Understanding and Treating Dental Caries in Young Children and Young Adults

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Tooth decay is the end result of a transmissible bacterial infection that is preventable. This disease is called caries. Yet just placing fillings on teeth, which is what dentists have been doing all along, does not in the long haul stop this disease process. The bacteria responsible for tooth decay generate acids from the fermentable carbohydrates we eat every day.

transcript

Understanding and Treating

Dental Caries in Children and

Young  Adults:  It’s  Not  Just  

Filling Teeth

Dr. Stephen Abrams Dr. Ian McConnachie

Overview of the Day

Introduction

Cariology 101

Risk Factors

Detection

Remineralization Therapies

Early Childhood Caries

Clinical Presentation

Sealants, Preventive Resin Restorations, ICON

Office Integration

Summary

Take Home Materials

Dentistry and the Public; Some Concerns

Survey results CDA Initiative

• Current reputation has precarious level of trust and skepticism of the value that dentists offer

• More people see dentists as business people than see dentists as doctors

• Dental plans matter; level of coverage takes precedence over advice of dentists

• Dentists see patients often as misinformed, which presents opportunity for education

• Dentists see relationships as key to building trust and maintaining a strong patient base

What this Lecture is Not

A clinical  technique  “how  to”

A commercial for specific products

No commercial sponsorship*

Materials shown are representative

examples, not endorsements*

*Disclaimer

Dr. Abrams is President and CEO of Quantum Dental Technologies (QDT), the creator of The Canary System

Dr. McConnachie is an unpaid dentist advisor

To QDT

Acknowledgements

• DR. MARIELLE PARISEAU

– www.shapingthefutureofdentistry.org

– Dentists Leaders in Health: Thinking Outside of the Mouth

– http://www.jcda.ca/article/b157

• DR. CLIVE FRIEDMAN

– U. of Western Ontario and U. of Toronto

• Access  to  Today’s  Presentation  on  Shaping  the  Future of Dentistry website next week

Today and Evidence-Based Dentistry

Integration of Evidence-based literature with clinical opinion

If  it  is  opinion,  we’ll  try  to  say  so

Recommendation

Very good overview of the concepts and the process –

J Can Dent Assoc 2001 Apr-Nov

• Clinical practice guidelines in dentistry Part I and II

• Evidence-based dentistry Part I-VI

Concepts of EBD

TIP: www.aapd.org

PubMed

http://www.ncbi.nlm.nih.gov

• Great free open source site for search of

literature

• Access to article abstracts and full articles

• Service of

– U.S. National Institutes of Health – U.S. National Library of Medicine

What is Caries?

NIH Consensus Conference on Caries 2001

“Dental  caries  is  an  infectious,  communicable disease resulting in destruction of tooth structure by acid-forming bacteria found in dental plaque, an intraoral biofilm, in the presence of sugar."

NIH Consensus Conference March 2001

Caries is a bacterial infection caused by specific bacteria.

Caries is a reversible multi-factorial process.

In other words, caries is an infectious disease with cavitation being the last step of the process

The Paradigm Shift

One can place a number of restorations in a mouth and yet not treat the underlying disease. The bacteria remain in the plaque biofilm on the remainder of the teeth capable of creating new areas of decalcification and cavitation.

We need to shift from a surgical approach to a disease management & preventive approach.

CHMS Oral Health Data

CHMS vs U.S. Data

The Problem

Relevant Issues arising in the article

• “I  had  a  lot  on  my  mind,  and  brushing  his  teeth  was  an  extra  thing  I  didn’t  think  about  at  night”

• CDC and P report on increase in decay in preschoolers 5 years ago-first time in 40 yrs.

• “No  one  told  us  when  to  go  to  the  dentist,  when  we  should  start  using  fluoride  toothpaste”

• Dentists routinely recommend general anesthesia for preschoolers with extensive problems-cost  to  parents…ranges  from  $2,000  to  $5,000

• Using general anesthesia has risks-vomiting,  nausea,…brain  damage  even  death

• “It’s  not  just  about  kids  in  poverty…”

• Brushing twice a day used to be nonnegotiable, but not anymore-”He  doesn’t  want  his  teeth  brushed.  We’ll  wait  until  he’s  more  emotionally  mature”

• Staff treated a 3-year-old who was making his second visit to the operating room for dental work. The boy arrived with a bottle of Coca-Cola

0

10

20

30

40

50

60

Percentage of children &adolescents ages 5 to 17

Caries

Asthma

Hay Fever

ChronicBronchitis

Note: Data included decayed or filled primary and or decayed filled or missing permanent teeth. Asthma, chronic bronchitis and hay fever based upon household respondent about the sampled 5 – 17 year old Source NCHS 1996

Oral Health in America: A Report of the Surgeon General DHHS 2000

Dental Caries is one of the most common diseases among 5 – 17 year olds

Public Perception

– In other words – NO BIG DEAL

Our Reality

A VERY BIG DEAL

Lower body weight

Psychological impact

Caries is a transmissible bacterial infection and a multifactorial disease that reflects change in one

or more significant factors in the total oral environment.

(NIH Consensus Conference 2001)

Terminology

Early Childhood Caries (ECC)

“The  presence  of  one  or  more  decayed  (noncavitated or cavitated lesions), missing (due

to caries), or filled tooth surfaces in any primary

tooth  in  a  child  71  months  of  age  or  younger.”

Definition from National Institute for Dental and Craniofacial research (NIDCR) workshop 1999

Terminology

Severe Early Childhood Caries (S-ECC)

“Any  sign  of  smooth-surface caries in a child younger than 3

years  of  age”                                                              AAPD

“One  or  more  cavitated, missing (due to caries), or filled smooth surfaces in primary maxillary anterior teeth, or decayed, missing or filled score of at least 4 (Age 3), 5 (age 4), or 6 (age 5)  surfaces” Drury et al 1999

Diagnosis involves recognition of these changes rather than s i m p l y n o t i n g c a v i t i e s

• Don’t treat underlying disease

• Don’t address plaque biofi lm i s s u e s

• Don’t change risk level

We need to from a surgical approach to a RISK management & preventive approach.

Cariology

What is Tooth Decay?

Caries Risk?

Caries Progression

What do you need to create tooth decay?

• Teeth

• Food particularly carbohydrates

• Bacteria in Plaque or Biofilm

Plaque containing bacteria

Sugars & Carbohydrate Exposure

Tooth

When all three are present, and enough time passes, large carious lesions will occur

Caries

Elements involve in the Caries Process

Restorations

•Restorations have no measurable effect on bacteria.

•Restorations have a finite life span.

•Each replacement restoration leaves less tooth structure.

•Restorations increase the risk of an abscess.

•Restorations may increase the risk of tooth fracture & periodontal disease.

Caries Evolution

Caries Progression

Caries Progression

Caries Progression

Caries Progression

White Spot Lesion Really a subsurface lesion

External (outer) surface

Internal loss of minerals

White Spot Lesion

Early Carious Lesion in Enamel

ENAMEL SALIVA PLAQUE PLAQUE

SUGARS

Polysaccharides

Bacterial Enzymes

Salivary buffers

Plaque buffers

Calcium Salts

Calcium Salts

ACID

mouth inside of tooth

Demineralization Re-mineralization

ENAMEL

Pathogenesis of Dental Caries

The Caries Balance

Pathological Factors •Acidogenic Bacteria (S. Mutans, S. Sobrinus & Lactobacilli) •Reduced Salivary Flow •Frequency of fermentable carbohydrate ingestion

Caries

Protective Factors •Saliva flow & components •Proteins, calcium, phosphate, fluoride, immungloulins

•Antibacterials In saliva and extrinsic Fluoride, Chlorhexidine, iodine

No Caries Adapted from Featherstone, J. D. B., JADA 2000

Demineralization

Dental Mineral Acid soluble

Calcium phosphate + Organic

Acids

Demineralization Calcium &

Phosphate into solution

If fluoride is present in the water between the crystals it inhibits mineral loss

Remineralization

Calcium in tooth Water (from saliva) +

Phosphate In tooth

Water (from Saliva)

Remineralization •Builds on existing crystal remnants •New mineral less soluble •Fluoride helps

Fluoride speeds up remineralization creating a less soluble mineral

pH

FAP HAP

deposit caries erosion

demineralization

remineralization

pH

Critical pH

Carious lesion forms at pH 4.5 - 5.5 Erosion lesion forms when pH <

Cyclic Process of Decay

Demineralization

Remineralization

Bacteria plus food makes the saliva very acidic within

5 minutes

Saliva pH is normal

30 minutes after eating

Stephan Curve

Stephan RM. JADA 1940;27:718-723 Changes in hydrogen-ion concentration on tooth surfaces and in carious lesion. Stephan RM. JADA 1944; 23:257-266 Intra-oral hydrogen-ion concentrations associated with dental caries activity.

?

?

?

• Type & amount of

carbohydrate available

• Bacteria present

• Salivary composition &

flow

• Other food ingested

• Thickness and age of

dental plaque

What Contributes to the Extent of pH Drop after Glucose Exposure?

Resting plaque pH:

• Constant within each individual, but

differences among groups.

• Caries-inactive – resting pH ~ 6.5 - 7

• Caries-prone – lower resting pH

Bacterial composition affects metabolic properties of plaque

Storage form of CHO energy source when diet is depleted

When  the  host  does  not  ‘eat’,  cariogenic  bacteria  still  produce acids from stored carbohydrates

What Contributes to the Differences in Resting Plaque?

pH Change During the Course of The Day

Caries is a Bacterial Infection

Web of Transmission

PATIENT SIBLINGS

PLAYMATES/PEERS

CAREGIVERS

2008 Copyright T .Rodriguez,DDS

Mode of Transmission

Both this spoon and pacifier have been in the mouth and then cultured in a selective broth. They show S. Mutans growing on them.

Courtesy of Ivoclar Vivadent.

Caries Is An Infectious Disease

“Demonstration of Mother to Child Transmission of Streptococcus mutans using Multilocus Sequence Typing” Lapirattanakul et al. Caries Research 2008

“Genotypic Diversity of Mutans Streptococci in Brazilian Nursery Children Suggests Horizontal Transmission”

Mattos-Graner et al. J Clin. Microbiology 2001

Bacteria Involved in Caries

Streptococcus Mutans, Streptococcus Sobrinus Lactobaccillus

Streptococcus Mutans

• Caries initiators • Triggers the process that leads to mineral

loss and that allows bacteria to penetrate tooth structure

• Capacity to adhere to the tooth surface • Sugar transport system • Production of lactic acid from sugar • Tolerance to an acid environment

Lactobacillus

• They are responsible for caries progression.

• They do not adhere to tooth surfaces but need carious lesions to colonize.

– Pits and fissures

– Cavities

– Marginal gaps of restorations

– Brackets

Plaque & Biofilms

Some New Thoughts on Plaque

• A well organized, cooperating community of microorganisms.

• The slime layer that forms on rocks in streams is a biofilm .

• It is estimated over 95% of bacteria existing in nature are in biofilms.

What is a Biofilm?

Phases of Plaque Formation

Pellicle Formation

Thin bacteria free layer forms within minutes on cleaned tooth surfaces

Pellicle Attachment

Within hours bacteria attach to pellicle & slime layer forms around the bacteria Formation

Young Supragingival Plaque

Mainly gram + cocci & rods

Some gram – cocci & rods

Aged Supragingival Plaque

Increase in percentage of gram – anaerobic bacteria

Subgingival Plaque

Tooth Attached & Epithelial Attached & Un-Attached Plaque

Bacteria cluster together to form sessile mushroom-shaped micro-colonies Each micro colony is an independent community with its own customized living environment Protective slime layer surrounds the micro-colonies Fluid channels allow movement of nutrients & bacterial by-products through the biofilm Primitive communications system of chemical signals

Host Factors That Influence Microbial Composition

Dental Plaque: Caries & Periodontal Disease

Marsh  et  al.  “Dental  Plaque  Biofilms:  Communities  Conflict  &  Control”  Periodontology  2000  December  2011  

Control of Biofilms

Control of nutrients • addition of base-generating nutrients (arginine) • reduction of gingival cervicular flow through

anti-inflammatory agents • inhibition of key microbial enzymes Control of biofilm pH • sugar substitutes • antimicrobial agents • fluoride • stimulate base production

Agents for Control of Biofilm

Vast majority of agents for control

of biofilm are broad spectrum

non-specific microbiocide agents:

• CHX

• Triclosan

• Essential Oils (Listerine)

• Povidone Iodine

Saliva

A Very Important Component in the

Oral Environment

Multifunctionality

Salivary Families

Anti- Bacterial

Buffering

Digestion

Mineral- ization

Lubricat- ion &Visco- elasticity

Tissue Coating

Anti- Fungal

Anti- Viral

Carbonic anhydrases, Histatins

Amylases, Mucins, Lipase

Cystatins, Histatins, Proline- rich proteins, Statherins

Mucins, Statherins

Amylases, Cystatins, Mucins, Proline-rich proteins, Statherins

Histatins

Cystatins, Mucins

Amylases, Cystatins, Histatins, Mucins, Peroxidases

adapted from M.J. Levine, 1993

Saliva’s  Protective  Function

• Mechanical cleansing (water/flow)

• Lubrication of tissues and teeth (secreted proteins)

• Buffering of acids (HCO3-, HPO42-, peptides)

• Maintaining tooth integrity

– Post-eruptive maturation (Ca2+, F-, HPO42-)

– Mineralization equilibrium (Ca2+, F-, HPO42-)

– Pellicle

• Maintaining tissue integrity

• Regulation of the oral flora

Saliva & Oral Function

Food processing (water)

• Taste solute

• Bolus formation and swallowing (secreted proteins)

• Digestion (secreted proteins)

Speech (water, secreted proteins)

• Lubrication and rehydration

Excretion

• Small molecules (nitrate, thiocyanate. etc.)

• May interact with salivary proteins, oral bacteria

Remineralization Of Enamel & Calcium Phosphate Inhibitors

•Early caries are repaired despite presence of mineralization inhibitors in saliva

•Sound surface layer of early carious lesion forms impermeable barrier to diffusion of high mol.wt. inhibitors.

•Still permeable to calcium and phosphate ions

• Inhibitors may encourage mineralization by preventing crystal growth on the surface of lesion by keeping pores open

Summary

• Caries is an infection disease

• Bacteria live in Biofilms not Petri dishes

• pH drives changes in biofilm ecosystem

• Caries is reversible if detected early

• Initially, demineralization begins below the tooth surface

• White spots and brown spots are surface phenomena

• Demineralization / Remineralization is a balancing act depending upon bacterial metabolism

Risk Factors

Caries is a Disease

Risk Defined

• Risk is a prediction that disease will occur or progress

• Risk is distinct from disease and cannot be accurately predicted from the disease state

• Risk is determined by risk factors

Caries Risk Factors • Low Socio-economic Status • High Titers Of Cariogenic Bacteria • Poor Oral Hygiene & Cariogenic Diet • Poor Family Dental Habits & Irregular Access to Dental Care • Developmental Or Acquired Enamel Defects • Genetic Abnormality Of Teeth • Many Multi-surface Restorations (High DMFT, DMFS)

– Restoration Overhangs And Open Margins

• Eating Disorders • Drug Or Alcohol Abuse • Active Orthodontic Treatment • Presence Of Exposed Root Surfaces • Physical Or Mental Disability With Inability Performing Oral Health

Care • Xerostomia: Medication, Radiation Or Disease Induced

Risk Factors

• Social Determinants

• BioMedical

Risk Factors: History

• Child has special needs

• Socio-economic status of the family

• Parents & siblings have decay

Risk Factors: Dental History

• Child has decay

• Time elapsed since last cavity

• Child wears braces or oral appliance

• Reduced saliva flow

Risk Factors: Dental History

• Frequency of brushing

• Daily between meal exposure to sugars & carbohydrates

–On demand bottle

– Sippy cup

– Sports drinks & carbonated beverages

Risk Factors: Fluoride exposure

• Fluoridated water

• Fluoride supplements

• Fluoridated toothpastes

Risk Factors: Clinical Evaluation

• Visible plaque

• Gingivitis

• Areas of enamel demineralization

– ICDAS 1 – 3

• Enamel defects / deep fissures

Risk Factors: Clinical Evaluation Part 2

• Radiographic evidence of caries

• Levels of Strep Mutans in saliva

– Use commercial tests

– Not critical for establishing risk

Risk Definitions & Treatment Recommendations

Low Risk

Caries Risk Indicators

•Dmfs , ½ childs age •No new lesions in 1 year •No white spot lesions •Low titers of mutans strep

•High SES

Diagnostic Procedures

•Examination interval 12 – 18 months •Radiograph interval 12 – 14 months •Initial strep mutans evaluation

Preventive Therapy

•Fluoridated tooth paste

Restorative Therapy

•None

Medium Risk

Caries Risk Indicators

•dmfs>  ½  child’s  age •1 or more lesions in 1 year •infrequent white spot lesions •moderate titers of mutans strep •middle SES

Diagnostic Procedures

•Examination interval 6 - 12 months •Radiograph interval 12 months

•Initial strep mutans evaluation

Medium Risk (continued)

Preventive Therapy

•Fluoridated tooth paste •Systemic fluoride supplements •Professional topical fluoride treatment •Sealants

Restorative Therapy

•Monitor enamel proximal lesions •Restoration of progressing lesions •Restoration of cavitated lesions

High Risk

Caries Risk Indicators

•dmfs>  child’s  age •2 or more lesions in 1 year numerous white spot lesions •high titers of mutans strep •low SES •appliances in mouth high frequency of sugar consumption.

Diagnostic Procedures

•Examination interval 3 - 6 months •Radiograph interval 6 -12 months •Strep mutans testing to monitor compliance

•Diet analysis

High Risk (continued)

Preventive Therapy

•Fluoridated tooth paste •Systemic fluoride supplements (age & water supply considerations) •Professional topical fluoride treatment •Sealants •Daily home fluoride or antimicrobials

•Dietary counselling and adjustments

Restorative Therapy

•Monitor enamel proximal lesions •Restoration of progressing lesions •Restoration of cavitated lesions •Aggressive treatment to minimize continued caries progression

CAMBRA

Caries Management by Risk Assessment

The Caries Balance

ad Bacteria

bsence saliva

ietary habits poor

The Caries Balance

ad Bacteria

bsence saliva

ietary habits poor

aliva adequate

nti- microbial

luoride

ffective diet

ad Bacteria

bsence saliva

ietary habits poor

aliva adequate

nti- microbial

luoride

ffective diet

A Caries Risk Assessment (CRA) is just “weighing”  the  factors  of  each  patient.

CAMBRA is just “removing  weight” from one side and “adding  weight” to the other.

Current State of Risk Assessment

“No  existing instrument can ensure accurate categorization  of  children  by  risk….”

Common aspects of all current risk assessment models

• Historical and clinical data collected by clinicians

• Quantification of risk by an algorithm

• Assignment of individuals into a risk category

“Any  model  of  caries  risk  assessment  must  address  both the biologic and behavioural management of the disease”

Pediatric Oral Health Research Policy Center AAPD 2012

Objectives of CAMBRA in Children

CAMBRA=Caries Management by Risk Assessment

• Assess child and caregiver caries risk in an individualized manner

• Tailor a specific preventive therapeutic management plan

• Customize a restorative plan in conjunction with the preventive plan

• Plan timely, specific and appropriate periodicity schedule  based  on  the  child’s  caries  risk

Ramos-Gomez F, Ng WM, Oct 2011

Tools for Assessing Caries

“  It is change, continuing change, inevitable change, that is the dominant factor in society today. No sensible decision can be made any longer without taking into account not only the world as it is, but the world as it will  be” Isaac Asimov

Sensitivity & Specificity

• Sensitivity refers to the ability of a test to correctly identify those patients with the disease.

• A test with 100% sensitivity correctly identifies all patients with the disease.

• However, a test with 60% sensitivity correctly identifies 60% of patients with the disease (true positives) but the remaining 40% of patients with the disease are incorrectly identified as negative results and go undetected (false negatives).

• Specificity refers to the ability of the test to correctly identify those patients without the disease. Therefore, a test with 100% specificity correctly identifies all patients without the disease.

• However, a test with 60% specificity correctly identifies 60% of patients without the disease (true negatives) but 40% of patients without the disease are incorrectly identified as positive results (false positives).

• Therefore, an experimental test aims to achieve 100% sensitivity and 100% specificity

Tools for Detection

• Visual Exam with or without Explorer

• Radiographs

• DIAGNODent

• Caries ID

• QLF

• Spectra

• Sopro

• CarieScan

• The Canary System

Principles of Diagnosis

The goal of examining a patient for the

presence of dental caries is to detect the

earliest signs of carious demineralization

on enamel & root surfaces.

If early signs of demineralization are

detected, preventive care may reverse the

caries process.

White Spots????

Examining a White Spot

Classical Detection Tools

Health Decalcification Decay

Visual Normal tooth color White spot Black or

brown

Feel Hard Hard Soft

X-Ray Normal Normal Black area

None of these methods can detect all lesions early enough to implement treatment to reverse the disease process

Visual Tools for Assessing Caries

• DMFT and DMFS

• ICDAS

• CAMBRA

DMFT and DMFS

DMFT: decayed, missing, filled teeth

DMFS: decayed missing filled surfaces

Only a measure of past caries experience does

not measure early lesions which can be

remineralized

ICDAS International Caries Diagnosis & Assessment System

• Used to rank tooth surfaces

• Ranks lesions

• Ranks restorations

• Ranks missing teeth

• More sensitive and robust than DMFT system

• Now a 2 digit system

ICDAS Coding Summary

Use of Explorers (?contentious)

In the ICDAS-system perio probes are used to feel with

Explorers are not recommended as they may produce traumatic defects

Ball-ended

Ekstrand et al., 1987

UNDERLYING DARK

SHADOW +/-

SURFACE INTEGRITY

LOSS

Score 4

Score 5

DISTINCT CAVITY

WITH VISIBLE

DENTINE

EXTENSIVE DISTINCT CAVITY

WITH VISIBLE DENTINE

Score 6

OPACITY Distinct Visible Change

without air-

drying: WHITE, BROWN

Score 2

Score 0

LOCALISED ENAMEL

BREAKDOWN

SURFACE INTEGRITY

LOSS

Score 3

OPACITY First Visible

Change

only after airdrying: WHITE, BROWN

Score 1

SOUND

ICDAS-II detection criteria, 2005

Enamel Caries Dentin Caries

UNDERLYING DARK

SHADOW +/-

SURFACE INTEGRITY

LOSS

Score 4

Score 5

DISTINCT CAVITY

WITH VISIBLE

DENTINE

EXTENSIVE DISTINCT CAVITY

WITH VISIBLE DENTINE

Score 6

OPACITY Distinct Visible Change

without air-

drying: WHITE, BROWN

Score 2

Score 0

LOCALISED ENAMEL

BREAKDOWN

SURFACE INTEGRITY

LOSS

Score 3

OPACITY First Visible

Change

only after airdrying: WHITE, BROWN

Score 1

SOUND

ICDAS-II detection criteria, 2005

ICDAS II (International Caries Detection & Assessment System) scores Enamel Caries Dentin Caries

2 A. VISUAL APPEARANCE

ICDAS Code Summary

Score 5

DISTINCT CAVITY

Score 6

EXTENSIVE CAVITY

SOUND

Score 0

2. ACTIVITY DETECTION AND SEVERITY OF THE LESION

SURFACE INTEGRITY

LOSS

Score 3

OPACITY without

air-drying: WHITE, BROWN

Scores 2W,2B

Ekstrand et al., modified by ICDAS (Ann Arbor), 2002; further modified by ICDAS (Baltimore) 2005

OPACITY with air-drying: WHITE, BROWN

Scores 1W,1B

UNDERLYING GREY

SHADOW

Score 4

Lesion in Dentin Lesion in Enamel

Lesion in

Enamel/Dentin

http://www.dundee.ac.uk/dhsru/news/icdas.htm

Visual vs. Caries Detection Devices

• Visual only provides information on the surface

• Caries starts as a sub surface lesion

• All white and brown spots are not created equal

• Need a system that can detect, measure and monitor the evolution of a carious lesion.

Does this look suspicious?

Use of an Explorer

• Care in not poking or disturbing the enamel surface

• Probing fissures may break the enamel crystals lining the fissure

• Probing will also introduce more bacteria into the fissure

Probing Drives Bacteria & Debris into Fissures

Explorers & Pit & Fissure Caries

“Probing  found  unreliable  in  finding  fissure  caries”

Penning, van Amerongen, Seef & ten Cate. Caries Research 1993

“The  reliability  of  carious  lesion  diagnosis  by  sharp  explorer compared to diagnosis of carious lesion by histological  cross  section  was  25%.”

“A  seemingly  intact  occlusal  enamel  surface  may  conceal an extensive lesion of the dentin”

Al-Sehaibany, White & Rainey J Clin Pediatr Dent 1996

Light Interaction with Teeth

•Reflection •Transmission •Absorption •Backscatter Backscattered

light from lesion

Reflection of light from tooth surface

Methods for Caries Detection

Conventional methods

• Visual examination: + non-destructive + safe - poor resolution - unable to detect incipient demineralization - unable to detect subsurface caries

• X-rays: + non-destructive + can detect subsurface caries - limited safety - unable to detect incipient demineralization - low resolution

Radiographs

• Radiographic imaging of pits and fissures is of minimal diagnostic value because of the large amounts of surrounding enamel .

• Literature review by Dove: • “overall  the strength of the evidence for radiographic methods

for the detection of dental caries is poor for all types of lesions on  proximal  and  occlusal  surfaces”.    

• “it is beneficial only if the intervention is the surgical removal of tooth structure and detrimental if it is used for non-invasive remineralization  methods.”    

McKnight-Hanes C, Myers DR, Dushku JC, Thompson WO, Durham LC. Radiographic recommendations for the primary dentition: comparison of general dentists and pediatric dentists. Pediatr Dent. 1990 Jul-Aug;12(4):212-216 Flaitz CM, Hicks MJ, Silverston LM. Radiographic, histologic, and electronic comparison of basic mode videoprints with bitewing radiography. Caries Res. 1993; 27(1): 65-70. Lussi A, Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 27:409-16, 1993 Dove,  S.  B.,  “Radiographic  Diagnosis  of  Dental  Caries  in  Consensus  Conference  on  Dental  Caries  Management  Throughout  Life, March 2001, Journal of Dental Education, 2001; 65 (10): 985 – 990

Radiographs

Radiograph unable to locate caries and crack beneath the restoration

Methods for Caries Detection

Fluorescence-based methods • DIAGNODent (Kavo Danaher): detects fluorescence light emitted by porphyrins present in carious tissue following absorption of laser light + non-invasive - low resolution - risk of false diagnosis (porphyrins are present in stained healthy enamel, and not in the primary bacteria that cause

tooth decay) - unable to quantify the level of demineralization • Caries ID (MidWest Dentsply) • Detection similar to DIAGNODent –Looks at fluorescence and reflection +Not repeatable –Low resolution

Methods for Caries Detection

Fluorescence-based methods • Quantitative Light-Induced Fluorescence (QLF):

+ non-invasive + quantifies mineral gain & loss + repeatable measurements - low resolution - expensive - unable to quantify lesion depth - unable to detect interproximal lesions

Spectra QLF based Technology • May be issues with accuracy and sensitivity of the

technology • Only monitors porphyrin metabolites • Camera may not capture pixels as accurately • Need more clinical information including comparison

to original QLF • Scale of 0 – 5 with std .25

Methods for Caries Detection

Methods of Caries Detection

DIFOTI (Digital Fibreoptic Transillumination)

+ non-invasive - Low resolution - Tooth decay scatters &

absorbs more light than healthy tissue.

+ DIFOTI is 2x, more sensitive than bite-wing radiography for detection of decay * (Caries Research, 1997)

Methods of Caries Detection

Caries Scan (Electrical Impedance Measurement)

Tooth decay delays or changes the conduction of an electric current.

- Only detects surface defects - Need clean dry tooth surface +Repeatable +Non-invasive - May be able to monitor and quantify mineral loss - Can not detect caries at restoration margins - Can not monitor interproximal lesions or root surface

lesions - Low resolution

The Canary System

• Full Spectrum of Caries Detection

• Accurate

• Repeatable

• Reliable

• Engages Patients & Builds a Practice

• 2 Health Canada approved Clinical Trials

• Over 50 research papers & Ongoing R&D

• Over 11 years of R&D

The Science Behind The Canary System

•Pulses of laser light hit the tooth surface.

•Tooth glows (Luminescence, LUM) and releases heat (Photo-Thermal Radiometry, PTR).

Energy Conversion Technology

Temperature increase < 1oC not harmful

•Detected  signals  reflect  the  tooth’s  condition.  

•Detects 50 micron lesion up to 5 mm below the surface.

Caries Detection on All Surfaces

• Occlusal Pits & Fissures • Smooth Surfaces • Interproximal Regions • Around the Visible Margins of Restorations

(Composite, Amalgam, Porcelain or Gold) • Beneath Sealants • Root Surfaces

The Canary detects small lesions 50 microns in size up to 5 mm below the tooth surface.

Canary Patient Report Customized patient

report on dental practice letterhead

Clear simple indication of problem areas

Patient can track their progress

Engages patient in their oral health care

39

60

Case Study: Caries Beneath an Amalgam

Canary Finds Caries & Cracks Around Amalgam

97

58 36

Canary Numbers (in yellow) indicate caries & pathology. Upon removal of the amalgam cracks and caries found on marginal ridges and caries on the lingual margin.

Tooth Surface Overall Occlusal Buccal Mesial

The Canary System

Sensitivity 97% 100% 100% 100%

Specificity 82% 80% 100% 75%

Visual Examination

Sensitivity 80% 88% 64% 88%

Specificity 91% 80% 100% 75%

Study 1: Detection on All Surface

Study 2: Detection of Pit & Fissure Caries Caries detection method

The Canary System DIAGNODent ICDAS II (visual ranking system)

Sensitivity 92% 41% 77%

Study 3 : Detection of Early Carious Lesions & Lesion Depth

Caries detection method The Canary System DIAGNODent

Sensitivity 100% 18%

Correlation with lesion depth 84% 21%

Sensitivity & Specificity Studies

Detection of Pit & Fissure Caries

• Low Caries Patient

• Only 1 restoration in the last 40 years

• Stained distal pit on # 45

• Scan open & found large carious lesion

• Scanning on tooth 44 was normal

Distal Pit # 45 Canary Number 86

Caries into dentin

Demineralized enamel

Caries detection method

The Canary System

DIAGNOdent

Sensitivity 83% 64%

Specificity 79% 46%

• Canary Numbers >20 when scanning sealants (3M™  ESPE™  Clinpro™  Sealant™)  placed over pit & fissure caries.

• The caries detection ability of the Canary System was not affected by sealant & was more accurate than DIAGNOdent

Sensitivities and specificities for pit & fissure caries detection after sealant placement.

Canary Number 66

Canary Number 37 Caries into dentin

Post-sealant

Pre-sealant

Cross-section

Sealant

Detection of Caries Beneath Sealants

The Characteristics of an Ideal Caries Detection System 1. High sensitivity & specificity for caries detection 2. Detects & monitors de & re-mineralization 3. Detects smooth surface, root surface, occlusal surface &

interproximal lesions 4. Detects caries around restoration margins 5. Non-invasive & safe 6. Repeatable measurements 7. Imaging and or image capture 8. System for recording & storing measurements 9. Patient Education and Motivation 10. In-vitro and in-vivo data & publications including clinical trial data

demonstrating to detect & monitor carious lesions 11. Minimal or no preparation of the tooth surface before a reading 12. Ability to detect and monitor erosion lesions

The key is to understand what the device is measuring.

Remineralization and Other Therapies

Minimally Invasive Dentistry

Understanding your choices?

Product Decisions?

Fluoride CPP-ACP (Recaldent) NovaMin ProArgin Xylitol products Antibacterial rinses Salivary products Neutralizing agents Silver Diamine Fluoride Povidone Iodine CHX varnish (Prevora) Sealants ICON

• RISK Demand? • Age and Ability? • Buffering? • Fluoride Uptake? • Contact time needed? • Desensitization? • Antibacterial Activity? • Salivary Stimulant? • Compliance?

Important Reference Paper on the Journey

Non-fluoride caries preventive agents: Full report of a systematic review and evidence-based recommendations Council on Scientific Affairs, ADA May 2011 Questions Does the use of a non-fluoride caries preventive agent reduce the incidence, arrest or reverse caries a) In the general population b) In individuals with higher caries risk

“The  recommendations  in  this  document  do  not  purport  to  define  a standard of care and rather should be integrated with a practitioner’s  professional  judgement  and  a  patient’s  needs  and  preferences”

Requirements of an Ideal Remineralization Material

• Diffuses into the subsurface or deliver calcium and phosphate into the subsurface

• Does not deliver an excess of calcium • Does not favour calculus formation • Works at an acidic pH • Works in xerostomic patients • Boosts the remineralization properties of saliva • For novel or new materials; shows a benefit over fluoride

Walsh, L. J., Australasian Dental Practice March/April 2009

Topical Fluoride

The Original Remineralization Agent

• Water Fluoridation

• Toothpaste

• Fluoride Rinse

• Fluoride Varnish

• Bottled Water

Water Fluoridation

• Remains a major source of reduced decay

• Many studies with average reduction 25%

• Recommended by all major health organizations

• No evidence of health or environmental risk • Under attack by extremist U.S organization

Fluoride Action Network

Community Water Fluoridation Canada

Water Fluoridation

Critical role for local dental community

• Proactive lobby

• In-office activity

Recent Manitoba Activity

• Churchill maintains fluoridation Oct 2011

• Flin Flon ends fluoridation July 2011

Key Canadian Government References on Water Fluoridation

• Fluoride Expert Panel 2007 • http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-

fluorure/index-eng.php

• Water Quality Fluoride in Drinking Water 2009 • http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-

fluorure/draft-ebauche-eng.php

• Response to Environmental Petition 2008 • http://fptdwg.ca/assets/PDF/0804-

JointGovernmentofCanadaresponse.pdf

Fluoride – Mechanisms of Action • Enhances remineralization

– Adsorbs onto mineral surfaces, attracts calcium and phosphate ions in saliva, results in the formation of fluorapatite

– Fluorapatite exhibits lower solubility than naturally occurring hydroxyapatite, helps resist the inevitable acid challenge*

• Helps inhibit demineralization – Adsorbs onto mineral surfaces and protects the tooth against

dissolution*

• Inhibits bacterial activity – Inhibits cariogenic bacteria metabolism of carbohydrates – less acid

and less adhesive polysaccharides are products**

* Featherstone JDB. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31–40. ** Hamilton IR. Biochemical effects of fluoride on oral bacteria. J Dent Res 1990;69(special issue):660–7

Fluoride Action

A brief review:

– Effect largely topical • At low levels

– Inhibits demineralization at crystal surfaces – Enhances remineralization at crystal surfaces

• At high levels

– Inhibits bacterial enzymes

Fluoride - Some Interesting Pieces

Low levels after several hours in plaque and saliva can have a profound effect on demin/remin – i.e. TOOTHPASTE – MOUTHRINSE? Lynch RJ, Navada R, Walia R, Low levels of fluoride in plaque and

saliva and their effects on the demineralization and remineralization of enamel: role of fluoride toothpastes. Int Dent J 2004:54(5 Suppl 1):304-9

TOPICAL FLUORIDE

Toothpaste

• Position Statements

– Canadian Dental Association

– American Academy of Pediatric Dentistry

CDA Position on Use of Fluorides in Caries Prevention revised March 2012

• Water fluoridation

• Fluoride toothpaste and Mouthrinse

– Children 0-3 years

– Children 3-6 years

• Professional topical application of fluoride gels, pastes and varnishes

• Fluoride supplements

• Fluoride exposure from multiple sources

CDA Position on Use of Fluorides in Caries Prevention revised March 2012

Children 0 - 3 years

• The use of fluoridated toothpaste in this age group is determined by the level of risk

• Parents brush under 3 years and assist 3-6 years

• “Grain  of  rice”  of  toothpaste

• All children supervised or assisted till appropriate dexterity

Topical Fluoride – The Gold Standard

J Dent Educ. 71(3): 393-402 2007 © 2007 American Dental Education Association Professionally Applied Topical Fluoride: Evidence-Based Clinical Recommendations American Dental Association Council on Scientific Affairs Key words: fluoride, caries, caries prevention, evidence-based dentistry, clinical recommendations

ADA Evidence-based Recommendations

Assess – Caries Risk

–Low –Medium –High

Decide – Whether to apply fluoride – Type of fluoride – Frequency of application – How often to re-evaluate

ADA Evidence-based Recommendations Professionally Applied Topical Fluoride

Risk group /Age

Less than 6 years

Low Patient may not receive any additional benefit

Medium Varnish every 6 months

High Varnish every 6 months (or 3 months)

ADA Recommendation Professionally Applied Topical Fluoride

Low risk under 6 years

• Fluoridated water and toothpaste may

provide adequate caries prevention in low

risk category

• Fluoride foam and gel not recommended in

this age group

Fluoride Varnish – Why?

• Higher percentage of caries reduction

• Prolonged uptake of fluoride by enamel

versus other topical systems

• Sets on contact with intraoral moisture

• Greater efficacy versus other delivery

systems

• Fluoride deposited on demineralized

enamel greater than on sound enamel

• May produce redistribution of ions within

caries and increasing fluoride infusion

Beltran-Aguilar et al, 2000

Fluoride Varnish (5% NaF = approx 22,500 ppm)

• Safe and well tolerated • Inexpensive • Greater fluoride uptake

than with gels or foams

No special equipment

No prophylaxis prior to application

Easy to apply

Dries on contact with saliva

Evaluating Fluoride Varnish

• Concentration of Fluoride in Varnish

• Fluoride availability in saliva over a 1 – 4 hour time period

• Lab and Clinical trial evidence of efficacy

• Other additives?

• Ease of application

• Patient comfort issues – Colour

– Grittiness

Applying Fluoride Varnish

Fluoride Varnish Application

• Gentle  finger  pressure  to  open  child’s  mouth

• Remove excess saliva from the teeth

• Apply a thin layer of varnish to all surfaces of the teeth

• Varnish hardens on contact with saliva

Post-application instructions

• Recommendations vary with manufacturer, but generally:

• Can eat within 30 minutes avoiding hot food/drink

• Soft, non-abrasive diet for the rest of the day

• No floss of teeth until the next morning

• Inform the caregiver of appearance/film until teeth are brushed

Migration of Fluoride Varnish after Application: an In Vivo Study

Kolb V et al, 3M ESPE Dental Products, St. Paul, MN

2009 IADR Abstract #1170

Results of the Study: Vanish reached a greater number of tooth surfaces than the other fluoride varnish products immediately after application and continued to migrate for up to 4 hours. This in vivo study demonstrates that Vanish varnish exhibits enhanced flow characteristics compared to the other fluoride varnishes tested.

Fluoride and Safety Concerns

Three real issues • Fluoride toxicity

• Fluorosis

• Allergy

• Age of greatest risk for fluorosis

• 0-3 years

• Especially 22-26 months

– Findings and recommendations of the Fluoride Expert Panel Health Canada Jan 2007

Estimation of Potential Toxic Dose Considering the Child

Age/Weight Verronneau 2007

Variable Volume or Weight

(Youngest child and inferior border)

Volume or Weight (Oldest Child and Superior Border)

Age 6 months 36 months

Mean Weight 8.25 kg +/- 0.5 (Demerjian 1985)

19.75 kg +/- 2.0kg

Fl Varnish 0.1 ml (Ripa, 1990) 0.5 ml

Ingestion presumed 2.30 mgr (Johnston, 1994) 11.30 mgr

Potential toxic dose 41.25 mgr/kg/total weight 101.50 mgr/kg/total weight

Protective factor 17 10

Courtesy of Medicom

Fluoride Varnish – Toxicity

0

1

2

3

4

5

ml

Use

0

5

10

15

20

25

mg

IngestionComparative fluoride ingestion rates

Varnish APF (Gel)

Fluorosis

Total daily fluoride intake from all sources should not exceed 0.05-0.07 mg F/kg of body weight in order to minimize the risk of dental

fluorosis

– Canadian Dental Association Nov. 2008

Fluorosis – Dean’s  Index

Fluorosis – CHMS Data

Children 6-12 years

• 60% with normal enamel • 24% with white flecks or spots where cause questionable • 12% very mild • 4% mild • Mod-severe too low to report

*Remember that many of mild areas of enamel variation will spontaneously improve into teen years

Fluoride Varnish (5% NaF = approx 22,500 ppm)

• Safe and well tolerated • Inexpensive • Greater fluoride uptake

than with gels or foams

No special equipment

No prophylaxis prior to application

Easy to apply

Dries on contact with saliva

Fluoride Varnish Allergy Risk

Potential resin peptide allergen link to pine nut allergies Oral Science X-Pur 5% NaFl “…current  formulation altered to refined, purified colophony  resin.  …Health  Canada  no  longer  require  allergy  warning” 3MEspe Vanish Fluoride Varnish allergen is abietic acid, not peptide-no cross reactivity colophony purified-allergen risk lowered

Recommendation Ask your supplier re process Allergy warning required?

Current Toothpastes

0.243-0.254% NaF or 0.454% SnFl

= 0.115% Fl- = approx. 1100 ppm Fl

1.1% NaF

= 0.495 Fl-= approx. 5000 ppm Fl

NOTE: Federal advisory panel recommends

low-dose fluoride toothpaste be available for

children in Canada

High fluoride toothpaste 5000 ppm

3M  Clinpro™  5000  Tooth  Paste

Dentifrice • Contains 1.1% NaF (5000

ppm fluoride ion) • Contains innovative calcium

and phosphate ingredient which is broken down upon contact with the tooth surface.

Mechanism of Action As the paste reaches the tooth

surface: – Organic components (often

surfactants) have an affinity for tooth surfaces

– Carries the calcium to the tooth surface, protected from fluoride ion High fluoride bioavailability during application

– Saliva activates the calcium compound degrading the protective coating, releasing calcium at the tooth surface Calcium bioavailability during application

Protected calcium oxides are released

As the ingredient reaches the tooth surface • Organic materials (often surfactants) have

an affinity for tooth surfaces – Carries the calcium to the tooth surface,

protected from fluoride ion High fluoride bioavailability during application

• Saliva activates the calcium compound degrading the protective coating, releasing calcium at the tooth surface Calcium bioavailability during application

Clinical Trial (preliminary analysis)

Recaldent (CPP-ACP)

• Casein Phosphopetides – From  cow’s  milk – Stabilize calcium and

phosphate ions – Facilitate intestinal

absorption – pH dependent – Modified to create bio-

available calcium and phosphate for remineralization

• Amorphous Calcium Phosphate – Developed by ADA Health

Foundation – Original intent is surface

deposition of hydroxyapatite – Developed for desensitization

Recaldent

MI Paste MI Paste Plus Trident Xtra Care Gum Trident White Gum

Novamin®

• Calcium sodium phosphosilicate: Ca and P04 ions protected by glass particles

• Sodium buffers salivary pH for precipitation of crystals

• Contact with H20 or saliva, activates release of Ca and P04

A breakthrough remineralization ingredient Comprised of calcium ( ), sodium ( ), phosphorous ( ), and silica ( ), all natural elements found in the body

pH

NovaMin immediately

reacts w/saliva or water

NovaMin reaction elevates pH to ideal remin range (8-9),

releases C and P ions

High pH + Ca and P ions turbo charge

remin process. Demineralized

surface is replenished +

NovaMin Particles

How NovaMin Works

ADA Report Recommendations

“There  is  insufficient  evidence  from  clinical  trials  that  the use of agents containing calcium and/or phosphates with or without casein derivatives lowers incidence of either coronal or root caries Opinion: Given individual cases of considerable success, this is most likely dependant on careful case selection and frequent reinforcement KNOW YOUR PATIENT

Silver Diamine Fluoride- the new silver bullet?

• -currently not approved in N. America

• -38% concentration shows significant caries reduction and caries arrest

• -alternative treatment when restoration not an option

• Yee et al 2009

• -more effective than fluoride varnish

• -lowest prevented fraction for caries arrest 96.1%

• -lowest prevented fraction for caries prevention 70.3%

• Rosenblatt et al 2009

Silver Diamine Fluoride- the new silver bullet?

-frequency of application 1x/yr -excavation of soft caries reduces black discoloration -metallic taste -greater efficacy vs multiple FV applications Chu et al JDR 2002

-frequency of application 2x/yr -reduction of new lesions on primary and first permanent molars (preventive fraction 79.7% & 65%) Llodra et al JDR 2005

Silver Diamine Fluoride- the new silver bullet?

Safety Issues -pulp irritation no evidence -caries stain yes but...7%found objectionable -tissue irritation yes, white lesions with mild pain lasting 48 hrs. -fluorosis theoretical possibility in animal studies - needs more study Rosenblatt et al 2009

Remineralization and Other Therapies

Antimicrobial treatment (remember the

biofilm!)

• Xylitol

• Povidone iodine

• Chlorhexidine

• Delmopinol

• Triclosan

Remineralization and Other Therapies

Xylitol

The Xylitol Story in Brief

• Natural long chain sugar • Non-cariogenic • Can reduce mutans strep in plaque and

saliva • Can reduce caries in young children,

mothers and in children via their mothers • Anti-caries benefit for high risk for both

caries reduction and enamel remineralization

Soderling et al 2001 Maternal transmission of MS

• Xylitol gum – Starts 3 months after delivery and for 21 months

• Fluoride varnish – Applied at 6, 12, 18 months

• CHX varnish – Applied at 6, 12, 18 months

Measured MS levels in children at age 3 and 6

Key Xylitol Studies for ECC

Key Xylitol Studies for ECC

Soderling et al 2001 Results

• Children age 3 – MS levels 2.3x higher with Fl Var and CHX Var in

mother • Children age 6 – Protection maintained with same higher benefit of

xylitol in mother Results reconfirmed by Thorild et al 2006

Mutans streptococci of the 2-year-old children (Söderling et al., JDR 2000)

• The  child’s  risk  of  having mutans streptococci colonization in the dentition was 5-fold in the F group and 3-fold in the CHX group as compared to the Xylitol group

60

50

40

30

20

10

0CONTROL CHX XYLITOL

n=33 n=28 n=103

%

Caries occurence in children• At the age of 5 years

the need of restorative treatment was 71-75% lower in the Xylitol group as compared to the F and CHX groups

• The occurence of caries and early mutans streptococci colonization were in agreement

CHX

Control

Xylitol

Age

dmf

3

2

1

00 1 2 3 4 5 6

Why Xylitol and when

• Maternal 3 months post partum (Soderling 2001)

• Characteristic of infection at eruption determines

life-long (Loesche 1985)

• Once colonized with benign, ms will not displace

(Svanberg and Loesche 1977)

• May be due to less cariogenic xylitol-metabolizing

ms strain (Trahan et al 1996)

Xylitol as a Remineralization Agent

“These  results  indicate  that  xylitol  can  induce  remineralization of deeper layers of demineralized enamel by facilitating Ca2+ movement  and  accessibility.”

Miake Y, Saeki Y, Takahashi M, Yanagisawa J Electron Microsc (Tokyo). 2003;52(5):471-6

Xylitol More than a Remineralization Agent

• Inhibits adhesion, growth and metabolism of oral

microorganisms. Suppresses ms even with sucrose

intake.

• Allows remineralization of initial enamel

lesions. Enhances reversals (Turku study).

• Chewing gum enhances with increased salivation

• Synergistic with fluoride

Mucositis Oral

Lesions Oral

Candida Rampant

Caries Periodontal

Disease

LOSS OF PROTECTIVE QUALITIES OF SALIVA XEROSTOMIA

HEAD & NECK RADIATION AND CHEMOTHERAPY

•  Increase of oral acidity and decrease of healthy PH • Acceleration of the demineralization process

3

• Increase of pathogenic bacteria • Increase of pathogenic biofilm

Xylitol; A Remineralization Agent

Reported Xylitol Availability

• Gum – sole or in combination • Toothpaste • Lollipops • Syrup • Tooth wipes • Slow release in pacifiers • Gummy bears • Combination with: fluoride or chlorhexidine

Xylitol Syrup (Marshall Islands Study)

•No. decayed teeth

–Control: 1.9 +/- 2.4 –Xylitol 2x: 0.6 +/- 1.1

•% with decayed teeth

–Control: 51.7% –Xylitol 2x: 24.2%

Milgrom AAPD 2009

Xylitol – Widely Accepted Opinion

• habitual use of xylitol reduces incidence of caries

• habitual use remineralizes enamel and dentin caries

• other polyols also reduce caries

• probable hierarchy of effect of polyols based on number of hydroxyl groups:

erythritol_>xylitol>_sorbitol

Makinen, KK, 2010

www.oralscience.com 220

BOTTLES •  180  pieces  of  gum  – Peppermint • 180 pieces of gum – Fruit •  400  mints  – Peppermint • 400 mints - Fruit TINS •  20 pieces of gum – Peppermint • 60 mints - Peppermint

Issue of accurate contents

• Gums, mints do not have to meet high standards re accuracy of content

• Some question whether you are getting 1 mg each gum or mint

Opinion: • Oral Science product being used in hospital oncology

programmes and seeking status under Canadian Natural Health Product designation

• I would opt for this product for Xylitol source

Spiffies Wipes

Toxicity Issue?

• Each wipe contains 0.5 g xylitol

• Estimated absorption 0.25 g

• 3-5 applications/day i.e.0.75-1.25 g/day

• Everyday use is 0.2g/kg (assuming a 7 kg infant)

• Threshold level is 1-2 g/kg

• Safety factor 5-10

Spiffies now available in Canada through DR Products at www.spiffies.com

Clinical Significance

Right now Xylitol seems to be most

appropriately considered an adjunct measure

for targeted individuals. It cannot be

recommended as a public health measure as

yet. Furthermore, carefully designed and

conducted studies are required to determine

what role it will ultimately play Tweetman S, Current controversies-Is there merit? Adv Dent Res 21:48-52, 2009

• Significant reduction of caries polyol gums vs. no gum • Preventive effect xylitol highest vs. other polyols • Benefit related to load mg/day • Benefit related to chewing 10-20 minutes after meals • Concern re choking kids less than 5 years • Lozenges/tablets reduces coronal caries – low

certainty • Encourage to suck lozenges to extend time in mouth • Syrup under 2 years -insufficient evidence • 5-8 gms/day divided doses • Insufficient evidence xylitol under 5 years • Insufficient evidence xylitol in toothpaste

ADA Report Recommendations

Remineralization and Other Therapies

Povidone Iodine – Betadine

-potent antibacterial

-safe to swallow

-disrupts binding to biofilm

Povidone Iodine

• Applied in combination with Fl. Varnish

• Complementary to fluoride

• Disrupts binding of biofilm

• Can work up to 20-24 weeks

• Differing protocols supported by evidence

Milgrom AAPD 2009

Povidone Iodine Topical

• Used post-GA restoration suppresses MS levels over

90 days P<0.00001 Berkowitz et al 2009

• Safe to swallow, even for babies Milgrom 2009

• Kids tolerate re nausea and taste

• Contraindications

• New formulations in research

Povidone Iodine Results ECC

PVP-I + FV vs FV only 2.5-2.8 times over 1 year infants 12-30 mths • New decay reduced 31%

Milgrom et al J Dent Child Dec 2011

PI + FV vs no tx q2M over 1 yr. infants 12-19 mths

• 91% disease-free vs 54%

Lopez Ped Dent 2002

PVP-I post GA at baseline, 6, 12 mths • Reduced patients with new decay (small sample) • Amin et al Ped Dent 2004

ADA Report Recommendations Insufficient evidence iodine lowers decay

Anti-Bacterial Agents

Mechanism of Action: Reduce Bacterial Levels in the Oral

Cavity • Prevora • Cervitec • Povidone Iodine • Chlorhexidine Mouth Rinses (Peridex) • Triclosan

Chlorhexidine

• Now available in both rinse and varnish

• Anti-bacterial and anti plaque

• Used for treatment of gingivitis and caries

• Efficacy in very young inconclusive

Zhang et al Eur J Oral Science 2006

Available as

•Cervitec Plus

•Chlorhexidine

•Thymol Plus

Cervitec Plus

• Used as cervical desensitizer and caries preventive

• Application to mothers q6m til baby 3 yrs

• caries in infants significantly lower

• Inhibition of MS transfer to baby to age 2

• Treatment of high risk infants q3m from 1 yr

• caries reduced but not if diet not also controlled

• Reduced caries development if none at baseline but no

improvement if caries at baseline

• Inhibition zones adjacent to placement

• Role for newly erupting molars followed by sealants?

Prevora

• CHX Varnish originally for root caries • Studies on mother child being analyzed.

Report available soon • Efficacy in xerostomia patients

ADA Report Recommendations CHX

10-40% CHX Varnish kids 4-18 yrs Does not reduce incidence of caries-moderate certainty

CHX-Thymol Varnish kids up to age 15 1:1 ratio varnish does not reduce incidence of caries

CHX Mouthrinse 0.05-0.12% rinse does not reduce incidence of coronal caries

Insufficient Evidence Efficacy of treatment of mothers post-partum on incidence of caries in infants Impression: Jury still out on this one

Remineralization and Other Therapies

Delmopinol Hydrochloride

• reductions in total cultivable plaque and salivary flora Hase et al 1998

• inhibits glucan synthesis of MS in vitro Baehni 2003 • used currently largely for anti-gingivitis properties as mouth

rinse (Decapinol Mouthwash)

Remineralization and Other Therapies

Triclosan

• -broad spectrum antibacterial used in toothpaste

• -reduces supragingivial plaque

• -enhances anti-caries activity of fluoride

• -used widely in other health/body products

• -recent concerns re carcinogenic potential with probable

removal from products in future

ADA Report Recommendations: Insufficient evidence that it lowers

caries incidence

Pro Argin®

• Highly soluble arginine bicarbonate - amino acid complex that binds to calcium carbonate

• This binds particles of calcium carbonate to dentin and enamel

• Purpose: reduce dentinal hypersensitivity • Contained in Colgate’s Sensitive Pro-Relief

desensitizing prophy paste. • Anticaries benefit under study

Remineralization and Other Therapies

Arginine and Probiotics Newer research with products on the market ADA Report Comments: • Arginine added to food or oral care products to

inhibit initiation and progression of caries and promote remineralization

• Probiotics goal to promote healthier plaque ecologies. Safety and Effectiveness not rigorously tested

“In  light  of  the  state  of  development  and  the  lack  of  human  research  reports…not  evaluated  by  the  panel

Opinion: Not Ready for Prime Time

What is the Recipe?

Office + Home Therapy

Office • Topical Fluoride (gels and

foams) • Fluoride Varnish • Anti-Microbial Therapy

– Prevora

– Cervitec

• Oral Hygiene & Patient Motivation

• Diet Counselling • Ongoing Monitoring

Home Toothpastes & Topical Application • Clinpro 5000 Toothpaste • ProArgin in Colgate • MI Paste • Prevident

Sugar Substitutes • Xylitol • Novamin

Mouthwashes • Peridex • Tricolsan Products

Gums & Mints • Recaldent • Xylitol

+

Effective Plaque Removal with Brushing & Flossing

Does Remineralization Work?

Case Study Remineralization

0200400600

Initial 2 months 3 months 5 months

Canary Number

ICDAS: 02 ICDAS: 02 ICDAS: 02 ICDAS: 02

Visit #1 Visit #2: Visit #3: Visit #4: 2 Months 3 Months 5 Months

3M Vanish & Clinpro 5000 Toothpaste

Remineralization 5th and 7th Quads

Remineralization Case Slides courtesy of Dr. Clive Friedman

Remineralization Case Slides courtesy of Dr. Clive Friedman

Canary Numbers for This Case

Tooth

October 2011 April 2012

M O D M O D

47 26 20

46 46 16 19 19

37 31 27 15 24

36 21 35 16 30

Does Remineralization Work?

Yes

But

You need to monitor and motivate

your patient

Remineralization + Monitoring

Essential components of any program: • Need to monitor progress • Need to record progress • Need to be able to change therapy if

lesions increase in size • Need to engage your patient

Bottom Line: Case Selection

Integration into Clinical Practice

USCLS Codes and Descriptions

Code Description Fee

13601 – 13609 Topical application to Hard Tissue of Anti-Microbial or Remineralization Agents

1 unit $34.10 + E 2 units $68.20 + E

12101 Fluoride Treatment (topical application) $16.90

12102 Fluoride Treatment Supervised Self-administered brush in

$15.70

12601 – 12602 Fluoride Custom Appliances $60.70 + lab

1321*, 1323* Oral Hygiene Instruction (individual, group & re-instruction)

$31.00

96103 Dispensing of Non-Emergency (fluorides etc.) No fee + E

04201 Test Analysis, Caries Susceptibility (technical procedure only) Bacteriological testing for determination of caries susceptibility

$40.00 + lab

Code 13601 Remineralization

• Designed for the topical application of fluoride varnish and other agents in a dental office

• Introduced into the ODA Fee Guide in September 2008 in response to symposium at the IADR sponsored by the ODA

• Fee: $47.00 per 15 minute unit of time

• Can be done by hygienists or dental assistants (under supervision of the dentist)

Office Integration

Recall or Specific Exam •Identify White Spots •ICDAS or Measure •Risk Assessment •Apply Remineralization Therapy •Oral Hygiene Instruction •Provide Home-based Therapy

Reassess 3 Months •Assess lesion •ICDAS or Measure •Apply Remineralization therapy •Dispense Home-based therapy

Reassess 6 Months •Assess Lesion •ICDAS or Measure •Apply Remineralization Therapy •Dispense Home-Based Therapy

Remineralization + Monitoring

• Essential components of any program • Need to monitor progress • Need to record progress • Need to be able to change therapy if

lesions increase in size • Need to engage your patient

Early Childhood Caries

Clinical Presentation: Early Lesions ECC

• Begins soon after dental

eruption

• Typically develops on smooth

surfaces

• If enamel not uniformly

white, patient is at risk

• Appear as chalky white

decalcification

• Most often starts on lingual

surfaces of maxillary incisors

Early Childhood Caries

Clinical Presentation

(Advancing)

• Virulent caries with rapid

progression

• Enamel chips away as

lesions advance

• Colour of caries indicates

speed of progression

Advanced Tooth Decay photo Dr. Joanna Douglass, Smiles for Life

Early Childhood Caries

Facial Cellulitis Infection spreading into surrounding tissues

Early Childhood Caries

% Population Age Author

4% Quebec children Convenience sample of 301 infants

12 – 24 month infants Veronneau et al

1% US children representative sample of 654

12 – 23 month Kasteet et al. 1996

17% US children sample of 1,627

2 – 4 year olds Kaste et al. 1996

30% Cree population Quebec 12 – 24 month Veronneau et al. 2002

55% Inuit population of NWT 24 – 36 month Albert et al. 1998

87% Ojibway sample 470 residents of Northern Ontario

24 – 48 months Lawrence 2008

Prevalence of ECC in children under 4 years of age. DMFT / DMFS screening tool ICDAS not used

Early Childhood Caries

Prevalence 0 - 5 years United States

• Decay  rates  dropped  until  1990’s • Rates now documented as increasing

2 - 5 year olds 24% in 1988 - 1994 28% in 1999 - 2004

• Wide variability with population groups

Dye et al, National Center for Health Statistics NHANES 2007

Early Childhood Caries

Lida et al 2007

Early Childhood Caries

Prevalence 0-5 Years British Columbia

– 64% inner city Vancouver sample Szeto thesis 2004

– 11% community dental health (range 7.9-27.4%) Bassett et al 1999

– 20.5% Vancouver low-income Vietnamese over 18 mths Harrison et al 1997

* Surveys vary in sampling methods * Children sampled not representative of population in general

Prevalence 0 - 5 Years Ontario

– 87% of First Nations sample Lawrence 2008

– 34% in Health Units Survey* OAPHD 2008

– 30% of Toronto 5-year olds 1999-2000* Leake 2001

– 25.1% in daycare community

Ottawa Public Health 2007-08*

* Survey under reports children sampled due to methods

* Children sampled not representative of population in general

Early Childhood Caries

Systemic Effects of Severe ECC

Malnourishment In A Population With Severe Early Childhood Caries

Among the findings: – 66% have normal weight, 18 % underweight – 28% have haemoglobin levels below acceptable and 46% in the

low range of acceptable – 51% have low albumin levels – 77% have low ferritin

Conclusion: Children with severe tooth decay have borderline or low nourishment

Clarke et al 2006

Detrimental Health Effects Of ECC

• pain, infection, loss of function • affects learning, communication, nutrition, sleep • lower body weight • chronic inflammation • psychological impact • lasting detrimental impact on the dentition

Not Just the Poor

National O.R. Stats • Pediatric dental procedures #1 O.R. procedure with longest waiting lists

CHEO  Stats  (Children’s  Hospital  of  Eastern  Ontario) • Waiting time for O.R. was 14 months • Children over 5 years not eligible for care

London, ON Mall Exams • 82 children under 20 months • 32 with early signs of caries (ICDAS 1+2) • 3 with S-ECC requiring sedation of GA Dr. Clive Friedman

ECC – Other Aspects to Consider

• New approach needed

• Social determinants

• Role of physicians, nurses

• Motivational interviewing

• Role of dental public health

• ECC as predictor

The New Approach Needed for ECC

Quality Improvement • Combine efforts of Health Care professionals, patients, families, researchers, payors, planners, educators • Objective is improved outcomes, system performance and professional development

• Ultimate objective is Disease Management

Ramos-Gomez F, Ng M Oct 2011

Copyright ©2007 American Academy of Pediatrics

Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520

FIGURE 1 Child, family, and community influences on oral health outcomes of children

Smiles for Life Pocket Cards for Physicians

Smiles for Life Pocket Cards for Physicians

Principles of Motivational Interviewing

• Establish a therapeutic alliance

• Recognize that people value their independence

• Ask questions, and listen

• Once 1-3 then advice, giving choices to explore and a tailored course of action

• Once the patient/parent is receptive, MI does not take long

Weinstein P, MI and Its Relationship to Risk Management and Patient Counseling, Cal Dent Assoc J, Oct 2011

Models of Individual Oral Health

Promotion

Brickhouse T.H. Virginia Commonwealth University presented at AAPD Symposium October 2009

Evidence: Models of Individual Oral Health Promotion

• Systematic review 2000-2007

• Database examined for articles evaluating effectiveness of health behaviour models

• 32 studies

– 9 health education and clinical prevention studies – WEAK

– 3 counseling studies with varnish – STRONG

– 9 studies of model based interventions – MODERATE

– 11 studies of motivational interviewing – STRONG

• Yevlahova and Satur, Australia Dental Journal 2009

Evidence: Models of Individual Oral Health Promotion

• Health Education

– Information and expert advice with passive patient

• Counseling

– Extremely specific and tailored to the patient, increased time and

expense

• Model based interventions

– Health Belief Model, Locus of Control, Self Efficacy, Attitudes

• Motivational Interviewing

– Trans-theoretical model of behaviour change focusing on personal

dynamics of change

– Patient  centered  style  with  sensitivity/empathy  to  patient’s  social  and  environmental circumstances

• Significant reductions in smoking, diabetes, obesity, substance abuse and oral

health

Motivational Interviewing

Success in dentistry

• Early childhood caries

• Harrison RL, Wong T. An oral health promotion program for an urban minority population of preschool children. Community Dent Oral Epidemiol, 2003 Oct;31(5):393-9

Dental Public Health

• Big picture reality – getting to the populations

• Making connections • Identifying high risk populations • Individual evidence-based oral health

promotion • Role of medical community

Dental Public Health Service Populations

from Quinonez C et al 2005

Province

Persons covered by social assistance 1995

Persons covered by social assistance 2003

Children <19 living in poverty

BC

374,300

180,700

182,577

AB

113,200

57,800

132,806

SK

82,200

53,200

53,110

MN

85,200

59,900

67,540

Ontario Perspective on Government Plan Coverage

Gap Coverage

• High needs, not high risk

– Low socioeconomic levels –Disabled and their families

• Emphasis on basic or urgent treatment

with minimal emphasis on prevention

or education

Colorado Study

Hirsch et al. A simulation model for designing effective interventions in early childhood caries. Prev Chronic Dis 2012;9:110219 CDC&P • Projects 10-yr intervention costs and relative reductions in

cavity prevalence • Interventions target 2-4 yr. olds • Targeting high risk provides greatest return on investment • Combined interventions have greatest potential for cavity

reduction • All produce substantial reductions in repair costs; some save

more than their cost Interventions Assessed Fluoridation, Fluoride varnish, Bacterial transmission, Xylitol with children, Secondary prevention, Motivational interviewing, Combined interventions

Colorado Study

Preventive Therapy Caries Reduction Cost of Treatment

Water Fluoridation 25.4%

Fluoride Varnish 33% $16 per application

Bacterial Transmission (Education, restorative treatment for mothers)

73% $100 per mother

Xylitol (several simulation models

44% - 77% $100 per child

Secondary Prevention (follow-up care including restorative procedures)

50% – 75% $242 per child

Motivational Interviewing 63%

Combined Therapies

Combining several therapies will create a cumulative & complementary effect

Combining several interventions can produce a smaller fraction of children with cavities than can any of the single interventions.

CDA Position-Risk of ECC 1. The child lives in an area with a non-fluoridated water supply and low (< 0.3

ppm) natural fluoride levels.

2. Visible defect, notch, cavity or white chalky area on a baby tooth in the front of the mouth.

3. The child regularly consumes sugar (even natural sugars) between meals. This includes use of a bottle or sippy cup filled with any liquid other than water and consumption of sweetened medications.

4. The child has special health care needs that limit his or her cooperative abilities, thus  making  it  difficult  for  the  parent  to  brush  the  child’s  teeth.  

5. The  child’s  teeth are brushed less often than once a day.

6. Born prematurely with a very low birth weight of less than 1500 grams [3 pounds].

7. The parent or caregiver has tooth decay.

8. The child has visible plaque, such as white or yellow deposits on the teeth.

Early Childhood Caries

Lida et al 2007

Risk Factor For Future Caries or Good Indicator Of Future Caries Experience ??

*Al-Shalan TA, et al. Primary Incisor Decay Before Age 4 As A Risk Factor For Future

Dental Caries. Pediatr Dent. 19(1):37-41, 1997

*O'Sullivan DM, Tinanoff, N, The Association Of Early Dental Caries Patterns With

Caries Incidence In Preschool Children., J Public Health Dent 56(2):81-3, 1996

*Kaste, LM, et al. The Assessment Of Nursing Caries And Its Relationship To High

Caries In The Permanent Dentition. J Public Health Dent. 52(2):64-8, 1992

*Almeida, Al et al. Future Caries Susceptibility In Children With Early Childhood

Caries Following Treatment Under General Anesthesia. Pediatr Dent 22 (4) 302 -

306, 2000

• BY THIS TIME IT IS TOO LATE

Early Childhood Caries

Clinical Management in Your Practice Decision Tree in different clinical situations

Initial Management follows Risk Assessment

CAMBRA=Caries Management by Risk Assessment THE NEW STANDARD OF CARE • Assess child and caregiver caries risk in an individualized manner • Tailor a specific preventive therapeutic management plan • Customize a restorative plan in conjunction with the preventive plan • Plan timely, specific and appropriate periodicity schedule  based  on  the  child’s  caries  risk

Ramos-Gomez F, Ng WM, Oct 2011

ECC Decision Tree – Low Risk

ECC Decision Tree – Low Risk 0-5 yrs.

Caries free with low risk • Accept as patient or refer If Providing Care Diet and hygiene review Exam frequency 9-12 months Radiographs BW’s  if  contacts  tight  and  co-op Fluoride not in office, Fl T.P. optional Prevent Interventions no Restorations no

ECC Decision Tree – Moderate Risk 0-5 yrs

Caries free with moderate risk Diet and hygiene review and self goals Exam frequency 6 months Radiographs BW’s  if  tight  contacts 12-18 month interval Fluoride Varnish with 6 month interval Fl T.P. at home Prevent interventions Consider GI sealant on at risk Restorations no Consider more frequent assess and Fl Var if questionable compliance or after initial exam

ECC Decision Tree – Moderate Risk 0-5 yrs

Moderate risk with poor hygiene Diet and hygiene review and self goals Exam frequency 6 months Radiographs BW’s  if  tight  contacts 12-18 month interval Fluoride Fl Var q6M, consider 3M Fl T.P. at home, consider 5000 ppm Prevent intervention consider PVP-I with Fl Var q3M consider GI sealants on risk sites Restorations no Considerations depend on family motivation and anticipated compliance

ECC Decision Tree – High Risk

Accept as patient or refer

If Providing Care Diet and hygiene review and self goals Exam frequency 6 M consider 3M initially Radiographs BW’s  if  tight  contacts 12 month interval initially Fluoride Fl Var q6M, consider q3M Fl T.P. at home, consider 5000 ppm Prevent intervention consider PVP-I with Fl Var q3M for 12M Restorations consider GI sealants on risk sites Considerations depend on family motivation and anticipated compliance

ECC Decision Tree – High Risk with Caries

Accept as patient or refer If Providing Care Diet and hygiene review and self goals Exam frequency 3M until caries stable Radiographs BW’s  if  tight  contacts 12 month interval initially Fluoride Fl Var q3M until caries stable Fl T.P. at home, consider 5000 ppm Prevent intervention PVP-I with Fl Var q3M until stable Restoration ITR or perm restoration consider GI sealants on at risk Considerations include patient co-op, sedation/GA, family motivation and compliance

First Teeth First Visit

Integration into Clinical Practice

Are Parents / Patients Interested?

• Why do I get cavities? • I  brush  and  floss  doesn’t  that  prevent  any  

cavities? • I  brush  my  child’s  teeth  before  bed  like  

you showed us and in the morning now look at what happened?

• My child eats no sweets yet we still have cavities?

• What can I do as a parent to prevent cavities?

First Teeth First Visit: Why Bother

• Early  intervention  maintains  child’s  oral  health

• Delegation of a series of procedures to other staff

• Good practice builder • Build strong long lasting relationships with the

family

• Develops good referral base The key is to assess risk, motivate parent /

caregiver to provide proper care with appropriate in-office care.

Elements:

• Parent / Guardian interview • Visual exam to assess risk • Assess / facilitate parental motivation • Oral Hygiene Instruction • Develop a preventive protocol • Apply or dispense preventive

therapies

The key is to establish an effective collaboration.

Staff Involvement:

1. Parent / Guardian interview

2. Visual exam to assess risk

3. Oral Hygiene Instruction

4. Develop a preventive protocol

5. Apply or dispense preventive therapies

6. Charting & post-op instructions

Parent / Guardian Interview:

• History of active decay • parent, child & sibling

• Medical history • Diet • Oral Hygiene • Motivation

Anticipatory Guidance for Mother

Goal:

Anticipatory guidance for the mother both before the baby is born and following the infant’s  birth  on  several  information items:

Water

• Good  for  mom’s  health • Does it have fluoride • If bottled water, does it

contain fluoride

Oral Hygiene Care

• For  mom’s  health  as  well as control of bacterial transfer

• Brush and floss daily to disturb cariogenic bacteria and reduce bacterial plaque levels

• Use toothpaste with fluoride

Diet

• Choose foods low in sugar.

• Eat healthy snacks like fruit, cheese and vegetables.

• Get enough calcium for mom    and  baby’s  healthy  teeth and bones.

• Calcium is in milk, cheese, dried beans and leafy green vegetables.

• Avoid carbonated drinks

ODA’s  “Ten  Tips  For  Parents”

Downloadable from the

website www.youroralhealth.ca

Oral Hygiene Instruction:

1. Lift the lip

2. Use of tooth paste

3. Other aids

4. Diet

5. Motivation

Examination of the Young Child

Early Childhood Caries

Infant Oral Health Exam • The new standard of Care CDA, CAPD, ADA, AAPD

• Optimal evidence-based preventive Practices Practice-building opportunity

The 12 Month Oral Health Exam

Objectives

• Recording medical history & dental history

• Complete oral exam

• Assess infant risk & determine prevention plan

• Provide anticipatory guidance

• Plan for comprehensive care

• Refer where appropriate if necessary

Sealants, Preventive Resin

Restorations, ICON & Ortho-

Related Caries

Pit & Fissure Sealants

Systematic review on first permanent molars comparing sealant and fluoride varnish as well as sealant and varnish versus just fluoride varnish • Conclusion: There was some evidence of the superiority

of pit and fissure sealants over fluoride varnish application in the prevention of occlusal decay. However, it remained unclear to what extent there is difference between the effectiveness of pit and fissure sealants and flouride varnishes. Therefore more high quality research is needed

» Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003067

• Benefits determined in systematic review as being very weak

– Grade of evidence III

– Strength of recommendation D

• (Evidence on permanent molars of children and adolescents when at risk of caries)

– Grade of evidence 1a

– Strength of recommendation B

Beauchamp J et al, Evidence-based clinical recommendations for the use of pit-

and-fissure sealants, JADA 2008: 139(3)257-66

Pit & Fissure Sealants on Primary Molars

Sealing Over Caries

Griffin et al The effectiveness of sealants in managing caries lesions, J Dent Res 2008 Is it safe

• Conclusion: Sealed caries fissures showed significantly more microleakage and insufficient sealant penetration depth than sound fissures. Neither the use of an adhesive nor its interemediate curing influenced the microleakage score and the penetration ability of sealants

– Hevinga MA et al, Can Caries Fissures be Sealed as Adequately as Sound Fissures, J Dent Res 2008 May;28(5):495-8

In My Opinion – NO- • Better to do a Preventive Resin Restoration

Newly Erupting Permanent Molar

Options:

-Resin sealant

-Glass Ionomer sealant

-CHX varnish followed by

Sealant once erupted

Evidence:

GI (Triage) seals and

protects better than resin

Photo courtesy of Ivoclar Vivadent

Glass Ionomer Sealant

• Moisture friendly

• Fluoride-release potential

• Does not have steps resin-based sealants require – No acid etching or the application of a

primer

– No bonding age

JADA Feb 2012

BUT

• It is temporary until the tooth is fully erupted

Application Technique – Newly Erupted Teeth Vanish XT Extended Contact Varnish 3MESPE

© 3M 2008. All Rights Reserved.

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5 6 8 7

© 3M 2008. All

Rights Reserved.

Questions & Answers

Can Vanish XT Varnish be used as a full mouth treatment?

• Vanish XT varnish is designed for site-specific applications.

Can Vanish XT Varnish be removed from the tooth surface?

• If necessary, the coating can be removed with the use of a coarse prophy paste or pumice.

How thick should the coating of Vanish XT Varnish be applied?

• You need only apply a thin layer (1/2mm or less) of Vanish XT varnish to the tooth surface.

Pit and Fissure Sealants

OPINION • transparent rather than opaque

• rarely on primary molars, PRR instead

• (JADA systematic review)

• interesting idea with Helioseal

• Clear Chroma

Photo courtesy of Ivoclar Vivadent

Take-Home Message on Primary Molars

When sealants on primary molars • Only when risk of occlusal caries is high

• Second primary molars before first primary molars

Consider • Preventive Resin Restoration for high risk patient

Atraumatic Restorative Treatment (ART) (and ITR)

Features -useful alternative to composite resin and Amalgam restorations -usually compomer material -faster treatment at less expense -can be a psychologically desensitizing procedure -usually done without local anesthesia -semi-permanent restoration on primary dentition -can be bonded with or without acid-etch -longevity 2 years +

ART

Kemoli AM et al, 2-Yr Survival Rates of Proximal ART Restorations…. Ped Dent 33(3): May-June 2011 Proximal restorations • 3 Glass Ionomer Cements – Fuji IX, KMA, Ketac Molar • 31% survival rate after 2 years • Survival rate depended also on consistency of meal

consumed after restoration

Comment One can logically assume higher retention rates with compomer material or etching prior to use of conditioner

ART Case study

ART Case Study

ART Case Study

ART Case Study

ART Case Study

Interim Therapeutic Restorations

A Variant of A.R.T.

• Advantages –Temporization restoration – Fluoride-releasing –Minimal/no preparation –Opportunity  to  “buy  time”   • Materials –Resin-modified glass ionomer or –Glass ionomer –CaOH or GI base as necessary

Case example

• 20 months old

• Pre-GA

• Cold-sensitive

• Toothbrush-sensitive

• GA wait time at least 4 months

Resin-modified Glass Ionomer – Ketac Nano

ICON Resin Infiltration

Intermediate treatment Neither preventive nor restorative Resin infiltrant into pre-cavitated carious lesion

Smooth surface and interproximal surface versions Resin infiltrant for pre-cavitated lesions E1 up to D1 (ICDAS score)

• ICON etch 15% HCl

• ICON dry ethanol

• ICON infiltrant resin + ethanol

Research “Comparison  of  the  radiological  lesion  progression of proximal caries after infiltration or standard therapy-18  months  follow  up” Paris S, Meyer-Luckel H

• radiographic assessment no reported side

effects-pain, vitality, stain • 10% show progression of lesion vs.38% in

control group

ICON – Latest Results Paris S, Meyer-Lueckel H 2010

in situ bovine enamel samples in human subjects 100 days with plaque and sucrose solution Measure change in lesion depth and integrated mineral loss Slight progression in mineral loss and no progression of lesion depth versus negative control Conclusion:  “the  clinical  efficacy  of  the  resin  infiltration  in  natural  lesions  needs  to  be  explored  in  clinical  studies”

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

Limitations with ECC -Patient selection monitoring post-treatment co-operation for treatment -Non-radiopaque material -Handling awkward -No insurance code under USC&LS -Expense

ICON Resin Infiltrant

Opinion: • limited case selection in ECC • needs more clinical trial results • would benefit from improved delivery

tools

Not ready for Prime Time

ICON Resin Infiltrant

ICON Resin Infiltrant

ICON Resin Infiltrant

Detection Around ICON

Detection Around ICON

Case Scenario-”Incipient”  Interproximal  Caries

Treatment Options: What does that mean NOW

• Monitor • Review and/or alter preventive care – Flouride varnish, Povidone Iodine, home care including high

fluoride T.P., diet review • More frequent office preventive visits • Glass Ionomer sealant • Vanish XT Extended Contact Varnish • ICON • Restoration

GI Sealant with Triage

ORTHODONTIC

DECALCIFICATIONS & CARIES

Incidence of White Spots During Orthodontic Treatment

• 11.7% Mizrahi E., Am. J. Ortho 1982 • 16% Ogaard, B., Am. J. Ortho Dentofacial Orthop 1989 • 25.6% Gorelick et al. Am J. Ortho. 1982

Richter et al. AJO-DO May 2011

Examined 350 patient records

U of Michigan Grad Ortho

White Spots 24 Year Old Male

Detecting and Measuring with The Canary

34

64

21

15

38

14

11

64

13

Orthodontic decalcifications and caries

Orthodontic Decalcifications and Caries Strategies and Solutions

Objectives of Orthodontics Esthetics Function Stability Conclusion Decalcification and Caries are a failure of orthodontic outcomes

Strategy For Caries Control

• Risk Assessment

• Collaboration Triad

• Communication Agreement

• Individualized Prevention Programme

Dear Dr. Re: Patient Our mutual patient was in recently for regular care. You will recall that he/she demonstrates a higher risk for dental caries. As a result, we have initiated a customized preventive programme for him/her while undergoing the orthodontic care under your supervision. Specific components of this preventive programme include: ___ Higher fluoride toothpaste used at bedtime ___ More frequent dental hygiene visits for scaling, prophylaxis ___ More frequent dental hygiene visits for additional fluoride varnish application ___ Review of home hygiene techniques including use of floss and proxybrush ___ Scanning of at risk sites on teeth with the Canary System The  current  review  of  ________’s  oral  hygiene  and  caries  status  reveals: ___ Oral hygiene is under control ___ Adjustments to the preventive programme are required and involve the following: ___ A rescan of the at risk sites is planned for ___ months We appreciate your collaboration in the oral care for _______. Please contact our office if you have concerns about anything for him/her. Sincerely yours, Ian McConnachie B.Sc., D.D.S., M.S., F.R.C.D.(C )

Solutions for Caries Control

Solutions for Caries Control Filled Resin Sealant

Pro-Seal Technique

Slides courtesy of Reliance Orthodontics

Opinion: Why ProSeal over Opalseal

PREVENTION OF ENAMEL DEMINERALIZATION WITH LIGHT

CURE FILLED SEALANTWei Hu, DDS, MSc, PhD, John D.B. Featherstone, MSc, PhD

University of California San Francisco, CA.

CONCLUSION:The results of the study indicate that ProSeal® could be considered for use as a preventive method to reduce enamel demineralization adjacent to orthodontic attachments, particularly in patients who exhibit poor compliance with oral hygiene and home fluoride use.

Opinion: Why ProSeal over OpalSeal

Treated with Opalseal

Application Technique – Orthodontics Vanish XT Extended Contact Varnish

© 3M 2008. All Rights Reserved.

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Application Technique – Orthodontics Vanish XT Extended Contact Varnish

© 3M 2008. All Rights Reserved.

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Patient Education

Positioning Your Practice

Patient Messages

• Caries is a Disease • Caries, if detected early can be treated

with a wide range of therapies • Caries can be prevented • Treatment needs to be home and

office based • Fillings, root canals are really later

stage treatments

Decay Potential of Certain Foods

High Potential for Decay • Dried fruits • Candy, hard candy • Cake, cookies, pie • Crackers • Chips Moderate Potential for Decay • Fruit juice • Sweetened, canned fruit • Soft drinks • Breads

Low Potential for Decay • Raw vegetables • Raw fruits • Milk No Potential to Decay • Meat, fish, poultry • Fats, oils Ability to Stop Decay • Cheeses, • Xylitol • Nuts

Sugars & Snack Foods

SWEET DRINKS

ARE GOOD FOR HUMMINGBIRDS

Did you know?

Kaplowitz, G. an Update on the Dangers of Soda Pop. Dental CE Digest, PennWell Publications

• 56-85% of school-aged children consume at least ONE soda per day • at least 20% of school-aged children

consume a minimum of 4 sodas per day • a dangerous level of consumption exists

among that 20%, which indicates that some of these children are drinking approximately 12 cans of soda in one day

Office Integration

Office Integration

1. Staff training 2. Patient education 3. Selection of products 4. Charting and recording lesions 5. Billing codes and payments 6. Introduction into clinical practice 7. What to do when things fail

First Visits

Office Codes • 00011 First dental visit/orientation up to 3

years

• Option: 01101 NP Exam • Option: 01204 Specific Exam

Remineralization Visits

Office Codes • Progress visit with Fluoride Varnish

application • If combined with Monitoring such as The

Canary System – 01204 Specific Exam – 13601 Topical application of antimicrobial agent – 99555 Unit cost of Varnish

Remineralization codes do exist in some provinces Topical application of anti-microbial Specific examination, oral hygiene instruction,

Office Integration Who • Entire staff

• Assistants

• Hygienist

• Dentist

What • Exam, Risk Assessment, Treatment

Why • Quality of Care

• Restorative vs. Minimal Intervention / Early Treatment

• Practice Builder & Revenue Stream

Office Integration

Introducing this to patients New Patient Recare Exam Recall Risk Assessment Risk Assessment Treatment Treatment

Office Integration

What is Treatment? • Remineralization • Anti-Microbial • Sealant • ITR • ART • Restorative / Surgical

Summary

Some Parting Thoughts

• Caries is an infectious disease

• Biofilms are Bacterial Communities

• Caries is reversible if detected and treated early

• Home and office based prevention require monitoring

• Risk Assessment should be part of ongoing management

Some Parting Thoughts Part 2

• Understand caries detection devices

• Remineralization does work

• Remineralization means treatment & monitoring

• Engage patients in their care • ART works

The Shift in Dealing with Caries

• Growing awareness of social determinants

• Newer recording of caries levels-ICDAS

• Risk-based care

• Patients want to avoid restorations

• A myriad of new products

• New diagnostic devices