“The Preventive Philosophy” PREVENTION I “The Preventive Philosophy”

PREVENTION. . . The Concept The emergence of a new philosophy of dentistry based on prevention rather than repair and replacement has been the most significant development in the history of dentistry. In a World Health Organization (WHO) study, it was found that countries with dental care systems that emphasized restorative care had the highest caries experience in the world, as measured by the number of decayed, missing and/or filled teeth, (DMFT). These countries also had the highest number of completely edentulous individuals. In countries where prevention was emphasized, the number of DMF teeth was substantially smaller.

PREVENTION . . . The Concept The following data bear testimony to the futility of a mechanistic approach to gain and maintaining oral health for Americans: 98% of 40-44 year olds have had tooth decay, with an average 45 affected tooth surfaces. the average American has between 9-10 missing permanent teeth; 6.8% of the American population is completely edentulous; 27% of Americans over 65 have no teeth at all. 44% of Americans have gingivitis; and 13% of Americans have periodontal disease.

PREVENTION . . . The Concept The resolution of such extensive problems of dental caries and periodontal disease by a “restorative philosophy” yields low efficiency and efficacy. It is not a cost/benefit effective way to achieve oral health. As a consequence, the far-sighted in the profession have turned to prevention as the only feasible solution to a problem of such severity. Oral health care systems which emphasize prevention will yield populations with good oral health; those that do not, will not.

PREVENTION . . . The Concept A philosophy of prevention is basic to a good contemporary practice. Dentistry exists to facilitate the gaining of oral health by society. Individual dentists profess to exist to help their patients gain oral health. The preventive concept should be the thread that is woven through the entire fabric of dental practice. The concept of prevention can be understood to apply to all aspects of practice by understanding prevention to exist at primary, secondary, and tertiary levels.

LEVELS OF PREVENTION PRIMARY PREVENTION Occurs in the clinically pre-pathologic period. Involves promotion of oral health concepts, as well as specific protection. Examples: oral health education, water fluoridation, plaque removal through brushing and flossing, antimicrobials, topical fluorides, pit and fissure sealants, mouth guards. Prevent: caries, gingivitis, trauma to the teeth from occurring.

LEVELS OF PREVENTION SECONDARY PREVENTION Occurs in the early period of pathogenesis. Involves early recognition and prompt therapy. Examples: Radiographic examination, Root scaling, conservative restorative treatment Prevent: further deterioration of health that would result in extensive lesions of the teeth, pulpal involvement, or periodontitis.

LEVEL OF PREVENTION TERTIARY PREVENTION Occurs later in the period of pathogenesis. Involves limitation of disability and rehabilitation. Examples: pulpal therapy, periodontal surgery, extractions, fixed prosthodontics, space maintainers. Prevent: loss of teeth, disseminated infection, loss of space, occlusal disharmonies, and other significant oral disabilities.

CHILDREN IN “THE CONCEPT” “He who is wise begins with the child CHILDREN IN “THE CONCEPT” “He who is wise begins with the child.” Goethe As primary prevention is the ultimate goal of the dental profession, it necessarily follows that the thrust of any comprehensive oral health program be directed at the child. Children must be the foundation of a practice that is focused on prevention.

UNDERSTANDING THE PROBLEM To understand the problem of prevention as it relates to children, an understanding of the profile of oral disease experience of children (in America) is necessary. Epidemiology is that branch of medicine that deals with the study of the causes, distribution, and control of disease in populations. The epidemiological term for the magnitude of a disease existing in a population at a point in time is referred to as prevalence. Prevalence must be differentiated from a related term, incidence. Incidence is the disease occurring in a population during a specific period of time. To say that the average 17 year old has 4.96 decayed, missing or filled teeth is to make a statement of prevalence. To say that the average child will develop a new carious lesion between ages of 6 and 10 is to make a statement of incidence.

PREVALENCE OF DENTAL CARIES IN CHILDREN Two epidemiological measures will serve as indices of prevalence of caries: DMFT: An index that represents the number of decayed (D), missing (M), and filled (F) teeth (T). Index is total of these three assessments in the individual. DMFS: An index that represents the number of decayed, missing, and filled surfaces (S), in the individual. DMFS is the more sensitive measure of the magnitude of disease in the oral cavity.

PREVALENCE OF DENTAL CARIES IN CHILDREN The mean dft of preschool children 2-5 is 1.17; dfts is 2.5. 20.48% of decay is untreated. The mean dft in school age children age 6-11 is 1.84; dfts is 4.3. 24.49% is untreated. The mean DMFT (permanent teeth) of children age 6-11 is approximately 1. By age 11, approximately one-third of children have experiences dental care in their permanent teeth. Two-thirds (67%) of 19 year olds have experienced dental decay. At age 19 the mean DMFT is 3.31; 24% of these 19 year olds have untreated tooth decay.

PREVALENCE OF DENTAL CARIES IN CHILDREN Only 1/3 of children have had no carious experience by age 19. 80% of the dental carious experience occurs in 25% of the children in this country. This concentration of disease has become greater through time. In 1980, approximately 65% of the caries was found in 24% of the children. The prevalence of caries experience among children has declined significantly since 1970. Approximately 80% of the carious lesions occurring in school age children are on the occlusal surface.

PREVALENCE OF DENTAL CARIES IN CHILDREN Children from lower socio-economic families experience more tooth decay than do children from more affluent families. Studies have confirmed that the percentage of decayed teeth in the index declines with increasing household income. African-Americans have a higher percentage of the dmft/DMFT index in the decayed and missing category. Euro-Americans have a higher percentage of the index in the filled category. This difference reflects the differential in professional oral health care accessed by these two groups.

RELATED INFORMATION Dental caries is the single most common chronic childhood disease, 5 times more common than asthma, and 7 times more common than hay fever. There are striking disparities in caries prevalence by income. Poor children suffer twice as much caries as non-poor, and their disease is more likely to be untreated. One out four children in America are born into poverty--$24,600 in 2017 for a family of four. The majority of children, 40 million of 78.6 million, are eligible for Medicaid /CHIP public insurance. Twenty-five percent of poor children have not seen a dentist prior to kindergarten. 51 million school hours are lost each year to dental-related illness. Toothaches are the most common classroom health problem. Over one-third of American children do not have the benefit of water fluoridation; our most effective caries preventive strategy.

EARLY CHILDHOOD CARIES (NURSING CARIES) 5-10% children have Early Childhood Caries (ECC), sometimes called nursing (or bottle) caries; the rate is even higher among families with low incomes, and among racial/ethnic minorities. ECC is the result of poor nursing/feeding habits; associated with children being given the bottle past 12 month, and/or given the bottle with cariogenic solutions in it at night, and allowed to keep it in the mouth for a prolonged period. ECC significantly increases a child’s risk of future caries experience.

RISK FACTORS FOR CARIES AMONG CHILDREN Children born to mothers in their teens have a 5X greater chance of having carious lesions by age 5. Living in a rural area doubles the likelihood of having caries. Mothers who do not brush their teeth regularly, have children with double the risk for caries. Children from low SES families are at greater risk for dental caries.

Caries Risk Assessment Fisher-Owens, et al., Influences on Children’s Oral Health: A Conceptual Model. Pediatrics 2007;120(3):e510-e520

CARIES RISK GUIDELINES (American Dental Association) LOW: No carious lesions in last year Coalesced or sealed pits and fissures Relatively plaque free Fluoride in water supply and use of fluoride dentifrice Regular dental visits

CARIES PREVENTION MODALITIES FOR CHILDREN BY RISK CATEGORY (American Dental Association) LOW Educational reinforcement: Daily plaque removal with floss and brush Fluoride dentifrice One year recall

CARIES RISK GUIDELINES (American Dental Association) MODERATE One carious lesion in the last year Deep pits and fissures Some plaque accumulation No fluoride in water White spot lesions Irregular dental visits Orthodontic treatment

CARIES PREVENTION MODALITIES FOR CHILDREN BY RISK CATEGORY (American Dental Association) MODERATE Pit and Fissure Caries Sealants Smooth Surface Caries Education Daily flossing and brushing Dietary Counseling Fluoride dentifrice (low potency fluoride) Fluoride mouthrinse (low potency fluoride) Professional topical fluoride (high potency fluoride) Six month recall

CARIES RISK GUIDELINES (American Dental Association) HIGH Two ore more carious lesions in last year Past smooth surface caries Deep pits and fissures No or little systemic and topical fluoride exposure Plaque accumulation Frequent fermentable carbohydrate intake Irregular dental visits Inadequate salivary flow Inappropriate feeding habits (infants/young children)

CARIES PREVENTION MODALITIES FOR CHILDREN BY RISK CATEGORY (American Dental Association) HIGH Pit and Fissure Caries Sealants Smooth Surface Caries Education Daily flossing and brushing Dietary counseling Fluoride dentifrice Fluoride mouthrinse Professional topical fluoride (3-6 months) Three to six month recall Antimicrobial agents (Chlorohexidene)

PREVENTIVE FOCUS IN THIS MINICOURSE In this Minicourse we will focus primarily and specifically on the preventive issues associated with caries and periodontal disease. Prevention associated with malocclusions, trauma, and oral cancer will be addressed when these issues are addressed. Our approach to prevention of caries and periodontal disease diseases will be multi-dimension and comprehensive.

IMPLEMENTING THE CONCEPT OF PREVENTION Prevention of dental caries and periodontal disease is possible by directing our efforts to the four variables that are involved: the teeth, the bacteria, the substrate, and the understanding and motivation of the child and parent. It is imperative that the problem of prevention be approached by addressing all the variables of the disease process not just one or some. The focusing on only one aspect of a multifaceted problem leads to a distorted understanding of the problem, and an inadequate result.

“THE BLIND MEN AND THE ELEPHANT” BY GEOFFREY SAXE It was Six men of Indostan To learning much inclined, Who went to see the Elephant (Though all of them were blind), That each by observation Might satisfy his mind. The First approached the Elephant, And happening to fall Against his broad and sturdy side, At once began to bawl: "Bless me! but the Elephant Is very like a wall!"

The Second, feeling of the tusk, Cried, "Ho! What have we here, So very round and smooth and sharp? To me tis mighty clear, This wonder of an Elephant Is very like a spearl" The Third approached the animal, And happening to take The squirming trunk within his hands; Thus boldly up and spake: "I see", quoth he, "the Elephant Is very like a snake!” The Fourth reached out his eager hand, And felt about the knee, "What most this wondrous beast is like Is might plain", quoth he: "'Tis clear enough the Elephant Is very like a tree!"

The Fifth, who chanced to touch the ear Said, "E'en the blindest man Can tell what this resembles most; Deny the fact who can, This marvel of an Elephant Is very like a fan!" The Sixth no sooner had begun About the beast to grope, Than, seizing on the swinging tail That feel within his scope, "I see," quoth he, "the Elephant Is very like a rope!" And so these men of Indostan Disputed loud and long, Each in his own opinion Exceeding stiff and strong, Though each was partly in the right, And all were in the wrong!

PREVENTIVE MEASURES DIRECTED TO THE TEETH Water Fluoridation High Potency Topical Fluorides Fluoride Dentifrices Fissure Sealants

PREVENTIVE MEASURES DIRECTED TO THE MICROFLORA Plaque removal by daily flossing and brushing Antimicrobials

PREVENTIVE MEASURES DIRECTED TO THE SUBSTRATE Dietary Analysis and Counseling

PREVENTIVE MEASURES DIRECTED TO THE EDUCATING CHILDREN AND PATIENTS Educational Techniques Educational Resources Audio-Visual Materials Patient Educational Brochures