Preventive Dentistry

The prevalence of oral disease is increasing and is becoming a major concern for the society. Oral diseases are classified into three major categories: dental caries, periodontal disease, and oral cancer. There are many factors that contribute to the diseases mentioned above and the occurrence or progression of the disease can be minimized via the primary, secondary and tertiary prevention methods.
Primary prevention is basically taking the necessary precautions to maintain a disease free state. The secondary prevention mainly targets to limit the progression of disease before it causes any functional disability and the tertiary prevention focuses on rehabilitation once the disease has caused some functional disability.
Moreover, management of oral disease is the fundamental role of a dental practitioner. Establishing a good rapport aids in obtaining a meticulous patient medical and dental history which is of paramount importance in rigorous diagnosis and management of a particular disease.
This assignment focuses on a high caries risk patient and the identification of its causes and will elaborate on a preventive regime designed for that patient which will prevent any functional disability.

2.0 Medical History
A thorough medical history of the patient was obtained by asking questions that have been outlined in the patient folder. It was found that the patient has never stayed in the hospital or had an operation. The patient does not have any allergies or systemic diseases. The patient has never experienced any other diseases such as tuberculosis, asthma and does not have any bleeding problem or blood disorder/diseases. The patient is sero-negative for HIV and does not take any medication.

2.1 Dental History
The reason for visit for the patient was that he was experiencing tooth ache from the posterior part of the upper left arch
History of chief complaint: The patient experiences pain while eating or drinking something cold. There is no pain after eating and the patient does not take any medications.
The patient is an irregular visitor and his last visit was in the year 2014. The patient has an experience of conservative treatment without any complications

2.2 Social History
The patient is single and is a wood Jepson Consultant and is 40 years old. According to the behaviour assessment, the patient was cooperative

2.3 Diet History
Diet Frequency Amount Notes
Sugar daily 1 teaspoon Coffee, tea
Snack twice a day 1 packet (20-25g) Bhuja
Fizzy Drink daily 600ml Coke, fanta
Night Drink - - -

The table above depicts that the patient's diet is cariogenic (containing high levels of fermentable sugars) and also the frequency of intake is high.
2.4 Oral Hygiene and Habits
Oral hygiene is of utmost importance in prevention of oral diseases. The patient employs a medium bristled toothbrush together with a fluoridated dentifrice for brushing daily (once a day). He does not utilize any mouth rinse, floss or picks for plaque control.
The patients does not have any para-functional habits such as thumb sucking, nail biting, etc.
Also, the patient does not consume any carcinogenic substances such as tobacco, alcohol or betel nut.

3.0 Examination
The extra oral examination of the patients divulges no abnormalities. The intra oral examination, however, revealed that the patient has cheek bites on the buccal mucosa. No anomalies were detected for the rest of the intra oral structures. The flow of saliva and its consistency was found to be normal.
Hard tissue charting is an important aspect for the detection of caries. It depicts patient's level of home care, aids in following-up with the progression of disease and maintains a record of completed dental treatment procedures.
Consequently, the hard tissue charting disclosed that the patient was edentulous for 17,24,25,45. It also revealed that there was amalgam restoration placed on 14, 16, 47 and temporary restoration on 12, 13, and 22. Upon being examined, it was determined that the patient also has Class I occlusal carious lesions on 36, 37, 38, 46, small cavity on 26, 27,48 (occlusal pits) and class III mesial carious lesions on 11. The patient also has tooth wear on 38, 37, 36, 35, 34, 32, 31, and 41. Tooth number 28 had deep stained fissure and the total plaque score was 6/18 and the CPITN score was within the normal parameters.
Furthermore, after conducting some tests, it was diagnosed that tooth 26 had reversible pulpitis with no periapical involvement and a temporary GIC restorations was placed.
From the examinations, it was established that the patients is at a high risk of caries and tooth surface loss, however, the risk of periodontal disease and oral cancer is low. This is due to the fact that the patient's diet is cariogenic which causes caries. Researches have shown that if a patient has more than 1 interproximal carious lesion or more that 1 carious lesion/white spot lesions or enamel defect, then the patient is at a high risk of caries and it can be seen that this patient has got multiple carious lesions on the occlusal and 1 interproximal lesion, hence, is at a high risk of caries. The patient is also at a high risk for tooth surface loss as depicted in the hard tissue charting. Fizzy drinks in the diet and the use of medium bristled tooth brush may be the contributing factors for tooth surface loss. The depth of the periodontal pockets are normal, hence the patients is at low risk of periodontal disease. Also, the patient does not consume any carcinogenic substances such as alcohol, tobacco or betel nut, thus, at a low risk for oral cancer.

4.0 Preventive Regime
Since the patient is at a high risk of caries, proper methods of plaque control should be executed which includes brushing and flossing. Considering the information procured during the assessment of oral hygiene, the patient should be advised to increase the frequency of tooth brushing from once a day to at least twice a day. Tell-show-do technique using the tooth brush model should be used to gauge the technique of brushing used by the patient and, if necessary, some changes in the technique should be recommended. Also, the patient should be advised to floss after every meal to remove food debris and plaque trapped in the interproximal region. Moreover, appropriate method should be taught as improper technique can cause damage to the gingiva. For efficient plaque control, the patient can be provided with plaque disclosing tablets and its use should be strongly recommended for disclosing areas that are usually missed while brushing. Mouth rinse containing chlorhexidine (0.12%) should be advocated as a plaque control measure.
Mitchell suggests that chlorhexidine is a positively charged antiseptic which has bactericidal properties. It works by attracting the negatively charged cells on the bacterial cell membrane causing the disorientation of the lipoprotein structure, hence, increasing the permeability. This causes the intracellular ions such as potassium to leak out of the cell, coagulating other structures present inside the membrane resulting in death, thus, leading to its bactericidal properties.
To add on, dental plaque contains a variety of microorganisms which can be harmful to the oral environment, therefore it is essential to conduct effective plaque control. This is because plaque removal aids in the reduction of the number of cariogenic organisms present in the oral cavity. It also aids in building the tooth resistance and maintains healthy gingiva and adds on to the repair process.
In addition to plaque control measure, topical fluoride treatment can be carried out every 3 months. This is important because it helps strengthen the enamel of the tooth and increase resistance to caries. Fluoride can be applied in the clinic in by placing fluoride containing trays in the mouth and biting onto it for either 1 minute, for 80% effectiveness, or for 4 minutes, for 100% effectiveness.
According to Limeback, the incorporation of fluoride into the enamel makes the tooth more resistant to acid attacks. This is due to the dynamics of demineralization and remineralization process that occurs in the plaque biofilm that is adherent to the tooth surface. The enamel is majorly made up to hydroxyapatite crystals that have hexagonal structure of phosphate and calcium with central hydroxyl ion. The substitution of fluoride ion for the hydroxyl ion makes the apatite crystal more stable (fluorapatite). The fluoride ion has a high electronegativity which enables it to form very strong hydrogen bonds with hydroxyl and acid phosphate groups in the hydroxyapatite (critical pH of 4.5), thus, making the enamel surface more difficult to penetrate. This essentially makes the enamel more difficult to demineralize, favoring remineralization.
Furthermore, the patients should be counseled regarding his diet since it consists of cariogenic food. The patient should be advised to substitute bhuja for something which is less cariogenic e.g. a piece of cheese or fruits. However, if the patient wishes to consume bhuja, it can be limited to meal times. It was divulged from the diet history obtained that the patient also consumes fizzy drinks daily. Fizzy drinks are acidic which leads to demineralization of the enamel making the patient more prone to caries and erosion. The patient can be advised to substitute Fanta and Cola beverages with water or fresh fruit juice with no added sugar. However, if he still wishes to consume fizzy drinks, he should be advised to reduce the quantity and the time he takes to consume the drink. This is because the more time the patient takes to finish his drink, the more the time the oral cavity is exposed to acidic environment. The patient should also be advised to brush his teeth 30 minutes after consuming fizzy drinks and chew sugar free gums to stimulate saliva flow.
As stated by Harris, dental caries is a multifactorial disease i.e. many factors are required to cause it. The major factors that contribute to dental caries are the diet high in fermentable sugars, presences of pathogenic microorganisms, susceptible host (tooth) and time. Once fermentable sugars are introduced in the oral cavity, the acidogenic bacteria start to produce acid derived from sugars. This lowers the pH causing demineralization. Consuming foods such as cheese and other dairy products after meal or after consuming acidic beverages adds onto the buffering capacity of saliva as it contains many phosphate and calcium ions which aids in remineralization.
From the charting, it was also disclosed that the patient has deep stain fissure for 28. Deep fissures are more likely to get carious as it can harbor cariogenic bacteria. Moreover, food debris are likely to be retained in deep fissures which increasing bacterial proliferation and since it becomes difficult to clean fissures efficiently, the cariogenic bacterial colonies may flourish and cause more harm to the host. To overcome this issue, prophylaxis followed by fissure sealant should be carried out.
As mentioned by Harris, fissure sealants prevent bacterial penetration and proliferation. As long as the sealant is retained, bacterial acids cannot cause demineralization of the sealed area, thus reducing the risk of caries.
Consequently, bilateral bitewings of the patients every 3 months should be taken. Since, the patient is at a high risk of caries, this will aid in the detection of interproximal caries. This should be continued until the patient's risk status is altered.
Upon examination, it was established that the patient is at a high risk of tooth surface loss. Therefore, the patient should be apprised of the detrimental effects of consuming fizzy beverages, for example, explaining the patient that consumption of fizzy beverages decreases the pH of the oral cavity. This acidic pH causes dissolution of the enamel which leads to erosion i.e. removal of enamel layer by layer which causes the structures of the tooth become less prominent or clear.
As reported by Limeback, the causative agent of tooth erosion is acid, either extrinsic or intrinsic. Extrinsic acid are the acidic food and beverages while intrinsic acids are the gastric influxes, bulimia, and anorexia. Acid attack on tooth causes the tooth to become soft and makes it liable to have further tooth wear resulting from attrition and abrasion (as in this case by the use of medium bristled tooth brush). The protective effect of saliva is important because it provides inherent protection against erosion. Acid in the mouth is buffered and diluted by saliva which assists in neutralizing the acids that are retained in the mouth. Further protection is provided by the salivary glycoproteins on the enamel and dentine surfaces by protecting the hydroxyapatite crystals and reducing their decalcification in the low pH environment that causes erosion. There is also calcium present in saliva which aids in re-calcification of decalcified surface following an acid attack.
Therefore, the patients should be encouraged to engage into activities that stimulate saliva flow such as chewing on sugar free gum after consumption of fizzy or any acidic beverage or foods.
In addition, tooth mousse containing recaldent' (casein phosphopeptide -amorphous calcium phosphate) can be applied to the patient's teeth. CPP-ACP binds to the biofilm and the tooth surface and localizes bio-available calcium and phosphate. It helps by providing extra protection for the teeth, helps buffer the acid challenges from acidogenic bacteria in plaque and buffer acid challenges from external and internal acid sources.
Limeback suggests that CPP-ACP is a protein nanotechnology that contain and releases calcium, phosphate and fluoride ions. It has an anti-cariogenic and remineralizing property. CPP-ACP provides an extremely effective means for increasing calcium levels in dental plaque fluid, something which is desirable for enhancing remineralization. It is anti-cariogenic agent for enamel caries as well as for root caries in xerostomic patients and is more effective than saliva for remineralization after erosion like assaults or caries in enamel. It effectively influences the behaviour and properties of plaque by (1) binding to adhesion molecules on Mutans Streptococcus thus disabling them to incorporate into dental plaque, (2) increasing levels of calcium in plaque to inhibit fermentation, (3) providing protein and phosphate buffering plaque pH, which suppresses the overgrowth of aciduric bacteria in conditions where there is excess fermentable carbohydrates.
Thorough prophylaxis can also be carried out on annual basis to minimize the risk of caries and maintain a healthy state for the soft tissues in the oral cavity.

5.0 Conclusion
To begin with, devising a proper preventive regime is better the cure. It enables a practitioner to detect and limit the disease progression via the secondary prevention measures. The desired outcome by intervention can be attained much more effortlessly compared to the later stages where rehabilitation is required. Obtaining the legitimate dental and medical history plays a critical role in accurate interpretation and rigorous diagnosis, which facilitates in formulating preventive measures for the patient. It also aids in counseling the patient regarding his/her detrimental practices.
Moreover, educating the patient about the correct tooth brushing and flossing techniques empowers the patient to maintain proper oral hygiene without causing any injuries to the soft tissues. Advising patient about their pernicious habits enables a practitioner to motivate the patient to take care of their oral hygiene.
Overall, designing a preventative plan which is realistic and achievable for the patient assists in altering the risk status and management of the disease and prevents any functional disability.

6.0 Reference
Limeback H, eds. Comprehensive preventive dentistry. New York: Wiley-Blackwell; 2012
Mitchell DA, Mitchell L, Brunton P. Oxford handbook of clinical dentistry. 4th edn: New York, Oxford Universrity Press; 2005
Harris N, Godoy FG, Primary preventive dentistry. 6th edn. New Jersey: Julie Levin Alexander; 2004
Klemperer G. The elements of clinical diagnosis. The Macmillan Co, 2003; 189 ' 91.
Bader JD, Rozier G, Harris R and Lohr KN. Dental caries prevention ' the physicians role in child oral health systematic evidence review. U.S Preventive Services Task Force, 2004; 29: 1161 ' 1170.
Touger ' Decker R and Loveren C. Sugars and dental caries. The American Journal of Clinical Nutrition, 2003; 78: 881 ' 892.
Steiner M, Buhlmann S, Menghini G, Imfeld C and Imfeld T. Caries risk and appropriate intervals between bitewing X-ray examinations in school children. Schweiz Monatsschr Zahnmed, 2011; 121.

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