preventive dentistry

1. Preventive
Measures in
Restorative
Dentistry

2. Health
• WHO :-
– Health is a state of complete physical , mental
and social well-being, and not merely the
absence of Disease or infirmity.
• Dental Health :-
– Dental Health is defined as a state of complete
physical , mental and social well – being , and
not merely the absence of Disease or infirmity

3. Preventive Dentistry
• Definition
• Principal of Preventive Dentistry
• Levels of Preventive Dentistry
• Sugar Subsitutes
• Fluorides
• Pit & Fissure sealant
• Prevention to Traumatic Injuries

4. Preventive Dentistry
• Definition :
– Employment of all measures necessary to attain
and maintain optimal oral health .
- Robert C.Caldwell
– Procedure employed in practice of dentistry and
community dental health programmes which
prevent occurrence of oral disease and oral
abnormalities: early loss of deciduous teeth .
- Soben Peter

5. Principles of Preventive
Dentistry
• Control of disease.
• Patient education and motivation .
• Development of host resistance.
• Restoration of function
• Maintenance of oral health.
Inc resistance Inc. susptblty

6. Levels of Prevention
• Primordial level of Prevention
• Primary level of Prevention
• Secondary level of Prevention
• Tertiary level of Prevention

7. Levels of Prevention
• Primordial Prevention :-
– New concept
– Primary Prevention in purest sense
– Prevention of emergence or development of
risk factors in countries or population group
– Obesity , hypertension – childhood – life style
are formed e.g :- food habits , physical exercise
, smoking etc
– Discouraging children – harmful lifestyle
– Intervention – education

8. Levels of Prevention
• Primary level :-
– Action taken prior to onset of disease which
removes the possibility that a disease will ever
occur .
– Concept of – “Positive Health” – encourages
achievement of maintenance of an acceptable
level of health that will enable every individual
to lead socially &economically productive life .
– Prevention of chronic disease

9. Levels of Prevention
• Secondary Prevention :-
– Action which halts the progress of a disease at
its incipient stage and prevents complication .
– Early diagnosis & adequate Rx – arrest disease
& restore health

10. Levels of Prevention
• Tertiary Prevention :-
– All measure available to reduce or limit
impairment and disabilities , minimize suffering
caused or by existing departures from good
health and to promote the patients adjustment to
irremediable condition .
– Prevent sequelae
– Limits disability
– rehabilitation

11. Caries Primary
Secondary
Tertiary

12. Cariogenicity of foods
• Cariogenicity- food composition, texture,
solubility, retentiveness, and rate of salivary
clearance than sucrose alone
• Based on acidogenic potential
Raw vegetables<nuts<milk<corn chips<fresh fruit<ice
cream<French fries<dried fruit.
• Retention
High sugar foods- caramel, chocolate bars , sticky - sucrose

13. Sugar substitutes

14. Sugar substitutes
• Caloric sweeteners e.g:- polyalcohols , starch
hydrolysates
• Low – caloric sweetener e.g :- asparate ,saccharin,
cyclamate .
• Other sweetener derived from plant sources e.g :-
monellin , licorice , dihydrochalcone , miraculin .
Caloric sweetener
- Polyalcohols e.g :- sorbitol and xylitol
- Starch Hydrolysates e.g :- Lycasin

15. Xylitol
CH2OH
• H ---C--- OH
HO--- C --- H
H--- C ---O H
CH2OH
• Source :Fruits – strawberries , plums , raspberries
. Vegetables – lettuce , cauliflower ,mushrooms .

16. Studies Results Shortcomings
Turku sugar
substitution study
(2 yr )
0.8–0.0 = xylitol
5.8-7.2= sucrose
(3 months )
-personal pref
-uptake- amt
- dt awareness
WHO Thailand
study & French
Polynesia field
study
Chewing gum-
F+xylitol+sorbitol;
xylitol/sucrose,
Na F rinses
(15days)
-Drop out : 69%-
Thailand , 60-83%-
Polynesia
-Fluoride rinse
group – high caries
incidence
WHO Hungary
field study (3yrs)
Xylitol chewing
gum ,
MFPdentrif,F-milk
lowest caries –
xylitol group ; mean
caries increment =
Xylitol4.3<7.8contr
ol group.
baseline - caries
experience .
Drop outs – 30.5%

17. studies Results shortcomings
Xylitol chewing
gum studies ( 1
yr )
DMFS(noncavitate
d)lesions :-
Sucrose –48.2
Xylitol – 50.8
The Canadians
chewing gum
study , 9 yr , low
socio-economic ,
high caries,
control/xylitol-
15% or 65%
Progression of
decayed surface –
Control/15% X
/65% X ::
3.54/1.58/1.45
Control group –
placebo

18. Sorbitol
CH2OH
H ---C---OH
HO---C---H
H--- C---OH
H---C---OH
CH2OH
• Berries , apples , plums , pears , seaweed & algae
• Metabolism :
• Slow, incomplete absorbed
• Animal studies –less plaque accumulation& caries
-sorbitol

19. Low calorie sweeteners
• E.g :- aspartame , saccharin and cyclamate
• Aspartame :-
– Greater sweetness
– Not fermented to acid by oral bacteria- not lower pH
– Dose : 34 mg / kg body wt
– Limit amount of fermentable sugar
N2N-CH-CONH-CH-COOMe
CH2
HOOC
CH2

20. Low calorie sweetener
• Saccharin :-
– Pharmacologically inert , stable
– Soft drinks , dietetic foods , mouth washes ,
medical preparations .
– Banned – Canada & USA
SO2
NH
O

21. Low calorie sweetener
• Cyclamate :-
– 30 times as sweet as sucrose
NHSO3Na
-1% - laxative effect
-Absorbed into blood stream and excreted unchanged in urine

22. Plant Derived sweetners
• Monellin
– Grapelike red berry cluster – Africa
– 3,000 times sweeter> sucrose
– Sweetness lost – higher temp
• Licorice
– Roots of small shrub (Glycyrrhiza glabra)
– Central Asia & Europe
– 50 times > sucrose
– Beverages , desserts , dentifrices
pharmaceutical preparations

23. Plant Derived sweetners
• Miraculin (Miracle fruit )
– Shrub (Synsepalum dulciticum )- West Africa
– Molecular wt : 42,000
– Macro molecule – taste modification

24. Fluorides :-

25. Fluorides
• Systemic fluorides
Milk fluoridation
Salt fluoridation
Fluoride tablet & drops
Water fluoridation

26. Systemic Fluorides
• Supplemental F dosage schedule :-
AGE
Concentration of F in water
<0.3ppm 0.3- 0.6 ppm > 0.6 ppm
Birth – 6 month 0 0 0
6months – 3 yr 0.25 mg 0 0
3 – 6 yrs 0.50 mg 0.25 mg 0
6 – 16 yrs 1.00 mg 0.50 mg 0

27. Topical Fluorides
APF Gels
Stannous F

28. Topical fluoride
< 4yr old Fl tooth paste not recommended
4-6 yr old Brush once daily, other two times without a paste
6-10 yr old Twice with Fl tooth paste, other time without
paste
>10 yr old Thrice daily with Fl tooth paste

29. AGE Preventive Measures
0 – 3 yrs Diet modification
Fluorides
Home care
P/Sealant – if indicated on
2nd dec molar (2-6yr)
3 – 6 yrs F administration
Dietary counseling &
management
Home care
P/F – 1st permanent M erupts
6 – 12 yrs F administration
Home care
Diet counseling
P/F – 2nd M erupts

30. Pit & Fissure

31. Pit and Fissure sealant
• Occusal surface :-

32. Pit and fissure
• Pit – small pin point depression located at
junction of developmental groove or at
terminal of those grooves.
• Fissure :deep cleft between adjoining cusps
– Provide retention for caries producing agents
• Pit & fissure caries : are those originating
in pit & fissure found on occlusal , buccal ,
lingual surface of posterior teeth and lingual
surface of max anterior teeth .

33. Pit and fissure
• Morphological types of occlusal fissure :-
-34 % 14 %
7%

34. Pit and fissure
• Morphological types of occlusal Fissure
26% 19%

35. Diagnosis – Pit & Fissure caries
• Preventive management is difficult
in fissure lesions
• The walls of the fissure cannot be seen and
the size and the depth of fissures varies
considerably

36. Pit and Fissure caries
• Diagnosis of P/F caries :-
– Conventional
• Visual (dry tooth)
• Probe (explorer) ? ? ?

37. Diagnosis – Pit & Fissure caries
• Probes may stick in sound but deep fissure,
giving false diagnosis.
• The probe may also damage the enamel if
forced into a fissure to detect stickiness.
• The use of “stickiness” with a probe as the
sole diagnostic criterion for fissure caries is
unreliable.

38. Diagnosis – Pit & Fissure caries
• Fissure depth extend until half of enamel
thickness
Probe tip may or may not stick in the fissure

39. Diagnosis – Pit & Fissure caries
• Stained Fissure Showing Its Depth Almost To
Dentin
The fissure is sound , the probe if
applied with firm pressure – stick –
false diagnosis

40. Diagnosis – Pit & Fissure caries
• Deep Narrow Fissure
Cavitations have to occur
before a probe would enter the
fissure

41. Diagnosis – Pit & Fissure caries
• Fissure is carious extending into dentin
The probe will not enter the
fissure and therefore will not
aid in the diagnosis

42. Diagnosis – Pit & Fissure caries
• Enamel lesions involving side walls of the
fissures
The bulk of the enamel may mask such lesions
until lateral spread has occurred

43. Pit and Fissure caries
• Diagnosis of P/F caries :-
– Bitewing Rd –Fiber optic transillumination
–Digital Rd
Caries detecting dyes

44. Pit and Fissure caries
• Diagnosis of P/F caries :-
– Laser Fluorescence
– Ultrasonic imaging
– Electrical resistance
– Xeroradiography

45. Pit and fissure sealants
- Is to describe a material that is introduced into
occlusal pit & Fissure of caries susceptible teeth ,
thus forming o micro mechanically – bonded,
protective layer cutting access of caries –
producing bacteria from their source of nutrient.
- Simonsen

46. Age Ranges For Sealant Application
A. 3-4 years of age for the primary molar sealant
application
B. 6-7 years of age for the first permanent molar
C. 11-13 years of age for the second permanent
molars and the premolars.

47. Pit and Fissure sealant
• Classification :-
• Based on generations :
– First generation sealant
• Activated – UV light 350 μm
• No more used
• Excessive absorption & incomplete polymerization
• E.g : nuva – seal
– Second generation
• Self curing resins / chemical curing resin
• Catalyst – accelerator system
• E.g : nuva – cote , white sealant system ( 3M)

48. Pit and Fissure sealant
– Third generation sealant
• Visible (blue) light – 430 – 490 nm
• Filled / unfilled,with / without opacifier
• E.g : Fissurit Delton (Johnson & Johnson)
– Fourth generation
• Flourides containing
– Anionic exchange system
– Adhesion of f to unpolymerized resin
– E.g : Fluro sealant ,embrace wetbond

49. Pit and Fissure sealant
• Based on filler content :-
– Unfilled (free of fillers)
• Flow is better
• Retention is more
• Abrade rapidly
• E.g : Concise white , Delton
– Filled
• More resistant to wear
• Occlusal adjustment
• E.g : Kerr p/f –40% quartz filler
• Nuva – cote – 64% lithium aluminium silicate

50. Pit and Fissure sealant
Based on Translucency :
– Clear
• Esthetic (recall visit )
• Better flow
– Tinted / opaque
• Easily identified
– Colored
• Easy – placement & recall
• More retention

51. • Based on curing :
– Auto polymerizing
• Retention – 88%
• Exothermic reaction
– Light cure
• Retention – 75 %

52. Pit and Fissure sealant
• Requirement :-
– Non toxic , non irritating
– Thin layer – adhere to tooth structure
– Consistency & viscosity
– Compressive & tensile strength
– Shrinkage and expansion
– Water absorption & solubility
– Harmonious - tooth structure
– Cariostatic action

53. Pit and Fissure sealant
• Material used as P/F sealant :-
– Resins
• Acid etch tech
• Tight seal
• Pure resin , composite , compomers
• Chemically / light cured

54. Pit and Fissure sealant
• GIC :-
– Chemically bond + F release
– Moisture control is diff – can be used
– F release high – 24 hrs , dec
– Cariostatic effect
• Compomer
– F release – less than GIC
– Grobler et al(1998);Show et al (1998), Meyer et
al (1998) – compomer - comparable – resin
sealant

55. Pit and fissure sealants
• Indications :-
– Deep ,retentive pit and fissure which may cause
wedging or catching of an explorer .

56. Pit and fissure sealants
– Stained p/f with min appearance of
decalcification or opacification & no softness at
base of fissure .

57. – Questionable enamel caries in p /f
Pit & Fissure sealant

58. Pit and fissure sealants
• Contraindications :-
– Well coalesced , self cleansing p /f
– Dental caries

59. Pit and fissure sealants
• Contraindications :-
– Tooth – not fully erupted
– Isolation - problem
– Limited life expectancy of tooth .
– P / f remained caries free – 4 years or longer.

60. Pit and fissure sealants
Surface Δs Cl.
considerations
Do seal Do not seal
Carious Occlusal
anatomy
If p/f separated
by transverse
ridge ;a sound
P/F may be
sealed
Carious P/F
Questionable prox caries
Caries activity
Sound
-Many occlusal
caries , few prox
caries
Carious
Many prox
carious

61. Pit and fissure sealants
Surface Δs Cl.
considerations
Do seal Do not seal
Sound Occlusal
morphology
Tooth age
Status of prox
surface
Caries activity
Deep, narrow
P/F
Recently erupted
teeth
sound
Many occlusal ,
few prox lesion
Broad ,well
coalesced P/F
Teeth caries free
for 4 yrs or
longer
carious
Many prox
lesion

62. Pit and Fissure sealant
• Clinical Technique :-
– Step 1 : Dental prophylaxis
– Step 2 : Isolation
– Step 3 : Acid etching of tooth surface
– Step 4 : Rinse/ Washing and drying
– Step 5 : application of bonding agent (
optional )

63. Pit and Fissure sealant
• Clinical Technique :-
Step 6: Apply sealant to tooth surface
Step 7: Explore the sealed tooth surface
Step 8 : Evaluate the occlusion
Step 9 : Recall and re-evaluation

64. Step 2 : Isolation
– Rubber dam isolation
– Cotton roll
– Vac - Ejector
Isolation

65. Step 3 : Acid etching
– 37 % orthophosphoric acid
– Gel / liquid
– Shaffer – 15 sec / 30 sec
- no significant diff
– Duggal (1997)- no diff in relation to P/F- 1yr
– 15/30/45/60 sec
– Tandon S – 15 sec etching suff

66. Step 3 : Acid etching
– ADA 1991
Step Primary Permanent
Acid
etching
30 sec 20 sec
Wash 30 sec 20 sec
Dry 15 sec 15 sec

67. Step 3 : Acid etching
• The etched enamel surface provides increased
surface area and porosity.
• Enamel – low energy,weakly reactive ,
hydrophobic
• Acid – high energy , strong reactive , hydrophilic

68. Step 3 : Acid etching
• Transverse section showing honey comb appearance
of enamel
-selective demineralization of the
hexagonal prisms.
Three surface patterns are
described
- preferential removal of prism
core.
- preferential removal of prism
periphery
- both of these patterns

69. Step 3 : Acid etching
•Amount of enamel surface lost due to etching is 8-10m, but
the normal average depth is 1500m.
•Mechanical retention of sealants is the direct result of resin
penetration into the porous etched enamel ,forming tags
40m deep.

70. Step 3 : Acid etching
• Etched Zone --- Removes Surface Enamel
Resulting in More reactive surface,
Increase in surface area and
Decrease in surface tension
that allows the resin to wet the enamel surface

71. Function of resin tags
• Provide mechanical means for Retention of
cement
• Surround the enamel crystals and provide
resistance to demineralization by acid products
from plaque
• BIS-GMA sealants are resistant to acid dissolution
and provide protection against caries along enamel
– resin interface
• Creates a protective barrier against bacterial
colonization of sealed fissure

72. Step 3 : Acid etching
• Etching in Primary teeth :-
– Less mineral & more organic content in enamel
– Larger internal pore volume – more exogenic
organic material
– Surface prism less enamel
– Prism rod – approach surface at greater degree of
angulation – difficult to etch .

73. • Removes etching agent
• Removes reaction
products from the
surface
• Dry for 15 secs.
• Dried surface – frosted
white appearance.
• Salivary contamination
has occurred – retch for
10 secs and repeat the
procedure
Step 4 :Washing & Drying :-

74. Step 5 : Bonding Agent application
• (optional)
– Inc wettability , remove
contaminants
– Modify superficial layer
– Inc surface bonding
– Surface irregularities

75. Step 6 : Sealant Application
•Apply the material to the fissures
and allow it to flow. This avoids
incorporating air into material
which creates voids.
•Use fine brush to apply the
cuspal inclines to seal the
secondary and supplemental
fissures
•Mand. Teeth – apply sealant
distally allow it to flow mesially

76. Step 6 : Sealant Application
• Polymerization :-
•Light cured Cure the sealant
according to manufacturer
instructions
•Auto polymerizing sealants
takes 10-20 secs

77. Step 7 :Explore The Sealed Tooth Surface
Explore the entire surface for pits that have
not been sealed and for voids in the material

78. Step 8 :Evaluate the Occlusion
With articulating paper to determine if any
excessive sealant is present and needs to be
removed.
A small discrepancy in occlusion may be in
case of unfilled sealant is easily tolerated
but in case of filled resin sealant occlusal
adjustment is necessary to avoid discomfort

79. Final

80. • Recall and check the patient at subsequent
visits i.e., every 4-6 months
• Necessary to reevaluate the sealed tooth
surface for loss of material, exposure of
voids , caries development especially in the
first six months of placement
Step 9: recall and reevaluation

81. Pit and Fissure sealant
• Periodic evaluation :-
– recall – 6 month /depend on caries activity
– Clinical re – evaluations
• Visually & tactually – loss of material
• Exposure of voids / caries development
• Marginal integrity
• Buccal pits (mand molars ) & lingual pits ( max
molars ) > occlusal surface
– Radiographic evaluation
• Bitewing radiograph

82. Pit and Fissure sealant
• Clinical problems:-
– Lack of universal usage
– Technique sensitivity
– Caries susceptibility of etched enamel
– Detection of loss sealant
– Inadvertent placement over active carious sites

83. Preventive Sports

84. Sports Injuries
What is a mouthguard?
A mouthguard is a flexible appliance
made out of plastic that is worn in
athletic and recreational activities to
protect teeth from trauma.
More than 200,000 injuries to the mouth
and jaw occur each year
• Players who participate in basketball,
wrestling, soccer, rugby, in-line skating,
and martial arts as, well as recreational
sports such as skateboarding, and
bicycling should wear mouthguards
while competing

85. Sports Trauma
• Mouth Guards
• Advantages :
– Protection of teeth and intraoral structures
– Jaw fracture & edentulous areas.
– Reduction of other Head & neck injuries with
mouthguards.
– Athletic confidence
– Facial injuries.
– Economic considerations

86. Mouth Guards
• Disadvantage :
– Comfort :-bulk , improper fit , gagging ,
nausea, xerostomia , durability , stability ,
staining , bad odor , bad taste
– Tissue reaction
– Function & maintenance :- normal breathing ,
impair speech , restrict intake of fluid, reduce
peripheral vision.
– Attitude and rules of sports group

87. Mouth Guard
• Characteristics :-
• Protection – lips ,external nasal area, oral hard &
soft tissues.
• Retention :Retentive & remain in place,readily
adapt to tooth structures, even after prolonged
replacement & removal from mouth.
• Function : tongue , speech ,breathing
• Fabrication :easy , min chair side & lab time
• Soft & comfortable
• Does not deteriorate even after prolonged use.
• Offensive odor or taste.
• Non toxic.

88. Mouth Guards
• Types
– Stock mouth guard
– Mouth formed
– Pre fabricated Custom – formed mouthguard
– Custom – formed (vacuum) mouthguard

89. Mouth Guards
• Stock mouth guards :
– Preformed , readily available,
– Inexpensive , colors
– Bulky , interfere with breathing & speech
– Thermoplastics – boil and bite technique
– Stream of hot air – warm water – softened-
insertion in mouth.

90. Mouth Guards
• Mouth formed mouthguards :
Thermoplastic
Shell – lined
Thermoplastic
– Adapted directly to teeth & max arch
– Prior – oral prophylaxis & restorative treatment
– Thermoplastic – hot water – cold water- adapted to
rigid plastic tray – inserted in mouth
– Mouthguard – max arch – upward & backward
direction – bite for 30 sec
– Cold water – 20 sec
– Check – fit

91. Mouth guard
• Mouth formed mouth guards
Shell – lined
- good adaptability , retention
- Mouth guard shell – lined – soft ethly
methacrylate
- Powder & liquid mixed ,doughy
consistency – loaded mouthguard shell
- Molded – max teeth& soft tissues
- Excess - trimmed

92. Mouth Guard
• Prefabricated custom – formed mouthguard
– Alginate impression – model
– Mouth guard – soften – molded over dental
cast / model
– useful in athletes wearing braces.
– Area where orthodontic bracket – fitted loosely
– mouth guard can be relined prior to each
game with soft material

93. Mouth Guard
• Custom – formed (vacuum ) mouth guard.
– Fabricated over dental cast using vacuum
formed material .
– Best adaptation , max retention , protection
– interfere least with breathing and speech
– 2 office visits as well as lab time
– Expensive
– Method :
– Examination of dentition , restoration, oral-
prophylaxis , remove – removal appliance

94. Mouth guard
• Custom – formed(vaccum) mouth guard
– Method :-
– Alginate impression(muscle molding rim lock
trays) - cast – vent hole in palatal region
– Cast – vacuum former , heated sheets
compressed over cast , trimmed
– Mouth guard should not extend beyond the
middle of occlusal surfaces of first Per M
/mesial of 2nd Per M
– 2nd appointment – mouth guard - try –in
– Adv – several guards can be fabricated over
same cast.