1. PREVENTION OF DENTAL CARIES-II

2. Contents Mechanical measures for caries control
Oral prophylaxis
Toothbrushing
Mouthrinsing
Use of dental floss or toothpicks
Incorporation of detergent foods in the diet
Pit and fissure sealants
Diagnosis of dental caries
Methods of caries detection
Caries risk assesment
Caries risk classification guidelines
Cariogram

3. Caries activity tests
School dental health programs
Methods on the horizon
Conclusion

4. Mechanical measures for caries control
Refers to procedures specifically designed for and aimed at removal of plaque from tooth surfaces.
Although progress has been made in identifying the pathogens,mechanical removal of plaque and promotion of remineralisation of the tooth surfaces remain as the primary method in preventing dentalcaries.
The mechanical methods of tooth cleaning were reviewed and classified by HINE as:
oral prophylaxis by dentist
Toothbrushing
Mouthrinsing
Use of dental floss or tooth picks
Incorporation of detergent foods in the diet
Pit and fissure sealants

5. Oral prophylaxis
In the control of periodontal diseases,the value of routine scaling and polishing of the teeth at periodic intervals of 3-6 months is important.
Careful polishing of roughened tooth surfaces and correction of faulty restorations reduces development of new caries.
Plaque control efforts should be directed towards 2 goals:
1)limiting the no: of S.mutans in dental plaques by mechanical elimination of supragingival plaque and limitation of dietary sucrose.
2)maintaining gram positive flora associated with gingival health by subgingival removal of plaque.

7. Tooth brushing Most widely used technique for plaque removal on teeth.
Minimum time of 5min daily has been recommended for brushing,flossing or using interproximal cleaning aids.
Developed from ancient custom of chewing twigs of lentisk wood or other aromatic twigs to avoid badbreath.
Sponges,shredded ends of sticks,index finger covered with cloth,salt were used.

8. Earliest toothbrush of ivory or bone made in china in 1600AD.
First nylon brushes in 1938.
However value of toothbrushing in dental caries control is still under argument.

9. mouthrinsing
Use of mouthwash loosens food debris from teeth and helps in caries control.
Detranase, an agent that helps to disperse dental plaque by hydrolysing streptococcal polysaccharides in vitro has been used in mouthrinses,
Here the therapeutic agent is directed at a specific metabolic product of causative organism rather than organism itself.

10. Oral irrigators
Use of flushing devices was first reported in early 1900s.
Though beneficial on gingival infections, effect on dental caries control have not been reported.

11. Dental floss Gillings developed flouridated dental flosses.
As early as 1819, Levi Parmly wrote of dental floss “it is to be passed through the interstices of the teeth between their necks and arches of the gum to dislodge that irritating matter which is the real source of disease.”
Found effective in removing plaque from an area gingival to the contact area on proximal surfaces of the teeth,an area impossible to reach with the toothbrush.
Gillings developed flouridated dental flosses.

12. Detergent foods
High caries incidence among modern civilized races is related to use of soft,sticky,refined foods.
Fibous food in diet prevent food lodging in the pits and fissures of teeth and thus act as detergents.
Crowley and Rickert reported 18% reduction in no: of bacteria in the mouth after eating.

13. Pit and fissure sealants
Pit and fissure caries are the most prevalent type,since they are the most difficult area on teeth to clean.
Hyatt in 1923, in ‘Prophylactic odontomy’advocated filling of fissures with silver/copper oxyphosphate cement as soon as teeth erupts and later,preparing a small cavity and filling it with amalgam.So these pits and fissures will be less susceptible to caries.
In 1960s sealants were developed by BUONOCORE which were acrylic filling material applied with acid pretreatment(30-50%H₃PO₄ for 60 sec) to enhance retention.

14. Caries of pit and fissure
In 1897 BLACK noted that pit and fissure don’t cause caries but provides a sanctuary to those carious agents.
Micro organisms and food enter into these sheltered,warm,moist area and dental plaque can be expected to form here.
In caries susceptible persons,when carbohydrates come in contact with the plaque,acidogenic bacteria in plaque create acid which damages enamel walls of pits and fissures and result in caries.

15. Morphology of fissures
NANGO(1960) described 4 principal types of fissures based on alphabetical description of shape:
1)V type shallow,wide and tend to be self cleansing
2)U type and somewhat caries resistant.
3)I type –deep,narrow,resembling bottleneck caries susceptible.
4)K type –caries susceptible.

16. Frequency of pit and fissure caries
Lower molar -50%
Upper molar %
Upper and lower 2nd Pm
Upper lateral & upper 1st Pm
Upper central & lower 1st Pm

17. Sealants contain a)Cyanoacrylate or b)Polyurethane or
c)bisphenol-A & glycidyl methacrylate
RIPA and COLE (1970) reported 84.3%reduction in occlusal caries on cyanoacrylate sealant application.
GIC(Glass ionomer cement)also used due to high fluoride content.
Studies indicate that an easily applied anticariogenic material that readily bonds to enamel surface after mechanical cleaning and cheap enough to be applied routinely on regular visits might be the answer to prevent occlusal caries on a large scale.

18. Thus pit and fissure sealants are materials which are designed to prevent pit and fissure caries which are applied to the occlusal fissures and remove the sheltered environment in which caries may thrive,forming a mechanical,physical protective layer against the action of caries producing bac and substrate.

19. DIAGNOSIS INVIVO METHOD INVITRO METHOD Single tooth measurements
Chemical analysis
Crosssectional microhardness testing
Polarised light microscopy
Traditional transverse microradiography(TMR)
Microprobe analysis
Methods for sequential measurements on toothslabs
Iodine absorbitometry
Longitudinal microradiography
Light scattering
Surface microhardness
Visual examination
Tactile examination
Radiography-conventional,digital,xeroradiography
FOTI
Optical methods-fluorescence,light scattering
Electronic resistance measurements
Ultrasonics
Dyes

20. IOPA
Optical aids
DIAGNOdent
FOTI

21. Newer advances like Microprobe analyser Microhardness tester
Infrared tomography
Infrared thermography
Optical coherence tomography
Digital detectors

22. Caries risk assessment
RISK – probability that some harmful events will occur.
Risk Indicators
Circumstances that may indicate increased caries risk.
Factors related to general health which may indicate increased caries risk.
Epidemiological factors
Clinical findings
Biochemical factors like dental plaque.

23. FACTOR
Amount of plaque
Type of bacteria
Type of diet
Frequency of carbohydrates
Saliva secretion
fluorides
HIGH RISK
↑ plaque , ↑ bacteria that can produce acids..
↑ cariogenic bacteria results in low pH and sticky plaque.
↑ carbohydrate specially sucrose,sticky diet results in low pH.
High sugar frequency
↓ saliva flow lead to prolonged sugar clearance time.
Absent:reduced remineralisation.
LOW RISK
↓ bacteria=good oral hygiene.
↓ cariogenic bacteria.
Low sugar content
Non sticky diet.
Low sugar frequency.
Optimal ,helps to wash out sugars and acids.
Present: increased remineralisation.

24. Low Moderate RISK CATEGORY Age category for recall child /adolescent
Patients
Adult
Low
Moderate
No carious lesion in last year.
Sealed pits and fissures.
Good oral hygiene.
Appropriate fluoride use.
Regular dental visits.
1 carious lesion in last yr.
Deep pits and fissures.
Fair oral hygiene.
Inadequate Fl white spots and/or interproximal radiolucencies.
Orthodontic treatment.
No carious lesion in last 3 yrs.
Adequately restored surfaces.
1carious lesion in last 3yrs
Exposed roots.
White spots and /or radiolucencies.
Irregular dental visits.
Orthodontic treatment.

25. High risk
≥2 carious lesions in last yr.
Past smooth surface caries.
Elevated mutans streptococci count.
Deep pit and fissure.
Poor oral hygiene.
Frequent sugar intake.
Irregular dental visits
Inadequate saliva flow.
Inappropriate bottle feeding or nursing.
2 carious lesions in last 3 yrs.
Past root caries.
Elevated st.mutans count.
Deep pit and fissures.
Poor oral hygiene.
Frquent sugar intake.
Inadequate use of topical Fl.
Irregular dental visits.
Inadequate salivary flow.

26. CARIOGRAM
Model proposed by BRATTHALL.DOUGLAS (1996),WHO collaborating centre,Malma University,Sweden.
Introduced to illustrate interactions between bacteria,diet and host response.
Process of making evaluation – CARIOGRAPHY.

27. CHANCE - chance to avoid new cavities in near future.
DIET frequency of eating as well as contents of diet.
BACTERIA-plaque amount as well as type of bacteria.
SUSCEPTIBILITY-tooth resistance (Fl)and saliva characteristics.
CIRCUMSTANCES –past caries experience and general diseases and condition.

28. Cariogram principles
Caries risk is expressed as “percent chance to avoid caries”
For eg: a low percentage ie 5% indicates high caries risk whereas 90% indicates low risk.
Chance to avoid cavities must be between 0-100%,it cannot be –ve or more than 100%.

29. Broken circle illustrates a situation where something is missing for cavity formation.Its a +ve situation.
Large sector (any colour)indicates increased caries risk.
The interactive cariogram computer program calculates the present chance to avoid cavities,by entering values ranging from 0-3 for different parameters.”0” is the most favourable value,and maximum “3” indicates a high unfavourable risk value.

31. How to control caries?how to avoid cavities?
Open the circle!!
Dark blue sector is reduced indicating that frequency of sugar containing snacks have been reduced…
Result:less frequent acid attacks.

32. Red sector is reduced indicating the number of cariogenic bac
Proper oral hygiene,reduction of S.mutans & lactobacilli are examples of this action.
RESULT: less acid formed ,slower demineralisation.

33. RESULT: slow demineralisation ,more efficient remineralisation.
Light blue sector reduced indicating that susceptibility to disease has been reduced,by proper use of Fl.
RESULT: slow demineralisation ,more efficient remineralisation.

34. Caries activity tests
Caries activity refers to the increment of active lesions over a stated period of time.Its a measure of speed of progression of a carious lesion.
Its also defined as “the occurrence and rate at which teeth are destroyed by the acid produced by plaque bacteria”
Caries susceptibility –inherent tendency of the host and target tissues ,the tooth, to be affected by the carious lesions.
The test measures the degree to which the local environmental challenge favours probability of occurrence of carious lesions.

35. Identify high risk groups and individuals.
CARIES ACTIVITY TEST helps us to
Identify high risk groups and individuals.
Determine need for personalised preventive measures and motivate the individual.
Monitor the effectiveness of oral health education programs by establishing an initial baseline level of cariogenic pathogen as a basis for future evaluation.
Ensure a low level of caries activity before starting any extensive restorative procedures.
Serve as an index of success of therapeutic measures by monitoring patient behaviour towards reducing the no: of S.mutans & Lactobacilli as part of councelling to curtail sucrose intake.

36. ideal requisities of caries activity test-SNYDER
Should have a sound theoretical basis.
Should show max correlation with clinical status.
Should be accurate with respect to duplication of result.
Should be simple.
Should be inexpensive.
Should take little time.

37. The Various caries activity tests are:
Lactobacillus colony count test
Colorimetric snyder test
Swab test
S.Mutans level in saliva
Dipslide method for S.mutans count
Salivary buffer capacity test
Salivary reductase test
Enamel solubility test
Alban test
Streptococcus mutans screening test
Fosdick calcium dissolution test
Dewar test

38. Lactobacillus in tomato peptone agar
Swab test
Snyder test
S.Mutans in saliva
Salivary buffer capacity test

39. Limitations…
Not highly reliable as the tests measure a single parameter..
However dental caries is a multifactorial disease and so caries activity can be found out from combined use of several selected tests…

40. School dental health program.
Beginning of school health services in India dates back to 1909 – medical examination of school children in BARODA city.
COLGATE ORAL PHARMACEUTICALS have developed an oral health educational program to teach children about caring for their teeth through website

41. Elements/components of school dental health program.
Improving school community relations
Conducting dental inspections
Conducting dental health education
Performing specific programs
-Toothbrushing programs
-classroom based Fl programs
Fl mouth rinse program
Fl tablet program
-School water fluoridation program
-nutririon as a part of school preventive dentistry programs
-sealant placement
-science fairs
Referral for dental care
Follow up

42. Some school dental health programs:
Learning about your oral health-a prevention oriented school program
Tattletooth program-Texas statewide preventive dentistry program
ASKOV dental demonstration
North Carolina Statewide Preventive dental health program
Headstart –pre school dental health program
SHARP-School Health Additional Referral Programme
Teenage Health Education Teaching Assistants Program(THETA program)
Colgate’s Bright Smiles ,Bright Future

44. Advantages
Can bring out comprehensive dental care incluing preventive measures.
Students can be assessed during their formative years.
Less threatening than private offices
Helps to develop lasting effect in attitude towards dentistry.
Helps to maintain dental health in adult life.
Regular dental attendance pattern can be developed.
Can facilitate valuable consultation on medicodental problems.
Less expensive and less time consuming when compared to private dental clinic visit.
Health of school staff,families and community members can be enhanced.

45. Methods on the horizon…..
Upcoming methods based on 3 strategies:
Combating caries inducing micro-organisms
Increasing tooth resistance against acid attack
Modifying cariogenic diet ingredients
ANTIPLAQUE AGENTS
Antibacterial and antiadherence agents are being tested as plaque building blockers.
Rajesh et al (1997) tested efficacy of mango leaf,neem leaf and tea extracts and found that all 3 were effective in reducing plaque formation.

46. Single dose can be effective for several hours…
KEEP 32
A new molecule that kills S.mutans found out by 2 scientists,Jose Cordova,a researcher at Yale University & Erich Astudillo from Chile….
If proved to be succesfull it will be added to toothpastes and food items…
Single dose can be effective for several hours…

47. 2.Surface active polymeric agents for surface adhesive binding has been developed by Bowen for increasing tooth resistance.
3.LASERS
CO₂ lasers used to alter tooth surface of enamel and make it less prone to caries.Pits and fissures are the target areas of lasers.
4.BENIGN MICROORGANISMS/REPLACEMENT THERAPY
Use a thorn to draw a thorn philosophy to superside cariogenic bacteria by more benign ones.
The dominant lactic acid produced by S.mutans controlled by a gene that can be mutated with genetic engineering.

48. 5. SAP(Self assembling polypeptides)
Strafford et al suggested SAP inorder to promote enamel remineralisation.
These protective peptides are used as pacifiers for young children to help modify bacterial flora against baby bottle caries.
Also used in mouthrinses and dentifrices.
6.CHEWING GUMS
Use of sugar free chewing gums with additions like xylitol,lacitol and urea after meals to counter Pᴴ drop that occurs with intake of sugars.
Gopinath & Tandon (1996) ,found that urea showed highest Pᴴ and so can be used in high risk caries children.

49. 7.TOOTH FRIENDLY SWEETS 8.MICRODENTISTRY
Use of noncariogenic sweeteners proved to be excellent measures in caries control.
Eg:LACTITOL 4-0-D-GLUCITOL incorporated in biscuits.
8.MICRODENTISTRY
An educational and motivational tool that enables use of microscope to detect conditions invisible to naked eye.
Aim is to remove as little of natural tooth as possible while removing decay.

50. Enhanced microscopic view.
Magnified image
Digital monitoring
Intraoral digital camera
Rondoflex air abrasion

51. TELEDENTISTRY
Field of dentistry that uses dental health records,telecommunication technology,digital imaging and internet to link dental care workers in rural or remote communities with specialists in larger communities.
Dental colleges could be ideal places to serve as hubsites for teledentistry consultation as they encompass all specialists serving under a common roof.

52. CONCLUSION
Control and prevention of dental caries presents one of the greatest challenge in dental profession today.
As KAUFFMAN has stated “the supreme ideal of the dental profession should be to eliminate the necessity for its own existence”

53. REFERENCE
SOBEN PETER:Essentials of Preventive and Community Dentistry(3rd & 4th edition)
SHOBHA TANDON:Textbook of Pedodontics
S.G.DAMLE:Textbook of Pediatric Dentistry
GEORGE .M. GLUCK &
WARREN.M.MORGANSTEIN:Jong’s Community Dental Health,5th edition
Shafer’s Textbook of Oral Pathology-6th edition
SATISH CHANDRA & SHALEEN CHANDRA:Textbook of Preventive Dentistry.
British Dental Journal
PubMed.com

54. Thank
You