PREVENTIVE APPROACH TO DENTAL CARIES

SUBMITTED BY:
BABU RAO FINAL YEAR
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INDEX
1. Introduction 2. Definition Caries Prevention 3. Why prevention is necessary? 4. Level of prevention Primary Secondary Tertiary 5. Methods of prevention of dental caries Infant oral health care Parent counseling Diet counseling Pit and fissure sealant Fluorides Systemic administration Topical application Methods on horizon Antiplaque agents and detector Altering surface morphology Lasers Self assembling polypeptides (SAP) Chewing gums Tooth friendly sweets Microdentistry Teledentistry Indigenous products Caries vaccine 6. Conclusion 7. Bibliography

INTRODUCTION DEFINITION

CARIES :

dental caries is an irreversible microbial of calcified tissues of the teeth, characterized by demineralization of the inorganic portion and destruction of the organic substance of the tooth, which often leads to cavitation. approach to preventing the development of dental caries is to establish and maintain good oral hygiene, optimize systemic topical fluoride exposure and eliminate prolong exposure to simple sugar in diet.

PREVENTION :

Prevention of dental caries based on breaking the chain of events that promote the formation of caries:
By modifying the cardiogenic bacterial flora. By altering the substance on which these bacterias survive. By rendering the tooth less susceptible.

WHY PREVENTION IS NECESSARY?

While the industrialized countries may claim of reduction in caries incidence, developing countries such as India still face an uphill task as the caries incidence still on increase. In an attempt to strike at the root of the problem, prevention of dental caries is an invaluable foundation step. While assessment as to the risk of the infant developing oral disease in lateral life may not be entirely accurate, a general policy will go a long way in reducing the incidence of the same. When better timing exists, to initiate the preventive measures in its truest forms i.e. primordial or primary prevention, secondary prevention and tertiary prevention. Time and again, measures initiated before the onset of the disease have proven to be effective.

LEVELS OF PREVENTION OF DENTAL CARIES

METHODS OF PREVENTION OF DENTAL CARIES Infant oral health care Parent counseling Diet counseling Pit and fissure sealant Fluorides Systemic administration Topical application Methods on horizon Antiplaque agents and detector Altering surface morphology Lasers Self assembling polypeptides (SAP) Chewing gums Tooth friendly sweets Microdentistry Teledentistry Indigenous products Caries vaccine

INFANT ORAL HEALTH CARE

Goals of an infant Oral Health Care Program The infant oral health program is meant for early dental evaluation of infants/ toddlers and providing parent education regarding their important role in preventing oral diseases from occurring in their child. The goals of such a program are : 1. 2. To identify, intercept and modify the potentially harmful parenting practices that may adversely affect the infants oral health. Parent education right from the prenatal period highlighting the importance of their role in the prevention of dental disease for their child. Parent/ caregiver orientation to perceive dental services as an integral part of infants overall health program. Periodic evaluation of the orofacial development and oral health by the clinician.

3. 4.

Why Infant Oral Health Care? While the industrialization countries may claim of a greater attention being given in the oral health care of children, developing countries such as India still face an uphill task, as the incidence of oral diseases in children is still on the increase (not withstanding the goals of WHO). In an attempt to strike at the root of the problem, Infant Oral Health Care is an invaluable foundation step. While assessment as to the risk of the infant developing oral diseases in later life may not be entirely accurate, a general policy will go a long way in reducing the incidence of the same. What better timing exists than to initiate the preventive measures in its truest form i.e. primordial or primary prevention. Time and again, measures initiated before the onset of the disease have proven to be more effective. The following are few reasons why infant oral health care should be an integral component of Pedodontics in India: 1. Infectious diseases of the oral cavity: Oral cavity of the infant is invaded by a variety of microorganisms but most of them us transient. This is the first habitat in the human body where
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microorganisms are seen to be established soon after the birth within 6 to 8 hours in an infant. Streptococcus is found to be consistently present within few hours after birth. The eruption of teeth is an event that brings about a qualitative and quantitative change in the microflora. The colonization of the 'Pioneer Bacteria' is a special process, which then gives a substrate to attach the 'Secondary Invaders'. Oral health cue measures at this stage prevent the colonization by the secondary and generally more pathogenic microorganisms. It has been proven that Streptococcus mutans, a primary causative factor in the initiation of caries, is transmitted from the mother to the infant. These gather a foothold in the mouth immediately after the eruption of teeth. With weaning and adoption of a cariogenic diet, caries may develop in the oral cavity and cause severe and rapid destruction of the hard tissues if left unchecked. The diet, particularly drinks with low pH, has the potential to cause erosion. Nursing bottle caries has been found to be prevalent in the infants and preschoolers due to faulty feeding practices by the mothers. It has also been reported that children who are "easy to manage" are more likely to be younger, have their teeth brushed twice per day and be breast fed to sleep throughout the night. However, "difficult" children and more likely to be bottle fed and thus predisposed to have non cavitated/white spot lesions. The caries preventive program needs an individualized approach which can and should be started right from the prenatal period through infancy to adolescence and even further. It thus includes measures such as: Infant oral health care Parent counseling, diet counseling Fluoride programs Pit and fissure sealants, and Other methods on the horizon.

The preventive and treatment protocol would be guided by the risk group of the individual. Table : Modalities of treatment based on risk assessment HIGH- RISK GROUP Professional Home care therapy Supervised Oral home care prophylaxis (use of Complete disclosing rehabilitation of agents for all carious patient lesions motivation) Antimicrobial Home fluoride therapy application (chlorhexidine Sustained gel) release of Pit and fissure fluoride tablets sealants Self gel (specially in applications young permanent Fluoride teeth) dentifrice (if not in use, Topical fluride above 4 years) applications (preferably Salivary varnish) substitutes (in case of Diet xerostomia) modification Chewing gum Dental health with education anticariogenic A more properties frequent recall and review program (every 3 months) 2. LOW- RISK GROUP Professional Home care therapy Annual topical Fluoride application dentifrice (if not in use) Regular recall for 6 months Dental health education

Traumatic injuries: With lack of motor coordination trauma to the developing primary dentition may also occur.

3. 4. 5.

Habits: Such as thumb sucking usually have their inception at this age and may persist to cause several dental problems. Child abuse and neglect may also be detected. Care of the alternatively abled children: Cleft lip and palate cases and other such children requiring special attention, may do so right from birth. Problems of speech and language would require early detection.

6.

To all these problems, the traditional approach has been to treat the effects of the disease. By delineating an infant oral health care policy, one may not have to encounter the disease process or its effects. Thus Nowak (1997) has stated that "the goal of the first oral supervision visit is to assess the risk for dental disease, initiate a preventive program, provide anticipatory guidance and decide on the periodicity of subsequent visits". HOW TO PROCEED FOR INFANT ORAL HEALTH CARE? The first step should be to establish a "Dental Home" for each infant. The dental home is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral to dental specialists when appropriate (AAPD, 2004). By visiting the dentist at such an early age, a dental home can be established and anticipatory dental guidance be made, part of the child's total health care experience. Recommendations for First Dental Examination and to Establish a Dental Home include the following 1. 2. Immediate referral of infants with an apparent dental problem due to trauma, disease or developmental abnormality. Examination at no later than 6 months or when the first tooth empts

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Objectives of Dental Home To enhance the dentist's ability to assist children and their parents/caregivers in the quest for optimum oral health cue. To schedule early oral health examinations and preventive services for cost effectiveness. To offer parents and caregivers resources which assist them in making the best informed choice. Individual child risk assessment for dental diseases. Monitoring the growth and development. Referrals to dental specialists when care cannot directly be provided with the dental home. Interaction with early intervention programs, schools, early childhood education and child care programs, members of the medical and dental communities, and other public and private community agencies to ensure awareness of age-specific oral health issues. To make the parents aware of when and how frequently should they visit a dental home for their child.

Essential Steps to be Taken When a Parent/ Caregiver Approach Dental Home As in the evaluation of any case, a proper history coupled with a vigilant assessment including knowledge of what is normal and what is not at this age is essential. 1. History: A detailed history involving the prenatal, birth and postnatal periods is necessary. Demographic details of the parents including the socioeconomic status need to be evaluated. Grindefford (1995) has stated that one of the factors which is a significant predictor of early caries development is socio-demographic factors (importantly, the mother's education). Examination: A dentist should not be blinded by the necessity to do a dental examination only, A general assessment would provide an insight to systemic problems, if any. Once satisfied that the infant is

2.

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in apparently normal health, a thorough oral examination is warranted. 3. Risk assessment is carried out by noting down various factors. These include dietary factors, amount of the plaque present on the teeth and feeding practices. This should be followed by customization of a preventive protocol, rather than generalization. Any therapy, restorative procedure or prophylactic measures needed should be instituted.

4.

Role of Dentist in Providing Care to an Infant a) The dentist is a valuable source of information, on a one-to-one basis or in small gatherings. On a lager scale, the dental association can be involved in teaching the masses regarding the timing of first visit. The dentist is well placed to formulate individualized comprehensive preventive program for every infant visiting the dental home. It is also the duty of the dentist to answer the queries of the parents as to when do the teeth erupt. The age at which teeth erupt varies greatly between children and. a difference of 6-12 months can be considered normal. Age 6-10 months 9-13 months 13-19 months 2-3 years Teeth erupted Bottom front teeth, then top front or side bottom front teeth Top front teeth First molars than canines, then second molar All the teeth

Since the parent encounters eruption of teeth for the first time, the signs of teething should be made aware to the parent. Various home remedies may be traditionally carried out in these circumstances, such as rubbing honey over the gums. Such practices predisposing to

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caries should be strictly discouraged. Symptomatic treatment such as teething toys or hard sugar free rusks are however acceptable. b) Feeding Practices: From nutritional point of view, breast milk has several systemic and immunologic advantages over proprietary formulas. Thus the importance of breast-feeding should be explained to the parents. However, on the flip side, prolonged and at will breast-feeding, beyond the stipulated weaning time of the child, especially throughout the night and sometimes throughout the day, has been associated with nursing caries.

Advantages or Breast-feeding 1. 2. 3. Breast milk has the ideal composition for infant's needs, provided in a safe clean form at the right temperature. The feeds need no preparation mid there is no equipment to sterilize. Breast milk contains anti-infective factors which cannot be manufactured and added to infant formulae. This has considerable health benefits for the infant both in childhood and later life. Psychologists say that it is of psychological advantage to mother and child, increases bond strength and there is sense of accomplishment and indispensability to mother. Child being fed on breast milk is less likely to develop arterial disease because of fat, as fats in breast milk are better emulsified. Easily digestible and has low osmatic load. Confers passive immunity to the baby. A lack of breast-feeding has been associated with developmental defects of the primary dentition particularly in premature children. Thus it can be concluded that breast-feeding also prevents the occurrence of developmental defects.

4.

5. 6. 7. 8.

Anti-infective and andicariogenic agents in human milk 1. Immunoglobulins. Secretory IgA, IgG, IgM

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2. 3. 4. 5. 6. 7. 8. 9. c)

Cellular elements. Lymphoid cells, polymorphs, macrophages, plasma cells. Opsonic and chemotactic activities of C3 and C4 complement system. Unsaturated lactoferrin and transferrin Lysozyme Lactoperoxidase Specific inhibitors (non antistaphylococcal factors immunoglobulins): Antiviral and

Growth factors for Lactobacillus bifidus Para amino benzaic acid may afford some protection against malaria. Sucking and Suckling: Parents should also be made to realize the difference of sucking and suckling, by the dentist, to prevent the onset of deleterious oral habits. Suckling at the breast is good for the infant's tooth and jaw development. Nursing technically is different from artificial feeding in that the bottle fed infant does not have to exercise the jaws so energetically, in as much as light suckling alone produces a rapid flow of milk. Bottle fed infants use their tongue in a manner quite opposite that of the breast fed baby; the flow of milk through the rubber nipple is produced by the tongue thrusting motion with each suck while the infants lips create a negative pressure in the oral cavity, thus suctioning milk from the bottle. The breast fed baby places the tongue over the lower jaw, where it remains throughout the nursing session, and draws the nipple by suction well into the mouth, elongating it to three times its normal length and extending it to the junction between the hard and soft palates. The elongated nipple rests in a trough formed by the Ushaped tongue. As each suckling cycle is initiated, the infant's jaws compress the milk sinuses just under and proximal to the areola, pinching of a bolus of milk and propelling it toward the posterior pharynx by a peristaltic wave like motion. This roller-like movement, which begins at the anterior tip of the tongue and progresses towards its base, effectively, strips the milk bolus from the proximal portion of the nipple out towards its tip, where it exits into the infant's mouth and is swallowed. The jaw muscles are thus strenuously exercised, encouraging the development of well-formed jaws and straight healthy teeth.
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d)

Importance of weaning: Weaning is a process of expanding the diet to include foods and drinks other than breast milk or milk formulae. It is a gradual process - the age at which it is started and the rate at which it progresses vary between babies. Weaning should occur between 4 and 6 months, although a minority of babies will be ready for weaning at 3 months. Some important tips on bottle feeding Often, parents who are too busy to deal with the crying child, try to quieten the child by using the bottle containing milk or other sweetened drinks as a pacifier. This, when given frequently to the child before and during sleep has been seen to cause a devastating pattern of nursing caries. In this respect, the sugars taken before sleep, when little saliva cleaning action is present, should be assessed and highlighted to the parents. A simple schematic representation of the carious process, with the acid production destroying the teeth should be explained.

e)

Parents should be instructed to: Provide more attention to the child. Remove the bottle immediately after feeding. Substitute the milk or non-sweetened juices with plain boiled water. Encourage your baby to stay in upright position with a bottle. Use a bottle with a nipple that has a small hole to enable the infant to work with his muscles activity to get the milk from bottle. Introduce a cup to drink as soon as possible. Bottle feeding be allowed at intervals. It should not be used as a pacifier. Give water after feeding with the bottle and clean the mouth soon after feeding.

This cleaning activity should be preferably performed after every meal or at least once in a day. Besides the maintenance of good oral hygiene at this age, this routine also goes a long way in establishing a practice to be followed in the years to come.

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The parents should be advised to thus take care of gumpads and teeth as they erupt, till the time where the child develops sufficient neuromuscular central to brush his/her teeth. f)

Use of Pacifiers: Several disadvantages have been found with the use of pacifiers such as : Those dipped in honey or sugars can cause increased caries Malocclusion Unhygienic conditions leading to infections and GIT disorders

g)

Anticipatory guidance Nowak (1995) describes anticipatory guidance as a proactive, developmentally based counseling technique that focuses on the needs of a child at each stage of life. What it effectively means is that one should not get disheartened, for many times a patient may lack cooperation at this young age. Providing an insight into the development of a child will involve the parent, with a much more focused strategy. Also, at every stage it is essential that the dentist takes into consideration the various milestones of dental development. Such anticipatory guidance can make the parents more at ease during childhood dental visit; these pointers are also essentials in preventing many of the possible dental problems children would otherwise often face.

h)

Oral hygiene practices Many parents would not be even aware of the fact that oral hygiene practices can be essential at this age. A thorough intraoral examination may reveal the plaque on the tooth surfaces and food debris as well. In such cases and in all other cases as well if the child has been brought early, the proper technique for positioning and tooth cleaning should be demonstrated.

i)

Gumpads: The cleaning of gumpads can be started as early as within the first week of birth.

Cleaning infant's mouth The parents can be instructed to;

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 ii)

Lay the baby down with his/her head in your lap and feet pointing away. Open the baby's mouth and slide the forefinger inside along the cheek and press down on the back side lower gumpad. Take a small gauze (2 x 2") between thumb and forefinger and wipe vigorously over the ridge of the baby's top and bottom jaws. Nowadays specially designed for infants tooth brushes, finger cots and wipes are available, which can also be used. Use adequate pressure just to remove the film that covers the child's gumpad. Clean at least every day twice after morning and last feed in the night. Spend at least two to three minutes in cleaning. Teeth: The positioning of the infant, depending on whether one or both the parents are involved in the procedure should be first demonstrated and then supervised by the dentist.

While performing these procedures care should be taken that the child is supported at all times and the movements are slow and careful, so as to not cause any injury and address the problem in that light, not just keep reinforcing a particular set of instructions. Role of Pediatricians The pediatricians or primary care physicians treat infants and monitor the growth and development of children. They are thus usually the first health care providers and can act to evaluate their oral health status.

In this respect, they can be the forebearers in providing information to the parents as they are more often in contact with the child and parents. The dentist should establish a contact with pediatrician and formulate a policy regarding dental health for the infant. Following topics needed to be discussed by a pediatrician: Tooth eruption Preventive oral hygiene Orufacial development Fluoridation Diet
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Johnson (1997) has also discussed the interaction with the pediatrician at the time of weaning. When the child is 10 months old, the assertiveness of the child may make the parents to give in by giving a sleep time bottle. A solution suggested is the gradual dilution of the liquid. Thus I week 2nd week 3rd week 1/3 bottle water 2/3 bottle water only water

Weaning foods free of, or low in non-milk extrinsic sugars should be recommended to the mothers. Depending on the amount of fluoride present in community water, and the requirements of the child, a fluoride supplementation program can be instituted.

Pediatrician should be made aware of the dentist population in his vicinity for the purpose of referral. This in cases of large multi-specialty centers it is easily done, but in smaller places with dental centers spread over a larger area may be difficult.

GUIDELINES TO PARENTS
Children are our most precious resource. Their optimal oral health should be provided not only on a therapeutic but also on a preventive basis early in life itself, Parents should be educated at the earliest possible time by not only the dentist but also the general practitioner in order to provide them a disease-free environment. 1. 2. 3. The parents should bring their child for his/her first dental visit early, at least by the time the baby is 6 months of age. Breast feed the baby but do not indulge at will. Avoid frequent use of the bottle with sugared ma or drinks as this can lead to nursing bottle caries. Instead, give the child more attention. Do not put the child to bed with the bottle or at the breast but take the bottle away immediately after feeding. Dilute the milk gradually in the bottle and end with plain water.

4. 5.

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6. 7. 8. 9. 10. 11. 12. 13. 14.

Feeding should be supervised at all times. Start the child on semi-solid foods by 5-6 months and reduce the use of bottle or breast-feeding. Do not use pacifiers or dummies dipped in honey or other sugar items. Avoid extended use of sugared medicines such as syrups. Clean the gums and later teeth with a cloth or soft brush after every meal or before sleep. Parents should brush or clean their baby's gums/teeth everyday till the child is old enough to manage himself. Contact the dentist immediately if there is my accident or trauma to the baby's teeth. Parents should know about the benefits of fluoride and its proper use such as that used in infant formulas and dentifrices. Half-yearly visits to the dentist should be routine.

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PARENT COUNSELLING
Definition Parent counselling can be defined as educating the parents regarding the child's oral health status, optimal health care and informing them about the prevention of potential dental diseases. Purpose The purpose of parent counselling in pediatric dentistry involves:

Discussion of emotional problems of children, particularly in relation to dental treatment. To offer the dentist an insight into parental influences which may produce unnecessary anxieties. Knowing about the attitude of parents towards behavior management techniques used during dental treatment of children. Obtaining the cooperation of a child patient, establishing a good rapport with the child and also using effective techniques of behavior management. Educating the parents about various dental problems, diseases and their sequelae and how they can be prevented with accurate preventive measures if recognized earlier.

If we are to have a good child patient we must first educate the parents. A dentist who fails to do so is not using every means available to him in management of the child. INSTRUCTIONS TO THE PARENT Inform the Parents Not to voice their own personal fears in front of the child. Never to use dentistry as a threat of punishment.

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 To familiarize their child to dentistry by taking the child to the dentist. This helps in making the child accustomed in the dental office and to get acquainted to the dentist.
About the home environment and importance of moderate parental

attitudes in building well-adjusted children. Regular dental care helps in preserving the teeth and also in formation of good dental patients. Never to embarass, scold or ridicule the child to over come the fear of dental treatment. Not to promise the child what the dentist is or is not going to do.

Not to bribe their child to go to the dentist.

To convey to the child in a casual manner that they have been invited to visit the dentist. To commit the child to dentist's cue in the office and should not enter the treatment room unless requested by the dentist.

Occasional display of courage by the parent's in dental matters will build courage in the child. EDUCATION OF PARENTS IN VARIOUS ASPECTS OF DENTISTRY Preventing Dental Disease From Conception to 3 Years of age A large number of children experience dental disease before 3 years of age. Nursing caries is particularly a devastating form of caries frequently seen in this age group. Thus, it is important to educate the parents so they can make appropriate decisions regarding the management of their infants and toddlers oral health. Prenatal Counseling Parents should be educated regarding: a) b) c) Dental development of their child. The dental disease process. Appropriate feeding practices emphasizing the hazards of improper bottle and breast-feeding.

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d) e)

Oral hygiene measures appropriate for infants and toddlers. Expectant parents can also be told regarding the mother's health during pregnancy and the potential detrimental effects that poor health and unhealthy habits may have on their child's dental development. Also in pregnancy the food need increases to meet the special physiological changes in the body to support the growth of the fetus and facilitate normal labor.

f)

Why are the Primary Teeth important? Primary teeth act like the foundation stone for permanent teeth.

They maintain proper space for the permanent teeth to occupy. These teeth help in normal growth of jaw height and give shape to the face, just like in older individuals whose face looks completely collapsed when they take out their denture. Teeth provide a sense of self worth by contributing to one's appearance. Primary teeth certainly help in the first step of grinding of food, once the infants start eating solid food.

Preventing Dental Disease From 3 to 6 Years of Age Children in this age group frequently exhibit gingivitis and may experience rampant decay. The rampant decay is often a sequelae to timing caries initiated during the first 3 years of life or extensive caries may develop as a result of eating patterns initiated after weaning. 1.

Diet: Parents are educated about the role of diet and their ill-effect on initiation of caries. The frequency of exposure is the most important factor in development of dental caries. The rate at which sugar is cleared from the oral cavity is also an important factor in the cariogenic potential of diet. The sticky retentive items such as chocolates, toffees have more cariogenic potential than sugared drinks that are quickly cleared.

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When the exposures are too frequent or the sugar is retained too long, the net result is dissolution of tooth structure and formation of a carious lesion. Food items that can be recommended as relatively safe snacks include cheese, peanuts, milk, sugarless gum, and raw vegetables. Items to be particularly avoided include sugared gum, dried fruits, fruit juices, and sugared soft drinks, cakes and candy items. The most important dietary advice is to limit the number of carbohydrate exposures per day rather than to limit the total carbohydrate consumed. Oral Hygiene

2.

The 3-6 year olds require parental assistance to achieve effective plaque removal. Parents should be instructed to brush for the child at least once a day, and to clean between any teeth that are in contact with each other with dental floss. Bedtime is the ideal time to establish this routine because the salivary flow rate slows during sleep. Thus natural protective mechanisms are reduced. Additional brushings may be performed by the child unaided. Fluorides

3.

Fluoride consumption should be investigated and supplemented, if appropriate. The use of fluoride-containing toothpaste (once daily) should be carefully monitored. Parents should be instructed to dispense only a pea-sized amount for their child. The child should brush under the supervision of the parent so that they can monitor to ensure expectoration. Other times the child can brush with non-fluoridated toothpaste. Professional application of high concentration fluoride gels is usually begun at the age of 3 years when swallowing can be controlled. Professional dental care

4.

The parents are educated that in small primary teeth, caries progresses at a high rate. Also, because of rapid developmental

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changes, the timings of the visits can be critical for initiating preventive measures.

Semiannual dental visits should begin at the age of 3 years and continue throughout childhood and adolescence.

Prevention of Dental Disease From 6 to 12 Years of Age Eruption of the first permanent molar at about the age of 6 years is a milestone requiring preventive action. Parents are educated about the importance of the first permanent molar. They are told how the various preventive measures taken at this stage can prevent the progression of caries. 1.

Sealants The most effective aid for preventing pit and fissure decay is professionally applied sealants. Most children benefit from the application of sealants to their permanent molars which allows them to maintain a caries-free dentition into adulthood. Diet

2.

Children of school age are developing some autonomy in eating habits. They often make their own food choices at school and may purchase snack items. Parents are instructed to monitor the dietary practices, especially for children who experience smooth surface decay. Fluorides

3.

As the child develops control over swallowing, topical fluorides can be safely used and at this age. They begin to assume an important role in prevention. Regular use of toothpaste (twice-daily fluoridated toothpaste) is recommended for its abrasive action in removal of the plaque as well as fluoride exposure. By the age of 6 years most patients are capable of expectorating but parents should monitor it. Oral hygiene

4.

Parents need to remain active in supervising the home care practices of 6-12-year olds.

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During this age span a transition can be made from care provided by the parent to supervised selfcare. By the age of 10 most children are capable of fine motor coordination necessary for adequate tooth brushing and begin to assume responsibility for daily brushing and flossing. Therefore it is the duty of the dental practitioner to teach proper oral hygiene maintenance technique to these children. Parents should continue to monitor brushing and flossing frequency and adequacy. Habits

5.

Education about any oral habit, if it is present. Also educate the parents about transitional in the developing dentition and the importance of primary and permanent dentition.

Prevention of Dental Diseases in the Adolescent

Prevention of dental caries continues to be an oral health priority during adolescence and prevention of periodontal disease becomes a special concern. This is a very unique age group. At the stage of adolescence the main processes utilized are :

a) Rejection of many parental values. b) The beginning of independent struggle. c) The testing out types of behavioural experimentations. Parents are educated that they should tackle the child at this stage very diplomatically. The child should he given enough emotional support from the family and his various habits should be monitored by the parents. The parents should have a friendly approach. 1.

Oral hygiene The adolescent patient possesses the fine motor skills necessary for adequate tooth brushing and flossing, but problems in compliance are likely to be encountered. For periodontal health it is necessary to remove the plaque from all areas of the tooth that contact the gingiva. Dental floss can be used to effectively remove the interproximal plaque.

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2.

Diet In patients with a high caries rate, rampant dental decay may result in an extensive damage to the dentition. It is usually associated with poor oral hygiene practices and a high frequency of sugar consumption. Progress of lesions can be halted with an appropriate diet control and an aggressive topical fluoride therapy. Fluorides

3.

Systemic fluorides are no longer of benefit after the last permanent tooth erupts at about age of 13 years, except for patients who have functional third molars. Topical fluorides me the most effective preventive measure for the patients who experience smooth surface caries. Use of fluoride-containing dentifrices regularly (thrice daily) provides an economical and effective fluoride source. Orthodontics

4.

Many patients undergo orthodontic treatment during adolescence. These patients are at a high risk for both gingivitis and the resultant gingival hyperplasia and for dental caries around and under the appliance or braces. Topical fluoride therapy is indicated to prevent decay. A thorough removal of plaque from the gingival areas should be performed to prevent gingivitis and periodontitis. Smokeless tobacco

5.

Peer pressure and advertising exert pressure on children and adolescents to establish a habit that may result in addiction and ultimately induce oral cancer. Evidence of tobacco use, such as shreds of tobacco present in the oral cavity or localized hyperkeratosis should be a signal to initiate efforts to motivate the patients to discontinue the habit. Parents should be instructed/ counselled not to nag or punish the adolescent as it might further entrench the habit.
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Preventing Dental Injuries An injury to the teeth of a young child can have serious and long term consequences that may lead to discoloration, malformation add even the loss of teeth. Such consequences can have a considerable emotional impact on the children.

If during trauma to the orofacial structure tooth is avulsed, the parents should be instructed to keep the avulsed tooth under the tongue of child or to store the tooth in milk or saline. The survival of replanted avulsed tooth will be enhanced if avulsed tooth is stored in some media prior to replantation. Parents are advised to immediately contact the dentist, as in nearly all situations of dental injuries the prognosis worsens. The unfavorable consequences are more likely to occur with delay in treatment of the injury.

However, the best approach is to take active measures to prevent injuries. Most injuries to the primary teeth occur within toddlers 12 to 30 months of age.

Another major cause of dental injuries in children is falls during play. Children who engage in contact sports are at the greatest risk of dental injuries. Athletic mouth protector (mouth guards) significantly reduce dental injuries.

In order to achieve maximum effective results, preventive efforts should be initiated early in the life of the child. Although most children experience dental disease, a mouth free of caries and periodontal disease is a potentially attainable goal for all children when they use currently available techniques.

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DIET COUNSELLING
INTRODUCTION
It has become increasingly evident that dietary counseling is the most neglected of all preventive measures suggested by the researchers in terms of daily diet on the level of health as well as the susceptibility to a wide variety of diseases including that of the oral cavity. The dental practitioner is faced with a wide variety of patients and the clinician must accept each individual as he or she is, and be prepared to adapt his or her technique to the specific needs of that individual. At times the clinician must teach the patient about diet, health and cause and prevention of disease. Successful diet counselling depends on the ability of the clinician to make the patient see the problem clearly and thereby work upon its solution. Definitions Nutrition : The sum of processes concerned in the growth, maintenance and repair of living body as a whole or its constituent parts. Science of food and its relationships to health. It is concerned primarily with the part played by the nutrients in body growth, development and maintenance (WHO 1971). Food: Any substance which when taken into the body of an organ may be used either to supply energy or to build a tissue (Oxford Dental Dictionary).

Anything that is eaten, drunk or absorbed for maintenance of life, growth and repair of the tissues (Nizel 1989).

Diet: It is referred to as food and drink regularly consumed (Oxford Dental Dictionary). Total oral intake of a substance that provides nourishment and energy (Nizel, 1989). Balanced diet : It is one which contains varieties of foods in such quantities and proportion that the need for energy, amino acids, vitamins, fats, carbohydrates and other nutrients is adequately met for maintaining health, vitality and general well-being and also makes provision for a short duration of leanness (Chaudiac, 1994).

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HOW OUR FOOD AFFECTS HEALTH? The food that we eat affects our body in two ways: Systemic effect: depends on their content of nutrients and includes the influence of such nutrients on general health. growth and development, cell renewal, ability of the tissues to repair and resistance to disease. Local effect: consists of what food can do to the tissues or their environment because of their mere presence in such an environment. In dentistry, most local effects result from the interaction between food residues and oral bacteria, which leads to plaque formation. The metabolites from the plaque bacteria have effects on the soft and hard oral tissues. CLASSES OF NUTRIENTS The classes of nutrients necessary for the growth of the child are: Energy providing charbohydrates and lipids. Tissue building proteins. Regulator vitamins and minerals. Water comprising 55 to 65% of the total body weight. Table : Daily caloric and protein requirement for different age groups
Toddler Caloric requiremen t RDA protein requiremen t 12001500 18-20g Preschool 1500 School 1800 Adolescent 2500 Adult 2800 Pregnant women 2800

22 g

33 g

50 g

55 g

100 g

29

30

Table : Daily food plan for different age groups

Daily food Plan Cereals Cereals Pulses Toddler S-g Preschool School S-9 S-g Adolescent Adult S-g S-g Pregnant women. S-g

2 1/3-90 1 -35

2-200 2-60

3-250 2-70

4-350 2-70

5 1/3-475 4 - 400 21/ -80 2-70

Vegetable Green leafy vegetables - 60 Other vegetables - 30 roots & Tubers Fruits Fruits Milk Milk & milk product Meat Meat & fish Egg Others Fats/oils Sugar 4 tap- 20 4 tap- 20 1 -30

-40 1 -40

1 -75 2-70

2 -150 2-75

2-120 5-175

2 -150 5 - 175

1 -40

1 -50

2-75 2-200 ml

1 -30 2-200 ml

1 -35 3 1/4-325

1 -150ml 2 -250ml 2-200 ml

1 -30 1 -50 5 tsp- 25 2 tap- 30

1 -30 1 -30 2 tsp- 30 2 top- 30

1 -30 1 -30 7 tsp - 35 2 tsp - 30

1 -30

1 -30 1-30 lift

2 tsp-40 7tsp - 35 2 tsp-40 2tsp - 30

S - Servings g - grams tsp - tea spoon

DIET AND DENTAL CARIES

The patient's diet and dental caries activity are related. From the dietetic viewpoint, dental caries is widely accepted as being caused by the ingestion of fermentable carbohydrates, particularly sucrose. Fermentable carbohydrates and more Specifically Sucrose are rarely eaten as such. They are eaten as components, of foods that contain nation ingredients and have different textures.

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The cariogenic potential of foods communing sucrose depends on many variables such as the ability to: - Be retained by teeth - Form acids - Dissolve enamel - Neutralize or buffer acids.

Certain characteristics of sucrose-containing foods or conditions surrounding their consumption are more important in terms of cariogenicity than the amount of sugar they contain. Thus, solid and retentive sucrose-containing foods are more cariogenic than sugar containing foods that are liquid and non-retentive. The frequency and time of ingestion of foods are also important. The sucrose-containing food becomes more dangerous if it is eaten more frequently. Food eaten at meals produces less caries than the same eaten in between meals.

In decreasing order of cariogenicity, the food are grouped as: - Adherent, sucrose-containing foods eaten frequently between meals. - Adherent, sucrose-containing foods eaten during meals. - Non-retentive (liquid) sucrose-containing beverages consumed frequently between meals. - Non-retentive (liquid) sucrose-containing foods consumed during meals. PROPOSED DIET COUNSELLING PROGRAM Objectives of Diet Counselling Program for the Comprise

Dental

Office

The correction of diet imbalances that could affect the patient's general health and sometimes is also reflected in his oral health.

32

The modification of dietary habits, particularly the ingestion of sucrose-containing foods in forms, amounts and circumstances that promote caries formation.

Who Should Give Counselling? The counsellor should possess dental and nutrition knowledge as a result of professional education and training. These best-qualified professionals are: Dentist Dental hygienist Nutritionist DIETARY COUNSELLING First Appointment Before counselling a child or his mother, determine what the child is eating. In a 15 to 20 minutes appointment the diet diary forms are introduced with a brief discussion of the purpose of diet counseling such as, explain to the patient:

That we are looking for possible dietary causes of the caries problem of the patient, so that we can reduce the risk of future caries by dietary means. What beneficial outcome could be available for him in better oral health and appearance and possibly improved health in general.

Here it is important

Not to be judgmental about the patient's responses as otherwise he may tend to present his best side. Not to emphasize the role of sucrose-containing foods before the diet diary is completed, for otherwise the patient may tend to present an ideal rather than real diet.

The patient should not be patronized or lectured.

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Diet Diary

Please record every food item consumed-solid, liquid - during 6 consecutive days. Record food consumed at mealtime, between meals, at soda fountain or while watching television. Also record candies chewing gum, cough crops or syrups. The approximate amount in household measures such as 1 cup, 1 table spoon (T), 1 tea spoon (t). The kind of food and how it was prepared, such as baked chicken, raw apple, cooked cereal, etc. Additions to food in cooking or at the table: butter, sugar, cream, etc.

Table : List of foods containing sugar Foods containing sugars in solution

Soft drinks, soda pop, powdered drink mixes, fruit drinks Sweetened condensed milk, syrups. Sweetened sauces such as chocolate, butterscotch. Chocolate milk, hot chocolate, cocoa. Milk shakes, malts.

Solid retentive foods containing sugar

Cakes, doughnuts, cookies, candy bars, brownies, chocolates.

Pastries, pudding, muffins, sweet rolls, pies. Sugar-containing cereals, sugar-coated gum. Dried fruits such as raisins, dates, apricots.

Fruit cooked in sugar.

Ice cream, jams, jellies, marmalades.

Sugar-containing chewing gum, caramels, bonbons.

Hard candy, mints, lollipops, jelly beans.

Frosting, honey. Cough drops, syrups.

34

In addition to these foods some medicines such as cough syrups, antacids (both liquid and tablets) contain variable amounts of sucrose. Isolate The Sugar Factors

The patient should be aided in identification of those foods which are likely to cause oral diseases, the time when they are most harmful and also those which are most nutritious and least cariogenic.

Educate the patient in the role of sugar in decay process The plaque that forms in the teeth every day contains bacteria (germs). These bacterial change the sugar present in food into acids. Sugar (in food) + Plaque/ Bacteria (germs) = Tooth + Acid = Decay The grand total time of exposure to acid is used here, to give the patient a rough idea of the risk that his diet is imposing on his teeth. Suggested Substitutes for Foot Items From the summary of exposures to fermentable carbohydrates, determine the dietary changes that are to be achieved for better dental health : Table : List of substitutes Peanuts, walnuts, peacans, almonds, other types of nuts.

Popcorn, corn chips, potato chips, whole wheat biscuits, unsweetened, dry cereals. Cubes of cheese. Fresh fruits, salads. Vegetables such as carrot slices, celery sticks, cucumber slices. Hamburgers, hot dogs. Unsweetened fruit juices freshly squeezed fruit juices. Sugarless chewing gum. Sandwiches.
35

Cold cuts of meats (unsweetened).

Pizza, toasts.

Baked potatoes, fried potatoes.

Katz and other researchers in 1981, suggested that nuts and cheese tend to diminish the pH in plaque after the ingestion of acetic foods or those containing sugar.

The substitutes should be reasonable, which are acceptable to the dentists in terms of lesser cariogenicity as well as to the patient as far as taste and preferences are concerned. The list of substitutes should be prepared by the joint efforts of the dentist and the patient. The dentist should propose the substitutes and also ask what substitutes the patient will be willing to accept. It is not fair to cut down all the sugar from the child diet. Intelligent use of sugar must be there and that is:

- Use sugared food during meal time and - Food consumption followed by appropriate oral hygiene measures.

Sometimes a compromise may be necessary. It is better to go from a very cariogenic to a less cariogenic than to obtain nothing.

Recall Visits

During the next months at regular intervals, the dentist should evaluate the patient's progress and provide psychological reinforcement. Evaluations are made by means of: - The patient's comments - New diet diaries - Susceptibility tests such as Snyder test, and - Clinical judgment

Reinforcement is provided by praising the patient's efforts. Point out the improvements made in the diet as well as in the test results and the absence of new carious lesions.

36

Emphasis should he placed on making the patient fully aware of the benefits derived from the program and that the benefits are the product of the patient's own efforts. PATIENTS WITH HIGH CARIES ACTIVITY DIET

For Such a Patient Counseling Should be Part of Preventive Procedure and it Should Include

Immediate removal of all carious tissue and placement of ZnOE (temporary) restorations. Topical fluoride applications Plaque control instructions

Home use of fluoride containing dentifrices and mouth rinses.

37

HOME ORAL HYGIENE MAINTENANCE FOR CHILDREN

Oral hygiene In simplified terms oral hygiene is the practice which enables to keep the oral cavity clean in order to prevent the onset and progression of common problems like dental caries, gingivitis, periodontits, halitosis, and other dental disorders. This may consist of both personal and professional care. However, professional care cannot be obtained daily, so the personal care forms a more important aspect of oral hygiene maintenance. As a part of the personal care plaque control needs to be emphasized because dental plaque has been found to be the culprit for causation of various dental diseases. Goals of Plaque Control Various studies in the past have suggested that the microbiology of dental plaque is related to the pathogencity of plaque to cause the dental diseases. Therefore plaque control should have two broad goals:
1. Use of mechanical and chemical agents on a personal day-to-day

basis to eliminate supragingival plaque along with dietary control to prevent the onset of dental caries.
2. Mechanical removal of subgingival plaque through professional

means periodically so as to maintain predominantly gram-positive flora associated with gingival health. COMMON ORAL HYGIENE AIDS USED IN CHILDREN Mechanical Aids 1. 2. 3. 4. 5. 6. 7. Gauze piece for use in infants Manual toothbrush and dentrifices Electronic/Powered toothbrush Dental floss Disclosing agents Tongue scrapers Oral irrigators

38

Chemotherapeutic Aids 1. Antiseptic mouthwashes 2. Antibiotics 3. Enzymes 4. Plaque modifying agents 5. Sugar substitutes 6. Plaque attachment interference agents Gauze Piece for Use in Infants A moist gauze piece wrapped around the finger can be ideal for cleaning gumpads in infants. Manual Toothbrush & Dentifirices These have been the most common age old methods of mechanical plaque control. There is a large range of toothbrushes available in the market based on the following variables:

Diameter of fibers - soft (0. 16-0.22 mm), medium (0.23 0.29 mm), hard (> 0.30 mm)

Length of the toothbrush Length of the bristles No. of bristles No. and arrangement of bristles as tufts Length of the toothbrush head Angulation of head Shape of the bristle head Design of the handle There is no single brush design which is scientifically proven superior over others for use. However, for pediatric usage it is preferable to use a toothbrush with a head size that conveniently fits the oral cavity of the child. Recently a lot of manufacturers have introduced kid toothbrushes for use by children and as per the preference of the user a range of colors,

39

handle shapes and head shapes are available. The brush handle should be of the length appropriate enough to be held by the child and the angulation of the head should be enough so that the child can carry the brush to his posterior teeth easily. Most of the bristles are made up of nylon these days and the diameter should be such that the bristles are soft so that these do not traumatize the gingiva and provide better cleaning efficacy. The ideal time to replace a toothbrush is three months or the moment when the bristles appear worn out (whichever occurs first). Brushing Technique used Commonly in Children The circular brushing method or Fone's technique is a natural brushing method to use with young children who want to do their own brushing but do not have the muscle development for techniques that require more coordination. To help young children learn this method and have fun too, ask the child to stretch out his or her anus so they are parallel to the floor. Begin by asking the child to make big circles using the whole arm to draw circles in the air. Then ask the child to make smaller circles and finally, very small circles in front of the mouth. Now the child is ready to make circles on the teeth with the toothbrush being sure the teeth and gums are covered in the circular motion. To be effective, toothbrushing should remove dental plaque from the outer, inner and chewing surfaces as well as the surface of the tongue. The child can be helped by directing the sequence of the brushing so that all of these surfaces have been brushed. The horizontal scrub technique has also been found efficacious in the toddlers and preschoolers. The Bass method of brushing is more commonly recommended for the school going child. Dentifrices The use of dentifrices is very common these days for mechanical removal of plaque along with toothbrush. Dentifrices contain abrasives, surfactants, humectants, antiplaque substances, antitartar substances (pyrophosphates), stain removers and can be fluoridated for anticanogenic

40

properties. A wide range of flavoring agents and colors are also used in various products. However, for pediatric use it is best to select fluoridated toothpaste for any child above 36 months of age which has low abrasive content, is flavored and accepted by ADA. No fluoridated toothpaste should be used till 36 at months of age due to increased risk of systemic ingestion in children. Till the child is 7 years of age only pea size quantity of dentifrice should be dispensed for brushing. Parents should be counseled on their child's caries risk and frequency and supervision of tooth brushing. Recommendations for use of fluoridated dentifrices, in children Age 6 months to 3 years Type of dentifrice Non fluoridated Frequency of brushing Twice daily in morning or at night, in very young child brushing without any dentifrice is also acceptable. Once daily every morning Once daily at night before going to bed Twice daily brushing

3 to 7 years

Non fluoridated Fluoridated Fluoridated

> 7 years

Electronic/Powered Toothbrush The electric toothbrush was introduced in 1960s; and these have evolved into the "power" toothbrush, encompassing the high-tech rechargeable models as well as the low cost battery-powered toothbrushes. Brush head and bristle designs are more advanced, based on oscillating/translating, vibrating, or ultrasonic technology. Power toothbrushes provide anywhere from 10-49% greater plaque removal than manual toothbrushes. These can cause a significant reduction in plaque of adults and children. Use of powered tooth brushes reduces the brushing force needed during brushing to reduce gum recession. Children tend to brush longer with a power toothbrush. 67% of children studied preferred a power toothbrush due to the smaller brush head, easier to reach all areas of their mouth and the repetitive movement of the brush. They automatically confer good brushing technique.

41

42

Electronic Toothbrushes are very Beneficial in the Following Areas

Patients who lack the manual dexterity or have any disability that limits their ability to brush. Orthodontic patients or those with implants as these toothbrushes may reach crevices which can't be otherwise cleared.

Dental Floss Dental floss is either a bundle of thin nylon filaments or a plastic (teflon or polyethylene) ribbon used to remove food and dental plaque from interproximal areas of the teeth. The floss is gently inserted between the teeth and scraped along the teeth sides, especially close to the gums. Dental floss is flavored or unflavored, and can be waxed or unwaxed. Waxed floss is coated with wax which makes it easier for the floss to slide into the adjacent tooth surface. It is advised to use waxed dental floss in children. Fluoride coated floss is intended to prevent dental caries from occurring on the adjacent tooth surfaces, but its effectiveness has not yet been proven. Floss holder/dental floss stick is a supplementary tool for flossing. It is suitable for parents or caregivers in helping children or individuals with special needs to clean the adjacent surfaces of their teeth. There me many different types of floss holder/dental floss sticks in the market. Parents should be advised to choose the appropriate type according to their durability, shape, and handle length. Floss holder and dental floss sticks come in either a "knife" shape or a "Y" shape. They are similarly effective in cleaning teeth. A new thread of dental floss can be reattached to the floss holder every time after use. When cleaning the posterior teeth using a "knife" shaped dental floss stick, one will need to stretch his lips to facilitate the access of the floss stick. Handles of floss holder/dental floss sticks differ in length. Those with shorter handles at are more difficult to use. Therefore, parents and caregivers should choose the one with a longer handle to floss for their children. Flossing Technique

Take 12 to 18 inches of floss and grasp it so that you have a couple inches of floss taut between your hands.

43

Slip floss between teeth and into the area between your teeth and gums as far as it will go. Floss with 8 to 10 vertical strokes to dislodge food and plaque. Try to floss at least once a day. The most important time to floss is before going to bed. Flossing before or after brushing, either is fine.

Plaque Disclosing Agents In order to increase the plaque control by the patient it is very important to increase the visualization of plaque by the patients so as to educate the patient and facilitate removal. The plaque disclosing agents are the most commonly used dye based products which can contain iodine, erythrosine, gentian violet, basic fuschin, fast green, fluorescien, or a two tone dye. These are commonly available as, liquid preparations which can be applied on the teeth or as chewable tablets as well. Most of these disclosing agents stain soft tissues and pellicle as well as plaque. Oral Irrigators These are devices which use pulses of water or chemotherapeutic agents used to dislodge plaque particularly from interdental areas. These are not very commonly recommended for pediatric usage. Tongue Scrapers These may be flat, flexible, plastic sticks which help in cleaning the rough dorsal surface of the tongue. Additionally gauze piece can also be used as tongue scraper. Tongue cleaning should be routinely recommended for all the patients. Chemotherapeutic Aids The use of chemotherapeutic aids for plaque control is mainly recommended in patients who are unable, unwilling or untrained to practice routine effective mechanotherapy. Thus these agents are actually adjuncts in plaque control. The most commonly used in children are antiseptic mouthwashes which are discussed in detail:

44

Antimicrobial Mouthwashes From simple breath fresheners to products that can really influence oral health by inhibiting the growth of oral microflora, a variety of mouthwashes are available in the market for pediatric use. Fluoride-containing mouth rinses help to prevent dental decay. They may be recommended for 1. Children having orthodontic treatment 2. Children with high caries risk 3. Patients suffering from dry mouth, and 4. Patients who have undergone radiation therapy. Antiplaque care or antimicrobial mouthwash is used to inhibit bacterial plaque formation and prevent or resolve chronic gingivitis. They can affect only supragingival plaque. The important concern is that most mouth washes contain pharmaceutical grade alcohol, as a preservative and as a semi-active ingredient. Significant amounts of alcohol contained in many mouth washes can lead to certain disadvantages. Care should be taken that they are not accidentally swallowed, especially by children, to avoid toxicity. Small children should not be advised mouthwashes, because they me not able to spit out properly. Moreover, most children have good gingival health. The use of mouthwashes is recommended in children above 7 years of age, The commonly used mouthwashes are : Chlorhexidine, which is the gold standard, a bisbiguanide with antiplaque efficacy. Different brands of Chlorhexidine are available in the market, e.g., Rexidin (warren), Clohex (Group) and A.M.- P.M (Elder). It is generally used in a concentration of 0.12% and patient can be advised to use it once daily ranging from 5 mL to 10 ml. Side Effects : a) b) It has an unpleasant taste. It alters taste sensation.

45

c)

Produces brown stains on teeth, which is very difficult to remove. This can also affect the mucous membranes and tongue and may be related to the precipitation of chromogenic dietary factors onto the teeth mucous membranes. Its use should be restricted in patients with visible anterior composite and glass ionomer restorations since they also get stained. Chlorhexidine encourages supragingival calculus formation. Mucosal erosion and parotid swelling are other much rarer side effects.

d) e)

Mouth Washes Containing Essential Oils Listerine, one of the oldest mouthwashes available, is an essential oil/phenolic mouth wash. It has been shown to have moderate plaque inhibitory effect and some antigingivitis effect. Its lack of profound plaque inhibitory effect is because it has poor oral retention. It is not very commonly used in children. HOME ORAL HYGIENE INSTRUCTIONS FOR VARIOUS AGE GROUPS Prenatal Period

The best time to counsel parents is when the mother is expecting because the parents me most receptive at this time. The importance of oral hygiene maintenance should be stressed at each visit and the myths about teething and the initiation of brushing in an infant should be cleared to the parents.

Infants (0-1 year old)

Mechanical plaque removal should be initiated by the parent after the emption of first tooth using moistened, soft bristled infant size toothbrush. However, the cleaning and massaging of gumpads using wrapped, moistened gauze piece need to be taught to the parent or caretaker. This helps in enhancing the blood circulation, establishment of healthy flora and facilitates teething.

46

Also the parents should be instructed to feed the child with plain water after milk or rinse the mouth particularly before the child is put to sleep.

Toddlers (1-3 years old)

This is the best age to introduce toothbrush if it has, not been done earlier. Only non-fluoridated dentifrice should be recommended. Flossing can be used in patients with closed contacts. Brushing should be carried out by the parent or caregiver as the child does not have enough muscular coordination to use the brush by himself. The brushing can be carried out using lap to lap position of the child.

Preschoolers (3-6 years old)

Fluoridated dentifrice can be introduced after 3 yeas; of age. The brushing in this age group should either be done by the parent or should be properly supervised. Only pea size mount of toothbrush should be dispensed. The parent should stand behind the child and assist in brushing. Fluoride gels or rinses can be introduced in this age group in limited manner. Other chemotherapeutic aids should be avoided.

Flossing can be used in patients with closed contacts School-going Children (6-12 years old)

Parents need to only actively supervise brushing for this age group. Expectoration is now learned by the child so concern over the use of fluoridated dentifrices is not pronounced. The child now possesses the dexterity to brush on his own.

47

The use of fluoride gels, rinses and other chemotherapeutic aids can be recommended for this age group.

Adolescents (12-18 years old)

Patient compliance is the most important area of concern in this age group. The pedodontist needs to continually guide these patients for mechanical and chemotherapeutic plaque control.

Home oral hygiene maintenance forms the most important aspect of preventive dentistry and should be practiced by every pedodontist. However, only educating a child regarding the oral hygiene maintenance is not the important step which needs to be followed; rather a constant monitoring and reinforcement are more essential and this should be taken cue of.

48

PIT AND FISSURE SEALANTS

Introduction The high susceptibility of pit and fissures to caries presents a major dental problem and provides the rationale for caries control of these areas. While occlusal surfaces represent approximately 10% of the enamel surface at risk, they account for almost 50% of the caries in human dentition. DEFINITIONS Pit: It is defined as a small pinpoint depression located at the junction of developmental grooves or at terminals of those grooves. The central pit describes a landmark in the central fossae of the molars where developmental grooves join (Ash, 1993). Fissure: It is defined as deep clefts between adjoining cusps. They provide mesa for retention of caries producing agents. These defects occur on occlusal surfaces of the molars and premolars, with tortuous configurations that are difficult to assess from the surfaces. These areas are impossible to keep clean and highly susceptible to advancement of the carious lesion (Orbans, 1990). PIT AND FISSURE SEALANTS Fissure sealants are defined as whereby pits and fissures that occur principally on the occlusal surfaces of the molar and premolar teeth are occluded by application of fluid materials, which are then polymerized. Currently used methods are based on the principle that the adhesion of acrylic and composite resin to enamel is greatly increased if surfaces are first etched with an acid. The acids used me of two main types: those that polymerize after mixing two components and those that polymerize only after exposure to an appropriate light .source. Effectiveness of Sealants For sealant to be effective, first of all it must be retained. Whether or not a sealant is retained is dependant upon the:

49

1. Technique of application. 2. The type of sealant material. 3. The morphology of the tooth surface to which it is applied. Classification of Pit and Fissure Sealants Mitchell and Gordon (1990) stated that the sealants can be differentiated in the following ways: 1. Polymerization methods a) Self activation (mixing two components) b) Light activation: - First generation: Ultraviolet light - Second generation: Self cure - Third generation: Visible light - Fourth generation: Fluoride releasing 2. Resin systems BIS-GMA Urethane acrylate Filled and unfilled Clear or tinted

3. 4.

Clear sealants have been shown to have better flow characteristics than tinted or opaque, but this can be an advantage or disadvantage depending position of the tooth to be sealed. Although the retention rates of the two types are similar, colored sealants are more easily appreciated by the patient and monitored by the dentist at subsequent recalls. The sealant is applied in a viscous liquid state that enters the micropores, which have been enlarged through acid conditioning. Then the resin because of either a sell-hardening catalyst or application of a light source. The extensions of the hardened resin that have penetrated and filled the pores are called lags.

50

Requisites of an Efficient Sealant (Brauer, 1978)

1.

2. 3. 4. 5. 6.
7.

8.

A viscosity allowing penetration into deep and narrow fissures even in the maxillary teeth Adequate working time Rapid cure Good and prolonged adhesion to the enamel Low sorption and solubility Resistance to wear Minimum irritation to tissues Carmstatic action

Indications Clinical is the deciding factor in the placement of sealants. Newly erupted both primary molars and permanent bicuspids and molars with complete recession of pericoronal operculum and with open and/or sticky grooves and fissures. Stained pits and fissures with minimum decalcificalion or opacification and no softness at the base of fissures. The tooth in question should have empted less than 4 years ago.

Contraindications Individual with no previous caries experience and well coalesced pit and fissures. Monitor if the individual and the teeth are not at risk.

Radiographic or clinical evidence of caries on the proximal surface of the tooth should not be sealed. Wide and self-cleansable pit and fissures. Tooth that cannot be isolated or partially erupted tooth. Pit and fissures that have remained carious free for 4 years or longer.

Technique of Application 1. Cleaning: the surface of the tooth selected for seatant placement should be cleaned first with a slurry of pumice and water. It is important that neither a prophy paste nor a paste containing fluoride
51

be used as they will compromise the acid etching procedure and therefore the sealant's effectiveness. 2. 3. Washing and drying: immediately following cleaning, the tooth is washed with water and air-dried. Etching: occlussal surface is then etched with a 30-50% solution of phosphoric acid liquid or gel for 60 seconds. Etching produces microscopic porosities in the enamel. The resin extends into these microscopic porosities and forms tags which attach it firmly to the tooth surface.

With different etch times, no quantitative differences in the surface morphology of enamel are observed (Tandon et al, 1989). This shows that the retentive character of the etched surface is similar for different etch times. Thus, a short etch time of 15 seconds is satisfactory for primary enamel and is also sufficient to produce the required etch pattern for the strong binding of sealants.

4.

Washing and drying: following etching, the tooth surface is washed with water for 30 seconds to remove all the etchant and then air-dried. A properly etched tooth surface has a dull frosted appearance. After etching the tooth, the surface should remain dry and free of my moisture contamination until the resin is applied and cured. The tooth can usually be kept dry with cotton rolls and suction. If not, then a rubber darn must be used.

If the surface becomes contaminated, it must be re-etched for an additional 10 seconds.

5. 6.

Application of material: care must be taken when applying the material to avoid incorporating air bubble. Curing: material is cured according to the manufacturer's directions. Once the material has been fully cured, it is carefully examined with an explorer to make certain that: all pits and fissures are covered. all excessive material has been removed. material is firmly adherent to the enamel surface.

52

7.

Recall: as with other forms of dental cue, the sealants should be thoroughly checked at subsequent recall appointments to ensure:

it is still firmly adherent no sealant material has been lost

If it is necessary, the sealant material should be added at this time. Sealants have been shown to be safe, efficient and effective methods of preventing pit and fissure caries and as such should be used by all dental personnel for prevention of ravages of dental caries. Recent Pit and Fissure Sealants 1. 2. ACP releasing sealant Enamel Loc The first self-etching light-cured pit & fissure sealant with the following properties: Fluoride Release One step application Natrual white color Low viscosity Filled resin Embracer WetBondTM pit and fissure sealant. Embrace sealant is unique because it bonds to the moist tooth, and provides an easy way to dispense and use. It has embrace sealettes which are pipettes containing 0.2 mL of Embrace Wetbond Pit and Fissure Sealant, an amount sufficient to seal four teeth. The user simply has to snip off the narrow end of the pipette and gently squeeze the bulb to dispense the sealant. This is an ideal dispensing system for clinics, schools, institutions, public health, large groups and independent dental practices where inventory control, cost control, and cross-contamination are major concerns.

3.

53

FLUORIDES
Fluoride is the most electronegative element which never exists in free state in nature but combines chemically with other elements as fluoride compound. It has not only notable chemical qualities but also physiological properties of great importance for human health and well being. Its selective effect on the hard tissues of the body attributes significantly to prevention and control of dental caries. Fluorine word is derived from the Russian word "flor" which comes from "floris" meaning destruction in Greek and from Latin word "fluor" that means to flow since it was used as a flux. Fluoride apparently is ubiquitous in its distribution and is the 13th among the trace elements in order of abundance in the earth's crust. It is a highly reactive anion with an atomic weight of 19 and atomic number of 9. Fluoride is widely distributed in the biosphere; is present in the lithosphere, hydrosphere, atmosphere and in all living organisms. It enters into the atmosphere by volcanic action and inter action of the soil and water vapors due to the action of the wind. It returns to the earth be deposition as dust or in rain, snow and fog. It comes to the hydrosphere by leaching from the soil and minerals in to the ground. The action of fluoride on the enamel surface can be divided into the following: Fluoride incorporation in enamel Incorporation of fluoride into enamel throughout development is not a principal mechanism of cariostatic effect. It is believed that pre-eruptive exposure to fluoride may produce teeth more resistant to caries by making pits and fissures shallower, but posteruptive exposure of fluoride too has a significant role in it. Pre-eruptive incorporation Fluoride gets incorporated in the fluid filled sac, which surrounds the developing tooth. It then enters the developing enamel. Highest concentration of fluoride is seen in crown enamel located at or near the tooth surface. Posteruptive incorporation Fluoride continues to enter the enamel surface, causing crystals to change from predominantly carbonated apatite and hydroxyapatite to

54

fluorapatite (FAP) and fluorhydroxyapatite (FHAP) crystals. These fluoride ride rich crystals are less acid soluble than the original enamel apatite.

Remineralization of acid dissolved enamel Minerals of tooth enamel are continuously in exchange with the minerals of saliva and thus the balance is maintained. This equilibrium can get disturbed with the organic acids produced by the metabolism of fermentable carbohydrates by the microorganisms. This leads to a drop in pH of the plaque on the enamel surface and in the sub-surface. Mmerals, particularly calcium and phosphate, leave the dissolved enamel in their ionic form and enter the plaque fluid. This process is called as "demineralization. This gets reversed with the factors like fluoride and is termed remineralization. The surface and sub-surface of the enamel absorb and hold minerals and fluoride, which are present in the plaque fluid and enhance the regrowth of the partially dissolved crystals, Fluoride's ability to facilitate the remineralization process is presently believed to be more significant than its inhibition of demineralization. The regrowth by fluoride incorporation chemically forms new crystals that are larger and more acid resistant and contain a higher concentration of fluoride. This explains why the "white spots", i.e., incipient lesions which have been arrested or healed due to fluoride application, are considerably less reactive to further acid challenge than the adjacent unaffected enamel. MODES OF FLUORIDE ADMINISTRATION SYSTEMIC FLUORIDE

Fluoride after the ingestion can get absorbed and incorporated into developing enamel and can benefit teeth before eruption. It also benefits the teeth after their eruption, when it returns to mouth in saliva and gingival exudate. Community Water Fluoridation Community water fluoridation is the process of adjusting the amount of fluoride in a community water supply to an optimum level for the prevention of dental caries. The effect of fluoride in drinking water on dental caries has been the subject of research commenced decades before. Studies have shown
55

that the adjustment of fluoride concentration in drinking water to the optimat level of 1 ppm is associated with a marked decrease in dental caries. The World Health Organization recognized these facts by its resolutions in 1969 and 1975, in which it is stated that water fluoridation application should be the cornerstone of national health policies for prevention of caries.

The recommended daily dosage of fluoride for children above 3 years of age is 1 mg. This can be obtained by drinking one liter of water with a concentration of 1 ppm fluoride ion. Since the amount of water consumed will vary with temperature, the fluoride ion concentration considered optimal for a particular locality is predicted upon the average of the maximum daily temperature.

Benefits of Water Fluoridation Cariostatic effects of water fluoridation in children are not limited to permanent dentition but extended to primary dentition as well. This method is preferred since some tooth surfaces receive greater protection against caries than others. For example, smooth surfaces of teeth, especially proximal surface, derive maximum protection than do pits and fissures on the occlusal surface.
Water fluoridation has both pre-eruptive and post-eruptive effects.

Fluoridated drinking water not only acts systemically during tooth formation to make dental enamel more resistant to dental decay, but also has topical effect through the release in saliva after ingestion. Fluoride in saliva through the systemic mode remains elevated for an extended period, provides protection against demineralization and facilitates remineralization. fissures more shallow and self-cleansing.

It changes the morphology of occlusal surfaces by making pit and

Fluoridation of community water is the least expensive and most effective way to provide fluoride to a large group of people.

If there is a question regarding the fluoride concentration, which is not an additive but is naturally present to some degree in water, the local authority of health can test samples and am provide accurate information.

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 Beverages bottled in fluoridated areas or other such products may pass on the beneficial effects to fluoride deficient/deprived population. This is termed 'Diffusion' or 'Halo' effect. Recommended Level of Fluoride in Water (WHO 1971) Concentration 0.7 to 1.2 ppm Depending upon a community mean maximum daily temperature: Cold climate 1.2 ppm Summer season or temperate climate 0.7 poor Calculation of Optimum Level of Fluoride ppm fluoride = 0.34/E E = -0.038 + 0.0062 x temp. in oF (E is estimated water intake) Recent Recommendations (WHO 1994) In view of the increased concern about the toxic effect of fluoride through systemic ingestion, especially about opacities of developing dentition, WHO has recommended optimum level of fluoride in drinking water as: 0.5 to 1.0 ppm Table : Percentage caries reduction with different methods Method of fluoride administration Community water fluoridation Salt water fluoridation Dietary supplements Fluoride dentifrices Professionally applied topical fluoride Self-applied topical application School Water Fluoridation

Average % reduction of caries 50-60% 40% 50-85% 20-30% 30-40% 20-50%

School water fluoridation is the adjustment of the fluoride concentration of a schools water supply for caries prevention.

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After observing the beneficial effects of community water fluoridation, an alternative method of supplying systemic fluoride for children was decided. School water was fluoridated to provide maximum cariostatic, effect in developing teeth. Since children spend only 6 to 8 hours in school, concentration of fluoride 4 to 6 times more than that designated for community water, was recommended. For instance, in Elk lake, Pennsylvania, the school water supply was fluoridated at 5 ppm and in five years there was a reduction of 28.6% seen in caries. After 10 years of school water fluoridation, the children who attended school continuously had 39 percent less decayed, missing and filled teeth than did their counterparts. Similarly several hundred of rural schools in the United States and few schools in Brazil and Thailand practice school water fluoridation.

Advantages and Disadvantages Results of several school water fluoridation programs indicate that it can be an effective public health measure to reduce dental caries in communities where fluoridation of water supply is not possible.

This method has some disadvantages also. Most of children are 5 to 6 years old upon starting school; at this age their dental development precludes the fluoride from school water fluoridation and will not provide pre-emptive contact to the primary teeth. It allows only limited pre-eruptive protective benefits to primary teeth. Another disadvantage is intermittent fluoride exposure of children. Most children who attend school for 5 to 6 hours are actually in school less than 180 days during a year and do not receive complete effect of fluoride.

Dietary Fluoride Supplementations Though a school based program assures that participating children are regularly receiving their fluoride supplements, the time of exposure to the developing dentition is not at the maximum level. In community water fluoridation they receive an advantage of being able to administer the fluoride for the entire calendar year. They also allow supplementation to begin at birth, so that maximum protection can be afforded to both primary and permanent teeth.

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Dietary fluoride supplements are administered in the following forms:

1.

2. 3. 4.
5. 6. 7.

8. 9.

Fluoridated milk Fluoridated salt Fluoride in sugar Fluoride in citrus beverages Fluoride drops Fluoride drops with vitamins Fluoride tablets/ lozenges Fluoride tablets with vitamin Fluoride oral rinse supplements

Fluoridated Milk Milk fluoridation is suggested as an alternative to water fluoridation for caries prevention. Jolan Banoczy et al (1984) undertook a longitudinal study to see the effect milk consumption in 3 to 9 years old children with homogeneous living condition. Children were given 200 ml milk daily, fluoridated with 0.4 mg of fluoride for preschoolers (3 to 5 years old) and 0.75 mg, for schoolers (6 to 9 years old) for 300 days in a year. Caries increment was seen considerably less in the second year and the third year computed to the first year. Disadvantages Although most of the studies have shown evidence of protection from caries, milk is not an ideal vehicle for fluoride delivery because of the following reasons

It provides only a limited exposure to children, as consumption of milk tends to decline with increase in age. Absorption is slow as compared to water fluoridation. Table : Recommended Dietary Fluoride supplements (Revised Schedule, 2003)

Age Birth 6 mths 6 mths 3 yrs 3 6 yrs 6 yrs upto at least 16 yrs

<0.3 ppm F 0 0.25 mg 0.50 mg 1.00 mg

0.3 0.6 ppm F 0 0 0.25 mg 0.50 mg

> 0.6 ppm F 0 0 0 0

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Fluoridated salt The addition of fluoride to table salt is a feasible way to deliver systemic fluoride, particularly in countries that lack a widespread municipal water svstem. Fluoridated salt has been sold in Switzerland for many years. France and a few countries in western hemisphere have introduced salt fluoridation in recent yyears. Wespi (1961) first promoted the use of table salt as a vehicle for fluoride in the mid 1940s. Initially, supplementation was 90 mg F/kg of salt. Recently it has been recommended in the range of 200 to 250 mg F/kg salt. Commonly used salts are potassium fluoride (250 mg/kg) and sodium fluoride (225 mg/kg). All over the world only five countries (Belgium, France, Germany, Spain and Switzerland) have specific policies of use of salt fluoridation. A sixth, Hungary, is presently contemplating a recommendation (Banding, 1999). Advantages and Disadvantages Salt fluoridation holds a great promise for underdeveloped countries and countries like India where water fluoridation is not feasible due to a limited central water supply and not accessible to a majority of the community. Salt is the vehicle, which is not expensive and is used almost in all the houses. Fluoride supplied in salt is usually ingested with meals, hence absorption is relatively slow. Fluoride in Sugar

Several studies have shown that adding fluoride to sugar and sugar products has potential to reduce the cariogenic effect of sugar or fermentable carbohydrates among population groups, especially where it is impractical to use other fluoride vehicles. 42% reduction in caries was observed in a 3-year clinical trial (Luoma et al 1979).

At our Department of Pedodontics, Manipal, too, a clinical trial conducted with fluoridated sugar rinse in children has shown a high potential in controlling caries risk factors like salivary pH and S mutant count computed to the control group (Tandon 1994, unpublished data).

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Disadvantages It is believed that the marketing of cariologically harmless fluoridated sucrose products would increase the general consumption of sucrose and thus will promote a nutritional unbalance. Furthermore, one type of fluoridated sugary product may not reach all those needing the fluoride supplements. Fluoride in Citrus Beverages Citrus beverages may also be considered as a potential vehicle for the administration of fluoride as dietary supplements (Gaton et al, t983). Prescribed Fluoride supplements (Tablets, drops, vitamins etc.) Fluoride supplements are prescribed by the practitioner for children living in areas with a suboptimal level of fluoride in the drinking water. Recently, the recommendations of American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatrics (AAP) have been revised by qualified health cue providers. Precautions to be Considered

Before prescribing a fluoride supplement for a child, a physician or dentist should know the child's age. The concentration of fluoride in the child's "primary source" of drinking water.

Generally infants are given fluoride drops with or without vitamins, which are directly placed in the mouth or added as foods. Fluoride tablets are generally prescribed after a child has a full complement of the primary teeth. The effectiveness of fluoride drops or tablets is neither enhanced nor reduced by adding vitamins. However, there may be increased compliance as a separate route is avoided when fluoride is prescribed in vitamins. Prenatal Fluoride Supplements Prior to 1966, fluoride was prescribed in prenatal supplements for potential caries prevention in teeth where development begins in intrauterine life and at birth. There was a belief that fluoride would cross the placental barrier and get acquired by the developing teeth sufficiently to provide caries
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protection. Legros et at (1983) reported that prenatal fluoride protect the teeth by: a) b) Affecting the morphology of teeth, promoting the formation of smooth teeth with shallow grooves and fissures. Enamel shows less depth of etching and is composed of more densely placed enamel rods with more mineralized apatite crystals and with a slightly better crystallinity. Recently, another school of thought is that dietary fluoride supplements to pregnant women cannot be recommended because there is no conclusive evidence that it reduces dental caries in the teeth of their offspring.

c)

Fluoride oral rinse supplements Fluoride oral rinse supplements provide both a systemic and topical effect. The patient swishes the solution producing a topical effect, and then swallows the solution, providing a later systemic effect. TOPICAL APPLICATIONS Topical fluorides arc directly applied to the erupted teeth. Fluoride ions in such agents do not penetrate deeply into enamel. These ions tend to provide only local protection. Indications for use of topical fluorides in children Caries active children In children shortly after periods of tooth eruption In patients with reduced salivary flow due to medications Those receiving radiation of head and neck Patients with fixed or removable appliances, e.g. before cementation of bands - After placement or replacement of restorations and before cementation of stainless steel crowns - Patients with eating disorders or undergoing a change in lifestyle - Disabled or alternatively abled children

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Recommendations for topical application of "high potency" fluoride products - No more than 2 g of gel per tray or 40% of tray capacity should be dispensed. - Saliva ejector should be used. - Expectorate for 30 seconds to I minute after 4 minutes application. - 5-10 drops of product per tray should be used in custom individually fitted trays. Professional Application When fluoride is applied to an enamel surface it diffuses inward by way of the less dense inter prismatic spaces to a depth related to its concentration, the treatment time, pH and the type of fluoride agent. Fluoride agent should now be swallowed while applied. Procedure to be followed : To reduce the likelihood of ingestion of fluoride during a professionally applied topical application, the following procedures should be kept in mind: Seat the patient in an upright position Use trays with absorptive liners Limit the amount of the agent, for example: during gel application, the gel is placed in a tray to no more than 2.5 ml (one half of a teaspoon). Use suction during and after treatment. Have the patient expectorate thoroughly after the trays are removed.

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Table : Commonly used fluoride agents in clinics Solution Amount Method of preparation 2% NaF (9.040 plan) pH -7 - To prepare 2% Na F, dissolve 20 g of NaF powder in 1 liter of distilled water in a plastic bottle - NaF should always be stored in plastic bottles. If stored in glass containers, the F of the solution can react with the silica of glass forming SiF2 reducing the availability of free active fluoride for anticares action Knutson and Feldman technique (1948) - Clean and polish the teeth in only the first of four applications - Isolate the upper and opposing lower quadrant with cotton rolls - Dry the teeth thoroughly - Apply the 2% NaF with cotton rolls applicators and allow it to dry on the teeth for about 4 minute - NaF is applied once because once a layer of CaF2 (dominant product of reaction) gets formed it interferes with further diffusion of F to react with hydroxyapatitie. This is called choking off phenomenon - Instruct the patient to avoid eating, drinking for 30 minutes - Second, third and fourth applications are done at weekly interval - Application is recommended at 3, 7, 11 and 13 yr Chemically stable Acceptable taste because of neutral pH Non-irritating to the gingiva Does not blender the teeth Cheap and inexpensive

Technique of application

No. of applications per year Advantages

Disadvantages

- Patient has to make four visits to the dentist within a relatively short time

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Amount Method of Preparation

8%, SnF2 (19,360 ppm) - 'O' No. gelatin capsules are priorly filled with 0.8 g, powdered SNF2 and are stored in airtight plastic containers - To prepare 8% SNF2 , content of one capsule is dissolved in 10 ml of distilled water in a plastic container and then shaken - SnF2 solution is to be prepared just before each application. Muhler (1957) technique. - Do a thorough prophylaxis. - Isolate a quadrant with cotton rolls and dry the teeth. - Apply the freshly prepared 8% SNF2 continuously to the teeth with cotton applicators. - Reapply the solution to the tooth every 15-30 sec, so that the teeth are kept moist with the solution for 4 minutes. - Instruct the patient not to eat, drink or rinse for 30 minutes. This helps in prolonging the availability of F to react with the tooth surfaces. Once per year - The rapid penetration of tin and fluoride within 30 seconds - Highly insoluble tin-fluoro phosphate complex forms on enamel solace that is more resistant to decay than enamel. - Unstable in aqueous solutions and should be prepared fresh for each patient. - Its naturally low pH (2.1 to 2.3) is rather as tringent and the solution has a metallic taste. - It may cause gingival irritation particularly to the dehydrated and diseased gingival tissue. - Produce discoloration of the teeth particularly in hypocalcified areas. - Causes staining on the margins of restoration.
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Technique of Application

No. of applications Per year Advantages

Disadvantages

Mechanism of action: NaF Ca10 (PO4)6 (OH)2 + 20 F CaF2 + 2Ca5 (PO4)3 OH Mechanism of action: SnF 2 Low concentration Ca5 (PO4)3 OH + 2SnF2 High concentration Ca5 (P04)3 OH + 16SnF2 2Ca5 (PO4)3 OH + CaF2 CaF2 + 2Sn3F3PO4 + Sn2(OH)PO4 + 4CaF2 (SnF3)2 2Ca5 (PO4)3 F + Ca (OH)2 2CaF2 + Sn2 (OH)PO4 + Ca3 (PO4)2 10 CaF2 + 6P04 + 20H 2Ca5 (P04)3 F + Ca (OH)2

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Table : Commonly used fluoride agents in clinics Solution Amount Method of preparation 1.23% F APF (12,300 ppm) pH 3.0 - To prepare APF solution dissolve 20 g of NaF in 1 liter of 0.1 M phosphoric acid - To this add 50% hydro fluoride acid to adjust the PH at 3.0 and F concentration at 1.23% Brudevold technique (1963) - Do a thorough prophylaxis and isolate a quadrant with cotton rolls - APF solution is continuously and repeatedly applied with cotton applicators - Keep the teeth moist for 4 minutes - Pass the floss through each interproximal embrasure to ensure wetting of those surface - Repeat the procedure for remaining quadran - Instruct the patient not to pair drink or rinse for 30 minutes - Semiannual - Fluoride uptake following the application of APF solution is greatly accelerated whereas that following NaF is much slower. 50% more effective than NaF - APF solution is cheap, can be prepared easily - It is stable with a long shelf-life, when stored in an opaque plastic battle - Teeth must be kept wet with the solution for 4 minutes - APF solution is acidic, sour and bitter in taste so necessitates the use of suction

Technique of application

No. of applications per year Advantages

Disadvantages

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Gel Amount Method of Preparation Technique of Application 1.23% F APF (12,300 ppm) pH 4-5 To prepare a gel, a gelling agent methylcellulose or hydroxyethyl cellulose is to be added to the solution and the pH is adjusted between 4-5. - Do a thorough prophylaxis and dry the teeth. - Fill the U/L tray with APF gel - Insert the U/L trays simultaneously into the mouth and have the patient bite down tightly for 4 min - Thixotropic gel displays a high viscosity at low shear rates and a very low viscosity at higher shear rates. The clinical importance of this is that the gel thins out under biting forces and more easily penetrates between the teeth Conversely, when it is not under stress it remains in the tray and does not tend to run down the patient's throat - Instruct the patient not to eat, drink or rinse for 30 minutes - Semiannual - Acceptable by the child due to flavored taste - Easy to apply as with gel fluoride comes in constant contact with teeth, so re-appxlication is not required - Can be self-applied - Thixotropic property - Caries reduction more than when compared to APF solution - Can cause irritation to inflamed gingival tissue and to the open carious lesion; thus, it should be applied only after restoration of all carious teeth

No. of applications per year Advantages

Disadvantages

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Mechanism of action: APF Ca5 (PO4)3 OH 4H 5Ca++ + 3HPO4 + H2O (dehydration and shrinkage)

Ca++ + HPO4 Ca.HPO4 2H2O (DCPD) (hydrolysis) (Di calcium phosphate dinhydrate) (Intermediate product) 5Ca.HPO4 2H2O + F Varnish Amount Method of preparation Technique of application Bifuoride 12 (2.71% NaF, 2.92% CaF2) - Commercially available (discovered by Schmidt in 1964) - Do the thorough prophylaxis and dry the tooth (do not use cotton for isolation as varnish is sticky and tends to stick to cotton) - Drop the varnish onto the brush or foam pellet - Paint the varnish thinly first on the lower arch (as saliva collects more rapidly on it) and then on upper arch starting from the proximal surfaces Layers, which are too thick, separate too easily - Instruct the patient: a) Not to rinse or drink anything at all for that day b) Not to eat solid for that day c) Take liquid and semisolids till next morning d) Not to brush that day. Semiannual application - Forms a watertight protective film insulating against thermal and chemical influences - With correct application and proper mouth hygiene varnish remains in place for several days. During this time fluorides act on the treated surface - Patient compliance is required
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Ca5(PO4)3F + 2HPO4 + 3H+ + 2H2O Table : Fluoride foam and varnish

No. of applications per year Advantages

Disadvantages

* Other varnish preparations: Duraphat (Germany), Fluorprotector (Lichenstein), Fluoritop (India) Foam Amount Method of No. of application Per year Advantages 0.92% F (9200 ppm) pH 4.5 - Commercially available Semiannual application - It is less dense than gel and is able to flow better, allowing a free movement of the fluoride ion on the tooth surface and interproximal areas - Total density by weight is less than gel Application. This reduces the risk of ingestion and systemic toxicity of fluoride - Retention on to the tooth surface is less as no polymers are added.

Mechanism of action Varnish 10Ca5(PO4)3 OH + 10F 2Ca5(PO4)3OH + CaF2 6Ca5(PO4)2F + 6Ca3(PO4)2 + 10OH 2Ca5(PO4)3 F + Ca (OH)2

Other Fluoride Applications (by the Professional) 1. Fluoride Impregnated Prophylaxis Paste and Cup

The temperature of enamel surface is raised during a prophylaxis because of the friction between the prophylaxis cup and the tooth. High temperature enhances the uptake from fluoride containing prophylaxis paste or solutions (Putt et al, 1978). It is therefore reasoned that if a fluoride impregnated prophylaxis cup or paste are developed, fluoride would be released under optional conditions. Laboratory evidence have also confirmed that prophylaxis cup made from a blend of thermoplastic resins and impregnated with sodium fluoride and stannous fluoride will increase the fluoride content of enamel. When fluoride containing prophylaxis pastes
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are used, the effects were generally found to be similar whether a conventional or fluoride impregnated prophylaxis cup was used (Stookey and Statiman, 1976). 2. Iontophoresis

It is based on the theory that small electric current will help to drive fluoride ion further into the dental enamel, producing the desired effect, reduced enamel solubility, increased fluorapatite formation, reduced dentine sensitivity and even sterilization of root canals. 3. Dental Materials Containing Fluoride

Several studies have been conducted to see the cariostatic effect of denial materials containing fluoride and a highly significant fluoride uptake by enamel has been recorded that was placed in contact with the materials.

Carboxylate cements are now used more extensively for cementation of crowns and orthodontic hands. Fluoride in amalgams has also been tried. Jerman (1970) added 1.5% of stannous fluoride to silver amalgam alloy and noted that the enamel surface placed in contact with this alloy showed a significant reduction in enamel acid solubility. Fluoride containing varnish and sealants were considered of potential value in pedodontic practice. A polyurethane based material containing 10% sodium monofluorophosphate commercially available as Expoxylite 9070" has shown 36.6% less carious surface on first permanent molar. Glass ionomers are the recent innovation which seem dominate the other materials because of their fluoride leaching property. Self Applied Topical Applications

Fluoride Dentifrices Fluoride containing toothpastes now account for approimately 85% of dentifrices market in the world, especially in the USA. The Council on Dental Therapeutics or the American Dental Association currently recognizes few caries preventive dentifrices with ADA seal acceptance. They all contain between 1,000 and 1,500 ppm fluoride formulated from

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either sodium fluoride or sodium mono-fluorphosphate and none contains stannous fluoride. Advantages Because fluoride dentifrices usually are used regularly two or three times a day, they provide a frequent source of fluoride in low concentration that can inhibit demineralization and enhance remineralization. Availability Fluoride dentifrices are available and recommended for the people of all ages whether they live in fluoridated or non-fluoridated areas. Precautions to be considered

Preschool age children should be supervised while brushing to avoid ingestion of excessive amount of paste.

Only a dab or pea-size amount of dentifrice should be used by six years of age or below. A ribbon of dentifrice that covers the bristles of an adult-sized toothbrush contains about one gram of dentifrice. Swallowing the amount of fluoride which is present in this toothpaste should be avoided. At least one brushing with fluoride toothpaste should be done just before bedtime, placing fluoride in the mouth prior to a period of low salivary flow, thus prolonging fluoride availability. Table : Use of fluoride tooth pastes Child age Below 4 yr 4 to 6 yr 6 to 12 yr Recommendations for use of fluoride tooth paste Fluoride tooth paste is not recommended. Brushing once daily with fluoridated times with a non-fluoridated toothpaste Brushing twice daily with fluoridated toothpaste and once with a non-fluoridated toothpaste Brushing three times with fluoride toothpaste.
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Above 12 yr

Fluoride Impregnated Dental Floss Dental floss is air essential part in the plaque control in the interproximal enamel surface. If the interproximal surfaces receives the benefit of additional fluoride dental flossing, this may increase its value as a caries preventive aid. Gillings (1973), utilizing sodium fluoride and stannous fluoride successfully developed and patented several formulas of fluoridated dental floss. Because of the unknown sample size and the lack of clinical size and date, no definitive conclusions about this cariostatic effect could be made. Fluoride Rinses Fluoride mouth rinses for school based health programs or in home are currently popular as a simple way to expose teeth to fluoride frequently. The early trial with neutral sodium fluoride, acidulated phosphate fluoride and stannous fluoride rinse proved to reduce caries by 20 to 50 percent.

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METHODS ON THE HORIZON

A lot of research has been directed towards efforts to develop methods to prevent caries, which have ranged front simple to highly sophisticated techniques. These current approaches are still under trial, and based on three-prong strategies: 1. 2. 3. 1. Combating canes inducing microorganisms. Increasing tooth resistance against acid attack. Modifying cariogenic diet ingredients. Antiplaque agents and detector The role of plaque in the formation of dental caries is well documented. Thus antibacterial and antiadherence agents are being tested as a plaque building blockers.

The enzyme glucosyltranferase (GTF) may be inhibited by the use of analogues of sucrose interfering with glucan synthesis. In the recent times some plant and fungal products that alter the adhesion of cell surface glucans are also being identified. In this Context, cheaper modalities that are accessible to the masses are being tested in the form of indigenous products. Rajesh et at (1997) tested the efficacy of mango leaf. neem leaf and tea extracts and found that all the three products were effective in reducing the plaque formation as well as the Streptococcus mutans count. The antibacterial products may have the drawback of being rapidly eliminated from the oral cavity and for this purpose, Controlled Release Devices (CRD) or polymers are being used to increase the substantivity in the oral cavity. A new prophy paste with ACP (Amorphous Calcium Phosphate) has been introduced. It creates ACP on contacting the patients teeth and saliva. As ACP forms, it is incorporated within the enamel surface where it remains after rinsing. The available ACP helps prevent future damage by stimulating remineralization of the tooth enamel. ACP fills in surface enamel crevices for an intense polish and shine. Scientific data

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supports that it actually gives greater luster for whiter, brighter teeth.

Lyre-Jet is a new system comprising a water-jet and lyre-shaped heads. A length of dental floss is stretched tightly across the tips of the heads and two jets of water me sprayed on either side of the lyre along the floss. The floss vibrates when the water is sprayed. Instant Intraoral Camera with Plaque Detector is an easy yet effective intraoral camera. The remarkable Plaque Detector Mode helps patients to visualize dental plaque and tartar, which is illuminated in pink color. It helps to educate patients on using proper brushing technique and the importance of periodic dental cleaning.

2.

Altering surface morphology/ Increasing tooth resistance A so-called surface active polymeric agents for surface adhesive binding has been developed by Bowen et al (1995) comprising applications in two stages for increasing tooth resistance to dental decay : Monomer which would have a chemical bond followed by a polymeric top coat which would enhance durability and esthetics. Tooth resistance is improved using two-steps procedure by enhancing the fluoride uptake in enamel. This method involves initial application of an acidified calcium phoshate solution followed by suitable fluoride solution. Such two component system can be used as a professional topical application or self-applied month rinse or alternatively using chewing gum of an amorphous calcium phosphate (ACP) and toothpaste containing fluoride.

5% NaF White Varnish is a new product which disappears after application, setting the new standard in fluoride varnish therapy. The features of this product are :

Safely delivers 22,600 ppin fluoride New formulation is quick and clean Sets rapidly in the presence of saliva

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Enhanced flow characteristics allow it to reach areas traditional varnishes may miss Toothpaste containing an exclusive proprietary called the Polyfluorite System, is the first and only toothpaste to protect against gingivitis, caries, and sensitivity. A combination of stabilized stannous fluoride (0.454%) and sodium hexametaphosphate, an advanced whitening agent, Crest Pro-Health is a next generation ADA accepted toothpaste. New pit & fissure sealant with ACP that is more resilient and flexible, creating a stronger, longer-lasting sealant is available. This light-cured product has a controlled flowability that keeps the sealant on the tooth structure while completely filling occlusal surfaces. It forms a chemical and thermal barrier protecting the tooth enamel on the occlusal surface from carious attacks. It can be used with any light-curing device. It also offers the added convenience and placement accuracy.

3.

Lasers

CO2 lasers can be used to alter the tooth surface of enamel and make it less prone to caries. Concern however exists regarding the depth control and optimum irradiation conditions. Pits and fissures and root surfaces may be the areas targeted by the lasers.

4.

Benign microorganisms/Replacement therapy

Using the use a thorn to draw a thorn philosophy, an approach would be to supersede the cariogenic bacteria by more benign ones.

The dominant acid (lactic acid) produced by S mutans is controlled by a gene which can be mutated.

Generic engineering provides a better alternative producing inactivated forms and then cloning it, for example, a new approach is being used to transfer the genes from bacteria that naturally produces enzymes such as mutanase which degrades the extracellular sticky polymers involved in plaque adhesion and build tip into bacteria such as Streptococcus gordoni.

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An attempt to transfer arginine diminase gene, which produces base in S sanguis into S mutans, to counter its acidogenic potential has been made.

5.

SAP (Self- assembling polypeptides) Preliminary reports have suggested the use of selfassembling polypeptides (Strafford at al, 1999) for augmentating host resistance. These may be useful in promoting enamel remineralization, presumably as a result of their nucleating potential. Following incubation in the mineralizing solution, large crystal deposits were found within the SAP. These protective peptides are used as pacifiers for young children to help modify the bacterial flora against baby bottle caries. These peptides have also been used in mouth rinses and dentifrices.

6.

Chewing gums

A novel technique involves the use of chewing gums after meals in order to counter the pH drop that occurs with the intake of sugar. Various sugar free gums have been tried out with additions such as xylitol, lactitol and area. A clinical trial conducted by Gopinath and Tandon (1996) compared the plaque pH change in the groups using urea, fluoride and sugars. The results indicated that the chewing gum containing urea showed the highest pH followed by fluoride and sugar. Thus the study concluded that chewing gum containing therapeutic agents such as urea may be recommended in highrisk caries children.

7.

Tooth friendly sweets

Use of non-cariogenic sweeteners have proved to be excellent measures in the control of caries, A short term plaque study was undertaken by Tandon et al (1997) to evaluate effect of lactitol 4-0 (b-Galactosy)-D-glucitol on plaque by incorporating it as a sweetener in biscuits. Significant reduction was found in plaque formation, carbohydrate content, increase in calcium, phosphate and protein with lactitol when compared with the control.

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8.

Microdentistry Here treatment begins before conditions arise. It enables the use of a microscope to detect conditions invisible to the naked eye. This can again be used as an educational and motivational tool by helping the patient observe his own oral conditions. For example, letting the patient see the microorganisms in the plaque.

9.

Teledentistry It is the provision of dental cue where the patient and provider are not physically in the same location. This is a relatively new field of study, which can also be used as an adjunct in providing Preventive home cue advices.

10.

Indigenous products Recently a lot of emphasis has been placed on the utilization of the rich natural resources present in India. In this context studies have been conducted on the use of various products such as mango leaf, neem and tea. These have been found to have antiplaque and anticariogenic potential. CARIES VACCINE

Preventive dentistry has taken long strides in the direction of eliminating dental diseases. In this endeavor, the caries vaccine has generated a good deal of enthusiasm. This modality of treatment can prevent the occurrence of canes on a large scale. Definition A vaccine has been defined as 'a suspension of attenuated or killed microorganisms administered for the prevention, amelioration or treatment of infectious diseases'. (Stedman's dictionary, 1990). The concept of a vaccine can be visualized primarily with the recognition of mutans streptococci as the key microorganisms in the development of caries. Thus efforts have been directed at preventing its colonization in the oral cavity.

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How it Works The basis of a vaccine is that it keeps the patient in a state of readiness such that in case an infection does occur, the immune response (i.e., the secondary immune response) which is more rapid and effective can be mounted. Thus during the first response, both B and T lymphocytes form memory cells that later 'remember' the earlier attack and respond much better. The main immunglobulin in saliva, as in any other secretions in the body, is the secretory IgA. On the other hand the lgG is present in very low concentrations. The significance of antibodies in the protection against dental caries lies in that, the presence of high levels of antibodies in the gingival fluid has been correlated with low levels of caries, Also the T lymphocytes, in caries-free subjects, have been found to possess T lymphocytes with greater potential for antigenic stimulation with S. mutans than caries-prone individuals. Routes of Administration In general, two schools of research have evolved. One concerned with IgG and systemic vaccination using a cell wall constituent of S. mutans, while the other with the oral route of vaccination and stimulation of IgA. The various routes that have been tried out include: 1. 2. 3. 4. 5. 1. Oral route Systemic route Active gingivo-salivary route Active immunization Passive immunization. Oral Route

The oral route of administration has concentrated on stimulation of the secretary IgA antibodies via the common mucosal system (consisting of MALT and GALT), which is activated in the special cells of the intestinal tract. For the colonization of Streptococcus mutans in oral cavity, the enzyme glucosylatransferase is of paramount importance. Thus several studies have been carried out using it.

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The disadvantages associated with the oral route of delivery is the rapid breakdown of the protiens or peptides. But it is also considered safer than the systemic route due to the concern of cross reactivity to the strepatococcal antigens. 2. Systemic Route

Subcutaneous administration of S matans has been tried out is monkeys and it elicited predominantly IgG, IgM and 1gA antibodies. These were found to enter the oral cavity through the gingival crevicular fluid. 3. Active gingival-salivary Route

There has been same concern expressed regarding the side effects of using these vaccines with the other routes. In order to limit these potential side effects, and to localize the immune response, the gingival crevicular fluid has been used as the route of administration. Apart from the IgG, it also associated with increased IgA levels. The various modalities tried out were :

Direct injection of lyzozyme into rabbit's gingiva which has elicited local antibody forming cell response.

Brushing live S mutans onto the gingival of rhesus monkeys (which failed to induce antibody formation).

Using smaller molecular weight streptococci antigen, which resulted in better performance, probably due to better penetration.

4.

Active immunization Various new approaches have been tried out in order to overcome the existing disadvantages : Synthetic peptides :

Any antigen derived from animals or humans has the potential for hypersensitivity reaction. The chemically synthesized peptides hold an advantage in that this reactivity can be avoided. This has also been found to enhance the immune response. In humans synthetic peptides elicited both IgG and T-cell proliferative

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response, and the antibodies were both anti-peptide and antinative. The synthetic peptides gives antibodies not only in the gingival crevicular fluid but also in the saliva. The synthetic peptide used is derived from the glucosyl transferase enzyme (purified water soluble and insoluble). Coupling with cholera toxin subunits

It has been found that coupling of the protein with nontoxic unit of the cholera toxin was effective in suppressing the colonization of Streptococcus mutans. This approach was tried out as the cholera toxin effectively binds to the lymphoid cells and functions as an excellent adjuvant. The intra-oral of administration was tried out (Katz, 1993). Fusing with Salmonella

The avirulent strains of Salmonella are an effective vaccine vector so that fusion using recombinant techniques have been used. Liposomes

These have been used in the delivery of several, particularly anticancer, drugs so as to effectively target the cells to where it should reach. These liposomes are closed vesicles with bilayered phospholipid membrane. The efficacy using liposomes has been found to increase two fold in a rat model. In humans increased IgA antibodies have been found. 5. Passive Immunization As the name suggests, passive immunization involves passive or external supplementation of the antibodies. This carries the disadvantage of repeated applications as the immunity conferred is temporary. Several approaches tried out are: Monoclonal antibodies Monoclonal antibodies to the S mutans cell surface antigen I/II has been investigated. The topical application in human subjects brought

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a marked reduction in the implanted streptococcus mutans. Thus by passing the system less concern exists about the potential side effects. Bovine milk and whey Systemic immunization of cows with a vaccine using whole mutans streptococci lead to the bovine milk and whey containing IgG antibodies. This was then added to the diet of a rat model. The immune whey brought a reduction in the caries levels. This whey was also used in a mouth rinse by Filler et al (1991). This resulted in lower percentage of Streptococcus mutans of plaque.

Egg-yolk antibodies

The novel concept of using hen egg-yolk antibodies against the cell associated glucosyl transferase of S. mutans was introduced by Hamada (1990). Vaccines used were formalin-killed whole cells and cell associated glucosyl transferase in the other. Caries reduction has been found with both these treatments.

Transgenic plants

Latest in these developments in passive immunization is the use of transgenic plants to give the antibodies. They have the advantages that: The genetic material can be easily exchanged. It is possible to manipulate the antibody structure so that while the specificity of the antibody is maintained, the constant region can be modified to adapt to the human conditions, thus avoiding cross reactivity. Large scale production is possible as it would be quite cheap. An apple a day keeps the tooth doctor away

Researchers are working on ways to inject a peptide - a fragment of a protein that blocks the bacterium Streptococcus mutans which causes tooth decay into the fruit so that cavities and painful visits to the dentist could become a thing of the past.

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British scientists at Guys Hospital in London have already isolated a gene and the peptide that prevents the bacterium from sticking to the teeth.

Professor David James (2000), a plant biotechnologist at the Horticulture Research International in Southern England, is trying to find ways to deliver the peptide into the mouth through apples or strawberries.

Though some difficulties are being faced at the present, caries vaccine is certainly a very vibrant issue. The potential implications are enormous and should be pursued with the same vigor as before.

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CONCLUSION Since dental caries is a highly prevalent disease, control of dental caries is a concern of all the people. Ideal control measures for dental caries must have immediate, high and lasting effectiveness. Preventive measures should perform not only for reducing the economic burden of restorative care but also eliminating pain and improving overall quality of life.

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BIBLIOGRAPHY TEXT BOOK OF PEDODONTICS SHOBHA TONDON TEXTBOOK OF PEDODONTICS AARTI RAO CLINICAL PEDODONTICS FINN INTERNET - GOOGLE

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