertain:
- the amount of disease present in a population
- its severity
- how quickly it spreads & how widespread it is geographically
- where disease is orinated
epidemiologist deals with disease in population groups not individuals
epidemoiology surveys accurately measure disease in populations
- capture information from hundreds or thousands of people
- UK government organisation concerned with collecting data is the office for national statistics (ONS)
- surveys monitor medical conditions & help us take appropriate action
epidemiology surveys
2 surveys of interest to OHE held every 10 years
- national survery of adult dental health - in years ending in 8 next one took place in 2009
- national survey of child dental health- in years ending in 3
- raw data is gathered in each area of the country by community dental offices, often assisted by dental nurses
- data is then sent to the ONS whos analyse & publish report, used by:
- area authorities eg to assess if fluoridation is necessary
- the government eg making sure sufficient dentists are being trained to deal with disease trends
survey terminology
- screening- process of examining people & gathering data
- prevalence - the number of people affected by a disease at a particular time
- incidence - how often a disease occurs
- distribution - assesses where most disease occurs in the population
indices
- an index a numerical method of measuring a particular disease or condition. indicies can accurately compare the appearance of dieases and medical conditions across large populations
Silness & Loe plaque index 1964
- shows whether someone has visible plaque or not.
- patient is disclosed & presence of plaque measured according to:
- code 0 = no plaque deposits are visible in gingival area
- code 1= plaque deposits are visible in the gingval area
Turesky plaque index 1970
- used by many dental professionals to measure plaque as:
- has high degree of sensitivity
- useful patient motivation tool
- patient is disclosed & plaque on buccal, labial, palatal and lingual surfaces recorded
OHI index
oral hygiene index - OHI
- combined 2 indicies (calculus & debris) for each tooth but proved too complex
- simplified OHI in 1964- renamed the simplified oral hygiene index (OHI-S) which measures surfaces of 6 teeth from different areas to be representative of whole mouth.
- scores :
- 0 - none present
- 1- supra gingival calculus covering less than 1/3 of tooth
- 2- supragingivial calclus covering 1/3 or 2/3 of tooth and small amount of subgingival calculus
- 3- supra gingival calculus covering more than 2/3 of the tooth or continuous bands of subgingival calculus
DMFT index
- DMFT (decayed, missing, filled teeth) is most common caries index used
- DMFT denotes permanent teeth; dmft denotes deciduous teeth
- number of decayed, missing & filled teeeth is counted to measure extent of caries in population
- DMFT-S is more specific - counts the surfaces that are decayed or filled
- score 1- filled tooth
- score 3- if surfaces filled are counted
- score 5 - tooth extracted due to caries
BPE examination
basic periodontal examination - tooth divided in 6 sextants & a probe used to measure depth of pockets & recorded as codes 0-4, with code 4 having teh deepest pocket
codes are used to judge treatment required
- code 0- pockets are 0-3mm. healthy gingivae with no bop
- treatment - none
- code 1- pockets are 0-3.5mm. coloured area of probe remains completely visible. no calculus or defective margins, bop
- treatment- OHI
- code 2- pockets 0-3.5mm coloured area of probe visible, supra gingival and subgingival calculus is detected or the defective margin of a filling or crown
- treatment- OHI plus removal of calculus and correction of plaque retentive factors
- code 3- pocket 3.5-5.5mm. coloured area of probe remains partially visible
- treatment - as per code 2 but more treatment time required. P&B scores recorded 3/12
- code 4- pockets 5.5mm and above. coloured area of probe disapears in pocket
- treatment- full 6ppc with p+b scores, recession and furcations. x-rays for greater than 7mm pocketing. undergo course of perio treatment
evidence based prevention
- OHEs need to know wheter advice is suported by evidance or opinion, example
- strong evidence that brushing with fluroide toothpaste 2 x daily can reduce caries
- only some evidence that avoiding sugars between meals & bedtime can reduce the risk of developing caries, - doesnt mean you shouldnt advise this
- patients are far more likely to change behaviour after discussions with a friendly OHE
- scientific basis of OHE standardised oral health advice to the public
professor archie cochrane was a pioneer in evidence to support clinical practice
- gave his name to the international collaborative cochrane network to develop evidence based approach to clincial treatments
- network www.cochrane.org produces reviews of scientific evidence including dentistry
scottish intercollegiate guidelines network (SIGN)
scottish intercollegiate guidelines network (SIGN)
established in 1993 to standardise & intergrate methods used for developing guidelines for clincial practice
- has improved quality of healthcare for patients in scotland by reducing variation in practices & outcome by developing national clincial guidelines based on current avidence including:
- prevention & management of dental decay in pre-school child
- preventing dental caries in children at high caries risk
primary dental health prevention
targets healthy people & aims to prevent illness & improve quality of life
examples of primary dental health prevention include:
- fluoridation in drinking water
- working with parents to encourage young children to brush reguarly with fluoride toothpaste & reduce unnecessary sugars in their diets
- fissure sealing first and second molars before caries develop
- making children aware fo the effects of smoking and alcohol
- encouraging children and adults to have regular dentak examinations
NICE guidelines
NICE guidelines on frequency of dental examinations
research by NICE found
- little evidence to suggest 6 monthly checkups better than regular checkups at other intervals
- shortening the interval less than six months resulted in a small reduction in caries but had no effect on other oral conditions & diseases
- in 2004 NICE produced new guidelines on the frequency of routine exmainations:
- shortest interval for all patients should be 3 months
- longest interval younger than 18 years should be 12 months
- the longest interval for patients aged 18 years & older should be 24 months
secondary dental health prevention
directed at people with exisiting condition, whose health can be restored/prevented from deteriorating
examples:
- resolving gingivitis through oral health + preventing progression of periodontitis
- remineralisation of early caries by using fluroide toothpaste + modifying diet
- small restorations to halt caries & need for larger and more expensive restorations
tertiary prevention
directed at people with terminal, irresolvable comdition or disability
educate patinet to maximise potential for healthy living
relatives and carers may also require help & advive on tertiary care
examples:
- care of crown or bridge
- care of full or partial denture
- maintaining oral health when advanced periodontal disease is present
- maintaining oral health when systemic disease or disability makes difficult
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