Caries Prevention And Caries Control

What is Caries??
Dental caries is an infectious microbiologic disease of the teeth that results in localised dissolution and destruction of the calcified tissues.

Keys diagram

Bacterial enzyme

Fermentable carbohydrate

Acid

Acid

Enamel

Dental caries

Demineralisation-remineralisation process

Caries Prevention
Primary goal should be to reduce the number of cariogenic bacteria.

Consider the overall resistance of the patient to infection by these bacteria.

Caries Risk
General health of the patient Fluoride exposure history Function of the immune system Function of the salivary glands Diet Oral hygiene Use of anti-microbial agents Dental care-sealants and restorations

Caries Prevention
Methods are designed to limit the tooth demineralization caused by cariogenic bacteria,thereby preventing cavitated lesions.

Limiting pathogen growth and metabolism

Increasing the resistance of the tooth to demineralization

Caries Control
Operative procedures used both:
1.To stop the advance of individual lesions 2.To prevent the spread of pathogenic bacteria to other tooth surfaces.

Caries Control
Most effective -all active,cavitated lesions single appointment.
pulp therapy restoration of the damaged tooth structure

Methods:Limit Substrate
IndicationsReduce Rationale - Technique Number Frequent sucrose exposure Eliminate sucrose from between meal snacks Duration Substantially reduce or eliminate sucrose from Poor quality diet Intensity of acid attacks
meals

Methods:Modify Microflora
Technique Rationale mouthrinse Bactericidal Indications (Chlorhexidine) Intensive antimicrobial High MS counts treatment to eliminate Topical Fluoride MS from mouth treatment High Lactobacillus counts Select against Antibiotic treatment reinfection by MS (vancomycin, tetracycline)

Methods:Plaque Disruption

Indications Prevents plaque succession Rationale - High Plaque Scores Technique Puffy red gingiva Brushing Decrease plaque mass Flossing High bleeding point scores Promotes buffering aids Other oral hygiene

Methods:Modify Tooth structure

Rationale - Technique Indications resistance to Increase Fluorides Systemic Incipient lesions demineralization Topical Fluorides Surface rougheningretention Decrease plaque Smooth surfaces

Methods:Stimulate Saliva Flow

Technique Indications-cariogenic foods that Rationale Eat non Dry mouth withchewing substrate require lotsClearance of Increases of little saliva Redacids and Mucosachewing gum Sugarless Medications that reduce salivary Promotes buffering Medications to stimulate flow salivary flow

Methods:Restore tooth surfaces

Rationale Indications Technique - Eliminate lesions Cavitated nidus of lesions Restore all cavitated MS and lactobacillus Pits and fissures at risk infection Seal pits and fissures at caries risk Deny habitat for Defective restorations Correct all defects MS for reinfection (Marginal Cervices ,Proximal overhangs)

General Health
Declining health - increased preventive measures, including more frequent recall visits. Patients at risk:

Radiation/Chemotherapy Medically compromised Multiple medications

Medications
Antispasmodic-Belladona alkaloids Antidepressant-Amitriptyline AntipsychoticChlorpromazine Skeletal muscle relaxantCyclobenzaprine Parkinson's-Benztropine Arrythmia-Disopyramide AntihistamineChlorpheneramine Appetite DepressantsChlorphentermine AnticonvulsantCarbamazepine Anxiolytic-Alprazolam Antihypertensive-Atenolol Diuretic-Hyrochlorthiazide

Fluoride
Anticariogenic Effect
precipitation of fluorapatite Replaces the soluble salts containing manganese and carbonate makes the enamel more acid resistant.

 Remineralization of incipient,non cavitated carious lesions

Antimicrobial activity
Glycosyltransferase
Prevents glucose from forming extra cellular polysaccharides,and this reduces bacterial adhesion and plaque succession. Intracellular polysaccharide formation also is inhibited,preventing storage of carbohydrates by limiting the metabolism between the hosts meals.

Antimicrobial activity
Enolase Inhibits cell wall synthesis thereby damages the cell. In high concentrations(12,000ppm) as used in topical applications,causes direct toxic effect to the bacteria including Mutans Streptococci.

Fluoride Treatment Modalities

ROUTE METHOD OF DELIVERY PUBLIC WATER SUPPLY Self-application Low-Dose/High-Frequency rinses (0.05% Sodium fluoride daily) High-Dose/Low-Frequency rinses (0.2% Sodium fluoride weekly) CONCENT RATION (PPM) 1 225 CARIES REDUCTION (%) 50-60 30-40

SYSTEMIC TOPICAL

900

30-40 after 2 years

Fluoridated dentifrices (daily)

Professional application Acidulated phosphate fluoride gel (1.23 %) annually or semiannually Sodium fluoride solution (2%) Stannous fluoride solution (8%)

1000
12,300

20
40-50

20,000 80,000

40-50 40-50

Fluoride
Fluoridated Tea Fluoridated Salt Varnishes Bonding Agents Restorative materials Iontophoresis

Casein Phosphopeptides (CPP)

Used alone or as CPP-ACP (casein phophopeptides with amorphous calcium phosphate) or CPP-ACFP (casein phophopeptides with amorphous calcium fluoride phosphate).

Shown to reduce demineralization and enhance remineralization of the enamel subsurface carious lesions.

 The main function of casein phosphopeptides is to modulate bioavailability of calcium phosphate levels by maintaining ionic phosphate and calcium supersaturation to increase remineralization.
The role of ACP is also said to control the precipitation of CPP with calcium and phosphate ions.

Casein Phosphopeptides (CPP)

The advantage of CPP-ACFP is the availability of calcium, phosphate, and fluoride in one product.
25 calcium ions

15 phosphate ions

5 fluoride ions

CPP

The calcium phosphate in these complexes is biologically available for remineralization of subsurface lesions in tooth enamel.

Casein Phosphopeptides (CPP)

Antibacterial Buffering effect on plaque

Interfere in the growth and adherence of streptococcus mutans and streptococcus sorbinus.

1% CPP-ACP 55% reduction in smooth surface caries 46% reduction in fissure caries activity, which is similar in effect to that produced by 500 ppm of fluoride.

Calcium Sodium Phosphosilicate

NovaMin (calcium sodium phosphosilicate) is a bioactive glass composed of minerals that naturally occur in the body and reacts when it comes into contact with water, saliva, or other body fluids.

This reaction releases calcium, phosphorus, sodium, and silicon ions in a way that results in the formation of new hydroxycarbonateapatite (HCA) crystals.

ANTIMICROBIAL AGENTS
Mechanism of action Spectrum Side Effects

Antibiotics Vancomycin
Kanamycin Actinobolin Bis Biguanides Alexidine Chlorhexidine Halogens Iodine Fluoride

Blocks Cell wall synthesis Blocks Protein synthesis -same-

Narrow Broad Streptococci

Increases G-ve flora Can increase caries activity Unknown Bitter taste,stains teeth and tongue brown,mucosal irritation

Antiseptic,prevents Broad bacterial adherence

Bacteriocidal

Broad

Metallic taste Fluorosis

PIT-AND-FISSURE SEALANTS
Prevent caries in newly erupted teeth

Arrest incipient caries

Prevent odontopathogenic bacterial growth in sealed fissures Prevent infection of other sites.

PIT-AND-FISSURE SEALANTS
Mechanically fill pits and fissures with an acid resistant resin. Sealants deny MS and other cariogenic organisms their preferred habitat. Render pits and fissures easier to clean by toothbrushing and mastication.

Diet
Dietary counseling-Frequency/Quality Reduced sucrose intake Sugar substitute-Sugar free

Oral Hygiene
Tooth brushing-Bass Method/Sulcular cleaning method

 Tooth Brushing

Oral Hygiene
Flossing-removes bacterial plaque from proximal surfaces.

Floss Holder

Interdental Aids

Indicated in periodontally compromised and orthodontic care

Others
Caries Vaccine Xylitol gums Lasers

Xylitol
Pure Xylitol is a white crystalline substance that looks and tastes like sugar

A popular sweetener for the diabetic diet

A sugar substitute Long-lasting and possibly permanent effect

Xylitol
Xylitol is the best sweetener for teeth. Xylitol use reduces tooth decay rates both in - High-risk groups (high caries prevalence, poor nutrition, and poor oral hygiene) - Low risk groups (low caries incidence using all current prevention recommendations).

 Use xylitol at least three, and preferably 5 times every day. Use immediately after eating and clearing the mouth by swishing water, if possible. Between meals, replace ordinary chewing gum, breath mints, or breath spray with comparable xylitol products

Caries vaccine
RATIONALE Vaccine against SM to prevent initiation. Vaccination before 6 months or before deciduous eruption Along with DPT and booster doses could be given. Source of infection- Maternal. Environmental conditions. Children who do not become infected by 3yrs. appear to remain uninfected for several yrs.,possibly until eruption of the secondary dentition.{Caufield et al,1993:Smith et al,1998}.

MOLECULAR TARGETS FOR DENTAL CARIES VACCINE

Rationale :

1. Clear the microorganism by antibodies before aggregation while still in the salivary phase, prior to colonization.
2. Block receptors of the enzyme to prevent further colonization or accumulation. 3. Action of Salivary IgA may be enhanced or redirected