kariesprevention før førskolebarnet, skolbarnet & tonåringen
Selwitz et al. Dental caries. Lancet 2007
Svante Twetman, Faculty of Health Sciences, University of Copenhagen
the caries balance
sociodemography
socioeconomy
education
ATTACK
• bacterial overgrowth
• decreased saliva
function
• frequent sugar intake
demineralisation
remineralisation
DEFENCE
• fluoride, Ca, P
• saliva content
• buffer capacity
• antibacterial agents
behavior
• oral hygiene
• small eating
knowledge
attitudes
broken homeostasis = ecological catastrophe
the ecological plaque hypothesis
1
** = aciduric bacteria
pH
******
******
******
tid
pH
******
******
******
tid
prevention
– action taken before a disease occur
primary-primary prevention
intervention to parents
primary
-primary
primary
secondary
child gets the benefit
Koch, Poulsen: Pediatric Dentistry. A clinical approach. 2001
primary prevention
actions to prevent the initiation of a disease
secondary prevention
non-invasive actions to prevent progression of
an existing disease
2
distribution of DMFS-appr at 12-13 yrs (n=392)
80
risk patients and risk groups
PERCENT
70
20% stands for
80% of the disease
60
50
40
30
20
10
0
0
1
2-3
4-5
DMFS appr
Västerhaninge.1
6-16
> 10
from Mejàre et al, 2006
caries risk assessment
population strategy vs. high risk strategy
caries risk
low risk
“under-treatment”
• good risk assessment
• effective methods
“over-treatment”
true positive
true negative
false positive
false negative
risk ages and risk surfaces
0 yr
low education
socio economy
geographic
area
19 yr
1-3 yr
5-7 yr
12-15 yr
different measures
to prevent caries in
low caries
different areas
sub-population,
immigrants
20 new teeth
”4” new surfaces
76 new surfaces (32 proximal)
3
strategies to reduce caries risk
1966-2003
evaluated >1,500 papers on
caries preventive methods
fluoride
triclosan
chlorhexidine
www.sbu.se
probiotics
xylitol
tooth
cleaning
diet control
sugar
substitutes
fissure
sealants
www.cochrane.org
CPP-ACP
evidence-based dentistry – a process
hierarchy of evidence
1. question of clinical relevance
randomized
randomizedcontrolled
controlledtrials
trials
2. systematic search for literature and inclusion of
relevant papers
non-randomized
non-randomizedcontrolled
controlledtrials
trials
cohort
cohortstudies
studies
3. critical appraisal of selected papers and compilation of
findings
case-control
case-controlstudies
studies
4. a graded statement, based on high quality studies,
systematic review or meta-analysis
cross-sectional
cross-sectionalstudies
studies
case
casestudies,
studies,expert’s
expert’sopinions
opinions
5. clinical recommendations or guidelines
definition of evidence levels
randomised controlled trial (RCT)
level
level11
strong scientific evidence
>2 studies with high quality and relevance
intervention
level
level22
representative
sample
BL
1 study with high quality and at least 2 with medium
ΔDMFS
level
level33
control
placebo
best clinical practice
moderately strong scientific evidence
limited scientific evidence
>2 studies with high quality and relevance
insufficient or contradictory scientific evidence
level
level44
no studies or studies of equal quality with
conflicting results
4
level of evidence
evidence-based care
best available evidence
EBD = best available evidence
lack of evidence not the same as lack of effect
lack of research or less good quality
caregiver’s knowledge,
experience and skill
patient’s preferences
and economy
www.sbu.se
evidence levels
fluoride and caries
level
level11
level
level11
level
level22
level
level22
level
level33
level
level33
level
level44
level
level44
CHX
Xylitol
1-3 year
risk ages and risk surfaces
0 yr
19 yr
1-3 yr
5-7 yr
12-15 yr
caries prevalence in Sweden
(cavitated + enamel)
20 new teeth
”4” new surfaces
76 new surfaces (32 proximal)
1 yr
2 yr
3 yr
4 yr
<1%
8%
27%
46%
prevention must start early
5
how to prevent caries 0-3 year
some factors associated with ECC
psychosocial
behavior
medical
ethnicity
socio-economy
education level
immigrants
refugees
family stress
baby bottle
diet
tooth brushing
attitude
selfconsciousness
self-efficacy
locus of control
mutans strept
breeding
chronic diseases
medication
hypomin
some
evidence
inconclusive
evidence
X
early start
oral health campaigns
diet counseling
“lift-the-lip”
tooth brushing instruction (X)
X
fluoride exposure
X
outreach dental health
Harris et al. 2004: 106 different risk factors associated with ECC
key person 1-3 yr
X
X
X
X
key message
custodians, especially the mother
low concentration of
fluoride in any form
into the mouth of the
baby at least once daily
daily care
cooking
shopping
verbal contact
emotional
dental health education (DHE)
outreach DHE
Davies, 2005
UK, 2 yr
Vichiraroijpisan, 2005 Thailand, 1 yr
matched health districts
tooth
brushing habits
-improved
DHE in small
groups,
but
failed
to
reduce
ECC
- support positive dental
behavior
- gift-bags (F-toothpaste, brushes etc)
Kowash 2000, UK, home visits, 228 children
A.
B.
C.
D.
E.
intervention
diet (4x/year) 1% caries
oral hygiene (F-toothpaste) (4x/year)
diet + oral hygiene (F-toothpaste) no
(4x/year)
caries
diet + oral hygiene (F-toothpaste) once/yr)
no DHE 33% caries
control
normal program
6
supportivechina
F-toothpaste studies in China
DHE
Weinstein, 2006 USA 2-yr RCT
motivational interviewing
n=240
6-18 m
significantly
less caries
traditional education
Schwartz, 1998
3-yr CCT 1000 ppm vs. nothing
-26%
You, 2002
2-yr CCT 1100 ppm vs. placebo
-21%
Rong, 2003
2-yr CCT 1100 ppm vs. nothing
-30%
greater compliance with F-varnish
start from first tooth
adjust the amount to the “size” of the child
children need
training and parental
support until they can
write with a good hand
no significant caries-inhibiting effect
with low-F toothpaste <500 ppm
Twetman et al., 2003; Ammari et al., 2003
7
F-varnish
F-varnish vs. F-gel
22.600 ppm
F-gel: uncertain evidence on primary teeth
Weintraub et al., 2006
2-yr RCT
F-gel: each application 4 min or more
counseling
F-gel: increased risk of swallowing
fluoride varnish takes less time, create less patient
discomfort and achieve greater patient acceptability,
especially in pre-school children
OR=2.2
376
caries-free
1.8 yrs
counseling
FV 2x/year
OR=3.8
counseling
FV 4x/year
American Dental Association Council on Scientific Affairs, 2006
results
younger than 6 years
topical fluoride varnish should be applied at least twice
3
yearly for preschool children assessed as being at increased
newlesions
2,5
2
incipient
1,5
risk of dental caries
manifest
1
0,5
0
advice
FVx2
FVx4
SIGN, 2005
ADA Council on Scientific Affairs, 2006
strength of recommendation B
strength of recommendation A
Weintraub et al., 2006
Rosengård project
intervention vs. historic controls
1. outreach facility
multi-cultural area
20.000 inhabitants
>50 languages
Arabic
85% caries prevalence
among 3-yr-olds
2. three-month recalls from 2-years
3. tooth brushing training
4. F-toothpaste
5. F-tablets
I Wennhall, L Matsson, U Schröder, S Twetman
6. dietary advice
www.whocollab.od.mah.se
8
results after 1 year (3-year-olds)
N= 800
caries free (%)
90
80
70
60
50
40
30
20
10
0
intervention
dmft
3.0
reference
4.4
surprisingly good compliance with the Ftablets in this study group (75%)
Wennhall et al., 2005
age at risk of dental fluorosis?
Evans and Darvell, 1996
15-30 mo
Hong et al., 2006
0-24 mo
fluoride
beneficial effect on caries
- topical
risk for fluorosis
- systemic
“ first three years”
young children swallowing tooth paste etc = risk
try to minimize the systemic exposure
Thylstrup-Fejerskovs fluorosis index
fluorosis
mild form, increasing
but not perceived as a
problem
moderate form
very rare, stable
Menegim et al., 2007
9
5-7 yr
5-7 yr
4 occlusal surfaces = 70% of all dental costs
deep fissures
highly susceptible during first year after eruption
key persons 5-7 yr
the profession
an intact fissure sealant is caries protective
which are the indications?
soon after eruption
technique sensitive
must be checked and
maintained
high costs
10
all vs. risk
indication for fissure sealants
high risk
deep fissures
shallow fissures
X
X
low risk
X
all 1st perm molars
85%
6-19 yr
only those
considered at risk
20%
6-19 yr
little better health
(fewer decayed/filled
1st permanent molars)
--
60-70% FS
risk application was
less expensive
(0.7 vs. 1.6 h/saved
tooth)
Benteke, Twetman et al., 2006
indications for fissure sealants 5-7 yr
(non-evidence based)
all children with decayed primary teeth
all medically compromised children
plan B – if not dry
1. fissure sealant with GIC
2. fluoride varnish
3. CHX-varnish
all children with BMP
general health and caries
school-based supervised tooth brushing
with F-toothpaste reduces caries incidence
in immigrant and deprived areas
increased caries risk
_________________________
yes
overweight
OR 2-3
ADHD
OR 12
asthma
no
X
Type-1 IDDM
X (poor control)
_______________________________________________
Willershausen et al 2004; Broadbent et al 2004; Eloot et al., 2004; Twetman et al., 2003, 2005
11
12-15 yr
diabetes and caries
vulnerable & turbulent period
second molar & proximal surfaces at risk
poor metabolic control
(HbA1c > 8.0)
increased caries risk OR = 7.2
Twetman et al., 2003
teenager ”caries factors”
key person: own responsibility
liberation - communication problems
lifestyle changes, own money, soft drinks,
smoking, drugs
skip brushing – always “tired” (♂)
skip main meals (♀)
TV-behavior (junk food)
diminished salivary buffer capacity (♀)
sex hormones
gingivitis
daily tooth brushing?
daily tooth brushing?
12 yr
68%
14 yr
74%
16 yr
81%
girls better than boys
Kuusela et al., 1997; Koivusilta et al., 2003
12 yr
68%
14 yr
74%
16 yr
81%
girls better than boys
Kuusela et al., 1997
Koivusilta et al., 2003
12
empowerment by dialogue
#1 focus 12-15 yr: tooth brushing
relation
twice daily
but at least in the evening
≥1,500 ppm NaF
task
locus of control - focus on the message that they can
do something about their own situation
- build-up of faith and confidence
Hattne et al., 2007
why do you brush your teeth?
white teeth
avoid bad breath
Hattne et al., 2007
#2 focus 12-15 yr: F-varnish
professional F-varnish
applications every 6th month
helping them over a
troublesome period
newly erupted teeth benefits the
most from the varnish
Colgate Duraphat toothpaste 5,000 ppm
school as an arena for health promotion
≈20,000 hours in school
bridge gaps in oral health
outreach dental health promotion
dental professionals visible
preventive treatments to less costs
less no-shows
13
school-based fluoride programs: F-varnish
2x F-varnish
dfsa
ctr
maintain a good order of main meals
reduce snack and light between meals
“everything is allowed - but not always”
“rest, water & fluoride”
3,5
3
2,5
2
1,5
#3 focus 12-15 yr: diet
57%
1
0,5
0
low risk
medium risk
high risk
all
Moberg-Sköld et al., 2005
CHX and caries
MS may not be sensitive in the biofilm
level
level11
level
level22
for mutans streptococci
suppression
monocultures =
MS are sensitive
level
level33
level
level44
“complex community” =
individual susceptibility
inconclusive evidence for
caries prevention and control
systematic review: CHX-varnish for caries prevention
negative effect
positive effect
13
11
9
7
5
50% non-responders
3
1
-50
0
50
100
prevented fraction (%)
Zhang et al., 2006 Eur J Oral Sci
14
does a comprehensive non-invasive approach
work for the caries active teenager?
alternative methods for prevention
individually targeted program
counseling, “use your resources”
toothbrushes, F-toothpaste,
F-varnish, xylitol lozenges, CHX etc
500 with active
caries
(Nyvad criteria)
baseline
2.6 DMFS
3.4 yr PF 44%
basic preventive program
at PDC
4.6 DMFS
Hausen et al., 2007 Caries Res
xylitol – natures own “functional sugar”
plaque
if we cannot kill it, can we alter the impact of
acidogenesis and acidoduricity?
turn a bad plaque into a harmless plaque?
Natural Occurrence of Xylitol
PRODUCT
Yellow plums
Strawberries
Cauliflower
Raspberries
Endives
Aubergine
Lettuce
Spinach
XYLITOL CONTENT
(mg/100g ds)
935
362
300
268
258
180
131
107
Pratten & Wilson, 1999; Hope & Wilson, 2003
xylitol
sucrose, sorbitol
• sugar alcohol, polyol
• 5-carbon ring
• calories
xylitol can affect oral ecology in 3 ways
1. diminish pH-drop in plaque
2. reduce plaque volume
3. induce shift of MS strains (
pathogenic)
• similar sweetness
as sucrose
15
xylitol:
at least 6 gram/day
Milgrom et al., 2006
dose-response
relative caries reduction in recent studies
study
duration age
Kovari, 2003
Machiulskiene,-01
Alanen, 2000
Alanen, 2000
Mäkinen, 1995
Mäkinen, 1996
5 yr
3 yr
3 yr
3 yr
3.3 yr
2 yr
preschool
schoolchildren
schoolchildren
schoolchildren
schoolchildren
preschool
dose/day
outcome
DFS
RR
2.5 g
3.0 g
5.0 g
5.0 g
8.5 g
10.7 g
1.2/1.6
3.4/4.3
1.9/4.4
1.7/4.4
4.6/15.9
17.6/50.2
25%
21%
57%
61%
71%
65%
gum
gum
gum
tablet
gum
gum
threshold value – lower doses partly ineffective
5-6 grams per day for a significant impact on
oral ecology
higher doses does not seem to increase effect
NS
NS
S
S
S
S
xylitol and caries
number of pellets/tablets
level
level11
product
6 gram xylitol
Bamse chewing gum
120 pellets
EXTRA
13 pellets
Läkerol Plus
11 tablets
Xylifresh
7 pellets
Xylismile
10 pellets
Xylimax
6 pellets
V6
130 pellets
level
level22
level
level33
interfere with mother-child
mutans streptococci transmission
level
level44
inconclusive evidence for
caries prevention and control
in children
16
bacteriotherapy, replacement therapy
pro bios = for life
lactobacilli
bifidobacteria
streptococci
alternative way to combat infectious
diseases
may reduce the use of antibiotics
human isolates
aciduric
prevalent in oral cavity
not genetically modified
L. reuteri prodentis
Elie Metchnicoff (1845-1916)
synbiotics
prebiotics
promote
probiotics
replace
antibiotics
kill/inhibit
Noble prize 1908
living bacteria added to
food with beneficial effects
on general and oral health
how does it work?
lactic acid bacteria in the gastrointestinal tract
could improve wellbeing and prolong life
probiotic organisms - mechanisms of action
competition with pathogens
- nutrients
- adhesion sites
production of antimicrobial substances
immunomodulation
17
probiotics may affect oral cavity
mechanism of action
direct contact
local effect
☺
systemic effect
immune modulation
70%
H+
H+
plaque with
cariogenic bacteria
☺
enamel
evidence of effects on general health - GI tract
milk
cheese
yoghurt
preventive
therapeutic
_________________________________________________________
acute rotavirus diarrhea
strong
non-atopic eczema
suggested
Crohn’s, ulcerative colitis
strong
suggested
H. pyloris infections
possible
food allergies
possible
suggested
infections (upper resp. tract)
possible
__________________________________________________________
1.5-2 dl (108 CFU/ml)/day
probiotics and mutans streptococci
the Helsinki kindergarten study
author, yr
design
n, age
vehicle, time
strain
outcome
_________________________________________________________________________________
Näse, 2001
RCT
Ahola, 2002
RCT
594, 1-6 milk, 7m
L rhamnosus GG
Nikawa, 2004
decreased
levels
crossover
40, 20
yogurt,
2w
Montalto, 2004
RCT
35, 23-37 liquid/capsules
short-term
evaluationsLactobac
onlymix
LB increase
Caglar, 2005
crossover 21, 21-24 yogurt, 2w
bifidobact
MS decrease
Caglar, 2006
RCT
L reuteri
MS decrease
6 out74,of
7 studies demonstrated
18-35 cheese, 3w
Lactobac mix
120, 21-25tablets, 2w
of salivary
L reuteri MS
MS decrease
MS decrease
MS decrease
Caglar, 2007
RCT
80, 21-24 gums
L reuteri (2 strains) MS discrease
__________________________________________________________________________________
18
randomized double-blind placebo-controlled trial
(L. rhamnosus GG) – 3-4 year-olds
additional effects
16% less absence from daycare due to illness
probiotic milk, 5 days/w
n=594
1 to 6-yr-olds at
Day Care
Centers
BL
6% new
lesions
17% reduction in upper and lower respiratory
infections
7 months
control milk, 5 days/w
15% new
lesions
19% less antibiotics
Hattaka et al., 2001 Br Med J
(Näse et al., 2001)
probiotics and caries
reducing caries risk in preschool children
level
level11
individuals
stress brushing habits with
F-toothpaste from 1st tooth
professional varnish applications when risk
baby bottle restrictions
level
level22
vulnerable groups
level
level33
level
level44
early start, outreach DHE
any fluoride supplement
insufficient evidence for
caries prevention and control
reducing caries risk in schoolchildren
individuals
F-toothpaste with parent’s assist
fissure sealants when risk
professional varnish applications
vulnerable groups
school-based F-tooth brushing
school-based FMR
risk reduction in adolescents
individual
empowerment of personal resources
strongly review F-brushing habits
professional F-varnish applications
chewing gums
vulnerable groups
school-based F-rinses/F-varnish
19