It is 100 percent preventable - PDF Free Download

Leeds Dental Institute FACULTY OF MEDICINE AND HEALTH No mysteries in solving the caries riddle It is 100 percent preventable Professor Monty Duggal University of Leeds, UK

Aims of this presentation Dental caries de-mystified! Who develops the disease? Can we predict who will develop the disease? Preventive strategies and how thinking has evolved in recent years. What can you do in primary and secondary care paediatric practice.

PREVENTION Replacing windows in a burning house

Decayed primary (baby) teeth

Decayed Permanent teeth

Dental caries: An Ecological disaster Excess sugar Neutral ph S. sanguinis S. gordonii HEALTH space Stress Environmental change Ecological shift DISEASE Acid production Low ph Mutans streps lactobacilli CARIES Marsh, PD (2003) Microbiology, 149, 279-294 You cannot manage caries without managing the ecology

Physiological model of dental caries

Stress in the form of low ph

Figures are showing appliance in place and enamel slabs in situ covered with Dacron gauze

a)microradiographic image of a control slab and b) Microradiographic image of a test slab after 10 days in situ a b

Caries results from a complex and dynamic process involving the interaction of many biological processes Sound enamel Carious lesion

Mechanisms involved in caries Ca ++, Po4 out Cariogenic factors Demineralisation Remineralisation Protective factors Ca ++, Po4 -- in

Future Directions for caries control? Do we really differentiate between: caries Versus Cavities

Clinicians misunderstand what is caries? Confuse cavities with Caries Its all in the Biofilm process?

Importance of Recognition of Early Lesion REMINERALISATION

Preclinical phase Clinical phase Disease initiation Exposure Non-cavitated Cavity Cure Invalidity Death Early Diagnosis Late Diagnosis Primary prevention Secondary prevention Tertiary prevention Maintaining physiological equilibrium Disease control Non-operative Treatment Operative Treatment Dental caries pathway

White lesions ( Spots ) REVERSIBLE THROUGH A PREVENTIVE APPROACH

Sociological Model of Dental Caries

Social class Saliva (flow rate) Education Fluoride Microbial deposit ph Tooth Income Diet Composition frequency Microbiol species Time Buffer capacity Sugar Clearance rate Behaviour Microbial deposit ph Tooth Knowledge Saliva (Composition) Attitudes

Dental health of 5 year olds Bradford and Airedale according to deprivation quintile (IMD 2007) 3.5 3.2 3 2.5 2.3 2 1.5 1.39 1.78 dmft 1 0.5 0.47 0 1 least deprived 2 3 4 5 most deprived

Children who are afflicted with dental caries Younger From more deprived background Less likely to access care in a timely manner Less likely to comply with prevention and recall protocols

Extraction of decayed baby (primary) teeth is the most common reason for general anaesthesia in children in UK

But there is one caries entity that affects children from across the social spectrum! Early Childhood Caries (ECC) Previously known as Nursing Bottle Caries or Baby bottle caries

Prolonged on-demand breast feeding especially through the night can lead to similar clinical scenario as with bottle of milk at night

Crying belly-ache - anorexia Decay starts at as early as 8 months- Parents think teeth came through broken Tooth-ache at 2-3 years Loss of appetite Often first visit paediatrician Emergency management often required under GA

Summary of risk factors ORAL CLEANLINESS (presence of PLAQUE) HAVING sugary DRINKS IN BETWEEN HAVING sugary DRINKS at NIGHT Are the most important determinants for ECC and s-ecc (Martens et al., EAPD-2006)

Children who are afflicted with dental caries Younger From more deprived background Less likely to access care in a timely manner Less likely to comply with prevention and recall protocols

Caries Risk Assessment www.sign.ac.uk www.nice.org.uk

Caries risk predictors The most consistent predictor of caries risk is past caries experience (evidence of previous disease) When assessing caries risk for an individual patient: Caries in mothers and siblings; Medical History; Social History; Dietary Habits; Use of Fluoride; Salivary flow rate ; Oral Hygiene The clinical judgment of the dental professional and their ability to combine risk factors, based on their knowledge of the patient and clinical and socio-demographic information is as good as, or better than, any other method of predicting caries risk

Management of early lesions Plaque control Diet Fluoride Fissure Sealants Other new technologies Slow f release glass device

Plaque control is essential

Toothbrushing and Fluorides Cannot divorce these two so have to talked about in tandem Plaque control and delivery of fluoride into the oral environment go hand in hand

FLUORIDES

Key Point 1: It is the activity of the fluoride ion in the oral fluid that is of most importance in reducing enamel solubility rather than having a high content of fluoride in surface enamel.

Key Point 2: A constant supply of low levels of intra-oral fluoride, particularly at the saliva/plaque/enamel interface, is of most benefit in preventing dental caries.

We should not usually recommend a toothpaste with less than 1000 PPM fluoride to children irrespective of their caries status

DMFT Kg/yr per person Caries decline in Iceland vs trends in sugar and confectionery consumption (Einarsdottir and Bratthall, Eur. J. Oral Sci., 1996, 104 (4); 459-465) Kg/yr per person Litres per capita 9 8 140 7 6 5 4 3 2 1 0 60 50 40 30 20 10 0 1703 1981-82 1784 1982-83 1800 1983-84 1849 1886-90 1984-85 1901-05 1985-86 1911-15 1916-20 1986-87 1921-25 1987-88 1926-30 1931-35 1988-89 1941-45 1989-90 1946-50 1956-60 1990-91 DMFT for 12-yr-olds in Reykjavik according to School Health Reports 1965 1991-92 1970 1980 1992-93 Sugar consumption in Iceland according to various sources 1981-85 1993-94 1986-90 1991-93 1,2 120 100 1 0,8 0,6 0,4 0,2 0 80 60 40 20 0 1960 1980 1990 1993 Consumption of soft drinks in Iceland according to the national Economic Institute of Iceland 1960 1970 1980 1985 1990 1994 Import of toothpastes to Iceland according to the National Economic Institute of Iceland

DoH Prevention Toolkit

Evidence based simplified approach for prevention of dental caries-u.k Based on strength of evidence in <2 year-olds with caries Advice Prof. intervention Cease breast Feeding by 1 yr. Wean onto sugar free foods Apply F Varnish 2/yr. Parents help with brushing Use a smear of 1450 ppm FT

Brushing Children should be encouraged to spit out excess toothpaste and not rinse with water post-brushing. Supervision of toothbrushing with fluoride toothpaste is recommended as an effective caries prevention measure. Recommendation level A

Parents must help until child has enough manual dexterity

Professionally used Fluoride Varnish Duraphat 5%wt NaF 22,600 ppm F Fluor Protector 0.9% wt fluorsilane 50-70% Caries Reductions Biannual applications or quarterly for rampant caries cases. Quick and easy to use.

Fluoride Varnish-Correct Amount (0.5ml) Full Mouth Child Application

Decayed Permanent teeth

High Fluoride Prescription Only Toothpastes

Evidence based simplified approach for prevention of dental caries Based on strength of evidence in children and young adults >6yrs with caries Professional Intervention Fissure seal Molars F varnish 3-4 times/yr >8 yrs. prescribe daily F rinse >10 yrs. Prescribe 2800 ppm F TP >18 with active disease 5000 ppm F TP Investigate diet and good dietary practice.

Concerns regarding additional use of fluoride in some countries Public health VS Indivudualised Approach

A paediatric dentists losing battle for diet modification SUGAR AND SPICE And all things nice

Diet and Dental Health Dietary Celibacy

Hedonism Diet and Dental Health

Diet and Dental Health Frequency of eating Amount of eating

Enamel demineralisation in situ with varying frequency of carbohydrate consumption with and without fluoride toothpaste Duggal MS, et al J Dent Res 2001;8:1721-1724.

% change in mineral loss (vol%.µm) Percentage change in mineral loss of enamel slabs in subjects using a fluoride toothpaste, with varying frequency of carbohydrate consumption 80 Demineralisation Remineralisation 60 40 20 0-20 -40-60 -80 1x 3x 5x 7x 10x Frequency 3

% change in mineral loss (vol%.µm) Demineralisation Remineralisation Percentage change in mineral loss of enamel slabs in subjects using a fluoride free toothpaste, with varying frequency of carbohydrate consumption 60 40 20 0-20 -40-60 -80-100 1x 3x 5x 7x 10x Frequency 7

Implication In children where usage of fluoride toothpaste is low, frequency of snaking might be an important factor in the causation of dental caries

Practical Diet counselling!!

Diet and Dental Health Good food bad food debate should be replaced with: Good Diet, bad Diet

Diet and Dental Health Dietary advice should be: Realistic and Positive

Compliance? Communicating in the right way is the key

Diet counselling Focus on good diet and nutrition Make messages realistic and positive Emphasis oral hygiene and optimum use of fluoride

Practical Advice Encourage children/parents to brush twice a day with fluoride toothpaste Encourage dental counsultations as early as possible-when teeth are still healthy Confectionery and such foods used as a desert For soft drinks: Ideally serve at meal times Use straw wherever possible Never use on a dummy or comforter Never serve from a bottle Do not give at bedtime or during night

ROLE OF INDUSTRY

THE LEEDS SLOW-RELEASE FLUORIDE GLASS DEVICE

Ultradent Kit

New Devices & Brackets

Results: 67% Fewer new carious teeth dmft+dmft (p<0.01) 76% Fewer new carious surfaces dmfs+dmfs (p<0.001) Toumba & Curzon, Caries Res, 2005.

A childhood free from pain and oral discomfort QUALITY OF LIFE

Thank You for your attention