Lecture 11
Works in 3 ways to reduce and prevent dental caries:
1. Systematically-ingested and incorporated into enamel structure during tooth development
2. Topically by promoting remineralization and inhibiting demineralization of tooth surfaces after eruption
3. Topically by inhibiting glycolysis metabolizism in microorganisms hindering the of carbohydrates and production of acid
the 3 main forms of topical fluoride
1. Stannous Fluoride 2 (SNF2)
2. Acidulated Phosphate Fluoride (APF)
3. Sodium Fluoride (NaF)
What is the average dose for an adult?
What is the average dose in general?
Adult= 2.5-10g
General= 4-5g
What is communication made up of?
◦Actual words - conveys information
◦ Tone- conveys emotions and attitudes
◦Non-verbal communication or body language – communicate emotions and attitudes
Why not remove the dentine completely?
T/F- restoring a smooth surface lesions will increase longevity of the tooth.
◦Tubular mineralization and tertiary dentine formation
◦Reduce the permeability of the dentine
◦Wall off the pulp from the bacteria invading the dentine in the lesion
FALSE
Recommended amount of Fl for:
a- tropical areas
b- temperate areas
c- salt
d- milk
a- 0.7ppm to 1ppm
b- 1ppm to 1.2ppm
c- 20mg Fl/kg
d- 5mg/1 liter
List the steps in the application of fluoride gels and foam
Step 1- Select tray which should: ◦ cover all of the patient’s dentition ◦ have enough depth to reach beyond the CEJ and to contact the alveolar mucosa (prevent saliva from diluting the Fl) Step 2- Rinse the teeth
Step 3- Dry with compressed air
Step 4- Place a ribbon of gel or foam in the trough of the tray
Step5- Seat tray over entire arch (the gel must reach all the teeth and flow interproximally)
Step 6- Keep tray in place for 4 minutes for optimum Fl uptake (30- 60 seconds – follow manufacturers instructions)
Step 7 – Ask patient to expectorate without rinsing
Step 8- Advise patient not to eat, drink or rinse for 30 minutes
List the four general reactions to fluoride toxicity.
◦1. Concentrated Fl salt contacts moist mucous membranes- hydrofluoric acid forms causing a chemical burn.
◦2. Fl a general protoplasmic poison acts to inhibit enzyme systems.
◦3. Fl binds to calcium needed for nerve action.
◦4. Hyperkalemia (excessive amounts of phosphate in blood stream) occurs contributing to cardiotoxicity (damage to heart muscle).
1. use open and close questions- open->initiate discussion; closed-> focus on issues as the pt raises them.
2. dental jargons- pt can misunderstand words, choose them accordingly.
3. listening and empathy- repeat/paaraphrase, make an effort to understand situation from speaker's pov.
4. forgetting and distortion- donot uverload with info, wriite down /call if possible, info may be distorted as pt. got their own interpretation.
A) What are the checks to make before preparing a tooth for a restoration?
B) What are the two types of caries removal?
C) What are the two types of demineralized dentine removal? explain them
A)
1. ask the pt for symptoms upon stimuli, if pain doesn't go away after removal of stimuli-->irreversible pulpitis, may need to remove damaged pulp/root canal therapy.
2. check that there is no sinus tract--->pulp death
3. check pulp vitality--->cold/electrical stimulus
4. examine a radiograph
B) selective/partial removal and non selective/complete removal
C) stepwise excavation and indirect pulp capping?
stepwise involves selective removal then application of temporary restoration vs. indirect pulp capping involves selective removal the application of permanent restoration.
What are the considerations for using supplement schedule?
◦ If fluoride level is unknown, drinking water should be tested for fluoride content before supplements are prescribed.
◦ All sources of fluoride should be evaluated with a thorough fluoride history.
◦ To obtain the benefits from fluoride supplements, long-term compliance on a daily basis is required
List the four disadvantages of topical fluoride treatments
1. Some clinical situations may alter the selection of treatment agent. Eg: SnF2 may be contraindicated for esthetics because it results in a temporary brown pigmentation of carious tooth surfaces and also dissolves composite restorations.
◦ 2. Strong unpleasant taste of SnF2, flavoured APF is much more accepted.
◦ 3. APF systems have the disadvantage of possibly etching ceramic or porcelain surfaces, but the surfaces can be protected by coating with vaseline.
◦ 4. The tendency of dental offices is to use a specific topical fluoride system and treatment regimen for every patient.
A) Why is milk given as a first aid treatment for fluoride toxicity?
B) Actions needed to treat fluoride poisoning
A)
1. they act as demulcents- help to protect the mucous membrane of the upper GI tract from chemical burns.
2. they provide Ca that binds to Fluoride.
Lime water (CaOH) or Maalox (aluminum) can produce the same effect
B)
(1) immediate treatment
(2) induced vomiting
(3) protection of the stomach by binding fluoride with orally administered calcium or aluminum preparation
(4) maintenance of blood calcium levels with intravenous calcium
What are the theroies of changing behaviours? explain them
1.The health belief model
◦ for an individual to take action they need to believe they are susceptible to the disease.
2.The health locus of control model
◦ suggests individuals hold beliefs as to whether they have control over what happens to them.
◦An external locus of control implies a fatalistic approach—‘my teeth will rot and there is nothing I can do; it is the dentist’s job to control disease’.
◦An internal locus of control, the patient believes they can influence the process.
3. The transtheoretical model of behaviour change -describes the patient’s readiness for change.
◦This assumes that behaviour change is a dynamic, nonlinear process involving district stages:
◦● Pre-contemplation: not even considered change.
◦ ● Contemplation: considered change
◦● Preparation: getting ready to change.
◦ ● Implementation: changing.
◦● Maintenance: keeping it up
Four management options for cavitated deciduous lesions
1. Non restorative caries treatment (NRCT)
2. Hall crown- sealing with stainless steel crown.
3. Selective caries removal and restoration
4. Non selective caries removal and restoration
What are the effects of fluoride on plaque and bacterial metabolism?
fluoride inhibits glycolysis by interfering with the enzyme enolase
◦concentrations of fluoride as low as 50 ppm can interfere with bacterial metabolism.
◦fluoride can accumulate in dental plaque- concentrations higher than 100 ppm
List the seven(7) ways of administering topical fluoride treatments and state which two are the main ones and which are prescribes.
There are 2 main ways of administering topical fluoride treatments
◦ 1. Painting varnish unto tooth surfaces
◦ 2. Use of Fl foams or gels applied with a disposable tray
Other methods include:
3. Fluoride containing prophylactic pastes
4. Multiple Fluoride therapy (prescribed)
5. Fluoride mouth rinses
6. Fluoride gels for oral self care (prescribed)
7. Fluoride Releasing Dental Materials
A) A daily dose of more than ___ results in chronic fluorosis.
B) Skeletal fluorosis is characterized by three things, what are they?
C) Long term consumption of naturally flouridated water that contain __ppm or more of Fl can cause chronic fluorosis.
D) Three(3) preventions of fluoride toxicity
A) 20mg of Fl
B) osteosclerosis -abnormal increase in thickness and density of bone
calcification of the tendons
the appearance of multiple exostoses -bony growths that arise from the bone’s surface.
C) 14 ppm
D) Educate parents about fluoride and fluoride containing products.
Secure store fluoride and fluoride containing products properly in home.
Educate health professionals about emergency treatment for Fl toxicity.
What are the key principles of motivational interviewing?
What are some communication hints specific to motivational interviewing
SRED
1. Support self efficacy
2. Roll with resistance
3. Express empathy
4. Develop discrepancy
OARS
1. Open ended questions
2. Affirm the patient
3. Reflect what the pt is communicating
4. Summarize
10 things to consider when choosing how to manage deciduous teeth.
any 10
1. location
2. if a restoration s required and a conventional surgery is not available- ART is chosen.
3. pain might make extraction preferable.
4. size of lesion and age of child.
5. avoid pain/discomfort
6. price- dentist fee
7. combine techniques in same pt.
8. time taken in various techniques.
9. all approaches must be combined with encouraging parent to take responsibility for caries control.
10. skill of dental team.
11. how many children on waiting list?
12. view od pts and parents?
When was the dean index originally made and when was it revised?
List and describe the dean's index.
original date- 1934 ; revised date- 1942
1. Normal- translucent, glossy, pale creamy-white colour, smooth.
2. Questionable- a few white frecks to occasional white spots
3. Very Mild- less than 25%, paper white areas, tip of cusp show snow capping
4. Mild- more than 25% less than 50%, extensive paper white areas
5. Moderate- all surafces affected, brown staining
6. Severe- all surfaces affected, corrored appearance
Who are the high risk patients for fluoride mouth rinses?
hint: 8 types of pt
◦ 1. Pt who because of use of meds, surgery, radiotherapy and so on, have hyposalivation and increases caries formation.
◦ 2. Pts with ortho devices or removable prosthesis which act as traps for plaque accumulation.
◦ 3. Those who are unable to receive acceptable oral hygiene.
◦ 4. Extensive dental restorations and multiple restorative margins which are sites for high caries risk.
◦ 5. pts who cannot tolerate custom made trays but need Fl as a self care regimen daily.
◦ 6. Pts with gingival recession and susceptibility to root caries.
◦ 7. Those that have rampant caries, at least as long as the high caries activity persists.
◦ 8. Children living in non-fluoridated areas
List the seven(7) CDC report recommendations for reducing the risk of enamel fluorosis.
1. Know whether Fl conc. of primary drinking water source is below(<0.7ppm) or above optimal(>1.2ppm).
2. Parents shoud brush or supervise toothbrushing of children <6 years old.
3. Parents should consult dentist/health professionals before introducing fluoride toothpaste to children <2 years old.
4. For children <6 years old, use a pea size amount(0.25g) of toothpaste.
5. If community water contain a natural Fl conc. of >2ppm Fl, children <8 years should have an alternative source of drinking water.
6. Use of other methods of Fl should be limited to children who are at risk for developing caries. Supplements should be prescribed judiciously and in accordance with the dietary fluoride supplement schedule.
7. Parents of formula fed infants should weigh the balance between child's risk for very mild/mild enamel fluorosis and the benefit if fluoride for preventing caries.
a- What is the three step process for giving information?
b- List 5 things as it relates to failure to motivate a patient.
a ◦Step 1: elicit the patient’s or parent’s readiness to receive the information.
◦Step 2: provide the information in a neutral fashion first.
◦Step 3: elicit the person’s reaction to the information.
b any 5
◦Ask yourself if anything could have been done differently and ask the patient
◦The entire dental team should be involved in the process
◦What the dentist may not be able to achieve, the hygienist, nurse, or dental health educator may or vice versa.
◦Remember that behaviour change can be a slow process and does not usually happen after one visit.
◦It is often a continuous process of building up trust and rapport with a patient over many visits, continuing to be encouraging and finding small improvements to be positive about.
◦It is also an ethical necessity to be honest with patients, and it may be necessary to confront the patient and tell them they have two new lesions.
◦Where it is a parent who has failed in care, discussion in their child's absence is considerate and can be constructive.
◦what failed in one generation may succeed in another.
◦The greatest frustrations may occur where the dentist is powerless to improve things, perhaps because of financial constraints or perhaps because the patient needs help from someone else, which is not forthcoming.
◦Dental neglect is very distressing and can signal neglect or abuse of an even more serious nature.
What are the steps to take in managing permanent teeth in a conventional surgery setting? at least 5
any 5
◦1. Remove as little tooth structure as possible to preserve the strength of the tooth. (adhesive materials (composites and glass ionomer cement).
◦2. Protect the adjacent tooth when preparing an approximal restoration, particularly when using an air rotor.
◦3. Establish a contact point- but this can be technically difficult.
◦4. The margins should fit, which is a challenge cervically.
◦5. When deciding to replace a restoration, be very clear as to why this option has been chosen. (new lesions or technical failure)
◦6. Always consider whether the tooth could be repaired, rather than replacing the restoration.
(conserves tooth structure and safer in the log run)