Margherita Fontana, DDS, PhD University of Michigan School of - PowerPoint PPT Presentation

Margherita Fontana, DDS, PhD University of Michigan School of Dentistry Department of Cariology, Restorative Sciences and Endodontics

Agenda • What is Dental Caries? • Do we need to remove carious tissue to control disease? • Fluoride • Sealants and Hall crowns • SDF

What is Dental Caries? Dental caries is a: 1) chronic, 2) site-specific, 3) multifactorial, 4) dynamic (but not necessarily continuous) 5) disease process that involves the shift of the balance between protective factors (that aid in remineralization) and destructive factors (that aid in demineralization) to favor demineralization of the tooth structure over time. 6) The disease can be arrested at any point in time. D Bratthall

Fisher-Owens SA et al. Pediatrics 2007;120:e510-e520

Dental Caries is a Result of a Dysbiosis in the Biofilm Gross et al. 2012. PLOS-One 10:e47722

A necessary and sufficient cause MEDIATED Moderating SES VARIABLES Variables OH Food Policy Sealants Dietary Decayed (Parent) Child Biofilm Culture Diet Tooth Behavior changes Sugars Fluoride Geography Dental Genetics Caries Sugar Dr. Weyant

Strategies with the strongest, consistent, highest quality evidence now-a-days are: Fluoride Sealants • Use other strategies to supplement well known interventions, rather than substituting them

Caries Management Medical, Dental, Social History Caries Risk Assessment No Initial Moderate Moderate Extensive Extensive Initial Disease Lesion Lesion Lesion Lesion Lesion Lesion ICDAS 0 ICDAS 2 ICDAS 3 ICDAS 4 ICDAS 5 ICDAS 6 ICDAS 1 Caries Lesion Activity Assessment Radiographs and Other Diagnostic Aids DIAGNOSIS No Remineralize Arrest Sealant Minimal Traditional Endodontic Extraction Treatment Surgical Treatment Surgical Non-Surgical Surgical

Many protocols are available…. 9

• Enhances Remineralization * • Reduces Demineralization • Antimicrobial The Cochrane Database of Systematic Reviews, 2003, 2006, 2008

Fluoride Mechanisms of Action

SELF-APPLIED 100 ppm F or 0.02% NaF MOUTHRINS 0.01% F PRODUCTS ES 0.02% F 226 ppm F or 0.05% NaF 0.09% F 905 ppm F or 0.2 % NaF Over-the-counter 0.10% F 1,000 ppm F or 0.76% SMFP Needs prescription DENTIFRICE 0.11% F 1,100 ppm F or 0.243% NaF S 0.11% F 1,100 ppm F or 0.454% SnF 2 0.5% F 5,000 ppm F or 1.1% NaF GELS/FOAMS PROFESSIONALLY-APPLIED PRODUCTS 0.9% F 9,050 ppm F or 2% NaF 1.23% APF 12,300 ppm F or 1.23% APF 2.26% F 22,600 ppm F or 5% NaF VARNISHES 1.13% F 11,300 ppm F or 2.5% NaF 0.77% F 7,700 ppm F or 1.5% NH 4 F 0.1% F 1,000 ppm F 0 5,000 10,000 15,000 20,000 25,000 0 5000 10000 15000 20000 25000 Concentration in ppm F 38% SDF (~44,800 ppm*) *Up to 55,800 ppm; Mei et al., 2012 Fernandez and Gonzalez-Cabezas, 2015

CDC Recommendations

Dentifrices (toothpastes) ppm F 10 0 2 4 6 8 Baseline am Brushing 15 min 30 min 45 min 1 h 2 h 8 h pm Brushing Upon Rising

Fluoride and Dentin % Inhibition of Demineralization 100 90 80 70 60 50 40 30 20 10 0 0.01 0.1 1 10 Fluoride Concentration (ppm) Enamel Dentin ten Cate et al., 1998

Mouthrinses

Fluoride In- 6 – 18 Years Risk Group < 6 Years > 18 Years Root Caries Office Low May not receive additional benefit from topical fluoride Moderate/High 2.26 % Fluoride 2.26% Fluoride Varnish every 3-6 months or 1.23% APF fluoride gel application for 4 min every 3-6 months Varnish every 3-6 months JADA, Nov 2013 The Cochrane Database of Systematic Reviews, 2003, 2006, 2998 Marinho et al., 2013

• National recommendations around children’s oral health (i.e., AAP, 18 AAPD, USPTF, etc.) include that every child have an age 1 dental visit, conducting an oral health screening at every well child visit starting at age 6 months and at every well-child visit thereafter, and applying fluoride varnish every 3-6 months starting when the first tooth erupts with the most benefit being received with application every 3 months. • Reimbursement for Medicaid eligible children in ALL 50 states. There are a number of states that include additional funding for oral examinations and other services.

Fluoride Dilemmas Frequency vs. Concentration F Levels Time We need to find the ideal balance for each patient

An Update on Dental Sealants (and Sealing Caries) Margherita Fontana, DDS, PhD mfontan@umich.edu

CDC, 2016

Sealants for Caries Prevention

Summary Evidence (Efficacy of sealants): Median Caries Reduction: 81% at 2 year follow-up (Ahovuo-Saloranta et al. 2013) 2013

• Resin-based sealants are effective for preventing caries in children and adolescents. • Moderate-quality evidence that they reduce caries by 11-51% compared to no sealant. • Similar benefit up to 48 months; after longer follow-up, the quantity and quality of evidence is reduced (need longer follow-up studies). • Insufficient evidence to judge the effectiveness of GI sealant or other types of sealants. • Information on adverse effects is limited, but none occurred where this was reported. Ahovuo-Saloranta et al., 2017

What about sealing caries lesions? (Non cavitated lesions) Effective Seal A Sealant is NOT a Preventive Resin Restoration

NIH Consensus Development Conference: Dental Sealants in the Prevention of Tooth Decay (1983)

Diagnosis and Management of Dental Caries Throughout Life (2001) National Institutes of Health Consensus Development Conference Statement; March 26-28, 2001 • Effective in the primary prevention of caries • Their effectiveness remains strong as long as the sealants are maintained • The evidence for caries arrest supports its use

The Effectiveness of Sealants in Managing Caries Lesions • Sealed non-cavitated lesions consistently had better outcomes than not sealed lesions • Caries reduction was about 71%

Reduction in Bacteria Counts by Time since Sealant Placement ( Oong et al., 2008 100.0% • Bacterial reductions 90.0% % Reduction in Mean Bacteria Counts (4 studies) ranged 80.0% from 50.8% to 99.9% 70.0% and appeared to increase as time since 60.0% sealant placement 50.0% increased 40.0% 3 5 3 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 2 3 5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 . . . . . . . . . . . . . . . . . . . . 0 0 0 0 0 1 1 2 2 4 4 6 6 7 2 2 4 0 0 0 1 1 2 6 6 6 Months since Sealant Placement

Caries Prevention Sealants should be placed in pits and fissures of primary and permanent teeth when it is determined that the tooth, or the patient, is at risk of developing caries Noncavitated Carious Lesions Sealants should be placed on early (noncavitated) carious lesions, in children, adolescents and adults to reduce the percentage of lesions that progress

How to assess teeth J Pub Health Dent, 1995 for sealant placement Non-Cavitated Cavitated (Gooch et al., 2009; Fontana et al., 2010; Wright et al., 2016)

Sealants Sealants (sound vs. and non-cavitated nothing lesions) Sealants (sound Sealants and non-cavitated vs. FV lesions) Sealants Unable to determine vs. which is superior nothing

Wright et al., 2016 (ADA) • Unclear if one sealant material is superior to another • Take into account the likelihood of experiencing lack of retention when choosing the type of material • If dry isolation is difficult, such as a tooth that is not fully erupted, then a material that is more hydrophilic (e.g., GI) would be preferable • If the tooth can be isolated to ensure a dry site and long- term retention is desired, then a resin-based sealant is preferable. • Monitor sealants over time, especially sealants showing a higher risk of experiencing retention loss (i.e., GI)

Placement Techniques • Routine mechanical preparation of enamel before acid etching is not recommended Sealant Failure - With Enameloplasty Beneath Dr. Fiegal 34 Wright et al., 2016

• Four-handed sealant placement is associated with higher retention rates. Griffin SO, Jones K, Gray SK, Malvitz DM, Gooch BF. 2008. Exploring four-handed delivery and retention of resin-based sealants. Journal of the American Dental Association 139(3):281 – 289. • Sealant retention rates for teeth cleaned with a toothbrush are at least as high as for teeth cleaned with a handpiece. Kolavic Gray S, Griffin SO, Malvitz DM, Gooch BF. 2009. A comparison of the effects of toothbrushing and handpiece prophylaxis on retention of sealants. Journal of the American Dental Association 140(1):38 – 46.

Evidence synthesis: • The median one-time SSP cost per tooth sealed was $11.64. • Labor accounted for two thirds of costs, and time to provide sealants was a major cost driver. • benefits of SSPs exceed their costs when SSPs target schools attended by a large number of high- risk children 2016