Recent Advances in Caries Prevention: Saurabh S. Chandra Dept. of Conservative Dentistry Recent Advances in Caries Prevention PowerPoint Presentation: Introduction Current Concepts & Risk Factors Caries Risk Assessment Caries Prevention Recent Advances Conclusion PowerPoint Presentation: Dental caries is an infectious microbiologic disease of the teeth that results in localized dissolution and destruction of the calcified tissues (Sturdevant) Dental caries is an infectious, communicable disease resulting in destruction of tooth structure by acid-forming bacteria found in dental plaque, in the presence of sugar (NIH 2002) PowerPoint Presentation: There has been a shift towards improved diagnosis and treatment of non-cavitated, incipient lesions as well as prevention and arrest of such lesions Restorations repair the tooth structure, but do not stop caries & have a finite life span and are susceptible to disease (Ref: Fontana and Zero, 2006) PowerPoint Presentation: During the past few decades, changes have been observed not only in the prevalence of dental caries, but also in the distribution and pattern of the disease in the population PowerPoint Presentation: Prevention ??? PowerPoint Presentation: 46.6 Billion US $ (1995) 54.2 Billion US $ (2000) 62.9 Billion US $ (2005) > 75 Billion US $ (2010) (Ref: JADA, Oct 2006) Incidence in India: Incidence in India According to a survey done by WHO in schools across India, it was reported that 81.2% of children between the age group of 5-6 years had a mean DMF of 4.9 In the age group of 12-14 years, 59.4% had a mean DMF of 3.1 (Ref: WHO Global Infobase) PowerPoint Presentation: Some of the important changes that have taken place over the last few years that have influenced caries prevention are: Changes in disease level among different populations Increased understanding of caries pathogenesis process Material and operative technique development Changes in patient behavior and requests (Ref: DCNA, Vol 44 July 2000) PowerPoint Presentation: The most important part in the treatment of disease is caries prevention The preventive approach model recognizes that caries is a chronic process having episodes of activity and inactivity and that with early recognition of the disease process, before cavitation, intervention will stop and even reverse the disease process What is the need for Prevention: What is the need for Prevention Symptomatic treatment is intensive The cost of treatment is high Compromises nutrition Results in dysfunctional speech Causes severe pain and suffering Goals of Prevention: Goals of Prevention Reduce the number of cariogenic bacteria Early detection of incipient lesion Limitation of caries activity Identification of high risk patients Begin with an evaluation of overall resistance of the patient to infection by cariogenic bacteria (Risk Assessment) Levels of Prevention: Levels of Prevention Primary prevention: Aimed at reducing the occurrence of a disease in a population. Accomplished by health promotion and specific prevention. Eg : Community water fluoridation and diet control Secondary prevention: Aims at reducing the number of existing cases of an illness or dysfunction. Early detection, preventive resin restorations Tertiary prevention: Disability limitation and rehabilitation Current Concepts: Current Concepts Disease Environment Genetics Infectious Agents PowerPoint Presentation: MULTIFACTORIAL DISEASE DISEASE GENETIC & ENVIRONMENTAL FACTORS BIOLOGIC FACTORS SOCIAL FACTORS BEHAVIORAL FACTORS PSYCHOLOGICAL FACTORS Dental caries is conceptualized as an interaction between Genetic, environmental and other factors Keyes Diagram: Keyes Diagram Keyes Diagram SALIVA PowerPoint Presentation: HOST (Tooth) Age Fluoride Genetics Morphology Nutrition SUBSTRATE Carbohydrates Frequency of eating Oral clearance Physical nature of food Detergency of food FLORA Fluoride in plaque Lactobacilli Oral hygiene Streptococci Virulence factors Transmissibility SALIVA pH Flow rate Composition Buffering capacity Bicarbonate levels PowerPoint Presentation: Microorganisms Streptococci Mutans (MS) Sorbinus Gordonii Oralis Salivarius Lactobacillus Casei Fermentum Oris Actinomyces Israelis Naslundii (Ref: DCNA & Caries Research 2001) Veillonella, Bifidobacterium, Eubacterium, Fusobacterium, Peptostreptococcus, Prevotella, Porphyromonas spp (Isolated from carious dentin) PowerPoint Presentation: Pathogenic properties of Cariogenic Bacteria: Rapidly transport fermentable sugars when in competition with plaque bacteria and the conversion of such sugars into acid (Acidogenic) Produce extracellular and intracellular polysaccharides (Glucans & Fructans) Have the ability to maintain sugar metabolism under extreme environmental conditions (Aciduric) PowerPoint Presentation: MS and LB remain viable at low pH They grow and metabolize (Acidogenic & Aciduric) This ability lies on: The ability to maintain a favorable intracellular environment and pump out protons even in acidic conditions The possession of enzymes with a more acidic pH The production of specific acid stress response proteins PowerPoint Presentation: Fejerskov & Manji 2005 The Dynamics of Caries : The Dynamics of Caries Caries is a dynamic process, where there is an imbalance between mineral loss and gain Over time if there is a net mineral loss, it leads to Cavitation Studies of incipient lesions have shown that in the same lesion, some areas can be demineralizing while some re-mineralizing (Surface layer – RM; Subsurface – DM) Enamel Caries Process: Enamel Caries Process Production of acids by microorganisms: MS & LB produce Lactic acid Heterofermentive bacteria form Acetic, Formic, Butyric & Succinic Acids Acid diffuses into plaque, which increases the H+ ion conc. The pH of plaque represents the net effect of a complex interaction between bacterial, salivary & dietary factors Diffusion of Acids into the Tooth: Diffusion of Acids into the Tooth As pH of plaque drops, conc. of acid builds up, thus producing a conc. gradient that causes acids to penetrate into enamel Acid diffusion into enamel takes place through the intercrystalline and interprismatic spaces, developmental defects etc Clinical Manifestations: Clinical Manifestations Early Changes: The earliest changes in enamel which occurs after demineralization cannot be detected clinically White Spot Lesion: First visual clinical presentation 300-500 μ m to be detectable Caused by enamel subsurface loss leading to loss of translucency Lesion can be arrested Arrested lesion may remain white or brown White spot lesion is a reversible stage of the carious process White Spot vs. Enamel Hypoplasia: White Spot vs. Enamel Hypoplasia On drying On wetting Surface Caries “White Spot” Appears opaque Appears translucent Softer than normal enamel Enamel Hypoplasia Appears opaque Appears opaque Hard PowerPoint Presentation: Risk Factors & Caries Risk Assesment PowerPoint Presentation: Identify Risk Factor Dental Caries Distribution Diagnosis Pattern Prevalence Risk factors: Risk factors An environmental, behavioral, or biologic factor, which if present directly increases the probability of a disease occurring, and if absent or removed reduces the probability Risk factors are part of the causal chain or expose the host to the causal chain Once disease occurs, removal of a risk factor may not result in a cure Beck, 1996 PowerPoint Presentation: Reduce risk factors associated with major diseases and increase factors that protect health throughout the life course - Tobacco - Physical activity - Nutrition - Healthy eating - Oral Health - Psychological factors - Alcohol and drugs - Medication PowerPoint Presentation: Caries risk assessment determines the probability of caries incidence in a certain period Risk assessment is the use of knowledge of factors associated with disease to determine which patients are more or less likely to prevent or control their disease Benefits of Caries Risk Assessment: Knowing risk factors can increase prediction of who will get the disease and who will not Identify groups that will benefit from prevention Increase level of suspicion leading to better and more thorough examination & diagnosis Identifying patients at a younger age group Benefits of Caries Risk Assessment PowerPoint Presentation: Risk assessment identification can be further broken down: Different Age groups Individuals Teeth Tooth Surfaces PowerPoint Presentation: Different Age groups: Key risk groups from ages 1 to 2 years and 5 to 7 years; Ages 11 to 14 years Key risk age group in young adults and adults Individual Risk: By combining etiologic factors, caries prevalence and incidence, external or internal modifying risk indicators PowerPoint Presentation: 1 2 3 4 Prediction based on socio-economic status, oral hygiene and dietary factors Prediction based on behavioral factors Prediction based on past caries experience Prediction based on salivary factors and microbial colonization Messer, 2000 PowerPoint Presentation: Microbial Colonization Caries Experience Behavior SES, Oral Hygiene, Diet Saliva PowerPoint Presentation: Low indices of socioeconomic status (SES) have been associated with elevations in caries, although the extent to which this indicator may simply reflect previous correlates is unknown Low SES is also associated with reduced access to care, reduced oral health aspirations, low self efficacy, and health behaviors that may be enhance caries risk Wilman 2002 Diet: Diet Sugar exposure is important factor in caries development Frequency and amount of sugar intake has been shown related to dental caries incidence PowerPoint Presentation: The best available evidence indicates that the level of dental caries is low in countries where the consumption of free sugar is below 15–20 kg/person/yr. This is equivalent to a daily intake of 40–55 g and the values equate to 6–10% of energy intake. Individuals should be recommended to reduce the frequency with which they consume foods containing free sugars to four times a day and thereby limit the amount of free sugars consumed (European workshop on Oral care and general health, 2003) Behavior : Behavior Age Nocturnal bottle usage Additive On pacifier during sleep Breast feeding (Ho and Messer, 1993) Breast feeding Bottle feeding Regularity of snacks Drinking sweet beverage Watching television during meal Brushing by mother (Kawabata et al., 1997) Caries Experience : The most consistent predictor of caries risk in children is past caries experience NIH, 2001 Previous caries experience was an important predictor in most models tested for primary, permanent and root surface caries Zero et al., 2001 Caries Experience PowerPoint Presentation: Miravet et al., 2007 PowerPoint Presentation: Mutan streptococci Ecological Plaque Lactobacilli Association of Lactobacilli and dental caries. Association of Lactobacilli and fermentable carbohydrates. Innoculation of S.mutans shows higher caries activity. High acid production activity of S.mutans Other oral bacteria are sufficiently acidogenic. Adherence of plaque without mutan streptococci. PowerPoint Presentation: Van Houte, 1993 Saliva: Saliva affects all three of components of Keyes’ classic Venn Diagram of caries etiology Dodd et al., 2005 Saliva PowerPoint Presentation: Lenander-Lumikari & Loimaranta, 2000 PowerPoint Presentation: Xerostomia Genetic Drugs Therapy Miscellaneous Salivary Flow Rate Hyposalivation Objective salivary flow rate that is under 0.1 or 0.16 ml/min (or 0.1 ml/min; relate to medication and systemic disease Tanathipanont & Korwanich, 2008 PowerPoint Presentation: Additional potential risk assessment tools require sophistication generally outside the reach of the practitioner Advanced Sialometry (Unstimulated & Stimulated secretions) Salivary Composition – Antibacterial factors, IgG, Anti acid factors, Anti solubility factors Pooled and site specific plaque analysis – detailed microbiological analysis, inorganic components, pH Tooth characteristics Oral clearance PowerPoint Presentation: Commercial kits for saliva and microbial test Other commercial kits: Other commercial kits Caries Screen Proflow Oricult Mucount Advances in Caries Diagnostic Aids: Advances in Caries Diagnostic Aids Quantitative light induced fluorescence Digital radiography Measurements by electrical conducting devices Direct fiberoptic transillumination Who is a High Risk Patient ?: Who is a High Risk Patient ? Past caries experience Low SES; Unaware of dental needs Two or more active carious lesions High DMF Poor dietary habits/Poor nutrition High sugar intake Low Salivary flow High MS, LB Count or Plaque Accumulation People with special needs Geographical area PowerPoint Presentation: An illustration of how risk assessment and diagnostic testing of the future might be integrated to allow more accurate targeting of dental therapies PowerPoint Presentation: Caries Prevention PowerPoint Presentation: A lot of research has been directed towards efforts to develop methods to prevent caries These range from simple to highly sophisticated techniques PowerPoint Presentation: 1 Combating the caries inducing microbes 2 Increase the resistance of tooth structure to caries attack 3 Modifying the diet and augmenting salivary factors Walsh, 2004 Reduce the pathogenic potential of dental plaque: Reduce the pathogenic potential of dental plaque Mechanical plaque control 1 Chemotherapeutic method 2 Food intake restriction 3 Replacement Therapy 4 Mechanical & Chemical Plaque Control: Mechanical & Chemical Plaque Control The control of dental caries by mechanical measures refers to procedures aimed at removal of plaque from tooth surfaces Brushing Flossing Oral irrigators Mouthwash Chewing gums PowerPoint Presentation: Toothbrushes: Medium and Small head Manual or Powered Proper brushing techniques Replacement on time Interdental brushes Cone shaped brushes used in patients with wide interdental spaces Single tufted brushes Used in areas of malalignement Floss Nylon or Teflon tape; Used in young healthy mouths with healthy interdental papillae Wooden Sticks Soft traingular, wooden toothpicks Used in patients with gingival recession Inhibition of microbial colonization : Inhibition of microbial colonization Reduce microbial adhesion by modifying the surface characteristics of teeth, pellicle and/or microorganism by lowering its surface free energy Surface-modifying agents include anionic polymers, substituted amino alcohols, polymethyl siloxane, alkyl phosphate combined with a non-ionic surfactant and polyphosphates Antimicrobial agents such as Chlorhexidine, cetylpyridinium chloride, amino fluoride and sodium dodecyl sulfate (SDS) are also surface-active agents Several antimicrobial agents impaired expression of surface adhesins Anti Plaque Agents: Anti Plaque Agents Antiplaque agents may be delivered to the oral cavity by various delivery agents (vehicles), i.e. mouth rinses, sprays, dentifrices, gels, chewing gum/lozenges or sustainedrelease vehicles such as varnishes Cationic: Eg: Chlorhexidine, Cetylpyridinium chloride, Delmopinol, Hexetidine, Sanguinaria extracts, Metal ions(zinc) Anionic: Eg: Sodium dodecyl sulfate Non-ionic agents: Eg: ,Triclosan Other agents: eg: Enzymes, Xylitol PowerPoint Presentation: Chlorhexidine: Most effective anti plaque agent Bisbiguanide with both hydrophilic and hydrophobic properties More effective against Gram-positive than against Gramnegative microorganisms The positively charged Chlorhexidine molecule binds probably through electrostatic forces , i.e. to phosphate,carboxyl or sulfate groups on the oral mucosa, on microorganisms and in the pellicle PowerPoint Presentation: Interferes with the normal membrane function, causing leakage of cell constituents and precipitation of cell contents CHX reduces the metabolic activity of the dental plaque Inhibits enzymes that are essential for microbial accumulation on tooth surfaces, i.e. glucosyltransferase, and metabolic enzymes, i.e. phosphoenolpyruvate phosphotransferase . Advances in Anti Plaque Agents : Advances in Anti Plaque Agents Anti-bacterial and anti-adherence agents are being tested as plaque building blockers The enzyme Glucosyltransferase is inhibited by use of analogues of sucrose interfering with glucan synthesis (Competitive inhibitors, Anti GTF antibodies) Some plant and fungal products alter adhesion of cell membrane Rajesh et al tested efficacy of Mango & Neem leaf as well as Tea extracts and found that they inhibited plaque formation (Interfere with adhesion and co-aggregation) Controlled release devices or Polymers are being used in the oral cavity to increase the substantivity Replacement Therapy: Replacement Therapy Lactic acid produced by MS is controlled by a gene which can be mutated Genetic engineering provides an alternative of producing inactivated forms and cloning A new approach is used to transfer the genes from the bacteria that naturally produces enzymes like mutanase which degrades extra cellular sticky polymers involved in plaque adhesion An attempt to transfer arginine diminase gene, which produces base in S.sanguis into MS, to counter the acidogenic potential has been made Inhibition of Glucan Mediated Adhesion: Inhibition of Glucan Mediated Adhesion Glucan mediated adhesion of MS can be minimized by substituting a structural analogue of sucrose for dietary sucrose. The include D-amino derivative of sucrose, Acarbose, 6-deoxysucrose etc. These are all capable of competing with sucrose for effective site of Glucosyltransferase Diet & Salivary factors: Diet & Salivary factors Sugar free chewing gum 1 Supportive life style 2 Diet 3 Diet Counseling 4 Enhance Fluoride in saliva 5 Xylitol – A Sweet Alternative: Xylitol – A Sweet Alternative Discovered in 1891 by German chemist Emil Fischer Pure 100% pharmaceutical-grade xylitol is a white, crystalline carbohydrate that is classified, according to some, as a sugar It is found naturally in fibrous vegetables and fruit, as well as in various hardwood trees like birch. It is even produced by the human body during normal metabolism (up to 15 grams daily from other foods) It is a naturally occurring form of the 5-carbon sugar, Xylose (xyl in Greek means 'wood') PowerPoint Presentation: The main sources of commercially produced xylitol are corncobs and wood scraps from the lumber industry Xylitol is more narrowly classified as a polyol or sugar alcohol (without inebriating qualities) Polyols possess functional hydroxyl groups. It is important to note that xylitol differs from other polyols like sorbitol Xylitol is a 5-carbon pentatol whereas sorbitol is a 6-carbon hexitol PowerPoint Presentation: Keeps the sucrose molecule from binding with MS MS cannot ferment (metabolize) Xylitol Xylitol reduces MS by altering their metabolic pathways and enhances Remineralization Recommended to chew gum after meals/snacking for 5-30 mins Reduces the acidogenicity of plaque and increases salivary flow Protects salivary proteins, has a protein-stabilizing effect PowerPoint Presentation: To be effective, 4 to 12 grams of xylitol per day are needed (gums and mints contain about 1 gram each) ADA suggests using xylitol 3-5 times daily between meals Increasing dental benefits level off at around 15 grams per day Diet & Diet Counseling: Diet & Diet Counseling Goals of Diet Counseling: Reducing high frequency exposures to sugars Avoid frequent consumption of sugar containing drinks Restricting sugar containing snacks that are eaten slowly Limiting cariogenic foods to mealtimes and promoting non-cariogenic food for snacking Rapidly clearing cariogenic foods from the oral cavity by brushing or by protective means (Xylitol) (Ref: DCNA, October 2006) Oral Health dietary guideline for Parents: Oral Health dietary guideline for Parents Dental Period Nutrition Pregnant Women Follow the healthy eating pyramid, taking into account increased needs for pregnancy Prenatal vitamin & mineral supplements; Limit intake of cariogenic food Birth to 1 year Avoid allowing infant to sleep with a bottle; Avoid excessive beverages (juice); Eliminate dipping pacifiers in sweetened food 1 to 2 years Avoid frequent consumption of sugar containing drinks; Encourage Weaning; Promote non-cariogenic snacks 2- 7 years Discourage slowly eaten sugar containing foods; Promote non- cariogenic foods for snacks; Encourage eating at meals (Pyramid) Increase tooth structure resistance to caries attack: Increase tooth structure resistance to caries attack Community fluoride program 1 Fluoride Application 2 Remineralization 3 Pit & Fissure Sealants 4 Lasers 5 Caries Vaccine 4 Fluoride: Fluoride Systemically, from ingestion of fluorides in water, beverages Topically from the bathing of enamel by oral fluids such as saliva, water, topical fluoride solutions Systemic: Pre-eruptive, from the fluid filled sac which surrounds the tooth. Highest concentration at the surface, decreasing towards the interior. Post-eruptive , through the porous enamel, converting hydroxyapatite crystals into fluorapatite . PowerPoint Presentation: Topical acquisition by enamel: Concentration is high in areas that is very porous, like hypomineralized enamel Low pH facilitates fluoride uptake At the high concentrations used during topical application a layer of calcium fluoride is formed Acquisition by dentin and cementum: In dentin the crystals are smaller, so it has high concentration of fluoride Cementum is very thin, so it accumulates the maximum amount of fluoride, however the superficial cementum is not highly concentrated, since it is very rapidly deposited Mechanism of Action : Mechanism of Action Increase enamel resistance or reduction in enamel solubility Effect of fluoride on mineral phase crystal structure Effect of fluoride on Remineralization Antibacterial effect of salivary and plaque fluoride Effect of fluoride and tooth morphology PowerPoint Presentation: Rendering the enamel more resistance for acid dissolution : Fills the voids (missing hydoxyapatite) with hydrogen bonding and stabilizes the crystal lattice structure Under the influence of fluoride tooth produce large crystal with less imperfection and having small surface area for dissolution Inhibits demineralization- by replacing OH – ion of hydoxyapatite by an F - ion resulting in gap forming fluorapatite which is highly resistance to acid dissolution PowerPoint Presentation: Anti bacterial effect: Fluoride ion does not cross the cell wall of micro organisms of cariogenic bacteria, but as pH drops dental plaque release H + F - + H + = FH (dissolves the cell wall of micro organisms and inhibits enzymes eg ;(glucosyl transferase) and act directly on digestive system of microorganisms ,reduce the uptake of glucose into cell of microorganisms PowerPoint Presentation: Mode of fluoride administration: (Systemic) Water fluoridation Milk Salt Dietary fluoride supplements PowerPoint Presentation: Topical: Solution Varnish Foam Gels Dentifrices Fluoride rinses Professionally Applied Topical Fluorides: Professionally Applied Topical Fluorides Prophylactic pastes: Used for professional tooth cleaning; Contain stannous fluoride with Zirconium silicate abrasive or low viscosity silica acidulated phosphate fluoride paste Fluoride Solutions: NaF(2%) & SnF(8%) may be applied for children at periodic intervals Fluoride Gels: APF is an effective topical agent, recommended for children who are at high risk for caries PowerPoint Presentation: Dual component Dentifrices containing NaF and Dicalcium Phosphate Dihydrate NaF and Dical are incompatible in a single formulation as they form a very stable & insoluble salt The effect may be through- Effect of fluoride alone Combined effect of F and Ca to increase F deposition Effect of Dicalin providing additional Ca which enhances remineralization PowerPoint Presentation: Fluoride releasing Pit & Fissure sealant (FISSURIT-F) Argon Laser curing of Fluoride releasing Pit & Fissure sealant Westermen et al (2000) – Argon laser polymerization resulted in greater degree of protection against an artificial caries challenge Demineralization - Remineralization: Demineralization - Remineralization Dental mineral mainly consists of carbonated calcium HA, which differs from calcium HA by the substitution of carbonate for a portion of the phosphate in calcium HA Carbonated calcium HA is more soluble than calcium HA, especially in acidic media Although quite insoluble at pHs greater than 7, carbonated calcium HA becomes increasingly soluble as the pH is lowered PowerPoint Presentation: Demineralization occurs while the plaque pH remains in the acidic range and the plaque fluid is under saturated with respect to tooth mineral Neutralization of plaque acids by the alkaline buffer system in saliva can take as long as two or more hours Once plaque acids are neutralized, remineralization can take place PowerPoint Presentation: In addition to buffers, saliva contains calcium and phosphate ions, which enter the enamel during remineralization Remineralization occurs between periods of demineralization Thus, demineralization and remineralization can be considered a dynamic process characterized by the flow of calcium and phosphate out of and back into tooth enamel Remineralization: Remineralization The demineralization process can be reversed if the pH is neutralized and there are sufficient Ca 2+ and PO 4 ions available Apatite dissolution products can reach neutrality by buffering or Ca 2+ and PO 4 ions in saliva and inhibit the process of dissolution through the common ion effect This enables the rebuilding of partly dissolved apatite crystals Fluo roapatite is more acid-resistant than hydroxyapatite, making the tooth less susceptible to subsequent demineralization PowerPoint Presentation: The demineralization-remineralization equilibrium Mineral loss from the lesion occurs when the plaque pH drops. Mineral flows back when the plaque acids are neutralized. Saliva serves as a natural source of acid-neutralizing buffers and mineral ions, which may be supplemented by fluoride from dentifrices. (Ref: Mellberg, American Journal of Dentistry) Remineralization Therapy: Remineralization Therapy Fluoride containing dentifrices (Sodium fluoride, Sodium monofluorophosphate and Stannous fluoride) Community water fluoridation School water fluoridatio Fluoride mouth rinses Chewing gums Topical application of GC Mousse PowerPoint Presentation: Dual-phase systems that isolate the calcium portion from the phosphate and fluoride portion until the time of application to the teeth have been shown to be effective. In various in vitro studies, Schemehorn and colleagues, found that such a dual-phase toothpaste increased fluoride uptake, reduced enamel solubility, re-strengthened weakened enamel and prevented demineralization more effectively than a conventional fluoride toothpaste Newer Approaches To Remineralization : Newer Approaches To Remineralization A new RM technology has been developed based on Phosphopeptides from Milk Casein The Casein Phosphopeptides (CPP) contain multiphosphoseryl sequences that have the ability to stabilize calcium phosphate in nano-complexes in solution as amorphous calcium phosphate (ACP) The CPP binds to ACP in a metastable solution thus preventing its growth to the critical size required for nucleation and phase transformation to an insoluble crystalline calcium phosphate PowerPoint Presentation: The CPP-ACP nanocomplexes have been shown to localize at the tooth surface and prevent enamel demineralization They remineralize enamel subsurface lesions by producing and amorphous calcium fluoride phosphate, stabilized by CPP at the tooth surface The soluble Ca, Po4 and Fl ions promote RM with fluorapatite that is more resistant to acid challenge and capable of full penetration into depths of enamel lesion The chemical basis of DM-RM is same for Enamel, Dentin & Cementum PowerPoint Presentation: Calcium phosphate is normally insoluble i.e., forms a crystalline structure at neutral pH. However, CPP keeps the calcium and phosphate in an amorphorous, non-crystalline state In this amorphous state, calcium and phosphate ions can enter the tooth enamel, thus promoting remineralization The high concentration of calcium and phosphate ions at the tooth’s surface move into the precavity lesions in the tooth and recrystallize thereby adding minerals into enamel and repairing lesion PowerPoint Presentation: CPP-ACP technology has been trademarked as Recaldent CPP-ACP contains no lactose, the carbohydrate in milk, which causes gastrointestinal upset The CPP-ACP can be added to sugar containing foods, toothpaste, mouthwash, chewing gums, and confectionary PowerPoint Presentation: Bioactive ACP- based composites Uses: Preventive dentistry a) Remineralizing agent for recurrent caries b) Pts undergoing radiation therapy c) Healing of root caries d) Desensitizing agent Orthodontics Remineralizing adhesive agent Endodontics Remineralizing root sealer Caries Vaccine : Caries Vaccine Vaccine is defined as a “Suspension of attenuated or killed microorganisms administered for the prevention, amelioration or treatment of infected diseases The concept of a vaccine can be visualized primarily with the recognition of MS as the key organism in caries development How it works ??: How it works ?? The basis of the vaccine is that it keeps the patient in a state of readiness such that in case an infection does occur, the immune response (secondary) which is more rapid and effective can be mounted Thus during the first response, both B & T Lymphocytes form Memory cells that later remember the earlier attack and respond in a much better and improved manner PowerPoint Presentation: The primary IgG that affect the dental caries is secretory IgA The principal effect of IgA is to tie up the specific sites on MS, which allow it to bind to the tooth pellicle complex, thereby lowering the opportunity for MS to establish itself in plaque ecosystems, thus decreasing acid formation PowerPoint Presentation: Routes of Administration: Oral Systemic Gingivo-Salivary Rote Active Immunization Passive Immunization PowerPoint Presentation: Oral Route: Concentrates on the stimulation of secretory IgA via mucosal system (MALT & GALT) Disadvantage is the rapid break down of the proteins or peptides Systemic Route: Subcutaneous administration of MS has been tried in animals Elicited primarily through IgG, IgM, IgA antibodies Found to enter through the GCF PowerPoint Presentation: Active Immunization: Synthetic Peptides: These give antibodies not only in the GCF but also in the saliva. The synthetic peptide used is derived from Glucosyl Transferase enzyme Coupling with Cholera toxins subunits: Effective in suppressing the MS colonization. The cholera txin binds to the lymphoid cells and is given intra-orally Fusing with Salmonella Liposomes PowerPoint Presentation: Passive Immunization: Involves passive or external supplementation of antibodies Monoclonal Antibodies to MS cell surface antigen have been investigated (Significant reduction of count in MS) Bovine Milk – Systemic immunization of cows with a vaccine using whole MS led to bovine milk containing IgG antibodies. Egg Yolk Antibodies – introduced by Hamada; uses hen egg yolk antibodies against cell associated glucosyl transferase of MS are used PowerPoint Presentation: Transgenic Plants: They are used to give antibodies and their advantages are: Genetic material can be easily exchanged Possible to manipulate the antibody structure so that while the specificity of the antibody is maintained, the constant region can be modified to adapt to the human conditions, thus avoiding cross reactivity Large scale production is possible and is economical Ozone: Ozone Recently Ozone has been proposed as a preventive mode for caries Ozone treatment has shown to eliminate bacteria associated with caries; it can also lead to lesion reversal It is delivered to the tooth surface for 10-40 secs The Ozone delivery should be followed by remineralization solutions and fluoride rinses PowerPoint Presentation: Heal Ozone Carious enamel and dentine is ozone permeable Ozone deactivated 99% of the bacteria Acids from bacteria are thus largely neutralized Reductant fluid neutralizes residual acid and supplies fluorides and minerals A neutral medium enriched with minerals is now available Minerals can be added using a patient kit Remineralization occurs within 4-12 weeks PowerPoint Presentation: Indications: Pit fissure caries Smooth surface caries Root and cervical caries Nova Min Technology: Nova Min Technology Nova Min, a patented ingredient that represents a fundamental change in oral care technology Clinically proven to reverse the negative effects of time and age on teeth as well as reduce decay by employing the rebuilding minerals It is the only man made mineral which directly leads to formation of hydroxyapatite crystals PowerPoint Presentation: Odorless, colorless and biocompatible Promotes remineralization, strengthening of teeth, as well as extraordinary desensitization and whitening effects Composition: Proprietary formulation of calcium, phosphate, sodium and silica White powder that can be incorporated into many dental care products PowerPoint Presentation: The biomimetic process uses the body’s existing mechanism for the defense and rebuilding of teeth When Nova Min is exposed to moisture from saliva, it releases Ca and Po 4 ions that become available to the body’s natural RM process These ions combine with naturally occurring ions in saliva to HA crystals In toothpaste, Nova Min improve RM in early lesions by 68% as against fluorides Lasers: Lasers Co2 laser irradiation increased acid resistance of enamel Resistance could result from chemical changes such as reduction of the carbonate content of the enamel surface or partial decomposition of the organic matrix It caused an irregular ,rough and melted enamel surface and increased the bonding strength between the resin and enamel surface Polypeptides: Polypeptides Polypeptides based on the sequence from the SmaA protein that can prevent the adherence or binding of bacteria such as Streptococcus mutans to tooth These compete with the SmaA protein of the bacteria and prohibit the actual binding of the bacteria to tooth enamel This inhibit’s the ability of the bacteria to bind to the enamel and prevent’s the formation of caries Conclusion: Conclusion PowerPoint Presentation: “Prevention is better than Cure” It is imperative that we, as dentists should focus on treating not only those who are ill, but also treat those who are more likely to get ill… References : References Art and science of operative dentisry –Sturdevant (4 th & 5 th editions) Textbook of Pedodontics – Shobha Tandon Essentials of Community Dentistry – Soben Peter Understanding Dental Caries – Gordon Nikiforuk Essentials of Dental Caries - E A M Kidd DCNA – 1998, 1999, 2000, 2005 JADA - 2000 Journal of Operative Dentistry - 2003 Caries Research – 2002, 2005 Journal of Dental Education Lancet - 2007 Internet Sources PowerPoint Presentation: Thank You !