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Understanding and Treating Dental Caries in Young Children and Young Adults


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Tooth decay is the end result of a transmissible bacterial infection that is preventable. This disease is called caries. Yet just placing fillings on teeth, which is what dentists have been doing all …

Tooth decay is the end result of a transmissible bacterial infection that is preventable. This disease is called caries. Yet just placing fillings on teeth, which is what dentists have been doing all along, does not in the long haul stop this disease process.
The bacteria responsible for tooth decay generate acids from the fermentable carbohydrates we eat every day.

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  • 1. Understanding and TreatingDental Caries in Children andYoung  Adults:  It’s  Not  Just  Filling Teeth Dr. Stephen Abrams Dr. Ian McConnachie
  • 2. Overview of the Day Introduction Cariology 101 Risk Factors Detection Remineralization Therapies Early Childhood Caries Clinical Presentation Sealants, Preventive Resin Restorations, ICON Office Integration Summary Take Home Materials
  • 3. Dentistry and the Public; Some Concerns Survey results CDA Initiative • Current reputation has precarious level of trust and skepticism of the value that dentists offer • More people see dentists as business people than see dentists as doctors • Dental plans matter; level of coverage takes precedence over advice of dentists • Dentists see patients often as misinformed, which presents opportunity for education • Dentists see relationships as key to building trust and maintaining a strong patient base
  • 4. What this Lecture is Not A clinical  technique  “how  to” A commercial for specific products No commercial sponsorship* Materials shown are representative examples, not endorsements*
  • 5. *Disclaimer Dr. Abrams is President and CEO of Quantum Dental Technologies (QDT), the creator of The Canary System Dr. McConnachie is an unpaid dentist advisor To QDT
  • 6. Acknowledgements • DR. MARIELLE PARISEAU – – Dentists Leaders in Health: Thinking Outside of the Mouth – • DR. CLIVE FRIEDMAN – U. of Western Ontario and U. of Toronto • Access  to  Today’s  Presentation  on  Shaping  the   Future of Dentistry website next week
  • 7. Today and Evidence-Based Dentistry Integration of Evidence-based literature with clinical opinion If  it  is  opinion,  we’ll  try  to  say  so Recommendation Very good overview of the concepts and the process – J Can Dent Assoc 2001 Apr-Nov • Clinical practice guidelines in dentistry Part I and II • Evidence-based dentistry Part I-VI
  • 8. Concepts of EBD
  • 9. TIP:
  • 10. PubMed• Great free open source site for search of literature• Access to article abstracts and full articles• Service of – U.S. National Institutes of Health – U.S. National Library of Medicine
  • 11. What is Caries?
  • 12. NIH Consensus Conference on Caries 2001 “Dental  caries  is  an  infectious,   communicable disease resulting in destruction of tooth structure by acid- forming bacteria found in dental plaque, an intraoral biofilm, in the presence of sugar."
  • 13. NIH Consensus Conference March 2001 Caries is a bacterial infection caused by specific bacteria. Caries is a reversible multi-factorial process. In other words, caries is an infectious disease with cavitation being the last step of the process
  • 14. The Paradigm Shift One can place a number of restorations in a mouth and yet not treat the underlying disease. The bacteria remain in the plaque biofilm on the remainder of the teeth capable of creating new areas of decalcification and cavitation. We need to shift from a surgical approach to a disease management & preventive approach.
  • 15. CHMS Oral Health Data
  • 16. CHMS vs U.S. Data
  • 17. The Problem
  • 18. Relevant Issues arising in the article • “I  had  a  lot  on  my  mind,  and  brushing  his  teeth  was  an  extra  thing  I  didn’t  think   about  at  night” • CDC and P report on increase in decay in preschoolers 5 years ago-first time in 40 yrs. • “No  one  told  us  when  to  go  to  the  dentist,  when  we  should  start  using  fluoride   toothpaste” • Dentists routinely recommend general anesthesia for preschoolers with extensive problems-cost  to  parents…ranges  from  $2,000  to  $5,000 • Using general anesthesia has risks-vomiting,  nausea,…brain  damage  even   death • “It’s  not  just  about  kids  in  poverty…” • Brushing twice a day used to be nonnegotiable, but not anymore-”He  doesn’t   want  his  teeth  brushed.  We’ll  wait  until  he’s  more  emotionally  mature” • Staff treated a 3-year-old who was making his second visit to the operating room for dental work. The boy arrived with a bottle of Coca-Cola
  • 19. Dental Caries is one of the most common diseasesamong 5 – 17 year olds 60 50 Note: Data included Caries decayed or filled primary 40 and or decayed filled or missing permanent teeth. Asthma Asthma, chronic bronchitis 30 and hay fever based upon 20 Hay Fever household respondent about the sampled 5 – 17 year old Source NCHS 1996 10 Chronic 0 Bronchitis Oral Health in America: A Percentage of children & Report of the Surgeon General DHHS 2000 adolescents ages 5 to 17
  • 20. Public Perception – In other words – NO BIG DEAL
  • 21. Our Reality Psychological impact Lower body weight A VERY BIG DEAL
  • 22. Terminology Caries is a transmissible bacterial infection and a multifactorial disease that reflects change in one or more significant factors in the total oral environment. (NIH Consensus Conference 2001)
  • 23. Early Childhood Caries (ECC) “The  presence  of  one  or  more  decayed   (noncavitated or cavitated lesions), missing (due to caries), or filled tooth surfaces in any primary tooth  in  a  child  71  months  of  age  or  younger.” Definition from National Institute for Dental and Craniofacial research (NIDCR) workshop 1999
  • 24. Terminology Severe Early Childhood Caries (S-ECC) “Any  sign  of  smooth-surface caries in a child younger than 3 years  of  age”                                                              AAPD “One  or  more  cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or decayed, missing or filled score of at least 4 (Age 3), 5 (age 4), or 6 (age 5)  surfaces” Drury et al 1999
  • 25. Diagnosis involves recognitionof these changes rather thansimply noting cavities
  • 26. • Don’t treat underlying disease • Don’t address plaque biofilm i s s u e s • Don’t change risk levelWe need to from a surgical approach to a RISK management & preventiveapproach.
  • 27. CariologyWhat is Tooth Decay?
  • 28. Caries Risk?
  • 29. Caries Progression
  • 30. What do you need to create tooth decay? • Teeth • Food particularly carbohydrates • Bacteria in Plaque or Biofilm
  • 31. Elements involve in the Caries Process Sugars & Plaque Carbohydrate containing Exposure bacteria Caries Tooth When all three are present, and enough time passes, large carious lesions will occur
  • 32. Restorations •Restorations have no measurable effect on bacteria. •Restorations have a finite life span. • Each replacement restoration leaves less tooth structure. •Restorations increase the risk of an abscess. •Restorations may increase the risk of tooth fracture & periodontal disease.
  • 33. Caries Evolution
  • 34. Caries Progression
  • 35. Caries Progression
  • 36. Caries Progression
  • 37. Caries Progression
  • 38. White Spot Lesion Internal loss of minerals External (outer) surface White Spot Lesion Really a subsurface lesion
  • 39. Early Carious Lesion in Enamel
  • 40. Pathogenesis of Dental Caries SALIVA PLAQUE PLAQUE ENAMEL ENAMEL Polysaccharides Calcium Salts Plaque buffers mouth inside of tooth SUGARS ACID Calcium Salts Bacterial Enzymes Salivary buffers Demineralization Re-mineralization
  • 41. The Caries Balance Pathological Factors Protective Factors •Acidogenic Bacteria •Saliva flow & components (S. Mutans, S. Sobrinus & •Proteins, calcium, phosphate, Lactobacilli) fluoride, immungloulins •Reduced Salivary Flow •Antibacterials •Frequency of In saliva and extrinsic fermentable Fluoride, Chlorhexidine, iodine carbohydrate ingestion Caries No Caries Adapted from Featherstone, J. D. B., JADA 2000
  • 42. Demineralization Demineralization Dental Mineral Organic Calcium & Acid soluble + Acids Phosphate intoCalcium phosphate solution If fluoride is present in the water between the crystals it inhibits mineral loss
  • 43. Remineralization Phosphate Remineralization Calcium in tooth In tooth •Builds on existing Water (from saliva) + Water (from crystal remnants Saliva) •New mineral less soluble •Fluoride helps Fluoride speeds up remineralization creating a less soluble mineral
  • 44. demineralizationpH FAP Critical pH HAP deposit caries erosionpH remineralization Carious lesion forms at pH 4.5 - 5.5 Erosion lesion forms when pH <
  • 45. Cyclic Process of DecayBacteria plus food Demineralization makes the salivavery acidic within 5 minutes Saliva pH is Remineralization normal 30 minutes after eating
  • 46. Stephan Curve ? ? ? Stephan RM. JADA 1940;27:718-723 Changes in hydrogen-ion concentration on tooth surfaces and in carious lesion. Stephan RM. JADA 1944; 23:257-266 Intra-oral hydrogen-ion concentrations associated with dental caries activity.
  • 47. What Contributes to the Extent of pHDrop after Glucose Exposure?• Type & amount of carbohydrate available• Bacteria present• Salivary composition & flow• Other food ingested• Thickness and age of dental plaque
  • 48. What Contributes to the Differencesin Resting Plaque? Resting plaque pH: • Constant within each individual, but differences among groups. • Caries-inactive – resting pH ~ 6.5 - 7 • Caries-prone – lower resting pH Bacterial composition affects metabolic properties of plaque Storage form of CHO energy source when diet is depleted When  the  host  does  not  ‘eat’,  cariogenic  bacteria  still   produce acids from stored carbohydrates
  • 49. pH Change During the Course of The Day
  • 50. Caries is a BacterialInfection
  • 51. Web of Transmission PLAYMATES/PEERS CAREGIVERS SIBLINGS PATIENT 2008 Copyright T .Rodriguez,DDS
  • 52. Mode of Transmission Both this spoon and pacifier have been in the mouth and then cultured in a selective broth. They show S. Mutans growing on them. Courtesy of Ivoclar Vivadent.
  • 53. Caries Is An Infectious Disease “Demonstration of Mother to Child Transmission of Streptococcus mutans using Multilocus Sequence Typing” Lapirattanakul et al. Caries Research 2008 “Genotypic Diversity of Mutans Streptococci in Brazilian Nursery Children Suggests Horizontal Transmission” Mattos-Graner et al. J Clin. Microbiology 2001
  • 54. Bacteria Involved in Caries Streptococcus Mutans, Streptococcus Sobrinus Lactobaccillus
  • 55. Streptococcus Mutans• Caries initiators• Triggers the process that leads to mineral loss and that allows bacteria to penetrate tooth structure• Capacity to adhere to the tooth surface• Sugar transport system• Production of lactic acid from sugar• Tolerance to an acid environment
  • 56. Lactobacillus • They are responsible for caries progression. • They do not adhere to tooth surfaces but need carious lesions to colonize. – Pits and fissures – Cavities – Marginal gaps of restorations – Brackets
  • 57. Plaque & BiofilmsSome New Thoughts on Plaque
  • 58. What is a Biofilm? • A well organized, cooperating community of microorganisms. • The slime layer that forms on rocks in streams is a biofilm . • It is estimated over 95% of bacteria existing in nature are in biofilms.
  • 59. Phases of Plaque Formation Pellicle Formation Thin bacteria free layer forms within minutes on cleaned tooth surfaces Pellicle Attachment Within hours bacteria attach to pellicle & slime layer forms around the bacteria Formation Young Supragingival Plaque Mainly gram + cocci & rods Some gram – cocci & rods Aged Supragingival Plaque Subgingival Plaque Increase in percentage of gram – anaerobic Tooth Attached & Epithelial Attached & Un- bacteria Attached Plaque
  • 60. Fluid micro colony is movement of nutrients & bacterial by-Each channels allow an independent community with its ownBacteria cluster together to form sessile mushroom-shapedProtective slime layer surrounds the micro-coloniesPrimitive communications system of chemical signalsproducts through the biofilmmicro-colonies environmentcustomized living
  • 61. Host Factors That Influence Microbial Composition
  • 62. Dental Plaque: Caries & Periodontal DiseaseMarsh  et  al.  “Dental  Plaque  Biofilms:  Communities  Conflict  &  Control”  Periodontology  2000  December  2011  
  • 63. Control of Biofilms Control of nutrients • addition of base-generating nutrients (arginine) • reduction of gingival cervicular flow through anti-inflammatory agents • inhibition of key microbial enzymes Control of biofilm pH • sugar substitutes • antimicrobial agents • fluoride • stimulate base production
  • 64. Agents for Control of Biofilm Vast majority of agents for control of biofilm are broad spectrum non-specific microbiocide agents: • CHX • Triclosan • Essential Oils (Listerine) • Povidone Iodine
  • 65. SalivaA Very Important Component in theOral Environment
  • 66. MultifunctionalityAmylases, Cystatins, Carbonic anhydrases,Histatins, Mucins, Histatins Anti- BufferingPeroxidases Bacterial Cystatins, Amylases, Mucins Anti- Mucins, Lipase Viral Digestion Salivary Families Anti- Mineral- Fungal ization Cystatins, Histatins Histatins, Proline- Lubricat- Tissue ion &Visco- rich proteins,Amylases, Coating elasticity StatherinsCystatins, Mucins,Proline-rich proteins, Statherins Mucins, Statherins adapted from M.J. Levine, 1993
  • 67. Saliva’s  Protective  Function • Mechanical cleansing (water/flow) • Lubrication of tissues and teeth (secreted proteins) • Buffering of acids (HCO3-, HPO42-, peptides) • Maintaining tooth integrity – Post-eruptive maturation (Ca2+, F-, HPO42-) – Mineralization equilibrium (Ca2+, F-, HPO42-) – Pellicle • Maintaining tissue integrity • Regulation of the oral flora
  • 68. Saliva & Oral Function Food processing (water) • Taste solute • Bolus formation and swallowing (secreted proteins) • Digestion (secreted proteins) Speech (water, secreted proteins) • Lubrication and rehydration Excretion • Small molecules (nitrate, thiocyanate. etc.) • May interact with salivary proteins, oral bacteria
  • 69. Remineralization Of Enamel &Calcium Phosphate Inhibitors •Early caries are repaired despite presence of mineralization inhibitors in saliva •Sound surface layer of early carious lesion forms impermeable barrier to diffusion of high mol.wt. inhibitors. •Still permeable to calcium and phosphate ions • Inhibitors may encourage mineralization by preventing crystal growth on the surface of lesion by keeping pores open
  • 70. Summary • Caries is an infection disease • Bacteria live in Biofilms not Petri dishes • pH drives changes in biofilm ecosystem • Caries is reversible if detected early • Initially, demineralization begins below the tooth surface • White spots and brown spots are surface phenomena • Demineralization / Remineralization is a balancing act depending upon bacterial metabolism
  • 71. Risk FactorsCaries is a Disease
  • 72. Risk Defined • Risk is a prediction that disease will occur or progress • Risk is distinct from disease and cannot be accurately predicted from the disease state • Risk is determined by risk factors
  • 73. Caries Risk Factors • Low Socio-economic Status • High Titers Of Cariogenic Bacteria • Poor Oral Hygiene & Cariogenic Diet • Poor Family Dental Habits & Irregular Access to Dental Care • Developmental Or Acquired Enamel Defects • Genetic Abnormality Of Teeth • Many Multi-surface Restorations (High DMFT, DMFS) – Restoration Overhangs And Open Margins • Eating Disorders • Drug Or Alcohol Abuse • Active Orthodontic Treatment • Presence Of Exposed Root Surfaces • Physical Or Mental Disability With Inability Performing Oral Health Care • Xerostomia: Medication, Radiation Or Disease Induced
  • 74. Risk Factors • Social Determinants • BioMedical
  • 75. Risk Factors: History • Child has special needs • Socio-economic status of the family • Parents & siblings have decay
  • 76. Risk Factors: Dental History • Child has decay • Time elapsed since last cavity • Child wears braces or oral appliance • Reduced saliva flow
  • 77. Risk Factors: Dental History • Frequency of brushing • Daily between meal exposure to sugars & carbohydrates – On demand bottle – Sippy cup – Sports drinks & carbonated beverages
  • 78. Risk Factors: Fluoride exposure • Fluoridated water • Fluoride supplements • Fluoridated toothpastes
  • 79. Risk Factors: Clinical Evaluation • Visible plaque • Gingivitis • Areas of enamel demineralization – ICDAS 1 – 3 • Enamel defects / deep fissures
  • 80. Risk Factors: Clinical Evaluation Part 2 • Radiographic evidence of caries • Levels of Strep Mutans in saliva – Use commercial tests – Not critical for establishing risk
  • 81. Risk Definitions &TreatmentRecommendations
  • 82. Low Risk Caries Risk •Dmfs , ½ childs age Indicators •No new lesions in 1 year •No white spot lesions •Low titers of mutans strep •High SES Diagnostic •Examination interval 12 – 18 months Procedures •Radiograph interval 12 – 14 months •Initial strep mutans evaluation Preventive •Fluoridated tooth paste Therapy Restorative •None Therapy
  • 83. Medium RiskCaries Risk •dmfs>  ½  child’s  ageIndicators •1 or more lesions in 1 year •infrequent white spot lesions •moderate titers of mutans strep •middle SESDiagnostic •Examination interval 6 - 12 monthsProcedures •Radiograph interval 12 months •Initial strep mutans evaluation
  • 84. Medium Risk (continued) Preventive •Fluoridated tooth paste Therapy •Systemic fluoride supplements •Professional topical fluoride treatment •Sealants Restorative •Monitor enamel proximal lesions Therapy •Restoration of progressing lesions •Restoration of cavitated lesions
  • 85. High Risk Caries Risk •dmfs>  child’s  age Indicators •2 or more lesions in 1 year numerous white spot lesions •high titers of mutans strep •low SES •appliances in mouth high frequency of sugar consumption. Diagnostic •Examination interval 3 - 6 months Procedures •Radiograph interval 6 -12 months •Strep mutans testing to monitor compliance •Diet analysis
  • 86. High Risk (continued)Preventive •Fluoridated tooth pasteTherapy •Systemic fluoride supplements (age & water supply considerations) •Professional topical fluoride treatment •Sealants •Daily home fluoride or antimicrobials •Dietary counselling and adjustmentsRestorative •Monitor enamel proximal lesionsTherapy •Restoration of progressing lesions •Restoration of cavitated lesions •Aggressive treatment to minimize continued caries progression
  • 87. CAMBRACaries Management by Risk Assessment
  • 88. The Caries Balance
  • 89. The Caries Balancead Bacteriabsence salivaietary habits poor
  • 90. aliva adequate nti-ad Bacteria microbialbsence saliva luoride ffective dietietary habits poor
  • 91. ad Bacteria aliva adequatebsence saliva nti- microbialietary habits poor luoride ffective diet
  • 92. A Caries Risk Assessment (CRA) is just“weighing”  the  factors  of  each  patient.
  • 93. CAMBRA is just “removing  weight” from one sideand “adding  weight” to the other.
  • 94. Current State of Risk Assessment “No  existing instrument can ensure accurate categorization  of  children  by  risk….” Common aspects of all current risk assessment models • Historical and clinical data collected by clinicians • Quantification of risk by an algorithm • Assignment of individuals into a risk category “Any  model  of  caries  risk  assessment  must  address   both the biologic and behavioural management of the disease” Pediatric Oral Health Research Policy Center AAPD 2012
  • 95. Objectives of CAMBRA in Children CAMBRA=Caries Management by Risk Assessment • Assess child and caregiver caries risk in an individualized manner • Tailor a specific preventive therapeutic management plan • Customize a restorative plan in conjunction with the preventive plan • Plan timely, specific and appropriate periodicity schedule  based  on  the  child’s  caries  risk Ramos-Gomez F, Ng WM, Oct 2011
  • 96. Tools for AssessingCaries
  • 97. “  It is change, continuing change, inevitable change,that is the dominant factor in society today. No sensibledecision can be made any longer without taking intoaccount not only the world as it is, but the world as itwill  be” Isaac Asimov
  • 98. Sensitivity & Specificity• Sensitivity refers to the ability of a test to correctly identify those patients with the disease.• A test with 100% sensitivity correctly identifies all patients with the disease.• However, a test with 60% sensitivity correctly identifies 60% of patients with the disease (true positives) but the remaining 40% of patients with the disease are incorrectly identified as negative results and go undetected (false negatives).• Specificity refers to the ability of the test to correctly identify those patients without the disease. Therefore, a test with 100% specificity correctly identifies all patients without the disease.• However, a test with 60% specificity correctly identifies 60% of patients without the disease (true negatives) but 40% of patients without the disease are incorrectly identified as positive results (false positives).• Therefore, an experimental test aims to achieve 100% sensitivity and 100% specificity
  • 99. Tools for Detection• Visual Exam with or without Explorer• Radiographs• DIAGNODent• Caries ID• QLF• Spectra• Sopro• CarieScan• The Canary System
  • 100. Principles of Diagnosis The goal of examining a patient for the presence of dental caries is to detect the earliest signs of carious demineralization on enamel & root surfaces. If early signs of demineralization are detected, preventive care may reverse the caries process.
  • 101. White Spots????
  • 102. Examining a White Spot
  • 103. Classical Detection Tools Health Decalcification Decay Normal tooth Black or Visual White spot color brown Feel Hard Hard Soft X-Ray Normal Normal Black area None of these methods can detect all lesions early enough to implement treatment to reverse the disease process
  • 104. Visual Tools for Assessing Caries • DMFT and DMFS • ICDAS • CAMBRA
  • 105. DMFT and DMFS DMFT: decayed, missing, filled teeth DMFS: decayed missing filled surfaces Only a measure of past caries experience does not measure early lesions which can be remineralized
  • 106. ICDAS International Caries Diagnosis &Assessment System • Used to rank tooth surfaces • Ranks lesions • Ranks restorations • Ranks missing teeth • More sensitive and robust than DMFT system • Now a 2 digit system
  • 107. ICDAS Coding Summary
  • 108. Use of Explorers (?contentious)In the ICDAS-system perio Explorers are not recommended asprobes are used to feel with they may produce traumatic defects Ekstrand et al., 1987 Ball-ended
  • 109. ICDAS-II detection criteria, 2005SOUND OPACITY OPACITY LOCALISED UNDERLYING DISTINCT EXTENSIVE First Visible Distinct ENAMEL DARK CAVITY DISTINCT Change Visible BREAKDOWN SHADOW CAVITY only after Change +/- airdrying: without air- WITH WITH VISIBLE SURFACE SURFACE WHITE, drying: INTEGRITY INTEGRITY VISIBLE DENTINE BROWN WHITE, LOSS LOSS DENTINE BROWN Enamel Caries Dentin CariesScore Score Score Score Score Score Score 0 1 2 3 4 5 6
  • 110. ICDAS-II detection criteria, 2005SOUND OPACITY OPACITY LOCALISED UNDERLYING DISTINCT EXTENSIVE First Visible Distinct ENAMEL DARK CAVITY DISTINCT Change Visible BREAKDOWN SHADOW CAVITY only after Change +/- airdrying: without air- WITH WITH VISIBLE SURFACE SURFACE WHITE, drying: INTEGRITY INTEGRITY VISIBLE DENTINE BROWN WHITE, LOSS LOSS DENTINE BROWN ICDAS II (International Caries Detection & Assessment System) scores Enamel Caries Dentin CariesScore Score Score Score Score Score Score 0 1 2 3 4 5 6
  • 111. ICDAS Code Summary DETECTION AND SEVERITY OF THE LESION 2 A. VISUAL APPEARANCE 2. ACTIVITY EXTENSIVE DISTINCT UNDERLYING SURFACE OPACITY OPACITY SOUND CAVITY CAVITY GREY INTEGRITY without with air- SHADOW LOSS air-drying: drying: WHITE, WHITE, BROWN BROWN Score Lesion in Dentin Score Score Score Lesion Lesion in Scores Scores Score 6 5 4 3 2W,2B in 1W,1B Enamel 0 Enamel/Ekstrand et al., modified by ICDAS (Ann Arbor), 2002; Dentinfurther modified by ICDAS (Baltimore) 2005
  • 112. Visual vs. Caries Detection Devices• Visual only provides information on the surface• Caries starts as a sub surface lesion• All white and brown spots are not created equal• Need a system that can detect, measure and monitor the evolution of a carious lesion.
  • 113. Does this look suspicious?
  • 114. Use of an Explorer • Care in not poking or disturbing the enamel surface • Probing fissures may break the enamel crystals lining the fissure • Probing will also introduce more bacteria into the fissure
  • 115. Probing Drives Bacteria & Debris into Fissures
  • 116. Explorers & Pit & Fissure Caries “Probing  found  unreliable  in  finding  fissure  caries” Penning, van Amerongen, Seef & ten Cate. Caries Research 1993 “The  reliability  of  carious  lesion  diagnosis  by  sharp   explorer compared to diagnosis of carious lesion by histological  cross  section  was  25%.” “A  seemingly  intact  occlusal  enamel  surface  may   conceal an extensive lesion of the dentin” Al-Sehaibany, White & Rainey J Clin Pediatr Dent 1996
  • 117. Light Interaction with Teeth •Reflection •Transmission •Absorption •Backscatter Reflection Backscattered of light light from from tooth lesion surface
  • 118. Methods for Caries Detection Conventional methods • Visual examination: + non-destructive + safe - poor resolution - unable to detect incipient demineralization - unable to detect subsurface caries • X-rays: + non-destructive + can detect subsurface caries - limited safety - unable to detect incipient demineralization - low resolution
  • 119. Radiographs • Radiographic imaging of pits and fissures is of minimal diagnostic value because of the large amounts of surrounding enamel . • Literature review by Dove: • “overall  the strength of the evidence for radiographic methods for the detection of dental caries is poor for all types of lesions on  proximal  and  occlusal  surfaces”.     • “it is beneficial only if the intervention is the surgical removal of tooth structure and detrimental if it is used for non-invasive remineralization  methods.”     McKnight-Hanes C, Myers DR, Dushku JC, Thompson WO, Durham LC. Radiographic recommendations for the primary dentition: comparison of general dentists and pediatric dentists. Pediatr Dent. 1990 Jul-Aug;12(4):212-216 Flaitz CM, Hicks MJ, Silverston LM. Radiographic, histologic, and electronic comparison of basic mode videoprints with bitewing radiography. Caries Res. 1993; 27(1): 65-70. Lussi A, Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 27:409-16, 1993 Dove,  S.  B.,  “Radiographic  Diagnosis  of  Dental  Caries  in  Consensus  Conference  on  Dental  Caries  Management  Throughout   Life, March 2001, Journal of Dental Education, 2001; 65 (10): 985 – 990
  • 120. Radiographs Radiograph unable to locate caries and crack beneath the restoration
  • 121. Methods for Caries Detection Fluorescence-based methods• DIAGNODent (Kavo Danaher): detects fluorescence light emitted by porphyrins present in carious tissue following absorption of laser light + non-invasive - low resolution - risk of false diagnosis (porphyrins are present in stained healthy enamel, and not in the primary bacteria that cause tooth decay) - unable to quantify the level of demineralization• Caries ID (MidWest Dentsply)• Detection similar to DIAGNODent–Looks at fluorescence and reflection+Not repeatable–Low resolution
  • 122. Methods for Caries Detection Fluorescence-based methods• Quantitative Light-Induced Fluorescence (QLF): + non-invasive + quantifies mineral gain & loss + repeatable measurements - low resolution - expensive - unable to quantify lesion depth - unable to detect interproximal lesions
  • 123. Methods for Caries Detection Spectra QLF based Technology • May be issues with accuracy and sensitivity of the technology • Only monitors porphyrin metabolites • Camera may not capture pixels as accurately • Need more clinical information including comparison to original QLF • Scale of 0 – 5 with std .25
  • 124. Methods of Caries Detection DIFOTI (Digital Fibreoptic Transillumination) + non-invasive - Low resolution - Tooth decay scatters & absorbs more light than healthy tissue. + DIFOTI is 2x, more sensitive than bite-wing radiography for detection of decay * (Caries Research, 1997)
  • 125. Methods of Caries Detection Caries Scan (Electrical Impedance Measurement) Tooth decay delays or changes the conduction of an electric current. - Only detects surface defects - Need clean dry tooth surface + Repeatable + Non-invasive - May be able to monitor and quantify mineral loss - Can not detect caries at restoration margins - Can not monitor interproximal lesions or root surface lesions - Low resolution
  • 126. The Canary System • Full Spectrum of Caries Detection • Accurate • Repeatable • Reliable • Engages Patients & Builds a Practice • 2 Health Canada approved Clinical Trials • Over 50 research papers & Ongoing R&D • Over 11 years of R&D
  • 127. The Science Behind The Canary System•Pulses of laser light hit the tooth surface.•Tooth glows (Luminescence, LUM) and releases heat (Photo- Thermal Radiometry, PTR).Energy Conversion Technology Temperature increase < 1oC not harmful•Detected  signals  reflect  the  tooth’s  condition.  •Detects 50 micron lesion up to 5 mm below the surface.
  • 128. Caries Detection on All Surfaces • Occlusal Pits & Fissures • Smooth Surfaces • Interproximal Regions • Around the Visible Margins of Restorations (Composite, Amalgam, Porcelain or Gold) • Beneath Sealants • Root Surfaces The Canary detects small lesions 50 microns in size up to 5 mm below the tooth surface.
  • 129. Canary PatientReportCustomized patient report on dental practice letterheadClear simple indication of problem areasPatient can track their progressEngages patient in their oral health care
  • 130. Case Study: Caries Beneath an Amalgam 39 60
  • 131. Canary Finds Caries & Cracks Around Amalgam Canary Numbers (in yellow) indicate caries & pathology. Upon removal of the amalgam cracks 58 36 and caries found on marginal ridges and caries 97 on the lingual margin.
  • 132. Sensitivity & Specificity Studies Study 1: Detection on All Surface Tooth Surface Overall Occlusal Buccal Mesial The Canary System Sensitivity 97% 100% 100% 100% Specificity 82% 80% 100% 75% Visual Examination Sensitivity 80% 88% 64% 88% Specificity 91% 80% 100% 75% Study 2: Detection of Pit & Fissure Caries Caries detection The Canary System DIAGNODent ICDAS II method (visual ranking system) Sensitivity 92% 41% 77% Study 3 : Detection of Early Carious Lesions & Lesion Depth Caries detection method The Canary System DIAGNODent Sensitivity 100% 18% Correlation with lesion depth 84% 21%
  • 133. Detection of Pit & Fissure Caries • Low Caries Patient • Only 1 restoration in the last 40 years • Stained distal pit on # 45 • Scan open & found large carious lesion Distal Pit # 45 Canary Number 86 • Scanning on tooth 44 was normal
  • 134. Detection of Caries Beneath Sealants• Canary Numbers >20 when scanning sealants (3M™  ESPE™  Clinpro™  Sealant™)   placed over pit & fissure caries.• The caries detection ability of the Canary System was not affected by sealant & was more accurate than DIAGNOdent Canary Number 66 Sensitivities and specificities for pit & fissure caries detection after sealant Sealant placement. Caries The Canary DIAGNOdent Demineralized detection System Pre-sealant enamel method Sensitivity 83% 64% Canary Number 37 Caries into Specificity 79% 46% dentin Cross-section Post-sealant
  • 135. The Characteristics of an Ideal Caries Detection System 1. High sensitivity & specificity for caries detection 2. Detects & monitors de & re-mineralization 3. Detects smooth surface, root surface, occlusal surface & interproximal lesions 4. Detects caries around restoration margins 5. Non-invasive & safe 6. Repeatable measurements 7. Imaging and or image capture 8. System for recording & storing measurements 9. Patient Education and Motivation 10. In-vitro and in-vivo data & publications including clinical trial data demonstrating to detect & monitor carious lesions 11. Minimal or no preparation of the tooth surface before a reading 12. Ability to detect and monitor erosion lesions  The key is to understand what the device is measuring.
  • 136. Remineralization andOther Therapies Minimally Invasive Dentistry
  • 137. Understanding your choices?
  • 138. Product Decisions?  Fluoride • RISK Demand?  CPP-ACP (Recaldent) • Age and Ability?  NovaMin • Buffering?  ProArgin • Fluoride Uptake?  Xylitol products • Contact time needed?  Antibacterial rinses • Desensitization?  Salivary products • Antibacterial Activity?  Neutralizing agents • Salivary Stimulant?  Silver Diamine Fluoride • Compliance?  Povidone Iodine  CHX varnish (Prevora)  Sealants  ICON
  • 139. Important Reference Paper on the Journey Non-fluoride caries preventive agents: Full report of a systematic review and evidence-based recommendations Council on Scientific Affairs, ADA May 2011 Questions Does the use of a non-fluoride caries preventive agent reduce the incidence, arrest or reverse caries a) In the general population b) In individuals with higher caries risk “The  recommendations  in  this  document  do  not  purport  to  define   a standard of care and rather should be integrated with a practitioner’s  professional  judgement  and  a  patient’s  needs  and   preferences”
  • 140. Requirements of an Ideal Remineralization Material • Diffuses into the subsurface or deliver calcium and phosphate into the subsurface • Does not deliver an excess of calcium • Does not favour calculus formation • Works at an acidic pH • Works in xerostomic patients • Boosts the remineralization properties of saliva • For novel or new materials; shows a benefit over fluoride Walsh, L. J., Australasian Dental Practice March/April 2009
  • 141. Topical Fluoride The Original Remineralization Agent • Water Fluoridation • Toothpaste • Fluoride Rinse • Fluoride Varnish • Bottled Water
  • 142. Water Fluoridation • Remains a major source of reduced decay • Many studies with average reduction 25% • Recommended by all major health organizations • No evidence of health or environmental risk • Under attack by extremist U.S organization Fluoride Action Network
  • 143. Community Water Fluoridation Canada
  • 144. Water Fluoridation Critical role for local dental community • Proactive lobby • In-office activity Recent Manitoba Activity • Churchill maintains fluoridation Oct 2011 • Flin Flon ends fluoridation July 2011
  • 145. Key Canadian Government References onWater Fluoridation• Fluoride Expert Panel 2007• fluorure/index-eng.php• Water Quality Fluoride in Drinking Water 2009• fluorure/draft-ebauche-eng.php• Response to Environmental Petition 2008• JointGovernmentofCanadaresponse.pdf
  • 146. Fluoride – Mechanisms of Action • Enhances remineralization – Adsorbs onto mineral surfaces, attracts calcium and phosphate ions in saliva, results in the formation of fluorapatite – Fluorapatite exhibits lower solubility than naturally occurring hydroxyapatite, helps resist the inevitable acid challenge* • Helps inhibit demineralization – Adsorbs onto mineral surfaces and protects the tooth against dissolution* • Inhibits bacterial activity – Inhibits cariogenic bacteria metabolism of carbohydrates – less acid and less adhesive polysaccharides are products** * Featherstone JDB. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31–40. ** Hamilton IR. Biochemical effects of fluoride on oral bacteria. J Dent Res 1990;69(special issue):660–7
  • 147. Fluoride Action A brief review: – Effect largely topical • At low levels – Inhibits demineralization at crystal surfaces – Enhances remineralization at crystal surfaces • At high levels – Inhibits bacterial enzymes
  • 148. Fluoride - Some Interesting Pieces Low levels after several hours in plaque and saliva can have a profound effect on demin/remin – i.e. TOOTHPASTE – MOUTHRINSE? Lynch RJ, Navada R, Walia R, Low levels of fluoride in plaque and saliva and their effects on the demineralization and remineralization of enamel: role of fluoride toothpastes. Int Dent J 2004:54(5 Suppl 1):304-9
  • 149. TOPICAL FLUORIDE Toothpaste • Position Statements – Canadian Dental Association – American Academy of Pediatric Dentistry
  • 150. CDA Position on Use of Fluorides in Caries Prevention revised March 2012• Water fluoridation• Fluoride toothpaste and Mouthrinse – Children 0-3 years – Children 3-6 years• Professional topical application of fluoride gels, pastes and varnishes• Fluoride supplements• Fluoride exposure from multiple sources
  • 151. CDA Position on Use of Fluorides in CariesPrevention revised March 2012 Children 0 - 3 years • The use of fluoridated toothpaste in this age group is determined by the level of risk • Parents brush under 3 years and assist 3-6 years • “Grain  of  rice”  of   toothpaste • All children supervised or assisted till appropriate dexterity
  • 152. Topical Fluoride – The Gold Standard J Dent Educ. 71(3): 393-402 2007 © 2007 American Dental Education Association Professionally Applied Topical Fluoride: Evidence- Based Clinical Recommendations American Dental Association Council on Scientific Affairs Key words: fluoride, caries, caries prevention, evidence-based dentistry, clinical recommendations
  • 153. ADA Evidence-based Recommendations Assess – Caries Risk –Low –Medium –High Decide – Whether to apply fluoride – Type of fluoride – Frequency of application – How often to re-evaluate
  • 154. ADA Evidence-based RecommendationsProfessionally Applied Topical Fluoride Risk group Less than 6 years /Age Low Patient may not receive any additional benefit Medium Varnish every 6 months High Varnish every 6 months (or 3 months)
  • 155. ADA RecommendationProfessionally Applied Topical Fluoride Low risk under 6 years • Fluoridated water and toothpaste may provide adequate caries prevention in low risk category • Fluoride foam and gel not recommended in this age group
  • 156. Fluoride Varnish – Why? • Higher percentage of caries reduction • Prolonged uptake of fluoride by enamel versus other topical systems • Sets on contact with intraoral moisture • Greater efficacy versus other delivery systems • Fluoride deposited on demineralized enamel greater than on sound enamel • May produce redistribution of ions within caries and increasing fluoride infusion
  • 157. Fluoride Varnish (5% NaF = approx 22,500 ppm)No special equipment • Safe and well toleratedNo prophylaxis prior to • Inexpensive application • Greater fluoride uptakeEasy to apply than with gels or foamsDries on contact with saliva
  • 158. Evaluating Fluoride Varnish • Concentration of Fluoride in Varnish • Fluoride availability in saliva over a 1 – 4 hour time period • Lab and Clinical trial evidence of efficacy • Other additives? • Ease of application • Patient comfort issues – Colour – Grittiness
  • 159. Applying Fluoride Varnish
  • 160. Fluoride Varnish Application • Gentle  finger  pressure  to  open  child’s   mouth • Remove excess saliva from the teeth • Apply a thin layer of varnish to all surfaces of the teeth • Varnish hardens on contact with saliva
  • 161. Post-application instructions • Recommendations vary with manufacturer, but generally: • Can eat within 30 minutes avoiding hot food/drink • Soft, non-abrasive diet for the rest of the day • No floss of teeth until the next morning • Inform the caregiver of appearance/film until teeth are brushed
  • 162. Migration of Fluoride Varnish after Application:an In Vivo Study Kolb V et al, 3M ESPE Dental Products, St. Paul, MN Results of the Study: Vanish reached a greater number of tooth surfaces than the other fluoride varnish products immediately after application and continued to migrate for up to 4 hours. This in vivo study demonstrates that Vanish varnish exhibits enhanced flow characteristics compared to the other fluoride varnishes tested. 2009 IADR Abstract #1170
  • 163. Fluoride and Safety Concerns Three real issues • Fluoride toxicity • Fluorosis • Allergy • Age of greatest risk for fluorosis • 0-3 years • Especially 22-26 months – Findings and recommendations of the Fluoride Expert Panel Health Canada Jan 2007
  • 164. Estimation of Potential Toxic Dose Considering the Child Age/Weight Verronneau 2007Variable Volume or Weight Volume or Weight (Oldest (Youngest child and inferior Child and Superior Border) border)Age 6 months 36 monthsMean Weight 8.25 kg +/- 0.5 (Demerjian 19.75 kg +/- 2.0kg 1985)Fl Varnish 0.1 ml (Ripa, 1990) 0.5 mlIngestion presumed 2.30 mgr (Johnston, 1994) 11.30 mgrPotential toxic dose 41.25 mgr/kg/total weight 101.50 mgr/kg/total weightProtective factor 17 10
  • 165. Fluoride Varnish – Toxicity Comparative fluoride ingestion rates Use Ingestion 5 25 4 20 3 15ml mg 2 10 5 1 0 0 Varnish APF (Gel) Courtesy of Medicom
  • 166. Fluorosis Total daily fluoride intake from all sources should not exceed 0.05-0.07 mg F/kg of body weight in order to minimize the risk of dental fluorosis – Canadian Dental Association Nov. 2008
  • 167. Fluorosis – Dean’s  Index
  • 168. Fluorosis – CHMS Data Children 6-12 years • 60% with normal enamel • 24% with white flecks or spots where cause questionable • 12% very mild • 4% mild • Mod-severe too low to report *Remember that many of mild areas of enamel variation will spontaneously improve into teen years
  • 169. Fluoride Varnish (5% NaF = approx 22,500 ppm)No special equipment • Safe and well toleratedNo prophylaxis prior to • Inexpensive application • Greater fluoride uptakeEasy to apply than with gels or foamsDries on contact with saliva
  • 170. Fluoride Varnish Allergy Risk Potential resin peptide allergen link to pine nut allergies Oral Science X-Pur 5% NaFl “…current  formulation altered to refined, purified colophony  resin.  …Health  Canada  no  longer  require   allergy  warning” 3MEspe Vanish Fluoride Varnish allergen is abietic acid, not peptide-no cross reactivity colophony purified-allergen risk lowered Recommendation Ask your supplier re process Allergy warning required?
  • 171. Current Toothpastes 0.243-0.254% NaF or 0.454% SnFl = 0.115% Fl- = approx. 1100 ppm Fl 1.1% NaF = 0.495 Fl-= approx. 5000 ppm Fl NOTE: Federal advisory panel recommends low-dose fluoride toothpaste be available for children in Canada
  • 172. High fluoride toothpaste 5000 ppm
  • 173. 3M  Clinpro™  5000  Tooth  PasteDentifrice Mechanism of Action• Contains 1.1% NaF (5000 As the paste reaches the tooth ppm fluoride ion) surface:• Contains innovative calcium – Organic components (often surfactants) have an affinity for and phosphate ingredient tooth surfaces which is broken down upon – Carries the calcium to the contact with the tooth tooth surface, protected from surface. fluoride ion  High fluoride bioavailability during application – Saliva activates the calcium compound degrading the protective coating, releasing calcium at the tooth surface  Calcium bioavailability during application
  • 174. Protected calcium oxides are released As the ingredient reaches the tooth surface • Organic materials (often surfactants) have an affinity for tooth surfaces – Carries the calcium to the tooth surface, protected from fluoride ion  High fluoride bioavailability during application • Saliva activates the calcium compound degrading the protective coating, releasing calcium at the tooth surface  Calcium bioavailability during application
  • 175. Clinical Trial (preliminary analysis)
  • 176. Recaldent (CPP-ACP)• Casein Phosphopetides • Amorphous Calcium – From  cow’s  milk Phosphate – Stabilize calcium and – Developed by ADA Health phosphate ions Foundation – Facilitate intestinal – Original intent is surface absorption deposition of hydroxyapatite – pH dependent – Developed for desensitization – Modified to create bio- available calcium and phosphate for remineralization
  • 177. Recaldent MI Paste MI Paste Plus Trident Xtra Care Gum Trident White Gum
  • 178. Novamin®• Calcium sodium phosphosilicate: Ca and P04 ions protected by glass particles• Sodium buffers salivary pH for precipitation of crystals• Contact with H20 or saliva, activates release of Ca and P04
  • 179. How NovaMin Works  A breakthrough remineralization ingredient  Comprised of calcium ( ), sodium ( ), phosphorous ( ), and silica ( ), all natural elements found in the body High pH + Ca and P pH ions turbo charge remin process. Demineralized NovaMin reaction surface is elevates pH to ideal replenished + remin range (8-9), NovaMin releases C and P ions immediately reacts w/saliva or water NovaMin Particles
  • 180. ADA Report Recommendations “There  is  insufficient  evidence  from  clinical  trials  that   the use of agents containing calcium and/or phosphates with or without casein derivatives lowers incidence of either coronal or root caries Opinion: Given individual cases of considerable success, this is most likely dependant on careful case selection and frequent reinforcement KNOW YOUR PATIENT
  • 181. Silver Diamine Fluoride- the new silver bullet?• -currently not approved in N. America• -38% concentration shows significant caries reduction and caries arrest• -alternative treatment when restoration not an option• Yee et al 2009• -more effective than fluoride varnish• -lowest prevented fraction for caries arrest 96.1%• -lowest prevented fraction for caries prevention 70.3%• Rosenblatt et al 2009
  • 182. Silver Diamine Fluoride- the new silver bullet? -frequency of application 1x/yr -excavation of soft caries reduces black discoloration -metallic taste -greater efficacy vs multiple FV applications Chu et al JDR 2002 -frequency of application 2x/yr -reduction of new lesions on primary and first permanent molars (preventive fraction 79.7% & 65%) Llodra et al JDR 2005
  • 183. Silver Diamine Fluoride- the new silver bullet? Safety Issues -pulp irritation no evidence -caries stain yes but...7%found objectionable -tissue irritation yes, white lesions with mild pain lasting 48 hrs. -fluorosis theoretical possibility in animal studies - needs more study Rosenblatt et al 2009
  • 184. Remineralization and Other Therapies Antimicrobial treatment (remember the biofilm!) • Xylitol • Povidone iodine • Chlorhexidine • Delmopinol • Triclosan
  • 185. Remineralization and Other Therapies Xylitol
  • 186. The Xylitol Story in Brief • Natural long chain sugar • Non-cariogenic • Can reduce mutans strep in plaque and saliva • Can reduce caries in young children, mothers and in children via their mothers • Anti-caries benefit for high risk for both caries reduction and enamel remineralization
  • 187. Key Xylitol Studies for ECC Soderling et al 2001 Maternal transmission of MS • Xylitol gum – Starts 3 months after delivery and for 21 months • Fluoride varnish – Applied at 6, 12, 18 months • CHX varnish – Applied at 6, 12, 18 months Measured MS levels in children at age 3 and 6
  • 188. Key Xylitol Studies for ECC Soderling et al 2001 Results • Children age 3 – MS levels 2.3x higher with Fl Var and CHX Var in mother • Children age 6 – Protection maintained with same higher benefit of xylitol in mother Results reconfirmed by Thorild et al 2006
  • 189. Mutans streptococci of the 2-year- old children (Söderling et al., JDR 2000) % 60• The  child’s  risk  of   50 having mutans streptococci 40 colonization in the 30 dentition was 5-fold in the F group and 20 3-fold in the CHX 10 group as compared to the Xylitol group 0 n=33 n=28 n=103 CONTROL CHX XYLITOL
  • 190. dmf Caries occurence in children CHX 3• At the age of 5 years the need of restorative treatment Control was 71-75% lower in 2 the Xylitol group as compared to the F and CHX groups 1• The occurence of caries and early Xylitol mutans streptococci colonization were in 0 agreement 0 1 2 3 4 5 6 Age
  • 191. Why Xylitol and when • Maternal 3 months post partum (Soderling 2001) • Characteristic of infection at eruption determines life-long (Loesche 1985) • Once colonized with benign, ms will not displace (Svanberg and Loesche 1977) • May be due to less cariogenic xylitol-metabolizing ms strain (Trahan et al 1996)
  • 192. Xylitol as a Remineralization Agent “These  results  indicate  that  xylitol  can  induce   remineralization of deeper layers of demineralized enamel by facilitating Ca2+ movement  and  accessibility.” Miake Y, Saeki Y, Takahashi M, Yanagisawa J Electron Microsc (Tokyo). 2003;52(5):471-6
  • 193. Xylitol More than a Remineralization Agent • Inhibits adhesion, growth and metabolism of oral microorganisms. Suppresses ms even with sucrose intake. • Allows remineralization of initial enamel lesions. Enhances reversals (Turku study). • Chewing gum enhances with increased salivation • Synergistic with fluoride
  • 194. HEAD & NECK RADIATION AND CHEMOTHERAPY LOSS OF PROTECTIVE XEROSTOMIA QUALITIES OF SALIVA • Increase of pathogenic bacteria •  Increase of oral acidity and decrease of healthy PH • Increase of pathogenic biofilm • Acceleration of the demineralization process Oral Oral Rampant PeriodontalMucositis Lesions Candida Caries Disease 3
  • 195. Xylitol; A Remineralization Agent Reported Xylitol Availability • Gum – sole or in combination • Toothpaste • Lollipops • Syrup • Tooth wipes • Slow release in pacifiers • Gummy bears • Combination with: fluoride or chlorhexidine
  • 196. Xylitol Syrup (Marshall Islands Study) • No. decayed teeth – Control: 1.9 +/- 2.4 – Xylitol 2x: 0.6 +/- 1.1 • % with decayed teeth – Control: 51.7% – Xylitol 2x: 24.2% Milgrom AAPD 2009
  • 197. Xylitol – Widely Accepted Opinion • habitual use of xylitol reduces incidence of caries • habitual use remineralizes enamel and dentin caries • other polyols also reduce caries • probable hierarchy of effect of polyols based on number of hydroxyl groups: erythritol_>xylitol>_sorbitol Makinen, KK, 2010
  • 198. 220BOTTLES•  180  pieces  of  gum  –Peppermint• 180 pieces of gum – Fruit•  400  mints  – Peppermint• 400 mints - FruitTINS•  20 pieces of gum – Peppermint• 60 mints - Peppermint
  • 199. Issue of accurate contents • Gums, mints do not have to meet high standards re accuracy of content • Some question whether you are getting 1 mg each gum or mint Opinion: • Oral Science product being used in hospital oncology programmes and seeking status under Canadian Natural Health Product designation • I would opt for this product for Xylitol source
  • 200. Spiffies Wipes Toxicity Issue? • Each wipe contains 0.5 g xylitol • Estimated absorption 0.25 g • 3-5 applications/day i.e.0.75-1.25 g/day • Everyday use is 0.2g/kg (assuming a 7 kg infant) • Threshold level is 1-2 g/kg • Safety factor 5-10 Spiffies now available in Canada through DR Products at
  • 201. Clinical Significance Right now Xylitol seems to be most appropriately considered an adjunct measure for targeted individuals. It cannot be recommended as a public health measure as yet. Furthermore, carefully designed and conducted studies are required to determine what role it will ultimately play Tweetman S, Current controversies-Is there merit? Adv Dent Res 21:48-52, 2009
  • 202. ADA Report Recommendations• Significant reduction of caries polyol gums vs. no gum• Preventive effect xylitol highest vs. other polyols• Benefit related to load mg/day• Benefit related to chewing 10-20 minutes after meals• Concern re choking kids less than 5 years• Lozenges/tablets reduces coronal caries – low certainty• Encourage to suck lozenges to extend time in mouth• Syrup under 2 years -insufficient evidence• 5-8 gms/day divided doses• Insufficient evidence xylitol under 5 years• Insufficient evidence xylitol in toothpaste
  • 203. Remineralization and Other Therapies Povidone Iodine – Betadine -potent antibacterial -safe to swallow -disrupts binding to biofilm
  • 204. Povidone Iodine • Applied in combination with Fl. Varnish • Complementary to fluoride • Disrupts binding of biofilm • Can work up to 20-24 weeks • Differing protocols supported by evidence Milgrom AAPD 2009
  • 205. Povidone Iodine Topical • Used post-GA restoration suppresses MS levels over 90 days P<0.00001 Berkowitz et al 2009 • Safe to swallow, even for babies Milgrom 2009 • Kids tolerate re nausea and taste • Contraindications • New formulations in research
  • 206. Povidone Iodine Results ECC PVP-I + FV vs FV only 2.5-2.8 times over 1 year infants 12-30 mths • New decay reduced 31% Milgrom et al J Dent Child Dec 2011 PI + FV vs no tx q2M over 1 yr. infants 12-19 mths • 91% disease-free vs 54% Lopez Ped Dent 2002 PVP-I post GA at baseline, 6, 12 mths • Reduced patients with new decay (small sample) • Amin et al Ped Dent 2004 ADA Report Recommendations Insufficient evidence iodine lowers decay
  • 207. Anti-Bacterial Agents Mechanism of Action: Reduce Bacterial Levels in the Oral Cavity • Prevora • Cervitec • Povidone Iodine • Chlorhexidine Mouth Rinses (Peridex) • Triclosan
  • 208. Chlorhexidine• Now available in both rinse and varnish• Anti-bacterial and anti plaque• Used for treatment of gingivitis and caries• Efficacy in very young inconclusive Zhang et al Eur J Oral Science 2006Available as •Cervitec Plus •Chlorhexidine •Thymol Plus
  • 209. Cervitec Plus • Used as cervical desensitizer and caries preventive • Application to mothers q6m til baby 3 yrs • caries in infants significantly lower • Inhibition of MS transfer to baby to age 2 • Treatment of high risk infants q3m from 1 yr • caries reduced but not if diet not also controlled • Reduced caries development if none at baseline but no improvement if caries at baseline • Inhibition zones adjacent to placement • Role for newly erupting molars followed by sealants?
  • 210. Prevora • CHX Varnish originally for root caries • Studies on mother child being analyzed. Report available soon • Efficacy in xerostomia patients
  • 211. ADA Report Recommendations CHX 10-40% CHX Varnish kids 4-18 yrs Does not reduce incidence of caries-moderate certainty CHX-Thymol Varnish kids up to age 15 1:1 ratio varnish does not reduce incidence of caries CHX Mouthrinse 0.05-0.12% rinse does not reduce incidence of coronal caries Insufficient Evidence Efficacy of treatment of mothers post-partum on incidence of caries in infants Impression: Jury still out on this one
  • 212. Remineralization and Other Therapies Delmopinol Hydrochloride • reductions in total cultivable plaque and salivary flora Hase et al 1998 • inhibits glucan synthesis of MS in vitro Baehni 2003 • used currently largely for anti-gingivitis properties as mouth rinse (Decapinol Mouthwash)
  • 213. Remineralization and Other Therapies Triclosan • -broad spectrum antibacterial used in toothpaste • -reduces supragingivial plaque • -enhances anti-caries activity of fluoride • -used widely in other health/body products • -recent concerns re carcinogenic potential with probable removal from products in future ADA Report Recommendations: Insufficient evidence that it lowers caries incidence
  • 214. Pro Argin® • Highly soluble arginine bicarbonate - amino acid complex that binds to calcium carbonate • This binds particles of calcium carbonate to dentin and enamel • Purpose: reduce dentinal hypersensitivity • Contained in Colgate’s Sensitive Pro-Relief desensitizing prophy paste. • Anticaries benefit under study
  • 215. Remineralization and Other Therapies Arginine and Probiotics Newer research with products on the market ADA Report Comments: • Arginine added to food or oral care products to inhibit initiation and progression of caries and promote remineralization • Probiotics goal to promote healthier plaque ecologies. Safety and Effectiveness not rigorously tested “In  light  of  the  state  of  development  and  the  lack  of   human  research  reports…not  evaluated  by  the  panel Opinion: Not Ready for Prime Time
  • 216. What is the Recipe?
  • 217. Office + Home Therapy Office Home Toothpastes & Topical Application • Topical Fluoride (gels and • Clinpro 5000 Toothpaste foams) • ProArgin in Colgate • MI Paste • Fluoride Varnish • Prevident • Anti-Microbial Therapy + Sugar Substitutes • Xylitol – Prevora • Novamin – Cervitec Mouthwashes • Oral Hygiene & Patient • Peridex Motivation • Tricolsan Products • Diet Counselling Gums & Mints • Recaldent • Ongoing Monitoring • Xylitol Effective Plaque Removal with Brushing & Flossing
  • 218. Does Remineralization Work?
  • 219. Case Study Remineralization 600 400 Canary Number 200 0 Initial 2 months 3 months 5 months 3M Vanish & Clinpro 5000 Toothpaste Visit #1 Visit #2: Visit #3: Visit #4: 2 Months 3 Months 5 Months ICDAS: 02 ICDAS: 02 ICDAS: 02 ICDAS: 02
  • 220. Remineralization 5th and 7th Quads
  • 221. Remineralization CaseSlides courtesy of Dr. Clive Friedman
  • 222. Remineralization CaseSlides courtesy of Dr. Clive Friedman
  • 223. Canary Numbers for This Case Tooth October 2011 April 2012 M O D M O D 47 26 20 46 46 16 19 19 37 31 27 15 24 36 21 35 16 30
  • 224. Does Remineralization Work? Yes But You need to monitor and motivate your patient
  • 225. Remineralization + Monitoring Essential components of any program: • Need to monitor progress • Need to record progress • Need to be able to change therapy if lesions increase in size • Need to engage your patient Bottom Line: Case Selection
  • 226. Integration intoClinical Practice
  • 227. USCLS Codes and Descriptions Code Description Fee13601 – 13609 Topical application to Hard Tissue of Anti- 1 unit $34.10 + E Microbial or Remineralization Agents 2 units $68.20 + E12101 Fluoride Treatment (topical application) $16.9012102 Fluoride Treatment $15.70 Supervised Self-administered brush in12601 – 12602 Fluoride Custom Appliances $60.70 + lab1321*, 1323* Oral Hygiene Instruction $31.00 (individual, group & re-instruction)96103 Dispensing of Non-Emergency (fluorides etc.) No fee + E04201 Test Analysis, Caries Susceptibility (technical $40.00 + lab procedure only) Bacteriological testing for determination of caries susceptibility
  • 228. Code 13601 Remineralization • Designed for the topical application of fluoride varnish and other agents in a dental office • Introduced into the ODA Fee Guide in September 2008 in response to symposium at the IADR sponsored by the ODA • Fee: $47.00 per 15 minute unit of time • Can be done by hygienists or dental assistants (under supervision of the dentist)
  • 229. Office Integration Recall or Specific Exam Reassess 6 Months •Identify White Spots •Assess Lesion •ICDAS or Measure •ICDAS or Measure •Risk Assessment •Apply Remineralization •Apply Remineralization Therapy Therapy •Dispense Home-Based •Oral Hygiene Instruction Therapy •Provide Home-based Therapy Reassess 3 Months •Assess lesion •ICDAS or Measure •Apply Remineralization therapy •Dispense Home- based therapy
  • 230. Remineralization + Monitoring • Essential components of any program • Need to monitor progress • Need to record progress • Need to be able to change therapy if lesions increase in size • Need to engage your patient
  • 231. Early ChildhoodCaries
  • 232. Clinical Presentation: Early Lesions ECC• Begins soon after dental eruption• Typically develops on smooth surfaces• If enamel not uniformly white, patient is at risk• Appear as chalky white decalcification• Most often starts on lingual surfaces of maxillary incisors
  • 233. Early Childhood Caries Clinical Presentation (Advancing) • Virulent caries with rapid progression • Enamel chips away as lesions advance • Colour of caries indicates speed of progression
  • 234. Early Childhood CariesAdvanced Tooth Decayphoto Dr. Joanna Douglass, Smiles for Life
  • 235. Facial CellulitisInfection spreading into surrounding tissues
  • 236. Early Childhood Caries % Population Age Author4% Quebec childrenConvenience sample of 301 12 – 24 month infants Veronneau et alinfants1% US children 12 – 23 month Kasteet et al. 1996representative sample of 65417% US children 2 – 4 year olds Kaste et al. 1996sample of 1,62730% Cree population Quebec 12 – 24 month Veronneau et al. 200255% Inuit population of NWT 24 – 36 month Albert et al. 199887% Ojibwaysample 470 residents of Northern 24 – 48 months Lawrence 2008Ontario Prevalence of ECC in children under 4 years of age. DMFT / DMFS screening tool ICDAS not used
  • 237. Early Childhood Caries Prevalence 0 - 5 years United States • Decay  rates  dropped  until  1990’s • Rates now documented as increasing 2 - 5 year olds 24% in 1988 - 1994 28% in 1999 - 2004 • Wide variability with population groups Dye et al, National Center for Health Statistics NHANES 2007
  • 238. Early Childhood Caries Lida et al 2007
  • 239. Early Childhood Caries Prevalence 0-5 Years British Columbia – 64% inner city Vancouver sample Szeto thesis 2004 – 11% community dental health (range 7.9-27.4%) Bassett et al 1999 – 20.5% Vancouver low-income Vietnamese over 18 mths Harrison et al 1997 * Surveys vary in sampling methods * Children sampled not representative of population in general
  • 240. Early Childhood Caries Prevalence 0 - 5 Years Ontario – 87% of First Nations sample Lawrence 2008 – 34% in Health Units Survey* OAPHD 2008 – 30% of Toronto 5-year olds 1999-2000* Leake 2001 – 25.1% in daycare community Ottawa Public Health 2007-08* * Survey under reports children sampled due to methods * Children sampled not representative of population in general
  • 241. Systemic Effects of Severe ECC Malnourishment In A Population With Severe Early Childhood Caries Among the findings: – 66% have normal weight, 18 % underweight – 28% have haemoglobin levels below acceptable and 46% in the low range of acceptable – 51% have low albumin levels – 77% have low ferritin  Conclusion: Children with severe tooth decay have borderline or low nourishment Clarke et al 2006
  • 242. Detrimental Health Effects Of ECC • pain, infection, loss of function • affects learning, communication, nutrition, sleep • lower body weight • chronic inflammation • psychological impact • lasting detrimental impact on the dentition
  • 243. Not Just the Poor National O.R. Stats • Pediatric dental procedures #1 O.R. procedure with longest waiting lists CHEO  Stats  (Children’s  Hospital  of  Eastern   Ontario) • Waiting time for O.R. was 14 months • Children over 5 years not eligible for care London, ON Mall Exams • 82 children under 20 months • 32 with early signs of caries (ICDAS 1+2) • 3 with S-ECC requiring sedation of GA Dr. Clive Friedman
  • 244. ECC – Other Aspects to Consider • New approach needed • Social determinants • Role of physicians, nurses • Motivational interviewing • Role of dental public health • ECC as predictor
  • 245. The New Approach Needed for ECC Quality Improvement • Combine efforts of Health Care professionals, patients, families, researchers, payors, planners, educators • Objective is improved outcomes, system performance and professional development • Ultimate objective is Disease Management Ramos-Gomez F, Ng M Oct 2011
  • 246. FIGURE 1 Child, family, and community influences on oral health outcomes of children Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520Copyright ©2007 American Academy of Pediatrics
  • 247. Smiles for Life Pocket Cards for Physicians
  • 248. Smiles for Life Pocket Cards for Physicians
  • 249. Principles of Motivational Interviewing • Establish a therapeutic alliance • Recognize that people value their independence • Ask questions, and listen • Once 1-3 then advice, giving choices to explore and a tailored course of action • Once the patient/parent is receptive, MI does not take long Weinstein P, MI and Its Relationship to Risk Management and Patient Counseling, Cal Dent Assoc J, Oct 2011
  • 250. Models of Individual Oral Health PromotionBrickhouse T.H.Virginia Commonwealth Universitypresented at AAPD Symposium October 2009
  • 251. Evidence: Models of Individual Oral HealthPromotion • Systematic review 2000-2007 • Database examined for articles evaluating effectiveness of health behaviour models • 32 studies – 9 health education and clinical prevention studies – WEAK – 3 counseling studies with varnish – STRONG – 9 studies of model based interventions – MODERATE – 11 studies of motivational interviewing – STRONG • Yevlahova and Satur, Australia Dental Journal 2009
  • 252. Evidence: Models of Individual Oral Health Promotion• Health Education – Information and expert advice with passive patient• Counseling – Extremely specific and tailored to the patient, increased time and expense• Model based interventions – Health Belief Model, Locus of Control, Self Efficacy, Attitudes• Motivational Interviewing – Trans-theoretical model of behaviour change focusing on personal dynamics of change – Patient  centered  style  with  sensitivity/empathy  to  patient’s  social  and   environmental circumstances • Significant reductions in smoking, diabetes, obesity, substance abuse and oral health
  • 253. Motivational Interviewing Success in dentistry • Early childhood caries • • Harrison RL, Wong T. An oral health promotion program for an urban minority population of preschool children. Community Dent Oral Epidemiol, 2003 Oct;31(5):393-9
  • 254. Dental Public Health • Big picture reality – getting to the populations • Making connections • Identifying high risk populations • Individual evidence-based oral health promotion • Role of medical community
  • 255. Dental Public Health Service Populations Persons covered Persons covered Children <19 living Province by social by social in poverty assistance 1995 assistance 2003 BC 374,300 180,700 182,577 AB 113,200 57,800 132,806 SK 82,200 53,200 53,110 MN 85,200 59,900 67,540 from Quinonez C et al 2005
  • 256. Ontario Perspective on Government Plan Coverage Gap Coverage • High needs, not high risk – Low socioeconomic levels – Disabled and their families • Emphasis on basic or urgent treatment with minimal emphasis on prevention or education
  • 257. Colorado Study Hirsch et al. A simulation model for designing effective interventions in early childhood caries. Prev Chronic Dis 2012;9:110219 CDC&P • Projects 10-yr intervention costs and relative reductions in cavity prevalence • Interventions target 2-4 yr. olds • Targeting high risk provides greatest return on investment • Combined interventions have greatest potential for cavity reduction • All produce substantial reductions in repair costs; some save more than their cost Interventions Assessed Fluoridation, Fluoride varnish, Bacterial transmission, Xylitol with children, Secondary prevention, Motivational interviewing, Combined interventions
  • 258. Colorado Study Preventive Therapy Caries Reduction Cost of TreatmentWater Fluoridation 25.4%Fluoride Varnish 33% $16 per applicationBacterial Transmission(Education, restorative 73% $100 per mothertreatment for mothers)Xylitol (several simulation 44% - 77% $100 per childmodelsSecondary Prevention(follow-up care including 50% – 75% $242 per childrestorative procedures)Motivational Interviewing 63% Combining several Combining several interventions can produce a therapies will create aCombined Therapies smaller fraction of children with cumulative & cavities than can any of the single complementary effect interventions.
  • 259. CDA Position-Risk of ECC1. The child lives in an area with a non-fluoridated water supply and low (< 0.3 ppm) natural fluoride levels.2. Visible defect, notch, cavity or white chalky area on a baby tooth in the front of the mouth.3. The child regularly consumes sugar (even natural sugars) between meals. This includes use of a bottle or sippy cup filled with any liquid other than water and consumption of sweetened medications.4. The child has special health care needs that limit his or her cooperative abilities, thus  making  it  difficult  for  the  parent  to  brush  the  child’s  teeth.  5. The  child’s  teeth are brushed less often than once a day.6. Born prematurely with a very low birth weight of less than 1500 grams [3 pounds].7. The parent or caregiver has tooth decay.8. The child has visible plaque, such as white or yellow deposits on the teeth.
  • 260. Early Childhood Caries Lida et al 2007
  • 261. Risk Factor For Future Caries or Good Indicator Of FutureCaries Experience ??  *Al-Shalan TA, et al. Primary Incisor Decay Before Age 4 As A Risk Factor For Future Dental Caries. Pediatr Dent. 19(1):37-41, 1997  *OSullivan DM, Tinanoff, N, The Association Of Early Dental Caries Patterns With Caries Incidence In Preschool Children., J Public Health Dent 56(2):81-3, 1996  *Kaste, LM, et al. The Assessment Of Nursing Caries And Its Relationship To High Caries In The Permanent Dentition. J Public Health Dent. 52(2):64-8, 1992  *Almeida, Al et al. Future Caries Susceptibility In Children With Early Childhood Caries Following Treatment Under General Anesthesia. Pediatr Dent 22 (4) 302 - 306, 2000 • BY THIS TIME IT IS TOO LATE
  • 262. Early Childhood Caries Clinical Management in Your Practice Decision Tree in different clinical situations
  • 263. Initial Management follows Risk Assessment CAMBRA=Caries Management by Risk Assessment THE NEW STANDARD OF CARE • Assess child and caregiver caries risk in an individualized manner • Tailor a specific preventive therapeutic management plan • Customize a restorative plan in conjunction with the preventive plan • Plan timely, specific and appropriate periodicity schedule  based  on  the  child’s  caries  risk Ramos-Gomez F, Ng WM, Oct 2011
  • 264. ECC Decision Tree – Low Risk
  • 265. ECC Decision Tree – Low Risk 0-5 yrs. Caries free with low risk • Accept as patient or refer If Providing Care Diet and hygiene review Exam frequency 9-12 months Radiographs BW’s  if  contacts  tight  and  co-op Fluoride not in office, Fl T.P. optional Prevent Interventions no Restorations no
  • 266. ECC Decision Tree – Moderate Risk 0-5 yrs Caries free with moderate risk Diet and hygiene review and self goals Exam frequency 6 months Radiographs BW’s  if  tight  contacts 12-18 month interval Fluoride Varnish with 6 month interval Fl T.P. at home Prevent interventions Consider GI sealant on at risk Restorations no Consider more frequent assess and Fl Var if questionable compliance or after initial exam
  • 267. ECC Decision Tree – Moderate Risk 0-5 yrs Moderate risk with poor hygiene Diet and hygiene review and self goals Exam frequency 6 months Radiographs BW’s  if  tight  contacts 12-18 month interval Fluoride Fl Var q6M, consider 3M Fl T.P. at home, consider 5000 ppm Prevent intervention consider PVP-I with Fl Var q3M consider GI sealants on risk sites Restorations no Considerations depend on family motivation and anticipated compliance
  • 268. ECC Decision Tree – High Risk Accept as patient or refer If Providing Care Diet and hygiene review and self goals Exam frequency 6 M consider 3M initially Radiographs BW’s  if  tight  contacts 12 month interval initially Fluoride Fl Var q6M, consider q3M Fl T.P. at home, consider 5000 ppm Prevent intervention consider PVP-I with Fl Var q3M for 12M Restorations consider GI sealants on risk sites Considerations depend on family motivation and anticipated compliance
  • 269. ECC Decision Tree – High Risk with Caries Accept as patient or refer If Providing Care Diet and hygiene review and self goals Exam frequency 3M until caries stable Radiographs BW’s  if  tight  contacts 12 month interval initially Fluoride Fl Var q3M until caries stable Fl T.P. at home, consider 5000 ppm Prevent intervention PVP-I with Fl Var q3M until stable Restoration ITR or perm restoration consider GI sealants on at risk Considerations include patient co-op, sedation/GA, family motivation and compliance
  • 270. First Teeth First Visit Integration into Clinical Practice
  • 271. Are Parents / Patients Interested? • Why do I get cavities? • I  brush  and  floss  doesn’t  that  prevent  any   cavities? • I  brush  my  child’s  teeth  before  bed  like   you showed us and in the morning now look at what happened? • My child eats no sweets yet we still have cavities? • What can I do as a parent to prevent cavities?
  • 272. First Teeth First Visit: Why Bother • Early  intervention  maintains  child’s  oral   health • Delegation of a series of procedures to other staff • Good practice builder • Build strong long lasting relationships with the family • Develops good referral base  The key is to assess risk, motivate parent / caregiver to provide proper care with appropriate in-office care.
  • 273. Elements: • Parent / Guardian interview • Visual exam to assess risk • Assess / facilitate parental motivation • Oral Hygiene Instruction • Develop a preventive protocol • Apply or dispense preventive therapies The key is to establish an effective collaboration.
  • 274. Staff Involvement: 1. Parent / Guardian interview 2. Visual exam to assess risk 3. Oral Hygiene Instruction 4. Develop a preventive protocol 5. Apply or dispense preventive therapies 6. Charting & post-op instructions
  • 275. Parent / Guardian Interview: • History of active decay • parent, child & sibling • Medical history • Diet • Oral Hygiene • Motivation
  • 276. Anticipatory Guidance for Mother Goal: Anticipatory guidance for the mother both before the baby is born and following the infant’s  birth  on  several   information items:
  • 277. Water • Good  for  mom’s  health • Does it have fluoride • If bottled water, does it contain fluoride
  • 278. Oral Hygiene Care • For  mom’s  health  as   well as control of bacterial transfer • Brush and floss daily to disturb cariogenic bacteria and reduce bacterial plaque levels • Use toothpaste with fluoride
  • 279. Diet • Choose foods low in sugar. • Eat healthy snacks like fruit, cheese and vegetables. • Get enough calcium for mom    and  baby’s  healthy   teeth and bones. • Calcium is in milk, cheese, dried beans and leafy green vegetables. • Avoid carbonated drinks
  • 280. Canada’s  Food  Guide Interactive guide for all family guide-aliment/index-eng.php
  • 281. ODA’s  “Ten  Tips  For   Parents” Downloadable from the website
  • 282. Oral Hygiene Instruction: 1. Lift the lip 2. Use of tooth paste 3. Other aids 4. Diet 5. Motivation
  • 283. Examination of theYoung Child
  • 284. Early Childhood Caries Infant Oral Health Exam • The new standard of Care CDA, CAPD, ADA, AAPD • Optimal evidence-based preventive Practices Practice-building opportunity
  • 285. The 12 Month Oral Health Exam Objectives • Recording medical history & dental history • Complete oral exam • Assess infant risk & determine prevention plan • Provide anticipatory guidance • Plan for comprehensive care • Refer where appropriate if necessary
  • 286. Sealants, Preventive ResinRestorations, ICON & Ortho-Related Caries
  • 287. Pit & Fissure Sealants Systematic review on first permanent molars comparing sealant and fluoride varnish as well as sealant and varnish versus just fluoride varnish • Conclusion: There was some evidence of the superiority of pit and fissure sealants over fluoride varnish application in the prevention of occlusal decay. However, it remained unclear to what extent there is difference between the effectiveness of pit and fissure sealants and flouride varnishes. Therefore more high quality research is needed » Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003067
  • 288. Pit & Fissure Sealants on Primary Molars • Benefits determined in systematic review as being very weak – Grade of evidence III – Strength of recommendation D • (Evidence on permanent molars of children and adolescents when at risk of caries) – Grade of evidence 1a – Strength of recommendation B Beauchamp J et al, Evidence-based clinical recommendations for the use of pit- and-fissure sealants, JADA 2008: 139(3)257-66
  • 289. Sealing Over Caries Griffin et al The effectiveness of sealants in managing caries lesions, J Dent Res 2008 Is it safe • Conclusion: Sealed caries fissures showed significantly more microleakage and insufficient sealant penetration depth than sound fissures. Neither the use of an adhesive nor its interemediate curing influenced the microleakage score and the penetration ability of sealants – Hevinga MA et al, Can Caries Fissures be Sealed as Adequately as Sound Fissures, J Dent Res 2008 May;28(5):495-8 In My Opinion – NO- • Better to do a Preventive Resin Restoration
  • 290. Newly Erupting Permanent Molar Options: -Resin sealant -Glass Ionomer sealant -CHX varnish followed by Sealant once erupted Evidence: GI (Triage) seals and protects better than resin
  • 291. Glass Ionomer Sealant• Moisture friendly• Fluoride-release potential• Does not have steps resin-based sealants require – No acid etching or the application of a primer – No bonding age JADA Feb 2012BUT• It is temporary until the tooth is fully erupted
  • 292. Application Technique – Newly Erupted Teeth © 3MVanish XT Extended Contact Varnish 3MESPE 2008. All Rights Reserv ed. 1 2 3 4 5 6 7 8
  • 293. © 3M 2008. AllQuestions & Answers Rights Reserved. Can Vanish XT Varnish be used as a full mouth treatment? • Vanish XT varnish is designed for site-specific applications. Can Vanish XT Varnish be removed from the tooth surface? • If necessary, the coating can be removed with the use of a coarse prophy paste or pumice. How thick should the coating of Vanish XT Varnish be applied? • You need only apply a thin layer (1/2mm or less) of Vanish XT varnish to the tooth surface.
  • 294. Pit and Fissure Sealants OPINION • transparent rather than opaque • rarely on primary molars, PRR instead • (JADA systematic review) • interesting idea with Helioseal • Clear Chroma Photo courtesy of Ivoclar Vivadent
  • 295. Take-Home Message on Primary Molars When sealants on primary molars • Only when risk of occlusal caries is high • Second primary molars before first primary molars Consider • Preventive Resin Restoration for high risk patient
  • 296. Atraumatic Restorative Treatment (ART) (andITR) Features -useful alternative to composite resin and Amalgam restorations -usually compomer material -faster treatment at less expense -can be a psychologically desensitizing procedure -usually done without local anesthesia -semi-permanent restoration on primary dentition -can be bonded with or without acid-etch -longevity 2 years +
  • 297. ART Kemoli AM et al, 2-Yr Survival Rates of Proximal ART Restorations…. Ped Dent 33(3): May-June 2011 Proximal restorations • 3 Glass Ionomer Cements – Fuji IX, KMA, Ketac Molar • 31% survival rate after 2 years • Survival rate depended also on consistency of meal consumed after restoration Comment One can logically assume higher retention rates with compomer material or etching prior to use of conditioner
  • 298. ART Case study
  • 299. ART Case Study
  • 300. ART Case Study
  • 301. ART Case Study
  • 302. ART Case Study
  • 303. Interim Therapeutic Restorations A Variant of A.R.T. • Advantages – Temporization restoration – Fluoride-releasing – Minimal/no preparation – Opportunity  to  “buy  time”   • Materials – Resin-modified glass ionomer or – Glass ionomer – CaOH or GI base as necessary
  • 304. Case example• 20 months old• Pre-GA• Cold-sensitive• Toothbrush-sensitive• GA wait time at least 4 months
  • 305. Resin-modified Glass Ionomer –Ketac Nano
  • 306. ICON Resin InfiltrationIntermediate treatmentNeither preventive nor restorativeResin infiltrant into pre-cavitated carious lesion
  • 307. Smooth surface and interproximal surfaceversionsResin infiltrant for pre-cavitated lesions E1 upto D1 (ICDAS score)• ICON etch 15% HCl• ICON dry ethanol• ICON infiltrant resin + ethanol
  • 308. Research“Comparison  of  the  radiological  lesion  progression of proximal caries after infiltrationor standard therapy-18  months  follow  up” Paris S, Meyer-Luckel H• radiographic assessment no reported side effects-pain, vitality, stain• 10% show progression of lesion vs.38% in control group
  • 309. ICON – Latest Results Paris S, Meyer-Lueckel H 2010in situ bovine enamel samples in human subjects100 days with plaque and sucrose solutionMeasure change in lesion depth and integrated mineral lossSlight progression in mineral loss and no progression of lesiondepth versus negative controlConclusion:  “the  clinical  efficacy  of  the  resin  infiltration  in  natural  lesions  needs  to  be  explored  in  clinical  studies”
  • 310. ICON Resin Infiltrant
  • 311. ICON Resin Infiltrant
  • 312. ICON Resin Infiltrant
  • 313. ICON Resin Infiltrant
  • 314. ICON Resin Infiltrant
  • 315. ICON Resin Infiltrant
  • 316. ICON Resin Infiltrant
  • 317. ICON Resin Infiltrant Limitations with ECC -Patient selection monitoring post-treatment co-operation for treatment -Non-radiopaque material -Handling awkward -No insurance code under USC&LS -Expense
  • 318. ICON Resin Infiltrant Opinion: • limited case selection in ECC • needs more clinical trial results • would benefit from improved delivery tools Not ready for Prime Time
  • 319. ICON Resin Infiltrant
  • 320. ICON Resin Infiltrant
  • 321. ICON Resin Infiltrant
  • 322. Detection Around ICON
  • 323. Detection Around ICON
  • 324. Case Scenario-”Incipient”  Interproximal  Caries Treatment Options: What does that mean NOW • Monitor • Review and/or alter preventive care – Flouride varnish, Povidone Iodine, home care including high fluoride T.P., diet review • More frequent office preventive visits • Glass Ionomer sealant • Vanish XT Extended Contact Varnish • ICON • Restoration
  • 325. GI Sealant with Triage
  • 327. Incidence of White Spots During Orthodontic Treatment Examined 350 patient records U of Michigan Grad Ortho Richter et al. AJO-DO May 2011• 11.7% Mizrahi E., Am. J. Ortho 1982• 16% Ogaard, B., Am. J. Ortho Dentofacial Orthop 1989• 25.6% Gorelick et al. Am J. Ortho. 1982
  • 328. White Spots 24 Year Old Male
  • 329. Detecting and Measuring with The Canary 34 38 64 21 14 15 11 13 64
  • 330. Orthodontic decalcifications and caries
  • 331. Orthodontic Decalcifications and CariesStrategies and Solutions Objectives of Orthodontics Esthetics Function Stability Conclusion Decalcification and Caries are a failure of orthodontic outcomes
  • 332. Strategy For Caries Control • Risk Assessment • Collaboration Triad • Communication Agreement • Individualized Prevention Programme
  • 333. Dear Dr. Re: PatientOur mutual patient was in recently for regular care. You will recall that he/she demonstrates ahigher risk for dental caries. As a result, we have initiated a customized preventive programmefor him/her while undergoing the orthodontic care under your supervision. Specific componentsof this preventive programme include:___ Higher fluoride toothpaste used at bedtime___ More frequent dental hygiene visits for scaling, prophylaxis___ More frequent dental hygiene visits for additional fluoride varnish application___ Review of home hygiene techniques including use of floss and proxybrush___ Scanning of at risk sites on teeth with the Canary SystemThe  current  review  of  ________’s  oral  hygiene  and  caries  status  reveals:___ Oral hygiene is under control___ Adjustments to the preventive programme are required and involve the following:___ A rescan of the at risk sites is planned for ___ monthsWe appreciate your collaboration in the oral care for _______. Please contact our office if youhave concerns about anything for him/her.Sincerely yours,
  • 334. Solutions for Caries Control
  • 335. Solutions for Caries ControlFilled Resin Sealant
  • 336. Pro-Seal Technique
  • 337. Slides courtesy of Reliance Orthodontics
  • 338. Opinion: Why ProSeal over Opalseal PREVENTION OF ENAMEL DEMINERALIZATION WITH LIGHT CURE FILLED SEALANTWei Hu, DDS, MSc, PhD, John D.B. Featherstone, MSc, PhD University of California San Francisco, CA.CONCLUSION:The results of the study indicate that ProSeal® could beconsidered for use as a preventive method to reduceenamel demineralization adjacent to orthodonticattachments, particularly in patients who exhibit poorcompliance with oral hygiene and home fluoride use.
  • 339. Opinion: Why ProSeal over OpalSeal
  • 340. with Opalseal
  • 341. Application Technique – OrthodonticsVanish XT Extended Contact Varnish 1 2 3 4 5 6 7 8© 3M 2008. AllRights Reserved.
  • 342. Application Technique – OrthodonticsVanish XT Extended Contact Varnish 9 10 11© 3M 2008. AllRights Reserved.
  • 343. Patient Education
  • 344. Positioning Your Practice
  • 345. Patient Messages • Caries is a Disease • Caries, if detected early can be treated with a wide range of therapies • Caries can be prevented • Treatment needs to be home and office based • Fillings, root canals are really later stage treatments
  • 346. Decay Potential of Certain Foods High Potential for Decay Low Potential for Decay • Dried fruits • Raw vegetables • Candy, hard candy • Raw fruits • Cake, cookies, pie • Milk • Crackers No Potential to Decay • Chips • Meat, fish, poultry Moderate Potential for Decay • Fats, oils • Fruit juice Ability to Stop Decay • Sweetened, canned fruit • Cheeses, • Soft drinks • Xylitol • Breads • Nuts
  • 347. Sugars & Snack Foods
  • 349. Did you know?• 56-85% of school-aged children consume at least ONE soda per day• at least 20% of school-aged children consume a minimum of 4 sodas per day• a dangerous level of consumption exists among that 20%, which indicates that some of these children are drinking approximately 12 cans of soda in one day Kaplowitz, G. an Update on the Dangers of Soda Pop. Dental CE Digest, PennWell Publications
  • 350. Canada’s  Food guide-aliment/index-eng.phpInteractive guide for all family members
  • 351. Office Integration
  • 352. Office Integration 1. Staff training 2. Patient education 3. Selection of products 4. Charting and recording lesions 5. Billing codes and payments 6. Introduction into clinical practice 7. What to do when things fail
  • 353. First Visits Office Codes • 00011 First dental visit/orientation up to 3 years • Option: 01101 NP Exam • Option: 01204 Specific Exam
  • 354. Remineralization Visits Office Codes • Progress visit with Fluoride Varnish application • If combined with Monitoring such as The Canary System – 01204 Specific Exam – 13601 Topical application of antimicrobial agent – 99555 Unit cost of Varnish Remineralization codes do exist in some provinces Topical application of anti-microbial Specific examination, oral hygiene instruction,
  • 355. Office Integration Who • Entire staff • Assistants • Hygienist • Dentist What • Exam, Risk Assessment, Treatment Why • Quality of Care • Restorative vs. Minimal Intervention / Early Treatment • Practice Builder & Revenue Stream
  • 356. Office Integration Introducing this to patients New Patient Recare Exam Recall Risk Assessment Risk Assessment Treatment Treatment
  • 357. Office Integration What is Treatment? • Remineralization • Anti-Microbial • Sealant • ITR • ART • Restorative / Surgical
  • 358. Summary
  • 359. Some Parting Thoughts • Caries is an infectious disease • Biofilms are Bacterial Communities • Caries is reversible if detected and treated early • Home and office based prevention require monitoring • Risk Assessment should be part of ongoing management
  • 360. Some Parting Thoughts Part 2 • Understand caries detection devices • Remineralization does work • Remineralization means treatment & monitoring • Engage patients in their care • ART works
  • 361. The Shift in Dealing with Caries • Growing awareness of social determinants • Newer recording of caries levels-ICDAS • Risk-based care • Patients want to avoid restorations • A myriad of new products • New diagnostic devices