Innovations in Preventive Dentistry

Christian Splieth, Christian Splieth

• Editorial: Quintessenz Verlag
• Año: 2021
• ISBN:
  9783868675627
• Edición: 1
• Categoría: Medicina
• Categoría: Odontología

Prevention is better than healing... or treatment. Thus, preventive dentistry is a cross-sectional challenge for all fields in dentistry, and one that has already achieved great success, as shown by the caries decline in many countries. The walls between prevention and treatment have recently fallen in caries and periodontal disease, as well as in orthodontics, where guidance of function and space maintenance are a combination of prevention and treatment.This book discusses new developments and innovations in preventive dentistry, from primary "real" prevention to secondary prevention by inactivating initial lesions, and on to tertiary prevention to avoid subsequent progression andcomplications of manifest oral disease. This evidence base is then translated into clinical dental practice.The book addresses everyone interested or involved in dentistry, including students, the whole dental practice team, educators, health scientists, and policy makers, who want to gain insight into these up-to-date clinical practices and future developments. It intends to make an impact on teaching and all fields of clinical dentistry – not by giving cookbook recipes, but by pointing out the rationale behind the changes in our routines.Presented by an international group of recognized specialists in their fields, the topics include the new understanding and management of caries and periodontal disease, prevention of orthodontic problems, diagnostic approaches, the role of diet and according recommendations for oral health, routes to better oral hygiene, changes in oral disease patterns and their consequences, non- and minimally invasive caries treatment, current fluoride guidelines including the use of silver fluorides, risk management, a common risk-factor approach, facilitating behavior changes, sealants, and probiotics. This broad spectrum is elucidated for the most relevant dental problems from early childhood to seniors to implement preventively oriented dental practice.

1

Understanding caries

Christian H. Splieth, Mhd Said Mourad, Mohammad Alkilzy, Julian Schmoeckel, Ruth M. Santamaría

In their new consensus statement on the terminology of dental caries and dental caries management, the European Organisation for Caries Research (ORCA) and the International Association for Dental Research (IADR) define caries as “a biofilm-mediated, diet modulated, multifactorial, noncommunicable, dynamic disease resulting in net mineral loss of dental hard tissues. It is determined by biologic, behavioral, psychosocial and environmental factors. As a consequence of this process, a caries lesion develops.”¹ This very modern definition is based on the concept that caries is an imbalance of demineralization and remineralization that results from a dysbiosis of the oral biofilm, the overconsumption of carbohydrates, and insufficient oral hygiene (Fig 1-1).

Thus, the prevention of caries aims to adjust and ensure a healthy balance of the oral microbiome, dietary intake, oral hygiene, and mineral supply to avoid a net loss in enamel and dentin of healthy teeth. Caries therapy can only be successful in the long run if this is achieved when demineralization has already taken place. Therefore, caries prevention and its treatment employ the same concept and are nowadays combined as caries control, management, or care.

Figs 1-1a and b Caries is nowadays understood as an imbalance between de- and remineralizing factors resulting in a net loss of minerals (a). Thus, modern caries management modifies oral hygiene, diet, the biofilm, and the mineral equilibrium, keeping sound tooth surfaces healthy, inactivating existing caries lesions (b), and preventing recurrent demineralization around restorations.

This is also reflected in the ORCA/IADR definition of caries care, management, or control comprising “actions taken to interfere with mineral loss at all stages of the caries disease, including nonoperative and operative interventions/treatment. The terms caries care/management/control may be more appropriate than the term ‘caries prevention’ and because of the continuous de- and remineralization processes, caries control needs to be continued throughout the life course.”¹

In consequence, the terms of caries prevention and therapy merge, which is not really surprising as restorative care and accompanying efforts to reduce caries activity have been viewed as secondary and tertiary prevention for a long time. Taking this into account, ORCA/IADR state that caries prevention “traditionally meant inhibition of caries initiation, otherwise called primary prevention. Primary, together with secondary and tertiary prevention, comprising nonoperative and operative treatments, are now summarized under caries care, management, or control.”¹

The following chapters regarding caries risk prediction, fluoride use, biofilm and diet control, and promoting oral health are based on this new understanding of caries. As in periodontal disease, the primary goal of all preventive and therapeutic approaches is to achieve a high quality of life by establishing a physiologic, regenerative balance to maintain proper oral health.

Caries epidemiology and its consequences

On a global level, a remarkable caries decline could be achieved for the permanent dentition in children and adolescents in many industrialized regions such as the US, Canada, Europe, or Oceania. Although Germany was not the first country to experience this, consecutive and recent national surveys for all ages allow for a detailed analyses, which reveal trends^2,3 that seem to be similar in many countries (Figs 1-2 and 1-3):

• Caries prevalence has reduced from ten or more affected permanent teeth in adolescents during the 1970s to a mean of less than one decayed, missing, or filled teeth (DMFT) in 12-year-olds nowadays.⁴
• About 90% of the caries burden can be prevented and tooth loss is almost eradicated in the permanent dentition in adolescents.^2,4
• After the caries decline, 80% of the adolescents are caries-free on a DMFT level and this is not much changed by lowering the threshold to initial caries lesions.³
• Thus, the caries distribution is polarized and a so-called high-risk group of about 20% exhibits almost the complete caries burden.^2,4
• The high-risk group is primarily associated with a low socioeconomic status that leads to less sufficient oral hygiene, fluoride exposure, and often more frequent sugar intake.^2,5
• In the primary dentition and especially for early childhood caries, the situation is far from satisfactory in many countries.⁶ In spite of a less pronounced caries decline in the primary dentition, caries patterns and distribution are equivalent to the situation in adolescents.⁷ This is also true for caries in adults.² Most likely a further caries decline will also increase the polarization in adults.
• Due to the caries distribution after a major caries decline, primary caries prevention needs a dual strategy of maintaining the high levels of oral health in the majority of the population and trying to find intensified measures to improve the situation in the risk group mostly characterized by a low socioeconomic status.³
• There is a realistic perspective that caries levels even in risk groups can be significantly reduced in the future, as the caries decline in this group was proportional to the reductions in the whole population, at least in German adolescents.⁴

Figs 1-2a and b Decayed, missing, and filled teeth (dmft/DMFT) in Germany in (a) schoolchildren,^3,7 adolescents,^3,4 and (b) adults. In many industrialized countries such as Germany, a remarkable caries decline has been recorded for the permanent dentition in adolescents, as well as in adults, and to a lesser extent for the primary dentition in schoolchildren.

Figs 1-3a to d A large percentage of children are caries-free (80%) (a and b), while a small group of children (20%) (c and d) present with high caries rates (80%). The polarization of the caries distribution especially in children leads to two different preventive approaches: Maintaining the high degree of oral health in the majority group of the population and intensifying measures for the high caries risk group.

In contrast to the general caries decline in many industrialized countries, caries levels in the emerging market economies are still at a high level for most of the population, or even on the rise due to increased wealth and sugar consumption.⁸ This imposes a great challenge to these countries; in spite of choosing the restorative approach as was done by many Western countries, strengthening primary prevention would be a better choice.

The current epidemiologic situation of a polarized caries distribution calls for two distinctly different approaches to primary caries prevention: For the majority of the population, individual and professional prevention can reduce 90% of the caries burden and keep it at a tolerable very low level.

The so-called caries risk group that accumulates about 80% of the caries defects and the according treatment needs is characterized by a low socioeconomic status. It seems that outreach programs and tailored health regulations are necessary to achieve further healt...