prevention dr. mohira. part two.pdf

Prevention of dental caries Presented by dr: mohira ezzeldin  There are four practical factors to the prevention of dental caries:  Plaque control/ tooth brushing.  Diet control. home  Fluoride.  Fissure sealing. professional Flouride – F termed a seeker of mineralized tissues it is deposited...

Prevention of dental caries Presented by dr: mohira ezzeldin  There are four practical factors to the prevention of dental caries:  Plaque control/ tooth brushing.  Diet control. home  Fluoride.  Fissure sealing. professional Flouride – F termed a seeker of mineralized tissues it is deposited in bone and excreted by kidneys – Repeated use of fluorides is of critical importance for the control and prevention of dental caries – Fluoride use is the most effective way of caries prevention. – F is most effective in proximal &smooth surfaces Mechanism of Fluoride in caries prevention: Pre-eruptive effects : replacing the hydroxyl iron during tooth formation thereby reducing the solubility of the tooth tissues.[Ca10.(PO4)6. F2] affects the morphology of the crown of the tooth, making the coronal pits and fissures shallower. Post-eruptive effect Act topically promoting remineralization & By combining with calcium and phosphate to form fluorapatite The reminerlized enamel is more caries resistant due to formation of fluoroapetite.(critical pH for fluorapatite is pH 3.5 Enhances crystal growth, stabilizes the tissue, and makes it resistant to further acid attack. F can inhibit plaque bacterial growth and glycolysis(inhibiting the enzyme enolase in the glycolytic pathway) Modes of Application of Fluorides Systemic Topical Systemic  Community water fluoridation Water fluoridation is the controlled addition of flouride to a public water supply to achieve a conc b/w 0.8 and 1 ppm Advantages Effective ,efficient ,safe , low cost and extended to many people Caries reduction 40-50% for primary teeth 50-60% for permanent teeth  Home water fluoridation In non-fluoridated community sodium fluoride tabs used as water supplement One 2.2 sodium fluoride tabs(contain 1 mg F) is dissolve in 1 L of water.  School Water Fluoridation: using high levels of fluorides e.g. 5ppm  Fluoride Supplements Fluoride supplements can be in the form of :  tablets  drops Use of this method depends on:  Age of the patient  Level of fluoride in the drinking water The tablets should be allowed to dissolve slowly in the mouth, thus providing a topical application of fluoride to the teeth.  Fluoride supplements should be prescribed only for: Children who are at high risk of developing caries, Only in cases when the use of topical fluoride is not possible, After all other sources of fluoride (toothpaste, fluoride in water, infant formula, prepared baby food, etc.) have been evaluated. Associated with increased risk of fluorosis Recommended Fluoride Supplement schedule Fluoride Concentration in Community Drinking Water Age 0.6 ppm 0–6 months None None None 6 mo–3 yrs 0.25 mg/day None None 3 yrs–6 yrs 0.50 mg/day 0.25 mg/day None 6 yrs–16 yrs 1.0 mg/day 0.50 mg/day None MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm. Alternative Vehicles: Fluoridated milk and salt could be public measure in target group with high caries prevalence and low compliance for tooth brushing in areas without water fluoridation. salt: 250mg F/1kg salt. (50% caries reduction) milk: 5mg F/1l milk(15–65% caries reduction) Halo effect – The ‘halo effect’ is the term used to describe the ingestion of fluoride from hidden sources – The preparation of numerous foods and beverages in fluoridated communities and their consumption in non fluoridated communities. – Decrease the caries prevalence in non fluoridated area Topical fluoride Professionally applied Gels, rinses, varnishes, foams Home applied Tooth paste Mouth rinse Topical Fluoride Topical action of fluoride is essential for caries prevention. It is the activity of the fluoride ion in the oral fluid that is of most importance in reducing enamel solubility rather than having a high content of fluoride in surface enamel. A constant supply of low levels of intra-oral fluoride, particularly at the saliva–plaque–enamel interface, is of most benefit in preventing dental caries. Factors to be consider before F application Caries risk Cariogencity of diet Pt age and compliance Use of systemic and topical F modalities Community water F level Existing medical conditions Home applied 1.Fluoridated tooth paste: Fluoride in tooth paste in the form of: sodium fluoride sodium monofluorophosphate (MFP) Stannus or amine F It causes 25% reduction in caries Fluoride concentration in toothpaste Children below 5 yrs F conc 400-500ppm 6 or more F conc 1000 ppm young child under 6 years presents with caries, toothpaste of at least 1000 ppm is indicated Teenage ,adult at higher caries risk F conc 1500 ppm or more Fluoride amount – A smear of fluoride-containing toothpaste is the recommended amount of fluoride (applied 2 times a day) for a 2-year-old child. – Children 3 - 6 years of age should use only a pea-sized amount of fluoridated toothpaste 2. Mouth rinses (MR) – The most common F compound used is sodium fluoride. – Weekly 0.2%(900ppm) NaF. – Daily 0.05% sodium fluoride (225ppm)NaF – Caries reductions of 20–50%  Indication – Pt with ortho appliance – Pt with post-irradiation hyposalivation – Pt unable to perform adequate tooth brushing – Pt with high risk of caries  Contraindication – children below 6 yrs(Swallowing reflex present at >7yrs) Professional Use 1. Fluoride Varnish Provide prolong contact times b/w fluoride and enamel to increase formation of fluoroapetite. It is effective in both 1ry and 2 ry dentition. It provide 30% reduction in caries Indication Hypersensitive area Newly erupted teeth Local remineralization of white spot lesion High caries risk pt Used for pre school children (younger than 6 years) due to immature swallowing reflexes.  Duraphat 5%NaF 22600pp) remains on the teeth up to 12-48 hrs Fluor Protector (Ivoclar Vivadent 0.1% F Diflourosilane Application of the varnish Prophylaxis of teeth before application is not require Gross plaque and stain should be removed Drying of the teeth facilitates the adhesion Applying Fluoride Varnish(duraphat) 2. Gels/foams: acidulated phosphate fluoride that contains 1.23% fluoride ion. Indication Orthodontic patients, Pts with decreased salivary flow, Children whose permanent molars cannot be sealed. Caries reductions : 26% Professional use → It is applied by mouth tray, which contains the product. The tray is held by biting for 4 minutes Home application. The concentration of fluoride much lower than in professional products. can be applied in trays or by brush Recommendation for use (1) no more than 2 ml per tray; (2) sit patient upright with head inclined forward; (3) use a saliva ejector; (4) instruct the patient to spit out for 30 s after the procedure (usually 4 mins but newer types are for 1 min). (5) Do not use for children under 6 years. Slow-release devices – Devices slowly release fluoride , – Can be implanted on the side of a molar. – It is effective in raising fluoride concentrations and in preventing cavities. – Problem ? retention rates, the devices can fall off too often Professional Use Three agents: - 2% sodium fluoride. - 8% stannous fluoride. - 1.23% acidulate phosphate fluoride (APF) Sodium fluoride: 2% Chemically very stable Acceptable taste Non-irrtant to the gingiva Doesn’t color teeth , resin or porcalin restoration stannous fluoride. 8% Rapid penetration of F into enamel Bitter taste not stable. Does not etch porcelain restorations. Cause discoloration of teeth and margin of restoration esp in hypocalcified areas APF (1.23% acidulate phosphate fluoride (APF)) acceptable taste, different flavours. no staining. can be applied to both arches simultaneously. stable. may damage porcelain restorations (cover with Vaseline). Post operative instruction after topical fluoride application: Don't eat, drink or rinse for 30 minutes. Do not brush or floss the child's teeth for at least 4 hours, preferably 24 hours. Avoid hot drinks and products containing alcohol (beverages, oral rinses) for 4 hours Fluoride toxicity Probable toxic dose (PTD): the threshold dose that could cause serious or life threatening systemic signs and symptoms. for fluoride is 5 mg F/kg wt. lethal dose is 32mg-64 mg F/Kg Symptoms of acute fluoride toxicity :  Develop very fast.  Nausea, vomiting, and abdominal pain, hypersalivation, tears, discharge from nose and mouth, diarrhea, and headache. Management As general it consist of: Estimating the amount of F engested Minimise further absorption Removing F from body fluid Supporting the vital signs Management Fluorosis Excessive intake of fluoride, either from naturally occurring sources such as drinking water with fluoride levels over 1.2 ppm, or from over use of fluoride supplements or fluoride toothpastes. The condition is dose-dependant The most critical ages are from 0 to 6 years. After 8 years, risk of fluorosis is essentially past. mild pitting moderate severe Treatment modalities for fluorosis  Tooth whitening.  Bonding, which coats the tooth with a hard resin that bonds to the enamel.  Crowns.  Veneer.  MI Paste, a calcium phosphate product that is sometimes combined with methods like microabrasion to minimize tooth discoloration Fissure sealant The anatomical pits & fissures recognized as susceptible areas for initiation of caries. G.V Black note 43-45% of all caries occurred on occlusal surfaces This can be explained by the morphological complexity of these surfaces, which favors plaque accumulation to the extent that the enamel does not receive the same level of caries protection from fluoride as does smooth surface enamel Pit and fissure sealants a material that is placed in the pits and fissures of teeth in order to prevent or arrest the development of dental caries“. This is the most effective clinical technique to prevent pit and fissure caries.((Sealant caused 92% reduction of caries if it remain intact for 5 yrs. )  Potential role of pit-and-fissure sealants in primary and secondary prevention: From a primary prevention perspective: anatomic grooves or pits and fissures trap food debris and promote the presence of bacterial biofilm, thereby increasing the risk of developing carious lesions. Effectively sealing these surfaces with a dental material—can prevent lesions From a secondary prevention perspective,: there is evidence that sealants also can inhibit the progression of noncavitated carious lesions.  The sealing procedure is based on: Decreasing bacteria. Reduction of plaque retention. Arrest of caries process. The development of pit and fissure sealants was based on the discovery of etching enamel with phosphoric acid increased the retention of resin restorative materials and improved marginal integrity Indication Deep, retentive pits and fissures. Stained pits and fissures with minimum appearance of decalcification(Discolored fissures) No radiographic or clinical evidence of interproximal caries in need of restorations on teeth to be sealed. Caries free pits or questionable enamel caries on P&F High caries index (pit and fissure caries or restorations in other primary or permanent teeth). Contraindications shallow fissures.(well coalesced, self cleansing ) present of interproximal caries. dentinal caries tooth can not be isolated for resin based fs (relative contraindication-GIC ). life expectation of primary tooth is limited (near to exfoliation). Patient selection 1. Children with special needs. medically compromised, physically or mentally disabled, or have learning difficulties 2. Children with extensive caries in their primary teeth should have all permanent molars sealed soon after their eruption. 3. Children with carious-free primary dentitions do not need to have first permanent molars sealed routinely; but should be reviewed at regular intervals. Tooth selection 1. Fissure sealants have the greatest benefit on the occlusal surfaces of permanent molar teeth, cingulum pits of upper incisors, the buccal pits of lower molars, and the palatal pits of upper molars. 2. Sealants should normally be applied as soon as the selected tooth has erupted sufficiently to permit moisture control. 3. Any child with occlusal caries in one first permanent molar should have the fissures of the sound first permanent molars sealed. 4. Occlusal caries affecting one or more first permanent molars indicates a need to seal the second permanent molars as soon as they have erupted sufficiently. Summary for criteria of selection Criteria Seal Do not seal Tooth age A tooth that has just come through into the mouth. Teeth that have remained free of decay for 4 years or longer. Tooth type Molars Front teeth (very rarely is there a need to seal front teeth) Depth of pits and fissures Deep, retentive, narrow pits and fissures, which are excellent at attracting plaque Wide, unretentive, shallow grooves that are easily cleaned by the person The risk of decay Teeth that are soft, or in a person who has had decay in two or more teeth Teeth that have remained free of decay for 4 years or longer Availability of other preventive measures Person is having fluoride in their diet and still has decay Person is not following dentist's advice, and is continually getting more decay; this will require a filling rather than a sealant Materials used There are 4 sealant materials 1.Resin-based sealants. 2.Glass ionomer sealants. 3. polyacid-modifid resin sealants. 4.resin-modifid GI sealants 1.Resin-based sealants: Several sealant materials are available but the most effective is Bis-GMA resin (bisphenol A-glycidyl methaccrylate). Another available resin is urethane dimethacrylate, “UDMA,” Classification of resin based fissure sealant Based on filler content a. Unfilled b. Filled better flow, more retention, abrade easily more resistance to wear, need occlusal adjustment Based on color a. Clear esthetic ,difficult to detect on recall visit b. Tinted opaque can be identified c. Coloured easy to see during placement and recall Sealant Color Clear Tinted Opaque  Based on curing a. Autopolymerisation (chemical cured) b. Light cure Advantages of light cure quick setting command setting no mixing and thus elimination of air bubbles incorporation. Its main disadvantage is the cost.  Based on fluoride content a. Fluoride releasing sealant b. Non-fluoride releasing sealant What about Partially erupted teeth? 2.Glass ionomer sealants. Glass ionomer may be useful as a sealant material in 1. Deeply fissured primary molars that are difficult to isolate due to the child's pre cooperation 2. In partially erupted permanent molars that the clinician believes are at risk for developing decay. The traditional glass-ionomer cements have shown very poor retention rates as well as leakage. glass ionomer materials must considered a transitional sealant to be reevaluated and probably replaced with resin-based sealants when better isolation is possible and the tooth is fully erupted. Application of glass ionomer sealants: a. b. c. d. Clean the surface. Isolate the tooth. Run the glass ionomer into the fissures. Protect the material during initial setting.( Apply unfilled resin, petroleum jelly, or fluoride varnish to protect the material). Clinical technique for fissures sealant 1.Cleaning Adequate retention of the sealant requires that the pits and fissures be clean and free of excess moisture. Use a rotating dry bristle brush. 2-Isolation: Isolate the tooth (or quadrant of teeth) to be sealed. Rubber dam is ideal. Cotton rolls, absorbent shields, high volume suction. 3- acid etching This is the most critical step in the sealant application technique (the retention of the sealant depends on the proper acid conditioning of the tooth's surface). facilitates the application of a low-viscosity resin that penetrates the roughened surface and produces a mechanical lock of resin tags when cured. Itching with phosphoric acid 37% for 30 sec Liquid etchant allow more penetration than gel The etchant in solution should be placed on the enamel with a brush, small sponge, cotton pellet, or applicator provided by the manufacturer  Enamel exposed to fluoride is more resistant to etching, needs longer time. Primary teeth also need longer time (60 – 120 seconds). Why…….?  4- washing and drying Tooth surface is rinse thoroughly for 20-30 sec and dry for 15 sec(with a compressed air stream) The dry etched enamel should exhibit a characteristic frosty appearance If salivary contamination occur re-etch for 10 sec 5-bonding Optional step Increase the bonding strengh in both saliva contaminated enamel and uncontaminated enamel. Is advantageous on the buccal surfaces of molars When used, the bonding agent must be thoroughly air dried across the surface to be sealed (to avoid a thick layer of adhesive residue). 6-placement of the materials and curing The sealant is applied to the prepared surface in moderation and then gently teased with a brush or probe into the pits and grooves. If a large surface area requires polymerization, place the light directly over each area of the occlusal surface for the recommended time. After the material has been cured and while the treated teeth are still isolated, the unpolymerized surface layer should be removed by washing and drying to avoid an unpleasant taste. 7- Finish Feel gently with blunt explorer or small ball ended burnisher for the edges. 8- Evaluation of occlusion With articulating paper. All centric stops should be on the enamel. A small round bur at slow speed will remove the excess effectively 9- Recall and evaluation Reevaluate for the surface for loss of materials ,voids and caries development esp in the 1st month 5% to 10% of sealants need to be repaired or replaced yearly. If a sealant is partially or completely lost, any discolored or defective old sealant should be removed and the tooth re-evaluated Recommendations: 1. Sealants should be placed into pits and fissures of teeth based upon the patient’s caries risk, not the patient’s age or time lapsed since tooth eruption. 2. Sealants should be placed on surfaces judged to be at high risk or surfaces that already exhibit incipient carious lesions to inhibit lesion progression. Follow-up care, as with all dental treatment, is recommended. 3. Sealant placement methods should include careful cleaning of the pits and fissures without removal of any appreciable enamel. Some circumstances may indicate use of a minimal enameloplasty technique. (with a round carbide bur or tapered fissure bur). 4. A low-viscosity hydrophilic material bonding layer, as part of or under the actual sealant, is recommended for long-term retention and effectiveness. conclusion. The placement of sealants is relatively simple but is technique sensitive Preventive resin restoration PRR Is an alternative procedure for restoring young permanent teeth that require only minimal tooth preparation for caries removal but also have adjacent susceptible fissures. PRR consist of 2 part: P=preventive=fissure sealant RR=resin restoration=composite. Indication of PRR Small pits or fissure caries in post teeth in non stress bearing area Deep pit and fissure  Anesthetized the tooth( if necessary). Isolate the tooth. Remove the caries. Etched the cavity and the enamel beside the susceptible grooves(A gel or liquid form of 37% phosphoric acid is commonly used for 20 seconds0. Thoroughly wash the tooth for approximately 30 to 40sec then dry the tooth. Apply a thin layer of bonding agent to the cavity (extreme of air)????  Fill the cavity or cavities with a light-curing composite or resin-modified glass ionomer and cure it Place a light-curing sealant over th remaining susceptible areas and brushed into the pits and grooves. check the occlusal contacts.  The lingual grooves of maxillary molars and the buccal grooves of mandibular molars are also commonly etched and sealed.