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RECENT ADVANCES IN CARIES DIAGNOSIS &

PREVENTION
INTRODUCTION

DIAGNOSTIC TOOLS

♦ VISUAL
♦ TACTILE
♦ VISUAL TACTILE
♦ RADIOGRAPHS - Conventional – IOPAR & Bitewing
- Xeroradiography
- Digital – 1. Enhancement
2. Subtraction
3. Tuned Aperture Computed
Tomography (TACT)

♦ BASED ON VISIBLE LIGHT


Optical caries monitor (OCM)
FOTI and DIFOTI
QLF & DIAGNODENT, DELF
Ultraviolet

♦ BASED ON ELECTRICAL CURRENT


Electric conductance
Electric Impedence

♦ 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.

♦ Minimally Invasive preparation

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.

Most currently used diagnostic methods are subjective in nature.


1. Detect lesion only at an advanced level.
2. Cannot quantify the mineral loss
3. Cannot measure the small changes in mineral loss (gain) on demineralization
Early detection of carious lesions is an important and necessary process in
order to detect the early stages of demineralization. Operative treatment should be
required only when the caries process has reached a non reversible point. The
same treatment philosophy should apply to secondary caries. Secondary caries is a
major reason for replacing restorations, however it is difficult to detect at early
stages. Wall lesion cannot easily be detected until they have reached an advanced
stage. Colors next to restoration are not always predictive of secondary caries.
Stained composites margins and ditching of amalgam restorations are not
necessarily signs of decay, although they indicate greater risk. Despite the fact that

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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.

Due to nature of secondary caries, which in many instances presents an


outer and wall lesion, validation of secondary caries is difficult. There are several
methods available to measure mineral loss such as histopathology (Silverstone
1973) which requires thin section 100 micro meter and micro radiography
(Arends 1987), which involves use of radiation and thin section. Confocal laser
scanning microscopy presents several advantages such as not requiring a thin
section / involving radiation and can be done in a shorter times.

DIAGNOSTIC TOOLS FOR CARIES


Several methods have been employed for caries diagnosis. These include
a. Visual method
b. Tactile method (probing)
c. Visual – Tactile – European system, USA system
d. Radiographs
• Conventional –IOPAR, Bitewing
• Xeroradiography
• Digital
Digital enhancement
Subtraction Radiography
TACT (Tuned aperture computed tomography)
e. Based on visible Light
• Optical caries monitor

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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)

Criteria for visual examination

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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

B) PROBING (TACTILE EXAMINATION)


During the past 10 years the role of explorers in caries detection has
become a controversial issue. There was no difference in diagnostic accuracy
between explorer and visual inspection.
Sensitivity – 62%
Specificity – 84%
Disadvantage
- It can produce traumatic defects in lesions arrested by plaque control alone.
- Does not improve accuracy of diagnosis.
- Inter operative variables.

C) VISUAL TACTILE METHOD


Makes use of both visual along with tactile sensitivity with a probe /
explorers.
European System depends on detailed visual examination. Subjects clean their
teeth before examination, tooth surface dried with compressed air, and
examination requires 10 minutes / subject.
American Dental Association Criteria (USA) uses the softened enamel that
catches an explorer and resists its removal and allows the explorer to penetrate the
proximal surfaces with moderate to firm probing pressure. Here teeth are well lit,
but neither cleaned nor dried and it takes 3 minutes per subject.

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D) RADIOGRAPHIC
The purpose of the radiograph is to detect lesions that are clinically hidden
from careful visual examination.

CRITERIA (MEJARE et al 1999)


R0 = no radioluscency
R1 = Radioluscency confined to outer half of enamel
R2 = Radioluscency in inner half of enamel + extending upto but not beyond DEJ.
R3 = Radioluscency in dentin, broken DEJ, but with no obvious spread in dentin
R3 = Radioluscency with obvious spread in outer half of dentin.
R4 = Radioluscency with obvious spread in inner half of dentin (> half way
through to the pulp)

(Five point scale for occlusal caries) (Espelidel, 1994)


Based on clinical visual examination + radiographs

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

Radiographic appearance of caries


a) Occlusal caries
radiography are ineffective for detection until it reaches the dentin.
Limitations
-Super imposition of enamel over fissures, lesions involving buccal groove
can simulate an occlusal lesion.
-Difficult to diagnose between occlusal caries and internal resorption.

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

Diagnosis is not difficult except where lesion is hidden by periodontal pockets..

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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).

Mechanism of image formation


When exposed to radiation, the covalent bunds between silicon atoms are
broken – electron hole pairs – get attracted to the potential to form charge packet.
Each pocket corresponds to 1 pixel___ the charged pattern from individual pixels
form the latent image.
The image is read by transferring each row of pixel charges form one pixel
to the next. As the charge reaches the end of the row – transferred to a read out
amplifier and transmitted as voltage – gets converted to digital image.
Voltages from each pixels are sampled and assigned a numerical value on
the gray scale. Pixel size varies from 20-70%

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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.

E.g. of Direct digital radiography.


RVG (Trophy Japan) 10 x 28 mm
Flash (Villa Italy) 20 x 24
Sens – A ray (Regan) 17 x 26
Vixa – (Gendex) 18 x 24

-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

DIGITAL IMAGE ENHANCEMENT


It was shown that the resolution of digital image is lower than radiographs
and the range of grey shades is limited to 256, where as in a radiographic film,
over one million shades of grey appear. The diagnostic performance of un
enhanced digital image does not exceed radiographs. Therefore, the contract can
be digitally enhanced using a mathematical rule often decided by the algorithm /
filter.

DIGITAL SUBTRACTION RADIOGRAPHY


Here, a digital bitewing radiograph is taken and sometime later a second
radiograph of exactly the same region is produced with identical exposure time,
tube current and voltage. By subtracting the gray values for each coordinate of the
first radiograph from equivalent coordinate of second, a subtraction image is
obtained.

TUNED APERTURE COMPUTED TOMOGRAPHY (TACT)


This technique is recently introduced and is still under development. This
method contracts radiographic section through teeth. The slices can be viewed for
presence of radioluscencies. Slices can be brought together in 3-D computer model
called a psedohologram. TACT slices and pseudohologram are adequately detect
primary and secondary caries.

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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.

c) Quantitative Laser or Light Induced Fluorescence (Laser Auto


Fluorescence ) : The use of Fluorescence for detection of caries dates back

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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

Method :- Blue-green visible light emitted from a argon ion laser of


wavelength 488 nm wavelength is used. When the tooth is exposed to this
light, Fluorescence of enamel occurring in yellow wavelength is observed.
(540 nm) through a yellow high pass filter to exclude the scattered blue/green
light. Demineralized appear as dark spots. To facilitate clinical studies a
portable variant QLFTM is used. QLF is two step procedure. –
1) Image acquisition with CCD camera
2) Image analysis using the software

DIAGNODENT : A variant of QLF system, a diagnodent (KAVO – 1999) was


based on research Hibst and Gal. Light source – diode laser red light 655 nm.
Method :
Red light is transported via an angulated tip with central fiber. Reflected
light is eliminated by and taken up by the photo-diode and processed and
presented on display as 0-99.

Values : 5-25 initial lesions in Enamel


25-35 initial dentinal caries
> 35 advanced dentinal lesion.

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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.

DYE-ENHANCED LASER FLUORESCENCE :


It had higher sensitivity than laser auto Fluorescence alone. Dyes used are
- Pyro methane 556
- Sodium Fluorescin

F) DIAGNOSTIC METHODS BASED ON ELECTRIC CURRENT :


a) Electrical conductance measurement : This is based on the principle that
a demineralized tooth has more pores filled with water and this is more
conductive than intact tooth surface. When current is applied by placing an
electrode on tooth surface, the electrical conductance is measured between
this electrode and contra electrode.
b) Electrical impedance measurement : Impedance is a measure of degree
which an electric current resists electric current flow when a voltage is
applied across two electrodes. Caries tissue has lower impedance(or
conduct electricity better) than sound tooth.

G) DIAGNOSTIC METHODS BASED ON ULTRASOUND


MEASUREMENTS :
Ultrasound makes use of sound wave with a frequency ranging from 1.6 to
10 MHz. Ultrasound interacts differently with different tissues. Ultrasound
production – by application of an alternating voltage applied to an piezo electric
crystal.

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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.

Disadvantages : Only for superficial enamel lesions.

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.

NEW DIAGNOSTIC MODALITIES FOR CARIES LESION


- Multi photon imaging
- Terahertz imaging
- Transversal wavelength independent microradiography
- Infra red thermography or infra red fluorescence
- Frequency domain photo thermal radio metry and
Frequency domain luminescence

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.

Optical Coherence Tomography (OCT)


OCT is a method of imaging that has been developed for transparent and
semi transparent structures. It was first developed in medicine for use in

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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

Despite the major accomplishments of preventive dentistry in reducing caries


prevalence, the problem is still with us. There is a continuing need for improvement in
existing preventive products and technique. And the broadening of our anti-caries
armamentarium.
It is apparent that caries is considered as a infectious disease, and it should not be
considered as a result of infection with one specific type of microorganisms. The
infectious agents are the indigenous flora of the oral cavity.

Can caries be prevented ?


The formation of biofilm on tooth surface cannot be prevented in surface
irregularities such as occlusal fissures. The formation of cavities can be prevented by
controlling the caries process, but metabolic fluctuations in the biofilm cannot be
prevented. Thus caries is a ubiquitous natural process. Thus accepting that biofilm
constantly form and grow on any tooth surface, these regular demineralization and
remineralization, which occur at random cannot be prevented because they are a
ubiquitous and natural process. There effect on tooth surfaces overtime can however be
influenced and the metabolic process can be modified. Caries lesion development and
progression can thus be controlled. Therefore, by controlling the disease process it is
possible to prevent cavities from occurring.

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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.

CURRENT STRATEGIES IN CARIES PREVENTION


The current approaches to caries prevention are essentially the same as that
proposed by the NATIONAL CARIES PROGRMME 1971-1983. As such the national
institute of dental research has developed the following three part strategy. This includes
a) Combating caries inducing microorganisms and preventing plaque buildup
b) Modifying caries from promoting ingredients of the diet.
c) Increasing the resistance of tooth to decay
d) Enhancing host resistance

COMBATING CARIES INDUCING MICROORGANISMS AND PLAQUE BUILD


UP :
These include
i) Personal oral hygiene methods for plaque control
a) Mechanical b) Chemical plaque control
ii) Fluorides
iii) Caries vaccine
iv) Blocking plaque built up

A) ORAL HYGIENE METHODS :


a) Mechanical means:
Manual
i) Tooth brushes
Electric

Manual tooth brushes : Tooth brushing is the most widespread


mechanical means of plaque control in the world. The tooth brush has very

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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.

Electric tooth brushes : In 1986, An international workshop on


Oral hygiene concluded that, to date power tooth brushes remove no more
plaque than manual tooth brushes regardless of methods.(Loe and
Kleinmal, 1996) Eg : Rotadent , Interplak , Sonicare electric brush.

ii) Inter dental cleaning aids : These include interdental brushes (manual and
electric) toothpick, dental floss and dental tape with or without holder.

iii) Professional tooth cleaning : (PMTC) : PMTC is a service provided by


dental personnel (Specially trained dental nurses , dental hygienist and
dentist.) and is defined as selective removal of all plaques from all tooth
surfaces. This is known as KARL STAD Programme, and was developed by
Axelson and Lindhe(1974)

b) Chemical plaque control


There are contrasting opinions among dental professionals as to the use of
chemical agents in the prophylaxis and treatment of dental caries. Those in favour are
of the opinion that any reduction of dental plaque is beneficial if accomplished safely,
self performed mechanical control of plaque is difficult to perform and often
inadequate. Thus, chemical agents may offer an adjunct. Those opposing the use of
these agents argue that they may disturb the ecological balance within the oral cavity,
and that resistant strains may emerge.

Principle modes of action of an anti-plaque agent are


- Inhibition of microbial colonization
- Inhibit microbial growth and metabolism
- Disrupts matured plaque

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- Modification of plaque, bio chemistry and ecology

Vehicles for administration of anti-biotics:


Toothpaste, Dentifrices, Mouth rinses, Irrigants, Gels, Spray, Chewing gum and
Losenges, sustained released devices.

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

In chewing gums – 20 mg per piece.


In tooth paste 0.4%

b) Cetylpyridinium chloride : A quaternary ammonium compound used in mouth


rinses. The anti microbial activity of CPC is equal to or better than CH but its plaque
inhibitory property is inferior as it losses its anti microbial properties upon absorption
to tooth surfaces.
c) Heavy metal salts : (Cu2+ Sn2+ , Zn2+)
As early as 1890, Miller proposed the use of metal ions to treat rampant
caries. The anti microbial efficacy is proportional to the concentration of free metal
ions. The anti microbial effect is unspecific. Cu2+ and Sn2+ are more potent than Zn2+.

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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

d) Pyrimidines (Hexitidine) : It is a synthetic hexahydropyridine which has anti


microbial and anti fungal activity.
Mechanism of action : Not known.
Dosage : -,. 0.10 to 0.14% in mouth rinses along with divalent metallic ions like Cu 2+
and Zn2+
e) Herbal extracts – Sanguinaria : Sanguinaria is a herbal preparation. It is a mixture
benzophenanthridine alkaloids, obtained by alcohol extraction , form the blood root plant
sanguinaria Canadensis.
Mechanism of action : - Suppresses the activity of several enzymes.
Bactericidal effect by interfering with essential steps in the synthesis of microbial cell
wall.
Dosage : Available along with Zncl2 in mouth rinses and tooth paste.

II) ANIONIC AGENTS :


Sodium dodecyl sulphate (sodium lauryl sulphate) : It is the most
frequently used detergent in commercial dentifrices.
Mechanism
i) gets absorbed on the microbial surface and interferes with cell wall integrity.
And causes cellular components.

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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

III) NONIONIC AGENTS


- Triclosan , Thymol , Listerine , 2 poly phenol , Hexyle resorcinol

Listerine and triclosan are the most frequently used.


a) Triclosan : It has a broad anti microbial spectrum.
Mechanism of action: Inhibits lipid synthesis and leads to defective cell
membrane synthesis.
Disadvantage : Low substantivity and decreased anti microbial effect.
Formulation – in dentifrices and mouth rinses
Dosage – 10 ml of 0.03% mouth rinse and 0.3% in tooth paste
b) Listerine : Listerine named after Lister was tested for efficacy against
oral bacteria as early as 1884 by W.D. Miller. It is a combination of
thymol, Eucalyptus, Menthol and methyl salicylate in a hydro alcoholic
solution (Mandel 1988)
Mechanism of action :
o At low concentration – Inactivation of essential enzymes
o At high concentration – cell wall disruption and precipitation of proteins.

c) Salifluor : It is a chemical derivative of Aspirin with antibacterial and


anti inflammatory properties.
Dosage : 0.12% in mouth rinses

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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

b) Enzymes : Hydrogen peroxide controls the proliferation of microorganisms and


through its peroxidase activity oxidizes thiocynate to hypo thiocynate that is an
anti microbial. Therefore this activity depends on presence of hydrogen peroxide.
Formulation : Toothpaste and mouth rinses

c) Xylitol : It is five carbon natural sugar alcohol (Pentilol) is used as alternative


sugar substitute. Like all other polyols, It can’t be fermented by oral
microorganisms, non acidogenic and does not promote dental caries.
Mechanism of action
- Inhibitory effect on glycolysis in certain micro organisms.
- Reduces adhesiveness through impaired polysaccharide formation of
microorganism.
- Remineralization
- Less carcinogenic flora
Formulation
Dentifrices and chewing gums
However evidence is still lacking to confirm the claimed effects of xylitol.

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

Mouth rinse Varnishes

Tablets & Lozenges Slow release Fluoride

Gels & Foams Aqueous solutions

Toothpick, Floss, Tape Prophylaxis paste

Chewing gum

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Topical fluorides
Available fluoride agents include
a) Inorganic compounds
- NaF , SnF2 , Ammonium Fluoride, Titanium tetra Fluoride

b) Mono fluoro phosphate containing compounds


- Sodium monofluoro phosphate
c) Organic Fluorides
- Amine and silane fluorides
d) Combinations
- AmF+ NaF(Prophylaxis paste)
- NaF + SmFP

Topical Fluorides for self application includes


1) Dentifrices
Fluoride in the form of
NaF – (0.20%)
SmFP (076%)
SnF2 – (0.40%)
Formulation – 1000 ppm of fluoride that is 0.1% F= 1 mg Fl-/1 gm of paste
Caries reduction by 20%
2) Mouth rinses
Low doses – 0.04 – 0.05 % NaF (daily use 225 ppm of fluoride)
Caries reduction 30-40%
High doses – 0.2% NaF (909 ppm weekly or fortnight)
Caries reduction – 30-40% in 2 years
Typically 10 ml of solution is swished in the mouth for 1 min.
3) Fluoride gels and foams : They contain a variety of fluoride levels ranging from
those found in mouth rinses to 5000 ppm fluoride.
4) Fluoride lozenges : Slow release fluoride – 0.25 mg Fl-

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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)

3) Fluoride Prophylaxis paste: Sodium fluoride is the most commonly used


agent. Fl- concentration ranges from 0.1 – 1%

4) Fluoride varnishes: Fluoride varnishes have been available in Europe


since 30 years and widely used for professional application.

Eg: Duraphat (5% NaF varnish containing 2.26% Fl-)


Fluorprotector – Polyurethane based varnish(0.9% silane
fluoride with 0.1% fluoride.)
5) Slow Release Fluoride Agents : Fluoride varnishes with retention for
about 1 week may be regarded as slow release agents. Intra oral slow
fluoride release is provided by a device that can deliver a constant supply
of fluoride ions over a period of 2 years or by Dental materials that release

30
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

Fluoride releasing dental materials: The assortment of restorative materials, sealants ,


liners and cements that contain fluoride act as slow release fluoride agents.
Eg : Restorative materials
- Silicate and glass ionomer contain large amount of fluoride
- Fluorinated amalgam has been shown to increase the fluoride in surrounding
enamel and dentil.
- Resin modified glass ionomer cements (Light and Chemically cured)
Eg : Photac - Fil , Vitremer
Compomers
Eg : Dyract , Compoglass,

Fissure Sealants
Low viscocity glass ionomer cements – Fuji III
RMGIC – Vetrebond
Fluorinatted resins – Helioseal F, Fissurit F

C) BLOCKING PLAQUE BUILDUP:


By
a) Inhibition of Glucosyltransferase(GTF) using
i) Competitive inhibition – Like analogues of sucrose that interfere with
glucan synthesis
ii) Plant and fungal products – That alter the adhesion of cell surface
glucans

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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.

B) MODIFYING CARIES PROMOTING INGREDIENTS OF THE DIET.


Initially dietary modification was synonymous with restricting intake of
sugars especially sucrose. This required a proper dietary assessment of each
individual that allotting them with a proper schedule dietary chart fulfilling the
dietary needs. These include
- Encouragement of sugar substitution – the use of hypo acido genic and non acido
genic Eg : Xylitol
Mechanism of action :
 Enhances remineralization, decreases dental caries , alters metabolic pathways
and reduces S-mutans.
 Use of preservatives with enhanced antibacterial activity
 Increased use of natural inhibitors of demineralization such as various
phosphates
 Employment of protective components in food.

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Eg : Polyphenols in chocolates. Protective components in Oat and pecan hulls

C) INCREASING TOOTH RESISTANCE


By :
i) Various forms of fluoride application
ii) Methods used to increase fluoride uptake
iii) Remineralizing agents – Calcium phosphates , CPP - ACP
iv) Polymeric coatings
v) Fissure sealants
vi) Laser application
vii) Disinfection therapies

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

- Minimally invasive preparations


♦ Preventive resin restoration (PRR)  Conservative resin restorations
(CAR)
♦ Atraumatic restorative treatment (ART)

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♦ Enameloplasty

D) AUGMENTING HOST RESISTENCE


1) By mimicking natural protective system present in human saliva – By
recombinant DNA technologies
Eg : Antibacterial – Lysozyme
Aggregating – Mucins
pH regulating – Histidine
Ionic regulation – Statherin
2) By use of artificial saliva with natural salivary molecules added to increase
their protective qualities inpatients with xerostomia
3) By adding protective pep tides to pacifiers for young children .
4) Salivary enhancement therapies
Local or topical sialogogues
Eg :
– Gustatory stimulation
– Masticatory stimulation
– Oral rinses, artificial saliva
– Anhydrous crustalline maltos
– Acupuncture

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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