Preventive therapies in pediatric dentistry
1. Introduction:
Prevention can take place at different levels :
_ Primary prevention: all the means implemented to prevent the appearance of a disorder, pathology or symptom
_ Secondary prevention : which concerns the initial stage of the disease and includes measures such as screening and interventions
early therapeutics.
_ Tertiary prevention : which aims to limit to a minimum the complications caused by the disease.
2. Definition of prevention :
Prevention is defined as all the measures that are undertaken to avoid the appearance, worsening, spread and also the recurrence of carious disease.
It is also a program of cooperation, information, and education between the dentist and his caregivers with regard to the patient.
3 The different types of prevention:
3.1. Collective mass prevention: it concerns the general public (the population as a whole or at least the large mass of the population).
3.2. Targeted collective prevention: is aimed at specific groups of the population (schools, businesses, etc.). The actions of this prevention are: screening, epidemiological surveys and education.
3.3. Individual prevention in the dental office: this concerns the patient and their dentist, it is based on preventive examinations to put in place a treatment in the face of a problem.
Preventive therapies in pediatric dentistry
4. Preventive measures in pediatric dentistry:
4.1. Pregnancy : According to the recommendations of the European Academy of Pediatric Dentistry EAPD, the ideal age for the first consultation is before birth.
This examination, carried out from the 4th month of pregnancy, must assess the individual caries risk (ICR) of the pregnant woman:
– eating behaviors,
– carious experience,
– fluoride topics,
– oral hygiene habits,
– salivary flow,
– salivary levels of streptococcus mutans and lactobacilli.
4.2. Breastfeeding
Breast milk should be encouraged as it has many benefits (nutritional, developmental, psychological, social, economic and environmental. It significantly reduces the risk of developing several acute and chronic diseases).
. Exclusive up to 6 months, it can be extended up to 2 years, according to WHO recommendations, subject to cleaning teeth and reducing the frequency and consumption of sugary foods in parallel (4 meals a day). Do not let the child fall asleep at the breast while breastfeeding.
4.3. Fluoridation:
4.3.1. Systemic fluoride: Systemic fluoridation is effective in primary dentition, its prescription could be interesting in children with high RCI. Before prescribing fluoride, it is essential to examine the dietary sources of fluoride (e.g., all sources of drinking water, consumed beverages, prepared foods, toothpaste) to determine the patient’s true exposure to fluorides, and to take into consideration the child’s caries risk.
The optimal prophylactic dose is 0.05 mg fluoride/kg/day for all fluoride intakes combined, without exceeding 1 mg/day.
From a daily ingestion of 0.1 mg/kg/day, the risk of fluorosis appears. In children, the lethal dose is 20 mg/kg (up to 100 mg/kg/day in adults).
In the absence of other sources of fluoride intake, the recommended daily dose is indicative:
♣ From 3 to 9 kg (approximately up to 18 months): 0.25 mg of fluoride/day;
♣ From 10 to 15 kg (approximately 18 months to 4 years): 0.50 mg of fluoride/day;
♣ From 16 to 20 kg (approximately 4 to 6 years): 0.75 mg of fluoride/day;
♣ From 20 kg and more: 1 mg of fluoride/day.
Other sources of fluoride intake are:
Drinking water , table salt, certain foods and toothpaste: Drinking water: Adjusting the fluoride level in community water to the optimal concentration is the most beneficial and inexpensive method of reducing the incidence of cavities.
* Tap water and spring water: depends on the region,
* Mineral water : less than 0.1 to 9 mg/L, appears on the label.
Fluorinated salt : after 2 years, represents an average dose of 0.25 mg/day of fluoride absorbed during meals (very little salt consumed before 2 years).
Other foods : contain little fluoride except sea fish (1 to 3 mg/100 g) and tea. Most foods containing fluoride are of no interest to children.
Toothpaste : The amount of fluoride depends on the toothpaste used by the child and his age (the amount of fluoride swallowed by the child depends on his age).
4.3.2. Other topics
4.3.2.1. Chlorhexidine : Chlorhexidine is known for its antibacterial action, however, due to the very high level of evidence for Chlorhexidine-based topicals for professional use in primary carioprevention (10% varnish and 0.12% gel, respectively evaluated on permanent and temporary teeth), they cannot replace fluoride topicals.
4.3.2.2. Casein phosphopeptide-amorphous calcium phosphate (CPP-ACP): CPP-ACP releases calcium and phosphate ions that are useful for remineralization. CPP-ACP pastes are available for home use and are effective in intercepting non-cavitary lesions. CPP-ACP fluoride varnish at 22,600 ppm has never been evaluated in children and adolescents. These CPP-ACP or ACPF pastes are not substitutes for fluoride topicals.
4.3.2.3. Silver Diamine Fluoride (SDF): This has recently been approved by the U.S. Food and Drug Administration and is currently used to stop dentin caries. SDF stops caries by the antibacterial effect of silver and by remineralizing enamel and dentin. The product is highly concentrated, less than one drop is needed to treat several carious lesions. The only reported side effects of SDF are that carious lesions turn black after treatment, and it temporarily stains the skin on contact.
4.4. Means of prevention :
4.4.1/ Prevention of the accumulation and formation of dental plaque:
4.4.1.1 / Outside dental practice :
Prevention outside the dental office is done through:
School hygiene :
-Starts in kindergarten, primary school, CEM and high school either through teachers who are already aware or through health professionals.
Raising awareness among parents :
-if parents brush their teeth, the child will do the same; and this act will become a habit.
Raising awareness among the general public :
-Through the media: press, radio, magazines, reports, surveys, advertisements, and television.
Dietetics :
-Educate people and especially children to eat a balanced diet, less sugar, more fruits and vegetables, and less hard, fibrous and sticky foods.
4.4.1.2/ At the dental office :
In the dental office, prevention begins in the waiting room and then in the dental chair.
1/ In the waiting room :
- Magazines, posters, leaflets, television animation for children and short shock reports for adults.
The assistant plays a very important role, she must be able to answer the patient’s various questions since the latter is more comfortable with her than with the dentist for fear of being judged for the state of his teeth.
The hygienist also plays a very important role in raising awareness as well as motivating the patient to use the various oral hygiene instruments.
2/ On armchair :
The work of the dental surgeon is not limited to dental care alone; motivation, teaching, and education are an integral part of these exercises.
5. *definition of oral hygiene:
-It is the set of explanations that the practitioner gives to his patient so that he takes care of his oral cavity and so that he is aware of the need for oral hygiene.
-The practitioner must raise awareness among his patient using simple arguments:
healthy gum healthy tooth.
-We must explain to him the harmful effects of bacterial biofilm and show him the means of combating it.
Preventive therapies in pediatric dentistry
6. Assessment of oral hygiene:
a) Plaque developers:
Presentation: _ Tablets. _ Solution
b) Goals:
_ Assess the child’s oral hygiene.
_ Educate the child by showing him the distribution and location of the
plaque and the effective method of removing this plaque.
c) Method:
- Give the child a tablet of developer which he must let melt in
mouth for one minute or brush the tooth surfaces with the
plaque developer solution.
- Ask the child to run his tongue over all accessible surfaces of the teeth.
- It should be rinsed to remove the excess.
- Show the child the colored areas that reveal dental plaque.
Preventive therapies in pediatric dentistry
7-Brushing teeth
7.1*definition:
It is a simple mechanical act essential to dental hygiene, allowing the elimination of dental plaque and preventing the development of cavities and periodontal disease.
-it is a most important preventive and complementary therapeutic process carried out by the patient himself.
7.2*objectives:
– Elimination of soft deposits and bad breath.
-Perform a gum massage (blood circulation).
-Strengthen gingival epithelialization.
-Prevent the formation of tartar.
7.3. TECHNIQUES FOR MECHANICAL REMOVAL OF BACTERIAL PLAQUE:
7.3.1) The toothbrush:
_ Recommend a brush with synthetic bristles, soft, with rounded ends.
_ the size of the toothbrush will be chosen according to the patient’s oral cavity.
_ Warn parents that a toothbrush needs to be replaced approximately every 2 to 3 months.
7.3.2) Toothpaste:
_ Children under 4 years old: no fluoride toothpaste.
_ Children aged 4 to 7: cosmetic fluoride toothpaste (1500 ppm).
_ Children over 7 years old: therapeutic fluoride toothpaste (1500 ppm).
7.3.3) Brushing techniques:
Regardless of the method used, it is recommended to divide the mouth into segments, starting with the molar region of the right upper jaw, and brushing until all accessible surfaces have been cleaned.
a- the horizontal method:
A back and forth movement in the ant-post direction 🡪 Indicated for children up to three years old
Disadvantages: persistence of food debris in the gingival sulcus
b- the circular method (Fones):
Indicated for children and patients with healthy periodontium
Disadvantage: no cleaning of interdental spaces, occlusal surfaces and gingivodental groove. Appearance of erosions and recessions
D- Bass method
: Brush applied halfway on the gum and teeth, at an angle of 45° in the apical direction. The ends of the bristles are at the level of the gingivodental groove and the interdental spaces, small vibratory movements are carried out.
- Indicated: healthy periodontium,
- periodontal diseases.
*modified:
irritated gums, deepened gingival groove.
-45° angle, back and forth movements and sweeping.
E- STILLMAN’s method:
The toothbrush is applied against the gum at an angle of 45° in the apical direction; the end of the bristles extends 2 mm beyond the marginal edge.
A mesiodistal vibrational movement is performed without changing the initial position.
Indicated for patients with periodontal disease, it ensures cleaning of interdental spaces and gingival massage.
F- The modified STILLMAN method:
The brush is placed at the level of the muco line
– gingival, the bristles are pressed above the crowns and moved in small strokes along the attached gingiva, marginal and dental surface
Indicated: periodontitis and edematous gingivitis
G- the charter method:
making small oxillations of the brush so that the end of the bristles penetrates the interdental spaces and finishing with a sweeping movement. Indicated in case of recession and diastema.
8. Brushing frequency
_ In the morning: after breakfast
_ After lunch
_ In the evening: before going to bed.
In addition, the child will have to brush his teeth after each ingestion of sugary foods.
9-brushing adjuvants:
A- Mechanics:
1-Dental floss/
- It complements brushing by removing plaque in the interdental areas that are inaccessible with a toothbrush.
_ Indication
- From the age of 8, the child must be helped by the parents in the first 3 years.
_ Method
_ Use an unwaxed silk thread (“30cm)
_ Wrap each end of the thread around the index fingers.
_ Insert the wire into the interdental space up to the level of the sulcus
gingival.
_ The role of the support points is fundamental, the passage of the point of contact
should not be done too quickly, so as not to traumatize the ligament.
- _ Slide the taut wire along the mesial wall of the distal tooth.
- _ Repeat the same movements to clean the distal face of the mesial tooth.
2- Interdental brushes :
- -Used in cases of absence of interdental contacts.
- -Different sizes depending on the morphology of each interdental space.
3- interdental sticks:
- Thanks to their shape adapted to interdental spaces and their soft and fibrous wood texture.
- Indications: retracted gingival papilla, under bridge intermediaries, under ODF arches and around implants.
4- Interdental Stimulation Cones :
used with a handle that serves as a support made of rubber or plastic intended to clean the gingival sulcus in the interdental area. This gingival stimulation seems to have a positive effect on the keratinization and vascularization of the tissues.
5- Water Flossers :
Allow the projection of a pulsed water jet at a rate of 20 times/s, allowing an intense massage of the gums and the elimination of particles retained in the proximal areas.
B- chemical adjuvants: are not indicated for children.
10. Plaque control in subjects with ODF devices:
- Hygiene is hampered by the presence of vestibular or lingual boxes.
- The use of a rotating electric toothbrush is necessary.
-the presence of vestibular or lingual arches hinders interdental hygiene
(use of interdental floss).
-the use of water jets allows the elimination of large food waste.
-use of listerine or sanguinarine mouthwashes.
-in case of loss of attachment, the use of interdental brushes does not pose any problem.
11. Prophylactic brushing:
Performed by the practitioner, it consists of removing bacterial plaque, or exogenous colorations of bacterial plaque.
Method
_ apply the polishing paste to a brush mounted on a micro lathe, and also to the dental surfaces.
_ Brush at slow speed on all accessible surfaces.
_ Rinse.
_ Slide a silk thread between the proximal contacts.
_ Rinse.
12. LEARNING ABOUT ORAL HYGIENE:
It requires motivation from the child and his parents.
It will begin on the patient’s second visit, who is advised to bring his or her toothbrush and toothpaste.
_ Place the child in the chair.
_ Use the plaque revealer and show him the location of the bacterial plaque on his teeth.
_ Ask him to clean his teeth without showing him the brushing method.
_ Show him the result.
_ Explain the brushing method.
_ Brush the child in front of you.
_ Do a prophylactic brushing.
_ Prescribe a toothbrush if necessary.
NB: This learning may require several sessions.
Preventive therapies in pediatric dentistry
13. TOPICAL APPLICATIONS OF FLUORINE:
13.1._ Fluoride gels
The gels are applied using either:
_ Gutters, available in various sizes on the market.
_ Gutters made by the practitioner for individual use.
_ Products used:
_ Bifluorinated fluocaril gel 2000 (Goupil Dentoria lab).
_ Elmex gel (Inava).
Method :
_ Choice of topical holder: it must fit the shape of the arch,
_ Prophylactic brushing.
_ Rinsing and drying teeth.
_ Put a small amount of fluoride gel in each topical door, spread it
with a cotton swab to avoid excess.
_ Insert it on the lower arch first, _ Do the same operation for the upper arch.
_ Ask the patient to refrain from rinsing, eating or brushing teeth for 30 min.
13.2. Fluoride varnishes:
_ Aim
They adhere to the enamel surface for extended periods of time (up to
12 hours and more) in order to slowly release their fluoride to the teeth.
_ Method of application
_ The varnish is applied to the teeth using a cotton ball.
_ Once the teeth are coated, the varnish film is left in place until it comes off spontaneously.
_ The patient is asked not to eat or drink for 4 hours following treatment and not to use a toothbrush on the day of treatment.
_ Indications
_ Desensitization of collars.
_ Treatment of pre-carious leukomas.
14. Sealing of grooves ( PITS AND CRACKS) : The sealing of pits and cracks should not be systematic.
_ Objective
Prevent pit and fissure cavities.
_ Materials
Bis GMA resins which can be classified according to:
_ Indications
_ Depending on the type of tooth
_ 1st and 2nd permanent molars
_ Lateral incisors
_ Premolars
_ 2nd deciduous molars.
_ Depending on the degree of eruption
Teeth that have recently erupted (less than 2 years) because their receptivity to caries is at its highest.
_ Depending on the condition of the tooth
Pits and fissures free of caries.
_ Depending on the terrain
Children at risk: heart disease, blood disease, etc.
Preventive therapies in pediatric dentistry
_ Operating protocol
1) Ensure the integrity of the enamel-dentin junction (clinical and radiographic examination).
2) Tooth isolation
3) Cleaning
4) Etching the enamel
5) Installation of the sealant
The self-polymerizing sealant:
The photopolymerizable sealant:
6) Verification
Check with the probe that the sealant remains in place.
If part of the resin comes off, repeat the operating procedure.
After removing the dam, check the occlusion.
7) Periodic checks
Carried out every 6 months by a visual examination and a survey which must not reveal any defect in retention or sealing.
15. CLASS I PREVENTIVE RESTORATIONS:
_ The technique is applied to teeth with minor occlusal carious lesions.
15.1._ Operating protocol
_ Local anesthesia if necessary.
_ Laying the surgical field.
_ Cleaning the occlusal surface using a rubber cup and polishing paste.
_Preparation of the obturation cavity:
_ At least with a round or cylindrical cutter.
_ The edges of the restoration are not beveled.
_ A small excavator allows the cavity to be cleaned.
_ No retention or prophylactic extension will be sought.
_ Classic production of a composite. Photopolymerization of the filling material.
Rinse, dry, and etch for 20 seconds in the pits and fissures of the enamel.
Rinse and dry for 30 seconds and apply sealant to the entire reconstruction and to all pits and fissures free of caries.
_ Checking retention and sealing.
_ Regular periodic checks.
Preventive therapies in pediatric dentistry
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.