Introduction to Preventive Dentistry

Dr Hakan Çolak

Ishik University School of DentistryDepartment of Restorative Dentistry

A brief introduction to oral diseases: caries, periodontal disease, and oral cancer

Introduction

•By the late 1990s,▫treating dental disorders cost more than it

did to treat mental disorders, digestive disorders, respiratory diseases, and cancer, at least in Canada (Leake 2006).

•The only group of disorders that exceeded dental treatment in terms of direct cost of illness was cardiovascular disorders

Introduction

•In 2010, an estimated $108 billion was spent on dental services in the United States.

“prevention is better than a cure”

Dental disorders are an enormous burden to society, especially when one now considers the

connection between poor oral health and systemic illness, which is a topic that is becoming

increasingly important and a focus of other scholarly books.

Dentistry

treatment orientedprevention

General disease categories of focus in dentistry

•Dental decay•Periodontal disease•Oral cancer

Definition of disease preventionAnticipatory action taken to reduce the possibility of an event or condition occuring or developing or to minimize the damge that may result from the event or condition if it does occur

Levels of prevention

Primary Prevention

Secondary Prevention

Tertiary Prevention

Prevention strategy

Primary Secondary Tertiary

Disease Status Susceptible Asymptomatic Symptomatic

Effects Reduced disease incidience

Reduced prevalance/consquence

Reduced complicationsdisability

Primary prevention

•Maintaining a disease-free state“When lifestyle changes are made early on, the

risk for developing dental disease are minimized”

Primary prevention•Primary prevention can be defined as the

action taken prior to the onset of disease, which removes the possibility that the disease will ever occur.

•It signifies intervention in the pre-pathogenesis phase of a disease or health problem.

•Primary prevention may be accomplished by measures of “Health promotion” and “specific protection”

Primary prevention (cont.)

•It includes the concept of "positive health", a concept that encourages achievement and maintenance of "an acceptable level of health that will enable every individual to lead a socially and economically productive life".

•Primary prevention may be accomplished by measures designed to promote general health and well-being, and quality of life of people or by specific protective measures.

Primary prevention

Health promotion

Life style and behavioral changes

Nutritional interventions

Health education

Environmental modifications

Specific protection

Immunization and seroprophylaxis

Use of specific nutrients or supplementations

Protection against occupational hazards

Safety of drugs and foods

Control of environmental hazards,

Health promotion

•Health promotion is “ the process of enabling people to increase control over the determinants of health and thereby improve their health”.

EXAMPLE OF HEALTH EDUCATION & PROMOTION SERVICES, ACTIVITIES, AND PROGRAMS

• Nutrition Counseling• Nutrition education• Safe driving programs• First aid training• Aerobic fitness, dance, and exercise, high impact• Smoking cessation, group approach• Walking for fitness• Weight loss, group approach

Approaches for Primary Prevention

•The WHO has recommended the following approaches for the primary prevention of chronic diseases where the risk factors are established:

▫a. Population (mass) strategy ▫b. High -risk strategy

Population (mass) strategy• “Population strategy" is directed at the whole

population irrespective of individual risk levels.

• For example, studies have shown that even a small reduction in the average blood pressure or serum cholesterol of a population would produce a large reduction in the incidence of cardiovascular disease

• The population approach is directed towards socio-economic, behavioral and lifestyle changes

High -risk strategy

•The high -risk strategy aims to bring preventive care to individuals at special risk.

•This requires detection of individuals at high risk by the optimum use of clinical methods.

Primary Prevention• Goal:

Reduce number of new cases• Rationale:

By reducing exposure rates and increasing resistance, can reduce number of new cases

• Target population: Those who are most likely to be exposed and/or could

increase their resistance• Typical activities:

Remove or reduce source of the risk Educate and make aware of disease risk

Include behavioral changes to reduce exposure Improve general health

• Outcome measure: incidence of exposure; incidence of disease

Secondary prevention and early inter-vention •Reverse the initiation of disease

•An outcome of good health can still be achieved

“when incipient enamel lesions are reversed before cavities form, when gingivitis is reversed before periodontitis sets in”

Secondary prevention• It is defined as “ action which halts (stop) the progress of a

disease at its incipient stage and prevents complications.”

• The specific interventions are: early diagnosis (e.g. screening tests, and case finding programs….) and adequate treatment.

• Secondary prevention attempts to arrest the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.

• It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

Secondary prevention (cont.)•Secondary prevention attempts to arrest

the disease process, restore health by seeking out unrecognized disease and treating it before irreversible pathological changes take place, and reverse communicability of infectious diseases.

•It thus protects others from in the community from acquiring the infection and thus provide at once secondary prevention for the infected ones and primary prevention for their potential contacts.

Secondary Prevention• Goal:

Reduce number of new cases; reduce number of severe cases

• Rationale: By reducing number of exposures and early disease that

progress to more severe disease, mortality and morbidity can be reduced

• Target population: Those who have been exposed to the disease-causing agent

or have early symptoms of the disease• Typical activities:

Screening for exposure and/or disease Post-exposure prophylaxis Early treatment to reduce impact of disease/reverse course

• Outcome measure: incidence of disease

Primary and Secondary Prevention

Tertiary Prevention• Goal:

Reduce number of complications, deaths• Rationale:

By reducing disease severity and increasing recovery, can reduce number of premature deaths or complications

• Target population: Those who have disease and need treatment

• Typical activities: Treatment tailored to the patient Rehabilitation to promote recovery

• Outcome measure: incidence of death and long-term disability

A hierarchy of prevention and treatment of oral diseases

Levels of Prevention Table

Pharmacy in Public Health

Example of Prevention Levels:Motor vehicle injuries•Primary

▫Building divided airways•Secondary

▫Requiring safer cars (airbags) or▫Driving practices (wearing seatbealts)

•Tertiary▫EMS systems

Example of Prevention Levels:High Blood Pressure

•Primary▫Dietary education and exercises

•Secondary▫BP control medications

•Tertiary▫Treatment of diease sequelae of HBP

Example Infectious Disease• Disease: Seasonal influenza• Primary prevention:

▫ target population – everyone; all ages▫ Goal – reduce number of cases of flu▫ Rationale – reduce exposures; bolster immune system▫ Actions

Education: cough and sneeze etiquette, hand washing, know risk groups Immunization: vaccination to develop antibodies

• Interventions at the individual level: ▫ vaccinate; good nutrition, sleep, and exercise to optimize health; good

cough/sneeze etiquette; frequent hand washing; avoid others who are sick

• Interventions at the community/population level:▫ Provide access to vaccines▫ Use Public Service Announcements (PSAs) to educate public▫ Prepare plans for schools, worksites, and hospitals/clinics for outbreak

Example: Infectious Disease• Disease: Seasonal influenza• Secondary prevention:

▫ target population – everyone who has been exposed to the virus▫ Goal – reduce number and severity of cases of flu▫ Rationale – early treatment to reduce severity of disease▫ Actions

Screening: identify those who are most likely exposed from those who are not Early treatment Immunization: vaccination to develop antibodies

• Interventions at the individual level: ▫ Post flu symptoms and suggestions for self-care▫ Provide antiviral within 48 hours of symptom onset

• Interventions at the community/population level:▫ Use quarantine or isolation measures; ban gatherings of large

groups; travel restrictions▫ Send sick children home from school; enforce sick leave at work

Example: Infectious Disease• Disease: Seasonal influenza• Tertiary prevention:

▫ target population – everyone who has influenza▫ Goal – reduce number and severity of flu-related complications

and deaths▫ Rationale treatment and rehabilitation can reduce deaths and

help return individual to a normal lifestyle▫ Actions

Provide supportive care and early treatment of complications Use rehabilitation to increase recovery of normal lifestyle

• Interventions at the individual level: ▫ Tailor treatment to symptoms; monitor and treat complications

• Interventions at the community/population level:▫ Ensure access to treatment (health insurance, local clinics

available)▫ Protect employees who are out sick from losing jobs▫ Research to find better treatments; monitor resistance patterns

Disease Prevention

•Primary prevention for dental diseases (dental caries and periodontal disease) ▫eating a healthy diet, ▫maintaining low intake of fermentable

carbohydrates, ▫practicing meticulous oral hygiene

throughout life, ▫reducing the other risk factors, (smoking)

Disease Prevention

•Secondary prevention (‘caution’)▫“suggests that the disease has started but

can be reversed, and good health can still be achieved

•Forexample▫incipient carious lesions (white spot enamel

lesions) can be arrested and reversed using appropriate ‘preventive’ measures

Disease Prevention

•Secondary periodontal disease prevention might include other strategies such as the chemical elimination of bacteria known to initiate periodontal disease

Disease Prevention

•Primary, secondary, and tertiary prevention are integral to the dentist daily practice.

•Disease prevention attributes the health of the client, whether the client is an individual or a community, to the interaction among four key elements

Disease Prevention•Human biology,

▫which is the basic biology of an individual resulting in both physical and mental aspects of health, such as diabetes

Disease Prevention

•Environment, ▫encompasses everything external to the

body and over which the individual has little or no control, such as natural disasters and industrial pollution

Disease Prevention

• Lifestyle ▫includes all decisions made by individuals

that affect their health and over which they, more or less, have control, such as smoking, diet, exercise, excessive alcohol consumption, and wearing seatbelts

Disease Prevention

• Healthcare organization▫encompasses the quantity, quality, and

administration of the healthcare system, such as the availability of dental hygiene appointments and other health services needed, the purchase of magnetic resonance imaging (MRI) technology, and the monies to finance research

SCENARIO•Alper Yılmaz, a father of two college students,

smokes 20 cigarettes per day. Engin Bozkurt, her dentist, recommends she consider joining the tobacco cessation program she is running at the Ankara Dental Center.

•Engin encourages Alper to do so because Alper is at risk for oral cancer. Alper says, “I know I should quit. I realize I should because it is likely killing me. I just can’t even consider doing it right now.”

SCENARIO•Scenario provides a good example of the

denist using a disease-prevention approach. Blaming Mary for putting herself at risk for cancer is an oversimplification of why Mary smokes.

•Rather, the four elements of human biology, environment, lifestyle, and healthcare organization should be included in counseling Mary, because they influence Mary’s tobacco-use habit in the following ways:

SCENARIO• Human biologic element: Alper is physically and

psychologically addicted to tobacco.• Lifestyle element: It was not until the 1960s that

society began to be informed that tobacco use has negative health effects. By this time it was the socially acceptable thing to do. Smoking was the norm; the nonsmoker was in the minority. Today, although the message is clear, Alper still chooses to use tobacco. The evidence for this choice appears to be related in part to the psychosocial gratification of tobacco use as part of her lifestyle

SCENARIO•Environmental element:

▫Relevant environmental elements are as follows: Turkish society increasingly is taking a strong anti–

tobacco-use stance, as is evident by many policies now in effect to reduce tobacco use in public places such as airplanes, restaurants, and worplaces.

The tobacco industry employs a large number of people, thus contributing to the economy of the country.

The government receives revenue from the sales of tobacco products

SCENARIO• Healthcare organization element:

▫ In 1970 the Turkish Health Ministry stated that smoking is a health hazard.

▫ Initially, much of the healthcare response was focused on the treatment of tobacco-related diseases instead of the prevention of the tobacco-use habit.

▫ Even though significant healthcare liras/dollars are spent on the treatment of such diseases, additional funding for tobacco cessation programs is required to help many tobacco users overcome their addiction

•Recognizing and discussing these elements with Mary provide a more comprehensive analysis of her problem and may motivate her to think more objectively about finding solutions for her tobacco use.

The global burden of oral diseases

Definition of Health

“a state of complete physical, mental and social well-being and not merely the

absence of disease or infirmity”

World Health Organization 1946

Indicators of a Good Quality of Life

•true physical, mental, and social well-being, includes being in good general

health

Risk factors associated with oral diseases and their consequences

Poverty in Developing Counties

•burden of chronic and severe caries•periodontal disease•tooth loss•oral cancer•other oral disorders

How to poor oral health can be broken?

•Improving ▫the socio-economic status▫education▫literacy▫oral education▫access to affordable dental care

List of some problems related to oral health care in developing countries

•few organized public health programs•uneven distribution of dental services

▫( concentration of dentists in urban centers)

•lack of modern dental services

Dental decay (dental caries): global patterns

extreme shortage of sugar

The reason for the decline in caries worldwide

• Introduction of the electric refrigerator▫increased the consumption of fresh

fruit,vegetables and fresh milk•Vitamin D-fortified milk

▫Calcium intake• Penicillin

▫effective against streptococci•Non-cariogenic sweeteners (xylitol and

sorbitol)•Fissure sealants •Chlorhexidine

a) Dental caries levels (DMFT) of 12-year-olds worldwide

Dental caries levels (DMFT) of 35–44-year-olds worldwide. Reprinted from Petersen 2003, with permission from John

Wiley & Sons, Inc.

New Zealand Cohort Study

• A cohort of children was followed from the time of their birth in 1972–1973, and their caries experience recorded until age 30

•Only dental study that followed a group from birth to adulthood

15.1% experiencing a high increment of caries, 44.7% experiencing a moderate level of caries,

40.2% very low level of caries

Caries prevention: how far we have come in one century!

terminal stage of caries is the loss of a tooth

early intervention (minimal intervention dentistry)

“Extension for Prevention”• It has taken over a century

for dentistry to advance from the pioneering

“extension for prevention” concepts proposed by Dr.

G.V. Black. • By removing a significant

proportion of tooth structure so that only the

easily cleansed tooth surfaces remained, there

was a reduction in the need for further operative

treatment

Minimal Intervention Dentistry

“a principle of treatment in dentistry in which early intervention minimizes tooth

destruction because the disease is diagnosed prior to cavitation, and steps

are taken to remineralize the enamel and arrest the decay”

•“The main components of MID are assessment of the risk of disease, with a focus on early detection and prevention; external and internal remineralization; use of a range of restorations, dental

materials and equipment; and surgical intervention only when required and only

after disease has been controlled.”

A clinical image of a typical class II amalgam restoration showing ‘extension for prevention’ as well as an amalgam restoration in the furcation area of the exposed root.

Photo courtesy of Dr. Aaron Fenton, University of Toronto.

Kansas City Library

Caries results when all of the factors that contribute to caries overlap. One must have a tooth, plaque bacteria, fermentable carbohydrate, saliva,

and enough time in order for a carious lesion to develop (red color,

center). Several factors influencing each

component, listed in the diagram, affect the rate and severity of the

caries

Responsibility of Dental Professionals

•Recognition of early enamel lesions (arrested or active)

•Provide the initial care•Reversing caries•Guide patients to maintain the good

habits at home

An introduction to dental decay

Caries as an infectious disease

•Dental caries does not occur in a sterile mouth.

• No mouth can ever be made sterile. •The conditions in the oral cavity are ideal

for the growth of bacteria that metabolize sugar to acids.

•The oral cavity is generally a warm place, at body temperature (37°C) encouraging the growth of bacteria.

Caries as an infectious disease

Caries is an infectious disease that is actually transmissible, usually when the mother, infected with

S. mutans, infects her infant when the child’s first teeth appear in the oral cavity (Kulkarni et al.1989).

The role of saliva

Because of its buffering capacity and ability to

neutralize acids, a simple intervention such as

stimulating the saliva with chewing gum can

arrest white spot lesions and prevent cavities from forming (Stookey 2008).

The role of dietary sugars

One of the strategies in prevention of caries is to limit access to the more cariogenic sugars and substitute them with the anti-cariogentic ones

Plaque biofilms and their role in caries and periodontal disease

Caries

Periodontal Disease

Biofilm

(a) 2-Tone. Plaque on a teenager revealed with Young’s cherry-flavored 2-Tone Disclosing Solution. New plaque is stained red, and old plaque is stained blue to identify areas continually missed

(b) Red-Cote. Plaque revealed on adult teeth with Red Cote (Butler G.U.M.) disclosing solution. Chewable

tablets produce the same effect

Changes in oral flora under controlled culture conditions.

The demineralization–remineralization balance in caries

•As plaque thickens in vivo, and becomes dominated by cariogenic bacteria

•More plaque there is, the more acid is produced

•acids have a longer time to penetrate into the enamel under thick biofilm

•When the saliva reaches the acids they are washed away and neutralized by the salivary buffers▫This allows the tooth to remineralize

The repeated cycle of ‘sugar attacks.’

Preventive interventions

Preventive interventions aim to modify the steps in the repeat demineralization and remineralization

cycles.

1. Neutralize the plaque acids

•This can be done by adding buffers such as sodium bicarbonate (baking soda) to the saliva to boost (support) its ability to neutralize acid

2. Improve hygiene

•With bacterial levels low, less acid is produced. Also, plaque layers don’t have a chance to grow thick; saliva can penetrate better to the enamel surface through thin layers of plaque.

3.Introduce antimicrobials

•Since caries is a disease caused by bacteria, simply eliminating the bacteria or controlling their growth would go far to reduce the caries incidence. ▫Chlorhexidine▫xylitol▫ozone▫even experimental antibodies

have been used to control bacterial growth.

4. Stimulate saliva

•Saliva contains numerous components that fight tooth decay (buffers, remineralizing minerals, antimicrobial enzymes, antibodies).