This document provides an introduction to primary preventive dentistry. It defines key terms like health, primary prevention, secondary prevention, and tertiary prevention. It discusses strategies to reduce dental caries and periodontal disease like plaque control, fluoride therapy, sealants, and education. It emphasizes that primary prevention is most effective and least costly, and that early diagnosis and treatment are important when primary prevention fails. The goal of preventive dentistry is maintaining maximum oral health through a person's life.

1. Introduction to Primary
Preventive Dentistry

2. • 1. Define the following key terms: health, primary prevention, secondary
prevention, and tertiary prevention. Also, provide one specific example of
each.
• 2. Name three convenient categories that aid in classifying dental disease
and in planning oral-disease prevention and treatment programs.
• 3. Name four strategies and two administrative means for reducing the
prevalence of dental caries and/or periodontal disease.
• 4. Cite two early actions that are essential for arresting the progression of
the plaque diseases once primary preventive measures have failed.
• 5. Explain why the planned application of preventive-dentistry concepts
and practices, including use of sealants and fluoride therapy, when coupled
with early detection and immediate treatment of the plaque diseases, can
result in a zero or near zero annual extraction rate.

3. INTRODUCTION…
• In the year 2000, in the Executive Summary of the Surgeon Generals
Report a on the "Oral Health in America," some of the major
challenges facing American dentistry were listed.
• It is appropriate to abstract a number of these problem areas in
order to better understand the role that prevention can play in their
solution

4. ……….. problem areas………..
• 1. Tobacco: This is a major societal health problem with very strong
relationships to dentistry.
• Smoking has a very devastating relationship to periodontal disease
and oral and pharyngeal cancer, while the use of chewing tobacco is
associated with oral cancer as well as root decay

5. CHILDREN
• a. Dental caries is the most common chronic childhood disease.
• b. Over 50% of 5- to 9-year-olds have at least one cavity or filling; by
age 17, the percentage has increased to 78%.
• c. As a part of childhood, children have many injuries to the head,
face, and neck.
• d. Twenty-five % of the children have not seen a dentist before
entering kindergarten.
• e. More than 51 million school hours are lost each year to dental-
related illness

6. ADULT
• a. Most adults show signs of periodontal or gingival diseases. Severe
periodontal disease [measured as 6 millimeters of periodontal
attachment loss (pockets)] affects about 14% of adults aged 45 to 54.
• b. Employed adults lose more than 164 million hours of work each
year because of dental disease and dental visits.
• c. A little less than two-thirds of adults report having visited a dentist
in the past 12 months.

7. OLDER ADULT
• a. Twenty-three % of 65- to 74-year-olds have severe periodontal disease
(characterized by 6 millimeters or more of periodontal attachment loss).
• At all ages, men are more likely than women to have more severe disease.
• b. About 30% of adults 65 years and older are edentulous, compared to
46% 20 years ago.
• c. Oral and pharyngeal cancers are diagnosed in about 30,000 Americans
annually.
• Nine thousand die from these diseases each year. Prognosis is poor.
• d. At any given time, 5% of Americans aged 65 and older (currently some
1.65 million people) are living in long-term care facilities where dental care
is problematic.

8. Public Health Service
• Throughout the entire Surgeon General's report, there is major emphasis
on the great disparity between those who get dental care and those that
do not have access to a dental facility.
• These are the people who are poor, are mentally handicapped, those that
are disabled, children,9-12 the aged,13 and those without dental
insurance.
• To address these problems a national program and guidelines of dental
care is needed that will include these dentally neglected groups.
• The questions then become, "What kind of a national program should it
be? Is it possible to take care of so many people with so few dental health
professionals?

9. Cont…
• It is the goal of the dental profession to help individuals achieve and
maintain maximum oral health throughout their lives.
• Success in attaining this objective is highlighted by the decline of
caries throughout the Western world, and the dramatic reduction of
tooth loss among adults in the United States.
• This progress has been mainly attributed to the use of water
fluoridation and fluoride-containing products, toothpastes and mouth
rinses and the growing acceptance and practice of primary preventive
care.
• Yet, dental caries remains a major public-health problem

10. Cont…
• All health professions emphasize that patients should seek entry into
well-planned preventive programs.
• For dentistry, lack of prevention results in more restorations,
periodontal treatment, extractions, and dentures.
• The changeover in priority from treatment to prevention will require
active leadership and health promotion by the dental profession,
consumer advocates, public health educators, and health-policy
planners.

11. Cont…
• Public-health delivery systems, such as the military, national and state
public-health services, and industrial organizations that provide
benefits to their personnel, have usually been in the forefront of such
change because of the economic advantages accruing to the provider
and health benefits to the recipients.
• Service in the Oklahoma City area. The total number of visits
increased by 10%, yet the number of dental personnel remained
constant.
• The percentage of preventive services increased, along with a
decrease of restorative procedures.

12. Benefits of Primary Preventive Dentistry to
the Patient
• For the patient who thinks in terms of economic benefits and enjoyment of life, prevention pays.
• Many studies document the prevalence of dental disease, but behind these numbers there is little
mention of the adverse affects on humans caused by dental neglect.
• One study points out that 51% of dentate patients have been affected in some way by their oral
health, and in 8% of the cases, the impact was sufficient to have reduced their quality of life.
• If preventive programs are started early by the patient long-range freedom from the plaque
diseases is possible a sound cost-benefit investment.
• After all, the teeth are needed over a lifetime for eating. Speech is greatly improved by the
presence of teeth.
• A pleasant smile enhances personality expression. Teeth also contribute to good nutrition for all
ages.
• At rare times, teeth have even provided a means of self-defense.
• On the other hand, the absence of teeth or presence of broken-down teeth often results in a loss
of self-esteem, minimizes employment possibilities and often curtails social interaction.

13. Benefits to the Dentist
• Possibly the first benefit of preventive dentistry is the fulfillment of the
moral commitment to the Hippocratic Oath that was taken by health
professionals at graduation "to render help to those in need, and to do no
harm."
• Through ethics and training, the dentist should derive a deep sense of
satisfaction by helping people maintain their oral structures in a state of
maximum function, comfort, and aesthetics.
• A well-balanced practice that actively seeks to prevent disease but is also
able to care for those individuals where prevention has failed should
prosper.
• Patients can be outstanding public relations advocates if they are
convinced that their dentist and staff are truly interested in preventing
disease.

14. BENEFIT..CONT…
• If for no other reason, a dentist should consider prevention to avoid
possible legal problems.
• A now strongly supported law for medicine, but to a lesser extent for
dentistry, requires that prior to treatment, all options preventive as well as
treatment should be explained to secure informed patient consent.
• This discussion should include a comparison of health benefits and hazards,
as well as the economic and the oral-health benefits of prevention.
• Long-term patients, the lawyers and the court system are taking a more
unsympathetic attitude toward practitioners who have permitted a disease
to progress over many years without having taken some accepted primary
preventive actions to have slowed, or halted its progress.
• Patients no longer tolerate supervised professional neglect.

15. WHAT IS PRIMERY PREVENTION
• Health is what we want to preserve, and it is defined as a state of
complete physical, mental, and social well-being, and not merely the
absence of disease or infirmity.
• For instance, some individuals may actually be in excellent health but
believe, for some reason logical to them, that they have oral cancer.
• Such individuals do not have an optimum mental well-being and will
continue to worry until they are somehow convinced otherwise that they
are indeed healthy.
• Another person may be functionally healthy, although facially disfigured,
and as such be socially shunned throughout life. Thus, health can at times
be what the patient thinks and not the actual condition of the body.

16. CONT….HEALTH
• Even the terminology "preventive dentistry" has different
connotations to different people.
• As a result, preventive dentistry can be arbitrarily classified into three
different levels.
• Primary prevention employs strategies and agents to forestall the
onset of disease, to reverse the progress of the disease, or to arrest
the disease process before secondary preventive treatment becomes
necessary.

17. SECO…
• Secondary prevention employs routine treatment methods to
terminate a disease process and/or to restore tissues to as near
normal as possible.
• Tertiary prevention employs measures necessary to replace lost
tissues and to rehabilitate patients to the point that physical
capabilities and/or mental attitudes are as near normal as possible
after the failure of secondary prevention

19. CONT…
• In going from primary to tertiary prevention, the cost of health care
increases exponentially, and patient satisfaction decreases proportionately.
• An excellent example of the comparative cost of these two levels of care
was the treatment of an individual with poliomyelitis.
• It has only been a few years ago that the cost of the polio vaccine was only
a few dollars.
• The use of the polio vaccine to prevent the onset of the disease was highly
effective. But, for someone not adequately immunized, the cost of
treatment for poliomyelitis and subsequent rehabilitation approximated
$50,000 or more for the first 7 weeks of hospitalization and outpatient
care.
• Yet, the individual receiving the $50,000 worth of tertiary preventive
treatment and the attendant disability was certainly not as happy as the
one who benefited from only a few dollars' worth of primary preventive
care.

20. ANOTHER…EXA
• Another appropriate example is the fluoridation of drinking water.
This costs approximately $0.50 per year per individual, yet it reduces
the incidence of dental caries in the community by 20 to 40%.
• If this primary-preventive measure is not available, the necessary
restorative dentistry (secondary prevention) can cost approximately
100 times more, or about $50.00 per restoration.

21. TERTIA…
• Finally, if restorative dentistry fails, as it often does,
prosthetic devices must be constructed at an even
greater cost.
• This great disparity between the lower cost of
prevention and the much higher cost of treatment
must be seriously considered if the United States is
to develop an affordable national health program in
which dentistry is represented.

22. FAILURE..OCCURE…
• This text emphasizes primary prevention, and specifically focuses on
primary prevention as it applies to the control of dental caries and
periodontal disease.
• On the other hand, it must be recognized that primary prevention
often fails for many reasons. When such failure occurs, two actions
are essential to contain the damage:
(1) early identification of the disease (diagnosis) and
(2) immediate treatment of the disease

23. Categories of Oral Disease
• For planning purposes, dental diseases and abnormalities can be
conveniently grouped into three categories:
(1) Dental caries and periodontal disease, both of which are acquired
conditions,
(2) opportunistic infections, oral cancer, HIV/AIDS), and
(3) Craniofacial disorders which would include a wide variety of conditions
ranging from heredity to accidents.
For instance, the ordinary seat belt and the air bags in a car exemplify how a
simple preventive measure can greatly reduce the facial injuries of car
accidents.

24. CONT…
• Both caries and periodontal disease are caused by the presence of a
pathogenic dental plaque on the surfaces of the teeth and hence are
known as the plaque diseases.
• Any major reduction in the incidence of caries and periodontal
disease will release resources for the investigation and treatment of
conditions included in the acquired and craniofacial category.

25. CONT…
• The ideal, or long-range planning objectives for coping with both
dental caries and periodontal disease should be the development of a
preventive delivery system and methods to eventually attain a zero or
near-zero disease incidence for the target population.
• However, a more realistic and feasible shorter-term goal is the
attainment of a zero or near-zero rate of tooth loss from these
diseases by integrated preventive and treatment procedures.

26. Strategies to Prevent the Plaque Diseases
• Before providing an overview of methods used to implement primary
prevention programs, it is important to point out that both dental
caries and periodontal disease are transmissible diseases.
• If a child is considered at high risk for caries, one of the parents
usually the mother can usually be identified as high risk; if a child has
periodontal problems, usually one of the parents is also afflicted.
• Any infectious (acquired) disease can only begin if the challenge
organisms are in sufficient numbers to overwhelm the combined
manmade and body defenses and repair capabilities.

27. CONT……
• For this reason, all strategies to prevent, arrest, or reverse the ravages
of the plaque diseases are based on
(1) reducing the number of challenging oral pathogens,
(2) building up the tooth resistance and maintaining a healthy gingiva,
and
(3) Enhance repaire processes

28. STRATEGIES
• In general, periodontal disease is a disease that involves the soft
tissue and bone surrounding the affected teeth.
• Caries involves the demineralization and eventual cavitation of the
enamel and often of the root surface.
• If the incipient lesions (earliest visible sign of disease) of caries and
periodontal disease are recognized at the time of the initial/annual
dental examination, they can often be reversed with primary
preventive strategies.
• For caries, the visible incipient lesion is a white spot, which appears
on the surface of the enamel as a result of subsurface acid-induced
demineralization.

29. STRATEGIES…CON
• For periodontal disease, the visible incipient lesion is gingivitis
• An inflammation of the gingiva that is in contact with the bacterial
plaque. Not all "white spots" go on to become caries, nor do all cases
of gingivitis go on to become periodontal disease.
• In both cases, i.e., caries and periodontal disease, it should be noted
that if dental plaque did not exist, or if the adverse effects of its
microbial inhabitants could be negated, the decrease in the incidence
of the plaque diseases would be very dramatic.
• Based on these facts, it is understandable why plaque control is so
important in any oral-health program.

30. STRATEGIES… …GEN
• To control the plaque diseases with available methods and
techniques, strong emphasis has been directed to general strategies
to reduce caries and two administrative requirements

31. General Strategies
1. Mechanical (toothbrush, dental floss, irrigator, or rinse)
2. Chemical plaque control.
Use of fluorides to inhibit demineralization and to enhance
remineralization; use of antimicrobial agents to suppress cariogenic
bacteria.
3. Sugar discipline.
4. Use of pit and fissure sealants, when indicated, on posterior occlusal
surfaces

32. GENERAL STRATE….
• 5. Education and health promotion.
• 6. Establish access to dental facilities where diagnostic, restorative,
and preventive services are rendered, and where planned recalls
based on risk are routine.

33. Plaque Control
• Dental plaque is composed of salivary proteins that adhere to the teeth, plus
bacteria and end-products of bacterial metabolism.
• Plaque collects more profusely in these specific areas because none of these
locations is optimally exposed to the normal self-cleansing action of the saliva,
the abrasive action of foods, nor the muscular action of the cheeks and tongue.
• Plaque decreases in thickness as the incisal or occlusal surface is approached.
Little plaque is found on the occlusal surface except in the pits and fissures.
• As would be expected, plaque forms more profusely on mal-posed teeth or on
teeth with orthodontic appliances, where access for cleaning is often difficult

34. CONT….
• In the gingival sulcus between the gingiva and the tooth, little or no
plaque normally accumulates until gingival inflammation begins, at
which time the bacterial population increases in quantity and
complexity.
• This is the beginning of gingivitis that, if continued, may eventually
result in an irreversible periodontitis.

35. CONT…
• It is important to differentiate between the supragingival and the
subgingival plaques.
• The supragingival plaque can be seen above the gingival margin on all
tooth surfaces; the subgingival plaque is found in the sulcus and
pocket below the gingival margin, where it is not visible.
• The supragingival plaque harbors specific bacteria that can cause
supragingival (coronal) caries.

36. CONT….
• Gram-positive aerobic cocci (Streptococcus and
Staphylococcus) were predominant.
• The pathogenicity of each of the plaques can vary independently of
the other.
• For example, it is possible to have periodontal disease with or without
caries, to have neither, or to have a shifting status of caries or
periodontal disease, or both.

37. CONT….
• The pathogenicity of the subgingival plaque is becoming an increasing
concern.
• Not only does it cause periodontal disease, which is a lifelong
debilitating disease of the tooth supporting tissues, but it is now
believed that there is a causal relationship between periodontitis and
such diverse conditions as, cardiovascular disease, diabetis mellitus,
chronic respiratory disease, and immune function.
• There is also the possibility in some cases that this is a bi-directional
association where the oral problem begins with a systemic condition,
instead of vice versa.

39. IDENTIFY…..
• In many cases, plaque is difficult for a patient to identify.
• This problem can be In many cases, plaque is difficult for a patient to
identify, Where problem can be overcome, at least in the case of the
supragingival plaque, by the use of disclosing agents, which are
harmless dyes such as the red-staining agent, FD&C Red.

40. CONT…
• tablets which are chewed, swished around the mouth, and then
expectorated.
• Once disclosed, most of the supragingival plaque and food debris can be
easily removed by the daily use of a toothbrush, floss, and an irrigator .
• Plaque can also be removed at planned intervals by the dental hygienist or
a dentist as part of an oral prophylaxis.
• This is a procedure that has as its objective the mechanical removal of all
soft and hard deposits, followed by a polishing of the tooth surfaces.
However, because daily removal of the plaque is more effective, it is the
individual not the hygienist or the dentist who is vital for preserving
lifelong intact teeth

41. DEVELOPMENT…CARES
• One site where neither the dentist nor an individual can successfully
remove plaque is in the depth of pits and fissures of occlusal surfaces
where the orifices are too small for the toothbrush bristle to
penetrate .
• flow of saliva or the muscular action of the cheeks and tongue also
have little influence over the eventual development of caries in these
areas.
• Not coincidentally, the occlusal surface is where the greatest
percentage of caries lesions occur.
• For this reason, it is recommended that all occlusal surfaces with
deep convoluted fissures be sealed with a pit-an fissure sealant.

42. CONT….
• This should not be unexpected, since by definition, dental plaque is
composed of salivary residue, bacteria, and their end-products, all of which
are always present in the mouth. Thus, a good plaque-control program
must be continuous. It must be a daily commitment over a lifetime.
• Not only does the daily removal of dental plaque reduce the probability of
dental caries; equally important, it also reduces the possibility of the onset
of gingivitis.
• This occurs when the metabolic end-products of the periodonto patho-
gens that are contained in the plaque irritate the adjacent gingival tissues,
producing an inflammation (i.e., gingivitis).
• This gingivitis can be arrested and reversed (cured) in the early stages by
proper brushing, flossing, and irrigation, especially if accompanied with
professional guidance.

43. PLAQUE
• Plaque concentrates mineralizing ions such as calcium, phosphate, magnesium,
fluoride and carbonates from the saliva to provide the chemical environment for
the precipitation and formation of calculus, a concretion that adheres firmly to
the teeth.
• This additional mass of periodontopathic plaque covering the rough porous
surface causes the stagnation of even more bacteria and is responsible for the
damage to the periodontal tissues. Also, the hard, irregular calculus deposits
pressing against the soft tissues serves to exacerbate the inflammation caused by
the bacteria alone.
• The daily removal of plaque can successfully abort or markedly retard the build-
up of calculus.
• Once the calculus forms, the brushing and flossing usually used for plaque
control does not remove the deposits.
• At this time, the dental hygienist or dentist must intercede to remove the calculus
by instrumentation

44. CHEMICAL PLAQUE CONTROL….
• Rapidly growing in importance as a supplement to mechanical plaque
control (but not as a replacement), is chemical plaque control.
• This approach utilizes mouth rinses containing antimicrobial agents that
effectively help control the plaque bacteria involved in causing both caries
and gingivitis.
• For helping to control gingivitis, a popular and economical over-the
counter product is Listerine;
• the most effective prescription rinse is chlorhexidine.
• Many studies indicate that chlorhexidine is as effective in suppressing
cariogenic organisms as it is effective in controlling gingivitis and
periodontitis.

45. Fluorides
• The use of fluorides has provided exceptionally meaningful reductions
in the incidence of dental caries.
• Because of water fluoridation, fluoride dentifrices, and mouth
rinses, dental caries is declining throughout the industrialized world.
Historically, the injection of fluoride into water supplies in the mid-20th
century resulted in a decrement of approximately 60 to 70% in caries.

46. FLOURIDE..CONT
• Many times during the past years, it has not been possible to
fluoridate city water supplies because of political, technical, or
financial considerations.
• In such cases, it is still possible to receive the systemic benefits of
fluoride by using dietary supplements in the form of fluoride tablets,
drops, lozenges, and vitamin preparations.
• Some countries permit fluorides to be added to table salt. Elsewhere,
ongoing research studies are being conducted to determine the anti
cariogenic effect of fluoride when placed in milk, and even sugar.

47. TOPICAL …………..
• The extent of caries control achieved through topical applications is
directly related to the number of times the fluoride is applied and the
length of time the fluoride is maintained in contact with the teeth.
• Research data also indicate that it is better to apply lower
concentrations of fluoride to the teeth more often than to apply
higher concentrations at longer intervals

48. FLUORIDE…AND..CLH
• Fluorides and chlorhexidine are the most effective agents used by the
profession to combat the plaque diseases.
• The fluorides help prevent demineralization and enhance
remineralization, while chlorhexidine severely suppresses the mutans
streptococci that cause the demineralization.
• Chlorhexidine also helps suppress bacteria causing the inflammation
of periodontal disease.

49. FLUORIDE…KEY…
• It is believed that fluoride has several key actions:
• (1) it may enter the dental plaque and affect the bacteria by
depressing their production of acid and thus reduce the possibility of
demineralization of the teeth;
• (2) it reacts with the mineral elements on the surface of the tooth to
make the enamel less soluble to the acid end-products of bacterial
metabolism; and It facilitates the remineralization (repair) of teeth
that have been demineralized by acid end-products.
• The latter is probably the most important of these three effects.

50. Sugar and Diet
• (1) diet, (2) inherent factors of host resistance, (3) the number of challenge
bacteria located in the dental plaque, and (4) time .
• But, as soon as sugar and sugar products are included in the diet of the host,
bacterial acid production markedly increases in the plaque.
• This release of acid end-products is the major cause of the initiation and
progression of caries.
• The continuous snacking of refined carbohydrates that characterizes modern
living results in the teeth being constantly exposed to bacterial acids .
• For example, the prolonged adherence of sugar products to the teeth, such as
that experienced after eating taffies and hard candies, results in prolonged
production of the plaque acids that are in direct contact with the tooth surface.
Thus, if caries incidence is to be reduced, all three factors total intake of sugar,
consistency of the cariogenic foods, and especially frequency of intake should be
considered

51. Reducing…substitutes..
• Possibly one of the most promising means of reducing caries incidence in the
United States has been the wide-scale acceptance of sugar substitutes such as
NutraSweet, Sweet'n Low, and Splenda.
• Xylitol has been found to inhibit decay, reduce the amount of plaque and plaque
acid, inhibit growth and metabolism of streptococci, reduce decay in animal
studies, and contribute to remineralization.
• It is considered noncariogenic and cario static.
• One of the favorite ways to take advantage of xylitols unique anti-caries property,
has been to use it to sweeten chewing gum, a product that is a popular item
among school children.

52. Pit and Fissure Sealants
• Approximately 90% of all the carious lesions in the mouth occur on the
occlusal surfaces of the posterior teeth.
• These surfaces represent only 12% of the total number of tooth surfaces,
so that occlusal surfaces with their deep pits and fissures are
approximately eight times as vulnerable as all the other smooth surfaces.
• With the use of sealants, a thin layer of a plastic, called Bis-GMA, is flowed
into the deep occlusal pits and fissures of teeth not having open carious
lesions.
• Since no cavity preparation is necessary, no pain or discomfort
accompanies sealant placement.
• Following the placement of the sealant in the deep fissures, the newly
created fossae can be effectively cleaned with a toothbrush.

53. CONT…
• As long as the sealants are retained, no bacteria or bacterial acids can
affect the sealed areas.
• If they are not retained, no damage to the teeth results from a
retreatment.
• In another study, approximately 95% retention occurred over 2 years.
• With these performances, the average life of the sealant approximates the
10 years projected for an amalgam.
• It should be emphasized that sealant placement should be followed by a
topical fluoride application to the teeth, because fluorides are most
effective in protecting the smooth surfaces and least effective on the
occlusal surfaces, a situation that is the reverse of the results expected of
the sealants

54. Public Dental Health Education
• If the profession of dentistry can control caries effectively through
plaque control, systemic (ingested) and topical (local application) use
of fluorides, dietary control, and the use of plastic sealants, two
important questions need to be asked.
• If daily toothbrushing, flossing of teeth, and irrigation removes
plaque and food residue, why are these simple procedures not used
effectively to control both caries and periodontal disease?

55. Public dental health…con
• Probably the best answer to these questions is that people must first
know what they need to do as well as how it is to be done.
• Unfortunately, the public has relatively little information about the
tremendous potential of primary preventive dentistry for reducing
their adverse exposures to the plaque diseases.
• Without this information, it is difficult to convince people that they
can greatly control their own dental destiny.
• Many individuals think of dentistry as a treatment-oriented
profession that specializes in periodontal treatment, restorations,
endodontics, exodontias, and prosthetics.

56. PATIENT..EDUCATION
• In dentistry, a one-on-one relationship between the patient and the
health professional is still a basic approach to patient education and
motivation.
• The main thrust of public dental-health education and oral-health
promotion is provided by the various dentrifice manufacturers
advocating the daily tooth brushing routine and biannual visits to the
dentist for a checkup.
• The effectiveness of this approach was underlined by the long-
running advertisement for the first marketed, stannous fluoride
containing, Crest toothpaste, "Look Mom, no cavities."

57. Cont..
• Knowing facts and applying the information are two separate processes.
The application of knowledge by an individual requires a personal
commitment
• it is a this point of personal commitment that most primary preventive-
dentistry programs fail.
• If people embraced the daily use of mechanical and chemical plaque
control regimens, the risk of caries and gingivitis would be minimized.
• If people would exercise reasonable sugar discipline the possibility of
caries development would be further reduced.
• If individuals rejected the use of cigarettes as well as smokeless ("spit")
tobacco, oral and pharyngeal cancer and periodontitis would be much less
prevalent.
• Clearly, education, motivation, and behavior modification are a necessary
part of enjoying good oral and general health.

58. Cont…applying..the..information…
• A sound, well-planned program of dental-health education and promotion is lacking in
the curriculum of the great majority of primary and secondary schools.
• Few people can discuss the advantages and disadvantages of water fluoridation and the
topical application of fluorides.
• Few have any detailed information about the dental plaque and the disease-inducing
potentialities of this bacterial film.
• Few people know why sugar is cariogenic.
• Even fewer people know that gingivitis can be cured, but that if allowed to progress,
there is the possibility of a life long future of periodontal disease treatment and
maintenance.
• Finally, the public has not been adequately informed that the timely use of sealants and
remineralization therapy provides a hope of possessing a full intact dentition for life.
• Even though the Internet has greatly expanded the delivery of health education, there is
always the question of the quality of information (or misinformation) that is
disseminated.

59. CONT….
• Ideally, school-based and public-education programs should exist to
help people to help themselves in applying primary preventive
procedures.
• The same programs should also teach all individuals to recognize the
presence of oral disease.
• Only the individual can seek immediate treatment when pain or
disease occurs.

60. Access to Comprehensive Dental Care
• This factor is probably the most important of all preventive options.
• Without the benefit of a routine periodic dental examination, it is difficult for individuals to realize that they
are vulnerable to oral disease.
• The first indication of a dental problem is pain, which is the wrong starting point for prevention.
• An example of the benefits of combining prevention with the advantages of early identification, prevention
and treatment is seen in the New Zealand school-dental-nurse program.
• the New Zealand School Dental Service, a dental nurse visits every primary and secondary school in the
country at approximately 6-month intervals. At that time, all children receive a dental examination.
• If necessary, the dental nurse applies fluoride varnish to achieve remineralization of incipient caries,
removes visible calculus, or when indicated, refers the child to a dentist for more complex treatment
requirements.
• As a result of this program, the average rate of extractions dropped from 19 per 100 students in 1960, to 2
per 1,000 in 1979. From 1973 until 1992, the average decayed, missing, or filled permanent teeth (DMFT) for
12- to 14-year-old children plummeted from 10.7 to 1.88 per child.
• Approximately 96% of all New Zealand schoolchildren are enrolled in this program. Unfortunately, relatively
few comprehensive primary-preventive dentistry school programs are being conducted in the United States
school systems. However, there are more than 1,400 School Based Dental Health Clinic now in operation in
the United States

61. Prognostic and Diagnostic Tests
• Because it is impossible to apply vigorously all the preventive procedures
to all the people all the time,
• it would be desirable to have some tests to indicate the extent of caries
and periodontal disease risk of an individual at any given time.
• This need is highlighted by the fact that an estimated 60% of all carious
lesions in schoolchildren occur in 20% of the students. It would save much
time to be able to identify this 20% group of high-risk students without
having to examine an entire school population.
• To be successful, such screening tests should be simple to accomplish,
valid, economical, require a minimum of equipment, be easy to evaluate,
and be compatible with mass-handling techniques.

62. Screeing..test
• Laboratory methods exist for counting the number of bacteria in the saliva. If the
caries-causing mutans streptococci or lactobacilli counts are high.
• whereas a low count permits the opposite assumption.
• A second general method for estimating caries susceptibility is by use of a
refined-carbohydrate dietary analysis to
(1) evaluate the patient's overall diet with special attention to food preferences
and amounts consumed and
(2) to determine if the intake of refined carbohydrates is excessive in quantity or
frequency.
• A well-balanced diet is assumed to raise host resistance to all disease processes,
whereas a frequent and excessive intake of refined carbohydrates (i.e., sugar) has
been associated with a high risk of caries development.
• The dietary analysis is very effective when used as a guide for patient education.

63. Screening…gingivitis…
• The onset of gingivitis is much more visible than the early
demineralization that occurs in caries.
• The sign of impending periodontal disease is an inflammation of the
gingiva that can be localized at one site, or generalized around all the
teeth. Red, bleeding, swollen, and a sore gingiva are readily apparent
to dentist and patient alike

64. Remineralization of Teeth
• Both demineralization and remineralization occur daily following the cyclic ebb-
and flow of the caries process during and after eating meals and snacks.
• An eventual caries lesion develops over a period of time when the rate of acid-
induced demineralization of teeth exceeds the capability of the saliva to
demineralize the damaged enamel components.
• A negative mineral balance at the enamel-plaque interface, if continually
repeated, results in an incipient lesion that eventually can become an overt
lesion.
• It often requires months, or even years, for the overt lesion to develop.
• During this time, under proper conditions, remineralization can reverse the
progress of the caries front, with the mineral components coming from the saliva.
• There is a physiological precedent for such a mineralization.

65. Cont…
• Clinical experience indicates that as long as the lesion is incipient (i.e.,
with no cavitation), remineralization is possible.
• The outstanding electron microscope research contributions of
Silverstone several decades ago clearly demonstrated that
demineralized tooth structure could be remineralized.

66. Cont…incipient..lesion..
• Several reports from now indicate that even when the caries front of
an incipient lesion extends past the dentino-enamel junction, it can
be remineralized.

67. SUMMARY
• Each year more than $60 billion is spent in the United States for
dental care, mainly for the treatment of dental caries and periodontal
disease or their sequelae.
• Yet, strategies now exist that with patient knowledge and
cooperation, could greatly aid in preventing, arresting, or reversing
the onset of caries or periodontal disease.
• The zeal and thoroughness with which these preventive measures
should be prescribed and used are indicated by the information
obtained from the clinical and roentgenographic oral examination,
dietary analysis, patient history, and laboratory tests.

68. Summary..cont…
• The six general approaches to the control of both caries and
periodontal disease involve (1) plaque control, (2) water fluoridation
and use of fluoride products for self-care and for professionally
initiated remineralization procedures, (3) placement, when indicated,
of pit and fissure sealants, and (4) sugar discipline. Supporting these
measures are (5) public and private enterprise financed media
distributed programs extolling the benefits of oral health and
proprietory products for family prevention; and (6) access to a dental
facility where diagnosis, comprehensive preventive, restorative
treatment, and planned recall and maintenance programs are
available.

69. Cont…
• If at the time of the clinical and roentgenographic examinations,
emphasis was placed on searching out the incipient lesions ("white
spots") and early periodontal disease (gingivitis), preventive strategies
could be applied that would result in a reversal or control of either/or
both of the plaque diseases.
• It is essential that both the profession and the public realize that
biologic "repair" of incipient lesions, and "cure" of gingivitis is a
preferred alternative to restorations or periodontal treatment.

70. SUMMARY..CONT
• Even if these primary preventive dentistry procedures fail, tooth loss
can still be avoided.
• In practice, the early identification and expeditious treatment of
caries and periodontal disease greatly minimizes the loss of teeth.
When such routine diagnostic and treatment services are linked with
a dynamic preventive-dentistry program that includes an annual
dental examination and recall program based on risk assessment,
tooth loss can realistically be expected to be reduced to zero or near-
zero