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kariesprevention før førskolebarnet, skolbarnet & tonåringen

Svante Twetman, Faculty of Health Sciences, University of Copenhagen

Selwitz et al. Dental caries. Lancet 2007

the caries balance

demineralisation remineralisation

ATTACK • bacterial overgrowth • decreased saliva

function• frequent sugar intake

DEFENCE• fluoride, Ca, P• saliva content• buffer capacity• antibacterial agents

socioeconomy

knowledge

attitudes

behavior• oral hygiene• small eating

education

sociodemography

the ecological plaque hypothesis

broken homeostasis = ecological catastrophe

2

pH

tid

****** ****** ******

tid

pH

*

******************

* = aciduric bacteria

prevention – action taken before a disease occur

primary-primary primary secondary

Koch, Poulsen: Pediatric Dentistry. A clinical approach. 2001

primary-primary prevention

intervention to parents

child gets the benefit

primary prevention

actions to prevent the initiation of a disease

secondary prevention

non-invasive actions to prevent progression of an existing disease

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Västerhaninge.1

distribution of DMFS-appr at 12-13 yrs (n=392)

0

10

20

30

40

50

60

70

80

0 1 2-3 4-5 6-16 > 10DMFS appr

PERCENT

from Mejàre et al, 2006

risk patients and risk groups

20% stands for80% of the disease

“over-treatment”

“under-treatment”• good risk assessment• effective methods

population strategy vs. high risk strategy caries risk assessment

caries risklow risk

true positivetrue negative

false positivefalse negative

low caries

geographicarea

sub-population,immigrants

low educationsocio economy

different measures to prevent caries in different areas

risk ages and risk surfaces

0 yr 19 yr

1-3 yr 5-7 yr 12-15 yr

20 new teeth ”4” new surfaces 76 new surfaces (32 proximal)

4

strategies to reduce caries risk

triclosanfluoride

chlorhexidine

xylitolprobiotics

CPP-ACP

tooth cleaning

sugarsubstitutes fissure

sealants

diet control

1966-2003

evaluated >1,500 papers on caries preventive methods

www.sbu.se

www.cochrane.org

evidence-based dentistry – a process

1. question of clinical relevance

2. systematic search for literature and inclusion of relevant papers

3. critical appraisal of selected papers and compilation offindings

4. a graded statement, based on high quality studies,systematic review or meta-analysis

5. clinical recommendations or guidelines

hierarchy of evidence

randomized controlled trialsrandomized controlled trials

cohort studiescohort studies

non-randomized controlled trialsnon-randomized controlled trials

case-control studiescase-control studies

cross-sectional studiescross-sectional studies

case studies, expert’s opinionscase studies, expert’s opinions

randomised controlled trial (RCT)

representative sample

BL ΔDMFS

intervention

controlplacebobest clinical practice

level 1level 1

level 2level 2

level 3level 3

level 4level 4

definition of evidence levels

strong scientific evidence>2 studies with high quality and relevance

moderately strong scientific evidence1 study with high quality and at least 2 with medium

limited scientific evidence>2 studies with high quality and relevance

insufficient or contradictory scientific evidenceno studies or studies of equal quality with conflicting results

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level of evidence

www.sbu.se

EBD = best available evidence

lack of evidence not the same as lack of effect

lack of research or less good quality

evidence-based care

best available evidence

caregiver’s knowledge, patient’s preferencesexperience and skill and economy

level 1level 1

level 2level 2

level 3level 3

level 4level 4

fluoride and caries

level 1level 1

level 2level 2

level 3level 3

level 4level 4

evidence levels

Xylitol

CHX

risk ages and risk surfaces

0 yr 19 yr

1-3 yr 5-7 yr 12-15 yr

20 new teeth ”4” new surfaces 76 new surfaces (32 proximal)

caries prevalence in Sweden (cavitated + enamel)

1 yr <1%2 yr 8%3 yr 27%4 yr 46%

prevention must start early

1-3 year

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some factors associated with ECC

psychosocial

ethnicitysocio-economyeducation levelimmigrantsrefugeesfamily stress

behavior

baby bottlediettooth brushingattitudeself-consciousnessself-efficacylocus of control

medical

mutans streptbreedingchronic diseasesmedicationhypomin

Harris et al. 2004: 106 different risk factors associated with ECC

how to prevent caries 0-3 year

some inconclusiveevidence evidence

early startoral health campaignsdiet counseling “lift-the-lip”tooth brushing instructionfluoride exposureoutreach dental health

X

XXX

(X) XXX

key person 1-3 yr

custodians, especially the mother

daily carecookingshoppingverbal contactemotional

key message

low concentration of fluoride in any form into the mouth of the baby at least once daily

dental health education (DHE)

Davies, 2005 UK, 2 yrVichiraroijpisan, 2005 Thailand, 1 yr

matched health districts- DHE in small groups, - support positive dental behavior - gift-bags (F-toothpaste, brushes etc)

intervention controlnormal program

improved tooth brushing habits but failed to reduce ECC

outreach DHE

Kowash 2000, UK, home visits, 228 children

A. diet (4x/year) B. oral hygiene (F-toothpaste) (4x/year) C. diet + oral hygiene (F-toothpaste) (4x/year) D. diet + oral hygiene (F-toothpaste) once/yr)E. no DHE 33% caries

1% caries

no caries

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DHE

Weinstein, 2006 USA 2-yr RCT

motivational interviewing

n=2406-18 m

traditional education

significantly less caries

greater compliance with F-varnish

chinachinasupportive F-toothpaste studies in China

Schwartz, 1998 3-yr CCT 1000 ppm vs. nothing -26%

You, 2002 2-yr CCT 1100 ppm vs. placebo -21%

Rong, 2003 2-yr CCT 1100 ppm vs. nothing -30%

start from first toothadjust the amount to the “size” of the child children need

training and parental support until they can write with a good hand

no significant caries-inhibiting effectwith low-F toothpaste <500 ppm

Twetman et al., 2003; Ammari et al., 2003

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F-varnish vs. F-gel

F-gel: uncertain evidence on primary teeth

F-gel: each application 4 min or more

F-gel: increased risk of swallowing

fluoride varnish takes less time, create less patient discomfort and achieve greater patient acceptability, especially in pre-school children

American Dental Association Council on Scientific Affairs, 2006

FF--varnishvarnish

Weintraub et al., 2006 2-yr RCT

376caries-free

1.8 yrs

counseling

counselingFV 2x/year

counselingFV 4x/year

OR=2.2

OR=3.8

22.600 ppm

results

0

0,5

1

1,5

2

2,5

3

advice FVx2 FVx4

new

lesi

ons

incipientmanifest

Weintraub et al., 2006

younger than 6 years

topical fluoride varnish should be applied at least twice

yearly for preschool children assessed as being at increased

risk of dental caries

SIGN, 2005 strength of recommendation BADA Council on Scientific Affairs, 2006 strength of recommendation A

multi-cultural area20.000 inhabitants

>50 languagesArabic

85% caries prevalenceamong 3-yr-olds

Rosengård project

I Wennhall, L Matsson, U Schröder, S Twetman

www.whocollab.od.mah.se

1. outreach facility

2. three-month recalls from 2-years

3. tooth brushing training

4. F-toothpaste

5. F-tablets

6. dietary advice

intervention vs. historic controls

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results after 1 year (3-year-olds)

0

10

20

30

40

50

60

70

80

90

intervention reference

cari

es fr

ee (

%)

dmft 3.0 4.4Wennhall et al., 2005

N= 800

surprisingly good compliance with the F-tablets in this study group (75%)

age at risk of dental fluorosis?

Evans and Darvell, 1996 15-30 moHong et al., 2006 0-24 mo

“ first three years”

young children swallowing tooth paste etc = risk

fluoride

beneficial effect on caries - topical

risk for fluorosis - systemic

try to minimize the systemic exposure

Thylstrup-Fejerskovs fluorosis index fluorosis

mild form, increasingbut not perceived as aproblem

moderate formvery rare, stable

Menegim et al., 2007

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5-7 yr 5-7 yr

4 occlusal surfaces = 70% of all dental costs deep fissureshighly susceptible during first year after eruption

key persons 5-7 yr

the profession

soon after eruption

technique sensitive

must be checked and maintained

high costs

an intact fissure sealant is caries protective which are the indications?

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indication for fissure sealants

deep fissures X X

shallow fissures X --

high risk low risk

60-70% FS

all vs. risk

all 1st perm molars85%

only those considered at risk

20%

6-19 yr

6-19 yr

Benteke, Twetman et al., 2006

little better health (fewer decayed/filled 1st permanent molars)

risk application was less expensive (0.7 vs. 1.6 h/saved tooth)

indications for fissure sealants 5-7 yr(non-evidence based)

all children with decayed primary teeth

all medically compromised children

all children with BMP

plan B – if not dry

1. fissure sealant with GIC

2. fluoride varnish

3. CHX-varnish

school-based supervised tooth brushingwith F-toothpaste reduces caries incidencein immigrant and deprived areas increased caries risk

_________________________yes no

overweight OR 2-3

ADHD OR 12

asthma X

Type-1 IDDM X (poor control)_______________________________________________

general health and caries

Willershausen et al 2004; Broadbent et al 2004; Eloot et al., 2004; Twetman et al., 2003, 2005

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poor metabolic control(HbA1c > 8.0)

increased caries risk OR = 7.2

diabetes and caries

Twetman et al., 2003

12-15 yr

vulnerable & turbulent periodsecond molar & proximal surfaces at risk

teenager ”caries factors”

liberation - communication problemslifestyle changes, own money, soft drinks,smoking, drugsskip brushing – always “tired” (♂)skip main meals (♀)TV-behavior (junk food) diminished salivary buffer capacity (♀)sex hormonesgingivitis

key person: own responsibility

daily tooth brushing?

12 yr 68%

14 yr 74%

16 yr 81%

girls better than boys

Kuusela et al., 1997; Koivusilta et al., 2003

12 yr 68%

14 yr 74%

16 yr 81%

girls better than boys

daily tooth brushing?

Kuusela et al., 1997Koivusilta et al., 2003

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relation

task

empowerment by dialogue

locus of control - focus on the message that they can do something about their own situation

- build-up of faith and confidence

Hattne et al., 2007

#1 focus 12-15 yr: tooth brushing

twice daily but at least in the evening≥1,500 ppm NaF

white teeth

avoid bad breath

why do you brush your teeth?

Hattne et al., 2007 Colgate Duraphat toothpaste 5,000 ppm

#2 focus 12-15 yr: F-varnish

professional F-varnish applications every 6th month

helping them over a troublesome period

newly erupted teeth benefits themost from the varnish

school as an arena for health promotion

≈20,000 hours in schoolbridge gaps in oral healthoutreach dental health promotiondental professionals visible preventive treatments to less costs

less no-shows

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school-based fluoride programs: F-varnish

0

0,5

1

1,5

2

2,5

3

3,5

low risk medium risk high risk all

2x F-varnish ctr

dfsa

Moberg-Sköld et al., 2005

57%

#3 focus 12-15 yr: diet

maintain a good order of main mealsreduce snack and light between meals“everything is allowed - but not always”“rest, water & fluoride”

level 1level 1

level 2level 2

level 3level 3

level 4level 4

CHX and caries

inconclusive evidence for caries prevention and control

for mutans streptococci suppression

MS may not be sensitive in the biofilm

monocultures =MS are sensitive

“complex community” =individual susceptibility

50% non-responders

-50 0 50 100

1

3

5

7

9

11

13

prevented fraction (%)

negative effect positive effect

Zhang et al., 2006 Eur J Oral Sci

systematic review: CHX-varnish for caries prevention

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does a comprehensive non-invasive approach work for the caries active teenager?

500 with active caries

(Nyvad criteria)

individually targeted programcounseling, “use your resources”

toothbrushes, F-toothpaste, F-varnish, xylitol lozenges, CHX etc

basic preventive programat PDC

baseline 3.4 yr

2.6 DMFS

PF 44%

4.6 DMFS

Hausen et al., 2007 Caries Res

alternative methods for prevention

plaque

if we cannot kill it, can we alter the impact of acidogenesis and acidoduricity?

turn a bad plaque into a harmless plaque?

Pratten & Wilson, 1999; Hope & Wilson, 2003

xylitol – natures own “functional sugar”

PRODUCT XYLITOL CONTENT(mg/100g ds)

Yellow plums 935Strawberries 362Cauliflower 300Raspberries 268

Endives 258Aubergine 180

Lettuce 131Spinach 107

Natural Occurrence of Xylitol

xylitol sucrose, sorbitol

• sugar alcohol, polyol

• 5-carbon ring

• calories

• similar sweetnessas sucrose

xylitol can affect oral ecology in 3 ways

1. diminish pH-drop in plaque

2. reduce plaque volume

3. induce shift of MS strains ( pathogenic)

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Milgrom et al., 2006

xylitol:

at least 6 gram/day

study duration age dose/day outcome RRDFS

Kovari, 2003 5 yr preschool 2.5 g gum 1.2/1.6 25% NSMachiulskiene,-01 3 yr schoolchildren 3.0 g gum 3.4/4.3 21% NSAlanen, 2000 3 yr schoolchildren 5.0 g gum 1.9/4.4 57% SAlanen, 2000 3 yr schoolchildren 5.0 g tablet 1.7/4.4 61% SMäkinen, 1995 3.3 yr schoolchildren 8.5 g gum 4.6/15.9 71% SMäkinen, 1996 2 yr preschool 10.7 g gum 17.6/50.2 65% S

relative caries reduction in recent studiesdose-response

threshold value – lower doses partly ineffective5-6 grams per day for a significant impact on oral ecologyhigher doses does not seem to increase effect

10 pelletsXylismile

6 pelletsXylimax

130 pellets

7 pellets

11 tablets

13 pellets

120 pellets

6 gram xylitol

V6

Xylifresh

Läkerol Plus

EXTRA

Bamse chewing gum

product

number of pellets/tabletslevel 1level 1

level 2level 2

level 3level 3

level 4level 4

xylitol and caries

inconclusive evidence for caries prevention and controlin children

interfere with mother-childmutans streptococci transmission

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pro bios = for life

lactobacillibifidobacteriastreptococci

human isolatesaciduricprevalent in oral cavity not genetically modified

L. reuteri prodentis

alternative way to combat infectious diseases

may reduce the use of antibiotics

bacteriotherapy, replacement therapy

prebioticspromote

probioticsreplace

antibioticskill/inhibit

living bacteria added to food with beneficial effects on general and oral health

synbioticsElie Metchnicoff (1845-1916)

Noble prize 1908

lactic acid bacteria in the gastrointestinal tract could improve wellbeing and prolong life

how does it work?probiotic organisms - mechanisms of action

competition with pathogens- nutrients- adhesion sites

production of antimicrobial substances

immunomodulation

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probiotics may affect oral cavity

direct contactlocal effect

systemic effectimmune modulation70%

mechanism of action

☺

☺plaque with cariogenic bacteria

enamel

H+H+

milk cheese yoghurt

1.5-2 dl (108 CFU/ml)/day

evidence of effects on general health - GI tract

preventive therapeutic_________________________________________________________

acute rotavirus diarrhea strong strong

non-atopic eczema suggested

Crohn’s, ulcerative colitis suggested

H. pyloris infections possible suggested

food allergies possible

infections (upper resp. tract) possible__________________________________________________________

probiotics and mutans streptococci

author, yr design n, age vehicle, time strain outcome_________________________________________________________________________________

Näse, 2001 RCT 594, 1-6 milk, 7m L rhamnosus GG MS decrease

Ahola, 2002 RCT 74, 18-35 cheese, 3w Lactobac mix MS decrease

Nikawa, 2004 crossover 40, 20 yogurt, 2w L reuteri MS decrease

Montalto, 2004 RCT 35, 23-37 liquid/capsules Lactobac mix LB increase

Caglar, 2005 crossover 21, 21-24 yogurt, 2w bifidobact MS decrease

Caglar, 2006 RCT 120, 21-25tablets, 2w L reuteri MS decrease

Caglar, 2007 RCT 80, 21-24 gums L reuteri (2 strains) MS discrease__________________________________________________________________________________

6 out of 7 studies demonstrated

decreased levels of salivary MS

short-term evaluations only

the Helsinki kindergarten study

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randomized double-blind placebo-controlled trial (L. rhamnosus GG) – 3-4 year-olds

n=5941 to 6-yr-olds at

Day Care Centers

BL 7 months

probiotic milk, 5 days/w

control milk, 5 days/w

6% new lesions

15% new lesions

(Näse et al., 2001)

additional effects

16% less absence from daycare due to illness

17% reduction in upper and lower respiratory infections

19% less antibiotics

Hattaka et al., 2001 Br Med J

level 1level 1

level 2level 2

level 3level 3

level 4level 4

probiotics and caries

insufficient evidence for caries prevention and control

reducing caries risk in preschool children

individuals stress brushing habits with F-toothpaste from 1st toothprofessional varnish applications when riskbaby bottle restrictions

vulnerable groupsearly start, outreach DHEany fluoride supplement

reducing caries risk in schoolchildren

individuals

F-toothpaste with parent’s assistfissure sealants when riskprofessional varnish applications

vulnerable groups

school-based F-tooth brushingschool-based FMR

risk reduction in adolescents

individual

empowerment of personal resources strongly review F-brushing habitsprofessional F-varnish applicationschewing gums

vulnerable groups

school-based F-rinses/F-varnish