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Protocols and Prevention of Dental Caries Part 2

• By Dr. M. Cahoon, Principles of Dental Hygiene II

Objectives

• Determine caries risk potential from patient records on food and diet.
• Define pit and fissure sealants, including preventive and therapeutic rationales in an exam.
• Explain indications and contraindications for sealant placement.
• Assess patient needs for pit and fissure sealants using case-based scenarios.
• Define factors contributing to hypersensitivity.
• Describe pain stimuli associated with hypersensitivity.
• Describe desensitizing agent types and their indications for use.

Non-Fluoride Caries Preventive Agents

• Use for dental hygiene therapies.

Casein Phosphopeptides-Amorphous Calcium Phosphate (CPP/ACP)

• Formulated from two parts, CPP and ACP.
• It stabilizes calcium phosphate in solution, increasing calcium phosphate levels in dental biofilm.
• Buffers free calcium and phosphate ion activities. This saturates the tooth surface for remineralization by acting as a reservoir of calcium and phosphate ion forms.
• Derived from cow's milk.
• Contraindicated in people with milk allergies due to the casein protein derived from cow's milk.
• Available as a professionally applied Recaldent (MI Paste).
• Self-applied products include Trident White and Trident Extra Care chewing gum.
• Enhances fluoride uptake when used with fluoride.

Indications for Use of CPP/ACP

• White spot lesions
• Hypomineralized enamel
• Mild fluorosis
• Tooth sensitivity and erosion
• Poor biofilm control with orthodontic brackets

Tri-calcium Phosphate

• Hybrid material made by milling beta tricalcium phosphate (B-TCP) fused with sodium lauryl sulfate or fumaric acid.
• Unique calcium environments exist. These are capable of reacting with fluoride and enamel.
• It is activated by the presence of saliva.
• Provides catalytic amounts of calcium to boost fluoride efficacy.
• Best designed to coexist with fluoride in a mouthwash, dentifrice, or varnish.
• Only available in prescription products: ClinPro 5000, and OmniVarnish (combination 5000ppm NaF and TCP).

Xylitol

• Naturally occurring 5-carbon sugar alcohol.
• Inhibits attachment and transmission of bacteria in biofilm growth.
• Assists in stimulating saliva. Effective for xerostomia.
• Recommended with fluoride therapy for moderate, high, and severe caries risk management.
• Overall caries prevention is less effective than fluoride.
• Present in OTC oral hygiene products.
• Can be delivered through chewing gum or lozenges.
• A therapeutic dose is 2 pieces of gum, mints, or lozenges 4-5x daily for 20-30 mins minimum.
• Xylitol should be listed as first active ingredient on the label.

Sodium Bicarbonate

• Neutralizes acids produced by acidogenic bacteria.
• Exhibits antibacterial properties.
• Severe caries risk patients with xerostomia benefit from sodium bicarbonate rinse. Use 1tsp baking soda into 1 cup of warm water.
• It is also available in chewing gum and fluoridated toothpaste.

Chlorhexidine

• CHX Gluconate is a broad-spectrum antimicrobial agent.
• High substantivity provides immediate bacterial action and prolonged bacteriostatic action for 8-12 hours.
• Use 0.12% CHX Gluconate rinse 1x/daily for 1 week each month to reduce caries-causing bacteria levels.
• Repeat and assess at 6-month intervals.
• Must be used with fluoride therapy.
• Cons include altered taste, teeth staining, and increased calculus formation.
• For treating high and severe caries risk patients

Salivary Substitutes for Caries Prevention

• Xerostomia may be multifactorial, caused by: -Medication -Radiation -Contributing medical conditions.
• Saliva substitutes include: -Aqueous ion solutions -Aqueous ion-carboxymethylcellulose preparations -Mucin-containing solutions -Glycoprotein-containing agents -Enzyme-containing gels

OTC Xerostomia Treatment

• Oral moisturizers and lubricants
• Mouthrinses and sprays
• Lozenges and gums
• Combination therapies -Fluoride, calcium phosphate, and xylitol -Humidifier while sleeping
• Remember, most only provide short term relief.

Prescription Treatments for Xerostomia

• Two medications are approved in the U.S. to treat xerostomia: -Pilocarpine -Cevimeline
• Require communication and collaboration with patients' primary care physicians for patients with: -Sjogren's syndrome -Radiation therapy

Caries Prevention and Management Future

• Silver Diamine Fluoride and related products
• Nano-hydroxyapatite
• Oral probiotics and evaluation of oral pH
• Arginine
• Propolis (derived from bees)

Dental Sealants

• A comprehensive prevention plan

Factors to Teach the Patient About Sealants

• Sealants are part of a total preventive program.
• Sealants prevent dental caries in pits and fissures.
• Sealant applications require meticulous application.
• Sealants need maintenance.
• Sealants are expensive, but are better than a restoration because they do not require cavitation.

Purpose of Dental Sealants

• Provides barrier to "seal off" pit or fissure.
• Sealants prevent collection of oral bacteria in pits or fissures.
• Fills pits or fissures as deeply as possible with a tight junction to the surface of enamel.
• Material includes organic resin or filled glass ionomer to bond by mechanical retention to the surface of a tooth.

Classification by Method of Polymerization

• Self-cured/Autopolymerization does not require a curing light, but mixing limits working time.
• Light-cured/Photopolymerized requires no mixing, hardens when exposed to curing light, and is more expensive.

Classification by Filler Content

• Filled sealant resin contains glass or quartz particles, increasing bond strength and resistance to wear, increasing hardness to occlusion, and requiring occlusal adjustment after placement
• Unfilled sealant resin has no particles, is clear in application, is less resistant to abrasiveness and occlusal forces, does not require occlusal adjustment, and works for community outreach settings.
• Fluoride Releasing sealants enhance remineralization at the base of the pit and fissure if an incipient lesion is present. Glass ionomer is ideal for teeth where isolation may not be possible.

Indications for Sealant Placement

• Individual considerations include diet and lifestyle, age of tooth, past caries experience, and tooth anatomy.
• Key risk factors at any age: Xerostomia, active orthodontic treatment, incipient pit and fissure lesion without radiographic evidence of decay, low socioeconomic status/low access to care, poor oral hygiene, diet high in fermentable carbohydrates.

Selection of Teeth for Sealants

• Ideal Tooth Surface should be newly erupted, contain deep occlusal pits & fissures or have irregular patterns, and the patient should have a caries history.
• Contraindications for Sealant Placement include radiographic evidence of proximal decay on adjacent teeth, pits and fissures that are well-coalesced, a tooth that has not completely erupted, and primary tooth near exfoliation.

Penetration of Sealant

• The anatomy and depth of fissures, presence of debris or biofilm, and properties of the sealant itself are all factors to consider.
• Clinical Procedures must: -Clean tooth surface of debris, -Complete tooth isolation from moisture, -Use acid etch to increase retention, -Place sealant material following manufacturer's instructions, -Check for voids.

Sealant Placement Decision Tree

• The decision tree is a flowchart to assist in the decision-making for placement of sealants.
• Developed by Jill C. Moore, EdD, MHA, BSDH, RDH.

Maintenance of Dental Sealants

• Check Retention at each continuing care appointment.
• Properly placed sealants can last for many years.
• The placement area must remain contamination/moisture-free during placement.
• Patient habits such as nail biting and chewing on hard items reduces retention
• Avoid direct use of air polisher during dental hygiene appointments.
• Must re-etch when replacing sealants.

Documentation After Sealant Placement

• Caries Risk Level
• Type of sealant used
• Preparation of tooth
• Method of isolation
• Patient compliance
• Post-operative care instructions

Diet and Dietary Analysis Related to Dental Caries

• Dietary considerations in relation to dental caries

Oral Health and Nutrition

• Nutrition, diet, and oral health are closely related.
• Optimum health, including oral tissues, requires healthy diets that provide essential nutrients.
• Consumption of healthy foods relates to proper masticatory function of the teeth.
• Soft, sticky diets stay on tooth surfaces (especially cervical third) and contributes to biofilm adherence.
• Malnutrition suppresses the immune system.

Role of Cariogenic Foods

• Dental caries is not a result of nutritional deficiency.
• Acidogenic and aciduric bacteria use fermentable carbohydrates as food.
• Consistent intake of food that is soft and sticky that is not cleared easily is associated the development and maintenance of carious lesions.

Dietary Assessment

• Must consider patient's complete medical, social, and dental assessment.
• Include results of clinical examination.
• Types of dietary assessments with a patient include 24-hour recall and dietary analysis recording form for 3-7 days.

Analysis of Cariogenic Foods

• Identify physical form of carbohydrate: -Liquids -Soft/solid, sticky retentive foods -Hard/solid, slowly dissolving foods
• Identify frequency of meals and snacks: -How many snacks between meals? -What are meal times, and how many meals? -Frequency is more relevant than quantity.

Hierarchy of Cariogenic Foods

• Slowly Dissolving Cariogenic Foods: hard candies, cough drops, antacids, breath mints.
• Solid and Sticky Cariogenic Foods: cakes, cookies, cupcakes, potato chips, pretzels, dried fruit, canned fruit in syrups, jelly beans, bananas.
• Cariogenic Liquids: Regular and diet soda, fruit/juice drinks, added sugar and honey to beverages, sweetened creamers, ice cream, frozen yogurts.

Challenges to Nutritional Counseling

• Patient attitude and health literacy level
• Discussions of diet and nutrition are often overwhelming.
• Common misconceptions exist about concentrations of sugars.
• Cultural or religious patterns may be associated with food.
• Emotional eating habits
• Socioeconomic status and access to healthy foods
• Parent/child relationship with sugary foods.
• Foods are often a reward for good behavior.

Dental Hygiene Care and Low Caries Risk

• Continue oral health education. Caries risk status may change in the future.
• Provide Positive feedback and encourage and reinforce!
• Review existing habits that make a patient low risk. -Use OTC fluoridated toothpaste -Healthy diet -Effective biofilm removal
• Dental hygiene continuing care appointments should be every 6 months.

Dental Hygiene Care and Moderate Caries Risk

• Provide positive feedback for existing protective factors, or provide Supportive feedback.
• Create a plan to reduce risk factors like removing acidic beverages or frequent snacking between meals and allowing the patient to choose the behavior to modify.
• Increase the number of protective factors: -In-office fluoride therapies such as fluoride varnish applications should be followed with Xylitol products after meals. -OTC fluoridated toothpaste and rinse at home
• Plan appropriate dental hygiene continuing care appointments: 4-6 months

Dental Hygiene Care and High or Severe Caries Risk

• Nidus of infection must be addressed with active dental caries treatment.
• Decrease mechanical bacterial infections with professional biofilm removal by a clinician and individualized oral hygiene instruction.
• Create strategies for reducing existing risk factors. Motivational interviewing techniques may be useful to find the patient's intrinsic motivation for change.
• Educate and create a plan for increasing protective factors: -Providing in-office fluoride therapies -Encourage at home remineralization therapies for oral hygiene (though OTC toothpaste is often not enough.) -Choice of recommended products should be based on individual risk factors and management of xerostomia.
• Recommend appropriate dental hygiene continuing care intervals of 3-4 months.

Dentinal Hypersensitivity

• Overview and causes of dentinal hypersensitivity

Dentinal Hypersensitivity Defined

• Pain elicited from a stimulus and alleviated upon removal of the stimulus.
• Types of Stimuli: tactile, thermal, evaporative, osmotic, and chemical.

Characteristics of Hypersensitivity

• Teeth most affected: mandibular premolars and anterior teeth; facial surfaces of premolars and molars.
• Sharp, short, or transient pain with rapid onset.
• Cessation of pain with removal of stimulus.
• Chronic condition with acute episodes.
• Pain response to a stimulus that would not normally cause pain.
• Discomfort that cannot be ascribed to any other dental pathology or is unrelated to caries.

Relationship of Nerve Endings to Tubules

• Nerve endings from the pulp wrap around odontoblasts.
• Nerve endings extend a short distance into tubules.
• Fluid-filled dentinal tubules transmit fluid disturbances.

Hydrodynamic Theory

• Transmission of stimuli from the outer surface of the dentin to the pulp from fluid movement.
• Fluid movement creates pressure on the nerve endings within the dentinal tubule.

Causes of Hypersensitivity

• Loss of enamel or cementum can expose dentin gradually or suddenly.
• Lower mineral content of cementum and dentin.
• Contributing factors: -Tooth fracture -Attrition -Abfraction -Erosion -Gingival Recession

Factors Contributing to Gingival Recession

• Effects of improper self-care.
• Anatomically narrow zone of attached gingiva
• Tooth orientation
• Short frenum attachment
• Apical migration from periodontal diseases
• Periodontal surgeries
• Orthodontic tooth movement
• Facial/tongue/lip piercings

Differential Diagnosis

• It is critical to distinguish dentinal hypersensitivity from other conditions with similar symptoms, which include caries extending into dentin, pulpal caries, fractured restorations, fractured teeth, a recently placed restoration, occlusal trauma, pulpitis, sinus infection, galvanic pain, and periodontal ligament inflammation.

Questions for Differential Diagnosis

• Which teeth/tooth are sensitive?
• On a scale of 1 to 10, with 10 being the most pain, what is your pain intensity?
• How long does the pain last?
• Does it hurt when you bite down (pressure)?
• Which word best describes the pain: dull, shooting, throbbing, persistent, intermittent?
• Is it stimulated by certain foods?
• Is it stimulated by hot or cold?
• Does the discomfort stop immediately or linger?
• Have you used any whitening products recently?

Diagnostic Techniques

• Visual assessment of tooth and surrounding tissues
• Palpation of area
• Occlusal examination
• Radiographic examination
• Percussion with an instrument handle
• Assessment for mobility
• Pain from biting on a bite stick
• Transillumination for fracture detection
• Pulp testing

Oral Hygiene Treatment Recommendations

• Behavioral Changes -Diet modifications
• Biofilm control
• Eliminate contributing parafunctional habits by addressing Bruxism
• Assess toothbrushing techniques
• Choose appropriate desensitizing agents with: -Potassium salts -Fluorides -OTC and Rx -Oxalates -Calcium Phosphate technology

Desensitizing Agents

• Calcium Phosphate Technology: -Casein Phosphopeptide (CPP-ACP) -Tri-calcium Phosphate
• Potassium Salts: -Potassium Nitrate, Potassium Citrate, Potassium Chloride -5% Potassium Nitrate is combined with fluoride in many toothpaste. combinations. Available as an addition to some prescription strength toothpastes
• Fluorides: -5% NaF Varnish treatment of choice for professional application -Silver Diamine formulations -5000ppm Gel formulations best for at-home use prescription treatments

Factors to Teach Patient

• Etiology and prevention of gingival recession
• Factors contributing to hypersensitivity
• Mechanisms of dentinal tubule exposure
• Appropriate self-care
• Relationship to diet, including that patients with sensitivity should not brush after ingesting acidic foods.
• Behavior modifications
• Hierarchy of treatments