Transcript PREVENTION I - University of Kentucky

PREVENTION I
“The Preventive Philosophy”
PREVENTION. . .
The Concept
• The emergence of a new philosophy of dentistry based on
prevention rather than repair and replacement has been the
most significant development in the history of dentistry.
• In a World Health Organization (WHO) study, it was found
that countries with dental care systems that emphasized
restorative care had the highest caries experience in the
world, as measured by the number of decayed, missing
and/or filled teeth, (DMFT).
• These countries also had the highest number of completely
edentulous individuals.
• In countries where prevention was emphasized, the number
of DMF teeth was substantially smaller.
PREVENTION . . .
The Concept
• The following data bear testimony to the futility of a
mechanistic approach to gain and maintaining oral health for
Americans:
– 98% of 40-44 year olds have had tooth decay, with an
average 45 affected tooth surfaces.
– the average American has between 9-10 missing
permanent teeth;
– over 4% of the American population (between 10-12
million individuals) is completely edentulous; 30% of
Americans over 65 have no teeth at all.
– 44% of Americans have gingivitis; and
– 13% of Americans have periodontal disease.
PREVENTION . . .
The Concept
• The resolution of such extensive problems of
dental caries and periodontal disease by a
“restorative philosophy” yields low efficiency and
efficacy. It is not a cost/benefit effective way to
achieve oral health.
• As a consequence, the far-sighted in the
profession have turned to prevention as the only
feasible solution to a problem of such severity.
• Oral health care systems which emphasize
prevention will yield populations with good oral
health; those that do not, will not.
PREVENTION . . .
The Concept
• A philosophy of prevention is basic to a good contemporary
practice.
• Dentistry exists to facilitate the gaining of oral health by
society.
• Individual dentists profess to exist to help their patients
gain oral health.
• The preventive concept should be the thread that is woven
through the entire fabric of dental practice.
• The concept of prevention can be understood to apply to all
aspects of practice by understanding prevention to exist at
primary, secondary, and tertiary levels.
LEVELS OF PREVENTION
• PRIMARY PREVENTION
– Occurs in the clinically pre-pathologic period.
– Involves promotion of oral health concepts, as
well as specific protection.
– Examples: oral health education, water
fluoridation, plaque removal through brushing
and flossing, antimicrobials, topical fluorides,
pit and fissure sealants, mouth guards.
– Prevent: caries, gingivitis, trauma to the teeth
from occurring.
LEVELS OF PREVENTION
• SECONDARY PREVENTION
– Occurs in the early period of pathogenesis.
– Involves early recognition and prompt therapy.
– Examples: Radiographic examination, Root
scaling, conservative restorative treatment
– Prevent: further deterioration of health that
would result in extensive lesions of the teeth,
pulpal involvement, or periodontitis.
LEVEL OF PREVENTION
• TERTIARY PREVENTION
– Occurs later in the period of pathogenesis.
– Involves limitation of disability and
rehabilitation.
– Examples: pulpal therapy, periodontal surgery,
extractions, fixed prosthodontics, space
maintainers.
– Prevent: loss of teeth, disseminated infection,
loss of space, occlusal disharmonies, and other
significant oral disabilities.
CHILDREN IN
“THE CONCEPT”
“He who is wise begins with the child.”
Goethe
• As primary prevention is the ultimate goal of
the dental profession, it necessarily follows
that the thrust of any comprehensive oral
health program be directed at the child.
• Children must be the foundation of a
practice that is focused on prevention.
UNDERSTANDING THE
PROBLEM
• To understand the problem of prevention as it relates to children, an
understanding of the profile of oral disease experience of children
(in America) is necessary.
• Epidemiology is that branch of medicine that deals with the study of
the causes, distribution, and control of disease in populations.
• The epidemiological term for the magnitude of a disease existing in a
population at a point in time is referred to as prevalence.
• Prevalence must be differentiated from a related term, incidence.
• Incidence is the disease occurring in a population during a specific
period of time.
• To say that the average 17 year old has 4.96 decayed, missing or
filled teeth is to make a statement of prevalence.
• To say that the average child will develop a new carious lesion
between ages of 6 and 10 is to make a statement of incidence.
PREVALENCE OF DENTAL
CARIES IN CHILDREN
• Two epidemiological measures will serve as indices
of prevalence of caries:
– DMFT: An index that represents the number of
decayed (D), missing (M), and filled (F) teeth
(T). Index is total of these three assessments
in the individual.
– DMFS: An index that represents the number of
decayed, missing, and filled surfaces (S), in the
individual.
– DMFS is the more sensitive measure of the
magnitude of disease in the oral cavity.
PREVALENCE OF DENTAL
CARIES IN CHILDREN
• The average DMFT in school age children (age 5-17) is 1.97.
• The average DMFS is school age children (age 5-17) is 3.07.
• Over 50% of 5-9 year old children have at least one carious
lesion or restoration.
• At age 17, the average child has 4.96 DMFT, (1.0 due to a
missing tooth); and 8.04 DMFS; 80% of adolescents have
dental caries by age 17.
• Obviously, the teeth are more vulnerable to decay the longer
they are in the oral cavity.
PREVALENCE OF DENTAL
CARIES IN CHILDREN
• Only 20% of children have had no carious experience by age 17.
• 80% of the dental carious experience occurs in 25% of the
children in this country. This concentration of disease has
become greater through time. In 1980, approximately 65% of
the caries was found in 24% of the children.
• The prevalence of caries experience among children has
declined significantly since 1970.
• Approximately 80% of the carious lesions occurring in school
age children are on the occlusal surface.
PREVALENCE OF DENTAL
CARIES IN CHILDREN
• The highest DMFT is found in the Northeastern United
States; the lowest in the Western United States.
• African-American children have a lower DMFT than EuroAmerican children.
• However, the profile of the DMFT is different. AfricanAmericans have a higher percentage of the index in the
decayed and missing category. Euro-Americans have a higher
percentage of the index in the filled category.
• This difference reflects the differential in professional oral
health care accessed by these two groups.
• Studies have confirmed that the percentage of decayed
teeth in the index declines with increasing household income.
RELATED INFORMATION
• Dental caries is the single most common chronic childhood
disease, 5 times more common than asthma, and 7 times
more common than hay fever.
• There are striking disparities in caries prevalence by income.
Poor children suffer twice as much caries as non-poor, and
their disease is more likely to be untreated. (One out four
children in America are born into poverty--$17,000 for a
family of four.)
• Twenty-five percent of poor children have not seen a dentist
prior to kindergarten.
• 51 million school hours are lost each year to dental-related
illness.
• Toothaches are the most common classroom health problem.
• Over one-third of American children do not have the benefit
of water fluoridation; our most effective
EARLY CHILDHOOD
CARIES
(NURSING CARIES)
• 5-10% children have Early Childhood Caries (ECC),
sometimes called nursing (or bottle) caries; the
rate is even higher among families with low
incomes, and among racial/ethnic minorities.
• ECC is the result of poor nursing/feeding habits;
associated with children being given the bottle
past 12 month, and/or given the bottle with
cariogenic solutions in it at night, and allowed to
keep it in the mouth for a prolonged period.
• ECC significantly increases a child’s risk of
future caries experience.
RISK FACTORS FOR CARIES
AMONG CHILDREN
• Children born to mothers in their teens
have a 5X greater chance of having carious
lesions by age 5.
• Living in a rural area doubles the likelihood
of having caries.
• Mothers who do not brush their teeth
regularly, have children with double the
risk for caries.
CARIES RISK GUIDELINES
(American Dental Association 1996)
LOW:
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No carious lesions in last year
Coalesced or sealed pits and fissures
Relatively plaque free
Fluoride in water supply and use of fluoride
dentifrice
• Regular dental visits
CARIES PREVENTION MODALITIES
FOR CHILDREN BY RISK CATEGORY
(American Dental Association, 1996)
LOW
• Educational reinforcement:
– Plaque removal (oral physiotherapy)
– Fluoride dentifrice
– One year recall
CARIES RISK GUIDELINES
(American Dental Association, 1996)
MODERATE
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One carious lesion in the last year
Deep pits and fissures
Some plaque accumulation
No fluoride in water
White spot lesions
Irregular dental visits
Orthodontic treatment
CARIES PREVENTION MODALITIES
FOR CHILDREN BY RISK CATEGORY
(American Dental Association, 1996)
MODERATE
• Pit and Fissure Caries
– Sealants
• Smooth Surface Caries
– Education
– Dietary Counseling
– Fluoride dentifrice (low potency fluoride)
– Fluoride mouthrinse (low potency fluoride)
– Professional topical fluoride (high potency fluoride)
– Six month recall
– Fluoride supplements (depending on age of child and
absence of water fluoridation)
CARIES RISK GUIDELINES
(American Dental Association, 1996)
HIGH
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Two ore more carious lesions in last year
Past smooth surface caries
Elevated mutans streptococci count
Deep pits and fissures
No or little systemic and topical fluoride exposure
Plaque accumulation
Frequent fermentable carbohydrate intake
Irregular dental visits
Inadequate salivary flow
Inappropriate nursing habits (infants)
CARIES PREVENTION MODALITIES FOR
CHILDREN BY RISK CATEGORY
(American Dental Association, 1996)
HIGH
• Pit and Fissure Caries
– Sealants
• Smooth Surface Caries
– Education
– Dietary counseling
– Fluoride dentifrice
– Fluoride mouthrinse
– Professional topical fluoride (3-6 months)
– Three to six month recall
– Monitoring of mutans Streptococci
– Antimicrobial agents (Chlorohexidene)
– Fluoride supplements ( depending on age of child and
presence of water fluoridation
PREVALENCE OF
PERIODONTAL DISEASE
IN CHILDREN
• Approximately 60% of school age children will
have at least one site of gingival bleeding on
probing.
• 8% of children will have bleeding at multiple
probing sites.
• Less than 1% of children, 5-17, will have a loss of
periodontal attachment.
• One-third of teen-age children will have some
supragingival calculus.
• Ninety-eight percent (98%) of school age children,
ages 5-17, have normal periodontal tissues.
PREVALANCE OF
MALOCCLUSION IN
CHILDREN
• Reliable epidemiological indices to assess malocclusions do
not exist.
• Data from one study indicate that approximately 40% of
children have occlusions close enough to ideal to be
considered normal; 60% do not.
• However, one study found that 75% of school age children,
age 6-11, were judged to have some degree of occlusal
disharmony; 37% were judged to have a handicapping
malocclusion.
• Another study found that only 14% of the age group present
a handicapping malocclusion; while an additional 38% could
benefit from treatment; meaning 50+% of children could
benefit.
PREVALANCE OF
MALOCCLUSION IN CHILDREN
PREVALANCE OF
MALOCCLUSION IN CHILDREN
• Rarely are malocclusions seen in the primary
dentition, though pre-dispositions to such can be
identified.
• Rather, malocclusions tend to emerge with the
eruption of the permanent dentition and the
growth spurts that occur during the school-age
years.
• The most common malocclusion identified in the
primary dentition is the posterior crossbite. One
study found it to exist in approximately 8% of
primary dentitions.
OTHER PREVENTIVE
ISSUES OF ORAL HEALTH
• Cleft lip/palate, one of the most common
birth defects, effects 1 in 600 life births
in Euro-Americans and 1 in 1,850 live births
in African-Americans.
• Trauma to the cranio-facial complex are
relatively common in children--studies are
highly variable, 4-24%.
• Tobacco-related oral lesions are prevalent
among adolescents who use smokeless (spit)
tobacco.
PREVENTIVE FOCUS IN
THIS UNIT
• In this unit we will focus primarily and
specifically on the preventive issues
associated with caries and periodontal
disease.
• Prevention associated with malocclusions,
trauma, and oral cancer will be addressed
when these issues are addressed.
• Our approach to prevention of caries and
periodontal disease diseases will be multidimension and comprehensive.
IMPLEMENTING THE
CONCEPT OF PREVENTION
• Prevention of dental caries and periodontal
disease is possible by directing our efforts to the
four variables that are involved: the teeth, the
bacteria, the substrate, and the understanding
and motivation of the child and parent.
• It is imperative that the problem of prevention be
approached by addressing all the variables of the
disease process not just one or some.
• The focusing on only one aspect of a multifaceted
problem leads to a distorted understanding of the
problem, and an inadequate result.
“THE BLIND MEN AND THE
ELEPHANT”
BY GEOFFREY SAXE
It was Six men of Indostan
To learning much inclined,
Who went to see the Elephant
(Though all of them were blind),
That each by observation
Might satisfy his mind.
The First approached the Elephant,
And happening to fall
Against his broad and sturdy side,
At once began to bawl:
"Bless me! but the Elephant
Is very like a wall!"
The Second, feeling of the tusk,
Cried, "Ho! What have we here,
So very round and smooth and sharp?
To me tis mighty clear,
This wonder of an Elephant
Is very like a spearl"
The Third approached the animal,
And happening to take
The squirming trunk within his hands;
Thus boldly up and spake:
"I see", quoth he, "the Elephant
Is very like a snake!”
The Fourth reached out his eager hand,
And felt about the knee,
"What most this wondrous beast is like
Is might plain", quoth he:
"'Tis clear enough the Elephant
Is very like a tree!"
The Fifth, who chanced to touch the ear
Said, "E'en the blindest man
Can tell what this resembles most;
Deny the fact who can,
This marvel of an Elephant
Is very like a fan!"
The Sixth no sooner had begun
About the beast to grope,
Than, seizing on the swinging tail
That feel within his scope,
"I see," quoth he, "the Elephant
Is very like a rope!"
And so these men of Indostan
Disputed loud and long,
Each in his own opinion
Exceeding stiff and strong,
Though each was partly in the right,
And all were in the wrong!
PREVENTIVE MEASURES
DIRECTED TO THE TEETH
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Water Fluoridation
High Potency Topical Fluorides
Fluoride Dentifrices
Fissure Sealants
PREVENTIVE MEASURES
DIRECTED TO THE
MICROFLORA
• Plaque Removal
• Antimicrobials
PREVENTIVE MEASURES
DIRECTED TO THE
SUBSTRATE
• Dietary Analysis and Counseling
PREVENTIVE MEASURES
DIRECTED TO THE
EDUCATING CHILDREN
AND PATIENTS
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Educational Techniques
Educational Resources
Audio-Visual Materials
Patient Educational Brochures