‫بسم ال الرحمن الرحيم‬

In this lecture we are going to talk about Prevention aspects of

caries

Aspect of prevention of dental caries:

 Oral hygiene instruction (OHI)
 Diet advice
 Fluoride
 Fissure sealants
 Chemotherapeutic agents
 Recalls: recalling patient comes every 6 month for
check up
 Vaccines: which mean vaccination for dental cares
which is still under research.

1) Oral hygiene instructions:

• Firstly you instruct the patient to use fluoridated type tooth
paste.
• Child type tooth paste has a lower concentration of fluoride
compared to adult type tooth paste:
- Child tooth paste contains 500-550 ppm fluoride.
- Adult tooth paste about 2 or 3 times more than child
meaning
1000 - 1500 ppm or sometimes a little bit more.

So we always instruct patients to use child type tooth paste. Any

type of Colgate or manufactured tooth paste gives age ranges so it
gives age range on tooth paste tube
E.g. if you see 2-6 years on tube it means it is used for patient in
this range, OR
it could be 6-12 years old and so on.
This means tooth paste comes in different types that serve different
age groups.
Other companies' manufacturers do not specify age group on the
tooth paste only if for children or adult use. You are supposed to
read what is written on tooth paste tube.

• Secondly start brushing as soon as 1st tooth erupt. If

only Incisors had erupted they can be wiped with gauze. This
gauze can be wetted with water and then later on when
molars erupt, children have to start brushing their teeth.

Please refer to slide no.4: These are examples of tooth pastes. It

does not matter what type (brand) of tooth paste as long as it is
fluoridated.
"Most important thing is whether tooth paste
fluoridated or not."
 • Brush teeth twice daily. The number of cleaning times
should be at least once after a meal and once before going to
bed. Most important time is before going to bed and 2nd time
after a meal during a day. It could be after breakfast or lunch
however usually after breakfast is preferred.

•You should instruct the patient to use small tooth brush with
a very small head. Choose it not to be bulky; because bulky
tooth brushes are difficult to insert into the mouth and difficult
to clean with the buccal aspect of teeth. Use small, soft, and
multi-tufted nylon bristle Tooth Brush according to specific
age group.

•Electronic brushes have no clear advantage over manual

brushes. They are not better, however, the only difference is
that:
1) They help children with reduced manual dexitrity,
e.g. children having Down syndrome to brush their
teeth.
2) They look like electronic device or toy that
motivates children a little bit more for brushing their
teeth.
As far as for their cleaning effect, electronic are not more
efficient or better than manual ones. The only important part is
how children brush there teeth and if they are consistent with
brushing or not.

Please refer to slide 6: these are examples of different tooth

brushes. Look at the head of the tooth brushes; they are small;
always try to choose small ones.

•The technique of brushing is not critical as long as the

individual regularly cleans the teeth (i.e. consistency of
brushing). Children mostly miss cleaning on the lingual
surface of the teeth and the side of handedness. The
child should be taught the method which is most comfortable
to him; mostly it is horizontal technique (If using a soft
brush it is ok to use horizontal technique at this age).
You have to instruct them to brush the lingual surface and
side of handedness so if the child is right handed they miss to
clean the right side. Most children use the horizontal technique,
you don’t have to be strict with child of 5-6 years old & tell them
to put the toothbrush at 45 degrees or brush from up to down
because children really don’t recognize that until they are older.
In mixed dentition stage, you might give the child
instructions but in the primary dentition stage, as long as the
child is brushing that is the only important matter.
 •It is recommended that parents assume the primary
responsibility for brushing the teeth of their children. Children
under 9 years still don’t have the dexterity to clean them
properly.
So in this case (dr. showed a child in picture) this child is 4
years old. Should he brush his teeth on his own?? NO, his parents
should start at age of 2-3 years to brush their children teeth, the
way is to seat your child on your lap with his back facing you and
then ask him to open his mouth and you should start brushing his
teeth. Start brushing the maxilla from right to left, buccally then
lingually. Repeat same procedure right to left for mandibular
teeth, finally brushing the occlusal surface. If you teach your
child, it will become a habit for him brushing. In this case, this
child started brushing from 2 years and he likes to brush his
teeth so he will ask you to let him brush his teeth on his own. Let
him brush his teeth and have the fun and then you brush it again
after he finishes, or let him brush in the morning and you at night
so compromise. Until age 9 the child will then be ready to brush
on his own.

•What about flossing?? Do we need to floss for children, in

most cases we don’t need because of wide contact points, but
if the teeth are in close contact points in some cases you need
to floss between primary teeth. When a child progress towards
mixed and permanent dentition flossing is necessary.
In mixed dentition, the 6th (the first molar) starts to erupt and
starts to put a force mesially on the primary teeth so the contact
between the 6th and distal of E comes tight and by time, contact
becomes tighter and by that time you need to start flossing. Use
waxed floss, because it is easier to get contact point and
fluoridated is better.

•Upon eruption of first permanent molars, spaces start to

close and the parent must assume responsibility for flossing,
concentrating on the interproximal surfaces of molars and the
anterior sometimes. Parents should be taught to floss the
child's teeth when the child is lying in supine position flossing
might take a while for child to practice well.

Teaching Oral hygiene instruction disclosing agent

You should teach the child how plaque accumulates on tooth

surface and how it cause caries and how efficient is brushing. e.g.
you should let him brush his teeth and then apply the disclosing
agent, so if there is remaining plaque you should let the patient see
it and teach him where to concentrate more. So teach the patient
and educate the parents because parent at home will be assisting
the child to brush his teeth. Flossing might take time and wait for
them to do it correct.
2) Diet advice
 Aim: limitation of sugar and sweet intake.
 Rationale: is to identify the cariogenic foods in the diet with
emphasis on the frequency of consumption ( we are concerned with
the quantity and frequency of intake and retentiveness of the food;
making appropriate substitutes and providing follow-up evaluation
for reinforcement, so after you identify these exposures, we should
give reasonable substitute to patient and give him appropriate
advice.
Follow-up evaluation means as soon as you see the patient,
examine him, give him a diet sheet and evaluate his diet after you
have treated him and motivate him toward his diet. You should
make another diet sheet and see his progress or difference.
 Counseling should be made to parents on role of sugars in
cariogenic process in form of printed or verbal information.
- Verbal meaning talking
- Written is stronger, parents can memorize it or read it more
than once.
Keeping a dietary dairy and assessment of the child's diet and
implementing realistic achievable changes. Changes should be
realistic.
E.g. you can't say NO chips. NO Pepsi, NO chocolate
because no one will listen to you because it is part of life but you
can tell the child to reduce it. Tell him to drink Pepsi when he go out
for a meal, tell him to eat sweets straight after meal after that he
have to brush his teeth so we can allow sweets with in limitation and
certain rules.
 Advice should focus on:
1- Reducing the frequency of cariogenic food and drinks
intake. Reduce sugar in retentive form and in the solution
form.
2- Confining cariogenic food to meal time because greatest
hazard when they eat cariogenic in-between meals, so you
ask them to eat it with the meal. E.g. Pepsi + meal.
"Limit intake to meal time"
3- Subsisting cariogenic snacks with anticariogenic snacks
such as: eggs, cheese (any type of cheese), peanuts and
walnuts, other fats and protein.

In the clinic, these diet sheets are available in Arabic language. The
patient should write what he eats in 3 consecutive days one after
the other in which one of days must be holiday (day off). During
these 3 days the patient should write all what he eat or drank during
these 3 days.
There are 3 gaps for main meal (breakfast, lunch, and dinner). And
gap in between each meal for snacks; write what he eats and
quantity. Mark cariogenic food in the diet then count them and take
average. Count all cariogenic in retentive in each day and take an
average out of 3. Count all sugar in solution form over 3 days and
take an average of them.
There is no specific number to tell us if cariogenic intake is too
high or too low, but if over 3 days average more than one, then you
have to talk your patient to reduce it.
Chips are cariogenic because they are retentive. They stick to
teeth and cause caries. It contains Starch and starch is cariogenic if
it stays for a long time in the mouth. Mashed potatoes aren’t
cariogenic because they aren’t sticky. Bread isn’t cariogenic but if it
stays more than one day in the mouth it become cariogenic,
however, if regular tooth brushing is done, bread wont be cariogenic
because it is complicated sugar and needs time to be analyzed.
Chocolate milk contains sugar so it is cariogenic in solution form.
Difference of having Pepsi in between meals or at meal is that in
between meals teeth exposed to erosive and cariogenic processes
together. But with meal it gets swallowed with other food if alone it
stays longer time on teeth.
E.g. of a diet sheet:
Glass of milk
Water
Manderina
Jam sandwish
Chesse + cracker
2 glasses of milk Cariogenic
Chips
Glass of milk
Eggs

3) Recalls
 1st dental visit should be as soon as the primary tooth erupts and
no later than the first year of age.
 Recalls after 3 (high risk patient); 6 (moderate caries level); or 12
(low caries level) months depending on the risk of caries.
 Recalls are necessary to diagnose any existing problems and
prevent them.

4) Fissure sealant
DEFINIFION:
"Pit and fissure sealant" is a material that is placed in the pits
and fissures of caries-susceptible teeth, thus forming and
micromechanically-bonded, protective layer cutting access of caries-
producing bacteria from their source of nutrients. so bonded by
micromechanically retentive because of acid etching which perform
micro porosity form pores in enamel and the resin gets incorporated
within these pores and is micromechanically bonded so after this
layer is formed it cut access for any microbes to enter into pits and
fissure and thus prevent caries, so it form and protective layer
cutting access of caries produce bacteria from the source of
nutrients and it make tooth surface smooth and flow and easy to
clean (make it cleansable).
Pit and fissure sealant is made of composite or glass inomer.

Epidemiology of caries
Pit and fissure sealant evolve because they are changes in
epidemiology of caries distribution over the last 3 decades about
developed countries:
1- There is decline in prevalence of dental caries in
children.
2- Most disease found in a small number of children, so if
there is and dental caries it present in a small population of
people who are susceptibility of low social economic state or
medically compromised
3- Concentration of caries in pit and fissure due to
anatomic features that harbor bacteria so if there is caries
most in pit and fissure, smooth caries has decline a lot most in
pit and fissure due to Inaccessibility to cleaning and features
that harbor bacteria, closeness to ADJ. Easy for caries to
develop in these sites even after use of fluoride in the
developed countries for several years. Fluoride has reduced
caries in these countries but it decreased in smooth surface
caries but not in pit and fissures. So fluoride is the least
effective in occlusal surface 30% VS smooth surface 80%.
Meaning 80% decrease in dental caries in smooth surface and
30% decrease in dental caries in occlusal surface.
Therefore, in these countries 80% of caries is present in
20% of population
so there is still caries but in very small group of people.

Historic development of prevent technique for the

occlusal surface

1) When first introduction acid etching technique came by

buonocure (1955) and he came out with this technique how to
adherer and resin to tooth surface or acid etching an enamel
2) Later in 1967 the study was first reported of a clinical trial of
sealant use
(cyanoacrylate sealant in form acylic) before development of
resin.

Rational for occlusal sealant use

Occluding the pit and fissure by the fissure sealant,
therefore, removing stagnation areas for bacteria and plaque and
making the surface easily cleansable.

Q: does the fissure sealant affect the occlusion?

 No it does not because we usually check the occlusion
and make it compatible.

Normal enamel is composed” compromised” of hydroxyl apatite crystals,

they are arranged in hexagonal prisms forming the rods and these rods are
at right angle with the tooth surface .
Enamel is about 1.5 mm thick (1500 Mm) and the depth of acid
demineralization after applying the acid is about 40 Mm , that means
after you apply the acid to enamel the depth of penetration of the acid is
about 40 Mm .
Acid etching the enamel will produce increased the surface area which
will increase the bond of fissure sealant to the tooth. There is selective
demineralization to enamel prisms, means that each prism is
demineralized in different way to the prism next to it, depend on the
etching time and the acid type, so we have three patterns :
1. Type one : preferential removal of prism core

2. Type two : prism periphery removal

3. Type tree : mixture of both, random pattern of both

So the retention of the sealant is a direct result of the risen penetration

into the pores which are 40 Mm deep end this is micro-mechanical
retention.
Clinically acid etched enamel has chalky, dull-opaque appearance, so
after you acid etch the enamel it will look like chalks.

“Retention rates for sealants in primary teeth were thought to be lower

than permanent teeth.”
This thought was in the past and attributed to:
 The primary teeth are prismless”have no prisms” BUT
this was denied by Silverstone who did a study in 1970
and said that primary teeth enamel has prisms and only
prismless in the cervical part and this area is not acid
etched because the F.S are usually put on the occlusal
surface so even if the cervical is prismless in 17% of the
cases it does not concern us if we want to place F.S.

 The second reason: there is more organic material and

fewer minerals in primary teeth so FS will be less
effective and that was proven to be wrong.

Indications for fissure sealants “when do we use FS”:

  PATIENT:

1.Patient medical history: patient with MH you

should use FS for them because they are high
risk factor for caries why??? Because the
medications they take are very sweetened and
have side effect like xerostomia also the sick
patient always gets what he wants because of his
medical problems “‫"يعني بدلعوه اهله كتير‬

So the patient with special needs, medically

compromised, physically disabled, patient with
learning difficulties or any patients with medical
problems has high risk of caries so you need to
fissure seal their teeth

2. Oral hygiene “OH” : we usually like the patient to

have good OH and to be good motivated patient,
OH will differ between patients of course but we
want to establish good OH before placing FS
cause no use of placing it if the patient does not
have good OH .

**“Good point to mention: you have to explain to

pt that once we put the FS that does not mean
that no caries will happen, if they do not clean or
brush their teeth caries can still happens.”

3. Behavior: pt should have good and cooperative

behavior on recalls so they have to come back
every 6 months to recheck FS because
sometimes part of it get lost and you have to
apply it again or caries could happen so pt should
come regularly on recalls.

 TOOTH:

1. FS could be place on primary or permanent.

 2. Morphology of the toot: this is important cause if
you have very deep fissure you place sealant but
if you have dull fissure you won’t need to use it.

3. It is placed occlusally in molars and premolars

with incipient caries in deep occlusal grooves and
upper incisors with deep lingual pits and in teeth
with gemination and other deep pits

4. it can be placed on a sound tooth “no caries” or

incipient tooth means beginning of caries but it
have not progressed into dentin to form a cavity
and on recently erupted tooth we can place it . It
is so important that we should not have caries
approximately.

5. Dental history and caries experience :

If there is history of dental caries in primary teeth

we have to seal the permanent teeth as soon as
they erupt and if there is caries in one of the
molars it is an indication to fissure seal all other
6’s and 7’s to protect them.

INDICATIONS FOR FS IN PRIMARY TEETH:

As we said they used to think that primary teeth are less retentive and
many primary teeth may be judge to be at risk due to fissure anatomy or
pt caries risk factors due to early suggestions were that primary tooth
enamel does not etch well and therefore was difficult to bond but the
effectiveness of acid etching primary teeth has since been established and
this denies the previous study. So FS in primary teeth is as effective as in
permanent. Clinical studies reporting on sealant success when applied to
primary molars are rare .those that have been published report retention
and success equivalent “exactly the same” to permanent molar sealants
 CLINICALY :

• You have to examine the tooth with direct light and it

must be dry

• TAKE A BITEWING X -RAY: we have to take BW

radiograph before applying FS to check for the
 presence of any proximal lesion because if we do
have proximal caries “class 2” I have to restore it
with filling first then apply the FS.

• If there is early dentine involvement we do

preventive resin restoration “PRR”.

TYPES OF SEALANT MATERIALS:

There are resin or glass inomer “GI” but with respect to acid etch:
Ideal acid concentration combines the least loss of surface contour with
the greatest depth of penetration. The most effective acid concentration
appears to be between 30 – 40% and the one that we use is 37%
phosphoric acid.
There is a big study by Brown where he took different concentrations of
acid then he acid etched different teeth and looked at them in histological
sections and noticed the best acid concentration which had the best
penetration and the least loss of tooth structure then identified it as 37%
phosphoric acid.
Types of acid have no influence on the retention of the sealant, but
Brown tried maleic acid and phosphoric acid end he found that maleic
acid vs phosphoric acid – easier to identify etched surface.
15 seconds is the etching time and is enough in primary and permanent
teeth (higher success rate and more cooperation) the less the time the
better because child cooperation, patience is not enough so if we find acid
that etch enamel in less time it will be better. Acid etching material could
come in two forms the gel form or the liquid form. The liquid form is
good because it flows into deep fissures but the gel form confines to
occlusal surface but there is no difference in the effectiveness.
Sealant types:
1. The first generation of resin based sealant cured
through ultraviolet light is no longer available or in
use.

2. The second generation cured automatically through

chemical reaction “chemically cured”

3. The third generation cured from visible light

4. The fourth generation has fluoride incorporated in

the resin and cured by visible light.
Sealant is unfilled resin, resin may be: bis-GMA (bis-glycidyl-
methaacrylate), UDMA (urethane dimethacrylate ),TEGDMA
(triethylene glycol dimethacrylate) .
The glass inomer cement was also introduced as an alternative to the
resin based sealant in 1970 but it is now mainly used as FS in partially
erupted molars not the resin type because the partially erupted molar is
still covered by the operculum on the tooth surface and there is difficulty
in controlling the moisture so we use GI material because it is less
moisture sensitive.
**SEALANTS:
• Filled vs unfilled: unfilled sealant is a bit more
retentive cause it can flow into fissures more and
the occlusal adjustment is easier with the unfilled.

• Color vs clear: the colored can be seen on the surface

and detect for its retention unlike the clear which
you hardly see, but the clear you can check the
caries progression underneath it. The one we use in
the clinic is the colored one .

• Auto cured vs light cured : effectiveness and

retention of visible light is similar to auto cured but
both are better than UV light which is no longer in
use . the light cured has less micro leakage
comparing it to chemically cured type .

** FLUORIDE:
Fluoride gel can be placed before or after fissure sealant but it is better
to apply the fluoride after the sealant because when applying fluoride gel
we have to wait for 30 min before we can put or do anything even water
so it is easier to put FS first then the fluoride.
Fluoride release from the FS is the greatest in the first 24 hours then it
decreases and this is only in the FS that fluoride has been added to.
There was a picture that is not found in the slides but the doctor
explained it: there was FS on molar; its color is pink and it is from fuji
company. Fuji Company producing many types of GI 1,2,7,9. Type 9 : is
a filling material, type 1: cement for crowns, type 7: is a glass inomer
cement material that is to be used as fissure sealant in partially erupted
teeth because its sensitivity to moisture -which is hard to control in
erupting teeth - is less than resin, the other advantage is the fluoride
release. After the tooth has fully erupted and fully into occlusion we can
replace it with resin.
Q. from student: why we don’t use this type “GI” as FS for all type of
teeth? Doc: because the retention of this type is less than the resin so it
is good as temporary measurement only.
So these fluoride releasing sealants are placed on the grooves and
fissures to release fluoride and they can be re-charged when the pt
brushes his teeth because the fluoride can get incorporated with the
cement particles then be released to tooth surface . They come in white
or pink color. So GI as sealant has higher fluoride release but poorer
retention “GI: resin = 10:90 %” after 3 years study on retention. There is
no data to support GI in preference to resin-based sealant except in
partially erupted teeth where it’s hard to control the moisture.
For example if you have Down syndrome pt who is very uncooperative in
dental chair then you do general anesthesia for her and restore all his
teeth and after a year of general anesthesia 6 starts to erupt and he has
high risk for caries do you put the pt under GA again for FS? No you just
place GI FS and you should put the light cured type because it’s quicker
TYPES OF SEALANT MATERIALS:
A. AECR “Acid etched composite resin type” (Delton) :
it’s resin based material, it has better retention,
resist wear and effective in caries prevention

B. GIC “glass inomer cement” (fuji 3.7) poor retention

and micro leakage, less cost effective , no evidence
of continued fluoride release

C. RMGI “resin modified glass inomer” (vitremer) : war

more than AECR, but more retention than GIC , it is
light cured so quicker in uncooperative pt .

GIC FS indicated as temporary application on primary teeth with

inadequate moisture control to be replaced later with resin-based type.
Picture slide# : 23 : this is fuji 7 and placed on a premolar it has pink
color.
Picture slide#: this is also Fuji 7. In the upper picture there is hypo plastic
molar very prone to caries and partially erupting. The lower picture GI
has been put on the tooth then to be replaced by resin sealant; the sealant
also protected this tooth from abrasion and attrition.
HOW DO WE PLACE A SEALANT?
It is only two steps you acid etch then place the FS, so you:
I. Isolate the tooth: rubber dam is better but if it is hard
to place you can put cotton rolls buccally and
lingually and put the suction all the time.
 II. Cleaning the tooth surface:

- Prophylaxis: is it required to clean the tooth surface

before applying the FS? No it is not required but if
there is abundant plaque on the occlusal surface
you need to clean the teeth and do prophylaxis to
place the FS.

- Air abrasion and enameloplasty: give better

penetration and retention of the sealant. Air
abrasion use is just like sand particles which abrade
the tooth surface forming porosity just like acid
etching. Enameloplasty: using very small round bur
to open the fissures and widening them so you still
in the enamel this increase retention.

III. Etching: you place the acid gently on the tooth

surface you do not need to rub it “gentle dapping”.

IV. Washing and drying: “critical period”: when you wash

the acid you should make sure that no saliva has
contaminated your tooth. If saliva contamination
occurs after acid etching then you have to repeat it
again because saliva will remineralize the tooth and
the pores will become closed and the FS will not stay
on the tooth and it will pull off away when the patient
is still on the chair and you will be embarrassed. So
what can you do in case the patient is moving around
and hard to manage? You should put some bonding
agent that is used in composite restoration and place
it on the tooth surface then place the FS on top.

What the bonding agent does? It makes a layer on

the tooth and protects it from moisture.

V. Applying the FS then light cure it.

VI. Check the occlusion.

Picture slide #27: this is the rubber dam technique, you can make a big
slit “one big hole” for all teeth or hole for each tooth.
Picture slide #28: quadrant isolation for mixed dentition, put the clamp on
the 6 and a hole for each tooth.
Picture slide #29: just to show you that children can adapt to rubber dam.
CLINICAL PROBLEMS:
I. Technique sensitivity and cooperation of the
child.

II. Difficulty in detection of caries or recurrent

caries under FS, you have to be wise and check
it every 6 months.

III. Loss of the sealant: it could be partial loss or

total, so in case of partial loss there are
remnant resin tags in pores that can protect
tooth for some time. Partially retained FS has
risk of caries similar to no FS so you have to
reapply the FS straight away after it gets lost.

Would you place FS over dental caries??

There was a study by (Going) where he placed FS over caries then he
looked at the microorganisms after a while and found that 89% of
microorganisms were dead or inactive lesion and that was because of:
1. The acids that we place will the MO.

2. Isolation of the MO from oral environment cuts O2

and nutrition away.

But the doctor will not allow us the place FS on top of caries, it is alright
to place it on incipient lesion.
EFFECTIVENESS OF SEALANT:
It depends on the retention, as long as you have the sealant remained in
the fissure it will be effective. So 50% of the caries reduction and 37% of
FS has lost in 15 years study.
- Caries risk increased by 7.5 when no FS vs presence
of FS, so when FS is retained you can reduce caries
by 7.5 times.

- Strep. Mutans -ve after 5 years beneath FS, lesion

progressed in control teeth meaning that the fissure
sealed tooth after 5 years will have no strep.
Mutans but not fissure sealed teeth will have them.
Retention is primary factor:
• In premolar >molar because it is more anterior and
easier to control the moisture.

• Partially retained FS risk of caries similar to no FS.

• Retention in primary similar to permanent teeth.

Cost:
FS is higher than amalgam but if tooth is not fissure sealed we have to
restore it and it will cost more so it is better to FS the tooth for the long
term.
If you want to use FS with other caries preventive method like Fluoride
Gel, chlorohexidine, xylitol or any combination will have +ve interaction
between Fluoride “from drinking water, mouth rinse or tablets” and FS in
preventing caries.
So in our treatment plan the doc want to see different methods for
preventing dental caries, Like FS, mouth rinse, xylitol mouth gum……
In slide 35 is another study to show that fluoride is effective with FS and
mouth rinse and cause 96% caries free. With regard to time amalgam
takes longer time to be placed than FS. The effectiveness of FS decreases
with time and get lost and you have to reapply it later on. And next time
we will talk about estrogenicity of the sealant .
The end
Your colleges: Noor
Al Njjar
Muna Koro

Thank you Lamyia for the lab top “nice hours by the way “