Caries prevention

Dr.MadhuBilla
II MDS
CARIES PREVENTION
Dr.Madhu Billa
2nd year PG
SIBAR Institute Of Dental Sciences

CONTENTS
• Introduction
• Need for prevention
• Aims of prevention
• Levels of prevention
• Methods to control caries
o Nutritional
o Chemical
o Mechanical
• Pit and fissure sealants
• Caries vaccines
• Lasers in caries prevention
• Conclusion

• Dental caries is an irreversible microbial disease of
the calcified tissues of the teeth, characterized by
demineralization of the inorganic portion and
destruction of the organic substance of the tooth ,
which often leads to cavitation” (Shafers)
• Prevention refers to act of stopping something
from happening or arising (Oxford Dictionary)

• Primary goal of caries prevention program should
be to reduce the number of cariogenic bacteria.

AIMS OF PREVENTION
• Limiting pathogen growth and metabolism
• Limitation of caries activity
• Early detection of incipient caries
• Identification of high risk patients
Essentials of Preventive and Community
dentistry. Soben Peter. 2nd edition

NEED FOR PREVENTION
• caries may cause severe pain
• Symptomatic treatment is intensive
• Caries Results in dysfunctional speech
• Compromises nutrition
• The cost of treatment is high

LEVELS OF PREVENTION
• There are three levels of prevention of dental caries.
1. Primary prevention – is defined as
“actions taken prior to the onset of the disease, which
removes the possibility that the disease will ever occur.”
2. Secondary prevention - is defined as
“actions which halt the progress of a disease at its incipient
stage and prevents complications.”

3. Tertiary prevention- is defined as
“ all measures available to reduce or limit impairments &
disabilities, minimizing suffering caused by existing
departures from good health & to promote the patients
adjustments to the irremediable condition.”

PREVENTIVE
SERVICES
HEALTH
PROMOTION
SPECIFIC
PROMOTION
EARLY DIAGNOSIS
AND PROMPT
TREATMENT
DISABILITY
LIMITATION
REHABILITATION
CARE TO BE
TAKEN BY THE
PATIENT
Diet planning
Demand for
preventive services
Periodic visits to
the dental office
Appropriate use of
fluorides
Ingestion of
fluoridated water
Use of fluoridated
dentifrice
Oral hygiene
practices
Self examination
and referral
Utilization of
dental services
Utilization of
dental services
Utilization of
dental services
SERVICES
PROVIDED BY
THE DENTAL
PROFESSIONAL
Patient education
Plaque control
program
Diet counseling
Recall and
reinforcement
Caries activity tests
Topical application
of fluorides
Topical fluoride
supplements/rinses
Pit and fissure
sealants
Complete
examination
Prompt treatment
of incipient lesions
Preventive resin
restorations
Simple
restorative
procedures
Pulp capping
Complete
restorative
dentistry
Pulpotomy
RCT
Extraction
Fixed and removal
prothodontics
Minor tooth
movements
Implants
LEVELS OF
PREVENTION PRIMARY PREVENTION
SECONDARY
PREVENTION
TERTIARY PREVENTION
LEVELS OF PREVENTION

Methods Of Caries Prevention
1.Nutritional measures.
2.Chemical measures.
3.Mechanical measures.

NUTRITIONAL MEASURES
• Nutrition: The sum processes concerned in the growth,
maintenance and repair of living body as a whole or its
constituent parts. (Oxford Dental Dictionary)
• Science of food and its relationships to health. It is
concerned primarily with the part played by the
nutrients in body growth, development and
maintenance. (WHO 1971)

• "Diet refers to the customary allowance of food and drink
taken by any person from day to day.
• Thus, the diet may exert an effect on caries locally in the
mouth by reacting with the enamel surface and by serving
as a substrate for cariogenic microorganisms."
(Newbrun, E. Cariology. Third ed. 1989).

Effect Of Nutrition On Dental Caries
• Systemic effect:
- Depends on their content of nutrients and includes their
influence on general health, growth and development ability of
the tissues to repair and resistance to diseases.
• Local effect:
- Consists of what food can do to the tissues or their environment
because of their presence in such an environment .
- It result from the interaction between food residues and oral
bacteria leading to plaque formation.
- Their metabolites in turn effect the soft and hard oral tissues

DIETARY ANALYSIS
Objectives of a dietary analysis includes-
o To obtain an overall picture of the types of food in the patient diet,
food preference and quantity of food eaten.
o Correction of diet imbalances that could effect the patient's general
health & also reflected in his oral health.
o Modification of dietary habits, particularly the ingestion of sucrose
containing foods in forms, amounts and circumstances that promote
caries formation.

• To record for study and future comparison of the types and
frequency of use of potential cariogenic food.
• To provide a basis for making individual recommendation for
changes in diet, important to the health of the oral mucosa and
the prevention of dental caries.

Diet analysis program consists of:
• The interview, where diet diary forms are introduced with a brief
discussion of the purpose of diet counseling.
• A 24 hour diet record is prepared to get an idea of food being
consumed.
• A six days diet diary is advised to be prepared by the patient.

Diet diary of the patient for a
week

• Sugar factors are isolated.
• Patient is educated about the role of sugar in the decay
process & the consumption of acceptable substitutes .
• Practical limitations to immediate success are recognized.
• Provision for a continuous positive reinforcement are
planned.

Continuous production of acid by plaque
bacteria and
Insufficient time for the saliva to
neutralize the acid.
Persistent acidic environment favoring the
development of dental caries.
Consequences of frequent snacking

First appointment: In a 15 to 20 minutes appointment the diet diary
forms are introduced with a brief discussion of the purpose of diet
counseling. Patient is explained –
1.That we are looking for possible dietary causes of the caries to
reduce the risk of future caries by dietary means.
2.What beneficial outcome could be available for him in better oral
health and possibly improved health in general.
DIETARY COUNSELLING

PATIENT EDUCATION:
• The cariogenic potential of a patient's diet is evaluated by
determining the total number of exposures to sucrose-
containing foods during 6 consecutive days.
• Exposure is defined as eating the food at one time and is
not related to the amount of food sucrose ingested.
• Total time of exposure to acid =
(total exposure X 20minutes)

Stephan’s curve
 This time is based on Stephan's curve that the pH of the
plaque drops and remains below a critical level at which
enamel decalcification can occur for an average of 20
minutes after the introduction of sucrose into the mouth.

Dietary Changes
o From the summary of exposures to fermentable carbohydrates
the dietary changes that are better for dental health are
determined.
o Substitutes should be reasonable, which are acceptable to the
dentists in terms of lesser cariogenicitv as well as to the patient
as far as taste and preferences are concerned.
o Substitution can be :
- Use sugared food during meal time .
- Food consumption followed by appropriate oral hygiene
measures.

• To reduce the frequency of snacks, sufficient amount of food
should be taken during breakfast, lunch and dinner at regular
intervals.
• If hungry in between meals, healthy snacking is advised.
• Sweets or beverages - eat or drink them right after meal.
• To quench thirst - plain water is preferred to sweet beverages.

RECALL VISITS
• During the next months at regular intervals, the dentist
should evaluate the patient's progress and provide
psychological reinforcement.
• Evaluations are made by means of:
-The patient' s response to questionnaires.
-New diet diaries.

Reinforcement is provided by-
• praising the patient's efforts
• improvements made in the diet as well as in the test results
and the absence of new caries lesions.
Emphasis should be placed on-
• making the patient fully aware of the benefits derived from
the program
• benefits are the product of the patient's own efforts.

SUGAR SUBSTITUTES
• Are less cariogenic or non-cariogenic.
• Sweeteners stimulate the flow of saliva
• Have a smaller role or no effect on bacterial glycolysis.
• Plaque ph raises with sweeteners, it mobilizes the
calcium and phosphates for remineralization of the
tooth surface
• In children consuming sucrose containing snacks more
frequently, it is ideal to replace the sucrose by sugar
substitutes.

Sweeteners are of two types:
(I) Non-caloric Sweeteners
(Ii) Caloric Sweeteners.

NON CALORIC SWEETNERS
• Provide no energy but provide intense sweet taste.
• Are not metabolized to acids.
• Disadv:
Instability and lack of volume.
• Ex - saccharin and aspartate.

CALORIC SWEETNERS
• Include
1. Sugars—e.g. fructose, glucose, lactose.
2. Sugar alcohols —e.g. lycasin, sorbitol, Xylitol
• Used in- sugar free chewing gums, medicines, food
products, and toothpaste.
• xylitol is the most popular and widely used at present.

Sugar Alcohols
Xylitol.
o is non-acidogenic.
o is a sugar alcohol having an acceptable sweetening taste.
o approved as a sweetener in more than 45 countries.
o used mainly in chewing gums, ice creams, jams, cookies and
soft drinks.
Xylitol:C5

• Allows remineralization of initial
enamel lesions. (Turku study).
• Incorporated in chewing-gum, its
action is increased due to the
stimulation of salivary secretion.
• Synergic action with fluoride.
o Disadvantages-
- Toxicity studies have shown it
increases urinary bladder
calculi formation, epithelial
hyperplasia & neoplasia of the
bladder.
- laxative effect at high conc.

2. Sorbitol
• Is a low cariogenic sugar substitute used mainly as
sweetener in chewing gums, soft drinks, cookies and jams.
• Not as sweet as sucrose.
• Sweets made of it cannot be stored for long.

3. Coupling sugar.
• Are very effective sugar substitutes and anticariogenic &
exactly resembles sucrose
• Widely used in a variety of snacks.
• Disadv- is too expensive.
4. Saccharin.
• Is non-caloric, and less cariogenic.
• Leaves some bitter aftertaste.
• Is highly intense sweetener

Chemical methods
1) Substances which alter the surface of tooth structure
a. Fluoride.
b. Iodides.
c. Bis-biguanides.
d. Silver nitrate.
e. Zinc chloride and potassium ferrocyanide.
2) Substances which interfere with carbohydrate
degradation through enzymatic reaction/alterations
a. Vitamin K.
b. Sarcoside.

3)Substance which interfere with bacterial growth and
metabolism
a. Urea and ammonium compounds
b. Chlorophyll
c. Nitrofurans

Substances which alter the surface of tooth
structure
Iodine:
• Miller (1980) reported the intraoral use of iodine
solution as an antibacterial mouth rinse.
• Bactericidal effectiveness is not time dependent i.e. it kills
microorganisms immediately once contact with the
organisms is established.
• Disadv:-
-Metallic taste.
-Tendency to stain silicate or composite restoration.
-Allergic potential.

• Commercially available forms -
a) Chlorhexidine
b) Alexidine
• They are effective antiplaque agents and thus potential
anticaries agents.
• Topical antiseptics characterized by molecular structure
having both hydrophobic and hydrophilic constituents and
possess a net positive charge at physiologic pH.
Bis-biguanides:

Mode of action:
• Ionic adsorption of negatively charged bacterial surface
• Interaction with and damage to permeability barrier of
cytoplasmic membrane
• Penetration into cells and subsequent penetration of
cytoplasmic constituents and culmination in membrane
leakage and cell death.
Disadv
• Bitter taste
• Brownish discoloration of soft & hard tissue.
• Painful desquamation of mucosa.

Silver Nitrate:
• It was used clinically for many years to prevent or arrest
dental caries.
• Earlier workers believed that silver 'plugged' the enamel,
either the organic invasion pathways such as the enamel
lamellae or the inorganic pathways, combining with the
soluble inorganic portion of enamel to form less soluble
combination.
• But studies by Klein & Knutson indicated it had no significant
difference in the appearance of new lesion.

• Gottleib proposed they act by effectively impregnating the
enamel and seal off caries invasion pathways.
• But clinical results did not substantiate the theories
proposed.
Zinc Chloride and Potassium Ferrocyanide

Substances Which Interfere With Carbohydrate Degradation
Through Enzymatic Reaction/Alterations
Vitamin K-
• 2-methyl-1,4-naphthoquinone was suggested by Fosdick as
a anticaries agent.
• Invitro studies have found it prevents acid formation in
incubated mixtures of glucose & saliva.

Substance which interfere with bacterial growth and
metabolism
1.Urea & ammonia compounds-
-Decrease oral bacteria count & increase the salivary pH to
over 8 for more than an hour after an quinine-ammonia
mouthwash. (Wach et al)
-Urea upon degradation by urease yields ammonia which
neutralizes acids & interferes with bacterial growth.
(Stephan et al)
- Though some studies have shown some reduction in dental
caries but magnitude of reduction has not been so great that
their widespread use can be advocated.

Chlorophyll:
• Bacteriostatic against lactobacilli, streptococci & micrococci.
(Griffith et al).
• Sodium copper chlorophyllin prevents or reduces pH fall of in
carbohydrate- saliva mixtures in vivo. (Shaffer et al).
• Short term clinical studies have suggested their use in reducing
mouth odors & allaying gingivitis but anticariogenic properties are
still inconclusive.

Nitrofurans
o Are derivatives of furfural.
o exert a bacteriostatic and bactericidal action in many Gram
positive and Gram negative organisms.
o Even in low concentrations, acid production in saliva from
caries active persons was prevented. (Driezen et al 1951)
o Data from studies, indicate that they significantly reduces
dental caries experience and that this substance may have
potential use as an anticariogenic agent.

ANTIBIOTICS
1. PENICILLIN :
• Tested as an anticariogenic compound, because
of its antibiotic property.
• Reduction from an average of 72000 colony count to an
average of 300 was found after use of the dentifrice
containing 1000 units of Penicillin per gram, for 5 weeks.
• However the wisdom of using this material for such a
purpose has been further questioned because of the
possibility of development of penicillin resistant
pathogenic microorganisms and sensitization, as well as
development of allergic reactions.

PROBIOTICS
• Probiotics (derived from the Greek pro bios, for life) are
defined by the World Health Organization as live
microorganisms which when administered in adequate
amounts confer a health benefit on the host
• Probiotics are nonmodified human isolates from healthy
individuals and most of them belong to the lactobacilli and
bifidobacteria groups which are naturally present in the
intestinal flora
Treatment Protocols: NonfluorideManagement ofthe Caries
Disease Process and Available Diagnostics (DCNA2009)

MECHANISM OF ACTION
1. Probiotic bacteria compete for nutrients and binding
sites in the biofilm.
2. When attached, probiotic bacteria can produce
bacteriocins (eg, hydrogen peroxide and reuterin) that
hamper and inhibit growth of a variety of bacteria.
3. Probiotic bacteria stimulate the specific and nonspecific
immune response through activation of T cells and
production of cytokines that mediates the inflammatory
process.
Treatment Protocols: NonfluorideManagement ofthe Caries
Disease Process and Available Diagnostics (DCNA2009)

2. ERYTHOMYCIN
• 35% decrease in plaque formation after a seven day test
period of rinsing, then swallowing the agent 4 times a day
(LOBENE et al). Was found with erythromycin
• Disadvantage : causes diarrhea as a side effect.
3. KANAMYCIN
-reduces plaque weight & improves oral health if applied
topically.
-Reduces S.mutans & S.sanguis population

4. TETRACYCLINE
• decrease plaque scores when used as an 0.5 per cent
mouthwash three times a day for five days in place of
mechanical oral hygiene (Loe et al).

5 Vancomycin
• Temporarily suppress streptococcus mutans when applied
to the teeth of children as a 15 percent gel on five successive
days.
• Diminution in s. mutans was found following testing with
1 percent vancomycin paste.
• Statistically significant reduction in dental caries experience
in fissures but not on smooth surfaces in the experimental
groups (depaola et al).

FLUORIDES
• Ranks 13th among the elements in the order of their
abundance.
• Most electronegative element
Highly reactive

FORMS OF FLUORIDE
• Inorganic Fluoride
a.Ionic Fluoride
b.Nonionic Fluoride
• Organic Fluoride

ANTICARIES MECHANISM OF FLUORIDES
Anticaries mechanism can be broadly grouped into
1.Increased enamel resistance
2.Increased rate of maturation
3.Remineralization of incipient lesion
4.Antimicrobial activity

FLUORIDE DELIVERY METHODS
MAIN FLUORIDE DELIVERY
SYSTEMS
• SYSTEMIC
• TOPICAL

SYSTEMIC FLUORIDES
• WATER
FLUORIDATION
• SALT
FLUORIDATION
• MILK
FLUORIDATIONS
• FLUORIDE
SUPPLEMENTS

TOPICAL FLUORIDES
Agents
• SODIUM
FLUORIDE
• STANNOUS
FLUORIDE
• ACIDULATED
PHOSPHATE
FLUORIDE
• FLUORIDE
VARNISH
• FLUORIDE
DENTIFRICES
• FLUORIDE
MOUTH RINSE
Forms

WATER FLUORIDATION
Water fluoridation is defined as controlled adjustment
of the concentration of fluoride in a communal water
supply so as to achieve maximum caries reduction and
a clinically insignificant level of fluorosis (SOBEN PETER)
Water fluoridation is one of the most effective, practical,
and economical public health measure for prevention of
dental caries.
• Reduction in prevalence of dental caries in
 primary teeth range from 40%-50%
 permanent teeth was between 50%-60%

FLUORIDE COMPOUNDS USED IN WATER
FLUORIDATION
• Fluorspar
• Sodium fluoride
• Silicofluorides
• Sodium silicofluoride
• Hydroflurosilicic acid
• Ammonium silicofluoride

BENEFITS OF WATER FLUORIDATION
• Reduction in caries rate by 50%-70%
• 75% reduction in first permanent molar loss
• There is a reduction in progression and development of
dental caries in fluoridated area
• Reduction in the number of surface attacked by dental caries
• Prevents malocclusion due to prevention of early loss of
contact points due to proximal caries

LIMITATIONS
• Can be implemented only in areas which have central pipe
water system
• It interferes with personal choice
• Initial cost for installing fluoridation plant is high

DEFLUORIDATION
• Defluoridation is downward adjustment of fluoride ion
concentration in a public drinking water supply so that the
level of fluoride is maintained at the normal physiological
limit of 1 ppm to prevent dental caries with minimum
possibility of causing dental flourosis.
• Methods of defluoridation
a. based on ion exchange or adsorption
b. based on addition of chemicals to water

• Based on ion exchange
materials used include synthetic tricalcium phosphate,
hydroxyapatite, magnesia, activated alumina, activated
carbon.
• Based on addition of chemicals
materials used includes lime either alone or with
magnesium salts or aluminium salts.

NALGONDA TECHNIQUE
• Was developed by NEERI
• It is a simple and economical process
• Highly effective for removal of fluoride from 1.5-2mg F- /l to
desired level
• Method could be used for defluoridation of domestic and
community water supply
• Uses readily available chemicals – sodium aluminate or lime,
bleaching powder and filter alum

SALT FLUORIDATION
• As a dietary vehicle for ensuring adequate ingestion of
fluoride domestic salt comes second
• Was introduced by Wespi in Switzerland in 1955
• Most popular in Spain, Hungary and Columbia
• Recommended concentration is 250µg of fluoride/g salt

Advantages
• Economical
• Practical
• Caries reduction about 40 %
Disadvantages
• Consumption of salt till 4-5 yrs after birth is negligible, hence
no benefit for younger children.
• Not useful in case of medically compromised patients
(hypertension and renal failure)

MILK FLUORIDATION
• It is the addition of a measured quantity of fluoride to
bottled milk packet
• Mainly recommended for growing children
• Substantial caries reduction noticed when milk consumption
begins before the eruption of permanent teeth
• Rationale for adding fluoride to milk is that this procedure
targets fluoride directly to children

Concentration
• 2.2mg of NaF added to 1/4litre of milk
• Later milk bottles of 250 ml, containing 0.625mg of fluoride
was introduced
Caries reduction is about 60%

Limitations
• Since children from lower socioeconomic groups tend to
drink less amount of milk or no milk at all, hence they
would be benefited least.
• Any benefits cease, as an individual grows older and if he
or she drinks less milk.
• Expensive.
• Parent co-operation is important.

School water fluoridation
o Recommended -for communities with no central water
supply or fluoride deficient water supply.
o Reduces dental caries by 40%.
o Primary effects are systemic but also has a topical effects.
o Caries reduction –
57% in teeth erupted after exposure to school water
fluoridation.
31% if the teeth have already erupted.
o For maximum benefit, children should attend the school
regularly and stay their till they complete the higher
secondary school.
• Recommended conc.- 4.5 ppm.

Reasons for recommending high conc. :
1. Students receive only small part of the daily intake of
water when they are in school.
2. Students may not attend the school throughout the
year.
3. Frequency of drinking water in school by children is
variable.
4. Children attend the school only for a few hours.

Advantages
1) Target population—school children.
2) Caries experience is high during the developmental
period (among children).
3) Quite economical
Disadvantages
1) Need for cooperation from school authorities.
2) All children may not attend the school all days.

FLUORIDE SUPPLEMENTS
• When community water fluoridation is not feasible or where
there is political opposition preventing its implementation,
fluoride supplements offer an alternate source of systemic
fluoride
• Can be given in the form of fluoride tablets, fluoride drops
and lozenges
• The cariostatic effect ranges from 30 to 70% depending-on
dosage and degree of compliance.

RECOMMENDED DOSAGE LEVELS OF SUPPLEMENTAL
FLUORIDE

TOPICAL FLUORIDES
Topical fluoride therapy refers to
the use of systems containing
relatively large conc. of fluoride
applied locally or topically to the
erupted tooth surfaces to prevent
formation of dental caries

The various topical fluorides used are
• Sodium fluoride
• Stannous fluoride
• Acidulated phosphate fluoride
• Fluoride varnish

SODIUM FLUORIDE
• developed by Knutson so technique of use also called
Knutson’s technique
• Conc: 2% of NaF
• pH :7
• Prepared by dissolving 2gm of NaF in 100 ml of
distilled water
• A full series of 4 treatments recommended at the
ages of 3, 7, 10, 13years, coinciding with the eruption
of different groups of primary and permanent teeth

Method of application
• Oral prophylaxis is done in first visit.
• Each quadrant is isolated
• 2% NaF is then applied to the tooth surface with cotton
applicators and kept wet for about 4 minutes. The
procedure is repeated for the remaining quadrants.
• After the treatment, the patient is instructed to avoid eating,
drinking or rinsing for 30 minutes. This is to prolong the
availability of "F" ion to react with tooth surface.
• 2nd, 3rd and 4th applications are given at weekly intervals

Mechanism of action
 Ca10(PO4)6(OH)+F 10 CaF2+6PO4 +20H-
 As a result of this reaction, the principal compound formed
is CaF2 and this is due to high concentration of "F" (9000
ppm) in 2% NaF.
 This results in the phenomenon called "choking off
phenomenon“ — once a thick layer of CaF2 forms, it
interferes with further uptake of "F-" ions'.
 Hence, NaF is applied once left to dry for 4 minutes.
 Later CaF2 dissolves slowly in oral fluids and CaF2 breaks
down into Ca+ and ion. This fluoride is in free ionic form.
 CaF => Ca++ + F-
 This " F- " is highly reactive and reacts with HA to form
fluoridated hydroxyapatite.

Disadvantages
• The patient must make 4 visits to the dentist
within a relatively short time (weekly intervals
for four weeks).
• The expected caries reduction is not
satisfactory (20-25%)

STANNOUS FLUORIDE
• Developed by Muhler
• Annual or biannual application
• pH is 2.4-2.8.
• Available in gel and solution forms
• It has to be freshly prepared before use each time as has a
very short shelf-life
• It is chemically highly unstable.
• Prepared by dissolving 0.8 gm or 1 gm of SnF2 powder is in
10 ml of distilled water to get 8% or 10%

Mechanism of Action
Ca10(PO4)6(OH)2 + 19SnF2 10CaF2 + 6Sn3F3P04 + SnO.H2O
• Compared with that of NaF, the reaction of SnF2 with
enamel is unique in that both the cations (stannous)
and anions (fluoride) react chemically with enamel
components.
• Formations of stannous fluorophosphates, prevent at least
temporarily the phosphate loss which is typical of NaF applications.
• The CaF2 so formed, further reacts with Hydroxyapatite
forms fluoridated Hydroxy Apatite (FHA).
• The tin hydroxy phosphate gets dissolved in oral fluids and is
responsible for metallic taste.
• The Sn3F3P04 makes the tooth structure more stable and less
susceptible to acid dissolution

Advantages
•Applied every 6 or 12 months.
•Very potent and effective topical fluoride preparation
•Very useful for spot application among patients with
nursing bottle caries and rampant caries.
•Stable stannous fluoride gel is available and is the
recommended and ideal preparation in case radiation
caries (cervical) among patients undergoing radiation
therapy for head and neck cancers.
•Expected caries reduction is 25-35%.

Disadvantages
•Chemically more unstable (cannot be stored
hence, requires instant preparation just prior to the
application (takes more chair side time).
•Pigmentation of teeth after application of SnF2 and
brown discoloration can occur on demineralised enamel
and anterior restorations.
•Metallic taste (astringent taste)—children do not like
the taste.
•When brought in contact with gingiva, during
application it causes blanching and burning sensation
due to astringent property.
•It is not economical.

ACIDULATED PHOSPHATE FLUORIDE (APF)
• APF was introduced by Brudevold and co-workers.
• Developed in an effort to achieve greater amounts of
fluoridated hydroxyapatite and lesser amounts of calcium
fluoride formation.
• Composition: 1.23% of NaF buffered to a pH of 3-4 in
phosphoric acid.
• Prepared by dissolving 2gm of NaF in 100ml of 0.1 M
phosphoric acid. To this 50% HF is added to adjust pH at 3
and F- conc to 1.23%
• Semiannual or annual application.

Mechanism of action
Ca10(P04)6 + NaF CaHP04.2H20
CaHP04.2H20 + F- Ca5 (P04)3F + HP04
When APF is applied on the teeth, initially leads to
dehydration and shrinkage in the volume of HA crystals and
formation of dicalcium phosphate di hydrate (DCPD). This
DCPD is highly reactive with "F" and leads to the formation of
Fluorapatite "FA"

Advantages
• Semiannual or annual application.
• Chemically stable and can be stored for ready use.
• Does not produce staining of enamel.
• Available in different flavours.
• Expected caries reduction is about 30 to 40% (better than
NaF and SnF2).
• Can be recommended for home use by self-application.

FLUORIDE VARNISH
• Fluoride has been incorporated in varnishes since they have
the ability to adhere to enamel for long period, and it is
hypothesized that it will slowly release fluoride to the teeth.
• The retentive and possible slow release of fluoride from
these products
-increase the exposure time of the fluoride by several
days, without increasing chairside time,
- allow fluoride to be more permanently bound to the
teeth.

INDICATIONS:
- Exposed roots and root caries
- Erupting teeth
- White spot lesions
- Margins of restorations
- Carious anterior tooth in young children

Types:
• Duraphat: 22.6 mg F/ml.
5% NaF in Colophonium base—available in 10 ml
tube.
1% difluorisilane in polyurethane base (1 mg/ml)
• Fluorprotector
pH lower than Duraphat and is available in box with 20 vials—each
vial contains 0.4 ml of solution.
• Duraflour : 22.6 mg/ml.
5% NaF in.alcoholic suspension of natural resins. Addition of
sweetening agent—xylitol.
• Cavity shield:
5% NaF in resinous base.

Technique
Oral prophylaxis.
Isolation –
•of quadrant using cotton rolls.
•set in the presence of moisture, so meticulous drying of teeth
is not critical.
Application-
• using disposable brush or cotton applicator.
•The entire surface of the teeth must be treated.
• Avoid getting varnish on the soft tissue.
Sets in few seconds leaving a fluoride rich layer adjacent to
the tooth surface.

• The entire process takes 3-4 minutes.
• Duraphat and Duraflour set to a yellowish-brown layer
causing a temporary change in tooth colour.
• Parents and patients should be instructed that this
discolouration is temporary and will vanish once
toothbrushing is commenced.
• Patient should avoid brushing for the rest of the day

FLUORIDE DENTIFRICES
• Considered as a major reason for decline in dental caries in
many parts of the world
• Most widely used method of topical application of fluoride
• Most widely used fluoride in dentifrices is sodium
monofluorophosphate
• Mechanism of action: Dentifrices serve as a constant source
of supply of fluoride in the oral environment hence
accelerate the remineralisation process.

FLUORIDE MOUTHRINSES
• Found to be an effective tool in prevention of dental caries in
areas where water fluoridation is not possible/not been
implemented
• Dosage
Once daily-0.02%of NaF
0.05% of NaF
Once weekly-0.2%NaF
0.5% of NaF

Indications
• Caries prone children over the age of 6 yrs
• Patients with orthodontic appliance
• Patients with erosions and root caries
• Patients with dentine hypersensitivity
Contraindications
• Children under 6 yrs of age who are not capable of rinsing
adequately (when reflex control of swallowing absent)

Fluorosis
• Fluorosis is a disease caused by deposition of fluorides in the
hard and soft tissues of the body.
• It is not merely caused by excess intake of fluoride but there are
many other attributes and variables which determine the onset of
fluorosis in human population.
• Characterized by discoloration of teeth and skeletal crippling
disorders.

DENTAL FLUOROSIS
• occurs by excessive intake of fluoride during tooth development.
• Once the crowns of the teeth are formed no further fluorosis can
be induced by additional intake of fluoride
• Occurs symmetrically within the dental arches.
• Clinical features are characterized by lusterless opaque white
patches in enamel which may become mottled, striated and/or
pitted

Fluorosis in India
• Rajasthan and Gujarat in North India and Andhra in South India
are worst affected.
• Throughout India fluorosis is essentially Hydrofluorosis except in
parts of Gujarat and U.P. where industrial fluorosis is also seen.

FLUORIDE LEVEL FLUORIDE IN DRINKING
WATER
EFFECTS
0.7-1.2 Depending upon the temp
of the area
Prevents dental caries.
No dental/skeletal
fluorosis
1.5-3.0 Consumption of water for a
period of 5-10 yrs or more
Milder form of dental
fluorosis
3.0-8.0 Consumption of water for a
period over 15-20 yrs
Severe form of dental
fluorosis and milder
form of skeletal
fluorosis
8.0 ppm or more Consumption of water for a
period of 5-10 yrs or more
Severe form of dental
and skeletal fluorosis
EFFECT OF FLUORIDES

DEANS FLOUROSIS INDEX(1938)
DEANS
SCORE
CRITERIA
0 Normal enamel
0.5 Questionable mottling :normal translucency is varied by a
few white flecks
1 Very mild mottling :small opaque paper white areas are
scattered over the teeth ,involving less that 25% of surface
2 Mild mottling: white opaque areas are extensive ,but do not
extend more than 50% of surface
3 Moderate mottling: all enamel surfaces are effected and
those subjected to attrition show wear. Brown stains are a
frequent disfiguring feature
4 Severe mottling: all enamel are affected and hypoplasia is so
marked that tooth form may be altered. Major diagnostic
feature is discrete or confluent pitting

Mild Dental fluorosis Moderate Dental fluorosis
Severe Dental fluorosis

FLUORIDE TOXICITY
• Fluoride is often called as a double edged sword -
inadequate intake is associated with dental caries; excessive
intake leads to dental ,skeletal fluorosis which has no cure.
• Toxic effects of fluoride can be classified as
a. Acute
b. Chronic

ACUTE TOXICITY
• Results from rapid excessive ingestion of fluoride at one time
• Speed and severity of the response depends on the amount
of fluoride ingested and the weight and age of the individual
• Could be fatal if not treated within 2-4 hrs

• Certainly Lethal Dose (CLD) is 32 to 64mg of fluoride per kg of
body weight. i.e approx 2.5-5gm in case of children and 5-10gm
one single dose in case of adults.
• Safely tolerated dose 8-16 mg of fluoride per kg of body weight.
• Acute poisoning causes death by blocking normal cellular
metabolism.
• Death usually occurs due to either cardiac failure or respiratory
paralysis.

Emergency treatment for fluoride over dose
Fluoride ion
per mg/kg
Treatment
Less than 5.0
mg/kg
Give calcium orally(milk) to relieve GI symptoms.
Observe for a few hours.
Induced vomiting not necessary.
More than 5.0
mg/kg
Empty stomach by induced vomiting with emetic.
For patients with depressed gag reflex caused by
age(<6 months old), downs syndrome, or severe
mental retardation, induced vomiting is
contraindicated and endotracheal intubations
should be performed before gastric lavage.
Give orally soluble calcium in any form (milk
,5%calcium gluconate, or calcium lactate
solution).
Admit to hospital and observe for a few hours.

More than
15 mg/kg
Admit to hospital immediately
Induce vomiting.
Begin cardiac monitoring and be prepared for cardiac
arrhythmia. observe for peaking t-waves and prolonged
q-t intervals.
Slowly administer intravenously 10 ml of 10% calcium
gluconate solution. Additional doses may be given if
clinical signs of tetany, or q-t interval prolongation
develops, electrolytes, especially calcium and
potassium, should be monitored using diuretics if
necessary.
Adequate urine out put should be maintained using
diuretics if necessary
General supportive measures for shock.

CHRONIC TOXICITY
• Results from long term ingestion of small amounts of
fluoride.
• Effect of chronic fluoride toxicity- severe dental fluorosis
and skeletal fluorosis.
• Fluorosis is an endemic disease in geographic areas where
content of fluoride ion exceeds 2ppm.

Effect Dosage Duration
Dental fluorosis 2 time optional Until 5 years of
(excluding third
molars)
Skeletal fluorosis 10-25 mg/day 10-20years
Kidney damage 5-10 mg/day 6-12months

TOOTHBRUSHES
• The bristle toothbrush appeared about the year 1600 in China
• First patented in America in 1857
• Toothbrushes vary in size and design as well as in length, hardness, and
arrangement of the bristles.
MECHANICAL METHODS

TOOTHBRUSH DIMENSIONS(ADA specifications)
Total length: 6.0-7.5 inches
Length of brushing plane: 1-1.25 inches
Width of brushing plane: 5/16-3/8 inch
Filament height: 7/16 inch
Filament diameter
Soft: .007 inch
Medium: .012 inch
Hard: .014 inch

POWER TOOTHBRUSH
•Better effectiveness in removing plaque and reducing gingivitis than
manual brushes is still not proven.
• Enhance patient motivation.
• Use less brushing force.
•Head: Detachable and replaceable.
•Size: ¼ to 1/2 inch wide by ¾ inch long.

MECHANISM OF ACTION
• Mechanical contact between bristle and tooth.
• Low frequency acoustic energy generating fluid movement, cleans
slightly away from the bristle tips.
• Vibrations interfere with bacterial adherence to oral surfaces.
• Hydrodynamic shear forces disrupt plaque a short distance from
the bristle tips.

Precautions
• Avoid excessive force on restorations.
• Avoid pressure with abrasive dentifrice on exposed
cementum or dentin.
Recommendations
•Encourage ones who prefer to use powered toothbrushes to
do so.
•Poor brushers, children .

TOOTHBRUSHING METHODS
Categorized primarily a/c the pattern
of motion-
• Roll -The Roll Method or Modified
Stillmans Technique
• Vibratory- Charters Technique, Bass
Technique
• Circular- Fones Technique
• Vertical-Leonards technique
• Horizontal- Scrub Technique
(CARRANZA 9TH EDITION)

-Place head of the brush parallel to the occlusal plane.
-Establish a 450 angle between bristles and long axis of
the head.
-Place bristles in the gingival sulcus as well as partially
into the embrasure.
-Move back and forth with vibratory motion 20 strokes
per segment. (CARRANZA 9TH EDITION)
-1 to 15 secs per area. (SOBEN PETER 2ND EDITION)
ADV- Easy to master.
- Concentrates cleaning in areas where plaque
accumulates.
-For any patient with or without periodontal
involvement.
BASS TECHNIQUE

DENTAL FOLSS
• Dental floss is best indicated for plaque and debris removal from
embrasure where the papilla fills the interproximal space, and the
teeth are in contact
• Objectives
-removes plaque and debris from interproximal embrasure and
around implants
-aids in identifying overhanging restorations
-may be used as a vehicle for application of chemotherapeutic
agents in interproximal and subgingival areas

Types of dental floss
• Unwaxed floss:
Thinnest type.
Separates during use to cover larger surface area
• Waxed floss:
Used in tight proximal contacts and overhanging
restorations
• Dental tape:
Wider and flatter than conventional floss.

• Polytetrafluoroethylene (PTFE) floss
Coated with teflon material.
Resistant to fraying.
• Braided nylon floss, G-floss and tapered G-floss
Cleaning dental implants.
• Tufted floss
Variable diameter.

METHOD
• Take a floss 12-18 inches long.
• Wrap around the right middle finger 2-3 times and then around
left middle finger.
• Fulcrum on the cheek or in the mouth.
• Pass through contact using a gentle seesaw motion.
• Pass floss below the gingival margin.
• Wrap it tightly around the tooth in a “C” shape.
• Move the floss up and down, 3 or 4 strokes.
• Remove floss using a seesaw motion.

WOODEN TOOTHPICKS
Used in cases of
• Concave proximal surfaces.
• Furcation areas.
• Class II and III embrasure spaces.
• Also used to introduce fluoride and chlorhexidine into proximal
areas.

Method of use
• Insert toothpick into an angled plastic holder and break off the
longer end.
• Moisten the end with saliva.
• Place the tip at the gingival margin, at 90o to the long axis of the
tooth and trace it around the tooth
• If possible, point the tip at less than a 45 degree angle into the
sulcus, around the tooth surfaces and in root concavities.
• Stop inserting once resistance is felt.
• Concave proximal surfaces are cleaned using an up and down
motion.
• Clean exposed furcation areas by moving the toothpick in and
out.

TYPE I
embrasure
TYPE II
embrasure
TYPE III
embrasure

DISADVANTAGES OF TOOTHPICKS
• Causes breakdown of tooth
• Causes increased interproximal spaces

Enameloplasty
• It is removal of a shallow, enamel
developmental fissure or pit to create a smooth
,saucer–shaped surface that is self cleansing or
easily cleaned.
INDICATIONS-
Fissure depth less than ¼ to 1/3 the thickness of
the enamel.
Procedure
Developmental faults are removed with the
side of a flame shaped diamond stone, leaving a
smooth surface.
Sturdevant V edition

PIT AND FISSURE SEALANTS
A fissure sealant is a material applied to occlusal surfaces
of the teeth in order to obliterate the occlusal fissures
and remove the sheltered environment in which caries
may thrive (Gordon 1962).
- Non invasive
- Preventive
- Seals deep narrow grooves

• Pit: It is defined as a small pinpoint depression located at the
junction of developmental grooves or at terminals of those
grooves. The central pit describes a landmark in the central
fossae of the molars where developmental grooves join (Ash,
1993).
• Fissure: It is defined as deep clefts between adjoining cusps..
These defects occur on occlusal surfaces of the molars and
premolars, with tortuous configurations that are difficult to
assess from the surfaces. (Orbans, 1990)

Milestones of pit and fissure sealants
• 1895, Wilson reported the placement of a dental cement in pit &
fissures to prevent caries.
• Hyatt(1923) Proposed technique called prophylactic odontotomy.
Technique consisted of filling the fissures with silver or copper
oxyphosphate cement as soon as the teeth erupted into the oral
cavity. Later when fully erupted, preparing a small occlusal cavity
and filling it with amalgam.
• Bodecker (1929) -Proposed a technique called fissure eradication.
Involved mechanical eradication of fissures in order to transform
deep, retentive fissures into cleansable areas

o Bunocore (1955) - Advocated the filling of pit and fissure
with bonded resin.
o Mid1960's First materials used experimentally as sealants
were based on cynoacrylates but they were never marketed.
o Bowen (1965) - Reported BIS-GMA material development.
The basis of BIS-GMA resin is the reaction product of
bisphenol A and glycidyl-methacrylate

Indications of pit & fissure sealants
• Presence of deep occlusal pit and fissures of newly erupted teeth
(molars and premolars).
• Presence of lingual pits or palatal pits in relation to upper lateral incisors
and molars.
• Presence of incipient lesion in the pit and fissure system.
• Children and young people with medical, physical or intellectual
impairment with high caries risk.
• Children and young people with signs of higher caries activity and
coming from non-fluoride area.

Contraindications
• Presence of shallow pit and fissures of molars and premolars.
• An open occlusal caries lesion with extension into dentin.
• Presence of large occlusal restoration.
• Presence of proximal caries extending on to occlusal surface.
• Partially erupted tooth where in isolation is a problem.
• Uncooperative patient (getting adequate dry field is a problem).

Types of fissure system
U type almost the same
width from top to bottom
(12-15%)
V type-wide at top and
gradually narrowing
towards the bottom.
(30-35%)
IK type, extremely narrow
slit with a larger space at
bottom.(24-26%)
I type with a extremely
narrow slit.(18-20%) Inverted Y. (5-10%)
FISSURE SYSTEM

TYPES OF PIT AND FISSURE SEALANTS
A. Generations of sealants:
i. First generation sealants- ultraviolet light cure
ii. Second generation - chemically cured (autopolymerized),
iii. Third generation - visible light cure.
iv. Fourth generation- contain fluorides

B. Three different kinds of materials have been used as occlusal
sealants:
1. Resin based sealants- -Polyurethanes
-Cyanoacrylates
-Bisphenol a glycidylmethacrylate(BIS-GMA)
2. Glass ionomer sealants
3. Fluoride containing sealants

C. Type of fissure sealant
1.Filled and unfilled
2.Light cured and chemically (self) cured
3.Clear and tinted

• Polyurethanes
- were among the first to be commercially marketed.
-but proved to be too soft and totally disintegrated in the mouth after 2
or 3 months
• Cyanoacrylates
- they too disintegrated after a slightly longer time.
-their use has been discontinued on account of low shelf-life and high
instability.
• Bisphenol a glycidyl methylaerylate (BIS-GMA)
-is a mixture of Bis-GMA and methyl methacrylate.
-In 1972 Nuva-Seal was the first successful commercial sealant to be
placed on the market. Since then more effective second and third-
generation sealants have become available.

Resin Based Sealants
• are bonded to underlying enamel by
use of acid-etch technique.
• form a tight seal, which prevents
leakage of nutrients to the microflora in
deeper parts of the fissure.
• may be either pure resin, composites
or compomers, and their
polymerisation may be initiated
chemically or by lightcomparative
• In studies of longer duration(>5yrs),
greater longevity was reported for the
chemically cured sealants .

• Work exceptionally well, and serve their function for many years
when placed properly.
• Clinical limitation
 difficulty of handling in a moist environment.
 Unless complete isolation of the tooth has been achieved, salivary
contamination will result in failure of the sealant.
• Many studies have confirmed that resin-based sealants have greater
retention than glass ionomer sealants, but these studies were all
conducted under conditions of good isolation and moisture control.

Glass ionomer Sealants
CLINICAL ADVANTAGES
• is their ability to bond chemically to dentin and
enamel without the use of the acid-etch
technique which makes them less vulnerable to
moisture.
• active fluoride release into the surrounding
enamel.
DISADVANTAGES
• poor retention, over periods, as short as 6 to
12 months.

• However, several studies have found that GIC's exert a cariostatic effect
even after they had disappeared macroscopically. This effect might be
based on remnants of the cement in the fissure as well as increased
levels of fluorides on the enamel surface.
• used as an alternative to resin sealants, especially where resin sealants
are contraindicated.

Clinical situations in which glass ionomer may serve as a good sealant
include-
treatment of children whose primary molars have deeply pitted or
fissured surfaces
 isolation may be difficult
treatment of permanent first or second molars that have not fully
emerged
 situations where a “transitional” sealant may be considered before
placement of a “permanent” resin sealant

Fluoride-releasing sealants
• Incidence and severity of secondary caries are reduced or minimized
around fluoride-releasing materials .
• Fluoride uptake may provide an additional anticariogenic effect if the
fluoride released from its matrix is incorporated into the adjacent
enamel.
• However, further long-term clinical trials are necessary to determine
that the clinical longevity of the sealant retention is not adversely
affected by the presence of incorporated fluoride

CARIES VACCINE
'Vaccine' is an immunobiological substance designed to produce
specific protection against the given disease. It stimulates the
production of protective antibody and other immune mechanisms.
HISTORY
o First developed by Williams 1944 using a homologus lactobacillus
vaccine.
o Bowen in 1976 demonstrated monkeys immunized by whole live
cells of S.mutans developed lesser caries.
o Underwood and Miller published in 1881 bacteria are involved in the
pathogenesis of dental caries was clearly expressed in a paper .

PROSPECTIVE FOR VACCINATION
• Which Type of S. mutans is most important?
- S. mutans (containing strains of serotypes c, e, and f), and
possibly S. sobrinus (serotypes d and g) is more imp in
promoting dental caries.
- The others, S. cricetus (serotype a), S. rattus (serotype b), S.
ferus (serotype c) and S. macacae (serotype c) are only very
rarely or never isolated from human dental plaque.

• The salivary immunoglobulin may act as a specific agglutinin
interacting with the bacterial surface receptors and inhibiting
colonization and subsequent caries formation.
• They inactivate surface glucosyltransferase, which would then
reduce the synthesis of extra cellular glucans resulting in
reducing plaque formation.
• The salivary glands produce secretory IgA antibodies by direct
immunization of the gut associated lymphoid tissue, they
prevent S. mutans from adhering to the enamel surface or they
may prevent formation of dextran by inhibiting the activity of
glucosyltransferase
MECHANIISM OF ACGTION OF CARIES VACCINE

• The gingival crevicular mechanism involves all the humoral and
cellular components of the systemic immune system, which
may exert its function at the tooth surface.
• After subcutaneous immunization with S. mutans, the organism
is phagocytosed and undergoes antigenic processing by
macrophages.

Effective molecular targets for vaccine
development
The subcellular component which are currently being seriously proposed
as vaccines are
(a) Glucosyltransferases (GTF)
(b) Wall associated proteins.
(c) Adhesins.
(d) Glucan- binding protein.

Glucosyltransferase (GTF):-
• Group of the extracellular enzymes involved in synthesis of polymer
(glucans) from sucrose.
• Genes responsible for glucan synthesis in S. mutans are gtfB, gtfC, and
gtfD
• Inactivation of the gtfD gene has also resulted in a mutant with lower
cariogenicity on smooth surfaces
• Passive administration of antibody to GTF in diet can also protect rats
from experimental dental caries.
• Thus, presence of antibody to glucosyltransferase in oral cavity prior
to infection can significantly influence the disease outcome,
presumably by interference with one or more of the functional
activities of the enzyme

Wall Associated Proteins
Two purified proteins from the surface of S. mutans serotype c are
currently being suggested for use as dental caries vaccines-
1. Antigen I/II or B described by Lehner and his colleagues,
2. Antigen A - a small molecular weight cell wall protein
The antibody to the Wall associated proteins should prevent dental
caries by blocking both the colonization of the tooth and the build-
up of dental plaque by S. mutans
Expression of Streptococcus mutans Wall-Associated Protein A Gene in Chinese Hamster Ovary Cells: Prospect for
a Dental Caries DNA Vaccine DCB 2001

Adhesins
• Adhesins are the receptors which allow S.mutans to bind with
pellicle.
• Adhesins from two principal human pathogens, Streptococcus mutans
and Streptococcus sobrinus have been purified.
• Numerous immunization approaches have shown that active
immunization (with intact antigen) or passive immunization can protect
subjects from dental caries

Glucan-binding Proteins (GBP)
• The ability of mutans streptococci to bind to glucan is presumed to be
mediated by cell wall-associated GBP.
• S. mutans secretes at least three distinct proteins with glucan-binding
activity.
• Protection can be achieved by either subcutaneous injection of GBP in
the salivary gland region or by mucosal application by the intranasal
route.
• Saliva samples from young children often contain IgA antibody to GBP,
indicating that initial infection with S. mutans can lead to natural
induction of immunity to this protein.

• Challacombe et al. (1978) stated that IgG antibodies from serum reach
the oral cavity through the gingival crevicular fluid.
• Seward (1971) stated that when the teeth erupted the local
inflammation is common and during this time serum antibodies may
stimulate opsonization and phagocytosis of bacterial cell.

Hajishengallis and Michalek- Oral Microbiol Immunol 1999
Contains structural
elements of either
adhesins or GTF or
GBP.
Also called
attenuated
expression vectors.
Helpful in targeting
vaccine to
appropriate
lymphoid tissue for
mucosal response.
Chemical conjugation
of functionally
associated peptide
components with
bacterial
polyssacharides.
TYPES OF VACCINES
SUB UNIT VACCINE RECOMBINANT VACCINE CONJUGATE VACCINE

-Added to the value of including multiple targets within the vaccine
is that conjugation of protein with polysaccharide enhances the
immunogenicity polysaccharide entity.
- Subcutaneous injection with conjugate-induced systemic IgM and
IgG antibody responses to both peptide and polysaccharide, which
could be boosted upon subsequent injection.

ROUTE OF ADMINISTRATION OF VACCINE
• Both oral vaccine and passive immunization have been suggested as being
possibly safer, than injected vaccine with its resultant high levels of
circulating antibodies
• Subcutaneous administration of S. mutans was used successfully in
monkeys and elicited predominantly serum IgG, IgM, and IgA antibodies.
The antibodies find their way into the oral cavity via gingival crevicular
fluid and are protective against dental caries.
ROUTES OF ADMINISTRATION:
1. ORAL
2. INTRA NASAL
3. TONSILLAR
4. MINOR SALIVARY GLAND
5. RECTAL

Antibody responses
• Three main types of antibody response are:
(I) circulating antibody induced by systemic injection predominantly of IgG
class) which enters the oral cavity by way of gingival crevice.
(ii) a secretory IgA Antibody which is produced by salivary glands.
(iii) local synthesis of IgG antibody in the gingiva has also been recently
reported.

Concerns regarding use of caries vaccine
o Heart cross-reactive antigens HCRA have been identified in S. mutans ,
which when injected in animals may damage to the heart. Streptococcus
mutans antibodies, possibly reacts with, the myosin component of the
heart tissues .
o The precise timing and number of injections which might ultimately be
required in children has not yet been determined.
o Apart from logistic consideration of availability of patients and
coordination with other vaccine programmes, fundamental details of
the level and longevity of immune responses in humans are not yet
known.

Nasal vaccine-newer approach
• Unlike traditional vaccines, which are injected directly into the
bloodstream, the nasal spray vaccine works by way of the mucosal
immune system—an antibody-producing “factory” that resides in the
body’s mucosal surfaces, such as the lining of the respiratory, digestive,
and urogenital tracts.
• By introducing the vaccine into the mucosal cells lining the nasal
passages,( Michalek and Childers et al) hope to trigger an immune
response that will spread throughout the body’s other mucosal sites,
including the mouth.

Caries Vaccine
o Infants, representing the primary target population for a caries
vaccine, become mucosally immunocompetent and secrete salivary
immunoglobulin A antibodies during the first weeks after birth,
o Whereas mutans streptococci colonize the tooth surfaces at a discrete
time period that extends around 26 months of life.
o Therefore, immunization when infants are about one year old may
establish effective immunity against an ensuing colonization attempts
by mutans streptococci.
Hajishengallis and Michalek-
Oral Microbiol Immunol 1999

Introduction
• 'Laser' is an acronym for 'light amplification by the stimulation
emission of radiation'. Its theoretical basis was postulated by
Albert Einstein.
• First tooth exposed to laser light was in 1960.
• Laser light in dentistry is a unique, non-ionizing form of
electromagnetic radiation that can be employed as a controlled
source of tissue stimulation, cutting or ablation, depending on
specific parameters of wavelength, power and target tissue.

Laser use in dentistry
• Although Maiman had exposed an extracted tooth to his ruby
laser in 1960, the possibilities for laser use in dentistry did not
occur until 1989, with the production of the American Dental
Laser for commercial use.
• This laser, using an active medium of Nd:YAG, emitted pulsed light
and was developed and marketed by Dr Terry Myers, an American
dentist.
• Though low-powered and due to its emission wavelength,
inappropriate for use on dental hard tissue, the availability of a
dedicated laser for oral use gained popularity amongst dentists.

• In 1989, experimental work by Keller and Hibst using a pulsed
erbium YAG (2,940 nm) laser, demonstrated its effectiveness in
cutting enamel, dentine and bone.
• This laser became commercially available in the UK in 1995 and,
shortly followed by a similar Er,Cr:YSGG (erbium chromium:
yttrium scandium gallium garnet) laser in 1997, amounted to a
laser armamentarium that would address the surgical needs of
clinical dentistry in general practice

Advantages
o Appreciated by patients as they are more comfortable than drilling.
o With water-cooling appears to have less side effects such as vibration,
heat, sound or iatrogenic damages of adjacent teeth.
o Laser irradiation causes minimal damage to surrounding tissues,
minimal thermal changes of dental hard tissue composition, and creates
favorable surface characteristics (e.g. reduced smear layer, smooth
surface, and little debris).

LASERS IN CARIES PREVENTION
o Yamamoto and Oaya used as YAG laser at energy densities of 10 to 20
J/cm2 and demonstrated that the lased enamel surface was more
resistant to in vitro demineralization than non lased enamel.
o Stern and Sognnaes demonstrated in vivo that enamel subjected to
10 to 15 J/cm2 showed a greater resistance to dental caries than the
controls.
o Stern concluded that energy levels below 250 J/cm2 did not
permanently alter the pulp but necrosis could occur when energy
level, reached 1800 J/cm2 or higher.
o Lobene and Colleagues, observed that C02 laser irradiation to tooth
enamel caused small amounts of hydroxyapatite to be converted to
more insoluble calcium orthophosphate apatite. This paved the way
for widespread use laser in prevention of caries.

LASERS IN CARIES PREVENTION
• In 1985 Terry Myers used Nd:YAG laser for debridement of incipient
caries. When a topical fluoride treatment was performed after argon
laser conditioning of enamel, an even more dramatic reduction in
enamel acid demineralization was observed
• Studies have demonstrated the potential of laser pre-treatment of
enamel or tooth roots to inhibit subsequent acid-induced dissolution or
artificial caries-like challenge in the laboratory (Westerman et al, 1994).
• Nelson, 1987 demonstrated the potential caries-inhibitory effects of
pulsed carbon dioxide laser irradiation of enamel at low frequencies.
• Inhibition of subsequent demineralization of enamel of up to 50% with
the laser conditions they used, and reported that these effects were
wavelength-dependent.

EFFECTS OF LASERS ON ENAMEL
• Treatment with lasers can reduce the rate of subsurface
demineralization in enamel
• It may be due to combination of reduced enamel permeability
with a reduced solubility promoted by melting, fusion, and
recrystallization of enamel crystallites, which could seal the
enamel surface
• Studies showed the reduction of enamel solubility could be due
to changes in the ultrastructure of enamel, such as the reduction
of water and carbonate contents, the increase in the hydroxyl ion
contents, formation of pyrophosphates, and the decomposition
of proteins

Use of individual lasers
• Nd:YAG laser is indicated for use in superficial pigmented caries
removal.
• Erbium family(Er:YAG , Er:YSGG) of lasers are the lasers of choice &
most efficient for enamel, dentin & caries removal.
• They have shown to reduce the bacterial population & produce a
analgesic effect on the tissues.
• Lasers can also be used for sealant placement- to clean, sterilize
,clearly visualize & even etch the enamel grooves.

Different types of lasers and their
wavelengths
The frequent wavelengths used in studies for caries prevention are:
• Nd:YAG (λ = 1.64 µm)
• Er:YAG (λ = 1.94 µm)
• Er,Cr:YSGG (λ = 1.79 µm)
• Argon (λ = 488–514 nm)
• CO2 (λ = 9.6 and 10.6 µm)

Carbon Dioxide Lasers
• The CO2 laser was demonstrated to be the most successful laser for
increasing enamel’s acid resistance due to the higher absorption in
phosphate radicals of hydroxyapatite.
• Depending on the fluence applied, wavelengths of 9.3, 9.6, 10.3, and
10.6 µm promote melting of the enamel surface, which can be
achieved at a temperature of 1200°C.
• The 10.6-µm laser line is the strongest one, and most of the
commercially available
• The role of CO2 lasers in dental caries prevention has been explored
since the 1960s, and continuous wave mode and pulsed lasers are
used.
• The combination of CO2 laser irradiation with several types of
fluoride application showed important results and it was suggested
that laser irradiation can reduce initial enamel demineralization,
inhibit subsequent lesion progression, and enhance fluoride
adsorption.

Effectiveness of lasers in caries prevention
• Laser treatment particularly in combination with topical fluoride
application (NaF, APF), increase resistance against caries,
desensitization of hypersensitive dentine (Er:YAG) and improve
marginal seal under composite resin (Nd:YAG).
• C02-laser = Caries inhibition up to 82.7%
• Er:YAG-laser = Reduction in surface lesion depth (root surfaces 39%,
primary enamel surfaces 56%)
• Nd:YAG-laser (with Duraphat) = Caries inhibition (pits and fissures
43%, smooth surfaces 80%).

Conclusion
• Dental caries is a disease that usually can be successfully prevented or
controlled
• It is an important task for the dental team to teach individuals to take
correct actions to minimize the risk for the disease.
• It is also possible to identify and evaluate factors of importance for
cavity formation.
• By targeted actions, such risk factors can usually be changed, resulting
in a reduced risk for caries.
• In clinical practice, more emphasis is paid presently on treatment rather
than prevention. A lot of time, energy and manpower can be saved if
more attention is paid to prevention.
• Research in new evidence based – methods in prevention would help us
in reducing the morbidity associated with dental caries.

References
• Sturdevent’s Art and Science of Operative Dentistry – 5th edition
• Cariology. Ernest Newbrun. 3rd edition
• Essentials of Preventive and Community dentistry. Soben Peter. 2nd
edition
• Shafer’s textbook of oral pathology. 5th edition
• Clinical uses of fluorides. Stephen H.Y. Wei
• The biological basis of dental caries. Lewis Menakar

• Fluorides in caries prevention. J.J. Murphy.
• Fluorides in dentistry. Ole Feferkov.
• J Dent Research vol 77,June 1998
• General dentistry March/April 2007, Vol. 55 No. 2, Page 105-111.
• British dental journal volume 202 no. 1 jan 13 2007.
• British dental journal volume 202 no. 8 apr 28 2007 .

Caries prevention

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