Dental caries Lect

							What is New in Caries
   Management?
            Objectives
Define the disease of dental caries
Explain the caries balance concept
Discuss CAMBRA
Review protocols to:
– Reduce levels of pathogenic
  microorganisms
– Enhance remineralization
– Replace minerals missing in saliva
– Neutralize mouth acids
 Dental Caries- #1 Disease in
Children/Most Common Dental
      Disease in Adults
Bacterial challenge (plaque biofilm)
– Produces caries-causing acids as a
  byproduct of its metabolism
    Primary cause of gingivitis and caries
Paradigm Shift in Caries
     Management




     Source: Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
 http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf. March 17, 2009.
Demineralization - Remineralization




 Source: Collins F.M. The Role of Fluoride in Caries Control. http://www.ineedce.com/coursereview.aspx. March 17, 2009.
                                      Caries Balance




Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf.
CAMBRA
Paradigm Shift in Caries
     Management
Shift from restorative approach to a
strategy that focuses on:

-Early (prenatal) risk assessment and
education
-Risk assessment at
   6-months of age
-Reduction in the
 levels of MS and LB
                  Paradigm Shift in
                Caries Management
Reverse active caries (repair/remineralization):
 -Fluorides: toothpaste, rinses, gels, varnish
-Amorphous calcium phosphate (ACP: Liquid Calcium®)
-Casein Phosphopeptides-ACP (APP-ACP: Recaldent™)
-Calcium sodium phosphosilicate (NovaMin®)
-Arginine bicarbonate complex (Sensistat®)


Bacterial infection control
 (not just restorations):
-Chlorhexidine gluconate
-Xylitol
                  Paradigm Shift in
                Caries Management

Prev/control/treat pit & fissure caries:
 -Dental sealants
 - Minimally invasive restorations
Self-care and education:
 -Total mouth cleaning
 - Diet/use of soft, energy, sports drinks
  -Disease transmission control
       Vertical and horizontal
 Caries Disease Indicators
Four observations that indicate past
caries history/activity:
 – Cavities
 – White spots on smooth surfaces
 – Radiographic lesions to dentin
 – Restoration within the past 3 yrs
 HIGH RISK
Additional Criteria for High and
        Extreme Risk
And/or
 – Multiple risk factors
 – Coupled with little or no protective factors


Criteria for Extreme Risk-same as high
risk + saliva reducing factors or special
needs:
 – Medications
 – Radiation to head and neck
 – Systemic disorder or disease
        Caries Risk Factors
Biologic factors that contribute to risk for new
carious lesions or progression of lesions:
 – Medium to high MS and LB counts
 – Heavy plaque biofilm
 – >3 times daily snacking
 – Deep pits/fissures
 – Rrecreational drug use
 – Inadequate salivary flow; salivary reducing
   factors
 – Exposed roots
 – Orthodontic appliances
Sip All Day,
       Get Decay®
 Strong link between soda
 consumption and caries,
 diabetes, obesity and osteoporosis.
 Milk intakes have decreased-
 soda pop, sports drinks, and juice
 intakes have increased.
 Caffeine contributes to xerostomia
 Steady diet of soft drinks is one of the
 leading causes of demineralization.
Acidity of Various Soft Drinks
 DRINKS pH           DRINKS           pH
 Water     neutral   Surge           3.02
 Barq’s    4.61      Gatorade        2.95
 Diet 7 Up 3.67      Hawaiian Pch    2.82
 Diet Coke 3.34      Orange MM       2.80
 Mt Dew 3.22         Classic Coke    2.63
 Propel     3.20     Pepsi           2.49
 Nestea     3.04     Battery Acid    1
     Enamel demineralization: ≤ 5.5 pH
              Saliva Test
Resting flow rate        Stimulated pH
Salivary consistency     Resting pH
Stimulated flow rate     Buffer capacity
                       http://www.gcamerica.com/
                       saliva.html
Bacterial Load Tests
            Laboratory:
            Incubation yields results
            for SM and LB
            Results in 48-72 hrs: low,
            medium, high

            Chairside:
            Test strip contains 2
            monoclonal antibodies
            that detect SM species
            Results in 15 mins:
            patient has level of SMs
             ≥ 500,000 cfu/ml saliva.
    Caries Protective Factors
Biologic/therapeutic factors that
collectively offset the caries risk factors
– Fluoridated community (lives, works, school)
– Uses fluoride toothpaste at least 1-2x daily
– Uses .05% fluoride mouthrinse daily
– Uses 5000ppm fluoride toothpaste daily
– Had office topical F in last 6 months
– Used CHX daily for one week in each of the last 6
  months
– Uses xylitol gum, lozenges 4-5x daily last 6 months
– Uses calcium and phosphate paste last 6 months
– Has adequate salivary flow (≥1ml/min stimulated)
Age Continuum and Risk Factors




 Source: Collins F.M. The Role of Fluoride in Caries Control. http://www.ineedce.com/coursereview.aspx. March 17, 2009.
Change in Character of Caries




        Source: Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
    http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf. March 17, 2009.
Change in Character of Caries

 4-6 years to develop a clinically
 detectable cavity
 – Delayed cavitation
 – Cavitation occurs within the tooth without
   a clinically detectable cavity


 We have time to intervene
 to heal enamel
  Paradigm Shift in
    Caries Diagnostics
Separate demineralized surfaces from
surfaces that can be remineralized or
sealed
– Avoid cavitation- DO NOT push explorer
  into pit/fissures or demineralized surfaces
--Radiographs
    50% sensitivity on interproximal caries
    39% sensitivity on occlusal caries
    Digital radiographs
    better than traditional
    Adjunctive detection
     devices
             Paradigm Shift in
              Caries Diagnostics


Identify source of infection
– Intervene with evidence-based protocols


Technology-enhanced caries
detection systems
   Goal-to detect demineralized areas and
   white spot lesions so they can be treated
Antibacterial Therapies
  Chlorhexidine Gluconate
Aimed at treating the bacterial infection
that causes dental caries

Effective for reducing S. mutans associated
with dental caries by 54-97%
  Chlorhexidine Gluconate
         Protocol
Used in high and extreme high caries risk
infants, children, mothers, or other adults

Recommendation:
 – Rinse for 1 min daily for one week of each month for
   six months
 – Apply at least 30 mins after use of toothpaste
   because F and SLS in most toothpastes will
   neutralize CHX.
 – Same protocol for infants/small children except
   brush on CHX
  Xylitol-Sweetness Without
            Caries
Non-cariogenic, low caloric sweetener used
worldwide in foods, oral hygiene products, and
pharmaceuticals:
 – desserts, energy bars, chewing gum, mints,
   candy
 – toothpaste, rinses, sprays; infant tooth wipes
   and gels
Clinically proven to prevent caries with
regular use even without reducing other
sugars/starches in the diet
Safe for children, diabetics,
pregnant and nursing women
            Xylitol Reduces Caries


Can prevent transfer of bacteria from
parent to infant when used by parent
(vertical transmission)

Bacteria cannot readily metabolize xylitol
– Cannot produce acids
– Decreases S. mutans in plaque and saliva
– Decreases ability of S. mutans to adhere to tooth
  surfaces
           Xylitol Protocol

Recommend ingestion of 6–10g xylitol daily
in moderate, high, and extreme high risk
– chew xylitol gum (1-1.7 g) for 5 minutes 4-5x/day
– suck 2 xylitol mints (0.5 g each ) 5x/day

Not all products list amount of xylitol so all products
may not be effective in caries control:
    -number of grams in products
    -ingredients on package listing xylitol first
    -product uses xylitol only for its sweetener
                                       Xylitol


  Xylitol Information Center:
  www.xylitolinfo.com
  www.epicdental.com
  www.xlear.com

www.emediawire.com/spillout-pink.jpg
            Mineralization-
       Remineralization Therapies




http://www.piedmontpediatricdentistry.com/

                                       www.dentaleconomics.com/display_artic
                                       le/22490...
Amorphous
   Calcium
     Phosphate
 Goal: Increase ambient Ca & PO4, enhance
 saliva, repair early lesions, form new
 apatite, fill in enamel defects
 – FDA approval as desensitizing agent
 – Ex: Toothpaste with ACP, Enamel Pro® Prophy
   Paste, Enamel Pro ® Fluoride varnish
   http://www.premusa.com/dental/newproducts.asp
 Activated on contact with saliva
                    PRC@ada.org
Amorphous Calcium Phosphate
 Not a substitute for fluoride therapy

 Needs more research
  – Highly soluble/low substantivity
  – Action takes place within 30 secs
  – Not available after rinsing
  – Enamel Pro® Prophy Paste
    boosts fluoride uptake with 30 sec
    exposure (enhanced F delivery)
  – Concept of the therapeutic polishing
                                  CPP-ACP
                               (Recaldent®)
                     Source: Malcmacher L. Minimal Intervention Dentistry and Caries
                     Prevention. MinimalIntervention.pdf. March 17, 2009.
                     http://www.ineedce.com/courses/1553/PDF/




Casein phosphopeptide (CPP)
– Casein derived from cows milk
– Milk allergy contraindication
– Safe for lactose intolerant patient
– Used as a carrier for ACP
Creates a reservoir that releases Ca &
PO4 during an acid challenge
CPP-ACP (Recaldent®)
          Ex: Trident Extra Care,
          MI Paste, MI Plus Paste
        – Gum chewed frequently
        – Paste applied via tray, with a
          prophylaxis cup, via a finger
          multiple times daily

          More research needed
          Not a substitute for F therapy
    Azarpazhooh A, Limeback H (2008). "Clinical Efficacy of Casein
         Derivatives: A Systematic Review of the Literature". J Am
         Dent Assoc 139 (7): 915-924. PMID 18594077
CPP-ACP Paste (Recaldent®)
  Calcium phosphate paste
  recommendations:
  – 2x daily application for high and extreme
    risk patients ages 0-5
  – Optional for extensive root exposure of
    sensitivity in low or moderate risk patients ≥6
    yrs
  – Optional for high risk patients ≥6 yrs
  – Required 2x daily application for extreme
    high risk patients ≥6 yrs
Demineralized Enamel




   Source: Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf. March 17, 2009.
Remineralized Enamel at Surface
   of Lesion Using Fluoride




       Source: Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
    http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf. March 17, 2009.
       Body of Lesion Remineralized
              with CPP-ACP




Source: Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf. March 17, 2009.
          Remineralized Enamel Using
            Fluoride and CPP-ACP




Source: Malcmacher L. Minimal Intervention Dentistry and Caries Prevention.
http://www.ineedce.com/courses/1553/PDF/MinimalIntervention.pdf. March 17, 2009.
       Calcium Sodium
       Phosphosilicate
         (NovaMin®)
Bioactive silica as a carrier for Ca &
PO4
Releases Ca & PO4 immediately upon
interaction with saliva
Forms hydroxycarbonate apatite (HCA)
Continued release for 7 days post
application
Goal: Repair surface lesions, decrease
sensitivity (occludes tubules-
SootheRx), enhance F uptake
             NovaMin®
Fluoride varnish
Toothpaste
– 5,000 ppm remineralizing and
  desensitizing toothpaste used at least
  1/day (Sultan; Dentsply)
Prophylaxis paste
- apply, wait one minute and polish
   (therapeutic polish)
              Sensistat®
Arginine bicarbonate calcium complex
Calcium carbonate is poorly soluble so little
Ca is released
Goal: sensitivity reduction
Needs more research
Ex: DenClude™ and ProClude® by Colgate
      Neutralizing Acids
Sodium bicarbonate (baking soda)
Delivered to extreme high risk clients
via:
– Chewing gum with xylitol and baking soda
  (Arm & Hammer)
– Toothpaste with baking soda and F
– Frequent rinsing or irrigation with baking
  soda rinses (1 tsp baking soda, ½ tsp salt,
  32 oz water)
 Mechanical Caries
   Management
        Dental Sealants
Glass Ionomer Restorations (MI)
    Traditional Restorations
    ADA Council on Scientific
      Affairs-Conclusions
  Resin-based are more effective than
  glass ionomer
  Total etch bonding systems improve
  retention
  Four handed application
  Not recommendated:
   – Mechanical preparation of tooth surface
   – Use of self-etch bonding systems
http://ada.org/prof/resources/pubs/jada/reports/report_sealants.pdf
        Minimally Invasive
          Restorations
Atraumatic                No anesthesia or
RestorativeTreatment      power equipment
Caries treatment          AAPD recognized as
procedure involving       an interim restorative
the removal of soft       therapy
demineralized tooth       Endorsed by WHO,
tissue using hand         IADR
instruments, followed
by an adhesive
restorative material

                        www.gcasia.info/content_techniquestips_1.html
Caries Management By
   Risk Assessment
  Clinical Guidelines
‫نجمة كلية طب األسنان/ جامعة بغداد‬