PREVENTION I

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PREVENTION I

• The Preventive Philosophy

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PREVENTION. . . The Concept

• The emergence of a new philosophy of dentistry
  based on prevention rather than repair and
  replacement has been the most significant
  development in the history of dentistry.
• In a World Health Organization (WHO) study, it
  was found that countries with dental care systems
  that emphasized restorative care had the highest
  caries experience in the world, as measured by
  the number of decayed, missing and/or filled
  teeth, (DMFT).
• These countries also had the highest number of
  completely edentulous individuals.
• In countries where prevention was emphasized, the
  number of DMF teeth was substantially smaller.

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PREVENTION . . .The Concept

• The following data bear testimony to the futility
  of a mechanistic approach to gain and maintaining
  oral health for Americans
• 98 of 40-44 year olds have had tooth decay, with
  an average 45 affected tooth surfaces.
• the average American has between 9-10 missing
  permanent teeth
• over 4 of the American population (between 10-12
  million individuals) is completely edentulous
  30 of Americans over 65 have no teeth at all.
• 44 of Americans have gingivitis and
• 13 of Americans have periodontal disease.

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PREVENTION . . . The Concept

• The resolution of such extensive problems of
  dental caries and periodontal disease by a
  restorative philosophy yields low efficiency
  and efficacy. It is not a cost/benefit effective
  way to achieve oral health.
• As a consequence, the far-sighted in the
  profession have turned to prevention as the only
  feasible solution to a problem of such severity.
• Oral health care systems which emphasize
  prevention will yield populations with good oral
  health those that do not, will not.

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PREVENTION . . . The Concept

• A philosophy of prevention is basic to a good
  contemporary practice.
• Dentistry exists to facilitate the gaining of
  oral health by society.
• Individual dentists profess to exist to help
  their patients gain oral health.
• The preventive concept should be the thread that
  is woven through the entire fabric of dental
  practice.
• The concept of prevention can be understood to
  apply to all aspects of practice by understanding
  prevention to exist at primary, secondary, and
  tertiary levels.

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LEVELS OF PREVENTION

• PRIMARY PREVENTION
• Occurs in the clinically pre-pathologic period.
• Involves promotion of oral health concepts, as
  well as specific protection.
• Examples oral health education, water
  fluoridation, plaque removal through brushing and
  flossing, antimicrobials, topical fluorides, pit
  and fissure sealants, mouth guards.
• Prevent caries, gingivitis, trauma to the teeth
  from occurring.

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LEVELS OF PREVENTION

• SECONDARY PREVENTION
• Occurs in the early period of pathogenesis.
• Involves early recognition and prompt therapy.
• Examples Radiographic examination, Root scaling,
  conservative restorative treatment
• Prevent further deterioration of health that
  would result in extensive lesions of the teeth,
  pulpal involvement, or periodontitis.

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LEVEL OF PREVENTION

• TERTIARY PREVENTION
• Occurs later in the period of pathogenesis.
• Involves limitation of disability and
  rehabilitation.
• Examples pulpal therapy, periodontal surgery,
  extractions, fixed prosthodontics, space
  maintainers.
• Prevent loss of teeth, disseminated infection,
  loss of space, occlusal disharmonies, and other
  significant oral disabilities.

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CHILDREN IN THE CONCEPTHe who is wise
begins with the child.Goethe

• As primary prevention is the ultimate goal of the
  dental profession, it necessarily follows that
  the thrust of any comprehensive oral health
  program be directed at the child.
• Children must be the foundation of a practice
  that is focused on prevention.

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UNDERSTANDING THE PROBLEM

• To understand the problem of prevention as it
  relates to children, an understanding of the
  profile of oral disease experience of children
  (in America) is necessary.
• Epidemiology is that branch of medicine that
  deals with the study of the causes, distribution,
  and control of disease in populations.
• The epidemiological term for the magnitude of a
  disease existing in a population at a point in
  time is referred to as prevalence.
• Prevalence must be differentiated from a related
  term, incidence.
• Incidence is the disease occurring in a
  population during a specific period of time.
• To say that the average 17 year old has 4.96
  decayed, missing or filled teeth is to make a
  statement of prevalence.
• To say that the average child will develop a new
  carious lesion between ages of 6 and 10 is to
  make a statement of incidence.

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PREVALENCE OF DENTAL CARIES IN CHILDREN

• Two epidemiological measures will serve as
  indices of prevalence of caries
• DMFT An index that represents the number of
  decayed (D), missing (M), and filled (F) teeth
  (T). Index is total of these three assessments in
  the individual.
• DMFS An index that represents the number of
  decayed, missing, and filled surfaces (S), in the
  individual.
• DMFS is the more sensitive measure of the
  magnitude of disease in the oral cavity.

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PREVALENCE OF DENTAL CARIES IN CHILDREN

• The average DMFT in school age children (age
  5-17) is 1.97.
• The average DMFS is school age children (age
  5-17) is 3.07.
• Over 50 of 5-9 year old children have at least
  one carious lesion or restoration.
• At age 17, the average child has 4.96 DMFT, (1.0
  due to a missing tooth) and 8.04 DMFS 80 of
  adolescents have dental caries by age 17.
• Obviously, the teeth are more vulnerable to decay
  the longer they are in the oral cavity.

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PREVALENCE OF DENTAL CARIES IN CHILDREN

• Only 20 of children have had no carious
  experience by age 17.
• 80 of the dental carious experience occurs in
  25 of the children in this country. This
  concentration of disease has become greater
  through time. In 1980, approximately 65 of the
  caries was found in 24 of the children.
• The prevalence of caries experience among
  children has declined significantly since 1970.
• Approximately 80 of the carious lesions
  occurring in school age children are on the
  occlusal surface.

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PREVALENCE OF DENTAL CARIES IN CHILDREN

• The highest DMFT is found in the Northeastern
  United States the lowest in the Western United
  States.
• African-American children have a lower DMFT than
  Euro-American children.
• However, the profile of the DMFT is different.
  African-Americans have a higher percentage of the
  index in the decayed and missing category.
  Euro-Americans have a higher percentage of the
  index in the filled category.
• This difference reflects the differential in
  professional oral health care accessed by these
  two groups.
• Studies have confirmed that the percentage of
  decayed teeth in the index declines with
  increasing household income.

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RELATED INFORMATION

• Dental caries is the single most common chronic
  childhood disease, 5 times more common than
  asthma, and 7 times more common than hay fever.
• There are striking disparities in caries
  prevalence by income. Poor children suffer twice
  as much caries as non-poor, and their disease is
  more likely to be untreated. (One out four
  children in America are born into
  poverty--17,000 for a family of four.)
• Twenty-five percent of poor children have not
  seen a dentist prior to kindergarten.
• 51 million school hours are lost each year to
  dental-related illness.
• Toothaches are the most common classroom health
  problem.
• Over one-third of American children do not have
  the benefit of water fluoridation our most
  effective

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EARLY CHILDHOOD CARIES (NURSING CARIES)

• 5-10 children have Early Childhood Caries (ECC),
  sometimes called nursing (or bottle) caries the
  rate is even higher among families with low
  incomes, and among racial/ethnic minorities.
• ECC is the result of poor nursing/feeding habits
  associated with children being given the bottle
  past 12 month, and/or given the bottle with
  cariogenic solutions in it at night, and allowed
  to keep it in the mouth for a prolonged period.
• ECC significantly increases a childs risk of
  future caries experience.

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RISK FACTORS FOR CARIES AMONG CHILDREN

• Children born to mothers in their teens have a 5X
  greater chance of having carious lesions by age
  5.
• Living in a rural area doubles the likelihood of
  having caries.
• Mothers who do not brush their teeth regularly,
  have children with double the risk for caries.

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CARIES RISK GUIDELINES(American Dental
Association 1996)

• LOW
• No carious lesions in last year
• Coalesced or sealed pits and fissures
• Relatively plaque free
• Fluoride in water supply and use of fluoride
  dentifrice
• Regular dental visits

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CARIES PREVENTION MODALITIES FOR CHILDREN BY RISK
CATEGORY(American Dental Association, 1996)

• LOW
• Educational reinforcement
• Plaque removal (oral physiotherapy)
• Fluoride dentifrice
• One year recall

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CARIES RISK GUIDELINES(American Dental
Association, 1996)

• MODERATE
• One carious lesion in the last year
• Deep pits and fissures
• Some plaque accumulation
• No fluoride in water
• White spot lesions
• Irregular dental visits
• Orthodontic treatment

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CARIES PREVENTION MODALITIES FOR CHILDREN BY RISK
CATEGORY(American Dental Association, 1996)

• MODERATE
• Pit and Fissure Caries
• Sealants
• Smooth Surface Caries
• Education
• Dietary Counseling
• Fluoride dentifrice (low potency fluoride)
• Fluoride mouthrinse (low potency fluoride)
• Professional topical fluoride (high potency
  fluoride)
• Six month recall
• Fluoride supplements (depending on age of child
  and absence of water fluoridation)

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CARIES RISK GUIDELINES(American Dental
Association, 1996)

• HIGH
• Two ore more carious lesions in last year
• Past smooth surface caries
• Elevated mutans streptococci count
• Deep pits and fissures
• No or little systemic and topical fluoride
  exposure
• Plaque accumulation
• Frequent fermentable carbohydrate intake
• Irregular dental visits
• Inadequate salivary flow
• Inappropriate nursing habits (infants)

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CARIES PREVENTION MODALITIES FOR CHILDREN BY RISK
CATEGORY(American Dental Association, 1996)

• HIGH
• Pit and Fissure Caries
• Sealants
• Smooth Surface Caries
• Education
• Dietary counseling
• Fluoride dentifrice
• Fluoride mouthrinse
• Professional topical fluoride (3-6 months)
• Three to six month recall
• Monitoring of mutans Streptococci
• Antimicrobial agents (Chlorohexidene)
• Fluoride supplements ( depending on age of child
  and presence of water fluoridation

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PREVALENCE OF PERIODONTAL DISEASE IN CHILDREN

• Approximately 60 of school age children will
  have at least one site of gingival bleeding on
  probing.
• 8 of children will have bleeding at multiple
  probing sites.
• Less than 1 of children, 5-17, will have a loss
  of periodontal attachment.
• One-third of teen-age children will have some
  supragingival calculus.
• Ninety-eight percent (98) of school age
  children, ages 5-17, have normal periodontal
  tissues.

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PREVALANCE OF MALOCCLUSION IN CHILDREN

• Reliable epidemiological indices to assess
  malocclusions do not exist.
• Data from one study indicate that approximately
  40 of children have occlusions close enough to
  ideal to be considered normal 60 do not.
• However, one study found that 75 of school age
  children, age 6-11, were judged to have some
  degree of occlusal disharmony 37 were judged to
  have a handicapping malocclusion.
• Another study found that only 14 of the age
  group present a handicapping malocclusion while
  an additional 38 could benefit from treatment
  meaning 50 of children could benefit.

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PREVALANCE OF MALOCCLUSION IN CHILDREN
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PREVALANCE OF MALOCCLUSION IN CHILDREN

• Rarely are malocclusions seen in the primary
  dentition, though pre-dispositions to such can be
  identified.
• Rather, malocclusions tend to emerge with the
  eruption of the permanent dentition and the
  growth spurts that occur during the school-age
  years.
• The most common malocclusion identified in the
  primary dentition is the posterior crossbite. One
  study found it to exist in approximately 8 of
  primary dentitions.

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OTHER PREVENTIVE ISSUES OF ORAL HEALTH

• Cleft lip/palate, one of the most common birth
  defects, effects 1 in 600 life births in
  Euro-Americans and 1 in 1,850 live births in
  African-Americans.
• Trauma to the cranio-facial complex are
  relatively common in children--studies are highly
  variable, 4-24.
• Tobacco-related oral lesions are prevalent among
  adolescents who use smokeless (spit) tobacco.

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PREVENTIVE FOCUS IN THIS UNIT

• In this unit we will focus primarily and
  specifically on the preventive issues associated
  with caries and periodontal disease.
• Prevention associated with malocclusions, trauma,
  and oral cancer will be addressed when these
  issues are addressed.
• Our approach to prevention of caries and
  periodontal disease diseases will be
  multi-dimension and comprehensive.

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IMPLEMENTING THE CONCEPT OF PREVENTION

• Prevention of dental caries and periodontal
  disease is possible by directing our efforts to
  the four variables that are involved the teeth,
  the bacteria, the substrate, and the
  understanding and motivation of the child and
  parent.
• It is imperative that the problem of prevention
  be approached by addressing all the variables of
  the disease process not just one or some.
• The focusing on only one aspect of a multifaceted
  problem leads to a distorted understanding of the
  problem, and an inadequate result.

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THE BLIND MEN AND THE ELEPHANTBY GEOFFREY SAXE

• It was Six men of Indostan
• To learning much inclined,
• Who went to see the Elephant
• (Though all of them were blind),
• That each by observation
• Might satisfy his mind.
• The First approached the Elephant,
• And happening to fall
• Against his broad and sturdy side,
• At once began to bawl
• "Bless me! but the Elephant
• Is very like a wall!"

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The Second, feeling of the tusk, Cried, "Ho! What
have we here, So very round and smooth and
sharp? To me tis mighty clear, This wonder of an
Elephant Is very like a spearl" The Third
approached the animal, And happening to take The
squirming trunk within his hands Thus boldly up
and spake "I see", quoth he, "the Elephant Is
very like a snake! The Fourth reached out his
eager hand, And felt about the knee, "What most
this wondrous beast is like Is might plain",
quoth he "'Tis clear enough the Elephant Is very
like a tree!"
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The Fifth, who chanced to touch the ear Said,
"E'en the blindest man Can tell what this
resembles most Deny the fact who can, This
marvel of an Elephant Is very like a fan!" The
Sixth no sooner had begun About the beast to
grope, Than, seizing on the swinging tail That
feel within his scope, "I see," quoth he, "the
Elephant Is very like a rope!" And so these men
of Indostan Disputed loud and long, Each in his
own opinion Exceeding stiff and strong, Though
each was partly in the right, And all were in the
wrong!
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PREVENTIVE MEASURES DIRECTED TO THE TEETH

• Water Fluoridation
• High Potency Topical Fluorides
• Fluoride Dentifrices
• Fissure Sealants

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PREVENTIVE MEASURES DIRECTED TO THE MICROFLORA

• Plaque Removal
• Antimicrobials

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PREVENTIVE MEASURES DIRECTED TO THE SUBSTRATE

• Dietary Analysis and Counseling

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PREVENTIVE MEASURES DIRECTED TO THE EDUCATING
CHILDREN AND PATIENTS

• Educational Techniques
• Educational Resources
• Audio-Visual Materials
• Patient Educational Brochures