Preventive Dentistry

Mechanism of action

systemically and topically

Systemically

Ingested, or taken into the body during consumption of foods or beverages

Topically

Directly to the exposed surfaces of teeth erupted into the oral cavity

Maximum caries inhibiting effect includes

systemic exposure before eruption, topical fluoride throughout life

After eruption and throughout the life span of teeth, fluoride on the outer most surface of enamel is dependent on (topical/systemic)

Prevent demineralization, encourage remineralization

daily topical sources of fluoride

Post-eruption

continuous daily presence of fluoride can inhibit initiation and progression of dental caries

uptake is the most rapid during the 1st years after eruption

Uptake of fluoride is the most rapid during the __ years after eruption

1st

Fluoride in enamel

• Uptake of fluoride depends on the level and length of time exposed

• Hypomineralized enamel absorbs fluoride in greater quantities than healthy enamel

• Hydroxyapatite crystalline becomes fluorapatite

• Intact outer surface enamel has the greatest concentration

Mechanism of action of fluoride to bacteria

• Bacteriocidal to Strep Mutans:

-Bacteriostatic vs. Bacteriocidal?

-inhibits bacterial activity by inhibiting enolase

• Inhibits demineralization

• Facilitates remineralization due to formation of fluorapatite

Cariostatic benefits recap

Formation of fluorapatite crystals

Remineralization of enamel-Greatest concentration of fluoride occurs in the outermost surface layers of the enamel

Benefits are related to the number and frequency of fluoride treatments

Topical fluoride therapy

• Delivery Types:

-Rinses

-Dentifrices/toothpastes

-Gels

-Foams

-Varnish

Professional topical fluoride applications

• 2% Sodium Fluoride (NaF) gel or foam

• 1.23% acidulated phosphate fluoride (APF)

• 5% Sodium Fluoride (NaF) varnish

• Silver Diamine Fluoride (SDF)

2% Sodium Fluoride Foam

-Available as gel, foam, liquid, & varnish

Basic pH of 9.2

-Because there is an absence of taste, this type of fluoride usually has additive flavoring or sweeteners

1.23% Acidulated Phosphate Fluoride (APF) Gel

Available as a liquid, foam, or gel

Contains 12,300 ppm

Acidic pH of 3.5

Foam applications are widely accepted

by patients because of the pleasant taste

Silver diamine fluoride

-Antimicrobial

-Remineralizing

-Caries arresting

-SDF Information

Fluoride varnish

• Resin material is painted on the teeth

• Basic pH of 9.2

• Main ingredient?

• Sets up quickly when interacting with saliva

• Releases fluoride up to several hours after application

• Safe for young children under the age of 6

• Reduces demineralization around ortho brackets

Stannous fluoride

Liquid most common-Available in a powdered form in either bulk containers or capsules

An acidic solution which should be prepared just prior to use-Acidic pH of 2.4-2.8

Bitter or metallic taste

May be combined with glycerin to mask the adverse taste

Compare and contrast

Application of fluoride

In office:

• Fluoride trays

• Fluoride varnish with special applicator brush

• Brush on foam (can also use cotton applicator)

• Rinse

At home:

• Custom fluoride trays

• Toothpaste

• Rinse

Application of fluoride (how long?)

• 60 seconds for those patients whose fluoride treatment is either a maintenance or a preventative measure

• 4 minutes for those patients who have caries or potential carious activity

Application of fluoride precautions when administering treatments

• Minimal amount needed

• Upright patient position

• Use efficient suctioning

• Patient expectorates thoroughly on completion of the fluoride application

Application of foams/gels

Adequate size tray for the patient

Have patient rinse prior to the fluoride treatment

Tray remains in the patients mouth for 60 seconds to 4 minutes

Patient is instructed not to eat, drink, or rinse for 30 minutes following the treatment

Application of varnish

• Recommended primarily for children

• Contain 5% NaF

• Recommend repeating at 4–6 month intervals

• Dry teeth prior to painting on the varnish

• Patients should be instructed to avoid abrasive foods, hot foods and liquids and brushing teeth for approximately 24 hours (see manuf. Instructions)

• Do not use suction –varnish creates a clogged hose line

Application frequency

Following the initial fluoride therapy, patients should have a fluoride treatment at either a 3-,6-,9-, or 12-month interval depending on the caries status.

Patients at a low caries risk should have fluoride treatments every 6–12 months.

Other sources of fluoride

Prophylaxis paste

Mouthrinses (ACT, Biotene)- Recommended for patients with dry mouth, orthodontics, patients undergoing radiation/chemo, high caries risk (low potency and high frequency)

Prescription toothpastes (Control Rx, Prevident)

Take-home gels

Fluoride-releasing dental materials (i.e., sealants and composites)

Multiple fluoride therapy

• No single fluoride treatment provides total protection against dental caries

• Fluoride combination programs use a fluoride-containing prophylactic paste and a topically applied fluoride solution

• Systemic fluoride can be included

• Results in overall caries reduction of 75%

MI Paste - Remineralizing

Not a fluoride:

• MI Paste Plus does contain a small amount of fluoride (900ppm), otherwise same formula as MI Paste

• Casein (milk protein) and Recaldent are active ingredients: Do not use in a patient with an allergy to milk proteins BUT Lactose intolerant patients are okay

• Recaldent = calcium and phosphate; these minerals stabilize acid, reduce tooth sensitivity, and strengthen tooth enamel

• Minerals released when saliva comes into contact

Acute fluoride toxicity

results from large doses of fluoride over a short period of time

symptoms:

•Nausea and vomiting

•Increased salivation

•Stomach cramping

•Convulsions

Acute fluoride toxicity treatment

• Immediate treatment

• Induced vomiting

Protection of the stomach by binding fluoride with orally administered calcium/aluminum preparations:

• MILK!

• Lime water or Maalox

Maintenance of blood calcium levels with intravenous calcium

Chronic toxicity

skeletal fluorosis

dental fluorosis

Purpose of toothbrushing

Removal of plaque biofilm and disturbance of its re-formation (to control and prevent periodontal diseases and carious lesions)

Removal of food, debris, and stain

Stimulation of the gingival tissues (remove biofilm from gingiva as well)

Application of a dentifrice containing specific ingredients to address caries, periodontal disease, or sensitivity

Tooth brush history

Chew sticks (siwak) found in Egyptian tombs in 3500 BC (1st oral hygiene care); twigs have antimicrobial properties (oils and tannins) and freshen breath

First toothbrush invented in China (1728); 1st modern day replica of a toothbrush

• Handle made of bone

• Bristles made of wild boar hair

Early 1900’s, first toothbrush was patented

• Switched from natural bristles to nylon bristles during WWI (able to change size and shape of bristles)

1916-Dr. Alfred C. Fones, founder of dental hygiene, wrote Mouth Hygiene; How to teach school children how to brush; public health out-reach program

• Developed Fones brushing method

• 1939-first power toothbrush was developed in Switzerland (Broxodent; had a cord)

1960s-US was introduced to it

1980s-electrical toothbrushes hit the market in the US

The first oral hygiene care product is dated all the back to ___ BC

3500

1st toothbrush was invented in China in

1728

The first toothbrush was patented in the early

1900s

In 1916, Dr. Alfred C. Fones wrote Mouth Hygiene and developed the __ brushing method

Fones

In 1939, the 1st power toothbrush was developed in Switzerland and it was called the

Broxodent

The US was introduced to powered toothbrushes in the

1960s

The electrical toothbrushes hit the US market in

1980s

Manual toothbrush design

Head-working end, has bristles

Handle-part grasped; angulations can help ergonomic graso

Shank-connects head and hanlde

Sizes-large, medium small

Texture (hardness, firmness, stiffness) of the bristle-hard, medium soft, extra soft

Little evidence of the most effective characteristics of a toothbrush, so clinical expertise and individual patient needs should be considered (true/false)

true

When bristles are bunched together they are called

tufts

Which textures of the bristle is preferred? (hard, medium soft, extra-soft)

soft, extra soft

Why is medium and hard not recommended for bristle texture

can cause abrasions

What we recommend for manual toothbrush designs depends on

patient’s needs

Ex) small mouth need a small head or orthodontic patients needs a specific head

Manual toothbrush design Lateral Basic Profiles

Concave

Convex

Multilevel

Flat

Concave

short bristles in the middle

better for facial surfaces

Convex

long bristles in the middle

better for lingual surfaces

Multilevel

multi lengths=improved cleaning

effective in interproximal surfaces compared to flat

Flat

same bristle length

(Nylon/natural) bristles are superior

Nylon

Texture refers to

hardness, firmness, and stiffness of the bristle

Shorter bristles means the bristles are (stiffer/softer) and (more flexible/less flexible)

stiffer, less flexible

Nylon

• Superior to natural hog bristles

• Flex 10x more often before breaking

• Do not split

• Do not abrade

• Easier to clean

• Create Texture (End-rounding)-due to heat treatment; no sharp edges which decreases gingival trauma

Can be standardize (shape and stiffness of the bristles)

End rounding bristles are the result of ___ treatment

heat

Toothbrush handles

Provides comfort and compliance

Important aspects:

• Easy to hold

• Does not slip/rotate during use

• No sharp corners/projections

Durable

Moisture resistant (no mold)

Angles and curves may help reach hard to reach areas

Larger handle best suited for patients with limited dexterity which include: older patients, children, those with a disability

Note) can place a tennis ball at the end of a handle for an easier grip

Tooth selection is based on

Patient dexterity (larger handle?)

Gingival condition (slimmer bristle for subgingival? Bulbous tissue, receding gums/soft?)

Specific patient needs (powered over manual; size of mouth and handle)

Bristle Stiffness:

• Types of bristles/filaments

• Diameter

• Length

• Number of bristles/filament

Soft and extra soft are the golden rule!!!

Soft and extra soft bristles (are/aren’t) the golden rule

are

Bass Method

• Acceptable for all patients

• Periodontal Involvement

• Toothbrush bristles are angled apically at a 45-degree angle to the long axis of the tooth

• Filaments subgingival

• Jiggle with short horizontal strokes

• 2–3 teeth at a time

Rolling Method

• Most appropriate for children

• Bristles positioned apically along the long axis of the tooth

• Bristles rolled against the tooth from the apical position toward the occlusal plane

• Repeat several times

Stillman Method

• Bristles positioned apically along the long axis of the tooth

• Edge of the brush head touches the facial or lingual aspect of the tooth

• Brush is slightly rotated at a 45-degree angle and vibrated over the crown

• Massage and stimulate gingiva while cleansing cervical areas

Charters Method

• Used to clean around appliances

• Bristles placed at a 45-degree angle toward the occlusal or incisal surface of the tooth

• Bristles should touch at the junction of the free gingival margin and tooth

• Circular vibratory motion is used

Fones method

• Used mainly by young children

• Teeth are clenched, brush is placed inside cheeks

• Brush moved in circular motions

• Can be damaging if done too vigorously

Leonard method

• Toothbrush is placed at a 90-degree angle to the long axis of the tooth

• Moved in a vertical, vigorous motion up and down the teeth

Horizontal method

• Teeth are edge to edge

• Brush maintains a 90-degree angle to long axis of tooth

• Horizontal strokes

• Can cause toothbrush abrasion

Smith Method

• Physiologic technique –follows the pattern of food during mastication

• Bristles are positioned directly onto the occlusal surface

• Brush is moved back and forth

• Recommends a few gentle horizontal strokes to clean the sulcus areas near furcations

Scrub technique

• Combination of horizontal, vertical, and circular strokes

• Incorporates vibration movements in certain areas

• Not an appropriate method

Which technique is not recommended for brushing?

Scrub

Modified brushing method

Integrates a rolling stroke after use of the vibratory motion

Brush position maintained after the completion of the original method's stroke

Bristles then rolled coronally over the gingiva and teeth

Used with any and all of the previous methods

Summary of methods chart

Powered toothbrushes

electric or battery operated

brush movements range from 3,800 to 7,600 per minute

Main pattern of movements: oscillation, reciprocation, rotational

Oscillation

bristles move in a constant back and forth motion

Reciprocation

up and down or back and forth movement

Rotational

circular pattern

Powered tooth brush movement

Sonic-sound waves that disrupt/break up biofilm

Ultrasonic-higher electrical frequency that disrupt biofilm

Ionic-temporarily reverse negative charge to a positive charge on a tooth that will help break up biofilm

Advantages of powered toothbrushes

• Helpful for

Parents who brush their children's teeth

• Physically or developmentally disabled

• Elderly or arthritic

• Dexterity issues (larger handle is easier to grasp)

Patients with a history of failed attempts at more traditional biofilm removal methods

Orthodontic patients

Patients undergoing complex restorative and prosthodontic treatment

Aggressive brushers

Caretaker must brush another person’s teeth

Faster brush movements compared to a manual brushing movements (true/false)

true

Powered toothbrushes should use __ pressure

light

lightly press bristles, don't press too hard since it may cause gingival recession some powered toothbrushes have sensors that warn you if there's excessive pressure

Time and frequency

2 minutes twice a day

Factors that can extend brushing time/frequency:

-Orthodontics brush longer/frequently

-Patients with higher sugar intake

How long should be brush?

2 minutes

How often should we brush?

Twice a day

Factors that extend brushing time and frequency

Orthodontics brush longer/frequently

Patients with higher sugar intake

Supplemental brushing (Tongue Scaper)

• Remove bacteria from tongue that the toothbrush may not be able to reach

Remove bacteria that induce halitosis (anaerobic bacteria that produce sulfur products)

ADA seal of acceptance

Marketing tool

Expensive process (larger corporations may have more compared to smaller companies)

Clinical assessment of toothbrushing

• Goal: Remove dental plaque biofilm from teeth without damaging teeth and surrounding structures.

• Prevent toothbrush abrasion

• Evaluation: Disclosing solution/tablets

Tablets may be taken home by patients! Chew one before brushing to see where the biofilm is (pink), they can brush and then take another tablet to evaluation brushing effectiveness

Toothbrush care

Rinse brush after every use

Store in a cool dry place (prevent moisture and therefore mildew and mold)

Replace toothbrush every 2-3 months

Can share if each person has a different brush head

Discard toothbrush after a contagious sickness

•Strep throat, flu, etc.

We can share manual toothbrushes (true/false)

false, biofilm is contagious

Ultimate goal for toothbrushing

remove dental plaque biofilm from teeth without damaging teeth and surrounding structures

You should replace a toothbrush every __ months unless the bristles worn out before then

2-3 months

Powered toothbrushes (can/can’t) be shared

can due to people having different brush heads

ADHA definition

The father of dental hygiene is

Dr. Alfred C. Fones (1900s)

The first licensed dentist hygienist is

Irene Newman

Events from 1910-1919

• First dental hygiene school in Connecticut

• First licensed dental hygienist, Irene Newman

• Hygienists were working in public school settings

Timeline cont.

Timeline cont. 2

Basic roles of a DH

Education

Assessment

Diagnosis

Prevention

Nonsurgical therapy

Research

Administration

Entrepreneur

Education and prevention is the primary role of a dental hygienist (true/false)

true

Dental hygienists support oral health through their work in many settings including

general and specialty dental practices

public health programs

research centers

educational institutions

hospital and residential care facilities

federal programs, including the military

dental corporate industries

Professional roles of the DH

Clinician

Corporate

Public health

Research

Educator

Administrator

Entrepreneur