Preventive Agents/Products Board Review DH227 Concorde Career College Lisa Mayo, RDH, BSDH

Fluoride Fluoride in average topical treatment Toxic Dose Safe Dose 45mg for NaF 61.5mg for APF Toxic Dose Induce emesis F ion can bind to a liquid of MILK or LIME JUICE Call 911 Safe Dose Adult: 1.25-2.5G Child: 0.5G Lethal Dose F 32-64mg of PURE fluoride per Kg body weight Adult: 5-10G Child: 0.5-1.0G

Fluoride: Toxicity Symptoms being within 30min – 24hrs GI: hydrochloric acid acts on F ion to form hydrofluoric acid – irritates stomach lining Nausea, vomit, diarrhea, abdominal pain, increase salivation, thirst Systemic Involvement Symptoms of hypocalcemia Hyper-reflexia, convulsions, parasthesia Cardiac failure, resp. paralysis Treatment Induce vomiting (emesis) Administer F-binding agents

Fluoride: Toxicity Skeletal fluorosis Dental fluorosis Results after long-term use of water with 10-25ppm for industrial exposure Dental fluorosis When excess F is in drinking water during the years of tooth development Birth til 12-16yrs or when crowns of permanent 3rd molars are completed

Amt F Ingested Emergency Tx ≤5mg/kg 1. Admin fluoride-binding agent ≥5mg/kg 1. Induce vomiting (emesis) 2. Admin fluoride-binding agent 3. Seek medical tx ≥15mg/kg 1. Seek medical tx 2. Induce vomiting 3. Cardiac monitoring

Question What is the first measure that should be taken when a child ingests a toxic amount of topical fluoride? Drink milk Induce vomiting Seek medical attention Administer fluoride-binding agent

Answer What is the first measure that should be taken when a child ingests a toxic amount of topical fluoride? Drink milk Induce vomiting Seek medical attention Administer fluoride-binding agent

Question How long can acute fluoride toxicity last? 1 hour 10 hours 10 minutes Up to 24 hours

Answer How long can acute fluoride toxicity last? 1 hour 10 hours 10 minutes Up to 24 hours

Question What is the safely tolerated dose of topical fluoride? >5mg/kg >15mg/kg ¼ the certainly lethal dose The amount of drug likely to cause death if not intercepted by antidotal therapy

Answer What is the safely tolerated dose of topical fluoride? >5mg/kg >15mg/kg ¼ the certainly lethal dose The amount of drug likely to cause death if not intercepted by antidotal therapy

Fluoride Absorption In Body Begins in stomach as hydrogen fluoride Rate depends on solubility of F compound & gastric activity ↓ when taken with milk/food Most absorbed in 60min Whatever not absorbed by stomach – small intestine Plasma in blood carries it through body Max blood levels reached in 30min after intake

Fluoride Distribution In Body Strong affinity for calcified tissues – 99% located in mineralized tissues Highest concentration in surfaces closest to the source supplying F: Highest level is on the tooth surface Stored in crystal lattice of teeth and bones Amount stored varies w/ intake amt, exposure time, age/stage of development Exposed dentin F concentrations < enamel

Fluoride Excretion In Body Kidneys by urine Small amts in sweat and feces Limited transfer via breast milk Pre-Eruptive Stage Deposited during formation of enamel starting at DEJ Incorporated in crystals during mineralization New crystals = fluoroapatite = less soluble then hydroxyapatite Results = shallower grooves, less fissures Post-Eruptive Stage F benefits from topical application only Uptake most rapid on enamel surface during 1st 2yrs after eruption Topical = fluorhydroxyapatite (Free F ion moves into crystal & forms) Mature enamel reacts with fluoride to primarily form CaF Demin: CaF dissolves 1st, then hydroxyapatite, then fluorhydroxyapatite

Fluoride: Role in Caries Process Reacts with hydroxyapatite to form FLUORAPATITE Interferes with bacterial metabolism High concentrations: bactericidal Low concentrations: bacteriostatic Has substantivity: ability to be bound to pellicle and tooth surface and be released over a period of time with retention of potency Aids in accelerated maturation At time of tooth eruption, enamel not fully calcified and undergoes post-eruptive period during which enamel calcification continues F will be rapidly absorbed into the enamel

Fluoride Therapy Methods Systemic Systemic: water, supplements, food Topical: toothpaste, rinse, in-office Systemic Most F absorbed by stomach and intestines and stored in the bone as fluoroapatite Most efficient from 6mo-14yrs Excreted by kidneys

Fluoride Therapy Systemic Fluoridation: adjustment of F ion content of domestic water supply to the optimum physiologic concentration that will provide max. protection against caries and enhance appearance of the teeth with min. possibility of producing objectionable enamel fluorosis 1965: 1st communities fluoridated Avg cost: $0.13 - $5.48 per person/year Most cost effective way to bring F to a community

Fluoride Therapy Community Fluoridation Levels range 0.7-1.2ppm mg/L Warmer climate = lower Colder climate = higher EPA monitors Compounds used: 1. Sodium fluoride 2. Sodium silicofluoride 3. Hydrofluosilic acid

NBQ To deliver water to a community through water fluoridation. If a person lives in a colder climate, what ppm fluoride would be expeted? 0.7ppm 0.9ppm 1.2ppm 1.4ppm

NBQ To deliver water to a community through water fluoridation. If a person lives in a colder climate, what ppm fluoride would be expeted? 0.7ppm 0.9ppm 1.2ppm 1.4ppm

Fluoride Therapy Community Fluoridation Most effective in reducing caries smooth surface Least effective in reducing caries pit and fissures Ant teeth have better protection then post Adv: Decrease caries by 25% in post eruptive teeth Cost effective Safe Benefits kids and adults

Fluoride Therapy Community Fluoridation Disadv. 1. Have to drink community water Reasons why not universal 1. Controversial effects of systemic F 2. Public not informed of benefits of F 3. Powerful Lobbyist's - Courts have upheld the legality of water fluoridation

Fluoride Therapy Tooth colored restorations: NaF Topical APF: Acidulated Phosphate F NaF: Sodium F SnF: Stannous F MFP: monofluorophosphate

Fluoride Therapy: Topical Stannous F Unpleasant taste, Unstable solution Stains teeth in demin areas Gingival sloughing Discoloration restorations APF Not for tooth colored restorations: acid will etch glass components - pits and roughens material Varnish 5% NaF (22,600ppm) ADA recommended Desen roots, Caries (14% more effective than other topicals) Retained for 24-48HRS during which time F released for reaction w/enamel 2 to 4 times per year

Fluoride Therapy NaF APF SnF2 Concentration 2% 1.23% 8% ppm F 9,050 12,300 19,360 Efficacy 29% 28% 32% pH 9.2 3.0-3.5 2.1-2.3 Adverse Rxns None May etch rest materials Brown staining, gingiva rxn Application Freq 4x/yr ages 3,7,10,13 1-2x/yr

Fluoride Therapy: Topical Safety Under 6yrs – no rinses (swallow) Self-Applied F Tray, rinse, toothbrush Frequent, low concentrations F to promote remin. Bacteriostatic

At-Home Fluoride Application: tray, rinse, toothbrush Low concentration, frequent application Promote remin (bacteriostatic effect) Ex: Rinse: 0.05% NaF, 225ppm Dentifrice: 400-1500ppm Gels: 0.4% Stannous (1,000ppm) pH2.8-5.0 or 1.1% NaF (5,000ppm)

Question Which of the following topical fluoride delivery systems is BEST for an individual with rampant caries? Tray Rinse Painting Toothbrushing

Answer Which of the following topical fluoride delivery systems is BEST for an individual with rampant caries? Tray Rinse Painting Toothbrushing

Question Self-applied fluoride rinses are: Rarely suggested for adults Available by prescription only Are effective in caries prevention and control Too expensive to be considered cost-effective

Answer Self-applied fluoride rinses are: Rarely suggested for adults Available by prescription only Are effective in caries prevention and control Too expensive to be considered cost-effective

Question In what percentage is professional strength, in-office sodium fluoride gel? 2% 5% 1.2% 1.23%

Answer In what percentage is professional strength, in-office sodium fluoride gel? 2% 5% 1.2% 1.23%

Dietary Fluoride Supplements Recommended for kids who live in areas with inadequate water fluoridation NOT recommended for pregnant women Fluoride in foods: tea/fish contain large amounts Includes tablets, lozenges, drops, liquids, F-vitamin preparations containing NaF (most common) or APF Tablets intended to be chewed, swished and swallowed Drops are used on infants Daily use better at caries reduction then systemic F Not recommended on infants who are breastfed (breast milk contains 0.0004ppm) School-based F supplement programs yield 30%↓ caries

Question What is the best method of fluoride application for caries prevention? Concentration Frequency Low Low Low High High Low High High

Question What is the best method of fluoride application for caries prevention? Concentration Frequency Low Low Low High High Low High High

ADA Table Age Concentration of Fl Ion in Drinking Water ≤0.3ppm Birth-6mo None 6mo-3yrs 0.25mg/day 3-6yrs 0.5mg/day 6-16yrs 1.0mg/day

Board Question What agency monitors the amount of fluoride in community water supply? Bureau of Land Management Food and Drug Administration Environmental Protection Agency Occupational Health and Safety Administration

Board Question What agency monitors the amount of fluoride in community water supply? Bureau of Land Management Food and Drug Administration Environmental Protection Agency Occupational Health and Safety Administration

Board Question All of the following are added to the water for community water fluoridation, EXCEPT one. Sodium fluoride Sodium silicofluoride Hydrofluorosilic acid Acidulated phosphate fluoride

Board Question All of the following are added to the water for community water fluoridation, EXCEPT one. Sodium fluoride Sodium silicofluoride Hydrofluorosilic acid Acidulated phosphate fluoride

Systemic Fluoride Pre-Eruptive Circulates in the bloodstream and is incorporated into the enamel of developing teeth Rapidly absorbed in stomach and small intestine Effective for 6mo-14 years of age Amount not used is excreted through kidneys Once thought to be primary action, now understood to be a minor effect compared with the post-eruptive action of fluoride F incorporated into the mineralized tooth structure during tooth development by the replacement of hydroxyapatite w/fluorapatitie during enamel formation

Demineralization Dissolution of the Calcium and Phosphate ions from the hydroxyapatite crystal of the tooth that are lost into the plaque and saliva Occurs when pH drops below 4.5-5.5 enamel 6.0-7.0 cementum Prevention 1. Good plaque control 2. Fluoride uptake 3. Restricted sugar intake

Remineralization Calcium, phosphate, other ions in saliva and plaque are re-deposited into previously demin. areas When pH rises above “critical levels” Remin. areas tend to be stronger and more acid resistant then original structure Fluoroapatite has been formed Requirements same as demin.

NBQ Prevention and control of smooth surface dental caries if MOST effectively managed by: Biannual dental hygiene recall visits Early radiographic detection Dental sealant application Diet rich in fermentable carbohydrates Fluoride therapy

NBQ Prevention and control of smooth surface dental caries if MOST effectively managed by: Biannual dental hygiene recall visits Early radiographic detection Dental sealant application Diet rich in fermentable carbohydrates Fluoride therapy

NBQ Acidulated phosphate fluoride (APF) Is an acidic preparation of stannous fluoride Is difficult to use because of its instability in solution Should be applied every 6 months Is not recommended for children Is commonly recommended for OTC preparation

NBQ Acidulated phosphate fluoride (APF) Is an acidic preparation of stannous fluoride Is difficult to use because of its instability in solution Should be applied every 6 months Is not recommended for children Is commonly recommended for OTC preparation

Chemotherapeutics Definition: Treatment of disease by means of chemical substances or pharmaceutical agents Purposes In-Office 1. Pretx rinse to reduce org. 2. Pretx rinse to reduce aerosol contamination 3. Facilitate impressions 4. Rinse and fresh breathe 5. Replace surface F removed during tx 6. F rinse as part of caries prevention pgrm At Home 1. Vigorous rinsing to aid in oral cleansing 2. Saline rinse after nonsurgical perio therapy 3. Caries prevention

Chemotherapeutics Commercial Mouthrinses 1. Oxygenating Agents Cleanse via effervescent action Antimicrobial Active ingredients: H2O2, Na perorbate, Urea peroxide Concerns: black hairy tongue, sponginess of tissues, hypersensitivity of exposed roots, demin. tooth surface 2. Antimicrobial To reduce oral microbial count Inhibit bacterial activity Active ingredients: Chlorahexidine, iodine, iodophores, fluorides, phenol, essential oils, cetylpyridinum chloride, sanguinarine

Chemotherapeutics: CHX Mechanism of Action Bactericidal: active against wide range Gram (+) & Gram (-) Alters cell wall so that lysis occurs – cell destroyed Substantivty: rapidly absorbed into teeth and pellicle and is released slowly Clinical Uses Preprocedural rinse, decrease supragingivial bacteria, inhibits gingivitis, short-term adjunct following SRP, implants, suppresses S.mutans (may aid in prevention caries) Side effects (next slide)

Chemotherapeutics Side Effects Temp loss of taste Bitter taste Burning sensation of mucosa Dryness Epithelia desquamation Discoloration of teeth, tongue, restorations Slight increase supragingival calculus formation (related to dead bacteria that remin. as a result of bactericidal action)

CHX RX Most effective ant-plaque/gingivitis chemotherapeutic agent Broad specturm bacterio-static/cidal Kills gram (+)(-) microbes US only 0.12% Mode of action: binds to hydroxyapatite and glycoPRO thus ↓ pellicle formation Absorbs into bacterial cell surface & interferes with cell attachment Prevents bact accumulation Inactivated by SLS detergents 8-12 active hours

Antimicrobials Tobacco User Cancer Pt Acute Perio Disease Advise to use non-alcohol Alcohol + tobacco = synergistic effect, increase risk of cancer Cancer Pt Rinse baking soda/saline followed by H2O/CHX, avoid alcohol mouthrinses Acute Perio Disease Warm water or weak saline solution, CHX Alcohol Condition Avoid alcohol rinses, if being treated with DISULFIRAM can have medical emergency

Xylitol Used in food/snack items as a noncariogenic sweetner Evidence of anticariogenic and cariostatic properties Control dental caries in people with moderate to high risk for caries Reduced S.mutans Makes plaque biofilm less adhesive Allows enamel surface to remin.

Novamin Ca and Phosphate ions in ACP will seek out areas of demin and enhance enamel remin., occlude dentinal tubules, increase F uptake, prevent caries progression High risk caries groups should use People w/ sensitivity should use Should be used in combo with F Toothpaste, polish paste, sealant

Recaldent / Casein Phosphopeptides Enhance the effects of F & provides a supersaturated environment of Ca and P for remin. Not a F substitute High caries risk, sensitivity issues Caries prevention Gum, pastes, professional application

Oral Irrigation Effective method of delivery for Chemotherapeutic agents Disrupts loosely adherent microbial colonization Point tip perpendicular to long axis of tooth BOARDS: GOOD FOR GINGIVITIS REDUCTION

Oral Irrigator Indications Delivery of liquid antimicrobial agent Presence of gingival inflammation and bleeding Disruption of loosely adherent plaque Ortho Least effective method of removing plaque when compared to other oral physiotherapy aids

NBQ What is the purpose of an oral irrigator? To remove subgingival plaque that is adherent to the tooth To remove supragingival plaque that is adherent to the tooth To disrupt loosely adherent plaque in the sulcus To disrupt tightly adherent plaque in the sulcus

NBQ What is the purpose of an oral irrigator? To remove subgingival plaque that is adherent to the tooth To remove supragingival plaque that is adherent to the tooth To disrupt loosely adherent plaque in the sulcus To disrupt tightly adherent plaque in the sulcus

Supplemental Aids Disclosing agents Floss and tape Floss threader Tufted floss, yarn, gauze: embrasures, pontics, ortho, implants End Tuft Interproximal: embrasures, pontics, FPD, ortho, perio splints, proximal cavities, class V furcation’s, delivering chemotherapeutics Wooden/plastic/triangular wedges/sticks: embrasures Toothpicks, perio aid, rubber tip: embrasures, concavities, furcation's, ortho, apply chemotherapeutics, biofilm removal at/below gum line Tongue cleaners Power brush Oral Irrigation

Denture/Partial Care Rinse under water Brush: water, soap, non-abrasives (toothpaste, paste, powders) 3. Immersion: solvent, detergent, prevent drying them out, use mouthrinse for pleasant taste, daily Alkaline Hypochlorite: bleach, loosen debris and stains, dissolve plaque matrix Alkaline Peroxide: loosen debris, stains, not for heavy stains Dilute Aids: dissolve inorganic components of deposits Enzymes: break down plaque PRO Disinfectants: NaCl - antimicrobial agent, not use metal dentures, good stain remover, soak 10-15min 4. Mechanical cleanser: ultrasonic, magnetic, sonic

Denture/Partial Oral Lesions Reactive / Traumatic Acute or chronic Ulcers, focal hyperkeratosis, denture-induced fibrous hyperplasia, redness Infectious Lesions Denture stomatitis, angular cheilitis, candidiasis/thrush Mixed Reactive Etiology: Trauma and infection Root caries, papillary hyperplasia

Denture/Partial Oral Lesions Systemic-Disease Related Paget’s Disease: rapid resorption and deposition of bone, enlarged jaw bones, fuzzy-looking on radiographs, etiology unknown Acromegaly: overproduction growth hormone, enlarged mandible, lips, tongue, hands, feet Oral Cancer Pernicious Anemia: vitamin deficiency (B12)

Power Toothbrush Indications People with manual dexterity problems Caregivers providing oral care Implants

Interdental Brushes Indications Open embrasure spaces Diastema’s Implants – only if plastic wire Mild arthritis Accessible Class III or IV furcation areas

Tufted Brushes Indications Rotated teeth Hard to access third molars Accessible Class III or IV furcations

Toothpick Indications Accessible furcation areas Shallow pockets Normal sulcus depths Patient who already uses toothpicks

Floss Threader Indications Fixed bridges Ortho Use in conjunction w/dental floss

Floss Holder Indications People who are physically / dexterity challenged to use dental floss with fingers Those with large hands Gag reflex

Tufted Floss Indications Bridges Ortho Does not need floss (bridge) threader

Dental Floss Indicated for use proximal surfaces Aids in min interprox decay Should start flossing child’s teeth when proximal surfaces contact each other

NBQ Powered toothbrushes may be: Indicated for individuals who are physically or mentally challenged Effective tools for subgingivial plaque control in pocket depths up to 4mm More traumatic to gingiva and cementum that manual toothbrushes Contraindicated for individuals with mitrovalve prolapse More difficult to use and require increased instructions time

NBQ Powered toothbrushes may be: Indicated for individuals who are physically or mentally challenged Effective tools for subgingivial plaque control in pocket depths up to 4mm More traumatic to gingiva and cementum that manual toothbrushes Contraindicated for individuals with mitrovalve prolapse More difficult to use and require increased instructions time

NBQ Which of the following home care armamentariums is the LEAST effective plaque control tool for a client with dental implants and a fixed prosthesis? Tapered end tuft toothbrush Soft bristled, multi-tufted nylon toothbrush Rubber tip stimulator Mild abrasive, ADA approved toothbrush Unwaxed dental floss

NBQ Which of the following home care armamentariums is the LEAST effective plaque control tool for a client with dental implants and a fixed prosthesis? Tapered end tuft toothbrush Soft bristled, multi-tufted nylon toothbrush Rubber tip stimulator Mild abrasive, ADA approved toothbrush Unwaxed dental floss

NBQ Interdental cleaning devises Conform to the anatomy of the proximal tooth surface May result in the loss of interdental papillae Are selective on the architecture and position of the gingiva Compare favorably with toothbrushing for interdental bacterial plaque removal Require excellent manual dexterity to manipulate

NBQ Interdental cleaning devises Conform to the anatomy of the proximal tooth surface May result in the loss of interdental papillae Are selective on the architecture and position of the gingiva Compare favorably with toothbrushing for interdental bacterial plaque removal Require excellent manual dexterity to manipulate

Oral Deposits Acquired Pellicle Amorphous, acellular, unstructured Reforms w/in min. after removal Composed of salivary glycoPRO Materia Alba Loosely adherent mass of bact and cellular debris Unstructured Resembles cottage cheese in appearance Forms over plaque in neglected mouths Can be removed by oral irrigation or water spray

Oral Deposits Food Debris Unstructured, loosely attached Collects at cervical 1/3 and interprox Can be removed by oral irrigation/water spray Plaque (Biofilm) Dense, nonmineralized mass of bacteria Organized and closely adherent Caries and perio d. are infectious d. caused by biofilm Not caused by single microorganism Pellicle – Biofilm - Calculus

Biofilm Formation Stages Pellicle formation Bacterial colonization Absorption of glycoPRO from saliva Bacterial colonization Colonies form and coalesce Maturation Bact multiply and may increase thickness Matrix formation Supragingival biofilm: saliva Subgingival biofilm: sulcular fluid Both contain polysaccharied (adherence properly)

Biofilm Composition 1-2 Cocci, aerobic, gram (+) Days Biofilm Composition 1-2 Cocci, aerobic, gram (+) S.mutans, S.sanguis, Actinomyces 2-4 Cocci, may see filaments and rods Colonization occurs in stratified layers against the tooth surface, matrix 4-7 Filamentous forms ↑, fusobacteria appear Biofilm thicken at margin 7-14 Vibrios and spirochetes appear, gram (-), aerobic, ↑WBC Sign of inflammation begin 14-21 Densely packed vibrios, spirochetes, filamentous bact. Biofilm blooms into mushroom shape attached by a narrow base that incorporates channel to capitalize on fluid movement Gingivitis

Biofilm 80% water 20% inorganic/organic elements 70-80% microbes Inorganic: Ca, phosphorous, fluoride Organic: CHO, PRO, Lipids

Calculus Mineralized plaque Formation 24-48 hours Centers grow and coalesce Ave time for detectable calculus = 12 days Pellicle – Plaque biofilm – Mineralization Sub-g vs Supra: sub harder and darker in color (pigments from blood breakdown) Attach supra via acquired pellicle Attach sub directly to cementum Significance Allows for bact attachment DOES NOT cause pocket formation!!!

Calculus Composition 10-30% water and organic elements Microbes Cells 70-90% inorganic Ca, phosphorous, carbonate, sodium, magnesium, potassium, trace elements, fluoride Rapid formers: greater Ca-phosphate Slow formers: greater pyrophosphate

Calculus Supra Sub-g Nutrient is saliva Color often white, yellow, gray Most commonly found near opening of salivary gland ducts Sub-g Nutrient source crevicular fluid & inflammatory exudate Color dark brown, dark green, black

Calculus Detection Explorers Dry teeth w/ compressed air 11/12 and pigtail for posteriors Orban-type for ant and cervical 1/3 of post Dry teeth w/ compressed air Radiographs (not always show calculus)

Question From which of the following is calculus most easily removed? Pellicle Enamel Cementum Restorative material

Answer From which of the following is calculus most easily removed? Pellicle Enamel Cementum Restorative material

Stain Color Cause Extrinsic Intrinsic Yellow/Brown Biofilm, food pigments, CHX, SnF x Orange, Red Chromogenic bact in plaque Poor OH, ant teeth Green Chromogenic bact, poor OH Fungi, Decomposed hemoglobin Black Line Bact (gram +), iron 1/3 of F/L Brown Tobacco, SnF, CHX, Cetylpyridinium, Food Source, Betel Nut Blue-Green Mercury, Lead Dust (occupational exposure), poro OH, dark beverages Gray, Black Metallic Ions from amalgam Gray, Brown Caries

Question What kind of stain does stannous fluoride cause? Brown Green Black Orange

Answer What kind of stain does stannous fluoride cause? Brown Green Black Orange

Stain Intrinsic (endogeneous) Not removable Possible causes Pulpal necrosis Internal resorption Excessive systemic fluoride Tetracycline

Question Which of the following stains is not caused by poor oral hygiene or smoking? Brown Orange Bluish-green Yellow-brown

Answer Which of the following stains is not caused by poor oral hygiene or smoking? Brown Orange Bluish-green Yellow-brown

Question An industrial worker presented to the dental office with a bluish-green stain on his teeth. The inhalation of which type of metallic dust from occupational exposure caused this stain? Gold Coal Nickel Copper

Answer An industrial worker presented to the dental office with a bluish-green stain on his teeth. The inhalation of which type of metallic dust from occupational exposure caused this stain? Gold Coal Nickel Copper

Toothbrushing Review Methods Handout Roll Bass Sulcular Modified Bass Stillman Modified Stillman Fones(circular) Horizontal (scrub) Leonard (Vertical) Occlusal

Question If your patient was a child with limited dexterity what method of brushing would you recommend?

Answer Roll or Fones Fones 1st technique for kids prior to dexterity development Roll: good as a technique prior to being able to use sulcular

Question What method of brushing is recommended for a 12 year old patient in full orthodontics?

Answer Charters Filaments 45 degree angle toward occlusal Enough pressure to force filaments between teeth Vibrate back and for 10sec 2-3x/teeth Heel/toe for anterior lingual’s

Question A 14-yr old girl presents to the office with swollen, bleeding gingiva. Which of the following would you recommend? Oral irrigator End-tuft toothbrush Soft toothbrush Disclosing solution

Answer A 14-yr old girl presents to the office with swollen, bleeding gingiva. Which of the following would you recommend? Oral irrigator End-tuft toothbrush Soft toothbrush Disclosing solution

Question A patient presents with misaligned mandibular anterior teeth. Which of the following oral physiotherapy aids would be BEST to recommend to clean these teeth at home? Dental tape End-tuft toothbrush Interdental brush Toothpick holder

Answer A patient presents with misaligned mandibular anterior teeth. Which of the following oral physiotherapy aids would be BEST to recommend to clean these teeth at home? Dental tape End-tuft toothbrush Interdental brush Toothpick holder

Dentifrices ↓ Caries ↓ Biofilm formation ↓gingivitis ↓ Supragingivial calculus ↓ tooth sensitivity Remove stains Whitening

Dentifrices Abrasives (20-40%) Humectants (20-40%) Detergents (1-2%) Clean and polish Physically remove biofilm and stain Smooth teeth: resists bact. accumulation & stains Factors that affect: particle hardness, size, shape, toothpaste pH, water and glycerin content, salivary characteristics Humectants (20-40%) Retain moisture Prevent hardening when exposed to air Stabilize preparation Detergents (1-2%) Loosen debris Surfactant (↓ surface tension) Foaming and emulsify debris

Dentifrices Binders (1-2%) Sweeteners (1-2%) Coloring agents Thickener Prevent separation of solid and liquid ingredients Sweeteners (1-2%) Create a favorable taste Xylitol, glycerine, manitol, sorbitol, saccharine Coloring agents Attractiveness but may cause mucosal rxns Vegetable dyes, tartrazine

Dentifrices Flavoring agents Preservatives (2-3) Mask other ingredients and present a pleasant taste and after-taste Essential oils, peppermint, cinnamon, spearmint, clove, wintergreen, menthol Preservatives (2-3) Prevent bact growths, formaldehyde, dichlorinated phenols Prolong shelf life Alcohols, benzoate

Specialty Dentifrices Whitening: some use hydrogen peroxide and others use carbamide peroxide Tooth sensitivity: occlude dentinal tubules Potassium nitrate/citrate/chloride; strontium chloride, sodium citrate, SnF Gingivitis reduction SnF, triclosan, zinc citrate + NaMFP Calculus reduction Tetrapotassium pyrophosphate Tetrasodium hexametaphosphate Zinc chloride, zinc citrate, triclosan/copolymer

Specialty Dentifrices Caries Prevention NaF, Na-monofluorophosphate, stannous, xylitol Halitosis Essential oils, chlorine dioxide, triclosan/copolymer, stannous fluoride, sodium hexametaphosphate

Mouthrinses Cosmetic/Breath-Freshner or Therapeutic General Functions ↓ biofilm, bact, inflammation General Functions Oxygenation, astringent, buffering, deodorizer, anodyne(pain relief), bacterio-static/cidal Ingredients Water: largest amt of volume Alcohol: ↑ stability essential oils, ↓ surface tension, 15-30% Flavoring agents: essential oils, eucalyptus oil, oil of wintergreen Aromatic waters: peppermint, spearmint, wintergreen Coloring: must not discolor tissues Sweetening agents Astringents: zinc chloride, zinc acetate, alum tannic, acetic acids, citric acids

Question Which of the following is the cause of dentinal hypersensitivity? Irritation to the pulp Aggressive toothbrushing Use of abrasive toothpaste Movement of fluid within the dentinal tubule

Answer Which of the following is the cause of dentinal hypersensitivity? Irritation to the pulp Aggressive toothbrushing Use of abrasive toothpaste Movement of fluid within the dentinal tubule

Which of the following is a TRUE statements regarding fluoride Which of the following is a TRUE statements regarding fluoride? (there is more then one right answer) Fluorine, the precursor to fluoride, is a naturally occurring element in air & water Fluoride is the end result of sodium bicarbonate mixing underground with clean well water The practice of civilized water fluoridation in populated areas is supported by scientific research to help prevent widespread tooth decay in children and adults. Persons who are at risk for developing early gum disease in their teens are recommended to buy meat and dairy with products injected with antibiotics to support their immune system. The level of fluoride recommended in drinking water for optimal dental health is 10.0ppm Fluoridation of city water systems has been common practice in the US since WWI g. Young children who ingest too much fluoride early in life develop teeth with short roots.

Correct Answers: A, C, F B = derived from hydrofluoric acid D= person at risk for tooth decay are to brush 2x/day with fluoride toothpaste E= Should be 1.0ppm G= would develop white spots on enamel

Order the following 1-4 to show the most reasonable steps in conducting a periodontal exam: Collect samples from the pockets to conduct a bacterial evaluation by microscope Do a visual inspections of the gums, connective tissues, lips, tongue Measure the distance ranging between 1-12mm of the gum tissue from the tooth Grow a culture of the bacteria collected to exactly identify strain and variety.

Answer 2, 3, 1, 4

For each symptoms, match correct disorder 1. Migraine Headache a. Oral Cancer 2. Canker sore, aphthous ulcer b. Lichen Planus 3. Bright red, smooth area c. Sutton’s Disease 4. Lines of lesions that form lacey-looking patterns d. TMD 5. Black tongue e. Sjogren’s Syndrome

Answer D C A B E Symptom Disorder 1. Migraine Headache a. Oral Cancer 2. Canker sore, aphthous ulcer b. Lichen Planus 3. Bright red, smooth area c. Sutton’s Disease 4. Lines of lesions that form lacey-looking patterns d. TMD 5. Black tongue e. Sjogren’s Syndrome D C A B E