Coordinated by: Bonnie Bruerd, Drph and Kathy Phipps, Drph april 2007



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Chemotherapeutics for Dental Caries


There is a need for simple and effective professional interventions to prevent and treat dental caries. Various chemotherapeutics, and even a caries vaccine, are being researched throughout the world.


There are various products on the market today that can lower the number of S. mutans. Some of the most common antimicrobial/chemotherapeutic agents include: fluoride, chlorhexidine, and xylitol. (33-41)
Antimicrobial agents can:





  • reduce existing plaque and prevent formation of plaque




  • inhibit acid production


Chlorhexidine
Chlorhexidine is recommended for parents and other primary caregivers to prevent transmission of S. mutans to their infants. Modification of the mother’s dental flora during the period from birth until the child is two years of age can lower the bacteria transmitted to the baby and positively affect the child’s future dental caries risk.

How to Use Chlorhexidine

Chlorhexidine therapy would consist of 0.12 percent chlorhexidine gluconate, used as a prescription mouthrinse, 10 ml daily for one week per month or for 2-3 weeks straight and repeated every 2-3 months, for approximately a year.


Chlorhexidine can also be brushed on the teeth. Chlorhexidine gels and varnishes have been used in Europe and may soon be on the market in the U.S. Both of these products are currently being tested in American Indian communities.

Target Groups:


  • Pregnant women

  • Mothers or other primary caregivers of infants.

Note: Chlorhexidine rinses are not recommended for young children.


Xylitol Fact Sheet

What is Xylitol?

Pure xylitol is a white crystalline substance that looks and tastes like sugar. On food labels, xylitol is classified broadly as a carbohydrate and more narrowly as a polyol. Xylitol is slowly absorbed and only partially used, so it has about 40 percent fewer calories than sucrose. Xylitol has been used in foods since the 1960’s. Over 25 years of testing in widely different conditions confirm that xylitol prevents cavities.



How does Xylitol work?

Xylitol works in many ways to prevent dental cavities. First of all, it is a 5-carbon sugar that cannot be used by bacteria, leading to ingestion by the cell and cell death. There is also a reduction of lactic acid which may lead to reduction in demineralization.



Why Use Xylitol?
►Effective

Studies using xylitol as either a sugar substitute or a small dietary addition have demonstrated a dramatic reduction in new tooth decay, along with arrest and even some reversal of existing dental caries. This xylitol effect is long-lasting and possibly permanent. Low decay rates persist even years after the trials have been completed.


►Natural

Xylitol is not a strange or artificial substance, but a normal part of everyday metabolism. Xylitol is widely distributed throughout nature in small amounts. Some of the best sources are fruits, berries, mushrooms lettuce, hardwoods, and corn cobs. Most xylitol used in gums and mints is harvested from the birch tree.


►Safe

In the amounts needed to prevent tooth decay (5-10 grams per day), xylitol is safe for everyone. The only known side effects are intestinal gas and osmotic diarrhea, especially if xylitol is taken in large amounts. Even then, tolerance builds and the diarrhea will stop.



How to use Xylitol

It is not necessary to replace all sweeteners to get the dental benefits of xylitol. Look for xylitol sweetened products that encourage chewing or sucking to keep the xylitol in contact with your teeth. Look for products that have xylitol as the first listed ingredient. Beware that there are many products that list xylitol as a 3rd or 4th ingredient. These products do not have enough xylitol to be therapeutic.


Studies have shown that the therapeutic dose is 5-10 grams of xylitol per day, at least five days a week. It must be used 3-5 times during the day.


Which groups should I target?


  • Four and five year olds in Head Start.




  • Fourth and fifth graders in elementary school. These grades were chosen to have the maximum effect on the first and second permanent molars.



  • Mothers, during the period when the child is two or three months old until the child is two years old. Xylitol used during this stage can prevent colonization of cavity-causing bacteria in the infant and prevent future dental caries.




  • Any patients at high risk for dental caries, including those with exposed root surfaces and xerostomia. 



There is no evidence that xylitol is effective if used inconsistently and in amounts less than those recommended. Therefore, they will be most effective when institutionalized as part of a school or Head Start program.

FLUORIDES


Fluoride works in several ways to prevent caries. A major goal of each dental program should be to provide topical fluoride, with an increased effort targeted to those children who are caries active.
Effective methods of delivering the fluoride ion include community water fluoridation, systemic supplements, professionally applied topical gels and varnishes, and self-applied mouth rinses and toothpastes. (5-17, 31-32) The ideal is to have a fluoride exposure (including optimally fluoridated water) every four hours. The chart below lists the various methods of administering fluoride and their relative effectiveness.
How fluoride works

The effectiveness of fluoride involves several mechanisms. Fluoride reduces the

solubility of enamel during the repeated cycles of demineralization and remineralization in the caries process. When ingested before tooth eruption, fluoride enhances the

development of fluorapatite which makes enamel resistant to the carious process. Also, topical fluoride establishes a more acid-resistant enamel surface when used

continually at low levels. Finally, high-concentration fluoride gels/varnishes may have a bactericidal action on cariogenic bacteria in plaque.

EFFECTIVENESS OF VARIOUS FLUORIDES



Method


Frequency/duration


Concentration of dosage



Approximate reduction in dental caries

Community water fluoridation



Lifetime consumption


0.7-1.2 ppm


Primary teeth 30-60%

Adults 20-40%

Fluoride Tabs/Drops


Preschool-8th grade


Varies by age



30%


Mouthrinses


School year


0.05% NaF (daily)

0.2% NaF (weekly)


20-35%

Toothpaste

Lifetime

0.24% NaF

0.76% MFP

0.4% SNF2


20-30%

APF/tray gel

1-2 times a year


1.2% APF


20-26%


Fluoride varnish


2-4 times a year


.2% NaF


20-40%


Safety of Fluoride Supplementation


Like many other nutrients, fluoride is beneficial in small amounts and toxic in large doses. The safety and effectiveness of fluoride is supported by a long list of

professional associations and research. However, to effectively promote the use of fluorides, we must be aware of its potential for toxicity and thus keep our prescriptions within the recommended dosages. First aid for a toxic dose of fluoride consists of

inducing vomiting as quickly as possible or ingesting a material to bind fluoride. Milk is usually the most readily available.

As a safety precaution, the American Dental Association (ADA), Council on Dental Therapeutics, makes the following recommendations:





  • Do not store large quantities of sodium fluoride in the home.



  • When prescribing fluoride supplements, no more than 264mg. of sodium fluoride

(120mg.fluoride) should be dispensed at one time. Commercial fluoride preparations available for home use are generally dispensed in bottles of 100 to 200 tablets. Fluoride rinses and gels recommended for home use are also

dispensed in these recommended concentrations.





  • In addition to the use of child-proof containers, each package dispensed should also bear the statement: CAUTION-STORE OUT OF REACH OF CHILDREN.



  • If it is determined that a young child is routinely swallowing rather than expectorating a topical fluoride agent, such as a toothpaste, the therapy should be modified or closely supervised.



  • For dental clinics or institutions that store fluoride preparations in amounts that may be harmful if consumed at one time, it is essential that these supplies be kept in a locked storage area.



Cavities used to be a fact of life. But over the past few decades, tooth decay has been reduced dramatically. The key reason: fluoride. Research has shown that fluoride reduces cavities in both children and adults. It also helps repair the early stages of tooth decay even before the decay becomes visible. Unfortunately, many people continue to be misinformed about fluoride and fluoridation. Fluoride is like any other nutrient; it is safe and effective when used appropriately. ADA website, 2007

Systemic Fluoride Supplements


Young children (birth to 16 years) not receiving the benefits of optimally

fluoridated water should receive a prescription for systemic supplementation.


1. Document the source of drinking water and the fluoride content.
2. Write the appropriate prescription. Determine whether there are other young children in the home and use this opportunity to prescribe the appropriate dose for each child. Prenatal fluoride supplementation is not recommended. Instruct the parent that the tablets should be chewed and swished before swallowing when possible. This provides both a topical and systemic benefit.
3. Counsel the parents on the importance of systemic supplementation. Parents are much more likely to comply if they thoroughly understand the significance of the

prescription. It will also increase compliance if you can help the parent arrange the best time of day to fit this new habit into their life style.


4. On return visits, check for compliance and further counsel the parent if there is

noncompliance. Document each counseling session in the chart.


When prescribing systemic fluoride, you have an excellent opportunity to educate families about the importance of water fluoridation. Example: "Since your water is not fluoridated, you need to supplement your diet with a fluoride tablet."
Note: Fluoride lozenges can be beneficial (as a topical agent) for caries-active adults.
Fluoride Supplement Dosage Schedule—1994

Approved by the American Dental Association, American Academy of Pediatrics and American Academy of Pediatric Dentistry



Age

Fluoride Ion Level in Drinking Water (ppm)*

 

<0.3

0.3-0.6

>0,6

Birth-6 months

None

None

None

6 months-3 years

0.25 mg/day**

None

None

3-6 years

0.50 mg/day

0.25 mg/day

None

6-16 years

1.0 mg/day

0.50 mg/day

None

* 1.0 ppm = 1 mg/liter
** 2.2 mg sodium fluoride contains 1 mg fluoride ion.

Fluoride Toothpaste


When doing the prophylaxis, inform patients about the importance of using a fluoride toothpaste daily. Reinforce this message on subsequent appointments. A pea-sized dab, or small smear of toothpaste is the recommended amount of toothpaste for young children. This can best be achieved by swiping the toothpaste across the toothbrush instead of along the length of the toothbrush. This will minimize the possibility of fluorosis if the toothpaste is frequently swallowed.


Fluoride Mouthrinses


Daily fluoride mouthrinses (.05% NaF) may be recommended for children

and adults with smooth surface caries. Do not recommend them for children

under the age of six because they may swallow it. These rinses can be

beneficial for targeted patients and are available over-the-counter. You may

find a low rate of compliance because daily rinses require a certain amount

of patient motivation.


Professionally Applied APF Gels


Professionally applied gels are recommended for children (ages 6 and older) and adults with smooth surface caries. The acidulated phosphate fluoride (APF) and tray method is

recommended. A four-minute treatment is the most effective. The treatments should be given 2-6 times a year for caries-active patients.




  • Dry the teeth. A rubber cup prophy is not necessary before a fluoride treatment.




  • Use a fluoride tray for isolation.




  • Leave the fluoride on the teeth for four minutes.




  • Be sure the patient is seated upright. Suction as much fluoride as possible from the patient's mouth. These fluorides are highly concentrated formulations and are not meant to be swallowed.




  • Instruct the patient not to rinse, eat, or drink for 30 minutes.

Fluoride Varnish

Fluoride varnish is an alternative to the APF topical gel or foam previously used in most dental clinics. In fact, most IHS and Tribal dental clinics use fluoride varnish exclusively for patients of all ages. When painted on the teeth, the fluoride is held in contact with the enamel until the varnish wears off. More fluoride is incorporated into the outer enamel with a fluoride varnish treatment than with a topical APF application. Some of the advantages of fluoride varnish vs. a traditional gel/foam application include:




  • Fluoride varnish stays on the teeth longer.





  • It is ideal for young children who tend to swallow other topical fluorides.



  • There is no tray to cause young children to gag.



  • Fluoride levels remain low because the varnish wears off over a matter of days.



  • The "paint-on" application technique is quick and the varnish sets on contact with saliva.

For patients with white spot lesions, consider 3 applications in a two-week period, with a reassessment in 4-6 months. Dental auxiliaries, as well as other health care providers, can be taught how to apply the varnish, therefore eliminating some of the access and manpower issues. Fluoride varnish is shown to be effective in preventing dental caries, is safe, is easy to apply, and requires very little patient cooperation. Fluoride varnish has been used on young children and has been shown to be effective in preventing caries in both permanent and primary dentitions. The reported caries reduction ranges from 18 to 54 percent.

PIT AND FISSURE SEALANTS

Sealants are an effective method for preventing decay. Sealants protect the caries-susceptible occlusal and pitted surfaces that receive the least benefit from fluoride.


Do NOT use a sharp explorer to diagnose caries. It has been demonstrated that using a sharp explorer may produce irreversible traumatic defects in demineralized areas in occlusal fissures and hasten lesion progression.


Support

There are more than 20 years of research that shows sealants to be effective in caries prevention. (16-20) There is a 100 percent reduction in pit and fissure caries if the

sealants are retained without leakage. We can expect to see 80-100 percent retention after two years and 55-66 percent retention up to seven years after sealants are placed. It has been demonstrated that incipient lesions will not progress when sealed and that an incipient lesion is five times more likely to decay if not sealed.

Criteria


  • Although permanent molars and premolars are targeted for sealants, primary molars may also be appropriate for some children. The placement of sealants should be limited to incipient carious lesions and previously unrestored pits and fissures.


Open grooves very selectively, and only when you are certain there is decay.

Code PRRs as sealants until they are into the dentin.


  • The placement of sealants should be accomplished as soon as possible following the eruption of the targeted teeth and when a dry field can be maintained.




  • Patients receiving sealants should ideally be on some type of preventive fluoride program to reduce the risk of smooth surface caries. However, the absence of water fluoridation or topical fluoride programs should not preclude the use of dental sealants.


Check It Out

Is your air line contaminated?

Has your sealant expired?

For primary molars and partially erupted teeth, consider using a tinted fluoride-releasing product. This is better than waiting and the tinted material will serve as a reminder to reseal the tooth at the next appointment.
Application Procedure

Check It Out

Is your air line contaminated?

Has your sealant expired?


Four-handed technique is recommended for the placement of dental sealants.
1. Remove any debris from the occlusal surfaces using a toothbrush or prophy brush.

A prophy jet also works well to clean the surfaces.


2. Isolate the teeth to be sealed with cotton rolls and absorbent shields.
3. Dry the teeth for 15 seconds.
4. Apply etching gel. Apply the gel over all pits and fissured surfaces. Do not rub. Allow gel to remain for 20-30 seconds.
5. Rinse the teeth to remove gel. A high speed evacuator should be held close to the tooth while rinsing to keep the sour-tasting acid from patient's tongue and to keep

cotton rolls as dry as possible.


6. Dry the teeth for 20 seconds and examine the etched surfaces. They should be frosty in appearance.


Maintaining a dry field is critical at this point.

7. Place additional cotton rolls if necessary to maintain field isolation. If contamination occurs, re-isolate and re-etch the teeth to be sealed for 10 seconds.


8. Dry the teeth and gently apply a thin coat of sealant, trying not to touch the enamel surface. Maintain a perfectly dry field until the sealant has been completely

polymerized by the light.


9. Place the curing light 2-3mm from tooth surface for 20 seconds. Buccal and lingual grooves will require an additional 20 seconds. Depending on the size of the light wand, you may need to cure for an additional 20 seconds.
10. After polymerization is complete, evaluate the sealant for retention and occlusion.

If the coverage is deficient in any areas or there are bubbles, apply more material.


11. Remove isolation materials and rinse.

DIETARY COUNSELING


Dietary factors play a role in the prevention of dental caries. (21-23) Unfortunately, it is difficult to recommend specific foods to patients because it is the patient's susceptibility to caries and the combination and frequency of foods that determine if a food is cariogenic. Nonetheless, dietary counseling should not be overlooked as a method of caries prevention for patients who are caries-active.



Support

While researchers are still struggling with the exact relation between diet and dental caries, there is little question that the total intake of dietary sugars and highly refined

carbohydrates play a role in dental caries. There is little difference in cariogenicity between white sugar, brown sugar, fructose, dextrose, and honey but sucrose remains the "arch-criminal" because of its greater availability and frequency of consumption. Sticky foods do not appear to be more cariogenic than liquids. Artificial sugars such as aspartame (Nutrasweet) and saccharin are not cariogenic and can be recommended as substitutes. Studies suggest that chewing sugarless gum after meals or other exposures to sugars is helpful in clearing the sugar left in the mouth and reducing the drop in salivary pH.
Efforts should be directed towards a decrease in the amount and frequency of those foods that are acidogenic. Any snack recommendations should adhere to general

standards for nutrition (i.e. although chocolate is not acidogenic, it is non-nutritive and should not be recommended for children as a healthy snack). Likewise, although fresh fruit contains natural sugar, it is recommended as a "good" snack for children.


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