Dental Caries Dental Caries in the New Millennium:in the New Millennium:Diagnosis and TreatmentDiagnosis and Treatmentgg

Not a problem!Not a problem!Not a problem!Not a problem!

SSubjectiveubjectivejjOObjectivebjectiveOObjectivebjectiveAAAAssessmentssessmentPPlanlan

Caries Risk AssessmentCaries Risk Assessment

Caries versus CavitiesCaries versus CavitiesCaries versus CavitiesCaries versus CavitiesCaries is the diseaseCaries is the disease Cavities are theCavities are theCaries is the disease Caries is the disease process initiated process initiated

d i l bd i l b

Cavities are the Cavities are the result of the caries result of the caries didipredominately by predominately by

mutans mutans StreptococciStreptococcidisease processdisease process

Caries to CavitiesCaries to CavitiesCaries to CavitiesCaries to Cavities

1. Healthy tooth2. White spot lesion (caries process)3. Caries process with cavitation4. Restoration with caries process and cavitation

C i d d i li i d d i d l5. Continued demineralization and undermined enamel6. Fractured tooth

High Risk Factors from History High Risk Factors from History –– KidsKids

Systemic diseasesSystemic diseasesImmune compromiseImmune compromiseM h b hiM h b hi

Bottles and sippy cups with Bottles and sippy cups with milk and/or sugary liquidsmilk and/or sugary liquids

Mouth breathingMouth breathingGums bleed when brushingGums bleed when brushingSweetened medicinesSweetened medicines

High intake of fermentable High intake of fermentable high density carbohydrates high density carbohydrates between mealsbetween meals

Family members with cavitiesFamily members with cavitiesInsufficient fluoride in Insufficient fluoride in

fl id t dfl id t d

Raisins, cereals, sugar treats Raisins, cereals, sugar treats between meals between meals

nonnon--fluoridated areasfluoridated areasDeep unsealed teethDeep unsealed teeth

History of ECCHistory of ECCHistory of fillingsHistory of fillingsI l d l i iI l d l i iIrregular dental visitsIrregular dental visits

High Risk Factors from History High Risk Factors from History –– AdultsAdultsg yg y

Systemic diseasesSystemic diseases DiseaseDiseaseyyImmune compromiseImmune compromiseMouth breathingMouth breathingG bl d h b hiG bl d h b hi

Poor dexterityPoor dexterityInadequate fluoride sseInadequate fluoride sseF i k fF i k fGums bleed when brushingGums bleed when brushing

Orthodontic appliancesOrthodontic appliancesWhite spot lesions orWhite spot lesions or

Frequent intake of Frequent intake of fermentable high density fermentable high density carbohydratescarbohydratesWhite spot lesions or White spot lesions or

incipient lesions on xincipient lesions on x--raysraysSporadic dental visitsSporadic dental visitsF ili iF ili i

More than two cavities in the More than two cavities in the last year or active caries.last year or active caries.Use of smokeless tobaccoUse of smokeless tobaccoFailing restorationsFailing restorations

High caries rate in family High caries rate in family membersmembers

Use o s o e ess ob ccoUse o s o e ess ob ccoXerostomia by itself or with Xerostomia by itself or with exposed root surfacesexposed root surfacesR di i hR di i hRadiation therapyRadiation therapy

Department of CariologyDepartment of CariologyDepartment of CariologyDepartment of CariologyUniversity of MalmöUniversity of Malmö

CariogramCariogramggwww.db.od.mah.se/car/cariogram/cariograminfo.htmlwww.db.od.mah.se/car/cariogram/cariograminfo.html

Application

Caries Risk AssessmentCaries Risk AssessmentCaries Risk AssessmentCaries Risk AssessmentLevel 1Level 1 –– Inactive / No DiseaseInactive / No DiseaseLevel 1 Level 1 Inactive / No DiseaseInactive / No Disease

(Caries (Caries --)) (Cavities (Cavities ––))

L l 2L l 2 PP M if DiM if DiLevel 2 Level 2 –– PostPost--Manifest DiseaseManifest Disease(Caries (Caries --)) (Cavities +)(Cavities +)

Level 3 Level 3 –– PrePre--Manifest DiseaseManifest Disease(Caries +)(Caries +) (Cavities (Cavities ––))

Level 4 Level 4 –– Manifest DiseaseManifest Disease(Caries +)(Caries +) (Cavities +)(Cavities +)( )( ) ( )( )

Caries TreatmentCaries Treatment

Surgical ModelSurgical ModelSurgical ModelSurgical ModelversusversusANDAND

Medical ModelMedical ModelMedical ModelMedical Model

Surgical ModelSurgical ModelSurgical ModelSurgical ModelDiagnose earlyDiagnose earlyDiagnose earlyDiagnose earlyMinimum intervention dentistryMinimum intervention dentistryyyTreatment of cavitiesTreatment of cavitiesTreatment of secondary cavitiesTreatment of secondary cavitiesDo what you have to doDo what you have to doDo what you have to doDo what you have to do

Medical ModelMedical ModelMedical ModelMedical ModelDiagnose earlyDiagnose earlyDiagnose earlyDiagnose earlyPrevention and therapeutics are active Prevention and therapeutics are active and linkedand linkedTreatment of cariesTreatment of cariesTreatment of cariesTreatment of cariesCan remineralize lesions up to Can remineralize lesions up to ⅓⅓ into into d i if i id i if i identin if no cavitationdentin if no cavitationTreatment of secondary cariesTreatment of secondary cariesyy

Medical ModelMedical ModelDiagnosis

C i C iCaries+

Cavities + Cavities -

Caries -

Cavities -Cavities +L3

Treat Caries

Treat Cavities

Cavities Cavities Cavities Cavities

L1

L2

L3

L4

L4

Treat Cavities

Maintenance Home and

L4

Professional

Health

Adapted from A Comprehensive Review of Pediatric Dentistry ManualSan Diego, CA September 2002.

Examination and Re-evaluation Schedule

InitialInitial

VisitVisit

33

MonthsMonths

66

MonthsMonths

99

MonthsMonths

1212

MonthsMonths

Level 1Level 1 Exam, xExam, x--rays, etc.rays, etc. Possible recare Possible recare Recare apptRecare appt,, y ,y ,apptappt

pppp

ADA CodeADA Code D0150D0150 D0120D0120 D0150D0150

Level 2Level 2 Exam, xExam, x--rays, etc. rays, etc. Recare appt, Recare appt, Recare apptRecare apptTreat cavities then Treat cavities then

B/TG/FVB/TG/FVxx--raysrays

ADA CodeADA Code D0150D0150 D0120D0120 D0150D0150

L l 3L l 3 EE tt B/TG/FVB/TG/FV R pptR ppt B/TG/FVB/TG/FV R pptR pptLevel 3Level 3 Exam, xExam, x--rays, etc. rays, etc. B/TG/FV full mouthB/TG/FV full mouth

B/TG/FVB/TG/FV Recare appt, xRecare appt, x--rays rays B/TG/FVB/TG/FV

B/TG/FVB/TG/FV Recare appt, xRecare appt, x--rays rays B/TG/FVB/TG/FV

ADA CodeADA Code D0150D0150 D0170D0170 D0120D0120 D0170D0170 D0150D0150

Level 4Level 4 Exam xExam x--rays etcrays etc B/TG/FVB/TG/FV Recare appt xRecare appt x--raysrays B/TG/FVB/TG/FV Recare appt xRecare appt x--raysraysLevel 4Level 4 Exam, xExam, x rays, etc. rays, etc. Treat cavities then Treat cavities then

B/TG/FVB/TG/FV

B/TG/FVB/TG/FV Recare appt, xRecare appt, x rays rays B/TG/FVB/TG/FV

B/TG/FVB/TG/FV Recare appt, xRecare appt, x rays rays B/TG/FVB/TG/FV

ADA CodeADA Code D0150D0150 D0170D0170 D0120D0120 D0170D0170 D0150D0150

B = Betadine TG = Xylitol Tooth Gel FV = Fluoride Varnish

Medical ModelMedical ModelMedical ModelMedical Model

Adjunctive TestsAdjunctive Tests

Oral pH TestingOral pH TestingOral pH TestingOral pH Testing

Caries Risk TestsCaries Risk Tests –– Bacterial CountsBacterial CountsCaries Risk Tests Caries Risk Tests Bacterial CountsBacterial Counts

DentocultDentocult®® SMSMDentocultDentocult SMSMLow sensitivityLow sensitivity –– does not identify truedoes not identify trueLow sensitivity Low sensitivity –– does not identify true does not identify true positives wellpositives wellGood specificity Good specificity –– identifies low ms identifies low ms countscountsHelpful in initial risk assessment and Helpful in initial risk assessment and monitoring progress at reducing msmonitoring progress at reducing msmonitoring progress at reducing ms monitoring progress at reducing ms countscounts

DentocultDentocult®® LBLBDentocultDentocult LBLBNot as useful as DentocultNot as useful as Dentocult®® SMSMNot as useful as DentocultNot as useful as Dentocult SMSMMay aid in understanding greater acid May aid in understanding greater acid y g gy g gproduction as production as LactobacilliLactobacilli can survive in can survive in and produce acidsand produce acidsand produce acidsand produce acids

Caries Risk TestsCaries Risk TestsCaries Risk Tests Caries Risk Tests ATP BioluminescenceATP Bioluminescence

ATP BioluminescenceATP BioluminescenceATP BioluminescenceATP Bioluminescence

Initially developed as a test to assureInitially developed as a test to assureInitially developed as a test to assure Initially developed as a test to assure clean (bacteriaclean (bacteria--free) surfaces in free) surfaces in industryindustryATP combines with reagent toATP combines with reagent toATP combines with reagent to ATP combines with reagent to produce light (bioluminescence)produce light (bioluminescence)

ATP BioluminescenceATP BioluminescenceATP BioluminescenceATP Bioluminescence

All living organisms contain varyingAll living organisms contain varyingAll living organisms contain varying All living organisms contain varying amounts of ATPamounts of ATPAcidAcid--producing bacteria contain 100X producing bacteria contain 100X more ATP than bacteria that do notmore ATP than bacteria that do notmore ATP than bacteria that do not more ATP than bacteria that do not produce acidsproduce acidsReported as RLUs (relative light units)Reported as RLUs (relative light units)

Caries Risk TestsCaries Risk TestsCaries Risk Tests Caries Risk Tests RealReal--time PCRtime PCR

RealReal--time PCRtime PCRRealReal time PCRtime PCR

PCR assay specific forPCR assay specific for StreptococcusStreptococcusPCR assay specific for PCR assay specific for Streptococcus Streptococcus mutansmutansVisible marker positive if >500,000 Visible marker positive if >500,000 CFUCFUCFUCFU

Medical ModelMedical ModelMedical ModelMedical Model

Treatment Procedures and ProtocolsTreatment Procedures and Protocols

XylitolXylitolXylitolXylitol

XylitolXylitolXylitolXylitolGum (1g)Gum (1g) chew 2chew 2 3 pieces for 53 pieces for 5Gum (1g) Gum (1g) –– chew 2chew 2--3 pieces for 5 3 pieces for 5 minutes 5 times a dayminutes 5 times a dayMints (1g) Mints (1g) –– dissolve 2dissolve 2--3 pieces 5 3 pieces 5 times a daytimes a daytimes a daytimes a day1212--16 grams total per day16 grams total per dayg p yg p yInfant tooth gel Infant tooth gel –– apply to teeth 2apply to teeth 2--3 3 i di dtimes a daytimes a day

Xylitol StudiesXylitol Studies

Caries prevention by xylitol compared to a control group

% Reduction in Caries for Xylitol vs. Control

-40-30-20-10

0

90-80-70-60-50

0

-90

Turku 1

Turku 2

Soviet

Union

nch Poly

nesia

Hungary

Mon

treal

Ylivies

kaBeli

zeStan

n Cree

kDay

tonEsto

nia

SFren

c S

“Xylitol is only one part of a “Xylitol is only one part of a multiple intervention approach for multiple intervention approach for the prevention of dental caries the prevention of dental caries along with fluoride, chlorhexidine, along with fluoride, chlorhexidine, dental sealants, mechanical dental sealants, mechanical plaque removal, and regular plaque removal, and regular ggprofessional care.”professional care.”

John Peldyak DMDJohn Peldyak DMDJohn Peldyak DMDJohn Peldyak DMDXylitol Sweeten Your SmileXylitol Sweeten Your Smile

Advanced Developments, Inc.Advanced Developments, Inc.Mt. Pleasant, MIMt. Pleasant, MI

Properties of XylitolProperties of XylitolProperties of XylitolProperties of XylitolF l C H OFormula C5H12O5

Relative sweetness Equal to sucroseRelative sweetness Equal to sucrose

Glycemic index 7y

5%: 5.6 pH in water 10%: 5.5

40%: 5.4

Xylitol is:Xylitol is:Xylitol is:Xylitol is:NonNon cariogeniccariogenicNonNon--cariogeniccariogenicDoes not contribute to the disease processDoes not contribute to the disease process

CariostaticCariostaticThe disease process does not occur in the presence of The disease process does not occur in the presence of d s s p c ss d s cc p s cd s s p c ss d s cc p s cxylitolxylitol

AntiAnti cariogeniccariogenicAntiAnti--cariogeniccariogenicThe disease process may be reversed by appropriate The disease process may be reversed by appropriate exposure to xylitolexposure to xylitolexposure to xylitolexposure to xylitol

Turku Sugar StudyTurku Sugar StudyTurku Sugar StudyTurku Sugar StudySummarySummary

TwoTwo--year clinical trial at Turku University (Finland) year clinical trial at Turku University (Finland) to determine impact of xylitol as a complete to determine impact of xylitol as a complete

b i f hb i f hsubstitute for other sugarssubstitute for other sugarsMethod:Method:R d l i i i hR d l i i i hRandomly assign participants to three groupsRandomly assign participants to three groups

One to eat foods sweetened with sucroseOne to eat foods sweetened with sucroseO t t f d t d ith f tO t t f d t d ith f tOne to eat foods sweetened with fructoseOne to eat foods sweetened with fructoseOne to eat foods sweetened with xylitolOne to eat foods sweetened with xylitol

Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar studies: V. Acta Odontol Scand 1975; 33 (suppl 70)

Ch i DMFSChange in DMFS

8

4

6

8

crem

ent

0

2

4

DFM

S In

c

0Sucrose Fructose Xylitol

D

Scheinin A, Mäkinen KK, Ylitalo K. Turku sugar studies: V. Acta Od t l S d 1975 33 ( l 70)Odontol Scand 1975; 33 (suppl 70)

Belize Chewing Gum StudyBelize Chewing Gum Studyg yg ySummarySummary

2424--month doublemonth double--blind study of 510 6blind study of 510 6--yearyear--old children to old children to determine the effect of xylitol on the rehardening of dentin determine the effect of xylitol on the rehardening of dentin lesions in the primary dentitionlesions in the primary dentition

MethodMethodMethodMethodRandomly assigned subjects to 7 groups and provide xylitol, Randomly assigned subjects to 7 groups and provide xylitol, sorbitol, xylitolsorbitol, xylitol--sorbitol mixture and a control group.sorbitol mixture and a control group., y, y g pg pRegular supervision by school teachers for 200 daysRegular supervision by school teachers for 200 daysInstructions for use on nonInstructions for use on non--school daysschool daysEvaluate rehardening process of caries lesionsEvaluate rehardening process of caries lesions

Mäkinen KK, Mäkinen PL, Pape HR. Stabilization of rampant caries: polyol gums p p p gand arrest of dentine caries in two long-term cohort studies in young subjects. Int Dent J 1995; 45: 93-107

Change in DMFSChange in DMFS

8t

4

6

crem

ent

0

2

DM

FS In

c

-2 No Gum SugarGum

SorbitolGum

X/S Gum XylitolGum

D

Mäkinen KK, Mäkinen PL, Pape HR. Stabilization of rampant caries: polyol gums and arrest of dentine caries in two long-term cohort studies in young subjects. Int Dent J 1995; 45: 93-107

Before and After PhotosBefore and After PhotosBefore and After PhotosBefore and After PhotosFrom the office ofFrom the office ofFrom the office ofFrom the office of

Russ Misner, DDS and Larry Bybee, DDSRuss Misner, DDS and Larry Bybee, DDSKiDDS DentalKiDDS Dental

716 Yellowstone716 Yellowstone716 Yellowstone716 YellowstonePocatello, Idaho 83210Pocatello, Idaho 83210

208208--478478--54375437infor@kiddsdental cominfor@kiddsdental cominfor@kiddsdental.cominfor@kiddsdental.com

100% Xylitol Gum Only100% Xylitol Gum Only100% Xylitol Gum Only100% Xylitol Gum Only

Before 1 Week

100% Xylitol Gum 100% Xylitol Gum yyand 0.12% Chlorhexidineand 0.12% Chlorhexidine

Before 3 Months

Xylitol Reduces Bacterial RegrowthXylitol Reduces Bacterial RegrowthAfter Oral DisinfectionAfter Oral Disinfection

100

80

100

Xylitol

Sorbitol

Pl bevel

s (%

)ev

els

(%)

40

60 Placebo

Bac

teri

al L

eB

acte

rial

Le

0

20

Mea

n B

Mea

n B

Hild br dt GH Sp rk BS M i t i i t t pt i ppr i

Time Since Oral Disinfection (Months)Time Since Oral Disinfection (Months)

1100 22 33

Hildebrandt GH, Sparks BS. Maintaining mutans streptococci suppression with xylitol chewing gum. J Am Dent Assoc 2000; 131: 909-916

FluorideFluorideFluorideFluoride

FluorideFluorideFluorideFluorideSystemicSystemicSystemicSystemicToothpasteToothpasteppRinseRinseFluoride varnishFluoride varnish1 1% neutral sodium fluoride gel1 1% neutral sodium fluoride gel1.1% neutral sodium fluoride gel1.1% neutral sodium fluoride gel

Fluoride Toothpaste for ChildrenFluoride Toothpaste for ChildrenFluoride Toothpaste for ChildrenFluoride Toothpaste for Children

Under age 2, waterUnder age 2, waterUnder age 2, water Under age 2, water only only Small, peaSmall, pea--sized sized , p, pamount beginning at amount beginning at age 2age 2Supervised use under Supervised use under age 8 yearsage 8 years

Fluoride VarnishFluoride VarnishFluoride VarnishFluoride Varnish2500 ppm fluoride2500 ppm fluoride2500 ppm fluoride2500 ppm fluorideCopal varnishCopal varnishppSets in contact with moistureSets in contact with moistureWill initially discolor teeth (~24 hours)Will initially discolor teeth (~24 hours)

Fluoride Varnish InstructionsFluoride Varnish InstructionsFluoride Varnish InstructionsFluoride Varnish InstructionsNo eating for the next hourNo eating for the next hourNo eating for the next hourNo eating for the next hourEat only soft foods at the next mealEat only soft foods at the next mealyyDo not eat sticky foods for 24 hoursDo not eat sticky foods for 24 hoursDo not brush teeth for 24 hoursDo not brush teeth for 24 hours

Oral AntimicrobialsOral AntimicrobialsOral AntimicrobialsOral AntimicrobialsPovidonePovidone iodine (Betadine) 10% (B)iodine (Betadine) 10% (B)PovidonePovidone--iodine (Betadine) 10% (B) iodine (Betadine) 10% (B) Chlorhexidine 0.12 % (CHX)Chlorhexidine 0.12 % (CHX)Carbamide peroxide 10Carbamide peroxide 10--20 % (CP)20 % (CP)

LongLong--term use of oral antimicrobials should be term use of oral antimicrobials should be avoided as it may be possible that after exposureavoided as it may be possible that after exposureavoided, as it may be possible that after exposure avoided, as it may be possible that after exposure the oral flora may develop resistance to these just the oral flora may develop resistance to these just as other microas other micro--organisms have done withorganisms have done withas other microas other micro organisms have done with organisms have done with antibiotics.antibiotics.

PovidonePovidone--iodine Protocol iodine Protocol f L2 L3 d L4f L2 L3 d L4for L2, L3 and L4for L2, L3 and L4

All age groupsAll age groupsTreat cavity preparation at the time of the procedure Treat cavity preparation at the time of the procedure using povidoneusing povidone--iodine for toilet of cavityiodine for toilet of cavityT t th d t i hi h th dT t th d t i hi h th dTreat the quadrant in which the procedure was Treat the quadrant in which the procedure was performed with povidoneperformed with povidone--iodineiodineAt completion of all restorative procedures treat theAt completion of all restorative procedures treat theAt completion of all restorative procedures treat the At completion of all restorative procedures treat the entire mouth with povidoneentire mouth with povidone--iodine, xylitol tooth gel iodine, xylitol tooth gel and fluoride varnishand fluoride varnishIf feasible have fluoride varnish applied an 2 additional If feasible have fluoride varnish applied an 2 additional times in a 10 day periodtimes in a 10 day period

Note: This is an offNote: This is an off--label use for povidonelabel use for povidone--iodine.iodine.DenBesten P, Berkowitz R.. Early childhood caries: An overview with reference to our experience in DenBesten P, Berkowitz R.. Early childhood caries: An overview with reference to our experience in California. California. J California Dent AssocJ California Dent Assoc 2003; 31: 1392003; 31: 139--143143

PovidonePovidone--iodine Protocol (Continued)iodine Protocol (Continued)ff 3 d 43 d 4for for L3 and L4L3 and L4

Apply povidoneApply povidone--iodine, xylitol tooth gel and fluoride iodine, xylitol tooth gel and fluoride varnish every 3 months for a two year period or until varnish every 3 months for a two year period or until y y py y pyou feel confident that the patient is following through you feel confident that the patient is following through with the xylitol program and you have a negative CRT.with the xylitol program and you have a negative CRT.

Note: This is an offNote: This is an off--label use for povidonelabel use for povidone--iodine.iodine.DenBesten P, Berkowitz R.. Early childhood caries: An overview with reference toDenBesten P, Berkowitz R.. Early childhood caries: An overview with reference toDenBesten P, Berkowitz R.. Early childhood caries: An overview with reference to DenBesten P, Berkowitz R.. Early childhood caries: An overview with reference to our experience in California. our experience in California. J California Dent AssocJ California Dent Assoc 2003; 31: 1392003; 31: 139--143143

Chlorhexidine Rinse ProtocolChlorhexidine Rinse Protocolf L3 d L4f L3 d L4for L3 and L4:for L3 and L4:

Age 6 and olderAge 6 and olderAge 6 and olderAge 6 and olderRinse with ½ ounce once daily at bedtime for 14 daysRinse with ½ ounce once daily at bedtime for 14 daysRepeat rinse cycle in 2 monthsRepeat rinse cycle in 2 monthsRepeat rinse cycle in 2 monthsRepeat rinse cycle in 2 monthsMust be done 30 minutes after brushing, if patient is Must be done 30 minutes after brushing, if patient is using a toothpaste containing sodium lauryl sulfateusing a toothpaste containing sodium lauryl sulfateusing a toothpaste containing sodium lauryl sulfateusing a toothpaste containing sodium lauryl sulfateInstitute a periodic fluoride varnish programInstitute a periodic fluoride varnish programMaintain a xylitol protocolMaintain a xylitol protocolMaintain a xylitol protocolMaintain a xylitol protocolFollow up with a CRT in 12 weeksFollow up with a CRT in 12 weeks

Carbamide Peroxide Protocol Carbamide Peroxide Protocol f L3 d L4f L3 d L4for L3 and L4for L3 and L4

Age 14 and olderAge 14 and olderAge 14 and olderAge 14 and olderApply via custom traysApply via custom traysFor disinfection need only be applied once as per usualFor disinfection need only be applied once as per usualFor disinfection, need only be applied once as per usual For disinfection, need only be applied once as per usual whitening routine whitening routine Repeat in two monthsRepeat in two monthsRepeat in two monthsRepeat in two monthsIf performing a whitening procedure, oral disinfection If performing a whitening procedure, oral disinfection is also occurringis also occurringggInstitute a 1.1% neutral sodium fluoride program. Institute a 1.1% neutral sodium fluoride program. Maintain a xylitol protocolMaintain a xylitol protocolMaintain a xylitol protocolMaintain a xylitol protocolFollow up with a CRT 12 weeksFollow up with a CRT 12 weeks

PROSPECPROSPEC™™ MI PasteMI PastePROSPECPROSPEC MI PasteMI Paste

PROSPECPROSPEC™™ MI PasteMI PastePROSPECPROSPEC MI PasteMI Paste

Contains RECALDENTContains RECALDENT™™ (CPP(CPP--ACP)ACP)Contains RECALDENTContains RECALDENT (CPP(CPP ACP)ACP)Casein phosphopeptide (CPP)Casein phosphopeptide (CPP)A h l i h h (ACP)A h l i h h (ACP)Amorphous calcium phosphate (ACP)Amorphous calcium phosphate (ACP)Promotes remineralizationPromotes remineralizationUnder acidic conditions, CPPUnder acidic conditions, CPP--ACP releases ACP releases calcium and phosphate ions into tooth enamelcalcium and phosphate ions into tooth enamelp pp pProducts containing CPPProducts containing CPP--ACP should not be ACP should not be consumed by people with milk protein allergiesconsumed by people with milk protein allergiesconsumed by people with milk protein allergiesconsumed by people with milk protein allergies

P bi iP bi iProbioticsProbiotics

ProbioticsProbioticsProbioticsProbiotics

“Live microorganisms, which “Live microorganisms, which when administered in when administered in adequate amounts, confer a adequate amounts, confer a health benefit on the host” health benefit on the host” (Guarner et al 2005)(Guarner et al 2005)( )( )

Theory dates to early 1900’s Theory dates to early 1900’s Nobel Laureate Ilya Nobel Laureate Ilya MetchnikofMetchnikof

Recent Dental Research in ProbioticsRecent Dental Research in ProbioticsRecent Dental Research in ProbioticsRecent Dental Research in Probiotics

(Meurman 2007)(Meurman 2007)

2001 N t l 594 hild d i d DB PCT 7 th2001, Nase et al, 594 children; randomized; DB; PCT; 7 month

Significant decrease in Strept mutans counts, on the order of one log value decrease in the experimental group and no change inlog value decrease in the experimental group and no change in the control.

Statistically significant reductions in caries in 3-4 year olds.Statistically significant reductions in caries in 3 4 year olds.

Study was too short to obtain conclusive data regarding caries reduction.

R l ThR l ThReplacement TherapyReplacement Therapy

Replacement TherapyReplacement TherapyReplacement TherapyReplacement Therapy

“a “a naturallynaturally occurring or occurring or laboratorylaboratory derived effector derived effector yystrain is used to intentionally strain is used to intentionally colonize the colonize the nicheniche in in susceptible host tissues that is susceptible host tissues that is normally colonized by the normally colonized by the p th ” (Hill 2002)p th ” (Hill 2002)pathogen…” (Hillman 2002)pathogen…” (Hillman 2002)

1984 JH1140 Strain Created1984 JH1140 Strain Created1984 JH1140 Strain Created1984 JH1140 Strain Created

Natural S M strain present in 2% of populationNatural S M strain present in 2% of populationNatural S.M. strain present in 2% of populationNatural S.M. strain present in 2% of populationProduced bacteriocin, muProduced bacteriocin, mu--11401140B i i kill d i ll ll h S MB i i kill d i ll ll h S MBacteriocin killed virtually all other S.M.Bacteriocin killed virtually all other S.M.Modified strain to produce 3x more muModified strain to produce 3x more mu--11401140Strain termed JH1140.Strain termed JH1140.

(Hillman 1984)(Hillman 1984)(Hillman 1984)(Hillman 1984)

1985 Human Colonization1985 Human Colonization1985 Human Colonization1985 Human Colonization

Three volunteers, 3 minute single application. Three volunteers, 3 minute single application. (Hillman 1985 1987(Hillman 1985 1987 J Dent ResJ Dent Res))(Hillman 1985, 1987, (Hillman 1985, 1987, J Dent ResJ Dent Res))Three year recall Three year recall –– all three volunteers still all three volunteers still

l i dl i dcolonized.colonized.2002 2002 –– two of three volunteers still colonized two of three volunteers still colonized

(Hillman 2002)(Hillman 2002)

Modification of JH1140Modification of JH1140Modification of JH1140Modification of JH1140

JH1140 still produced lactic acidJH1140 still produced lactic acid20002000 d l d h dd l d h d2000 2000 –– removed lactate dehydrogenase gene; removed lactate dehydrogenase gene; inserted alcohol dehydrongenase geneinserted alcohol dehydrongenase geneNo detectable lactic acid; ethanol primary No detectable lactic acid; ethanol primary productproduct50% decrease in caries in rat model50% decrease in caries in rat model

FDA TrialsFDA TrialsFDA TrialsFDA Trials

Cleared for Phase 1 Safety TrialsCleared for Phase 1 Safety TrialsFDA i d difi iFDA i d difi iFDA required modifications to prevent FDA required modifications to prevent community spread community spread (Hillman et al, 2007)(Hillman et al, 2007)

Studies will be in edentulous patients Studies will be in edentulous patients Slated to begin “soon”Slated to begin “soon”gg

(onibiopharma.com)(onibiopharma.com)

Palmetto Health Dental Center10 Richland Medical Park

Columbia, South Carolina 29203803 - 434 - 6567

Patient Name: __________________________________________________________________

to Prevent Tooth Decay Infectionsto Prevent Tooth Decay Infections

□ Standard fluoride toothpasteBrush for 2 minutes after each meal

□ Floss or Proxabrush®□ Floss or ProxabrushClean between teeth daily with dental floss, Proxabrush® or other aids

□ Xylitol mintsEnjoy 2-3 mints at least 5 times a day

□ Prescription fluoride gelh f d l b f b d b d T f d)Brush for 2 minutes immediately before bedtime (spit out, but do NOT rinse afterward)

□ MI PastePlace paste in tray, insert and wear for 5 minutes immediately before bedtime (spit out,but do NOT rinse afterward)

□ Chlorhexidine 0.12% rinseRinse for 30 seconds and spit twice a day for 2 weeks

Oral health takes a 24-hour a day commitment from you. The recommendations provided willhelp to treat and prevent tooth decay infections, if you follow them regularly. Adjust therecommendations to fit your daily lifestyle, but don’t neglect them. If you miss one of theitems on the list just continue with the next one at the appropriate timeitems on the list, just continue with the next one at the appropriate time.

Doctor: _______________________________________ Date: ___________________

Palmetto Health Dental Center10 Richland Medical Park

Columbia, South Carolina 29203803 - 434 - 6567

Patient Name: __________________________________________________________________

to Prevent Tooth Decay Infections

□ Standard fluoride toothpasteBrush for 2 minutes before each meal

□ After meal rinseRinse with water or water containing ½ teaspoon of dissolved baking sodaRinse with water or water containing ½ teaspoon of dissolved baking soda

□ Floss or Proxabrush®

Clean between teeth daily with dental floss, Proxabrush® or other aids□ Xylitol mints

Enjoy 2-3 mints at least 5 times a day□ Prescription fluoride gel

Brush for 2 minutes immediately before bedtime (spit out, but do NOT rinse afterward)□ MI Paste

Place paste in tray, insert and wear for 5 minutes immediately before bedtime (spit out,but do NOT rinse afterward)

□ Chlorhexidine 0.12% rinseRinse for 30 seconds and spit twice a day for 2 weeks

Oral health takes a 24-hour a day commitment from you. The recommendations provided willhelp to treat and prevent tooth decay infections, if you follow them regularly. Adjust the

d i fi d il lif l b d ’ l h If i f hrecommendations to fit your daily lifestyle, but don’t neglect them. If you miss one of theitems on the list, just continue with the next one at the appropriate time.

Doctor: _______________________________________ Date: ___________________

StROOBStROOBStROOBStROOB(Strategic Reset of Oral Biofilms)(Strategic Reset of Oral Biofilms)(Strategic Reset of Oral Biofilms)(Strategic Reset of Oral Biofilms)

Professors Brian B. Novy &Professors Brian B. Novy &Brian P. BlackBrian P. Black

Loma Linda UniversityLoma Linda UniversityyySchool of DentistrySchool of Dentistry

Do not wait until the restorative Do not wait until the restorative procedures are completed to begin procedures are completed to begin

StROOBing and using xylitolStROOBing and using xylitolStROOBing and using xylitol.StROOBing and using xylitol.

StROOB InStROOB In--office Protocoloffice ProtocolStROOB InStROOB In office Protocoloffice Protocol

Step #1Step #1Step #1Step #1Polish or Prophy JetPolish or Prophy Jet

S #2S #2Step #2Step #2Immediate 2 minute 10% povidone iodine rinseImmediate 2 minute 10% povidone iodine rinse

Step #3Step #3Immediate liberal application of MI PasteImmediate liberal application of MI PasteImmediate liberal application of MI PasteImmediate liberal application of MI Paste

Step #4Step #4K H b 7K H b 7Keep pH above 7Keep pH above 7

StROOB AtStROOB At--home Protocolhome ProtocolStROOB AtStROOB At home Protocolhome Protocol0.12% chlorhexidine (CHX) rinse b.i.d.0.12% chlorhexidine (CHX) rinse b.i.d.

NOT within 1 hour of using F toothpasteNOT within 1 hour of using F toothpasteI di t li ti f MI P t f ll iI di t li ti f MI P t f ll iImmediate application of MI Paste following Immediate application of MI Paste following

CHX rinseCHX rinseKeep pH above 7Keep pH above 7

Sodium bicarbonate rinses or lozengesSodium bicarbonate rinses or lozengesSodium bicarbonate rinses or lozengesSodium bicarbonate rinses or lozengesXylitol 12Xylitol 12--15 grams per day15 grams per day

Repeat for 7 daysRepeat for 7 days

Strept mutansStrept mutans does NOT does NOT ppproliferate when oral pH is proliferate when oral pH is

above 6.6above 6.6

I t i I f t d T ddlI t i I f t d T ddlIntensive Infant and ToddlerIntensive Infant and ToddlerCaries Prevention ProgramCaries Prevention ProgramCaries Prevention ProgramCaries Prevention Program

“Cavitation eradication and ms control in mothers while “Cavitation eradication and ms control in mothers while pregnant, and from the time the baby is 6pregnant, and from the time the baby is 6--30 months old, 30 months old, is crucial. This is the tooth eruption period and the child is crucial. This is the tooth eruption period and the child is most receptive to ms transmission from the mother at is most receptive to ms transmission from the mother at hi i Child l i k i i bhi i Child l i k i i bthis time. Children are also at risk to transmission, but to this time. Children are also at risk to transmission, but to

a lesser degree, between 6a lesser degree, between 6--12 years of age.”12 years of age.”

Arnold D. Steinberg, DDS, MSArnold D. Steinberg, DDS, MSSteven C. Steinberg DDSSteven C. Steinberg DDSgg

University of Illinois at Chicago School of DentistryUniversity of Illinois at Chicago School of Dentistry

MS transmitted from mother or other MS transmitted from mother or other

fingersfingers

primary caregiver to infant by…primary caregiver to infant by…fingersfingerssharing eating utensilssharing eating utensilscleaning pacifier with cleaning pacifier with mother’s salivamother’s salivamother s salivamother s saliva

When to Start Caries PreventionWhen to Start Caries PreventionWhen to Start Caries PreventionWhen to Start Caries Prevention

Prevention of dental caries should begin six Prevention of dental caries should begin six ggweeks before the end of term or just after the weeks before the end of term or just after the child is bornchild is bornAlternatively, prevention can begin or should Alternatively, prevention can begin or should continue when the child is 6 months oldcontinue when the child is 6 months oldcontinue when the child is 6 months oldcontinue when the child is 6 months oldCare must be given to include the primary Care must be given to include the primary

r i r d l r l tir i r d l r l ticaregiver and close relativescaregiver and close relatives

Children Have Fewer CavitiesChildren Have Fewer CavitiesChildren Have Fewer Cavities Children Have Fewer Cavities When Mothers Use XylitolWhen Mothers Use Xylitol

3

3.5

4

1.5

2

2.5 XylitolChlorhexidineFluoride

DM

FD

MF

0

0.5

1

2 3 4 5

Years

I k P S d rli E Pi ik kki Al P O rr f d t l d i hildrIsokangas P, Soderling E, Pienikakkinen, Alanen P. Occurrence of dental decay in children after maternal consumption of xylitol chewing gum, a follow-up from 0-5 years of age. J Dent Res 2000; 79: 1885-1889

KneeKnee--toto--Knee ExaminationKnee ExaminationKneeKnee toto Knee ExaminationKnee Examination

Xylitol Infant and Toddler Tooth GelXylitol Infant and Toddler Tooth GelXylitol Infant and Toddler Tooth GelXylitol Infant and Toddler Tooth Gel

Used after 6 months of age until child can chewUsed after 6 months of age until child can chewUsed after 6 months of age until child can chew Used after 6 months of age until child can chew gum responsiblygum responsiblyAllows xylitol coverage during the eruptionAllows xylitol coverage during the eruptionAllows xylitol coverage during the eruption Allows xylitol coverage during the eruption phase of the primary teethphase of the primary teethEarly intervention can significantly reduce theEarly intervention can significantly reduce theEarly intervention can significantly reduce the Early intervention can significantly reduce the risk of the caries disease process and limit the risk of the caries disease process and limit the number of cavities even furthernumber of cavities even further

Establish a Dental HomeEstablish a Dental Home –– Physician ReferralPhysician ReferralEstablish a Dental Home Establish a Dental Home Physician ReferralPhysician Referral

Refer highRefer highRefer high Refer high risk risk children by children by 6 months6 monthsRefer all Refer all children by children by the age of the age of oneone

Di i d M fDi i d M fDiagnosis and Management of Diagnosis and Management of Dental Caries Throughout LifeDental Caries Throughout LifeDental Caries Throughout LifeDental Caries Throughout Life

National Institutes of HealthNational Institutes of HealthConsensus Development Conference StatementConsensus Development Conference Statement

M h 26M h 26 28 200128 2001March 26March 26--28, 200128, 2001

Journal of Dental EducationJournal of Dental EducationJ fJ f

Volume 65Volume 65Volume 65Volume 65Issue 10Issue 10

20012001

oralhealth.dent.umich.edu/CDRAM/Links.htmoralhealth.dent.umich.edu/CDRAM/Links.htmoralhealth.dent.umich.edu/CDRAM/Links.htmoralhealth.dent.umich.edu/CDRAM/Links.htm

C i Di i Ri k A t d M tC i Di i Ri k A t d M tCaries Diagnosis, Risk Assessment, and ManagementCaries Diagnosis, Risk Assessment, and ManagementUniversity of MichiganUniversity of Michigan

www.db.od.mah.se/car/carhome.htmlwww.db.od.mah.se/car/carhome.html

University of MalmöUniversity of MalmöF l f Od lF l f Od lFaculty of OdontologyFaculty of Odontology

Department of CariologyDepartment of Cariology

Basic CariologyBasic Cariologygygywww.db.od.mah.se/car/data/basic.htmwww.db.od.mah.se/car/data/basic.htm

www.uic.edu/classes/peri/peri343/www.uic.edu/classes/peri/peri343/

Cariology ClassCariology ClassgygyUniversity of Illinois at ChicagoUniversity of Illinois at Chicago

www.ahrq.gov/clinic/epcsums/dentsumm.htmwww.ahrq.gov/clinic/epcsums/dentsumm.htm

Agency for Healthcare Research and QualityAgency for Healthcare Research and Qualityg y Q yg y Q y(AHRQ)(AHRQ)