Concepts of Prevention in Dentistry PDF

Concepts of Prevention in Dentistry Associate Professor Dr Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Department of Family Oral Health Faculty of Dentistry, UKM nuru...

Concepts of Prevention in Dentistry Associate Professor Dr Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Department of Family Oral Health Faculty of Dentistry, UKM [email protected] NAY_DEC2 3 1 Lecture outline Definition of prevention in dentistry. Objectives of prevention Levels of prevention Prevention of dental diseases The impact of dental caries on individuals: Disability, handicap, rehabilitation NAY_DEC2 3 2 Prevention in Dentistry Prevention in dentistry refers to the systematic application of measures and strategies to avoid the development, progression, or recurrence of dental diseases and conditions. This proactive approach involves a combination of patient education, lifestyle modifications, routine examinations, and interventions designed to diminish risk factors associated with oral health issues. NAY_DEC2 3 3 Prevention in Dentistry Prevention in dentistry encompasses a broad spectrum of activities, ↳F including promoting optimal oral hygiene practices, advocating for healthy put effect... into dietary choices, and implementing preventive treatments such as fluoride. applications and dental sealants. Prevention in dentistry aligns with the philosophy of preserving natural teeth, reducing the need for extensive dental interventions, and promoting the long-term well-being of individuals. NAY_DEC2 3 4 Goal of prevention The overarching goal is to empower individuals to actively maintain their oral health, identify potential issues early on, and work collaboratively with dental professionals to minimise the impact of dental diseases. NAY_DEC2 3 5 The primary objectives 1. Promoting Optimal Oral Health Encouraging individuals to adopt and maintain proper oral hygiene practices. Educating patients about the importance of a balanced diet and its impact on oral health. Emphasizing the role of lifestyle choices, such as tobacco cessation and limiting alcohol intake, in promoting optimal oral well -being. NAY_DEC2 3 6 The primary objectives 2. Preventing the Onset of Dental Diseases Implementing primary prevention measures to eliminate or reduce risk factors for dental diseases. Advocating for community-based interventions like water fluoridation to strengthen tooth enamel and prevent cavities. Applying dental sealants to protect vulnerable surfaces from decay. NAY_DEC2 3 7 The primary objectives 3. Early Detection of Oral Health Issues checkups Conducting routine dental check-ups and screenings to identify signs of dental diseases at their earliest stages. Utilizing diagnostic tools, including X -rays and visual examinations, to detect hidden or developing issues. NAY_DEC2 3 8 The primary objectives 4. Minimising the Progression of Dental Diseases Implementing secondary prevention strategies to treat and manage dental diseases in their early stages. Providing non-invasive interventions for incipient cavities, such as fluoride treatments or remineralisation agents. Offering periodontal treatments to address early signs of gum disease. NAY_DEC2 3 9 The primary objectives 5. Reducing the Need for Extensive Dental Interventions Emphasizing proactive care to prevent the development of advanced dental diseases. Encouraging adherence to preventive measures to reduce the likelihood of requiring complex restorative or surgical procedures. NAY_DEC2 3 10 The primary objectives 6. Empowering Patients through Education Equipping individuals with knowledge about oral health, preventive practices, and the impact of lifestyle choices. Fostering a sense of responsibility and active participation in one's oral health journey. NAY_DEC2 3 11 The primary objectives 7. Improving Overall Well-Being Recognizing the interconnectedness of oral health with systemic health and well-being. Collaborating with patients to establish a comprehensive preventive dental care plan that aligns with their overall health goals. NAY_DEC2 3 12 Levels of prevention In dentistry, preventive measures are often categorised into three levels to address different stages of disease development and promote overall oral health. These levels are primary prevention, secondary prevention, and tertiary prevention. NAY_DEC2 3 13 Primary Prevention 10 Definition: Primary prevention in dentistry focuses on preventing the onset of dental diseases and promoting general oral health. It aims to eliminate or reduce risk factors before any disease manifests. Examples: Community water fluoridation to strengthen tooth enamel and prevent tooth decay. Promotion of proper oral hygiene practices, such as regular brushing and flossing. Application of dental sealants to protect the chewing surfaces of molars from cavities. Education campaigns encouraging a low -sugar diet to reduce the risk of dental caries. NAY_DEC2 3 14 Secondary Prevention : 2 Definition: Secondary prevention aims to detect and treat dental diseases in their early stages, preventing their progression and minimising potential complications. Examples: Regular dental check-ups and screenings to identify early signs of decay, gum disease, or oral cancer. Diagnostic tools like X-rays to detect hidden cavities or issues between teeth. Early intervention through non-invasive treatments for incipient cavities, such as fluoride therapy or remineralisation agents. NAY_DEC2 3 15 Tertiary Prevention: Definition: Tertiary prevention is focused on managing and preventing the progression of advanced dental diseases and complications. It aims to restore oral health and function after the disease has developed. Examples: Restorative procedures like dental fillings, crowns, or bridges to repair damaged teeth. Periodontal treatments for advanced gum disease, such as scaling and root planning. Prosthodontic interventions like dental implants or dentures to replace missing teeth. Rehabilitation following oral surgery or treatments for oral cancers. NAY_DEC2 3 16  Levels of Prevention Primary number of new cases of a disorder Prevent a disease before it occurs Prevention or illness - - fissure sealant education when - no disease yet - campaign. - scaling if no gum disease the rate of Secondary established cases of 0 Treating/controlling - scaling ~ gum disease if a disorder or illness disease after it Prevention in the population (prevalence) do occurs composite rectoration if get cavity aldy nee screening,(wanna catch disease) * already have disease Limiting a disability the amount of Tertiary disability (stroke) from a disease, or rehabilitating an associated with an Prevention limit disability existing disorder individual with disabilities renabilitate individual -restore function I so pt can eat, talk - denture, crown, bildge Approaches of Prevention I patient ~treating Individual patient ~treating approach /vaccination -vaccination Community approach  Approaches of Prevention II Indicated Identify individuals who are exhibiting early signs of disease and target them with special fissure programs to prevent further sealant. onset of difficulties. I Targeted oral cancer. - Indians-betel chewing Selecting subsets of the total me community / population that are assessed as at risk for disease by virtue of their un membership to a particular population segment. Universal fluoridated drinking water Addresses the entire population with messages and programs aimed at preventing or delaying subset if disease. total population total population Prevention of Dental Diseases Dental Caries NAY_DEC2 3 17  Methods of prevention for caries Which of these are examples of a primary level of prevention? What would be examples of secondary and tertiary levels of prevention? Water Fluoridation Fluoride toothpaste Fluoride mouthwash Host Topical F application Fissure sealant Resistant Reduce carbohydrate intake Diet Plaque Oral hygiene practices Artificial sweeteners (use Dental prophylaxis with caution) control control Patient motivation Control patterns of food consumption NAY_DEC2 3 18 Rehabilitation Rehabilitation in the context of dental caries involves interventions and treatments aimed at restoring oral health and minimising the functional limitations and disadvantages associated with the condition. Rehabilitation strategies may include: 1. Restorative Treatments: Dental fillings, crowns, or other restorative procedures to repair damaged teeth affected by caries. 2. Prosthodontic Interventions: Replacement of missing teeth with dental implants, bridges, or dentures. 3. Periodontal Treatment: Addressing gum disease, a common consequence of advanced dental caries, through scaling, root planning, or other periodontal procedures. 4. Pain Management: Addressing pain associated with dental caries through appropriate pain relief measures. 5. Patient Education: Empowering individuals with knowledge and skills to prevent further decay, maintain oral hygiene, and make lifestyle choices that support oral health. NAY_DEC2 3 19 The impact of dental caries Disability: In dental caries, disability refers to the functional limitations or impairments caused by cavities or other oral health issues. Disabilities may include pain, difficulty chewing, speaking, or maintaining oral hygiene. The severity of the disability can vary depending on the extent and progression of dental caries. NAY_DEC2 3 20 The impact of dental caries Handicap: Handicap refers to the social, economic, or personal disadvantages individuals with dental caries may experience. This can include limitations in daily activities, challenges in social interactions, and potential barriers to education or employment due to oral health issues. The impact of dental caries on one's quality of life and overall well -being contributes to the handicap associated with the condition. NAY_DEC2 3 21 X International Classification of Impairments, Disabilities and Handicaps (ICIDH) Conclusion The prevention concepts in dentistry embody a comprehensive and proactive approach to maintaining optimal oral health. Through primary prevention, efforts are directed at eliminating or minimising risk factors before dental diseases manifest. This involves education, community-based interventions, and lifestyle modifications. Secondary prevention emphasises early detection and intervention to halt the progression of diseases in their initial stages, employing regular check-ups, diagnostic tools, and targeted interventions. Tertiary prevention focuses on managing and preventing the progression of advanced diseases, aiming to restore oral health and function. NAY_DEC2 3 22  Books to read! 1. Murray, J.J., Nunn, J.H., & Steele, J.G. (2003). The prevention of oral disease. 2. Daly, Blánaid, and others. Essential Dental Public Health (Oxford, 2013) 3. Alison Chapman, Simon H. Felton. Basic Guide to Oral Health Education and Promotion, 3rd Edition. NAY_DEC2 3 23  ORAL HYGIENE MEASURES Associate Prof. Dr. Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Faculty of Dentistry, UKM January 2024 1 NAY23 Characteristics of toothbrush Soft-bristled brush Small headed brushes: tapered or rectangular Long handle with non-slip grip What determine the efficacy of plaque removal is The individual’s manual dexterity Thoroughness in cleaning, concentrate on the cervical and interproximal area Brushing method Bass’ Most effective in 1. Direct bristles apically to sulcus at 45° to the Method cleaning cervical 1/3 long axis of the tooth. Use gentle force & beneath gingival removing bristle ends from sulcus. B margins 2. Apply firm but gentle 10 back-and-forth strokes Cleanses sulcus of vibratory motion without removing bristle (space between tooth ends from sulcus. Move brush head to the next and group of teeth by overlapping with the gums-recommended completed area. for periodontal 3. On the lingual surfaces of front teeth, brush is patients) placed vertically and applies gentle vibratory motion of up-and-down strokes.  4. On the chewing surface apply a motion of back-and-forth brushing strokes. Stillman’s Provides gingival 1. Direct bristles apically to sulcus at 45° to Method stimulation vertical axis of tooth. Place bristles partly on the (vibratory motion) cervical part of teeth and partly on the gingiva Suitable for and apply vibratory motion with slight pressure S individuals with to stimulate gingiva. gingival recession (toothbrush bristle 2. Repeat for the lingual surface of the tooth ends not directed into 3. Place toothbrush perpendicular to the tooth sulcus surface and use short back-and-forth strokes on Less traumatic to the occlusal surfaces gently. gingiva Charter’s Efficiently cleans 1. Place bristles at gingival margin, 45° to the Method interproximal areas occlusal plane rather than the roots and pt Useful to clean areas vertical axis of tooth. Direct bristles towards C between fixed vibrate into the interdental spaces, using short appliances and back and forth strokes. gingival margins Suitable for those 2. Repeat for other parts of the mouth. just undergo perio 3. Place toothbrush perpendicular to the tooth surgery surface and use short back-and-forth strokes on the occlusal surfaces gently. al margins Dental Floss For removing interdental plaque & reducing interdental gingival inflammation. Waxed or unwaxed, fluoridated. Requires greater dexterity and motivation than toothbrushing. Parents should floss for children under 8 years old. Not effective for wide interdental spaces, root surfaces or concavities. Incorrect flossing can cause gingival inflammation, trauma, ulceration. Interdental Brush Single tufted brush Toothpaste/ Dentifrices Potassium nitrate > strontium chloride → blk nerve pathway (potassium nitrate) Mouthwash Common mouth rinse : 225ppm Lecture outline toothbrush Dental floss Mechanical Interdental brush Oral hygiene Single tufted brush measures Dentifrices Chemotherapeutic Mouthrinses Chewing gum 2 NAY23  MECHANICAL ORAL HYGIENE MEASURES 3 NAY23 In the beginning…. Ancient people Chinese European history Twigs & woods Hog(pig) bristles A piece of rag cloth Baking soda, chalk embedded in bone handles 1961 1950’s Du Pont 1938 1st electric Softer nylon bristles Nylon bristles (harsh toothbrush & stiff) Broxodent (USA) 4 NAY23  Toothbrush beat out cars and computers as the invention Americans can't live without, according to the Lemelson-MIT Survey. January 2003  While it may seem that cell phones, computers, and other technological gadgets are Americans' most coveted items, teens and adults agree that the toothbrush is the one invention they cannot live without.  The 2003 Lemelson-MIT Invention Index, an annual survey of Americans' perceptions about inventing and innovating, found that technologically advanced items significantly lag in importance behind the toothbrush developed in the 15th century. 5 NAY23  The right toothbrush: what you should look for… 1. Soft-bristled brush 2. Small headed brushes: tapered or rectangular 3. Long handle with non-slip grip …..Whichever is comfortable to use. The BEST… One that fits in your mouth and allows you to reach all teeth easily. 6 NAY23 No one manual toothbrush design appears superior for plaque removal What determine the efficacy of plaque removal is… The individual’s manual dexterity Thoroughness in cleaning, concentrate on the cervical and interproximal area. 7 NAY23  Why do we brush our teeth? To REMOVE PLAQUE or To DELIVER FLUORIDE interfere with its formation (chemotherapeutic agents) to prevent it from from dentifrice to provide becoming pathogenic, at anticaries effect. least 48 hrs interval. 8 NAY23  1 2 5 4 3 Brushing technique 9 NAY23 Techniques of toothbrushing  Modified Bass Technique:  Dentists and dental hygienists widely recommend this technique for its effectiveness in cleaning the teeth and along the gumline.  Modified Stillman Technique:  This technique is another effective method for cleaning teeth and gums, particularly in cases of gum recession or when there is a need for gentle brushing. 10 NAY23 Tooth brushing for children  An adult should perform tooth brushing until the child is about six years old.  Start as soon as the first tooth erupts. 11 NAY23 Toothbrushing in adults  Chronic marginal gingivitis suggests poor toothbrushing compliance or low-performance dexterity.  Improper brushing can damage teeth and surrounding tissues, causing abrasion and gum recession.  It is important to re-educate the toothbrushing technique. 12 NAY23 Toothbrushing in the elderly  Diminished cognition and medical conditions may hinder toothbrushing.  Poor manual dexterity: decreased visual acuity and physical ability  Institutionalized elderly: inadequate brushing by carers.  Need to modify handle or use electric toothbrush by individual or carer. 13 NAY23 Dental Floss  For removing interdental  Parents should floss for plaque & reducing children under 8 years old. interdental gingival  Not effective for wide inflammation. interdental spaces, root  Waxed or unwaxed, surfaces or concavities. fluoridated.  Incorrect flossing can  Requires greater dexterity cause gingival and motivation than inflammation, trauma, toothbrushing. ulceration. 14 NAY23 CARA MEMFLOS 1 GIGI Mulakan dengan sehelai flos gigi sepanjang 18 inci panjangnya. Lilitkan benang flos pada jari tengah pada satu tangan. Lilitkan hujung satu lagi pada jari tengah pada tangan yang sebelah pula. 15 NAY23 CARA MEMFLOS 2 GIGI Untuk membersihkan gigi atas pegang flos diantara ibu jari dan jari telunjuk dan masukkan flos di celah- celah gigi. Lalukan flos mengikut garisan gusi dengan pergerakan atas dan kebawah berulang kali. Ulangi pada setiap gigi. 16 NAY23 Interdental brush  To remove plaque and  In areas such as… accumulated food debris 1. Proximal tooth surfaces from… 2. Wide interdental spaces 1. Areas inaccessible to 3. Exposed root surfaces, toothbrushes concavities and furca in 2. Deliver periodontally involved chemotherapeutic dentitions. agents 4. Between proximal tooth 3. Reduce interdental surfaces and ortho gingivitis brackets. 17 NAY23 18 NAY23 Interdental brush  ….needs… good manual dexterity and visual acuity for effective usage.  Not suitable for children and elderly. 19 NAY23 Single tufted toothbrush  A single-tufted toothbrush is a specialised dental tool designed with a small, isolated cluster of bristles at the tip.  This unique design serves specific purposes and has various applications in oral care. 20 NAY23 Common uses of single-tufted toothbrushes  Orthodontic Care  Post-surgery oral care  Difficult-to-Reach Areas  Special Needs Patients  Wisdom teeth  Children's Oral Care  Implant Care  Travel and On-the-Go  Periodontal Pockets  Post-Operative Care  Interdental Spaces  Post-dental procedures 21 NAY23 22 NAY23 Toothpaste/ dentifrice  Toothpaste is a gel or paste used in conjunction with a toothbrush to clean and maintain the health of teeth. 23 NAY23 The key uses of toothpaste: 1. Removal of Plaque and Bacteria:  Toothpaste contains abrasive particles that aid in removing plaque, a sticky film of bacteria that forms on teeth.  The mechanical action of brushing, combined with toothpaste, helps to eliminate bacteria prevent the formation of dental plaque and contribute to gum health.  This can aid in preventing gum diseases such as gingivitis and periodontitis. 24 NAY23 The key uses of toothpaste: 2. Prevention of Cavities:  Fluoride, a common ingredient in toothpaste, helps prevent tooth decay by strengthening tooth enamel.  It promotes remineralisation, making teeth more resistant to acid attacks from bacteria and acids produced by sugars in the mouth. 25 NAY23 The key uses of toothpaste: 3. Freshening Breath:  Many toothpaste formulations include flavouring agents such as mint to leave a fresh taste in the mouth and combat bad breath.  Additionally, removing bacteria and plaque contributes to improved breath odour. 26 NAY23 The key uses of toothpaste: 4. Reduction of Tooth Sensitivity:  Some toothpaste varieties are formulated with desensitising agents to help reduce tooth sensitivity.  These agents block the microscopic channels (dentinal tubules) that transmit sensations from the tooth surface to the nerves. 27 NAY23 The key uses of toothpaste: 5. Stain Removal:  Abrasive particles in toothpaste assist in removing surface stains from teeth.  This is particularly helpful in countering stains caused by beverages like coffee, tea, or red wine, as well as tobacco use. 28 NAY23 The key uses of toothpaste: 6. Therapeutic effect  The consistency of toothpaste also helps distribute the active ingredients, such as Fluoride, evenly across the teeth.  There are various specialised toothpaste formulations targeting specific oral health concerns, such as tartar control, whitening, and natural or herbal options.  These cater to individual preferences and needs. 29 NAY23 Chemotherapeutic Agents in toothpaste 1. Anti-calculus agents (pyrophosphate) 2. Antibacterials (Triclosan TM and chlorhexidine) 3. Anticaries agents (fluoride) 4. Whitening agents (alumina) 5. Desensitizing agents (strontium chloride) 30 NAY23 31 NAY23 Fluoride content in dentifrices. Children* Risk of dental fluorosis if Adults ingested  Concentration:  Concentration: - - Parts per million 1,000-1,500 ppm F as sodium 600ppm or less fluoride or sodium  Use only a smear of children’s monofluorophosphate toothpaste for young children ( the under-2 )  Use a small quantity of children’s fluoridated toothpaste, i.e. 0.25 to 0.5g or the equivalent of a groundnut-size or strip less than 5mm long* 32 NAY23 Mouthrinses  Adjunct to mechanical plaque control  Does not replace brushing & flossing  Generally, regular brushing and proper flossing is enough  May be prescribed for certain patients  Not suitable for young children 33 NAY23 Mouthrinses CHILDREN ELDERLY  Few benefits.  May replace mechanical  Indicated for those plaque control. wearing orthodontic  Address poor oral hygiene appliances. and periodontal disease.  Not advised for preschool  Prevent root caries. children due to toxicity. 34 NAY23 35 NAY23 36 NAY23 Sugar-Free Chewing Gums  Sugar-free gum as a mechanical salivary stimulant after eating can…  accelerate the clearance of dietary substances and microorganisms,  Promote buffers to neutralise plaque acids,  Provide antibacterial substances.  Promote salivation and require hydration to release chemotherapeutic agents, which can be effective for longer periods than rinses or dentifrices. 37 NAY23 REFERENCES 1. A Choo, D M Delac, L B Messer. Oral hygiene measures and promotion: Review and considerations. Australian Dental Journal 2001; 46 (3): 166-173. 2. Textbook of preventive dentistry. SS Hiremath. Elsevier 2007. 3. Prevention of oral disease. JJ Murray Oxford Press 4th Edition. 38 NAY23  THANK YOU 39 NAY23 FLUORIDE IN DENTISTRY Associate Prof. Dr Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Dept. of Family Oral Health, Faculty of Dentistry, Universiti Kebangsaan Malaysia January 2024  History of fluoride use in dentistry Fluorosis Fluoride & caries LECTURE OUTLINE Physiology & metabolism of fluoride Fluoride toxicity Fluoride & human health  HISTORY OF FLUORIDE Sir James Crichton Browne remark upon the possible connection between fluoride and the incidence of 1892 (UK) caries. Dr F McKay observed ‘mottled enamel’ in patients. 1901 (Colorado Springs, USA) Dr McKay & Dr GV Black associated the mottled enamel and low incidence of caries with high levels of 1930s (USA) fluoride in drinking water – fluorosis (A) Dr. Black in Colorado Springs, 1909. (B, C) Typical photographic representations of “Colorado brown stain” and mild mottled enamel, respectively.  HISTORY OF FLUORIDE H. Trendley Dean showed that fluoride concentration in water affected the severity of mottling. He observed an association 1930-40 (South between mild fluorosis and low caries experience. A near maximum Dakota, USA) reduction (optimum level) occurred when fluoride was 1ppm. Sodium fluoride was added to drinking water in Grand Rapids, MI 1945 (Michigan, and resulted in a 50%  in caries incidence. USA) Kilmarnock, Watford, and part of Anglesey had 1ppm Fl in water. After five years, 50%  in caries. After Kilmarnock halted 1955 (UK) fluoridation, caries rose steadily to previous levels.  POLITIC AL PROGRESS OF FLUORIDATION IN THE UK 12% population fluoridated 1970s Court case in Scotland 1980s Water (fluoridation) bill 1985 Judicial Review finds legislation inadequate 1998 York Center for Reviews –review of efficacy and safety of 2000 fluoridation  WATER FLUORIDATION IN MALAYSIA (1957) Tebran , G Pulai Johor. Water fluoridation was first introduced in Malaysia in 1957 in the Tebrau & Gunung Pulai Water Treatment Plant in Johor. This plant served the Johor Bahru District. Fluoridation of public water supplies in other towns commenced in 1965. Meanwhile, in Sarawak, water fluoridation was first introduced in the Simanggang water treatment plant in November 1961 at Simanggang (Sri Aman). It was later expanded to Serian in Mac 1962. 15 water treatment plants were involved in water fluoridation in 1976.  WATER FLUORIDATION IN MALAYSIA In 1969, The Committee on Fluoridation of Public Water Supplies in West Malaysia was appointed by the Honourable Minister of Health Malaysia to study and report on the feasibility of introducing the fluoridation of public water supplies as a public health measure in all states in West Malaysia. Based on this recommendation, in 1972, the Cabinet of the Federal Government approved the addition of fluoride to the public water supplies as a primary prevention measure to prevent dental caries. Following this, the nationwide water fluoridation programme has been implemented incrementally since 1974.  WATER FLUORIDATION IN MALAYSIA In early implementation, the recommended optimum level was 0.7 ppm based on the volume of water intake in our climate. However, the level was reviewed by OHP in 2005 to 0.5 ppm after considering the findings from the study on Fluoride Exposure and Fluorosis among Schoolchildren in Malaysia. This is mainly due to the consumption of alternative sources of fluoride in the population. The recommended accepted optimum level of fluoride lies between 0.4 to 0.6 ppm due to difficulty obtaining the exact reading of 0.5 ppm.  In 2010, about 95% of the population received a piped water supply. Most states had a good coverage of 98% to 100% except Sarawak (93.3%), Sabah (79.0%) and Kelantan (57.0%). In 2022, 76.8% of the population benefitted from fluoridated public water supplies.  In most states, more than 90% of the population received fluoridated water except for Pahang, Sabah, Kelantan and Sarawak. In Sarawak, about 61.1% of the population received fluoridated water in 2022. Approximately 13.6% of the population in Kelantan received fluoridated water. While in Sabah and Pahang, the percentages were 4.9% and 0.0%, respectively. The cessation of water fluoridation programmes in Sabah, Kelantan and Terengganu occurred in 1988, 1995 and 2000, respectively. With the efforts of OHP and OHD, the programmes were reinstituted in 1996 in Sabah, 2006 in Kelantan and 2008 in Terengganu. However, in 2010, the Sabah State Cabinet agreed on the expansion of water fluoridation, as the coverage in 2009 was only 4.5%.  DENTAL FLUOROSIS A developmental disturbance of dental enamel caused by excessive exposure to high concentrations of fluoride during tooth development. Thin, white opaque lines Snowcapping of incisal Cloudy areas of opacity edges and cusp tips Chalky white appearance Opacity with small pits Pits merged to form bands Loss of enamel: irregular Loss of enamel > ½ Anatomical changes  DENTAL FLUOROSIS The risk of developing fluorosis is strongly correlated to the regular intake of fluoride during tooth mineralization and particularly during the maturation phase of the enamel Chronological pattern corresponding to time & duration of exposure Dose dependent  FLUORIDE & C ARIES ’ Fluoride  caries ’ Pre-eruptive mechanism ’ Post-eruptive mechanism  FLUORIDE & C ARIES Pre-eruptive Mechanism Post-eruptive Mechanism* Fluoride is ingested and incorporated Fluoride acts directly on the tooth into the enamel during mineralization surface: of the developing tooth, favouring the Forms fluoroapatite, which is less soluble crystallization of larger and more than hydroxyapatite regular fluoroapatite crystals, which Inhibits demineralization by lowering the are less susceptible to acid dissolution critical pH for dissolution of tooth enamel Enhances remineralization by lowering of the energy needed for reformation of * Post-eruptive mechanism is calcium fluoride the primary mode of caries Inhibits acid formation by prevention microorganisms involved in caries formation Interferes with growth and metabolism of these microorganisms at higher fluoride concentrations PHYSIOLOGY & METABOLISM OF F Absorption Excretion Storage GIT Rapid, through kidney Has an affinity for the Lungs (inhalation of Also lost through calcified tissue i.e. fluoride gas & dust) sweat, feces bone and developing Absorbed fluoride Traces can be found in teeth begins to leave the milk, hair, saliva, tears Storage is dynamic blood within minutes Bone: 800-10,000ppm Outer enamel: 400- 3000ppm  FLUORIDE TOXICITY Probable Toxic Dose (PTD) The minimum dose that can cause toxic signs & symptoms; including death Require immediate intervention & hospitalization PTD = 5 mg F for each kg body weight FLUORIDE TOXICITY A one-year-old child weighs 10kg. PTD = 5mg F x 10kg This is equivalent to the ingestion of: 50 one-mg F tablets 50 g of 1000ppm F toothpaste 50ml of 0.2% NaF rinse 50ml of 0.4% SnF2 rinse 85 gallons of 1ppm water  FLUORIDE TOXICITY Diffuse  Plasma To induce Signs Treatment Symptoms abdominal calcium vomiting pain  Plasma ASAP e.g. Diarrhea & potassium emetic vomiting  Pulse To bind Excessive rate fluoride e.g. salivation  BP consuming Perspiration milk, gastric lavage with Painful calcium/ spasms of activated the limbs, charcoal convulsions Headache  LONG-TERM EFFECTS: YORK REVIEW(2000) Studies Conclusion included 29 studies No association was found between fluoridated water and bone fractures or bone development problems 26 studies No association was found between water fluoridation and bone, thyroid and all other cancers 32 studies No clear evidence on the association of water fluoridation with various different outcomes, including Down’s Syndrome, Mortality, Senile Dementia, Goitre & IQ.  FLUORIDE Systemic Topical Use Use Water Toothpaste Milk Mouthrinse Salt Floss, tape, toothpicks Tablets Gel Chewing gum Prophylaxis paste Varnish  REFERENCES Duffin S, Duffin M, Grootveld M. Revisiting Fluoride in the Twenty-First Century: Safety and Efficacy Considerations. Front Oral Health. 2022 Jul 4;3:873157. doi: 10.3389/froh.2022.873157. PMID: 35860375; PMCID: PMC9289262. Karim, F. A., Yusof, Z. Y. M., & Nor, N. A. M. (2020).Water Fluoridation And Oral Health In Malaysia: A Review Of Literature: Received 2020-02-22; Accepted 2020-09-15; Published 2020-12-14. Journal of Health and Translational Medicine (JUMMEC), 23(2), 76-91. Murray, J. J., Nunn, J. H., & Steele, J. G. (Eds.). (2003).The prevention of oral disease. Oxford University Press, USA. (Chapter 3) Systemic Use of Fluoride Associate Prof. Dr. Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Dept. of Fam ily Oral Health, Faculty of Dentistry, UKM January 2024 Lecture Outline Community Water Fluoridation (CWF) Milk Fluoridation Salt Fluoridation Fluoride Supplements Fluoride Systemic Use Water Milk Salt Supplements Community Water Fluoridation (CWF) Water Fluoridation Basics The mineral fluoride occurs naturally on earth and is released from rocks into the soil, water, and air. All water contains some fluoride. Usually, the fluoride level in water is not enough to prevent tooth decay; however, some groundwater and natural springs can have naturally high fluoride levels. Community water fluoridation CWF is adjusting the amount of fluoride in drinking water to a level recommended for preventing tooth decay. The artificial and controlled addition of a fluoride compound to a public water supply to adjust its fluoride concentration to an optimal level for preventing dental caries. CWF has been identified as the most cost-effective method of delivering fluoride, reducing tooth decay by 25% in children and adults. Exposure to fluoride in PWS appears highly protective against dental caries and reduces oral health inequalities. Community water fluoridation Benefits: Strong Teeth For children younger than 8, fluoride helps strengthen the adult (permanent) teeth that are developing under the gums. For adults, drinking water with fluoride supports tooth enamel, keeping teeth strong and healthy. The health benefits of fluoride include having: ❖Fewer cavities. ❖Less severe cavities. ❖Less need for fillings and removing teeth. ❖Less pain and suffering because of tooth decay. Cost Savings of Community Water Fluoridation Economic evaluations reaffirm the cost benefits of community water fluoridation. Studies show that widespread community water fluoridation prevents cavities and saves money for families and the health care system. An economic review of multiple studies found that savings for communities ranged from $1.10 to $135 for every $1 invested. Per capita annual costs for community water fluoridation ranged from $0.11 to $24.38, while per capita annual benefits ranged from $5.49 to $93.19.2 A 2016 economic analysis found that for communities of 1,000 or more people, the savings associated with water fluoridation exceeded estimated program costs, with an average annual savings of $20 per dollar invested.3 Additionally, individuals in communities that fluoridate water save an average of $32 per person by avoiding treatment for dental caries. Nationwide, this same study found that community water fluoridation programs have been estimated to provide nearly 6.5 billion dollars a year in net cost savings by averting direct dental treatment costs (tooth restorations and extractions) and indirect costs (losses of productivity and follow-up treatment). Findings indicated that CWF represents an appropriate use of communities’ resources (Mariño and Zaror, 2020). Water Fluoridation Oremove debris both floating on - water suf I submerged in water  Fluoride Used ① Sodium fluoride (NaF) ② Fluorosilicic C - - acid (H2SiF6) · Sodium fluorosilicate (Na2SiF6) C-- ❖ Choice depends on availability, material and shipping cost, solubility, safety, corrosiveness and stability in water. Statement on the Evidence Supporting the Safety and Effectiveness of Community Water Fluoridation by Centers for Disease Control and Prevention (CDC) An effective intervention A cost-saving intervention A safe intervention ‘Halo effect’ Persons in non-fluoridated areas also receive fluoride through beverages and foods processed in fluoridated areas –diminished difference in caries observed between fluoridated and non- fluoridated communities in recent years However, there is still a noticeable difference in dental caries between fluoridated and non-fluoridated communities. – Kumar JV. Is water fluoridation still necessary? Adv Dent Res 20:8-12, July 2008 Multisectoral Collaboration World Health Jabatan Bekalan Ministry of Health State government Organization Air Kementerian Environmental & Syarikat Bekalan Tenaga, Teknologi Local community Occupational Air Hijau dan Air Scientists Engineering Researchers To determ ine the optim um To ensure sustained level delivery To im prove access To m onitor safety Controversy of Water Fluoridation For Against 1 We should have freedom of choice It is unethical, as it is m ass m edication 2 Relatively inexpensive Mainly only benefits children 3 It is the safest way of adm inistering Fluoride is also used as a poison fluoride 4 It is the m ost effective way of reducing There are other m ethods of reducing caries incidence caries incidence 5 It works system ically & topically System ic: natural foodstuffs Topical: topical 6 It  the necessity of extractions under Its toxicity can lead to stom ach upsets, GA, therefore  m ortality rate m ental & physical disability & cat deaths 7 It is particularly beneficial in  caries Can cause fluorosis – im possible to in children of low SES regulate how m uch fluoride children consum e 8 Knox Report & York Review said that Som e experts have argued that it can fluoridated water does not cause cause cancer of the thyroid & bones cancer Milk fluoridation Milk Fluoridation According to O’Mullane et al. (2016), the concept of milk as a vehicle for fluoride emerged in the early 1950s and was first investigated almost simultaneously in Switzerland, the US, and Japan (18). Proposed in 1953 by Dr Ziegler in Switzerland; The first community scheme commenced in 1958 in Switzerland. Since 1986, programs aiming to validate the feasibility of community use of fluoridated milk for caries prevention were promoted and supported by the WHO International Programme for Milk Fluoridation. At present, milk fluoridation programmes, supported by the WHO and Food and Agriculture Organization, are running continuously in about 15 countries. Various channels provide fluoridated milk to children attending kindergarten and school. Milk Fluoridation: Uses and Application Fluoride form s a soluble com plex with the protein fraction of m ilk and is bioavailable after ingestion. Com munity-based m ilk fluoridation program s have been im plemented in several countries, including Bulgaria, Chile, China, Peru, the Thailand UK Russian Federation and Thailand. Fluoride is added to fresh, UHT or powdered m ilk in com munity schem es. One glass of m ilk supplem ented with fluoride is served to preschool and/or school children once daily on school days. China Chile Milk Fluoridation: Uses and Application In general, milk fluoridation is effective in preventing dental caries. To protect and reduce caries in primary teeth, it was recommended that children consume fluoridated milk early on, preferably before the age of 4 years, and at the eruption of their first permanent molars. Milk fluoridation is the addition of fluoride to milk and milk- based products at levels of 2.5 to 5 mg/L. Children are advised to drink around 200 mL of fluoridated milk daily for about 200 days per year. Milk Fluoridation: Effectiveness, Efficacy & Safety Worldwide cohort studies have consistently reported substantial caries reduction, particularly in primary dentition, with a prevented fraction equivalent to 31%. In a review on safety, milk fluoridation was reported to be safe, and the occurrence of mild fluorosis was low. No other adverse effects have been reported, but some children may not tolerate the lactose content of milk. Milk Fluoridation: Cost effectiveness The cost of milk fluoridation programmes is low, with significant savings per averted caries lesion after four years. Costs vary depending on region, availability of product and distribution. Recommendation: – Fluoridated milk is a community-based alternative for children living in countries with limited access to community dental care and/or where water fluoride is not feasible. Milk Fluoridation: Limitations Absorption < water F Lactose intolerance Varying pattern of milk consumption Logistic costs & problems of handling & delivery Inequality in distribution Salt fluoridation Salt Fluoridation: History The addition of fluoride to salt to prevent dental caries began in Switzerland in the mid- 1950s and has expanded to around 50 countries worldwide. The European Union has approved adding potassium fluoride and sodium fluoride to salt for caries prevention, and salt fluoridation programmes are currently available across Europe and South and Central America.  Salt Fluoridation: Use and Application This community-based measure is available for the consumer as table salt for domestic use and also for use in commercial food production. The addition of fluoride to certain brands of salt gives the consumer the choice to supplement their diet or use alternative products. The fluoride content is normally 200-250 ppm F. Children less than three years old have a low intake of salt and are unlikely to benefit from salt fluoridation. Salt Fluoridation: Effectiveness, Efficacy and Safety Although substantial caries reductions (50% or more) in schoolchildren from Latin America have been reported, systematic reviews have graded the confidence in the evidence as very low. It is commonly reported that the effectiveness of salt fluoridation equals that of water fluoridation amongst those who use it. Salt fluoridation is considered safe, with a minimal risk of harm and virtually no increase in the prevalence of enamel fluorosis. The combination of salt fluoridation and water fluoridation is not recommended. Salt fluoridation: Cost-effectiveness Salt fluoridation, like other community fluorides, is cost-effective in school schemes. A cost-effectiveness analysis of seven dental caries prevention programmes among schoolchildren in Chile concluded that salt fluoridation was the most cost-effective when measured as dental caries averted over six years compared to no intervention. Recommendation: – Salt fluoridation offers a freedom–of choice and could be considered an inexpensive and practical alternative where water fluoridation is not socially accepted or feasible. Fluoride supplements Fluoride Supplements: Overview When daily tooth brushing with fluoridated toothpaste is not carried out, or when the caries risk is increased, additional supplemental sources of fluoride may be recommended. Fluoride supplements may come in drops, lozenges, tablets or chewing gums. Most products contain sodium fluoride and are flavoured (mint or fruit) and sweetened by “tooth-friendly” xylitol or sorbitol. The mechanism of action is local rather than systemic. The guidelines for fluoride supplements vary across the world. Fluoride Supplements Tablets Chew or dissolve it in the mouth before swallowing so that the teeth will also absorb the fluoride Drops/Liquid Measure the dose carefully using the specially marked medicine dropper provided and swallow directly Lozenges Place the lozenge in mouth and allow it to dissolve Fluoride Supplements: Dosage Fluoride supplements should be used as prescribed by the dentist. The most common prescription for children is 1-2 tablets or lozenges daily containing 0.25 mg NaF. For adults, lozenges up to 0.75 mg NaF are available. The prescription is determined by age and by the level of fluoride in the local drinking water. Fluoride Supplements: Effectiveness, Efficacy & Safety Evidence of the effectiveness of fluoride supplements is inconsistent, and confidence in the evidence available is very low. Practitioners are encouraged to conduct a caries risk assessment before prescribing fluoride supplements. When fluoride supplements are prescribed, they should be taken daily to maximise the caries prevention benefit. The use of fluoride supplements in infants is controversial due to the risk of dental fluorosis and the total fluoride exposure from other sources must be considered. Fluoride supplements must be stored out of reach of small children. For patients aged three years and above, fluoride supplements are safe across the life course. Fluoride Supplements: Cost-effectiveness There is a lack of contemporary studies concerning the cost-effectiveness of fluoride supplements, and no current comparisons with other self-applied fluorides are available. Poor compliance with fluoride supplements is a serious drawback to their cost- effectiveness. Recommendation: – Fluoride supplements are a preventive option for subjects with increased caries risk. In particular, elderly patients with impaired saliva functions may benefit from fluoride lozenges and chewing gums, which stimulate saliva secretion. – Fluoride supplements are generally no longer a first-choice treatment option in population-based programs. Malaysian Dental Council (MDC) Does not recommend the use of fluoride supplements, salt fluoridation or milk fluoridation There should only be one form of artificially adjusted systemic source of fluorides, which already exists in the form of water fluoridation. Conclusion Systemic fluoridation has proven to be a valuable public health intervention, effectively reducing dental caries in communities. Despite ongoing debates, its demonstrated benefits in promoting oral health underscore its importance as a preventive measure. Continued research and public awareness will contribute to informed decisions on its implementation. Topical Fluorides Associate Prof. Dr. Nurul Asyikin Yahya BDS, MSc, DDPHRCS, PhD Dept. of Family Oral Health, Faculty of Dentistry, UKM January 2024 Lecture Outline Pre- and post-eruptive mechanism of F F Toothpaste High F Toothpaste F Mouth rinse Professionally applied F gel and varnish Post-eruptive Mode of action of fluoride for caries control: Under a cariogenic challenge (left), the layer of phosphate covering calcium fluoride deposits dissolves, allowing the release of calcium and fluoride. The fluoride released from calcium fluoride adds to the pool of fluoride present in the enamel fluid, which adsorbs to the hydroxyapatite crystals. When these crystals are completely covered by adsorbed fluoride, their surfaces become similar to fluorapatite and are not dissolved by bacterial- derived acids; demineralisation is inhibited. However, the uncoated surfaces are dissolved when the hydroxyapatite crystals are only partially covered by adsorbed fluoride. After the acidic challenge (right), the salivary buffers gradually increase the pH. At pH >5.5, remineralisation will naturally occur, since saliva is supersaturated concerning the dental mineral. In the presence of low fluoride levels, the fluids become supersaturated for fluorhydroxyapatite, which allows the precipitation of fluoridated apatite over the partially dissolved crystals. This newly formed mineral is more resistant to future acidic challenges. Fluoride Ion Reactivity With Apatite By Chemical Equation Occurs when Form Iso-ionic exchange Ca10 (PO4)6OH2 + 2 Long-term exposure Firmly-bound of F– for OH– in F–  Ca10(PO4)6F2 + to low fluoride fluoride apatite 2 OH– levels in the solution (0.01 -10 Crystal growth of 10 Ca2+ + 6 PO43– + 2 ppm F) from either fluorapatite from F–  Ca10(PO4)6F2 systemic or latent super-saturated topical sources solutions (waterF) Pre- & Post- eruptive Apatite dissolution Ca10 (PO4)6 OH2 + 20 High fluoride Loosely-bound with CaF2 formation F–  10 CaF2 +6 concentration fluoride (calcium- PO43– + 2 OH– (100–10,000 ppm fluoride formation) F), eg. professional gels , varnishes or OTC toothpastes & mouthrinses Post-eruptive F Toothpaste Fluoride toothpaste: overview Fluoride toothpaste (dentifrice) is purchased over the counter. The standard toothpaste contains 1,000-1,500 ppm F. Low fluoride options are available for young children. Dental professionals may recommend using high-fluoride toothpaste (over 1,500 ppm F). Fluoride toothpaste helps to prevent dental caries by interacting with tooth structures and the oral biofilm. Fluoride toothpaste: use & application Twice daily, apply approximately 1cm of the paste to the head of a toothbrush and brush the teeth for 2 minutes. Spit out and do not rinse, or rinse with a minimal amount of water. Children under the age of 6 should use an amount equal to the size of their little fingernail, and children under two years are recommended a smear layer (or grain of rice). Fluoride toothpaste: Effectiveness, Efficacy & Safety Strong evidence suggests that daily fluoride toothpaste is fundamental for effective caries prevention in all age groups and in all populations. The prevented fraction in permanent teeth is 24% compared with placebo. Toothpaste formulas containing less than 1,000 ppm F are less effective across the life course. Fluoride toothpaste is safe when used according to recommendations. Ingestion of fluoride during the first three years of life may increase the risk of dental fluorosis. The amount of toothpaste used by toddlers and preschool children should be carefully monitored. Personalized fluoride regimens should be based on a risk analysis and a review of the patient’s current exposure. Fluoride toothpaste: Cost-effectiveness & Recommendation Being a self-applied preventive measure, the cost-effectiveness of fluoride toothpaste is outstanding. It is important that fluoride toothpastes are made available and affordable for customers worldwide. Twice a day brushing with fluoride toothpaste has been shown to reduce caries in all age groups. Its use should be strongly advocated and encouraged with individual instructions. Prescription Home Care High F Toothpaste High fluoride toothpaste (HFT) High fluoride toothpaste (HFT) refers to toothpaste containing fluoride concentrations above 1,500 ppm F, typically containing 2,800 up to 5,000 ppm F. The availability of ‘over the counter’ HFT products, such as Duraphat 5,000 ppm toothpaste, varies from country to country. HFT is used in the same manner as regular toothpaste. Apply 1 cm of paste onto the head of a toothbrush and brush the teeth for 1-2 minutes, ideally twice daily. Spit out and do not rinse, or rinse with a minimal amount of water. HFT: Effectiveness, Efficacy & Safety The anticaries effect of HFT has been estimated in clinical trials and summarised in systematic reviews [1,2,3]. A positive dose-response benefit has been observed, and HFT is superior to low-fluoride toothpaste in reducing caries. The anticaries effect of HFT (5,000 ppm F) to arrest root caries lesions is very positive, with 51% more lesions becoming inactive than conventional toothpaste. HFT toothpaste should be kept out of reach by children and is usually not recommended for use by children under the age of 16 years. Otherwise, HFT is safe when used according to instructions. HFT: Cost-effectiveness & Recommendation HFT costs more than standard ‘over the counter’ toothpaste. As a self-applied preventive measure, the cost is favourable compared with professional fluoride alternatives. Further health-economic evaluations are required to establish the costs for high-risk groups. HFT is particularly recommended for preventing and controlling caries in high-risk individuals and patients with active disease. Typical cases are patients with impaired saliva functions, frail elderly with exposed root surfaces and cancer patients who have been treated with head and neck radiation.  Toothpaste Active Components Sodium fluoride Sodium Monofluoro-phosphate Stannous Fluoride Amine Fluoride Formula NaF Na2FPO3 SnF2 C27H60F2N2O3 Concentration 1000, 1100 or 1000 ppm total F , mostly as 1000 - 1500 ppm F, 1000 - 1450 ppm F, 1450 ppm free FPO32- ion that does not enhance mostly mostly fluoride ion F- reminera-lizatio, but hydrolyzes free fluoride ion F- free fluoride ion F- rapidly in dental plaque to form free F- ion which then acts Stannous ion antibacterial. Anti- gingivitis activity Must have a compatible abrasive P P P that does not bind the fluoride e.g. hydrated silica All other components must not P P P interfere with fluoride topical actions Must be stable with time and P P P P temperature F Mouth rinse Fluoride Mouth Rinse (FMR) Fluoride mouth rinses (FMR) are neutral water solutions containing between 0.05% (230 ppm) and 0.2% (900 ppm) sodium fluoride, with or without flavour. They are traditionally applied in school-based programmes but are currently recommended by dental professionals for home use. The fluoride ions interact with the tooth structures and the oral biofilm to prevent caries. FMR: Use & Application 10 mL of the solution is “swished” around the teeth for 1 minute 1-2 times daily. The solution should be spat out and not swallowed. Avoid eating and brushing your teeth for 60 minutes. The lower concentration (0.05%) is intended for children between 6 and 12 years, the higher (0.2%) for caries-active subjects above 12 years. Children under age 6 should not use fluoride mouth rinses as they cannot spit out effectively. FMR: Effectiveness, Efficacy & Safety In supervised fluoride mouth rinsing programs among children and adolescents, the caries preventive effect is 27% compared to placebo. Some clinical trials have shown that the caries preventive effect of FMR equals that of professional fluoride applications. Fluoride mouth rinses seem better than placebo in arresting root caries in dry mouth elderly. Fluoride mouth rinses are safe to use. FMR: Cost-effectiveness & Recommendation The cost-effectiveness of FMR, particularly in supervised school settings, is specifically favourable in communities with low fluoride exposure and low socio-economic status. The cost-effectiveness compared with other preventive strategies for children is sparsely investigated. FMR is a home-use option for high-risk and caries-active subjects over six years of age. In particular, daily rinses are suitable for patients undergoing orthodontic treatment, compliant dry mouth patients and those with irregular, non-daily tooth brushing with fluoride toothpaste. Various F concentration of Mouth rinses Plax PreviDent/ Phos-Flur Duraphat Content NaF 0.05% w/w NaF 0.2% w/v APF 0.044% w/v Ppm F ion 225 900 200 School-based Fluoride Rinse Programme In the non-fluoridated area, 10ml fluoride mouth rinses containing 0.2% sodium fluoride are prescribed for weekly school fluoride rinsing programs. Professionally-Applied Topical Fluoride Professionally-Applied Topical Fluoride Concentrated forms of topical fluorides such as fluoride varnishes, gels or foams should only be applied by dental professionals or the appropriate allied operating personnel. Fluoride varnishes, gels or foams should be limited to individuals professionally assessed as being at risk for dental caries.  Fluoride Gel Sodium fluoride , NaF Stannous Fluoride, APF SnF2 Percent 2% 8% 1.23% ppm 9,200 19,500 12,300 Stability Stable Unstable Stable in plastic container pH 7.0 2.4-2.8 3.5 Limitations: Bitter, metallic taste, Increased uptake. C/I Gagging reversible gingival for patients with fixed Ingestion irritation, staining of prosthesis Not suitable for teeth young children Fluoride Varnish Fluoride varnish (FV) is a resin-based product that contains 2.26% fluoride (22,600 ppm F) from 5% sodium fluoride (NaF) in an alcoholic solution of natural tree resin. The FV adheres strongly to teeth, allowing prolonged fluoride contact and interaction with the hard tissues of teeth over time. Fluoride is slowly released, helps prevent mineral loss from teeth, and enhances remineralization to reverse or slow the progression of early carious lesions. Fluoride Varnish: Use & Application FV treatments are carried out by a dental professional after thorough cleaning and drying. The varnish is topically applied with a small brush, probe or applicator in a thin layer on high-risk tooth surfaces, such as occlusal fissures, between teeth (proximal surfaces) or exposed root surfaces. FV can also be applied directly on early caries lesions to arrest or re-mineralize the surface. The varnish should dry and set for one minute. Patients should be instructed to avoid eating, drinking, and cleaning their teeth for a few hours after application. Moderate-risk patients should receive FV at 6-month intervals, whereas high-risk groups should get FV applied at 3-month intervals. FV: Effectiveness, efficacy & safety A Cochrane systematic review has shown that FV provides caries protection at 43% in young permanent teeth and 37% in primary teeth. There is evidence showing that FV is effective for arresting or reversing non-cavitated lesions and may reverse root caries in the elderly. FV is the only high-fluoride product suitable for children under six years old. The average amount of FV used in one application for a child is around 0.3-0.5 mL, which will deliver around 6.8-11.3 mg F in the oral cavity. This dose is far below the probably toxic dose. FV: Cost-effectiveness & Recommendation The cost of FV varies widely between providers and suppliers. The costs for FV programs have been reported to be lower than fissure sealant programs. FV applied in the clinical setting is unlikely to be cost-effective in low-risk populations but more favourable in medium and high-risk patients. The WHO and many professional organisations worldwide endorse FV for prevention and non-restorative management of caries lesions. Target populations are communities with low socio-economy and low health literacy, high- risk individuals and patients with active caries disease. The current recommendations suggest that FV should be topically applied by dental professionals 2-4 times per year. The use of FV is safe and suitable for all age groups. References 1. Walsh T, Worthington HV, Glenny AM, Marinho VCC, Jeroncic A. Fluoride toothpaste of different concentrations for preventing dental caries. Cochrane Database of Systematic Reviews 2019, Issue 3. Art. No.: CD007868. 2. Marinho, V.C., Cochrane reviews of randomised trials of fluoride therapies for preventing dental caries. Eur Arch Paediatr Dent 2009; 10(3):183-191. 3. Pretty IA. High Fluoride Concentration Toothpastes for Children and Adolescents. Caries Res. 2016;50 Suppl 1:9-14. 4. Singh A, Purohit BM. Caries Preventive Effects of High-fluoride vs Standard-fluoride Toothpastes – A Systematic Review and Meta-analysis. Oral Health Prev Dent. 2018;16(4):307-314. 5. Wierichs RJ, Meyer-Lueckel H. Systematic review on non-invasive treatment of root caries lesions. J Dent Res. 2015 Feb;94(2):261-71. 6. Marinho VC, Worthington HV, Walsh T, Clarkson JE. Fluoride varnishes for preventing dental caries in children and adolescents. Cochrane Database Syst Rev. 2013 Jul 11;(7):CD002279. 7. O’Mullane DM, Baez RJ, Jones S, Lennon MA, Petersen PE, Rugg-Gunn AJ, Whelton H, Whitford GM. Fluoride and Oral Health. Community Dent Health. 2016;33:69-99. Thank you  Principles of Minimal Intervention Dentistry Associate Prof. Dr Nurul Asyikin Yahya Dept of Family Oral Health, Faculty of Dentistry, UKM January 2024 Slides courtesy of Dr Amy Liew Lecture Outline Definition Minimally Invasive Dentistry Vs. Minimal Intervention Dentistry FDI Principles of Minimal Intervention Dentistry Special Techniques Minimal Intervention Dentistry A response to the traditional, surgical manner of managing dental caries, that is based on the operative concepts of G.V. Black of more than a century ago. A philosophy that attempts to ensure that teeth are kept functional for life. This term, therefore, is not restricted to the management of dental caries but is also applicable to other areas of oral health; such as periodontology, oral rehabilitation and oral surgery. Frencken JE, Peters MC, Manton DJ, Leal SC, Gordan VV, Eden E. Minimal Intervention Dentistry (MID) for managing dental caries - a review. Int Dent J. 2012 Oct;62(5):223–43.  Minimal Intervention Dentistry A concept that is based on all the factors that affect the onset Minimal and progression of disease, therefore integrates concepts of Invasive prevention, control and treatment. Dentistry A concept that is aimed at conserving the maximum amount of dental tissue.  Minimal Intervention Dentistry Minimal Invasive Dentistry Featherstone JDB, Doméjean S. Minimal intervention dentistry: part 1. From ‘compulsive’ restorative dentistry to rational therapeutic strategies. BDJ 2012:9;442. MID for Managing Caries Early caries Remineralisation Optimal caries detection and of enamel and preventive caries risk dentine carious measures assessment lesions Minimally invasive operative Repair rather than approaches for replace defective Frencken JE, Peters MC, managing restoration Manton DJ, Leal SC, Gordan VV, Eden E. Minimal cavitated dentine intervention dentistry for managing dental caries – a carious lesions review. Int Dent J. 2012 Oct 1;62(5):223–43. Early caries detection and caries risk assessment Caries Risk Assessment  Fluoride exposure  Sugary foods or drinks  Caries experience of mother/ caregiver/ siblings  Dental home  Special Health Care Needs  Chemo/radiation therapy  Eating disorders  Medications ↓ saliva  Drug/alcohol abuse  Cavitated/non-cavitated lesions/restorations within 36mth  Teeth missing d/t caries  Visible plaque  Unusual tooth morphology  Root caries  Overhang/deficient margin  Dental/ortho appliance  Xerostomia American Dental Association, 2009, 2011. Diagnostic Aids  Radiographs  Optical aids (loupe, microscope)  Fiberoptic transillumination (FOTI)  Intraoral cameras  Fluorescence systems  Infrared laser (DIAGNOdent®)  Quantitative light fluorescence  LED cameras Caries Detection Probing Does not improve the diagnostic sensitivity of visual examination, especially in detecting pits and fissure lesions. It is not reliable, depending on the size of the probe tip, the resistance of the enamel, and the force exerted by the probe. Iatrogenic damage to enamel, loss of the possibility of remineralization, favour lesion progression. Guerrieri A, Gaucher C, Bonte E, Lasfargues JJ. Minimal intervention dentistry: part 4. Detection and diagnosis of initial caries lesions. Br Dent J. 2012 Dec;213(11):551–7. ICDAS ICDAS Remineralisation of enamel and dentine carious lesions Remineralisation of enamel and dentine carious lesions Plaque Control Fluoride (self-care) Fluoride (professional care)  Optimal caries preventive measures  Diet Counseling Fluoride agents Non-Fluoride agents Community-based methods Sugar Substitutes -Water fluoridation - Xylitol - Salt fluoridation - Sorbitol - Milk fluoridation? Chlorhexidine? Professional-based methods - Fluoride gels & varnish Pit and fissure sealants Individual methods - Toothpaste & mouthwash Non-fluoride agents Chlorhexidine Evidence regarding chlorhexidine gel and varnish for carious control is inconclusive, and there is a lack of evidence that chlorhexidine rinses are useful as a preventive measure against dental caries. Sugar Substitutes Xylitol and sorbitol are the most frequently used sugar substitutes. The use of sugar-free dental chewing gum had proved to be effective for carious lesion control on school premises. Non-cavitated lesions of enamel and dentine Holmgren C, Gaucher C, Decerle N, Doméjean S. Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions – non-invasive approaches through remineralisation and therapeutic sealants. Br Dent J. 2014 Mar 7;216(5):237–43. Fissure Sealant Fissure Sealant “Even when a minimal invasive approach such as air-abrasion or micro-preparation is used, it condemns the tooth irreversibly to a repeat restoration cycle, since no restoration can be considered permanent and will ultimately need to be replaced.” Elderton R J. Clinical studies concerning re-restoration of teeth. Adv Dent Res 1990; 4: 4–9. Fissure Sealant Routine mechanical enamel preparation before acid etching is NOT recommended (B). NOT for teeth with evidence of a shadow indicating dentinal caries or radiographic evidence of occlusal or proximal signs of dentinal caries ADA Evidence-based Sealant Chairside Guide Minimally invasive operative approaches for managing cavitated dentine carious lesions Cavity design Extension for Prevention Extension for prevention Minimal Invasive Dentistry Conservation of tooth structure. Each prepared cavity is therefore unique and is primarily dependent on the extent of infected dentine rather than on a predetermined cavity design. Minimally Invasive Approaches Cutting & caries excavation Adhesive Special restorative Techniques materials  Affected dentine Infected dentine Few bacteria Bacterial invasion Remineralizable Unremineralizable Vital Dead Sensitive Without sensation Useful Not useful Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART)--a minimum intervention and minimally invasive approach for the management of dental caries. Br Dent J. 2013 Jan;214(1):11 –8.  How much dentine should be removed? Extent of viable Pulp status Lesion depth tooth structure Clinical factors: access, moisture Patient’s caries risk control, gingival margin Banerjee A. Minimal intervention dentistry: part 7. Minimally invasive operative caries management: rationale and techniques. Br Dent J. 2013 Feb;214(3):107–11.  Cutting & Caries Excavation Mechanism Dental substrate Tooth-cutting technology affected Mechanical, rotary Sound or carious SS, CS, diamond, TC and plastic burs* enamel & dentine Mechanical, non- Sound or carious Hand instruments (excavators, chisels), air-abrasion, rotary enamel & dentine air-polishing**, ultrasonics, sono-abrasion Chemomechanical Carious dentine Caridex , Carisolv gel (amino acid-based), Papacarie® gel (papain-based), pepsin-based solutions/gels Photo-ablation Sound or carious Lasers enamel & dentine Others Bacteria Photo-active disinfection (PAD), ozone Key: * = works only on carious dentine; ** = used for stain-removal3 Banerjee A. Minimal intervention dentistry: part 7. Minimally invasive operative caries management: rationale and techniques. Br Dent J. 2013 Feb;214(3):107–11. Adhesive Restorative Materials GIC Composite Resin  Special Techniques Preventive Resin Restoration Sandwich Technique Tunnel preparation ART Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry--a review. FDI Commission Project 1-97. Int Dent J. 2000 Feb;50(1):1–12.  Atraumatic Restorative Treatment Use enamel access cutter Clean tooth surface Access using hatchet when access is small Caries removal using Insertion of GIC using Slightly overfill to spoon excavator plastic instrument adjacent pit and fissure Press-finger technique to Remove excess Restored compact GIC Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART)--a minimum intervention and minimally invasive approach for the management of dental caries. Br Dent J. 2013 Jan;214(1):11 –8. Repair rather than replace defective restoration Replace or repair? Removal of restorations results in an inevitable increase in cavity size because of the removal of sound tooth structure. Depending on the dentist's clinical judgement, repair could be considered an alternative to replacement in some circumstances. FDI Policy Statement: Minimal Intervention in the Management of Dental Caries. Adopted by the FDI General Assembly: 1 October 2002 – Vienna, Austria  Extension for Prevention Ensure all carious tissue was removed Recontouring Patch with a originally, and Consider and compatible that caries risk repolishing material secondary caries has not developed Tyas MJ, Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry--a review. FDI Commission Project 1-97. Int Dent J. 2000 Feb;50(1):1–12.  Extension for Prevention 2003 2004 2005 2007 Holmgren C, Gaucher C, Decerle N, Doméjean S. Minimal intervention dentistry II: part 3. Management of non-cavitated (initial) occlusal caries lesions – non-invasive approaches through remineralisation and therapeutic sealants. Br Dent J. 2014 Mar 7;216(5):237–43.  MID for Managing Caries Early caries Remineralisation Optimal caries detection and of enamel and preventive caries risk dentine carious measures assessment lesions Minimally invasive operative Repair rather than approaches for replace defective Frencken JE, Peters MC, managing restoration Manton DJ, Leal SC, Gordan VV, Eden E. Minimal cavitated dentine intervention dentistry for managing dental caries – a carious lesions review. Int Dent J. 2012 Oct 1;62(5):223–43.