Tooth decay is the end result of a transmissible bacterial infection that is preventable. This disease is called caries. Yet just placing fillings on teeth, which is what dentists have been doing all along, does not in the long haul stop this disease process. The bacteria responsible for tooth decay generate acids from the fermentable carbohydrates we eat every day.

1. Understanding and Treating
Dental Caries in Children and
Young Adults: It’s Not Just
Filling Teeth
Dr. Stephen Abrams
Dr. Ian McConnachie

2. Overview of the Day
Introduction
Cariology 101
Risk Factors
Detection
Remineralization Therapies
Early Childhood Caries
Clinical Presentation
Sealants, Preventive Resin Restorations, ICON
Office Integration
Summary
Take Home Materials

3. Dentistry and the Public; Some Concerns
Survey results CDA Initiative
• Current reputation has precarious level of trust and
skepticism of the value that dentists offer
• More people see dentists as business people than
see dentists as doctors
• Dental plans matter; level of coverage takes
precedence over advice of dentists
• Dentists see patients often as misinformed, which
presents opportunity for education
• Dentists see relationships as key to building trust
and maintaining a strong patient base

4. What this Lecture is Not
A clinical technique “how to”
A commercial for specific products
No commercial sponsorship*
Materials shown are representative
examples, not endorsements*

5. *Disclaimer
Dr. Abrams is President and CEO of Quantum
Dental Technologies (QDT), the creator of The
Canary System
Dr. McConnachie is an unpaid dentist advisor
To QDT

6. Acknowledgements
• DR. MARIELLE PARISEAU
– www.shapingthefutureofdentistry.org
– Dentists Leaders in Health: Thinking Outside of the
Mouth
– http://www.jcda.ca/article/b157
• DR. CLIVE FRIEDMAN
– U. of Western Ontario and U. of Toronto
• Access to Today’s Presentation on Shaping the
Future of Dentistry website next week

7. Today and Evidence-Based Dentistry
Integration of Evidence-based literature with
clinical opinion
If it is opinion, we’ll try to say so
Recommendation
Very good overview of the concepts and the process –
J Can Dent Assoc 2001 Apr-Nov
• Clinical practice guidelines in dentistry Part I and II
• Evidence-based dentistry Part I-VI

8. Concepts of EBD

9. TIP: www.aapd.org

11. PubMed
http://www.ncbi.nlm.nih.gov
• Great free open source site for search of
literature
• Access to article abstracts and full articles
• Service of
– U.S. National Institutes of Health
– U.S. National Library of Medicine

12. What is Caries?

13. NIH Consensus Conference on Caries 2001
“Dental caries is an infectious,
communicable disease resulting in
destruction of tooth structure by acid-
forming bacteria found in dental plaque,
an intraoral biofilm, in the presence of
sugar."

14. NIH Consensus Conference March 2001
Caries is a bacterial infection caused by
specific bacteria.
Caries is a reversible multi-factorial
process.
In other words, caries is an infectious
disease with cavitation being the last
step of the process

15. The Paradigm Shift
One can place a number of restorations in a
mouth and yet not treat the underlying
disease. The bacteria remain in the plaque
biofilm on the remainder of the teeth capable
of creating new areas of decalcification and
cavitation.
We need to shift from a surgical approach to a
disease management & preventive approach.

17. CHMS Oral Health Data

18. CHMS vs U.S. Data

19. The Problem

21. Relevant Issues arising in the article
• “I had a lot on my mind, and brushing his teeth was an extra thing I didn’t think
about at night”
• CDC and P report on increase in decay in preschoolers 5 years ago-first time in
40 yrs.
• “No one told us when to go to the dentist, when we should start using fluoride
toothpaste”
• Dentists routinely recommend general anesthesia for preschoolers with
extensive problems-cost to parents…ranges from $2,000 to $5,000
• Using general anesthesia has risks-vomiting, nausea,…brain damage even
death
• “It’s not just about kids in poverty…”
• Brushing twice a day used to be nonnegotiable, but not anymore-”He doesn’t
want his teeth brushed. We’ll wait until he’s more emotionally mature”
• Staff treated a 3-year-old who was making his second visit to the operating
room for dental work. The boy arrived with a bottle of Coca-Cola

22. Dental Caries is one of the most common diseases
among 5 – 17 year olds
60
50 Note: Data included
Caries decayed or filled primary
40 and or decayed filled or
missing permanent teeth.
Asthma Asthma, chronic bronchitis
30
and hay fever based upon
20 Hay Fever household respondent about
the sampled 5 – 17 year old
Source NCHS 1996
10
Chronic
0 Bronchitis
Oral Health in America: A
Percentage of children & Report of the Surgeon General
DHHS 2000
adolescents ages 5 to 17

23. Public Perception
– In other words – NO BIG DEAL

24. Our Reality
Psychological impact
Lower body weight
A VERY BIG DEAL

25. Terminology
Caries is a transmissible bacterial infection and a
multifactorial disease that reflects change in one
or more significant factors in the total oral
environment.
(NIH Consensus Conference 2001)

26. Early Childhood Caries (ECC)
“The presence of one or more decayed
(noncavitated or cavitated lesions), missing (due
to caries), or filled tooth surfaces in any primary
tooth in a child 71 months of age or younger.”
Definition from National Institute for Dental and Craniofacial
research (NIDCR) workshop 1999

27. Terminology
Severe Early Childhood Caries (S-ECC)
“Any sign of smooth-surface caries in a child younger than 3
years of age” AAPD
“One or more cavitated, missing (due to caries), or filled smooth
surfaces in primary maxillary anterior teeth, or decayed,
missing or filled score of at least 4 (Age 3), 5 (age 4), or 6 (age
5) surfaces” Drury et al 1999

28. Diagnosis involves recognition
of these changes rather than
simply noting cavities

29. • Don’t treat underlying disease
• Don’t address plaque biofilm
i s s u e s
• Don’t change risk level
We need to from a surgical approach to a RISK management & preventive
approach.

30. Cariology
What is Tooth Decay?

31. Caries Risk?

32. Caries Progression

33. What do you need to create tooth decay?
• Teeth
• Food particularly carbohydrates
• Bacteria in Plaque or Biofilm

34. Elements involve in the Caries Process
Sugars &
Plaque Carbohydrate
containing Exposure
bacteria
Caries
Tooth
When all three are present, and enough time passes, large
carious lesions will occur

36. Restorations
•Restorations have no measurable effect on
bacteria.
•Restorations have a finite life span.
• Each replacement restoration leaves less tooth
structure.
•Restorations increase the risk of an abscess.
•Restorations may increase the risk of tooth
fracture & periodontal disease.

37. Caries Evolution

38. Caries Progression

39. Caries Progression

40. Caries Progression

41. Caries Progression

42. White Spot Lesion
Internal
loss of
minerals
External
(outer)
surface
White Spot Lesion
Really a subsurface lesion

43. Early Carious Lesion in Enamel

44. Pathogenesis of Dental Caries
SALIVA PLAQUE
PLAQUE ENAMEL
ENAMEL
Polysaccharides
Calcium
Salts
Plaque
buffers
mouth inside of tooth
SUGARS ACID
Calcium
Salts
Bacterial
Enzymes
Salivary
buffers
Demineralization Re-mineralization

45. The Caries Balance
Pathological Factors Protective Factors
•Acidogenic Bacteria •Saliva flow & components
(S. Mutans, S. Sobrinus & •Proteins, calcium, phosphate,
Lactobacilli)
fluoride, immungloulins
•Reduced Salivary
Flow •Antibacterials
•Frequency of In saliva and extrinsic
fermentable Fluoride, Chlorhexidine, iodine
carbohydrate ingestion
Caries No Caries
Adapted from Featherstone, J. D. B., JADA 2000

46. Demineralization
Demineralization
Dental Mineral Organic Calcium &
Acid soluble + Acids Phosphate into
Calcium phosphate solution
If fluoride is present in the water
between the crystals it inhibits mineral
loss

47. Remineralization
Phosphate Remineralization
Calcium in tooth In tooth •Builds on existing
Water (from saliva) + Water (from crystal remnants
Saliva) •New mineral less
soluble
•Fluoride helps
Fluoride speeds up remineralization
creating a less soluble mineral

48. demineralization
pH
FAP
Critical pH
HAP
deposit caries erosion
pH
remineralization
Carious lesion forms at pH 4.5 - 5.5
Erosion lesion forms when pH <

49. Cyclic Process of Decay
Bacteria plus food Demineralization
makes the saliva
very acidic within
5 minutes
Saliva pH is
Remineralization
normal
30 minutes
after eating

51. Stephan Curve
?
?
?
Stephan RM. JADA 1940;27:718-723
Changes in hydrogen-ion concentration on tooth surfaces and in carious lesion.
Stephan RM. JADA 1944; 23:257-266
Intra-oral hydrogen-ion concentrations associated with dental caries activity.

52. What Contributes to the Extent of pH
Drop after Glucose Exposure?
• Type & amount of
carbohydrate available
• Bacteria present
• Salivary composition &
flow
• Other food ingested
• Thickness and age of
dental plaque

53. What Contributes to the Differences
in Resting Plaque?
Resting plaque pH:
• Constant within each individual, but
differences among groups.
• Caries-inactive – resting pH ~ 6.5 - 7
• Caries-prone – lower resting pH
Bacterial composition affects metabolic properties of plaque
Storage form of CHO energy source when diet is depleted
When the host does not ‘eat’, cariogenic bacteria still
produce acids from stored carbohydrates

54. pH Change During the Course of The Day

55. Caries is a Bacterial
Infection

56. Web of Transmission
PLAYMATES/PEERS
CAREGIVERS SIBLINGS
PATIENT
2008 Copyright T .Rodriguez,DDS

58. Mode of Transmission
Both this spoon and pacifier have been in the mouth
and then cultured in a selective broth. They show S.
Mutans growing on them.
Courtesy of Ivoclar Vivadent.

59. Caries Is An Infectious Disease
“Demonstration of Mother to Child Transmission of
Streptococcus mutans using Multilocus Sequence
Typing”
Lapirattanakul et al. Caries Research 2008
“Genotypic Diversity of Mutans Streptococci in Brazilian
Nursery Children Suggests Horizontal Transmission”
Mattos-Graner et al. J Clin. Microbiology 2001

60. Bacteria Involved in Caries
Streptococcus Mutans,
Streptococcus Sobrinus
Lactobaccillus

61. Streptococcus Mutans
• Caries initiators
• Triggers the process that leads to mineral
loss and that allows bacteria to penetrate
tooth structure
• Capacity to adhere to the tooth surface
• Sugar transport system
• Production of lactic acid from sugar
• Tolerance to an acid environment

62. Lactobacillus
• They are responsible for caries progression.
• They do not adhere to tooth surfaces but
need carious lesions to colonize.
– Pits and fissures
– Cavities
– Marginal gaps of restorations
– Brackets

64. Plaque & Biofilms
Some New Thoughts on Plaque

65. What is a Biofilm?
• A well organized,
cooperating community of
microorganisms.
• The slime layer that forms
on rocks in streams is a
biofilm .
• It is estimated over 95% of
bacteria existing in nature
are in biofilms.

66. Phases of Plaque Formation
Pellicle Formation
Thin bacteria free layer forms within minutes on cleaned tooth
surfaces
Pellicle Attachment
Within hours bacteria attach to pellicle & slime layer forms
around the bacteria Formation
Young Supragingival Plaque
Mainly gram + cocci & rods
Some gram – cocci & rods
Aged Supragingival Plaque Subgingival Plaque
Increase in percentage of gram – anaerobic Tooth Attached & Epithelial Attached & Un-
bacteria Attached Plaque

67. Fluid micro colony is movement of nutrients & bacterial by-
Each channels allow an independent community with its own
Bacteria cluster together to form sessile mushroom-shaped
Protective slime layer surrounds the micro-colonies
Primitive communications system of chemical signals
products through the biofilm
micro-colonies environment
customized living

68. Host Factors That Influence Microbial Composition

69. Dental Plaque: Caries & Periodontal Disease
Marsh et al. “Dental Plaque Biofilms: Communities Conflict & Control” Periodontology 2000 December 2011

70. Control of Biofilms
Control of nutrients
• addition of base-generating nutrients (arginine)
• reduction of gingival cervicular flow through
anti-inflammatory agents
• inhibition of key microbial enzymes
Control of biofilm pH
• sugar substitutes
• antimicrobial agents
• fluoride
• stimulate base production

71. Agents for Control of Biofilm
Vast majority of agents for control
of biofilm are broad spectrum
non-specific microbiocide agents:
• CHX
• Triclosan
• Essential Oils (Listerine)
• Povidone Iodine

72. Saliva
A Very Important Component in the
Oral Environment

73. Multifunctionality
Amylases, Cystatins, Carbonic anhydrases,
Histatins, Mucins, Histatins
Anti- Buffering
Peroxidases
Bacterial
Cystatins, Amylases,
Mucins Anti- Mucins, Lipase
Viral Digestion
Salivary
Families
Anti- Mineral-
Fungal ization Cystatins,
Histatins
Histatins, Proline-
Lubricat-
Tissue ion &Visco- rich proteins,
Amylases, Coating elasticity Statherins
Cystatins, Mucins,
Proline-rich proteins, Statherins Mucins, Statherins
adapted from M.J. Levine, 1993

74. Saliva’s Protective Function
• Mechanical cleansing (water/flow)
• Lubrication of tissues and teeth (secreted proteins)
• Buffering of acids (HCO3-, HPO42-, peptides)
• Maintaining tooth integrity
– Post-eruptive maturation (Ca2+, F-, HPO42-)
– Mineralization equilibrium (Ca2+, F-, HPO42-)
– Pellicle
• Maintaining tissue integrity
• Regulation of the oral flora

75. Saliva & Oral Function
Food processing (water)
• Taste solute
• Bolus formation and swallowing (secreted proteins)
• Digestion (secreted proteins)
Speech (water, secreted proteins)
• Lubrication and rehydration
Excretion
• Small molecules (nitrate, thiocyanate. etc.)
• May interact with salivary proteins, oral bacteria

76. Remineralization Of Enamel &
Calcium Phosphate Inhibitors
•Early caries are repaired despite presence of
mineralization inhibitors in saliva
•Sound surface layer of early carious lesion
forms impermeable barrier to diffusion of
high mol.wt. inhibitors.
•Still permeable to calcium and phosphate ions
• Inhibitors may encourage mineralization by
preventing crystal growth on the surface of
lesion by keeping pores open

77. Summary
• Caries is an infection disease
• Bacteria live in Biofilms not Petri dishes
• pH drives changes in biofilm ecosystem
• Caries is reversible if detected early
• Initially, demineralization begins below the
tooth surface
• White spots and brown spots are surface
phenomena
• Demineralization / Remineralization is a
balancing act depending upon bacterial
metabolism

78. Risk Factors
Caries is a Disease

79. Risk Defined
• Risk is a prediction that disease
will occur or progress
• Risk is distinct from disease and
cannot be accurately predicted
from the disease state
• Risk is determined by risk factors

80. Caries Risk Factors
• Low Socio-economic Status
• High Titers Of Cariogenic Bacteria
• Poor Oral Hygiene & Cariogenic Diet
• Poor Family Dental Habits & Irregular Access to Dental Care
• Developmental Or Acquired Enamel Defects
• Genetic Abnormality Of Teeth
• Many Multi-surface Restorations (High DMFT, DMFS)
– Restoration Overhangs And Open Margins
• Eating Disorders
• Drug Or Alcohol Abuse
• Active Orthodontic Treatment
• Presence Of Exposed Root Surfaces
• Physical Or Mental Disability With Inability Performing Oral Health
Care
• Xerostomia: Medication, Radiation Or Disease Induced

81. Risk Factors
• Social Determinants
• BioMedical

82. Risk Factors: History
• Child has special needs
• Socio-economic status of the family
• Parents & siblings have decay

83. Risk Factors: Dental History
• Child has decay
• Time elapsed since last cavity
• Child wears braces or oral appliance
• Reduced saliva flow

84. Risk Factors: Dental History
• Frequency of brushing
• Daily between meal exposure to
sugars & carbohydrates
– On demand bottle
– Sippy cup
– Sports drinks & carbonated beverages

85. Risk Factors: Fluoride exposure
• Fluoridated water
• Fluoride supplements
• Fluoridated toothpastes

86. Risk Factors: Clinical Evaluation
• Visible plaque
• Gingivitis
• Areas of enamel demineralization
– ICDAS 1 – 3
• Enamel defects / deep fissures

87. Risk Factors: Clinical Evaluation Part 2
• Radiographic evidence of caries
• Levels of Strep Mutans in saliva
– Use commercial tests
– Not critical for establishing risk

91. Risk Definitions &
Treatment
Recommendations

92. Low Risk
Caries Risk •Dmfs , ½ childs age
Indicators •No new lesions in 1 year
•No white spot lesions
•Low titers of mutans strep
•High SES
Diagnostic •Examination interval 12 – 18 months
Procedures •Radiograph interval 12 – 14 months
•Initial strep mutans evaluation
Preventive •Fluoridated tooth paste
Therapy
Restorative •None
Therapy

93. Medium Risk
Caries Risk •dmfs> ½ child’s age
Indicators •1 or more lesions in 1 year
•infrequent white spot lesions
•moderate titers of mutans strep
•middle SES
Diagnostic •Examination interval 6 - 12 months
Procedures •Radiograph interval 12 months
•Initial strep mutans evaluation

94. Medium Risk (continued)
Preventive •Fluoridated tooth paste
Therapy •Systemic fluoride supplements
•Professional topical fluoride treatment
•Sealants
Restorative •Monitor enamel proximal lesions
Therapy •Restoration of progressing lesions
•Restoration of cavitated lesions

95. High Risk
Caries Risk •dmfs> child’s age
Indicators •2 or more lesions in 1 year numerous white
spot lesions
•high titers of mutans strep
•low SES
•appliances in mouth high frequency of
sugar consumption.
Diagnostic •Examination interval 3 - 6 months
Procedures •Radiograph interval 6 -12 months
•Strep mutans testing to monitor compliance
•Diet analysis

96. High Risk (continued)
Preventive •Fluoridated tooth paste
Therapy •Systemic fluoride supplements (age & water
supply considerations)
•Professional topical fluoride treatment
•Sealants
•Daily home fluoride or antimicrobials
•Dietary counselling and adjustments
Restorative •Monitor enamel proximal lesions
Therapy •Restoration of progressing lesions
•Restoration of cavitated lesions
•Aggressive treatment to minimize continued
caries progression

97. CAMBRA
Caries Management by Risk Assessment

98. The Caries Balance

99. The Caries Balance
ad Bacteria
bsence saliva
ietary habits poor

100. aliva
adequate
nti-
ad Bacteria microbial
bsence saliva luoride
ffective diet
ietary habits poor

101. ad Bacteria
aliva
adequate
bsence saliva
nti-
microbial
ietary habits poor
luoride
ffective diet

102. A Caries Risk Assessment (CRA) is just
“weighing” the factors of each patient.

103. CAMBRA is just “removing weight” from one side
and “adding weight” to the other.

104. Current State of Risk Assessment
“No existing instrument can ensure accurate
categorization of children by risk….”
Common aspects of all current risk assessment
models
• Historical and clinical data collected by clinicians
• Quantification of risk by an algorithm
• Assignment of individuals into a risk category
“Any model of caries risk assessment must address
both the biologic and behavioural management of
the disease”
Pediatric Oral Health Research Policy Center AAPD
2012

105. Objectives of CAMBRA in Children
CAMBRA=Caries Management by Risk
Assessment
• Assess child and caregiver caries risk in an
individualized manner
• Tailor a specific preventive therapeutic management
plan
• Customize a restorative plan in conjunction with the
preventive plan
• Plan timely, specific and appropriate periodicity
schedule based on the child’s caries risk
Ramos-Gomez F, Ng WM, Oct 2011

113. Tools for Assessing
Caries

114. “ It is change, continuing change, inevitable change,
that is the dominant factor in society today. No sensible
decision can be made any longer without taking into
account not only the world as it is, but the world as it
will be”
Isaac Asimov

115. Sensitivity & Specificity
• Sensitivity refers to the ability of a test to correctly identify those patients with
the disease.
• A test with 100% sensitivity correctly identifies all patients with the disease.
• However, a test with 60% sensitivity correctly identifies 60% of patients with
the disease (true positives) but the remaining 40% of patients with the disease
are incorrectly identified as negative results and go undetected (false
negatives).
• Specificity refers to the ability of the test to correctly identify those patients
without the disease. Therefore, a test with 100% specificity correctly identifies
all patients without the disease.
• However, a test with 60% specificity correctly identifies 60% of patients without
the disease (true negatives) but 40% of patients without the disease are
incorrectly identified as positive results (false positives).
• Therefore, an experimental test aims to achieve 100% sensitivity and 100%
specificity

116. Tools for Detection
• Visual Exam with or without Explorer
• Radiographs
• DIAGNODent
• Caries ID
• QLF
• Spectra
• Sopro
• CarieScan
• The Canary System

117. Principles of Diagnosis
The goal of examining a patient for the
presence of dental caries is to detect the
earliest signs of carious demineralization
on enamel & root surfaces.
If early signs of demineralization are
detected, preventive care may reverse the
caries process.

118. White Spots????

119. Examining a White Spot

120. Classical Detection Tools
Health Decalcification Decay
Normal tooth Black or
Visual White spot
color brown
Feel Hard Hard Soft
X-Ray Normal Normal Black area
None of these methods can detect all lesions early enough to implement
treatment to reverse the disease process

121. Visual Tools for Assessing Caries
• DMFT and DMFS
• ICDAS
• CAMBRA

122. DMFT and DMFS
DMFT: decayed, missing, filled teeth
DMFS: decayed missing filled surfaces
Only a measure of past caries experience does
not measure early lesions which can be
remineralized

123. ICDAS International Caries Diagnosis &
Assessment System
• Used to rank tooth surfaces
• Ranks lesions
• Ranks restorations
• Ranks missing teeth
• More sensitive and robust than DMFT system
• Now a 2 digit system

124. ICDAS Coding Summary

125. Use of Explorers (?contentious)
In the ICDAS-system perio Explorers are not recommended as
probes are used to feel with they may produce traumatic defects
Ekstrand et al., 1987
Ball-ended

126. ICDAS-II detection criteria, 2005
SOUND OPACITY OPACITY LOCALISED UNDERLYING DISTINCT EXTENSIVE
First Visible Distinct ENAMEL DARK CAVITY DISTINCT
Change Visible BREAKDOWN SHADOW CAVITY
only after Change
+/-
airdrying: without air- WITH WITH VISIBLE
SURFACE SURFACE
WHITE, drying:
INTEGRITY INTEGRITY VISIBLE DENTINE
BROWN WHITE, LOSS LOSS DENTINE
BROWN
Enamel Caries Dentin Caries
Score Score Score Score Score Score Score
0 1 2 3 4 5 6

127. ICDAS-II detection criteria, 2005
SOUND OPACITY OPACITY LOCALISED UNDERLYING DISTINCT EXTENSIVE
First Visible Distinct ENAMEL DARK CAVITY DISTINCT
Change Visible BREAKDOWN SHADOW CAVITY
only after Change
+/-
airdrying: without air- WITH WITH VISIBLE
SURFACE SURFACE
WHITE, drying:
INTEGRITY INTEGRITY VISIBLE DENTINE
BROWN WHITE, LOSS LOSS DENTINE
BROWN
ICDAS II (International Caries Detection & Assessment System) scores
Enamel Caries Dentin Caries
Score Score Score Score Score Score Score
0 1 2 3 4 5 6

128. ICDAS Code Summary
http://www.dundee.ac.uk/dhsru/news/icdas.htm
DETECTION AND SEVERITY OF THE LESION
2 A. VISUAL APPEARANCE
2. ACTIVITY
EXTENSIVE DISTINCT UNDERLYING SURFACE OPACITY OPACITY SOUND
CAVITY CAVITY GREY INTEGRITY without with air-
SHADOW LOSS air-drying: drying:
WHITE, WHITE,
BROWN BROWN
Score Lesion in Dentin
Score Score Score Lesion Lesion in
Scores Scores Score
6 5 4 3 2W,2B
in 1W,1B
Enamel 0
Enamel/
Ekstrand et al., modified by ICDAS (Ann Arbor), 2002; Dentin
further modified by ICDAS (Baltimore) 2005

129. Visual vs. Caries Detection Devices
• Visual only provides
information on the
surface
• Caries starts as a sub
surface lesion
• All white and brown
spots are not created
equal
• Need a system that
can detect, measure
and monitor the
evolution of a carious
lesion.

130. Does this look suspicious?

131. Use of an Explorer
• Care in not poking or
disturbing the enamel
surface
• Probing fissures may
break the enamel
crystals lining the
fissure
• Probing will also
introduce more
bacteria into the
fissure

132. Probing Drives Bacteria & Debris into Fissures

133. Explorers & Pit & Fissure Caries
“Probing found unreliable in finding fissure caries”
Penning, van Amerongen, Seef & ten Cate. Caries Research 1993
“The reliability of carious lesion diagnosis by sharp
explorer compared to diagnosis of carious lesion by
histological cross section was 25%.”
“A seemingly intact occlusal enamel surface may
conceal an extensive lesion of the dentin”
Al-Sehaibany, White & Rainey J Clin Pediatr Dent 1996

134. Light Interaction with Teeth
•Reflection
•Transmission
•Absorption
•Backscatter
Reflection Backscattered
of light light from
from tooth lesion
surface

135. Methods for Caries Detection
Conventional methods
• Visual examination:
+ non-destructive
+ safe
- poor resolution
- unable to detect incipient demineralization
- unable to detect subsurface caries
• X-rays:
+ non-destructive
+ can detect subsurface caries
- limited safety
- unable to detect incipient demineralization
- low resolution

136. Radiographs
• Radiographic imaging of pits and fissures is of minimal
diagnostic value because of the large amounts of surrounding
enamel .
• Literature review by Dove:
• “overall the strength of the evidence for radiographic methods
for the detection of dental caries is poor for all types of lesions
on proximal and occlusal surfaces”.
• “it is beneficial only if the intervention is the surgical removal of
tooth structure and detrimental if it is used for non-invasive
remineralization methods.”
McKnight-Hanes C, Myers DR, Dushku JC, Thompson WO, Durham LC. Radiographic recommendations for the primary
dentition: comparison of general dentists and pediatric dentists. Pediatr Dent. 1990 Jul-Aug;12(4):212-216
Flaitz CM, Hicks MJ, Silverston LM. Radiographic, histologic, and electronic comparison of basic mode videoprints with
bitewing radiography. Caries Res. 1993; 27(1): 65-70.
Lussi A, Comparison of different methods for the diagnosis of fissure caries without cavitation. Caries Res 27:409-16, 1993
Dove, S. B., “Radiographic Diagnosis of Dental Caries in Consensus Conference on Dental Caries Management Throughout
Life, March 2001, Journal of Dental Education, 2001; 65 (10): 985 – 990

137. Radiographs
Radiograph unable to
locate caries and crack
beneath the restoration

138. Methods for Caries Detection
Fluorescence-based methods
• DIAGNODent (Kavo Danaher):
detects fluorescence light emitted by porphyrins
present in carious tissue following absorption of laser light
+ non-invasive
- low resolution
- risk of false diagnosis (porphyrins are present in stained
healthy enamel, and not in the primary bacteria that cause
tooth decay)
- unable to quantify the level of demineralization
• Caries ID (MidWest Dentsply)
• Detection similar to DIAGNODent
–Looks at fluorescence and reflection
+Not repeatable
–Low resolution

139. Methods for Caries Detection
Fluorescence-based methods
• Quantitative Light-Induced Fluorescence (QLF):
+ non-invasive
+ quantifies mineral gain & loss
+ repeatable measurements
- low resolution
- expensive
- unable to quantify lesion depth
- unable to detect interproximal lesions

140. Methods for Caries Detection
Spectra QLF based Technology
• May be issues with accuracy and sensitivity of the
technology
• Only monitors porphyrin metabolites
• Camera may not capture pixels as accurately
• Need more clinical information including comparison
to original QLF
• Scale of 0 – 5 with std .25

141. Methods of Caries Detection
DIFOTI (Digital Fibreoptic
Transillumination)
+ non-invasive
- Low resolution
- Tooth decay scatters &
absorbs more light than
healthy tissue.
+ DIFOTI is 2x, more sensitive than
bite-wing radiography for detection of
decay * (Caries Research, 1997)

142. Methods of Caries Detection
Caries Scan (Electrical Impedance
Measurement)
Tooth decay delays or changes the conduction of an electric
current.
- Only detects surface defects
- Need clean dry tooth surface
+ Repeatable
+ Non-invasive
- May be able to monitor and quantify mineral loss
- Can not detect caries at restoration margins
- Can not monitor interproximal lesions or root surface
lesions
- Low resolution

143. The Canary System
• Full Spectrum of Caries
Detection
• Accurate
• Repeatable
• Reliable
• Engages Patients & Builds a
Practice
• 2 Health Canada approved
Clinical Trials
• Over 50 research papers &
Ongoing R&D
• Over 11 years of R&D

144. The Science Behind The Canary System
•Pulses of laser light hit the tooth surface.
•Tooth glows (Luminescence, LUM) and releases heat (Photo-
Thermal Radiometry, PTR).
Energy Conversion Technology
Temperature
increase < 1oC
not harmful
•Detected signals reflect the tooth’s condition.
•Detects 50 micron lesion up to 5 mm below the surface.

145. Caries Detection on All Surfaces
• Occlusal Pits & Fissures
• Smooth Surfaces
• Interproximal Regions
• Around the Visible Margins of Restorations
(Composite, Amalgam, Porcelain or Gold)
• Beneath Sealants
• Root Surfaces
The Canary detects small
lesions 50 microns in size
up to 5 mm below the
tooth surface.

146. Canary Patient
Report
Customized patient
report on dental
practice letterhead
Clear simple indication
of problem areas
Patient can track their
progress
Engages patient in their
oral health care

147. Case Study: Caries Beneath an Amalgam
39
60

148. Canary Finds Caries & Cracks Around Amalgam
Canary Numbers (in
yellow) indicate caries &
pathology. Upon removal
of the amalgam cracks 58
36
and caries found on
marginal ridges and caries 97
on the lingual margin.

149. Sensitivity & Specificity Studies
Study 1: Detection on All Surface
Tooth Surface Overall Occlusal Buccal Mesial
The Canary System
Sensitivity 97% 100% 100% 100%
Specificity 82% 80% 100% 75%
Visual Examination
Sensitivity 80% 88% 64% 88%
Specificity 91% 80% 100% 75%
Study 2: Detection of Pit & Fissure Caries
Caries detection The Canary System DIAGNODent ICDAS II
method (visual ranking system)
Sensitivity 92% 41% 77%
Study 3 : Detection of Early Carious Lesions & Lesion Depth
Caries detection method The Canary System DIAGNODent
Sensitivity 100% 18%
Correlation with lesion depth 84% 21%

150. Detection of Pit & Fissure Caries
• Low Caries Patient
• Only 1 restoration in the
last 40 years
• Stained distal pit on # 45
• Scan open & found large
carious lesion Distal Pit # 45
Canary Number 86
• Scanning on tooth 44
was normal

151. Detection of Caries Beneath Sealants
• Canary Numbers >20 when scanning sealants (3M™ ESPE™ Clinpro™ Sealant™)
placed over pit & fissure caries.
• The caries detection ability of the Canary System was not affected by sealant
& was more accurate than DIAGNOdent
Canary Number 66 Sensitivities and specificities for pit &
fissure caries detection after sealant
Sealant placement.
Caries The Canary DIAGNOdent
Demineralized detection System
Pre-sealant enamel
method
Sensitivity 83% 64%
Canary Number 37
Caries into Specificity 79% 46%
dentin
Cross-section
Post-sealant

153. The Characteristics of an Ideal Caries Detection System
1. High sensitivity & specificity for caries detection
2. Detects & monitors de & re-mineralization
3. Detects smooth surface, root surface, occlusal surface &
interproximal lesions
4. Detects caries around restoration margins
5. Non-invasive & safe
6. Repeatable measurements
7. Imaging and or image capture
8. System for recording & storing measurements
9. Patient Education and Motivation
10. In-vitro and in-vivo data & publications including clinical trial data
demonstrating to detect & monitor carious lesions
11. Minimal or no preparation of the tooth surface before a reading
12. Ability to detect and monitor erosion lesions
 The key is to understand what the device is measuring.

154. Remineralization and
Other Therapies
Minimally Invasive Dentistry

156. Understanding your choices?

157. Product Decisions?
 Fluoride • RISK Demand?
 CPP-ACP (Recaldent) • Age and Ability?
 NovaMin • Buffering?
 ProArgin • Fluoride Uptake?
 Xylitol products • Contact time needed?
 Antibacterial rinses • Desensitization?
 Salivary products • Antibacterial Activity?
 Neutralizing agents • Salivary Stimulant?
 Silver Diamine Fluoride • Compliance?
 Povidone Iodine
 CHX varnish (Prevora)
 Sealants
 ICON

158. Important Reference Paper on the Journey
Non-fluoride caries preventive agents: Full report of a
systematic review and evidence-based
recommendations Council on Scientific Affairs, ADA
May 2011
Questions
Does the use of a non-fluoride caries preventive agent
reduce the incidence, arrest or reverse caries
a) In the general population
b) In individuals with higher caries risk
“The recommendations in this document do not purport to define
a standard of care and rather should be integrated with a
practitioner’s professional judgement and a patient’s needs and
preferences”

159. Requirements of an Ideal Remineralization Material
• Diffuses into the subsurface or deliver calcium and
phosphate into the subsurface
• Does not deliver an excess of calcium
• Does not favour calculus formation
• Works at an acidic pH
• Works in xerostomic patients
• Boosts the remineralization properties of saliva
• For novel or new materials; shows a benefit over fluoride
Walsh, L. J., Australasian Dental Practice March/April 2009

160. Topical Fluoride
The Original Remineralization Agent
• Water Fluoridation
• Toothpaste
• Fluoride Rinse
• Fluoride Varnish
• Bottled Water

162. Water Fluoridation
• Remains a major source of reduced decay
• Many studies with average reduction 25%
• Recommended by all major health
organizations
• No evidence of health or environmental risk
• Under attack by extremist U.S organization
Fluoride Action Network

163. Community Water Fluoridation Canada

164. Water Fluoridation
Critical role for local dental community
• Proactive lobby
• In-office activity
Recent Manitoba Activity
• Churchill maintains fluoridation Oct 2011
• Flin Flon ends fluoridation July 2011

165. Key Canadian Government References on
Water Fluoridation
• Fluoride Expert Panel 2007
• http://www.hc-sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-
fluorure/index-eng.php
• Water Quality Fluoride in Drinking Water 2009
• http://www.hc-sc.gc.ca/ewh-semt/consult/_2009/fluoride-
fluorure/draft-ebauche-eng.php
• Response to Environmental Petition 2008
• http://fptdwg.ca/assets/PDF/0804-
JointGovernmentofCanadaresponse.pdf

166. Fluoride – Mechanisms of Action
• Enhances remineralization
– Adsorbs onto mineral surfaces, attracts calcium and phosphate ions
in saliva, results in the formation of fluorapatite
– Fluorapatite exhibits lower solubility than naturally occurring
hydroxyapatite, helps resist the inevitable acid challenge*
• Helps inhibit demineralization
– Adsorbs onto mineral surfaces and protects the tooth against
dissolution*
• Inhibits bacterial activity
– Inhibits cariogenic bacteria metabolism of carbohydrates – less acid
and less adhesive polysaccharides are products**
* Featherstone JDB. Prevention and reversal of dental caries: role of low level fluoride. Community Dent Oral Epidemiol 1999;27:31–40.
** Hamilton IR. Biochemical effects of fluoride on oral bacteria. J Dent Res 1990;69(special issue):660–7

167. Fluoride Action
A brief review:
– Effect largely topical
• At low levels
– Inhibits demineralization at crystal surfaces
– Enhances remineralization at crystal surfaces
• At high levels
– Inhibits bacterial enzymes

168. Fluoride - Some Interesting Pieces
Low levels after several hours in plaque and
saliva can have a profound effect on
demin/remin
– i.e. TOOTHPASTE
– MOUTHRINSE?
Lynch RJ, Navada R, Walia R, Low levels of fluoride in plaque and
saliva and their effects on the demineralization and remineralization
of enamel: role of fluoride toothpastes. Int Dent J 2004:54(5 Suppl
1):304-9

169. TOPICAL FLUORIDE
Toothpaste
• Position Statements
– Canadian Dental Association
– American Academy of Pediatric Dentistry

170. CDA Position on Use of Fluorides in Caries
Prevention revised March 2012
• Water fluoridation
• Fluoride toothpaste and
Mouthrinse
– Children 0-3 years
– Children 3-6 years
• Professional topical
application of fluoride gels,
pastes and varnishes
• Fluoride supplements
• Fluoride exposure from
multiple sources

171. CDA Position on Use of Fluorides in Caries
Prevention revised March 2012
Children 0 - 3 years
• The use of fluoridated
toothpaste in this age
group is determined by
the level of risk
• Parents brush under 3
years and assist 3-6 years
• “Grain of rice” of
toothpaste
• All children supervised or
assisted till appropriate
dexterity

173. Topical Fluoride – The Gold Standard
J Dent Educ. 71(3): 393-402 2007
© 2007 American Dental Education Association
Professionally Applied Topical Fluoride: Evidence-
Based Clinical Recommendations
American Dental Association Council on Scientific
Affairs
Key words: fluoride, caries, caries prevention,
evidence-based dentistry, clinical recommendations

174. ADA Evidence-based Recommendations
Assess
– Caries Risk
–Low
–Medium
–High
Decide
– Whether to apply fluoride
– Type of fluoride
– Frequency of application
– How often to re-evaluate

175. ADA Evidence-based Recommendations
Professionally Applied Topical Fluoride
Risk group Less than 6 years
/Age
Low Patient may not receive any additional benefit
Medium Varnish every 6 months
High Varnish every 6 months (or 3 months)

176. ADA Recommendation
Professionally Applied Topical Fluoride
Low risk under 6 years
• Fluoridated water and toothpaste may
provide adequate caries prevention in low
risk category
• Fluoride foam and gel not recommended in
this age group

177. Fluoride Varnish – Why?
• Higher percentage of caries reduction
• Prolonged uptake of fluoride by enamel
versus other topical systems
• Sets on contact with intraoral moisture
• Greater efficacy versus other delivery
systems
• Fluoride deposited on demineralized
enamel greater than on sound enamel
• May produce redistribution of ions within
caries and increasing fluoride infusion

178. Fluoride Varnish (5% NaF = approx 22,500 ppm)
No special equipment • Safe and well tolerated
No prophylaxis prior to • Inexpensive
application • Greater fluoride uptake
Easy to apply than with gels or foams
Dries on contact with saliva

179. Evaluating Fluoride Varnish
• Concentration of Fluoride in Varnish
• Fluoride availability in saliva over a 1 – 4 hour
time period
• Lab and Clinical trial evidence of efficacy
• Other additives?
• Ease of application
• Patient comfort issues
– Colour
– Grittiness

180. Applying Fluoride Varnish

181. Fluoride Varnish Application
• Gentle finger pressure to open child’s
mouth
• Remove excess saliva from the teeth
• Apply a thin layer of varnish to all
surfaces of the teeth
• Varnish hardens on contact with saliva

182. Post-application instructions
• Recommendations vary with manufacturer,
but generally:
• Can eat within 30 minutes avoiding hot
food/drink
• Soft, non-abrasive diet for the rest of the day
• No floss of teeth until the next morning
• Inform the caregiver of appearance/film until
teeth are brushed

183. Migration of Fluoride Varnish after Application:
an In Vivo Study
Kolb V et al, 3M ESPE Dental Products, St. Paul, MN
Results of the Study:
Vanish reached a greater number of tooth surfaces
than the other fluoride varnish products
immediately after application and continued to
migrate for up to 4 hours. This in vivo study
demonstrates that Vanish varnish exhibits
enhanced flow characteristics compared to the
other fluoride varnishes tested.
2009 IADR Abstract #1170

184. Fluoride and Safety Concerns
Three real issues
• Fluoride toxicity
• Fluorosis
• Allergy
• Age of greatest risk for fluorosis
• 0-3 years
• Especially 22-26 months
– Findings and recommendations of the
Fluoride Expert Panel Health Canada Jan
2007

185. Estimation of Potential Toxic Dose Considering the Child
Age/Weight Verronneau 2007
Variable Volume or Weight Volume or Weight (Oldest
(Youngest child and inferior Child and Superior Border)
border)
Age 6 months 36 months
Mean Weight 8.25 kg +/- 0.5 (Demerjian 19.75 kg +/- 2.0kg
1985)
Fl Varnish 0.1 ml (Ripa, 1990) 0.5 ml
Ingestion presumed 2.30 mgr (Johnston, 1994) 11.30 mgr
Potential toxic dose 41.25 mgr/kg/total weight 101.50 mgr/kg/total weight
Protective factor 17 10

186. Fluoride Varnish – Toxicity
Comparative fluoride ingestion rates
Use Ingestion
5 25
4 20
3 15
ml mg
2 10
5
1
0
0
Varnish APF (Gel)
Courtesy of Medicom

187. Fluorosis
Total daily fluoride intake from all sources
should not exceed 0.05-0.07 mg F/kg of body
weight in order to minimize the risk of dental
fluorosis
– Canadian Dental Association Nov. 2008

189. Fluorosis – Dean’s Index

190. Fluorosis – CHMS Data
Children 6-12 years
• 60% with normal enamel
• 24% with white flecks or spots where cause
questionable
• 12% very mild
• 4% mild
• Mod-severe too low to report
*Remember that many of mild areas of enamel
variation will spontaneously improve into teen years

191. Fluoride Varnish (5% NaF = approx 22,500 ppm)
No special equipment • Safe and well tolerated
No prophylaxis prior to • Inexpensive
application • Greater fluoride uptake
Easy to apply than with gels or foams
Dries on contact with saliva

192. Fluoride Varnish Allergy Risk
Potential resin peptide allergen link to pine nut
allergies
Oral Science X-Pur 5% NaFl
“…current formulation altered to refined, purified
colophony resin. …Health Canada no longer require
allergy warning”
3MEspe Vanish Fluoride Varnish
allergen is abietic acid, not peptide-no cross reactivity
colophony purified-allergen risk lowered
Recommendation
Ask your supplier re process
Allergy warning required?

193. Current Toothpastes
0.243-0.254% NaF or 0.454% SnFl
= 0.115% Fl- = approx. 1100 ppm Fl
1.1% NaF
= 0.495 Fl-= approx. 5000 ppm Fl
NOTE: Federal advisory panel recommends
low-dose fluoride toothpaste be available for
children in Canada

194. High fluoride toothpaste 5000 ppm

195. 3M Clinpro™ 5000 Tooth Paste
Dentifrice Mechanism of Action
• Contains 1.1% NaF (5000 As the paste reaches the tooth
ppm fluoride ion) surface:
• Contains innovative calcium – Organic components (often
surfactants) have an affinity for
and phosphate ingredient
tooth surfaces
which is broken down upon
– Carries the calcium to the
contact with the tooth
tooth surface, protected from
surface. fluoride ion  High fluoride
bioavailability during
application
– Saliva activates the calcium
compound degrading the
protective coating, releasing
calcium at the tooth surface 
Calcium bioavailability
during application

196. Protected calcium oxides are released
As the ingredient reaches the tooth surface
• Organic materials (often surfactants) have
an affinity for tooth surfaces
– Carries the calcium to the tooth surface,
protected from fluoride ion  High
fluoride bioavailability during application
• Saliva activates the calcium compound
degrading the protective coating, releasing
calcium at the tooth surface  Calcium
bioavailability during application

197. Clinical Trial (preliminary analysis)

198. Recaldent (CPP-ACP)
• Casein Phosphopetides • Amorphous Calcium
– From cow’s milk Phosphate
– Stabilize calcium and – Developed by ADA Health
phosphate ions Foundation
– Facilitate intestinal – Original intent is surface
absorption deposition of hydroxyapatite
– pH dependent – Developed for desensitization
– Modified to create bio-
available calcium and
phosphate for
remineralization

199. Recaldent
MI Paste
MI Paste Plus
Trident Xtra Care Gum
Trident White Gum

200. Novamin®
• Calcium sodium
phosphosilicate: Ca and
P04 ions protected by glass
particles
• Sodium buffers salivary pH
for precipitation of crystals
• Contact with H20 or saliva,
activates release of Ca and
P04

201. How NovaMin Works
 A breakthrough remineralization ingredient
 Comprised of calcium ( ), sodium ( ),
phosphorous ( ), and silica ( ), all natural
elements found in the body
High pH + Ca and P
pH
ions turbo charge
remin process.
Demineralized
NovaMin reaction
surface is
elevates pH to ideal
replenished
+ remin range (8-9),
NovaMin releases C and P ions
immediately
reacts w/saliva or
water
NovaMin Particles

202. ADA Report Recommendations
“There is insufficient evidence from clinical trials that
the use of agents containing calcium and/or
phosphates with or without casein derivatives lowers
incidence of either coronal or root caries
Opinion:
Given individual cases of considerable success, this is
most likely dependant on careful case selection and
frequent reinforcement
KNOW YOUR PATIENT

203. Silver Diamine Fluoride- the new silver bullet?
• -currently not approved in N. America
• -38% concentration shows significant caries reduction
and caries arrest
• -alternative treatment when restoration not an option
• Yee et al 2009
• -more effective than fluoride varnish
• -lowest prevented fraction for caries arrest 96.1%
• -lowest prevented fraction for caries prevention 70.3%
• Rosenblatt et al 2009

204. Silver Diamine Fluoride- the new silver bullet?
-frequency of application 1x/yr
-excavation of soft caries reduces black discoloration
-metallic taste
-greater efficacy vs multiple FV applications
Chu et al JDR 2002
-frequency of application 2x/yr
-reduction of new lesions on primary and first
permanent molars (preventive fraction 79.7% & 65%)
Llodra et al JDR 2005

205. Silver Diamine Fluoride- the new silver bullet?
Safety Issues
-pulp irritation no evidence
-caries stain yes but...7%found objectionable
-tissue irritation yes, white lesions with mild pain
lasting 48 hrs.
-fluorosis theoretical possibility in animal
studies - needs more study
Rosenblatt et al 2009

206. Remineralization and Other Therapies
Antimicrobial treatment (remember the
biofilm!)
• Xylitol
• Povidone iodine
• Chlorhexidine
• Delmopinol
• Triclosan

207. Remineralization and Other Therapies
Xylitol

208. The Xylitol Story in Brief
• Natural long chain sugar
• Non-cariogenic
• Can reduce mutans strep in plaque and
saliva
• Can reduce caries in young children,
mothers and in children via their mothers
• Anti-caries benefit for high risk for both
caries reduction and enamel
remineralization

209. Key Xylitol Studies for ECC
Soderling et al 2001
Maternal transmission of MS
• Xylitol gum
– Starts 3 months after delivery and for 21 months
• Fluoride varnish
– Applied at 6, 12, 18 months
• CHX varnish
– Applied at 6, 12, 18 months
Measured MS levels in children at age 3 and 6

210. Key Xylitol Studies for ECC
Soderling et al 2001
Results
• Children age 3
– MS levels 2.3x higher with Fl Var and CHX Var in
mother
• Children age 6
– Protection maintained with same higher benefit of
xylitol in mother
Results reconfirmed by Thorild et al 2006

211. Mutans streptococci of the 2-year-
old children (Söderling et al., JDR 2000)
%
60
• The child’s risk of
50
having mutans
streptococci 40
colonization in the
30
dentition was 5-fold
in the F group and 20
3-fold in the CHX
10
group as compared
to the Xylitol group 0
n=33 n=28 n=103
CONTROL CHX XYLITOL

212. dmf
Caries occurence in children CHX
3
• At the age of 5 years
the need of
restorative treatment Control
was 71-75% lower in 2
the Xylitol group as
compared to the F
and CHX groups
1
• The occurence of
caries and early Xylitol
mutans streptococci
colonization were in 0
agreement 0 1 2 3 4 5 6
Age

213. Why Xylitol and when
• Maternal 3 months post partum (Soderling 2001)
• Characteristic of infection at eruption determines
life-long (Loesche 1985)
• Once colonized with benign, ms will not displace
(Svanberg and Loesche 1977)
• May be due to less cariogenic xylitol-metabolizing
ms strain (Trahan et al 1996)

214. Xylitol as a Remineralization Agent
“These results indicate that xylitol can induce
remineralization of deeper layers of
demineralized enamel by facilitating Ca2+
movement and accessibility.”
Miake Y, Saeki Y, Takahashi M, Yanagisawa
J Electron Microsc (Tokyo). 2003;52(5):471-6

215. Xylitol More than a Remineralization Agent
• Inhibits adhesion, growth and metabolism of oral
microorganisms. Suppresses ms even with sucrose
intake.
• Allows remineralization of initial enamel
lesions. Enhances reversals (Turku study).
• Chewing gum enhances with increased salivation
• Synergistic with fluoride

216. HEAD & NECK RADIATION
AND CHEMOTHERAPY
LOSS OF PROTECTIVE
XEROSTOMIA
QUALITIES OF SALIVA
• Increase of pathogenic bacteria • Increase of oral acidity and decrease of healthy PH
• Increase of pathogenic biofilm • Acceleration of the demineralization process
Oral Oral Rampant Periodontal
Mucositis Lesions Candida Caries Disease
3

217. Xylitol; A Remineralization Agent
Reported Xylitol Availability
• Gum – sole or in combination
• Toothpaste
• Lollipops
• Syrup
• Tooth wipes
• Slow release in pacifiers
• Gummy bears
• Combination with: fluoride or chlorhexidine

218. Xylitol Syrup (Marshall Islands Study)
• No. decayed teeth
– Control: 1.9 +/- 2.4
– Xylitol 2x: 0.6 +/- 1.1
• % with decayed teeth
– Control: 51.7%
– Xylitol 2x: 24.2%
Milgrom AAPD 2009

219. Xylitol – Widely Accepted Opinion
• habitual use of xylitol reduces incidence of caries
• habitual use remineralizes enamel and dentin caries
• other polyols also reduce caries
• probable hierarchy of effect of polyols based on
number of hydroxyl groups:
erythritol_>xylitol>_sorbitol
Makinen, KK, 2010

220. www.oralscience.com 220
BOTTLES
• 180 pieces of gum –
Peppermint
• 180 pieces of gum – Fruit
• 400 mints – Peppermint
• 400 mints - Fruit
TINS
• 20 pieces of gum – Peppermint
• 60 mints - Peppermint

221. Issue of accurate contents
• Gums, mints do not have to meet high standards re
accuracy of content
• Some question whether you are getting 1 mg each
gum or mint
Opinion:
• Oral Science product being used in hospital oncology
programmes and seeking status under Canadian
Natural Health Product designation
• I would opt for this product for Xylitol source

222. Spiffies Wipes
Toxicity Issue?
• Each wipe contains 0.5 g xylitol
• Estimated absorption 0.25 g
• 3-5 applications/day i.e.0.75-1.25 g/day
• Everyday use is 0.2g/kg (assuming a 7 kg infant)
• Threshold level is 1-2 g/kg
• Safety factor 5-10
Spiffies now available in Canada through
DR Products at www.spiffies.com

223. Clinical Significance
Right now Xylitol seems to be most
appropriately considered an adjunct measure
for targeted individuals. It cannot be
recommended as a public health measure as
yet. Furthermore, carefully designed and
conducted studies are required to determine
what role it will ultimately play
Tweetman S, Current controversies-Is there merit? Adv Dent Res 21:48-52, 2009

224. ADA Report Recommendations
• Significant reduction of caries polyol gums vs. no gum
• Preventive effect xylitol highest vs. other polyols
• Benefit related to load mg/day
• Benefit related to chewing 10-20 minutes after meals
• Concern re choking kids less than 5 years
• Lozenges/tablets reduces coronal caries – low
certainty
• Encourage to suck lozenges to extend time in mouth
• Syrup under 2 years -insufficient evidence
• 5-8 gms/day divided doses
• Insufficient evidence xylitol under 5 years
• Insufficient evidence xylitol in toothpaste

225. Remineralization and Other Therapies
Povidone Iodine – Betadine
-potent antibacterial
-safe to swallow
-disrupts binding to biofilm

226. Povidone Iodine
• Applied in combination with Fl. Varnish
• Complementary to fluoride
• Disrupts binding of biofilm
• Can work up to 20-24 weeks
• Differing protocols supported by evidence
Milgrom AAPD 2009

227. Povidone Iodine Topical
• Used post-GA restoration suppresses MS levels over
90 days P<0.00001 Berkowitz et al 2009
• Safe to swallow, even for babies Milgrom 2009
• Kids tolerate re nausea and taste
• Contraindications
• New formulations in research

229. Povidone Iodine Results ECC
PVP-I + FV vs FV only 2.5-2.8 times over 1
year infants 12-30 mths
• New decay reduced 31%
Milgrom et al J Dent Child Dec 2011
PI + FV vs no tx q2M over 1 yr. infants 12-19 mths
• 91% disease-free vs 54%
Lopez Ped Dent 2002
PVP-I post GA at baseline, 6, 12 mths
• Reduced patients with new decay (small sample)
• Amin et al Ped Dent 2004
ADA Report Recommendations
Insufficient evidence iodine lowers decay

231. Anti-Bacterial Agents
Mechanism of Action:
Reduce Bacterial Levels in the Oral
Cavity
• Prevora
• Cervitec
• Povidone Iodine
• Chlorhexidine Mouth Rinses (Peridex)
• Triclosan

232. Chlorhexidine
• Now available in both rinse and
varnish
• Anti-bacterial and anti plaque
• Used for treatment of gingivitis
and caries
• Efficacy in very young
inconclusive
Zhang et al Eur J Oral Science 2006
Available as
•Cervitec Plus
•Chlorhexidine
•Thymol Plus

233. Cervitec Plus
• Used as cervical desensitizer and caries preventive
• Application to mothers q6m til baby 3 yrs
• caries in infants significantly lower
• Inhibition of MS transfer to baby to age 2
• Treatment of high risk infants q3m from 1 yr
• caries reduced but not if diet not also controlled
• Reduced caries development if none at baseline but no
improvement if caries at baseline
• Inhibition zones adjacent to placement
• Role for newly erupting molars followed by sealants?

234. Prevora
• CHX Varnish originally for root caries
• Studies on mother child being analyzed.
Report available soon
• Efficacy in xerostomia patients

235. ADA Report Recommendations CHX
10-40% CHX Varnish kids 4-18 yrs
Does not reduce incidence of caries-moderate
certainty
CHX-Thymol Varnish kids up to age 15
1:1 ratio varnish does not reduce incidence of caries
CHX Mouthrinse
0.05-0.12% rinse does not reduce incidence of coronal
caries
Insufficient Evidence
Efficacy of treatment of mothers post-partum on
incidence of caries in infants
Impression: Jury still out on this one

236. Remineralization and Other Therapies
Delmopinol Hydrochloride
• reductions in total cultivable plaque and salivary flora Hase
et al 1998
• inhibits glucan synthesis of MS in vitro Baehni 2003
• used currently largely for anti-gingivitis properties as mouth
rinse (Decapinol Mouthwash)

237. Remineralization and Other Therapies
Triclosan
• -broad spectrum antibacterial used in toothpaste
• -reduces supragingivial plaque
• -enhances anti-caries activity of fluoride
• -used widely in other health/body products
• -recent concerns re carcinogenic potential with probable
removal from products in future
ADA Report Recommendations: Insufficient evidence that it lowers
caries incidence

238. Pro Argin®
• Highly soluble arginine bicarbonate - amino acid
complex that binds to calcium carbonate
• This binds particles of calcium carbonate to
dentin and enamel
• Purpose: reduce dentinal hypersensitivity
• Contained in Colgate’s Sensitive Pro-Relief
desensitizing prophy paste.
• Anticaries benefit under study

239. Remineralization and Other Therapies
Arginine and Probiotics
Newer research with products on the market
ADA Report Comments:
• Arginine added to food or oral care products to
inhibit initiation and progression of caries and
promote remineralization
• Probiotics goal to promote healthier plaque
ecologies. Safety and Effectiveness not rigorously
tested
“In light of the state of development and the lack of
human research reports…not evaluated by the panel
Opinion: Not Ready for Prime Time

240. What is the Recipe?

241. Office + Home Therapy
Office Home
Toothpastes & Topical Application
• Topical Fluoride (gels and • Clinpro 5000 Toothpaste
foams) • ProArgin in Colgate
• MI Paste
• Fluoride Varnish • Prevident
• Anti-Microbial Therapy + Sugar Substitutes
• Xylitol
– Prevora
• Novamin
– Cervitec
Mouthwashes
• Oral Hygiene & Patient • Peridex
Motivation • Tricolsan Products
• Diet Counselling Gums & Mints
• Recaldent
• Ongoing Monitoring • Xylitol
Effective Plaque Removal with Brushing & Flossing

242. Does Remineralization
Work?

243. Case Study Remineralization
600
400
Canary Number
200
0
Initial 2 months 3 months 5 months
3M Vanish & Clinpro 5000 Toothpaste
Visit #1 Visit #2: Visit #3: Visit #4:
2 Months 3 Months 5 Months
ICDAS: 02 ICDAS: 02 ICDAS: 02 ICDAS: 02

248. Remineralization 5th and 7th Quads

249. Remineralization Case
Slides courtesy of Dr. Clive Friedman

250. Remineralization Case
Slides courtesy of Dr. Clive Friedman

253. Canary Numbers for This Case
Tooth October 2011 April 2012
M O D M O D
47 26 20
46 46 16 19 19
37 31 27 15 24
36 21 35 16 30

254. Does Remineralization Work?
Yes
But
You need to monitor and motivate
your patient

255. Remineralization + Monitoring
Essential components of any program:
• Need to monitor progress
• Need to record progress
• Need to be able to change therapy if
lesions increase in size
• Need to engage your patient
Bottom Line: Case Selection

256. Integration into
Clinical Practice

257. USCLS Codes and Descriptions
Code Description Fee
13601 – 13609 Topical application to Hard Tissue of Anti- 1 unit $34.10 + E
Microbial or Remineralization Agents 2 units $68.20 + E
12101 Fluoride Treatment (topical application) $16.90
12102 Fluoride Treatment $15.70
Supervised Self-administered brush in
12601 – 12602 Fluoride Custom Appliances $60.70 + lab
1321*, 1323* Oral Hygiene Instruction $31.00
(individual, group & re-instruction)
96103 Dispensing of Non-Emergency (fluorides etc.) No fee + E
04201 Test Analysis, Caries Susceptibility (technical $40.00 + lab
procedure only)
Bacteriological testing for determination of
caries susceptibility

258. Code 13601 Remineralization
• Designed for the topical application of fluoride
varnish and other agents in a dental office
• Introduced into the ODA Fee Guide in
September 2008 in response to symposium at
the IADR sponsored by the ODA
• Fee: $47.00 per 15 minute unit of time
• Can be done by hygienists or dental assistants
(under supervision of the dentist)

259. Office Integration
Recall or Specific Exam
Reassess 6 Months •Identify White Spots
•Assess Lesion •ICDAS or Measure
•ICDAS or Measure •Risk Assessment
•Apply Remineralization •Apply Remineralization
Therapy Therapy
•Dispense Home-Based •Oral Hygiene Instruction
Therapy •Provide Home-based Therapy
Reassess 3 Months
•Assess lesion
•ICDAS or Measure
•Apply
Remineralization
therapy
•Dispense Home-
based therapy

260. Remineralization + Monitoring
• Essential components of any program
• Need to monitor progress
• Need to record progress
• Need to be able to change therapy if
lesions increase in size
• Need to engage your patient

261. Early Childhood
Caries

262. Clinical Presentation: Early Lesions ECC
• Begins soon after dental
eruption
• Typically develops on smooth
surfaces
• If enamel not uniformly
white, patient is at risk
• Appear as chalky white
decalcification
• Most often starts on lingual
surfaces of maxillary incisors

264. Early Childhood Caries
Clinical Presentation
(Advancing)
• Virulent caries with rapid
progression
• Enamel chips away as
lesions advance
• Colour of caries indicates
speed of progression

265. Early Childhood Caries
Advanced Tooth Decay
photo Dr. Joanna Douglass, Smiles for Life

266. Facial Cellulitis
Infection spreading into surrounding tissues

267. Early Childhood Caries
% Population Age Author
4% Quebec children
Convenience sample of 301 12 – 24 month infants Veronneau et al
infants
1% US children
12 – 23 month Kasteet et al. 1996
representative sample of 654
17% US children
2 – 4 year olds Kaste et al. 1996
sample of 1,627
30% Cree population Quebec 12 – 24 month Veronneau et al. 2002
55% Inuit population of NWT 24 – 36 month Albert et al. 1998
87% Ojibway
sample 470 residents of Northern 24 – 48 months Lawrence 2008
Ontario
Prevalence of ECC in children under 4 years of age. DMFT / DMFS screening tool
ICDAS not used

268. Early Childhood Caries
Prevalence 0 - 5 years United States
• Decay rates dropped until 1990’s
• Rates now documented as increasing
2 - 5 year olds
24% in 1988 - 1994
28% in 1999 - 2004
• Wide variability with population groups
Dye et al, National Center for Health Statistics NHANES 2007

269. Early Childhood Caries
Lida et al 2007

270. Early Childhood Caries
Prevalence 0-5 Years British Columbia
– 64% inner city Vancouver sample
Szeto thesis 2004
– 11% community dental health (range 7.9-27.4%)
Bassett et al 1999
– 20.5% Vancouver low-income Vietnamese
over 18 mths Harrison et al 1997
* Surveys vary in sampling methods
* Children sampled not representative of population in general

271. Early Childhood Caries
Prevalence 0 - 5 Years Ontario
– 87% of First Nations sample Lawrence 2008
– 34% in Health Units Survey* OAPHD 2008
– 30% of Toronto 5-year olds 1999-2000* Leake 2001
– 25.1% in daycare community
Ottawa Public Health 2007-08*
* Survey under reports children sampled due to methods
* Children sampled not representative of population in general

272. Systemic Effects of Severe ECC
Malnourishment In A Population With Severe Early
Childhood Caries
Among the findings:
– 66% have normal weight, 18 % underweight
– 28% have haemoglobin levels below acceptable and 46% in the
low range of acceptable
– 51% have low albumin levels
– 77% have low ferritin
 Conclusion: Children with severe tooth decay have
borderline or low nourishment
Clarke et al 2006

273. Detrimental Health Effects Of ECC
• pain, infection, loss of function
• affects learning, communication, nutrition, sleep
• lower body weight
• chronic inflammation
• psychological impact
• lasting detrimental impact on the dentition

274. Not Just the Poor
National O.R. Stats
• Pediatric dental procedures #1 O.R. procedure with
longest waiting lists
CHEO Stats (Children’s Hospital of Eastern
Ontario)
• Waiting time for O.R. was 14 months
• Children over 5 years not eligible for care
London, ON Mall Exams
• 82 children under 20 months
• 32 with early signs of caries (ICDAS 1+2)
• 3 with S-ECC requiring sedation of GA
Dr. Clive Friedman

275. ECC – Other Aspects to Consider
• New approach needed
• Social determinants
• Role of physicians, nurses
• Motivational interviewing
• Role of dental public health
• ECC as predictor

276. The New Approach Needed for ECC
Quality Improvement
• Combine efforts of Health Care
professionals, patients, families, researchers,
payors, planners, educators
• Objective is improved outcomes, system
performance and professional development
• Ultimate objective is Disease Management
Ramos-Gomez F, Ng M Oct 2011

277. FIGURE 1 Child, family, and community influences on oral health outcomes of
children
Fisher-Owens, S. A. et al. Pediatrics 2007;120:e510-e520
Copyright ©2007 American Academy of Pediatrics

280. Smiles for Life Pocket Cards for Physicians

281. Smiles for Life Pocket Cards for Physicians

282. Principles of Motivational Interviewing
• Establish a therapeutic alliance
• Recognize that people value their
independence
• Ask questions, and listen
• Once 1-3 then advice, giving choices to
explore and a tailored course of action
• Once the patient/parent is receptive, MI
does not take long
Weinstein P, MI and Its Relationship to Risk Management and
Patient Counseling, Cal Dent Assoc J, Oct 2011

283. Models of Individual Oral Health
Promotion
Brickhouse T.H.
Virginia Commonwealth University
presented at AAPD Symposium October 2009

284. Evidence: Models of Individual Oral Health
Promotion
• Systematic review 2000-2007
• Database examined for articles evaluating effectiveness of health
behaviour models
• 32 studies
– 9 health education and clinical prevention studies – WEAK
– 3 counseling studies with varnish – STRONG
– 9 studies of model based interventions – MODERATE
– 11 studies of motivational interviewing – STRONG
• Yevlahova and Satur, Australia Dental Journal 2009

285. Evidence: Models of Individual Oral Health
Promotion
• Health Education
– Information and expert advice with passive patient
• Counseling
– Extremely specific and tailored to the patient, increased time and
expense
• Model based interventions
– Health Belief Model, Locus of Control, Self Efficacy, Attitudes
• Motivational Interviewing
– Trans-theoretical model of behaviour change focusing on personal
dynamics of change
– Patient centered style with sensitivity/empathy to patient’s social and
environmental circumstances
• Significant reductions in smoking, diabetes, obesity, substance abuse and oral
health

286. Motivational Interviewing
Success in dentistry
• Early childhood caries
•
• Harrison RL, Wong T. An oral health promotion program for
an urban minority population of preschool children.
Community Dent Oral Epidemiol, 2003 Oct;31(5):393-9

287. Dental Public Health
• Big picture reality – getting to the
populations
• Making connections
• Identifying high risk populations
• Individual evidence-based oral health
promotion
• Role of medical community

288. Dental Public Health Service Populations
Persons covered Persons covered Children <19 living
Province by social by social in poverty
assistance 1995 assistance 2003
BC 374,300 180,700 182,577
AB 113,200 57,800 132,806
SK 82,200 53,200 53,110
MN 85,200 59,900 67,540
from Quinonez C et al 2005

289. Ontario Perspective on Government Plan Coverage
Gap Coverage
• High needs, not high risk
– Low socioeconomic levels
– Disabled and their families
• Emphasis on basic or urgent treatment
with minimal emphasis on prevention
or education

290. Colorado Study
Hirsch et al. A simulation model for designing effective
interventions in early childhood caries. Prev Chronic Dis
2012;9:110219 CDC&P
• Projects 10-yr intervention costs and relative reductions in
cavity prevalence
• Interventions target 2-4 yr. olds
• Targeting high risk provides greatest return on investment
• Combined interventions have greatest potential for cavity
reduction
• All produce substantial reductions in repair costs; some save
more than their cost
Interventions Assessed
Fluoridation, Fluoride varnish, Bacterial transmission, Xylitol with
children, Secondary prevention, Motivational interviewing,
Combined interventions

291. Colorado Study
Preventive Therapy Caries Reduction Cost of Treatment
Water Fluoridation 25.4%
Fluoride Varnish 33% $16 per application
Bacterial Transmission
(Education, restorative 73% $100 per mother
treatment for mothers)
Xylitol (several simulation
44% - 77% $100 per child
models
Secondary Prevention
(follow-up care including 50% – 75% $242 per child
restorative procedures)
Motivational Interviewing 63%
Combining several
Combining several
interventions can produce a
therapies will create a
Combined Therapies smaller fraction of children with
cumulative &
cavities than can any of the single
complementary effect
interventions.