Teachers' Reference Manual of Dental Information Table of Contents

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ONTARIO ASSOCIATION OF PUBLIC HEALTH DENTISTRY

Teachers’ Reference Manual of
Dental Information

Table of Contents

Section 1: General Information
Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 1-1
Oral Health Education and Ontario Health and Physical Curriculum
for Grades 1 to 8 . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 1-2
Dental Dictionary . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 1-3

Section 2: Oral Anatomy
The Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 2-1
Cross-Section of a Molar Tooth . . . . . . . . . . . . . . . . . . .. . . . . . . . 2-2
Dental Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 2-3
Types of Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 2-4
Functions of Teeth . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 2-5

Section 3: Tooth Decay
The Process of Decay . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 3-1
Steps in the Decay Process . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 3-3
Early Childhood Caries (ECTD) . . . . . . . . . . . . . . . . . .. . . . . . . . 3-4

Section 4: Periodontal (Gum) Disease
Periodontal Disease, What is it? . . . . . . . . . . . . . . . . . .. . . . . . . . 4-1
Risk Factors and Signs of Periodontal Disease . . . . . . . . . . .. . . . . . . . 4-2
Other Types of Periodontal Disease . . . . . . . . . . . . . . . . .. . . . . . . . 4-4
Prevention of Periodontal Disease . . . . . . . . . . . . . . . . .. . . . . . . . 4-5
Did You Know? . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 4-6
Section 5: Dental Nutrition
How Food Affects Your Dental Health . . . . . . . . . . . . . . .. . . . . . . . 5-1
Choosing Snacks that Promote Dental Health . . . . . . . . . . .. . . . . . . . 5-4
Sweeteners in Medication . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 5-5
Canada’s Food Guide to Healthy Eating . . . . . . . . . . . . . .. . . . . . . . 5-6
Label Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 5-9
Eating Disorders and Body Image . . . . . . . . . . . . . . . . .. . . . . . . . 5 - 10

Section 6: Prevention of Dental Disease
Why Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6-1
Tooth Brushing . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6-2
Flossing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6-5
Fluoride . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6-8
Pit and Fissure Sealants . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6 - 10
Dental Office Visits . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6 - 11
Dental Public Health . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 6 - 13
Over the Counter Dental Products . . . . . . . . . . . . . . . . .. . . . . . . . 6 - 14

Section 7: Personal Safety and Injury Prevention
Rules for Tooth Safety . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 7-1
Dental First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 7-2
Mouth Protection . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 7-3
Family Violence - The Dental Perspective . . . . . . . . . . . . .. . . . . . . . 7-5
January 2000
Ontario Association of
Public Health Dentistry

Section 1

General Information

Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 1
Oral Health Education and Ontario Health and Physical Education
Curriculum for Grades 1 to 8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 2
Dental Dictionary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 - 3
January 2000
Ontario Association of
Public Health Dentistry

Forward:
To the Teacher

The Ontario Association of Public Health Dentistry is pleased to provide the “Teacher’s
Reference Manual of Dental Information” for your use. This Manual has been prepared to make
dental information available to supplement other dental resources and to assist in the
implementation of dental expectations in the four components of the Healthy Living Strand in the
Health and Physical Education Curriculum.

As a teacher, you are in a unique position to provide the guidance and motivation necessary to
assist your students in establishing effective oral care habits that will benefit them throughout
their lives. It is important because oral disease is one of the most prevalent health problems
today and optimal oral health is an integral part of total health.

We are optimistic that this opportunity will provide a new focus in the development of a health
education partnership. As health education partners, we can make a difference.

Teacher’s Reference Manual of Dental Information (the Manual) was made possible through the
support of the Ontario Association of Public Health Dentistry (OAPHD), the input of Dental
Public Health Staff and the committee efforts of Donna English (Chair), Victoria Leck, Beth
McIntosh, Dianne Pella, Janet Rimar and Debbie Zanetti.

The Manual is intended to provide general dental information. The OAPHD takes no
responsibility for any harm suffered by any person for any reason as a result of any error or
omission in or any use or interpretation of the Manual information set out in it or if the
application of any activities described in the Manual is
unsuccessful.

The information in the Manual is current only as of January
2000.

If you require specific information on dental topics, please
contact the dental division of your local health agency.

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Ontario Association of
Public Health Dentistry

Oral Health and the Ontario Health & Physical Education Curriculum

Grade Healthy Eating Growth & Personal Safety & Substance Use &
Development Injury Prevention Abuse
1 Care of teeth Teeth eruption Dental safety rules Fluoride warning in
Good dental snacking Types of teeth - helmets & mouthguards toothpaste
- playground Sugar in medication
2 Good dental snacking Oral anatomy Dental safety rules Fluoride warning in
Foods that promote - types, parts and - helmets & mouthguards toothpaste
healthy teeth and gums function of teeth - playground Sugar in medication
Decay process - tongue and taste
Care of teeth buds
Visiting the dentist Personal hygiene
3 Food Groups Eruption of permanent Dental safety rules Oral effects of
Foods that promote teeth - helmets & mouthguards tobacco use
healthy teeth and gums - playground
Care of teeth (brushing
and rinsing)
4 Good dental choices Orthodontic needs Dental safety rules Oral effects of
Hereditary dental - helmets & mouthguards tobacco use
affects - dental emergencies
5 Reading food labels Puberty (Gingivitis) Dental safety rules Oral effects of
(sugar content) Personal Hygiene - dental emergencies tobacco and alcohol
Advertising (oral care (Care of gums and
products) teeth)
6 Body Image Puberty (Gingivitis Dental Emergencies Oral effects of
- Eating disorders (oral and periodontal Babysitting (Early tobacco and alcohol
effects) disease) Childhood Tooth Decay)
Food choices (smart
snacking)
7 Body Image Oral effects of
- Eating disorders (oral tobacco and alcohol
effects)
8 Body Image Family violence and the Oral effects of
- Eating disorders (oral dental community tobacco and alcohol
effects)
- Sports dieting

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Ontario Association of
Public Health Dentistry

Dental Dictionary

Abscess
A localized infection containing pus and usually surrounded by inflammation. An
abscess results from tissue destruction.

Acid
A substance producing a corrosive etching effect on the tooth enamel surface. When food
containing sugar is eaten, bacteria in plaque break down the food and change the sugar to
acid.

Alveolar Bone
That part of the jaw bone or maxilla and mandible that holds and supports the teeth.

Amalgam
An alloy type material used to repair cavities in teeth; it contains several metals;
commonly referred to as a silver filling.

Anaesthetic, (freezing)
A drug that the dentist uses to put a tooth to sleep. This is normally required when a
tooth needs a filling or extraction.

Bacteria
Microscopic organisms of many different types and shapes, some of which are capable of
producing disease and acids.

Bicuspid
A permanent tooth with two points or cusps; it is shaped for tearing and grinding food.

Braces
The dentist places “bands” and wire springs on teeth to move them into their correct
position. This improves the appearance and functioning of the teeth.

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Bridge
A fixed or removable replacement for one or several, but not all of the natural teeth.

Bruxism
The grinding or gnashing of teeth. In most cases, it is done unconsciously as a sleeping
habit.

Calcium
An essential mineral that functions throughout the tissues of the body. It is especially
important in providing strength and hardness to bones and teeth. Also, it is essential for
normal muscle contraction and relaxation. Milk and cheese are two sources for obtaining
calcium.

Calculus
Mineralized plaque that forms around the necks of teeth; calculus can only be removed by
a dental professional. If plaque is not removed daily, it can harden by mixing with salts
in saliva. This hardened plaque (calculus) is also referred to as tartar.

Carbohydrate
A nutrient that provides the major source of energy for the body. Carbohydrates supply
energy so protein can be used for growth and development of body cells. Breads, fruits
and potatoes are some sources in obtaining carbohydrates.

Cementum
The thin bone-like covering of the root of the tooth.

Cleft Palate
A congenital fissure in the roof of the mouth often associated with a fissured lip.

Dentifrice
A gel or paste-like substance for cleaning teeth; toothpaste. It is flavoured and usually
contains fluoride.

Dentin
A bone-like tissue that underlies and supports the enamel in a tooth. The dentin forms the
greatest bulk of the tooth.

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Dentist
A general practitioner who is a graduate of an accredited school of dentistry with basic
skills in all areas of dental practice; a dentist is licensed to practice dentistry by the
provincial regulatory body. Specialists are general practitioners who have undergone
further training in specific areas of dentistry.

Dentistry
The science of prevention, diagnosis and treatment of diseases of the oral cavity.

Dentition
The type, number and arrangement of teeth.

Disclosing Agent
A harmless vegetable dye, used to colour or disclose dental plaque.

Enamel
The very hard outer covering of the crown of the tooth. It is the hardest tissue in the
body.

Endodontic Treatment
A dental procedure in which infected soft pulp tissues within the tooth (nerves and blood
vessels) are removed to relieve pain and prevent the spread of infection. This procedure
is also known as root canal therapy.

Endodontist
A dentist who specializes in diagnosis and treatment of diseases of dental pulp.

Eruption
The natural passage of the tooth through the gum into the oral cavity.

Explorer
A fine blunt metal instrument used by the dental professional to help find defects in the
enamel surfaces of teeth.

Extraction
The removal of a tooth from the oral cavity.

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Fat
A nutrient that constitutes part of the structure of every cell. As carbohydrates, fat
provides the energy and fuel to the body. However, it takes longer for the body to digest
and release the energy. The largest percentage of fat in our diets comes from foods such
as salad dressings, margarine or butter, oils and the fat on meat.

First Permanent Molars
The first permanent molar to erupt; they are guides for the position of the rest of the
permanent teeth. The tooth usually erupts around six years of age and is often called a
six-year old molar.

Fluoride
A nutrient that occurs naturally in some water sources and many foods. It functions to
make teeth more resistant to decay.

Frenum
The small band or fold of tissue which attaches the tongue, lips and cheeks to adjacent
structures.

Gingiva
The tissues which cover the alveolar bone of the upper and lower jaws and surrounds the
necks of the teeth; commonly referred to as gums.

Gingivitis
Inflammation of the gingiva (gums).

Halitosis
Stale or foul-smelling breath. (Bad breath/morning breath)

Incisors
The four front teeth in each jaw, shaped for biting and cutting food.

Infection
Invasion of the body by pathogenic micro-organisms and the body’s response to the
micro-organisms and their toxic products. The transfer of disease from one part to
another or one person to another.

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Inflammation
Reaction of living tissue to injury. A defensive reaction of the body characterized by
heat, redness, swelling, pain and loss of function.

Inlay
A solid filling of gold, plastic, or porcelain, fitted to a cavity in the tooth and cemented
into place.

Inter-Dental Device
An instrument used to clean between the teeth (i.e. floss, rubber tip device, wood points,
etc.)

Intra-Oral Mouth Protector (Mouthguard)
Fitted, flexible mouth and tooth protector, either custom-made, mouth-formed, or stock
ready made; effective in the prevention of mouth injury. This protective device is worn
primarily when engaging in contact sports.

Lingual Frenum
Attaches the tongue to the floor of the mouth.

Malocclusion
Poor closure or alignment of teeth.

Mandible
The lower jaw.

Maxilla
The upper jaw.

Minerals
Naturally occurring inorganic substances that are essential for body structure and
functions. Calcium, phosphorus, iron, iodine, zinc, copper, magnesium, and manganese
are minerals needed in the diet. Minerals can be obtained by eating a well-balanced diet
of foods from the Four Food Groups.

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Molars
The eight primary or twelve permanent teeth, farthest back in the jaw that are shaped for
grinding food.

Mouth Mirror
A small round mirror used by a dental professional to examine the teeth.

Mouthwash
A substance that temporarily freshens breath and the mouth. It does not remove plaque.

Occlusion
The way in which teeth and jaws come together for biting and chewing.

Oral Health
The state or condition of the structures and tissues of the mouth.

Oral Irrigating Devices
Devices that spray small jets of water between and around the teeth to assist in the
removal of food and debris. They are not substitutes for a toothbrush and dental floss.

Oral and Maxillofacial Surgeon
A dentist who specialized in diagnosis of injuries, diseases and malformation of the oral
cavity and related structures and provides special treatment for those conditions.

Oral Pathologist
A dentist who specializes in the study of the nature of diseases of the mouth, their causes,
processes and effects through laboratory or clinical diagnosis.

Orthodontist
A dentist who specializes in the study of the growth and development (positioning) of
teeth and surrounding structures. Treats, and where possible prevents abnormal
alignment of teeth and jaws.

Palate
The roof of the mouth; it consists of a hard anterior (front) part called the hard palate, and
a soft movable posterior (back) part called the soft palate.

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Paedodontist
A dentist who specializes in providing care and treatment for children and adolescents.

Papillae
Gum tissue between the teeth.

Periodontal (Gum) Disease
A group of diseases that affect the soft tissues (gums), the periodontal fibres which hold
the teeth in place and the bone surrounding the teeth.

Periodontal Ligament
Connective tissue band that anchors the tooth root to the alveolar bone.

Periodontist
A dentist who specializes in prevention and treatment of diseases of the supporting
tissues surrounding the tooth.

Periodontitis
Severe form of periodontal disease usually non-reversible to underlying tissue. Pockets
form in the underlying bone and inflammation process extends from the gingiva and is
usually accompanied by bone destruction. If not treated, the alveolar bone is destroyed
and teeth become loose and are eventually lost.

Permanent Teeth
Sometimes called adult teeth. They begin to erupt at about age six. These replace
primary (deciduous) teeth. An individual can have up to thirty-two permanent teeth.

Phosphorus
A mineral that is essential for the body. It gives strength and hardness to bones and teeth.
Phosphorus is found in milk, cheese, whole grain cereals, nuts, seafood, eggs and meat.

Pits and Fissures
The naturally occurring crevices and grooves on the surfaces of the teeth.

Plaque
A soft, sticky, colourless layer of bacteria and their by-products that is constantly forming
on the teeth.

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Ontario Association of
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Professional Cleaning
A procedure to remove extraneous materials including stains and calculus from tooth
surfaces using polishing and/or scaling.

Prosthodontist
A dentist who specializes in replacing missing natural teeth and related structures with
fixed and removable substitutes.

Protein
A nutrient that is essential for the growth and repair of animal tissue; protein furnishes
heat and energy like two other nutrients, carbohydrates and fat. It is the chief constituent
of muscle, gland and nerve tissue and blood. Sources of protein are milk, cheese, eggs,
meat, poultry, fish and peanut butter.

Public Health Dentist
A dentist who specializes in the control and prevention of dental disease and the
promotion of oral health through organized community efforts. Often employed by a
government agency.

Pulp
Innermost tissues of the tooth contained in the root canal which include nerves and blood
vessels.

Restoration (Filling)
A material inserted in the prepared cavity of a tooth. May be gold, amalgam, cement,
plastic (composite), or porcelain.

Root
The part of the tooth that anchors it in the jawbone.

Saliva
A watery substance made in glands and secreted into the mouth that helps lubricate
chewed food making it easier to swallow. It also contains enzymes that initiates food
digestion.

Sealants or Fissure Sealants
Special clear plastic coatings used to protect tooth surfaces by sealing the pits and fissures
of the teeth.

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Ontario Association of
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Shedding
The loss of primary teeth by natural process that usually begins at age six and is
completed by age eleven.

Space Maintainer
A device used to keep space open when a primary tooth has been lost prematurely. The
space maintainer may prevent shifting of teeth into space where the permanent tooth will
erupt.

Third Permanent Molar (Wisdom Tooth)
The last permanent molar to erupt at the back of each arch usually erupting between the
ages of seventeen and twenty-one.

Topical Fluoride Application
The application of fluoride to the tooth surface to increase resistance against decay.

Vitamins
Naturally occurring substances that are essential to good nutrition. Scientists have
discovered fourteen of these substances that are required to serve the nutritional
requirements of man. Most people can get all the vitamins they need by eating a well
balanced diet of foods from the Four Food Groups.

Xerostomia
Dryness of mouth.

X-Ray (Radiograph)
A radiograph or x-ray photograph producing shadow images on a film; in the dental
office it is used as an aid to diagnosis and treatment.

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Ontario Association of
Public Health Dentistry

Section 2

Oral Anatomy

The Mouth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 1
Cross Section of a Molar Tooth .............................. 2-2
Dental Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 3
Types of Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 4
Functions of Teeth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 - 5
January 2000
Ontario Association of
Public Health Dentistry

The Mouth
Primary Teeth
i Primary or baby teeth
i These are the teeth that are lost
when adult teeth erupt
i We have twenty primary teeth
(See Dental Chart) page 2 - 3

Permanent Teeth
i Adult or permanent teeth
i Teeth meant to last for a lifetime
i We have up to thirty-two adult teeth
(See Dental Chart) page 2 - 3

Gingiva (Gums)
i Soft tissue which covers the bone in which
our teeth are anchored
i If healthy, they are pink, stippled and tightly
adapted to the teeth

Palate (Soft and Hard)
i Roof of the mouth
i Separates the oral cavity and nasal passage
i Bony front is the hard palate
i Fleshy back is the soft palate

Uvula
i Located above the tongue and is suspended from the centre of the soft palate
i It is a small fleshy mass of tissue

Tongue
i Fleshy, muscular organ that is attached to the floor of the mouth
i Important for speech, chewing, swallowing and sensing taste and temperature of food

Taste Buds
i Tiny surface on tongue that distinguishes flavours (i.e. sweet, salty, sour and bitter)

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Ontario Association of
Public Health Dentistry

Cross Section of a Molar Tooth
Enamel
i Outer covering of the crown of the tooth
i Hardest tissue in the body
i It is smooth and glistens
i It protects the tooth
i It cannot be replaced

Dentin
i Ivory-like substance under the enamel
i Forms body of the tooth
i Bone-like tissue that is less hard than enamel
i Gives the tooth elasticity so the tooth will not break apart

Pulp
i Centre of the tooth
i Holds the nerve and blood supply
i Gives the tooth nourishment and sensitivity

Cementum
i Live layer of bone-like tissue that covers the root of
the tooth
i Forms a surface to which the periodontal ligament
attaches

Periodontal Ligament
i Fibrous tissue which anchors the root to the bone
i Helps support the tooth in its socket

Tooth Structure
Tooth consists of two parts:

1. Crown Usually appears above the gums
and is visible in the mouth .
2. Root Anchors the tooth in the bony socket of
jaw bone.

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Public Health Dentistry

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Public Health Dentistry

Types of Teeth – Four Types

Incisors
i Four front teeth in each jaw (two central and two lateral)
i Used for biting and cutting

Cuspids (or Canines)
i Two in each jaw
i Used for tearing

Bicuspids (or premolars)
i Permanent teeth only
i Four in each jaw
i Used for tearing and crushing

Molars
i Four in primary jaw
i Six in permanent jaw
i Deep grooves on top of these teeth making them susceptible to pit and fissure decay
i Used for grinding food

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Ontario Association of
Public Health Dentistry

Functions of Teeth
Incisors are cutting
teeth that work like
scissors to bite off
pieces of food.

Cuspids (canines) are
pointed teeth that
work like a fork to tear
food into small pieces.

Bicuspids (premolars)
have pointed chewing
surfaces and work like
a nutcracker to crush
food.

Molars have strong,
broad surfaces and
work like a mortar and
pestle to grind food.

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January 2000
Ontario Association of
Public Health Dentistry

Section 3

Tooth
Decay

The Process of Tooth Decay ................................. 3-1
Steps in the Decay Process .................................. 3-3
Early Childhood Tooth Decay (ECTD) . . . . . . . . . . . . . . . . . . . . . . . . . 3 - 4
January 2000
Ontario Association of
Public Health Dentistry

The Process of Tooth Decay

Plaque + Sugar = Acid
Acid + Tooth = Decay

Plaque forms constantly on everyone’s teeth. When food containing sugar is eaten, bacteria in
plaque break down the food and change the sugar to acid. Plaque holds acid to the tooth surface
causing it to decay, making a cavity. The longer the plaque stays on the tooth and the more sugar
that is eaten the larger the cavity grows.

The dental decay process will only take place if all three factors are present: the agent (plague),
the host (tooth), and the environment (sugar). The decay process can be interrupted by
controlling these factors. Toothbrushing and flossing will reduce the build-up of plague. Use of
fluoride will make the tooth structure tougher and more resistant to decay. Smart snacking and
attention to diet can reduce the number of times the tooth is exposed to sugar and acid attack.

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Public Health Dentistry

Steps in the Decay Process
Tooth decay is a slow gradual process.

Demineralization starts on the outer surface of the enamel forming a white spot lesion. Good
oral hygiene, diet control and use of fluoride toothpaste can reverse the process at this point.

The more often the tooth is exposed to acid attack the further the decay penetrates into the
enamel. Eventually it reaches the dentin. At this point remineralization is no longer possible,.
The tooth has a cavity and requires a filling.

The decay process moves much more quickly when it reaches the dentin. If left untreated the
cavity will reach the pulp, resulting in pain and possible abscess. At this point the tooth may be
saved with root canal treatment or will have to be extracted (pulled out).

For further information about preventing tooth decay see
Section 5: Dental Nutrition
Section 6: Prevention of Dental Disease.

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Ontario Association of
Public Health Dentistry

Early Childhood Tooth Decay (ECTD)
ECTD is a form of dental caries that attacks children up to age four. Many synonyms are used to
describe this decay pattern. These include ECTD, baby bottle tooth decay and most recently,
early childhood tooth decay.

ECTD is a significant childhood disease for several reasons. Prevalence rates are greater than all
other childhood diseases combined, at five to fourteen percent in Ontario. It is a painful dental
condition that can interfere with eating and speaking and commonly progresses to the formation
of abscesses. Such infection can affect the developing permanent teeth. The treatment of ECTD
is costly both financially and emotionally. Frequently, treatment must be performed while the
child is sedated or under general anaesthetic, often in a hospital.

Studies suggest that ECTD is an infectious and transmissible disease. It is caused by a number of
factors: pathogenic bacteria, prolonged and frequent exposure of the teeth to sugar-containing
substances, decreased host resistance and time for the decay to develop and progress. Research
generally has shown that most children acquire the caries causing bacteria at age 22 months to 26
months and that the source of transmission of the bacteria is from parents or caregivers.
Transmission can be indirect (via eating utensils, cups, glasses, etc.) or directly through kissing.
For dental caries to occur three essential factors must be present at the same time: an adequate
number of cariogenic bacteria; a susceptible tooth surface to be attacked and available food to
support the growth of the bacteria.

The caries process either will not occur or can be prevented or interrupted if any one of these
conditions does not exist or is modified. This suggests that the parent or caregiver can inhibit the
process by reducing the frequency of eating fermentable carbohydrates.

While bottle feeding practices have been implicated in the aetiology of ECTD, these practices are
not the sole dietary factor in the disease. In addition, frequent snacking, feeding on demand,
breast feeding and the addition of highly sugared substances have been associated with the
disease.

It is important to look for and recognize the early warning signs of ECTD. The decay begins
with white spots or areas at the gum line of the upper anterior teeth, observable by lifting the
upper lip.

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ECTD is a preventable disease. The best preventive strategy is early intervention, before the
habits that lead to the condition are established. Habits once established are difficult to break.
The early establishment of good oral health habits, cleaning baby’s teeth as soon as they erupt
and lifting the lip are good preventive strategies.

Continued use of a bedtime bottle containing liquids other than water (e.g. milk or juice), nursing
a toddler to sleep, or continuous sucking on a bottle or soother dipped in syrup or honey during
the day can result in damage to the primary teeth. If a bedtime bottle is provided, it should
contain only water.

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Ontario Association of
Public Health Dentistry

Section 4

Periodontal (Gum)
Disease

Periodontal Disease, What is it? .............................. 4-1
Risk Factors and Signs of Periodontal Disease . . . . . . . . . . . . . . . . . . . 4 - 2
Other Types of Periodontal Disease ........................... 4-4
Prevention of Periodontal Disease ............................ 4-5
Did You Know? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 - 6
January 2000
Ontario Association of
Public Health Dentistry

Periodontal Disease What Is It?
Periodontal disease is an infection of the gums and other supporting structures of the teeth. It
starts as gingivitis (inflamed gums) which if not treated may lead to periodontitis which leads to
tooth and bone loss. A common name for periodontal disease is gum disease.

Cause
i Periodontal disease is linked to plaque accumulation
i These deposits can be above or below the gum line
i Plaque can harden and form calculus
i Bacteria in plaque produces toxins (by-products) which irritate gum tissue
i Gums can be more sensitive to these toxins during puberty and pregnancy due to
hormonal change and due to other medical conditions

Gingivitis
i Earliest form of inflammation of periodontal tissues may or may not lead to periodontitis
i Includes red, swollen and bleeding gums
i Gingivitis is preventable through proper diet, regular dental visits and daily oral hygiene
(i.e. brushing, flossing, massaging, etc.)
i Gingivitis is reversible with good oral hygiene practices

Periodontitis
i Signs are loss of healthy tone, blunt papillae between teeth, swelling
i Is not usually reversible
i Is a more intensive form of inflammation of periodontal tissues
i Plaque, calculus and pus may form around the tooth
i The space between the tooth and gum, called the pocket, becomes infected/inflamed
i Pockets contain numerous bacteria-producing toxins which destroy the periodontal
ligament and bone (supporting the tooth)
i Can lead to loss of involved teeth

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Risk Factors and Signs of Periodontal Disease
Signs
i Loss of tone of the gums
i Bad breath
i Bleeding, red swollen gums
i Pus
i Detachment of gum from teeth
i Mobile teeth
i Mouth pain
i Bad taste in the mouth
i Tender gums
i Gum recession
i Change in position of teeth/movement of teeth
i Blunt papillae

Risk Factors
1. Dental Plaque and Calculus Accumulation
Leads to more of a web for bacteria and toxins to accumulate thereby increasing risk of
the disease.
2. Age
3. Smoking
A Link exists between smoking and periodontal disease
4. Diabetes
Periodontal disease can be more prevalent and severe in diabetic patients
5. Maloclusion
Crowded teeth may be more prone to accumulation of dental plaque and hence
periodontal involvement.
6. Pregnancy
Hormonal changes makes gums more susceptible to infection.

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Perio’s Progress

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Ontario Association of
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Other Types of Periodontal Disease

Localized Juvenile Periodontitis
< Early onset in adolescents and young adults
< Usually shows no signs of gingivitis
< Severe bone loss in six year molars and front teeth
< Effects females and blacks more often
< Unknown cause
< Could be genetic

Acute Necrotizing Ulcerative Gingivitis (ANUG) Also called Trench Mouth)
< Often attacks college students and young adults under physical and emotional stress. So
named because of frequency among armed forces personnel.
< Also seen in cancer and AIDS patients (immune deficiency disorder)
< Onset – necrotic lesions in gums can cause a lot of pain, foul odour, profuse bleeding of
gums
< Usually the individual gets a fever and swelling of lymph nodes
< Treatment includes cleaning, oral hygiene and a course of antibiotics

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Prevention of Periodontal Disease
Self-Care
i Don’t smoke
i Oral rinses of chlorhexidene (an antibacterial agent) and use of anti-calculus
toothpaste shows some signs of promise

Daily Good Oral Hygiene
i Includes brushing and flossing
i Other specialized types of oral hygiene may include Waterpik, electric toothbrushes,
inter-dental stimulation, floss threaders, etc.

Professional Care

Regular Visits to Your Dental Team (includes the dentist and hygienist)
i Removal of calculus is essential
i Good dentistry as in cavity repair, crowns, tooth replacement (bridges and partials) are
essential
i Proper alignment of teeth is also important for preventing gum disease (an orthodontist
may be involved here)

A Well-Balanced Diet
i A well-balanced diet is essential for maintaining healthy gums and teeth (refer to
Nutrition section)
i Reduce added sugar (e.g. pop, candy) intake, frequency and type of sugars eaten – plaque
thrives on sugar

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Did You Know?
i According to some estimates seventy-five percent of adults over thirty may suffer from
some degree of gum disease
i Most people do not even know they have it because it is painless until the very latter
stages
i Periodontal disease is the most prevalent adult infectious disease

Gum disease is now considered a risk factor for cardiovascular disease (heart attack and stroke),
premature births, low birth weight babies, pneumonia and other respiratory diseases and diabetes.

If periodontal disease does not respond to these preventative measures, the patient is referred to a
specialist called a periodontist. More radical therapy (i.e. surgery or root planing of cementum)
may be necessary.

Gum Disease and Heart Attacks: A Connection
Introduction

Suppose you could prevent a heart attack with a 2-minute, no-sweat exercise that could be
performed anywhere. Would you be interested? Researchers believe that the connection
between heart attacks (medically termed myocardial infarction) and periodontal disease is so
convincing that flossing your teeth might actually be an exercise that saves your life.

From Plaque to Attack

Plaque, a neutral enough term, is actually a sticky film on the teeth made up almost entirely of
colonies of bacteria. While the mouth usually maintains the proper balance of bacteria for our
safety, the food we eat is broken down into sugars and starches, which encourage bacteria to
thrive. If these bacteria are not removed consistently by brushing and flossing, the results will be
bacterial plaque that hardens into tartar. Tartar can’t be removed with brushing and flossing.
Eventually these bacteria inflame the gums causing gingivitis or the more severe gum disease
known as periodontitis, in which the jawbone is dissolved and teeth may be lost. Although it
may seem unlikely that an infection in the mouth may result in heart disease, there are several
possible links that might explain this association.

For example, it is well known that if a person has gum disease, oral bacteria will enter the blood
stream even after chewing or tooth brushing. When bacteria from inflamed gum tissue enter the

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bloodstream they trigger platelets (tiny disc-shaped clotting cells) to gather around them in a
clump, and possibly settle on injured tissue such as a replaced heart valve on a damaged blood
vessel. This clump of oral bacteria can then infect and obstruct blood vessels.

A heart attack happens when a clot/clump lodges in a coronary artery restricting oxygen blood
flow to the point of heart muscle damage (tissue death). Further, when these bacteria enter the
blood stream, they can trigger the liver to produce proteins, which in turn can exaggerate heart
damage. In fact, there are other infections in the body, including respiratory infection caused by
Chlamydia pneumoniae, gastric ulcers caused by Helicobacteria, and cytomegalovirus infections,
which have been associated with an increased risk of heart disease.

Recent Research

Previous studies have already shown a strong relationship between myocardial infarction and
periodontal disease. The results, thus far, have been impressive. In a study reported by the
Journal of Periodontology, patients were found to have a 50% increased risk for heart disease if
they also had periodontitis.

A study of Pima Indians, relatively few of whom smoke, was performed by researchers at the
University of Buffalo and showed that individuals who had periodontitis were almost three times
more likely to have heart attacks than those who did not have periodontal disease. This study is
important because it illustrates that people who do not smoke or use tobacco products have an
increased risk of heart disease if they also have gum disease.

A Significant Connection

Cardiovascular disease is the leading cause of death in most developed countries and periodontal
disease is one of the most common infections in humans, affecting as many as one third of those
over 50. Even if periodontal disease has only a modest effect on increasing the risk of heart
attack, its prevalence may make it a significant contributor to the risk for heart disease in the
population as a whole.

Therefore, while all the information is not available, many clinicians feel that infections do play a
role in heart disease and may explain some of the risk that is not accounted for by other factors
including high cholesterol, smoking, diabetes, homocysteine levels, being overweight, and living
a sedentary lifestyle. Certainly total management of patients who are candidates for heart disease
must encompass all risk factors. Infection, including gum infection, is yet another possible area
for consideration. Preventing gum disease from occurring, or treating it early if it has occurred,
will help save your smile and may also decrease your risk for heart disease.

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Ontario Association of
Public Health Dentistry

Section 5

Dental
Nutrition

How Food Affects Your Dental Health . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 1
Choosing Snacks that Promote Dental Health ................... 5-4
Sweeteners in Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 5
Canada’s Food Guide to Healthy Eating . . . . . . . . . . . . . . . . . . . . . . . . 5 - 6
Label Reading ............................................ 5-9
Eating Disorders and Body Image . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 - 10
January 2000
Ontario Association of
Public Health Dentistry

How Food Affects Your Dental Health
i What you eat makes a BIG difference to your teeth
i Food that is good for your teeth is also healthy for your body
i Food that will help prevent cavities and gum disease must include, grains, milk,
vegetables, fruit, eggs and meat or fish because such foods are rich in essential nutrients
i Many foods contain some sugar (e.g. grains, vegetables, fruit, milk products)

Sugars
Sugar includes all forms of sugar: white sugar, brown sugar, syrups, honey molasses and the
sugars found naturally in foods like fruit, fruit juices and milk. Sometimes sugars added to food
beverages and medicines are listed by their chemical names. Ingredients ending in “ose” like
sucrose, glucose, dextrose, fructose, maltose are sugars too. The exception is “sucralose”
(Splenda) which is a sweetener

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Cariogenic Foods (contribute to decay)
i Fermentable carbohydrates (sugars) when they are in contact with oral micro-organisms
(bacteria) can cause PH to drop to less than 5.5 (the level at which decay starts to form)
i Normal PH is 6 and in fluoridated communities it is 7

Examples of Fermentable Carbohydrates
i Grains
i Starches such as breads, crackers, hot and cold cereals, pretzels, chips
i Canned, dried and fresh fruits, fruit juices, milk products
i Added sugars such as sucrose or fructose and sweetened beverages

Cariostatic Foods (do not contribute to decay)

Examples of Cariostatic Foods
i Protein foods such as eggs, fish, meat, poultry, nuts, sugarless candies and sugarless gum,
popcorn and vegetables

Anti-cariogenic Foods (if eaten after a cariogenic food - will help to reduce acid
production)

Examples of Anti-cariogenic Foods
i Xyletol gum
i Certain cheeses such as Swiss, Monterey Jack and Cheddar

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When eating foods that are cariogenic it is important to
consider:

i How often these foods are eaten
More often causes PH to remain lower for longer periods of time therefore, more chance
of decay

i The consistency of the food
The stickier the food, the longer it will be retained in the mouth (especially in the deep
grooves) therefore, the more difficult it is to remove by brushing

i The amount of sugar in the cariogenic food
The sugar provides the bacteria with a source of energy therefore, the greater amount of
sugar the more chance of decay (more harmful)

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CHOOSING SNACKS
THAT PROMOTE DENTAL HEALTH

( NUTRITIOUS SNACKS ; OCCASIONAL SNACKS
FRESH FRUIT RAISINS OR OTHER DRIED FRUIT
APPLES, KIWI, BANANAS, PERSIMMONS, MANGOS,
STAR FRUIT...

VEGETABLES
OKRA, CELERY CARROTS, BROCCOLI, CUCUMBER,
BOK CHOY

SWEETENED FRUIT DRINKS
UNSWEETENED FRUIT AND VEGETABLE JUICE SOFT DRINKS

MILK
CHEESE (FETA, CHEDDAR)
YOGURT

CANDIES SUC H AS
FRUIT ROLL-UPS
HARD BOILED EGGS DUNKAROOS
TOFU CHOCOLATE BARS
SUSHI FUDGE
SANDWICH OR PITA WITH MEAT, POULTRY, FISH, MARSHMALLOWS
EGGS, ETC. LICORICE
ENRICHED SOY MILK REGULAR CHEWING GUM
FRUIT BY THE FOOT
MINTS OR TOFFEE

NUTS
SEEDS CHIPS
POPCORN CHEESIES
PIGEON PE AS NACHOS
BROWN BEANS PRETZELS
NUTS AND BOLTS

WHOLEWHEAT CRACKERS RICE MARSHMALLOW SQUARES
BREAD STICKS COOKIES
MELBA TOAST TARTS
MUFFINS (WITHOUT DRIED FR UIT OR CHOCOLATE PIES
CHIPS) GRANOLA BARS
CHAPATI DONUTS
CHALLAH HONEY BUNS
PITAS PUDDINGS

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Sweeteners in Medication

The Canadian Dental Association is concerned about the high levels of sugar used as sweeteners
in both prescription and over-the-counter drugs. The sugar content of the formulations is from
20% to 80%.

Patients particularly at risk include those with special needs and infants on long-term medications
who have not yet established proper oral hygiene. The presence in the mouth of sweet syrupy
medications can contribute to high rates of dental caries (such as those seen in early childhood
caries). There are sugar substitutes that do not contribute to dental caries.

The Canadian Dental Association position is as follows:

1. Health care providers, especially physicians, dentists and pharmacists, should be made
aware of the high sugar content of oral elixirs, suspensions and chewable medications and
should be advised to try to prescribe/dispense drugs utilizing sugar substitutes whenever
possible.

2. The Pharmaceutical Manufacturers Association and Proprietary Drug Association should
be made aware of the high risk of decay associated with prescription and over-the-counter
drugs containing sugar and should be encouraged to employ sugar substitutes in
medications.

3. Special needs patients and/or parents/caregivers of children should be advised of the
increased risk of tooth decay associated with the chronic use of sugar sweetened
medications. They should also be counselled regarding oral hygiene and other preventive
measures.

4. Labelling of medication should indicate sugar content to assist the choice of alternatives.
High sugar content medications such as oral elixirs, suspensions and chewable
medications should include warnings regarding the increased risk of dental caries from
chronic use on labels and/or drug monographs.

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Ontario Association of
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Main Nutrients Contributed by the Food Groups
T h e fo l lo w ing c h ar t d e m on s tr a te s ho w cer tain foods pr om ote strong teeth and gum s

Grain Products

Vegetables and

Milk Products

Alternatives
Meat and
Some Major
Nutrient Functions

Carbohyd rate # Supplies energy
# Assists in the utilization of fats
# Spares protein

Fat # Supplies energy
# Aids in the absorption of fat soluble vitamins

Protein # Builds and repairs body tissues
# Builds antib odies to fig ht infection

*Vitamin A # Aids normal bone and tooth development
# Maintains the health of the skin and lining membranes
# Permits good night vision

Some B Vitamins # Releases energy from carbohydrates
# Aids in norm al growth an d appetite
# Maintains normal function of the nervous system and
Thiamin
gastrointestinal tract

B12 # Aids in cell metabolism, tissue growth and the
maintenance of the central nervous system

Riboflavin # Maintains healthy skin and eyes
# Maintains a normal nervous system
# Releases energy to body cells during metabolism

Niacin # Aids normal growth and development
# Maintains normal function of the nervous system and
gastrointestinal tract

Folic Acid or # Aids red blood cell formation
Folate

*Vitamin C # M a i nt a in s h ea l th y te e th a n d g u m s
# Maintain s strong blood ve ssel walls

*Vitamin D # Enhances calcium and phosphorus utilization in the
formation an d maintenan ce of healthy bo nes and teeth
(in fluid milk or
milk powder only)

*Calcium # Aids in the formation and maintenance of strong bones
and teeth
# Permits healthy nerve function and normal blood clotting

Iron # An esse ntial part o f haemo globin, th e red bloo d cell
constituent that transports oxygen and carbon dioxide

Magnesium # Assists in the manufacture of protein and the
transportation of oxygen molecules

*Zinc # Assists in the development of strong, healthy bones and
teeth
# Accelerates the healing of wounds

Label Reading

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The ingredients are listed in descending order of quantity. The ingredient present in the largest
quantity is first, while the ingredient present in the smallest quantity is last on the list.

Compare products, for example, verify if a can of beef stew contains more beef than other
ingredients or if it contains a lot of sugar, salt, additives, etc.

Identifying sugars
When checking the amount of sugar in foods – remember sugar is also listed by its chemical
name (e.g. fructose, dextrose, sucrose, glucose and maltose)
Sugar also includes all forms of sugar (e.g. white, brown and golden) plus syrups (honey,
molasses and corn syrup)

When we read on the label

Low in sugar L means that the food contains no more than 2 grams of sugar per
serving

No sugar added L means that the food contains no added sugar although it may
(or unsweetened) contain naturally present sugar

Sugar free L means that the food contains almost no sugar and very little energy

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Eating Disorders and Body Image
Anore xia nervo sa, bulim ia nervos a and bu limarex ia are all exa mple s of serio us eating disorder s.
Anorexics show severe weight loss, hyperactivity, excessive exercising, a refusal to eat and tend to be shy
and introv erted . A bu limic exhib its a n orm al or s lightly ov erwe ight b ody typ e, ex ces sive e xerc ising a nd is
extroverted. Bulimics have recurrent episodes of uncontrollable binge eating followed by either strict
dieting and fasting [no n purging type] or by purg ing with laxa tives and diuretics o r self-induc ed vom iting.
Both gro ups are very aware that their eatin g habits a re abno rma l and are o ften ade pt at hiding the m.
They may suffer from feelings of guilt and low self-esteem.

The observation of normal body weight, extroverted personality and calloused fingers would indicate the
person suffers from bulimia nervosa rather than anorexia nervos a. Further indications of long term
purging include: pre viously failed de ntal work ; tooth eros ion of the g ingival thirds; an d restora tions with
failed margins.

Serious medical problems may exist and psychiatric therapy is indicated. Client resistance and denial
ma y ma ke re ferra l for he lp diffic ult or im pos sible. Med ical co mp licatio ns inc lude d ehyd ration , elec trolytic
imbalance, protein malnutrition and cardiac arrhythmia. Prolonged use of laxatives and diuretics
contribute to gastrointestinal disturbances. Treatment may include hospitalization, antidepressants,
individ ual ps ycho thera py and fam ily grou p the rapy.

Bulimics may exhibit any combination of the following oral conditions:
< the chemical erosion of teeth by acid regurgitated from the stomach
< raised restoration margins due to the erosion of the enamel
< increased dental caries from the large quantities of cariogenic food ingested during binges
< dem inera lizing o f the e nam el due to sa livary a cidity a nd xe rosto mia
< dehydration of the oral soft tissue caused by a decrease in the quantity and quality of saliva
< xerostomia due to loss of body fluid from vomiting and the use of diuretics
< sensitive teeth due to the loss of enamel from the erosion
< wear facets indicating bruxism
< traumatized palate due to induced vomiting by either fingers or an object

Bulimics may complain of an altered taste perception.

Recommendations for the bulimic client may include:
< referral to a ppropria te profes sionals [ph ysician, psyc hiatrist, nutritionist]*
< if possible, defer restorative treatment until the bulimia is under control
< client instruction in the cause and prevention of and dental caries through;
a) restriction of cariogenic foods
b) improved oral hygiene
c) use of a sodium bicarbonate rinse followed by a .05% sodium fluoride rinse after episodes
of vomiting [NO brushing after purging]
< daily home use of custom-fitted tray with 1.1 neutral fluoride gel, daily rinses with .05% sodium
fluoride and use of fluoride dentifrice
< if neces sary, a saliva substitute with fluoride a nd che wing sug arless g um o r mints to help with
xero stom ia

*In Canada, consult a dietitian or a public health nutritionist

Reference:
W ilkins, E., Clinical Practice of the Dental Hygienist 7 th Edition, Lea & Febiger, Philadelphia. 1994

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Ontario Association of
Public Health Dentistry

Section 6

Prevention
of
Dental Disease

Why Prevention? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 1
Tooth Brushing ........................................... 6-2
Flossing ................................................. 6-5
Fluoride ................................................. 6-8
Pit and Fissure Sealants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 10
Dental Office Visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 11
Dental Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 13
Over the Counter Dental Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 - 14
January 2002
Ontario Association of
Public Health Dentistry

Why Prevention?
An ounce of prevention is worth a pound of cure, the old axiom reminds us, and certainly this
is true in the case of good, early dental care.

There are several reasons why dental problems exist. Lack of knowledge and practice of proper
oral care techniques, misconceptions about dental visits, economic considerations, poor nutrition
and poor consumer habits are contributing factors to dental disease. Dental problems do exist,
but almost all can be prevented if children, parents and teachers are well informed of the causes
of dental disease, practice proper methods of prevention and are aware of the need for regular
dental care. Healthy teeth and gums are important and, fortunately, with all the scientific
advances in the dental profession today, they are within the reach of everyone.

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Tooth Brushing

Brushing teeth with fluoride toothpaste is one of the most effective ways of removing decay
causing plaque from the exposed surfaces of teeth. Effective brushing takes approximately two
to three minutes and is recommended twice daily, once in the morning and especially before
bedtime. If brushing once a day is the only time available, then bedtime brushing is the most
important. If the food is left on the teeth at bedtime it can be converted to useable food for the
bacteria to form acids thereby decreasing PH levels and causing decay. Also, during the night,
there is a decrease of saliva and therefore less buffering of acids. Supervision and adult assisted
brushing is advised. When your child can write (not print) his or her name, your child is ready
to do a good job brushing.

When brushing is not possible, alternatives such as rinsing the mouth with water, eating a piece
of cheese or chewing sugar-free gum immediately after eating may be beneficial in the
prevention of dental disease.

When choosing a toothbrush look for one that has
i soft bristles
i a small head which makes it easier to reach every tooth, especially those at the very back
i a bulky handle – easier to grasp especially for the children

Electric toothbrushes are available with a variety of different features and may be
recommended by dental professionals for individuals with specific needs. Rotary-type action
electric toothbrushes are recommended (e.g. Braun, Oral B, etc.)

To care for a toothbrush
i Rinse toothbrushes after each use and allow to air dry.
i Replace toothbrushes when they become frayed or worn, approximately every 3 months.
i Replace toothbrushes following an illness, cold or the flu.
i Toothbrushes should not be shared with anyone! Dental dise ase is cause d by bacteria
and is infectious!

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Toothbrushing Method

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Worn Bristles

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Flossing
Flossing removes plaque and debris from areas between the teeth and gums which are
inaccessible to tooth brush bristles. Flossing may precede or follow brushing in daily oral care
programs. Flossing once a day is recommended for the prevention of tartar formation for
children 10 years of age or older. Parents of children younger should floss their children’s teeth.
Younger children do not have the manual dexterity to floss.

Dental floss is a strong thread-like strand usually made of nylon fibres.

Which dental floss is best?
There are no known studies to indicate that one type of dental floss is better than another.
However, conditions in an individual’s mouth may respond more favourable to one particular
type of floss. Seeking advice from a dental professional in determining the most appropriate
floss is recommended.

Types of dental floss

Waxed dental floss has a wax-like coating and is available in various forms (i.e. lightly waxed).

Unwaxed dental floss does not have a wax coating. Fibres in unwaxed floss separate and flatten
out as it moves over the tooth surface.

Flavoured dental floss is available in waxed or unwaxed form.

Dental tape or ribbon is a wider version of regular dental floss and is flat while dental floss is
round.

Fluoridated floss has fluoride incorporated in its fibres.

Super floss is approximately 12 inches long, is stiff for about 2 inches, followed by 2 to 3 inches
of “wool-like” material and the remainder is standard unwaxed floss. The “wool-like” section
can be used to clean under dental bridges and in areas where teeth are missing.

PTEE (Polytetra fluoroethylene) dental floss slides very easily between teeth and does not fray.

Braided nylon dental floss is used for dental implants.

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The “how to” of flossing

It is important to know that improper usage of dental floss may damage tooth structure, gums and
supporting tissues. Individuals may experience sore, bleeding gums after initiating flossing. If
the sore, bleeding gums continue after the first week, a consultation with a dental professional is
recommended. Flossing can be a challenging skill to acquire and persistence and continuous
practice is often necessary. First-time flossers may find the use of a mirror helpful.

Children with orthodontic appliances may require professional assistance to learn how to
effectively floss using a flossing aid.

Floss holders are designed to hold dental floss therefore eliminating the need to place fingers in
the mouth. There are several designs available. However, the “wish-bone” style is the most
popular. The handle of the floss holder is held and the floss is guided between the contact points
in the mouth. Floss holders may be effective for individuals who have reduced dexterity, have
physical limitations have very large hands, or for those with a strong gag reflex.

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Flossing Method
Wrap the floss around the middle
fingers. The floss should be
approximately an arm’s length or
1 m long.

For the upper teeth use the index
finger and the thumb to guide the
floss. The thumb should be on the
outside.
Use the two index fingers for
flossing the lower teeth.
Note: The fingers guiding the floss
should not be more than 2.5 cm
apart.

Gently insert floss between the
teeth by moving back and forth in
a see-saw fashion. Do not force
the floss between the teeth or
press down so hard as to cause
bleeding.

Move the floss up and down on the
side of one tooth two or three times
until clean.
Move the floss to the side of the
neighbouring tooth and repeat.
Note: When the floss becomes
frayed or soiled, rotate the floss
from one middle finger to the other,
so that a new section of floss is in
position.

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Fluoride
Fluoride is a naturally occurring mineral found in water, soil, rocks, air, plant and animal tissues.
Exposure to appropriate amounts of fluoride significantly reduces the risk of dental decay. The Canadian
Dental Association (CDA) supports the use of fluorides in the prevention of dental decay. Fluoridation of
communal water supplies is recognized as one of the most successful preventive health measures in the
history of health care.

How does fluoride work?
Fluoride reduces the risk of dental decay in two ways. When ingested during the time a tooth is forming
fluoride becomes incorporated into the developing dental tissue creating a more resistant form of enamel
(systemic fluoride). However, the greatest benefit comes from the surface of a tooth being exposed to
fluoride after it has erupted into the mouth (topical fluoride). Dental enamel and dentin are composed of
mineral crystals (calcium and phosphate) held in a protein maitrix. These dental minerals are readily
dissolved by acid produced by bacteria during carbohydrate metabolism. Topical fluoride becomes
concentrated in dental plaque inhibiting the dissolution of the minerals. Fluoride can repair the early
stages of decay through remineralization by being absorbed onto the tooth surface and attracting calcium
ions from the saliva. In addition, the fluoride interferes with the enzyme activity of the bacteria reducing
their ability to produce acid.

How do we get fluoride?
Fluoride comes from many sources both systemic and topical.

Systemic fluoride is ingested through the metabolic system and sources include;
i Food and drinks such as vegetables, fish and beverages.
i Drinking water from wells or communal systems may have a natural fluoride content.
i Fluoridated municipal water offers benefits of reduced dental caries at a minimal cost. There
is no difference in the dental benefits from fluoride that is naturally occurring in water to that
which is added to community water.
i Fluoride supplements – tablets/drops should only be taken at the recommendation of a dentist.
They are recommended only for children at high-risk of experiencing dental decay and who live
in a community with no fluoridated water. Before fluoride supplements are considered for
children who consume water from natural sources (wells), testing by a qualified laboratory is
recommended. These test results should be shared with the family dentist who will then be able
to provide appropriate recommendations.
i Bottled water may or may not contain fluoride. The fluoride concentration should be included
on the product label.

Topical fluoride is applied to the tooth surface and sources include;
i Fluoride rinses, gels and varnishes are provided on the advice of a dental professional. The

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application of these fluorides may be recommended for individuals at high risk of developing
dental disease and for the treatment of tooth sensitivity.
i Fluoride toothpaste. This is the most common, and possibly the most important, source of
fluoride. While it is meant as a topical therapy, many children age three or less swallow rather
than spit out during tooth brushing. Unless a small amount of toothpaste is used, this can lead to
the formation of chalky white spots (fluorosis) in the enamel of permanent teeth. The guidelines
for the use of fluoride-containing toothpaste are as follows;

Children under 6 years of age who use fluoridated toothpaste should:
i have toothpaste dispensed by a supervising adult,
i use only a light smear of toothpaste twice a day as soon as teeth erupt, and
i be encouraged not to swallow toothpaste during brushing

Fluoride has proven to be an inexpensive way of preventing tooth decay when taken in proper dosages.
While the addition of fluoride to community water supplies, toothpaste, rinses and other products has
contributed to a decrease in tooth decay in all age groups there are concerns that young children may be
receiving too much fluoride increasing the risk of fluorosis of the teeth. No other harmful effects from
the ingestion of optimal levels of fluoride have been identified.

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Pit and Fissure Sealants
Dental sealants are very thin plastic protective coatings applied to the chewing surfaces of molars.
Sealants prevent cavities by creating a physical barrier, filling in the pits and fissures where food debris
and bacteria may get stuck, causing cavities.

i Sealants are applied by qualified dental professionals

i Sealants remain in place for many years but should be checked at regular dental visits

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Dental Office Visit
Regular visits to a dental professional are an important part of good general health and an essential part
of maintaining optimal oral health.

Prepare children for the visit by discussing the dental team’s role as friendly, concerned adults who help
care for their teeth. Avoid giving the child the impression that the dentist may cause pain. Children
who develop positive attitudes early will be more willing to take an active part in their dental
health.

When a first visit is not an emergency, the dental team may spend time familiarizing the children with the
dental office and equipment. Many books and videos are available in libraries and stores which may be
useful in preparing children for their “dental office experience”.

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The Dental Office Team
Dental visits provide an ideal opportunity for children to develop a positive attitude towards the dentist
and dental auxiliaries and to develop an understanding of the role the dental team has in the prevention
and treatment of dental disease.

The Dentist
i Provides examinations and advice and recommendations on dental health
i Provides comprehensive preventive and treatment services
i Teaches people how to care for their teeth

The Hygienist
i Teaches people how to care for their teeth
i Provides treatment that helps prevent oral disease such as caries (cavities) and periodontal (gum)
disease
i May take radiographs (x-rays) of the teeth if prescribed by the dentist
i Performs a variety of roles including clinical therapy such as application of pit and fissure
sealants, topical fluoride and professional cleaning of teeth if prescribed by the dentist

The Dental Assistant
i Assists the dentist, hygienist, or teaches people how to care for their teeth
i Sterilizes instruments
i Sometimes polishes the teeth and applies fluoride to reduce tooth decay
i May take radiographs (x-rays) of the teeth if prescribed by the dentist

The Receptionist
i Schedules appointments
i Takes care of billing and payments
i Orders supplies as directed

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Dental Public Health
The Health Protection and Promotion Act specifies that public health agencies (boards of health) are
required to provide or ensure the provision of a minimum level of dental public health programs in
schools as defined by the Mandatory Health Programs and Services Guidelines. These programs include;
i an annual oral health status assessment and data collection of targeted grades,
i administration of the Children In Need Of Treatment (CINOT) program including the referral
and follow-up of children found to be in acute need of dental treatment,
i the provision of dental health education resources,
i the provision of teacher in-services in schools defined through the screening assessment as high-
risk, and
i the provision of clinical preventive services for eligible students as defined by Ministry of Health
protocol.

Familiar dental faces in school are the dental hygienists and dental assistants involved in the annual
dental screenings, preventive clinics and the presentation of teaching resources. In addition to the
programs listed above, many larger regional governments and municipalities offer comprehensive
treatment programs to eligible students.

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Over the Counter Dental Products

Mouthwash
Some mouthwashes may assist in reducing bacteria. However, they are not effective in the removal of
plaque and bacteria. When bad breath is problematic, the use of mouthwash only temporarily masks the
odour.

Generally, mouthwash is not recommended for children or adults.

Some mouthwashes are recognized by the Canadian Dental Association and the label will be a reliable
verification.

Oral irrigation devices
Oral irrigation devices are capable of flushing away food debris but not plaque. These devices should
not be regarded as a substitute for tooth brushing and flossing, but as an adjunct to tooth brushing and
flossing. Dental professionals may recommend the use of oral irrigation devices for individuals with
orthodontic or prosthetic appliances.

Tooth whiteners
Tooth whiteners are available in liquid, gel or pastes. Tooth whiteners may lighten or bleach some stains
and discolourations in teeth which have been caused by coffee, tea, cola, red wine, or smoking. The side
effects could include papillae irritation, pulp inflammation which could lead to root canal therapy.

Plaque and Tartar Fighting Toothpastes contain ingredients which may prevent the build-up of plaque
and the accumulation of tartar (above the gum line). Some ingredients may also reduce gum
inflammation and bleeding.

Baking Soda Toothpaste may assist in the removal of stains and decrease acidity in the mouth thus
reducing the risk of developing tooth decay. The C.D.A. seal of approval can be found on some of these
products.

“Natural” Toothpaste may contain herbal extracts and no fluoride. These toothpastes are not
recommended for children because of lack of fluoride.

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Section 7

Personal Safety
and
Injury Prevention

Rules for Tooth Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 1
Dental First Aid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 2
Mouth Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 - 3
Family Violence – The Dental Perspective . . . . . . . . . . . . . . . . . . . . . . 7 - 5
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Ontario Association of
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Rules for Tooth Safety

1. Children should be encouraged not to place sharp objects in their mouths

2. Children should not attempt to open objects with their teeth – e.g. bobby pins, cans, etc.

3. Children should not push or shove especially around water fountains or stairs

4. Children must wear seatbelts

5. Children should be encouraged to wear mouth protection when playing sports

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Dental First Aid
TYPE OF INJURY FIRST AID

1. Toothache Rinse the mouth vigorously with warm water to clean out debris. Use
dental floss to remove any food that might be trapped within the cavity
(especially between the teeth). If swelling is present, place cold compresses
to the outside of the cheek. (DO NOT USE HEAT). DO NOT place
aspirin on gum tissue of aching tooth. Take the individual to the dentist.

2. Knocked-out Place tooth only in milk or hold in mouth under tongue or place in saliva or
tooth water. DO NOT CLEAN TOOTH. Take the individual and tooth to the
dentist immediately.

3. Broken or Try to clean dirt or debris from injured area with warm water. Place cold
bumped tooth compresses on face next to injured tooth to minimize swelling. Take
individual to the dentist immediately. Check for broken tooth chips,
fragments in lip cheeks, etc.

4. Bitten tongue or Apply direct pressure to bleeding area with a sterile clean cloth. If swelling
lip is present, apply cold compresses. If bleeding does not stop readily or the
bite is severe, take the individual to the hospital emergency room.

5. Orthodontic A. If a wire is causing irritation, cover the end of the wire with a small
problems (braces cotton ball or piece of gauze and take the individual to the
and retainers) orthodontist immediately.

B. If a wire is imbedded in the cheek, tongue or gum tissue, DO NOT
attempt to remove it. Take the individual to the orthodontist
immediately.

C. If there is a loose or broken appliance, take the individual and
appliance to the orthodontist immediately.

6. Objects wedged Try to remove the object with dental floss. Guide the floss in carefully so as
between teeth not to cut the gums. If unsuccessful, take the individual to a dentist. DO
NOT try to remove with sharp or pointed objects.

7. Possible If suspected, immobilize jaw by any means (handkerchief, neck tie, towel)
fractured jaw and take the individual to the hospital emergency room.

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Mouth Protection
i according to Statistics Canada 45% of all women and men over the age of 15 participate
in sports
i 39% of all dental injuries are sports related
i an athlete is 60 times more likely to sustain damage to the teeth when not wearing a
mouthguard
i long-term costs of treating a single tooth could be 20 times the cost of a custom-made
mouthguard
i more than 5 million teeth are knocked out each year (many during sports activities)
i one third of all dental trauma sports injuries occur at the Junior and Senior School Levels

Injury Age
4.8% 11 – 15 years of age
29.9% 16 – 20 years of age
31.4% 21 – 25 years of age

i in 1990 the National Collegiate Athletic Association in the United States estimated that
about 200,000 oral injuries a year were preventable in football alone with the use of a
mouth or sports guard
i When participating in the following sports, wear a mouthguard:

aerobics baseball boxing discus field hockey
throwing
football gymnastics handball ice hockey in-line skating
lacrosse martial arts racquetball rugby shotput
skateboarding skiing snowboarding skydiving soccer
squash surfing volleyball water polo weight lifting
wrestling

i Mouthguards should be worn whether it is a friendly game, practice or competitive game

The dental community endorses the use of custom-made mouthguards

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Types of Mouthguards

Type Description Advantages Disadvantages
Stock or ready-made Available in many Inexpensive. No Generic fit, limited
sports stores. forming of comfort, protection
Usually made of impressions required. and durability. May
rubber or poly-vinyl. interfere with
breathing and speech.
Often bulky and
loose-fitting.
Boil and bite or Mouthguard is heated Fairly inexpensive. Not ideal for all
mouth-formed in warm water. Fit Better fit than stock. patients, especially
achieved by biting Can be re-fitted if not children. Heating
into warm plastic. properly made on process may weaken
Usually made of first try. plastic. May feel
acrylic gel or bulky. Can interfere
thermoplastic with speech and
materials. Available breathing.
in sports stores.
Custom-made Dentist takes an Optimal fit, Initially more
impression of protection and expensive and time-
patient’s mouth. comfort. Most consuming in
Fabricated from a durable. Can be fabrication process.
cast model of teeth. modified for specific
sports and patient
need. Does not
interfere with speech
or breathing

Care of Mouthguards

i rinse your mouthguard under cold water after each use and air dry
i occasionally clean it with mild soap and water or mouthwash
i check mouthguard regularly and let dentist know if it shows any signs of wear or has any
tears or cracks that may weaken it
Family Violence - The Dental Perspective
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i Family violence is a major health problem as well as a serious social issue

i Need for all health care professionals to recognize the impact of family violence – this
includes the dental professional

i This abuse may be: physical
emotional
sexual

i Neglect and financial exploitation are types of abuse

i Family violence is not a private family matter but a criminal offense

i It is the responsibility of every person in the dental community to be an advocate on
behalf of any patient/client suspected of being a victim of abuse

i Oral indicators of family abuse may include fractured teeth, oral lacerations, jaw and
facial fractures, etc

i Teachers and students should be aware that the dental community is obliged by law and
ethics to respond to any signs of abuse or suspicions of abuse/neglect

i The students should be aware that the dental staff (public health and private dentistry)
will try to help them by:

" getting in touch with CAS to get help for the child
" obtaining financial help through the Ministry of Health (Welfare or CINOT) for
all dental work that is urgent or acute
" giving advice and or treatment to repair the results of family violence

i Students should 1) learn about family violence issues
2) recognize indicators
3) get help for themselves or a friend through the medical,
dental or social services community if needed

i Each student should obtain their own community resource list

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Physical Indicators of Abuse

Teeth
i missing teeth in unexpected areas
i areas of avulsion (loss of tooth/teeth), broken roots or teeth
i trauma to teeth where explanation does not fit the injury

Gingiva and Tongue
i bruises to hard and soft palate (possibility of forced feeding or oral sex)
i burns, scars and sloughing of tissue inside the mouth (can be from scalding foods,
cigarettes or other implements)
i signs of infection i.e. gonorrhea, venereal warts, syphilis, herpes, moniliasis, trichomonas
i tears of the lingual frenum (not an unusual injury in a young child learning to walk but
should arouse suspicion in a non-ambulatory infant or an older child)
i tear of the maxillary frenum, especially in young infants. May be indicative of slap
across the face.

Lips
i scarring of the lips
i burns from chemicals, hot food, cigarettes
i rope burns that indicate gagging
i bruises from forced feeding, slapping, forcing of pacifiers
i signs of infection with venereal warts

Jaw and Facial Fractures
i marks showing hand or belt buckle bruises may indicate underlying fractures

Ears
i bruises, cuts
i cauliflower ear indicating pulling or twisting
i perforated tympanic membrane

Nose
i broken or bruised
i deviated septum
i blood clots in nose
L

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Physical Indicators of Abuse (continued)

Head and Scalp
i bald or sparse spots that indicate malnutrition or hair pulling
i lack of hygiene (scabs, excessive dandruff, lice)

Bruises and Burns
i bruises or burns in various stages of healing

Neck
i bruises on the neck may suggest an attempt to strangle
i rope burns, hand marks from choking

Bite Marks
i Sixty-five percent of all bite marks can be seen without disrobing

Other Possible Indicators
i chronic throat infections
i overall dental neglect and lack of dental care may be an indicator of physical or emotional
abuse
i poor oral hygiene concurrent with low self-esteem in the adolescent may be an indicator
of abuse

Source: Based on the article by Ambrose, J.V., “Orofacial signs of child abuse and
neglect: a dental perspective”, Pediatrician. 1989; 16 (3-4): pp. 189-192

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Ending Family Violence is Everybody’s Responsibility
Community Resources List

Emergency Services Telephone Numbers

Police –

Hospital Emergency –

Crisis Line (24 hour) –

Dentist –

Sick Children’s Crisis Line –

Health Department Dental Division –

Other Services Telephone Numbers

Child Protection Services –

Children’s Help Line 1 (800) 268-6868

Women’s Shelter/Centre –