In The Name Of God

1. In The Name Of God Oral health and Prevention in Dentistry MojtabaSedaghat Assistant Professor of Community and Preventive Medicine Tehran University of Medical Sciences

2. WHAT IS ORAL HEALTH? • Being free of : • Chronic mouth and facial pain, • Oral and throat cancer, • Oral sores, • Birth defects such as cleft lip and palate, • Periodontal (gum) disease, • Tooth decay and tooth loss,

3. WHAT ARE COMMON CAUSES OF ORAL • DISEASE? • Share common risk factors with the four leading • chronic diseases -- cardiovascular diseases, • cancer, chronic respiratory diseases and diabetes : • Unhealthy diet, • Tobacco use, and • Harmful alcohol use • Poor oral hygiene

4. HOW CAN THE BURDEN OF ORAL DISEASES BE REDUCED? • Addressing common risk factors such as tobacco use and unhealthy diet: • Decreased intake of sugars and well-balanced nutrition prevent tooth decay and • premature tooth loss. • Tobacco cessation and decreased alcohol consumption reduce risk for oral • cancers, periodontal disease, and tooth loss. • Fruit and vegetable consumption is protective against oral cancer. • Effective use of protective sports and motor vehicle equipment reduces facial • injuries • Dental cavities : prevented by a low level of fluoride constantly maintained in the • oral cavity. Fluoride can be obtained from : • Fluoridated drinking water, salt, milk, • Mouth rinse or toothpaste, • Professionally-applied fluorides.

5. INTEGRATED PREVENTION OF ORAL DISEASE AND HEALTH PROMOTION Most effective when they are integrated with other chronic diseases and with national public health programs Advocacy for a common risk factor approach to prevent oral and other chronic diseases simultaneously .The focus is on modifiable risk behaviors related to diet, nutrition, use of tobacco and excessive consumption of alcohol, and hygiene Fluoridation programs to improve fluoride access in low-income countries

6. Strategies:

7. 1- Development and implementation of community-oriented demonstration projects for oral health promotion and prevention of oral diseases with focus on disadvantaged and poor population groups in developed and developing countries • 2- Encourage national health authorities to implement effective • fluoride programmes • automatic fluoride administration (e.g. water or salt fluoridation) • use of affordable fluoridated toothpastes. • Self-care practices in relation to oral hygiene • 3- Effective control of diet and nutrition risk factors for dental • diseases, oral cancer, and cranio-facial development diseases • through the WHO Global Strategy on Diet, Physical Activity and • Health. • 4- Tobacco use (smoking and smokeless tobacco) - risk factor to • conditions such as oral cancer, oral mucosal lesions and • periodontal disease. 5- Community programs for improved oral health of the elderly and of children : high priority

8. Community Prevention • Infants and young children rarely visit a dentist • Professionals who have frequent contact with infants and • children be able to help prevent or reduce the risk of tooth decay • and to provide appropriate referrals • Steps to prevent or reduce the risk of tooth decay: • Perform an oral health risk assessment. • If qualified, conduct a basic oral health screening and initiate • appropriate preventive interventions. • Record oral health information. • Refer infants and children to a dentist. • Provide anticipatory guidance.

9. What is an Oral Health Risk Assessment Oral health risk assessment involves identifying an infant’s or child’s risk or protective factors that may impact oral health All infants and children are not equally likely to develop oral health problems Checks more than one of the boxes (the next slide) Refer the infant or child to a dentist for an oral health examination and/or possible treatment.

10. RISK FACTORS FOR ORAL DIISEASE FACTORS THAT PROMOTE ORAL HEALTH ORAL HEALTH HISTORY ❏ Active untreated dental decay ❏ Previous dental decay experience ❏ Deep pits & fissures in teeth ❏ Severely crowded teeth ❏ Poor oral hygiene ❏ Reduced saliva flow / dry mouth ❏ Inadequate fluoride ❏ Poor family oral health ❏ No family dentist ❏ Last visit to dentist over one year ❏ No active decay / all teeth restored ❏ No or minimal history of dental decay ❏ Sealants on back teeth ❏ Properly aligned and positioned teeth ❏ Good oral hygiene ❏ Mouth lining moist with clear saliva ❏ Optimal fluoride ❏ Good family oral health ❏ Visits dentist for routine periodic exams ❏ Visits dentist at least once a year

11. MEDICAL HISTORY ❏ Healthy balanced diet ❏ Medical condition managed and stable ❏ Medical condition managed and stable ❏ Medical condition managed and stable ❏ Alternative medication if possible ❏ Medical condition managed and stable ❏ Occasional snacks: fruits & vegetables

12. ❏ Bottles only for routine feeding ❏ Poor diet ❏ Metabolic disease (e.g., diabetes) ❏ Infectious disease ❏ Neoplastic disease (e.g., leukemia) ❏ Gastric reflux ❏ Frequent snacks ❏ Baby bottle at night for sleep, or at will ❏ Income higher than 400% of poverty ❏ Good dental insurance coverage ❏ Parents’ education beyond 12th grade ❏ No tobacco or alcohol use ❏ Poverty, low income ❏ No or inadequate dental insurance ❏ Parents’ education up to 12th grade ❏ Tobacco or alcohol use CULTURAL / SOCIAL / FINANCIAL STATUS ❏ Medications that affect the mouth (e.g., Dilantin, sugary liquid medications)

14. Oral Health Risk Assessment Results (check one) At high risk for tooth decay (refer immediately to a dentist) At low risk for tooth decay (refer to a dentist) Oral Health Screening Clinical Findings (circle “present” or “absent”) 1. Pain and/or infection related to oral problems: present OR absent (If present, refer immediately to a dentist) 2. Developmental problems: present OR absent 3. Dental restorations or fillings: present OR absent 4. Untreated tooth decay: present OR absent (If present, refer as soon as possible to a dentist) 5. Dental sealants: present OR absent 6. Trauma: present OR absent

15. Trained professionals, can perform an oral health screening of the • lips, • tongue, • teeth, • gums, • inside of the cheeks, and • roof of the mouth to identify oral disease, especially tooth decay, or other oral conditions (for example, delayed tooth eruption or premature tooth loss, abscesses, or trauma) • An oral health screening takes only 2 or 3 minutes to complete. • Screenings are not examinations and do not involve making • Diagnoses that lead to treatment plans A dental chair is not needed

16. For infants and children under age 3, the professional and the parent should sit face to face with their knees touching, with the child placed in the professional’s and the parent’s lap. The child’s head should be nestled securely against the health professional’s abdomen with the child facing the parent

17. With a gloved hand, the professional • lifts the lips, • feels the soft tissues, • views the health of the teeth, and • looks throughout the mouth • Any type of lighting, such as a flashlight, a portable gooseneck lamp, an examination light, or a headlamp, will work for an oral health screening. • A tongue depressor or child-sized toothbrush can be used to move the lips to view the teeth. • A dental mirror or other similar-sized mirror can make it easier for the professional to see behind the teeth and may make it possible to perform a more thorough screening, but such a mirror is not necessary

18. When performing the oral health screening, the professional should note whether the infant or child is currently in pain or has a dental abscess on the gums above/below the teeth. An abscess may look like a “gum boil” and may or may not have localized or generalized swelling with or without pus draining from the area. If the infant or child is in pain or has an abscess, refer the infant or child to a dentist immediately. Check whether tooth eruption and loss are proceeding according to schedule (see tooth eruption chart). Check the teeth for plaque and food debris. If the parent is present, demonstrate how to remove plaque and food debris from teeth using the appropriate-sized toothbrush

21. Photographs of tooth development, past history of tooth decay, tooth decay, and dental sealants can help professionals screen infants and children. • Note whether any teeth appear to have developmental problems. • Note whether any teeth have untreated decay. Tooth decay may occur on any tooth surface. Tooth decay initially appears as a chalky white area on the enamel. More advanced tooth decay appears as cavities or stains. When decay is observed, refer the infant or child to a dentist. • Discolored teeth may be difficult to distinguish from stains associated with tooth decay. When in doubt, refer the infant or child to a dentist. • Note whether any dental trauma has occurred. If the teeth are prematurely missing, refer the infant or child to a dentist for possible space management. If trauma may be the result of physical abuse, record observations and call the local social service agency.

26. What is Oral Health Anticipatory Guidance? Helps families understand what to expect during their infant’s or child’s current and approaching stage of development. Primary care professionals, other health professionals, and early childhood professionals. Prevent or reduce tooth decay in their infants and children. For parents of infants and children, anticipatory guidance topics :include oral development, tooth eruption, gum/tooth cleaning, appropriate use of fluoride, bottle use, and feeding and eating practices. Bacteria (Streptococcus mutans [S. mutans]) can be transmitted from a parent, especially the mother or another intimate caregiver, to an infant or child through contact, anticipatory guidance should also be provided to pregnant women, new mothers, and other intimate caregivers

27. Can a Parent “Infect” an Infant or Child with Streptococcus Mutans? Transmitted from a parent or another intimate caregiver to an infant or child via saliva, for example, by allowing infants or children to put their fingers in the parent’s mouth and then into their own mouths, testing the temperature of a bottle with the mouth, sharing forks and spoons, and “cleaning” a pacifier or a bottle nipple that has fallen by sucking on it before giving it back to the infant or child. Even if an infant or child is already infected with S. mutans, transmission can increase the concentration of bacteria in the infant’s or child’s mouth, increasing the likelihood of tooth decay or resulting in more severe decay. Therefore, it is important that parents and other intimate caregivers practice good oral hygiene and avoid behaviors that could transmit S. mutans to an infant or child.

29. Food Interactions with Streptococcus Mutans? Foods containing fermentable carbohydrates, which include all sugars and cooked starches, interact with S. mutans, producing acids that can cause mineral loss from teeth. Sucrose, which is highly concentrated in candy, cookies, cake, and sweetened beverages (for example, fruit drinks and soda), is a major contributor to tooth decay. Fructose, the naturally occurring sugar contained in fruit, contributes to tooth decay, although fruit is more nutritious than candy, cookies, and cake. Lactose, the sugar contained in milk, contributes to tooth decay, although milk is more nutritious than candy, cookies, and cake. Starch, contained in processed foods such as bread, crackers, pasta, potato chips, pretzels, sweetened cereal, and French fries breaks down into simpler sugars. Processed foods containing starch produce as much acid in plaque as sucrose alone, but at a slower rate.

30. Frequent consumption of foods high in sugar (for example, candy, cookies, cake, sweetened beverages, and fruit juice) increases the risk for tooth decay. Even very small amounts of these foods consumed frequently over the course of a day will create an acid environment lasting many hours. Even though they contain sugar (fermentable carbohydrates), healthy foods like fruit, vegetables, grain products (especially whole grain), and dairy products should not be avoided. Snacking is important for infants and children; because their stomachs are small, they need to eat small amounts frequently to meet their nutritional requirements. However, it is important to limit snacking on foods high in sugar,

31. Can Tooth Decay Lead to Other Problems? • Painful, Destruction of teeth, Difficulty chewing, under nutrition • impaired physical development. • Speech problems. • Inability to concentrate, difficulty with learning, and impaired • performance in school. • Psychological problems such as low self-esteem and poor • social interaction. • Tooth decay in primary teeth most often means that there will be • tooth decay in permanent teeth.

32. Proper speech development • Development of the facial structure • Don’t assume that tooth decay will occur no matter what. • Any effort to save teeth, including primary teeth, will help • promote healthy development and reduce or eliminate the pain • associated with tooth decay

33. Module 1: Tooth Decay Key Points Tooth decay is an active process of tooth destruction resulting from interactions between teeth, food, and bacteria. The bacterium S. mutans is the main contributor to tooth decay. S. mutans is found mostly on tooth surfaces. It is most concentrated in the crevices, pits, and fissures that are a normal part of the teeth and surrounding structures. Bacteria can be transmitted from a parent or other intimate caregiver to an infant or child via saliva. Therefore, it is important that parents and other intimate caregivers practice good oral hygiene and avoid behaviors that could transmit S. mutans to an infant or child. Foods containing fermentable carbohydrates, which include all sugars and cooked starches, interact with S. mutans and produce acids that cause mineral loss from teeth. Each time such foods are consumed, the acid attacks the enamel of the teeth. This mineral loss results in cavities when the attack is prolonged and exceeds an individual’s resistance and the ability of the teeth to heal. Tooth decay can spread and be extremely painful. Tooth decay in primary teeth most often means that there will be tooth decay in permanent teeth.

34. Educational Module : Prevention of Tooth Decay / Feeding and Eating Practices • Do not put the infant or child to sleep with a bottle or sippy cup or allow frequent and prolonged bottle feedings or use of a sippy cup containing beverages high in sugar (for example, fruit drinks, soda, or fruit juice), milk, or formula during the day or at night. • Do not use a bottle to calm an infant or to put an infant to bed. Instead of a bottle try: • Giving the infant a favorite blanket or toy • Offering the infant a clean pacifier • Holding, patting, or rocking the infant • Reading to the infant • Softly talking or singing to the infant • If an infant is accustomed to being put to bed with a bottle, offer a bottle filled with plain water. If the infant does not adapt initially to the plain water, it may be necessary to fill the bottle with a mixture of juice and water, reducing the amount of juice slightly each night until only water is used. • Hold the infant or child while feeding. Never prop a bottle (that is, use pillows or any other objects to hold a bottle in the infant’s mouth).

35. Never add cereal to a bottle. This causes sugary fluids to pool around the teeth and can also cause choking if the infant is unable to swallow the extra food. Instead, always feed infants and children solid foods with a spoon or fork, or, if the infant or child is coordinated enough, encourage self-feeding. • Introduce a small cup when the infant can sit up without support. • As the infant begins to eat more solid foods and drink from a cup, the infant can be weaned from the bottle. Begin to wean the infant gradually, at about 9 to 10 months. By 12 to 14 months, most infants can drink from a cup. • Do not dip pacifiers in sweetened foods like sugar or honey.

36. Serve age-appropriate healthy snacks such as fruit, vegetables, grain products (especially whole grain), and dairy products instead of foods high in sugar such as candy, cookies, or cake. • Offer snacks at regular times between meals only. If a child snacks frequently, brush the child’s teeth three times a day. • Make sure the child drinks plenty of water throughout the day, especially between meals and snacks. • Don’t offer food in return for good behavior. This teaches children that foods are rewards and can lead to the development of unhealthy habits.

37. Educational Module : Prevention of Tooth Decay • What is Fluoride, and Who Needs It? • Enhances tooth and bone health, primarily through topical effects. Groundwater, Foods such as breads and beverages that are made using fluoridated water and in many public fluoridated water supplies. • Tooth decay can be reduced by 50 to 70 percent with exposure to the proper amounts of fluoride. • Water fluoridation is one of the best examples of a public health preventive intervention at the community level • .

38. Topical fluoride is probably the most important method of preventing tooth decay. • Works best when it is ingested in very small amounts many times a day through water, foods containing fluoride, and fluoridated toothpaste. • Unless a dentist or physician advises otherwise, fluoridated toothpaste should be introduced at around age 2. • Another form of topical fluoride is professionally applied fluoride (including gels, foams, and varnish), for children at high risk for tooth decay because they lack fluoridated water, have a history of tooth decay, snack frequently on foods high in sugar, or have a medical condition that makes them susceptible to decay. • Only a dentist, dental hygienist, physician, or other qualified health professional should apply topical fluoride

39. Who Needs Fluoride Supplements, and How Much Fluoride is Enough? Fluoride supplements are recommended only when an infant or child age 6 months or older consumes less than the optimal amount of fluoride (see Table 1. Systemic Fluoride Supplements: Recommended Dosage). Infants or children suspected of drinking mainly water that is not fluoridated should be considered for fluoride supplementation. The dentist or physician should consider the following before prescribing systemic fluoride drops: Is the infant’s or child’s source of water from a well? If it is, the water should be tested to determine how much fluoride it contains. Is the infant’s or child’s source of water bottled or processed? Bottled water often does not contain adequate amounts of fluoride; some water filtration systems filter out fluoride.

40. Educational Module : Prevention of Tooth Decay • What is Fluorosis? • Too much fluoride or use of too much topical fluoride during infancy and childhood, when the teeth are developing. • Fluorosis usually appears as small white areas in the enamel • Cosmetic problem that usually does not affect health. • Generally, infants and children will not consume too much fluoride as long as only a pea-sized amount of toothpaste is used for toothbrushing (for children ages 2 and above), • only plain water is used for toothbrushing (for infants and children under age 2), • an adult brushes the infant’s or child’s teeth or, for older children, supervises toothbrushing.

41. Educational Module : Prevention of Tooth Decay What are Dental Sealants? Dental sealants are thin plastic coatings applied to pits and fissures on the chewing surfaces of the teeth to prevent tooth decay by creating a physical barrier against dental plaque. Applying dental sealants to tooth surfaces with pits and fissures shortly after the teeth erupt helps prevent decay.

42. Educational Module : Prevention of Tooth Decay • Key Points • Children should visit a dentist within 6 months of the eruption of the first primary tooth, and no later than age 12 months. • Parents should begin cleaning an infant’s teeth as the first tooth erupts, usually around age 6 to 10 months. • Tooth decay can be reduced by 50 to 70 percent with exposure to proper amounts of fluoride. • All infants and children who drink fluoridated water benefit from systemic ingestion by incorporating fluoride into their developing teeth, as well as from important topical effects. • Topical fluoride is probably the most important method for preventing tooth decay.

43. Dental sealants are thin plastic coatings applied to pits and fissures on the chewing surfaces of the teeth to prevent decay by creating a physical barrier against dental plaque. • Fluoride varnish is a topical fluoride-containing lacquer that can be easily “painted” onto the susceptible surfaces of a child’s teeth. • Xylitol, a low-calorie sugar substitute used in certain chewing gums and other food products, may reduce the incidence of tooth decay in mothers and children.