Cariology: Caries is dental decay, a transmissible, microbiological, infection.

Caries is a Bacterial infection.

Old theories: Sumerians, Shang Dynasty China = tooth worm. WD Miller 1890s-1930
proposed a chemo-parasitic theory (fermentation of food by parasites, acid erodes tooth
surface). Keyes and Jordan 1963: plaque, tooth, diet required for caries.
A Localized destruction of tooth/teeth by high concentrations of organic acids produced by
bacteria from dietary carbohydrates.
Theories:
o Millers Chemo-Parasitic Theory: The mineral phase of tooth is dissolved by acid
produced by the metabolism of dietary carbohydrates by oral bacteria. In a
secondary step, the organic phase of enamel and dentin is broken down.
o Featherstone & Silverstone (Tooth Demineralization and Remineralization): Dental
decay occurs when demineralization is more rapid than remineralization; The
organic material between enamel prisms destroyed first, then demineralization of
enamel and dentin continue if not remineralized.
Early Caries Initiation: Subsurface decalcification with relatively intact enamel surface.
Biological Battle: Remineralization Zones: Surface Zone & Dark Zone. Demineralization
Zones: Body of Lesion and Translucent Zone.
Types of Caries:
o Incipient - enamel demineralization but NO cavitation. Clinically appears as a
White spot.
o Arrested incipient or advanced lesion that has stopped or remineralized. Brown
pigmented area.
o Active more demin than remin at the present time. Clinically appears yellow-
orange (chronic) or dentin-colored (acute).
o Recurrent lesion at the interface of a restoration.
o Residual caries that was left after cavity prep.
o Rampant - sudden rapid destruction, 10+ in one year
What Can It Lead To: Infection, Sepsis, and Death. Abstract: pain, lost time, cost.

How Does Decay Begin: Sugar + Bacteria = Acid. Acid on Tooth = Decay.
Caries = Agent + Host + Environment.
o Agent: Plaque Biofilm: S. Mutans, S. Sobrinus, Lactobacilli and other pathogens.
o 12h plaque = still soft enough to be scratched off with fingernail. 24h plaque =
begins to harden. 10d plaque = considered tartar or calculus.
o Host: The Tooth, Saliva Quantity, Saliva Quality, Immune Responses.
Functions of Saliva
Lubrication & Flushing
Dilution & Chemical Buffering of Acid
Antimicrobial Functions
o Mucins Aggregate Bacteria
 o Lactoferrins Inhibit S. Mutans Adherence & Deprive
Bacteria of Iron
o Peroxidase Inhibits Ability to Use Glucose
Provide Calcium & Phosphate for Remineralization
Medications Cause Xerostomia
Anticholinergic Properties Reduce Saliva
Quality and Quantity
Common Medication Types Include:
Anti-anxiety and Anti-psychotic Agents
Anti-hypertensive Agents
Allergy and Asthma Medications, especially inhaled
glucocorticosteroids
o Environment: Dietary fermentable carbohydrates. Sugar includes sucrose, glucose,
maltose, and fructose.
Fermentable Carbohydrates
Relative Cariogenicity of Foods
o Acidic Content & Ability to Form Acid with Bacteria
Sucrose Content & Form
o Sticky Candy, Breath Mint, Soda
Maltose (Cooked Starch/Sugar)
o Breakfast Cereal, Pancakes, Donuts, Potato Chips, Breads
Time of Ingestion
o Eaten with a Meal or Snacking
Frequency and Duration Higher frequency is worse
Caries is Infectious and Transmissible
o Infants acquire bacteria beginning at birth, S. Mutans appears around 8 months
with first tooth.
o S. Mutans transmitted easily through saliva.
o S. Mutans adheres well to tooth due to pellicle & extracellular polysaccharides.
Calcium bridging, hydrophobic interactions, and adhesions also help.
o S. Mutans produces organic acid rapidly
o S. Mutans remains in tooth structure and saliva to reinfect tooth and adjacent teeth
o Restorative treatment does not always remove bacterial infection
Enamel: Is the most mineralized structure in the human body. Is composed of tightly-
packed carbonated hydroxyapatite crystals, arranged in rods or prisms.
Rods: Viewed in cross-section, appears as keyhole-shaped structures. Are separated from
the next by a space filled with water and organic material. Have intercrystalline spaces
forming pathways through which fluid diffusion can occur.
Susceptibility Within Tooth
o Demineralization begins in the organic interprismatic spaces.
o Enamel demineralization follows the rods
o Initial dentin demineralization does not spread along the DEJ beyond the periphery
of the enamel lesion.
 Two layers of carious dentin
o Outer infected: Bacterial Infection, Unremineralizable, Dead, Without sensation
o Inner affected: Minimal bacterial invasion, Remineralizable, Alive, Sensitive
Occurrence by tooth type
o HIGH Susceptibility: Mandibular Molars, Maxillary Molars
o INTERMEDIATE Susceptibility: Maxillary Premolars, Mandibular Premolars,
Maxillary Incisors
o LOW Susceptibility: Maxillary Canines, Mandibular Incisors, Mandibular Canines
Functions of Saliva (3 salivary glands)
o Lubrication & Flushing
o Dilution & Chemical Buffering of Acid
o Antimicrobial Functions
Mucins Aggregate Bacteria
Lactoferrins Inhibit S. Mutans Adherence & Deprive Bacteria of Iron
Peroxidase Inhibits Ability to Use Glucose
o Provide Calcium & Phosphate for Remineralization
Medications Cause Xerostomia
o Anticholinergic Properties Reduce Saliva
o Quality and Quantity
o Common Medication Types Include:
Anti-anxiety and Anti-psychotic Agents
Anti-hypertensive Agents
Allergy and Asthma Medications, especially inhaled glucocorticosteroids
Lots of medications contain sugar such as candies, mints, or sugary
liquids. Recommend: saliva substitute, water increase, sugarless gum.
The Stephan Curve
o Stephan Curve: After acid exposure, saliva takes 20min (or even up to 2hrs) to
return to normal pH; drops below 5.5 (critical pH) for ~5min. **FREQUENCY
NOT AMOUNT**
o What else could drop pH down? Salivary problems (e.g. oral cancer radiation),
bulimia (stomach acid).
Complicated etiology: Community level (social, culture, economy), family level, child level.

Infection Control: OSHA & CDC Guidelines

Three Modes of Contact: Dermal Contact, Respiratory/Aerosol, Blood Borne

Transmission
Penn follows OSHAs bloodbourne pathogen rules established in 1991.
Universal Precautions: Treat all human source material as being potentially
infectious.
Blood Borne Pathogens: Hep B Virus (can remain viable on surfaces for up to 7
days), HIV (anti-HIV factor in saliva), Hep C (Hep B most common)
 Is it right to shun HIV patients? No, chance of getting HIV from a needle stick is
0.3% HCV = 1.8%, Hep B = 1-62% depending on pt surface antigen differences.
Aerosol Transmitted Infections:
o TB caused by Mycobacterium tuberculosis. Affects the lungs.
o Influenza attacks the lungs, throat and nose.
Personal Protective Equipment: Gloves, Surgical Masks, Protective glasses with side
shields for patient and operator, Clinic gowns (clinic floor only!) and lab coats.
Hand washing/sanitizing is the most important procedure in infection control.
Chairs should not be setup more than 15 minutes before appointment.
Biofilm forms when bacteria adhere to surfaces in aqueous environments and begin
to excrete a slimy, glue like substance that can anchor them to all kinds of material.
The plaque that forms on your teeth and causes tooth decay is a type of bacterial
biofilm
All air/water LINES have to be flushed for 30-60 seconds between each patient.
Sharps Container: Burrs, Scalpels, Wire, Needles and all used glass from anesthetic
injections.
How do we reduce risk? Standard precautions #1, treat OPIM as infectious.
Engineering precautions sharps, hazard removal.
Work precautions: Proper instrument use. Sharps: disposable best, if must recap recap
with one hand only.
PPE: Personal protective equipment, mask, gloves.

Evidence Based and Risk Approach to Caries Prevention

-Strengthen Host: F-, sealants
-Remove Agent: Brush, floss, mouthwash
-Change Environment: Better nutrition, smoking cessation

Risk Based and Evidence Based Approach to Caries Prevention

Risk Assessment for Dental Decay

o History of Dental Decay & Dental Visits, Presence of Susceptible Occlusal
Grooves, Salivary Status, Fluoride Use, Oral Hygiene, Nutritional Patterns,
Parental Involvement.
Risk Assessment to Caries Prevention
o Risk Behaviors:
Low Risk For Decay:
No caries within 1 year: Child, 2 years: Adult
No current dental decay
Good oral hygiene
Use of fluoride toothpaste
No sealants
Regular dental visits
Moderate Risk For Decay:
 1-2 recent caries
Teeth without sealants, exposed roots, orthodontic care
Fair oral hygiene
Fair use of fluoride
Irregular dental visits
High Risk For Decay:
2 or more recent caries
Susceptible Teeth
Poor oral hygiene brushing frequency/brush type
Reduced salivary flow Rx, radiation
Cariogenic Diet snacking?
Little or no fluoride
Irregular dental visits
Surfaces at Risk for Dental Decay
o Decayed, Missing and Filled Surfaces (DMFS) 28 Teeth
o 16 Occlusal Surfaces (Most at Risk), 124 Smooth Surfaces, 140 Total
Surfaces
Dental Sealants: #1 Preventive Strategy against Dental Decay/Caries Prevention
o 100% caries reduction as long as sealant is retained
Less Fluoride = Moderate to High Risks For Decay
Fluoride: Cochrane study and CDC 2001 study reinforce safety/usefulness:
o Enhances Remineralization: Absorbs onto crystal surface and attracts Ca and
P ions. Excludes carbonate to allow more fluorapatite crystal growth. Speeds
the growth of new crystalline surface by attracting more Ca and P. Alters
hydroxyapatite crystals to fluorapatite crystals. Flouride helps create a more
perfect crystal
o Inhibits Demineralization: Fluoride in water phase collects in intercrystalline
space and inhibits acid dissolution of teeth. Fluorapatite (FAP) in enamel
crystal lattice is most resistant to demineralization. When carbonate ion is lost
and replaced by FAP, demineralization is inhibited.
o Inhibits Bacterial Metabolism: Acid produced by S mutans converts topical F
into HF which is incorporated in cells in biofilm. Reduces acid by inhibiting
enolase, enzyme necessary for carbohydrate metabolism. Reduces
mucopolysaccharides. Inhibits glycolysis.
o Topical Fluoride: Affects tooth surface and sub surface enamel. Remineralizes
active subsurface decay.
o Systemic Fluoride: Affects developing tooth enamel via bloodstream.
Increases fluorapatite crystals in developing tooth
o Fluoride Dentrifice : Kids should be supervised for brushing until they can
write cursive, ~ age 8.
0.2% Sodium Fl 1000 ppm
0.454% Stannous Fl 1000 ppm (Crest Pro Health)
Whitening agents are abrasive: mechanical stain removal
 SLS used for foaming, but linked to canker sores/allergy
o Fluoride Home Rinses Use decreased DMFS by 26% (Cochrane 2005)
Daily 250 ppm
0.05% Sodium ACT
0.025% - Purple Listerine
0.044% Acidulated phosphate
Weekly 1000 ppm
0.2% Sodium (Good for use with school children)
o Fluoride Home Gels: Pooled study, caries reduction 28% (2005)
Daily 5000 ppm
1.1% Sodium Fluoride
o Effective for caries control with neutral formulation
o Good with esthetic restorations & dry mouth
Daily 1000 ppm
0.4% Stannous Fl
o Effective in root sensitivity & caries control
o Stains due to tin ion & can pit restorations due to acidic
formulation
o Professional Fluoride Treatments
Clinic Procedure:
Dry Teeth, Apply Fluoride for 4 minutes, Use Saliva ejector,
Stay with Patient, Ensure Fluoride is removed at end, Patient
should NOT eat or drink or smoke for 30 minutes after. Begin
posteriorly and lingually.
5.0% Sodium Fluoride Varnish (20,600 ppm): 46% caries
reduction in adults, 33% in children.
o Easy to apply, even in infants
o Accepted for root sensitivity
1.23% Acidulated Phosphate Fluoride (12,300 ppm)
o Easily applied at 6 month intervals
o Acidic formulation speeds fluoride penetration
o Acid may pit or stain esthetic restorations
o Difficult with patients with dry mouth
o Insurance covers this for children usually
2.0% Sodium Fluoride (9,040 ppm)
o Neutral Formulation (Safe for all patients)
o Research unclear on efficacy
o Guidelines for Fl Supplementation (If pills, limit to once/month Rx)
0-6 months: NO Supplementation
6 months-3 years: 0.25mg when Fl less than 0.3ppm
3-6 years: 0.5mg when Fl less than 0.3ppm, 0.25mg when Fl 0.3-0.6
ppm
 6-16 years: 1mg when Fl less than 0.3 ppm, 0.5mg when Fl 0.3-0.6
ppm
o Fluoride Toxicity
Certainly Lethal Dose (CLD) potential for causing death
5-10 gram NaF or 32-64 mg F/kg
Safely Tolerated Dose (STD) consumed without toxic symptoms
CLD or 8-16 mg F/kg
o Fluoride Overdose Care
Less than 5.0 mg/kg: Give oral calcium (milk or lime juice)
More than 5.0 mg/kg: Empty stomach by inducing vomiting, give oral
calcium, hospitalize
More than 15.0 mg/kg: Hospitalize, induce vomiting, give calcium iv,
cardiac monitoring
o Fluorided water benefits
Available to all regardless of economic or dental status
Easy compliance just drink or eat ambient F products (pasta sauce,
frozen foods, juice)
What is caries reduction in recent studies? 25-30%
What % of US population has access? 61-69%

Ways to Control Bacteria

o Mechanical: Toothbrush, Floss. Chemical: 0.12% Chlorhexidine. Vaccine: S.
Mutans
Limitations of Bacterial Control in Preventing Decay
o Thorough bacterial removal difficult especially in occlusal grooves
o Bacteria combine with refined carbohydrates to form acid
o Stephan Curve = 20 minute time frame
o Microenvironment for acid formation
o Patient compliance in thorough biofilm removal

Prevention and Control of Periodontal Diseases Part I and II

Periodontal Diseases: Combination of Bacteria (Agent) + Host + Environment.

Gram Negative Anaerobes: Reside subgingivally in sulcus/pocket. Very difficult to
access and control daily by patient
Campylobacter Rectus, Porphyromonas Gingivalis, Prevotella Intermedia, Tannerella
Forsythia, AA: Actinobacillus Actinomycetemcomitans
Most persistant = AA
Innate risk factors: gender, race, congenital disorders such as MR, diabetes.
Acquired risk factors: Diabetes, HIV/AIDS, stress, medications, etc.
More than 50% of adult periodontal cases are attributable to cigarette smoking
Change Local Environmental Factors: Identify and Eliminate Iatrogenic Restorations,
Eliminate pocket depth. (0.5-3mm healthy) Complete ortho & occlusion adjustment.
 Identify & reduce risks: Monitor healthcare (work together with endocrinologist),
patient education more intensive, more frequent recall (every 6 weeks).
Pt education: Work together with physician, explain systemic links.

Microbial Plaque Biofilm

o Bacterial Biomass Pathogenesis:
Initiate local inflammation process
Infection increases in markers of inflammation
Bacterial load increases level of circulating microorganisms in blood
stream
Potential for bacteria to translocate
Mechanical Oral Hygiene
o Minimum Criteria: Soft Bristles, Safe GMP Product, Efficacy, Equivalence,
Superiority
Brushing Techniques
o Bass generally recommended, cleans sulcus 45 deg angle. Modified Bass =
Bass + Rolling Stroke. Stillman. Charters. Fones recommended for
children, uses circular motion. With children, make sure they understand to
brush twice a day and make sure they have their own brush no sharing! Use
disclosing tablets to show where they are missing spots.
Powered Brushing
o 3 Basic Types:
AA Battery Powered Spin Brush, Actibrush
Rechargeable Battery Braun Oral B
Sonic Rechargeable Battery Sonicare, Braun Sonic
o Reduce physical skill and cognitive abilities necessary for brushing
o Remove more plaque in less time
o Reduce Gingivitis and Bleeding
o Reduce Stain
o Provide Easier Compliance for Patient
o Rotation oscillation (Oral B Braun) most effective in reducing plaque,
gingivitis and bleeding.
o Plaque Reduction: Manual toothbrush 67%, electronic 85% (2 min). Can even
lower amounts of proximal plaque and gingivitis.
o 2003 Cochrane Review: Oral B Braun is best, but whatever a patient is
comfortable using is better!!
Interproximal Plaque Control
o Dental Floss:
Effective in cleansing with healthy tissue
No difference waxed/unwaxed
No added benefit with fluoride floss
o Tissue and Bone loss create increased proximal space:
Promixal brush very effective!
Toothpick/ floss swords
 Perio Aid
Stimudent
Anything is better than nothing!
Ortho/crownbridge pts? Still use superfloss/proximal brush
Chemotherapeutic Agents
o 0.12% Chlorhexidine
Complete Microbial Kill in 30 seconds with a 15ml rinse twice a day
Controls Gingivitis & Candida
Disrupts cell wall
Substantive for 12 hours
Available in alcohol free versions
Brown stain
Strong flavor
Reduces Taste. Compliance thus bad after 6 weeks.
Interacts with SLS in toothpaste. DO NOT USE in combination, CHX
will be rendered inactive.
Essential Oil MouthRinse & Toothpaste
o Listerine Mouthrinse
o 21% / 28% Alcohol concentration
o Use a 20ml rinse full strength for 30 seconds Twice Daily
o Non-alcohlic? Does not have ADA seal. Alcohol keeps essential oils stable.
o Compared to chlorohex? About as effective compared to control.
0.07% Cetylpyridinium Chloride (CPC) Crest Pro Health Not ADA approved yet.
0.454% SnF2 Crest Pro Health Toothpaste
o Stannous ion in Fluoride stabilized with sodium hexametaphosphate
o Reduce plaque, gingivitis, and dentin hypersensitivity ~20%
0.3% Triclosan
o Formulated in toothpaste (Colgate Total) that is accepted for antiplaque,
antigingivitis, anticaries and tartar control claims
o Hypersensitivity = ZnCl2
o Antibacterial and substantive for 12 hours
Water pic decreases instance of gingivitis but NOT plaque (unless used w/ rinse).
Used with chlorohex or Listerine has much better plaque.
Tartar Control Products
o Calcium Scavengers reduce new calculus formation
o Cosmetic, not therapeutic
o Pyrophosphates
o Zinc Chloride
Xylitol
Increase salivary volume, increase buffering capacity, reduce food retention in
mouth. Antibacterial, effective with 8 pieces/day or 8 mints/day.
ADA 2008: Brush-Floss-Rinse: Is this for everyone? Yes, if they are physically able.
Teaching & Motivating Patients To Change Their Behaviors
Our relationship with patient: Teacher/learner. We teach them something.

What do dentists need to teach their patients:

o Knowledge Preventative home care, causes of dental disease, rationale for
dental care. (e.g. oral surgery and ortho can you deal with the tx plan?)
o Performance Best ways to care for mouth at home, oral facial self exam.
o Value Why is dental care and oral health important for general health, value
of frequent, routine dental appointments. Dont want pt to disappoint.
Teaching Knowledge: 6 levels Blooms Taxonomy
o Knowledge Do you understand? We focus on this stage. Remember, patient
should only be told what they N2K Need to know. Can they understand it?
Are they literate? Use illustrations when possible. Demonstrate for the
patient, show how they should evaluate. Model the change you want to see in
your own life, and reinforce you are part of the team: We can do this
together. Make health the easy choice = See how change can be easy in a
patients life.
o Comprehension
o Application Can you apply this in a new situation?
o Analysis Does it work?
o Synthesis New solution
o Evaluation Was this solution helpful?
Motivating Patients
o Why People Change: Maslows Needs & Drives (personal needs)
o How People Change: Health Belief Model & Social Cognitive Theory
o When People Change: Trans-theoretical Theory
Maslows 5 Needs & Drives (Pyramid 1 at bottom)
o 1. Physical Safety Pain, time lost, hunger = bad
o 2. Social Safety & Security
o 3. Love & Relationships (Social Belonging = esthetics)
o 4. Self Esteem Do the right thing You are worth it
o 5. Self Actualization
Health Belief Model
o People change based on beliefs about risks and rewards in 5 areas:
Perceived Susceptibility
Perceived Severity
Perceived Benefits
Perceived Barriers
Self Efficacy
Social Cognitive Theory
o Reciprocal Determinism
 Personal Factors Social Influences Behavior Personal
Factors
Role Modeling as Learning Strategy
Stages of Change: Transtheoretical Model
o Six Predictable Changes in a Spiral Pattern
Precontemplation - lack of awareness that life can be improved by a
change in behavior.
Contemplation - recognition of the problem, initial consideration of
behavior change, and information gathering about possible solutions
and actions.
Preparation - introspection about the decision, reaffirmation of the
need and desire to change behavior, and completion of final pre-action
steps
ACTION - implementation of the practices needed for successful
behavior change (e.g. exercise class attendance).
Maintenance - consolidation of the behaviors initiated during the
action stage.
Termination - former problem behaviors are no longer perceived as
desirable (e.g. skipping a run results in frustration rather than
pleasure).
Relapse = Natural with change, but should get back on track.
Motivational Interviewing
Show empathy, collaborate, resolve ambivalence, emphasize choice, evaluate
their environment, etc.

Extra

Oral Health Risk

o 1. Medical History
o 2. Orofacial Exam
o 3. Dietary Evaluation
6-11 starch, 3-5 vegetables, 2-4 fruit, 2-3 dairy, 2-3 meat
Vitamin deficiency (particularly B12 in vegetarians, causes tongue
swelling)

Intro to Clinic (Lecture 1)

1) Why take a medical history? Convenience, generic pt info, legal implications
(writing is admissible, spoken dialogue isnt), documentation for reimbursement, to
help diagnose.
2) Art of medical history taking: Focused on problems with health, broad overview,
looks at past and future health, affects diagnosis and treatment, reveals
contraindications.
 3) 8 Components: chief complaint, HPI (hx present illness), past medical hx (surgeries,
disease, hospitalization), past dental hx, ROS = review of systems, Rx history, family
hx (genetics/risk), social hx (tobacco, substance, lifestyle).
4) What is required to take a good medical history? Know the patient, know your
anatomy, know your physiology, have a good pt-doctor interaction, understand their
complaint. This will take time and practice. Make a note if a pt is a poor historian.
5) What can a good medical history do? Give you differential diagnosis before the
exam, guide you towards specific testing, save you time in exam, hint if chief
complaint is really dental related is it more systemic?
6) Standard forms Saved in our Dentrix program. Dentrix is common in private
practive.
7) Ex 1: 47 y/o male with aplastic anemia, presents with upper right tooth trouble.
Reveals in history is transfusion dependant and has had infectious complications.
Currently on 25 medications. Labs suggest no megakaryotes found in the differential
count. Physical exam notes several hemorrhagic lesions in the mouth. Thus, although
the physical exam also reveals dental decay in the first molar you cant extract.
8) Ex 2: 58 y/o female presents with palatal burning. HPI includes hypertension and
diabetes II with high HgbA1c level in labs. Note redness on palate around partial
denture. This pt should be checked for xerostomia using the appropriate index (11
questions).
9) Review of systems vocab: Symptoms are pt reported and subjective (pain). Sign is
observed by the clinician and objective (swelling). Diseases have both and dental
emergencies have both. The ROS focuses on symptoms.
10) Review of systems: structured by organ system, patient centered. Choose most
pertinent symptoms per system. Driven by common diseases per system. For
example, for HENT the pt would report dizziness, blurry vision, headache, etc.
11) The ROS does not offer a diagnosis. For example, could you tell apart IBS from
Crohns Disease pertaining to GI tract health? What about diabetes from an adrenal
disorder or thyroid problem?
12) Examples: Toothache and sores HEENT and respiratory ROS very important.

Dental Sealants
1) What is reduction in caries? 70-100%
2) Retained 52% over 15 years.
3) Current utilization (2005) = 32% of children.
4) Beauchamp 2008 study, Grade I (strongest) evidence = place on healthy, non-cavitated
surfaces of kids/adults with high caries risk. Grade III weak evidence = place on primary
dentition. Griffin 2008 study, sealants can create anaerobic environment and kill exisit S.
Mutans in site of sealant.

Perio Disease Intro

1) Silent Disease, disease of the unseen root, cementum, and PDL.
2) Different types of epithelium: mucosa, mucoginigival jxn, gingiva. Probe sulci for pocket
depth, healthy is 0.5-3mm. However, bleeding is much more important indicator there
should be no bleeding or pain!!
3) Radiograph: Small ligamental space, sockets intact, bone well trabeculated.
 4) Gingivitis is just inflammation, no involvement of bone or PDL yet. Pts usually deny, no
pain or other markers. Perhaps papillae are blunted.
5) When does it become perio disease? Bone involvement, tartar/calculus needs
debridement, furcation involvement.
6) Aggressive perio disease: rapid bone loss, teeth will be lost. Tissue regen not possible.
7) Five categories for insurance purposes, I-V. V= aggressive
8) What are the risk factors? More common in men, the elderly, Mexican Americans, and
the poor. 47% of total population??
9) Study between 30 and 80 year olds, 70% chance you will have PD by higher age (60+).
10) What type is most common? Moderate PD
11) Link to diabetes? Perio disease is a complication of diabetes. Conversely, better pocket
health can help control A1c levels and blood glucose.
12) How does diabetes affect perio? Change in macrophages, vascular flow, collagen
metabolism (gums), and salivary content.
13) Complications with diabetic patients: increased gingivitis and perio disease, thrush (yeast
infection), xerostomia, enlarged parotid gland. Also, medications dry mouth out seek
sugary treats. Tongue and mouth burning.
14) Link to cardiovascular health? Perio bacteria found in plaques? C Reactive protein levels
generally higher.
15) Respiratory problems? Direct aspiration, pneumonia, COPD link.
16) Link to pre-term delivery? Can prostaglandins and CRP from infections cause early
contractions? Poor association but worth a mention.

Ethics
1) Definition: Principles and morals that guide the behavior of a group or individual
2) Answers: what should we do and why?
3) Legal standards are the bare minimum of ethical practices. As far as the state boards go
one should not get DUIs, be involved with drugs, or run into financial problems with the
IRS.
4) Principalism theory: Autonomy, pt has the right to choose their care they are in control
of their body. Veracity: Tell truth, explain, document. Do not exclude important info. Do
not fail to document or explain to pt anything. Writing is your legal record. Beneficence:
Do good, do no harm. Do not every work when too impaired from illness, make sure you
know procedures, refer when necessary. Justice: Be fair, as different pts will have
different backgrounds, insurance, etc. Do not turn away or abandon patients.
5) Casuitry: Case-Based decision making. Return to decision later.

Risk Assessment: Who is most at risk for caries?

1) How to measure? DMFS = Decayed, missing, filled / total surfaces (128).
2) From 1988-92, and 99-02 decay is on the rise in total surfaces decayed. Males, Mexican
americans, and age 6-11 at higher risk. (Decay before first premolars at age 12)
3) Huge increase in decayed surfaces from age 2-11 to age 12-15. Although rate overall
went down, and now girls more at risk.
4) In adults, see that rates of decay have gone down in recent time. Also, see Caucasians and
females more at risk. Smokers and people with less than high school education have more
decay.
 5) Root caries, a marker of additional decay: More prevalent in the aged, males, those below
poverty level, smokers, and the uneducated.
6) Edentulism = follows same trends.
7) How many have had at least one area of decay? 2-5yrs 25%, 5-11 50%, 12-19 67%,
adults: 94%. Almost double (44% vs 23%) in the poor.
8) Caries imbalance, what contributes: Disease indicators (CAMBRA) and Risk Factors
(gender, age, poverty, race).
9) CAMBRA clinical guidelines: Determine radiograph frequency, recall rate, saliva test,
etc.
10) Remember: Grade I evidence for pit and fissure sealants on adults and children!
11) Flouride: Low intake is moderate or high risk for caries already. Strongly recommended
for all except under age 6. Ages 6-18 varnish or gel recommended for moderate or high
risk patients.

LECTURE NOTES:
 Health Promotions

Introduction to Cariology:
How best to promote oral health:

Sealants

Anti-microbial products/Fluoride

Dental Visits

Brush/Floss

Eat less candy

3 major dental diseases (all treatable if detected early):

Dental decay (the most common childhood disease)-infectious, transmissible

-ECC applies to kids who get decay before 2 years

white spots=demineralized enamel

most commonly front teeth

The 1st molar is most prone to decay

CEJ is prone to decay

Oral Health linked to systemic health:

Diabetes:Periodontaldiseaseisacomplicationofdiabetesandinterfereswith[blood
sugar]
HIV: 1st signs present in the mouth; shows compromised immune response

Respiratory: oral bacteria translocates to the lungs to lead to pneumonia

Cardiovascular:oralbacteriatracedtoplaquesinBVaroundheart;inflammationlink
Low birth weight: women with perio disease have children with low birth
weights

Obesity: childhood obesity linked with dental decay

Introduction to Cariology II:
5 areas of initiation, progression, and prevention interact:

Plaque biofilm

Tooth structure

Saliva

Host response

Nutrition

Theories of Caries:

Wormslikemaggots.VanLeeuwenhoeksawwormsinmicroscopesbuttheywere
reallyelongatedbacteria
Humortheorydecayinthemouth.Illwillspiritscausingcaries.Inhaleherbsoverfire
toridhumors.
Vitaltheorysignsofillnessshowninteeth.
Chemicaltheoryacidicattacks.

Moderndefinition:Cariesisabacterialinfection.Localizeddestructionoftoothbyhigh
concentrationsoforganicacidsproducedbybacteriafromdietarycarbohydrates.
Miller(ChemoparasiticTheory)/Featherstone&Silverstone:decayoccurswhen
demineralizationoccursmorerapidlythanremineralization.Firstthe
enamel/dentinisbrokendown.Thendemineralizationcontinuesbytheacid
producedbythemetabolismofdietarycarbohydratesoftheoralbacteria.

BiologicalBattle:Alwayswantremineralizationtowin.Demineralizationoccursatthebottom.
Besureyoucanremineralizebothareas.Lotsofremineralizationatthesurfacebecause
thefluoridegetshere.

StagesofCaries:Clincally,youneverknowhowfardecayhasprogressed.
Incipient:earlycaries,withintheenamel.Abletoremineralize.Doesnotneedtobe
repaired.
Frank,Cavitated:reversetrianglespreadsatDEJ.Restore.Dentaldecaywillcontinueto
progresstothepulpchamber.
Toothissemipermeablemembrane.Youwantfluoridetogoinbutnottheacid,orit
willdemineralize.
***Sugar+Bacteria=Acid.AcidonTooth=Decay.Decaybeginsinsidethetoothand
breaksopentothesurface.***
OcclusalCaries:
Darkening,buttoothintact
Mustlookatradiograph!BIGcavity,butyouwouldntknowitwithoutXray.

SmoothSurfaceCaries:
Lossofproximaltoothsurface,aswellasdamagedrootareas.
Methmouthdryoutsalivaandinduceimmuneproblems

TypesofCaries:
IncipientenameldemineralizationbutNOcavitation.Clinicallyappearsaswhitespot.
Donotrepeair
Arrestedincipientoradvancedlesionthathasstoppedorremineralized.Brown
pigmentedarea.Doesntneedtobefixed.
Activemoredemineralizationthanremineralizationatthepresenttime.Clinically
appearsasyelloworange(chronic)ordentincolored(acute).
Recurrentlesionattheinterfaceofarestoration.
Residualcariesthatwasleftaftercavityprep.
Rampantsuddenrapiddestruction.10+inoneyear.
Ifonepersoninthefamilyhasacavity,thewholefamilyisatriskbecauseofkissing,
sharingdrinks,etc.

Whatcanitleadto?
Infection
Septsis
Death

CariesCircles:
HOSTpersonsimmuneresponse
Enamelisnaturallyroughandporousacid/bacteriacanenter.98%inorganic.
Demineralizationbeginsintheorganicinterprismaticspaces.
Enameldemineralizationfollowstherods
InitialdentindemineralizationdoesntspreadalongtheDEJbeyondtheperiphery
oftheenamellesionbutthenwillnarrowdowntopulpchamber.
Streaks/trailsalongdentinisactivedecay.
Cariousdentin:
Outerinfectedbacterialinfection;unremineralizabeth;dead;without
sensation
Inneraffectedminimalbacterialinvasion;remineralizable;alive;
sensitive(painsensation)
Occurance:
HighSusceptibility:Mand/MaxMolarsbcdeepgrooves
Intermediate:Premolars,Maxincisors
Low:Canines,Mandibularincisors
 *Mandibularteethdecaymorethanmaxillary
*Pit/fissureisthemostcommon
Genetics:Teethvaryinmineralizationbutnotenoughvariationininorganic
tooth.Itstheexternalfactorslikesalivaamountthatmaybeafactor.
Saliva:importantforlubrication(speech)andflushingofthemouth.Dilutionand
chemicalbufferingofacid.Antimicrobialfunctions(mucinsaggregate
bacteria;lactoferrinsinhibits.mutansadherenceanddeprivebacteriaof
iron;proxidaseinhibitsabilitytouseglucose.)Providecalciumand
phosphateforremineralization.Salivabelowph7=dentaldecay.The
moresalivathebetterbecauseitclumpsbacteriasoyoucanswallowit,
insteadofhavingfreebacteriatoadheretothepellicle.
MedscauseXerostomia:Anticholinergicpropertiesreducesalivaqualityand
quantity.Inhaledmedsretainedinlungs,increasesyeastinmouth.Brush
teethaftermedsbecausemayhavesugaradded.
Radiationkillssalivaryglands!!!
Bulimia:usesodiumbicarbonaterinsetoneutralizesaliva,thenwaita1/2hourto
brush.Erosiononlingualanteriors.
AGENTplaquebiofilm
Pelliclenaturallydepositedonteethbysalivaallthetime;protectsteethfrom
erosion(ofphosphoricacid);however,itformsagoodmediumforthe
bacteriatoadhereto.Startofplaquebiofilm.
Cocciarethefirstbacteriatocome(Streptococciaretheyoung,aerobic,gram+
plaqueresponsiblyfordentalcaries!)Biofilmforms(nowolderplaque
presentareGRodsandspirillaanaerobicsowillproduceperiodisease),
buteasilyremovedbymechanicalforce.
Mostcommon1stbacteriatoarrive:s.mutans.
Rootcaries:A.viscosus.
Periodiseasebeginsinthesulcus(bwgum&tooth)bchardtoclean
4waysbacteriaadheretothepellicle:
Surfaceappendages:bacterialfimbraeattachingtoadhesions.Strep
Mutans!!!!
Extracellularpolysaccharides
Calciumbridging:easyforbacteriatogoovertopCa2+toadhere
Hydrophobicinteractions
Mustcombinerestorationwithpreventativecare.
Decayprocessbeginsw/i20minutes
ENVIRONMENTdietaryfermentablecarbohydrates
Relativecariogenicityoffoods(acidiccontentsandabilitytoformacidwith
bacteria)
Sucrosecontentandform(stickycandy,breathmind,soda,raisins,bananas)
Maltose(cookedstarch/sugar,breakfastcereal,pancakes,donuts,potatochips,
breads)
Timeofinjestion(eatenwithmealorsnacking)
Frequencyandduration
 Eatcarbsanddropstoph5.5for20minuteswhereyoucanpromotedecay
Themoresugaryouhavedoesntmatterbcyourebelow5.5already.
Artificialsweetnersdontgetbelow5.5
AvoidsnackingtoavoiddipsinpH.
Xylitolisanticaries!Preventative!

RiskAssessmentforDentalDiseases
Risk=probabilitythatsomethingharmfulwillhappen.Pastdiseasesinthemouthareagood
predictoroffuturediseases.

ApproachforRisk/RiskReduction
Identifypatternsofpast/currentdiseaseetiology
Identifyfactorsthatcorrelatewiththedisease
Controlandreduceriskthroughcustomizedintervention:patientschoicesareabig
variable.Individualcare.

HealthPromotionTreatmentPlan:multiplecomponents.
Specificquestionstoaddresspatientsperceptionofprevention.Beginwith
questionnaire.Openendedquestionswillgiveyouthemostinformation.
Combinewithoralexamination
Review/evaluatepatientspreviousrecords

Analyzing Risk:

History of previous disease-obtain medical records

Presenceofcurrentdisease(patientsperception/dentalexamination,radiographs,chart)
ASKapatienttheirhistory,buttakeitwithagrainofsalt.Clincialexams/xrays
canseestuff/historyinpermanentdentitionbutnotinmucosaltissue
Oralhygieneandlevelofbiofilmonteeth(patientsreportofhomecareactivities/dental
examination)

DentalCaries:Etiology
*Whenyoulookatrisksfordisease,youneedtolookatthecauses
Toothage,fluorides,morphology,nutrition,carbonatelevel
Substrateoralclearance/hygiene,salivarystimulants,snaking,carbs
Florastrepmutans,oralhygiene,fluorideinplaque

EvaluatingTeeth:
Occlusalsurfacesaremostatrisksometimesgroovesaremorenarrowthantoothbrush
bristle
Mandibular1stmolaristhemostcavityprone
 Diseaseinprimaryteethmeansprobablediseaseinpermanentteeth
~DentalSealants:forcariespreventionearlyon;resinsapplied

DentalSealants:
#1preventativestrategyagainstentaldecay
70%cariesreduction
100%cariesreductionifsealantisretained(degradesquickly)
Currentsealantutilization:32%.Thishasincreased;howeverkidswiththe
highestincomehavethemostsealants.Povertystatus/race/ethnicityhas
aneffectontheliklihoodofhavingsealants
Someonewithoutsealantsisatmoderateriskfordecaybecausetheyhaveopen
occlusalgrooves!

EvaluatingHostRisk:
Priorcarieshistory(age,frequency,location)
Currentdecay(amount,location)
Currentsusceptiblepitandfissures
Absenceofdentalsealants
Salivaevaluation:
Xerostomiaordecreasedsalivaryoutput
Medicationsthatinducedrymouth?
Needtodrinkwatertoswallow?(Lowsalivameanslesslubrication)
Noticeadry/uncomfortabletasteinyourmouth?
*Lesssaliva=moderatetohighriskfordecay!*
Prescribe:artificialsaliva,mouthrinses(todecreasebacteriasocanmaintainoral
healthwithlesssaliva),sugarlessgum/mints,drinkexcesswater
Lackofconsistentfluoridetherapy:
Drinkingwaterorsupplementaltablets
Toothpaste
Mouthrinsesorgels
Professionaldentaltreatments
*Lessfluoride=moderatetohighriskfordentaldecay*
Prescribe:multiplesourcesoffluoridebasedonrisk

EvaluatingEnvironmentalComponent:
NutritionalCounseling
Frequencyofeating/snaking
Retentivesugarsmorecariogenic:raisins,fruitrollups,granolabar
Bemindfulofhiddensugarsandacids(applejuice,milkformula,sweetened
coffeeandsoda)
DietCounseling:identifyandreduceacidexposuresthroughouttheday
Whatareyoudrinking?!Oftenoverlooked,butcanhavealargeeffect
Controlthesubstrate:reducesugarexposuresduringtheday;limitsnakingandsugar
intaketomealtime;increasesalivatobufferacidviachewingsugarlessgum
(xylitolandsorbitol)andartificialsaliva;potentialacidbuffermouthrinses
researchpromisingbutinconclusive

Controlbacteriatopreventdecay:s.mutansisinfectionsandtransmissible!
Mecanical:
Toothbrush:brush2xaday.Anglebristlesintothegumline.Gently
wigglebrushagainstthetooth.Dontforgetthetongue!
Floss:usedaily.Stretchbetweenfingers.Glidebetweenteeth.Slide
undergums.Scrapeflossagainstsideofeachtooth.
Chemical:
Antisepticmouthrinses:0.12%chlorhexidine(onlyonewithresearchto
decreasedecay),Listerine
Vaccine:v.s.mutans
XylitolRinses,chewinggum,othersugarlessgum
Topicalozonetherapy
Limitationsinbacterialcontrol:difficulttoremovefromocclusalgrooves;
bacteriacombinewithrefinedcarbstoformacid;Stephancurveillustrates
a20minutetimeframe;microenvironmentforacidformation;patient
complianceinthroughbiofilmremoval
If you have one area of decay, youre at moderate risk.

Periodontal Disease

Combinationofriskfactors:bacteria,environment(tartar,etc),host(immunuestatus,age,ability
tocleanteeth)

Healthy Periodontium

Gingiva-surrounds teeth

OralMucosatissuethatslooseandnotfirmlybound.Shouldbelightandpink
andfirmlymove.Connectstolips.
Mucogingivaljunctiontissuebetweenlooseandboundtissue.Manylesions
beginhere.
-Attached gingival firmly bound

-Marginal gingival against the tooth

-Healthy gingival sulcus: 1-3mm. This is the normal space bw

gum/tooth

Periodontal Ligament holds tooth to bone (alveolar).

 Cementum to bone.

Microbial Plaque:

Plaque: Supragingival or subgingival

Calculus (tartar): Supragingival or subgingival

Gram Negative Plaque: reside subgingivally in sulcus/pocket. Very difficult to

access and control daily by patient.

3 major periopathogens: Porphyomonas gingivalis. Bacteriocides

forsythus. AA: actinobacillus actinomycetemcomitans. These
give off exo/endotoxins to start inflammatory response and
tissue destruction.

Local environmental factors:

Eliminate pocket depth

Plaque retention

Iatrogenic restorations dental work causes problems

Occlusion if teeth dont match, it will lead to stress and then problems

Host factors:

Age

Race

Genetic factors

Prior tooth loss

Health status: diabetes, HIV, cardiovasc disease, hormonal changes,

pregnancy

Bone loss usually due to perio disease: Can be a manifestation of systemic disease.
Gingivitis=inflammation,justinthegingival.Boneremains,soshouldhavenormalprobing.
Redgums.
Periodontitis=boneinvolved.Deeperpocketdepths.Teetharentanchored.Moremobile.
Gumsarenotred.Haltinfectionsanduseplasticsurgerytoregrowtissue.

Tobacco:
50%ofadultperiocasesareattributedtosmoking
Incurrentsmokers,75%ofcasesmaybecausedbysmoking
Linkbetweenincreasedcariesandsmoking
Tobaccoasrisksfordecay,periodiseaseandoralcancer:
Wontcauseperiodiseaseinabsenceofbacteria
Routinequestionsonmedicalhistory
Specificquestionsonhealthpromotiontreatmentplan
AnytobaccousertreatedasHIGHRISKforanydentaldisease
Smokingandperiodisease:
Smokingpromotesperiodiseasebcitlowersneutrophils,acceleratesalveolar
boneloss,andincreasesplaqueandcalculusbuildup
Smokingaffectstreatmentbydelayingwoundhealingandsuppressingthe
immuneresponse
SecondHandSmoke:
Childrenexposedhave2xtherateofcariesinprimaryteeth
Nicotinepromotesthegrowthofs.mutans
Smokingparentswhokisschildrentransmitthisbacteria
Effectsofsmoking:
Badbreath
Discoloredteeth
Mouthsores
Hairytongue
Alteredsenseoftasteandsmell
Oralcancer,pharyngealcancer,andleukoplakia
Caries
Gingivalrecessionandperiodontitis
Damagetooralbonestructure

RiskofOralCancer:
Tobaccoexposure
Exposuretosunlightwithoutprotection
Alcoholconsumption
Ageoldermen
EthnicityAfricanAmericansmorecommon

RiskBasedApproachtoPreventionofDentalDiseases:
CustomizepreventativeactivitiesforpatientsbasedontheirRISKSfordisease
Pasthistoryandcurrentdiseasestatus
 Askandevaluatepatientbehaviors
Identifyriskcategories(low,medium,high)

EvidenceBasedApproachtoCariesPrevention
DentalSealants
#1Effectivenessincariesprevention(butonlyonocclusals)
70%sealanteffectivenessbcphysicallyoccludethegroovessobacteriacantgetin

Surfacesatriskfordentaldecay:
DMFS(Decayed,MissingandFilledSurfaces)=Index
16occlusalsurfaces(2premolars,3molars,butexclude3rdmolarbcvariable)
124smoothsurfaces(buccal,lingual,mesial,distal)
140totalsurfaces
Sealantsonlyworkonthe16occlusalsurfacessomustusepreventativemeasures

Fluorideasthemajorcariespreventativeagent
Worksgreatonsmoothsurfaces
Preventsdecayonsurfaces
Usedateveryage!Cariesreductionthroughoutthelifespan!
Needtherightkindoffluoride,withtherightamount,attherighttime
Topicalfluoride(onsurface):toothpaste,mouthwash,gels
SystemicFluorides:ingestandthensecretedinthesaliva,goesintohardtoothsurface
Wewanttocombinetheuseoftopicalandsystemicflurorides

FluorideMechanismofAction
1. Enhancesremineralizatoin
a. AbsorbsontocrystalsurfaceandattractsCa2+ionsfirst,thenphosphateions
becausefluorideisnegativelycharged
b. Excludescarbonatetoallowmorefluorapatite(insteadofhydroxyapatitewith
carbonate)crystalgrowth.Carbonateisnotasresistanttodemineralization,
sodemineralizationcanbegoodifyoucangetcarbonateoutsoitsreplaced
bycrystallinestructure.
c. SpeedsthegrowthofnewcrystallinesurfacebyattractionmoreCa2+/P
d. Altershydroxyapatitecrystalstofluorapatitecrystals
2. Inhibitsdemineralization
a. Fluorideinwaterphasecollectsinintercrystallinespaceandinhibitsacid
dissolutionofteeth
b. Fluorapatite(FAP)inenamelcrystallatticeismostresistantto
demineralization.WhencarbonateionislostandreplacedbyFAP,
demineralizationisinhibited.
3. InhibitBacterialMetabolism
a. Acidproducedbys.mutansconvertstopicalfluorideintoHF,hydrogen
fluorideion,whichisincorporatedincellsinbiofilm
 b. Reducesacidbyinhibitingenolase,enzymenecessaryforcarbmetabolism
c. Reducesmucopolysaccharides(whichs.mutansneedtoadhere)
d. Inhibitsglycolysis
e. Killsbacteriaandcontinuestoinhibitbacterialmetabolism

Fluoridetopreventdentalcaries:
Notrecommendedforpregnantwomentotakesupplementsbecauseitdoesntcrossthe
placenta.Besides,kidsarentbornwithpermanentteeth.
Getfluoridebyputtingitinwaterandputtingitinschools(1part/million).School
fluoridationusedasabackupwhencommunitycantbefluorinated(iftheyrely
onwells,etc.)
Fluoridemouthrinses,gels,varnishonlyreallyrecommendedforhighriskpatients.

TypesofFluoride:
TopicalFluoride:affectstoothsurfaceandsubsurfaceenamel
Remineralizesactivesubsurfacedecay
Takenupthroughenamelsurfaceandintodentin
SystemicFluoride:affectsdevelopingtoothenamelviabloodstream
Increasesfluorapatitecrystalsinthedevelopingtooth
Swallowbloodstreamaffinityforhardstructuressoeruptedteetharealready
strongerifkidshaveit.

TopicalFluorideTherapies:
1. Toothpaste(FluorideDentrifrice)
a. 0.2%SodiumFl1000ppm
b. 0.454%StannousFl1000ppm(STAINING,MATALLIC,ANTIBACT)
c. Since1000ppmintoothpaste,neverletkidsswallowit.
d. ContainsSLS=foamingagent,sotheywillvomit.
e. Gelsandwhiteningpastesaremoreabrasive,sonotforsensitiveteeth.
f. Brushfor2minutessotoothpasteisavailabletotoothandcanbeattainedin
saliva
2. FluorideHomeRinses
a. Daily250ppm
i. 0.05%Sodium
ii. 0.044%Acidulatedphosphateetchessoitcangodeeper
b. Weekly1000ppm
i. 0.2%Sodium
c. Ifyouhaveoneareaofdecayoranypriordecay,youshouldusetheserinses2x
daily
d. Uptakenquicklyandretainedinsalivafor2hours
e. Providesadditionalremineralization(espfororthopatients)
f. Ifswallowed,youllprobablythrowuptogetFout
3. FluorideHomeGels
 a. Daily5000ppm
i. 1.1%SodiumFluoride(DOESNTSTAIN)
ii. Effectiveforcariescontrolwithneutralformulation
iii. Goodwithestheticrestorationsanddrymouth
iv. Verystableandnosideeffects
v. Forpatientsatthehighestriskofdentaldecay
b. Daily1000ppm
i. 0.4%StannousFl
ii. Effectiveinrootsensitivityandcariescontrol
iii. Stainsduetotinionandcanptrestorationsduetoacidicformula
iv. Goodforpatientsofperiosurgery
v. Stannous=antibacterial.Alsoforcariesprevention
4. ProfessionalFluorideTreatments
a. Gives2030%cariesreduction(Frequencyoffluoridegetsbestresults,sohome
productsaregreat.Multiplefluorideproductscangive4050%cariesrecution)
b. 80%offluorideuptakehappensin1stminute,but4minutesrecommended
becausethatsthetimetheresearchused.
c. Foamincorporatesair,solessfluoridebutmorecoverage.
d. 1.23%AcidulatedPhosphateFluoride(12,300ppm)
i. Easilyappliedat6monthintervals
ii. Acidicformulaspeedsfluoridepenetration
iii. Acidmaypitorstainestheticrestorations(sousebeforerestoration)
iv. Difficultwithpatientswithdrymouth
v. Highdosage(dontswallow!)butatlowfrequency
e. 2.0%SodiumFluoride(9,040ppm)
i. Neutralformula,safeforallpatients
ii. Researchprotocolapplicationin2wkintervals,soresearchisonly
moderateregardingcariesprevention
iii. Betterchoiceforolderpatientsorthosewithdrymouth
f. 5.0%SodiumFluorideVarnish(20,600ppm)
i. Easytoapply,evenininfants(helpsdecreaseincidenceofhighrisk
children)
ii. Acceptedforrootsensitivity
iii. OfflabeluseduetonoUSAFDAapprovalforcariesprevention,only
desensitization
SystemFluoridation
1.WaterFluoridation
a. Singlemosteffectivepenetrationagent(morethansealants!)
b. Provencariesreductionsince1945
c. 5060%cariesreductionin1950/2530%morerecentstudies
a. Benefitsforbothchildrenandadultsbecausefluorideismaintainedandexcretedin
salivainconstantsmalldoses
d. Antifluoridationargumentsinvolvesafetyandfreedomofchoice
2.CommunityWideBenefits
a. Accesstoalldespiteeconomicstatusordentalvisits.Topicaltreatmentscanbe
expensive,butsystemicfluorideisuniversalaccess.
b. Easycompliancewithouteffort
c. Ambientfluoridefromproductsmadewithfluoridatedwater(soda,juice,spaghetti
sauce,frozenfoods)
d. Fluoridealsousedaspesticideingrapessobecarefulwhengivingchildren(white)grape
juice.

RecommendedDietaryFluorideIntake
Rightamountattherighttime
Agewedontstartuntilthechildis6monthsold
Weight
Adequateintake
Mg/PerDay
TolerableupperMg/Intakeperday
Dontstartuntilkidis6months
Mostcitiesfluorinate1ppm(Phillyis0.7ppm)

GuidelinesforFlSupplementation
Morefluorideisntbetter
6mo3years:0.25mgwhenFllessthan0.3ppm
36years:0.5mgwhenFllessthan0.3ppm(barelyanyFlinH20);
0.25mgwhenFl0.30.6ppm(someFl)
616years:1mgwhenFllessthan0.3ppm
0.5mgwhenFl0.30.6ppm

FluorideToxicity:
Certainlylethaldosepotentialforcausingdeath(510gramNaFor3264mgF/kg)
Safelytolerateddoseconsumedwithouttoxicsymptoms(1/4ofCertainlyLethalDose,
or816mgF/kg)
Canonlysupplya3mo.supplyforfamilies(bc320mgislethalforchild)

FluorideOverdoseCare
Less5.0mg/kg:giveoralcalcium(milkorlimejuice)bindsupfluoridesoitcanbe
safelyexcreted.
Morethan5.0mg/kg:emptystomachbyinducingvomiting,giveoralcalcium,
hospitalize
Morethan15.0mg/kg:hospitalize,inducevomiting,givecalciumiv,cardiacmonitoring

RiskBasedApproachtoCariesPrevention
CustomizepreventativeactivitiesforpatientbasedontheirRISKSfordentalcaries
Currentcariesstatus
Riskbehaviors:low,moderate,high
Fluorideprescriptionsbasedonrisksfordentalcaries:
Carieshistory
Toothstructurerotatedteethwherebacteriacancollect
Oralhygiene
Fluorideuse
Dentalvisits
Fluorideinterventions

LowRiskPatients:
Nocaries
Sealed/restoredteeth
Goodoralhygiene
Adequatefluoride
Regulardentalvisits
*onlyhastousefluoridetoothpaste

ModerateRiskPatientsnosealants,exposedteeth,orthotreatment
12recentcaries
Teethwithoutsealants,exposedroots,orthodonticcare
Fairoralhygiene
Fairuseoffluoride
Irregulardentalvisits
*Useoffluoridedentifrice,mouthrinse,andprofessionalTmts

HighRiskPatientsthosewithlesssaliva
23recentcaries
Susceptibleteeth
Poororalhygiene,littlesaliva
Littleornofluoride
Irregulardentalvisits
*Usefluoridedentifrice,homegels/rinses/professionaltmts

FluorideInstructions
Allpatientsshouldusefluoridetoothpaste,exceptpreschoolagedchildreninordertoreducethe
riskoffluorosis.

Allpatientsshouldreceivetopicalfluoridetherapybasedontheirriskfordentaldecay,basedon
thefollowingfactors:
Presenceofexistingcoronaland/orrootdecay
Extensivecrownandbridgerestorations
Postperiodontalcaretoreducesensitivityandpreventrootdecay
Patientswithgingivalrecessionand/orrootsensitivity
Medicationswhichproducexerostomia
Orthodonticappliances
Moderateriskpatients(presenting1factor)shouldreceive:
Professionaltopicalfluoridetreatmentsevery6months
Homefluoridetherapy,toincludefluoridedentifrice

Highriskpatients(severcase,ormorethan1factor)shouldreceive:
Professionaltopicalfluoridetreatmentsevery6months
Homefluoridetherapy,toincludefluoridedentifriceandfluorideriseorgel
Patientsreceivingradiationtherapytothehead/neckareconsideredhighriskforcoronal
androotcaries,andshouldreceiveintensiveoralhygieneinstructions,twicedaily
neutralsodiumfluoridetreatmentsappliedinatrayform,andnutritional
counselingformucositis,dysphagia,andotheroralchanges.
*Fluoridemouthrinsesandgelsarenotindicatedforpreschoolagedchildren.

ProfessionalTreatments:
1.23%acidulatedphosphatefluoride(APF12,000ppmfl)isthebestchoiceformostpatients,
andcanbeprovidedevery6monthstocoincidewithoralprophylaxisvisits.Donotuse
withextensivecrownandbridgeestheticrestorationsduetothepotentialforsurface
pittingandcementwashoutbecausethisfluorideisformulatedwithanacidicbase.

2%sodiumfluoride(9,000ppmfl)isgoodforpatientswhoneedaneutralformulationsuchas
crownandbridgepatients,orthodonticpatients,andthosewithxerostomia.

5%sodiumfluoride(20,000ppmfl)isusefulwithcrownandbridgepatientsbecausethisthick
varnishcanbepainteddirectlyondrycrownandrootsurfacesasanintensivefluoride
treatment.Fluoridevarnishworkswelltoquicklydesensitizedexposedrootsurfaces.

HomeTreatments:
0.4%Stannousfluoride(GelKam,GelTin,1,000ppmfl)reducesdentinhypersensitivityas
wellasremineralizeddecay.Stannousfluorideisgoodforpatientsafterperiodontalcare.

1.1%Sodiumfluoride(Prevident,NeutraCareat5,000ppmfl)inaneutralformulaisbestfor
patientswithcrowns,bridges,andotherestheticrestorations.Sodiumfluorideisthebest
forpatientswithreducedsalivaryflowand/ormucositisduetoitsneutralformula.

0.05%Sodiumfluoriderinses(ACT,Fluorigard,OralBanticavityrinseat250ppmfl);0.044%
Acidulatedphosphatefluoriderinses(PhosFlur,Orthocheckat250ppmfl)areused
onceaday,areeasytouse,inexpensive,andquiteeffectiveinreducingdecay.

Preventionandcontrolofdentaldiseases
MultiDimensionalApproachPreventsandPeriodontalDiseases
IdentifyRisks:Bacterial.Environmental.Host.
MicrobialPlaqueBiofilm
Individualbacteriaisnttheproblem.Itswhentheyreincolonies,whichformafter24
hoursofnobrushing.
Salivarypellicleisagoodprotectivelayerbutservesasasubstratethatbacteriacan
attachto.
Plaquebacteriabiofilmcauses:
DentalDecayfromG+,aerobes,includings.mutans,s.salivarius,s.sanguis,
lactobacillus
PeriodontalDiseasefromGram,Anerobes,includingporphyromonas,
prevotellaintermedia,bacteroidesforsythus,AA,eikenellacorrodens

Targetpatientsatriskfordentaldiseases:
Collaboratewithpatienttoidentifyandreducerisks
Providemorefrequentdentalvisitsforeducation,treatment,andpreventivecareso
moretimecanbeusedforeducation
Compliancedecreasesafter23weeks

IdentifyandIncreasePatientsEducationalLevel
Makesurepatientshavethecognitiveknowledgeandanphysicallydostuffsuchas
brushingandflossing.
Practiceteachingoralhygieneskills:watchpatientpracticeandfloss/brushandgivethem
tipsforimprovement

MechanicalOralHygiene:
Widerangeofacceptableproducts
Minimalcriteria:
Softbristles
SafeGoodManufacturingPractices(GMP)Produce.BrushesmadeinGMP
facility.
Efficacyshownewbrushisaseffectiveinremovingplaqueandpreventing
gingivitis
Equivalenceitsnotthebrush,itsthepersonthatusesitwhichmakeitgood
Superiority

ControversiesinToothbrushDesignbristlesatdifferentanglessonomatterhowthe
patientisanglingthebrush,itwillgetintogrooves/sulcus.

BrushingTechniques:
Bassplacebristlesat45degreeangleandvibrate.Getbristlesinsulcusto
breakupbacteria
ModifiedBass=Bass+RollingStroke:breakupplaqueat45degreeangleand
thensweepitdown.Gumlinebrushing.Vibrate(notbackandforth)and
vibratedown.
Stillmanplacebristlesat90degreeangleandtotallyflexandrolldown
 Chartersopposite.Placebristlesinocclusalpositionandrollup
Fonescirculararoundteeth(becausekidsdonthavethedexterityformodified
bass)

PowerBrushing
3Basictypes:
AAbatterypoweredSpinbrush,Actibrush
RechargeableBatteryBruanOralB
SonicRechargeableBatterySonicare,BraunSonic
Originallydesignedforthosewithreducedphysicalskillandcognitiveabilities
necessaryforbrushing
Removesmoreplaqueinlesstime
Reducegingivitisandbleeding
Reducestain
Provideeasiercomplianceforpatients
*Rotationoscillation(OralBBraun)mosteffectiveinreducingplaque,gingivitis,
andbleeding

InterproximalPlaqueControl
DentalFloss
Effectivecleansingwithhealthytissue
Nodifferenceinwaxed/unwaxed
Noaddedbenefitwithfluoridefloss
Toothandbonelosscreateincreasedproximalspace
Proximalbrushbrushwithonlyfewbristlestocleansebwteeth
Toothpick
PerioAid
Stimudent

Chemotherapeuticagentsplaqueisfirmlyattachedtothesalivarypelliclesomustuse
mechanicalmotion,butthesechemicaladjuntsworkwellespeciallyforpeoplewith
periodontaldisease
0.12%Chlorhexidineadherestocellandlysessocellcontentsspillout
Completemicrobialkillin30secondswitha15mlrinsetwiceaday
ControlsgingivitisandCandida
Disruptscellwall
Substantivefor12hours
12%alcoholconcernforalcoholics
Brownstainsbcdoesntremovebacteria,itjustkillsthemsocellcontentsstill
onsalivarypellicle
Badtaste!Reducestaste.
InteractswithSLSintoothpasteDONOTuseincombination,orCHXwillbe
inactive.Waitatleast30minutesBrushpriortousesoyoudecreasestain
byremovingplaque.
 Researchshowsthiskillss.mutansanddecreasescaries
Becauseofsideeffects,lowpatientcompliance
Usedforthosepostsurgical,afterimplants,injury,orimmunecompromised
and/oryeastinfections

EssentialOilMouthRinseandToothpaste
ListerineMouthrinseandothergenericproducts
Thymol,Methol,EucalyptusOildisruptcellfunction
2128%alcoholconcentration
Usea20mlrinsefullstrengthfor30seconds,twicedaily
Useforthoseatriskforperiodontaldisease
Essentialoilsareonlyactiveinanalcoholbase
Doesntlysethecellwall:itdisruptsthecellfunction/metabolism
Listerineiseffectiveinplaquereductionandgingivitisreduction.Doesnothavetooth
stainingbecausecellwallisnotretained.
*Essentialoilsarewhatmakesthedifference!(Waterdoesnothingtobacteria.Alcohol
alonedecreasessomebacteria.Oilsgreatlydecreasebacteria.)

ComparativeEfficacyofListerineandFlossing
MoreplaquedecreasewithListerineoverflossing.Peopleatriskshouldusethiswith
floss.

0.07%CetylpyridiumChloride(CPC)CrestProHealth
Alcoholfreerinsemakesantiplaque,antigingivitisclaims
Atleastasgoodasessentialoilsinreducingplaque,gingivitis,andbleeding
Notalotofresearchyet.
99%bacterialkillinvitro
Plaquereductiononallsurfaces:CPC(25%)EssentialOils(39%)
Plaquereductiononnonbrushedsurfaces:CPC(30%)Oils(28%)

0.454%SnF2CrestProHealthToothpaste
Stannousioninfluoridestabilizedwithsodiumhexametaphophatesoitskeptactive
Plaquereductionsrangefrom222.7%
Gingivitisreductionsrangefrom1822%
Dentinhypersensitivityreductions24%

0.3%Triclosan
Formulatedintoothpaste(ColgateTotal)thatisacceptedforantiplaque,antigingivitis,
anticariesandtartarcontrolclaims
Antibacterialeffectsin44studies:
24%lessplaquebiofilm,57%lessgingivitis,14%cariesreduction
Antiinflammatoryeffects:itreducesmarkersofinflammation(PGE2,IL1beta,TNF
alpha,Creactiveprotein)somayincreasetotalbodyhealth
PVM/MACopolymerensuresstabilityand12hoursubstantivity
 ZincChloridereducesdentinhypersensitivityandalsoreducescalculusbybindingtothe
plaquesoitdoesntbindtothetooth
Reducesdecayduetosodiumfluorideanticaries
ComparingOilsandTriclosan:rinsewillalwayswinwithplaqueindex

Tartarcontrolproducts:
Notantibacteriabutdecreasesnewcalculusformation
Cosmetic,nottherapeutic
Pyrophosphatesbindstobactinsalivasothatitdoesntbindtothetooth
Zincchloride
Doesntremoveexistingcalculus
YouneedCa2+/calculustocoattherootsobecarefulabouttoomuchphyrophosphates

Helpingpatientstopreventperiodiseasesandcaries:
Identifyriskfactors
Designprogrambasedonneeds
Involve,educate,andmotivate

LinkingNutritionandClinicalPractice
Whatroledoesnutritionplayinpromotingoralhealthandgeneralhealth:
Foodpyramid
Cariogenicityoffood
Dietaryassessment
Systemicdiseases
Oralhealthriskassessments
Nutritionalscreening

Mustconsidertheiroverallhealth:
Environmental:accessv.barriers,communication,program/policies,sociostatus
Individual:perceptions,behaviors,characteristics
Theseleadto:HealthStatus!(Bothoralandgeneral)

Whatyoushoulddotoappropriatelytreatyourpatients:
RiskassessmentconsultmedicalhistoryANDsocialhistory.Completemedicalhistory,
orofacialexamination,anddietaryevaluation.
NutritionalscreeninganutritionalevaluationisnecessaryonALLpatients!
Goalistoeliminatediseaseandrestoreoralfunction.Considerwithtreatmentoptionthe
patientsdesiresandexpectations,abilitytomaintainoralhygiene,andnutrition

TreatmentGoal:Riskassessmentandriskmanagement
IDENTIFYpatientsathighnutritionalriskforgeneralandoralhealthpromotion
EffectivelyEDUCATEandcounselaboutpropernutrition
MakeappropriateREFERRALSasneeded
Determineyournutritionalhealthchecklist:
Disease
Eatingpoorly
Toothloss/mouthpain
Economichardshipnomoney,cantbuyfood!
Reducedsocialcontactdontcareaboutyourselfsowonttakecareofteeth.
Socialisolationmayleadtodepression.Mayover/undereat.Getsocial
backgroundonpatient!
MultiplemedicinesdrymouthMEDCONSULT
Involuntaryweightloss/gainsignofotherchronicdiseases:MEDCONSULT
Needsassistanceinselfcareneedhelpeating.Nursinghome.Educatecarer.
Elderyearsabove80

Rationalforadequatenutrition:
Needsufficientfoodintakeformetabolicrequirementsforenergyandnutrientsthat
cannotbesynthesizedinthebody.

3mainguidelines:
Balancetogetallofouressentialnutrients
Moderationknowwhenenoughisenough
Variation
7guidelinesforahealthfuldiet:
Varietyoffoods
Physicalactivity
Dietlowinfag,saturatedfat,andcholesterol
Moderatesugars
Moderateinsaltandsodium
Plentyofgrains,vegetables,andfruits
Alcoholinmoderation

Nutritionallinktooralandgeneralhealthpromotion:
Healthypeople2010objectivesnutritionplaysaroleinfitness,overallharmony,oral
health,wellbeing,maternalandinfanthealth(badmomdietleadstolower
birthweight),mentalhealth,diabetes(plaquebacteriainperiodiseasemakesit
hardertocontroldiabetesandglycemicindex),heartdisease(linksofperio
diseaseandheartproblems),stroke,cancer.
Oralsurgeongeneralsreport
Systemicdiseaseslinkedtonutrition
Athersclerosis:riskfactors:hypertension,highbp.Diet:muchNa+,saturatedfat.
ChronicObstructivePulmonaryDiseasehighenergyrequirementstobreath,
impairedfoodintake(medssideeffects,anorexia,chronicinfections),
Impairedimmunefunction(increasesriskofinfection).
 DiabetesMellitus:DietControl(weightreduction):varietyoffoods,reducefat,
moderation.Improveglucosemetabolismandhomestasis.
Osteoporosis:Bonehomeostasis:calcium,VitDandC,protein,F,fiber.Boneva
meansriskformandibularnecrosis.Getmedicalconsult!
Cariogenicityoffood4factorsrelatetodentalcaries:
Plaquebaceteria
Fermentablecarbslowerbelowph5.5,whichisthecriticalpHwhichcauses
demineralization(breakdownofenameloftooth)
Salivacompositionandamountantibacterialagents.Decreasingsaliva
increasestheriskforcaries.
Susceptibilityoftoothsurface
Aftereating,acidproductionbeginsimmediately
12hoursuntilreturnofnormalpH6.27
EatcompletelyataSINGLEexposure

AdequateNutritionisEssential:
Growth
Development
Maintenanceoforaltissues

EvaluateNutritionalStatusIssues:
Oral,functional,psychosocial,economicfactors
Understandingofrelationships
Affecttreatmentdecisionsandsuccessoftreatment
*NutritionalevaluationofALLpatients!

Bottomlinepointstoremember:
Adequatedailyfoodintakeofvitaminsandmineralsarenecessaryfororalandgeneral
health
DietaryscreeningshouldbeincorporatedinthecomprehensiveassessmentofALL
patients
Appropriatecounselingandreferralsshouldbemadeifdietaryproblemsarenoted

Factorscontributingtothenutritionalproblemsandlifeofelderly:
Functional
Oral
Economic
Psychosocial

TeachingandMotivatingPatientstoChangeTheirBehaviors
Educationalpartnership:dentistsandpatients/teachersandlearners
WorkWITHthepatient,notONthepatient
5componentsintodayslecture:
Teachingfactsandinformation
 Skillstrainingthroughcoaching
Communicatingvaluesandattitudes
Helpingpatientschangetheirbehaviorsoftenneedassistance
Reinforcingadherencetonewbehaviors
Notjustteaching,butmotivatingiscrucial!

Whatdodentistsneedtoteachtheirpatients:
Knowledge
Preventativehomecare,causesofdentaldisease,rationalfordentalcare
Performance
Bestwaystocareformouthathome,oralfacialselfexam(Patientsshouldbe
awareofchanges.Teachthemnow.)Askthemtoshowyouhowtheydoit.
Value
Whyisdentalcareandoralhealthimportantforgeneralhealth.Valueof
frequent,routinedentalappointments.Makesurepatientunderstandsthevalueof
adentalvisitandthevalueyouprovide.

Teachingknowledge:6LevelsofBloomsTaxonomy
Knowledgefacts(whatcausescaries)
Comprehensiondoyouunderstand?Importanceoffacts?
Application(biofilmiscausingmycaries)
AnalysisIfIgotoadentist,Icanpreventperiodiseases
SynthesisHowcanIbestavoiddiseases?
EvaluationStructureandevaluatelesson.

FocusingonKnowledge:
ContentareandpatientspecificNEEDTOKNOW
Buildingonwhatthepatientknowsandcanunderstandaskthemwhattheyalready
know,thisindicateswhattheycanunderstand.
Evaluateliteracyandcomprehensionlevels
SmallstepsinsequenceDontoverwhelmthem!Focusonthecriticalparts.Small
stepsincreasestheprobabilityofcompliance
Talkcombinedwithillustrationpicturesareworth1000words;showwhatperiodisease
lookslike

CoachingandSkillTraining:
Clearunderstandingofobjective/rationale
Specificdemonstrationwithappropriateproducts.Dontjusttellthemthefacts:coach.
Practicewithcoachingtips
Continuedpracticeandevaluation
Periodicreinforcementat36monthsyoudecreasenewhabits.Reinforcebehaviorsof
goodoralcare(properbrushing)andencouragefrequentcheckups.

CommunicatingValues
 Arrangethephysicalenvironment:makesurechairisinanuprightpositionfor
communicationandteaching.Sitinfrontofthepatient.
Settheculturalnormdressnicely,cleanenvironment.Makethenormbethatteethare
importantandyoushouldtakecareofthem!
Modelthechangeyouwanttosee
Establisharelationshipsotheywanttocomeback
MakeHealththeEasyChoiceherearetheproductsandwhenyourunout,heres
whereyoucangetthem.Haveearlyandlateappointmentsavailableforthose
thatwork.

MotivatingPatients
WhatpeoplechangeMaslowsNeedsandDrives
HowpeoplechangeHealthbeliefmodel/Socialcognitivetheory
Whenpeoplechangetranstheoreticaltheory

WHAT:
Maslows5NeedsandDrives:
1. Physicalsafetymustbefreeofpaintobeatthenextlevel.
2. Socialsafetyandsecurityfeelsecurewithfriends.
3. Loveandrelationshipsdrivesethetics
4. Selfesteemneedtofeelimportant;goodrolemodel
5. Selfactualizationdrivenbecauseyouwanttobethebestyoucanbe.
Mustovercomethebottomleveltogettothenext.

HOW:
HealthBeliefModelusedtohelppatientsonhowtheycanchange.Interviewandlisten.
Peoplechangebasedonbeliefsaboutrisksandrewardsin5areas:
1. PerceivedsusceptibilityamIreallysusceptible?
2. Perceivedseveritydentalproblemsarentlookedatassevere.
3. Perceivedbenefitsdopatientsthinkitwillreallymakeadifference?
4. Perceivedbarrierswhatpreventspatientsfromdoingthis?Busy,cost,friends.
5. SelfefficacyDotheyfeeltheycanchangeanddoit?Empowerspatients.

SocialCognitiveTheory:
ReciprocalDeterminism=multiplefactorsacttogetherwhetheryouwillchangeornot
PersonalFactorsSocialInfluence(*biggestfactoronwhetherpeoplewillchange)
Behavior(lookatbehaviorsyouremodeling.Rolemodelsandpeerpressurehaveabig
influenceonbehavior)PersonalFactors

RoleModelingasalearningstrategyhelpspatientsfindgoodrolemodelsandsocial
influences.

WHEN:
TranstheoreticalModel:Stagesofchange
Sixperceivablechangesinaspiralpattern.(PeoplecangobackandforthBUTyouonly
moveonestageatatime.):
1. Precontemplationhaventreallythoughtaboutchange;paranoidthoughtsabout
change
2. Contemplationstartthinkingaboutit
3. PreparationDONTSKIP!Alotyouhavetodotogetready.Findbesttime.
4. ACTIONactuallychange.Setaquitdate.
5. Maintenanceplanhowyouwillmaintainit.
6. Terminationstopprofessionalsupport.Notasintensive.
Trytomoveonestep.Successiswhenyougoinsmallsteps.
Peoplerelapseandthatsanotherpartofchange.GetbacktoACTION.Spiral!