Medalla, A.

DDM-3

Caries Process and Prevention Strategies: INTERVENTION

Cariology

HISTORY
FLOURIDE is one of the biggest success stories in the field of public health in preventing
caries.
- In 1999, the water fluoridation was declared as one of the 10 most important
public health measures in 20th century by the US CDC.

- It is beneficial in dentition because it can reduce caries, but if it taken too

much can cause a detrimental effect on teeth called dental fluorosis.

- Using fluoride, some dent professionals are advocates, some are not.

Frederick Mckay and H. Trendley Dean

- Two American dentists, given credit for the identification of fluoride as an
effective means of caries prevention.

Note:
Colorado Brown Stain (McKay)
 Colorado Springs, Colorado 1901
 90% children are affected, mottled/ brown enamel in US, England, Italy
 Oakley, Idaho put into theory due to water supply using water pump that leads to mottled enamel.
 Bauxite, Arkansas – water with high fluoride content.

1942; 21 City Study (Dean)

 Fluoride levels and caries level in children
 Develop 1st classification system for recording severity of mottled enamel using the terms
questionable, very mild, mild, moderate, and severe.

MECHANISMS OF ACTION OF FLOURIDE

3 Topical Mechanisms on the surface of the tooth
By Dr. John Featherstone
1ST MECHANISM
- Fluoride, if it is present, when the acids are produced by the bacteria, will go
into the tooth at the same time or before the acid.
It will stick or absorb on the surface (crystals) inside the tooth acting like body
guard and stopping the acid from dissolving the crystal surface.
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2ND MECHANISM

- If fluoride is present when the acid is neutralized, and that happens by action
of the saliva in the mouth, then the fluoride, together with the calcium and
phosphate from the saliva goes back into the tooth and remineralize or grows
a new surface of those tiny crystals- much more resistant.
3RD MECHANISM
- If the fluoride is present among the bacteria in the tooth when they produce acid, that
fluoride gets taken into the bacteria, slowing them down or even killing them.

Note:
Dental Fluorosis
 Detrimental effect of excessive fluoride on tooth enamel
 Teeth becomes speckled with white flecks.
 Severe: teeth become mottled with brown stains and pieces of surface enamel might easily break off.

FLOURIDE IN THE BODY AND ITS ROLE IN ENAMEL DEVELOPMENT

Enamel Maturation, How Fluoride Is Incorporated into The Inorganic Phase Of
Enamel Both In Pre And Post-Eruptive Stages
(By Dr. George Stookey)
 Fluoride is incorporated into the inorganic part of the enamel by substitution for either
hydroxyl ions or carbonate ions within the apatite lattice- demineralization of matured
or developed apatite crystal.

 Fluoride – most electronegative of all elements (bonds firmly with calcium)

 Right after the tooth erupts – best time.

 Pre-maturation (2-15 yrs.)- best time to apply fluoride.

 Post ingestion- 86%- 97% fluoride absorbed in stomach and small intestine

 Fasting- increase in fluoride absorption; Ca, Al, Mg- dec. fluoride absorption

 0.01-0.04 part per million – presence of fluoride in saliva.

 If low fluoride level there has a positive impact on dental caries.

 0.1 ppm - human milk; 100 microns- fluoride on enamel

FLOURIDE CONCENTRATION IN TEETH

Fluorapatite formation incorporated into the crystal lattice structure of teeth when the fluoride
ingested and then absorbed and distributed in all organs of the body.
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The human teeth fluoride concentration are very high on surface enamel, falls sleepy
within the first 100 micrometer, remains constant up to enamel-dentin junction, inside
the dentin fluoride level increases, and it accumulated over a life-time at the dentin-pulp
interface.

Note:
 There is no homeostatic mechanism that maintains fluoride concentration in the body.
 To maintain fluoride concentration in enamel, saliva, biofilm in dental surface regular
exposure is required.

FLOURIDE IN CARIES PROTECTION AND FLUOROSIS

 REDUCED DEMINERALIZATION AND ENHANCE REMINERALIZATION
- Main mechanism: Fluoride have anticaries benefits
- 5.5 below pH level – hydroxyapatite starts to dissolve.
- 4.5 below pH – fluorapatite starts to dissolve.
- >4.5 but <5.5 pH biofilm – Fluoride is available and fluorapatite forms on
surface
- It reduces dental demin… due to protective out layer of fluorapatite
- <5.5 pH- Fluoride enhances enamel-dentin remin….

 ANTIMICROBIAL QUALITIES
- Dental biofilm that contains: 5 ppm of Fluoride containing toothpaste inhibits
the adhesion, multiplication of caries linked to oral streptococcus.
- 10 and 100ppm fluoride- (higher concentration) inhibit acid production

 DENTAL FLUOROSIS
- Due to excessive exposure to fluoride and leads to hypomineralization of
enamel that increases porosity that is reflected in opacity of enamel creating
an appearance of chalky white lines or stains.
- Severe excessive exposure of fluoride means severe hypomineralization
increases that later leads to appearance of brown and fragile porous enamel.

SYSTEMIC FLUORIDE DELIVERY

 Water fluoridation – primary systemic method of fluoride delivery (American
population)

 Salt fluoridation – method of fluoride delivery in Europe, Costa Rica, Columbia,

Jamaica

 Adding fluoride to liquid powdered and long life milk – Eastern Europe, China, U.K.
has advantage over water fluori.. no well studies
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DDM-3

 Topical (toothpaste -1995 by crest, gels, varnishes, and mouth rinses)

FLUORIDATES DENTRIFICE

Note:
Benefits of Fluoridated Dentifrice:
 Fluoride in saliva and plaque promotes remineralization
 It has modest antimicrobial effect on plaque
 Stannous fluoride is effective against Strep. mutans

COMMON FORMS OF FLUORIDE:

 Sodium Fluoride (NaF)
 Sodium monofluorophosphate (SMFP)
 Stannous fluoride
 SnF – mixture of NaF and SMFP, NaF and SnF
 Amine fluoride (AMF)

RECOMMENDATIONS FOR FLUORIDE TOOTHPASTE

1. Use an accredited fluoride toothpaste
2. Toothpaste with an appropriate fluoride concentration after assessing potential caries
risk and overall fluoride exposure.
3. Brush twice daily, once at night, and once more at another time during the day,
preferably around mealtime.
4. Children be given minimum amount of toothpaste and be supervised when brushing.

OTHERS IN DENTIFRICE
Use of other types of specialty dentifrice:
 Plaque and gingivitis protection
 Tartar control
 Whitening
 Sensitivity protection
 Erosion protection
 Protection from oral malodor
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DDM-3
 Also it may a Combination of other types of dentifrice

FLUORIDE MOUTH RINSES

 stannous fluoride rinses have been associated with discoloration.
 Acidulated phosphate fluoride – contraindicated in people with porcelain or
composite restoration because it can cause pitting or etching.

Antimicrobial agents:

 Chlorhexidine
 Hexetidine
 Sanguinaria extract
 Delmopinol
 Cetylpyridinium chloride

 Professional fluoride varnishes – only in dent office; applied when a patient is at

extreme risk of caries, inappropriate dental care measures, such as good oral hygiene
or use of oral toothpaste is not working or not being followed.

 Professional Slow-Release Fluoride- still being developed, intended for small

amount of fluoride a day, the approach is like the composite and amalgam fillings, and
to prevent secondary caries.
 Glass ionomer cements - able to absorb fluoride from other sources such as
toothpaste and slow to release this into the oral cavity.
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DDM-3

Caries Process and Prevention Strategies: RISK ASSESSMENT

Cariology

CLINICAL SIGNIFICANCE
 help identify those patients who are at higher risk of developing caries and those who
are at low risk
 In differentiation, preventive efforts can be focused on the high-risk group so that their
risk is reduced and caries reduced or avoided altogether.
 identified the risk factor in the high-risk group, a treatment plan can be designed to
risk, to reduce the risk factors such as dietary modification, use of additional fluoride
agents, etc.
 high-risk group should be recalled more frequently.
 The low-risk group still has some risks and they should be recalled and examined at
appropriate intervals to make sure that their risk is not increasing.

STRONGEST INDICATORS OF RISK

 active disease, new lesions in the patient
 active disease where new lesions in other family members are noted
 frequent sugar intake
 irregular oral hygiene, and infrequent use of fluoride toothpaste
 poor quantity or quality of saliva
 age (very young or very old)
 presence of restored teeth or teeth having been extracted due to caries

INTRODUCTION
Dental caries (tooth decay) - An oral disease in which the acid generated by specific
types of unfriendly bacteria cause damage to the hard tooth structure.
 Assessment of patient’s caries activity and risk of future caries are important
 To make an individual involved, manage, and be aware of their dental health
like developing caries or lesions.

WHY SHOULD RISK ASSESSMENT FOR DENTAL CARIES BE CONDUCTED

By Dr. Margherita Fontana
RISK ASSESSMENT
- essential part of caries management.
- a way of identifying what are the reasons why that patient is at risk so that it
preventive tailored treatment plan to that particular patient needs is developed.
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DDM-3
TERMINOLOGY:
 Risk - the probability that an event will occur
 Risk factor - an environmental, biological, behavioral, or social factor confirmed by
temporal sequence, which directly increases the probability of a disease occurring if it
is present.
 Risk assessment - the qualitative or quantitative estimation of adverse effects that
may result from exposure to specific hazards or the absence of biologic influences
 Risk Survey- assessment tool for gathering broad range of patient data

Note:
 An ideal risk assessment tool should not be time-
consuming or too complex for use in a busy dental
practice
 Information must be gathered in organized and
methodological manner.

3 STEPS TO IDENTIFY BIOLOGICAL AND ENVIRONMENTAL RISK FACTORS

STEP 1: Noting the patient's medical history.

- Include questions about the patient's current and past diseases or illnesses,
current or past medications and current or past disease treatments.

Note:
 Sjögren's syndrome
- condition that can cause dry mouth, autoimmune condition that causes
immune cells to attack mucus producing cells in the body and presents itself
mainly in women in their forties and fifties.
 Causes of dry mouth:
- Rheumatoid arthritis, diabetes, HIV Aids, Parkinson's disease, Alzheimer's
disease, cystic fibrosis, asthma, hormonal changes related to pregnancy,
perimenopause or menopause, lupus, anorexia nervosa, and pancreatic or
liver disturbances, smoking and drug abuse, particularly of alcohol, opiates,
and methadone

STEP 2: Noting the patient's dental history.

- It depends on the high risk of caries gather information about current oral
hygiene practices and proficiency, including how often teeth are cleaned, what
type of brush and inter-dental cleaning agents used, which toothpaste is used
and how it's cleared from the mouth, use of fluoridated water and diet.

STEP 3: Know what is happening in the oral cavity.

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- Besides looking for present and previous caries activity, it's important to note
other factors that increase caries risk. Tooth morphology and alignment, such
as areas that are crowded, teeth that are pitted or rough or teeth that are
physically difficult to clean can play a role in increasing caries risk.

RISK ASSESSMENT PROTOCOL

STEP 1: Conduct a risk assessment survey
- aid the dental health practitioner in determining the level of risk present in each
individual patient in organize and can serve as an aid in both the initial
assessment of risk, as well as tracking the implementation and progress
against an intervention program.

STEP 2: Consider individualized non-operative strategies for caries control

- This includes cleaning. The dental health care provider can start by reiterating
simple oral hygiene tips for plaque control in the whole mouth, such as brushing
teeth twice a day and flossing in between teeth, interdental cleaning.
- This includes the use of fluoride
- Includes Diet Modification
- Recalling the Patient

STEP 3: Consider additional strategies for special patients.

- Need extra attention patients who have a dry mouth; brushing, interdental
cleaning, use of fluoride, in compliance with commonly recommended diet
modification tips, patients with dry mouth can benefit from sipping water all day
long and restricting intake of substances that increase dry mouth such as
caffeine containing drinks. Most people will also benefit from saliva substitutes
in the form of sprays, lozenges, sugar-free chewing gum or mouthwashes,
some of which contain fluoride.
- Special needs with patients who are ill

CAMBRA SYSTEM
CARIES MANAGEMENT BY RISK ASSESSMENT
- developed as an evidence-based approach to the prevention, reversal, and
treatment of patients with dental caries.
- focuses both the dental professional and the patient or their caregiver to
consider all the factors relevant to the patient's risk and disease state.

 employs the caries balance method

 taking account of all factors that contribute to the development of dental
caries
- Assigns patients to low, moderate, high or extreme risk and available to
patients aged 0-5 years and 6 and over.
- Its key benefit is to force dent prof and patients (caregiver) to consider all
relevant factors.
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DDM-3

Note: