Dental Clinic Structure

and Ergonomics
DDS. Mariam Khardziani
Invited Lecturer
Department of Medicine
Ivane Javakhishvili Tbilisi State University
Dentistry

 Dentistry, also known as dental medicine and oral medicine, is a branch of

medicine that consists of the study, diagnosis, prevention, management, and
treatment of diseases, disorders, and conditions of the oral cavity.
 Dental treatments are carried out by a dental team, which often consists of a
dentist and dental auxiliaries (dental assistants, dental hygienists, dental
technicians). Most dentists either work in private practices (primary care),
dental hospitals or (secondary care) institutions (prisons, armed forces bases,
etc.).
 The term dentistry comes from dentist, which comes from French dentiste,
which comes from the French and Latin words for tooth. The term for the
associated scientific study of teeth is odontology (from Ancient Greek: ὀδούς,
romanized: odoús, lit. 'tooth') – the study of the structure, development, and
abnormalities of the teeth.
Dental specialties
 Some dentists undertake further training after their initial degree in order to
specialize. Examples include:
 Cosmetic dentistry
 Endodontics
 Geriatric dentistry
 Oral and maxillofacial surgery
 Oral Surgery
 Oral implantology
 Orthodontics
 Periodontology
 Prosthodontics
 Pediatric dentistry
 Oral pathology
 Special need dentistry
 Veterinary dentistry
What does the patient expect from
dental clinic?
 High quality treatment
 Safety
 Compliance with sanitary and hygienic norms
 Confidentiality
 Reliability
 Focusing on the patient's needs
 Goodwill
Structure and Function of Dental Clinic

 Reception
 Waiting Room
 Isolated treating room/treating hall
 X-Ray Room
 Sterilization Room
 Fitting and Resting rooms for dental personell
 Utilization Room
Reception – 11m2
Waiting Room – 11m2
Treating Room – 12m2
Surgery Room – 12-24m2
Sterilization Room – 8-12m2
X-Ray Room – 14m2
Dental Staff Room – 10m2
Structure of Treating Room
 Walls and floor should be easy to clean and sanitize
 Preferable to color the walls with oil or silicate paintings
 The walls should be light color
Mobile dental clinic
Reasons for Early Retirement among
Dentists
 Musculoskeletal disorders (29.5%)
 Cardiovascular disease (21.2%)
 Neurotic symptoms (16.5%)
 Tumors (7.6%)
 Diseases of the nervous system (6.1%).

Gupta A, Bhat M, Mohammed T, Bansal N, Gupta G. Ergonomics in Dentistry. Int J Clin

Pediatr Dent 2014;7(1):30-34.
Dental Risk Factors

 Awkward postures
 Forceful exertions
 Repetitive motions
 Duration
 Contact stress
 Vibration
 Psychosocial factors
Reasons of awkward positions:

 To coordinate the relative positions between dentist and assistant.

 To obtain optimal view of teeth within the patient's mouth.
 To provide a comfortable position for the patient.
 To maneuver complex equipment and reach for instruments.
Forceful exertions

Force requirements may increase with:

 Use of an awkward posture.
 The speeding up of movements.
 Use of small or narrow tool handles that lessen grip capacity.
 Increased slipperiness of the objects handled.
 Use of the index finger and thumb to forcefully grip an object (i.e. a pinch
grip compared with gripping the object).
Repetitive motions

 If motions are repeated frequently and for prolonged periods, fatigue and
muscle-tendon strain can accumulate. Effects of repetitive motions from
performing the same work activities are increased when awkward postures
and forceful exertions are involved. Repetitive actions as a risk factor can
also depend on the body area and specific act being performed.
Duration
 If motions are repeated frequently and for prolonged periods, fatigue and
muscle-tendon strain can accumulate. Effects of repetitive motions from
performing the same work activities are increased when awkward postures
and forceful exertions are involved. Repetitive actions as a risk factor can
also depend on the body area and specific act being performed.
Vibration
 Repeated or continuous contact with hard or sharp objects, such as
nonrounded desk edges or unpadded, narrow tool handles may create
pressure over one area of the body (e.g., the forearm or sides of the fingers)
that can inhibit nerve function and blood fow.
Sings of Musculoskeletal Disorders

 Decreased range of motion

 Loss of normal sensation
 Decreased grip strength
 Loss of normal movement
 Loss of coordination
Symptoms of Musculoskeletal Disorders

 Excessive fatigue in the shoulders and neck

 Tingling, burning or other pain in arms
 Weak grip, cramping of hands
 Numbness in fingers and hands
 Clumsiness and dropping of objects
 Hypersensitivity in hands and fingers.
6 keys to wellness

 First and foremost, correct the ergonomic problems in the operatory.

 Physical therapists, neuromuscular therapist should be consulted for
musculoskeletal disorders.
 Major trigger points should be resolved before any strengthening exercise is
attempted.
 Strengthen specific stabilizing muscles (like shoulder and back).
 Be patient, but most of all commit to a regular regimen of prevention
strategies.
 Chairside stretching is an important strategy to perform throughout the
workday to prevent microtrauma and muscle imbalances.
What is ERGONOMICS?
 Ergonomics can be defined as ‘an applied science
concerned with designing and arranging things people
use so that the people and things interact most
Efficiently and safely’.
Dentists working position
Dentists positions for functional groups
Position of Dental Assistant
The dentist uses indirect visualization
with a dental mirror to allow the assistant
to achieve improved direct visualization
to avoid an awkward posture

The assistant should be seated

on a stool so that his or her eyes are
15-20 cm higher than the dentist’s eyes.
The stool should have a foot support
to allow the assistant to work both within
and out of the oral cavity
Thank You for Your Attantion!
Dental anatomy, morphology and
evolutionary aspects
2022
Ann Margvelashvili
Tbilisi State University
Georgian National Museum
Part I
Why teeth?
 Because they are:

• Identifiers
 Georges Cuvier
• Show me your teeth and I will tell you who
you are
 Teeth
• Species
• Age
• Life-style
Teeth and Evolution
 Basic considerations

• Teeth are set close to the

sense organs

• Lifespan of dentition can

be a factor of determining
the lifespan of many
mammals
Leonardo Da Vinci

8
 What are teeth needed for?

• Ingestion

• Chewing
 Conodont primitive “teeth”

Pre-Cambrian – Triassic
570-240 mln. years Goudemand et al 2011, PNAS
Conodont teeth

Goudemand et al. 2011, PNAS

How conodont teeth worked?

Goudemand et al 2011, PNAS

 Teeth
• Most frequent paleontological finding
• Hardest tissue in organism
• Keeps lot of information
– Key to reconstructing the stages of evolution
Teeth

Luo et al 2001, nature

 What kind of teeth exist?
• Single-cusped
– Homodonty

• Multi-cusped I
– Heterodonty C
P
M
 Tooth crown differentiation in non-mammals
Sheepshead fish

http://ldarrasresearchdiary.wordpress.com/2011/12/06/si
ze-matters-1/ http://mantisshrimp.wordpress.com/tag/bony-teeth/

http://qilong.wordpress.com/2011/02/18/why-dont-tyrannosaurs-
have-all-bananas-for-teeth/

Varanus exanthematicus Varanus gouldii After Ungar 2010

Sheepshead fish
Tuatara

Varanus exanthematicus Varanus gouldii

 Tooth crown differentiation in non-mammals

Albertosaurus
Apatosaurus

http://www.redbubble.com/people/cascoly/works/2049603-
albertosaurus-head-with-jawful-of-teeth

http://www.flickr.com/photos/astrangerinthealps/49941813
07/sizes/l/in/photostream/

http://carnivoraforum.com/topic/9322562/1/

Brachylophosaurus მოდიფ. Ungar 2010

http://en.wikipedia.org/wiki/File:Pharyngeal_jaws_of_moray_eels.svg
Eel
Sucking & Biting

Collar et. al. 2014

 First mammals
• 228 mya (Late Triassic)
– Traits:
• Well-developed TMJ
• Diphyodont dental replacement
• Precise molar occlusion
• Rodentlike and probably faunivorous

www.mirror.co.uk
Occlusion Tooth structure

23

23
 Tooth structure

Enamel
Dentine

Pulp chamber

Cervix

Cementum

Image: http://pocketdentistry.com/1-
functional-anatomy-and-biomechanics-of-
the-masticatory-system/ 24
 Specializations in mammals
• Sublingua and tooth comb
Specializations in mammals
Enamel
Dentine

Pulp chamber

Cervix

Cementum
 Elephant (polyphyodont)

https://blogs.ucl.ac.uk/museums/2018/09/21/specimen-of-the-week-359-the-infant-elephant-molar/
 Mammalian dentition
• Diversity
Carnivores

Rodents
Herbivores

Evans et. al 2007

 Mammalian dentition
• Heterodonty
 Mammalian dentition
• Thecodonty

tooth tooth
r
o
o bone
t
bone
 Mammalian dentition
• Succession
Deciduous Permanent
 Mastication
mammalian innovation
• Palate

• Occlusion

• Strong
masticatory
muscles

Lucas 2004 Mid-section of a human skull

Trend in dental evolution

homodont heterodont

Evolution
 Evolution of mammalian dentition
• A) spaced
singe cusps

• B) occlusion of
early mammals

• C) triangulated
molars of
mammals

After Lucas 2004

Evolution of mammalian dentition
• Tribosphenic teeth

Luo 2007
 Tribosphenic tooth

Pa Me
Trigon
Talon
Prd
Pr Hyd Hyld
Trigonid Talonid

Pad Med End

Ungar 2010
 Phylogeny

NWM OWM orangutan gorilla chimp human

tarsier 4.5-6 mln

lemur
loris
6-8 mln

12-16 mln

25-33 mln

Locke et al 2011
Monkeys and Apes
New and Old World Monkeys
New and Old World Monkeys
 Dental formulae

lemurs •Incisors
•Canines
•Premolars
new world monkeys •Molars

old world monkeys

 Modern hominoid tooth structure
Buccal Lower
Upper
Paracone Metacone Protoconid
Hypoconid

Oblique crest

Distal
Mesial

Trigonid
Trigon
Talonid
Talon

Hypoconulid

Protocone Hypocone Entoconid

Metaconid

Lingual
Tooth interaction
Tooth interaction
Evolution of primate dentition
Upper Lower
 Evolution of mammalian dentition:
Hominoids
CHEECK CHEECK

Lower
Upper

Y pattern
Crista obliqua

PALATE TONGUE
Teeth and dental surfaces

Occlusal
Buccal
Molars

Lingual

Distal
nePremolars
Mesial

Incisive
C a ni

Inicisors bial
La
 Hominoid (including Human) Dentition

• Heterodonty
 Hominoid (including Human) Dentition

• Thecodonty

tooth tooth
r
o
o bone
t
bone
Meckel’s Cartilage
Meckel’s Cartilage
 Hominoid (including Human) Dentition

• Succession
Decidous Permanent
Hominoid (including Human) Dentition

Molars
C a nine emolars
Pr

Incisors
Hominoid (including Human) Dentition

Incisors –>
mammelons

Premolars Molars
Canince –> One main
cusp
პრემოლარები –> 2-
Cusps
მოლარები –> 3-7
e

Cusps
anin C

Incisors Pan troglodytes

Hominoid (including Human) Dentition
Incisors: 1 root
Canie: 1 root
Premolars: 1 or 2 roots
Molars: 2 to 5 roots
Tooth we need and what make is tooth
we need?

Several aspects

Shape
and
Function
 Incisors

Spatulate

Cutters
 Lemurs
• Toothcomb

Eulemur fulvus

http://animaldiversity.ummz.umich.edu/site/resources/anatomical_images/i
ncisors_jpeg/lemur.jpg/view.html geo-reisecommunity.de
 Aye-aye
• Rodent-like ever growing incisors

Images: Wikipedia
Bone clones
 Canines

Conical

Tearers
 Primate canines
• Prominent and sexually dimorphic

F M
 Premolars & Molars

Multi-cuspids

Grinders
 Human tooth Distal

Mx Md
X-pattern

Buccal
+-pattern

Y-pattern
Dental formula:
I2-C1-P2-M3/I2-C1-P2-M3
 Dryopithecus pattern
• Contact between metaconid and hypoconid

Me
Hy

http://www.wadsworth.com/anthropology_d/templates/stripped_features/primate_evolution/
 Dryopithecus
One of the oldest hominoids.
Living in seasonal forests.

Begun et. Al. 2012

 Part II
• Monday, 18.07.2022
• 11:00
Dental anatomy, morphology and
evolutionary aspects
2022
Ann Margvelashvili
Tbilisi State University
Georgian National Museum
Part II
Why teeth?
 Because they are:

• Identifiers
 Georges Cuvier
• Show me your teeth and I will tell you who
you are
 Basic considerations

• Teeth are set close to the

sense organs

• Lifespan of dentition can

be a factor of determining
the lifespan of many
mammals
Leonardo Da Vinci

71
 Mastication
mammalian innovation
• Palate

• Occlusion

• Strong
masticatory
muscles

Lucas 2004 Mid-section of a human skull

Evolution of mammalian dentition
• Tribosphenic teeth

Luo 2007
 Hominoid (including Human) Dentition

• Heterodonty
 Hominoid (including Human) Dentition

• Thecodonty

tooth tooth
r
o
o bone
t
bone
 How to indentify a tooth
Incisors
• Group
– Flat, spatulate, blade-
shape. Dentine
patches have
rectangular or square
shape.
• Sidedness
– The distal corner is
more rounded than
the mesial, root tip
and the axis of the
root is tilted distally
 How to indentify a tooth
Canines
• Group
– Conical. Dentine
patches are
diamond shaped.
Roots are longer

mesial

distal
than in any other

mesial
mesial

distal
teeth.
• Sidedness
– Mesial occlusal
edge is shorter
than the distal one,
axis of the root is
tilted distally
 How to indentify a tooth
Premolars
• Group
– Round, bicuspids, can

mesial
distal
distal
mesial
mesial
be single- or double-
rooted.
• Sidedness UP3
– Lingual cusp is smaller
than the buccal cusp

distal
and is placed more mesial

mesial
distal
mesial
mesially. Root is tilted
distally
LP3
 How to identify a tooth
Molars
• Group
– Multi-cusped and
multi-rooted: 3 roots
on upper molars and 2
roots on lower ones. 4
cusps on upper molars
and 5 cusps on lower.
• Sidedness
– Protocone/id is the
largest cusp.
– Metaconid (lower
teeth) is the highest
Is the tooth deciduous
or permanent?
Distinguishing features of
deciduous dentition:
1. Smaller size.
2. Thinner enamel.
3. Shorter, thinner and more
divergent roots that are often
White&Folkens
resorbed.
4. More bulbous in shape.
5. Bulging out above the
cervicoenamel line more
prominently.
6. 1st molars are very different in
shape.
 Function & Diet
• Insectivores
• Frugivores
• Folivores
 Function & Diet
• Insectivores
– Short pointed front teeth (to kill and immobilize
the prey).
– Steep, transversely oriented shearing blades on
posterior dentition Tarsius syrichta

epicpictures.org
http://planete.simiesque.free.fr
 Function & Diet
• Frugivores
– Long, protruding front teeth.
Papio ursinus
– Low and blunt molars

profimedia.si
 Function & Diet
• Folivores
– Small front teeth.
– Sharp cutting edges on post-canine teeth for
extensive mastication.
Colobus guereza

http://planete.simiesque.free.fr
 Function and Diet
Gorilla
Orangutan
Orangutan
 Function asnd Diet
Chimpanzee Human
Diet

Ungar&Sponheimer 2011
 Diet

A: Lophocebus albigena; B: Homo erectus; C: Homo habilis; D: Gorilla gorillas

Ungar, Grine & Teaford 2010
 Tooth-Food “death match”

• Enamel prisms (Hydroxiapatite crystals bundle to form

prisms - Ca10(PO4)6(OH)2)
Prism size: 5μm
(0.005mm)

Zeygerson et. al.2000

 Tooth-Food “death match”
• Enamel prism oriantation

Raue et. al. 2012

 Enamel thickness in Hominoids
• (a) Area of the
enamel cap.
• (b) Thin line indicates
enamel dentine
junction (EDJ).
• (c) Dentine area
under the enamel
cap hemmed by both
lines.

Pampush et. al. 2013

 Life of Tooth
• Growth

• Calcification
Tim

•Eruption
e

•Tooth wear
 Tooth development

Action and interaction of ectoderm and

underlying mesenchyme
Tooth formation stages

Abigail Tucker & Paul Sharpe

Nature Reviews Genetics 5, 499-508 (July 2004)
 Tooth
formation

Jernvall & Thesleff & 2012

 Tooth
formation

Thesleff & Tummer 2009

 Shape, size and position of teeth
• Mammalian molars develop in anterior to posterior
direction.
• Relative size of the adjacent teeth allows us to predict the
presence and size of additional teeth .
• It is unlikely that a large M2 is followed by a very small M3
• It is unknown how molar initiation or size is regulated

Posterior
Anterior

Kavanagh et al 2007
 Shape, size and position of teeth
• The last teeth to form, will be the first to be lost.
Permanent molars
Permanent molars
Deciduous molars
Deciduous molars

Last teeth to form X

Tooth loss

Premolars Premolars

Transition to tooth loss

Modified from Lucas 2004
Teeth and Human Evolution
 Paleoanthropology
• Study of human evolution

http://www.blogos.org/gotquestions/christians-
evolution.htmlv
https://www.history.com/news/humans-evolution-neanderthals-denisovans

104
http://humanorigins.si.edu/evidence/human-family-tree
Evolution of the human skull
Teeth and human evolution

Early Homo Modern human

 Teeth in human evolution
• Reduction in number of teeth/M3s especially
• Reduction in tooth size
• Reduction in dental and alveolar arch length
• Simplification of dental morphological
complex

15mm

Modern human Early homo

 Teeth in human evolution
A. anamensis H. erectus
 Teeth in human evolution
• Australopiths and Paranthropus have smaller
anterior teeth and huge posterior.
• H. erectus and H. habilis have bigger anterior
teeth, more spatulate incisors and reduced
posterior ones.
• Later species of genus Homo reduced both,
anterior and posterior teeth.

Bailey & Wood 2007

Lucas 2004
 Teeth in human evolution

Modern human Early homo

 Paranthropus and modern human

https://phys.org/news/2011-05-nuts-nutcracker-early-human-relative.html
Paranthropus
Shape

Lewin &Foley 2005 Fig. 8.9

CP3 complex
CP3 complex
CP3 today
CP3 today
Dmanisi pathologies

Margvelashvili et al, 2016, AJPA

120
 Health & Habits
Tooth-picking
Local infections
Hypercemetosis

Margvelashvili et. al. 2013

 Toothpick and local infections
• Dmanisi

Margvelashvili et al, 2013, 2016

122
 Toothpick
• Dmanisi

123
124
 Health and habits

Caries

Margvelashvili et. al. 2016

Fractures zygomatic arch and TMD
• D4500 & D2600

Lordkipanidze et al, 2013

126
• D4500

Lordkipanidze et al, 2013

127
 Edentulism
• D3444 & D3900

128
 Edentulism
• დმანისი

16 mm
Lordkipanidze et al, 2005
Margvelashvili et al, 2016

129
 Labial scratches
• A: D2735
• B: D2600

Margvelashvili et al, 2016

130
Teeth and language
 Labiodentals

30 years old/Lower Paleolithic 40 years ols / Bronz age

30 years old/Mesolithicლითი Blasi et al, 2019

132
Australian Hunter-Gatherers

133
Labiodentals

134
• Science is NOT democracy: public or majorital
acclaim is itself no guarantee that any view is
the correct one
• Henry Gee
INTRODUCTION
INTRODUCTION TO
TO
ORTHODONTICS
ORTHODONTICS
Elene Golovachova
MULTIDISCIPLINARY TREATMENT
APPROACH
PROSTHODO
NT

GENERAL ORTHODONTI
DENTIST ST

SURGICAL
DENTIST
 OBJECTIVES
OBJECTIVES OF
OF THIS
THIS
LECTURE
LECTURE
• WHAT IS ORTHODONTICS
• WHAT DO WE DO
• WHAT WILL YOU GET TO DO
 What is orthodontics

Orthodontics is that branch of dentistry concerned with

prevention, interception and correction of malocclusion
and other abnormalities of the dentofacial region. The
word orthodontics is derived from the Greek words
orthos meaning correct and odontos meaning teeth.
 What is occlusion?
In its simple definition occlusion is the way maxillary and
mandibular teeth articulate. In reality dental occlusion is
much more complex relationship because it involves the
study of teeth, their morphology and angulations, the
muscles of mastication, the skeletal structures, the
temporomandibular joint, the functional jaw movements. In
addition it involves the relationship of teeth in centric
occlusion, centric relation and during function. Because all
this requires neuromuscular coordination, occlusion also
involves an understanding of the neuromuscular function.
 What is malocclusion?
Malocclusion is a misalignment or incorrect relation
between the teeth of the two dental arches when they
approach each other as the jaws close. The term was
coined by Edward Angel, the father of modern orthodontics,
as a derivative of occlusion. This refers to the manner in
which opposing teeth meet.

(mal- + occlusion = “incorrect occlusion”)

Unfavourable effects of malocclusion

Malocclusion

POOR FACIAL RISK OF CARIES, PERIODONTAL PSYCHOLOGICAL

APPERANCE TRAUMA DISEASE DISTURBANCES DIS-FUNCTION TMJ PROBLEMS
 Poor facial appearance
Malocclusion is capable of adversely affecting facial
appearance.
Smile
Attractive smile
 Risk of caries
Malalignment of teeth make oral hygiene maintenance
difficult task, thereby increasing risk of caries.
 Predisposition to periodontal diseases

Malocclusion associated with poor oral hygiene is a

frequent cause of periodontal disease. In addition teeth
that are placed in abnormal positions can be cause for
traumatic occlusion, with resultant periodontal tissue
damage.
 Psychological disturbances
The malocclusion that adversely affects appearance of
person lead to psychological disturbances. Unsightly
appearance of teeth makes a person highly self-conscious
and turns him into introvert. Treatment of malocclusion of
such patients helps in improving the mental well being and
confidence.
 Risk of trauma

Teeth that are severely proclined are at high risk of injury

especially during play or by an accidental fall
 Abnormalities of function
Many malocclusions cause abnormality in the functioning
of the stomatognathic system:

• Swallow It is almost impossible to distinct

• Speech
malocclusion is caused by disfunction
• Breathing
• Chewing or vice versa.

Malocclusion Disfunction
 Temporomandibular joint problems
Malocclusion such as deep bite or cross bite can cause
TMJ problems:
• Pain in TMJ region
• Difficulty in mouth opening
• Restricted mandibular movement
• Popping, cracking sound.
TEMPOROMANDIBULAR JOINT
PROBLEMS
Temporomandibular joint problems
People affected with TMJD are aged 20-40
20-30% of adult population
More affected female than male
What does orthodontist deal with?

AESTHETICS FUNCTION STABILITY

Orthodontics consists of the parts below:

PREVENTIVE ORTHODONTICS

INTERCEPTIVE ORTHODONTICS

CORRECTIVE ORTHODONTICS

SURGICAL ORTHODONTICS
 Preventive orthodontics
“Prevention,” they say, is “better than cure”. Preventive
orthodontics includes procedures undertaken prior to
the onset of a malocclusion. Preventive orthodontics
can be defined as, actions taken to preserve the
integrity of what appears normal for that age.
 Interceptive orthodontics
Interceptive orthodontics includes procedures that are
undertaken at an early stage of a malocclusion to
eliminate or reduce the severity of the same. By
undertaking appropriate interceptive procedures, it is
possible to prevent establishment of a fully fledged
malocclusion that may require long term orthodontic
treatment at a later age. Interceptive orthodontics
includes treatment with fixed and removable appliances.
 Corrective orthodontics
Orthodontic procedures undertaken to correct a fully
established malocclusion.
 Surgical orthodontics
They are surgical procedures that are undertaken in
conjunction with or as an adjunct to orthodontic
treatment. The surgical orthodontic procedures are
usually carried out to remove an etiologic factor or to
treat severe dento-alveolar deformities that cannot be
treated by orthodontic therapy alone.
 Age groups
According to age, teeth formation,eruption and dental
arch development we can divide growth for several
stages:
• Fetal development and birth
• Infancy and early childhood: primary dentition years.
Begins form eruption of first deciduous incisor till
eruption of first permanent tooth. About 6-8 months to
5-6 years.
• Late childhood: mixed dentition years. Begins from 5-6
years and continues to the onset of puberty.
• Adolescence: early and late permanent dentition years.
• Adulthood:permanent dentition years
 HISTORY OF ORTHODONTICS

Crowded, irregular or protruding teeth have been a

problem for some individuals since antiquity and
attempt to correct this disorder go back at least to
1000 BC. Primitive orthodontic appliances have been
found in both Greek and Etruscan materials.
 HISTORY OF ORTHODONTICS
25 B.C.-50 A.D

AULUS
CORNELIU CELSUS
 HISTORY OF ORTHODONTICS
18TH CENTURY
PIERRE FAUCHARD
 HISTORY OF ORTHODONTICS
19-20th century
EDWARD H. ANGLE-
(1855-1930)

Father of Modern
orthodontics
HISTORY OF ORTHODONTICS
Edward Angle devised the first simple
classification system for malocclusions, such
as Class I, Class II, Class III.
He founded the first school and college of
orthodontics.
Organized the American Society of Orthodontia
in 1901 which became the American
Association of Orthodontists (AAO) in the 1930s.
Founded the first orthodontic journal in 1907
 ANGLE classification
Key of occlusion is first permanent molar
Ethics in Dentistry
DDS. Mariam Khardziani
Invited Lecturer
Department of Medicine
Ivane Javakhishvili Tbilisi State University
Content

 Origin and Definition

 History - Hippocratic Oath
 Nuremberg Code
 Ethical Principles
 Obligations of dentist to patients
 Obligations of dentists to colleagues
 Obligations of dentists to society
 Helsinki Declaration
 Conclusion
Origin and Definition

 The world ethics is derived from the Greek word ‘ethos’ meaning
custom or character.
 Ethics is the philosophy of human conduct.
 "the science of the ideal human character and behaviour in
situations where distinction must be made between right and
wrong, duty must be followed and good interpersonal relations
maintained".
History

 Hippocratic Oath written by Hippocrates, the father of medicine in 4th

century BC.
 Highlights

“I will prescribe regimens for the good of my patients and never do harm to
anyone, I will not prescribe deadly drugs. I will not cut for stone; I will leave
operations to be performed by specialists. All that may come to my knowledge in
the exercise of my profession I will keep secret and not reveal.”
Hippocrates Oath

 I swear to fulfill, to the best of my ability and judgment, this covenant:

 I will respect the hard-won scientific gains of those physicians in whose steps I
walk, and gladly share such knowledge as is mine with those who are to follow.
 I will apply, for the benefit of the sick, all measures [that] are required, avoiding
those twin traps of overtreatment and therapeutic nihilism.
 I will remember that there is art to medicine as well as science, and that
warmth, sympathy, and understanding may outweigh the surgeon's knife or the
chemist's drug.
 I will not be ashamed to say "I know not", nor will I fail to call in my colleagues
when the skills of another are needed for a patient's recovery.
Hippocrated oath

 I will respect the privacy of my patients, for their problems are not disclosed to me that the
world may know. Most especially must I tread with care in matters of life and death. If it is
given me to save a life, all thanks. But it may also be within my power to take a life; this
awesome responsibility must be faced with great humbleness and awareness of my own
frailty. Above all, I must not play at God.
 I will remember that I do not treat a fever chart, a cancerous growth, but a sick human
being, whose illness may affect the person's family and economic stability. My responsibility
includes these related problems, if I am to care adequately for the sick.
 I will prevent disease whenever I can, for prevention is preferable to cure.
 I will remember that I remain a member of society, with special obligations to all my fellow
human beings, those sound of mind and body as well as the infirm.
 If I do not violate this oath, may I enjoy life and art, respected while I live and remembered
with affection thereafter. May I always act so as to preserve the finest traditions of my
calling and may I long experience the joy of healing those who seek my help.
Nuremberg Code 1947

 Set of research ethical principles for human experimentation set as a result of

Nuremberg Trials at the end of the Second World War.
 They were created in response to the inhumane Nazi experiments on
prisoners during second world war.

Sulfonamide experiments
Subjects were deliberately wounded on the outer side of their
calves. Physicians then rubbed a mixture of bacteria into the open
wounds before sewing them shut.
Nuremberg code

1. The voluntary consent of the human subject is absolutely essential. This means that the
person involved should have legal capacity to give consent; should be so situated as to
be able to exercise free power of choice, without the intervention of any element of force,
fraud, deceit, duress, overreaching, or other ulterior form of constraint or coercion; and
should have sufficient knowledge and comprehension of the elements of the subject
matter involved as to enable him to make an understanding and enlightened decision.
This latter element requires that before the acceptance of an affirmative decision by the
experimental subject there should be made known to him the nature, duration, and
purpose of the experiment; the method and means by which it is to be conducted; all
inconveniences and hazards reasonably to be expected; and the effects upon his health
or person which may possibly come from his participation in the experiment. The duty and
responsibility for ascertaining the quality of the consent rests upon each individual who
initiates, directs, or engages in the experiment. It is a personal duty and responsibility
which may not be delegated to another with impunity.[13]
2. The experiment should be such as to yield fruitful results for the good of society,
unprocurable by other methods or means of study, and not random and unnecessary in
nature.
Nuremberg Code

3.The experiment should be so designed and based on the results of animal experimentation
and a knowledge of the natural history of the disease or other problem under study that the
anticipated results will justify the performance of the experiment.
4. The experiment should be so conducted as to avoid all unnecessary physical and mental
suffering and injury.
5. No experiment should be conducted where there is an a priori reason to believe that
death or disabling injury will occur; except, perhaps, in those experiments where the
experimental physicians also serve as subjects.
6. The degree of risk to be taken should never exceed that determined by the humanitarian
importance of the problem to be solved by the experiment.
7. Proper preparations should be made and adequate facilities provided to protect the
experimental subject against even remote possibilities of injury, disability, or death.
8. The experiment should be conducted only by scientifically qualified persons. The highest
degree of skill and care should be required through all stages of the experiment of those
who conduct or engage in the experiment.
Nuremberg code

9. During the course of the experiment the human subject should be at liberty to bring the
experiment to an end if he has reached the physical or mental state where continuation of
the experiment seems to him to be impossible.
10. During the course of the experiment the scientist in charge must be prepared to
terminate the experiment at any stage, if he has probable cause to believe, in the exercise
of the good faith, superior skill and careful judgment required of him that a continuation
of the experiment is likely to result in injury, disability, or death to the experimental
subject.
Principles of ethics

 Non-maleficence
 Beneficence
 Respect for persons
 Justice
 Veracity
 Confidentiality
To Do No Harm (Non-maleficence)

 Hippocrates, pioneer in Greek medicine has laid an emphasis on non-

maleficence or to do no harm.
 As per this, the first and foremost duty of the health care professional is to
ensure that his actions do not harm the patient in any way.
 Use of unsterilized instruments, under filling or overfilling, carelessness in
handling hard and soft tissues of the mouth are some of the instances, which
can harm the patients.
To Do Good (Beneficience)

 The health care professional, before instituting any

action or care should question himself whether such
actions will help the patient to recover or to perform
his functions better or not.
 He has to place the interest of the patient above his
own interest.
 He has to plan a treatment or order an investigation
only if it is necessary.
 In the process of treating a patient –weigh the
consequences of treatment Vs no treatment.
 E.g. in questionable dental caries - the attempts should
be to maximize the benefits and minimize the harm.
Respect for people

 Incorporates two other ethical principles:

 1. Autonomy
 2. Informed consent
Autonomy

 This principle is in line with interactive model of health

care wherein patient is the prominent member in the
process of decision making.
 This principle emphasizes the patient's right to make
decisions and is free to determine what will happen on
his/her body.
 A patient is diagnosed with dental caries in relation to
46 and 36. The treatment of choice which could be
given here are silver amalgam , GIC, composites.
However, the dentist attending the case insists on a
composite restoration.
Informed consent

 The health care professional has to ensure that consent

is obtained before any care is instituted.
 Patients are provided with relevant information such
as different modes of treatment, their risks and
benefits consequences of not availing the treatment
etc.
 Information given should be easily understood
facilitating the patient to make a voluntary consent.
 In case of minors, parents or legal guardians can grant
the consent for the care.
Justice

 This principle directs health care professional to provide equal

treatment to all, giving to each patient what he/she needs.
 Dental practitioners are often found to be reluctant to treat the poor
because they cannot afford; treat the children or mentally retarded
because it takes longer time.
 Dentists also have responsibilities for such group of patients and
cannot shy away from the responsibilities bestowed on them by the
society.
 Dentists probably can provide care at a concessional rate or
designate certain time for the care of such patients or support
programmes for such patients conducted by local, regional or state
bodies.
Veracity
 Patient-doctor relationship is based on mutual trust.
 Patients expect the dentist to be truthful about the
information given, treatment rendered, and the prognosis.
 Even if the dentist believes lying or concealing or
manipulation of the information is required in the best
interest of the patient, the relationship is bound to suffer.
 The dentist may feel that it would be better if the patient
took certain course of action and therefore manipulates the
information that is given to the patient. Whatever the
reason, the relationship will suffer and the dentist will be
guilty of transgressing a major ethical principle.
 Mr. Y comes to the dental clinic complaining of pain in lower
right back tooth (46). The dentist tells the patient that an RCT
has to be done. And the patient agrees for the same. While
doing the RCT the dentist happens to breaks a file in the canal
which he is not able to retrieve. But he does not tell the
patient about it. After the treatment, the patient returns with
pain in the teeth after 6 months. The dentist says there is
infection in the canal and that the tooth cannot be saved and
that it has to be extracted.
Confidentiality

 Patients have the right to expect that all communications and

records pertaining to their care will be treated as
confidential.
 Gossiping/discussing about patient (some famous
patient/neighbor) would break a bond of trust between
dental professional and patient.
 Now, patients permission has to be sought to disclose
the confidentiality, even if it is beneficial to the patient.
Obligations towards Patients

 Every dentist should be courteous, sympathetic, friendly and helpful.

 He should observe punctuality in fulfilling his appointments.
 He should establish a well merited reputation for professional ability
and fidelity.
 The welfare of patient should be conserved to the utmost of the
practitioner’s ability.
 A dentist should not permit considerations of religion, nationality,
race, party politics or social standing to intervene between his duties
and his patients.
 Information of personal nature which may be learned about or directly
from a patient in the course of dental practice should be kept in utmost
confidence. It is also obligation of the dentist to see that his auxiliary
staff observed this rule.
Obligations towards Professional
Colleagues
 Every dentist should cherish a proper pride in his/her colleagues
and should not disparage them either by act or word.
 Mutual arrangements should be made regarding remuneration,
when other dentist’s patient is taken care in his
sickness/absence.
 If a dentist is called for providing emergencies, he should retire
after it is over (in favor of the regular dentist), but is entitled to
charge the patient for his services.
 If a dentist is consulted by the patient of another dentist and the
former finds that the patient is suffering from previous faulty
treatment it is his duty to institute correct treatment at once
with as little comments as possible and in such a manner as to
avoid reflection on his predecessor.
Duties towards Society

 The dentist has to assume leadership in the

community on matters pertaining to dental health.
 People should be urged to seek care without influencing
the choice of dentist.
Unethical Practices

 Unregistered persons
 Advertising
 Undercutting charges to solicit patients
 Accepting or paying commission
 Use of bogus diploma
 Unethical practices
 Not referring the patient to the consultant if the
planned treatment is beyond the skills of the dentist.
 Emergency consultation, not sending the patient back
to previous care provider
Helsinki Declaration

 Recommendations guiding physicians in biomedical

research involving human subjects.
 Issued by World Medical Association in 1964 in Helsinki, Finland
General Principles of Helsinki
Declaration
 The Declaration of Geneva of the WMA binds the physician with the words, “The health of my patient
will be my first consideration,” and the International Code of Medical Ethics declares that, “A physician
shall act in the patient’s best interest when providing medical care.”
 It is the duty of the physician to promote and safeguard the health, well-being and rights of patients,
including those who are involved in medical research. The physician’s knowledge and conscience are
dedicated to the fulfilment of this duty.
 Medical progress is based on research that ultimately must include studies involving human subjects.
 The primary purpose of medical research involving human subjects is to understand the causes,
development and effects of diseases and improve preventive, diagnostic and therapeutic interventions
(methods, procedures and treatments). Even the best proven interventions must be evaluated
continually through research for their safety, effectiveness, efficiency, accessibility and quality.
 Medical research is subject to ethical standards that promote and ensure respect for all human subjects
and protect their health and rights.
 While the primary purpose of medical research is to generate new knowledge, this goal can never take
precedence over the rights and interests of individual research subjects.
General Principles of Helsinki
Declaration
 It is the duty of physicians who are involved in medical research to protect the life, health, dignity, integrity,
right to self-determination, privacy, and confidentiality of personal information of research subjects. The
responsibility for the protection of research subjects must always rest with the physician or other health care
professionals and never with the research subjects, even though they have given consent.
 Physicians must consider the ethical, legal and regulatory norms and standards for research involving human
subjects in their own countries as well as applicable international norms and standards. No national or international
ethical, legal or regulatory requirement should reduce or eliminate any of the protections for research subjects set
forth in this Declaration.
 Medical research should be conducted in a manner that minimises possible harm to the environment.
 Medical research involving human subjects must be conducted only by individuals with the appropriate ethics
and scientific education, training and qualifications. Research on patients or healthy volunteers requires the
supervision of a competent and appropriately qualified physician or other health care professional.
 Groups that are underrepresented in medical research should be provided appropriate access to participation
in research.
 Physicians who combine medical research with medical care should involve their patients in research only to
the extent that this is justified by its potential preventive, diagnostic or therapeutic value and if the physician
has good reason to believe that participation in the research study will not adversely affect the health of the
patients who serve as research subjects.
 Appropriate compensation and treatment for subjects who are harmed as a result of participating in research
must be ensured.
THANK YOU!
Ethics in Dentistry
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will respect the hard-won scientific gains of those physicians in whose steps I walk,
and gladly share such knowledge as is mine with those who are to follow.
I will apply, for the benefit of the sick, all measures [that] are required, avoiding those
twin traps of overtreatment and therapeutic nihilism.
I will remember that there is art to medicine as well as science, and that warmth,
sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.
I will not be ashamed to say "I know not," nor will I fail to call in my colleagues when the
skills of another are needed for a patient's recovery.
I will respect the privacy of my patients, for their problems are not disclosed to me that
the world may know. Most especially must I tread with care in matters of life and death.
If it is given me to save a life, all thanks. But it may also be within my power to take a
life; this awesome responsibility must be faced with great humbleness and awareness
of my own frailty. Above all, I must not play at God.
I will remember that I do not treat a fever chart, a cancerous growth, but a sick human
being, whose illness may affect the person's family and economic stability. My
responsibility includes these related problems, if I am to care adequately for the sick.
I will prevent disease whenever I can, for prevention is preferable to cure.
I will remember that I remain a member of society, with special obligations to all my
fellow human beings, those sound of mind and body as well as the infirm.
If I do not violate this oath, may I enjoy life and art, respected while I live and
remembered with affection thereafter. May I always act so as to preserve the finest
traditions of my calling and may I long experience the joy of healing those who seek my
help.
 Ethics

A branch of philosophy and theology, is

the systematic study of what is right and
good with respect to conduct and
character.
ETHICS=Moral Responsible.

John Seear wrote the first edition of Law

and Ethics in dentistry in 1975.
 Ethics

 Ethics is a part of philosophy that deals with

moral conduct and judgment.
Or Ethics are guidelines derived from values
and principles intended for the appropriate
behavior while practicing various
professional activities.
 Dental ethics would mean moral duties and
obligations of the dentist towards his
patients, professional colleagues and to the
Codes of Ethics:

All professional organisations should have

published code to which all members of the
profession are expected to adhere.
ADA’s principles of Ethics and Code contains-
1.SERVICE OF PROFESSION
2.EDUCATION
3.RESEARCH AND DEVELOPMENT
 6
Principles of Ethics

There are several principles that health care professionals

must aware of in the practice of their profession.
The principles of Ethics are as:
1. To do no harm (Non-maleficence)
2. To do good (Beneficence)
3. Respect for persons
4. Justice (Fairness)
5. Truthfulness (Veracity)
6. Confidentiality
Beneficence: which basically means
to do no harm and promote good for
others.
Autonomy: which is respect for all
persons and all points of view.
Justice: providing a person with what
is due.
 1. To Do No Harm (Non-maleficence)

 The first and foremost duty of the

health care professional is to
ensure that his actions do not
harm to the patient in any way.
“Either help or do not harm the
patient”
 2. To Do Good (Beneficence)

 The role of all health care professional is to

benefit patients.
 A healthcare professional has to place the
interest of the patient above his own
interest.
 3. Respect for Persons

 The patient (and the person treating the

patient) have the right to be treated with
dignity.
 Respect for persons incorporates at least
two other ethical principles;
I. Autonomy
II. Informed Consent
 I. Autonomy

 A patient has the right to make decisions and

is free to determine what will happen on his/
her body.
 Autonomy is a principle that dictates that
health care professionals respect the
patients right to make decisions concerning
the treatment plan.
 Health care professional have a duty to treat
the patient according to the patients need
within the limits of accepted treatment.
II. Informed Consent
12
 The health care professional has to ensure
that consent is obtained before any
treatment.
 Patients are provided with relevant
information such as different modes of
treatment, their risks and benefits, so patient
can make voluntary consent.
 In case of minors, parents or legal guardians
can give consent for treatment.
4. Justice (Fairness) 13

 The primary duty of the health care

professional is to give the services
irrespective of class, creed, etc.
 Justice demands that a health care
professional should treat people fairly that
means provide equal treatment to all, giving
to each patient what he/she needs.
 14
5. Truthfulness (Veracity)
 Patient–doctor relationship is based on
mutual trust. Patient expect the dentist is to
be truthful about the information given,
treatment rendered, and the prognosis.
 A health care professional have a duty to be
honest and trustworthy in their dealings
with people and communicating truthfully
without deception.
6. Confidentiality 15

 Health care professional have a legal and

ethical duty to keep patient information
confidential.
 Patient have the right to expect that all
communications and records pertaining to
their care will be treated as confidential.
 Confidential information should be kept in a
secure place at all times to prevent
unauthorized or accidental disclosure.
Professional liability
In a doctor patient relationship, the
doctor owes a duty to take care of
the patient as much as possible.
Failure to take proper care results
in breach of contract and on
sufficient proof of the same, the
doctor becomes liable for criminal
punishment.
 Negligence Liability
Negligence is defined as a “ failure to exercise
reasonable skill and care”.
The three essential elements of negligence are:
a. Duty: The defendant (doctor) owes a duty of
care to the plaintiff (patient).
b. Breach: the defendant has breached this duty of
care.
c. injury: The plaintiff has suffered an injury due to
the defendant’s breach of duty.
Liability

Liability of a doctor arises when the patient has

suffered an injury which is a consequence of a
breach in his or her own duty.
To show that the breach of duty has been done by
the doctor, it is important :
a. To show, what is considered as reasonable under
those circumstances.
b. That the conduct of the doctor was below this
reasonable degree.
Important factors:
1. Once a doctor-patient relationship is
established, the law imposes duty of proper care
and treatment on the part of the doctor.

2. The law does not expect the doctor to cure all

the cases or even the given case. It only expects
him to make a reasonable attempt and take
reasonable care under the circumstances.
3. The duty owed by a doctor cannot be altered
so as to reduce it from the standard of
reasonableness.

Liability of a doctor does not arise in all cases

even where the patient is injured by the act of the
doctor. He/she is liable only if he/she has
committed a breach of duty in the process.
 Consent

The doctor is expected to obtain consent from the patient

with regard to treatment, preoperative care, postoperative
care and surgical intervention.

A. Consent and informed consent:

Consent to treatment:

The consent is a process which involves a treatment

relationship with effective agreement and communication.
The patient agrees to submit to specific
diagnostic, medical or surgical measures to be
carried out by the doctor.
In turn, the doctor agrees to perform the
specified treatment within the limitations set
down by both the parties.
Consent can be implied, verbal or written.
b. Consent to surgical operations:
All surgical operations involve bodily touching
and this breaches a person’s right to bodily
integrity.
Individual Consent:
It refers to a situation where the particular
person in question can give legally effective
consent or not.
There are two basic factors to be considered :
1. Status of the person:
If the person is above 18yrs of age and is
mentally sound, he/she has the capacity to
consent.
2.Understanding of the person:
It all depends on whether the minor can
understand what is involved in the procedure
in question for which consent is required.
Criminal Aspects

A surgical operation performed by a doctor

without legally effective consent results in an
offence being committed by the doctor.
Exceeding consent:
A surgeon who has taken consent from a patient
for a particular operation cannot depart from it
and perform a bigger or different operation. He
cannot do anything more than what the patient
has consented to only if it is to save the life or
preserve the health of the patient.
 Treatment without consent

There are many situations in which a patient can be

treated without consent. This can be justified in law
on two grounds.
a. Necessity
b. Implied consent.
Necessity is probably a better legal basis than
implied consent, especially in operating on mentally ill
patient.
Implied Consent: If a patient enters the clinic, sits on
the dental chair and opens his/her mouth, the
consent is implied.
The principle of treating without
consent in emergencies is simple. A
doctor can do all acts to save life or
preserve health of the patient.
 Eg. Of a Consent Form
1. I………….of……………..(name and address of person giving consent)
Hereby consent to undergo
OR
Hereby consent to ………………undergoing
(name of the patient)
the operation/treatment of …………………
the nature and purpose of which has been explained to me by
Dr…………………………
I also consent to such further or alternative operative measures
or treatment as may be found necessary during the course of the
operation/treatment and to the administration of general or other
anaesthetics for any
of these purposes.
No assurance has been given to me that the
operation/treatment will be performed or
administered by any particular practitioner.
Date…………………Signature……………………
(patient/parent/guardian)
2. I confirm that I have explained the nature and
purpose of this operation/treatment to the
person(s) who signed the above form of
consent.
Date………………………signature……………….
(physician/surgeon)
For permanently mentally ill and mentally
retarded persons, any treatment which is clearly
for the medical benefit of the patient could be
given and the consent of the guardian of the
patient should be taken.
Confidentially: One of the most fundamental
ethical obligations owed by a doctor to his/her
patient is to respect the confidences of his/her
patient.
Case involving allegations of
negligence

Burns:
A. Due to instruments:
It has been occasionally observed that burns
to the face, lips and oral tissues occur from
overheated appliances and when instruments
are insufficiently cooled after sterilisation.
B. Due to chemicals:
1. Use of excessive quantity of chemical
in the mouth causing spreading to areas
other than requiring the application.
2. Inadvertent use of stronger solution.
3. Accidental dripping or spilling of a
caustic or acidic solution on to exposed
areas.
Hazards of local anaesthesia

The most common problems with the injection of

local anaesthesia which give rise to allegations of
negligence are:
1. Fracture of needle in situ.
2. The production of haematoma.
3. Fainting of a patient.
4. Trismus.
5. Injection of an incorrect fluid.
6. Anaphylactic shock.
Consent form: the use of a printed slip fro signature by a
patient. A copy of the slip can be given to the patient and
the original is retained with the patient’s records.

Use of Radiographs:
Most dental diseases cannot be properly diagnosed
without the assistance of radiographic evidence. Failure
to obtain radiographs in some instances coupled with
consequential damage to the patient, can be proved as a
failure to exercise reasonable skill and care. It can also
provide grounds for negligence.
AVOIDNCE OF NEGLIGENCE.

1.Keeping knowledge and skills updated.

2.Taking all reasonable care to maintain standard.
3.Develop doctor-patient relationship.
4.Maintenance of records.
5.Employ qualified assistants.
6.Professional indemnity insurance.
Record keeping

Good record keeping is and integral part of the use of

reasonable skill and care.
One of the most important factors in self protection for a
doctor is the maintenance of accurate, full and complete
records of all treatments provided, pre and post
operative advice given, unusual sequelae, drugs
prescribed and any treatment advice given to the patient.
Ownership of Records

Dental records are the property of the practitioner

concerned.
Sometimes, a patient moving to another area may
request for his records and radiographs. Practitioners
are advised not to accede to such requests but to
inform the person concerned that these items will be
available to the patient’s next practitioner upon the
latter's request.
Preservation of records

All treatment records and relevant documents and

radiographs, and in certain cases ,models should be
preserved as long as possible and a minimum of 7
years from the date of last entry is recommended. In
case of minors, it is advisable to retain the records until
at least 7 years after the child has reached the age of
maturity.
Careers in Dentistry
Careers in Dentistry

The goal of the dental team is to provide optimal

care of the oral cavity for all patients
Dental team members can work in:
– Group or specialty(solo) practice
– Schools with dental clinics
– Government or community clinics
– Dental insurance companies
 Dentist
Education
4-5year degree from college or university
Degrees:
Bachelor of Dentistry (BDS)
Doctor of dental surgery (DDS)
Doctor of medical dentistry (DMD)
– A years of dental school training – Internship (12 months)
– 2-3 years of additional training for specialty (Msc-Clinical
Speciality)
MDS
PhD
– National examination required for licensure.
What Does a Dentist Do?

Diagnose and Treat diseases, injury and

malformations of the teeth and mouth
Improve a patient’s appearance by using a variety
of cosmetic procedures
Perform surgical procedures such as implants,
tissue grafts, and extractions
Educate patients
Perform research – improving oral health and
developing new treatments
Specialties of Practice

• Endodontics
• concerned with the human dental pulp and
periradicular tissues
• Oral and maxillofacial pathology
• deals with the nature, identification, and management
of diseases affecting the oral and maxillofacial regions.
• includes research and diagnosis of diseases using
clinical, radiographic, microscopic, biochemical, or other
examinations.
• Oral and Maxillofacial Radiology
• concerned with the production and interpretation of
images that are used for the diagnosis and
management of diseases, disorders and conditions of
the oral and maxillofacial region.
Specialties of Practice
Pediatric dentistry is a branch of dentistry that deals with the examination
and management of dental health in children.
Periodontics
encompasses the prevention, diagnosis and treatment of diseases of the
supporting and surrounding tissues of the teeth - Gums
Prosthodontics
specialty pertaining to the diagnosis, treatment planning, rehabilitation
and maintenance of the oral function, comfort, appearance and health of
patients with missing or deficient teeth and/or oral and maxillofacial
tissues
Public health dentistry
form of dental practice which serves the community as a patient rather
than the individual
concerned with the dental health education of the public, with applied
dental research, and with the administration of group dental care
programs
 The role and function of the dentist
in maintaining the general health of the human body

Assistant Professor Sopho

Puturidze
Oral health is an important part of general health,
while affecting a person's quality of life throughout their life
 Common risk factors

Among the main risk factors for chronic diseases are:

tobacco
Malnutrition, especially high sugar intake
Lack of physical activity
Excessive intake of alcohol

The mentioned risk factors also cause oral diseases.

 In recent decades:

developed preventive measures,

Restoration technique
Dental materials

Edentulism is a significant problem worldwide

due to its high prevalence and associated limited opportunities
The development of edentulism is influenced by various somatic diseases:

Hypertension, asthma, arthritis, angina.

Rheumatoid arthritis and edentulism share

common genetic and environmental factors
Oral health affects many important human abilities:

chewing
sense of taste
facial expression
speaking
psycho-social behaviors
the quality of life
Edentulism is not an independent cause of death,
but it negatively affects a number of important opportunities,
including:

in the nature of food

to talk
facial expression
on social integration
Oral health affects
a person's self-confidence and social integration.
in individuals with edentulism

Along with the decrease in vertical dimensions,

the chin is shifted forward
The face has a progeny view
develops the so-called “elderly progeny"

It is noted:
Drooping of the corners of the lips
Reduction of lip muscle tone
Thinning of red lipstick
Deepening of the nasolabial fold
The patient at rest has unhappy face appearance
Oral condition, among other factors,
is one of the important factors that influence the eating habits.

Decreased chewing power is one of the risk factors for eating disorders
The lack of teeth and the presence of dentures
lead to the restriction of the intake of foods that are difficult to chew,
such as raw vegetables, fruits and meat.

Inadequate nutrition is a big problem for the health of the body

Epidemiological studies confirm that
intake of fruits and vegetables is important and
has a positive effect on human health.

The nature of food is an important factor determining health.

Prosthetic status is not the only factor that affects the eating hab

Even in the case of full dentures, it is possible to observe

irrational nutrition, due to habit, taste acquisition,
socio-economic status.
Loss of teeth leads to a decrease in the frequency of eating
raw fruits and vegetables.

As a result, serum beta-carotene, folic acid, and vitamin C levels are

markedly lower in edentulous individuals due to malnutrition.

Inadequate dentures lead to deterioration of nutritional status

Maintaining oral health in the elderly is important
so that they can eat healthy foods, as eating disorders affect their
overall health and quality of life.

Adequate nutrition is especially important in the elderly.

Adequate nutrition in the elderly is extremely important

for maintaining general health
Nutrition as a method of treatment is one of the most
important issues in the treatment and prevention of somatic diseases.
In individuals with edentulism, chewing power is reduced,
which leads to restriction of intake of hard-to-chew foods.

The chewing ability is significantly related with the number

of teeth, with the quality of the prosthesis and
Oral health-related quality of life
According to some studies, financial and socioeconomic status
influence food choices more than dental status
According to various studies, orthopedic treatment has a great impact
on the general health of the body.

Masticatory abilities influence oral health-related quality of life in

individuals with removable partial dentures.
Epidemiological studies to determine the correlation between
oral health and general health are conducted all over the world.
Unsatisfactory oral hygiene conditions can lead to abscess,
pain, bacteremia, septicemia and chronic diseases,
complex somatic diseases, such as diseases of the cardiovascular system
and stroke.
According to various scientific studies, local periodontal
diseases are independent risk factors:
Osteoporosis of
diabetes
Diseases of the cardiovascular system
Kidney diseases
dementia
Cancer
lung infections
Erectile dysfunctions
premature birth
Nutritional disorders
Oral diseases are associated with rheumatoid arthritis
and immune system problems.

Data from various studies show the possible impact of

periodontal diseases on dementia and cognitive impairment.

According to some studies, periodontal diseases may have some

influence on Alzheimer's disease
Inflammatory processes of the periodontium, as a result of
worsening of local gingivitis, may lead to bone destruction
and tooth loss.

Tooth loss is one of the most important factors affecting

the quality of life.
It has been established that there are some kind of correlations
between diabetes and periodontal diseases

Oral hygiene and the course of periodontal diseases are relatively

difficult in diabetic individuals.
However, there was no significant difference in the prevalence
of periodontal disease
The pain caused by dental caries affects the quality of life,
because the feeling of pain limits various types of physical activity.
According to some studies, pain of odontological origin
can be more complicated and cause physical,
psychological and social limitations

It eventually manifests itself in psychological infirmity,

especially in the elderly population.

Timely elimination of odontological pain is important

Complete oral hygiene does not mean only cleaning teeth and dentures.

Cleaning the tongue is a fairly simple procedure that can

improve the functioning of the digestive system
Oral health is considered one of the main factors in the
prevention of aspiration pneumonia,
as risk factors can be controlled in this way.
Plaque of teeth and dentures is a reservoir of respiratory pathogens,
elderly people with poor oral hygiene are at particular risk.

As a result of aspiration, oral microflora may enter the trachea or

lungs and cause inflammation.

The microflora of the oral cavity is responsible for the development

of pneumonia, and respiratory diseases can be prevented
by hygienic care of the oral cavity.
As a result of professional cleaning, it is possible to eliminate candida
and bacteria that colonize the oral cavity and are potential risk factors
for the development of pneumonia.

Also, one of the important aspects of prevention of aspiration

pneumonia is the normalization of saliva secretion
Aspiration pneumonia is one of the leading causes of death in
hospitalized elderly patients.

However, the elderly have fewer opportunities to maintain satisfactory

oral hygiene and complete dental treatment, resulting in worsening
periodontitis, pain and an increase in the degree of tooth decay,
which ultimately leads to tooth loss.
Local infection in the periodontium may become an independent
risk factor for the development of cardiovascular system diseases.

Periodontal inflammation begins as a result of the action of pathogenic

bacteria accumulated in the gum area

Simple gingivitis can lead to bone destruction with corresponding

complications

It is manifested by shaking the tooth and subsequent extraction

• the body's local reaction to pathogens is expressed by the locally
produced inflammatory infiltrate.

• in the most difficult cases, the formation of a pathological pocket,

damage of the epithelium, then the transfer of microorganisms of
the mouth, bacterial endotoxins, bacterial antigens
and proinflammatory mediators to the blood circulation system.
Bone-joint diseases increase the relative chance of developing periodontal
disease,

Bone and joint diseases, especially rheumatoid arthritis and

post-menopausal osteoporosis, are an important risk factor not only for
periodontal diseases, but also for the development of peri-implantitis.

Poor oral hygiene is positively correlated with gastroenterogenic diseases

• Some people have opportunities to get proper oral
treatment, they can replace loosed teeth with dental
implants or even with removable partial dentures.
• National health organizations should develop
policies and have defined goals to improve oral
health.
• The World Health Organization recommends the
development and implementation of appropriate
strategies in individual countries to improve the oral
health of the elderly population.
The prices and availability of dental services, as well as the attitude
of doctors, are closely related to the improvement of oral health.
Dentists should pay attention
• patient-centered solutions, diagnostic criteria and
stages of diagnosis
• To help patients and their families understand the
benefits of all types of tooth replacement and
treatment
• Dentists should prioritize replacing missing teeth with
dental implants.

• The rational use of this method of treatment helps to

improve the quality of life of an elderly patient.
• Dental caries and periodontal diseases are a major
public health problem in most countries.
• Epidemiological indicators of oral cavity diseases
show significant differences between regions
• The prevalence of tooth loss and oral problems
varies widely between regions of World Health
Organization, depends on national income
• Traditional oral self-care is common in various
African and Asian countries. While fluoridated
toothpastes are widely used in developed countries,
they are very rare in most developing countries
• Dental services are available in developed countries.
• The use of such services is low among older people.
• Lack of financial support from the government and/
or less integration of oral health into health systems
limits access to dental treatment for them
• According to data from different countries, oral
health promotion programs aimed at the health of
older persons are rare and this reflects the lacks of
the insurance systems.
• Although some countries have introduced oral
health promotion initiatives, there are currently few
population-based prevention and treatment
activities that focus specifically on older adults
worldwide.
• It is recommended that countries implement oral
health programs according to the needs of the
elderly. Relevant and measurable goals should be
set to improve their oral health.
• Common risk factors should be used in public
health interventions to prevent disease.
• Integration of oral health into national health
programs may be effective in improving the oral
status and quality of life of the population
• In order for the population of the country to
maintain oral health and a high quality of life, it is
important to encourage them and increase their
knowledge.
• One of the important strategies is to transfer the
necessary knowledge to the public so that they can
properly and fully take care of themselves and
prevent diseases.
Health education is considered to be one of the most important
strategies to adopt the habits needed to promote and maintain health
• Considering the presence of common rick-factors of
chronic diseases and oral diseases, the World
Health Organization recommends combining the
prevention and treatment of oral diseases with
somatic diseases in health care programs.
Different programs were developed in Georgia, promoting the health
of the population of Georgia

• Stopping the increase in the incidence of diabetes,

• reducing premature deaths from diabetes,
• Reducing the morbidity, mortality and community spread of hepatitis
• C and tuberculosis
Thank you for attention!
Special needs Dentistry
DDS. Mariam Khardziani
Invited Lecturer
Department of Medicine
Ivane Javakhishvili Tbilisi State University
Definition of Special Needs Dentistry

 “That part of dental practice which deals with patients where intellectual
disability, medical, physical or psychiatric conditions require special methods
or techniques to prevent or treat oral health problems, or where such
conditions necessitate special dental treatment plans.” (ADA)
Definitions of some terms

 Impairment
 as any loss or abnormality of physiology or anatomical structure or function
 Disability
 any restriction or lack (resulting from an impairment) of ability to perform an
activity in a manner or within the range considered normal for a human being
 Handicap
 seen as the disadvantage for a given individual, resulting from an impairment or a
disability, which limits or prevents the fulfillment of a role that is normal
(depending on age, sex, social and cultural factors) for that individual
Intellectual Disability

 A disability characterized by significant limitations both in intellectual

functioning and in adaptive behavior, which covers many everyday social and
practical skills. This disability originates before the age of 18 (AAIDD website,
2011)
 Examples:
 Down syndrome
 Global developmental delay
Physical disability

 Either loss or missing body parts and/or functions including hemiplegia,

paraplegia, tetraplegia which affecting activities of daily living such as
personal care, movement and body posture (JKM website,2011)
 Examples of etiology:
 Spinal Cord Injury
 Stroke
 Traumatic brain injury
 Cerebral Palsy
Psychiatric/psychological disorders

 a broad range of problems, with different symptoms. However, they are

generally characterized by some combination of abnormal thoughts,
emotions, behaviour and relationships with others (WHO website, 2011)
 Examples:
 Schizophrenia
 Depression
Geriatric Dentistry

 Focuses on the diagnosis, prevention and treatment of oral diseases in adults

who, because of their medical condition or old age, are handicapped or
institutionalised and require special management during their dental
treatment
Common Dental Problems of People with
Special Needs
 Chronic periodontitis
 Chronic generalized marginal gingivitis
 Dental caries
 Poor Oral Hygiene
 Xerostomia
Key Considerations in SND

 Treatment modifications
 Hearing and visual impairment
 Wheelchair users
 Managing the challenging behaviour
 Ensuring airway patency
 Referral for treatment and consultation by specialists
 Inter-collaboration with other health care providers
 Physical interventions
Geriatric Dentistry

 Geriatrics is the branch of medicine that studies elderly diseases.

 It is distinguished from Gerontology that is the study of the social,
psychological & biological aspects of aging
 The terms “geriatric dentistry” & “gerodontology” emerged in the 1970s,
with the recognized need for health care for aging baby boomers (persons
born between 1946 and 1964, after World War II)
Geriatric Patient

 Generally elderly were classified according to age group in to:

I. Young-old → 65-74
II. Middle-old → 75-84
III. Oldest-old → ≥ 85
Zizza et al., 2009

 It was suggested to further categorize them into three functional groups,

based on their ability to seek dental care independently

 Classifying them allows for a more detailed & accurate analysis &makes
diagnosis & treatment planning more personalised
I. The fit elderly or functionally
independent elderly
 They function independently, can drive their own vehicles, or use public
transport
 They can receive care from their general dentists who need to take a
thorough medical & drug history before treatment planning
 They do not receive regular prescribed medication
 These elderly are thus not defined as having special needs
II. The Frail Elderly

 They lost some of their independence, but still live in the community with the
help of family, friends or professional support services
 Can still access general dental services, but may need help with transport
 Their oral health require a greater understanding of medicine &
pharmacology & a careful evaluation of their ability to tolerate dental
treatment & to maintain daily oral hygiene
 Common conditions contributing to frailty include Alzheimer's disease, multi-
infarct cerebrovascular disease, Parkinsonism, osteoporosis, osteoarthritis &
healed fracture events
 They may require regular prescribed drug therapy
III. The functionally dependent elderly

 Have chronic, debilitating, physical & medical or emotional problems or any

combination that compromises their capacity &independency thus they are
homebound or institutionalized
 Both frail elderly & functionally dependent groups are included in the special
care definition
Physiological changes in Geriatric
Patients
 Aging is related with a number of physiological changes
 The gastrointestinal, renal, cardiovascular, respiratory & immune systems often decrease
in efficiency impacting the entire body including oral health
 Mobility might decrease due to physical changes such as reduced bone, muscle mass &
osteoarthritis that impact health care utilization
 A variety of audio & visual changes such as cataracts & hearing loss can make
communication, patient education & oral health care increasingly difficult to maintain
 Most elderly have one or multiple chronic condition including hypertension, arthritis,
diabetes, stroke, respiratory infections, cardiovascular & cancers.
 These conditions have oral manifestations & require consideration before initiating any
dental treatment Long et al., 1998; WHO 2018
 Other common conditions include Dementia that is characterized by a progressive
deterioration in cognition affecting individual’s capability to function independently & to
manage their medications, systemic conditions & oral hygiene thus increasing their
susceptibility to develop dental caries, periodontal disease & oral infection
Pharmacological considerations of
Geriatric Patients
 Most of elderly are taking prescribed or over the counter medications
 These medication may cause a dry mouth or xerostomia & thus affecting
speak & chew ability, leading to increasing caries rate, periodontal disease,
traumatic ulcers, fungal infections & reduces denture retention in the
edentulous patient
Oral Health in Geriatric patients

 The links between oral diseases & general health are multifaceted & complex:
 Systemic diseases influence oral health, either directly via pathological pathways &
indirectly via disease or therapy-related changes
 Oral health changes also have an impact on systemic health, periodontitis has been
found to be associated with higher mortality & increased risk of numerous NCDs, such as
diabetes, cardiovascular disease, chronic renal disease, pneumonia & gastritis

 Number of lost teeth has been shown to be a predictor of cardiovascular mortality

as well as reductions in quality of life:
 Poor dental status with missing teeth or ill fitting dentures & even well-fitted dentures
(that are less efficient than natural teeth in terms of chewing), push changes in diet to
softer foods
 Such foods often contain more fermentable carbohydrates, which raise elderly’ risk to
developing dental caries & generally causing malnutrition
Objectives of Geriatric Dental Care

1. To recognize & relieve oral health issues of elderly people

2. Restoration & preservation of function for maintaining normal life in elderly
patients
3. To maintain ideal health & function of masticatory system by establishing
adequate preventive measures
Geriatric Dentist – Required
Competencies
Recommendations

 Collaboration, communication & exchange of information between dentists &

physicians is necessary to integrate health promotion strategies into Common risk
factors approach
 Using firm, standard height chairs with arms for support
 Providing adequate lighting in each room, to minimize any visual disorientation or
mental confusion
 Setting up dental furniture to promote & facilitate good communication & access,
the dental room should accommodate wheelchair patients or those who use
walkers
 Carefully selecting & placing signs to support the independence of the elderly
patient
 Large-print leisure & oral preventive educational material should be available for
geriatric patients in the reception room
 Portable dental equipment for providing care to the functionally dependent
elderly at home or in nursing homes
Fear management in
Dentistry
Introduction
 This is much serious condition than anxiety because people will feel too much
fear therefore, they will do everything possible to avoid not visiting their
dentist.
 If extreme discomfort will happen on their teeth, they will be forced to have
dental check-up. In some cases, it might need for psychiatric consultation.
 Other Signs of Dental Phobia Inclusions:
 Difficulty sleeping at night prior the dental consultation
 Feelings of anxiousness while staying in the dental office waiting area
 Crying or feeling physically ill when thinking to have dental check-up
 Feeling there’s a problem of breathing when the objects are placed in your mouth
either by thoughts or the actual dental treatment
Common Causes of Dental Phobia
1. Fear of pain
 It’s very common reason for avoiding the dentist;
 It could come from previous dental experience which is painful of from dental
“pain and horror” stories told by others.
 Nowadays, most of the dental procedures resulting to less pain or even no pain at
all, because there are already many advanced study un dentistry.
2. Fear of injections
 Most people are afraid of needles especially when enserted inside their mouth.
 Some humans fear no effect using anesthesia or it doesn’t contain large enough
dose to remove any pain before the dental procedure starts.
3. Fear of anesthetic side effects
 Some people are afraid for possible side effects of anesthesia like dizziness,
feeling faint or nausea.
 Other people don’t like the numbness, which is related with local anesthetics
4. Feelings of helplessness and loss of control
 This is very common for patients to feel these emotions when sitting in a dental chair
with your mouth widely open and you can’t see what’s going on.
Common Causes of Dental Phobia

5. Embarrassment and loss of personal space

 Lot of people feel uneasy when the dentist is very close to them, while others might
feel embarrassed pertaining to the appearance of their teeth or possible mouth odors.
Examples from everyday practice

 How, when, or why it happened is a mystery to me, but somehow I’ve

developed a dental phobia so extreme as to keep me away from a dental
office most of my adult life. Just mentioning the word “dentist” made me
cringe. Hearing an orthodontic or toothpaste commercial on radio or TV
made me run from the room.
[Adult female]
 I don’t know, just the word “dentist” does something to me. So after I got in
the chair, I asked the dentist if I could go to the bathroom. He said “yes,” so I
went to the waiting room, grabbed my hat and coat, and ran out.
[Adult male]
Behavioral Techniques to Reduce patient
Fear
1. non-relaxationbased techniques,
2. “quasi-relaxation”-based techniques,
3. relaxation-based techniques.
Non-relaxation-based techniques

 communication skills (including the redefining of

sensations)
 Distraction
 behavior modification
 Modeling
 cognitive restructuring or cognitive
 behavior modification
 stress inoculation
 Iatrosedation
 acupressure
Quasi-relaxationbased techniques

 guided imagery
 paced breathing
 Biofeedback
 graduated exposure
 meditation.
Relaxation-based techniques

 progressive relaxation
 systematic desensitization
 hypnosis
Somatic and cognitive orientation of various
relaxation methods. Adapted from Davidson and
Schwartz (1976)
Thank You For your Attention!