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PREVENTION OF CARIES

INTRODUCTION
LEVELS OF CARIES PREVENTION
CHEMICAL MEASURES OF CARIES PREVENTION
NUTRITIONAL MEASURES OF CARIES PREVENTION
MECHANICAL MEASURES OF CARIES PREVENTION
CONCLUSION
REFERENCES
1
PREVENTION OF CARIES
INTRODUCTION:
Dental caries and periodontal disease are proal! t"e #ost co##on
c"ronic disease in t"e $orld% Alt"o&'" caries "as a((ected "&#an since pre"istoric
ti#es) t"e pre*alence o( t"is disease "as 'reatl! increased in #odern ti#es on t"e
$orld $ide asis and increase stron'l! associated $it" t"e dietar! c"an'es%
Ho$e*er e*idence no$ indicates t"at t"is trend pea+ and e'an to decline
in #an! co&ntries in t"e late 1,-.s and earl! 1,/.s and t"e decline $as #ost
noticeale in certain se'#ents o( pop&lation in de*eloped co&ntries% A si#ilar
polari0ation is occ&rrin' on t"e $orld $ide asis $"ere t"e pre*alence o( caries is
declinin' in de*eloped co&ntries) is increasin' in less de*eloped co&ntries and is
epide#ic in co&ntries $it" e#er'in' econo#ies% T"&s caries ein' locali0ed in t"e
se'#ent o( pop&lations t"at can least a((ord t"e necessar! dental treat#ent%
A caries pre*ention pro'ra# is co#ple1 process in*ol*in' #&ltiple
interrelated (actors% T"e pri#ar! 'oal o( caries pre*ention pro'ra# s"o&ld red&ce
t"e n&#er o( cario'enic acteria% Pre*ention s"o&ld start $it" a consideration o(
t"e o*erall resistance o( patients to in(ection ! t"e cario'enic acteria% Alt"o&'"
'eneral "ealt" o( t"e patient) (l&oride e1pos&re "istor! and (&nction o( i##&ne
s!ste# and sali*ar! 'lands "a*e a si'ni(icant i#pact on t"e patient2s caries ris+%
Caries control #et"ods are t"e operati*e proced&res &sed ot" to stop t"e
ad*ance o( t"e indi*id&al lesions and to pre*ent t"e spread o( pat"o'enic acteria
to ot"er toot" s&r(aces and in t"is sense) t"e! are pre*enti*e proced&res%
3
Mana'e#ent o( dental caries and its conse4&ences re#ain t"e do#inant
acti*it! o( dentists% Ho$e*er pre*enti*e and dia'nostic ser*ice) percenta'es o(
practice acti*ities are increasin'% Alt"o&'" t"ese acti*ities relate to *ariet! o(
dental prole#s) dia'nosis and pre*ention o( caries are #a5or part o( t"ese
increases%
No lon'er is t"e restoration o( cario&s lesion considered to e c&re% Rat"er
t"e practitioner #&st identi(! t"ose patients $"o "a*e acti*e cario&s lesions and
t"ose at "i'" ris+ o( caries and instit&te appropriate pre*enti*e and treat#ent
proced&res%
METHODS OF CARIES PREVENTION:
T"e control o( dental caries presents one o( t"e 'reatest c"allen'es t"at
#&st e #et toda! ! t"e dental pro(ession% It "as een a 'eneral (ailin' o( "ealin'
pro(ession t"at t"e treat#ent o( disease "as een o*ere#p"asi0ed and pre*ention
is #ini#i0ed%
6a&((#an "as stated t"at 7T"e s&pre#e ideal o( dental pro(ession s"o&ld e
to eli#inate t"e necessit! (or its o$n e1istence8%
T"is s&''estion e#p"asi0es t"e necessit! (or #ore (orce(&l approac" to t"e
prole# o( pre*entin' dental caries) alt"o&'" t"e ideal "as not een reac"ed) t"ere
"a*e een de(inite acco#plis"#ents in t"e (ield o( caries control%
T"e le*els o( pre*ention o( dental caries9:
Pri#ar! pre*ention
Secondar! pre*ention
;
Tertiar! pre*ention
T"e #et"ods to control dental caries can e classi(ied into ; 'eneral 'ro&ps
<t!pes=9
C"e#ical #eas&res
N&tritional #eas&res
Mec"anical #eas&res
CHEMICAL MEASURES:
1= S&stances $"ic" alter t"e s&r(ace o( toot" str&ct&re
a% Fl&oride
% Iodides
c% >is:i'&anides
d% Sil*er nitrate
e% ?inc c"loride and potassi&# (erroc!anide
3= S&stances $"ic" inter(ere $it" caro"!drate de'radation t"ro&'"
en0!#atic reaction@ alterations
a% Vita#in 6
% Vita#in D
;= S&stance $"ic" inter(ere $it" acterial 'ro$t" and #etaolis#
a% Urea and a##oni&# co#po&nds
% C"lorop"!ll
c% Nitro (&rans
d% Caries *accine
A
B
FLUORIDES:
History:
1/-A9 T"e (irst re(erence to prop"!lactic role o( (l&oride ! Er"adt% In
contri&tion to CMe#orailia2 D A #ont"l! p&lication "e reported% As (or a
lon' ti#e) iron $as 'i*en (or lood) calci&#) and p"osp"or&s (or t"e ones) so
it "as een s&ccess(&ll! to add (l&oride to toot" ena#el in sol&le and
asorale (or#% It is (l&oride t"at 'i*es "ardness and d&railit! to t"e toot"
ena#el and protects a'ainst t"e caries%
1,EB D Pindor' F 1,/3 D H&ns(ordraten ot" re(er to pa#p"let p&lis"ed)
entitled 7Flo&rides8 Ho$ to re#ed! t"e deca! o( t"e toot"G T"e te1t o( t"e
roc"&re stated t"at *ario&s s&stances $ere essential (or "ealt" o( t"e teet")
ao*e all (l&orine%
1,/E D Dr% A Denni'ar 'a*e a lect&re entitled C(l&orides2 an a'ent to co#at
dental diseases% Fl&orine is an ele#ent $"ic" is close to c"lorine) ro#ine and
iodine and #ost (re4&entl! o&nd to Ca) occ&rs as CaF3 in #inerals% T"e lac+
o( (l&orine in (ood st&((s still see#s to e a *er! i#portant (actor in t"e ca&se
o( dental diseases%
ANTICARRIES MECHANISM OF FLUORIDE:
T"e #ec"anis# ! $"ic" (l&oride increases caries resistance #a! arise
(ro# ot" s!ste#ic and topical applications o( (l&oride and can e roadl!
'ro&ped into D
1= Increased ena#el resistance
E
3= Increased rate o( #at&ration
;= Re#inerali0ation o( incipient lesion
A= Inter(erence $it" #icroor'anis#
B= I#pro*ed toot" #orp"olo'!
1) Increase ena!e" resistance:#
H"en ena#el is e1posed to a pH o( ao&t B%B or lo$er) it $ill dissol*e
accordin' to t"e (ollo$in' e4&ation%
Ca
1.
<PO
A
=
E
<OH=
3
I /H
I
1.Ca
3I
I EHPO
A

I 3H
3
O
H!dro1!apatite
T"e presence o( (l&oride in t"e dissol&tion #edi&# e((ecti*el! red&ces t"e
sol&ilit! o( ena#el ! pro#otin' t"e (or#ation o( (l&oroapatite and pre*entin'
t"e (or#ation o( #ore sol&le calci&# and p"osp"ate #inerals%
Ca
1.
<PO
A
=
E
<OH=
3
I 3F

Ca
1.
<PO
A
=
E
F
3
I3OH

Fl&orapatite
$) Increase rate o% !at&ration:#
T"e resistance o( teet" to caries appears to increase poster&pti*el! $it" a'e
and 'reater ene(its are otained ! topical (l&oride application s"ortl! a(ter
er&ption o( t"e teet"% T"e ne$l! er&pted teet" "as areas $"ere #ini#al deposition
is not co#plete% T"ese "!po#inerali0ed areas #a! eco#e (&ll! #inerali0ed
$it"in (e$ #ont"s a(ter er&ption% T"e presence o( e*en s#all a#o&nts o( (l&oride
in a #inerali0in' sol&tion en"ances t"e precipitation o( t"e #ineral
"!po#inerali0ed areas t"at #at&re in t"e presence o( (l&oride contain #ore
(l&oride t"an ena#el t"at $as (&ll! #inerali0ed &pon er&ption% T"ese areas $ill
-
t"ere(ore e #ade #ore resistant to acid% T"e presence o( (l&oride in #inerali0in'
sol&tion also increases t"e rate o( #at&ration%
') Re!inera"i(ation o% inci)ient "esions:#
Incipient lesions are opa4&e) $"ite areas on t"e ena#el "a*in' relati*el!
so&nd s&r(ace &t $it" s&stantial #ineral loss ;. to E. # elo$ t"e s&r(ace
la!er% H"en t"e en*iron#ent is cario'enic) de#inerali0ation contin&es &ntil t"e
ca*it! is (or#ed% Ho$e*er) i( t"e en*iron#ent is c"an'ed to allo$ (ree access to
sali*a) t"e lesion eco#es arrested or act&all! disappears eca&se o( redeposition
o( #ineral $it"in t"e lesion%
Alt"o&'" sali*a is t"e nat&ral re#inerali0in' sol&tion) t"ere is e*idence t"at
(l&oride is #ore e((ecti*e% >ro$n color o( an arrested lesion in presence o(
(l&oride is d&e to t"e precipitated proteins and #inerals%
*) Inter%erence +it, !icroor-anis!s:#
Inter(erence $it" t"e #etaolis# o( #icroor'anis#s in*ol*ed in caries
(or#ation "as een proposed as t"e possile #ec"anis# (or anti:cario'enic
propert! o( (l&oride%
Fl&orides can a((ect #icroor'anis#s in se*eral $a!s% At lo$ (l&oride
concentrations it in"iits acid (or#ation) at "i'"er concentrations it can a((ect
'ro$t" and #etaolis# and at *er! "i'" concentrations it is let"al%
In"iition o( acterial 'ro$t" and #etaolis# is related to e((ect o(
(l&orides on en0!#es% T"e en0!#es #ost sensiti*e to (l&oride d&rin' t"e
(or#ation o( acid is enolase and in t"e (or#ation o( pol!sacc"arides it is
p"osp"o'l&co#&tase% Also it in"iits t"e 'l&cose trans(er across t"e cell $all%
/
.) I!)ro/e toot, !or),o"o-y:#
T"e areas o( teet" #ost s&sceptile to dental caries are t"e occl&sal s&r(aces
and t"ose $it" t"e deep (iss&res% T"e (l&oride tend to #a+e t"e teet" sli'"tl!
s#aller and #ore i#portant) s"allo$er (iss&res%
F"&ories %or Caries Pre/ention:
S!ste#ic
Topical
S!ste#ic (l&orides Topical (l&orides
Hater (l&oridation
Salt (l&oridation
Mil+ (l&oridation
Fl&oride s&pple#ents
Sodi&# (l&oride
Stanno&s (l&oride
Acid&lated p"osp"ate (l&oride
Fl&oride *arnis"
Fl&oride denti(rices
Fl&oride #o&t" rinse
$) Sa"t %"&oriation:
In S$it0erland in t"e earl! 1,B.2s) initiall! t"e (l&oride concentration &sed
$as ,.#'F@+') later t"e! increased t"e concentration to 3B.#'F@+') eca&se t"e
initial concentration &sed $as too lo$ (or t"e #ost e((ecti*e cariostasis%
') Mi"0 %"&oriation:#
Mil+ (l&oridation is t"e addition o( a #eas&red 4&alit! o( (l&oride to ottled
or pac+a'ed #il+% Alt"o&'") s&stantial red&ction in caries is oser*ed $it" #il+
,
(l&oridation% Mil+ (l&oridation started in S$iss cit! o( Hintert"en in 1,BB)
pro#oted ! ?ei'ler%
*) F"&orie ta1"ets:#
T"e! are #an&(act&red as)
a= talets or drops) intended to e s$allo$ed
= talets o( c"e$in'
c= lo0en'es
S&pple#ents contain a #eas&red a#o&nt o( (l&oride) t!picall! .%3B #')
.%B#' or 1%.#') &s&all! as sodi&# (l&oride &t so#eti#es as acid&lated
p"osp"ate (l&oride) potassi&# (l&oride or calci&# (l&oride%
Dail! dosa'e o( (l&oride) reco##ended ! ADA9:
A-e F"&orie concentration in rin0in- +ater
234' 34' 5 346
. D 3 !ears
3 :; !ears
; D 1E !ears
.%3B #'
.%B #'
1%. #'
.
.%3B #'
.%B #'
To)ica" F"&ories:
Topical (l&orides (or t"e pre*ention o( dental deca! are t"e #ost $idel!
&sed dental prod&cts at "o#e and in dental clinics% Jenerall!) "i'" (l&oride
concentration a'ents are applied pro(essionall! and lo$:(l&oride concentration
a'ents or prod&cts are applied ! t"e indi*id&als t"e#sel*es%
1.
Pro%essiona""y a))"ie %"&ories:
1) Soi&! %"&orie:# Introd&ced ! >i! and 6n&tson in 1,A.
T"e #ost accepted #et"od o( NaF application is 6n&tson2s tec"ni4&e)
$"ere 3K NaF sol&tion is &sed%
Mec"anis# o( action9:
Ca
1.
<PO
A
=
E
<OH=
3
I OH

1.CaF
3
I EPO
A

I 3OH

Hi'" concentration o( (l&oride <,)... pp#= in 3K NaF d&e to $"ic"


sol&ilit! prod&ct o( CaF
3
'ets e1ceeded (ast and t"is initial rapid reaction is
(ollo$ed ! drastic red&ction in its rate) t"is p"eno#enon is called as c"o+in' o((%
F&rt"er CaF
3
reacts $it" "!dro1!apatite to (or# (l&oridated "!dro1!apatite%
CaF
3
I 3Ca
B
<PO
A
=
;
OH 3Ca
B
<PO
A
=
;
F I Ca<OH=
3
$) Stanno&s %"&orie:# Introd&ced ! D&ddin' F M&"ler in 1,E3
M&"ler co#pared t"e e((ecti*eness o( NaF and SnF
3
F (o&nd t"at SnF
3
o(
t"e sa#e concentration as t"at o( NaF is #ore e((ecti*e in red&cin' t"e incidence
o( caries%
Concentration a*ailale /K to red&ce t"e n&#er o( applications% SnF
3
is
prepared (res"l! as it "as no s"el( li(e% it is prepared ! dissol*in' .%/ '#s o(
po$der in 1. #l distilled $ater%
To)ica" a))"ications:#
Mec"anis# o( action9:
At lo$ concentration
Ca
B
<PO
A
=
;
OH I 3SnF
3
3CaF
3
I Sn
3
<OH=PO
A
I Ca
;
<PO
A
=
3
11
At "i'" concentration <1,B.. pp#=
Ca
B
<PO
A
=
;
OH I 1ESnF
3
CaF
3
I 3Sn
;
F
;
PO
A
I Sn<OH= PO
A
I ACaF
3
<SnF
;
=
3
Stanno&s tri(l&oro Calci&#
p"osp"ate tri(l&oro
stannate
3 Ca
B
<PO
A
=
;
OH I CaF
3
3Ca
B
<PO
A
=F I Ca<OH=
3
') Aci&"ate ),os),ate %"&orie:#
Introd&ced ! >r&de*old and "is co$or+ers $"o s!ste#atic in*esti'ation
to (ind o&t an opti#al (l&oride acid sol&tion $"ic" $o&ld pro*ide #a1i#al
(l&oride deposition $"ile ca&sin' #ini#al de#inerali0ation and reported t"at
p"osp"ate containin' (l&oride #a1i#&# ene(icial e((ect%
APF sol&tions &s&all! contains 1%3;K (l&oride in .%1M p"osp"oric acid at
pH o( ;%.%
To)ica" a))"ication:#
Mec"anis# o( action9: H"en APF is applied to t"e teet") it initiall! leads to t"e
de"!dration and s"rin+a'e in t"e *ol&#e o( "!dro1!apatite cr!stal $"ic" on
(&rt"er "!drol!sis (or#s an inter#ediate prod&ct called Dicalci&# p"osp"ate
de"!drate% T"is is "i'"l! reacti*e $it" (l&oride and start (or#in' i##ediatel!
$"en APF is applied and (l&oride penetrate into t"e cr!stals #ore deepl! and leads
to (or#ation o( (l&oroapatite%
13
Co#parati*e clinical c"aracteristics o( topical (l&oride sol&tion9:
C"aracteristic NaF SnF
3
APF
Percent 3K /K 1%3;K
Pp# (l&oride ,... 1,B.. 13);..
Fre4&enc! o(
application
A ti#es at $ee+l!
inter*al at a'e ;) -)
1. F 1;
Once@ !ear T$ice@ !ear
Taste >land Metallic Acidic
Stailit! Stale Unstale Stale in plastic
container
Toot"
pi'#entation
No Les No
Jin'i*al irritation No Occasional No
A*era'e e((ecti*e 3,K ;3K 3/K

F"&orie Varnis,:
T"e cariostatic e((ect o( topical (l&oride a'ents "as een related to t"eir
ailit! to deposit (l&oride in t"e ena#el and t"eir dept" o( penetration% T"e #ost
co##onl! &sed *arnis"es are9:
1= D&rap"at <NaF *arnis" containin' 3%3EK (l&oride in or'anic lac4&er=%
3= Fl&orprotector <saline (l&oride containin' .%-K (l&oride in a pol!&ret"ane
ased lac4&er=%
D&rap"at "ardens into a !ello$is" ro$n coatin' in t"e presence o( sali*a
<33E.. pp# (l&oride=%
Fl&orprotector lea*es a clear) transparent (il# on t"e teet" <-... pp#
(l&oride=
1;
Met,o o% A))"ication:#
Mec"anis# o( action9: H"en d&rap"at is applied to t"e s&r(ace) a reser*oir o(
(l&oride ions 'ets &ilt &p aro&nd t"e ena#el% Fro# t"is) (l&oride +eeps on slo$l!
releasin' and contin&o&sl! reactin' $it" t"e "!dro1!apatite cr!stals o( ena#el
o*er a lon' period o( ti#e leadin' to deeper penetration o( (l&oride and (or#ation
o( (l&orapatite%
1. Ca<PO
A
=
;
OH I 1.F

ECa
B
<PO
A
=
;
F I 3CaF I ECa
;
F"&orie Denti%rices:#
Toot" r&s"in' $it" a (l&oride denti(rice is ! (ar t"e #ost co##on (or#
o( caries control in &se toda! and can e &sed e((ecti*el! in indi*id&als o( all a'es%
Denti(rices contain di((erent t!pes o( (l&oride co#po&nd s&c" as NaF) SnF
3
)
sodi&# #ono(l&orop"osp"ate or a#ine (l&oride%
Co##onl! &sed arasi*es $it" sodi&# (l&oride are calci&#
p!rop"osp"ate) "!drated silica) sodi&# icaronate) insol&le sodi&#
#etap"osp"ate) acr!lic pol!#er%
Reco##endations (or (l&oride denti(rice in c"ildren9:
>elo$ A !rs Fl&oride toot" paste is not reco##ended%
A D E !rs >r&s"in' once dail! $it" (l&oride toot" paste and ot"er t$o ti#es
$it"o&t (l&oride toot" paste%
E D 1. !rs >r&s"in' t$ice dail! $it" (l&oride toot" paste and once $it"o&t
(l&oride toot" paste%
Ao*e 1. !rs >r&s"in' t"rice dail! $it" (l&oride toot" paste%
F"&orie Mo&t,rinse:#
1A
T"e ene(its (ro# (l&oride #o&t"rinsin' ran'e (ro# 3.K : B.K less deca!%
Mo&t"rinses can e &sed dail! or $ee+l! ased on t"e concentration o( t"e
co#po&nd &sed%
Co#position and &sa'e o( (l&oride #o&t"rinses9
So&rce o% %"&orie F"&orie 7 Content ))! Reco!!ene
&sa-e
NaF
NaF
NaF
APF
SnF
3
.%3K
.%.3K
.%.BK
.%.3B
.%1.K
,..
,.
33B
3..
3A;
Hee+l!
T$ice dail!
Dail!
Dail!
Dail!
IODINE:
Miller <1,/.= reported t"e intraoral &se o( iodine sol&tion as an
antiacterial #o&t"rinse% T"e actericidal e((ecti*eness is not ti#e dependent i%e%
it +ills #icroor'anis#s i##ediatel! once contact $it" t"e or'anis#s is
estalis"ed%
Disa/anta-e:#
: Metallic taste
: Tendenc! to stain silicate or co#posite restoration
8is#8i-&anies:
T"e t$o #ost co##on co##erciall! a*ailale is:i'&anides are D
a= C"lor"e1idine = Ale1idine
T"e! are e((ecti*e anti:pla4&e a'ents and t"&s potential anticaries a'ents%
1B
Topical antiseptics c"aracteri0ed ! #olec&lar str&ct&re "a*in' ot"
"!drop"oic and "!drop"ilic constit&ents and possess a net positi*e c"ar'e at
p"!siolo'ic pH%
Moe o% action:
a= Ionic adsorption o( ne'ati*el! c"ar'ed acterial s&r(ace
= Interaction $it" and da#a'e to per#eailit! arrier o( c!toplas#ic
#e#rane
c= Penetration into cells and s&se4&ent penetration o( c!toplas#ic
constit&ents and c&l#ination in #e#rane lea+a'e and cell deat"%
SILVER NITRATE:
Sil*er nitrate i#pre'nation o( teet" $as &sed clinicall! (or #an! !ears to
pre*ent or arrest dental caries% T"e earlier $or+er elie*ed t"at sil*er Cpl&''ed2
t"e ena#el) eit"er t"e or'anic in*asion pat"$a!s s&c" as t"e ena#el la#ellae or
t"e or'anic pat"$a!s) co#inin' $it" t"e sol&le inor'anic portion o( ena#el to
(or# less sol&le co#ination%
9inc C,"orie an Potassi&! Ferro cyanie:
Jottlei proposed t"at i#portance o( protein #atri1 o( t"e ena#el in dental
caries process% T"e &se o( 0inc c"loride and potassi&# Ferro c!anide $o&ld
e((ecti*el! i#pre'nate t"e ena#el and seal o(( caries in*asion pat"$a!s%
S&stances $"ic" inter(ere $it" t"e de'radation t"ro&'" en0!#atic alterations9:
a= Vita#in 6
= Sarcoside
1E
S&stances $"ic" inter(ere $it" acterial 'ro$t" and #etaolis#9:
a= Urea F a##oni&# co#po&nds
= C"lorop"!ll
c= Nitro(&rins
CARIES VACCINE:
T"e elie( t"at acteria are in*ol*ed in t"e pat"o'enesis o( dental caries
$as clearl! e1pressed in a paper ! Under$ood and Miller p&lis"ed in 1//1%
Since t"e dental caries (&l(ills t"e criteria o( t"e in(ectio&s disease) t"e
possiilities o( t"e *accination "a*e een considered% CVaccine2 is an i##&no:
iolo'ical s&stance desi'ned to prod&ce speci(ic protection a'ainst t"e 'i*en
disease% It sti#&lates t"e prod&ction o( protecti*e antiod! and ot"er i##&ne
#ec"anis#%
O*er t"e past #an! !ears) t"ere "as een a st&d! acc&#&lated o( e*idence
t"e S%#&tans is t"e acteri&# #ost inti#atel! associated $it" t"e initiation and
de*elop#ent o( cario&s lesion%
Mec,anis! o% action o% a /accine:
Since i##&ne response cannot e #o&nted *ia ena#el) t"e onl! $a! in
$"ic" i##&ne ele#ent can reac" t"e or'anis# responsile (or dental caries is (or
t"e# to lierate into sali*a or in t"e cases o( cell to #i'rate o*er t"e toot" s&r(ace%
Protection a'ainst dental caries ! i##&ni0ation $o&ld e ac"ie*ed ! i##&ne
co#ponents (ro# ser&#) ! I'A antiodies in sali*ar! secretions%
1-
T"e #a5or i##&no'lo&lin in sali*a is secretor! I'A and /.K o( I'J is
present in /.K o( t"e total i##&no'lo&lin in ser&#% T"e #olec&lar con(i'&ration
renders t"e secretar! I'A antiod! e1ceptionall! resistant to di'estion !
proteol!tic en0!#es conse4&entl!) it can (&nction "i'"l! e((ecti*el! in oral
en*iron#ent $"ic" contain #icroial proteases%
E*en i( an anticaries *accine $ere de*eloped) t"e concern re#ain t"at #a!
a((ects its $idespread &se%
First9:t"e potential side e((ect o( caries *accine s"o&ld e identi(ied% Sa(et! o( s&c"
*accines "as not een de#onstrated in (act t"ere is concern o( a possile cross
reaction $it" "&#an "eart tiss&e%
Second9: Its cost #&st e co#pared $it" p&lic $ater (l&oridation $"ic" is
ine1pensi*e and alread! *er! e((ecti*e in t"e (l&oride t"erap!%
T"ird9: Li#itation i#posed ! 'o*ern#ental re'&lator! a'encies #a! a((ect t"e
$idespread &se o( anticaries *accine%
NUTRITIONAL MEASURES:
Diet:# T"e role o( diet and n&tritional (actors deser*e special consideration
eca&se o( t"e o(ten oser*ed di((erences in caries incidence o( *ario&s pop&lation
$"o s&sist on dissi#ilar diets%
O1:ecti/es o% Dietary Ana"ysis:
1= To pro*ide an opport&nit! (or patient to st&d!) o5ecti*el! personal dietar!
"aits%
3= To otain an o*erall pict&re o( t"e t!pe o( (ood in t"e patient diet) (ood
pre(erence and 4&alit! o( (ood eaten%
1/
;= To st&d! t"e (ood "aits $it" partic&lar re(erence to (re4&enc! and re'&larit!
o( eatin' and t"e order in (ood is ta+en%
A= To record (or st&d! and (&t&re co#parison o( t"e t!pes and (re4&enc! o( &se o(
potential cario'enic (ood%
B= To deter#ine t"e o*erall (re4&enc! o( cario'enic e1pos&re $it" clinical and
radiolo'ic (indin's res&ltin' in caries acti*it! test%
E= To pro*ide a asis (or #a+in' indi*id&al reco##endation (or c"an'es in diet)
i#portant to t"e "ealt" o( t"e oral #&cosa and t"e pre*ention o( dental caries%
Ro"e o% Car1o,yrates in caries e/e"o)!ent:
Dental caries is t"e co##on pla4&e dependent acterial in(ection t"at is
stron'l! a((ected ! diet% De*elop#ent o( clinical caries is contin'ent &pon t"e
interaction o( t"e t"ree local (actors in t"e #o&t"%
a= S&sceptile toot"
= Cario'enic acteria
c= Fer#entale caro"!drates
Asence o( an! one o( t"e (actors dra#aticall! red&ces t"e caries ris+%
M&tans streptococci are t"e predo#inant oral acteria t"at initiate t"e caries
process% H"en t"e starc"es and s&'ars are (er#ented ! cario'enic acteria)
or'anic acids are prod&ced $"ic" de#inerali0es t"e dental ena#el% T"&s (or t"e
patient $it" "i'" ris+ o( caries) t"e dietar! co&nselin' ao&t t"e da#a'in' e((ect
o( (er#entale caro"!drates on t"e teet" are essential%
Deca! pro#otin' eatales are s&'ar <s&crose=) corn s$eeteners <ABK
'l&cose I BBK (r&ctose=) #il+ <lactose=) "one! <ABK (r&ctose I ;BK 'l&cose I BK
1,
s&crose= and "i'"l! re(ined coo+ed starc" s&'ar co#ination s&c" as Do&'"n&ts)
coo+ies) potato c"ips and read! to eat rea+(ast cereals $"ic" prod&ce a prolon'ed
acido'enic response $"en retained in t"e interpro1i#al spaces% H"en t"e starc"es
are coo+ed t"e! are partiall! de'raded% T"is allo$ :a#!lase to con*ert starc"
particles retained on t"e ton'&e) oral #&cosa and teet" to #altose% Ma+in' #altose
a*ailale to pla4&e) pH $ill re#ain lo$ and per#it #ore de#inerali0ation to
occ&r%
Ot,er %actors a%%ectin- enta" ecay:
Fre4&enc! o( eatin'9: T"e positi*e relations"ip et$een t"e (re4&enc! o( s&'ar
inta+e in "&#ans and dental caries $as (irst de#onstrated in Vipe"ol# st&d!%
S&5ects $"o cons&#ed candies in et$een t"e #eals de*eloped #ore caries
t"an t"ose $"o $ere (ed e4&al a#o&nt o( s&'ars $it" #eals%
One snac+ et$een t"e #eals is not "ar#(&l eca&se t"ere is a ti#e (or
re#inerali0ation o( cario&s lesions% Ho$e*er snac+in' #an! ti#es t"ro&'"o&t
t"e da! +eeps t"e pla4&e pH lo$ and e1tends t"e ti#e (or ena#el
de#inerali0ation%
P"!sical (or# o( caro"!drates9: >acterial (er#entation can contin&e as lon'
as caro"!drate ad"eres to t"e dental ena#el s&r(ace% Solid (oods t"at are
retained on t"e toot" s&r(aces (or prolon'ed periods o( ti#e and can e1tend t"e
acid prod&ction e!ond E. #in&tes% T"&s retenti*e (oods are #ore li+el! to
prod&ce #ore toot" deca! t"an s&crose s$eetened sol&tions li+e 5&ices and
p&nc"es $"ic" are cleared (ro# t"e #o&t" easil!%
3.
Se4&ence o( (ood9: Co((ee $it" s&'ar cons&#ed at t"e end o( a #eal ca&ses t"e
pla4&e pH to re#ain lo$ (or lon'er ti#e t"an $"en &ns$eetened (ood is eaten
(ollo$in' inta+e o( co((ee $it" s&'ar% H"en c"eese is eaten (ollo$in' t"e
s&crose rinse) t"e pH re#ains "i'"er t"an t"ose $"en no c"eese (ollo$s a
s&crose rinse%
Re/ie+ artic"es on t,e re"ations,i) 1et+een s&-ar ;iet) an enta" caries:
A&t,or;s) Main conc"&sions
Mart"aler <1,E-= Food st&((s containin' si#ple s&'ars are (ar #ore
cario'enic t"an co##on starc"! (oods%
Ne$r&n <1,E,= Called (or t"e speci(ic eli#ination o( s&crose or s&crose:
containin' (oods rat"er t"an restrictin' total caro"!drate
cons&#ption%
>i! <1,-B= Snac+ (oods s"are i#portance $it" s&crose in caries
ca&sation%
Sreen! <1,/3a= Total cons&#ption and (re4&enc! o( inta+e contri&te to
dental cariesM lac+in' e*idence ao&t t"e precise de(inition
o( t"e relations"ip%
Ne$r&n <1,/3= Co#pellin' e*idence t"at t"e proportion o( s&crose in a
(ood is one i#portant deter#inant o( its cario'enicit!%
S"ei"a# <1,/;= S&'ar is t"e principal ca&se o( caries in ind&striali0ed
co&ntriesM reco##ended t"at s&'ar cons&#ption e
red&ced to 1B +'@person@!ear or elo$%
S"a$ <1,/;= St&dies in ani#als consistent $it" t"e clinical e*idence on
t"e relations"ip et$een s&'ar and caries%
R&'':J&nn <1,/E= Cario'enicit! o( staple starc"! (oods is lo$M t"e addition
o( s&crose to coo+ed starc" is co#parale to si#ilar
4&antities o( s&croseM (res" (r&its appear to "a*e lo$
cario'enicit!%
31
>o$en and >ir+"ed
<1,/E=
Fre4&enc! o( eatin' s&'ars is o( 'reater i#portance t"an
total s&'ar cons&#ption%
Hal+er F Cleaton:
Nones <1,/,=
De'ree o( incri#ination o( s&'ar as a ca&se o( caries is
'rossl! e1a''eratedM 4&estioned predictions o( red&ctions
in caries (ro# decreases in s&'ar and snac+ inta+es%
Mart"aler <1,,.= In spite o( dra#atic red&ctions in caries d&e pri#aril! to
$idespread &se o( (l&oride) s&'ars contin&e to e t"e #ain
t"reat to dental "ealt"%
R&':J&nn <1,,.= Dietar! #odi(ication in*ol*in' restriction on t"e
(re4&enc! and a#o&nt o( e1trinsic s&'ars can e #ore
e((ecti*e t"an ot"er control #eas&res%
6oni' and Na*ia
<1,,B=
Ac+no$led'ed t"e relations"ip et$een (re4&enc! and
s&'ar inta+e and caries9 reco##ended re#o*in' t"e (oc&s
a$a! (ro# eli#ination o( s&'ar and to$ards i#pro*ed oral
"!'iene and &se o( (l&oride toot"paste%
R&1ton et al% <1,,,= E*idence stron'l! s&pports (or#&lation o( ad*ice on
(re4&enc! o( cons&#ption) not a#o&nt%
6oni' <3...= Dental "ealt" prole#s do not re4&ire an! dietar!
reco##endations ot"er t"an t"ose re4&ired (or
#aintenance o( 'eneral "ealt"%
Van Lo*eren <3...= I( 'ood oral "!'iene is #aintained and (l&oride is s&pplied
(re4&entl!) teet" $ill re#ain intact e*en i( caro"!drate:
containin' (ood is (re4&entl! eaten%
S"ei"a# <3..1= S&'ars) partic&larl! s&crose) are t"e #ost i#portant dietar!
ca&se o( cariesM t"e inta+e o( e1trinsic s&'ars 'reater t"an
A ti#es a da! increases caries ris+M s&'ar cons&#ption
s"o&ld not e1ceed E. '@da! (or teena'ers and ad&lts and
proportionall! less (or !o&n'er c"ildren%

33
C"assic e/ience %ro! ,&!ans s&))ortin- t,e ro"e o% s&-ar in enta" caries:
St&y Re%erence;s) Main conc"&sions
Vipe"ol# st&d! J&sta(sson et al%
<1,BA=
T"e #ore (re4&entl! s&'ar is cons&#ed t"e
'reater t"e ris+M s&'ar cons&#ed et$een
#eals "as #&c" 'reater caries potential
t"an $"en cons&#ed d&rin' a #eal%
T&r+& S&'ar
St&d!
Sc"einin et al%
<1,-E=
H"en s&'ars are al#ost co#pletel!
replaced ! non:(er#entale s&'ar
s&stit&tes <1!litol=) caries incre#ent is
dra#aticall! red&cedM (r&ctose is less
cario'enic t"an s&crose%
Horld Har II To*er&d
<1,B-a)=
Te+e&c"i <1,E1=
Caries decreased and increased $it" s&'ar
cons&#ption d&rin' and a(ter t"e $ar)
respecti*el!%
Hope$ood
Ho&se
Harris <1,E;= Modern diet ore cario'enic t"an *e'etarian
lo$ s&'ar diet%
Tristan da
C&n"a
Hollo$a! et al%
<1,E;=) Fis"er
<1,E/=
Introd&ction o( a #odern diet incl&din'
s&'ar and re(ined caro"!drates to t"is
re#ote island 'reatl! increased caries
pre*alence%
Hereditar!
Fr&ctose
Intolerance
Mart"aler <1,E-=)
Ne$r&n et al%
<1,/.=
Less caries in indi*id&als t"at #&st a*oid
s&crose and (r&ctose) &t not ot"er s&'ars
and co#ple1 caro"!drate%
E1peri#ental
Caries in Man
Von der Fe"r et
al% <1,-.=)
Jeddes et al%
<1,-/=
Incipient caries can e rapidl! ind&ced !
(re4&ent rinsin' $it" "i'":concentration
s&crose sol&tions in t"e asence o( oral
"!'iene%
Step"an Pla4&e
pH Response
Step"an <1,A.)
1,AA=
De#onstrated t"e relations"ip et$een
s&'ar e1pos&re res&ltin' in t"e
acidi(ication o( dental pla4&e and caries
e1perience
Data %ro! nationa" S&r/eys:
3;
Re%erence Para!eters Main %inin-s< conc"&sions
Sreen! <1,/3= d#(t in E:!ears olds
(ro# 3; nations and
DMFT in 13:!ear:olds
(ro# A- nationsM s&'ar
s&ppl! <'@person@da!=
Si'ni(icant positi*e correlation
<rO.%-3M pP.%..B= et$een caries
pre*alence and national s&'ar
s&pplies (or 13:!ear:olds onl!M
in'estion o( B. ' o( s&'ar@da! #a!
e t"e &pper li#it o( Csa(e2 or
Cacceptale2 s&'ar cons&#ption%
Hood$ard and
Hal+er <1,,A=
DMFT in 13:!ear olds
(ro# ,. nationsM s&'ar
s&ppl! <+'@person@!ear=
Linear relations"ip et$een DMFT
and s&'ar cons&#ption $"en all ,.
nations $ere incl&dedM no e*idence
o( a relations"ip $it" a separate
anal!sis o( 3, ind&strali0ed
nations%
Mi!a0a+i and
Mori#oto <1,,E=
DMFT in 13:!ear olds
<+' s&'ar@!ears=M 1,B-:
1,/-M lo$ (l&oride
e1pos&re
E1cellent correlation <rO.%,1M
pP.%.1= et$een DMFT and per
capita s&'ar cons&#ption in Napan%
*an Palenstein
Helder#an et al%
<1,,E=
Caries e1perience in
A(rica) E&rope and
Nort" A#ericaM sali*ar!
#&tans Streptococci
Caries e1perience on t"ree
continents is attri&tale to dietar!
di((erences and not pre*ailin'
#&tans streptococci species%
Da$ner <1,,,= d#(t in B:!ear olds and
DMFT in 13:!ear oldsM
a*ailale s&'ar
<+'@person@ !ear=
Stron' positi*e correlation o*er
ti#e <B. !ears= et$een caries
e1perience and national s&crose
a*ailailit! in t"e U6%
For! Fre=&ency Points
Li4&id9 so(t drin+s) (r&it drin+s) s&'ar and "one! in
e*era'es) ice crea#) 'elatin dessert) (la*ored !o'"&rt
QQQ 1 B O
3A
Solid F stic+!9 Ca+e) c&pca+es) don&ts) s$eet rolls)
pastr!) canned (r&it in s!r&p) ananas) coo+ies) c"ocolate
cand!) 5ell! ea#s) c"e$in' '&#s) 5a#s%
QQQ 1 1. O
Slo$l! dissol*in'9 "ard candies) reat" #ints) antacid
talets) co&'" drops%
QQ 1 1BO
Total score O
E/a"&ation o% s+eet scores:
S,ort:# To assess t"e cario'enic potential o( t"e diet t"e client records a 3A "r diet
t"at represents t"e clients t!pical eatin' patterns% T!pe and a#o&nt o( eac" (ood
eaten) (ood preparation and ti#e o( da! t"e (ood $as not eaten are reported%
T"e 3A "r diet recall is t"en &sed to calc&late t"e cario'enic potential o( t"e
diet% T"e s&'ar in'ested reported on t"e 3A "r diet (or# is cate'ori0ed accordin' to
li4&id s&'ars) solid and stic+! s&'ars and slo$l! dissol*in' s&'ars% T"e (re4&enc!
$it" $"ic" eac" s&'ar is in'ested and #&ltiplied ! B) 1. or 1B dependin' on t"e
s&'ar so&rce%
A s$eet score o( 1B or #ore indicates t"at t"e indi*id&al is needed o( t"e
n&tritional co&nselin' to red&ce t"e cario'enic potential o( "is or "er diet%
Hea+ lon'9: T"e sa#e proced&re is done (or a $ee+ lon' to e*al&ate t"e caries
potential o( t"e di((erent eatales%
3B
Dietary reco!!enations %or t,e re&ction o% enta" caries:
Li#it t"e &se o( (er#entale caro"!drates to #ealti#e% Foods ot"er t"an
caro"!drates ser*e as &((er to "elp ne&trali0e t"e pla4&e acids%
O#it s$eet (oods e*en $it" #eals i( t"e client is s&sceptile to caries%
>et$een #eal snac+s s"o&ld consist o( protecti*e non:cario'enic (ood s&c" as
ra$ *e'etales% Ra$) &nre(ined (oods in t"e *e'etale and (r&it 'ro&p re4&ire
c"e$in'% T"e c"e$in' action increases t"e sali*ar! (lo$) t"&s aidin' t"e
re#o*al and dil&tion o( s&'ars and t"eir "ar#(&l !prod&cts%
Use a (e$ concentrated s$eets in t"e preparation o( (oods as possile%
Do not eat s$eets e(ore edti#e &nless t"e teet" are r&s"ed% Sali*ar! (lo$
decreases at ni'"t and (oods are not readil! cleared (ro# t"e #o&t" as t"e! are
d&rin' $a+in' "o&rs% Acid le(t &ndist&red re#ain in t"e #o&t" (or 1 R to 3
"rs%
A*oid nat&ral s&'ars as t"e! are detri#ental to t"e toot" s&r(ace as re(ined
s&'ars%
A*oid stic+! (oods eca&se t"e! are retained in t"e #o&t" lon'er t"an non:
stic+! (ood%
Use o( s&'ar alco"ols) t"e #ost $idel! s&ed s&'ar alco"ols are9 1!liol) soritol)
#annitol) #altitol) lactitol and t"e prod&cts l!casin and palatinit% S!litol in
c"e$in' '&# #a! red&ce t"e dental pla4&e% C"e$in' s&'ar (ree '&#s ; or
#ore ti#es dail! (or prolon'ed periods o( ti#e #a! red&ce caries incidence
irrespecti*e o( t"e t!pe o( s&'ar alco"ol &sed%
3E
Usin' c&rrent diet patterns as t"e asis (or disc&ssion patient s"o&ld e ta&'"t
t"e role o( diet in caries) di((erences et$een cario'enic and non:cario'enic
eatin' patterns and "o$ to adapt c&rrent diet to lo$er t"e cario'enic ris+%
T"e #et"ods o( control o( caries can e classi(ied into ; 'eneral t!pes9:
a= C"e#ical
= N&tritional #eas&res
c= Mec"anical #eas&res
A) C,e!ica":
A last n&#er o( c"e#ical s&stances "a*e een proposed (or t"e p&rpose
o( controllin' dental caries%
>isi'&anides9: C"lor"e1idine D anticario&s e((ecti*eness o( c"lor"e1idine is #ore
prono&nced (or s#oot" s&r(ace caries t"an (or pit and (iss&re caries%
Side e((ects9:
a= Transient di#in&tion o( t"e taste sensation
= Parotitis
c= M&cosal irritation and des4&a#ation
d= Aller'ic reaction
1= Sil*er nitrate9: So#e st&dies s"o$ t"at sil*er nitrate is ine((ecti*e in caries
pre*ention%
It inter(eres $it" caro"!drate de'radation t"ro&'" en0!#atic alteration%
T"ere are #an! s&stances t"at "a*e ailit! to inter(ere $it" t"e en0!#e s!ste#s
responsile (or caro"!drate de'radation and s&se4&ent (or#ation o( acid% I(
3-
s&c" an in"iitor is e((ecti*e in clinical preparation o( dental caries) it #&st reac"
t"e s&sceptile areas o( t"e #o&t" in s&((icient concentrations%
Vita!in >:
S!nt"etic *ita#in 6 <3 #et"!l:1)A:napt"o4&inone= in pre*ention o( caries
in *itro st&dies% He (o&nd t"at *ita#in 6 pre*ents t"e acid (or#ation in inc&ated
#i1t&res o( 'l&cose and sali*a%
In anot"er st&dies "a*e tested t"e clinical e((ecti*eness o( *ita#in 6% a
'ro&p o( st&dents recei*ed a c"e$in' '&# containin' t"e s!nt"etic *ita#in 6 and
sodi&# is&l(ite and $ere instr&cted to c"e$ t"is 'er# (or at least 1. #in a(ter
eatin' an! (ood%
T"e control 'ro&p recei*ed t"e sa#e c"e$in' '&# $it"o&t t"e *ita#in 6%
T"e occ&rrence o( ne$ ca*ities $ere deter#ined at 13 and 1/ #ont"s inter*als) it
$as (o&nd t"at t"e incidence o( ne$ cario&s lesions $as decreased ! ,/K and
A3K respecti*el! (or t"e t$o inter*als in t"e e1peri#ental 'ro&p%
Sarcosie:
Fosdic+ and "is co:$or+ers in 1,B/) tested se*eral "&ndred co#po&nds and
noted t"at sodi&#:N:la&ro!l sarcosinate and sodi&# de"!droacetate $ere
pro#isin' en0!#e in"iitors or Cantien0!#e2%
>r&de*old and Little <1,BA= contin&ed in*esti'ation o( t"is sarcoide in
patients $"o r&s"ed t"eir teet" $it" sol&tion o( t"e #aterial and t"en #eas&red
t"e (all in pH o( pla4&e #aterial (ro# pro1i#al s&r(aces a(ter a s&'ar rinse% T"e
test $as ne'ati*e and it $as concl&ded t"at t"e sarcoside did not red&ce acid
prod&ction in s&s&r(ace%
3/
S&1stances +,ic, inter%ere +it, 1acteria" -ro+t, an !eta1o"is!:
De'radation o( caro"!drates to acid is pre*ented ! acterial 'ro$t" and
#etaolis#%
1) Urea an a!!oni&! co!)o&ns:#
Urea and a##oni&# co#po&nds "a*e een tested e1tensi*el! (or &se in
t"e oral ca*it! as anticario'enic a'ents% Hac" and "is associates <1,A3= reported
t"at a 4&inine:&rea sol&tion pre*ented acid (or#ation in tests in *itro on
caro"!drate sali*a #i1t&res% T"e! also noted t"at oral acteria co&nt $as
decreased a(ter t"e &se o( 4&inine &rea #o&t"$as"%
Step"an <1,A;= contin&ed t"e st&d! o( &rea applied to dental pla4&es (or
se*eral #in&tes pre*ented t"e t!pical pH (all) (ollo$in' a caro"!drate rinse (or
periods &p to 3A "rs%
Alt"o&'" so#e st&dies indicate t"at a##oniated denti(rices are capale o(
prod&cin' so#e red&ction in dental caries incidence) t"e #a'nit&de o( t"is
reaction is not so 'reat as to 5&sti(! reco##endin' t"e# (or $idespread &se as an
anticario'enic a'ent%
$) C,"oro),y"":#
C"lorop"!ll is t"e 'reen pi'#ent o( plants) as "as een proposed as an
anticario'enic a'ent% S"a(er F S"a(er <1,B.= reported t"at a $ater sol&le (or# o(
c"lorop"!ll% Sodi&# copper c"lorop"!ll $as capale o( pre*entin' or red&cin' t"e
pH (all in caro"!drate D sali*a #i1t&res in *itro%
3,
Jri((itts F Rapp <1,B.= and 6n&tson F >i! <1,B1= reported t"e
acteriostatic $it" respect to #an! oral #icroor'anis# incl&din' lactoacilli)
streptococci and #icrococci%
Nitro%&rans::
T"e! are t"e deri*ati*es o( F&rans% T"e! "a*e een (o&nd to e1ert a
acteriostatic and acteriocidal action on #an! 'ra# positi*e and 'ra# ne'ati*e
#icroor'anis#s%
No"n and associates <1,B1= reported t"at e*en in lo$ concentrations) acid
prod&ction in sali*a (ro# caries acti*e person $as pre*ented%
Anti1iotics:
1= Penicillin9: Anticario'enic co#pared eca&se o( antiiotic propert!% Hill
st&died t"e e((ect o( dentri(ices containin' 1... &nits o( Penicillin per 'ra#)
on t"e oral lactoacill&s co&nts o( a 'ro&p o( 1. st&dents% A re#ar+ale
red&ction (ro# an a*era'e o( -3)... colon! co&nt to an a*era'e o( ;.. $as
(o&nd a(ter &se o( t"e denti(rices (or B $ee+s%
3= Er!t"ro#!cin9: Ripa and associates (o&nd t"at a ;BK decrease in pla4&e
(or#ation a(ter a se*en da! test period o( rinsin') t"en s$allo$in' t"e a'ent A
ti#es a da!%
;= 6ana#!cin9: Loesc"e <1,-E= reported t"at 6ana#!cin "as een s"o$n to
red&ce pla4&e $ei'"t and to i#pro*e oral "ealt" in "&#an ein' retarded
s&5ects $"en &sed a topical paste% It red&ced t"e S%#&tans and S%san'&is
pop&lation in t"e pla4&e% Ot"er antiiotics li+e Lipna#!cin) Tetrac!cline)
T!rot"ricin) Vanco#!cin "a*e een s"o$n to e anticario'enic%
;.
Caries Vaccine:
T"e elie( t"at acteria are in*ol*ed in t"e pat"o'enesis o( dental caries
$as clearl! e1pressed in a paper ! Under$ood and Milles p&lis"ed in 1//1%
Since t"e dental caries (&l(ills t"e criteria o( t"e in(ectio&s decrease) t"e
possiilities o( t"e *accination "a*e een considered% CVaccine2 is an i##&no:
iolo'ical s&stance desi'ned to prod&ce speci(ic protection a'ainst t"e 'i*en
disease% It sti#&lates t"e prod&ction o( protecti*e antiod! and ot"er i##&ne
#ec"anis#s%
Vaccine deri*ed (ro# Latin $ord D a s&spension o( atten&ated or +illed
#icroor'anis# <acteria) *ir&ses or ric+etsiae= ad#inistered (or pre*ention)
a#elioration or treat#ent o( in(ectio&s diseases%
O*er t"e past #an! !ears) t"ere "as een a st&d! cond&cted $it" S%#&tans
is t"e acteri&# #ost inti#atel! associated $it" initiation and de*elop#ent o(
cario&s lesion% Laorator! st&dies "a*e (&rt"er s"o$n t"at streptococci is a
"etero'eno&s collection o( t"e or'anis# $"ic" can e s&di*ided into at least E
distinct species <Containin' strains o( serot!pes C) E and F=%
Cario'enicit! o( S%#&tans "as een related to9:
: Its &ni4&e co#ination o( properties i%e% ailit! to coloni0es on t"e teet"%
: To prod&ce e1tra and intra cell&lar pol!sacc"arides
: To prod&ce lar'e a#o&nt o( acids e*en at lo$ pH *al&es%
: To &tili0e sali*ar! 'l!coproteins%
A))ro)riate i!!&ni(ation a-ents:#
T"e s&cell&lar co#ponent $"ic" are c&rrentl! ein' serio&sl! proposed as
*accines are <a= Jl&cos!latrans(erases <JTF=) <= Hall associated proteins%
;1
a= Jl&cos!ltrans(erase <JTF=9: Jro&p o( t"e e1tracell&lar en0!#es in*ol*ed
in s!nt"esis o( pol!#er <'l&cans= (ro# s&crose%
= Hall associated proteins9: T$o p&ri(ied proteins (ro# s&r(ace o( S%#&tan
serot!pe C are c&rrentl! ein' s&''ested (or t"e &se o( t"e dental caries
*accine% T"is anti'en > s"o$s so#e asis o( t"e "&#an caries *accine and
"as t"e ad*anta'e o( ein' (o&nd in all serot!pe o( S%#&tans and
S%sorin+s% It co&ld t"ere(ore 'i*e a $ide:ran'in' protection% T"e ot"er
$all associated protein o( interest is anti'en A $"ic" is a s#all #olec&lar
$ei'"t cell $all protein%
Mec,anis! o% action o% a /accine:
Since local response cannot e #o&nted *ia ena#el) t"e onl! $a! in $"ic"
i##&ne ele#ents can reac" t"e or'anis#s responsile (or dental caries is (or t"e#
to lierated into t"e sali*a or in t"e case o( cells to #i'rate o*er t"e toot" s&r(ace%
Protection a'ainst dental caries ! i##&ni0ation $o&ld e ac"ie*ed !
i##&ne co#ponents (ro# ser&#) ! I'A antiodies in sali*ar! secretions%
T"e *ario&s st&dies "a*e done to (ind o&t t"e #ec"anis# o( action o( *accine9
C"allaco#e et al% <1,-/= stated t"at I'J antiodies (ro# ser&# reac" t"e
oral ca*it! t"ro&'" t"e 'in'i*al cre*ic&lar (l&id%
Se$ard <1,-1= stated t"at $"en t"e teet" er&pted t"e local in(la##ation is
co##on and d&rin' t"is ti#e ser&# antiodies #a! sti#&late opsonisation and
p"a'oc!tosis o( acterial cell%
;3
Hillia#s and Jion <1,-3= s"o$ed t"at t"e secretor! I'A antiodies in
"&#an sali*a "a*e een (o&nd to in"iit t"e attac"#ent o( S%san'&is to epit"elial
cells%
Dia'ra##atic ill&stration o( t"e t$o #ain i##&nolo'ical #ec"anis#
in*ol*ed in protectin' t"e "ost a'ainst dental caries ! i##&ni0ation%
T"e (irst #ec"anis# in*ol*es t"e secretor! I'A secreted in sali*a%
T"e second #ec"anis# in*ol*es t"e s!ste#ic i##&ne s!ste# an
prod&ction o( antiodies t"at tra*el t"ro&'" t"e 'in'i*al epit"eli&# into t"e
cre*ic&lar (l&id t"at at"es toot" and pla4&e%
T"e #a5or i##&no'lo&lin in sali*a is secretor! I'A and /.K o( I'J is
present in /.K o( t"e total i##&no'lo&lin in ser&#% T"e #olec&lar con(i'&ration
renders t"e secretor! I'A antiod! e1ceptionall! resistant to di'estion !
proteol!tic en0!#es conse4&entl!) 7It can (&nction "i'"l! e((ecti*el! in oral
en*iron#ent $"ic" contains #icroial proteases8%
E*en i( an anticaries *accine $ere de*eloped) t"e concerns re#ain t"at #a!
a((ect its $idespread &se% First) t"e potential side e((ect o( t"e caries *accine
s"o&ld e identi(ied) sa(et! o( s&c" *accines "as not een de#onstrated in (act
t"ere is concerns o( a possile cross reaction $it" "&#an "eart tiss&e% Second) its
cost #&st e co#pared $it" t"e p&lic $ater (l&oridation $"ic" is ine1pensi*e and
alread! *er! e((ecti*e at t"e (l&oride t"erap!%
T"ird) li#itations i#posed ! 'o*ern#ental re'&lator! a'encies #a! a((ect
t"e $idespread &se o( anticaries *accine%
;;
N&tritiona" Meas&res:
Diet: T"e role o( diet and n&tritional (actors deser*es special consideration
eca&se o( t"e o(ten oser*ed di((erences in caries incidence o( *ario&s pop&lation
$"o s&sist on disse#inator diets%
O1:ecti/es o% Dietary Ana"ysis:
a= To pro*ide an opport&nit! (or patient to st&d!) o5ecti*el! personal dietar!
"aits%
= To otain an o*erall pict&re o( t"e t!pes o( (ood in t"e patient diet) (ood
pre(erence and 4&antit! o( (ood eaten%
c= To st&d! t"e (ood "aits $it" partic&lar re(erence to (re4&enc! and re'&larit!
o( eatin' and t"e order in $"ic" t"e (ood is ta+en%
d= To record (or st&d! and (&t&re co#parison o( t"e t!pes and (re4&enc! o( &se o(
potential cario'enic (ood%
e= To deter#ine t"e o*erall (re4&enc! o( cario'enic e1pos&re $it" clinical and
radiolo'ic (indin's and res&ltin' in caries acti*it! test%
(= To pro*ide a asis (or #a+in' indi*id&al reco##endation (or c"an'es in diet)
i#portant to t"e "ealt" o( t"e oral #&cosa and t"e pre*ention o( dental caries%
Denta" caries: ro"e o% car1o,yrates in caries e/e"o)!ent:
Dental caries is t"e co##on pla4&e dependent acterial in(ection t"at is
stron'l! a((ected ! diet% De*elop#ent o( clinical caries is contin'ent &pon t"e
interaction o( t"e t"ree local (actors in t"e #o&t" D <a= s&sceptile toot") <=
cario'enic acteria) <c= (er#entale caro"!drate%
;A
Asence o( an! one o( t"ese (actors dra#aticall! red&ces t"e caries ris+%
M&tans streptococci are t"e predo#inant oral acteria t"at initiate t"e caries
process% H"en t"e starc"es and s&'ars are (er#ented ! cario'enic acteria)
or'anic acids are prod&ced $"ic" de#inerali0ed dental ena#el%
T"e presence o( ot"er #ineral s&c" as Ca) F) and P in pla4&e and sali*a
pro#ote re#inerali0ation o( incipient lesion% Ot"er "ost (actors t"at in addition ar
t"e sali*a containin' t"e &((erin' a'ents) icaronates and p"osp"ates t"at
ne&trali0es t"e or'anic acids%
Ot"er "ost (actors t"at in(l&ence t"e caries ris+M i##&ne stat&s) 'enetic
predisposition) #aln&trition d&rin' toot" (or#ation) ed&cation le*el and inco#e
stat&s% T"&s (or t"e patient $it" t"e "i'" ris+ o( caries t"e dietar! co&nselin' ao&t
t"e da#a'in' e((ects o( (er#entale caro"!drates on teet" are essential%
Decay )ro!otin- ietary )ro&cts:
1= S&crose9: Predo#inant role in de*elop#ent o( t"e caries on s#oot" s&r(ace%
One o( t"e s&crose #etaolic ! prod&ct) an e1tracell&lar pol!sacc"aride called
'l&can enales t"e #&tan streptococci to ad"ere to t"e s#oot" ena#el s&r(aces%
3= Corn s$eeteners9: Hi'" (r&ctose co# s!r&p is #i1t&re o( ABK 'l&cose and
BBK (r&ctose%
;= Mil+9: A so&rce o( lactose "as lo$ cario'enicit! e1cept $"en &sed in n&rsin'
ottle at ed ti#e%
A= Hone!9: ABK (r&ctose) ;BK 'l&cose and BK s&crose%
Hi'"l! re(ined coo+ed starc" s&'ar co#inations s&c" as do&'"n&ts)
coo+ies) potato c"ips and read! to eat rea+(ast cereals prod&ce a prolon'ed
;B
acido'enic response $"en retained in t"e interpro1i#al spaces% H"en t"e starc"es
are coo+ed t"e! are partiall! de'raded% T"is allo$s t"e :a#!lase to con*ert
starc" particles retained on t"e ton'&e) oral #&cosa and teet" to #altose%
Ma+in' #altose a*ailale to pla4&e pH $ill re#ain lo$ and per#it #ore
ena#el de#inerali0ation to occ&r% T"&s retenti*e) "i'" starc" (oods #a! e #ore
acido'enic t"an "i'" s&'ar@ lo$ starc" (oods t"at are rapidl! eli#inated (ro# t"e
#o&t"%
Ot,er %actors a%%ectin- t,e enta" caries:
1= Fre4&enc! o( eatin'
3= P"!sical (or# o( caro"!drate <li4&id *s% solid=
;= Retenti*eness o( a (ood on t"e toot" s&r(ace
A= Se4&ence in $"ic" t"e (oods are cons&#ed <e%'% c"eese eaten e(ore a
s$eet (ood li#its t"e pH drop=%
B= Presence o( #inerals in a (ood%
1) Fre=&ency o% eatin-:#
T"e positi*e relations"ip et$een t"e (re4&enc! o( s&'ar inta+e in "&#ans
and dental caries $as (irst de#onstrated in Vipe"ol# st&d!% S&5ects $"o
cons&#ed candies in et$een t"e #eals de*eloped #ore caries t"an t"ose $"o
$ere (ed e4&al a#o&nts o( s&'ars $it" #eals%
One e1pos&re o( s&'ar et$een t"e #eal is not "ar#(&l eca&se t"ere is
ti#e (or re#inerali0ation o( cario&s lesions) "o$e*er snac+in' #an! ti#es
t"ro&'"o&t t"e da! +eeps t"e pla4&e pH lo$ and e1tends t"e ti#e (or ena#el
de#inerali0ation%
;E
$) P,ysica" %or! o% t,e car1o,yrate:#
>acterial (er#entation can contin&e as lon' as caro"!drate ad"eres to t"e
dental ena#el s&r(ace% Solid (oods t"at are retained on t"e toot" s&r(aces (or
prolon'ed periods o( ti#e and cane e1tend t"e acid prod&ction e!ond E. #in&tes%
T"&s retenti*e (oods are #ore li+el! to prod&ce #ore toot" deca! t"an s&crose
s$eetened sol&tions li+e 5&ice and p&nc"es $"ic" are cleared (ro# t"e #o&t"
easil!%
') Se=&ence o% %oo:#
Co((ee $it" s&'ar cons&#ed at t"e end o( a #eal ca&ses t"e pla4&e pH to
re#ain lo$ (or lon'er ti#e t"an $"en an &ns$eetened (ood is eaten (ollo$in'
inta+e o( co((ee $it" s&'ar%
H"en c"eese is eaten (ollo$in' t"e s&crose rinse) t"e pH re#ains "i'"er
t"an t"ose $"en no c"eese (ollo$s a s&crose rinse%
E/a"&ation o% cario-enic )otentia" o% iet &sin- a s+eet score: ;Foo iary)
: S"ort <one da!=
: Hee+ lon'
S,ort:# To assess t"e cario'enic potential o( t"e diet) t"e records o( a 3A "o&r diet
t"at represent t"e clients t!pical eatin' patterns% T!pe and a#o&nt o( eac" (ood
eaten) (ood preparation and ti#e o( da! t"e (ood $as not eaten are reported%
T"e 3A "o&r diet recall is t"en &sed to calc&late t"e cario'enic potential o(
t"e diet% T"e s&'ar in'ested reported on t"e 3A "o&r diet (or# is cate'ori0ed
accordin' to li4&id s&'ars) solid and stic+! s&'ars and slo$l! dissol*in' s&'ars%
;-
T"e (re4&enc! $it" $"ic" eac" s&'ar is in'ested is tallied and #&ltiplied
! ) 1. or 1B dependin' on t"e s&'ar so&rce% A s$eet score o( 1B or #ore indicates
t"at t"e indi*id&al is needed o( t"e n&tritional co&nselin' to red&ce t"e cario'enic
potential o( "is or "er diet%
?ea0 "on-:
T"e sa#e proced&re is done (or a $ee+ lon' to e*al&ate t"e caries potential
o( t"e di((erent eatales%
Deca! pro#otin' potential
Mean cario'enic potential indices in ascendin' order (or 33 (oods &sin' t"e
rat #odel%
Dietary reco!!enations %or t,e re&ction o% enta" caries:
Li#it t"e &se o( (er#entale caro"!drates to #ealti#e (oods ot"er t"an
caro"!drates ser*e as &((ers to "elp ne&trali0e pla4&e acid%
O#it s$eet (oods e*en $it" #eals i( t"e client is s&sceptile to caries%
>et$een #eal snac+s s"o&ld consist o( protecti*e) non:cario'enic (ood
s&c" as ra$ *e'etales% Ra$) &nre(ined (oods in t"e *e'etale and (irst
'ro&p re4&ire c"e$in'% T"e c"e$in' action increases t"e sali*ar! (lo$)
t"&s aidin' in t"e re#o*al and dil&tion o( s&'ars and t"eir "ar#(&l
!prod&cts%
Use o( concentrated s$eets in t"e preparation o( (oods as possile%
Do not eat s$eets e(ore edti#e &nless t"e teet" are r&s"ed) sali*ar! (lo$
decreases at ni'"t and (oods are not as readil! cleared (ro# t"e #o&t" as
;/
t"e! are d&rin' $a+in' "o&rs% Acid le(t &ndist&red re#ains in t"e #o&t"
(or 1 R to 3 "o&rs%
A*oid nat&ral s&'ars) t"e! are detri#ental to t"e toot" s&r(ace as re(ined
s&'ars%
A*oid stic+! (oods eca&se t"e! are retained in t"e #o&t" lon'er t"an non:
stic+! (oods%
N&tritiona" nees o% c"ients +it, enta" caries ris0:
N&tritional co&nselin' (or dental caries pre*ention #&st e#p"asi0e
decreasin' t"e (re4&enc! $it" $"ic" t"e s&'ar is cons&#ed and replacin'
cario'enic (ood $it" n&tritionall! so&nd (oods%
Acid prod&cin' #icroor'anis# <Lactoacill&s) Streptococc&s #&tans=
A (er#entale caro"!drate
A s&sceptile toot" s&r(ace
N&tritional co&nselin' (or dental caries pre*ention tar'ets t"e eli#ination
or red&ction o( (er#entale caro"!drates (ro# t"e diet% Acid prod&ction
de#inerali0ation (or#ation o( dental caries%
Co&nse"in- )oints %or caries )re/ention:
Dietar! ed&cation and '&idance is i#portant (or pre*ention and control o(
dental caries% Patient s"o&ld e care(&ll! assessed to deter#ine t"e le*el o(
pre*ention and n&trition '&idance needed%
1= Pri#ar! pre*ention
3= Secondar! pre*ention
;,
;= Tertiar! pre*ention
Pri!ary )re/ention:# T"e patient does not appear to e ris+ (or de*elopin' caries
at present ed&cation s"o&ld e pro*ided on diet caries relations"ip to pre*ent
(ract&re prole#%
Seconary )re/ention:# T"e patient is ris+ (or de*elopin' caries ased &pon
(actors s&c" as cario'enic diet pattern) 1erosto#ia) (a#il! "istor!) oral
acteriolo'ic test res&lts%
Usin' c&rrent diet patterns as t"e asis (or disc&ssion) patient s"o&ld e
ta&'"t t"e role o( diet in caries) di((erence et$een cario'enic and non:cario'enic
eatin' pattern and "o$ to adapt c&rrent diet to lo$er cario'enic ris+%
Tertiary Pre/ention:#
: Patient presents $it" acti*e caries and need t"e i##ediate tar'eted
inter*ention%
: Red&ced cario'enicit! o( c&rrent diet%
: Factors in(l&encin' t"e c&rrent "aits and $or+in' $it" t"e patient to de*elop
strate'ies (or i#pro*e#ent $"ic" are appropriate and acceptale%
A.