PREVENTIVE

DENTISTRY
INTRODUCTION
 PUBLIC HEALTH DENTISTRY
Health [WHO] : A state of complete physical , mental and
social well being and not merely the absence of
disease .

Dental Public Health [The American Board of Dental

Public Health] : The science & art of
Preventing disease,
prolonging life,
promoting health & efficiency
through organized community effort (Winslow, 1920)
 TOOLS OF DENTAL PUBLIC HEALTH
1. Epidemiology:

2. biostatistics: is that branch of statistics concerned with mathematical facts

and data relating to biological events.

3. SOCIAL SCIENCES :is very dependent upon

the group behavior of individuals, determined by their
culture.
4.organization :WHO,FDA………

5. Preventing Dentistry:
DEFINITION OF EPIDEMIOLOGY:
“THE STUDY OF THE DISTRIBUTION AND DETERMINANTS OF
HEALTH-RELATED STATES OR EVENTS IN SPECIFIED POPULATIONS,
AND THE APPLICATION OF THIS STUDY TO THE PREVENTION AND
CONTROL OF HEALTH PROBLEMS” .

AS DEFINED BY JOHN M. LAST (1988)

 CHARACTERISTICS OF DENTAL PUBLIC HEALTH:
• 1. PUBLIC HEALTH METHOD DEPENDS ON TEAM WORK.
• 2. PUBLIC HEALTH WORK SHOULD DEAL WITH ALL PARTS OF PROBLEMS; INVOLVING THE HOST,
AGENT AND THE ENVIRONMENT.
• 3. PREVENTION IS CONSIDERED A MAJOR OBJECTIVE OF PUBLIC HEALTH PROGRAMS. THIS IS
BECAUSE:
A) PREVENTION OF THE DISEASE IS BETTER AND CHEAPER THAN ITS CURE.
B) PREVENTION CAN BE BETTER PERFORMED ON MASS POPULATION THROUGH PUBLIC HEALTH.
• 4. PUBLIC HEALTH DEALS WITH HEALTHY AND APPARENTLY HEALTHY AS WELL AS WITH
• DISEASED PEOPLE.
PREVENTIVE DENTISTRY

• • DEFINITION:
− PREVENTIVE DENTISTRY COMPRISES THE VARIOUS PROCEDURES USED BY DENTISTS,
DENTAL HYGIENISTS, PHYSICIANS, NURSES, TEACHERS, AND OTHERS TO DEVELOP SCIENTIFIC
ORAL HEALTH KNOWLEDGE AND HABITS.
− IT CONSISTS OF THOSE TECHNIQUES WHICH PREVENT THE INITIATION OF ORAL DISEASES AND
PREVENTION OF SUCH SEQUELAE OF NEGLECTING THESE DISEASES. [AS ORAL AND
SYSTEMIC INFECTION AND INTERFERENCE WITH NORMAL GROWTH AND DEVELOPMENT.]
Remember that primary prevention activities will actually stop the illness happening, while secondary
activities stop the illnesses getting worse.
 INTRODUCTION

Definition of dental caries?

“Dental caries is a microbial disease of the calcified
tissues of the teeth, characterized by
demineralization of the inorganic portion and
destruction of the organic substance of the tooth ,
which often leads to cavitation”
 AIMS OF PREVENTION

Limiting pathogen growth and metabolism

Limitation of caries activity
Early detection of incipient caries
Identification of high risk patients
LEVELS OF PREVENTION
❑ Primary prevention
❑ Secondary prevention
❑ Tertiary prevention
 LEVELS OF PREVENTION
1. Primary prevention(true prevention)
❑ Actions taken prior to the onset of the disease, which removes
the possibility that the disease will ever occur.
❑ By plaque control programme, caries activity test, patient
education, topical application, pit and fissure sealants.
LEVELS OF PREVENTION
2. Secondary prevention (prevent
disease progression)
Limits the progression and extent of a disease at
as early stage as possible after onset.
By preventive resin restoration, pulp capping.
 LEVELS OF PREVENTION
3. Tertiary prevention(prevent
loss of function)
▪ Limits the extent of disabilities once a
disease has caused any functional
limitation.
▪ By complex restorative dentistry.
Asmaa Aly
associate professor
pediatric and preventive dentistry and dental public
health
 :What is dental plaque

Dental plaque is a soft sticky and

colorless deposit that accumulates on
the teeth
Plaque control

• isthe mostessential Steptowards maintaining a proper and ahealthy Oral

Environment
• Alsoit isthe removal of microbial plaque and the prevention of its
accumulation onthe teeth and adjacent gingival tissues
❖Mechanical :

❖Chemical :
Individual mechanical plaque control is
achieved by :
1 -tooth brush
2-interdental aids
3-other
▪ Mechanical
▪ Electrical
t
• 1- handle:The part grasped in the hand
o
during tooth brushing.
o
t • 2- head : it is the working end of tooth
brush that hold bristles.
h
b • 3- tufts: clusters of bristles secured
r into head
u
s
h
 Toothbrush bristles
• Natural: hog
• Artificial filaments: nylon which are
uniform in size & elasticity, resistant to
fracture & doesn’t get contaminated.

Bristle hardness
• Soft brush: 0.007 inch(0.2 mm)
• Medium brush: 0.012 inch(0.3
mm)
• Hard brush: 0.014 inch(0.4 mm)

American Dental Association (ADA)

• Brush length: 1-1.25 inches
• Brush width: 5/16-3/8 inches
• 2-4 rows
• 5-12 tufts per row
 Effects and sequelae of the
incorrect use of mechanical plaque
removal devices
• Gingival erosion • Toothbrush
• Gingival recession stiffness
• Cervical abrasion • Method of
brushing
• Brushing frequency
 MODIFIED STILL MAN

Modified Stillman method. This method requires

placement of the sides of the bristles against the
teeth and gingiva while moving the brush with
short, back-and-forth strokes in a coronal
direction.
– Dental plaque removal from cervical areas
below the height of contour of the enamel
& from exposed proximal surfaces .
– General application for cleaning tooth
surfaces and massage of the gingiva
– Recommended for cleaning in areas with
progressing gingival recession & root
exposure to prevent further tissue
destruction.
 Bass method

Bass method. A, Proper position of the brush in the

mouth aims the bristle tips toward the gingival
margin. B, Diagrams shows the ideal placement,
which could permit slight subgingival penetration of
the bristle tips
• Technique. Place the head of a soft brush parallel with the
occlusal plane,
• Place the bristles at the gingival margin,
• establishing an angle of 45 degrees to the long axis of the
teeth.
• Exert gentle vibratory pressure, using short back and- forth
motions without dislodging the tips of the bristles.
• This motion forces the bristle ends into the gingival sulcus area
as well as partially into the interproximal embrasures.
• The pressure should produce perceptible blanching of the
gingiva.
• Complete approximately 20 strokes in the same position.
 CHARTER’S METHOD

Charters method. The Charters method requires that

the bristles be pressed against the sides of the teeth
and gingiva.The brush is moved with short circular or
back-and-forth strokes
This brush position on occlusal surfaces of the
teeth is used with any technique, including the
Bass, Stillman, or Charters method.
 Powered toothbrushes

• Powered toothbrushes are not generally

superior to manual ones

• The heads of these tooth brushes

oscillate in a side - to – side motion or in
a rotary motion
•
• Powered toothbrushes have been shown
to improve oral health:
Children and adolescents
Children with physical or mental
disabilities
Hospitalized patients
Patients with fixed orthodontic
appliances
They where introduced in 1939
Interdental cleaning aids

•Dental floss
• Interdental brushes
• Wooden or rubber tips
It's the most commonly recommend method of
removing plaque from interdental areas
Multifilament vs. monofilament
• Twisted vs. untwisted
• Waxed vs. unwaxed
• 12-18 inches for use
• Stretch: thumb and forefinger
• wrapped around proximal surface, and removes plaque by using
• several up-and-down strokes. The process must be repeated for
the distal surface of tooth
Flossing can be made easier by using a floss
holder
• Although use of such devices can be more
time
consuming than finger flossing, they are
helpful for
patients lacking manual dexterity and for
nursing
personnel
• assisting handicapped and hospitalized
patients in
cleaning their teeth.
• The disadvantage of floss tools is that they
must be
rethreaded whenever the floss becomes soiled
or
begins to shred.
▪ Gingival massage :
can be performed with a toothbrush
rubber tip stimulator or interdental
cleaning devices .
it produces :-
1 epithelial thickening
2 increased keratinization
3 increased mitotic activity in epithelium
and connective tissue
They are several types :
1 use water faucet to irrigate between and
around the teeth the water is steady and is
controlled turning the fenced handle
2 useand intermittent water jet
• Antimicrobial
• Plaque removal
• Remineralization
• sensitivity
Vehicles for the delivery of chemical agents

• Toothpaste
• Mouthrinses
• Spray
• Irrigators
• Chewing gum
 Dentifrices

• Dentifrices aid in cleaning and polishing

tooth surfaces

• Paste, powder and gel

• Abrasive: silica, alumina, dicalcium phosphate,
and calcium carbonate make up 20% to 40% of
a dentifrice. Tooth powders
• contain about 95% abrasives and are five
times more abrasive than pastes.
• Detergent: sodium lauryl sulfate
• Thickeners: silica and gums
• Sweeteners: saccharine
• Humectants: glycerine and sorbitol
• Flavors: mint, peppermint
• Actives: fluorides, triclosan and stannous
fluoride
 Mouthrinse

• ADA has accepted two agents for

treatment of gingivitis:
solutions of chlorhexidine digluconate
mouthrinse
• essential oil mouthrinse thymol,
eucalyptol,menthol, and mythyl
salicylate work by altering bacterial cell
wall
• Chlorohexidine action:
• Increase bacterial membrane permeability
followed by coagulation of cytoplasmic
macromolecules
• Has substantivity ability of substance to
adher to the structur to be released for
long time
• Chlorhexidine-side effects
• Brown discoloration
• Taste perturbation
• Oral mucosal erosion
• capable of staining
bacterial plaque deposits on
the surfaces of teeth,
tongue, and gingiva

• Erythrosine

• Fluorescein-containing dye
Asmaa Aly
associate professor
pediatric and preventive dentistry and dental
public health
 INTRODUCTION

• DENTAL CARIES:- Acc to Shafers in 1993

Dental caries is an irreversible microbial disease of the
calcified tissue of the teeth, characterized by demineralization
of inorganic portion and destruction of organic substance of
tooth which often leads to cavitation.
CARIES BALANCE
 CARIES IMBALANCE

Protective factors:
•Saliva & sealants
•Antibacterial
Risk Factors •Fluorides
•Bad bacteria •Effective diet
•Absence of saliva
Disease indicators: •Dietary
•White spots habits(poor)
•Restorations >3
years
•Enamel lesions
•Cavities/ dentin

Caries progression No caries

 RISK ASSESSMENT
Risk assessment is a professional judgment of an individual’s future risk
of disease based on the best information available.

• CARIES RISK ASSESSMENT:- can be defined as a

procedure to predict future caries development before the
clinical onset of the diseases.

• It determines the probability of caries incidence that is the

(number of new cavities or incipient lesions) in a certain
period. It also involves the probability that there will be a
change in the size or activity of the lesion in the mouth.
AIM
to identify caries-active individuals and to convert them
to caries-inactive status so that become low risk for the
disease

GOALS
Screen out low risk patients
Identify high risk patients before they become
caries- active and
Monitor changes in disease status in caries-active
patients
RISK FACTOR RISK INDICATOR
plaque

An environmental, behavioral or biological factor is a factor or circumstance that is indirectly associated

which if present directly increases the probability of with the disease.
disease occurring and if absent or removed reduces
the probability.
Risk factors are part of the causal chain, or expose
the host to the causal chain.

Microflora Past disease experience

Diet Salivary !!!!!flow rate, ph, buffer capacity,
Tooth antimicrobial effect
Plaque !!!!!!! Sociodemographic factors
Saliva !!!!! Oral hygiene
Fluoride exposure
 CARIES RISK
FACTORS
1)- PLAQUE

Important to estimate

• the number of surfaces affected

• the amount of plaque accumulated

• age of the plaque

• whether its presence is associated with carious lesions in those

same sites.
2)- SPECIFIC MICROBES

• Can readily estimate bacterial levels in saliva, and dentists can

identify patients with a high bacterial load

• A high count in saliva more than 1 million colony forming

units per ml of saliva indicates that most teeth are colonized by
bacteria i.e. many tooth surfaces are subject to increased risk.
3)-DIET
• Diet rich in fermentable carbohydrates (frequent sugar
intake) is a very powerful external risk factor and
prognostic risk factor for dental caries in populations with
poor oral hygiene habits and associated lack of regular
topical fluoride exposure from tooth pastes

• In populations with good oral hygiene and daily use of

fluoride toothpaste, sugar is a very weak RF and PRF
4)- EATING PATTERN
•Fall in plaque pH after consumption of sugary foods may be
modified by the consumption of less fermentable foods before,
concurrently or afterward egs: cheese.
•Infants and toddlers - regularly bottle fed with sweet drinks at
night or breast fed for > twelve months- risk factors for
caries.

•Teenagers and young adults- excessive consumption of soft

drinks risk factors for caries
5) SALIVA

•Saliva plays an important role in the health of soft and hard

tissues in the oral cavity.

SALIVARY FLOW RATE

• Chronically low salivary flow rate one of the strongest

salivary factors increased risk of developing caries.

• caries is extreme absence of saliva.

DEMINERALIZATION AND REMINERALIZATION

•Main factors governing stability of enamel are the pH and

concentration of Ca, PO3 4-, and F in solution which are all derived
from saliva.

•The role of saliva in this process is highly dependent on

accessibility, which is closely related to thickness of plaque.
IMMUNE SYSTEM AND CARIES RISK

•Salivary immunoglobulin are mucosal antibodies that act as

the first line of defense, and they include two major antibodies,
namely, secretory IgA and IgG.
 CARIES RISK INDICATORS

• 1- Past caries experience

• 2- Dietary habits
• 3- Socioeconomic status
• 4-Fluoride exposure
• 5-Medical factors
 1)PAST CARIES EXPERIENCE
They are indicators or clinical signs that either disease is present or
that there has been recent disease..
(1) frank cavitation or lesions that radiographically show penetration into
dentine;
(2) approximal radiographic lesions confined to the
enamel only;
3) visual white spots on smooth surfaces
(4) any restorations placed in the last three years
Pathological factors: Protective factors are:
2) Dietary factors
• Dietary factors:
• Frequent between meal
• Sugar exposures are limited to
snacking
meal times
• Prolonged night-time or
at will bottle/breast
feeding of infant • Preference for non-cariogenic

• Multiple sugar exposures snacks

through the day

• Infant Ready availability • No deleterious bottle/breast
of cariogenic snacks feeding of the infant
Socioeconomic factors SOCIOECONOMIC FACTORS;
• High caries risk in • Good oral hygiene in
siblings/parents parents with adequate
knowledge about dental
• Socioeconomically Children health & prevention
deprived or immigrant
backgrounds
• Regular access to a well-
established dental home
•
• Fluoride exposure FLUORIDE EXPOSURE:
• No exposure to fluoridated • Presence of continuous, low

drinking water concentration of free F- ions

around teeth especially at the

time of a cariogenic acid attack.
• No access to professionally
applied topical fluorides
• Daily use of a fluoridated
especially when permanent
dentifrice
molars erupt delaying post-
eruptive maturation
• Living in an area with community
water fluoridation
• Medical factors
MEDICAL FACTORS
• Special child (i.e. a child with a •Institution & maintenance
physical,mental, or medically
of an intensive preventive
compromising condition that may
limit oral health care measures or regimen in the special child
make the child more susceptible
to caries.)

• Salivary dysfunction caused by •Saliva substitutes

medications, radiation therapy or
general systemic conditions

• sugar-free medications
• Long term cariogenic medication
 • Salivary factors • Salivary factors
• Salivary buffers that aid in
• High salivary MS & neutralizing acids
Lactobacilli counts
• Salivary proteins and lipids that
• Poor salivary flow form pellicle & protect tooth
rate impeding
surface Salivary Calcium &
clearance
Phosphate ions can enhance
remineralization & delay
mothers with high salivary MS levels
frequently transmit MS to their babies as demineralization
soon as the first primary teeth erupt,
leading to greater development of caries
 • Caries Risk Assessment Tools

Caries Risk Assessment Tool (CAT): This tool was developed

by the American Academy of Paediatric Dentistry (AAPD) in
2006. Depending on the age of children CAT incorporates
three factors in assessing caries risk, namely, biological as well
as protective factors and clinical findings
 CARIOGRAM

LOW RISK TO
HIGHT RISK TO CARIES
CARIES
 Prevention
of Traumatic
Injuries
DR.ASMAA ALI
 Traumatic dental injury (TDI)
Is considered a dental public health problem because:

The incidence of TDI is high world-wide.

Trauma to the oro-facial structures can cause severe damage to
the teeth, supporting structures, and craniofacial structures (facial
bone fracture and more seriously, neck or brain injury).

Oro-facial injuries occur at a young age, and treatment may

continue for the rest of the patient’s life.
 The most common causes of oro-facial
trauma
• Sports related injury: sports accidents account for 10-39% of all dental injuries
occurring in children.

• Falls
• Violence
• Traffic accidents
• Baby walkers
• Child abuse
• Bike and car accidents
 epidemiology
1. Age The main peak periods for dental injury are described as
being between the ages of 1 &3, and again between the ages of
6 &12 (school aged children).

• Children under 3 years of age: Falls are the most common

cause of injury as they are usually both unsteady on their legs and
lacking a proper sense of caution.
 Age

• In school- age children: Bicycle, skateboard, micro- scooters,

and road accidents are the most significant factors. Sports injuries
are also common at this age, as it is the age at which most
children participate in contact or non-contact sports.

• In adolescence: there is another, although less marked, peak

largely due to fights, car and road accidents as well as sports
injuries.
2. Teeth
The labial proclination of maxillary anterior teeth especially
during the mixed dentition period (children are usually
active) makes them more subjected to traumatic injuries
than other teeth.

Fractured permanent teeth cause serious esthetic and

psychological problems to children.
 Epidemiology

3. Gender
Males are more commonly affected than females.

The male to female ratio is estimated to be 1.5:1

 risk factors
1- Presence of illness, learning difficulties or physical
limitations

• Presence of illness, learning difficulties or physical limitations

• Epilepsy
• Cerebral palsy
• Deaf and blind child
 .2- Emotionally stressful states
• broken family
• Parental abuse
• AHAD child
• Obese child
 Inappropriate use of teeth

• Oral piercing
• A quite new category is TDIs that result from piercing of the
tongue and lips, lip and tongue piercing may lead to chipping and
fracturing of teeth and restorations .
• Inappropriate use of teeth
• many individuals have injured their teeth
when using them as a tool to open hair
clips, fix electronic equipment, cut or
hold objects or opening bottles of soda.
 3-Oral predisposing factors

• Increased Overjet (more than

6mm) .( E.g cl II div 1)
 Inadequate lip coverage.
 Weak teeth :as well as root
canal treated teeth, severely
hypo-plastic or decayed
teeth.
 Most affected teeth
• Upper central 66.7%
• lateral incisors 17.4%
• Enamel fracture 63.7-80%
• enamel-dentin fracture 32%
• one-third of the injuries
were preventable
(Andreasen et al.,
2001
)
Prevention of dental trauma
Primary level of prevention
 Educational prevention.
• Best way to prevent dental and oral injuries is
education on how to avoid them and what to
do if an injury occurs
• Education should be targeted equally at
children, teenagers .
• individuals with severe maxillary overjet
should have preventive orthodontic treatment
before the age of 11
• Information campaigns
 Primary prevention :
1-provide safe home environment
a) Use doorknob covers to keep children
away from rooms and other areas with
hazards, such as swimming pools.

b) But corner and edge bumpers on

furniture and other items like a
fireplace hearth to protect against
injury.
 Primary Prevention

a) Use safety gates at the top and bottom of stairs and in the
doorways of rooms with hazards.

b) Cover unused electrical outlets protectors or safety caps.

c) Install toilet locks to keep toilet lids closed.
• Prohibit the use of equipment such as
walkers or trampolines
• wear helmets when riding tricycles
• Treatment of children with
increased overjet
• Playground Surfaces
“Shock absorber”
• The use of car seatbelts
• Promote the use of protectors
 Appliances used for prevention of
sports injuries.
• 1. EXTRA ORAL:Faceguards
• 2. INTRA ORAL: Mouth guards
 Types of Protectors

1. Extra-oral Protectors: Faceguards

There are several types of extra-oral protectors and they are sport
specific

e.g. football helmet,

face mask used in boxing.

 2. INTRA ORAL:
Mouthguards
• It is a resilient appliances placed inside the
mouth to reduce oral injuries, particularly to
teeth and surrounding structures .
 Types of mouthguards

1. Custom-fabricated 2. Mouth-formed 3. Stock

mouthguards ( Boil & bite mouthguards
mouthguards )
 1. Custom fabricated mouthguards

Produced on patients cast either by :

• The vacuum-forming technique . ( single layer )
• Heat-pressure lamination technique ( multipe layers –
different thickness ).
 The Boil and Bite type

The most common mouth formed protector is

the Boil and Bite type. They are made of a
prefabricated thermoplastic shell that is softened
in boiling water and then molded in the mouth
by the athlete’s tongue, fingers and biting
pressure.

Boil-and-bite mouth guards are sold over-the-

counter at pharmacies.
 3. Stock mouthguards

• Designed for use without any

modification ( Least accurate )
• It must be held in place by
clenching the teeth together
to provide a protective benefit.
• Clenching a stock mouthguard in place can interfere
with breathing and speaking .
 Intra-oral Protectors
 Requirements: they must be
a) Made of a resilient material, mostly polyvinyl acetate- polyethylene
copolymer (PVA-PE).

b) Retentive.
c) Comfortable. Providing ease of speech and breathing. And don’t
exceed the free-way space.

d) Protect teeth and soft tissues.

e) Can be easily washed, cleaned and disinfected.
f) Allow normal occlusal relationship for maximum protection and
comfort.
 Mechanism of action
Mouthguards reduce the risk of trauma by :
• Acting as Cushion .
• Redistributing shock during forceful impacts
• Stabilizing the mandible.
 Conclusion
• It is far better to prevent injuries than to
have to deal with them after they occur.

• Anterior trauma can have life-long

consequences affecting aesthetics, self-
image.
Asmaa Aly
associate professor
pediatric and preventive dentistry and dental public
health
Dental caries was first described in Miller’s chemo
parasitic theory in 1890. Caries is caused by the
dissolution of the teeth by acid produced by the
metabolism of dietary carbohydrates by oral
bacteria. The 2 primary bacteria involved in caries
formation are mutans streptococci and lactobacilli.
In the 1960s the caries theory was depicted as 3
circles representing the3 prerequisites for dental
caries: the tooth, the diet, and dental plaque
(1)Acidogenic/
Old Theories
Chemoparasitic Theory
➢ (1) Role of carbohydrates

✓ food substances act as

substrate for microorganisms
of dental plaque

✓ various carbohydrates have

been examined for cariogenic
potential
Acidogenic/
Chemoparasitic Theory

CHO ESP. FREELY

FERMENTABLE
TYPE
SUCROSE

ELIMINATION OF ANY OF THESE FACTORS WILL PREVENT

CARIES
(1)Acidogenic/
Old Theories
Chemoparasitic Theory
➢ (1) Role of carbohydrates

✓ cariogenicity of carbohydrate
varies with:

• (1) frequency of ingestion

• (2) physical form
• (3) chemical composition
• (4) route of administration
• (5) presence of other food
constituents
➢ (1) Role of carbohydrates

• (1) frequency of ingestion(Frequency means the number of

times per day, the sugary foods are eaten. )

The Vipeholm study: [Gustafsson et al 1954]

The main conclusion was:

1. Consumption of sugars, even at high levels, is associated
with only a small increase in caries increment if the sugar
is taken with meals and none between meals.

2. Increase in sugar intake increases caries activity (Higher frequency means more
demineralization and less remineralization.)

3. Consumption of sugar both between meals and at meals

is associated with marked increase in caries increment.
Role of carbohydrates

• (2) physical form(liquid or sticky )

Prolonged oral retention of cariogenic components of
food may lead to extended periods of acid production and
demineralization and to shortened periods of remineralization.
❑ Liquid sugars, such as those found in beverages and milk drinks, pass through
the oral cavity fairly quickly with limited contact time or adherence
to tooth surfaces.
❑ Long-lasting sources of sugars, such as chocolates, hard candies and lollipops,
have extended exposure time in the oral cavity
❑ refined pure carbohydrates more caries producing

❑ The risk of caries is greater, if the sugar is consumed inform which is sticky
and its oral clearance time is prolonged
1. metabolism by microorganisms
2. adsorption onto oral surfaces
3. degradation by plaque and salivary enzymes
4. saliva flow, and
5. swallowing. Most carbohydrates will be cleared by these
simultaneous mechanisms.

the longer the foods are retained

in the oral cavity, the greater the potential the starch has to
break down into sugars and contribute to the caries process
The caries potential of
glucose, fructose, lactose
or maltose were
almost same as of starch
but sucrose was much
more cariogenic

glucose,
sucrose + fructose
due to low molecular weight

rapidly diffuse into plaque

make themselves easily

available for fermentation
by plaque bacteria
➢ (1) ROLE OF CARBOHYDRATES

• (4) Route of administration

▪ oral intake of sticky

food
5) presence of other food constituents
(presence of high fat and proteins gives less cariogenic diet)

❑ PROTECTIVE FACTORS )
✓ Cheese
Studies have shown that several types of cheese are not only
non-cariogenic but also have anti-cariogenic properties. Cheese
stimulates salivary secretion and increases plaque calcium
concentration, and causes adsorption of protein (casein) on
to the enamel surface thereby physically slowing the caries
process.
RAISE oral ph to 7.5 within 3 minuts

✓ Milk
Cow’s milk and human milk contain lactose which may be
classified as cariogenic. But lactose is least cariogenic of the
dietary sugars and milk also contains calcium, phosphorus
and casein which inhibit caries.
cow’s milk is not only non-cariogenic,
but also has an anti-cariogenic effect.
✓ Fibrous Foods
Fibrous foods protect the teeth because they mechanically
stimulate salivary flow. Other foods that are good gustatory
and/or mechanical stimulants to salivary flow are peanuts,
hard cheese.

✓ Black and green Tea

Black tea contains fluoride, polyphenols and flavanoids. Black
tea extract increases plaque fluoride concentration and reduces
the cariogenicity of a sugar rich diet.
Artificial sweeteners are called as sugar substitutes
Added to foods to provide sweetness
without adding extra calories

➢ Sorbitol
➢Xylitol
➢Mannitol
 Xylitol
Xylitol is widely used in sugar-free products such as
chewing gums, candies, and toothpastes
Commonly used by diabetic
patients.
High dosage causes diarrhoea.

xylitol has been widely

researched and
globally accepted as a
natural sweetener
approved by the US Food
and Drug
Administration (FDA) and
the American
Academy of Pediatric
Dentistry.
Microorganisms do not readily metabolize xylitol into energy
sources, and its consumption has a minimal effect on
plaque pH.
Xylitol has been shown to have a protective effect
and to reduce tooth decay in part by reducing the levels of
Strepto coccus mutans in plaque and saliva and by reducing
the level of lactic acid produced by these bacteria.

xylitol is incorporated into the cells of MS

as xylitol-5-phosphate, This results in inhibition of both
growth and acid production.
 DIET HISTORY ANALYSIS:

Aim: − Determination of individual eating habits when vague

reports from patient make it impossible to determine whether
an adequate diet is being obtained.
TECHNIQUE:

• − In this analysis the patient has to record his exact food intake for a period of
one day; 3 days or preferably one week and then analyze the report for calories,
carbohydrates, protein; fat and the important minerals and vitamins.
• − From this analysis factors can be brought to light which may have escaped the
patient's notice.
• − According to this analysis recommendations for changing the dietary habits
of this patient can help in improving his caries condition.
❖ DIET FOR GOOD GENERAL NUTRITION:

• Diet for good general nutrition is the diet that must contain the essential nutrients:
• 1. Sufficient amount of minerals especially calcium and phosphorous.
• 2. Sufficient amount of vitamins particularly vitamins D&C.
• 3. Reduced amount of carbohydrates, especially freely fermentable varieties.
• 4. Enriched phosphates.
 ❖ DIETARY RECOMMENDATION:

• 1) Keep the carbohydrate content of the diet as low as possible consistent with satisfactory caloric intake. It is preferable
that no more than half the daily calories be carbohydrate.

• 2) When carbohydrates are used select wherever possible the soluble forms or those that clear the mouth most quickly.
Leafy, green or yellow vegetables are good carbohydrate sources with low retention. Avoid sticky candy and suckers.

• 3) Consume carbohydrate at meals so far as possible. Avoid between meal snacks, substitute the sticky sweets with nuts, raw
fruits or vegetable for the in-between meal snacks if such snacks are unavoidable.

• 4) Cheese is recommended as caries preventive food because it causes strong stimulation of salivary flow, raise the calcium
concentration in the plaque and raise the PH within 3 minutes after ingestion.
ASMAA ALY
ASSOCIATE PROFESSOR
PEDIATRIC AND PREVENTIVE DENTISTRY AND DENTAL
PUBLIC HEALTH
 PERIODONTAL DISEASES
Periodontal diseases are inflammatory conditions affecting the
periodontium.

The periodontium comprises the gingiva, the periodontal

ligament, the alveolar bone and the cement covering the
roots of the teeth.
Qasim – Taif Collaberation © QUCD all right reserved
Local factors
• Poor oral hygiene resulting in
accumulation of dental plaque and
calculus
• Food impaction
• Chewing and smoking of tobacco
• Faulty restorations
• Badly designed partial dentures
• Orthodontic appliances
• Malalignment of teeth
• Lack of lip seal/mouth-breathing
• Improper brushing technique
Systemic factors
• Malnutrition- deficiency of vitamins A and C
• Endocrine disturbances
- Physiological (puberty, pregnancy and the menopause)
- Pathological (hyperthyroidism, hyperparathyroidism and
diabetes mellitus)
• Decreased immunity (HIV infection, persons on
immunosuppressive drugs)
• Blood disorders: Anaemia, leukaemia
• Drug induced- phenytoin sodium .
Qasim – Taif Collaberation © QUCD all right reserved
ASMAA ALY
ASSOCIATE PROFESSOR
PEDIATRIC AND PREVENTIVE DENTISTRY AND DENTAL
PUBLIC HEALTH
Prevention of Dental Caries with Fluoride:
• It is one of the halogens.
• It is the most active element of this group.
• It is not present in the free form.
• It is present in soil, sea water, rain water, sea
food, etc.
• Fluoride is the only proved diet substance to
be of anti-cariogenic benefit for humans.
SOURCES OF FLUORIDE:
− Humans obtained fluoride from three sources: water, foods and air.
− Water and food, may contribute significant amounts to the daily intake.
− Water from deep wells and artesian wells usually provide high natural
fluoride concentration. (fluorosis)
− Most vegetables, fruits and dairy products contain low amount of fluoride.

− But sea foods (fish sp. salmon and sardines, shrimp, crab, etc) may
contain
2.5 ppm.
− Most beverages especially tea.
− Fruit juices and soft drinks are generally low in fluoride, but the fluoride
content of the water used in the preparation of such beverages or in the
cooking of food will be reflected in the fluoride concentration of the final
product.
Recommended optimal fluoride dose:
− The recommended optimal fluoride doses
for community water supplies vary
with the annual mean of the maximum daily
temperature (0.7 to 1.2 ppm).

−The average diet provides 0.2-0.3 mg of

fluoride daily.
Uptake of Fluoride by the Teeth:
− Fluoride is incorporated in enamel and dentine in two stages:
A. BEFORE ERUPTION:
During Calcification, traces of fluoride incorporated into the crystalline
structure of appetite lattice.

B. AFTER ERUPTION:
▪ Enamel surface continues to pick up fluoride derived from diet,
water and saliva.
▪ The post-eruptive acquisition of fluoride continues throughout life
and is directly proportional to the concentration in food and water
ingested.
 Action on tooth size and morphology: In communities with
fluoridated water supply, there is a trend towards shallower
Fluoride lowers free surface fissures and lower cusp height and smaller tooth size. This will
energy: This will decrease decrease caries susceptibility.
the plaque
accumulation on the
. Enzymatic inhibition: interfering with the
treated enamel surface.
breakdown of glucose to lactic
and pyruvic acid. Both phosphatase and
enolase enzymes are inhibited by
fluoride.
3. Bacterial inhibition: fluoride has a
direct inhibitory effect on the bacteria of
the dental plaque
Ionic exchange of fluoride with the
hydroxyl group of calcium
Hydroxy appetite in the surface
Fluoride has the ability to precipitate minerals from layers of enamel changing it into
saturated Solutions: As fluorapatite
saliva is saturated by minerals, fluoride favors the which is less soluble in acids.
precipitation of the calcium
phosphate on the surface of enamel, so it aids in
remineralization of partially
demineralized enamel in early caries
Acute fluoride toxicity:
− High doses of fluoride are toxic and may be
lethal. Fortunately, this is rare
and only few accidental cases are reported (4-5
gm for adult, 0.25 mg for
infants).
− Ingestion of massive single dose of fluoride
may cause, vomiting, nausea,
coma hypocalcemia and cardiac arrest.
− For treatment of this case, intake of large
amount of calcium orally like milk
is a must. And give 10% calcium gluconate
injection to control convulsions.
Chronic fluoride toxicity:
− Chronic fluorosis results in skeletal or dental changes. If
fluoride was ingested
during the tooth developmental period at levels injurious to the
ameloblasts.
− Mottled enamel (dental fluorosis) may result with various
degrees of severity
when water fluoride concentration is (6-8 ppm).
− Later in life, the ingestion of high levels of fluoride may result
in bony deformities joint fixation and calcification of the
ligaments.
 FLUORIDES DELIVERY METHODS

Topically applying fluoride: FLUORIDES

Systemic fluoridation:
which means applying of
which means ingestion of
preparations on
calculated amount of
exposed tooth surfaces to
fluoride to be
increase their resistance to TOPICAL FLUORIDES SYSTEMIC FLUORIDES
incorporated in the
cariogenic processes
developing teeth.
PROFESSIONAL SELF APPLIED I.Water Fluoridation
•Dentifrices i. Community Water
•Neutral Sodium fluoride
•Mouth Washes Fluoridation
•Stannous fluoride
•Fluoride Gels ii. School Water Fluoridation
•APF
•low fluoride I. Salt Fluoridation
• Solu /Gels concentration
products II. Milk Fluoridation
•Varnish
ranging from 200- III. Fluoride tablets/ drops/ lozenges
1000ppm or 0.2-1
8
FLUORIDES DELIVERY METHODS

FLUORIDES
Systemic fluoridation:
which means ingestion of
calculated amount of
SYSTEMIC FLUORIDES fluoride to be
incorporated in the
I.Water Fluoridation developing teeth.
i. Community Water
Fluoridation

ii. School Water Fluoridation

I. Salt Fluoridation
II. Milk Fluoridation
III. Fluoride tablets/ drops/ lozenges

9
[1]Systemic Fluoride:
1. Water fluoridation:
− There is an inverse relationship between the fluoride level in drinking
water supplies and the incidence of dental caries.
− It should be noticed that there is also a direct relationship between
fluoride
level in water and the incidence of mottled enamel. − A fluoride
concentration of 1 ppm in communal water was found to be
optimum regards the effective anti-caries effect and lower mottled
enamel.
− It is recommended that optimal dose of fluoride ingested daily in
children from 0.5 -1.0 mg fluorides (WHO).
− So this 1 ppm fluoride concentration in water is suitable for
countries with
cold weather whereas in countries with hot weather the concentration
of fluoride in public water supplies should be lower and this depends
on the daily water consumption which is usually double or triple them
in comparison with
cold weather .
− In Egypt the fluoride concentration of Nile water is about 0.36 ppm
in which is considered optimum.
3. Fluoride supplements:
4. Fluoride incorporation in
− When fluoridation of water supply is not possible, fluoride supplements can
various foods:
be resorted.
− e.g. salt, milk, bread,
− This can be in the form of fluoride tablets, drops or syrups.
rise…etc. but the problem is
the difficulty in adjustment
F conc. To satisfy individual
Fluoride preparations should be kept out of reach of children to avoid over
personal intake due to
dosage.
difference in food
− Fluoride tablets digested as sweets are not advised.
consumption from person to
DOSE:
another.
6M.-3Y…….0.25mg/day
− A careful regulation of the
3y-6y……….0.5mg/day
prescribed daily dose and a
6y-12y………1mg/daY
constant cooperation
− Fluoride administration should continue till the age of complete crown
by the parents is required.
formation of the second permanent molar, i.e. about the age of 10\12 years.
 FLUORIDES DELIVERY METHODS

Topically applying fluoride: FLUORIDES

which means applying of
preparations on
exposed tooth surfaces to
increase their resistance to TOPICAL FLUORIDES
cariogenic processes

PROFESSIONAL SELF APPLIED

•Dentifrices
•Neutral Sodium fluoride
•Mouth Washes
•Stannous fluoride
•Fluoride Gels
•APF
•low fluoride concentration
• Solu /Gels products ranging from
•Varnish 200-1000ppm or 0.2-1 mgF/ml.

1
TOPICAL FLUORIDES
• Topical fluorides are those fluoride containing agents which are applied to
the tooth surface in regular intervals in order to prevent the development of
caries.

• These exert an anticaries effect by increasing the concentration of fluoride in

the outermost surface of the enamel.

1
INDICATIONS FOR TOPICAL FLUORIDES
1. Caries-active individuals i.e. those with past caries experience or those who
develop new carious lesion on smooth tooth surfaces.

2. Children shortly after periods of tooth eruption, especially those who are not
carries free.

3. Medication to reduce salivary flow or had undergone head and neck radiation.

4. After periodontal surgery when roots of teeth have been exposed.

5. Patients with fixed or removable prosthesis and after placement or replacement
of restorations.

6. Patients with an eating disorder or who are undergoing a change in lifestyle

which may affect eating or Oral Hygiene Habits conductive to good oral health.

7. Mentally or physically challenged individuals.

7
SELF APPLIED TOPICAL FLUORIDES
Self applied fluorides products are usually bought and dispended by the individual patient but at the
recommendation of a dental professional. These fluoride products are of low concentration ranging
from 200-1000 ppm or 0.2-1.0 mgF/ml. The self applied fluoride usually are:-
1. Fluoride Dentifrices
2. Fluoride gels(1.23% fluoride)
3. Fluoride rinse
0.2% sodium fluoride-0.02% will reduce dental caries
incidence.
− The principle to be noted is the frequent rinsing with
very dilute fluoride solution.
This is to be done after the routine tooth brushing to
obtain clean tooth surface

Highly diluted solution (0.02%) can be used daily

4.Fluoride dental floss:(un-waxed )
2. Professionally applied fluoride:
− It is very beneficial in reducing dental caries particularly for
children who
live in area with low fluoride concentration in the drinking
water.
− Different forms of fluorides have been utilized for the topical
use, such as:
 Sodium Flouride Stannous Fluoride APF
(NaF) (SnF2)

Percentage 2% COMPARIS
8% 1.23%
Fluoride
concn.(ppm)
9,200
ON 19,500 12,300

pH Neutral (7) 2.4 - 2.8 3.0

Frequency of 4 at weelky intervals 3,7,11,13 yrs Biannually Biannually
Application

Adverse effect - -
Staining of teeth,
Pigmentation of hypo plastic
areas and margins of
restoration
Metallic taste, due to low pH &
high conc. of Sn2F
Astringent taste and difficult to
mask with flavoring agents
 Procedure for application of Sodium Fluoride
[ Knutsons Technique ]:
oral prophylaxis done

teeth isolated either by quadrant or by half mouth

2% NaF solution is painted on the air dried teeth so that all surfaces are visibly
wet

allowed to dry for 3-4 minutes

repeated for each of the isolated segments until all teeth are treated

2nd, 3rd and 4th NaF application, each not preceded by a prophylaxis, is
scheduled at intervals of approximately one week.

The fourth visit procedure is recommended for ages 3,7,11 and 13 years,
coinciding with the eruption of different age groups of primary and permanent
teeth. Thus, most of the teeth will be treated soon after their eruption, maximizing
the protection afforded by topical application.
19
Procedure for application of Acidulated Phosphate Fluoride

The patient seated upright position in chair & Oral prophylaxis is done& teeth are treated
completely.

Clinical application of APF gel by tray technique [disposable foam line tray is preferred] To

reduce ingestion a minimal amount of fluoride gel kept [coverage of tooth surfaces ,<5ml ]

The patient is told not to swallow the gel but to exert slight pressure using the cheeks and the
tongue as well as light biting forces in order to cause the gel to flow inter-proximally. The gel
thins out under the biting force because of thixotropic nature.

The fluoride gel should be in mouth for 4 minutes and remaining oral fluids should be
expectorated.

saliva ejector is used to wipe out saliva and excess fluoride

The patient is instructed not to eat drink or rinse his mouth for at least 30 minutes.
21
 FLUORIDE VARNISH:
➢Child-Friendly

➢Another aspect of fluoride varnish that makes applying fluoride on

children’s teeth easier for a dental professional and more comfortable for the
child is the fact that the varnishes come in many different flavors. The
American Academy of Pediatrics recommends fluoride varnish treatments
beginning at initial tooth eruption.
DURAPHAT:

➢It s a viscous yellow material, containing 22,600 ppm fluoride as sodium

fluoride in a neutral colophonium base.

FLUORPROTECTOR:

➢Its a clear polyurethane based product containing 7000 ppm fluoride from
difluorosilane.
➢ Its dispensed in 1ml ampules each ampule containing 6.21mg of fluoride.
FOAM:

Developed to minimize the risk of fluoride over dosage as well as to

maintain the efficacy of topical fluoride treatment.

Advantages :

▪Its lighter than a conventional gel & therefore only a small amount of
agent is needed for topical application

▪The surfactant has cleansing action by lowering surface tension, this

The ADA recommends fluoride varnish
facilitates the penetration of material into interproximal surfaces. over foam for children under six years
of age, not only due to efficacy but the
▪It doesn’t require suctioning so it offers advantages for home use risks (ingestion) outweighing the
benefits.
THE LATEST VERSION OF THE FLUORIDE
GLASS SLOW RELEASE DEVICE AND PLASTIC
RETENTION BRACKET

Latest glass device and bracket attached

to upper
first permanent molar tooth
62
ASMAA ALY
ASSOCIATE PROFESSOR
PEDIATRIC AND PREVENTIVE DENTISTRY AND DENTAL
PUBLIC HEALTH
 Topical protection of teeth: This includes all measures applied
to increase the resistance of the intact outer tooth surface.
Among these measures are:

1. Topical chemotherapy. (as fluoride)

2. Fissure sealants.
3. Preventive resin restoration.
4. A traumatic dentistry (ART) are the most essential.
1. Fissure sealants: − Fissure sealants are materials used to
(correct) seal deep pits and fissures and change them into
non-retentive surfaces. − There is considerable evidence
that a significant caries reduction observed when fissure
sealants are correctly applied to deep pits and fissures of
newly erupted teeth.
2. Types:
• Dimethacrylate bis-GMA resin (the most commonly used) •
• Glass ionomer: provide good adhesion and fluoride release.
• • Compomer.

1. Indication of pit and fissure sealants:

• Newly erupted posterior teeth with deep pits and fissures are
the suitable teeth for application.
• Medically compromised patient • Patient with high risk to
dental caries.
Steps of application of pit and fissure sealants are: • Remove any
debris using pumice slurry on small brush or prophy rubber
cup. • Wash the tooth with air water spray. • Isolate the tooth
with cotton rolls and use saliva ejector. • Dry the tooth with
compressed air. • Etch the occlusal tooth surface with enamel
etching solution or gel (37% ortho-phosphoric acid) for one
minute. • Wash thoroughly with air water spray.

• Dry with compressed air till chalky white enamel surface

appears. • Apply the fissure sealant with little brush. •
Polymerize light cure sealant for 20 seconds keeping the tip of
the light gun as close to the surface as possible. • Check the
height (high spots) of the polymerized material and correct
with fine stone when possible. • Check the success of sealant
application at 6 monthly periods.
2. Preventive resin restoration: − The technique is based upon restoring
minimal carious lesion usually in young permanent molars with minimum removal of tooth
structures, while concomitantly preventing caries from attacking other pits and fissures on
the same surface without mechanically removal of these areas. − Technique: • A small round
bur may be used for access and removal any carious tissue. • The tooth is then etched then
bonding agent is applied • A composite of thin consistency is used to restore the cavity. •
then, fissure sealant is applied over the remaining pits and fissures
A traumatic restorative
treatment (ART)
− The two main principle of ART are: a. Removing carious tooth tissue using
hand instruments only.
b. Restoring the cavity with adhesive filling material currently a glass ionomer.
− Carious cavities suitable for ART should be: a. Involving the dentin with no
pulpal involvement.
b. Accessible to hand instruments.
The advantages of ART include:
a. Use of easily available and inexpensive procedure to conserve sound tooth
surfaces.
b. Permit oral health care workers to reach people who otherwise never
would have received any oral care; such as handicapped, villages in rural and
suburban areas, home-bound, institutionalized people and economically less
developed countries.
 The Role of
DENTIST
in Detection and Prevention
of Oral Cancer

ASMAA ALI
0At present, total prevention of cancer before its
occurrence is nearly impossible.
0 It can be prevented from causing rapid destruction
of tissues and death to the patient by early detection
and treatment.
0In other words, early detection and the use of control
methods can prevent mutilation of tissues and
metastasis of the disease, providing a greater chance
for survival and complete cure for the patient.
 Predisposing factors

IN CASE OF ORAL CANCER

TOBACCO&ALCOHOL
ill-fitting dentures,
broken teeth or teeth with sharp edges,
poor diet and
systemic diseases(autoimmune conditions)
 PRIMARY LEVEL
OF PREVENTION

0Recognition of the
predisposing factors is of
great importance.
1.Stop smoking
2.Stop alcohol
3.Good oral hygiene
4.Eat fresh vegetables, fruits and balanced food
5.Use a cap when working under sun
6. Wear facemasks/ cover your mouth when

working with dusts and chemicals

SECONDARY
LEVEL OF
PREVENTION
0I

0 the main function of the dental health worker is

not that of a thorough diagnosis but that of
suspecting a lesion and consulting a specialist.
WHERE CAN YOU FIND???
1. NON-HEALING
ULCER

2.Unknown source
of bleeding
3. Loose Tooth
4. Loose Fitting
Dentures
5. Difficulty in Speaking
6. Difficulty in
Swallowing
7. Unexplained Pain

8. Weight
Loss
HOW CAN IT START???
WHAT ARE PRE-
CANCEROUS LESIONS?

White Patches that will not rub

off 4-18% turn into cancer!
RED PATCHES that do not go away (> 2
weeks)
***Recommend Removal
20-30% will develop into cancer!
0In case of suspecting lesion to be neoplastic, do not
hesitate in consultation, which may save a life.

0 The observation over a period of time may be

essential to detect changes in the size or character of
the suspected lesion.

0 Ulcers in the mouth of unclear cause and not

responding to indicated treatment should not be
neglected for long time.
0Do not apply local drug or medication and caustics
in particular to an ulcer with uncertain diagnosis.
0The dentist can apply simple tests (in case of doubt)
to suspected lesions.
Cytodetection, exofoliative cytology and oral smears
provide the dentist another diagnostic measure.
It is estimated that 80% of the deaths from oral
cancer could prevented by early detection and
prompt adequate therapy .
: ORAL CYTOLOGY OR ORAL
EXOFOLIATIVE CYTOLOGY

0Is the study of normal and

abnormal desquamated cells
of the oral cavity.
0Cells may be scrapped from
surfaces or aspirated from
natural fluid and examined
special staining.
 : TOLUIDINE BLUE
TEST
0Toluidine blue is an acidophilic metachromic nuclear
stain, which has an affinity for areas of carcinoma in
situ and invasive carcinoma but not for normal
mucosa .
 : TECHNIQUE

1. The patient is instructed to rinse with water. Excess

saliva is removed by suction.

2. A mucolytic agent, 1 % acetic acid is applied to the

mucosa with a cotton applicator.

3. Toluidine blue, 1 % is then applied with a cotton

applicator. The dye should cover the entire lesion and
clinically normal margins.
4. Excess Toluidine blue is removed by rinsing with
water.
5. Lesions which retain the dye stain blue and are
classified as positive. Negative lesions do not retain
the dye.
6. Lesions which retain the stain should be biopsied.
Negative lesions should be followed clinically for
variable periods and restaining.
 Public Health
• Definition of Public Health:
Public Health is that it is the art and science of:
1-preventing disease
2-prolonging life
3-promoting physical and mental efficiency
Through organized community effort.

− The individual patient is not the sole object of study. Now the entire
community is the focus.
− This includes not only those suffering from disease, but also healthy
people, both resistant and susceptible to disease.
• Definition of health:
According to WHO "Health is a state of complete physical, mental and social
well-being, and not a mere absence of disease or disability".
• Definition of Dental public health:
It was defined by the American Dental Association as the science and art of
preventing and controlling dental diseases and promoting dental health through
organized community efforts.
• Dental public health is concerned with:

1. Dental health education of the public.

2. Applied dental research.
3. The administration of group dental care.
4. prevention and control of dental diseases.
On community dental basis.

• Characteristics of Dental public health:

1. It must be done in areas where group responsibility is recognized.
2. Public health method depends on team work.
3. Public health work should deal with all parts of problems; involving the host,
population and the environment.
4. Prevention is considered a major objective of public health programs. This is
because:
 a) Prevention of the disease is better and cheaper than its cure.
b) Prevention can be better performed on mass population through public
health.
5. Public health methods must depend on biostatistics which appraises the
variability and the errors to be found in almost all arithmetic measurements of
a disease in a large population.
6. Public health deals with healthy and apparently healthy as well as with
diseased people.

• Objectives of dental public health:

1. It gives an accurate indication about dental diseases.
2. It takes into consideration the current social changes in the community that
influence the prevalence of dental diseases.
3. It provides the dentist with specialized skill and knowledge to plan, interpret
and evaluate dental health programs, to bring dental care to large population.
4. It stresses the importance of prevention in the minds of the public.

Preventive Dentistry

• Definition:
− Preventive Dentistry comprises the various procedures used by dentists,
dental hygienists, physicians, nurses, teachers, and others to develop scientific
oral health knowledge and habits.
− It consists of those techniques which prevent the initiation of oral diseases and
prevention of such sequelae of neglecting these diseases. [As oral and
systemic infection and interference with normal growth and development.]

• Objectives of Preventive Dentistry:

In the broader senses it aims to prevent:
1. Factors which predispose to disease or the disease itself.
2. Factors which:
a) evoke more severe manifestations of acute diseases.
b) Maintain disease in a chronic state.
c) permit the progressive advance of disease.
d) maintain disability resulting from disease.
e) interfere with rehabilitation.
Thus preventive dentistry consists of techniques which prevent:
 Occurrence of dental disease
Sequelae of neglecting disease

− Dental practice is changing fundamentally from a procedure orientation to a

preventive orientation.
− This shift in oral health care encourages providers to prevent illnesses through
what is called risk assessment which aims mainly at targeting preventive efforts
towards those who are in need.

Risk Assessment
• Definition:
It is the identification of individuals at high risk for any future disease as dental
caries, periodontal disease, etc.
• Importance of caries risk assessment:
1. Defines those in most need.
2. Improves the effectiveness of preventive measures and levels of treatment.
Accordingly, preventive dent. Should involve individuals at higher risk.

Caries Susceptibility (Activity) Tests:

− There are a number of tests which are made to predict future Caries activity.
− They may be used to provide an illustration of acid production in the carious
process to the patient, so, he becomes alert to the need for regular oral hygiene
and the avoidance of carbohydrate snacks.

• Advantages:
1. Permit the identification of individuals with a higher risk of developing dental
caries.
2. Permit dental health personnel to screen large segments of the population e.g.
school children.
3. Provide a patient with an evaluation of caries risk before dental procedure
and therefore gives the appropriate line of treatment.

• Types of caries susceptibility test:

A. Lactobacillus count test:

− There is generally a correlation between the number of lactobacilli and dental
caries activity.
 − In this test a specimen of saliva is collected by the patient chewing on a cube
of paraffin wax first thing after getting up in the morning and spitting into a
sterile bottle.
− The saliva is diluted (1 ml is mixed with 4 ml beef extract adjusted to pH 5
spread on tomato agar plates) and incubated for 96 hours.
− The colonies are counted and the number of lactobacilli per ml of the original
saliva is calculated.
− Patients with a count over 10,000 have moderate to marked caries activity
between 1000 and 10,000 slight to moderate activity, and below 1000 very
slight or none.

B. Methyl red test:

− Another method of caries activity is the use of water soluble methyl red pH
indicator for disclosing those areas of the tooth surface that develop pH below
5.
− Aqueous methyl red is a chemical indicator that changes from yellow at pH 6
or above to deep red at pH 5.
− This solution which is yellow is applied to all the teeth and after [half a
minute] some areas of red coloration appear indicating acid formation.
− The patient then rinses with 1 % sugar solution and after few minutes reapply
methyl red solution, the change in color to red will be found in active carious
areas in proportion to their activities.
− Red areas, which are not already showing caries activity, may suggest the site
of future caries.
− This test is a convenient method of demonstrating to parents the importance
of freely fermentable carbohydrates in the caries process and the value of
immediate brushing and rinsing immediately after the ingestion of refined
food.

C. The Snyder test:

− This test measures the ability of oral micro-organisms to form acid from a
Carbohydrate medium.
 − A sample of 0.2 ml of the saliva specimen obtained and incubated into a
glucose agar medium with indicator bromo-cresol green.
− Change in color to yellow indicates a fall in pH or acid formation.
− If the change occurs within 24 hours, it indicates marked caries activity in the
child.
− If it occurs within 48 hours, it indicates moderate activity.
− If it occurs within 72 hours, this indicates slight caries activity.
− If the change occurs above 72 hours, this indicates no caries activity.

D. The Modified Snyder test (Alban's test):

− This modified Snyder's method uses the same formula as Snyder's media with
the exception that less agar is added.
− At the time of the test a 5ml tube of semisolid agar is removed from the
refrigerator.
− The patient is asked to spit unstimulated saliva directly into the tube until there
is a thin layer of saliva covering the surface of the green agar, the tube is then
incubated for 4 days.
− Color changes will be observed.
− Scores from 0 to 4 will be the scored based on the amount of color changes
occurring from top to bottom in the tube.
▪
A zero score indicated no color change
▪
1+ score is a color change to yellow in the top 1/4 of the tube.
▪
2+ score is to the half way mark.
▪
3+ score is to the 3/4 mark.
▪
4+ score is when the entire length of the agar column has changed to
yellow.
− The Alban test is ideal for patient's education motivation and cooperation.
− It is also easy to accomplish for routine dental office use.

E. Dip Slide Method:

The dip slide test is a practical method to quantities lactobacilli or streptococci.
1. Dip-slide method for lactobacillus count:
 − A specially designed dip slide of plastic is coated with lactobacilli
selective agar added to saliva is flowed over the agar surface.
− The slide is then placed into sterile tube, which is tightly closed and
incubated at 370C for 4 days.
− It is then removed, and the colony density is determined by comparing it
with a model chart.
− Reading of more than 10.000 colonies/ml of saliva will be considered
high.
− Reading of less than 1000 colonies/ml of saliva will be considered low.
− Reading between 1000 -10.000 colonies/ml of saliva will be considered
medium.

2. Dip-slide method for S. mutants count:

− Saliva is poured on a special plastic slide that is coated with Mitis Salivarius
agar, containing 20% sucrose.
− The slide is then tightly screwed into covered tube and incubated at 3 7°C for
48 hours in a sealed candle jar.
− The density of Streptococcus Mutans colonies is evaluated as follows:
▪ 1= Low when the colonies are discrete less than 200 colonies.
▪ 2= Medium when the colonies are more than 200 colonies.
▪ 3= High when the colonies are tiny and uncountable.
− The dip slide method is simple, practical arid cost reasonable to be used in a
private dental office.
 LEVELS OF PREVENTION

Period of Pre- Period of Pathogenesis

pathogenesis
Primary level of prevention Secondary level of Tertiary level of
prevention prevention

Health Specific Early Diagnosis and Disability Rehabilitatio

promotion protection prompt treatment limitation n

− Health − Good − Periodic • Treatmen • Replacemen

educatio oral detailed t of well- t of the tooth
n in oral hygiene oral develope structure by
hygiene. . examinatio d lesions. appliances
• Good • Fluoridation of n with X- • Pulp (bridge,
standard of public water ray. capping partial....)
nutrition. supplies. •Prompt treatment of • Root canal
• Diet • Topical fluoride incipient lesions. therapy.
planning. application. • Extension for • Restoration
• Periodic • Avoidance of sticky prevention. of natural
inspection foods, particularly • Attention to teeth
between meals. developmental defects. • Extraction.
•Tooth brushing after • Compulsory •Orthodontic
eating. examination of school treatment.
• Dental prophylaxis. children.
• Treatment of highly
susceptible but
uninvolved areas in
highly susceptible
persons.
•Preventive
orthodontics.
 PREVENTION OF DENTAL CARIES

Dental caries is a preventable disease with a multifactorial etiology related to the

interaction overtime between specific microorganisms and dietary carbohydrates on
tooth substance with production of dental plaque.

Bacteria +sucrose (in plaque)→ acid

Acid +susceptible tooth surface → dental caries

Prevention of dental caries can be done through:

I- Dietary measures……..CHO
II- Oral hygiene measures……..M.O
III- Topical protection of teeth………TOOTH
IV- Fluoride application…………..TOOTH+M.O

I- Dietary Control of Dental Caries (dietary measures):

− Diet refers to the total oral intake of substance that provide nourishment and or
calories.
− Improving the oral environment through the prompt eliminating of fermentable
carbohydrates has an important effect upon caries rate after the teeth are fully
developed and functioning in the oral cavity.
❖ Oral clearance of carbohydrate:
− The Some forms of carbohydrates take significantly longer time to be cleared
from the mouth.
− The caries activity is greater with increase in clearance time because it stays
for longer time to be cleared from the mouth.
− Sticky sweets such as chocolate, toffee, caramel, are much more harmful than
similar amount of more directly soluble carbohydrates.
− Also there is difference in oral clearance when sweets are consumed with
meals or between meals. It takes significantly longer time for sugar to be
cleared from the mouth when sweets are consumed between meals.
− Caries activity is also directly related to the amount and frequency of
consuming carbohydrates.
 − Sucrose is the traditional sweetener, it is sweeter and cheaper than any simple
carbohydrate. Sorbitol, Xylitol, and Mannitol (sugar alcohol) are caloric
sweetener with very low cariogenic potential.
− Sorbitol sweetened chewing gum and candies are much less cariogenic than
those containing sucrose. Xylitol is also used nowadays in confectionary and
toothpaste.
− Apart from sucrose, other simple carbohydrates such as fructose, glucose
occurring naturally in honey, fruits and vegetables can produce acid.
− Human milk is more acidogenic than bovine milk, as bovine milk has higher
calcium phosphate and protein than human milk.

❖ Diet history analysis:

Aim:
− Determination of individual eating habits when vague reports from patient
make it impossible to determine whether an adequate diet is being obtained.
Technique:
− In this analysis the patient has to record his exact food intake for a period of
one day; 3 days or preferably one week and then analyze the report for calories,
carbohydrates, protein; fat and the important minerals and vitamins.
− From this analysis factors can be brought to light which may have escaped the
patient's notice.
− According to this analysis recommendations for changing the dietary habits
of this patient can help in improving his caries condition.

❖ Dietary Recommendation:
1) Keep the carbohydrate content of the diet as low as possible consistent with
satisfactory caloric intake. It is preferable that no more than half the daily
calories be carbohydrate.
2) When carbohydrates are used select wherever possible the soluble forms or
those that clear the mouth most quickly. Leafy, green or yellow vegetables
are good carbohydrate sources with low retention. Avoid sticky candy and
suckers.
3) Consume carbohydrate at meals so far as possible. Avoid between meal
snacks, substitute the sticky sweets with nuts, raw fruits or vegetable for the
in-between meal snacks if such snacks are unavoidable.
 4) Consume carbohydrate at meals so far as possible. Avoid between meal
snacks, substitute the sticky sweets with nuts, raw fruits or vegetable for the
in-between meal snacks if such snacks are unavoidable.
5) Cheese is recommended as caries preventive food because it causes strong
stimulation of salivary flow, raise the calcium concentration in the plaque and
raise the PH within 3 minutes after ingestion.

❖ Diet for good general nutrition:

Diet for good general nutrition is the diet that must contain the essential nutrients:
1. Sufficient amount of minerals especially calcium and phosphorous.
2. Sufficient amount of vitamins particularly vitamins D&C.
3. Reduced amount of carbohydrates, especially freely fermentable varieties.
4. Enriched phosphates.

II. Oral Hygiene Measures:

The objectives of oral hygiene measures are:
1. remove all food debris from tooth surface.
2. Maintain the least possible amount of dental plaque.

1- Tooth brush and tooth paste:

i. Tooth brushing:
A. Tooth brush design:
− There are different shapes, textures, sizes and patterns of tooth brushes
available.
− A straight brush is the one generally preferred, it offers an overall efficiency
to all parts of the mouth.
− Nylon bristle is superior to the natural (hog)bristle s it is more flexible, easier
on cleaning, cheap, and do not become wet. The only advantage of natural
bristles is that they cause less tooth wear because they become wet.
B. Tooth brush types:
1. Manual tooth brush.
2. Electric tooth brush.
3. sonic and ultrasonic toothbrushes.
4. Ionic tooth brushes.
1. Manual tooth brush:
− Man-made bristles of about 0.4mm thick x 12mm long.
− Firm and resilient bristles with rounded and polished ends.
− Short head (about 2.5cm) with flat brushing surface (2.5x0.5cm) to permit
access to all surfaces of the teeth.
− Multi tufted, 2 or 3 rows of separate bundles of bristles allows the bristles to
enter easily in the embrasures and in the depth of the fissures.
− Able to remove plaque from teeth.

2. Electric tooth brush:

Offers mechanical aid and less manual effort, it is recommended in case of
disabled individuals.

3. Sonic and ultrasonic toothbrushes:

Produce high frequency vibrations (1.6 MHz), aids in stain removal as well as
disruption of the bacterial cell wall (bactericidal)

4. Ionic toothbrushes:
− Change the surface charge of a tooth by an influx of positively charged
ions.
− The plaque with a similar charge is repelled from the tooth surface and is
attracted by the negatively charged bristles of the toothbrush.
 C. special types of tooth brushes:
1. Orthodontic brush.
2. Tooth brush for dental wearer.
3. Tooth brush for handicapped patient.

D. Learning effective tooth brushing technique:

− It should be remembered that it is not possible to achieve 100% plaque removal
in any patient with the use of tooth brush.
− And yet it is important to emphasize that most of our patients will show great
improvement in gingival condition, even complete resolution of the
inflammation.
− For the patient to continue regularly and routinely brushing effectively his teeth,
he must be educated and convinced by the importance and benefits of cleaning
his teeth.
− So for teaching an effective tooth brushing technique, the dentist must
emphasize the following:

1) Motivation:
The nature of the plaque and its adhesion to the tooth is explained. The role of
plaque in caries and periodontal disease is outlined.
2) Education:
The right way for brushing is any one which suits the particular patient. At this
stage paint the teeth with a disclosing agent.
3) Demonstration:
− The patient is asked to bring the brush which up to the present has been
used at home, not a new one, and is asked to demonstrate completely how
the usual brushing is carried out.
− Errors in brushing, areas omitted, lack of organized method are noted.
− Using life-size models for tooth brush demonstration, each quadrant is
divided into three areas: posterior, middle and anterior.
− Each surface should be brushed with 10 strokes of the brush (buccally,
lingually and occlusally) in a systematic manner.
− The usual effective brushing time is between 2-4 minutes.
4) Assessment:
− After each demonstration, this patient is asked to brush his teeth similarly
and disclosing agent is used to indicate the amount of residual plaque
overlooked.
− Further training is given and other devices may be prescribed.

 Disclosing agents:
Definition:
Disclosing agents are water soluble dyes used to stain the plaque and other
deposits and make them obvious to point out the plaque to the patient.
Advantages:
• Visualize dental plaque to the patient and hence facilitate instruction on its
removal.
• Enable the dentist to confirm that teeth surfaces are free of all deposits during
scaling and polishing.
Forms:
Tablets, liquid, wafers, swabs.

Types:
Iodine, Basic fuccine.
Requirements:
• Stain plaque selectively.
• Do not stain the rest of the oral structures.
• Do not discolor anterior teeth fillings.
• Has an acceptable taste.
• Has no harmful effect when swallowed.

E. Methods of tooth brushing:

− The rotation or roll method:

− This method is the most commonly recommended.
− The side of the bristles press against the attached gingival and sulcus area.
 − The bristles are then rolled across the gingival towards the occlusal keeping
the sides of the bristles pressed firmly against the tissue (they should appear
to blanch) and with many of the bristles sweeping through the embrasures.
− This stroke is repeated 10 times in each region. Assuming that the buccal area
was brushed, this is followed by the lingual and repeated around the whole
arch.
− The occlusal surfaces are then brushed with a to and fro action, the emphasis
in all the brushing is that the brush should be used as a broom to sweep, not
as a scrubbing brush to polish.
− The brush is often held vertically for the lingual surfaces of the upper and
lower incisor teeth.

− The Fone's Method:

− For young children, Fone's method of tooth brushing from the outer surface
of the teeth is recommended.
− The upper and lower teeth are put together into occlusion; the brush being
carried in a circular motion without any twisting of the handle.

When brushing techniques are instructed, it should not be forgotten to stress that:
a) The brushing should be done immediately after eating at least twice a day.
b) While brushing, teeth should be put in occlusion.
c) Systematic way of brushing should be used so that all the teeth receive proper
brushing.
d) Brushing the lingual surfaces of the teeth must be done.

ii. Tooth paste (Dentifrices) and tooth powder:

− A dentifrice is a substance used with a tooth brush to remove bacterial plaque,
materia alba, and debris from the gingiva and the teeth for cosmetic purposes
and for applying specific agents to the tooth surfaces for preventive and \or
therapeutic purposes.
− Therapeutic dentifrices are those containing agents designated to inhibit the
growth of oral microorganisms increase the resistance of dental hard tissues.
− Some dentifrices long ago used to contain ammonium compounds,
chlorophyll, antibiotics, fluorides, etc.
− The best so far are those containing fluorides as they can be of significant anti-
caries value when routinely used.
 − The range of content of the various components in commercially available
dentifrice is as follows:
▪ Detergent 1 -2%
▪ Cleaning and polishing agents 20-40 %
▪ Binder (thickener) 1-2%
▪ Humactant 20-40%
▪ Flavoring 1-1.5%
▪ Water 20-40%
▪ Therapeutic agent 1-2%
▪ Preservative, sweetener and coloring agent 2-3%

 Fluoride-containing tooth pastes:

− The incorporation of fluoride into dentifrice is a practical approach to the
problem of delivering topically applied fluoride to large numbers of persons.
− Several studies have produced positive results, showing reductions in the
incidence of dental caries in the range of 10-30%.
− Analysis of the collected data suggests that greater caries inhibition is
produced in proximal surfaces than in occlusal or buoco-lingual surfaces.
− The compounds that have been studied most intensively are
• sodium monofluorophosphate (MFP) as Colgate and Signal 2
• sodium fluoride as Crest and Close up
• acidulated phosphate fluoride
• amino fluoride.
− The success of any fluoride containing dentifrice depends upon the
availability of a free fluoride ion capable of reacting with enamel surface on
brushing.
− Since fluoride ion is a highly reactive ion, there is a greater possibility of
combining with other tooth paste ingredients and thus the expected value is
lost.
− Clinical investigations support the value of stannous fluoride dentifrices
although some tooth pigmentation has been reported.
− MFP dentifrice presents greater Caries inhibitory effect and no staining.
Sodium fluoride; dentifrices are hot effective while amino fluoride dentifrices
are not widely commercially available.
 Special Guidelines specific for young children:

1. Use a pea -sized amount of toothpaste on the brush.

2. Use formulations with low fluoride concentration (500-600ppm) for children
younger than 7 years .Children above 8 years are safe to use family toothpaste.
3. To avoid increased risk of toothpaste ingestion brushing should be supervised
by parents.

 Special purpose of tooth pastes:

Some patients who have sensitive cervical areas on their teeth may benefit from
the use of desensitizing pastes such as "Sensodyne" or "Emoform" although there
is no justification for recommending them.

2- Other Cleaning Devices:

Sometimes it is advisable to use other devices than a tooth brush to achieve through
plaque removal.

A. Mouth Wash:
• Advantage:
− Clean the mouth.
− Freshen the breath.
− Reduce plaque and gingivitis.

• Types of mouth rinse have been available:

− Cosmetic oral rinse: help to reduce halitosis and provide good taste.
− Therapeutic oral rinse: such as chlorohexidine and fluoride for removal of
plaque.
− Herbal oral rinse: it have antiseptic and antibacterial properties, also it have
natural ingredient such as chloropyyll which is powerful breath fresher

B. Dental Floss:
− This is a tool used to disorganize and remove the microbial masses that are
located below the gum margins interproximally.
− Dental floss may be either waxed or un-waxed or medicated (fluoride,
chlorohexidine).
− The un-waxed floss is recommended for cleaning purpose because it is said
that in use, strands open and trap plaque and debris, and hence clean the
interdental space better.
− The thin nylon fibers of this floss serve as individual knives or cutting edges
as it is manipulated to scrap the plaque from the tooth.
− This floss spreads easily over the tooth surface, which allows it to pass easily
between the contact points of the teeth.

C. The tooth pick (wedge stimulator):

− This is used to remove bacterial mass from areas inaccessible to the brush
bristle.
− They should be only recommended where there is sufficient interdental space
not filled with gingival tissues.
− wooden, plastic and medicated tooth picks are available.
− They should be inserted into the embrasure pointed end first, with the stick at
an angle of 450 to the long axis of the tooth, and the sharp edge of the stick
away from the gingiva.
− The stick is rubbed about 12 times in each space with the tip pointing
coronally.
− They are also effective in disturbing the plaque in periodontal pockets,
cleaning root surfaces, cleaning buccal surfaces of third molars and the lingual
surfaces of lower molars.

D. The rubber tip (interdental tip stimulator):

− Located on the handle of some tooth brushes and it is used for further
stimulation and massaging of the gingiva.

E. The Interdental Brush:

− It is a single tufted brush used for cleaning the interdental spaces from the
lingual and labial aspects.
− Patients find no difficulty in its handling.
− The brush has the advantage of reaching posterior areas easily.
3- Oral Rinsing:
− The purpose of rinsing the mouth is to remove the material that has been
loosened with the floss and the tooth brush bristles.
− The teeth and the mouth are rinsed by forcing water vigorously back and forth
through the teeth several times.
− There is a special appliance available for this purpose (the water irrigator) it
is used to clean the pockets that form along the sides of the roots, around and
under bridges, and around and under orthodontic appliances.

4- Dental Prophylaxis:
− This procedure consists of removing the hard deposits on the surfaces of the
teeth by scaling, then smoothening and polishing the surfaces with pumice on
rubber cups and brushes.
− The smooth well-polished surfaces of the teeth are less susceptible to be
stained or coated by dental plaque.
− By this procedure, early carious lesions can be easily recognized.
III- Topical protection of teeth:

This includes all measures applied to increase the resistance of the intact outer tooth
surface. Among these measures are:
1. Operative dentistry.
2. Prophylactic odontotomy.
3. Prophylactic fissure filling.
4. Topical chemotherapy.
5. Fissure sealants.
6. Preventive resin restoration.
7. A traumatic dentistry (ART) are the most essential.

1. Fissure sealants:
− Fissure sealants are materials used to (correct) seal deep pits and fissures and
change them into non-retentive surfaces.
− There is considerable evidence that a significant caries reduction observed
when fissure sealants are correctly applied to deep pits and fissures of newly
erupted teeth.
− Types:
• Dimethacrylate bis-GMA resin (the most commonly used)
• Glass ionomer: provide good adhesion and fluoride release.
• Compomer.

− Indication of pit and fissure sealants:

• Newly erupted posterior teeth with deep pits and fissures are the
suitable teeth for application.
• Medically compromised patient
• Patient with high risk to dental caries.

− Steps of application of pit and fissure sealants are:

• Remove any debris using pumice slurry on small brush or prophy
rubber cup.
• Wash the tooth with air water spray.
• Isolate the tooth with cotton rolls and use saliva ejector.
• Dry the tooth with compressed air.
• Etch the occlusal tooth surface with enamel etching solution or
gel (37% ortho-phosphoric acid) for one minute.
• Wash thoroughly with air water spray.
 • Dry with compressed air till chalky white enamel surface appears.
• Apply the fissure sealant with little brush.
• Polymerize light cure sealant for 20 seconds keeping the tip of the
light gun as close to the surface as possible.
• Check the height (high spots) of the polymerized material and
correct with fine stone when possible.
• Check the success of sealant application at 6 monthly periods.

2. Preventive resin restoration:

− The technique is based upon restoring minimal carious lesion usually in young
permanent molars with minimum removal of tooth structures, while
concomitantly preventing caries from attacking other pits and fissures on the
same surface without mechanically removal of these areas.

− Technique:
• A small round bur may be used for access and removal any carious tissue.
• The tooth is then etched then bonding agent is applied
• A composite of thin consistency is used to restore the cavity.
• then, fissure sealant is applied over the remaining pits and fissures

3. A traumatic restorative treatment (ART)

− The two main principle of ART are:
a. Removing carious tooth tissue using hand instruments only.
b. Restoring the cavity with adhesive filling material currently a glass
ionomer.
− Carious cavities suitable for ART should be:
a. Involving the dentin with no pulpal involvement.
b. Accessible to hand instruments.
− The advantages of ART include:
a. Use of easily available and inexpensive procedure to conserve sound tooth
surfaces.
b. Permit oral health care workers to reach people who otherwise never
would have received any oral care; such as handicapped, villages in rural
and suburban areas, home-bound, institutionalized people and
economically less developed countries.
IV- Prevention of Dental Caries with Fluoride:

• It is one of the halogens.

• It is the most active element of this group.
• It is not present in the free form.
• It is present in soil, sea water, rain water, sea food, etc.
• Fluoride is the only proved diet substance to be of anti-cariogenic benefit
for humans.

Mode of Action of Fluoride:

The role played by fluoride in the control of dental caries is mainly as follows:
1. Ionic exchange of fluoride with the hydroxyl group of calcium
hydroxyapetite in the surface layers of enamel changing it into fluoroapetite
which is less soluble in acids.
2. Enzymatic inhibition: interfering with the breakdown of glucose to lactic
and pyruvic acid. Both phosphatase and anulase enzymes are inhibited by
fluoride.
3. Bacterial inhibition: fluoride has a direct inhibitory effect on the bacteria of
the dental plaque.
4. Fluoride has the ability to precipitate minerals from saturated Solutions: As
saliva is saturated by minerals, fluoride favors the precipitation of the calcium
phosphate on the surface of enamel, so it aids in remineralization of partially
demineralized enamel in early caries.
5. Fluoride lowers free surface energy: This will decrease the plaque
accumulation on the treated enamel surface.
6. Action on tooth size and morphology: In communities with fluoridated water
supply, there is a trend towards shallower fissures and lower cusp height and
smaller tooth size. This will decrease caries susceptibility.

Sources of Fluoride:

− Humans obtained fluoride from three sources: water, foods and air.
− Water and food, may contribute significant amounts to the daily intake.
− Water from deep wells and artesian wells usually provide high natural fluoride
concentration.
− Most vegetables, fruits and dairy products contain low amount of fluoride.
 − Meat and poultry also contain little fluoride
− But sea foods (fish sp. salmon and sardines, shrimp, crab, etc) may contain
2.5 ppm.
− Most beverages contain amounts of fluoride especially tea.
− Fruit juices and soft drinks are generally low in fluoride, but the fluoride
content of the water used in the preparation of such beverages or in the
cooking of food will be reflected in the fluoride concentration of the final
product.
− The total amount of fluoride consumed daily will depend upon both the
concentration of the fluoride in the water and food as well as the amount
consumed.
Recommended optimal fluoride dose:
− The recommended optimal fluoride doses for community water supplies vary
with the annual mean of the maximum daily temperature (0.7 to 1.2 ppm).
− The average diet provides 0.2-0.3 mg of fluoride daily.

Uptake of Fluoride by the Teeth:

− Fluoride is incorporated in enamel and dentine in two stages:
a. Before eruption:
During Calcification, traces of fluoride incorporated into the crystalline
structure of appetite lattice.

b. After eruption:
▪ Enamel surface continues to pick up fluoride derived from diet,
water and saliva.
▪ The post-eruptive acquisition of fluoride continues throughout life
and is directly proportional to the concentration in food and water
ingested.
Toxicity of Fluoride:
Acute fluoride toxicity:
− High doses of fluoride are toxic and may be lethal. Fortunately, this is rare
and only few accidental cases are reported (4-5 gm for adult, 0.25 mg for
infants).
− Ingestion of massive single dose of fluoride may cause, vomiting, nausea,
coma hypocalcemia and cardiac arrest.
− For treatment of this case, intake of large amount of calcium orally like milk
is a must. And give 10% calcium gluconate injection to control convulsions.
Chronic fluoride toxicity:
− Chronic fluorosis results in skeletal or dental changes. If fluoride was ingested
during the tooth developmental period at levels injurious to the ameloblasts.
− Mottled enamel (dental fluorosis) may result with various degrees of severity
when water fluoride concentration is (6-8 ppm).
− Later in life, the ingestion of high levels of fluoride may result in bony
deformities joint fixation and calcification of the ligaments.

Methods of Providing Fluoride:

This can be achieved either by:
[1] Systemic fluoridation: which means ingestion of calculated amount of
fluoride to be incorporated in the developing teeth.
[2] Topically applying fluoride: which means applying of preparations on
exposed tooth surfaces to increase their resistance to cariogenic
processes

[1] Systemic Fluoride:

1. Water fluoridation:
− There is an inverse relationship between the fluoride level in drinking water
supplies and the incidence of dental caries.
− It should be noticed that there is also a direct relationship between fluoride
level in water and the incidence of mottled enamel.
− A fluoride concentration of 1 ppm in communal water was found to be
optimum regards the effective anti-caries effect and lower mottled enamel.
− It is recommended that optimal dose of fluoride ingested daily in children
from 0.5 -1.0 mg fluorides (WHO).
− So this 1 ppm fluoride concentration in water is suitable for countries with
cold weather whereas in countries with hot weather the concentration of
fluoride in public water supplies should be lower and this depends on the daily
water consumption which is usually double or triple them in comparison with
cold weather .
− In Egypt the fluoride concentration of Nile water is about 0.36 ppm in which
is considered optimum.

2. Fluoridation of school water supply:

− Where fluoridation of communal water supply is not possible fluoridation of
school water supply can be approached.
− School children are exposed to the benefit of fluoridation only during school
days and hours.
− In this case higher fluoride concentration up to 5 ppm have been tested and
proved effective in caries control.
− The decrease in DMFS is about 40% with no evidence of dental fluorosis.

3. Fluoride supplements:
− When fluoridation of water supply is not possible, fluoride supplements can
be resorted.
− This can be in the form of fluoride tablets, drops or syrups.
− Studies have shown considerable reduction in dental caries in deciduous and
permanent dentition when consumption of fluoride has been started early
enough.
− The usual dose is 0.5 mg F/day for children up to 3 years of age and 1.0 mg
F/day for children over 3 years of age.
− The fluoride tablets usually contain 1.0 mg F, to be crushed in water or fruit
juices.
− Fluoride administration should continue till the age of complete crown
formation of the second permanent molar, i.e. about the age of 10 years.
 − Fluoride preparations should be kept out of reach of children to avoid over
dosage.
− Fluoride tablets digested as sweets are not advised.

DOSE:
6M.-3Y…….0.25mg/day
3y-6y……….0.5mg/day
6y-12y………1mg/day

4. Fluoride incorporation in various foods:

− e.g. salt, milk, bread, rise…etc. but the problem is the difficulty in adjustment
F conc. To satisfy individual personal intake due to difference in food
consumption from person to another.
− A careful regulation of the prescribed daily dose and a constant cooperation
by the parents is required.

[2] Topically applied fluorides:

The topical application of fluoride can be carried out either by the patient himself or
by members of the dental profession.

1. Self-administered fluoride applications:

a. Fluoride tooth pastes (dentifrices):
− Daily use of fluoridated tooth paste can reduce dental caries by 15 to 30%.
b. Brushing or rinsing with fluoride solution:
− Studies have shown that regular rinsing or brushing (every week or fortnight)
with 0.2% sodium fluoride will reduce dental caries incidence.
− The principle to be noted is the frequent rinsing with very dilute fluoride
solution.
− This is to be done after the routine tooth brushing to obtain clean tooth surface
and direct access to the enamel surface.
− Highly diluted solution (0.02%) can be used daily for patients showing high
caries susceptibility.
c. Fluoride gel:
− This is usually commercially available product containing 1.23% fluoride. It
is widely used.
− The gel has added flavors. It has to be loaded in a special applicator to hold
the gel in place for about 4 minutes.
− With some applicators, the whole mouth can be treated at once.

d. Fluoride dental floss:

− Dental floss (un-waxed) impregnated with fluoride is a valuable topical
fluoride vehicle.
− Flossing will result in a significant uptake of fluoride and a reduction in the
colonies of microorganisms on the proximal tooth surfaces

2. Professionally applied fluoride:

− It is very beneficial in reducing dental caries particularly for children who
live in area with low fluoride concentration in the drinking water.
− Different forms of fluorides have been utilized for the topical use, such as:

a. Sodium fluoride:
− The recommended procedure of 4 applications of a 2% sodium fluoride
solution, one-week interval, between every application result in a 40%
reduction in dental caries incidence.
− These 4 applications are considered a single application and have to be
applied every year or at the age of 3, 7, 10, and 13 years.
− Sodium fluoride has a good shelf-life, the solution can be kept for a
long period of time without deterioration.

b. Stannous fluoride:
− Single annual application of 8% stannous fluoride gives about 65%
reduction in caries incidence.
− Stannous fluoride solution is unstable.
− It has a short shelf life3 so it has to be prepared freshly for each
application by dissolving 0.8 gm. Of stannous fluoride in 10 ml distilled
water.
− The solution has a disagreeable astringent taste, and it discolors
decalcified enamel.
−
 c. Acidulated phosphate fluoride:
− Combination of sodium fluoride with phosphoric acid.
− 1.23% sodium fluoride in 0.1 Mole ortho-phosphoric acid produces an
acidulated phosphate fluoride mixture which when applied topically to the
teeth of children on an annual basis has decreased caries from 50-70%.
− This agent is stable, so it does not have to be prepared freshly for every
treatment as in cases of stannous fluoride.
− also it does not discolor decalcified enamel.

 Procedure for applying fluorides topically:

a. Sodium fluoride:
1. A thorough prophylaxis should be performed, each available tooth surface
should be cleaned and polished with pumice and rubber cup. It is preferable
to add one drop of 8% stannous fluoride solution to the polishing paste.
2. The upper and lower teeth on one side are isolated at a time, this is achieved
with a long cotton roll in the upper and lower buccal sulci; and a short roll
in the lingual area. A saliva ejector helps to keep the area dry. The teeth
are then air dried.
3. An 8% stannous fluoride solution is freshly prepared and applied to all
surfaces of the dried teeth with a cotton applicator. The teeth are kept moist
with the solution for 4 mm. by applying it every 15 to 30 sec.
b. Acidulated phosphate fluoride:
The same technique as for stannous fluoride.
c. Sodium fluoride:
1. A thorough prophylaxis is performed.
2. Teeth on one side are isolated as mentioned before.
3. Teeth are then dried and the 2% sodium fluoride solution applied to
each tooth surface including the interproximal surfaces with a cotton
applicator. The solution is allowed to dry on the teeth for 3 to 5 mm.
4. On 3 subsequent visits, usually one week apart, the same procedure
is repeated with the exception that prophylaxis is omitted and these
4 times are considered one application. The teeth have to be treated
every year.
 − For those children to whom it is difficult to apply fluorides every year; it
is customary to treat the teeth with topical fluorides at 3,7,10 and 13 years
of age.
− This is to insure that all the primary teeth and most of the permanent ones
receive the beneficial effect of fluorides just after their eruption.

d. Prophylactic paste:
− The routine uses of prophylactic pastes containing fluoride in the dental office
is expected to increase the fluoride content of surface enamel and
consequently, its resistance to additional attack.
− This will be advantageous when carried out every six months as part of the
regular dental examination.
− The. most recently available are stannous fluoride - zirconium silicate paste
and an acidulated phosphate fluoride - silicone dioxide paste.

e. Fluoride varnish:
− 5% sodium fluoride containing varnish is available commercially in several
countries.
− The varnish is applied using a paint-on technique using a brush and allowed
to harden foe 5-6 minutes.
− It should be applied at interval f 3-6 months.
− Advantage:
• Ease application
• Accepted by patient
• Higher fluoride acquisitions than gel and foam.
• Negligible amount of ingested fluoride.
 Prevention of periodontal disease

Periodontal disease
- It is the affection of periodontium or the supporting tissue of the teeth. It may
range from mild inflammation of the gingiva to severe destruction of
periodontal ligament or bone.
- Normal gingiva is pink, firm, stippled, and have shallow gingival sulcus
depth.
- While inflamed gingiva (gingivitis) characterized by redness, swelling of the
gingival margin with loss of stippling and bleeding.
- In more advanced case (periodontitis) there is destruction in the periodontal
ligament, bone resorption, with pocket formation and looseness of the tooth.

Causes of Periodontal Disease:

I- Local factors:
1. The consistency of the diet:
Eating hard and fibrous food allow for functional stimulation of the gingiva
and underlying tissues, while soft food do no afford functional stimulation. It
also allows for faster accumulation of debris at the gingival margins which
can cause gingivitis.
2. Calculus:
Accumulation of calculus in children is much lesser than that of adult.
3. The process of shedding of deciduous teeth and eruption of
permanent teeth:
− The present of loosely shedding teeth in the child mouth cause
moderate pain, so the child will avoid chowing on this site
 (non-functioning site) allowing deposit to be left on and around
the affected site causing gingivitis.
− Unequal root resorption can also hurt the underlying tissues
4. Occlusal abnormalities:
Crowding, open bite, proclined maxillary incisors and incompetent lips are
common cause of gingivitis as it allows for stagnation of food and interfere
with normal function.
5. Untreated caries:
− Open occlusal cavity causes decreased function and food accumulation in
the affected side.
− Cervical and interproximal cavities cause food impaction and gingival
inflammations.
− Poorly contoured restorations or overhanging margins are also a cause of
periodontal disease.
6. Prosthetic and orthodontic appliances:
Prosthetic and orthodontic appliance when it is poorly fitted or incorrectly
designed can cause periodontal disease.
7. Mouth breathing:
cause dryness of the gingival tissue.

II- Systemic factors:

1. Endocrinal disorders:
− Hormonal changes that happened during puberty can cause gingival
inflammation
− Diabetes can cause gingival disease particularly if there is neglected
oral hygiene.
2. Drugs:
Dilantin is a common drug used for treatment of epilepsy. This drug can cause
gingival hyperplasia which start at the interdental papilla and spread over the
tooth until it completely covers it.
3. During acute fevers:
As in typhoid and measles, severe gingival inflammation may happen which
subside after recovery from the disease.
4. Blood dyscrasis:
Such as leukemia which cause bleeding of the gingiva, ulceration and
enlargement.
5. Avitaminosis:
Specially vitamin C which gives rise to scurvy.
Preventive Measures of periodontal disease:
I- Dental prophylaxis:

− It is more important in the control of periodontal disease. This is because

deposits of calculus cannot be removed by the patient in home.
− Many periodontal patients must receive dental prophylaxis every 3 months or
every 4 months.
− Posterior bite-wing X-ray films should be taken at annual intervals and
studied for any alveolar bone loss.

II- Good oral hygiene (plaque control)

− It should be recommended that children eat some hard, fibrous and fresh foods
in addition to the rather soft diet prevalent today.
− It must be stressed also that the toothbrush is really a mouth brush and the care
of the gingival tissues is just as important as that of the teeth.

Types of tooth brushes:

1) Manual tooth brush
2) Powered tooth brush
3) sonic and ultrasonic toothbrushes
4) Ionic tooth brushes

Tooth brushing methods

1) Charter's method
2) Bass method
3) Stallman ‘s method.
 Method Bristle placement Motion Adv./ Disadv

Bass Apically, at 45 to tooth Very short back and -Remove plaque

surface (into gingival sulcus) forth vibratory with from cervical area
bristles remain in and sulcus.
the sulcus -easily learned

Charter Coronally, with side of Small circular with -Clean

bristles half on teeth and half bristles remain interproximals
on gingival at 45 to tooth stationary -don’t go into
sulcus
-gingival
stimulation
Roll Apically, nearly //to tooth Slight pressure, -don’t clean sulcus
then, rolling of the area
head to sweep -easy to learn
bristles over -require moderate
gingival and tooth dexterity
surface -good gum
stimulation
Fone Perpendicular to tooth surface Wide circular -don’t clean
movement on interproximal
baccal to include -easy to learn
gum and tooth -possible trauma to
gum
Stillman Apically at 45 to tooth with Slight rotary with -gum stimulation
bristles rest on gum and bristles ends remain -don’t enter sulcus
cervical portion of tooth stationary -interpximal is
cleaned
- require moderate
dexterity

III- Early treatment of carious cavities:

− Cervical cavities and interproximal caries should be treated as soon as a cavity
is spotted.
− The use of bite wing radiographs in the early detection of interproximal
lesions is advisable.
− New restorations should be carefully inserted, contoured and polished.
 − Old restorations should be checked.

IV- disorders in occlusion:

Early diagnosis of occlusal disorders and early treatment by preventive or
interceptive measures will save the gingiva.

V- Mouth breathing:
This should be treated either by clearing the air passages (Oro-nasal part) by surgical
or medical specialists, or by orthodontic means as oral screen.

VI- In the presence of prosthetic, surgical or orthodontic appliances:

− The patients must be aware of the role of such appliances in encouraging the
stagnation of debris and traumatizing oral soft tissues including the gingiva.
− It is necessary to maintain good oral hygiene and cleaning the removable
appliances thoroughly outside the mouth.
− It is occasionally suggested to relief the oral tissues by leaving dentures out at
night.

VII- Systemic diseases:

− Medical referral is recommended in the presence of systemic disease.
− Give dietary recommendation in case of vitamin deficiency.

VIII- chemical control of dental plaque

− Antibiotic.
− Chlorhexidine:
• Inhibit pellicle formation
• Reduce number of bacteria in saliva
• Decrease adsorption of bacteria to the teeth
• Reduce cohesiveness of plaque bacteria
− Enzymes: dextranase containing mouth rinses