Training Manual on Oral Care for Medical Officer

at Ayushman Bharat - Health and Wellness Centres

2021
 Contents
Chapter 1: Primary Care in Oral Health 1
Chapter 2: Service Delivery Framework 3
Chapter 3: Prevention and treatment protocol for common conditions/ diseases 8
3.1 General Oral Examination Procedure 8
3.2 Common Oral Hard Tissue Diseases/ Conditions: 11
3.3 Common Oral Periodontal Diseases/ Conditions 23
3.4 Common Oral Soft Tissue Conditions 29
Chapter 4: Oral care-emergency Management protocol 36
4.1 Pain, swelling/ abscess 36
4.2 Avulsion/Fractured Tooth 37
4.3 Haemorrhage 40
4.4 Management of Maxillo-facial Trauma 40
42
4.5 Non healing ulcer
Annexures: 47
Annexure I (a): Atraumatic Restorative Technique (ART) 47
Annexure I (b): Medicines and Consumables 48
Annexure II- Myths and Facts about Oral Health 49
Annexure III: Oral health promotion- points for health education 51
52
Annexure IV – Service Delivery Framework for different Oral conditions/ Diseases

iii
Chapter 1: Primary Care in Oral Health
World Health Organization has defined ‘Oral Health’ as a state of being free from mouth and facial pain, oral
and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases
and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.
(WHO, 2012)

Oral health is an important part of general health, affecting not only the individual, but also the broader health
system and economy. The consequences of widespread poor oral health can be seen on the personal, population,
and health systems level, as caries and periodontal diseases deteriorate the individual health and wellbeing, decrease
economic productivity, and act as significant risk factors for other systemic health ailments. Approximately 33%
of adult population suffers from dental caries and 16% from periodontal problems which are easily preventable.
Indians have relatively high incidence/prevalence of dental caries of permanent teeth and about 16% with
periodontal problems. About a third of the population suffers from dental caries that require treatment. There is
also a difference in oral health status between urban and rural populations, with enormous disparities in access
to quality oral health care, predominantly in rural areas. India’s 60-65% population is living in rural areas, where
there is limited access to oral health care system. 40-45% of population have dental caries, often leading to pain
and discomfort. More than 90% of the population has periodontal diseases. 19-32% of population aged more
than 65 years is edentulous while 12.6 per one lakh population have oral cancer. The growing incidence of some
chronic diseases like diabetes can further have a negative impact on oral health and adds to the burden.

In most developing countries including India, there is a limited access to oral health care services at the primary
health care level. There is a huge unmet need for primary health care for oral [Link] at the secondary levels
i.e., Community Health Centers and District Hospitals, where Dental surgeons are posted, comprehensive oral
health services are largely unavailable due to inadequate instruments, equipment and dental materials. Currently
assured oral health services are largely available at tertiary level which are mostly concentrated in urban areas.
This leads to significant gap in demand and availability of services.

The National Oral Health Programme (NOHP), was launched in the year 2014-15 to address this issue by
strengthening the public health facilities of the country for an accessible and affordable oral health care delivery.
It provides support to states to set up Dental Care Units at District Hospitals and lower levelfacilitiesby equipping
them with appropriate manpower, equipment and consumables.

1
Operational Guidelines for Oral Health care at Health and Wellness Centres
2
Burden of Oral Diseases (Multi Centric Survey 2007)

1
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Comprehensive primary health care- Oral Health:

The National Health Policy, 2017 recommended strengthening the delivery of primary health care, through
establishment of “Health and Wellness Centers” (HWCs) as the platform to deliver Comprehensive Primary
Health Care (CPHC).

Ayushman Bharat- HWCs is an attempt to move from a selective approach to health care to delivering
comprehensive range of services spanning preventive, promotive, curative rehabilitative and palliative care. As
part of this initiative, about 1,50,000 existing Sub- Health Centres (SHCs) & Primary Health Centres (PHCs)
in rural and urban area, will be transformed to Health & Wellness Centres (HWCs) to deliver Comprehensive
Primary Health Care, that is universal and free to users, with a focus on wellness and the delivery of an
expanded range of services close to the community. The wide range of services provided at these Health
and Wellness Centres will encompass strengthening of existing Maternal and Child health and communicable
disease related services and roll out of additional services such asNon-Communicable diseases, Oral health,
Mental health, ENT, Ophthalmology, elderly care, palliative care and trauma care. Thus HWCs provide an
opportunity to strengthen the delivery of integrated oral health care services in the country.

Basic oral health care has been introduced as one of the elements of Comprehensive Primary Health Care
delivered through Health and Wellness Centers to expand the availability of all aspects of oral health including
referral to appropriate health facilities.

This module will elaborate on roles and responsibilities of Medical Officer in provision of primary oral health
care.

2
Chapter 2: Service Delivery Framework
The organization of services under AB- HWCs focuses on strengthening continuum of care across levels of
care. Hence the delivery of quality services is envisioned as joint team effort of ASHAs at community level,
Community Health Officers and Multi-purpose Workers at SHC- HWC level, Medical Officer at PHC- HWC
level and specialists at secondary tertiory level care.

The service delivery begins with the ASHAs at Community Level. Their role primarily is to promote
healthy behaviors and create awareness about common risk factors. ASHAs would also be empowered
with skills to identify common oral diseases, provide symptomatic pain relief, facilitate referral in case of
emergencies and provide follow up care for patients undertreatment. In addition, ASHAs are expected to
support the HWC team at community and various school oral health programs.

At HWC-SHC level, the Community Health Officer/ Mid-Level Health Providers and MPWs have a
major role to play in early identification of nine common oral conditions, management of simple oral health
problems with symptomatic treatment referral of any complicated oral health problems, follow up of all cases
referred and organizing community programs for promoting oral hygiene and health

At HWC-PHC, if dentist is available, preventive, curative and rehabilitative services will be provided for oral
conditions as per protocols for primary care. In case of non-availability of dentist, MO will provide the basic
oral health care services such as emergency management of pain, uncontrolled bleeding, tooth avulsion and
first aid management of trauma, and Atraumatic Restorative Treatment for deep occlusal cavities. In addition,
PHC team will focus on oral health promotion, coordinate with school health programme, mentoring of
SHC- HWC teams and monitoring delivery of services through HWCs.

At the referral centre, management of all oral diseases/conditions as per clinical protocols and supporting
outreach activities under the facility catchment area.

3
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Table 1 – Service Delivery Framework

Care at Community Level Care at SHC-HWC Care at PHC-HWC/UPHC-HWC
Awareness generation and Health Community Health Officer Screening and identification (MO/dentist)
promotion (ASHAs, MPW and Screening and Identification • Opportunistic screening for dental
CHO) conditions
• Opportunistic dental screening
• Through home visits, for individuals (18-29 years) who • Examination of cases referred by
VHNDs,VHSNC, MAS are not covered under CBAC for ASHAs, MPW, CHO
meetings etc. NCD screening. Management
• Measures for health • Early detection, screening MBBS MO:
promotion with special and first level management of
focus on pregnant women, • Emergency management of pain,
common dental diseases
mothers, children, elderly uncontrolled bleeding, tooth avulsion
• Identification and referral for and first aid management for
and medically compromised.
tooth loss, mal-alignment of maxillofacial trauma.
• Oral Health Education- teeth/jaws, dental fluorosis,
addressing oral hygiene • Topical application of fluoride for caries
premalignant lesions, and oral
practices, habits, myths and prevention.
manifestations of systemic
taboos. conditions to facility where • Atraumatic Restorative Technique
• Prevention of common dentist is available and dental lab (ART) after adequate training.
oral diseases through is functional. Additional services if dentist available:
dietary advice and tobacco Management • Restoration of carious teeth using Glass
cessation. Ionomer Cement (GIC) or Composites.
• First level management of
Screening and early detection common dental diseases like • Sealing deep pits and fissures with
• Population based screening arresting bleeding, temporary sealants when indicated.
for 0-18 years (under pain relief, antibiotic/anti- • Scaling, root planning and polishing of
RBSK) and completion inflammatory medication etc. teeth.
of Community Based • Maintaining case records and
Assessment Checklist • Emergency access opening and pulp
providing follow up care. therapy to address infections of dental
(CBAC) for people > 30
• Coordinate with RBSK and origin.
years.
School health program to ensure • Address fractured restorations and
• Assessment of individuals for oral health check-up for all
oral health conditions using faulty restorations.
children.
CBAC form by ASHAs. • Simple extractions and abscess
• Mentor ASHA and MPW drainage.
• Early identification of for imparting preventive and
specified common conditions • Emergency management of dental/
promotive oral health education
including pain and any facial trauma.
in coverage area
potential malignant lesion • Referral to CHC/DH for identified
• Oral Health Promotion
by ASHAs and MPW and cases for tooth loss, mal-alignment
referral to CHO at Health • Oral health Promotion among of teeth/jaws, cleft lip/palate, dental
and Wellness Centres. out patients through: fluorosis, premalignant lesions, and oral
• Follow-up care of identified • IEC activities manifestations of systemic conditions
cases for treatment • Oral Health Education – Oral • Coordinate with school oral health
adherence during home hygiene practices, habits, programs, RBSK, NPPCF, RCH, ICDS,
visits and outreach activities addressing myths and taboos NTCP.
• Prevention of common oral • Monitoring of activities undertaken at
diseases through dietary advice SHC-HWCs
and tobacco cessation • Capacity building of primary healthcare
team at SHC-HWCs.

4
Role of Medical Officer:
1. Health promotion, health education

¾ Raising awareness on support networks, programmes and available services at higher centres to
address habits such as tobacco and alcohol consumption.

¾ This is to be complemented by inter personal communication and group health education, and using
platforms such as the Village Health and Nutrition Day (VHND), Meeting at Village Health Sanitation
& Nutrition committee (VHSNC) or Mahila Arogya Samiti (MAS)

¾ Raising awareness on risk factors for developing caries and periodontal diseases.

¾ Demonstrating tooth brushing technique

¾ Reinforcing consumption of fibre rich food which are protective for tooth and gum health. Discourage
consumption of aerated drinks, sticky and sweet food.
2. Management and Referral

¾ Assured services ( if only MBBS doctor available) -

¾ Emergency management of pain, uncontrolled bleeding, tooth avulsion and first aid management for
maxillofacial trauma.

¾ Topical application of fluoride for caries prevention.

¾ Atraumatic Restorative Technique (ART) after adequate training.

Others-

¾ Reinforced, one-on-one behavioral intervention for tobacco and/or alcohol cessation during all
possible interactions with individuals/ families

¾ Identification and appropriate referral for cases of malocclusion, suspected cancer, dental fluorosis,
cleft lip/ palate

¾ Decipher medical history and forewarn about possible oral health complications like pregnancy
induced gum changes/ epulis, dramatic periodontopathy, effects of intake of anti-epileptic medicines/
antihypertensive

¾ Coordinate with school oral health programs, RBSK, NPPCF, RCH, ICOS and NTCP.

¾ Insist on regular oral health checkup particularly in special needs groups and geriatrics

¾ Emphasize on the role of hygiene, particularly in individuals with systemic compromise

5
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

3. Capacity Building

¾ Medical Officer at PHC will mentor the staff at PHC and primary health care team at HWCs for
delivering primary oral health care.

¾ They will conduct and coordinate oral healthcare trainings for various healthcare workers, school
teachers, volunteers and other Self-Help Groups.

¾ They may also conduct Mock-a-mouth session where they can start role plays for better reception of
trainings/ health talks
4. Monitoring and Supervision

¾ Technical support for PHC staff and staff at HWCs for appropriate maintenance of records and
reports on screening, treatment, counselling, referral and follow up and timely submission to higher
level.

¾ Monitoring and ensuring quality care and smooth functioning of oral health services at HWCs.

¾ Ensure proper inventory management of the health facility to prevent stock out of required consumables
and medicines.

6
 Referral pathway for Oral Health
Care at Health and Wellness Centres

Community based risk assessment by ASHAs

Individuals with history of tobacco/areca All individuals with known risks for cancer;
nut/ alcohol habit irrespective of age Age 30 years and above

Tobacco Cessation Centers [TCC] &/or Screening by NCD Nurse/ANMs/Male

Alcohol Deaddiction Centre at nearest Health Workers: Oral Visual Examination
Medical/Dental college

Normal findings on Oral Any abnormalityon Oral

Visual Examination Visual Examination

Evaluated by the Dentist/surgeon/ENT specialist/MO at PHC/CHC/DH

Potentially Malignant Suspected Oral Cancer Clinically Diagnosed

Lesions Oral Cancer

Elimination of Etiological Detailed Intraoral Examination and biopsy (if

factors and Tobacco required), Histo-pathological reporting- CHC/DH,
Cessation Intervention will be decided based on the presence
(Observe for 6 weeks) of dysplasia.

Regression No change/
Progression
Non dysplastic Dysplastic & needs
Surgicalintervention
Medical Management
• Reinforced counselling
• Follow up and monitoring

Referral to Tertiary
Cancer Care Centres/
Medical colleges

7
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Chapter 3: Prevention and treatment protocol for

common conditions/ diseases
3.1 General Oral Examination Procedure
In all cases the Medical Officer will do a general examination of all patients in the following manner:
1. History Taking
History recording is vital to find out the root cause of the current problem and similar associations in the
past. Dental History taking includes asking and recording the following details for the patient presenting with
dental problems:
i. Demographic data- includes Name, Age, Sex, Contact details, Marital status, Residence etc
ii. Chief complaints- includes recording the symptoms, problems, condition for which patient is seeking
medical help
iii. History of presenting illness- Followed by Chief complaint , includes recording the duration, location,
Severity, Aggravation/relieving factors, Associated signs and symptoms etc
iv. Previous History of Oral Illness- Includes history of problems of Dental origin or exposure to any
Dental procedures in past
v. Previous Medical History- History of Systemic diseases
2. Examination of the Oral cavity
The Oral examination constitutes systematic examination and an evaluation of the hard and soft tissues
(see Fig 1) in conjunction with a thorough medical and dental history. The entire mouth should be inspected
regardless of the patient’s chief complaint and reasons for the visit
In Order to perform an Intraoral Examination following set of medical instruments are required:
• Mouth Mirror
• Gloves
• Torch
• Face mask
Steps involved in an Intra Oral systematic examination includes:
Step 1: Examination of Lips
Examine the outer surface and the inner lining of the lips along with borders. The inner part of the lip will be
examined by gently turning the lip out. The inner lining would appear wet and shiny in a person with healthy
oral cavity. Examine the lips for pigmentation, presence of ulcers, swelling and crusts.

8
Step 2: Examination of Cheeks
Examine the inside of the cheeks, using a mouth mirror to push back the inner part of the cheek to one side.
The gloved index finger can also be used. The inner part should be smooth, moist, shiny and pink in color.
You should inspect for change in color, presence of any swelling and patches.
Step 3: Examination of Gums
Inspect the gums for color, consistency, contour and size. Healthy gingiva is pink, and regular.
Step 4: Examination of Floor of the mouth
Examine by asking the patient to touch the roof of the mouth with tip of his tongue. Check for pooling of
saliva in floor of the mouth. Any abnormal swellings or patches or crushing at the floor of the mouth should
be noted.
Step 5: Examination of Tongue
The top of the tongue will be examined first, followed by the sides of the tongue, which may stretch the
tongue slightly. The tip of the tongue will be held with a piece of gauze and the tongue moved from one side
to the other. To examine the top of the tongue ask the patient to protrude the tongue forward, keeping the
mouth open. To inspect the lower surface, patient is instructed to touch the roof of the palate with tip of his
tongue. Particular attention should be paid to the sides of the tongue, movements of tongue and the floor of
the mouth, as cancers develop in these areas more frequently than on the top of the tongue or the palate.
Oral cancers may have the appearance of ulcers, masses, red areas, or white areas.
Step 6: Examination of Palate:
Hard Palate (bony part of palate): Examine the hard palate by using a mouth mirror. It is pink in color, firm
and shows a corrugated pattern in anterior portion. Examine for change in color, swelling, ulcer, and cleft.
Soft Palate (soft part behind hard palate): Normally, it is reddish pink in color. Examine for swelling or ulcers.

Figure 1 Steps in Systematic Oral Examination

9
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Step7: Examination of Teeth:

Examine the surfaces of all teeth. Look for the following- tooth decay, missing teeth, brown/black discoloration
on teeth, small pits and fissures, cavities on the tooth/between teeth.

Figure 2 Dentition in Adults and Children

Morphology of Tooth:
Parts of teeth
Broadly tooth is divided into two parts- The visible white
part above the gumline is called crown and the part below
the gumline is called root.
Crown is covered by a outermost hardest part called as
Enamel. Enamel protects the tooth. The inner part of
enamel that is less hard and slight yellow in color is called
as Dentin. It surrounds the Pulp containing blood vessels
and nerves of the tooth. Blood vessels and nerves enter
the pulp chamber through root canal. In the root portion,
dentin is covered by Cementum.
Humans have two set of teeth: Milk teeth/baby teeth/
primary teeth and adult teeth / permanent teeth. There are
total thirty two permanent teeth in adults, eight incisors,
four canines, eight premolars and twelve molars in both
upper and lower arches.

10
 Important points to keep in mind:
• Wash your hands before starting oral examination and use disposable gloves
• Briefly explain to the patient what the examination involves
• Instruments need to be sterilized after each time they are used

3.2 Common Oral Hard Tissue Diseases/ Conditions:

3.2.1 Dental Caries/ tooth decay
• Dental caries is a multifactorial microbiological tooth
disease characterized by demineralization of inorganic
substance and dissolution or destruction of organic
substance of the tooth. Dental caries primarly affects
calcified structures of the teeth. Dental caries is mostly
associated to the lifestyle factors, but sometimes it
can be hereditary. Dental caries is characterized as
brown or black spot or cavity on the tooth surface. If
left untreated it can progress further leading to pulpal
involvement.
• Risk factors- Consumption of sweet and sticky food
(refined carbohydrates), in between snacking, lack of
proper oral hygiene can lead to formation of caries.
• Signs and Symptoms-
- Initial stages: Black or brown spot or discoloration
on tooth surface. Patient often complaints of
sensitivity to hot or cold, sweet or sour food. It
often leads to food lodgement in the cavity.
- Later stages: If left untreated in addition to
symptoms above dental caries can progress further
leading to the involvement of pulp. Patient presents
with severe pain which is often aggravated on
lying down or consumption of food. It can also be
associated with swelling and pus discharge.
• Prevention - Figure 3 Risk Factor for Dental Caries
¾ Meticulous oral hygiene through proper brushing (annexure)
¾ Dietary modifications: Reduced intake of refined carbohydrates and in between meal snacking.
Consumption of food that stimulates saliva production.
¾ Rinsing/swishing with water after consumption of any type of food
¾ Topical fluoride application – Only for individuals with the risk of Dental caries

11
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Figure 4 Dental caries affecting Molar Figure 5 Dental Caries affecting Incisors

Figure 6 Progression of Dental Caries

Early childhood caries (ECC) has also been called nursing caries, nursing bottle caries, and baby bottle
tooth decay. The cavities are mostly seen on upper front teeth but can affect other teeth also. This is only
seen in small children (0-6 years age group), mainly in those who are drinking bottled milk.
ECC leads to early loss of milk teeth, delayed eruption of permanent
teeth, difficulty in eating, pain, abscess and malnourishment.
Clinical Features:
• White spots on teeth initially along the gum line
• Brownish/black discoloration

Figure 7 Early Childhood caries

12
Risk Factors:
• Teeth exposed to sugary liquids for long periods of time.
• Children who fall asleep with a bottle in their mouths or who carry a bottle and drink sweetened liquids
throughout the day.
• Lack of proper oral hygiene
• Frequent consumption of sticky/sweet food in-between meals
• Continuous presence of sweetened milk/sticky/sweet food in the mouth
• Prolonged Bottle feeding
[Link]. Management of Caries -
Symptomatic management:
1. Dental decay unaccompanied by swelling or abscess: Treatment comprises of removal of the decay part
of the tooth and restoring them with the restorative materials like amalgam, composites, glass inomer
cements etc. Restoration requires adequate training and should be performed by Dentists at CHC/DH.
2. Dental decay accompanied by swelling or abscess: Immediate pain relief should be provided through
prescription of Analgesics and Antibiotics. Incision and drainage of the abscess should be performed for
symptomatic relief.
3. Dental decay involving pulp: Treatment comprises of Endodontic Root Canal Treatment where nerves
and vessels of tooth are removed and replaced with the restoration materials. Root Canal Treatment
requires extensive training and should be performed by Dentists at CHC/ DH.
Other Management:
1. Atraumatic Restorative Technique (ART): A method in which the infected dentine and soft debris is
excavated from the cavity using excavators, generally done for deep cavities on molars. Medical Officers
of PHC-HWCs can perform ART treatment after adequate training. Details about the ART treatment is
mentioned later.
2. Topical Fluoride application: fluoride treatments involves application in the form of rinse, foam, gel,
or varnish. The treatment may be applied with a swab, brush, tray, or mouthwash. Details about the
procedure is mentioned later.
[Link] Atraumatic Restoration Treatment (ART)
The ART was developed in Tanzania in mid-1980s as part of a community-based primary oral health
program. The technique consists of caries removal using hand instruments only, followed by restoration of
the cavity with an adhesive filling material, such as glass-ionomer cement (GIC)
As the name suggests this treatment procedure is atraumatic to the tooth. Word atraumatic means it provide
minimal or no trauma to the tooth. The procedure involves the removal of soft and demineralized tooth
tissue, with the help of hand instruments alone, followed by restoration with an adhesive restorative material,
usually glass-ionomer cement. This technique is recommended by the World Health Organization for bringing

13
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

dental treatment to people who would not normally have access to dental care. It was also developed as a
means of treating dental caries in areas where extraction would otherwise prevail.

Considerations for Atraumatic Restorative Treatment (ART)

a. A method in which the infected dentine and soft debris is excavated from the cavity, generally done for
deep cavities on molars.
b. Once it is assured that a healthy, hard layer of dentine covers the underlying pulp, restorative materials
like Glass Ionomer Cement or Zinc Oxide Cement mixed with eugenol(clove oil) are used to pack the
cavity
c. It is important to assure that there is no bleeding spot / pulp exposure once caries is excavated
d. ART can be done only in cases where there is no pain and the cavity is not involving the pulp chamber.
Deep cavities (involving pulp) with no pain are not recommended for ART Treatment.

Indications Contraindications
- Small and Shallow cavities (involving - Presence of Swelling or abscess with the origin to the teeth
dentine only) that are accessible to
hand intruments - Carious tooth with pulpal exposure

- In High-risk caries cases as - Tooth with acute or chronic pain

intermediate treatment - Caries is inaccessible to hand instruments
- Dental caries not involding pain or - Caries is present in proximal areas (in between teeth)
any form of swelling

Why ART? Why adhesive material?

Less trauma to the tooth during preparation Chemical adhesion
Low cost of hand instruments Minimizes cutting
No need of anesthesia Fluoride release-prevents and arrests caries
Simplified infection control Does not cause pulp inflammation
Reduces physiological trauma to patients

Instruments Materials
Mouth mirror Cotton rolls
Tweezer Cotton pellets
Hatchet Petroleum jelly
Spoon excavator Plastic strip
Carver Wedges
Mixing pad and spatula Type IX Glass Ionomer cement
Plastic filling instrument
Enamel Hatchet

14
Figure 8 Instruments required for ART Figure 9 Glass Ionomer cement for filling of carious
lesions

Procedure
1. Position- Patient-supine on a simple table with head support and operator-head of table
2. Tooth Isolation- Isolate tooth with cotton.
3. Preparing the cavity
a. Clean the tooth surface to be treated with wet cotton
b. Soft caries is removed using spoon excavators in the circular scooping movements. If the opening of
hole is narrow, Widen the entrance of lesion with hatchet Place the blade of the dental hatchet into
the cavity and turn the instrument forward and backwards like turning a key in a lock.
4. Cleaning the prepared cavity:
a. Clean the prepared cavity using chemical solvents like dental conditioner or tooth cleaner or the liquid
supplied with the glass-ionomer cement
b. 10% solution of polyacrylic acid is used cavity cleaning or conditioning. Apply a drop of conditioner
on a pad or the slab. Dip a cotton wool pellet in the drop and clean the entire cavity for 10-15
seconds.
c. Immediately wash the cavity after conditioning with the cotton pellet dipped in clean water and let
the cavity dry
5. Mixing of Restorative material:
a. Follow the manufacturer instructions carefully with respect to the powder and liquid ratios.
b. Place powder on the glass slab or mixing pad and using mixing spatula divide the powder into two
equal portions
c. Dispense a drop of liquid next to the powder and start mixing the one half of the powder using
spatula. Roll the powder into the liquid gently wetting the particles without spreading them around.

15
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

d. As soon as all powder particles are wetted, the second portion is folded into the mix
e. Mixing should be completed within 20-30 seconds depending on the brand of the cement and final
mixture should look smooth like chewing gum
6. Restoring cavity:
a. Insert the cement mixure into the prepared cavity immediately. Use applier/carver to place the
small amount of mixture into the cavity and fill the cavity incrementally. Entire procedure should be
completed in 30-40 seconds
b. Rub a small amount of petroleum jelly on the gloved index finger and press the material firmly into
the cavity and remove the excess of the cement with the carver.
Advantages
¾ Easily available instruments, less expensive
¾ Conservation of tooth structure
¾ No noise
¾ No water and suction required
¾ Minimal pain
¾ Less anxiety
¾ Minimal operator training
¾ Steps in Art Treatment
1. Isolation of Carious tooth with Cotton 2. Removal of Soft Caries with Excavator

16
[Link] prepared cavity with Polyacrylic acid 4. Mix Glass Ionomer cement

5. Filling the conditioned cavity with mixed GIC Cement 6. Carving the finishing the filling

[Link] Fluoride Application

Topical fluoride treatment is the direct application of fluoride onto the teeth in the form of varnishes, paste,
gel or foam. It works by binding to the tooth structure at the molecular level, thereby forming a protective
layer. This layer is more resistant to bacterial decay and reduces the risk of caries.
Indications:
- Individuals with the High or Moderate risk of caries
- Patients with reduced salivary flow, or following periodontal surgery, and patients with fixed or removable
prostheses
- Patients with exposed roots
Advantages of Tropical Fluoride Application -
i. Prevention of Dental Caries: Fluoride treatment is recommended for individuals who are prone to or
have a higher risk of developing caries. Direct application of fluoride is especially beneficial in all children
shortly after the eruption of new milk or permanent teeth, in order to reduce the risk of developing tooth
decay in the future. Fluoride can also be used to ‘heal’ initial caries lesions which present as white spots
on the teeth. These spots are porous and the accumulation of a high concentration of fluoride prevents
further decay in the area.

17
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

ii. Treatment of Sensitive Teeth: Sensitive teeth can be treated with fluoride application as the
protective layer of ‘fluorapatite’ formed over tooth structure acts as a barrier over the teeth when exposed
to cold air or water.
Required instruments and materials:
¾ Applicator tip
¾ Varnish
¾ Gauze / cotton
Steps:
1. Wipe off plaque from teeth using brush / gauze
2. Dry the teeth with cotton / gauze / compressed air
3. Put two drops of fluoride varnish on primary teeth and use the brush to apply a thin layer of brush on
the tooth. Once the varnish comes in contact with the saliva, it sets.
4. Instruct the patient to not eat foods / drink anything for several hours so that varnish stays in contact for
as much time as possible
5. Inform the caregiver that the Varnish will leave a light yellow tinge on teeth till it dissolves or is brushed
off several hours later.
Semi-annual application should be recommended. However, care should be taken that Fluoride application
should be avoided in the High fluoride endemic areas.
[Link] Standard Care Pathway for Dental Caries/Tooth Decay

Oral Examination by MO at PHC-HWC

Identify sign & symptoms of tooth decay: In case of nursing bottle caries- Look/Ask for:
- − Brown/black discoloration ‰ White spots around margin of tooth
- − Hole /cavity on the tooth/between tooth ‰ Brown /black discoloration/pain/pus
discharge
- − Broken tooth
‰ Take history regarding bottle feeding
- − Pain on chewing food
- − Sensitivity to hot/cold/sweet/sour
- − Any swelling or pus discharge around tooth

18
Individual identified with any of above
mentioned signs & symptoms of tooth decay Individual without tooth decay

Symptomatic care at PHC-HWC Counseling /Advice on:

by MO:
z Brushing teeth twice a day with pea size
Look for discoloration/hole/pain/pus amount of tooth paste
discharge
z Meticulous oral hygiene
z For pain relief:
z Rinsing mouth with water after every
‰ Warm saline rinses meal

‰ Clove oil application inside tooth z Avoid consumption of sticky & sugary
cavity diet

‰ Single dose of paracetamol z Avoid self-medication for pain

‰ Refer to nearest health facility z Avoid picking of teeth with any objects
with dentist for further care
z For babies above 6 months of age give
z For Prevention: water as a last feed

‰ ART Treatment to stop the z Avoid letting baby sleep with bottle in
progression of caries the mouth

‰ Topical Fluoride application z Cleaning of gums and teeth with clean

cloth after breast feeding
z Avoid bottle feeding
3.2.2 Fluorosis
• What is fluorosis?
¾ Teeth have brownish-yellow spots on them and sometimes they also have rough surfaces and jagged
margins. The condition could be due to the presence of high amount of fluoride in the drinking water
supply and is called Fluorosis.
¾ Many areas in our country have more than the normal limits of fluoride, which result in fluorosis. This
is a regional problem.
¾ The excessive fluoride gets incorporated into the developing teeth and manifests in various forms like
chalky white teeth, brownish yellow stains, and pitting on the surface.
¾ If the fluoride level is greater than 4 PPM (Parts Per Million) can also cause more debilitating conditions
like skeletal fluorosis

19
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Figure 10 Dental Fluorosis affecting lower incisors

• Requirement of optimum fluoride-
It is necessary to mention here that optimum level of fluoride (1ppm) is beneficial for dental health. If
optimal amount of fluoride ion gets incorporated into the tooth enamel, it makes enamel less prone
to dissolution by bacterial products: acids. One of the reasons why, the dentist prescribes fluoridated
toothpaste for children.
• Management-
Referral to the higher centre

ROLE OF THE MO IN DENTAL FLUOROSIS

DO:
¾ When such cases are reported to PHC MO, he/she should coordinate water sample
collection from respective villages or localities for testing presence of high fluoride
levels in water.
¾ If high fluoride levels are confirmed, then engage in further management regarding
defluoridation of water, conduct awareness session in community, etc.
ADVISE
¾ Advise on use of very little (pea size) toothpaste for brushing.
¾ Advise on use alternative source of water for drinking in fluoride endemic areas

20
3.2.3 Irregular arrangement of teeth and jaws- Malocclusion
• Signs
¾ Excessive crowding of teeth
¾ Spacing between the teeth
¾ Teeth may be placed abnormally forwards or backwards or be rotated
¾ The entire upper or the lower jaw may be placed abnormally forward or backward.
¾ A defect in the form of a cleft may be present in the upper lip or palate or both.

Figure 11 Malocclusion due to crowding

Figure 12 Deep Bite

21
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

• Symptoms
¾ Difficulty in pursing lips
¾ Unpleasant appearance
¾ Difficulty in keeping teeth clean because of the abnormal position
¾ Recurring dental decay
• Causes of malocclusion
¾ Early loss of milk teeth due to dental decay.
¾ Oral habits causing abnormal pressure on teeth and surrounding structures such as thumb and finger
sucking, tongue thrusting, mouth breathing, nail biting, clenching and bruxism.
• Untoward effects of malocclusion-
¾ Increased chances of dental decay and gum problems
¾ The joint between the upper and lower jaw bones can get affected
¾ Teeth that are very forward can easily get traumatize due to a blow or a fall.
¾ Appearance- Personality
• Prevention-
¾ Identification of habits like thumb sucking/ mouth breathing
¾ Counselling the parents about correct feeding techniques
• Management-
¾ At PHC- identification of malocclusion and health education about brushing technique
¾ Providing information about untoward effects and treatment availability at higher center.
3.2.4 Tooth loss
Untreated and advanced dental caries, periodontal diseases, trauma and old age can lead to loss of permanent
teeth.
• Untoward effects of missing teeth
¾ Migration of other teeth in edentulous area leading to malocclusion
¾ Some sharp cusps of isolated teeth may cause a traumatic ulcer
¾ Difficulty in chewing, eating
¾ Compromised aesthetics

22
• Management
¾ Health education about untoward effects of missing teeth
¾ Referral to the higher centre for replacement of missing teeth
¾ If person is using dentures, look for ulcers/ epulis/ candidiasis and give symptomatic relief
¾ Look for faulty dentures, if any

Figure 13 Missing tooth/teeth

3.3 Common Oral Periodontal Diseases/ Conditions:

3.3.1 Periodontal diseases/ gum diseases
Healthy gums are pink in color with some pigmentation. The edges are firmly attached around the tooth, and
do not bleed on normal [Link] oral hygiene is neglected, gums tend to swell and bleed. Early stage
of the disease is called Gingivitis.
Signs and symptoms of gingivitis
¾ Change of color to red from coral pink /pigmented
¾ Bleeding from the margins of the gum during brushing
¾ Swollen gums that might bleed even on the slightest touch
¾ Later, the bleeding may even occur spontaneously. Even at this late stage, the condition may be
painless.
¾ Sensitivity to hot and cold food/water
If Gingivitis is not treated, the disease may progress to involve the surrounding bone, leading to a gap

23
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

between the gum and the tooth known as pocket, leading to Periodontitis or Pyorrhoea. The same condition
if seen in children is termed as Juvenile Periodontitis.
Symptoms of periodontitis
¾ Itching sensation around tooth and on gingiva
¾ Dull constant ache
¾ Food lodgement/ impaction
¾ Loose teeth/ increase in mobility of teeth
¾ Bad odour from the mouth
¾ Migration of teeth and exposed root surfaces- gingival recession
¾ Sensitivity to hot and cold food/water

Figure 14 Healthy Gingiva in Adults Figure 15 Healthy Gingiva in Children

Figure 16 Gingivitis Figure 17 Periodontitis

• Causes:
¾ Gum diseases are caused by plaque accumulation. Bacteria present in plaque form toxic substances
that may cause inflammation of gums.
¾ If plaque is not removed regularly, it may harden to form calculus (tartar).
¾ This tartar with its rough surface attracts further deposition of plaque and bacteria, sustaining the
inflammation and destruction of supporting bone.

24
• Management:
¾ Symptomatic relief- Suggest warm saline rinses, suggest not to stop brushing
¾ Management of abscesses
¾ Refer to the nearest dentist for mobility of teeth and other complications.

ROLE OF THE MO IN HANDLING PERIODONTAL DISEASES/ GUM

DISEASES
DO:
¾ Check gums for bleeding and change in color from normal
¾ Patient having diabetes, heart diseases or any regular medication will require extra care
and precautions.
¾ Management of abscesses- antibiotics and drainage Refer to nearest facility where
dentist is available in case you see above symptoms
ADVISE:
¾ Rinse mouth with warm saline water
¾ Brushing of teeth twice a day
¾ Avoid picking teeth using any objects

[Link] Standard Care Pathway for Gum Diseases

Identification of common gum diseases - Evaluation of associated cause -

• Bleeding Gums • Poor Oral Hygiene
• Swollen Gums • Tobacco Use
• Foul Smell • Hormonal Changes- Pregnancy,
• Deposits and Discoloration of Teeth Menopause, Menstrual Phase
• Loose Teeth (Advanced Disease) • Poor Nutrition
• Widening between Teeth (Advanced Disease) • Chronic diseases
• Immuno compromised conditions

At HWC- PHC- Medical Officer

• Do Oral Visual Examination and check for any associated oral disease.
• Reinforce maintenance of proper oral Hygiene. Demonstrate Correct Brushing Technique.
• Counsel pregnant patients, patients having chronic diseases on oral hygiene and nutrition.
• Advice tobacco users to quit tobacco.
• Management of abscesses- antibiotics and drainage(discussed in Emergency Chapter)
• Referral to the nearest health facility having Dental Set Up for oral prophylaxis.
• Referral to SDH/ DH for advanced periodontal disease.

25
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

3.3.2 Oral infections and oral symptoms of systemic conditions

a. Diabetes:

Research reveals that there is an increased prevalence of gum disease among patients with diabetes, thereby
adding gum/periodontal disease to the list of other complications associated with diabetes, such as heart
disease, stroke, kidney disease etc. This relationship between periodontal disease and diabetes is two-way.
Periodontitis has been identified as the sixth complication of diabetes.

Not only the people with diabetes are more susceptible to periodontal disease, but periodontal disease may
also have the potential to affect blood glucose control and contribute to the progression of diabetes.

Oral Changes in Patients with Diabetes

• Cheilosis
• Mucosal drying and cracking
• Burning mouth and tongue
• Diminished salivary flow
• Alterations in the flora of the oral
cavity
• Increased rate of dental caries
• consistent foul odour from mouth
• yellowish plaque deposits
Periodontal Changes in Patients
with Diabetes
• pus exuding from gums, tenderness
or swelling in gums
• red and swollen gum that bleeds on
brushing
• Enlarged gingiva
• Sessile or pedunculated gingival polyps
• Polypoid gingival proliferations Fig 18 Periodontal condition in patients with diabetes
• Abscess formation (Source- Textbook on Clinical Periodontology by
Newman and Carranza)
• Periodontitis and loosened teeth mobility of teeth

Line of Management
¾ Control of blood glucose levels is the key to control and prevent dental problems.
¾ Also, maintenance of good oral hygiene, warm saline rinsing may help keep inflammation under
check
¾ Smoking cessation is highly recommended in such patients because of documented negative impact
of smoking on diabetic complications.

26
b. Pregnancy and Oral Health / Hormones and oral health
A number of hormonal conditions affect the periodontal tissues, including diabetes mellitus and fluctuations
in female sex hormones associated with puberty, pregnancy, and menopause. Changes in corticosteroid
and thyroid hormone homeostasis may also affect the oral cavity. Hormonal changes may directly alter the
periodontal tissues or may change the way the host responds to accumulation of local factors such as plaque
and calculus. In addition, the presence of certain hormonal conditions may require alterations in dental
treatment.
Various hormones can impact the development or progression of gum diseases
Hormonal changes occur throughout a woman’s life during puberty, menstruation, pregnancy and menopause.
Research data reveal that the fluctuating female hormone levels can impact conditions inside the mouth,
allowing bacterial growth, increase blood flow to gingival tissues, and aggravate health issues, such as fetal
death, pre-term births and bone loss.
• Puberty
During puberty, there is surge in production of the female sex hormones which can increase the blood flow
to the gums and change the way gum tissue reacts to irritants in plaque, causing the gum tissue to become
red, tender, swollen, and more likely to bleed during brushing and flossing.
• Pregnancy
As with other systemic conditions, pregnancy itself does not cause gingivitis. Gingivitis during pregnancy
is caused by bacterial plaque, just as it is in non-pregnant women. The hormonal changes of pregnancy
accentuate the gingival response to plaque and modify the resultant clinical picture.
However, an increased level of progesterone is considered to cause gum diseases, especially during second
to eighth month of pregnancy. Gums may feel sore, itchy or may even bleed while brushing. Also, pregnancy
sometimes may be associated with overgrowth of gum tissue leading to formation of pregnancy epulis/
granuloma.

Figure 19 Pregnancy Induced Gingival Enlargement

27
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Menstruation
During the menstrual period, the prevalence of gingivitis increases. Some patients may complain of bleeding
gums or a bloated, tense feeling in the gums during the days preceding menstrual flow. The exudate from
inflamed gingiva is increased during menstruation, which suggests that preexisting gingivitis is aggravated by
menstruation; however, the crevicular fluid of normal, healthy gingiva is unaffected.
• Menopause
As a result of decline in female hormone levels, women in this phase may experience altered taste, burning
sensation of mouth or tongue, dryness of mouth. Also, low estrogen levels may impact the bone density
during this period.
c. Medicines and Oral Health
Effect of systemic drug therapy on periodontium can range from various adverse effects on periodontal
tissues to increased periodontal breakdown to affording some degree of protection.
• Drug induced gingival enlargement ( DIGE) is well known adverse reaction of systemic medications like some
anticonvulsants, immunosuppressant’s, and calcium-channel blockers such as phenytoin, cyclosporine The
condition may create speech, mastication, tooth eruption, and esthetic problems.

Figure 20 Drug Induced Gingival Enlargement

• The nature and the course of periodontal disease can also be affected by those medications that
interact with immune and inflammatory responses like anti-inflammatory drugs, corticosteroids and
immunosuppressant.
• Dry mouth, Abnormal bleeding from gums, altered taste, inflammation of soft tissues of mouth, enlarged
gums, color change of teeth and gums are some of the common side effects of medications affecting oral
health.

28
• Antihistamines, decongestants, antihypertensive, antidepressants, sedatives, painkillers, blood thinners,
oral contraceptives are some of the medications that can impact oral health.

• Hormonal contraceptives aggravate the gingival response to local factors in a manner similar to that
seen during pregnancy; when these drugs are taken for longer than 1.5 years, there is an increase in
periodontal destruction. Although some brands of oral contraceptives produce more dramatic changes
than others, no correlation has been found to exist on the basis of differences in the progesterone or
estrogen content of various brands.

Management

• Patients taking mediations impacting periodontal health may need adjunctive plaque control agents and
more rigorous monitoring of the status of the periodontal tissues.

• Patients taking aspirin or other anticoagulants should inform dentist beforehand about these medications.
Use of a soft tooth brush with gentle strokes and flossing might reduce the chances of bleeding.

• For the patients taking medications that causes dryness of oral cavity, frequent sipping of water, chewing
sugarless gum and regular brushing is necessary.

• Gums enlargement or overgrowth requires professional diagnosis and management. Depending on

severity, dentist may consult physician to substitute a drug or may perform prophylaxis followed by gum
surgery if overgrowth interferes with function or esthetics of the patient.

3.4 Common Oral Soft Tissue Conditions:

3.4.1 Abnormal growth, patch or ulcers

• Abnormal growth, patch- white or red or chronic non-healing ulcers can be indications of precancerous
lesions.

• Risk factors
Tobacco chewing is the single most important risk factor for oral cancer. Other risk factors include
alcohol use,betel nut chewing, and chronic trauma to oral mucosa by sharp tooth or ill-fitting dentures.
Chronic exposure to these risk factors causes changes in the oral mucosa and these changes are visible
as pre-cancerous [Link] a period of time, malignancy may develop in these lesions.
• Pre-cancerous lesions

Pre-cancerous lesions or conditions are local/generalized disturbances that predispose to malignancy in

aparticular site. Leukoplakia, erythroplakia, palatal changes associated with reverse smoking or beedi
smokingand submucous fibrosis are local pre-cancerous lesions. Plummer Vinson syndrome, syphilis, and
erosive lichenplanus are generalized pre-cancerous conditions. All these conditions are amenable to early
diagnosis, and treatment is possible in many cases.

[Link] White Patch/ Leukoplakia

Oral leukoplakia is a precancerous condition that causes white or gray patches inside the mouth or on the
tongue that can be thick and develop slowly over time.

29
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Causes:
• Smoking/tobacco/ betel nut use
• Injury to the inside the cheek, such as from biting
• Rough, uneven teeth
• Dentures, especially if improperly fitted
• Chronic alcohol abuse
Clinical features:

Symptoms Signs
Restricted mouth opening Patch of white or grey color over inner surface of
lips, cheeks, gums or tongue.
Decreased tongue movements associated with lesion
over base of tongue or near floor of mouth. Thick, hard and raised surface over the lesion

ROLE OF THE MO IN HANDLING WHITE PATCH/ LEUKOPLAKIA

DO:
¾ Identify white to red patches on tongue, inner lining of lips and cheeks
¾ Redness may be a sign of cancer. Refer immediately to dentist if you see any patches or
patches with red spots.
¾ For all abnormal growths, patch and ulcers follow the protocols as per population based
screening program for NCDs.
ADVISE
¾ Stop smoking or chewing tobacco and alcohol
¾ Intake of food rich in antioxidants such as spinach and carrots.
¾ Maintain good oral hygiene by brushing and mouth rinsing
ROLE OF THE MO IN HANDLING WHITE PATCH/ LEUKOPLAKIA
DO:
¾ Identify white to red patches on tongue, inner lining of lips and cheeks
¾ Redness may be a sign of cancer. Refer immediately to dentist if you see any patches or
patches with red spots.
¾ For all abnormal growths, patch and ulcers follow the protocols as per population based
screening program for NCDs.
ADVISE
¾ Stop smoking or chewing tobacco and alcohol
¾ Intake of food rich in antioxidants such as spinach and carrots.
¾ Maintain good oral hygiene by brushing and mouth rinsing

30
 Universal NCD screening protocol

Community based risk assessment by ASHAs

Individuals with history of tobacco/areca All individuals with known risks for cancer;
nut/ alcohol habit irrespective of age Age 30 years and above

Tobacco Cessation Centers [TCC] &/or Screening by NCD Nurse/ANMs/Male

Alcohol Deaddiction Centre at nearest Health Workers: Oral Visual Examination
Medical/Dental college

Normal findings on Oral Any abnormalityon Oral

Visual Examination Visual Examination

Evaluated by the Dentist/surgeon/ENT specialist/MO at PHC/CHC/DH

Potentially Malignant Suspected Oral Cancer Clinically Diagnosed

Lesions Oral Cancer

Elimination of Etiological Detailed Intraoral Examination and biopsy (if

factors and Tobacco required), Histo-pathological reporting- CHC/DH,
Cessation Intervention will be decided based on the presence
(Observe for 6 weeks) of dysplasia.

Regression No change/
Progression
Non dysplastic Dysplastic & needs
Surgicalintervention
Medical Management
• Reinforced counselling
• Follow up and monitoring

Referral to Tertiary
Cancer Care Centres/
Medical colleges

31
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

[Link] Candidiasis
It is the most common oral fungal infection. It can present as an acute or chronic condition.
Causes:
¾ Poor oral hygiene, especially in individuals using
artificial teeth/ dentures.
¾ Systemic condition- diabetes, immuno
compromised patients
¾ Smoking
¾ Use of Steroids
Signs and symptoms
¾ Patchy white layers on tongue/inner surface of
cheeks and lips, tongue etc.
¾ In individuals wearing dentures, redness will be Figure 21 Oral Candidiasis
observed on the palate and at corners of lip
Management
¾ Check for signs of systemic diseases like diabetes
¾ Suggest topical anti-fungal medications
¾ Advise rinsing mouth with warm saline
¾ Refer to dentist for ill-fitting dentures
[Link] Recurring Oral Ulcers
Recurring oral ulcers are among the most common problems reported. A person presenting with symptoms
of recurring oral ulcers should be asked for history of
systemic diseases. If the systemic condition is ruled out,
Recurrent Apthous Stomatitis (RAS), is usually the most
common condition.
Recurrent apthous stomatitis is characterized by
recurring ulcers confined to the oral mucosa in patients
with no other signs of disease.
Predisposing factors:
1. Genetics
2. Trauma
Figure 22 Aphthous Ulcers affecting floor of
3. Tobacco use
the mouth

32
4. Medicines
5. Hematinic deficiency
6. Hormonal changes
7. Stress
Signs and symptoms:
Most common presentation- shallow painful ulcers (8-10 mm in size) on inner surface of lips, cheek and on
the floor of the mouth. These ulcers health within 10-14 day without scarring.
Management:
For minor ulcers- symptomatic treatment
¾ Application of protective emollient
¾ Application of topical anesthetic agent
¾ Advice on eating soft, non-spicy food for rapid healing.
¾ Cooling mouth rinses with cold water or applying ice on ulcer
¾ Avoid very hot food and drinks
¾ Referral to dentist in case of traumatic ulcers due to sharp tooth/ dentures
Advice on maintaining oral hygiene
¾ Advise on rinsing the mouth with salt water
¾ Advice to follow health oral care practices as brushing twice a day
¾ Bland and healthy diet rich in vitamin B,C and zinc
Treatment of major ulcers
1. Local application of betamethasone with neomycin ointment helps to reduce the healing time. Fluocinolone
gel, clobetasol cream, beclomethasone spray have been tried.
2. Dissolve 250 mg of tetracycline in 50 ml of water and rinse mouth 4 times a day for 5–6 days (Special
considerations for pregnant mothers and breastfeeding mothers).
3. Levamisole tablet (anthelminthic) 150 mg 1 tablet twice a day for 2 days has been tried. Levamisole
is an immune-potentiating drug that restores deficient phagocytic function and cutaneous delayed
hypersensitivity reaction and increases absolute and relative T cell count
4. Tab Rebamipide 100 mg BD for 7 days
5. PMNR—intralesional injection of steroids
6. Since ulcers are extremely painful, topical protective orabase can be used
7. Lactobacillus therapy

33
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

8. Vitamin B complex tablets

9. Iron replacement
10. In severe cases tranquilizers; chemical cautery with phenol has been used
11. Gentian violet
12. Fermented milk

ROLE OF THE MO IN HANDLING ORAL ULCERS/APHTHOUS ULCER

DO:
¾ Cooling mouth rinses with cold water or applying ice on ulcer
¾ Avoid very hot food and drinks

ADVISE:
¾ Advise on rinsing the mouth with salt water
¾ Advice to follow health oral care practices as brushing twice a day
¾ Bland and healthy diet rich in vitamin B,C and zinc

3.4.2 Cleft lip/ palate

Cause:
¾ Genetic disorders
¾ Deficiency of folic acid during pregnancy
¾ Smoking and drinking alcohol during pregnancy
Sign & Symptoms:
¾ Spilt lip/palate or both
¾ Difficulty in feeding, swallowing and speech
¾ Unpleasant appearance of the face

Child Health Screening and Early Intervention Services

under RBSK envisage to cover 30selected health conditions
for screening, early detection and free management
including cleft lip and palate. Under Rashtriya Bal
Suraksha Karyakram, District Early Intervention Centre’s (DEIC) are operational in all districts of the country
for providing management of cases referred from the blocks and also link identified children with tertiary
level health services, in case surgical management is required.

34
A team consisting of Pediatrician, Medical officer, Dental officer, Staff Nurses, Paramedics from multiple
disciplineare engaged to provide a holistic service to children in these center’s.

ROLE OF THE MO IN CLEFT LIP/PALATE

DO:
¾ Refer identified cases of cleft lip and palate to District Early Intervention Centre’s (DEIC)
¾ Do detailed examination of all systems and from head to toe for screening of other
deformities
ADVISE
¾ Advise pregnant women to take full course of Iron Folic Acid tablets during pregnancy.

35
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Chapter 4: Oral care-emergency Management

protocol
4.1 Pain, swelling/ abscess
• Tooth/Pulpal pain:

¾ It is spontaneous, strong, often throbbing,

exacerbated by temperature, and outlasts the
evoking stimulus. Localization is poor, and pain
tends to radiate to the ear, temple, or cheek.

¾ The pain may subside spontaneously, but the

patient should still be referred for dental advice
because the pulp has probably necrosed, dental
abscess will probably follow. Root canal treatment
or tooth extraction is required.

¾ Management at PHC, if dentist not available:

Analgesic prescription and referral to the nearest
dentist.
Figure 23 Periapical Abscess
• Pain in tooth and around the tooth- periapical abscess

¾ Pain is spontaneous, severe, persists for hours, is

well localized, and is exacerbated by biting. The
adjacent gum is often tender to palpation.

¾ An abscess may form (gumboil), sometimes with

facial swelling, fever, and illness.

¾ In the absence of immediate dental attention, it

is best to incise a fluctuant abscess and to give
antimicrobial agents (such as amoxicillin) and
analgesic medication.

¾ The acute situation usually then resolves, but

the abscess will recur because the necrotic
pulp will become reinfected unless the tooth is
Figure 24 Dental abscess with sinus opening
endodontically treated or extracted.

¾ A chronic abscess, however, may be asymptomatic apart from a discharging sinus. Rarely, this may
open on to the skin.

Endodontic Emergencies Presenting with Pain

Pain is one of the oldest universal medical and dental problems. The management of pain in endodontics
is primarily achieved by a combination of endodontic therapy and pharmacotherapy. The two groups of

36
analgesics that are commonly employed are elaborated below -

Pharmacotherapy for Endodontic Pain Management

1. Non-narcotic analgesics
a. Acetaminophen (325–1000 mg)
b. NSAIDs
c. Ibuprofen (200–800 mg)
d. Aspirin (325–1000 mg)
e. Diclofenac (sodium/potassium) (50–100 mg)
f. Others
2. Opioid analgesics
a. Codeine (60 mg)
b. Tramadol (50 mg)

Endodontic Emergencies presenting with swelling

The emergency treatment of suppurative lesions involves establishing drainage. This procedure releases the
purulent exudate from the periapical tissues and aids in relieving pain and pressure. After initial management,
MO may refer the case to the nearest facility with dentist.
4.2 Avulsion/Fractured Tooth
Avulsion
Definition: It is defined as the complete and total displacement of the tooth from its socket. The incidence
of avulsion varies from 0.5 to 3% of traumatic injuries in permanent dentition and 7 to 13% in primary
dentition. The main etiological factors for avulsion are sports and fight injuries. The maxillary central incisors
are the most frequently avulsed teeth.

The avulsed or luxated tooth is both a dental and an emotional problem. It is usually the result of trauma to
an anterior tooth of a child or young adult. The shock and pain of the injury and the loss of a tooth needed
for eating, speaking, and smiling often lead to emotional upheaval in patient and parent. The situation is
compounded by the need for emergency treatment, to enhance the prognosis. The longer the luxated tooth
is out of its socket, the less likely it will remain in a healthy, functional state after replantation.

Avulsed permanent anterior teeth can be replanted successfully in a child, particularly if the root apex is not
completely formed (children younger than 16 years). Avulsed primary teeth should not be replanted.

37
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Figure 25 Picture showing avulsion of Central Incisors, Storage in HBSS, Intraoral Image, Restoration with
Dental splits and Post-Operative Xray (as per sequence)

The tooth has already been replanted at the site of avulsion –

The following instructions should be given to the parent or patient as soon as the MO/ dentist has been
informed of the accident and in preparation for an imminent visit.

i. Carefully hold the tooth by the crown and gently wash the tooth in running water without brushing or
cleaning it, and examine it to be certain that the tooth is intact.

ii. Avoid touching or scraping the root surface of the tooth.

iii. Have the patient to rinse his/her mouth.

iv. Replace tooth in its socket using gentle, steady finger pressure.

v. If the patient is cooperative and able, have the patient gently close the teeth together to force the tooth
back into its original position.

vi. Refer the patient to the nearest dentist immediately. Further course of treatment would depend on
whether the apex is open/closed.

38
The tooth has been kept in special storage media with the extraoral dry time less than 60
minutes. If the patient or parent cannot replace the tooth in its socket, then care in transporting that tooth
to the dentist becomes essential. The tooth must be carried in a moist vehicle to maintain the viability of the
torn PDL. The most readily available vehicle is the patient’s mouth, in which the tooth is bathed in saliva at
body temperature. If this cannot be safely done (if the patient is too young), then the tooth has to be placed
in a suitable storage while transporting it to the dental office for further management.

Transport Medium for an Avulsed Tooth –

The choice of storage media for preserving the avulsed tooth is extremely important for the success of future
replantation. Suggested storage media are as follows:

1. HBSS (Hank’s balanced salt solution)

2. Patient’s own saliva (a) Vestibule of the mouth (b) Container into which the patient spits

3. Milk

4. Coconut water

Figure 26 Restoration of Fractured tooth

39
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

4.3 Haemorrhage
Whilst haemorrhage from the oro-facial region may present spontaneously, particularly from gingival tissue
as a result of a bleeding diathesis or a haematological abnormality such as leukaemia, the most common
cause is in response to trauma or a post-operative haemorrhage following dental [Link] history
should help to determine the precise cause of a presenting haemorrhage, but a thorough and detailed clinical
examination should be expedited to assess the patient’s general condition, and pulse and blood pressure
measurements should be taken to determine the risk of hypovolaemic shock. The management of an intra-
oral haemorrhage is summarised below-

Management of Intra-oral haemorrhage

¾ Review medical history and any recent surgery.
¾ Assess patient’s general condition and measure pulse and blood pressure.
¾ Reassure patient and clean away excess blood.
¾ Careful oral examination in good light with adequate suction.
¾ Identify the precise source of bleeding.
¾ Administer local anaesthesia and apply pressure to wound for 10 minutes.
¾ Suture with or without packing of wound.
¾ Re-examine to confirm haemostasis. If persistent bleeding, refer to maxillofacial unit for
specialist surgical management.

Fracture of the tooth involving pulp will need management similar to that of tooth pain- pulpal pain

4.4 Management of Maxillo-facial Trauma

Note- In addition to the content here, to supplement your learning, please refer to Emergency and
Trauma Management in Emergency Module Training.

Trauma or accident is the most common type of emergency. Although often dramatic in appearance,
maxillofacial injuries by themselves are rarely life-threatening. Patients with maxillofacial
injury often have significant associated injuries which confer increased mortality. These include
airway obstruction, head and cervical spine injury, and cavitary organ injury with ongoing hemorrhage. A
thorough understanding of the basic management principles of the multi-injured trauma patient is therefore
essential.

Though it can be fatal, major disability or even death can be prevented by providing stabilization using two
modes:

- Immobilization

- Control of bleeding

40
The primary survey is performed to identify immediately life-threatening injuries.

1. Airway control with cervical spine protection

2. Breathing and ventilation

3. Circulation with hemorrhage control

4. Disability: neurological status

5. Exposure-environment control

First check the victim’s level of consciousness and check for HABCDE to assess the status of the victim.

Keep DRS in mind: Danger (check the scene for danger), Response (check for the victim’s consciousness)
and Send someone to call for help.
Moving the victim:

• Victim should be moved very carefully keeping in mind the immobilization and bleeding.

• Immobilise the victim and provide support to injured body parts, retain the helmet in case of a motorcycle
accident.

• If the victim presents with branch of tree, steering wheel, any other object lodged in the body, do not
attempt to remove it since it will cause uncontrollable damage.

• When the victim has been carried to your PHC-HWC in a stretcher, removing the patient from the
stretcher has to be carried out in one swift movement.

• If ASHA is present with the victim, or any other first responder is present, gather and understand the
details of the victim and the accident.

*Remember that you can only help the victim, if you yourself are safe. Before attending to the victim, make
sure that any open wounds, skin tears on your body are covered so there is no spread of infection.

Airway Management in Trauma Setting

The first priority in treatment of the trauma patient is assessment of airway patency, adequate oxygenation,
ventilation, and protection from aspiration. Airway compromise can occur insidiously and rapidly as a result
of facial injury. The upper airway may be obstructed by the tongue or dislodged teeth. Blood, vomitus, a
foreign body, or swollen tissues may also compromise the airway. If the obstruction is due to tissue laxity
or posterior displacement of the tongue, a simple jaw thrust or chin lift maneuver may quickly alleviate the
problem. However, if the blockage is due to a foreign body, distorted tissue, or vomited material, evacuating
the airway becomes crucial. Important information regarding previous difficult intubations; major comorbid
diseases; medications; allergies; drug or alcohol use; and oropharyngeal, laryngeal, or dental diseases is not
available in the trauma setting. Dysphonia, nasal or pharyngeal intonation, and other speech abnormalities
noted during the initial examination may suggest either laryngeal injury or nasoethmoid or basilar skull
fracture, with retropharyngeal or parapharyngeal edema.

41
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Noisy breathing such as snoring, gurgling, and crowing sounds (stridor) may be caused by partial obstruction
of the pharynx or larynx. Hoarseness (dysphonia) implies functional laryngeal obstruction. Edema and/or
hematoma of the neck is a harbinger impending airway loss and should lead to early intubation.

Immediate Need for Definitive Airway

Suspect cervical spine injury


Oxygenate/ventilate

Severe maxillofacial injury

Orotracheal intubation with in-line manual

Cervical immobilization

Unable to intubate

4.5 Non healing ulcer

Ulcers are full-thickness breaks in the continuity of oral mucosa, usually caused by death of epithelial cells,
whilst erosions refer to areas of superficial epithelial tissue loss. A variety of mucosal disorders may present
acutely as ulcerations. Definitive diagnosis and management usually requires referral to oral medicine services
but there are a series of important clinical observations every clinician should make when examining an ulcer

Causes of acute mucosal ulceration Examination of an ulcer

¾ Trauma: Mechanical/thermal/chemical ¾ Define anatomical site

¾ Drug induced: Cytotoxic/nicorandil/ ¾ Single or multiple

NSAIDs ¾ Size (measure accurately)
¾ Recurrent aphthous stomatitis ¾ Shape – round/oval/irregular
¾ Mucocutaneous disorders: Lichen planus/ ¾ Base – soft/indurated/fixed
p e mp h i g o i d / p e mp h i g u s / e r y t he m a
¾ Floor-smooth/granulating/sloughing/fungating
multiforme
¾ Edge – distinct/raised/everted
¾ Haematological disease: Anemia/leukaemia
Examination of an ulcer
¾ Malignancy: Squamous cell carcinoma/
minor salivary gland carcinoma ¾ Define anatomical site

42
Whilst multiple persistent ulcerations may represent mucocutaneous diseases such as pemphigoid or lichen
planus, the most significant clinical presentation is, of course, the solitary non-healing ulcer present for longer
than 2 weeks and which persists in the absence of an obvious traumatic cause. Here, one must consider oral
squamous cell carcinoma as a possible cause. Classic signs of malignancy include irregular ulcer margins, raised
or everted edges, induration (hardness) of the ulcer base and fixity to the surrounding tissues. Figure below
illustrates the classical appearance of an invasive oral squamous cell carcinoma. Oral cancer may present
in a number of ways, however, and these are summarised. It is also worth remembering that non-healing
ulcerated or nodular lesions on the face, representing skin cancers such as basal cell carcinoma or squamous
carcinoma may be noticed, often as incidental findings,during oro-facial examination and practitioners should
be alert to recognising and documenting such lesions during patient examination.

Clinical presentation of oral cancer

¾ Oral ulceration (non-healing) Red or white
patches
¾ Abnormal swellings
¾ Loss of tongue mobility
¾ Cauliflower-like growths
¾ Abnormal, localised tooth mobility
¾ Non-healing tooth sockets
¾ Colour changes in mucosa (brown/blue)
¾ Erosions in mucosa

Figure 27 Non-Healing Intraoral Cancer

Patient education points:

• Avoid self-medication

• Avoid picking teeth / in between teeth

• Avoid placing camphor/ tobacco/ petroleum products/ salt/ pain balm at site of pain

• Avoid application of heat or any pain relief cream on the cheek

• Avoid application of heat or any pain relief balm at the site of swelling

• Avoid continuous medication

43
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Table 4.1 Do’s and Don’ts in emergencies

Symptoms Do’s Don’ts

PAIN • Identify the reason for pain • Avoid continuous medication

• Give One Dose Paracetamol STAT

• Refer to the nearest dentist.

SWELLING/ • Decipher the cause of swelling: • Avoid continuous medication
ABSCESS
- decay

- gum problem

- cancer

- postextraction/Trauma

44
 • Rule outsystemic cause like diabetes
for multiple unhealed abscesses

• Analgesic and Antibioticprescription

• Drainage of abscess
TRAUMA/ • Manage the wound and try to arrest • Do not tamper with the tooth if
AVULSION the bleeding unsure

• Refer to the nearest dentist

ULCER • Follow the guidelines in the • Avoid delay in referral
Population Based Screening,
• Trying pain relief / relief of
Management and Control of NCDs.
symptoms using othermedications
• Educate the community on mouth
self examination and tobacco
cessation
UNCONTROLLED • First aid • Delay in referral
BLEEDING
• Arrest bleeding • Trying pain relief / relief of
symptoms using othermedications
• Rule outsystemic causes for
uncontrolled bleeding
• Report to higher centre

45
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

References
Guidelines -
1. Operational Guidelines for Oral Health Care at Health and Wellness Centres, 2019

2. Rashtriya Bal Suraksha Karyakram Guidelines

Textbooks -
1. Concise Oral Medicine - HR Umarji - (2018) 296 pp., ISBN: 9788123928685

2. Dental Emergencies – Mark Greenwood, Ian Corbett, Wiley Blackwell

3. Facial Trauma - edited by Seth R. Thaller W. Scott Mcdonald ,University of Miami School of Medicine
Miami, Florida, U. S. A.

4. Grossman’s Endodontic Practice 13th edition

5. Pediatric Dentistry- Shobha Tandon 2nd edition

Academic Journal Articles -

1. An Era from Extention for Prevention to Constriction with Conservation 1 Dr. Suyash Jain, 2 Dr.
AlpanaKatiyar 1,2M. D. S. Pediatric Dentistry International Journal of Dental Science and Innovative
Research ,IJDSIR

2. Alliance for a Cavity-Free Future. 2010: 1-5

Picture Courtesy -
1. National Oral Health Programme, Ministry of Health and Family Welfare

2. Developed and Conceptualised at Centre for Dental Education and Research, National Centre of
Excellence for the Implementation of National Oral health Programme, All India Institute of Medical
Sciences, New Delhi

Training Modules -
1. Training Manual on Oral Health Promotion for Health Workers- National Oral Health Programme,
Ministry of Health and Family Welfare, Government of India

46
 Annexures:
Annexure I (a): Atraumatic Restorative Technique (ART) after adequate
training.

ADDITIONAL REQUIREMENTS
Basic Dental Kit • Drugs for pain relief (Paracetamol)
• Clove oil
• Basic diagnostic instruments:
• Dental explorer
• Mouth mirror
• Tweezer
• Povidone Iodine (mouth wash)
• 0.2% Chlorhexidine Gluconate Mouth Wash
• Tannic Acid Astringent Gum Paint
• Interdental cleaning aids (Interdental brush)
• Consumables like gloves, cotton, gauge, mouth masks.
• Torch
• Wooden spatula
ART • Spoon excavators
WHO Specified • Cement carriers
• GIC cement
• Petroleum jelly/ Vaseline
• Cement slab and spatula
• Amalgamator (for premix GIC)
• Cellophane strips
• Articulating paper
Diagnostic X ray machine • Preferably digital (RVG)– as the dark room/ black box for develop-
ing the X rays will require additional resources, where the dental
chair, equipment is available and dentists are provisioned

47
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Annexure 1 (b)
Annexure I(b): Medicines and Consumables
[Link] Level Essential Requirements
1 Community Level • Analgesics – Paracetamol
2 HWC • Sufficient stock of analgesics and antibiotics as per Essential
Medicine List
• 0.2% Chlorhexidine Gluconate Mouth Wash
• Tannic Acid Astringent Gum Paint
• Anaesthetic gel for topical application
• Wooden spatula
• Torch with white light for oral visual examination
• Emergency kit – cold pack/ pressure pack, container for keeping
avulsed tooth.
• Betadine and Chlorhexidine mouthwash
• Cotton
3 PHC/UPHC • Kit for ART as recommended by WHO
• Analgesic and antibiotic medicines as per Essential Medicine List.
• Anaesthetic gel / spray for topical application
• Denture fixatives
• Premix (amalgamated) Glass Ionomer Cement (GIC)
• Mouth mirror
• Spoon excavator
• Emergency kit – cold pack/ pressure pack, container for keeping
avulsed tooth.
• Betadine
• Cotton
• Suture Material:
• Local Anesthetic (2% Lignocaine)
• Syringes
• Tissue holding forceps
• Needle holder/ artery forceps
• Needle
• Suturing material
• Scissors
• Curved Hemostat
• Scalpel
Blade No.11 and 15

Frencken JE, Leal SC, Navarro MF. Twenty-five-year atraumatic restorative treatment (ART) approach: a
comprehensive overview. Clinical Oral Investigations. 2012;16(5):1337-1346

48
Annexure II- Myths and Facts about Oral Health
As you age, it is normal to lose teeth
The life of your teeth depends on how well you keep them. Factors like diet, correct oral hygiene practices,
regular dental check-up are very vital for healthy teeth. If you take care of teeth and gums they are with you
all your life
Using gul manjan, coal, brick powder, ash, charcoal powder is beneficial to teeth.
These substances have abrasives that wear out the tooth structure at a fast rate and are not recommended to
clean your teeth. Gul manjan has nicotine as one of its components and can get one addicted to the use of
tobacco therefore, it must be avoided altogether
Keeping /chewing tobacco numbs tooth pain
Tobacco should not be considered as a remedy for tooth pain, one can start warm saline rinses or take
medicines as prescribed by a qualified doctor and visit the dentist at the earliest to identify the cause of dental
pain and seek dental treatment.
Tooth extraction can lead to loss of eyesight
Tooth removal has no known impact on the vision / eyesight.
Scaling weakens the teeth and loosens them,
Scaling is done with special instruments to facilitate the removal of tartar and calculus only, They do not have
detrimental effects on the teeth or the gums. Scaling is recommended at timely intervals to maintain good
gum health
Tooth powder is a better alternative to toothbrush and toothpaste
Tooth powder/dantmanjan has abrasives in high quantities that can wear off and damage teeth over a period
of time. Hence, it is recommended to clean your teeth using toothbrush and toothpaste everyday
Worms can be removed from teeth upon noticing decay and cavity.
There are no worms in a tooth that are visible to naked eye. Small microscopic organisms called bacteria can
damage the tooth structure and lead to cavities. However, these organisms are too small to be appreciated
without microscopes. The dentist can remove the damaged tooth structure and place a filling to prevent
deepening of existent cavities or perform a root canal treatment if the cavity involves pulp.
Cavities on milk teeth can be left untreated as they will shed and new teeth will come in
their place.
Cavities if left unfilled, may lead to destruction and loss of milk teeth. Premature loss of milk teeth may lead
to chewing and speaking difficulty in children and result in irregular alignment of permanent teeth.
Milk teeth should only be brushed after all of them erupt
As soon as the first tooth erupts in the mouth, one must start brushing the tooth/teeth using a baby tooth
brush
Cleft is caused because of curse or exposure during eclipse
Cleft of the lip or palate in a child can occur due to some reasons like lack of nutrition including Iron
and folic acid in the mother, consumption of alcohol/ tobacco products during pregnancy, as a result of

49
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

consanguineous marriages, in certain genetic diseases or syndrome.

Brushing during pregnancy can worsen the gum bleeding/gum enlargement
The gum disease gets aggravated during pregnancy due to changes in hormone levels. Continue with brushing
and consult a dentist for further advice and treatment.
Oral health has no impact on General Health
Oral cavity is the mirror of your body. It is very important to maintain good oral health and go for timely
dental checkups. Poor oral health can impact overall health

50
Annexure III: Oral health promotion- points for health education
¾ Brush your teeth twice daily
¾ Avoid aerated drinks sticky/ sweet food Snacking between meals Consumption of raw food rich in fibre,
Vitamin A
¾ Brushing and rinsing mouth with water
¾ Do not quit brushing during pregnancy
Brushing technique

Figure 27 Brushing Technique

• For the outer portion of tooth surfaces, place the toothbrush at a 45-degree angle toward the gum margin
and move the brush from above to down for the upper jaw and from down to above for the lower jaw.
• To clean the outer front tooth surfaces, hold the brush upright and use gentle up and down strokes with
the tip of the toothbrush.
• For the chewing surface use gentle, short back and forth motion so that teeth are cleaned.
• After brushing the teeth make sure to clean the tongue also, you can use the same toothbrush and apply
gentle strokes. Kindly avoid using stainless steel tongue cleaners as they get rusted in time and may cause
infection.
• After brushing do not forget to massage gums with finger and rinsing thoroughly.

51
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

Annexure IV – Service Delivery Framework for different Oral conditions/

Diseases
Table Service delivery framework for dental caries/tooth decay care

ASHA HWC- ANM and PHC- MO Referral center’s

MHP (where dentist is
available)
• Early identification • Competencies of • Competencies • Pit and fissure sealant
the ASHA of the CHO/ / fluoride application
• Educate about healthy habits: MLHP and
brushing, rinsing with water, + MPW • Permanent
consumption of raw, fibre rich Restoration
food • Putting clove oil • Topical
in a visible cavity Fluoride • Root canal treatment
• Reinforce families to avoid Application followed by crown/
sticky/sweet foods and aerated • Symptomat ic prosthesis
drinks pain relief and • Symptomat ic
referral pain relief and • Extraction of tooth
• Promote self-examination to referral
identify early signs of decay like • Reinforce healthy
black spots/ food lodgement hygiene and diet • A t r a u m a t i c
Re storat ive
• Demonstrate tooth brushing Treatment and
technique referral

Table 4.2 Service Delivery Framework for gingivitis and periodontitis

ASHA HWC- ANM and PHC- MO Referral center’s

CHO/MLHP (where dentist is
available)
• Early identification • Competencies of • Competencies • Reinforce healthy
the ASHA of the CHO/ habits
• Educate about healthy habits: MLHP and
brushing, rinsing with water + MPW • Demonstrate tooth
brushing technique
• Reinforce finger massage of • Mouth rinses +
gums after brushing with warm saline • Advise mouth rinsing
• Ma nagement
• Educate on not stopping of abscesses- • Advise finger
brushing even when bleeding antibiotics and massage of gums
gums are found drainage after brushing
• Educate pregnant women to • Advise warm saline
not neglect oral hygiene and to rinses in case of
continue tooth brushing severe inflammation

52
• Promote self examination to • Scaling- cleaning of
identify early signs of gum teeth
disease
• Periodontal surgery,
• Demonstrate tooth brushing if required
technique
• Extraction of mobile
teeth which cannot
be saved

Table 4.3 Service delivery framework for emergencies

Community: ASHA HWC: MPW and PHC Referral centres

CHO/MLHP (where dentist is
available)
• Symptomatic pain relief- • Keeping the avulsed • Symptomatic • Replantation of
painkiller stat tooth intact as per relief, avulsed tooth
protocol
• Advise for keeping tooth • Arresting bleeding, • Emergency access
intact and store the same • Symptomatic relief- suturing if required opening
in milk in case of avulsed analgesic
tooth • Swelling/ • Abscess drainage
• Emergency abscess- antibiotic
• Incase of swelling, management- and analgesic • Tooth removal
advise not to foment the arresting bleeding, and drainage if • Biopsy for
swelling using any source suturing if required required. establishing oral
of heat cancer diagnosis
• Swelling/ abscess-
• Advise pregnant women antibiotic and • Perform dental
not to neglect oral analgesic treatment for the
hygiene, insist on warm pronging woman in
saline rinses in case of the safe trimester-1st
bleeding gums and 3rd

53
Training Manual on Oral Care for Medical Officer
at Ayushman Bharat - Health and Wellness Centres

List of Contributors
Contributors from MoHFW:
1. Sh. Vishal Chauhan, Joint Secretary (Policy), MoHFW
2. Smt. Preeti Pant, Joint Secretary, MoHFW
3. Dr Sudhir Gupta, Senior CMO(SAG), Dte. GHS, MoHFW
4. Dr L. Swasticharan, Addl. DDG, Dte. GHS, MoHFW
5. Dr Pradeep Khasnobis, Addl. DDG, Dte. GHS, MoHFW
6. Dr Gursimarjit Singh Chhatwal, Staff Surgeon, Dr. RML Hospital, New Delhi
7. Dr Ankita Piplani, Consultant, National Oral Health Program, MoHFW
8. Dr Abhishek Khanna, CVH Consultant, WHO-India

Contribution from specialists:

1. Dr Ritu Duggal, Chief, CDER
2. Dr Vijay Mathur, Professor and Head, Pediatric and Preventive Dentistry, CDER, AIIMS
3. Dr OP Kharbanda, Ex Chief, CDER
4. Dr Rakesh Sharma, Professor, Dept. of Oral and Maxillofacial Surgery, LHMC
5. Dr Harsh Priya, Associate Professor, Dept. of Public Health Dentistry, CDER
6. Dr Arpit Gupta, Associate Professor, Dept. of Community Dentistry, PGIMER, Chandigarh
7. Dr Utkal Mohanty, Associate Professor, Dept. of Community Dentistry

Contributors from NHSRC:

1. Maj Gen (Prof) Atul Kotwal, Executive Director
2. Dr (Flt Lt) M A Balasubramanya, Advisor, CP-CPHC Division
3. Dr Neha Dumka, Lead Consultant, Knowledge Management Division
4. Dr Neha Singhal, Senior Consultant, CP-CPHC Division
5. Dr Suman Bhardwaj, Senior Consultant, CP-CPHC Division
6. Dr Anwar Mirza, Consultant, CP-CPHC Division
7. Dr Rupinder Sahota, Ex-Senior Consultant
8. Dr Maya Mascarenhas, External Consultant, CP-CPHC Division
9. Dr Vijaya Salkar, Junior Consultant, CP-CPHC Division

54