Preventive therapies in pediatric dentistry

Preventive therapies in pediatric dentistry

In children, the carious process develops very quickly due to the anatomical characteristics of temporary teeth and the anatomical position of erupting teeth.

Early management and specific recommendations regarding oral hygiene, diet and prevention are necessary.

1. Definitions:
   1. Prevention

• Prevention : is the set of measures aimed at avoiding or reducing the number and severity of diseases
• Primary prevention : intervenes before caries disease develops
• Secondary prevention : concerns measures to intercept symptomatic and asymptomatic carious lesions
• Tertiary prevention : aims to prevent failures of the treatments implemented, it corresponds to the commonly accepted surgical method
• 

2. Definition of dental caries

• Dental caries is an infectious, transmissible, chronic and multifactorial disease (Caulfield et al, 2000Fejerskov, 2004)
• It is considered by the WHO as the third scourge of global morbidity.
• It affects 5 billion people worldwide and is the most common chronic disease in children in the United States.
• It can develop quietly and affects the individual throughout his or her life.

2. Assessment of individual caries risk:

• Its assessment allows the identification of children at increased risk of developing cavities in order to determine preventive treatment.
• To determine the individual caries risk, the practitioner must estimate the risk factors that will be revealed during the anamnesis and clinical examination.

1. Risk factors revealed by the anamnesis:

• Eating habits: regular sugary intake outside of meals or snacks:
  • Sweet food
  • Sweet drink
  • candy
• Oral hygiene : lack of daily brushing with fluoride toothpaste
• Long-term use of sugary medications or medications that cause hypoasia
• Illnesses and disabilities causing brushing difficulties
• Poor oral health of parents and siblings
• Low socioeconomic level or education level of parents

2. Risk factors revealed during clinical examination

• History of caries: CAO and CAOF, presence of caries, damage to dentin and/or initial reversible lesions (temporary and/or permanent damage to tooth enamel)
• Morphology of the tooth: anfractious grooves of the molars
• Dental plaque: plaque visible to the naked eye
• Presence of elements promoting plaque retention: orthodontic or prosthetic appliance, defective restorations
• Orthodontic treatment in progress
• Additional saliva tests

3. ICDAS classification of carious lesions:

4. Oral health prevention:
   1. Primary prevention:

It consists of preventing the onset of the disease, that is to say, preventing cavities. According to Courson et al. (2010), this action is essentially done by acting on the child ‘s caries risk factors .

1. Avoiding the transmission of cariogenic bacteria to the child:

• Vertical transmission of mutans streptococci from mother to child is well documented
• Since tooth decay is a bacterial disease, it is important that the mother and caregivers do not transmit tooth-causing bacteria to the infant:

• not to taste his dishes
• don’t lick your spoon
• not cleaning their pacifier in their mouth

• It has been shown that the earlier the colonization, the less likely the child is to have cavities at the age of 2.
• Improving maternal oral health in the prenatal period is desirable and would reduce vertical transmission of streptococci

2. Oral hygiene:
   1. When to start brushing?
      • It is essential that parents introduce brushing their children’s teeth as soon as the first teeth appear, or even before, and that this habit is

established during the eruption of temporary molars

• The equipment must be adapted to the child’s size

2. Who should manage the brushing:

• Children do not have effective brushing until they have reached a certain maturity in their psychomotor development.
• It is therefore up to parents to brush their teeth until the age of 6 to 8.
• From the age of 8, the child must take charge of his or her dental hygiene, but parents are responsible for the regularity and effectiveness of brushing as well as the choice of equipment until the age of 10 to 12.
• It is important to complete brushing on the lingual surfaces and to insist on the brushing time and then to remind the importance of its regularity

From 6 months to 2 years :

• A wet compress or a finger “toothbrush” can be used in

replacement of a “baby” toothbrush, the use of which becomes the rule as soon as the first molars appear toothpaste 500 ppm in trace amounts

• Horizontal method (20 round trips per sector)
• Brushing carried out by an adult at least once a day, in the evening

From 2 to 6 years old

• The toothbrush is filled with a quantity of fluoride toothpaste equivalent to the size of a pea (brushing surface only filled along its length)
• Brushing carried out by an adult twice a day in parallel with the child gradually acquiring autonomy
• Horizontal method or making circular movements (2 minutes)

From 6 to 12 years old:

• The junior toothbrush is filled with fluoride toothpaste over a third of the length of the brushing surface
• Toothpaste of at least 1500 ppm
• Brushing supervised by an adult for at least 8 years and carried out by the child himself if the child or adolescent is not very independent
• Brushing twice a day for 2 to 3 minutes with rotating or non-rotating movements in different directions of space
• ​

After 12 years

• In addition to the previous instructions, the adult toothbrush, of a more suitable size, can now be used
• It is filled with fluoride toothpaste over a third of the length of the brushing surface
• Its action is complemented by that of dental floss, the aim of which is to eliminate plaque at the interdental contact points.
• Electric vs. Manual Toothbrushes

• Both types are equally effective
• For older children, the electric toothbrush seems superior at the gingival level, thanks to its oscillating-rotating movements.

⦿ +++ in a situation of disability

3. Food :

• 4 meals a day are recommended (breakfast, lunch, snack, dinner)
• Avoid snacking
• The only recommended drink is water
• Know which foods contain sugar in its different forms and reduce your consumption
• Avoid untimely breastfeeding: when the first teeth appear and

If other carbohydrates are introduced into the diet, it is recommended to stop breastfeeding on demand (especially at night or to ensure teeth are cleaned after feedings)

• unlimited bottles of milk or sugary drinks during the day and/or when falling asleep should be avoided
• Avoid foods that stick to the teeth and are difficult to clean
• chew sugar-free gum for 10 minutes immediately after eating without brushing
• Promote the consumption of so-called cariostatic foods

4. Fluorine:
   1. Mode of action of fluorides:

• The presence of fluoride inhibits the production of acids by biofilm bacteria
• Fluoride ions combine with calcium and phosphate ions in the enamel, released during demineralization secondary to acid attack, and accelerate the remineralization phenomenon.
• They transform the structure of the enamel into fluoroapatite, which strengthens its resistance to acid attacks.

2. Administration of fluoride:
3. Systemic fluoride:

Systemic fluoride intake can be achieved through different routes:

• Drops and tablets:

-take into account the child’s weight

• only for children with high RCI
  • Tap water
  • Bottled water
  • Table salt
  • Food
  • Fluoridated milk
  • Toothpaste ingested

2. Topical fluoride:

• Toothpastes:

-they represent by far the most used topical form

-It is one of the most effective measures against caries with a high level of evidence

-The preventive effect of fluoride toothpastes increases:

-when the caries index is high at the start

-When their concentration is high

-With the frequency of brushing

-When brushing is supervised by an adult

• fluoride varnishes:

Fluoride varnishes are fluoride concentrates in a resin or synthetic base. The concentration level of fluorides varies depending on the marketed products from 1000 to 56300 ppm.

• Indications for fluoride varnishes : Fluoride varnish is indicated in:

• caries prevention. (primary and secondary prevention)
• It can be used in children under 6 years old because the risk of fluoride ingestion remains limited.
• In children at high risk of caries, particularly in patients undergoing multi-bracket orthodontic treatment.
• Treatments for dentin hypersensitivity that can affect children with hypomineralization of incisors and molars
• Contraindications for fluoride varnishes :

• Hypersensitivity to rosin or any of the components of the varnish
• Ulcerative-necrotic gingivitis.
• Stomatitis.
• Duraphat is contraindicated in patients suffering from bronchial asthma.
• Operating protocol:

• Clean dental surfaces with a dry brush
• Isolate teeth by dials using rolls of salivary cotton
• Apply the varnish after drying the teeth using a brush.
• On the proximal surfaces, the application is carried out with dental floss impregnated with varnish.
• if orthodontic treatment is in progress: application of fluoride varnish in vulnerable areas
• Remove the saliva swabs 30 seconds to 2 minutes later
• Advice to give to the patient following the application of fluoride varnish:

-it is recommended not to drink for two hours, not to eat if possible for 4 hours and to avoid hard foods and brushing on the day of application.

-These tips are essential in order to allow the calcium fluorides to precipitate in the form of labile microcrystals as much as possible upon contact with the enamel.

Fluoride gels:

• Fluoride gels can be prescribed at home or applied by the practitioner in the office
• They are indicated in patients at high risk of caries
• Fludentyl (13500PPM or bifluorinated fluocaril 2000 (20000PPM)
• Applied using a suitable gutter
• Contact time of the gel with dental surfaces is 4 minutes
• Ask the child not to drink for 2 hours and not to eat for 4 hours
• Fluoride mouthwashes:

• Reserved for children over 6 years old (risk of swallowing), with a high RCI
• The concentration generally varies from 0.05% (250 ppm) for daily use to 0.2% (900 ppm) for weekly use
• 2 half-yearly applications, 3 annual applications 08 applications per year with one month interval

5. Other products used in caries prevention:

• Chlorhexidine:

• Chlorhexidine is an anti-infectious agent effective against the main germs involved in oral infections with a broad spectrum of activity.
• It exists in various presentations: varnish, gel or mouthwash
• Application of chlorhexidine varnish to the sulci of erupting first molars appears to have a positive effect on caries reduction.
• The best effectiveness is obtained by combining fluorides and chlorhexidine
• Casein phosphopeptide:

• The complex formed by the association of casein phosphopeptide and amorphous calcium phosphate appears to limit demineralization, inhibit cariogenic bacteria and promote remineralization.
• There is a synergy of action between ACP-CCP and fluoride
• The ACP-CPP complex exists in different forms: the prophylactic paste can be used in the dental office or at home by applying it to the finger or in individual trays.
• ACP-CPP is also associated with fluorine in a varnish

2. secondary prevention

• It consists of detecting the disease early, at the initial stage, in order to prevent its worsening or even cure it.
• According to Courson et al. (2010), this is the set of means implemented to detect and intercept the first signs of dental caries (simple

demineralization of the enamel, which is still reversible, for example), with the aim of avoiding the transition to a more advanced stage, or even of obtaining remineralization

1. -Sealing of pits and cracks:

The occlusal surface, which only constitutes 21% of dental surfaces, represents almost 85% of cavities in 5-17 year olds and more than two thirds of children develop cavities in this area.

Pit and fissure sealing aims to prevent or stop the development of initial carious lesions by forming a physical barrier that is impervious to cariogenic bacteria.

• Indications:

• High individual caries risk (ICR)
• Anfractured grooves of the healthy permanent molar (ICDAS0), i.e. the narrow and deep main groove with or without the presence of secondary grooves
• enamel carious lesion (ICDAS1, 2) or very limited in the external third of the dentine (ICDAS3), provided it is non-cavitary (ICDAS4) and located at the level of the grooves (pits and fissures) of the permanent molar
• Permanent molar affected by mild incisor molar hypomineralization
• Permanent molar affected by mild to moderate erosive lesions
• Contraindication :

• Non-cavitated dentin carious lesion clearly visible on a retrocoronary (ICDAS4) or cavitated (ICDAS 5, 6) at the level of the grooves of the permanent molar
• Tooth isolation not possible
• Operating protocol:

• Cleaning the occlusal surface with a dry brush mounted on a contra-angle or using an air polisher projecting sodium bicarbonate
• Waterproof operating field: placement of the dam
• Etch for 20 seconds with orthophosphoric acid after drying the occlusal surfaces
• Rinse for 15 seconds and dry to achieve a chalky appearance
• Apply the sealing material to the bottom of the grooves
• Wait 15 to 20 seconds before curing to allow good wetting of the material
• Check that the material is properly adhered before placing the surgical drape.
• Occlusion Control: Remove Excess with a Composite Polishing Cup
• Alternatives in case of impossible insulation:

2. Preventive therapies according to ICDAS classification:
   1. Minimal dentistry of the occlusal surfaces of permanent molars

Therapeutic management of carious lesions: It depends on the severity of the carious lesion

1. ICDAS 1,2 enamel lesions
   • inactive:

• Inactive lesions: sealing of the fissures if the molar is fractured or if there is a high caries risk (RCI)

Active lesions:

• Sealing of the furrows with a resin sealing material subject to the quality of the salivary isolation
• Otherwise, there are several solutions to adopt with the agreement of the parents and the child due to the constraints of each:

• use of a CVI-based sealing material (3-month control);
• weekly professional applications of fluoride varnish! 22,600 ppm until remineralization of the lesion monitored by laser fluorescence before each reapplication
• prescription of 5,000 ppm fluoride toothpaste under parental supervision for children aged 6 to 10 years (check-up at 1 month).

2. ICDAS 3 lesions

Sealing of fissures regardless of the activity of the carious lesion

Sealing a carious lesion requires regular monitoring of the patient to repair it or resume treatment if necessary, in order to prevent the lesion from worsening.

3. ICDAS 4 lesions

There is currently no consensus on the management of this non-cavitary lesion:

• some advocate systematizing their sealing;
• the others indicate a composite restoration at least if the dentin demineralization is clearly visible on the retrocoronal radiograph or if the DIAGNODENT Pen indicates a value greater than 40.

The choice depends on the follow-up agreed upon by both the family and the practitioner as well as the correction of the RCI.

4. ICDAS 5 Lesions:

Minimal composite restorations after removal of demineralized tissue by air abrasion (possibly supplemented by mechanical instrumentation), sonoabrasion or using micro-burrs

• Special case of minimal air-abrasion dentistry

– Contraindications:

• Respiratory pathologies.
• Impossibility of putting up the dike

– Operating protocol :

1. Diagnosis based on visual examination, radiographic examination (retrocoronary) and/or fluorescence measurement.
2. Anesthesia depending on the severity of the injury.
3. Installation of the dike.
4. Removal of demineralized enamel by projection of aluminum oxide under water irrigation.
5. Control of tissue hardness with a probe or with laser fluorescence if the resulting cavity is very sharp.
6. In case of residual demineralized dentin, remove it with a small diameter round bur on a contra-angle because the removal of demineralized tissue is less selective in the case of dentin.
7. Control of tissue hardness with the probe, rinsing and drying of the microcavity.
8. Depending on the proportion of enamel and dentin tissue, prefer an adhesive with prior etching or a SAM 1 or 2 (self-etching system if the majority of dentin tissue).
9. Placement of the restoration material:
   • if limited size (depth < 2 mm): fluid composite;
   • If air abrasion has been used on the entire enamel surface, the flowable composite can seal all the grooves
   • in other cases, microhybrid, hybrid or bulk composite.
   • If the tooth has erupted less than 2 years ago, it is advisable to seal the entire occlusal surface with a resin sealing material.
10. Occlusion control and polishing of the filling with composite polishing instruments on CA. Prophy paste on a rubber cup can be used to improve polishing.
11. Monitoring: At most every 6 months due to the high RCI.
12. Minimal dentistry and proximal surfaces of permanent teeth:

Minimal dentistry in the case of proximal lesions of posterior teeth follows the same rules as their occlusal counterparts. Only the diagnostic approach and the resulting therapeutic solutions can be more delicate near the point of contact.

The differential diagnosis between cavitary and non-cavitary lesions requires direct vision of the proximal surface (orthodontic spacer or not, adjacent tooth absent).

— The method used to treat the cavitary lesion must not damage the adjacent proximal face, whether healthy or affected by a non-cavitary lesion

1. Inactive ICDAS 1, 2 lesions :

Therapeutic abstention at the level of the lesion in the absence of bleeding during delicate probing

of the papilla (sign of inactivity of the carious lesion).

2. Active ICDAS 1, 2 lesions and early non-cavitary ICDAS 4 lesions

In the presence of a non-cavitary lesion near the enamel-dentin junction, there are several solutions to select depending on the child’s cooperation and the frequency of follow-up validated by the parents and the child:

• erosion-infiltration technique (lcon®, DMG)
• remineralization
• by weekly professional applications of

fluoride varnish! 22,600 ppm until remineralization of the lesion monitored with a laser fluorescence device before each reapplication (on average 4 to 6 sessions required);

• by home applications, at least twice a day, of 5,000 ppm fluoride toothpaste under parental supervision from 6 to 10 years old (check-up at 1 month).

3. ICDAS 3, 5 cavitary lesions and ICDAS 4 non-cavitary lesions:

In the presence of a proximal dentin lesion clearly visible on the retroalveolar image (see chapter 5), different microdentistry methods can be used:

• small rotary instruments with protective matrix
• sonoabrasion

4. Erosion infiltration technique:

The necessary equipment differs slightly from that used on the vestibular surfaces; the same products are applied with a perforated tip on one side only (so as not to damage the adjacent tooth) after placing a spacer.

1. Installation of the dam and the spacer supplied by the manufacturer.
2. Etch with Icon-Etch® (15% hydrochloric acid) for 2 minutes, orienting the green (perforated) side of the proximal tip towards the lesion.
3. Rinse, dry and apply Icon-Dry® primer for 30 seconds to dehydrate the surface .
4. Application of Icon-infiltrant® resin, with a new perforated proximal tip, allowing 3 minutes for photopolymerization, so that it penetrates the demineralized tissues by capillarity.
5. This is preceded by the elimination of excess resin by passing dental floss along the treated proximal surface.
6. A second 1-minute application is carried out before photopolymerization.
7. A radiological check-up at 3 months is required to verify that the lesion has stopped progressing because the material is not radiopaque.
8. Microdentistry:

• The concept of minimal dentistry or microdentistry is based on prevention,

the interception of initial or reversible lesions and maximum preservation of enamel-dentin tissues as part of regular monitoring of the child in order to control their risk of caries.

• The restoration of irreversible lesions must prioritize the preservation of the tooth’s resistance zones (enamel bridge, marginal ridges) as much as possible and eliminate only demineralized dentin tissue, regardless of its location.
• This is due to new devices used in addition to adhesive restorative materials. Thus, the proximal carious lesion limited to the external third of the dentine and located below the contact point is no longer eliminated by creating a proximal access box but by eliminating only the carious tissue accessible by the vestibular or lingual route: this is the principle of sonoabrasion .

6. Dentistry at least by sonoabrasion:

1. Anesthesia depending on the severity of the injury.
2. Installation of the dike.
3. Removal of demineralized tissue with a proximal lesion insert on a handpiece (SON|Cfiex®, Kavo; Newtron®, Satelec-Acteon). The working, diamond-coated, convex part must be opposite the proximal lesion; thus the non-working, flatter part prevents iatrogenic lesions of the proximal face prevents iatrogenic lesions of the adjacent proximal face.
4. After removal of the demineralized tissue, application:

-an adhesive with prior etching or a SAM 1 or 2 depending on the proportion of enamel/dentin tissue if a composite material is to be used;

– polyacrylic acid rinsed after 15-20 seconds for

the application for a glass ionomer cement (GIC) based material.

5. Restoration:
   • with a composite material (fluid or not) if the access to the lesion was occlusal (small proximal box);
   • with a CVI, CVIMAR or possibly composite if |the access was vestibular or palatine/lingual (horizontal minicavity).
6. After photopolymerization, passage of an abrasive strip opposite

|’shuttering.

7. Minimal dentistry with rotary instruments

An anatomical wedge fitted with a protection allows the proximal lesion to be prepared without damaging the adjacent tooth despite the use of microburs. This protection is then replaced by a sectoral matrix held by a ring or by a matrix mounted on an anatomical wedge.

Conclusion :

Preventive therapies in pediatric dentistry include all measures intended to prevent the onset of the disease or

Limit its progression whether in terms of health education or preventive measures in the dental office

Preventive therapies in pediatric dentistry

  Untreated cavities can cause painful abscesses.
Untreated cavities can cause painful abscesses.
Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
Dental implants restore chewing function and smile aesthetics.
Fluoride mouthwashes strengthen enamel and prevent cavities.
Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

Preventive therapies in pediatric dentistry