DENTAL CARIES: PREVENTION AND TREATMENT Significant information for us to really diagnose our patient.

3 Factors Involving in the Formation of Dental Caries INFORMATION GATHERING

1. Medical, dental, psychosocial histories
Tooth - Part and parcel of data gathering for us to get the
dental health record of our patient. Once a patient
comes to our clinic, we interview and ask them what
are their concerns and why they seek dental treatment
Substrate Bacteria (chief complaint or chief concern). When we write
that one in our patient chart, it should be patient’s own
words.
1. Suitable Substrate 2. Clinical Examination
- Types of carbohydrates - We perform clinical examination may it be extra-rally
2. Bacteria or intra-orally.
- Microorganisms 3. Radiographic Examination and Diagnostic Aids
3. Tooth - If there is a need for us to use radiograph to evaluate
what is inside the tooth or other diagnostic aids.
Modifying and Contributing Factors in Dental Caries
EVALUATION AND SIGNIFICANT FINDINGS
- We need to collate all the significant findings.

PROBLEM LIST
- For you as beginners, sometimes or most of the
pathologic conditions or diseased process are not yet
that introduce to you, you are not yet familiar with all
the disease conditions, we do problem listing. List all
the significant problems and come up with your
treatment plant. But before with our treatment plan is
we need to consider the treatment objectives.
- Treatment plan we consider the patient. It’s not only
the dentist to dictate what will be done in the
treatment but we need to consider the status of the
patient.

TREATMENT
- After diagnosis, we provide treatment it does not end
in diagnosis or assessment without providing
treatment like preventive measures, disease control, a
TREATMENT PLANNING PROCESS definitive or final treatment for patients.

INFORMATION GATHERING TREATMENT OBJECTIVES

1. Medical, Dental, Psychosocial Histories
2. Clinical Examination
3. Radiographic Examination
v v
4. Diagnostic Aids v
PATIENT MODIFIERS v MODIFIERS
DENTIST
v
v v
EVALUATION OF FINDINGS v
TREATMENT PLAN(S) v
v Systemic Phase v
Acute Phase
Disease Control Phase
SIGNIFICANT FINDINGS Definitive Phase
Maintenance Phase
Risk
Assessment c
PROBLEM LIST DIAGNOSIS
v
TREATMENT

c
TREATMENT OBJECTIVES v
MAINTENANCE/MONITORING/PREVENTION
 - With the treatment, it does not end there also.
We need a maintenance phase, we need to
monitor the patient ad somehow prevent again
the onset of a disease entity. It’s a cycle.
Methods of Caries Prevention
1. Limit Substrate
- Substantially reduce sucrose from diet
- Eliminate sucrose from between meal snacks
- Xylitol reduces MS by altering their metabolic
pathways and enhances remineralization and helps
arrest dentinal caries.
- It is usually recommended that a patient chew a piece
of xylitol gum after eating or snacking for 5 to 30
minutes.
- Chewing any sugar-free gum after meals reduces the
acidogenicity of plaque, stimulates salivary flow, and
improves the buffering of the pH drop that occurs
after eating. Neutralizes the pH.

Rationale: 3. Modify Microflora

§ Reduce number, duration, and intensity of
acid attacks
§ Reduce selection pressure for Streptococcus
Mutans MS to grow fast in the oral cavity
- Bactericidal mouthrinses (chlorhexidine)
- Topical fluoride treatments
- Antibiotic treatment (vancomycin, tetracycline,
polymyxin). Antibacterial drugs that will alter
particularly with the synthesis of certain proteins and
metabolic activity of microorganisms.
Rationale:
§ Eliminate MS from mouth

*Dentist usually advise patients to gargle 5-10 mL of

chlorhexidine for about 30 seconds to 1 minute.

Mouth Rinsing/Washing

4. Plaque Disruption/ Removal

- Brushing
- Flossing
Goal of diet counseling is to identify sources of sucrose in the - Other oral hygiene aids (water piks, interdental
diet and reduce the intake of these food. brushes)

*Our main goal in terms of the substrate intake for individual Rationale:
we do diet counseling, the patient will identify already the § Decrease plaque mass
source of sucrose and advise or educate them to at least limit § Promote buffering (neutralize ph)
or reduce the intake of these foods. § Prevents plaque succession

2. Stimulate Salivary Flow

- Sugarless chewing gums (Xylitol)
- Eat non-cariogenic food that require lots of chewing
- Medications to stimulate salivary flow

Rationale: Brushing Flossing

§ Increase clearance of substrate and acids.
§ Promote buffering

*The more saliva present in our mouth, the more we achieve

the buffering action, self-cleansing action and we limit acid
formation inside our oral cavity.
Water Piks Interdental brush
- MS cannot ferment (metabolize) xylitol.
Types of Toothbrushing Techniques
Toothbrushing Method
Bass Method/Sulcular
Brushing
Roll or Rolling Stroke
Stillman Method
Modified Stillman
Charters Method
Circular/Sones
Vertical/Leonard
Horizontal
Clinical Practice of the Dental Hygienist 9th Edition
Bass Method/Sulcular Brushing
Purpose/Indication
Widely accepted biofilm
removal adjacent to and
beneath gingival margin
(most common)
Toothbrush should be in a
45 degree angle.
Cleaning gingiva and
removing biofilm, materia
alba, and food debris from
teeth without emphasis on
gingival sulcus.
Designed for massage and
stimulation and cleaning of
the cervical areas.
Incorporates a rolling stroke
after vibratory (rotary)
phase to minimize the
possibility of gingival
trauma and increase biofilm
removal effects.
Interproximal toothbrushing
method which removes fil
and mucin from the
proximal surfaces and
gingival massage through
mechanical stimulation
Method recommended for
children
Up and down stroke
(detrimental to our gums)
Crosswise brushing
(detrimental to our gums)
- Is used by patients that have good manual dexterity
and limited gum recession.
Steps:
1. The brush is placed at a 45 degrees angle on the front
surface of the teeth, with the bristles projecting into
the pocket surrounding the tooth.
2. A small circular motion is made with the bristles into
the pocket.
3. Then, the bristles is swept from the gumline to the
biting surface of the tooth. Brushing over the entire
front surface. This technique is then completed on the
inside surfaces of the teeth.
4. The toothbrush is once again placed into the pocket at
a 45 degree angle completing small circle.
5. Then brush from the gumline to the biting surface of
the tooth.
Proper Tooth Brushing Technique
Watch: https://youtu.be/FLrAPj8a1bs
- Toothbrushing is an essential part of good oral health.
- It is recommended that a soft bristle toothbrush is
used.
Steps:
1. Add a small amount of toothpaste on the toothbrush.
2. When brushing, make sure to use a circular scrub
motion across all the surfaces of the teeth but the
action of the bristles is moving away from the gums.
3. For those surfaces of the tooth that are not accessible
by the bristles of the toothbrush, make sure to floss to
get areas that are in between the teeth.
4. Be sure to clean all surfaces of the tooth that can be
reached by the toothbrush bristles.
*Flossing
- Similarly, there may be instances wherein we cannot
really clean the teeth particularly the interproximal
surfaces.
- The significance of dental floss is to clean properly
those areas that are not really reach by the bristles of
our toothbrushes. - - - Ideally flossing is done prior to
tooth brushing

Flossing
- Is the technique of using dental floss to clean in
between the teeth.
Steps:
1. Before brushing your teeth, measure out 18
approximately 18 inches of floss and wind each
end around your middle finger.
2. Grasp 1-2 inches of the floss with your index or
pointer finger and thumb.
3. Gently glide the floss in between the teeth in a
sawing motion. Use care not to smock the floss
in between the teeth as this may cause trauma to
the tissue
4. Angle the floss so it hooks the tooth in a C-
shaped
5. Gently slide the floss up and down on the surface
Modified Bass Method Tooth Brushing of the tooth making sure it goes slightly below
Watch: https://youtu.be/-j2Y_xSlDOY the gumline
 6. When complete, angle the floss to hook the tooth
in the opposite direction and repeat this step
7. When you have finished flossing, follow with
brushing and a mouthrinse. Try to floss before
every brushing. If you don’t have time in
flossing in the morning, always floss in the
evening before your final brush of the day.
Water Pik
- Pressurized or other than the power toothbrush
attached to it. There is the component of a syringe
wherein, it is pressurized. You can just direct this one
towards the interdental areas. Press the button, and a
pressurized water or mouthwash.
- Ex. Powered toothbrushes (people who lack manual
dexterity) It rotates and vibratory motion but you
need to position the brush in proper angulation.
Other Tooth Regimen
- Tongue Scraper
- Interdental Brushes
Flossing: Threader Floss
- Is a specialized floss with multiple thickness and
texture.
- An area of unwax flaws to get in between teeth.
- An area of thicker nylon meshwork to clean larger
surfaces
- And a stiffened to allow for threading underbridges
beneath tight contact areas through exposed furcation
and around orthodontic braces.
Steps:
1. When using threader floss, it is necessary to glide the
floss through the space between the bridge and the
gingiva in order to clean the underside of the bridge.
2. Then, glide the floss at the opposite surface.
*Threader floss is used for bridges and crowns to
really clean underneath because these areas are prone
to food entrapment.
Rubber Tip Stimulator
- Is a conical, flexible, rubber or plastic tip attached to
a handle at the end of a toothbrush.
- It is primarily used to promote, healthy and firm
gums and prevent gum disease.
Steps:
1. The tip is placed at a 45 degree angle to the long axis
of the tooth to prevent damage to the soft tissues, care
should be taken to apply only very moderately
pressure along the gumline.
2. The tip is then moved along the gumline working
around the entire mouth on both the outside and
inside surfaces of the tooth.
*Although this rubber tip stimulator is made up of rubber,
definitely care must be taken into consideration, sometimes
kasi, it may impede or cause irritation to the gumline.
- Rubber Tip Stimulator remove stains
- Massage gumline with proper technique and manipulation.
Floss Pick
- Is designed with a tooth pick-like projection at one
end and a fork-like floss pick at the other.
- It provides individual with reduced manual dexterity
with an easier way to floss their teeth.
Steps:
1. Cleaning starts with the movement of the floss pick
up and down in between the teeth as well as sliding it
gently under the gumline to further clean these areas
of any food particles.
2. These can be repeated 2-3 times for effective
cleaning.
3. The opposing end can further aid as a toothpick to
help remove food particles.
*we don’t advise the use of toothpick. If we try to use
toothpick, gum tissue will be impeded when we insert
toothpick interdentally Black triangles are present in between
the teeth. The more you are causing irritation towards the
gums.
Methods of Caries Prevention
5. Modify Tooth Surfaces
- Systemic fluoride
o Ingested from the food we eat, drinks we
consume or water.
- Topical fluoride application
o Gel or a varnish
- Preventive Resin Restoration (PRR)
o Arrest incipient caries and its progression
- Enameloplasty
- Prophylactic Odontotomy
Rationale:
§ Decrease plaque retention and increase
resistance to demineralization
*We need to make the tooth stronger and resistant to any
forms of cavitation or formation of decay.
*We only need 1 part per million of fluoride. Excessive
fluoride intake may lead to fluorosis.
Anticaries Activity of Fluoride
1. The presence of fluoride ion greatly enhances the
precipitation into tooth structure of the fluoroapatite
from calcium and phosphate ions present in saliva.
This insoluble precipitate replaces the soluble salts
containing manganese and carbonate that were lost
because of bacterial-mediated demineralization. This
exchange process results in the enamel becoming
more acid-resistant.
2. Incipient, non-cavitated, carious lesions are
remineralized by the same process.
3. Fluoride has antimicrobial activity.
*Fluoride attracts calcium and phosphate (hydroxyapatite)
back into the tooth structure.
*Remineralization only takes place on the enamel and not on
the dentin.
 Resin Sealant Placement Technique or PRR

Fluoride Gel Application

- Usually when we apply fluoride, the tooth must be
clean. We must do scaling and polishing.

Steps: Steps:
1. We place fluoride gel on the tray and choose what 1. Using the smallest size of bur or fissurotomy bur,
particular tray is appropriate on a certain patient. we just need to remove them following the
2. Opt to do first on the maxillary or mandibular. The grooves of pits and fissures.
tray is detachable. 2. After tooth preparation, we do etching. Place
3. Place after proper isolation 37% phosphoric acid for about 15 seconds.
* Gel is less concentrated, that is why we need to 3. After 15 seconds, we rinse and dry the tooth.
isolate the tooth properly. 4. After cleaning and drying, place sealant or
4. After isolation, cheek retractor is used and the tray is flowable composites.
placed. 5. Apply bonding agents and cure for about 20
5. Let the patient bite on it for about 4-5 minutes. seconds.
6. After 4-5 minutes, remove the tray and let the patient 6. After bonding agent, place sealant or flowable
spit the excess the fluoride but without rinsing composite or resin
anymore. 7. Cure for about 20 seconds.
7. The patient is advised not to drink or eat at around 30 8. After curing, check the bite if there are
minutes to 1 hour. But the longer the time, the patient interferences, if none you are done with the
don’t eat or drink the more the fluoride will be preventive resin restoration or resin sealant
absorbed by our teeth. placement.
8. Brushing also is not advisable.
*Similar to pit and fissure sealants. But in pit and fissure
Fluoride Varnish sealants, we don’t need to prepare the tooth.
- More concentrated and sticky
Methods of Caries Prevention
Steps: 6. Restore Tooth Surfaces
1. Just brush on the surfaces of the teeth particularly on - Restore all cavitates lesions
the labial area because it is more thinner. - Seal pit and fissures at caries risk
- Correct all defects (marginal crevices, cervical
Silver Diamine Fluoride overhangs)
- Not common in the Philippines
- Utilized by some dental professionals abroad instead Rationale:
of restoration § Eliminate sites of infection and deny habitat
Steps: for re-infection.
1. Place silver diamine fluoride into the cavitated tooth,
it burns the cavity then turns into black.
Advantage
- Arrest dental caries and cavitations.
Disadvantage
- Cavitated tooth becomes black which means that the
cavity is already arrested. Once a carious lesion is
arrested, it does not progresses anymore.

*Nevermind the black discoloration because sooner deciduous

teeth will be replaced by the permanent teeth.

Phosphoric Acid
- Creates micro porosities for the retention of your
sealant.
 *After final sealant, make sure there is no interference on
the bite either premature contact or high contact.
Sealants
- Teeth that have particularly deep grooves and pits on
the biting surfaces are more susceptible to trapping
plaque and food particles.
- If these groves are not properly cleaned, they may
become a starting point of cavities early in life.
- Your dentist may suggest sealants as a preventive
measure to protect these chewing surfaces.
- Sealants are meant to last several years under normal
chewing function. They are routinely check at regular
dental visits for any signs of breakdown. At which
point, a quick reapplication can take place if needed.
Steps:
1. Prepare the groove and pits with an application of a
special gel.
2. The gel is then rinsed off with water and dry for
sealant placement.
3. A plastic filling material is then carefully painted on
the enamel of the susceptible back teeth where it
flows into the pits and grooves.
4. It is then hardened and bonded to the tooth surface
with a specialized light source, sealing off and
protecting chewing surfaces of molar.
*For enameloplasty and prophylactic odontotomy, similarly
we are recontouring the structure of the tooth. Instead of
sealant, dentists use finishing bur and reduce tooth structures
to make deep fissures to be shallow.
Composite Restorations
Cervical abrasion
Treatment:
§ Restore with composite
§ Do etching (place etchant for
microporosities to aid retention)
§ No need to prepare the tooth.
§ Bonding agent placement
§ Cure for about 20 seconds
§ Apply composites
Secondary Caries Formation
Treatment:
§ Remove the existing amalgam and carious lesion
surrounding the restoration.
§ Place a new composite filling.
White Fillings
- Dental decay is one of the most common diseases In
the world.
- If left unchecked, can lead to extensive breakdown of
tooth and potential loss.
- Decay is caused by bacteria, bacteria living in a
biofilm known as plaque.
- Decay-causing bacteria feed on a starchy food that
sticks to teeth. The by product of these bacterial
consumption of starchy food are acidic.
- These acids caused the decalcification and
breakdown of tooth structure.
- To prevent further decay of the tooth and restore that
which has been destroyed. Dentist may choose to
place a white bonded fillings
- White fillings are not only highly aesthetic, but their
bond strength and compatibility with the tooth
structure make them a good choice as a restorative
material.
Steps:
1. Procedure begins with the removal of the decayed
tooth structure.
2. Once the cavity has been removed, there is a clean
space left on the tooth known as the cavity
preparation.
3. The tooth is first prepared with a cleaning agent to
make ready the site for adhesive agent that is used to
make the filling tightly bond to the tooth structure.
4. This cleaning agent is rinsed off.
5. Then, the adhesive bonding agent is applied.
6. These adhesive is then cured with blue light so that it
hardens. The blue light waves have energy required
to polymerized the bonding agent.
7. The white filling material is then placed into the
cavity preparation.
8. Shape with special instruments and cure to hardness
by the blue light.
9. Final anatomical details and shaping of the filling is
accomplished by the high speed drill and special drill
beads.
Amalgam Fillings
- If the decay affects a tooth in area where moisture
control during placement is difficult then ideal filling
material may be an amalgam.
- Also referred to as silver fillings.
- It requires approximately 24 hours to be fully set.
After which, it is ready for normal chewing function.
Steps:
1. Begins with the removal of the decayed tooth
structure.
2. Amalgam filling material is then incrementally
packed and condensed into the cavity preparation.
3. Once filled, the material is then carved, shaped, and
burnished to match the anatomy of the tooth.
*Composite fillings
- Medicaments is then place approximate in the pulp
tissue to protect it.
- Calcium hydroxide as a liner.
- Etching, bonding, then place the composite in
increments, until you fully restore it occlusally.
 - It’s not enough that you place the composite on top of have deep pit and fissures. He is fond of eating
the prepared cavity, but definitely you try to simulate sweets as well.
good anatomy.

Problem List Possible Treatment

Black discoloration of Composite Restoration
12 and 22 (not amalgam because
the teeth are anteriorly
located)
Gingival bleeding Scaling and polishing
(oral prophylaxis) +
oral hygiene instruction
Missing 14, 34, and Fixed partial denture
35/edentulous are
between 13 & 15, 33,
and 36
Fond of eating sweets Diet counselling
Deep pit and fissures on Pit and fissure sealants
molars

Treatment Plan (traditional)

Ecological Approaches to Caries Prevention I. Systemic Phase • Vitamin C
• Antimicrobial Peptides (AMPs) (addresses the systemic supplement
• Probiotics condition of the patient) 500 mg/day
• Prebiotics II. Acute Phase • Composite
• Sugar Polyols (emergency situation or Restoration
• Quorum-sensing Targets that we address patient’s of 12 and 22
• Natural Products concern)
• Replacement Therapy with “Designer” Bacteria III. Disease Control • Diet
Phase Counselling
Rationale: (preventive measures for • Oral Hygiene
§ Modify and eliminate microbes in the oral cavity the formation of any instruction
§ All of these addresses the number of disease entity inside the • Oral
microorganisms inside the oral cavity. oral cavity) Prophylaxis
§ With great number of microorganisms, they are • Pit and
really capable to grow and eventually gift effect fissure
towards the tooth structure. With the limitations sealants on
with their number, carious lesion would not molars
develop. IV. Definitive Phase • Fixed bridge
(final treatment that is to in between
Other Approaches be done inside the oral 13 and 15, 33
• Compounds that specifically affect bacterial virulence cavity) and 36.
proteins V. Maintenance Phase • Reinforce
• Calcium Phosphate Osteopontin particles that can (recall visits) Oral Hygiene
inhibit biofilm formation and reduce the fall in pH Instruction
without affecting bacterial viability. • OP/check up
• Nanoparticles every 6 mos.
• Graphene oxide
• Ceramic water

Rationale:
§ Addresses the number of microbes inside the
oral cavity.

Case Analysis
- A 30 year old male student complains of black
discoloration of tooth 12 and 22. The said teeth have
class III caries on their mesial aspects. She also
complains of bleeding on his gums during
toothbrushing. Due to severe caries, his 14, 34, and
35 were extracted. His molars were not carious but