Practical measures to prevent caries and periodontopathies - Preventive dentistry
Practical measures to prevent caries and periodontopathies
Measures to prevent mouth problems can be taken by the patient, the dental staff and by the government. These measures may include nutrition and eating habits, oral hygiene and the use of fluoride.
The measures that the patient can take are:
- Optimal oral hygiene;
- Use of fluoride (e.g. in toothpaste);
- Limit no more than seven food moments in a day and limit sugar consumption;
- Regular visit to the dentist.
The measures that the dentist or dental hygienist can take are:
- Provide information regarding oral hygiene;
- Provide information regarding nutrition;
- Treatment of the teeth and periodontium: good dental cleaning, caries treatment and elimination of retention factors such as overhanging fillings, correcting unfavorable tooth positions with orthodontics;
- Fluoride advice and possibly fluoride application in the patient.
The government can apply the following measures:
- Collective (for the entire population) use of fluoride, for example in drinking water (this has not proved politically feasible in the Netherlands);
- Information campaigns on caries and periodontal disease in schools, health centers, etc.
- Ensuring accessible and affordable (dental) healthcare for everyone.
Nutrition and eating habits
The role of sugars in the caries process and the role of acids in dental erosion have been discussed. It is therefore important to give the patient good nutritional advice. The patient must be informed about the harmfulness of sugars and acids.
As dietary advice, the patient can be told that he should not use sweets too often. After sugar consumption, the acid can act on the teeth for a long time (up to 40 minutes). In this context, it is therefore better to eat a drop of liquorice all at once, than to have a drop spread throughout the day. If one eats sweets, this is best after the main meal, after which the teeth must be cleaned immediately. It is best to limit the diet to the three main meals and a maximum of four snacks.
Offering good alternatives for the possible use of sugary snacks is also part of the nutritional advice. For example, the patient may be advised to take sugar-free chewing gum instead of sugary candy. The food industry has been trying for some time to make artificial sweeteners that are as close as possible to the natural cane and beet sugar taste. It does this partly with the aim of being able to offer low-calorie, low-calorie food and beverages (light products), partly from the point of view of caries prevention.
So there are sugar substitutes that are not or hardly cariogenic, but do contain calories. Examples are sorbitol and xylitol. These sweeteners are often used in chewing gum. A caries-inhibiting effect is even attributed to xylitol chewing gum. In any case, these chewing gums stimulate saliva production and, unlike sugary sweets, they are tooth-friendly. Sacharine and aspartame are examples of low-calorie and also dental-friendly artificial sweeteners. Stevia is a natural sweetener that is used in soft drinks, among other things. This sweetener contains relatively many calories.
The nutritional advice to prevent dental erosion is to limit acid-containing foods. Examples of this are soft drinks, tea with a taste, but also orange juice. It is advisable to rinse the mouth with water immediately after consuming an acidic product.
Oral hygiene information
Given the role of plaque in the development or worsening of caries and periodontal disease, proper cleaning of the oral cavity by the patient is very important. Information regarding oral hygiene can consist of teeth cleaning instructions and explanations about the use of aids.
Tooth brushing instruction
Points that are discussed in the brushing instruction are the brushing method, the tools (toothbrush and toothpaste) and the order of brushing teeth. There are many brushing techniques that focus on the care of the teeth to prevent caries and periodontal abnormalities. Most patients who have never had an instruction brush with a vertical or horizontal brushing method, without any system. It is important to teach the patient a certain systematic order of brushing. For example first the outside, then the inside and finally the top of the teeth in the upper and lower jaw.
The following brushing techniques are most recommended.
- The horizontal or scrubbing method is suitable for children up to around 12 years old. The buccal planes are brushed with horizontal movements, with the elements in occlusion. The lingual, palatal and occlusal surfaces are then cleaned.
- The bass method is often advised in patients with periodontal disease. Use is made of a soft toothbrush that is placed at an angle of 45 degrees with the hair in the sulcus. Then the brush is moved back and forth with a vibrating movement, so that the sulcus is cleaned.
- The electric brushing method requires a different technique than manual brushing. No brushing is made, but the round brush head is placed behind an element without pressure. Next, turn the cup over the bulging of the element forward. The brush is then moved to the next element (see images below).
Electric brush method.
With all these brushing techniques, the palatal and lingual surfaces of the front will be difficult to reach due to the size of the brush and the direction of the handle. It is then better to place the brush handle in the longitudinal direction of the elements (see figure below).
The inside of the front is brushed with the brush in a vertical position.
The patient is advised that little force should be used when brushing his teeth. (This also applies to electric brushing). Brushing too long and too hard causes the gums to retract. This partially exposes the root surface. This soft root cement and the underlying root dentin can wear out quickly. Sensitive tooth necks and the occurrence of root caries are the result. By taking the toothbrush in the pen handle, less pressure is automatically exerted.
The toothbrush. The purpose of the toothbrush is to remove plaque and food residues from the oral cavity and also to massage the gingiva. The toothbrush has a handle and a brush section, on which the hairs are implanted in clumps. The brush must be small and sturdy. The handle can vary (some dentists recommend a straight handle, others one with a kink) to optimally perform the brushing method. There is also a difference in the hardness of the bristles: there are hard, medium and soft bristles. A soft or medium toothbrush is recommended for adult patients.
The way in which the bristles are embedded in the brush section can also differ. A multi-tufted brush is usually recommended. This is a brush where the bristles are very close to each other, so that more bristles are available per surface for cleaning. The lifespan of a toothbrush is limited; as soon as the bristles start to bend, it should actually be replaced with a new one (see image below).
In general, it doesn't really matter which toothbrush is recommended, the most important thing is that the patient knows how to keep the mouth plaque free. A smaller toothbrush is recommended for children than for adults.
In addition to the "regular" toothbrush, there are electric brushes. These toothbrushes consist of a handle section and exchangeable brush heads. To function, they must be charged in the special charger. The brush heads come in different forms: straight brush heads that make an up-and-down movement on the tooth surface, round brush heads that make a rotating movement and brush heads in which each tuft of tufts rotates separately.
The electric toothbrush is an effective plaque fighter, but is certainly no better than the manual toothbrush.
The toothpaste . Toothpaste is a means used with the toothbrush to clean the teeth. In general, there are a number of solid ingredients in a toothpaste, namely abrasive, soap, flavoring, binder, preservative and moisture retainer. In addition, substances are often added that have or would have a therapeutic or preventative effect.
- Fluoride pastes. Ninety percent of the toothpastes currently on the market contain one or more fluoride compounds. The fluoride content is 1,000 to 1,500 ppm (0.1-0.15%). The mutual differences in efficacy are small. Fluoride ions can be incorporated into the enamel in two ways: during the remineralization phase and through ion exchange between dental enamel and the oral environment.
- Children's toothpastes are generally less strong in taste and contain less fluoride, namely 500-750 ppm (0.05-0.075%). This is because young children up to the age of 5 appear to swallow toothpaste while brushing. This could lead to an overdose.
- Anti-toothpaste pastes. Substances have been added to these pastes that prevent the precipitation of calcium phosphate in dental plaque. Reductions of 30 to 50% in supragingival tartar have been demonstrated.
- Toothpastes counter-sensitivity of exposed tooth necks. Potassium nitrate or strontium chloride has been added to these pastes. After some time brushing with such a toothpaste it appears that the sensitivity to cold, warm, sweet and acid due to exposed root dentin diminishes. It is important to properly instruct these patients about their brushing method (not too long, not too hard).
Assistive products for interdental cleaning
With all brushing techniques, the interdental spaces and surfaces are only partially cleaned. Observations show that pockets are interdentally deeper than vestibular and oral. For good interdental cleaning, there are aids on the market that produce good results.
Toothpicks should be pushed into the interdental space without forcing. There are various thicknesses on the market that match the size of the interdental space. When using toothpicks, those from a soft, non-splitting wood are preferred (see figure below).
Dental floss can be used to clean the contact point between the elements. The thread can vary in thickness (dental floss is a thin thread and dental tape a thick thread) and may or may not be soaked with wax (waxed or unwaxed thread). With a sliding movement, the dental floss is slid between the elements in the direction of sulcus, which is thereby also cleaned.
Superfloss. This is a reinforced floss with a foam spiral section in the middle. The superfloss is particularly useful under intermediate parts of bridges and etching bridges (see image below).
Dressing gauze. For single elements and for the back of the last molars, a triple folded single gauze can do good service. A piece of bandage gauze is inserted between the fingers in the same way as a floss and then slid down the contour of the element in the direction of sulcus.
Interdental brushes or brushes can be used for the cleaning of larger approximal spaces, under intermediate parts of a bridge, and for furcation disorders. The interdental brushes come in various designs and sizes. The diameter varies and there is a division into extra-fine, fine, medium and large. The interdental brushes can also be placed in special attachments, which can be particularly useful for handling in the premolar and molar regions (see images below).
Interdental brushes in different sizes.
Plaque is removed from the tongue with a tongue scraper.
Plaque clickers or disclosing. This can be a liquid or a tablet. Both colors the present plaque on the dentition. The liquid is applied with a cotton ball. The tablet is crushed in the mouth. The mouth is then rinsed. The patient can see for himself where he has not properly cleaned his teeth. The places where there is still dental plaque can also be noted in a plaque score. This allows the practitioner to assess which method and means the patient can best use to keep his teeth clean. It is also a way to be able to check next time whether oral hygiene has improved (see image below).
After a dietary advice and brushing instruction tailored to the patient has been prepared, this information must be transmitted to the patient by the dentist, dental hygienist or assistant.
The patient will only put the recommendations into practice if he understands their importance and he understands the information well. It is therefore of great importance to adjust the amount of information and the way in which it is transferred to the individual patient. Talk to children in a different way than with adults. Some people can process more information than others.
In general, short, clear advice, supported by written information, is best communicated. If possible, the information is divided over more sessions. In this way it can also be checked whether this is understood and remembered. Possible difficulties can be discussed and advice that is unfeasible for the patient can be adjusted. Guidance and information about preventive measures must be continuous processes throughout the entire dental life.
At the beginning of this century, many areas of the tooth enamel were found in certain areas of the United States. The cause of this was unknown. It was later discovered that these stained teeth, also called mottled teethoffluorosis, were caused by the high natural fluoride content in the drinking water. It was also discovered that far fewer caries occurred in these areas than in other parts of the country.
Research has shown that these enamel stains arise during the development of the tooth in the maturation phase of the enamel, so before the breakthrough. The ameloblasts (glaze-forming cells) are unable to build in the apatite regularly if the fluoride supply is too large.
Apart from these enamel stains, which can be aesthetically disturbing, no side effects occur. Fluoride is hardly, if at all, piled up in the soft parts of the body, but in bone and dentition. Health problems were only observed after prolonged intake of higher doses of fluoride (bone compaction).
There is an acute danger to life with a single intake of large amounts of fluoride of = 5 mg per kilo body weight. For a 10 kg child of about 1 year, this is a third tube of toothpaste for adults. When a lot of fluoride enters the body in a short time, the victim must try to vomit and drink large amounts of milk. Milk contains calcium that binds fluoride and inhibits absorption from the stomach. The victim must be taken quickly to the hospital to have the stomach pumped out if necessary.
Taking small amounts of fluoride in the drinking water or feeding during childhood ensures that there is greater resistance to caries. A relatively large amount of fluorapatite is formed during the formation of the tooth enamel, which is less soluble in lactic acid. In addition, it has been found that it is not so much the built-in fluoride that determines the resistance to acid of the tooth, but rather the presence and concentration of fluoride in the plaque and mouth fluid during both the demineralization and remineralization periods.
The decrease in the presence of caries due to fluoride use has been proven. The prevention by fluoride can be achieved in various ways. A distinction can be made between individual and collective measures. The individual measures depend on the will of the patient and therefore require proper information about use and application. In the case of collective measures, the effective substance is added to another substance that is used regularly by as many people as possible, for example drinking water or table salt. In the Netherlands, no collective measure has been possible that reaches the entire population. This leaves individual prevention with the help of fluoride.
Forms of fluoride
Toothpastes. The fluoride concentration in toothpaste may not exceed 0.15%. Regular brushing with a fluoride-containing toothpaste can result in a substantial caries reduction. As fluoride compound, amino fluoride, sodium monofluorophosphate or sodium fluoride can be used. The fluoride compound can determine the choice of toothpaste, but the choice is often determined by taste or price. For toddlers / pre-schoolers up to the age of 5 there is a special fluoride toothpaste. In this toothpaste, the fluoride concentration is half the dose of the regular fluoride toothpaste.
Fluoride mouthwash. In supermarkets, drugstores and pharmacies, fluoride mouthwashes for daily use are available with 0.025% fluoride. On the prescription of the dentist you can rinse with a rinse aid of 0.09% weekly. It is useful to use these rinsing fluids with caries-sensitive dentures, in a mouth with many descaled root necks, when orthodontic equipment is worn or when a patient has received radiation.
Local application. Currently, fluoride applications are only applied if early caries are observed. Local application is in the form of a gel, a liquid or a varnish.
- Gels are applied in plastic or styrofoam confection spoons or in individually shaped spoons from washing templates. The spoons are placed in the mouth for about five minutes and then removed. The patient can spit out the excess gel. The advice may be given not to eat or drink for about half an hour afterwards in order not to dilute the concentration in the mouth. An advantage of this method is the simple application method. Disadvantages of this method are that the fluoride gel is also applied in places where there is no risk of caries and that children appear to swallow quite a bit of gel, which can cause nausea. For this reason, fluoride gel for local applications contains no more than 0.4% F-. In addition, it is difficult for the gel to reach interdental spaces and deep fissures.
- It is also possible to apply fluoride solutions in liquid form to the teeth. The liquid is applied to the previously cleaned elements by means of a cotton ball. This should then remain in place for approximately five minutes. The advantage of the liquid above the gel is that it also works well interdally.
- In addition to gels and fluoride liquid, there are fluoride lacquers. Fluoride lacquers consist of sodium fluorides that are embedded in an alcoholic solution of a lacquer. The varnish is applied to the cleaned elements with cotton pellets or a cotton swab and remains there for a long time. After all, the paint hardens (see image below).
Plaque control with chemical agents
In addition to fluoride that inhibits the development of dental plaque, chlorhexidine must also be mentioned. This substance, which can be administered in the form of rinsing liquid or varnish, reduces the number of Streptococcus mutans. The lacquer is mainly used for patients who develop a lot of root caries and as a plaque fighter in periodontology.
Sealing of dental elements
In addition to information in the field of oral hygiene, nutrition and use of fluoride, the dentist can also provide a fissure seal for broken teeth. We also call this sealing. The fissure is thereby filled with a liquid and permanent synthetic resin. This treatment aims to prevent the risk of caries by reducing the number of plaque retention sites. It usually concerns the permanent molars. However, sometimes it is also advisable to provide milk molars, premolars or the pits in the lateral upper incisions with a sealant.
If elements break through, they are more susceptible to caries for a number of reasons.
- Shortly after the breakthrough of the teeth, the enamel has not fully matured.
- The shape of a fissure or pit can be so narrow and deep that even with good oral hygiene, dental plaque remains in it.
- The glaze layer on the bottom of a fissure is very thin or even absent.
- The motor skills of children are not yet so good that they can keep their teeth optimally clean.
- The mouth opening is still small and the molars are difficult to reach with a toothbrush.
- During the breakthrough the gums can be too painful to brush properly.
Children often develop poor drinking and eating habits during puberty (see images below).
Glaze thickness in a fissure: a molar with a shallow fissure; b molar with a narrow and deep fissure. A sealing is provided in the second figure.
If there is a high risk of caries or in cases where early-onset caries are present, it may be decided to seal this place. As a result, caries can no longer occur at this location. Moreover, the fissure has become less deep due to the applied sealant and therefore easier to clean.
Certainly in the case of incipient caries, the fissure is first ground with a narrow diamond drill to ensure that the caries process has not yet progressed into the dentine. If that is the case, a filling will be made. The tooth surface is also clean after grinding, which promotes the adhesion of the sealant.
There are sealant materials made from unfilled synthetic resin and glass ionomer cement. Both have good flow properties, so that they can reach the bottom of the fissure. Glass ionomer cements have the advantage that they release fluoride for some time.