Professional Documents
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PREVENTION
INTRODUCTION
DIAGNOSTIC TOOLS
♦ VISUAL
♦ TACTILE
♦ VISUAL TACTILE
♦ RADIOGRAPHS - Conventional – IOPAR & Bitewing
- Xeroradiography
- Digital – 1. Enhancement
2. Subtraction
3. Tuned Aperture Computed
Tomography (TACT)
♦ ULTRASOUND
♦ ENDOSCOPY, Videoscope
♦ DYES – Enamel & Dentin
NEWER TECHNOLOGIES:
1. Terahertz
2. Multi-photon Imaging
3. Optical coherence tomography
4. Infrared fluorescence
5. Infrared thermography
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CARIES PREVENTION
♦ Current Strategies
1. Combating microorganisms
2. Diet modification
3. Increasing tooth resistance
4. Increasing host resistance.
CONCLUSION
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INTRODUCTION
Caries diagnosis is the art or act of identifying a disease from its signs and
symptoms.
Caries process is dynamic, with demineralization and remineralization
occurring overtime such that the net balance of these events determines whether a
lesion ever progresses to the stage where it can be seen as a white spot / detected
by other means. In recent years, a dramatic decline in caries incidence and
prevalence has occurred in most industrialized countries, as a result of efficacy of
various form of fluoride. Clearly, a decrease prevalence also indicates that fewer
lesions now progress from the stage of sub surface demineralization to frank
cavitations. The changing nature of the disease process has therefore accentuated
the need for more precise detection methods. Unfortunately, because of the nature
of disease process in the past, the currently available diagnostic methods have
limitations due to which the dynamic nature of lesion is not measured.
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sharp probes have been used, visual examination with tactile instrument is still the
most commonly widely used method. Several additional detection techniques are
available for secondary caries detection and quantification. They include ECM,
light and laser induced fluorescence, fibrocoptic transillumination and ultrasonic
measurement.
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• FOTI & DIFOTI
• Quantitative Light Induced fluorescence (QLF)
f. Based on Laser Light
• Laser Auto fluorescence (Diagnodent)
• Dye enhanced Laser fluorescence (DELF)
g. Electrical current
• ECM (Electrical Conductance Measurement)
• Electrical Impedance (ACIST)
h. Ultrasound – Ultrasound caries detector
i. Ultraviolet
j. Endoscope (Endoscopic filtered fluorescence EFF)
k. Dyes – Enamel & Dentin
l. Dye penetration method
A) VISUAL METHOD
Ranking systems:
Criteria for clinical and radiography
Score Criteria
0 Sound
1 Active, surface intact
3 Active, surface discontinuity
4 Active with cavity
5 Inactive, surface intact
6 Inactive, surface discontinue
7 Inactive, cavity
8 Filled with active lesion
9 Filled with inactive lesion
10 Extracted due to caries
MACHIULSKIENE, et al (1998)
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0 No or slight change in enamel transparency after prolonged drying
1 Opacity or discoloration hardly visible on wet surface but distinct
on air drying
2 Opacity distinctly visible without air drying
3 Localized breakdown in opaque or discolored enamel and gray
discoloration of dentin
4 Cavitations in opaque/enamel exposing the dentin
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D) RADIOGRAPHIC
The purpose of the radiograph is to detect lesions that are clinically hidden
from careful visual examination.
Grade 1: Non cavitated white spot / slightly discolored caries lesion in enamel not
detected in the radiograph.
Grade 2: Some superficial cavitation in the fissure entrance, some non cavitated
mineral loss in the surface of the enamel. Surrounding the fissure / and a caries
lesion in enamel detected on the radiograph.
Grade 3: Moderate mineral loss with limited cavitation in the extreme of fissure /
lesion in the outer third of dentin, detected on radiograph.
Grade 4: Considerable mineral loss with cavitation / or lesion into the middle third
of the dentin, detected on the radiograph.
Grade 5: Advanced cavitation / or lesion into the inner thirds of dentin, detected on
radiograph.
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Disadvantages
- Overlapping of approximal contact
- Cavitation not made out
- two dimensional representation
- Cervical burnout may mimic cervical caries
- False diagnosis of lesion depth
b) Interproximal
A considerable loss of mineral content is mandatory before lesion becomes
visible on radiograph. The actual depth of lesion is always deeper than on
radiograph.
Root caries / cemental caries / senile caries
Lesions on root with ill defined saucer appearance.
Grading
Grade I – Incipient
II – Shallow, less than 0.5 mm
III – Deep
IV – Pulpally involved
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Secondary Caries
Limitations of radiographs
Difficult to diagnose between residual and secondary caries
Cannot be visualized unless it reaches an additional stage.
Other problems
- Discoloration at margins could be due to corrosion products
- Cannot differentiate between activity of lesion
- Marginal failure to be distinguished from secondary caries
XERORADIOGRAPHY
Image is recorded on aluminum plate coated with layer of selenium
particles. These particles have a uniform electrostatic charge. When x-rays are
passed on the film, this causes selective discharge of particles.
> latent image formed > converted to a positive image by a process called
“development.”
-Advantages: Edge enhancement, no dark tooth procession
-Disadvantages: The electric charge over the film may cause discomfort to the
patient, exposure time varies
DIGITAL IMAGING
A digital imaging is an image formed and represented by a image formed
and represented by a spatially distributed set of discrete sensors and pixels when
viewed from a distance the image appear continuous, but on closer inspection it
has individual pixels. Digital image is simple means where image is recorded in
non film receptors. There are 2 types.
-Direct- the direct image receptor that collects the x-ray directly e.g. RVG
-Indirect- E.g. Video camera is used for forming digital images of a radiograph.
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The advent of digital imaging has revolutionized digital imaging. The term
digital refers to the numerical format of the image content as well as its
discreteness.
-DIGITAL DETECTORS
Charged Couple Device (CCD)
Complementary metal oxide semi conductor (CMOS)
Phosphostimulable phosphorous plates
CCD was the first direct digital image receptor adapted for intra oral imaging and
was introduced the dentistry in 1987. The CCD is a solid state detector array with
metal oxide semi conductor structure, such as silicon that is coated with X-ray
sensitive phosphorous and is extremely sensitive to electromagnetic radiation
whether X-rays / visible light. These phosphorous converts incoming x-rays to
wavelength that match the peak response of silicon. The detector array consists of
either a column (Linear detector) or a chip (in which pixels are arranged in row
and columns (area detector).
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CMOS
These detectors are silicon based and are fundamentally different from
CCD’s in the way that each pixel charge is read. Each pixel as connected directly
to a transistor.
Phosphostimulable Phosphor Plate (PSP)
PSP absorb and store energy from X rays and then release this energy as
light (phosphorescence) when stimulated by light of appropriate wavelength. The
material used in Europeum doped Barium Fluorohalide. Barium in combination
with iodine, chlorine, bromine forms crystal lattice. The addition of europium
creates imperfections in this lattice. When simulated, valence electrons Europium
can absorb energy and move into conduction bond. These electron migrate to
nearby (F centers) halogen valencies in the fluorohalide lattice and become
trapped there.
When stimulated by Red Light around 600 nm, the barium fluorohalide
releases trapped electrons to the conduction band. When an electron returns to
Europium ions, energy is released in the green spectrum between 300-500 nm.
Fiber optics conduct light from PSP plate to photo multiplier tube.__ Converts
light to electrical energy (A red light filter removes the stimulating light, and the
remaining green light is detected and converted to varying voltage – digital image.
-Advantages
♦ Instant image, no dark room, Consistent image
♦ Eliminates hazards of film development
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♦ Radiation dose is decreased
♦ Capable of tele transmission
-Disadvantage
♦ Cost
♦ Life expectancy of chip
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E) DIAGNOSTIC METHODS BASED ON VISIBLE LIGHT :
Includes
a) Optical caries monitor
This comprises of light source, measuring and reference units and a
detection part. The light is transported through a fiber bundle to the tip of
hand piece. The tip is placed against the tooth surface and the reflected light
is collected by different fibers of the same tip. Disadvantage – used only for
smooth surface lesion.
b) Quantitative fiber optic transillumination : FOTI works under the
principle that since an area of carious lesion has a lowered index of light
transmission, an area of caries appears as a darkened shadow. FOTI was
initially developed for proximal caries detection.
Method -- A 150 watt halogen lamp and rheostat is used to produce a light
of variable intensity. A fiber optic probe of 0.5 mm diameter is used to
place in embrasure area. The marginal ridge is viewed from occlusal
surface.
Advantage : No hazards , lesion not diagnosed by radiographs can be
diagnosed
Disadvantage : Subject to inter and intra observer variation.
The major problem being low sensitivity.
Therefore DIFOTI was introduced. Here instead of human eye a CCD
receptor is used. The receptor with photocells converts photon energy to
electrical energy – transmitted to a video processor-converted into colour
value and displayed on video monitor. Advantage initial results indicate that
both specificity and sensitivity are high.
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to 1929, when Benedict observed that normal teeth fluoresce under
ultraviolet illumination. There is a difference in the Fluorescence of sound
and caries teeth.
Loss of Auto- Fluorescence is due to
1) Light scattered and thus the absorption per unit volume is small.
2) Light scattering in the lesion and prevents the light from reaching the
Fluorescing dentin.
3) Protenic chromophores are removed by caries process
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ULTRAVIOLET : UV light is used to increase the optical contrast between
caries region and surrounding sound teeth.
Advantage : Sensitive than visual tactile method
Disadvantage : Specificity is a problem as it cannot detect between caries lesion
and developmental defect.
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Method :
To reach the target tissue, a coupling agent namely water, glycerin is used.
A flexible probe tip is fit into wedge shaped inter proximal contours to confirm to
the shape of the tooth.
H) ENDOSCOPE :
A blue light (400-500 nm) is used to excite Fluorescence with in the tooth.
Advantage : 5-10 fold magnification
Disadvantage :
Requires meticulous drying and isolation. Takes 5-10 minutes compared to 3-5
minutes for conventional technique.
Additionally a camera can be used to store the image. The integration of camera +
endoscope is called video scope. A miniature colour video camera is mounted in a
custom made metal holder. Thus image is directly viewed on a television screen.
I) DYE-PENENTRATION METHODS :
a) For caries Enamel :
●Procion disadvantage - irreversible as dye reacts with
nitrogen and hydroxyl groups of enamel.
●Calcein : Complexes with calcium
●Fluorescent Dye : i) Brilliant blue ii) ZygtoZX - 22
b) For Caries Dentin :
●0.5% basic fuschin in propylene glycol
●1% acid red in propylene glycol
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Modified dye penetration method – Iodine penetration method for
measuring enamel porosity of incipient caries region was developed
by Balnos in 1977.
Multiphoton imaging :
Advantage :
1) Non invasive method – that measures the amount of mineral loss as a
function of fluorescence loss.
2) Low average level of laser power. Therefore lower risk of photo toxicity to
the pulp.
3) Longer incident wave length results in increased penetration.
Disadvantage :
1) The Micron assay movements required to produce serial tomographic
images over a period of 1 min or so is well beyond the capabilities of
most dentists.
2) Can collect information from caries lesion up to 500 µm
3) Currently the technique is performed only on extracted teeth and large
laser equipment required to produce such an image will take years to
develop.
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Infra-Red Thermography :
This technique has described as method of determining lesion activity
rather than a method of determining of presence or absence of disease.
Principle - thermal radiation energy travels in the form of waves. It is possible to
measure changes in thermal energy when fluid is lost from a lesion by
evaporation.
Disadvantages :
1) Not used intra orally
2) Variation will exist in temperature of mouth with respiration or fluid
evaporation from oral surfaces.
3) The source to specimen distance is unsuitable for posterior teeth.
4) There is no data that the rate of fluid loss from the lesion is directly related
to the reactivity of the lesion.
Infra-red Fluorescence :
Method : Tooth is exposed to light with the wave length between 700 and 15,000
nm. Barrio filters are used to observe any resulting Fluorescence.
Disadvantages :
1) Results are not documented.
2) May have potentially damaging effects on the pulp given the increased
penetration and decreased scattering of the longer wave length.,
3) Sources of such irradiation are difficult to acquire.
4) Detection involves the use of infra red sensitive detectors as CCDs or film.
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ophthalmology and only in recent years interest in use of OCT for dental imaging
has grown. Wave length of light 840-1310 nm depth 0.6-2 mm.
Principle : It is based on interference of light. When a light beam is split into two
and then recombine interference produces a pattern the intensity of which is
determined by the level of light in each beam. OCT uses super luminescent
diodes. (SLD) as light source. This type of source produces light with the broad
range of wave length.
Advantage :
1) Non-invasive diagnosis of secondary caries
2) Development of prototype hand pieces for intra-oral OCT
Disadvantage
1) Stain uptake will interfere with the intake.
Terahertz Imaging : Uses waves with terahertz frequency (15 µm to 1 mm) This
wavelength form a short enough to provide a reasonable resolution but long
enough to prevent a serious loss of signal due to scattering. A good overview of
this technique is provided by Arnone et. al.
Source of Terahertz radiation – In 1980 It was discovered that photoconductive
emitters of certain crystals (Zinc telluride) exposed to short pulses (<10-12)
seconds of visible infra red light would emit electromagnetic waves with the
frequency in the terahertz range.
Method : For image to be obtained , the object is placed in the path of terahertz
beam or the terahertz beam can be scanned over the surface of the object, the
image is recorded using CCD imaging.
Advantages
1) Low powers used for imaging.
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2) Use of Non-ionizing radiation.
3) No alteration of electrical charge of tissue examined.
Disadvantages :
1) low spatial resolution due to long wave length of the source.
2) Alterations in image interpretation since terahertz waves are strongly
absorb by water, a potential complication in the mouth.
CARIES PREVENTION
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Thus, it is illogical to use the term “Preventive” as strictly speaking, preventing a
disease means to eliminate it, and it is not possible to eliminate the ubiquitos physiologic
process called caries process. But it is possible to avoid it resulting I extensive de-
mineralization by controlling the outcome.
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limited access to the wide approximal surfaces of the molars and pre-
molars. Therefore supplementary plaque control methods should be
performed on these high risk surfaces.
ii) Inter dental cleaning aids : These include interdental brushes (manual and
electric) toothpick, dental floss and dental tape with or without holder.
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- Modification of plaque, bio chemistry and ecology
Classification of Agents :
I. Cationic agents
II. Anionic agents
III. Nonionic agents
IV. Other agents
V. Comination of plaque control agents
I) CATIONIC AGENTS :
These includes
ii) Bisguanides – Chlorhixedene and Alexidene
iii) Quaternary ammonium compounds - Cetyl pyridinium chloride ,
Benzethonium chloride, Domiphen bromide
iv) Hesvy metal salts – Copper, Zinc , Tin
v) Pyrimidines - Hexitindene
vi) Herbal extracts – Sanguinarine
Cationic agents are generally more potent than nonionic or ionic agents. This is
because cationic agents bind readily to the negative charged microbial surface.
They interact with gram positive and gram negative micro organisms.
Binding sites
– On gram positive microorganisms – With the free carboxyl group from
Peptidoglycans, with phosphate groups from lipoteichoic and teichoic acid
within the cell wall.
– On gram negative microorganisms – Lipopolysaccharides in cell walls.
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a) Chlorhexidene : (CH) It is the most thoroughly studied and most effective anti
plaque agent. It is often used as old standards against which the measure potency
of other agents. CH is bisguanide used with both hydrophilic and hydro phobic
properties. It was first tested intra orally by Schroeder(1969)
Mechanism of action :-
- Bacteriacidal on high concentration, causing precipitation of cell wall constituents
and contents.
- Bacteriostatic at low concentration – causing interference with normal membrane
functions.
- Inhibits enzymes that are essential for microbial contamination on tooth surface.
Eg:- Glucosyltransferase and microbial metabolism.
Superior anti-plaque agent due to – substantivity
Microbial reduction –
80 to 95% via single mouth rinse with 0.2% CH
Dosage – In mouth rinse –
- 10 ml of 0.2% - twice daily
- 15 ml of 0.12% - twice daily
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But Zn2+ is a known anti calculus agent and it can combine with sulphur containing
compounds in the pellicle to form metal sulphides.
Disadvantage : Staining due to metal sulphides.
Dosage – mouth rinses containing Cu2+ (0.25 to 5%) }10 ml solution for 1 min
Zn2+ ( 5 to 30%)
Zinc citrate 0.5% in dentifrices.
Mechanism of action
- Inhibits glycolytic enzyme.
- Inhibits adsorption of bacteria to the tooth surface and growth of existing bacteria
in plaque.
- Increase substantivity of triclosal
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ii) Inhibits specific microbial enzymes.
iii) Competes with negative charged microbes for absorption sites on tooth. Has
high affinity for tooth Ca2+
Negative effect –
SLS binds to hydroxyapatite and brings about increasing clearence of
sodium monofluoro phosphate in tooth paste thus decreasing the fluoride
effect of sodium mono fluro phosphate.
Interacts with CHx
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IV) OTHER AGENTS
a) Delmopinol : It is a surface modifying agent that belongs to the group of
compounds known as substituted amino alcohol.
Mechanism of action : Unclear but disrupts bacterial matrix formation by
interfiering with bacterial attachment.
Dosgae : 0.1 and 0.2% in mouth rinses.
Side effects : Anesthesia
V) COMBINATION OF AGENTS
Plaque is a complex aggregation of various bacterial species. It is therefore
unlikely that one single agent can be effective against the complex flora. The
combination of two or more agents may enhance the efficacy and reduce adverse effects
of chemo prophylactic agents. E.g. :
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1) Heavy metal salts + detergents (Cu2+ or Zn2+ + Sodium lauryl sulphate)
2) Triclosan combinations (Triclosan + Zn2+)
3) Fluoride + CHX(NaF (0.044% + CHX 0.05%)
4) Fluoride Combinations (Amine fluoride + Snf2)
B) FLUORIDES :
Fluorides is still the corner stone of modern non invasive dental caries
management. However the actual mechanism of fluoride action remains a subject of
debate. From earlier clinical and laboratory studies it can be concluded that the main
action of flurode is post eruptive.
Modes of Delivery :
Systemic
Topical
Systemic :
- Public water – 1-1.2 mg / L Fl-
- Fluoride tablets – 2.2 mg NaF (1 mg Fl-)
- Salt fluoridation – 90 mg / kg Fl-
- Milk fluoridarion – 0.05 mg / L Fl-
- Fluoride drops – 1 drop = 1 mg of Fl-
Topical
Self application Professional
Toothpaste Gels
Chewing gum
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Topical fluorides
Available fluoride agents include
a) Inorganic compounds
- NaF , SnF2 , Ammonium Fluoride, Titanium tetra Fluoride
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5) Fluoride chewing gums : (Fludent , Fluorette ) Each piece contains 0.25 mg of Fl-
chewed for a duration 20 min - releases 80% of fluoride.
6) Fluoridated toothpick or floss and tape
Wooden toothpick (4% NaF) used for 2 min – releases 0.15 mg of fluoride.
7) Fluoridated artificial saliva spray : Sprays of artificial saliva containing NaF to
be applied 20-30 times a day inpatients with xerostomia.
Professional Application :-
1) Aqueous Fluoride solutions : Introduced in 1940 this was the first method
professional fluoride application. Includes :-
Neutral sodium fluoride 2% (1% F)
Stannous fluoride 8% (2% F)
Acidulated phosphate fluoride (1.23% F)
2) Fluoride Gels: They are similar to those for self care but have higher
fluoride concentration.
Eg : 2% NaF (0.9% F) , 2% SnF2 (0.5F)
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fluoride slowly and can be repeatedly replenished with fluorides from
topical agents.
Intra oral slow release device can be either
Co polymer membrane
Fluoride glass device
Fissure Sealants
Low viscocity glass ionomer cements – Fuji III
RMGIC – Vetrebond
Fluorinatted resins – Helioseal F, Fissurit F
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iii) Anti GTF antibodies – That reduces colonisation and accumulation of
S.mutans. Eg : Chicken antibodies in Egg. , Mouth rinse with Egg yolk
antibodies
b) Interfering with specific molecules involved in bacterial adhesion and
congregation by :
i) Soluble analogs of receptors
ii) Soluble adhesions
iii) Use of lectins
c) Use of effective antibacterial systems by –
i) Combination products – of heavy metals + antiseptics
ii) Slow release devices – Anti microbials Eg : 25% tetracycline HCl film
strips
D) CARIES VACCINE
The concept of preventing dental caries by vaccination has existed for almost as long
as dental caries has been known as infectious disease process and considerable
progress towards this goal has been accomplished during the past decades.
ACTIVE IMMUNIZATION
A variety of new approaches to active immunization against dental caries by oral and
systemic inoculation have been introduced. These include-
-synthetic streptococcus mutans peptide.
-s.mutans antigens coupled to cholera toxin subunit.
-s.mutans genes fused to avirulent salmonella.
-liposome coated delivery systems.
PASSIVE IMMUNIZATION
- topical application of monoclonal antibodies.
- immune bovine milk and whey (mouth rinse)
- egg yolk antibody.
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-Transgenic plant antibody
A) REPLACEMENT THERAPY
It is a subtle type of antibacterial treatment in which cariogenic bacteria are super
seeded by more benign counter parts.These include—
a) Since the dominant acid formed by S.mutans is lactic acid, mutation of this
organism lacking the gene responsible for lactate dehydrogenase (LDH) were
sought and propogated. Since it is difficult to be certain that only one gene is
mutated, genetic engineering techniques have been used to produce a inactivate
form of cloned LDH gene , which was then inserted in S.Mutans. chromosome to
create a known isogene.
b) An attempt to transfer an Arginine Deminase gene responsible for base production
streptococcus sanguas into S.mutans to counteract the acidogeneic potential.
c) Transfer genes some bacteria that naturally produce enzymes such as mutanase ,
Dextranase which degrade the extra cellular sticky polymers involved in plaque
adhesion and buildup into oral bacteria such as strpeococcus gordonii.
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Eg : Polyphenols in chocolates. Protective components in Oat and pecan hulls
These include
– Ozone therapy (Heal ozone)
– PAD (Photo Activated Disinfection) : It is a photodynamic therapy wherein a
diode laser of wavelength 635 nm is used in conjugation with a die tolonium
chloride.
– Antibacterial treatment :
Uses a step wise excavation and application of anti bacterial agents to
remineralize the lesion and sterlize the cavity.
Agents used are
Calcium hydroxide
Cements with metronidazole, Ciprofloxacin , Cefalor
Glass ionomer cements with antiseptics like chlorhexidine
Copper phosphate cements
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♦ Enameloplasty
Systemic therapies Eg :
- Pilocarpine HCl i.e. 5-10 mg
- Cevimeline 30 mg
- Bromhexine , Yohimbine , Interferon α
- Essential fatty acids – linoleic acid
CONCLUSION :
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The ultimate goal of any caries detecting diagnostic tool is to improve both the
sensitivity and specificity level. If disease can be detected before cavitations occurs,
preventive therapy may avoid the need for any unnecessary operatory intervention.
This would be stepping stone towards a more conservative and minimally invasive
treatment approach.
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