The Preventive Philosophy

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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 foundthat countries with dental care systems that emphasizedrestorative care had the highest caries experience in theworld, as measured by the number of decayed, missing

and/or filled teeth, (DMFT).• These countries also had the highest number of completelyedentulous individuals.

• In countries where prevention was emphasized, the numberof 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 forAmericans:

– 98% of 40-44 year olds have had tooth decay, with anaverage 45 affected tooth surfaces.

– the average American has between 9-10 missingpermanent teeth;

– over 4% of the American population (between 10-12

million individuals) is completely edentulous; 30% ofAmericans 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 andefficacy. It is not a cost/benefit effective way toachieve oral health.

• As a consequence, the far-sighted in theprofession 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 oralhealth; 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 bysociety.

• Individual dentists profess to exist to help their patientsgain oral health.

• The preventive concept should be the thread that is woventhrough the entire fabric of dental practice.

• The concept of prevention can be understood to apply to allaspects of practice by understanding prevention to exist atprimary, secondary, and tertiary levels.



LEVELS OF PREVENTION

• PRIMARY PREVENTION– Occurs in the clinically pre-pathologic period.

– Involves promotion of oral health concepts, aswell as specific protection.

– Examples: oral health education, waterfluoridation, plaque removal through brushingand flossing, antimicrobials, topical fluorides,pit and fissure sealants, mouth guards.

– Prevent: caries, gingivitis, trauma to the teethfrom occurring.



LEVELS OF PREVENTION

• SECONDARY PREVENTION

– Occurs in the early period of pathogenesis.– Involves early recognition and prompt therapy.

– Examples: Radiographic examination, Rootscaling, conservative restorative treatment

– Prevent: further deterioration of health thatwould 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, spacemaintainers.

– 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 ofthe dental profession, it necessarily followsthat 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 THEPROBLEM

• To understand the problem of prevention as it relates to children, anunderstanding 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 lesionbetween 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 ofdecayed (D), missing (M), and filled (F) teeth(T). Index is total of these three assessmentsin the individual.

– DMFS: An index that represents the number ofdecayed, missing, and filled surfaces (S), in theindividual.

– DMFS is the more sensitive measure of the

magnitude of disease in the oral cavity.




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 cariouslesion or restoration.

• At age 17, the average child has 4.96 DMFT, (1.0 due to amissing tooth); and 8.04 DMFS; 80% of adolescents have

dental caries by age 17.• Obviously, the teeth are more vulnerable to decay the longerthey are in the oral cavity.




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 hasbecome greater through time. In 1980, approximately 65% ofthe caries was found in 24% of the children.

• The prevalence of caries experience among children hasdeclined significantly since 1970.

• Approximately 80% of the carious lesions occurring in schoolage children are on the occlusal surface.




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 Euro-American children.

• However, the profile of the DMFT is different. African-Americans have a higher percentage of the index in thedecayed 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 decayedteeth in the index declines with increasing household income.



RELATED INFORMATION

• Dental caries is the single most common chronic childhooddisease, 5 times more common than asthma, and 7 timesmore 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 fourchildren in America are born into poverty--$17,000 for afamily of four.)

• Twenty-five percent of poor children have not seen a dentistprior to kindergarten.

• 51 million school hours are lost each year to dental-relatedillness.

• Toothaches are the most common classroom health problem.

• Over one-third of American children do not have the benefitof water fluoridation; our most effective



EARLY CHILDHOODCARIES

(NURSING CARIES)

• 5-10% children have Early Childhood Caries (ECC),

sometimes called nursing (or bottle) caries; therate is even higher among families with lowincomes, and among racial/ethnic minorities.

• ECC is the result of poor nursing/feeding habits;associated with children being given the bottlepast 12 month, and/or given the bottle withcariogenic solutions in it at night, and allowed tokeep 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 cariouslesions by age 5.

• Living in a rural area doubles the likelihoodof having caries.

• Mothers who do not brush their teethregularly, have children with double therisk for caries.



CARIES RISK GUIDELINES

(American Dental Association 1996)

LOW:• No carious lesions in last year• Coalesced or sealed pits and fissures• Relatively plaque free

• Fluoride in water supply and use of fluoridedentifrice• Regular dental visits



CARIES PREVENTION MODALITIESFOR CHILDREN BY RISK CATEGORY

(American Dental Association, 1996)

LOW

• Educational reinforcement:– Plaque removal (oral physiotherapy)

– Fluoride dentifrice

– One year recall





MODERATE

• 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 MODALITIESFOR 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)





HIGH• 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 FORCHILDREN 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 OFPERIODONTAL 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 OFMALOCCLUSION IN

CHILDREN• Reliable epidemiological indices to assess malocclusions do

not exist.

• Data from one study indicate that approximately 40% ofchildren have occlusions close enough to ideal to beconsidered 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 handicappingmalocclusion.

• Another study found that only 14% of the age group presenta handicapping malocclusion; while an additional 38% couldbenefit 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 beidentified.

• Rather, malocclusions tend to emerge with theeruption of the permanent dentition and thegrowth spurts that occur during the school-age years.

• The most common malocclusion identified in theprimary dentition is the posterior crossbite. Onestudy found it to exist in approximately 8% ofprimary 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 birthsin African-Americans.

• Trauma to the cranio-facial complex arerelatively 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 periodontaldisease.

• 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 multi-

dimension and comprehensive.



IMPLEMENTING THE

CONCEPT OF PREVENTION• Prevention of dental caries and periodontal

disease is possible by directing our efforts to thefour variables that are involved: the teeth, thebacteria, the substrate, and the understandingand motivation of the child and parent.

• It is imperative that the problem of prevention beapproached 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 theproblem, and an inadequate result.

“THE BLIND MEN AND THE



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 fallAgainst 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 ElephantIs 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 ElephantIs very like a snake!”

The Fourth reached out his eager hand,And felt about the knee,

"What most this wondrous beast is likeIs might plain", quoth he:

"'Tis clear enough the Elephant

Is very like a tree!"



The Fifth, who chanced to touch the earSaid, "E'en the blindest man

Can tell what this resembles most;

Deny the fact who can,This marvel of an ElephantIs very like a fan!"

The Sixth no sooner had begunAbout the beast to grope,

Than, seizing on the swinging tailThat feel within his scope,

"I see," quoth he, "the ElephantIs very like a rope!"

And so these men of IndostanDisputed 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

• Water Fluoridation

• High Potency Topical Fluorides• Fluoride Dentifrices

• Fissure Sealants

P E E E E E



PREVENTIVE MEASURESDIRECTED TO THE

MICROFLORA

• Plaque Removal• Antimicrobials

PREVEN VE ME RE




SUBSTRATE

• Dietary Analysis and Counseling




EDUCATING CHILDRENAND PATIENTS

• Educational Techniques

• Educational Resources

• Audio-Visual Materials• Patient Educational Brochures

Documents

The Preventive Philosophy