Cariology Lecture Notes PDF

Cariology Lecture 1 Caries Prevention via Plaque and Diet Control Evidence of tooth cleaning is considered at three levels; 1. Individual site 2. Individual patients 3. The community 2. Individual pts - Brushing twice daily develop less lesions than those brushing less frequentl...

Cariology Lecture 1 Caries Prevention via Plaque and Diet Control Evidence of tooth cleaning is considered at three levels; 1. Individual site 2. Individual patients 3. The community 2. Individual pts - Brushing twice daily develop less lesions than those brushing less frequently - Fluoride toothpaste reduces caries abt 24% 3. Community - Plaque = diet - Sugar consumption = higher caries and plaque - Plaque removal = progression of caries Mechanical removal Seeing plaque - Disclosing gel (liquids, tablets, gels or capsules containing erythrosine or veg dyes) to stains the plaque Using tri-plaque gel/ disclosing solution - pink/red (immature biofilm) - blue /purple (thick plaque, not been cleaned for 48+hrs, gingivitis) - Light blue (acid production, biofilm with a ph of 4.5 or lower, high risk biofilm) Tooth brushing - Handle (appropriate to age) - Head size - Compact (medium soft rounder nylon filament) - Bristle patterns (flat trims, different height and angle) brushing methods 1. Modified bass 2. Toothpick method (most effective cleaning ⅓ beneath gingival margins and interproximal areas, perio maintenance, cleanses sulcus) Interdental cleaning - Dental floss or tape - Interdental brushes - Single tuft brushes - Superfloss - Water pick Reduces cries by 50% fortnightly fl rinse reduces decay by 25% Toothpaste Containing Arginine ( plaque modification) Arginine - metabolised by plaque bacteria to ammonia which neutralizes plaque acids Resin infiltration procedure - Initial clinical procedure - Bitewing x-ray - Rubber dam - Separation with dental wedge - Etching - Drying - Infiltrating - Removal excess - Light cure Stannous Fluoride (SnF2) - SnF2 or Tn(II) fluoride is used in toothpastes to prevent gingivitis, cavities, dental infection and relieve dental hypersensitivity. More effective in reversing/ stopping dental lesions. - Stannous Fluoride used 8% for children, 10% concentration for adult = 2 to 2.5% FL  - 8% SnF2 application for 5 min in deep cavities produce local necrosis and moderate inflammation of pulp adjacent to cavity floor Diet in caries prevention Risk factors for caries - Use of calories sports drinks - gatorade - Use of non-fluoridated bottled water - Tap filters that remove fluoride Periotised caries reduction strategies 1. Maximise the fluoride effect 2. Focus on better control of caries causative agent - dental plaque Effect of FL toothpaste - Reduce plaque thickness - saliva gains access to tooth surfaces - Provide fluoride Lecture 2 Caries prevention via FL Learning objectives - Caries prevention via topical FL - Mechanisms of FL and guidelines for use of FL - FL supplements - FL varnish - CPP-ACP - silver di-amine FL mechanism and guideline - FL toxicity Mechanism of action of FL Halo effect of FL Tropical effects of FL - Water fluoridation - Fluoride tablets - Fluoride toothpaste - Fluoride rinse - Fluoride gel - Fluoride varnish - Calcium FL exists in pores of enamel for extended periods and acts as FL reservoir during remineralization. - Standard fl toothpaste colgate = 1000-1100 ppm fl (11.1mg) - Higher risk pts can use fl toothpaste with 1500-5000 ppm (1.5-5.0mg  - Oral B toothpaste can cause chemical ulcerations 2019 guidelines for FL toothpaste - 6-17 months of aged children’s teeth should be cleaned without toothpaste by adult - Children from 18 months - 5 yrs should clean twice daily with toothpaste of 0.5-0.55 mg/g fl (500-550 ppm). - 6 yrs and more cleaned twice daily with standard toothpaste containing 1-1.5mg/g fl (1000-1500 ppm), should spit out not swallow and not rinse Sodium fluoride Lecture 3 Caries prevention via microbiological consideration Bacterial Specific Approaches for caries prevention Issues with specific approach for caries prevention 1. Salivary kits - dont target bacteria that are predictive of caries 2. Passive immunisation - requires long term application 3. Active immunisation - not successful clinically Non- specific Approaches Prebiotic Lecture 4 Diet & Teeth Sugar  Sugar substitute Artificial sweeteners - Non- nuritive - does not contribute to energy intake nor dental decay - Saccharine - Aspartame - Overall effects on health Protective food against caries - Xylitol - Crunchy fruit and veges - Cheese and dairy - Seafood - Nuts Acid erosion & hypersensitivity Hypersensitivity - intense and transient pain in response to stimuli eg. thermal ostomic, tactile or chemical - Tubules need to be patent for hypersensitivity to occur Dietary acid causes erosion - Acid wear - Dential hypersensitivity - 41.7% pts without wear hv dental hypersensitivity Lecture 5 Arrest & remineralising caries lesion Arrest and remin agents - Fluorides - SF/SDF - CPP/ACP - hydroxyapetite Sliva related - Chewing gum - Bicarb mouth rinse - xylitol Fluorides \ Silver Fluoride/ silver diamine Fluoride - SDF is a colourless, odourless solution of silver, fluoride and ammonium ions, the ammonia acting as a stabilising agent for the solution. Other caries preventions - Saliva - chewing gum - bicarbonate mouth rinse Saliva’s role in arrest and remin Normal salivary function - speech , digestion and swallowing - Antimicrobial - Stimulated saliva high serous volume bicarbonate buffering - Oral clearance of glucose bacteria Xerostomia - Aging population - Polypharmacy - Medical conditions - Lifestyle factors Bicarb mouth rinse ​ Instruction - Dissolve one teaspoon of sodium bicarbonate in a glass of water - Rinse thorough after - Do not swallow Saliva substitutes CPP-ACP Recommendation - Milk protein allergy contraindication - Families who have no access to fluoride or choose fluoride free - Frail old people (CPP-ACP cream remineralize teeth and use adjunct fluoride) Hydroxyapatite Recommendation - Ha-based toothpaste is useful for early childhood caries (ECC) and for disabilities - Safe to swallow by accident Lecture… Caries prevention via fissure sealants Caries polarisation Polarisation - defined as percentages of people with caries and without caries - Generally a decline in caries - Low SES=low fissure sealants - Low income are 3 times more cavities in permanent first molars compared to children with fissure sealants Plaque retention in pits and fissures - Toothbrush bristles does not reach all pits and fissures - Dietary carbohydrate can become logged in fissures and becomes a source of nutrients - Some pits/fissures is difficult & impossible to clean What is it and its role? Evidence based clinical practice guildlines Sealants (material option & what to consider) Less technique sensitive (fuji 2&1) (Fuji 2 light cured) Fissure and non-cavitated caries Lecture 6 Histopathology of dental caries Learning outcomes - Describe the histopathological features of caries lesions - Understand the zonal structures of enamel and dentinal caries - Explain the histopathological progression of the enamel and dentinal caries Enamel caries dentine caries Case studies Lecture 7 Salivary Dysfunction Minor (palatine glands) Xerostomis - xeros (dry) & stoma (Mouth) Hyposalivation - condition known as (reduced saliva production)  Consistency of saliva - Frothy - Thick - Ropey saliva Sialometry (Measurement of salivary flow ) - Oral moisture level - Stimulated whole saliva volume - Unstimulated whole saliva /spitting Measured by - Imaging (sialography, ultrasound,MRI - Blood test - sialendoscopy/biopsy (surgical) Oral complications Halitosis - Decrease in saliva - Increase in odour Candidiasis - mutual vicious cycle - Decrease in saliva flow encourage candida infections - Candida infections damages salivary glands (angular cheilitis, stomatitis) Hydroxyapatite toothpaste for pts against FL Example questions Which of the following is a diagnostic tool for sjogren's syndrome related to saliva dysfunction? - Blood test - Sialometry - Eye exam Which statement abt SD is incorrect? - It can lead to difficult in speaking and swallowing - It is always caused by underlying disease - It can increase the risk of caries - It can cause a persistent feeling of dry mouth Lecture 8 Clinical Cariology - Managment System Dental caries require … - Cariogenic (acidogenic) bacteria - Bacterial plaque - biofilm - Stagnation areas - Fermentable bacterial substrate (sugars) - Susceptible tooth surfaces - Time Modern management - Caries treatable to controllable - Slow progression of lesion and cavitate later in post fluoride era - Caries can be arrested at early stage Laser and blue light fluorescence examination - Detects initial occlusal carious lesion - DIAGNOdent pen (KaVo) used for detection of proximal lesions - Monitor changes of tooth sites over time Classifying and diagnosing caries HOW? - By tooth surface site and size/integrity - By caries progression rate - By initial attack on sound teeth (primary caries), (secondary caries) and failure of treatment Patient Assessment DENTAL HISTORY - Obtain initial dental history - Update dental history - Compare the medical and dental history and diagnose DIET HISTORY - Intake of snack/soft drink/sports drink between meals - Sugar in tea/coffee - Intake of acidic food (fruit,juice, tomatoes, olive and lemon) Clinical Assessment PLAQUE SCORE ICDAS BITEWING SURVEY Lecture 9 Clinical assessment - plaque score - ICDAS - Bitwing survey Learning objectives - CMS/ assessment treatment monitoring - Clinical management (ICDAS and bitewing radiographic survey) What is ICDAS? International caries detection and assessment system (ICDAS-II). IcDS clinical scoring system (0-6) for detecting and classification of caries in dental education, clinical practice, dental research and dental public health. ICDAS codes apply to.. - Smooth surface caries - Pit fissure caries - Caries associated with restorations and sealants - Root surface caries Aim of planning ICDAS - Diagnosis - Prognosis - Clinical management of dental caries at both individual and public health levels by identifying patients who require intensive preventive intervention Equipments for ICDAS - Good light and good eyesight - Blunt probe (WHO, CPI probe - Mirror Code 1 is not recorded Root caries codes Code 0 - sound Code 1 - arrested root lesion, using WHO probe for hard lesions, stained and shiny Code 2 - active root lesion, soft Bitewing radiographic survey Is for recording lesions on non-restored D (distal), O(occlusal) and M (mesial) surfaces. DOM Lesions that - Progress - Remain static - Regress C1 - outer ½ of enamel C2 - inner ½ of enamel C3 - just into dentine C4 - outer ⅓ of dentine C5 - inner ⅔ of dentine Lecture 10 Patient assessment - Diagnosis - Risk determination - Oral care plan - Step 4 & 5 Diagnosis of caries Refers to the process of identifying a carious lesion and its characteristics, severity (depth mineral loss) and activity as well as other risk factors Identifying a carious lesion by - Visual examination - Radiographs (bitewing) - Clinical scoring ICDAS Evaluate the lesion characteristics - Severity - depth of lesion (mineral loss - Activity - is lesion progressing or arrested Caries risk assessment Completed after caries risk factors, clinical and radiographic examination Factors to consider when assessing caries risk - Past caries experience - most reliable predictor for future caries risk - Microbiological tests - predicting the association between the salivary levels of s-mutans and number of caries lesion has limited power - Saliva analysis - reduced saliva flow increases caries risk - Diet analysis - dietary habit, frequency of sugar intake - oral hygiene - plaque buildup on teeth and caries risk - Social and economic factors - regular check up due to economy increases caries risk Points to remember - Molars are 6-15 time more likely to decay than premolar - Premolar are 2 to 5 times more likely to decay than upper incisors - Uper incisors are 5 -10 times more likely to decay than canines, buccal carries on canine sign of extreme caries risk - Lower incisors are 0-20 times more likely to decay than canines and 200-3000 less likely to decay than molars Saliva Maintain ecological balance in the oral cavity Functions of saliva - debridement / lavage - remove food debris and bacteria from oral cavity - Aggregation and reduced adherence - a process that immunological and non-immunological mechanisms causes bacteria yo clump together and reduces the ability to stick to tooth surfaces - Direct antibacterial activity - antimicrobial agents that kill bacteria - Antifungal and antiviral properties - control the growth of fungi and viruses in the mouth - PH regulation - maintain PH balance and neutralise acid produced by bacteria through diet reflux. Buffering capacity protects teeth from demineralisation (damage) - Tooth integrity - mechanical cleansing and carbohydrate clearance, po-eruptive maturation of enamel, remineralisation (repair tooth enamel) Xerostomia (dry mouth) symptoms - Medical conditions (diabetes) - Salivary gland diseases - Chronic multim-system , autoimmune disorder - Ageing 20% - Submandibular gland progressive loss - Medication - Xerogenic drug - Inference with neural transmission - antidepressants - Decrease in mastication Other causes - alcohol,caffeine , smoking - Illicit drug - Stress, exercise and dehydration - Trauma to salivary glands, ducts and nerves - Radiation therapy Saliva testing Visual examination for hydration, appearance time of saliva droplets from minor salivary glands (buccal mucosa) on lower lip. - Droplet appearance time greater than 60 sec is low salivary flow - Appearance time between 30-60 seconds is normal - Appearance time less than 30 second is high salivary flow Saliva viscosity Observing the consistency of saliva - Sticky frothy saliva suggests increased viscosity - Water clear saliva indicates normal viscosity Normal saliva flow rate - Unstimulated - approximately 0.3ml/min - Stimulated 1-2 ml/min Parotoid glands contribute to 30% of unstimulated saliva Submandibular and sublingual glands contribute to remaining 70% Unstimulated salivary flow rate drops to 50% is when patient have oral dryness Four caries risk factors - Florudie factor use of fluoride toothpaste, florida rinse - Saliva factor lower pH reduced, saliva flow, use of calcium and phosphate substitute? - Plaque factor oral care effective, cariogenic biofilm, age, antibacterials use? - Diet factor sugar substitutes, frequency and consistency of sugar and timing? 2 effective Brushing technique - Effective plaque removal - effectively removing accessible dental biofilm - Prevention of tissue damage - avoiding techniques that cause tissue damage such as recession Lecture 11 ORal care planning Caries risk management system (CMS) - assessment, treatment and monitoring Risk management step 6,7,8 - Case presentation - Importance of oral health - educating the patient about the connection between oral health and overall health and treatments - Lifelong commitment to care - regular dental visits and oral care treatment tailored to their risk levels - Voluntary risk reduction - understanding that reducing caries is achievable by good and immediate oral practices - Informed consent - Presenting details of treatment process, options and costs - Risk associated with the treatment - Side effect of treatment - Alternative to proposed treatment - Prognosis with or without treatment - Behaviour management and oral hygiene coaching Behaviour management  Oral hygiene coaching - Visual observation and providing tailored oral care instruction - Tell-show-Do tooth brushing method - modified bass technique for cervical ¼ and beneath gingiva cleaning as well as toothpick method for interproximal areas - Brush swish spit and don't rinse toothpaste - Home and professional care - Lesions management according to ICDAS and BW ICDAS - Code 1-2 - apply fluoride varnish to 1 arrest amd remineralise active lesions and 2 maintain arrested lesion - Code 3-4 - restore with minimally invasive restoration only if radiolucenecy extend deeper than C4 otherwise review in 6 months - Code 5 - restore with minimally invasive restoration - Code 6 - restore Bitewing radiographic - C1 - do not restore apply fluoride and monitor - C2 - do not restore apply fluoride and monitor - C3 - do not restore apply fluoride and monitor - C4 - restore only after further consideration (examine, restore if cavitated and no sign of lesion arresting - C5 - restore now - Dietary advice Food and drinks (low sugar fibrous food like veggies, fresh fruits, xylitol sweeteners, cheese and dairy) - Balanced diet rich in whole grain like fruit and vegetables - Reduced the intake of sugary and acidic food - Avoid sugar and acidic food and drink close to bedtime - Chew sugarless gum - Drink rather than sip sweet and acidic drinks - Mother should breastfeed up to 6 months Lecture 11 Monitoring step 9 and 10 - Behaviour change - Effective plaque disruption - through regular and proper brushing and flossing - Home fluoride and antibacterial treatments - using high fluoride toothpaste, chlorhexidine are key component of treatment plan - Diet management - reducing the amount of sugar intake to minimise caries risks Collaborative approach - Intensive coaching - ensuring the patient understand the importance of changes and developing skills to implement effectively - Regular monitoring of behaviour changes at each appointment - tracking progress to provide positive reinforcement and address the challenges patients face - Open communication and negotiation - recommendation for decision making process - Plaque control Targeting root of the problem Monitoring plaque index at each appointment - provide insight into patient oral hygiene effectiveness Recommending specific oral hygiene products - using high fluoride toothpaste, chlorhexidine are key component of treatment plan Providing clear instruction and demonstrations - proper brushing and flossing techniques empower patient to maintain effective plaque control at home - Clinical outcome - Changes in appearance of white spot lesion (WSLs) - successful treatment should result in WSLs becoming shiny and potentially regressin on radiographs however deeper lesions may not exhibit these changes  - Arrest of existing lesions -reducing the progression of existing carious lesion through visual examination and radiographic monitoring - Absence of new lesions - prevent the development of new carious lesion and successfully control disease process Recommendation for high medium risk patients - Radiographic review at 6-12 months - used to assess hard tissue response to treatment and check new lesion - Regular monitoring of risk factors - oral hygiene practices, plaque levels and dietary habits helps to identify areas for further intervention - The presence of cavitation - key indicator for operative intervention such as restoration Collaboration between the patient and dental practitioner - Regular recall appointment - monitoring clinical outcome , review risks factors and reinforce positive behaviour change - Patient education and empowerment - long term success, patient undersation of caries risk and consequences - CMS involves the recognition of the following - Empowering patient - Limitation of restorative dentistry alone - Measuring the severity and extent - Impact of sealing dentine lesions - Importance of monitoring - Home care Lecture 12 Fluorosis sign of dental fluorosis is paper white flecks scattered across the tooth surface, in senever cases white flecks merge into paper white patches Stages - Normal - enamel is translucent no sign of fluorosis - Questionable - enal central incisors has a milky appearance  - Very mild - paper white flecks symmetrically om left and right teeth covering up to 25% of tooth surface - Mild - the paper fleck merge into white patches covering up to 5% of tooth surface - Moderate - the opaques merge to cover most of the surface - Severe - pits appear on the paper white tooth surfaces Q&A Q. in the caries management system after an nintensive treatment phase the first radiograic review for medium and high risk patients will occur at? A. 6 months Q. The two criteria by which a dental practitioner can be sure that the disease of dental decay is under control (low risk) at the review appointment are? A. There is less than 1 new lesion and no progression of existing lesions