1. Caries Management and Prevention
—— ——
John D.B. Featherstone
University of California San Francisco

2. Disclaimer
Any products referred to in this presentation are given as examples and illustrations only by the presenter.
There is no implied endorsement of any of the examples given.
There are other brands and manufacturers of each of the products that are used as illustrations

3. “White spot” lesion
Protective Factors

4. Protective Factors
Frank occlusal
cavity

5. Early
Childhood
Caries
Protective Factors

6. The Caries Balance No Caries Caries Protective Factors
Saliva flow and components
Fluoride - remineralization
Antibacterials:-
chlorhexidine, xylitol, new?
Pathological Factors
Acid-producing bacteria
Frequent eating/drinking of
fermentable carbohydrates
Sub-normal saliva flow and
function
Caries
No Caries
Featherstone, Community Dent Oral Epidem, 1999

7. Often a delicate balance
Protective Factors
Often a delicate balance

8. The Caries Imbalance Caries Progression No Caries Risk Factors
Acidogenic
bacteria
Frequent
carbohydrates
Sub-normal
saliva
Protective
Factors
Saliva
Fluoride
Antibacterials
Disease Indicators
Cavities/dentin
Enamel lesions
Restorations < 2 yr
White spots
Caries Progression
No Caries

9. Caries Risk Assessment – High-Risk
One or more disease indicators
Cavities, radiographic lesions to dentin, recent restorations, white spots
And/or multiple risk factors
Coupled with little or no protective factors

10. High-Risk Indicator in Infants

12. Guiding Principles for Caries Management for High-Risk Individuals
Placing restorations does not reduce the bacterial challenge
Increase fluoride for remineralization
Decrease bacterial challenge by antibacterial therapy
Balance pathological factors with protective factors

13. Fluoride Works Primarily Through Topical (Surface Mechanisms) - Inhibits demineralization and enhances remineralization
Therefore products applied to the mouth are the most effective
Fluoride products are effective for adults as well as children of all ages

14. Brushing twice daily with a fluoride-containing dentifrice is one of the most effective ways to control dental decay.
High bacterial challenge overcomes the therapeutic effects of fluoride.

15. Fluoride Toothpaste Children under 6 years of age:
Pea sized amount twice daily
Children 6 years and older:
Brush at least 2X daily with a fluoride toothpaste -> major caries reduction
High risk: use 5000 ppm F toothpaste

16. High concentration 5000 ppm fluoride toothpaste/gel for high-risk patients from age 6 years upwards.

17. Evidence-based Clinical Recommendations:
Professionally Applied Topical Fluoride
American Dental Association: May, 2006
Fluoride gel applied for 4 minutes or more is effective
Fluoride varnish applied every 6 months is effective
Two or more applications of fluoride varnish per year are effective in high caries risk individuals
Office topical applications no added benefit for low-risk individuals

18. Weintraub et al, J Dent Res, 2006
Weintraub et al, J Dent Res, Fluoride varnish in infants (approx 2 years old at start). Percent with decay vs treatments
Protective Factors

19. Fluoride Varnish 2-3 X a year for high-risk children and adults

20. Antibacterial Therapy-Age 6 Years Up
Chlorhexidine gluconate 0.12%
Rinse 10 ml daily for one week
Repeat every month for 6 months and reassess
Continue until cariogenic bacteria are controlled
Must be used together with fluoride therapy

21. Xylitol Gum, Mints Xylitol Noncariogenic sweetener
Inhibits transfer of bacteria from mother to child
Can reduce loading of cariogenic bacteria in the mouth

22. Guiding Principles for Caries Management for High-Risk Individuals
Placing restorations does not reduce the bacterial challenge
Increase fluoride for remineralization
Decrease bacterial challenge using antibacterial therapy
Balance pathological factors with protective factors

23. Therapeutic Summary - High Caries Risk
Fluoride toothpaste at least 2x daily
Increase the fluoride to 5000 ppm toothpaste for age 6 years through adult
Fluoride varnish 2-3 x annually
Xylitol for mothers and caregivers of 0-5 year olds
Chlorhexidine (1x daily, 1 week, each month) and xylitol for age 6 years through adult

24. Additional Therapy
Calcium phosphopeptide paste with fluoride (MI paste plus)
Sealants
Glass ionomer restorations/sealants
Minimally invasive restorations

25. Acknowledgements California Dental Association Journal
October/November 2007

27. Disclosure:
I have no personal financial interest in any company relevant to this presentation.
I consult for, have consulted for, or have done research funded or supported by:
Arm and Hammer, Beecham, Cadbury, GSK, KaVo, Novamin, Omnii Oral Pharmaceuticals, Oral B, Philips Oralcare, Procter and Gamble, Wrigley, and the National Institutes of Health.

28. Where do the cariogenic bacteria
come from in children?
Mothers and caregivers transmit bacteria to children
Children can transmit to children
Treat the caregivers to reduce the transmission