PREVENTION by liaoqinmei

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									    PREVENTION I

“The Preventive Philosophy”
            PREVENTION. . .
               The Concept
• The emergence of a new philosophy of dentistry based on
  prevention rather than repair and replacement has been the
  most significant development in the history of dentistry.
• In a World Health Organization (WHO) study, it was found
  that countries with dental care systems that emphasized
  restorative care had the highest caries experience in the
  world, as measured by the number of decayed, missing
  and/or filled teeth, (DMFT).
• These countries also had the highest number of completely
  edentulous individuals.
• In countries where prevention was emphasized, the number
  of DMF teeth was substantially smaller.
           PREVENTION . . .
              The Concept
• The following data bear testimony to the futility of a
  mechanistic approach to gain and maintaining oral health for
  Americans:
   – 98% of 40-44 year olds have had tooth decay, with an
     average 45 affected tooth surfaces.
   – the average American has between 9-10 missing
     permanent teeth;
   – over 4% of the American population (between 10-12
     million individuals) is completely edentulous; 30% of
     Americans over 65 have no teeth at all.
   – 44% of Americans have gingivitis; and
   – 13% of Americans have periodontal disease.
         PREVENTION . . .
            The Concept
• The resolution of such extensive problems of
  dental caries and periodontal disease by a
  “restorative philosophy” yields low efficiency and
  efficacy. It is not a cost/benefit effective way to
  achieve oral health.
• As a consequence, the far-sighted in the
  profession have turned to prevention as the only
  feasible solution to a problem of such severity.
• Oral health care systems which emphasize
  prevention will yield populations with good oral
  health; those that do not, will not.
        PREVENTION . . .
            The Concept
• A philosophy of prevention is basic to a good contemporary
  practice.
• Dentistry exists to facilitate the gaining of oral health by
  society.
• Individual dentists profess to exist to help their patients
  gain oral health.
• The preventive concept should be the thread that is woven
  through the entire fabric of dental practice.
• The concept of prevention can be understood to apply to all
  aspects of practice by understanding prevention to exist at
  primary, secondary, and tertiary levels.
 LEVELS OF PREVENTION

• PRIMARY PREVENTION
 – Occurs in the clinically pre-pathologic period.
 – Involves promotion of oral health concepts, as
   well as specific protection.
 – Examples: oral health education, water
   fluoridation, plaque removal through brushing
   and flossing, antimicrobials, topical fluorides,
   pit and fissure sealants, mouth guards.
 – Prevent: caries, gingivitis, trauma to the teeth
   from occurring.
  LEVELS OF PREVENTION

• SECONDARY PREVENTION
 – Occurs in the early period of pathogenesis.
 – Involves early recognition and prompt therapy.
 – Examples: Radiographic examination, Root
   scaling, conservative restorative treatment
 – Prevent: further deterioration of health that
   would result in extensive lesions of the teeth,
   pulpal involvement, or periodontitis.
  LEVEL OF PREVENTION

• TERTIARY PREVENTION
 – Occurs later in the period of pathogenesis.
 – Involves limitation of disability and
   rehabilitation.
 – Examples: pulpal therapy, periodontal surgery,
   extractions, fixed prosthodontics, space
   maintainers.
 – Prevent: loss of teeth, disseminated infection,
   loss of space, occlusal disharmonies, and other
   significant oral disabilities.
            CHILDREN IN
          “THE CONCEPT”
        “He who is wise begins with the child.”
                       Goethe


• As primary prevention is the ultimate goal of
  the dental profession, it necessarily follows
  that the thrust of any comprehensive oral
  health program be directed at the child.
• Children must be the foundation of a
  practice that is focused on prevention.
         UNDERSTANDING THE
              PROBLEM
• To understand the problem of prevention as it relates to children, an
  understanding of the profile of oral disease experience of children
  (in America) is necessary.
• Epidemiology is that branch of medicine that deals with the study of
  the causes, distribution, and control of disease in populations.
• The epidemiological term for the magnitude of a disease existing in a
  population at a point in time is referred to as prevalence.
• Prevalence must be differentiated from a related term, incidence.
• Incidence is the disease occurring in a population during a specific
  period of time.
• To say that the average 17 year old has 4.96 decayed, missing or
  filled teeth is to make a statement of prevalence.
• To say that the average child will develop a new carious lesion
  between ages of 6 and 10 is to make a statement of incidence.
   PREVALENCE OF DENTAL
    CARIES IN CHILDREN
• Two epidemiological measures will serve as indices
  of prevalence of caries:
   – DMFT: An index that represents the number of
     decayed (D), missing (M), and filled (F) teeth
     (T). Index is total of these three assessments
     in the individual.
   – DMFS: An index that represents the number of
     decayed, missing, and filled surfaces (S), in the
     individual.
   – DMFS is the more sensitive measure of the
     magnitude of disease in the oral cavity.
    PREVALENCE OF DENTAL
     CARIES IN CHILDREN

• The average DMFT in school age children (age 5-17) is 1.97.
• The average DMFS is school age children (age 5-17) is 3.07.
• Over 50% of 5-9 year old children have at least one carious
  lesion or restoration.
• At age 17, the average child has 4.96 DMFT, (1.0 due to a
  missing tooth); and 8.04 DMFS; 80% of adolescents have
  dental caries by age 17.
• Obviously, the teeth are more vulnerable to decay the longer
  they are in the oral cavity.
    PREVALENCE OF DENTAL
     CARIES IN CHILDREN
• Only 20% of children have had no carious experience by age 17.
• 80% of the dental carious experience occurs in 25% of the
  children in this country. This concentration of disease has
  become greater through time. In 1980, approximately 65% of
  the caries was found in 24% of the children.
• The prevalence of caries experience among children has
  declined significantly since 1970.
• Approximately 80% of the carious lesions occurring in school
  age children are on the occlusal surface.
    PREVALENCE OF DENTAL
     CARIES IN CHILDREN
• The highest DMFT is found in the Northeastern United
  States; the lowest in the Western United States.
• African-American children have a lower DMFT than Euro-
  American children.
• However, the profile of the DMFT is different. African-
  Americans have a higher percentage of the index in the
  decayed and missing category. Euro-Americans have a higher
  percentage of the index in the filled category.
• This difference reflects the differential in professional oral
  health care accessed by these two groups.
• Studies have confirmed that the percentage of decayed
  teeth in the index declines with increasing household income.
    RELATED INFORMATION
• Dental caries is the single most common chronic childhood
  disease, 5 times more common than asthma, and 7 times
  more common than hay fever.
• There are striking disparities in caries prevalence by income.
  Poor children suffer twice as much caries as non-poor, and
  their disease is more likely to be untreated. One out four
  children in America are born into poverty--$17,000 for a
  family of four. The majority of children, 40 million of 78.6
  million, are eligible for Medicaid /CHIP public insurance.
  Twenty-five percent of poor children have not seen a dentist
  prior to kindergarten.
• 51 million school hours are lost each year to dental-related
  illness.
• Toothaches are the most common classroom health problem.
• Over one-third of American children do not have the benefit
  of water fluoridation; our most effective caries preventive
  strategy.
 EARLY CHILDHOOD CARIES
    (NURSING CARIES)
• 5-10% children have Early Childhood Caries (ECC),
  sometimes called nursing (or bottle) caries; the
  rate is even higher among families with low
  incomes, and among racial/ethnic minorities.
• ECC is the result of poor nursing/feeding habits;
  associated with children being given the bottle
  past 12 month, and/or given the bottle with
  cariogenic solutions in it at night, and allowed to
  keep it in the mouth for a prolonged period.
• ECC significantly increases a child’s risk of
  future caries experience.
RISK FACTORS FOR CARIES
    AMONG CHILDREN
• Children born to mothers in their teens
  have a 5X greater chance of having carious
  lesions by age 5.
• Living in a rural area doubles the likelihood
  of having caries.
• Mothers who do not brush their teeth
  regularly, have children with double the
  risk for caries.
     CARIES RISK GUIDELINES
    (American Dental Association)

LOW:
• No carious lesions in last year
• Coalesced or sealed pits and fissures
• Relatively plaque free
• Fluoride in water supply and use of fluoride
  dentifrice
• Regular dental visits
CARIES PREVENTION MODALITIES
FOR CHILDREN BY RISK CATEGORY
   (American Dental Association)

 LOW
 • Educational reinforcement:
   – Plaque removal (oral physiotherapy)
   – Fluoride dentifrice
   – One year recall
     CARIES RISK GUIDELINES
    (American Dental Association)

MODERATE
•   One carious lesion in the last year
•   Deep pits and fissures
•   Some plaque accumulation
•   No fluoride in water
•   White spot lesions
•   Irregular dental visits
•   Orthodontic treatment
CARIES PREVENTION MODALITIES
FOR CHILDREN BY RISK CATEGORY
   (American Dental Association)
 MODERATE
 • Pit and Fissure Caries
    – Sealants
 • Smooth Surface Caries
    – Education
    – Dietary Counseling
    – Fluoride dentifrice (low potency fluoride)
    – Fluoride mouthrinse (low potency fluoride)
    – Professional topical fluoride (high potency fluoride)
    – Six month recall
    – Fluoride supplements (depending on age of child and
       absence of water fluoridation)
      CARIES RISK GUIDELINES
     (American Dental Association)

HIGH
•   Two ore more carious lesions in last year
•   Past smooth surface caries
•   Elevated mutans streptococci count
•   Deep pits and fissures
•    No or little systemic and topical fluoride exposure
•   Plaque accumulation
•   Frequent fermentable carbohydrate intake
•   Irregular dental visits
•   Inadequate salivary flow
•   Inappropriate nursing habits (infants)
CARIES PREVENTION MODALITIES FOR
    CHILDREN BY RISK CATEGORY
     (American Dental Association)
 HIGH
 • Pit and Fissure Caries
    – Sealants
 • Smooth Surface Caries
    – Education
    – Dietary counseling
    – Fluoride dentifrice
    – Fluoride mouthrinse
    – Professional topical fluoride (3-6 months)
    – Three to six month recall
    – Monitoring of mutans Streptococci
    – Antimicrobial agents (Chlorohexidene)
    – Fluoride supplements ( depending on age of child and
       presence of water fluoridation
      PREVALENCE OF
 PERIODONTAL DISEASE IN
         CHILDREN
• Approximately 60% of school age children will
  have at least one site of gingival bleeding on
  probing.
• 8% of children will have bleeding at multiple
  probing sites.
• Less than 1% of children, 5-17, will have a loss of
  periodontal attachment.
• One-third of teen-age children will have some
  supragingival calculus.
• Ninety-eight percent (98%) of school age children,
  ages 5-17, have normal periodontal tissues.
     PREVALANCE OF
MALOCCLUSION IN CHILDREN
• Reliable epidemiological indices to assess malocclusions do
  not exist.
• Data from one study indicate that approximately 40% of
  children have occlusions close enough to ideal to be
  considered normal; 60% do not.
• However, one study found that 75% of school age children,
  age 6-11, were judged to have some degree of occlusal
  disharmony; 37% were judged to have a handicapping
  malocclusion.
• Another study found that only 14% of the age group present
  a handicapping malocclusion; while an additional 38% could
  benefit from treatment; meaning 50+% of children could
  benefit.
     PREVALANCE OF
MALOCCLUSION IN CHILDREN
      PREVALANCE OF
 MALOCCLUSION IN CHILDREN
• Rarely are malocclusions seen in the primary
  dentition, though pre-dispositions to such can be
  identified.
• Rather, malocclusions tend to emerge with the
  eruption of the permanent dentition and the
  growth spurts that occur during the school-age
  years.
• The most common malocclusion identified in the
  primary dentition is the posterior crossbite. One
  study found it to exist in approximately 8% of
  primary dentitions.
OTHER PREVENTIVE ISSUES
    OF ORAL HEALTH
• Cleft lip/palate, one of the most common
  birth defects, effects 1 in 600 life births
  in Euro-Americans and 1 in 1,850 live births
  in African-Americans.
• Trauma to the cranio-facial complex are
  relatively common in children--studies are
  highly variable, 4-24%.
• Tobacco-related oral lesions are prevalent
  among adolescents who use smokeless (spit)
  tobacco.
    PREVENTIVE FOCUS IN
      THIS MINICOURSE
• In this Minicourse we will focus primarily
  and specifically on the preventive issues
  associated with caries and periodontal
  disease.
• Prevention associated with malocclusions,
  trauma, and oral cancer will be addressed
  when these issues are addressed.
• Our approach to prevention of caries and
  periodontal disease diseases will be multi-
  dimension and comprehensive.
IMPLEMENTING THE CONCEPT
      OF PREVENTION
• Prevention of dental caries and periodontal
  disease is possible by directing our efforts to the
  four variables that are involved: the teeth, the
  bacteria, the substrate, and the understanding
  and motivation of the child and parent.
• It is imperative that the problem of prevention be
  approached by addressing all the variables of the
  disease process not just one or some.
• The focusing on only one aspect of a multifaceted
  problem leads to a distorted understanding of the
  problem, and an inadequate result.
“THE BLIND MEN AND THE
       ELEPHANT”
         BY GEOFFREY SAXE
      It was Six men of Indostan
       To learning much inclined,
     Who went to see the Elephant
    (Though all of them were blind),
       That each by observation
        Might satisfy his mind.

   The First approached the Elephant,
          And happening to fall
   Against his broad and sturdy side,
         At once began to bawl:
      "Bless me! but the Elephant
           Is very like a wall!"
   The Second, feeling of the tusk,
    Cried, "Ho! What have we here,
 So very round and smooth and sharp?
        To me tis mighty clear,
      This wonder of an Elephant
         Is very like a spearl"

  The Third approached the animal,
        And happening to take
 The squirming trunk within his hands;
       Thus boldly up and spake:
   "I see", quoth he, "the Elephant
         Is very like a snake!”

The Fourth reached out his eager hand,
       And felt about the knee,
"What most this wondrous beast is like
      Is might plain", quoth he:
   "'Tis clear enough the Elephant
         Is very like a tree!"
The Fifth, who chanced to touch the ear
     Said, "E'en the blindest man
  Can tell what this resembles most;
        Deny the fact who can,
      This marvel of an Elephant
           Is very like a fan!"

    The Sixth no sooner had begun
      About the beast to grope,
   Than, seizing on the swinging tail
      That feel within his scope,
   "I see," quoth he, "the Elephant
         Is very like a rope!"

    And so these men of Indostan
       Disputed loud and long,
        Each in his own opinion
     Exceeding stiff and strong,
  Though each was partly in the right,
      And all were in the wrong!
     PREVENTIVE MEASURES
    DIRECTED TO THE TEETH

•   Water Fluoridation
•   High Potency Topical Fluorides
•   Fluoride Dentifrices
•   Fissure Sealants
   PREVENTIVE MEASURES
     DIRECTED TO THE
        MICROFLORA


• Plaque Removal
• Antimicrobials
  PREVENTIVE MEASURES
    DIRECTED TO THE
       SUBSTRATE


• Dietary Analysis and Counseling
   PREVENTIVE MEASURES
DIRECTED TO THE EDUCATING
  CHILDREN AND PATIENTS

•   Educational Techniques
•   Educational Resources
•   Audio-Visual Materials
•   Patient Educational Brochures

								
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