Journal of Minimum Intervention in Dentistry
J Minim Interv Dent 2011; 4 (2)
According to the patient susceptibility, two types of
preventive care are available: standard and active
preventive care. Preventive standard care is
indicated for patient with low susceptibility for caries
occurrence, in order to reduce the risk for recurrence
of caries. Standard preventive care includes daily oral
hygiene (tooth brushing, the use of fluoride
toothpaste and flossing), dietary advice and patient
motivation. The patient is instructed to brush at least
twice a day with fluoride toothpaste and clean
between teeth once a day with floss or another
interdental cleaner. Low sugar diet has to be advised
without frequent snacks between meals. Regular
dental visits are recommended to the patient as well.
This type of care can be compared to conventional
maintenance therapy for patients who have not
developed any new caries lesions in the past 2 or 3
years. For individuals highly susceptible to caries,
active care is recommended. Active preventive care
includes the standard care regime with addition of
professional
decontamination,
remineralisation,
management of aetiological factors and the use of
fissure sealants.
Standard and active preventive
care
1
1
Miletic I , Baraba A .
1
Department of Endodontics and Restorative
Dentistry, School of Dental Medicine, University of
Zagreb, Gunduliceva 5, 10 000 Zagreb, Croatia
According to the patient susceptibility, two types
of preventive care are available: standard and
active preventive care. Preventive standard care
is indicated for patient with low susceptibility for
caries occurrence, in order to reduce the risk for
recurrence of caries. This type of care could be
compared to conventional maintenance therapy
for patients who have not developed any new
caries lesions in the past 2 or 3 years. For
individuals highly susceptible to caries, active
care is recommended. Active preventive care
includes the standard care regime with addition
of
professional
decontamination,
remineralisation, management of aetiological
factors and the use of fissure sealants.
Decontamination is used to rebalance the oral
microflora. Few actions of decontamination are
available: professional mechanical tooth cleaning
(PMTC),
Chlorhexidine
and
stabilizing
restorations. Remineralisation is indicated for
incipient, non-cavitated lesions with a use of
fluorides or more recently introduced casein
derivates.
When
Casein
PhosphopeptideAmorphous Calcium Phosphate (CPP-ACP) or
Casein Phosphopeptide-Amorphous Calcium
Fluoride Phosphate (CPP-ACFP) is applied in
Decontamination is used to rebalance the oral
microflora. Few actions of decontamination are
available: professional mechanical tooth cleaning
(PMTC), Chlorhexidine and stabilizing restorations.
PMTC involves the removal of dental plaque using an
ultrasonic scaler and a fluoride prophypaste with a
polishing brush. PMTC is the most effective method
for plaque removal; it suppresses dental caries and
reduces salivary levels of mutans streptococci.
Chlorhexidine is a topical antimicrobial agent,
effective in the elimination of mutans streptococci in
the oral cavity [1,2]. Periodic use of Chlorhexidine is
helpful for patients with Periodontitis or those with
high salivary levels of cariogenic bacteria. Application
of Chlorhexidine is recommended if the test for S.
mutans (e.g. GC Saliva-Check SM) is found positive,
indicating high number of bacteria in saliva.
Decontamination
is
performed
with
0.12%
Chlorhexidine mouthwash or by professional
application of chlorhexidine gel directly into the
pockets, providing a high concentration of the agent.
the oral environment, it will bind to biofilms,
plaque,
bacteria,
hydroxylapatite
(tooth
structure) and soft tissue localising bioavailable calcium, phosphate and fluoride
ions. Therapy of aetiological factors can also be
Stabilizing restorations are indicated for patients
highly susceptible to caries and are placed after
excavation of caries using Atraumatic Restorative
Treatment (ART) (Figure 1).
.
Figure 1. 17-year-old female patient with
extensive caries lesions, highly susceptible to
caries (Image: Ivana Miletic).
managed by some simple advice on oral hygiene,
diet or saliva flow stimulation, to help rebalance
the oral environment. Since dental caries is a
bacteria-dependent,
multifactorial
disease,
preventive measures such as sealants, can be
implemented once patients susceptible to caries
are identified. Sealants act as a barrier, protecting
tooth enamel from plaque, bacteria and acid and
preventing pit and fissure caries.
Correspondence address:
Professor Ivana Miletic DDS, PhD
Department of Endodontics and
Dentistry, School of Dental Medicine,
University of Zagreb,
Gunduliceva 5,
10 000 Zagreb,
Croatia
Restorative
20
Journal of Minimum Intervention in Dentistry
J Minim Interv Dent 2011; 4 (2)
This technique is based on the partial removal of
caries tissue, using only manual cutting instruments
(Figure 2).
Remineralisation is indicated for incipient, noncavitated lesions with a use of fluorides or more
recently introduced casein derivates. Casein
Phosphopeptide-Amorphous Calcium Phosphate
TM
(CPP-ACP, Recladent ), (e.g. GC Tooth Mousse)
has a capacity to deliver higher amounts of
phosphate and calcium ions on the tooth surface.
Casein
Phosphopeptide-Amorphous
Calcium
Fluoride Phosphate (CPP-ACFP), (e.g. GC MI Plus
Paste) contains fluoride ions beside calcium and
phosphate. When placed on the tooth surface,
TM
Recladent
interacts with hydrogen ions and forms
the neutral ion species calcium hydrogen phosphate,
which can enter the tooth and produce the enamel
mineral. When CPP-ACP or CPP-ACFP is applied in
the oral environment, it will bind to biofilms, plaque,
bacteria, hydroxylapatite (tooth structure) and soft
tissue providing bio-available calcium, phosphate and
fluoride ions [7]. CPP-ACFP is contraindicated for
children under six, because of high amount of fluoride
ions and risk of fluoride ingestion.
Figure 2. Caries is excavated using hand
instruments (ART technique) (Image: Ivana Miletic).
Therapy of aetiological factors can also be managed
by some simple advice on oral hygiene, diet or saliva
flow stimulation, to help rebalance the oral
environment. The use of chewing gums, especially
with
xylitol
and
CPP-ACP,
can
promote
remineralisation, saliva stimulation, increasing flow
output and buffering capacity. For dry mouth
conditions, different products can be advised to the
patient to decrease discomfort or increase salivary
flow rate (e.g. GC Dry Mouth Gel), (Figure 4).
The material used for stabilizing restorations is glassionomer cement (GIC), (e.g. GC Fuji IX, Fuji Triage),
(Figure 3).
Figure 3. After caries removal, stabilizing
restorations, using GIC (GC Fuji Triage) are placed
(Image: Ivana Miletic).
Figure 4. GC Dry Mouth Gel (Image: Anja Baraba).
High-viscosity GICs have higher compression
strength, wear resistance and material surface
hardness values when compared to the conventional
GICs and some of the resin modified GICs [3-5].
High-viscosity GICs are capable to form satisfactory
bonds with enamel and dentin. Furthermore, they
release fluoride ions over a prolonged period,
promote good biological response (biocompatibility)
and have a coefficient of thermal expansion close to
that of tooth structures [6]. Setting of these materials
is rapid and early moisture sensitivity is reduced.
With stabilizing restorations the reservoir of bacteria
is removed and the remaining tooth structure is
protected.
Stabilizing
restorations
help
in
maintenance of oral hygiene by decreasing the
discomfort caused by brushing on exposed dentine.
Final restorations are not indicated until the patient's
susceptibility to caries is under control.
Since dental caries is a bacteria-dependent,
multifactorial disease, preventive measures such as
sealants, can be implemented once patients
susceptible to caries are identified. Daily brushing
and flossing help remove food particles and bacteria
from the smooth surfaces. However, pits and fissures
are more difficult to keep clean. Toothbrush cannot
reach into the microscopic grooves to remove tiny
particles of food or plaque.
21
Journal of Minimum Intervention in Dentistry
J Minim Interv Dent 2011; 4 (2)
Sealants are indicated [8]:
On pits and fissures of children’s primary
teeth when it is determined that the tooth,
or the patient, is susceptible to caries;
On pits and fissures of children’s,
adolescents’ and adults’ permanent teeth
when it is determined that the tooth, or the
patient, is susceptible to caries;
On early (non-cavitated) carious lesions, in
children, adolescents and adults to reduce
the percentage of lesions that progress.
References:
1.
2.
3.
Sealants act as a barrier, protecting tooth enamel
from plaque, bacteria and acid and preventing pit and
fissure caries. Sealants should be placed as soon as
possible in highly susceptible patients (Figures 5 and
6) [8]. When sealants are applied to incipient lesions,
bacteria become nonviable and caries does not
progress. Sealant material effectively eliminates the
nutrient source for S. mutans, thus changing a lesion
from caries-active to caries-inactive [9]. To ensure an
effective seal, sealants must remain in place and
completely cover pits and fissures. As long as the
sealant remains intact, the occlusal surface will be
protected from decay. Regular dental visits are
important so that the sealants could be checked and
reapplied when needed. GIC and flowable resin
composites are materials used for fissure sealing.
GIC are less sensitive to moisture control with the
ability to release fluoride ions, which may contribute
to caries prevention.
4.
5.
6.
7.
8.
Figure 5. Tooth 36, in an 8-year-old female
patient, highly susceptible to caries (Image:
Ivana Miletic).
.
9.
Figure 6. GIC fissure sealant (GC Fuji Triage)
placed on tooth 36 (Image: Ivana Miletic).
.
22
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