Basic concepts of Health Planning

Planning is making current decisions in the light of their future effects.

Health planning is a process culminating in decisions regarding the future provisions of health facilities and services to meet health needs of the community.

Atraumatic Restorative Treatment (ART) for tooth decay

Atraumatic Restorative Treatment (ART), is based on removing decalcified tooth tissue using only hand instruments and restoring the cavity with an adhesive filling material.
A minimally invasive approach to both prevent dental carious lesions and stop its further progression. 

Guidelines on Behavior Guidance for the Pediatric Dental Patient

Safe and effective treatment of dental diseases often requires modifying the child’s behaviour. Behaviour guidance is a continuum of interaction involving the dentist and the dental team, the patient, and the parent directed toward communication and education.

Recommendations for Basic behavior guidance

Communication and communicative guidance

Communicative management and appropriate use of commands are used universally in paediatric dentistry. Communicative management comprises a host of techniques which include, tell-show-do, voice control, nonverbal communication, positive reinforcement, and distraction. The dentist should consider the cognitive development of the patient, as well as the presence of other communication deficits (eg, hearing disorder), when choosing specific communicative management techniques.

1.Tell-show-do

A technique of behaviour shaping used by many paediatric professionals. The technique involves verbal explanations of procedures in phrases  appropriate to the developmental level of the patient (tell); demonstrations for the patient of the visual, auditory,  olfactory, and tactile aspects of the procedure in a carefully defined, nonthreatening setting (show); and then, without deviating from the explanation and demonstration, completion of the procedure (do).

2. Voice control

Voice     control  is             a              controlled           alteration            of            voice         volume, tone, or pace to influence and direct the patient’s     behaviour. Parents unfamiliar with this possibly aversive technique may benefit from an explanation prior to its use to      prevent misunderstanding.                       

3. Nonverbal communication

Reinforcement     and guidance of behaviour through appropriate contact, posture, facial expression, and body language.

4.  Positive reinforcement

In            the         process of            establishing        desirable             patient     behaviour, it is essential to give appropriate feedback. Positive     reinforcement is an effective technique to reward desired     behaviours and, thus, strengthen the recurrence of those behaviours. Social reinforces include positive voice modulation, facial expression, verbal praise, and appropriate physical    demonstrations of affection by all members of the dental team. Non-social reinforces include tokens and toys.                               

5. Distraction

It is the technique           of            diverting              the         patient’s attention from what may be perceived as an unpleasant procedure. Giving the patient a short break during a stressful procedure can be an effective use of distraction prior to considering more advanced behaviour guidance techniques.

Parental presence/absence

The        presence             or            absence               of            the         parent  sometimes can be used to gain cooperation for treatment. Parents’ desire to be present during their child’s treatment does not mean they intellectually distrust the dentist. It might mean they are uncomfortable if they visually cannot verify their child’s safety.  It is important to understand the changing emotional needs of parents because of the growth of a latent but natural sense to be protective of their children. Practitioners should become receptive to the involvement of parents and welcome the questions and concerns for their children.

Nitrous oxide/oxygen inhalation

Safe       and        effective technique to reduce anxiety and enhance effective communication. Its onset of action is rapid, the effects easily are titrated and reversible, and recovery is rapid and complete. Additionally, nitrous oxide/oxygen inhalation mediates a variable degree of analgesia, amnesia, and gag reflex reduction.

Adopted from the guidelines of AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

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Triangles of the root of the neck

Face, Scalp and parotid region

Face,Scalp and Parotid region

Face,Scalp and Parotid region

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Cranial contents, Reflection of head and pharynx

Bisection of the head, pharynx and temporal region

Bisection of the head, pharynx and temporal region

Bisection of the head, pharynx and temporal region

Bisection of the head, pharynx and temporal region

Orbit, pterygopalatine fossa and nasal region

Mouth, tongue and pharynx

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MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

MEDICAL MNEMONICS -MUSCLES OF THE HEAD AND NECK REGION

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MEDICAL MNEMONICS -CRANIAL NERVES

MEDICAL MNEMONICS -CRANIAL NERVES

MEDICAL MNEMONICS -CRANIAL NERVES

MEDICAL MNEMONICS -CRANIAL NERVES

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Molar Incisor Hypomineralization

The term molar incisor hypomineralization (MIH) was introduced in 2001 to describe the clinical appearance of enamel hypomineralization of systemic origin affecting one or more permanent first molars (PFMs) that are associated frequently with affected incisors. The condition is attributed to disrupted ameloblastic function during the transitional and maturational stages of amelogenesis. This condition is recognized in various terms such as hypomineralized PFMs, idiopathic enamel hypomineralization , dysmineralized PFMs, nonfluoride hypomineralization and cheese molars.

Molar incisor hypomineralization

Epidemiology

The prevalence data for MIH are limited due to various diagnostic classifications. According to existing data the prevalence ranges from 4% to 25% across different populations. The number of hypomineralized PFMs in an individual can vary from 1 to 4, affecting particularly 2 or more molars including the contralateral tooth, where the teeth are moderately or severely affected. The risk of involvement of the permanent maxillary incisors appears to increase when more PFMs are affected.

Putative factors associated with disrupted amelogenesis of PFMs include systemic conditions and environmental insults influencing natal and early development specially during the child’s first 3 years.  The systemic conditions implicated to date include nutritional deficiencies, brain injury and neurologic defects, cystic fibro­sis, syndromes of epilepsy and dementia (Kohlschutter-Tonz syndrome), nephrotic syndrome, atopia, lead poisoning, repaired cleft lip and palate, radiation treatment, rubella embryopathy, epidermolysis bul­losa, ophthalmic conditions, celiac disease, and gastrointestinal disorders. Conditions common in the first 3 years, such as up­per respiratory diseases, asthma, otitis media, tonsillitis, chicken pox, measles, and rubella, are also known to be associated with MIH. Some studies suggest the association of Preterm birth with increased prevalence of enamel defects, including hypomineralization and hypo­plasia in the permanent dentition.

Clinical presentation and Diagnosis

Criteria for the diagnosis of demarcated opacities, post-eruption breakdown (PEB), atypical restorations, and extracted PFMs due to MIH were developed by Weerheijm et al. Dentitions with generalized opacities present on all teeth rather than limited to the PFMs and permanent incisors, are not considered to have MIH.

Four PFMs and 8 erupted permanent incisors are examined wet for demarcated opacities (white-cream or yellow-brown in color, of normal thickness with a smooth surface), post eruptive breakdown, and atypical restorations.

·      

     The opacities are usually limited to the incisal or cuspal one third of the crown, rarely involving the cervical one third.

·   

   Due to the unusual size and shape, restorations may not conform to typical caries patterns and frequently involve the cuspal or incisal one third of the crown.

·         Enamel opacities may occur adjacent to restoration margins.

Diagnostic Categories of MIH

·         Mild MIH

o   Demarcated opacities are in nonstress-bearing areas of the molar

o   No enamel loss from fracturing is present in opaque areas

o   There is no history of dental hypersensitivity

o   There are no caries associated with the affected enamel

o   Incisor involvement is usually mild if present

·         Moderate MIH

o   Atypical restorations can be present

o   Demarcated opacities are present on occlusal/incisal third of teeth without posteruptive enamel breakdown

o   Posteruptive enamel breakdown/caries are limited to 1 or 2 surfaces without cuspal involvement

o   Dental sensitivity is generally reported as normal

·         Severe MIH

o   Posteruptive enamel breakdown is present

o   There is a history of dental sensitivity

o   Caries is associated with the affected enamel

o   Crown destruction can advance to pulpal involvement

o   Defective atypical restoration

o   Aesthetic concerns are expressed by the patient or parent

Differential Diagnosis

Fluorosis

Amelogenesis imperfecta

Enamel hypoplasia

o   It can be differentiated from fluorosis as its opacities are demarcated, unlike the diffuse opacities that are typical of fluorosis. Fluorosis is caries resistant and MIH is caries prone and also fluorosis can be related to a period in which the fluoride intake was too high

o   Choosing between amelogenesis imperfecta (AI) and MIH: only in very severe MIH cases, the molars are equally affected and mimic the appearance of AI

o   In MIH, the appearance of the defects will be more asymmetrical and in AI, the molars may also appear taurodont on radiograph and there is often a family history.

Management

MIH’s clinical management is challenging due to:

1. The sensitivity and rapid development of dental caries in affected PFMs

2. The limited cooperation of a young child

3. Difficulty in achieving anesthesia

4. The repeated marginal breakdown of restorations.

Management of Molar incisor hypomineralization

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