A Case-Based Review of Medical Emergencies in

Transcription

Best Practices and Products for Oral Health
Smile, You’re in the Dental Aisle!
Best Practices and Products
for Oral Health
118th Annual Scientific Session
UCSF Alumni Association
May 31, 2014
Denise Bowen, RDH, MS
Professor Emeritus in Dental Hygiene
Idaho State University
Oral-B tv spot
Mouthrinses
• Used to



Therapeutic and Mouth Freshening

MOUTHRINSES
Promote fresh breath
Prevent/control caries
Reduce plaque biofilm
Prevent/reduce gingivitis
Hola Image
Mouthrinses
• Two Types to Augment Oral Hygiene

Cosmetic mouthrinses – temporarily
 Control
 Leave

or reduce halitosis
pleasant taste
Therapeutic mouthrinses – active
ingredients reduce:
 Plaque,
gingivitis, dental caries, halitosis
Antimicrobial Mouthrinses
• Recommended for




Gingival inflammation
Prevention of periodontitis
Post-surgical use during healing
Peri-implant inflammation
Van Leeuwen MP, Slot DE, Van der Weijden GA. .Essential oils compared to chlorhexidine with
respect to plaque and parameters of gingival inflammation: a systematic review. J Periodontol. 2011
Feb;82(2):174-94.
Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent 2010;38(Suppl):S6-10.
Moran JM. Home use oral hygiene products: mouthrinses. Periodontology 2000. 2008;48:42-53.
Denise M. Bowen, RDH,MS
Jean Poupard Memorial Lecture
UCSF 118th Annual Scientific Session
May 31, 2014
• Antimicrobial – not always necessary
• Initial Recommendation




Immunocompromised
Oral hygiene challenges, disabilities,
extensive restorations
Severe inflammation or bleeding
Inability to adequately control plaque
• Three active antiplaque agents – most
commonly employed and studied:



Mouthrinses
• Manufacturers’ instructions are
important.


• Instruct patients

Most antimicrobials 2x day
• Chlorhexidine Gluconate 0.12% (CHX)

0.12% chlorhexidine gluconate
Cetylpyridinum chloride/CPC
Essential oils
• FDA – safe and effective
Amount and duration
30 or 60 seconds; 10 or 15 ml
Meta-analysis of 6-month studies
 Plaque
reductions 50-55%
29-50%
 Gingivitis reductions
Van Stydonck, DA, Slot DE, Van der Weidjen F. Effect of a chlorhexidine mouthrinse on plaque, gingival
inflammation, and staining in gingivitis patients. J Clin Periodontol 2012;39(11):1042-55.
Gunsolley JC. A meta-analysis of 6-month studies of antiplaque and antigingivitis studies.
J Amer Dent Assoc 2006;137:1649-1657.
• Chlorhexidine Gluconate 0.12% (CHX)

Antimicrobial Rinses
• CHX and Periodontal Treatment
Alcohol-free formulation

– Indicate equal effectiveness in
↓ gingival inflammation
 CHX

Todkar R, Sheikh S, Byakod G, Muglikar S. Efficacy of chlorhexidine mouthrinses with and without
Alcohol – a clinical study. Oral Health Prev Dent. 2012;10(3):291-6.
Lopez-Jornet P, Plana-Ramon E, Lesson JS, Pons-Foster A. Short-term effects of 0.2% alcohol-free
chlorhexidine mouth rinses in geriatric patients: a randomized, double-blind, placebo-controlled study.
Gerodontology. 2012 Dec;29(4):292-8.
SC/RP vs.
 Professional plaque
 Clinical trials
control (2xweek) vs.
rinsing (2xday) – 42 days
CHX - Greatest microbiological & clinical
benefits
Feres M et al. (2009) Clinical and microbiological benefits of strict supragingival plaque control
as part of the active phase of periodontal therapy. J Clin Periodontol; 36:857-867.
May 31, 2014
• Essential Oils (EO) Antiseptic Only
Meta-analysis of 6 month studies

• Cetylpyridinum Chloride (CPC)

Meta-analysis of 6-month studies
 Antiplaque
and antigingivitis
 Effectiveness of EO about 60% of CHX,
or 30-35% reduction


Not plaque control
• 0.075% Cetylpyridinium chloride

Colgate Total® Advanced Pro-Shield™
 Not
for children  6
• Similar claims to 0.07% ProHealth®




12 hours of antibacterial protection
Helps reduce plaque and gingivitis
Kills 99% bacteria
Alcohol-free
Post Treatment Rinsing?
• Essential oils antiseptic rinse for 2
weeks after periodontal treatment

Reduced level of bloodstream bacteria
 Subjects
with mild-to-moderate gingivitis
• Could patients with systemic health
challenges benefit?
Fine DH, Furgang D, McKiernan M, Tereski-Bischio D, Ricci-Nittel D, Zhang P, Araujo MW.
An investigation into the effect of an essential oil mouthrinse on induced bacteraemia: a
pilot study. J Clin Periodontol. 2010 Sep;37(9):840-7.
Results mixed:

0.07% – ↓ plaque and gingivitis
 CPC
Systematic review - EO may be as
effective for gingival inflammation,
Gunsolley JC. A meta-analysis of 6-month studies of antiplaque and antigingivitis studies.
J Amer Dent Assoc 2006;137:1649-1657.
Van Leeuen MP, Slot DE, Van der Weijden GA. Essential compared to chlorhexidine with respect
to plaque and parameters of gingival inflammation: a systematic review. J Periodontol. 82(2):174-194.

0.05%, 0.045%, 0.07%
 Crest
ProHealth® - not for children  12
Gunsolley JC. Clinical efficacy of antimicrobial mouthrinses. J Dent 2010;38(Suppl):S6-10.
Avad F et al. A comparative investigation to evaluate the clinical efficacy of an alcohol-free CPCcontaining mouthwash as compared to a control mouthwash in controlling dental plaque and
gingivitis: a six-month clinical study on adults in San Jose, Costa Rica. J Clin Dent. 2011; 22(6):204-12.
Preprocedural mouthrinses
• CDC (2003) recommends preprocedural
rinse – ↓ microbes in dental aerosols.

http://www.cdc.gov/mmwr/preview/mmwrh
tml/rr5217a1.htm
• Chlorhexidine gluconate, essential oils, CPC
Thomas E. Efficacy of two commonly available mouthrinses used as preprocedural rinses in children.
J Indian Soc Pedod Prev Dent. 2011 Apr-Jun;29(2):113-6.
Feres M, et al. The effectiveness of a preprocedural mouthrinse containing cetylpyridinum chloride in
reducing bacteria in the dental office. J Am Dent Assoc. 2010 Apr;141(4):415-22.
Fine DH, et al. Efficacy of preprocedural rinsing with an antiseptic in reducing viable bacteria in dental
aerosols. J Periodontol. 1992 Oct;63(10):821-4.
Delmopinol Hydrochloride 0.2%
Mouthrinse
• Preliminary results indicated:



Affects adherence of biofilm
Reduces gingival bleeding
Especially effective:
 Heavy
plaque; chronic gingivitis
• More long-term trials needed
Addy, Moran, et al. Meta-analyses of studies of 0.2% delmopinol mouth rinse as an adjunct
to gingival health and plaque control measures. J Clin. Periodontol 2007;34:58-65.
May 31, 2014
• Effectiveness against dental caries
Dental Implants & Antimicrobials
• Reducing Bleeding & Plaque Scores

Evidence supporting effectiveness of
antimicrobial rinses in caries prevention

 Limited

to chlorhexidine.
Hold that thought for caries risk discussion!

Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, Zhan L, Gansky SA.
A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries
management by risk assessment). Caries Res. 2012;46(2):118-29. Epub 2012 Apr 3.
Woken Albertson K, Persson A, van Dijken JW. Effect of essential oils containing and alcohol-free
chlorhexidine mouth rinses on cariogenic microorganisms in human saliva. Acta Odontol Scand. 2013
May-Jul;71(3-4):883-91.

• Need more controlled trials
Grusovin MG, Coulthard P, Worthington HV, George P, Esposito M. Interventions for replacing missing teeth:
maintaining and recovering soft tissue health around dental implants. Cochrane Database of Systematic
Reviews 2010, Issue 8. Art. No.: CD003069. DOI: 10.1002/14651858.CD003069.pub4.
Mouthrinses
Mouthrinses
• Halitosis Systematic Review
• Breath/Halitosis





Promote fresh breath
Prevent/control caries
Reduce plaque biofilm
A combination
halitosis-producing
bacteria on the tongue
Alcohol-free EO mouthrinse
recently has been supported
(e.g., Listerine Zero)
Mouthrinses
• Halitosis – most compelling evidence


Chlorhexidine
Combination of cetylpyridinum
chloride and zinc
Little data with respect to tongue
coating
 No
beneficial effect
Blom T, Slot DE, Quirynen M, Van der Weijden BA. The effect of mouthrinses on oral malodor:
a systematic review. Int J Dent Hyg. 2012 Aug;10(3):209-22.
CHX & CPC mouthrinses –
 Reduce
http://www.drweb.de/magazin/35-splendidexamples-of-forced-perspective-photography

CHX irrigation – more effective compared
to chlorhexidine mouthwash
EO mouthwash – significantly better than
placebo
Triclosan also ↓ inflammation
http://www.drweb.de/magazin/35splendid-examples-of-forced-perspectivephotography
Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V. Mouthrinses for the treatment of halitosis.
Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006701. DOI: 10.1002/14651858.
CD006701.pub2.
Mouthrinses
• Halitosis Systematic Review

Mouthrinses containing
 chlorine
dioxide
 zinc
 chlorine

dioxide plus zinc
Neutralize VSC
Fedorowicz Z, Aljufairi H, Nasser M, Outhouse TL, Pedrazzi V. Mouthrinses for the treatment of halitosis.
Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006701.
Dadamio J, Van Tournout M, Teughels W, Dekeyser C, Coucke W, Quirynen M. Efficacy of different
mouthrinse formulations in reducing oral malodour: a randomized clinical trial. J Clin Periodontol 2013
May;40(5):505-13
May 31, 2014
Mechanical Devices to Reduce
Halitosis
• Tongue brushing/scraping temporarily
reduces halitosis

Reduced bacterial load and coating; not
necessarily lower VSC
• Dentifrices - SnF2 & triclosan copolymer
• Chewing gum – ↓ for 5-15 min.
Alcohol in Mouthrinses
• Stabilizing, Emulsifying, FlavorEnhancing Agents
• Many Alcohol-Free Choices Available

• FDA (2003) found no relationship to
oral cancer
Prudent to avoid in
high risk cases

Scully C and Greenman J. Halitosis (breath odor). Periodontology 2000, Vol. 48, 2008,
66–75.
1.8% Hydrogen Peroxide
Hydrogen Peroxide Rinses
• Meta-analysis – do not prevent plaque

Long-term adjunct to oral hygiene
 One
study showed reduced redness.
• Tray delivery used to reach into
pockets 5mm

• Data show some safety concern if 100%

Dilute 1:1 with water or more
 Most
Goal is anti-biofilm oxygenating action
e.g., PerioProtect® used with NSPT

studies ≤ 1.5% concentration

Hossaninian N, Slot DE, Afennich F, Van der Weijden GA. The effects of hydrogen peroxide
mouthwashes on the prevention of plaque and gingival inflammation: a systematic review. Int J
Dent Hyg. 2011 Aug;9(3):171-81. doi: 10.1111/j.1601-5037.2010.00492.x. Epub 2011 Jan 31.
Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: a review of its use in dentistry. J
Periodontol 1995 Sep;66(9):786-96.
CHX, EO, CPC, Fluoride

1 study concluded ↓PPD maintained
up to 6 months  SC/RP alone ( 1mm)
Sensitivity reported
Additional research needed
Putt MS, Proskin HM. Custom tray application of peroxide gel as an adjunct to scaling and root planing in the
treatment of periodontitis: results of a randomized controlled trial after 6 months. J Clin Dent 2013(3):100-7.
Antimicrobials in Dentifrices
• Advantages to Toothpaste
Toothbrushing - most common
daily oral hygiene regimen
 Fluoride needed daily
 Substantivity of agents is <12 hours
 No additional step for compliance

(Better Known as Toothpaste)
DENTIFRICES: ANTIMICROBIAL
May 31, 2014
• Stannous Fluoride: Systematic Review
 7 studies – significant reduction in
gingivitis compared with placebo or NaF
formulation (18 to 22%)
 3 studies – significant plaque reduction
(7-22%)
• Triclosan/Copolymer: Systematic Review

Moderate-quality evidence
↓
plaque, gingival inflammation and gingival
bleeding

High-quality evidence

Weaker evidence

Insufficient evidence
 Small
reduction in coronal caries.
 Reduced
root caries & calculus
 Prevented periodontitis.
Paraskevas S and van der Weijden GA. A review of stannous fluoride on periodontitis. J Clin
Periodontol 2006;13:1-13.
• Triclosan


Weak, inconclusive evidence supporting
dentifrice with triclosan/copolymer plus
pyrophosphate
May want to suggest this dentifrice without
tarter control
Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database
Syst Rev. 2013 Dec 5;12:CD010514.
Concerns About Triclosan
• Primarily environmental

Multiple uses
• CDC and Canadian Health Ministry

No evidence of concern for safety in
humans
Sources:
Gunsolley JC. A meta-analysis of 6-month studies of antiplaque and antigingivitis studies. J
Amer Dent Assoc 2006;137:1649-1657.
http://www.hc-sc.gc.ca/ahc-asc/media/nr-cp/_2012/2012-48-eng.php
http://www.cdc.gov/biomonitoring/Triclosan_FactSheet.html
Davies, RM. Toothpaste in the control of plaque/gingivitis and periodontitis. Periodontology
2000. 2008;48:23-30.
Dwindle MT, Terry PD, Jiangang C. Commentary: Recent evidence regarding
triclosan and cancer risk. Int. J. Environ. Res. Public Health 2014, 11, 2209-2217
Mouthrinses (and Dentifrices)
• Other Ingredients/Claims





Whitening
Desensitization
Tarter Control
Stain
Xylitol
• Read the evidence - go to Web site &
check ingredients.
What is Complimentary and What is Not When Treating
Caries and Gingivitis?
RECOMMENDING COMBINATIONS
OF AGENTS
May 31, 2014
General Rule
• Try to Obtain Desired Effect With As
Few Agents and Steps Needed


Increased Compliance
Less Cost and Side Effects
Chlorhexidine and Caries
• Reduces bacterial count of S mutans

Sodium Fluoride (NaF) does not.
• Add 0.12% CHX to 0.05% NaF rinse

Arrests active enamel caries after 28 days
 NaF
rinse & CHX rinse arrested caries
from SLS and F >30 min. or 2hrs.
 Separate
Kolahi J and Soolari A. Rinsing with chlorhexidine gluconate solution after brushing and flossing
teeth: a systematic review of effectiveness. Quintessence Int. 2006 Sep;37(8):605-12.
Duarte AR et al. Effectiveness of two mouth rinses solutions in arresting caries lesions: a shortterm clinical trial. Oral Health Prev Dent. 2008;6(3):231-8.
ADA Expert Panel
Recommendation #1
ADA Expert Panel
Recommendation #2
• "Although chlorhexidine has been shown to
reduce S mutans in the oral cavity
temporarily, most of the clinical study
investigators who evaluated coronal caries as
the outcome did not show a statistically
significant reduction in caries with the use of
chlorhexidine in any vehicle.
• On the basis of the results of these studies, the
panel recommended against using
chlorhexidine products for coronal caries
prevention at this time.”
• “With respect to root caries, the panel
concluded that application of chlorhexidinethymol varnish may help reduce the incidence
of root caries in adults and elderly people and
reported insufficient evidence supporting the
use of 10 to 40 percent chlorhexidine varnish.“
Recent Findings
• 3-year clinical trial – in high risk adults.

Markedly ↓ MS levels; 24% ↓ in caries
• The regimen


0.12% CHX 10 ml rinse 1x day, 1 week/mo.
Reduced MS almost two log levels > 2 years.
• Fluoride added for remineralization.


1,100 ppm NaF toothpaste
0.05% NaF rinse
Featherstone JD, White JM, Hoover CI, Rapozo-Hilo M, Weintraub JA, Wilson RS, Zhan L, Gansky SA.
A randomized clinical trial of anticaries therapies targeted according to risk assessment (caries
management by risk assessment). Caries Res. 2012;46(2):118-29. Epub 2012 Apr 3.
Rethman M. et al Nonfluoride caries-preventive agents Executive summary of evidencebased clinical recommendations. JADA 142(9): Sept. 2011
•
Fluoride varnish also has been shown to be
effective in prevention of root caries.
Slots DE et al. The effect of chlorhexidine varnish on root caries: a systematic review. Caries Res.
2011;45(2):162-73. Epub 2011 Apr 27.
Essential Oils and Coronal Caries
• Need long-term clinical trials with
clinical outcomes
• Recent findings


No reduction in mutans streptococci and
lactobacilli in saliva with EO
Reduction with alcohol-free CHX
Wiken AK, Persson A, van Dijken JW. Effect of alcohol free chlorhexidine mouthrinses on cariogenic
micro-organisms in human saliva. Acta Odontol Scand. 2013 May-Jul;71(3-4):883-91.
May 31, 2014
CHX, EO and Root Caries
• CHX and EO in reducing root caries
pathogens

New Horizons
• Probiotics and Oral Health

Streptococcus mutans, Streptococcus
sobrinus, Lactobacillus rhamnosus and
Actinomyces naeslundii in vitro study
has the most significant effect on
inhibition of the putative root-caries
bacteria with exception of L rhamnosus
 Compete
for adhesion sites and nutrients
antimicrobial compounds (e.g.,
acids – a benefit?)
 Enhance immune responses
 Produce
 CHX
Zheng CY, Wang ZH. Effects of chlorhexidine, Listerine and fluoride listerine mouthrinses on four
putative pathogens in biofilm. Chin J Dent Res. 2011;14(2):135-40.


Systematic Review
 Insufficient
evidence that probiotics can
prevent caries, but they have potential
 Can reduce mutans streptococci counts.
Common - lactobacilli or bifidobacteria
Haukioja A. Probiotics and Oral Health. Eur J Dent 2010;4:348 355
Twetman S, Keller MK. Probiotics for caries prevention and control. Adv Dent Res. 2012
Sep;24(2):98-102.
New Horizons
• Probiotics and Oral Health
Potential mechanisms of action:
New Horizons
• Probiotics and Periodontal Disease
Data – in vitro studies, short pilot studies
Small but significant reductions
gingival inflammation
Possible pathogen antagonist
No conclusive evidence




 Except
Laleman I, Detailleur V, Slot DE, Slomka V, Quirynen M, Tueghels W. Probiotics reduce mutans
streptococci counts in humans: a systematic review and meta-analysis. Clin Oral Investig 2014 Mar
25. [Epub ahead of print]
safety
Haukioja A. Probiotics and Oral Health. Eur J Dent 2010;4:348 355
van Essche M, Loozen G, Godts C, Boon N, Pauwels M, Quirynen M, Teughels W. Bacterial
Antagonism against periodontopathogens J Periodontol. 2012 Aug 16. [Epub ahead of print]
New Horizons
• More combinations


Mouthrinse – 0.1% chlorhexidine & xylitol &
essential oil.
Varnish – CHX/thymol to prevent root caries
New Horizons
• Ingredients


 Effective in geriatric population
• More long-term, large scale
studies needed


Fluoride and Xylitol
Menthol, Sodium Bicarbonate, Fluoride
and Xylitol
Alcohol free
More research needed
Baca p, et al. J Dent. 2009 Sep;37(9):679-85.
Tan HP et al. A Randomized Trial on Root Caries Prevention in Elders. J Dent Res 2010 89: 1086
May 31, 2014
New Horizons



Desensitizing Mouthrinses
Sodium Fluoride 0.05%, Water, Xylitol,
Menthol, Natural Flavors, Sodium Benzoate,
Poloxomer 407, Sodium Hydroxide,
Sodium Hypochlorite.
Sodium hypochlorite, aloe vera,
zinc, xylitol
Sodium hypochlorite, xylitol and
0.05% sodium fluoride
• Pro-Argin™ - Reduces sensitivity with
home treatment of tooth sensitivity
 Colgate
Sensitive Pro Relief
• 1.4% potassium oxylate - Reduces
sensitivity within a 5-day period
 Listerine Advanced
Defense Sensitive
Markowitz K. A new treatment alternative for sensitive teeth: a desensitizing oral rinse. J Dent 2013
Mar;41 Suppl 1:S1-11.
Sharma D, McGuire JA, Amini P. Randomized trial of the clinical efficacy of a potassium oxalate-containing
mouthrinse in rapid relief of dentin sensitivity. J Clin Dent 2013;24(2):62-7.
What Seems to Get Along?
BREAK
None of the Antimicrobials Seem to Be
Mutually Exclusive
CHX
• All are can be used
with FLUORIDE

Chlorhexidine ideally
separated by 60 min.
EO
Triclosan
[email protected]
Power Toothbrushes
• Cochrane Collaboration 2009 review:

Only rotation oscillation shown to be
better than manual toothbrushes
 Removing
Does evidence support what we tell our patients?
POWER TO REDUCE GINGIVITIS,
STAIN, & HALITOSIS
plaque
gum inflammation
 No more likely to cause injuries to gums
 Reducing
Robinson P, et al. Manual versus powered toothbrushing for oral health.
Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD002281.;
updated 2009.
May 31, 2014
Power Toothbrushes
• Cochrane Collaboration 2010 review:



15 trials with 1015 participants.
Dearth of trials assessing same mode of
action = no definitive conclusions
regarding superiority of one mode over
any other.
Only minor/transient side effects.
Deacon SA, et al. Different powered toothbrushes for plaque control and gingival health. Cochrane
Database of Systematic Reviews 2010, Issue 12. Art. No.: CD004971.
Power Toothbrushes
• Tissues Around Dental Implants

No significant differences
in soft tissue health found
between powered vs.
manual toothbrushes
Grusovin MG, Coulthard P, Worthington HV, George P, Esposito M. Interventions for replacing
missing teeth: maintaining and recovering soft tissue health around dental implants. Cochrane
Database of Systematic Reviews 2010, Issue 8. Art. No.: CD003069.
Safety Warning: Spinbrush
Power Toothbrushes
• Safety Systematic Review

A large body of published research over
2 decades has consistently shown
 Oscillating-rotating toothbrushes
are safe
compared to manual toothbrushes
 Do not pose a clinically relevant concern to
hard or soft tissues.
Van der Weijden FA, Campbell, SL, Dorfer CE, Gonzalex-Cabezas C, Slot DE. Safety of oscillating-rotating
powered brushes compared to manual toothbrushes: a systematic review. J Periodontol 2011
Jan;82(1):5-24.
Power Toothbrushes & Stain
• No systematic reviews
• Studies indicate




Better stain removal with power over
manual TB
No effect on recession with 6-month use
(after professional instruction)
Same stain removal as prophylaxis
Whitening benefit
Power Flossers

Safety Notice: Please remember to replace your brush head after 3 months of use,
or if the brush is damaged, or if parts become loose. Extended usage, loose parts
or excessive wear could lead to brush head breakage, generation of small parts
and possible choking hazard. Inspect brush for loose parts before use.

Studies show as effective as traditional
flossing in reducing gingivitis
Floss reduces gingival inflammation beyond
toothbrushing alone
 Not
shown to reduce caries in adults*
flossing reduces caries in
children*
 Only professional
*Berchier CE, Slot DE, Haps S, Van der Weijden GA. The efficacy of dental floss in addition to a
toothbrush on plaque and parameters of gingival inflammation: a systematic review. Int J Dent Hygiene
6, 2008; 265–279
May 31, 2014
Air Flossing Device
• Clinical studies indicate


Water Flosser Device
• No Systematic Reviews
• Clinical studies have shown

To improve compliance & ease
of use
To reduce gingivitis beyond
toothbrushing alone
de Jager M, Jain V, Schmitt P, DeLaurenti M, Jenkins W, Milleman J, Milleman K, Putt M. Effect of
Sonicare Airfloss on interproximal plaque and gingivitis. J Dent Res 90 (spec iss A), 2011

50% more effective than
traditional dental floss
Orthodontic tip 3X as effective dental as
floss cleaning around ortho
Sharma NC et al. Effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent
patients with fixed orthodontic appliances. Am J Orthod Dentofacial Orthop 2008; 133:565-571.
Barnes CM et al. Comparison of irrigation to floss as an adjunct to toothbrushing: Effect on bleeding,
gingivitis, and supragingival plaque. J Clin Dent 2005; 16:71-77.
Toothpastes
• Contain additives for:
(Better Known as Toothpaste)
DENTIFRICES: FLUORIDE,
DESENSITIZING, WHITENING….
Fluoride Toothpaste
• Proven to reduce tooth decay (avg. 24%)

Most studies – 2x/day use
• For children – encourage supervision,
smear or pea-sized amount

Dispense across the bristles

Caries prevention (fluoride)

Antimicrobial action (gingivitis reduction)

Desensitizing (dentinal hypersensitivity)

Anti-calculus

Whitening
Fluorosis: Mild
• No significant association with frequency or
amount of toothpaste
• < 1000 ppm toothpaste if concern- No clear evidence
 No fluoride under 2 years of age
 Aquafresh, Orajel

Toddler Training, Tom’s of Maine
Most range from 100-1100ppm
 Tom’s of
Maine 0.76% Sodium MFP, Crest Kids Cavity
Protection w/Fluoristat, Aquafresh w/ 0.423% NaF
Walsh T, Worthington HV, Glenny AM, Appelbe P, Marinho VCC, Shi X. Fluoride toothpastes of different concentrations
for preventing dental caries in children and adolescents. Cochrane Database of Systematic Reviews 2010, Issue 1.
Art. No.: CD007868.
Wong MC, Glenny AM, Tsang BW, LoEC, Worthington HV, Marinho VC. Topical fluoride as a cause
of dental fluorosis in children. Cochrane Database of Systematic Reviews 2010, Jan20;(1): CD007693.
Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride toothpastes for preventing dental caries in children and
adolescents. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD002278
Walsh T, Worthington HV, Glenny A-M, Appelbe P, Marinho VCC, Shi X. Comparison between
different concentrations of fluoride toothpaste for preventing tooth decay in children and
adolescents, published Online: February 2010
May 31, 2014
Desensitizing Dentifrices
• Etiology of hypersensitivity



Differential Diagnosis
• Determine Cause (Is it hypersensitivity?)
Gingival recession, periodontal disease,
Toothbrush abrasion, abrasive
toothpastes
Other – tobacco, wear, acidic diet





• Treatment – need to address all
aspects of etiology


Cracked tooth syndrome
Incorrect placement of dentin adhesives
Fractured restorations
Pulpal response to caries/restorations
Traumatic occlusion
Chipped teeth causing exposed dentine
Vital bleaching.
West N. Dentine hypersensitivity: Preventive and therapeutic approaches to treatment.
Periodontology 2000, Vol. 48, 2008, 31–41
• Systematic Review


Multiple treatment approaches appear
to provide clinical success
Far from being unequivocal in
pronouncing one superior strategy.
• OTC options for dentin
hypersensitivity

Dentifrice formulations
Shiau JH. Dentin hypersensitivity. J Evid Based Dent Pract 2012 Sep;12(3 Suppl):220-8.
West N. Dentine hypersensitivity: Preventive and therapeutic approaches to treatment.
Periodontology 2000, Vol. 48, 2008, 31–41
Dentin Hypersensitivity
• 0.454% Stannous Fluoride (SnF2) Dentifrice

Effective against cavities, gingivitis, plaque,
sensitivity, stains and bad breath (ADA Council
Dentin Hypersensitivity
• Systematic Review

on Scientific Affairs, 2009)

Evidence better for paste than 0.64% rinse
• Staining?


FDA requires warning for SnF2
SnF2, silica, & sodium hexametaphosphate
(whitening)
Schiff T, He T, Sagel L, Baker R. Efficacy and safety of a novel stabilized stannous fluoride and sodium
hexametaphosphate dentifrice for dental hypersenstivity. J Contemp Dent Pract. 2006;7(2):1-8.


A potential role for arginine-containing toothpastes
in managing dentine hypersensitivity
Based on small samples and short-term studies
Well-designed RCTs needed for definitive
recommendations
(US formulation does not contain arginine technology)
Carson SJ. Possible role for arginine-containing toothpastes in managing dentine
hypersensitivity. Evid Based Dent 2013;14(2):44-5.
May 31, 2014
In-Office Desensitization
• After or in Conjunction with Home Rx
5% fluoride varnish

• New sensitive relief



Pro Arginine Technology – 8%
arginine & 1450ppm MFP in calcium carbonate
Professionally-applied paste
May decrease dentin sensitivity prior to bonding

No interference with bonding agents
Garcia-Godoy A, Garcia-Godoy F. Effect of an 8.0% arginine and calcium carbonate in-office desensitizing
Paste on the shear bond strength of composites in human dental enamel, Am J Dent 2010 Dec;23(6):324-6.
• 15% Calcium sodium phosphosilicate
(NovaMin®, Nupro Sensodyne Prophy
Paste)

 Significant
reduction of dentine
hypersensitivity up to at least 28 days.
Neuhaus KW, Milleman JL, Milleman KR, Mongiello KA, Simonton TC, Clark EC, Proskin JM Seemann R.
Effectiveness of a calcium sodium phosphosilicate-containing prophylaxis paste in reducing dentine
hypersensitivity immediately and 4 weeks after a single application: a double-blind randomized
controlled trial. J Clin Periodontol 2013 Apr;40(4):349-57.
• Systematic Review – 6 treatments
compared

Placebo, physical occlusion, chemical
occlusion, nerve desensitization, laser
therapy and combined treatments
Anti-Calculus Agents
• Pyrophosphate inhibits formation




Concentration of bleaching agents
• Differences – levels of active ingredients,
hydrogen peroxide/carbamide peroxide
Demarco FF, Meireles SS, Masotti AS. Over-the-counter whitening agents: a concise review.
Braz Oral Res. 2009;23 Suppl 1:64-70
No interference with fluoride
Clinical reports
 May
be problematic for patients with
dentinal hypersensitivity
Lin P-Y, Cheng Y-W, Chu C-Y, Chien K-L, Lin C-P, Tu Y-K. In-office treatment for dentin
hypersensitivity: a systematic review and network meta-analysis. J Clin Periodontol 2013;
40: 53–64.
• Whitening toothpastes
• Abrasive action – minimally lightens color
• Other products – several shades
Mucosal irritation – discontinue
• Combination with other agents
• All better than placebo
Whitening Agents in Dentifrice
Single application of both fluoridated
and non-fluoridated prophylaxis pastes
Whitening Agents in Dentifrice
• People should be made aware of:

Increased porosity of tooth surface
 Staining?
 Dental

caries risk?
Common side effects include
 Tooth
sensitivity
to the gums
 Irritation
Hasson H, Ismail A, Neiva G. Home-based chemically-induced whitening of teeth in adults. Cochrane
Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006202. DOI: 10.1002/14651858.CD006202.
May 31, 2014
Whitening Dentifrices &
Stain/ Whitening
TOOTHPASTE ABRASIVENESS RANKED BY RDA
Examples
cited by
http://www.
Teeth
whitening
reviews.com/
artman/
publish/
whiteningtoothpastesexposed.php
• Check Relative Dentin Abrasivity (RDA)
Experts and governmental agencies
recommended upper limit of 200 or 250
 Most formulations lower
• Educate patients
• ACP (Amorphous calcium phosphate) may
help fill surface defects

Other Ingredients
Consumer Preference/Demand
• Sodium Bicarbonate (Baking Soda)

04
Plain baking soda
07
Arm & Hammer Advance Whitening/
Peroxide
42
Tom's of Maine Sensitive
49
Colgate Total
70
Arm & Hammer Advance Sensitive
70
Crest Regular
95
Sensodyne Extra Whitening
104
Aquafresh Whitening
113
Arm & Hammer Advance White Gel
117
Colgate Whitening
124
Crest Extra Whitening
130
Ultra Brite
133
Pepsodent
150
Colgate Tartar Control
165
Other Ingredients
Consumer Preference/Demand


• Moisturizing Ingredients
Toothbrush with plain water

Natural ingredients
Low abrasive
Xylitol
Low or No Sodium Lauryl Sulfate (SLS)
Caries Risk Assessment
•Formal CRA Forms
CDA
(California Dental Association)
Ages
0-6 and older than 6
(treatment guidelines)
CAMBRA
ADA
Self Care and Treatment Recommendations
CARIES RISK ASSESSMENT (CRA)
(American Dental Association)
Ages
0-6 and older than 6
CAT
(American Academy of Pediatric Dentistry)
CariFree (Oral BioTech)
Cariogram® (interactive Internet-based model)
May 31, 2014
CAMBRA
Disease Indicators
• Caries Management by Risk
Assessment
Demineralization/
Remineralization
• Markers indicative of current or past
caries (WREC)



Pathologic Factors
Acidogenic bacteria
Inhibited salivary function
Frequency of CHO ingestion
Protective Factors
Salivary flow & components
Antibacterials
Extrinsic fluoride
Some dietary components
Risk Factors
Protective Factors
• Biological predisposing factors








White spot lesions
Restorations in the last 3 years
Enamel/proximal lesions
Cavitation
MS or LB - medium or high cultures
Visible heavy biofilm
> 3 between meal snacks
Deep pits and fissures
Inadequate saliva
Exposed roots
Orthodontic appliances
• Biologic or therapeutic measures






Fluoridated water
Fluoride dentifrice 1-2x daily
5,000 ppm fluoride dentifrice daily
Chlorhexidine/used 1xday, 1 week/month
Xylitol gum/mints/lozenges 4x daily
Adequate saliva flow
Risk Assessment Over Age 6
Risk Assessment Age 6 & Over
Moderate
Moderate
Contributing Conditions
 No fluoride
 If 6-14 years old, caries
experience of mother,
caregiver, siblings
 7 to 23 months
 No dental home
High
 Sugar exposure –
frequent or prolonged
between meals
 If 6-14 years old, caries
experience of mother,
caregiver, siblings
 6 months
High
General Health Conditions
 Eating disorders
 Smokeless Tobacco Use
 Medications Reducing
Salivary Flow
 Drug/Alcohol Use
General Health Conditions
 Special Health Care
Needs
 Chemo or Radiation
Therapy
May 31, 2014
Self Care Recommendations
Moderate Risk
High Risk
• Brushing w/ F toothpaste
 2x day
• Interdental cleansing
 1-2x day
• Low dose, OTC sodium
fluoride rinse or stannous
fluoride gel/dentifrice
 1x day
• Calcium phosphate (CP)
paste optional
• Substitute higher dose
(5,000 ppm) prescription F
• Add 0.12% CHX rinse daily
 Research suggests 1
minute 1xday first week
of each month
• Fluoride rinse/CP paste
optional
• Acid-neutralizing rinse
Xylitol for Caries Prevention
• Systematic Reviews conclude


Well designed, controlled RCTs needed
High risk of bias & effects of confounders
 Fluoride

Variability in designs, dosages, protocols
precludes clinical guidelines
Antonio AG, Pierro VS, Maia LC. Caries preventive effects of xylitol-based candies and lozenges: a
systematic review. J Public Health Dent 2011 Spring;71(2):117-24.
Fontana M, Gonzalex-Cabezas C, Are we ready for definitive clinical guidelines on xylitol/ polyol use?
Adv Dent Res 2012 Sep;24(2):123-8.
Mickenautsch S, Yengopal V. Anticariogenic effect of xylitol vs. fluoride – a quantitative systematic
review of clinical trials. Int Dent J 2012 Feb;62(1):6-20.
Calcium Phosphate Supplements
CPP-ACP – Amorphous form of calcium phosphate &
complex casein phosphopeptides (MI Paste, Recaldent)
• Most research in vitro or in situ

Need long-term, in-vivo, anti-caries data
• Value when added to fluoride – check ppm
• Goal is remineralization – has potential

Lack evidence – post-ortho treatment of white spot lesions
Chen H, Liu X, Dai J, Jiang Z, Guo T, Ding Y. Effect of remineralizing agents on white spot lesions after
Orthodontic treatment: a systematic review. Am J Orthod Dentofacial Orthop 2013 Mar;143(3):376-382.
Zero DT. Recaldent – evidence of clinical activity. Adv Dent Res. 2009;21(1):30-4.
Dietary Analysis & Counseling
Introduce Nutrition Counseling (D 1310)



Patient records daily food intake and
frequency
Emphasis on frequency and between
meal sugar exposures
Remember hidden sugars
• How much to charge for diet analysis
and counseling?
Reynolds EC et al. Fluoride and casein phosphopeptide-amorphous calcium phosphate. J Dent Res.
2008 Apr;87(4):344-8.
Hyposalivation/Xerostomia
• Sodium bicarbonate (baking soda rinses or
paste)


Neutralize acids
Have antibacterial properties
• Some products – lactoferron and
lactoperoxidase for buffering, antibacterial
action, and remineralization
• Sugarless candy
• Xylitol gum or mints
• Prescribe saliva stimulant (e.g., Pilocarpine)
Measuring Saliva
• Measures Mutans Streptococci & Lactobacilli



CRT Caries Risk Test (Vivodent/Ivoclar)
Dentocult SM and Dentocult LB (Edge Dental)
Caries Susceptibility Swab (CariScreen)
• Saliva, pH and Buffering


Saliva Check (GC Corporation)
CRT Buffer
• Monitor reductions over time.
• CDT - Caries Susceptibility Test (D0425 )
May 31, 2014
Treatment Recommendations
Moderate Risk
High Risk
• 1-2 applications F varnish
initially, then 1 every
recall
• 4-6 month recall
• PFS as indicated
• Restorative (depending
on involvement)
• 1-3 applications F varnish
initially, then 1 every
recall
• 4-6 month recall
• PFS as indicated
• Restorative (depending
on involvement)
Professional Fluoride Application
• Most evidence for effectiveness in
children and adolescence – ↓ 21%
• Recommend/pair with home use
• Adults with root exposure

Consider fluoride or chlorhexidinethymol
varnish
• Individualize treatment plans
Marinho VCC, et al. Fluoride gels for preventing dental caries in children and adolescents. Cochrane Database
of Systematic Reviews 2002, Issue 1. Art. No.: CD002280. DOI: 10.1002/14651858.CD002280.
International Caries Detection and
Assessment System (ICDAS-II) Codes
Revise Dental Charting
• 3 levels caries detection – widely used


D1 is incipient (intact), D2 is enamel, D3
dentin caries
Level D1 is treated by conservative or
nonsurgical means
 Fluoride
therapy, pit and fissure sealants, etc.
• 2 levels restorative treatment – D2 & D3

Small restorations and large restorations
ICDAS System (www.icdas.org)
• PFS Evaluation/Changes (1-3)




0 = Sound, no caries change after air dry
1 = Thin, only after air dry, limited to P/F
2 = Distinct change, seen wet or dry, slightly
“wider” – P/F
3 = Localized change, no shadow,
widened – P/F
• 4-6 = Dentin affected; minimal- intervention
dentistry
Pit and Fissure Sealants (PFS)
vs. Fluoride
• Systematic review - some evidence

PFS were superior to fluoride varnish
prevention of occlusal decay
 Both
have some preventive effect
amount of data available
 Limited

Additional high-quality research needed
Hiiri A, Ahovuo-Saloranta A, Nordblad A, Makela M. Pit and fissure sealants versus fluoride
varnishes for preventing dental decay in children and adolescents. Cochrane Database Syst
Rev 2010;(3):CD003067.
May 31, 2014
Risk Assessment Age 0-5 Years
Assessment of Clinical Conditions
Moderate
High
Moderate Risk
High Risk
• No fluoride
• Sugar exposure – frequent
or prolonged between
meals
• No dental home
• Caries experience of others
– 7 to 23 months
• Eligible for gov’t programs
• Sugar exposure –
bottle/sippy cup with
anything but water
• Caries experience of others
– 6 months
• Special needs*
• Visible plaque
• Compromised hygiene
• Any new carious lesions or
restorations in last 24
months
• Teeth missing due to
carious lesions
• Visually inadequate salivary
flow
Self Care Age 0-5 Years
• Oral hygiene & antibacterial

Caregiver involved
• Fluoride – No rinses


Paste/gel for moderate and high
Consider dose <1,000 ppm – if fluorosis concern
• Xylitol gum/lozenges for caregiver

Spray for child
Orthodontics/appliances

Chlorhexidine and Children
• No FDA Approval



 Off


• Eliminate all active caries
• Use therapeutic measures for mother

Oral hygiene, antibacterial therapy,
restorative
• No sharing utensils, tasting food for baby,
or putting pacifier in own mouth.
• ↓ # of times/day for bottle with
sugar/CHO.
• Anticipatory guidance
label
• Prescribe for parent/caregiver if high risk
• Anticipatory guidance for parent
Discussion with Mother of Child
Age 0-5 Years
No rinses before age 6
CHX not studied under age 18
Sources suggest brushing on child’s teeth
Inoculation with Mutans streptococcus – 32%
by age 3 months and 80% by 24 mo.
Caution with pregnancy and nursing mothers
Treatment Age 0-5 Years
• Sealants – high fluoride glass ionomer

After age 2
• Fluoride

Varnish at initial visit and at each recall
• Recall Interval


Moderate – 6 months
High – 3 months
May 31, 2014
Caregiver Recommendations Form
• Use Checklist to Assure Parents/
Caregivers Remember Instructions:
Daily Oral Hygiene/Fluoride Use
 Diet
 Antibacterial Rinse (Parent/Caregiver).
http://www.cdafoundation.org/library/doc
s/jour1007/ramos.pdf

Implementation in Practice
• Requires office support
Online references
available

Milicich GW. Caries
Management in Dental
Practice. Compend Contin
Educ Dent, 30(2):63-73,
March 2009.

Gutkowski S et al. The role of
dental hygienists assistants
and office staff in CAMBRA.
CDA Journal 35(11):786-783,
November 2007.

Experts suggest dispensing
products as package with
associated fee(s)
Determine what to include in
program based on available
technology, practitioners’
philosophy, & practice profile.
Include regular assessments,
preventive/therapeutic
interventions
Summary
• Consider individual
patient needs
Add Agents
• Is an adjunctive
antimicrobial
needed?
• Is caries risk higher?
Mechanical
Devices
• Consider compliance
challenges, cost,
side effects, and
interactions
Make
Recommendation
May 31, 2014

A Case-Based Review of Medical Emergencies in

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