DENTAL

CARIES
PREVENTION
&
MANAGEMEN
T

Presented By:-

Dr. Abhishek Gupta

PG 1st year

Cons. & Endo

INTRODUCTION
The idea that caries might be prevented by such methods has a long history, but in
the last decade has stimulated increasing interest.
The defenses of the body are of two types, non-specific and specific. In the mouth,
properties of saliva such as its buffering power, its calcium and phosphate levels,
and its lubricating and cleansing functions may be thought of as non-specific
defense mechanisms, but the term is normally reserved for antibacterial systems of
saliva such as lysozyme, lactoperoxidase, and lactoferrin which are active against
many species many of bacteria.
Management of dental caries and its consequences remains the dominant activity
of dentists.

CARIES PREVENTION
General Health
Fluoride Exposure

 Salivary Function
Diet
Sugar free chewing gums
Oral Hygiene
Caries Vaccine
Probiotics

GENERAL HEALTH
The patient's general health has a significant impact on overall caries risk. The
effectiveness of a patient's immunologic system is highly dependent on overall
health status.
Patients undergoing radiation or chemotherapy treatment have significantly
decreased immunocompetence and are at risk for increased caries. Medically
compromised patients should be examined for changes in the following: plaque
index, salivary flow, oral mucosa, gingiva, and teeth. Early signs of increased risk
include increased plaque; puffy, bleeding gingiva; dry mouth with red, glossy
mucosa; and demineralization of the teeth. Decreased saliva flow is very common
during acute and chronic systemic illnesses.
The saliva should be tested for both flow and buffering capacities when changes
are detected from an oral examination.

FLUORIDE

Goals of Fluoride (F) Administration

1) Do not harm the patient.
2) Prevent decay on intact dental surfaces.
3) Arrest active decay.
4) Remineralize decalcified tooth surfaces.

The older view of caries prevention was that FHA deposition in non-carious dental
surfaces should be maximized by systemic fluoride administration during tooth
development, and post-eruptively by topical fluoride treatments. It was believed
that increased FHA provided increased protection against caries. Although
implementation of high FHA deposition has proved beneficial, it does not afford as
much protection as bioavailable fluoride. Moreover, the high doses of F required,
systemically or topically (which often becomes systemic intake) are partly
responsible for the increasing incidence of fluorosis.
Current clinical recommendations for preventive F measures are
1. To determine total F intake per day from all sources in order to assess over or
under F exposure.
2. Determine caries risk.
3. Institute a regimen commensurate with individual caries risk status which
emphasizes bioavailability of post-eruptive topical F (e.g. Regular use of F
dentifrice and other home products if indicated).
4. Administer professional topical F treatments, the timing of which should also
be gauged to caries risk (This may not be needed in low risk individuals).
5. Administer systemic topical F if indicated. (The latter is currently under
review).

SALIVARY FUNCTION
Saliva is very important in the prevention of caries. While xerostomia may occur
because of aging, it is more commonly a result of a medical condition or
medication. Lack of saliva greatly increases the incidence of caries. If a patient is
xerostomic, consultation with the physician may be necessary to identify alternate
treatments, if possible, with less salivary impact. Saliva stimulants (gums, paraffin
waxes, or saliva substitutes) also may be prescribed for patients with impaired
salivary functioning.

SALIVARY FLOW RATE

XEROSTOMIA

HYPOSALIVATION

Subjective report of oral dryness related Objective salivary flow rate that is
to gender

under 0.1 or 0.16 ml/min (or 0.1

ml/min;

relate

to

medication

and

systemic disease

SIGNS AND SYMPTOMS OF XEROSTOMIA

Individuals with xerostomia often complain of problems with eating, speaking,
swallowing and wearing dentures.
Dry, crumbly foods, such as cereals and crackers, may be particularly difficult
to chew and swallow.
Denture wearers may have problems with denture retention, denture sores and
the tongue sticking to the palate.

 Patients with xerostomia often complain of taste disorders (dysgeusia), a painful

tongue (glossodynia) and an increased need to drink water, especially at night.
Xerostomia can lead to markedly increased dental caries, parotid gland
enlargement, inflammation and fissuring of the lips (cheilitis), inflammation or
ulcers of the tongue and buccal mucosa, oral candidiasis, salivary gland
infection (sialadenitis), halitosis and cracking and fissuring of the oral mucosa.

COMMON CAUSES OF XEROSTOMIA

Medications
The most prevalent cause of xerostomia is medication.
Xerogenic drugs can be found in 42 drug categories and 56 subcategories.14 More
than 400 commonly used drugs can cause xerostomia.10,14 The main culprits are
antihistamines, antidepressants, anticholinergics, anorexiants, antihypertensives,
antipsychotics, anti-Parkinson agents, diuretics and sedatives.
Other drug classes that commonly cause xerostomia include antiemetics, antianxiety
agents, decongestants, analgesics, antidiarrheals, bronchodilators and skeletal muscle
relaxants. It should be noted that, while there are many drugs that affect the quantity
and/or quality of saliva, these effects are generally not permanent.
Diseases and other conditions
The most common disease causing xerostomia is Sjgren's syndrome (SS).
It is a chronic inflammatory autoimmune disease that occurs predominantly in
postmenopausal women. SS is characterized by lymphocytic infiltration of salivary
and lacrimal glands, resulting in xerostomia and xerophthalmia. This combination is
called the sicca complex. There is no cure for the disease. The goal of therapy is to
manage symptoms. Common symptoms associated with SS, in addition to xerostomia

and xerophthalmia, include blurred vision, recurrent eye and mouth infections,
dysphagia or difficulty swallowing, oral soreness, smell and taste alternations, fissures
on the tongue and lips, fatigue, dry nasal passages and throat, constipation and vaginal
dryness.
Sarcoidosis and amyloidosis are other chronic inflammatory diseases that cause
xerostomia.
HIV-salivary gland disease occurs in some individuals infected with HIV,
mainly in children. This disease results in enlargement of the parotid glands
and, occasionally, the submandibular glands, resulting in xerostomia.
Other systemic diseases that can cause xerostomia include rheumatoid arthritis,
systemic lupus erythematosus, scleroderma, diabetes mellitus, hypertension,
cystic fibrosis, bone marrow transplantation, endocrine disorders, nutritional
deficiencies, nephritis, thyroid dysfunction and neurological diseases such as
Bell's palsy and cerebral palsy.
Hyposecretory conditions, such as primary biliary cirrhosis, atrophic gastritis
and pancreatic insufficiency, may also cause xerostomia.
Dehydration resulting from impaired water intake, emesis, diarrhea or polyuria
can result in xerostomia.
Psychogenic causes, such as depression, anxiety, stress or fear, can also result
in xerostomia.
Alzheimer's disease or stroke may alter the ability to perceive oral sensations.
Dry mouth is often exacerbated by activities such as hyperventilation, breathing
through the mouth, smoking or drinking alcohol.
Trauma to the head and neck area can damage the nerves supplying sensation to
the mouth, impairing the normal function of the salivary glands.
Cancer therapy
Xerostomia is the most common toxicity associated with standard fractionated
radiation therapy to the head and neck. Acute xerostomia from radiation is due to an
inflammatory reaction, while late xerostomia, which can occur up to one year after

radiation therapy, results from fibrosis of the salivary gland and is usually permanent.
Radiation causes changes in the serous secretory cells, resulting in a reduction in
salivary output and increased viscosity of the saliva. The degree of permanent
xerostomia depends on the volume of salivary gland exposed to radiation and the
radiation dose. When the total radiation dose exceeds 5,200 cGy, salivary flow is
reduced, and little or no saliva is expressible from the salivary ducts. These changes
are typically permanent.

TREATMENT
Self-care
Saliva substitutes
Saliva stimulants or sialagogues
Over-the-counter products

Dentifrices
Self-care:
Patients suffering from xerostomia should be encouraged to take an active role in
management of their xerostomia with regard to both identifying products and
practices that are most useful to them and in being vigilant to minimize the risks to
dental health.

Saliva substitutes:
Artificial saliva or saliva substitutes can be used to replace moisture and lubricate
the mouth. These substitutes are available commercially, but they can also be

compounded. Artificial salivas are formulated to mimic natural saliva, but they do
not stimulate salivary gland production. Therefore, they must be considered as
replacement therapy rather than a cure.

Over-the-counter products
There are several over-the-counter products that are available to provide assistance
in the management of xerostomia. These products range from saliva substitutes and
stimulants to products designed to minimize dental problems.

Saliva stimulants:
Natrol Dry Mouth Relief, which has recently been developed, utilizes a patented
pharmaceutical grade of anhydrous crystalline maltose (ACM) to stimulate saliva
production. As its effect is to stimulate functional salivary glands, it would not be
appropriate for patients whose salivary gland function has been lost through
radiological treatment. Natrol Dry Mouth Relief is formulated as lozenges which
are to be dissolve in the mouth three times daily.

Dentifrices:
Biotene and Oralbalance products are available over-the-counter from Laclede,
Inc. (These are antixerostomia dentifrices that contain three salivary enzymes,
lactoperoxidase, glucose oxidase and lysozyme, specifically formulated to activate
intra-oral bacterial systems.

DIET
Dietary sucrose has two important detrimental effects on plaque. First, frequent
ingestion of foods containing sucrose provides a stronger potential for colonization

by MS, enhancing the caries potential of the plaque. Second, mature plaque
exposed frequently to sucrose rapidly metabolizes it into organic acids, resulting in
a profound and prolonged drop in plaque pH.

Phosphates added to cariogenic diets.

Show Cariostatic action

Distinct physiological differences b/w rodents and humans that may explain low
Cariostatic response in human to directly supplement of Po4 are
1. Rodents have higher salivary pH and lower salivary phosphate content
that humans.
2. In animal experiments phosphate content is homogenized I diet
whereas in humans phosphate content is added to only are 1 portion of
the diet.

Evidence have shown

1. Ingestion of selenium increased dental caries
2. Trace elements such as molydednm (M0), vanadium (V), strontium (Sr) may
have on influence on prevalence of caries.

HUMAN CARIES VACCINE

The protection against caries achieved in the animal experiment just described has
generated hopes for developing an effective vaccine for use in man. However, a
number of major problems remain, first in most of the experiments the caries in the
control animal has been induced by infection with Strep.mutans, usually of the
same stains as that used for vaccination. In gnotobiotic experiments, the plaque
consists of a pure culture of the organism, while in animals with conventional
floras, superinfection with Strep.mutans has been employed because of the need to
achieve rapid caries in view of the prolonged vaccination period, after weaning and
before administering the cariogenic diet. With monkeys, superinfection has also
been employed.
A vaccine against the most prevalent of the serotypes of Strep.mutans (serotype c)
which acted specifically to eliminate this serotypes, might simply lead to a shift
toward other serotypes without reducing the level of cariogenic challenge.
However elimination of all strains of Strep.mutans may not necessarily lead to
reduced caries, as other species may take over the role of the target species.
Inhibition of bacterial attachment, perhaps including inhibition of GTF activity,
may be important in the action of salivary IgA antibodies, while the action of IgG
antibodies by crevicular PMNLs as well as complement mediated lysis.
GTF preparations are attaractive possible vaccines, as they may consitute an
important target of the antibacterial mechanism of the immune response. These
antigens have been less successful in conferring protection both in rats and
monkeys.
Oral vaccination with whole-cell or cell-wall vaccine stimulates a secretory IgA
response but does not c\elicit serum antibodies, presumably including any possible
heart-reactive antibody.

The potential benefits of vaccination (alongside other preventive measures

including fluoride treatments and diet control (in the elimination of caries from the
community may, if they can be achieved prove sufficient to warrant the effort and
expense of development. However even if the effort is successful vaccination will
not remove the need for continued fluoride therapy or allow young patients to
consume limitless cariogenic foods with immunity.

TYPES OF LESIONS
Smooth surface incipient caries;
Sticky pits and fissures
Sticky pits and fissures with incipient caries
Small and moderate lesions
Deep lesions
Root caries

CHOICE OF TREATMENT
Smooth surface incipient caries:
Remineralize with clinical topical fluoride applications and home
application of fluoride by various means; toothpaste, rinses, brush-on
gels, custom tray-applied gels, ect.

 Sticky pits and fissures:

Pit and fissure sealants
Sticky pits and fissures with incipient caries
Preventive resin/sealants (Remove caries, place composite in the
cavity and cover all with sealant)
Definitive amalgam restorations
Small and moderate lesions
Definitive amalgam, composite or glass ionomer restorations
Deep lesion:
Caries control restorations with calcium hydroxide, glass ionomer or
amalgam, and the definitive resotrations after caries activity has
decreased
Root caries:
Fluoride applications
Glass ionomer restoration

CARIES CONTROL RESTORATION

The term caries control refers to an operative procedure in which multiple teeth
with acute threatening caries are treated quickly by:
(1) Removing the infected tooth structure
(2) Medicating the pulp, if necessary
(3) Restoring the defects with a temporary material.
With this technique, most of the infecting organisms and their protecting sites
are removed, limiting further acute spread of caries throughout the mouth.
Teeth rapidly treated by caries control procedures are subsequently treated by
using routine restorative techniques, if appropriate pulpal responses are
obtained.
Also, the intent of caries control procedures is to make immediate, corrective
intervention in advanced carious lesions to both prevent and assess pulpal

disease and avoid possible sequelae such as toothache, root canal therapy, or
more complex ultimate restorations.
CARIES CONTROL PROCEDURE IS INDICATED WHEN:
The caries is extensive enough that adverse pulpal sequelae are soon likely to
occur.
The goal of treatment is to remove the nidus of caries infection in the patient's
mouth.
A tooth has extensive carious involvement that cannot or should not be
permanently restored because of inadequate available time or questionable
pulpal prognosis.
VARIOUS PROCEDURES ARE

Kinetic cavity preparation

Chemico mechanical method
Lasers
Ozone therapy
Smart Prep

KINETIC CAVITY PREPARATION

Originally developed in 1951 as air abrasive technique.
Now modified and improved as
KINETIC CAVITY PREPARATION SYSTEM
Principle: Utilization of kinetic energy or inertia as a rapid means of removing
tooth structure by incorporating a fine abrasive material in a high velocity gaseous
propellant, rotary instrumentation is a form of mechanically energy & air abrasion
is a form of kinetic energy.

THE EFFICIENCY OF AIR ABRASION IS INFLUENCED BY

1.
2.
3.
4.
5.
6.

Air pressure
Particle size
Powder flow
Tip size
Tip angle
Tip distance from tooth

AIR PRESSURE:
The air abrasive units are used with 20 to 120psi.
Higher pressure increases the sensitivity when cutting is in dentine.
Most advisable pressure is 40 to 60psi (not going beyond 80 psi)
PARTICLE SIZE:
The particle size used in Air abrasion are 27 - 27.5 micron (27 micron - 3/4 the size
of human hair)
Smaller particle cuts faster and smoother when propelled at high speed.
Smaller article 27-27.5 microns are used to cut teeth.
Large particle are heavier and need more velocity to move.
Large particle 50 micron are used to clean the provisional restoration and inside of
crown.
POWDER FLOW:
When pressure is reduced the flow will increase and its difficult to evacuate

TIP SIZE:
It may be small or large
Small - 0.28mm(0.011 inch) to Large- 0.8mm(0.32inch)

TIP ANGLE
Tip is angulated 45 degree while doing Air abrasion procedure.

TIP DISTANCE
Kinetic energy decreases with increase in tip distance
Focused mode - 1-2 mm
Defocused mode - farther away
While using the Air abrasion device, It is adviced to give a short burst(3secs)
instead of long spray

ADVANTAGE
Pain during tooth structure removal is eliminated or at least reduced.
No vibration occurs during Air abrasion procedure
The only noise produced by Air abrasion is a familiar vacuum cleaner sound.
Well-designed tips provide good control during the procedure.
Patients who are afraid of traditional dentist techniques and the noise of airrotor
handpieces can be treated, without anesthesia, using air abrasion.
It is an especially useful technique for children.
Used properly, air abrasion "explores" incipient carious lesions extremely well,
often locating carious areas previously undetectable visually or by radiography.

DISADVANTAGE:
Air abrasion technique is not familiar, period to accustom themselves so
dentists require a learning to it.
Tooth preparations do not resemble traditional, precise, clearly identifiable
outlines.
The practitioner's tactile perception during tooth structure removal is minimal.
At this time, only small tooth preparations can be accomplished with the Air
abrasion technique.
Expertise is required to control it by proper direction of the Air abrasion
handpiece tip, excellent suction and, potentially, by use of air filtration devices.
The practitioner's vision is sometimes obscured by debris while tooth structure
is being removed.
Performing air abrasion on Class II and III areas requires more extensive
learning than that required for using the technique on other tooth locations.
Old
amalgam
cannot
be
removed
produce
mercury
dust.
It doesnot remove soft decay bcoz the particles are absorbed to remove the soft
decay one should use slow hand piece with no.2 or no.4 round bur or sharp
spoon
Crown preparations are not possible with Air abrasion.

CHEMICO-MECHANICAL METHOD:

The chemo-mechanical caries removal involves the application of a solution

that selectively softens the carious dentin, thus facilitating its removal by gentle
excavation.

This limits the removal of sound tooth structure, the cutting of open dentinal
tubules, pulpal irritation and pain compared with conventional mechanical methods
Materials:
Caridex - N-monochloro-DL-2-aminobutyric acid (GK-1O1E)

Carisolv - One syringe contains NaOCl

Second syringe contains 3 amino acids (glutamic acid, leucine, lysine);gel
substance (carboxy methylcellulose), Nacl/NaOH and saline.

MECHANISM OF ACTION
Caridex - Disruption of collagen in the carious dentin, thus facilitating its

removal.

Carisolv - Involving proteolytic degradation of collagen rather than

demineralization, thus softening the altered carious dentin and preserving the
sound dentin

OZONE THERAPY:
Ozone therapy is a new dental innovation that actually can help heal cavities. This
means that a cavity that would traditionally have required drilling and a filling
might not need this procedure. Currently, there are only a handful of dentists in the
US using the procedure
Principle: OZONE is natures most powerful oxidant which accounts for its ability
to kill bacteria, spores & viruses.Primary carious lesions when exposed to ozone
become sterile & remineralize after sometime.
PARTS
1. Air dryer: The device takes in ambient air. The air dryer with automatic humidity
sensor ensures that air humidity is stable and that the ozone concentration within
the silicone cup is steady
2. Differential pressure sensor: Registers leaks and activates the ozone generator.

3. Ozone generator: The ozone generator, which is connected to the system,

generates ozone from atmospheric oxygen.

4. Handpiece tip: An ozone concentration of 2,100ppm with a ~ 100 times/s

exchange rate at the vacuum-sealed silicone cup.
5. Moisture trap: Prevents moisture from contaminating the ozone neutraliser.
6. Ozone neutraliser: Converts the ozone back into oxygen and releases neutral air
into the practice environment.
7. Vacuum pump: Ensures low pressure to prevent the system leaking ozone.

After the Ozone Treatment:

Get a patient kit for your use at home to help the tooth remineralize. The kit
contains a special toothpaste, oral rinse and spray.
Use the toothpaste twice per day and the rinse or spray three times per day.

ADVANTAGES & DISADVANTAGES

Healozone therapy involves much less discomfort than drilling and filling.
The procedure is generally painless.

Ozone therapy can be used for a tooth that has decay close to the nerve,
sometimes eliminating the need for a root canal. The dentist drills away a good bit
of the decay, stopping before reaching the nerve. The ozone is used, with the hopes
that the area near the nerve will remineralize and harden, thus protecting the nerve.
If the decay has reached the nerve, the dentist will follow the same process of
removing most of the decay, but leaving some tooth structure over the nerve. The
ozone will permeate the nerve, getting rid of the infection and bacteria and helping
the nerve to heal along with the tooth structure remineralizing. This may be able to
prevent a root canal as well!

If you have deeper decay, the dentist might recommend more than one ozone
treatment, to give your teeth a better chance to remineralize and heal. For instance,
you might have treatment every two weeks for a period of months instead of just
one treatment and a potential second one at the three month time.

Healozone is not currently approved by the FDA in the United States.

Clinical trials began at three different locations in the USA, with the hope of
gaining FDA approval after the results of a 12 month study on the effects of
Healozone and its safety. Site is listed in the resources.

Most healthcare plans will not pay for Ozone therapy, because it has not
even been approved by the FDA in the United States yet. Plan to have to pay for
the treatment out of pocket.

It is essential to follow through with the use of the patient kit as instructed to
help your teeth have the ability to reminralize.

POLYMER BUR or SMART BUR

The SMARTPREP Instrument is a medical grade polymer that safely and

effectively removes decayed dentin, leaving healthy dentin intact.

The hardness of instrument is less than that of healthy dentin and enamel but
harder than carious dentin.

The polymer instrument is self-limiting and will not cut sound dentin unless
applied with great force, and then it will only wear away, rather than cut, the
healthy dentin.

Smartprep instrument in a range of sizes (equivalent to round burs nos. 2, 4 and

6).

The Smartprep Instrument is used in a slow speed handpiece (500-800 rpm)

to complete caries removal.

They are single-patient-use rotary instruments.

Carious tissue is removed with circular movements starting from the centre
to the periphery.

ADVANTAGE

They are being used for deep caries removal in anticipation of an indirect

pulp capping procedure

Use the Smart-Prep burs in the beginning of their clinic experience and
hopefully avoid iatrogenic pulp exposures

DISADVANTAGE

Polymer

bur

left

large

amount

of

decayed

tissue

unexcavated

(underprepation).

Technique sensitive

The burs disintegrate when they touch enamel or even sound dentin

Expensive