Primary Preventive Dentistry: Indian Scenario

INDEXING

INTRODUCTION 1 Primary prevention 1 Secondary prevention 1 Tertiary prevention 1 CARIES 4 PERIODONTAL DISEASES 8 MALOCCLUSION 10 ORAL CANCER 13 DISCUSSION 15 DENTAL CARIES 16 Primary prevention of dental caries 17 Prevention and its levels 17 Community-, dental professional-, and individual-active measures 17 Caries Risk Assessment 18 Diet counseling 19 Sugar Substitute 20 Xylitol acts by 20 Anticipatory guidance/counseling 20 Fluoride 20 Mechanisms of Action 21 Topical fluoride 21 Sodium Fluoride (NaF) 22 Stannous Fluoride (SnF2) 22 Acidulated Phosphate Fluoride (APF) 22 Fluoride Varnishes 22 Fluoride-Releasing Dental Restorative Materials 23 Pit and fissure sealants 23 PERIODONTAL DISEASES 24 Primary prevention of periodontal diseases 25 Biofilm 25 Dental home 26 Dental health education 26 Promotion of research efforts 26 Lobby efforts: 26 Provision of oral hygiene aids 27 Brushing techniques 27 MALOCCLUSION 28 Malocclusion can be divided into genetic and Acquired 28 Primary prevention of malocclusion 28 Sports dentistry 29 Dental/Or official Trauma Prevention 29 ORAL CANCER 30 Healthy People 2000 Oral Cancer Objectives includes: 30 Primary prevention of oral cancer 30 Health education and motivation; 30 Awareness about a etiological factors 31 Alcohol Consumption 31 Sunlight (Actinic Radiation) 32 Diet and Nutritional Status 32 Viral Infections 32 Screening for oral cancer; 32 Counseling for cessation of habit; 33 SUMMARY 33 ANNEXURE 35 REFERENCES 36

DR. Parul Tyagi1 DR. Nikhil Srivastava2 DR. Vivek Adlakha3 DR. Noopur Kaushik 4

1Postgraduate, Dept. of Pedodontics, Subharti Dental College, Meerut 2Principal, Subharti Dental College, Meerut 3Professor Dept. of Pedodontics, Subharti Dental College, Meerut 4Reader Dept. of Pedodontics, Subharti Dental College, Meerut Primary Preventive Dentistry: Indian Scenario

INTRODUCTION

Prevention is defined as the action of stopping something from happening or arising. Prevention includes a wide range of activities -known as “interventions” - aimed at reducing risks or threats to health.

As a whole preventive healthcare (alternately preventive medicine or prophylaxis) consists of 1 measures taken for disease prevention, as opposed to disease treatment.

Prevention in healthcare is typically classified into primary prevention (avoiding disease through eliminating disease agents or increasing resistance), secondary prevention/ early detection and treatment, and tertiary prevention/ rehabilitation.

In the field of dentistry, preventive measures or care required to prevent disease of the teeth and supporting structures is known as preventive dentistry.

Primary prevention employs strategies and agents to prevent the onset of disease, to reverse the progress of the disease, or to arrest the disease process. e.g the use of a topical fluoride gel to prevent caries.

Secondary prevention employs action which halts the progress of a disease at its incipient stage and prevents complications. e.g use of remineralizing agents in incipient carious lesions.

Tertiary prevention employs measures necessary to replace lost tissues and to rehabilitate patients to the point that physical capabilities and/or mental attitudes are as near normal as possible after the failure of secondary prevention e.g fixed bridge.

Dental caries is a nonclassic infectious disease2 that results from an interaction between oral flora and dietary carbohydrates on the tooth surface. To adhere to tooth structure, oral flora utilize dietary sugars to create a sticky biofilm that is referred to as dental plaque. Dietary sugar can change the biochemical and microbiologic composition of dental plaque.

The understanding of normal dental flora serves as a foundation for the development of preventive strategies, with two important considerations. First, dental flora exists in symbiosis with the human species. Second, only a small number of the organisms within dental flora cause caries. Therefore, the objective is not to eliminate all dental flora, but to suppress the cariogenic bacteria within the flora.

Preventive strategies can be differentiated into two distinct categories. Primary prevention involves optimization of maternal dental flora before and during colonization of the oral flora of the infant (during eruption of the primary dentition). This invaluable mode of prevention provides an opportunity for a reduction in the mother’s constitutionally virulent, aciduric flora and down regulation of virulence genes within the aciduric flora, decreasing the child’s risk of dental decay, and is the basis for first dental visit recommendations at 1 year or earlier made by various medical and dental organizations.

Risk assessment is a key element of contemporary preventive care for infants, children, adolescents, and persons with special health care needs. Its goal is to prevent disease by identifying and minimizing causative factors (eg, microbial burden, dietary habits, plaque accumulation) and optimizing protective factors (eg, fluoride exposure, oral hygiene, 3 sealants).

An individualized preventive plan increases the probability of good oral health by demonstrating proper oral hygiene methods/techniques and removing plaque, stain, and calculus.4 Fluoride contributes to the prevention, inhibition, and reversal of caries.5 6 Professional topical fluoride treatments are based on caries risk assessment.

Primary Preventive Dentistry: Indian Scenario

Early diagnosis and management of incipient lesions can lead to new era in preventive dentistry in the form of remineralization. The best mode for caries management is use of remineralizing products. Presently fluoride, calcium phosphate-based systems, calcium sodium phosphosilicate, etc., that help in remineralization are available commercially. They are supplied in the form of dentifrices and rinses for personal use. Professional- ly, they are 7 used in the form of varnishes, solutions, gels and fluoride releasing restorative materials.

Despite diligent oral hygiene procedures, optimal fluoride environment and a realistic approach to dietary modifications, occlusal caries are inescapable for most children and adolescents as a result of the anatomy of pit and fissure surfaces, which favors stagnation of bacteria and substrates.8Sealants reduce the risk of pit and fissure caries in susceptible teeth and are cost-effective when maintained.9 They are indicated for primary and permanent teeth with pits and fissures that are predisposed to plaque retention.10 At-risk pits and fissures should be sealed as soon as possible. Because caries risk may increase at any time during a patient’s life due to changes in habits (eg, dietary, home care), oral microflora, or physical condition, unsealed teeth subsequently might benefit from sealant application.9 The need for sealant placement should be reassessed at periodic preventive care 10 appointments. Sealants should be monitored and repaired or replaced as needed.

Oral diseases are not life-threatening but they represent a major public health problem because of their high prevalence and significant impact on general health.11 Dental caries and periodontal disease are among the most widespread diseases in human population. The most common form of periodontal disease is gingivitis and, to a lesser extent, periodontal disease.12 Gingivitis is nearly universal in children and adolescents; it usually responds to thorough removal of bacterial deposits and improved oral hygiene. Hormonal fluctua- tions, including those occurring during the onset of puberty, can modify the gingival inflammatory response to dental plaque. Children can develop any of the several forms of periodontitis, with aggressive periodontitis occurring more commonly in children and adolescents than adults. The important risk factors for periodontal disease include poor oral hygiene, tobacco use, excessive alcohol consumption, stress, poor general health, diabetes mellitus, and HIV13. Maintenance of oral health is largely achieved through tooth brushing to provide plaque control (for gingival and periodontal health) combined with fluoride toothpaste (for caries prevention and treatment).14 Self-care should also be supported by a healthy diet, refraining from excessive alcohol intake or use of tobacco and regular visits to a dental professional to assess any disease activity or increased risk.

Oral cancer represents the eighth most common cancer worldwide among the male population. Alcohol consumption, cigarette smoking, oncogene viruses such as human papillomavirus, recurrent oral inflammation, and consumption of spices and betel nuts are the most documented risk factors associated with oral and oral pharyngeal cancers.15 Smoking and smokeless tobacco use are almost always initiated and established during adolescence. During this sensitive period of adolescence, they may be exposed to opportunities to experiment with other substances that negatively impact their health and well-being. Practitioners should educate the patients regarding the serious consequences of tobacco use, exposure to second hand smoke, alcohol and drug abuse. Dentists can display educational material on anti-tobacco themes in their clinics and hospitals and can sensitize youth groups to become efficient awareness generators in the community and monitor the implementation of tobacco control laws. When substance abuse has been identified referral 16 for appropriate intervention is indicated.

Guidance of eruption and development of the primary, mixed and permanent dentitions is an integral component of comprehensive oral health care for all pediatric dental patients. Early

Primary Preventive Dentistry: Indian Scenario

detection and management of oral conditions can improve a child’s oral health, general health and well-being.17 Delayed diagnosis of dental disease can result in exacerbated problems which lead to more extensive and costly care.18 Early diagnosis of developing 19 malocclusions may allow for timely therapeutic intervention.

Non – nutritive oral habits and pacifier habits may apply forces to teeth and dento alveolar structures. Although the use of pacifiers and digit sucking are considered normal, habits of sufficient intensity, duration and frequency can contribute to deleterious changes in occlusion and facial development.18 For school aged children and adolescents patient counselling regarding any existing habits (nail biting, bruxism, clenching) is appropriate. Early screening and diagnosis help in preventing and intercepting the severity of the 20 malocclusion which helps in addressing the esthetic and functional concerns.

Another important aspect of preventive dentistry is prevention for sports related injuries. All athletes consti- tute a population that is extremely susceptible to dental trauma. Dental injuries are the most common type of orofacial injury and an athlete has a greater chance of receiving an orofacial injury.Due to the high incidence of sports-related dental injuries, it is vital that primary healthcare providers such as school nurses, athletic trainers, team physicians, and emergency personnel are trained in the assessment and management of dental injuries. The main method for preventing orofacial injuries in sports is to wear mouthguards and headgear, consisting of a helmet and face protector. Parental perceptions of children’s risks to injury, expenses associat-ed with protective gear, and peer pressure may influence use of mouthguards. Players’ perceptions of mouthguard use and comfort largely determine their compliance and enthusiasm. Therefore, the dental profession needs to influence and educate all stakeholders about the risk of sports-related orofacial injuries and available preventive strategies. Routine dental visits can be an opportunity to initiate patient/parent education and make appropriate recommendations for use of a properly-fitted athletic mouthguard.

All health professionals emphasize that patients should seek entry into well-planned preventive programs. For dentistry, lack of prevention results in more restorations, periodontal problems, malocclusions, and occurrence of oral cancer. The changeover in priority from treatment to prevention will require active health promotion by the dental professionals.

Therefore this dissertation is planned with the aim to understand the importance and benefits of primary preventive dentistry.

The main goal of primary preventive dentistry is to emphasize on the importance of early detection and prevention of dental problems. The term “primary prevention” refers to actions taken before onset of disease, thereby preventing people from moving into groups at risk. Presented here are some studies and reviews on primary preventive considerations in paediatric and adolescent patients.

CARIES

• Shi S et al21 ( 1999) conducted “A study of the relationship between caries activity and the status of dental caries: application of the Dentocult LB method”. The authors concluded that as Caries Activ- ity Test (CAT) helps in the detection of Lactobacilli, it may reveal the status of dental cariesand provide valuable information for the prevention and treatment ofdental caries. • A study was conducted by Zero D et al22 (2001) to determine the predictive validity of currently available multivariate caries risk-assessment strategies. The authors concluded that in many instances, the use of a single risk indicator gave

Primary Preventive Dentistry: Indian Scenario

equally good results as the use of a combination of indicators and the best predictor of caries in primary teeth was previous caries experience, followed by parents’ education and socioeconomic status. • A study was conducted by Nishimura M et al23 (2008)to show the predictive abilities of a caries activity test (Cariostat, Dentsply-Sankin, Tokyo), and to include the predicted screening indexes which were based on previous caries activity test results and lifestyle factors. The authors concluded that early weaning, less sucrose intake and toothbrushing by parents were effective in reducing a child’s caries risk. • Tavares M and Chomitz V24 (2009) conducted a study on “A healthy weight intervention for children in a dental setting”. They tested the intervention with 139 children, ages 6 to 13, who returned for two or three visits over 18 months. At each preventive/diagnostic visit, a hygienist collected information about each child’s obesity risk factors with respect to food, physical activity, “screen time” and meal habits. They concluded that healthy eating and lifestyle also have potentially positive results for oral health and systemic health. Better food choices can reduce dental caries; while prevention of obesity-related systemic diseases, particularly diabetes, have an impact on oral health. • A study was conducted by Maltz M et al25 (2010)on “Health promotion and dental caries” and the authors concluded that oral hygiene is a major aspect when it comes to caries, since dental biofilm is its etiological factor. Oral hygiene procedures are effective in controlling dental caries, especially if plaque removal is performed adequately and associated with fluoride. An alternative to a more efficient biofilm control in occlusal areas is the use of dental sealants, which are only indicated for caries-active individuals. If a cavity is formed as a consequence of the metabolic activity of the biofilm, a restorative material or a sealant can be placed to block access of the biofilm to the oral environment in order to prevent caries progress.Berger et al26 (2010) conducted a cross-sectional study on “Are pit and fissure sealants needed in chil-dren with a higher caries risk?” to analyse the preventive need of pit and fissure sealants (PFS) in a German population with a relatively high caries risk. The authors concluded that children with at least one fissure sealant are less likely to have decayed fissures or fissures with non-cavitated lesions on their permanent molars. Therefore, PFS are needed and indicated in caries-risk children. • Simonsen RJ et al27 (2011) presented a review of the clinical application and performance of pit and fissure sealants and they summarized that the application of pit and fissure seal ant to newly-erupted posterior (and occasionally, anterior) teeth is the best method to prevent pit and fissure caries, and/or to prevent the continued development of incipient caries into frank caries when the incipient lesion is sealed over with resin. • Saxena S et al28 (2013) conducted a study on “Oratest: A new concept to test caries activity” and they concluded that a caries activity test helps in clinical management of patients as they determine the need and extent of personalized preventive measures. It also helps to motivate and monitor the effectiveness of educational programs related to dietary and oral hygiene procedures. • A study was conducted by Naidoo S et al29 (2013) on “Oral health and nutrition for childrenunder five years of age: a paediatricfood-based dietary guideline” and they concluded thatdiet and nutrition are associated with oral diseases such as dental caries, early childhood caries and dental erosion in children under five years of age. The authors recommended that evidence-based strategies to prevent

Primary Preventive Dentistry: Indian Scenario

and improve oral health and nutrition need to be integrated into policies, programmes and practices that reduce the overall caries burden. They further added that paradigm shift in health promotion and preventive initiatives is needed to promote oral health in children under five years of age, and to alleviate the barriers (physical, cultural, racial, ethnic, social, educational, environmental and those pertaining to health care) that prevent optimal oral health from being achieved. • Ahmadi-Motamayel F et al30 (2013) conducted a study on “Antibacterial Activity of Honey on Car- iogenic Bacteria” in which solutions containing 0%, 5%, 10%, 20%, 50% and100%(w/v) of natural Hamadan honey were prepared. Each blood (nutrient) agar plate was then filled with dilutions of the honey. Significant antibacterial activity was detected for honey on Streptococcus mutans in concentrations more than 20% and on Lactobacillus in 100% concentration (P<0.05). After getting these results, the authors concluded that antibacterial activity of honey can be used for prevention and reduction of dental caries. • Datta A and Datta G31 (2014) conducted a study on “Nutritional counselling in prevention of caries – a team approach” and they concluded that dental caries is a diet related disease that continues to be a problem for majority of the population. Therefore, the primary health care providers and dentists should thoroughly understand the relationship of diet to caries and conscientiously apply that knowledge to educate the patients in general as well as counsel the high risk individuals. Thus, a collab- orative effort is mandatory for the successful implementation of nutritional counseling in pediatric medical and dental settings as It is the time to think and act together. • A systematic review of studies in humans was conducted by Moynihan PJ and Kelly SAM32 (2014) on “Effect on caries of restricting sugars intake: systematic review to inform WHO Guidelines” and the authors concluded that there was a consistent evidence of moderate quality supporting a relationship between the amount of sugars consumed and dental caries development. Dental caries progresses with age, and the effects of sugars on the dentition are lifelong and there may be beneficial in limiting sugars to minimize the risk of dental caries throughout the life course. • A study was conducted by Tang LH et al33 (2014) on “Effectiveness of 3 different methods in prevention of dental caries in permanent teeth among children” to compare the effectiveness of fluoride van- ish, fluoride foam, pit and fissure sealant with fluoride in prevention of dental caries, and investigated appropriate approach to prevent dental caries at schools. The authors concluded that the placement of resin sealant with fluoride and annual application of fluoride protector are effective in prevention of dental caries in permanent teeth of children. • A study on “Association between knowledge of caries preventive practices, preventive oral health habits of parents and children and caries experience in children resident in sub-urban Nigeria” was conducted by Folayan MO et al34 (2014) and the authors concluded that there is a significant role of mothers in promoting adoption of caries risk preventive measures by children and maternal oral health behaviour is the most significant factor that had effect on the oral health behaviour of children aged • 8 years to 12 years of age. They also emphasized the important role of mothers in helping children develop good oral health practices.

Primary Preventive Dentistry: Indian Scenario

• Schroth RJ et al35 (2014) conducted a study on “PrenatalvitaminD and dental caries in infants” to determine the relationshipbetween prenatal vitamin D levels and dental caries among offspring during the first year of life. The authors concluded that prenatal vitamin D levels prevents ECC to develop. Spe- cifically, lower levels are associated with increased risk for dental caries in infants. Prenatal vitamin D levels, enamel hypoplasia, and infant age are independent predictors for caries. • Almasi A et al36 (2015) assessed the associations between nutrition and dental caries in permanent dentition among school children and they concluded that girls were at a higher risk of caries than boys and the nutritional status has a significant effect on caries in permanent teeth. They recommended that health promotion activities in school should be emphasized on healthy eating practices; especially by limiting sugar containing beverages between meals only. • A study was conducted by Kim MJ37 (2015)to estimate the fluoride intake from food and drink in • 5-year-old Korean children, and to measure the association between estimated fluoride intake and dental caries prevalence. The authors concluded that the estimated dietary fluoride intake via food was lower than the widely accepted optimal intake of fluoride, which is between 0.05 and 0.07 mg/kg of body weight.The higher prevalence of dental caries among children of lower dietary fluoride intake implies that the introduction of community caries prevention programmes such as fluoridation and fluoride supplementation should be considered. • A review was conducted by Fleming P38 (2015) on “Timetable for oral prevention in childhood—a current opinion” and the authors concluded that a child’s first dental visit should be at approximately • 12 months of age, and this should facilitate the provision of anticipatory guidance concerning oral health and dental development to the child’s parents/guardians. The authors also stated that the dietary advice and motivational interviewing proves to be helpful for parents to adopt good oral health practices for their children. They further added that toothbrushing using toothpaste that contains fluoride in the range of 1000–1500 ppm F also proves to be a most important preventive measure followed by the professional application of topical fluoride varnish twice yearly. • Algarni AA et al39 (2015) conducted a study on “The Impact of Stannous, Fluoride ions and Its Com- bination on Enamel Pellicle Proteome and Dental Erosion Prevention”. The authors concluded that acquired enamel pellicle (AEP) proteome varied according to the treatment received and all the tested rinses were able to reduce enamel erosion progression. The authors suggested that the formation of the AEP can contribute to the biological effect related to protection of enamel against erosion. • A study on “Xylitol-containing products for preventing dental caries in children and adults” was conducted by Riley P et al40 (2015)which included randomised controlled trials assessing the effects of xylitol products on dental caries in children and adults. The authors found that fluoride toothpaste containing xylitol are more effective than fluoride-only toothpaste for preventing caries in the permanent teeth of children, and that there are no associated adverse-effects from such toothpastes. • Gupta N et al41 (2015) conducted a study on “Radiation-induced dental caries, prevention and treatment - A systematic review” to understand the

Primary Preventive Dentistry: Indian Scenario

mechanisms underlying the development of radiation-induced caries including its prevention and clinical management. The authors concluded that radiotherapy leads to changes in dentition, saliva and oral microflora of head an neck cancers (HNC) patients. Radiation caries has multifactorial etiology, but hyposalivation remains the primary cause. Therefore, prevention of dentalcaries is achieved with comprehensive dental care before, during, and after radiation therapy. Motivation of patients, adequate plaque control, stimulation of salivary flow, and fluoride use are essential in reducing the incidence of radiation caries and improved quality of life of HNC patients. • Kakuda S et al42 (2015) conducted a study on “Buffering or non-buffering; an action of pit-and-fissure sealants” to evaluate the buffering capacity of glass- ionomer material in vitro. The authors concluded that the glass-ionomer countered the acid of the solution rapidly and preserved the structure of human tooth enamel. • A study aimed to assess the self-reported knowledge and attitude of dentists towards fluoride prescription was conducted by Pakdaman A et al43 (2015). A questionnaire survey was conducted at the national annual dental congress in Tehran-Iran in which a total of 347 dentists including 232 (73.4%) males and 84 (26.6%) females responded. The authors concluded that there was a good level of knowledge in dentists about preventive effect of topical fluoride and positive attitude towards fluoride application for children under 12 years of age. • Byeon SM et al44 (2016) conducted a study to assess the effect of single and combined applications of fluoride on the amount of fluoride release, and the remineralization and physical properties of enamel. They concluded that the combined topical applications of fluoride used in this study showed improved remineralization effects and strengthened enamel. They futher added that the combined applications of fluoride products and solutions could be used as the basis for designing more effective methods of fluoride application in protection against dental caries.

PERIODONTAL DISEASES

• Baehni PC and takeuchi Y45 (2003) conducted a study on “Anti-plaque agents in the prevention of biofilm-associated oral diseases”. The authors concluded that anti-plaque agents with properties other than bactericidal or bacteriostatic activities may be used in primary prevention.Chlorhexidine, hex- etidine, delmopinol, amine fluoride/stannous fluoride, triclosan, phenolic compounds, among others, may inhibit biofilm development and maturation as well as affect bacterial metabolism and plays an important role in prevention of oral diseases. • Igic et al46 (2008) conducted a study on “The importance of health education in prevention of oral health in children”. The authors stated that it is necessary to inform as many people as possible about oral hygiene effectiveness and its necessity in preventing oral and dental diseases, and to develop the habits of regular oral hygiene maintenance in the young children. They alsoconcluded thathealth education should be provided to the patients and parents and it should pointthe significance of proper nutrition, regular oral hygiene and fluoride prophylaxis, all aimed at preventing dental diseases. • Smutkeeree A et al47 (2011) conducted a study to compare the efficacy of the horizontal Scrub and modified Bass methods of toothbrushing in visually impaired students for 6 months. Sixty visually impaired students, aged 10–12

Primary Preventive Dentistry: Indian Scenario

years, were recruited to a randomized controlled clinical trial. At baseline, plaque index (PI) and gingival index (GI) were assessed, and then subjects were randomly divided into the horizontal Scrub and modified Bass groups. The authors concluded that both the horizontal Scrub and modified Bass methods effectively reduced plaque and gingival index in visually impaired students and the efficacy of both the methods was not different. • Another study was conducted by Nassar PO et al48 (2013) on” Periodontal evaluation of different tooth brushing techniques in patients with fixed orthodontic appliances”. The authors concluded that the Bass technique is effective on the reduction of periodontal clinical parameters of Plaque index and Gingival index in patients with fixed orthodontic appliances. • A study conducted by Poklepovic T et al49 (2013) on “Interdental brushing for the prevention and control of periodontal diseases and dental caries in adults” was aimed to evaluate the effects of interdental brushing in addition to toothbrushing, as compared with toothbrushing alone or toothbrushing and flossing for the prevention and control of periodontal diseases, dental plaque and dental caries. The authors concluded that there is a low quality evidence present which states that interdental brushing plus toothbrushing is more beneficial than toothbrushing alone for gingivitis and plaque at one month. Also, the evidence proved that interdental brushing reduces gingivitis when compared with flossing but these results were only found at one month. Also, the authors further stated that there was insufficient evidence to determine whether interdental brushing reduced or increased levels of plaque when compared to flossing. • Rath SK and SINGH M50 (2013) conducted a study on “Comparative clinical and microbiological efficacy of mouthwashes containing 0.2% and 0.12% chlorhexidine”. The authors concluded that the mouth rinses enhance the efficacy of plaque control when used as supplements to mechanical oral hygiene procedures. Thorough debridement consisting of meticulous root planing forms the basis of prevention in periodontal diseases. Therefore, using an additional adjunct like CHX helps to pevent the pathogenic microbial population. • Varela-Centelles P et al51 (2015) conducted a study on “Periodontitis Awareness Amongst the Gen- eral Public: A Critical Systematic Review to Identify Gaps of Knowledge” and they concluded that the number of available community-based investigations on periodontal knowledge is scarce. The results of this study also highlighted the need for local, community-based investigations about periodontal knowledge and the barriers hampering early diagnosis. • A literature review was conducted by Chalas R et al52 (2015) on “Dental plaque as a biofilm - a risk in oral cavity and methods to prevent”. Based on the literature analyzed, they concluded that the biofilm, due to its complex structure and numerous mechanisms of bacteria adaptation, is an effective barrier against the traditional agents with antibacterial properties. The use of antibacterial properties of na- no-silver used in dentistry significantly also reduces the metabolic activity and the number of colony forming bacteria and lactic acid production in the biofilm which in turn helps in prevention from periodontal problems. • Reza Karimi M et al53 (2015) conducted a study on “The Relationship Between Maternal Periodontal Status of and Preterm and Low Birth Weight Infants in

Primary Preventive Dentistry: Indian Scenario

Iran: A Case Control Study” to obtain information which is necessary for the planning of preventive programs of periodontal disease for pregnant women and the authors emphasized on the importance of periodontal care in prenatal health programs and also future research should focus on large-scale longitudinal studies, as well as interventional studies to determine that periodontal treatment or prevention reduces the risk for adverse pregnancy outcomes. • NagyP et al54 (2016)conducted a review study on “Evaluation of the efficacy of powered and manual toothbrushes in preventing oral diseases” on the basis of periodontal parameters and safety . They concluded that the investigated rotation oscillation and vibrating toothbrushes appeared to be statistically more effective in removing plaque , reducing gingivitis and preventing calculus formation than their manual counterparts. • A study was conducted by Jafer M et al55 (2016) on “Chemical Plaque Control Strategies in the Pre- vention of Biofilm-associated Oral Diseases” and they concluded thatadequate control of biofilm accumulation on teeth has been the cornerstone of prevention of periodontitis and dental caries. Mechanical plaque control is the mainstay for prevention of oral diseases, but it requires patient cooperation and motivation; therefore, chemical plaque control agents act as useful adjuvants for achieving the desired results. Hence, it is imperative for the clinicians to update their knowledge in chemical antiplaque agents and other developments for the effective management of plaque biofilm-associated diseases. • Malhotra R et al56 (2016) conducted a study on “Periodontal vaccine”. The authors concluded that vac- cines are generally prophylactic, i.e. they ameliorate the effects of future infection. One such vaccine they considered was the “Periodontal vaccine”. Till date, no preventive modality exists for periodontal disease and treatment rendered is palliative. Thus, availability of periodontal vaccine would not only prevent and modulate periodontal disease, but also enhance the quality of life of people for whom periodontal treatment cannot be easily obtained. There should be development of a multispecies vaccine targeting the four prime periodontal pathogens, viz. Porphyromonas gingivalis, T. forsythus, T. denti-cola and A. comitans which will prevent the periodontal diseases to develop.

MALOCCLUSION

• Stokes AN et al57 (1987) conducted a study on “Comparison of laboratory and intraorally formed mouth protectors”. One type of mouth protector was worn for 8 weeks and then exchanged for the other. The authors concluded that both mouth protector types prevented dental injury, but the laboratory type fit was better and was more comfortable. • A study on “the role of prevention and simple interceptive measures in reducing the need for orthodontic treatment” was conducted by Kerusuo H et al58 (2002). The authors concluded that attempts at prevention and early orthodontic intervention are generally successful in minimizing the detrimental dental and occlusal effects of nonnutritive sucking habits and early loss of primary molars. • A study was conducted by Bijoor RR and Kohli K59 (2005) on “Contemporary space maintenance for the pediatric patient”. The authors concluded that space maintenance forms an integral part of preventive and interceptive

Primary Preventive Dentistry: Indian Scenario

orthodontics. After the premature loss of a tooth, not only dospacemaintainers- maintainfunction and preserve arch length, they also maintain esthetics and eliminate any potential psychological damage a child could face as a result of the premature loss of teeth. The space maintain- erallows the permanent tooth to erupt unhindered into proper alignment and occlusion. • Gujjar KR et al60 (2012) conducted a study on “Modified distal shoe appliance- fabrication and clinical performance”. The authors concluded that when the primary second molar is prematurely lost, mesial movement and migration of the permanent first molar often occurs. This is one of the most difficult problems of the developing dentition confronted by pediatric dentists. Use of a space maintainer that will guide the permanent first molar into its normal position is indicated. In cases with bilateral premature loss of primary molars, the conventional design of distal shoe poses a variety of problems and, therefore, necessitates a customized design for the eruption guidance of permanent first molars which prevents malocclusion to develop during mixed dentition stage. • A study on “Modified Distal Shoe Appliance for Premature Loss of Multiple Deciduous Molars: A Case Report” was published by Bhat PK et al61 (2014). They stated that a primary second molar needs to be extracted prior to the eruption of the first permanent molar. It prevents the malocclusion to de- velope and provides increased stability and strength and less chairside time. The authors concluded that the modified distal shoe appliance is time efficient, more stable, better accepted by the child and meets all the criteria for proper space maintainer. • Ramagoni NK et al62 (2014) conducted a study on “Sports dentistry: A review” and they concluded that sports dentistry encompasses a wide range of preventive and treatment modalities of oral/facial athletic injuries and related oral diseases and their manifestations. Thus the pediatric dentist must possess a sound clinical working knowledge regarding sports-related orofacial injuries in children and adolescents and also the various methods of prevention as there is an increasing trend of sports partic- ipation in schools and colleges, protective devices and preventive options gain significance therefore, the pediatric dentist must work in close association with the teachers, coaches/trainers, parents, and other health professional to ensure comprehensive dent-facial care. Preventive programmers should include information regarding sports-related orofacial injuries, preventive measures like helmets and mouthguards, and their management, resulting in better awareness of the general population. They also emphasized that it is paedodontist’s responsibility to identify, educate, and provide the athletes preventive measures like mouthguards. • A retrospective study on “Association between breastfeeding duration, non- nutritive sucking (NNS) habits and dental arch dimensions in deciduous dentition: a cross-sectional study” was conducted by Agarwal SS et al63 (2014) and they concluded that an increased prevalence of NNS is a dominant variable in the association between breastfeeding duration and reduced intra-arch transverse diameters which leads to increased prevalence of posterior crossbites. The authors recommended that a child should not be breastfed for more than six months as he/she would develop non-nutritive sucking habbit. • Tiwari V et al64 (2014) conducted a study on “Dental trauma and mouthguard awareness and use among contact and noncontact athletes in

Primary Preventive Dentistry: Indian Scenario

central India”. The authors concluded that with the support of dentists and public health professionals, the risks of orofacial injury should be made known to athletes, parents, coaches, and school and college officials. Coaches and teachers should be encouraged to insist the players to wear mouthguards during training and matches. Also, the sports governing bodies and major games organizing committees should work with dental hospitals and colleges in taking a more active role in promoting programs to prevent oral injury and disease and in requiring mandatory mouthguard use. • Vidovik D et al65 (2015) conducted a study on “Prevalence and prevention of dental injuries in young taekwondo athletes in Croatia” which aimed to evaluate the occurrence of dental and facial injuries, the habit of wearing mouthguard and the awareness regarding injury prevention and first aid after tooth avulsion among young taekwondo athletes. The authors concluded thatTaekwondo players know the importance of mouthguard use, but only 5% use custom made mouthguards. This is not adequate for dental injury prevention and highlights the important role of dental professional in education of athletes for advocating the use of custom made mouthguards. • A study was conducted by Hermont AP et al66 (2015) on “Breastfeeding, Bottle Feeding Practices and Malocclusion in the Primary Dentition: A Systematic Review of Cohort Studies” The authors concluded that the scientific evidence could not confirm the types of malocclusion associated with bottle feeding or a proper period for breast feeding in order to protect against malocclusion. Until further studies are conducted to confirm the evidence related to the association between bottle feeding and malocclusion, exclusive breastfeeding for at least six months of age is still the best recommendation to benefit children regarding their systemic health. • Lopes-Freire GM et al67 (2015) conducted a study on “Exploring the association between feeding habits, non-nutritive sucking habits, and malocclusions in the deciduous dentition” and they concluded that there was no association between feeding habits and malocclusions in the deciduous dentition in this sample of children. However, exclusive breastfeeding reduces the risk of acquiring non- nutritive sucking habits. • Peres KG et al68 (2015) conducted a study on “Exclusive Breastfeeding and Risk of Dental Malocclu- sion”. They concluded that the detrimental effect of the pacifier seemed higher among children who received predominant breast milk compared with those receiving exclusive breast milk on malocclusion • Kataoka K et al69 (2015) conducted a studyto examine the association between self-reported bruxism and malocclusion in university students. Malocclusion was defined using a modified version of the Index of Orthodontic Treatment Need. The presence of buccal mucosa ridging, tooth wear, dental impression on the tongue, palatal/mandibular torus, and the number of teeth present were recorded, as well as body mass index (BMI). Additional information regarding gender, awareness of bruxism, orthodontic treatment, and oral habits was collected via questionnaire. The results of the study revealed that the proportion of students with malocclusion was 32% (n = 481).The authors concluded that awareness of clenching and underweight were related to malocclusion (crowding) in university male students. The awareness of clenching in males with malocclusion was significantly higher than in those with normal occlusion (chi square test, p < 0.01)

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• A study was conducted by Wang XT and Ge et al70 (2015) on “Influence of feeding patterns on the development of teeth, dentition and jaw in children”. They concluded that breastfeeding has been rec- ognized as the most natural and nutritious way of feeding babies. Bottle feeding has been proved to be closely related with the non-nutritive sucking habits which can cause malocclusion and it should be pointed out that breast feeding should be the only feeding source in the first 6 months of life, then supplementary foods should be added and prolonged bottle feeding should be avoided to prevent malocclusion. • A case report was published by Srivastava N et al71 (2016) on “Space Maintenance with an Innovative “Tube and Loop” Space Maintainer (Nikhil Appliance). The authors stated that premature loss of primary teeth results in disruption of arch integrity and adversely affects the proper alignment of permanent successors and they concluded that this innovative “Tube and Loop” space maintainer (Nikhil appliance) offers several advantages over the conventional band and loop SM. It is not only easy and quick to fabricate but can also be completed in a single sitting and cumbersome steps like impression making and laboratory procedures namely soldering are eliminated and it helps inmaintaining space created due to premature loss of primary teeth.

ORAL CANCER

• Macpherson LM et al72 (2003) conducted a study on “The role of primary healthcare professionals in oral cancer prevention and detection” to investigate current knowledge, examination habits and preventive practices of primary healthcare professionals in Scotland, with respect to oral cancer, and to determine any relevant training needs. The authors concluded that further training is required at both undergraduate and postgraduate levels to increase awareness of oral cancer and its associated risk factors, and to strengthen primary care practitioners’ abilities to diagnose potentially cancerous intra-oral lesions. • Cruz GD et al73 (2005)conducted a study to examine oral cancer prevention and early detection practice patterns in a population-based random sample of practicing oral health care professionals in New York state and they concluded that oral health care providers should be offered training in tobacco-use cessation and alcohol-abuse counselling. Also the oral health care providers should be encouraged to include these services as a standard aspect of their practice in order to help their patients avoiding not only the devastating consequences of oral cancer but also the myriad of other tobacco- and alcohol- in- duced oral diseases. • Peterson PE74 (2008) conducted a study on “Oral cancer prevention and control – The approach of the World Health Organization”. The authors concluded thatthe overall goal of cancer prevention and control is to reduce the incidence and mortality of cancer and to improve the quality of life of cancer patients and their families. A well conceived national cancer control programme is the most effective instrument to bridge the gap between knowledge and practice and achieve this goal. • A study was conducted by Pelucchi C et al75 (2009) on “Selected aspects of Mediterranean diet and cancer risk” and they concluded that in Mediterranean countries, olive oil is largely consumed and is the main source of monounsaturated fats. Olive oil has been shown to have a favourable

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influence on various neoplasms, including oral cavity and pharyngeal cancer possibly on account of its antioxidant properties attributable both to oleic acid itself and to the presence of other nutrients, such as vitamin E and polyphenols. • Rosseel JP et al76 (2011) conducted a study on “Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report”. The authors concluded that smoking contributes to the onset of oral cancer, increases the occurrence of periodontitis, raises the risk of periodontal attachment loss, formation of the periodontal pockets as well as alveolar bone loss, more dental implant failures, poor wound healing and discoloured teeth. They also mentioned that by stimulating the use of simple advice protocols, a good strategy develops to raise the involvement of dental professionals which would prevent tobacco addiction. The provision of smoking cessation advice and support can therefore only be improved via encouragement of interaction and communication between the different members of a dental care team. • Chainani-Wu N et al77 (2011) conducted a study on “Dietandprevention of oral cancer: strategies for clinical practice”. The authors concluded that a diet high in fruits, vegetables and plant-based foods is important for for prevention of oral cancer. Dietary supplements-including vitamins and minerals-have not been shown to be effective as substitutes for a diet high in fruits and vegetables. They also recommended that in addition to discussing tobacco and alcohol use with patients (and, if relevant, betel nut and gutka consumption), as well as the risk of sexual transmission of human papillo-mavirus, clinicians should provide dietary advice for the prevention of oral cancers as part of routine patient education practices. • A study was conducted on “Oral Cancer Awareness and Knowledge in the City of Valongo, Portu- gal”by Monteiro LS et al78(2012) by means of a questionnaire survey and they concluded that there is a general lack of awareness and knowledge on oral cancer among a population of Valongo. Almost all the individuals had never been submitted to oral cancer screening nor they had knowledge of been examined for case detection. Therefore, an oral health promotion strategy should involve elements of basic education on oral cancer as well oral cancer screening that should be implemented for this population. • Xu J et al79 (2014) conducted a review on “Meat consumption and risk of oral cavity and oropharynx cancer: a meta-analysis of observational studies”. The authors concluded that high consumption of processed meat was significantly associated with an increased risk of cancers of oral cavity, while there was no obvious association between total meat, red meat or white meat and the risk of oral cavity and oropharynx cancer. • A study was conducted by Mangalath U et al80 (2014) on “Recent trends in prevention of oral cancer” and they concluded that the key to prevent oral cancer is to educate the mass in the primary level to quit the etiological factors. Also, the mortality and morbidity of oral cancer can be significantly reduced if detected in early stages and the dentists alongwith dental hygienists are critical players for tobacco cessation methods. • Wollina U et al81 (2015) conducted a study on “Oral submucous fibrosis: an update” and they concluded that major constituents of betel quid are arecoline from betel nuts and copper, which are responsible for fibroblast dysfunction and

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fibrosis as the treatment of OSF is difficult and not many large, randomized controlled trials have been conducted. Therefore, in such cases prevention is most important, as no healing can be achieved with available treatments. • Aljabab MA et al82 (2015) conducted a study on “Evaluation of Oral Changes Among Tobacco Users of Aljouf Province, Saudi Arabia” which aimed to know the prevalence of tobacco associated changes among male population so they concludedthat use of tobacco can be positively correlated to the occurrence of various benign, premalignant and malignant oral changes. This study thus aids in creating awareness among the public regarding the deleterious effects of tobacco by motivating them for cessation of tobacco use. • Das S and shenoy S83 (2015) conducted a study on “Sneak PeekintoTobaccoHabitsandAssociatedIn- sidiousOralLesionsin an Odisha Sample Population”. They concluded that there is a need to spread the awareness of the ill effects of the tobacco and other associated habits far and wide and more impor- tantly educate the general public on the appearance of associated lesions as these are almost always insidious in nature with which the patients can self-examine, detect lesions early when present and approach the dentist at the earliest opportunity. • A study on “Greater access to information on how to prevent oral cancer among elderly using primary health care” was conducted by Martins AM et al84 (2015)to identify whether access to information regarding the prevention of oral cancer is greater among elders whose residences are registered with the (family health strategy) FHS. The authors concluded that there is a need to increase the provision of this preventive information by oral healthcare professionals, especially among those who did not live in registered residences, are socially disadvantaged, are tobacco users, and among those that report discomfort in the mouth, head and neck. • A study was conducted by Secchi DG et al85 (2015) on “Red meat, micronutrients and oral squamous cell carcinoma of argentine adult patients”. The authors concluded that high fruit and vegetable intake is inversely related to risk of oral squamous cell carcinoma while high consumption of red and processed meats and high-sugar foods has been associated with increased risk. • A study was conducted by Shaik SS et al86 (2016) on “Tobacco Use Cessation and Prevention - A Re- view”. The authors concluded that smoking or chewing tobacco can seriously affect oral, as well as general health and tobacco consumption is one of the main causes of oral cancer, a serious and growing worldwide problem therefore oral health professionals should take part in tobacco control initiatives and cessation programs. They should counsel their patients not to smoke; and reinforce the anti-tobacco message and refer the patients to smoking cessation services. Moreover, there should be availability of leaflets, brochures, continuing patient education materials regarding tobacco cessation.

DISCUSSION

In today’s scenario there is a considerable rise in the burden of oral problems like dental caries, periodontal disease, malocclusion and oral cancer which ultimately results in deprived quality of life. In perspective of oral health, people are affected mostly by periodontal diseases (90-95%) followed by dental caries (60-80%), malocclusion (30%) and lastly by oral cancer which accounts for almost (30-35%) of the total diagnosed cancer

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cases. The greatest burden of all these oral problems is on the deprived and socially 87 marginalized people.

Hence, the decision makers should encroach upon the various oral primary preventive measures and their applicability and should also assess the ongoing program for their future buttress.

The term prevention has its origin from a Latin word “praevenire” which denotes to stop 88 something from happening in the field concerned.

Although prevention of oral diseases is a dream that can be realized only by the combined actions of the dentist, the patient and the community, however it goes without objection that the dentist definitely plays the lead role. Dentists’ acquisition of knowledge and skills has constantly paved the path towards prevention. The trend from extraction to restoration and to prevention is a perfect example of the same. The dentist not only has re- sponsibilities towards progress of the profession but also has his share of duties towards improvement of oral health of the community. Leatherman, in 1979, rightly stated, “It is the dental professional’s responsibility to teach and motivate the patient and the whole community to 89 prevent dental diseases.

Primary preventive approaches have not only emerged as a supplemental measure to reduce the burden of dental diseases but also as a promise of predominant form of service of dental practice in the future.

The major primary prevention approaches can be broadly classified in the field of: Dental caries (tooth decay, cavities), periodontal disease (gum disease), malocclusion (crooked teeth) and Oral cancer.

DENTAL CARIES

Miller’s “chemoparasitic theory” states that caries is brought about by acid dissolution of mineral phase of teeth, the acid being produced by metabolism of dietary carbohydrates and oral bacteria. This theory emphasizes that there is an association between mineral content of teeth and dental caries.

Dental hard tissues are continuously undergoing cycles of demineralization and remineralization. A drop in pH of oral cavity results in demineralization which if continued leads to loss of minerals from tooth structure resulting in dental caries. The reversal of the process can occur if pH of the oral cavity rises resulting in deposition of calcium, phosphate and fluoride.90,91 Dental caries is a dynamic process which occurs when demineralization exceeds remineralization. But progression of dental caries is a slow process, however during early stages non-invasive intervention can convert the active lesion to inactive state.92 This principle is the key to preventive dentistry. The preventive approach of identification, conservative, non-restorative treatment of incipient caries saves both dental manpower for profession as well as expense and suffering for the patient.

The key microbial feature of dental caries is a dietary carbohydrate-induced enrichment of the dental plaque microbiota with bacteria such as Streptococcus sobrinus and Streptococcus mutans which are both acidogenic and acid tolerant (aciduric) and causes a shift toward aciduric organisms also promotes an increase in the proportion of lactobacilli, which are highly acidogenic in their own right.93 Although, lactobacilli are not regarded as important in the initiation of caries, their presence in large numbers indicates that the necessary environmental conditions for producing dental caries exist.94 Early childhood caries is associated with pain and tooth loss, as well as impaired growth, decreased weight gain, and negative effects on speech, appearance, self-esteem, school performance, and quality of

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life.95,96Dental caries disproportionately affects minority and economically disadvantaged children.97 Risk factors for dental caries include high levels of colonization by cariogenic bacteria, frequent exposure to dietary sugar and refined carbohydrates, sugar contained med- icines, inappropriate bottle feeding, low saliva flow rates, developmental defects of tooth enamel, previous caries, lack of access to dental care, low community water fluoride levels, inadequate tooth brushing or use of fluoride-containing toothpastes, lack of parental knowledge regarding oral health, and maternal risk factors, including caries, high levels of cariogenic bacteria, or poor maternal oral hygiene.98,99

Primary prevention of dental caries

Dental caries is one of the most prevalent diseases on the globe. Although all the preventive modalities are important, modification of diet is most important, followed by oral hygiene compliance and then administration of fluorides and application of pit and fissure sealants. Preventive strategies for this complex, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment.

Prevention and its levels

An integrated model for the opportunities for prevention, summarizes levels of prevention and target populations and specific interventions at every level of the approach100 .

Primary prevention refers to actions taken before onset of disease, preventing people from moving into groups at risk. Secondary prevention includes interventions to identify the early onset of disease and to reduce risk factors101. Primary and secondary preventive actions are of the utmost importance for the approach, because they are more affordable than interventions at other levels, and the population, or a significant part of it, benefits100. Other levels, with their target populations being people with diagnosed conditions and controlled disease, are also part of the approach: to prevent reoccurrence of disease and promote the oral health-related quality of life. The interventions of the last two levels are relatively expensive.

Community-, dental professional-, and individual-active measures

Effective preventive measures in dentistry have been developed and refined, some of them emphasising the role of community and dental professionals and others the patients’ own responsibility in managing oral diseases. Based on the role and responsibility of the main decision-maker to carry out preventive measures, these can be called community-, dental 102 professional-, or individual-active measures (Figure 1).

Community-active measures need approval to be adopted at a nationwide level, to be endorsed, and to be fund- ed and carried out for example preventive programmes in different settings such as school-based tooth-brushing and rinsing programmes, water, salt, and milk fluoridation need recommendation by professional organi- sations and approval by states to be adopted. Therefore, the main decision-maker is a person or organisation that may or may 102 not be affiliated with the dental profession, but holds a position of power.

Dental professional-active measures are those applied by dentists, hygienists, and dental assistants to individuals on a one-to-one basis, e.g., application of fluoridated (varnish, gels, and rinses) and antimicrobial (chlorhexidine) compounds and placement of sealants, based on an assessment of each individual’s risk, taking into consideration his or her current fluoride exposure. A decision-maker may have standards on how and when to use available preventive measures. Mostly, in any dental team, a dentist is the main decision-maker within the confines of his or her professional license. Individuals and patients are passive recipients 102 of the measures.

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Individual-active measures are any kind of oral hygiene measures such as toothbrushing and interdental cleaning performed by individuals, the home use of fluoridated toothpaste, fluoride compounds, antimicriob- al agents, and xylitol, and adoption of sensible use of sugary food. Dental professionals are responsible for providing information on healthy habits for dental well-being and for instructing and motivating individuals in order to modify detrimental behaviours and lifestyles toward oral health and to encourage healthy ones. They thus provide necessary knowledge to facilitate recipients’ making healthy decisions and choices for the benefit of their oral health. These measures, however, always require an active role and responsibility from individuals hence, the main decision-maker here is an individual.102

Caries Risk Assessment

Caries risk assessment, which is based on the developmental, biological, behavioral, and environmental factors, evaluates the probability of enamel demineralization exceeding enamel remineralization over time. The goal of risk assessment is to anticipate and prevent caries initiation before the first sign of disease. Assessing every child’s risk of caries and tailoring preventive strategies to specific risk factors are necessary for improving oral health in a cost-effective manner. A study by Zero et al103 evaluated the reliability of multiple risk indicators which determined that there is no consistent combination of risk variables that provide a good predictor of caries risk when applied to different populations across different age groups. The authors concluded that the best predictor of caries in primary teeth was previous caries experience, followed by parents’ education and socioeconomic status. Though, previous caries experience cannot be used as a risk indicator for the predentate or very young child, whitespot lesions, as precursors to cavities, can be considered analogous to previous caries experience when assessing the risk of a very young patient (Figure. 2). An analysis of National Health and Nutrition Examination Survey (NHANES) III data revealed that children from households with low income levels are more likely to experience caries and have higher levels of untreated caries than their counterparts 104 from higher-income households.

Caries risk factors unique to infants and young children include perinatal considerations, establishment of oral flora and host-defense systems, susceptibility of newly erupted teeth, dietary transition from breast and bottle feeding to cups and solid foods, and establishment of childhood food preferences. Although, preterm birth per se is not a risk factor, a child with low birth weight may require a special diet or have developmental enamel defects or disabilities that increase caries risk. Early acquisition of S mutans is a major risk factor for early childhood caries and future caries experience.105 A reduction of the salivary level of S mutans in highly infected mothers can inhibit or delay colonization of their infants.106 Although evidence suggests that children are most likely to develop caries if S mutans is acquired at an early age, this may be compensated in part by other factors such as good oral hygiene and a noncariogenic diet.107 High-risk dietary practices seem to be established early, probably by 12 months of age, and are maintained throughout early childhood.108 In addition to the amount of sugar consumed, frequency of intake is important. Sugar consumption likely is a more significant factor for those without regular exposure to fluorides.109 Children experiencing caries as infants and toddlers have a much greater 110 probability of subsequent caries in both the primary and permanent dentitions.

The chronic, complex nature of caries requires that risk be reassessed periodically to detect changes in the child’s behavioral, environmental, and general health conditions. All available data must be analyzed to determine the patient’s caries risk profile. Periodic reassessment

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allows the practitioner to individualize preventive programs and optimize the frequency of recall and dental radiographic examinations.

Diet counseling

Oral health is an integral part of general health and well-being of an individual, in which a major part is played by good nutrition which helps in the development and integrity of the oral cavity.111 A nutritious diet not only protects against other major health conditions, such as obesity, but it may also reduce dental caries.

Global economic growth has given rise to a new term “nutrition transition”. According to which, as incomes have risen and populations became more urban, there has been a shift in diet from complex carbohydrates, fibre, whole grains, vegetables and fruit to a Western diet that has a high proportion of fat, salt and added sugar.112,113 It also emphasizes to distinguish between sugar that is naturally present in vegetables, fruit, grains and milk for oral health and general health purposes (as evidence shows that these foods are not associated with dental 114 caries), and sugar that is added.

Sugars are a critical factor in caries development. Caries risk is greatest if sugars are consumed at high frequency and are in a form that remains in the mouth for longer periods.115 Sucrose is the most cariogenic sugar, because it can form glucan, which enables bacterial adhesion to teeth and limits diffusion and buffering of acids. Although starch-rich foods pose a low caries risk, mixtures of finely ground, heat-treated starch and sucrose (eg, 116 cereals, potato or corn chips) are also cariogenic.

Caries-active patients probably present the dietary component strongly involved in the carious process. It is necessary to evaluate patients’ dietary habits in order to propose realistic changes that may lead to the reestab- lishment of the balance between demineralization and remineralization. Advice to restrict the consumption of sugary snacks and drinks is part of general dietary counseling117 since diet is a common risk factor for other chronic diseases such as obesity and diabetes. Although some cut-off values have been suggested for the maximum frequency and amount of sugar to be consumed in order to prevent tooth decay (< 4 times/day; < 60 g/ day),118 one must remember that dental caries is a multifactorial disease, and other factors such as oral hygiene and access to fluoridated products are also determinants of the carious process and should be addressed for caries prevention and treatment.

Consumption of drinks containing sugars leads to a drop in the ph of dental plaque. Saliva flow and salivary components can neutralize this acid and usually within 20-30 minutes the pH of plaque reaches its resting level.119 However, the consumption of such drinks becomes dangerous when they are used frequently for a long time.34 In addition, sweet biscuits are identified as a factor increasing on the incidence of dental caries. It is very important to consider the consumption of this type of snacks, because they are widely available to all children in schools and can remain on the surface of tooth for hours in school time. Generally, this type of snack does not have much nutritional value and even can reduce food 120 intake at the mealtime.

Sugar should not be added to food or drink that is given to babies, as this can lead to tooth decay when the first teeth erupt. Governments should set stringent codes of practice on the sugar content of commercial baby food. Paediatric medicine and medicine that is sold over the counter should not contain sugar. Health professionals should always check if a medicine contains sugar and prescribe or offer sugar-free alternatives, wherever possible. In addition, government control on advertising, including on the internet, of sugar-rich items directed at

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children, needs to be implemented. Food manufacturers could produce low-sugar or sugar- 121,122 free alternatives to products that are rich in free sugars, including baby drinks.

Sugar Substitute

Xylitol is a naturally occurring pentilol which is a sugar substitute incorporated in chewing gums. Manton et al. showed that remineralization can occur with the use of sugar-free gum containing xylitol123.

Xylitol acts by

Reducing plaque formation

Making plaque less adhesive

Neutralize plaque acids by decreasing the production of lactic acid

Reducing the levels of streptococcus mutans

124,125 Increasing the salivary flow

Anticipatory guidance/counseling

Anticipatory guidance is the process of providing practical, developmentally-appropriate information about children’s health to prepare parents for the significant physical, emotional, 126,127 and psychological milestones.

Oral hygiene counselling involves the parents and the child. As the child develops, home care is performed jointly by parent and child. When a child demonstrates the understanding and ability to perform personal hygiene techniques, the health care professional should counsel the child. The effectiveness of home care should be monitored at every visit and a discussion on the consistency of daily preventive activities should be done.128,129

The evidence that suggests that prolonged and nocturnal breastfeeding is associated with an increased risk of early childhood caries is limited and inconsistent, and is based primarily on cross-sectional studies that rely on the retrospective recall of infant feeding practices.130-133 Furthermore, these studies and subsequent longitudinal studies have failed to adequately measure and control for confounding variables in their study design, such as dental hygiene practices, fluoride usage and dietary factors, including the intake of sugar-based food or beverages, and noncariogenic food, such as milk and dairy products. Scientific evidence of the beneficial effects of breastfeeding on general health is well accepted. Epidemiological studies have also shown minimal adverse effects from breastfeeding on caries 134-136 development.

The role of carbohydrates in caries initiation is unequivocal. Even acids in carbonated beverages and sports drinks can have a deleterious effect (ie, erosion) on enamel.137-139 Excess consumption of carbohydrates, fats, and sodium also contribute to poor systemic health.140-142 Dietary analysis and the role of dietary choices on oral health, malnutrition and obesity should be addressed through nutritional and preventive oral health counselling at 143 periodic visits.

Fluoride

The role of fluoride in protecting teeth against dental caries is well established, and optimal exposure to fluoride remains the cornerstone of caries prevention. Exposure to fluoride alters the sugar-caries relationship. When there is good exposure to fluoride, sugar

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consumption is a moderate risk factor for caries. With widespread use of fluoride, sugar consumption still has a role to play in the prevention of caries, but this role is not as strong as it is without exposure to fluoride.119 At a biological level, fluoride promotes the remineralisation and inhibits the demineralisation of the tooth structure. The sustained presence of low concentrations of ionic fluoride in the oral environment enhances remineralistaion and has a bacteriostatic effect.144 The twice-daily use of a pea-sized amount of fluoridated toothpaste is an important preventive practice to reduce dental caries and, if available, fluoride varnishes are also useful.145Improving access to affordable fluoride toothpaste is an essential component of a caries-prevention programme. As many countries are still undergoing nutritional transitions, they may not have adequate exposure to fluoride. Therefore, there is a call for the promotion of fluoride via appropriate vehicles, like affordable toothpaste, water, salt and milk. Water fluoridation, when feasible and culturally acceptable, could be considered as a public health option, particularly in 146 populations with high levels of caries.

The American Dental Association officially defines water fluoridation as “the adjustment of the natural fluoride concentration of fluoride-deficient water supplies to the recommended level for optimal dental health (Table 2).”147 It is a population-based method of primary prevention which uses piped water systems to deliver low- dose fluoride over frequent intervals. However, continued monitoring of fluoride exposure, especially from adjunctive sources like fluoride-containing dentifrices, is important in achieving the appropriate balance between maximum caries preventive benefit and minimal risk of fluorosis.

Mechanisms of Action

Systemic fluorides are beneficial in decay prevention in that they are ingested and incorporated directly into the hydroxyapatite crystalline structure of the developing tooth. The smaller fluoride ions replace hydroxyl ions in the crystalline structure of the tooth, producing a less-soluble apatite crystal.148,149 Over the past several decades, the caries- preventive properties of fluoride have been attributed primarily to its preeruptive effects on the developing teeth. But systemic fluorides also provide a topical effect resulting in marked post-eruptive benefits. Saliva, which contains fluoride from ingestion, is continually available at the tooth surface and becomes concentrated in dental plaque where it inhibits acid-producing cariogenic bacteria from demineralized tooth enamel. Fluoride accomplishes this by interfering with the enzymatic activity of the bacteria and by controlling intracellular pH, thus reducing bacterial acid production and thereby reducing dissolution of tooth enamel.150-152 (Figure 3).

Topical fluoride

Fluoride interacts with calcium and phosphate ions from saliva and adsorbs to the tooth surface, thereby en- hancing remineralization153. Recent research shows that remineralization represents the primary mechanism by which fluoride works, occurring after tooth eruption, and making the topical effect important in caries reduction for people of all ages. The U.S. Preventive Services Task Force (USPSTF) recommends that primary care clinicians prescribe oral fluoride supplementation starting at six months of age for children 154 whose water supply is deficient in fluoride. (Table 3)

Topical fluorides can be divided into

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• Professionally applied fluorides (neutral NaF, stannous fluoride, acidulated phosphate fluoride, amine fluoride, fluoride varnishes, fluoride gels).

• Self-applied fluorides (tooth brushing dentifrices and mouthwashes).

Sodium Fluoride (NaF)

This material is available in powder, gel, and liquid form. The compound is recommended for use in a 2% concentration, which may be prepared by dissolving 0.2 g of powder in 10 mL of distilled water. The prepared solution or gel has a basic pH and is stable if stored in plastic containers. Ready-to-use 2% solutions and gels of NaF are commercially available; because of the relative absence of taste considerations with this compound, these solutions 155 generally contain little flavoring or sweetening agents.

Stannous Fluoride (SnF2)

This compound is available in powder form either in bulk containers or preweighed capsules. The recommended and approved concentration is 8%, which is obtained by dissolving 0.8 g of the powder in 10 mL of distilled water. Stannous fluoride solutions are quite acidic, with a pH of about 2.4 to 2.8. Aqueous solutions of SnF2 are not stable because of the formation of stannous hydroxide and, subsequently, stannic oxide, which is visible as a white precipitate. As a result, solutions of this compound must be prepared immediately prior to use. As will be noted later, SnF2 solutions have a bitter, metallic taste. To eliminate the need to prepare this solution from the powder and to improve patient acceptance, a stable, flavored solution can be prepared with glycerine and sorbitol to retard hydrolysis of the SnF2 and with any of a variety of compatible flavoring agents. Ready-to- use solutions or gels with the proper SnF2 concentration, however, are not commercially 156 available.

Acidulated Phosphate Fluoride (APF)

This treatment system is available as either a solution or gel, both of which are stable and ready to use. Both forms contain 1.23% fluoride, generally obtained by the use of 2.0% sodium fluoride and 0.34% hydrofluoric acid. Phosphate is usually provided as orthophosphoric acid in a concentration of 0.98%. The pH of true APF systems should be about 3.5. Gel preparations feature a greater variation in composition, particularly with regard to the source and concentration of phosphate. In addition, the gel preparations 157 generally contain thickening (binders), flavoring, and coloring agents.

The European Academy of Paediatric Dentistry (EAPD) recommends to everybody, including pregnant women, the preventive use of fluoride toothpaste as a primary preventive measure against caries. The most effective way to prevent dental caries is tooth brushing twice a day. Children should only spit out the toothpaste and not rinse with water afterwards. Parents should start brushing children’s teeth with fluoride toothpaste as soon as the first tooth erupts in the concentration and quantity recommended by the EAPD (Table 4)158. Parents should use the recommended amount of toothpaste and assist or supervise their 159 children with tooth brushing at least up to the age of 7.

Fluoride Varnishes

Most varnishes contain 5.0% sodium fluoride (2.26% fluoride) and a typical application requires only 0.3 to 0.5 mL of the varnish, which contains 3 to 6 mg of fluoride. The application procedure involves cleaning the tooth surfaces by toothbrushing, painting the varnish on the teeth, and drying. The varnish is retained for 24 to 48 hours during which

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time fluoride is released for reaction with the underlying enamel. It is recommended that the applications be repeated at 4- to 6-month intervals.160 The efficacy of fluoride varnishes for caries prevention has been repeatedly demonstrated in Europe, where they have been in common use for many years, and the results of these studies have demonstrated a significant reduction in the incidence of dental caries and also have indicated that the magnitude of the benefit is related to the frequency of application, particularly in children at high risk for caries. Promising research has been conducted in the United States, specifically aimed at using fluoride varnishes as a preventive agent for children 161 at high risk for early childhood caries.

Fluoride-Releasing Dental Restorative Materials

Fluoride-releasing dental restorative materials may provide an additional benefit in preventive dentistry. Al- though not currently available in the United States, a fluoride- releasing amalgam has demonstrated recurrent caries inhibition at enamel and dentin restoration margins.162 Likewise, both chemical-cured and light-cured glass ionomer cements have demonstrated caries inhibition at enamel and dentin restoration margins.163- 165

Fluoride-releasing resin composites have also consistently demonstrated recurrent caries inhibition at enamel margins, yet there are conflicting results whether caries inhibition occurs at dentin margins.166,167 Preliminary studies indicate that glass ionomer cement and fluoride-releasing resin composite have synergistic effects with fluoride rinses and fluoridated dentifrices, in the remineralization of incipient enamel caries.168-170 The materials may act as a fluoride delivery system. Upon exposure to additional external fluoride, the material surface undergoes an increase in fluoride. This fluoride is subsequently released and has demonstrated demineralization inhibition and even remineralization at adjacent tooth structure. Further clinical research to evaluate these fluoride-releasing restorative materials 171 may provide more information for clinical recommendations.

Pit and fissure sealants

Fluorides are highly effective in reducing the number of carious lesions occurring on the smooth surfaces of enamel and cementum. Unfortunately, fluorides are not equally effective in protecting the occlusal pits and fissures, where the majority of carious lesions occur.172 Considering the fact that the occlusal surfaces consti- tute only 12% of the total number of tooth surfaces, it means that the pits and fissures are approximately eight times as vulnerable as the smooth surfaces. The placement of sealants is a highly effective means of preventing 173 these.

Deep pits and fissures (Deep, narrow I-shaped and K shaped) which are not accessible for cleaning, have the highest caries susceptibility and have always remained an area of concern for the dentists.174 Sealing of these caries susceptible sites is considered an effective method of caries prevention.175 Pit and fissure sealants are defined as the materials, which are placed in the pits and fissures of teeth in order to prevent or arrest the development of dental 176 caries.

A sealant is effective in preventing caries, only when it is successfully retained in the fissures. Hence, the retention becomes a major factor, influencing the efficacy of the sealant. The retention of resin based pit and fissure sealant is through micromechanical interlocking between the resin and the etched enamel. Mechanical retention of sealant is the direct result of resin penetration into the porous enamel forming tags. This occurs by capillary action. The resin monomer polymerizes and becomes interlocked with the enamel surface.177

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The cariostatic properties of sealants are attributed to the physical obstruction of the pits and fissures. This prevents colonization of the pits and fissures with new bacteria and also prevents the supply of fermentable carbohydrates so that any bacteria remaining in the pits 178 and fissures can not produce acid in cariogenic concentrations.

Indications include a deep occlusal fissure, fossa, or incisal lingual pit is present while sealants are not indicated in the cases where patient behaviour does not permit use of adequate dry-field techniques throughout the procedure, an open carious lesion exists, caries exist on other surfaces of the same tooth in which restoring will disrupt an intact sealant and 179 a large occlusal restoration is already present.

Educating parents and patients on the importance of dental sealants is critical. Parents are often unaware of the existence of dental sealants. Parents need to be informed about dental sealants before they can make an educated choice for their children.

PERIODONTAL DISEASES

Effective oral hygiene is a crucial factor in maintaining good oral health, which is associated with overall health and health-related quality of life.180 Poor oral health may affect appearance in terms of stained or missing teeth and can contribute to bad breath thus 181 negatively influencing confidence, self expression and communication.

Epidemiological studies like experimental gingivitis in human beings182 and clinical research studies have concluded that plaque is the etiological factor in gingival inflammation and has been found to be associated with the initiation and progression of periodontal diseases. On the basis that plaque-induced gingivitis pre- cedes periodontitis,183 the main stay of primary and secondary prevention of periodontal diseases is the control of supra gingival plaque.

Susceptibility to periodontal disease is variable and depends upon the interaction of factors such as genetic predisposition, smoking, stress, immunocompromising diseases and drugs, and certain systemic diseases, for example diabetes.184 Socioeconomic factors, for instance, educational and income levels have been found to be strongly associated with the prevalence 185 and severity of periodontal diseases.

Plaque is the primary cause of gingival disease. The other factors that can contribute to periodontal disease includes186:

• Hormonal changes, which occur during pregnancy, puberty, menopause, and monthly menstruation, makes gingiva more sensitive which is more susceptible for gingivitis to occur. • Illnesses such as cancer, HIV and diabetes which interfere with immune system. Patients with these diseases are at higher risk of developing infections, including periodontal disease. • Medications (atropine) could affect oral health because some drugs could lessen the flow of saliva, which has a protective effect on teeth and gums. Some drugs, such as the anticonvulsant medication, Dilantin and the anti-angina drug, Procardia and Adalat can cause gingival hyperplasia. • Habits such as smoking in which it is harder for gum tissue to heal itself. • Poor oral hygiene habits such as not brushing or flossing on a daily basis makes it easier for gingivitis to progress. • Family history of dental disease also act as a contributing factor for the development of gingivitis and periodontitis.

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Primary prevention of periodontal diseases

Prevention of gingivitis refers to inhibition of the development of clinically detectable gingival inflammation or its recurrence. It is currently unknown whether low levels of gingival inflammation are compatible with maintenance of oral health or should be considered a risk for development of periodontitis in susceptible individuals. Primary prevention of gingivitis aims to avoid the development of more severe and widespread forms of gingivitis that may ultimately convert to periodontitis.

The ultimate goal of periodontal disease prevention is to maintain the dentition over a lifetime in a state of health, comfort, and function in an aesthetically pleasing presentation. Primary prevention of periodontitis refers to preventing the inflammatory process from destroying the periodontal attachment; it consists of treating gingivitis through the disruption/removal of the bacterial biofilm and the consequent resolution of inflammation. In addition, adjunctive interventions including pharmacological modification of the disease- associated biofilm and host modulation have been explored.

Biofilm

Oral biofilm consists of oral bacteria, glucan and debris. Among these components, glucan is a key contribu-tor to the development of biofilm via formation of thick barrier. The biofilm of a healthy person maintains a balanced composition of bacterial species. However, when the conditions of the oral biofilm are changed by a sugar-rich diet, low pH and low saliva flow, the proportion of S. mutans in the oral biofilm increases compared to other streptococci. Also, continuous production of glucan and acid by S. mutans reduces the pH level and leads to formation of mature biofilm that ultimately induces dental caries. Therefore, the glucosyltransferases (Gtfs) and acid production are virulence factors of S. mutans. Cariogenic biofilm as oral biofilm including S. mutans is considered to be greater risk factor for induction of dental caries than planktonic S. mutans.187

Prevention of periodontal disease consists of patient-performed control of the dental biofilm and professional interventions. Following measures can be taken to prevent occurrence and prevention of periodontal diseas- es188;

• Daily mechanical plaque removal plays an important role in primary (managing gingivitis) and secondary (preventing recurrence of periodontitis) prevention and when correctly performed is effective in reducing plaque and gingivitis. • Professional oral-hygiene-instructions, helps and motivate the patients to achieve the required standard of plaque removal. This is best demonstrated in the patient’s own mouth and dentist should check whether the patient can achieve this prior to leaving the clinic. It also requires appropriate time within the treatment plan. • Patients should be informed that periodontal prevention is a life-long commitment and that reinforce-ment of techniques to improve efficacy is vital at recall appointments. • Both manual and power toothbrushes are effective in reducing plaque and gingivitis. • Re-chargeable power toothbrushes are slightly more effective at reducing plaque levels and gingival inflammation than manual brushes, but there is insufficient evidence at this time to recommend one brush design over another. Recommendations should also take account of financial costs and also patient dexterity/needs. • Daily interproximal cleaning is essential for maintaining interproximal gingival health, but it is not advised in periodontitis patients. Interdental brushes are the most effective method and the method of choice where spaces will accommodate

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their atraumatic use. However, dental floss is advised at healthy sites where interdental spaces may be too narrow to safely accommodate them. • 2 minutes brushing twice daily may be effective for primary prevention of periodontitis in low-risk groups. High-risk patients and secondary prevention require much longer period of brushing. • Chemical anti-plaque agents accompanied with mechanical plaque removal provide significant benefits in gingivitis management and preventing plaque accumulation. However, financial cost, environmental issues, side-effects, and the need for additional patient actions for mouth-rinse use should be borne in mind when making such recommendations.

“Home care” means the sum effect of motivation, knowledge, oral hygiene instruction, oral hygiene aids and motor skill. Tooth-brushing and other mechanical cleansing procedures are the most reliable means of controlling plaque at home.

Dental home

The American Academy of Pediatric Dentistry (AAPD) and the American Dental Association (ADA) support the concept of a “Dental Home,” which is the is the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way. Establishment of a dental home begins no later than 12 months of age and includes referral 189 to dental specialists when appropriate.

There is a strong correlation between brushing frequency and the reduction in plaque/gingivitis on the buccal surfaces. The vast majority of self-taught toothbrushers begin by scrubbing the buccal surfaces, especially at the frontal region, and rarely proceed to the lingual surfaces. Interproximal cleaning is simply non-existent in the self-taught.190 Ramya191 presented an overview on the applicability of various primary preventive measures for oral diseases at public/community level in India (Table. 5).

Dental health education

This should aim at providing dental health education programs, stressing on the plaque control measures with repeated instructions and demonstrations to maintain oral hygiene. According to Chawla192, frequent professional scaling and regular tooth brushing are the main public health measures available for preventing and controlling periodontal disease. However, more intensive measures (quarterly prophylaxis) will further improve the 193 periodontal health and lessens the calculus accumulation.

Promotion of research efforts

While there is adequate information to commence programs for the primary prevention of gum disease in India, but research is needed to better inform policies and strengthen programs. Research must also identify economic and acceptable methods by the public for utilizing the primary preventive dental services. It is also important to focus on the interventional programs towards tobacco control as it is one of the promoting factors for gum diseases.

Lobby efforts:

It is the role of dental and other allied members to influence the government and other agencies to initiate the programs against the agents that are detrimental to oral health. Efforts should be made for prohibition of tobacco and its products which are harmful to periodontal

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health. Hence, there is a need for positive lobby efforts towards tobacco cessation and other 194 agents which are detrimental to periodontal health.

As smoking is a risk factor shared among several of the most prevalent diseases of mankind including periodontitis, avoiding tobacco consumption also contributes to periodontitis prevention. A systematic review by Ramseier and Suvan195 identified strong evidence that brief interventions in the dental setting increase the smoking cessation rate.

Provision of oral hygiene aids:

Oral hygiene aids are the tools used in the mouth to remove food residue and plaque, a bacterial film that causes dental caries, periodontal disease, and halitosis. Toothbrush, dental floss and mouth rinse containing fluoride are the primary oral hygiene aids for this process. Hence, programs at public level should target the populations at high risk for gum diseases who cannot maintain or prevent these such as handicapped, medical- ly compromised, people of poor socio-economic status, remote communities, also school 196 children, should be provided with the necessary oral hygiene aids.

The objectives of toothbrushing are to

• Remove plaque and disturb reformation. • Clean teeth of food, debris, and stain. • Stimulate the gingival tissues. • Apply dentifrice with specific ingredients to address caries, periodontal disease or sensitivity.

Brushing techniques

There are several manual toothbrushing techniques. They include the horizontal scrub, Bass, Stillman, Char- ters, and Fones, to name a few. The most popular method that an uneducated patient uses is the horizontal scrub. Unfortunately, gingival and enamel damage can occur with aggressive strokes and too firm of bristles. The Stillman method is used for massage and stimulation of the gingiva with a 45 degree angle of the bristles and a vibratory/ pulsing method. The Charters method also involves a 45 degree angle with the bristles and a rotary or vibratory motion forcing the bristles interproximally. The Charters method can be recommended for orthodontic patients to clean ortho brackets and bands. A preferred method for adults is the Modified Bass Method. This method was the first to focus on the removal of plaque and debris from the gingival sulcus with the combined use of the soft toothbrush and dental floss. The method is effective for removing plaque at the gingival margins and controlling plaque that leads to periodontal disease and caries. In the Bass technique, the toothbrush is positioned in the gingival sulcus at a 45-degree angle to the tooth apices. A vibratory action, described as a back and-forth horizontal jiggle, causes a pulsing of the bristles to clean the sulcus. The term ‘modified’ indicates a final ‘sweep’ with the toothbrush toward the occlusal surfaces to remove debris subgingivally. Ten strokes are recommended for each area. This is the only toothbrush method that places the toothbrush bristles into the sulcus. For children, the rotary method called the Fones technique is 197 preferred since children do not have the manual dexterity for a more advanced technique.

The Fones technique is a circular method similar to the motion of the old rotary telephone. The teeth are clinched and the toothbrush is placed inside the cheeks. The toothbrush is moved in a circular method over both the maxillary and mandibular teeth. In the anterior region, the teeth are placed in an edge-to edge position and the circular motion is continued. Children adapt to this technique rather quickly.198

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MALOCCLUSION

Millions of individuals worldwide are suffering from orthodontic problems, it is not a disease but a mor- phological variation which may or may not be associated with pathological conditions. It is one of the most prevalent oral pathologies, next to dental caries and periodontal disease and is usually ranked third among worldwide public health dental 199 disease priorities.

Malocclusion can be divided into genetic and Acquired

Acquired causes of malocclusion include early loss of deciduous teeth, late eruption of the permanent teeth, early loss of the permanent teeth, dental caries (proximal), loss of mesio-distal diameter of the teeth and co-incidental retardation of the antero-posterior development of the jaw, improper restoration of lost tissue, mouth-breathing and habits.

Preservation of a healthy primary dentition until the time of normal shedding is of the utmost importance for normal eruption of premolars and canines.200 Loss of interproximal tooth material due to untreated caries of primary molars or premature extractions of these teeth is associated with mesial migration of the permanent molars. The consequence may be a shortening of the dental arch, crowding of the permanent dentition and alteration of the anteroposterior molar relationships.201,202 The risk may be particularly high if the events occur early, before the eruption of the first permanent molars. In addition, preexisting crowding may accentuate the potential for space loss. Although a recent study in a ‘caries-affected’ group of children suggests that mandibular crowding is more frequent than maxillary, it is 203 generally accepted that the risk of space loss is highest in the maxillary arch.

Primary prevention of malocclusion

Routine use of space maintainers has been recommended following any early loss of primary molars more than 6 months before the expected eruption of the permanent successors. The space may be maintained with fixed as well as removable appliances. The advantage of fixed designs is that they are less dependent on patient cooperation compared to removable ones. Removable space maintainers have also been suggested to prevent the increase in intercanine arch width and length during the transition period from the primary to the permanent 204 dentition.

Extraction of primary teeth can be planned in a sequential manner followed by extraction of first premolars to allow the normal alignment of permanent teeth, provided the arch length 205 discrepancy is identified at an early stage. This is called as serial extraction.

Serial extraction is indicated when a Paedodontist sees a child 5 or 6 years of age with all the deciduous teeth present in a slightly crowded state or with no spaces between them, he can predict, with a fair degree of certainly, that there will not be enough space in the jaws to accommodate all the permanent teeth in their proper alignment while it is not indicated when there is Congenital absence of teeth providing space, mild to moderate crowding, deep or open bites, severe class ii, iii of dental/skeletal origin, cleft lip and palate, spaced dentition, anodontia / oligodontia, midline diastemia, dilacerations, extensive caries and 206 disportion between arc length and tooth material which can be treated by serial extraction.

Advantages of Serial Extractioninclude: psychological trauma can be avoided by treatment, reduces the duration of the multi banded treatment, physiologically treatment as it involves the guidance of teeth into normal positions making use of physiological forces, better oral 207 hygiene and more stable results.

Disadvantages of Serial Extraction: Patient co-operation is needed, risk of arch length reduction is present, requires proper professional and clinical judgment, as extraction spaces

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are created the patient may develop the tendency of tongue thrusting and spacing may 207 develop between canine and second premolar.

Complication of serial extraction – when premature eruption of permanent canines occur, 208 the first premolars are impacted between the canines and the second premolars.

According to Graber, the best stage for diagnosing definitive primary crowding, and for initiating the serial extraction protocol is, undoubtedly, the stage when the permanent 209 incisors erupt into the oral cavity.

Guidance of eruption and development of the primary, mixed, and permanent dentitions is an integral component of comprehensive oral health care for all paediatric dental patients.210 Early diagnosis and successful treatment of developing malocclusions can have both short- term and long-term benefits, while achieving the goals of occlusal harmony and function and dentofacial esthestics.211-213 Early treatment is beneficial for many patients, but is not indicated for every patient. When there is a reasonable indication that an oral habit will result in unfavourable sequelae in the developing permanent dentition, any treatment must be appropriate for the child’s development, comprehension, and ability to cooperate. Use of an appliance is indicated only when the child wants to stop the habit and would benefit from 214 a reminder.

At each stage of occlusal development, the objectives of intervention/treatment include:

• Reversing adverse growth • Preventing dental and skeletal disharmonies • Improving esthetics of the smile • Improving self-image • Improving the occlusion.

Non–Nutritive oral habits and pacifier habits may apply forces to teeth and dentoalveolar structures. Although the use of pacifiers and digit sucking are considered normal, habits of sufficient intensity, duration and frequency can contribute to deleterious changes in occlusion and facial development. So it becomes important to discuss the need to wean from the habits as early as possible (by 3years of age).215 For school aged children and adolescents patient counselling regarding any existing habits (nail biting, bruxism, clenching) is appropriate. The consequences of eating or drinking acidic foods should be elaborated to the 216 children.

Sports dentistry

According to the International Academy for Sports Dentistry, the main goals of sports dentistry include prevention and treatment of sports related dental/orofacial injuries, information collection, information dissem- ination and promotion of research on the preventive procedures related to injuries of such a specific aetiology.217 The maxillary incisors are the most frequently injured teeth in the primary and permanent dentition. Teenage years cause a significant number of dental injuries as they engage in contact sports. Children with accident prone profile, i.e. class II division I or class I type II malocclusion are more prone for injuries because of the proclined incisors.218Traumatic injuries to the young permanent teeth are common and affect about 30% of the children.219

Dental/Orofacial Trauma Prevention

Mouth guard is meant to act as a buffer by moving the soft tissues in the oral cavity away from the teeth preventing lacerations, bruising of lips, cheeks, and tongue during an impact.

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It is supposed to prevent tooth fractures or dislocations by cushioning the teeth from direct frontal blows while redistributing the force of the blow over all the teeth. Opposing teeth are protected from seismic contact with each other. Mandible is afford- ed elastic, recuperative support can prevent fracture or damage to the unsupported angle of the lower jaw.220

ORAL CANCER

Each year, oral cancer kills more people than does cervical cancer, malignant melanoma,221 or Hodgkin’s disease. Oral cancers usually involve the tongue, lips, floor of the mouth, soft palate, tonsils, salivary glands, or back of the throat.

Theoretically, morbidity and mortality due to oral cancers can be reduced dramatically with appropriate interventions; because of this, potential of the objectives in Healthy People 2000222 relate to oral cancer prevention and early detection.

Healthy People 2000 Oral Cancer Objectives includes:

• Increase complex carbohydrates and fiber containing foods in the diets of adults to 5 or more daily servings for vegetables (including legumes) and fruits, and to 6 or more daily servings for grain products. • Reduce the initiation of cigarette smoking by children and youth so that no more than 15% have be-come regular cigarette smokers by age 20. • Reduce smokeless tobacco use by males aged 12 through 24 to a prevalence of no more than 4%. • Increase to at least 75% the proportion of primary care and oral health care providers who routinely advise cessation and provide assistance and followup for all of their tobacco-using patients. • Reduce the proportion of high school seniors and college students engaging in recent occasions of heavy drinking of alcoholic beverages to no more than 28% of high school seniors and 32% of college students. • Reduce alcohol consumption by people aged 14 and older to average of not more than 2 gallons of ethanol per person per year. • Increase to at least 75% the proportion of primary care providers who screen for alcohol and other drug use problems and provide counselling and referral as needed. • Increase to at least 70% the proportion of people aged 35 and older using the oral health care system during each year. • Increase to at least 40% the proportion of people aged 50 and older visiting a primary care provider in the preceding year who have received oral, skin, and digital rectal examinations during one such visit.

Primary prevention of oral cancer

1. Health education and motivation 2. Awareness about various aetiological factors 3. Screening of patients 4. Counselling for cessation of habit

Health education and motivation

It should be imparted to masses with the help of various communication media like television, radio, newspa- pers, films, posters, folk dramas and lecture demonstration series. Health education encompasses the following aspects;

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• Programmes to educate adolescents including school children against tobacco use with the aim of pre-venting them from acquiring them from acquiring any tobacco taking in any form of habits. • Educational programmes for current tobacco users to stop or decrease their use of tobacco including their family members. • People should be educated about warning signals of oral cancer so that they can do the self examination and report at the earliest for necessary investigation and required treatment. • The importance of regular oral check-up by a qualified dental surgeon should be emphasized. • Importance of good oral hygiene and role of diet and nutrition in prevention of oral cancer should be emphasized. • Importance of various sources of proteins, vitamins, minerals and trace elements, balanced diet, as well as right method of cooking and preserving the nutrient of food items is not well understood by people, hence these aspects should be stressed.

Awareness about aetiological factors

Primary prevention focuses on avoidance of known aetiological factors and alterations in lifestyle to prevent cancer developing in the first place. This is particularly important because oral cancer is one of the few cancers with a high potential for prevention. The main aetiological factors implicated in oral cancer aretobacco use, alcohol consumption, sunlight, diet and nutritional status, chronic candidal infection, viral infection and immune 223 deficiency

It was only in the late 1950s that one of the main aetiological factors in the development of oral cancer was discovered. Smoking (cigarettes, cigars, pipes), reverse smoking and tobacco chewing are all associated with oral cancer in those patients who are susceptible to the carcinogens contained in tobacco. The risk of developing mouth cancer rises with increasing intake, although there is great variation between reports on how intake affects the relative risk. However, oral cancer is not common amongst non-users of tobacco.

Alcohol Consumption

An independent causative role for alcohol is less clear, mainly due to the fact that most heavy drinkers also smoke. There is a definite synergistic effect between alcohol and tobacco (increasing the risk 324), which is much intake, although there is great variation between reports on how intake affects the relative risk. One estimate puts the risk of a person who smokes more than 20 cigarettes a day of developing the disease at 10 times that of a non-smoker. The difficulty of accurately assessing daily use of tobacco over a number of years and the honesty (or memory) of the individual may blur the issue. However, oral cancer is not common amongst non-users of tobacco. greater than the risk of alcohol alone (∞2.5) or tobacco alone (∞10). This is thought to be due in part to alcohol acting as a solvent for the carcinogens in tobacco. Religious groups that do not take alcohol or tobacco show a decreased risk of developing oral cancer.

The exact mechanism by which alcohol exerts its effect is unknown. The bulk of alcohol is metabolized in the liver, although extrahepatic metabolism (including in the oral mucosa) is known. Normally alcohol is metabolized to acetaldehyde, which has been shown to be mutagenic (although pure ethanol has not). Varia- tion between individuals in isoenzymes responsible for the metabolism of alcohol may explain differences in susceptibility to cancer. The various mechanisms by which alcohol may affect the oral mucosa are reviewed elsewhere.

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Sunlight (Actinic Radiation)

The incidence of lower lip cancer is higher in Caucasians in sunnier climates, and fair- skinned people are ad-vised to wear sunscreen to prevent actinic damage.224

Diet and Nutritional Status

There have been numerous studies indicating a relationship between chronically low vitamin A or betacaro-tene plasma levels and oral cancer. Other epidemiological studies suggest that micronutrients such as selenium may also protect against cancer. Studies on diet and nutritional state are difficult because few centres regularly assess these factors in their patients with oral cancer. Some studies have found that eating fresh fruit and vegetables lowers the risk; however, the daily amount required to confer protection is not known. Lucenteforte et al225 noted a consistent decrease in risk with increasing consumption of fruits and vegetables.The antioxidants vitamin C, beta-carotene and vitamin E may be protective factors. Although some vegetables may be high in nitrates and nitrites (which have been associated with upper aerodigestive tract cancers), the overall effect of increased intake is to 226 reduce susceptibility.

Dietary iron may play a role in maintaining epithelial thickness. Deficiency of iron is said to lead to upper aerodigestive tract cancers (Plummer-Vinson or Brown Kelly Patterson syndrome: a rare combination, particularly affecting northern European women, of glossitis, dysphagia and hypochromic anaemia, in which post- cricoid carcinoma develops). Recent case-controlled studies have found an increased risk for head and neck cancers in 85 patients with high fat and red meat intake.

Viral Infections

Despite various candidate viruses (e.g. Epstein-Barr virus, cytomegalovirus, herpes virus) there is no strong evidence for an important association between oral cancer and viral infection. Although in one study, RNA complementary to herpes virus DNA was found in oral cancer (and not the normal mucosa), it may still be a passenger and not active. Indeed, oral cancers do not commonly arise in the intra-oral sites of previous her- petic infection. Oncogenic human papilloma viruses (HPV) have been detected in oral cancer (usually HPV6, HPV16 and HPV18) but these viruses may also be found in normal oralmucosa. HPV may help promote cancer by blocking tumour suppressor gene function. However, the fact that a virus cannot be detected does not necessarily exclude its role, as it may have exerted an influence previously (the hit and run theory).227

Screening for oral cancer;

Early diagnosis is ensured by the prompt response of patients and healthcare professionals to early signs and symptoms in order to facilitate diagnosis and treatment before the disease becomes advanced.

• A sore that bleeds easily or does not heal. • A colour change of the oral tissue. • A lump thickening, rough spot, crust, or small eroded area. • Pain, tenderness or numbness anywhere in the mouth or on the lips.

Dentists can perform quick, painless tests, such as a brush biopsy in which tissue specimens, taken from the mouth by a brush, undergo computer analysis to determine the presence of precancerous or cancerous cells.

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Knowing the risk factors and taking steps to prevent potentially cancerous lesions from developing can go a long way towards limiting the influence of oral cancer that could affect the people’s life. Counselling for cessation of habit;

Tobacco cessation is essential to reduce the mortality and morbidity related to tobacco use. Presently, India has about 18 Tobacco Cessation Clinics (TCCs) across the country. This clearly is an inadequate effort taking the existing 250 million tobacco consuming population into consideration.

The tobacco use cessation practices are based on the U.S. Department of Health and Human Services (DHHS) Public Health Service clinical practice guidelines, “Treating Tobacco Use and Dependence.” These guidelines include a list of activities and behaviours called “the five As”228: –

• Ask the patient about his or her tobacco use • Advise the patient to quit • Assess the patient’s willingness to make a quit attempt • Assist in the quit attempt • Arrange follow-up contact, preferably within the first week after the quit date. The clear link between oral diseases and tobacco use provides an ideal opportunity for oral health professionals to partake in tobacco control initiatives and cessation programs. They should counsel their patients not to smoke; and reinforce the anti-tobacco message and refer the patients to smoking cessation services. Moreover, there should be availability of leaflets, brochures, continuing patient education materials regarding tobacco cessation.

SUMMARY

Prevention is defined as the action of stopping something from happening or arising. Prevention includes a wide range of activities — known as “interventions” — aimed at reducing risks or threats to health.

In perspective of oral health, most of the people are affected with the common oral problems like periodontal disease (90-95%) followed by dental caries (60-80%), followed by malocclusion (30%) and lastly by oral cancer which accounts for almost 30-35% of the total diagnosed cancer cases. However, most of the studies have shown that, greatest burden of all these oral problems is on the deprived and socially marginalized people.

Oral health is a vital part of general health and hence affects the total well-being of individuals. Oral health promotion is aimed at four preventable oral diseases: dental caries, disease of supporting structures, oral pharyngeal cancers, and malocclusion. This is known as ‘felt need’. The overall aim of oral health promotion is to influence the social norms of a community towards change and improvement (e.g. water fluoridation, smoking cessation, etc.). The need for a dental health programme to target this specific segment of the population should be through systematic public and school oral health promotion programmes.

Dental caries is one of the most prevalent diseases on the globe. Preventive strategies for this complex, chronic disease require a comprehensive and multifocal approach that begins with caries risk assessment. Although all the preventive modalities are important, modification of

Primary Preventive Dentistry: Indian Scenario

diet is most important, followed by oral hygiene compliance and then administration of fluorides and application of pit and fissure sealants. By controlling these risk factors before disease occurs, the probability of preventing disease, both in the immediate future and the long-term, is improved.

Inadequate oral hygiene is predictive of gingivitis, and also mild to moderate chronic periodontitis. Main- taining good oral hygiene is one of the most important regimen for healthy teeth and gums. Prevention of periodontal disease consists of patient-performed control of the dental biofilm and professional interventions. Daily mechanical and chemical plaque removal plays an important role in primary (managing gingivitis) and secondary (preventing recurrence of periodontitis) prevention and when correctly performed is effective in reducing plaque and gingivitis. Also, professional oral-hygiene-instructions, manual and power brushes, daily interproximal cleaningand chemical anti-plaque agents are essential for good oral hygiene maintenance.

Malocclusion being one of the most prevalent oral pathologies, next to dental caries and periodontal disease is usually ranked third among worldwide public health dental disease priorities. Malocclusion further can be divided into genetic and acquired.

Prevention of malocclusion includes routine use of space maintainers following any early loss of primary molars more than 6 months before the expected eruption of the permanent successors. The space may be maintained with fixed as well as removable appliances. Extraction of primary teeth planned in a sequential manner followed by extraction of few permanent teeth to allow the normal alignment of permanent teeth. Early diagnosis and successful treatment of developing malocclusions can have both short-term and long-term benefits, while achieving the goals of occlusal harmony and function and dento-facial esthetics.

Prevention of occurrence of proximal caries by various preventive programmes and an early treatment of caries is one of the best means of reducing the occurrence of malocclusion traits, especially crowding. Though, early treatment is beneficial for many patients, but is not indicated for every patient. Also, for school aged children and adolescents patient counseling regarding any existing habits (nail biting, bruxism, clenching) is appropriate for prevention of malocclusion.

Oral diseases are not life-threatening but they represent a major public health problem because of their high prevalence and significant impact on general health. The changeover in priority from treatment to prevention will require active health promotion by the dental professionals.

Each year, oral cancer kills more people than does cervical cancer, malignant melanoma, or Hodgkin’s disease. Oral cancers usually involve the tongue, lips, floor of the mouth, soft palate, tonsils, salivary glands, or back of the throat.

Primary prevention of oral cancer focuses on avoidance of known aetiological factors and alterations in lifestyle to prevent cancer developing in the first place. Healthy People 2000 Oral Cancer Objectives include increasing consumption of complex carbohydrates and fiber containing foods, reduction in the initiation of cigarette smoking by children and adults, reduction of smokeless tobacco use and alcohol consumption.

People should be educated about warning signals of oral cancers so that they can do self examination and report at the earliest for necessary investigation and required treatment. The clear link between oral diseases and tobacco use provides an ideal opportunity for oral health professionals to take part in tobacco control initiatives and cessation programs.

Primary Preventive Dentistry: Indian Scenario

All health professionals emphasize that patients should seek entry into well-planned preventive programs. For dentistry, lack of prevention results in more restorations, periodontal problems, malocclusions, and occurrence of oral cancers. The changeover in priority from treatment to prevention will require active health promotion by the dental professionals.

ANNEXURE

Figure 1: Preventive measures, based on the decision- maker, to be applied

Table 2 Dietary fluoride supplementation schedule

Age <0.3 ppm F 0.3 to 0.6 ppm F >0.6 ppm F Birth to 6 months 0 0 0 6 mo to 3 years 0.25 mg 0 0 3 to 6 years 0.50 mg 0.25 mg 0 6 to at least 16 years 1.00 mg 0.50 mg 0

Table 3 Prevention of Dental Caries in Child ren from Birth through Five Years of Age: Clinical Sum- mary of the U.S preventive services task force (USPSTF) Recommendation

Population Children five years and younger Prescribe oral fluoride Apply fluoride varnish to the supplementation starting at six primary teeth of all infants and Routine oral screening examinations: Recommendation months of age for children children starting at the age of no recommendation Grade: I statement whose water supply is deficient primary tooth eruption. Grade: in fluoride. Grade: B B All children are at potential risk of dental caries; those whose primary water supply is deficient in fluoride are at particular risk. There are a number of individual factors that elevate risk, such as low Risk assessment socioeconomic status, being an ethnic minority, frequent sugar exposure or snacking, inappropriate bottle feeding, developmental defects of the tooth enamel, dry mouth, history of previous caries, lack of access to dental care, and inadequate preventive measures Preventive Oral fluoride supplementation prevents dental caries in children with inadequate water fluoridation. All medications children with erupted primary teeth can benefit from the periodic application of fluoride varnish. There is a moderate net benefit There is a moderate net The evidence on performing routine of providing oral fluoride benefit of providing fluoride oral screening examinations for Balance of supplementation at varnish application to all dental caries in children from birth to benefits and recommended doses in children children starting at five years of age is insufficient, and harms older than six months of age the age of eruption of primary the balance of benefits and harms who reside in communities teeth to five years of age. cannot be determined. with inadequate water fluoride.

Primary Preventive Dentistry: Indian Scenario

Table 4 Recommended use of fluoride toothpaste for children. (EAPD recommendation)

Age Fluoride concentration Daily use Daily mount 6 months –2 years 500 ppm 2× pea size 2–6 years 1000 ppm 2× pea size 6 years and over 1450 ppm 2× 1-2 cm

Table 5 Applicability of various primary preventive measures for oral diseases at

public/community level in India

Health promotion Specific protection 1. Oral health education program 1.Community or school water fluoridation Dental caries 2. Promotion of research efforts 2.School water mouth rinse pro-gram 3. Lobby efforts 1.Dental health education pro-gram Periodontal disease 2.Promotion of research efforts Supervised school brushing pro-gram 3.Lobby efforts 4.Provision of oral hygiene 1. Prenatal care 1.Dental health education pro-gram Malocclusion 2. Mouth guard program 2.Promotion of protective care 3. Safety of children toys. 1.Dental health education pro-gram Oral cancer 2.Promotion of research efforts Avoidance of known irritants 3.Lobby efforts

Figure 3 Mechanism of action of fluoride REFERENCES

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