Preventive

Dentistry

Department of Preventive Dentistry

School of Stomatology
Wuhan University
Minquan Du 杜民权
 What is health?
- No disease
- Body has no problems
- Nothing wrong

- Able to do all the things I like

- Feel good
- Live happily
 Definition of “Health”
Lay public
- no disease/problem
Dictionary
- condition of the body in which its
functions are efficiently discharged
W.H.O.
- not just the absence of disease
- state of complete physical, mental and
social well-being
 Types of prevention
Primary
- to prevent onset of disease

Secondary
- to prevent progression of disease

Tertiary
- to prevent loss of function and disability
 Primary prevention
Not disease specific
- general health promotion, e.g. healthy diet
- common risk factor approach, e.g. good
plaque control

Disease specific
- act on disease agent, e.g. vaccination,
antibiotics
- act on host, e.g. fissure sealant
 Secondary prevention
Early detection
- sensitive tools, e.g. x-ray
- frequent examinations, e.g. regular check-up
- cost, risk, benefit

Appropriate treatment
- effectiveness
- acceptable
- affordable
 Tertiary prevention

Restore
- replace missing tissues with other materials

Rehabilitate
- train to perform function with residual parts

Both actions are complementary

 Summary on prevention
Disease Before onset Disease started
stage
Aim Prevent Prevent Prevent
onset progression disability

Type Primary Secondary Tertiary

Methods Promote Early Restore body

health detection parts

Specific Prompt Rehabilitate

protection treatment
Deciding on a preventive method

Stage of disease
- pre-clinical, clinical

Type of prevention
- primary, secondary, tertiary

Factors to act on
- host, agent, environment
Dental caries
Periodontal
diseases
Malocculasion
NON-CARIOUS
CERVICAL LESIONS
Fluorosis
Lip and palate cleft
 Oral Epidemiology Survey

 Pit and fissure sealant

 Fluoride application

 Oral Health education and promotion

Oral Epidemiology Survey
in Hubei Province
 Aims of epidemiology

- to study the distribution of health and

diseases in populations

- to study the factors which affect the

distribution (especially a cause-effect
relationship)
 Types of study
 Descriptive studies: cross-sectional,
longitudinal, historical

 Analytical studies: case-control,

cohort

 Experimental study: Clinical trials,

Intervention, fields trials
 Descriptive study
 patterns of health / disease in populations
 identify differences between populations
 observe changes over time
 suggestive of risk factors
 gives rise to hypotheses
 Analytical studies
 planned to test hypothesis
 two types
 case-control
cohort
 case-control - retrospective, collecting
information about exposure to factors that
are correlated to an outcome
 cohort - prospective, following populations
over time
 Longitudinal observation
Cause Outcome : case / control

Past Present

Case – people with the condition of interest

Control – people without the condition
Retrospective study
 Longitudinal observation

Past Present Future

Cohort study – select a group of people and

follow them to see what happens (to study
changes) ; prospective
 Experimental studies
Can be conducted in laboratories or on human
subjects

Study on human is called clinical trial

- in hospitals and clinics
- in field, i.e. where people work and live

Randomized controlled clinical trial is commonly

regarded as the gold standard for evidence-based
dentistry (best evidence)
 Randomized controlled trial

 Randomization: Random numbers, throw a

coin, dice.
 Control: Study group, Positive control,
Negative control
 Blind: Single blind, Double blind, or placebo
 Ethical Considerations: GCP requirements
Dental caries of primary teeth in 5 years old
(Hubei Province)

year dmft Prevalence (%)

1995 3.64 70.2

2005 2.42 55.5
Dental caries of permanent teeth (1995)

DMFT Prevalence(%)

1995 2005 1995 2005

5 0.01 0.01 0.75 0.33

12 0.61 0.36 34.1 22.7
15 0.94 0.45 41.8 24.4
35~44 1.44 1.17 65.1 47.0
65~74 3.04 3.67 74.4 77.2
Pits and Fissure Sealants
 Introduction
 Fluorides: Smooth surfaces ( 10%),
Occlusal pits and fissures ( 90%)

 Occlusal surfaces: 12%

 Concept
Pits and fissure sealants are materials
which are designed to prevent pit and
fissure caries. They are applied mainly
to the occlusal surfaces of the teeth in
order to obliterate the occlusal fissures,
and remove the sheltered environment
in which caries may thrive.
 Indication of Sealants
 A deep occlusal fissure, fossa or lingual pit is present

 An intact occlusal surface is present where the

contralateral tooth surface is carious or restored

 An incipient lesion exists

 3-4 years: deciduous molars;

6-7 years: the first permanent molars

11-13 years: the second

Contraindication of Sealants
 Patients behaviour does not permit use of
adequate dry-field techniques throughout the
procedure

 An open occlusal carious lesion exits

 Caries exit on other surfaces of the came

tooth

 A large occlusal restoration is already

present
 Background of Sealants
 Polyurethanes ( 氰基丙烯酸脂 )

 Cyanoacrylates ( 聚氨基甲酸乙脂 )

 Bisphenol A –glycidyl methylacrylate (Bis-

GMA) ( 双酚 A 甲基丙烯酸缩水甘油酯 )
 Composition of sealants
 Resin: Gis-GMA

 Monomer:

 Catalyst: benzoyl peroxide

Polymerization of Sealants
 Monomer + catalyst ----- Polymer

 Light curing: ultraviolet, visible blue light

 Self-curing: autopolymerization, cold

cure
 Self-curing Sealants

 Do not require light source

 The time allowed for sealant manipulation

and placement must not be exceeded
 Light-curing Sealants
 Operator can initiate polymerization at any
time
 Polymerization is shorter than self-curing
 Require a light source
 Equal in retention
 Etching
 Buomocore: 1960s

 30—40% phosphoric acid: liquid or gel

 Enamel: tags
 Clinical Application
1. Surface cleanliness:
Remove heavy stains, deposits and
debris. Nonfluoride, oil-free
mixture:pumice, toothpaste

2. Acid etching: liquid etchant is placed on

the tooth, daubed, not rubbed.
1 minute for permanent tooth,
11/2 minutes for deciduous teeth
 Clinical Application
3. Water flush and dryness: 10 seconds
rubber dam, cotton rolls, bibulous pads
high-volume,low vacuum aspirator
White, dull, frosty appearance (5-10um)

4. Application of the sealant

light-cured, self-cured sealants
tags
 Clinical Application
5. Polymerisation
light-cured, 20 seconds
self-cured, 1—2 minutes

6. Examination
carefully, any voids, occlusion
Fluoride and Dentistry
 Background
In the early 1900s, McKay noticed “Colorado
Brown Stain”
By 1920s, McKay: the agent was an
unidentified constituent of the water supply
In 1928, Mckay: caries experience was
reduced by the same water that produced
mottled enamel
By 1931, spectrographic analysis identified
fluoride in the water
 Background
Dean (1935) renamed mottled enamel as
fluorosis and devised a weighted
community fluorosis index
Dean (1941) “21 Cities” study – adoption of
1.0-1.2 mg F/L as the appropriate
concentration of fluoride in drinking water
for temperate climates in USA
In 1945, Grand Rapids, Michigan, became the
first community to add fluoride to its
municipal water supply
 World status of water
fluoridation
HK and Singapore: 100% population

Fluoridation reaches more than 50% of

the population in Australia, Ireland,
Malaysia, New Zealand, and the USA.

There is little water fluoridation in Europe

except parts of UK, Switzerland, and
Spain.
 Optimal concentration of fluoride

Dean concluded from his surveys in 21 U.S.

cities that the optimal fluoride concentration
in water for temperate climate zone in U.S.
was 1.0 ppm

WHO Expert Committee stated that optimum

fluoride concentration will normally be within
the range 0.5-1.0 ppm
Salt fluoridation - background
 first suggested as a means to prevent
caries in around 1950, based on the
success of iodized salt in Switzerland

 first used in Switzerland in 1955 (90 mg

F/kg salt)

 by late 1980s, fluoridated salt accounted for

75% of the national domestic salt market

 changed to 250 mg F/kg salt in 1983

Salt fluoridation - background
 A salt fluoridation trial was supported by
WHO & NIDR in Colombia in 1965. Studies
with fluoridated salt began in Hungarian
communities in the mid-1960s (200-250 mg
F/kg to 350 mg F/kg from 1981)

 it has been adopted in France (1986),

Germany (1991), Spain (1968), Costa Rica
(1987), Jamaica (1987), Mexico (1988), Peru
(1989) ……
Salt fluoridation – chemicals
• Sodium Fluoride (NaF)

• Potassium Fluoride (KF)

• Calcium Fluoride (CaF2)

 Salt fluoridation - effectiveness
• Switzerland: mean DMFT dropped 32-
79% in 7-9-year-old children

• Colombia: 47% caries reduction found

among 12-14-year-olds

• Germany: 50% decrease in DMFT in the

12-year-old from 2.4 in 1994 to 1.2 in 2000
Salt fluoridation - summary
 lowto moderate level of evidence on
effectiveness of salt fluoridation on caries
prevention
 thoughthere is an increase in the
adoption in Europe, and Central & South
America, population coverage is still small

 studieson population acceptance and

fluorosis resulting from salt fluoridation
are need
Milk fluoridation - background
- The first project with fluoridated milk was
in Winterthur, Switzerland in 1955

- The Borrow Dental Milk Foundation

(renamed as Borrow Foundation in 2002)
was established in 1971, as a charity,
non-profit organization actively involved in
promoting milk as a vehicle for fluoride for
the benefit of children’s oral health.
Milk fluoridation - background
- The first fluoridated milk community
schemes was established in Bulgaria by
BDMF and the WHO in 1988. Then in
UK, the Russian Federation, China,
Chile, Peru, Thailand …..
 Milk fluoridation – chemicals,
vehicles
Sodium Fluoride (NaF) in fresh milk
Disodium Monofluorophosphate in
powdered milk products in Chile

• Fresh milk
• Powdered milk
• UHT (Ultra-High Temperature) milk
 Milk fluoridation - summary
- moderate level of evidence on the
effectiveness on caries prevention with
30-70% caries reduction
- trend for adoption of milk fluoridation
seems increasing, but is still uncommon

- can it be an useful community public

health measure?
Topical fluorides
 Fluoride toothpaste (dentifrice)
 Fluoride mouthrinse
 Fluoride varnish
 Fluoride gel/foam
Fluoride toothpaste
Common chemicals used
 Stannous fluoride (SnF2)
 Sodium monofluorophosphate (MFP)
 Sodium fluoride (NaF)
 Fluoride toothpaste
Concentration of fluoride used
 Conventional : 1000ppm
 Higher dose : >1000ppm, up to 2800ppm
 Lower dose : <1000ppm, down to 136ppm
Cochrane review by Marinho et
al.
74 studies reviewed
Prevented fraction (PF) = 24% (95% C.I. = 21-28%)
Effectiveness increase with
 higher baseline caries level
 higher F concentration
 higher frequency of use
 supervised brushing

Effectiveness not affected by water fluoridation

Little information in primary teeth
Fluoride mouthrinse
 Common chemicals:
NaF, APF, SnF2, ammonium fluoride, amine
fluoride

 Administration:
high concentration with low frequency
low concentration with high frequency
Fluoride mouthrinse
Compound Concentration Frequency % caries
(ppm) reduction
NaF 112-1000 Daily 8-50
SnF2 100-250 Daily 20-38
Ammonium 1000 Daily 42
fluoride

APF 100-300 Daily 28

Amine 250 Daily 22

fluoride
Cochrane review by Marinho et
al.
36 studies reviewed
PF = 26% (95% C.I. = 23-30%)
No relationship found between effectiveness
and:
 baseline caries level

 background exposure to F

 rinsing frequency

 F concentration
Fluoride varnish
Background:
 developed more than 30 years ago

 as an attempt to increase the caries-

inhibiting properties of fluoride by holding
it to tooth surfaces for longer periods of
time than other fluoride product
Fluoride varnish
Formulations:
 Duraphat: 5% NaF (2.26% F)

• Fluor Protector: 1% difluorosilane (0.1% F)

• Bifluorid 12: 2.71% NaF + 2.92% CaF2
• Carex: 1.8% NaF
F varnish in permanent teeth
Systematic review (Helfenstein, 1994):
 5% NaF (Duraphat, 22,600ppm F)

 subjects aged 6-15 years, permanent

teeth
 30 studies from 1975-1991; 14 included
in a meta-analysis
 PF = 38% (95% CI = 25-50%)
F varnish in primary teeth
 Not many studies on the effectiveness of
fluoride varnish used in primary teeth
 Only 3 are randomized controlled trials
and they had inconsistent findings
 Comparisons with controls in many
studies found no significant results
Cochrane review by Marinho et
al.
9 studies reviewed
PF = 46% in permanent teeth (95% C.I. = 30-63%)
PF = 33% in primary teeth (95% C.I. = 19-48%)
No relationship found between effectiveness
and:
 baseline caries level

 background exposure to F

Studies are of relatively poor quality

Need more RCTs
Fluoride gel and foam
APF products:
 1.23% (12,300 ppm) F

 pH: 3-4

Neutral gel and foam:

 2.0% NaF (0.9% F)

 pH: 6.2-7.2
Fluoride gel
Systematic review (van Rijkom, 1998)
 17 RCTs, 1965-1995

 1.23% APF gel

 Subjects aged 6-15 years

 Meta-analysis: prevented fraction of 22%

(95% CI = 18-25%)
Cochrane review by Marinho et
al.
25 studies reviewed
PF = 28% (95% C.I. = 19-37%)
Effectiveness higher in studies with non-
placebo control (single blind)
Little information in primary teeth
Fluoride foam
F foam was developed to minimize the
potential risk of excessive F ingestion
following gel application and to maintain
the efficacy of topical F treatment
Results of RCT show that compared to F
gel, use of F foam provided less exposure
and retention of F but with equivalent F
uptake by enamel.

Wuhan study (introduction)

Professionally applied varnishes 22,600
Oral Health Promotion Project
in Chinese Schools
Wuhan City
 The Attached Primary School of Huazhong Normal
University has a 6-year teaching system. A dental clinic
was set up there for the implementation of the oral
health promotion of 6 years

 2001 – 2002 Preparation

2002 – 2005 Implementation
2006 – 2007 Evaluation
 Objectives
 Set up a dental clinic with sound facilities and two
dental chairs in one of the primary schools of Wuhan
( the Attached Primary School of Huazhong Normal
University)

 All the students from Grade One to Grade Si (aged

between 6 and 12 years old) all participated in the
program
Contents
1. Regular oral health education courses for students,
parents and teachers
2. Put up posters in school and classroom
3. Hand out pamphlet to students and parents
4. Visit School of Stomatology
5. Hold oral health knowledge competition, tooth
brushing competition and drawing competition
Project involved 　
1. Regular dental examination
2. Fluoride toothpaste and Fluoride treatment
3. Application of pits and fissures sealant
4. ART
5. Application of stainless steel crown
 Dental Clinics in School

2002
Project Implementation
Oral Health Education
Teaching Tooth-brushing
Tooth-brushing with fluoride toothpaste
Fluoride gel
 Pit and Fissure Sealants

2003
 Dental Caries Treatment

2004
Tooth-brushing
Oral Health Check-up
Table 1 　 Pupils benefit from Fluoride gel

Year First Second Total

Semester Semester
　　　　　
　　　　

2003 1794 1800 3594

2004 1815 1876 3691
2005 1883 1890 3773
Table 2 　 Pupils with pit & fissure
sealants

Year Number of Number of

students teeth
2003 350 1129

2004 387 1074

2005 214 685

 Summary
 Significantimprovements of the oral health
knowledge, attitudes and practices of the
primary school students

 Lower caries rate and higher oral hygiene

level after two years’ implementation
 Effect of a school-based
oral health education
programme in Wuhan City,
Peoples Republic of China
International Dental Journal
2004;54(1):33-41
Welcome to Wuhan