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Primary Prevention of Dental Caries: An Overview
Int J Clin Prev Dent 2020;16(4):143-148
Published online December 31, 2020;  https://doi.org/10.15236/ijcpd.2020.16.4.143
© 2020 International Journal of Clinical Preventive Dentistry.

Eman Khalifa Mohammed Mansur

Department of Community and Preventive Dentistry, Faculty of Dentistry, University of Benghazi, Benghazi, Libya
Correspondence to: Eman Khalifa Mohammed Mansur
E-mail: emanmansur80@gmail.com
https://orcid.org/0000-0002-4540-9120
Received September 17, 2020; Revised September 26, 2020; Accepted September 28, 2020.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Dental caries is a multifactorial disease. Plaque bacteria, fermentable carbohydrates, and a susceptible tooth surface are basic requirements to its occurrence. Dental caries is a preventable infectious disease, and the early identification of risk factors and implementation of oral health preventive measures at a young age can reduce or even avoid this lesion progression. It is recommended that a dental home should be established by age one or within 6 months from eruption of the first primary tooth. Child oral health visits should include caries risk assessment, individualized preventive strategies, and anticipatory guidance. A treatment plan and a periodic supervision of oral care for each child, should be determined based on his/her risk of disease and include appropriate age and preventive measures. This plane may include some specific preventive measures, such as dietary cancelling, oral hygiene instructions, topical antimicrobials, pit and fissure sealant, fluoride therapy, and using Casein PhosphoPeptide-Amorphous Calcium Phosphate (Tooth mousse, GC Co., Japan).
Keywords : disease prevention, primary prevention, dental caries, preventive care
Introduction

Dental caries is a multifactorial disease. Plaque bacteria, fermentable carbohydrates, and a susceptible tooth surface are basic requirements to its occurrence. These factors are influenced by other variables include genetics, lifestyle, education, and socio-economic, cultural and environmental conditions [1].

Once bacteria colonize the tooth surface and metabolize dietary carbohydrates, acids will be produced. These acids diffuse into the enamel, and dissolve tooth minerals, mainly calcium and phosphate, this process is known as demineral-isation. The saliva plays an important role in buffering the acid and replacing minerals, this process is called remineralisation [2]. Therefore, it is essential to maintain a balance between factors that promote remineralisation and those cause demin-eralization.

Dental caries is a preventable infectious disease, and the early identification of risk factors and implementation of oral health preventive measures at a young age can reduce or even avoid this lesion progression [3]. Child is susceptible to caries once his/her first tooth is erupted, which usually occurs around age 6 months [4]. It is recommended that a dental home should be established by age one or within 6 months from eruption of the first primary tooth [5]. A dental home is defined as the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated and family centered way, and includes referrals to dental specialists when appropriate [5,6].

The Oral Health Visit

Child oral health visits should include caries risk assessment, individualized preventive strategies, and anticipatory guidance [7].

1. Caries risk assessment

Recently, there has been an increased highlighting on the concept of risk assessment to guide treatment planning decisions and recall intervals for each patient [8]. For every child an individualized risk assessment should be developed to establish an appropriate preventive caries strategy [9]. This strategy works as the foundation for health care providers and parents/caregivers in identifying and understanding the child’s risk factors [8]. The definite information that is gained from a systematic assessment of caries risk helps in building the treatment and preventive protocols for children already with disease and those considered at risk [10]. This recording allows changes over time to be monitored. Consequently, treatment planning and recall interval may be adjusted [11]. Caries risk assessment should be done before the onset of the disease process for optimal outcomes. Both risk and preventive factors are determined from an interview with the parent and from a clinical assessment of the child [9,11].

A number of caries risk assessment checklists and tools have been developed, which include many known risk factors for caries, in order to help dentists in assessing their patient’s caries risk and to encourage a systematic approach to caries risk assessment [12]. In general, the dentist can simply circle (Yes) beside the risk or protective factors that apply to make a decision whether the risk factors outweigh the protective factors or vice versa. As, the balance between caries pathological and protective factors, according to the caries balance concept (Figure 1), determines the progression or reverse of dental caries [2]. As a result, a risk status of low, moderate, or high is determined, and the appropriate care strategy is established depending on this risk level.

Figure 1. Caries balance.

2. An individualized treatment plan

A treatment plan for each child is determined by his/her caries risk level [11]. Specific strategies may be needed to modify the cariogenic bacteria through the potential use of chlorhexidine rinse and xylitol products [13]. As well, the need to change in the child’s diet and toothbrushing habits, and for fluoride (F) application is determined by the risk level (Table 1, 2) [14,15]. It is important to counsel parents regarding changing specific risk factors, where they should be given additional information and anticipatory guidance on the prevention of dental disease that is specific to their child’s needs and caries risk factors [5].

Table 1 . Caries preventive strategy for 1 to 6 year old children

Preventive measureRisk category

LowModerateHigh
Recall visitEvery 12 monthsEvery 6 monthsEvery 3 months
Anticipatory guidanceYesYesYes
Dietary counsellingNoYesYes
Oral hygiene instructionsNoYesYes
AntibacterialNoYesYes
Pit and fissure sealantNoYesYes
Fluoridated toothpasteYesYesYes
Fluoride varnishNoApplication at 6 month intervalsApplication at 3- to 6-month intervals
Fluoride mouthrinseNoNoNo
Fluoride gelNoNoNo


Table 2 . Caries preventive strategy for >6 year old children

Preventive measureRisk category

LowModerateHigh
Recall visitEvery 12 monthsEvery 6 monthsEvery 3 months
Anticipatory guidanceYesYesYes
Dietary counsellingNoYesYes
Oral hygiene instructionsNoYesYes
AntibacterialNoYesYes
Pit and fissure sealantNoYesYes
Fluoridated toothpasteYesYesYes
Fluoride varnishNoApplication at 6 month intervalsApplication at 3- to 6-month intervals
Fluoride mouthrinseNoYesYes
Fluoride gelNoApplication at 6 month intervalsApplication at 3- to 6-month intervals


3. Recall visits (periodicity)

Periodic supervision of oral care should be determined based on each child’s risk of disease and include appropriate age and risk preventive measures. In general, these intervals are set on a 3-month, a 6-month, and 12-month intervals for children at high risk, moderate risk and low-risk for dental caries, respectively. However, some cases with high caries risk may need to be re-evaluated on a monthly basis. During the recall visit, both the previous risk factors and the established self-management goals are reassessed [16].

The Primary Preventive Measures

1. Dietary control

For children at moderate or high risk, a dietary diary should be completed and discussed. Based on this dietary diary, a specific dietary counselling should be given to the child and family, and initially limited obtainable targets are set. Then, the compliance should be monitored in the recall visits [6].

2. Oral hygiene

Tooth brushing is efficient in removing dental plaque. Skills of toothbrushing should be taught to children of all ages, and they should be encouraged to brush their teeth at least twice a day, especially before bedtime. The proper brushing technique should be demonstrated during the dental visit. The use of fluoridated toothpaste should be emphasized [17].

3. Topical antimicrobials

Topical antimicrobials aim at reducing the burden of bacteria [18].

1) Chlorhexidine

It is an antibacterial agent that helps in caries prevention by reducing the mutans streptococci levels. To date, chlorhexidine remains the gold standard of antiplaque agents. A number of over-the-counter and professionally administered chlorhexidine-based preparations are available in a variety of formulations and in a range of strengths. It is available in form of toothpastes, mouthrinses, varnishes, gels, and gums and sprays [13].

2) Xylitol

It is a naturally occurring sugar substitute that can reduce levels of caries-forming mutans streptococci in the plaque and saliva. Xylitol can be administered as a syrup or topically via wipes for young children. It can be administered in gum, lozenges, or snack foods, in older children [18].

4. Pit and fissure sealants

Sealant is a low viscous material that is placed in the pits and fissures on occlusal, buccal, and lingual surfaces of teeth to prevent or arrest the development of caries. Sealant polymerizes into a hard material to act as a physical barrier between the sealed area of the tooth and the bacteria and make pit and fissures easier to clean by brushing and mastication. Sealants have been used for over 30 years as a caries preventive measure, and evidence from clinical trials have demonstrated their effectiveness [19]. Applying a fissure sealant decision should be made on clinical bases, after a full clinical examination that is supported by a caries risk assessment. If doubt exists over the caries status of a susceptible site, a bitewing radiograph should be taken. If it is certain that, the carious lesion is confined to the enamel surface a sealant should be placed and monitored closely. As applying a sealant over an incipient carious lesion (noncavitated carious lesion) does not lead to progress, if this sealant remains intact. However, if caries is found to extent to dentine, a restoration should be placed [20].

It is recommended to use the sealants compared with both nonuse of sealants and use of F varnishes in permanent molars with both sound occlusal surfaces and noncavitated occlusal carious lesions in children. The proper ages that are indicated for application of sealant are 3-4 years, 6-7 years, and 11-13 years, for deciduous teeth, first permanent molars, and second permanent molars and premolars, respectively. Nevertheless, sealant is contraindicated if patient behavior does not permit isolation, there is an open occlusal carious lesion, caries exist on other surfaces of the same tooth, a large occlusal restoration is already present, and if pits and fissures are well coalesced and self-cleansing [21].

5. F therapy

F is an important and cost-effective caries preventive measure. F is up-taken by tooth in the pre-eruptive and post- eruptive stages. A distinction is made between F that is ingested systemically and that is applied topically (Figure 2) [21]. Nevertheless, as seen by Murray and Naylor [22] in 1996, such distinctions are not helpful since all methods of F delivery can have both systemic and topical effects.

Figure 2. Methods of fluoride de-livery.

1) Water fluoridation

It is the controlled adjustment of a F compound to a public water supply in order to bring the F ion concentration up to a level that effectively prevents caries. According to the World Health Organization guidelines, the optimal F concentration in drinking water is a range of 0.7-1.2 ppm, depending on the climate. Many studies conducted around the world reported that water fluoridation reduces dental caries experience by the half [23].

2) F toothpaste

All children should regularly use fluoridated toothpaste to reduce the risk of development of caries [6]. Regarding children under the age of 6 years, if they are at low caries risk, a toothpaste that containing no more than 600 ppm of F should be used. Those with a higher risk of developing caries should use a standard 1,000 ppm paste [14]. Regards children over the age of 6 years should use a standard 1,000 ppm or even higher F level paste [15]. Children under 7 years old should brush their teeth under their parents supervision. Parents should be instructed to use just a smear layer of fluoridated tooth paste for children under 2 years old, and a pea-sized for those aged 2-6 years. Children should be instructed to spit out the excess amount of the toothpaste during and after brushing [6].

3) F varnish

It is a professionally applied adherent material and not intended to be as permanent as pit and fissure sealant. The use of F varnish is based on the premise that longer duration and more intimate contact between F ions and enamel leads to a higher F uptake by the enamel. The application of high F concentrations, around 22,000 mg F/L, in small amount of material, leads to slowly release of F into the surrounding envir-onment. This release has been shown to continue for 5-6 months [24].

F varnish has been used widely for over three decades both as part of community-based programmes and on individual basis. It is effective in preventing new carious lesions and halting the progression of established ones. It is the treatment of choice for children at high caries risk. F varnishes typically contain 5% sodium F (NaF), which is equivalent to 2.26% F (Duraphat) and an organic F varnish contains 0.1% F (Fluor Protector) are available. It is applied to teeth by the paint-on technique [20].

4) F mouthrinse

It is s not recommended in fluoridated community and for children under 6 years, due to the risk of F ingestion. The two main concentrations available are 0.05% (225 ppm F) NaF, and 0.2% (900 ppm F) NaF. For daily and weekly uses, respectively [6].

5) F gel

Many of the problems associated with F solutions were overwhelmed by the introduction of F gels. Gels are produced by the addition of a gelling agent such as methyl or hydroxyethyl cellulose to the F preparation, which increases its viscosity. It was found that F gel effectively may lead to 28% reduction in dental caries. The most commonly used gel is 12,300 ppm of F Acidulated Phosphate Fluoride (APF). APF thixotropic gel is available, thixotropic denotes a solution that sets in a gel like state but is not a true gel on application of pressure thixotropic gel behaves like a solution. It is s not recommended for children under 6 years, due to the risk of F ingestion. It is applied to teeth by the tray technique [6].

6) F supplements

F supplements are provided in the form of tablets, lozenges, drops, liquids, and F-vitamin preparations. These supplements usually contain neutral NaF as the active ingredient. All potential F sources should be evaluated and a caries risk assessment should be conducted to every child before prescribing, to reduce the risk of over-dosage and fluorosis. For children at low caries risk, dietary F supplements are not recommended and other sources of F should be considered as a caries preventive measure [24]. F supplements have some topically effect by elevating salivary and plaque levels of F for some hours. F drops are placed directly on the tongue or inside the cheeks, and it is used until a child is old enough to swallow. The tablets and lozenges are intended to be chewed or sucked before swallowing. The use of F-vitamin preparations is recommended when the patient requires both F and vitamins. This combined preparation may aid motivation for continued and regular F ingestion. However, it cannot provide a topical effect to the erupted teeth because it has to be swallowed directly [6].

There have been a number of recommendations for sharply reduced F supplement schedules in recent years. One of them is the dietary F supplement schedule for children at high caries risk, as recommended by the American Dental Association in 2010 (Table 3) [24].

Table 3 . Dietary fluoride supplement schedule for children at high caries risk

Fluoride concentration in drinking water (ppm)Age (yr)

Birth to 6 months>6 months to 3>3 to 6>6 to 16
<0.3None0.25 mg/d0.50 mg/d1.00 mg/d
0.3-0.6NoneNone0.25 mg/d0.50 mg/d
>0.6NoneNoneNoneNone


7) Silver diamine fluoride (SDF)

SDF is used to prevent and arrest caries across the globe, particularly in the developing world. Its potential side effects include staining of carious tooth structure, but in some cases that is acceptable to patients and their parents. SDF has the potential to play an important role in managing dental disease in both primary and permanent dentations [25].

6. Casein PhosphoPeptide-Amorphous Calcium Phosphate (CPP-ACP)

The anitcariogenic effect of CPP-ACP (Tooth mousse, GC Co., Japan) has been attributed to the multiphosphoseryl-con-taining sequences of casein. CPP can stabilize the level of ACP in saliva as it act as reservoir of calcium [26]. It is available in a form of chewing gum, mouthrinses, lozenges, topical cream, dentifrices, sprays, and energy drinks. CPP-ACP prevents caries by remineralizing early carious lesions, and it is a cost-effective method in high risk population [26]. It has been reported that the use of CPP-ACP tooth-mousse has an advantage over F toothpaste in neutralizing acids in the oral cavity [27].

Conclusion

Dentists have a critical role in preventing and reducing the prevalence and severity of dental caries. Employing the concepts of caries risk assessment and early establishment of a dental home are essential to develop an individualized treatment plan for each child. This plane may include some specific preventive measures, such as dietary cancelling, oral hygiene instructions, topical antimicrobials, pit and fissure sealant, F therapy, and using CPP-ACP.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

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