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Prevention of Dental Caries

Dental caries or also known as tooth decay or cavitation on the tooth surface is the most common disease in developed countries due a higher consumption of simple sugar as compared to developing world. Preventative measures needed to be done in order to reduce the incidence of dental caries and also prevent the progression of existing decays in the oral cavity.

Dental Caries

Definition

Dental caries is an irreversible microbial disease of calcified tissues of the teeth which are characterised by the demineralisation of inorganic portion and destruction of organic substances of the tooth.

Class 5 cavities on the upper teeth.

A class 2 cavity showing dental caries on the distal surface of lower first molar.

Aetiology

It is a multifactorial disease.

Formation of Dental Caries

Pathogenesis

Individuals who regularly consume fermentable carbohydrates will lead to exposure of dental plaque to fermentable sugar. This condition causes prolonged condition of low pH within the biofilm as fermentation of dietary sugars by oral microorganism produces lactic acid allowing the growth of acidogenic and acid-tolerating microorganisms such as Streptococcus Mutans. , Lactobacilli and Bifidobacteria. It increases the risk of demineralisation of tooth structure leading to formation of caries and accelerates the progression of caries.

Theory of Formation of Dental Caries

Caries found on the cervical portion of anterior teeth on the upper and lower teeth.

Miller's Chemico-Parasitic Theory/ Acidogenic theory

Dental caries on the mesio-buccal of first molar.

Most widely used theory for formation of caries and was published by Willoughby D Miller at 1882. According to Miller, caries are caused by acids that were produced by microorganisms in the mouth and consists of 2 stages: decalcification of enamel and dentin followed by dissolution of softened residue. The acid that are produced at the primary decalcification stage are from the fermentation of starches and sugars from retaining teeth. There are 3 main factors that causes dental caries formation: oral microorganisms, carbohydrate substrate and acid.

Preventing Dental Caries

Reason

Symptomatic treatment can be intensive and the cost can be expensive. Untreated caries can affect one’s nutritional status and growth especially in children. High severity caries can compromise patient’s quality of life causing pain and discomfort.

Goals

Caries risk assessment can be evaluated to identify high, moderate and low risk patients. Interventions can be carried out to limit caries activity. Incipient lesion can be detected earlier to prevent worsening of caries activity.

Strategies

There are many strategies to prevent the formation of dental caries in each individuals such as increasing host resistance i.e via water fluoridation, using fluoride mouthwashes or having professional intervention and care. Secondly, controlling diet will help in delaying the process of caries formation. Examples for diet controls are reducing carbohydrate intake or substitute non cariogenic sweeteners. Lastly, plaque removal and control also contributes into the strategies for prevention of dental caries. Plaque removal and control can be done by mechanical or chemical means. Mechanical measures can be done improving one's oral hygiene by toothbrushing and flossing whereas plaque can be controlled using chemical agents such as Chlorhexidine mouthwash which destroys or inhibits the formation bacteria and disrupts plaque structure.

Professional interventions could also be done as one of the strategies for prevention of dental caries. Examples of interventions could be done are dental prophylaxis which is dental scaling which removes plaque and calculus.

Dental caries prevention can be categorised into 3 types: primary prevention, secondary prevention and tertiary prevention.

Primary Intervention

The aim of primary prevention is to prevent the formation of caries. This is attributed to an individual’s behaviours such as ingestion of fermentable carbohydrates, inadequate oral hygiene and insufficient fluoride exposure. Therefore, primary prevention strategies needed to be directed to modifying or eliminating etiological factors that contributes to the progress and formation of caries.

Modify / Eliminate Etiological Factors

Biofilm

Biofilm is essential in initiating caries and to control the formation of biofilm is by having correct tooth brushing method and flossing. Cochrane review concluded that toothbrushing with fluoride toothpaste with concentration more than 1000ppm is beneficial in preventing caries. However, the use of antimicrobial agents such as mouth rinse, gels or varnishes have not been proven to be effective in reducing the incidence of caries. Professional prophylaxis using rubber cup for removal of biofilm before application of topical fluoride in children has no benefit in prevention of caries in children.

Diet

Caries is much less likely to occur in the absence of dietary free sugar intake above the threshold of 5% of energy intake in our daily life. This threshold was based on WHO guidelines of sugar intake for adults and children. Evidence shows that there is a positive association between the intake of free sugars and caries. Below this threshold, individuals are at a lower risk of developing caries. Evidence shows that caries rates are lower when the intake of free sugars is equivalent to approximately 5% as compared with when it is above 5% but below 10%.  However, a systematic review shows that there is not much information on reducing sugar intake as a single preventive measure.

Salivary stimulation

Salivary flow rate and the composition of saliva are important in etiological host factors that modifies caries process. Patient with decreased salivary flow has a higher risk of developing caries. Chewing sugar-free gum after meals have been recommended to reduce coronal caries.

Increase Resistance

Fluoride

Fluoride comes in a variety of forms. It has been proven that fluoride helps in prevention of caries. The most cost effective way is by water fluoridation and is also the most effective in controlling caries by population level. A Cochrane review concluded that water fluoridation helps in reducing DMFT results. But the applicability of the evidence on water fluoridation to today’s society remains unclear and highly likely to vary according to setting.

Fluoride toothpaste is the main primary prevention and it is very widely used form of fluoride. The effectiveness of fluoride has been documented in many clinical trials and systematic quantitative evaluations which concluded that the higher the concentration of fluoride, the more effective it is in preventing tooth decay. However, it should also be balanced against the risk of developing fluorosis in younger children. Most over the counter toothpaste contains 250ppm to 2800ppm fluoride content. It is recommended that all adult patients to use fluoridated toothpaste with at least 1350ppm fluoride content, brushing at least 2 times per day and brush right before bed. For children and young adults, use fluoridated toothpaste with 1350ppm to 1500ppm fluoride content, brushing 2 times per day and also brush right before bed. American Dental Association Council suggest that for children <3 years old, caregivers should begin brushing their teeth by using fluoridated toothpaste with an amount no more than a smear. Supervised toothbrushing must also be done to children below 8 years of age to prevent swallowing of toothpaste. Toothpaste must also be spit instead of rinsing with water. For individuals who are at a higher risk of developing caries, fluoride mouth rinse is recommended along with fluoride toothpaste. Cochrane Collaboration systematic review reported that supervised use of fluoride mouth rinse for children and exposure to water fluoridation are associated with a clear reduction in caries.

Dietary Fluoride Supplements

The use of fluoride drops and tablets as another means of fluoride delivery to individuals living in communities that have less than optimal fluoride levels in water is somewhat controversial. Fluoride toothpaste is a more generally accepted means of delivering adequate fluoride, careful consideration needs to be given before fluoride supplements are recommended.

Dental Sealants

Usage of dental sealants for preventing the initiation or progression of caries on occlusal surfaces of permanent molars has a very strong evidence in both clinical and school settings. Based on a recent updated Cochrane review, there is limited evidence indicating resin-based fissure sealants are superior to fluoride varnish application for preventing occlusal caries in permanent molars and also for supporting the benefits of the combined use of resin based sealant and fluoride varnish over fluoride varnish alone itself.

Secondary Prevention

Secondary prevention is considered when caries is clinically seen but not until the extent where it requires operative intervention (tertiary prevention). The goal is to reduce the impact of caries and possibly reversing the caries process in favour of remineralisation. However, secondary prevention requires oral health professional intervention to either reverse or arrest the caries progression.

Non Invasive Strategies

This is to prevent disease progression by empowering patients to improve on their own oral hygiene habits. This may arrest or reverse the caries process as long as the surface layer of the lesion is still intact.

Modify/ Eliminate Aetiology Factors

This can be done by improving oral hygiene to effectively remove biofilm on teeth surface. Reducing free sugar intake will help in remineralisation of teeth and prevent further demineralisation of tooth.

Remineralise Caries Lesion/ Arrest Caries Strategies

Fluoride

A systematic review for non-surgical management shows that fluoride intervention (varnishes, gels and toothpaste) helps in decreasing the progression and incidence of caries. It concluded that application of 5% NaF varnish is able to remineralise early enamel caries.

Dental Sealants

Occlusal pits and fissures are resistant to effective oral hygiene. Fluorides are successful in increasing the resistance of inter-proximal, facial and lingual tooth surfaces but less effective on occlusal pits and fissures. Several systematic reviews have proved that sealing non-cavitated carious lesions in permanent teeth do help in reducing progression of caries. It has been shown that placing sealants help in preventing bacteria when placed over carious lesion and the reduction increases with time.

Micro-invasive Strategies- Resin infiltration

Systematic review have concluded that resin infiltration is an effective method in arresting the progression of non-cavitated proximal lesions. It is also being said that it is even more effective than application of fluoride varnish or improving oral hygiene habits. However, some concerns are being brought up where it is a technique sensitive method to apply resin infiltration onto approximate site without removing the intact surface layer of enamel.

Epidemiology

Dental caries is an important public health problem. According to World Health Organization (WHO), caries affects approximately 60-90% of school children and majority of the adults. It contributes to the majority of natural tooth loss in older people globally (Peterson, 2008a; WHO, 2016) .

In the 1940s, addition of fluoride into drinking water where fluoride concentration is below optimal levels and ever since then there are many researches confirmed the reduction in caries in many countries worldwide.

Systematic review and Cochrane Collaboration Oral Health group has concluded a few findings as listed below:

Water fluoridation successfully reduces the prevalence of caries by 15% and in absolute terms by 2.2 dmft/DMFT. By using fluoride toothpaste and mouth rinse, it reduces the DMFT 3 year increment by 24-26%. There is no evidence shown that there is an association between water fluoridation and adverse health effects. However, water fluoridation is associated with an increased risk of dental fluorosis when it exceeded a certain concentration of fluoride although further analysis shows that the risk might be higher in naturally fluoridated areas but lesser in artificially fluoridated areas. There was a paucity of research into any possible adverse effect of fluoridated toothpaste and rinses.