Recent advances in preventive dentistry

ADVANCES INADVANCES IN
PREVENTIVEPREVENTIVE
DENTISTRYDENTISTRY
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CONTENTSCONTENTS
 INTRODUCTIONINTRODUCTION
 MINIMAL INTERVENTIONMINIMAL INTERVENTION
DENTISTRYDENTISTRY
 CARIES VACCINECARIES VACCINE
 TELEDENTISTRYTELEDENTISTRY
 EVIDENCE BASED DENTISTRYEVIDENCE BASED DENTISTRY
 FLUORIDE UPDATEFLUORIDE UPDATE

 COMPUTERSCOMPUTERS
 PROBIOTICSPROBIOTICS
 CHEM0-MECHANICAL REMOVAL OFCHEM0-MECHANICAL REMOVAL OF
CARIESCARIES
 ARREST OF CARIES TECHNIQUEARREST OF CARIES TECHNIQUE
 GENETICSGENETICS
 CONCLUSIONCONCLUSION

 Prevention is derived from the wordPrevention is derived from the word
“PRAEVENTO” it means a forestalling = to“PRAEVENTO” it means a forestalling = to
act before hand; Hinderact before hand; Hinder
 PREVENTION= TO KEEP FROMPREVENTION= TO KEEP FROM
HAPPENING; MAKE IMPOSSIBLE BYHAPPENING; MAKE IMPOSSIBLE BY
PRIOR ACTION; HINDER.PRIOR ACTION; HINDER.

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 Prevention is defined as actions and interventionsPrevention is defined as actions and interventions
designed to identify risks and reduce susceptibilitydesigned to identify risks and reduce susceptibility
or exposure to health threats prior to disease oror exposure to health threats prior to disease or
injury onset, detect and treat diseases in earlyinjury onset, detect and treat diseases in early
stages to arrest progress or recurrence andstages to arrest progress or recurrence and
alleviate the effects of Disease or injury.alleviate the effects of Disease or injury.
 It is the action of stopping something fromIt is the action of stopping something from
happening or making impossible an anticipatedhappening or making impossible an anticipated
event or intended to act.event or intended to act.

OBJECTIVES OF THEOBJECTIVES OF THE
PREVENTIONPREVENTION
 To avert initiation of disease process.To avert initiation of disease process.
 To intercept their progress.To intercept their progress.
 To control their spread.To control their spread.
 To limit their complications and afterTo limit their complications and after
effects.effects.
 To provide rehabilitationTo provide rehabilitation

 WHY PREVENTION IS BETTER THANWHY PREVENTION IS BETTER THAN
CURE?CURE?
 BECAUSEBECAUSE
 ETHICAL: It prevents mental anguish,ETHICAL: It prevents mental anguish,
physical pain and loss of productivityphysical pain and loss of productivity
to the communityto the community
 ECONOMICALECONOMICAL
 CAN BE DONE EVEN FOR LARGERCAN BE DONE EVEN FOR LARGER
POPULATION.POPULATION.
 NO AFTER EFFECTNO AFTER EFFECT

MINIMUMMINIMUM
INTERVENTIONINTERVENTION
DENTISTRYDENTISTRY

 To intervene – to come between, so as toTo intervene – to come between, so as to
prevent or alter the result or course ofprevent or alter the result or course of
events.events.

 The term “minimum intervention” isThe term “minimum intervention” is
relatively new in dentistry and beenrelatively new in dentistry and been
introduced to suggest to the professionintroduced to suggest to the profession
that is time for change in the principlesthat is time for change in the principles
of operative dentistry. The conceptof operative dentistry. The concept
evolved as a consequence of ourevolved as a consequence of our
increased understanding of cariesincreased understanding of caries
process and the development ofprocess and the development of
adhesive restorative materials.adhesive restorative materials.

 It is now recognized that demineralized but non-It is now recognized that demineralized but non-
cavitated enamel and dentin can be healed andcavitated enamel and dentin can be healed and
that the surgical approach to the treatment of athat the surgical approach to the treatment of a
carious lesion along with extension forcarious lesion along with extension for
prevention as proposed by G.V.Black is noprevention as proposed by G.V.Black is no
longer tenable. This adopts a philosophy thatlonger tenable. This adopts a philosophy that
integrates prevention, remineralization andintegrates prevention, remineralization and
minimal intervention for the placement andminimal intervention for the placement and
replacement of the restoration.replacement of the restoration.

EVOLUTION OF THEEVOLUTION OF THE
CONCEPTCONCEPT
 Dental caries has long been recognizedDental caries has long been recognized
as an infectious disease requiring aas an infectious disease requiring a
susceptible host, a cariogenic microflorasusceptible host, a cariogenic microflora
and diet high in refined carbohydrate,and diet high in refined carbohydrate,
causing demineralization of hard tissues ofcausing demineralization of hard tissues of
tooth leading to cavity formation, thetooth leading to cavity formation, the
ultimate symposium of the disease.ultimate symposium of the disease.

 The primary problem encountered in thisThe primary problem encountered in this
disease is control of microflora and secondarydisease is control of microflora and secondary
problem is elimination of cavity and restorationproblem is elimination of cavity and restoration
of crown back to its original forms.of crown back to its original forms.
 Till now there was a lack of understanding of theTill now there was a lack of understanding of the
carious process, in particular potential forcarious process, in particular potential for
remineralization and physical properties ofremineralization and physical properties of
available materials were poor. Hence theavailable materials were poor. Hence the
secondary problem commanded most attention.secondary problem commanded most attention.

 A number of problems arises from Black’s “A number of problems arises from Black’s “
Extension for prevention” approach.Extension for prevention” approach.
 Idiosyncratic caries diagnosisIdiosyncratic caries diagnosis
 Risk factors disregardedRisk factors disregarded
 Need for restoration emphasizedNeed for restoration emphasized
 Aggressive restorative treatment decisionsAggressive restorative treatment decisions
 Cavity preparations dictated by outline formsCavity preparations dictated by outline forms
 Caries not managed as a diseaseCaries not managed as a disease

 Inadequate preventive backupInadequate preventive backup
 Restorations readily failedRestorations readily failed
 Restorations repeatedRestorations repeated
 Cavities increase in sizeCavities increase in size
 Teeth become weakerTeeth become weaker
 Endodontics – prognosis deterioratesEndodontics – prognosis deteriorates
 REPLACEMENT DENTISTRYREPLACEMENT DENTISTRY

 The philosophy of minimum interventionThe philosophy of minimum intervention
dentistry has now arisen as an attempt todentistry has now arisen as an attempt to
combine all the present knowledge ofcombine all the present knowledge of
prevention, remineralization, ionprevention, remineralization, ion
exchange, healing and adhesion with theexchange, healing and adhesion with the
object of reducing carious damage in theobject of reducing carious damage in the
simplest and least invasive manner assimplest and least invasive manner as
possible.possible.

Factors influencing minimallyFactors influencing minimally
invasive dentistryinvasive dentistry
 The demineralization – remineralizationThe demineralization – remineralization
cyclecycle
 Adhesion in restorative dentistryAdhesion in restorative dentistry
 Bio-mimetic restorative materialsBio-mimetic restorative materials

Minimum interventionMinimum intervention
techniquestechniques
 Tunnel preparationTunnel preparation
 Internal restorationInternal restoration
 Preventive resin restorationPreventive resin restoration
 Preventive glass ionomer restorationPreventive glass ionomer restoration
 Pit and fissure sealantsPit and fissure sealants
 LasersLasers
 Air abrasionAir abrasion
 Ozone applicationOzone application
 Atraumatic restorative treatmentAtraumatic restorative treatment

TUNNEL PREPARATIONTUNNEL PREPARATION
 Done in situations like early proximalDone in situations like early proximal
lesions in posterior teeth, below thelesions in posterior teeth, below the
contact area, which causes accumulationcontact area, which causes accumulation
of plaque.of plaque.
 Marginal ridge and contact area is soundMarginal ridge and contact area is sound
 Lesion should be 2.5mm below the crestLesion should be 2.5mm below the crest
of the marginal ridge.of the marginal ridge.

 Access gained through occlusal surface.Access gained through occlusal surface.
Preparation is limited to achieve visibility.Preparation is limited to achieve visibility.
 GIC is recommended as it flows readilyGIC is recommended as it flows readily
and has ability to remineralise bothand has ability to remineralise both
enamel and dentine.enamel and dentine.

Types of tunnelTypes of tunnel
 Internal tunnelInternal tunnel
 Partial tunnelPartial tunnel
 Blind tunnelBlind tunnel
 Class –I tunnelClass –I tunnel

AdvantagesAdvantages
 ConservativeConservative
 Marginal ridge retainedMarginal ridge retained
 Damage to adjacent approximal surfaceDamage to adjacent approximal surface
non-existentnon-existent
 Normal contact area maintainedNormal contact area maintained
 No risk of approximal restorationNo risk of approximal restoration
overhangsoverhangs

INTERNAL RESTORATIONSINTERNAL RESTORATIONS
 These are similar to tunnel preparations.These are similar to tunnel preparations.
Difference is both marginal ridge andDifference is both marginal ridge and
proximal enamel surface are maintained inproximal enamel surface are maintained in
it. Studies suggest that risk of failures areit. Studies suggest that risk of failures are
higher than in tunnel restorations.higher than in tunnel restorations.

PREVENTIVE RESINPREVENTIVE RESIN
RESTORATION(PRR)RESTORATION(PRR)
 It is a conservative treatment that involvesIt is a conservative treatment that involves
limited excavation to remove caries tissue,limited excavation to remove caries tissue,
restoration of excavated area withrestoration of excavated area with
composite resin and application of acomposite resin and application of a
sealant over the surface of restoration andsealant over the surface of restoration and
remaining sound, continuous pits andremaining sound, continuous pits and
fissures.fissures.

IndicationsIndications
 Site – occlusal surface of premolars,Site – occlusal surface of premolars,
molars and primary molarsmolars and primary molars
 No radiographic evidence of proximalNo radiographic evidence of proximal
cariescaries
 Occlusal lesions that can be identifiedOcclusal lesions that can be identified
clinically but not radiographically.clinically but not radiographically.

ArmamentariumArmamentarium
 Excavation should be performed withExcavation should be performed with
small round, pear shaped or round endedsmall round, pear shaped or round ended
bur.bur.
 Width of bur should not exceed 1mmWidth of bur should not exceed 1mm
 If the width of the preparation exceedsIf the width of the preparation exceeds
more than one third of the distancemore than one third of the distance
between buccal and lingual cusp tips,between buccal and lingual cusp tips,
conventional restoration should beconventional restoration should be
planned.planned.

TechniqueTechnique
 AnesthesiaAnesthesia
 IsolationIsolation
 Caries removalCaries removal
 Pulpal protection if necessaryPulpal protection if necessary
 Clean the occlusal surfaceClean the occlusal surface
 Conditioning the entire occlusal surfaceConditioning the entire occlusal surface
 Placement of bonding agentPlacement of bonding agent
 Placing the resin restorationPlacing the resin restoration
 Apply sealantApply sealant
 Equilibrate occlusionEquilibrate occlusion

 Less invasiveLess invasive
 No preconceived cavity designNo preconceived cavity design
 Good success rate over 10 yearsGood success rate over 10 years
 Protective sealing of adjacent pits andProtective sealing of adjacent pits and
fissures.fissures.

 Over the past several years, there hasOver the past several years, there has
been a strong emergence of lasers inbeen a strong emergence of lasers in
the field of dentistry. Lasers are not newthe field of dentistry. Lasers are not new
to the field; in-vitro studies date back toto the field; in-vitro studies date back to
the 1960’s. In 1980’s they saw their firstthe 1960’s. In 1980’s they saw their first
use in clinical practice.use in clinical practice.

 Laser is an acronym for “Light amplification byLaser is an acronym for “Light amplification by
stimulated emission of radiation.”stimulated emission of radiation.”
 Basically, a laser beam is generated when anBasically, a laser beam is generated when an
external power source stimulates a chamber ofexternal power source stimulates a chamber of
laser medium – solid, liquid or gas.laser medium – solid, liquid or gas.
 The resulting spontaneous emission of photonsThe resulting spontaneous emission of photons
resonates between the mirrored ends of theresonates between the mirrored ends of the
laser chamber.laser chamber.
 These bouncing photons further excite otherThese bouncing photons further excite other
atoms in the laser medium. Momentum buildsatoms in the laser medium. Momentum builds
until a highly concentrateduntil a highly concentrated

 Pioneers such as Fischer and Frame in U.K,Pioneers such as Fischer and Frame in U.K,
Picaro and Pick in U.S, Melker in FrancePicaro and Pick in U.S, Melker in France
(initiated hard tissue applications with CO(initiated hard tissue applications with CO22
lasers) laid the foundation for future endeavorslasers) laid the foundation for future endeavors
in this field. When used efficaciously andin this field. When used efficaciously and
ethically lasers are an exceptional modality ofethically lasers are an exceptional modality of
treatment for many clinical conditions thattreatment for many clinical conditions that
dentists or dental specialists treat on a dailydentists or dental specialists treat on a daily
basis. A new era has begun in the use of lasersbasis. A new era has begun in the use of lasers
in dentistry, especially in regard to hard tissuesin dentistry, especially in regard to hard tissues
of the teeth.of the teeth.

 THE RUBY LASER:THE RUBY LASER:
 Dental laser research began in 1963 at theDental laser research began in 1963 at the
University of California at Los Angeles SchoolUniversity of California at Los Angeles School
of Dentistry with the investigations ofof Dentistry with the investigations of
Ralph.H.Stern and Reidar.F.Sognnaes.Ralph.H.Stern and Reidar.F.Sognnaes.
 Development of cratering and glasslike fusionDevelopment of cratering and glasslike fusion
of enamel, and the penetration and charring ofof enamel, and the penetration and charring of
dentin followed a single milli-second pulse ofdentin followed a single milli-second pulse of
the ruby laser at 500-2000J/cmthe ruby laser at 500-2000J/cm22
IncreasedIncreased
resistance to acid penetration into enamelresistance to acid penetration into enamel
suggesting a possible role for the laser insuggesting a possible role for the laser in
caries preventioncaries prevention

 First report of laser exposure to a vital humanFirst report of laser exposure to a vital human
tooth appeared in 1965 when Leon Goldman, atooth appeared in 1965 when Leon Goldman, a
dermatologist applied 2 pulses of a ruby laserdermatologist applied 2 pulses of a ruby laser
to the tooth of his brother, Bernard, who was ato the tooth of his brother, Bernard, who was a
dentist.dentist.
 According to their report the first dental laserAccording to their report the first dental laser
patient experienced no pain with onlypatient experienced no pain with only
superficial damage to the crown.superficial damage to the crown.

COCO22 LASERLASER
 In the United States, Sterne and LobeneIn the United States, Sterne and Lobene
shifted their attention towards COshifted their attention towards CO22 laserlaser
from the 1960’s to early 1980’s.Becausefrom the 1960’s to early 1980’s.Because
of its wavelength of 10.6Mm,it was wellof its wavelength of 10.6Mm,it was well
absorbed by the enamel and was thoughtabsorbed by the enamel and was thought
to be suitable in sealing of pits andto be suitable in sealing of pits and
fissures or the prevention of dental cariesfissures or the prevention of dental caries

 NEODYMIUM LASERNEODYMIUM LASER
 In a series of experiments YamamotoIn a series of experiments Yamamoto
determined that the Nd: YAG laser was andetermined that the Nd: YAG laser was an
effective tool for inhibiting the formation ofeffective tool for inhibiting the formation of
incipient caries both in vivo and invitroincipient caries both in vivo and invitro

 COMBINATION OF ABLATIONCOMBINATION OF ABLATION
AND CARIES PREVENTION.AND CARIES PREVENTION.
 It would be desirable to develop a laserIt would be desirable to develop a laser
that would remove carious tissue initiallythat would remove carious tissue initially
and treat subsequently the walls of theand treat subsequently the walls of the
area where carious tissue is removed toarea where carious tissue is removed to
make them resistant to subsequentmake them resistant to subsequent
carious challenge.carious challenge.
 Fried et al have described a CO2 laserFried et al have described a CO2 laser
that removes carious tissue efficientlythat removes carious tissue efficiently
and can inhibit caries progressionand can inhibit caries progression

 CREATING VALUE FOR LASERCREATING VALUE FOR LASER
DENTISTRY.DENTISTRY.
 The publics’ positive view on lasers and theThe publics’ positive view on lasers and the
dental professions use of lasers create valuedental professions use of lasers create value
for laser dentistry that drives modern laserfor laser dentistry that drives modern laser
practice management.practice management.
   Reduced anxiety / fear of drillReduced anxiety / fear of drill
       Reduced noise from drillReduced noise from drill
     Needle-free or no anesthesia dentistry.Needle-free or no anesthesia dentistry.
       Desensitization of teeth.Desensitization of teeth.
       Less chair-time.Less chair-time.

Faster and better treatmentFaster and better treatment
   Reduced need for sutureReduced need for suture
    New approaches for dental infectionsNew approaches for dental infections
   Requiring less antibiotics Requiring less antibiotics
Regenerative techniques enabling fewerRegenerative techniques enabling fewer
extractionsextractions
     Faster healingFaster healing
Less pain Less pain
Less bleeding and less discomfort.Less bleeding and less discomfort.

AIR ABRASIONAIR ABRASION
 Kinetic energy is used for caries removal.Kinetic energy is used for caries removal.
Narrow powerful stream of movingNarrow powerful stream of moving
aluminium oxide particles are directedaluminium oxide particles are directed
against the surface to be cut. When theyagainst the surface to be cut. When they
hit the tooth, they abrade the surface. Canhit the tooth, they abrade the surface. Can
be used for both diagnosis and treatmentbe used for both diagnosis and treatment
of early occlusal lesions.of early occlusal lesions.

 Decreased noiseDecreased noise
 Reduced vibrationReduced vibration
 Reduced sensitivityReduced sensitivity
 More rounded internal contours – lessMore rounded internal contours – less
fracture.fracture.

OZONE APPLICATIONOZONE APPLICATION
 This is one of methods of minimal toothThis is one of methods of minimal tooth
preparation thereby the maximum toothpreparation thereby the maximum tooth
structure is saved. In this method anstructure is saved. In this method an
oxidant is used which is toxic to cariogenicoxidant is used which is toxic to cariogenic
micro flora, thereby producing colonymicro flora, thereby producing colony
forming units.forming units.

ConceptConcept
 Reduction of colony forming unitsReduction of colony forming units
 Reduction of further demineralisationReduction of further demineralisation
through by – productsthrough by – products
 Reduction of nutrients, necessary forReduction of nutrients, necessary for
bacterial recolonisationbacterial recolonisation
 Promotion of rapid remineralisation andPromotion of rapid remineralisation and
caries arrest.caries arrest.

 Minimal invasive, good patient complianceMinimal invasive, good patient compliance
 Supports rapid remineralisation and cariesSupports rapid remineralisation and caries
arrest.arrest.

DisadvantagesDisadvantages
 More research needed.More research needed.

Clinical procedureClinical procedure
 Cleaning of tooth surfaceCleaning of tooth surface
 Measurement, using laser fluorescentMeasurement, using laser fluorescent
caries diagnosticcaries diagnostic
 Clinical diagnosis (CSI) and treatmentClinical diagnosis (CSI) and treatment
planplan
 Ozone exposureOzone exposure
 Ozone removalOzone removal
 Rinsing with mineral fluidRinsing with mineral fluid
 Recall after 3 months.Recall after 3 months.

ATRAUMATIC RESTORATIVE TREATMENTATRAUMATIC RESTORATIVE TREATMENT
{ART}{ART}
Rationale and techniqueRationale and technique

 IntroductionIntroduction
 Development of ARTDevelopment of ART
 Rationale of ARTRationale of ART
 Principles of ARTPrinciples of ART
 Armamentarium and Technique of ARTArmamentarium and Technique of ART
 Advantages and LimitationsAdvantages and Limitations
 ART—A myth or reality?ART—A myth or reality?
 ConclusionConclusion

Despite long term efforts toDespite long term efforts to use appropriate dentaluse appropriate dental
Equipment for treating dental caries in less developedEquipment for treating dental caries in less developed
countries, the predominant treatment remainscountries, the predominant treatment remains
extraction.extraction.
The need to develop a new approach forThe need to develop a new approach for
oraloral
care in economically was necessary andcare in economically was necessary and
also stressedalso stressed
upon by WHOupon by WHO..

Unfortunately, in most cases the use of importedUnfortunately, in most cases the use of imported
technology astechnology as
a new approach to has proven to be tooa new approach to has proven to be too
complicated forcomplicated for
sustained use.sustained use.
Attempts to further simplify the equipment hasAttempts to further simplify the equipment has
resulted inresulted in
the introduction of airdriven drills and suctionthe introduction of airdriven drills and suction
equipment,equipment,
and simplified operating beds such as those madeand simplified operating beds such as those made

Mobile oral equipment is rarely used to its full capacity inMobile oral equipment is rarely used to its full capacity in
these countries for a number of reasons: vehicles are requiredthese countries for a number of reasons: vehicles are required
to transport the equipment to the outreach situations,to transport the equipment to the outreach situations,
technical skills are required to maintain the equipment, and ittechnical skills are required to maintain the equipment, and it
uses electricity.uses electricity.
All these additional requirements either cannot be met or areAll these additional requirements either cannot be met or are
met unreliably, and present a huge problem of excessive costmet unreliably, and present a huge problem of excessive cost
for communities that cannot afford it.for communities that cannot afford it.

Obviously, a new approach was needed to make oral care moreObviously, a new approach was needed to make oral care more
available for the majority of people in economically lessavailable for the majority of people in economically less
developed countries.developed countries.
The search for a new approach was accelerated by results ofThe search for a new approach was accelerated by results of
oral health research done in the economically developed world.oral health research done in the economically developed world.

This research included the study of:This research included the study of:
(1) The longevity of amalgam restorations in general(1) The longevity of amalgam restorations in general
Practice.Practice.
(2) Adhesive restorative materials (composites and glass(2) Adhesive restorative materials (composites and glass
ionomers), which opened up the possibility of developingionomers), which opened up the possibility of developing
restorative treatment techniques requiring minimal or norestorative treatment techniques requiring minimal or no
cavity preparationcavity preparation

(3) The fate of cariesinducing microorganisms under fillings(3) The fate of cariesinducing microorganisms under fillings
and sealants that showed reduced viability and numbers overand sealants that showed reduced viability and numbers over
time concurrent with arrested carious lesionstime concurrent with arrested carious lesions
(4) The need for complete caries removal, where some evidence(4) The need for complete caries removal, where some evidence
suggested that perhaps caries need not always be removedsuggested that perhaps caries need not always be removed
completely from the deeper parts of the cavity.completely from the deeper parts of the cavity.

These studies and associated caries investigations haveThese studies and associated caries investigations have
provided a better understanding of the dynamics involved inprovided a better understanding of the dynamics involved in
the caries process.the caries process.
As a result, “ Shift has occurred from the traditional approachAs a result, “ Shift has occurred from the traditional approach
of maximal intervention and invasiveness in oral care basedof maximal intervention and invasiveness in oral care based
on Black's principles and the use of amalgam, to the modernon Black's principles and the use of amalgam, to the modern
approach of minimal intervention and invasion, maximalapproach of minimal intervention and invasion, maximal
caries prevention based on retaining sound tooth tissues, andcaries prevention based on retaining sound tooth tissues, and
the use of modem adhesive materials”the use of modem adhesive materials”

In the economically developed world, minimal interventionIn the economically developed world, minimal intervention
and invasive procedures can be carried out using electricallyand invasive procedures can be carried out using electrically
driven equipment. In the economically less developed world,driven equipment. In the economically less developed world,
where sophisticated dental equipment orwhere sophisticated dental equipment or even electricity is noteven electricity is not
always availablealways available, the modern approach for the control of, the modern approach for the control of
dental caries can be performed without this special equipmentdental caries can be performed without this special equipment

The New Approach for ControllingThe New Approach for Controlling Dental CariesDental Caries
ATRAUMATIC RESTORATIVE TREATMENTATRAUMATIC RESTORATIVE TREATMENT
(ART).(ART).
This approach was pioneered and conceptualized inThis approach was pioneered and conceptualized in
Tanzania in the mid1980s as part of a communityTanzania in the mid1980s as part of a community
based primary oral health program by the Universitybased primary oral health program by the University
of Dar es Salaam.of Dar es Salaam.

RATIONALE OF ARTRATIONALE OF ART
ART consists of an elementary technique of caries removalART consists of an elementary technique of caries removal
using hand instruments only, combined with the use of ausing hand instruments only, combined with the use of a
modem restorative material with adhesive characteristics.modem restorative material with adhesive characteristics.
Currently, glass ionomers that leach fluoride and minimize theCurrently, glass ionomers that leach fluoride and minimize the
onset of secondary caries are used.onset of secondary caries are used.

In developed countries, the ART Technique has found a placeIn developed countries, the ART Technique has found a place
in the modern surgery.in the modern surgery.
A patient with multiple carious lesions is treated with theA patient with multiple carious lesions is treated with the
ART Technique and the carious process stabilized before aART Technique and the carious process stabilized before a
more definitive restoration is placed.more definitive restoration is placed.
Dentists have found that this technique is useful for nervousDentists have found that this technique is useful for nervous
patients who are scared of the drill, and restorative procedurespatients who are scared of the drill, and restorative procedures
are accomplished using hand instrumentation only.are accomplished using hand instrumentation only.

ART is also found to be useful in treating patients withART is also found to be useful in treating patients with
medical or physical disability.medical or physical disability.
The procedure may be carried out in the patient's home or inThe procedure may be carried out in the patient's home or in
the hospital.the hospital.
Use of the ART Technique is also useful in introducingUse of the ART Technique is also useful in introducing
children to dental care and helps to overcome any fears ofchildren to dental care and helps to overcome any fears of
traditional dental treatment.traditional dental treatment.

Therefore………Therefore………
The two main principles of ART areThe two main principles of ART are
 Removing carious tooth tissue using hand instruments onlyRemoving carious tooth tissue using hand instruments only
 Restoring the cavity with a glass ionomerRestoring the cavity with a glass ionomer

The often cited disadvantages of glass ionomers, namelyThe often cited disadvantages of glass ionomers, namely lowlow
wear resistance and strength, are minimizedwear resistance and strength, are minimized
because thebecause the
cavity preparations of the ART technique usuallycavity preparations of the ART technique usually
result inresult in
relatively small restorationsrelatively small restorations ..
Furthermore, new glass ionomers with improved wearFurthermore, new glass ionomers with improved wear
resistance and strength are being developed specifically for theresistance and strength are being developed specifically for the
ART technique.ART technique.

What Instruments and MaterialsWhat Instruments and Materials
Are Used ?Are Used ?
The essential instruments for ART are:The essential instruments for ART are:
 Mouth mirror,Mouth mirror,
 Explorer,Explorer,
 Pair of tweezers,Pair of tweezers,
 Dental hatchet,Dental hatchet,
 Small and mediumsized spoonSmall and mediumsized spoon
excavators,excavators,
 Glass slab/ mixing padsGlass slab/ mixing pads
 Spatula,Spatula,
 Carver/applierCarver/applier

MOUTH MIRRORMOUTH MIRROR
This is used to reflect light onto the field of operation, toThis is used to reflect light onto the field of operation, to
view the cavity indirectly, and to retract the cheek or tongueview the cavity indirectly, and to retract the cheek or tongue
as necessaryas necessary..

EXPLOREREXPLORER
This instrument is used to identify where soft cariousThis instrument is used to identify where soft carious
dentine is present. It should not be used to poke into verydentine is present. It should not be used to poke into very
small carious lesions. This may destroy the tooth surface andsmall carious lesions. This may destroy the tooth surface and
the caries arrestment process. It should also not be used forthe caries arrestment process. It should also not be used for
probing into deep cavities where doing so might damage orprobing into deep cavities where doing so might damage or
expose the pulp.expose the pulp.

PAIR OF TWEEZERSPAIR OF TWEEZERS
This instrument is used for carrying cotton wool rolls,This instrument is used for carrying cotton wool rolls,
cotton wool pellets, wedges and articulation papers from thecotton wool pellets, wedges and articulation papers from the
tray to the mouth and back.tray to the mouth and back.

DENTAL HATCHETDENTAL HATCHET
This instrument is used for further widening the entrance toThis instrument is used for further widening the entrance to
the cavity, thus creating better access for the excavator andthe cavity, thus creating better access for the excavator and
for slicing away thin unsupported and carious enamel leftfor slicing away thin unsupported and carious enamel left
after carious dentine has been removed.after carious dentine has been removed.

SPOON EXCAVATOR (S,M,L)SPOON EXCAVATOR (S,M,L)
This instrument is used for removing soft carious dentine.This instrument is used for removing soft carious dentine.
There are 3 sizes:There are 3 sizes:
* small with a diameter of approximately 1.0mm* small with a diameter of approximately 1.0mm
* medium, a diameter of approximately 1.2mm* medium, a diameter of approximately 1.2mm
* large with a diameter of approximately 1.4mm* large with a diameter of approximately 1.4mm

MIXING PAD and SPATULAMIXING PAD and SPATULA
These are necessary for mixing glass ionomer. These items areThese are necessary for mixing glass ionomer. These items are
included with the Fuji IX pack.included with the Fuji IX pack.

APPLIER/CARVERAPPLIER/CARVER
This double ended instrument has 2 functions. The bluntThis double ended instrument has 2 functions. The blunt
end is used for inserting the mixed glass ionomer into theend is used for inserting the mixed glass ionomer into the
cleaned cavity and into pits and fissures. The sharp end iscleaned cavity and into pits and fissures. The sharp end is
designed to remove excess restorative material and to shapedesigned to remove excess restorative material and to shape
the glass ionomer.the glass ionomer.

NEW INSTRUMENT AVAILABLE : ENAMELNEW INSTRUMENT AVAILABLE : ENAMEL
ACCESS CUTTERACCESS CUTTER
This new instrument is designed to assist the clinician inThis new instrument is designed to assist the clinician in
creating access and further widening the entrance to thecreating access and further widening the entrance to the
cavity to facilitate excavation of the carious dentine usingcavity to facilitate excavation of the carious dentine using
the excavators.the excavators.

To improve working visibility, a special light source fixed to aTo improve working visibility, a special light source fixed to a
pair of spectacle frames that is powered by a rechargeablepair of spectacle frames that is powered by a rechargeable
battery source is used.battery source is used.
This unit also permits magnifying glasses to be attached.This unit also permits magnifying glasses to be attached.

The essential materials are:The essential materials are:
 Gloves,Gloves,
 Cotton wool rolls and pellets.Cotton wool rolls and pellets.
 Glass ionomer restorative material (powder/liquid),Glass ionomer restorative material (powder/liquid),
 Dentin conditioner,Dentin conditioner,
 Petroleum jelly (Vaseline),Petroleum jelly (Vaseline),
 Wedges and plastic stripsWedges and plastic strips
 Clean water.Clean water.

Description of the ART TechniqueDescription of the ART Technique As with any other oralAs with any other oral
treatment procedure, ART requires a proper patienttotreatment procedure, ART requires a proper patientto
operator position.operator position.
A number of devices have been developed and one that is veryA number of devices have been developed and one that is very
useful is a lightweight, cushioned headrest attached to theuseful is a lightweight, cushioned headrest attached to the
short end of a table combined with a foldable cushion for theshort end of a table combined with a foldable cushion for the
comfort of the person receiving the treatment.comfort of the person receiving the treatment.

Since its inception, the ART technique has undergone revisionsSince its inception, the ART technique has undergone revisions
aimed at improving the basic technique.aimed at improving the basic technique.
Unlike many other restorative procedures, usually there is noUnlike many other restorative procedures, usually there is no
need to give local anesthesia when using the ART techniqueneed to give local anesthesia when using the ART technique
because temperatureinduced pain from using a drill isbecause temperatureinduced pain from using a drill is
Avoided.Avoided.

Because the technique mainly involves the removal ofBecause the technique mainly involves the removal of
decalcified tooth tissue, pain can be minimized, and oftendecalcified tooth tissue, pain can be minimized, and often
does not occur at all.does not occur at all.
Thus, fear of dental procedures is reducedThus, fear of dental procedures is reduced..

THE STEPS OF ARTTHE STEPS OF ART
1.1. Isolate the tooth with cotton wool rolls.Isolate the tooth with cotton wool rolls. OnlyOnly
the tooth orthe tooth or
teeth to be treated need to be isolated.teeth to be treated need to be isolated.
Rationale:Rationale: It is easier to work in a dry environment than in aIt is easier to work in a dry environment than in a
wet one.wet one.
2.2. Clean the tooth surfaceClean the tooth surface toto be treated with a wetbe treated with a wet
cottoncotton
wool pellet.wool pellet. Have a small cup of water available.Have a small cup of water available.
Rationale: TheRationale: The wet cotton wool pellet removes the debris andwet cotton wool pellet removes the debris and
Plaque from the surface thus improving visibility.Plaque from the surface thus improving visibility.
The extent of the lesion and any unsupported enamel can beThe extent of the lesion and any unsupported enamel can be

3.Widen the entrance of the lesion:3.Widen the entrance of the lesion:
It is necessary if the entrance of the lesion is small.It is necessary if the entrance of the lesion is small.
Rationale: The Hatchet replaces the bur. ByRationale: The Hatchet replaces the bur. By
rotating therotating the
instrument tip ,unsupported enamel will breakinstrument tip ,unsupported enamel will break
off.off.

4.Remove the caries:4.Remove the caries:
Depending on the size of the cavity,the size of the excavator isDepending on the size of the cavity,the size of the excavator is
chosen.Using circular scraping movements of the excavatorchosen.Using circular scraping movements of the excavator
the soft caries is removed.the soft caries is removed.
Rationale: When all the soft caries is removed, theRationale: When all the soft caries is removed, the
thinthin
decalcified unsupported enamel is relatively easydecalcified unsupported enamel is relatively easy
to break off.to break off.

5.Provide pulpal protection if necessary:5.Provide pulpal protection if necessary:
It is indicated for deep cavities that are relatively close toIt is indicated for deep cavities that are relatively close to
pulp. This can achieved by using Calcium Hydroxide pastepulp. This can achieved by using Calcium Hydroxide paste
to the deeper parts of the floor of the cavity.to the deeper parts of the floor of the cavity.
The cavity floor does not need to be covered completelyThe cavity floor does not need to be covered completely
because it will reduce the area available for adhesion of thebecause it will reduce the area available for adhesion of the
filling material.filling material.
Rationale:Rationale: Calcium hydroxide stimulates repair ofCalcium hydroxide stimulates repair of
dentin anddentin and
glass ionomers are biocompatible.glass ionomers are biocompatible.

6.Clean the occlusal surface:6.Clean the occlusal surface: All pits and fissures should beAll pits and fissures should be
clear of plaque and debris as much as possible.clear of plaque and debris as much as possible.
Use a probe and a wet pellet for cleaning.Use a probe and a wet pellet for cleaning.
Rationale:Rationale: The remaining pits and fissures will beThe remaining pits and fissures will be
sealed withsealed with
the same material used for filling the cavity.the same material used for filling the cavity.

7. Condition the cavity and occlusal surface:7. Condition the cavity and occlusal surface:
Use a drop of dentin conditioner on a cotton wool pellet andUse a drop of dentin conditioner on a cotton wool pellet and
rub both the cavity and the occlusal surfaces for 10 to 15rub both the cavity and the occlusal surfaces for 10 to 15
seconds.seconds.
The conditioned surfaces should then be washed several timesThe conditioned surfaces should then be washed several times
with wet cotton wool pellets.with wet cotton wool pellets.
The surfaces are then dried with dry pellets.The surfaces are then dried with dry pellets.
Rationale:Rationale: Conditioning increases the bondConditioning increases the bond
strength of glassstrength of glass
ionomers.ionomers.

8. Mix glass ionomer according8. Mix glass ionomer according toto manufacturers' instructions.manufacturers' instructions.
9. Insert mixed glass ionomer into the cavity and overfill9. Insert mixed glass ionomer into the cavity and overfill
slightly.slightly. The mixed material is inserted using the flat end ofThe mixed material is inserted using the flat end of
the applier, and plugged into corners of the cavity with thethe applier, and plugged into corners of the cavity with the
smooth side of an excavator or with a ball burnisher.smooth side of an excavator or with a ball burnisher.
Avoid the inclusion of air bubbles.Avoid the inclusion of air bubbles.
The material also is placed over pits and fissures in smallThe material also is placed over pits and fissures in small
amounts.amounts.

10. Press coated gloved finger on top of the entire occlusal10. Press coated gloved finger on top of the entire occlusal
surface and apply slight pressure.surface and apply slight pressure.
Petroleum jelly (Vaseline) is used to coat the gloved finger toPetroleum jelly (Vaseline) is used to coat the gloved finger to
prevent the glass ionomer from sticking to the glove.prevent the glass ionomer from sticking to the glove.
Place the finger on top of the mixture, apply slight pressure forPlace the finger on top of the mixture, apply slight pressure for
a few seconds, and remove the finger.a few seconds, and remove the finger.
Rationale:Rationale: The finger pressure should push theThe finger pressure should push the
glass ionomerglass ionomer
into the deeper parts of the pits and fissures. Anyinto the deeper parts of the pits and fissures. Any
excessexcess
Material will overflow and can be removed easily.Material will overflow and can be removed easily.

11. Check the bite.11. Check the bite.
Place articulating paper over the filling /Place articulating paper over the filling /
sealant and ask the patient to close.sealant and ask the patient to close.
The petroleum jelly (Vaseline) left on the surface will preventThe petroleum jelly (Vaseline) left on the surface will prevent
saliva contact with the filling/ sealant while the bite issaliva contact with the filling/ sealant while the bite is
checked.checked.

12. Remove excess material with the carver.12. Remove excess material with the carver.
13. Recheck the bite and adjust the height of the restoration13. Recheck the bite and adjust the height of the restoration
until comfortable.until comfortable.
14. Cover filling/sealant with petroleum jelly (Vaseline) once14. Cover filling/sealant with petroleum jelly (Vaseline) once
againagain oror apply varnish.apply varnish.
15. Instruct the patient not15. Instruct the patient not toto eat for at least one hour.eat for at least one hour.
For restoring proximal cavities, a plastic strip and wedgesFor restoring proximal cavities, a plastic strip and wedges
are used to produce a correct contour to the filling.are used to produce a correct contour to the filling.

What are the advantages and limitations ART ?What are the advantages and limitations ART ?
 

The ADVANTAGES include:The ADVANTAGES include:
 The use of easily available and relatively inexpensive handThe use of easily available and relatively inexpensive hand
instruments rather than expensive electrically driven dentalinstruments rather than expensive electrically driven dental
Equipment.Equipment.
 A biologically friendly approach involving the removal ofA biologically friendly approach involving the removal of
only decalcified tooth tissues, which results in relativelyonly decalcified tooth tissues, which results in relatively
small cavities and conserves sound tooth tissue.small cavities and conserves sound tooth tissue.

 the limitation of pain, thereby minimizing the need for localthe limitation of pain, thereby minimizing the need for local
anesthesia.anesthesia.
 A straightforward and simple infection control practiceA straightforward and simple infection control practice
without the need to use sequentially autoclaved hand pieces.without the need to use sequentially autoclaved hand pieces.
 The chemical adhesion of glass ionomers that reduces theThe chemical adhesion of glass ionomers that reduces the
need to cut sound tooth tissue for retention of the restorativeneed to cut sound tooth tissue for retention of the restorative
Material.Material.

 The leaching of fluoride from glass ionomers, which preventsThe leaching of fluoride from glass ionomers, which prevents
secondary caries development and probably remineralizessecondary caries development and probably remineralizes
carious dentin.carious dentin.
 · The combination of a preventive and curative treatment in· The combination of a preventive and curative treatment in
one procedure.one procedure.
 The ease of repairing defects in the restoration;The ease of repairing defects in the restoration;

One of the greatest advantages of ART cited is that itOne of the greatest advantages of ART cited is that it makesmakes
it possible to reach people who otherwise neverit possible to reach people who otherwise never
would havewould have
received any oral care.received any oral care.
The technique allows oral care workers to leave the clinic andThe technique allows oral care workers to leave the clinic and
to visit people in their own living environments, e.g., in seniorto visit people in their own living environments, e.g., in senior
citizen homes, institutions for the handicapped, villages incitizen homes, institutions for the handicapped, villages in
rural and suburban areas in economically less developedrural and suburban areas in economically less developed
countries, and in their own homes.countries, and in their own homes.
From a health point of view, these possibilities must beFrom a health point of view, these possibilities must be
considered a huge advantage.considered a huge advantage.

Limitations of ART…Limitations of ART…
 longterm survival rates for glass ionomer ART restorationslongterm survival rates for glass ionomer ART restorations
and sealants are not yet available.and sealants are not yet available.
 The technique's acceptance by oral health care personnel isThe technique's acceptance by oral health care personnel is
not yet assured.not yet assured.
 At the moment its use is limited to small and mediumAt the moment its use is limited to small and medium
sized, onesurface lesions because of the low wear resistancesized, onesurface lesions because of the low wear resistance
and strength of existing glass ionomer materialsand strength of existing glass ionomer materials..

 The possibility exists for hand fatigue from the use of handThe possibility exists for hand fatigue from the use of hand
instruments over long periods.instruments over long periods.
 Hand mixing might produce a relatively unstandardizedHand mixing might produce a relatively unstandardized
mix of glass ionomer, varying among operators and differentmix of glass ionomer, varying among operators and different
geographical climatic situations.geographical climatic situations.

 ·· The misapprehension that ART can be performed easilyThe misapprehension that ART can be performed easily
this is not the case and each step must be carried out tothis is not the case and each step must be carried out to
Perfection.Perfection.
 · The apparent lack of sophistication of the technique,· The apparent lack of sophistication of the technique,
which might make it difficult for ART to be easily accepted bywhich might make it difficult for ART to be easily accepted by
the dental profession.the dental profession.
 · A misconception by the public that the new glass ionomer· A misconception by the public that the new glass ionomer
"white fillings" are only temporary dressings."white fillings" are only temporary dressings.

Some of these disadvantages of glass ionomers, such as lowSome of these disadvantages of glass ionomers, such as low
wear resistance and reduced strength, are being consideredwear resistance and reduced strength, are being considered
andand reinforced materials being under research forreinforced materials being under research for
useuse..
When improved materials become available, larger onesurfaceWhen improved materials become available, larger onesurface
and small to mediumsized multisurface lesions might alsoand small to mediumsized multisurface lesions might also
bebe
managed with the ART technique.managed with the ART technique.
Also, the variation in mixtures of handmixed glass ionomerAlso, the variation in mixtures of handmixed glass ionomer
can be reduced bycan be reduced by making the materials more usermaking the materials more user
friendly, afriendly, a
particularly important factor in the economicallyparticularly important factor in the economically

Till date studies have been done to assess the life of ARTTill date studies have been done to assess the life of ART
restorations to a maximum of 3 years only.restorations to a maximum of 3 years only.
A study done by NATY LOPEZ and SARAA study done by NATY LOPEZ and SARA
SIMPSERAFLIN on the retentivity of ART restorationsSIMPSERAFLIN on the retentivity of ART restorations
among the underserved population in Mexico yielded theamong the underserved population in Mexico yielded the
following results….following results….

Is ART a Myth or Reality?Is ART a Myth or Reality?
The removal of caries by hand instruments alone is by noThe removal of caries by hand instruments alone is by no
means a new approach since over the years dentists have usedmeans a new approach since over the years dentists have used
hand instruments when they considered it necessary or whenhand instruments when they considered it necessary or when
they could not use other dental equipment.they could not use other dental equipment.
The ART technique, however, differs in concept from previousThe ART technique, however, differs in concept from previous
treatment.treatment.

Instead of filling excavated cavities with a temporary fillingInstead of filling excavated cavities with a temporary filling
material that later needs to be replaced with permanentmaterial that later needs to be replaced with permanent
restoration, a chemically bonding material is used.restoration, a chemically bonding material is used.
““Furthermore, the minimal cavity preparationFurthermore, the minimal cavity preparation
resulting fromresulting from
the use of hand instruments is in line with modemthe use of hand instruments is in line with modem
concepts forconcepts for
a biologic cavity preparationa biologic cavity preparation .”.”

CONCLUSIONCONCLUSION
The greater part of the world's population has no access toThe greater part of the world's population has no access to
restorative dental care.restorative dental care.
One of the main obstacles is the traditionalOne of the main obstacles is the traditional
manner of treatingmanner of treating
caries, which relies on electrically drivencaries, which relies on electrically driven
equipment.equipment.
The basic concepts of the ART technique are the removal ofThe basic concepts of the ART technique are the removal of
decalcified dental tissues using only readily available handdecalcified dental tissues using only readily available hand
instruments, following the modern concepts of cavityinstruments, following the modern concepts of cavity
preparation, and the use of a high technology adhesivepreparation, and the use of a high technology adhesive
restorative material.restorative material. This technique has the potentialThis technique has the potential
to maketo make

References:References:
1.1. Jo E Frencken,Taco pilot et al;ART-Jo E Frencken,Taco pilot et al;ART-
rationale and development:Journal Ofrationale and development:Journal Of
Public health Dentistry(JPHD) Vol 56 no.3Public health Dentistry(JPHD) Vol 56 no.3
19961996
2.2. Jo Frencken,Prathip Phantumavit; ManualJo Frencken,Prathip Phantumavit; Manual
of ART-WHO series 1997of ART-WHO series 1997
3. Naty lopez and saraSimpseraflin;3. Naty lopez and saraSimpseraflin;
Atraumatic restorative treatment forAtraumatic restorative treatment for
prevention and treatment of caries in anprevention and treatment of caries in an
underserved community.underserved community.
American Journal of Public health AUGAmerican Journal of Public health AUG
2005vol 90 page 8-132005vol 90 page 8-13

4.www.googlesearch/mit/oralheathpubli.html4.www.googlesearch/mit/oralheathpubli.html
5.www.gcfuji-asia.org5.www.gcfuji-asia.org

INDEXINDEX
 INTRODUCTIONINTRODUCTION
 HISTORY OF CARIES VACCINATIONHISTORY OF CARIES VACCINATION
 ACQUISITION OF MUTANS STREPTOCOCCIACQUISITION OF MUTANS STREPTOCOCCI
 ONTOGENY OF IMMUNITY IN SALIVAONTOGENY OF IMMUNITY IN SALIVA
 MOLECULAR PATHOGENESISMOLECULAR PATHOGENESIS
 EFFECTIVE MOLECULAR TARGETSEFFECTIVE MOLECULAR TARGETS
 SUBUNIT VACCINESSUBUNIT VACCINES
 CONJUGATE VACCINESCONJUGATE VACCINES
 ADJUVANTS AND DELIVERY SYSTEMS FORADJUVANTS AND DELIVERY SYSTEMS FOR
DENTAL CARIES VACCINESDENTAL CARIES VACCINES

Dental Caries, an InfectiousDental Caries, an Infectious
DiseaseDisease
 DDental caries remains one of most widespread diseases ofental caries remains one of most widespread diseases of
mankind.mankind.
 Advances in prophylactic measures to deal with thisAdvances in prophylactic measures to deal with this
disease have significantly reduced overall caries rate in US.disease have significantly reduced overall caries rate in US.
 However, Surgeon General’s 2000 report on Oral Health inHowever, Surgeon General’s 2000 report on Oral Health in
America stated that majority of 5 to 9 year old US childrenAmerica stated that majority of 5 to 9 year old US children
have at least one lesion on crowns of their teeth.have at least one lesion on crowns of their teeth.
 This % increases to 84.7% in adults who are at least 18This % increases to 84.7% in adults who are at least 18
years of age.years of age.

 Nearly 50% of elder population have root-surface caries.Nearly 50% of elder population have root-surface caries.
 Being poor is clearly risk factor for increased decay.Being poor is clearly risk factor for increased decay.
 This high caries rate continues among less economicallyThis high caries rate continues among less economically
advantaged.advantaged.
 Thus, more effective public health measures are neededThus, more effective public health measures are needed
to address this worldwide problem.to address this worldwide problem.
 Vaccines are particularly well suited for public healthVaccines are particularly well suited for public health
applications, especially in environments that do not lendapplications, especially in environments that do not lend
themselves to regular health carethemselves to regular health care

HISTORYHISTORY
 Great strides are made in understanding dental cariesGreat strides are made in understanding dental caries
etiology.etiology.
 Infection as key component was uncovered more than 110Infection as key component was uncovered more than 110
years ago by Miller who made link among microorganisms,years ago by Miller who made link among microorganisms,
dietary carbohydrates, & dental disease.dietary carbohydrates, & dental disease.
 Early in last century Clarke isolated Streptococcus mutans,Early in last century Clarke isolated Streptococcus mutans,
upon which modern dental research has cast its brightestupon which modern dental research has cast its brightest
light.light.
 In latter half of 20th century, research efforts at NIH & inIn latter half of 20th century, research efforts at NIH & in
Scandinavia confirmed cariogenic properties of thisScandinavia confirmed cariogenic properties of this
organism, demonstrated its transmissibility, &organism, demonstrated its transmissibility, &

described its worldwide distribution.described its worldwide distribution.
 Later, others identified many of its virulenceLater, others identified many of its virulence
characteristics & unraveled its biochemistrycharacteristics & unraveled its biochemistry..
 Ultimately, complete genome sequence of S. mutans wasUltimately, complete genome sequence of S. mutans was
reported in 2002.reported in 2002.
 Although molecular biological & cultural techniques haveAlthough molecular biological & cultural techniques have
also incriminated other bacteria in process, S. mutansalso incriminated other bacteria in process, S. mutans
continues to be Public Enemy #1, especially for earlycontinues to be Public Enemy #1, especially for early
childhood dental disease.childhood dental disease.

 Concept of vaccination against caries has existed almostConcept of vaccination against caries has existed almost
from time that this disease was recognized to result fromfrom time that this disease was recognized to result from
colonization of teeth by acidogenic bacteria, even thoughcolonization of teeth by acidogenic bacteria, even though
etiological agents were originally thought to beetiological agents were originally thought to be
lactobacilli.lactobacilli.
 Given general appreciation for infectious component ofGiven general appreciation for infectious component of
dental caries, injected vaccines containing lactobacillidental caries, injected vaccines containing lactobacilli
were administered with limited success in the 1940s.were administered with limited success in the 1940s.
 However, at that time molecular pathogenesis of S.However, at that time molecular pathogenesis of S.
mutans was unknown, nor was there an understanding ofmutans was unknown, nor was there an understanding of
immune mechanisms that operate in oral cavity.immune mechanisms that operate in oral cavity.

 Most virulence characteristics were unclear, withMost virulence characteristics were unclear, with
exception of ability of cariogenic bacteria to produceexception of ability of cariogenic bacteria to produce
enamel-dissolving acid.enamel-dissolving acid.
 Modern era of vaccine therapy began in late 1960sModern era of vaccine therapy began in late 1960s
with William Bowen’s use of S. Mutans towith William Bowen’s use of S. Mutans to
intravenously immunize irus monkeys.intravenously immunize irus monkeys.
 Today we have answered many of these questions,Today we have answered many of these questions,
permitting us to more knowledgeably explorepermitting us to more knowledgeably explore
potential for vaccine therapy for dental cariespotential for vaccine therapy for dental caries
associated with S. mutans.associated with S. mutans.

Acquisition of MutansAcquisition of Mutans
StreptococciStreptococci
 Landmark experiments in 1960s (reviewed in Gibbons & vanLandmark experiments in 1960s (reviewed in Gibbons & van
Houte, 1975; Loesche, 1986) established that mutansHoute, 1975; Loesche, 1986) established that mutans
streptococci are primary etiologic agents of this disease &streptococci are primary etiologic agents of this disease &
that infection is transmissible.that infection is transmissible.
 Strong association exists b/n level of colonization with mutansStrong association exists b/n level of colonization with mutans
streptococci & caries, although other organisms, such asstreptococci & caries, although other organisms, such as
lactobacilli, have also been implicated in this disease.lactobacilli, have also been implicated in this disease.

 Under normal circumstances of diet & challenge, childrenUnder normal circumstances of diet & challenge, children
become permanently colonized with mutans streptococcibecome permanently colonized with mutans streptococci
between middle of 2between middle of 2ndnd
year & end of 3year & end of 3rdrd
year of life, duringyear of life, during
a so-calleda so-called “window of infectivity”“window of infectivity”
 Many studies have shown that primary source of infectionMany studies have shown that primary source of infection
is maternal, although there is recent evidence to suggestis maternal, although there is recent evidence to suggest
that non-familial transfer can occur when environmentalthat non-familial transfer can occur when environmental
conditions favor colonizationconditions favor colonization

 Infection is related to maternal dose (Kohler etInfection is related to maternal dose (Kohler et
al., 1984; Caufield et al., 1993), in that higheral., 1984; Caufield et al., 1993), in that higher
level of maternal mutans streptococcallevel of maternal mutans streptococcal
infection, higher % of children who becomeinfection, higher % of children who become
infected.infected.
 If environment strongly favors mutansIf environment strongly favors mutans
colonization —for Ex, if high maternal infectioncolonization —for Ex, if high maternal infection
levels are combined with high dietary sucroselevels are combined with high dietary sucrose
levels—this so-called “window of infection”levels—this so-called “window of infection”
shifts to an earlier age.shifts to an earlier age.

 Many have also suggested that mutansMany have also suggested that mutans
streptococci can be found in oral cavity duringstreptococci can be found in oral cavity during
11STST
year of life, especially in caries proneyear of life, especially in caries prone
populationspopulations
 However, despite influence of maternal dose,However, despite influence of maternal dose,
children who do not become infected by # 3children who do not become infected by # 3
years of age appear to remain uninfected, oryears of age appear to remain uninfected, or
minimally colonized for several years , possiblyminimally colonized for several years , possibly
until new opportunities for colonization occuruntil new opportunities for colonization occur
upon eruption secondary dentition.upon eruption secondary dentition.

 This suggests that longer-term benefit couldThis suggests that longer-term benefit could
ensue if mutans streptococcal colonization couldensue if mutans streptococcal colonization could
be impeded in early childhood by measuresbe impeded in early childhood by measures
such as immunization. such as immunization.

Ontogeny of Immunity in SalivaOntogeny of Immunity in Saliva
 Immunological interception of initial attempts ofImmunological interception of initial attempts of
mutans streptococci to colonize tooth surfacemutans streptococci to colonize tooth surface
would seem to be preferred vaccine strategywould seem to be preferred vaccine strategy
since these organisms are exceedingly difficult tosince these organisms are exceedingly difficult to
displace once they become part of dental biofilm.displace once they become part of dental biofilm.
 Given natural history of mutans streptococcalGiven natural history of mutans streptococcal
infection, this strategy would require year oldinfection, this strategy would require year old
children to be sufficiently mature immunologicallychildren to be sufficiently mature immunologically
to form protective levels of antibody in their oralto form protective levels of antibody in their oral
cavity at this time.cavity at this time.

 Secretory IgA (SIgA)Secretory IgA (SIgA) is principal immuneis principal immune
component of major & minor gland salivarycomponent of major & minor gland salivary
secretions & thus would be considered to besecretions & thus would be considered to be
primary mediator of immunity.primary mediator of immunity.
 Although SIgA antibody in saliva & other secretionsAlthough SIgA antibody in saliva & other secretions
is essentially absent at birth, mature SIgA—is essentially absent at birth, mature SIgA— isis
principal salivary immunoglobulin secreted by 1principal salivary immunoglobulin secreted by 1
month of age.month of age.
 Induced by Environmental antigenic challenge,Induced by Environmental antigenic challenge,
mucosal IgA antibody to pioneer oral microbiotamucosal IgA antibody to pioneer oral microbiota
appears in secretions within weeks of initialappears in secretions within weeks of initial
microbial exposure.microbial exposure.

 By 6 to 9 months of age most children exhibit anBy 6 to 9 months of age most children exhibit an
adult like distribution of salivary IgA subclasses,adult like distribution of salivary IgA subclasses,
which include antibody to several antigens ofwhich include antibody to several antigens of
predominant pioneer oral flora.predominant pioneer oral flora.
Can children respond to natural exposure toCan children respond to natural exposure to
mutans streptococcimutans streptococci ??
 The answer is yesThe answer is yes
 Salivary antibody to mutans streptococcalSalivary antibody to mutans streptococcal
antigens is usually 1antigens is usually 1STST
observed inobserved in 22ndnd
& 3& 3rdrd
years of life.years of life.
 Salivary responses are often directed to thoseSalivary responses are often directed to those
streptococcal components that are important instreptococcal components that are important in
colonization & accumulation, such ascolonization & accumulation, such as antigenantigen

 Most children apparently respondMost children apparently respond
immunologically to transient infection or ongoingimmunologically to transient infection or ongoing
colonization with mutans streptococci in earlycolonization with mutans streptococci in early
childhood.childhood.
 Although distribution & specificity of children’sAlthough distribution & specificity of children’s
responses are not identical, antibody to a fewresponses are not identical, antibody to a few
major antigens predominates.major antigens predominates.
 These data suggest possibility that suchThese data suggest possibility that such
responses could be protective if induced prior toresponses could be protective if induced prior to
critical colonization events.critical colonization events.

MOLECULAR PATHOGENESISMOLECULAR PATHOGENESIS
 Thirty years ago British & American scientistsThirty years ago British & American scientists
demonstrated that experimental protectiondemonstrated that experimental protection
could be achieved by immunization with mutanscould be achieved by immunization with mutans
streptococci (reviewed by Michalek andstreptococci (reviewed by Michalek and
Childers7).Childers7).
 Attention then focused on immunologicallyAttention then focused on immunologically
intercepting properties of these organisms thatintercepting properties of these organisms that
led to disease.led to disease.
 Molecular pathogenesis of mutans streptococciMolecular pathogenesis of mutans streptococci
involves several phases, each of which offersinvolves several phases, each of which offers
targets for immunological intervention.targets for immunological intervention.

 Initial attachment to toothInitial attachment to tooth
occurs by interaction ofoccurs by interaction of
bacterial proteins i.ebacterial proteins i.e
adhesins with lectins inadhesins with lectins in
dental pellicle coveringdental pellicle covering
tooth surface.tooth surface.
 These bacterial adhesins,These bacterial adhesins,
first described by Russell &first described by Russell &
Lehner is referred asLehner is referred as
antigen I/II.antigen I/II.
 Bacterial adhesins binds toBacterial adhesins binds to
glycoproteins found inglycoproteins found in
salivary pellicles that coatsalivary pellicles that coat
tooth surfacetooth surface

 In presence ofIn presence of
dietary sucrose,GTFsdietary sucrose,GTFs
synthesizesynthesize
extracellularextracellular
glucans.glucans.
 glucans provideglucans provide
scaffolding forscaffolding for
aggregation of mutansaggregation of mutans
through interactionthrough interaction
with bacterial cell-with bacterial cell-
associated glucan-associated glucan-
binding proteins .binding proteins .
 GTFs also containGTFs also contain
glucan-bindingglucan-binding
domains.domains.
• Interactions of glucans with GTFs & GBPs combine to cause
extensive accumulation of mutans streptococci .

 Theoretically, next phase of pathogenesisTheoretically, next phase of pathogenesis
results from metabolic activities of theseresults from metabolic activities of these
masses of accumulated mutans streptococci.masses of accumulated mutans streptococci.
 Mutans streptococci are most prolificMutans streptococci are most prolific
producers of lactic acid in theseproducers of lactic acid in these
accumulations although other “low pHaccumulations although other “low pH
bacteria” may also contribute.bacteria” may also contribute.
 Dental caries ultimately ensues becauseDental caries ultimately ensues because
resulting increase in lactic acidresulting increase in lactic acid
concentration cannot be sufficiently bufferedconcentration cannot be sufficiently buffered
to prevent enamel dissolution.to prevent enamel dissolution.

Effective Molecular Targets forEffective Molecular Targets for
Dental Caries VaccinesDental Caries Vaccines
Several stages in molecular pathogenesis of dentalSeveral stages in molecular pathogenesis of dental
caries are susceptible to immune intervention.caries are susceptible to immune intervention.
1.1. Microorganisms can be cleared from oral cavityMicroorganisms can be cleared from oral cavity
while still in salivary phase by antibody-mediatedwhile still in salivary phase by antibody-mediated
aggregation.aggregation.
2.2. Antibody could also block receptors necessary forAntibody could also block receptors necessary for
- colonization (e.g., adhesins)/- colonization (e.g., adhesins)/
- accumulation (GTF)- accumulation (GTF)
3. Immune inactivation of GTF enzymes - prevent3. Immune inactivation of GTF enzymes - prevent
formation of glucan matrix.formation of glucan matrix.

 Most of recent experimental effortMost of recent experimental effort hashas
been directed towardbeen directed toward
1.1. ADHESINS,ADHESINS,
2.2. GTFSGTFS
asas vaccine targets.vaccine targets.

ROUTES TO PROTECTIVE RESPONSESROUTES TO PROTECTIVE RESPONSES
 Mucosal applications of caries vaccines areMucosal applications of caries vaccines are
generallygenerally preferred for induction of secretory IgApreferred for induction of secretory IgA
antibody in salivary compartment, since this Igantibody in salivary compartment, since this Ig
constitutesconstitutes major immune component of major &major immune component of major &
minor salivary glandminor salivary gland secretions.secretions.
 Many investigators have shown that exposure ofMany investigators have shown that exposure of
antigenantigen to mucosally associated lymphoid tissueto mucosally associated lymphoid tissue
in gut, nasal, bronchial,in gut, nasal, bronchial, or rectal site can give riseor rectal site can give rise
to immune responses not only in region ofto immune responses not only in region of
induction, but also in remote locations.induction, but also in remote locations.

 ThisThis has given rise to the notion of "commonhas given rise to the notion of "common
mucosal immune system"mucosal immune system"
 Consequently, several mucosal routes haveConsequently, several mucosal routes have
been used to induce protective immunebeen used to induce protective immune
responses to dental cariesresponses to dental caries vaccine antigens.vaccine antigens.

(A) ORAL(A) ORAL
 Many of earlier studies relied on oralMany of earlier studies relied on oral
induction of immunityinduction of immunity in gut-associatedin gut-associated
lymphoid tissues (GALT) to elicit protectivelymphoid tissues (GALT) to elicit protective
salivary IgA antibody responses.salivary IgA antibody responses.
 In these studies, antigen wasIn these studies, antigen was applied byapplied by
oral feeding, gastric intubation, or inoral feeding, gastric intubation, or in
vaccine-containingvaccine-containing capsules or liposomes.capsules or liposomes.

 Although oral route was not idealAlthough oral route was not ideal {{
for reasonsfor reasons
including detrimental effects of stomach acidityincluding detrimental effects of stomach acidity onon
antigen, or inductive sites were relatively distant,}antigen, or inductive sites were relatively distant,}
experiments with this route established that itexperiments with this route established that it
was sufficient to change course of mutanswas sufficient to change course of mutans
streptococcal infection & disease in animalstreptococcal infection & disease in animal
models (Michalek et al., 1976;models (Michalek et al., 1976; Smith et al., 1979)Smith et al., 1979)
and humans (Smith and Taubman, 1987).and humans (Smith and Taubman, 1987).

B) INTRANASALB) INTRANASAL
 More recently, attempts have been made toMore recently, attempts have been made to
induce protectiveinduce protective immunity in mucosal inductiveimmunity in mucosal inductive
sites that are in closer anatomicalsites that are in closer anatomical relationship torelationship to
oral cavity.oral cavity.
 Intranasal installation ofIntranasal installation of antigen, which targetsantigen, which targets
nasal-associated lymphoid tissuenasal-associated lymphoid tissue (NALT)(NALT)
(Brandtzaeg and Haneberg, 1997), has been(Brandtzaeg and Haneberg, 1997), has been
used to induceused to induce immunity to many bacterialimmunity to many bacterial
antigens, including those associatedantigens, including those associated with mutanswith mutans
streptococcal colonization & accumulation.streptococcal colonization & accumulation.
 ProtectiveProtective immunity after infection withimmunity after infection with
cariogeniccariogenic

(C) TONSILLAR(C) TONSILLAR
 Ability of tonsillar application of antigen toAbility of tonsillar application of antigen to
induce immuneinduce immune responses in oral cavity is ofresponses in oral cavity is of
great interest.great interest.
 TonsillarTonsillar tissue contains required elements oftissue contains required elements of
immune induction ofimmune induction of secretory IgA responsessecretory IgA responses
(van Kempen et al., 2000).(van Kempen et al., 2000).
 Nonetheless, palatineNonetheless, palatine tonsils, & especiallytonsils, & especially
nasopharyngeal tonsils, have beennasopharyngeal tonsils, have been suggested tosuggested to
contribute precursor cells to mucosal effectorcontribute precursor cells to mucosal effector
sites , such as salivary glands.sites , such as salivary glands.

(D) MINOR SALIVARY GLAND(D) MINOR SALIVARY GLAND
 The minor salivary glands populate lips,The minor salivary glands populate lips,
cheeks, & softcheeks, & soft palate.palate.
 These glands have been suggested asThese glands have been suggested as
potential routespotential routes for mucosal induction offor mucosal induction of
salivary immune responses Experiments insalivary immune responses Experiments in
which S. sobrinus GTF was topicallywhich S. sobrinus GTF was topically
administered onto lower lips of youngadministered onto lower lips of young
adults have suggestedadults have suggested that this route havethat this route have
potential for caries vaccinepotential for caries vaccine delivery.delivery.

 In these experiments, those who received labialIn these experiments, those who received labial
applicationapplication of GTF had significantly lowerof GTF had significantly lower
proportions of indigenous mutansproportions of indigenous mutans
streptococci/total streptococcal flora in theirstreptococci/total streptococcal flora in their
whole salivawhole saliva during 6-week period followingduring 6-week period following
dental prophylaxis, compareddental prophylaxis, compared with placebowith placebo
group.group.

(E) RECTAL(E) RECTAL
 More remote mucosal sites have also beenMore remote mucosal sites have also been
investigated for theirinvestigated for their inductive potential.inductive potential.
 For example, rectal immunization with non-oralFor example, rectal immunization with non-oral
bacterial antigens such as Helicobacter pylori orbacterial antigens such as Helicobacter pylori or
Streptococcus pneumoniae ,presented in contextStreptococcus pneumoniae ,presented in context
of toxin-based adjuvant, can resultof toxin-based adjuvant, can result in appearancein appearance
of secretory IgA antibody in distant salivaryof secretory IgA antibody in distant salivary sites.sites.
 Colo-rectal region as an inductive location forColo-rectal region as an inductive location for
mucosalmucosal immune responses in humans isimmune responses in humans is
suggested from fact that thissuggested from fact that this site has highestsite has highest
concentration of lymphoid follicles inconcentration of lymphoid follicles in lowerlower
intestinal tract.intestinal tract.

 One could, therefore, foresee use of vaccineOne could, therefore, foresee use of vaccine
suppositoriessuppositories as one alternative for children inas one alternative for children in
whom respiratory ailmentswhom respiratory ailments preclude intranasalpreclude intranasal
application of vaccine.application of vaccine.

CONCLUSIONCONCLUSION
 During the past 2 decades, numerousDuring the past 2 decades, numerous
advancements have been made towardadvancements have been made toward
development of a safe caries vaccinedevelopment of a safe caries vaccine for use infor use in
humans.humans.
 However, it is still difficult to predict when or if aHowever, it is still difficult to predict when or if a
vaccine will be available for actual use sincevaccine will be available for actual use since
appropriate clinical studies have yet to be performed.appropriate clinical studies have yet to be performed.

REFERENCESREFERENCES
D.J. Smith: Dental Caries Vaccines: Prospects andD.J. Smith: Dental Caries Vaccines: Prospects and
Concerns: Crit Rev Oral Biol Med13(4):335-349 (2002)Concerns: Crit Rev Oral Biol Med13(4):335-349 (2002)
Daniel J. Smith, Ph.D: Caries Vaccines for theDaniel J. Smith, Ph.D: Caries Vaccines for the
Twenty-First Century:Twenty-First Century: Transfer of Advances inTransfer of Advances in
Science into Dental Education: Journal of DentalScience into Dental Education: Journal of Dental
Education Volume 67, Number 10 : pg no 1130-39Education Volume 67, Number 10 : pg no 1130-39
Suzanne M. Michalek and Noel K. Childers DevelopmentSuzanne M. Michalek and Noel K. Childers Development
and Outlook for a Caries Vaccine: Oral Biology andand Outlook for a Caries Vaccine: Oral Biology and
Medicine:Volume 1, Issue 1Medicine:Volume 1, Issue 1

MichaelW. Russella Noel K. Childersb SuzanneMichaelW. Russella Noel K. Childersb Suzanne
M. Michalekc Daniel J. Smith Martin A.M. Michalekc Daniel J. Smith Martin A.
Taubmand;Taubmand; A Caries Vaccine? The State of theA Caries Vaccine? The State of the
Science of Immunization against Dental Caries:Science of Immunization against Dental Caries:
Caries Res 2004;38:230–235Caries Res 2004;38:230–235
Dr. Noel K. Childers: Immunobiology of Dental Caries:Dr. Noel K. Childers: Immunobiology of Dental Caries:
nkc@uab.edunkc@uab.edu
The Scientific and Moral Imperative for a DentalThe Scientific and Moral Imperative for a Dental
Caries Vaccine : iadr.confex.com/iadr/2004Caries Vaccine : iadr.confex.com/iadr/2004
Hawaii/ techprogram/sessionHawaii/ techprogram/session
Caries Immunology:Caries Immunology:Chapter 13Chapter 13

INTRODUCTIONINTRODUCTION
 The explosive growth of theThe explosive growth of the
Internet and its use bring with itInternet and its use bring with it
the potential for electronic mediathe potential for electronic media
to fundamentally alter the wayto fundamentally alter the way
dentistry and medicines aredentistry and medicines are
practiced.practiced.
 The profession has come a longThe profession has come a long
way from extractions andway from extractions and
dentures.dentures.
 Now digital technology is takingNow digital technology is taking
dentistry to another level-dentistry to another level-
creating practice possibilitiescreating practice possibilities
that were hardly imaginable eventhat were hardly imaginable even
10 years ago10 years ago

 Teledentistry is a relatively new field thatTeledentistry is a relatively new field that
combines telecommunication technology andcombines telecommunication technology and
dental care.dental care.
 It provides new opportunities for educationIt provides new opportunities for education
and delivery of care that offer much potentialand delivery of care that offer much potential
and challenges.and challenges.
 The practice of teledentistry broadly definesThe practice of teledentistry broadly defines
the use of electronic communication andthe use of electronic communication and
information technologies to provide or supportinformation technologies to provide or support
clinical care at a distance is becomingclinical care at a distance is becoming
increasingly common due to the recentincreasingly common due to the recent
innovations in data communication as well asinnovations in data communication as well as
increased demand for accessible and costincreased demand for accessible and cost
effective health care.effective health care.

DefinitionsDefinitions
 Teledentistry's roots lie in telemedicine.Teledentistry's roots lie in telemedicine.
 One of the best definitions of telemedicine is thatOne of the best definitions of telemedicine is that
expressed by the Association of Americanexpressed by the Association of American
Medical Colleges or AMMC.Medical Colleges or AMMC.
 "Telemedicine is the use of telecommunication"Telemedicine is the use of telecommunication
technology to send data, graphics, audio andtechnology to send data, graphics, audio and
video images between participants who arevideo images between participants who are
physically separated (i.e. at a distance from onephysically separated (i.e. at a distance from one
another) for the purpose of clinical care.another) for the purpose of clinical care.

 The state of California considers Telemedicine toThe state of California considers Telemedicine to
be "The practice of health care delivery, diagnosis,be "The practice of health care delivery, diagnosis,
consultation, treatment and education, usingconsultation, treatment and education, using
interactive audio. video or data communications.interactive audio. video or data communications.
 The Federal Government in its 1997 TelemedicineThe Federal Government in its 1997 Telemedicine
report to Congress defined it asreport to Congress defined it as ““the use ofthe use of
electronic communication and informationelectronic communication and information
technologies to provide or support clinical care at atechnologies to provide or support clinical care at a
distance.distance.
 The term Teledentistry was used in 1997 whenThe term Teledentistry was used in 1997 when
Cook defined it as "... The practice of using videoCook defined it as "... The practice of using video
conferencing technologies to diagnose and provideconferencing technologies to diagnose and provide
advice about treatment over a distance.advice about treatment over a distance.

History of TeledentistryHistory of Teledentistry
 The United States military formally launched aThe United States military formally launched a
coordinated telemedicine program in 1994.coordinated telemedicine program in 1994.
 One of the military telemedicine efforts was toOne of the military telemedicine efforts was to
start a teledentistry project.start a teledentistry project.
 The Total Dental Access (TDA) is a tri-serviceThe Total Dental Access (TDA) is a tri-service
teledentistry project, which started in 1994.teledentistry project, which started in 1994.
 One of the goals of this project is to increaseOne of the goals of this project is to increase
patient access to quality dental care.patient access to quality dental care.
 The other goal is to establish a cost effectiveThe other goal is to establish a cost effective
telemedicine system.telemedicine system.
 The Total Dental Access project focuses on threeThe Total Dental Access project focuses on three
areas of dentistry.areas of dentistry.

Patient-care:Patient-care:
 In some of the remote clinics, a patient must travelIn some of the remote clinics, a patient must travel
hundreds ofhundreds of files to receive specialty care.files to receive specialty care.
 With the implementation of teledentistry, there is aWith the implementation of teledentistry, there is a
potential of savings in cost and travel timepotential of savings in cost and travel time
required by the patient.required by the patient.
 Referral to specialists, consultations andReferral to specialists, consultations and
laboratory communications are some of thelaboratory communications are some of the
clinical areas where teledentistry could improveclinical areas where teledentistry could improve
the patient care.the patient care.

Continuing dental education:Continuing dental education:
 Through the use of video teleconferencingThrough the use of video teleconferencing
equipment, the lectures could be broadcasted toequipment, the lectures could be broadcasted to
any clinic where continuing dental education isany clinic where continuing dental education is
difficult to obtain.difficult to obtain.

Dentist-laboratory communicationsDentist-laboratory communications ::
 Occasionally, cases. submitted to the dentalOccasionally, cases. submitted to the dental
laboratories have subtle complications orlaboratories have subtle complications or
esthetic nuances that require direct contactesthetic nuances that require direct contact
between the dentist and the laboratorybetween the dentist and the laboratory
technician.technician.
 In these instances, the ability to send colourIn these instances, the ability to send colour
images of the patientimages of the patient’’s teeth and then to talks teeth and then to talk
about the images can help to prevent makingabout the images can help to prevent making
improperly constructed appliances, therebyimproperly constructed appliances, thereby
saving time and money.saving time and money.

Step 1:Step 1: ImageImage File Transfer via ModemFile Transfer via Modem
 The US Army conducted the first study ofThe US Army conducted the first study of
teledentistry at Fortteledentistry at Fort Gordon, Georgia in JulyGordon, Georgia in July
1994.1994.
 In this study a dental image managementIn this study a dental image management
system was used in conjunction with an intra-system was used in conjunction with an intra-
oral camera to capture color images of aoral camera to capture color images of a
patient's mouth.patient's mouth.
 These images were then transmitted to FortThese images were then transmitted to Fort
Gordon, a distance of 120 miles.Gordon, a distance of 120 miles.
 They concluded that 14 of the 15 patientsThey concluded that 14 of the 15 patients
saved the return trip to Fort Gordon.saved the return trip to Fort Gordon.

Step 2: File lmage Transfer via SatelliteStep 2: File lmage Transfer via Satellite
 The second study was performed in Haiti in 1995. InThe second study was performed in Haiti in 1995. In
this study a video teleconferencing system was usedthis study a video teleconferencing system was used
allowing the deployed dentists to talk face to faceallowing the deployed dentists to talk face to face
with specialists at Walter Reed Army Medical Centrewith specialists at Walter Reed Army Medical Centre
in Washington.in Washington.
Step 3: ISDN-Based Teledentistry SystemStep 3: ISDN-Based Teledentistry System
 For this project the Army posts were networkedFor this project the Army posts were networked
using desktop video teleconferencing equipment andusing desktop video teleconferencing equipment and
ISDN linesISDN lines
 This equipment allows live video consulting as wellThis equipment allows live video consulting as well
as capability to send still images.as capability to send still images.

Step 4: Web-Based Teledentistry SystemsStep 4: Web-Based Teledentistry Systems
 Since most of the dental clinics in Europe have aSince most of the dental clinics in Europe have a
local area network (LAN) and access to Internetlocal area network (LAN) and access to Internet
through the medical hospitals, this system is beingthrough the medical hospitals, this system is being
used in over 50 tri-service dental clinics in Europe.used in over 50 tri-service dental clinics in Europe.
 Advantages of a web-based teledentistryAdvantages of a web-based teledentistry
consultation system include low cost, expandableconsultation system include low cost, expandable
to a wide range of locations, more completeto a wide range of locations, more complete
information for data analysis.information for data analysis.

TELERADIOLOGYTELERADIOLOGY
 Teleradiology is the most common application ofTeleradiology is the most common application of
telemedicinetelemedicine
Domain of TeleradiologyDomain of Teleradiology
 In 1994, the American College of Radiology (ACR)In 1994, the American College of Radiology (ACR)
defined teleradiology as the electronic transmissiondefined teleradiology as the electronic transmission
of radiologic images from one location to anotherof radiologic images from one location to another
for the purposes of interpretation, consultation, orfor the purposes of interpretation, consultation, or
both.both.
 Teleradiology systems allow direct digital orTeleradiology systems allow direct digital or
digitized film images to be transmitted to distantdigitized film images to be transmitted to distant
locations, where they can be viewed andlocations, where they can be viewed and
downloaded to hard copy for reading anddownloaded to hard copy for reading and
interpretation.interpretation.

 The first apparent instance of aThe first apparent instance of a
dental radiograph beingdental radiograph being
transmitted over distance was intransmitted over distance was in
1920 by the Western union1920 by the Western union
Telegraph CompanyTelegraph Company
 No difference in image quality wasNo difference in image quality was
quality was found between thequality was found between the
initial digitized and theinitial digitized and the
transmitted images.transmitted images.
 Hence, Teledentistry can be usedHence, Teledentistry can be used
to link dental practitioners into link dental practitioners in
remote sites to professionalremote sites to professional
expertise.expertise.

TELESTOMATOLOGYTELESTOMATOLOGY
 An E-mail based oral medicine consultationAn E-mail based oral medicine consultation
was undertaken as a pilot study by Younaiwas undertaken as a pilot study by Younai
and Messadi in 2000 to assess whether textand Messadi in 2000 to assess whether text
based electronic patient data transmissionbased electronic patient data transmission
(e-mail) is a reliable source of information for(e-mail) is a reliable source of information for
the diagnostic decision making process.the diagnostic decision making process.
 Two post graduate residents transfer all theTwo post graduate residents transfer all the
relevant information to a standard patientrelevant information to a standard patient
datadata

 Each form was then coded and given toEach form was then coded and given to
Oral Medicine faculty judges who wereOral Medicine faculty judges who were
blinded to identify the patientsblinded to identify the patients
 They concluded that face to face patientThey concluded that face to face patient
examination is more accurate inexamination is more accurate in
establishing a correct diagnosis for oralestablishing a correct diagnosis for oral
mucosal pathologies that transmittedmucosal pathologies that transmitted
descriptive patient data alone.descriptive patient data alone.

TELE ORAL SURGERYTELE ORAL SURGERY
 Coultard et al in 1999 did a study in greatCoultard et al in 1999 did a study in great
Manchester to know the requirementManchester to know the requirement ofof
telemedicine in oral surgery referrals.telemedicine in oral surgery referrals.
 400 general dental practitioners were400 general dental practitioners were
randomly selected for the study.randomly selected for the study.
 It was concluded that a significant numberIt was concluded that a significant number
of dentist suggested that there was a needof dentist suggested that there was a need
to change the system of oral surgeryto change the system of oral surgery
specialist care.specialist care.

 The principal concern being the amount ofThe principal concern being the amount of
time wasted for consultation and thetime wasted for consultation and the
treatment and perceived difficulty intreatment and perceived difficulty in
travelling to the specialist unit.travelling to the specialist unit.
 Coultard et al suggested that telemedicineCoultard et al suggested that telemedicine
in oral surgery could conceivable bein oral surgery could conceivable be
another way to improve access toanother way to improve access to
specialist oral surgery care.specialist oral surgery care.

TELEPATHOLOGYTELEPATHOLOGY
 Very few teleconsultations is being used inVery few teleconsultations is being used in
the field of pathology.the field of pathology.
 1998 Dr Vincent Menoli, section chief of1998 Dr Vincent Menoli, section chief of
Anatomic pathology at Dartmouth-HitchcockAnatomic pathology at Dartmouth-Hitchcock
medical centre started experimenting withmedical centre started experimenting with
telepathology system.telepathology system.
 It worked reasonably well but did not allowIt worked reasonably well but did not allow
him to scan the glass slides in real to selecthim to scan the glass slides in real to select
exactly the right fields, focal depth andexactly the right fields, focal depth and
magnification.magnification.

 He planned a Digital Meeting SystemHe planned a Digital Meeting System
based Telepathology system, with 2 ruralbased Telepathology system, with 2 rural
sites and the hub at the medical centre.sites and the hub at the medical centre.
 The equipment delivered very reasonableThe equipment delivered very reasonable
image fidelity and allowed for fullimage fidelity and allowed for full
interaction between the rural pathologistinteraction between the rural pathologist
and medical centre suband medical centre sub specialists.specialists.

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