Caries prevalence has decreased significantly among industrialized countries during the last two decades as a result of the wide spread use of preventive programs.

In developing countries, the general tend is for caries prevalence to increase. In Egypt, although caries prevalence is low and the trend is not increasing, there is accumulated unmet needs.

1. Primary prevention: The aim is to reverse the progress of the initial stages of disease, or to arrest the disease process before treatment becomes necessary.

2. Secondary prevention: The aim is to use routine treatment methods to terminate the disease process and to restore tissues to as near normal as possible.

3. Tertiary prevention: The aim is to use measures to replace lost tissues and to rehabilitate patients so that the function is as normal as possible.

Dental caries is a multifactorial disease involving the interplay of several factors:- 1. Micro flora (etiologic factors): acidogenic bacteria that colonize the tooth surfaces.

2. Host (internal modifying factors): Quantity and quality of saliva, the quality of the tooth, macro and macro-anatomy of the teeth that favor plaque retention. Etc...

3. Diet (external modifying risk factor): Intake of fermentable carbohydrates especially sucrose, but also starch.

4. Time: Total exposure time to inorganic acids produced by the bacteria of the dental plaque.

1. fighting caries-inducing microorganism. 2. Increasing the resistance of the teeth to decay. 3. Modifying caries-promoting diet.

These three strategies should be followed at home by the individual patient, in the dental office and at the community level.

1- Targeting those in most need. 2- Greater effectiveness of preventive procedures. 3- Appropriate level of care. 4- Economic efficacy and cost control.

I- Oral hygiene measures. II- Fluoride administration. Ill- Diet and its oral effect.

The objectives of oral hygiene measures: 1- Remove all food debris from tooth surfaces. 2- Maintain the least possible amount of dental plaque.

Simple oral rinsing is very helpful in clearing fermentable carbohydrates and neutralizes any acid present.

Rinsing the mouth after meal with water is recommended especially at school time and among very young children who are unable to brush.

a) Cosmetic mouth rinses: which help to reduce halitosis, provide pleasant taste and temporary suppresses the bacterial count.

b) Therapeutic mouth rinses: such as dextranase, chlorohexidine and fluorides. chlorohexidine The only recommended antibacterial agent for caries other than fluoride is the chlorohexidine (CHX).

1- Chemical property which causes it to adhere to almost everything giving the drug substantively. 2- Has selective effect against cariogenic bacteria.

3-Maintains suppression of streptococcus mutans for at least six weeks following discontinuation. 4- Inhibits caries formation by decreasing acid production.

% rinse on a prescription basis for high-risk patients for short term use (30 days or less). 2- Self applied (1%) chlorohexidine gel may be applied by flossing or in trays.

3-Chlorohexidine varnishes are applied once and repeated if streptococci recolonize the oral cavity % fluoride combined with 0.12% chlorohexidine mouth rinses in pregnant women can significantly reduce transmission of mutans streptococci to their children.

1- Staining of teeth. 2- Some patients find the taste offensive. 3- Inflammation of gingiva may occur.

Brushing should start in infancy. Studies have confirmed that the bacteria for dental diseases are present at the eruption of the primary teeth.

Tooth brushing Type of brush Brushing technique Dentifrices Manual Powered Ionic Sonic or ultrasonic It is most widely form of oral hygiene measure.

Made up of different materials, such as acrylic or polypropylene Its flexibility, size and shape must be convenient for manual use in the mouth the handle must be comfortable and rest securely in the hand It should be thick enough to allow a firm grip and good control Handle ShankTufts Bristles Made of either polyester or nylon These are inert polymers Nylon has more wear resistant and more hygienic, due to its antistatic properties bristles may be soft( mm), medium ( mm) or hard ( mm). Children brush should always be soft bristled

Manual vs. Powered Requires manual dexterity and delegacy Incorrect technique can be harmful Effort needed can cause the person to limit time spent on brushing Only minimal effort is needed to brush properly Can be helpful for people with less manual dexterity Head is small in size, can reach all surfaces More helpful in patients with braces Aids in motivation

Relative Indications for Powered brush Those with physical or learning disability Aged persons Children Fixed orthodontic appliances Institutionalized patients who depend on health providers for oral care Arthritic patients Individuals with poor dexterity Poorly motivated patients

Ionic brush Light stimulates titanium dioxide rod to generate negatively charged electrons Positively charged hydrogen ions in plaques acid are attracted by the electrons The acid is neutralized ad plaque breaks down

The technique should clean all tooth surfaces, specially the area of gingival crevice and the interdental region The movement of the brush should not injure the soft or hard tissue. Certain methods eg., vertical and horizontal scrubbing methods can produce gingival recession and tooth abrasion The technique should be simple to use and easy to learn The method must be well organized so that each part of the dentition is brushed in turn and no area overlooked

1. Scrub technique 2. Fones technique

3. Roll technique apically towards A.G apically towards A.G. 4. Charters technique occlusally lateral, downward occlusally lateral, downward pressure. pressure.

Tips of bristles: on the gingival margin Direction of bristles : pointing apically, about 45 degree to the long axis of teeth Movement: vibrate the brush, not changing the position of the bristles Bass method

Tooth brushing alone cannot effectively control interproximal plaque

Dental floss Removes plaque and debris adherent to interproximal surfaces Polishes proximal surface as it removes plaque Massage the interdental papilla Reduces gingival bleeding Maintenance of general oral hygiene and prevents halitosis

Dental floss Waxed unwaxed Unwaxed is recommended for individuals with normal tooth contacts Waxed is recommended for individuals with tight contact, moderate to heavy calculus deposits, crowded teeth, and overhanging restorations 1

Recommended for teens and adults with good neuromuscular coordination and mental maturity

Indications Large embrasures Diastemas Exposed root furcation Orthodontic and fixed appliances Application of fluoride or desensitizing agents 2 Interdental oral hygiene aids Interdental brushes

Interdental oral hygiene aids 4 Wedge stimulator Wooden or plastic oral hygiene devices designed for individual cleaning and stimulation, some are treated with xylitol They are recommended for use only from the facial aspect, where the proximal surfaces are exposed to avoid traumatizing gingiva Inserted interproximally with the base of the triangle resting on the gingival side

Adjunctive Aids dental irrigation device Eliminate plaque and soft debris by the use of a jet stream of water May be also used with antimicrobial agent Cosmetic to decrease halitosis Therapeutic ( dextranase, CHX, Fl)

Sewak chewing sticks The miswak, a traditional chewing stick for cleaning teeth, is made from the plant Salvadora persica It was concluded that miswak use was at least as effective as tooth brushing for reducing plaque and gingivitis, and that the antimicrobial effect of S. persica is beneficial for prevention/treatment of periodontal disease.

Cosmetic Therapeutic Cleans, removes materia alba, plaque,biofilm and food debris Transports the drug substance to the tooth surface. Effective to decrease incidence of caries, gingivitis, calculus formation or tooth sensitivity Ingredients Abrasives 40:50% Humectant 20-30% Water 20-30% Binding agent 1-2% Foaming agent 1-3% Flavoring agent 1-2% Preservative

Abrasives Calcium carbonate and calcium phosphate react adversely with fluoride ions Most dentifrices now use silicon oxides and insoluble sodium monophosphate abrasives Detergents They give the foaming action of a dentifrice They clean tooth surface Sodium lauryl sulfate is the most common and has antibacterial effect

These are harmless dyes that helps the patient to identify plaque and thus, aid in the mechanical removal of plaque by the tooth brush and dental floss. They also help in patient motivation and evaluation of the thoroughness of cleaning.

Diet history assessment Instruct the patient to write down anything he/she eats or drink For at least 3-7 days including a vacation day Assess fluoride intake Diet Analysis

Cariogenic food typeFrequenc y per day Liquid (Soft drinks, fruit drinks, cocoa, sugar, and honey in beverages, non-dairy creamers, ice cream) X 1 points Solid and sticky (Cake, donuts, pastry, canned fruit in syrup, bananas, cookies, chocolate candy, caramel, toffee, jelly beans, other chewy candy, chewing gum that contains sugar, dried fruit, marshmallows, jelly, jam) X 2 points Slowly dissolving (hard candy, cough syrup, antacids) X 3 points CARIES RISK Points: [0 1 Low Risk] [2 7 Moderate Risk] [8 9 High Risk] Tufts School of Dental Medicine Diet Analysis for caries risk assessment Dr. Ghada Mahmoud

Remarks & Recommendations Praise good habits Explain healthy balanced diet Decrease consumption of fermentable CHO Restrict sugar intake to meal time Avoid in between meals snacks Select soluble forms and avoid sticky candy Encourage good habits

Non-cariogenic sweeteners are increasingly used to replace sugar in foods, drinks and medicines. They cannot be fermented by microorganisms to any great extent and so are considered non cariogenic. Intense Sweeteners Bulk Sweeteners Saccharin Aspartame sucralose Xylitol Sorbitol Mannitol

Fluoride- containing dentifrice 1000, 1100 or 1500 ppm in the form of: Sodium fluoride: directly provides free Fl, cant be used with abrasive tooth paste Sodium fluoride/silica combination (recent crest formulation) Sodium monofluorophosphate: can be used with calcium containing abrasives, because it holds fluoride ions in complex form (Colgate) Amine fluoride: the superficial enamel layer seems to be more stable after amine Fl application Stannous fluoride: the original crest formula. Discolors tooth, has astringent taste

Brush twice daily, before going to bed and at one other time during the day just after eating.

Dietary fluoride supplements are administered as single dose, either daily or periodically, therefore they produce much higher peaks of fluoride in the plasma than the multiple divided doses received from the water supply

Self-applied rinsing using 0.05% sodium fluoride for high-risk individuals who are aged 6 years and over, in addition to fluoridated dentifrice and professional fluoride treatment.

Mouthrinse should be used at different time from brushing, to help maintain a low concentration of fluoride throughout the day.

These products contain 0.4% stannous fluoride and are formulated in aqueous gel base that doesn't contain an abrasive system.

The gel is left on the teeth for five minutes to exert its maximum cariostatic effect and the patient is instructed not to rinse, eat or drink for 30 minutes, but he should expectorate the excess gel and not swallow it. This routine is followed on daily basis especially before bed time.

They are prescribed for home use for patients with rampant caries or in high risk patients in areas with or without fluoridated water.

I- Oral hygiene instruction. II- Fluoride therapy. III- Sealant application IV- Diet control.

The following systems are available for professional application: fluoride solutions for painting, gels, prophylaxis pastes, and slow-release agents, such as varnishes and glass- ionomer cements.

The most common fluoride solutions for painting are: neutral 2% NaF (1% F) 8% SnF2 (2% F) acidulated phosphate fluoride (1.23% F). Amine fluoride solutions are also used.

Fluoride gels for professional use neutral NaF, acidulated phosphate fluoride, SnFa, amine fluoride plus NaF, and by prescription, NaF + chlorhexidine.

For optimal accessibility, the gel is syringed into the posterior interproximal spaces, followed by gel application in a customized tray for more than 4 minutes.

Gels containing SnFa, amine fluoride plus NaF, and particularly NaF+ chlorhexidine have combined fluoride and antiplaque effects.

Semislow-release and slow-release fluoride agents, such as fluoride varnishes and glass-ionomer cements, are rapidly growing for professional use, because of the greater cost effectiveness of the slow release of fluoride.

Three major fluoride varnishes are commercially available: Three major fluoride varnishes are commercially available: Duraphat (5% NaF; 2.3% F), Fluor protector (silan fluoride; 0.1% F) and Bifluorid 12 (6% NaF + 6% CaF2, about 6% F).

1- Oral hygiene instruction. 2-Dietary modification on a public health scale. 3-Fluorides which include: a) Community water fluoridation. b) School water fluoridation.