New Approaches to Caries Prevention and Control

1
New Approaches to Caries Prevention and Control

• Silver Nitrate, Silver Diamine Fluoride
• And Xylitol

2
Silver Nitrate

• Silver has been used medicinal since 1,000 B.C.
• Silver nitrate is used in medicine today for its
  effective anti-microbial effect.
• Leaders in dentistry in the early part of the
  20th Century, G.V. Black, W.D. Miller and Percy
  Howe, utilized silver nitrate to arrest active
  carious lesions.
• In the later 20th Century it fell in to disuse,
  potentially due to the emphasis on eradicating
  caries and restoring the tooth, not simply
  arresting the active caries process.
• The epidemic of dental caries in young children
  has prompted a reassessment of silver nitrate as
  a means of arresting dental caries in young
  children until that time at which children can
  cooperate for having he teeth restored.

3
Silver Nitrate Caries Arrestment Technique

• 25 Silver Nitrate (25 silver nitrate and 75
  water) Available from Henry Schein company at
  www.HenrySchein.com
• In article by Duffin (see course website for
  article) the technique of use calls for
  application of the silver nitrate to an active
  carious lesion, followed by placing 5 fluoride
  varnish over the treated lesion.
• Duffin suggests the placement of the fluoride
  varnish prevents contact of the silver nitrate
  with the soft tissue (it is caustic) provides a
  protective layer to prevent the silver nitrate
  from being immediately washed away by saliva and
  adds the preventive effect of fluoride.

4
Application Technique
Duffin recommends that the application be
repeated at two, four, eight and twelve weeks.
5
Silver Diamine Fluoride

• In several countries of the world, notably Brazil
  and Japan, a compounded combination of silver
  nitrate and fluoride is being used to prevent
  dental caries, as well as to arrest lesions
  silver diamine fluoride.
• It is marketed with a number of names and
  concentrations
• Cariostatic (10 SDF) Cariestop (12 and 38
  SDF), and Saforide (38 SDF)
• The FDA recently classified silver diamine
  fluoride as a fluoride and thus can be used as
  such.
• A systematic review of the literature (Journal of
  Dental Research) supporting the efficacy of
  silver diamine fluoride is at the modules
  webpage.
• SDFs prevented caries at a rate of 70.3 Fl
  Varnish at 55.7
• SDF arrested caries at 96.1 Fl Varnish
  arrested caries at 21.3

6
Contraindications

• History of any pain from the tooth, indicating
  the lesion is approximating or has invaded the
  pulp.
• Lack of sound dentin between the lesion and the
  pulp.
• Evidence that the tooth is non-vital, such as
  presence of a parulis (gum boil).

7
Advantages and Disadvantages

• The carious lesion is arrested though the
  structure, function, and esthetics of the tooth
  is not restored.
• Caries is prevented from invading the pulp with
  subsequent pain and loss of vitality of the pulp
  and the tooth requiring extraction.
• In a very young uncooperative child arresting
  early childhood caries can permit delaying
  restoration until the child is older and able to
  cooperate for restoration of the teeth.
• Currently, young children with dental caries who
  are uncooperative have to be treated under
  general anesthesia in a hospital or out patient
  surgical center. This is a very expensive
  setting.
• Use of silver nitrate or a silver diamine
  fluoride regime is medical rather than
  surgical approach to treating caries.

8
Xylitol

• Xylitol, in the form or chewing gum or candy, is
  being used as a significant caries preventive
  agent in Europe, particularly in Scandinavia.
• Field trials in the late 1960s and early 1970 in
  Finland demonstrated a significant caries
  preventive effect from diets sweetened with
  Xylitol rather than sucrose.
• Xylitol is a sugar alcohol (polyol) with
  sweetness equal to table sugar, but with 40
  fewer calories. A primary source of Xylitol is
  from the sap of birch trees.
• Xylitol is not fermented by plaque bacteria. Thus
  it reduces accumulation of plaque on the teeth.
  Plaque pH does not drop when xylitol sweetened
  gum is chewed, therefore remineralization is
  enhanced.
• In Finland, school children typically chew
  Xylitol chewing gum three times a day for five
  minutes as a caries preventive regimen.
• One Finnish study found a 40 reduction in dental
  caries in adolescents after two years, versus a
  control group.

9
Xylitol

• Dental caries is an infectious disease.
• Infants are typically infected with mutans
  streptococci from their mothers as a result of
  the exchange of saliva.
• Mothers with open carious lesions or poor oral
  hygiene infect their children earlier with the
  microorganism. The earlier the infection of
  infants the more vulnerable the child becomes to
  dental caries.
• It is desirable to reduce the mutans streptococci
  load in pregnant women. This is typically done by
  restoring carious teeth, rinsing with
  chlorohexidine, and the use of high potency
  topical fluoride.

10
Xylitol

• Xylitol reduces mutans strep counts therefore,
  use of xylitol chewing gum by pregnant women is
  advocated as an additional preventive strategy in
  reducing transmission of from mother to infant.
• In one study, in which mothers chewed xylitol gum
  three times a day for three months before
  delivery, their children had significantly lower
  mutans steptococci counts than a control group,
  even up to six years of ageand significantly
  less caries experience than controls.
• Three articles on the use of Xylitol in
  preventing dental caries are at the modules
  webpage.