Proven

 prac+cal  preven+on  
And  the  children  in  your  prac+ce  
Thank  You  
Trends  in  Oral  Health  Status  

“Tooth  decay  in  primary  teeth  of  

children  aged  2  –  5  between  1988  –  
1994  and  1999  –  2004  increased  from  
24  –  28%”  CDC  2007    oral  health  report    
The  Caries  Sequence  
Low  Intraoral  
pH  
<6.6  

Overgrowth   Growth  of  

of  Cariogenic   Aciduric  
Bacteria   Bacteria  

Decrease  in  
Growth  of  
the  
Acidogenic  
Protec+ve  
Bacteria  
Commensals  
 Defini+on  ECC  S-­‐ECC  
ECC  =  early  childhood  caries  
     The  presence  of  one  or  
more  decayed,  missing  or  
filled  tooth  in  a  child  71  
months  of  age  or  younger.  
S-­‐ECC  =  severe  early  
childhood  caries  
 <  5  yrs  –  any  smooth  
surface  lesion  
   3  yrs  –  DMFT  of  4  
 4  yrs  –  DMFT  of  5  
 5  yrs  –  DMFT  of  6  
•  AAPD    reference  manual  2010  
What  is  Risk  Assessment?  

 “An  es+ma+on  of  the  

likelihood  that  an  event  will  
occur  in  the  future.”  
 What  Does  Risk  Assessment  Allow  Us  to  
Do?  
Allows  us  the  ability  to  
guide  the  clinical  
decision  making  
process.    
Caries  risk  assessment  
models  are  a  cost-­‐
effec+ve  approach  for  
community-­‐based  
programs  to  follow.    
 Young,  Buchanan,  Lubman,  Badway,  2007;  ADA,  
2006;  Bradhall,  Hansel  Petersson,  2005;  AAPD,  
2002  
 Disease  Indicators  for  Children  
•  Mother  with  ac+ve  caries  
•  Socio  economic  risk  
•  Visible  cavita+ons  
•  Cavity  in  the  last  2  years  
•  Obvious  white  spot  lesions  
Risk  Factors  for  Children  (in  
descending  order)  
•  Obvious  Plaque    
•  Gingiva  bleeds  easily  
•  Inadequate  saliva  flow  
•  Appliances  
•  No  dental  home  
•  Medica+ons  
•  Bodle  use  con+nuous  or  
nurses  on  demand  
•  Bodle  use  at  bed  
•  Frequent  snacking  
 Salivary  Flow  
•  To  determine  salivary  flow  rate    
have  your  pa+ent  chew  on  a  paraffin    
pellet  for  1  minute  and  then  spit  into    
a  cup  for  3  –  5  minutes.  
•  Flow  rate  =  ml  /  min.  
•  >  1  ml  /  min  is  considered  normal  flow  
pH  tes+ng  
 Association between caries and
bacterial levels in infants and toddlers.  

•  MS count was highest in children with ECC, lowest in those without

caries, and intermediate in those with incipient lesions

•  The salivary level of LB was highest in children with ECC, but these
bacteria were present at lower levels in children with incipient lesions
and in those with no caries

•  MS and LB threshold levels associated with caries were lower than those
considered significant in older children and adults  

•  Francisco J. Ramos-Gomez, Jane A. Weintraub, Stuart A. Gansky, Charles I. Hoove, John D. B.

Featherstone. Bacterial, behavioral and environmental factors associated withearly childhood
caries J Clin Pediatr Dent 26(2): 165-173, 2002

 Dentocult  SM  -­‐  Strip  mutans  Test  
•  Used  to  detect  S  mutans  
in  saliva  and  plaque.  
•  Based  on  the  use  of  a  
selec+ve  culture  broth  
and  the  adherence  and  
growth  of  S  mutans  
bacteria  on  the  test  strip.  
•  Shows  S  mutans  as  dark-­‐
blue  to  light-­‐blue,  raised  
colonies  on  the  surface  of  
the  test  strip.  
Dentocult  Tests  
 ADA  Council  on  Scien+fic  Affairs  
Guidelines  
HIGH  CARIES  RISK     HIGH  CARIES  RISK    
(  <  6  years)   (  >  6  years)  
Any  of  the  following:   Any  of  the  following:  
•  Any  lesion  in  the  past  3  
•  3  or  more  lesions  in  the  
year    
past  3  years  
•  Mul+ple  risk  factors  
•  Low  socioeconomic   •  Mul+ple  risk  factors    
status   •  Insufficient  fluoride  
•  Insufficient  fluoride   exposure    
exposure     •  Xerostomia.  
•  Xerostomia.  
•  JADA  August  2006  Special  Supplement  
 The  Balance  
Unhealthy   Healthy    
Tooth   Tooth  

ANTIBACTERIAL  
THERAPY  

ACID  PRODUCING  
BACTERIA  
GOOD  OH  

POOR  ORAL  HYGIEN

E  
GOOD  DIET  

FREQUENT  SNACK
ING  
FLUORIDE  

JDB  Featherstone,  J  Dent  Res  83  (Sp  Issue  C)  C39  –  C42,  2004    
 Tools  
 1)  Behavioural:    
 DIET,  ORAL  HYGIENE  

 2)  Therapeu+c      
 Chlorhexidine,  xylitol,  FLUORIDE  VARNISH,  
FLUORIDE  

 3)  Repara+ve    
 sealants,  GI  
Pictograms  
 Toothpaste  
•  “250  ppm  fluoride  den+frice  was  not  as  
effec+ve  in  caries  preven+on  in  permanent  
den++on  as  den+frice  containing  1,000  ppm  F  
or  more”  

 Systema)c  Review  of  Studies  Comparing  the  An)-­‐Caries  Efficacy  of  Children’s  Toothpaste  Containing  600  ppm  of  Fluoride  
or  Less  with  High  Fluoride  Toothpastes  of  1,000  ppm  or  Above  
A.B.  Ammari,  A.  Bloch-­‐Zupan,  P.F.  Ashley  

Department  of  Paediatric  Den)stry,  Eastman  Dental  Ins)tute  for  Oral  Health  Care  Sciences,  University  College  London,  
London,  UK  Vol.  37No.  2,  2003  
Fluoride  Toothpaste  
•  The  subjects  were  required  to  drink  500  mL  
of  a  120-­‐gm/L  sugar  solu+on  either  once,  3,  
5,  7,  or  10  +mes/day  for  30  sec  on  each  
occasion,  for  a  period  of  5  days.  
•  While  brushing  their  teeth  twice  daily  with  
either  a  F  (1450  ppm  NaF)  or  a  F-­‐free  
toothpaste.    
•  Mineral  analysis  revealed  that  when  the  
subjects  used  a  F  toothpaste,  net  
demineraliza+on  was  evident  only  with  the  
seven-­‐  and  10-­‐+mes/day  regime  (ns).    
•  When  F-­‐free  toothpaste  was  used,  
sta+s+cally  significant  demineraliza+on  was  
observed  when  the  frequency  exceeded  3  
+mes/day.  
 Duggal  MS,  Toumba  KJ,  Amaechi  BT,  Kowash  MB,  Higham  SM  
(2001).  Enamel  demineraliza+on  in  situ  with  various  
frequencies  of  carbohydrate  consump6on  with  and  without  
fluoride  toothpaste.  J  Dent  Res  80:1721–1724.  
 Gel  vs.  Varnish  
•  Gel  –  evidence  is  
inconclusive  for  efficacy,  
none  less  than  4  minute  
applica+on.  
•  Varnish  –  ease  of  
applica+on,  beder  
pa+ent  compliance,  less  
swallowed.  
•  American  Dental  Associa+on  Council  
on  Scien+fic  Affairs,  2006  
 Clinpro  White  Varnish  
•  Releases  Calcium  in  the  
form  of  TCP  
•  Takes  just  seconds  to  
paint  on  
•  Sets  rapidly  in  the  
presence  of  saliva  
•  Flows  well  
•  Contains  22,600  ppm  
Fluoride  
•  Classified  as  a  natural  
health  product  
•  Mint,  cherry,  or  melon,  
 Vanish™  5%  Sodium  Fluoride  White  Varnish  
 with  Tri-­‐Calcium  Phosphate  

What  is  Tri-­‐Calcium  Phosphate?  

–  Stable  crystal  structure  similar  to  natural  tooth  

mineral  (hydroxyapa+te-­‐  “HAP”)  
–  Predictable  chemical  proper+es  
–  Biocompa+ble  and    bioac+ve  
–  Coated  calcium  mineral  does  not  bind  to  fluoride  
in  the  Vanish  formula+on    
–  Op+mized  to  release  calcium  &  phosphate  at  the  
tooth  surface  
Karlinsey  RL,  Mackey  AC,  Walker  ER,  Frederick  KE.  Prepara+on,  characteriza+on  and  in  vitro  efficacy  of  an  acid-­‐modified  beta-­‐TCP  
©  3M  ESPE  2material  
007.    Afll  
or  Rdights  
ental  R
heserved  
ard-­‐+ssue  remineraliza+on.  Acta  Biomaterialia  2010;6:969-­‐978  
 The  Studies  …  
“Several  recent  studies  have  shown  that  fluoride  varnish  is  efficacious  in  reducing  
decay  in  the  primary  teeth  of  high-­‐risk  children.”    

“Programs  using  fluoride  varnish  will  be  more  likely  to  demonstrate  benefits  and  
reduce  dental  caries  in  at-­‐risk  popula+ons  when  applica+ons  are  offered  at  least  at  
six-­‐month  intervals  over  at  least  two  years  in  dura+on  in  combina+on  with  
counseling.  For  the  preven+on  of  early  childhood  caries,  ini+a+on  of  fluoride  
varnish  should  begin  no  later  than  age  one  for  highest  risk  children.”    
Weintraub,  Ramos-­‐Gomez,  June,  2006  
Lawrence,  Binquis,  Douglas  et  al,  2006    
  Before  Caries  is  Observed  
There  is  evidence  that  the  preven+ve  effect  is  strongest  when  fluoride  varnish  is  
applied  before  the  onset  of  detectable  dental  caries.    

•  Randomized  clinical  trial  in  Canada,    

1,146  young  aboriginal  children  with  high  caries  incidence  
caregiver  counseling    
fluoride  varnish  three  +mes  a  year  
two  years  
reduc+ons  in  dental  caries  of  18%  to  25%  
WHEN  INITIATED  BEFORE  CARIES  IS  OBSERVED    
•  Infants,  toddlers  and  preschool  children  who  were  caries  free  at  baseline  
benefited  most  from  the  interven+on.  (Lawrence,  Binquis,  Douglas  et  al,  2006)    
CHLORHEXIDINE  
•  Bisguanide  an+sep+c  
•  Mechanism  of  ac+on  is  to  
damage  the  cell  wall  of  the  micro-­‐
organism  
•  Effec+ve  on  a  wide  range  of  
micro-­‐organisms,  including  gram  
–ve,  +ve,  anaerobes  and  yeast.  
•  Adherent  over  prolonged  periods  
of  +me  and  thus  is  it’s  an+-­‐
bacterial  proper+es  are  released  
over  +me  
•  It’s  an+  plaque  proper+es  are  
unsurpassed    
•  Leads  to  a  decrease  in  the  pH  
drop  
 Recommended  Regimen  
•  Rinse  bid  for  1  minute  with  
0.12%  CHX  for  one  week    

•  Rinse  bid  for  1  minute  with  

a  0.5%  fluoride  rinse  for  the  
subsequent  3  weeks  

•  Repeat  the  cycle  

•  For  children  unable  to  rinse  

and  spit,  brush  teeth  with  
CHX    
 Xylitol  
•  A  natural  sugar  found  in  
plums,  strawberries,  and  
raspberries,  xylitol  is  used  
as  a  sweetener  in  some  
"sugarless"  gums  and  
candies.    
•  Not  only  does  xylitol  
replace  sugars  that  can  
lead  to  tooth  decay,  it  
also  helps  to  prevent  
caries  by  inhibi+ng  the  
growth  of  bacteria,  such  
as  Streptococcus  mutans.    
 Mechanism  of  Ac+on  of  Xylitol  
•  Not  fermented  by  bacteria  
•  Acid  is  not  produced  and  
the  pH  is  not  decreased  
•  Demineraliza+on  is  
prevented  and  
remineraliza+on  is  
enhanced  
•  Reduces  the  accumula+on  
of  plaque  on  the  surface  of  
the  tooth.  
•  Xylitol  s+mulates  salivary  
func+on  
•  Over  +me  the  bacterial  
make  up  of  the  plaque  
changes  allowing  for  less  
and  less  strep  mutans  to  
survive  
 Recommended  Dosage  
•  According  to  studies  the  recommended  
dosages  for  cavity  preven+on  ranged  from  4.3  
to  10  gm  per  day.    
•  These  doses  are  divided  throughout  the  day,  
usually  a|er  meals.    
•  (Frequency  of  less  than  3  +mes  per  day  
showed  no  effect)  Rekola  M  Correla+on  between  caries  incidence  and  frequency  of  
chewing  gum  sweetened  with  sucrose  or  xylitol.  Proc  Finn  Dent  Soc  1989;  85(1):  21  -­‐  4  
 Turku  studies  
•  DMF  of  sucrose  gum  chewers  was  2.92  
•  DMF  of  xylitol  gum  chewers  was  1.04  

•  Scheinin  A  eta  alFinal  report  of  the  effects  of  sucrose  fructose  and  xylitol  diets  on  caries  incidence  in  man.  Acta  Odontol  
Scand  1976;  34  (4)  179  –  216.  
 Mechanism  of  Ac+on  
•  Physically  obstruc+on  of  the  pits  and  grooves  
•  Prevents  coloniza+on    
•  Prevents  penetra+on  of  fermentable  
carbohydrates  
 Simplified  Sealant  Technique  
•  Brush  self  etch  adhesive  onto  surface  to  be  sealed;  scrub  for  15  seconds  
applying  moderate  pressure.  Do  not  shorten  this  +me.  Proper  bonding  will  
not  occur  if  the  solu+on  is  simply  applied  and  dispersed.  
•  Use  a  gentle  stream  of  air  to  thoroughly  dry  the  adhesive  to  a  thin  film.  A  
second  layer  is  not  required  for  bonding  sealants.  
•  Apply  sealant  
•  Light-­‐cure  the  sealant  and  adhesive  together.  
 Glass  Ionomers  
•  “Fluoride  releasing  bonding  and  restora+ve  
materials  have  been  shown  to  be  beneficial  
and  are  best  u+lized  as  part  of  a  
comprehensive  preventa+ve  program  in  the  
dental  home”  
•  AAPD  reference  manual  2010/2011  
•  Nowak  AJ,  Cassamassimo  PS    The  dental  home  A  primary  care  oral  health  concept.  J  Am  Dent  Assoc  2002;  
133  (1):  93  -­‐8.