Understanding and TreatingDental Caries in Children andYoung  Adults:  It’s  Not  Just  Filling Teeth Dr. Stephen Abrams D...
Overview of the Day       Introduction       Cariology 101       Risk Factors       Detection       Remineralization Thera...
Dentistry and the Public; Some Concerns         Survey results CDA Initiative         • Current reputation has precarious ...
What this Lecture is Not       A clinical  technique  “how  to”       A commercial for specific products       No commerci...
*Disclaimer       Dr. Abrams is President and CEO of Quantum       Dental Technologies (QDT), the creator of The       Can...
Acknowledgements • DR. MARIELLE PARISEAU    – www.shapingthefutureofdentistry.org    – Dentists Leaders in Health: Thinkin...
Today and Evidence-Based Dentistry       Integration of Evidence-based literature with       clinical opinion       If  it...
Concepts of EBD
TIP: www.aapd.org
PubMedhttp://www.ncbi.nlm.nih.gov• Great free open source site for search of literature• Access to article abstracts and f...
What is Caries?
NIH Consensus Conference on Caries 2001        “Dental  caries  is  an  infectious,          communicable disease resultin...
NIH Consensus Conference March 2001        Caries is a bacterial infection caused by        specific bacteria.        Cari...
The Paradigm Shift        One can place a number of restorations in a        mouth and yet not treat the underlying       ...
CHMS Oral Health Data
CHMS vs U.S. Data
The Problem
Relevant Issues arising in the article • “I  had  a  lot  on  my  mind,  and  brushing  his  teeth  was  an  extra  thing ...
Dental Caries is one of the most common diseasesamong 5 – 17 year olds  60  50                                           N...
Public Perception – In other words – NO BIG DEAL
Our Reality              Psychological impact                                     Lower body weight                       ...
Terminology      Caries is a transmissible bacterial infection and a      multifactorial disease that reflects change in o...
Early Childhood Caries (ECC)  “The  presence  of  one  or  more  decayed    (noncavitated or cavitated lesions), missing (...
Terminology   Severe Early Childhood Caries (S-ECC)   “Any  sign  of  smooth-surface caries in a child younger than 3     ...
Diagnosis involves recognitionof these changes rather thansimply noting cavities
• Don’t treat underlying disease                        • Don’t address plaque biofilm                          i    s    ...
CariologyWhat is Tooth Decay?
Caries Risk?
Caries Progression
What do you need to create tooth decay?       • Teeth       • Food particularly carbohydrates       • Bacteria in Plaque o...
Elements involve in the Caries Process                                       Sugars &      Plaque                         ...
Restorations      •Restorations have no measurable effect on       bacteria.      •Restorations have a finite life span.  ...
Caries Evolution
Caries Progression
Caries Progression
Caries Progression
Caries Progression
White Spot Lesion                              Internal                              loss of                              ...
Early Carious Lesion in Enamel
Pathogenesis of Dental Caries            SALIVA              PLAQUE                            PLAQUE                     ...
The Caries Balance Pathological Factors         Protective Factors •Acidogenic Bacteria         •Saliva flow & components ...
Demineralization                                    Demineralization  Dental Mineral        Organic        Calcium &   Aci...
Remineralization                           Phosphate      Remineralization  Calcium in tooth          In tooth     •Builds...
demineralizationpH                                          FAP               Critical pH                                 ...
Cyclic Process of DecayBacteria plus food   Demineralization makes the salivavery acidic within    5 minutes              ...
Stephan Curve                                                                 ?                                           ...
What Contributes to the Extent of pHDrop after Glucose Exposure?•   Type & amount of    carbohydrate available• Bacteria p...
What Contributes to the Differencesin Resting Plaque?                                        Resting plaque pH:           ...
pH Change During the Course of The Day
Caries is a BacterialInfection
Web of Transmission                   PLAYMATES/PEERS      CAREGIVERS                          SIBLINGS                   ...
Mode of Transmission  Both this spoon and pacifier have been in the mouth  and then cultured in a selective broth. They sh...
Caries Is An Infectious Disease  “Demonstration of Mother to Child Transmission of  Streptococcus mutans using Multilocus ...
Bacteria Involved in Caries       Streptococcus Mutans,       Streptococcus Sobrinus       Lactobaccillus
Streptococcus Mutans• Caries initiators• Triggers the process that leads to mineral  loss and that allows bacteria to pene...
Lactobacillus   • They are responsible for caries progression.   • They do not adhere to tooth surfaces but     need cario...
Plaque & BiofilmsSome New Thoughts on Plaque
What is a Biofilm?                     • A well organized,                       cooperating community of                 ...
Phases of Plaque Formation                                             Pellicle Formation                          Thin ba...
Fluid micro colony is movement of nutrients & bacterial by-Each channels allow an independent community with its ownBacter...
Host Factors That Influence Microbial Composition
Dental Plaque: Caries & Periodontal DiseaseMarsh  et  al.  “Dental  Plaque  Biofilms:  Communities  Conflict  &  Control” ...
Control of Biofilms         Control of nutrients         • addition of base-generating nutrients (arginine)         • redu...
Agents for Control of Biofilm          Vast majority of agents for control          of biofilm are broad spectrum         ...
SalivaA Very Important Component in theOral Environment
MultifunctionalityAmylases, Cystatins,                      Carbonic anhydrases,Histatins, Mucins,                        ...
Saliva’s  Protective  Function  • Mechanical cleansing (water/flow)  • Lubrication of tissues and teeth (secreted proteins...
Saliva & Oral Function       Food processing (water)       • Taste solute       • Bolus formation and swallowing (secreted...
Remineralization Of Enamel &Calcium Phosphate Inhibitors          •Early caries are repaired despite presence of          ...
Summary     • Caries is an infection disease     • Bacteria live in Biofilms not Petri dishes     • pH drives changes in b...
Risk FactorsCaries is a Disease
Risk Defined       • Risk is a prediction that disease         will occur or progress       • Risk is distinct from diseas...
Caries Risk Factors  •   Low Socio-economic Status  •   High Titers Of Cariogenic Bacteria  •   Poor Oral Hygiene & Cariog...
Risk Factors       • Social Determinants       • BioMedical
Risk Factors: History          • Child has special needs          • Socio-economic status of the family          • Parents...
Risk Factors: Dental History         • Child has decay         • Time elapsed since last cavity         • Child wears brac...
Risk Factors: Dental History         • Frequency of brushing         • Daily between meal exposure to           sugars & c...
Risk Factors: Fluoride exposure          • Fluoridated water          • Fluoride supplements          • Fluoridated toothp...
Risk Factors: Clinical Evaluation           • Visible plaque           • Gingivitis           • Areas of enamel deminerali...
Risk Factors: Clinical Evaluation Part 2           • Radiographic evidence of caries           • Levels of Strep Mutans in...
Risk Definitions &TreatmentRecommendations
Low Risk  Caries Risk   •Dmfs , ½ childs age  Indicators    •No new lesions in 1 year                •No white spot lesion...
Medium RiskCaries Risk   •dmfs>  ½  child’s  ageIndicators    •1 or more lesions in 1 year              •infrequent white ...
Medium Risk (continued)  Preventive    •Fluoridated tooth paste  Therapy       •Systemic fluoride supplements             ...
High Risk  Caries Risk   •dmfs>  child’s  age  Indicators    •2 or more lesions in 1 year numerous white                sp...
High Risk (continued)Preventive    •Fluoridated tooth pasteTherapy       •Systemic fluoride supplements (age & water      ...
CAMBRACaries Management by Risk Assessment
The Caries Balance
The Caries Balancead Bacteriabsence salivaietary habits poor
aliva                      adequate                      nti-ad Bacteria           microbialbsence saliva        luoride  ...
ad Bacteria                      aliva                      adequatebsence saliva                      nti-               ...
A Caries Risk Assessment (CRA) is just“weighing”  the  factors  of  each  patient.
CAMBRA is just “removing  weight” from one sideand “adding  weight” to the other.
Current State of Risk Assessment        “No  existing instrument can ensure accurate        categorization  of  children  ...
Objectives of CAMBRA in Children        CAMBRA=Caries Management by Risk        Assessment        • Assess child and careg...
Tools for AssessingCaries
“  It is change, continuing change, inevitable change,that is the dominant factor in society today. No sensibledecision ca...
Sensitivity & Specificity• Sensitivity refers to the ability of a test to correctly identify those patients with  the dise...
Tools for Detection•    Visual Exam with or without Explorer•    Radiographs•    DIAGNODent•    Caries ID•    QLF•    Spec...
Principles of Diagnosis       The goal of examining a patient for the       presence of dental caries is to detect the    ...
White Spots????
Examining a White Spot
Classical Detection Tools                    Health          Decalcification            Decay               Normal tooth  ...
Visual Tools for Assessing Caries       • DMFT and DMFS       • ICDAS       • CAMBRA
DMFT and DMFS      DMFT: decayed, missing, filled teeth      DMFS: decayed missing filled surfaces      Only a measure of ...
ICDAS International Caries Diagnosis &Assessment System        • Used to rank tooth surfaces        • Ranks lesions       ...
ICDAS Coding Summary
Use of Explorers               (?contentious)In the ICDAS-system perio           Explorers are not recommended asprobes ar...
ICDAS-II detection criteria, 2005SOUND   OPACITY            OPACITY         LOCALISED   UNDERLYING     DISTINCT        EXT...
ICDAS-II detection criteria, 2005SOUND   OPACITY         OPACITY         LOCALISED   UNDERLYING    DISTINCT        EXTENSI...
ICDAS Code Summary         http://www.dundee.ac.uk/dhsru/news/icdas.htm                    DETECTION AND SEVERITY OF THE L...
Visual vs. Caries Detection Devices• Visual only provides  information on the  surface• Caries starts as a sub  surface le...
Does this look suspicious?
Use of an Explorer                     • Care in not poking or                       disturbing the enamel                ...
Probing Drives Bacteria & Debris into Fissures
Explorers & Pit & Fissure Caries       “Probing  found  unreliable  in  finding  fissure  caries”       Penning, van Amero...
Light Interaction with Teeth •Reflection •Transmission •Absorption •Backscatter                 Reflection    Backscattere...
Methods for Caries Detection                  Conventional methods • Visual examination:        + non-destructive        +...
Radiographs      • Radiographic imaging of pits and fissures is of minimal        diagnostic value because of the large am...
Radiographs       Radiograph unable to       locate caries and crack       beneath the restoration
Methods for Caries Detection                   Fluorescence-based methods• DIAGNODent (Kavo Danaher):     detects fluoresc...
Methods for Caries Detection                Fluorescence-based methods• Quantitative Light-Induced Fluorescence (QLF):    ...
Methods for Caries Detection             Spectra QLF based Technology             • May be issues with accuracy and sensit...
Methods of Caries Detection DIFOTI (Digital Fibreoptic  Transillumination) + non-invasive - Low resolution - Tooth decay s...
Methods of Caries Detection Caries Scan (Electrical Impedance Measurement)  Tooth decay delays or changes the conduction o...
The Canary System • Full Spectrum of Caries   Detection • Accurate • Repeatable • Reliable • Engages Patients & Builds a  ...
The Science Behind The Canary System•Pulses of laser light hit the tooth surface.•Tooth glows (Luminescence, LUM) and rele...
Caries Detection on All Surfaces       • Occlusal Pits & Fissures       • Smooth Surfaces       • Interproximal Regions   ...
Canary PatientReportCustomized patient   report on dental   practice letterheadClear simple indication   of problem areasP...
Case Study: Caries Beneath an Amalgam                    39                    60
Canary Finds Caries & Cracks Around Amalgam Canary Numbers (in yellow) indicate caries & pathology. Upon removal of the am...
Sensitivity & Specificity Studies  Study 1: Detection on All Surface Tooth Surface                         Overall        ...
Detection of Pit & Fissure Caries • Low Caries Patient • Only 1 restoration in the   last 40 years • Stained distal pit on...
Detection of Caries Beneath Sealants• Canary Numbers >20 when scanning sealants (3M™  ESPE™  Clinpro™  Sealant™)    placed...
The Characteristics of an Ideal Caries Detection System    1. High sensitivity & specificity for caries detection    2. De...
Remineralization andOther Therapies Minimally Invasive Dentistry
Understanding your choices?
Product Decisions?       Fluoride                  •   RISK Demand?       CPP-ACP (Recaldent)       •   Age and Ability?...
Important Reference Paper on the Journey         Non-fluoride caries preventive agents: Full report of a         systemati...
Requirements of an Ideal Remineralization Material     • Diffuses into the subsurface or deliver calcium and       phospha...
Topical Fluoride        The Original Remineralization Agent        •   Water Fluoridation        •   Toothpaste        •  ...
Water Fluoridation       • Remains a major source of reduced decay       •     Many studies with average reduction 25%    ...
Community Water Fluoridation Canada
Water Fluoridation       Critical role for local dental community       • Proactive lobby       • In-office activity      ...
Key Canadian Government References onWater Fluoridation• Fluoride Expert Panel 2007• http://www.hc-sc.gc.ca/ewh-semt/pubs/...
Fluoride – Mechanisms of Action • Enhances remineralization         – Adsorbs onto mineral surfaces, attracts calcium and ...
Fluoride Action       A brief review:       – Effect largely topical       • At low levels        – Inhibits demineralizat...
Fluoride - Some Interesting Pieces       Low levels after several hours in plaque and       saliva can have a profound eff...
TOPICAL FLUORIDE        Toothpaste        • Position Statements         – Canadian Dental Association         – American A...
CDA Position on Use of Fluorides in Caries  Prevention      revised March 2012• Water fluoridation• Fluoride toothpaste an...
CDA Position on Use of Fluorides in CariesPrevention      revised March 2012  Children 0 - 3 years  • The use of fluoridat...
Topical Fluoride – The Gold Standard       J Dent Educ. 71(3): 393-402 2007       © 2007 American Dental Education Associa...
ADA Evidence-based Recommendations      Assess        – Caries Risk                –Low                –Medium            ...
ADA Evidence-based RecommendationsProfessionally Applied Topical Fluoride         Risk group   Less than 6 years         /...
ADA RecommendationProfessionally Applied Topical Fluoride        Low risk under 6 years        • Fluoridated water and too...
Fluoride Varnish – Why?        • Higher percentage of caries reduction        • Prolonged uptake of fluoride by enamel    ...
Fluoride Varnish (5% NaF = approx 22,500 ppm)No special equipment           • Safe and well toleratedNo prophylaxis prio...
Evaluating Fluoride Varnish      • Concentration of Fluoride in Varnish      • Fluoride availability in saliva over a 1 – ...
Applying Fluoride Varnish
Fluoride Varnish Application        • Gentle  finger  pressure  to  open  child’s            mouth        • Remove excess ...
Post-application instructions        • Recommendations vary with manufacturer,          but generally:        • Can eat wi...
Migration of Fluoride Varnish after Application:an In Vivo Study           Kolb V et al, 3M ESPE Dental Products, St. Paul...
Fluoride and Safety Concerns              Three real issues          •    Fluoride toxicity          •    Fluorosis       ...
Estimation of Potential Toxic Dose Considering the Child Age/Weight            Verronneau 2007Variable                    ...
Fluoride Varnish – Toxicity           Comparative fluoride ingestion rates               Use                              ...
Fluorosis        Total daily fluoride intake from all sources        should not exceed 0.05-0.07 mg F/kg of body        we...
Fluorosis – Dean’s  Index
Fluorosis – CHMS Data       Children 6-12 years       • 60% with normal enamel       • 24% with white flecks or spots wher...
Fluoride Varnish (5% NaF = approx 22,500 ppm)No special equipment           • Safe and well toleratedNo prophylaxis prio...
Fluoride Varnish Allergy Risk        Potential resin peptide allergen link to pine nut        allergies        Oral Scienc...
Current Toothpastes         0.243-0.254% NaF or 0.454% SnFl            = 0.115% Fl- = approx. 1100 ppm Fl         1.1% NaF...
High fluoride toothpaste 5000 ppm
3M  Clinpro™  5000  Tooth  PasteDentifrice                      Mechanism of Action• Contains 1.1% NaF (5000       As the ...
Protected calcium oxides are released         As the ingredient reaches the tooth surface         • Organic materials (oft...
Clinical Trial (preliminary analysis)
Recaldent (CPP-ACP)•   Casein Phosphopetides       •   Amorphous Calcium    – From  cow’s  milk             Phosphate    –...
Recaldent      MI Paste      MI Paste Plus      Trident Xtra Care Gum      Trident White Gum
Novamin®• Calcium sodium  phosphosilicate: Ca and  P04 ions protected by glass  particles• Sodium buffers salivary pH  for...
How NovaMin Works   A breakthrough remineralization ingredient   Comprised of calcium ( ), sodium ( ),    phosphorous ( ...
ADA Report Recommendations        “There  is  insufficient  evidence  from  clinical  trials  that          the use of age...
Silver Diamine Fluoride- the new silver bullet?• -currently not approved in N. America• -38% concentration shows significa...
Silver Diamine Fluoride- the new silver bullet?          -frequency of application 1x/yr          -excavation of soft cari...
Silver Diamine Fluoride- the new silver bullet?           Safety Issues           -pulp irritation no evidence           -...
Remineralization and Other Therapies          Antimicrobial treatment (remember the          biofilm!)          • Xylitol ...
Remineralization and Other Therapies                     Xylitol
The Xylitol Story in Brief         • Natural long chain sugar         • Non-cariogenic         • Can reduce mutans strep i...
Key Xylitol Studies for ECC         Soderling et al 2001         Maternal transmission of MS         • Xylitol gum        ...
Key Xylitol Studies for ECC        Soderling et al 2001        Results        • Children age 3         – MS levels 2.3x hi...
Mutans streptococci of the 2-year-    old children (Söderling et al., JDR 2000)                             %             ...
dmf    Caries occurence in children                CHX                          3• At the age of 5 years  the need of  res...
Why Xylitol and when       • Maternal 3 months post partum (Soderling 2001)       • Characteristic of infection at eruptio...
Xylitol as a Remineralization Agent       “These  results  indicate  that  xylitol  can  induce         remineralization o...
Xylitol More than a Remineralization Agent          • Inhibits adhesion, growth and metabolism of oral             microor...
HEAD & NECK RADIATION                                 AND CHEMOTHERAPY                                                 LOS...
Xylitol; A Remineralization Agent          Reported Xylitol Availability          •   Gum – sole or in combination        ...
Xylitol Syrup (Marshall Islands Study)       • No. decayed teeth         – Control: 1.9 +/- 2.4         – Xylitol 2x: 0.6 ...
Xylitol – Widely Accepted Opinion       • habitual use of xylitol reduces incidence of caries       • habitual use reminer...
www.oralscience.com                220BOTTLES•  180  pieces  of  gum  –Peppermint• 180 pieces of gum – Fruit•  400  mints ...
Issue of accurate contents        • Gums, mints do not have to meet high standards re          accuracy of content        ...
Spiffies Wipes         Toxicity Issue?         • Each wipe contains 0.5 g xylitol         • Estimated absorption 0.25 g   ...
Clinical Significance        Right now Xylitol seems to be most        appropriately considered an adjunct measure        ...
ADA Report Recommendations•    Significant reduction of caries polyol gums vs. no gum•    Preventive effect xylitol highes...
Remineralization and Other Therapies       Povidone Iodine – Betadine       -potent antibacterial       -safe to swallow  ...
Povidone Iodine         • Applied in combination with Fl. Varnish         • Complementary to fluoride         • Disrupts b...
Povidone Iodine Topical       • Used post-GA restoration suppresses MS levels over         90 days P<0.00001 Berkowitz et ...
Povidone Iodine Results ECC        PVP-I + FV vs FV only 2.5-2.8 times over 1                year infants 12-30 mths      ...
Anti-Bacterial Agents Mechanism of Action: Reduce Bacterial Levels in the Oral   Cavity • Prevora • Cervitec • Povidone Io...
Chlorhexidine• Now available in both rinse and  varnish• Anti-bacterial and anti plaque• Used for treatment of gingivitis ...
Cervitec Plus        • Used as cervical desensitizer and caries preventive        • Application to mothers q6m til baby 3 ...
Prevora          • CHX Varnish originally for root caries          • Studies on mother child being analyzed.            Re...
ADA Report Recommendations CHX        10-40% CHX Varnish kids 4-18 yrs        Does not reduce incidence of caries-moderate...
Remineralization and Other Therapies  Delmopinol Hydrochloride  • reductions in total cultivable plaque and salivary flora...
Remineralization and Other Therapies  Triclosan  • -broad spectrum antibacterial used in toothpaste  • -reduces supragingi...
Pro Argin®      • Highly soluble arginine bicarbonate - amino acid        complex that binds to calcium carbonate      • T...
Remineralization and Other Therapies          Arginine and Probiotics          Newer research with products on the market ...
What is the Recipe?
Office + Home Therapy                  Office                                      Home                                   ...
Does Remineralization      Work?
Case Study Remineralization       600       400                                                                  Canary Nu...
Remineralization 5th and 7th Quads
Remineralization CaseSlides courtesy of Dr. Clive Friedman
Remineralization CaseSlides courtesy of Dr. Clive Friedman
Canary Numbers for This Case Tooth        October 2011            April 2012         M         O         D   M        O   ...
Does Remineralization Work?                    Yes                    But      You need to monitor and motivate           ...
Remineralization + Monitoring      Essential components of any program:      • Need to monitor progress      • Need to rec...
Integration intoClinical Practice
USCLS Codes and Descriptions    Code                          Description                              Fee13601 – 13609   ...
Code 13601 Remineralization      • Designed for the topical application of fluoride        varnish and other agents in a d...
Office Integration                                     Recall or Specific Exam     Reassess 6 Months               •Identi...
Remineralization + Monitoring      • Essential components of any program      • Need to monitor progress      • Need to re...
Early ChildhoodCaries
Clinical Presentation: Early Lesions ECC• Begins soon after dental  eruption• Typically develops on smooth  surfaces• If e...
Early Childhood Caries  Clinical Presentation          (Advancing) • Virulent caries with rapid   progression • Enamel chi...
Early Childhood CariesAdvanced Tooth Decayphoto Dr. Joanna Douglass, Smiles for Life
Facial CellulitisInfection spreading into surrounding tissues
Early Childhood Caries          % Population                       Age                       Author4% Quebec childrenConve...
Early Childhood Caries  Prevalence 0 - 5 years United States     • Decay  rates  dropped  until  1990’s     • Rates now do...
Early Childhood Caries                         Lida et al 2007
Early Childhood Caries  Prevalence 0-5 Years British Columbia  – 64% inner city Vancouver sample                          ...
Early Childhood Caries  Prevalence 0 - 5 Years Ontario   – 87% of First Nations sample                                    ...
Systemic Effects of Severe ECC     Malnourishment In A Population With Severe Early               Childhood Caries  Among ...
Detrimental Health Effects Of ECC       • pain, infection, loss of function       • affects learning, communication, nutri...
Not Just the Poor       National O.R. Stats       •      Pediatric dental procedures #1 O.R. procedure with           long...
ECC – Other Aspects to Consider        • New approach needed        • Social determinants        • Role of physicians, nur...
The New Approach Needed for ECC      Quality Improvement      • Combine efforts of Health Care       professionals, patien...
FIGURE 1 Child, family, and community influences on oral health outcomes of                                 children      ...
Smiles for Life Pocket Cards for Physicians
Smiles for Life Pocket Cards for Physicians
Principles of Motivational Interviewing        • Establish a therapeutic alliance        • Recognize that people value the...
Models of Individual Oral Health PromotionBrickhouse T.H.Virginia Commonwealth Universitypresented at AAPD Symposium Octob...
Evidence: Models of Individual Oral HealthPromotion • Systematic review 2000-2007 • Database examined for articles evaluat...
Evidence: Models of Individual Oral Health Promotion• Health Education   – Information and expert advice with passive pati...
Motivational Interviewing        Success in dentistry        • Early childhood caries        •        • Harrison RL, Wong ...
Dental Public Health       • Big picture reality – getting to the          populations       • Making connections       • ...
Dental Public Health Service Populations                 Persons covered   Persons covered   Children <19 living    Provin...
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
Understanding and Treating Dental Caries in Young Children and Young Adults
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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 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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Understanding and Treating Dental Caries in Young Children and Young Adults

  1. 1. Understanding and TreatingDental Caries in Children andYoung  Adults:  It’s  Not  Just  Filling Teeth Dr. Stephen Abrams Dr. Ian McConnachie
  2. 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. 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. 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. 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. 6. Acknowledgements • DR. MARIELLE PARISEAU – www.shapingthefutureofdentistry.org – Dentists Leaders in Health: Thinking Outside of the Mouth – http://www.jcda.ca/article/b157 • 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. 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. 8. Concepts of EBD
  9. 9. TIP: www.aapd.org
  10. 10. PubMedhttp://www.ncbi.nlm.nih.gov• 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. 11. What is Caries?
  12. 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. 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. 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. 15. CHMS Oral Health Data
  16. 16. CHMS vs U.S. Data
  17. 17. The Problem
  18. 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. 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. 20. Public Perception – In other words – NO BIG DEAL
  21. 21. Our Reality Psychological impact Lower body weight A VERY BIG DEAL
  22. 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. 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. 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. 25. Diagnosis involves recognitionof these changes rather thansimply noting cavities
  26. 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. 27. CariologyWhat is Tooth Decay?
  28. 28. Caries Risk?
  29. 29. Caries Progression
  30. 30. What do you need to create tooth decay? • Teeth • Food particularly carbohydrates • Bacteria in Plaque or Biofilm
  31. 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. 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. 33. Caries Evolution
  34. 34. Caries Progression
  35. 35. Caries Progression
  36. 36. Caries Progression
  37. 37. Caries Progression
  38. 38. White Spot Lesion Internal loss of minerals External (outer) surface White Spot Lesion Really a subsurface lesion
  39. 39. Early Carious Lesion in Enamel
  40. 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. 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. 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. 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. 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. 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. 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. 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. 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. 49. pH Change During the Course of The Day
  50. 50. Caries is a BacterialInfection
  51. 51. Web of Transmission PLAYMATES/PEERS CAREGIVERS SIBLINGS PATIENT 2008 Copyright T .Rodriguez,DDS
  52. 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. 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. 54. Bacteria Involved in Caries Streptococcus Mutans, Streptococcus Sobrinus Lactobaccillus
  55. 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. 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. 57. Plaque & BiofilmsSome New Thoughts on Plaque
  58. 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. 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. 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. 61. Host Factors That Influence Microbial Composition
  62. 62. Dental Plaque: Caries & Periodontal DiseaseMarsh  et  al.  “Dental  Plaque  Biofilms:  Communities  Conflict  &  Control”  Periodontology  2000  December  2011  
  63. 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. 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. 65. SalivaA Very Important Component in theOral Environment
  66. 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. 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. 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. 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. 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. 71. Risk FactorsCaries is a Disease
  72. 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. 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. 74. Risk Factors • Social Determinants • BioMedical
  75. 75. Risk Factors: History • Child has special needs • Socio-economic status of the family • Parents & siblings have decay
  76. 76. Risk Factors: Dental History • Child has decay • Time elapsed since last cavity • Child wears braces or oral appliance • Reduced saliva flow
  77. 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. 78. Risk Factors: Fluoride exposure • Fluoridated water • Fluoride supplements • Fluoridated toothpastes
  79. 79. Risk Factors: Clinical Evaluation • Visible plaque • Gingivitis • Areas of enamel demineralization – ICDAS 1 – 3 • Enamel defects / deep fissures
  80. 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. 81. Risk Definitions &TreatmentRecommendations
  82. 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. 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. 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. 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. 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. 87. CAMBRACaries Management by Risk Assessment
  88. 88. The Caries Balance
  89. 89. The Caries Balancead Bacteriabsence salivaietary habits poor
  90. 90. aliva adequate nti-ad Bacteria microbialbsence saliva luoride ffective dietietary habits poor
  91. 91. ad Bacteria aliva adequatebsence saliva nti- microbialietary habits poor luoride ffective diet
  92. 92. A Caries Risk Assessment (CRA) is just“weighing”  the  factors  of  each  patient.
  93. 93. CAMBRA is just “removing  weight” from one sideand “adding  weight” to the other.
  94. 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. 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. 96. Tools for AssessingCaries
  97. 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. 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. 99. Tools for Detection• Visual Exam with or without Explorer• Radiographs• DIAGNODent• Caries ID• QLF• Spectra• Sopro• CarieScan• The Canary System
  100. 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. 101. White Spots????
  102. 102. Examining a White Spot
  103. 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. 104. Visual Tools for Assessing Caries • DMFT and DMFS • ICDAS • CAMBRA
  105. 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. 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. 107. ICDAS Coding Summary
  108. 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. 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. 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. 111. ICDAS Code Summary http://www.dundee.ac.uk/dhsru/news/icdas.htm 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. 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. 113. Does this look suspicious?
  114. 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. 115. Probing Drives Bacteria & Debris into Fissures
  116. 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. 117. Light Interaction with Teeth •Reflection •Transmission •Absorption •Backscatter Reflection Backscattered of light light from from tooth lesion surface
  118. 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. 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. 120. Radiographs Radiograph unable to locate caries and crack beneath the restoration
  121. 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. 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. 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. 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. 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. 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. 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. 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. 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. 130. Case Study: Caries Beneath an Amalgam 39 60
  131. 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. 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. 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. 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. 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. 136. Remineralization andOther Therapies Minimally Invasive Dentistry
  137. 137. Understanding your choices?
  138. 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. 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. 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. 141. Topical Fluoride The Original Remineralization Agent • Water Fluoridation • Toothpaste • Fluoride Rinse • Fluoride Varnish • Bottled Water
  142. 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. 143. Community Water Fluoridation Canada
  144. 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. 145. Key Canadian Government References onWater Fluoridation• Fluoride Expert Panel 2007• http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride- fluorure/index-eng.php• Water Quality Fluoride in Drinking Water 2009• http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride- fluorure/draft-ebauche-eng.php• Response to Environmental Petition 2008• http://fptdwg.ca/assets/PDF/0804- JointGovernmentofCanadaresponse.pdf
  146. 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. 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. 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. 149. TOPICAL FLUORIDE Toothpaste • Position Statements – Canadian Dental Association – American Academy of Pediatric Dentistry
  150. 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. 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. 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. 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. 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. 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. 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. 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. 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. 159. Applying Fluoride Varnish
  160. 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. 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. 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. 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. 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. 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. 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. 167. Fluorosis – Dean’s  Index
  168. 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. 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. 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. 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. 172. High fluoride toothpaste 5000 ppm
  173. 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. 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. 175. Clinical Trial (preliminary analysis)
  176. 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. 177. Recaldent MI Paste MI Paste Plus Trident Xtra Care Gum Trident White Gum
  178. 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. 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. 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. 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. 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. 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. 184. Remineralization and Other Therapies Antimicrobial treatment (remember the biofilm!) • Xylitol • Povidone iodine • Chlorhexidine • Delmopinol • Triclosan
  185. 185. Remineralization and Other Therapies Xylitol
  186. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 198. www.oralscience.com 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. 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. 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 www.spiffies.com
  201. 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. 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. 203. Remineralization and Other Therapies Povidone Iodine – Betadine -potent antibacterial -safe to swallow -disrupts binding to biofilm
  204. 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. 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. 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. 207. Anti-Bacterial Agents Mechanism of Action: Reduce Bacterial Levels in the Oral Cavity • Prevora • Cervitec • Povidone Iodine • Chlorhexidine Mouth Rinses (Peridex) • Triclosan
  208. 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. 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. 210. Prevora • CHX Varnish originally for root caries • Studies on mother child being analyzed. Report available soon • Efficacy in xerostomia patients
  211. 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. 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. 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. 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. 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. 216. What is the Recipe?
  217. 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. 218. Does Remineralization Work?
  219. 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. 220. Remineralization 5th and 7th Quads
  221. 221. Remineralization CaseSlides courtesy of Dr. Clive Friedman
  222. 222. Remineralization CaseSlides courtesy of Dr. Clive Friedman
  223. 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. 224. Does Remineralization Work? Yes But You need to monitor and motivate your patient
  225. 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. 226. Integration intoClinical Practice
  227. 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. 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. 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. 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. 231. Early ChildhoodCaries
  232. 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. 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. 234. Early Childhood CariesAdvanced Tooth Decayphoto Dr. Joanna Douglass, Smiles for Life
  235. 235. Facial CellulitisInfection spreading into surrounding tissues
  236. 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. 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. 238. Early Childhood Caries Lida et al 2007
  239. 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. 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. 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. 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. 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. 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. 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. 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. 247. Smiles for Life Pocket Cards for Physicians
  248. 248. Smiles for Life Pocket Cards for Physicians
  249. 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. 250. Models of Individual Oral Health PromotionBrickhouse T.H.Virginia Commonwealth Universitypresented at AAPD Symposium October 2009
  251. 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. 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. 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. 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. 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

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