Caries Risk Assessment and Fluoride in Paediatric Dentistry .pdf

Caries Risk Assessment and Fluoride in Paediatric Dentistry Prevalence of Caries in Kuwait - 87% of 5-year olds - 73.6% of 12-year olds Consequences of Early Childhood Caries Increased risk of new carious lesions in both the primary and permanent dentitions Hospital isations and emergency room...

Caries Risk Assessment and Fluoride in Paediatric Dentistry Prevalence of Caries in Kuwait - 87% of 5-year olds - 73.6% of 12-year olds Consequences of Early Childhood Caries Increased risk of new carious lesions in both the primary and permanent dentitions Hospital isations and emergency room visits Diminished oral health-related quality of life Loss of school days Plaque Microorganisms comprise 70% of dental plaque Cariogenic bacteria ferment carbohydrate to acids (mainly lactic acid) Plaque bacteria can store carbohydrate intracellularly and extracellularly Intracellular carbohydrates allow further acid production when sources of carbohydrate are absent (such as between meals) Diet Sucrose most cariogenic sugar Intrinsic dietary sugars (fruits and vegetables) less cariogenic than extrinsic dietary sugars (added sugars, fruit juices) Cooked starch + sucrose (cakes and biscuits) more cariogenic than sucrose alone Sticky food retained for longer periods Frequent snacks Prolonged breastfeeding or night bottle feeding Tooth Tooth morphology (Pits and ssures > smooth surfaces) Enamel and dentine defects (e.g. enamel hypomineralisation, amelogenesis imperfecta) Newly erupted teeth Hydroxyapatite vs. uorapatite Fluorapatite : Forms when uoride is present during remineralisation More stable and resistant to further acid attack Fluorapatite critical pH 3.5 1 of 7 fl fl fi  Saliva - PROTECTIVE ROLE - Acts as a bu er neutralizing plaque pH after eating to minimize time for demineralization - Source of calcium and phosphate ions for remineralization - Patients with reduced salivary ow are at increased caries risk (xerostomia, head and neck radiation, medication) Stephan’s Curve - Following rinsing with 10% glucose solution plaque pH drops from 7.0 —> 5.0 - Critical pH = 5.5 (demineralization of enamel occurs) - pH returns to baseline value after 30-40 minutes *Chewing gum help in neutralizing the mouth by saliva stimulation. Diagnosis VISUAL - Probing damaged pits and ssures is not an acceptable method for detecting the presence of carious lesions in pits and ssures. RADIOGRAPHS - Bitewing radiographs detect more approximal lesions of molars compared to visual inspection only. (Always take if you have proximal contacts) - More than one third of 5 year olds in Sweden and Norway had approximal carious lesions that could not be detected by visual inspection. SPECIAL TESTS Tooth separation May be used in patients who cannot tolerate radiographs Space created within 20-60 minutes (could take 1 day) Fibre-optic transillumination (FOTI) Demineralized dental hard tissues scatter and absorb light more than hard tissues Other Examples: DIAGNOdent Laser light uorescence Quantitative light uorescence (QLF) Caries Risk Assessment: is the determination of the likelihood of the increased incidence of caries during a certain time period or the likelihood that there will be a change in the size or activity of lesions already present. 1. Fosters the treatment of the disease process instead of treating the outcome of the disease. 2. Allows an understanding of the disease factors for a speci c patient and aids in individualizing preventive discussions. 3. Individualizes, selects, and determines frequency of preventive and restorative treatment for a patient. 4. Anticipates caries progression or stabilization. 2 of 7 fl ff fl fi fi fl fi  Factors associated with development of caries: Clinical evidence of previous caries Dietary habits (especially frequency of sugary food and drink consumption) Social history Saliva Use of uoride Medical history Plaque control Limitations of Caries Risk Assessment Past caries experience is not particularly useful in young children, and activity of lesions may be more important than number of lesions. Low salivary ow is di cult to measure and may not be relevant in young children Frequent sugar consumption is hard to quantitate. Sociodemographic factors are just a proxy for various exposures/behaviors which may a ect caries risk. Caries risk assessment continues… Although there are many caries risk assessment tools the published evidence o ers no consensus as to which tool is most e ective. THE OBJECTIVE CLINICAL JUDGEMENT OF THE DENTIST, their ability to combine and use caries risk factors and their knowledge of the patient has been shown to be one of the most powerful predictors of that individual’s caries risk. PREVIOUS CARIES EXPERIENCE appears to be the most important risk indicators for caries Recalls: - High caries recall every 3 months - Low caries 6-12 months. We can stop caries in the clinic by: Fluorides Diet Oral hygiene instructions Fissure sealants Dietary Advice Limit consumption of food and drinks containing sugar Drink only water or milk between meals Snack on healthier foods, which are low in sugar, such as cheeses and vegetables Do not eat or drink, apart from water, after brushing at night Be aware of hidden sugars in food A great advice: TAKE A 3-HOURS BREAK BETWEEN MEALS AND SNACKS Dietary Advice on Bottle Feeding Sugar should not be added to food or drinks given to babies and toddlers Only plain milk and water should be consumed in a bottle Babies should not sleep with the bottle of milk in their mouth from the age of 6 months Babies should be introduced to drinking from a free- ow cup from the age of 6 months Feeding from a bottle should be discouraged from the age of 1 year Fluorides: Systemic and Topical Toothpastes Silver diamine uoride Mouth-rinses Fluoride supplements Fluoride varnishes Water, milk, salt Fluoride gels 3 of 7 fl fl fl ffi ff fl ff ff  Fluoride: Mechanisms of Action (The rst two are most important) 1. Inhibits demineralisation when in solution 2. Enhances remineralisation by forming uorapatite when in solution 3. A ects the crown morphology making pits and ssures shallower 4. E ect during tooth formation making enamel crystals larger and more stable 5. Inhibits plaque bacteria by blocking the enzyme enolase during glycolysis For a high risk patient 1450 ppm uoride is important Toothbrushing with uoridated toothpaste you need to memorize it. Should start as soon as the rst primary tooth erupts Brushing twice daily as a minimum Clean teeth LAST THING AT NIGHT before bed and at least one other time each day Supervised toothbrushing by an adult until about 7 years SPIT AND DON’T RINSE Concentration of Fluoride Toothpaste Toothbrushing with 1450 to 1500 ppm uoride toothpaste reduced the amount of new decay more than 1000 to 1250 ppm toothpaste. In the range of 1000 ppm F and 2500 ppm F, for every additional 500ppm F there was a 6% reduction in caries. Disclosing Plaque Disclosing tablets can help to indicate areas that are being missed Patient’s existing method of brushing may need to be modi ed to maximize plaque removal No particular toothbrushing technique has been shown to be better than another Fluoride Mouthrinses Daily uoridated mouthrinses 0.05% NaF ( 225 ppmF) Weekly uoridated mouthrinses 0.2% NaF ( 900 ppmF) Recommended for use: Orthodontic patients High caries risk Erosion 20% caries reduction in permanent teeth (Marinho et al,. 2016. Cochrane Review) NOT RECOMMENDED FOR CHILDREN UNDER THE AGE OF 6 YEARS due to the increased risk of swallowing the product. Fluoride Varnish (5% NaF) 22,600 ppm F A small pea-size amount is su cient for a full mouth application in children up to 6 years Low risk: Application every 6 months High risk: Application every 3 months 40% caries reduction in the primary and permanent dentition Fluoride varnish concentration is. 22600 ppm 4 of 7 ff ff fl fl fl ffi fi fl fl fi fl fi fi Silver diamine you have to consent the parent and tell them that it might stain the tooth Fluoride Gel Acidulated phosphate uoride (APF) gel Professional use: 12,300 ppm F (1.23% APF) Low risk: Application every 6 months High risk: Application every 3 months Caries reduction: 20% in primary dentition 30% in permanent dentition SAFETY RECOMMENDATIONS FOR USE Use appropriate size tray No more than 2 ml per tray Sit patient upright with head inclined forward Use a saliva ejector Instruct patient to spit out after the procedure Application time: 4 minutes * Not recommended for children younger than 6 years old due to risk of swallowing Silver Diamine Fluoride 38% SDF (44,800 ppm) Used to promote the arrest and remineralization of active carious lesions May be useful for permanent molar teeth with MIH (molar incisor hypominerlization) as blocking the dentinal tubules may reduce sensitivity It can also be used as a caries detection tool as it stains only carious tooth tissue but it must be remembered that this staining is permanent. Should not be used for teeth with pulpal symptoms 5 of 7 fl  Water Fluoridation Systemic method: provides uoride on a community basis Available naturally and arti cially Concentration varies Reduces dental caries by: 35% primary dentition 26% permanent dentition The majority of studies were conducted prior to 1975 and the widespread introduction of the use of uoride toothpaste Fluoride supplements (Tablets and drops) DEPENDS ON PATIENT COMPLIANCE Caries reduction in permanent dentition 24% No evidence uoride supplements taken by women during pregnancy are e ective in preventing dental caries in their o spring. Dose depends on age and level of uoride in drinking water No supplements if uoride water level >0.6ppm Other Fluoride Systemic Sources Concentrations of uoride in foods was estimated to range from 0.85 to 7.09 ppm Examples: Fish Spinach Tea Forti ed milk and salts Grapes Fluoride Toxicity Safely tolerated dose (1mg/kg) : Dose below which symptoms of toxicity unlikely to occur Potentially lethal dose (5mg/kg) : Lowest dose associated with a fatality Certainly lethal dose (32-64mg/kg) Survival after consuming this amount of uoride is unlikely Acute Fluoride Toxicity Early symptoms of toxicity Nausea Abdominal pain Vomiting Diarrhea Hypersalivation Late symptoms of toxicity Convulsions (depression of plasma calcium levels) Cardiac failure Respiratory failure 6 of 7 fi fl fl fl fl ff fi fl fl ff fl  Chronic Fluoride Toxicity Dental uorosis Demarcated opacities Di use (con uent, patchy, lines) Hypoplastic ** FOR PERMANENT CENTRAL INCISORS THE PERIOD OF MAXIMUM RISK IS A 4-MONTH PERIOD FROM 22–26 MONTHS OF AGE Skeletal uorosis Can be crippling Fusion of intervertebral discs/ligaments Osteoporosis Fracture of head of femur (elderly and post-menopausal women). Amount swallowed (mgF/kg) Management Fissure Sealants “Resin-based sealants applied to occlusal surfaces of permanent molars reduced caries when compared to no sealant. The incidence of caries at 24 months ranged from 16% to 70% in the control groups of the studies included, corresponding to absolute reductions in caries risk of between 11% and 51%.” School based sealant programs resulted in bene ts that outweighed costs, including reduced rates of dental caries, untreated decay, and school absenteeism. Glass ionomer sealant: Partially erupted tooth Child with limited cooperation Used as temporary measure Lower retention rates than resin-based ssure sealants CHECK the SCENARIOs 1 and 2 in slides 69 and 72 7 of 7 ff fl fl fl fi fi