Understanding and Treating Dental Caries in Young Children and Young Adults
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Transcript of Understanding and Treating Dental Caries in Young Children and Young Adults
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Understanding and Treating
Dental Caries in Children and
Young Adults: It’s Not Just
Filling Teeth
Dr. Stephen Abrams Dr. Ian McConnachie
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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
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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
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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*
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*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
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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
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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
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Concepts of EBD
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TIP: www.aapd.org
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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
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What is Caries?
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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."
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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
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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.
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CHMS Oral Health Data
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CHMS vs U.S. Data
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The Problem
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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
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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
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Public Perception
– In other words – NO BIG DEAL
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Our Reality
A VERY BIG DEAL
Lower body weight
Psychological impact
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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
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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
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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
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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
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• 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.
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Cariology
What is Tooth Decay?
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Caries Risk?
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Caries Progression
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What do you need to create tooth decay?
• Teeth
• Food particularly carbohydrates
• Bacteria in Plaque or Biofilm
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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
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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.
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Caries Evolution
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Caries Progression
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Caries Progression
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Caries Progression
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Caries Progression
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White Spot Lesion Really a subsurface lesion
External (outer) surface
Internal loss of minerals
White Spot Lesion
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Early Carious Lesion in Enamel
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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
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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
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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
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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
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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 <
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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
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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.
?
?
?
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• 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?
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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?
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pH Change During the Course of The Day
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Caries is a Bacterial Infection
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Web of Transmission
PATIENT SIBLINGS
PLAYMATES/PEERS
CAREGIVERS
2008 Copyright T .Rodriguez,DDS
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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.
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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
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Bacteria Involved in Caries
Streptococcus Mutans, Streptococcus Sobrinus Lactobaccillus
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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
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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
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Plaque & Biofilms
Some New Thoughts on Plaque
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• 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?
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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
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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
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Host Factors That Influence Microbial Composition
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Dental Plaque: Caries & Periodontal Disease
Marsh et al. “Dental Plaque Biofilms: Communities Conflict & Control” Periodontology 2000 December 2011
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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
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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
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Saliva
A Very Important Component in the
Oral Environment
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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
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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
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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
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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
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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
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Risk Factors
Caries is a Disease
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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
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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
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Risk Factors
• Social Determinants
• BioMedical
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Risk Factors: History
• Child has special needs
• Socio-economic status of the family
• Parents & siblings have decay
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Risk Factors: Dental History
• Child has decay
• Time elapsed since last cavity
• Child wears braces or oral appliance
• Reduced saliva flow
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Risk Factors: Dental History
• Frequency of brushing
• Daily between meal exposure to sugars & carbohydrates
–On demand bottle
– Sippy cup
– Sports drinks & carbonated beverages
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Risk Factors: Fluoride exposure
• Fluoridated water
• Fluoride supplements
• Fluoridated toothpastes
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Risk Factors: Clinical Evaluation
• Visible plaque
• Gingivitis
• Areas of enamel demineralization
– ICDAS 1 – 3
• Enamel defects / deep fissures
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Risk Factors: Clinical Evaluation Part 2
• Radiographic evidence of caries
• Levels of Strep Mutans in saliva
– Use commercial tests
– Not critical for establishing risk
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Risk Definitions & Treatment Recommendations
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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
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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
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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
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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
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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
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CAMBRA
Caries Management by Risk Assessment
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The Caries Balance
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ad Bacteria
bsence saliva
ietary habits poor
The Caries Balance
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ad Bacteria
bsence saliva
ietary habits poor
aliva adequate
nti- microbial
luoride
ffective diet
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ad Bacteria
bsence saliva
ietary habits poor
aliva adequate
nti- microbial
luoride
ffective diet
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A Caries Risk Assessment (CRA) is just “weighing” the factors of each patient.
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CAMBRA is just “removing weight” from one side and “adding weight” to the other.
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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
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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
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Tools for Assessing Caries
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“ 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
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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
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Tools for Detection
• Visual Exam with or without Explorer
• Radiographs
• DIAGNODent
• Caries ID
• QLF
• Spectra
• Sopro
• CarieScan
• The Canary System
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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.
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White Spots????
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Examining a White Spot
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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
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Visual Tools for Assessing Caries
• DMFT and DMFS
• ICDAS
• CAMBRA
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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
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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
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ICDAS Coding Summary
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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
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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
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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
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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
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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.
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Does this look suspicious?
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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
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Probing Drives Bacteria & Debris into Fissures
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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
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Light Interaction with Teeth
•Reflection •Transmission •Absorption •Backscatter Backscattered
light from lesion
Reflection of light from tooth surface
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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
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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
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Radiographs
Radiograph unable to locate caries and crack beneath the restoration
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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
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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
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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
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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)
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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
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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
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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.
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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.
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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
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39
60
Case Study: Caries Beneath an Amalgam
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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.
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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
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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
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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
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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.
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Remineralization and Other Therapies
Minimally Invasive Dentistry
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Understanding your choices?
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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?
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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”
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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
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Topical Fluoride
The Original Remineralization Agent
• Water Fluoridation
• Toothpaste
• Fluoride Rinse
• Fluoride Varnish
• Bottled Water
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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
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Community Water Fluoridation Canada
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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
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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
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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
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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
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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
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TOPICAL FLUORIDE
Toothpaste
• Position Statements
– Canadian Dental Association
– American Academy of Pediatric Dentistry
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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
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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
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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
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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
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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)
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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
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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
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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
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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
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Applying Fluoride Varnish
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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
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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
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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.
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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
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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
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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)
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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
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Fluorosis – Dean’s Index
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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
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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
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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?
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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
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High fluoride toothpaste 5000 ppm
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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
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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
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Clinical Trial (preliminary analysis)
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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
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Recaldent
MI Paste MI Paste Plus Trident Xtra Care Gum Trident White Gum
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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
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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
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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
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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
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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
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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
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Remineralization and Other Therapies
Antimicrobial treatment (remember the
biofilm!)
• Xylitol
• Povidone iodine
• Chlorhexidine
• Delmopinol
• Triclosan
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Remineralization and Other Therapies
Xylitol
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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
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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
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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
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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
%
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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
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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)
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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• 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
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Remineralization and Other Therapies
Povidone Iodine – Betadine
-potent antibacterial
-safe to swallow
-disrupts binding to biofilm
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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
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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
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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
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Anti-Bacterial Agents
Mechanism of Action: Reduce Bacterial Levels in the Oral
Cavity • Prevora • Cervitec • Povidone Iodine • Chlorhexidine Mouth Rinses (Peridex) • Triclosan
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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
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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?
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Prevora
• CHX Varnish originally for root caries • Studies on mother child being analyzed.
Report available soon • Efficacy in xerostomia patients
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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
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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)
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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
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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
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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
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What is the Recipe?
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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
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Does Remineralization Work?
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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
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Remineralization 5th and 7th Quads
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Remineralization Case Slides courtesy of Dr. Clive Friedman
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Remineralization Case Slides courtesy of Dr. Clive Friedman
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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
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Does Remineralization Work?
Yes
But
You need to monitor and motivate
your patient
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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
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Integration into Clinical Practice
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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
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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)
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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
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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
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Early Childhood Caries
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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
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Early Childhood Caries
Clinical Presentation
(Advancing)
• Virulent caries with rapid
progression
• Enamel chips away as
lesions advance
• Colour of caries indicates
speed of progression
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Advanced Tooth Decay photo Dr. Joanna Douglass, Smiles for Life
Early Childhood Caries
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Facial Cellulitis Infection spreading into surrounding tissues
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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
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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
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Early Childhood Caries
Lida et al 2007
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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
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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
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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
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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
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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
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ECC – Other Aspects to Consider
• New approach needed
• Social determinants
• Role of physicians, nurses
• Motivational interviewing
• Role of dental public health
• ECC as predictor
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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
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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
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Smiles for Life Pocket Cards for Physicians
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Smiles for Life Pocket Cards for Physicians
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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
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Models of Individual Oral Health
Promotion
Brickhouse T.H. Virginia Commonwealth University presented at AAPD Symposium October 2009
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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Early Childhood Caries
Lida et al 2007
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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
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Early Childhood Caries
Clinical Management in Your Practice Decision Tree in different clinical situations
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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
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ECC Decision Tree – Low Risk
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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
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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
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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
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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
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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
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First Teeth First Visit
Integration into Clinical Practice
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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?
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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.
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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.
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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
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Parent / Guardian Interview:
• History of active decay • parent, child & sibling
• Medical history • Diet • Oral Hygiene • Motivation
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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:
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Water
• Good for mom’s health • Does it have fluoride • If bottled water, does it
contain fluoride
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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
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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
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Canada’s Food Guide
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php
Interactive guide for all family members
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ODA’s “Ten Tips For Parents”
Downloadable from the
website www.youroralhealth.ca
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Oral Hygiene Instruction:
1. Lift the lip
2. Use of tooth paste
3. Other aids
4. Diet
5. Motivation
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Examination of the Young Child
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Early Childhood Caries
Infant Oral Health Exam • The new standard of Care CDA, CAPD, ADA, AAPD
• Optimal evidence-based preventive Practices Practice-building opportunity
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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
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Sealants, Preventive Resin
Restorations, ICON & Ortho-
Related Caries
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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
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• 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
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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
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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
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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
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Application Technique – Newly Erupted Teeth Vanish XT Extended Contact Varnish 3MESPE
© 3M 2008. All Rights Reserved.
1 2 4 3
5 6 8 7
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© 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.
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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
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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
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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 +
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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
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ART Case study
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ART Case Study
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ART Case Study
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ART Case Study
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ART Case Study
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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
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Case example
• 20 months old
• Pre-GA
• Cold-sensitive
• Toothbrush-sensitive
• GA wait time at least 4 months
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Resin-modified Glass Ionomer – Ketac Nano
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ICON Resin Infiltration
Intermediate treatment Neither preventive nor restorative Resin infiltrant into pre-cavitated carious lesion
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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
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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
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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”
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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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
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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
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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ICON Resin Infiltrant
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Detection Around ICON
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Detection Around ICON
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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
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GI Sealant with Triage
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ORTHODONTIC
DECALCIFICATIONS & CARIES
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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
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White Spots 24 Year Old Male
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Detecting and Measuring with The Canary
34
64
21
15
38
14
11
64
13
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Orthodontic decalcifications and caries
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Orthodontic Decalcifications and Caries Strategies and Solutions
Objectives of Orthodontics Esthetics Function Stability Conclusion Decalcification and Caries are a failure of orthodontic outcomes
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Strategy For Caries Control
• Risk Assessment
• Collaboration Triad
• Communication Agreement
• Individualized Prevention Programme
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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 )
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Solutions for Caries Control
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Solutions for Caries Control Filled Resin Sealant
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Pro-Seal Technique
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Slides courtesy of Reliance Orthodontics
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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.
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Opinion: Why ProSeal over OpalSeal
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Treated with Opalseal
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Application Technique – Orthodontics Vanish XT Extended Contact Varnish
© 3M 2008. All Rights Reserved.
1 2 4 3
5 6 8 7
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Application Technique – Orthodontics Vanish XT Extended Contact Varnish
© 3M 2008. All Rights Reserved.
9 10 11
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Patient Education
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Positioning Your Practice
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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
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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
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Sugars & Snack Foods
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SWEET DRINKS
ARE GOOD FOR HUMMINGBIRDS
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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
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Canada’s Food Guide
www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php
Interactive guide for all family members
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Office Integration
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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
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First Visits
Office Codes • 00011 First dental visit/orientation up to 3
years
• Option: 01101 NP Exam • Option: 01204 Specific Exam
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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,
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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
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Office Integration
Introducing this to patients New Patient Recare Exam Recall Risk Assessment Risk Assessment Treatment Treatment
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Office Integration
What is Treatment? • Remineralization • Anti-Microbial • Sealant • ITR • ART • Restorative / Surgical
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Summary
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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
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Some Parting Thoughts Part 2
• Understand caries detection devices
• Remineralization does work
• Remineralization means treatment & monitoring
• Engage patients in their care • ART works
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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
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