Protocols and Prevention of Dental Caries Part 2 PDF

PROTOCOLS AND PREVENTION OF DENTAL CARIES PART 2 Dr. M. Cahoon Principles of Dental Hygiene II Objectives 1. Determine the caries risk potential for a patient’s food record and diet 2. Define pit and fissure sealants and explain the preventive and therapeutic rationales in...

PROTOCOLS AND PREVENTION OF DENTAL CARIES PART 2 Dr. M. Cahoon Principles of Dental Hygiene II Objectives 1. Determine the caries risk potential for a patient’s food record and diet 2. Define pit and fissure sealants and explain the preventive and therapeutic rationales in an exam 3. Explain indications and contraindications for sealant placement 4. Assess a patient’s needs for pit and fissure sealants on a simulated case-based experience 5. Define the factors contributing to hypersensitivity 6. Describe the pain stimuli associated with hypersensitivity 7. Describe the types of desensitizing agents and indication 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 Ability to stabilize calcium phosphate in solution and to increase the level of calcium phosphate in dental biofilm Buffers free calcium and phosphate ion activities to saturate the tooth surface for remineralization– a reservoir of calcium and phosphate ions forms Derived from cow’s milk Contraindicated in people with milk allergies Casein –protein derived from cow’s milk Professionally Application: Recaldent (MI Paste) Self-applied products: Trident White and Trident Extra Care chewing gum When used with fluoride enhances uptake 4  Hypomineralized White spot lesions enamel Indication s for Use Mild fluorosis Tooth sensitivity and erosion of CPP/ ACP Poor biofilm control with orthodontic brackets Tri-calcium Phosphate Hybrid material created with a milling technique that fuses beta tricalcium phosphate (ß-TCP) and sodium lauryl sulfate or fumaric acid Possesses unique calcium environments capable of reacting with fluoride and enamel Activated by presence of saliva Provides catalytic amounts of calcium to boost fluoride efficacy Best designed to coexist with fluoride in a mouthwash, dentifrice, or varnish Available in Prescription Products Only: ClinPro 5000, OmniVarnish (combination 5000ppm NaF and TCP) Xylitol Naturally occurring 5-carbon sugar alcohol Inhibits attachment and transmission of bacteria in biofilm growth Assists stimulate saliva Excellent for xerostomia Recommended for management of moderate, high, and severe caries risk in conjunction with fluoride therapy Overall caries prevention is less than fluoride Available in the OTC oral hygiene products Delivered through chewing gum or lozenges Therapeutic dose: 2 pieces of gum, mints, or lozenges 4-5x daily for 20-30 mins Xylitol should be listed as first active ingredient  Sodium Bicarbonate Neutralizes acids produced by acidogenic bacteria Antibacterial properties Severe caries risk patients with xerostomia benefit from sodium bicarbonate rinse 1tsp baking soda into 1 cup of warm water Also available in chewing gum and fluoridated toothpaste Chlorohexidine CHX Gluconate Broad-spectrum antimicrobial agent High substantivity – immediate bacterial action and prolonged bacteriostatic action (8-12hrs) 0.12% CHX Gluconate rinse 1x/daily for 1 week each month shown to reduce levels of caries causing bacteria Repeat and assess at 6-month intervals Must be used in conjunction with fluoride therapy Cons: alters taste, stains teeth, increases calculus formation High and severe caries risk patients Salivary Substitutes for Caries Prevention Xerostomia may be multifactorial Medication-induced Radiation-induced 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 w/ fluoride, calcium phosphate, and xylitol Humidifier while sleeping Remember, most only provide short term relief  2 medications in U.S. approved to treat xerostomia Prescription Pilocarpine Treatments Cevimeline for Require communication and collaboration with patients’ Xerostomia primary care physicians Sjogren’s syndrome Radiation therapy What products contain which active ingredient? https://www.dimensionsofdentalhygiene.com/ uploadedfiles/DDH/Magazine/2006/10_October/ toothpastefocus.pdf https://www.colgateprofessional.com/products/ toothpaste# https://multimedia.3m.com/mws/media/1683234O/3m- clinpro-5000-anti-cavity-toothpaste-sell-sheet.pdf Caries Prevention and Management Future Silver Diamine Fluoride and related products* Nanohydroxyapatite Oral probiotics and evaluation of oral pH Arginine Propolis (derived from bees) DENTAL SEALANTS Comprehensive Prevention Plan Part of a total preventive program Prevent dental caries in pits & fissures Factors to Teach Meticulous application rationale the Patient Need for maintenance of sealants About Sealants Expensive but better than a restoration because it does not require cavitation Purpose of dental sealants To provide a physical barrier to “seal off” pit or fissure To prevent oral bacteria from collecting in the pit or fissure To fill the pit or fissure as deep as possible and with a tight junction to surface of enamel Material is organic resin or glass ionomer filled to bond by mechanical retention to the tooth’s surface  Classification by Method of Polymerization Self-cured/Autopolymerization No curing light required Limited working time due to mixing Light-cured/Photopolymerized No mixing required Hardened when exposed to curing light More expensive  Classification by Filler Content Filled: Resin w/ glass or quartz particles Increases bond strength and resistance to wear Increases hardness to occlusion Requires occlusal adjustment after placement Unfilled: Resin w/ No particles Clear in application Less resistant to abrasiveness and occlusal forces Does not require occlusal adjustment Good for community outreach settings Fluoride Releasing Enhances remineralization at base of pit and fissure if incipient lesion is present Glass Ionomer: Ideal for teeth where isolation may not be possible Indication Individual considerations: Diet and lifestyle Age of tooth Past caries experience s for Tooth anatomy Key risk factors relating to sealant placement at any age: Sealant Xerostomia Active orthodontic treatment Incipient pit and fissure lesion with no Placemen radiographic evidence of proximal decay Low socioeconomic status/low access to care t Poor oral hygiene Diet high in fermentable carbohydrates  Selection of teeth Ideal Tooth Newly erupted Deep occlusal pits and fissures or irregular patterns of surface should pits and fissures be: Caries history Radiographic evidence of proximal decay on adjacent Contraindication teeth s for Sealant Pits and fissures are well-coalesced – why? Tooth not completely erupted Placement Primary tooth near exfoliation Penetration of Sealant Factors to Consider Anatomy and depth of fissures Presence of debris or biofilm Properties of sealant itself Clinical Procedures Clean tooth surface free of debris Complete tooth isolation from moisture Use of acid etch to increase retention Placement of sealant material following manufacturer’s instructions Check for voids Placement of Dental Sealant Material Sealant Placement Decision Tree Maintenance of Dental Sealants Retention Checked at each continuing care appointment Properly placed sealants last many, many years Contamination or moisture during placement Patient habits (i.e. chewing ice, pen caps) Avoid direct use of air polisher during dental hygiene appts Replacements Must re-etch during replacement of sealants Documentation After Placement Caries Risk Level Type of sealant used Preparation of tooth Method of isolation Patient compliance Post-operative care instructions SDF: Silver diamine fluoride. NaF: Sodium fluoride. APF: Acidulated phosphate fluoride. ACP: Amorphous calcium phosphate. CPP: Casein phosphopeptide DIET AND DIETARY ANALYSIS RELATED TO DENTAL CARIES Oral Health and Nutrition Nutrition, diet and oral health closely related Healthy diets provides essential nutrients for optimum health, including the oral tissues Proper masticatory function of the teeth relates to consumption of healthy foods Soft, sticky diet stays 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 Caries development and relationship to nutritional counseling Consistency of food Soft, sticky is not easily cleared in the oral cavity, especially without good salivary flow Dietary Assessment Must consider patient’s complete, medical, social and dental assessment Include results of clinical examination Types of dietary assessments w/ patient 24-hour recall Dietary analysis recording form 3-7 days  Identify physical form of carbohydrate Liquids Soft/solid, sticky retentive foods Hard/solid, slowly dissolving foods Identify frequency of meals and snacks Analysis of How many snacks between meals? What are meal times? How many “meals”? Cariogenic Frequency is more relevant than quantity Foods  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 often overwhelming Common misconceptions about concentrations of sugars Cultural or religious patterns associated with food Emotional eating habits Socioeconomic status and access to healthy foods Parent/child relationship with sugary foods Foods 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 Positive feedback Encourage and reinforce! Review existing habits that make a patient low risk Use of OTC fluoridated toothpaste Healthy diet Effective biofilm removal Dental hygiene continuing care appointments: 6 months Dental Hygiene Care and Moderate Caries Risk Provide positive feedback for any existing protective factors Supportive feedback Create plan to reduce risk factors EX: Removal of acidic beverages or frequent snacking between meals Allow patient to choose behavior to modify Increasing number of protective factors In-office fluoride therapies such as fluoride varnish application Xylitol products after meals OTC fluoridated toothpaste and rinse at home Plan appropriate dental hygiene continuing care appointments: 4-6 months  Nidus of infection must be addressed Dental Active dental caries Mechanical reduction of bacterial infection Hygiene Professional biofilm removal by clinician Individualized oral hygiene instruction Create strategies for reducing existing risk factors Care and Motivational interviewing techniques may be very effective here to find patient’s intrinsic motivation for change High or Education and plan of increasing protective factors In-office fluoride therapies At home remineralization therapies for oral hygiene (OTC toothpaste not enough) Severe Choice of recommended products based on individual risk factors Management of xerostomia Recommend appropriate dental hygiene continuing care intervals Caries Risk 3-4 month continuing care intervals Dentinal Hypersensitivity This Photo by Unknown Author is licensed under CC BY  Pain elicited from a stimulus and alleviated upon removal of the stimulus What is dentinal hypersensitivity? Types of Stimuli Evaporativ Tactile Thermal Osmotic Chemical e 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 in response to a stimulus that would not normally cause pain Discomfort that cannot be ascribed to any other dental pathology or defect So not dental caries! Relationship of Nerve Endings to Tubules Nerve endings from the pulp wrap around odontoblasts Extending 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 How does it happen? 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*  Effects of improper self-care Factors Anatomically narrow zone of attached gingiva Tooth orientation Contributing Short frenum attachment to Gingival Apical migration from periodontal diseases Periodontal surgeries Recession Orthodontic tooth movement Facial/tongue/lip piercings Differential Diagnosis  Which teeth/tooth are sensitive? On a scale of 1 to 10, with 10 being the most Questions pain, what is your pain intensity? How long does the pain last? Does it hurt when you bite down (pressure)? for Which word best describes the pain: dull, shooting, throbbing, persistent, intermittent? Differential Is it stimulated by certain foods? Is it stimulated by hot or cold? Diagnosis Does the discomfort stop immediately or linger? Have you used any whitening products recently?  Visual assessment of tooth and surrounding tissues Palpation of area Diagnostic Occlusal examination Radiographic examination Technique Percussion with an instrument handle Assessment for mobility s 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 Bruxism Assess toothbrushing techniques Choose appropriate desensitizing agent Potassium salts Fluorides OTC and Rx Oxalates Calcium Phosphate technology  Calcium Phosphate Technology Casein Phosphopeptide (CPP-ACP) Tri-calcium Phospate Potassium Salts Potassium Nitrate, Potassium Citrate, Potassium Desensitizing Chloride 5% Potassium Nitrate combined with fluoride in many toothpaste combinations Agents Available as addition to some prescription strength dentifrices Fluorides 5% NaF Varnish treatment of choice for professional application Silver Diamine formualtions 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 Patients with sensitivity should not brush after ingesting acidic foods Behavior modifications Hierarchy of treatments