Infant Oral Health Care Babu

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1. Introduction2. Definition

Caries

Prevention3. Why prevention is necessary?4. Level of prevention

Primary

Secondary

Tertiary5. Methods of prevention of dental caries

Infant oral health care

Parent counseling

Diet counseling

Pit and fissure sealant

Fluorides

Systemic administration Topical application

Methods on horizon

Antiplaque agents and detector

Altering surface morphology

Lasers

Self assembling polypeptides (SAP)

Chewing gums

Tooth friendly sweets

Microdentistry

Teledentistry

Indigenous products

Caries vaccine6. Conclusion7. Bibliography

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: dental caries is an irreversible microbialof calcified tissues of the teeth, characterizedby demineralization of the inorganic portionand destruction of the organic substance ofthe tooth, which often leads to cavitation.

: approach to preventing thedevelopment of dental caries is toestablish and maintain good oralhygiene, optimize systemic topicalfluoride exposure and eliminate prolongexposure to simple sugar in diet.

By modifying the cardiogenic bacterial flora. By altering the substance on which these bacterias

survive. By rendering the tooth less susceptible.

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While the industrialized countries may claim of reduction incaries incidence, developing countries such as India still face anuphill task as the caries incidence still on increase. In an attemptto strike at the root of the problem, prevention of dental cariesis an invaluable foundation step. While assessment as to the riskof the infant developing oral disease in lateral life may not beentirely accurate, a general policy will go a long way in reducingthe incidence of the same. When better timing exists, to initiate

the preventive measures in its truest forms i.e. primordial orprimary prevention, secondary prevention and tertiaryprevention. Time and again, measures initiated before the onsetof the disease have proven to be effective.

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Parent counseling

Diet counseling

Pit and fissure sealant

Fluorides

Systemic administration

Topical application

Methods on horizonAntiplaque agents and detector

Altering surface morphology

Lasers

Self assembling polypeptides (SAP)

Chewing gums

Tooth friendly sweets

Microdentistry

Teledentistry

Indigenous products

Caries vaccine

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The infant oral health program is meant for early dental evaluation ofinfants/ toddlers and providing parent education regarding their importantrole in preventing oral diseases from occurring in their child. The goals ofsuch a program are :

1. To identify, intercept and modify the potentially harmful parentingpractices that may adversely affect the infants oral health.

2. Parent education right from the prenatal period highlighting theimportance of their role in the prevention of dental disease for theirchild.

3. Parent/ caregiver orientation to perceive dental services as anintegral part of infants overall health program.

4. Periodic evaluation of the orofacial development and oral health bythe clinician.

While the industrialization countries may claim of a greater attention beinggiven in the oral health care of children, developing countries such as Indiastill face an uphill task, as the incidence of oral diseases in children is stillon the increase (not withstanding the goals of WHO). In an attempt tostrike at the root of the problem, Infant Oral Health Care is an invaluablefoundation step. While assessment as to the risk of the infant developingoral diseases in later life may not be entirely accurate, a general policy will

go a long way in reducing the incidence of the same. What better timingexists than to initiate the preventive measures in its truest form i.e.

primordial or primary prevention. Time and again, measures initiatedbefore the onset of the disease have proven to be more effective.

The following are few reasons why infant oral health care should be anintegral component of Pedodontics in India:

1. : Oral cavity of the infant is

invaded by a variety of microorganisms but most of them ustransient. This is the first habitat in the human body where

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microorganisms are seen to be established soon after the birth within6 to 8 hours in an infant. Streptococcus is found to be consistentlypresent within few hours after birth.

The eruption of teeth is an event that brings about a qualitative andquantitative change in the microflora. The colonization of the 'PioneerBacteria' is a special process, which then gives a substrate to attachthe 'Secondary Invaders'. Oral health cue measures at this stageprevent the colonization by the secondary and generally morepathogenic microorganisms.

It has been proven that Streptococcus mutans, a primary causative

factor in the initiation of caries, is transmitted from the mother to theinfant. These gather a foothold in the mouth immediately after theeruption of teeth.

With weaning and adoption of a cariogenic diet, caries may developin the oral cavity and cause severe and rapid destruction of the hardtissues if left unchecked. The diet, particularly drinks with low pH,has the potential to cause erosion. Nursing bottle caries has beenfound to be prevalent in the infants and preschoolers due to faultyfeeding practices by the mothers.

It has also been reported that children who are "easy to manage" aremore likely to be younger, have their teeth brushed twice per dayand be breast fed to sleep throughout the night. However, "difficult"children and more likely to be bottle fed and thus predisposed tohave non cavitated/white spot lesions.

The caries preventive program needs an individualized approachwhich can and should be started right from the prenatal period

through infancy to adolescence and even further. It thus includesmeasures such as:


Parent counseling, diet counseling

Fluoride programs

Pit and fissure sealants, and

Other methods on the horizon.

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The preventive and treatment protocol would be guided by the riskgroup of the individual.

Professionaltherapy

Home care Professionaltherapy

Home care

Oralprophylaxis

Completerehabilitation of

all cariouslesions

Antimicrobialtherapy(chlorhexidinegel)

Pit and fissuresealants(specially inyoung

permanentteeth)

Topical flurideapplications(preferablyvarnish)

Dietmodification

Dental health

educationA more

frequent recalland reviewprogram (every3 months)

Supervisedhome care(use ofdisclosing

agents forpatientmotivation)

Home fluorideapplication

Sustainedrelease offluoride tablets

Self gelapplications

Fluoridedentifrice (ifnot in use,above 4 years)

Salivarysubstitutes (incase ofxerostomia)

Chewing gum

withanticariogenicproperties

Annual topicalapplication

Regular recallfor 6 months

Dental healtheducation

Fluoridedentifrice (ifnot in use)

2. : With lack of motor coordination trauma to thedeveloping primary dentition may also occur.

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3. : Such as thumb sucking usually have their inception at thisage and may persist to cause several dental problems.

4. may also be detected.

5. : Cleft lip and palate casesand other such children requiring special attention, may do so rightfrom birth.

6. would require early detection.

To all these problems, the traditional approach has been to treat the effects

of the disease. By delineating an infant oral health care policy, one may nothave to encounter the disease process or its effects.

Thus Nowak (1997) has stated that "the goal of the first oral supervisionvisit is to assess the risk for dental disease, initiate a preventive program,provide anticipatory guidance and decide on the periodicity of subsequentvisits".

The first step should be to establish a "Dental Home" for each infant. Thedental home is the ongoing relationship between the dentist and thepatient, inclusive of all aspects of oral health care delivered in a compre-hensive, continuously accessible, coordinated, and family-centered way.Establishment of a dental home begins no later than 12 months of age andincludes referral to dental specialists when appropriate (AAPD, 2004).

By visiting the dentist at such an early age, a dental home can beestablished and anticipatory dental guidance be made, part of the child's

total health care experience.

1. Immediate referral of infants with an apparent dental problem due totrauma, disease or developmental abnormality.

2. Examination at no later than 6 months or when the first tooth empts

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To enhance the dentist's ability to assist children and their

parents/caregivers in the quest for optimum oral health cue.

To schedule early oral health examinations and preventive servicesfor cost effectiveness.

To offer parents and caregivers resources which assist them inmaking the best informed choice.

Individual child risk assessment for dental diseases.

Monitoring the growth and development.

Referrals to dental specialists when care cannot directly be providedwith the dental home.

Interaction with early intervention programs, schools, early childhoodeducation and child care programs, members of the medical anddental communities, and other public and private communityagencies to ensure awareness of age-specific oral health issues.

To make the parents aware of when and how frequently should theyvisit a dental home for their child.

As in the evaluation of any case, a proper history coupled with a vigilantassessment including knowledge of what is normal and what is not at thisage is essential.

1. History: A detailed history involving the prenatal, birth and postnatalperiods is necessary. Demographic details of the parents includingthe socioeconomic status need to be evaluated. Grindefford (1995)has stated that one of the factors which is a significant predictor ofearly caries development is socio-demographic factors (importantly,the mother's education).

2. Examination: A dentist should not be blinded by the necessity to do adental examination only, A general assessment would provide aninsight to systemic problems, if any. Once satisfied that the infant is

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in apparently normal health, a thorough oral examination iswarranted.

3. Risk assessment is carried out by noting down various factors. Theseinclude dietary factors, amount of the plaque present on the teethand feeding practices. This should be followed by customization of apreventive protocol, rather than generalization.

4. Any therapy, restorative procedure or prophylactic measures neededshould be instituted.

a) , on a one-to-onebasis or in small gatherings. On a lager scale, the dental associationcan be involved in teaching the masses regarding the timing of firstvisit. The dentist is well placed to formulate individualizedcomprehensive preventive program for every infant visiting the dentalhome.

It is also the duty of the dentist to answer the queries of the parentsas to when do the teeth erupt. The age at which teeth erupt varies

greatly between children and. a difference of 6-12 months can beconsidered normal.

6-10 months Bottom front teeth, then top front orside bottom front teeth

9-13 months Top front teeth

13-19 months First molars than canines, thensecond molar

2-3 years All the teeth

Since the parent encounters eruption of teeth for the first time, thesigns of teething should be made aware to the parent. Various homeremedies may be traditionally carried out in these circumstances,

such as rubbing honey over the gums. Such practices predisposing to

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caries should be strictly discouraged. Symptomatic treatment such asteething toys or hard sugar free rusks are however acceptable.

b) : From nutritional point of view, breast milk hasseveral systemic and immunologic advantages over proprietaryformulas. Thus the importance of breast-feeding should be explainedto the parents. However, on the flip side, prolonged and at willbreast-feeding, beyond the stipulated weaning time of the child,especially throughout the night and sometimes throughout the day,has been associated with nursing caries.

1. Breast milk has the ideal composition for infant's needs, provided in asafe clean form at the right temperature.

2. The feeds need no preparation mid there is no equipment to sterilize.

3. Breast milk contains anti-infective factors which cannot bemanufactured and added to infant formulae. This has considerablehealth benefits for the infant both in childhood and later life.

4. Psychologists say that it is of psychological advantage to mother andchild, increases bond strength and there is sense of accomplishmentand indispensability to mother.

5. Child being fed on breast milk is less likely to develop arterial diseasebecause of fat, as fats in breast milk are better emulsified.

6. Easily digestible and has low osmatic load.

7. Confers passive immunity to the baby.

8. A lack of breast-feeding has been associated with developmentaldefects of the primary dentition particularly in premature children.Thus it can be concluded that breast-feeding also prevents theoccurrence of developmental defects.

1. Secretory IgA, IgG, IgM

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2. . Lymphoid cells, polymorphs, macrophages,plasma cells.

3. activities of C3 and C4 complementsystem.

4. Unsaturated lactoferrin and transferrin

5. Lysozyme

6. Lactoperoxidase

7. : Antiviral andantistaphylococcal factors

8. for Lactobacillus bifidus

9. may afford some protection againstmalaria.

c) : Parents should also be made to realize thedifference of sucking and suckling, by the dentist, to prevent theonset of deleterious oral habits. Suckling at the breast is good for theinfant's tooth and jaw development. Nursing technically is differentfrom artificial feeding in that the bottle fed infant does not have toexercise the jaws so energetically, in as much as light suckling alone

produces a rapid flow of milk. Bottle fed infants use their tongue in amanner quite opposite that of the breast fed baby; the flow of milkthrough the rubber nipple is produced by the tongue thrustingmotion with each suck while the infants lips create a negativepressure in the oral cavity, thus suctioning milk from the bottle.

The breast fed baby places the tongue over the lower jaw, where itremains throughout the nursing session, and draws the nipple bysuction well into the mouth, elongating it to three times its normallength and extending it to the junction between the hard and soft

palates. The elongated nipple rests in a trough formed by the U-shaped tongue. As each suckling cycle is initiated, the infant's jawscompress the milk sinuses just under and proximal to the areola,pinching of a bolus of milk and propelling it toward the posteriorpharynx by a peristaltic wave like motion. This roller-like movement,which begins at the anterior tip of the tongue and progressestowards its base, effectively, strips the milk bolus from the proximalportion of the nipple out towards its tip, where it exits into theinfant's mouth and is swallowed. The jaw muscles are thus

strenuously exercised, encouraging the development of well-formedjaws and straight healthy teeth.

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d) : Weaning is a process of expanding the dietto include foods and drinks other than breast milk or milk formulae.

It is a gradual process - the age at which it is started and the rate atwhich it progresses vary between babies. Weaning should occurbetween 4 and 6 months, although a minority of babies will be readyfor weaning at 3 months.

e)

Often, parents who are too busy to deal with the crying child, try toquieten the child by using the bottle containing milk or other

sweetened drinks as a pacifier. This, when given frequently to thechild before and during sleep has been seen to cause a devastatingpattern of nursing caries. In this respect, the sugars taken beforesleep, when little saliva cleaning action is present, should beassessed and highlighted to the parents. A simple schematicrepresentation of the carious process, with the acid productiondestroying the teeth should be explained.

Provide more attention to the child. Remove the bottle immediately after feeding.

Substitute the milk or non-sweetened juices with plain boiled water.

Encourage your baby to stay in upright position with a bottle.

Use a bottle with a nipple that has a small hole to enable the infantto work with his muscles activity to get the milk from bottle.

Introduce a cup to drink as soon as possible.

Bottle feeding be allowed at intervals.

It should not be used as a pacifier.

Give water after feeding with the bottle and clean the mouth soonafter feeding.

This cleaning activity should be preferably performed after every meal or atleast once in a day. Besides the maintenance of good oral hygiene at thisage, this routine also goes a long way in establishing a practice to befollowed in the years to come.

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The parents should be advised to thus take care of gumpads and teeth asthey erupt, till the time where the child develops sufficient neuromuscularcentral to brush his/her teeth.

f) : Several disadvantages have been found with theuse of pacifiers such as :

Those dipped in honey or sugars can cause increased caries

Malocclusion

Unhygienic conditions leading to infections and GIT disorders

g)

Nowak (1995) describes anticipatory guidance as a proactive,developmentally based counseling technique that focuses on theneeds of a child at each stage of life.

What it effectively means is that one should not get disheartened, formany times a patient may lack cooperation at this young age.Providing an insight into the development of a child will involve theparent, with a much more focused strategy. Also, at every stage it isessential that the dentist takes into consideration the various

milestones of dental development. Such anticipatory guidance canmake the parents more at ease during childhood dental visit; thesepointers are also essentials in preventing many of the possible dentalproblems children would otherwise often face.

h)

Many parents would not be even aware of the fact that oral hygienepractices can be essential at this age. A thorough intraoral

examination may reveal the plaque on the tooth surfaces and fooddebris as well. In such cases and in all other cases as well if the childhas been brought early, the proper technique for positioning andtooth cleaning should be demonstrated.

i) : The cleaning of gumpads can be started as early aswithin the first week of birth.

The parents can be instructed to;

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Lay the baby down with his/her head in your lap and feet pointingaway.

Open the baby's mouth and slide the forefinger inside along the cheekand press down on the back side lower gumpad.

Take a small gauze (2 x 2") between thumb and forefinger and wipevigorously over the ridge of the baby's top and bottom jaws.

Nowadays specially designed for infants tooth brushes, finger cots andwipes are available, which can also be used.

Use adequate pressure just to remove the film that covers the child'sgumpad.

Clean at least every day twice after morning and last feed in the night.

Spend at least two to three minutes in cleaning.

ii) : The positioning of the infant, depending on whether one orboth the parents are involved in the procedure should be firstdemonstrated and then supervised by the dentist.

While performing these procedures care should be taken that the child issupported at all times and the movements are slow and careful, so as tonot cause any injury and address the problem in that light, not just keepreinforcing a particular set of instructions.

The pediatricians or primary care physicians treat infants and monitorthe growth and development of children. They are thus usually thefirst health care providers and can act to evaluate their oral healthstatus.

In this respect, they can be the forebearers in providing informationto the parents as they are more often in contact with the child andparents. The dentist should establish a contact with pediatrician andformulate a policy regarding dental health for the infant.

Following topics needed to be discussed by a pediatrician:

- Tooth eruption- Preventive oral hygiene- Orufacial development

- Fluoridation- Diet

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Johnson (1997) has also discussed the interaction with thepediatrician at the time of weaning. When the child is 10 months old,

the assertiveness of the child may make the parents to give in bygiving a sleep time bottle. A solution suggested is the gradual dilutionof the liquid. Thus

I week 1/3 bottle water2nd week 2/3 bottle water3rd week only water

Weaning foods free of, or low in non-milk extrinsic sugars should be

recommended to the mothers. Depending on the amount of fluoride present in community water,

and the requirements of the child, a fluoride supplementationprogram can be instituted.

Pediatrician should be made aware of the dentist population in hisvicinity for the purpose of referral. This in cases of largemulti-specialty centers it is easily done, but in smaller places withdental centers spread over a larger area may be difficult.

Children are our most precious resource. Their optimal oral health shouldbe provided not only on a therapeutic but also on a preventive basis earlyin life itself, Parents should be educated at the earliest possible time by notonly the dentist but also the general practitioner in order to provide them adisease-free environment.

1. The parents should bring their child for his/her first dental visit early,at least by the time the baby is 6 months of age.

2. Breast feed the baby but do not indulge at will.

3. Avoid frequent use of the bottle with sugared ma or drinks as thiscan lead to nursing bottle caries. Instead, give the child moreattention.

4. Do not put the child to bed with the bottle or at the breast but takethe bottle away immediately after feeding.

5. Dilute the milk gradually in the bottle and end with plain water.

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6. Feeding should be supervised at all times.

7. Start the child on semi-solid foods by 5-6 months and reduce the use

of bottle or breast-feeding.

8. Do not use pacifiers or dummies dipped in honey or other sugaritems.

9. Avoid extended use of sugared medicines such as syrups.

10. Clean the gums and later teeth with a cloth or soft brush after everymeal or before sleep.

11. Parents should brush or clean their baby's gums/teeth everyday tillthe child is old enough to manage himself.

12. Contact the dentist immediately if there is my accident or trauma tothe baby's teeth.

13. Parents should know about the benefits of fluoride and its proper usesuch as that used in infant formulas and dentifrices.

14. Half-yearly visits to the dentist should be routine.

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Parent counselling can be defined as educating the parents regarding thechild's oral health status, optimal health care and informing them about theprevention of potential dental diseases.

The purpose of parent counselling in pediatric dentistry involves:

Discussion of emotional problems of children, particularly in relationto dental treatment.

To offer the dentist an insight into parental influences which mayproduce unnecessary anxieties.

Knowing about the attitude of parents towards behaviormanagement techniques used during dental treatment of children.

Obtaining the cooperation of a child patient, establishing a goodrapport with the child and also using effective techniques of behaviormanagement.

Educating the parents about various dental problems, diseases andtheir sequelae and how they can be prevented with accuratepreventive measures if recognized earlier.

If we are to have a good child patient we must first educate the parents. Adentist who fails to do so is not using every means available to him inmanagement of the child.

Not to voice their own personal fears in front of the child.

Never to use dentistry as a threat of punishment.

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To familiarize their child to dentistry by taking the child to the dentist.This helps in making the child accustomed in the dental office and toget acquainted to the dentist.

About the home environment and importance of moderate parentalattitudes in building well-adjusted children. Regular dental care helpsin preserving the teeth and also in formation of good dental patients.

Never to embarass, scold or ridicule the child to over come the fearof dental treatment.

Not to promise the child what the dentist is or is not going to do.

Not to bribe their child to go to the dentist.

To convey to the child in a casual manner that they have beeninvited to visit the dentist.

To commit the child to dentist's cue in the office and should not enterthe treatment room unless requested by the dentist.

Occasional display of courage by the parent's in dental matters willbuild courage in the child.

A large number of children experience dental disease before 3 years of age.Nursing caries is particularly a devastating form of caries frequently seen inthis age group. Thus, it is important to educate the parents so they canmake appropriate decisions regarding the management of their infants andtoddlers oral health.

Parents should be educated regarding:

a) Dental development of their child.

b) The dental disease process.

c) Appropriate feeding practices emphasizing the hazards of improperbottle and breast-feeding.

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d) Oral hygiene measures appropriate for infants and toddlers.

e) Expectant parents can also be told regarding the mother's health

during pregnancy and the potential detrimental effects that poorhealth and unhealthy habits may have on their child's dentaldevelopment.

f) Also in pregnancy the food need increases to meet the specialphysiological changes in the body to support the growth of the fetusand facilitate normal labor.

Why are the Primary Teeth important?

Primary teeth act like the foundation stone for permanent teeth.

They maintain proper space for the permanent teeth to occupy.

These teeth help in normal growth of jaw height and give shape tothe face, just like in older individuals whose face looks completelycollapsed when they take out their denture.

Teeth provide a sense of self worth by contributing to one'sappearance.

Primary teeth certainly help in the first step of grinding of food, oncethe infants start eating solid food.

Children in this age group frequently exhibit gingivitis and may experiencerampant decay. The rampant decay is often a sequelae to timing cariesinitiated during the first 3 years of life or extensive caries may develop as aresult of eating patterns initiated after weaning.

1. : Parents are educated about the role of diet and their ill-effecton initiation of caries.

The frequency of exposure is the most important factor indevelopment of dental caries.

The rate at which sugar is cleared from the oral cavity is also animportant factor in the cariogenic potential of diet. The sticky

retentive items such as chocolates, toffees have more cariogenicpotential than sugared drinks that are quickly cleared.

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When the exposures are too frequent or the sugar is retained toolong, the net result is dissolution of tooth structure and formation ofa carious lesion.

Food items that can be recommended as relatively safe snacksinclude cheese, peanuts, milk, sugarless gum, and raw vegetables.Items to be particularly avoided include sugared gum, dried fruits,fruit juices, and sugared soft drinks, cakes and candy items.

The most important dietary advice is to limit the number ofcarbohydrate exposures per day rather than to limit the totalcarbohydrate consumed.

2.

The 3-6 year olds require parental assistance to achieve effectiveplaque removal.

Parents should be instructed to brush for the child at least once aday, and to clean between any teeth that are in contact with eachother with dental floss. Bedtime is the ideal time to establish thisroutine because the salivary flow rate slows during sleep. Thusnatural protective mechanisms are reduced.

Additional brushings may be performed by the child unaided.

3.

Fluoride consumption should be investigated and supplemented, ifappropriate.

The use of fluoride-containing toothpaste (once daily) should becarefully monitored. Parents should be instructed to dispense only apea-sized amount for their child. The child should brush under thesupervision of the parent so that they can monitor to ensureexpectoration. Other times the child can brush with non-fluoridatedtoothpaste.

Professional application of high concentration fluoride gels is usuallybegun at the age of 3 years when swallowing can be controlled.

4.

The parents are educated that in small primary teeth, cariesprogresses at a high rate. Also, because of rapid developmental

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changes, the timings of the visits can be critical for initiatingpreventive measures.

Semiannual dental visits should begin at the age of 3 years andcontinue throughout childhood and adolescence.

Eruption of the first permanent molar at about the age of 6 years is amilestone requiring preventive action. Parents are educated about theimportance of the first permanent molar. They are told how the variouspreventive measures taken at this stage can prevent the progression ofcaries.

1.

The most effective aid for preventing pit and fissure decay isprofessionally applied sealants. Most children benefit from theapplication of sealants to their permanent molars which allows themto maintain a caries-free dentition into adulthood.

2.

Children of school age are developing some autonomy in eatinghabits. They often make their own food choices at school and maypurchase snack items. Parents are instructed to monitor the dietarypractices, especially for children who experience smooth surfacedecay.

3.

As the child develops control over swallowing, topical fluorides can besafely used and at this age. They begin to assume an important role

in prevention.

Regular use of toothpaste (twice-daily fluoridated toothpaste) isrecommended for its abrasive action in removal of the plaque as wellas fluoride exposure. By the age of 6 years most patients are capableof expectorating but parents should monitor it.

4.

Parents need to remain active in supervising the home care practices

of 6-12-year olds.

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During this age span a transition can be made from care provided bythe parent to supervised selfcare.

By the age of 10 most children are capable of fine motor coordinationnecessary for adequate tooth brushing and begin to assumeresponsibility for daily brushing and flossing. Therefore it is the dutyof the dental practitioner to teach proper oral hygiene maintenancetechnique to these children. Parents should continue to monitorbrushing and flossing frequency and adequacy.

5.

Education about any oral habit, if it is present.

Also educate the parents about transitional in the developingdentition and the importance of primary and permanent dentition.

Prevention of dental caries continues to be an oral health priorityduring adolescence and prevention of periodontal disease becomes aspecial concern. This is a very unique age group. At the stage ofadolescence the main processes utilized are :

a) Rejection of many parental values.

b) The beginning of independent struggle.

c) The testing out types of behavioural experimentations.

Parents are educated that they should tackle the child at this stage verydiplomatically. The child should he given enough emotional support fromthe family and his various habits should be monitored by the parents. The

parents should have a friendly approach.

1.

The adolescent patient possesses the fine motor skills necessary foradequate tooth brushing and flossing, but problems in complianceare likely to be encountered.

For periodontal health it is necessary to remove the plaque from allareas of the tooth that contact the gingiva. Dental floss can be used

to effectively remove the interproximal plaque.

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2.

In patients with a high caries rate, rampant dental decay may result

in an extensive damage to the dentition. It is usually associated withpoor oral hygiene practices and a high frequency of sugarconsumption.

Progress of lesions can be halted with an appropriate diet control andan aggressive topical fluoride therapy.

3.

Systemic fluorides are no longer of benefit after the last permanent

tooth erupts at about age of 13 years, except for patients who havefunctional third molars.

Topical fluorides me the most effective preventive measure for thepatients who experience smooth surface caries.

Use of fluoride-containing dentifrices regularly (thrice daily) providesan economical and effective fluoride source.

4.

Many patients undergo orthodontic treatment during adolescence.These patients are at a high risk for both gingivitis and the resultantgingival hyperplasia and for dental caries around and under theappliance or braces.

Topical fluoride therapy is indicated to prevent decay.

A thorough removal of plaque from the gingival areas should beperformed to prevent gingivitis and periodontitis.

5.

Peer pressure and advertising exert pressure on children andadolescents to establish a habit that may result in addiction andultimately induce oral cancer.

Evidence of tobacco use, such as shreds of tobacco present in theoral cavity or localized hyperkeratosis should be a signal to initiateefforts to motivate the patients to discontinue the habit.

Parents should be instructed/ counselled not to nag or punish theadolescent as it might further entrench the habit.

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An injury to the teeth of a young child can have serious and long term

consequences that may lead to discoloration, malformation add even theloss of teeth. Such consequences can have a considerable emotional impacton the children.

If during trauma to the orofacial structure tooth is avulsed, theparents should be instructed to keep the avulsed tooth under thetongue of child or to store the tooth in milk or saline. The survival ofreplanted avulsed tooth will be enhanced if avulsed tooth is stored insome media prior to replantation.

Parents are advised to immediately contact the dentist, as in nearlyall situations of dental injuries the prognosis worsens. Theunfavorable consequences are more likely to occur with delay intreatment of the injury.

However, the best approach is to take active measures to preventinjuries.

Most injuries to the primary teeth occur within toddlers 12 to 30months of age.

Another major cause of dental injuries in children is falls during play.Children who engage in contact sports are at the greatest risk ofdental injuries. Athletic mouth protector (mouth guards) significantlyreduce dental injuries.

In order to achieve maximum effective results, preventive efforts should beinitiated early in the life of the child. Although most children experiencedental disease, a mouth free of caries and periodontal disease is a

potentially attainable goal for all children when they use currently availabletechniques.

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It has become increasingly evident that dietary counseling is the mostneglected of all preventive measures suggested by the researchers in termsof daily diet on the level of health as well as the susceptibility to a widevariety of diseases including that of the oral cavity. The dental practitioneris faced with a wide variety of patients and the clinician must accept eachindividual as he or she is, and be prepared to adapt his or her technique tothe specific needs of that individual. At times the clinician must teach the

patient about diet, health and cause and prevention of disease. Successfuldiet counselling depends on the ability of the clinician to make the patientsee the problem clearly and thereby work upon its solution.

: The sum of processes concerned in the growth, maintenanceand repair of living body as a whole or its constituent parts.

Science of food and its relationships to health. It is concernedprimarily with the part played by the nutrients in body growth,development and maintenance (WHO 1971).

: Any substance which when taken into the body of an organ may beused either to supply energy or to build a tissue (Oxford Dental Dictionary).

Anything that is eaten, drunk or absorbed for maintenance of life,growth and repair of the tissues (Nizel 1989).

: It is referred to as food and drink regularly consumed (Oxford DentalDictionary).

Total oral intake of a substance that provides nourishment andenergy (Nizel, 1989).

: It is one which contains varieties of foods in suchquantities and proportion that the need for energy, amino acids, vitamins,fats, carbohydrates and other nutrients is adequately met for maintaining

health, vitality and general well-being and also makes provision for a shortduration of leanness (Chaudiac, 1994).

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The food that we eat affects our body in two ways:

: depends on their content of nutrients and includes theinfluence of such nutrients on general health. growth and development, cellrenewal, ability of the tissues to repair and resistance to disease.

: consists of what food can do to the tissues or theirenvironment because of their mere presence in such an environment. In

dentistry, most local effects result from the interaction between foodresidues and oral bacteria, which leads to plaque formation. Themetabolites from the plaque bacteria have effects on the soft and hard oraltissues.

The classes of nutrients necessary for the growth of the child are:

Energy providing charbohydrates and lipids.

Tissue building proteins.

Regulator vitamins and minerals.

Water comprising 55 to 65% of the total body weight.

Caloricrequirement

1200-1500

1500 1800 2500 2800 2800

RDA proteinrequiremen

t

18-20g 22 g 33 g 50 g 55 g 100 g

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Cereals 2 1/3-90 2-200 3-250 4-350 5 1/3-475 4 - 400Pulses 1 -35 2-60 2-70 2-70 21/ -80 2-70

Green leafyvegetables - 60 -40 1 -75 2 -150 2-120 2 -150Other

vegetables - 30 1 -40 2-70 2-75 5-175 5 - 175roots & Tubers

Fruits 1 -30 1 -40 1 -50 2-75 1 -30 1 -35

MilkMilk & milk 1 -150ml 2 -250ml 2-200 ml 2-200 ml 2-200 ml 3 1/4-325product

Meat & fish 1 -30 1 -30 1 -30 1 -30 1 -30Egg 1 -50 1 -30 1 -30 1-30

lift

Fats/oils 4 tap- 20 5 tsp- 25 2 tsp- 30 7 tsp - 35 2 tsp-40 7tsp - 35Sugar 4 tap- 20 2 tap- 30 2 top- 30 2 tsp - 30 2 tsp-40 2tsp - 30

S - Servingsg - gramstsp - tea spoon

The patient's diet and dental caries activity are related. From thedietetic viewpoint, dental caries is widely accepted as being causedby the ingestion of fermentable carbohydrates, particularly sucrose.

Fermentable carbohydrates and more Specifically Sucrose are rarelyeaten as such. They are eaten as components, of foods that containnation ingredients and have different textures.

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The cariogenic potential of foods communing sucrose depends onmany variables such as the ability to:

- Be retained by teeth

- Form acids

- Dissolve enamel

- Neutralize or buffer acids.

Certain characteristics of sucrose-containing foods or conditionssurrounding their consumption are more important in terms ofcariogenicity than the amount of sugar they contain. Thus, solid andretentive sucrose-containing foods are more cariogenic than sugarcontaining foods that are liquid and non-retentive.

The frequency and time of ingestion of foods are also important. Thesucrose-containing food becomes more dangerous if it is eaten morefrequently. Food eaten at meals produces less caries than the sameeaten in between meals.

In decreasing order of cariogenicity, the food are grouped as:

- Adherent, sucrose-containing foods eaten frequently betweenmeals.

- Adherent, sucrose-containing foods eaten during meals.

- Non-retentive (liquid) sucrose-containing beverages consumedfrequently between meals.

- Non-retentive (liquid) sucrose-containing foods consumed duringmeals.

The correction of diet imbalances that could affect the patient'sgeneral health and sometimes is also reflected in his oral health.

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The modification of dietary habits, particularly the ingestion ofsucrose-containing foods in forms, amounts and circumstances thatpromote caries formation.

The counsellor should possess dental and nutrition knowledge as a result ofprofessional education and training.

These best-qualified professionals are:

Dentist

Dental hygienist Nutritionist

Before counselling a child or his mother, determine what the child is eating.In a 15 to 20 minutes appointment the diet diary forms are introduced witha brief discussion of the purpose of diet counseling such as, explain to the

patient:

That we are looking for possible dietary causes of the caries problemof the patient, so that we can reduce the risk of future caries bydietary means.

What beneficial outcome could be available for him in better oralhealth and appearance and possibly improved health in general.

Not to be judgmental about the patient's responses as otherwise hemay tend to present his best side.

Not to emphasize the role of sucrose-containing foods before the dietdiary is completed, for otherwise the patient may tend to present anideal rather than real diet.

The patient should not be patronized or lectured.

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Please record every food item consumed-solid, liquid - during 6

consecutive days. Record food consumed at mealtime, betweenmeals, at soda fountain or while watching television. Also recordcandies chewing gum, cough crops or syrups.

The approximate amount in household measures such as 1 cup, 1table spoon (T), 1 tea spoon (t).

The kind of food and how it was prepared, such as baked chicken,raw apple, cooked cereal, etc.

Additions to food in cooking or at the table: butter, sugar, cream,etc.

Soft drinks, soda pop, powdered drink mixes, fruit drinks

Sweetened condensed milk, syrups.

Sweetened sauces such as chocolate, butterscotch. Chocolate milk, hot chocolate, cocoa.

Milk shakes, malts.

Cakes, doughnuts, cookies, candy bars, brownies, chocolates.

Pastries, pudding, muffins, sweet rolls, pies.

Sugar-containing cereals, sugar-coated gum.Dried fruits such as raisins, dates, apricots.

Fruit cooked in sugar.

Ice cream, jams, jellies, marmalades.

Sugar-containing chewing gum, caramels, bonbons.

Hard candy, mints, lollipops, jelly beans.

Frosting, honey.

Cough drops, syrups.

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In addition to these foods some medicines such as cough syrups, antacids(both liquid and tablets) contain variable amounts of sucrose.

The patient should be aided in identification of those foods which arelikely to cause oral diseases, the time when they are most harmfuland also those which are most nutritious and least cariogenic.

The plaque that forms in the teeth every day contains bacteria(germs). These bacterial change the sugar present in food intoacids.

Sugar (in food) + Plaque/ Bacteria (germs) = Tooth + Acid = Decay

The grand total time of exposure to acid is used here, to give the patient arough idea of the risk that his diet is imposing on his teeth.

From the summary of exposures to fermentable carbohydrates, determine

the dietary changes that are to be achieved for better dental health :

Peanuts, walnuts, peacans, almonds, other types of nuts.

Popcorn, corn chips, potato chips, whole wheat biscuits,unsweetened, dry cereals.

Cold cuts of meats (unsweetened).

Cubes of cheese.

Pizza, toasts.

Fresh fruits, salads.

Vegetables such as carrot slices, celery sticks, cucumber slices.

Baked potatoes, fried potatoes.

Hamburgers, hot dogs.

Unsweetened fruit juices freshly squeezed fruit juices.

Sugarless chewing gum.

Sandwiches.

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Katz and other researchers in 1981, suggested that nuts and cheese tendto diminish the pH in plaque after the ingestion of acetic foods or those

containing sugar.

The substitutes should be reasonable, which are acceptable to thedentists in terms of lesser cariogenicity as well as to the patient asfar as taste and preferences are concerned.

The list of substitutes should be prepared by the joint efforts of thedentist and the patient. The dentist should propose the substitutesand also ask what substitutes the patient will be willing to accept.

It is not fair to cut down all the sugar from the child diet. Intelligentuse of sugar must be there and that is:

- Use sugared food during meal time and

- Food consumption followed by appropriate oral hygiene measures.

Sometimes a compromise may be necessary. It is better to go from avery cariogenic to a less cariogenic than to obtain nothing.

During the next months at regular intervals, the dentist shouldevaluate the patient's progress and provide psychologicalreinforcement.

Evaluations are made by means of:

- The patient's comments

- New diet diaries

- Susceptibility tests such as Snyder test, and

- Clinical judgment

Reinforcement is provided by praising the patient's efforts. Point outthe improvements made in the diet as well as in the test results andthe absence of new carious lesions.

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Emphasis should he placed on making the patient fully aware of thebenefits derived from the program and that the benefits are theproduct of the patient's own efforts.

Immediate removal of all carious tissue and placement of ZnOE(temporary) restorations.

Topical fluoride applications

Plaque control instructions

Home use of fluoride containing dentifrices and mouth rinses.

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In simplified terms oral hygiene is the practice which enables to keep theoral cavity clean in order to prevent the onset and progression of commonproblems like dental caries, gingivitis, periodontits, halitosis, and otherdental disorders. This may consist of both personal and professional care.However, professional care cannot be obtained daily, so the personal careforms a more important aspect of oral hygiene maintenance. As a part ofthe personal care plaque control needs to be emphasized because dentalplaque has been found to be the culprit for causation of various dental

diseases.

Various studies in the past have suggested that the microbiology of dentalplaque is related to the pathogencity of plaque to cause the dentaldiseases. Therefore plaque control should have two broad goals:

1. Use of mechanical and chemical agents on a personal day-to-daybasis to eliminate supragingival plaque along with dietary control toprevent the onset of dental caries.

2. Mechanical removal of subgingival plaque through professionalmeans periodically so as to maintain predominantly gram-positiveflora associated with gingival health.

1. Gauze piece for use in infants

2. Manual toothbrush and dentrifices

3. Electronic/Powered toothbrush

4. Dental floss

5. Disclosing agents

6. Tongue scrapers

7. Oral irrigators

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1. Antiseptic mouthwashes

2. Antibiotics

3. Enzymes

4. Plaque modifying agents

5. Sugar substitutes

6. Plaque attachment interference agents

A moist gauze piece wrapped around the finger can be ideal for cleaninggumpads in infants.

These have been the most common age old methods of mechanical plaquecontrol. There is a large range of toothbrushes available in the marketbased on the following variables:

Diameter of fibers - soft (0. 16-0.22 mm), medium (0.23 0.29 mm),hard (> 0.30 mm)

Length of the toothbrush

Length of the bristles

No. of bristles

No. and arrangement of bristles as tufts

Length of the toothbrush head

Angulation of head

Shape of the bristle head

Design of the handle

There is no single brush design which is scientifically proven superior overothers for use. However, for pediatric usage it is preferable to use atoothbrush with a head size that conveniently fits the oral cavity of thechild. Recently a lot of manufacturers have introduced kid toothbrushes foruse by children and as per the preference of the user a range of colors,

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handle shapes and head shapes are available. The brush handle should beof the length appropriate enough to be held by the child and the angulationof the head should be enough so that the child can carry the brush to his

posterior teeth easily.

Most of the bristles are made up of nylon these days and the diametershould be such that the bristles are soft so that these do not traumatizethe gingiva and provide better cleaning efficacy.

The ideal time to replace a toothbrush is three months or the momentwhen the bristles appear worn out (whichever occurs first).

The circular brushing method or Fone's technique is a natural brushingmethod to use with young children who want to do their own brushing butdo not have the muscle development for techniques that require morecoordination.

To help young children learn this method and have fun too, ask the child tostretch out his or her anus so they are parallel to the floor. Begin by askingthe child to make big circles using the whole arm to draw circles in the air.

Then ask the child to make smaller circles and finally, very small circles infront of the mouth. Now the child is ready to make circles on the teeth withthe toothbrush being sure the teeth and gums are covered in the circularmotion.

To be effective, toothbrushing should remove dental plaque from the outer,inner and chewing surfaces as well as the surface of the tongue. The childcan be helped by directing the sequence of the brushing so that all of thesesurfaces have been brushed.

The horizontal scrub technique has also been found efficacious in thetoddlers and preschoolers. The Bass method of brushing is more commonlyrecommended for the school going child.

The use of dentifrices is very common these days for mechanical removalof plaque along with toothbrush. Dentifrices contain abrasives, surfactants,humectants, antiplaque substances, antitartar substances (pyrophos-

phates), stain removers and can be fluoridated for anticanogenic

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properties. A wide range of flavoring agents and colors are also used invarious products.

However, for pediatric use it is best to select fluoridated toothpaste for anychild above 36 months of age which has low abrasive content, is flavoredand accepted by ADA. No fluoridated toothpaste should be used till 36 atmonths of age due to increased risk of systemic ingestion in children. Tillthe child is 7 years of age only pea size quantity of dentifrice should bedispensed for brushing. Parents should be counseled on their child's cariesrisk and frequency and supervision of tooth brushing.

6 months to 3years

Non fluoridated Twice daily in morning or atnight, in very young childbrushing without any dentifriceis also acceptable.

3 to 7 years Non fluoridatedFluoridated

Once daily every morningOnce daily at night before goingto bed

> 7 years Fluoridated Twice daily brushing

The electric toothbrush was introduced in 1960s; and these have evolvedinto the "power" toothbrush, encompassing the high-tech rechargeablemodels as well as the low cost battery-powered toothbrushes. Brush head

and bristle designs are more advanced, based on oscillating/translating,vibrating, or ultrasonic technology. Power toothbrushes provide anywherefrom 10-49% greater plaque removal than manual toothbrushes. These cancause a significant reduction in plaque of adults and children. Use ofpowered tooth brushes reduces the brushing force needed during brushingto reduce gum recession. Children tend to brush longer with a powertoothbrush. 67% of children studied preferred a power toothbrush due tothe smaller brush head, easier to reach all areas of their mouth and therepetitive movement of the brush. They automatically confer good brushingtechnique.

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Patients who lack the manual dexterity or have any disability that

limits their ability to brush.

Orthodontic patients or those with implants as these toothbrushesmay reach crevices which can't be otherwise cleared.

Dental floss is either a bundle of thin nylon filaments or a plastic (teflon orpolyethylene) ribbon used to remove food and dental plaque frominterproximal areas of the teeth. The floss is gently inserted between the

teeth and scraped along the teeth sides, especially close to the gums.Dental floss is flavored or unflavored, and can be waxed or unwaxed.

Waxed floss is coated with wax which makes it easier for the floss to slideinto the adjacent tooth surface. It is advised to use waxed dental floss inchildren. Fluoride coated floss is intended to prevent dental caries fromoccurring on the adjacent tooth surfaces, but its effectiveness has not yetbeen proven.

Floss holder/dental floss stick is a supplementary tool for flossing. It issuitable for parents or caregivers in helping children or individuals withspecial needs to clean the adjacent surfaces of their teeth. There me manydifferent types of floss holder/dental floss sticks in the market. Parentsshould be advised to choose the appropriate type according to theirdurability, shape, and handle length.

Floss holder and dental floss sticks come in either a "knife" shape or a "Y"shape. They are similarly effective in cleaning teeth. A new thread of dentalfloss can be reattached to the floss holder every time after use. Whencleaning the posterior teeth using a "knife" shaped dental floss stick, onewill need to stretch his lips to facilitate the access of the floss stick. Handlesof floss holder/dental floss sticks differ in length. Those with shorterhandles at are more difficult to use. Therefore, parents and caregiversshould choose the one with a longer handle to floss for their children.

Take 12 to 18 inches of floss and grasp it so that you have a couple

inches of floss taut between your hands.

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Slip floss between teeth and into the area between your teeth andgums as far as it will go.

Floss with 8 to 10 vertical strokes to dislodge food and plaque.

Try to floss at least once a day. The most important time to floss isbefore going to bed.

Flossing before or after brushing, either is fine.

In order to increase the plaque control by the patient it is very important to

increase the visualization of plaque by the patients so as to educate thepatient and facilitate removal. The plaque disclosing agents are the mostcommonly used dye based products which can contain iodine, erythrosine,gentian violet, basic fuschin, fast green, fluorescien, or a two tone dye.

These are commonly available as, liquid preparations which can be appliedon the teeth or as chewable tablets as well. Most of these disclosing agentsstain soft tissues and pellicle as well as plaque.

These are devices which use pulses of water or chemotherapeutic agentsused to dislodge plaque particularly from interdental areas. These are notvery commonly recommended for pediatric usage.

These may be flat, flexible, plastic sticks which help in cleaning the roughdorsal surface of the tongue. Additionally gauze piece can also be used as

tongue scraper. Tongue cleaning should be routinely recommended for allthe patients.

The use of chemotherapeutic aids for plaque control is mainlyrecommended in patients who are unable, unwilling or untrained to practiceroutine effective mechanotherapy. Thus these agents are actually adjunctsin plaque control. The most commonly used in children are antisepticmouthwashes which are discussed in detail:

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From simple breath fresheners to products that can really influence oral

health by inhibiting the growth of oral microflora, a variety of mouthwashesare available in the market for pediatric use.

Fluoride-containing mouth rinses help to prevent dental decay. They maybe recommended for

1. Children having orthodontic treatment

2. Children with high caries risk

3. Patients suffering from dry mouth, and4. Patients who have undergone radiation therapy.

Antiplaque care or antimicrobial mouthwash is used to inhibit bacterialplaque formation and prevent or resolve chronic gingivitis. They can affectonly supragingival plaque. The important concern is that most mouthwashes contain pharmaceutical grade alcohol, as a preservative and as asemi-active ingredient. Significant amounts of alcohol contained in many

mouth washes can lead to certain disadvantages. Care should be taken thatthey are not accidentally swallowed, especially by children, to avoid toxicity.Small children should not be advised mouthwashes, because they me notable to spit out properly. Moreover, most children have good gingivalhealth.

The use of mouthwashes is recommended in children above 7 years of age,The commonly used mouthwashes are :

, which is the gold standard, a bisbiguanide with antiplaque

efficacy. Different brands of Chlorhexidine are available in the market, e.g.,Rexidin (warren), Clohex (Group) and A.M.- P.M (Elder). It is generallyused in a concentration of 0.12% and patient can be advised to use it oncedaily ranging from 5 mL to 10 ml.

Side Effects :

a) It has an unpleasant taste.

b) It alters taste sensation.

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c) Produces brown stains on teeth, which is very difficult to remove.This can also affect the mucous membranes and tongue and may berelated to the precipitation of chromogenic dietary factors onto the

teeth mucous membranes. Its use should be restricted in patientswith visible anterior composite and glass ionomer restorations sincethey also get stained.

d) Chlorhexidine encourages supragingival calculus formation.

e) Mucosal erosion and parotid swelling are other much rarer sideeffects.

Listerine, one of the oldest mouthwashes available, is an essentialoil/phenolic mouth wash. It has been shown to have moderate plaqueinhibitory effect and some antigingivitis effect. Its lack of profound plaqueinhibitory effect is because it has poor oral retention. It is not verycommonly used in children.

The best time to counsel parents is when the mother is expectingbecause the parents me most receptive at this time.

The importance of oral hygiene maintenance should be stressed ateach visit and the myths about teething and the initiation of brushingin an infant should be cleared to the parents.

Mechanical plaque removal should be initiated by the parent after theemption of first tooth using moistened, soft bristled infant sizetoothbrush.

However, the cleaning and massaging of gumpads using wrapped,moistened gauze piece need to be taught to the parent or caretaker.This helps in enhancing the blood circulation, establishment ofhealthy flora and facilitates teething.

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Also the parents should be instructed to feed the child with plainwater after milk or rinse the mouth particularly before the child is putto sleep.

This is the best age to introduce toothbrush if it has, not been doneearlier.

Only non-fluoridated dentifrice should be recommended.

Flossing can be used in patients with closed contacts.

Brushing should be carried out by the parent or caregiver as the childdoes not have enough muscular coordination to use the brush byhimself.

The brushing can be carried out using lap to lap position of the child.

Fluoridated dentifrice can be introduced after 3 yeas; of age.

The brushing in this age group should either be done by the parentor should be properly supervised.

Only pea size mount of toothbrush should be dispensed.

The parent should stand behind the child and assist in brushing.

Fluoride gels or rinses can be introduced in this age group in limitedmanner.

Other chemotherapeutic aids should be avoided.

Flossing can be used in patients with closed contacts

Parents need to only actively supervise brushing for this age group.

Expectoration is now learned by the child so concern over the use offluoridated dentifrices is not pronounced.

The child now possesses the dexterity to brush on his own.

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The use of fluoride gels, rinses and other chemotherapeutic aids canbe recommended for this age group.

Patient compliance is the most important area of concern in this agegroup.

The pedodontist needs to continually guide these patients formechanical and chemotherapeutic plaque control.

Home oral hygiene maintenance forms the most important aspect ofpreventive dentistry and should be practiced by every pedodontist.

However, only educating a child regarding the oral hygiene maintenance isnot the important step which needs to be followed; rather a constantmonitoring and reinforcement are more essential and this should be takencue of.

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The high susceptibility of pit and fissures to caries presents a major dentalproblem and provides the rationale for caries control of these areas. Whileocclusal surfaces represent approximately 10% of the enamel surface atrisk, they account for almost 50% of the caries in human dentition.

: It is defined as a small pinpoint depression located at the junction ofdevelopmental grooves or at terminals of those grooves. The central pitdescribes a landmark in the central fossae of the molars where

developmental grooves join (Ash, 1993).

: It is defined as deep clefts between adjoining cusps. They providemesa for retention of caries producing agents. These defects occur onocclusal surfaces of the molars and premolars, with tortuous configurationsthat are difficult to assess from the surfaces. These areas are impossible tokeep clean and highly susceptible to advancement of the carious lesion(Orbans, 1990).

Fissure sealants are defined as whereby pits and fissures that occurprincipally on the occlusal surfaces of the molar and premolar teeth areoccluded by application of fluid materials, which are then polymerized.Currently used methods are based on the principle that the adhesion of

acrylic and composite resin to enamel is greatly increased if surfaces arefirst etched with an acid.

The acids used me of two main types: those that polymerize after mixingtwo components and those that polymerize only after exposure to anappropriate light .source.

For sealant to be effective, first of all it must be retained. Whether or not asealant is retained is dependant upon the:

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1. Technique of application.

2. The type of sealant material.

3. The morphology of the tooth surface to which it is applied.

Mitchell and Gordon (1990) stated that the sealants can be differentiatedin the following ways:

1.

a) Self activation (mixing two components)b) Light activation:- First generation: Ultraviolet light- Second generation: Self cure- Third generation: Visible light- Fourth generation: Fluoride releasing

2.

BIS-GMA

Urethane acrylate

3.

4.

Clear sealants have been shown to have better flow characteristicsthan tinted or opaque, but this can be an advantage or disadvantagedepending position of the tooth to be sealed. Although the retention

rates of the two types are similar, colored sealants are more easilyappreciated by the patient and monitored by the dentist atsubsequent recalls.

The sealant is applied in a viscous liquid state that enters themicropores, which have been enlarged through acid conditioning.Then the resin because of either a sell-hardening catalyst orapplication of a light source. The extensions of the hardened resinthat have penetrated and filled the pores are called lags.

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1. A viscosity allowing penetration into deep and narrow fissures

even in the maxillary teeth2. Adequate working time3. Rapid cure4. Good and prolonged adhesion to the enamel5. Low sorption and solubility6. Resistance to wear7. Minimum irritation to tissues8. Carmstatic action

Clinical is the deciding factor in the placement of sealants.

Newly erupted both primary molars and permanent bicuspids andmolars with complete recession of pericoronal operculum and withopen and/or sticky grooves and fissures.

Stained pits and fissures with minimum decalcificalion or opacificationand no softness at the base of fissures.

The tooth in question should have empted less than 4 years ago.

Individual with no previous caries experience and well coalesced pitand fissures. Monitor if the individual and the teeth are not at risk.

Radiographic or clinical evidence of caries on the proximal surface ofthe tooth should not be sealed.

Wide and self-cleansable pit and fissures.

Tooth that cannot be isolated or partially erupted tooth.

Pit and fissures that have remained carious free for 4 years or longer.

1. : the surface of the tooth selected for seatant placement

should be cleaned first with a slurry of pumice and water. It isimportant that neither a prophy paste nor a paste containing fluoride

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be used as they will compromise the acid etching procedure andtherefore the sealant's effectiveness.

2. : immediately following cleaning, the tooth iswashed with water and air-dried.

3. : occlussal surface is then etched with a 30-50% solution ofphosphoric acid liquid or gel for 60 seconds.

Etching produces microscopic porosities in the enamel. Theresin extends into these microscopic porosities and forms tagswhich attach it firmly to the tooth surface.

With different etch times, no quantitative differences in thesurface morphology of enamel are observed (Tandon et al, 1989).This shows that the retentive character of the etched surface issimilar for different etch times. Thus, a short etch time of 15seconds is satisfactory for primary enamel and is also sufficient toproduce the required etch pattern for the strong binding ofsealants.

4. : following etching, the tooth surface is washed

with water for 30 seconds to remove all the etchant and thenair-dried. A properly etched tooth surface has a dull frostedappearance.

After etching the tooth, the surface should remain dry and freeof my moisture contamination until the resin is applied and cured.The tooth can usually be kept dry with cotton rolls and suction. Ifnot, then a rubber darn must be used.

If the surface becomes contaminated, it must be re-etched for

an additional 10 seconds.

5. : care must be taken when applying thematerial to avoid incorporating air bubble.

6. : material is cured according to the manufacturer's directions.Once the material has been fully cured, it is carefully examined withan explorer to make certain that:

all pits and fissures are covered.

all excessive material has been removed.

material is firmly adherent to the enamel surface.

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7. : as with other forms of dental cue, the sealants should bethoroughly checked at subsequent recall appointments to ensure:

it is still firmly adherent

no sealant material has been lost

If it is necessary, the sealant material should be added at this time.

Sealants have been shown to be safe, efficient and effective methods ofpreventing pit and fissure caries and as such should be used by all dentalpersonnel for prevention of ravages of dental caries.

1. ACP releasing sealant

2. Enamel LocThe first self-etching light-cured pit & fissure sealant with thefollowing properties: Fluoride Release One step application

Natrual white color Low viscosity Filled resin

3. Embracer WetBondTM pit and fissure sealant.

Embrace sealant is unique because it bonds to the moist tooth, andprovides an easy way to dispense and use. It has embrace sealetteswhich are pipettes containing 0.2 mL of Embrace Wetbond Pit andFissure Sealant, an amount sufficient to seal four teeth. The usersimply has to snip off the narrow end of the pipette and gentlysqueeze the bulb to dispense the sealant. This is an ideal dispensingsystem for clinics, schools, institutions, public health, large groupsand independent dental practices where inventory control, costcontrol, and cross-contamination are major concerns.

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Fluoride is the most electronegative element which never exists in free

state in nature but combines chemically with other elements as fluoridecompound. It has not only notable chemical qualities but also physiologicalproperties of great importance for human health and well being. Itsselective effect on the hard tissues of the body attributes significantly toprevention and control of dental caries. Fluorine word is derived from theRussian word "flor" which comes from "floris" meaning destruction in Greekand from Latin word "fluor" that means to flow since it was used as a flux.Fluoride apparently is ubiquitous in its distribution and is the 13th amongthe trace elements in order of abundance in the earth's crust. It is a highly

reactive anion with an atomic weight of 19 and atomic number of 9.Fluoride is widely distributed in the biosphere; is present in the lithosphere,hydrosphere, atmosphere and in all living organisms. It enters into the

atmosphere by volcanic action and inter action of the soil and water vaporsdue to the action of the wind. It returns to the earth be deposition as dustor in rain, snow and fog. It comes to the hydrosphere by leaching from thesoil and minerals in to the ground.

The action of fluoride on the enamel surface can be divided into thefollowing:

Incorporation of fluoride into enamel throughout development is nota principal mechanism of cariostatic effect. It is believed thatpre-eruptive exposure to fluoride may produce teeth more resistantto caries by making pits and fissures shallower, but posteruptiveexposure of fluoride too has a significant role in it.

Fluoride gets incorporated in the fluid filled sac, which surrounds thedeveloping tooth. It then enters the developing enamel. Highestconcentration of fluoride is seen in crown enamel located at or nearthe tooth surface.

Fluoride continues to enter the enamel surface, causing crystals tochange from predominantly carbonated apatite and hydroxyapatite to

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fluorapatite (FAP) and fluorhydroxyapatite (FHAP) crystals. Thesefluoride ride rich crystals are less acid soluble than the originalenamel apatite.

Minerals of tooth enamel are continuously in exchange with theminerals of saliva and thus the balance is maintained. Thisequilibrium can get disturbed with the organic acids produced by themetabolism of fermentable carbohydrates by the microorganisms.This leads to a drop in pH of the plaque on the enamel surface and inthe sub-surface. Mmerals, particularly calcium and phosphate, leave

the dissolved enamel in their ionic form and enter the plaque fluid.This process is called as "demineralization. This gets reversed withthe factors like fluoride and is termed remineralization. The surfaceand sub-surface of the enamel absorb and hold minerals and fluoride,which are present in the plaque fluid and enhance the regrowth ofthe partially dissolved crystals, Fluoride's ability to facilitate theremineralization process is presently believed to be more significantthan its inhibition of demineralization. The regrowth by fluorideincorporation chemically forms new crystals that are larger and moreacid resistant and contain a higher concentration of fluoride. This

explains why the "white spots", i.e., incipient lesions which havebeen arrested or healed due to fluoride application, are considerablyless reactive to further acid challenge than the adjacent unaffectedenamel.

Fluoride after the ingestion can get absorbed and incorporated into

developing enamel and can benefit teeth before eruption. It also benefitsthe teeth after their eruption, when it returns to mouth in saliva andgingival exudate.

Community water fluoridation is the process of adjusting the amountof fluoride in a community water supply to an optimum level for theprevention of dental caries.

The effect of fluoride in drinking water on dental caries has been thesubject of research commenced decades before. Studies have shown

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that the adjustment of fluoride concentration in drinking water to theoptimat level of 1 ppm is associated with a marked decrease indental caries. The World Health Organization recognized these facts

by its resolutions in 1969 and 1975, in which it is stated that waterfluoridation application should be the cornerstone of national healthpolicies for prevention of caries.

The recommended daily dosage of fluoride for children above 3 yearsof age is 1 mg. This can be obtained by drinking one liter of waterwith a concentration of 1 ppm fluoride ion. Since the amount ofwater consumed will vary with temperature, the fluoride ionconcentration considered optimal for a particular locality is predictedupon the average of the maximum daily temperature.

Cariostatic effects of water fluoridation in children are not limited topermanent dentition but extended to primary dentition as well.

This method is preferred since some tooth surfaces receive greaterprotection against caries than others. For example, smooth surfacesof teeth, especially proximal surface, derive maximum protection

than do pits and fissures on the occlusal surface.

Water fluoridation has both pre-eruptive and post-eruptive effects.

Fluoridated drinking water not only acts systemically during toothformation to make dental enamel more resistant to dental decay, butalso has topical effect through the release in saliva after ingestion.

Fluoride in saliva through the systemic mode remains elevated for anextended period, provides protection against demineralization andfacilitates remineralization.

It changes the morphology of occlusal surfaces by making pit andfissures more shallow and self-cleansing.

Fluoridation of community water is the least expensive and mosteffective way to provide fluoride to a large group of people.

If there is a question regarding the fluoride concentration, which isnot an additive but is naturally present to some degree in water, thelocal authority of health can test samples and am provide accurateinformation.

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Beverages bottled in fluoridated areas or other such products maypass on the beneficial effects to fluoride deficient/deprivedpopulation. This is termed 'Diffusion' or 'Halo' effect.

Concentration 0.7 to 1.2 ppm

Depending upon a community mean maximum daily temperature:

Cold climate 1.2 ppm

Summer season or temperate climate 0.7 poor

ppm fluoride = 0.34/EE = -0.038 + 0.0062 x temp. in oF(E is estimated water intake)

In view of the increased concern about the toxic effect of fluoride throughsystemic ingestion, especially about opacities of developing dentition, WHOhas recommended optimum level of fluoride in drinking water as:

0.5 to 1.0 ppm

Community water fluoridation 50-60%

Salt water fluoridation 40% Dietary supplements 50-85% Fluoride dentifrices 20-30% Professionally applied topical 30-40%

fluoride Self-applied topical application 20-50%

School water fluoridation is the adjustment of the fluoride

concentration of a schools water supply for caries prevention.

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After observing the beneficial effects of community waterfluoridation, an alternative method of supplying systemic fluoride forchildren was decided. School water was fluoridated to provide

maximum cariostatic, effect in developing teeth. Since children spendonly 6 to 8 hours in school, concentration of fluoride 4 to 6 timesmore than that designated for community water, was recommended.For instance, in Elk lake, Pennsylvania, the school water supply wasfluoridated at 5 ppm and in five years there was a reduction of28.6% seen in caries. After 10 years of school water fluoridation, thechildren who attended school continuously had 39 percent lessdecayed, missing and filled teeth than did their counterparts.Similarly several hundred of rural schools in the United States and

few schools in Brazil and Thailand practice school water fluoridation.

Results of several school water fluoridation programs indicate that itcan be an effective public health measure to reduce dental caries incommunities where fluoridation of water supply is not possible.

This method has some disadvantages also. Most of children are 5 to6 years old upon starting school; at this age their dental development

precludes the fluoride from school water fluoridation and will notprovide pre-emptive contact to the primary teeth. It allows onlylimited pre-eruptive protective benefits to primary teeth.

Another disadvantage is intermittent fluoride exposure of children.Most children who attend school for 5 to 6 hours are actually inschool less than 180 days during a year and do not receive completeeffect of fluoride.

Though a school based program assures that participating children areregularly receiving their fluoride supplements, the time of exposure to thedeveloping dentition is not at the maximum level. In community waterfluoridation they receive an advantage of being able to administer thefluoride for the entire calendar year. They also allow supplementation tobegin at birth, so that maximum protection can be afforded to both primaryand permanent teeth.

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Dietary fluoride supplements are administered in the following forms:

1. Fluoridated milk

2. Fluoridated salt3. Fluoride in sugar4. Fluoride in citrus beverages5. Fluoride drops6. Fluoride drops with vitamins7. Fluoride tablets/ lozenges8. Fluoride tablets with vitamin9. Fluoride oral rinse supplements

Milk fluoridation is suggested as an alternative to water fluoridation forcaries prevention. Jolan Banoczy et al (1984) undertook a longitudinal studyto see the effect milk consumption in 3 to 9 years old children withhomogeneous living condition. Children were given 200 ml milk daily,fluoridated with 0.4 mg of fluoride for preschoolers (3 to 5 years old) and0.75 mg, for schoolers (6 to 9 years old) for 300 days in a year. Cariesincrement was seen considerably less in the second year and the third yearcomputed to the first year.

Although most of the studies have shown evidence of protection fromcaries, milk is not an ideal vehicle for fluoride delivery because of thefollowing reasons

It provides only a limited exposure to children, as consumption ofmilk tends to decline with increase in age.

Absorption is slow as compared to water fluoridation.

Birth 6 mths 0 0 0

6 mths 3 yrs 0.25 mg 0 0

3 6 yrs 0.50 mg 0.25 mg 0

6 yrs upto atleast 16 yrs 1.00 mg 0.50 mg 0

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The addition of fluoride to table salt is a feasible way to deliver systemicfluoride, particularly in countries that lack a widespread municipal watersvstem. Fluoridated salt has been sold in Switzerland for many years.France and a few countries in western hemisphere have introduced saltfluoridation in recent yyears. Wespi (1961) first promoted the use of tablesalt as a vehicle for fluoride in the mid 1940s. Initially, supplementationwas 90 mg F/kg of salt. Recently it has been recommended in the range of200 to 250 mg F/kg salt. Commonly used salts are potassium fluoride (250

mg/kg) and sodium fluoride (225 mg/kg). All over the world only fivecountries

(Belgium, France, Germany, Spain and Switzerland) have specific policies ofuse of salt fluoridation. A sixth, Hungary, is presently contemplating arecommendation (Banding, 1999).

Salt fluoridation holds a great promise for underdeveloped countries and

countries like India where water fluoridation is not feasible due to a limitedcentral water supply and not accessible to a majority of the community.Salt is the vehicle, which is not expensive and is used almost in all thehouses. Fluoride supplied in salt is usually ingested with meals, henceabsorption is relatively slow.

Several studies have shown that adding fluoride to sugar and sugar

products has potential to reduce the cariogenic effect of sugar orfermentable carbohydrates among population groups, especiallywhere it is impractical to use other fluoride vehicles. 42% reductionin caries was observed in a 3-year clinical trial (Luoma et al 1979).

At our Department of Pedodontics, Manipal, too, a clinical trialconducted with fluoridated sugar rinse in children has shown a highpotential in controlling caries risk factors like salivary pH and Smutant count computed to the control group (Tandon 1994, unpub-lished data).

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It is believed that the marketing of cariologically harmless fluoridated

sucrose products would increase the general consumption of sucrose andthus will promote a nutritional unbalance. Furthermore, one type of fluori-dated sugary product may not reach all those needing the fluoridesupplements.

Citrus beverages may also be considered as a potential vehicle for theadministration of fluoride as dietary supplements (Gaton et al, t983).

(Tablets, drops, vitamins etc.)

Fluoride supplements are prescribed by the practitioner for children living inareas with a suboptimal level of fluoride in the drinking water. Recently, therecommendations of American Academy of Pediatric Dentistry (AAPD) andthe American Academy of Pediatrics (AAP) have been revised by qualifiedhealth cue providers.

Before prescribing a fluoride supplement for a child, a physician ordentist should know the child's age.

The concentration of fluoride in the child's "primary source" ofdrinking water.

Generally infants are given fluoride drops with or without vitamins, whichare directly placed in the mouth or added as foods. Fluoride tablets are

generally prescribed after a child has a full complement of the primaryteeth. The effectiveness of fluoride drops or tablets is neither enhanced norreduced by adding vitamins. However, there may be increased complianceas a separate route is avoided when fluoride is prescribed in vitamins.

Prior to 1966, fluoride was prescribed in prenatal supplements for potentialcaries prevention in teeth where development begins in intrauterine life and

at birth. There was a belief that fluoride would cross the placental barrierand get acquired by the developing teeth sufficiently to provide caries

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protection. Legros et at (1983) reported that prenatal fluoride protect theteeth by:

a) Affecting the morphology of teeth, promoting the formation ofsmooth teeth with shallow grooves and fissures.

b) Enamel shows less depth of etching and is composed of moredensely placed enamel rods with more mineralized apatite crystalsand with a slightly better crystallinity.

c) Recently, another school of thought is that dietary fluoridesupplements to pregnant women cannot be recommended becausethere is no conclusive evidence that it reduces dental caries in the

teeth of their offspring.

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Infant Oral Health Care Babu